44.02 Risk Factors for Post-operative Complications After Lymph Node Dissection for Melanoma

Posted on January 26, 2017

B. Sunkara1, S. Diljak1, R. D. Kramer1, R. J. Strobel1, D. J. Mercante1, J. S. Jehnsen1, J. F. Friedman1, A. Durham1, T. Johnson1, M. S. Cohen1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:  While the literature looking at complications after lymphadenectomy for melanoma is fairly robust, the root cause analysis of risk factors contributing to those complications has not been as well studied and often reported only in smaller case series. The purpose of this study is to analyze in the largest melanoma lymphadenectomy cohort to date the risk factors that have significant association with development of post-operative complications outside of lymphedema or lymphocele. 

Methods:   This is a retrospective review of a prospectively collected database cohort of consecutive patients having either an axillary lymph node dissection (ALND) or inguinal lymph node dissection (ILND) at our institution since January 2005. Complications were defined as occurring in the first 30 days after surgery and not including lymphocele or lymphedema. Exclusionary criteria for this study include patients with bilateral dissections or those having both an ILND and an ALND. Patients were stratified according to presence or absence of complications associated with their surgery and analyzed for associated risk factors using Chi Squared tests, and Student T tests with significance defined as p< 0.05. 

Results:  Of the 524 patients who were included in our study: 175 patients (33.4%) had post-op complications. Complications were more likely to occur in females compared to males (38.5% vs 30.1%; p=0.046), those having a right-sided procedure compared to the left (38.1% vs 28.3%; p=0.017), and those having an ALND vs. ILND (50.4% vs 20.9%; p= <0.001). Other risk factors significantly correlating with post-op complications included pre-operative hypertension (39.6% with vs 29.0% without; p=0.011), or patients with a readmission within 30 days after surgery (84.2% of those readmitted had a post-op complication as the reason for re-admission vs 24.8% readmitted without a post-op complication; p=<0.001). Interestingly having a micrometastasis in the sentinel lymph node biopsy (vs. macroscopic disease and having no positive nodes on the dissection each decreased the chance of developing a post-op complication (p=0.003). Patients who developed lymphedema or a lymphocele after their surgery were also more likely to develop another post-operative complication (p=0.002 and <0.001 respectively).  Finally the number of lymph nodes removed did not correlate with any significant increased risk of developing post-operative complications. 

Conclusion:   This is the largest series to date evaluating risk factors for post-operative complications following ALND and ILND for melanoma.  Risk factors correlating with higher post-op complication rates included being female, right sided operations, pre-op HTN, or development of lymphedema or lymphocele. Protective factors included microscopic disease in the sentinel node or lack of additional positive nodes in the lymphadenectomy specimen. These factors are important and should be included in pre-operative discussions with patients having ALND and ILND for metastatic melanoma. 

 

44.01 Greater Lymph Node Retrieval and Lymph Node Ratio Impacts Survival in Resected Pancreatic Cancer

Posted on January 26, 2017

K. A. Mirkin1,2, C. S. Hollenbeak1,2, J. Wong2  1Penn State University College Of Medicine,Department Of Public Health Sciences,Hershey, PA, USA 2Penn State University College Of Medicine,Department Of Surgery,Hershey, PA, USA

Introduction:
Surgical resection is the mainstay of pancreatic cancer treatment, however, the ideal lymphadenectomy remains unsettled.  Several meta-analyses have concluded that extended lymphadenectomies do not impact survival.  The objective of this study was to determine if number of examined lymph nodes (eLN), a proxy for lymphadenectomy, and lymph node ratio (LNR) impact survival.

Methods:

The U.S. National Cancer Data Base (2003-2011) was reviewed for patients with clinical stage I and II resected pancreatic adenocarcinoma.  Patients who received neoadjuvant therapy were excluded.  Patients were stratified by eLN: 0-6, 7-12, 13-15, and >15, and LNR (LNR= #positive nodes/ #eLN):0, 0-0.2, 0.2-0.4, 0.4-0.8, and >0.8.  Univariate and multivariate survival analyses were performed.

 

Results:

14,807 patients with clinical stages I-II resected pancreatic adenocarcinoma were included.  Of these, 15.6% (N=2,309) of patients had 0-6 eLN, 27.1% (N=4,012) had 7-12, 13.4% (N=1,977) had 13-15, and 38.6% (N=5,709) had >15 eLN.  The majority of patients underwent pancreaticoduodenectomy (N=7,720, 55.1%), while the remainder underwent distal pancreatectomy (N=1,833, 13.1%), total pancreatectomy (N=1,850, 13.2%) and other (N=2,604, 18.6%).  Patients who underwent pancreaticoduodenectomy had a median eLN of 11, while those who underwent distal or total pancreatectomy or another procedure had 14. Patients with >15 eLN had significantly improved survival over the other cohorts in both node negative and node positive disease (P<0.001, both).   After controlling for patient, disease, and treatment characteristics, patients with 7-12, 13-15, and >15 eLN had improved survival relative to patients with 0-6 eLN (HR 0.87, p<0.001, HR 0.89, p=0.002, HR 0.82, p<0.001, respectively).

32.6% (N=4,829) of patients had a LNR of 0, 29.8% (N=4,414) £0.2, 9.2% (N=2,843) 0.2-0.4, 11.0% (N=1,643) 0.4-0.8, and 1.9% (N=278) had a LNR >0.8.  Patients with LNR 0 had improved survival in T1-T3 disease (P<0.01).  After controlling for patient, disease and treatment characteristics, higher LNR was negatively associated with survival (LNR 0-0.2: HR 1.44, p<0.001, LNR 0.2-0.4: HR 1.82, p<0.001, LNR 0.4-0.8: 2.03, p<0.001, LNR >0.8, p<0.001).

Even when a suboptimal number of lymph nodes were examined (eLN £6 or £12), higher LNR remained an independent predictor for mortality.

Conclusion:

Greater lymph node retrieval in stage I & II pancreatic adenocarcinoma appears to have therapeutic and prognostic value, even in node-negative disease, suggesting a comprehensive lymphadenectomy is beneficial.  Lymph node ratio is inversely related to survival and may be useful when suboptimal lymph node retrieval is performed.

43.20 Functional Recovery in Transfemoral Versus Transapical Transcatheter Aortic Valve Replacement

Posted on January 26, 2017

N. K. Asthana1, A. Mantha4, G. Vorobiof3, P. Benharash2  1University Of California – Los Angeles,Los Angeles, CA, USA 2University Of California – Los Angeles,Cardiothoracic Surgery,Los Angeles, CA, USA 3University Of California – Los Angeles,Cardiology,Los Angeles, CA, USA 4University Of California – Irvine,Orange, CA, USA

Introduction: Transcatheter aortic valve replacement (TAVR) has greatly improved treatment options for severe aortic valve stenosis patients (AS) at high surgical risk. Typically, a transfemoral (TF) approach is preferred due to being less invasive than a transapical (TA) approach. However, in patients where peripheral access is limited due to tortuosity, size, or calcification, a TA approach is preferred. This study assessed whether myocardial functional recovery differed significantly post-TAVR between patients who received a TF approach vs. a TA approach.

Methods: Echocardiograms of all severe AS patients that underwent TAVR at Ronald Reagan UCLA Medical Center from 2012-2016 were evaluated. Parameters that were assessed include left ventricular ejection fraction (LVEF), left ventricular internal diameter (LVID), interventricular septal thickness at end-diastole (IVSd), and posterior wall thickness at end-diastole (PWd). Moreover, left ventricular segmental longitudinal strains and global longitudinal strain (GLS) were measured using two-dimensional speckle tracking echocardiography (2D-STE). Echocardiograms were evaluated pre-TAVR (mean: 20.1 d), post-operatively (mean: 2.5 d), and at a 1-month follow-up (mean: 32.7 d). Statistical analysis was conducted using a repeated measures analysis of variance (rANOVA), where p < .05 was considered significant.

Results: Of the 216 patients assessed, 42 patients had complete data available. Patients that underwent TAVR with a TF approach (N = 31, 67% male, 81.6 y in age) were compared to those that underwent a TA approach (N = 11, 55% male, 87.3 y in age). For the entire cohort, between the pre-TAVR baseline and the 1-month follow-up: (i) There were no significant changes in LVEF, LVID, IVSd, or PWd (p > .05). (ii) Segmental longitudinal strains significantly increased in the apex (from -18.9 to -21.5%, p < .0001), anterior segments (from -15.5 to 18.3%, p < .0001), lateral segments (from -14.0 to -17.1%, p < .0001), inferior segments (from -14.9 to -18.1%, p < .0003), and septal segments (from -14.2 to -16.9%, p < .0002). (iii) GLS significantly improved (from -15.6 to ?18.2%, p < .001). When comparing the TF and TA groups, there were no significant differences in LVEF, LVID, IVSd, PWd, GLS, and anterior, lateral, inferior, and septal segmental longitudinal strains (p > .05). However, there was a significant difference in longitudinal strain at the apex between the TF and TA groups (TF vs. TA at 1-month follow-up: -22.3 +/- 7.63% vs. -15.9 +/- 7.47% respectively, p < .05).

Conclusion: Patients that underwent a TF approach showed significantly greater post-TAVR improvement in apical longitudinal strain, although myocardial functional recovery did not significantly differ between TF vs. TA groups otherwise. Additionally, it appears that myocardial strains measured by 2D-STE are more sensitive in detecting subclinical functional changes compared to more customary measures of cardiac remodeling.

 

43.19 Patterns of Mediastinal Metastasis after Robotic-Assisted Lobectomy for Non-Small Cell Lung Cancer

Posted on January 26, 2017

R. Gerard4, F. O. Velez-Cubian2, E. P. Ng4, C. C. Moodie1, J. R. Garrett1, J. P. Fontaine1,2,3, E. M. Toloza1,2,3  1Moffitt Cancer Center,Thoracic Oncology,Tampa, FL, USA 2University Of South Florida Morsani College Of Medicine,Surgery,Tampa, FL, USA 3University Of South Florida Morsani College Of Medicine,Oncologic Sciences,Tampa, FL, USA 4University Of South Florida,Morsani College Of Medicine,Tampa, FL, USA

Introduction:   Many thoracic surgeons perform mediastinal lymph node (LN) sampling (MLNS) in order to minimize morbidity believed to be associated with complete mediastinal LN dissection (MLND).  In order to focus attention of MLNS to the most likely LN levels involved for a given lung cancer, we sought to determine the patterns of mediastinal LN metastasis found after robotic-assisted video-thoracoscopic pulmonary lobectomy for non-small cell lung cancer (NSCLC).

Methods:   We retrospectively analyzed prospectively collected data for all patients who underwent robotic-assisted pulmonary lobectomy for NSCLC by one surgeon over 69 months.  Clinical stage was determined by history & physical examination, computerized tomography, positron-emission tomography, brain imaging studies, and/or endobronchial ultrasonography. Pathologic stage was based on intraoperative findings and final pathology. The pulmonary lobe resected and any mediastinal LNs involved by metastasis were noted.

Results:  Of 303 NSCLC patients (pts), mean age was 69±0.5 yr (range 39-98 yr), with most common histologies being adenocarcinoma (66%), squamous cell carcinoma (21%), and neuroendocrine carcinoma (10%).  Tumors were located in the right lung in 198 (65.3%) pts and in the left lung in 105 (34.7%) pts.  The three most common anatomic locations were right upper lobe (RUL; 39.6%), left upper lobe (LUL; 21.8%), and right lower lobe (RLL; 18.5%).  Frequencies of stage-3 disease were similar for left NSCLC compared to right NSCLC (p=0.59), but the frequency of stage-2 disease was higher for left NSCLC (28.6%) compared to that for right NSCLC (17.2%; p=0.02).  Of stage-3A right NSCLC, 56.8% were in the RUL, while 69.6% of stage-3A left NSCLC were in the LUL.  Among N1 LNs, level 11 involvement was more common than level 10 involvement for all right and left NSCLC combined (72/103, 69.9% vs. 20/103, 19.6%; p<0.0001).  Mediastinal LN involvement was highest in level 4R (23/198; 11.6%), level 5 (11/105; 10.5%), level 7 (25/303; 8.3%), and level 2R (10/198; 5.1%).  Stage-3A RLL NSCLC most commonly metastasized to level 7 (12/26; 46.2%), while stage-3A left lower lobe NSCLC metastasized most commonly to level 9L (3/6; 50.0%).

Conclusion:  After robotic-assisted pulmonary lobectomy, mediastinal LN metastatic disease was similarly frequent for right versus left NSCLC, while stage-2 disease was more frequent with left NSCLC.  Among N1 LNs, interlobar LNs were more commonly involved than hilar LNs.  For stage-3A NSCLC, there was upper lobe predominance on both sides.  Level 4R LNs were the most frequently found to be positive with right NSCLC, mostly due to RUL NSCLC, while level 5 LNs were most frequently found to be positive with left NSCLC, mostly due to LUL NSCLC.  These patterns of N1 and mediastinal LN involvement should assist in guiding thoracic surgeons to perform a more focused MLNS or a more complete MLND for more accurate NSCLC staging.

43.18 Predictors of Cardiogenic Shock in Cardiac Surgery Patients Receiving Intra-Aortic Balloon Pumps

Posted on January 26, 2017

A. Iyengar1, O. Kwon2, R. Shemin2, P. Benharash2  1University Of California – Los Angeles,David Geffen School Of Medicine,Los Angeles, CA, USA 2University Of California – Los Angeles,Division Of Cardiac Surgery,Los Angeles, CA, USA

Introduction:  Cardiogenic shock following cardiac surgery is a rare complication that leads to increased morbidity and mortality. Intra-aortic balloon pumps (IABPs) may be used during the perioperative period to increase coronary perfusion and support cardiac output. The purpose of this study was to characterize predictors of postoperative cardiogenic shock in cardiac surgery patients, and examine differences between those with and without IABP support.

Methods:  Retrospective analysis of UCLA’s Society of Thoracic Surgeon’s (STS) database was performed between January 2008 and July 2015. Preoperative demographic data for all patients were queried, and patient’s receiving IABP support during the perioperative period were identified. The Kruskal-Wallis and chi-squared tests were used for comparisons between IABP and control cohorts. Multivariable logistic regression with step-wise elimination was used to model postoperative cardiogenic shock in both the IABP and control cohorts. 

Results: During the study period, 4,741 cardiac surgery patients were identified during the study period, of whom 268 (6%) received an IABP. IABP patients had higher rates of previous cardiac surgery (54% vs. 38%, p<0.001), congestive heart failure (69% vs. 43%, p<0.001), and preoperative cardiogenic shock (22% vs. 2%, p<0.001). Furthermore, IABP patients were more likely to have emergent operations (84% vs. 42%, p<0.001) and receive coronary artery bypass grafts (CABG, 63% vs. 32%). IABP patients had significantly greater ventilation times, ICU/total hospital stays, and 30-day mortality (all p<0.001), and more postoperative cardiogenic shock (10% vs. 3%, p<0.001).
Among the IABP cohort, preoperative dialysis, arrhythmias, and previous cardiac surgery were all associated with higher odds of postoperative cardiogenic shock (all p<0.10), while CABG operations were found to be protective compared to other cardiac operations (OR 0.33 vs 2.28, p=0.008 and 0.053, respectively). On multivariate analysis, previous cardiac surgery and preoperative arrhythmia remained significant (AOR 5.95, p=0.005, and 2.94, p=0.015, respectively)predictors of postoperative cardiogenic shock. In the control cohort, several factors including hypertension, chronic lung disease, preoperative congestive heart failure, cardiogenic shock, inotropic medications, urgent/emergent status, non-CABG/Valve cardiac surgery, and prolonged bypass times, were associated with postoperative cadiogenic shock.

Conclusion: Factors associated with cardiogenic shock among post-cardiac surgery patients differ between those patients receiving IABP and those who do not. Among IABP patients, previous cardiac surgery and arrhythmias were associated with increased rates of cardiogenic shock, while shock was multifactorial among control patients. The etiology of cardiogenic shock may differ between these two cohorts, and early identification of those patients at risk may lead to improved outcomes.

43.17 Tumor Size and Perioperative Outcomes after Robotic-Assisted Pulmonary Lobectomy

Posted on January 25, 2017

R. Gerard4, F. O. Velez-Cubian2, E. P. Ng4, C. C. Moodie1, J. R. Garrett1, J. P. Fontaine1,2,3, E. M. Toloza1,2,3  1Moffitt Cancer Center,Thoracic Oncology,Tampa, FL, USA 2University Of South Florida Morsani College Of Medicine,Surgery,Tampa, FL, USA 3University Of South Florida Morsani College Of Medicine,Oncologic Sciences,Tampa, FL, USA 4University Of South Florida,Morsani College Of Medicine,Tampa, FL, USA

Introduction:   Tumor size is one factor that determines whether lobectomy is performed via open or minimally invasive approach.  We investigated whether tumor size affects perioperative outcomes after robotic-assisted video-thoracoscopic (RAVT) pulmonary lobectomy.

Methods:   We retrospectively studied all patients (pts) who underwent RAVT pulmonary lobectomy between September 2010 and May 2016 by one surgeon at our institution.  Patients were grouped by greatest tumor diameter on pathologic measurement of lobectomy specimens.  Perioperative outcomes, including estimated blood loss (EBL), skin-to-skin operative time, conversion to open lobectomy, intraoperative and postoperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality were compared.  Chi-square test, Student’s t-test, and Kruskal-Wallis test were used, with p≤0.05 as significant.

Results:  We identified and grouped 359 pts by greatest tumor diameter being ≤10mm, 11-20mm, 21-30mm, 31-50mm, or ≥51mm.  Tumor histology was comprised of NSCLC (89.4%), SCLC (1.9%), and pulmonary metastases (8.6%), with the most common NSCLC histology being adenocarcinoma (63.8%), squamous cell (21.5%), and neuroendocrine (9.7%).  No differences were noted in mean age, female:male ratio, or mean body surface area among the groups, but mean body mass index was lowest in pts with tumors ≥51mm.  Lobar distribution of lung tumors did not differ among the groups (p>0.14), but extent of resection differed by pts with tumors ≥51mm having a lower rate of simple lobectomies (p<0.001) and a higher rate of en bloc chest wall resection (p<0.001).  Neither overall intraoperative complications nor overall or emergent conversion to open lobectomy differed among the groups (p>0.21), but pulmonary artery (PA) injury occurred in as high as 7.2% of pts in groups with tumors ≥21mm (p=0.014).  While median EBL was higher in pts with tumors ≥51mm (p≤0.003) and median operative time was higher in pts within groups with tumors ≥31mm (p≤0.019), median chest tube duration and median hospital LOS did not differ among the groups (p>0.37).  Neither overall total postoperative complications nor overall pulmonary or cardiovascular complications differed among the groups (p>0.23), but pneumothorax after chest tube removal and requiring intervention was more frequent in pts who had tumors ≤10mm (p=0.03).  In-hospital mortality did not differ among the groups (p=0.60).

Conclusions: Patients who undergo RAVT lobectomy for tumors ≥51mm are associated with lower BMI and are less likely to have simple lobectomies and more likely to require en bloc chest wall resection.  Patients with larger tumors also are at increased risk of PA injury, higher EBL, and longer operative times, but are at lower risk for pneumothorax after chest tube removal and that require intervention.  However, tumor size does not affect chest tube duration, hospital LOS, or in-hospital mortality.

43.16 Weekend Discharge and Readmission Rates After Cardiac Surgery

Posted on January 25, 2017

G. Ramos1, R. Kashani1, Y. Juo1, A. Lin2, N. Satou1, R. J. Shemin1, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Division Of Cardiac Surgery,Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles,Division of General Surgery,Los Angeles, CA, USA

Introduction:  Unintended rehospitalization within 30 days serves as a quality metric for institutions and may lead to financial penalties. Few studies have examined the implications of weekend discharges on readmission rates. Limited care coordination and cross coverage of surgeons are known challenges of weekend hospital function and may lead to less comprehensive post-discharge care plan. Based on this knowledge, we hypothesized that patients discharged on weekends would be more likely to be readmitted. 

Methods:  Using the institutional Society of Thoracic Surgeons (STS) database, all adult patients (>18) undergoing cardiac surgery between 2008 and 2015 were identified. 44 demographic and perioperative characteristics were collected and accounted for in a multivariate model. Emergency, transplant and mechanical assist patients were excluded. Weekday discharge was defined as being discharged on Monday through Friday while weekend discharge was limited to Saturdays and Sundays. The primary outcome variable was any readmission within 30 days of discharge. 

Results: Of the 4416 patients included in the study, 3632 (82%) were discharged on a weekday, and 783 (18%) were discharged on a weekend; 495 (11%) patients were readmitted within 30 days. The readmission rates for the weekday and weekend cohorts were similar (10% vs.11%, p=0.4). After adjustment for other risk factors of readmission, there was no association between discharge day of the week and readmission (adjusted odds ratio [AOR]= 1.08, 95% CI=0.83-1.42, p=0.6).  Significant risk factors for readmission included receiving dialysis (AOR=1.6, 95% CI=1.09-2.30, p=0.016), undergoing an urgent operation (AOR=1.24, 95% CI=1.01-1.53, p=0.04), and taking preoperative Coumadin (AOR=1.43, 95% CI=1.04-1.97, p=0.03) or beta-blockers (AOR=1.32, 95% CI=1.07-1.63, p=0.01).

Conclusion: In this study, weekend discharge status was not associated with an increased risk of readmission after cardiac surgery. However, patients having an urgent surgery, receiving dialysis, or taking preoperative Coumadin or beta-blockers were more likely to be readmitted. Our findings suggest that readmission reduction programs should focus on patient factors rather than providing additional weekend coverage beyond existing care coordination resources. 

 

43.15 Impact of Prior Myocardial Infarction on Myocardial Recovery after Transcatheter Aortic Valve Replacement

Posted on January 25, 2017

A. Mantha2, N. Asthana3, G. Vorobiof3, P. Benharash1  1University Of California – Los Angeles,Cardiac Surgery,Los Angeles, CA, USA 2University Of California – Irvine,Orange, CA, USA 3University Of California – Los Angeles,Cardiology,Los Angeles, CA, USA

Introduction:  Transcatheter valve replacement (TAVR) is a definitive, minimally invasive treatment for patients with severe stenosis (AS) and has been shown to improve myocardial remodelling. However, it is unclear whether these changes occur in patients who have a history of myocardial infarction. This study sought to evaluate the impact of TAVR in patients who had previously suffered a myocardial infarction and have undergone PCI or CABG.

Methods:  A review of our prospectively-maintained institutional Society of Thoracic Surgeons database and Transcatheter valve Registry was performed to identify all patients undergoing TAVR from Jan. 2013- Mar. 2016. Chi-square test and regression were used to evaluate differences in patient demographics, readmission rate and length of stay. Repeated measures analysis of variance was used to compare myocardial strain and function among forty-two patients with speckle data through one-month follow-up. 

Results: Of the 172 patients included in the analysis, 62 (36%) had previously experienced a myocardial infarction. 22 (33%) underwent PCI alone, 18 (27%) underwent CABG alone and 9 (13%) underwent both PCI and CABG. Patients who underwent PCI alone had a significantly longer length of stay (7.2 vs 4.4 days, p<0.001) after TAVR and higher proportion of patients readmitted within 30 days (37%, p<0.01). Patients with history of MI had consistently lower magnitudes of strain in the septal (p<0.01), anterior (p<0.02), lateral (p<0.01), and inferior (p<0.01) ventricular walls despite having similar ventricular diameter (p=0.77) and septal thickness (p=0.82). Both cohorts demonstrated significant improvement in global longitudinal strain (-19.0 vs -16.0 in control, -17.1 vs -14.1 in MI, p<0.01) and interaction between history of MI and GLS was not significant.

Conclusion: Patients with history of myocardial infarction benefit similarly from TAVR as control patients with no history of MI despite having poorer pre-operative ventricular contractility. However, management strategy of infarction episode may have differential impact on tissue ischemia leading to increased length of stay and risk of readmission after TAVR.
 

43.14 Thoracoscopic Lobectomy Reliability for NSCLC is an Important Indicator of Program Development

Posted on January 25, 2017

M. Hennon1,2, J. Xiao2, M. Huang1, E. Dexter1,2, A. Picone1,2, S. Yendamuri1,2, C. Nwogu1,2, W. Tan3, T. Demmy5  1Roswell Park Cancer Institute,Thoracic Surgery,Buffalo, NY, USA 2State University Of New York At Buffalo,Surgery,Buffalo, NY, USA 3Roswell Park Cancer Institute,Biostatistics,Buffalo, NY, USA 5Rutgers Cancer Institute Of New Jersey,Cardiothoracic Surgery,New Brunswick, NJ, USA

Introduction:  Outcomes for thoracoscopic (VATS) lobectomy at the institutional level can be affected by numerous variables, including selection bias. The total percentage of cases completed by VATS for locally advanced nonsmall cell lung carcinoma may be an important component of individual program quality.

Methods:  Over 11 years (from January 2002 to March 2013), 1289 consecutive lobectomies were performed, of which 300 were for patients with locally advanced NSCLC (tumors greater than 4cm, T3, T4, or patients who underwent induction chemotherapy).  Patients requiring chest wall resection, sleeve lobectomy, or pneumonectomy were excluded.  Cases were divided into three sequential groups of 100 patients for comparison.  Reliability is defined as the total number of cases completed thoracoscopically (VATS) divided by all cases (VATS + Conversion+ Open). Conversion rates, percentage of cases completed by VATS, along with preoperative, perioperative and outcome variables were compared and analyzed by Mann-Whitney-Wilcoxon and Fisher’s exact tests. Estimated overall survival and disease free survival distributions were obtained using the Kaplan-Meier method.

Results: Of 300 cases during the study period, 219 were completed by VATS.  VATS reliability increased from 62% (early), to 77% (middle), and 80% (late).  Reliability increased due to a steady decrease in planned thoracotomy from 17%, to 9% and 2.1% respectively.  A higher percentage of patients in the late group had more preoperative comorbidities (CAD/MI 27% vs. 19% vs. 42.6%, p = 0.0016). Median operative time increased over the study period from 225 min. [96-574] vs. 328 min. [115-687] vs. 340 min. [140-810], presumably due to approaching more complex tumor pathology.  Median operative blood loss was the same for all groups at 200 mL (10-2200).  Median postoperative ICU stay was 1 day (0-92) for all groups.  Higher neoadjuvant therapy rates (16% vs. 54% vs. 50%, p <0.0001) were achieved in the middle/late groups.  Fewer postoperative complications occurred in the middle and late time groups (any major complication was 38% vs. 13% vs. 16%, p < 0.0001; bleeding 23% vs. 4% vs. 6%, p < 0.0001; air leak 16% vs. 13% vs. 3%, p = 0.0037).   Number of lymph nodes harvested during surgery (10.2 vs. 12.5 vs. 22.8, p <0.0001) improved significantly. 

Conclusion: In our experience, VATS reliability increased over time with favorable perioperative and postoperative outcomes due to fewer cases being approached by planned thoracotomy. Since there were associations with factors like lymph node harvest, VATS reliability deserves additional study as an indicator of individual program achievement and as a tool to explain differences between VATS and open surgeries reported in large, cooperative databases.

 

43.13 The Use of Peri-operative Ketorolac in Surgical Treatment of Pediatric Spontaneous Pneumothorax

Posted on January 25, 2017

R. M. Dorman1,2, G. Ventro1,2, S. Cairo1, K. Vali1,2, D. H. Rothstein1,2  1Women And Children’s Hospital Of Buffalo,Pediatric Surgery,Buffalo, NY, USA 2State University Of New York At Buffalo,Pediatric Surgery,Buffalo, NY, USA

Introduction:
The effect of post-opertative anti-inflammatory medications on pleurodesis success after treatment of spontaneous pneumothorax is uncertain. We sought to determine if the use of post-operative ketorolac is associated with an increased risk of recurrence in the surgical treatment of primary spontaneous pneumothorax in children.

Methods:
The Pediatric Health Information System database was queried for all patients age 10-16 years discharged ibetween 2004-2014 with a primary diagnosis of pneumothorax or pleural bleb and a thoracotomy, thoracoscopy, or lung resection procedure. Deaths, encounters representing readmission after previous operative treatment of pneumothorax in the prior year, patients requiring extra-corporeal life support, and patients with diagnoses or concurrent procedures that may lead to secondary or iatrogenic pneumothorax were excluded. Variables included basic demographics, discharge in the first or second half of the study period, chronic renal or hematologic disease, intensive care unit admission or post-operative mechanical ventilation, and whether a lung resection or plication was coded. The primary predictor of interest was ketorolac administration any time in the period from post-operative day 0 to 5. The primary outcomes of interest were thoracentesis, thoracostomy, thoracotomy, thoracoscopy, lung resection or plication, or pleurodesis within 1 year of the index admission. Bivariate analyses were carried out for all outcomes and multivariate logistic regression analyses were then performed for reintervention and readmission.  

Results:
1,678 records met inclusion criteria. Three hundred ninety-five (23%) were subsequently excluded (227 readmissions and the remainder for one of the above-listed criteria), leaving 1,283 patients for analysis. The cohort was predominately male (79%), white (74%), and older (mean age 15.5 ± 1.2 years). Most patients had some lung resection recorded (78%), a majority were administered ketorolac (57%), and few required reintervention (20%) or readmission (18%). Mean postoperative length of stay was 5.2 ± 3.8 days and mean cost was $17,649 ± $10,599. Older patients and those in the earlier years of the study were more likely to receive ketorolac. There was significant variation in frequency of ketorolac administration by geographic region, ranging from 32% to 68%. On multivariate analysis, no variable was predictive of reintervention, and only lung resection correlated with readmission (adjusted odds ratio 0.63 [95% C.I. 0.45-0.90]). 

Conclusion:
Post-operative ketorolac administration was not associated with an increased likelihood of reintervention or readmission within 1 year of operative treatment of primary spontaneous pneumothorax, suggesting that it may be used safely as part of a post-operative pain control regimen. Effects on postoperative length of stay and cost, however, were not demonstrated.
 

43.12 Acute Retrograde Type A Aortic Dissection: Morphological Analysis and Clinical Implications

Posted on January 25, 2017

B. L. Rademacher1, P. D. DiMusto2, J. L. Philip1, C. B. Goodavish3, N. C. De Oliveira3, P. C. Tang3  1University Of Wiscosin,Department Of Surgery, Division Of General Surgery,Madison, WISCONSIN, USA 2University Of Wisconsin,Department Of Surgery, Division Of Vascular Surgery,Madison, WISCONSIN, USA 3University Of Wiscosin,Department Of Surgery, Division Of Cardiothoracic Surgery,Madison, WISCONSIN, USA

Introduction: Numerous studies have described thoracic stent graft induced retrograde type A dissections (rTAD), however, much less is known about acute spontaneous rTAD with tears originating past the left subclavian without prior aortic instrumentation. This study compares the morphology of acute rTAD with both acute antegrade type A dissection (aTAD) with primary tears in the ascending aorta and acute type B dissection.

Methods: From 2000 to 2016, there were 12 acute rTAD, 96 aTAD, and 92 acute type B dissections with available imaging that underwent operative intervention at our institution. Dissection morphology along the length of the aorta was characterized using 3-dimensional reconstruction based on computerized tomography angiography (CTA) images. We examined primary and secondary tear characteristics, true lumen area as a fraction of the total lumen area, and false lumen contrast intensity as a fraction of the true lumen contrast intensity.  Features of presentation and operative parameters were compared between rTAD and aTAD.

Results: Compared with acute type B dissections, primary rTAD tears were more common in the distal arch (75% vs 43%, p=0.04), and the false lumen to true lumen contrast intensity ratio at the mid-descending thoracic aortic level was lower (0.46 vs 0.71, P=0.02) indicating more sluggish blood flow or thrombosis in the false lumen. rTAD cases had less decompression of the false lumen compared with acute type B dissections such that there were fewer aortic branch vessels distal to the subclavian that were either exclusively perfused through the false lumen or through both the false and true lumen (0.40 vs 2.19, P<0.001). Compared with aTAD, rTAD had a tendency for less root involvement where true lumen as a fraction of total lumen area at the root level was higher (0.88 vs 0.76, P=0.081). rTAD had a lower false lumen to true lumen contrast intensity ratio compared to aTAD at the root (0.25 vs 0.57, P<0.05), ascending aorta (0.25 vs 0.72, P<0.001), and proximal arch (0.39 vs 0.67, P<0.05) indicating more sluggish flow or greater tendency to thrombose. rTAD patients were more likely to undergo aortic valve resuspension (100% vs 74%, P=0.044) than aortic valve replacement, and tend to have lower aortic cross-clamp times (83 vs 108 min, P=0.066) (Table 1).

Conclusion: This study suggests that retrograde propagation of the false lumen to the arch and ascending aorta tends to occur when the primary tears that occur distal to the left subclavian are in close proximity to the aortic arch and when false lumen decompression through the distal aortic branches are less effective. Compared to aTAD, rTAD tends to have less root involvement and successful aortic valve resuspension is more likely.

43.10 Are Non-Emergent Cardiac Surgeries Performed During Off-Time Associated with Worse Outcome?

Posted on January 25, 2017

R. Ou1, G. Ramos1, Y. Juo1, R. J. Shemin1, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Division Of Cardiac Surgery,Los Angeles, CA, USA

Background:

With the implementation of value-based healthcare, it is of increasing interesting to understand whether performing elective surgeries during off-time impacts surgical outcomes. In cardiac surgery, interdisciplinary coordination in the operating room is crucial. Factors such as end of day fatigue, care team transitions, and physiologic changes in patients can negatively affect coordination and precipitate adverse events in patient care. We hypothesized that “off-time” cases, including late start and weekend operations, are associated with higher postoperative mortality and major adverse events in patients receiving elective cardiac operations. 

Methods:

The institutional Society of Thoracic Surgeons (STS) database was used to identify all adult elective cardiac operations performed between January 2008 and December 2015 at a university hospital. Patients receiving transplants and extracorporeal mechanical circulatory support were excluded. ”Off-time” was defined as either operation “late starts,” i.e. an incision time after 3PM, or procedures occurring during the weekends. Univariate and multivariate logistic regression were performed to examine its impact on in-hospital mortality and major adverse events (MAE). MAE were defined as postoperative atrial fibrillation, stroke, transient ischemic attack, myocardial infarction, renal failure, surgical site infection, sepsis, prolonged respiratory support, and unplanned reoperations. Available cost data was directly obtained from the departmental BIOME database.

Results:

Of the 3,399 non-emergent cardiac operations included in the study, 468 (13.8%) were performed during off-time. After adjusting for patient and operative characteristics, cases performed off time were not associated with increased in-hospital mortality (P=0.58, CI 95%  0.99—1.02), readmissions (P=0.20, CI 95%  0.99—1.07), or MAE (P=0.10, CI 95%  0.99—1.11). Cost data were available in 1650 (48.5%) patients. Of the patients with cost data available, late start operations were associated with a 16.4% increase in total cost (P<0.01), however after adjusting for patient comorbidities this was no longer significant (P=0.17).

Conclusions:

These findings suggest that cases performed during off time are not associated with increased mortality or other complications in a tertiary-care academic medical center. Our findings should be considered during operative scheduling in order to optimize resource distribution and patient care strategies.

43.09 A Protocol to Decrease Post Operative Chylous Effusion Duration in Pediatric Patients

Posted on January 25, 2017

M. M. Winder1, D. K. Bailly3, R. J. Smout1, J. Marietta1, A. W. Eckhauser2  1Primary Childrens Hospital,Salt Lake City, UT, USA 2University Of Utah,Pediatric Cardiothoracic/Cardiothoracic Surgery/Surgery,Salt Lake City, UT, USA 3University Of Utah,Critical Care/Pediatrics,Salt Lake City, UT, USA

Introduction:  Chylothorax following pediatric cardiac surgery occurs in 2.8% of patients nationwide and leads to significant morbidity. Currently no evidence-based protocol for the treatment of chylothorax exists, which leads to wide practice variation specifically in the timing of treatments and surgical interventions. Our primary goals were to decrease variability among providers treating pediatric patients with chylothorax following cardiac surgery by developing and implementing a management protocol and to decrease time to resolution of chylothorax as demonstrated by total days of chest tube utilization.

Methods:  A chylothorax management protocol was implemented at Primary Children’s Hospital in July 2015. We included all patients aged 0-17y with chylothorac within 30 days of surgery. We excluded congenital chylothorax, Fontan patients, and those with chylothorax duration <24 hours. Retrospective analysis was completed on patients treated with chylothorax following cardiac surgery in a pre-protocol implementation cohort (July 2014 to June 2015, n = 19) and a post-protocol implementation cohort (July 2015 to March 2016, n = 13). Any patient with a diagnosis of chylothorax unrelated to cardiac surgery was excluded.

Results:  Patient characteristics including age at time of surgery, sex, race, weight on admission, RACHS categories 1-3 and 4-6 and presence of genetic abnormalities were similar pre and post protocol implementation. Protocol compliance was 92%. Following protocol implementation, duration of chest tube used decreased from 12 days to 6.2 days (p = 0.04). Time to resolution of chylothorax decreased from a mean of 7.4 days to 4.1 days (p = 0.11), with a decrease in maximum time to resolution from 30 days to 9 days (see figure). Duration of medium chain triglyceride feeds decreased from 42 days to 30 days (p=0.03). Pre and post protocol duration of mechanical ventilation (4.7 days vs. 4.5 days; p = 0.91), hospital length of stay (13.1 days vs. 14.8 days; p = 0.73, and CICU length of stay (29 days vs. 21.8 days; p =0.33) were unchanged post protocol. There were no chest tube re-insertions, readmissions, or surgical interventions related to chylothorax in either the pre- or post-protocol cohorts.

Conclusion:  Adoption of a chylothorax management protocol is feasible and in our small cohort of patients, implementation led to significantly improved duration of chest tube use and decrease from maximal time to resolution of chylothorax.

 

43.08 Lobectomy, Segmentectomy or Wedge Resection for T1a NSCLC: a Systematic Review and Meta-analysis

Posted on January 25, 2017

M. A. IJsseldijk1,2, M. Shoni3, C. Siegert5, J. Seegers2, T. Van Engelenburg2,5, T. Tsai3, A. Lebenthal3,4,5, R. Ten Broek1,2  1Radboud University Medical Center,General Surgery,Nijmegen, GELDERLAND, Netherlands 2Slingeland Hospital,Surgery,Doetinchem, GELDERLAND, Netherlands 3Brigham And Women’s Hospital,Surgery,Boston, MA, USA 4Harvard School Of Medicine,Brookline, MA, USA 5VA Boston Healthcare System,West Roxbury, MA, USA

Introduction:
The optimal treatment of small (T1a) non-small cell lung cancer (NSCLC) remains subject to debate. Lobar resection is considered the standard of care. However, recent studies indicate sublobar resection (segmentectomy or wedge resection) as a promising, parenchymal sparing treatment yielding comparable oncological outcomes. We conducted a systematic review and meta-analysis to compare oncological outcomes after lobar resections and parenchymal sparing resections in T1a NSCLC.

Methods:
We searched MEDLINE, PubMed, EMBASE, Web of Knowledge and CENTRAL to identify studies reporting overall survival (OS) or disease-free survival (DFS) following lobar resection or parenchymal sparing resections in early-stage NSCLC. Two researchers independently identified  studies and extracted data. Oncological outcomes after lobar resection and parenchymal sparing resections were compared using the Mantel-Haenszel method and outcomes were pooled for each surgical modality using the inverse variance method. 

Results:
A total of 8781 studies were identified, from which 24 articles were included. There was no difference in 5-year OS in pT1a tumors when lobar resection was compared to a lung parenchymal sparing resection (Relative Risk=0.90 (95%CI 0.80-1.02)). Moreover, there was no difference in 5-year DFS for pT1a tumors or 5-year OS for cT1a tumors between lobar surgery and a lung parenchymal sparing resection. Strikingly, there was a minor difference in 5-year DFS favoring a parenchymal sparing resection over lobar surgery for cT1a tumors.
The point estimates of 5-year OS of both comparative and non-comparative studies for pT1a tumors were 86% (95% CI: 84-89%) following lobar resection (n=1538), 83% (95%CI: 75- 91%) following segmentectomy (n = 402) and 71% (95% CI: 65 – 76%) following wedge resection (n = 65). There were no differences in pooled estimates for 5-year OS in cT1a tumors and 5-year DFS for pT1a tumors.

Conclusion:
This systematic review and meta-analysis shows that parenchymal sparing surgery in the form of segmentectomy yields equivocal results in terms of 5-year OS or DFS compared to lobar surgery for T1a NSCLC tumors. However, nodal upstaging is present in approximately 10% of patients.

 

43.07 Outcomes of Acute Renal Failure Evolved During Veno-Venous ECMO for Severe ARDS Patients

Posted on January 25, 2017

R. Devasagayaraj1, N. Cavarocchi1, H. Hirose1  1Thomas Jefferson University,Philadelphia, PA, USA

Introduction:  Patients who develop severe acute respiratory distress syndrome (ARDS) with stable hemodynamics may be placed on veno-venous extracorporeal membrane oxygenation (VV ECMO) to support respiratory recovery.  Survival outcomes remain unclear in those who develop acute kidney injury (AKI) requiring continuous veno-venous hemodialysis (CVVHD).

Methods:  A retrospective chart review (2010-2016) of patients who underwent VV ECMO for ARDS was conducted with IRB approval.  Patients supported by veno-arterial ECMO due to cardiac failure or hemodynamic instability were excluded. Analyses of patient demographics, clinical risk factors, respiratory parameters, and laboratory data were conducted.  AKI was defined by receiving CVVHD, which was used for patients with oliguria despite administration of diuretics, acute renal failure, severe metabolic acidosis, and/or uncontrollable fluid overload.  VV ECMO was performed via right internal jugular access using dual lumen ECMO cannula, while CVVHD was performed via groin access using a separate dialysis catheter.  Patients on VV ECMO were divided by development of AKI into two groups, AKI and non-AKI and survival analysis was performed.

Results: We identified 54 ARDS patients (aged 45 ± 13y, 33 males) supported by VV ECMO (mean ECMO days 12 ± 6.7) including 16 (29.6%) in AKI group and 38 (70.4%) in non-AKI group.  No patients had previous renal failure, and serum creatinine was similar between AKI and non-AKI group at the time of ECMO initiation (1.8 ± 1.1 mg/dl in AKI group vs. 1.4 ± 0.7 mg/dl in non-AKI group, p=0.194).  Survival of AKI group (56.3% [9/16]) was inferior to the non-AKI group (86.8% [33/38]), p=0.013.  At the time of initiation of ECMO, patients demographics, lung, renal, and liver functions were similar between AKI and non-AKI group.  However, at the time of decannulation of ECMO, AKI group showed higher lactate (5.2 ± 5.1 mmol/L in AKI group vs 2.1 ± 1.2 mmol/L in non-AKI group, p=0.046), metabolic acidosis (bicarbonate level, 23 ± 3.4 mmol/L vs. 27 ± 9.9 mmol/L, p=0.032), despite similar creatinine levels (1.2 ± 0.6 mg/dL vs. 1.0 ± 0.5 mg/dL, p=0.272).  AKI group showed greater incidence of complications during ECMO including liver failure (37.5% [6/16] vs. 5.2% [2/38], p=0.002) and internal hemorrhage (68.8% [11/16] vs. 21% [8/38], p<0.001). Among the survivors of ECMO, 79.2% [38/48] survived hospital stay and 43.8% [7/16] recovered renal function without need of permanent dialysis.

Conclusion: In our experience, patients initially placed on VV ECMO for single organ injury due to ARDS when complicated by AKI showed decreased survival.  Patients developing AKI are likely to develop hepato-renal syndrome and internal bleeding, all which may lead to multi-organ failure.  VV ECMO alone successfully manages patients with severe ARDS; however, other end-organ function needs careful monitoring and appropriate treatment to improve outcome.

43.06 Meta-analysis of Thromboelastography for Postoperative Hemorrhage After Cardiac Surgery

Posted on January 25, 2017

J. Parreco1, M. Eby1, A. A. Kurian1, C. Faber1, R. Kozol1  1University Of Miami,Miami, FL, USA

Introduction:
Thromboelastography (TEG) has been used since the 1940s and the first use in cardiac surgery was reported in the 1980s. The purpose of this meta-analysis was to evaluate and compare the results of implementing TEG in the routine monitoring for postoperative bleeding after cardiac surgery.

Methods:
Studies involving TEG and cardiac surgery were systematically reviewed. Studies comparing TEG to conventional assessments were included in this meta-analysis and analyzed using random or fixed effect models to determine the mean difference or odds ratio.

Results:
Six studies were identified and included 1,770 patients undergoing cardiac surgery. This included 880 patients having TEG testing performed and 890 control patients without TEG testing performed. The patients undergoing the TEG assay were less likely to require transfusions of red blood cells (RBC), plasma or platelets. For these transfusions the odds ratios (OR) with confidence interval (CI) were: 0.58 (95% CI 0.46 to 0.73, p<0.01) for RBC, 0.57 (95% CI 0.45 to 0.72, p<0.01) for plasma and 0.60 (95% CI 0.48 to 0.74, p<0.01) for platelets. The number of patients requiring reexploration for bleeding was also less in the patients having TEG testing with an OR of 0.38 (95% CI 0.22 to 0.67, p<0.01). The chest tube drainage amounts were also less in the TEG patients with a mean difference (MD) of -450.1 (95% CI -875.5 to -24.7, p=0.04).

Conclusion:
Transfusion requirements for patients undergoing cardiac surgery with TEG testing were significantly less than patients undergoing conventional assessments for postoperative hemorrhage. The rate of reexploration and chest tube drainage was also significantly less for patients undergoing TEG testing.
 

43.05 Robotic-Assisted Lobectomy Outcomes for Early vs. Late Pathologic Stages of Primary Lung Cancer

Posted on January 25, 2017

B. Montane4, F. O. Velez-Cubian2, K. Toosi4, R. Gerard4, C. C. Moodie1, J. R. Garrett1, J. P. Fontaine1,2,3, E. M. Toloza1,2,3  1Moffitt Cancer Center,Thoracic Oncology,Tampa, FL, USA 2University Of South Florida Morsani College Of Medicine,Surgery,Tampa, FL, USA 3University Of Sough Florida College Of Medicine,Oncologic Sciences,Tampa, FL, USA 4University Of South Florida,Morsani College Of Medicine,Tampa, FL, USA

Introduction:   Surgical resection is still the gold standard for early stages of primary lung cancers.  More advanced stages, including nodal involvement, are approached with a multimodality therapy.  The purpose of our investigation was to determine the surgical outcomes of robotic-assisted video-thoracoscopic (RAVT) surgery for early versus late primary lung cancer stages.

Methods:   We retrospectively analyzed perioperative outcomes of consecutive patients with primary lung cancer and who underwent RAVT lobectomy by one surgeon at our institution during a 6-year period.  Patients were grouped by pathologic stage (pStage) into 4 groups:  pStage1, pStage2, pStage3, and pStage4.  Patient characteristics, operative times, intraoperative estimated blood loss (EBL), lymph node (LN) dissection, perioperative complications, chest tube duration, hospital length of stay (LOS), and in-hospital mortality were compared among the pStage groups.  Chi-square test, Student’s t-test, and Kruskal-Wallis or Mood’s median test were used, with p≤0.05 as significant.

Results:  A total of 359 patients underwent RAVT lobectomy by one surgeon between September 2010 and May 2016.  Thirty-one patients had pulmonary metastases or benign lesions and were excluded.  A cohort of 328 patients was analyzed in our study.  Patients’ characteristics differed only by pStage4 having lower body mass index (BMI; p=0.04).  Neither overall intraoperative complications nor conversion to open lobectomy differed among pStage groups (p≥0.09), although recurrent laryngeal nerve injury was highest in pStage3 (p=0.02).  Overall postoperative complications did not differ among pStage groups (p≥0.18), with the most common postoperative complication being prolonged air leak >5 days (20.5% vs. 19.4% vs. 25.0% vs. 44.4%, respectively, for pStage1 through pStage4; p=0.57).  Median EBL and median operative times were lowest for pStage1 (150 mL, p<0.001, and 162 min, p<0.001, respectively), but chest tube duration, hospital LOS, and in-hospital mortality did not differ among pStage groups (p≥0.15).  Efficacy of LN dissection was best for pStage2 and pStage3 for numbers of individual N1 (p≤0.02) and N2 (p≤0.002) LNs harvested, respectively, but did not differ among pStage groups for numbers of LN stations assessed (p≥0.16).

Conclusions:  Robotic-assisted lobectomy is feasible not only for early stages, but also as part of multi-modality treatment for more advanced primary lung cancers.  More advanced pStage, particularly LN involvement, resulted in increased EBL and longer operative times, but did not result in increased perioperative complication risk, hospital LOS, or in-hospital mortality.  Robotic-assisted lobectomy should be considered for the surgical component for multi-modality treatment of resectable advanced-stage primary lung cancers.

43.04 Simplifying Postoperative Outcome Prediction Scores In Cardiac Surgery

Posted on January 25, 2017

Y. Juo1, N. Satou1, R. Shemin1, P. Benharash1  1University Of California – Los Angeles,Cardiac Surgery,Los Angeles, CA, USA

Introduction:
The Society of Thoracic Surgeons Predicted Risk of Mortality (STS PROM) Score is developed specifically for calculation of short-term postoperative mortality and morbidity risks. It is a composite score from 35 variables encompassing demographics, baseline comorbidities, severity/complexity of primary cardiac disease, and anatomic/technical factors for specific procedures. The calculation of PROM involves a special online calculator that is beyond the immediate reach of most surgeons in a clinical setting. Here we seek to evaluate the efficacy of simpler prediction scores such as CHADS2 and CHA2DS2-VASC in comparison with PROM score.

Methods:
All adult patients undergoing cardiac surgery at a single institution from 2008 to 2015 were identified using the institutional Society of Thoracic Surgeons database. Patients receiving transplant, ECMO and ventricular assist devices were excluded.  An area under the curve (AUC) analysis  was performed to evaluate the discriminatory abilities of STS PROM, CHADS2, and CHA2DS2-VASC scores in predicting postoperative mortality, complications, major adverse cardiac events (MACE), acute renal failure, and prolonged length of stay.

Results:
4,232 patients underwent major cardiac surgery during the study period. Most common procedures were valve replacement (n=1,356, 32.04%) and coronary artery bypass grafting (n=875, 20.67%). 30-day mortality occurred in 118 (2.79%) patients while postoperative morbidity occurred in 1,686 (39.84%) patients, including 678 (16.02%) MACE, 145 (3.43%) acute renal failures, and 482 (11.39%) prolonged length of stays. The only outcome in which STS PROM Score demonstrated a larger AUC than either CHA2DS2-VASC or CHADS2 was postoperative mortality (0.82 vs 0.65 vs 0.57, p=0.0489). There was no significant AUC difference when comparing STS PROM Score against either CHA2DS2-VASC or CHADS2 when used in prediction of postoperative complications (0.60 vs 0.57 vs 0.57, p=0.48), MACE (0.55 vs 0.53 vs 0.54, p=0.60), acute renal failure (0.74 vs 0.66 vs 0.67, p=0.37), or prolonged length of stay (0.65 vs 0.67 vs 0.64, p=0.72). 

Conclusion:
STS PROM score was superior to both CHADS2 and CHA2DS2-VASC scores in prediction of postoperative mortality. There was no significant difference in the predictive value between the three prediction scores for other postoperative morbidities Furthermore, none of the scoring systems provided satisfactory discriminatory power for the prediction of complications in view of most AUC values approximating 0.5. Further investigation is required for a more parsimonious and effective morbidity prediction score. 
 

43.03 Incidence of Cerebral Microemboli in Single-Dose vs Multi-Dose Cardioplegia in Adult Cardiac Surgery

Posted on January 25, 2017

L. Mukdad1, S. Barajas1, K. Kim1, W. Toppen1, R. Gevorgyan2, H. Laks1, P. Benharash1  1David Geffen School Of Medicine, University Of California At Los Angeles,Cardiac Surgery,Los Angeles, CA, USA 2University Of California – Los Angeles,Los Angeles, CA, USA

Introduction:  Cerebral microemboli have been associated with neurocognitive deficits after cardiac operations using cardiopulmonary bypass (CPB). Interventions by the perfusionist and alterations in flow account for a large proportion of previously unexplained microemboli. This study compared the incidence of microemboli during cardiac operations using conventional (multi-dose) and Del Nido (single-dose) cardioplegia delivery. 

Methods:  Transcranial Doppler ultrasonography was used to detect microemboli in bilateral middle cerebral arteries of 14 adult patients undergoing cardiac operations using cardiopulmonary bypass and aortic clamping. Multi-dose cardioplegia (MDC) was used in 6 patients and single-dose cardioplegia (SDC) in the remaining 8. Manual count of microemboli during cross-clamp and during administration of cardioplegia was performed. Data were analyzed using STATA 13.0 statistical software (StataCorp, College Station, TX). Categorical variables were analyzed by Fisher’s exact test and continuous variables were analyzed by the independent sample T-test for unequal sample size. An alpha of < 0.05 was considered statistically significant.

Results: Baseline preoperative characteristics were similar between groups as shown in table 1. There were no differences in the ascending aortic atheroma grade (1.2 ± 0.4 MDC vs 1.6 ± 0.7 SDC, p=0.20), bypass times (141 ± 36 min MDC vs. 171 ± 33 min SDC, p=0.18), and cross-clamp times (118 ± 32 min MDC vs. 108 ± 45 min SDC, p=0.31). Use of multi-dose cardioplegia was associated with a seven-fold increase in the number of microemboli per minute of cross-clamp time (1.65 ± 1 vs 0.24 ± .18 emboli/min SDC, p=0.002). 

Conclusion: In this prospective pilot study, we found that the use of single-dose cardioplegia led to fewer cerebral microemboli when compared to the traditional multi-dose approach. This finding deserves further investigation to evaluate the benefits of single-dose delivery vs potential reduction in myocardial protection.

 

43.02 Diagnostic Imaging and Resource Utilization in Spontaneous Pneumomediastinum

Posted on January 25, 2017

K. Williams1, L. M. Baumann1, C. Stake2, R. J. Hendrickson3, F. Abdullah1,2, T. A. Oyetunji1,2  1Northwestern University,Feinberg School Of Medicine,Chicago, IL, USA 2Ann & Robert H Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 3Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction:  Primary spontaneous pneumomediastinum is a rare, often benign, self-limiting condition typically affecting the male adolescent population.  Several single-institution retrospective studies have shown that an extensive imaging workup is invariably negative and does not significantly affect clinical decision-making. It has also been shown that these children are often admitted to a critical care setting but are discharged from hospital within three days. Given the current trend toward increasing healthcare expenditure and the need for efficient resource utilization, our aim was to explore current practices in the management of spontaneous pneumomediastinum by analyzing a national database.

Methods:  The Pediatric Health Information System (PHIS) database from January 2011 to December 2015 was retrospectively analyzed.  All patients aged 10 to 21 years with a principal diagnosis of interstitial emphysema (ICD9 518.1) who were admitted for 3 days or less were included. Patient demographics, imaging studies and associated charges, as well as ICU admission, were extracted. Descriptive analysis was performed using Stata 11. 

Results: A total of 368 patients with a principal diagnosis of interstitial emphysema between the ages of 10 and 21 and a hospital LOS less than 3 days were identified. Of these, 77% were male and the mean age at admission was 12.5y(+/-4.8). 15 patients were admitted to the ICU. Among the 368 patients, 863 imaging studies were done. Chest X-ray was the imaging modality used most frequently in all patients; with 21 (5.7%) patients having 3 or more. Over a quarter of the patients (27.1%) had either esophageal or stomach and upper gastrointestinal fluoroscopy. Computed tomography scans were done in approximately 1 in 5 of the patients (18.5%). The associated cost of fluoroscopy in this population was approximately $72,222 while computed tomography added another $140,849.

Conclusion: Besides plain radiography, several other imaging modalities and some ICU care are currently being used in the management of spontaneous pneumomediastinum. This extensive resource utilization is not only expensive, but also associated with unnecessary radiation exposure, particularly for a condition that has been shown to be self-limiting in the vast majority of cases. There is therefore a need for better education and knowledge dissemination. 

 

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