29.07 Clinical Fate of T0N1 Squamous Cell Carcinoma of the Esophagus

Posted on January 25, 2017

R. Shridhar2, j. Huston1, S. Kucera1, K. Meredith1  1Florida State University College Of Medicine/Sarasota Memorial Health Care System,Gastrointestinal Oncology,Sarasota, FL, USA 2University Of Central Florida,Radiation Oncology,Orlando, FLORIDA, USA

Introduction: The long-term survival for patients with locally advanced esophageal SCC remains poor despite improvements in multi-modality care. Neoadjuvant chemoradiation(NCR) followed by surgical resection remains piviotal in the management of patients with locally advanced SCC.  Response to NCR is predictive of overall survival.  However the outcomes of patients whose primary tumor exhibits a complete response with residual regional nodal disease (T0N1) remains unclear as well as the role for adjuvant therapy. 

Methods: Utilizing the National Cancer Database we identified patients with SCC of the esophagus who underwent NCR followed by esophagectomy. Outcomes of patients with pathologic T0N1 were then compared.  Baseline univariate comparisons of patient characteristics were made for continuous variables using both the Mann-Whitney U and Kruskal Wallis tests as appropriate. Pearson’s Chi-square test was used to compare categorical variables. Survival was evaluated on the basis of time from date of diagnosis to date of death or censoring. Unadjusted survival analyses were performed using the Kaplan-Meier method comparing survival curves with the log-rank test. All statistical tests were two-sided and α (type I) error <0.05 was considered statistically significant.

Results:We identified 1,743 patients with SCC of the esophagus with a median age of 61 (25 – 83) years.  There were 1204 (69.1%) males and 539 (30.9%) females. The location was 639 (36.7%) middle, 845 (48.5%) lower, and 173 (9.9%) gastroesophageal junction.   R0 resections were achieved in 1594 (95.2%) patients and this correlated to improved survival, median survival 55.4 (RO) and 24.4 (R1) months respectively, p,0.001. The median nodes harvested were 10 (0-99) and did not correlate to an increase in survival as more nodes were resected. Complete response (pCR) was achieved in 375 (34.9%), partial response (pPR) 356 (33.2 %) and non response (pNR)297 (27.7%).  There were 45 (4.2%) patients deemed as pathologic T0N1.  The median survival of patients with pCR was 72.6 months compared to 26.3 months in the T0N1 patients p<0.001. T0N1 patients did not demonstrate an improved survival over T1-4 N1 patients who had a median survival of 21.8 months p=0.7. Adjuvant chemotherapy in T0N1 did not provide a benefit in survival, median survival adjuvant versus no adjuvant 33 vs 26.6 months respectively, p=0.7. Similarly adjuvant therapy in all node positive patients did not demonstrate significant benefit in survival p=0.1.

Conclusion:Patients with squamous cell carcinoma of the esophagus who exhibit a pathologic T0N1 after neoadjuvant chemoradiation have oncologic fates similar to node positive patients.  Patients with complete pathologic response of the primary tumor and regional lymph nodes continue to demonstrate significant survival benefits over all remaining pathologic cohorts.  Adjuvant therapy failed to improve survival in T0N1 or any node positive SCC esophageal patients.

 

29.06 Impact of Lymph Node Ratio in Selecting Patients with Resected Gastric Cancer for Adjuvant Therapy

Posted on January 25, 2017

Y. Kim1, M. H. Squires2, G. A. Poultsides3, R. C. Fields4, S. M. Weber5, K. I. Votanopoulos6, D. Kooby2, D. J. Worhunsky3, L. X. Jin4, W. G. Hawkins4, A. W. Acher5, C. S. Cho5, N. Saunders7, E. A. Levine6, C. R. Schmidt7, S. K. Maithel2, T. M. Pawlik1,7  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA 2Emory University School Of Medicine,Atlanta, GA, USA 3Stanford University,Palo Alto, CA, USA 4Washington University,St. Louis, MO, USA 5University Of Wisconsin,Madison, WI, USA 6Wake Forest University School Of Medicine,Winston-Salem, NC, USA 7Ohio State University,Columbus, OH, USA

Introduction:  The impact of adjuvant chemotherapy (CTx) and chemo-radiation therapy (cXRT) in the treatment of resectable gastric cancer remains varied.  We sought to define the clinical impact of lymph node ratio (LNR) on the relative benefit of adjuvant CTx or cXRT among patients having undergone curative-intent resection for gastric cancer.

Methods:  Using the multi-institutional U.S. Gastric Cancer Collaborative database, 769 patients with gastric adenocarcinoma who underwent curative-intent resection between 2000 and 2012 were identified. Patients with metastasis or an R2 margin were excluded. The impact of LNR on disease-free survival (DFS) among patients who received CTx or cXRT was evaluated.

Results: Median patient age was 65 years and the majority of patients were male (55.8%).  The majority of patients underwent either subtotal (40.9%) or total gastrectomy (41.4%), with the remainder undergoing distal gastrectomy or wedge resection (17.7%). On pathology, median tumor size was 4 cm; more patients had a T3 (33.5%) or T4 (28.7%) lesion and lymph node metastasis (60.6%).  Margin status was R0 in 92.2% of patients.  A total of 361 (46.9%) patients underwent surgery alone, 257 (33.4%) patients received 5-FU based cXRT, whereas the remaining 151 (19.6%) received CTx. Recurrence occurred in 236 (30.7%) patients.  At a median follow-up of 17.2 months, median disease-free survival (DFS) was 29.0 months and 5-year DFS was 34.7%. According to LNR categories, 5-year DFS for patients with LNR of 0, 0.1-0.10, >0.10-0.25, >0.25 were 52.2%, 40.0%, 43.0% and 13.9%, respectively. Factors associated with worse DFS included age (hazard ratio [HR] 1.01), tumor size (HR 1.08), tumor grade (moderate/poor: HR 1.27), GE junction (HR 1.87), T-stage (3-4: HR 2.66), and LNR (>0.25: HR 2.18) (all P<0.05). In contrast, receipt of adjuvant cXRT was associated with an improved DFS in the multivariable model (vs. surgery alone: HR 0.57; vs. CTx: HR 0.45, both P<0.001). The benefit of cXRT for resected gastric cancer was noted only among patients with LNR >0.25 (vs. surgery alone: HR 0.39; vs. CTx: HR 0.44, both P<0.001).  In contrast, there was no noted DFS benefit of CTx or cXRT among patients with LNR ≤0.25 (all P>0.05) (Figure).

Conclusion: Adjuvant CTx or cXRT were utilized in over one-half of patients undergoing curative-intent resection for gastric cancer. LNR may be a useful tool to select patients for adjuvant cXRT, as the benefit of cXRT therapy was isolated to patients with higher degrees of lymphatic spread (i.e., LNR >0.25).

 

29.05 Failure to Rescue Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

Posted on January 25, 2017

K. Li1, A. A Mokdad1, M. Augustine1, S. Wang1, M. Porembka1, A. Yopp1, R. Minter1, J. Mansour1, M. Choti1, P. Polanco1  1University Of Texas Southwestern Medical Center,Division Of Surgical Oncology,Dallas, TX, USA

Introduction: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has been shown to significantly improve the survival of selected patients with peritoneal carcinomatosis (PC). However, this invasive procedure can result in significant morbidity and mortality. Using a national cohort of patients, this study aims to identify perioperative patient characteristics predictive of failure to rescue (FTR)–mortality following postoperative complications from CRS/HIPEC.

Methods: Patients who underwent CRS/HIPEC between 2005 and 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program dataset (NSQIP). Patients who suffered any post-operative complication were identified. Major complications were defined as those corresponding to Clavien-Dindo grade III or IV. Failure to rescue (FTR) was defined as 30-day mortality in the setting of a treatable complication. Patients who suffered FTR were compared against those who survived a complication (non-FTR) using patient characteristics, pre-operative clinical information, types of resections, and severity of complication. Univariable comparisons were conducted using the Wilcoxon rank-sum test for continuous variables and the Fischer’s exact test for categorical variables. Predictors of FTR were identified using a multi-variable logistic regression model.

Results: From the NSQIP database, 915 eligible CRS/HIPEC cases were identified in the study period. Overall, 382 patients (42%) developed postoperative complications and constituted our study population. A total of 88 (10%) patients suffered one or more major complications. Seventeen patients died following a complication, amounting to an FTR rate of 4%. Patients’ age, gender, and race were similar between FTR and non-FTR groups. Colorectal cancer was the most common diagnosis in the FTR and non-FTR groups (35% vs 25%, respectively). The rates of multi-visceral resections were also similar (88% vs 86%, p=1.00). FTR patients were more likely than non-FTR patients to have dependent functional status (18% vs 2%, p=0.01), have ASA class 4 status (29% vs 8%, p=0.01), develop three or more complications (65% vs 24%, p<0.01), and suffer a major complication (94% vs 20%, p<0.01). Independent predictors of FTR were as follows: having a major complication (odds ratio [OR] 66.0, 95% confidence interval [CI] 8.4-516.6), dependent functional status (OR 5.9, 95%CI 0.8-41.9), and ASA class 4 (OR 13.4, 95%CI 1.2-146.8). Procedure type and diagnosis were not predictive of FTR.

Conclusion: Morbidity associated with CRS/HIPEC is comparable to other complex surgical procedures and has an acceptable low rate of death in this national cohort of patients. Dependent functional status and ASA class 4 are patient factors predictive of FTR. These patients have a prohibitively high risk of 30-day mortality following postoperative complications and should be considered ineligible for CRS/HIPEC.

29.04 Clinicopathologic Score Predicting Lymph Node Metastasis in T1 Gastric Cancer

Posted on January 25, 2017

T. B. Tran1, D. J. Worhunsky1, M. H. Squires2, L. X. Jin3, G. Spolverato4, K. I. Votanopoulos7, C. S. Cho5, S. M. Weber5, C. Schmidt6, E. A. Levine7, R. C. Fields3, T. Pawlik4,6, S. Maithel2, J. A. Norton1, G. A. Poultsides1  2Emory University,Atlanta, GA, USA 3Washington University In St. Louis,St. Louis, MO, USA 4John Hopkins Hospital,Baltimore, MD, USA 5University Of Wisconsin,Madison, WI, USA 6The Ohio State University,Columbus, OH, USA 7Wake Forest University,Winston-Salem, NC, USA 1Stanford University,Palo Alto, CA, USA

Introduction:  While gastrectomy with D2 lymphadenectomy is considered the standard treatment for invasive gastric adenocarcinoma, endoscopic resection (ER) has been described by Asian authors in select patients with T1 gastric cancer. Accurate preoperative prediction of lymph node (LN) metastasis in this setting is critical, since ER omits LN harvest. The objective of this study is to identify preoperative predictors of LN metastasis in US patients with T1 gastric cancer.

Methods:  Patients who underwent surgical resection for T1 gastric cancer (T1a: into lamina propria or muscularis mucosa, and T1b:  into submucosa) between 2000 and 2012 in 7 US academic institutions were identified. Clinicopathologic predictors of LN metastasis were determined using univariate and multivariate logistic regression. A preoperative score was created assigning points based on each variable’s beta-coefficient.

Results: Among 965 patients with gastric cancer undergoing surgical resection, 198 patients (20.5%) had T1 disease confirmed on final pathology.  Of those, 40 patients (20%) had LN metastasis. Independent predictors of LN involvement on multivariate analysis were poor differentiation (OR 4.5, P=0.002, beta 1.5), T1b stage (OR=4.5, P=0.02, beta 1.5), lymphovascular invasion (OR 2.8, P=0.049, beta 1.4), and tumor size > 2 cm (OR 2.8, P=0.026, beta 1.0). A clinicopathologic risk score predicting LN metastasis was created, assigning 3 points for the first 3 variables and 2 points for the last variable. The performance of the score was evaluated with an ROC curve (Figure) showing excellent discrimination (AUC = 0.79) and 100% sensitivity in detecting LN metastasis in patients with a score of 3 or less.

Conclusion: In this cohort of US patients with T1 gastric adenocarcinoma, lack of LN involvement could be predicted if none or one of the following unfavorable factors is present (T1b, poor differentiation, lymphovascular invasion, size > 2 cm). For these patients, endoscopic resection may be a potential treatment option provided it could be achieved with negative margins. 

 

29.03 Trends in major abdominal surgery for cancer in octogenarians

Posted on January 25, 2017

M. G. Neuwirth1, A. J. Sinnamon1, D. L. Fraker1, R. R. Kelz1, R. E. Roses1, G. C. Karakousis1  1Hospital Of The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA

Introduction: While there is the general perception as the population ages that we are operating on older patients for cancer, there is little data on trends in major resections for cancer in this population when adjusted for cancer incidence and short-term outcomes in this group.

Methods: The Nationwide Inpatient Sample was used to estimate the national trends of major abdominal resections for cancer in octogenarians from 2000 through 2011 including pancreatic resections, total gastrectomies, hepatectomies, and total colectomies.  Partial resections of the stomach, colon and liver lobes were excluded in order to target a subset of elderly patients undergoing comparably morbid procedures.  Rates of resections performed per year were incidence-adjusted to the US incidence among octogenarians for each cancer type as determined by the SEER registry.  Joinpoint regression was used to calculate annual percentage change (APC) and average annual percentage change (AAPC) when evaluating trends over time.

Results:Over the study period, an estimated 17,002 major abdominal organ resections for cancer were performed in patients 80 or older in the U.S, 44.2% were pancreatic resections, with 27.9% total gastrectomies, 18.2% total colectomies 9.5% and major liver resections.   The estimated number of resections per year in the elderly increased substantially over time from 732 in 2000 to 1848 in 2011 (APC=8.0%, p<.01) along with an increase in Elixhauser comorbidities in this group from a mean of 2.3 in 2000 to 3.4 in 2011 (APC=3.5, p<.001).  However, inpatient mortality during this time decreased in octogenarians from 23.5% to 18.1% (AAPC=-1.8, p<.001) with the most significant decrease over the latest 5 years of 2007 to 2011 (APC =-6.97, p<.001).  Pancreatic resections increased at the fastest rate in elderly patients, APC=11.3, p<.001, fatality rates decreased from 15.6 to 7.8% (APC= -6.2, p<.001).  Major liver resections and total with incidence of pancreatic cancers in this age group increasing by 21.2% and colectomies increased slightly (APC=4.28, p=.1 and APC=3.37 p<.001 respectively).  Total gastrectomies for cancer decreased over time in this population, although the trend was not significant (APC=-.5, p=.8), and fatality rates also decreased during this time from 17.1 to 12.6%, with a significant decrease over time from 2004 to 2011 (APC=-8.0, p<.001). 

Conclusion:Major abdominal resections for cancer are increasing over time in octogenarians at a disproportionally higher rate than respective increases in incidences of cancer diagnoses, and with a concurrent significant decrease in 30-day in-patient mortality rates. This pattern may suggest a shifting selection criterion for elderly surgical patients with time.

29.02 Preoperative Enteral Access is not Requite Prior to Multimodality Treatment of Esophageal Cancer

Posted on January 25, 2017

T. K. Jenkins4, A. N. Lopez4, G. A. Sarosi1,2, K. Ben-David3, R. M. Thomas1,2  1University Of Florida,Department Of Surgery,Gainesville, FL, USA 2North Florida/South Georgia Veterans Health System,Department Of Surgery,Gainesville, FL, USA 3Mount Sinai Medical Center,Department Of Surgery,Miami Beach, FL, USA 4University Of Florida,College Of Medicine,Gainesville, FL, USA

Introduction:  While prior research has shown that preoperative (preop) enteral access is feasible and safe in patients to support their nutrition prior to esophagectomy, controversy exists regarding its necessity, as subjective dysphagia is a poor indicator of need for enteral access. We hypothesized that patients who underwent preop enteral access prior to esophagectomy for cancer fared no better than those who had surgical enteral access performed at the time of esophagectomy.

Methods: An IRB approved retrospective database of patients undergoing esophagectomy for esophageal malignancy from 2007-2014 was established. Clinicopathologic factors were recorded including preop enteral access, weight change, nutritional labs, preop cancer stage, operative details, and perioperative complications.

Results: One hundred fifty-six patients were identified, of which 99 (63.5%) received preop chemoradiation (cXRT) prior to esophagectomy. Since preop cXRT can influence perioperative nutrition, this group comprised the study cohort. Fifty (50.5%) underwent preop enteral access [esophageal stent (1), gastrostomy (14), jejunostomy (32), nasoenteric (1), combination (2); “access group”] prior to cXRT followed by esophagectomy and feeding jejunostomy unless it was pre-existing. There was no difference in demographics, preop tumor staging, or operative details between the access and non-access groups. No difference was noted between access and non-access groups in subjective dysphagia [n=43 (86%) vs 37 (75.5%), respectively; p=0.2)] or mean preop serum albumin (gm/dl) [3.9 (range 3.1-4.5) vs 4 (range 3.3-6.4), respectively; p=0.2]. To account for potential cXRT delays, there was no difference in median time from diagnosis to surgery in the access vs non-access groups (126d vs 126d, p=0.5). Comparing weight loss 6mo preop to surgery, the access group had a mean 5.2% weight loss (range -29.4 – +6.6%) vs 4.5% reduction (range -19.4% – +68.2%) in the non-access group (p=0.8). Additionally, mean weight loss 6mo preop to 6mo postop was similar in the access vs non-access groups [-11.2% (range -44% – +5.3%) vs -15.4% (range -34.1% – -1.4%), respectively p=0.1].  Complication rates between access and non-access groups (64% vs 51%, respectively; p=0.2) were likewise similar.  In patients with reported dysphagia, there was no difference in weight change 6mo preop to 6mo postop in the access vs non-access group (-11% vs -15.2%, p=0.1; respectively).

Conclusions: Despite the bias of establishing enteral access prior to preop cXRT for esophageal malignancy in candidates for esophagectomy, there was no difference in weight change, preop albumin, or complication rates in patients who had preop enteral access versus those who did not. Patients with esophageal malignancy should therefore proceed directly to appropriate neoadjuvant and surgical therapy with enteral access performed at the time of definitive resection or reserved for those with obstruction confirmed on endoscopy.

29.01 Prognostic impact of pancreastatin following chemoembolization for neuroendocrine tumors

Posted on January 25, 2017

D. S. Strosberg1, J. Onesti4, N. Saunders3, G. Davidson1, M. Shah5, M. Dillhoff1, C. Schmidt1, M. Bloomston2, L. A. Shirley1  1The Ohio State University Wexner Medical Center,Surgical Oncology,Columbus, OH, USA 221st Century Oncology,Fort Meyers, FL, USA 3Emory University School Of Medicine,Atlanta, GA, USA 4Mercy Health Grand Rapids,Grand Rapids, MI, USA 5The Ohio State University Wexner Medical Center,Medical Oncology,Columbus, OH, USA

Introduction: Transarterial chemoembolization (TACE) is a viable treatment option for patients with metastatic neuroendocrine tumors (NETs) to control tumor progression and palliate symptoms of hormone excess.  Pancreastatin, a split product of chromogranin, has been shown to correlate with survival in patients with NETs. The objective of this study was to investigate the prognostic impact of pancreastatin levels in patients with metastatic NETs treated with TACE.

Methods: Patients with metastatic NET treated with TACE at a single institution from 2000 to 2013 were analyzed. Clinical variables were analyzed with Chi-square, Fisher Exact, or independent T-test as appropriate.  Kaplan-Meier curves for overall survival (OS) were analyzed using log-rank testing for curve differences.

Results: 188 patients underwent TACE for metastatic NETs during the study period.  An initial pancreastatin level greater than 5000 pg/mL correlated with worse OS from time of first TACE (Median OS 58.5 months vs 22.1 months, p<0.001). A decrease in pancreastatin levels by 50% or more after TACE treatment correlated with improved OS (Median OS 53.8 months vs 29.9 months, p=0.032). Patients with carcinoid syndrome were more likely to have a subsequent increase in pancreastatin after initial drop post-TACE (percent of patient with increase 78.1% vs 55.2%, p=0.002). Patients who had an increase in pancreastatin levels after initial drop post-TACE were also more likely to have liver progression on axial imaging (70.7% vs 40.7%, p=0.005) as well as more likely to need repeat TACE (21.1% vs 6.7%, p=0.009).

Conclusion: For patients with liver metastases from NET, measurement of pancreastatin levels can be useful in several steps during potential TACE treatment.  Extreme high levels prior to TACE can predict poor outcomes, significant drops in pancreastatin after TACE correlate with improved survival, and a rise in levels after initial drop may predict progressive liver disease requiring repeat TACE.  As such, pancreastatin levels should be measured throughout the TACE treatment period.

 

28.10 Should hepatectomy for breast cancer metastasis be standard treatments? A propensity score analysis.

Posted on January 25, 2017

T. Cheung1, W. Dai1, S. H. Tsang1, W. She1, A. C. Chan1, K. S. Chok1, C. Lo1  1The University Of Hong Kong,Hong Kong, HONG KONG, Hong Kong

Introduction:  

Survival of patients with carcinoma of the breast with liver metastases is very poor. This study aimed to analyze the survival outcome of hepatic resection for this patient population.

Methods:

From January 1995 to December 2014, 773 patients with (Non HCC) liver cancer received hepatectomy at our hospital. Twenty-one of them, all female, received the operation for breast cancer liver metastases. Performance were compared with patients with colorectal liver metastases treated with hepatectomy after propensity score analysis in a ratio of 1:3.

Results:

Twenty one patients received hepatectomy for breast cancer. After propensity score matching, sixty three patients who had hepatectomy for colorectal cancer were selected for comparison. There was no significant different in immediate short term outcome between the 2 groups of patients in term of operation time, blood loss and surgical morbidities. All patient with breast cancer had R0 resections. No hospital death occurred. After hepatectomy, the 1-year, 3-year and 5-year survival rate was 100%, 58.9% and 58.9% in patients with CA breast.  The 1-year, 3-year and 5-year survival rate was 95%, 57.2% and 39.7% respectively in patients with CA colon (p=0.572). Multivariate analysis showed that all PR, ER and HER negative was an independent significant factor for poor survival (p=0.027; hazard ratio, 5.58; confidence interval, 1.21-25.73).

Conclusion:
Hepatic resection is a safe and effective treatment for breast cancer liver metastases. It should be considered more frequently as part of the multidisciplinary care for this patient population.
 

28.09 Mortality of Severely Injured Adult Trauma Patients in Two Countries: Does Age Matter?

Posted on January 25, 2017

M. Dasari1, S. D. David2, J. Puyana1, N. Roy2  1University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA 2TATA Institute Of Social Sciences,School Of Habitat,Mumbai, MAHARASHTRA, India

Introduction:  The mean age of trauma patients can differ significantly between countries, based on prevalent mechanisms of injury and other factors. The differences in mortality based on age and country have not been analyzed previously. We hypothesized that severely injured trauma patients in India and the United States (US) have different risks of mortality based on age and mechanism of injury. 

Methods:  Two urban trauma registries from India (n=11,670), and the United States (n=14,155) between 2013-2015 were analyzed for patients with an Injury Severity Score (ISS) ≥ 15. We stratified patients into three age groups: 18-44, 45-64, and greater than 65 years of age. The primary outcome of in-hospital death was analyzed for the three most prevalent mechanisms of injury in both countries: falls, motor vehicle collisions (MVC) and assaults. Logistic regression was performed across the three age groups to compare the odds of death between the two countries while controlling for ISS.

Results: 1,709 patients from India and 1,526 patients from the U.S. met inclusion criteria.  The mean age in India was 38.7 years (IQR: 25-49) and 55.2 years in the US (IQR: 35-73). Indian patients had a higher proportion of in-hospital death for all age groups and all mechanisms. Age-stratified mortality increased with age group in both countries for both falls and MVCs.  Indian patients had higher age-stratified mortality than US patients who sustained falls or were in MVCs across all age groups; however, there was no significant difference in age-stratified mortality between the two countries who were victims of assault. After controlling for ISS, Indian patients in the 45 to 64-year age group had 6.7 times the odds of in-hospital death than US counterparts in the same age group; this was the highest odds of ISS-adjusted mortality across all other age groups and both countries (Table 1).

 

Conclusion:  Increasing age group consistently correlated with increased age-stratified mortality for severely injured patients who sustained falls and MVCs in both countries. Significantly higher age-stratified mortality for falls and MVCs in India for all age groups suggest that there are pre-hospital and/or risk factors affecting adult patients who fall or are involved in MVCs in India that are different in the US. The adjusted odds of death was the highest within the 45 to 64-year age group in India. Differences in these pre-hospital and injury risk factors for fall and MVC patients, as well as the injuries affecting the middle age cohort in India compared to the US, can be an important subject of future research and injury prevention.
 

28.08 Road Traffic Injuries: Cluster Randomized Countrywide Population Data from 4 Low-Income Countries

Posted on January 25, 2017

S. Zafar3, J. Canner2, N. Nagarajan1,2, G. SOSAS4 Research4, A. L. Kushner4  1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Johns Hopkins University School Of Medicine,Center For Outcomes Research,Baltimore, MD, USA 3Howard University College Of Medicine,Surgery,Washington, DC, USA 4Surgeons OverSeas,New York, NY, USA

Introduction:
Road traffic injuries (RTI) are the leading causes of morbidity and mortality in people under the age of 45 years. The burden is highest in low and middle-income countries (LMICs) and is increasing. We aimed to describe the epidemiology of RTIs in 4 low-income countries using recent nationally representative survey data.

Methods:
The Surgeons Overseas Assessment of Surgical Needs (SOSAS) survey tool was administered in four countries: Sierra Leone, Rwanda, Nepal and Uganda. We performed nationally representative cross-sectional, cluster randomized surveys in each country. Information regarding demographics, injury characteristics, anatomic location of injury, healthcare seeking behavior, disability from injury, and injury-related deaths was collected. Data were reported with descriptive statistics and evaluated for differences between the four countries using statistical tests where appropriate.

Results:
A total of 13,765 respondents from 7,115 households in the four countries were surveyed. RTIs occurred in 2.2% (95% CI , 2.0-2.5%) of the population and accounted for 12.9% (95% CI: 11.5-14.2%) of all injuries incurred. The mean age was 34 years (standard deviation ±1years);74% of road injured were male. Motorcycle crashes accounted for 44.7% of all RTIs. The body regions most affected included head/face/neck (36.5%) followed by extremity fractures (32.2%). Healthcare was sought by 78% road injured; 14.8% underwent a major procedure (i.e., a procedure requiring anesthesia). Serious disability (resulting in limitations of work or daily activity) occurred in 38.5% (33.0-43.9%). Three of the four countries reported death data (death data was not reported from Rwanda). RTIs accounted for 2.5% (95% CI 1.8-3.3%) of all deaths and 40.6% (95% CI; 30.8-50.4%) of all injury-related deaths. Healthcare was sought prior to death by 68% of road injured. Of those who died, a surgical procedure was not performed even when indicated due to lack of finances in 29% of people. In 57% of cases the patient died before arrangement could be made. 

Conclusion:
RTIs account for a significant proportion of death and disability from injury. Younger men are most affected, raising concerns for potential detrimental consequences to local economies. Prevention initiatives are urgently needed to stem this growing burden of disease; additionally, access to timely emergency, trauma and surgical care may help alleviate the burden for RTI in LICs.
 

28.07 Long-term follow-up is possible for short-term surgical trips

Posted on January 25, 2017

J. S. Broecker1, J. Rappaport1, W. Liu1, C. Poorman1, M. Lagina1, L. Philipp1, J. Srinivasan2, J. Sharma2  1Emory University,School Of Medicine,Atlanta, GA, USA 2Emory University,Department Of Surgery,Atlanta, GA, USA

Introduction:

Achieving adequate follow-up for surgical patients is challenging in resource-poor environments, especially for short-term surgical trips. The aim of this study was to evaluate the extent of follow-up for a short-term surgical trip, to evaluate the success of using mobile phones to reach patients at least one year post-operatively, and to evaluate post-surgical quality of life.  

Methods:
At a single institution, the School of Medicine and Department of Surgery have provided surgical care yearly to patients at a public hospital in the central plateau of Haiti since 2008. During the 2016 surgical trip, operative patients from 2014-2015 trips were called on mobile phones to invite to clinic for further evaluation. Patients who were unable to return to clinic were interviewed over the phone. Clinical data from patients’ clinic visits or phone interviews were then reviewed. Post-surgical quality of life was determined using an institution-generated tool that measured patients’ ability to perform activities of daily living (ADLs). For patients who underwent a prostatectomy, the tool also incorporated the International-Prostate Symptom Score (I-PSS), and measured the extent of obstructive urinary symptoms. 

Results:

With a mean length of follow-up of 17.8 months (range: 3-60), follow-up was achieved in 34 (28%) of 122 operative patients. 19 (56%) of these patients returned to clinic, 25 (74%) were able to be reached by phone, and 2 (6%) were reached via another source. Prior to using mobile phones to facilitate follow-up, during 2014 and 2015 clinics, four post-operative patients followed-up in clinic. Follow-up patients had received the following operations: 14 (41%) inguinal hernia repair, 8 (24%) open prostatectomy, 5 (15%) lipoma removal, 2 (6%) hydrocelectomy, 1 (3%) cystoscopy and dilation, 1 (3%) celiotomy for bilateral kidney stone obstruction, 1 (3%) meatoplasty, and 1 (3%) drainage for enlarged cervical lymph nodes.  Mean age was 44 (range: 6-76). Mean minutes of travel time for patients was 65 minutes (range: 5-300 minutes); and the majority of patients used motorcycle to travel to clinic. There was a 41% improvement in patients’ ability to complete activities of daily living (ADLs) and a 38% reduction in patients who reported pain from the pre-operative to the post-operative time period. Among the prostatectomy patients, 7 (88%) pre-op vs 0 post-op were catheter-dependent.  

Conclusion:

Achieving long-term follow-up for operative patients following short-term surgical trips is challenging but mobile phones facilitate patient follow-up. Barriers encountered that limited the extent of patient follow-up included language barriers, limited means of communication with patients, far distance for patients to travel, and limited time in country. The follow-up data obtained demonstrates that quality of life appears to improve after short-term surgical trips.  

28.06 Global Capacity Building and Environmental Protection Through Salvage of Operating Room Supplies

Posted on January 25, 2017

J. Bailey1, P. Johnston1, M. Maloney1, A. Panigrahi1, A. V. Gore1, Z. Sifri1  1New Jersey Medical School,Newark, NJ, USA

Introduction:  Many opened operating room (OR) supplies are not used during surgery due to bulk packaging, unanticipated findings leading to a change in strategy, or case cancellation. These unused supplies are disposed of despite remaining free from biohazards and often sterile, resulting in environmental burden and disposal cost. It is estimated that approximately two million pounds of recoverable supplies worth over $15 million are disposed of annually at the average academic medical center. These same supplies are in need in many low- and middle-income countries (LMICs) where humanitarian teams use donated funds to purchase similar items. We hypothesized that implementation of a material salvage program could reduce the environmental burden of the OR while financially benefitting the academic medical center, humanitarian organizations, and LMICs.

Methods:  Volunteers planned the salvage of clean, non-sterile items that were previously discarded as medical waste. Goals were widespread implementation and ease of collection as to not place additional burden on the OR staff.  Signage was posted at central locations in the OR to educate on the purpose of and to encourage participation in the program.  Bins were located centrally, labeled for supply collection and emptied twice weekly. Supplies were then weighed, inventoried, and packaged for utilization in resource poor areas. The cost of shipment was covered by fundraising efforts of global heath medical-student interest groups.

Results: Materials were salvaged from 14 operating rooms at an urban academic medical center for 107 consecutive days in 2016. In total, 909 pounds of supplies were collected, of which 854 pounds (94%) were salvageable materials, with 54 pounds (6%) deemed unusable. Annualizing these data, this program would lead to salvage of approximately 1.5 tons of usable materials per year for a savings of more than $500 in waste disposal. Of the materials salvaged, 70% were OR supplies, 17% were wound care supplies, and 13% were personal protective equipment. To date, these supplies have been shipped to Ecuador for disaster relief following the recent earthquakes, to Ebola endemic areas for personnel protection, and for capacity building and support for short-term surgical missions in LMICs. Total investment is 7 hours per month, and less than $100 per year.

Conclusion: Implementation of a program to salvage OR supplies from a single hospital generated a significant amount of usable materials to support surgical care in LMICs with minimal cost and time investment. There is a financial benefit to hospitals in decreasing waste disposal costs and to humanitarian teams in decreasing purchasing costs of supplies. The cumulative environmental benefit of salvaging items that would have been disposed of is significant. Ancillary benefits of providing these materials for disaster relief or short-term surgical missions still need to be quantified to fully evaluate the impact of this program.

28.04 The Surgical Experience Aboard USNS Comfort (T-AH 20) During Operation Continuing Promise 2015

Posted on January 25, 2017

R. D. Restrepo1,3, L. M. Fluke1, H. I. Pryor2,3, J. E. Duncan2, K. E. Mann1,3  1Naval Medical Center Portsmouth,Department Of General Surgery,Portsmouth, VA, USA 2Walter Reed National Military Medical Center,Department Of General And Pediatric Surgery,Bethesda, MD, USA 3Uniformed Services University Of The Health Sciences,Department Of Surgery,Bethesda, MD, USA

Introduction:   As part of a recurring humanitarian assistance mission designated Continuing Promise 2015 (CP15), the United States Navy hospital ship USNS Comfort (T-AH 20) deployed to a total of eleven Caribbean and Latin American countries over a six-month deployment. U.S. Navy medical personnel and surgeons, in addition to those from non-governmental organizations, collaborated to offer humanitarian surgical and medical care at each mission stop. We describe the collective surgical experience while aboard during CP15.

Methods:   The data analyzed included all patients evaluated and treated by the Directorate of Surgical Services (DSS) of the USNS Comfort between 11 April 2015 and 17 September 2015. A medical chart was created for each patient screened for surgery and these records were utilized for this analysis. Comparative and descriptive statistics were performed to analyze patient demographics, surgical subspecialty performing the procedures, types of General and Pediatric surgical procedures performed by the thirteen operating surgeons, operative times, and complication rates.

Results:  Of the 1,256 surgical cases performed aboard USNS Comfort during CP15, 24.8% were General Surgery cases, followed by 16% Ophthalmology, 10.6% Pediatric Surgery, 10% Plastic Surgery, and eight additional specialties with <10% of the cases each. For General Surgery, the most common procedure was inguinal hernia repair (27.6%) followed closely by laparoscopic cholecystectomy (28.2%) and ventral/incisional/umbilical hernia repair (23.4%).  The most common procedures within the other specialties respectively were phacoemulsification/cataract excision (64.1%), inguinal hernia/hydrocele/orchidopexy (48.5%), and soft tissue/scar excisions/revisions (38.1%) Total operative time was 1253 hours with a total room time of 1896.5 hours.  The identified complication rate was very low at 1.99% across all specialties. 

Conclusion:  The USNS Comfort platform offers a unique capability to provide vital humanitarian surgical assistance in the Caribbean and Latin American region, greatly enhancing the lives of those that received this world-class care.  Future missions will benefit greatly from continued access to surgical assets.  

 

28.03 Multinational Validation of the AAST Appendicitis Severity Grade in a Pediatric Population

Posted on January 25, 2017

M. C. Hernandez1, S. F. Polites1, J. M. Aho1, V. Y. Kong2, D. Clarke2, M. Zielinski1  1Mayo Clinic,Department Of Surgery,Rochester, MN, USA 2Pietermaritzburg Metropolitan Complex,Department Of Surgery,Durban, KWA-ZULU, South Africa

Introduction:

Acute appendicitis is the most common emergent pediatric surgical condition but lacks a standard classification for disease severity.  The American Association for the Surgery of Trauma (AAST) developed an emergency general surgery grading system for various diseases including appendicitis. We aim to determine if the AAST grading system is valid in a heterogeneous, pediatric population in Minnesota, USA and KwalaZulu Province, South Africa.

Methods:

Retrospective review of electronic databases for patients <18 years old with acute appendicitis presenting during 2008 to 2016 was performed. Basic demographics, preoperative physiologic and symptom data, procedure details, postoperative complications based upon NSQIP and Clavien-Dindo classification were recorded. AAST grades were generated based upon intraoperative findings. Summary statistical univariate and nominal logistic regression analyses were performed to compare AAST grade and outcomes.

Results:
A total of 732 patients were identified with median [IQR] age of 11 [9-13], 59% male. Appendectomy was performed in all patients; 57.9% laparoscopic, 25.1% McBurney incision, and 17% midline laparotomy. Increasing AAST grade was associated with increasing incidence of complication severity as described by Clavien Dindo, p=0.001. The most frequent complications were surgical site infection (7.9%), abscess formation (4.5%), pneumonia (4.3%), and acute renal failure (1.7%). Patients with postoperative complications had greater median [IQR] AAST grades than those without, (4 [2-5] vs 1 [1-2], p=0.001). Median length of stay was increased for patients with higher AAST grade (V vs I) (10 vs 1 days, p=0.001). Nominal logistic regression identified the following predictors of any complication included (p<0.05): AAST grade, preoperative duration of symptoms, and initial temperature.

Conclusion:
The AAST appendicitis grading system is valid in a multinational pediatric population and increased grade is associated with patient outcomes. Increasing grade is associated with increased risk for complication. Preoperative imaging warrants validation with operative findings.

28.02 Global Users, Usage, and Importance of an Anesthesia Smartphone App

Posted on January 25, 2017

V. O’Reilly-Shah1,2, S. Gillespie1, G. Easton1  1Emory University School Of Medicine,Anesthesiology,Atlanta, GA, USA 2Children’s Healthcare Of Atlanta,Pediatric Anesthesiology,Atlanta, GA, USA

Introduction: The rapid global adoption of mobile health (mHealth) smartphone apps by healthcare providers presents challenges and opportunities in medicine. Ensuring the delivery of high-quality, up-to-date, and optimized information is the obligation of authors, regulatory bodies, and the biomedical community itself. Studying apps to achieve these goals carries accompanying opportunities to study medical practice patterns, access to medical and surgical care, and continuing medical education needs on a large scale.

 

Methods: We studied users of Anesthesiologist, a free Android app providing age and weight based guidelines for airway equipment, physiological reference data, and drug dosing. It is installed on ~100,000 devices globally. We combined traditional app analytics with basic app user demographics collected via in-app surveys.

 

Results: 39,181 users updated the app to the study version, 22,572 (58%) subjects consented to enrollment. Users were from 192 countries and included all levels of healthcare providers. Individuals from low-, middle-, and high-income countries (as defined by the World Bank) represented 3%, 63%, and 33% of users, respectively. Users from lower income countries had significantly greater rates of app use and higher ratings for the importance of the app to their practice (p<0.01). Significant differences were also found in the rate of app use and app importance based on provider type (p<0.01), with less training generally correlating with higher rates of app use and higher scoring of app importance. App importance itself was significantly correlated with greater app use (p<0.01). 72% of users report having used the app in an emergency, supported by data indicating app activations during evenings and weekends. Time of app use peaks in the morning, indicating a high level of use for routine cases as well. The app was primarily used for pediatric cases, with 71% of uses involving patients less than 12 years old, and 28% under 12 months. Mining 482,975 app uses, we detected rare events such as interest in intralipid (n=287 clicks) and dantrolene (n=162). The most common searches, however, were related to commonly used drugs such as succinylcholine (n=1191 clicks), fentanyl (n=1250) and propofol (n=1293).

 

Conclusions: Combined demographics and app analytics collected from this widely used mHealth app provided a window into the detailed app usage habits of global anesthesia healthcare providers. These findings demonstrate that this mHealth app is a valuable decision support tool for global healthcare providers in both routine and emergency patient management, particularly those in more resource-limited settings and with less training. Current usage indicates that the app supports decision-making in pediatrics far better than in adults, indicating an opportunity for feature expansion to meet the needs of adult physicians and providers.

27.10 Taking Control of Your Surgery: The Impact of a Prehabilitation Program on Major Abdominal Surgery

Posted on January 25, 2017

Y. S. Yin1, L. McCandless1, S. Wang1, M. Englesbe1, D. Machado-Aranda1  1University Of Michigan,Surgery,Ann Arbor, MI, USA

Introduction: Surgery causes physiologic stress similar to intense exercise. When the body’s aerobic and metabolic demands are not met, organ dysfunction may occur and lead to unfavorable complications, or worse, potential deaths. The severity of this outcome is largely determined by a patient’s cardiopulmonary reserve. Current preoperative workup focuses mainly on screening and identifying risk factors. Little attention has been devoted to improve cardiopulmonary reserve beyond counseling. We propose that patients could be optimized for a “surgical marathon” similar to preparing an athlete for a sports competition.

Methods: Retrospective demographic, (first hour) intra-operative and post-operative data were obtained from patients who underwent colectomy from 2014-2015 and divided into three observational groups: (1) Emergency; (2) Elective Non-Prehabilitation and (3) Elective with Prehabilitation. Enrollment into the prehabilitation program was completely voluntary for both physicians and patients, and referrals were made 4-6 weeks prior to scheduled operation. This program consisted in the following components: 1) MOVE, physical activity measured by a pedometer; 2) BREATHE, pulmonary rehabilitation using an incentive spirometer; 3) EAT, a dietary and 4) RELAX, a stress-reducing – coaching program. Progress was followed by nurse coordinators and compliance was measured by the frequency of engagement into the web portal.

Results: Age, gender, ASA-grade, BMI, operative time, IV fluids and blood loss were similar in all three groups. At 1-hour post-anesthesia, positive physiologic responses characterized by higher systolic and diastolic blood pressure(s) and lower heart rate were observed in the prehabilitation cohort. Mortality was similar in all three groups (~3 %). However, the rate of complications was significantly reduced [14.2 vs. 45%; RR: 0.31 (95% CI: 0.13 – 0.71); p = 0.0082] in the prehabilitation group as compared to non-prehabilitation elective patients. This further allowed a significant reduction in the length of stay [5 days vs. emergency (p < 0.05) and 2 days vs. other elective surgery (p=0.11)]. Hospital savings averaged $6800, which amply offset any cost incurred with the program ($600/patient). In addition, the prehabilitation program was viewed favorably by patients, with a compliance rate of 70%.

Conclusions: Prehabilitation showed positive physiologic effects during first hour of surgery in colectomy patients. Patients engaged in a systematic optimization program experienced an improvement in their clinical outcomes with hospitals being benefited by a shorter length of stay and a reduction in costs. 

27.09 Early Operative Management of Perforated Appendicitis is Associated with Improved Surgical Outcomes

Posted on January 25, 2017

M. M. Symer1, J. Abelson1, T. Sun2, A. Sedrakyan2, H. Yeo1,2  1Weill Cornell Medical College,Surgery,New York, NY, USA 2Weill Cornell Medical College,Healthcare Policy And Research,New York, NY, USA

Introduction: Acute appendicitis is one of the most common surgical diseases in the U.S., with up to 30% of patients presenting with perforation. Recent data suggests that it is safe to treat some patients with antibiotics alone. Despite this, there is no consensus on the optimal timing of surgical management. We evaluated 1-year outcomes in early versus delayed surgery for perforated appendicitis in a large administrative database.

Methods: We analyzed the New York Statewide Planning and Research Cooperative database, an all-payer, in- and out-patient longitudinal database which captures all admissions and surgical procedures in New York State. ICD-9 codes were used to identify all patients undergoing appendectomy for perforated appendicitis from 2000 to 2013. Primary outcome was any complication within one year of follow up. Secondary outcomes included length of stay, hospital charges, utilization of laparoscopy, and conservative management failure rate. Outcomes were compared in patients undergoing appendectomy before or after 48h from admission.

Results:31,167 patients ≥18 y.o. age were identified for analysis, 28,015(89.9%) of whom underwent early appendectomy. Patients undergoing immediate appendectomy were more likely to be male (54.8% vs. 45.2% p<0.01), white (69.8% vs. 64.2% p<0.01), and have commercial insurance (53.1% vs 45.4%, p<0.01). Of the 3152 patients initially managed nonoperatively, 1610(51.1%) required surgery on their index admission and an additional 715(22.7%) were readmitted urgently and underwent appendectomy at another admission (failure of conservative management). Only 827(26.2%) made it to interval appendectomy within one year of index admission. Patients undergoing late appendectomy were more likely to have at least one complication (47.9% vs. 33.2%, p<0.01) and less likely to have a laparoscopic procedure (40.0% vs 42.1%, p=0.03). After multivariate adjustment, patients undergoing delayed surgery were more likely to have a complication (OR 1.56 95%CI 1.43-1.69), be readmitted (OR 1.55 95%CI 1.42-1.70), have high hospital costs (OR 4.79 95%CI 4.35-5.27), and have a prolonged length of stay (OR 6.12 95%CI 5.61-6.68).

Conclusion:While recent data have suggested that non-operative management or delayed operative management of appendicitis is safe, there is a paucity of real world data on this topic. In this population-level study of early versus late appendectomy in adults with perforated appendicitis we demonstrate more complications, longer length of stay, and higher costs in patients who do not undergo immediate surgery.

 

27.08 Nationwide Analysis of Active Adrenal Tumors Highlights Perioperative Morbidity in Pheochromocytoma

Posted on January 25, 2017

P. P. Parikh1, G. A. Rubio1, J. C. Farra1, J. I. Lew1  1University Of Miami Miller School Of Medicine,Endocrine Surgery,Miami, FL, USA

Introduction:  Adrenal adenomas are benign neoplasms commonly discovered incidentally on radiologic studies, and >70% are hormonally inactive. The remaining subset of adrenal adenomas, however, is commonly associated with excess production of aldosterone, cortisol or catecholamines. Perioperative outcomes following adrenalectomy for excess hormone producing or “hormonally active” adrenal tumors have not been well defined. This study examines in-hospital outcomes after unilateral adrenalectomy in patients with hormonally active adrenal tumors.  

Methods: A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample database (2006-2011) to identify patients who underwent unilateral open or laparoscopic adrenalectomy for a hormonally active or inactive adrenal adenoma. Malignant adrenal tumors were excluded. Patient demographic, comorbidities and postoperative complications were evaluated by univariate and risk-adjusted multivariate logistic regression. Univariate analyses included two-tailed Chi-square and t-tests.

Results: Of 27,312 patients who underwent adrenalectomy during the 5-year period, 78% (n=21,279) had hormonally inactive and 22% (n=6,033) had hormonally active adrenal tumors. Among patients with hormonally active adrenal tumors, 65% (n=4000) had primary hyperaldosteronism (Conn’s Syndrome), 33% (n=1996) had hypercortisolism (Cushing’s Syndrome) and 1.4% (n=85) had pheochromocytoma. Patients with pheochromocytoma had a higher rate of chronic lung disease and malignant hypertension compared to the remaining hormonally active adrenal patients (18% vs 10%, 6% vs 2%; P<0.01). Pheochromocytoma patients also required more blood transfusions intraoperatively than patients with other hormonally active tumors (21% vs 3%; P<0.01). Pheochromocytoma patients also had more postoperative cardiac (6% vs 0.5%; P<0.01) and respiratory complications (17% vs 7%; P<0.01) than patients with other hormonally active tumors. Mean length of stay was 5 versus 3 days for pheochromocytoma patients compared to the remaining adrenal patients, respectively (P<0.01). Furthermore, total in-hospital cost was approximately $50,000 for pheochromoctyoma patients compared to $39,000 for their counterparts, respectively (P<0.01). On risk-adjusted multivariate logistic regression, pheochromocytoma had an independently higher risk for intraoperative blood transfusion (4.2, 95% CI 2.4-7.2) and postoperative respiratory (1.9, 95% CI 1.0-3.3) and cardiac (7.6, 95% CI 2.8-20.2) complications.

Conclusion: Among benign hormonally active adrenal tumors, patients with pheochromocytoma have a high rate of preoperative comorbidities, contributing to significant postoperative cardiopulmonary complications that ultimately lead to longer and more expensive hospitalizations. Such patients at high risk should undergo appropriate preoperative medical optimization and counseling in preparation for adrenalectomy. 

 

27.07 Intraoperative PTH Spikes During Parathyroidectomy May Be Associated with Multigland Disease

Posted on January 25, 2017

R. Teo1, J. C. Farrá1, O. P. Roque1, A. R. Marcadis1, J. I. Lew1  1University Of Miami,Division Of Endocrine Surgery,Miami, FL, USA

Introduction: Intraoperative parathormone (ioPTH) monitoring is widely used to predict operative success for targeted parathyroidectomy (PTX) using a >50% PTH drop criterion in patients with primary hyperparathyroidism (pHPT). However, the significance of ioPTH “spikes” at the pre-excision measurement during targeted PTX, commonly from gland manipulation by the surgeon, remains unclear with the assertion that multigland disease (MGD) may be missed. This study compares targeted PTX with and without ioPTH spikes using the >50% PTH drop criterion, and determines the effect of ioPTH spikes on operative outcome.

Methods: A retrospective review of prospectively collected data of 783 patients who underwent targeted PTX guided by ioPTH monitoring for pHPT confirmed by elevated serum calcium and parathormone (PTH) levels was performed. All patients had >6 months of follow-up with a mean of 42 months. When a >50% drop from the highest pre-incision or pre-excision PTH level was achieved at 10 minutes intraoperatively, the operation was completed. An ioPTH ‘spike value' (SV) was calculated by subtracting the pre-incision ioPTH value (PI) from the pre-excision ioPTH value (PE) (SV = PE – PI). An ioPTH spike was defined as having a positive SV ≥ 9 pg/ml (≥10th percentile of positive SV). Operative success was defined as eucalcemia ≥6 months after PTX. Operative failure was defined as elevated calcium and PTH levels <6 months after PTX. MGD was defined as persistently elevated ioPTH levels despite removal of one hypersecreting gland, or when removing a single parathyroid gland resulted in operative failure.

Results: Overall, 256 of 783 patients (33%) with ioPTH spikes had a significantly higher rate of MGD (n=21/256, 8% vs. n=21/527, 4%, p<0.05) and bilateral neck exploration (BNE) (n=44/256, 17% vs. n=61/527, 12%, p<0.05) compared to patients without ioPTH spikes, respectively. Accordingly, more ioPTH spike patients also did not meet the >50% PTH drop criterion from the highest PI or PE value at 10 minutes (n=42/256, 16% vs. n=44/527 8%, p<0.05) compared to patients without ioPTH spikes. Of the 42 patients with ioPTH spikes without a >50% PTH drop, 21 underwent BNE (14 met criteria for MGD and 7 had unnecessary BNE) and 21 did not undergo BNE (2 met criteria for MGD). Overall, there were no differences between PTX patients with ioPTH spikes and no-spikes in terms of operative success (97% vs. 98%), operative failure (3% vs. 2%) or recurrence rates (0.8% vs. 1.0%), respectively.

Conclusion: Although patients who underwent targeted PTX with ioPTH spikes had a higher rate of MGD requiring BNE, operative success was similar to those patients without ioPTH spikes. While the presence of ioPTH spikes may increase suspicion for MGD, the ability of targeted PTX guided by ioPTH monitoring in predicting operative success is not affected by spikes and reaffirms the utility of the >50% PTH drop criterion.

27.06 Predictors of Quality of Life in Hepatic Resection and its Prognostic Value

Posted on January 25, 2017

V. Patel2, S. S. Tohme3, K. Bess1, A. Krane1, N. Ahmed1, A. Tsung1, J. L. Steel1  1University Of Pittsburgh School Of Medicine,Department Of Surgery, Division Of Hepatobiliary And Pancreatic Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh,School Of Medicine,Pittsburgh, PA, USA 3University Of Pittsburgh,Department Of Surgery,Pittsburgh, PA, USA

Introduction:  There is little evidence to show that health-related quality of life predicts survival across all hepatic malignancies regardless of origin. In addition, there is scant literature on what clinical data can predict a lowered health-related quality of life (HRQL).  This study aimed to assess if hepatic resection improved the quality of life of our patient population, if quality of life is a prognostic factor for survival, and to identify predictors of quality of life score.

Methods:  The study was a secondary analysis in which patients were enrolled in one of two prospective studies between January 2008 to November 2011. The Functional Assessment of Cancer Therapy-Hepatobiliary, Center for Epidemiologic Studies-Depression, Functional Assessment of Cancer Therapy-Fatigue, and the Brief Pain Inventory were administered.  Pearson correlations, ANOVA, Kaplan-Meier and Cox regression analyses were performed to test the aims of the study.

Results: 

Of the 128 patients, the mean age was 61 years (S.D.=11.6), 71.9% of patients had stage 4 cancer, 42.6% had hepatocellular carcinoma, and 50.7% had metastatic colorectal carcinoma.  Overall HRQL decreased from baseline at the 4-month follow-up but then improved and surpassed baseline at 8 and 12 months.

Using Cox regression, after adjusting for age, diagnosis, Clavien-Dindo Grade, tumor stage, and extrahepatic recurrence, HRQL prior to surgery predicted overall survival (Table 1).

Depressive symptoms (r=-0.666, p<0.001), pain (r=-0.192, p=0.032), and fatigue (r=-0.468, p<0.001) were significantly correlated with HRQL prior to surgery.  Significant predictors of HRQL at 8 months follow up included extrahepatic recurrence (p=0.002), depressive symptoms (r=-0.640, p<0.001), pain (r=-0.529, p<0.001), fatigue (r=-0.668, p<0.001), tumor macrovascular invasion (p=0.011), and tumor microvascular invasion (p=0.003) (Table 2).

Conclusion:Surgical resection of hepatic malignancies improved HRQL over the course of one year. HRQL is prognostic of survival in patients with hepatic malignancies undergoing surgery while adjusting for demographics, disease-specific factors, and treatment-related factors.  Psychological and disease-specific factors predicted HRQL at baseline and 8 month follow up.
 

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