76.08 Some is Not Better Than None: A Meta-Analysis of Total and Proximal Gastrectomy for Gastric Cancer.

Posted on January 31, 2019

B. P. Stahl1, J. B. Rose1, C. M. Contreras1, M. J. Heslin1, T. N. Wang1, S. Reddy1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction: Surgical resection is a mainstay for treating gastric cancer. There is significant controversy surrounding the appropriate operation to maximize oncological benefit and functional outcome for proximal gastric cancer. Some advocate total gastrectomy (TG) with roux-en Y esophagojejunostomy reconstruction claiming that this operation provides optimal lymph node staging for this disease and eliminates post-operative reflux.  Others favor proximal gastrectomy (PG) with esophagogastric reconstruction hoping that the residual gastric reservoir will improve nutrition. We sought to address this question by reviewing oncological, perioperative, and functional outcomes of patients undergoing these two operations for proximal gastric cancer.

Methods: We performed a systematic review and meta-analysis of patients undergoing TG and PG for gastric cancer using PubMed, Embase, and the Cochrane Library from 2007 to 2018 with the MeSH terms “proximal”; “total”; and “gastrectomy” in English-language publications. We identified 659 results; 359 remained after duplicates were purged. From this dataset, 23 articles were selected for the present study. Studies were evaluated for quality with the Newcastle-Ottawa scale for non-randomized evaluations and via the Jadad scale for randomized-control trials.

Results: 23 articles were included in the quantitative synthesis (17 retrospective and 6 prospective studies) with 3227 patients (1984 TG and 1243 PG).  Most of the studies originated from Asia (Japan 13, Korea 5, China 2, Italy 1, India 1, United States 1) with patients cared for from 1990-2012. Most of the patients (96%) had Stage I or II gastric cancer. 30% (6/20) of the studies used perioperative chemotherapy. Median follow up was reported in 19/23 studies (range 17-60 months). TG retrieved a larger number of lymph nodes (OR 13.11, P<0.00001; FIGURE A), had fewer anastomotic stenoses (OR 3.13, P=0.0004; FIGURE B), and had less post-operative reflux symptoms (OR 2.72, P=0.01; FIGURE C) compared to PG.  The two operations had similar complication (FIGURE D) and 5-year overall survival rates (FIGURE E).  Mortality was similar between the two operations (PG 3.5% vs. TG 1.3%, P=0.66).

Conclusion: Although TG obtains a greater number of lymph nodes, both operations offer similar long-term overall survival—raising the question of whether these additional distal gastric resected lymph nodes are important in early stage proximal gastric cancer. PG is a safe and effective operation for early stage proximal gastric cancer if surgeons are willing to accept postoperative gastric reflux and anastomotic stenosis. These findings will need to be evaluated in advanced gastric cancer.

76.07 Learning Curve Bias Can Significantly Influence Results Of Surgical Randomized Controlled Trials

Posted on January 31, 2019

F. Van Workum1, G. Hannink2, C. J. Van Der Velde4, H. J. Bonenkamp1, I. D. Nagtegaal3, M. M. Rovers2, C. Rosman1  1Radboud University Medical Center,Surgery,Nijmegen, GELDERLAND, Netherlands 2Radboud University Medical Center,Evidence Based Surgery,Nijmegen, GELDERLAND, Netherlands 3Radboud University Medical Center,Pathology,Nijmegen, GELDERLAND, Netherlands 4Leiden University Medical Center,Surgery,Leiden, NOORD HOLLAND, Netherlands

Introduction:
Learning curves are often observed after introduction of innovative surgical techniques, but there is currently no robust data suggesting that learning curves can influence outcome of high quality surgical randomized controlled trials (RCTs). 

Methods:
Individual patient data was acquired from the Dutch D1-D2 trial, in which 1078 patients were randomised between D1 gastrectomy (old intervention) or D2 gastrectomy (innovative intervention). This RCT concluded that postoperative complications and mortality were significantly higher in the D2 group and that this did not support implementation of D2 resection into practice. Data from centres that included at least 10 consecutive cases (the minimum to perform meaningful trend analysis) were pooled for individual consecutive case numbers. Weighted moving average analysis was performed for the main outcome parameters and incidence graphs showing trends in outcome were plotted.

Results:
The incidence of postoperative death was 6% in the D1 group and no trend was observed during the trial, but in the D2 group, the incidence of postoperative death decreased from 10% to 3%. The incidence of postoperative complications increased from 19% to 20% in the D1 group (no significant trend). However, the incidence of postoperative complications decreased from 42% to 25% in the D2 group.

Conclusion:
This study showed significantly improving trends in the D2 group (innovative intervention) but not in the D1 group (old intervention), reflecting learning curve bias. Learning curve bias can significantly influence high quality RCT results and lead to misinterpretation of trial results. Incorporation of trend analysis in RCT reporting can assist clinicians with the interpretation of trial outcome data. Methodology to incorporate this into the design of RCTs is proposed.
 

76.06 Assessment of a Readmission Risk Model in Cancer Patients and the Impact on Patient Care and Outcome

Posted on January 31, 2019

E. A. Armstrong1, R. K. Pickard4, K. L. Johnson4, S. Abdel-Misih5,6  4Ohio State University,Cancer Program Analytics, James Cancer Hospital And Solove Research Institute, Comprehensive Cancer Center,Columbus, OH, USA 5Ohio State University,Department Of Surgery,Columbus, OH, USA 6Ohio State University,Division Of Surgical Oncology,Columbus, OH, USA 1Ohio State University,College Of Medicine,Columbus, OH, USA

Introduction:
Hepato-pancreatico-biliary (HPB) and gastrointestinal (GI) cancer patients receiving surgical care are at a significant risk for post-operative hospital readmission. At a tertiary academic center, a Readmission Risk Model was developed to identify cancer patients at increased risk for readmission with a list of suggested post-discharge interventions intended to lower readmission rates for HPB and GI Surgical Oncology (SONC) services. This study investigates the utility of these interventions in lowering patient readmission rates.

Methods:
153 patients with 163 surgical admissions related to their cancer diagnosis between September 1, 2016 and September 30, 2017 were analyzed. Patients were stratified into one of four risk categories based on variables in the established Readmission Risk Model. A chi-square analysis of readmission rates before and after implementation of the Readmission Risk Model Suggested Interventions (RRMSI) for HPB and SONC was performed as well as for each risk category. Chi-square analysis was further performed to determine difference in patient readmission rates based on type of surgery performed and difference in number of days to readmission before and after RRMSI. Additionally, compliance for each suggested intervention was analyzed using univariate analysis.

Results:
There were no significant differences in readmission rates among HPB or SONC patients before and after implementation of the RRMSI. There were also no significant differences for readmission rates based on patient Readmission Risk Category. There was also no difference in readmission rates for patients based on type of surgery performed. Median number of days to readmission was not significantly changed after the RRMSI. While "moderate risk" patients in both the pre-RRMSI and post-RRMSI groups were readmitted at rates betwen 0% and 14%, patients in the "high risk" pre- and post-RRMSI groups were readmitted at rates ranging between 33% and 45%. The HPB service showed overall a greater rate of compliance for the suggested interventions, ranging from 39.3% and 79.1% for individual interventions, while SONC showed a compliance ranged from 6.7% to 70.0%.

Conclusion:
The RRMSI did not affect patient readmission rates for any analyzed group. Implementation of more robust interventions for patients to avoid readmission and compliance improvement strategies should be goals for future clinical practice. Because of the discrepancy between predicted and actual readmission rates among "high risk" patients, additional studies should look into the ability of this Readmission Risk Model to accurately predict surgical cancer patient readmission rates.?
 

76.05 Features of Synchronous versus Metachronous Metastasectomy for Adrenal Cortical Carcinoma

Posted on January 31, 2019

K. M. Prendergast1, P. Marincola Smith2, C. M. Kiernan2, S. K. Maithel4, J. D. Prescott5, T. M. Pawlik5, T. S. Wang6, J. Glenn6, I. Hatzaras7, J. E. Phay8, L. A. Shirley8, R. C. Fields9, S. M. Weber10, J. K. Sicklick11, A. C. Yopp12, J. C. Mansour12, Q. Duh13, E. A. Levine14, G. A. Poultsides3, C. C. Solorzano2  1Vanderbilt University Medical Center,School Of Medicine,Nashville, TN, USA 2Vanderbilt University Medical Center,Department Of Surgery,Nashville, TN, USA 3Stanford University School of Medicine,Department Of Surgery,Palo Alto, CA, USA 4Emory University School Of Medicine,Department Of Surgical Oncology,Atlanta, GA, USA 5Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA 6Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA 7New York University School Of Medicine,Department Of Surgery,New York, NY, USA 8Ohio State University,Department of Surgery,Columbus, OH, USA 9Washington University School of Medicine,Department Of Surgery,St. Louis, MO, USA 10University Of Wisconsin School of Medicine and Public Health,Department Of Surgery,Madison, WI, USA 11University Of California – San Diego,Department Of Surgery,San Diego, CA, USA 12University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 13University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 14Wake Forest University School Of Medicine,Department Of Surgery,Winston-Salem, NC, USA

Introduction:  Adrenocortical carcinoma (ACC) is a rare and aggressive cancer and many patients present with metastases. We describe the features of patients presenting with metastatic disease who underwent synchronous metastasectomy and contrast them with patients who underwent metastasectomy for recurrent ACC.

Methods:  Adult patients who underwent resection for metastatic ACC from 1993-2014 at 13 participating institutions of the US-ACC Group were analyzed retrospectively. Patients were categorized as “synchronous” if they underwent metastasectomy at the time of their index adrenalectomy or “metachronous” if they underwent resection for disease recurrence. Differences between groups were summarized using descriptive statistics. Factors associated with overall survival were assessed by univariate analysis.

Results: 84 patients with ACC underwent metastasectomy: 26 (31%) synchronous and 58 (69%) metachronous. Demographics were similar between groups. Patients in the synchronous group had more right-sided (54 vs. 40%) and glucocorticoid-secreting tumors (27 vs. 16%); however these differences were not significant (p=0.341 and  p=0.304, respectively). The synchronous group had a higher percentage of T4 tumors at index resection (42 vs. 3%, p<0.001); both groups had a similar proportion of N1 disease (11 vs. 7%, p=0.734). There were no significant differences between groups in the rate of treatment with neoadjuvant chemotherapy or adjuvant chemotherapy, mitotane, or radiation. The most common site of metastasectomy in the synchronous group was liver (58%), followed by lung (23%). The most common site of metastasectomy in the metachronous group was local (36%), followed by multiple sites (17%). The metachronous group had prolonged median survival following index resection (86.3 vs. 17.3 months, p<0.001) and following first metastasectomy (36.9 vs. 17.3 months, p=0.007). In the synchronous group, patients with R0 resection had improved survival over patients with R1 or R2 resection (p=0.008), while margin status at metastasectomy was not significantly associated with survival in the metachronous group (p=0.452).

Conclusion: Select patients with metastatic ACC may benefit from metastasectomy. Compared to patients with metachronous metastases, those with synchronous metastases have shortened survival following metastasectomy. This study highlights the need for future studies examining differences in tumor biology that might influence treatment decisions in these two distinct patient populations.
 
 

76.04 Trends in the Use of Adjuvant Chemotherapy for High-Grade Truncal and Extremity Soft Tissue Sarcoma

Posted on January 31, 2019

M. H. Squires1, L. Suarez-Kelly1, P. Y. Yu1, T. M. Hughes1, R. Shelby1, C. G. Ethun2, T. B. Tran3, G. Poultsides3, J. Charlson4, T. Gamblin4, J. Tseng5, K. K. Roggin5, K. Chouliaras6, K. Votanopoulos6, B. A. Krasnick7, R. C. Fields7, R. E. Pollock1, V. Grignol1, K. Cardona2, J. Howard1  1Ohio State University,Division Of Surgical Oncology,Columbus, OH, USA 2Emory University School Of Medicine,Division Of Surgical Oncology,Atlanta, GA, USA 3Stanford University,Department Of Surgery,Palo Alto, CA, USA 4Medical College Of Wisconsin,Division Of Surgical Oncology,Milwaukee, WI, USA 5University Of Chicago,Department Of Surgery,Chicago, IL, USA 6Wake Forest University School Of Medicine,Department Of Surgery,Winston-Salem, NC, USA 7Washington University,Department Of Surgery,St. Louis, MO, USA

Introduction:  In the randomized controlled trial (RCT) EORTC-62931, adjuvant chemotherapy failed to show improvement in relapse-free survival (RFS) or overall survival (OS) for patients with resected high-grade soft tissue sarcoma (STS). We sought to evaluate whether the negative results of this 2012 RCT have influenced multidisciplinary treatment patterns for patients with high-grade STS undergoing resection at 7 academic referral centers.

Methods: The US Sarcoma Collaborative (USSC) database was queried to identify patients who underwent curative-intent resection of primary high-grade truncal or extremity STS from 2000-2016. Patients with recurrent tumors, metastatic disease, and those receiving neoadjuvant chemotherapy were excluded.

 

Patients were divided by treatment era into early (2000-2011, pre-EORTC trial) and late (2012-2016, post-EORTC trial) cohorts for analysis. Rates of adjuvant chemotherapy delivery, standard demographics, and clinicopathologic variables were compared between the two cohorts. Univariate and multivariate regression analyses (MVA) were used to determine factors associated with OS and RFS. 

Results: 949 patients who met inclusion criteria were identified, with 730 patients in the early cohort and 219 in the late cohort. Adjuvant chemotherapy rates were similar between the early and late cohorts (15.6% vs 14.6%; p=0.73). Patients within the early and late cohorts demonstrated similar median OS (128 mos vs median not reached [MNR], p=0.84) and RFS (107 mos vs MNR, p=0.94).

 

Receipt of adjuvant chemotherapy was associated with larger tumor size (13.6 vs 8.9cm, p<0.001), younger age (53.3 vs 63.7 yrs, p<0.001), margin-positive resection (p=0.04), and receipt of adjuvant radiation (p<0.001).

 

On MVA, risk factors associated with decreased OS (Table 1) were increasing ASA class (p=0.02), increasing tumor size (p<0.001), and margin-positive resection (p=0.01). Adjuvant chemotherapy was not associated with OS (p=0.88). Risk factors associated with decreased RFS included increasing tumor size (p<0.001) and margin-positive resection (p=0.04); adjuvant chemotherapy was not associated with RFS (p=0.22). 

Conclusion: Rates of adjuvant chemotherapy for resected high-grade truncal or extremity STS have not decreased over time within the USSC, despite RCT data suggesting a lack of efficacy. In this retrospective multi-institutional analysis, adjuvant chemotherapy was not associated with RFS or OS on multivariate analysis, consistent with the results from EORTC-62931. Rates of adjuvant chemotherapy for high-grade STS were low in both cohorts, but may be influenced more by selection bias based on clinicopathologic variables such as tumor size, margin status, and patient age, than by prospective, randomized data.

76.03 Predictors of narcotic requirements after cervical endocrine surgery: results of a prospective trial

Posted on January 31, 2019

L. I. Ruffolo1, K. M. Jackson1, T. Chennell1, D. M. Glover1, J. Moalem1  1University Of Rochester,Department Of Surgery,Rochester, NY, USA

Introduction:

We adopted an opt-in narcotic prescription program for patients undergoing outpatient thyroid and parathyroid surgery. All patients received preoperative bilateral cervical blocks, and perioperative pain management was at the discretion of the anesthesia and perioperative staff.  Patients were discharged with acetaminophen, unless they requested narcotic medications. Here we report our experience with this program, as well as the factors which correlated with patients requesting narcotic prescription for discharge.

Methods:

We prospectively collected data on patient demographics, their medical/social history, operative details, and postoperative pain medication use and prescription. Univariate and multivariate analyses were performed using Student’s T test for continuous variables, Chi square analysis for categorical variables, and nominal logistic regression. Patients who requested narcotics at discharge were contacted at least 1 month following surgery to determine the number and disposal status of any unused narcotic tablets. This study was approved by the university’s institutional review board.

Results:

Of 219 patients who had outpatient surgery during our study, only nine (4%) requested narcotic prescription at discharge, and none called after discharge to request analgesic prescription. Univariate analysis demonstrated that patients with longer incisions (p=0.007) or with a history of substance abuse (p<0.001), anxiety (p=0.012), depression (p<0.001), baseline narcotic use (p=0.002), or elevated higher pain scores post anesthesia (p=0.003) were more likely to request narcotic medications at discharge. Multivariate logistic regression again demonstrated larger incision length (OR 42.6, CI 1.12-1612, p=0.04) and history of substance abuse (OR 52.3, CI 1.6-1713, p=0.01) as predictive of requesting narcotic prescriptions.

Patients who opted to receive a narcotic prescription received 10-20 tablets of hydrocodone-acetaminophen (mean=16.1).  All of the patients used at least one of the prescribed pills, and 2 used all of their prescribed pills. In total, 74 (51%) of the 145 tablets prescribed were consumed. On follow up call 1 month after surgery, none of the unused tablets were disposed of and all remained in the patients’ medicine cabinets.

Conclusion:

The vast majority of patients can be comfortably managed without narcotic medications after thyroid and parathyroid surgery. No patient who was discharged without narcotics called to request a prescription.  Both patient and procedural factors contribute to narcotic requirement at discharge.

Even under this paradigm, approximately half of the prescribed pain tablets were unused, and were retained in patients’ homes. Ongoing efforts to reduce unnecessary narcotic prescriptions, as well as community educational programs and mechanisms for narcotic disposal remain paramount for reducing narcotics tablets at risk for diversion.

76.02 The Comparison of Recurrent Locations of HCC after Surgical Resection and Radiofrequency Ablation

Posted on January 31, 2019

S. Liu1, R. Hu1  1National Taiwan University Hospital,Department Of Surgery,Taipei City, TAIWAN, Taiwan

Introduction:
Hepatocellular carcinoma (HCC)  was characterized with its high recurrence rate and poor long term prognosis. There was few study described the difference of HCC recurrent locations among different treatment. The present study aimed to compare the recurrent locations after the patients receiving curative surgical resection or receiving RFA.

Methods:
A total of 419 patients with single solitary HCC ≤ 5 cm who underwent curative-intent surgical resection (SR) or radiofrequency ablation (RFA) as initial treatment were retrospectively collected between January 2013 and December 2015. Electric medical charts and image were reviewed to collected clinical characteristics data and patterns of recurrence. Clinical follow-up of these patients were traced to December 2017, with the mean follow-up time 35.2 months. Recurrent locations were classified into recurrence occurred only in the same or nearby segment compared with primary tumor location, recurrence involved to distal segment, and recurrence involved extrahepatic recurrence. Other recurrence patterns including recurrent AFP, recurrent tumor number, time period to recurrence, and major vessels invasion were also collected. The recurrence patterns and outcomes were compared between the patients who received SR and the patients who received RFA.

Results:
There were 157 patients enrolled in SR group and 262 patients enrolled in RFA group. Comparing two treatment groups, the outcomes evaluation showed better overall survival (p = 0.001) and disease free survival (p< 0.001) in SR. Comparing the recurrence pattern, the RFA group showed significant higher rate in only same or nearby segment recurrence (SR: 29.5% vs RFA: 60.1%, p-value 0.001). The multivariate analysis identified receiving RFA as significant risk factor for same or nearby segment recurrence. There was no difference in other recurrence pattern  between two groups.

Conclusion:
For HCC patients with single solitary tumor ≤ 5 cm, receiving RFA as initial treatment may have higher same or nearby recurrence rate compared to receiving SR as initial treatment
 

76.01 Centralization of High-Risk Cancer Surgery Within Hospital Networks

Posted on January 31, 2019

K. H. Sheetz1, J. B. Dimick1, H. Nathan1  1University of Michigan,Surgery,Ann Arbor, MI, USA

Background:

Hospital consolidation has the potential to improve the quality of care within regional delivery networks. We evaluated the extent to which hospital networks centralize high-risk cancer surgery and whether centralization is associated with changes in short-term clinical outcomes.

Methods:

We merged results from the American Hospital Association’s annual survey on network participation with Medicare claims to identify patients undergoing surgery for pancreatic, esophageal, colon, lung, or rectal cancer between 2005 and 2014. We calculated the degree to which networks centralized each procedure by calculating the annual proportion of surgeries performed at the highest volume hospital within each network. We then estimated the independent effect of centralization on the incidence of postoperative complications, death, and failure to rescue after accounting for patient complexity, hospital volume, and overall hospital quality. 

Results:

The average degree of centralization varied from 25.2% (Range 6.6–100%) for colectomy to 71.2% (Range 8.3–100%) for pancreatectomy. Greater centralization was associated with lower rates of postoperative complications and death for lung resection, esophagectomy, and pancreatectomy. For example, there was a 1.6% (95% CI -2.3 to -0.9) absolute reduction in 30-day mortality following pancreatectomy for each 20% increase in the degree of centralization within networks. Independent of volume and hospital quality, postoperative mortality for pancreatectomy was 58% lower in the most centralized networks compared to the least centralized networks (8.9% vs. 3.7%, p<0.01). Centralization was not associated with better outcomes for colectomy or proctectomy.

Conclusions:

Greater centralization of complex cancer surgery within existing hospital networks was associated with better outcomes. As hospitals affiliate in response to broader financial and organization pressures, these networks may also present unique opportunities to improve the quality of high-risk cancer care.

75.10 Incompatible Living Donor Kidney Transplantation in Older Recipients

Posted on January 31, 2019

J. Long1, K. Jackson1, J. Motter1, M. Waldram1, K. Covarrubias1, B. Orandi2, D. Segev1, J. Garonzik-Wang1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA 2University Of Alabama at Birmingham,Birmingham, Alabama, USA

Introduction: Older individuals represent the fastest-growing population with end-stage renal disease (ESRD) in need of a kidney transplant. While incompatible living donor kidney transplantation (ILDKT) is known to provide survival benefit it is unknown if older individuals have similar post-ILDKT outcomes. Knowledge of the risk profile of older ILDKT recipients could help inform patient counseling and clinical management of this rapidly growing group of transplant recipients.

Methods: Using a 22-center ILDKT cohort linked to SRTR data, we compared post-transplant outcomes of 154 older (age >60) ILDKT recipients to 871 younger (age < 60) recipients. We analyzed mortality and death-censored graft failure using multivariable Cox regression. Delayed graft function (DGF) and length of stay (LOS) were evaluated using multivariable logistic regression and negative binomial regression, respectively. All models were adjusted for the following recipient and transplant characteristics: gender, body mass index, race, blood type, years on dialysis, panel reactive antibody, donor-specific antibody, and number of human leukocyte antigen mismatches.

Results: Compared to younger recipients, older recipients were more likely to be female (81.2% vs 64.5%, p<0.001), white (76.6% vs 64.5%, p=0.014), and to have been on dialysis prior to transplant (21.4% vs 10.8%, p<0.001). Older recipients were less likely to have had a prior transplant (16.2% vs 68.4%, p<0.001). The 1, 5, and 10-year post-transplant survival for older recipients were 92.2%, 81.1% and 50.0% compared to 95.5%, 86.6%, and 64.9% for younger recipients (p=0.02). The 1, 5, and 10-year death-censored graft survival were 96.6%, 84.6%, and 79.0% for older recipients compared to 93.6%, 76.0%, and 56.8% for younger recipients (p=0.005) (Table 1). In adjusted models, older recipients had a 60% increased risk of mortality (adjusted hazard ratio [aHR]: 1.101.602.34, p=0.01) and a 45% decreased risk of developing death-censored graft failure (HR: 0.360.550.86, p<0.01) compared to their younger counterparts. There were no differences in LOS (adjusted LOS ratio: 0.870.991.13, p=0.9) or DGF (adjusted odds ratio: 0.481.092.45, p=0.8).

Conclusion: While older ILDKT recipients have worse survival compared to younger recipients, their long-term survival is still good, and they have similar LOS and DGF. Older recipients should not be denied ILDKT based on age alone.

 

75.09 Pediatric Deceased Donor Kidney Transplantation Under the New Kidney Allocation System

Posted on January 31, 2019

K. R. Jackson1, S. Zhou1, J. Ruck1, C. Holscher1, A. Massie1, A. Kernodle1, J. Glorioso1, J. Motter1, N. Desai1, D. Segev1, J. Garonzik-Wang1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction:  The new Kidney Allocation System (KAS) has resulted in fewer pediatric kidneys being allocated to pediatric deceased donor kidney transplant (pDDKT) recipients. This has prompted concerns that post-pDDKT outcomes may worsen and led to suggestions that KAS should be modified to reverse this change.

 

Methods:  To study whether post-transplant outcomes have worsened under KAS, we used SRTR data to compare outcomes of 953 pre-KAS pDDKT (age < 18 years) recipients (12/4/2012-12/3/2014) to 934 post-KAS pDDKT recipients (12/4/2014-12/3/2016). We analyzed mortality and graft loss using Cox regression, delayed graft function (DGF) using logistic regression, and length of stay (LoS) using negative binomial regression. Multivariable models were adjusted for donor and recipient characteristics.

Results: Post-KAS recipients had longer dialysis times (median 1.26 vs. 1.07 years, p=0.02) and were more often cPRA 100% (2.0% vs. 0.1%, p=0.001). Post-KAS recipients had less graft loss than pre-KAS recipients (hazard ratio [HR]: 0.350.540.83, p=0.005, Table), but equivalent mortality (HR: 0.230.722.28, p=0.6), DGF (odds ratio [OR]: 0.931.321.87, p=0.1), and LoS (LoS ratio: 0.961.061.16, p=0.3). After adjusting for donor/recipient characteristics, there were no post-KAS differences in mortality (adjusted HR [aHR]: 0.230.933.73, p=0.9), DGF (adjusted OR: 0.931.372.03, p=0.1), or LoS (adjusted LoS ratio: 0.931.041.16, p=0.5). However, post-KAS pDDKT recipients still had less graft loss (aHR: 0.390.610.96, p=0.03).

Conclusion: Despite a decrease in pediatric donor kidneys being allocated to pDDKT recipients, there is no evidence that post-transplant outcomes have worsened for pDDKT recipients under KAS. Therefore, any KAS modification discussions should consider this context.

 

75.08 Trends in Incidence, Treatment and Survival of Gallbladder Cancer; a Nation-Wide Cohort Study.

Posted on January 31, 2019

E. A. De Savornin Lohman1, T. De Bitter2, R. Verhoeven3, I. Nagtegaal2, C. Van Laarhoven1, R. Van Der Post2, P. De Reuver1  1Radboudumc,Surgery,Nijmegen, Netherlands 2Radboudumc,Pathology,Nijmegen, Netherlands 3Netherlands Comprehensive Cancer Organization,Eindhoven, Netherlands

Introduction:

Gallbladder cancer (GBC) is a rare but lethal malignancy, primarily diagnosed in an advanced stage unless detected incidentally after laparoscopic cholecystectomy for benign gallbladder disease. Scarce data is available on GBC treatment and survival outcomes in Western populations. Consequently, controversy exists regarding surgical and systemic treatment. Using data from the Netherlands Cancer Registry, trends in incidence, treatment and survival of GBC patients were evaluated.

Methods:
Data of 2427 GBC patients diagnosed between 2000 – 2015 were included in this nationwide population-based study. Incidence and demographics were assessed. Treatment strategies and associated survival were analysed using Kaplan-Meier methods and propensity score matching.

Results:
Age-standardised incidence of GBC varied from 0.6 to 0.9 per 100.000 person years and did not change significantly over time. Demographic characteristics are presented in Table 1. Most tumours (67.2%) were detected pre-operatively. The overall median survival was 5.2 months and primarily determined by tumour stage, ranging from 36.2 months in stage I patients to 3.0 months   in stage 4 patients. Between 2000 and 2015 median survival improved from 4.1 to 6.6 months (p < 0.01). After propensity score matching, median survival in surgically treated stage III + IV gallbladder cancer was 7.4 months, compared to 3.3 months for non-surgically treated patients (p < 0.001). Stage II GBC patients receiving additional liver bed resection showed superior median survival to those whom did not receive additional surgery (21.7 vs. 46.6 months, p < 0.001). Systemic therapy in advanced stage GBC improved median survival from 2.8 to 7.4 months.

Conclusion:

Although an increase of 2 months in overall survival was demonstrated over time, the clinical significance of this finding is debatable and outcome of GBC patients is still poor. A considerable, clinically relevant increase in survival was seen in two subgroups: patients with early GBC receiving additional resection and patients with advanced GBC treated with systemic therapy. More aggressive treatment strategies should be advocated, as they appear to improve the prospects of GBC patients.

75.07 Effects of Kidney Allocation System on Deceased Donor Kidney Transplant Rates Across Race/Ethnicities

Posted on January 31, 2019

A. C. Perez-Ortiz1,2, N. Elias1  1Massachusetts General Hospital,Transplant Center,Boston, MA, USA 2Yale University School Of Public Health,New Haven, CT, USA

Introduction:
The new deceased donors (DD) Kidney Allocation System (KAS) aimed to decrease racial allocation disparity, indirectly improving DD transplant rates (TR) for non-Whites. Three years after implementation, we lack evidence of this specific efficacy. We here assess whether the waitlisting and transplant rates across races/ethnicities have improved after KAS implementation.

Methods:
To assess any systematic difference in US TR (1989-2017) and the effect pre- (1989-2014) and post-KAS (2015-2017), we calculated the slope per year basis with data from the Organ Procurement and Transplantation Network database. We then, using regression modeling, estimated the effect of race/ethnicity on kidney waitlist addition and TR across periods adjusting for meaningful covariates. To eliminate improved deceased donation rates effect, we compared kidney to liver TR; a difference indicates a positive impact of KAS. Finally, we similarly evaluated the slope of change for kidney waitlist additions.

Results:
We show three distinct periods wherein the kidney TR varied for all ethnicities. Between 1989–2006 and 2015–2017, there was a significant positive slope -growth of TR on a yearly basis- (β=456.5, and 913.7, respectively), higher in the latter (p<0.02). However, between 2006–2014 there was no change in TR (β=1.6, p<0.01). Furthermore, compared to DD liver TR after KAS implementation (2015-2017), DD kidney TR increased up to 76% (p=0.02). Before 2015, there were no differences between the two groups (p>0.20). Moreover, kidney TR have steadily risen for non-Whites compared to Whites (p=0.03) (Figure). KAS implementation increased the rate for non-Whites ~12-fold (β=344.8, SE=169.4) compared to Whites (β=28.4, SE=45.3) (p = 0.04). Lastly, this improvement was not mirrored in the waitlist additions, and KAS did not change the slope (p=0.25).

Conclusion:
We have preliminary evidence that KAS has improved TR especially benefiting non-Whites (Blacks, Hispanics, and Asians). This improvement is independent of organ donation rates in the same era. Waitlist addition did not equally change, arguing for the need for improved education and other means to alter referral and listing practice.?
 

75.06 Impact of Area of Deprivation Index On Hospital Readmissions after Surgery for Pancreas Cancer

Posted on January 31, 2019

A. N. Krepline1, J. Mora1, M. Aldakkak1, S. Misustin1, K. Christians1, C. N. Clarke1, B. George2, P. S. Ritch2, W. A. Hall3, B. A. Erickson3, N. Kulkarni4, A. H. Khan5, D. B. Evans1, S. Tsai1  1Medical College Of Wisconsin,Division Of Surgical Oncology,Milwaukee, WI, USA 2Medical College Of Wisconsin,Division Of Hematology And Oncology,Milwaukee, WI, USA 3Medical College Of Wisconsin,Department Of Radiation Oncology,Milwaukee, WI, USA 4Medical College Of Wisconsin,Department Of Radiology,Milwaukee, WI, USA 5Medical College Of Wisconsin,Division Of Gastroenterology And Hepatology,Milwaukee, WI, USA

Introduction: Area of deprivation index (ADI) is a validated metric used to quantify socioeconomic disadvantages by neighborhood.  The ADI is composed of 17 educational, employment, housing, and poverty measures abstracted from the US Census Long Form and the American Community Survey; higher ADIs signify a more disadvantaged neighborhood. We sought to examine the impact of ADI on readmission rates after surgery among patients with pancreatic cancer (PC).

Methods: Patients with resectable and borderline resectable PC treated at the Medical College of Wisconsin from 2009 to 2018 were identified.  The ADI for all patients was obtained using the zip code+4 code.  Patients were dichotomized into low and high ADI categories based on the median ADI. Demographic, clinicopathologic, and readmission data for patients were abstracted.

Results: Neoadjuvant therapy and surgery was completed in 310 patients with resectable and borderline resectable PC.  The median ADI was 97.32 (IQR 17.7), 155 (50%) with low ADI and 155 (50%) with high ADI.  No differences were observed between groups in demographic characteristics, clinical stage, baseline carbohydrate antigen 19-9, or type of neoadjuvant therapy received.  In addition, no differences were observed between low and high ADI groups in the types of operation performed, need for vascular reconstruction, hospital length of stay, or pathologic stage. Of the 310 patients, 66 (21%) had a readmission within 90 days of surgery; 26 (17%) of the 155 patients with a low ADI and 40 (26%) of the 155 patients with high ADI (p=0.049).  Among the low and high ADI groups, the most common reasons for readmission were procedure-related complications (n=16 (10%) vs. 23 (15%) patients, p=0.30) and failure to thrive (n=7 (5%) vs. 13 (8%) patients, p=0.25), respectively.  For patients with low vs. high ADI, readmission occurred at a median of 19 days (IQR 14) and 27 (IQR 24), respectively (p=0.02).  In a multivariable logistic regression, high ADI was associated with 1.80-fold increased odds of 90-day readmission (Table 1: 95% CI:1.02-3.16, p=0.04). 

Conclusion: ADI was not associated with more advanced clinical or pathologic stage or operation performed. However, patients with high ADI were at increased risk for 90-day readmission. Additional studies are needed to identify modifiable factors associated with readmissions in this high-risk group.

 

75.05 Racial disparities in Hepatocellular Carcinoma outcomes are driven by access to care.

Posted on January 31, 2019

C. Akateh1, S. M. Black1  1Ohio State University,Surgery,Columbus, OH, USA

Introduction:
Hepatocellular carcinoma (HCC) remains a major leading cause of end-stage liver disease and cancer-related mortality in the United States. While advances in various treatment strategies have contributed to improved outcomes overall, surgical resection remains the preferred choice of therapy and in many cases the only hope of a cure. Despite improving outcomes, minority patients with HCC continue to have worse outcomes compared to non-minorities. The goal of this study is to identify underlying mechanisms for disparities in HCC outcomes.

Methods:
The Surveillance, Epidemiology and End Results (SEER) database was used to identify White and Black patients diagnosed with hepatocellular carcinoma between 2000-2014.   Age, race, marital status, stage, and receipt of surgery were evaluated as predictors of disparate outcomes and mortality in multivariate analyses.  

Results:
43,877 patients (75.6% White, 12.8% Black and 11.6% Other Races) were identified, 73% of whom were male, and 26% were female. Black patients were significantly younger at diagnosis compared to Whites (60 vs. 64 (p<0.001) and were slightly more likely to have the advanced/regional disease at presentation (18.8 vs. 21.2%, p<0.001), respectively.  Overall, blacks were significantly less likely to undergo cancer-directed surgery, including liver transplantation (OR 0.84, 95% CI= 0.76-0.92).  This decrease in odds of surgery persisted after adjusting for patient-level factors such as age, sex, marital status, and year of diagnosis (adjusted OR 0.80, 95% CI= 0.73-0.88). However, these odds of surgery were equivalent when adjusted for disease stage (adjusted OR 0.94, 95% CI= 0.82-1.10). The unadjusted hazard of mortality was 1.11 times higher in blacks compared to whites (p<0.001). However, these hazards disappeared when adjusted for disease stage (HR 0.99, p=0.908).

Conclusion:
Significant racial disparities in HCC outcomes are largely related to the advanced presentation at diagnosis and resulting underuse of cancer-directed surgery.  It is therefore imperative to address barriers to care as receipt of appropriate care eliminates these disparities.
 

75.04 Maximum Diameter is a Poor Surrogate Measure for Volume and Surface Area of Small Pancreatic Cysts

Posted on January 31, 2019

A. M. Awe1, V. Rendell3, M. Lubner2, E. Winslow3  1University Of Wisconsin,School Of Medicine & Public Health,Madison, WI, USA 2University Of Wisconsin,Department Of Radiology,Madison, WI, USA 3University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: Determining an appropriate surveillance strategy for pancreatic cysts (PC) presents a challenge due to management guideline heterogeneity and a relatively poor ability to predict the malignant potential of PCs. Current management protocols use maximum axial diameter (MAD) to steer treatment; however, other measures may better capture the evolution of PCs. The aim of this study is to determine whether MAD is an appropriate surrogate measure for volume and surface area of PCs.

Methods: A single-institution retrospective analysis of patients with radiologically confirmed PCs was conducted. Patients with a PC >1cm and a contrast-enhanced CT or MR scan were included. Patients with pancreatic pseudocysts, underlying pancreatitis, genetic syndromes, or solid tumors were excluded. MAD, volume, and surface area data were collected using HealthMyne, a novel lesion detecting software. Pearson’s correlations were used to determine associations between volume and MAD, and surface area and MAD for total patients and size sub-groups from the Fukuoka guidelines for PC surveillance and treatment.

Results: In total, 202 patients were included in the analysis. The MADs of the cysts ranged from 1.0 cm to 7.5 cm. PC volume as a function of the MAD for all PC sizes had a strong correlation of r=0.94. When sub-grouped by size based on the Fukuoka guidelines, correlations with volume varied: 1-2 cm (n=87), 2-3 cm (n=61), and >3 cm (n=54) PCs had correlations of 0.78, 0.53, 0.90, respectively (Fig. 1A-C). Volumes ranged for 1-2 cm cysts from 0.3- 3.8 cm3, for 2-3 cm cysts from 1.1- 10.8 cm3, and for >3 cm cysts from 6.7- 104.3 cm3. Based on volume alone, 95 cysts (47%) overlapped in Fukuoka size groupings. PC surface area as a function of the MAD for all PC sizes had a strong correlation of r=0.96. When sub-grouped by Fukuoka guideline size, correlations varied: 1-2 cm (n=87), 2-3 cm (n=61), and >3 cm (n=54) had correlations of 0.80, 0.56, 0.92, respectively (Fig. 1D-F). Surface area ranged for 1-2 cm cysts from 0.2- 13.2 cm2, for 2-3 cm cysts from 7.3- 29.6 cm2, and for >3 cm cysts from 19.6- 126.2 cm2.  Based on surface area alone, 77 cysts (38%) overlapped between axial diameter size groupings in the Fukuoka guidelines.

Conclusion: Overall, there is strong correlation between PC volume, surface area and MAD, suggesting that unidimensional size is an appropriate surrogate measure. However, grouping PCs based on the Fukuoka guideline size criteria reveals poor volume and surface area correlation with MAD for small cysts. This suggests volume and surface area may be a useful adjunct measurements to guide surveillance and treatment decisions for smaller PCs.

 

75.03 NQO1 Expression Predicts OS and Response to Preoperative Chemotherapy in Colorectal Liver Metastasis

Posted on January 31, 2019

Y. Hirose1, J. Sakata1, T. Kobayashi1, K. Takizawa1, K. Miura1, T. Katada1, M. Nagahashi1, Y. Shimada1, H. Ichikawa1, T. Hanyu1, H. Kameyama1, T. Wakai1  1Niigata University Graduate School of Medical and Dental Sciences,Division Of Digestive And General Surgery,Niigata, NIIGATA, Japan

Introduction:  NAD (P) H: quinone oxidoreductase – 1 (NQO1) protects human cells against redox cycling and oxidative stress. We hypothesized that immunohistochemical expression of NQO1 in the resected specimen of colorectal liver metastasis (CRLM) has impact on the response to preoperative chemotherapy for CRLM and survival after liver resection in patients with CRLM.

Methods:  A retrospective analysis was conducted of 88 consecutive patients who underwent initial liver resection for CRLM from January 2005 through December 2016 in Niigata university medical and dental hospital. The median follow-up time was 65.4 months. Immunohistochemistry was conducted for the resected specimen using a monoclonal anti-NQO1 antibody. According to the NQO1 expression in tumor cells of CRLM, the patients were classified into two groups: the NQO1 positive group and the loss of NQO1 group. According to the NQO1 expression in non-neoplastic epithelial cells of the large intrahepatic bile ducts, the patients were classified into two groups: the NQO1 non-polymorphism group, which had NQO1 expression in those cells, and the NQO1 polymorphism group, which had no NQO1 expression in those cells. Overall survival (OS) after liver resection for CRLM were evaluated by univariate and multivariate analyses taking into consideration 15 other clinicopathological factors. Among 30 patients who received preoperative chemotherapy for CRLM, association between response to preoperative chemotherapy for CRLM and NQO1 status of those patients was evaluated. Response to preoperative chemotherapy was determined according to pathologic response and RECIST criteria using multidetector row CT. All tests were two-sided and P < 0.05 were considered statistically significant.

Results: Of the 88 patients, 61 were classified as the NQO1 positive group and 27 as the loss of NQO1 group, whereas 21 were classified as the NQO1 non-polymorphism group and 67 as the NQO1 polymorphism group. The loss of NQO1 group was associated with a lower prehepatectomy serum CEA level. The NQO1 polymorphism group was associated with higher frequency of bilobar metastases. The loss of NQO1 group had significantly better OS than the NQO1 positive group (cumulative 5-year OS rate: 90.9% vs 66.5%, P = 0.026), and loss of NQO1 expression was an independent favorable prognostic factor in multivariate analysis (relative risk: 0.139, P = 0.001). Regarding association between the response to preoperative chemotherapy for CRLM and NQO1 status, the presence of NQO1 polymorphism was significantly associated with a better response to preoperative chemotherapy in RECIST (P = 0.004). The absence or presence of NQO1 expression in CRLM was not associated with response to preoperative chemotherapy for CRLM.

Conclusion: Loss of NQO1 expression indicates favorable prognosis for patients with CRLM. The presence of NQO1 polymorphism may predict a good response to preoperative chemotherapy for CRLM.

 

75.02 Laparoscopic Distal Pancreatectomy is Associated with a Cost Savings in High Volume Centers

Posted on January 31, 2019

E. Eguia1, P. C. Kuo2, P. J. Sweigert1, M. H. Nelson1, G. V. Aranha1, G. Abood1, C. V. Godellas1, M. S. Baker1  1Loyola University Chicago Stritch School Of Medicine,General Surgery,Maywood, IL, USA 2University Of South Florida College Of Medicine,General Surgery,Tampa, FL, USA

Introduction:
Little is known regarding the impact of minimally invasive approaches to distal pancreatectomy (DP) on the aggregate costs of care for patients undergoing DP. 

Methods:
We queried the Healthcare Cost and Utilization Project State Inpatient Database to identify patients undergoing laparoscopic (LDP) or open (ODP) distal pancreatectomy in FL, MD, MA, NY and WA between 2014 and 2016. Multivariable regression (MVR) was used to evaluate the association between surgical approach and rates of postoperative complication, overall lengths of stay (LOS) and aggregate costs of care including readmissions to 90 days following DP. Candidate variables were determined a priori using best variable subsets and included: age, gender, insurance, race/ethnicity, Charlson comorbidity index (CCI), pathology (benign vs. malignant), annual hospital DP volume broken into terciles (low: <6 DPs/year; moderate: 641 DPs/year) and overall LOS. 

Results:

297 (11%) patients underwent LDP; 2,436 (89%) underwent ODP. On univariate analysis, patients undergoing LDP had higher rates of malignant pathology (53% vs. 39%, p<0.001), shorter overall LOS (6 days, IQR [5-10] vs. 7 days, IQR [5-13], p< 0.001) and lower aggregated costs of care ($22,734 vs. $26,910, p<0.001) than those undergoing ODP.

On MVR adjusted for age, gender, malignant pathology, CCI and hospital volume, LDP was associated with a decreased risk of prolonged LOS (OR 0.47; 95% CI [0.30, 0.74]) relative to ODP.  Rates of perioperative morbidity and readmission for patients undergoing LDP were identical to those undergoing ODP.

On MVR adjusted for age, insurance, CCI and LOS, and volume, factors associated with being in the highest quartile for aggregate costs following DP included: male gender (OR 1.50; 95% CI [1.24,1.82]), CCI (OR 1.25; 95% CI [1.19, 1.31]), black race (OR1.40; 95% CI [1.02,1.91]), having Medicaid (OR 1.59 95% CI [1.12,1.25]), malignant pathology (OR 2.10; 95% CI [1.61, 2.74]) and readmissions (OR 5.29; 95% CI [4.35, 6.43]). Patients undergoing LDP had a lower risk of being in the highest quartile for costs (OR 0.52, 95% CI [0.37, 0.74]) than those undergoing ODP. The reduction in risk of being a high outlier for cost was independent of hospital volume but only high-volume centers realized an average lower aggregate cost of care (-$4,803; 95% CI: [-$8,341, -$1,265]) when utilizing LDP.  In low (-$3,3010; 95% CI [-$8,008, $1,988]) to moderate (+$3,606; 95% CI [-$6,629, $13,841]) volume centers, the aggregate costs of care for LDP and ODP were statistically identical. 

Conclusion:
Patients undergoing LDP have a lower risk of prolonged overall LOS relative to those undergoing ODP. This association is independent of hospital volume but translates into cost savings in high volume centers only. This finding suggests that high volume centers develop efficiencies of scale that allow them to realize aggregate cost savings when utilizing laparoscopic approaches to DP. 

75.01 Current Preoperative Ultrasound Imaging of Gallbladder Polyps is Unspecific and Risks Overtreatment

Posted on January 31, 2019

S. Z. Wennmacker1, E. De Savornin Lohman1, P. De Reuver1, N. Hasami1, M. Boermeester2, J. Verheij3, E. Spillenaar Bilgen4, J. Meijer5, K. Bosscha6, H. Van Der Linden7, I. Nagtegaal8, J. Drenth9, C. Van Laarhoven1  1Radboudumc,Surgery,Nijmegen, Netherlands 2AmsterdamUMC,Surgery,Amsterdam, Netherlands 3AmsterdamUMC,Pathology,Amsterdam, Netherlands 4Rijnstate Hospital,Surgery,Arnhem, Netherlands 5Rijnstate Hospital,Pathology,Arnhem, Netherlands 6Jeroen Bosch Hospital,Surgery,’s-Hertogenbosch, Netherlands 7Jeroen Bosch Hospital,Pathology,’s-Hertogenbosch, Netherlands 8Radboudumc,Pathology,Nijmegen, Netherlands 9Radboudumc,Gastroenterology And Hepatology,Nijmegen, Netherlands

Introduction: Cholecystectomy is only needed for neoplastic gallbladder polyps, in order to halt or prevent the development of gallbladder cancer. Current international guidelines advocate surgery for all gallbladder polyps ≥1cm, in view of the elevated risk of neoplasia of these polyps. However, the validity of this threshold may be questioned as one third of the polyps are wrongly classified. The aim of this study was to identify preoperative clinical and imaging characteristics associated with neoplastic polyps. Secondly, the concordance between imaging findings and pathological findings of gallbladder polyps was assessed.

Methods: A retrospective analysis of all histopathologically proven gallbladder polyps in four Dutch hospitals between 2003-2013 was performed. Patients were identified through PALGA, the Dutch nationwide network and registry of histo- and cytopathology. Clinical and imaging characteristics of patients with neoplastic versus nonneoplastic polyps were assessed using univariable and multivariable analysis. Concordance of polyp size, number of polyps and polyp type on ultrasound and histopathology were assessed using McNemars’ test, and subsequent sensitivities and specificities were calculated.

Results: A total of 208 patients were included of whom 95 patients (43.7%) were diagnosed with a neoplastic polyp on histopathological evaluation. Patients’ age (OR 1.06 per year (1.03-1.08), p<0.001) and a history of gallbladder disease (OR 2.80 (1.03-7.62), p=0.04) were significantly associated with neoplastic polyps on multivariable analysis. A total of 156 patients underwent preoperative ultrasound. In 88 patients (56.4%) the polyps were preoperatively identified on ultrasound. Polyp characteristics (shape, surface, echogenicity and internal echogenic pattern) were frequently unreported in imaging reports. Polyp size and number of polyps on ultrasound were significantly associated with neoplastic polyps in univariable, but not in multivariable analysis. Polyp size as assessed on ultrasound was significantly inconsistent with size on histopathology (p=0.002). Sensitivity and specificity of ultrasound for polyp size ≥1cm were 96% and 41%, for presence of a single polyp 92% and 62%, and for identifying neoplastic polyp type 70% and 25%.

Conclusion: Patients >50 years of age and with a history of gallstone disease are more likely to have neoplastic polyps. Current standard preoperative (ultrasound) imaging has low specificity for polyp size, presence of a single polyp, and the overall diagnostic accuracy of ultrasound in establishing polyp type is poor, risking considerable surgical overtreatment of patients with nonneoplastic polyps.

74.10 Impact of Socioeconomic Status on Surgical Outcomes: Does it Matter in Rural Areas?

Posted on January 31, 2019

F. Rahim1, E. De Jager1, M. A. Chaudhary1, J. M. Havens3,4, E. Goralnick1,2, A. Haider1,4  1Center for Surgery and Public Health,Boston, MA, USA 2Brigham And Women’s Hospital,Emergency Preparedness And Access Center,Boston, MA, USA 3Harvard School Of Medicine,Brookline, MA, USA 4Brigham And Women’s Hospital,Surgery,Boston, MA, USA

Introduction:
Emergency General Surgery (EGS) conditions account for more than 2 million US hospital admissions annually. EGS patients in the highest income quartile have lower odds of mortality compared to the lowest income quartile, which may be related to a disparity in access to high quality centres. Rural areas have fewer providers and subsequently less provider choice compared with urban areas. Our objective was to examine if the high income EGS survival benefit holds true in rural areas. 

Methods:
The National Inpatient Sample (2007-2014) was queried for patients aged 18-64, with a primary diagnosis of the American Association for Surgery of Trauma’s 10 most common EGS procedures. The effect of patient income quartiles on surgical adverse events (total complications and mortality) was assessed using multivariable regression models in urban and rural cohorts adjusting for age, race/ethnicity, sex, Charlson Comorbidity Index, insurance status, hospital region and teaching status. 

Results:
1,687,828 patients underwent one of the EGS procedures performed during the study period. 16.59% (n=280,036) of patients were rural. The overall distribution of income quartiles was 21.35% (n=351,500) highest, 24.37% (n=401,292) high middle, 25.78% (n=424,409) low middle and 28.50% (n=469,152) lowest. Compared to urban settings, rural settings had higher mortality (1.16 vs 1.23% p<0.001) and complication rates (15.46 vs 16.54%, p<0.001) in our univariate analysis. In the urban cohort multivariate analysis, lower income quartiles were associated with higher odds of in hospital mortality and total complications relative to the high-income quartile. In the rural cohort, income quartiles were not associated with the odds of adverse events (Table).

Conclusion:
Patients in the highest income had a survival benefit and lower risk of postoperative complications in urban but not in rural settings. The disparity in EGS outcomes between higher and lower socioeconomic status in urban settings, but not in rural settings, could be related to limited provider choice in rural areas. 

74.09 Using the Social Vulnerability Index to Examine Local Disparities in Emergent and Elective Cholecystectomy

Posted on January 31, 2019

H. Carmichael1, A. Moore1, L. Steward1, C. G. Velopulos1  1University Of Colorado Denver,Department Of Surgery,Aurora, CO, USA

Introduction:
The Social Vulnerability Index (SVI) is a composite scale formulated by the Centers for Disease Control to determine resource allocation for natural disasters. It includes 15 variables in four categories of socioeconomic status, household composition/disability, minority status/language, and housing/transportation, and is geocoded as a percentile ranking at the census tract level. Because many of these variables are associated with disparity in access to surgical care, SVI is potentially applicable to assess risk and target populations that are likely to present emergently for disease that could have been treated electively. Because regional variation exists in access to care, future interventions depend on understanding disparity at the discrete, local level. We applied the SVI to compare cholecystectomy patients presenting emergently versus electively.

Methods:
We identified patients who had undergone cholecystectomy at our academic medical center over a 6-month period. We excluded patients <18 yo and pregnant patients. Cases were classified as emergent or elective; cases where the patient presented electively for interval operation after a presentation in the emergent setting requiring intervention were excluded. We abstracted patient demographics, residential address, insurance status, chronic and acute symptom duration, diagnosis, and operative outcomes from the EMR. Patient addresses were geocoded to identify their census tract of residence and estimated SVI. Wilcoxon rank sum tests were used for univariable analysis, followed by multivariable logistic regression modeling.

Results:
Of 289 patients who underwent cholecystectomy, 267 met inclusion criteria. Most patients (n=196, 73.4%) had surgery in the emergent setting. Emergent patients lived in areas of greater social vulnerability compared to elective patients (median SVI 75th vs. 64th percentile, p=0.007). On multivariable analysis adjusting for patient age, sex and chronicity of symptoms, having high SVI (>80th percentile) was associated with higher odds of undergoing an emergent versus an elective procedure (OR 2.19, p=0.02). Models were then compared, with AUC of 0.819 for a model including insurance, PCP, minority, and need for interpreter versus AUC of 0.831 for the model using SVI only.

Conclusion:
The SVI has potential utility for examining health care disparities, performing comparably to a more complex model. Because it is a composite measure geocoded at the census tract level for all communities in the United States, it has potential for targeting relatively discrete geographic areas for intervention. Being a geocoded measure also offers opportunity for linking with other datasets using Geographic Information Systems.
 

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