54.07 Outcomes of Palliative Surgery in Retroperitoneal Sarcoma – Results from the US Sarcoma Collaborative

Posted on January 31, 2019

S. Z. Thalji1, M. Hembrook1, S. Tsai1, T. C. Gamblin1, C. Clarke1, M. Bedi2, J. Charlson3, C. G. Ethun4, T. B. Tran5, G. Poultsides5, V. P. Grignol6, J. H. Howard6, J. Tseng7, K. K. Roggin7, K. Chouliaras8, K. Votanopoulos8, D. Cullinan9, R. C. Fields9, K. A. Vande Walle10, S. Ronnekleiv-Kelly10, H. Mogal1  1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Department Of Radiation Oncology,Milwaukee, WI, USA 3Medical College Of Wisconsin,Department Of Medical Oncology,Milwaukee, WI, USA 4Emory University School Of Medicine,Division Of Surgical Oncology, Winship Cancer Institute,Atlanta, GA, USA 5Stanford University,Department Of Surgery,Palo Alto, CA, USA 6Ohio State University,Department Of Surgery,Columbus, OH, USA 7University Of Chicago,Department Of Surgery,Chicago, IL, USA 8Wake Forest University School Of Medicine,Department Of Surgery,Winston-Salem, NC, USA 9Washington University,Department Of Surgery,St. Louis, MO, USA 10University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Objective: While outcomes of patients with Retroperitoneal Sarcomas (RPS) who have microscopically or macroscopically positive margins after curative-intent resection has been studied, few studies have focused on outcomes in patients undergoing surgery with a palliative intent. This study aims to define common indications for and to elucidate factors that determine outcomes after palliative-intent resection of RPS.

 

Patients and

Methods: Using the retrospective 8-institution United States Sarcoma Collaborative (USSC) database, all patients who underwent resection of a primary or recurrent RPS (including intraabdominal or distant metastasis) with palliative intent between 2000 and 2016 were identified. Overall Survival (OS) was estimated by the Kaplan-Meier method and compared using the log-rank test. Multivariable logistic regression and Cox-proportional hazards models of patient- and treatment-related factors were constructed to determine their effect on postoperative complications and OS.

 

Results: Of a total of 3,088 patients, 70 patients underwent 87 distinct palliative-intent surgeries for RPS. Median age was 62.3 years (IQR 46.7–71.5) and 57% (n=50) were female. Most common indications for palliative surgery included pain (n=23, 26%), bowel obstruction (n=18, 21%), bleeding (n=7, 8%), and infection (n=2, 2%). Dedifferentiated liposarcoma (n=18, 21%) and leiomyosarcoma (n=17, 20%) were the predominant tumor types. Median OS for the entire cohort was 10.69 months (IQR 3.91-23.23). R2 resection status was the only factor independently associated with incidence of postoperative complications (OR 4.42, CI 1.01-19.38, p=0.049). The presence of complications (HR 3.25, CI 1.35-7.81, p=0.008) and high-grade histology (HR 4.45, CI 1.19-16.62, p=0.026) were associated with increased mortality. While OS was not independently affected by resection status, in patients who underwent R2 resections, the development of postoperative complications significantly reduced survival (p=0.042) (figure 1).

 

Conclusions: The occurrence of postoperative complications and high grade tumor biology rather than resection status determines survival in patients undergoing palliative-intent resections for RPS. Palliative-intent R2 resections should be cautiously performed for RPS given the higher-incidence of post-operative complications which may significantly lower survival.

54.06 Morbidity, Mortality and Temporal Trends in the Surgical Management of Retroperitoneal Sarcoma

Posted on January 31, 2019

S. J. Judge1, K. Lata-Arias5, M. Yanagisawa1, M. A. Darrow3, A. M. Monjazeb4, S. W. Thorpe2, A. R. Kirane1, R. J. Bold1, D. J. Canter5, R. J. Canter1  1University Of California – Davis,Surgical Oncology,Sacramento, CA, USA 2University Of California – Davis,Orthopedic Surgery,Sacramento, CA, USA 3University Of California – Davis,Pathology,Sacramento, CA, USA 4University Of California – Davis,Radiation Oncology,Sacramento, CA, USA 5Ochsner Health System,Urologic Oncology,New Orleans, LA, USA

Introduction:

Advocates of extended surgical resection to optimize oncologic outcomes in retroperitoneal sarcoma (RPS) are increasing, and selected studies have demonstrated that short- and long-term outcomes following multivisceral resection (MVR) of RPS are acceptable. We sought to analyze surgical outcomes following RPS resection in a contemporary cohort, hypothesizing that 30-day morbidity and mortality rates and prevalence of MVR in a larger sample size would remain consistent with prior studies.

Methods:

Utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified 636 patients with primary malignant neoplasms of the retroperitoneum from 2012 to 2015. Overall morbidity, severe morbidity, and mortality rates were compared among MVR and non-MVR patients, and univariate and multivariate analysis was performed to identify predictors of overall and severe postoperative morbidity (mortality rate was too low for meaningful analysis). The Cochran-Armitage trend test was used to assess for temporal trends in the utilization of MVR.

Results:
Of the 636 patients, 51% were female with a mean age of 59.8 ± 12.6 years. The majority were ASA class 3 (62%). Overall, median operative time was 228 minutes (range 47-987), and 256 (40%) underwent MVR (bowel resection = 119, nephrectomy = 91, cholecystectomy = 15). When comparing MVR to no MVR, there was no significant difference in overall morbidity (23% vs. 17%), severe morbidity (9% vs. 6%), and mortality (<1% vs. 2%), although overall morbidity approached statistical significance (P = 0.06). MVR patients did experience higher rates of deep incisional surgical site infection (SSI) (3% vs 1%, P = 0.03) and organ space SSI (7% vs 3%, P = 0.05) in the 30-day postoperative period. On multivariate analysis, MVR was not associated with increased overall morbidity (OR 0.92, 95% CI 0.57-1.49) or severe morbidity (OR 0.96, 95% CI 0.47-1.96). Rates of MVR ranged from a low of 38% in 2013 to a high of 45% in 2015 with no significant change over time (P = 0.53).

Conclusion:
Short-term morbidity and mortality rates after multivisceral resection of RPS remain acceptable, although rates of MVR show little change over time in NSQIP hospitals. Concerns about increased morbidity and mortality should not be viewed as a contraindication to wider implementation of extended resection for RPS.

54.05 Developing Patient-Centered Outcomes in Cancer Surgery: Survey Approaches for Digital Phenotyping

Posted on January 31, 2019

N. Panda1,2, I. Solsky1, J. P. Onnela3, A. B. Haynes1,2  1Ariadne Labs,Boston, MA, USA 2Massachusetts General Hospital,Surgical Oncology,Boston, MA, USA 3Harvard School Of Public Health,Biostatistics,Boston, MA, USA

Introduction:
Digital phenotyping is the moment-by-moment quantification of physical, social, behavioral, cognitive, and emotional functioning as reflected in smartphone data collected passively from smartphone sensors and actively through surveys. This approach to measuring individual functioning has the potential to improve shared decision-making, patient engagement, and improve outcomes that matter most to patients. The feasibility of active data gathering via surveys as acquired using digital phenotyping requires further investigation.

Methods:
Patients enrolled in a prospective study who underwent surgery for abdominal cancer downloaded the Beiwe smartphone app, developed by our research team for digital phenotyping. Beiwe, in addition to collecting passive data (i.e. GPS, accelerometer, call frequency) from smartphone sensors, pushed perioperative surveys to patients. Pre-operative surveys included the validated Short Form-36 (SF36) and Decision Conflict Scale (DCS) as well as a baseline survey on treatment expectations developed by our research team (ExpB). Post-operative surveys included a single item on the alignment of treatment expectations created by our team (ExpL, pushed at week 1, 4, 12, and 24 after surgery), SF36 (pushed at week 4, 12, and 24 after surgery), and the validated Decision Regret Scale (DRS, pushed at 12 and 24 weeks after surgery). Daily microsurveys (5-question survey generated randomly from SF36) were also administered perioperatively. Enrollment time and survey completion rates were analyzed. Responses gathered via intermittent SF36 versus daily microsurvey pushes were also compared.

Results:
Twenty patients with primary abdominal malignancies (10 sarcoma, 5 liver, 5 colon) who underwent surgery were followed for a median of 117.5 days [IQR 65.5, 158.0]. Pre-operative survey completion rates were 0.90 (±0.31), 0.90 (±0.31), and 0.95 (±0.22) for the SF36, ExpB, and DCS, respectively. Microsurvey completion rate throughout the study was 0.63 (±0.29). Post-operatively, the completion rates of the ExpL (pushed at 1 week), ExpL+SF36 (pushed at 4 weeks), and DRS+SF36+ExpL (pushed at 12 and 24 weeks) were 0.53 (±0.29), 0.71 (±0.32), 0.44 (±0.46), and 0.27 (±0.36), respectively. The mean number of items completed by patients through the intermittent complete SF36 administration was lower (75.9 (±38.5)) compared to daily microsurveys (347.8 (± 276.6), p=0.002).

Conclusion:
Active gathering of patient-reported quality of life outcomes is feasible several months into post-operative recovery in a digital phenotyping study. The daily administration of SF36 microsurveys resulted in a significantly greater number of total items completed throughout the study period in comparison to intermittent distribution of the SF36 in full. This suggests that microsurveys may allow for greater data collection; however, the validity of this approach must be studied further.

54.04 Differentiating ED Diagnosis and ED Use: Healthcare Utilization Patterns and GI Cancer Mortality

Posted on January 31, 2019

D. Steinmetz1, I. Solsky1, B. Rapkin2, M. Parides1, J. M. Leider3, H. In1,2  1Montefiore Medical Center/Albert Einstein College of Medicine,Department Of Surgery,Bronx, NY, USA 2Montefiore Medical Center/Albert Einstein College of Medicine,Department Of Epidemiology And Population Health,Bronx, NY, USA 3Jacobi Medical Center/ Albert Einstein College of Medicine,Internal Medicine,Bronx, NY, USA

Introduction:  Diagnosis of a gastrointestinal (GI) cancer via the emergency department (EDdx) is considered a marker of poor outcomes. Understanding patterns of health care usage of EDdx patients may illuminate targets for intervention to improve patient outcomes.

Methods:  Cancer registry and pre-diagnosis administrative data were collected for patients diagnosed with GI cancers (esophagus, stomach, pancreas, colon, rectal and anal cancers) in 2010-2014 at a single academic institution serving one of the poorest urban regions of the country. Persons with an ED visit in the month prior to cancer diagnosis were considered to have EDdx. Descriptive statistics were performed including classification of patients by patterns of healthcare utilization in the year prior to diagnosis (outpatient only, ED with or without outpatient visits (EDuser), no visits, and prior hospitalizations). Logistic regression identified predictors of EDdx. Kaplan-Meier method and Cox proportional hazards regression assessed the influence of patterns of healthcare utilization on survival for EDdx and non-EDdx patients.

Results: Of 3,174 patients analyzed, 13% were EDdx patients. EDdx patients were more commonly non-white (82.5% vs. 77.8%), with non-private insurance (72.4% vs. 66%), more comorbidities (≥3: 74% vs. 67%), upper GI cancers (52% vs. 39%) and late cancer stage (56% vs. 40%). Patients with prior hospitalizations were more likely to be EDdx (OR 1.76, 95%CI: 1.21-2.54); however no difference in ED diagnosis rates was observed for other care patterns. EDdx was associated with improved survival for EDuser and worse survival for all other care patterns (Figure 1). Significant interaction was found between EDdx and care patterns for overall mortality (p = <0.05).  After controlling for demographics and cancer factors, EDusers had improved mortality regardless of location of diagnosis, with markedly improved outcomes when diagnosed in the ED (EDuser & non-EDdx HR 0.74 95% CI: 0.58-0.94, EDuser & EDdx HR 0.42 95% CI: 0.25-0.71) compared to patients who were outpatient only and non-EDdx. As expected, EDdx patients with no prior visits or with prior hospitalizations had the worst outcomes (no visits & EDdx HR: 1.20 95% CI 1.65-2.94, prior hospitalization & EDdx HR: 1.52 95% CI 1.11-2.06).

Conclusion: Diagnosis in the ED was not uniformly a predictor of poor outcomes. Patients in this inner city hospital who rely on routine ED healthcare experienced better than expected outcomes and the diagnosis of cancer in the ED resulted in improved outcomes for these patients. Results suggest the need to understand benefits as well as harms before implementing broad-brush policies to divert routine ED care.

 

54.03 Patient Perceptions about the Role of Spirituality and Faith During Cancer Treatment

Posted on January 31, 2019

E. N. Palmer Kelly1, B. A. Fischer3, A. E. Onuma2, K. J. Deans3, T. M. Pawlik2  1Ohio State University,Comprehensive Cancer Center,Columbus, OH, USA 2The Ohio State University Wexner Medical Center,Surgery,Columbus, OH, USA 3Nationwide Children’s Hospital,Center For Surgical Outcomes Research,Columbus, OH, USA

Introduction: The availability of spiritual/faith resources during cancer treatment may positively impact patient outcomes, feelings of wellbeing, and be important components of holistic, patient-centered care. We sought to characterize the perspectives of cancer patients on the role of spirituality and faith in order to better define the desired access to related resources during cancer care.

Methods:  The listserv ResearchMatch was utilized to survey a convenience sample of adult cancer patients electronically. Demographic data were collected and information on spirituality/faith was assessed using quantitative tools such as FACIT-SP, Meaning of Cancer Subscale (IOC), and select items from the AYA HOPE survey. The bidirectional influence between cancer and spirituality/faith, including access to related resources, were assessed using open-ended questions. Analyses included descriptive statistics and content analysis.

Results: Among the 116 respondents, cancer diagnoses included breast (n=39), prostate (n=17), thyroid (n=10), gastrointestinal (n=8), and other (n=29). Surgery was the most common treatment modality (n=77) followed by radiation (n=54) and chemotherapy (n=52).  Overall, 72% of respondents (n=100) self-identified with a religion (Christian/Protestant: n=49, 49%; Christian/Catholic: n=19, 19%; Judaism: n=8, 9% other: n=7, 7%) and 13 (13%) identified as Agnostic. Roughly one-half of patients (48%) reported that their cancer diagnosis had an impact on their spiritual/religious beliefs, noting that cancer deepened (n=19, 40%) more often than weakened (n=9, 19%) their beliefs. Participants were asked to rank-order who they would want to speak to about their spirituality/faith. Rather than a member of the healthcare team, the first preference was a family or friend (n=39, 48%), followed by hospital chaplain (n=12, 15%) or personal spiritual advisor (n=11, 13%). Content analysis identified a subset of patients who expressed a desire to have the healthcare team introduce the topic of spirituality/faith (n=13, 20%); however, more patients did not see this as part of the healthcare team’s role (n=24, 38%).  Rather, participant responses suggested that utilized spirituality/faith resources were mostly personal (e.g., their pastor, family, books; n=17; 37%) rather than a resource provided by the medical center (e.g., chaplaincy; n=7, 16%).

Conclusion:Spirituality/faith can be an important need for some cancer patients as one-half of respondents expressed a relationship between the cancer diagnosis and their spiritual/religious beliefs. However, most patients desired to talk about spirituality/faith with a family or friend instead of a member of the healthcare team. These data can help inform future research aimed at addressing patient-centered spirituality/faith needs of cancer patients.

 

54.02 Patient Preferences on the Use of Technology in Cancer Surveillance After Curative-Intent Surgery

Posted on January 31, 2019

A. Onuma2, E. Palmer2, J. Chakedis2, B. Wiemann2, M. Johnson2, K. Merath2, O. Akgul2, J. Cloyd2, T. Pawlik2  2The Ohio State University Medical Center,Department of Surgery,Columbus, OHIO, USA

Introduction:  Advances in communication technology have enabled new methods of delivering test results to patients. Nevertheless, patient preferences regarding the manner in which surveillance test results are shared with cancer patients during the survivorship period have not been previously assessed.

Methods:  A single institutional, cross-sectional analysis of the preferences of adult cancer survivors regarding the means (secure digital communication vs. phone-call or office visit) to receive surveillance test results was undertaken.

Results:Among 241 respondents over a 6-month period, the average age was 68.4±13.6 years and 61.8% were female. The most common malignancies included breast (22.8%), melanoma/sarcoma (29.5%), gastrointestinal (22.0%) and thyroid (25.7%). Patients were surveyed on average 33.6±31.5 months following surgery. While patients expressed a relative preference to receive normal surveillance results via MyChart/Secure-email, the majority of patients preferred that abnormal imaging (56.2%) or blood (50.4%) results be communicated only by in-office appointments regardless of age or cancer type. Patients with a college degree were more likely to prefer receiving normal imaging (52.7% vs 38.1%, p=0.029) and blood (69.6% vs 48.9%, p=0.002) results electronically than those without a degree. Patients < 65 more often preferred to receive normal blood surveillance results electronically versus patients ≥65 years old (50.0% vs. 32.9%, p=.012). Preference also varied according to malignancy type (Figure1).

Conclusion: While many patients preferred to receive “normal” surveillance results via MyChart/secure-email, the majority preferred receiving abnormal results via direct conversation with their provider. Shifting routine communication of normal surveillance results to technology-based applications may improve patient satisfaction and decrease health care system costs.

54.01 The impact of a prior history of cancer upon trauma related outcomes.

Posted on January 31, 2019

C. Parker1, T. J. Miner1, D. S. Heffernan1  1Brown University School Of Medicine,Department Of Surgery,Providence, RI, USA

Introduction: Trauma remains a leading cause of death and, among survivors, long term disability and organ dysfunction. Underlying medical comorbidities are significant drivers of trauma related complications. A history of having survived a prior cancer diagnosis is also a common finding among the general population. Cancer survivors often display long term depressed physiologic and/or immunologic reserve. Given that robust immune and physiologic systems are critical to trauma survival, we hypothesize that trauma patients with a history of a prior cancer will display markedly worsened compared to patients with no prior malignancy.

Methods: This is a retrospective review of 4 years of prospectively collected data from a Level 1 trauma center. Charts were reviewed for patient characteristics, injuries sustained and injury severity score (ISS), medical history, with a focus on prior malignancy, presence of DNR/DNI upon presentation, hospital course, and trauma related outcomes, including mortality and discharge disposition. Patients were divided into those with a History of Cancer (HxC) versus those with no prior Cancer (noC). Given the considerable age difference between groups, from among the noC patients, we selected an age matched cohort for comparison.

Results: Among the trauma population as a whole HxC patients were older (73.4 vs 59.2 years; p<0.001). HxC patients, compared to the selected aged matched control displayed no difference in male gender (50.5% vs 49.3%;p=0.9) or ISS (11.2 +/-0.8 vs 10.2+/-0.1; p=0.2). HxC patients had higher average number of non-cancer medical comorbidities (3.1 +/-0.2 vs 2.5+/-0.02; p=0.005). With respect to specific comorbidities, there was no difference in CHF (10.1% vs 7.9%;p=0.5) but HxC patients had significantly higher rates of COPD (23.6% vs 10.6%; p<0.001) and were markedly more likely to be DNR/DNI upon initial presentation following the traumatic injury (27% vs 10.6%; p<0.001). There was no difference in overall hospital length of stay (5.7 +/-0.3 vs 6.4+/-0.1 days; p=0.3). HxC patients had overall greater mortality (13.5% vs 5.4%; p=0.002). Among survivors, HxC patients were less likely to be discharged home (25.9% vs 44.7%; p=0.002) and were markedly more likely to discharged to a hospice (11.7% vs 2.2%; p<0.001). 

Conclusion: Among our trauma population, patients with a prior history of a malignancy present with higher rates of DNR and exhibit overall lower survival and higher rate of discharge to hospice. It is possible that having survived a major cancer diagnosis, HxC patients cannot tolerate the physiologic or immunologic “second hit” burden of a major traumatic injury. We further speculate that our data may have uncovered an unconscious lack of motivation to undergo extensive lifesaving measures after being exhausted by a cancer diagnosis.  

 

53.20 Effect of Surgical Day of Week on Postoperative Outcomes with Robotic-Assisted Pulmonary Lobectomy

Posted on January 31, 2019

T. Chambers2, F. Velez-Cubian2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. Toloza1,2  1Moffitt Cancer Center And Research Institute,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   The purpose of this study was to assess if patients who underwent surgery received immediate postoperative care at the beginning of the week (Monday through Wednesday [M-W]) had different outcomes than patients who had surgery and immediate postoperative care at the end of the week (Thursday and Friday [Th-F]).  In theory, surgical patients at the end of the week would receive different care due to their postoperative care being given by a partial weekend staff as compared to the full staff during the work week.  This is important to this practice because if there is a difference in outcomes, hospital staffing for weekend care should be adjusted accordingly.

Methods:   Patients, who underwent robotic-assisted pulmonary lobectomy from 2010 to 2016, were divided into the M-W group or the Th-F group according to their surgical day of the week.  Patient demographics, tumor histopathology, intraoperative and postoperative complications, and perioperative outcomes were assessed and compared between groups using independent samples t-test, Pearson Chi-square analysis, Levene’s test, Mann-Whitney U test, and Fisher’s exact test, with significance at p≤0.05.

Results:  There were 344 patients in the study cohort.  After analysis of each of these variables, the Th-F groups had a median skin-to-skin operative time that was 23 minutes longer than that for the M-W group and a median total operative time that was 27 minutes longer than that for the M-W group.  There were significantly more non-small cell lung cancer (NSCLC) and larger tumors resected in the M-W than in the Th-F group.  There were no significant differences between the two groups in the other variables assessed.

Conclusions:  NSCLC tumors were more common in the M-W group and tended to be larger tumors; however, these tumors took less time to resect.  These differences in outcomes based on surgical day of the week could be due to differences in surgeon and/or surgical team performance during different days of the week.  Surgical team schedules should be varied to allow more veteran surgical members to be distributed evenly among the week, which can help lower median surgical times and the amount of anesthesia exposure needed for each case.  Future studies can look to see if this finding continues across other procedures.

53.18 Nodal Skip Metastasis and Outcomes after Robotic-Assisted Pulmonary Lobectomy for Lung Cancer

Posted on January 31, 2019

R. Gerard2, D. Nguyen2, F. Velez-Cubian2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. Toloza1,2  1Moffitt Cancer Center And Research Institute,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   We sought to evaluate both short- and long-term postoperative outcomes between patients with continuous nodal metastasis (NoSkip) compared to those with nodal skip-metastasis (Skip).

Method:   We retrospectively analyzed patients who underwent robotic-assisted video-thoracoscopic (RAVT) pulmonary lobectomy by one surgeon between September 2010 and May 2017.  Patients with final pathology reporting pulmonary metastasis or benign lesion were excluded.  Inclusion criteria consisted of obligatory pathologic mediastinal nodal (pN2) classification.  Patients were then stratified into two groups:  Skip or NoSkip.  Patients’ demographics, perioperative outcomes, perioperative complications, and overall survival (OS) were compared.

Results:  Of a total of 423 patients who underwent RAVT lobectomy, 390 patients had non-small cell lung cancer (NSCLC).  While 319 patients with NSCLC were pN0 or pN1, 71 patients had pN2 disease, of which 18 (25.3%) were Skip and 53 (74.7%) were NoSkip.  Mean age, gender distribution, and body habitus were similar between groups (p=0.617, p=0.194 and p=0.091, respectively).  Patients with Skip had lower mean pre-operative forced expiratory volume in 1 second as percent of predicted (FEV1%; 79.5±3.5% vs. 89.7±2.8%), but this difference was not quite significant (p=0.053).  Albeit not significant, patients in the NoSkip group had slightly more intraoperative complications (15.1% vs. 5.6%) and slightly more often required conversion to thoracotomy (15.1% vs. 5.6%) compared to the Skip group (p=0.293 and p=0.293, respectively).  Incidence of postoperative complications were similar between groups (p>0.05).  Patients in both groups had similar median estimated blood loss (EBL; 200 mL vs. 200 mL), operative time (214.5 min vs. 197 min), chest tube duration (4.5 d vs. 4 d), and hospital length of stay (LOS; 5 d vs. 5 d) (p=0.734, p=0.178 and p=0.973, respectively).  Mean number of N1 lymph node (LN) stations reported and mean number of N1 LNs evaluated were similar between groups (1.9±0.1 vs. 1.7±0.1 [p=0.226] and 7.6±0.6 vs. 6.7±0.6 [p=0.441], respectively).  Mean number of N2 LN stations reported and mean number of N2 LNs evaluated were also similar between groups (3.7±0.0 vs. 3.4±0.2 and 11.4±1.1 vs. 9.4±1.4, respectively).  Patients with nodal skip metastasis (Skip group) had slightly less favorable 1-yr (50.7%±13.8% vs. 80.0%±6.4%) and 3-yr OS (42.2%± 13.9% vs. 57.1%±9.2%) (p=0.077).

Conclusion:  Mean patient age, gender distribution, and body habitus did not differ between groups.  Patients with Skip had reduced FEV1% pre-operatively, but the number of postoperative complications remained similar between groups.  No significant differences were noted in EBL, operative times, chest tube duration, and hospital LOS.  Skip is associated with worse OS compared to patients with NoSkip.

53.17 Indocyanine Green for Ureter Identification During Robotic Colectomy: A Single Center Study

Posted on January 31, 2019

S. B. Bryczkowski1, J. E. Glanville2, A. H. Khosravi3, A. S. Rosenstock1, G. Mazpule1, S. G. Pereira1  1Hackensack University Medical Center,Surgery,Hackensack, NJ, USA 2Hospital Corporation of America,Surgery,Richmond, VA, USA 3St. Joseph Hospital,Surgery,Tustin, CA, USA

Introduction: Robotic surgery has gained favor across specialties. There is an ongoing effort to make colorectal surgery safer. Urologists have used indocyanine green (ICG) dye to identify ureters during robotic ureterolysis, but no studies existed on ICG use during robotic colectomy. We hypothesized that intraureteral ICG would decrease the time to identify the ureters during robotic sigmoid colectomy.

 

Methods: A retrospective review of prospective data at a single academic center. The use of ICG for ureteral identification reflected a change in practice. Patients either had ureteral stents with intraureteral ICG or stents alone (no ICG). Colectomies were performed by one of three attending surgeons and assisted by one of three robotic fellows. The primary outcomes were time to identify ureters and operative (OR) time. Secondary outcomes were complications of ureteral injury, leak, and infection. All adults (>18) who presented for elective robotic sigmoid colectomy between Oct ’15 – Aug ‘17 were included. Exclusion criteria were pregnancy, age ≤18, and emergency surgery. Data collection included demographics (age, gender), surgical indication (complicated or recurrent diverticulitis or neoplasm), and clinical data (number (n) diverticulitis episodes, n previous surgeries). Data were analyzed using student t test, chi square analysis, or one-way ANOVA.

 

Results: Of 151 patients admitted for colectomy, 30 met criteria. Of those, 16 received ICG and 14 did not (no ICG). There were no differences in age between ICG and no ICG, [presented as mean (m), ± standard deviation (sd)] (59 ± 15 vs. 63 ± 10, p=0.21) or gender, [% female] (50% vs. 71%, p=0.23). There was a statistically significant decrease in the time to identify the ureters in the ICG group [m ± sd] (10min ± 12 vs. 38 ± 81, p=0.04). There were no differences in OR time (264min ± 63 vs. 281 ± 52, p=0.11), n diverticulitis episodes (4 ± 3 vs. 5 ± 9, p=0.39), n previous abdominal surgeries (0.9 ± 0.8 vs. 0.5 ± 0.8, p=0.06), cases of complicated diverticulitis, [n, %] (6, 38% vs. 6, 43%, p=0.76), or in rate of ureteral identification (16, 100% vs. 13, 93%, p=0.14).

 

Conclusion: This single center study demonstrated that intraureteral ICG allowed faster ureteral identification during robotic sigmoid colectomy. Although overall OR time did not differ between the groups, all ureters were identified when ICG was used. Early ureteral identification with ICG could lead to safer colorectal surgery by preventing injury to the ureters. Future studies should focus on whether early ureteral identification using ICG leads to decreased incidence of ureteral injury during robotic colectomy.

53.16 Cement Volume, Height Restoration and Outcomes Following Kyphoplasty

Posted on January 31, 2019

J. H. Mooney1, J. Amburgy1, M. Self1, P. Pritchard1, B. Agee1, M. R. Chambers1  1University Of Alabama at Birmingham,Neurosurgery,Birmingham, Alabama, USA

Introduction:

Kyphoplasty is a minimally invasive surgery developed to restore height and stabilize painful vertebral compression fractures (VCFs). There is an abundance of published data illustrating reduction of pain, disability and improved quality of life following kyphoplasty.  However, there has been no clear correlation between patient outcomes and the volume of cement injected or degree of vertebral height restoration.  The objective of this analysis is to determine if cement volume or height restoration following kyphoplasty correlate with improvements in pain, disability, and quality of life.

Methods:

In this case series, we assessed outcomes following kyphoplasty in 136 Medicare-eligible patients with 1 to 3 painful VCFs between T5 and L5 due to osteoporosis or cancer. The total volume of bone cement injected at each level was recorded for each patient.  Anterior, middle, and posterior vertebral body heights were measured in fifty-nine patients pre and post-operatively utilizing computerized lateral thoracic and/or lumbar radiographs. Patient outcomes were evaluated before and after surgery. The Visual Analog Scale (VAS, range: 0(none) – 10(worst)) was used to prospectively measure back pain preoperatively in all patients.  Pre and post-operative measurements of disability and quality of life were retrospectively collected using the Roland Morris Disability Questionnaire (RMDI, range: 0(no disability) -24(high disability)) and EuroQol 5-Domain scale (EQ5D, range: -0.11(poor quality of life) – 1.0(perfect health)).  Pearson correlations as well as linear regression models were derived for association of total cement volume and vertebral height restoration with patient outcomes. 

Results:

For VAS, RMDI, and EQ5D improvements, neither Pearson correlations (r= 0.042, 0.167, and 0.091), respectively, nor multiple linear regression models (R²= 0.002, 0.029, 0.023), respectively, reveal either a correlation or an association with total cement volume.  Additionally, neither Pearson correlations (r coefficients ranging from 0.001-0.152) nor linear regression models (R² values ranging from 0.0002-0.1133) reveal either correlation or association between anterior, middle, or posterior vertebral body height improvements with VAS, RMDI or EQ5D improvements. 

Conclusion:

This is the largest known study to assess associations of vertebral body height improvements and cement volumes with patient outcomes.  Most patients improved regardless of the vertebral height improvements or cement volumes injected.

 

53.15 The optimal surgical management for colorectal liver metastases in the era of multidisciplinary treatment.

Posted on January 31, 2019

T. Ochiai1, T. Shigeno1, M. Sakano1, T. Igaki1, R. Matsumoto1, N. Chiyonobu1, I. Saito1, K. Saito1, S. Yamazaki1  1Ohta Nishinouchi General Hospital,Suregry,Koriyama, FUKUSHIMA, Japan

Introduction:  Recent advances in chemotherapy have expanded the resectability of colorectal cancer with liver metastases (CRLM), optimal surgical management for the patients with CRLM is controversial. We studied treatment results in the patients with CRLM since molecular target-based agent was approved in Japan since 2008. 

Methods: Based on data collected retrospectively, we analyzed the demographics, clinical data, operative findings, chemotherapy, and outcomes of 285 consecutive CRLM patients treated between 2008 and 2017. To investigate the optimal surgical management, we devided the observation periods into 2 periods, 2008-2011 and 2012-2017, and analyzed resectability and response rate of chemotherapy. 

Results:The 1-, 3-, and 5-year overall survival rates for the entire CRLM patient and 109 patients who underwent liver resection were 80.4%, 48.4%, and 30.0%, and 94.3%, 72.5%, and 52.8%, respectively. Out of synchronous/metachronous, neo-adjuvant and adjuvant chemotherapy, repeat liver resection, only perioperative chemotherapy revealed significant difference in resected 109 patients. The resectability of whole CRLM was 38.2% in 2008-2017, 46.2% in 2008-2011, and 33.5% in 2012-2017. The response rate of patients with unresectable or neoadjuvant chemotherapy were 43.8% in 2008-2017, 43.1% in 2008-2011, and 45.0% in 2012-2017. The 1-, 3-, and 5-year overall survival rates for the entire CRLM patient and 101 patients who underwent liver resection were 74.8%, 48.4%, 32.6%, and 93.7%, 80.7%, 55.5% in 2008-2011, and 84.0%, 47.1%, 25.2%, and 94.9%, 71.1%, 49.5% in 2012-2017. Three cases of initially unresectable CRLM converted to complete resection with neoadjuvant chemotherapy. 

Conclusion:Although development of various molecular target-based agents has improved short-term survival of CRLM patients, liver resection is the key of long-survival. Neither neoadjuvant nor adjuvant chemotherapy is not significantly different in survival, but perioperative chemotherapy is effective in this study. To improve survival of the patients with CRLM, aggressive surgery and perioperative chemotherapy without missing the timing of hepatectomy are required. 

 

53.14 Influence of Tumor Distance from Carina on Outcomes with Robotic-Assisted Pulmonary Lobectomy

Posted on January 31, 2019

J. Bennett1,2, F. Velez-Cubian2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. Toloza1,2  1Moffitt Cancer Center And Research Institute,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   Tumor location can vary within the lung, and the location of a tumor has an impact on the surgical approach used during a minimally invasive thoracic surgery.  This study investigated the relationship between the location of lung tumors and post-surgical hospital length stay.

Methods:   We retrospectively analyzed clinical data from patients who underwent robotic-assisted pulmonary lobectomy for non-small-cell lung carcinoma.  Hospital length of stay was assessed through chart reviews.  Location of tumor (distance from the carina) was assessed using a direct measurement tool in a computerized tomography (CT) scan image-viewing program.  Student’s t-test, Kruskal-Wallis median test, and Chi-square test were used to compare variables, with significance at p≤0.05.  Multivariable regression analysis was performed to assess the relationship of tumor distance from carina, age, gender, body mass index (BMI), and hospital length of stay. 

Results:  Among 299 patients (mean age, 67.2 ± 0.6 yr; median age, 68.0), there was one patient excluded from the study due to incomplete data.  Mean distance from the center of the tumor to the carina was 9.0 ± 0.2 cm.  The patient cohort exhibited a gender distribution of 55% female and 45% male, with a mean BMI was 27.6 ± 0.3 kg/m2.  Length of stay was found to have a mean of 5.3 ± 0.3 days and median of 4.0 days.  Although univariate analysis of the variables demonstrated that gender was a significant indicator of hospital length of stay, multivariable regression analysis, adjusting for variables of age, BMI, and tumor distance discounted the notion that gender was significant in predicting hospital length of stay.  Age significantly predicted hospital length of stay, while adjusting for tumor distance, gender, and BMI [F(4, 281) = 2.475, p=.045, R2 = .020].  Tumor distance from the carina was not a significant predictor of hospital length of stay (p= 0.530).

Conclusion:  Given these findings, we do not believe that tumor distance from the carina is an effective indicator for hospital length of stay for pateints undergoing robotic-assisted pulmonary lobectomy.  Instead, age was the best independent predictor of hospital length of stay.

53.13 Two Port plus Teleflex Minigrasper Transabdominal preperitoneal (TAPP) Inguinal Hernia Repair

Posted on January 31, 2019

H. J. Bonatti1, H. Bonatti1  1Meritus,Surgical Specialists,Hagerstwon, MD, USA

Introduction: Transabdominal preperitoneal (TAPP) inguinal hernia repair requires a 10mm and two 5mm trocars. When using a transverse peritoneal flap, a rather long incision is required. Tacks for MESH fixation and re-approximation of the flap may be associated with pain and are costly.

Methods: A two port technique was used replacing one 5mm instrument with a Teleflex minigrasper. The peritoneal flap was created from a 5-10cm vertical incision in the infraumbilical peritoneum and re-approximated with a running suture or tacks. Dissection of the inguinal region was done in a reduced size pocket.

Results: Median age of the 17 men and five women was 64.4 (range 29.5-84.8) years; there were 16 unilateral and six bilateral inguinal hernias (including three recurrent hernias and two incarcerated hernias). Two patient had large inguinoscrotal hernias. Tacks for the flap were used in four of the first seven cases; in the last 15 suture closure was used in all patients. Various techniques to suture the flap were tried out, the V-lock turned out to be the easiest option and was made standard. In eight patient only two 5mm trocars were used, in two patients a 5mm and an 8mm trocar was inserted and in 12 patients a 5mm and a 10mm trocar was used. Progrip MESH without tacks was placed in 20 patients. TAPP was done as outpatient procedure in 50% of cases, six patients required 23 hours extended recovery; only five patients with severe co-morbid conditions required admission. Complication included seroma (n=2), bladder injury (n=1) and urinary retention (n=2); two patients with preexisting groin pain had ongoing symptoms post TAPP. No recurrence was observed during a median follow up of 722 (range 14-1299) days.

Conclusion: Creation of the peritoneal flap from a midline incision and re-approximation using a running suture is technically feasible. The created preperitoneal pocket is smaller than in conventional TAPP but still allows good exposure. TAPP can be done with two 5mm ports and the Teleflex minigrasper. The minigrasper can be used for laparoscopic suturing.

 

53.12 Risk Factors for and Associations of Prolonged Air Leak after Robotic-Assisted Pulmonary Lobectomy

Posted on January 31, 2019

R. Gerard2, R. Patel2, D. Nguyen2, F. Velez-Cubian2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. Toloza1,2  1Moffitt Cancer Center And Research Institute,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   Prolonged air leak (PAL) is the most common complication following partial lung resection and an important determinant of hospital length of stay (LOS).  This study sought to identify risk factors for developing PAL after robotic-assisted video-thoracoscopic (RAVT) pulmonary lobectomy.

Methods:   We retrospectively analyzed prospectively-collected data from patients who underwent RAVT lobectomy by one surgeon between September 2010 and May 2017.  Patients were grouped based on having or not having PAL, defined as an air leak persisting >5 days, during the postoperative period.  Patients’ demographics, intraoperative complications, perioperative outcomes, and postoperative complications were compared.

Results:  Of 423 total patients who underwent RAVT lobectomy, 89 patients (21%) experienced PAL.  Patients with PAL had lower mean body mass index (BMI) compared to patients with no PAL (26.9 kg/m2 vs. 28.7 kg/m2, p=0.045).  Patients who developed PAL postoperatively were more likely to have chronic obstructive pulmonary disease (COPD) (33% vs. 16%, p<0.001) or history of previous pneumonia (14% vs. 7%, p=0.045).  Patients with PAL had lower pre-operative forced expiratory volume in 1 second as percent of predicted (preopFEV1%) (81.2% vs. 87.4%, p=0.010).  Patients with repeat pulmonary surgery were more likely to experience PAL postoperatively, with 50% of those 14 patients developing PAL.  Patients who had intraoperative tracheobronchial injury were also at higher risk for PAL (p=0.032).  Patients with PAL experienced greater median estimated-blood-loss (EBL) (200 mL vs. 150 mL, p=0.013) and greater median operative time (208 min vs. 172 min, p=0.001).  Patients with PAL had longer median hospital LOS (9 d vs. 4 d, p<0.001).

Conclusion:  Decreased BMI, decreased preopFEV1%, COPD, previous pneumonia, re-do surgery, and intraoperative bronchial injury were identified as being risk factors for the development of PAL during the postoperative period.  These patients also experienced increased EBL, operative time, and had longer hospital LOS.

53.11 Effect of Insurance Type on Postoperative Outcomes after Robotic-Assisted Pulmonary Lobectomy

Posted on January 31, 2019

P. Deol2, J. Sipko2, A. Kumar2, A. Tsalatsanis2, F. Velez-Cubian2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. M. Toloza1,2  1Moffitt Cancer Center,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   Underinsured patients reportedly are less likely to undergo surgical treatment for lung cancer.  We studied the effect of insurance type on patient outcomes following minimally invasive pulmonary lobectomy.

Methods:   We retrospectively analyzed patients who consecutively underwent robotic-assisted pulmonary lobectomy by one surgeon over an 80-month period.  Perioperative outcomes as well as intraoperative and postoperative complications were noted.  Disposition at discharge after surgery (favorable, e.g. transfer to home with self-care or home health nursing and/or physical therapy, vs. unfavorable, e.g. long-term acute care or rehabilitation facility, hospice, or expired) and 5-year overall survival (5-yr OS) were also recorded.  We used Pearson Chi-square (X2), Analysis of Variance (ANOVA), and Kruskal-Wallis test to compare variables, and Cox regression for survival analysis, with statistical significance established at P<0.05.

Results:  Of 433 study patients, 107 patients had private insurance (mean age 57.5 yr), 118 had public insurance [Medicare or Medicaid (mean age 70.3 yr)], 196 patients had combination insurance plans [Medicare plus a privately supplied supplemental plan (mean age 71.8 yr; P<0.001)], and 12 patients had no insurance (excluded due to low sample size).  There were more current smokers in the public insurance group, more former smokers in the combination insurance group, and more nonsmokers in the private insurance group (P=0.03).  There were more comorbidities in the public and combination insurance groups vs. the private insurance group, including gastroesophageal reflux disease (P=0.003), hypertension (P=0.01), and hyperlipidemia (P<0.001).  The groups had no differences in tumor size or pathologic stage.  There were a higher rate of intraoperative conversions to open lobectomy in the private and public insurance groups vs. the combination insurance group (P=0.001).  The private and combination insurance groups had more cases of favorable disposition at discharge after surgery compared to the public insurance group (P<0.001).  Multi-variable regression analyses identified private insurance type as an independent predictor of favorable disposition at discharge [public vs. private plan; odds ratio (OR): 0.43 [95% confidence interval (CI): 0.22 – 0.85], P=0.02] as well as 5-yr OS [(combination vs. private plan; hazard ratio (HR): 2.68 (95% CI: 1.26 – 5.67), P=0.01), (public vs. private plan; HR: 2.84 (95% CI: 1.37 – 5.89), P=0.01)].

Conclusions:  Although public or combination insurance type was associated with greater risk of all-cause 5-yr mortality, and public insurance type was associated with overall conversion to open lobectomy and less favorable disposition at discharge after surgery, insurance type was not associated with increased intraoperative complications, hospital length of stay, or in-hospital mortality following minimally invasive robotic-assisted pulmonary lobectomy.

53.10 Guidelines for Symptom Recurrence in Achalasia: Defining ‘Failed Myotomy’

Posted on January 31, 2019

E. H. Bruenderman1, R. C. Martin1, M. P. Fox2, V. H. Van Berkel2, S. B. Block1, F. J. Kehdy1  1University Of Louisville,Department Of Surgery,Louisville, KY, USA 2University Of Louisville,Department Of Cardiovascular And Thoracic Surgery,Louisville, KY, USA

Introduction: Current treatments of achalasia aim to relieve the outlet obstruction at the gastroesophageal junction (GEJ) but cannot address the progressive degeneration of neurons affecting esophageal motility.  Heller myotomy provides excellent short-term relief, however, long-term symptom recurrence is common.  The term ‘failed myotomy’ is often used to reference symptom recurrence but has no universally accepted definition and is not addressed in SAGES guidelines, last updated in 2011. Standardizing the approach to symptom recurrence will delineate what constitutes a ‘failed myotomy’ versus progressive peristaltic failure.

Methods: Patients with achalasia who underwent laparoscopic Heller myotomy at a single center between 2013 and 2018 were reviewed and data extracted.  Patient demographics and characteristics were compared.  Patients with symptom recurrence were noted.  Follow-up imaging studies were reviewed for objective evidence of GEJ outflow obstruction versus none.  Results were used to compose an algorithm to address symptom recurrence and define ‘failed myotomy.’

Results: A total of 59 patients with a median age of 50 (range 13 to 91) years, 26 (44.1%) were male, median BMI was 27.76 (range 16.13 to 49.03), 18 (30.5%) had undergone prior Botox injection, 30 (50.8%) had undergone prior dilation.  Fundoplication was performed on 21 (35.6%) patients.  Median follow-up was 3 (range 0.5 to 60) months.  Symptom recurrence occurred in 23 (39.0%) patients, with a median interval to recurrence of 13 (range 0.5 to 45) months.  Of those with symptom recurrence, 15 (65.2%) underwent repeat upper gastrointestinal series (UGI), with 7 showing narrowing at the LES. Of 17 (73.9%) who underwent repeat EGD, 4 showed narrowing at the LES.  Of 5 (21.7%) who underwent repeat high resolution manometry (HRM), 1 revealed impairment of LES relaxation.  One (4.3%) patient was lost to follow-up prior to undergoing repeat imaging.  A total of 7 (30.4% of recurrence cohort, 11.9% of total cohort) patients with symptom recurrence required repeat intervention – 4 dilations, 1 dilation and subsequent POEM, 1 redo Heller myotomy, and 1 lost to follow-up before intervention.  A diagnostic algorithm for recurrence was created, defining ‘failed myotomy’ as symptom recurrence after myotomy, with objective findings confirming GEJ outflow obstruction, either on HRM alone, or on UGI and subsequent EGD.

Conclusion: Treatment of achalasia aims to relieve a hypertensive LES.  Symptom recurrence occurs frequently, underscoring the importance of distinguishing a true ‘failed myotomy’ from the progressive degeneration of peristalsis that characterizes achalasia.  Objective evidence of GEJ outflow obstruction in the form of UGI with EGD, and/or HRM, is crucial to label recurrence as a ‘failed myotomy’ and direct further treatment.  We propose updated guidelines to reflect this common issue in the treatment of achalasia.

53.09 Effect of Smoking on Atrial Fibrillation following Robotic-Assisted Video-Thoracoscopic Lobectomy

Posted on January 31, 2019

J. Sipko2, P. Deol2, T. Reljic2, F. Velez-Cubian2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. Toloza1,2  1Moffitt Cancer Center And Research Institute,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   Patients’ smoking history, including smoking status and length of smoking cessation prior to surgery, have been reported as risk factors for post-operative (post-op) atrial fibrillation (A-fib) after non-cardiac thoracic surgery.  However, no research to date has determined if smoking history serves as a risk factor for A-fib following lobectomies performed via the minimally invasive robotic-assisted technique.  The present study sought to determine the effect of patients’ smoking history and length of smoking cessation prior to surgery on the risk of developing A-fib following robotic-assisted video-thoracoscopic (RAVT) lobectomy to allow for more appropriate dispositioning of patients.

Methods:   This study is a retrospective, cross-sectional, observational study, in which data was collected by chart review of 450 consecutive eligible patients who underwent RAVT lobectomy by a single surgeon between October 2010 and August 2017.  The presence of new onset post-op A-fib was analyzed in patients who never smoked, currently smoke (including those who quit within two months prior to surgery), quit smoking between 2-12 months prior to surgery, and quit smoking >12 months in order to identify an optimal timeframe for smoking cessation.  Odds ratios were calculated using logistic regression, with a 95% confidence interval.

Results:  Our cohort consisted a median age of 68 yr (IQR 61-74), a median BMI of 27.35 kg/m2 (IQR 24-31), and a median BSA of 1.87 m2 (IQR 1.71-2.04), with only 9.75% of patients developing post-op A-fib.  A univariate logistic regression yielded a statistically significant association between smoking status and post-op A-fib (P=.013), but this association was lost when adjusting for age, hypertension, and FEV-1.  However, patients who quit smoking >12 months prior to surgery demonstrated increased odds of developing A-fib compared to those who never smoked, even while adjusting for age, hypertension, and FEV-1 (OR 4.74 (95%CI 1.05-21.35), P=0.04).  Current smokers and patients who quit smoking 2-12 months prior to surgery also had increased odds of developing A-fib when compared to those who never smoked; however, these results were not statistically significant (OR 2.65 (95%CI 0.49-14.28), P=0.26) and (OR 3.90 (95%CI 0.59-26.64), P=0.17).  Former smokers who quit >12 months also possessed more pre-operative comorbidities (median 3, mean 2.96, P=0.04) compared to current smokers (median 2, mean 2.44, P=0.04) and former smokers who quit between 2-12 months prior to surgery (median 2, mean 2.57, P=0.04). 

Conclusions:  Former smokers who quit greater than 12 months prior to surgery were associated with an increased risk of post-op A-fib compared to never smokers, current smokers, and smokers who quit between 2-12 months prior to RAVT lobectomy.  This finding may be explained by former smokers who quit >12 months prior to surgery having a greater number of comorbidities compared to the other 3 groups.

53.08 Intraoperative Fluids and Post-Operative Atrial Fibrillation after Robotic Pulmonary Lobectomy

Posted on January 31, 2019

D. Holliday2, R. Gerard2, F. Velez-Cubian2, C. Moodie1, J. Garrett1, J. Fontaine1,2, E. Toloza1,2  1Moffitt Cancer Center And Research Institute,Tampa, FL, USA 2University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:   We investigated whether intraoperative fluids given to patients during robotic-assisted pulmonary lobectomy correlate with frequency of postoperative atrial fibrillation (PostOp Afib).

Method:   We retrospectively studied all patients who underwent robotic-assisted pulmonary lobectomy from September 2010 through May of 2017 by one surgeon.  A total of 419 patients were analyzed for types and volumes of intraoperative fluids received, such as intravenous (IV) crystalloid, colloid, packed red blood cells (PRBC), fresh frozen plasma (FFP), platelets, and phenylephrine, for fluids that were lost during surgery, such as estimated blood loss (EBL) and urine output (UOP), and for the calculated balance of these fluids.  These patients were then analyzed based on whether they had PostOp AFib (n=39) or not (n=380).  We also grouped patients by level of intraoperative crystalloids given (<1500 mL, n=86; 1500-2500 mL, n=211; >2500 mL, n=122) and analyzed differences in demographics and in perioperative complications and outcomes.  Statistical significance was defined as p-value≤0.05.

Results:  Patients who had PostOp Afib had a significantly higher mean fluid balance than those without PostOp AFib (2273±499 mL vs 1532±100 mL; p=0.034), while none of the IV fluids given, including PRBC, FFP, platelets, or phenylephrine, nor EBL or UOP significantly differed between the two groups.  When grouped by IV crystalloid volume received, proportionately more females receive <2500ml IV crystalloid, while proportionately more males received >2500 ml (p=0.012).  Higher IV crystalloid volumes correlated with higher rates of intraoperative complications (p<0.001), which was mainly bleeding (p<0.001) during the robotic portion of the procedure (p<0.001), higher rates of overall conversions (p<0.001), emergent conversions due to bleeding (p<0.001), and elective conversions due to pleural or tumor adhesions (p=0.001), and higher rates of postoperative complications regardless of whether these were solely cardiac complications (p=0.003), solely pulmonary complications (p=0.012), or combined pulmonary and cardiac complications (p=0.001), but no individual complications correlated with IV crystalloid volume received (all p>0.206).  Higher IV crystalloid volumes also correlated with EBL (p<0.001), skin-to-skin operative time (p<0.001), chest tube duration (p=0.006), and hospital length of stay (LOS; p=0.004)

Conclusion:  Occurrence of PostOp Afib was associated with greater positive fluid balances after robotic-assisted pulmonary lobectomy, but not with greater volumes of  crystalloid, colloid, PRBC, FFP, platelets, or phenylephrine received nor with EBL or UOP.  Higher IV crystalloid volumes received were associated with higher conversion rates, EBL, and operative times, increased pulmonary and/or cardiac complication rates, and longer chest tube duration and hospital LOS.

53.07 Prevalence and Impact on Quality of Life of Hernias Among Patients Undergoing Computed Tomography

Posted on January 31, 2019

O. A. OLAVARRIA1, K. Bernardi1, A. Milton1, N. B. Lyons1, P. Shah1, T. C. Ko1, L. S. Kao1, M. K. Liang1  1McGovern Medical School at UTHealth,General Surgery,Houston, TX, USA

Introduction:
Two thirds of all Americans are overweight or obese and one half will receive a computed tomography (CT) scan in their lifetime. With the growing obesity epidemic and widespread use of advanced imaging there is a pressing need to quantify the prevalence and impact of hernias among these individuals. Our aim was to determine the prevalence of abdominal wall hernias (clinical and radiographic) among patients undergoing CT scans and their impact on patients’ quality of life.

Methods:
Consecutive patients undergoing elective CT scans of abdomen/pelvis from a single institution were enrolled. In general, CT scans were performed with oral and intravenous contrast with 5 mm cuts. Brief history was obtained in the radiology suite and quality of life (QoL) was measured through the modified Activities Assessment Scale, a validated, hernia-specific survey. On this scale, 1 is poor QoL and 100 is perfect; a change of 7 is the minimum clinically important difference. Standardized abdominal and groin examinations were performed by a surgeon blinded to the CT scan results. Three surgeons blinded to the results of the physical examination reviewed the CT scans for the presence of ventral or groin hernias. The number of patients and their QoL scores were determined for four groups of patients: no hernia, clinical or radiographic hernias, clinically apparent hernias, and occult hernias or hernias only seen on radiographic imaging. Pairwise differences between groups were compared using a Mann-Whitney U test.

Results:
A total of 246 patients were enrolled of whom 76 (30.8%) were overweight and 105 (42.6%) were obese. Physical examination detected a ventral hernia in 50 (20.3%) patients and a groin hernia in 17 (6.9%) patients while CT scan revealed 128 (52.0%) and 64 (26.0%) respectively. Of patients with a hernia on CT scan, 85 (34.5%) had an occult ventral hernia and 40 (16.2%) had an occult groin hernia. The QoL, median (IQR), of patients with no clinical or radiographic hernia was 84 (46), while the QoL of those with a clinical hernia was 62 (55) and 77 (57) among those with an occult hernia (Table).

Conclusion:
In the era of the obesity-epidemic and widespread use of radiographic imaging, hernias are extremely common. One fourth of individuals undergoing CT abdomen and pelvis scans have a clinical hernia while over 40% have an occult hernia. These hernias have a substantial impact on an individual’s QoL. Compared to individuals with no hernias, patients with a clinically apparent hernia and patients with occult hernias have significantly lower median QoL (by 22 and 7 points respectively). Randomized trials are needed to determine if operative repair can result in a clinically significant improvement in QoL.
 

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