48.02 Satisfaction after Lung Cancer Surgery: Do Clinical Outcomes Affect HCAHPS Scores?

Posted on January 31, 2019

E. S. Singer1, S. D. Moffatt-Bruce2, D. M. D’Souza2, L. Luo2, R. E. Merritt2, P. J. Kneuertz2  1The Ohio State University, Wexner Medical Center,Department Of Surgery,Columbus, OH, USA 2The Ohio State University, Wexner Medical Center,Thoracic Surgery Division, Department Of Surgery,Columbus, OH, USA

Introduction: Hospital consumer assessment of health care providers and systems (HCAHPS) surveys capture patients’ hospital experience and satisfaction, and are used as a patient-centered quality metric by CMS and hospital administrators. The effects of clinical outcomes on HCAHPS ratings following thoracic surgery are ill defined. We hypothesized that increased length of hospital stay (LOS) and postoperative complications negatively affect HCAHPS scores.

Methods:  Patients undergoing lung resection for cancer at a single academic cancer center between years 2014-2018 were analyzed. Clinical data were derived from the institutional Society of Thoracic Surgeons (STS) database and supplemented with HCHAPS survey data. The endpoints were overall top-box satisfaction scores, as well as domain-specific scores in communication with physicians and nurses. Multivariate regression analysis was used to test the association between clinical outcomes and HCAHPS top-box scores.

Results: In total, 181 out of 478 (38%) patients who underwent pulmonary resection for lung cancer completed HCAHPS surveys. Patient median age was 65 years, and most underwent lobectomy (94%). Median LOS was 4 days (IQR 3-6 days). The rate of top-box rating for the overall hospital experience, communication with doctors, and communication with nurses were 92%, 84%, and 69%, respectively. Patient factors associated with lower satisfaction scores with doctors included Asian/Other race and never-smoking status (p=0.02 and p=0.03, respectively). Increasing LOS was associated with worse satisfaction with doctors’ communication (Figure). Overall and major complication rates were 43% and 3% and were not associated with top-box HCAHPS scores. In multivariate analysis adjusted for patient factors, increasing LOS remained independently associated with worse patient satisfaction in the domains of communication with physicians and nurses. Specifically, patients with LOS >6 days compared to LOS <4 days were less likely to endorse top-box scores reflecting that doctors gave understandable explanations (OR 0.15, 95%CI 0.04-0.56) and nurses listened carefully (OR 0.11, 95%CI 0.06-0.69).

Conclusion: Overall HCHAPS satisfaction scores following lung cancer surgery were high and negatively associated with increasing length of stay, but not by postoperative events. Thoracic surgeons should be aware that patient satisfaction may be impacted more by the perception of effective communication during prolonged hospitalizations than by complications.

 

48.01 A Modern Propensity Score Matched Analysis Of Transthoracic Versus Transhiatal Esophagectomy

Posted on January 31, 2019

C. Takahashi1, R. Shridhar2, J. Huston3, K. Meredith4  1National Naval Medical Center,Surgery,Portsmouth, VIRGINIA, USA 2Florida Hospital Cancer Institute,Radiation Oncology,Orlando, FLORIDA, USA 3Sarasota Memorial Institute for Cancer Care,Gastrointestinal Oncology,Sarasota, FLORIDA, USA 4Florida State University College Of Medicine/ Sarasota Memorial Institute for Cancer Care,Gastrointestinal Oncology,Sarasota, FL, USA

Introduction: Surgical resection has become a mainstay of therapy for esophageal cancer and can increase survival significantly. With the advancement of minimally invasive surgery, there is still debate on the best approach for esophagectomy. We report a modern analysis of outcomes with transthoracic (TT) versus transhiatal (TH) esophagectomy.

Methods: A prospectively managed esophagectomy database was queried for patients undergoing transthoracic or transhiatal esophagectomy between 1996 and 2016.  Propensity score matching was perfomred based upon age and stage. Statistical analysis was performed using SPSS® version 23.0 (IBM®, Chicago, IL). Continuous variables were compared using the Kruskal Wallis or the ANOVA tests as appropriate. Pearson’s Chi-square test was used to compare categorical variables. Unadjusted survival analyses were performed using the Kaplan-Meier method comparing survival curves with the log-rank test.

Results: We identified 846 patients who underwent esophagectomy with a mean age of 64  ± 10 years. There was no difference in EBL for TT and TH, but the mean OR times were longer for TT vs. TH  (p<0.001) and the number of retrieved lymph nodes was higher for TT vs. TH (p<0.002).  Post-operative complications occurred in 207 (29.0%) patients who underwent a TT approach versus 59 (44.7%) who underwent a TH approach, (p<0.001).  The most common complications in TT versus TH techniques respectively were anastomotic leaks: 4.3% versus 9.8%, (p=0.01), anastomotic stricture 7% versus 26.5%, (p<0.001) and pneumonia 12.6% versus 22.7%, (p<0.002). Other outcomes that were also improved in TT vs. TH were aspiration (p<0.001), wound infections (p=0.004), and pleural effusions (p<0.001). Median survival was also significantly improved in patients undergoing TT (62 months) vs TH  (39 months) p=0.03. After matching there were 131 in the TT and 131 in the TH groups.  Post-operative complications remained lower in the TT (32.1%) vs TH (44.3%), p=0.04. Among these, anastomotic strictures (p<0.001), pulmonary complications (p=0.006), aspirations (p<0.001), and pleural effusions (p<0.001) were all lower in the transthoracic cohorts. There were lower incidences of anastomotic leaks in the TT 6 (4.6%) vs TH 13(9.9%), p=0.09 and wound infections: TT 6 (4.6%) vs TH 14(10.7%) p=0.06 which did not reach significance.

Conclusion: In this modern propensity score matched analysis of transthoracic versus transhiatal esophagectomy we found that a transthoracic approach was associated with lower pneumonias, anastomotic leaks, wound infections and strictures with an improvement in nodal harvest.  Survival was also significantly improved in patients who underwent transthoracic esophagectomy.

 

47.20 Implant Sparing Nipple Sparing Mastectomy

Posted on January 31, 2019

E. E. Burke1, C. Laronga1, W. Sun1, S. J. Hoover1, N. Khakpour1, J. V. Kiluk1, M. C. Lee1  1Moffitt Cancer Center,Breast Oncology,Tampa, FL, USA

Introduction: Nipple sparing mastectomy has become an option for the treatment and prevention of breast cancer in selected women. Our experience with implant sparing mastectomy suggests that this is a safe and effective option for women with previous retropectoral implant augmentation. We aimed to explore outcomes of patients that underwent concurrent implant and nipple sparing mastectomy (ISNSM) at our institution.

Methods:  A retrospective review of patients undergoing ISNSM for either prevention or treatment of breast cancer from 2009 until 2017 was performed at a single institution. Data including patient and tumor characteristics, stage, systemic and radiation therapy use, 90-day complication rates, additional reconstruction, and disease recurrence was collected.

Results: A total of 11 patients were identified after ISNSM; the average BMI was 22.8kg/m2 (range 18.6-30.9). Four (36.4%) had breast cancer in the breast undergoing ISNSM, 3 (27.3%) had a known pre-operative diagnosis of invasive breast cancer or ductal carcinoma in situ (DCIS) in the contralateral breast for which the nipple was excised, and 4 (36.4%) had no disease in either breast. The mean age of the cohort was 48 years, with mean of 52.1 years in those with breast cancer and 41 years in those without breast cancer. Average tumor size was 15mm in breasts treated with ISNSM; all had negative margins of resection, negative analysis of nipple base, and none had disease recurrence after average follow up of 34.9 months (range 0.4-80 months). Final pathological stage was stage 0 for 1 patient, Ia for 3 patients, IIa for 1 patient and IIb for 1 patient. In the 4 disease free patients, 2 were BRCA1+, 1 was BRCA2+, and 1 had a PALB2 mutation. There have been no diagnoses of breast cancer in the 7 patients that pursued implant and nipple sparing mastectomy in breasts without cancer after an average of 33.5 months (range 7-63 months). Ninety-day complication rates in this group were low overall. There was no nipple necrosis, 1 patient developed wound dehiscence with skin flap loss requiring operative intervention, 1 patient required takeback to OR for hematoma and 1 patient had a wound infection requiring antibiotics. Of the 11 patients, 9 (81.8%) have undergone delayed reconstruction requiring only implant exchange. One has not required implant exchange and one has not yet undergone implant exchange. Average time to exchange was 12.5 months (range 3-52 months).  None of these patients required delayed flap reconstruction. 

Conclusion: ISNSM was effective and well tolerated in this highly selected group of patients with acceptable oncologic outcomes and low complication rates. Patients undergoing this procedure pursued delayed reconstruction and none required flap reconstruction. Further investigation into this option for the treatment and prevention of breast cancer is warranted.   
 

47.19 Is Excision of Radial Scar Identified on Core Needle Biopsy (CNB) Necessary?

Posted on January 31, 2019

K. Nimtz1, K. Hookim2, A. Sevrukov3, T. Tsangaris1, A. Willis1, A. Berger1, M. Lazar1  1Thomas Jefferson University,Surgery,Philadelphia, PA, USA 2Thomas Jefferson University,Pathology,Philadelphia, PA, USA 3Thomas Jefferson University,Radiology,Philadelphia, PA, USA

Introduction: Quantifying the risk of upgrade to malignancy with radial scars has been an ongoing challenge in the breast cancer research community. Previous reviews show radial scars account for 5-9% of findings on core needle biopsy. The upgrade rate varies from 0-40% making management of radial scars controversial.  Multiple studies have investigated the association of radial scar and malignancy, with recent studies indicating lower rates. The lack of consensus on the optimal management highlights the need for further analysis of radial scar and its risk of upgrade to malignancy. We sought to identify our institutional upgrade rate of radial scar identified on core needle biopsy.

Methods: An IRB approved retrospective review of pathology and radiology databases from 2010 to 2017 was performed to identify radial scar found on core needle biopsy.  We excluded patients with malignancy associated with radial scar and those who did not undergo surgical excision. The initial imaging findings prompting the core needle biopsy as well as the upgrade rate to malignancy (invasive ductal/lobular carcinoma and ductal carcinoma in situ) on surgical excision were assessed. 

Results: We identified 127 patients with radial scar on a core needle biopsy.  Due to malignancy associated with radial scar, no surgical excision or incomplete records, we excluded 75 patients leaving 52 patients for analysis. Of these, 4 of 52 (7.7%) patients had an upgrade to malignancy upon surgical excision of the radial scar—2 with DCIS and 2 with invasive ductal cancer.  All 4 of these patients had findings on both mammography and ultrasound.  Eight patients had atypia associated with radial scar on core needle biopsy, two of which were upgraded to malignancy at the time of surgical excision.  The rate of upgrade for radial scar alone on core needle biopsy was 2 of 44 (4.5%).  Of the 44 patients with radial scar alone on core needle biopsy, 15 (34%) were found to have atypia (6 with flat epithelial atypia, 5 with atypical ductal hyperplasia, 2 with lobular carcinoma in situ, one with atypical lobular hyperplasia and one with both atypical ductal and lobular hyperplasia) on surgical excision.

Conclusion: With the increasing use of digital tomosynthesis, it is possible that more radial scars will be identified on core needle biopsy.  Although  the upgrade rate to malignancy was only 4.5%, there was a substantial upgrade rate of pure radial scar to some type of atypia which could alter subsequent management. Additionally, one-quarter of radial scars with atypia upgraded to malignancy on excision. For these reasons, careful consideration should be given to re-excision of core needle biopsy showing radial scar with and without atypia.

 

47.18 Is Cervical Node Ultrasound Useful for Indeterminate or Malignant Subcentimeter Thyroid Nodules?

Posted on January 31, 2019

F. B. Karipineni1, Z. Sahli2, J. Canner3, A. Mathur3, J. Prescott3, R. Tufano4, M. Zeiger2  1UCSF Fresno,Department Of General Surgery,Fresno, CALIFORNIA, USA 2University Of Virginia,Department Of General Surgery,Charlottesville, VA, USA 3The Johns Hopkins University School Of Medicine,Department Of General Surgery,Baltimore, MD, USA 4The Johns Hopkins University School Of Medicine,Department Of Otolaryngology,Baltimore, MD, USA

Introduction:
Preoperative neck ultrasound (US) in patients with thyroid cancer can detect suspicious lymph nodes that may in turn result in a change in surgical management. However, in patients with indeterminate or malignant subcentimeter thyroid nodules, the role of neck ultrasound and extent of surgery is controversial. Our study evaluates the utility of preoperative neck ultrasonography in this subset of patients.

Methods:
Medical records of patients with biopsy-proven, unifocal Bethesda III, IV, V or VI thyroid nodules ≤ 1.0 centimeter between January 2006 and December 2016 were retrospectively reviewed. Patients with multifocal papillary thyroid carcinoma (PTC) or medullary carcinoma, those who did not undergo preoperative cervical US, and those who underwent prophylactic central lymph node dissection (CLND) were excluded. Clinical, radiologic, cytologic, and pathologic variables were analyzed to determine change in clinical management or operative approach based on US findings of suspicious cervical lymph nodes.

Results:
The records of 217 patients met study criteria. A total of 14 (6.5%) patients had suspicious lymphadenopathy on US, 5 (2.3%) in the central neck and 9 (4.1%) in the lateral neck. Of the 5 patients with suspicious central nodes, none underwent biopsy prior to surgery. Only 2 (0.9%) who had obvious lymphadenopathy at surgery underwent CLND; the other 3 had negative frozen section analysis and therefore did not undergo CLND. Of the 9 patients with suspicious lateral neck nodes, only one (0.4%) had a positive aspiration biopsy and underwent lateral selective neck dissection. 

Conclusion:
Surgical approach was altered in only three patients (1.4%) as a result of preoperative neck ultrasonography in our cohort, thus challenging the need for routine preoperative neck US to evaluate for the presence of lymph node metastases in this patient population. The identification of cervical lymph node metastases in the 2 patients with positive central neck US in our cohort would have likely been achieved without the use of US. Further studies are needed to delineate whether performing routine neck US in patients with unifocal, subcentimeter indeterminate or malignant nodules is cost-effective.
 

47.17 An Analysis of Factors Resulting in Thyroid Reoperations

Posted on January 31, 2019

T. Longoria Dubocq1, M. Serpa1, A. Lugo1, E. Santiago1, A. Gonzalez1, W. Mendez-Latalladi1  1University Of Puerto Rico School Of Medicine,Endocrine Surgery Section. Department Of Surgery,San Juan, Puerto Rico, USA

Introduction: Thyroid surgery has been practiced for many years by General Surgeons to treat benign and malignant disease. However, the development of new surgical sub-specialties have demonstrated that treating thyroid disease at a high volume center (HVC) improves outcomes in this kind of patients. Many studies have showed that thyroid reoperations have a higher complication rate when compared to single thyroid surgery. We studied the incidence of causes for surgery reoperation and if whether the initial surgery was performed at a low volume center (LVC) or HVC.

Methods: This is a retrospective study were we analyzed all thyroid reoperations from 2013 to 2018 at a HVC institution. HVC was defined as hospital that performed more than 100 thyroid surgeries per year and surgeons with more than 25 thyroid surgeries per year. Data from previous surgeries, and reasons for reoperation was gathered and evaluated statistically. Reoperation was defined as a patient who had thyroid surgery with previous history of thyroid surgery. Patients were also divided into two groups depending on where their first surgery took place: LVC (Group 1) or HVC (Group 2). SPSS statistical software and Pearson’s Chi-Square test used for analysis and comparison. To establish statistical significance a p-value ≤ 0.05 was utilized.

Results: We examined 786 records of which 105 (7.49%) had undergone a previous thyroid surgery. Five were excluded due to lack of information. There were 86% (86/100) females and 14% (14/100) male in our study. The most common overall reason for re-operation was completion thyroidectomy due to previous lobectomy pathology positive for cancer 35% (35/100); followed by recurrence of malignant disease 34% (34/100) overall. Reoperation for benign disease was 23% (23/100) overall. Group 1 consisted of 40% (40/100) of patients while Group 2 had 60% (60/100) of patients. In Group 1, the most common reason for reoperation was malignant disease recurrence with 47.5% (19/40). In Group 2, the incidence of malignant disease recurrence occupied 25% (15/60) of the cases which was significant when compared between the two groups (p=0.001). Group 2 most common reason for reoperation was a malignant lesion requiring completion thyroidectomy with 53.33% (32/60).

Conclusion: The most common reason for reoperative thyroid surgery was a previous lobectomy with incidental malignancy and indications for a completion thyroidectomy. When the first surgery was performed in a LVC, the most common reason for reoperation was recurrence of malignancy.

47.16 Does thyromegaly with tracheal deviation or substernal extension pose high risk of acute airway compromise?

Posted on January 31, 2019

Y. Qudah1, J. Crystal1, J. Wade1, T. Davidov1  1Robert Wood Johnson – UMDNJ,General Surgery,New Brunswick, NJ, USA

Introduction:   Thyromegaly with tracheal deviation and substernal extension is an indication for surgery in part because of concerns over airway compromise.  However, the exact risk is unclear.

Methods:   CT scans of the neck or chest from 2009-2017 performed at a single hospital were queried for findings of thyromegaly with substernal extension, tracheal deviation, or tracheal compression. The charts of these patients were retrospectively reviewed to determine whether acute airway compromise with sudden intubation or urgent surgical intervention was required.

Results: A total of 682 scans were queried, revealing 209 patients whose scans demonstrated  substernal extension or tracheal deviation or compression. Of 209 patients, 125 patients (60%) were asymptomatic with CT findings incidentally discovered.  Eighty-four patients (40%) presented with symptoms including dyspnea, dysphagia, chest pain, neck pain, or visible neck mass.  Nineteen patients that had these CT findings required intubation during their hospital stay, of which 18 intubations were emergent.  Of these 19 patients, 18 had confounding cardiopulmonary problems. No patients required cricothyroidotomy or urgent tracheostomy. There were no mortalities related to sudden airway compromise.  Five patients progressed to surgery, one of whom required sternotomy.

Conclusion: While thyromegaly with substernal extension or tracheal deviation may an indication for thyroidectomy in part to prevent sudden airway compromise, the majority of patients with these CT findings are asymptomatic and only rarely do these patients sustain an airway emergency requiring an intervention.

 

47.15 Si vs. Xi Robot for Adrenalectomy: A 10-year experience

Posted on January 31, 2019

A. Lucy1, E. Malone1, J. Richman1, J. Owen1, J. R. Porterfield1  1University Of Alabama at Birmingham,Surgery,Birmingham, Alabama, USA

Introduction: Over the last decade, robotic adrenalectomy has been increasingly used for surgical management of adrenal masses. The da Vinci Xi robot was introduced in 2014 as a more versatile upgrade to their Si robot with the goal of promoting OR efficiency and multi-quadrant access. The specific benefits of the Xi robot have only been addressed in a limited number of specialties and procedures. The aim of this study was to compare the outcomes of the Xi vs. the Si system for robotic adrenalectomy in a high-volume center.                                                         

Methods: All patients at a single institution undergoing adrenalectomy between June 2008 and May 2018 were captured prospectively (n=515). We excluded patients who had an adrenalectomy by a non-robotic approach and who were <18 years old (n=212). Demographic, clinical, pathological, and operative variables were collected from electronic medical records. An adjusted negative binomial regression model was used to examine the change in total operating room time by robot type adjusting for all covariates significantly associated with room time in bivariate tests. These included diabetes, facility (main hospital vs. outpatient surgery center), robot type, and final pathology. Chi-square or Fisher's Exact Tests and t-tests were used to examine differences in categorical and continuous variables by robot type.

Results: Robot type was documented for 99% of 212 cases (n=209). There were no significant differences in patient demographics or preoperative comorbidities by the robot type. Median total room time using the Xi was 215 minutes (IQR: 190-254) vs. 235 (IQR 203-279) for the Si system (p=0.03). Other perioperative and pathological variables were similar. In adjusted models, total room time was 11% longer for diabetic patients vs. non-diabetics (IRR 1.11, 95% CI: 1.03-1.20), procedures done at our outpatient surgery center were 22% shorter vs. our main facility (IRR 0.78, 95% CI 0.68-0.89), and Xi robot procedures were 9% shorter than those done with the Si robot (IRR 0.91, 95% CI 0.83-0.99).

Conclusion: In adjusted analyses, the Xi robot has shorter adrenalectomy times compared to the Si robot. We attribute this decrease in operative time to the improved instrumentation, ease and efficiency in docking and patient positioning. More multi-institutional studies with larger groups of patients are needed to document the effect of advancing technology and carefully track and publish outcomes.

 

47.14 Clinical Significance of Increased Body Mass Index in Breast Cancer Patients

Posted on January 31, 2019

S. R. Kaslow1, C. Cartier1, M. L. Plasilova1  1New York University Langone Health,Department Of Surgery,Brooklyn, NY, USA

Introduction:
Multiple studies have associated increased body mass index (BMI) with more aggressive breast cancer tumor biology and worse clinical outcomes, however, many of these studies were conducted with primarily non-Hispanic white patients. We aimed to compare the clinical outcomes and breast cancer tumor biology of patients with increased BMI (≥25) and normal BMI (18-25) at New York University Langone Health (NYULH), which serves a racially and ethnically diverse patient population. 

Methods:
We extracted data on geography, race/ethnicity, breast cancer recurrence rates, and tumor biology from the NYULH Institutional Breast Cancer Database, which contains sociodemographic and clinical information for breast cancer patients who received first definitive surgery at New York University Langone Medical Centers in Manhattan and Brooklyn.

Results:
Our data included 3,091 patients with invasive breast cancer and ductal carcinoma in situ. Breast cancer patients living in Brooklyn had increased BMI compared to breast cancer patients living in Manhattan (p=0.013). There was no statistically significant difference in breast cancer recurrence in patients with increased BMI relative to those with normal BMI (p>0.5). Our data show a higher proportion of ethnic minorities diagnosed with breast cancer in Brooklyn compared to Manhattan, including African Americans (35.2% vs. 17.6%) and Asian Americans (12.1% vs. 8.5%). We did not find a significant difference in breast cancer recurrence when comparing White and non-White patients with increased BMI.

Conclusion:
Despite differences in ethnic minority status between two study sites and statistically significant differences in BMI based on residence, breast cancer patients treated within NYULH with increased body mass index did not have statistically significant different breast cancer recurrence rate.
 

47.13 Standardization of Oncotype DX Ordering By Surgery at a Safety Net Hospital: Pilot Study

Posted on January 31, 2019

A. Keshinro1, E. Johnson1, E. Horowitz1, E. Warnack1, K. Joseph1  1NYU School of Medicine,Surgery,New York, NEW YORK, USA

Introduction:

Oncotype DX is a useful assay that helps oncologists and patients determine whether patients should undergo adjuvant chemotherapy or hormonal therapy. Testing for Oncotype may lead to delays in chemotherapy that can lead to clinically adverse outcomes. In order to decrease the delays in ordering the test as well as the turn around time, and as a result, initiation of chemotherapy, we implemented a new ordering protocol at Bellevue Hospital involving pathology, breast surgery to standardize the criteria for ordering Oncotype DX.  

Methods:  

As part of a quality improvement process to standardize the ordering process for Oncotype DX post-operatively, pathology and breast surgery met with representatives of Genomic Health to determine new workflows to improve the ordering process for Oncotype DX. In addition, methods for communicating pathology results and insurance status were identified. After new workflows were put in place, any patient that fit the criteria for Oncotype DX testing was ordered by breast surgery as soon as the final pathology was received (May-August 2018). Time from surgery to order, time from surgery to report, number of Oncotype DX orders, method by which oncotype dx is ordered, and type of insurance were examined.

 

Results:

There was a significant decrease in the overall turnaround time from surgery to Oncotype DX result from 64 days to 29 (55% reduction) (p<0.05). Implementation of the new workflow had the largest impact on reducing time from surgery to ordering the test (50 days to 17 days), a 66% reduction (p<0.05). 72% of the orders are now being placed by portal vs 6% before standardization, 14% by paper vs 88% before standardization, 14% by fax vs 6% before standardization. In addition, the payor mix has changed to include 11.3% Medicare vs 0% before standardization. Total number of Oncotype orders for 2017 were 16 (eligible cases 41), and cases YTD 2018-18.

Conclusions:

Implementation of a new ordering process has allowed access to individualized treatment planning to more eligible patients; 12.5% increase over 2017 orders within 7 months into the year (16 orders in 2017 vs. 18 orders by July 2018), ordering by portal helps to improve efficiency of ordering and receiving results.

Less than half of eligible patients were offered Oncotype DX in 2017, before adoption of the new protocol. By implementing this protocol more eligible patients will receive appropriate management.

Given the medically underserved population that our clinic serves (64% are immigrants and 73% have Medicaid or self pay), we can improve the level of care to our patients.

As we continue the protocol we will examine the impact on reduction on chemotherapy wait times.

 

 

 

47.12 Quilting Suture in Closure of Mastectomy Skin Flaps for Locally Advanced Breast Cancer in Myanmar

Posted on January 31, 2019

S. Myint1, T. Lwin1, W. Yee1, H. Thuya1, A. Myat1, Y. Kyaw1, K. Nyunt1, K. Khaing1, T. Lwin1  1University of medicine (1), Yangon,Department Of Surgery,Yangon, YANGON, Myanmar

Introduction: Seroma formation is the most frequent postoperative complication after breast cancer surgery. In 2015 surgery for breast cancer at the Yangon General Hospital amounted to 17.12% (229) of all the elective major operations. In 2016, 244 cases of modified radical mastectomy (MRM) were carried out and 32.38 % of locally advanced breast cancer patients developed seroma post operatively. Seroma cause discomfort, and wound complications.Seroma prolonged hospital stay and delayed adjuvant therapy. It can leads to poor prognosis. We explored whether quilting sutures could reduce seroma occurrence. Quilting sutures aim to prevent shearing between skin flaps and chest wall and to reduce the dead space.

Methods: Twenty five breast cancer patients from 1st July 2017 to 31st December 2017 were included in this descriptive study. All underwent modified radical mastectomy. After MRM  quilting sutures were applied to approximate  skin flaps to underlying pectoral muscle at an interval of 2 to 3 cm. Customized, strategically placed, multiple alternating interrupted quilting sutures are put with 3/0 vicryl at various parts of the flaps. A close drainage tube was usually inserted into the axilla. The skin was closed with two layer techniques. Drainage tube was removed when the 24 hour drain amount was less than 30mls in two consecutive days. Patients were followed up in the outpatient clinic and the clinically significant seroma were detected by clinical examination and ultrasoung examination. 

Results: The average time to insert quilting suture is 12 mins. None of the cases develop permanent skin dimplings one month after operation. Post-operatively,mean amount of drainage tube output is 274.9 ml. Five patients (20%) developed clinically significant seroma in follow-up visits and underwent needle aspiration. The mean number of needle aspiration is 3 times. Mean amount of seroma aspirated is 300 ml. None of the patients develop wound sepsis or wound gaping.   

Conclusion:MRM is frequently performed at the Yangon General Hospital and seroma is a common complication. It can prolong hospital stay and can lead to frequent visits to clinic and delay adjuvant therapy. Quilting suture reduced the incidence of seroma formation from 32% to 20%. This technique is cost effective and can be performed by general surgeons. We feel that this may be an important technique for breast cancer surgery in low resource settings and warrants further investigation.

 

47.11 Postoperative Hypomagnesemia Levels Predict Post-thyroidectomy Hypocalcemia

Posted on January 31, 2019

B. M. Launer1, R. McIntyre1, L. J. Helmkamp1, C. D. Raeburn1, M. B. Albuja-Cruz1  1University of Colorado School of Medicine,GI, Tumor And Endocrine Surgery,Aurora, CO, USA

Introduction
Hypocalcemia is a frequent complication of thyroidectomy. Magnesium (Mg) and calcium metabolism are closely related. There is a paucity of studies evaluating the role of preoperative and postoperative Mg levels in post- thyroidectomy hypocalcemia. 

Methods
Retrospective review of prospectively collected data of 389 patients who underwent thyroidectomy.  We followed a standard protocol to manage hypocalcemia. Calcium, albumin, PTH and magnesium levels were checked immediately after surgery.  Patients were stratified into 3 categories: high, intermediate, and low risk of hypocalcemia.  High risk patients were started on oral calcitriol and calcium.  Intermediate risk patients were given only oral calcium and low risk received no supplementation.  Hypocalcemia was defined as corrected calcium level (CCL) < 8 mg/dl.   Severe hypocalcemia was defined as a CCL < 7 mg/dl.  Hypocalcemia event was defined as an episode of hypocalcemia at any point after the operation.  Symptomatic hypocalcemia was defined as CCL <8 mg/dl plus symptoms of hypocalcemia.  Hypomagnesemia was defined as Mg level <1.7mg/dl.  Patients with and without hypomagnesemia preoperatively and immediately postoperatively were compared.  Data were analyzed for demographics, operative procedure, calcium levels, PTH levels and complications of hypocalcemia.

Results
Seventy-eight patients (23%) had preoperative hypomagnesemia and 106 patients (37%) had postoperative hypomagnesemia.  There was no difference in biochemical or symptomatic hypocalcemia, severity of symptoms of hypocalcemia, need for IV calcium, emergency department (ED) visits, readmissions, and permanent hypocalcemia between normal preoperative Mg and low preoperative Mg groups.  Patients with low postoperative Mg levels had a significant higher risk of hypocalcemia (28% vs. 16%, p 0.007).  Patients with low postoperative Mg levels also had a significantly higher rate of requiring I.V calcium (9% vs. 3%, p 0.023) based on our protocol.  However, there was no difference between these two groups in regards to symptomatic hypocalcemia, severity of hypocalcemia, severity of symptoms of hypocalcemia, ED visits, readmissions, or permanent hypocalcemia.  On multivariate analysis, postoperative hypomagnesemia was an independent predictor of hypocalcemia with 1.71 risk ratio (1.09, 2.68; 95% CI).

Conclusion
Postoperative hypomagnesemia is seen in more than one third of patients after thyroidectomy and it is associated with a significantly higher risk of hypocalcemia and need for I.V calcium.  The risk of hypocalcemia is doubled for those patients with immediate postoperative hypomagnesemia.  Therefore, postoperative Mg levels should be closely monitored and replaced as necessary in patients after thyroidectomy.

 

47.09 Epidural anesthesia is safe in open resection of pheochromocytoma and abdominal paraganglioma

Posted on January 31, 2019

D. Wiseman1, J. McDonald1, D. Patel1, E. Kebebew3, K. Pacak2, N. Nilubol1  1National Cancer Institute,Bethesda, MD, USA 2National Institute of Child Health and Human Development,Bethesda, MD, USA 3Stanford University,Surgery,Palo Alto, CA, USA

Introduction:

The most common side effect of epidural anesthesia (EA) is hypotension. Because hypotension frequently occurs after a removal of pheochromocytoma-paraganglioma (PPGLs) from the alpha-adrenergic blockade and the abrupt reduction of catecholamine production, we aimed to determine if EA is associated with an increased risk of postoperative hypotension and complications from postoperative fluid overload.

Methods:

We performed a retrospective review of a prospectively collected cohort of patients who underwent open resections of PPGLs from 2009-2018.  The EA infusion started before patient transfer to ICU. Clinical characteristics, tumor burden, and perioperative parameters were analyzed by the use of EA. The primary endpoint was postoperative hypotension.

Results:

Of 66 patients who underwent open resections of PPGLs, 52 (78.8%%) received EA. No differences in patient demographics and clinical characteristics were found by the use of EA except the significantly lower rate of EA used in patients with von Hippel-Lindau disease due to the presence of spinal hemangioblastoma (0% vs. 82.5%, p=0.008) and a higher rate of EA use in patients undergoing reoperation (85.7% vs. 58.8%, p=0.035). We found that postoperative hypotension was common following open resections of abdominal PPGLs (56.9%). However, there was no difference in the rates of postoperative hypotension by the use of EA (58.8% in EA group vs. 50.0% in non-EA group, p=0.561), the need for postoperative vasopressor (p=1.00) or diuretics (p=0.111), postoperative weight gain (p=0.436), hypoxia (p=0.703), or the volume of IV fluid in the first 24 hours postoperatively (p=0.903). EA was stopped because of postoperative hypotension in 13.6% of patients.

Conclusion:

Although postoperative hypotension is common after open resection of PPGLs, EA is safe as it was not associated with increased risk of postoperative hypotension or fluid overload.
 

47.08 Breast Cancer Treatment Patterns in Women Age ≥ 80: A Report from the National Cancer Database

Posted on January 31, 2019

J. Frebault1, C. Bergom2, M. Shukla2, Y. Zhang3, C. Huang3, A. Kong1  1Medical College Of Wisconsin,Department Of Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Department Of Radiation Oncology,Milwaukee, WI, USA 3University of Wisconsin-Milwaukee,Zilber School Of Public Health,Milwaukee, WI, USA

Introduction:
Women aged ≥80 are an increasing proportion of patients diagnosed with breast cancer in the US. There are no established guidelines for decision making in this population, particularly due to consideration of performance status and competing comorbidities. This study aims to identify national treatment patterns and survival outcomes in breast cancer patients aged 80 and over.

Methods:
Women aged ≥80 diagnosed with ductal carcinoma in situ (DCIS) or stage I-III invasive breast cancer from 2005-2014 were identified in the National Cancer Database. We excluded cases with incomplete staging and treatment details. Kaplan-Meier curves and Cox proportional hazard models were used to evaluate survival outcomes. Chi-square and logistic regression models were used to identify demographic, disease, and facility factors that influenced receipt of breast surgery.

Results:
We identified 62575 women with invasive cancer and 6070 with DCIS. Of the invasive cases, 94% received breast surgery. Age <85, white race, lower stage, and smaller tumor size were associated with receipt of surgical treatment (p<0.0001 for all). Those who received breast surgery were more likely to be estrogen receptor (ER)+ (p=0.001), HER2- (p<0.0001), and healthier, with a comorbidity score of 0 or 1 (p<0.0001). They were also more likely to have axillary surgery (p<0.0001), chemotherapy (p=0.0009), and radiation (p<0.0001). Among DCIS patients, 98% had breast surgery. White patients (p=0.003) and those <85 years old (p<0.0001) were more likely to receive surgery. Those who had surgery were more likely to receive radiation (p<0.0001). When compared to academic programs, surgical management was more likely to be performed in community cancer centers for both invasive cancer (p<0.0001) and DCIS (p=0.04). On multivariate analysis of invasive cancer patients, those with white race, age <90, lower stage, ER-, or fewer comorbidities were more likely to have surgery (all p<0.0001). On multivariate analysis of DCIS patients, those age <90 were more likely to have surgery (p<0.0001). Black women were half as likely to receive surgery (p=0.02). In both groups, overall survival was higher for those who received surgery compared to those who did not (p<0.0001), with a hazard ratio of 3.3 [95% CI 3.18-3.46] for invasive cancer (Fig. 1) and 2.2 [95% CI 1.72-2.83] for DCIS.

Conclusion:
The vast majority of breast cancer patients age ≥80 in this nationwide dataset received primary surgical management, which was associated with a significant survival advantage for both invasive and non-invasive disease. Surgical intervention should be considered in patients with few comorbidities and favorable tumor characteristics.

47.06 Impact of Geographic Dispersal of National Accreditation Program for Breast Centers on Quality Care

Posted on January 31, 2019

A. C. Alapati1, L. A. Riba1, R. B. Davis2, T. A. James1  1Beth Israel Deaconess Medical Center,Surgery,Boston, MA, USA 2Beth Israel Deaconess Medical Center,Medicine,Boston, MA, USA

Introduction: The National Accreditation Program for Breast Centers (NAPBC) is dedicated to the improvement of quality of care for patients with breast disease. Geographical distribution of healthcare resources is an important dimension of quality. Little has been published about breast center allocation patterns with respect to demand and impact on population health outcomes. The purpose of this study is to analyze incidence and mortality rates of breast cancer in relation to NAPBC distribution in the US.

Methods: The incidence and mortality rates of breast cancer per state in 2014 were retrieved from the Center for Disease Control and Prevention.  We determined the number of NAPBC centers in each state per 1000 cases of breast cancer. Data were analyzed by spearman (non-parametric) correlation.

Results:The total number of NAPBC centers is 570. Across the US there is an average of 2.8 centers/1000 cases of breast cancer; standard deviation 1.9, range from 0 to 8.7.  A positive correlation (r = 0.45) exists between breast cancer incidence and the number of centers (p=0.0009). The correlation between mortality and centers/1000 cases is weakly negative (r=-0.20), (p=0.16).

Conclusion:Our study demonstrates that NAPBC centers are adequately distributed according to breast cancer incidence in the US. However, the presence of NAPBC centers did not impact mortality rates. Additional strategies are warranted to control population mortality rates for breast cancer.

 

47.05 Optimizing Opioid Prescribing Practices Following Parathyroidectomy

Posted on January 31, 2019

A. Sada1, D. S. Ubl2, C. A. Thiels1, B. M. Dy1, M. L. Lyden1, G. B. Thompson1, T. J. McKenzie1, E. B. Habermann2  1Mayo Clinic,Department Of Surgery,Rochester, MN, USA 2Mayo Clinic,Surgical Outcomes Program, Robert D And Patricia E Kern Center For The Science Of Health Care Delivery,Rochester, MN, USA

Introduction:
With the increased awareness of the U.S. opioid epidemic, several initiatives have attempted to limit overprescribing of opioids. As the opioids requirements differ based on the procedure and patient specific factors, we conducted a large initiative that resulted in prescribing guidelines for different procedures. The aim of this study is to refine our guidelines for parathyroidectomy.

Methods:
Patients undergoing parathyroidectomy at three academic centers were asked to complete a 28-question telephone survey at 21-35 days post-discharge as part of a larger initiative. Surveys captured opioid consumption and patient experience while patient characteristics were abstracted. Discharge opioids were converted into Morphine Milligram Equivalents (MME) and reported as median and interquartile range (IQR). Univariate comparisons were used. Consumption was dichotomized into top quartile users (Q4), who consumed between 20-217 MME vs standard users (Q1-Q3), who consumed between 0-15 MME.

Results:
A total of 103 patients completed the survey; mean age was 65±12 years, 83% were female and 89% were opioid-naive. At discharge, opioid prescriptions were provided to 86% of patients. While the median prescribed was 75 (IQR 75-125, range 0-375) MME, the median consumed was 0 (IQR 0-20). Half (51%) of patients did not consume any, while only 11% consumed >50 MME. Patients who did not consume opioids reported a median last pain score before discharge of 1 (IQR 0, 2) while patients who did consume opioids reported a median score of 2 (IQR 2, 3), p<0.001.
There was no difference in opioids consumption between unilateral neck exploration (n=71), bilateral exploration (n=26) or thyroidectomy and parathyroidectomy (n=6) (p=0.10).
Overall, 98% of patients were satisfied with their pain control. While 31% reported being prescribed too much opioid, no patients reported they were not prescribed enough. All 4 patients requiring an opioid refill reported it was very easy to get a refill. Of those receiving a prescription, 95% had left-over opioids at the time of survey, resulting in 81% of prescribed opioids being unused. Only 6% of patients disposed of left-over opioids.

Conclusion:
While the majority of patients undergoing parathyroidectomy received opioids after discharge, over half of them did not consume any, and very few consumed more than a day or two of opioid medication. Moreover, surgical approach did not change consumption, illustrating that these guidelines are applicable to thyroidectomy given similarity between incisions and techniques. We recommend prescribing non-opioid analgesics for patients undergoing parathyroidectomy and thyroidectomy and considering less than 40 MME for patients with high pain scores.
 

47.04 Survival Outcomes of Early-Stage Hormone Receptor Positive Breast Cancer in the Elderly

Posted on January 31, 2019

A. Nayyar1, K. K. Gallagher1, P. D. Strassle1, C. G. Moses1, K. P. McGuire2  1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA 2Virginia Commonwealth University,Department Of Surgery,Richmond, VA, USA

Introduction:
Women ≥70 years old form a significant proportion of patients affected by breast cancer (BC). Treatment decisions for this patient population are complicated given presence of comorbidities, reduced tolerability of therapy and limited enrollment in clinical trials. A growing body of evidence suggests equivalent outcomes in elderly patients with hormone receptor positive, early-stage BC patients receiving primary endocrine therapy only or surgery with subsequent endocrine therapy. Whether these results are reproduced in the larger BC population outside of a clinical trial, currently remains unclear.

Methods:
Women ≥70 years old, diagnosed with early-stage invasive BC between January 2008 and December 2013, with tumor size T1 or T2 and minimal nodal involvement (N0 and N1), endocrine and/or progesterone receptor positive, and started endocrine therapy within a year of diagnosis were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked datasets. Endocrine therapy use was identified using outpatient prescription fills for Anastrozole, Exemestane, Fulvestrant, Letrozole, Raloxifene, Tamoxifen, and Toremifene. Surgical intervention included either breast conserving surgery or mastectomy. Trends in the use of primary endocrine therapy only were assessed using Poisson regression. Multivariable Cox proportional hazard regression was used to estimate the association between undergoing surgery within a year of diagnosis and 5-year all-cause mortality, after adjusting for patient demographics, comorbidities, and clinical cancer characteristics. Similar methods were used to assess 5-year cancer-specific mortality, where non-cancer mortality was treated as a competing risk. 

Results:
Overall, 8,968 women were included in the analysis; 8,146 (91%) received surgery with endocrine therapy and 832 (9%) received primary endocrine therapy alone. The proportion of women not receiving surgery remained consistent between 2008 and 2013, p=0.24. The 5-year mortality was 7% (n=660), and 21% of all deaths were due to cancer causes (n=140). After adjustment, 5-year mortality was lower among women undergoing surgery (HR 0.55, 95% CI 0.44, 0.67, p<0.0001) (Figure). Similar results were found when looking at 5-year cancer-specific mortality (HR 0.35, 95% CI 0.22, 0.56, p<0.0001).

Conclusion:
Elderly BC patients with early-stage, hormone receptor positive disease receiving primary surgical intervention plus endocrine therapy had improved survival compared to those receiving primary endocrine therapy alone. This study reflects the importance of surgical intervention for elderly BC patients and warrants further investigation to evaluate whether surgery may be omitted safely in subsets of elderly patients.

47.03 Implant Sparing Mastectomy: A Novel and Safe Surgical Approach for Breast Cancer

Posted on January 31, 2019

E. E. Burke1, C. Laronga1, W. Sun1, B. J. Czerniecki1, S. J. Hoover1, N. Khakpour1, J. V. Kiluk1, M. C. Lee1  1Moffitt Cancer Center,Breast Oncology,Tampa, FL, USA

Introduction:   In women undergoing mastectomy for breast cancer with prior retropectoral implant-based augmentation, implant sparing mastectomy has been reported. In this study, the safety and feasibility of this novel surgical approach was evaluated.

Methods:  A retrospective review of all patients undergoing implant sparing mastectomy from 2006 to 2018 for either breast cancer treatment or prevention at a single institution was performed. Data including patient and tumor characteristics, stage, use of systemic therapy and radiation therapy, 90-day complication rates, type of reconstruction, and recurrence of disease was collected.  

Results: A total of 74 women were identified with implant sparing mastectomy from 2006 to 2018.  Of these, 49 (66.2%) underwent bilateral mastectomy. A total of 66 (89.2%) received mastectomy after diagnosis of invasive breast cancer or ductal carcinoma in situ (DCIS) while 8 (10.8%) elected mastectomy for prophylaxis. Among 66 breast cancer patients, resection margins were negative in 53 (80.3%), negative but close (DCIS < 2mm) in 10 (15.2%), and positive in 3 (4.5%). Five (7.6%) of these breast cancer patients had a documented recurrence; 4 at distant sites, and 1 local recurrence in the chest wall despite adjuvant chemotherapy and radiation therapy in the setting of node positive disease for which axillary lymph node dissection was declined. No new breast cancer diagnoses were reported in the 8 patients that underwent implant sparing mastectomy for prophylaxis alone. Ninety-day complication rates for all patients were low; 1 patient (1.4%) had a seroma requiring aspiration, 1 patient (1.4%) had a wound infection requiring antibiotics, and 4 (5.4%) had a hematoma requiring operative intervention. Three patients (4.1%) had wound dehiscence and 8 (10.8%) had flap loss. Of those patients with flap loss, 6 required debridement in the operating room (OR), and 1 of these patients required OR for free flap loss that was performed immediately after implant sparing mastectomy. The only complication rate higher than expected based on the literature was that of hematoma requiring operative intervention.  The vast majority, 64 (86.5%) underwent delayed reconstruction. Of these, only 7 required flap reconstruction, the remainder of patients underwent implant exchange only. 

Conclusion: For patients with previous implant-based augmentation pursuing mastectomy for breast cancer treatment or prevention, implant sparing mastectomy is a novel surgical approach with local recurrence and overall complication rates comparable to skin-sparing mastectomy with the exception of a slightly increased hematoma rate.  Finally, delayed reconstruction for these patients often requires no more than implant exchange with a low rate of need for flap reconstruction. As such this study suggests that implant sparing mastectomy is a safe and reasonable approach for selected patients.

 

47.02 Are Tc-99m-Sestamibi Scans in Secondary Hyperparathyroidism Needed?

Posted on January 31, 2019

B. A. Jones1, B. Lindeman1, H. Chen1  1University Of Alabama at Birmingham,Department Of Surgery,Birmingham, Alabama, USA

Introduction:  Parathyroidectomy for patients with secondary hyperparathyroidism (2HPT) generally required a 4-gland exploration. Some groups have strongly recommended routine pre-operative Tc-99m-sestamibi scans to guide intraoperative planning and to potentially identify ectopic parathyroid glands. Others, including our team, practice scanning for only selected patients. In order to determine the utility of sestamibi scans in this patient population, we reviewed our experience.

Methods:  We performed a retrospective review of patients who underwent parathyroidectomy for 2HPT by one surgeon between 2000 and 2018. Data reviewed included patient demographics, laboratory results, pathology and radiology reports, and clinical and operative notes.

Results: Of the 72 patients in the cohort, mean age was 47.2 ± 15.6 and 50% were female. The pre-operative mean calcium and parathyroid hormone levels were 9.6 ± 1.1 mg/dl and 1192.1 ± 914.1 pg/ml, respectively. Sestamibi scans were performed in 21 patients (29%). Of these, 17 were re-operative cases. In the sestamibi cohort, only 4 patients had ectopic glands identified on the scan (2 retroesophageal, 1 thymic, 1 undescended). Among the 61 patients without pre-operative imaging, 16 had ectopic glands (12 thymic, 2 intrathyroidal, 1 carotid sheath, 1 undescended) (26.2% of non-imaged patients, 27.8% of all 2HPT patients). All of these 16 ectopic glands were found by the surgeon at the time of operation without the need for pre-operative imaging. All patients in the series were cured with a minimum follow-up of 6 mos.

Conclusion: Ectopic parathyroid glands are commonly seen in patients undergoing parathyroidectomy for 2HPT. The majority of ectopic glands were successfully identified during the operation without preoperative sestamibi scan. Therefore, routine pre-operative Tc-99m-sestamibi scans are not needed for successful parathyroidectomy for 2HPT.

47.01 Breast Reconstruction Disparities Remain Despite Affordable Care Act Medicaid Expansion

Posted on January 31, 2019

A. N. Cobb1, E. Eguia1, U. Maduekwe2, C. Godellas1, P. C. Kuo3  1Loyola University Medical Center,General Surgery,Maywood, IL, USA 2Loyola University Medical Center,Plastic Surgery,Maywood, IL, USA 3University Of South Florida College Of Medicine,Tampa, FL, USA

Introduction:

Following the implementation of Medicaid expansion via the Affordable Care Act (ACA), more women had access to cancer surgical care. However, the rates of reconstruction following mastectomy remain low. This study aims to evaluate the impact of Medicaid expansion on the utilization of breast reconstruction following mastectomy for breast cancer.

Methods:

We conducted a retrospective review using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) for the years pre (2010-2013) and post (2014) Medicaid expansion.  We compare the incidence of breast reconstruction in Medicaid expansion states (MD, NY, WA) vs. non-expansion (FL) states. Reconstruction was defined as the observed procedure rate per 1,000 cancer admissions. A generalized linear model with a Poisson distribution and logistic regression was used with incidence rate ratios (IRR) and difference-in-differences (DID).   

Results:

We identified 65,178 females diagnosed with breast cancer. Of those 13,161 (16%), underwent breast reconstruction.   Patients in non-expansion states were slightly older with a mean age of 49 (8.6) [vs 48 (8.6) p<.001] and had lower Elixhauser comorbidity indices at 2.0 (1.1) [vs. 2.1 (1.2) p<.0001]. Both groups were predominantly white (65%) and had Medicaid insurance, though there were a higher proportion of Medicaid patients in non-expansion states (86.1% vs. 84.5%). The rates of breast reconstruction did not significantly increase in expansion states, even when adjusting for age, comorbid disease and race (IRR=1.04 95% CI [.75,1.44]). Additionally, living in a Medicaid expansion state post-implementation did not increase patients’ odds of getting reconstructive surgery (OR 1.16 95% CI .82-1.65). African-American women were 30% (OR .68 95% CI .64-.72) less likely to get reconstruction than their white counterparts while Hispanic women had increased odds of reconstruction overall (OR 1.16 95% CI 1.08-1.24).

Conclusion:

The rates of breast reconstruction have remained virtually unchanged pre and post Medicaid Expansion in both expansion and non-expansion states. Disparities in breast reconstruction remain after the ACA's expansion of Medicaid and may disproportiontely impact African American women . 

 

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