77.18 Impact of insurance Status on Cytoreduction Surgery and Hyperthermic Intraperitoneal Chemotherapy

Posted on January 18, 2016

J. B. Oliver2, J. Rosado2, J. S. Patel2, K. M. Spiegler2, K. Houck3, R. J. Chokshi1 1New Jersey Medical School,Surgical Oncology,Newark, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3New Jersey Medical School,Obstetrics And Gynecology,Newark, NJ, USA

Introduction: Cytoreduction surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) offer the best opportunity for long term survival for peritoneal metastasis for colorectal, appendicular, and ovarian cancers. Multiple studies have shown that individuals with cancer that are under insured have worse outcomes. However, to the best of our knowledge outcomes in the uninsured and underinsured undergoing CRS-HIPEC have not been investigated. Therefore, we looked at the outcomes in our series of CRS-HIPEC patients stratified by insurance status to see whether these individuals suffer worse outcomes.

Methods: Demographics, comorbidities, intraoperative variables, and post-operative outcomes for all patients undergoing CRS/HIPEC at a single institution from 2012 to 2015 were analyzed. Variables were examined with chi squared or Wilcoxon Ranked Sum Test where appropriate. Survival was analyzed with Kaplan Meier curves and Cox Proportional Hazard Regressions.

Results:During this time frame, 27 individuals underwent CRS-HIPEC. Sixteen of these individuals were underinsured (either Charity Care or Medicaid) while 11 were insured (Medicare or private insurance). The median age of the underinsured group was significant lower than that of the insured group (54.1 years vs 62.3 years, p=0.02). The groups had similar distributions of the Charlson Comorbidity Index (0 vs 0, p=0.86) and peritoneal carcinoma index (25.5 vs 18, p=0.42). The under insured group had a higher preoperative albumin levels (4.0 vs 3.3, p=0.04). Both groups had similar distribution and total number of organs resected (3.5 vs 4 total organs, p=1.00). Operative time trended to being longer in the under insured group (573.5 minutes vs 510 minutes, p=0.06). Both groups had similar rate of major complications (Clavien Dindo complication of 3A or greater, 64.3% vs 63.6%, p=0.97) and length of stay (12 vs 11 days, p=0.98). Median follow up time for the under insured group was 8.5 months while the median follow up for the insured group was 1.7 months. During the follow up, 4 individuals in each group died; at 44, 71, 73, and 733 days within the under insured group the deaths occurred and at 16, 40, 41, and 72 days within the insured group. Survival was significantly better within the under insured group (p=0.02). After controlling for age and preoperative albumin, the survival difference remained significant improved within the under insured group (HR 0.02, 95% CI 0.00-0.76, p=0.04).

Conclusion:In this small, single center study with very short follow up, there was an improvement in survival for those underinsured undergoing CRS-HIPEC and no difference in length of stay or complications. Larger studies with longer follow up are needed to confirm these findings.

77.10 Immunonutrition is associated with a decreased incidence of graft-versus-host disease:Meta-analysis

Posted on January 18, 2016

H. Kota3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada

Introduction: Graft versus host disease (GVHD) is a serious complication of bone marrow transplantation requiring higher doses of glucocorticoids or immunosuppressive therapies, further straining transplant recipients. Immunonutrition, such as vitamins and amino acids, act to increase immunity, decrease inflammation, and decrease oxidative stress. This meta-analysis examines the impact of immunonutrition on the incidence of GVHD and post-operative infections among transplant recipients.

Methods: A comprehensive literature search for all published randomized control trials (RCTs) was conducted using Pubmed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Keywords in the search included all terms related to immunonutrition, such as ‘vitamin C’ or ‘ascorbic acid’ and ‘transplant.’ Outcomes analyzed included incidence of GVHD and infection.

Results: 8 RCTs involving 529 transplant recipients (261 receiving immunonutrition and 268 receiving standard nutrition) were analyzed. Immunonutrition reduced the incidence of GVHD by 17%; (RR = 0.832; 95% CI, 0.702-0.986; p=0.034). There was no significant difference in the incidence of infections with the use of immunonutrition (RR = 1.016, 95% CI, 0.819-1.261, p=0.885). Subgroup analysis by the type of immunonutrition, showed no difference in the incidence of GVHD or infections.

Conclusion: Immunonutrition reduces the risk of GVHD in transplant recipients possibly due to better nitrogen balance, immune support and free radical scavenging. Additional studies specifically evaluating the use of immunonutrition on infection incidence in bone marrow transplant recipients are required.

74.16 Abdominal Wall Reconstruction in Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy

Posted on January 18, 2016

J. Rosado2, J. B. Oliver2, J. Patel2, K. M. Spiegler2, K. Houck3, R. J. Chokshi1 1New Jersey Medical School,Surgical Oncology,Newark, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3New Jersey Medical School,Obstetrics And Gynecology,Newark, NJ, USA

Introduction: Cytoreduction surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) offer the best opportunity for long term survival for peritoneal metastasis for colorectal, appendicular, and ovarian cancers. There are times in which to achieve proper cytoreduction, abdominal wall resection is required. These resections in part the need for abdominal wall reconstruction while some patients require reconstruction for other reasons as well. It is known that chemotherapy and hyperthermia in part increased risks for wound infections, poor wound healing and further complications. Therefore, we looked at the outcomes in our series of CRS-HIPEC patients taking a look at the outcoomes, morbidity and mortality of those patients requiring abdominal wall reconstruction compared to those who did not.

Methods: Demographics, comorbidities, intraoperative variables, and post-operative outcomes for all patients undergoing CRS/HIPEC at a single institution from 2012 to 2015 were analyzed. Variables were examined with chi squared or Wilcoxon Ranked Sum Test where appropriate. Survival was analyzed with Kaplan Meier curves and Cox Proportional Hazards Regression..

Results:During this time frame, 27 individuals underwent CRS-HIPEC. There were 11 patients which underwent reconstruction, while 16 patients had no reconstruction. These patients were similarly aged and gender distribution. They had similar epidural use and similar number of organs removed. There was no difference in Peritoneal Carcinomatosis Index for the two groups (22 vs 19 p=0.74). Patients undergoing reconstruction tended to have increased operative time (663min vs 489min p=0.01) as well as increased blood loss (1000ml vs 500ml p=0.02). Both groups had similar complication rate (72.7% vs 57.1% p=0.42). Median follow up for the no reconstruction group was 4 months compared to 1.7 months for the reconstruction group. Five of the 16 individuals within the no reconstruction group and 3 of the 11 individuals with reconstruction died during the follow up period. The survival rate for the two groups were similar (68.8% vs 72.7%, p=0.44).

Conclusion:Thus the need for abdominal wall reconstruction had no impact on patient’s mortality but did impact their operative time and blood loss. Further evaluation with larger series and longer follow up is needed to confirm these findings.

73.05 No Difference in Reliability and Efficacy of Caudal versus Penile Block in Circumcision

Posted on January 18, 2016

K. Malik3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada

PURPOSE: Circumcision is one of the most common surgeries performed in the pediatric population. Multiple local analgesia techniques including caudal block (CB) and penile block (PB) have been utilized and championed as offering optimal pain control during circumcision in toddlers and older children with no clear consensus. This meta-analysis investigates the efficacy of CB and PB during circumcision and their impact on postoperative analgesic requirements in the pediatric population age 16 months to 18 years.

Methods: A comprehensive literature search of PubMed, Google Scholar, and Cochrane Central Registry of Controlled Trials (1966-2015) was completed for all published randomized control trials (RCTs). Keywords searched included ‘circumcision’, ‘caudal block’, and ‘penile block’. Inclusion criteria were limited to the comparison of PB versus CB in children 16 months to 18 years of age and its efficacy towards circumcision. The efficacy, time to first additive analgesia, time to first micturition, duration of prolonged motor blockade, incidence of vomiting, and length of stay were analyzed.

Results: 9 RCTs involving 574 children, 287 undergoing PB and 287 undergoing CB, were included. There was no difference between the efficacy (relative risk (RR) = 0.983, 95% confidence interval (CI) = 0.95 to 1.02; p = 0.328) or time to first additive analgesia (standardized difference in mean (SDM) = 0.510, CI = -0.07 to 1.09; p = 0.066). Time to first micturition (SDM = 0.767, CI = 0.51 to 1.02; p < 0.001) and duration of motor blockade (SDM = 0.788, CI = 0.08 to 1.50, and p = 0.03) was significantly greater for CB. No differences were observed between CB and PB for the incidence of vomiting (RR = 1.56, CI = 0.91 to 2.67, and p = 0.11) and length of stay (SDM = 0.741, CI = -0.05 to 1.53 and p = 0.066). No differences between levobupivacaine and bupivacaine are observed in regards to the efficacy of the blocks (p = 0.570), time to first micturition (p = 0.196), duration of prolonged motor blockade (p = 0.098), and risk of vomiting (p = 0.825).

Conclusion: CB and PB offer equivalent anesthetic outcomes in pediatric patients’ age 16 months to 18 years undergoing circumcision. CB is associated with a longer time to urination and ambulation. Additional adequately powered studies are needed to further investigate optimal medication dose and anesthetic choice.

73.06 Ultrasound Guided Central Venous Catheter Placement Increases Success Rates in Pediatric Patients

Posted on January 18, 2016

C. S. Lau1,3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada

Introduction: Real-time ultrasound guidance for central venous catheter (CVC) insertion has been shown to increase cannulation success rates and reduce complications in adults. Literature regarding ultrasound guided CVC placement in children remains limited and conflicting. This meta-analysis examines the impact of ultrasound guided CVC placement among pediatric patients in regards to success rate, number of attempts required, incidence of accidental carotid artery puncture, and time to cannulation.

Methods: A comprehensive literature search of all published randomized control trials (RCTs) assessing the use of real-time ultrasound guided CVC insertion in pediatric patients <18 years of age was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Keywords searched included ‘ultrasound guided’ and ‘central venous catheter’. Studies comparing the use of real-time ultrasound CVC insertion with anatomic landmark CVC placement in pediatric patients <18 years of age were included. Primary outcomes analyzed were cannulation success rate, number of attempts required, incidence of carotid artery puncture, and time to cannulation.

Results: 8 RCTs involving 760 patients (367 via ultrasound guidance and 393 via anatomic landmark placement) were analyzed. Ultrasound guided CVC insertion significantly increased success rates by 31.8% (Relative Risk (RR) = 1.318; 95% CI, 1.101 – 1.576; p=0.003) and decreased the mean number of attempts required (Mean Difference (MD) = -1.261; 95% CI, -1.711 to -0.812; p<0.001). A trend towards a decrease in the risk of accidental carotid artery puncture with the use of ultrasound guided CVC insertion was also observed (RR = 0.359; 95% CI, 0.118 – 1.093; p=0.071). Ultrasound guided CVC insertion was not associated with a significantly longer time to CVC placement (MD = 1.175 = -0.287 to 2.636; p=0.115).

Conclusion: Ultrasound guided CVC placement is associated with significantly higher success rates and decreased mean number of attempts required for cannulation. There is also a trend towards a decrease in accidental carotid artery puncture, which was not statistically significant likely due to inadequate sample size. Ultrasound guided CVC insertion improves success rates, efficacy, and safety among pediatric patients. Additional studies are required to determine the efficacy and safety of ultrasound guided CVC insertion in specific age populations of neonates compared to older children, and in the various healthcare settings.

07.14 The World Health Organization Surgical Safety Checklist Improves Post-Operative Outcomes

Posted on January 18, 2016

C. S. Lau1,3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada

Introduction: The incidence of in-hospital adverse events is about 10%, with a majority of these related to surgery, and nearly half of these considered preventable events. To improve patient safety, the World Health Organization (WHO) developed a checklist to be used at critical perioperative moments (induction, incision, and prior to the patient leaving the operating room (OR)). This meta-analysis examines the impact of the WHO surgical safety checklist on the incidences of overall complications, surgical site infections (SSI), unplanned return to the OR within 30 days, and overall mortality.

Methods: A comprehensive literature search of all published studies assessing the use of the WHO surgical safety checklist in patients undergoing surgery was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Keywords searched included ‘World Health Organization’, ‘surgical checklist’, and ‘safety checklist’. Inclusion criteria were the use of the WHO surgical safety checklist in any surgical setting, with pre-implementation and post-implementation surgical outcome data. The incidence of various patient outcomes (total complications, SSIs, unplanned return to the OR within 30 days, and overall mortality) and adherence to safety measures (airway evaluation, use of pulse oximeter, presence of catheter lines, prophylactic antibiotics, confirmation of patient and surgical site, and sponge count) were analyzed.

Results: 10 studies involving 51,125 patients (27,490 prior to implementation and 23,635 patients after the implementation of the WHO surgical safety checklist) were analyzed. The implementation of the WHO surgical safety checklist significantly reduced the risk of total complications by 37.9% (RR = 0.621; 95%CI 0.519 – 0.742; p<0.001), SSIs by 45.5% (RR = 0.545; 95%CI 0.416 – 0.714; p<0.001), unplanned return to OR by 32.1% (RR = 0.679; 95%CI 0.484 – 0.954; p=0.025), and mortality by 15.3% (RR = 0.847; 95%CI, 0.752 – 0.954; p=0.006). There was also a significant increase in adherence to safety measures including airway evaluation, use of pulse oximetry, prophylactic antibiotics when necessary, confirmation of patient name and surgical site, and sponge count.

Conclusions: The use of the WHO surgical safety checklist is associated with a significant reduction in post-operative complications and mortality. The WHO surgical safety checklist is a valuable tool that should be universally implemented in all surgical centers and utilized in all surgical patients. Additional studies are required to determine optimal strategies for implementation of the WHO surgical safety checklist in different healthcare settings and countries.

65.04 Leucocyte Filtered Blood Transfusions are Associated with Decreased Postoperative Infections

Posted on January 18, 2016

S. Kwon3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada

Introduction: Leucocyte filtered blood (LFB) has been shown to prevent cytomegalovirus reactivation, HLA immunization and recurrent febrile non-hemolytic reactions. LFB has been reported to decrease postoperative infections, however, prior reports are conflicting and contradictory. This meta-analysis examines the impact of LFB on the overall incidence of postoperative infections.

Methods: A comprehensive literature search of PubMed, Google Scholar, and the Cochrane Central Registry of Controlled Trials from January 1966 to July 2015 was conducted. Keywords included in the search were ‘leuk(c)oreduced’, ‘leuk(c)odepleted’, ‘filtered’, ‘white cell reduced’, ‘leuk(c)ocyte reduced’, ‘leuk(c)ocyte depleted’, and transfusions. Studies that compared LFB to non-leucocyte filtered blood and reporting postoperative infections were included. Outcomes analyzed included postoperative infections under ‘as per protocol’ (APP) and ‘intention-to-treat’ (ITT), as well as length of stay (LOS).

Results: 16 RCTs involving 6,776 randomized (ITT) patients (4,514 transfused (APP) patients) in various clinical settings (7 cardiac, 5 colorectal, and 4 other) were evaluated. The LFB group had an overall 25.6% reduction in postoperative infection risk when analyzed by APP (RR=0.744; 95% CI [0.593-0.934]; p=0.011) and 21.7% risk reduction when analyzed by ITT (RR=0.783; 95% CI [0.646-0.949]; p=0.013). When analyzed by APP, cardiac and colorectal surgeries derived the greatest infection reduction benefit (RR=0.748; 95% CI [0.623-0.897]; p=0.002 and RR=0.447; 95% CI [0.199-1.006]; p=0.052). LFB was also associated with a significant reduction in LOS (Standardized Difference of Mean (SDM) =-0.539; 95% CI [-1.038- -0.0040]; p=0.034).

Conclusion: LFB transfusions are associated with a significant decrease in postoperative infections for both APP and ITT populations, particularly in cardiac surgery patients. Additional adequately powered studies are needed to fully understand the benefits of LFB.

61.16 Intensive glycemic control reduces mortality and morbidity in cardiac surgery patients:Meta-analysis

Posted on January 18, 2016

K. P. Kulkarni3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada

PURPOSE: Optimal glycemic control in cardiac surgery patients remains a laudable but confusing practice. Existing studies have primarily employed two maintenance strategies using either tight glycemic control (maintain <120 mg/dl) or liberal control (<200 mg/dl) with conflicting outcomes. Meta-analysis and meta-regression were performed to better delineate which approach (if any) is associated with reduced perioperative morbidity and/or mortality.

Methods: A comprehensive literature search of PubMed, Google Scholar and the Cochrane Central Registry of Controlled Trials was completed. Keywords searched were ‘insulin’,‘bypass’,’coronary’,’CABG’,’glucose’,’artery’,’intensive’,’cardiac’, and ‘surgery’. Eligible studies were randomized control trials (RCTs) utilizing two different glycemic control strategies with a mortality outcome. Primary outcomes were mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS.

Results: 14 studies were included in this study. Intensive glucose control significantly reduced mortality (relative risk (RR) = 0.742, 95% CI=0.566 to 0.973; p=0.031) and ICU LOS (Standardized difference of mean (SDM) = -0.352, 95% CI=-0.352 to -0.692; p=0.042) but did not influence overall hospital LOS (SDM= -0.255, 95% CI = -0.722 to 0.211; p=0.283). Significant secondary outcomes were overall infection (RR=0.444, 95% CI=0.322 to 0.611; p<0.001) and atrial fibrillation rates (RR=0.722, 95% CI=0.582 to 0.896; p=0.003). No difference in stroke (RR=2.279, 95% CI=0.525 to 9.885; p=0.271), deep sternal infection (RR=0.599, 95% CI=0.242 to 1.484; p=0.268), acute renal failure (RR=1.337, 95% CI=0.468 to 3.821; p=0.588), or prolonged intubation rates were observed (RR=0.990, 95% CI=0.661 to 1.483; p=0.962).

Conclusion: Optimal glycemic control is significantly linked to improved perioperative outcomes in cardiac surgery patients. Intensive glucose control (< 120 mg/dl) reduces mortality and ICU LOS in cardiac surgery patients, while also decreasing overall postoperative infection and atrial fibrillation rates compared to more liberal glycemic strategies. Additional adequately powered studies are needed to further investigate the nuances of optimal intensity and duration of glycemic control in this patient population.

52.06 Enhanced Recovery After Surgery Programs Improve Patient Outcomes and Recovery: A Meta-Analysis

Posted on January 18, 2016

C. S. Lau1,3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada

Introduction: Enhanced recovery after surgery (ERAS) programs have been developed with the aim to improve patient outcomes and accelerate recovery after surgery. ERAS programs are a multimodal approach, with interventions during all stages of care: preoperative, intraoperative, and postoperative. ERAS programs have been proposed to improve patient outcomes and reduce health care costs. This meta-analysis examines the impact of ERAS programs on patient outcomes and recovery.

Methods: A comprehensive literature search of all published randomized control trials (RCTs) assessing the use of ERAS programs in surgical patients was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Keywords searched included ‘enhanced recovery’ and ‘fast track’. Studies using at least 4 components of the ERAS program were included. Primary outcomes analyzed were length of stay (LOS), overall mortality, readmission within 30 days, and total costs. Total complications, time to first flatus, and time to first bowel movement were also analyzed.

Results: 42 RCTs involving 5,241 patients (2,595 receiving ERAS and 2,646 receiving standard of care) were analyzed. ERAS programs significantly reduced LOS by 2.35 days (MD = -2.345; 95%CI, -2.733 to -1.958; p<0.001), total complications by 38.0% (RR=0.620; 95%CI 0.545 – 0.704; p<0.001), and total costs (SMD= -0.789; 95%CI, -1.093 to -0.485; p<0.001). LOS reductions varied by type of surgery, with a 3 day reduction after orthopedic surgery (p=0.017) and no significant reduction after cardiovascular surgery (p=0.073). Return of gastrointestinal (GI) function was also significantly improved, as measured by earlier time to first flatus (SMD= -0.987; 95%CI, -1.389 to -0.585, p<0.001) and time to first bowel movement (SMD= -1.074; 95%CI, -1.396 to -0.752; p<0.001). Overall mortality was reduced by 29.2% (RR=0.708; 95%CI 0.377 – 1.330; p=0.283). Overall, there was no difference in readmission rates within 30 days (RR=1.151; 95%CI 0.822–1.612, p=0.412); however, readmission rates within 30 days after upper GI surgeries nearly doubled with the use of ERAS programs (RR=1.922; 95%CI 1.111 – 3.324; p=0.019).

Conclusion: ERAS programs are associated with a significant reduction in LOS, total complications, total costs, as well as earlier return of GI function. Overall mortality rates remained similar, but readmission rates varied significantly depending on the type of surgery. ERAS programs are effective and a valuable part in improving patient outcomes and accelerating recovery after surgery. Additional studies are required to determine the specific components of the ERAS program that are most beneficial.

33.10 Breast Cancer in Native American Women: A Study of 863,958 Patients from the SEER Database(1973-2010)

Posted on January 18, 2016

S. Gopinath1, K. Mahendraraj1, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2Saint George’s University,Surgery,Grenada, Grenada, Grenada 3New Jersey Medical School,Surgery,Newark, NJ, USA

Introduction:

Breast cancer (BC) is the most common cancer among Native American (NA) women. Despite this fact, existing data suggests NA women have a lower than expected BC incidence rates, but a markedly higher mortality to incidence ratio compared to other racial/ethnic groups. This study sought to analyze demographic and clinical factors in a large NA BC cohort to further investigate the validity of these observations and to delineate clinical and pathological factors which may better risk stratify this unique population for optimal treatment protocols and clinical trial accrual.

Methods:

Demographic and clinical data on 863,958 women with invasive ductal carcinoma of the breast was abstracted from the Surveillance Epidemiology and End Result (SEER) database (1973-2010). Standard statistical methodology was used.

Results:

Among 863,958 BC patients, 4,289 (0.5%) were NAs and 859,669 (99.5%) were Caucasians. The majority of BC in both groups occurred in those 60 to 79 years (43.7% Caucasians and 33.5% NA). NA women had a higher incidence of BC at a younger age (9.2% vs. 5.1% for age 20-39, and 51.8% vs. 38.1% at age 40-59, p<0.001), as well as a higher rate of regional (34.0% vs. 31.3%) and distant metastasis (7.9% vs. 6.1%). The majority of women in both groups had tumor size <2 cm (56.4%) and moderately differentiated disease (42.3%), p<0.001. Mean overall survival (OS) was significantly longer in Caucasian women than NAs (7.40±6.7 vs. 6.66±6.1 years), p<0.001. The majority (54.3%) of all patients underwent surgery only. Cancer specific mortality (21.7% vs. 21.2%) as well as 1- and 5- year cumulative survival (94% and 74% vs. 94% and 76%) was similar between groups. Multivariate analysis identified that age>60 (OR 1.3), size >4cm (OR 1.8) and distant metastasis (OR 3) were associated with increased mortality, p<0.001.

Conclusion:

Invasive ductal carcinoma of the breast affects the NA population far less often than Caucasians. NA BC patients tend to be younger and present with more aggressive disease features. Despite these finding, NA BC patients have survival equivalent to similarly treated women in other ethnic groups. Surgical resection and combination surgery and radiation conferred the greatest survival advantage in NAs. Due to its rarity, NA women with breast cancer should be considered for clinical trial accrual to further delineate genetic and environmental factors which may affect incidence rates and prognosis.

32.06 Alvimopan Reduces Time to GI Recovery & Discharge After Abdomino-Pelvic Surgery: A Meta-Analysis

Posted on January 18, 2016

A. Chandrasekaran3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada

Introduction:

Postoperative bowel atony impedes recovery following abdominal surgery. Alvimopan is a competitive, selective µ-opioid receptor antagonist that has been extensively studied (with variable reported rates of efficacy) in regards to its ability to aid GI tract recovery in abdominal surgery patients. This meta-analysis critically examines the clinical and financial impact of impact of alvimopan on GI recovery.

Methods:

A comprehensive literature search of PubMed, Google Scholar, and the Cochrane Central Registry of Controlled Trials (1966-2015) was completed. Search terms were, ‘alvimopan’, ‘entereg’, ‘ADL 8-2698′, ‘Surgery’, and ‘randomized controlled trial’. Outcomes analyzed were time to tolerance of solid food and first bowel movement, time to hospital discharge order written, and opioid use.

Results:

Seven RCTs involving 2,955 abdominal and pelvic surgery patients receiving alvimopan 12mg versus placebo were included in this analysis. 1,644 patients received alvimopan 12mg and 1,311 received placebo two hours before the start of surgery and twice daily for seven days or until hospital discharge. 2,558 patients underwent bowel resection, 700 patients underwent total abdominal hysterectomy, 159 underwent radical hysterectomy, and 227 underwent radical cystectomy. Alvimopan 12mg was associated with a statistically significant reduction in mean time to tolerance of solid food and first bowel movement (SDM -0.326; 95% CI -0.411 to -0.240, p<0.001) as well as mean time to discharge order (SDM -0.215; 95% CI -0.301 to -0.130, p<0.001). No significant reduction in postoperative opioid use was identified in the included studies.

Conclusion:

Alvimopan significantly aids post-operative recovery after abdominal and pelvic surgery as measured by a significant decrease in return to GI function and time to hospital discharge order. No difference in opioid requirement is attributable to alvimopan use. Alvimopan should be considered an effective adjunctive aid to bowel recovery for patients undergoing abdominal or pelvic surgery. Alvimopan use in other types of surgery requires additional investigation.

23.30 The International General Surgery Journal Club: 12-Month Experience with a Twitter-based Journal Club

Posted on January 18, 2016

S. B. Bryczkowski1, A. L. Cochran2, N. J. Gusani3, C. Jones4, L. S. Kao5, B. C. Nwomeh6, M. E. Zenilman7 1New Jersey Medical School,Surgery/Rutgers,Newark, NJ, USA 2University Of Utah,Surgery,Salt Lake City, UT, USA 3Penn State Hershey Medical Center,Surgery,York, PA, USA 4Ohio State University,Trauma/Surgery,Columbus, OH, USA 5University Of Texas Health Science Center At Houston,Surgery,Houston, TX, USA 6Ohio State University,Pediatric Surgery,Columbus, OH, USA 7Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA

Introduction: Physician use of social media is becoming more common. Twitter-based journal clubs (JC) are effective, feasible venues for discussing high-impact articles. The purpose of the study was to describe the authors’ experience starting the Twitter-based JC, the International General Surgery Journal Club (IGSJC).

Methods: Monthly 2-3 day Twitter JCs were scheduled to discuss recent JAMA Surgery articles. The IGSJC executive committee moderated discussions among authors, followers, and Twitter participants. Descriptive analyses of Twitter transcripts were done. IGSJC followers and Tweets including the #IGSJC hashtag identified participants. The primary outcomes were number and profession of participants, transcript themes, and article downloads.

Results: During the first 12 months of JCs (March 2014 – March 2015), 514 participants from 69 countries tweeted 4,574 times creating 7,085,470 impressions. IGSJC transcript analyses revealed three themes: discussion of articles, physician education, and patient advocacy. There were 5,915 HTML views and PDF downloads combined for the first quarter.

Conclusion: A Twitter-based JC for general surgeons is feasible and surgeons are interested. The IGSJC is dynamic, allowing real-time conversations. The asynchronous design allows international involvement, making it superior to standard JCs. Future potential to communicate new surgical data and offer continuing medical education needs to be explored.

18.03 Efficacy of TAP Block for Early Postoperative Analgesia after Open Cholecystectomy in LMICs

Posted on January 18, 2016

A. Mansoor1, A. Scholer1, B. D. Patrick1, D. Grech1, Z. C. Sifri1 1New Jersey Medical School,Newark, NJ, USA

Introduction: Pain management after surgery is difficult in low middle income countries (LMICs) due to limited availability of narcotics. The transversus abdominis plane (TAP) block is designed to eliminate somatic incisional pain and is used at times during short-term surgical missions (STSM) to LMICs .We hypothesized that TAP would decrease both early narcotic consumption and postoperative pain during STSM.

Methods: A retrospective chart review was conducted of patients who underwent open cholecystectomy during STSM. All patients were treated with Tylenol 800- 1000 mg PO, Tramadol 50 mg PO, and Toradol 30 mg IV (standard postoperative analgesic regimen). TAP blocks were performed on select patients with 20 ml 0.5% Ropivacaine under ultrasound guidance 30 minutes post op. Data collected included age, gender, ASA, duration of anesthesia and surgery, initial post-op pain score. Outcomes measured included Visual Analog Scale (VAS) pain score at rest (30 mins -2 hrs post-op), intravenous (IV) narcotic doses administered and hospital length of stay (LOS). A comparative analysis was then performed using Student’s T-test (mean ± SD).

Results: 22 patients underwent open cholecystectomy, of those, 11 (50%) received a TAP block. Gender, ASA, and duration of anesthesia were not significantly different among the groups. Age, duration of surgery, and initial pain score were significantly different (Table). Patients who received a TAP block had a 46% decrease in narcotics administered and a 30% shorter LOS when compared to the standard group (Table). No significant difference was noted in the pain scores between the TAP and the standard group (5.2 ± 1.2 vs. 4.7 ± 2.2, respectively, p > 0.5) and no complications from the TAP procedure were reported.

Conclusion: TAP block after open cholecystectomy reduces narcotic usage and shortens LOS during STSMs. TAP block is safe and effective adjunct to standard pain regimen in the early postoperative course in LMIC. Larger prospective studies are needed to confirm these findings.

14.12 Gallbladder Carcinoma in the United States: Epidemiology and Outcomes Involving 14,903 Patients

Posted on January 18, 2016

K. Mahendraraj1, C. S. Lau1,3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada

Introduction: Gallbladder carcinoma (GBC) is the most common malignancy of the biliary tract and third most common gastrointestinal tract malignancy. Although GBC is much less prevalent in North America compared to Asia, it is associated with extremely poor prognosis. This study examines a large cohort of GBC patients in the United States in an effort to define demographics, clinical and pathologic features impacting clinical outcomes in GBC patients.

Methods: Demographic and clinical data on 14,903 GBC patients was abstracted from the SEER database (1973–2012). Statistical analysis was performed with SPSS©v20.0 software using Chi-square test, paired t-test, multivariate analysis, and Kaplan-Meier functions.

Results: 14,903 cases of GBC were abstracted with a mean age of 71 years. GBC was significant more common among Caucasian (65.3%) females (71.9%), p<0.001. GBC was most often poorly or moderately differentiated (40.9% and 40.1%), p<0.001). 37.6% of GBC cases presented with distant metastasis, p<0.01. Surgery was the most common treatment modality for GBC patients (60.7%), p<0.001. Combination surgery and radiation, which was utilized in 11.5% of GBC patients, achieved similar survival rates compared to surgery alone (3.637 vs. 3.435 years, p<0.001). There was a significant increase in GBC incidence since 2000, with a rise in mean incidence of 1.8% between 1973 and 1999 period to 4.6% between 2000 and 2010, accompanying a rise in the mean incidence of surgical resection from 2.5% from1973 to 1999 to 5.0% from 2000 to 2010. Overall mortality was 86.8%, with 1- and 5-year survival rates of 35% and 13%, respectively, p<0.001. Multivariate analysis identified regional (OR 2.8) or distant disease (OR 2.1), lymph node positivity (OR 1.6), undifferentiated grade (OR 1.3), Caucasian race (OR 2.0), and male gender (OR 1.2) as independently associated with increased mortality for GBC, p<0.001.

Conclusions: GBC is an uncommon malignancy that presents most often among Caucasians females in their 8th decade of life, with over a third of cases presenting with distant metastasis. The incidence of GBC has doubled in the last decade concurrent with increases in cholecystectomy rates attributable in part to improved histopathological detection, as well as laparoscopic advances and enhanced endoscopic techniques. Surgical resection confers significant survival benefit in GBC patients, although a significant portion of GBC patients with regional disease remain untreated or undertreated. Given its rarity, all GBC patients should be enrolled in clinical trials or registries to optimize treatment and clinical outcomes for these patients.