8.11 Analysis of Intestinal Failure in Premature Infants and Premature Infants with Gastroschisis

Posted on December 22, 2014

D. M. Hook-Dufresne1, X. Yu4, A. Olsen1, L. Putnam1, S. D. Moore-Olufemi1  1University Of Texas Health Science Center At Houston,Pediatric Surgery,Houston, TX, USA 4Baylor College Of Medicine,Pediatric Epidemiology,Houston, TX, USA

Introduction: Gastroschisis (GS) is the most common congenital abdominal wall defect and is associated with poor clinical outcomes associated with the development of intestinal failure (IF). GS patients are often born at less than 37 weeks gestational age (GA), classifying them as premature, and are at increased risk for feeding difficulties associated with prematurity. The purpose of this study was to analyze the effect of prematurity on the development of IF in both GS and non-GS patients and analyze IF related outcomes between the two groups.

Methods:  A single institutional database of GS patients born less than 37 weeks GA (N=49) was queried for the following: GA, birth weight, length of stay (LOS), time to initial feeds (TIF), time to full feeds (TFF) and days on total parenteral nutrition (TPN), rate of catheter related blood stream infections (CRBSI) and 30 day mortality.  Control infants (N=343) with no gastrointestinal pathology were 7:1 matched with the GS infants on GA by week. We defined IF as requiring TPN for ≥ 60 days. The Wilcoxon rank sum test and Chi-square test  were used to test the differences between two groups for the continuous and categorical variables respectively.

Results: Premature GS infants had significantly lower birth weight than non-GS premature infants (2145 vs. 2485 gm, p< 0.0007). Premature GS infants had significantly longer LOS, TPN days, TIF and TFF when compared to non-GS premature infants (Table 1). Premature GS infants had significantly higher incidence of CRBSI (20% vs. 0.3%, p<0.0001) and 30 day mortality (4% vs. 0.3%, p<0.04). No patients in the non-GS premature group were diagnosed with IF, while the IF rate in the GS group was 29% (14 of 49).

Conclusion: Premature GS infants have significantly longer LOS, time on TPN and time to inital and full feeds when compared to their non-GS counterparts. Our study demonstrates that the poor nutritional outcomes and the development of IF in premature patients with GS is more likely a function of the intestinal dysfunction associated with GS than of prematurity. Further research into the factors that promote the intestinal dysfunction associated with GS is needed to improve clinical outcomes for these patients.

 

8.12 Elective Over Selective Silo Placement for Gastroschisis Treatment Results in Increased Morbidity

Posted on December 22, 2014

A. R. Raines1, P. C. Mantor1, T. Garwe1,2, P. Motghare2, J. Hunter3, K. Roselius4, A. Adeseye1, R. Letton1  1University Of Oklahoma College Of Medicine,Surgery,Oklahoma City, OK, USA 2University Of Oklahoma College Of Medicine,Biostatistics And Epidemiology,Oklahoma City, OK, USA 3University Of Oklahoma College Of Medicine,Oklahoma City, OK, USA 4University Of Oklahoma College Of Medicine,College Of Public Health,Oklahoma City, OK, USA

Introduction: Active debate exists regarding the use of the primary abdominal closure versus silo placement for gastroschisis treatment.  In 2005, we changed our strategy from primary closure and selective silo placement to elective silo placement with delayed closure. We reviewed our experience with each strategy.

Methods: This retrospective study, evaluating infants born with gastroschisis, used data from a single children’s hospital between 1999 and 2012.  Before 2005, our preferred gastroschisis treatment was primary closure with selective silo placement.  After 2005, our preferred treatment was elective silo placement with delayed closure.  Morbidity outcomes were evaluated based on whether treatment was received before or after 2005 (SELECTIVE SILO and ELECTIVE SILO groups, respectively).  In both groups, there were patients who were not managed with the preferred standard at the time, and two analyses were performed including and excluding these patients.  Morbidity outcomes of interest were total parenteral nutrition (TPN) days, ventilator days, hospital days, infectious complications, and need for unplanned re-operation.

Results: A total of 250 neonates were included (108 and 142 patients in the SELECTIVE SILO and ELECTIVE SILO groups, respectively).  No significant differences (p > 0.05) were observed in gestational age, gender, birth weight, APGARs, delivery type, or rate of complicated gastroschisis (atresia, bowel necrosis, obstruction) between the two groups regardless of whether patients who did not receive the elective treatment of choice for the time period were included or excluded.  The ELECTIVE SILO group had significantly (p<0.05) longer average TPN days (31 vs. 23), hospital days (41 vs. 28), and a higher rate of wound infections (18% vs. 4%) as compared to the SELECTIVE SILO group regardless of whether patients who did not receive the elective treatment of choice were included or excluded.  Overall, the ELECTIVE SILO group experienced significantly (p<0.05) fewer mean ventilation days, however, excluding patients not receiving elective treatment of choice resulted in no significant mean difference.  Unplanned reoperation rates between the two groups were similar, although, there was a trend toward higher reoperation rates in the ELECTIVE SILO group (15% vs 3%; p=0.0792) when excluding patients not receiving elective treatment.

Conclusion: These data suggest that the strategy of elective silo placement and delayed closure in gastroschisis patients significantly increases the total number of hospital days, TPN days, and wound infections as compared to primary closure and selective silo placement. Based on these results, primary abdominal closure should be the recommended approach in managing infants with gastroschisis.  Carefully controlled prospective studies are required to further validate these conclusions.

 

8.13 Gastroschisis: Outcomes of Extremely Premature Infants

Posted on December 22, 2014

T. Nice1, R. Russell1, N. Fineberg2, D. Rogers1, C. Martin1, B. Chaignaud1, S. Anderson1, M. Chen1, E. Beierle1  1University Of Alabama At Birmingham,Pediatric Surgery,Birmingham, AL, USA 2University Of Alabama At Birmingham,School Of Public Health,Birmingham, AL, USA

Introduction:

There has been little information focused on the management of gastroschisis in extremely premature infants.  The purpose of this study was to identify potential differences in treatments and outcomes of gastroschisis in very premature versus later gestational age infants.

Methods:   

A retrospective review of all infants with gastroschisis was performed from October 1999 to December 2012 (IRB # X100817009).  Infants were stratified based on gestational age: group 1 (very premature <32 weeks); group 2 (near-term 32-37 weeks); and group 3 (term > 37 weeks).   Demographic and treatment data were collected.  Complicated gastroschisis included cases with bowel perforation, necrosis, volvulus, or atresia.  Outcome measures included length of stay, TPN days, total operations and non-central venous line (CVL)-related operations, sepsis, necrotizing enterocolitis (NEC), and death.  Analysis was done using Chi square and ANOVA tests with Tukey HSD for post-hoc testing.  (α=0.05)

Results:  

A total of 247 infants were included: 13 very premature, 121 near-term, 113 term.  Demographically the groups differed only by gestational age, birth weight, and lower APGAR scores in group 1.  Treatment was similar across all groups with no statistical difference in operation type, timing, or use of mesh.  Group 3 had a lower risk of complicated gastroschisis [Table 1].  Within the first year of life, non-CVL-related operations were required more often in group 1 (53.8%) compared to group 2 (39.7%) or group 3 (27.4%) [p=0.049].  Group 1 also experienced a longer length of stay (114.9 vs 57.3 vs 46.8), increased incidence of sepsis (53.8% vs 20.7% vs 23.9%) , and increased mortality (38.5% vs 4.1% vs 2.7%) [Table 1].  NEC accounted for a large portion of the sepsis events.  Increased ventilator days (23.8 vs 4.6 vs 4.1, p<0.001) and increased TPN days (88.5 vs 48.4 vs 39.4, p<0.001) were also seen in group 1.

Conclusion:  

Extremely premature infants with gastroschisis underwent similar treatment but required more operations, total parenteral nutrition and ventilator days, and had a higher risk for sepsis and death.  While many did well, survival was markedly lower (62%).  Incidence of necrotizing enterocolitis and mortality in this extremely premature infant population with gastroschisis were higher than previously reported for infants of this gestational age range.  These results can be used to guide future efforts to improve the management of these patients and to improve counseling for their parents.

 

8.14 Giant Cell Tumor of the Bone: Epidemiology and Ouctomes for 281 Pediatric and Adult Patients.

Posted on December 22, 2014

T. K. Woleston1,3, K. Mahendraraj1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2Rutgers University, New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, ST. GEORGE’S, Grenada

Introduction: Giant cell tumors of the bone (GCT) are very rare in the pediatric population, with an incidence of 1.8%-10.6%. GCT are typically benign, although malignant GCTs have been described and are poorly understood based on the few case series published. This study reports the largest cohort of GCT patients from the SEER database to better characterize clinical and pathologic factors associated with pediatric and adult GCT cases.

Methods: Demographic and clinical data on 281 GCT patients was abstracted from the SEER database (1973-2010). Pediatric patients were defined as those aged ≤19. Data was analyzed using the Chi square test, t-test, and multivariate analysis. Kaplan-Meier analysis was used to compare long-term survival between groups.

Results: Among 281 GCT patients, 48 (17%) were pediatric (mean age 18±2), and 233 (82.9%) were adult (mean age 42±16). GCT was significantly more common among pediatric females (58.3% vs. 41.7%, female vs. male, p<0.001), compared to a more evenly distributed adult group (F:M=1:1, p<0.001). While GCT was most common overall among Caucasians (48.9% and 59.6%, p<0.001), it was significantly more common among pediatric Hispanics than adults (33% vs.16.5%, p=0.01). Pediatric GCT was more often well differentiated (22% vs.18.2%), localized (54.5% vs. 46.2%), had size <2 cm (4.5% vs. 0%), and had a lower lymph node positivity rate (0% vs. 1.7%), although none were statistically significant. Surgery was the most common therapy in both groups (75.6% and 63.2%, p=0.07), and was the only treatment associated with significant improvement in both pediatric (36.6±0.9, p<0.001) and adult (28.9 ± 1.3, p<0.001) survival. Cancer-specific mortality was significantly lower in the pediatric group (2.1% vs. 16.8%, p<0.001), and median survival significantly longer (13.9±5.7 years vs. 9.1±5.3 years, p<0.001). Multivariate analysis identified distant metastases (OR 2.6, CI=1.2-5.7) as the only risk factor for increased mortality among pediatric patients, p=0.021.

Conclusions: Pediatric GCT has higher incidence among females and Hispanics compared to adult GCT. Clinicians should consider the possibility of GCT in a symptomatic patient from these populations. Pediatric GCT was observed to be more often well differentiated and localized, with size <2 cm, no lymph node positivity, and significantly longer survial. Surgical resection was the most common treatment and conferred the longest survival advantage in both groups. Resection should be considered in pediatric GCT patients with resectable disease. Adult GCT patients should be considered for clinical trial accrual given their relative rarity, and increased cancer-specific mortality.

8.15 Analysis of Trends Associated with Robotic-Assisted Surgery in Free Standing Children’s Hospitals

Posted on December 22, 2014

J. B. Mahida1,2, J. N. Cooper1, D. Herz3, K. A. Diefenbach2, K. J. Deans1,2, P. C. Minneci1,2, D. J. McLeod1,3  1Nationwide Children’s Hospital,Center For Surgical Outcomes Research,Columbus, OH, USA 2Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA 3Nationwide Children’s Hospital,Division Of Pediatric Urology,Columbus, OH, USA

Introduction: To evaluate current trends in the use and costs associated with robotic surgery at freestanding children’s hospitals.

Methods: We identified all patients less than 18 years of age in the Pediatric Health Information System (PHIS) database who underwent a robotic-assisted surgery between October 2008 and December 2013. After determining the six most frequently performed primary procedures in this group, we identified a cohort of patients who underwent equivalent open or laparoscopic procedures at the same hospitals over the same time period. We analyzed the overall frequencies and trends in the numbers of procedures performed over the study period and compared costs between patients undergoing robotic-assisted surgery and patients not undergoing robotic surgery for each of the six procedures.

Results: The six most common urologic or general surgery robotic-assisted cases performed were correction of ureteropelvic junction (UPJ) obstruction (n=760), ureteral reimplantation (n=351), nephrectomy (n=145), partial nephrectomy (n=56), gastrointestinal antireflux procedure (n=61), and cholecystectomy (n=46). The overall number of robotic-assisted surgeries performed at the 22 included hospitals increased by 19.8% per year (p<0.001); individual analyses of the six most commonly performed procedures revealed that this was primarily driven by significant increases in urologic procedures (17.4%/year, p<0.001). Differences in demographics, clinical characteristics, and length of stay between all patients undergoing robotic and non-robotic procedures are shown in the Table. Total hospital costs tended to be higher for robotic-assisted surgeries than comparable open or laparoscopic procedures (Urologic procedures median costs: robotic $14,583 vs. open $9,388, p<0.001) (General surgical procedures median costs: robotic $13,954 vs. laparoscopic $10,180, p<0.001).

Conclusion: Use of robotic-assisted surgery in pediatrics is increasing, especially in the management of urologic diseases. Costs of robotic-assisted surgery associated admissions were higher than non-robotic surgery associated admissions even though robotic procedures were associated with a shorter length of stay. Further analysis of specific procedure related outcomes and patient reported satisfaction, particularly for procedures that would otherwise be performed open, may be warranted in order to justify the increased cost of robotic surgery in children.

 

8.16 Predictors of Failure of Fish Oil Therapy for Parenteral Nutrition-Associated Liver Disease

Posted on December 22, 2014

P. Nandivada1, S. J. Carlson1, M. I. Chang1, A. A. O’loughlin1, K. M. Gura1, M. Puder1  1Children’s Hospital Boston,Pediatric Surgery,Boston, MA, USA

Introduction:
Parenteral fish oil (FO) therapy is a safe and effective treatment for parenteral nutrition-associated liver disease (PNALD), with successful resolution of cholestasis and avoidance of liver transplantation in 85% of infants. However, patients with PNALD who do not achieve resolution of cholestasis with parenteral FO therapy progress to end stage liver disease requiring liver transplantation or resulting in death.  The purpose of this study is to identify early patient factors that are associated with subsequent failure of parenteral FO therapy to guide prognostication and patient referral guidelines.

Methods:
A retrospective review of prospectively collected data for infants with PNALD treated with at least 4 weeks of parenteral FO at Boston Children’s Hospital (BCH) between January 2006 and January 2012 was performed. PNALD was defined as a direct bilirubin greater than 2 mg/dL. Resolution of cholestasis was defined as a sustained direct bilirubin less than 2mg/dL. Treatment failure was defined as the need for liver or multivisceral transplantation or death as of January 2013. Patient demographics, hospital transfer status, and laboratory values at the time of initiation of therapy were compared between patients who achieved resolution of cholestasis with parenteral FO therapy and those who failed therapy. 

Results:
138 infants with PNALD that were treated with parenteral FO were identified. Twenty-one patients (15.2%) failed therapy, with 32% of the infants failing therapy undergoing liver transplantation and mortality in 68%. There was no significant difference in gestational age, age at diagnosis of PNALD, or birth weight between the patients who responded to parenteral FO therapy and those who failed therapy. The most common diagnosis resulting in short bowel syndrome was necrotizing enterocolitis, followed by gastroschisis, in both groups. However, patients who failed therapy had more advanced liver disease at the time of therapy initiation. Patients who failed therapy had higher direct bilirubin (9.9 vs 6.2 mg/dL, p < 0.01), lower gamma glutamyl transferase (GGT) (85.4 vs 166.8 U/L, p = 0.03), and higher international normalized ratio (INR) (1.4 vs 1.2, p < 0.01) than patients who did not fail therapy. A higher proportion of infants that failed therapy were transfers from outside hospitals (85.7%) when compared to patients who responded to therapy (67.5%). This finding may represent delays in initiation of therapy due to unavailability of parenteral FO at the infants’ home institutions.

Conclusion:
Patients who initiate parenteral FO therapy for treatment of PNALD with biochemical evidence of severe liver disease as defined by bilirubin, GGT and/or INR are at risk for treatment failure.  For infants with PNALD at institutions without access to parenteral FO, earlier referral to centers where parenteral FO therapy is available may further improve response rates.
 

8.17 Mucoepidermoid Carcinoma in Children: A Population-Based Outcomes Study Involving 221 Patients

Posted on December 22, 2014

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

Introduction:
Salivary gland carcinomas are rare in adults and children, the most common form being mucoepidermoid carcinoma (MEC). Small cohort studies suggest different clinical characteristics of MEC in adults compared to children. This study sought to analyze demographic and clinical factors which affect outcomes in adult and pediatric patients that may be used to risk stratify patients for treatment and clinical trial accrual. 

Methods:
Demographic and clinical data on 4,234 patients with MEC was abstracted from the Surveillance Epidemiology and End Result (SEER) database (1973-2010). Children were defined as age ≤ 21 and adults as >22. Standard statistical methodology was used.

Results:
Among 4,234 MEC patients, 221 (5.2%) were children and 4,013 (94.8%) were adults. The majority of pediatric MEC occurred in females (55.7%), while most adults MEC patients were male (50.6%), p<0.001. Overall, 71% of MEC occurred in Caucasians, p<0.001. Among African-Americans and Hispanics, there were more pediatric patients than adults (16.3% vs. 10%, and 20.8% vs. 8.3%, respectively; p<0.001). Adults had a higher rate of poorly differentiated disease (12.6% vs. 2.7%) and metastasis (7.7% vs. 3.6%) compared to children, p<0.001. Most children (53.8%) and adults (44.8%) presented with tumor size 2-4 cm. 51.1% of all patients underwent surgery and 41% had combination surgery and radiotherapy. More children underwent primary surgical resection alone (64.3% vs. 50.4%), while more adults had combination surgery and radiotherapy (41.4% vs. 33.0%); p<0.001. Mean overall survival (OS) was significantly longer in children than adults (34.5 vs. 18.7 years), p<0.001. Surgical resection significantly improved OS in children (34.9±0.5 vs. 22.6±0.5 years; p<0.001). Children had a lower overall mortality (3.6% vs. 38.0%) as well as higher 5-year cancer-specific survival (98% vs. 82%). Multivariate analysis identified adults (OR 10.4), tumor size greater than 2 cm (OR 1.9), poor (OR 4.0) or undifferentiated grade (OR 5.0), regional disease stage (OR 1.5), and lymph node invasion (OR 1.6) as associated with increased mortality, p<0.05.

Conclusion:
MEC is an aggressive salivary gland cancer that is predominantly found in Caucasians. It is far more common in adults, and is associated with more advanced stage, poorer grade and worse overall prognosis compared to children. While MEC presented with similar tumor size in both age groups, tumors in children occurred less frequently, were more often localized, well differentiated and had better outcomes. Surgical resection significantly improved OS in MEC patients, particularly among children. Older age and advanced tumor stage were associated with increased mortality.

8.18 Is Routine Postoperative Follow-Up Necessary After Common Pediatric Surgical Procedures?

Posted on December 22, 2014

E. M. Knott1, S. Suh2, B. A. Dalton1, T. A. Wattsman2, S. D. St. Peter1, S. R. Shah1  1Chidren’s Mercy Hospital,Pediatric Surgery,Kansas City, MO, USA 2Virginia Tech Carilion School Of Medicine,Pediatric Surgery,Roanoke, VA, USA

Introduction:
The rate of postoperative complication is extremely low for common pediatric surgical procedures such as hernia repair, circumcision and pyloromyotomy.   However, most surgeons continue to request patients return for routine follow-up after these procedures.  The objective of this study was to evaluate the necessity of routine follow-up by determining the rate of interventions performed during the postoperative period at scheduled clinic follow-ups and emergency department visits.

Methods:
A retrospective review was performed of all patients undergoing inguinal hernia repair, umbilical hernia repair, epigastric hernia repair, circumcision, or laparoscopic pyloromyotomy at two institutions during a 6 month period. Charts were reviewed for postoperative clinic and emergency department visits during the initial 90 days after surgery. An intervention was defined as any laboratory or radiographic workup, prescription of medications, hospital admission, or scheduling further follow-up visits.

Results:
Chart review was performed in 270 patients undergoing the following procedures (n): inguinal hernia repair (76), umbilical hernia repair (42), epigastric hernia repair (9), circumcision (126), laparoscopic pyloromyotomy (10), or some combination of the above (7). Of these, 146 patients (54.1%) were seen in the surgery clinic for follow-up at a mean of 23.7 ± 12.7 days after the procedure. Thirteen of these follow-ups required an intervention: 12 after circumcision (related to wound healing or adhesions) and 1 after laparoscopic pyloromyotomy (for an umbilical granuloma).  Fourteen patients (5.2%) visited the emergency department during the postoperative period at a mean of 8.3 ± 7.1 days (range 2-21 days) after the procedure. Of these, 8 required an intervention:  2 after inguinal hernia repair (pain and cellulitis), 1 after epigastric hernia repair (cellulitis), 3 after circumcision (pain, cellulitis or bleeding), and 2 after pyloromyotomy (irritability and emesis).  No patients required readmission, and one patient required reoperation (for lysis of penile adhesions) during the follow- up period.

Conclusion:
These data demonstrate that patients after inguinal hernia repair, umbilical hernia repair, epigastric hernia repair, circumcision, and laparoscopic pyloromyotomy have a low rate of follow-up.  Of those that are seen in the postoperative period very few require any intervention, and patients having undergone circumcision are the ones that most frequently prompt an intervention.  Based on these data routine postoperative follow-up for select common pediatric surgical procedures may not be necessary and alternatives should be further investigated.  
 

8.19 Frequency of Cardiorespiratory Events in Premature Infants During Observation After Hernia Repair

Posted on December 22, 2014

E. M. Knott1, K. W. Schnell1, B. J. Pieters2, S. D. St. Peter1  1Children’s Mercy Hospital,Pediatric Surgery,Kansas City, MO, USA 2Children’s Mercy Hospital,Department Of Anesthesiology,Kansas City, MO, USA

Introduction:
Wide variation exists in criteria for overnight observation after inguinal hernia repair in former premature infants. We previously compiled retrospective data to demonstrate the risk of overnight apneic events. In order to validate these findings we initiated prospective observational study to capture the true event rates.

Methods:
After institutional review board approval, we have followed all premature infants admitted for overnight observation after inguinal hernia between 7/1/11 to 7/31/14. Children under an adjusted gestational age (AGA) of 60 weeks were admitted for observation. Patients undergoing hernia repair while inpatient in the intensive care nursery were excluded. Demographic data was collected. The lowest heart rate and oxygen saturation after leaving the recovery room were noted. Episodes of apnea, bradycardia and desaturation were recorded. 

Results:
To date, 96 patients have been accrued. AGA was 48.0 ± 5.5 weeks; 88.5% were male with an average weight of 4.7 ± 1.0 kg. Bilateral hernia repair was performed 55.2% of the time; laparoscopic repair was performed in 4.2%. Average length of stay was 24.1 ± 5.3 hours. While no patient had a recorded apneic episode, 1 was readmitted the night on postoperative day 1 for a witnessed episode of apnea after discharge. The 5 patients that had either bradycardia or desaturation are summarized in Table 1. Two of the 5 were on a home monitor. One had neurologic impairment and another had coarctation of the aorta; the remaining 3 had no significant comorbidities. No patient had more than one episode of either bradycardia or desaturation.

Conclusion:
The majority of postoperative episodes of bradycardia or desaturation are seen in infants undergoing inguinal hernia repair at less than 50 weeks adjusted gestational age. These events are short lived, resolve with supplemental oxygen and do not delay discharge. Lowering the AGA to 50 weeks or less for admission after inguinal hernia repair is supported by these data.
 

8.20 Effect of Variation in Non-operative Management of Acute Complicated Appendicitis in Children

Posted on December 22, 2014

A. C. Alder1,2, M. M. Hagopian2, R. I. Renkes1, L. Burkhalter1, R. P. Foglia1,2  1Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA 2University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA

Introduction:
Appendicitis is a common ailment in children. Treatment requires a tremendous allocation of resources especially for complicated cases. Initial non-operative management (NOM) has gained favor in selected cases of complicated appendicitis. Variations in this NOM approach include percutaneous drain placement or aspiration of intra-abdominal abscesses. We set out to review the effects of this variation on our population of patients with complicated appendicitis treated without initial appendectomy.

Methods:
All patients with appendicitis were reviewed between June 2009 and December 2012. Among these patients those who were treated with antibiotics +/- adjuncts and no appendectomy during the initial hospital stay were identified. Demographic and clinical data were collected with specific interest in data related to treatment variation (imaging technique, drain placement, antibiotic type, etc) and clinically relevant outcomes (length of stay (LOS), time to tolerating oral diet, etc). Data were analyzed using univariate and multivariate techniques as well as time to event tests.

Results:
Among 3491 patients found to have appendicitis, 101 patients were noted to have complicated appendicitis and were selected for NOM. All patients were given antibiotics. The mean age was 9 years with a slight majority of female patients. All patients had imaging – either CT, ultrasound or both. Patients with fever had a trend to a longer time to oral intake, a significantly longer time to tolerance of regular diet and no difference in LOS.  Patients with a fecalith had a significantly longer LOS, no difference in first oral intake and a trend toward a longer time to tolerance of a regular diet.  A change in antibiotics, use of TPN and an ICU stay were associated with an increased LOS and a longer time to tolerance of regular diet. Only ICU stays were associated with a longer time to first oral intake. Abscesses were found on imaging in over 90% of all patients. Drains were placed in 74/101 patients.  Placement of a drain was associated with a longer LOS and  prolonged time to tolerance of a regular diet when compared to aspiration and antibiotics alone.  Aspiration was associated with a significantly lower LOS, but no difference in first or tolerance of a diet. Time to event analysis confirmed  that the patients who were drained had a significantly longer time to tolerance of the regular diet but no difference in time to first oral intake.

Conclusion:
In this large series we found it surprising that patients with complicated appendicitis who underwent drainage of an abdominal abscess had a longer LOS. They were as quick to start a diet, but took longer to tolerate a regular diet. This effect may be related to the management style of the surgical team, but may also be related to the intra-abdominal process. This differs from previously published reports which indicate a quicker time to recovery when the abscess was amenable to drainage.  We believe this warrants further research into the best use of resources in the management of complicated appendicitis.
 

9.01 Improving Predictive Value of Trauma Scoring Through Integration of ASA-PS with ISS

Posted on December 22, 2014

D. Stewart1, C. Janowak1, H. Jung1, A. Liepert1, A. O’Rourke1, S. Agarwal1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:  Many methods exist for predicting mortality among adult trauma patients; however, most systems ignore patient co-morbidity, a significant predictor of outcome, in their calculations. The American Society of Anesthesiologists Physical Status (ASA-PS), a well-validated and easy-to-use scale, is an assessment of pre-operative status that has been shown to accurately predict post-operative mortality.  Using the ASA-PS as a marker of cumulative patient comorbidity severity we sought to test whether we would be able to improve the predictive power of the Injury Severity Score (ISS), the most commonly utilized trauma grading system, with respect to mortality, major complication, and discharge disposition.

Methods:  A retrospective review of a prospectively collected and internally validated database at an academic Level I trauma center was performed for consecutive adult admissions between 2009-2013.  Abbreviated Injury Scale (AIS) was measured by region (head/neck, face, thorax, abdomen, extremities, general) and severity of injury (1 to 5). ISS was measured by summing the squares of the three most injured regions [(AIS1)2 + (AIS2)2 + (AIS3)2].  ASA-PS scores were assigned based on patient comorbidities and then integrated with the traditional ISS in a variety of permutations, including adjustments of ASA-PS for patient age >70 and using individual AIS components of ISS.   We assessed these various models for predictive ability with a primary outcome of mortality and secondary outcomes of major complications as per National Trauma Data Bank (NTDB) definitions as well as discharge disposition using receiver operating characteristic (ROC) analysis.  These were compared with the ISS.

Results: All of the ISS/ASA-PS hybrid formulas outperformed ISS alone in predictive power for mortality, major complication, and discharge disposition.  The best overall permutation, (AIS1)2+(AIS2)2+(Age-Modified ASA-PS)2, yielded an ROC of 0.888 for mortality as compared to ISS with an ROC=0.853 (p<0.001).  Similar differences were seen for discharge disposition (Hybrid ROC=0.743; ISS ROC=0.639, p<0.001) and major complication (Hybrid ROC=0.761; ISS ROC=0.719, p<0.001).

Conclusion: Incorporating ASA-PS into calculations of trauma scoring is both simple and more predictive of mortality, major complication, and discharge disposition than the traditional ISS metric.  Replacing ISS with this new method, which takes patient age and comorbid condition into account through adaptation of the ASA-PS improves prognostication of outcomes and enables care providers to prioritize resources for injured patients.

 

9.02 Acute Ethanol Intoxication Inhibits Platelet Function in Healthy Individuals

Posted on December 22, 2014

A. Slaughter1,2, M. P. Chapman1,2, A. Banerjee1, E. Gonzalez1,2, H. B. Moore1,2, E. E. Moore1,2  1University Of Colorado Denver,Surgery,Aurora, CO, USA 2Denver Health Medical Center,Surgery,Aurora, CO, USA

Introduction:  Despite the established effects of moderate, long-term ethanol consumption on platelet function, the impact of acute ethanol exposure based on homotypic platelet aggregometry remains contradictory. Thus the role of acute ethanol intoxication in the pathogenesis of trauma induced coagulopathy has not been elucidated. The development of recent whole blood viscoelastic assays however provides the opportunity to better evaluate the effect of acute ethanol exposure on the hemostatic capacity of platelets. We hypothesized that acute ethanol intoxication will impair platelet function in otherwise healthy individuals.

Methods:  Healthy volunteers (n=7) participated in the study. Baseline venous blood samples for kaolin-activated whole blood thromboelastography (TEG) and platelet mapping (PM) were obtained at the beginning of the study. Additional blood samples were drawn and incubated with ethanol for 1 h (in vitro exposure). Participants then consumed ethanol to legal intoxication, a blood alcohol content of >0.1 g/dL, as monitored by repeated breathalyzer testing. Blood was drawn after 1h of sustained intoxication (in vivo exposure). We then repeated TEG and PM on the post-incubation and post-intoxication samples. Percentage platelet inhibition at the adenosine diphosphate (ADP) and thromboxane A2 (TxA2) receptors following ethanol exposure was calculated. 

Results: The platelet TxA2 receptor, stimulated by arachidonic acid (AA), demonstrated a significant increase median (IQR) percentage inhibition from baseline following in vivo ethanol intoxication, 50.4% (27.9) vs. 75.2% (25.3) (p=0.018). Likewise, the TxA2 receptor demonstrated a significant increase percentage inhibition from baseline following in vitro ethanol incubation, 50.4% (27.9) vs. 75.6% (30.35) (p=0.046).  Platelet ADP channel percentage inhibition comparing baseline and post-intoxication was 40.2% (35.7) vs. 61.3% (35.1) (p=0.398). ADP channel percentage inhibition comparing baseline and post-incubation was 40.2% (35.7) vs. 64.65 (42.6) (p=0.917).

Conclusion: Acute ethanol intoxication significantly impaired platelet function via the TxA2 receptor. Furthermore TxA2 receptor inhibition followed both in vivo and in vitro exposure. Our results therefore suggest that platelet dysfunction could exacerbate coagulopathy in intoxicated trauma victims.  

9.03 BMI is Inversely Proportional to Need for Therapeutic Operation after Abdominal Stab Wound

Posted on December 22, 2014

M. B. Bloom1, E. J. Ley1, D. Z. Liou1, T. Tran1, R. Chung1, N. Melo1, D. R. Margulies1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction:   Several authors have examined the relationship between trauma patient Body Mass Index (BMI) and blunt and polytrauma outcomes.  Less attention has been paid to the need for therapeutic intervention in penetrating trauma.  We sought to determine whether increasing BMI is protective in abdominal stab wounds, and predictive of need for intervention.

Methods:   We conducted a review of all patients presenting with abdominal and flank stab wounds at an urban level I trauma center from January 1, 2000 to December 31, 2012.  Patients were divided into four groups based on their BMI.  Abstracted data includes baseline demographics, physiologic data, and characterization of whether the stab wound had violated the peritoneum, caused intra-abdominal injury, or required an operation that was ultimately therapeutic. Patients who were safely observed without an operation were considered as having no intra-abdominal injuries, but were excluded from the peritoneal violation analysis. The one-sided Cochran-Armitage Trend was used for significance testing of the protective effect.

Results:  Of 281 patients with abdominal stab wounds, 249 had complete data for evaluation, grouped as BMI<18.5(underweight, n=6), BMI 18.5-29.9(normal to overweight, n=195), BMI 30-35(obese, n=38), and BMI>35(severely obese, n=10). There were no statistically significance differences between groups with respect to age, GCS score, SBP, ISS, AIS subtypes, and mortality, but greater BMI was more prevalent in females (p=0.015). All 6 patients with BMI<18.5 had peritoneal violation, and 5/6 (83%) had intra-abdominal injury. The rate of peritoneal violation trended downward as BMI increased (100%, 86%, 77%, 75%; p=0.147). Increasing BMI was associated with a significant decrease in actual visceral injury (83%, 56%, 50%, 30%; p=0.022). Of 6 patients with BMI<18.5, 4 (67%) had intra-abdominal injury requiring an operation that was therapeutic, whereas in BMI>35, only 2/10 (20%) did. The rate progressively decreased as BMI rose (67%, 44%, 39%, 20%; p=0.041).

Conclusion:  Increased BMI protects patients with abdominal stab wounds and is associated with both lower rates of injured viscera and a reduced need for operations. Heavier patients may be more suitable to observation and serial exams, while very thin patients are more likely to require an operation.

 

8.01 Surgical Management and Morbidity of Magnet Ingestions in Children: A Survey of AAP Surgeons

Posted on December 22, 2014

A. M. Waters1, D. H. Teitelbaum2, D. T. Bartle1, V. Thorne1, A. Bousvaros3, R. A. Noel4, E. A. Beierle1  1University Of Alabama,Birmingham, Alabama, USA 2University Of Michigan,Ann Arbor, MI, USA 3Children’s Hospital Boston,Boston, MA, USA 4Baylor College Of Medicine,Houston, TX, USA

Introduction: In children, most ingested foreign bodies will pass spontaneously without incident however; several reports describe significant sequelae associated with rare earth magnet ingestions.  The maker of the most popular of these toys, Buckyballs® , has stopped production, but these magnets continue to be found in items marketed to adults.  The aim of this survey was to determine the surgical interventions and outcomes of magnet ingestions in the pediatric population. 

Methods: Following IRB approval, an online survey tool was developed and distributed via email to all pediatric surgeons with membership in the Surgical Section of the American Academy of Pediatrics.  Respondents were anonymous and data tallied by a blinded investigator.   

Results: Out of about 630 surgeons polled, 101 responded reporting data on 99 magnet ingestions.  The majority of ingestions reported (71%) occurred after year 2010.  Two thirds (66%) of the ingestions were in boys, the median age at ingestion was 3.7 years (range: 1-16 years), and most of the children were Caucasian (80%).  In 34% of the children, over 48 hours lapsed between the reported time of ingestion and initiation of interventions.  All but one child had an x-ray study for magnet localization and abdominal films were the most commonly ordered test.  Thirty-two patients (32%) underwent endoscopy with successful removal of magnets in 70%; primarily from the esophagus, stomach and duodenum.  At endoscopy, multiple magnets were commonly found (65%) (range: 2 to 27 magnets) and removed.  One quarter of these children required subsequent surgery for complications noted on endoscopy.  In total, 73 children required either laparotomy (51) or laparoscopy (22) for magnet removal, and removal was successful in over 96% of attempts.  At surgery, 90% of children were discovered to have ingested more than one magnet with the number of magnets retrieved ranging from 1-45.  In addition, 17% of the children were found to have at least one perforation or fistula and 34% of children had multiple perforations or fistulae.  Most did well following their surgical interventions, but some (n=8) required prolonged (>7 days) hospitalization or additional surgical procedures (n=4) including reoperations for missed perforation and leak from a colotomy resulting in a colostomy.  Reported long-term outcomes (>30 days) included 9 children requiring long-term care for their injuries including repeat endoscopies.  One child died following hemorrhage from an esophago-aortic fistula.   

Conclusion: The findings of this survey demonstrate that rare earth magnets remain a serious health hazard for children, especially in the younger age ranges.  Ingestions of these objects may result in serious injuries to the gastrointestinal tract, even when removed expeditiously.  Surgeons must look for multiple magnets when encountered with such cases, and every effort should be made to remove these objects either by endoscopic or surgical means when discovered. 

 

8.02 An Assessment of Morbidity from Gastrojejunal Feeding Tubes in Children

Posted on December 22, 2014

I. Campwala1, E. Perrone1, G. Yanni2, M. Shah2, G. Gollin1  1Loma Linda University School Of Medicine,Pediatric Surgery,Loma LInda, CA, USA 2Loma Linda University School Of Medicine,Pediatric Gastroenterology,Loma LInda, CA, USA

Introduction: Long-term gastrojejunal (GJ) feeding is an increasingly popular alternative to gastric fundoplication for children with pathological reflux, particularly in patients with neurological impairment.   We sought to evaluate the morbidity associated with GJ feeding tubes in a large population of children.

Methods: The records of all children under 18 years of age who underwent placement of a GJ feeding tube in a large children’s hospital between January, 2005 and September, 2012 were reviewed.  Subjects were followed for an average of 5 years (range, 2-9 years). The indications for GJ feedings were noted.  Events including a requirement for tube replacement, small bowel obstruction requiring laparotomy, intestinal perforation, and a subsequent requirement for operative jejunostomy were evaluated.  Risk factors for morbidity were assessed.

Results: 124 children underwent GJ tube placement during the study period at an average age of 5.0 years (range, 2 months to 16 years).  51 (41%) subjects were neurologically impaired and 55 (44%) had undergone prior laparoscopic fundoplication.  Recurrent reflux symptoms occurred in 22 (18%).  Tubes were electively changed under sedation an average of 4 times per child and jejunal limbs dislodged 1.2 times per patient and more than 3 times in 17 (14%).   In 9 cases (7%), an operative jejunostomy was constructed due to difficulties with GJ feeding. Five children (4%) required emergent laparotomy for GJ tube complications including intestinal obstruction (2) and intestinal perforation (3).  These subjects were younger (9 months) than those without complications that required laparotomy (5.2 years, p=0.05).

Conclusion: GJ feeding tubes were associated with notable morbidity ranging from persistent reflux to dislodgement, intestinal obstruction and perforation.   Together with issues of inconvenience with continuous feedings, these complications should be taken into account in children, and particularly infants, with gastroesophageal reflux in whom GJ feedings are being considered as an alternative to fundoplication.

 

8.03 Prenatal Measurements of Vessel Size May Improve ECMO Cannulation for Infants with CDH

Posted on December 22, 2014

S. J. Clark2,3, F. Sheikh2,3, A. C. Akinkuotu2,3, I. J. Zamora2,3, T. C. Lee2,3, O. O. Olutoye2,3, A. Mehollin-Ray1,3, D. L. Cass2,3  1Baylor College Of Medicine,Radiology,Houston, TX, USA 2Baylor College Of Medicine,MIchael E. DeBakey Department Of Surgery,Houston, TX, USA 3Texas Children’s Fetal Center,Houston, TX, USA

Introduction: Infants with congenital diaphragmatic hernia (CDH) requiring extracorporeal membrane oxygenation (ECMO) may not be candidates for veno-venous (VV), and thus require veno-arterial (VA) ECMO, due to small right jugular vein sizes. The purpose of this study was to evaluate ECMO cannula types and sizes used in the treatment of infants with CDH, and to begin to determine whether prenatal imaging of right neck vessel size may help guide cannula selection.

Methods: The charts of all prenatally diagnosed neonates with CDH treated at a comprehensive fetal center from 2000 to 2013 were reviewed. Perinatal outcomes collected included fetal internal jugular vein (IJ) diameter as measured on fetal ultrasound, need for ECMO, ECMO cannula size, cannula cost, and number of cannulas used per operation.

Results: Of 201 CDH patients, 52 were treated with ECMO (6 VV and 47 VA) at mean day of life 2 ± 4 (range, 0-11 days). All patients treated with VV had 13 F cannulas, whereas those treated with VA ECMO had cannula sizes of 12 or 10 F venous and 10 or 8 F arterial. Thirty-two CDH patients had fetal measurement of right IJ size, of which 7 required ECMO. Of these 7, VV cannulation was attempted in 5 patients but successful only in the infant with prenatal right IJ size of > 4mm (Table 1). One patient was discovered to have an absent right IJ at attempted cannulation, and retrospective review of fetal imaging confirmed this finding. In total, 24 cannulas attempted on 22 patients (cost $349-$2699) were discarded at operation because they did not fit.

Conclusion: Many CDH patients cannulated for ECMO are not candidates for VV ECMO and/or have cannulas discarded from the surgical field due to inadequate right IJ vein size. Prenatal measurement of fetal neck vessels may be predictive of optimal cannula size, which may guide surgical management and maximize operative cost-savings.    

 

8.04 Protocol Workup for Suspected Pediatric Appendicitis Limits Computed Tomography Utilization

Posted on December 22, 2014

J. Tashiro1, B. Wang1, M. Curbelo2, E. A. Perez1,2, A. R. Hogan1,2, H. L. Neville1,2, J. E. Sola1,2  1University Of Miami,Division Of Pediatric Surgery, DeWitt Daughtry Family Department Of Surgery,Miami, FL, USA 2Baptist Children’s Hospital,Miami, FL, USA

Introduction: Appendicitis is the most common surgical emergency in children. However, diagnosis by history and physical exam can be challenging in children as classical signs and symptoms are often lacking and other childhood conditions can mimic appendicitis. Despite concerns for radiation, computed tomography (CT) is the favored imaging modality at many children’s hospitals for appendicitis. We sought to reduce CT utilization for appendicitis in a children’s hospital by adopting an algorithm (Figure 1), relying on 24-hour ultrasound (US) as the primary imaging study.

Methods: A standardized protocol was adopted at the end of fiscal year (FY) 2011 using US as the primary imaging study for diagnosing appendicitis in the emergency department (ED). Pediatric surgery service assumed patient care after US had been performed. A prospectively recorded database was analyzed 12 months prior to and 24 months after the employment of the protocol. The usage for each imaging test was adjusted per number of appendectomies performed. Training of ED staff continued for over 1 year after protocol implementation. Statistical analysis was performed using PASW Statistics V.21. Student t test was used to compare continuous data. Significance was determined at P value < 0.05.

Results: For FY 2011, 644 abdominal CT, and 1088 appendix U/S were ordered from the ED and 249 laparoscopic appendectomies (LA) were performed. After implementation of the protocol, FY 2012: 535 CT, 1285 appendix U/S, and 265 LA were performed; and FY 2013: 330 CT, 1235 appendix U/S, and 236 LA were performed. Paired t-test comparing monthly incidence of appendectomy between the three years did not show any significant difference. Length of stay decreased from FY 2011 to FY 2013 (2.57 ± 0.29 vs. 1.90 ± 0.15 days) and from pre- to post-protocol (2.57 ± 0.29 vs. 2.15 ± 0.11 days), both p<0.001. There was a 42% decrease in number of abdominal CT utilized per appendectomy performed from FY 2011 to FY 2013 (2.43 vs. 1.40, p<0.001) and 30% from pre- to post-protocol (2.43 vs. 1.70, p<0.001). In addition, a corresponding 27% increase in number of appendix US pre- to post protocol (4.11 vs. 5.20 US/appendectomy, p=0.004) occurred.

Conclusion: Protocol driven workup with US significantly reduced CT utilization and thereby radiation exposure in children with suspected appendicitis. Ongoing training of ED staff after implementation is required to ensure protocol compliance. 

8.05 Atypical Teratoid Rhabdoid Tumors: Epidemiology and Outcomes for 174 Patients

Posted on December 22, 2014

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

Introduction: Atypical teratoid rhabdoid tumors (ATRT) are rare, highly malignant embryonal malignancies of the central nervous system (CNS) accounting for ~3% of pediatric brain tumors, but ~20% of CNS tumors in children under the age of 3. To date few cases of ATRT have been reported, and no large patient series exist. This study examined a large cohort of ATRT patients to determine demographic, clinical, and pathologic factors which determine prognosis and survival.

Methods: Demographic and clinical data were abstracted on 174 patients from the SEER database from 1973–2010 and statistical analysis was performed using Chi-square test, paired t-test, multivariate analysis, and Kaplan-Meier functions.

Results: 174 cases of ATRT, with a mean age of 2.84 years were identified. 140 (80.5%) patients were <3 years old, 31 were 4-19 (17.8%) and 3 were ≥ 20 (1.7%), p<0.001. ATRT had a higher incidence in males (56.3% vs. 43.7%, p<0.001) and Caucasians (59.1%, p<0.001). The most common primary tumor sites were the cerebellum (17.8%), ventricles (16.1%), and frontal lobe (12.6%). Mean overall survival for ATRT was 3.2 ± 0.4 years, while overall and cancer specific mortality were 63.2% and 60.5% respectively (p=0.005). The majority of ATRT cases were treated with surgery alone (58.0%), followed by combination surgery and radiation (34.3%), no treatment (6.5%), and radiation alone (1.2%). The percentage of ATRT cases managed by combination surgery and radiation was significantly higher in the 2005-present study period compared to the 1973-2004 period (38.4% vs. 22.3%, p<0.001), while primary surgical resection and radiotherapy rates remained approximately the same. Longest survival was amongst ATRT patients receiving surgery and radiation (5.9 ± 0.7 years), followed by radiation alone (2.8 ± 1.2 years), surgery alone (1.9 ± 0.4 years) and no treatment (0.3 ± 0.2 years), p<0.001. Multivariate analysis identified distant metastases (OR 4.6, CI=2.7-6.9) as independently associated with increased mortality, p<0.005. Conversely, combination surgery and radiation treatment (OR 0.4, CI=0.1-2.0) was independently associated with reduced mortality, p<0.005.

Conclusions: ATRT is a rare, highly aggressive embryonal malignancy of the CNS that presents more often in male Caucasian children under the age of three, in the cerebellum, ventricles and frontal lobe with locoregional distribution and tumor sizes over 4cm. Combination surgery and radiotherapy significantly improves survival, and its use has been increasing since 2005. All ATRT patients should be enrolled into clinical trials or registries to allow for more defined multimodality management to achieve the best prognosis.

8.06 Using Preoperative Imaging to Predict Symptom Improvement in Children with Biliary Dyskinesia

Posted on December 22, 2014

J. B. Mahida1,2, J. P. Sulkowski1,2, J. N. Cooper1, A. King1, K. J. Deans1,2, P. C. Minneci1,2, D. R. King2  1Nationwide Children’s Hospital,Center For Surgical Outcomes Research,Columbus, OH, USA 2Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA

Introduction: The diagnosis and management of children with biliary dyskinesia are controversial. Our objective was to identify clinical determinants of pain improvement in children undergoing cholecystectomy for biliary dyskinesia.

Methods: This retrospective institutional cohort study included patients who underwent cholecystectomy for biliary dyskinesia between 2006 and 2013. All patients had their gallbladder ejection fraction (EF) measured by either cholecystokinin stimulated HIDA scan, fatty meal ultrasound (FUS; measures the change in gallbladder volume after consumption of a high fat meal), or both. Patients without postoperative follow up were excluded. Data collected included patient demographics, medical history, preoperative imaging, details of the surgery, and postoperative outcomes. The ability of the preoperative diagnostic tests to predict pain improvement was evaluated by examining overall accuracy, sensitivity, specificity, and negative and positive predictive values (PPV). Multivariable logistic regression models were used to identify preoperative characteristics associated with pain improvement.

Results: Of the 153 included patients, 76% were female, 89% were Caucasian, and 51% were either overweight (BMI >85th to ≤ 95th percentile; 12%) or obese (BMI >95th percentile; 39%). At postoperative evaluation, improvement of pain was reported by 82% of the patients. The median (interquartile range) gallbladder EFs were not statistically different in patients with and without pain improvement for both the HIDA (pain improvement EF 18% (17-31%) vs. no pain improvement EF 22% (3-36%), p=0.66) and the FUS (EF 35% (24-50%) vs. EF 41% (33-51%), p=0.31). For both the HIDA and FUS, the sensitivity of the test to predict pain improvement increased with higher ejection fractions while the PPV remained around 80% (Table). There was no correlation between EF measurements from HIDA and FUS in patients who had both tests (N=0.29, r=28, p=0.15), neither test showed superior performance, and the results were similar in obese and non-obese patients. Preoperative characteristics that were independent predictors of pain improvement included a shorter duration of pain (odds ratio of pain relief, 95% CI, p-value) (per month: 1.02, 1.0-1.05, p=0.03), a history of vomiting (2.62, 1.02-6.76, p=0.045), and absence of fever (3.95, 1.23-12.65, p=0.02).

Conclusion: Over 80% of patients undergoing cholecystectomy for biliary dyskinesia reported pain improvement. This study provides additional information on a combination of preoperative clinical characteristics and diagnostic test results that can be used to counsel patients and their families on the role of cholecystectomy in treating biliary dyskinesia.

7.12 Irradiated Rectal Cancer: Is There a Role for Preoperative Interventions?

Posted on December 22, 2014

D. M. Hayden1, C. Holmes1, A. Lasinski1, S. Nassoiy1, M. Chiodo2, K. Wolin1, T. Saclarides1  1Loyola University Medical Center,Department of General Surgery,Maywood, Illinois, USA 2Loyola University Medical Center,Stritch School Of Medicine,Maywood, Illinois, USA

Introduction:  The treatment course of locally advanced rectal cancer is long, tedious and wrought with morbidity.  This disease burden is underappreciated; however there may be amenable factors to improve peri- and postoperative outcomes. 

Methods:  Retrospective review of patients with stage II and III rectal cancer treated with neoadjuvant chemoradiation followed by radical resection at a single tertiary care center 2006-2013.

Results: 57 patients were included; mean age was 60.4 (36-82); 57.9% were male.  Mean BMI was 29.0 (19.0-43.4); 40.4% were obese and 15.8% had BMI>35.  Co-morbidities were common: 40.4% had hypertension, 24.6% diabetes, 8.8% CAD and 5.3% had COPD. 12.3% were current smokers and 49.1% previously smoked.  37 (64.9%) patients had LAR and 35.1% had APR. Only 7.0% had laparoscopic resection. Mean operative time 355.2 (120-630) minutes.  Mean blood loss was 452 ml (50.0-3000); 14.0% required transfusion and 28.1% ICU admission. Mean length of stay was 11.0 (4.0-62.0) days.  45.6% had complications, most commonly fever, ileus and abscess.  36.8% of patients required readmission.  Obese patients had longer LOS that trended toward significance (13.6 vs.9.2, p=0.078); however, complications were not more common. Those with BMI>35 had higher risk of pneumonia, DVT and sepsis (p=0.02-0.05).  Current and previous smokers were more likely to be readmitted (p=0.043).  4 of the 6 patients discharged to rehab/skilled nursing had BMI>30. 

Conclusion: The treatment of irradiated rectal cancer involves morbid operations, complications and readmissions. Our patients are obese with multiple comorbidities that contribute to poorer outcomes. However, lifestyle interventions like exercise and smoking cessation at diagnosis may help to decrease this burden. 

 

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