The Correlation of Thyroid Hormone Levels and Anti-Thyroidal Drugs on Thyroid Size, Weight, and Ease of Surgical Dissection for Thyroidectomy for Graves' Disease

BACKGROUND

Patients with Graves' Disease often have a larger thyroid size than patients without thyroid disease. These patients also have elevated T3 and T4 with decreased TSH.

PURPOSE

We evaluate whether these thyroid labs, the use of antithyroid agents, or the size of a thyroid on ultrasound, correlate with the pathological size of a thyroid in patients who undergo total thyroidectomy for Graves' Disease. We further determine whether these parameters affect perioperative complications.

RESEARCH DESIGN

A retrospective review of patients undergoing total thyroidectomy for Graves' Disease was performed from January 2004 to December 2016 in a single institution.

STUDY SAMPLE

392 patients were included in the study.

DATA COLLECTION AND/OR ANALYSIS

Univariate analyses were performed to compare thyroid size on US and pathology as well as weight to preoperative thyroid hormone values and medical comorbidities. Spearman rank correlation and ANOVA were used to identify factors associated with thyroid weight, total pathology size, and differences in size. Multivariate analysis was also performed to evaluate for correlation between thyroid function and perioperative complications.

RESULTS

We found that elevated pre-operative T3 levels were associated with larger pathologic size (P = .027) and a greater difference in pathology vs. US thyroid volumes (P = .005), but not increased thyroid weight (P = .286). No significant differences were found for thyroid weight, pathology size, or difference in size for TSH, T4, or any specific preoperative ATD given. Only postoperative calcium levels were found to be statistically significant for TSH < 0.27 (P = .024) for peri-operative complications.

CONCLUSIONS

These findings may allow for more accurate preoperative planning and intraoperative expectations in patients with Graves' Disease.

Impact of Urinary Catheterization on Postoperative Outcomes After Roux-En-Y Gastric Bypass Surgery in Propensity-Matched Cohorts

BACKGROUND

The impact of urinary catheter avoidance in bariatric enhanced recovery after surgery (ERAS) protocols is yet to be established. The purpose of the current study is to determine whether urinary catheter use in patients undergoing Roux-en-Y gastric bypass (RYGB) procedures has an effect on postoperative outcomes.

METHODS

An institutional database was utilized to identify adult patients undergoing primary minimally invasive RYGB surgery. Outcomes included incidence of urinary tract infection (UTI) within 30 days postoperatively, 30-day readmission rates, proportion of patients discharged after postoperative day 1 (delayed discharge), length of stay (LOS), and operating room time. These were compared between propensity-matched groups with and without urinary catheter placement.

RESULTS

There were no significant differences in postoperative UTI's (2.2% for both cohorts, P = .593) or 30-day readmission rates for patients with and without urinary catheters (6.6% and 4.4%, respectively, P = .260). Mean LOS (1.7 vs. 1.5 days, P = .001) and the proportion of patients having a delayed discharge (47.3% vs. 33.7%, P = .001) was greater in patients with a catheter. Operating room time was longer in the urinary catheter group (221.8 vs. 207.9 minutes, P = .002).

DISCUSSION

Avoidance of indwelling urinary catheters in RYGB surgical patients decreased delayed discharges and LOS without affecting readmission or reoperation rates. Therefore, we recommend that avoidance of urinary catheters in routine RYGB surgery be considered for inclusion into standardized ERAS protocols. Urinary catheters should continue to be utilized in select cases, however, as these were not shown to affect rate of UTIs.

POS0755 SAFETY, TOLERABILITY, PHARMACOKINETICS, AND PHARMACODYNAMICS OF A SINGLE ORALLY ADMINISTERED DOSE OF ENPATORAN IN A PHASE I STUDY OF HEALTHY JAPANESE AND CAUCASIAN PARTICIPANTS

Background

Enpatoran, a novel, highly selective and potent dual toll-like receptor (TLR) 7 and TLR8 inhibitor, is in development for the treatment of autoimmune disorders including systemic and cutaneous lupus erythematosus. A first-in-human study in healthy participants has shown that enpatoran is well-tolerated and has a linear pharmacokinetic (PK) profile.

Objectives

To compare the PK parameters, safety, and tolerability of single ascending oral doses of enpatoran in a Phase I study in Japanese and Caucasian participants, and to explore a potential PK/pharmacodynamic (PD) relationship.

Methods

A single-centre, open-label, sequential dose group study enrolled healthy Japanese and Caucasian participants into three dose cohorts. Each Caucasian participant was matched by body weight (± 20%), height (± 15%) and sex to a Japanese participant. Participants received a single orally administered enpatoran dose of 100 mg, 200 mg, or 300 mg as a film-coated tablet under fasting conditions. PK parameters, (maximum plasma concentration [Cmax]; area under the plasma concentration–time curve (AUC) from time 0 to infinity [AUC0-inf]; AUC from time 0 to the last sampling time [AUC0-tlast]) determined using noncompartmental analysis, were estimated post-dose from Day 1–3. Safety was assessed from Day -1 to 8. PK (exposure) between the two ethnic groups was compared using an analysis of covariance (ANCOVA) model including ethnic group, natural log-transformed dose, and ethnic group by natural log dose interaction. Ex vivo secretion of cytokines (PD) under stimulated (using the TLR7/8 agonist, R848) and unstimulated conditions, was assessed pre- and post-dose. A panel of cytokines was analysed by multiplex immunoassay; IL-6 was considered the primary PD biomarker.

Results

The study included 36 male participants (18 Japanese and 18 Caucasian) with a mean (± SD) age of 35.1 (± 10.8) years and mean (± SD) body mass index of 23.1 (± 2.1) kg/m2. Each dose group included six Japanese and six Caucasian participants. The geometric mean enpatoran plasma exposure parameters (Cmax, AUC0-inf, and AUC0-tlast) were consistent between the two ethnic groups for each dose level (Table 1) and indicated dose proportionality. ANCOVA modeling demonstrated comparable exposure between the two groups (geometric least square mean ratio [Japanese/Caucasian;90% CI] of Cmax: 0.9409 [0.7855–1.1270]; AUC0-inf: 0.8959 [0.7497–1.0704] and AUC0-tlast: 0.8963 [0.7511–1.0695]). Treatment-emergent adverse events (TEAEs) were observed in six Japanese (n = 0, 100 mg; n = 3, 200 mg; n = 3, 300 mg) and four Caucasian (n = 1, 100 mg; n = 0, 200 mg; n = 3, 300 mg) participants. There we no serious TEAEs; most were mild and not dose dependent. Treatment-related TEAEs were mild diarrhoea, mild flatulence, and moderate headache. There were no deaths, withdrawals, or early terminations due to TEAEs. Administering enpatoran effectively reduced ex vivo stimulated cytokine release, with maximal inhibition observed at 2 hours post-dose (IL-6: mean ≥99%). High inhibition levels were sustained through 24 hours in a dose-dependent manner (IL-6: mean ~76–97%). The pattern of cytokine release inhibition was consistent across doses and ethnic groups.

Table 1.

PK parameters in Japanese and Caucasian participants at the three enpatoran dose levels

Parameter100 mg200 mg300 mgJapaneseCaucasianJapaneseCaucasianJapaneseCaucasianN = 6N = 6N = 6N = 6N = 6N = 6Cmax139175260245486490(ng/mL)AUC0-inf7749481910185028403330(h*ng/mL)AUC0-tlast7589311880183028103270(h*ng/mL)

All values are Geometric mean.

Cmax, maximum plasma concentration AUC0-inf, area under the plasma concentration–time curve (AUC) from time 0 to infinity; AUC0-tlast, AUC from time 0 to the last sampling time.

Conclusion

There were no relevant ethnic differences in PK, PD, and safety between healthy Japanese and Caucasian participants across a range of single oral enpatoran doses, thus supporting the inclusion of Asian participants in future global Phase II studies.

Acknowledgements

We would like to thank those who took part in the study. This study was sponsored by the healthcare business of Merck KGaA, Darmstadt, Germany (CrossRef Funder ID: 10.13039/100009945), who funded medical writing support by Bioscript Stirling Ltd.

Disclosure of Interests

Sathej Gopalakrishnan Shareholder of: Merck Healthcare KGaA, Employee of: Merck Healthcare KGaA, Axel Krebs-Brown Employee of: Merck Healthcare KGaA, Marco Nogueira Filho Employee of: Merck Healthcare KGaA, Yoshihiro Kuroki Employee of: Merck Biopharma Co., Ltd., Angelika Bachmann Employee of: Merck Healthcare KGaA, Andreas Becker Shareholder of: Merck Healthcare KGaA, Employee of: Merck Healthcare KGaA, Frank Schippers Employee of: Merck Healthcare KGaA, Markus Fluck Shareholder of: Merck Healthcare KGaA, Employee of: Merck Healthcare KGaA, Özkan Yalkinoglu Employee of: Merck Healthcare KGaA, Lena Klopp-Schulze Employee of: Merck Healthcare KGaA

Short-term Outcomes of Emergent Versus Elective Gastrectomy for Gastric Adenocarcinoma: A National Surgical Quality Improvement Program Study

BACKGROUND

Gastric adenocarcinoma is a leading cause of cancer death worldwide and in the United States, and can present emergently with upper GI hemorrhage, obstruction, or perforation. Few large studies have examined how emergency surgery for gastric cancer affects patient outcomes.

METHODS

All patients from National Surgical Quality Improvement Program with gastric adenocarcinoma from 2005 to 2017 were examined retrospectively. Univariate and multivariate analysis of patient factors and perioperative outcomes was performed. P-values < .05 were significant.

RESULTS

Of 4663 total patients, 115 had emergency surgery and 4548 had elective surgery. Emergency surgery patients were more likely to be non-white, underweight, higher ASA class, require a preoperative blood transfusion, and were less likely to be functionally independent. Multivariate analysis demonstrates an increased likelihood of unplanned intubation, prolonged ventilation, and deep vein thrombosis (DVT).

DISCUSSION

There are no significant differences in mortality, reoperation, or infection when comparing emergent surgery for gastric cancer and elective surgery; however, there is an increased risk of reintubation, prolonged intubation, and DVT in patients undergoing emergent surgery. Patients requiring emergent surgery have more comorbidities, higher blood transfusion requirements, and worse preoperative functional status, and this study demonstrates that they also have worse perioperative outcomes. Previous studies have shown that long-term oncologic outcomes are worse for patients undergoing urgent surgery, and this study shows that perioperative outcomes are also somewhat worse. Thus, definitive surgery performed on a patient who presents emergently with gastric cancer should be considered but may come at the cost of increased perioperative respiratory complications, DVTs, and worse oncologic outcomes.

Improved Overall Well-Being After Breast Conserving Therapy Using Three-Dimensional Bioabsorbable Markers and Tissue Rearrangement, a Single Institution's Preliminary Experience

Tissue rearrangement (TR) is a basic oncoplastic technique to reshape the breast after breast conserving therapy (BCT). Tissue rearrangement can be combined with three-dimensional bioabsorbable markers (3DBM) as an easily adaptable technique to provide volume replacement and focused radiation. Since 3DBM can take time for absorption and symptoms related to its use have not been fully assessed, we evaluate patient's overall satisfaction and well-being after TR with 3DBM is performed. We surveyed patients receiving BCT with adjuvant radiotherapy using BREAST-QTM BCT satisfaction and physical well-being surveys comparing patients receiving BCT alone to BCT with TR and/or 3DBM. Of 68 patients, 56 underwent BCT alone, 10 had BCT with TR + 3DBM, and 2 had BCT with TR. No significant difference was seen in physical well-being (P = .39), while overall satisfaction was significantly improved following TR + 3DBM (P = .0088). In summary, TR with use of 3DBM provides basic oncoplastic options to improve patient satisfaction without significantly changing symptoms.

Incidence of polyp formation following bariatric surgery

BACKGROUND

Multiple studies have linked obesity to an increased risk of cancer. The correlation is so strong that the national cancer prevention guidelines recommend weight loss for patients with obesity to reduce their risk of cancer. Bariatric surgery has been shown to be very effective in sustained weight loss. However, there have been mixed findings about bariatric surgery and its effects on the risk of colorectal cancer.

OBJECTIVE

This study sought to examine bariatric surgery patients and their risk of pre-cancerous or cancerous polyps to elucidate any risk factors or associations between bariatric surgery and colorectal cancer.

SETTING

A retrospective review of the academic medical center's bariatric surgery database was performed from January 2010 to January 2017. Patients who underwent medical or surgical weight loss and had a subsequent colonoscopy were included in the study. Positive colonoscopy findings were described as malignant or premalignant polyps.

METHODS

A total of 1777 patients were included, with 1360 in the medical group and 417 in the surgical group. Data analysis included patient demographics, co-morbidities, procedure performed, surgical approach, weight loss, and colonoscopy findings. A multivariate analysis was used to determine whether an association exists between weight loss and incidence of colorectal polyps, and if so, whether the association different for medical versus surgical weight loss.

RESULTS

A higher percentage of body mass index (BMI) reduction was seen in the surgical group. An overall comparison showed average reductions in BMI of 27.7% in the surgical group and 3.5% in the medical group (P < .0001). Patients with the greatest reduction in BMI, regardless of medical or surgical therapy, showed a lower incidence of precancerous and cancerous polyps (P = .041).

CONCLUSION

This study offers a unique approach in examining the incidence of colorectal polyps related to obesity. Patients with the greatest reduction in their BMI, more common in the surgical group, had a lower incidence of precancerous and cancerous polyps.

Disparate opinions on the value of Vice Chairs of education in Departments of Surgery: A national survey of Department Chairs and other surgical education stakeholders

BACKGROUND

The position of Vice Chair of Education (VCE) is increasingly common in Surgery Departments. The role remains ill-defined. The purpose of this study was to explore perceptions of Department Chairs (DCs) and Other Education Stakeholders (OESs) regarding the VCE role.

METHODS

DCs and OESs at institutions with a VCE were surveyed. Descriptive statistics and cross-tabulations were calculated (SAS V9.4).

RESULTS

The overall response rate was 25% (166/666). There were significant differences in whether DCs and OESs agree that the VCE supports others in fulfilling educational roles (95.2% vs 49.5%, p = 0.0002), is critical in achieving education missions (90.5% vs 56.6%, p = 0.0032), enhances the quality of education (95.3% vs 65.7%, p = 0.0174), and is important to education teams (95.0% vs 68.7%, p = 0.0464).

CONCLUSIONS

DCs value the VCE role more so than OESs, whom VCEs support. In order for VCEs to be effective educational leaders in Departments of Surgery, the needs of key stakeholders deserve further clarification.

A 3-Year MBSAQIP propensity-matched analysis of Roux-en-Y gastric bypass with concomitant cholecystectomy: Is the robotic or laparoscopic approach preferred?

BACKGROUND

The primary objective of this study was to compare outcomes of patients undergoing minimally invasive RYGB (MIS/RYGB) versus MIS/RYGB with concomitant Cholecystectomy (CCY). A secondary objective was to compare the outcomes for laparoscopic RYGB (LRYGB) and robotic RYGB (RRYGB) with concomitant CCY.

METHODS

Outcomes of 117,939 MIS/RYGB with and without CCY were propensity-matched (Age, Gender, BMI, Comorbidities), 10:1, using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database from 2015-2017. The MIS/RYGB with CCY were then separated into LRYGB and RRYGB cases for comparison. Exclusion criteria included emergency cases, conversions to open, and age less than 18.

RESULTS

The operative time and length of stay (LOS) was significantly increased with addition of concomitant CCY. There was no significant difference in readmission, reoperation, intervention, morbidity, or mortality. The RRYGB with CCY approach was associated with a significantly longer operative times compared to the LRYGB with CCY (177 vs. 135 min, p < 0.0001). The laparoscopic and robotic groups demonstrated no significant difference LOS, readmission, reoperation, intervention, morbidity, or mortality rates.

CONCLUSIONS

Our study demonstrates that concomitant cholecystectomy increased the operative time and length of stay. However, concomitant CCY was not associated with any increased morbidity. The study demonstrated no significant difference in morbidity between robotic and laparoscopic approach. The robotic approach, however, was associated with a significantly longer operative time compared to the laparoscopic approach. While the indications for CCY remain controversial, concomitant CCY does not convey additional risk regardless of operative approach.

Use and Outcomes of Epidural Analgesia in Upper Gastrointestinal Tract Cancer Resections

BACKGROUND

Epidural analgesia (EA) is an appealing adjunct for esophageal and gastric cancer patients. It remains unclear whether EA usage affects postoperative outcomes. There are no national data on the trends of EA utilization for these procedures. This study aims to use the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to study the utilization and outcomes of EA in open upper GI tract cancer resections.

MATERIALS AND METHODS

A retrospective review of NSQIP was performed for patients undergoing open elective esophagectomies and gastrectomies for nonmetastatic cancer between 2014 and 2017. An Armitage trend test was performed. The population was propensity matched and assessed.

RESULTS

There were 4802 esophagectomies performed. Twenty-nine percent of patients received EA. Of 2599 gastrectomies, 18% of patients received EA. The recent trends of EA use for esophagectomies (EA range [26.9%, 30.3%] P = 0.6535) and gastrectomies (EA [16.9%, 18.4%], P = 0.7797) remain stable. Propensity matching was performed, and the groups with and without EA were compared. For esophagectomies, EA was associated with blood transfusions (EA 14% versus No EA 10.8%, P = 0.0156). For gastrectomies, EA was associated with longer length of stay (LOS) (EA median [IQR] 8 [7,11] versus No EA 7 [6,11], P = 0.0002).

CONCLUSIONS

Despite the current opioid epidemic, the recent trends of EA for esophageal and gastric cancer patients remain stable. EA was associated with blood transfusions for esophagectomies and with a longer LOS for gastrectomies. Therefore, EA should be carefully considered, and its analgesic efficacy in this population should be investigated closely in future studies.

Multimodal Postoperative Pain Control Is Effective and Reduces Opioid Use After Laparoscopic Roux-en-Y Gastric Bypass

BACKGROUND

Opioids have been the mainstay for postoperative pain relief for many decades. Recently, opioid-related adverse events and death have been linked to postoperative dependency. Multimodal approaches to postoperative pain control may be part of the solution to this health care crisis. The safety and effectiveness of multimodal pain control regimens after laparoscopic Roux-en-Y gastric bypass (LRYGB) has not been well studied. The primary aim of our study was to determine if an evidence-based, multimodal pain regimen during hospitalization could decrease the total oral morphine equivalent (TME) use after LRYGB.

STUDY DESIGN

We conducted a retrospective cohort study comparing outcomes prior to the implementation of a multimodal pain protocol (December 2010-December 2012) to those after implementation (April 2013-July 2015). The protocol utilized oral celecoxib and scheduled oral acetaminophen for pain control, with opioids used only as needed for breakthrough pain. Data was extracted from an electronic medical record and an institutionally maintained database of all patients undergoing bariatric surgery at a single center.

RESULTS

Compared to controls, the multimodal pain regimen significantly reduced TME used and maximum pain scores with no change in mean pain scores. Multimodal pain protocol patients had a shorter length of stay with no increase in bleeding complications or marginal ulcer rates.

CONCLUSIONS

An opioid-sparing multimodal pain regimen adequately controls pain while reducing TME use. The regimen appears to be safe and was associated with a reduced length of stay in patients undergoing LRYGB.

Urgent Surgery for Gastric Adenocarcinoma: A Study of the National Cancer Database

BACKGROUND

Gastric adenocarcinoma is a leading cause of cancer death worldwide and, in the United States, can present emergently with upper GI hemorrhage, obstruction, or perforation. No large studies have examined how urgent surgery affects patient outcomes. This study examines the outcomes of urgent versus elective surgery for gastric cancer.

MATERIALS AND METHODS

Patients with gastric adenocarcinoma from the National Cancer Database from 2004 to 2015 were examined retrospectively. Patients with metastatic disease or incomplete data were excluded. Urgent surgery was defined as definitive surgery within 3 d of diagnosis. Univariate and multivariate analysis of patient factors, surgical outcomes, and oncologic data was performed. P-values <0.05 were statistically significant.

RESULTS

Of 26,116 total patients, 2964 had urgent surgery and 23,468 had elective surgery. Urgent surgery patients were significantly older, were female, were nonwhite, had higher pathologic stage, and were treated at a low-volume center. Urgent surgery was associated with decreased quality lymph node harvest (odds ratio [OR] 0.68 95% confidence interval {CI} [0.62, 0.74]), increased positive surgical margin (OR 1.48, 95% CI [1.32, 1.65]), increased 30-d mortality (OR 1.38, 95% CI [1.16, 1.65]), increased 90-d mortality (OR 1.30, 95% CI [1.14, 1.49]), and decreased overall survival (hazard ratio 1.21, 95% CI [1.15, 1.27]).

CONCLUSIONS

Urgent surgery for gastric cancer is associated with significantly worse outcomes than elective surgery. Stable patients requiring urgent surgical resection for gastric cancer may benefit from referral to a high-volume center for resection by an experienced surgeon. Patients undergoing urgent resection for gastric cancer should be referred to surgical and medical oncologists to ensure they receive appropriate adjuvant therapy and surveillance.

Outcome of rectus femoris muscle flaps performed by vascular surgeons for the management of complex groin wounds after femoral artery reconstructions

OBJECTIVE

Groin wound complications after femoral artery reconstructions are highly morbid and notoriously difficult to treat. Successful techniques include long-term antibiotic therapy, operative débridement, and muscle flap coverage. Historically, more complex muscle flap coverage, such as a rectus femoris muscle flap (RFF), has been performed by plastic and reconstructive surgeons. In this study, the experience of vascular surgeons performing RFF in the management of wound complications after femoral artery reconstructions is reported.

METHODS

Clinical data between 2012 and 2018 were retrospectively analyzed. Data were summarized, and standard statistical analysis was performed.

RESULTS

There were 23 patients who underwent 24 RFFs for coverage of complex groin wounds after femoral artery reconstructions. One of the 23 patients underwent bilateral RFFs. In this study cohort, patients had a median age of 67.5 years, and 79% (n = 19) were male. Median body mass index was 28.0 kg/m², and 38% of patients were classified as obese on the basis of body mass index criteria. A history of tobacco use was present in 88%; however, only 29% were current smokers. Diabetes was present in 38% of patients and chronic kidney disease in 29%. Of the 24 RFFs, 14 (58%) were constructed in patients with reoperative groin surgery resulting in the need for muscle flap coverage. Femoral endarterectomy was the most common index procedure (46%), followed by infrainguinal leg bypass surgery (17%) and aortobifemoral bypass (17%). Grafts used during the original reconstruction included 12 bovine pericardial patches (50%), 6 Dacron grafts (25%), 4 PTFE grafts (17%), and 2 autogenous reconstructions (8%). Microbiology data identified 33% of patients (n = 8) to have gram-positive bacterial infections alone, 21% (n = 5) to have gram-negative infections alone, and 29% (n = 7) to have polymicrobial infections; 4 patients (13%) had negative intraoperative culture data. Median hospital stay after RFF was 8 days, and median follow-up time was 29.3 months. Major amputation was avoided in 20 of 24 limbs (83%) undergoing RFF. Eight patients underwent intentional graft or patch explantation (33%) before RFF, whereas 14 of the remaining 15 patients (93%) had successful salvage of the graft or patch after RFF. Two of the patients (13%) who underwent RFF with the intention of salvaging a prosthetic graft or patch required later graft excision. After RFF, 30-day and 1-year survival was 96% and 87%, respectively.

CONCLUSIONS

RFF coverage of complex groin wounds after femoral artery reconstructions may safely be performed by vascular surgeons with excellent outcomes.

Factors Associated with Failure of Nonoperative Management for Complicated Appendicitis

In recent years, nonoperative management of complicated appendicitis has become more common. Patients managed nonoperatively do well, but there is a paucity of literature on patients who fail nonoperative management. The purpose of this study was to examine the overall failure rate, morbidity associated with failure, and potential predictors of failure in nonop management of appendicitis. This is a descriptive retrospective review of patients from a single hospital system who were diagnosed with advanced appendicitis and underwent nonop management between January 1, 2007, and November of 2017. The data were obtained through review of patient charts from the electronic medical record. Failure was defined as requirement of an operation due to ongoing infection secondary to appendicitis. There were 183 patients initially managed non-operatively, with 70 patients failing nonoperative management. Patients failing nonoperative management experienced longer hospitalization (6.2 vs 2.9 days, P < 0.0001), and more patients in the failure group required admission to the ICU (10.0% vs 1.8%, P = 0.028). Multivariate analysis revealed that longer duration of symptoms reduced the likelihood of failure (odds ratio: 0.77 [0.64–0.92]). In this retrospective review, 38 per cent of patients failed nonop management of appendicitis. Symptom duration could provide insight for clinicians in assessing the role of non-operative management because increasing symptom duration reduced the likelihood of failure.

Thyroidectomy Remains a Safe Option for Graves’ Disease

Total thyroidectomy (TT) or near-TT (NTT) is often recommended over medical management for the treatment of Graves’ disease (GD). We assess the safety within surgical subspecialties at our institution for TT/NTT in GD patients. A retrospective review of patients undergoing TT/NTT for GD was performed from 2004 to 2016. Patient factors, thyroid size, surgeon subspecialty, and intraoperative/postoperative outcomes were all reviewed. Multivariate analyses were used to determine risk factors for complications. A total of 383 patients underwent TT/NTT. Two hundred thirty-three patients underwent TT/NTT by otolaryngology (n = 233, 60.8%), surgical oncology (n = 140, 36.6%), general surgery (n = 8, 2.1%), and unknown (n = 2, 0.5%). On multivariate analysis, surgical duration was longer for males ( P = 0.001) and increased thyroid weights ( P = 0.001). No association with hypocalcemia or recurrent laryngeal nerve paralysis was found with factors considered. No factors were found to be associated with the ability to identify the recurrent laryngeal nerve. Estimated blood loss (EBL) was increased in younger patients (0.010), males ( P = 0.001), increased BMI ( P = 0.012), and increased thyroid weight ( P < 0.001). EBL was also associated with the physician performing the operation, where EBL was greatest for TT/NTT performed by general surgeons, followed by surgical oncologists and then by otolaryngology ( P = 0.006). TT/NTT is safe and a reasonable option for the treatment of GD.

Factors Associated with Failure of Nonoperative Management for Complicated Appendicitis

In recent years, nonoperative management of complicated appendicitis has become more common. Patients managed nonoperatively do well, but there is a paucity of literature on patients who fail nonoperative management. The purpose of this study was to examine the overall failure rate, morbidity associated with failure, and potential predictors of failure in nonop management of appendicitis. This is a descriptive retrospective review of patients from a single hospital system who were diagnosed with advanced appendicitis and underwent nonop management between January 1, 2007, and November of 2017. The data were obtained through review of patient charts from the electronic medical record. Failure was defined as requirement of an operation due to ongoing infection secondary to appendicitis. There were 183 patients initially managed nonoperatively, with 70 patients failing nonoperative management. Patients failing nonoperative management experienced longer hospitalization (6.2 vs 2.9 days, P < 0.0001), and more patients in the failure group required admission to the ICU (10.0% vs 1.8%, P = 0.028). Multivariate analysis revealed that longer duration of symptoms reduced the likelihood of failure (odds ratio: 0.77 [0.64-0.92]). In this retrospective review, 38 per cent of patients failed nonop management of appendicitis. Symptom duration could provide insight for clinicians in assessing the role of nonoperative management because increasing symptom duration reduced the likelihood of failure.

Thyroidectomy Remains a Safe Option for Graves' Disease

Total thyroidectomy (TT) or near-TT (NTT) is often recommended over medical management for the treatment of Graves' disease (GD). We assess the safety within surgical subspecialties at our institution for TT/NTT in GD patients. A retrospective review of patients undergoing TT/NTT for GD was performed from 2004 to 2016. Patient factors, thyroid size, surgeon subspecialty, and intraoperative/postoperative outcomes were all reviewed. Multivariate analyses were used to determine risk factors for complications. A total of 383 patients underwent TT/NTT. Two hundred thirty-three patients underwent TT/NTT by otolaryngology (n = 233, 60.8%), surgical oncology (n = 140, 36.6%), general surgery (n = 8, 2.1%), and unknown (n = 2, 0.5%). On multivariate analysis, surgical duration was longer for males (P = 0.001) and increased thyroid weights (P = 0.001). No association with hypocalcemia or recurrent laryngeal nerve paralysis was found with factors considered. No factors were found to be associated with the ability to identify the recurrent laryngeal nerve. Estimated blood loss (EBL) was increased in younger patients (0.010), males (P = 0.001), increased BMI (P = 0.012), and increased thyroid weight (P < 0.001). EBL was also associated with the physician performing the operation, where EBL was greatest for TT/NTT performed by general surgeons, followed by surgical oncologists and then by otolaryngology (P = 0.006). TT/NTT is safe and a reasonable option for the treatment of GD.

MAGIC versus MacDonald treatment regimens for gastric cancer: Trends and predictors of multimodal therapy for gastric cancer using the National Cancer Database

BACKGROUND

Multimodal therapy is beneficial in gastric cancer, however this practice is not universal. This study examines trends, identifies associative factors, and examines overall survival (OS) benefit from multimodal therapy in gastric cancer.

METHODS

Gastric cancer patients staged IB-III from 2005 to 2014, identified using the National Cancer Database, were categorized by treatment: surgery alone, perioperative chemotherapy, and adjuvant chemoradiation. Groups were analyzed to identify associative factors of perioperative therapy.

RESULTS

We examined 9243 patients, with the majority receiving multimodal therapy (57%). The proportion of those receiving perioperative chemotherapy rose dramatically from 7.5% in 2006 to 46% in 2013. Academic center treatment was strongly associated with perioperative over adjuvant therapy (p < 0.0001). An OS advantage was clearly seen in those receiving multimodal therapy versus surgery alone (p < 0.0001), with no difference between perioperative and adjuvant therapies.

CONCLUSIONS

Treatment of gastric cancer with multimodal therapy has risen significantly since 2005, largely due to increasing use of perioperative chemotherapy. As perioperative therapy becomes more prevalent, more patients will have the opportunity for the improved survival benefit of multimodal therapy.

Neoadjuvant versus Adjuvant Chemotherapy for Resectable Pancreatic Adenocarcinoma: A National Cancer Database Analysis

There is controversy regarding the role of neoadjuvant versus adjuvant chemotherapy for pancreatic cancer (PAC). Neoadjuvant therapy has been touted as a method to improve survival in PAC patients. This study's objective is to investigate predictors and potential benefits of neoadjuvant therapy in resectable PAC patients. The National Cancer Data Base was used to retrospectively analyze stage I and II surgically resected PAC patients receiving adjuvant or neoadjuvant therapy from 2004 to 2012. A total of 12,983 patients were identified. A significant increase in the rate of neoadjuvant therapy was observed over time with 5 per cent receiving neoadjuvant therapy in 2004 versus 17 per cent in 2012 (P < 0.0001). Multivariate analysis showed that patients were more likely to receive neoadjuvant therapy if they were treated at an academic facility. Private insurance was associated with higher odds of neoadjuvant chemotherapy (P < 0.0001). Pathological outcomes were improved in neoadjuvant patients compared with adjuvant patients on multivariate analysis with neoadjuvant patients having higher rates of negative surgical margins (OR: 1.273, 95% Confidence interval: 1.099-1.474) and negative lymph nodes (OR: 2.852, 95% Confidence interval: 2.547-3.194). Pathological outcomes are improved after neoadjuvant therapy compared with adjuvant therapy, with more patients achieving negative margins and negative lymph nodes. Prospective studies are needed to compare these two treatment modalities in a head to head comparison.

Neoadjuvant versus Adjuvant Chemotherapy for Resectable Pancreatic Adenocarcinoma: A National Cancer Database Analysis

There is controversy regarding the role of neoadjuvant versus adjuvant chemotherapy for pancreatic cancer (PAC). Neoadjuvant therapy has been touted as a method to improve survival in PAC patients. This study's objective is to investigate predictors and potential benefits of neoadjuvant therapy in resectable PAC patients. The National Cancer Data Base was used to retrospectively analyze stage I and II surgically resected PAC patients receiving adjuvant or neoadjuvant therapy from 2004 to 2012. A total of 12,983 patients were identified. A significant increase in the rate of neoadjuvant therapy was observed over time with 5 per cent receiving neoadjuvant therapy in 2004 versus 17 per cent in 2012 (P < 0.0001). Multivariate analysis showed that patients were more likely to receive neoadjuvant therapy if they were treated at an academic facility. Private insurance was associated with higher odds of neoadjuvant chemotherapy (P < 0.0001). Pathological outcomes were improved in neoadjuvant patients compared with adjuvant patients on multivariate analysis with neoadjuvant patients having higher rates of negative surgical margins (OR: 1.273, 95% Confidence interval: 1.099–1.474) and negative lymph nodes (OR: 2.852, 95% Confidence interval: 2.547–3.194). Pathological outcomes are improved after neoadjuvant therapy compared with adjuvant therapy, with more patients achieving negative margins and negative lymph nodes. Prospective studies are needed to compare these two treatment modalities in a head to head comparison.

Analyzing the Impact of Compliance with National Guidelines for Pancreatic Cancer Care Using the National Cancer Database

IMPORTANCE

Management of pancreatic cancer is complex, requiring coordination of multiple providers. National Comprehensive Cancer Network guidelines, developed for standardization and quality improvement, recommend a multimodal approach.

OBJECTIVE

This study analyzed national rates of compliance with National Comprehensive Cancer Network recommendations, assessed factors affecting compliance, and evaluated whether compliance with evidence-based guidelines improved overall survival.

DESIGN

This is a retrospective review of adults diagnosed with pancreatic cancer entered into the National Cancer Database. Patients included had stage I and II pancreatic cancer, and complete data in the database. Patients were classified as compliant if they underwent both surgery and a second treatment modality (chemotherapy, radiation, or chemoradiation). Clinico-pathologic variables were analyzed using univariate and multivariate models to predict overall survival.

SETTING

Hospital-based national study population.

PARTICIPANTS

Patients with stage I or II pancreatic cancer.

MAIN OUTCOMES AND MEASURES

Compliance with National Comprehensive Cancer Network recommendations, factors affecting compliance, and overall survival based on compliance.

RESULTS

A total of 52,450 patients were included; 19,272 patients (37%) were compliant. Patients were found to be most compliant in the 50-59-year-old range (49% complaint), with decreased compliance at the extremes of age. Male patients were more compliant than female patients (39 vs 34%, p < 0.0001). Caucasians were more compliant (39%) than African Americans (32%) or other races (32%, p < 0.0001). Patients treated at academic/research centers were more compliant than patients treated at other facilities (39% compliant, p < 0.0001). Patients with stage II disease were more compliant compared with stage I disease (43 vs 18%, p < 0.0001). Compliance was shown to improve overall survival (p < 0.0001).

CONCLUSION

Adherence to National Comprehensive Cancer Network guidelines for pancreatic cancer patients improves survival. Compliance nationwide is low, especially for older patients and minorities and those treated outside academic centers. More studies will need to be performed to identify factors that hinder compliance.

Ten Year Projections for US Residency Positions: Will There be Enough Positions to Accommodate the Growing Number of U.S. Medical School Graduates?

OBJECTIVE

Recently, a multitude of new U.S. medical schools have been established and existing medical schools have expanded their enrollments. The National Residency Match Program (NRMP) reports that in 2016 there were 23,339 categorical residency positions offered in the match and 26,836 overall applicants with 17,789 (66.29%) of the total candidates being U.S. allopathic graduates. In view of the rapid growth of medical school graduates, the aim of this study is to determine if current trends suggest a shortage of residency positions within the next ten years.

DESIGN

The total number of graduates from U.S. medical schools was obtained from the Association of American Medical Colleges (AAMC) for 2005-2014 academic years and was trended linearly for a 10-year prediction for the number of graduates. The yearly number of categorical positions filled by U.S. graduates for calendar years 2006-2015 was obtained from the NRMP and was trended longitudinally 10 years into the future. Analysis of subspecialty data focused on the comparison of differences in growth rates and potential foreseeable deficits in available categorical positions in U.S. residency programs.

RESULTS

According to trended data from AAMC, the total number of graduates from U.S. medical schools has increased 1.52 percent annually (15,927 in 2005 to 18,705 in 2014); with a forecast of 22,280 U.S. medical school graduates in 2026. The growth rate of all categorical positions available in U.S. residency programs was 2.55 percent annually, predicting 29,880 positions available in 2026. In view of these results, an analysis of specific residencies was done to determine potential shortages in specific residencies. With 17.4 percent of all U.S. graduates matching into internal medicine and a 3.17 percent growth rate in residency positions, in 2026 the number of internal medicine residency positions will be 9,026 with 3,874 U.S. graduates predicted to match into these positions. In general surgery, residency positions note a growth rate of 1.55 percent. Of all U.S. graduates, 5.6 percent match into general surgery. Overall this projects 1,445 general surgery residency positions in 2026 with 1,257 U.S. graduates matching. In orthopedics with a growth rate of 1.35 percent and a match rate of 3.75 percent, there are projected to be 827 positions available with 836 U.S. graduates projected to match.

CONCLUSIONS

Despite the increasing number of medical school graduates, our model suggests the rate of growth of residency positions continues to be higher than the rate of growth of U.S. medical school graduates. While there is no apparent shortage of categorical positions overall, highly competitive subspecialties like orthopedics may develop a shortage within the next ten years.

Vemurafenib in metastatic melanoma patients with brain metastases: an open-label, single-arm, phase 2, multicentre study

Background

Vemurafenib has shown activity in patients with BRAFV600 mutated melanoma with brain metastases (BM). This phase 2 study evaluated vemurafenib in patients with/without prior treatment for BM.

Methods

Patients with BRAFV600 mutated melanoma with BM were enrolled into cohort 1 (previously untreated BM) and cohort 2 (previously treated BM) and received vemurafenib (960 mg BID) until disease progression (PD) or intolerance. Primary endpoint was best overall response rate (BORR) in the brain in cohort 1 that was evaluated using modified RECIST 1.1 criteria using lesions ≥0.5 cm to assess response.

Results

146 patients were treated (cohort 1 n = 90; cohort 2 n = 56), 62% of whom were male. Median (range) time since diagnosis of BM: 1.0 (0-9) month in cohort 1 and 4.2 (1-68) months in cohort 2. Median duration of treatment was 4.1 months (range 0.3-34.5) in cohort 1 and 4.1 months (range 0.2-27.6) in cohort 2. Intracranial BORR in cohort 1 by an independent review committee (IRC) was 18% (2 CRs, 14 PRs). Extracranial BORR by IRC was 33% in cohort 1 and 23% in cohort 2. Median PFS (brain only, investigator-assessed) was 3.7 months (range 0.03-33.4; IQR 1.9-5.6) in cohort 1 and 4.0 months (range 0.3-27.4; IQR 2.2-7.4) in cohort 2. Median OS was 8.9 months (range 0.6-34.5; IQR 4.9-17.0) in cohort 1 and 9.6 months (range 0.7-34.3; IQR 4.5-18.4) in cohort 2. Adverse events (AEs) were similar in type, grade and frequency to other studies of single-agent vemurafenib. Grade 3/4 AEs occurred in 59 (66%) patients in cohort 1 and 36 (64%) in cohort 2. Overall, 84% of patients died during the study (86% in cohort 1 and 80% in cohort 2), mainly due to disease progression.

Conclusions

The study demonstrates clinically meaningful response rates of melanoma BM to vemurafenib, which was well tolerated and without significant CNS toxicity.

Predictors of Utilization and Quality Assessment in Robotic Rectal Cancer Resection: A Review of the National Cancer Database

Robotic surgery (RS) is a novel treatment for rectal cancer resection (RCR); however, this technology is not widely accessible. The objective of this study is to evaluate the utilization of RS in RCR compared with open and laparoscopic techniques and to assess the quality of resection. RCR from 2010 to 2012 were identified using the National Cancer Database and placed into categories: open, laparoscopic, and robotic. A total of 23,857 patients who received open, laparoscopic, and robotic RCR were included (n = 14,735 (61.8%); 7,185 (30.1%); 1,937 (8.1%), respectively). Patients over 70 had a lower likelihood of robotic RCR. Patients with insurance were 2 times more likely to have robotic RCR. Patients at an academic/research program were more likely to undergo RS compared with a community cancer program (OR 3.6, 95% CI [2.79, 4.78]; P < 0.0001). Length of stay (LOS) was longer in open (7.9 ± 7.1) versus laparoscopic (6.6 ± 6.3) or robotic (6.8 ± 6.4) RCR (P < 0.0001). Although there was an increased likelihood of positive surgical margins with open RCR (OR 1.3, 95% CI [1.09, 1.66]; P < 0.0001), there was no difference in robotic and laparoscopic techniques. Younger insured patients at academic/research affiliated hospitals have a higher likelihood of receiving robotic RCR. Compared with open RCR, robotic RCR have a lower likelihood of positive surgical margins and shorter LOS.

Predictors of Utilization and Quality Assessment in Robotic Rectal Cancer Resection: A Review of the National Cancer Database

Robotic surgery (RS) is a novel treatment for rectal cancer resection (RCR); however, this technology is not widely accessible. The objective of this study is to evaluate the utilization of RS in RCR compared with open and laparoscopic techniques and to assess the quality of resection. RCR from 2010 to 2012 were identified using the National Cancer Database and placed into categories: open, laparoscopic, and robotic. A total of 23,857 patients who received open, laparoscopic, and robotic RCR were included (n = 14,735 (61.8%); 7,185 (30.1%); 1,937 (8.1%), respectively). Patients over 70 had a lower likelihood of robotic RCR. Patients with insurance were 2 times more likely to have robotic RCR. Patients at an academic/research program were more likely to undergo RS compared with a community cancer program (OR 3.6, 95% CI [2.79, 4.78]; P < 0.0001). Length of stay (LOS) was longer in open (7.9 ± 7.1) versus laparoscopic (6.6 ± 6.3) or robotic (6.8 ± 6.4) RCR (P < 0.0001). Although there was an increased likelihood of positive surgical margins with open RCR (OR 1.3, 95% CI [1.09, 1.66]; P < 0.0001), there was no difference in robotic and laparoscopic techniques. Younger insured patients at academic/research affiliated hospitals have a higher likelihood of receiving robotic RCR. Compared with open RCR, robotic RCR have a lower likelihood of positive surgical margins and shorter LOS.

Disparities in the Care of Differentiated Thyroid Cancer in the United States: Exploring the National Cancer Database

Differentiated thyroid cancer (DTC) treatment is multifaceted, and may be influenced by socio-economic factors. The goal of this study is to examine disparities in DTC treatment. DTC patients from 1998 to 2012 were identified using the National Cancer Database. DTC was identified in 262,041 patients. The mean age was 48.2. The majority of patients (52%) received care at Comprehensive Community Cancer Programs (CCCPs). Total thyroidectomy was less common at Community Cancer Programs (CCPs) [odds ratio (OR): 0.735; 95% confidence interval (CI): 0.707–0.764), and more common at academic centers (OR: 1.129; 95% CI: 1.102–1.157) compared with CCCP. A central neck dissection was performed most often at academic center (20.6%) versus CCP (10.0%). Black patients were less likely to undergo central neck dissection compared with white patients (OR: 0.468; 95% CI: 0.452–0.484). Patients more likely to receive radioactive iodine were white compared with black patients (hazard ratio: 0.833; 95% CI: 0.806–0.861), privately insured compared with uninsured patients (hazard ratio: 1.272; 95% CI: 1.210–1.341), and patients treated at CCCP. Disparities exist in DTC treatment. Individuals at risk for under-treatment are black patients, uninsured patients, and those treated at CCP. As the Affordable Care Act changes access to health care, future studies will be needed to readdress disparities.

Disparities in the Care of Differentiated Thyroid Cancer in the United States: Exploring the National Cancer Database

Differentiated thyroid cancer (DTC) treatment is multifaceted, and may be influenced by socioeconomic factors. The goal of this study is to examine disparities in DTC treatment. DTC patients from 1998 to 2012 were identified using the National Cancer Database. DTC was identified in 262,041 patients. The mean age was 48.2. The majority of patients (52%) received care at Comprehensive Community Cancer Programs (CCCPs). Total thyroidectomy was less common at Community Cancer Programs (CCPs) [odds ratio (OR): 0.735; 95% confidence interval (CI): 0.707-0.764), and more common at academic centers (OR: 1.129; 95% CI: 1.102-1.157) compared with CCCP. A central neck dissection was performed most often at academic center (20.6%) versus CCP (10.0%). Black patients were less likely to undergo central neck dissection compared with white patients (OR: 0.468; 95% CI: 0.452-0.484). Patients more likely to receive radioactive iodine were white compared with black patients (hazard ratio: 0.833; 95% CI: 0.806-0.861), privately insured compared with uninsured patients (hazard ratio: 1.272; 95% CI: 1.210-1.341), and patients treated at CCCP. Disparities exist in DTC treatment. Individuals at risk for under-treatment are black patients, uninsured patients, and those treated at CCP. As the Affordable Care Act changes access to health care, future studies will be needed to readdress disparities.

A lifting line model to investigate the influence of tip feathers on wing performance

Bird wings have been studied as prototypes for wing design since the beginning of aviation. Although wing tip slots, i.e. wings with distinct gaps between the tip feathers (primaries), are very common in many birds, only a few studies have been conducted on the benefits of tip feathers on the wing's performance, and the aerodynamics behind tip feathers remains to be understood. Consequently most aircraft do not yet copy this feature. To close this knowledge gap an extended lifting line model was created to calculate the lift distribution and drag of wings with tip feathers. With this model, is was easily possible to combine several lifting surfaces into various different birdwing-like configurations. By including viscous drag effects, good agreement with an experimental tip slotted reference case was achieved. Implemented in C++ this model resulted in computation times of less than one minute per wing configuration on a standard notebook computer. Thus it was possible to analyse the performance of over 100 different wing configurations with and without tip feathers. While generally an increase in wing efficiency was obtained by splitting a wing tip into distinct, feather-like winglets, the best performance was generally found when spreading more feathers over a larger dihedral angle out of the wing plane. However, as the results were very sensitive to the precise geometry of the feather fan (especially feather twist) a careless set-up could just as easily degrade performance. Hence a detailed optimization is recommended to realize the full benefits by simultaneously optimizing feather sweep, twist and dihedral angles.

[Malignant lymphoma of the skin: update on diagnostics and therapy of primary cutaneous B-cell lymphoma]

The diagnosis of primary cutaneous B-cell lymphoma is made based principally on the results of histological investigations and staging. For an exact staging abdominal sonography and chest X-ray examinations and for appropriate clinical symptoms special investigations as well as radiological imaging procedures including PET are indicated in addition to conventional laboratory investigations. For therapy rituximab is normally administered as monotherapy in order to avoid over therapy of indolent lymphoma. Further options are radiotherapy and new approaches with electrochemotherapy as well as pegylated doxorubicin.