Courtney N. Heins

On-pump coronary artery bypass graft operation: Is one crossclamp application better than two?

OBJECTIVES Several factors may increase the risk of stroke during coronary artery bypass grafting. These include age and atherosclerosis, which are not modifiable, and aortic manipulation, which may be modifiable. This study reports our experience with variable degrees of aortic manipulation (ie, single vs double [partial occlusion] aortic crossclamp techniques) and its influence on rate of operative stroke. METHODS We performed a retrospective review of 8497 patients treated with isolated on-pump coronary artery bypass grafting from 1993 to 2010. Demographics included an age of 66.8 ± 10.3 years and male sex in 6548 patients (77.1%). Operative technique used the single aortic crossclamp in 2051 patients (24.1%) and the partial aortic crossclamp in 6446 patients (75.9%). To adjust for differences in baseline patient characteristics, 2 propensity-matched cohorts of 1333 patients each were created using Society of Thoracic Surgeons risk calculator variables. RESULTS In the unmatched cohorts, stroke occurred in 25 patients (1.2%) in the single aortic crossclamp cohort and in 98 patients (1.5%) in the partial aortic crossclamp cohort (P = .320). Logistic regression analysis demonstrated no significant relationship between stroke and aortic occlusion clamp technique (single clamp odds ratio, 0.80; 95% confidence interval, 0.51-1.24; P = .321). In the matched cohorts, stroke occurred in 16 patients (1.2%) in both the single and partial occlusion clamp cohorts (P = 1.00). CONCLUSIONS Given the methods and limitations of the data analysis, the single and partial aortic crossclamp techniques result in similar rates of stroke during on-pump coronary artery bypass grafting.

Characterization of perioperative infection risk among patients undergoing radical cystectomy: Results from the national surgical quality improvement program.

OBJECTIVES To evaluate the incidence, risk factors, and timing of infections following radical cystectomy (RC). METHODS The American College of Surgeons National Surgical Quality Improvement Project database was queried to identify patients undergoing RC for bladder cancer from 2006 to 2013. Characteristics including year of surgery, age, sex body mass index, diabetes, smoking, renal function, steroid usage, preoperative albumin, preoperative hematocrit, perioperative blood transfusion (PBT), and operative time were assessed for association with the risk of infection within 30 days of RC using multivariable logistic regression. RESULTS A total of 3,187 patients who had undergone RC were identified, of whom 766 (24.0%) were diagnosed with a postoperative infection, at a median of 13 days (interquartile ranges 8-19) after RC. Infections included surgical site infection (SSI) (404; 12.7%), sepsis/septic shock (405; 12.7%), and urinary tract infection (UTI) (309; 9.7%). On multivariable analysis, body mass index≥30kg/m2 (odds ratios [OR] = 1.52; P<0.01), receipt of a PBT (OR = 1.27; P<0.01), and operative time≥480 minutes (OR = 1.72; P<0.01) were significantly associated with the risk of infection. When the outcomes of UTI, SSI, and sepsis were analyzed separately, operative time≥480 minutes remained independently associated with increased infection risk in each model (OR = 2.11 for UTI, OR = 1.63 for SSI, and OR = 1.80 for sepsis/septic shock; all P<0.05), whereas PBT was associated with SSI and sepsis/septic shock (OR = 1.33 and OR = 1.29, respectively; both P< 0.05). CONCLUSIONS Approximately 25% of patients undergoing RC experience an infection within 30 days of surgery. Several potentially modifiable risk factors for infection were identified, specifically PBT and prolonged operative time, which may represent opportunities for future care improvement.

Impact of neoadjuvant chemotherapy on pathologic axillary nodal status in HER-2 positive patients presenting with clinically node-negative disease.

We investigated the impact of neoadjuvant chemotherapy (NAC) on axillary disease burden in clinically node‐negative (cN0) HER‐2 positive breast cancer patients.

Abstract PD7-05: How 21-gene recurrence score assay is being used to individualize adjuvant chemotherapy recommendations in ER+/HER2 -node positive breast cancer -A national cancer data base study

Introduction: The 21-gene Recurrence Score (RS) assay has been shown in retrospective studies to predict benefit of adjuvant chemotherapy (AC) in node positive (N+) breast cancer (BC) patients (pts). This study evaluates the trends and patterns of use of RS assay in N+, ER+/HER2-breast cancer and the impact of RS on decision to use AC in a real-world multi-institutional database. Methods: Pts with T1-T4c, N1mi-N3, ER+/HER2- BC diagnosed between 2010 and 2013, included in the National Cancer Data Base were analyzed. Pts who received neo-AC were excluded. Analyses included Cochrane-Armitage tests for trends and multivariable logistic regression assessing factors influencing RS testing and AC recommendations based on RS. Results: Among 73,049 pts, RS was obtained in 20.6%, increasing from 14.9% in 2010 to 24.4% in 2013 (p 85%) with RS 26-30 or high risk RS were recommended AC regardless of N stage. For pts with low risk RS, recommendation for AC increased significantly with increasing N stage (see table). On multivariable analysis, in pts with low risk RS, AC was more likely to be recommended in those with N1/N2+ stage (OR 2.3 and 9.1 vs N1mi), T2 and T3/T4 tumors (OR 1.3 and 2.2 vs T1 tumors), poorly differentiated tumors (OR 1.6) and younger age (OR 3.4 and 1.7, respectively, for Conclusions: RS was obtained in about one fifth of pts with N+ ER+/HER2- BC, predominantly for N1mi and N1 disease. Overall, RS testing decreased frequency of recommendation of AC in N+ BC pts. The RS influenced use of AC particularly in N1mi and N1 pts, likely avoiding overtreatment of those with low risk RS and RS 18-25. Prospective data regarding RS to direct AC in N+ BC are awaited. Citation Format: Peethambaram PP, Hoskin TL, Heins CN, Habermann EB, Boughey JC. How 21-gene recurrence score assay is being used to individualize adjuvant chemotherapy recommendations in ER+/HER2 -node positive breast cancer -A national cancer data base study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD7-05.

PD12-09 CHARACTERIZATION OF INFECTION RISK AFTER RADICAL CYSTECTOMY: RESULTS FROM THE NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM

INTRODUCTION AND OBJECTIVES: Radical cystectomy (RC) represents the standard of care for muscle-invasive and high-risk non-muscle invasive bladder cancer. However, RC is associated with a high complication rate, including perioperative infection. In addition to causing patient morbidity, infections have been identified as a quality metric. Herein, we evaluated the incidence, risk factors, and timing of infection following RC. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify patients undergoing RC for bladder cancer from 2005-2013 using CPT procedure and ICD-9 diagnosis codes. Characteristics including age, gender, body-mass index (BMI), diabetes, smoking status, renal function, steroid usage, albumin, perioperative blood transfusion (PBT), and operative time were assessed for their independent association with the risk of infection (inclusive of urinary tract infection (UTI), surgical site infection (SSI), and sepsis) within 30 days of RC using multivariable logistic regression. RESULTS: A total of 3,187 patients were identified, of whom 2,604 (81.8%) were male. Median age was 70 years (IQR 62, 77). Infection within 30 days of RC was diagnosed in 766 (24%) patients, at a median of 13 days (IQR 8, 19) after RC. The most common infections were SSI (404; 12.7%) and sepsis (405; 12.7%), followed by UTI (309; 9.7%). On multivariable analysis (Table), factors significantly associated with an increased risk of postoperative infection were BMI 30 (OR 1.52; p<0.01), receipt of a PBT (OR 1.28; p<0.01), and operative time 480 min (OR 1.69; p<0.01). When the outcomes of UTI, SSI, and sepsis were analyzed separately, operative time 480 min remained independently associated with increased infection risk in each model (OR 2.07 for UTI, OR 1.62 for SSI, and OR 1.74 for sepsis; all p<0.05), while PBT was associated with SSI and sepsis (OR 1.31 and OR 1.35, respectively; both p<0.05). CONCLUSIONS: Approximately 25% of patients undergoing RC experience an infection within 30 days of surgery. Several potentially modifiable risk factors for infection were identified, specifically PBT and prolonged operative time, which represent potential targets for care improvement. Source of Funding: None

Incidence, timing, and risk factors for infection after radical cystectomy: Results from the National Surgical Quality Improvement Program.

445 Background: Radical cystectomy (RC) is the gold standard treatment for muscle-invasive and high-risk non-muscle invasive bladder cancer. However, the procedure has been associated with a high complication rate, including perioperative infection. In addition to resulting in patient morbidity, infections have been suggested as a quality metric. We sought to evaluate the incidence, risk factors, and timing of infection following RC. Methods: The National Surgical Quality Improvement Program (NSQIP) database was queried to identify patients undergoing RC for bladder cancer from 2005-2013 using CPT procedure and ICD-9 diagnosis codes. Infections (urinary tract infection (UTI), surgical site infection (SSI), and sepsis) within 30 days of RC were recorded. Characteristics including age, gender, ethnicity, body-mass index, diabetes, smoking status, renal function, steroid usage, albumin, receipt of perioperative transfusion, and operative time were abstracted, and relative risk of infection was assessed in un...