Selection Of Patients For Surgery Research Articles

Part 1: Artificial intelligence technology in surgery.

Artificial intelligence (AI) is one of the disruptive technologies of the fourth Industrial Revolution that is changing our work practices. This technology is in use in highly diverse industries including health care, defence, insurance and e-commerce. This review focuses on the relevance of AI to surgery. AI will aid surgeons with diagnostic decision-making, patient selection for surgery as well as improve patient pre- and post-operative care and management. Ethical considerations of AI with respect to patient rights and data privacy are highlighted. A further challenge is how best to present to national regulators a pragmatic way to assess AI as 'software as a medical device'. This relates to the ramifications for the adoption of AI technology in clinical practice, and its subsequent public funding support and reimbursement. It is evident that AI technology has important applications in surgery in the 21st century. The establishment of a key work programme in this area will be important if surgeons are to fully utilize AI in surgery.

33 CRISCO-UGIS: COMPOSITE RISK SCORE TO PREDICT POST-OPERATIVE COMPLICATIONS FOR UPPER GASTROINTESTINAL CANCER SURGERY

Abstract Gastroesophagectomy for cancer is associated with high risk of morbidity and mortality. Careful patient selection for surgery is essential for optimizing outcomes. The purpose of this study was to develop a reliable composite risk calculator to inform pre-operative decision-making using readily available patient and tumour characteristics. Methods Patients undergoing curative-intent resection for gastroesophageal cancer from January 2010 to December 2018 were identified from a prospectively collected database. Data were verified and collected from patients’ medical records. Multiple logistic regression modeling identified pre-operative variables associated with significantly elevated risk of moderate to severe post-operative complications (Clavien-Dindo score ≥ 2) within 30 days of surgery and a nomogram was developed to form the composite risk score (CRiSCo-UGIS). Internal model validation was performed. Results Among 520 patients, independent pre-operative risk factors for complications were: female sex, age-adjusted Charlson comorbidity index ≥5, albumin <35 g/L, proximal tumour location (esophagus and gastroesophageal junction) and reduced performance status (Eastern Cooperative Oncology Group performance status 2–3) (Table 1). CRiSCo-UGIS had a good model fit (Hosmer-Lemeshow p = 0.47, area under receiver operating characteristic curve = 0.69). The overall observed-to-expected ratio was 1.0 [95% confidence interval 0.9–1.1]. Patients were divided into low (0), moderate (1–2) and high (≥3 points) risk categories. The observed risk of complications was: 42% in low-risk, 53% in moderate-risk and 80% in high-risk. Conclusion CRiSCo-UGIS can reliably predict post-operative complications for gastroesophageal cancer resection based on readily available pre-operative characteristics. This composite score can be used to guide patient selection for surgery and enhance informed consent discussions.

Usefulness of Brain Positron Emission Tomography with Different Tracers in the Evaluation of Patients with Idiopathic Normal Pressure Hydrocephalous.

Idiopathic normal pressure hydrocephalus (iNPH) is the only form of dementia that can be cured by surgery. Its diagnosis relies on clinical and radiological criteria. Identifying patients who can benefit from surgery is challenging, as other neurological diseases can be concomitant or mimic iNPH. We performed a systematic review on the role of positron emission tomography (PET) in iNPH. We retrieved 35 papers evaluating four main functional aspects with different PET radiotracers: (1) PET with amyloid tracers, revealing Alzheimer’s disease (AD) pathology in 20–57% of suspected iNPH patients, could be useful in predictions of surgical outcome. (2) PET with radiolabeled water as perfusion tracer showed a global decreased cerebral blood flow (CBF) and regional reduction of CBF in basal ganglia in iNPH; preoperative perfusion parameters could predict surgical outcome. (3) PET with 2-Deoxy-2-[18F]fluoroglucose ([18F]FDG ) showed a global reduction of glucose metabolism without a specific cortical pattern and a hypometabolism in basal ganglia; [18F]FDG PET may identify a coexisting neurodegenerative disease, helping in patient selection for surgery; postsurgery increase in glucose metabolism was associated with clinical improvement. (4) Dopaminergic PET imaging showed a postsynaptic D2 receptor reduction and striatal upregulation of D2 receptor after treatment, associated with clinical improvement. Overall, PET imaging could be a useful tool in iNPH diagnoses and treatment response.

Comparative study of minimally invasive and traditional approaches for the microsurgical treatment of circle of Willis unruptured intracranial aneurysms

Objective. The study objective was to compare the effects of minimally invasive and traditional surgical approaches for treating patients with unruptured intracranial aneurysms (UIAs) to assess efficacy and safety of the keyhole concept in neurosurgery.Material and methods. We made a comparison of the microsurgical treatment outcomes of 204 patients harbouring UIAs who were operated on in the period from 2014 to 2019. Patients were divided into two groups: operated on using traditional approach (n = 85, 41.7%) and minimally invasive approach (n = 119, 58.3%). Patients of the first group were operated on using pterional (n = 31), orbitozygomatic (n = 16) and lateral supraorbital (n = 38) approaches; the second group patients underwent surgery using trans-eyebrow supraorbital (n = 35), minimal pterional (n = 38), trans-eyebrow transorbital (n = 20) and transpalpebral transorbital (n = 26) approaches. Rate of intraoperative and postoperative complications, surgery duration and postoperative in-hospital stay period were the factors to compare. The Modified Rankin Scale was used as a neurological outcomes measure. Also cosmetic results of surgery, hypesthesia from the site of the surgical approach, temporomandibular joint disorder and facial asymmetry were evaluated.Results. Compared to the traditional approach, minimally invasive technique incurred shorter surgery duration (р = 0.051) and inpatient stay (р > 0.001). Intraoperative and postoperative complication rates (р > 0.05) as well as functional outcomes (р > 0.05) were comparable between the two groups, while cosmetic effects (р < 0.05) were greater in minimally invasive group of UIA patients.Conclusion. Microsurgical treatment of UIA patients using minimally invasive approach is considered safe and effective. Adequate selection of patients for operation and exhaustive neuroimaging data assessment for choosing of neurosurgical technique are obligatory factors for keyhole surgery. The authors recommend using minimally invasive concept only for experienced neurosurgical teams in specialized clinics.

Is Bethesda classification sufficient to predict thyroid cancer in endemic regions?

Aim: Bethesda classification is widely used to determine the risk of malignancy of thyroid nodules and in many guidelines, treatment algorithms are determined according to this classification. We aimed to investigate the accuracy of malignancy predictions of Bethesda classification in patients who underwent surgery. Methods: In this retrospective cohort study, the medical records of patients who underwent thyroidectomy between 2013 and 2017 were analyzed. Patients’ demographic characteristics, fine needle aspiration biopsy (FNAB) results, ultrasonographic findings, number of nodules, diameter of nodules, type of surgeries performed, and the terminal pathology results were recorded. Malignancies that were detected in Bethesda 1-2 patients and in nodules other than the nodule to which FNAB was performed in other Bethesda categories were defined as incidental cancer. Results: Nine hundred sixty-seven patients were included in the study. The mean age of the patients was 46.9 (12.4) years and 82.4 % (n=797) were female. Mean nodule diameter was 29.7(13.9) mm and 64.3% (n=622) of the patients had 3 or more nodules. In our series, the rate of malignancy was 24.2% for Bethesda 1, 24.7% for Bethesda 2, 35 % for Bethesda 3, 52.1 % for Bethesda 4, 91.2 % for Bethesda 5 and 100 % for Bethesda 6. In all categories, the malignancy rate was higher than the expected range, but statistical significance was determined in Bethesda 1, 2, 4 and 5 groups. When compared to the whole series, rate of incidental cancer was 18.2%, whereas the incidental cancer rate was 49.5 % of all cancers. The tumor was multicentric in 34.6 % of malignant cases. Conclusion: In endemic regions, higher rates of malignancy are detected than that predicted by the Bethesda classification. Therefore, updates on guidelines in patient selection for surgery and in choosing the surgical technique may be necessary for endemic areas.

Thyroid fine-needle aspiration cytology in Taiwan: a nationwide survey and literature update.

In Taiwan, thyroid fine-needle aspiration cytology is easily accessible and reliable for evaluating thyroid nodules. The sonographic pattern plays a major role and is the deciding factor for aspiration. We conducted a nationwide survey in 2017 and it revealed that 31% of laboratories had adopted The Bethesda System for Reporting Thyroid Cytopathology. There was a relatively high unsatisfactory rate (24.04%) and low rates of indeterminate diagnoses, including atypia of undetermined significance/follicular lesions of undetermined significance: 4.87%, and follicular neoplasm/suspicious for a follicular neoplasm: 0.35%. Moreover, the risks of malignancy in benign, atypia of undetermined significance, and suspicious for a follicular neoplasm were relatively high. These may reflect strict diagnostic criteria for indeterminate categories and better patient selection for surgery. Improvements in specimen sampling and continuing education programs are crucial. Newly-developed thyroid cytology technologies, such as immunocytochemistry, molecular testing, and computerized cytomorphometry, may further facilitate cytology diagnoses.

Non-staged bilateral Globus Pallidus Internus deep brain stimulation lead revision using intraoperative MRI: a case report and literature review

Background Deep brain stimulation (DBS) lead revision due to suboptimal therapy is common but there is no standardised protocol. We describe a novel technique using iMRI to perform concurrent new Globus Pallidus Internus (GPi) DBS lead implantation and old lead removal in a dystonia patient. Case-description: A 60-year-old woman with medication and neurotoxin-refractory isolated cervical dystonia underwent awake bilateral GPi DBS surgery with MER-guided lead implantation. She initially had a favourable response but later reported suboptimal benefit despite reprogramming. MRI demonstrated suboptimal lead placement and MRI-guided revision surgery under general anesthesia was planned. The goal was to place new leads superior and medial to the existing leads. Using a 1.5 T iMRI and the ClearPoint® NeuroNavigation system, new leads were placed through the existing burr holes, into the new targets with radial errors < 0.08mm bilaterally without crossing the old leads. The old leads were then removed and the new leads connected to the existing pulse generator. The patient tolerated the procedure well and had improved side-effect profile at all contacts at 1-month follow-up. Conclusions Non-staged iMRI-guided DBS revision surgery under general anesthesia is technically feasible and is an alternative strategy to a staged iMRI-guided revision surgery or an awake MER-guided revision surgery in select patients.

Preoperative Liver Function Guiding HCC Resection in Normal and Cirrhotic Liver

Background: Liver resection is the most effective available therapy for patients with hepatocellular carcinoma (HCC). The accurate selection of patients for surgery requires determination of technical resectability and the risk of recurrence, as well as assessment of liver function and functional reserve to avoid postoperative liver failure. Previous studies have underlined the effectiveness and reliability of the LiMAx® test to evaluate liver function preoperatively. Nevertheless, data concerning HCC evaluation are lacking. Methods: From 2014 to 2019, 92 patients with HCC underwent additional assessment of liver function using the LiMAx test prior to decision for or against liver resection. Preoperative LiMAx results were compared between cirrhotic and noncirrhotic liver. The clinical decision for surgery was evaluated applying the various liver function parameters available. Results: Forty-six patients underwent liver resection. The LiMAx results were higher in resected patients (388 vs. 322 µg/kg/h; p = 0.004). LiMAx values were an independent risk factor for the presence of liver cirrhosis in multivariate analysis. In 17 patients, surgical treatment was cancelled due to major impairment of liver function. Only 4 out of 46 resected patients presented with post-hepatectomy liver failure (PHLF) grade ≥B. Histologic assessment revealed liver cirrhosis in 10 resected patients without PHLF. Conclusion: Preoperative determination of liver function by the LiMAx test enables effective and safe patient selection for HCC resection in both cirrhotic and noncirrhotic liver.

Prevention and control strategies of general surgeons under COVID-19 pandemic.

The novel coronavirus SARS-CoV-2 and the disease caused by it, COVID-19, have spread to virtually all countries worldwide within just a few months. The economic and sanitary impact has been enormous. In March 2020, the World Health Organization declared COVID-19 a pandemic. How to effectively prevent and control SARS-CoV-2 transmission while providing care to surgical patients during the pandemic is a crucial topic. In order to minimize the risk of cross-infection between patients and physicians, many hospitals have taken measures to limit outpatient services, elective hospitalizations, and the number of operations. Based on the prevention and control measures stipulated by major medical institutions in China, this overview provides recommendations for surgeons from three aspects: outpatient treatment, ward management and perioperative protection. Telemedicine should be encouraged as a means of social distancing. Outpatient examination should be selected. Reasonable spatial arrangement and effective environmental disinfection are important for ward management. Patient selection for surgery and timing of operations should be carefully discussed within multi-disciplinary teams. Appropriate personal protective equipment should be worn adapted to the situational risk.On December 31, 2019, China reported to the WHO Country Office a pneumonia of unknown cause detected in Wuhan [1], [3]. Subsequently, the disease later named COVID-19 affected a substantial proportion of the population in Wuhan and spread to other areas of China. Relying on a nationwide shutdown and mandatory quarantine, China has effectively curtailed the domestic outbreak. However, due to the high transmissibility of SARS-Cov-2 and the mobility of people, COVID-19 spread to the rest of the world. Many hospitals worldwide were faced with confirmed and suspected SARS-Cov-2 infections, putting a huge strain on the safety of patients and employees. Consequently, surgical patients who seek medical care during the COVID-19 pandemic present significant challenges. This paper summarizes medical care and infection prevention and control in general surgery patients during the COVID-19, pandemic in the light of the current situation in China. It provides reference for surgeons and decision makers in health care in other countries suffering from the COVID-19 pandemic.

Assessing the Burden of Nondeferrable Major Uro-oncologic Surgery to Guide Prioritisation Strategies During the COVID-19 Pandemic: Insights from Three Italian High-volume Referral Centres

The coronavirus 2019 (COVID-19) pandemic has led to an unprecedented emergency scenario for all aspects of health care, including urology. At the time of writing, Italy was the country with the highest rates of both infection and mortality. A panel of experts recently released recommendations for prioritising urologic surgeries in a low-resource setting. Of note, major cancer surgery represents a compelling challenge. However, the burden of these procedures and the impact of such recommendations on urologic practice are currently unknown. To fill this gap, we assessed the yearly proportion of high-priority major uro-oncologic surgeries at three Italian high-volume academic centres. Of 2387 major cancer surgeries, 32.3% were classified as high priority (12.6% of radical nephroureterectomy, 17.3% of nephrectomy, 33.9% of radical prostatectomy, and 36.2% of radical cystectomy cases). Moreover, 26.4% of high-priority major cancer surgeries were performed in patients at higher perioperative risk (American Society of Anesthesiologists score ≥3), with radical cystectomy contributing the most to this cohort (50%). Our real-life data contextualise ongoing recommendations on prioritisation strategies during the current COVID-19 pandemic, highlighting the need for better patient selection for surgery. We found that approximately two-thirds of elective major uro-oncologic surgeries can be safely postponed or changed to another treatment modality when the availability of health care resources is reduced. Patient summaryWe used data from three high-volume Italian academic urology centres to evaluate how many surgeries performed for prostate, bladder, kidney, and upper tract urothelial cancer can be postponed in times of emergency. We found that approximately two-thirds of patients with these cancers do not require high-priority surgery. Conversely, of patients requiring high-priority surgery, approximately one in four is considered at high perioperative risk. These patients may pose challenges in allocation of resources in critical scenarios such as the current COVID-19 pandemic.

A Historical Review of Indian Perspectives on Techniques of Tympanoplasty.

Reconstructive surgery of the conductive hearing mechanism is collectively called as tympanoplasty, which has gradually evolved over time with the contributions from all over the word. The aim of the present historical review is to summarize the Indian contributions in the development of the technique of tympanoplasty. The literature review was conducted using only the “Medline” search using keywords “tympanoplasty” and “ossiculoplasty” in “India” on 15th June 2016. A total of 195 articles and abstracts were found dated from the year 1998 onwards. Articles describing work on technique were included, and those describing only experimentation with graft material were excluded. All articles were fully read and analysed. It was found that there had been experiments regarding the choice of anaesthesia and the use of combinations of different chemical agents for this purpose. There were suggestions in favour of monitored anaesthesia care for the surgery in select patients. Surgeons expressed their perspectives on the time and conditions for the surgery, laterality of surgery, different types of incisions, use of endoscopes, graft placement techniques, ossicular replacements with autologous or allogenic grafts, and the timing of prophylactic antibiotic therapy given after or during the surgery. The range of work is wide and covers most of the aspects of surgery; however, the incorporation of a uniform methodology and standards reporting results were lacking in the articles reviewed.

Prediction of Memory Impairment in Epilepsy Surgery by White Matter Diffusion

To analyze the relationship between cognitive performance and white matter integrity in patients with temporal lobe epilepsy (TLE) to establish radiologic criteria to help with patient selection for surgery. The study included 19 adults with temporal lobe epilepsy. A tractography analysis of fractional anisotropy and mean diffusivity (MD) of the following fascicles was performed: arcuate fascicle, cingulum, fornix, inferior fronto-occipital fascicle, inferior longitudinal fascicle, parahippocampal fibers of the cingulum, and uncinate fascicle. The Wechsler Memory Scale-Third Edition neuropsychological test was performed to evaluate short- and long-term verbal (Logical Memory I and II subtests) and nonverbal (Visual Reproduction I and II subtests) memory. Relationships between memory scores and diffusion were calculated. Lower Logical Memory I subtest scores were correlated with lower MD of the right inferior fronto-occipital fascicle, while lower Logical Memory II subtest scores were related to higher values of fractional anisotropy in bilateral cingulum, right uncinate, and right parahippocampal fibers of the cingulum and lower MD in left cingulum fascicle. Finally, lower values in Visual Reproduction I subtest scores were associated with lower values in MD in right cingulum and inferior fronto-occipital fascicles. Structural changes of some white matter tracts were associated with deterioration of both short- and long-term memory. These alterations were more associated with verbal memory than with nonverbal memory. These changes mainly consist of an increase in fractional anisotropy and a decrease in MD, which could be interpreted as reorganization phenomena. Diffusion tensor imaging could be a useful tool for cognitive assessment in surgical candidates with temporal lobe epilepsy who are not suitable for neuropsychological testing or in whom their results do not lead to definitive conclusions.

Weightbearing Cone-Beam Computed Tomography of Acute Ankle Syndesmosis Injuries

Syndesmotic injuries are common, but only a subset of these injuries are unstable. A noninvasive tool for identifying instability would aid in the selection of patients for surgery. Weightbearing computed tomography (CT) data have been reported for healthy patients, but there are limited data on unstable syndesmoses. We evaluated the syndesmotic area of arthroscopically proven unstable ankles after acute injury. This is a prospective comparative study of consecutive patients recruited to a weightbearing CT database. Thirty-nine patients were included for analysis with arthroscopically proven unstable syndesmoses and an uninjured contralateral ankle. The syndesmosis area was measured for both ankles, in non-weightbearing and weightbearing positions, and compared. Syndesmosis area of the unstable ankle was significantly greater than the uninjured ankle of the same patient, by a mean of 22.9 ± 10.5 mm2. This was a significantly greater difference than that observed with non-weightbearing CT (9.8 ± 10.2 mm2, p < .001). Dynamic change in area, from non-weightbearing to weightbearing, of the unstable ankle (13.7% [16.6 ± 9.9 mm2]) was significantly greater than that of the uninjured ankle (3.1% [3.4 ± 6.7 mm2], p < .001). The intraobserver and interobserver correlations were good with intraclass correlation coefficients of 0.983 and 0.970, respectively. Weightbearing CT demonstrated significantly greater diastasis in unstable ankles than did conventional non-weightbearing CT. Syndesmosis area measurement was reliable and reproducible. Dynamic change in area and weightbearing comparison with the contralateral uninjured ankle are 2 parameters that may prove useful in the future for predicting syndesmotic instability.

Epidemiology of Distal Radius Fixations and Functional Outcomes in the Superelderly Population.

Background: Superelderly patients (defined as 80 years old and older) account for 18% of all distal radius fractures in our institution and this number is increasing with the ageing population. When faced with the option of surgery, patients in this age group have concerns with regards to the long term outcomes including functional outcomes and the time to fracture union. Therefore, the aim of this study was to evaluate the functional outcomes in this specific population. Methods: Patient selection for surgery was determined by the fracture stability, the patient's premorbid function and underlying comorbidities. Post operatively, the time to fracture union after surgical fixation, surgical complications and patients' functional outcome scores were recorded. The method of anaesthesia and any anaesthesia-related complications were also included. Results: There were 76 superelderly patients who underwent surgical fixation of their distal radius fractures identified from our institution's prospective database from 2009 to 2016. Overall there were good functional outcome scores. The DASH scores at 3 months and 6 months were 17 and 10 respectively. Furthermore, the mean time to fracture union in our population was 47 days (approximately 7 weeks). There were only 2 post-operative surgical complications but no anaesthesia-related complications. Conclusions: Surgical fixation of distal radius fractures in appropriately selected patients in the superelderly population yields good functional outcomes.

Plaque Echolucency Assessment Prior to Carotid Endarterectomy has No Long-Term Predictive Value for Stroke or Cardiovascular Death

Introduction - In patients with asymptomatic carotid artery disease receiving optimal medical treatment, carotid plaque echolucency has been shown to predict the risk of future ipsilateral stroke. Therefore, carotid endarterectomy may be more beneficial in patients with definite echolucent carotid plaque and as a result plaque echolucency has been suggested as a tool to aid in patient selection for surgery. However, carotid plaque echolucency is also thought to predict other systemic cardiovascular events (i.e.

"In-Office Balloon Sinus Ostial Dilation with Concurrent Antiplatelet and Anticoagulant Therapy for Chronic Rhinosinusitis without Nasal Polyps".

Functional endoscopic sinus surgery (FESS) and balloon sinus ostial dilation (BSD) are well-recognized minimally invasive surgical treatments for chronic rhinosinusitis without nasal polyps (CRSsNP) refractory symptoms to medical therapy. Patients on antiplatelet and anticoagulant therapies (AAT) usually are recommended to discontinue their medications around the period of endoscopic sinus surgery. The goal of this study is to assess the clinical experience of BSD in CRSsNP patients with concurrent anticoagulant or antiplatelet therapy. A review of prospectively-collected clinical data from October 2012 to March 2017 were used to perform a cohort study of subjects with CRSsNP who met criteria for surgical intervention while on antiplatelet and anticoagulant therapy. Data were collected on demographics, details of the procedures, type of AAT used, pre- and postoperative 22-item Sino-Nasal Outcome Test (SNOT-22) scores, and complications. Thirty-five patients underwent in-office BSD while on antiplatelet and/or anticoagulant therapy. The mean difference in pre- and postoperative SNOT-22 scores of 9.9 (SD 14.4, P < .001) was both statistically significant and exceeded the minimal clinically important difference of 8.9. Absorbable nasal packing was used for persistent bleeding immediately post-procedure in two patients. Intraoperative bleeding was associated with aspirin 325 mg and warfarin. FESS was required for further management of chronic sinusitis in four patients after anticoagulant/antiplatelet therapy could be discontinued. There were no systemic complications. None of the patients experienced significant bleeding events postoperatively after leaving the office. In-office BSD appears to be a safe alternative to endoscopic sinus surgery in select patients who cannot discontinue antiplatelet and anticoagulant therapy. IV.

Submandibular abscess following frenulectomy in a 12-day-old infant

Abstract Frenulectomy is the simple surgical release of tongue-tie (ankyloglossia), which is frequently performed in newborn babies. We present a 12-day-old boy who underwent uncomplicated frenulectomy to alleviate ankyloglossia and lactating problems and subsequently developed a submandibular abscess, a potentially life threatening complication. Surgical incision, drainage and antibiotic therapy successfully resolved the infection. To our knowledge, this is the first report of a submandibular abscess following frenulectomy in a baby. Although severe complications after frenulectomy are very rare, it is important for surgeons to thoroughly select patients for surgery and inform parents about the potential risks associated with frenulectomy.

Loss of SMAD4 Expression Associated with Worse Progression-Free and Overall Survival in Patients with Pancreatic Adenocarcinoma Treated Surgically

The tumor suppressor gene SMAD4 is inactive in roughly half of patients with pancreatic adenocarcinoma. Several studies have linked los23s of SMAD4 with worse oncologic outcomes, while other studies have refuted this association. In this study, we examined the association of SMAD4 loss with oncologic outcomes in a cohort of patients with pancreatic adenocarcinoma treated with resection +/- adjuvant chemo-radiotherapy. Patients with non-metastatic adenocarcinoma of the pancreas s/p radical resection +/- adjuvant chemo-radiotherapy at the University of Pennsylvania were included. SMAD4 status was determined by immunolabeling assessment from the surgical pathology. Multiple assessments of SMAD4 status were obtained for each patient and the maximum, mean, and median value were analyzed. Kaplan-Meier survival analysis and Cox regression analysis was performed to assess the association of SMAD4 status with different oncologic outcomes of interest [(local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and overall survival, (OS)]. PFS was defined as time to first recurrence or death. P<0.05 was considered significant. 66 patients had evaluable SMAD4 tumor status and were included in the analysis. 59 received adjuvant chemo-radiotherapy; 7 received adjuvant chemotherapy alone. Median age was 65 (range 43 – 85). 35 patients were male (53%). Median follow-up was 23.5 months (range 3 – 141 months). 40 of 66 patients had complete loss of SMAD4 (61%). There were no significant differences in baseline demographic, clinical, pathologic, and treatment-related variables between the patients with intact vs. lost SMAD4 (p>0.05). On univariable Cox regression analysis, SMAD4 intact status was marginally associated with improved DMFS [HR 0.74 (95%CI 0.54-1.01), p=0.06) but was not predictive of LRFS [HR 0.96 (95%CI 0.67-1.39), p=0.85]. SMAD4 intact status was associated with significantly improved PFS [HR 0.72 (95%CI 0.54-0.95), p=0.02] and overall survival [HR 0.73 (95%CI 0.55-0.98), p=0.04). Median survival for patients with intact SMAD4 vs. SMAD4 loss was 37 months vs. 21 months (log-rank p=0.08). Results were similar when analyzed using median and mean SMAD4 values. For patients treated with surgical resection +/- adjuvant chemo-radiotherapy, loss of SMAD4 expression correlated with significantly worse progression-free survival and overall survival compared to patients with intact SMAD4. Loss of SMAD4 may help to predict patients at higher risk for recurrence following surgical resection and could help to guide future adjuvant therapy or help select patients for surgery or definitive radiotherapy.

Patient-reported distress and symptoms predict post-esophagectomy outcomes.

e15567 Background: Esophagectomy is accompanied by significant morbidity, mortality and altered quality of life. Understanding the factors responsible for adverse post-operative outcomes is essential for risk stratification in the selection of patients for surgery. Patient-reported measures are important not only as treatment outcome metrics, but also in predicting tolerance to therapy. Postoperative length of stay is a convenient measurement of patient tolerance of surgery. Our study aim was to determine whether preoperative patient-reported measures could add additional predictive power to clinical variables in predicting postoperative length of stay. Methods: A tablet-based symptom screening tool measured Distress, Anxiety (GAD-2), and cancer-related symptoms preoperatively. A generalized linear model predicting postoperative length of stay was constructed using age, gender, insurance status, income, T stage, and sarcopenia (hand-grip strength &lt; 25kg). Patient-reported variables were then evaluated for their ability to predict length of stay in addition to these clinical factors. Factors found not significant (p &gt; 0.05) are indicated N.S. Results: Esophagectomy (n = 58): Median age 62 (IQR 54-70) and 46 men (79%). Adenocarcinoma in 52 (90%). Neoadjuvant chemoradiation administered in 37 (64%). Major complications occurred in 13 (22%). Median postoperative length of stay was 8 days (IQR 6-10). Distress, Pain, Nausea/Vomiting, Trouble Swallowing, and Insurance or Financial Concerns independently predicted postoperative longer length of stay on multivariable analysis, while accounting for preoperative clinical factors. Conclusions: Preoperative cancer patient symptom reporting adds additional information to traditional clinical factors in predicting length of stay post-esophagectomy. Patient-reported measures may identify patients who benefit from interventions for preoperative optimization.[Table: see text]

SAT-075 Introduction of a Single Radiologist Improves the Performance of Adrenal Vein Sampling for Primary Aldosteronism, but Does Not Ameliorate Suboptimal Selection of Patients for Surgery

Context: Adrenal vein sampling (AVS) should be performed in most patients with primary aldosteronism (PA) who want to pursue surgical cure. Objective: We aimed to compare the success rate of AVS at our center after the introduction of a single dedicated radiologist in 2012 to the period before that. We tried also to find out the percentage of patients with proven unilateral PA who ultimately had surgery. Patients and methods: A retrospective diagnostic cross-sectional study conducted at Slovenian national referral center included all patients with PA who underwent AVS after its introduction in 2004 until the end of 2017. AVS was performed sequentially during continuous Synacthen stimulation. When the selectivity index, calculated as the ratio of concentrations of cortisol from an adrenal vein and the infra-adrenal inferior vena cava, was at least 5, AVS was considered successful. Lateralization index, defined as the ratio of the higher over the lower cortisol-corrected aldosterone ratio, of more than 4 indicated unilateral aldosterone excess. The data were analyzed using descriptive statistics, t-test, exact Mann-Whitney test and Fisher's exact test for group comparison, and Cohen's kappa for assessing agreement. The study was approved by the National Medical Ethics Committee. Results: Data from 214 patients were examined (152 men and 62 women; age 32-73, median 57 years; BMI 18-48, median 30 kg/m2). The average number of AVS procedures performed per year increased significantly from 7 in the 2004-2011 period to 30 in the 2012-2017 period (p<0.001). AVS was successful in 85% of the patients; AVS had to be repeated in 11% of the cases; 89% of all AVS procedures were successful. The proportion of patients with successful AVS (91% vs. 66%, p<0.001) and of successful AVS procedures (80% vs. 61%, p=0.007) was significantly higher in the recent period. Adrenal hemorrhage due to vein rupture occurred during two procedures (0.83%), both resolved conservatively. Among the patients with successful AVS, 41% had unilateral disease; among them, only 83% underwent surgery. Main reason for not having surgery was patient’s reluctance (n=8). One patient was diagnosed with liver cirrhosis and was rejected by the surgeon, two patients were lost to follow-up and three patients were still on the waiting list. The proportion of patients with unilateral disease undergoing surgery did not differ significantly between the periods (89% vs. 81%, p=0.718). Conclusions: The introduction of a single, dedicated radiologist in 2012 expanded and improved the AVS performance at our center. A substantial number of patients with proven unilateral PA did not proceed to surgery, pointing to suboptimal selection of candidates for AVS.