Pac i f i c C oa s t S ur g i c a l A s s o c i at i o n
8 0 t h A n n u a l M e e t i n g
Fairmont Hotel ScientificSa n Fr a ncisco, CA FebruaProgramry 13–16, 2009
Jointly Sponsored by American College of Surgeons and Pacific Coast Surgical Association
Pacific Coa s t Sur g ic a l A s s o ciat ion 8 0 t h A nn u a l M ee t ing
Fairmont Hotel ScientificSan Francisco, CA FebruarProgramy 13–16, 2009 Arrangements/ProgramTable Committee ...... of Contents 3 PCSA Officers, Council, and Representatives...... 4 General Information...... 5 Program Information...... 6 Scientific Program...... 7 Industry Support Displays...... 8 Evening Activities...... 9 Optional Activities...... 10–11 General Program Agenda...... 12–14 Scientific Session Agenda...... 15–18 Scientific Papers 1–12...... 19–49 Poster Session 1A–10A...... 51–71 Poster Session 1B–10B...... 73–93 Scientific Papers 13–26(continued) ...... 97–131 Founders...... 132 Past Presidents and Meetings...... 132–134 New Members...... 135–138 In Memoriam...... 140–155 Deceased...... 156–158
Table of Contents 1 Table of Contents
Membership List...... 159–199 Members by Caucus...... 200–207 Members by Location...... 208–217 Constitution...... 218–221 Bylaws...... 222–225 Future Meetings...... 226
2 Table of Contents PresidenArrangementst & Spouse CommitteeOrlo and Carol Clark Arrangements Chairpersons Quan-Yang Duh and Ann Comer Vice-President Quan-Yang Duh Program Committee Chair Fred Weaver arrangements Committee Michael and Gretchen Harrison Neal and Phoebe Olcott William and Gisela Schecter Jerry and Oksana Sydorak Tennis John Roberts Golf Robert Allen
ProgramFred WeaverCommittee Recorder and Chair Orlo Clark President James Holcroft Secretary-Treasurer Jonathan Hiatt Incoming Recorder Robert Sawin Washington/British Columbia/Alaska Caucus Steven Stanten Northern California Caucus John Vetto Oregon/Hawaii Caucus Geoffrey Stiles Southern California Caucus
Arrangements/Program Committee 3 Orlo Clark, President (2009)Council Officers San Francisco, CA James Peck, President-Elect (2010) Portland, OR James Atkinson, President-Elect (2011) Los Angeles, CA Quan-Yang Duh, Vice-President (2009) Torrance, CA Roger Alberty, Historian Portland, OR James W. Holcroft, Secretary-Treasurer (2010) Sacramento, CA Fred A. Weaver, Recorder (2009) Los Angeles, CA Jonathan Hiatt, Recorder-Elect (2015) Los Angeles, CA President, President-Elect, Vice-President, Historian, Secretary-Treasurer,Council Recorder, Recorder-Elect Members Stephen N. Etheredge, Councilor (2009) Northern California Clifford Deveney,Councilor (2011) Oregon/Hawaii Lawrence D. Wagman, Councilor (2012) Southern California Mika Sinanan, Councilor (2013) Washington/British Columbia/Alaska Bruce E. Stabile, Immediate Past President (2008) Southern California Mika N. Sinanan, Seattle, WA, (10/2011) CouncilBoard of Governors, Representatives American College of Surgeons William P. Schecter, San Francisco, CA, (6/30/2010) American Board of Surgery Kenneth Waxman, Santa Barbara, CA, (12/31/2011) Advisory Council for General Surgery, American College of Surgeons
4 Council Officers, Members, Representatives RegistrationGeneral Information Registration is open to all PCSA members and invited guests of PCSA.
Member $590 Retired Member $465 Guest Physician $660 Resident/Fellow $400 Member/Nonmember $250 Accompany Person Resident/Fellow Accompany Person $190
REGISTRATION FEES INCLUDE: Member and Retired Member ff All scientific sessions and panels, President’s Address, Residents’ Forum, and E-Poster Presentations and Reception ff Industry Support Displays ff Welcome and New Members’ Reception and Dinner, and President’s Reception and Banquet ff All continental breakfasts and refreshment breaks ff Monday’s Membership Business Meeting Guest Physician and Resident Fellow ff All scientific sessions and panels, President’s Address, Residents’ Forum, and E-Poster Presentations Reception ff Industry Support Displays ff Welcome and New Members’ Reception and Dinner, and President’s Reception and Banquet ff All continental breakfasts and refreshment breaks Spouse or Guest ff President’s Address ff Welcome and New Members’ Reception and Dinner, and President’s Reception and Banquet ff All Continental Breakfasts and Industry Support Displays
General Information 5
Overall GProgramoal of the Prog Informationram The goal of the program is to furnish an educational program for members of the PCSA. Members are academic and community surgeons from the western part of the United States. Membership is very competitive. Attendees represent the leaders of their medical community. Learning Objectives The objectives are to provide the attendees with up-to-date information regarding clinical practice and research in the field of surgery. Learning Outcomes This meeting will provide high quality, up-to-date information involving those areas covered under general surgery, including vascular surgery, plastic surgery, cardiothoracic surgery, and transplant surgery. Attendees will learn, from leaders in their field, the most recent developments in the field of surgery. After each presentation, time will be provided for questioning of the speakers by the audience in order to clarify specific points of the presentation. Moderators will facilitate discussion and oversee sessions. CME Accreditation The activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American College of Surgeons and the Pacific Coast Surgical Association. The American College of Surgeons is accredited by the ACCME to provide continuing medical education for physicians. CME Credit The American College of Surgeons designates this educational activity for a maximum of 16 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. Disclosure In accordance with ACCME regulations, the American College of Surgeons, as the accredited provider of this activity, must ensure that all individuals who are in a position to control the content of the education activity have disclosed all relevant financial information pertaining to commercial interests. Planning Committee Members and Speakers will be contacted and any potential conflicts of interest will be managed prior to the meeting. Additional disclosure information will be included in the final program book. Disclaimer Attendees voluntarily assume all risks involved in travel to and from the Annual Meeting and in attendance of and participation in the program. PCSA and ACS Association Management Services shall not be liable for any loss, injury, or damage to person or property resulting directly or indirectly from any acts of God, acts of government or other authorities, civil disturbances, acts of terrorism, riots, thefts, or from any other similar causes.
6 Program Information
Scientific PaneScientificl Program The Scientific Panel is a selected group of panelists who will feature a focused scientific topic that is determined by the PCSA Program Committee and chaired by PCSA member experts. Saturday, February 14 1:30–4:00 pm E-Poster Session The e-poster presentations will be held during a wine and cheese reception and presented as a group. Each presenter will give a 3-minute oral presentation of his or her poster followed by a 2-minute question-and-answer session. Poster presentations will include completed research, research in progress, and case reviews. Innovative surgical practices and teachings will also be presented. Saturday, February 14 4:20–6:00 pm President’s Forum This year’s President’s Forum on“ Surgical Research” will feature a panel of experts who will discuss issues facing practicing surgeons. The distinguished list of participants are Dr. Thomas Russell, Executive Director of the American College of Surgeons, Dr. Haile Debas, Executive Director of Global Health Science and Dean Emeritus of the UCSF School of Medicine, Dr. Thomas Krummel, Chair of the Department of Surgery at Stanford, and Dr. Michael Harrison, past Chief of Pediatric Surgery at UCSF. Sunday, February 15 7:30–9:00 am Residents’ Forum The top-scoring resident papers from each caucus will be presented as a group during the scientific session. The presentation of each resident will be judged on clarity, focus, and the scientific relevance to surgical practice. Prizes will be presented at the President’s Banquet. Sunday, February 15 9:00–10:30 am
Scientific Program 7
A commercialIndustry display of scientific Support interest will be available Displays during the Annual Meeting, providing an opportunity to view products and services from various corporations. Continental breakfasts and refreshment breaks will be served in the exhibit area. Please be sure to visit the exhibits daily to express your appreciation and for a chance to win prizes. PCSA would like to thank the following companies for their support of our educational program: Aloka Ultrasound BK Medical Systems Cryolife, Inc. Gore & Associates Olympus-Gyrus ACMI Prime Clinical Systems, Inc. (confirmed as of December 2008)
8 industry Support Displays
Welcome & EveningNew Members’ Activities Reception & Dinner Friday, February 13, 2009 6:30–9:30 pm de Young Museum Please join us in giving a warm welcome to our new members. Gather your family and enjoy a relaxing and memorable evening at the de Young museum. The reception and dinner will take place in the Wilsey Court area. Guests will be able to explore the Concourse Level Galleries. Note: New members and their spouses will be wearing ribbons so they can be easily recognized. President’s Reception & Banquet Sunday, February 15, 2009 President’s Reception: 6:30–7:00 pm President’s Banquet: 7:00–10:00 pm Please join us this evening to honor our President Orlo and his wife, Carol. Cocktails will be served in the Crown Room. The reception will be held in the Crown Room followed by dinner in the beautiful Venetian Room. A fantastic band will entertain and have you dancing the night away! Note: Preferred attire for the President’s Reception and Banquet is black-tie formal. Seating plans will be available at the Registration Desk for you to reserve your table.
Evening Activities 9
Aerobic DanOptionalce Class Activities Saturday, Sunday, and Monday 9:00–10:00 am Free Led by our own Gretchen Harrison, this one-hour low-impact aerobic dance class will help you start your day with energy! Class will be held in the Cirque room. Bottled water and towels will be provided. San Francisco Stairway Tour Saturday, February 14 2:00–3:00 pm Free Our own Gisela Schechter will lead you on a walking tour of San Francisco’s hidden unique stairways. Please wear comfortable walking shoes, and don’t forget your camera! Teatro ZinZanni Saturday, February 14 6:30–10:00 pm $200 per person Set along San Francisco’s historic waterfront, Teatro ZinZanni is a bewitching evening of European Cabaret and Cirque, divas and madmen, and spectacle and sensuality. Join us for live music and a gourmet five-course dinner set in the nightclub of your dreams! Golf Tournament Sunday, February 15, 2009 tee times start at 12:30 pm $190 per person includes green fees, shared cart, a box lunch with soda or bottled water, tees, ball markers, tournament scoring, and a chance to win prizes. The golf tournament will be held at the Presidio Golf Course. This year’s format for the tournament will be a foursome with tee times and scoring. Tee times and foursomes will be posted at the Registration Desk starting on Friday, February 15. Teams: If you want to make up your own team, please include the information with your registration(s). No more than two people with handicaps under 10 on one team. Be sure to list your index/handicap on the registration form. NOTE: Transportation to and from Presidio Golf Course will be the respoinsibility of the player.
10 oPTional Activities Tennis Tournament Sunday, February 15, 2009 tournament starts at 2:00 pm $120 per person includes court fee, tennis pro, afternoon refreshments, and a chance to win a great prize. Join us at the San Francisco Tennis Club, located 10 minutes from the Fairmont Hotel, for a great tennis experience. This round robin tournament will be held from 2:00 to 4:30 pm. Afternoon refreshments will be provided. Note: Transportation to and from the tennis tournament will be the respoinsibility of the player. Babysitting Services The Fairmont San Francisco uses the services of the Bay Area Child-Care Agency, a well-known babysitting company in San Francisco. For information and reservations, please contact the hotel concierge at 415/772-5136. Club One Health Club and Spa Located on the Terrace Level of the Fairmont San Francisco, Club One offers a luxurious, comfortable environment for massages and skin treatments. In addition, the fitness center features state-of-the-art equipment and fitness classes that are designed to provide a daily infusion of energy. For a more structured workout, sign up for a personal training session. For more information or to make an appointment, call 415/834-1010. Open from 5:00 am to 10:00 pm Monday through Friday and 7:00 am to 7:00 pm Saturday and Sunday.
Optional Activities 11 80thGeneral Annual Pacific ProgramC oast Surgical AAgendassociation Meeting Subject to Change Thursday, February 12, 2009 Council Reception 6:00–7:00 pm Crystal Room (Invitation only) Council Dinner 7:00–9:00 pm Crystal Room (Invitation only) Friday, February 13, 2009 Finance Committee 7:00–8:00 am California Room Meeting (Invitation only) Council Breakfast 8:00 am California Room (Invitation only) Council Meeting 8:30 am–3:00 pm California Room (Invitation only) Council Photo 11:55 am–12:05 pm Lobby—Grand Staircase Council Lunch 12:05–1:00 pm California Room (Invitation only) Registration 1:00–6:00 pm Grand Ballroom Foyer Hospitality Desk 1:00–4:00 pm Grand Ballroom Foyer Speaker Ready Room 1:00–6:00 pm Grand Ballroom Lounge Spouse Hospitality Room 11:00 am–5:00 pm Cirque Room New Members’ Private 5:00–6:00 pm Fairmont Suite Reception (Invitation only) Welcome/New 6:30–9:30 pm de Young Museum Members’ Dinner
12 general program agenda Saturday, February 14, 2009 Continental Breakfast 7:00–9:00 am Terrace Room Industry Support Displays 7:00 am–6:00 pm Terrace Room Registration 7:00 am–5:00 pm Grand Ballroom Foyer Hospitality Desk 8:00 am–4:00 pm Grand Ballroom Foyer Speaker Ready Room 7:00 am–5:00 pm Grand Ballroom Lounge Spouse Hospitality Room 7:00 am–5:00 pm Cirque Room President’s Address 8:00–8:45 am Grand Ballroom Introduction of 8:45–9:00 am Grand Ballroom New Members Scientific Session I 9:00–10:20 am Grand Ballroom Morning Break/Industry 10:20–10:40 am Terrace Room Support Displays Scientific Session II 10:40 am–12:00 noon Grand Ballroom Industry Support 12:15–1:30 pm California Room Appreciation Lunch (Invitation only) Lunch at leisure 12:15–1:30 pm Individual on own Scientific Session III 1:30–2:30 pm Grand Ballroom Scientific Session IV 2:30–4:00 pm Grand Ballroom Poster Sessions & Industry 4:20–6:00 pm Terrace Room Support Displays Dinner at leisure
General program agenda 13 Sunday, February 15, 2009 Continental Breakfast 6:45–9:00 am Terrace Room Industry Support Displays 6:45–10:45 am Terrace Room Registration 6:45 am–12:00 noon Grand Ballroom Foyer Speaker Ready Room 6:45 am–12:00 noon Grand Ballroom Lounge Spouse Hospitality Room 6:45 am–5:00 pm Cirque Room President’s Forum 7:30–9:00 am Grand Ballroom Hospitality Desk 9:00 am–12:00 noon Grand Ballroom Foyer Scientific Session V 9:00–10:30 am Grand Ballroom Morning Break/Industry 10:30–10:50 am Terrace Room Support Displays Historical Vignette 10:50–11:10 am Grand Ballroom “Werner Forssman— Experiments on Myself” Scientific Session VI 11:10 am–12:30 pm Grand Ballroom Golf Tournament 12:00 noon–5:30 pm Presidio Golf Course Tennis Tournament 2:30–4:30 pm San Francisco Tennis Club President’s Reception 6:30–7:00 pm Crown Room President’s Banquet 7:00–10:00 pm Venetian Room Monday, February 16, 2009 Continental Breakfast 7:00–9:00 am Grand Ballroom Foyer Registration 7:00 am–12:00 noon Grand Ballroom Foyer Speaker Ready Room 7:00 am–12:00 noon Grand Ballroom Lounge Spouse Hospitality Room 7:00 am–12:00 noon Cirque Room Scientific Session VII 8:00–9:40 am Grand Ballroom Morning Break 9:40–10:00 am Grand Ballroom Foyer Hospitality Desk 10:00 am–12:00 noon Grand Ballroom Foyer Scientific Session VIII 10:00–11:30 am Grand Ballroom Business Meeting 11:30 am–12:00 noon Grand Ballroom Meeting Adjourns 12:00 noon
14 general program agenda 2009 ScientificSaturday, Feb ruSessionary 14, 2009 Agenda 8:00–8:45 am President’s Address “Influence of Endocrine Surgery on General Surgery and Surgical Science” Dr. Orlo Clark 8:45–9:00 am Introduction of New Members 9:00–10:20 am Scientific Session 1 Moderators: Orlo Clark, MD; Jerry Sydorak, MD 1 Are the ADAM and UK Small Aneurysm Trials Still Relevant in the Era of EVAR? 2 Open Abdominal Aortic Aneurysm Repairs in the Endovascular Era 3 Major Blood Vessel Reconstruction During Sarcoma Surgery 10:20–10:40 am Break 10:40 am–12:00 noon Scientific Session 2 Moderators: Quan-Yang Duh, MD; Armando E. Giuliano, MD 4 Results of 259 Central Neck Lymph Node Dissections for Papillary Thyroid Cancer: Is First-Time Operation Safer Than Reoperation? 5 Limited Value of Intraoperative PTH Monitoring in Localized Primary Hyperparathyroidism: A Cost-Utility Analysis 6 Are Additional Localization Studies and Referral Indicated for Patients With Primary Hyperparathyroidism Who Have Negative Sestamibi Scans? Lunch 1:30–2:30 pm Scientific Session 3: Scientific Panel: Esophagus Moderators: Tom R. De Meester, MD; John Hunter, MD 7 Outcomes of Nissen Fundoplication in GERD Patients With Delayed Gastric Emptying 8 Staging Accuracy of Endoscopic Ultrasonography Based on Pathologic Analysis After Minimally Invasive Esophagectomy 9 Progressive Mucosal Injury in Patients With Gastroesophageal Reflux Disease Is Associated With Increasing Peripheral Blood Eosinphil Counts 2:30–4:00 pm Scientific Session 4: Scientific Panel: Breast Moderators: James Goodnight, MD; Laura Esserman, MD 10 Radial Scar: No Longer an Indication for Surgical Excision
Scientific Session Agenda 15 11 Long-term Follow-up in Patients With Breast Cancer Who Have Metastasis in a Sentinel Node: Is Completion Axillary Lymph Node Dissection Required for Regional Control? 12 Underutilization of Axillary Dissection for the Management of Sentinel Node Micrometastases in Breast Cancer 4:45–6:00 pm E-Poster Presentations Session A: Vascular, Trauma, Education, GI Moderator: Geoffrey Stiles, MD 1a 10-Year Retrospective Analysis of Incisional Hernioraphy in Kidney Transplant Patients 2a Improved Survival of Elderly Patients After Renal Transplantation 3a Compartment Syndrome Following Thrombolysis for Acute Lower Extremity Arterial Insufficiency 4a A Review of 2,497 Peripherally Inserted Central Catheters 5a Epidemiology of the Non-Trauma Component of Acute Care Surgery: Analysis of a Clinician-Completed Registry 6a Bringing the Skills Lab Home: An Affordable Web-Cam- Based Box Trainer for Mastering Laparoscopic Skills 7a National Trends and Outcomes for the Surgical Therapy of Ileocolonic Crohn Disease: Recent Use of Laparoscopic Versus Open Approaches 8a Technical Factors Contributing to Recurrence of Incisional Hernia After a Previous Laparoscopic Ventral Hernia Repair 9a Predicting Mortality From Small Bowel Obstruction in Elderly Patients: Development of a Risk Calculator 10a The Diagnosis and Treatment of Pediatric Intussusception Based on Age 4:20–6:00 pm E-Poster Presentations Session B: GI, Oncology, Endocrine Moderator: Steven Stanten, MD 1b The Impact of Co-morbidity in Producing Race-based Outcomes Disparity in Patients With Gastrointestinal Cancers 2b Mitogen Inducible Gene-6 Is a Prognostic Marker for Patients with Colorectal Liver Metastases 3b Aggressive Surgery for Gallbladder Cancer: Is It Justifiable? 4b Is the Use of Epidural Analgesia in Liver Resection Safe? 5b Optimal Management of Patients With Neuroendocrine Tumors: Success of a Multidisciplinary Approach 6b Local and Regional Therapies Influence Overall Survival in Patients With Locally Advanced Breast Cancer 7b Use of Wound Protection System Reduces Postoperative Wound Infection Rate in Open Appendectomy: A Randomized, Prospective Trial
16 sCientific Session Agenda 8b Laparoscopic or Open Exploration Is Effective to Identify and Resect an Unknown Primary Tumor in Patients With Advanced Gastrointestinal Neuroendocrine Tumors 9b Efficacy of Laparoscopic Adrenalectomy for Large Unilateral Pheochromocytomas 10b Two Novel Loci Mapping to Chromosomes 1 and 6 Predispose to Familial Papillary Thyroid Cancer: A Preliminary SNP Array-Based Study Sunday, February 15, 2009 7:30–9:00 am President’s Forum: Research by Surgeons Moderator: Orlo Clark, MD, President, Pacific Coast Surgical Association “American College of Surgeon’s Position on Surgical Research and Support” Thomas Russell, MD, Executive Director, American College of Surgeons “Fetal Surgery and New Frontiers in Surgery” Michael Harrison, MD, UCSF “Why Surgeons Care About Science” Haile T. Debas, MD, UCSF “Training a Next Generation of Surgeon Innovators Like Tom Fogarty” Tom Krummel, MD, Stanford University 9:00–10:30 am Scientific Session 5: Resident’s Forum Moderators: Nancy Ascher, MD; Karen Deveney, MD 13 The Use of Lyophilized Plasma for Resuscitation in a Swine Model of Severe Injury 14 The Incidental Pancreatic Mass: Surgical Decision-Making and Outcomes 15 Early Postoperative Fever and the “Routine” Fever Work-up: Results of a Prospective Study 16 Lymph Node Counts: An Indicator of Quality in Colorectal Cancer Surgery? 10:30–10:50 am Break 10:50–11:10 am Historical Vignette: “Werner Forssman: Experiments on Myself” by Roger Alberty, MD 11:10 am–12:30 pm Scientific Session 6 Moderators: Mark Talamini, MD; Michael Bouvet, MD 17 Combination of Microsatellite Instability and Lymphocytic Infiltrate as a Prognostic Indicator for Adjuvant Therapy in Colon Cancer
Scientific Session Agenda 17 18 Selective Preoperative Biliary Drainage Alters Perioperative Resuscitation but Not Morbidity and Mortality in Patients Undergoing Pancreaticoduodenectomy 19 Decitabine, an Inhibitor of DNA Promoter Methylation, Has an Antineoplastic Effect in Adrenocortical Carcinoma Cells 20 Recurrence Rate and Complications of Open Incisional Hernia Repair at an Academic Tertiary Care Medical Center Monday, February 16, 2009 8:00–9:40 am Scientific Session 7 Moderators: James Peck, MD; David Hoyt, MD 21 Utilization of Routine Pathologic Examination for Specimens Removed From Trauma Patients 22 A Simplified Set of Trauma Triage Criteria Safely Reduces Over-triage: A Prospective Study 23 Creation of Inpatient Capacity for Disaster Management: Lessons Learned From a Major Hospital Relocation 9:40–10:00 am Break 10:00–11:30 am Scientific Session 8 Moderators: Orlo Clark, MD; Quan-Yang Duh, MD 24 Current Patterns in Prehospital Trauma Care in Kampala, Uganda, and the Feasibility and Effectiveness of Training Lay First Responders in Emergency First-aid for Trauma 25 Activated Recombinant Factor VIIa Reduces Repeated Operations for Hemorrhage Following Major Abdominal Surgery 26 Positive Serum Ethanol Level Is Associated with Improved Outcome In Severe Traumatic Brain Injured Patients 11:30–12:00 noon Member’s Business Meeting Conclusion of Meeting
18 sCientific Session Agenda Scientific Session 1 Saturday, February 14, 2009 9:00–10:20 am
Moderators: Orlo Clark, MD Gerald R. Sydorak, MD
SCIENTIFIC SESSION 19 1 Are the ADAM and UK Small Aneurysm Trials Still Relevant in the Era of EVAR?
Caucus: AUTHORS: Southern California Madhukar S. Patel, MD PRESENTER: David A. Brown, MD David A. Brown, MD Samuel E. Wilson, MD PRIMARY DISCUSSANT: INSTITUTION: Corneilus Olcott, MD University of California at Irvine Medical Center, Orange, CA DISCUSSION CLOSED BY: Samuel Eric Wilson, MD
Background: Neither the ADAM nor the UK Small Aneurysm trial showed an advantage for early, open surgical repair of abdominal aortic aneurysms (AAAs) smaller than 5.5 cm in diameter. However, their rigorous exclusion criteria limited surgery to low-risk patients. Hypothesis: We tested the hypothesis that endovascular aneurysm repair (EVAR) has been successfully used for higher-risk patients, thus questioning the utility of the ADAM and UK Small Aneurysm trials exclusion criteria in EVAR patient selection and the recommendation to observe small AAAs. Design: We reviewed 40 consecutives cases of patients with AAA who received EVAR at an urban Veterans Affairs Medical Center. Main Outcome Measures: Electronic medical records were accessed for 6 high-risk conditions that would have excluded patients from the open surgery trials, and 30-day interventional morbidity and mortality data were collected. Results: The mean age of patients who underwent EVAR was 72.7 years (SD, 10.7 years), with a mean AAA diameter of 5.9 cm (SD, 1.6 cm). Of 40 patients, 19 (48%) met at least 1 exclusion criterion for randomization in the small AAA trials, including 5 with symptomatic or ruptured aneurysms, 2 with high-growth-rate aneurysms, 6 with pulmonary disease, and 10 with cardiac disease. Of the patients, 4 (10%) experienced perioperative morbidity, including 1 case of pneumonia, 2 hematomas, and 1 myocardial infarction. One death occurred at home. Comparison with the ADAM/UK outcome data is shown (Table 1, page 21).
20 sCIENTIFIC SESSION Table 1. Comparative outcome data*
ADAM Trial (n UK Trial EVAR Outcome measure = 526) (n = 526) (n = 40) All-cause mortality 14 (2.7) 29 (5.5) 1 (3) Reoperation required 9 (1.7) NR 0 (0) Myocardial infarction 5 (1.0) NR 1 (3) Amputation/stroke/dialysis 6 (1.1) NR 0 (0) Abbreviation: NR, not reported. * Data are given as number (percentage). Conclusion: Patients who had EVAR had a greater prevalence of high-risk conditions than patients included in the ADAM and UK Small Aneurysm trials, but perioperative morbidity and mortality were lower. EVAR has extended aneurysm repair to a higher-risk population with greater safety. New data are needed to establish rational patient selection for small AAAs.
notes:
SCIENTIFIC SESSION 21 2 Open Abdominal Aortic Aneurysm Repairs in the Endovascular Era
AUTHORS: Caucus: Gregory J. Landry, MD Oregon/Hawaii Ignatius Lau PRESENTER: Timothy K. Liem, MD Gregory J. Landry, MD Erica L. Mitchell, MD Gregory L. Moneta, MD PRIMARY DISCUSSANT: INSTITUTION: Fred Weaver, MD Oregon Health and Science DISCUSSION CLOSED BY: University, Portland, OR Gregory L. Moneta, MD
Background: Endovascular abdominal aortic aneurysm (AAA) repair (EVAR) has gradually supplanted open surgical repair in patients who are appropriate anatomic candidates. While fenestrated and branched endografts are forthcoming, patients without suitable anatomy for currently approved devices still require standard open surgical repair. As a result, there is a dramatic shift toward proportionately more complicated AAA repairs as routine AAAs are generally repaired with EVAR. Objectives: We report a contemporary series of open AAA repairs in patients not suitable for EVAR. Hypothesis: With greater complexity of AAA repair, there is a higher risk for complications; however, the procedure can be safely performed by experienced surgeons. Design: Retrospective review of prospectively maintained operative database Setting: University hospital Patients or Participants: Patients undergoing elective open surgical repair of abdominal aortic aneurysms Methods: Consecutive nonruptured open aneurysms from 2000 to 2007 from a prospectively maintained operative database were reviewed. Patient demographics, intraoperative details, and perioperative outcomes were evaluated. Outcomes were stratified based on placement of the proximal aortic cross-clamp.
22 sCIENTIFIC SESSION Results: There were 189 AAAs treated with 103 infrarenal cross-clamps and 86 with suprarenal cross-clamps. Retroperitoneal exposure was used in 77% of suprarenal clamps and 60% of infrarenal clamps (P = .01). Additional grafts to renal and visceral vessels were required in 36% of suprarenal clamps. The overall complication rate was 36% with infrarenal cross-clamps, 61% with suprarenal cross-clamps (P = .001). The 30-day mortality was 3% in the infrarenal group and 8% in the suprarenal group (P = .18). The types of complications are shown inT able 1.
Table 1. Types of complications
Complication Infrarenal (%) Suprarenal (%) Significance Hemorrhage 0 5 .24 Cardiac 13 26 .14 Stroke 0 0 1 Renal failure 0 8 .12 Renal insufficiency 5 26 .01 LE ischemia 0 5 .24 Gastrointestinal 0 10 .06 Pulmonary 10 31 .02 Wound 8 13 .4 The placement of a suprarenal cross-clamp was also associated with higher intraoperative blood loss (2,600 vs 1,800 mL; P = .019), intensive care unit length of stay (4.5 vs 3 days; P = .006), and hospital length of stay (9 vs 7 days; P = .036). Operative time was not different (385 ± 87 vs 400 ± 92 minutes;P =0.5). At discharge, 31% of patients with a suprarenal clamp required temporary nursing home placement vs 25% in the infrarenal clamp group (P, not significant). Conclusion: In the EVAR era, until fenestrated and branched endografts become available, open AAA repairs will become increasingly complex. Suprarenal cross-clamping is associated with increased complications but no difference in mortality or need for nursing home placement. With the disappearance of “easy” open aneurysms, vascular trainees will have to learn AAA repair almost exclusively on complex AAAs. Thus, it is likely that fewer surgeons will be proficient in performing these repairs in the future.
notes:
SCIENTIFIC SESSION 23 3 Major Blood Vessel Reconstruction During Sarcoma Surgery
Caucus: AUTHORS: Northern California Tae Song, MD E. John Harris, MD PRESENTER: David Mohler, MD Tae Song, MD Jeffrey A. Norton, MD PRIMARY DISCUSSANT: INSTITUTION: Jeffrey Ballard, MD Stanford University School DISCUSSION CLOSED BY: of Medicine, Stanford, CA E. John Harris, MD
Background: Surgery is the only curative therapy for sarcomas. Often the ability to completely remove the tumor is affected by its relationship to major blood vessels. This study reviewed our experience with blood vessel reconstruction as an integral part of surgery to remove sarcoma. Objectives: Evaluate immediate outcome of major vessel reconstruction as part of surgery to remove retroperitoneal and extremity sarcomas Hypothesis: Arterial and venous involvement is not a contraindication to sarcoma resection. Design: Retrospective case series Setting: Tertiary, academic hospital Patients or Participants: Patients receiving vascular reconstruction as part of sarcoma resection during the last 5 years Main Outcome Measures: Operative morbidity and mortality, disease-free status, and functional outcome Results: We identified 11 patients with a mean age of 49.3 years (range, 13–80 years). Of the 11 patients, 4 had retroperitoneal sarcomas and 7 had extremity sarcomas. In the study group, 9 had high-grade sarcomas and 2 had low-grade. Each patient underwent computed tomographic angiography. In 10 patients (91%), reconstruction of a major artery was required, and 2 (18%) required reconstruction of 2 arteries. The 12 arteries that were reconstructed included 2 common femoral, 4 iliac, 2 superficial femoral, 1 brachial, 1 popliteal, and 2 aorta, one with implantation of both iliac arteries and the other with implantation of the left renal artery, SMA, and hepatic artery. Major venous reconstruction was required in 5 cases (45%), including 1 external iliac vein, 2 superficial femoral veins, 1 vena cava, and 1 popliteal vein. Postoperative Duplex ultrasound surveillance showed that each vascular reconstruction remained patent, with 3 early arterial graft revisions, 1 for 24 sCIENTIFIC SESSION graft stenosis, 1 for graft compression, and 1 for graft contamination. There were no major complications or deaths; there was 1 amputation. Each patient was disease-free at a mean follow-up of 9 months (range, 1–53 months). Conclusion: Involvement of major vascular structures is not a contraindication to resection of sarcomas, but appropriate planning is necessary to optimize outcome.
notes:
SCIENTIFIC SESSION 25 26 sCIENTIFIC SESSION Scientific Session 2 Saturday, February 14, 2009 10:40 am–12:00 noon
Moderator: Quan-Yang Duh, MD Armando E. Giuliano, MD
SCIENTIFIC SESSION 27 4 Results of 259 Central Neck Lymph Node Dissections for Papillary Thyroid Cancer: Is First-Time Operation Safer Than Reoperation?
AUTHORS: Wen T. Shen, MD Caucus: Lauren Ogawa Northern California Electron Kebebew, MD Quan-Yang Duh MD PRESENTER: Orlo H. Clark, MD Wen T. Shen, MD University of California, San PRIMARY DISCUSSANT: Francisco, Mt. Zion Medical Center, San Francisco, CA Philip I. Haigh, MD DISCUSSION CLOSED BY: INSTITUTION: University of California, Mt. Zion Orlo H. Clark, MD Medical Center, San Francisco, CA
Background: The American Thyroid Association recently changed its management guidelines for papillary thyroid cancer (PTC) to include routine central-neck lymph node dissection (CLND) during thyroidectomy. We currently perform CLND during thyroidectomy only if enlarged central nodes are detected by palpation or ultrasound; we perform CLND in the reoperative setting for recurrence in previously normal-appearing or incompletely resected nodes. Opponents of our approach argue that reoperative CLND has higher complication and recurrence rates than initial CLND. Hypothesis: Reoperative CLND for PTC has higher complication and recurrence rates than initial CLND. Design: Retrospective review Setting: University hospital Patients: All CLNDs for PTC between 1998 and 2007 Interventions: Thyroidectomy, CLND Main Outcome Measures: Complications and recurrence Results: During the study period, 259 CLNDs were performed; 189 were initial operations, and 70 were reoperations. Complication rates are listed in Table 1 (page 29).
28 sCIENTIFIC SESSION Table 1. Complication rates* peration eckhematoma ransient emporary O performed N T hoarseness Permanent recurrentlaryngeal nerveinjury T hypocalcemia Permanent hypocalcemia Parathyroid autotransplant
Initial CLND 2 (1.1) 13 (6.9) 2 (1.1) 59 (31.2) 3 (1.6) 28 (14.8) (n = 189) Reoperative CLND 1 (1) 2 (3) 1 (1) 11 (16)† 0 (0) 0 (0)† (n = 70) * Data are given as number (percentage). †P < .05. Recurrence rates in central (12% vs 18%) and lateral (21% vs 13%) compartments were not significantly different between initial and reoperative CLNDs; survival rates were identical (96%). Conclusions: Reoperative CLND for PTC has a lower rate of temporary hypocalcemia, the same rate of other complications, and the same recurrence rate compared with CLND performed during initial thyroidectomy. A selective approach to CLND during thyroidectomy does not result in increased complications or recurrence if reoperation is required.
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SCIENTIFIC SESSION 29 5 Limited Value of Intraoperative PTH Monitoring in Localized Primary Hyperparathyroidism: A Cost-Utility Analysis
AUTHORS: Lilah F. Morris, MD Caucus: Kyle Zanocco Southern California Philip H.G. Ituarte Kevin Ro PRESENTER: Quan-Yang Duh, MD Lilah F. Morris, MD Cord Sturgeon PRIMARY DISCUSSANT: Michael W. Yeh Michael Bouvet, MD INSTITUTION: DISCUSSION CLOSED BY: David Geffen School of Medicine, University of Quan-Yang Duh, MD California, Los Angeles, CA
Background: Minimally invasive parathyroidectomy (MIP) is the preferred approach to primary hyperparathyroidism (PHPT) when a single adenoma can be localized preoperatively. The added value of intraoperative PTH (IOPTH) monitoring remains debated because its ability to prevent failed parathyroidectomy due to unrecognized multiple gland disease (MGD) must be balanced against assay-related costs. We used a decision tree and cost-analysis model to examine IOPTH monitoring in localized PHPT. Methods: A meta-analysis identified 17 studies involving 4,280 unique patients, permitting estimation of base case costs and probabilities. Sensitivity analyses were performed to evaluate the uncertainty of the assumptions associated with IOPTH monitoring and surgical outcomes. IOPTH cost, MGD rate, and reoperation cost were varied to evaluate potential cost savings from IOPTH. Results: Under base case assumptions, IOPTH monitoring increased the success rate of MIP from 96.3% to 98.8%. The cost of IOPTH varied with operating room (OR) time used, with IOPTH becoming cost saving only when OR time was less than $1.45 per minute. Inaccurate localization and high reoperation cost both independently increased the value of IOPTH monitoring. When OR time was set to $10 per minute, IOPTH became cost saving when the rate of unrecognized MGD exceeded 6.5% or if the cost of reoperation exceeded $19,000 (compared with initial MIP cost of $3,733). Increasing the positive predictive value of IOPTH to 100% did not significantly alter these findings. Conclusions: Institution-specific factors influence the cost- utility of IOPTH. In this model, IOPTH increased the cure rate marginally while incurring significant additional cost.
30 sCIENTIFIC SESSION notes:
SCIENTIFIC SESSION 31 6 Are Additional Localization Studies and Referral Indicated for Patients With Primary Hyperparathyroidism Who Have Negative Sestamibi Scans?
AUTHORS: Caucus: Dina Elaraj, MD Northern California Sheila Lindsay, RN Ileana Sansano, MPH PRESENTER: Quan-Yang Duh, MD Dina Elaraj, MD Orlo H. Clark, MD PRIMARY DISCUSSANT: Electron Kebebew, MD John A. Ryan, Jr., MD INSTITUTION: DISCUSSION CLOSED BY: University of California, San Francisco, CA Electron Kebebew, MD
Background: Preoperative sestamibi scanning is used to determine if a patient with primary hyperparathyroidism (PHPT) is a candidate for a focused/minimally invasive parathyroidectomy (MIP). Some investigators have suggested that additional imaging studies and/or referral for parathyroidectomy are indicated when the sestamibi scan is negative. Hypothesis: Additional imaging studies are useful to select patients who are candidates for MIP, and referral is not indicated when a preoperative sestamibi scan is negative. Design/Subjects: Prospective analysis of 492 patients with PHPT who had parathyroidectomy from May 2005 to May 2007 Main Outcome Measures: Accuracy of imaging studies, pathologic findings, and biochemical cure Results: Of the patients, 96.3% were cured. Of the sestamibi scans, 91.4% were positive and 96.7% were true-positives. Ultrasound was positive in 53.8% of patients with negative sestamibi scans, and 100% were true- positives. Patients with positive vs negative sestamibi scans had a higher rate of single-gland disease (87.1% vs 58.8%) and lower rates of double adenoma (6.3% vs 23.5%) and asymmetric hyperplasia (6.3% vs 17.6%) (P = .0004). There was no significant difference in the rate of ectopic parathyroid glands (10% vs 12%) in patients with negative vs positive sestamibi scans results, but there was a significant difference in cure rate (8% vs 3.3%;P = .0195). Conclusions: Additional imaging with neck ultrasound is helpful for selecting an MIP in most patients with PHPT who have negative sestamibi scans. Referral for parathyroidectomy may be considered for patients with negative sestamibi scans because it is associated with multigland disease and lower cure rates. 32 sCIENTIFIC SESSION notes:
SCIENTIFIC SESSION 33 34 sCIENTIFIC SESSION Scientific Session 3: Scientific Panel: Esophagus Saturday, February 14, 2009 1:30–2:30 pm
Moderators: Tom R. DeMeester, MD John Hunter, MD
SCIENTIFIC SESSION 35 7 Outcomes of Nissen Fundoplication in GERD Patients With Delayed Gastric Emptying
Caucus: AUTHORS: Oregon/Hawaii Yashodhan S. Khajanchee, MD Christy M. Dunst, MD PRESENTER: Lee L. Swanstrom, MD Yashodhan S. Khajanchee, MD INSTITUTION: PRIMARY DISCUSSANT: Legacy Health System, David Easter, MD Minimally Invasive Surgery DISCUSSION CLOSED BY: Program, Portland, OR Lee L. Swanstrom, MD
Hypothesis: Patients referred for antireflux surgery sometimes have concomitant delayed gastric emptying (DGE). It has been suggested that DGE contributes to the development of gastroesophageal reflux disease (GERD) in certain patients and may adversely affect postoperative outcomes. The objective of this study was to investigate the effect of DGE on subjective and objective outcomes of GERD following Nissen fundoplication (NISSEN). Design: Retrospective analysis of prospectively collected data Setting: Tertiary-care teaching hospital Patients: The study included data for 141 consecutive patients considered for NISSEN and who had preoperative radionuclide gastric-emptying studies for suspected DGE. Interventions: Of 141 patients, 63 had DGE (T1/2 > 90 minutes); 47 of 63 having T1/2 > 150 minutes had NISSEN + pyloroplasty. Sixteen in the DGE group (T1/2 < 150 minutes) and all with normal gastric-emptying (NGE group [n = 78]) had NISSEN only. Outcome Measures: Postoperatively, patients with symptom scores of 2 or more and/or abnormal 24-hour pH study results (DeMeester score, >14.7) were considered to have treatment failure. GERD outcomes were compared between the DGE and NGE groups. Finally, outcomes of both groups were compared with a cohort of 418 NISSEN patients without DGE symptoms.
36 sCIENTIFIC SESSION Results: At a mean follow-up of 21 months, there were no differences between the 2 groups in relief of reflux symptoms (DGE group, 54/63 [86%] vs NGE group, 71/78 [91%]; P = .47) and objective control of acid reflux (DGE group, 33/39 [85%] vs NGE group, 41/51 [80%]; P = .78). Dyspeptic symptoms improved in the DGE group (P < .001); the overall incidence was higher than in the NGE group (P = .01). Postoperatively, T1/2 normalized in 88% of patients (15/17). Postoperative objective outcomes were also no different between these groups and NISSEN patients having no DGE symptoms (n = 418). Conclusions: Delayed gastric emptying does not affect outcomes of GERD following NISSEN. The patients have more gas bloat and/or nausea compared with patients with NGE.
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SCIENTIFIC SESSION 37 8 Staging Accuracy of Endoscopic Ultrasonography Based on Pathologic Analysis After Minimally Invasive Esophagectomy
AUTHORS: Caucus: Brian R. Smith, MD Southern California Kevin M. Reavis, MD Ken Chang, MD PRESENTER: John Lee, MD Brian R. Smith, MD Ninh T. Nguyen, MD PRIMARY DISCUSSANT: INSTITUTION: Richard Bold, MD Department of Surgery and DISCUSSION CLOSED BY: Medicine, University of California Irvine Medical Center, Orange, CA Ninh T. Nguyen, MD
Background: Endoscopic ultrasonography (EUS) is a common staging modality used for preoperative evaluation of a tumor’s depth of penetration and nodal status in patients with esophageal cancer. Objective: To evaluate the accuracy and sensitivity of EUS in determining the depth of penetration (T stage) and nodal status (N stage) in patients with esophageal cancer who underwent minimally invasive esophagectomy Setting: University hospital Methods: A retrospective analysis of all patients who underwent preoperative EUS followed by minimally invasive esophagectomy for cancer was performed. The main outcome measure was to compare the results of preoperative EUS with final histologic analyses of the esophageal specimen, examining the accuracy of T and N staging. Results: We identified 83 patients who underwent esophagectomy and had preoperative EUS; 28 patients were excluded because of the use of neoadjuvant therapy or because they had a complete response on pathologic analysis. Therefore, 55 patients were evaluated for accuracy of T and N staging. For T stage, the accuracy of EUS for T1 disease was 69%; for T2 disease, 55%; and for T3 disease, 86%. Overall, EUS was accurate for identification ofT stage in 74% of patients with overstaging in 15% and understaging 11% of patients. Overstaging of EUS occurred mostly for pathologic T1 tumors, and understaging occurred mostly for pathologic T3 tumors. For N stage, the sensitivity for detection of N1 disease was 70% and the specificity was 79%.
38 sCIENTIFIC SESSION Conclusion: Endoscopic ultrasonography is an accurate and sensitive modality for T and N staging in patients with esophageal carcinoma. The accuracy forT stage was highest for T3 tumors with overstaging primarily for T1 tumors and understaging for T3 tumors. Sensitivity for detection of N1 disease is adequate but may improve with the use of EUS-guided fine-needle aspiration.
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SCIENTIFIC SESSION 39 9 Progressive Mucosal Injury in Patients With Gastroesophageal Reflux Disease Is Associated With Increasing Peripheral Blood Eosinophil Counts
AUTHORS: Farzaneh Banki, MD Patrick Flanagan, MS Caucus: Joerg Zehetner, MD Southern California Jeffrey A.H agen, MD PRESENTER: Analisa Armstrong, MS Farzaneh Banki, MD Daniel Oh, MD Steven R. DeMeester, MD PRIMARY DISCUSSANT: John C. Lipham John Hunter, MD Tom R. DeMeester, MD DISCUSSION CLOSED BY: INSTITUTION: Peter Crookes, MD University of Southern California, Los Angeles, CA
Background: Intraepithelial eosinophils are a histologic marker of gastroesophageal reflux disease (GERD).L ittle is known about peripheral blood eosinophil counts in these patients. Hypothesis: The peripheral blood eosinophil count increases with the degree of mucosal injury associated with GERD. Design: Retrospective review Setting: Single institution, tertiary hospital Patients and Methods: There were 215 male and 80 female patients (median age, 57 years; IQR, 46–66 years). Of the 295 patients, 100 had GERD without intestinal metaplasia (IM), 100 had GERD with IM, 40 had dysplasia, and 55 had intramucosal cancer (IMC). Results of complete blood cell counts with differential and serum chemistry studies were compared between these groups using a nonparametric test for trend. Results: Patients with a higher degree of mucosal injury were older (P < .001). There were no differences between white blood cell counts, percentage of neutrophils, and hemoglobin levels between groups. The serum albumin level decreased as the degree of mucosal injury increased (P = .037) but lost significance when controlled for age P( = .534). The percentage eosinophil counts were 2.0 (range, 1.3–2.8) in patients with GERD without IM, 2.5 (range, 1.6–3.7) in GERD with IM, 2.6 (range, 1.7–4.4) in dysplasia, and 2.7 (range, 1.5–4.3) in IMC. This progressive
40 sCIENTIFIC SESSION increase in the percentage eosinophil count was statistically significant P( = .006) and remained significant after controlling for ageP ( = .042). Conclusion: There is a progressive increase in peripheral blood percentage eosinophil count associated with progressive mucosal injury in patients with GERD. This test may be useful as a simple complementary diagnostic tool to assess the progression of disease.
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SCIENTIFIC SESSION 41 42 sCIENTIFIC SESSION Scientific Session 4: Scientific Panel: Breast Saturday, February 14, 2009 2:30–4:00 pm
Moderators: James Goodnight, MD Laura Esserman, MD
SCIENTIFIC SESSION 43 10 Radial Scar: No Longer an Indication for Surgical Excision
AUTHORS: Caucus: Vance Y. Sohn, MD Washington/BC/Alaska Scott R. Steele, MD Marlin W. Causey, MD PRESENTER: Joren B. Keylock, MD Vance Sohn, MD Stephen Groo, MD PRIMARY DISCUSSANT: Tommy A. Brown, MD Kenneth Azarow, MD INSTITUTION: DISCUSSION CLOSED BY: Madigan Army Medical Center, Tacoma, WA Tommy Brown, MD
Background: The clinical significance of radial scar (RS) diagnosed by core needle biopsy (CNB) remains unclear. While follow-up surgical excision is routinely performed, this premise is discordant within modern-era breast imaging and sampling. Objectives: By determining the pathologic concordance rate, we sought to define the indications for surgical intervention for RSs diagnosed on CNB. Design: Retrospective review Methods: Patient demographics, method of diagnosis, and pathology results were analyzed and then compared with literature. Setting: Tertiary level medical center Results: Between January 1994 and December 2007, 38 RSs were diagnosed by CNB. Of the patients, 28 underwent surgical excision, with 27 (96%) having further benign diagnoses. One patient, who was found to have invasive cancer by CNB, was also found to have malignancy by open biopsy. Of the lesions, 14 were diagnosed by 8-gauge, 13 by 11-gauge, and 1 by 14-gauge biopsy needles. Of the 8 studies in literature, 290 lesions were identified. Of 290 lesions, 37 (12.8%) were found to harbor malignancy by surgical biopsy, but all had RS with concomitant atypia or malignancy on CNB. Only 6 (2.1%) of 290 lesions, all biopsied with a 14-gauge needle, were upgraded to a malignant diagnosis. With inclusion of the current study, no pure RS diagnosed by the larger 11- or 8-gauge biopsy needles resulted in upgraded lesions on follow-up surgical biopsy. Conclusion: Based on improved accuracy owing to larger biopsy needles, RS diagnosed by CNB does not mandate surgical excision. Indications for excision include the mammographic diagnosis of RS and specimens associated with atypia that would otherwise require open biopsy.
44 sCIENTIFIC SESSION notes:
SCIENTIFIC SESSION 45 11 Long-term Follow-up in Patients With Breast Cancer Who Have Metastasis in a Sentinel Node: Is Completion Axillary Lymph Node Dissection Required for Regional Control?
AUTHORS: Caucus: S. Yegiyants, MD Southern California P.I. Haigh, MD PRESENTER: L. Romero, MD Sara Yegiyants, MD J.M. Guenther, MD L.A. DiFronzo, MD PRIMARY DISCUSSANT: INSTITUTION: Shelley Hwang, MD Kaiser Permanente, Los Angeles DISCUSSION CLOSED BY: Medical Center, Los Angeles, CA L. Andrew DiFronzo, MD
Background: Axillary lymph node dissection (ALND) for patients with breast cancer who have a positive sentinel lymph node (SLN) provides useful prognostic information and remains the standard of care. However, the utility of completion ALND for regional control in patients with a positive SLN is unclear. Hypothesis: Completion ALND is not required for regional control in patients with metastasis in an SLN. Design: Prospective cohort study Setting: Urban teaching hospital Patients: We studied the data for 50 breast cancer patients who underwent breast-conserving surgery, had an SLN positive for metastasis, and did not undergo completion ALND. Interventions: Breast-conserving surgery with SLN biopsy without completion ALND; standard breast irradiation with no axillary radiation Main Outcome Measures: Locoregional and distant recurrence and survival Results: The mean patient age was 57 years (range, 29–83 years). The mean tumor size was 1.9 cm (range, 0.4–5 cm). The majority of patients had a grade II carcinoma. The mean number of LS Ns removed was 3 (median, 2; range, 1–9). The mean number of positive nodes was 1.3 (median, 1; range, 1–2). Of the patients, 14 (30%) had macrometastases (≥2 mm) and 33 (70%) had micrometastases (17 with cellular metastasis only). The mean duration of follow-up was 67 months (median, 59 months; range 6–128 months). In 1 patient (2%), axillary recurrence and distant metastasis developed, and 1 patient had a local recurrence in the ipsilateral breast.
46 sCIENTIFIC SESSION Conclusion: Patients with SLN metastases who do not undergo ALND have a low incidence of regional recurrence. ALND is not necessary for regional control in patients with micrometastatic disease. Additional studies are necessary to further define which patients can avoid and which patients would benefit from ALND.
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SCIENTIFIC SESSION 47 12 Underutilization of Axillary Dissection for the Management of Sentinel Node Micrometastases in Breast Cancer
Caucus: AUTHORS: Southern California Nabil Wasif, MD Melinda A. Maggard, MD PRESENTER: CliffordY . Ko, MD Nabil Wasif, MD Armando E. Giuliano, MD PRIMARY DISCUSSANT: INSTITUTION: James E. Goodnight, MD John Wayne Cancer Center, DISCUSSION CLOSED BY: Santa Monica, CA Armando E. Giuliano, MD
Background: Current American Society of Clinical Oncology (ASCO) guidelines for the management of sentinel node (SN) micrometastases (MM) in breast cancer recommend axillary dissection (ALND) for all patients. Our aim was to assess nationwide utilization of ALND for SN MM. Methods: The National Cancer Institute’s Surveillance, Epidemiology, and End Results database was queried to identify women who underwent sentinel node biopsy (SNB) for invasive ductal or lobular breast cancer between 1998 and 2004. Patients who had SN MM (N1mic) were the study population. Results: Of 5,531 patients with SN MM, 2,331 (42.1%) had no further nodal surgery and 3,200 (57.9%) underwent ALND. In the latter group, histopathologic examination of non-SNs upstaged 20.4% of cases to N1, 3.1% to N2, and 0.1% to N3 disease. The overall incidence of SN MM increased from 2.5% in 1998 to 17.7% in 2005. Multivariate analysis using logistic regression showed that ALND was more common in patients younger than 50 years (odds ratio [OR], 1.5; P < .0001), with high-grade tumors (OR, 1.36; P < .0001), ductal histologic features (OR, 1.2; P = .03), and tumor size of more than 2 cm (OR, 1.2; P < .01). Conclusion: Only about 58% of patients with SN MM from breast cancer are treated according to ASCO guidelines. Nodal staging based only on SNB may underestimate the extent of nodal disease in 23.6% of cases. Better education of physicians and patients is needed to standardize surgical management of SN MM and optimize risk stratification.
48 sCIENTIFIC SESSION notes:
SCIENTIFIC SESSION 49 50 sCIENTIFIC SESSION E-Poster Presentations Session A: Vascular, Trauma, Education, GI Saturday, February 14, 2009 4:45–6:00 pm
Moderator: Geoffrey Stiles, MD
SCIENTIFIC SESSION 51 1A 10-Year Retrospective Analysis of Incisional Herniorrhaphy in Kidney Transplant Patients
AUTHORS: INSTITUTION: Edward I. Chang University of California, Michael G. Galvez San Francisco, CA Benjamin E. Padilla Christopher E. Freise PRESENTED BY: William Y. Hoffman Edward I. Chang, MD
Background: While rejection has decreased following kidney transplantation, certain immunosuppressants are associated with increased infection and impaired wound healing. This study aimed to identify specific risk factors responsible for postherniorrhaphy complications in this complex patient population. Hypothesis: Repair of incisional hernias in kidney transplant recipients is compromised owing to immunosuppression. Design: Retrospective review Setting: University tertiary care institution Patients: Our study included 42 kidney or kidney/pancreas recipients who underwent incisional herniorrhaphy. Interventions: Herniorrhaphy Main Outcome Measures: Postoperative complications and recurrence Results: Forty-two patients (average age, 49.6 years) underwent incisional herniorrhaphy (average size, 99.9 cm2) following kidney transplants (12 SPK, 26 CRT, and 4 LRRT) from 1995 to 2005. Hernia repairs, using a variety of techniques, were performed on average 36.4 months following the transplant. Diabetes was the most common cause of ESRD (38.1%), followed by PCKD (14.3%), FSGS (7.1%), hypertension (4.8%), Alport syndrome (4.8%), and Berger disease (4.8%), and, less commonly, lupus, Buerger disease, and glomerulonephritis. Three patients required reoperation for infected mesh, and 4 patients required antibiotics for cellulitis. In 11 patients (26%), a recurrence developed, with one patient having a recurrence 5 times and another having a recurrence twice. Age, sex, comorbidities, smoking, method of repair, and perioperative antibiotics did not affect outcomes. Only sirolimus was found to be a significant independent risk factor for wound infections (P = .02) but not for recurrences.
52 POSTER SESSION Conclusions: To our knowledge, this is the largest series of incisional herniorrhaphies performed in post–kidney transplant patients. Aside from sirolimus, our study did not confirm prior correlations between postoperative complications and steroids, diabetes, smoking, and other risk factors.
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POSTER SESSION 53 2A Improved Survival of Elderly Patients After Renal Transplantation
AUTHORS: INSTITUTION: Richard V. Perez, MD University of California, Davis Christoph Troppmann, MD Medical Center, Sacramento, CA John McVicar, MD Michael F. Daily, MD PRESENTED BY: Angelo de Mattos, MD, MPH Richard V. Perez, MD
Background: Elderly patients with renal disease have high mortality rates and are increasingly being referred for transplantation. The potential impact of recent improvements in organ preservation and immunosuppression in elderly patients has not been well studied. Design: Historical cohort study Setting: Academic medical center Patients: 799 renal transplant recipients, 1997–2008 Methods: Kaplan-Meier patient survival curves after transplantation were compared among elderly (>65 years), middle-aged (50–64 years), and young (<50 years) patients. Survival was also examined during 2 eras, 1997–2002 and 2003–2008. Among other changes, the latter era was associated with institution of pulsatile perfusion organ preservation and steroid-free immunosuppression. Multivariate analysis was performed to identify factors associated with improved survival. Results: Of 799 total transplants, 102 were in elderly patients. Survival of elderly patients after transplantation was worse compared with younger patients (P < .001) during the first era. Overall patient survival improved during the second era but was most significant in elderly patients (respective 1-, 2-, and 3-year survival, 90%, 86%, and 65% vs 97%, 97%, and 95%, first vs second era, respectively; P < .018). Survival of elderly patients was equivalent to that of younger patients during the second era. Multivariate analysis identified second-era transplantation as one predictor of improved survival (P < .002). Conclusion: Renal transplantation in elderly patients can be performed with excellent survival. Factors contributing to recent improvement in outcomes need further investigation.
54 POSTER SESSION notes:
POSTER SESSION 55 3A Compartment Syndrome Following Thrombolysis for Acute Lower Extremity Arterial Insufficiency
INSTITUTION: AUTHORS: Vascular Institute of the Kaj Johansen, MD, PhD Northwest, Seattle, WA Sanjiv Parikh, MD PRESENTED BY: Kaj Johansen, MD
Background: Certain patients undergoing catheter-directed thrombolysis for native arterial thrombosis or embolism or bypass graft occlusion developed acute compartment syndrome (CS). This complication has not previously been widely reported. Objectives: Assess incidence of and risk factors for development of CS following thrombolysis for acute lower extremity arterial insufficiency Design: Retrospective review of a consecutive case series Setting: Tertiary vascular referral center Patients and Methods: Subjects undergoing lower extremity thrombolysis for acute arterial insufficiency during the 1995–2008 period were identified. The records of patients in whom CS developed in association with such therapy were investigated in detail regarding duration and degree of prethrombolysis ischemia and duration and outcome of thrombolytic therapy. Signs and symptoms of CS were noted for each patient, and subsequent surgical outcomes were recorded. Results: During this 13-year period, approximately 325 patients underwent lower extremity thrombolysis. Among 95 patients with symptoms and/ or signs of acute arterial insufficiency, acute CS developed in 12 (3.7% of all thrombolysis patients; 13% of patients with acute ischemia and referred for thrombolysis), and they underwent emergency 4-compartment fasciotomy. CS in the first 5 patients in this series was recognized late: each patient had far-advanced myonecrosis at the time of fasciotomy and required above- knee (4) or through-knee (1) amputation. A surveillance protocol was then established for all patients undergoing catheter-directed thrombolysis for acute lower extremity ischemia: since that time, no further major amputations (but 2 cases of extensive calf muscle debridement) have been required in this patient setting. Patients at high risk for thrombolysis-associated CS included patients with prolonged preintervention arterial insufficiency and symptoms and signs of far-advanced ischemia (loss of sensation and motor function).
56 POSTER SESSION Conclusion: Just as for patients undergoing open surgical revascularization to treat acute arterial insufficiency, in patients undergoing catheter-directed thrombolysis, the pathophysiologic consequences of ischemia-reperfusion injury that may result in compartmental hypertension may develop. Early recognition of thrombolysis-associated CS can be limb-saving.
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POSTER SESSION 57 4A A Review of 2,497 Peripherally Inserted Central Catheters
INSTITUTION: AUTHORS: Legacy Good Samaritan Hospital Mary L. Sorensen, MD and Medical Center, Portland, OR Earl Schuman, MD PRESENTED BY: Mary L. Sorensen, MD
Objectives: To understand outcomes of peripherally inserted central catheters (PICCs) placed at our institutions Design and setting: A retrospective database review of PICCs placed in 5 affiliated community-based hospitals in a single metropolitan area was conducted. Patients: From January 1994 through December 2006, 13,490 PICCs were placed. A subset of 2,497 patients was chosen for this study because of the completeness of their data. Methods and Main Outcome Measures: Range, mean, median, and SD were calculated for each catheter disposition and complication. Results: Catheter disposition was as follows: 153 (6.1%) fell out or were removed by the patient, 260 patients (10.4%) went home with the line in place, 65 patients (2.6%) died with the line in place, 486 (19.5%) were removed after completion of treatment, 1,480 (59.3%) were removed for complications, and the disposition of 53 (2.1%) was unknown. Reported complications included catheter bacteremia in 96 (3.8%), a clotted sheath in 215 (8.6%), central venous thrombosis in 35 (1.4%), difficulty with flushing or aspiration in 629 (25.2%), exit site infection in 10 (0.4%), phlebitis in 170 (6.8%), suspected infection in 371 (14.9%), and need for TPA bolus in 597 (23.9%). Conclusions: PICCs are useful and relatively safe. However, the high rate of complications should give us pause when selecting this device. This study helps to define complications that should be considered when making decisions about venous access and may help health care providers formulate practice guidelines.
58 POSTER SESSION notes:
POSTER SESSION 59 5A Epidemiology of the Nontrauma Component of Acute Care Surgery: Analysis of a Clinician-Completed Registry
AUTHORS: A.L. Speer INSTITUTION: J. Portillo University of Southern T. Clarke California, Keck School of A. Moazzez Medicine, Los Angeles, CA H.J. Sohn PRESENTED BY: N. Katkhouda Allison L. Speer, MD R.J. Mason
Background: Acute care surgery is an evolving discipline necessitated by declining availability of surgeons who will provide emergency care secondary to an increase in surgical subspecialists, limited financing of health care, decreased reimbursement, and lifestyle choices. Objectives: To identify the demographics and spectrum of pathology in patients with surgical emergencies and the resources necessary for the implementation of an acute care surgery model Design: Analysis of clinician-completed patient registry Setting: Large, urban, academic medical center Patients: Series of more than 5,000 consecutive emergency surgical consultations (January 2005 to the present) Methods: Retrospective review. Diagnoses were categorized into 5 groups (Table 1, page 61). Main Outcome Measures: Patient demographics, diagnosis, and prevalence of emergency surgeries Results: The median age was 41 years (range, 0-97 years), with 80% of patients between 20 and 59 years. Sex distribution was equal (49% male). The majority of patients wereH ispanic. A significant differenceP ( < .001) was noted in the prevalence of each of the 5 disease categories by race.
60 POSTER SESSION Table 1. Percentages of disease category by race
Hispanic (n = 10,540 Black (n = White (n = Asian (n = Diagnosis [68%]) 1,018 [7%]) 987 [6%]) 666 [4%]) Infectious-related 41 38 33 38 Gallstone-related 38 15 18 27 Hernia-related 9 17 15 7 Cancer-related 2 4 3 7 Other 10 26 31 21 Of the consultations, 37% resulted in an operative procedure, 10% needed further subspecialty intervention, and 14% did not require admission. Conclusion: Patients with nontrauma surgical emergencies are young, with a significantly wide range of pathology based on race. Only 37% required emergency surgery. Resources should be allocated to maximize the ability to treat infectious and gallstone-related diseases.
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POSTER SESSION 61 6A Bringing the Skills Lab Home: An Affordable Web-Cam-Based Box Trainer for Mastering Laparoscopic Skills
AUTHORS: S. Kobayashi INSTITUTION: R. Jamshidi University of California, P. O’Sullivan San Francisco, CA B. Palmer S. Hirose PRESENTED BY: L. Stewart Sow Kobayashi, BS E. Kim
Background: Teaching laparoscopic skills presents logistical challenges owing to limited access to training equipment. Laparoscopic simulators are expensive and not portable; therefore, trainees can practice only at skills centers where these simulators are housed. Objectives: Demonstrate that an inexpensive laparoscopic box trainer for home use is feasible and valid Participants: Novice junior surgical residents (n = 21) and expert senior residents and attending physicians (n = 5) Methods: Subjects used laparoscopic box trainers made of a plastic storage box, Web cam, and disposable instruments to complete the 5 tasks of The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS): pegboard transfer, pattern cutting, suture loop placement, and extracorporeal and intracorporeal suturing. The groups were compared witht tests. Experts provided subjective comments about the system. Feasibility was assessed by their feedback. Validity was supported if the scores from the box trainer distinguished experts and novices on the well-established MISTELS. Results: The cost of the trainer was $85. Expert surgeons’ feedback indicated that the box trainer was a realistic simulator, and all agreed its use would help develop technical skills. Expert surgeons scored significantly higher than the novices on 4 of the 5 tasks and in the total score (Table 1, page 63). Conclusion: This affordable laparoscopic trainer demonstrated feasibility and validity. With the ongoing efforts to incorporate simulation in technical skills training, portable systems such as this one will be essential. The ability to practice at home allows for flexibility and maximizes efficiency of training.
62 POSTER SESSION Table 1. Scores on the MISTELS*
Intracor- Extra- poreal Peg Pattern Suture corpore- Transfer† Cut† Loop† al Knot† Knot† Total‡ Novice 28 (± 27) 9 (± 14) 59 (± 27) 32 (± 30) 20 (± 23) 144 (n = 21) (± 84) Expert 71 (± 32) 68 (± 25) 79 (± 20) 85 (± 15) 80 (± 18) 383 (± 56) (n = 5) P .004 < .001 .14 < .001 < .001 < .001 * Data are given as mean (SD). † Maximum score, 100 points per task. ‡Maximum total score, 500 points.
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POSTER SESSION 63 7A National Trends and Outcomes for the Surgical Therapy of Ileocolonic Crohn Disease: Recent Use of Laparoscopic Versus Open Approaches
INSTITUTION: AUTHORS: Madigan Army Medical Kelly Lesperance, MD Center, Tacoma, WA Matthew J. Martin, MD, FACS Scott R. Steele, MD, FACS PRESENTED BY: Kelly Lesperance, MD
Objectives: Despite inherent challenges, laparoscopy for Crohn disease (CD) has demonstrated benefits in several small series and clearly has an evolving role. We sought to compare outcome data and identify predictors of undergoing a laparoscopic versus an open approach. Methods: All admissions with a diagnosis of CD requiring bowel resection were selected from the 2005–2006 Nationwide Inpatient Sample (NIS) database. Regression analyses were used to compare outcome measures and predictors of surgical approach with similar NIS data for the 2000–2004 period. Results: We identified 289,737 admissions for CD from the 2005–2006 data set and compared these with 396,911 admissions from the 2000–2004 data set. Although fewer patients required surgical treatment compared with the 2000– 2004 population (6% vs 12%), a higher percentage was treated laparoscopically (8% vs 6%) (both P < .01). Univariate analysis revealed similar demographics and outcomes measures for the 2 periods. Compared with the open surgical approach, laparoscopic resection was associated with fewer complications (9% vs 18%), shorter length of stay (7 vs 10 days), and lower mortality (0.5% vs 0.9%) (all P < .01). Open surgery was used more often when ostomies were required (14% vs 10%; P < .001). Small bowel resection was associated with open surgical resection (odds ratio [OR], 4.2; P < .01). Laparoscopy was independently predictive of fewer complications (OR, 0.5; P = .04). Sex, ethnic category, insurance status, and hospital type did not predict surgical approach (P < .05). Conclusion: Laparoscopic resection is associated with excellent short-term outcomes compared to open surgery. Recent trends indicate a decrease in surgical management of Crohns disease.
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POSTER SESSION 65 8A Technical Factors Contributing to Recurrence of Incisional Hernia After a Previous Laparoscopic Ventral Hernia Repair
AUTHORS: INSTITUTION: John Maa, MD, FACS University of California, David Chang, MD San Francisco, CA Khashayar Mohebali, MD PRESENTED BY: David Young, MD, FACS John Maa, MD, FACS
Introduction: Laparoscopic ventral hernia repair (LVHR) decreases postoperative pain and shortens length of hospital stay. However LVHR is associated with a recurrence rate of approximately 5%. Objectives: To characterize the factors contributing to recurrent hernia and need for mesh removal after previousL VHR Methods: We reviewed the records of patients referred for abdominal wall reconstruction at our institution between July 1, 2005, and July 1, 2008, with a recurrent hernia after previousL VHR. Setting: Retrospective case series at a university hospital Patients: We identified 15 patients who required open abdominal wall reconstruction after a previousL VHR. Main outcome measures: Technical factors contributing to the need for reoperation were categorized as a result of the following: (1) use of tacking device only, (2) use of suture alone, (3) fracture or retraction of the mesh, or (4) implantation of prosthetic material with risk of an enterocutaneous fistula. Results: Of the reoperations, 40% resulted from the isolated use of a tacking device, 13% from the use of suture alone, 33% from mesh retraction, and 13% from unsuitable mesh implantation. Of the patients, 73% reported persistent pain at the site of tacking. Mesh failure manifested as gastric outlet obstruction and chronic abdominal pain in 13%. Conclusions: The use of a tacking device alone and mesh retraction are the primary reasons for hernia recurrence afterL VHR. This finding highlights the importance of transabdominal suturing and adequate overlap to secure the mesh. Special attention with obese patients and larger hernia defects can minimize the need for reoperation.
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POSTER SESSION 67 9A Predicting Mortality From Small Bowel Obstruction in Elderly Patients: Development of a Risk Calculator
AUTHORS: Sierra R. Matula, MD Marcia McGory, MD, MSHS INSTITUTION: Evangelos Sekeris, PhD University of California, Nova Foster, MD, FACS Los Angeles, CA David Zingmond, MD, PhD Melinda Maggard- PRESENTED BY: Gibbons, MD, MSHS Sierra R. Matula, MD CliffordY . Ko, MD, MS, MSHS, FACS
Background: The number of elderly patients is increasing substantially. Our work has shown that small bowel obstructions (SBOs) in elderly patients have mortality rates of up to 14% in the hospital and 42% at 1 year. With such high rates, providers and patients may benefit from an ability to predict outcomes for elderly patients with SBO. Objectives: Develop a “risk calculator” for predicting mortality for elderly patients with SBO. Design: Population-based data analysis Methods: By using the California Inpatient File, we identified patients admitted with SBO. Demographic and clinical data were assessed; the probability of death in 30 days and at 1 year was determined by using logistic analysis. The variables of greatest significance were included in the prediction model. Accuracy of the model was tested using split and random subsample validation. Main Outcome Measures: 30- and 365-day mortality Results: In this cohort of 32,583 patients, 55% were 65 years or older and 35% were 75 years or older. The risk calculator to predict mortality was developed using 6 variables: age, congestive heart failure (CHF), pulmonary disease, hepatic dysfunction, renal dysfunction, and cancer. The test characteristics are high (negative predictive value, 82%; positive predictive value, 59%; C statistic. 79%; and area under the receiver operating characteristic curve, 0.81). The calculation for mortality risk is as follows:
68 POSTER SESSION Mortality risk = [(2.33*CHF)(2.11*pulmonary)(3.27*liver) (4.05*renal)(4.95*cancer)(1.03 age)(0.88*female)] ______(1+[(2.33*CHF)(2.11*pulmonary)(3.27*liver) (4.05*renal)(4.95*cancer)(1.03 age)(0.88*female)]) Age in years Conclusion: By using 6 clinical variables, a specific risk assessment may be performed with our outcomes calculator. Use of this calculator in provider-patient discussions may help in better informing clinical decision making for elderly patients with SBO.
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POSTER SESSION 69 10A The Diagnosis and Treatment of Pediatric Intussusception Based on Age
AUTHORS: INSTITUTION: Shant Shekherdemian, MD Kaiser Permanente, Los Angeles Steven L. Lee, MD Medical Center, Los Angeles, CA Roman M. Sydorak, MD PRESENTED BY: Harry Applebaum, MD Shant Shekherdemian, MD
Objectives: To compare the differences in diagnosis and treatment of pediatric intussusception based on age in general hospitals Design: Retrospective study Setting: 11 medical centers in southern California Patients or Participants: 188 patients treated for intussusception Methods: Patients were divided into groups based upon age: group A consisted of patients younger than 6 months, group B of patients 6 months to 4 years, and group C of patients older than 4 years. Diagnostic modality, operative reports, and hospital records were reviewed for each group. Statistical analysis was performed using analysis of variance and post hoc chi-square testing. Main Outcome Measures: Nonoperative reduction, operative intervention, and hospital stay Results: Median age was 9.9 months (range, 57 days–6.7 years), and the male-female ratio was 2.4:1. Table 1 (page 71) summarizes outcomes by age.
70 POSTER SESSION Table 1. Number (percentage) of outcomes and mean ± SD hospital stay by age
Group A, Group B, Group C, < 6 mo 6 mo–4 y >4 y Total (n = 37) (n = 126) (n = 25) (n = 188) Contrast enema*† 35 (95) 111 (88.1) 5 (20) 151 (80.3) Reduced by contrast enema 11 (31) 54 (48.6) 4 (80) 69 (45.7) Immediate surgery*† 0 (0) 2 (1.6) 4 (16) 6 (3.2) Operation†‡# 29 (78) 72 (57.1) 21 (84) 122 (64.9) Bowel resection 15 (52) 47 (65) 9 (43) 71 (58.2) Hospital stay (d) 4.2 ± 2.2 3.7 ± 2.2 5.2 ± 2.1 4.1 ± 2.2 *P < .05, group A vs group C. †P < .05, group B vs group C. ‡P <.05, group A vs group B. Conclusion: Contrast enema reduction of intussusception is moderately successful in general hospitals. The lowest reduction rate in children occurred in patients younger than 6 months, and the diagnosis of intussusception in older children was rarely made by contrast enema. Overall, there was a high operative rate, particularly at the extremes of ages.
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POSTER SESSION 71 72 POSTER SESSION E-Poster Presentations Session B: GI, Oncology, Endocrine Saturday, February 14, 2009 4:20–6:00 pm
Moderator: Steven Stanten, MD
SCIENTIFIC SESSION 73 1B The Impact of Comorbidity in Producing Race-based Outcomes Disparity in Patients With Gastrointestinal Cancers
INSTITUTION: AUTHORS: John Wayne Cancer Institute, V. Ahuja, MD Santa Monica, CA E. Cornwell, MD, FACS PRESENTED BY: D. Chang, PhD, MBA Vanita Ahuja, MD, MPH, David Chang, PhD, MBA
Background: There is a significant difference in the survival rates between black and white patients with gastrointestinal (GI) cancers. The reasons for this difference have not been explained. One cause for this disparity may be the role of comorbidity. Objective: Evaluate whether black compared with white patients with GI cancer are more likely to die of their comorbid conditions. Data Source: Surveillance, Epidemiology, and End Results database (1973–2003) Patients: 14,352 black patients (11%) and 100,129 white patients (78%) diagnosed with GI cancers (liver, intrahepatic bile duct, pancreas, and stomach). Methods: Unadjusted analysis, and multivariate regression with subset analysis Results: Blacks are more likely to die of comorbid conditions than whites (10% vs 8%; P = .001). The disparity is seen starting from 6 months of diagnosis and is the worst at 48 months, when about 22% of black patients died of the comorbid condition (Figure 1, page 75). After adjusting for age, sex, cancer stage, and surgery, blacks with GI cancer had a 22% greater chance (odds ratio, 1.22; P < .001) of dying of comorbid conditions compared with whites. The major cause at any time point was heart disease (>60%), while chronic disease and infection contributed about 25%. There is a trend of increasing racial disparity in terms of dying of comorbid conditions during the last decades, with the odds ratio for blacks vs whites increasing from 1.27 (P = .009; 1985–1994) to 1.41 (P < .0001; 1995–2003).
74 POSTER SESSION Figure 1. Proportion of deaths due to comorbid conditions in each period (by cohort)
Conclusions: More black than white patients with GI cancers die of comorbid conditions. Improved access to primary care physicians and control of heart and chronic diseases may improve life expectancy and reduce the disparity in GI cancer outcomes.
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POSTER SESSION 75 2B Mitogen Inducible Gene-6 Is a Prognostic Marker for Patients With Colorectal Liver Metastases
AUTHORS: Robert S. Warren INSTITUTION: David B. Donner University of California, Marlene Zuraek San Francisco, CA Mary Matli Emily K. Bergsland PRESENTED BY: Eric K. Nakakura Robert S. Warren, MD Dan T. Ruan
Background: Prognostic schemes that rely on clinical variables to predict outcome after resection of colorectal metastases remain imperfect. Hypothesis: We hypothesized that molecular markers can improve the accuracy of prognostic schemes. Methods: We screened the transcriptome of matched colorectal liver metastases (CRMs) and primary tumors from 42 patients with unresected CRM to identify differentially expressed genes. Among the differentially expressed genes, we looked for associations between expression and time to disease progression or overall survival. To validate associations, messenger RNA (mRNA) levels of the candidate genes were assayed by quantitative polymerase chain reaction (PCR) from CRMs in 56 additional patients who underwent hepatectomy. Results: Seven candidate genes were selected for validation based on their differential expression between metastases and primary tumors and a correlation between expression and surgical outcome: lumican; tissue inhibitor metalloproteinase 1; basic helix-loop-helix domain containing class B2; fibronectin; transmembrane 4 superfamily member 1; mitogen inducible gene-6 (Mig-6); and serpine 2. In the validation group, Mig-6 expression was independently predictive of poor survival after hepatectomy. Because only Mig-6 was associated with outcome in multivariate analysis, quantitative PCR of Mig-6 mRNA was performed on 25 additional hepatectomy patients to determine if Mig-6 expression could substratify patients beyond the clinical risk score. Patients within defined clinical risk score categories were effectively substratified into distinct groups by relative Mig-6 expression. Conclusion: Mig-6 expression is inversely associated with survival after hepatectomy and may be used to improve traditional prognostic schemes that rely on clinicopathologic data.
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POSTER SESSION 77 3B Aggressive Surgery for Gallbladder Cancer: Is it Justifiable?
INSTITUTION: AUTHORS: Oregon Health and Science D. Christante University, Portland, OR K.M. Hardiman B.C. Sheppard PRESENTED BY: Dara Christante, MD
Background: Justifying aggressive resections for gallbladder cancer can become difficult when surgical risks are weighed against a perceived meager survival benefit. Objectives: To assist with evidence-based decision making for the surgical management of gallbladder cancer, the experience with gallbladder cancer at a tertiary cancer was reviewed. Design: Retrospective review Patients: 45 patients diagnosed with gallbladder cancer between 1995 and 2008 Methods: Data regarding patient factors, method of diagnosis, tumor characteristics, and chemoradiation and surgical treatments were collected and compared by using appropriate statistical tests. Disease-specific survival rates were calculated by using the Kaplan- Meier method and compared by using log-rank analysis. Primary outcome: Surgical factors affecting disease-specific survival Results: Incidental diagnosis during cholecystectomy (25 patients) was significantly associated with early disease and complete resection compared with preoperative diagnosis (20 patients). Abdominal exploration after diagnosis, but before radical resection, altered surgical treatment in 41% of patients. The 1-year survival rate following complete resection was 88% and was 76% with microscopically positive margins only, 42% for resection with persistent macroscopic disease, and 36% for nonsurgical management (P < .001). The presence of microscopic versus macroscopic margins after resection was associated with a survival benefit P( = .002), even with node-positive disease (P = .002).
78 POSTER SESSION Conclusions: In the absence of metastatic disease, aggressive hepatobiliary resection of gallbladder cancer that achieves macroscopically negative margins may be justified by a significant survival benefit. The presence of regional node disease does not preclude aggressive resection. Despite recent cholecystectomy and/or preoperative evaluation, abdominal exploration before attempted radical resection is crucial for the identification of unresectable disease.
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POSTER SESSION 79 4B Is the Use of Epidural Analgesia in Liver Resection Safe?
INSTITUTION: AUTHORS: Virginia Mason Medical Michal Hubka, MD Center, Seattle, WA Daniel Warren, MD Thomas Biehl, MD PRESENTED BY: Michal Hubka, MD
Background: Epidural analgesia is a commonly applied method of perioperative pain management in abdominal surgery. Its efficacy in liver resection is poorly studied, and its safety has been questioned. This study reviewed clinical outcomes of epidural analgesia in liver surgery at our institution. Methods: Medical records of 94 consecutive patients who underwent a liver resection were retrospectively reviewed. From November 2004 to August 2008, all patients had an epidural catheter placed preoperatively. A nonfunctioning epidural was defined as the need to add intravenous patient-controlled analgesia (PCA). Results: The 94 patients who underwent liver resection all had preoperative epidural catheter placement. Of the patients, 55 had a functioning epidural, which was associated with decreased length of hospital (5.6 vs 6.9 days; P < .01) and intensive care unit (0.2 vs 0.6 days; P < .01) stays. Average pain scores were lower in the functioning epidural group (2.3 vs 3.1; P < .01). The incidence of epidural-related complications in the functioning group was 2% (urinary retention) versus 5% (pneumonia and pulmonary embolism) in the nonfunctioning group. Despite elevated postoperative international normalized ratio (average, 1.4), there were no epidural hematomas. In 39 patients, a nonfunctioning epidural required the addition of a PCA. These patients were younger (54 vs 60 years; P = .01), had a higher body mass index (BMI; 28 vs 26 kg/m2; P = 03), and had higher use of preoperative narcotics (20% vs 3%). Conclusions: Perioperative epidural analgesia in liver surgery is safe and efficacious and results in decreased length of stay. Preoperative use of narcotics, age, and BMI seem to have a role in predicting functionality of epidural analgesia.
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POSTER SESSION 81 5B Optimal Management of Patients With Neuroendocrine Tumors: Success of a Multidisciplinary Approach
AUTHORS: INSTITUTION: N.N. Nissen Cedars-Sinai Medical A.S. Kim, E.M. Wolin Center, Los Angeles, CA A.M. Wachsman R. Yu, M.L. Friedman PRESENTED BY: S.D. Colquhoun Nicholas Nissen, MD
Objectives: To assess outcomes in patients with neuroendocrine tumors (NET) aggressively treated using a multidisciplinary team approach Design, Setting, and Participants: The data for patients referred to single academic hospital-based NET program were reviewed retrospectively. All patients were treated in a multidisciplinary approach to management with participants from surgery, oncology, endocrinology, radiology, nuclear medicine, and pathology. From January 2003 to the present, a total of 141 patients were referred to our multidisciplinary NET program. Patients ranged in age from 29 to 84 years with a median age of 57 years. Of the patients, 75 (53.2%) were women and 63 (44.7%) had symptoms of carcinoid syndrome. Of the patients treated, we reviewed the data for 94 with follow-up of at least 6 months. Diseases were categorized by origin as foregut (n = 29 [31%]), midgut (n = 49 [52%]), hindgut (n = 1 [1%]), and lung/other (n = 15 [16%]). Of the 94 patients, 78 had liver metastases. Interventions: Most patients received combination therapy. Of the 94 patients, 73 (78%) underwent surgery, 67 (71%) received somatostatin analogs, 53 (56%) underwent hepatic artery therapy, 19 (20%) received other systemic therapy, and 11 (12%) underwent radiofrequency ablation. Main Outcome Measures: Treatment-related morbidity, mortality, improvement of symptoms, and reduction of tumor burden Results: Two major adverse outcomes directly related to treatment included a single death of sepsis and a right hepatic lobe infarct, both related to embolization. Among the patients with a midgut carcinoid syndrome, 17% (8/48) had stable symptoms, 75% (36/48) experienced improvement, and 8% (4/48) experienced complete resolution. Among patients with hepatic metastases, 67 had sufficient imaging and follow-up to assess impact of treatment: 49% (33/67) had significant improvement (range of decrease from 17% to 93%; median, 66%), 30% (20/67) had no change, while 21% (14/67) had disease progression.
82 POSTER SESSION Conclusions: Despite the passive attitudes of many physicians, the majority of NETs are often amenable to therapy. Aggressive combination therapy often results in significant objective improvement in symptoms and extent of disease. A multidisciplinary team approach seems key to the coordination of diagnostic and therapeutic options.
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POSTER SESSION 83 6B Local and Regional Therapies Influence Overall Survival in Patients With Locally Advanced Breast Cancer
INSTITUTION: AUTHORS: University of California, Davis Steve R. Martinez, MD Cancer Center, Sacramento, CA Steven L. Chen, MD, MBA Richard J. Bold, MD PRESENTED BY: Steve R. Martinez, MD
Background: Locally advanced breast cancer (LABC) is associated with poor survival. The primary benefit of local and regional therapies is disease control, although the impact of different strategies on overall survival (OS) is unknown. Hypothesis: We hypothesized that differences in local and regional therapies would not impact OS in LABC. Design: Retrospective review of Surveillance, Epidemiology, and End Results data Patients: 14,710 patients with stage IIIC (≥10 ALN metastases) breast cancer diagnosed between 1988 and 2004 Main Outcome Measure: Local and regional therapies examined included type of surgery (lumpectomy vs mastectomy), receipt of radiation therapy (RT), and extent of lymphadenectomy (lymph node yield [LNY]). Univariate analyses were performed using the Kaplan-Meier method and differences assessed via the log-rank test. Cox proportional hazards models assessed local and regional therapies and number of metastatic ALNs as predictors of OS with patient age, sex, tumor size, and hormone receptor status as covariates. Results: Among 14,710 patients, type of surgery (P < .001), number of metastatic ALNs (P < .001), LNY (P < .001), and receipt of RT (P < .001) significantly influenced OS. On multivariate analysis, improved OS was observed in patients undergoing lumpectomy (hazard ratio [HR], 0.83; P < .001), receiving RT (HR, 0.77; P < .001), and having more extensive lymphadenectomy (HR, 0.97; P < .001). Increasing numbers of metastatic ALNs (HR, 1.05; P < .001) were associated with poorer OS. Conclusions: Despite the poor prognosis of LABC, local and regional therapies have a modest impact on OS. Although most of the patients will die of systemic metastasis, appropriate local and regional therapy (ALN dissection and RT) should not be omitted.
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POSTER SESSION 85 7B Use of Wound Protection System Reduces Postoperative Wound Infection Rate in Open Appendectomy: A Randomized, Prospective Trial
caucus: AUTHORS: Southern California Pamela Lee, MD INSTITUTION: Kenneth Waxman, MD Santa Barbara Cottage Benedict Taylor, MD Hospital, Santa Barbara, CA Samantha Yim, BS PRESENTED BY: Pamela Lee, MD
Background: Wound infection in open appendectomy (OA) is reported at 10% and leads to an increase in hospital length of stay and cost. Objectives: To determine if use of a wound protection system (Alexis Wound Retractor System; Applied Medical, Rancho Santa Margarita, CA) in OA decreases the rate of wound infection Design: For the study, 109 patients undergoing OA were randomly assigned to receive conventional retraction or retraction with the wound protection system. Patients were blinded as to the arm of the study in which they were enrolled. A nurse blinded to the study arm then assessed the wound at 21 days postoperatively. Setting: A community hospital Methods: All patients were given standardized preoperative antibiotics. Demographics including age, sex, body mass index (BMI), history of type 2 diabetes, and tobacco use were collected. The severity of appendicitis as determined by the attending surgeon at the time of operation was also noted. Main Outcome Measures: Incidence of wound infection at 21 days postoperatively Results: The results are shown inT able 1 (page 87).
86 POSTER SESSION Table 1. Results of retraction with or without a wound protection system*
Wound protection system Conventional Infection + 1 (2) 7 (15) Infection – 60 (98) 41 (85) Total 61 48 * Data are given as number (percentage). The severity of appendicitis between the 2 groups was equally matched. The decrease in incidence of wound infection observed with the wound protection system was significant P( = .02). Conclusion: Use of a wound protection system reduces the incidence of surgical wound infection in OA.
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POSTER SESSION 87 8B Laparoscopic or Open Exploration Is Effective to Identify and Resect an Unknown Primary Tumor in Patients With Advanced Gastrointestinal Neuroendocrine Tumors
AUTHORS: Justin R. Parekh, MD INSTITUTION: Sam C. Wang, MD University of California, Alan P. Venook, MD San Francisco, CA Emily K. Bergsland, MD PRESENTED BY: Robert S. Warren, MD Justin R. Parekh, MD Eric K. Nakakura, MD, PhD
Background: For patients with advanced gastrointestinal neuroendocrine tumors (NETs), resection of the primary tumor and regional adenopathy and/or fibrosis prevent local complications (obstruction, ischemia, pain) and may improve survival. These tumors most commonly arise in the small intestine but are often small, submucosal, and multifocal and, thus, can be difficult to identify despite extensive preoperative evaluation. Hypothesis: Laparoscopic and open explorations are effective approaches to identify and resect the primary tumor in patients with advanced gastrointestinal NETs after preoperative evaluation has failed to localize the primary tumor. Design: Retrospective chart review Setting: Academic center Patients: We identified 11 patients with advanced gastrointestinal NETs but unknown primary tumors who underwent surgery between January 1, 2003 and August 15, 2008. Results: The primary tumor was localized in 5 (100%) of 5 open and 5 (83%) of 6 laparoscopic explorations. All tumors were in the ileum and safely resected. The average tumor size was 1.2 cm (range, 0.5–2 cm). Of 10 patients, 7 (70%) had multifocal disease, which was identified by palpation.
88 POSTER SESSION Conclusion: Laparoscopic and open explorations are effective techniques to identify and resect the primary tumor for patients with advanced gastrointestinal NETs for which the primary site is unknown. The operative approach depends in part on the extent of regional adenopathy or fibrosis. Because primary tumors are typically small and multifocal, we found that a hand-assisted approach is an important component of laparoscopic explorations so all tumors can be identified by palpation. Similarly, patients who are undergoing open operations for extensive regional or liver disease should have a thorough inspection of the small intestine by palpation.
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POSTER SESSION 89 9B Efficacy of Laparoscopic Adrenalectomy for Large Unilateral Pheochromocytomas
AUTHORS: INSTITUTION: Kyle A. Perry, MD Oregon Health & Science Raphael El-Youssef, MD University, Portland, OR Thai Pham, MD PRESENTED BY: Brett C. Sheppard, MD Kyle A. Perry, MD
Background: Laparoscopic adrenalectomy has become the treatment of choice for most adrenal lesions. Concerns have persisted, however, about the application of this technique to large pheochromocytomas owing to reports of intraoperative hemodynamic instability, difficult dissection, and tumor spillage. Hypothesis: Laparoscopic adrenalectomy is a safe and effective treatment for large unilateral pheochromocytomas. Design: Retrospective cohort study Setting: Tertiary care university hospital Patients and Methods: The data for patients undergoing pheochromocytoma resection between 1998 and 2006 were reviewed, and 30 underwent laparoscopic adrenalectomy for unilateral pheochromocytoma. Data are maintained in an institutional review board–approved prospective database, and outcomes were analyzed based on tumor size. Outcome measures included operative time, blood loss, intraoperative hemodynamic instability, conversion to open procedure, complications, and disease recurrence. Results: Of the 30 patients, 22 had small tumors (<6 cm) and 8 had large lesions (>6 cm). These groups did not differ in operative time (189 vs 212 minutes; P = .591), blood loss (67.5 vs 130 mL; P = .318), conversion rate (9.1% vs 37.5%; P = .102), length of stay (3.0 vs 3.5 days; P = .265), or complication rate (9.1% vs 12.5%; P = .787). Intraoperative hemodynamic instability occurred in 56.7% of cases but was not different between groups. There were no recurrences in either group at a median follow-up interval of 30 months. Conclusion: Laparoscopic adrenalectomy is a safe and effective treatment for small and large pheochromocytomas. Intraoperative hemodynamic instability is a frequent occurrence that must be managed aggressively but is not more common in patients with large tumors. There were no cases of disease recurrence or iatrogenic pheochromocystosis.
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POSTER SESSION 91 10B Two Novel Loci Mapping to Chromosomes 1 and 6 Predispose to Familial Papillary Thyroid Cancer: A Preliminary SNP Array–Based Study
AUTHORS: Insoo Suh, MD Eric Jorgenson, PhD INSTITUTION: Mariwil Wong, BS University of California, Wen T. Shen, MD San Francisco, CA Electron Kebebew, MD PRESENTED BY: Quan-Yang Duh, MD Insoo Suh, MD Analabha Basu, PhD Orlo H. Clark, MD
Background: Familial papillary thyroid cancer (FPTC) is clinically distinct from its sporadic counterpart, with a greater likelihood of early onset, multifocality, and aggressive behavior. Although several candidate loci responsible for FPTC variants have been mapped in isolated families, the gene(s) responsible for most cases has not been identified. Hypothesis: The germline mutation(s) responsible for FPTC can be mapped to specific chromosomal loci using single nucleotide polymorphism (SNP) array–based linkage analysis. Design and Participants: For the study, 48 FPTC families were pedigreed. All families had 2 or more affected first-degree relatives. Genomic DNA was extracted from peripheral blood samples of 126 selected family members and hybridized to Affymetrix GeneChip SNP arrays, covering up to 1.8 million genome-wide genetic variations. Genotyping and linkage analysis were performed using the Merlin software program. Main Outcome Measures: Exponential logarithm-of-the-odds (LOD) scores were calculated for each locus using the Kong-Cox model for linkage analysis. An LOD score of more than 3 denoted significant likelihood of linkage. Results: A total of 80 affected and 46 unaffected members of FPTC families were selected for SNP array analysis. Novel linkage loci across all families were detected at 6q22 and 1q21 (LOD scores, 3.3 and 3.04, respectively). No known genes map to either locus. Conclusion: High-resolution SNP array–based linkage mapping of a heterogeneous group of FPTC families has identified 2 novel loci on chromosomes 1 and 6. These regions may point to common germline mutations in heretofore-undiscovered “FPTC susceptibility” genes. Future studies will consist of subgroup analyses and validation in independent families.
92 POSTER SESSION notes:
POSTER SESSION 93 94 POSTER SESSION President’s Forum: Research by Surgeons Sunday, February 15, 2009 7:30–9:00 am
Moderator: Orlo Clark, MD, President Pacific Coast Surgical Association Thomas Russell, MD, Executive Director American College of Surgeons Michael Harrison, MD, UCSF Haile T. Debas, MD, UCSF Tom Krummel, MD, Stanford University
SCIENTIFIC SESSION 95 96 POSTER SESSION Scientific Session 5: Residents Forum Sunday, February 15, 2009 9:00–10:30 am
Moderators: Nancy Ascher, MD Karen Deveney, MD
SCIENTIFIC SESSION 97 13 The Use of Lyophilized Plasma for Resuscitation in a Swine Model of Severe Injury
AUTHORS: Nicholas Spoerke, MD Karen Zink, MD Caucus: S.D. Cho, MD Oregon/Hawaii Jerome Differding, MPH PRESENTER: Pat Muller Nicholas Spoerke, MD Z. Ayhan, MD Jill Sondeen PRIMARY DISCUSSANT: John B. Holcomb, MD David Hoyt, MD Martin A. Schreiber, MD, FACS DISCUSSION CLOSED BY: INSTITUTION: Martin A. Schreiber, MD Oregon Health & Science University, Portland, OR
Background: Recent studies have shown survival benefit for high ratios of plasma to packed red blood cells (PRBCs) in severe trauma. Implementation of these ratios and field availability are limited by the logistics of using fresh frozen plasma (FFP). Freeze-dried (lyophilized) plasma (LP) can be stored at room temperature, quickly reconstituted, and rapidly administered in diverse situations. Objectives: To test the efficacy ofL P versus FFP in a severe injury model in swine Hypothesis: LP is as effective as FFP for resuscitation after severe injury. Design: Prospective, randomized animal study Setting: Animal lab, Level I trauma center Participants: 32 Yorkshire crossbred swine Methods: Swine were subjected to complex polytrauma including extremity fracture, severe liver injury, acidosis, and hypothermia. They were then resuscitated with FFP, LP, or a ratio of 1:1 FFP-PRBCs or 1:1 LP-PRBCs. Main Outcome Measurements: Coagulation profiles, total blood loss, serum clotting factor levels and activity, hemodynamic parameters, mortality, and thromboelastogram (TEG) parameters Results: Survival and hemodynamic parameters were similar among all groups. Lyophilization decreased clotting factor activity by an average of 14%. Swine treated with LP had similar coagulation profiles, serum clotting factor levels, TEG parameters, bicarbonate levels,
98 sCIENTIFIC SESSION lactate levels, and postinjury blood loss as swine treated with FFP at all postinjury time points. Swine treated with 1:1 FFP-PRBCs were similar to swine treated with 1:1 LP-PRBCs with regard to all study points. Conclusion: The process of lyophilization and reconstitution of plasma reduces coagulation-factor activity. Despite this finding,L P can be used for resuscitation in severe polytrauma and hemorrhagic shock with efficacy equal to that of FFP.
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SCIENTIFIC SESSION 99 14 The Incidental Pancreatic Mass: Surgical Decision-Making and Outcomes
AUTHORS: Caucus: Robin M. Cisco, MD Northern California Robin O. Price, MD PRESENTER: Ellen H. Morrow, MD Robin Cisco, MD R. Brooke Jeffrey, MD Jeffrey A. Norton, MD PRIMARY DISCUSSANT: INSTITUTION: Howard Reber, MD Stanford University School DISCUSSION CLOSED BY: of Medicine, Stanford, CA Jeffrey Norton, MD
Background: As cross-sectional imaging becomes more sensitive and more frequently obtained, surgeons encounter an increasing number of asymptomatic patients with the incidental finding of a pancreatic mass. Objectives: Evaluate surgical decision-making and outcome of incidentally detected pancreatic masses Hypothesis: Some of these masses will be clinically significant. Design: Retrospective review of radiology and surgery results Setting: Tertiary academic hospital Patients or Participants: From 2002 to 2007, 157 patients were identified with incidental pancreatic masses ranging from 5 to 8 cm. A mass was incidental if the imaging study was ordered for another indication and the mass was asymptomatic. Main Outcome Measures: Subsequent imaging results, surgical or nonoperative results, pathology, and outcome Results: We identified 133 (84.7%) cystic and 24 (15.3%) solid masses. Each patient underwent pancreatic protocol computed tomography (CT) for further evaluation. Of 133 incidental cystic masses, 22 (16.5%) were resected, yielding 8 IPMNs, 8 serous microcystic adenomas, 5 mucinous cystic neoplasms, and 1 mucinous adenocarcinoma. For the remaining 111 patients, nonoperative management was pursued because of EUS results in 10, unchanged serial CT findings, and/or significant comorbidities. Of 24 patients with incidental solid masses, 18 underwent surgical resection. Pathology revealed 11 neuroendocrine tumors, 6 ductal adenocarcinomas, and 1 giant cell tumor. An additional 5 patients had biopsy-proven unresectable adenocarcinoma. A final patient had a biopsy-proven giant cell tumor but did not undergo surgery owing to comorbid illness.
100 sCIENTIFIC SESSION Conclusion: Asymptomatic patients with cystic masses had only a 10.5% chance of mucinous tumors that required resection. However, all solid asymptomatic incidentally discovered tumors were clinically significant and required surgical intervention.
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SCIENTIFIC SESSION 101 15 Early Postoperative Fever and the “Routine” Fever Workup: Results of a Prospective Study
AUTHORS: Caucus: Richard Lesperance, MD Washington/BC/Alaska Ryan Lehman, DO PRESENTER: Kelly Lesperance, MD Richard Lesperance, MD Daniel Cronk, MD Matthew Martin, MD PRIMARY DISCUSSANT: INSTITUTION: Ali Salim, MD Madigan Army Medical DISCUSSION CLOSED BY: Center, Tacoma, WA Matthew Martin, MD
Background: Fever in the postoperative period frequently results in a battery of diagnostic tests in search of an etiology. We sought to evaluate the incidence and utility of extensive postoperative fever evaluations in a teaching hospital setting. Design: Prospective observational study Setting: Academic tertiary care hospital Patients: All adult patients undergoing inpatient general, thoracic, or vascular surgical procedures during a 13-month period Results: Of 1,076 surgical procedures, 256 (23.8%) patients experienced a temperature of more than 100.4°F in the early postoperative period (<72 hours). There were 101 patients (9.4%) who underwent documented fever workup. Of the 101 patients, 36 (35.6%) had blood cultures with no positive results among elective surgery patients. Urine cultures were done for 46 patients (45.5%), and 4 infections were diagnosed (9%). Of 51 chest radiographs performed, the diagnosis of pneumonia was made by only 1 (2%). Ultimately, 18 febrile patients (17.8%) were diagnosed with an infectious source; in 9 of these patients, the physical examination and clinical picture accurately diagnosed the infection without need for further testing. In the remaining 9 patients, patients who were admitted directly for elective surgery had 3 urinary tract infections and 1 case of Clostridium difficile colitis that could have been diagnosed with a more focused evaluation. Conclusion: Early postoperative fever is a common event and rarely caused by an infection. A brief clinical evaluation has the highest yield for determining the fever etiology, and extensive evaluations with cultures and chest imaging have little to no benefit in patients admitted for elective surgery.
102 sCIENTIFIC SESSION notes:
SCIENTIFIC SESSION 103 16 Lymph Node Counts: An Indicator of Quality in Colorectal Cancer Surgery?
AUTHORS: Caucus: Caitlyn Truong, MD Southern California Sharmila Roy-Chowdhury, MD PRESENTER: Sharon S. Lum, MD Caitlyn Truong, MD John W. Morgan, PhD Jan H. Wong, MD PRIMARY DISCUSSANT: INSTITUTION: John M. Greif, DO Loma Linda University School DISCUSSION CLOSED BY: of Medicine, Loma Linda, CA Jan H. Wong, MD
Background: The number of lymph nodes examined is a powerful predictor of outcome in colorectal cancer (CRC). However, the value of lymph node counts as a benchmark of quality is controversial. Objectives: To examine the impact of lymph node counts on disease- specific survival (DSS) of patients with CRC at the hospital level Hypothesis: Lymph node counts are useful as an indicator of the quality of surgical/pathologic care provided in CRC. Design: Retrospective cohort study Setting: Region 5 of the California Cancer Registry (R5 CCR) Patients: The study used data obtained between January 1994 and December 2003 from R5 CCR. Methods: Hospitals in R5 CCR were characterized according to the median number of nodes examined and stratified into those hospitals with a median number of fewer than 7, 7 to 9, and 10 or more nodes harvested. Main Outcome Measures: 12-node threshold, frequency of positive lymph nodes, and DSS at the hospital level Results: A total of 8,521 patients with CRC underwent resection at 33 hospitals in R5 CCR during the study period. In 12 hospitals (1,840 pts), a median of fewer than 7 nodes was examined (group A), 12 hospitals (3,638 pts) had a median of 7 to 9 nodes (group B), and 9 hospitals (3,043 pts) had a median of 10 or more nodes examined (group C). Hospitals with the lowest lymph node count tended to treat more elderly patients and patients with a lower T stage. The median number of nodes (mean/SD) examined in group A was 4 (5.6/5.9); in group B, 8 (9.7/8.5); and in group C, 10 (11.3/9.2). The 12-node threshold was met by 13.7% of patients in group A, 32.8% of patients in group B, and 42.8% of patients in group C. Despite this difference, the respective frequencies of N1 and N2 disease for group A were 20.7% and 9.1%; for group B, 19. 7% and 11.1%; 104 sCIENTIFIC SESSION and for group C, 20.1% and 11.3% (P = .12). The 5-year DSS was 72.7% for group A, 73.7% for group B, and 76.7% for group C (P = .002). For patients with N0 disease, the DSS for group A was 78.6%, for group B was 81.5%, and for group C was 85.1% (P < .0001). There were no statistically significant differences in DSS for patients with N1 (P = .18) or N2 (P = .90) disease among the 3 groups. Conclusion: Lymph node counts at the hospital level are not associated with the frequency of node positivity. Lymph node counts at the hospital level are associated with improved DSS. The association with improved DSS can be attributed to improved DSS in patients with N0 disease. Lymph node counts may have value as a benchmark of the surgical/pathologic quality in CRC.
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SCIENTIFIC SESSION 105 106 sCIENTIFIC SESSION Scientific Session 6 Sunday, February 15, 2009 11:10 am–12:30 pm
Moderators: Mark Talamini, MD Michael Bouvet, MD
SCIENTIFIC SESSION 107 17 Combination of Microsatellite Instability and Lymphocytic Infiltrate as a Prognostic Indicator for Adjuvant Therapy in Colon Cancer
AUTHORS: Sandeep Kumar, MD Caucus: Eugene Y. Chang, MD Oregon/Hawaii Paul B. Dorsey, MS Joseph Frankhouse, MD PRESENTER: Randall G. Lee, MD Sandeep Kumar, MD Nathalie Johnson, MD PRIMARY DISCUSSANT: Legacy Health System, Portland, OR Clifford Ko, MD DISCUSSION CLOSED BY: INSTITUTION: Legacy Health System, Surgical Joseph Frankhouse, MD Associates, Portland, OR
Background: Microsatellite instability (MSI) and lymphocytic infiltrate L( I) are findings in colon malignancies associated with less aggressive colonic tumor biology. Among patients with stage II disease, patients without tumor LI have been found to have a markedly less favorable prognosis. It has been suggested that this subgroup of patients would be candidates for more aggressive adjuvant therapy. Objectives: To evaluate the outcomes of patients with and without adjuvant chemotherapy on the basis of stage, MSI, and LI in our colon cancer population Design: Colon cancers were prospectively evaluated for MSI by assessing for instability in 11 satellite markers. Tumors were classified asL I+ if at least 5 lymphocytes were observed per 10 high-power fields. The chemotherapy regimen given to each patient, if any, was recorded retrospectively. Settings: Community hospital system Patients: Patients undergoing definitive operation for colon cancer Main outcome measures: Disease-free survival (DFS) with and without chemotherapy was compared according to combined MSI and LI status. Results: MSI , LI status, and chemotherapeutic regimens were available for 140 patients who were classified as follows: MSI–/LI–, 89; MSI–/LI+, 9; MSI+/LI–, 26; and MSI+/LI+, 16. The median follow-up was 48.7 months. The 5-year DFS was 76.2% for patients with stage II disease who underwent chemotherapy compared with 50% for patients who did not (P = .016). This difference was driven primarily by the MSI–/LI– group, in which the DFS rates were 72.2% and 37.9%, respectively (P = .001). Patients with MSI+/LI– and
108 sCIENTIFIC SESSION MSI–/LI+ tumors had 5-year survival rates of 75.4% and 75.0%, respectively. Among 12 patients with stage II disease treated with chemotherapy, all were treated with 5-fluorouracil, and 5 were also treated with leucovorin. Conclusions: Colon cancer patients with MSI–/LI– tumors have a worse DFS regardless of stage at diagnosis. Patients exhibiting both MSI + and LI+ tumors have superior DFS. Treatment with 5-flurouracil with or without leucovorin does not seem to improve DFS in patients with MSI–/LI– stage II colon cancer. Addition of more aggressive treatment in this group (such as with irinotecan or oxaliplatin) may be warranted. Alternatively, forgoing adjuvant chemotherapy in this group should be considered. MSI and LI show promise as a combined prognostic marker and with further study may prove particularly useful in selecting patients with stage II disease for adjunctive therapy.
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SCIENTIFIC SESSION 109 18 Selective Preoperative Biliary Drainage Alters Perioperative Resuscitation but Not Morbidity and Mortality in Patients Undergoing Pancreaticoduodenectomy
Caucus: AUTHORS: Northern California Jodi M. Coates, MD Kimberly Vanderveen, MD PRESENTER: Richard J. Bold, MD Jodi M. Coates, MD Robert J. Canter, MD PRIMARY DISCUSSANT: INSTITUTION: Joe Hines, MD University of California Davis DISCUSSION CLOSED BY: Medical Center, Sacramento, CA Richard J. Bold, MD
Background: Biliary drainage before pancreaticoduodenectomy remains controversial. Proponents argue that it facilitates patient referral to high-volume centers, while detractors maintain that it increases surgical morbidity and mortality. Hypothesis: Preoperative biliary drainage increases perioperative morbidity in selected patients. Design: Retrospective analysis of institutional registry database Setting: University Patients or Participants: From October 1, 2003 to May 31, 2008, 92 patients underwent pancreaticoduodenectomy for periampullar lesions. Methods: Clinicopathologic data were analyzed among patients who underwent drainage and patients who did not for their association with perioperative outcomes. Chi-square and independent samples t tests were used as appropriate. Results: Of the 92 patients, 57 (62%) received stents and 45 (38%) did not. Intraoperative bile cultures were positive in 88% of patients who received stents (35/40). Patients who did not receive stents were more likely to have an intensive care unit stay of more than 3 days (25% vs 6%; P = .008) and a hospital length of stay of more than 14 days (29% vs 6%; P = .002). Operative time more than 8 hours, crystalloid transfusion of more than 9 L, and red blood cell transfusion of more than 2 U were all more frequent among patients who received stents (P < .05). Mortality was 4% for the entire cohort with a trend toward decreased mortality among patients who received stents (2% vs 9%; P = .12). Conclusion: Among patients undergoing pancreaticoduodenectomy,
110 sCIENTIFIC SESSION preoperative biliary drainage is associated with greater operative blood loss, perioperative volume resuscitation, and bactibilia. However, intensive care and overall lengths of stay are shorter among patients who receive stents, while no significant difference in mortality exists between groups. Selective preoperative biliary drainage is appropriate in the multidisciplinary management of patients with periampullar tumors.
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SCIENTIFIC SESSION 111 19 Decitabine, an Inhibitor of DNA Promoter Methylation, Has an Antineoplastic Effect in Adrenocortical Carcinoma Cells
AUTHORS: Caucus: Insoo Suh, MD Northern California Caucus Julie Weng, BS Wen T. Shen, MD PRESENTER: Quan-Yang Duh, MD Insoo Suh, MD Orlo H. Clark, MD PRIMARY DISCUSSANT: Electron Kebebew, MD Rodney Pommier, MD INSTITUTION: DISCUSSION CLOSED BY: Unniversity of California, San Francisco, CA Electron Kebebew, MD
Background: Adrenocortical carcinoma (ACC) is an aggressive malignancy, with significant morbidity from hormonal hypersecretion. ACC has been associated with gene silencing at chromosome 11q13. Recently, novel therapies such as decitabine have garnered interest owing to their ability to reexpress epigenetically silenced genes. Hypothesis: Decitabine recovers expression of silenced genes on chromosome 11q13 in ACC cells and has antineoplastic effects in ACC. Design: NCI-H295R ACC cells were treated with 0.1 to 1-µmol/L concentrations of decitabine during a 5-day period. Cells were evaluated at 24-hour intervals for decitabine’s effects on cell proliferation, cortisol secretion, and invasiveness. Gene expression was quantified for 6 genes on 11q13 (DDB1, MRPL48, NDUFS8, PRDX5, SERPING1, and TM7SF2) previously shown to be down-regulated in ACC. Main Outcome Measures: Cell proliferation, cortisol secretion, and invasion were measured using immunometric assays. Quantitative RT- PCR was used to measure gene expression relative to GAPDH. Results: Decitabine inhibited ACC cell proliferation by 39% to 47% at 5 days posttreatment compared with control samples (P < .0001). The inhibitory effect was cytostatic and time- and dose-dependent. Decitabine decreased cortisol secretion by 56% to 58% at 5 days (P = .02) and inhibited cell invasion by 64% at 24 hours (P = .03). Of the 6 down-regulated genes on 11q13, only NDUFS8 recovered expression with decitabine (18% increase; P = .04).
112 sCIENTIFIC SESSION Conclusion: Decitabine exhibits antitumoral properties in ACC cells at clinically achievable concentrations and, thus, may be an effective adjuvant therapy in patients with advanced disease. Decitabine recovers the expression of NDUFS8, which suggests a possible role of epigenetic gene silencing in adrenocortical carcinogenesis.
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SCIENTIFIC SESSION 113 114 sCIENTIFIC SESSION Scientific Session 7 Monday, February 16, 2009 8:00–9:40 am
Moderators: James Peck, MD David Hoyt, MD
SCIENTIFIC SESSION 115 20 Recurrence Rate and Complications of Open Incisional Hernia Repair at an Academic Tertiary Care Medical Center
AUTHORS: Khashayar Mohebali, MD Caucus: Scott L Hansen, MD Northern California John Maa, MD PRESENTER: David M. Young, MD Khashayar Mohebali, MD Christopher E. Freise, MD David S. Chang, MD PRIMARY DISCUSSANT: Hobart W Harris MD Rodney Mason, MD INSTITUTION: DISCUSSION CLOSED BY: University of California, Hobart W. Harris, MD San Francisco, CA
Objective: To describe the postoperative complication rates of a large consecutive series of patients who underwent open incisional ventral hernia repair Design: Retrospective chart review of accumulated database Setting: University tertiary care medical center Patients or Participants: All patients who underwent open incisional ventral hernia repair between March 1, 2003, and February 28, 2008 Interventions: Open incisional ventral hernia repair Main Outcome Measures: Postoperative complications and hernia recurrences Results: A total of 508 cases (462 patients) meeting inclusion criteria were identified; 50% were men; the mean follow-up was 35 months. In 119 cases (23.4%), there had been previous attempts at repair. In 83 cases (16.3%), patients had previously undergone organ transplantation. Postoperative complications occurred in 195 cases (38.4%). Hernia recurrence was observed in 95 cases (18.7%), including 13 enterocutaneous fistulas (2.6%). Perioperative mortality was 0.01%. Compared with nontransplant patients, transplant patients were more likely to have a hernia recurrence (17% vs 33%; P = .001) and were equally likely to have a postoperative complication (37% vs 45%; P = .24). Compared with initial hernia repairs, repairs of a recurrent incisional hernia were equally likely to have a hernia recurrence (18% vs 20%; P = .74) but more likely to have an overall complication (45% vs 35%; P = .03).
116 sCIENTIFIC SESSION Conclusion: In this series of incisional hernia repairs at a tertiary care center, there was an overall recurrence rate of 18.7%. While transplant patients had a significantly higher recurrence rate than nontransplant patients, an unexpected finding was that repairs of recurrent hernias had a recurrence rate similar to that of initial repairs.
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SCIENTIFIC SESSION 117 21 Utilization of Routine Pathologic Examination for Specimens Removed From Trauma Patients
AUTHORS: Caucus: Ryan Gertz, MD Southern California Ali Salim, MD Pedro Teixeira, MD PRESENTER: Para Chandrasoma, MD Ryan Gertz, MD Dennis Anderson, MD PRIMARY DISCUSSANT: Daniel Margulies, MD Lynette Scherer, MD INSTITUTION: DISCUSSION CLOSED BY: Cedars-Sinai Medical Center, Los Angeles, CA Ali Salim, MD
Background: Surgical specimens removed during trauma operations are routinely submitted for examination by pathology. This practice has not been systematically evaluated, and the incidence of abnormal results from these examinations remains unknown. Objectives: To review pathology reports from trauma patients to identify the incidence and management implications of abnormal findings Design: Retrospective chart and pathology review Setting: Academic Level I trauma center Methods: All pathology reports of surgical specimens obtained during laparotomy or thoracotomy for trauma from January 1, 1993, to December 31, 2005, were retrospectively reviewed. Reports were assessed for significant abnormal findings including malignancy, infectious processes, and chronic inflammation. Additional clinical and demographic data were obtained. Interventions: None Main Outcome Measures: Change in management owing to pathology result Results: During the study period, 1,686 specimens were obtained from 1,307 trauma patients: 475 spleen, 506 small bowel, 322 colon, 229 kidney, 125 lung, and 29 stomach tissue samples. There were 6 abnormal findings (0.5%), all of which were malignancies. The pathology reports did not alter care in any patients. In all cases, the malignancy was known or highly suspected before specimen examination based on other diagnostic modalities or gross examination during surgery. Patients with an abnormal finding were significantly older than patients with normal pathology reports (70.5 vs 30.4 years; P < .0001).
118 sCIENTIFIC SESSION Conclusion: Pathologic examination of specimens obtained during trauma operations did not alter patient care. Routine pathologic examination of tissue specimens may not be necessary in young trauma patients in whom there is low clinical suspicion for occult illness. The usefulness of this practice in older patients warrants further investigation.
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SCIENTIFIC SESSION 119 22 A Simplified Set of Trauma Triage Criteria Safely Reduces Overtriage: A Prospective Study
AUTHORS: Ryan Lehmann, DO Caucus: Lionel Brounts, MD Washington/BC/Alaska Kelly Lesperance, MD PRESENTER: Matthew Eckert, MD Ryan Lehmann, DO Linda Casey, RN Alec Beekley, MD PRIMARY DISCUSSANT: Matthew Martin, MD Martin Schreiber, MD INSTITUTION: DISCUSSION CLOSED BY: Madigan Army Medical Matthew Martin, MD Center, Tacoma, WA
Background: Many trauma systems have adopted complex triage algorithms that are difficult to use and contain poorly validated variables. Objectives: To prospectively evaluate the performance of our institution’s current triage system with a simplified system using only 4 highly predictive variables Design: Prospective observational study Setting: Academic Level II trauma center Patients or Participants: Trauma patients during a 9-month period Methods: All trauma admissions were analyzed for the need for immediate emergency interventions or operative procedures. The accuracy and safety of the current triage system was compared with a simplified triage protocol using only 4 variables (hypotension, mental status, altered respirations, and penetrating truncal wound). Overtriage and undertriage rates were compared, and a detailed analysis of the data for all undertriaged patients was performed. Main Outcome Measures: Rates of overtriage and undertriage, morbidity, and mortality Results: There were 244 trauma team activations, with 24% requiring urgent intervention. Existing criteria produced an overtriage of 79%, an undertriage of 1%, and mistriage in 14%. By using the simplified criteria, overtriage was reduced to 12% and undertriage to 4% (both P < .05). Undertriaged patients were all in hemodynamically stable condition, with 4 requiring tube thoracostomy only and 4 underwent nonemergency laparotomy (2 nontherapeutic laparotomies, 1 bladder repair, and 1 bowel mesenteric injury). There were no deaths among undertriaged patients with either system.
120 sCIENTIFIC SESSION Conclusion: Using a simplified triage system can safely reduce the rate of overtriage. This system could conserve resources, reduce mistriage from misunderstood guidelines, and improve specificity by including only the variables with high predictive value.
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SCIENTIFIC SESSION 121 23 Creation of Inpatient Capacity for Disaster Management: Lessons Learned From a Major Hospital Relocation
AUTHORS: Caucus: Howard C. Jen, MD Southern California Stephen B. Shew, MD James B. Atkinson, MD PRESENTER: J. Thomas Rosenthal, MD Howard C. Jen, MD Jonathan R. Hiatt, MD PRIMARY DISCUSSANT: INSTITUTION: Diana Farmer, MD David Geffen School of DISCUSSION CLOSED BY: Medicine at University of California, Los Angeles, CA James B. Atkinson, MD
Background: As most medical centers are operating near capacity, local or regional disasters of any size can easily overwhelm capacity to respond. We reviewed a planned reduction of inpatient census before relocation of a university hospital to identify tools to aid in disaster management. Interventions: The transition was directed by surgeons and included constriction of elective operating schedule, elimination of inpatient transfers, and discharge planning by senior physicians and nurses. Main Outcome Measures: Census figures and patient outcomes were compared for 1-week periods beginning 2 weeks (baseline) and 1 week (transition) before moving day. Results: The census decreased by 36% from 537 at baseline to 345 on moving day, a rate of 18 patients per day (P < .005). By comparing the 2 periods, we found the census was reduced by 22% for surgical services and 10% for nonsurgical services (both P < .05). Daily admissions to surgical services were reduced for elective (7 vs 18; P < .05) and emergency indications (8 vs 13; P < .05) but were not reduced for nonsurgical services (32 vs 42; P = .09) or trauma (2 vs 2; P = 1). Trends are shown in Figure 1 (page 65). Inpatient length of stay (6.5 vs 6.0 days; P = .52) and mortality (3% vs 3%; P = .68) were not affected. Conclusion: Our strategy produced a safe and rapid reduction in hospital census without interruption of emergency department and trauma services. Some interventions required a long lead time, while others could be implemented on-the-fly. This experience represents a model for large-scale disaster and daily census management. Hospitals should create an internal plan using these principles with modifications to reflect local characteristics.
122 sCIENTIFIC SESSION Figure 1. Trends in census, admissions, and discharges during hospital relocation.
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SCIENTIFIC SESSION 123 124 sCIENTIFIC SESSION Scientific Session 8 Monday, February 16, 2009 10:00–11:30 am
Moderators: Orlo Clark, MD Quan-Yang Duh, MD
SCIENTIFIC SESSION 125 24 Current Patterns in Prehospital Care in Kampala, Uganda, and the Feasibility and Effectiveness of Training Lay First Responders in Emergency First-aid for Trauma
AUTHORS: S. Jayaraman, MD D. Ozgediz Caucus: M. Lipnick Northern California N. Caldwell PRESENTER: N. Miyamoto Sudha Jayaraman, MD J. Mabweijano C. Mijumbi PRIMARY DISCUSSANT: R. Dicker Sherry Wren, MD R. Hsia DISCUSSION CLOSED BY: INSTITUTION: William Schecter, MD University of California, San Francisco, CA
Objectives: In Kampala, Uganda, no formal prehospital emergency system exists. This study hypothesized that lay first responders can be effectively trained using a context-appropriate first-aid course to provide basic prehospital trauma care. Design: An intervention study. Before training, a cross-sectional survey was used to capture data on injuries seen and determine the current skills, knowledge, and access to equipment. Fund of knowledge was tested before and after training. Setting: Kampala, Uganda Participants: Police officers, commercial taxi drivers, and local officials selected by convenience sampling Results: Participants included 307 people and, during 6 months, they saw a mean of 19 emergencies (95% confidence interval [CI], 16–21). Of the participants, 30.3% (n = 93) had seen a death (95% CI, 22%–42%), with 1–5 deaths (mean) each. The most common mechanisms were road crashes (89%; 95% CI, 84%–92%), assault (66%; 95% CI, 60%–71%), and burns (44%; 95% CI, 39%–50%). Of the 307 participants, 52% had some previous first-aid training (95% CI, 47%–58%), and 43% had some access to equipment (95% CI, 37%–49%). The most common aid given was lifting/moving (82%; 95% CI, 77%–87%) or transport (76%; 95% CI, 71%–80%). Lack of knowledge (37%; 95% CI, 18%–57%) and/or equipment (44%; 95% CI, 24%–65%) were main concerns when aid was not given. Initially, knowledge was low
126 sCIENTIFIC SESSION in moving (29% correct; 95% CI, 24%–26%), safe transport (32% correct; 95% CI, 26%–38%), and bleeding control (38% correct; 95% CI, 32%–44%). After training, knowledge increased from 45% to 86% P( < .0001). Conclusions: A context-appropriate first-aid course for lay people can improve the fund of knowledge and may be a step toward formal prehospital care in Kampala, Uganda.
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SCIENTIFIC SESSION 127 25 Activated Recombinant Factor VIIa Reduces Repeated Operations for Hemorrhage Following Major Abdominal Surgery
Caucus: AUTHORS: Northern California Thomas C.T sai, AB PRESENTER: James H. Rosing, MD Thomas C.T sai, AB Jeffrey A. Norton, MD PRIMARY DISCUSSANT: INSTITUTION: Brett Sheppard, MD Stanford University School of Medicine, Stanford, CA DISCUSSION CLOSED BY: Jeffrey A. Norton, MD
Background: Hemorrhage is a significant complication after major abdominal surgery. Recombinant factor VIIa may be effective in decreasing transfusion bleeding following trauma. Objective: Evaluate factor VIIa in reducing blood product requirements and reoperations for bleeding after major abdominal surgery Hypothesis: Factor VIIa reduces blood transfusions and avoids reoperation for postoperative hemorrhage. Design: Retrospective case series Setting: Tertiary academic hospital Patients or Participants: Patients receiving factor VIIa in the postoperative setting from 2004 to 2007 Main Outcome Measures: Packed red blood cell (pRBC) transfusions, clotting factor transfusions, reoperations for bleeding, deaths, and thromboembolic complications Results: During the study period, 17 patients with postoperative hemorrhage following abdominal tumor surgery (9 pancreas, 4 sarcoma, 2 gastric, 1 carcinoid, and 1 fistula) were treated with activated factor VII. In these 17 patients, factor VII was administered 18 times (dose, 2,400– 9,600 µg; 29.8–100.8 µg/kg). Transfusion requirements of pRBC, fresh frozen plasma (FFP), cryoprecipitate, and platelets were each significantly less than pre–factor VII amounts (paired Student t test; Table 1, page 129). Of the 18 episodes, bleeding was controlled in 17 (94%) without surgery, and 1 patient was returned to the operating room. There were no deaths or thrombotic complications. A 4,800-µg vial of NovoSeven costs $5,184, and 2 hours of operating room time costs $17,640.
128 sCIENTIFIC SESSION Table 1. Transfusion requirements
24 h Pre– 24 h Post– Factor VIIa Factor VII t Statistic P pRBC 5.2 0.83 6.83 < .0005 FFP 2 0.38 2.82 < .01 Cryoprecipitate 0.33 0 2.38 < .02 Platelet 0.39 0.06 1.84 < .05 Conclusion: Use of recombinant factor VIIa in resuscitation for hemorrhage after major abdominal surgery can dramatically reduce blood product requirements and the need for reoperation without thrombotic complications. It should be considered as a cost-effective, first-line therapy in postoperative hemorrhage.
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SCIENTIFIC SESSION 129 26 Positive Serum Ethanol Level Is Associated With Improved Outcome in Severe Traumatic Brain-Injured Patients
AUTHORS: Caucus: Ali Salim, MD Southern California Eric Ley, MD PRESENTER: Gil Cryer, MD Ali Salim, MD Daniel Margulies, MD Areti Tillou, MD PRIMARY DISCUSSANT: INSTITUTION: Eddie Cornwell, MD Cedars-Sinai Medical DISCUSSION CLOSED BY: Center, Los Angeles, CA Ali Salim, MD
Background: Animal studies suggest that low to moderate doses of ethanol (ETOH) before traumatic brain injury (TBI) may have a neuroprotective role, resulting in improved functional outcome. Hypothesis: Ethanol exposure is associated with improved outcome in patients with severe TBI. Design: Retrospective database review Setting: Academic Level I trauma center Patients and Methods: The NationalT rauma Database version 6.2 (2000– 2005) was queried for all patients with severe TBI (head abbreviated injury score ≥3) who had serum ETOH levels measured on admission. Demographics, injury severity score (ISS), and outcomes (mortality, intensive care unit [ICU] and hospital lengths of stay, and complications) were compared between patients with TBI with and without ETOH. Logistic regression analysis was used to investigate the relationship between mortality and ETOH. Interventions: None Main Outcome Measures: Mortality and complications Results: The data for a total of 38,019 patients with severeT BI were evaluated. Of the patients, 38% tested positive for ETOH. Table 1 (page 71) compares demographics and outcomes with and without ETOH.
130 sCIENTIFIC SESSION Table 1. Demographic and outcome data in TBI according to ETOH results
Compli- ICU Hospital cations Mortality Age (y) ISS days days (%) (%) ETOH + 38 ± 15 22 ± 10 7 ± 9 13 ± 16 13 8 ETOH - 44 ± 22 23 ± 10 8 ± 9 12 ± 15 10 10 P < .0001 < .0001 .0002 .042 < .0001 < .0001 ETOH significantly decreased the odds of death (adjusted odds ratio, 0.88; 95% confidence interval; 0.8–0.96;P = .0049). Conclusion: A positive serum ETOH is independently associated with higher survival in patients with severe head injury. Additional research is warranted to investigate the potential therapeutic implications of this association.
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SCIENTIFIC SESSION 131
Harold Brunn FoundersFrank Hinman Emmett Rixford Thomas O. Burger W. D. Kirkpatrick Samuel Robinson Samuel H. Buteau Otis F. Lamson Paul Rockey S. L. Caldbick A. Stewart Lobinger Henry Sherk Robert C. Coffey Charles D. Lockwood Ernst A. Sommer Walter B. Coffey A. O. Loe Stanley Stillman John F. Cowan J. Tate Mason Charles T. Sturgeon Richard B. Dillehunt A. Aldridge Matthews George W. Swift Sumner Everingham J. B. McNerthney Wallace G. Toland Charles Fox Wayland A. Morrison Alanson Weeks Edgar L. Gilcrest Howard C. Naffziger Horace G. Wethrill Philip K. Gilman Charles E. Phillips
Elected Meeting President PastLocation Presidents Caucus Year Year Bruce Stabile 2007 San Diego, CA 2008 SC Michael J. Hart 2006 Kohala Coast, HI 2007 WA/BC/AK Cornelius Olcott IV 2005 San Francisco, CA 2006 NC Samuel Eric Wilson 2004 Laguna Nigel/ 2005 SC Dana Point, CA Livingston Wong 2003 Wailea, HI 2004 OR /HI Thomas R. Russell 2002 Monterey, CA 2003 NC Theodore X. 2001 Las Vegas, NV 2002 SC O’Connell John K. MacFarlane 2000 Banff, AB 2001 WA/BC/AK Robert C. Lim, Jr. 1999 San Francisco, CA 2000 NC Thomas V. Berne 1998 San Jose del Cabo, 1999 SC Baja, Mexico R. Mark Vetto 1997 Kaanapali Beach, HI 1998 OR /HI F. William Heer 1996 Napa Valley, CA 1997 NC Ronald K. Tompkins 1995 San Diego, CA 1996 SC Meredith P. Smith 1994 Seattle, WA 1995 WA/BC/AK
132 founders | PAST PRESIDENTS AND MEETING LOCATIONS Elected Meeting President Location Caucus Year Year Norman M. 1993 Sacramento, CA 1994 NC Christensen Louis L. Smith 1992 Scottsdale, AZ 1993 SC Clare G. Peterson 1991 Keoneloa Bay at 1992 OR /HI Poipu, Kauai, HI Allen H. Johnson 1990 Pebble Beach 1991 NC Eric W. Fonkalsrud 1989 Laguna Nigel, CA 1990 SC George I. Thomas 1988 Vancouver, BC 1989 WA/BC/AK John K. Stevenson 1988 Vancouver, BC 1989 WA/BC/AK F. William Blaisdell 1987 San Francisco, CA 1988 NC John E. Connolly 1986 Rancho Mirage, CA 1987 SC Thomas J. Whelan, Jr. 1985 Maui, HI 1986 OR /HI Roy Cohn 1984 Monterey, CA 1985 NC Wiley F. Baker 1983 Newport Beach, CA 1984 SC Hilding H. Olson 1982 Seattle, WA 1983 WA/BC/AK David J. Dugan 1981 Napa Valley, CA 1982 NC William R. Mikkelsen 1980 Coronado, CA 1981 SC Thomas R. 1979 Hawaii 1980 OR /HI Montgomery Philip R. Westdahl 1978 Yosemite, CA 1979 NC William F. Pollock 1977 Newport Beach, CA 1978 SC Carl R. Schlicke 1976 Palm Springs, CA 1977 WA/BC/AK Ralph D. Cressman 1975 Monterey, CA 1976 NC Max R. Gasper 1974 Scottsdale, AZ 1975 SC Allen M. Boyden 1973 Kaanapali Beach, HI 1974 OR /HI Paul C. Samson 1972 Yosemite, CA 1973 NC Gordon K. Smith 1971 San Diego, CA 1972 SC Joel W. Baker 1970 Mexico City, Mexico 1971 WA/BC/AK H. Brodie Stephens 1969 San Francisco, CA 1970 NC Lyman A. Brewer III 1968 Palm Springs, CA 1969 SC Matthew McKirdie 1967 Honolulu, HI 1968 OR /HI Leon Goldman 1966 Monterey, CA 1967 NC Arthur Pattison 1965 Palm Springs, CA 1966 SC Ralph H. Loe 1964 Vancouver, BC 1965 WA/BC/AK Carleton 1963 San Francisco, CA 1964 NC Mathewson, Jr. John C. Jones 1962 Palm Springs, CA 1963 SC John E. Raaf 1961 Portland, OR 1962 OR /HI Robert A. 1960 San Francisco, CA 1961 NC Scarborough PAST PRESIDENTS AND MEETING LOCATIONS 133 Elected Meeting President Location Caucus Year Year Clarence J. Berne 1959 Palm Springs, CA 1960 SC Caleb S. Stone, Jr. 1958 Victoria, BC 1959 WA/BC/AK H. Glenn Bell 1957 Santa Barbara, CA 1958 NC William J. Norris 1956 Palm Springs, CA 1957 SC Louis R. Gambee 1955 Palm Springs, CA 1956 OR /HI Loren R. Chandler 1954 Yosemite, CA 1955 NC E. Eric Larson 1953 Santa Barbara, CA 1954 SC Alexander B. Hepler 1952 Harrison Hot Springs, BC 1953 WA/BC/AK Alson R. Kilgore 1951 Del Monte, CA 1952 NC William K. Kroger 1950 Coronado, CA 1951 SC Eugene W. Rockey 1949 Gearhart, OR 1950 OR /HI Howard C. Naffziger 1948 San Francisco, CA 1949 NC Leroy B. Sherry 1947 Los Angeles, CA 1948 SC Homer D. Dudley 1946 Victoria, BC 1947 WA/BC/AK Philip K. Gilman 1945 San Francisco, CA 1946 NC Philip K. Gilman 1944 No meeting due to WWII 1945 NC Philip K. Gilman 1943 No meeting due to WWII 1944 NC Philip K. Gilman 1942 No meeting due to WWII 1943 NC Philip K. Gilman 1941 No meeting due to WWII 1942 NC Charles T. Sturgeon 1940 Los Angeles, CA 1941 SC Richard B. Dillehunt 1939 Pointland, OR 1940 OR /HI Sumner Everginham 1938 Del Monte, CA 1939 NC Wayland A. Morrison 1937 Los Angeles, CA 1938 SC Otis F. Lamson 1936 Vancouver, BC 1937 WA/BC/AK Harold Brunn 1935 Del Monte, CA 1936 NC E. C. Moore 1934 Santa Barbara, CA 1935 SC Ernst A. Sommer 1933 Gearhart, OR 1934 OR /HI Emmet Rixford 1932 Del Monte, CA 1933 NC Rea Smith 1931 Santa Barbara, CA 1932 SC J. Tate Mason 1930 Victoria, BC 1931 WA/BC/AK Wallace I. Terry 1929 Del Monte, CA 1930 NC A. Stewart Lobinger 1928 No info available 1929 No info available Robert C. Coffey 1927 No info available 1928 No info available Stanley Stillman 1926 No info available 1927 No info available Charles D. Lockwood 1925 Del Monte, CA 1926 NC Founder’s Meeting San Francisco, CA 1925
134 PAST PRESIDENTS AND MEETING LOCATIONS New Members Name Caucus
Bard Clifford Cosman, MD SC
Joseph Frankhouse, MD OR/HI
Bruce L. Gewertz, MD SC
Jedediah A. Kaufman, MD WA/BC/AK
Ravin R. Kumar, MD SC
Gerald S. Lipshutz, MD SC
John Maa, MD NC
Matthew Martin, MD WA/BC/AK
Robert Martindale, MD, PhD OR/HI
Ian R. Neilson, MD WA/BC/AK
William John Orrom, MD WA/BC/AK
Bruce M. Potenza, MD SC
Vincent Lopez Rowe, MD SC
Scott R. Steele, MD WA/BC/AK
Mark Adams Talamini, MD SC
Ronald Wolf, MD OR/HI
NEW MEMBERS 135 Bard Clifford Cosman Jedediah A. Kaufman
Joseph Frankhouse Ravin R. Kumar
Bruce L. Gewertz Gerald S. Lipshutz
136 neW MEMBERS John Maa Ian R. Neilson
Matthew Martin William John Orrom
Robert Martindale Bruce M. Potenza
NEW MEMBERS 137 Vincent Lopez Rowe Ronald Wolf
Scott R. Steele
Mark Adams Talamini
138 neW MEMBERS
In Memoriam Deceased Members
Felix D. Battistella
Timothy J. Campbell
Ralph D. Cressman
J. Gordon Holmes
Allen H. Johnson
Stephen J. Mathes
Richard D. Sloop
James C. Thompson
Werner E. Zeller
140 in MEMORIAM Felix D. Battistella 1959–2008 Felix D. Battistella, MD, a gifted surgeon and chief of trauma surgery at the University of California, Davis Medical Center, died January 22, 2008, after a protracted struggle with cancer. An active member of the Pacific Coast Surgical Association, he was 48. Dr. Battistella earned a medical degree from the University of California, Davis in 1985 and joined the trauma faculty at that institution after completing his residency in 1991. He rose rapidly to the level of professor of surgery and chief of trauma and emergency surgery. He also served as hospital chief of staff from 2004 to 2006. Felix was highly respected as a superb clinician and technical surgeon. He was also an award-winning teacher and served for an extended period of time as his program’s residency director. He was kind and gentle with patients and their families, and his obituary in the Sacramento paper prompted a number of readers to write to the paper with personal stories detailing his care of their loved ones and expressing their sorrow at his passing. Felix was also a committed family man and is survived by his wife and two daughters. He once characterized what he did for a living as an essentially selfish pursuit, but somehow he managed to live his life such that patients, families, colleagues, and his own family always all knew that they were top priorities. Felix was a dedicated bicyclist and participated as a member of Team Donate Life, a group of medical professionals and a transplant recipient who, as part of the 2005 Race Across America held to promote organ donation, cycled across the United States in six days. During the race, Felix crashed at one point and broke his nose. He set it himself and kept riding. Team Donate Life finished sixth out of 51 entries. Felix will be sorely missed. He leaves enduring legacies from both his professional and personal life. —David Wisner, MD
IN MEMORIAM 141 Timothy J. Campbell 1938–2008 Timothy J. Campbell, MD, died on May 8, 2008, in Portland, OR. While a resident in general surgery, he developed deep venous thrombosis and was anticoagulated for the rest of his life. He developed a severe coagulopathy leading to multiple pulmonary emboli over a period of years. He died after a heroic struggle following bilateral pulmonary embolectomy. Tim, as he was known to his friends, was born in Salem, OR, on September 17, 1938, to Charles Campbell, an internist, and Della Campbell, a Republican committeewoman. He was one of four children. Tim graduated from Culver Military Academy. As a senior, he was voted best all-around athlete. He earned his BA from Willamette University, where he lettered in football, golf, and tennis, and he received his MD from the University of Oregon Medical School, now known as Oregon Health and Science University. His residency in general surgery was performed at the same institution, followed by a pediatric surgery fellowship at the Pittsburgh Children’s Hospital with Dr. William Kieswetter. Tim then returned to Portland to start his practice at Emanuel Hospital. For most of his career, he was also on the faculty of the Department of Surgery at Oregon Health and Science University. During the later part of his career, he was on the staff at Providence St. Vincent’sH ospital. During high school Tim met Peggy Hoffman, and they were married in 1960. They had two daughters, Allison and Jennifer. In 1986, he married Shelley LeDoux Bunce and welcomed into his family her children, Brandon and Kelly Bunce. Together he and Shelley built a life on their farm, Windbourne, where they enjoyed raising and showing black and tan coonhounds and horses.
142 in MEMORIAM Tim’s great joys were fly-fishing and playing golf and cards with his friends at the Lake Oswego Country Club, where he was the resident jester. For many years Tim was the Oregon left-handed golf champion.H e often organized the golf tournaments at the annual meetings of the American Pediatric Surgical Association and the Pacific Association of Pediatric Surgeons.T im was fun-loving, and his sense of humor was often on display. While on the pediatric outpatient rotation in medical school, it was customary for each student to give a talk to his fellow students following the Saturday clinic. Tim’s Saturday fell the morning after the senior banquet.H e showed up for clinic still in his formal attire. When called upon to give his talk he said, “My topic today is the poisonous birds of North America. There are no poisonous birds in North America.” The instructor immediately dismissed the class. A celebration of Tim’s life was held May 31, 2008. He will be missed not only by his family and many friends and colleagues, but by his grateful patients. Tim was not only a champion left-handed golfer, but also a champion left-handed pediatric surgeon. —John R. Campbell, MD
IN MEMORIAM 143 Ralph Cressman Ralph Cressman was born in Olgesbey, IL on January 17, 1909, to Dr. Ralph and Emily Cressman. He graduated from high school in Hastings, NE in 1925 and the University of California Berkeley with a BS in 1929 and a Masters in Anatomy in 1931. He completed Medical School in 1934 at the University of California San Francisco. From the time he was very young, Dr. Cressman knew he wanted to be a surgeon like his father, often sitting on the operating room floor while his father operated. He married the love of his life, Bunny, in August of 1935, and they had two offspring, Russell and Ann Caroline. Dr. Cressman’s medical career included an internship at Highland Hospital in Oakland, and then he returned to UCSF for his surgical residency from 1935 to 1939. He spent his final years in Nashville,T N, with Dr. Alfred Blalock. During World War II, Dr. Cressman served with the 59th Evacuation Hospital from April 1942 until September 1945. This hospital unit was organized at San Francisco General Hospital and was composed of Stanford and UC doctors, many of whom later became members of the Pacific Coast Surgical Association. After the war he joined the Palo Alto Clinic, where he worked until 1978. He also was Professor of Surgery at Stanford from 1970 through 1974, and Emeritus after that.H e was Secretary of the Board of Governors of the American College of Surgeons from 1967–1968. He served the Pacific Coast Surgical Association as Ttreasurer from 1964–1968 and was elected president in 1975. Following his retirement, Dr. Cressman spent his time traveling with his wife, Bunny. He also pursued his other favorite activities, duck hunting and playing golf. His life and career touched many, and in his wake there were always smiles. My own relationship with Ralph began when I was a senior pre-med student at Stanford, working as a night orderly in the operating room at the old Stanford hospital. Even to my unschooled eye, he and his partner, Blake Wilbur, at Palo Alto
144 in MEMORIAM Medical Clinic, were a cut (no pun intended) above his contemporaries. At that time, I too decided when I finished med school in the future, I would become a surgeon—hopefully modeled after Ralph. As summed up best by his wife, Bunny, “Ralph had all his buttons to the end of his life, for which I was so thankful. I miss him.” —Robert Seipel, MD
IN MEMORIAM 145 James Gordon Holmes 1924–2007 Born in Salt Lake City, UT, on January 14, 1924, Gordon Holmes was witness and participant to some of the most stressful events of our country’s history, including the Great Depression and World War II. His contributions to the well-being and improvement of his fellow man started at a young age in Utah, where he attended the University of Utah and was twice elected class president. He went on to medical school at Stanford University and residency at Stanford, training on the Stanford service at SF General Hospital. The war years intervened, and he served as a Captain and flight surgeon in the U.S. Army Air Corps for the duration of the war, returning home to the Bay Area following the war. He joined the medical staff of Alta BatesH ospital in Berkeley, later becoming chief of staff of both Alta BatesH ospital and Herrick Hospitals. He practiced general and vascular surgery in Berkeley for the next 40 years and was loved and lauded by his numerous patients and colleagues. Yet his true scope of influence spread far and wide beyond the hospital setting. Gordon was active as Professor of Human Anatomy in the joint UC Berkeley/UC San Francisco Medical School. His students named him top professor, and upon his retirement a scholarship was named in his honor. Gordon was also active in his chosen hometown of Lafayette, CA. He moved there in 1955 when it was a small bucolic suburb, then served on its city council and eventually become the town’s second mayor. He was never far removed from nature, taking hunting trips with his grown boys or horseback riding with his daughter in the Sierras. Gordon loved husbanding the land, planting fruit trees and a vegetable garden at his home in Lafayette. He always looked forward to sharing the bounty of his harvest with his family, especially his 12 grandchildren. His honors included his election to the Pacific Coast Surgical Association in 1983, his presidency of the Stanford Medical Alumni Association, and being a member of the Stanford academic senate. Gordon’s service to mankind included a UN- sponsored mission to the refugee camps of Southeast Asia following the Vietnam War. This mission altered the lives of the refugees, as well as the lives of Gordon and his sons who accompanied him there. He passed away on July 30, 2007, but his memory and his service will last a long time. He will be sorely missed. —Steve Etheredge, MD
146 in MEMORIAM Allen H. Johnson 1922–2008 Allen Johnson, MD, long-time San Jose resident and community leader, passed away peacefully on May 2, 2008. He is survived by his loving wife, Darlyn, and a wonderful blended family, which includes his children Katie Williams (Dick), Martha Gillespie (Jerry), Beth Riley (Mark), and Ken Johnson (Nina); Darlyn’s children Liz Del Plato (Will), Kathy Mazonni (Michael), and Craig Richardson (Kelli); 16 grandchildren, and 8 great- grandchildren. He was predeceased by his first wife, Mary, in July 1983. Dr. Johnson was born in Atascadero, CA, on January 23, 1922. He grew up in Paso Robles. He attended UC Berkeley, where he ran on the track and cross-country teams and served as president of his senior class. He remained a loyal Bear backer his whole life. He graduated from UCSF medical school in 1946 and did a rotating internship on the University of California service at San Francisco General Hospital. While there, he caught the attention of the acting chairman of surgery, Dr. Leon Goldman, who encouraged him to pursue a surgical career and selected him for the surgical residency at UC. After one year in the program, Allen went into the army for two years and was stationed in the Aleutian Islands, following which, in 1950, he returned to the UC surgical residency program. In 1952, Allen contracted polio, which temporarily halted his surgical career. While recovering, he spent a year in pathology but soon realized that his calling was in healing and working with people. So with courage and commitment he returned to surgery, becoming chief resident in 1954. In 1955, Dr. Johnson completed his surgical residency and began private practice in San Jose. While there he was also drawn into surgical teaching and served as a clinical professor of surgery at Stanford University, a surgical educator in the family practice residency program at San Jose Hospital, and a lecturer in the school of nursing at both San Jose Hospital and O’Connor Hospital. He practiced in San Jose for more than 35 years, serving as chief of staff of the Santa Clara Valley Medical Center and San JoseH ospital.
IN MEMORIAM 147 His leadership in his professional and community life is evident by the number of positions he held and honors he received. He was honored as UC San Francisco Alumnus of the Year in 1995, served as Governor of the American College of Surgeons, president of the Pacific Coast Surgical Society, and president of the Nafziger Society and the California Academy of Medicine. He also participated in a Harvard- sponsored People-to-People surgeon exchange program with China. Dr. Johnson was awarded the Legacy Medal from the city of San Jose in 1981 for his distinguished service to the city, the Community Service Award of the Santa Clara County Medical Association, and the Man and Boy Award of the Boy’s Club of Santa Clara County. He also served with distinction on a number of Boards of Directors in the San Jose area, including the San Jose Metropolitan YMCA, the central chapter of United Way, the American Red Cross, the Visiting Nurse Association, Church of the Valley, the San Jose Country Club, and the Institute for Medical Research. He also belonged to Spyglass Hill Golf Club and the Beethoven Society. Even with his strong commitment to his community and career, nothing was more important to him than his family. He loved traveling with them and they spent many summers camping together in the United States’ and Canada’s National Parks in a travel trailer. More recently, his whole family has enjoyed Hawaii and cruising the inside passage of Alaska. Allen Johnson was a man of integrity who lived his life with kindness and compassion. He touched the lives of all those who had the privilege to know him with his love of humanity and his devotion to his family. He will be greatly missed. Go Bears! —Robert Seipel, MD
148 in MEMORIAM Stephen J. Mathes 1943–2007 Stephen Mathes, MD, died on November 20, 2007, after a long and valiant battle with ALS (Lou Gehrig’s disease). Born and raised in New Orleans, LA, Stephen obtained his undergraduate BS degree at Louisiana State University in Baton Rouge in 1964 and his MD degree at LSU School of Medicine in New Orleans in 1968. While in Baton Rouge, he played for the LSU tennis team, and although his skills in tennis were not at the professional level, tennis remained his favorite sport, and he enjoyed matches with his colleagues throughout his career. He was called to serve as a major in the U.S. Army Medical Corps and asked to be stationed in south Louisiana, where he treated soldiers from his state who were wounded in Vietnam. He served as the Assistant Chief of Surgery at Fort Polk Army Hospital from 1970–1972. At Emory University in Atlanta, Stephen completed residencies in general surgery (1975) and plastic surgery (1977). Prompted by his experience working as a surgeon at Fort Polk, he developed a laboratory to explore the anatomy of muscle and musculocutaneous flaps and microsurgery. In this laboratory, he identified the pedicles to many of the muscles, which he soon would be describing as clinical flaps, to cover devastating wounds or to restore contour or provide stable coverage after tumor surgery or trauma. These anatomical preparations and his subsequent publications were the source of the musculocutaneous flaps soon to be adopted nationally and internationally for the coverage of previously untreatable wounds. Stephen chose an academic career in surgery and in 1977 was appointed head of the Burn Unit at Washington University in St. Louis, MO. He became the first surgeon in St.L ouis to use microvascular surgery to perform replantations and flap transplantation. One night, he encountered a dentist whose young son had amputated his dominant thumb. The father told Stephen that his son was talented enough to one day have a career as a football pro, and therefore must have the thumb replanted. Fortunately, the thumb replant was successful and many years later, Stephen opened his mail to find a sport’s
IN MEMORIAM 149 page showing a quarterback who was the hero of a game. The quarterback’s father had a red circle around the thumb that was about to release the ball for a forward pass. Above the passing hand was the word, “thanks.” In his initial year in academics, Stephen published his first textbook, Clinical Atlas of Muscle and Musculocutaneous Flaps. This text showed the vascular anatomy of flaps throughout the body and demonstrated how to transfer and rotate tissues to various sites as needed for reconstruction. In 1978, Stephen moved to San Francisco to join the faculty at the University of California San Francisco. Here he was involved in basic science and clinical research that received grant support through the NIH, Spinal Cord Research Society, and society grants. Over 42 research fellows from the United States, Europe, and Asia were supervised in his laboratory or on clinical projects. His major basic research showed the ability of the muscle flap to deliver leukocytes and antibiotics to prevent or eliminate harmful bacteria. This basic science work was successfully applied in clinical projects using aggressive debridement, muscle flaps, and limited antibiotics to treat chronic osteomyelitis and chronic radiation wounds. In 1984, Stephen was appointed Professor of Surgery, and in 1985, he became head of the Division of Plastic Surgery and Residency Program Director at UCSF. He held an additional appointment as Professor of Growth and Development in the School of Dentistry. During his 26 years on the faculty at UCSF, 62 residents completed their plastic surgery training. During his 20-year tenure as program director, 40 percent of these graduating residents accepted academic positions in surgery in university programs. Stephen received numerous awards recognizing his basic science and clinical research. These included six first prize awards from the Plastic Surgery Educational Foundation extending from 1981–1999. Other awards included: Special Achievement Award from the American Society of Plastic Surgeons, James Barrett Brown Award for best paper in the Journal of Plastic and Reconstructive Surgery, and Best Medical Book Award from the American Medical Writers Association. Stephen was a member of more than 32 national and international professional societies. He served as chairman of the Plastic Surgery Research Council, director of the American Board of Plastic Surgery, chair of the Residency Review Committee for Plastic Surgery, president of the Association of Academic Chairman in Plastic Surgery, president of the Plastic Surgery Educational Foundation, and secretary and trustee for the American Association of Plastic Surgery. He published more than 233 peer-reviewed papers and chapters as well as six books, most recently a two-volume text, Reconstructive Surgery, and the eight-volume edition of Plastic Surgery published in 2006. The latter text covers the scope and practice of the specialty of plastic surgery in 219 chapters, and the editing process alone took over five years. Stephen was a visiting professor in more than 25 countries, delivered over 400 formal lectures, and participated in symposia throughout the world.
150 in MEMORIAM Stephen Mathes was a towering figure in 20th Century plastic and reconstructive surgery. He was a role model, educator, mentor, and a gifted surgeon and will be remembered by his many friends and those he trained as brilliant, creative, supportive, energetic, lively, and fun- loving. He leaves his wife, Mary H. McGrath, MD; his mother, Norma D. Mathes; his sons David W. Mathes, MD, Brian A. Mathes, and Edward J. Mathes; and many friends and colleagues the world over. We miss him, and celebrate his exceptional career. —Mary H. McGrath, MD, MPH
IN MEMORIAM 151 Richard Donald Sloop 1931–2007 On October 27, 2007, peacefully and surrounded by family, friends, and devoted caregivers, Richard “Dick” Donald Sloop passed away at the age of 75. He died of Alzheimer’s disease. Dick was born in North Bend, OR, on December 3, 1931, the only child of Helen and Don Sloop. He was raised in Portland and graduated from JeffersonH igh School. Dick met his wife, Barbara Jean Smith of Portland, while they were both attending Oregon State College. They were married in 1953, following their graduation. Dick earned his medical degree from Oregon Health Sciences University’s School of Medicine and graduated first in his class in 1956. After medical school, he served in theU .S. Navy at the Glenview Naval Air Station in Evanston, IL. Dick’s medical training took him to Minneapolis, Seattle, and Los Angeles. He and Barbara settled in Salem, OR, where he was a general, thoracic, and vascular surgeon from 1965 until his retirement in 1998. Throughout his career, Dick strove to do what was best for his patients. He was vigilant about keeping up with the rapid progress in his field, and led by bringing surgical advances to the Salem medical community. Dick loved the outdoors and actively pursued a variety of activities as a way to bring together and educate his family. He shared the love of fishing, backpacking, and camping he acquired from his father. Over the years, he and Barb organized annual white-water rafting, hiking, and snow skiing vacations for family and friends. Dick was an accomplished carpenter, who built several drift boats with help from his kids.H e loved working in the family cherry orchard with the children, especially maintaining an antique Caterpillar tractor. In his youth, he was a fine pianist, and throughout his life he continued to share his love of music with his children and grandchildren. Dick is survived by his wife, Barbara, of Salem; five children, David, Janet, Mike, Steve, and Dan; and 11 grandchildren.
152 in MEMORIAM James C. Thompson 1928–2008 James C. Thompson, MD, FACS, one of the leading surgical scientists, educators, and statesmen of the past half-century, died in his home in Galveston, TX, on May 9, 2008, of prostate cancer. He was 79 years old. From 1970 to 1995 he was chairman of the Department of Surgery at the University of Texas Medical Branch (UTMB) in Galveston, where he also served as the Ashbel Smith Professor of Surgery and jointly as professor in the Department of Physiology and Biophysics. He is widely credited with building one of the leading surgical scientific programs in theU nited States and with bringing about a sea change throughout UTMB in education and research. Jim Thompson was not born with a silver spoon in his mouth. He grew up in the little cow town of Hebbronville in Jim Hogg County in south Texas, population 3,000. In 1944, when he had just turned 16, he entered the Agricultural and Mechanical College of Texas, now Texas A&M University, graduating with a BS degree in two years. In 1946, at 18, he entered medical school at UTMB. After two years in rotating internships and a year in the research lab, Dr. Thompson entered the clinical surgery residency at Penn in 1953 and completed residency in 1959. His training was interrupted during the Korean War by the “doctors draft,” which resulted in a two-year stint in the U.S. Army Medical Corps in Germany, where he achieved a modicum of fame in U.S. Army circles for the unanticipated “laryngitis” epidemic. When he completed the surgical residency at Penn, he was shunted off to the old Pennsylvania Hospital, a Penn affiliate, to fend for himself. What he accomplished on his own at the Pennsylvania Hospital from 1959 to 1963 was remarkable, and a tribute to his determination, tenacity, and ability. In 1963, he was recruited by Dr. Marshall Orloff toU CLA-Harbor General Hospital, and in 1967, he succeeded Dr. Orloff as Professor and Chief of Surgery. In 1970, he was recruited by his alma mater, UTMB, to return as Professor and Chair of Surgery for the next 25 years.
IN MEMORIAM 153 Scientific Contributions The research laboratory that Jim Thompson established was involved continuously in the investigation of basic and applied principles of gastrointestinal (GI) physiology and endocrinology. The numerous original and far-reaching studies undertaken by the Thompson laboratory focused particularly on the identification and function of GI hormones in health and disease. The laboratory and clinical research accomplished by the Thompson group resulted in 616 publications in peer-reviewed journals, 120 book chapters, and 588 scientific abstracts in the 54 years from 1953 to 2007. Service to Surgery and Society Dr. Thompson’s record of service to surgery and to society is unsurpassed. He was elected to the presidency of six major national surgical organizations, including the American College of Surgeons, the American Surgical Association, the Southern Surgical Association, the Society for Surgery of the Alimentary Tract, the Society of Surgical Chairmen, and the James IV Association of Surgeons. Contributions to Education Arguably, Jim Thompson’s most lasting contributions were in education. He trained 131 research fellows from the United States and 18 foreign countries and more than 200 residents in clinical surgery. Honors In 1993, Surgical Forum Volume 44 of the American College of Surgeons was dedicated to Jim Thompson, and in 1996, the American College of Surgeons selected him for the Distinguished Service Award. Qualities of Character and Personality Dr. Thompson will be remembered forever by his students, residents, research fellows, and coworkers, young and mature alike, as an inspirational teacher and role model of what a university professor should be. He will be remembered by his colleagues and the surgical profession as a leader who influenced the course of a great university.H e will be remembered by his many, many friends as a warm, thoughtful, generous, loyal, and engaging man who enriched the lives of all who had the good fortune of coming to know him. And, of course, he will be sorely missed by his six children, five grandchildren, long-time companion Bebe Jensen, and the entire Orloff family, who knew him asU ncle Jim. —Marshall J. Orloff, MD (edited for inclusion by L. Wagman)
154 in MEMORIAM Werner Emanuel Zeller 1911–2008 Werner “Bud” Emanuel Zeller, MD, born October 15, 1911, in Portland, OR, died on March 6, 2008, at the age of 96 years. Bud graduated from Washington High School and Reed College, and then attended the University of Oregon Medical School, graduating in 1937. He married Maxine Lois Lesseg in 1937. During World War II, he served as a Navy surgeon aboard the USS Tennessee, attaining the rank of lieutenant commander. Bud was appointed to the faculty of the University of Oregon Medical School as an Assistant Clinical Professor of Surgery in 1946. He practiced medicine and was a general surgeon on the staff of Providence Portland Medical Center and Woodland Park Hospital, practicing for more than 50 years until he retired in 1995. He was also mayor of Maywood Park for 11 years. Bud became a member of the North Pacific Surgical Association in 1950, and was also a member of the Pacific Coast Surgical Association and a leader in the Portland surgical community. He was preceded in death by his wife, Maxine, and is survived by his daughters, Mary Bess and Katherine Lamb, sons, Robert and Richard Zeller, eight grandchildren, and two great grandchildren. A celebration of life was held at Providence Portland Medical Center on April 4, 2008. —James W. Asaph, MD
IN MEMORIAM 155
Leroy C. Abbott 1966 TimothyDeceased J. Campbell 2008 David J. Dugan 1999 Alfred O. Adams 1989 James R. Cantrell 1983 John Duncan 1988 Lemuel P. Adams 1940 C. James Carrico 2002 J. Englebert Dunphy 1981 Frank Anderson 1989 Charles R. Cavanagh 2006 James B. Eagelson 1928 Harvey Baker 1990 Lawrence Chaffin 1995 K. William Edmark 1994 Joel Wilson Baker 1999 Loren R. Chandler 1982 William K. Ehrenfeld 2005 Edwin J. Bartlett 1954 Herbert S. Chapman 1963 Charles F. Eikenbary 1933 Felix D. Battistella 2008 Lester R. Chauncy 1962 Leo Eloesser 1976 Robert H. Beach 1969 Walter C. Chidester 1936 John E. Else 1935 Hiram Belding III 1984 Albert Guernsey Clark 2002 Sumner Everingham 1959 H. Glenn Bell 1981 James S. Clarke 1976 Fred R. Fairchild 1959 Folkert O. Belzer 1995 Edwin G. Clausen 1966 Jack M. Farris 1990 Frederick H. Bentley 1980 Harry B. Cliff 1951 Paul G. Flothow 1953 Clarence J. Berne 1987 John W. Cline 1974 Frederick C. Foote 1958 Eugene F. Bernstein 1995 Guy H. Cochran 1940 Robert D. Forbes 1974 Alexander H. Bill 1996 Robert C. Coffey 1933 Hugh S. Ford 2003 Frederick M. Binkley 2006 Walter B. Coffey 1944 Charles M. Fox 1962 John F. Binnie 1936 Arthur Cohen 1988 Donald M. Gallagher 1997 Walter D. Birnbaum 2004 Roy Cohn 1998 Louis R. Gambee 1957 Harry M. Blackfield 1983 Foster K. Collins 1939 Richard E. Gardner 1995 Harry Blair 1975 John Collins 1992 Frank Gerbode 1984 George M. Bogardus 1974 Hugh D. Colver 2002 August E. Gerhardt 1942 Frederic C. Bost 1959 Donald G. Corbett 1980 Edgar L. Gilcrest 1964 Allen Boyden 1993 John F. Cowan 1929 Philip K. Gilman 1948 Donald F. Brayton 2002 Francis J. Cox 1981 John Gius 1998 Lyman A. Brewer III 1988 Peter Crabtree 1955 John M. Goin 1995 A. Lincoln Brown 1962 Ralph D. Cressman 2008 Leon Goldman 1975 Maurice Brown 2003 Albert C. Daniels 1985 John N. Goodwin 1998 Rexwald Brown 1940 Sherman W. Day, Jr. 1999 Willard E. Goodwin 1998 Clarence W. Brunkow 1974 John H. Dawson 2006 H. Earl Gordon 2007 Harold Brunn 1950 Lawrence DenBesten 1988 Robert H. Gourlay 2001 Thomas O. Burger 1953 Richard Diefendorf 1994 Walter Graham 1990 Lucian C. Buscaglia 2004 David H. Dillard 1993 W. Wallace Greene 2003 Samuel H. Buteau 1926 Richard D. Dillehunt 1953 Charles A. Griffith 1995 Edmond Butler 1996 Edward T. Dillon 1939 Orville Frank Grimes 1998 Edmund Butler 1955 Leonard Dobson 1979 Leroy E. Groshong 2003 Ralph V. Byrne 1981 Frank Dolley 1961 Lewis Guiss 1992 Samuel L. Caldbick 1941 Homer D. Dudley 1950 Jack R. Gustafson 1998
156 deCEASED Russell G. Gustavson 2001 Thomas W. Jones 2006 Charles E. MacMahon 1980 Donald Hall 1994 Thomas M. Joyce 1947 Gordon E. Madding 1989 Bert L. Halter 1995 Charles Judd 1987 ThomasL . Marchioro 1995 John R. Hand 1991 James R. Judd 1947 J. Tate Mason 1936 Kenneth L. Hardy 1973 Maurice Kahn 1950 J. Tate Mason, Jr. 1997 Henry N. Harkins 1967 Edmund Kanar 1996 Stephen J. Mathes 2008 R. Cameron Harrison 2002 Allen B. Kanavel 1938 Carleton Mathewson, Jr. 1989 Sherman W. Hartman 1979 Joseph J. Kaufman 1999 Ralph C. Matson 1945 Leonard D. Heaton 1983 Paul A. Kennedy 1993 A. Aldridge Matthews 1940 Erle Hendriksen 1996 John H. Kieraldo 1977 Karl J. May, Jr. 2003 R. Bruce Henley 1966 Alson R. Kilgore 1959 Ray B. McCarthy 1950 Alexander B. Hepler 1971 Eugene S. Kilgore 2003 Horce McCorkle 2001 Clifford M.H erman 2007 Brien T. King 1965 Ian McDonald 1967 Siegfried F. Herrman 1970 Lawrence B. Kiriluk 1997 Robert E. McKechnie 1974 George A. Higgins, Jr. 1994 W. D. Kirkpatrick 1954 Francis M. McKeever 1973 John Higginson 1998 William S. Kiskadden 1969 Robert J. McKenna 2005 Lucius D. Hill 2001 Russell R. Klein 1991 Allen McKenzie 1992 Frank Hinman 1961 Samuel L. Kountz 1982 Matthew McKirkie 1984 Harold H. Hitchcock 1955 Wm. W. Krippaehne 1985 Thomas R. McNab 1948 William B. Holden 1955 William Kroger 1981 J. B. McNerthney 1928 Emile F. Holman 1977 William C. Krupski 2004 David Metheny 1972 J. Gordon Holmes 2008 Otis F. Lamson 1957 Bert W. Meyer 2006 George M. Horton 1927 Henry J. Lange 2002 Herbert W. Meyer 1973 Lucius W. Hotchkiss 1925 E. Eric Larson 1962 William P. Mikkelsen 1990 Martin A. Howard 1980 Earl P. Lasher, Jr. 1984 Thomas Montgomery 1999 Nelson J. Howard 1981 Roy E. Lau 2007 Herbert S. Mooney 1989 Arthur Hunnicutt 1993 G. Hugh Lawrence 2001 Alois E. Moore 1970 Verne C. Hunt 1943 Sanford Leeds 1995 E. C. Moore 1945 Thomas W.H untington 1929 Frederick Leix 2003 Thomas C. Moore 2004 Edward John Hurley 2007 George C. Lindesmith 2006 William Moore 1969 William B. Hutchinson 1927 Wm. K. Livingston 1966 Wayland A. Morrison 1949 Paul Pierce Jackson 2000 Allan W. Lobb 1998 Edmund G. Morrissey 1986 Conrad Jacobson 1955 A. Steward Lobinger 1939 Lewis B. Morton 1943 Robert W. Jamplis 2003 Charles D. Lockwood 1932 H. Stephens Moseley 1995 W. Kenneth Jennings 1981 A. O. Loe 1935 Roscoe E. Mosiman 1981 Floyd H. Jergensen 1990 Ralph H. Loe 1970 Herbert John Movius 2004 Eugene Joergenson 1990 William P. Longmire, Jr. 2003 George L. Mulfinger 2007 Allen H. Johnson 2008 Alvin H. Lorch 1962 Bernard P. Mullen 1978 Clark M. Johnson 1948 Leo S. Lucas 1961 Thomas F. Mullen 1967 Murray L. Johnson 1995 Vetnon Lundmark 1971 Joseph Murray 2004 John C. Jones 1976 Frank W. Lynch 1945 Joseph W. Nadal 2001 S. Austin Jones 1985 Clayton G. Lyon 1983 Howard C. Naffziger 1961
DECEASED 157 Gunther Nagel 1993 John R. Rydell 1991 Joseph E. Strode 1972 Millard T. Nelson 1945 Paul C. Samson 1982 J. Guy Strohm 1973 J. Norton Nichols 1972 Eric R. Sanderson 1982 C. T. Sturgeon 1967 William Norris 1987 Robert A. Scarborough 1976 William H. Sutherland 1988 Hilding H. Olson 2007 Willis C. Schaupp 2006 William R. Sweetman 1990 Claude H. Organ, Jr. 2005 John A. Schilling 2000 George W. Swift 1938 Atthur C. Pattison 1975 Carl P. Schlicke 2001 Joseph K. Swindt 1945 John R. Paxton 1968 John M. Schmcele 1963 David A. Taft 2008 J. Howard Payne 1984 Karl J. Schmutzer 1988 David Tapper 2002 Seibert Pearson 1993 G. Edward Schnug 2002 William A. Taylor 1947 Harry Emerson Peters 1998 Albert J. Scholl 1982 Wallace I. Terry 1950 Richard M. Peters 2006 Dean Seabrook 1960 James C. Thompson 2007 Clare Peterson 2007 Henry H. Searls 1974 Clarence G. Toland 1947 Charles E. Phillips 1945 Casper W. Sharples 1941 Donald Trueblood 1958 Roland Pinkham 1986 C. Hunter Shelden 2003 Ernest F. Tucker 1927 William F. Pollack 2001 Henry H. Sherk 1926 Robinson Ward 1976 John M. Porter 2001 LeRoy B. Sherry 1968 Horace D. Warden 2006 Frederick W. Preston 1996 Frederic P. Shidler 2004 Raymond E. Watkins 1945 Kirk H. Prindle 1975 Norman E. Shumway 2006 Edward Ewing Wayson 1982 John E. Raaf 2000 Henry L. Silvani 1983 Alanson Weeks 1947 Kenneth P. Ramming 2004 Richard D. Sloop 2008 Joseph A. Weinberg 1986 Beatty Haig Ramsey 2000 Andrew C. Smith 1944 Robert F. Welty 1989 Clarence E. Rees 1963 Ernest T. Smith 1995 Francis E. West 1982 David L. Reeves 1971 Gordon K. Smith 1982 Philip R. Westdahl 2005 Frederick L. Reichert 1969 Rea Smith 1935 Horace G. Wethrill 1941 George K. Rhodes 1944 William R. Smith 1988 Thomas J. Whelan, Jr. 1999 Dexter N. Richards 1965 William H. Snyder, Jr. 1974 ThomasT . White 1988 Victor Richards 2002 Ernest A. Sommer 1936 Parke Weede Willis 1958 Emmet Rixford 1938 Alfred B. Spalding 1942 Irving Wills 1967 Joseph M. Roberts 1990 Charles H. Sparks 1973 John Wilson 2001 Ross Robertson 1993 Edward Spier 1971 John C. Wilson 1957 R. Edward Robins 2004 David Sprong 1978 John C. Wilson, Jr. 1984 Samuel Robinson 1947 Clarence E. Stafford 1974 Nat D. Wilson 2006 A. E. Rockey 1927 Howard Stearns 1985 Roger Wilson 1973 Eugene W. Rockey 1970 Muriel Steele 1980 Dean F. Winn 2006 Paul Rockey 1952 John H. Steelquist 1986 Robert A. Wise 1972 William L. Rogers 1987 Edward A. Stemmer 2007 J. Homer Woolsey 1980 Grosvenor Root 1993 H. Brodie Stephens 1983 Edwin J. Wylie 1982 Millard Rosenblatt 2000 John K. Stevenson 1988 Raymond L. Zech 1963 Leonard Rosoff 2001 Stanley Stillman 1934 Werner E. Zeller 2008 Charles J. Rowan 1952 Caleb S. Stone, Jr. 1982 William R. Russell 1988 Brian D. Stringer 2005
158 deCEASED Members by Caucus NON-RESIDENT Kenneth R. Tyson Ben L. Bachulis Ronald J. Weigel Richard H. Bell, Jr. Eugene A. Woltering William Brock Michael J. Zinner P. Richard Carter NORTHERN CALIFORNIA Paul R. Cordts Burton E. Adams Edward E. Cornwell III Robert J. Albo John J. Coyle Robert E. Allen, Jr. Richard A. Crass Maria D. Allo Julie A. Freischlag John T. Anderson Jerry Goldstone James P. Anthony Michael S. Hickey Nancy L. Ascher Blair Jobe John N. Baldwin Sister Mary Ann Lou J. Augusto Bastidas G. Robert Mason Ramon Berguer David W. McFadden Carl A. Bertelsen Louis M. Messina F. William Blaisdell Stephen L. Michel Richard John Bold Don R. Miller Mervyn F. Burke Donald L. Morton Andre R. Campbell R. Lawrence Moss Guilherme Campos William H. Muller Robert A. Chase Sean J. Mulvihill Yaneck S. Y. Chiu Kenric Murayama Norman M. Christensen John E. Niederhuber Orlo H. Clark Lloyd M. Nyhus Luther Fuson Cobb Patrick J. Offner, Jr. Robert C. Combs Charles L. Rice Mahlon C. Connett Thomas R. Russell Myriam J. Curet Theodore R. Schrock Ronald L. Dalman M. Michael Shabot Lawrence A. Danto Stephen J. Shochat Orland G. Davies, Jr. Steven C. Stain James W. Davis Roy L. Tawes Haile T. Debas
200 members BY CAUCUS Alfred A. deLorimier Jan K. Horn Pieter A. Devries Scott A. Hundahl Frederick M. Dirbas Thomas K. Hunt Quan-Yang Duh Eun-Sil Shelley Hwang Roger R. Ecker Joseph A. Ignatius John M. Erskine Leigh I. Iverson Carlos O. Esquivel David Jablons Laura J. Esserman Sang-Mo Kang Samuel N. Etheredge Electron Kebebew Stephen N. Etheredge Paul B. Kelly, Jr. Cheryl Ewing Kimberly S. Kirkwood Diana L. Farmer Mary M. Knudson Robert Foster Shoichi Kohatsu David G. Fraser Thomas M. Krummel Chris E. Freise R. Hewlett Lee Charles F. Frey Stanley P. L. Leong James E. Goodnight, Jr. Sheldon Levin William H. Goodson III Robert C. Lim, Jr. Carlos Gracia John P. Loftus Ralph S. Greco John Maa David G. Greenhalgh G. Andrew Macbeth David L. Gregg James R. Macho Jon M. Greif Robert C. Mackersie Douglas P. Grey M. Ellen Mahoney James M. Guernsey James B. D. Mark Keene O. Haldeman Clifford C. Marr Albert D. Hall James W. Martin E. John Harris, Jr. Nathaniel M. Matolo Edmund J. Harris Ivan A. May Hobart W. Harris James H. McClenathan Michael R. Harrison Mary H. McGrath F. William Heer John P. McVicar Arthur C. Hill Scot H. Merrick J. Hill Maria T. Millan Frank Hinman, Jr. Dwight H. Murray Ryutaro Hirose Eric Nakakura Elsa R. Hirvela Thomas S. Nelsen Hung S. Ho Jeffrey A. Norton James W. Holcroft Harry A. Oberhelman
MEMBERS BY CAUCUS 201 Cornelius Olcott IV Donald Tsang John T. Owings Madhulika Varma Tina Palmieri W. Lane Verlenden III Steven N. Parks Gregory P. Victorino Edward P. Passaro Irene L. Wapnir Marco G. Patti Richard E. Ward Lamont D. Paxton Robert Warren Jeffrey M. Pearl Lawrence W. Way Richard V. Perez Mark L. Welton Gerald W. Peskin Wendell W. Wenneker Elizabeth C. Pohlson James E. Wiedeman John M. Rabkin David H. Wisner John P. Roberts Bruce M. Wolfe Benson B. Roe Earl F. Wolfman Stanley Rogers Sherry M. Wren Leonard D. Rosenman Kent T. Yamaguchi George M. Rugtiv Franklin K. Yee Oscar Salvatierra Laurence F. Yee William P. Schecter David M. Young Lynette Ann Scherer Christopher K. Zarins Philip D. Schneider OREGON, HAWAII Robert J. Schweitzer Aftab Ahmad Robert G. Scribner Roger E. Alberty Robert S. Seipel James W. Asaph David A. Spain William C. Awe Arthur Stanten John F. Balfour Steven A. Stanten Peter J. Barcia Thomas R. Stevenson John U. Bascom Lygia Stewart Kevin Billingsley Peter G. Stock Bolek Brant James M. Stone John R. Campbell Ronald J. Stoney Alan H. S. Cheung Clifford J. Straehley Mathew H. Chung Gerald R. Sydorak Adnan Cobanoglu Arthur N. Thomas David W. Cook Michael L. Trollope Emilia L. Dauway-Williams Christoph Troppmann Clifford W. Deveney Kathrin Troppmann Karen E. Deveney H. Ward Trueblood William S. Fletcher
202 members BY CAUCUS H. Storm Floten Edward A. Smeloff Joseph Frankhouse Philip A. Snedecor William Garnjobst Blayne A. Standage Paul D. Hansen Albert Starr Marvin W. Harrison Lee L. Swanstrom John G. Hunter Donald D. Trunkey Toshio Inahara John T. Vetto Stanley W. Jacob R. Mark Vetto Nathalie M. Johnson Ronald Wolf William E. Johnson Linda L. Wong Ali Khaki Livingston M. F. Wong Daryl Kurozawa James A. Wood Gary H. Leaverton SOUTHERN CALIFORNIA Patrick Yuk-Hoi Lee Maher A. Abbas Yeu-Tsu M. Lee Sam S. Ahn Christopher N. Lim Delmar R. Aitken Whitney M. L. Limm Niren Angle Thomas D. Lindell Harry Applebaum William B. Long III Juan A. Asensio Henry Louie M. Atik M. C. Theodore Mackett James B. Atkinson Robert Martindale Leonard L. Bailey John C. Mayberry J. Dennis Baker Donald B. McConnell Jeffrey L. Ballard Gregory L. Moneta Wiley F. Barker Richard J. Mullins John R. Benfield Susan L. Orloff Robert S. Bennion Philip F. Parshley George Berci John H. Payne, Jr. John J. Bergan James J. Peck Thomas V. Berne Rodney F. Pommier Sunil Bhoyrul J. Karl Poppe Anton J. Bilchik Vincent A. Reger Jack H. Bloch Martin Allan Schreiber Frederic S. Bongard Earl S. Schuman Michael Bouvet Brett C. Sheppard Ronald W. Busuttil Ambrose B. Shields John A. Butler Walton K. Shim John L. Cahill Richard D. Sloop Robert Cameron
MEMBERS BY CAUCUS 203 Timothy G. Canty Carlos A. Garberoglio J. Kenneth Chong Julio Garcia-Aguilar David Z. J. Chu Max R. Gaspar Ray Siu-Keung Chung Donald J. Gaspard Marianne Cinat Alan B. Gazzaniga Raul Coimbra Hugh A. Gelabert Clarence Cole Alex Gerber J. Craig Collins John C. German Steven D. Colquhoun Bruce L. Gewertz John E. Connolly R. Mark Ghobrial Bard Clifford Cosman Armando Giuliano Peter F. Crookes Ian L. Gordon Henry M. Cryer III Frederic W. Grannis, Jr. Donald Cameron Dafoe Edward M. Greaney Edward A. Dainko Gregory C. Greaney Christian de Virgilio Philip Haigh Giacomo A. Delaria Nora M. Hansen Tom R. DeMeester Newlin Hastings Demetrios Demetriades Daniel M. Hays William R. Dietrick Jonathan R. Hiatt L. Andrew DiFronzo John R. Hilsabeck Ralph B. Dilley Oscar Joe Hines Wilton A. Doane David B. Hinshaw Arthur J. Donovan Darryl T. Hiyama Erik Dutson E. Carmack Holmes David W. Easter Douglas B. Hood A. Brent Eastman David Hoyt Frederick R. Eilber David Hsiang Joshua D. I. Ellenhorn Robert J. Hye Richard Essner David K. Imagawa Gregory R. D. Evans Edward J. Jahnke Douglas G. Farmer George L. Juler Arthur W. Fleming Arthur M. Kahn Eric W. Fonkalsrud Steven G. Katz Richard G. Fosburg Andrew Scott Klein Clarence Foster Stanley R. Klein Nova Foster Clifford Y. Ko Gilbert C. Freeman Roy D. Kohl David W. Furnas Ravin R. Kumar
204 members BY CAUCUS Lily Lai William G. Plested III Ronald G. Latimer Bruce M. Potenza Peter F. Lawrence Brant Aaron Putnam Alan T. Lefor William J. Quinones-Baldrich Michael E. Lekawa Robert W. Rand Phillip M. Levin Irving Rappaport Richard A. Lim Anees J. Razzouk Harvey N. Lippman Howard A. Reber Gerald S. Lipshutz John M. Robertson Jerrold K. Longerbeam John J. Rosental Jack W. Love Vincent Lopez Rowe James V. Maloney, Jr. Richard P. Saik, Jr. Daniel R. Margulies Ali Salim Fredrick W. Marx, Jr. Joseph D. Schmidt Rodney John Mason Robert R. Selby P. Michael McCart Anthony Shaw P. Michael McFadden William C. Shoemaker Donley G. McReynolds Allan W. Silberman John H. Mehnert Howard Silberman Amir Mehran Michael J. Sise Philip Mercado Louis L. Smith Wesley S. Moore Edward N. Snyder Leon Morgenstern Bruce E. Stabile Donald G. Mulder Michael J. Stamos G. Arnold Mulder David State James A. Murray Robert A. Steedman Ronald J. Nelson W. Eugene Stern Ninh Tuan Nguyen Geoffrey M. Stiles Theodore X. O’Connell Quentin R. Stiles Lisa A. Orloff Mark Adams Talamini Marshall J. Orloff, Jr. Jose J. Terz Robert S. Ozeran Jesse E. Thompson, Jr. Tom Paluch Ralph J. Thompson Dilip Parekh Areti Tillou Chirag Vipin Patel Gail T. Tominaga I. Benjamin Paz Ronald K. Tompkins Jeffrey H. Peters Richard L. Treiman Edward H. Phillips William E. Trumbull Alessio Pigazzi Fred L. Turrill
MEMBERS BY CAUCUS 205 Lawrence D. Wagman Hugh M. Foy Donald E. Wagner Alfred D. Gerein Ellsworth E. Wareham George W. Girvin Kenneth Waxman Michael J. Hart Fred A. Weaver H. Clark Hoffman Rodney A. White Walter D. Holder, Jr. Russell A. Williams Marc D. Horton Samuel E. Wilson Karen D. Horvath George Wittenstein Robert T. Hosie Jan H. Wong Robert L. Howisey Morton M. Woolley Kaj H. Johansen Justin Wu Lloyd P. Johnson Albert E. Yellin Paul W. Johnston Harvey A. Zarem Frederick R. Johnstone WASHINGTON, BRITISH Stephen G. Jolley COLUMBIA, alaska Philip C. Jolly Deborah Lyn Aaron Jedediah A. Kaufman Richard E. Ahlquist, Jr. Howard B. Kellogg Richard P. Anderson Christian Kuhr Ralph W. Aye Lorrie A. Langdale Kenneth S. Azarow Daniel J. Ledbetter J. David Beatty Wei-i Li Thomas R. Biehl Gregory K. Luna Richard P. Billingham Dana Christian Lynge Kenton C. Bodily John K. MacFarlane Edwin C. Brockenbrough Ronald V. Maier Tommy Allen Brown Dev R. Manhas David R. Byrd Gary Neil Mann Preston L. Carter Peter B. Mansfield Stephen W. Chung William H. Marks Wallace B. Chung Matthew Martin Iain G. Cleator Paul T. McDonald Robert C. Coe Lisa Kuwamura McIntyre Noelle Lee Davis James E. McKittrick James C. Donald K. Alvin Merendino Sherif Emil Robert T. Miyagishima John W. Finley Roger E. Moe Richard J. Finley Ravi Moonka Michael G. Florence Alan Morgan
206 members BY CAUCUS Ian R. Neilson Geoffrey C. Nunes Brant Kurt Oelschlager William John Orrom Carlos A. Pellegrini Terence M. Quigley Robert Rush Conrad H. Rusnak John A. Ryan Lester R. Sauvage Robert S. Sawin Robert T. Schaller Nis Schmidt Charles H. Scudamore Christopher R. Shackleton David A. Simonowitz Mika N. Sinanan Erik D. Skarsgard Meredith P. Smith Michael Sobel Benjamin Ware Starnes L. Stanton Stavney Scott R. Steele David A. Taft Roger Perry Tatum Richard C. Thirlby George I. Thomas L. William Traverso William C. Trier Stanley W. Tuell John Henry T. Waldhausen Garth L. Warnock Donald K. Williams Loren C. Wintersheid, Jr. Sam Wiseman Peter Wu Raymond S. Yeung
MEMBERS BY CAUCUS 207 Members by Location CANADA TAIWAN BRITISH COLUMBIA Hsintien, Taipei His Bowen Island Sister Mary Ann Lou Frederick R. Johnstone UNITED STATES Delta ALASKA Alfred D. Gerein Anchorage Montreal Stephen G. Jolley Sherif Emil Ian R. Neilson Vancouver Ketchikan Stephen W. Chung Deborah Lyn Aaron Wallace B. Chung ARIZONA Iain G. Cleator Scottsdale Noelle Lee Davis Theodore R. Schrock Richard J. Finley Roy L. Tawes John K. MacFarlane CALIFORNIA James E. McKittrick Agoura Robert T. Miyagishima Wiley F. Barker Nis Schmidt Alameda Charles H. Scudamore Burton E. Adams Erik D. Skarsgard Roger R. Ecker Garth L. Warnock Alamo Sam Wiseman Carlos Gracia Victoria Bakersfield James C. Donald Jack H. Bloch Robert T. Hosie Ray Siu-Keung Chung William John Orrom Baldwin Park Conrad H. Rusnak Philip Mercado JAPAN Bayside TOCHIGI Luther Fuson Cobb Shimotsuke City M. Ellen Mahoney Alan T. Lefor Beverly Hills Arthur M. Kahn Burlingame Gerald R. Sydorak
208 members BY LOCATION Calistoga Idyllwild Edward P. Passaro M. Atik Clovis Indian Wells David B. Hinshaw John L. Cahill Corona del Mar P. Michael McCart J. Kenneth Chong Kentfield David W. Furnas Albert D. Hall Daly City Kneeland Robert G. Scribner Norman M. Christensen Dana Point La Jolla Edward A. Dainko John J. Bergan Del Mar Sunil Bhoyrul Alex Gerber Michael Bouvet Duarte Timothy G. Canty Joshua D. I. Ellenhorn Giacomo A. Delaria Carlos A. Garberoglio Ralph B. Dilley Julio Garcia-Aguilar Gail T. Tominaga Frederic W. Grannis, Jr. Laguna Hills Lily Lai Chirag Vipin Patel I. Benjamin Paz Larkspur Alessio Pigazzi Pieter A. Devries El Macero Loma Linda Nathaniel M. Matolo Leonard L. Bailey Earl F. Wolfman Jerrold K. Longerbeam Encinitas Anees J. Razzouk Richard P. Saik, Jr. Ellsworth E. Wareham Fair Oaks Jan H. Wong Paul B. Kelly, Jr. Long Beach Fresno Ian L. Gordon Orland G. Davies, Jr. James A. Murray James W. Davis John J. Rosental Steven N. Parks Los Altos Hills Elizabeth C. Pohlson George M. Rugtiv Kent T. Yamaguchi Los Angeles Geyserville Maher A. Abbas Alfred A. deLorimier Sam S. Ahn Hillsborough Harry Applebaum Robert C. Lim, Jr. James B. Atkinson Arthur N. Thomas J. Dennis Baker
MEMBERS BY LOCATION 209 John R. Benfield Edward H. Phillips Robert S. Bennion William G. Plested III George Berci William J. Quinones-Baldrich Thomas V. Berne Howard A. Reber Ronald W. Busuttil Vincent Lopez Rowe Robert Cameron Ali Salim Clarence Cole Robert R. Selby J. Craig Collins William C. Shoemaker Steven D. Colquhoun Allan W. Silberman Peter F. Crookes Areti Tillou Henry M. Cryer III Richard L. Treiman Donald Cameron Dafoe William E. Trumbull Tom R. DeMeester Fred A. Weaver L. Andrew DiFronzo Los Gatos Erik Dutson J. Augusto Bastidas Frederick R. Eilber Martinez Douglas G. Farmer James M. Guernsey Hugh A. Gelabert Mather Bruce L. Gewertz Scott A. Hundahl Philip Haigh James E. Wiedeman Jonathan R. Hiatt Menlo Park Oscar Joe Hines David L. Gregg Darryl T. Hiyama Montecito E. Carmack Holmes Wilton A. Doane Andrew Scott Klein Newlin Hastings Clifford Y. Ko Monterey Peter F. Lawrence W. Lane Verlenden III Phillip M. Levin Napa Harvey N. Lippman John P. Loftus Gerald S. Lipshutz Dwight H. Murray James V. Maloney, Jr. Wendell W. Wenneker Daniel R. Margulies Novato Rodney John Mason Ramon Berguer P. Michael McFadden Oakland Amir Mehran Robert J. Albo Wesley S. Moore Stephen N. Etheredge Leon Morgenstern Jon M. Greif Theodore X. O’Connell Elsa R. Hirvela Dilip Parekh Leigh I. Iverson
210 members BY LOCATION Robert J. Schweitzer Quentin R. Stiles Arthur Stanten Pasadena Steven A. Stanten Arthur J. Donovan Gregory P. Victorino Donald J. Gaspard Orange Edward M. Greaney Jeffrey L. Ballard Steven G. Katz John A. Butler Roy D. Kohl Marianne Cinat G. Arnold Mulder John E. Connolly Anthony Shaw Gregory R. D. Evans Point Reyes Station Clarence Foster Keene O. Haldeman John C. German Pomona David Hoyt Jose J. Terz David Hsiang Rancho Mirage David K. Imagawa Morton M. Woolley Michael E. Lekawa Rancho Palos Verdes Ninh Tuan Nguyen Arthur W. Fleming Michael J. Stamos Rancho Santa Fe Lawrence D. Wagman A. Brent Eastman Russell A. Williams Redding Samuel E. Wilson James M. Stone Orinda Redlands Samuel N. Etheredge Louis L. Smith Pacific Palisade Ralph J. Thompson Fredrick W. Marx, Jr. Rescue Donald G. Mulder Charles F. Frey Howard Silberman Sacramento Palm Desert John T. Anderson Richard G. Fosburg Richard John Bold Michael L. Trollope James E. Goodnight, Jr. Palm Springs David G. Greenhalgh Delmar R. Aitken Hung S. Ho Palo Alto James W. Holcroft Carlos O. Esquivel Clifford C. Marr Shoichi Kohatsu James W. Martin R. Hewlett Lee John P. McVicar Oscar Salvatierra John T. Owings Sherry M. Wren Tina Palmieri Palos Verdes Estates Richard V. Perez
MEMBERS BY LOCATION 211 Lynette Ann Scherer Robert Foster Philip D. Schneider Chris E. Freise Thomas R. Stevenson William H. Goodson III Christoph Troppmann Douglas P. Grey Kathrin Troppmann Hobart W. Harris Richard E. Ward Michael R. Harrison David H. Wisner F. William Heer Franklin K. Yee Arthur C. Hill San Diego J. Hill Niren Angle Frank Hinman, Jr. Raul Coimbra Ryutaro Hirose Bard Clifford Cosman Jan K. Horn David W. Easter Thomas K. Hunt Robert J. Hye Eun-Sil Shelley Hwang John H. Mehnert David Jablons Marshall J. Orloff, Jr. Sang-Mo Kang Tom Paluch Electron Kebebew Bruce M. Potenza Kimberly S. Kirkwood Joseph D. Schmidt Mary M. Knudson Michael J. Sise Stanley P. L. Leong Geoffrey M. Stiles Sheldon Levin Mark Adams Talamini John Maa Justin Wu James R. Macho San Francisco Robert C. Mackersie Robert E. Allen, Jr. Mary H. McGrath James P. Anthony Scot H. Merrick Nancy L. Ascher Eric Nakakura F. William Blaisdell Lisa A. Orloff Mervyn F. Burke Marco G. Patti Andre R. Campbell Jeffrey M. Pearl Guilherme Campos John M. Rabkin Yaneck S. Y. Chiu John P. Roberts Orlo H. Clark Stanley Rogers Haile T. Debas Leonard D. Rosenman Quan-Yang Duh William P. Schecter John M. Erskine Lygia Stewart Laura J. Esserman Peter G. Stock Cheryl Ewing Madhulika Varma Diana L. Farmer Robert Warren
212 members BY LOCATION Lawrence W. Way Robert W. Rand Laurence F. Yee John M. Robertson David M. Young W. Eugene Stern San Gabriel Ronald K. Tompkins David Z. J. Chu Donald E. Wagner San Jose Harvey A. Zarem Maria D. Allo Santa Rosa Carl A. Bertelsen Robert C. Combs San Leandro David G. Fraser Lamont D. Paxton Saratoga San Marino Robert S. Seipel William R. Dietrick Seal Beach Edward N. Snyder Max R. Gaspar San Mateo George L. Juler Edmund J. Harris Sierra Madre San Rafael Demetrios Demetriades Benson B. Roe Solana Beach Santa Ana Donley G. McReynolds Alan B. Gazzaniga Stanford John R. Hilsabeck Myriam J. Curet Irving Rappaport Ronald L. Dalman Robert A. Steedman Frederick M. Dirbas Santa Barbara Ralph S. Greco Gregory C. Greaney E. John Harris, Jr. Edward J. Jahnke Thomas M. Krummel Ronald G. Latimer James B. D. Mark Richard A. Lim Maria T. Millan Jack W. Love Thomas S. Nelsen Kenneth Waxman Jeffrey A. Norton George Wittenstein Harry A. Oberhelman Santa Clara Cornelius Olcott IV James H. McClenathan David A. Spain Santa Monica H. Ward Trueblood Anton J. Bilchik Irene L. Wapnir Richard Essner Mark L. Welton Eric W. Fonkalsrud Christopher K. Zarins Nova Foster Stockton Armando Giuliano G. Andrew Macbeth Donald L. Morton Fred L. Turrill
MEMBERS BY LOCATION 213 Summerland Richard A. Crass Joseph A. Ignatius Miami Sylmar Juan A. Asensio Jesse E. Thompson, Jr. HAWAII Temecula Haleiwa Gilbert C. Freeman Albert E. Yellin Torrance Honolulu Frederic S. Bongard John F. Balfour Christian de Virgilio Alan H. S. Cheung Stanley R. Klein Yeu-Tsu M. Lee Ravin R. Kumar Whitney M. L. Limm Brant Aaron Putnam Henry Louie Bruce E. Stabile Walton K. Shim David State Linda L. Wong Rodney A. White Livingston M. F. Wong Truckee Kailua Lawrence A. Danto Peter J. Barcia Twaine Harte John H. Payne, Jr. John N. Baldwin Kalaheao Walnut Creek Emilia L. Dauway-Williams Mahlon C. Connett Kealakekua Ivan A. May Daryl Kurozawa Gerald W. Peskin Wailea Maui Clifford J. Straehley Edward A. Smeloff COLORADO IDAHO Denver Lewiston Patrick J. Offner, Jr. Robert S. Ozeran CONNECTICUT ILLINOIS New Haven Caledonia R. Lawrence Moss William Brock DISTRICT OF COLUMBIA Chicago Edward E. Cornwell III John J. Coyle FLORIDA Nora M. Hansen Boca Raton Lloyd M. Nyhus Stephen L. Michel Thomas R. Russell Bradenton River Forest Ben L. Bachulis G. Robert Mason Jacksonville Springfield
214 members BY LOCATION Douglas B. Hood NEW YORK IOWA Albany Iowa City Steven C. Stain Ronald J. Weigel Pittsford KANSAS Jeffrey H. Peters Lawrence OHIO Don R. Miller Cleveland LOUISIANA Adnan Cobanoglu Kenner Jerry Goldstone Eugene A. Woltering OREGON MARYLAND Eugene Baltimore John U. Bascom Julie A. Freischlag Pacific City Bethesda William C. Awe John E. Niederhuber Portland Charles L. Rice Aftab Ahmad MASSACHUSETTS Roger E. Alberty Boston James W. Asaph Michael J. Zinner Kevin Billingsley Worcester Bolek Brant Louis M. Messina John R. Campbell David W. Cook MICHIGAN Clifford W. Deveney Grand Rapids Karen E. Deveney Mathew H. Chung William S. Fletcher MONTANA H. Storm Floten East Glacier Park Joseph Frankhouse Daniel M. Hays William Garnjobst Hamilton Paul D. Hansen Donald Tsang Marvin W. Harrison NEBRASKA John G. Hunter Omaha Toshio Inahara Kenneth S. Azarow Stanley W. Jacob NEVADA Nathalie M. Johnson Las Vegas William E. Johnson P. Richard Carter Ali Khaki NEW HAMPSHIRE Gary H. Leaverton Jaffrey Patrick Yuk-Hoi Lee Robert A. Chase Christopher N. Lim
MEMBERS BY LOCATION 215 Thomas D. Lindell TEXAS William B. Long III Burnet M. C. Theodore Mackett Kenneth R. Tyson Robert Martindale Fort Worth John C. Mayberry Michael S. Hickey Donald B. McConnell Houston Gregory L. Moneta R. Mark Ghobrial Richard J. Mullins M. Michael Shabot Susan L. Orloff UTAH Philip F. Parshley Salt Lake City James J. Peck Sean J. Mulvihill Rodney F. Pommier VERMONT J. Karl Poppe Burlington Vincent A. Reger David W. McFadden Martin Allan Schreiber VIRGINIA Earl S. Schuman Alexandria Brett C. Sheppard Paul R. Cordts Ambrose B. Shields Philip A. Snedecor Charlottesville Blayne A. Standage William H. Muller Albert Starr WASHINGTON Lee L. Swanstrom Bellevue Donald D. Trunkey Edwin C. Brockenbrough John T. Vetto H. Clark Hoffman R. Mark Vetto Bellingham Ronald Wolf Christopher R. Shackleton Bruce M. Wolfe Camano Island James A. Wood John W. Finley Salem Edmonds Richard D. Sloop Lloyd P. Johnson PENNSYLVANIA Gig Harbor Philadelphia Kenton C. Bodily Richard H. Bell, Jr. Tommy Allen Brown Kenric Murayama Kirkland Pittsburgh Roger E. Moe Blair Jobe Lakewood TENNESSEE Preston L. Carter Medina Memphis Stephen J. Shochat Howard B. Kellogg
216 members BY LOCATION Meredith P. Smith K. Alvin Merendino Mercer Island Ravi Moonka Robert C. Coe Alan Morgan Paul W. Johnston Ronald J. Nelson Wei-i Li Brant Kurt Oelschlager Loren C. Wintersheid, Jr. Carlos A. Pellegrini Olympia Terence M. Quigley Scott R. Steele John A. Ryan Port Haddock Lester R. Sauvage L. Stanton Stavney Robert S. Sawin Redmond Robert T. Schaller David A. Simonowitz Mika N. Sinanan Seattle Michael Sobel Richard P. Anderson Benjamin Ware Starnes Ralph W. Aye David A. Taft J. David Beatty Roger Perry Tatum Thomas R. Biehl Richard C. Thirlby Richard P. Billingham George I. Thomas David R. Byrd L. William Traverso Michael G. Florence William C. Trier Hugh M. Foy John Henry T. Waldhausen Michael J. Hart Peter Wu Walter D. Holder, Jr. Raymond S. Yeung Marc D. Horton Spokane Karen D. Horvath Richard E. Ahlquist, Jr. Robert L. Howisey George W. Girvin Kaj H. Johansen Gregory K. Luna Philip C. Jolly Geoffrey C. Nunes Jedediah A. Kaufman Tacoma Christian Kuhr Matthew Martin Lorrie A. Langdale Robert Rush Daniel J. Ledbetter Stanley W. Tuell Dana Christian Lynge Vancouver Ronald V. Maier Paul T. McDonald Dev R. Manhas Yakima Gary Neil Mann Donald K. Williams Peter B. Mansfield William H. Marks Lisa Kuwamura McIntyre
MEMBERS BY LOCATION 217
ARTICLE I Constitution Section 1. The name of this Association shall beTH E PACIFIC COAST SURGICAL ASSOCIATION. ARTICLE II Section 1. The object of the Association shall be to advance the science and practice of surgery. ARTICLE III Section 1. The Association shall consist of Active, Senior,H onorary, and Non-Resident Fellows. Section 2. Active membership shall be limited to 230 Fellows, the number elected each year to be left to the discretion of the Council. Section 3. No one shall be eligible for membership unless his/her practice is limited to surgery and he/she has established a reputation as a practitioner, author, teacher or original investigator, and has been recommended by the Council. Candidates must be in practice for two years on the West Coast. The candidate shall also have been certified either by the American Board of Surgery, the appropriate specialty Board, or its foreign equivalent. Section 4. The Council shall have the power of decision in the consideration of each candidate’s eligibility and its judgment upon such eligibility shall be final. No candidate for membership shall be voted upon at the executive session of the Association unless recommended by the Council. Section 5. Proposals for membership shall be made by Fellows on applications furnished by the Secretary of the Association. The proposal of a candidate for membership shall be supported by letters to the Secretary from each of the three sponsors who shall vouch for his/her character and standing. The application and letters shall be presented to the Council by the Secretary. Section 6. Proposals for membership, properly filled out, accompanied by the necessary endorsements and confidential letters from the sponsors, shall be in the hands of the Secretary at least six months before the date of the annual meeting. Three months before the annual meeting, the Secretary shall send to each member of the Association a list of all candidates for active membership and a printed summary of their qualifications, including educational attainments and professional positions. Members are encouraged to submit to the Council written comments on the candidates’ qualifications for membership. The Council at its Annual Meeting shall, after full consideration of all information available, recommend to the Association such candidates as are qualified for membership, The Council shall have the power to request
218 Constitution from any member of the Association a careful and unbiased investigation of the qualifications of any candidate for election to the Association. Any candidate for active membership may be assigned to a member of the Council for careful investigation as to his/her personal and professional qualifications. Section 7. After recommendation by the Council, election to Fellowship shall be by ballot at the executive session of each Annual Meeting and if three- quarters of the ballots are favorable, the candidate shall be declared elected. Section 8. Candidates who have not been recommended for active membership by the Council three years after nomination, shall be withdrawn and their sponsors notified. This action shall not prevent the reproposal of such candidates for membership. Any candidate for Fellowship who has been recommended by the Council, but not elected by the Association cannot be proposed again for membership for at least two years. Section 9. Prospective Fellows after election must qualify within three months bythe payment of the initiation fee and annual dues to the Treasurer and by filing a recent 8”×10” photograph with the Association.T o become an Active member, the nominee shall be expected to attend the first Annual Meeting after election to be introduced to the Association and to receive the certificate of membership. Should the nominee fail to attend the first subsequent meeting, the second Annual Meeting must be attended. If the nominee is unable to attend the second meeting, membership will not be conferred subject to action by the Council. Fees contingent on membership will not be refunded. ARTICLE IV Section 1. Candidates for Honorary Fellowship shall be nominated by the Council and elected by ballot at the executive session of the Annual Meeting. Honorary Fellows shall not be required to pay dues or initiation fee and shall enjoy all the privileges of other Fellows except those of voting and holding office. Section 2. All Fellows automatically shall become Senior Fellows at the age of sixty (60) years. They shall pay dues to the age of seventy (70) years or upon retirement from active practice, whichever occurs first. They shall have the privilege of voting and holding office. Section 3. A Non-Resident Fellow shall be a Fellow under the age of sixty who no longer resides in the Pacific Coast geographical area. He/She shall be excused from attendance requirements. He/She may vote at such meetings as he/she attends and enjoy all the privileges of the Association except that he/she may not hold office or membership on standing committees.H e/She shall pay annual dues. A request for non-resident status must be submitted in writing to the Secretary and shall be granted only by the Council. Upon written request the Council may restore a Non-Resident Fellow to active status. At its discretion, the Council may terminate membership as a Non-Resident Fellow. A Non-Resident Fellow shall automatically become a Senior Fellow at age sixty.
constitution 219 Section 4. The resignation of a Fellow may be accepted at the discretion of the Council. ARTICLE V Section 1. The officers of the Association shall be a President, a President- Elect who becomes President one year following election, a President-Elect who becomes President two years following election, a Vice-President, a Secretary- Treasurer, a Recorder, an Historian, and four Councilors. There shall be a Program Committee appointed by the President, consisting of five members, one representing each of the four geographical sections of the Association, and the Recorder, who shall act as Chairman. The Council member and the Program Committee member who resides in the same geographical area as the Recorder shall act as an Advisory Committee to him/her. Section 2. The Presidents-Elect, the Vice-President, the Secretary-Treasurer, the Recorder, and the Historian shall be elected for one year, and a Councilor shall be elected as provided by the Bylaws. The President shall not be eligible for reelection at any time. The Secretary-Treasurer and Recorder shall not serve more than six years, shall not both be retired in the same year, and shall not be elected from the same region of the Association. Section 3. All officers shall be nominated by a Committee, appointed by the President, consisting of the three most recent past Presidents, at least three (3) months prior to the Annual Meeting. Additional nominations may be made from the floor. Section 4. The election of officers shall take place at an executive session of the Annual Meeting. A majority of votes cast shall constitute an election. ARTICLE VI Section 1. It shall be the duty of the President to be present and to preside at all meetings of the Association; to see that the rules of order and decorum are properly enforced in all deliberations of the Association; to sign the certificates of Fellowship. Section 2. In the absence of the President, the Vice-President shall preside, and in the absence of the Vice-President, the Secretary-Treasurer shall preside. Section 3. In the absence of all three, the Association shall elect one of its Fellows to preside pro tem. Section 4. The Secretary-Treasurer shall keep the minutes of the Association and shall issue, at least six weeks prior to the Annual Meeting, a preliminary notice of the time and place of the meeting, and the business to be transacted. He/She shall issue the final program of the Annual Meeting and a list of the names of the candidates for Fellowship who are under consideration by the Council. He/She shall attest all official acts requiring certification, in connection with or independent of the President, notify officers and Fellows of their election, keep in his/her custody the Seal of the Association and affix it to all documents and papers that the Association may direct; take charge of
220 Constitution all papers not otherwise provided for. He/She shall serve as Secretary and keep minutes of the meetings of the Council. He/She shall, with the President, sign the certificates of Fellowship and receive all monies and funds belonging to the Association. He/She shall pay the bills of the Association, collect all dues and assessments as promptly as possible, report to the Association at each Annual Meeting the names of all Fellows in arrears who have, in accordance with the Bylaws, regulating the same, forfeited their Fellowship. He/She shall annually present a review of the Association’s finances performed by a Certified Public Accountant. A full audit shall be performed as determined by the Council. Section 5. It shall be the duty of the Historian to assemble and preserve the Archives of the Association for storage and reference. The Archives shall consist of the roster of the members of the Association since its inception, and such photographs as are available. It shall be his/her duty likewise to secure and file a photograph of each new member. Section 6. The Recorder shall, as Chairman of the Program Committee, assemble the scientific program and forward it to the Secretary at least two months before the annual meeting. The Recorder shall receive all papers and reports of discussion on papers presented before the Association and as the Chairman of the Program Committee take charge of the publication of the papers presented before the Association. Section 7. It shall be the duty of the President of the Association to appoint an Audit Committee, consisting of two (2) Fellows of the Association, whose duty it shall be to examine the books of the Secretary- Treasurer and report on the same during the annual session. ARTICLE VII Section 1. Vacancies occurring in the offices of the Association shall be filled by appointment by the President until the next meeting. He/She shall also have the authority to appoint all committees not otherwise provided for. ARTICLE VIII Section 1. The Constitution may be amended at any regular meeting by a written resolution embodying the proposed changes, which shall lie over for one year and which must receive approval by two-thirds of the members present and voting. ARTICLE IX Section 1. The President, the two Presidents-Elect, Vice-President, Secretary- Treasurer, Recorder and Historian shall act as ex- officio members of the Council with the right to vote.
constitution 221
CHAPTER I Bylaws Section 1. The Pacific Coast Surgical Association shall meet annually at such time and place as may be designated by the Council, preferably on President’s Day weekend. Section 2. There shall be at least one annual executive session of the Association, at which the order of business shall be as follows: (a) reading the minutes of the last meeting; (b) reports of the Secretary-Treasurer, Recorder and Historian; (c) reports of the Council; (d) report of Program Committee; (e) reports of representatives of the Association to the American Board of Surgery and to the American College of Surgeons; (f) unfinished business; (g) new business; (h) report of Auditing Committee; (i) report of Nominating Committee; (j) election of officers; (k) election of Fellows; (l) induction of new officers; (m) adjournment. CHAPTER II Section 1. The Fellows present at any executive session shall constitute a quorum for business. CHAPTER III Section 1. The annual dues and the initiation fee shall be recommended by the Council and voted upon by the membership each year at the Annual Meeting. Members may be exempted from payment of dues at the discretion of the Council. CHAPTER IV Section 1. The usual parliamentary rules (Robert’s Rules) governing deliberative bodies shall govern the business workings of the Association. CHAPTER V Section 1. All questions before the Association unless otherwise provided shall be determined by a majority vote of the members present and voting except changes in the Constitution and Bylaws and the election of new members which require a two-thirds (2/3) majority. CHAPTER VI Section 1. The President shall deliver an address at the Annual Meeting of the Association. CHAPTER VII Section 1. The Secretary-Treasurer and Recorder of the Association shall receive at each annual session a draft from the President for such sum as may be voted by the Council for services rendered the Association, and to this shall be added the necessary expense incurred in the discharge of his/her official duties.
222 bylaws CHAPTER VIII Section 1. Those members submitting titles of essays shall supply the Recorder with the title and an abstract of the proposed essay. The Program Committee shall have the responsibility for choosing the primary discussant. The discussant shall receive a copy of the essayist’s paper not later than two weeks before the Annual Meeting. The presenting author and opening discussant shall submit the manuscript and a text of the discussion ready for publication just prior to presentation. CHAPTER IX Section 1. The Council shall consist of five members, of which four are elected, the fifth member to be the retiring President who automatically serves for one year. The President, Presidents-Elect, Vice-President, Secretary-Treasurer, Recorder and Historian shall act as ex-officio members of the Council with the right to vote. One member of the Council shall be elected annually to serve four years. Any member of the Association shall be eligible for membership on the Council, provided that each regional section of the Association shall always be represented on the Council. These regional sections, which may be enlarged at the will of the Association, shall consist, respectively, of the Fellows residing in 1) Washington, British Columbia and Alaska, 2) Oregon and Hawaii, 3) Northern California to, but not including Santa Barbara and Bakersfield, 4) Southern California including Santa Barbara and Bakersfield. The President shall be notified by any Councilor who is unable to attend a meeting of the Council. Upon such notification, the President shall appoint from the Councilor’s regional section an alternate who shall act as Councilor for that meeting. Section 2. The President shall preside as Chairman of the Council and the Secretary-Treasurer shall keep a record of its proceedings. Section 3. The duties of the Council shall be:1. To investigate candidates for membership and report to the Association the names of such persons as are deemed worthy. 2. To take cognizance of all questions of an ethical, judicial, or personal nature, and upon these, the decisions of the Council shall be final, provided that appeal may be taken from such decision of the Council to the Association under a written protest, which protest shall be voted upon by the Association. 3. All resolutions before the Association shall be referred to the Council before debate, and the Council shall report by recommendation at the earliest hour possible. 4. The Program Committee and the Council shall have power to invite guests to appear on the scientific program. 5. The Council at the invitation of the President shall meet at some date preceding the Annual Meeting for consideration of matters of importance with reference to the Annual Meeting and particularly with reference to the eligibility of proposed candidates for admission. CHAPTER X Section 1. The Council shall have full power to withdraw from
Bylaws 223 submission for publication any paper that may be referred to it by the Association, unless specially instructed to the contrary by the Association, which shall be determined by vote. CHAPTER XI Section 1. The President shall appoint for the following Annual Meeting a Committee on Arrangements, and the Program Committee as provided in the Constitution. The Program Committee shall consist of four members representing each of the caucuses and a chairman. A Program Committee member shall serve for three years and shall be eligible for reappointment for one additional term. CHAPTER XII Section 1. Active membership shall be forfeited by failure to be present at four consecutive meetings. After failure to attend three consecutive meetings, the Secretary will notify the member that a fourth consecutive absence will terminate his/her membership. In cases where the fourth absence was caused by extremely compelling circumstances, the Council may at its discretion, stay the termination of membership. Failure by any member of the Association to pay dues for one year may be considered sufficient cause to drop the member from the membership roll on recommendation of the Council to the Association. Membership also may be forfeited for reasons deemed sufficient by the Association. Section 2. Attendance at an annual session shall be defined as registration with Secretary, payment of the registration fee and attendance at not less than one scientific session. Retired members and those exempt from dues because of illness shall have the privilege of attending the Annual Meeting at a registration fee determined by the Council. Section 3. At the discretion of the Council, and for good and sufficient reasons, an Active Fellow may be transferred to the list of Senior Fellows. CHAPTER XIII Section 1. A paper shall not be read before this Association which has been published previously or which does not deal with a subject of surgical importance. The member shall close the discussion. Section 2. The maximum time allowed essayists shall be 10 minutes, except by permission of the Program Committee. The primary discussant shall be allowed 5 minutes, each subsequent discussant 2 minutes, and final closing discussant 5 minutes. Section 3. No paper read before this Association shall be published in any medical journal or pamphlet for circulation as having been read before the Association without having received endorsement of the Program Committee.
224 bylaws Section 4. At the discretion of the Program Committee, poster sessions may be held during the Scientific Meeting. Papers representing work from these poster sessions may be submitted for consideration for publication. CHAPTER XIV Section 1. The Scientific Meetings shall be open to any doctor of medicine in good standing in his/her profession, provided he/she establish his/her identity. Only officially invited guests may register and attend functions. Section 2. Fellows may request invitations for guests by applying to the Secretary in writing at least one month prior to the first day of the annual meeting. The Council shall determine the number of guests which may be invited. Invitations to guests shall be issued only by the Secretary. A Fellow requesting that an invitation be extended to a guest shall assume such financial responsibility as may be determined by the Council for the guest so invited. The President may invite distinguished members of the profession to be guests of the Association. Section 3. The Association shall have no financial responsibility for invited guests, except distinguished guests invited by the President. CHAPTER XV Section 1. Pursuant to Article V, Section 3, of the Constitution, the Nominating Committee shall request some specific information from each of the four regional sections where new candidates are required for the offices of the President-Elect, Secretary-Treasurer, Recorder, and Regional Councilor. An election with written mail ballot shall be held within each regional section involved in selecting candidates for each of these four offices. The Regional Councilors will conduct the balloting and provide the Nominating Committee with a report reflecting the wishes of their caucus. The Nominating Committee may review the ballots if questions arise about the voting process. Section 2. The candidate for Vice-President shall be selected by each President-Elect. CHAPTER XVI Section 1. These Bylaws may be amended at any annual session by a two-thirds vote of the Fellows present and voting. Proposed amendments shall be made in writing as motions before the Association, and shall then be dealt with in accordance with the provisions of Chapter IX, Section 3, Paragraph 3, of the Bylaws.
Bylaws 225 2010 February 13–16Future Meetings Host: Oregon, Hawaii Site: Ritz-Carlton, Kapalua, Maui, HI
226 future Meetings