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FINAL PROGRAM

2014 Annual Meeting April 13 – 16, 2014 Westin Kierland Resort | Scottsdale, AZ THANK YOU

The Southwestern Surgical Congress would like to thank the following companies for their generous support of our meeting through educational grants: American College of Surgeons – Division of Education LifeCell Corporation

The Southwestern Surgical Congress gratefully acknowledges the support of the following exhibiting companies: American College of Surgeons – Division of Education American College of Surgeons – Division of Member Services American College of Surgeons Foundation Baxter Biosurgery Covidien Davol, Inc., A Bard Company Edwards Lifesciences KARL STORZ Endoscopy-America, Inc. LifeCell Corporation StarSurgical Simbionix USA Corp. TEI Biosciences TEM Systems, Inc. W. L. Gore & Associates, Inc.

Special thanks to the SWSC 2014 Program Committee: Shanu N. Kothari - Chair Kevin Reavis Brian Eastridge Randy Smith Ernie Gonzalez Kenric M. Murayama – President Laura Moore Courtney Scaife – Recorder John Myers Michael Truitt – CME Chair TABLE OF CONTENTS

2 Letter from the President 4 Officers,tate S Councilors & Representatives 6 Past Presidents & Meeting Locations 10 Educational Objectives 13 General Information 14 Presidential Address 15 Guest Speakers 21 Awards 23 Special Sessions 27 In Memoriam 28 New Members 29 Program Schedule 35 Scientific rogramP 57 Scientific aperP Abstracts 91 Quick Shot Abstracts 151 Top 5 Poster Abstracts 157 Poster Abstracts 215 Constitution 219 Bylaws 231 Notes

See inside back cover for future meetings.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 1 LETTER FROM THE PRESIDENT

On behalf of the Southwestern Surgical Congress, it my pleasure to welcome you to the 66th annual meeting at the Westin Kierland Resort and Spa in Scottsdale, Arizona. The Program Committee under the leadership of Dr. Shanu Kothari has assembled an outstanding educational program. As many of you know, the Southwestern Surgical Congress has a long tradition of providing outstanding science in a collegial environment with family- oriented activities. The Westin Kierland Resort and Spa is located in the heart of Scottsdale and provides numerous options for activities including challenging golf on three world-class courses, a tranquil spa, tennis courts, and fitness facilities. The property offers a spectacular outdoor pool complex with a sand beach, waterslide, and a 900-foot lazy river.

The meeting is organized to maximize the educational opportunities for attendees. There will be two parallel postgraduate courses on Sunday, April 13th, both free of charge. “Current Management of Hernias” will be co-directed by Dr. Dean Mikami and Dr. Kristi Harold, internationally recognized experts in the latest treatments for hernias, and an excellent faculty. Dr. Peter Angelos has organized an outstanding faculty for the second postgraduate course, “Updates in Endocrine Surgery”.

Our meeting begins officially in the afternoon on Sunday, April 13th with the opening plenary session. As in years past, we will have morning Quick Shot sessions and the traditional outstanding competition for the Jack Barney Award for the best resident paper. The debate this year will be titled, “Taking Call: Pay to Play”, during which Dr. Thomas White and Dr. Ronald Stewart will debate the rationale for being paid for taking call or not. Last year was the inaugural Partners in Practice Luncheon and we will have a similarly excellent lunch program this year. The graduate medical education luncheon will feature a panel presentation on “Practice Models in Surgery” moderated by our GME Chair, Dr. Daniel Vargo.

2 Southwestern Surgical Congress | 66th Annual Meeting LETTER FROM THE PRESIDENT (continued)

Th e invited lectures will feature Dr. Peter Angelos, Dr. Daniel Margulies, and Dr. Shanu Kothari. As has become a tradition of sorts, the American College of Surgeons will present two panels on Monday morning. Th e fi rst will be the annual update from the American College of Surgeons, “Aff ordable Care Act Repeal of the Sustainable Growth Rate” and the second panel will focus on the new “Transitions to Practice in General Surgery” program. We are honored that Dr. Don Nakayama, President of the Southeastern Surgical Congress, will be participating in our meeting as one of the panelists.

For our families, the resort off ers an outstanding program, Th e Kierland Mining Co. Guests can pick up a copy of the Kierland Pathfi nder, a daily Resort guide with all of the exciting activities happening during their stay including presentations from the Phoenix Zoo, “Kids in the Kitchen,” Adventure Water Park pool activities, Cardio Tennis, Poolside Movies, Digital Kids Zone, Arizona s ’mores, and much more. Additionally, we have organized several activities including a cooking demonstration, horseback riding, and athletic yoga.

I look forward to seeing all of you and hope you enjoy the program and social activities. I will be on site for the entire time so please feel free to stop me and let me know how we can increase value to our membership.

With Warm Regards,

Kenric M. Murayama, MD, FACS President, Southwestern Surgical Congress

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 3 OFFICERS, STATE COUNCILORS & REPRESENTATIVES

EXECUTIVE STATE OFFICERS COUNCILORS

PRESIDENT ARIZONA NEVADA Kenric M. Murayama, MD James Warneke, MD Shawn Tsuda, MD Abington, PA ARKANSAS NORTH DAKOTA PRESIDENT-ELECT Anne Mancino, MD Wayne Anderson, MD Ronald Stewart, MD San Antonio, TX CALIFORNIA OKLAHOMA (SOUTHERN) Gary Dunn, MD VICE PRESIDENT Daniel Margulies, MD John R. Potts, III, MD SOUTH DAKOTA Chicago, IL CALIFORNIA Lars Aanning, MD (NORTHERN) Christine Cocanour, MD TEXAS (NORTHERN) SECRETARY- Michael Truitt, MD TREASURER COLORADO Clay Cothren Burlew, MD John Moore, MD TEXAS (SOUTHERN) Denver, CO Ernie Gonzalez, MD HAWAII RECORDER Whitney Limm, MD UTAH Courtney Scaife, MD Ute Gawlick, MD Salt Lake City, UT KANSAS Michael Moncure, MD WISCONSIN EXECUTIVE Shanu Kothari, MD DIRECTOR MISSOURI James A. Edney, MD Richard Pennell, MD WYOMING Omaha, NE Sara Smith, MD

MONTANA

Glenn Winslow, MD

NEBRASKA Rudy Lackner, MD

4 Southwestern Surgical Congress | 66th Annual Meeting OFFICERS, STATE COUNCILORS & REPRESENTATIVES (continued)

COMMITTEES CONGRESS REPRESENTATIVES BUDGET AND MEMBERSHIP NEVADA FINANCE CHAIR CHAIR AMERICAN COLLEGE Shawn Tsuda, MD James Edney, MD S. Rob Todd, MD OF SURGEONS - Omaha, NE New York, NY BOARD OF NORTH DAKOTA GOVERNORS Wayne Anderson, MD CME CHAIR NOMINATING S. Rob Todd, MD Michael Truitt, MD CHAIR New York, NY OKLAHOMA Dallas, TX Robert McIntyre, MD Gary Dunn, MD Denver, CO AMERICAN COLLEGE CONSTITUTION OF SURGEONS - SOUTH DAKOTA & BYLAWS CHAIR PROGRAM ADVISORY COUNCIL Lars Aanning, MD Daniel Margulies, MD COMMITTEE FOR SURGERY Los Angeles, CA CHAIR Alicia Mangram, MD TEXAS (NORTHERN) Shanu Kothari, MD Phoenix, AZ Michael Truitt, MD CORPORATE La Crosse, WI RELATIONS CHAIR AMERICAN BOARD TEXAS (SOUTHERN) James Edney, MD PUBLICATIONS OF SURGERY, Ernie Gonzalez, MD Omaha, NE AND RESEARCH ADVISORY CHAIR REPRESENTATIVE UTAH GRADUATE Courtney Scaife, MD Roxie Albrecht, MD Ute Gawlick, MD MEDICAL Salt Lake City, UT Oklahoma City, OK EDUCATION CHAIR WISCONSIN Daniel Vargo, MD THE AMERICAN Shanu Kothari, MD Salt Lake City, UT JOURNAL OF SURGERY - EDITORIAL WYOMING HISTORIAN ADVISORY BOARD Sara Smith, MD William F. Sasser, MD Courtney Scaife, MD St. Louis, MO Salt Lake City, UT

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 5 PAST PRESIDENTS & MEETING LOCATIONS

1949 1958 *Walter Stuck, MD *Kenneth C. Sawyer, MD Shamrock Hotel, Houston, Texas Shamrock Hotel, Houston, Texas

1950 1959 *Thomas G. Orr, MD *Lewis M. Overton, MD Shirley Savoy, Denver, Colorado Brown Palace Hotel, Denver, Colorado

1951 1960 *Leo J. Starry, MD *Fred H. Krock, MD Hotel Jefferson, St. Louis, Missouri Riviera Hotel, Las Vegas, Nevada

1952 1961 *Michael E. DeBakey, MD *Howard D. Cogswell, MD Baker Hotel, Dallas, Texas Chase Park Plaza, St. Louis, Missouri

1953 1962 *Louis P. Good, MD *Charles M. O’Leary, MD Hotel Utah, Salt Lake City, Utah Western Skies Hotel, Albuquerque, New Mexico 1954 *Philip B. Price, MD 1963 Skirvin Hotels, Oklahoma City, *Edgar J. Poth, MD Oklahoma Maria Isable Hotel, Mexico City, Mexico

1955 1964 *Lawrence P. Engel, MD *Eugene M. Bricker, MD Hotel Muehlebach, Granada Hotel, San Antonio, Texas Kansas City, Missouri 1965 1956 *Wayne C. Bartlett, MD *Charles R. Rountree, MD Velda Rose Towers, Hot Springs, Pioneer Hotel, Tucson, Arizona Arkansas

1957 1966 *John V. Goode, MD *O. Ernest Grua, MD Broadway Hotel, Wichita, Kansas Flamingo Hotel, Las Vegas, Nevada

6 Southwestern Surgical Congress | 66th Annual Meeting PAST PRESIDENTS & MEETING LOCATIONS (continued)

1967 1976 *John A. Growdon, MD *John B. Gramlich, MD Del Webb-Town House, Hyatt Regency Hotel, Houston, Texas Phoenix, Arizona 1977 1968 *Howard T. Robertson, MD *Robert B. Howard, MD Princess Hotel, Acapulco, Mexico Brown Palace Hotel, Denver, Colorado 1978 1969 *Cyril Costello, MD *John H. Clark, MD Riviera Hotel, Palm Springs, California Sahara Tahoe Hotel, Lake Tahoe, Nevada 1979 1970 *MacDonald Wood, MD *Jean C. Gladden, MD Caesars Palace Hotel, Las Vegas, Nevada Sheraton-Dallas Hotel, Dallas, Texas 1980 1971 Gilbert S. Campbell, MD *J. Robert Spencer, MD Broadmoor Hotel, Colorado Springs, Caesar’s Palace Hotel, Las Vegas, Nevada Colorado

1972 1981 *John G. Shellito, MD *Wallace L. Chambers, MD Hilton Inn, Albuquerque, New Mexico Hyatt del Monte, Monterey, California

1973 1982 *James B. Growdon, MD *Albert J. Kukral, MD Mountain Shadows Hotel, Hotel del Coronado, Coronado, Scottsdale, Arizona California

1974 1983 *Lawrence H. Wilkinson, MD Livingston Parsons, Jr., MD Del Monte Hyatt House, The Pointe Resort, Phoenix, Arizona Monterey, California 1984 1975 Raymond C. Read, MD *George H. Mertz, MD The Hyatt Regency, Honolulu Caesars Palace Hotel, Las Vegas, Nevada & Maui, Hawaii

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 7 PAST PRESIDENTS & MEETING LOCATIONS (continued)

1985 1993 *Claude H. Organ, Jr., MD Dominic Albo, Jr., MD Caesars Palace Hotel, Las Vegas, Nevada Hyatt Regency Monterey, Monterey, California 1986 Ronald C. Elkins, MD 1994 Hyatt Regency San Francisco, Ernest Poulos, MD San Francisco, California The Westin LaPaloma, Tucscon, Arizona

1987 1995 *Joseph L. Kovarik, MD Robert B. Sawyer, MD Hotel del Coronado, Coronado, Hyatt Regency Hill Country Resort, California San Antonio, Texas

1988 1996 Arlo S. Hermreck, MD Carey P. Page, MD The Pointe at Squaw Peak, Marriott’s Camelback Inn Resort, Phoenix, Arizona Scottsdale, Arizona

1989 1997 Frederic C. Chang, MD James H. Thomas, MD Hyatt Regency Monterey, Westin Mission Hills Resort, Monterey, California Rancho Mirage, California

1990 1998 Kent C. Westbrook, MD Charles H. McCollum, MD LaQuinta Golf & Tennis Resort, Hyatt Regency Hill Country Resort, La Quinta, California San Antonio, Texas

1991 1999 William F. Sasser, MD Ernest E. Moore, Jr., MD The Mirage, Las Vegas, Nevada Loews Coronado Bay Resort, Coronado, California 1992 David V. Feliciano, MD 2000 Marriott’s Camelback Inn Resort, Victor J. Zannis, MD Scottsdale, Arizona The Broadmoor, Colorado Springs, Colorado

8 Southwestern Surgical Congress | 66th Annual Meeting PAST PRESIDENTS & MEETING LOCATIONS (continued)

2001 2008 Nicholas P. Lang, MD Alan G. Thorson, MD Fiesta Americana Coral Beach Resort, Fairmont Acapulco Princess Cancun, Mexico Acapulco, Mexico

2002 2009 James A. Edney, MD Maria D. Allo, MD Hotel del Coronado, Coronado, Hotel del Colorado California Coronado, California

2003 2010 Russell G. Postier, MD Frederick A. Moore, MD Loews Ventana Canyon Resort, Tucson, Loews Canyon Resort, Tucson, Arizona Arizona 2011 2004 Edward Nelson, MD Jon S. Thompson, MD JW Marriott Ihilani, Oahu, Hawaii Hyatt Regency Monterey, Monterey, California 2012 Robert C. McIntyre, Jr., MD 2005 Terranea Resort, Rancho Palos Verdes, Jeffrey R. Saffle, MD California Westin La Cantera Resort, San Antonio, Texas 2013 David Antonenko, MD, PhD 2006 Bacara Resort Ernest L. Dunn, MD Santa Barbara, California Kauai Marriott Resort and Beach Club Kauai, Hawaii * Deceased 2007 Scott R. Petersen, MD Rancho Las Palmas Resort and Spa Rancho Mirage, California

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 9 EDUCATIONAL OBJECTIVES

The scientific program of the Annual Meeting of the Southwestern Surgical Congress will provide up-to-date information for community surgeons, academic surgeons and the surgeon in training. Topics will cover a broad range of surgical practice interests including abdominal and gastrointestinal surgery, trauma and critical care surgery, surgical education, surgical oncology, and breast and endocrine surgery. The intent of the program is to improve the quality of patient care and improve patient safety. Audience participation and interaction will be encouraged. The content and format of the program have been determined based on evaluations and suggestions of attendees of previous programs.

At the end of this activity, attendees will: • Have an understanding and knowledge of hernia and endocrine surgeries. • Possess new information regarding the latest data and surgical techniques for the general surgeon, specifically in the areas of hernia, breast, endocrine, abdominal and gastrointestinal disease. • Understand and develop an implementation plan to introduce new technologies into current practice.

CME CERTIFICATES AND EVALUATION FORMS Please complete your evaluation form and return it to the Registration Desk. You may pick up your CME Certificate at this time. CME and Self-Assessment Credit may also be completed online.

ACCREDITATION STATEMENT This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the American College of Surgeons and the Southwestern Surgical Congress. The American College Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

10 Southwestern Surgical Congress | 66th Annual Meeting EDUCATIONAL OBJECTIVES (continued)

ANNUAL MEETING:

AMA PRA Category 1 Credits™ The American College of Surgeons designates this live activity for a maximum of 20.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Of the AMA PRA Category 1 Credits™ listed above, a maximum of 12.5 credits meet the requirements for Self-Assessment.

CURRENT MANAGEMENT OF HERNIAS - POSTGRADUATE COURSE:

AMA PRA Category 1 Credits™ The American College of Surgeons designates this live activity for a maximum of 3.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Of the AMA PRA Category 1 Credits™ listed above, a maximum of 3.5 credits meet the requirements for Self-Assessment.

UPDATES IN ENDOCRINE SURGERY - POSTGRADUATE COURSE:

AMA PRA Category 1 Credits™ The American College of Surgeons designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Of the AMA PRA Category 1 Credits™ listed above, a maximum of 3.75 credits meet the requirements for Self-Assessment.

American College of Surgeons Division of Education

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 11 GENERAL INFORMATION

HOTEL The Westin Kierland Resort & Spa 6902 E. Greenway Parkway Scottsdale, AZ 85254 480-624-1000 www.kierlandresort.com

REGISTRATION The registration desk hours are as follows: Sunday 8:00am – 5:00pm Monday 7:00am – Noon Tuesday 7:00am – 5:00pm Wednesday 7:00am – 11:00am

SPOUSE HOSPITALITY A Spouse Breakfast & Hospitality Suite will be offered for all registered spouses and guests on Monday and Tuesday mornings from 8:00am – 11:00am. All individuals must be registered and wear their name badge in order to be admitted.

12 Southwestern Surgical Congress | 66th Annual Meeting GENERAL INFORMATION (continued)

RECREATIONAL ACTIVITIES Athletic Yoga Monday, April 14, 2014 7:00am – 8:00am Cost: $35 per person Come join us and start your day right! This one hour outdoor class is sure to clear your head, and get you ready to participate in the afternoon’s sports activities!

Annual Golf Tournament Monday, April 14, 2014 Consecutive Tee Times beginning at 1:00pm Westin Kierland Golf Club Cost: $150 per person Join us for an afternoon on the greens. Be sure sign up for a foursome and tee time at the SWSC registration desk beginning Sunday, April 13. Fee includes transportation, greens fees, tournament coordination and prizes. Nike club rental $65/set.

Tennis Tournament Monday, April 14, 2014 Westin Kierland Resort 1:00pm - Round Robin Tournament Cost: $35 per person Join us for a fun afternoon on the courts. Register in advance on the enclosed registration form. The fee includes court time, loaner racquet, light refreshments, tournament coordination and prizes. If participant number is low, the tournament will be a singles format.

Please stop by the registration desk for additional details and registration information

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 13 PRESIDENTIAL ADDRESS

PYRAMIDS AND ROUNDTABLES

SUNDAY, APRIL 13, 2014 4:15pm – 5:00pm Herberger Ballroom 1, 2, 3

Speaker: Kenric M. Murayama, MD Abington, PA

Dr. Kenric Murayama, a native of Hawaii, did his undergraduate studies at the University of Washington and obtained his medical degree from the University of Hawaii John A. Burns School of Medicine. He completed his surgery training at Northwestern University Feinberg School of Medicine during which time he did a two year research fellowship in pancreatic physiology. Dr. Murayama began his academic surgery career at the University of Nebraska and has subsequently been on the surgical faculty at Saint Louis University, Northwestern University, the University of Hawaii, and the University of Pennsylvania. He is currently the Chair and Program Director at Abington Memorial Hospital in Pennsylvania and is Adjunct Professor of Surgery at Temple University School of Medicine. Dr. Murayama’s clinical interest is minimally invasive gastrointestinal surgery with a focus on laparoscopic treatment for benign esophageal disorders, abdominal wall hernias, and morbid obesity and its metabolic consequences. Dr. Murayama has a longstanding commitment to surgical education and leadership development in surgery.

14 Southwestern Surgical Congress | 66th Annual Meeting GUEST SPEAKERS (continued)

EDGAR J. POTH MEMORIAL LECTURESHIP SURGICAL ETHICS AND THE CHALLENGE OF SURGICAL INNOVATION

TUESDAY, MARCH 15, 2014 10:15am – 11:00am Herberger Ballroom 1, 2, 3

Speaker: Peter Angelos, MD, PhD Chicago, IL

Peter Angelos, MD, PhD, FACS is the Linda Kohler Anderson Professor of Surgery and Surgical Ethics, Chief of Endocrine Surgery, and Associate Director of the MacLean Center for Clinical Medical Ethics at the University of Chicago Medicine. He completed his undergraduate degree, medical school, and a Ph.D. in Philosophy at Boston University. He completed his residency in General Surgery at Northwestern University and went on to complete fellowships in Clinical Ethics at the University of Chicago and in Endocrine Surgery at the University of Michigan. Dr. Angelos has written widely on improving outcomes of thyroid and parathyroid surgery, minimally invasive endocrine surgery, and ethical aspects in the care of the surgical care of patients.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 15 GUEST SPEAKERS (continued)

EDGAR J. POTH MEMORIAL LECTURESHIP PAST PRESENTERS

1975 1988 2001 George H. Mertz, MD Kent C. Westbrook, MD Gregorio A. Sicard, MD

1976 1989 2002 Frank G. Moody, MD Carey P. Page, MD Layton F. Rikkers, MD

1977 1990 2003 Claude H. Organ, Jr., James H. Tomas, MD Kenneth W. Sharp, MD MD 1991 2004 1978 Lawrence W. Way, MD B. Timothy Baxter, MD Raymond C. Read, MD 1992 2005 1979 Jon M. Burch, MD John F. Eidt, MD William W. Monafo, MD 1993 2006 1980 Jeffrey R. Saffle, MD David Antonenko, MD, George C. Morris, MD PhD 1994 1981 G. Patrick Clagett, MD 2007 Ronald C. Elkins, MD Edward W. Nelson, MD 1995 1982 Jon S. Thompson, MD 2008 MacDonald Wood, MD Kenric Murayama, MD 1996 1983 Wayne H. Schwesinger, 2009 J. Bradley Aust, MD MD Karen R. Borman, MD

1984 1997 2010 Ernest E. Moore, Jr., MD Glenn C. Hunter, MD Alden D. Harken, MD

1985 1998 2011 Stephen L. Wangensteen, Courtney M. Townsend, Anees Chagpar, MD MD Jr., MD 2012 1986 1999 Clay Cothren Burlew, MD David V. Feliciano, MD James A. Edney, MD 2013 1987 2000 R. Stephen Smith, MD David Roos, MD Robert J. Fitzgibbons, MD

16 Southwestern Surgical Congress | 66th Annual Meeting GUEST SPEAKERS (continued)

THOMAS G. ORR MEMORIAL LECTURESHIP THE DIFFICULT GALLBLADDER: A NOVEL, SAFE APPROACH

TUESDAY, APRIL 15, 2014 2:45pm – 3:45pm Herberger Ballroom 1, 2, 3

Speaker: Daniel R. Margulies, MD Los Angeles, CA

Daniel R. Margulies, MD, FACS is Chief of Acute Care Surgery, Professor of Surgery, and Director of Trauma at Cedars-Sinai Medical Center in Los Angeles, California.

Dr. Margulies earned his Bachelors’ degree in mechanical engineering from Stanford University. Following that he returned to Hawaii, where he is from originally, to obtain his Medical degree from the University of Hawaii John A. Burns School of Medicine. He completed his general surgery residency at the University of Hawaii School of Medicine and then proceeded to obtain fellowship training in trauma and surgical critical care at Cedars-Sinai Medical Center in Los Angeles.

Dr. Margulies has directed Trauma at Cedars-Sinai for over 18 years. His surgical expertise includes trauma, critical care, emergency and general surgery. Dr. Margulies is a fellow of the American College of Surgeons (ACS) and has taken an active role in serving the ACS on a regional and national level. He is the recent past president of the Southern California Chapter of the ACS. He is currently a member of the ACS Committee on Trauma (COT) and past State Chair of the Southern California COT. He is active in a many surgical professional organizations and currently serves as a Commissioner of the State of California Emergency Medical Services. He has published extensively in the field of trauma, critical care and general surgery.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 17 GUEST SPEAKERS (continued)

THOMAS G. ORR MEMORIAL LECTURESHIP PAST PRESENTERS

1966 1982 1998 Michael E. DeBakey, MD Arlo S. Hermreck, MD Alden H. Harken, MD

1967 1983 1999 Edgar J. Poth, MD G. Rainey Williams, MD Frederick A. Moore, MD

1968 1984 2000 Stanley R. Friesen, MD Samuel A. Wells, Jr., MD H. Harlan Stone, MD

1969 1985 2001 Philip B. Price, MD Layton F. Rikkers, MD Russell G. Postier, MD

1970 1986 2002 Kenneth C. Sawyer, MD Ronald C. Jones, MD Richard J. Andrassy, MD

1971 1987 2003 Merlin K. DuVal, MD W. Sterling Edwards, MD Keith Lillemoe, MD

1972 1988 2004 C. Frederick Kittle, MD Laurence Y. Cheung, MD Alan Thorson, MD

1973 1989 2005 Erie E. Peacock, MD Tom R. DeMeester, MD Nathaniel Soper, MD

1974 1990 2006 Eugene M. Brickner, MD Charles M. Balch, MD Thomas Weber, MD

1975 1991 2007 William R. Waddell, MD Alex G. Little, MD Byers W. Shaw, MD

1976 1992 2008 Denton A. Cooley, MD Donald E. Fry, MD Shuvo Roy, PhD

1977 1993 2009 Gilbert S. Campbell, MD Keith Reemtsma, MD Mark A. Talamini, MD

1978 1994 2010 Howard T. Robertson, C. James Carrico, MD Barbara Lee Bass, MD MD 1995 2011 1979 Frederick L. Grover, MD John Potts, III, MD Norman M. Rich, MD 1996 2012 1980 Ernest E. Moore, Jr., MD David Mercer, MD W. Gerald Rainer, MD 1997 2013 1981 Nicholas P. Lang, MD Alicia Mangram, MD Arthur C. Beall, Jr., MD

18 Southwestern Surgical Congress | 66th Annual Meeting GUEST SPEAKERS (continued)

CLAUDE H. ORGAN, JR. MEMORIAL LECTURESHIP SURGICAL LESSONS FROM THE LAKE

WEDNESDAY, APRIL 15, 2014 8:15am – 9:00am Herberger Ballroom 1, 2, 3

Speaker: Shanu N. Kothari, MD La Crosse, WI Shanu N. Kothari M.D., FACS earned his medical degree from the University of Illinois College of Medicine-Peoria. He completed his general surgery residency at Gundersen Lutheran Medical Foundation in La Crosse, Wisconsin and his fellowship in Minimally Invasive Surgery at Virginia Commonwealth University in Richmond, Virginia.

Dr. Kothari established a minimally invasive bariatric surgery program at Gundersen Health System and has served as its Director since 2001. He has also established a Minimally Invasive Bariatric Surgery and Advanced Laparoscopy Fellowship through the Gundersen Lutheran Medical Foundation in 2003, and has served as the fellowship director since its inception.

Dr. Kothari has been a member of the program committee for the Southwestern Surgical Congress for the past four years, and is the current program chair. He is also the State Councilor for Wisconsin and was instrumental in getting Wisconsin inducted as a state chapter of the Southwestern Surgical Congress. He is currently the President of the Wisconsin Surgical Society - a chapter of the American College of Surgeons. His other appointments include adjunct Faculty at the University of Wisconsin School of Medicine and Public Health, Chair of the American Society for Metabolic and Bariatric Surgery (ASMBS) Clinical Issues Committee, selected member of the ASMBS Revisional Surgery and National Quality Forum Taskforces, and recent member of the Fellowship Council Executive Committee.

Dr. Kothari has over 70 publications in peer-reviewed journals, and has served as the senior editor of a Surgical Clinics of North America issue dedicated to Metabolic and Bariatric surgery. He is an Associate Editor of Evidence-Based Approach to Minimally Invasive Surgery and as an editorial board member of Surgery for Obesity and Related Diseases.

Dr. Kothari, an avid boater, had the privilege of taking sabbatical in the summer of 2011. During this time off, he circumnavigated Lake Michigan with his family. His lecture will focus on lessons learned and surgical parallels between boating and life as a surgeon. Topics will include the use of checklists, communication, teamwork, and surgical mentorship.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 19 GUEST SPEAKERS (continued)

CLAUDE H. ORGAN, JR. MEMORIAL LECTURESHIP PAST PRESENTERS

1996 2005 V. Suzanne Klimberg, MD Sean J. Mulvihill, MD

1997 2006 LaSalle D. Leffall, Jr., MD John Hanks, MD

1998 2007 Samuel A. Wells, Jr., MD Glen D. Warden, MD

1999 2008 Hiram C. Polk, Jr., MD Dmitry Oleynikov, MD

2000 2009 F. Charles Brunicardi, MD Mary L. Brandt, MD

2010 2001 Ernest E. Moore, MD John B. Cone, MD 2011 2002 Ronald M. Stewart, MD Douglas S. Reintgen, MD 2012 2003 Eugene Foley, MD Frank Lewis, MD 2013 2004 Kelly McMasters, MD Philip Schauer, MD

20 Southwestern Surgical Congress | 66th Annual Meeting AWARDS

JACK A. BARNEY RESIDENT’S AWARD Dr. Jack A. Barney received his medical degree in 1956 from the University of Oklahoma. He completed his surgical residency training at St. Anthony Hospital and the University of Oklahoma Health Science Center before entering private practice in Oklahoma City. Dr. Barney continued in private practice in Oklahoma City and Clinical Assistant Professor of Surgery at the University of Oklahoma. This award was established in 1986 to recognize the dedicated service of Dr. Barney, who served as Secretary-Treasurer of the Southwestern Surgical Congress from 1966 to 1986. It is awarded to the best paper presented by a resident. The first Jack A. Barney award was presented at the 1987 Annual Meeting.

1987 2001 Ronald M. Stewart, MD Elizabeth K. Paulsen, MD

1988 2002 T.L. Demmy, MD Sandra Wong, MD

1989 2003 Ronald M. Stewart, MD Ketan Desai, MD

1990 2004 George Orloff , MD Joseph A. Davis, MD

1991 2005 L. Lee Nelson, MD Elizabeth Fitzsullivan, MD

1992 2006 Phillip M. Brown, MD Hyong Kim, MD

1993 2007 Timothy C. Hollingsed, MD Marcene McVay, MD

1994 2008 Walter L. Biffl, MD Jodi Gerdes, MD

1995 2009 Daniel R. Meldrum, MD Jennifer Keller, MD

1996 2010 David A. Partrick, MD Brenda Kopriva, MD

1997 2011 Evan R. Kokoska, MD Stephanie Cohen, MD, MS

1998 2012 Tari King, MD Paul Bjordahl, MD

1999 2013 David G. Affleck, MD Irminne Van Dyken, MD

2000 Philip A. Woodworth, MD

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 21 AWARDS

BEST POSTER AWARD This award is presented to the highest ranked poster presented at the Southwestern Surgical Congress Annual Meeting. 1996 2004 Abdelkrim Touijer, MD Shawn St. Peter, MD

1997 2007 Joseph Huh, MD Shanu Kothari, MD

1998 2008 Hedieh Stefanacci, MD Candy Arentz, MD

1999 2009 Stacy L. Stratmann, MD Christian Jones, MD

2000 2010 Archana Ganaraj, MD Shuan Brown, MD

2001 2011 Erik B. Wilson, MD Amani Jambhekar, BA, BS

2002 2012 Danny Little, MD Gaurav Kaushik, PhD

2003 2013 Anees Chagpar, MD Anne Doughtie, MD

22 Southwestern Surgical Congress | 66th Annual Meeting SPECIAL SESSIONS

POSTGRADUATE COURSES

CURRENT MANAGEMENT OF HERNIAS

SUNDAY, APRIL 13, 2014 8:00am – 12Noon Herberger Ballroom 1, 2, 3

Course Directors: Dean Mikami, MD – Columbus, OH Kristi Harold, MD – Phoenix, AZ

Faculty: Dean Mikami, MD – Columbus, OH Shanu Kothari, MD – La Crosse, WI Dan Vargo, MD – Salt Lake City, UT Kristi Harold, MD – Phoenix, AZ Kenric Murayama, MD – Abington, PA Alyssa Chapital, MD – Phoenix, AZ David Chen, MD – Los Angeles, CA

Agenda 8:00am Welcome and Introductions 8:10am Comorbidities and Hernias / Patient Selection 8:40am Lap Ventral Hernia Repair – Considerations and Techniques 9:10am Component Separation – Open and Laparoscopic 9:40am Management of Atypical Abdominal Wall Hernias 10:10am Morning Break 10:30am Laparoscopic TEP and TAPP vs OPEN: Algorithm for When and Why 11:00am Controversy: Small Umbilical Hernia, Mesh or No Mesh? 11:30am Management of Post-Hernia Repair Pain (Triple Neurectomy) 12Noon Case Presentation / Panel Discussion and Q&A

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 23 SPECIAL SESSIONS (continued)

UPDATES IN ENDOCRINE SURGERY

SUNDAY, APRIL 13, 2014 8:00am – 12Noon Rainmakers Ballroom

Course Director: Peter Angelos, MD, PhD - Chicago, IL

Faculty: Glenda Callender, MD - New Haven, CT Mark Cohen, MD - Ann Arbor, MI Raymon Grogan, MD - Chicago, IL Marlon Guerrero, MD - Tucson, AZ Melanie Richards, MD - Rochester, MN

Agenda 8:00am - 8:05am Welcome and Introductions 8:05am - 8:25am Primary Surgery for Well-Differentiated Thyroid Cancer 8:25am - 9:00am Debate: Prophylactic Central Node Dissection 9:00am - 9:20am Strategies for Recurrent Thyroid Cancer 9:20am - 9:40am Neuromonitoring: Benefits and Limitations 9:40am - 10:00am Alternative Approaches to Thyroidectomy (Robotic, Axillary, Video-Assisted) A Critical Appraisal 10:00am - 10:15am Morning Break 10:15am - 10:35am Work up for Primary Hyperparathyroidism 10:35am - 10:55am Surgery for Primary Hyperparathyroidism 10:55am - 11:15am Strategies for Persistent HPT after Failed Surgery 10:55am - 11:15am Work up of the Incidental Adrenal Mass 11:15am - 11:35am Surgical Options for Adrenalectomy 11:35am - 12Noon Panel Discussion: Challenging Endocrine Cases

24 Southwestern Surgical Congress | 66th Annual Meeting SPECIAL SESSIONS (continued)

UPDATES IN ENDOCRINE SURGERY WOMEN IN SURGERY LUNCHEON

SUNDAY, APRIL 13, 2014 SUNDAY, APRIL 13, 2014 8:00am – 12Noon 12:00Noon – 1:00pm Rainmakers Ballroom Rainmakers Ballroom Moderator: Clay Cothren Burlew, MD Course Director: Peter Angelos, MD, PhD - Chicago, IL Presenters: Faculty: Alicia Mangram, MD Can You Be a Mom in “Academics”? Glenda Callender, MD - New Haven, CT Gail T. Tominaga, MD Dual-Career Couples Versus Stay-at-Home-Spouse Mark Cohen, MD - Ann Arbor, MI Raymon Grogan, MD - Chicago, IL Christine Cocanour, MD Challenges of the Single Female Attending and Climbing Marlon Guerrero, MD - Tucson, AZ the Professional Ladder Melanie Richards, MD - Rochester, MN

Agenda AMERICAN COLLEGE OF SURGEONS PRESENTATION

8:00am - 8:05am Welcome and Introductions MONDAY, APRIL 14, 2014 8:05am - 8:25am Primary Surgery for Well-Differentiated Thyroid Cancer 8:00am – 11:30am 8:25am - 9:00am Debate: Prophylactic Central Node Dissection Herberger 1, 2, 3 9:00am - 9:20am Strategies for Recurrent Thyroid Cancer 8:00am – 9:30am Panel 1: 9:20am - 9:40am Neuromonitoring: Benefits and Limitations AMERICAN COLLEGE OF SURGEONS UPDATE: 9:40am - 10:00am Alternative Approaches to Thyroidectomy AFFORDABLE CARE ACT REPEAL OF SUSTAINABLE (Robotic, Axillary, Video-Assisted) GROWTH RATE, AND ACS PAC A Critical Appraisal Moderator: David B. Hoyt, MD, FACS 10:00am - 10:15am Morning Break Panelists: Christian Shalgian 10:15am - 10:35am Work up for Primary Hyperparathyroidism John Hedstrom 10:35am - 10:55am Surgery for Primary Hyperparathyroidism 9:30am – 10:00am Beverage Break 10:55am - 11:15am Strategies for Persistent HPT after Failed Surgery 10:00am – 11:30am Panel 2: 10:55am - 11:15am Work up of the Incidental Adrenal Mass TRANSITION TO PRACTICE IN GENERAL SURGERY 11:15am - 11:35am Surgical Options for Adrenalectomy Moderator: R. Phillip Burns, MD, FACS 11:35am - 12Noon Panel Discussion: Challenging Endocrine Cases Panelists: R. Philip Burns, MD, FACS Ajit K. Sachdeva, MD, FRCSC, FACS Ronald M. Stewart, MD, FACS Don K. Nakayama, MD, FACS

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 25 SPECIAL SESSIONS (continued)

DEBATE PRESENTATIONS

TUESDAY, APRIL 15, 2014 7:45am – 8:45am Taking Call – “Pay to Play” Moderator: Shanu N. Kothari, MD

7:45am – 7:50am Introduction - Kenric Murayama, MD 7:50am – 8:10am “Everyone Taking Call Should Be Compensated” Tom White, MD 8:10am – 8:30am “No One Should Be Paid…It Is Our Responsibility” Ronald Stewart, MD 8:30am – 8:45am Q&A and discussion

GRADUATE MEDICAL EDUCATION LUNCHEON “Employment Models”

TUESDAY, APRIL 15, 2014 12:30pm – 1:45pm Merriam Room Moderator: Daniel Vargo, MD – Salt Lake City, UT Presenters: Private Practice: Marcus Torgenson, MD – Couer d’Alene, ID Academic: Don Nakayama, MD – Morgantown, WV Employed: Kenric M. Murayama, MD – Abington, PA Registration Fee: $25 per person

ADVANCED PRACTICE CLINICIANS LUNCHEON Tuesday, April 15, 2014 12:30pm – 1:45pm Deseo Restaurant Moderator: Walter Biffl, MD Presenters: Courtney Scaife, MD “Making the Case for Hiring ACPs in your Practice” Alicia Conrad, CRNP “Integrating ACPs Into an Academic Setting” Renee Bearman, CRNP “Adding Value to a Practice - Opportunities for the Future” Registration Fee: $25 per person

26 Southwestern Surgical Congress | 66th Annual Meeting IN MEMORIAM

DEATHS REPORTED 2013 – 2014 As of March, 2014

Jack A. Barney, MD - Oklahoma City, OK

Robert W. Gillespie, MD - Longmont, CO

Robert E. McCurdy, MD - Denver, CO

Victor B. Tsirline, MD - Lincolnshire - IL

Please report any known member deaths to the Southwestern Surgical Congress:

Southwestern Surgical Congress 5019 W. 147th Street Leawood, KS, 66224 Telephone: 913.402.7102 Fax: 913.273.9940 Email: [email protected]

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 27 2013–2014 NEW MEMBERS

NEW ACTIVE FELLOWS NEW ASSOCIATE FELLOWS

David C. Chen, MD Edward Llewelyn Jones, MD, MS Los Angeles, CA Aurora, CO

Samuel Richard Gordon Finlayson, James Wu, MD MD, MPH Los Angeles, CA Salt Lake City, UT

Philip Andrew Kladar, MD Coeur d’Alene, ID

Terry C. Lairmore, MD Temple TX

Jared H. Linebarger, MD La Crosse, WI

Dean Jiro Mikami, MD Columbus, OH

Ryan Lee Neff, MD St. Louis, MO

John Coppinger Russell, MD Albuquerque, NM

Mark T. Savarise, MD Salt Lake City, UT

Gus Jay Slotman, MD Vineland, NJ

Marcus Jewell Torgenson, MD Coeur d’Alene, ID

Karin P. Trujillo, MD Omaha, NE

28 Southwestern Surgical Congress | 66th Annual Meeting PROGRAM SCHEDULE

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 29 PROGRAM SCHEDULE

SATURDAY, APRIL 12, 2014

1:00pm – 2:00pm Executive Committee Meeting Powell

2:00pm - 5:00pm Council Meeting Powell

7:00pm - 8:30pm President’s & Resident Reception Northern Sky Terrace

SUNDAY, APRIL 13, 2014

8:00am - 5:00pm Registration Herberger West Foyer

8:00am – 12Noon Postgraduate Course: Current Management of Hernias Herberger 1, 2, 3

Postgraduate Course: Updates in Endocrine Surgery Rainmakers Ballroom

12Noon – 1:00pm Women in Surgery Luncheon Rainmakers Ballroom No Fee – pre registration required

1:00pm – 7:00pm Exhibits Open Herberger Ballroom 4, 5, A, B

1:00pm - 2:15pm Opening Scientific Session I Herberger Ballroom 1, 2, 3

30 Southwestern Surgical Congress | 66th Annual Meeting PROGRAM SCHEDULE (continued)

2:15pm - 2:30pm Introduction of New Members Herberger Ballroom 1, 2, 3

2:30pm – 3:00pm Beverage Break/Exhibits & Poster Displays Herberger Ballroom 4, 5, A, B

3:00pm – 4:15pm Scientific Session II Herberger Ballroom 1, 2, 3

4:15pm - 5:00pm Presidential Address: Pyramids & Roundtables Herberger Ballroom 1, 2, 3

5:00pm – 5:30pm Featured Poster Presentations – Top Five at Five Herberger Ballroom 4, 5, A, B

5:30pm – 7:00pm Welcome & Exhibitor Reception Herberger Ballroom 4, 5, A, B

MONDAY, APRIL 14, 2014

7:00am - 8:30am Continental Breakfast Herberger Ballroom 4, 5, A, B

7:00am – 12Noon Exhibits & Poster Displays Herberger Ballroom 4, 5, A, B

7:00am – 12Noon Registration Herberger West Foyer

7:00am - 8:00am Quick Shot Presentations: Trauma – Rainmakers Ballroom GI – Herberger Ballroom 1, 2, 3 Miscellaneous – Greenway AB

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 31 PROGRAM SCHEDULE (continued)

8:00am – 11:30am American College of Surgeons Presentations Herberger Ballroom 1, 2, 3

8:00am – 11:00am Spouse Hospitality Kirkland

9:30am – 10:00am Exhibits & Poster Displays Herberger Ballroom 4, 5, A, B

1:00pm - 6:00pm Afternoon Golf and Tennis

TUESDAY, APRIL 15, 2014

6:30am – 7:30am Quick Shot Presentations: Trauma – Rainmakers Ballroom GI/Hernia – Herberger Ballroom 1, 2, 3 Vascular/CT/Acute Care – Greenway AB

7:00am – 5:00pm Registration Herberger West Foyer

7:00am – 9:00am Continental Breakfast Herberger Ballroom 4, 5, A, B

7:00am – 2:45pm Exhibits & Poster Displays Herberger Ballroom 4, 5, A, B

7:45am - 8:45am Debate Presentation Herberger Ballroom 1, 2, 3

8:00am - 11:00am Spouse Hospitality Kirkland

32 Southwestern Surgical Congress | 66th Annual Meeting PROGRAM SCHEDULE (continued)

8:45am - 10:15am Scientific Session III: Trauma Herberger Ballroom 1, 2, 3

10:15am - 11:00am Edgar J. Poth Memorial Lecture SURGICAL ETHICS AND THE CHALLENGE OF SURGICAL INNOVATION Peter Angelos, MD, PhD Herberger Ballroom 1, 2, 3

11:00am – 11:30am Beverage Break / Exhibits & Poster Displays Herberger Ballroom 4, 5, A, B

11:30am - 12:30pm Scientific Session IV: Surgical Oncology Herberger Ballroom 1, 2, 3

12:30pm - 1:45pm Graduate Medical Education Luncheon: Employment Models Merriam

12:30pm – 1:45pm Advanced Practice Clinicians Luncheon Deseo Restaurant - Westin Kierland Hotel

1:45pm - 2:45pm Scientific Session V: Education Herberger Ballroom 1, 2, 3

2:45pm – 3:00pm Beverage Break / Exhibits & Poster Displays Herberger Ballroom 4, 5, A, B

2:45pm - 3:45pm Thomas G. Orr Memorial Lecture THE DIFFICULT GALLBLADDER: A NOVEL, SAFE APPROACH Daniel Margulies, MD Herberger Ballroom 1, 2, 3

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 33 PROGRAM SCHEDULE (continued)

3:45pm – 4:45pm Scientific Session VI: Breast and Endocrine Herberger Ballroom 1, 2, 3

4:45pm – 5:30pm SWSC Annual Business Meeting Herberger Ballroom 1, 2, 3 (members only)

7:00pm – 10:00pm SWSC Reception Northern Sky Terrace

WEDNESDAY, APRIL 16, 2014

7:00am – 8:00am Quick Shot Presentations: Oncology and Miscellaneous – Rainmakers Ballroom GI – Herberger Ballroom 1, 2, 3 Education and Trauma – Greenway AB

7:00am – 9:00am Continental Breakfast Herberger Ballroom 5B

7:00am – 11:00am Registration Open Herberger West Foyer

8:15am – 9:00am Claude H. Organ, Jr. Memorial Lecture: “SURGICAL LESSONS FROM THE LAKE” Shanu N. Kothari, MD Herberger Ballroom 1, 2, 3

9:00am – 10:00am Scientific Session VII: Trauma Herberger Ballroom 1, 2, 3

10:00am – 10:30am Award Presentations & Closing Session Herberger Ballroom 1, 2, 3

34 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PROGRAM

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 35 SCIENTIFIC PROGRAM *Indicates resident paper competing for Jack A. Barney Award. SUNDAY, APRIL 13, 2014

8:00am – 5:00pm Registration Herberger West Foyer

8:00am – 12Noon Postgraduate Course A: Current Management of Hernias Herberger Ballroom 1, 2, 3 Course Directors: Dean Mikami, MD; Kristi Harold, MD Faculty: Alyssa Chapital, MD David Chen, MD Shanu N. Kothari, MD Kenric M. Murayama, MD Daniel J. Vargo, MD No fee

8:00am – 12Noon Postgraduate Course B: Updates in Endocrine Surgery Rainmakers Ballroom Course Director: Peter Angelos, MD, PhD Faculty: Glenda Callendar, MD Mark S. Cohen, MD Ray Grogan, MD Marlon Guerrero, MD Melanie Richards, MD No fee

12Noon – 1:00pm Women in Surgery Luncheon Rainmakers Ballroom No fee – pre-registration required

1:00pm – 2:15pm Opening Scientific Session I: Abdominal & GI Herberger Ballroom 1, 2, 3 Moderators: Kenric M. Murayama, MD & Anne Mancino, MD

36 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PROGRAM (continued) *Indicates resident paper competing for Jack A. Barney Award. 1:00pm - 1:15pm *1. A COMPARISON OF POST-OPERATIVE EFFECTS OF BARIATRIC SURGERY ON MEDICAL MARKERS OF MORBIDITY Presenter: Gwen Bonner, MD - Temple, TX Discussant: Matthew Fabian, MD - Fargo, ND

1:15pm - 1:30pm *2. IS LAPAROSCOPIC SLEEVE GASTRECTOMY A LOWER RISK BARIATRIC PROCEDURE COMPARED TO LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS? A META-ANALYSIS Presenter: Jonathan Zellmer, MD - La Crosse, WI Discussant: Megan Gilmore, MD - Rochester, MN

1:30pm - 1:45pm *3. CAN IT WAIT UNTIL MORNING? A COMPARISON OF NIGHTTIME VS DAYTIME CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS Presenter: James Wu, MD - Los Angeles, CA Discussant: Marcus Jewell Torgenson, MD - Coeur d’Alene, ID

1:45pm - 2:00pm 4. ALVIMOPAN REDUCES LENGTH OF STAY AND COSTS IN PATIENTS UNDERGOING SEGMENTAL COLONIC RESECTIONS; RESULTS FROM MULTI-CENTER NATIONAL ADMINISTRATIVE DATABASE. Presenter: Anton Simorov, MD - Omaha, NE Discussant: Gary Dunn, MD - Oklahoma City, MD

2:00pm - 2:15pm 5. EFFECT OF HYPERBARIC OXYGEN THERAPY ON HEALING OF A BOWEL ANASTOMOSIS IN A PERITONITIS MODEL IN THE RAT (RATTUS NORVEGICUS) Presenter: Josiah Freemyer, MD - El Paso, TX Discussant: Mark S. Cohen, MD - Ann Arbor, MI

2:15pm – 2:30pm Introduction of New Members Herberger Ballroom 1, 2, 3

2:30pm – 3:00pm Beverage Break/Exhibits & Poster Displays Herberger Ballroom 4, 5, A, B

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 37 SCIENTIFIC PROGRAM (continued)

3:00pm – 4:15pm Scientific Session II: Miscellaneous Herberger Ballroom Ballroom 1, 2, 3 Moderators: Scott Petersen, MD Richard Frazee, MD

3:00pm - 3:15pm *6. SHOULD CLOPIDEGROL BE DISCONTINUED BEFORE LAPAROSCOPIC CHOLECYSTECTOMY? Presenter: Katherine Anderson, MD - Temple, TX Discussant: Kevin Riess, MD - Virginia, MN

3:15pm - 3:30pm *7. UNINTENTIONAL ELECTROMAGNETIC INTERFERENCE CAUSED BY COMMON SURGICAL ENERGY-BASED DEVICES ON IMPLANTABLE CARDIAC DEVICES Presenter: Alessandro Paniccia, MD - Aurora, CO Discussant: Dean Mikami, MD - Columbus, OH

3:30pm - 3:45pm *8. IMAGE GUIDED PLACEMENT OF IMPLANTED CENTRAL VENOUS CATHETERS REDUCES COMPLICATIONS AND COST Presenter: Megan Bowen, MD - Salt Lake City, UT Discussant: Jeremiah Lee Deneve, DO - Memphis, TN

3:45pm - 4:00pm 9. CAN SURGICAL PERFORMANCE BENCHMARKING BE GENERALIZED ACROSS MULTIPLE OUTCOMES DATABASES: A COMPARISON OF UHC AND NSQIP Presenter: Anton Simorov, MD - Omaha, NE Discussant: Alex Wade, MD - Viroqua, WI

4:00pm - 4:15pm *10. POSTOPERATIVE PNEUMOPERITONEUM ON COMPUTED TOMOGRAPHY: IS THE OPERATION TO BLAME? Presenter: Gregory Peirce, MD - El Paso, TX Discussant: Brandon Grover, MD La Crosse, WI

4:15pm – 5:00pm Presidential Address: Pyramids & Roundtables Kenric Murayama, MD - Abington, PA Herberger Ballroom 1, 2, 3

38 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PROGRAM (continued)

5:00pm – 6:00pm Featured Poster Presentations: Top Five at Five Herberger Ballroom 4, 5, A, B

5:30pm – 7:00pm Welcome & Exhibitor Reception Herberger Ballroom 4, 5, A, B

Evening Open

MONDAY, APRIL 14, 2014

7:00am – 8:30am Continental Breakfast Herberger Ballroom 4, 5, A, B

7:00am – 12Noon Registration Open Herberger West

7:00am – 8:00am Quick Shot Presentations: Abdominal and Gastrointestinal Surgery Herberger Ballroom 1, 2, 3 Moderators: Shanu Kothari, MD Megan Gilmore, MD

7:00am - 7:08am QS1. POST-OPERATIVE PNEUMOPERITONEUM: IS IT NORMAL OR PATHOLOGIC? Presenter: Brandon Chapman, MD - Denver, CO

7:08am - 7:16am QS2. INTER-RATER AGREEMENT IN EVALUATING THE ENDOSCOPIC APPEARANCE OF THE GASTROESOPHAGEAL JUNCTION IN COMMUNITY SETTING Presenter: Glenn Ihde, MD - Arlington, TX

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 39 SCIENTIFIC PROGRAM (continued)

7:16am - 7:24am QS3. MAGNETIC RESONANCE CHOLANGIO-PANCREATOGRAPHY BEFORE AN ENDOSCOPIC RETROGRADE CHOLANGIO- PANCREATOGRAPHY: IS IT REALLY REQUIRED? Presenter: Viraj Pandit, MD - Tucson, AZ

7:24am - 7:32am QS4. CHRONIC STEROID USE AND ITS EFFECT ON POST-OPERATIVE WEIGHT LOSS Presenter: Vishal Kothari, MD - Omaha, NE

7:32am - 7:40am QS5. INITIAL OPERATIVE TREATMENT OF ISOLATED ILEAL CROHN’S DISEASE IN ADOLESCENTS Presenter: Shannon Acker, MD – Aurora, CO

7:40am - 7:48am QS6. EARLY COMPLICATIONS BETWEEN “PULL” VS. “PUSH” PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) - “PULL” PEG TUBE DISLODGEMENT MAY BE UNDERAPPRECIATED Presenter: Victor Vallet, BA, MPH - Tucson, AZ

7:48am - 7:56am QS7Video. LAPAROSCOPIC ANTRECTOMY ROUX EN Y FOR GASTRIC ANTRAL VASCULAR ECTASIA (GAVE) Presenter: Ryan Jones, DO - Las Vegas, NV

7:00am – 8:00am Quick Shot Presentations: Miscellaneous Greenway AB Moderators: Ernest Gonzalez, MD Brandon Grover, MD

7:00am - 7:08am QS8. A STATEWIDE OBSERVATIONAL STUDY OF COMPLIANCE WITH SURGICAL SAFETY CHECKLISTS: WE’RE NOT AS GOOD AS WE THINK Presenter: Annalee Gallagher - Denver, CO

7:08am - 7:16am QS9. ORIGINAL EQUIPMENT MANUFACTURER SINGLE-USE ENERGY DEVICES FAIL MORE FREQUENTLY THAN REPROCESSED DEVICES Presenter: Terrence Loftus, MD - Phoenix, AZ

40 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PROGRAM (continued)

7:16am - 7:24am QS10. HIGH PREVALENCE OF DOMESTIC ABUSE AMONG TRAUMA PATIENTS, A HARSH REALITY Presenter: Bardiya Zangbar, MD - Tucson, AZ

7:24am - 7:32am QS11. THE UNDERESTIMATED EFFECT OF HYPOTHERMIA IN ORGAN DONATION Presenter: Mazhar Khalil, MD - Tucson, AZ

7:32am - 7:40am QS12. ENHANCING SURGICAL SAFETY USING DIGITAL MULTIMEDIA TECHNOLOGY Presenter: Jennifer Dixon, MD - Temple, TX

7:40am - 7:48am QS13. FETAL SURGERY AND OUTCOME OF CONGENITAL HIGH AIRWAY OBSTRUCTION SYNDROME (CHAOS) AT A SINGLE CENTER Presenter: Fariha Sheikh, MD - Houston, TX

7:48am - 7:56am QS14. DOES CONCOMITANT THERAPY WITH ALLOPURINOL PREVENT OXIDANT MEDIATED DAMAGE IN THE SETTING OF KIDNEY AND KIDNEY-PANCREAS TRANSPLANTATION? A RETROSPECTIVE REVIEW OF A TRANSPLANT CENTER Presenter: Angela Echeverria, MD - Tucson, AZ

7:00am – 8:00am Quick Shot Presentations: Trauma Rainmakers Ballroom – ABC Moderators: Randall Smith, MD Daniel Dent, MD

7:00am - 7:08am QS15. CERVICAL SPINE INJURIES: DO ALL FRACTURES REQUIRE SCREENING FOR BLUNT CEREBRAL VASCULAR INJURY? Presenter: Peter Fischer, MD, MS - Charlotte, NC

7:08am - 7:16am QS16. COST CONTAINMENT IN A RAPIDLY EXPANDING ELDERLY POPULATION: A PREDICTIVE MODEL TO GUIDE RIB FRACTURE MANAGEMENT Presenter: Katherine Schnell, MD - Temple, TX

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 41 SCIENTIFIC PROGRAM (continued)

7:16am - 7:24am QS17. IMPLEMENTATION OF AN INSTITUTIONAL PROTOCOL ACHIEVES NEAR-PERFECT RETRIEVAL RATES AMONG TRAUMA PATIENTS WITH RETRIEVABLE INFERIOR VENA CAVA FILTERS Presenter: Alexander Raines, MD - Oklahoma City, OK

7:24am - 7:32am QS18. IMPACT OF THE AGE OF BLOOD TRANSFUSED ON 30-DAY MORTALITY AFTER TRAUMA Presenter: Basem Marcos, MD - La Crosse, WI

7:40am - 7:48am QS20. PSYCHOLOGICAL FACTORS PREDICTING OUTCOME AFTER TRAUMATIC INJURY: THE ROLE OF RESILIENCE Presenter: Ann Marie Warren, PhD - Dallas, TX

7:48am - 7:56am QS21. DEFENSIVE MEDICINE IS PREVALENT AND COSTLY IN THE TRAUMA PATIENT’S RADIOGRAPHIC WORKUP Presenter: Sarah Majercik, MD, MBA - Salt Lake City, UT

8:00am – 11:30am American College of Surgeons Presentation Herberger Ballroom 1, 2, 3

8:00am – 9:30am Panel 1: AMERICAN COLLEGE OF SURGEONS UPDATE: AFFORDABLE CARE ACT REPEAL OF SUSTAINABLE GROWTH RATE, AND ACS PAC Moderator: David B. Hoyt, MD, FACS Panelists: Christian Shalgian John Hedstrom

9:30am – 10:00am Beverage Break

10:00am – 11:30am Panel 2: TRANSITION TO PRACTICE IN GENERAL SURGERY Moderator: R. Phillip Burns, MD, FACS Panelists: R. Philip Burns, MD, FACS Ajit K. Sachdeva, MD, FRCSC, FACS Ronald M. Stewart, MD, FACS Don K. Nakayama, MD, FACS

42 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PROGRAM (continued)

8:00am – 11:00am Spouse Hospitality Kirkland

9:30am – 10:00am Beverage Break/Exhibits & Poster Displays Herberger Ballroom 4, 5, A, B

1:00pm – 6:00pm Afternoon Golf and Tennis

TUESDAY, APRIL 15, 2014

6:30am – 7:30am Quick Shot Presentations: Gastrointestinal & Hernia Herberger Ballroom 1, 2, 3 Moderators: Kevin Reavis, MD Dean Mikami, MD

6:30am - 6:38am QS22. VENTRAL HERNIA GRADE IS ASSOCIATED WITH SIGNIFICANT IN-HOSPITAL COMPLICATIONS Presenter: Alessandra Landmann, MD - Oklahoma City, OK

6:38am - 6:46am QS23. VENOUS THROMOBEMBOLISM (VTE) AFTER VENTRAL HERNIA REPAIR (VHR): A “NEVER EVENT?” Presenter: Mimi Kim, MD - Charlotte, NC

6:46am - 6:54am QS24. SAFETY OF LAPAROSCOPIC VENTRAL HERNIA REPAIR IN HIGH RISK CARDIAC AND PULMONARY PATIENTS Presenter: Atul Nanda, MD - Phoenix, AZ

6:54am - 7:02am QS25. TRIPLE NEURECTOMY, MESH REMOVAL AND RECURRENT INGUINAL HERNIA REPAIR FOR INTRACTABLE INGUINODYNIA Presenter: Samuel Ross, MD, MPH - Charlotte, NC

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 43 SCIENTIFIC PROGRAM (continued)

7:02am - 7:10am QS26. POST-OPERATIVE COMPLICATIONS IN ELECTIVE VENTRAL HERNIA REPAIRS INCREASE SEQUENTIALLY ACROSS ALL BMI CATEGORIES Presenter: Mary Mrdutt, MD - Temple, TX

7:10am - 7:18am QS27. LAPAROSCOPIC APPENDECTOMY: A CALL FOR STANDARDIZATION OF SURGICAL SUPPLIES? Presenter: Nicholas Czosnyka, MD - La Crosse, WI

7:18am - 7:26am QS28. MANAGEMENT OF A PERFORATED POSTERIOR DUODENAL ULCER WITH PROXIMAL DUODENECTOMY, ANTRECTOMY, TRUNCAL VAGOTOMY, AND BILLROTH II RECONSTRUCTION IN THE SETTING OF SUSPECTED PERFORATED PARAESOPHAGEAL HERNIA Presenter: Brandon Grover, DO - La Crosse, WI

6:30am – 7:30am Quick Shot Presentations: Trauma Rainmakers Ballroom Moderators: Brian Eastridge, MD Richard Frazee, MD

6:30am - 6:38am QS29. REPEAT IMAGING MAY NOT BE WARRANTED FOR HIGH-GRADE BLUNT CEREBROVASCULAR INJURIES Presenter: Amy Wagenaar, BA - Denver, CO

6:38am - 6:46am QS30. CLINICAL OUTCOMES IN PATIENTS ON PRE-INJURY IBUPROFEN WITH TRAUMATIC BRAIN INJURY: A PROSPECTIVE ANALYSIS Presenter: Bardiay Zangbar, MD - Tucson, AZ

6:46am - 6:54am QS31. HELICOPTER VERSUS GROUND TRANSPORTATION OF TRAUMATICALLY INJURED CHILDREN: A NATIONAL TRAUMA DATA BANK STUDY Presenter: Camille Stewart, MD - Aurora, CO

44 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PROGRAM (continued)

6:54am - 7:02am QS32. THE EPIDEMIOLOGY OF TRAUMATIC BRAIN INJURY AFTER SMALL WHEEL VEHICLE TRAUMA IN UTAH Presenter: Sarah Majercik, MD, MBA - Salt Lake City, UT

7:10am - 7:18am QS34. OUTCOMES OF TRAUMATIC BRAIN INJURY IN ELDERLY: IT DOES NOT ALWAYS GET WORSE WITH AGE Presenter: Irada Ibrahim-zada, MD, PhD - Tucson, AZ

7:18am - 7:26am QS35. ADVERSE EFFECTS OF ADMISSION BLOOD ALCOHOL ON LONG TERM COGNITIVE FUNCTION IN PATIENTS WITH TRAUMATIC BRAIN INJURY Presenter: Ammar Hashmi, MD - Tucson, AZ

6:30am – 7:30am Quick Shot Presentations: Vascular/CT/Acute Care Greenway AB Moderators: Michael S. Truitt, MD; Lillian F. Liao, MD, MPH

6:30am - 6:38am QS36. FACTORS CONTRIBUTING TO MAJOR LOWER EXTREMITY AMPUTATION: THE 5-YEAR EXPERIENCE OF AN INTEGRATED LIMB SALVAGE SERVICE Presenter: Timothy Rankin, MD - Tucson, AZ

6:38am - 6:46am QS37. TRAUMATIC INJURY TO AORTIC ARCH GREAT VESSELS: OUR EXPERIENCE WITH OPEN VS ENDOVASCULAR REPAIR Presenter: Peter Tsai, MD - Houston, TX

6:46am - 6:54am QS38. OPTIMAL TIMING OF CORONARY ARTERY BYPASS GRAFT SURGERY POST ACUTE MYOCARDIAL INFARCTION Presenter: Bradley Clark, MS2 - Lubbock, TX

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 45 SCIENTIFIC PROGRAM (continued)

6:54am - 7:02am QS39. USE OF A WOUND VAC IN INFECTED DEVICE POCKET SHORTENS INTERVAL TIME TO REIMPLANTATION OF CARDIAC DEVICES Presenter: Robert Feldtman, MD - Dallas, TX

7:02am - 7:10am QS40. SURGERY IN PATIENTS WITH NECROTIZING SOFT TISSUE INFECTIONS: HOW EARLY IS EARLY ENOUGH? Presenter: Rifat Latifi, MD - Tucson, AZ

7:10am - 7:18am QS41. SHOULD PARA-PNEUMONIC EFFUSIONS IN CRITICALLY ILL SURGICAL PATIENTS WITH VENTILATOR-ASSOCIATED PNEUMONIA BE SAMPLED ROUTINELY? Presenter: Maria Rodil, BS - Denver, CO

7:18am - 7:26am QS42. IMPACT OF AGE IN ARTERIOVENOUS GRAFT PATENCY: A LARGE COMMUNITY TEACHING HOSPITAL EXPERIENCE Presenter: Sergio Casillas, MD - Abington, PA

7:00am – 9:00am Continental Breakfast Herberger Ballroom 4, 5, A, B

7:00am – 2:45pm Exhibits & Poster Displays Herberger Ballroom 4, 5, A, B

46 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PROGRAM (continued)

7:45am – 8:45am Debate: Taking Call – Pay to Play Moderator: Shanu N. Kothari, MD Herberger Ballroom 1, 2, 3

7:45am – 7:50am Introduction of the Topic Kenric Murayama, MD

7:50am – 8:10am “Everyone Taking Call Should be Compensated” Tom White, MD

8:10am – 8:30am “No One Should Be Paid… It Is Our Responsibility” Ronald Stewart, MD

8:30am – 8:45am Q&A and Discussion

8:45am – 10:15am Scientific Session III: Trauma Herberger Ballroom 1, 2, 3 Moderators: Alicia Mangram, MD S. Rob Todd, MD

8:45am - 9:00am *11. TUMOR NECROSIS FACTOR-Α DISRUPTION OF BRAIN ENDOTHELIAL CELL BARRIER IS MEDIATED THROUGH MATRIX METALLOPROTEINASE-9 Presenter: Katie Wiggins-Dohlvik, MD - Temple, TX Discussant: Josh Mammen, MD - Kansas City, KS

9:00am - 9:15am 12. PROGESTERONE EFFECTS IN THE BRAIN MICROCIRCULATIION AFTER TBI : HOW DO STANDARD OSMOTHERAPIES COMPARE ? Presenter: Kenichiro Kumasaka, MD - Philadelphia, PA Discussant: Herb A. Phelan, MD - Dallas, TX

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 47 SCIENTIFIC PROGRAM (continued)

9:15am - 9:30am *13. WHAT’S THE HOLD UP? FACTORS CONTRIBUTING TO DELAYS IN DISCHARGE OF TRAUMA PATIENTS AFTER MEDICAL CLEARANCE Presenter: Jose Raul Soto, MD, MPH - Dallas, TX Discussant: Lillian F. Liao, MD, MPH - San Antonio, TX

9:30am - 9:45am *14. OUTCOMES OF ENDOVASCULAR MANAGEMENT OF ACUTE THORACIC AORTIC EMERGENCIES AT AN ACADEMIC LEVEL ONE TRAUMA CENTER Presenter: Angela Echeverria, MD, PharmD - Tucson, AZ Discussant: Mark Langsfeld, MD - Albuquerque, NM

9:45am - 10:00am *15. TIME AND COST DIFFERENCE IN ACUTE GALLSTONE PANCREATITIS PATIENTS WHO WERE ADMITTED UNDER MEDICINE VS. SURGERY IN THE ACUTE CARE SURGERY ERA Presenter: John Watt, MD - Tucson, AZ Discussant: Sarah Majercik, MD, MBA - Murray, UT

10:00am - 10:15am *16. THE GERIATRIC TRAUMA INSTITUTE(GTI): REDUCING THE INCREASING BURDEN OF SENIOR TRAUMA CARE Presenter: Connie DeLa’O, MD - Johnstown, PA Discussant: Ernest Gonzalez, MD - Austin, TX

10:15am – 11:00am Edgar J. Poth Memorial Lecture: “Surgical Ethics and the Challenge of Surgical Innovation” Presenter: Peter Angelos, MD, PhD Herberger Ballroom 1, 2, 3

11:00am – 11:30am Beverage Break/ Exhibit &Posters Displays Herberger Ballroom 4, 5, A, B

48 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PROGRAM (continued)

11:30 am – 12:30pm Scientific Session IV: Surgical Oncology Herberger Ballroom 1, 2, 3 Moderators: Kelly McMasters, MD, PhD; James Warneke, MD

11:30am - 11:45am 17. HONOKIOL AFFECT MELANOMA CELL GROWTH BY TARGETING METABOLIC PATHWAY VIA AMPK SIGNALING Presenter: Fnu Gaurav, PhD - Kansas City, KS Discussant: Maria Allo, MD - Los Altos, CA

11:45am - 12:00pm 18. CORE-NEEDLE BIOPSY FOR THE DIAGNOSIS OF LYMPHOMA: A SAFE AND ACCURATE ALTERNATIVE TO EXCISIONAL BIOPSY Presenter: Brian Nguyen, MD - Torrance, CA Discussant: Richard (Rick) J. Gray, MD - Phoenix, AZ

12:00pm - 12:15pm 19. PREOPERATIVE DOSING OF LOW MOLECULAR WEIGHT HEPARIN IN HEPATOPANCREATOBILIARY SURGERY Presenter: Prejesh Philips, MD - Louisville, KY Discussant: Martin McCarter, MD - Aurora, CO

12:15pm - 12:30pm 20. SMALLER PELVIC VOLUME IS ASSOCIATED WITH POST-OPERATIVE INFECTION AND SEPSIS AFTER PELVIC SALVAGE SURGERY FOR RECURRENT MALIGNANCY Presenter: Justin Merkow, MD - Aurora, CO Discussant: Kyle Marthaller, MD - Denver, CO

12:30pm – 1:45pm Graduate Medical Education Luncheon: Employment Models Moderator: Daniel Vargo, MD - Salt Lake City, UT Fee: $25 per person Deseo Restaurant – Westin Kierland Hotel Moderator: Daniel Vargo, MD – Salt Lake City, UT Presenter: Private Practice Academic: Don Nakayama, MD – Morgantown, WV Employed: Kenric M. Murayama, MD – Abington, PA Registration Fee: $25 per person

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 49 SCIENTIFIC PROGRAM (continued)

12:30pm – 1:45pm Advanced Practice Clinician Luncheon Moderator: Walter Biffl, MD - Denver, CO Merriam Room – Westin Kierland Hotel Moderator: Walter Biffl, MD Presenters: Courtney Scaife, MD “Making the Case for Hiring ACPs in your Practice” Alicia Conrad, CRNP “Integrating ACPs Into an Academic Setting” Renee Bearman, CRNP “Adding Value to a Practice - Opportunities for the Future”

Registration Fee: $25 per person

1:45pm – 2:45pm Scientific Session V: Education Herberger Ballroom 1, 2, 3 Moderators: Ernest Dunn, MD Randolph (Randy) E. Zlabick

1:45pm - 2:00pm 21. GEOGRAPHIC MALDISTRIBUTION OF GENERAL SURGERY (GS) PGY1 RESIDENTS: ANOTHER U.S. SURGICAL DESERT Presenter: Kenneth Sirinek, MD, PhD - San Antonio, TX Discussant: Wayne Anderson, MD - Williston, ND

2:00pm - 2:15pm 22. USMLE SCORES AS PREDICTORS OF SUCCESS IN SURGICAL RESIDENCY – ARE THEY VALID INDICATORS? Presenter: Erica Sutton, MD - Louisville, KY Discussant: Daniel (Dan) L. Dent, MD - San Antonio, TX

2:15pm - 2:30pm *23. ENDOSCOPY EXPERIENCE IN A COMMUNITY-BASED SURGICAL RESIDENCY: RESIDENT CASE NUMBER AND RATE OF MEETING QUALITY MEASURES Presenter: Lindsey Barnes, MD - Wichita, KS Discussant: Randolph (Randy) E. Szlabick, MD - Grand Forks, ND

50 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PROGRAM (continued)

2:30pm - 2:45pm *24. DO MEDICAL STUDENT’S SURGICAL EXAMINATION SCORES CORRELATE WITH PERFORMANCE MARKERS? Presenter: Austin George, MD - Wichita, KS Discussant: Kenric Murayama, MD - Abington, PA

2:45pm – 3:45pm Thomas G. Orr Memorial Lecture: “The Official Gallbladder: A Novel, Safe Approach” Presenter: Daniel Margulies, MD - Los Angeles, CA Herberger Ballroom 1, 2, 3

3:45pm – 4:45pm Scientific Session VI: Breast & Endocrine Herberger Ballroom 1, 2, 3 Moderators: Edward Nelson, MD; Jaqueline S. Osland, MD

3:45pm - 4:00pm *25. METASTASECTOMY OF NEUROENDOCRINE TUMORS IN PATIENTS WITH MEN 1 Presenter: Benzon Dy, MD - Rochester, MN Discussant: John Moore, MD - Denver, CO

4:00pm - 4:15pm *26. OPTIMAL UTILIZATION OF A BREAST CARE ADVANCED PRACTICE CLINICIAN Presenter: Katie Russell, MD - Salt Lake City, UT Discussant: Emily K. Robinson, MD - Houston, TX

4:15pm - 4:30pm *27. OBESITY CONTRIBUTES TO COMPLICATIONS AFTER THYROIDECTOMY AND PARATHYROIDECTOMY Presenter: Alex Cardenas, MD - Tucson, AZ Discussant: Melanie L. Richards, MD - Rochester, MN

4:30pm - 4:45pm *28. HAVE THE ACOSOG Z0011 TRIAL RESULTS INFLUENCED THE NUMBER OF LYMPH NODES REMOVED DURING SENTINEL LYMPH NODE DISSECTION? Presenter: Kristin Robinson, MD Jaqueline S. Osland, MD - Wichita, KS

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 51 SCIENTIFIC PROGRAM (continued)

4:45pm – 5:30pm SWSC Annual Business Meeting Herberger Ballroom 1, 2, 3 (members only)

7:00pm – 10:00pm SWSC Reception Northern Sky Terrace

WEDNESDAY, APRIL 16, 2014

7:00am – 8:00am Quick Shot Presentations: Education & Trauma Herberger 4A Moderators: Daniel Vargo, MD; Narong Kulvatunyou, MD

7:00am - 7:08am QS43. GOOD NEWS FOR DUTY HOURS: INPATIENT DELAY IN APPENDECTOMY IS OKAY IN ACUTE APPENDICITIS Presenter: Deidre Wyrick, MD - Little Rock, AR

7:08am - 7:16am QS44. THE IMPACT OF DOCUMENTATION TRAINING ON PERFORMANCE REPORTING Presenter: Terrence Loftus, MD - Phoenix, AZ

7:16am - 7:24am QS45. COMPARISONS OF MEDICAL STUDENT KNOWLEDGE REGARDING LIFE-THREATENING CT IMAGES BEFORE AND AFTER CLINICAL EXPERIENCE Presenter: Barbara Nguyen, MS4 - Wichita, KS

7:24am - 7:32am QS46. ACCEPTING THE CHALLENGE: GENERAL SURGEONS PARTNERING WITH HOSPITAL ADMINISTRATORS TO MANAGE QUALITY CARE INITIATIVES Presenter: Alicia Mangram, MD - Phoenix, AZ

52 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PROGRAM (continued)

7:32am - 7:40am QS47. USE OF TEG/ROTEM ANALYSIS IN POINT OF CARE EVALUATION OF TBI PATENTS ON ANTI-PLATELET THERAPY: EFFECTIVENESS IN RESOURCE UTILIZATION BY REDUCTION IN PLATELET TRANSFUSION Presenter: Amanpreet Sherwal, MD - Johnstown, PA

7:40am - 7:48am QS48. FACTOR IX COMPLEX IN TRAUMA RESULTS IN RAPID REVERSAL OF COAGULOPATHY THAT PERSISTS AT 24 HOURS Presenter: Monica Jain, MD - Los Angeles, CA

7:48am - 7:56am QS49. DISPARITY IN CARE FOR TRAUMATIC BRAIN INJURY IN ARIZONA BY GEOGRAPHICAL LOCATION: WARM DESERT OR SNOWY PEAKS? Presenter: Lynn Butvidas, MD, MS

7:00am – 8:00am Quick Shot Presentations: Gastrointestinal Herberger Ballroom Ballroom 1, 2, 3 Moderator: Shawn Tsuda, MD; Sarah Majercik, MD, MBA

7:00am - 7:08am QS50. OUTCOMES OF TREATMENT OF CHRONIC MESENTERIC ISCHEMIA Presenter: Zhobin Moghadamyeghaneh, MD - Orange, CA

7:08am - 7:16am QS51. RE-EXAMINING THE BMI THRESHOLD FOR BARIATRIC SURGERY: A DECISION ANALYSIS Presenter: Rashikh Choudhury, BA - Philadelphia, PA

7:16am - 7:24am QS52. OPTIMAL RADIAL FORCE AND SIZE FOR PALLIATION IN GASTRO- ESOPHAGEAL ADENOCARCINOMA: A COMPARATIVE ANALYSIS OF CURRENT TECHNOLOGY Presenter: Prejesh Philips, MD - Louisville, KY

7:24am - 7:32am QS53. EFFECTS OF ASCITES ON OUTCOMES OF COLORECTAL SURGERY IN CONGESTIVE HEART FAILURE PATIENTS Presenter: Zhobin Moghadamyeghaneh, MD - Orange, CA

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 53 SCIENTIFIC PROGRAM (continued)

7:32am - 7:40am QS54. BARIATRIC SURGERY OUTCOMES: SPOUSES/DOMESTIC PARTNERS VERSUS CASE-MATCHED CONTROLS Presenter: Hassanain Jassim, MD - Milwaukee, WI

7:40am - 7:48am QS55. TYPE OF ANESTHESIA AFFECTS THE ASSESMENT OF GASTROESOPHAGEAL JUNCTION IN PATIENTS EVALUATED FOR ANTI- REFLUX SURGERY Presenter: Glenn Ihde, MD - Arlington, TX

7:48am - 7:56am QS56. PERCUTANEOUS CHOLECYSTOSTOMY FOR MANAGEMENT OF ACUTE CHOLECYSTITIS: ANOTHER PIECE OF THE PIE? Presenter: Bryan Morse, MD, MS - Atlanta, GA

7:00am – 8:00am Quick Shot Presentations: Oncology & Miscellaneous Greenway AB Moderators: Courtney Scaife, MD; Richard (Rick) J. Gray, MD

7:00am - 7:08am QS57. COMPARATIVE EFFECTIVENESS OF SURGEON VERSUS PHARMACIST PREOPERATIVE ANTIBIOTIC SELECTION Presenter: Joshua Pfeiffer, MD - La Crosse, WI

7:08am - 7:16am QS58. EXCISIONAL BIOPSY VERSUS FINE NEELE ASPIRATION FOR STAGE III MELANOMA: DOES IT AFFECT SURGICAL OUTCOMES, REUCRRENCE OR SURVIVAL Presenter: Justin Merkow, MD - Aurora, CO

7:16am - 7:24am QS59. SURGICAL MANAGEMENT OF CAROTID BODY TUMORS: A 10- YEAR EXPERIENCE EMPLOYING AN INTERDISCIPLINARY APPROACH Presenter: Jennifer Dixon, MD - Temple, TX

7:24am - 7:32am QS60. NODAL BASIN RECURRENCE AND ADEQUACY OF RESECTION FOLLOWING LYMPHADENECTOMY FOR MELANOMA Presenter: Charles Kimbrough, MD, PhD - Louisville, KY

54 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PROGRAM (continued)

7:32am - 7:40am QS61. PERCUTANEOUS EMBOLIZATION OF THORACIC DUCT INJURY POST–ESOPHAGECTOMY SHOULD BE CONSIDERED INITIAL TREATMENT FOR CHYLOTHORAX BEFORE PROCEEDING WITH OPEN RE-EXPLORATION Presenter: Kyle Marthaller, MD - Denver, CO

7:00am – 11:00am Registration Open Herberger West Foyer

7:00am – 9:00am Continental Breakfast Herberger 5B

8:15am – 9:00am Claude H. Organ, Jr. Memorial Lecture “Surgical Lessons From the Lake” Presenter: Shanu N. Kothari, MD La Crosse, WI Herberger Ballroom 1, 2, 3

9:00am – 10:00am Scientific Session VII: Trauma Herberger Ballroom Ballroom 1, 2, 3 Moderators: Brian Eastridge, MD; Alyssa Chapital, MD

9:00am - 9:15am 29. ELIMINATING CATHETER ASSOCIATED URINARY TRACT INFECTIONS IN THE INTENSIVE CARE UNIT: IS IT AN ATTAINABLE GOAL? Presenter: Achal Dhupa, MD - La Jolla, CA Discussant: Stephanie Gordy, MD - Houston, TX

9:15am - 9:30am 30. THE IMPACT OF EARLY FLOW AND BRAIN OXYGEN CRISIS ON THE OUTCOME OF PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY Presenter: Corrado Marini, MD - Valhalla, NY Discussant: Fredric Michael Pieracci, MD, MPH - Denver, CO

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 55 SCIENTIFIC PROGRAM (continued)

9:30am - 9:45am 31. AUTOTRANSFUSION OF HEMOTHORAX: ACCELERATION OF COAGULATION WHEN MIXED WITH NORMAL PLASMA Presenter: Hannah Harrison, MS - San Antonio, TX Discussant: Randeep Jawa, MD - Stony Brook, NY

9:45am - 10:00am 32. PELVIC RING FRACTURES: HAS MORTALITY IMPROVED FOLLOWING THE IMPLEMENTATION OF DAMAGE CONTROL RESUSCITATION? Presenter: Caitlin Fitzgerald, BS - Atlanta, GA Discussant: Narong Kulvatanyou, MD - Tucson, AZ

10:00am – 10:30am Award Presentations & Closing Session Herberger Ballroom 1, 2, 3

56 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 57 SCIENTIFIC PAPER ABSTRACTS *Indicates resident paper competing for Jack A. Barney Award. 1. A COMPARISON OF POST-OPERATIVE EFFECTS OF BARIATRIC SURGERY ON MEDICAL MARKERS OF MORBIDITY GL Bonner MD; AJ Nagy BS; JA Rodriguez MD; RE Symmonds MD; DC Jupiter PhD; RO Carpenter MD, MPH Temple, TX

BACKGROUND: Recent medical research demonstrates that bariatric surgery reduces the prevalence of type II diabetes mellitus and improves the lipid profiles of patients post-operatively. Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been shown to reduce HDL and LDL (LDL-C) cholesterol levels. However, a newer modality within the lipid panel, LDL particle (LDL-P) is a more accurate predictor of cardiovascular events. The effects of bariatric procedures on LDL-P have not been previously reported in the literature. Thus, our aim was to determine whether bariatric surgery reduced LDL-P levels and if one surgical approach was superior.

METHODS: Patients who underwent bariatric surgery, including LRYGB, laparoscopic sleeve gastrectomy (LSG), and LapBand placement (LBP) at a single institution were included. Laboratory values were collected, per standard treatment protocol, for patients undergoing surgery from January 2011 through June 2012. HDL, LDL-P, LDL-C, and hemoglobin a1c were measured pre-operatively and at three month, six month, and twelve months post-operatively. Weight was recorded at baseline and one year post-operatively. Changes in the laboratory values from baseline to post- operative levels were assessed by a one sample t-test. ANOVA was used to compare the difference between procedures. Association between the one-year changes in lab values and total weight loss was tested using a Pearson correlation. Significance was set at P value <0.05.

RESULTS: The study included 229 patients; 55% underwent LRYBG, while 32% had LSG and 13% had LBP. Those undergoing bariatric surgery exhibited a marked decrease in their serum LDL-P levels, with an average drop of 472.58 (p<0.0001) over one year. At three and six months, these average decreases were 183 (p=0.015) and 208 (p=0.005) respectively. HDL levels significantly increased an average of 4.58 (p<0.0055) over one year. At three and six months, there was actually a decrease in HDL of 7.6 (p<0.0001) and 1.4 (p =0.26) respectively. Hemoglobin a1c levels also declined, but this was less profound; 2.02 (p=0.1), 0.81 (p<0.00001), and 0.36 (p=0.62) at three, six, and twelve months respectively. LDL-C levels dropped 1.11 at three months and 5.86 at one year, but these changes were not statistically significant (p=0.8 and p=0.34). Average weight loss was 71 pounds. When comparing the three bariatric surgery groups, there was no statistically significant difference in changes of LDL-P, LDL-C, HDL, or a1c levels at three, six, or twelve months. Only the one-year reduction in LDL-P and LDL-C levels was associated with total weight loss.

CONCLUSION: In our study population, we demonstrated that LDL-P, a more accurate marker risk of cardiovascular events, is significantly decreased after bariatric surgery. This decrease was a function of total weight loss and was independent of procedure type. Thus, it may be inferred from this retrospective review that bariatric surgery decreases the risk of future cardiovascular events through excess weight loss.

58 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.) *Indicates resident paper competing for Jack A. Barney Award. 2. IS LAPAROSCOPIC SLEEVE GASTRECTOMY A LOWER RISK BARIATRIC PROCEDURE COMPARED TO LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS? A META-ANALYSIS JD Zellmer MD, MA; Mathiason MS; KJ Kallies MS; SN Kothari MD La Crosse, WI

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the current “gold standard” bariatric procedure in the U.S. Laparoscopic sleeve gastrectomy (LSG) has recently become a more commonly performed procedure for many reasons, including patients’ perception that LSG is associated with less complexity and invasiveness, and lower risk. Our objective was to review the literature to compare the leak rates as well as morbidity and mortality for LRYGB versus LSG.

METHODS: A MEDLINE search was performed to identify LRYGB and LSG reports from 2002-2012. Publications with n ≥25 and postoperative leak rate reported were included. Statistical analysis included chi-square test according to patient number.

RESULTS: Twenty-eight (10,906 patients) LRYGB and 34 (4,836 patients) LSG articles met inclusion criteria. The leak rates after LRYGB versus LSG were 1.9% (n=206) versus 2.3% (n=112), respectively (P=0.079). Mortality rates were 0.4% (27/7117) for LRYGB and 0.2% (7/3594) for LSG (P=0.110). Timing from surgery to leak ranged from 1-12 days for LRYGB versus 1-35 days for LSG. Mean excess weight loss at 1 year postoperative ranged from 50-79% for LRYGB (n=5) and 38-81% for LSG (n=16).

CONCLUSION: Both LRYGB and LSG are effective surgical options for weight loss. The leak rates, mortality rates, and excess weight loss after LRYGB and LSG were comparable. Patients should be advised of these similarities when considering LRYGB versus LSG. The appropriate procedure should be tailored based on a comprehensive multidisciplinary discussion between the patient and bariatric team weighing patient factors, comorbidities, patient and surgeon comfort level, surgeon experience, and the institution’s outcomes.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 59 SCIENTIFIC PAPER ABSTRACTS (cont.)

3. CAN IT WAIT UNTIL MORNING? A COMPARISON OF NIGHTTIME VS DAYTIME CHOLECYSTECTOMY FOR ACUTE CHOLECYSTITIS J Wu MD; AT Nguyen MD; C de Virgilio MD; DS Plurad MD; AH Kaji MD PhD; V Nguyen; E Gifford MD; M de Virgilio; R Ayabe; D Saltzman MD; DY Kim MD Los Angeles/Torrance, CA

BACKGROUND: There is debate regarding the urgency and optimal timing of cholecystectomy for acute cholecystitis. The BACKGROUND of this study is to evaluate nighttime cholecystectomy versus cholecystectomy done during normal working hours. We hypothesized that nighttime cholecystectomy would result in decreased overall length of stay.

METHODS: We performed a retrospective review of patients with a preoperative diagnosis of acute cholecystitis from two large urban referral centers. We compared patients undergoing daytime (7a-7p) versus nighttime (7p-7a) cholecystectomy. Primary outcome is overall length of stay. Secondary outcomes include rate of conversion to open surgery, complication rate, and time from admission to operation.

RESULTS: Of 1140 patients, 908 (79.6%) underwent daytime cholecystectomy and 232 (21.4%) underwent nighttime cholecystectomy. Patients that underwent nighttime cholecystectomy had a significantly decreased median time from admission to operation (1.5 vs 2.0 days, p<0.0001), but higher conversion rate to open cholecystectomy (11.2% vs 6.2%, p=0.008). There were no significant differences in complication rate (5.2% vs 6.5%, p=0.5) or median overall length of stay (3.7 vs 3.8 days, p=0.08). On multivariable analysis, after controlling for significant variables, including severity of cholecystitis, independent predictors of conversion to open procedures were: nighttime cholecystectomy (OR= 2.0, 95% CI 1.25-3.33, p=0.01), increasing age (OR=1.02, 95% CI 1.005-1.04, p=0.01) and gangrenous cholecystitis (OR=3.9, 95% CI 2.3- 6.4, p<0.0001). Gangrenous cholecystitis was the only independent predictor of complications (OR=2.0, 95% CI 1.1-3.7, p=0.02).

CONCLUSION: Nighttime cholecystectomy was independently associated with a higher rate of conversion to open surgery without significantly decreasing overall length of stay or the complication rate. These findings suggest that laparoscopic cholecystectomy should be delayed until normal working hours.

60 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

4. ALVIMOPAN REDUCES LENGTH OF STAY AND COSTS IN PATIENTS UNDERGOING SEGMENTAL COLONIC RESECTIONS; RESULTS FROM MULTI-CENTER NATIONAL ADMINISTRATIVE DATABASE. A Simorov MD; J Thompson MD; D Oleynikov MD Omaha, NE

BACKGROUND: Alvimopan (Entereg), a peripherally acting mu-opioid receptor antagonist, has been shown to expedite recovery of bowel function after colon-resection surgery. Most data are available from industry sponsored trials. This study aims to evaluate the clinical impact of this drug on perioperative outcomes and costs in patients undergoing segmental colonic resection for diverticular disease.

METHODS: A large administrative database maintained by the University Health System (UHC) Consortium, an alliance of over 200 academic and affiliate hospitals was queried from 2008-2011. International Classification of Diseases, (ICD 9th) codes for segmental colon resection due to diverticular disease were used to identify two matched cohorts of adult patients. Then, UHC’s Clinical Resource Manager was used to access pharmacy data and compare it with patient outcomes.

RESULTS: 5,299 patients met the above criteria. 438 patients received Alvimopan and 4,861 did not. Regardless of laparoscopic or open approach, Alvimopan significantly improved postoperative length of stay(4.43±2.02 vs. 5.92±3.79;p<0.0001), cost(9,974±4,077 vs. 11,303±6,968;p<0.0001) and ICU admission rate(1.83% vs. 7.20%;p<0.05) with no significant difference in mortality(0.0% vs. 0.19%;p=1.000), morbidity(5.93% vs. 8.39%;p=0.08) or 30-day readmission rate(4.40% vs. 4.63%;p=0.90).

CONCLUSION: Alvimopan significantly reduced length of stay, days in the ICU and hospital cost for patients undergoing colonic segmental resections. Unlike some previously reported studies, we also observed a significant reduction in the length of stay in patients undergoing laparoscopic colectomies who received the drug. Alvimopan may reduce total healthcare costs if used as part of a best care practice model for colon resections.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 61 SCIENTIFIC PAPER ABSTRACTS (cont.)

5. EFFECT OF HYPERBARIC OXYGEN THERAPY ON HEALING OF A BOWEL ANASTOMOSIS IN A PERITONITIS MODEL IN THE RAT (RATTUS NORVEGICUS) JD Freemyer MD; J Creamer MD; G Peirce MD; J Crossett MD; K Aluka MD; JV Freemyer Edd; R Smiley MS; S Tobias DVM; KG Davis MD El Paso, TX

BACKGROUND: The risk of a surgical site infection in colorectal surgery is as high as 30 percent. In order to reduce the risk of infections many different therapies have been attempted. One perioperative focus has been hyperoxygenation. The BACKGROUND of this study is to better define biochemical changes that occur at an intestinal anastomosis using hyperbaric oxygen therapy which is the highest level of achievable hyperoxygenation.

METHODS: 45 rats were randomized into three groups (C-control, P-Peritonitis, PH-Peritonitis Hyperbaric Oxygen). A cecal puncture fecal peritonitis model was utilized. The control group underwent cecal resection with a primary anastomosis. Fecal peritonitis was induced in the P and PH using cecal puncture and contamination for a 24 hour period followed by primary anastomosis. The PH group underwent daily hyperbaric oxygen therapy for 100min at 2.5 atm. The anastomosis was resected and evaluated for hydroxyproline, MMP9 (Matrix Metalloprotinase) and MMP3 levels. Matrix metalloproteinases are extracellular proteinases that perform extracellular matrix degradation during wound healing and play a role in angiogenesis branching.

RESULTS: Mean MMP9 levels in ng/mg protein were C-26.7, P-24, PH-15.57 (H(2, 41)= 6.374, p<.05). Mean MMP2 levels in ng/mg protein were C-5.59, P-4.1, PH 3.11 (F(2, 41) = 5.382, p < .01). Mean Hydroxyproline levels ug/mg protein were C-20.23, P-22, PH- 23.77 (H(2, 41) = .594, p > .05).

CONCLUSION: We were able to demonstrate a statistically significant reduction in the levels of MMP9 and MMP3 levels with hyperbaric oxygen therapy implying that hyperoxygenation results in a change in the wound healing process. Hyperoxygenation and hyperbaric oxygen therapy remain controversial with the benefit or detriment yet to be defined. Likely this is because oxygen has a broadly targeted effect. Determining which biologically active molecules are up or down regulated could lead to more targeted therapies in the future.

62 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

6. SHOULD CLOPIDEGROL BE DISCONTINUED BEFORE LAPAROSCOPIC CHOLECYSTECTOMY? KA Anderson MD; RC Frazee MD; Daniel Jupiter PhD; Stephen Abernathy MD Temple, TX

BACKGROUND: Anti-platelet therapy for cardiovascular disease has significantly increased. Many surgeons recommend cessation of Clopidogrel prior to surgery to avoid bleeding complications. However, cessation of Clopidogrel is associated with an increased risk of cardiovascular thrombotic events. The perioperative handling of Clopidogrel prior to non-cardiac surgery remains an area of controversy. We review our experience with patients undergoing laparoscopic cholecystectomy who remained on Clopidogrel in the perioperative period, and compare them to a matched cohort not on Clopidogrel.

METHODS: An IRB approved retrospective review of adult patients undergoing a laparoscopic cholecystectomy while on Clopidogrel at our institution from 2008- 2012 was performed. Laparoscopic cholecystectomy was performed for symptomatic cholelithiasis, acute and chronic cholecystitis, and gallstone pancreatitis. These patients were matched with a separate cohort based upon ASA score and emergency vs elective surgery (control group). Co-morbidities evaluated included diabetes mellitis, coronary artery disease, BMI, congestive heart failure, and hyperlipidemia to assess appropriateness of matching. Primary outcomes were intraoperative estimated blood loss and operative time. Secondary outcomes included hospital length of stay and 30 day morbidity.

RESULTS: Seventy-two patients (36 Clopidigrel group and 36 control group) having laparoscopic cholecystectomy were analyzed. The average age was 68 years (range 35- 89 years) and 58% of patients were male. The average BMI was 30 (range 16-48) and 55% of operations were performed in an acute/urgent setting. There were no significant differences in the two groups in mean age, BMI, gender, or incidence of coronary artery disease, diabetes, hyperlipidemia, and congestive heart failure. Estimated blood loss was an average of 50 ml in the Clopidigrel group and 47 ml in the control group (p=NS). Operative time was 79 minutes vs 64 minutes in the Clopidigrel and control groups respectively (p=NS). There were no significant differences between the two groups in 30 day morbidity (Clopidogrel 22% vs control 42%) or length of stay (Clopidogrel 2.86 days vs control 1.75 days) between the two groups.

CONCLUSION: Laparoscopic cholecystectomy performed on patients continued on Clopidogrel in the perioperative period did not produce an increase in blood loss, operative time, 30 day morbidity, or length of stay. Recommendations for cessation of Clopidogrel cessation during the perioperative period should be reassessed.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 63 SCIENTIFIC PAPER ABSTRACTS (cont.)

7. UNINTENTIONAL ELECTROMAGNETIC INTERFERENCE CAUSED BY COMMON SURGICAL ENERGY-BASED DEVICES ON IMPLANTABLE CARDIAC DEVICES A Paniccia MD; EL Jones MD; NT Townsend MD; C Weyer DO; PD Varosy MD; G Girard; JE Dunning; GV Stiegmann MD; TN Robinson MD Aurora, CO

BACKGROUND: Cardiac implantable electronic devices (e.g., pacemakers and defibrillators) are commonplace. Unrecognized implantable cardiac device electrical interference due to a surgical energy-based device can result in life threatening arrhythmias. Surgeons currently follow practice guidelines for the use of surgical energy-based devices in patients with implantable cardiac devices that are based on expert opinion and not scientific data. The BACKGROUND of this study was to quantify the amount of unintentional energy (electromagnetic interference (EMI)) transferred to the implantable cardiac device by commonly used surgical energy-based devices.

METHODS: A transvenous implantable defibrillator/pacemaker was placed in an anesthetized pig and set to overdrive pace the pigs native heart rate by 20%. Multiple different surgical energy-based devices were activated for 5 seconds at a constant distance (2.5 cm inferior to the generator) from the implanted cardiac generator. Each experimental condition was repeated 10 times. The primary outcome measure was the increase in electromagnetic interference sustained by the pacemaker measured in millivolts (mV) for each five second activation (baseline background EMI “noise” (0.23 mV) was subtracted from the interference measured on the generator). Clinically relevant energy-based device settings were used: monopolar “bovie” 30 Watts (W) coag, monopolar “bovie” 30W blend, traditional bipolar 30W, advanced bipolar 3 bars, ultrasonic shears “Max,” Hyfrecator 10W, Peak Plasma setting 6 coag and Argon Beam Coagulator 30W coag. Devices were grouped based on the amount of EMI caused by the device: LOW RISK (<0.1 mV), INTERMEDIATE RISK (≥0.1 mV – 1.0), and HIGH RISK (≥1.0 mV).

RESULTS: LOW RISK devices were: traditional bipolar (0.01±0.004 mV), advanced bipolar device (0.004±0.003 mV) and ultrasonic shears (0.01±0.004 mV) (p>0.05 comparing all devices to baseline of 0). INTERMEDIATE RISK devices were: monopolar bovie 30W coag (0.50±0.20 mV), monopolar bovie 30W blend (0.92±0.63 mV) and the Hyfrecator (0.21±0.07 mV). HIGH RISK devices were: Peak Plasma blade (3.48±0.78 mV) and the argon beam coagulator (2.58±0.34 mV). Statistical analysis found p<0.001 for all comparisons: low vs. intermediate, intermediate vs. high, and low vs. high.

CONCLUSION: Surgeons can reduce the amount of unintentional energy transferred to implantable cardiac device by choosing certain types of energy-based devices and avoiding others. Bipolar and ultrasonic devices caused the least electromagnetic interference. In contrast, argon beam and peak plasma blade caused the most electromagnetic interference. This study provides the first quantifiable data comparing different energy-based device’s effect on implantable cardiac devices.

64 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

8. IMAGE GUIDED PLACEMENT OF IMPLANTED CENTRAL VENOUS CATHETERS REDUCES COMPLICATIONS AND COST ME Bowen MD; CL Scaife MD; MC Mone RN BSE; ET Nelson MD Salt Lake City, UT

BACKGROUND: The complication rate related to placement of central venous catheters (CVC) via the internal jugular vein (IJV) with the use of ultrasound guidance has been found to be less than 5%. The use of fluoroscopy adds further imaging to confirm correct line placement and is commonly used with intraoperative placement of long-term implanted CVCs. The primary goal of this study was to evaluate the procedural complication rate of long-term, implanted CVC placement when ultrasound is used with fluoroscopic guidance. Initial review of local data revealed the rate of complications to be <5%. The secondary goal was a cost analysis of elimination of routine chest x-ray (CXR) after line placement in a subset of these CVC patients.

METHODS: In an IRB approved study retrospective data was collected from patients who underwent operative insertion of an implanted CVC employing ultrasound guidance and fluoroscopy. The rate of immediate procedural complications was determined. These complications include hemothorax, pneumothorax, catheter misplacement, or arterial stick. Post-placement CXR was eliminated in a subset of these cases; these were reviewed for immediate complications and a cost savings analysis was performed.

RESULTS: From January 2008 to August 2013, 351 cases employed ultrasound guidance for CVC placement via the IJV. Demographics of this patient group: age is 56.3±14.8 (range 19-94), body mass index 28.8±7.9 (range 16-57), and gender was 58.4% female. The preoperative ASA score of 56% of patients was ≥ 3. Monitored anesthesia care with IV sedation was used in 86% of cases with 14% receiving general anesthetic. The majority of cases, 93% (327 of 351), had a single, successful insertion via the IJV site. When IJV insertion was unsuccessful the subclavian vein site was used in 16 cases (4.6%). With ultrasound guidance, there were no hemothoraces or pneumothoraces and 3 arterial sticks (0.85%). Between October 2012 and August 2013, routine post-procedure CXR was eliminated. Of 176 possible cases, 2 patients had CXR for disease related issues and 4 patients had CXR for either an arterial stick, multiple site attempts, or subclavian vein placement. Not all patients in this group had ultrasound guidance. There were no delayed CXR performed for symptoms related to CVC placement. There was a 0% incidence of pneumothorax, hemothorax, and no misplaced lines in this group. In less than one year, a total of $29,750 in hospital charges was saved at a single institution by eliminating the post-procedure CXR with these patients.

CONCLUSION: The use of ultrasound and fluoroscopy in the placement of implanted CVCs via the IJV results in a very low complication rate. This review of data supports the research that intra-operative ultrasound and fluoroscopic guidance can significantly reduce the rate of procedural complications associated with line placement. Additionally, with intra-operative fluoroscopic imaging, a routine CXR can be safely eliminated with significant associated healthcare savings.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 65 SCIENTIFIC PAPER ABSTRACTS (cont.)

9. CAN SURGICAL PERFORMANCE BENCHMARKING BE GENERALIZED ACROSS MULTIPLE OUTCOMES DATABASES: A COMPARISON OF UHC AND NSQIP A Simorov MD; N Bills PhD; D Oleynikov MD Omaha, NE

BACKGROUND: Hospitals, insurance carriers, and the federal government track surgeon performance currently with patient outcomes databases. In this study we compared the data on patients who underwent laparoscopic cholecystectomy from two large administrative databases with significant institutional overlap to see if either patient characteristics or outcomes were similar enough to accurately compare performance.

METHODS: University HealthSystem Consortium (UHC) and American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) databases were used to collect the data for 2009-2011. UHC collects their data from over 200 medical centers and NSQIP collect from over 400. Both databases collect from the same 70 hospitals. We evaluated adult patients who had undergone laparoscopic cholecystectomy. Patient demographics, including pre-existing medical conditions, operative details, resident involvement and outcomes were compared.

RESULTS: 52,702 patients from UHC and 53,285 patients from NSQIP met criteria. Differences were noted in demographics, such as age (63.5 ± 64 UHC vs. 48.4 ± 16.9 NSQIP; p<0.05), gender (31.8% Males in UHC vs. 27.1% Males NSQIP; p<0.05), comorbidities, such as heart failure (3.5% UHC vs. 0.4% NSQIP; p<0.05), renal failure (4.6% UHC vs. 0.2% NSQIP; p <0.05), peripheral vascular disease (2.1% UHC vs. 0.5% NSQIP; p<0.05). Patient’s surgical outcomes such as overall morbidity (2.8% UHC vs. 3.1% NSQIP; p<0.05), wound infections (0.3% UHC vs. 0.6% NSQIP; p<0.05), pneumonia (0.7% UHC vs. 0.3% NSQIP; p<0.05), urinary tract infections (0.0% UHC vs. 0.6% NSQIP; p<0.05) and length of hospital stay (4.0±4.4 days UHC vs. 1.69±6.08 days NSQIP; p<0.05) were statistically different. The only outcomes measure that was similar was the rate of mortality (0.2% UHC vs. 0.2% NSQIP; p>0.05)

CONCLUSION: While there is considerable overlap between the institutions that contribute to these databases, patient demographics and surgical outcomes are significantly different. Physician whose performance is benchmarked by these data should be aware that significant bias might exist. A single unified national database may be required to correct this problem.

66 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

10. POSTOPERATIVE PNEUMOPERITONEUM ON COMPUTED TOMOGRAPHY: IS THE OPERATION TO BLAME? GS Peirce MD; JP Swisher MD; JD Freemyer MD; JR Crossett MD; TM Wertin MD; KJ Aluka MD SP Hetz MD; KG Davis MD El Paso, TX

BACKGROUND: Postoperative radiographs demonstrating pneumoperitoneum are a vexing problem for surgeons. This diagnostic dilemma stems from uncertainty regarding the length of time for complete resolution of air introduced operatively, via either an open or a laparoscopic approach. The high sensitivity of computed tomography, the increasing use of this modality in the perioperative period and the different absorption rates of carbon dioxide compared to air only increase this uncertainty. There have been numerous studies examining this, but the expected duration of postoperative pneumoperitoneum remains unclear. We attempted to quantify the duration of pneumoperitoneum after both laparoscopic and open surgery in an animal model.

METHODS: A prospective study utilizing 2 groups of 10 young Yorkshire pigs (Sus scrofa) was performed. The groups were randomly assigned to undergo a midline celiotomy or abdominal laparoscopic exploration. Sequential CT scans were then utilized to quantitatively assess free air volume post-operatively. In the laparoscopic group, the abdomen was insufflated to 15 mmHg, and an exploration of all quadrants was performed for a total duration of 10 min. Next, the pneumoperitoneum was released in standard fashion and the abdomen closed. In the laparotomy group, a sub- xiphoid midline incision was created—following an exploration of all quadrants for 10 min. The fascia and abdomen were then closed in the standard fashion.

Scheduled serial CT scans were performed on postoperative days 1, 2, 3, 5, 7, 10, and 14. The subjects were removed from the study once pneumoperitoneum completely resolved. A certified radiologist independently reviewed each CT scan.

RESULTS: The laparoscopic group had complete resolution of free air faster than open laparotomy group (1.8 vs 4.7 days respectively, P value of 0.02). In the laparoscopic group, complete CT resolution occurred on POD1 in 70% and in all animals by POD3. Conversely, on POD 1, only 10% of the laparotomy group had complete resolution and only 50% had complete resolution by POD 3.

CONCLUSION: Postoperative pneumoperitoneum resolves faster following laparoscopy when compared to laparotomy in the swine model. This information may aid in decision making regarding evaluating postoperative CT scans demonstrating free air.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 67 SCIENTIFIC PAPER ABSTRACTS (cont.)

11. TUMOR NECROSIS FACTOR-Α DISRUPTION OF BRAIN ENDOTHELIAL CELL BARRIER IS MEDIATED THROUGH MATRIX METALLOPROTEINASE-9 K Wiggins-Dohlvik MD; M Merriman; C Anasooya Shaji; M Grimsley; H Alluir MS; ML Davis MD; RW Smith MD; B Tharakan PhD Temple, TX

BACKGROUND: Traumatic brain injuries are known to cause blood-brain barrier dysfunction, with derangements in vascular endothelium leading to hyperpermeability. Many facets of process are unclear but it is known that the breakdown of endothelial cell tight junctions is integral. Tumor Necrosis Factor-α (TNF-α) plays a large role in this process but the avenues through which its effects are mediated are unknown. We hypothesized that TNF-α induced junctional damage and hyperpermeability occurs through a Matrix Metalloproteinase-9 (MMP-9) mediated pathway and consequently can be attenuated with inhibition of MMP-9.

METHODS: Rat brain microvascular endothelial cells (RBMEC) were grown as monolayers on Transwell inserts. Wells were divided into four groups (n=six) as follows: control, TNF-α, TNF-α plus MMP-9 inhibitor 1, and MMP-9 inhibitor 1. Fluorescein isothiocyanate-dextran flux across the Transwell was obtained and permeability was measured. RBMEC cells were also grown on chamber slides and divided into the same experimental groups listed above. Immunofluorescence staining of tight junction protein ZO-1 and staining of F-actin was performed. Images were obtained. Statistical analysis was conducted using Student’s t-test.

RESULTS: Monolayer permeability was increased with TNF-α when compared with sham. However, this increase in permeability was attenuated with inhibition of MMP- 9. Immunofluorescence showed damage of rat brain microvascular endothelial cell tight junctions occurred with exposure to TNF-α: MMP-9 inhibitor 1 restored integrity. Rhodamine phalloidin staining showed an increase in F-actin stress fiber formation following exposure to TNF-α and inhibition of MMP-9 decreased this.

CONCLUSION: Traumatic brain injuries induce microvascular hyperpermeability and damage endothelial tight junctions through Tumor Necrosis Factor-α. Inhibition of Matrix Metalloproteinase-9 attenuates the damage caused by Tumor Necrosis Factor-α. These data highlight a novel link between Tumor Necrosis Factor-α and Matrix Metalloproteinases in the pathophysiology of traumatic brain injury induced microvascular hyperpermeability and pave the way for better understanding and treatment of this process.

68 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

12. PROGESTERONE EFFECTS IN THE BRAIN MICROCIRCULATIION AFTER TBI : HOW DO STANDARD OSMOTHERAPIES COMPARE ? K Kumasaka MD; J Marks MD; M Murcy MD; R Eisenstadt; S Li MD; W Gong MD; D Samadi MD; V Johnson MD; K Browne BA; M Watanabe MD; D Smith MD; J Pascual MD Philadelphia, PA

BACKGROUND: Mannitol (MTL) and hypertonic saline (HTS) are osmotherapies used routinely to manage severe traumatic brain injury (TBI) and may also possess immunomodulatory properties. Progesterone (PRO) reduces mortality after TBI and may also block leukocyte (LEU) recruitment to the blood brain barrier (BBB). We hypothesized that, after TBI, osmotherapies block in vivo neutrophil recruitment to the BBB to a lesser degree than PRO.

METHODS: To simulate severe TBI, 19 CD1 male mice (30g) underwent a 4mm craniotomy and controlled cortical impact (CCI: 3mm impactor, 6.0m/sec, 1mm depth) after placement of a jugular venous line. Animals were randomized to repeated IV doses of 5%HTS, 20%MTL (+ normal saline [NS] to replace hypovolemia due to diuretic effect) or NS only at 0, 5, 10, 22, 27 and 32 hours after TBI. Progesterone (16mg/kg) was administered IP at similar time intervals after TBI. Sham animals underwent no CCI and no treatment. 32 hours after TBI, a cranial window was placed over a 2nd ipsilateral craniotomy for in vivo observation by intravital microscopy of pial LEUs rolling on EC. Brain wet/dry (WTD) ratio assessed brain edema postmortem. LEU/EC interactions were counted off line by a blinded observer. Neurological recovery was assessed by the standard Neurological Severity Score (NSS) at each time intervals. The Kruskal-Wallis test determined significance (p<0.05).

RESULTS: 32 hours after TBI, in vivo leukocyte rolling was significantly lower in MTL than PRO animals (795 ± 115 vs. 1636 ± 177 LEU/100µm/min, p<0.05). LEU rolling in NS (1170.3±51.9), HTS (1340.2± 105.7) and sham (1291.6± 163.7) groups was similar to that in PRO animals (P>0.05). 5 hours after TBI, only sham (17.2±0.5) animals displayed greater NSS score than NS (12.7 ± 0.7, p<0.05). NSS scores in MTL (13.2 ± 0.9) and HTS (13.5±0.5) animals did not differ from that of PRO (14.3 ± 0.8) counterparts. Vascular permeability, brain WTD and body weight loss was similar in all groups.

CONCLUSION: Contrary to our hypothesis, MTL blocks LEU recruitment to the BBB better than progesterone. Beneficial effects of MTL in the management of TBI may be partly due to reduced brain leukocyte recruitment. Hypertonic saline does not reduce BBB EC/LEU interactions. Further study is needed to determine the optimal agent to reduce ongoing post-TBI cerebral inflammation.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 69 SCIENTIFIC PAPER ABSTRACTS (cont.)

13. WHAT’S THE HOLD UP? FACTORS CONTRIBUTING TO DELAYS IN DISCHARGE OF TRAUMA PATIENTS AFTER MEDICAL CLEARANCE JR. Soto MD MPH; J. Watkins MD; B Bankhead-Kendall MD; G. Hambright MD; E. Dunn MD Dallas, TX

BACKGROUND: As the cost of providing healthcare in the United States continues to increase, hospitals and other organizations are identifying ways to reduce unnecessary costs. One area of potential cost reduction is delays in discharge. Following medical clearance there are often non-medical factors delaying discharge including placement, availability of equipment and other social issues. The BACKGROUND of this study was to identify patients who experienced a delay in discharge and determine factors associated with the delay.

METHODS: All patients admitted to the trauma service with social work consults at our Level II trauma center from January 1st, 2012 to December 31st, 2012 were identified. The charts were retrospectively reviewed to identify discharge readiness and note any discrepancy between the discharge date and the hospital day in which they were medically cleared for discharge by all treatment teams. Factors including mechanism of injury, intensive care unit (ICU) stay, length of stay (LOS), payer status, and placement type were identified and delay in discharge was calculated for each group.

RESULTS: One thousand-ninety four patients were admitted to the trauma service and 349 received social work consults. One hundred and eighty-five patients (53%) experienced a delay in discharge ranging from 1 day to 29 days. Mechanism of injury was noted to play a role in discharge. Patients in auto-pedestrian collisions and those with penetrating trauma experiencing a 2 day delay while patients with motor-cycle collisions and aggravated assaults had less than a 1 day delay. Falls and motor-vehicle collisions were similar at 1.4 days. Patients with an ICU stay spent an extra day in the hospital due to delayed discharge compared to those not requiring admission to ICU (2.2 days versus 1.1 days). Those patients who had LOS less than a week had 0.9 days average delay while 7 or greater days in the hospital was associated with a 2.8 day delay. Self-pay patients had a delay of 1 day while insured patients (Medicare, Medicaid and private) averaged 1.5 days. Patients who were sent to a SNF averaged a 2.1 day discharge delay while patients being discharged home only experienced an average of 1 day delay.

CONCLUSION: With cost-saving measures being implemented at an increasing rate, pressure is being placed on trauma surgeons to decrease hospital costs. In addition to increased costs, reporting of physician metrics is being made public which include LOS of patients. Previous studies report LOS to be an inaccurate measure of the quality of trauma care. We have shown that a large number of trauma patients experience non- medical related delays in discharge. These delays contribute to the overall increase of healthcare expenses and inaccurately hold the trauma surgeon responsible for an increased LOS. The factors associated with non-medically related delays in discharge must be used to implement strategies that will improve planning and help decrease healthcare costs.

70 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

14. OUTCOMES OF ENDOVASCULAR MANAGEMENT OF ACUTE THORACIC AORTIC EMERGENCIES AT AN ACADEMIC LEVEL ONE TRAUMA CENTER AB Echeverria MD; BC Branco MD; KR Goshima MD; JD Hughes MD; JL Mills Sr MD Tucson, AZ

BACKGROUND: Thoracic aortic emergencies (penetrating ulcer, ruptured aneurysm, acute dissection, and traumatic transection) account for 10% of thoracic-related admissions in the United States. Reported mortality approaches 45% with high morbidity. Open repair has declined due to the emergence of thoracic endovascular repair (TEVAR), but data on the use of TEVAR to manage the broad range of acute aortic pathology are limited. We therefore reviewed our experience.

METHODS: We retrospectively evaluated descending thoracic aortic endovascular interventions performed at a single academic level one-trauma center. Data were collected from consecutive TEVAR patients from 1/05 to 8/13 including all cases of symptomatic penetrating ulcer, acute dissection, traumatic transection, and aneurysm rupture. Demographics, clinical data, and outcomes were extracted. Clinical characteristics of survivors and non-survivors were compared.

RESULTS: During the study period, 51 patients underwent TEVAR; 22 (43.1%) cases were performed emergently [11 (50.0%) traumatic injury (TI), 4 aneurysm rupture, 4 type B dissection, 2 penetrating ulcer, 1 aorto-esophageal fistula]. Mean age was 54.8 ± 16 years (range 22-79); 73% were men. Nineteen patients (86.4%) required only a single TEVAR procedure, while 2 (9.1%) required additional endovascular therapy and 1 (4.5%) open thoracotomy. Four TI patients required exploratory laparotomy for concomitant intra-abdominal injuries. Survivors were less likely to be hypotensive on admission (MAP <60 mm Hg: 26.7% vs. 71.4%, p<0.001) and had lower transfusion requirements (pRBC: 3.9 ± 3.3 vs. 14.0 ± 5.8, p<0.001 and plasma: 1.5 ± 2.2 vs. 5.4 ± 2.8, p=0.002). Three patients (13.6%) developed major complications [multi-system organ failure (1), type A dissection/endoleak (1), iliac and femoral aneurysms (2)]. Mean hospital length of stay was 18.9 days (range 1-76). In-hospital mortality was 27.2% [6 deaths: traumatic brain injury (1), exsanguination in the operating room before repair could be achieved (2), bowel ischemia (1) and multi-system organ failure (1), family withdrew care (1)]. During a mean follow-up of 369 days (range 35-957), no subsequent major complications or deaths occurred. All patients underwent serial CTA surveillance and no device-related problems were identified.

CONCLUSION: Acute thoracic aortic syndromes remain challenging. Hypotension on admission and increased transfusion requirements strongly correlate with poor outcomes. Among the traumatic transection patients, 7/11 patients had major concomitant injuries that were associated with lower MAPs, greater transfusion requirements, and worse outcomes. Our experience in a moderate volume center suggests benefit of TEVAR in the acute setting, supporting at least one other study suggesting that transition from open repair to TEVAR has reduced the mortality of acute thoracic aortic catastrophies by more than 20%, with most deaths resulting from associated injuries.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 71 SCIENTIFIC PAPER ABSTRACTS (cont.)

15. TIME AND COST DIFFERENCE IN ACUTE GALLSTONE PANCREATITIS PATIENTS WHO WERE ADMITTED UNDER MEDICINE VS. SURGERY IN THE ACUTE CARE SURGERY ERA J Watt MD; N Kulvatunyou MD; RS Friese MD; L Gries MD; B Joseph MD; DJ Green MD; T O’Keeffe MD; AL Tang; G Vercruysse MD; P Rhee MD Tucson, AZ

BACKGROUND: As healthcare cost continues to rise, healthcare delivery must not only be effective, but also be time and cost efficient. There was limited evidence in the literature regarding outcome difference in acute gallstone pancreatitis (AGS) patients who were admitted under medicine (MED) vs. surgery (SUR). We hypothesized that admitting AGS patients under SUR decreased time to surgery, decreased length of stay, and saved hospital cost.

METHODS: Using our prospectively maintained acute care surgery database, we performed chart reviews from 10/1/2009 through 5/31/2013 on patients who underwent cholecystectomy for AGS. We excluded patients who were admitted to pediatric or obstetric services, who had severe or necrotizing pancreatitis, and who had alcohol-related pancreatitis. We collected demographics, baseline characteristics, laboratory values, and number of patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) before or after the surgery. We then compared outcomes between those admitted under MED vs. SUR

RESULTS: After the exclusion, there were 50 AGS patients admitted under MED and 52 patients admitted under SUR. Baseline characteristics and outcomes are shown in table. Medicine (N=50) Surgery (N=52) P Age, mean (SD) 58 + 16 45 + 22 0.001 Gender, male, % 52% 20% <.001 Body mass index, mean (SD) 32 + 8 31 + 8 0.48 History of diabetes, yes, % 20% 23% 0.71 History of coronary disease, yes, % 24% 10% 0.052 History of hypertension, yes, % 56% 37% 0.02 APACHEII score, median (IQR) 7 (5, 10) 5 (3, 8) 0.02 ASA, median (IQR) 3 (2, 3) 2 (2, 2) <.001 Time from admission to surgery, hours (IQR) 80 (65, 122) 44 (36, 66) <.001 Hospital length of stay, median (IQR) 5 (4, 9) 3 (2, 5) <.001 Hospital cost, $, mean (SD) 15,506 (11,000) 11,000 (6,600) 0.02 ERCP performed, yes, % 22% 21% 0.92

CONCLUSION: Although patients with AGS who were admitted under MED may be older with higher associated comorbid conditions than those admitted under SUR, but nothing that surgeons cannot manage. If AGS patients would have been admitted under SUR, one would have shortened the time to surgery by 1.5 days, decreased LOS by 2 days, and decreased the hospital cost by $4,000 per patients.

72 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

16. THE GERIATRIC TRAUMA INSTITUTE(GTI): REDUCING THE INCREASING BURDEN OF SENIOR TRAUMA CARE C DeLa’O MD; J Kashuk MD; R Dumire MD; J Zipf RN; A Rodriguez MD Johnstown, PA

BACKGROUND: Due to parallel advances in health care and an aging population, geriatric injury has become an increasing burden to trauma systems. Accordingly, with associated increased length of stay due to age associated frequent co-morbidities, optimal clinical pathways must be developed for the care and treatment of this cohort. We hypothesized that a dedicated geriatric trauma institute (GTI), with multidisciplinary support, as an integral part of our existing trauma program, would promote quality care, result in a reduced length of stay (LOS), and lead to reduced hospital charges.

METHODS: We performed a retrospective analysis of our level 1 trauma center’s prospective database. All patients >65 years were identified over the most recent 10 consecutive months, representing 5 months prior (PGTI) and 5 months after (AGTI) implementation of the multidisciplinary model. Variables of interest included ISS, mortality, ICU LOS, Glasgow Coma Scale (GCS), re-admission rates, and admitting service (trauma or non-trauma). Cost of care was estimated by assessing current daily ICU and/or floor charges. Of note, patients with isolated hip fractures were excluded from this study.

RESULTS: Of 490 consecutive patient admissions, 262 were PGTI and 228 AGTI. Overall mortality remained unchanged during the study period (0.03 % vs. 0.02%). ISS, ICU LOS, GCS, and re-admission rates were not different between groups. Significantly, of admissions to non-trauma services, there were 65 patients (24.5%) PGTI, vs. only 12(5%)AGTI(p=.001). Of note, the mean LOS AGTI was significantly reduced when admissions to a non-trauma vs. dedicated GTI service were evaluated. ( 5.64 vs.4.43, p=.03). These changes resulted in a charge reduction of 21.4%(>$775,000.00) in only the first 5 months since implementation of the GTI program.

CONCLUSION: Our findings suggest that admission to a dedicated geriatric trauma care multidisciplinary system results in significantly reduced LOS with associated reduced hospital charges. These preliminary results, which must be verified with longer term study and follow-up, suggest that a dedicated, multidisciplinary geriatric trauma care model may be an essential addition to current trauma care, given the growing burden of geriatric injury to trauma systems.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 73 SCIENTIFIC PAPER ABSTRACTS (cont.)

17. HONOKIOL AFFECT MELANOMA CELL GROWTH BY TARGETING METABOLIC PATHWAY VIA AMPK SIGNALING G Kaushik PhD; D Subramaniam PhD; S Anant PhD; J M V Mammen MD PhD Kansas City, KS

BACKGROUND: Malignant melanoma is an aggressive form of skin cancer with extremely poor survival and few therapeutic options. It is of prime importance to develop a therapeutic strategy that is able to exert the maximum effect on cancer cells with minimum toxicity on normal cells. AMP-activated protein kinase (AMPK) is an important regulator of cellular energy homeostasis. It has also been shown to control tumor progression by regulation of cell cycle, protein synthesis and cell growth and/ or survival. Dietary agents can affect AMPK signaling thereby reducing risk of cancer progression. Honokiol (HNK) is a biphenolic compound from Magnolia officinalis that is used in traditional Chinese and Japanese medicine for the treatment of various pathological conditions. Recent studies have shown that it has antitumor activity with low toxicity. In this study we show the inhibitory effect of HNK on melanoma cancer stem cells is mediated through activation of AMPK and hence AMPK signaling in melanoma cells.

METHODS: We tested the effect of HNK on two melanoma cell lines B16/F10 and SKMEL28.The effect of honokiol on cells was assessed in vitro. Proliferation and physiologic changes were determined using hexosaminidase assay and transmission electron microscopy. Protein expression was assessed by immunoblotting. Primary sheroid assays were used to assess stemness by growing single suspension cells on low affinity plates.

RESULTS: HNK is highly effective in inhibiting melanoma cancer cells by attenuating AKT/mammalian target of Results: HNK is highly effective in inhibiting melanoma cancer cells by attenuating AKT/mammalian target of rapamycin and AMPK signaling. Spheroid forming potential of cells in 3D culture represents stemness like phenotype due to tumor initiating cells or cancer stem cells. In this concern, honokiol showed significant inhibition of spheroid forming capacity of melanoma cancer cells hence stemness. HNK significantly decreased the number of spheroids by 50.56% for SKMEL-28 and 51.53% for B6/F-10 cells at the 30 um concentration of HNK.(n=3, p < 0.05) Western blot analyses also showed enhanced phosphorylation of AMPK. HNK was also found to modulate the cellular ATP levels, which might be the cause of AMPK signaling.

CONCLUSION: Taken together, these results suggest that HNK can target melanoma cancer cells and mark them for autophagy. Further studies are warranted for developing HNK as an effective chemopreventive/therapeutic agent in melanoma. These studies warrant further clinical evaluation or the combination of honokiol with present chemotherapeutic regimens for treating melanomas.

74 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

18. CORE-NEEDLE BIOPSY FOR THE DIAGNOSIS OF LYMPHOMA: A SAFE AND ACCURATE ALTERNATIVE TO EXCISIONAL BIOPSY BM Nguyen MD; P Traum MD; Y Olimpiadi BS; C Halprin BS; C Dauphine MD Torrance, CA

BACKGROUND: The standard of practice for diagnosis of pathologic lymphadenopathy suspicious for lymphoma has been open excisional biopsy. However, potential complications include wound infection, lymphocele, peripheral nerve damage, and vascular injury, all of which can delay the initiation of chemotherapy. Recent studies have suggested that core needle biopsy (CNB) can obtain adequate tissue for the diagnosis of lymphoma. The aim of this study is to evaluate the accuracy and safety of ultrasound-guided CNB in the diagnostic work up of lymphadenopathy suspicious for lymphoma.

METHODS: All CNBs performed by a single surgeon for suspicion of lymphoma between April 2008 and June 2013 at an urban public hospital were included. A standardized protocol was followed where 8 to 10 specimens were obtained using a 14-gauge core needle under ultrasound guidance and sent for pathologic analysis.

RESULTS: There were 61 patients that met the inclusion criteria. The diagnosis of lymphoma was made in 33 (54.1%) patients, and all were treated with chemotherapy based on the CNB results. No patient required further excisional biopsy for additional analysis. Of the 28 (42.6%) patients whose biopsy showed no evidence of lymphoma, 2 had metastatic carcinoma (breast, lung) with occult primaries and 4 subsequently underwent excisional biopsy, confirming the absence of lymphoma in all four cases. The remaining 22 had no subsequent diagnosis of lymphoma in a mean of 13.7 (range 0.13 to 50.33) months of follow up. All 61 patients had definitive diagnostic workup of their lymphadenopathy based on CNB results alone. There were no complications associated with CNB.

CONCLUSION: CNB is safe and accurate in the diagnostic workup of lymphadenopathy suspicious for lymphoma. The morbidity associated with the procedure is very low, making it a more optimal choice over open excisional biopsy.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 75 SCIENTIFIC PAPER ABSTRACTS (cont.)

19. PREOPERATIVE DOSING OF LOW MOLECULAR WEIGHT HEPARIN IN HEPATOPANCREATOBILIARY SURGERY C Anne Doughtie MD; Erin E Priddy MD; Prejesh Philips MD; Robert CG Martin MD PhD; Kelly M McMasters MD PhD; Charles R Scoggins MD MBA Louisville, KY

BACKGROUND: Venous thromboembolism (VTE) is a common cause of postoperative morbidity, especially for high-risk populations undergoing major oncologic resections. Current guidelines recommend perioperative pharmacologic thromboprophylaxis, but clinicians remain cautious due to bleeding risks.

METHODS: A retrospective analysis of a single institution’s prospective database was performed for patients undergoing HPB surgery between Jan 2010 - Feb 2013. 223 consecutive patients received postoperative thromboprophylaxis. 93 of these patients were also dosed with LMWH preoperatively. Matched variables included patient characteristics, case mix, and perioperative complications.

RESULTS: 223 patients were analyzed. 50.6% (n=113; 42 preop-LMWH) underwent pancreatic resection and 49.3% (n=110; 51 preop-LMWH) underwent liver resection. There were no differences in history of previous venous thromboembolism (3.8% vs. 3.3%, p=0.56) or preop-VTE score (5.74 vs. 5.67, p=0.82). Mean estimated blood loss (537mL vs. 592mL, p=0.54), post-operative transfusion rate (25.4% vs. 30.4%, p=0.25), and overall complication rate (52.3% vs. 43.5%, p=0.12) were equivalent between the control and preop-LMWH groups respectively. The incidence of thromboembolic events was significantly lower in those receiving preop-LMWH (6.1% vs. 1.1%, p=0.05). However, major post-operative bleeding requiring intervention was significantly increased in the preop-LMWH group (10.9% vs. 3.1%; p=0.026).

CONCLUSION: Caution must be exercised when using LMWH, as postoperative bleeding remains a concern for oncologic HPB surgery.

76 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

20. SMALLER PELVIC VOLUME IS ASSOCIATED WITH POST-OPERATIVE INFECTION AND SEPSIS AFTER PELVIC SALVAGE SURGERY FOR RECURRENT MALIGNANCY EL Jones MD; A Paniccia MD; TS Jones MD; JS Merkow MD; DM Wells MD; MD McCarter MD; NW Pearlman MD Aurora, CO

BACKGROUND: Patients with recurrent pelvic malignancy have few treatment options. Pelvic salvage surgery is difficult and associated with significant morbidity and mortality. The majority of patients considered for pelvic exenteration (PE) or abdomino-perineal resection (APR) have undergone prior surgery, chemotherapy and/ or radiation. The BACKGROUND of this study was to define peri-operative outcomes after pelvic salvage surgery in relationship to pelvic volume. Our HYPOTHESIS is that decreased pelvic volume is associated with post-operative complications after pelvic salvage surgery.

METHODS: A retrospective chart review of all patients undergoing salvage PE or APR for recurrent malignancy after radiotherapy between 1997 and 2012. Computed tomography was used to determine pelvic cavity volume calculated from pelvic cavity height, inlet and outlet areas.

RESULTS: Forty-two patients underwent PE (13 patients, 31%) or APR (29 patients, 69%) for rectal cancer (27 patients, 64%), prostate cancer (8 patients, 19%) or anal squamous cell cancer (7 patients, 17%). The majority of patients were male (30 patients, 71%) with a mean age of 56.2 years (range 30 – 78 years). The median follow-up from diagnosis was 45 months (8 – 204 months). Thirty-four patients (81%) had undergone surgery a mean 25 months prior (range 1 – 86 months) with 38 patients (90%) receiving chemotherapy and all (100%) receiving radiotherapy. The mean length of stay was 8.5 days after APR and 20 days after PE (p=0.001). Post-operative complications arose in 38 patients (90%). Twenty-two patients (52%) required re-intervention, most commonly for deep space/organ infections (5 patients, 12%) or fistula (4 patients, 9.5%). Univariate analysis demonstrated a significant correlation between decreasing pelvic volume and enterocutaneous fistula (p=0.05), sepsis (p=0.03) and deep/organ space infections (p=0.01). Upon multivariate analysis both deep space/organ infections and sepsis remained significant (p=0.01 and p=0.03 respectively).

CONCLUSION: Pelvic salvage surgery for recurrent malignancy is difficult and associated with a high complication rate. Radiographic pelvic volume may serve as a surrogate for a narrow & difficult pelvis. Smaller pelvic volume is associated with increasing risk of deep space/organ infection and sepsis.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 77 SCIENTIFIC PAPER ABSTRACTS (cont.)

21. GEOGRAPHIC MALDISTRIBUTION OF GENERAL SURGERY (GS) PGY1 RESIDENTS: ANOTHER U.S. SURGICAL DESERT KR Sirinek MD;PhD; R Willis PhD; RM Stewart MD San Antonio, TX

BACKGROUND: Surgeons are distributed unevenly across the U.S., with 30% of 3,107 U.S. counties having no surgeon (“Surgical Deserts”) with 95% being rural and 50% having a hospital. This study evaluates the geographic distribution of civilian general surgery PGYI positions and compares it to individual state and U.S. region populations.

METHODS: The number of civilian general surgery categorical PGYI positions offered by each state was obtained from NRMP results for 2012. State populations were obtained from the 2010 United States Census. The number of PGYI residents/ capita was determined for each state, District of Columbia, Puerto Rico and the American College of Surgeons’ (ACS) seven U.S. geographic regions for general surgical residencies. Results are displayed as number of PGY1 GS positions per million population. Results were analyzed by ANOVA.

RESULTS: The District of Columbia has the highest rate of general surgical PGYI positions per million population at 31.7, or 8 ½ times the national average of 3.7 (excluding DC). 27 states and Puerto Rico had less general surgery PGYI positions per capita than the country as a whole. The general surgery PGYI positions/ million population (mean ± SEM) for the seven ACS regions in ascending order are: Intermountain (1.4 ± 0.50), Pacific (1.86 ± 0.55), Southeast (2.96 ± 0.40), South (3.21 ± 0.45), Midwest (3.61 ± 0.43), New England (5.3 ± 0.83) and Northeast (9.92 ± 4.42, P< 0.01 vs other 6 regions). For the 19 states representing the membership of the Southwestern Surgical Congress, the general surgery PGYI positions /million population (mean ± SEM) is 2.19 ± 035 with only two states (NE, ND) above the mean for the country. Four of the 19 states do not have a General Surgery residency. Thirty-three percent of 1,146 civilian PGYI general surgery residency positions are in the Northeast and New England, (11 states and DC, representing 20% of the U.S. population).

78 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

# Civilian General Surgery PGY1 (Positions/Population) x 10⁶ By State, DC, Puerto Rico D.C. 31.7 MI 5.6 TN 4.8 IL 3.9 IA 3.3 NH 3.1 CO 2.4 UT 1.8 MA 8.2 RI 5.5 WV 4.7 US 3.7* KY 3.3 NC 3.1 OK 2.4 AR 1.7 DE 7.8 ND 5.0 NE 4.4 SC 3.7 WI 3.3 VA 2.9 WA 2.2 MS 1.7 CT 6.9 VT 5.0 AL 4.0 MO 3.5 NJ 3.2 TX 2.9 FL 2.1 HI 1.4 NY 6.9 LA 4.9 AZ 4.0 KS 3.4 OR 3.2 GA 2.8 IN 2.0 PR 1.4 PA 6.5 OH 4.9 MN 4.0 MD 3.4 ME 3.1 CA 2.5 NM 1.9 NV 1.1 States without GS Residency - Alaska, Idaho, Montana, South Dakota, Wyoming *Excluding DC

CONCLUSION: There is a maldistribution of civilian General Surgery PGYI positions compared to state and regional populations, particularly rural areas and states with a large and rapidly growing population. Since a large number of residents tend to establish their surgical practice in proximity to the location of their residency program, this surgical manpower maldistribution will be perpetuated. Additional general surgery residencies and resident positions are urgently needed to correct this “Surgical Desert” of graduate medical education.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 79 SCIENTIFIC PAPER ABSTRACTS (cont.)

22. USMLE SCORES AS PREDICTORS OF SUCCESS IN SURGICAL RESIDENCY – ARE THEY VALID INDICATORS? ER Sutton MD; JD Richardson MD; CH Ziegler MS; JM Bond BS; MB Poole BS; KM McMasters MD PhD Louisville, KY

BACKGROUND: Many programs rely extensively on USMLE scores for interviews/ selection of surgical residents. However, their predictive ability remains controversial. We examined the association between USMLE scores and success in surgical residency.

METHODS: We compared USMLE scores for 123 general surgical residents who trained in the past 20 years and their performance evaluation. Scores were normalized to the mean for the testing year and expressed as a ratio (1=mean). Performances were evaluated by (1) rotation evaluations, (2) “dropouts,” (3) overall ABS pass rate, (4) first time ABS pass, and (5) a retrospective comprehensive faculty evaluation. For the latter, 16 surgeons (average faculty tenure – 22 years) rated residents on a 1-4 score (1=fair; 4=excellent).

RESULTS: Rotation evaluations by faculty and “drop out” rates were not associated with USMLE score differences (dropouts had average above the mean). One hundred percent of general surgery practitioners achieved board certification regardless of USMLE score but trainees with an average above the mean had a higher first-time pass rate (p=.04). Data from the comprehensive faculty evaluations were conflicting: there was a moderate degree of correlation between board scores and faculty evaluations (r=0.287, p=0.001). However, a score above the mean was associated with a faculty ranking of 3-4 in only 51.7% of trainees.

CONCLUSION: Higher USMLE scores were associated with higher faculty evaluations and first time board pass rates. However, their positive predictive value was only 50% for higher faculty evaluations and a high overall board pass rate can be achieved regardless of USMLE scores. USMLE scores are a valid tool for selecting residents but caution might be indicated in using them as a single selection factor.

80 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

23. ENDOSCOPY EXPERIENCE IN A COMMUNITY-BASED SURGICAL RESIDENCY: RESIDENT CASE NUMBER AND RATE OF MEETING QUALITY MEASURES LJ Barnes MD; M Unruh MS; RM Drake MEd; SD Helmer PhD; AD Ammar MD; JS Osland MD Wichita; KS

BACKGROUND: In 2006 the Residency Review Committee for Surgery increased the total number of required endoscopy cases from 29 for graduating surgical residents, to 35 upper endoscopies (EGDs) and 50 colonoscopies (CEs). This requirement has been challenged by certain societies, citing that general surgery residents perform a fraction of the endoscopy procedures of gastrointestinal (GI) fellows, but there have not been any studies evaluating surgeon performance during residency. The BACKGROUND of this study was to evaluate general surgery resident experience in endoscopy, focusing on quality measures.

METHODS: A 9-year retrospective review was conducted of endoscopy case data for general surgery residents who graduated from a single program from 2008 to 2012. The ACGME case log website provided resident name, post-graduate year level (PGY), residency service, and procedure performed (EGD or CE). Medical records were accessed to collect the following data for CEs: patient identifiers and demographics, intended procedure, procedure performed, length of procedure, cecal intubation rate, number of polyps identified/biopsied, and complications, such as perforation or bleeding. Total number of CEs and EGDs performed by surgical residents during their first 4 years of residency training and number performed as a fifth year resident were recorded. In addition, endoscopic procedures performed by the fifth year residents while on the surgery chief resident service were evaluated. During this service the chief resident performs the endoscopy with only indirect supervision.

RESULTS: Of the 25 residents evaluated, each resident averaged 75.9 ± 19.1 EGDS and 147.0 ± 44.5 CEs through their first 4 years of residency. As chief residents, an average of 16.4 ± 9.2 EGDs and 22.1 ± 14.6 CEs were performed. Of the CE’s performed during their fifth year of residency, a total of 191 were performed while the resident was on the surgery chief service and are the basis for the remaining data. Of the procedures performed 69.8% were CE alone, while the remaining CEs were performed in conjunction with additional procedures. Rectal bleeding (33.9%), abdominal pain (20.8%), and diverticulitis (13.0%) accounted for the majority of indicators for CEs performed. Cecal intubation was achieved in 90.6% of cases. On average, 0.48 ± 1.0 polyps were identified. Total procedure time averaged 32.0 ± 15.8 minutes with an average time of 13.4 ± 7.1 minutes to withdraw the scope from the cecum.

CONCLUSION: A surgery resident appears to achieve competency in colonoscopy completion prior to performing 140 colonoscopies. Our data supports that a surgery residency can function as an excellent training ground for endoscopy.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 81 SCIENTIFIC PAPER ABSTRACTS (cont.)

24. DO MEDICAL STUDENT’S SURGICAL EXAMINATION SCORES CORRELATE WITH PERFORMANCE MARKERS? AB George MD; A Schuster MD; SD Helmer PhD; RM Drake MEd; TE Cusick MD; JS Osland MD; AD Ammar MD Wichita, KS

BACKGROUND: Some surgery programs across the United States evaluate medical students with oral examinations. Previous data suggests that this is an appropriate and worthwhile process. In addition, several other studies have shown correlation with certain National Board of Medical Examiners (NBME) Subject Exams and USMLE Step 1 and Step 2. The BACKGROUND of this study was to determine the predictive associations between USMLE Step 1 scores, oral surgery examination scores, NBME Surgery Subject Exam (SSE) scores, and Step 2 scores.

METHODS: A 9-year retrospective review was conducted of testing data for third- year medical students enrolled in a General Surgery clerkship from 2003-2012. Data collected included demographics, clerkship grade [comprised of the oral examination grade (10%), a case presentation (5%), clinical grade (50%), and the SSE raw score (35%)], and USMLE Step 1 and Step 2 scores. Student oral exams were based on common clinical surgical cases and occurred about 1 week prior to the SSE. Step 1 is typically taken prior to beginning clinical rotations and the surgery SSE, while Step 2 is taken after rotations and the SSE. During our study, the method for evaluating oral clinical cases changed from a percentage (Period 1, n=314) to pass or fail (Period 2, n=167). Students were stratified by Period, to evaluate the impact of this change on the predictive association with the SSE, Step 1, and Step 2.

RESULTS: A total of 480 students were included in the study. Step 1 scores were not predictive of Period 1 oral (percentage) scores (P=.055) or of Period 2 oral (P/F) performance (P=.148). Period 1 oral scores had a poor positive predictive association with SSE scores (Somers’ d=.112, P=.022) and with Step 2 scores (Somers’ d=.213, P<.001). Period 2 orals did not have a predictive association with SSE (P=.979), or Step 2 (P=.201). Step 1 scores did show a moderate, positive predictive association with SSE (Somers’ d=.497, P<.001); 16% of students had both their SSE and Step 1 scores in the bottom quartile. Similarly, SSE showed a moderate, positive predictive association with Step 2 scores (Somers’ d=.511, P<.001); 16% of students had both their SSE and Step 2 scores in the bottom quartile.

CONCLUSION: While oral examinations may be beneficial, they were poorly predictive of performance on the NBME SSE and USMLE Step 2. Similarly, Step 1 was poorly predictive of oral performance. Orals should not be used to identify those that will have difficulty passing the SSE. Since moderate, positive predictive associations exist between SSE, Step 1 and Step 2 performance, medical schools could use Step 1 to identify students at increased risk of poor performance on the SSE. Furthermore, they could use the SSE scores to identify students at increased risk for poor performance on Step 2.

82 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

25. METASTASECTOMY OF NEUROENDOCRINE TUMORS IN PATIENTS WITH MEN 1 Benzon M. Dy MD; Florencia G. Que; MD; William F. Young MD; Melanie L. Richards MD; William S. Harmsen MS; Geoffrey B. Thompson MD Rochester, MN

BACKGROUND: Patients with MEN 1 are affected by primary hyperparathyroidism (1HPT), pituitary lesions, and neuroendocrine tumors (NE) of the duodenum and pancreas. Survival is often limited by the NE tumors which most often recur within the pancreas and duodenum or metastasize to the liver. Patients with MEN 1 are thought to have improved survival compared to individuals with analogous lesions. However, the role of metastasectomy of NE tumors in patients with MEN 1 has not been defined.

METHODS: A review all patients with MEN 1 undergoing surgery for NE tumors from 1994-2010 at a single tertiary care center was performed. We examined tumor function, extend of spread, completeness of resection and survival.

RESULTS: We identified 30 patients with MEN 1 who underwent resection of their primary tumor and either synchronous or metachronous metastasectomy. Median age was 47 y (range 20-64). There were 28 patients who had a pancreatic resection including distal pancreatectomy (22), Whipple procedure (2), total pancreatectomy (1), partial (1), distal pancreatectomy with enucleation of the head of the pancreas (1) and ethanol ablation of an NE tumor (1). Duodenotomy with enucleation was performed in 8 and enucleation in 7 patients. Synchronous metastases were identified in 19 (63%) while 11 (37%) underwent surgery for metachronous disease. Hepatic metastases were resected in 50% of patients and lymph node metastases in 50%. R0 resection was achieved in 93% of patients undergoing metastasectomy. Post-operative mortality was 0%. At 10 years, Kaplan Meier estimated survival is 86.4% (95% CI, 60%-100%) with no factors predictive of OS. The disease free interval at 1, 5 and 10 y was 89%, 50% and 19% with recurrence after metastasectomy occurring at a median of 5.4 y (95% CI, 77.7%-100%). Synchronous metastasis (p=0.0072, HR 3.4) and non-functioning tumors (p=0.014, HR3.3) were more likely to recur while age (p=0.09, HR1.5), gender (p=0.49, HR 1.3), and site of metastasis (p=0.81, HR1.1) did not influence recurrence after metastasectomy. Those with non-functioning tumors and synchronous resection were most likely to recur (p=0.0034, HR 16.9).

CONCLUSION: Patients with MEN 1 benefit from resection of metastatic NE disease. Despite a high rate of recurrence, survival and DFI is favorable compared to our previously published rates for metastatic pancreatic neuroendocrine tumor for patients without MEN1.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 83 SCIENTIFIC PAPER ABSTRACTS (cont.)

26. OPTIMAL UTILIZATION OF A BREAST CARE ADVANCED PRACTICE CLINICIAN KW Russell MD; MC Mone RN BSE; VJ Serpico APRN; C Ward MBA; Joanna Lynch PA-C; LA Neumayer MD; EW Nelson MD Salt Lake City, UT

BACKGROUND: Incorporation of “lean” business philosophy within healthcare systems has the overall goal of adding value by reducing cost and improving quality. Implementation of lean principles within a system is based on a Japanese term, “Kaizen”, which means “improvement” or “change for the best.” Application of these principles to the role of Advance Practice Clinicians (APC) (Advanced Practice Registered Nurse or Physician Assistant) is especially relevant since these “physician extenders” have become essential members of the healthcare team in academic and community settings. As a part of an institution-wide effort to use the lean model to enhance value in patient care, a project to optimize APC utilization in a general surgery setting was designed. The objectives included better APC utilization (working at the “top of their license”) while maintaining or enhancing patient and physician satisfaction.

METHODS: Areas identified for improvement in a specific surgical clinic dedicated to breast care included; (1) longer than acceptable time to obtain an appointment; (2) unrealized utilization of a clinically skilled breast APC; (3) sub-optimal utilization of surgeon time and skills. An independent APC breast clinic, for both benign and malignant conditions was created to be directed by a single APC with a close working relationship to a single breast surgeon. Changes in APC functions included independent performance of minor procedures (i.e. chemotherapy catheter removal, sentinel node injections, breast cyst aspirations, etc.). Measurements of success included; appointment wait times (defined as days from scheduling to actual appointment) for both the APC and the surgeon, changes in APC billing and payments, and patient/APC/MD satisfaction.

RESULTS: During the 5 months studied (2 prior and 3 after the APC clinic started), the range of time (of the average) to be seen by the MD decreased from 12 to 20 days to 10 to 11 days. For the same period, the averaged APC charges increased from $371 to $12,634 and averaged payments increased from $309 to $2,140. Based on this data, projected annualized charges for the APC clinic were $170,940 with an additional potential for $74,796 in downstream charges (laboratory testing, radiologic examinations, etc.) to total $245,736. Patient satisfaction as evaluated by Press Ganey Scores averaged 95.2% for the APC as compared to 95.9% for surgeon provider. Finally, both the APC and MD expressed significant improvement in job satisfaction and improvement in working at the “top of their license”.

CONCLUSION: Initiation of an independent APC breast clinic reduced the time to obtain an appointment, documented significant revenue generation, and improved job satisfaction for both the APC and surgeon while maintaining outstanding patient satisfaction scores. The use of lean philosophy in this healthcare setting demonstrates that structured analysis of an opportunity in implementation of “change for the best” and follow-up can result in added value in patient care.

84 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

27. OBESITY CONTRIBUTES TO COMPLICATIONS AFTER THYROIDECTOMY AND PARATHYROIDECTOMY AR Cardenas MD; ES Ong MD; MA Guerrero MD Tucson, AZ

BACKGROUND: Thyroidectomy and parathyroidectomy are generally well-tolerated procedures with low incidence of reported morbidity or mortality. The effect of obesity on complications after thyroid or parathyroid surgery remains incompletely characterized. We hypothesized that obesity would predispose patients to complications after thyroidectomy and parathyroidectomy.

METHODS: The Nationwide Inpatient Sample (NIS) for the year 2010 was queried for all patients undergoing thyroidectomy (partial or complete) or parathyroidectomy during the index hospitalization. Patients with a diagnosis of obesity or BMI≥ 30 were used for case-control analysis. Two-tailed t-tests and χ2 were used to compare cases and controls on bivariate analysis. Logistic regression models were used to determine the effect of obesity on various post-operative complications. The models controlled for age, case complexity, elective admission status, race, primary insurance and number of comorbidities.

RESULTS: The analysis included 15270 patients, of whom 1640 (10.7%) were obese. Obesity was significantly associated with total complications (20.1 vs. 13.4%, p<0.001), infections (4.3 vs. 2.2%, p<0.001), bleeding (4.0 vs. 2.5%, p<0.001), respiratory arrest (4.8 vs. 1.4%, p<0.001) and vocal cord paralysis (2.2 vs. 1.4%, p=0.011). It was not associated with mortality (0.2%, p=0.718). On logistic regression, obesity was a significant independent predictor of total complications (OR 1.37, p<0.001), total infections (OR 1.46, p=0.011), respiratory failure (OR 2.96, p<0.001), bleeding (OR 1.60, p=0.009) and vocal cord paralysis (OR 1.64, p=0.009). Obesity was not a significant predictor of mortality (p=0.265).

CONCLUSION: Obesity is a significant predictor of in-hospital complications in the setting of thyroidectomy and parathyroidectomy. The rates of individual complications remain relatively low, showing that thyroidectomy and parathyroidectomy are safely performed in the obese patient. However, the presence of obesity may warrant consideration in the decision to perform these procedures on an inpatient versus outpatient basis.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 85 SCIENTIFIC PAPER ABSTRACTS (cont.)

28. HAVE THE ACOSOG Z0011 TRIAL RESULTS INFLUENCED THE NUMBER OF LYMPH NODES REMOVED DURING SENTINEL LYMPH NODE DISSECTION? KA Robinson MD; BA Pockaj MD; N Wasif MD; K Kaufman; RJ Gray MD Phoenix, AZ

BACKGROUND: The American College of Surgeons Oncology Group (ACoSOG) Z0011 trial results have caused many surgeons to forego axillary lymph node dissection (ALND) if sentinel lymph node (SLN) metastases are found in a patient undergoing breast conserving therapy (BCT). These changes in practice have the potential to bias the number of SLNs surgeons remove: either to remove more lymph nodes as SLNs out of concern for regional recurrence without ALND or to remove fewer lymph nodes as SLNs due to a perceived decrease in the value of axillary management. This study aims to evaluate if the number of SLNs removed at the time of breast cancer surgery changed after the results of the ACoSOG Z0011 trial became available.

METHODS: A single institution prospectively collected breast cancer database was queried for all patients with T1-2 clinically node-negative breast cancer patients who underwent BCT and SLN biopsy.

RESULTS: 923 patients underwent BCT with SLND for T1-2 breast cancer. The same three surgical oncologists performed all procedures for the cohort from July 2003 to July 2013. Mean age was 66 years (range 31-94 years). The mean tumor size was 1.36±0.77cm. The mean and median number of SLNs per patient for the entire cohort was 2.65 and 2 respectively. In the time periods before and after the Z0011 trial was presented (June 2010) 674 and 249 SLNDs were performed, respectively. Mean number of SLNs retrieved before the trial’s presentation was 2.69 (95% CI=2.58-2.78) compared to 2.56 (95% CI=2.42-2.70) after its presentation (p=0.19). In the time periods before and after the Z0011 trial was published (February 2011) 732 and 191 SLNDs were performed, respectively. Mean number of SLNs retrieved before the trial’s publication was 2.69 (95% CI= 2.59-2.79) compared with 2.51 (95% CI= 2.35-2.67) after publication (p=0.10).

CONCLUSION: The number of SLNs removed in the course of BCT has not significantly changed after the results of the ACoSOG Z0011 trial were presented and published. Surgeons should nonetheless be aware of the potential for bias influencing their diligence in seeking and removing SLNs in this setting.

86 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

29. ELIMINATING CATHETER ASSOCIATED URINARY TRACT INFECTIONS IN THE INTENSIVE CARE UNIT: IS IT AN ATTAINABLE GOAL? GT Tominaga MD; A Dhupa MD; R Calara RN; S McAllister RN; A Stuck PhD La Jolla, CA

BACKGROUND: Centers for Medicare and Medicaid Services have identified catheter associated urinary tract infection (CAUTI) as a hospital-acquired condition that will not be reimbursed unless documented as present on hospital admission. The Centers for Disease Control (CDC) has recommended practices for preventing CAUTI emphasizing hand hygiene, aseptic catheter insertion, and proper maintenance. Despite these recommendations CAUTIs have not been eliminated in the critically ill. The BACKGROUND of this study is to determine strategies to decrease CAUTI in the Intensive Care Unit (ICU) patients.

METHODS: All ICU patients with an indwelling urinary catheter (UC) in one tertiary community hospital (with a verified Level II Trauma Center, certified Comprehensive Stroke Center and regional Cardiac Surgery Center) were monitored for CAUTI. CDC guidelines were enforced; interventions were implemented sequentially from Fiscal Year (FY) 2010-2013. Data was collected quarterly (Q). Interventions included: A–auditing of UC (FY2010Q1); B–UTI/UC maintenance form (FY2010Q2); C-removal of prepackaged bath/pericare wipes (FY2010Q3); D-house wide reeducation on UC insertion/care (FY2011Q2); E–2 person UC insertion and documentation on each UC placed (FY2012Q1); F–daily auditing of UC insertion (FY2012Q2); G–emptying of UC drainage bags @ 400 ml (FY2012Q3); H-14French UC trial (FY2013Q1-2); I-CAUTI feedback to physicians (FY2013Q1); J–prepackaged bath/pericare wipes implemented and bath tub basins eliminated (FY2013Q2); K–once daily UC care instituted (FY2013Q2). Main outcome measures were infection ratio (IR =number of infections divided by catheter days x 1000), and device utilization rate (DUR=catheter days divided by patient days).

RESULTS: Catheter days (CD) and DUR decreased over time: FY2008–CD 11,414, DUR 0.85 vs. FY2013–CD 8144, DUR 0.70. IR for FY10 was 4.03. IR for 2 quarters prior to intervention C was 3.2-3.4 compared to 4.5-5.0 over 5 quarters after intervention C. IR for two quarters prior to intervention E and F was 4.8-5.6 up to 6.7- 8.8 for two quarters after the interventions. Intervention H demonstrated no difference in CAUTI rates. IR before and after intervention I went from 6.1 down to 4.7. IR before and after intervention J and K went from 4.7 down to 3.7.

CONCLUSION: Diligence in removing UC when no longer needed decreased DUR. We found an increase in IR when prepackaged bath/pericare wipes were discontinued, and when 2-person UC catheter insertion and twice daily UC care were implemented. Smaller 14 French UCs did not change CAUTI rates. Notification of CAUTI’s to physicians, reinstitution of prepackaged bath/pericare wipes and implementation of once daily UC care decreased CAUTI rates. Decreasing CAUTI in the ICU requires diligent monitoring and constant reevaluation of practice patterns to insure that interventions do not increase CAUTI rates. Elimination of CAUTI in the ICU may not be possible due to the need for UCs in critically ill patients.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 87 SCIENTIFIC PAPER ABSTRACTS (cont.)

30. THE IMPACT OF EARLY FLOW AND BRAIN OXYGEN CRISIS ON THE OUTCOME OF PATIENTS WITH SEVERE TRAUMATIC BRAIN INJURY CP Marini MD; M Stiefel MD; G. Lombardo MD; A Policastro MD; C. Stoller MD; V Blood MD; JA Asensio MD Valhalla, NY

BACKGROUND: A goal-directed multimodality monitoring and therapeutic protocol (GD-MM& TP)in patients with severe traumatic brain injury (sTBI) may prevent and treat secondary brain injury therefore it may improve outcome. However, early flow and brain oxygen crisis (Flow/PbO2c)events can occur despite a GD-MM&TP in patients with s TBI. In this study we examined the impact of Flow/PbO2c events on the mortality of patients with sTBI.

METHODS: 24 patients with sTBI (mean age 48 ± 22, GSC 4.6 ± 1.9) between 7/2011 and 9/2012 were treated with a 5-day GD-MM&TP that included maintenance of normothermia (37 degrees Celsius), PbO2 ≥ 20 mm Hg, ICP≤ 20 mm Hg, CPP≥ 60 mm Hg to keep bi-frontal Near Infrared Spectroscopy (NIRS) ≥ 60%, burst suppression as needed, nutritional support to achieve a respiratory quotient(RQ) of 0.83 by day 3 and positive nitrogen balance by day 5, osmotherapy and decompressive craniectomy (DECRA)when indicated. Flow/PbO2C was defined by either a ≥ 5 minutes simultaneous decrease of CPP < 60 mm Hg and PbO2 < 20 mm Hg with NIRS < 60% (sCPP+PbO2)or by a decrease of any of the two alone (CPPa;PbO2a). Fourteen-day predicted mortality (PM)by the CrasH model was compared to actual mortality (AM). Patients were also compared from the standpoint of survival status. Data are presented as mean ± standard deviation.

RESULTS: Two patients required DECRA; both survived. The PM was 58% whereas AM was 33.3% (8/24), yielding a 42% reduction in mortality. Non-survivors (NS) had a significantly higher number of Flow/PbO2C events non-responsive to treatment compared to survivors (Surv). Mortality was 87.5% and 6.3% in patients with > 20 and < 20 simultaneous Flow/PbO2C events, respectively.

Variable NS (n=8) Surv(n=16) P Age 62±21 41±20 0.02 GCS 4.6±2.1 4.6±1.9 1 PM% 83±17 45±28 0.005 CPPa <60 19±14 5±7 0.002 PbO2a <20 33±24 12±15 0.01 sCPPa+PbO2 45±29 3±5 0.001

CONCLUSION: A GD-MM&TP can decrease mortality in patients with sTBI. However, early simultaneous Flow/PbO2C events not responsive to treatment in patients with sTBI predict a poor outcome despite the implementation of a GD- MM&TP. Further studies are needed to identify therapeutic approaches aimed at preventing or reducing the occurrence of flow/brain oxygen crisis events in patients with sTBI.

88 Southwestern Surgical Congress | 66th Annual Meeting SCIENTIFIC PAPER ABSTRACTS (cont.)

31. AUTOTRANSFUSION OF HEMOTHORAX: ACCELERATION OF COAGULATION WHEN MIXED WITH NORMAL PLASMA Hannah Harrison MS; W. Zachary Smith BS; Marc Salhanick MD; Russell Higgins MD; Alfonso Ortiz; John Olson MD PhD; Martin G. Schwacha PhD; Chantal Harrison MD; Jayson Ayedelotte MD; Daniel L. Dent MD San Antonio, TX

BACKGROUND: Traumatic hemothorax (HTX) has been demonstrated to predictably contain low fibrinogen, low hematocrit, and low platelet counts. Analysis of shed HTX demonstrates coagulopathy. However, when mixed with normal pooled plasma (NPP) at physiologically relevant dilutions, HTX demonstrates accelerated coagulation. We hypothesize that when HTX is mixed with the patient’s own plasma, the mixture will demonstrate hypercoagulability. Hypercoagulability of this mixture would have important implications for the autotransfusion of HTX as a method of resuscitating a trauma patient.

METHODS: Adult trauma patients from whom >140mL of HTX was evacuated within 1 hour of tube thoracostomy were included. HTX was sampled at 1, 2, 3, and 4 hours after evacuation. A portion of each sample was centrifuged as frozen plasma for later analysis. The sample collected at 1 hour was analyzed (coagulation, hematology, electrolytes), and values were compared to concurrent venous values extracted via chart review. A discarded citrate tube containing the patient’s venous blood was spun down and frozen for later analysis.

Coagulation was further evaluated by mixing serial dilutions of the previously frozen HTX with NPP. Additionally, the previously frozen HTX was mixed in serial dilutions with the previously frozen sample of patient plasma (PP).

RESULTS: Subjects (10) were enrolled based on inclusion criteria and collection of a discarded venous sample. In HTX samples analyzed alone, no clot was formed in any coagulation test (aPTT >180). The mean aPTT of PP alone was 26.7. The mean aPTT of the NPP in a batch was 33.6. In 1 hour specimens mixed at a clinically relevant dilution of 1:4, HTX mixed with NPP had a mean aPTT of 26.24 vs 22.4 for HTX mixed with PP (p = 0.003). Additionally, the mixture of HTX and PP shows a statistically significantly lower aPTT value than PP alone (22.4 vs 26.7, p = 0.03), indicating a hypercoagulable specimen.

CONCLUSION: HTX demonstrates coagulopathy when analyzed independently, but induces a hypercoagulable condition when mixed with NPP or PP in vitro. Thus, autotransfusion of HTX may produce a hypercoagulable state in vivo and should not be viewed as preferable to other blood components if they are available.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 89 SCIENTIFIC PAPER ABSTRACTS (cont.)

32. PELVIC RING FRACTURES: HAS MORTALITY IMPROVED FOLLOWING THE IMPLEMENTATION OF DAMAGE CONTROL RESUSCITATION? CA Fitzgerald BS; BC Morse MD; CJ Dente MD Atlanta, GA

BACKGROUND: Pelvic fractures, especially when open, remain a source of significant morbidity. Over the last 10 years, the paradigm of damage control resuscitation (DCR) has been associated with improved patient outcomes. This study investigates the outcomes of both closed and open pelvic ring fractures at a single institution before and after the formal implementation of DCR principles.

METHODS: A retrospective chart review was performed in an urban level I trauma center of all patients who sustained open or closed pelvic ring fractures between 2002- 2012. Patients were categorized into cohorts based on whether their fracture was open or closed, and were then further categorized into DCR (2007-2012) and pre-DCR (2002-2007) groups. Cohorts were then compared for demographic data, hospital management, and overall outcomes. Massive transfusion was defined as ≥ 10 packed red blood cells (PRBCs) in 24 hours.

RESULTS: 2,247 patients presented with pelvic fractures between 2002-2012. 17 patients (0.6%) were excluded due to incomplete electronic medical records. Open pelvic fractures accounted for 8% (181/2230) of fractures. Overall mortality was 10% (n =212). Only 8% (100/1301) of all patients with closed fractures required DCR, compared to 28% (36/128) of patients with open fractures. When comparing open to closed pelvic fractures, patients with open fractures had higher 24-hour mortality (13/30, 43% vs. 40/182, 22%; P = 0.01) and overall mortality (30/181, 17% vs. 182/2049, 9%; P = 7 x 10-4). When looking specifically at closed pelvic fractures, patients in the pre-DCR cohort had a longer total length of stay (17.9 ± 22.1 vs. 15.6 ± 24.2, P = 0.03), and a longer emergency department length of stay (10 ± 9.0 vs. 7.7 ± 6.2, P = 3 x 10-11). Pre-DCR patients with closed pelvic fractures also had a higher initial ISS (20.3 ± 12.8 vs. 18.1 ± 12.7, P = 3 x 10-4) than patients in the DCR group. Hospital course and management were similar when comparing DCR and pre-DCR patients with open pelvic fractures. There were no differences in mortality or in systemic infectious complications when comparing DCR and pre-DCR cohorts for either open or closed pelvic fractures.

CONCLUSION: The incidence of pelvic fractures remains stable over time. Furthermore, in keeping with previously published trauma series, open pelvic fractures are associated with significantly higher morbidity and mortality when compared to closed pelvic fractures. However, mortality in each group seems less than what has been documented in previously published studies. Interestingly, while DCR seems to lead to more efficient initial resuscitations, further improvements in patient mortality were not realized with formal implementation of DCR principles.

90 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 91 QUICK SHOT ABSTRACTS (cont.)

1. POST-OPERATIVE PNEUMOPERITONEUM: IS IT NORMAL OR PATHOLOGIC? BC Chapman MD, KE McIntosh BSN, EL Jones MD, DM Wells MD, GV Stiegmann MD, TN Robinson MD Aurora, CO

BACKGROUND: Pneumoperitoneum on postoperative imaging is a common finding. The presence of postoperative free intra-peritoneal air may be normal, or may be evidence of a postoperative complication. The data on postoperative pneumoperitoneum is limited. The BACKGROUND of this study is to characterize the incidence and duration of post-operative pneumoperitoneum and its impact on the need for additional surgery in a large patient population.

METHODS: This retrospective cohort study reviewed all patients with a Computed Tomography (CT) scan of the abdomen within 30 days of abdominal surgery over 8 years. Data recorded included patient demographics, indication for imaging, days from surgery, presence/absence of pneumoperitoneum, presence/absence of a drain, open vs. laparoscopic surgery, and the need for additional surgery.

RESULTS: Three hundred forty-four patients underwent 399 CT scans up to 30 days after abdominal surgery. Pneumoperitoneum was found in 39% (136/344) of patients. Pneumoperitoneum was demonstrated on post-operative days (POD) 0-2 in 77% (24/31), POD 3-5 in 43% (30/70), POD 6-8 in 48% (38/79) and POD≥9 in 27% (44/164) (p<0.05 for comparison of POD 0-2 vs. POD 3-5, and for comparison of POD<5 vs. POD≥5). CT scans performed on POD 15-20 had pneumoperitoneum on 21% (9/43). No free air (0/22 patients) was found on POD≥24. Comparing patients with and without pneumoperitoneum on CT scan found no difference in age (53±16 vs. 55±17 p=0.208), gender (37% vs. 47% Male p=0.057), and body mass index (27±7 vs. 26±7 p=0.068). Comparing patients with CT scans in similar time periods (PODs 0-2, 3-5, 6-8 and ≥9): (1) open vs. laparoscopic initial operation was not related to pneumoperitoneum (p>0.05 for all comparisons), and (2) the presence of an intra-abdominal drain was not related to pneumoperitoneum (p>0.05 for all comparisons). Only 6% (8/136) of patients required surgery following the diagnosis of pneumoperitoneum. Intra-operative findings were: 3 anastomotic leaks (POD 7, 8 and 11), 2 colon perforations (POD 4, 12), 1 no evidence of perforation (POD 9), 1 jejunal serosal tear (POD 10) and 1 bladder injury (POD 10).

CONCLUSION: Postoperative pneumoperitoneum is a common finding on CT scans after abdominal surgery. Increased days from surgery is associated with a decreased incidence of pneumoperitoneum in a dose response fashion. Surprisingly, 20% of patients 15 to 20 days postoperatively continue to have pneumoperitoneum. Open vs. laparoscopic surgery and the presence of a drain were not associated with pneumoperitoneum. The majority of patients with postoperative pneumoperitoneum do not require an intervention. Better understanding the natural history of postoperative pneumoperitoneum will aid surgeons in interpreting their postoperative CT scans.

92 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

2. INTER-RATER AGREEMENT IN EVALUATING THE ENDOSCOPIC APPEARANCE OF THE GASTROESOPHAGEAL JUNCTION IN COMMUNITY SETTING GM Ihde MD, LA Dill DO, CF Lucchese DO, PK Krone MD, DG Cummins MD, CJ Cottrell MD, DG Lister MD Dallas, TX

BACKGROUND: A proper evaluation of the gastroesophageal junction (GEJ) is crucial to the decision tree that accompanies the use of novel surgical therapies for the treatment of reflux disease. The Hill grade classification, published originally in 1996, is a common means by which the appearance GEJ is evaluated. The aim of this study was to determine the inter-rater agreement in the assessment of the GEJ in reflux patients in community setting.

METHODS: One hundred and six videos of patients who underwent a preoperative endoscopic evaluation as part of a prospective institutional review board approved study on the treatment of reflux disease were evaluated. Each endoscopic video was edited by the leading author to display the GEJ at the time of full gastric distention. Random numbers, generated with a computer program, were assigned to each video. Eight community general surgeons, with experience in anti-reflux surgery, independently and blindly evaluated each video and assigned a Hill grade (I, II, III or IV) to the appearance of the GEJ on a scoring sheet immediately after reviewing the examples of the four Hill grades. The Kappa κ( ) coefficient was used to express the inter-rater agreement and agreement across Hill grades (categorical values). The closer the κ value is to 1, the more agreement there is; a κ value closer to zero indicates less agreement. The error rate, when compared to the reference values, was calculated by dividing incorrect values with number of cases.

RESULTS: Overall, in only 6% [(6/106), 95% confidence interval (CI) = 2.6 to 11.8] of cases, all raters agreed on the Hill grade (5 times on Hill grade IV and once on Hill grade III). The agreement across Hill grades was the highest for Hill grade IV κ( = 0.31) and the lowest for the Hill grade I (κ = 0.11). In the case of Hill grade II (κ = 0.28) and Hill grade III (κ = 0.21), the agreement was fair. Inter-rater agreement between eight surgeons ranged from κ = - 0.08 to κ = 0.54. There were no good κ( = 0.61-0.80) or very good (0.81-1.00) agreements. Of 28 possible inter-rater combinations, in 29% (8/28) the agreement was poor (κ < 0.20); in 43% (12/28) was fair (κ =0.21-0.40) and in 29% (8/28) the agreement was moderate (κ =0.41-0.60). Considering Hill grade assignments from the rater with the highest overall agreement as reference (standard) values, the error rate of the other seven raters ranged from 0.30 to 0.67. Combining Hill grade I and II into one group and Hill grade III and IV into another group, the overall agreement improved to 49% [(52/106), 95% CI = 39.7 to 58.4]. The agreement across these two groups was same (κ =0.37). Based on these two groups, inter-rater agreement ranged from poor [25% (7/28] to good [4% (1/28)].

CONCLUSION: In this study, inter-rater agreement in assigning Hill grade to the videos of patients undergoing endoscopic evaluation was inconsistent between eight community general surgeons. Further studies are needed to confirm our findings.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 93 QUICK SHOT ABSTRACTS (cont.)

3. MAGNETIC RESONANCE CHOLANGIO-PANCREATOGRAPHY BEFORE AN ENDOSCOPIC RETROGRADE CHOLANGIO- PANCREATOGRAPHY: IS IT REALLY REQUIRED? V. Pandit, P. Rhee, N. Kulvatunyou, A. Tang, T. O’Keeffe, D.J. Green, G. Vercruysse, R.S. Friese, B Joseph Tucson, A Z

BACKGROUND: Magnetic Resonance Cholangio-pancreatography (MRCP) is routinely performed before an Endoscopic Retrograde Cholangio-pancreatography (ERCP) for managing patients with gall bladder duct stones. The aim of this study was to evaluate the utility of an MRCP before an ERCP in patients with Choledocholithiasis

METHODS: This is a one year (2009) retrospective analysis of the Nationwide Inpatient Sample (NIS) database. Patients with Choledocholithiasis were identified using ICD 9 diagnosis codes (574.0-574.9). Patients who underwent an ERCP (51.10) and/or MRCP were abstracted using ICD 9 procedure codes. Only patients who underwent an ERCP were included. Primary outcome measure was hospital length of stay and secondary outcome was hospital charges.

RESULTS: A total of 33,474 patients with ERCP were included of which; 36.8% (n=12,318) patients underwent a MRCP before an ERCP. There was no difference in age (58.9+21.5 vs. 60.7+19.5, p=0.1), females (69.8% vs. 67.2%, p=0.09), and Charlson co-morbidity Index (1.8+0.7 vs. 1.6+0.9, p=0.2) between patients who underwent a MRCP before an ERCP and patients who underwent an ERCP alone. Patients who had an MRCP before an ERCP were more likely to be an emergent type of admission (25% vs. 15%, p=0.02) and admitted on a weekend (31.2% vs. 26.4%, p=0.04).

Patients with a MRCP before an ERCP were more likely to have longer hospital length of stay (12.5+8.1 vs. 8.9+5.9, p=0.01) and higher hospital charges (92,457+61657 vs. 64,123+059,618, p=0.01). There was no difference in in-hospital complications (p=0.1) between the two groups.

CONCLUSION: A MRCP before an ERCP in patients with Choledocholithiasis is not warranted. ERCP should be a definitive therapy for managing patients with Choledocholithiasis.

94 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

4. CHRONIC STEROID USE AND ITS EFFECT ON POST-OPERATIVE WEIGHT LOSS CJ Tadaki MD, NA Molacek BS, RA Jones MD, D Oleynikov MD, CL McBride MD, VM Kothari MD Omaha, NE

BACKGROUND: Many patients take chronic steroids for a variety of ailments including rheumatoid arthritis, degenerative joint disease, asthma, etc. Many of these diseases are prevalent in the obese population and in addition, one of the well documented side effects of chronic steroid use is weight gain. Subsequently chronic steroid users have a difficult time losing weight. For patients pursuing bariatric surgery perioperative steroid use may impact their post-operative weight loss. The goal of this study was to compare the loss of excess body weight (EBW) between bariatric surgery patients on chronic steroids to those who are not on steroids.

METHODS: The Bariatric Outcomes Longitudinal Database (BOLD) is a prospectively collected database of patients who have undergone bariatric surgery by a participant in the American Society for Metabolic and Bariatric Surgery (ASMBS) Bariatric Surgery Center of Excellence program. The BOLD data was queried for patients on chronic steroids for any reason and their data was compared to the non- steroid patients. Patients were defined as chronic steroid users if they were on a form of prednisone both before and after their bariatric procedure.

RESULTS: A total of 116,136 patients underwent bariatric procedures from June 2007 to December 2009. Of those, 165 individuals were identified as chronic steroid users: (77 gastric bypass; 76 adjustable gastric bands; 12 sleeve gastrectomies). There was no difference between non-steroid and steroid patients for pre-op BMI (46.2 vs 45.3; P=0.4453) or gender (21.4% vs 17.6% male; p=0.2342). There were more African Americans in the steroid group (10.8% vs 15.8%; p=0.0415). The non-steroid group was younger (46 vs 53;p<0.0001). The average EBW loss in kilograms (kg) was greater for non-steroid patients (32.2 ±18.8 vs. 26.4 ± 18.1; p<0.0001).

CONCLUSION: It is understood that weight loss is a multifactorial process with many variables that contribute to the success or failure of the individual. Chronic steroid use is linked to weight gain and can negatively impact patients’ efforts at weight loss. In our study we show that chronic steroid use predicts less weight loss after bariatric surgery as compared to non-steroid users. Though prednisone is not the only steroid chronically used by patients, this study demonstrates that chronic use of the drug is one factor that hampers patients’ weight loss after a bariatric surgical procedure.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 95 QUICK SHOT ABSTRACTS (cont.)

5. INITIAL OPERATIVE TREATMENT OF ISOLATED ILEAL CROHN’S DISEASE IN ADOLESCENTS AM Kulungowski MD, SN Acker, EJ Hoffenberg, DA Partrick Aurora, CO

BACKGROUND: The goal of therapy in children with Crohn’s disease (CD) is to not only induce and maintain remission with minimal side effects but also to adequately control the disease to maintain normal growth, nutrition, and development. Surgical intervention facilitates these treatment goals and allows a disease free interval to optimize growth and development. We hypothesize that in patients with disease isolated to a single site, resection of the diseased intestine leads to clinical improvement, decreased medication requirements, and improved growth.

METHODS: A retrospective review was conducted of patients with CD isolated to the terminal ileum undergoing operative intervention at the Children’s Hospital Colorado between 2002 and 2013. Clinical presentation, indications for surgery, operative intervention, complications, and condition at follow up were reviewed.

RESULTS: A total of 26 patients with disease isolated to the terminal ileum were identified. Average age at diagnosis was 14.1 (± 2.6) years; average age at resection was 15.7 (± 2.5) years. All patients underwent ileocecectomy. Common indications for operation included stricture (n=22), abscess (n=8), fistula (n=6), bowel obstruction (n=3), and perforation (n=3). There were five postoperative complications including wound infection (n=4) and intraabdominal abscess (n=1). Only one patient experienced disease recurrence requiring reoperation. Median time to follow up was 2 (± 1.5) years. At follow up, 22 (84.6%) patients reported a subjective improvement in disease severity. Preoperatively, 23 (86.5%) patients were receiving varying combinations of corticosteroid (n=18), immunomodulators (n =14), biologics (n=8) and salicylates (n=8) for maintenance and treatment of their CD. At follow up, 17 (65.4%) patients experienced a reduction in the number or dosage of their medications. A significant decrease in the number of patients receiving corticosteroid treatment following resection (18 preoperatively vs. 3 postoperatively; p<0.0001) was observed. Following resection, average weight (based on percentile) increased from 29th percentile to 45th percentile (p=0.09) at 1 year and continued to improve at 3 years to 56th percentile (p=0.02). Height also increased from 39th percentile at time of resection to the 51st percentile at three years (p=NS). Significant improvements were observed in body mass indices. The average BMI prior to intervention was 18.7 ± 3.5. At one and three years, the BMI increased to 21.2 ± 4.2 (p<0.05) and 22.5 ± 3.9 (p<0.01).

CONCLUSION: Timely surgical resection in adolescents with CD isolated to the terminal ileum allows for a period of catch up growth with improvement in heights, weights, and body mass indices. Our patients experienced sustained clinical improvement and reduction in medication requirements. Early operative intervention for isolated ileal CD is a valid treatment option in the pediatric population.

96 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

6. EARLY COMPLICATIONS BETWEEN “PULL” VS. “PUSH” PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) - “PULL” PEG TUBE DISLODGEMENT MAY BE UNDERAPPRECIATED V Vallet BS, N Kulvatunyou MD, RS Friese MD, DJ Green MD, L Gries MD, B Joseph MD, T O’Keeffe MD, AL Tang MD, G Vercruysse MD, P Rhee MD Tucson, A Z

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) complications are often underreported in the literature, in particular the incidence of tube dislodgement (TD). TD clinical consequence can be as benign as a simple tube replacement, or it can be as disastrous as a necrotizing fasciitis of the abdominal wall or a generalized peritonitis. We hypothesized that “pull” PEG had a higher incidence of TD because of its tube characteristic.

METHODS: We performed a chart review of our prospectively maintained acute care surgery database for patients who underwent PEG tube placement from July 1st, 2010, through June 30, 2012. Age, gender, body mass index (BMI), indications (trauma vs. non-trauma), and complications (including TD) were recorded. Procedural- related complications were classified as either major if patients required an operative intervention, or minor if they did not. We then conducted a multivariate logistic regression analysis factors contributing to TD.

RESULTS: During a 2-year study period, 128 patients underwent “pull” and 24 underwent “push” PEGs. Age, gender, BMI, and indications were similar between the 2 groups. The overall complications (major and minor) were similar (“pull”, n =22, 17% vs. “push, n=3, 13%; P = 0.56). The incidence of TD was higher in “pull” PEGs but was not statistical significant (10% vs. 8%, P = 0.3). However, the incidence of TD in “pull” PEG that would be considered a major complication was 4%, while there was none in “push” PEG (P=0.3). The regression analysis identified “pull” PEG had an increased odd for TD (odds ratio 1.24; 95% confidence interval, 0.26 to 5.9).

CONCLUSION: Although the study is limited by a small sample size, despite having similar overall complications, “pull” PEGs appeared to dislodge easier than “push” PEGs, which led to major complications. It may be the “pull” PEG’s flexible end disc that tends to easily dislodge and migrate, in comparison to the “push” PEG’s T-fasteners and the balloon tip that is less prone to dislodge and migrate.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 97 QUICK SHOT ABSTRACTS (cont.)

7 - Video. LAPAROSCOPIC ANTRECTOMY ROUX EN Y FOR GASTRIC ANTRAL VASCULAR ECTASIA (GAVE) RW Jones DO, S Tsuda MD, J Wray Las Vegas, NV

BACKGROUND: 65 year old female with a history of Gastric Antral Vascular Ectasia (GAVE) failed medical and endoscopic management. She was receiving multiple blood transfusions on a weekly and biweekly basis.

METHODS: She was referred for surgery. She underwent a laparoscopic antrectomy with a roux en y reconstruction.

RESULTS: The surgery lasted two hours and she received 2 units of blood intraoperatively. She was discharged home on post operative day number two. She followed up with us in clinic one month later. The patient has required no further blood transfusions to date.

CONCLUSION: Surgery can provide definitive treatment for patients with GAVE who do not respond to medical and endoscopic treatment. Laparoscopic antrectomy can be performed safely in patients with GAVE.

98 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

8. A STATEWIDE OBSERVATIONAL STUDY OF COMPLIANCE WITH SURGICAL SAFETY CHECKLISTS: WE’RE NOT AS GOOD AS WE THINK AW Gallagher, WL Biffl MD, F Pieracci MD, C Berumen Denver, CO

BACKGROUND: Surgical safety checklists (SSCs) are designed to improve team communication and consistency in care, and thereby ensure compliance with core measures, avoid wrong-site procedures, facilitate efficiency, and be prepared for challenging operative events. Although compliance with core measures has improved, a statewide survey by our State Hospital Association indicated that SSC use- and physician participation in particular- was inconsistent. We hypothesized that there was wide variation in the use of SSCs, and that patterns of noncompliance could identify target populations for future improvement interventions.

METHODS:Ten hospitals participated as a quality improvement initiative. Trained team members at each site recorded compliance with each of the components of an adaptation of the World Health Organization SSC, without the knowledge of the operating team. De-identified observation sheets were sent to the State Hospital Association where elements were entered into an Access database. Data analysis was performed using a chi-squared test or ANOVA, depending on the number of categorical variables being compared, with p<0.05 determining statistical significance.

RESULTS: Ten hospitals (3 rural, 7 urban/suburban; 2 academic, 8 community; 5 level I or II trauma centers) submitted 854 observations (median 98, range 24- 106). 83% of cases were elective, 13% urgent, and 4% emergent/trauma. There was significant variation across hospitals in the following (overall mean in parentheses): team introductions (30%), cessation of activity (77%), affirming correct procedure (95%), assessing hypothermia risk (48%), need for beta blocker (23%), or VTE prophylaxis (65%). Uniformly poor compliance, without significant variation, was observed with respect to assessment of case duration (16%), blood loss (19%), anesthesiologists’ concerns (39%), or display of essential imaging (36%). Only 71% reported active participation by physicians; 9% reported that “the majority did not pay attention” and 4% reported that the team was “just going through the motions.” There were significant differences among surgical specialty groups in the majority of the elements. Compared with orthopedic and neurosurgeons, general surgeons were more compliant with active participation, but less compliant with addressing critical steps, case duration, blood loss, anesthesia concerns, hypothermia risk, antibiotic administration, or imaging.

CONCLUSION: SSCs have been implemented by the vast majority of hospitals in our state; however, compliance with SSC completion in the operating room has wide variation and is generally suboptimal. Although this study was not designed to correlate SSC compliance with outcomes, there are concerns about the risk of a sentinel event or unanticipated complication resulting from poor preparation. A second phase of this project is under development to determine how compliance can be improved.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 99 QUICK SHOT ABSTRACTS (cont.)

9. ORIGINAL EQUIPMENT MANUFACTURER SINGLE-USE ENERGY DEVICES FAIL MORE FREQUENTLY THAN REPROCESSED DEVICES TJ Loftus MD Phoenix, AZ

BACKGROUND: Single use energy devices are increasingly used in surgical procedures. Reprocessing has emerged as an attempt to control the cost of this technology. Data on the failure rates of these medical devices remains limited. This study compares the reported failure rates between the original equipment manufacturer (OEM) single-use energy devices to reprocessed (RP) energy devices in a large healthcare system.

METHODS: Data was retrospectively collected over a seven month period for two types of commonly used energy devices. Rates were calculated based on the reported device failures and the number of devices used during the reporting period. A Z-test for two population proportions was performed comparing the failure rates of OEM energy devices to RP devices.

RESULTS: A total of 3112 devices were used in the reporting period. There is a significant difference (p < 0.01) in reported energy device failures between OEM and RP, with a higher percentage of failures (2.0% vs. 0.41%) reported with the OEM devices. OEM devices failed 4.9X more frequently than RP devices. This difference was maintained for both types of energy devices studied, Harmonic Scalpel (OEM vs. RP: p < 0.01) and Ligasure (OEM vs. RP: p < 0.01). There was no difference in failure rates between the two types of energy devices.

CONCLUSION: OEM single-use energy devices are reported to fail more frequently than RP devices.

100 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

10. HIGH PREVALENCE OF DOMESTIC ABUSE AMONG TRAUMA PATIENTS, A HARSH REALITY B Zangbar, P Rhee, V Pandit, N Kulvatunyou, A Tang, T O’Keeffe, DJ Green, G Vercruysse, RS Friese, B Joseph Tucson, A Z

BACKGROUND: Domestic violence is one of the most underreported crimes and a growing social problem in the United States. The aim of this study was to assess the prevalence of domestic violence among trauma patients using the National Trauma Data Bank (NTDB).

METHODS: This is a 4-year (2007 to 2010) retrospective analysis of the NTDB. Trauma patients with domestic violence were identified with E-codes (E967.0-967.9). Patients were stratified by age into three groups: children (age<18years), adults (age 19-54years), and elderly (age>55years). Trend analysis was performed to assess the incidence of domestic violence over the years.

RESULTS: A total of 14,235 patients with domestic violence were included. 63.7%(n=9,071) were children, 31.9%(n=4,534) were adults, and the remaining 4.4%(n=630) were elderly patients. The mean age was 19.9+14.9 years, 41.4% were males, and median Injury Severity Score was 14 [9-21]. Head injury (46.8%) followed by extremity fractures (31.2%) were the most common injury. 68.9% (n=9,808) of the patient were discharged home and the overall mortality rate was 6% (n=849). The incidence of domestic violence increased (2007:62.3% to 2010:66.1%, p=0.04) among children while decreased (2007:33.6% to 2010:29.2%, p=0.04) among adults over the years. On sub-analysis of adults and elderly patients, the incidence of domestic violence among females decreased over the years (2007:63.9% to 2010:58.9%, p=0.04).

CONCLUSION: Domestic violence is prevalent among trauma patients. Over the years, the incidence of domestic violence has been increasing among children and continues to remain high among female trauma patients. A mandatory screening for evaluating domestic violence among trauma patients along with focused national intervention is warranted.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 101 QUICK SHOT ABSTRACTS (cont.)

11. THE UNDERESTIMATED EFFECT OF HYPOTHERMIA IN ORGAN DONATION M. Khalil, B. Joseph, A. Hashmi, T. O’Keeffe, N. Kulvatunyou, A. Tang, D.J. Green, G. Vercruysse, R.S. Friese, P. Rhee Tucson, A Z

BACKGROUND: Hypothermia is a known predictor of mortality in trauma patients; however, its impact on organ procurement has not been defined. The aim of this study was to assess the effect of hypothermia on organ procurement. We hypothesized that admission hypothermia impedes successful organ procurement.

METHODS: We performed a 3 year retrospective analysis of all trauma patients approached for organ donation. Hypothermia was defined as a core body temperature <36°C/97°F. The two groups (Hypothermic vs. Normothermic) were matched in a 1:1 ratio using propensity score matching for age, gender, admission Glasgow Coma Scale (GCS) score, systolic blood pressure (SBP), International Normalized Ratio (INR), and Injury Severity Score (ISS). Primary outcome measure was eligibility for organ donation. Secondary outcome measure was vasopressor and blood product requirements.

RESULTS: The study composed of 537 brain dead patients of which, 416 [Hypothermic (208): Normothermic (208)] were included in the analysis. The mean age was 40.5+23.7 years, 75% were male, mean temperature was 36.6+1.7 C, and mean SBP 73.7+68.7 mm of Hg. There was no difference in age (p=0.8), gender (p=0.9), GCS score (p=0.8), SBP (p=0.9), INR (p=0.6), and ISS (p=0.8) between the two groups. Patients who were hypothermic on presentation were less likely to become organ donors (44.7% vs. 96%; p-0.001). There was no difference in the need for blood product transfusion (93% vs. 80%; p-0.2) and vasopressor support (73% vs. 58%; p-0.2). between the two groups.

CONCLUSION: Admission hypothermia impedes organ donation in potential organ donors independent of admission coagulopathy, hypotension, and injury severity. Resuscitation protocols must focus on early correction of hypothermia in potential organ donors.

102 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

12. ENHANCING SURGICAL SAFETY USING DIGITAL MULTIMEDIA TECHNOLOGY JL Dixon MD, J Hunt MD, D Mukhopadhyay MD, D Jupiter PhD, R W Smythe MD, HT Papaconstantinou MD Temple, T X

BACKGROUND: Surgical safety programs including the time out are widely adopted and effective tools to prevent patient harm; however, compliance and effective use are variable. Innovation using digital/video (multimedia) based checklist may increase participation and effective use of surgical safety tools. The BACKGROUND of this study is to determine if a multimedia-based checklist tool can enhance effective use of the time out.

METHODS: A pre- and post-intervention prospective pilot-study was performed. A multimedia-checklist including patient video (stating name, date of birth, surgical procedure and laterality) was developed that paralleled our established time out process. Forty case-observations of our established time out were compared to an equal number of the multimedia time out checklists for performance of key elements and completion times. Surgical team perceptions were compared using a modified operating-room safety attitudes questionnaire (SAQ) and satisfaction survey (Likert Scale 1-strongly disagree to 5- strongly agree). Statistical significance p<0.05.

RESULTS: At baseline, surgical teams scored high on the SAQ. Although the multimedia time out took longer to complete (49 vs. 79 seconds, p<0.01), there was a significant improvement in performance of key safety elements. Furthermore, there was a significant improvement in perception of ease of use (p<0.01), clarity of patient identification (p<0.05), and procedural laterality (p<0.01) with the multimedia method. Nearly 90% of responders preferred the multimedia time out.

CONCLUSION: A multimedia time out improves performance of key safety elements, and enhances patient and procedural clarity. These findings may result in improved compliance and effective use of patient safety tools.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 103 QUICK SHOT ABSTRACTS (cont.)

13. FETAL SURGERY AND OUTCOME OF CONGENITAL HIGH AIRWAY OBSTRUCTION SYNDROME (CHAOS) AT A SINGLE CENTER F Sheikh MD, B Kaul BS, IJ Zamora MD, OO Olutoye MD PhD, D Cass MD Houston, TX

BACKGROUND: Congenital high airway obstruction syndrome (CHAOS) is a rare diagnosis that was uniformly lethal until the development of fetal surgical techniques. We evaluated fetal interventions and outcomes of patients with CHAOS.

METHODS: A chart review of all patients evaluated at our fetal center and diagnosed with CHAOS by prenatal MRI between January 2008 and February 2013 was conducted. Data on procedures performed both pre- and postnatally were obtained, including complications and perinatal outcome. Follow-up data on surviving patients included duration of ventilation use, nutrition status, and ability to phonate.

RESULTS: Over the 5-year period, 4 fetuses were diagnosed with CHAOS at 20 – 21 weeks gestation. Patient 1 had a 4 mm segment of tracheal atresia seen on fetal MRI and underwent an EXIT procedure with tracheostomy at 28 3/7 weeks due to pre-term labor. His course was complicated by necrotizing enterocolitis that required multiple bowel surgeries. His trachea was repaired at age 9 months and by 11 months he was discharged home with ventilator support at night. His trachea was decannulated at 3 years of age and currently at age 5 he is tolerating oral feeds and his speech is improving with therapy. He does not have evidence of neurodevelopmental delay. Patient 2 underwent an attempt fetoscopic tracheal decompression because of worsening fetal hydrops but the procedure was technically unsuccessful. Preterm premature rupture of membranes at 25 weeks prompted EXIT-to-airway with tracheostomy. He was discharged home at 4 months, tolerated an oral diet at 5 months, and weaned to CPAP at 14 months. Laryngoscopy revealed a subglottic atresia and incompetent vocal cords making tracheal reconstruction a poor option. At 3 years he uses sign language to communicate and does not exhibit developmental delay. Patient 3 had fetal laryngoscopy at 21 6/7 weeks that revealed laryngeal atresia and malformed vocal cords. The family opted to terminate the pregnancy. Patient 4 was diagnosed with CHAOS and had concomitant anhydramnios that resulted in intrauterine fetal demise at 21 weeks.

CONCLUSION: Prenatal diagnosis of CHAOS can allow for better perinatal management. EXIT procedure with tracheostomy can prevent perinatal asphyxia and death. In appropriate cases, fetoscopic decompression of a short segment obstruction may be considered. Ability to phonate in survivors is dependent on the level pf obstruction and malformation of the vocal cords. This information can be useful when counseling parents on this rare and often fatal disease.

104 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

14. DOES CONCOMITANT THERAPY WITH ALLOPURINOL PREVENT OXIDANT MEDIATED DAMAGE IN THE SETTING OF KIDNEY AND KIDNEY-PANCREAS TRANSPLANTATION? A RETROSPECTIVE REVIEW OF A TRANSPLANT CENTER. AB Echeverria, MD, S Yost, PharmD, T Jie, MD Tucson, A Z

BACKGROUND: Allopurinol is a commonly utilized in the treatment of gout and hyperuricemia; it is an inhibitor of xanthine oxidase. Ischemia-reperfusion injury is a non-specific antigen independent process that can significantly influence the outcome of organ transplantation. When the organ is reperfused and the hypoxanthine comes into contact with oxygen, high levels of oxygen-derived free radicals (ODFR) are produced. These ODFRs can then influence tissue pressure to favor interstitial edema and microvascular permeability, leading to further increase in ODFR-mediated tissue damage. We hypothesize patients on allopurinol prior to renal transplant have a decreased incidence of delayed graft function.

METHODS: This is retrospective, case-controlled study at a single-center. The data collected was from patients that were admitted to the University of Arizona Medical Center 8/1/10-9/1/12 for a kidney or kidney-pancreas transplant. The numerical data was compared using a student’s t-test. Tests between proportions was analyzed using a Chi-squared test.

RESULTS: Of the one hundred eighty three patients, seventeen were on allopurinol prior to transplant and therapy was continued after transplant at discharge. The trend of serum creatinine (SCr) is lower at the time of transplant and postoperative day (POD) 5 but by POD 30 and 90 the SCR is similar between the allopurinol group and the non-allopurinol group. The percentage of patients that were discharged on dialysis were zero on the allopurinol group and 17 (9.3%) in the non-allopurinol group. The trends were also lower in the number of patients who required dialysis, were diagnosed with ATN, and rejection in the allopurinol group. If patients received allopurinol they had a 27% reduction in the diagnosis of ATN.

CONCLUSION: Though there appears to be a significant role in the prevention of anti-oxidant mediated damage in the setting of cardiovascular surgery for allopurinol, the same role has not been demonstrated to date for the renal transplant patient in the literature. Our findings demonstrate a reduction in delayed graft function in patients on preoperative Allopurinol. We recognize our small sample size and plan to proceed with a prospective randomized trial.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 105 QUICK SHOT ABSTRACTS (cont.)

15. CERVICAL SPINE INJURIES: DO ALL FRACTURES REQUIRE SCREENING FOR BLUNT CEREBRAL VASCULAR INJURY? PE Fischer MD MS, MJ Avery, AB Christmas MD, JM Green MD, MH Thomason MD, RF Sing DO Charlotte, NC

BACKGROUND: Given pressure to limit healthcare costs and the dangers of radiation exposure with diagnostic testing, the indications to perform computed tomographic angiography (CTA) for blunt cerebral vascular injury (BCVI) must be reevaluated. The BACKGROUND of this study was to examine the utility of CTA screening to diagnose BCVI at discrete levels of cervical spine injury.

METHODS: All trauma patients undergoing CTA for suspected BCVI from 2007 to 2012 were identified. Cervical spine injuries were divided into 4 categories: C1–C3, C4–C6, multiple level, and isolated C7 injuries. Multivariable logistic regression was used to determine which levels of injury were independent predictors of BCVI after adjusting for other known risk factors.

RESULTS: 753 patients underwent CTA evaluation for possible BCVI during the 6-year study period. 253 patients incurred at least one cervical spine fracture of which 65 (9%) had BCVI. The incidence of BCVI in C1-C3, C4-6, and combined injuries ranged from 27%, to 38%, but C7 fractures had a significantly smaller incidence of BCVI at 7% (p < 0.0001). In the multivariable model, the odds of BCVI were significantly increased with C1-C3 injury (OR 3.9, p < 0.0001), C4-C6 injury (OR 3.7, p < 0.0001), and multiple levels (OR 5.1, p = 0.0001). Mutivariable logistic regression failed to support C7 fractures as being an independent risk factor for BCVI after adjusting for other known risk factors including subluxation, neurologic deficit, basilar skull fracture, and admission Glasgow coma scale.

CONCLUSION: While judicious use of CTA screening should be encouraged, the risk of missing a BCVI remains too high without imaging in C1-C3, C4-C6, or combined fractures. However, in the absence of other known risk factors, C7 fractures demonstrated no increased association with BCVI.

106 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

16. COST CONTAINMENT IN A RAPIDLY EXPANDING ELDERLY POPULATION: A PREDICTIVE MODEL TO GUIDE RIB FRACTURE MANAGEMENT K Schnell MD, M Ghneim MD, F Kang BS, D Jupiter PhD, M Davis MD, J Regner MD Temple, T X

BACKGROUND: The Census Bureau predicts the elderly population (age ≥ 65 years) will increase from 40 to 81 million between 2010 and 2040, becoming the fastest growing cohort in the US. The most prevalent injury sustained by the elderly is rib fracture (fx). Prior studies have assessed rib fxs alone as predictors of morbidity, but none have accounted for baseline co-morbidities or the injury’s financial impact. We predict that triage of the elderly trauma patient (pt) sustaining rib fxs would be more accurate using a scoring system that incorporates both pre-existing comorbidities and new trauma burden.

METHODS: A retrospective cohort study evaluated 400 pts age ≥55 years, (229 (57%) were elderly), with rib fxs admitted to a Level I trauma center from 2007 to 2012. Comorbidities included COPD, CHF, CAD, tobacco use, obesity, and functional status. Trauma data points included number of rib fxs, tube thoracostomy, pulmonary contusions, spinal injury, and lower body fxs. Exclusion criteria included GCS<13, emergent thoraco-abdominal surgery, or deaths not due to rib fxs. Bivariate and logistic regression analysis determined the contribution of these factors to the combined outcome of intubation (INT) or pneumonia (PNA). Based on initial bi- and multivariate analysis, significant variables were then used in a logistic regression analysis to create a scoring system to predict morbidity. The scoring system was cross- validated and assessed for accuracy in predicting INT or PNA as markers for intensive care unit (ICU) admission.

RESULTS: Six variables increased the risk of INT or PNA: COPD (OR 3.9), low albumin < 3.5 g/dL (OR 3.0), assisted living status (OR 2.9), tube thoracostomy (OR 2.4), ISS (OR 1.09 per ISS), and total rib fx (OR 1.13 per rib fx)(p< 0.05). These six variables and CHF (OR 1.9, p = 0.06) were used to create a predictive model for risk of INT or PNA. This model assigns to each variable the scores: 1.4, 1.1, 1, 0.9, 0.1(n), 0.1(n), and 0.6 respectively. A total score of >3.7 had a sensitivity and specificity of 78.5% and 78.9% for INT or PNA but had a negative predictive value (NPV) of 94.5% suggesting pts with scores <3.7 were at minimal risk of requiring ICU. When applied to our cohort, 92 pts (40% of ICU admits) had <3.7 for a predictive score. Eleven (12%) of these pts had INT or PNA, however, only three were due to rib fxs. Of the remaining 81 pts with a score <3.7 admitted to the ICU, none developed PNA or INT. 40 had no other indication for ICU admission aside from the rib fx and could have been managed on the floor. These 40 pts had 1.7 day average length of stay in the ICU at an increased cost of $2200 per patient.

CONCLUSION: Rib fxs remain the most prevalent injury in the fastest growing cohort of the US, the elderly. We identified a scoring system with a strong NPV for PNA or INT. Pts with a score < 3.7 should be stable for floor rather than ICU admission. This scoring system should be assessed prospectively to minimize morbidity and cost in the elderly.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 107 QUICK SHOT ABSTRACTS (cont.)

17. IMPLEMENTATION OF AN INSTITUTIONAL PROTOCOL ACHIEVES NEAR-PERFECT RETRIEVAL RATES AMONG TRAUMA PATIENTS WITH RETRIEVABLE INFERIOR VENA CAVA FILTERS A Raines MD, T Garwe PhD, J Irvan MD, P Motghare MD, and R Albrecht MD Oklahoma City, OK

BACKGROUND: Retrievable inferior vena cava filters (RIVCFs) are often indicated in trauma patients as those patients have an increased susceptibility to the development of deep venous thrombosis and frequently have contraindications for anticoagulants. Retrieval rates of RIVCFs have been shown to be variable. This study aimed to determine if the implementation of an institutional follow-up and retrieval protocol would improve retrieval rates of RIVCFs.

METHODS: This was a retrospective cohort study of 122 trauma patients who underwent RIVCF placement at an ACS verified Level I Trauma Center between 2006 and 2012. In 2010, an institutional protocol for RIVCF removal was implemented. Patients from 2006 to 2009 were identified as pre-group (PRE) and those from 2010 to 2012 were identified as post-group (POST). Patients who died in the hospital with the RIVCF in place were excluded in calculation of retrieval rates in both groups. However, those with RIVCFs that were technically non-removable, and those patients who were not eligible for RIVCF removal were only excluded in the POST patients as their ineligibility was determined prospectively. A total of 23 patients were excluded. Due to significant differences in some patient characteristics, multivariable analysis using logistic regression was performed to determine the independent effect of implementing an institutional protocol on filter retrieval rates (outcome). During the study period, the median annual number of attending trauma surgeons involved with caring for these patients was 5, ranging from 4 to 9 at any given time.

RESULTS: The overall retrieval rate before implementing a protocol was 55% (40/73) which increased to 96% (47/49) after implementation. POST patients as compared to PRE patients were younger, had a lower mean ISS, less frequently had comorbidities, and had a lower mean red blood cell utilization rate (p<0.004). However, after adjusting for age, injury severity score (ISS), presence of comorbidities, and discharge destination, POST patients remained 6 times more likely to have their RIVCF removed (Odds Ratio = 5.963, Confidence Interval = 1.041-34.145). This lack of precision is likely due to the small number of non-removed RIVCFs in POST patients (n=2).

CONCLUSION: Implementation of an institutional protocol for RIVCF removal in trauma patients achieves near perfect retrieval rates. This is true despite institutional challenges such as revolving staff and resident appointments.

108 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

18. IMPACT OF THE AGE OF BLOOD TRANSFUSED ON 30-DAY MORTALITY AFTER TRAUMA B Marcos MD, M Al-Hamadini MBChB MPH, KJ Kallies MS, WA Bottner MD La Crosse, WI

BACKGROUND: More than 15 million units of blood are transfused annually in the U.S. Guidelines have been established to minimize the occurrence of transfusion- related adverse events; however, transfusion continues to be associated with increased mortality. The age of blood products transfused and its impact on mortality is not well understood. During storage, complex biochemical/biomechanical alterations modify the properties of red blood cells. Few studies have analysed the age of blood transfused, and the reports are highly varied with regards to the definition of “old” blood and the typical duration of blood storage. The objective of this study was to evaluate the effect of the age of blood transfused on mortality.

METHODS: A retrospective review of our institution’s trauma registry and blood bank database for all patients who were admitted from January 1, 2001 through May 31, 2012 as a trauma activation and received >1 unit of packed red blood cells (PRBC) within the first 24 hours was completed. Patients were grouped by the age of the majority of the blood transfused into <10 days, 10-20 days, and >20 days. Statistical analysis included χ2 and Fisher exact tests and multivariate logistic regression.

RESULTS: There were 270 patients included; 7 (3%) received PRBC <10 days old, 120 (44%) received PRBC 10-20 days old, and143 (53%) received PRBC >20 days old. Median ISS was 29, 27, and 26 in those who received PRBC <10 days, 10-20 days, and > 20 days old, respectively (P=0.519). Median length of stay was 12, 9, and 9 days in those who received PRBC <10 days, 10-20 days, and >20 days old, respectively (P=0.853). The mechanism of injury was predominantly blunt (86%, 90%, and 87% in those who received PRBC <10 days, 10-20 days, and >20 days, respectively; P=0.699). The number of units transfused was similar among the 3 groups (P=0.248). Thirty-day mortality rates were 29%, 29% and 34% in those who received PRBC <10 days, 10- 20 days, and >20 days old (P=0.672). When adjusting for other factors, multivariate logistic regression models indicated that ISS was a predictor of mortality in the PRBC 10-20 days (OR 1.237), and PRBC >20 days (OR 1.041) groups. Among patients who received PRBC >20 days old, hospital length of stay (OR 0.947) and transfusion of 3-5 units (vs. ≤2; OR 0.069) were also predictive of mortality.

CONCLUSION: There was no statistically significant difference observed in the mortality rates based on the age of blood transfused, however, the highest mortality rate was observed in those who received PRBC >20 days old. In patients who received older blood transfusions, ISS, length of stay, and number of units transfused was predictive of 30-day mortality. Future randomized controlled trials are needed to clarify any correlation between mortality and the age of PRBC transfused.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 109 QUICK SHOT ABSTRACTS (cont.)

20. PSYCHOLOGICAL FACTORS PREDICTING OUTCOME AFTER TRAUMATIC INJURY: THE ROLE OF RESILIENCE AM Warren PhD, ML Foreman MD, LB Petrey MD, EE Rainey BS, MC Reynolds MS, A Vemulapalli Dallas, TX

BACKGROUND: According to the Centers for Disease Control and Prevention, injuries are the leading cause of death among ages 1-44. Increasingly, negative psychological consequences of trauma (e.g., posttraumatic stress disorder and depression) are recognized as potential influencers of outcome and quality of life. However, less attention has been given to individual adaptive behavioral factors, such as resilience, that may have a buffering effect post injury. Resilience is defined as how an individual not only adapts but flourishes after adversity or trauma. The primary objective of the study was to examine psychological resilience and its relationship with depression among individuals at hospital admission following traumatic injury and one year post injury. Associations between resilience, demographics, and injury-related variables were also examined.

METHODS: This prospective cohort study included patients ≥18 years of age admitted to a Level 1 Trauma Center for ≥ 24 hours. Resilience and depression were measured at baseline and 12 months using the Connor Davidson Resilience Scale 10-Item (CD- RISC 10) and the Patient Health Questionnaire (PHQ-8). Resilience was categorized as high or low (± 1 SD) and positive depressive symptoms were classified with a cut- off score of ≥ 10. Injury-related variables included Glasgow Coma Scale (GCS) and Injury Severity Score (ISS). Signed rank tests, t tests, and Spearman Correlation were performed for analysis.

RESULTS: 110 patients completed baseline and 12 month follow up. Analysis revealed no significant change in overall resilience (p = 0.838). Negative correlations between resilience scores at baseline and depression scores at both baseline (p < 0.0001) and 12 months (p = 0.02) were present. A negative correlation was found between GCS and baseline depression scores (p = 0.022), as well as a negative correlation between GCS and ISS (p = 0.043). Analysis of demographic variables revealed a positive correlation among education level and resilience at both baseline and 12 months (p < 0.0001). A significant association was also found between baseline resilience score and employment (p = 0.0105).

CONCLUSION: Participants with high resilience at time of injury were less likely to be depressed at 12 months, whereas participants with low resilience at baseline were more likely to be depressed at 12 months. Resilience did not change over time, suggesting that resilience may be a predictor of later depression. GCS was negatively associated with depression scores as baseline, indicating that patients with a higher GCS upon arrival were less likely to be depressed at 12 months. Finally, high resilience was associated with employment and higher education at the time of injury. The results of this study suggest that identifying individuals with low resilience at time of injury may help identify those at risk for depression one year after injury, as well as the potential need for psychological support to improve outcome.

110 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

21. DEFENSIVE MEDICINE IS PREVALENT AND COSTLY IN THE TRAUMA PATIENT’S RADIOGRAPHIC WORKUP Sarah Majercik MD MBA, Joseph Bledsoe MD, Karen Connor MD, Brad Morris PA-C, Scott Gardner PA-C, Casey Scully PA-C, Tom White MD, Douglas Dillon MD Salt Lake City, UT

BACKGROUND: Currently, medical liability in the U.S. is inefficient, costly to our health care system, and potentially damaging to both physicians and patients. Most physicians believe that defensive medicine in the form of ordering extra tests is a significant contributor to rising health care costs. Health care policy analysts tend to disagree, saying that tort reform would not significantly help to contain costs. There is a paucity of objective data to support either side’s position. The objective of this study was to determine the prevalence and cost of defensive medicine in the radiographic workup of the trauma patient at a single, Level I Trauma Center.

METHODS: Prospective, observational study of trauma surgeon behavior in the computed tomography (CT) workup of trauma patients who presented to the ED as trauma activations. Actual CT ordered were recorded. Prior to the CT being completed, physicians filled out a survey asking “if there was zero risk of litigation, what CT would you order based solely on your best clinical judgement?” Physicians were also asked to rate (on a 1-10 scale) their clinical suspicion that each CT they ordered would have a clinically significant finding. Results and interventions resulting from all CT done were recorded. Patients transferred from another institution with CT already done were excluded from analysis, as were patients who did not have any CT.

RESULTS: Physicians completed surveys on 296 trauma patients between June and October 2012. 988 total CT were done, mean 3.33 per patient. The most commonly performed CT were c-spine (n=248), brain (n=213), abdomen/pelvis (n=160), and t-spine (n=160). Predicted likelihood of injury ranged from 2.5±0.1 for CT c-spine to 5.0±0.3 for CT face. Rate of clinically significant findings ranged from 8% for CT c-spine to 61% for CT face. In a litigation-free environment, physicians said that they would have ordered 688 total CT, a decrease of 30%. Spine CT would have decreased from 551 to 306, or 44%. Of those CT that would not have been ordered, 48 (7%) had a positive finding. None of these findings led to any change in therapeutic interventions. Total hospital costs for all CT was $151,654.30. Total hospital costs of CT ordered based on fear of litigation was $60,096.92, or 40% of the total CT costs of all patients.

CONCLUSION: Defensive behavior is prevalent in CT ordering on trauma activation patients at our institution. While CT ordered out of fear of litigation do identify some injuries, these findings never led to operative or procedural intervention. Defensive behavior significantly increases total hospital costs of the radiographic workup of the trauma patient.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 111 QUICK SHOT ABSTRACTS (cont.)

22. VENTRAL HERNIA GRADE IS ASSOCIATED WITH SIGNIFICANT IN-HOSPITAL COMPLICATIONS A Landmann MD; JS Bender MD; JS Lees MD; WS Havron MD; T Garwe PhD; RM Albrecht MD Oklahoma City, OK

BACKGROUND: Incisional hernias occur in 2-11% of patients who undergo a laparotomy and approximately 250,000 ventral hernia incisional repairs are performed each year. The ventral hernia working group (VHWG) has devised a hernia grading scale which has been proposed as a tool for risk stratification for surgical site occurrences. The BACKGROUND of this study was to evaluate whether this grading scale can be utilized to identify patients at risk for significant in-hospital postoperative complications.

METHODS: This was a retrospective cohort study of patients undergoing ventral incisional ventral hernia repair with mesh at a single institution between September 2008 and June 2012. Patients were identified from a mesh usage database. The outcome of interest was in-hospital incidence of significant post-operative complications that were associated with increasing morbidity and mortality.,including: bacteremia, pneumonia, sepsis, rhabdomyolysis, respiratory failure, cardiac arrest, pneumothorax, anastomotic leak, myocardial infarction, acute kidney injury, urosepsis, need for tracheostomy, bowel necrosis, septic shock and death. Covariates of interest included patient demographics, urgency of repair, hernia size, wound classification, history of previous hernia repair, radio/chemotherapy status, mesh type, mesh site, concurrent component separation, admission albumin and blood sugar levels during patient’s hospital stay.

RESULTS: 293 patients were included in the study. Of these 12% (35/293) had at least one in-hospital complication. Univariate analysis suggested no significant difference (p >0.05) between those with and without complications in the distribution of age, gender, urgency of repair, admission albumin. However, patients who experienced complications were significantly more likely (p<0.05) to have a higher hernia grade, a larger hernia, previous hernia repair, a component separation, a contaminated or dirty wound, a biologic mesh, an overlay mesh, and hyperglycemia postoperatively. Evaluation of the covariates in a multivariable model resulted in hernia grade and hernia size as the only independent predictors of in-hospital complications. After adjusting for hernia size, the odds of an in-hospital complication increased almost three-fold from one hernia grade to another (OR 2.63, 95%CI:1.3-5.3). Additionally hernia grade was significantly associated with increased risk of intraoperative complications and length of operation.

CONCLUSION: The VHWG hernia grading scale has been proposed as a stratification tool to assist with preoperative planning of complex ventral hernia repairs. Our institutional data shows that increasing hernia grade independently increases the risk for a significant postoperative complication almost three fold; the most common postoperative complications were pneumonia, respiratory failure and sepsis. The VHWG hernia grading system is a significant prognostic tool for morbidity and mortality, beyond surgical site occurrences.

112 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

23. VENOUS THROMOBEMBOLISM (VTE) AFTER VENTRAL HERNIA REPAIR (VHR): A “NEVER EVENT?” M Kim MD, SW Ross MD, K Williams MD, B Oommen MD,C Criss, VA Augenstein, BT Heniford MD, RF Sing DO Charlotte, NC

BACKGROUND: The recent effort by the Centers for Medicare & Medicaid Services to classify postoperative VTE as a “never event” and a “nonreimbursable serious hospital-acquired condition (HAC)” for a growing list of procedures has sparked intense debate about whether these complications truly represent negligence and are in fact preventable through use of current evidence-based guidelines. There is little data published about the incidence and risk factors of VTE in elective VHR hernia patients. Herein we analyze our institutional experience.

METHODS: Our institutional prospective database was queried for patients with VHR and postoperative VTE between January 2006 and July 2013. Patients with VTE were matched to VHR patients without VTE for age, BMI, and gender to create a nested case-control cohort. Patient characteristics, operative and perioperative details, complications and outcomes were evaluated by standard statistical methods with significance at p<0.05.

RESULTS: Of 2962 VHR, 21 had postoperative VTE(0.7%). Patients with VTE were matched with 72 control patients for age(62.4±11.9vs63.6±12.2years), gender(male, 71%vs65%), and BMI(35.7±9.7vs34.0±9.0kg/m2), p>0.05. 14.3% of VTE patients were inpatients at the time of VHR versus 15.7% of controls (range, 5-15 vs 1-11days prior to VHR), p>0.05. Prior history of VTE was present in 23.8% of case and 6.9% of control patients, p<0.05. All patients received standard prophylaxis doses of unfractionated or low molecular-weight heparin(LMWH) within 24 hours of surgery; chemoprophylaxis was begun before incision in 70% of VTE and 53.5% of controls, p>0.05. Sequential compression devices were started preoperatively in 90.5% of VTE and 58.3% of control patients, p<0.05. Laparoscopic VHR was performed in 19% of the VTE group and 5.6% of controls, and duration of surgery was also similar between groups, p>0.05. VTE patients had significantly more central venous catheters than controls(47.6%vs11.1%), p<0.05). Among VTE patients, 14 had deep vein thrombosis and 13 had pulmonary emboli; all started therapeutic anticoagulation upon diagnosis. Bleeding events occurred in 3 patients during systemic heparinization, and one required discontinuation of anticoagulation. One patient developed heparin-induced thrombocytopenia and required anticoagulation with argatroban. IVC filters were placed in 3 patients. VTE had longer length of stay (23.8±26.7vs7.0±5.8days) and four VTE patients died(18.2%vs0%), p<0.05.

CONCLUSION: Despite strict adherence to current guidelines for VTE prophylaxis and preoperative initiation of chemoprophylaxis in a majority of our VHR patients, the occurrence of postoperative VTE could not be entirely eliminated from this population. Significant risk factors included the presence of indwelling central venous catheters and prior history of VTE. Although VTE is a serious postsurgical condition, these data do not support its classification as a “never event.”

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 113 QUICK SHOT ABSTRACTS (cont.)

24. SAFETY OF LAPAROSCOPIC VENTRAL HERNIA REPAIR IN HIGH RISK CARDIAC AND PULMONARY PATIENTS Atul Nanda MD, Matthew Bean DO, Chady Makary MD, Alyssa Chapital MD, Daniel Johnson MD, Kristi Harold MD Phoenix, AZ

BACKGROUND: The hemodynamic changes induced by pneumoperitoneum are well documented including decreased cardiac output and functional residual capacity. Studies have previously demonstrated safety and efficacy of laparoscopic ventral hernia repair in young populations as well as the healthy elderly. The aim of this study was to present our experience in laparoscopic ventral hernia repair in high-risk cardiac and pulmonary patients.

METHODS: A retrospective chart review of all patients undergoing a laparoscopic ventral hernia repair between the years of 2005-2010 was performed. Four criteria were used to classify patients as high risk for laparoscopic surgery: Systolic heart dysfunction (defined as an ejection fraction below 50%), diastolic heart dysfunction (grade 2/4 or worse), moderate to severe pulmonary disease (based on history or pulmonary function test), or an elevated BMI above 35. A total of 148 who underwent primary laparoscopic ventral hernia repair were studied. Outcome included mortality, any cardiac or pulmonary complications, length of hospital stay, surgical site as well as mesh infection, hernia recurrence and readmission to the hospital within 30 days.

RESULTS: The average age of the population was 65 years old with 55% being female. There were only 2 conversions to open procedures in this cohort. 6 patients had diagnosed systolic dysfunction, 5 had diastolic dysfunction, 11 have moderate to severe pulmonary disease and 26 had a BMI greater than 35. The high-risk cohort had a higher readmission rate (p < 0.001) and recurrence rate (p < 0.001) and a trend toward higher mesh/surgical site infection that was not statistically significant. There was no difference however, in LOS (3.7 versus 4.3 days). There were significantly more females in the high risk group (49% versus 24%) p<0.001. No mortalities occurred and there were no post-operative re-intubations noted. There was no difference in post-operative new-onset arrhythmias.

CONCLUSION: Laparoscopic ventral hernia repair can be performed in high risk cardiac and pulmonary patients with low morbidity with adequate perioperative care. While there appears to be a higher rate of recurrence and readmission, there was not a higher incidence of cardiac or pulmonary events. Appropriate preoperative evaluation and optimization is recommended.

114 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

25. TRIPLE NEURECTOMY, MESH REMOVAL AND RECURRENT INGUINAL HERNIA REPAIR FOR INTRACTABLE INGUINODYNIA SW Ross MD, M Kim MD, B Oommen MD, AL Walters MS, KT Dacey MHA, RF Sing DO, BT Heniford MD, VA Augenstein MD Charlotte, NC

BACKGROUND: Chronic inguinodynia is a debilitating and little-discussed complication after inguinal hernia repair (IHR). Select patients benefit from aggressive surgical management: triple neurectomy, excision of old mesh and redo IHR (“Combo” procedure). This study describes our experience with this procedure and analyzes risk factors for failure to obtain post-operative groin pain relief.

METHODS: Our prospectively collected, institutional hernia specific database was queried for all Combo procedures from 2006-2013. The Combo procedure was performed open or laparoscopically opposite of the prior IHR to place the repair in a virgin field. Mesh resection was performed in the re-operative field when possible. Demographics, IHR history, nerve injections, operative characteristics, and postoperative pain were analyzed using standard statistical tests with a p≤0.05 being significant.

RESULTS: There were 55 Combo procedures performed. Mean: patient age was 48.9±12.0 years, BMI was 26.7±4.6, and previous number of hernia repairs 1.6±0.8. The patients were 81.8% male; 50.9% had nerve injections without improvement; 41.8% had prior failed surgery for inguinodynia, and 47.3% had “constant” groin pain. Neurectomy was performed open in all patients. IHR was performed: 67.3% laparoscopically, 30.9% open, and once by a dual repair. The hernias were bilateral in 9.1%, bilateral repairs and the hernia had recurred in 54.6% and were incarcerated in 14.6%. A cord lipoma was found and removed in 5.5%. Mesh was resected laparoscopically in 64.8%, open in 20.3% and 14.8% by dual approach in the presence of prior plug and patch repair. Mean follow-up time was 15.5±23.3 months and there was only one hernia recurrence (2.1%). Post-operative pain relief was complete in 58.3% and partial in 27.1%; 14.6% did not improve. Postoperative nerve injections were required in 25.5% of patients; however, only one patient required additional surgery for inguinodynia. When comparing refractory patients with no post-operative pain relief to those with partial or complete relief, refractory patients were older (46.8±11.4vs52.3±13.2% years), had more previous repairs (1.6±0.8vs1.9±0.9), had previous failed surgery for pain relief (41.5%vs71.4%), had more constant pain pre- operatively (43.9%vs85.7%), and more commonly had hernia recurrence at the time of the operation (51.2%vs71.4%); however, none of these clinically relevant differences were statistically significant (all p>0.05).

CONCLUSION: Chronic inguinodynia after IHR is partially or completely relieved in a high percentage of patients after triple neurectomy, mesh removal and IHR. Recurrent and incarcerated hernias are frequent in this patient population and should be a suspected cause of chronic groin pain. However, chronic pain is still not relieved in 14% of patients and patients should be counseled of these risks before surgery.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 115 QUICK SHOT ABSTRACTS (cont.)

26. POST-OPERATIVE COMPLICATIONS IN ELECTIVE VENTRAL HERNIA REPAIRS INCREASE SEQUENTIALLY ACROSS ALL BMI CATEGORIES MM Mrdutt MD, CL Isbell MD, DC Jupiter PhD, TS Isbell MD, ML Davis MD, JL Regner MD Temple, T X

BACKGROUND: Currently, over 35% of the US population is obese, and the Centers for Disease Control and Prevention projects that this subpopulation will exceed 40% by 2030: approximately 140 million Americans. However, despite this growing high risk patient (pt) population, the post-operative morbidity for common elective surgical procedures such as ventral hernia repairs has yet to be thoroughly explored or described. We sought to define the impact of increasing stages of obesity on early postoperative complications following elective ventral hernia repair.

METHODS: This study is a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2005-2011). Pts age ≥18 undergoing elective repair of ventral or incisional hernia as their primary procedure were included. Exclusion criteria included pregnancy, recent immunosuppression or chemoradiation, disseminated malignancy and co-diagnosis of ascites and esophageal varices. Pts were stratified based on recognized World Health Organization Body Mass Index (BMI) categories of normal weight (NLWT), overweight , and obesity classes I, II, and III, (BMI 20-25, 25-30, 30-35, 35-40, and ≥40). Demographics and 30 day postoperative complications (surgical site infections (SSI), fascial dehiscence, reoperation, pneumonia, failure to extubate within 48 hours, sepsis and septic shock) were evaluated and compared between BMI groups using ANOVA or chi-squared test. Significance was at p<0.05.

RESULTS: 93,533 pts were identified (mean age 53, 53% male) and grouped by BMI as (20-25 14.4%, 25-30 29.7%, 30-35 27.2%, 35-40 15.2%, ≥40 13.6%). ALL complications observed increased with increasing BMI. Superficial SSIs increased from 1.2% in NLWT to 5.3% in BMI ≥40 (OR for BMI groups vs NLWT 1.4, 1.9, 2.9, 4.5, respectively). Deep SSIs increased from 0.4% in NLWT to 2.03% in BMI ≥40 (OR 1.4, 2.3, 3.0, 5.3). Return to OR increased from 1.5% in NLWT to nearly 3.5% in BMI ≥40 (OR 1.1, 1.2, 1.5, 2.4 for all groups). Organ space infections, fascial dehiscence, pneumonia, sepsis and septic shock all had statistically significant increases but < 1.3% change between NLWT and BMI ≥40 groups. The combined risk of infection (superficial, deep and organ space) potentially compromising the mesh repair increased from 1.8% in NLWT to 8.2% in BMI ≥ 40. All tests were significant at p<0.0001.

CONCLUSION: There is a clear relationship between increasing BMI and post- operative complications after elective ventral hernia repair. Superficial SSIs markedly increase with increasing BMI, as do wound complications and return to OR. This data provides evidence to allow for preoperative surgical counseling. In addition, these findings should prompt further investigation in operative technique to minimize infectious complications and achieve equivalent outcomes in obese and normal weight patients.

116 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

27. LAPAROSCOPIC APPENDECTOMY: A CALL FOR STANDARDIZATION OF SURGICAL SUPPLIES? NM Czosnyka MD, AJ Borgert PhD, KJ Kallies MS, SR Hughes MD, SN Kothari MD La Crosse, WI

BACKGROUND: As healthcare cost containment becomes increasingly important, standardization of surgical supply costs for certain procedures, including laparoscopic appendectomy, has been proposed. The objective of this study was to determine whether increasing complexity of the case was directly associated with increasing surgical supply costs for laparoscopic appendectomy.

METHODS: A retrospective review of the medical and billing records of all patients who underwent a laparoscopic appendectomy from January 2002-March 2013 was completed. Pathology and surgical supply costs were analyzed. Patients were stratified by pathology results into 4 groups: 1) no evidence of acute appendicitis, 2) acute/ subacute appendicitis, 3) gangrenous appendicitis, and 4) perforated appendicitis. Statistical analysis included χ2 test and ANOVA.

RESULTS: There were 2154 patients included; 135 (6%) had no evidence of acute appendicitis, 1545 (72%) had acute/subacute appendicitis, 182 (8%) had gangrenous appendicitis, and 292 (14%) had perforated appendicitis. Mean age was 32.7, 32.1, 38.6, and 42.3 years for those without evidence of acute appendicitis, those with acute/subacute, gangrenous, and perforated appendicitis, respectively (P<0.001). There were a higher proportion of men in the gangrenous (58%) and perforated (59%) appendicitis groups vs. those with acute/subacute (55%) appendicitis and those without acute appendicitis (39%) (P<0.001). An American Society of Anesthesiologists’ (ASA) class ≥3 was present in 6%, 13%, 20%, and 7% for those with no acute appendicitis, and those with acute/subacute, gangrenous, and perforated appendicitis, respectively (P<0.001). The mean total cost at the time of surgery was $1277.59±701.96, $1281.63±686.10, $1445.31±756.53, and $1287.92±691.33 for patients with no evidence of acute appendicitis, those with acute/subacute, gangrenous, and perforated appendicitis, respectively (P=0.027). Post-hoc analysis confirmed the greatest cost associated with gangrenous appendicitis vs. the other 3 groups. When stratified by surgeon, there was no difference in supply costs for laparoscopic appendectomies in patients with no acute appendicitis (P=0.263); however differences were observed for acute/subacute (P<0.001), gangrenous (P<0.001), and perforated appendicitis (P<0.001).

CONCLUSION: There was no progressive increase in surgical supply cost with increased complexity. Patients with gangrenous or perforated appendicitis tended to be older, male, and have a higher ASA class. There may be a role for institutional standardization of surgical supplies as a cost control measure; however, surgeon equipment preference and patient factors also play a measurable role in determining the final supply cost.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 117 QUICK SHOT ABSTRACTS (cont.)

28 - Video. MANAGEMENT OF A PERFORATED POSTERIOR DUODENAL ULCER WITH PROXIMAL DUODENECTOMY, ANTRECTOMY, TRUNCAL VAGOTOMY, AND BILLROTH II RECONSTRUCTION IN THE SETTING OF SUSPECTED PERFORATED PARAESOPHAGEAL HERNIA BT Grover DO La Crosse, WI

BACKGROUND: This is a video presentation of a 69-year-old morbidly obese female who presented to the emergency department with a 2-3 day history of pain that started in her chest and migrated to her abdomen. On presentation, she was hypotensive and tachycardic with mental status changes. Her abdominal exam was concerning for peritonitis. Her pre-surgical evaluation included a CT scan of the abdomen and pelvis that revealed a large paraesophageal hernia with significant amount of free air in the hernia sac. The presumptive diagnosis was a strangulated paraesophageal hernia with gastric perforation.

METHODS: The use of laparoscopy and intraoperative endoscopy were used to explore the abdominal cavity and treat the underlying disease process.

RESULTS: She underwent a diagnostic laparoscopy with reduction of the paraesophageal hernia. The stomach was found to be viable without perforation. On intraoperative upper endoscopy she was found to have a perforated posterior duodenal ulcer and underwent proximal duodenectomy with antrectomy, truncal vagotomy, and Billroth II reconstruction performed laparoscopically. The type III hiatal hernia was reduced with dissection of the hernia sac, crural repair, and gastropexy. The patient had an uneventful recovery with transfer to a skilled care facility on postoperative day #7.

CONCLUSION: At times, unexpected findings are encountered intraoperatively. With increasing skill levels in laparoscopic surgery, many disease processes can be treated with minimally invasive techniques while maintaining good patient outcomes.

118 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

29. REPEAT IMAGING MAY NOT BE WARRANTED FOR HIGH-GRADE BLUNT CEREBROVASCULAR INJURIES AE Wagenaar BA, CC Burlew MD, WL Biffl MD, FM Pieracci MD, RT Stovall MD, CC Barnett MD, DD Bensard MD, JL Johnson MD, GJ Jurkovich MD, EE Moore MD Denver, CO

BACKGROUND: Current management algorithms for patients with blunt cerebrovascular injuries (BCVI) include repeat imaging 7-10 days after initial diagnosis. This recommendation, however, has not been systematically evaluated. The BACKGROUND of this study was to evaluate the impact of early repeat imaging on treatment course. We hypothesized that a minority of patients with high-grade injuries (grades III and IV) have complete resolution of their injuries early in their treatment course and hence repeat imaging does not alter their therapy.

METHODS: Our prospective BCVI database was queried from 1/1/97 to 1/1/13. Injuries were graded according to the Denver scale: grade I < 25% luminal stenosis, grade II > 25% luminal narrowing, grade III pseudoaneurysm, and grade IV vessel occlusion. Injuries, type of antithrombotic management, and repeat imaging results were analyzed. BCVI healing was defined as complete resolution of the injury on repeat imaging.

RESULTS: During the 16 year study, 550 patients sustained 788 BCVI; there were 401 carotid artery injuries and 387 vertebral artery injuries. The majority received antithrombotic therapy for their injuries; of the 788 BCVI, 78% were treated (475 with systemic heparin, 111 with aspirin, 25 with aspirin/clopidogrel). For the 286 (71%) CAI with repeat imaging, there was complete healing of the injury in 56% of grade I injuries, 20% of grade II injuries, 4% of grade III injuries and 0% of grade IV injuries. For the 247 (64%) VAI with repeat imaging, there was resolution of the injury in 54% of grade I injuries, 17% of grade II injuries, 14% of grade III injuries, and 3% of grade IV injuries. For BCVIs overall, there was healing documented on repeat imaging in 55% of grade I injuries, 19% of grade II injuries, 12% of grade III injuries, and 2% of grade IV injuries.

CONCLUSION: Injury grade of BCVI is associated with the healing rate of the injury. While approximately half of grade I BCVI resolved, only 6% of all high-grade injuries healed. Repeat imaging may not be warranted in high-grade BCVI; the minority of injuries resolve. Only in patients with complete healing of their BCVI is antithrombotic treatment halted. Therefore, the cost, radiation, and transport risk of early repeat imaging should be weighed against the potential treatment impact for individual patients.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 119 QUICK SHOT ABSTRACTS (cont.)

30. CLINICAL OUTCOMES IN PATIENTS ON PRE-INJURY IBUPROFEN WITH TRAUMATIC BRAIN INJURY: A PROSPECTIVE ANALYSIS B. Zangbar, B. Joseph, V. Pandit, N. Kulvatunyou, A. Tang, T. O’Keeffe, D.J. Green, G. Vercruysse, R.S. Friese, P. Rhee Tucson, A Z

BACKGROUND: The in vitro effects of ibuprofen on platelet function are well established. The aim of our study was to evaluate the clinical outcomes in patients on pre-injury ibuprofen with traumatic brain injury (TBI).

METHODS: We performed a 1 year prospective analysis of all patients on pre-hospital ibuprofen with TBI an intracranial hemorrhage (ICH) on initial head computed tomography (CT). Patients on pre-injury ibuprofen were matched using propensity score matching to patients not on ibuprofen in a 1:2 ratio for age, Glasgow Coma Scale (GCS) Score, head Abbreviated Injury Scale (h-AIS) Score, Injury Severity Score (ISS), and neurologic exam. Outcome measures were: progression on repeat head CT (RHCT) and neurosurgical intervention. Neurosurgical intervention was defined as craniotomy and/or craniectomy

RESULTS: A total of 150 [50: Ibuprofen, 100:Non-Ibuprofen] patients with TBI and ICH on initial head CT were prospectively enrolled. The mean age was 63.5+20.1 years, 69% were male, median ISS was 19 [16-26], and median h-AIS score was 3 [2- 4]. There was no difference in worsening on RHCT (18% vs. 23%, p=0.6), need for neurosurgical intervention (10% vs. 8%, p=0.8), and mortality (20.4% vs. 25%, p=0.6) between patients on ibuprofen therapy and patients not on ibuprofen therapy.

CONCLUSION: In a matched cohort of trauma patients, pre-injury ibuprofen use was not associated with progression of initial intracranial hemorrhage and the need for neurosurgical intervention. Pre-injury use of ibuprofen as an independent variable should not warrant the need for a routine repeat head CT scan.

120 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

31. HELICOPTER VERSUS GROUND TRANSPORTATION OF TRAUMATICALLY INJURED CHILDREN: A NATIONAL TRAUMA DATA BANK STUDY CL Stewart MD, S Tong PhD, SL Moulton MD Aurora, CO

BACKGROUND: Use of helicopter emergency medical services (HEMS) for the transportation of trauma patients is common. While HEMS are usually faster than ground emergency medical services (GEMS), there are additional risks and significantly greater expense for HEMS compared to GEMS. Studies comparing mode of transportation for traumatically injured adults are conflicting, raising questions about the value of HEMS. Currently, no published studies examine this question in pediatric trauma patients. The National Trauma Data Bank (NTDB) is the largest aggregation of US trauma registry data ever assembled. We hypothesized that HEMS would improve outcomes compared to GEMS for pediatric trauma patients, and that this could be determined by analysis of the NTDB.

METHODS: We queried data from the NTDB for years 2007-2010. Patients age 0-18 years old, transported either by HEMS or GEMS to a level I or II trauma center with known outcome were included in the study. Logistic regression was performed to model the probability of death, length of hospital stay, and discharge needs predicted by transportation mode while adjusting for a priori covariates. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were reported. SAS V9.3 was used to perform all statistical analyses.

RESULTS: Our inclusion criteria identified 48,315 traumatically injured children. HEMS were used to transport 8,632 (17.9%) children, with the remainder transported by GEMS. Fatal injuries were sustained by 1,090 (2.6%) children. In a univariate regression model, the odds of fatality were twice as high for children transported by HEMS compared to GEMS (OR 2.13, 95% CI 1.81-2.52, p<0.001). In the final multiple logistic regression model, adjusting for injury severity score (ISS), systolic blood pressure (SBP), respiratory rate (RR), heart rate, Glasgow coma scale (GCS), trauma type, and mechanism of injury, the odds of death were similar for children transported by HEMS and GEMS (OR 0.98, 95% CI 0.75-1.28, p=0.89). Similar results were found when only including inter-hospital transfers of children <15 years old to a level 1 pediatric trauma center (OR 0.99, 95% CI 0.28-3.54, p=0.99). Further sub- group analysis looking at children with ISS >15, SBP <80 mmHg, RR <8, tachycardia adjusted by age, and GCS <8 or <13, showed the odds of fatality were either similar for HEMS and GEMS, or favored GEMS. In addition, transport by GEMS was associated with a shorter hospital stay (OR 0.61, 95% CI 0.56-0.66, p<0.001), and lower likelihood of discharge home with additional services (OR 0.83, 95% CI 0.74-0.94, p=0.004), compared to HEMS.

CONCLUSION: Adjusting for injury severity, it appears that HEMS does not independently improve outcomes for traumatically injured children. Given the additional risk and expense associated with HEMS compared to GEMS, further consideration should be taken prior to requesting HEMS for the transportation of traumatically injured children.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 121 QUICK SHOT ABSTRACTS (cont.)

32. THE EPIDEMIOLOGY OF TRAUMATIC BRAIN INJURY AFTER SMALL WHEEL VEHICLE TRAUMA IN UTAH S Majercik MD MBA, S Day RN, MH Stevens MD, J MacDonald MD Salt Lake City, UT

BACKGROUND: Small-wheeled vehicles (SWV), including skateboards, long boards, non-motorized scooters, ice skates, and roller skates are popular, and their use results in many injuries each year. The objective of this study is to describe the nature and severity of traumatic brain injuries (TBI) that result from the use of SWV in Utah.

METHODS: The Utah State Trauma Registry was queried to identify all patients who were admitted to a Utah hospital after any SWV-related injury from 2001-2010. Patients who sustained TBI were identified using ICD-9 codes. Data are reported as mean±SEM. Fisher’s exact test was used to compare groups. P<0.05 was considered significant.

RESULTS: 907 patients admitted with SWV injury were identified. 392 (43%) were determined to suffer from TBI, 515 (57%) did not have TBI. Mean age of patients with TBI was 19.8±0.5 years. 234 (60%) were age 18 or under, and 119 (30%) age 19- 29. 333 (85%) were male. 341 (87%) of patients sustained TBI while using a skate or long board. Mean GCS in the Emergency Department (ED) was 12.8±0.2. 154 (39%) were admitted to the ICU, and 23 (6%) were taken straight to the OR from the ED for neurosurgical intervention. 33 (8.4%) patients were admitted with concussion; the rest had some degree of intracranial hemorrhage. 229 (78%) of patients had a head AIS of 3 or greater. Of 291 TBI patients on whom helmet use data was available, 8 (2.7%) were wearing a helmet. This was not different from the rate of helmet use (5.2%) in the non-TBI group (p=0.10). Overall mortality in the TBI group was higher than in the non-TBI group (2.3% vs. 0.2%, p=0.003).

CONCLUSION: Young people, especially males, who ride SWV in Utah are at risk for serious TBI, admission to the ICU, neurosurgical intervention, or death. Helmet use in these patients is rare. Although it did not reach statistical significance, there was a trend toward higher rates of helmet use in the non-TBI group (p=0.10). Injury prevention and outreach programs are necessary to educate young riders about the dangers of SWV and encourage helmet use.

122 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

34. OUTCOMES OF TRAUMATIC BRAIN INJURY IN ELDERLY: IT DOES NOT ALWAYS GET WORSE WITH AGE Ibrahim-zada I, MD PhD, Rhee P MD MPH, Hashmi A MD, Friese RS MD MSc Tucson, A Z

BACKGROUND: A recent meta-analysis suggested that trauma-related mortality rate among patients with Traumatic Brain Injury (TBI) does not sustain linear relationship with age in elderly. The aim of this study was to investigate the trend in mortality rates by age in elderly patients with TBI.

METHODS: We performed a retrospective analysis using State Trauma Registry (STR) from 2008 to 2012 for all patients diagnosed with TBI. Data on demographics, ISS, GCS, mechanism of injury, surgical procedures, and disposition were collected. Patients were grouped based on ISS (<16, 16-24, >24) and GCS (3-8, 9-12, 13-15) into mild, moderate, and severe groups. Univariate and multivariate regression analyses were performed to explore the relationship between mortality and age, while controlling for gender, mechanism of injury, GCS, ISS, neurosurgical intervention, laparotomy or thoracotomy, and patient disposition. Age groups were defined as adults (18-64 years, reference group), and elderly (>65 years, grouped at 5 year intervals). All possible interactions were included in the model.

RESULTS: The STR data set contained 30,237 patients with an average age of 46 and 68% male. 16% of patients had moderate ISS whereas 12% had severe injuries; 13% of patients had severe TBI. Among elderly, the highest rates of severe TBI were observed within 65-74 years old group (10.5%). Overall mortality rate was 25.8% in adults and 49.5% in elderly. Univariate analysis identified age groups, mechanism, ISS, neurosurgical intervention, severity of TBI as significant predictors of mortality (p<0.001). Multivariate analysis identified interaction of age groups combined with ISS, GCS, and mechanism as significantly associated with mortality after TBI (p<0.0001). Odds ratios (OR) for mortality among elderly in age groups of 65-70 and 70-74 were 7.7 (95CI 3.1; 18.9) and 7.5 (95CI 3.0; 18.9), respectively. Mortality risk was significantly lower in older age group: OR 3.5 (age 75-79) and 3.1 (age 80-84yrs), p<0.001. Review of mechanism of injury identified that among 65-74 year group MVC comprised higher proportion of cases compared to other elderly groups (34% vs. 23.9%). Contrary, super-elderly (>75 years of age) had falls as predominant mechanism (>60%). In severely injured patients with ISS>24 the same trend held true: OR for age 65-69 and 70-74 years were 1.5 and 1.6, respectively (p<0.001). Age was no longer a significant predictor of mortality in groups >75 years old.

CONCLUSION: Analysis of TBI patients from state trauma registry in the five year period revealed that mortality risk does not follow linear relationship with age and there is an infliction point after the age of 75. Super-elderly patients >75 years of age have 2-fold decrease in mortality risk compared to their younger elderly counterparts (age 65-74). Change in current care guidelines for TBI is warranted to reflect difference in outcomes between elderly and super-elderly patient population.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 123 QUICK SHOT ABSTRACTS (cont.)

35. ADVERSE EFFECTS OF ADMISSION BLOOD ALCOHOL ON LONG TERM COGNITIVE FUNCTION IN PATIENTS WITH TRAUMATIC BRAIN INJURY A Hashmi, Joseph B, Zangbar B, A. Tang, T. O’Keeffe, N. Kulvatunyou, D.J. Green, G. Vercruysse, R.S. Friese, P. Rhee Tucson, A Z

BACKGROUND: Alcohol is known to be protective in patients with traumatic brain injury (TBI) however; its impact on the long term cognitive function is unknown. We hypothesized that admission blood alcohol negatively affects patient’s long-term cognitive function.

METHODS: We performed a 2-year retrospective study of all trauma patients with isolated TBI at our Level I trauma center. Patients with moderate to severe TBI (head abbreviated injury scale (AIS) > 3), measured admission blood alcohol and measured cognitive function on hospital discharge and at 30 days post discharge were included. Cognitive function was assessed using Functional Independence Measures (FIM) scores. Improvement in cognitive function was defined as the difference between 30 day post discharge and hospital discharge cognitive FIM. Multivariate linear regression was performed.

RESULTS: A total of 64 patients were included. 69% were male, mean age was 51.8+ 23, median head AIS was 3[3-5], median Glasgow Coma Scale Score was 11[8-13]. Mean cognitive FIM on hospital discharge was 17+6 and mean cognitive improvement was 8.6+4.7. 60% (n=39) were under influence of alcohol on admission and the mean admission blood alcohol level 132 + 102. After adjusting for gender, injury severity, Glasgow coma scale score on presentation, and vitals on presentation, admission blood alcohol (beta: -0.4, 95% CI: -6.7 to -0.8, p=0.01) and age (beta: -0.5, 95% CI: -0.2 to -0.04, p=0.04) were negative predictors of improvement in cognitive function.

CONCLUSION: Admission blood alcohol adversely affects long term cognitive function in patients with moderate and severe traumatic brain injury. Older alcoholic patients are likely to have least cognitive improvement.

124 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

36. FACTORS CONTRIBUTING TO MAJOR LOWER EXTREMITY AMPUTATION: THE 5-YEAR EXPERIENCE OF AN INTEGRATED LIMB SALVAGE SERVICE TM Rankin MD, C Harrison BS, J Wisk BS, NA Giovinco DPM, DG Armstrong DPM MD PhD, JL Mills MD Tucson, A Z

BACKGROUND: Controversy persists regarding the major causes of lower extremity amputation, with several publications from the vascular surgical literature suggesting failed revascularization is the most common factor. Despite improved management of diabetic foot wounds and peripheral artery disease, major lower extremity amputations continue to be common, costly and morbid. Identifying the underlying causes of amputation and the risk factors associated with poor outcomes could prevent amputations and improve patient care.

METHODS: All major non-traumatic lower limb amputations performed at a regional university hospital were analyzed from 1/2008 to 6/2013. 3585 limb procedures were performed by a combined vascular and podiatric surgical, limb-salvage service. Major lower limb amputations were defined as ankle guillotines, below-the knee amputation (BKA) and above the knee amputation (AKA). Patient charts were reviewed retrospectively to identify causes and outcomes of these amputations.

RESULTS: A total of 131 (3.6%) consecutive major lower extremity amputations were performed on 111 limbs in 100 patients; 82% of patients had diabetes (73% Type 2, 9% type 1 DM). Mean age was 61 years and 67% were men. Amputations were elective in 111 (85%) patients and 20 (15%) guillotines were performed urgently for sepsis. Amputation levels were distributed as follows: 17 (15%) ankle guillotines followed by formal BKA; 3 (2.7%) knee guillotines followed by formal AKA; 55 (49.5%) primary BKA; 35 (31. 5%) primary AKAs; and 1 (0.9%) hip disarticulation. The BKA:AKA ratio was 1.84 and Major:Minor (toe/forefoot) amputation ratio was 0.36. Amputations were attributed to one or more of the following causes: infection (68.5%); gangrene (24.6%); chronic wound (26.2%); ischemia and failed revascularization (24.7%); osteomyelitis (8.5%); and contracture (2.3%). Thirty-day and overall mortality was only 4% and 18% during a mean follow-up 7 months. Increased mortality was associated with age (>56 yrs, OR 2.7), leukocytosis (OR 3), HTN (OR 1.3), AKA level (OR 2.6), PAD (OR 14.2) and failed revascularization (OR 4.6). Healing time was longer with guillotine (67 vs 43 days, p=.019), increased pack years of tobacco (72 vs 39 days, p=.01), and ABI > 1.2 (80 vs 40 days, p=.046). Only 13 (10%) amputations required proximal revision.

CONCLUSION: Our team-oriented approach has decreased the rate of major amputation and the mortality of major amputation. In sharp contrast to much of the available current literature, the most common underlying reason for amputation was infection. All intentionally staged guillotine amputations healed; reinforcing the validity of this concept. Additionally, trends among guillotine amputees were younger age, longer hospital stays, and increased costs. If we are to lower amputation rates in diabetics, the focus must be on upstream ulcer prevention, rapid response protocols to heal early stage ulcers, and aggressive management of supervening infection.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 125 QUICK SHOT ABSTRACTS (cont.)

37. TRAUMATIC INJURY TO AORTIC ARCH GREAT VESSELS: OUR EXPERIENCE WITH OPEN VS ENDOVASCULAR REPAIR PI Tsai MD, R Gilani MD, MJ Wall Jr MD, NM Lakkis MD, S Markan MD, KL Mattox MD Houston, TX

BACKGROUND: Penetrating and blunt injuries to the aortic arch great vessels (AAGV) present an extremely difficult entity to manage. Secondary to the anatomy of the thoracic inlet or outlet, adequate exposure and vascular control can be very difficult to establish with traditional open surgery. As a result, endovascular techniques are being increasingly utilized and updated to alleviate the challenges with repair through open surgery. We describe our single institutional experience with such injuries and the development of an approach combining open and endovascular surgery in the management of these injuries.

METHODS: Retrospective review of a prospectively collected trauma database identified 27 patients with AAGV injuries during a period when both endovascular and open repairs were performed. Injury severity score (ISS) was performed for each patient along with the mechanism of injury and survival. Relevant data was extracted for location of injury, associated injuries, means of diagnosis, and method of treatment.

RESULTS: 27 patients were reviewed, with 18 survivors and 9 deaths (5 of which occurred in Emergency Room). ISS for survivors(n=18) was 18.4 vs non survivors(n=9) 28.2(p=0.03). ISS for blunt(n=8) was 34.6 vs penetrating(n=19) 16.3 (p=0.0001); 4/8 (50%) blunt vascular injuries resulted in death, vs 5/19 (26.3%) penetrating injuries resulting in death. Of the 22 patients who survived ER and were amendable for further workup and treatment, 7 underwent open repair, 13 underwent endovascular repair, and 2 for observation only. Deaths resulting from open repair were 2/7 (28.6%); endovascular repair was 2/13 (15.4%); and observation only 0/2(0%). Subset analysis of endovascular repairs showed 0/8 (0%) mortality with an updated technique. Four patients had innominate injuries all from blunt mechanism and received open repairs with 1/4(25%) deaths. Twenty-three patients had subclavian/axillary artery injuries, of which 5 died in ER. In this subgroup, deaths from blunt injury was 3/4(75%), vs penetrating injury deaths of 5/19(26.3%).

CONCLUSION: AAGV injuries are devastating. They command a challenging treatment plan that may involve an open or endovascular repair. Blunt injuries tend to have higher ISS and demonstrated higher mortality, especially if they involved the subclavian/axillary arteries. Injuries to the subclavian/axillary arteries treated with our modified endovascular techniques resulted in significant reduction in mortality, even in the setting of hypotension and complete transection. Innominate artery injuries, still viewed as a direct aortic arch injury, tend to be repaired in open fashion requiring an open sternotomy. Proximal carotid injuries were not identified in our series but can be treated open or endovascular technique. We believe with the advent of improving endovascular technology, that increasing numbers of AAGV injuries will be addressed in an endovascular fashion, thereby improving on its already good survival percentage.

126 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

38. OPTIMAL TIMING OF CORONARY ARTERY BYPASS GRAFT SURGERY POST ACUTE MYOCARDIAL INFARCTION BL Clark, R Paone MD Lubbock, TX

BACKGROUND: The optimal timing of coronary artery bypass grafting (CABG) following an acute myocardial infarction (AMI) is a topic of debate. Studies have shown that a delay of greater than forty-eight hours from the time of infarction to the time of operation is beneficial (Baldwin 1995, Lichtenberg 2012), while other studies have failed to show this benefit (Gereaci 2002). The present study is designed to evaluate patients undergoing CABG both “early” (≤5days) and “late” (>5days) after AMI.

METHODS: The medical records at one institution with one cardiac surgeon were evaluated between 2008 and 2012. One hundred and twenty patients underwent CABG after AMI during this time period. We evaluated 45 patients who had CABG early and 75 who had CABG late. Death, stroke, cardiac index, need for intra-aortic balloon pump, development of renal failure, post-op ventilator days, and length of stay were all recorded. Significance was determined using the Fisher’s exact test or the unpaired t test where appropriate.

RESULTS: Patients undergoing CABG early had an increased need for intra-aortic balloon pump intra-operatively. There were no other correlations that we could discern between early and late CABG. P values for death, cardiac index, development of renal failure, post-op ventilator days, and length of stay were respectively: .1477, .7833, .8073, .4032, .9093. There were 4 deaths, 3 in the early CABG group and 1 in the late CABG group. A mortality rate of 3.33% was observed in the study as a whole. This did not provide statistical significance. No strokes were observed.

CONCLUSION: Our data demonstrates no statistical difference in the above noted morbidity factors and mortality between CABG early or late after AMI.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 127 QUICK SHOT ABSTRACTS (cont.)

39. USE OF A WOUND VAC IN INFECTED DEVICE POCKET SHORTENS INTERVAL TIME TO REIMPLANTATION OF CARDIAC DEVICES RW Feldtman MD, D Levine MD, A Guttigolli MD Dallas, TX

BACKGROUND: While implanted cardiac electronic devices have produced improved quality of life in millions, the rare instance of lead dysfunction or infection of the device has prompted removal and replacement of the devices in some. Those who are dependent on the device need a permanent reimplant as soon as it is safe to prevent re-infection of the new device. Delays can demand alternative pacing options or “life- vest” type ICD devices. Any method to decrease the time between extraction of the infected device and reimplant will add to the patients quality of life.

METHODS: Over a three year period, we performed 49 device and lead extractions in 50 patients. Twenty two patients had device infection – six with chronic infection and 16 with acute infection. Ten presented with sepsis. Nineteen required laser sheath extraction. Small vegetations apparent on echo were ignored, but one patient with a heavy burden of vegetation in the right atrium had these Candida laden clots removed with the Angiovac percutaneous system at the same time as laser lead extraction. Thirty eight males and 12 females were included with an average age of 68 yrs. Reimplant was done in infected patients when the wound pocket had healed and systemic infection had cleared. A wound vac was used in 18 patients and simple packing used in four. The wound vac was placed 24-72 hrs after removal and continued as an outpatient.

RESULTS: No operative complications occurred. Three deaths occurred, all in acutely septic patients and was attributed to sepsis in all. In patients treated with a wound vac, re-implant was accomplished in 32 days while open wound packing required 152 days before reimplant (not statistically significant due to sample size). No reinfections were encountered. Temporary pacing was required in two pacemaker dependent patients via the right IJ vein and life-vest was used in five of the overall group. Complete removal of all leads was accomplished in the infected group.

CONCLUSION: Cardiac lead extraction can be done safely even in septic patients and should be accomplished soon after diagnosis. Use of the wound vac shortens the interval time and should be considered in order to hasten the permanent reimplant of the next device.

128 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

40. SURGERY IN PATIENTS WITH NECROTIZING SOFT TISSUE INFECTIONS: HOW EARLY IS EARLY ENOUGH? Rifat Latifi MD, Judith Smith, George J. Hadeed MPH, Ayman El-Menyar, Terence O’Keeffe MD, Narong Kulvatunyou MD, Julie L. Wynne MD, Bellal Joseph MD, Randall S. Friese MD, Thomas L. Wachtel MD, Peter M. Rhee MD Tucson, A Z

BACKGROUND: Early diagnosis and emergent surgical debridement of necrotizing soft tissue infections (NSTIs) remains the cornerstone of care. Our objectives were to study the effect of early surgery on patients’ outcomes and, in particular, on hospital length of stay (LOS) and intensive care unit (ICU) LOS.

METHODS: Over a 6-year period, we analyzed the records of patients with NSTIs. We divided patients into 2 groups based on the time to surgery (i.e., the interval from being diagnosed to undergoing the operation): Group I, early (< 6 hours), and Group II, late (≥ 6 hours). For those 2 groups, we compared baseline demographic characteristics, symptoms, and outcomes. For our statistical analysis, we used the Student t test and Pearson chi-square (χ2) test. To evaluate the clinical predictors of early diagnosis of NSTIs, we performed multivariate logistic regression analysis. Significance was set at P<0.05.

RESULTS: A total of 87 patients (62% male, 38% female) with NSTIs were identified. The mean age was 46 ± 17 years. In almost 50% of the patients, the anatomic location of the NSTIs was the lower extremity, followed by the upper extremity, Fournier gangrene, buttocks, and trunk. We found no statistically significant difference in morbidity and mortality between the 2 groups. However, Group I had a significantly shorter time to surgery (2.95 ± 1.1 vs. 22.3 ± 17.8 hours), a significantly shorter median hospital LOS (13.5[4-33] Vs 18[1-82] days), and a significantly shorter median ICU LOS (4 vs. 10 days) than Group II. The overall mortality rate in our study group of 87 patients (62% male, 38% female) with NSTIs was 12.5%, but Group I had a mortality of 7.5%, but this did not reach statistical significance

CONCLUSION: Early surgery (within the first 6 hours after being diagnosed) may improve outcomes in patients with severe NSTIs and should be the overriding goal of treatment.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 129 QUICK SHOT ABSTRACTS (cont.)

41. SHOULD PARA-PNEUMONIC EFFUSIONS IN CRITICALLY ILL SURGICAL PATIENTS WITH VENTILATOR-ASSOCIATED PNEUMONIA BE SAMPLED ROUTINELY? MS Rodil, J Haenel, CC Burlew MD, W Biffl MD, DD Bensard MD, RT Stovall MD, GJ Jurkovich MD, FM Pieracci MD Denver, CO

BACKGROUND: Surgical intensive care unit (SICU) patients with ventilator associated pneumonia (VAP) frequently develop pleural effusions. The aim of this study was to identify the incidence, predictors, and outcomes of an infected para-pneumonic effusion (empyema) in this patient population in order to devise a practical algorithm for when to sample and drain these collections. We hypothesized that empyema was an infrequent complication of VAP that rarely required operative intervention.

METHODS: Data from SICU patients with VAP who underwent sampling of a para- pneumonic effusion within 30 days of the diagnosis of VAP were abstracted (October 2009-December 2012). VAP was defined as clinical suspicion of pneumonia plus growth of >105 cfu/mL of at least one pathogen on lower respiratory tract culture (>104 cfu/mL if drawn while on antimicrobial therapy). Empyema was defined as any pleural effusion with positive microbiology. Statistical analysis was performed with SAS 9.1; Data are expressed as median (range); No. (%). Wilcoxin rank & Fischer’s exact test. Alpha<0.05.

RESULTS: A total of 1,013 lower respiratory tract cultures were analyzed; 438 (43.2%) were diagnosed as VAP. Pleural fluid was sent in 63 of the 438 cases of VAP (14.4%). Time from lower respiratory tract culture to pleural culture was 2.3 days (range 0-30). There were 7 cases of empyema (11.1%); the likelihood of empyema was the same for patients with positive lower respiratory cultures (VAP) vs. those with negative lower respiratory cultures (11.1% vs. 14.9%, respectively, p=0.53). Age (p=0.97), gender (p=0.43), Clinical Pulmonary Infection Score (p=0.87), degree of hypoxia (p=0.78), days intubated (p=0.40), time from lower respiratory tract culture to pleural culture (p=0.62), and culture on antibiotics (p=0.30) did not predict a positive pleural culture. Pleural pathogens were identical microbiologically to lower respiratory tract pathogens in all cases. No cases of empyema required operative drainage. Length of stay (p=0.32) and mortality (p=0.40) were equivalent in the empyema vs. no empyema group.

CONCLUSION: Empyema is an infrequent complication of a para-pneumonic effusion in critically ill surgical patients with VAP. Microbiology is identical to that of the lower respiratory tract, infections responded to non-operative drainage, and outcomes were not worse than patients without empyema. These data do not support a strategy of routine sampling of para-pneumonic effusions in SICU patients with VAP.

130 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

42. IMPACT OF AGE IN ARTERIOVENOUS GRAFT PATENCY: A LARGE COMMUNITY TEACHING HOSPITAL EXPERIENCE S Casillas MD, C Balabanoff MD, J Jacob MD, J Tellagorry MD, R Jubelirer MD, T Sullivan MD Abington, PA

BACKGROUND: The use of prosthetic materials in vascular access for patients requiring hemodialysis (HD) is widespread. Arteriovenous grafts (AVG) are used in patients with failed AVFs, unfavorable vessels or exhaustion of superficial veins. With an increasingly prevalent elderly population in the United States the rate of vascular access for dialysis is increasing and more individuals are presenting features that favor the use of AVG. We theorize that the patency rates in elderly patients are decreased compared to younger patients.

METHODS: We retrospectively reviewed 49 consecutive cases treated at a single institution by 5 vascular surgeons from June 2011 to July 2013. We divided our population into two groups based on age and followed them at 3 months and 1 year. Patients on group A were 70 years old or greater (36) and group B were younger than 70 (13). We calculated the rate of AVG failure on each group described as inpatient readmission, insertion of new temporary HD catheters, the need for fistulogram, and the rate of intervention for graft recannalization via endovascular or open approach. Statistical analysis was done using SAS JMP 10.0. Odds Ratio was calculated and p value was obtained by using Fishers exact test.

RESULTS: At three month follow up the rate of overall patency was 57% in both groups combined and 45% at 1 year follow up. The rate of graft patency in patients of group A was 60% at 3 months and 50% at 1 year, group B patency rates were 50% at 3 months and 36% at 1 year. The odds ratio was .65 at three months and .57 at 1 year. At 3 months group A patients were 35% less likely to develop graft failure compared to younger patients on group B. The odds of an AVG being patent at one year were 1.75 times more probable in group A (CI 0.43-7.58) with a p value of 0.325 and at 3 months 1.58 (CI 0.39-6.9) with a p value of 0.345.

CONCLUSION: This study indicates no significant difference in patency in the two groups. Their outcomes are comparable to those of patients younger than 70 years with AVG. We conclude that the impact of age in both groups has minimal effect in the rate of graft patency and therefore supports the use of AVG in elderly patients not suitable for AVF.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 131 QUICK SHOT ABSTRACTS (cont.)

43. GOOD NEWS FOR DUTY HOURS: INPATIENT DELAY IN APPENDECTOMY IS OKAY IN ACUTE APPENDICITIS DL Wyrick, SD Smith, MS Dassinger Little Rock, AR

BACKGROUND: Recent literature has suggested that delaying operative intervention in patients with appendicitis increases the rate of perforation. However, these study populations included both adults and children. The BACKGROUND of this study was to determine, in a purely pediatric population, if the time from admission to operation in patients who are admitted with clinically non-perforated appendicitis increases the perforation rate.

METHODS: We retrospectively reviewed records of all patients who were admitted to the pediatric surgical service and underwent appendectomy for acute appendicitis at Arkansas Children’s Hospital from 2009-2012. Age, sex, body mass index, admission white blood cell count, time from admission to operation, surgical approach, pathology reports and comorbidities were extracted for analysis. Patients who underwent interval appendectomy, admitted to a different service, were presumed perforated on admission or had negative pathology were excluded from the study.

RESULTS: 714 were admitted to the surgical service and underwent appendectomy during the study period. Of these 714 patients, 224 were excluded: 2 interval appendectomies, 5 off-service admissions, 174 presumed perforations, and 43 negative pathologies. Of the 490 patients included in this analysis, 291 (62%) were male, 470 (96%) underwent laparoscopic appendectomy, and 110 (22%) were perforated at operation. In a logistic regression associating independent predictors of perforation, only white blood cell (WBC) count was associated with perforation (P<0.001); a WBC of 19 (75th percentile) was associated with an increase of 54% in odds of perforation compared to a WBC of 12 (25th percentile) [OR=1.54, 95% CI (1.18, 2.01)]. Type of surgery performed, age at surgery, gender, BMI, and presence of other comorbidities were not found to be statistically associated with perforation. Furthermore, time from admission to OR was not associated with perforation (P=0.980).

CONCLUSION: Time from admission to operation was not associated with increased perforation rates in the pediatric population.

132 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

44. THE IMPACT OF DOCUMENTATION TRAINING ON PERFORMANCE REPORTING TJ Loftus MD, H Najafian DO, SR Pandey MD, RS Ramanujam MD Phoenix, AZ

BACKGROUND: With the advent of public reporting of clinical performance for physicians, the need for accurate information is essential. The administrative databases of hospitals are the backbone of these types of performance reports. Performance is reflected in the data, which is derived from coding, and coding is a reflection of documentation in the patient’s chart. This study tested the hypothesis that a short tutorial on 5 key documentation tips, based on the most frequently cited complications for a group of colo-rectal surgeons, could significantly improve the groups reported clinical performance.

METHODS: Data was collected on a total of 626 consecutive in-patients during the time period of one year prior to and 10 months after introduction of a short tutorial focusing on 5 key documentation tips to a group of colo-rectal surgeons. Patients included were adults admitted to one hospital to this same group. The rates, as determined by an external reporting agency, were compared for: anemia, digestive system complications, hypokalemia, morbidity, mortality, overall complications, paralytic ileus, and readmissions.

RESULTS: Following introduction of a short tutorial on documentation there was a significant improvement (p < 0.05) in digestive system complications, hypokalemia, ileus and overall complications at 5 months. The improvements were significant (p < 0.05) at 10 months for digestive system complications, ileus, morbidity and overall complications.

CONCLUSION: A short tutorial focusing on 5 key documentation tips improves the reported clinical performance for colo-rectal surgeons.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 133 QUICK SHOT ABSTRACTS (cont.)

45. COMPARISONS OF MEDICAL STUDENT KNOWLEDGE REGARDING LIFE-THREATENING CT IMAGES BEFORE AND AFTER CLINICAL EXPERIENCE B Nguyen MS, B Werth MS, J Ward BA, P Twumasi-Ankrah PhD, J Nold MD, JM Haan MD Wichita, KS

BACKGROUND: No standard currently exists for traumatic radiographic education or evidence indicating level of improvement during clinical rotations for medical students. Exposure to radiologic images during clinical rotations may improve students’ skill level. This study aimed to quantify the knowledge of beginning third year compared with fourth year students.

METHODS: Following informed consent a cross-sectional study was performed comparing students beginning third year medical school (MS3) with those who had just completed their third year (MS4). Eleven deidentified computed tomography (CT) images reflecting life-threatening injuries were provided by an ACS level I trauma center. Images included head, chest, abdomen and pelvic injuries. Images were shown in a timed fashion with 22 open-ended questions regarding 1) injury diagnosis or 2) treatment. Scores were blindly assessed by two trauma surgeons and tabulated for incorrect, partially correct, and correct responses.

RESULTS: Survey results were collected from 65 of 65MS3 during student orientation. Of 60 MS4, 9 volunteered to participate. Proportions of incorrect responses to each question were calculated. Ninety-five percent confidence intervals, with continuity correction, were used to interpret differences. Despite sample size limitations, MS4s had consistently lower proportions of incorrect responses compared to MS3s, with the exception of two questions: treatment of grade III liver laceration (95.4% for MS3 and 100% MS4), and diagnosis of grade IV renal injury (96.9% vs. 100%). The CI indicated neither were statistically significant. Five of the 22 questions did reflect a statistically significant reduction in incorrect responses between MS3s and MS4s. These included: diagnosis of an intraparenchymal (IPH) hemorrhage (93.5% incorrect by MS3 versus 66.7% incorrect by MS4s, CI [1.0, 63.2]); treatment of subdural (SHD) hemorrhage (86.2% MS3 versus 44.4% MS4, CI [6.9, 71.6]); treatment of small bowel thickening (98.5% MS3 versus 66.7% MS4, CI [.3, 67.6]); diagnosis of grade III liver injury (100% MS3 versus 66.7% MS4, 95% CI [8.1, 69.1]) treatment of colon infarction (90.8% versus 55.6%, 95% CI [4.3, 68.6]). The image with the least incorrect by both MS3 and MS4 was the epidural hematoma, 33.8% and 18.5% incorrect by MS3 for diagnosis and treatment, respectively, and 11.1 and 0% for MS4. Outside of this, the range for MS3 incorrect was75.4% to 100%; MS4, 44.4% to 100%.

CONCLUSION: Although the MS4 sample size warrants caution in interpretation, consistent reductions in incorrect evaluations were seen for 20 out of 22 questions and 5 out of 22 attained statistical significance suggest improvements did occur. Statistically significant improvements included diagnosis of IPH, SDH and grade III liver injury, and treatment of small bowel thickening and colon infarction. Despite improvements these results indicate formal didactic lectures are needed regarding CT interpretation in traumatic injury.

134 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

46. ACCEPTING THE CHALLENGE: GENERAL SURGEONS PARTNERING WITH HOSPITAL ADMINISTRATORS TO MANAGE QUALITY CARE INITIATIVES. AJ Mangram MD, FN Rodriguez MD, JK Dzandu PhD Phoenix, AZ

BACKGROUND: In the current era of quality-based payment systems where payments are tied to quality outcomes, physicians and hospital administrators are challenged to create new ways to improve outcomes and reduce costs. Historically, payment was not tied to quality and physician payments were on a “fee for service” basis. Now, payments are tied to performance and quality, using the hospital value- based purchasing (VBP) program. We believe to improve quality care surgical leadership must be an integral component of the health care delivery process.

METHODS: A group of private practice surgeons developed a proposal to address what they coined as the “7 Deadly Sins” (Length of stay, surgical site infection, ventilator-associated pneumonia, re-admission, cost, patient satisfaction, morbidity/ mortality rates). The goal was to improve outcomes in these areas and examine the impact on VBP. Our surgical group designed a plan to address four key unmet needs critical to general surgery care with special focus on hospital VBP program. These are general surgery care processes, patient experience, surgical outcomes, and efficiency. To achieve these goals 10 objectives were examined: 1. Outpatient process efficiency, 2. Intra-operative processes, 3. Surgery supply chain management, 4. SCIP compliance, 5. Surgical site infections, 6. Length of stay, 7. Re-admission, 8. Patient satisfaction, 9. Ventilator associated pneumonia, and 10. Enhanced care in Geriatric “G-60” trauma patients. Performance standards were established to benchmark quality care in each area.

RESULTS: To implement our program, we began dialogue with key administrators (i.e., CEO’s, hospital president, etc) to obtain buy-in. In order to obtain buy-in from the individual surgeons we created an in-service to educate them on changes in health care (ACA, CMS, Bundled payments and ACOs, etc) and also emphasize that surgeons need to master the entire range of organizational and operational processes that improve patient outcomes. We entered into a contractual agreement with the hospital system. Individual projects were assigned to surgeon teams. Each team created simple action plans, to achieve desired and measurable outcomes. Evidence based practices, clinical pathways, decision rules, evaluation and follow up procedures were used. The hospital administrators provided assistance with implementing the action plans. All 10 action plans are currently being implemented.

CONCLUSION: This surgeon lead quality initiative provides surgeons with an opportunity to be leaders in response to health care and payment reform. Surgeons and hospital administrators can successfully partner in the era of quality-based payment. Surgeons must involve themselves early in this process or we will not have a voice.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 135 QUICK SHOT ABSTRACTS (cont.)

47. USE OF TEG/ROTEM ANALYSIS IN POINT OF CARE EVALUATION OF TBI PATENTS ON ANTI-PLATELET THERAPY: EFFECTIVENESS IN RESOURCE UTILIZATION BY REDUCTION IN PLATELET TRANSFUSION AS Sherwal MD, RD Dumire MD, A Rodriguez MD Johnstown, PA

BACKGROUND: Platelet transfusions are utilized for the reversal of anti-platelet therapy in patients with traumatic brain injury (TBI) and an intracranial hemorrhage. However, assessment of platelet inhibition and reversal by platelet transfusion has not been adequately distinguished. Prior to the availability of ROTEM, platelet function tests were used to guide platelet transfusion in patients on anti-platelet therapy or Platelets were prophalactically administered based on or clinical judgment. The use of thromboelastogram (TEG) in assessing coagulopathy in Trauma and its use in early goal-directed therapy has become well documented in the literature, however, the impact of TEG on resource utilization and reduction in need for platelet transfusion is not well documented. The aim of our study is to identify the impact of TEG/ROTEM as a means for better resource utilization and for reduction in the need for blood product (Platelet) transfusion in TBI patients with ICH on anti-platelet therapy.

METHODS: A retrospective analysis of greater than 1000 Blunt trauma patients at Conemaugh Memorial a level 1 trauma center between July 2012 through June 2013 (When ROTEM analysis was initiated). To July 2011 through June 2012 when the use if ROTEM had not been implemented as a Trauma protocol in the institution. Showed that prior to the availability of ROTEM when platelet function tests or prophalactically administered based on or clinical judgment was used there was significant number of additional platelet transfusions performed.

RESULTS: When patients in these two groups were matched for age as well as type of injury and injury severity, there was a significant reduction in platelet transfusion in the group of patients receiving goal directed hemostatic resuscitation based on point of care ROTEM testing. There was also a decrease in the total number of blood products administered ranging from 17 to 45% decrease based on the type of product. During the year after routine ROTEM was initiated in this patient population, the total number of platelets transfuse had decreased to only 67 as compared to greater than 100 and the years prior to routine point of care visoelastic(ROTEM) testing.

CONCLUSION: The early data analysis of this ongoing study demonstrates a significant reduction in platelets and/or blood product administration in a similarly matched patients through the implementation of routine point of care/goal directed hemostatic resuscitation at a community-based level one trauma center for patients with severe traumatic brain injury and documented intra-cranial hemorrhage. This is an ongoing study and has been expanded to include all trauma admissions at a community-based level one trauma center who are considered for or actually received blood products administration during their initial resuscitation.

136 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

48. FACTOR IX COMPLEX IN TRAUMA RESULTS IN RAPID REVERSAL OF COAGULOPATHY THAT PERSISTS AT 24 HOURS N Melo MD MS, T Imai MD, J Eng, J Mirocha MS, M Bloom MD, E Ley MD, R Chung MD, D Margulies MD Los Angeles, CA

BACKGROUND: Factor IX complex (FIX Complex) is useful in trauma for the rapid reversal of warfarin-induced coagulopathy and coagulopathy from severe injury. We reviewed our experience with FIX complex to determine the impact of immediate and 24-hour coagulopathy.

METHODS: A retrospective chart review was conducted between July 2006 and September 2012 on patients admitted to a Level 1 trauma center and received FIX complex for coagulopathy from warfarin or injury. Patient demographics, ISS scores, ICU and hospital LOS, death at 30 days, and PT and INR values initially, immediately after administration, and at 24 hours were reviewed. In addition, total blood products received and evidence of pro-thrombotic events were also included.

RESULTS: Thirty-three patients met criteria. The mean age was 73.1 ± 18.8, 71.4% male and 28.6% female, with mean ISS score of 15.1 ± 11.7. The majority of patients suffered ground-level falls (71.4%) followed by auto vs. pedestrian accidents (11.4%), motor vehicle collisions ( 8.6%) and stabbings (2.9¬%). The mean PT on admission was 24.9 ± 10.5 and the mean INR was 3.0 ± 1.5. The mean PT and INR after administration of Factor IX complex was 17.5 ± 4.1 and 1.7 ± 0.5 respectively. The ΔPT was 7.5 (p < 0.01) and the ΔINR was 1.3 (p < 0.01). Mean time from admission to coagulopathy correction was 184.8 minutes. At 24 hours, the PT and INR were 16.2 ± 1.8 and 1.6 ± 0.3. Nine patients (27.3%) died, 3 of which required massive transfusion (>10U pRBC). Three of 33 patients (9 %) had pro-thrombotic events. Median number of PRBC and FFP were 1 U each, respectively.

CONCLUSION: FIX complex is useful in trauma patients who have coagulopathy from warfarin or injury. It rapidly corrects coagulopathy and avoids high volume administration of FFP. We demonstrate an immediate reduction in PT and INR with FIX complex that persists for 24 hours. Monitoring for pro-thrombotic events is necessary. Further studies are needed to confirm whether its use will confer a survival advantage.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 137 QUICK SHOT ABSTRACTS (cont.)

49. DISPARITY IN CARE FOR TRAUMATIC BRAIN INJURY IN ARIZONA BY GEOGRAPHICAL LOCATION: WARM DESERT OR SNOWY PEAKS? LD Butvidas MD, I Ibrahim-Zada MD, P Rhee MD, T O’keeffe MD, RS Friese MD Tucson, A Z

BACKGROUND: The unique geographical location of this state impacts the distribution and pattern of accidents seen in Trauma Centers statewide. There is little evidence available to objectively assess public health needs in our state in Traumatic Brain Injury (TBI). We hypothesize that there is a disparity in access to care for the seriously injured patients with TBI that varies by region due to an uneven distribution of trauma centers.

METHODS: The State Trauma Registry (STR) was reviewed for all patients admitted with TBI to level I, III, IV and non-designated trauma centers between 2008 and 2012. Our primary outcome was mortality rate among TBI patients across 4 geographical state regions defined according to the trauma registry as South, North, Central, and Western. We collected data on demographics, severity of injury (ISS,GCS), location, mechanism and disposition. TBI severity was defined by GCS as mild (13-15), moderate (9-12), and severe (3-8). Chi-square and independent student t-test were used to compare categorical and continuous variables, respectively. A multivariate logistic regression analysis was performed to identify factors associated with mortality. Statistical significance was defined at p<0.05.

RESULTS: We identified 30,237 patients with TBI. The average age was 45.8 ± 20.8, 68% were male and the mean ISS was 11.63. A total of 26,214 patients received care at a Level I trauma center. Overall statewide mortality was 5.6%; however, it was much higher in the South (7%) and West (6.6%), with the lowest in the Northern region (5.6%). Amongst patients who received care at level I center, the mortality was the highest at the Western region (9.6%, p < 0.0001). Univariate analysis identified that the geographical region of injury, level of care, severity of TBI, mechanism of injury, concomitant major surgical procedures, age and severe ISS was predictive of higher mortality rates (p<0.01). Multivariate regression analysis showed that ISS and severity of TBI alone and combined with the geographical region of injury was a significant predictor of mortality after controlling for age, gender, and concomitant injuries. ISS>24 in the Western region had OR of 4.7 for mortality (95CI 1.7; 13.1). The OR for mortality by TBI severity in the Northern region was 1.4-fold higher (95CI 1.03; 1.77) than the reference group with OR of 1.96 (95CI 1.14; 3.36) in patients with severe TBI (1.96; 95CI 1.14; 3.36). The transfer rates were the highest amongst the Northern (44.9%) and Western regions (79.8%).

CONCLUSION: The accessibility to higher level of trauma care varies by region in our state. The Western region had the highest transfer rates for optimal care; however it also had the worst statewide outcomes in mortality. Conversely, the Northern region with more severe TBI had better outcomes. These results highlight the disparity in care and need for additional level I or II trauma centers in the state.

138 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

50. OUTCOMES OF TREATMENT OF CHRONIC MESENTERIC ISCHEMIA Z Moghadamyeghaneh MD, MJ Stamos MD Orange, CA

BACKGROUND: There is limited data regarding outcomes of chronic mesenteric ischemia (CMI) of the intestine. We sought to identify treatment methods, outcomes, and mortality factors of CMI.

METHODS: The National Inpatient Sample database was used to identify patients who had elective admission diagnosis of CMI between 2002 and 2011. Treatment methods and outcomes of patients were identified. Multivariate regression analysis was performed to identify predictive factors of mortality of CMI.

RESULTS: We identified a total of 24,256 patients who were electively admitted for CMI; of which 4,481 patents (18.5%) had angioplasty, 3,052 patients (12.6%) had bowel resection, 3,518 patients (14.5%) had open vascular procedures, and 16,407 patients (67.6%) didn’t have any type of surgery or angioplasty. Over the nine-year study period, there was a steady increase in the number of CMI patients undergoing angioplasty procedures from 12.8% in 2002 to 18.4% in 2011. The in-hospital mortality rate of patients who had open vascular procedures was four times more than patients who had angioplasty (1.8 vs. 7.5, OR: 4.24, P<0.01). Postoperative pneumonia (OR: 5.49, P<0.01), respiratory failure (OR: 4.73, P<0.01), acute renal failure (OR: 2.56, P<0.01), and myocardial infarction (OR: 1.29, P<0.01) were higher in open vascular procedures group. The postoperative mortality has an observed correlation (P<0.01) with coagulopathy (OR: 5.83), fluid and electrolyte disorders (OR: 3.97), liver disease (OR: 3.04), weight loss (OR: 1.72), and chronic renal failure (OR: 1.26) as preoperative comorbidities.

CONCLUSION: Most patients admitted for CMI are treated conservatively. In patients undergoing a procedure, angioplasty is the most common procedure used for treatment of chronic vascular insufficiency of intestine. However, regardless of having a procedure, a significant number of patients are treated with bowel resection. Some advantages of angioplasty over open vascular procedures include: lower mortality rate, less hospital charges, and shorter hospitalization periods. Also, in terms of postoperative complications, angioplasty patients have lower rates of myocardial infarction, acute renal failure, pneumonia, and respiratory failure.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 139 QUICK SHOT ABSTRACTS (cont.)

51. RE-EXAMINING THE BMI THRESHOLD FOR BARIATRIC SURGERY: A DECISION ANALYSIS RA Choudhury BA, C Neylan, NN Williams MD, K Murayama MD, KR Dumon MD Philadelphia, PA

BACKGROUND: The optimal management for patients with class I obesity (BMI: 30 kg/m2 – 35 kg/m2) is controversial. The objective of this study was to compare the impact of Roux-en-Y Gastric Bypass (RYGB) vs. diet and exercise on the long-term survival of patient with class I obesity.

METHODS: A decision analytic Markov state transition model was designed to simulate the life of obese patients. Life expectancy following RYGB, and moderate and optimal diet and exercise for two years was estimated and compared. 10,000 patients’ lives were simulated in each weight-loss intervention group in the model. In addition to base case analysis (45 kg/m2 BMI pre-intervention), sensitivity analysis of initial BMI at start of study was completed. Markov model parameters were extracted from the literature.

RESULTS: The impact of RYGB on survival depended on the effectiveness of diet and exercise. For patients who underwent two years of “moderate” diet and exercise (3.5% total body weight loss/year), RYGB improved long-term survival for patients whose BMI was above 32.5 kg/m2. For patients who underwent two years of “optimal” diet and exercise (7% total body weight loss/year) RYGB improved long-term survival for patients whose BMI was above 35.7 kg/m2.

CONCLUSION: Roux-en-Y Gastric Bypass can improve long-term survival for patients with class I obesity. This study suggests that Roux-en-Y Gastric Bypass should not be reserved for solely for patients with only class II or III obesity.

140 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

52. OPTIMAL RADIAL FORCE AND SIZE FOR PALLIATION IN GASTRO- ESOPHAGEAL ADENOCARCINOMA: A COMPARATIVE ANALYSIS OF CURRENT TECHNOLOGY Prejesh Philips, Ryan Anderson, Michael J Voor, Robert CG Martin II Louisville, KY

BACKGROUND: The optimal use of esophageal stents for malignant and benign esophageal strictures continued to be plagues with variability in pain tolerance, migration rates, and reflux related symptoms. The current esophageal technology was made for squamous cell carcinoma and has not been appropriately modified for GE junction adenocarcinoma. The aim of this study was to evaluate the differences in radial force exhibited by a variety of esophageal stents, in order to guide the physician on appropriate stent utilization and evaluate the current size and length of esophageal strictures in patients.

METHODS: Radial force testing was performed on 15 different stents manufactured by 4 different companies using a hydraulic press and a 5000 N force gauge. Radial force was measured using 3 different tests: transverse compression, circumferential compression and a 3 point bending test. Esophageal stricture composition and diameters were measured continuously to assess maximum diameter, length, and proximal esophageal diameter. 15 consecutive patients underwent esophageal sizing for their GE Junction adenocarcinoma prior to palliative/ neoadjuvant stenting inorder to better guide stent selection.

RESULTS: There was a statistically significant difference in mean radial force for transverse compression test at that middle (range 4.25 newtons/millimeter (N/mm) to 0.66 N/mm) and at the flange (range3.32 N/mm to 0.48 N/mm)(p < 0.001). There were also statistical differences in mean radial force for circumferential test (ranged from 1.19 N/mm to 10.50 N/mm p < 0.001) and the 3 point bending test (range 0.08 N/mm to 0.28 N/mm (p < 0.001). In an evaluation of esophageal stricture diameters and lengths, the smallest median diameter of the stricture was 10mm(range 5mm to 16mm) and the median diameter PROXIMAL normal esophagus was 25mm (range 22 to 33mm).

CONCLUSION: The current esophageal stent technology demonstrated significant differences in radial force, which provides further clarification into stent pain and intolerance in certain patients, with either benign or malignant disease. Similarly, the current stent diameters do not successfully exclude the proximal esophagus, which can lead to obstructive type symptoms. Awareness of radial force, esophageal stricture composition, and proximal esophageal diameter must be known and understood for optimal stent tolerance.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 141 QUICK SHOT ABSTRACTS (cont.)

53. EFFECTS OF ASCITES ON OUTCOMES OF COLORECTAL SURGERY IN CONGESTIVE HEART FAILURE PATIENTS Z Moghadamyeghaneh MD, MJ Stamos MD Orange, CA

BACKGROUND: There is limited data regarding the effects of ascites on outcome of patients undergoing colorectal resection. We sought to identify postoperative complications related to ascites in colorectal resections.

METHODS: The NSQIP database was used to evaluate all congestive heart failure (CHF) patients who had ascites before colorectal resection between 2005 and 2012. Multivariate regression analysis was performed to identify affected postsurgical complications.

RESULTS: We sampled a total of 290,941 patients who suffered CHF and underwent colorectal resection, of which 28,076 (9.6%) had preoperative ascites. Postoperative complications affected by ascites include (P<0.01): ventilator dependency more than 48hours (OR: 2.68), pneumonia (OR: 1.09), wound disruption (OR: 1.68), organ space surgical site infection (SSI) (OR: 1.86), and deep incisional SSI (OR: 1.48). There is no increase in superficial SSI rate in patients with ascites (OR: 0.67, CI: 0.6- 0.7, P<0.05).

CONCLUSION: Ascites increases pulmonary complications such as ventilator dependency and pneumonia in colorectal surgeries. Also ascites increase rate of deep incisional and organ space surgical site infection, but not superficial SSI rates in patients with ascites. Further studies are indicated to see if aggressive treatment of ascites in CHF will decrease complications.

142 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

54. BARIATRIC SURGERY OUTCOMES: SPOUSES/DOMESTIC PARTNERS VERSUS CASE-MATCHED CONTROLS HA Jassim MD, MJ Frelich MS, JR Wallace MD, JC Gould MD, MI Goldblatt MD Milwaukee, WI

BACKGROUND: Family and sibling support have been shown to improve weight loss after bariatric surgery. This may suggest that sibling support and encouragement enhances patient adherence to post-surgical protocols. However, the impact of spousal/ domestic partnerships on weight loss outcomes following bariatric surgery has not been previously reported. We hypothesized that spouses/domestic partners who both underwent bariatric surgery experienced significantly more favorable outcomes than case-matched controls.

METHODS: This is a retrospective review of prospectively collected data on spouses/ domestic partners who underwent primary bariatric surgery (within 13 months of each other) at an accredited bariatric program from July 2007 to June 2013. Procedures were performed by three surgeons (MIG, JRW, JCG). Clinical and perioperative information were collected up to 13 months following surgery. Case-matched controls were selected based on sex, surgery type, preoperative BMI (±5kg/m2), and age (±5 years).

RESULTS: A total of 36 patients (18 spousal/domestic partners and 18 case-matched controls) underwent primary bariatric surgery during the study period. 32 patients (88.9%) underwent laparoscopic Roux-en-Y gastric bypass, and 4 patients (11.1%) underwent laparoscopic sleeve gastrectomy, with a mean age of 48.4 ±11.4 years. The preoperative body mass index (BMI) between the two groups was similar, with an overall mean BMI of 45.3 ±7.5 kg/m2. The percentage of excess BMI lost (%EBMIL) was 64.2% ±21.7% and 64.8% ±20.9% at 6 months (P = 0.94), and 81.3% ±21.4% and 85.6% ±26.2% (P = 0.61) at 1 year in the spousal/domestic partner and control groups, respectively. BMI at 1 year was 29.7 ±5.5 kg/m2 in the spouses/domestic partners, and 29.3 ±7.0 kg/m2 for the controls (P = 0.85).

CONCLUSION: In this retrospective case-control study, we did not observe a difference in weight loss up to 1 year following bariatric surgery for couples when compared to control patients not involved in spousal/domestic relationships. It is possible that if there are positive impacts on long-term weight loss by having a patient’s spouse/domestic partner undergo the same procedure, this effect may be observed at intervals past 1 year postoperatively. Further evaluation is needed.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 143 QUICK SHOT ABSTRACTS (cont.)

55. TYPE OF ANESTHESIA AFFECTS THE ASSESMENT OF GASTROESOPHAGEAL JUNCTION IN PATIENTS EVALUATED FOR ANTI- REFLUX SURGERY GM Ihde MD, LA Dill DO, CF Lucchese DO, PK Krone MD, DG Cummins MD, CJ Cottrell MD, DG Lister MD Dallas, TX

BACKGROUND: Differences in assigning a Hill grade to a patient preparing for anti-reflux surgery (ARS) may exist depending on the conditions of the endoscopy. The BACKGROUND of this study was to assess the intra-rater agreement of assigning Hill grade to the appearance of gastroesophageal junction (GEJ) in patients who underwent pre-operative endoscopy under intravenous sedation (IVS) versus under general anesthesia (GA)

METHODS: Fifty three patients underwent a preoperative endoscopy under IVS as a part of a prospective study. The study was approved by the Institutional Review Board. Within 90 days following IVS endoscopy, patients presented for an ARS. The second endoscopy was performed under GA just prior to a surgery. Videos of each endoscopy under IVS and under GA were edited and blinded by the leading author to the videos presenting the appearance of GEJ at the time of full gastric distention. Eight general surgeons experienced in performing ARS independently evaluated each video and scored their Hill grade assignment on the scoring sheet. Intra-rater agreement was assessed by comparing Hill grade assessment of the GEJ under IVS versus their Hill grade assessment under GA. The Cohen’s Kappa κ( ) coefficient was computed and used as a measure of intra-rater agreement. Additionally, since there are 4 possible Hill grades (I, II, III and IV), a proportion of matched cases for each rater was assessed using the Bowker’s test of symmetry (an extension of the McNemar test for two variables with more than two categories). P values < 0.05 were considered significant.

RESULTS: In only one of 8 raters, there was no significant difference between endoscopic Hill grade assessments under IVS versus GA. This rater had 53% (28/53) of cases matched (P=0.358) However, the associated Cohen’s Kappa value was indicating a poor agreement (κ = 0.16). The agreement across Hill grades (I, II, II and IV) in this rater was strongest for Hill grade III (κ = 0.22; fair agreement) and lowest for Hill grade I (κ = -0.07; agreement occurs less often than predicted by chance alone).There was a significant difference in assigning Hill grades under IVS versus GA in other seven raters. In these seven raters, the proportion of matched cases ranged from 26% to 53% and associated P value ranged from 0.002 to 0.043. However, in 6 of 7 raters, the associated measure of agreement was considered poor (κ ranged from -0.03 to 0.152. One rater was considered to have fair agreement (κ = -0.23).Of these seven raters, 3 had the highest agreement by assigning Hill grade IV, 2 by assigning Hill grade III and 2 by assigning Hill grade II. Hill grade assignment was larger under IVS in 43% of cases; in 20% of the cases the surgeons found the Hill grade larger under GA than IVS.

CONCLUSION: In this study, type of anesthesia affected the endoscopic assessment of the GEJ, favoring a larger Hill grade assignment under IVS than GA.

144 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

56. PERCUTANEOUS CHOLECYSTOSTOMY FOR MANAGEMENT OF ACUTE CHOLECYSTITIS: ANOTHER PIECE OF THE PIE? BC Morse MS MD, JP Simpson MD, YR Jones MHA, DE Smith MD Atlanta, GA

BACKGROUND: Primarily used as an alternative to cholecystectomy in high risk patients, the current role of percutaneous cholecystectomy (PC) is being expanded at some centers as initial treatment for all adults presenting with acute cholecystitis. The goal of this study is to compare the efficacy and outcomes of PC and cholecystectomy in the management of acute cholecystitis.

METHODS: A retrospective review of the coding database at a tertiary care university medical center was performed from July 1, 2002 to June 30, 2012 to identify all patients with acute cholecystitis managed by cholecystectomy or PC. All cholecystostomy tubes were placed percutaneously by interventional radiology.

RESULTS: Over the 10 year study period, 2771 patients were treated for acute cholecystitis. Of these, 2663 (96%) patients (mean age 48 ± 18 years, female gender = 68%, median ASA class = III) underwent cholecystectomy and 148 (4%) patients (mean age 74 ± 16 years, female gender = 39%, median ASA class = III) had PCs as primary treatment. Mortality was significantly higher in the PC cohort compared to the cholecystectomy group (31/148, 21% vs. 4/2619, 0.15%; p<0.001). For survivors, the aggregate major morbidity rate was also higher in the PC group (20/117, 17%, vs. 34/2619, 1.3%; p<0.001). Major morbidities in the PC group included failure of therapy (4/117, 3%), tube dislodgement requiring replacement (6/117, 5%), and recurrence of cholecystitis (10/117, 9%). In the cholecystectomy group, major morbidities were categorized as bile leaks (13/2619, 0.5%), surgical site infections – deep and superficial – (7/2619, 0.3%), bowel injuries (4/2619, 0.1%), common bile duct injury (3/2619, 0.1%), cardiovascular events (4/2619, 0.1%), and hemorrhage (2/2619, 0.05%). The conversion rate from laparoscopic to open cholecystectomy was 2.6%.

CONCLUSION: Although PC is a useful alternative in high risk patients, cholecystectomy is a safe and effective operation for treatment of acute inflammation of the gallbladder and, despite developing technology, general surgeons should not relinquish cholecystectomy as the mainstay treatment for acute cholecystitis.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 145 QUICK SHOT ABSTRACTS (cont.)

57. COMPARATIVE EFFECTIVENESS OF SURGEON VERSUS PHARMACIST PREOPERATIVE ANTIBIOTIC SELECTION JD Pfeiffer MD, KL Gunderson, KJ Kallies MS, M Al-Hamadini MBChB MPH, RF Miller PharmD, SN Kothari MD La Crosse, WI

BACKGROUND: Preoperative antibiotic prophylaxis is an important adjunct in the prevention of surgical site infections (SSI) and infectious morbidity and mortality. At our institution, prior to September 2010, preoperative antibiotics were selected by the attending surgeon. Since that time, a pharmacy decision model (PDM) in which pharmacists review preoperative antibiotic selection and modify the order as needed was implemented. Appropriate antibiotic selection was based on an algorithm developed to account for patient risk factors for SSI. The PDM was initially applied to hernia repairs and then to colorectal procedures. Our objective was to evaluate the impact of this transition.

METHODS: After receiving IRB approval, a retrospective review of the medical records of patients who underwent hernia repairs and colorectal procedures between August 2009 to August 2010 (Pre-PDM) and November 2010 to December 2011 (Post- PDM) was completed. Variables included patient comorbidities, preoperative antibiotic selection, dose, and timing, operative data, and 30-day morbidity and mortality. Statistical analysis included chi-square and Wilcoxon Rank Sum Tests. A P value <0.05 was considered significant.

RESULTS: There were 472 patients in the Pre-PDM group, and 370 in the Post- PDM group. Age, sex, preoperative body mass index, and comorbidities (renal disease, type II diabetes, malignancy, tobacco use, antibiotic allergies and history of MRSA) were similar between the groups. Colorectal cases comprised 20.3% of the Pre-PDM group, and 27.0% of the Post-PDM group (P=0.023). Cases were performed laparoscopically in 29% and 37% of those in the Pre-PDM and Post-PDM groups, respectively (P<0.001). Mean length of stay among patients who underwent colorectal procedures was 5.5±3.2 and 5.8±3.2 days (P=0.331) in the Pre and Post-PDM groups, respectively. Mean length of stay for patients who underwent hernia repairs was 0.2±0.7 and 0.4±1.3 days in the Pre and Post-PDM groups, respectively (P=0.064). In the Post- PDM group, the surgeon’s preoperative antibiotic order was changed in 31% of the cases. Preoperative antibiotics were administered in 80% in the Pre-PDM group and 88% in the Post-PDM group (P<0.001). Cephalosporins were administered in 88% and 95% of those in the Pre and Post-PDM groups, respectively (P<0.001). In the Pre and Post-PDM groups, SSI rates were similar (5.3% vs. 4.9%; P=0.777) overall, and among colorectal procedures (13.5% vs. 14.0%, P=0.926) and hernia repairs (3.2% vs. 1.5%; P=0.168). Urinary tract infection (2.1% vs. 0.5%; P=0.055) and intra-abdominal infection (0.8% vs. 0.7%; P=0.871) rates were similar in the Pre and Post-PDM groups.

CONCLUSION: After implementation of the PDM, one third of the surgeon’s preoperative antibiotic orders were changed. Overall, more antibiotics were administered post-PDM. There was no difference in the rate of SSI after transitioning to a PDM for preoperative antibiotic selection.

146 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

58. EXCISIONAL BIOPSY VERSUS FINE NEELE ASPIRATION FOR STAGE III MELANOMA: DOES IT AFFECT SURGICAL OUTCOMES, REUCRRENCE OR SURVIVAL Merkow J, Pearlman NW ,Baumgartner JM, Alessandro P , Jones E, MacDermott T, Gajdos C, Gonzalez R, Lewis KD, Robinson WA, McCarter MD, Kounalakis N Aurora, CO

BACKGROUND: Completion lymph node dissection is recommended for clinically involved nodes in stage III melanoma. Patients presenting with adenopathy can undergo excisional biopsy (EB) or fine needle aspiration (FNA) to confirm the presence of regional metastasis. The aim of this study was to determine if the manner of diagnosis affects surgical outcomes, recurrence or survival following subsequent completion lymph node dissection.

METHODS: Clinical information was extracted from a retrospective chart review of stage III melanoma patients presenting with inguinal or axillary lymphadenopathy treated at a tertiary care center from 1991-present. Eligible patients had tissue confirmation of stage III disease with either fine needle aspiration (FNA) or excisional biopsy (EB) and then a completion lymph node dissection. Surgical outcomes, disease free survival and overall survival were recorded and compared between these 2 groups.

RESULTS: Sixty six patients were available for analysis: 25 underwent EB and 41 underwent FNA; total population median follow up was 59.5 months. Age at diagnosis and depth of melanoma were similar between the EB and FNA groups; 46 vs. 48 yrs, (p= 0.65) and 2.4 mm vs. 3.5 mm (p= 0.38). The mean ratio of positive to negative lymph nodes was 10% in the EB group vs. 25% in the FNA group, p=0.01. The overall complication rate after completion lymph node dissection was similar between the EB and FNA groups (12 patients, 48% vs. 21 patients, 53%). This included seroma formation in 2 (8%) vs. 3 (8%), wound infection in 5 (20%) vs. 3 (8%), and any lymphedema in 8 (40%) vs. 14 (35%) in the EB vs FNA groups respectively. There was no significant difference in the EB vs. FNA group for disease free survival (70 vs. 129 months, p = .168) or in overall survival (87 vs. 144 mo, p= 0.21). Six patients (24%) in the EB group experienced a recurrence in the regional lymph node basin at 12.6 months (range 2-71months) vs eight patients (20%) in the FNA group 13.6 months (range 2-57).

CONCLUSION: The use of EB versus FNA for the diagnosis of regional metastasis in Stage III melanoma affects neither complication rates nor overall survival after completion lymph node dissection. There is a trend towards a worse disease free survival with EB though this did not reach statistical significance.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 147 QUICK SHOT ABSTRACTS (cont.)

59. SURGICAL MANAGEMENT OF CAROTID BODY TUMORS: A 10-YEAR EXPERIENCE EMPLOYING AN INTERDISCIPLINARY APPROACH TC Lairmore MD, JL Dixon MD, WT Bohannon MD, MD Atkins MD, CJ Buckley MD Temple, T X

BACKGROUND: Carotid body tumors are rare neoplasms that may present as a mass in the neck, or may be detected radiographically during screening in patients with an hereditary paraganglioma (PG) syndrome. These tumors arise in the extra-adrenal paraganglia in close association with the cranial nerves and extracranial arterial system of the head and neck and therefore surgical extirpation can be challenging. Cervical PG are usually benign and biochemically silent, but functional and malignant tumors can occur in a subset of patients.

METHODS: A retrospective study was conducted of all patients undergoing operation for cervical PG between 2000 and the present. The demographic characteristics, clinical features, surgical approach and outcomes were reviewed.

RESULTS: A total of 15 cervical PG were excised in 13 patients. There were 10 female and 3 male patients, ages 39.8-79.0 years (mean 61.9 + 13.1) at the time of operation. The follow-up for the study patients was 0.1-10.5 years (mean 3.2 + 2.8). Ten patients had unilateral tumors and 3 patients had bilateral tumors. A cervical mass was present preoperatively in 7(54%) patients. Familial involvement was confirmed by history or direct genetic analysis in 4(31%) of the 13 patients. There were no malignant PG and only 1 tumor was determined to be functional. Eight right-sided tumors, 3 left-sided tumors, and 2 pairs of bilateral tumors were excised (one patient with bilateral tumors underwent resection on one side only), with a tumor size of 1.3 – 5.0 cm (mean 2.53 + 0.96 cm). One patient had a preoperative vocal cord paralysis due to a large PG involving the vagus nerve. Preoperative angiographic embolization was performed for 6(40%)/15 of the excised tumors. Two patients had a combined arterial resection as part of complete excision of the tumor. There were no permanent operative nerve injuries, no recurrences, minimal morbidity, and no mortality.

CONCLUSION: Optimal management of cervical PG should include thorough preoperative evaluation including family history/genetic testing, biochemical evaluation to identify functioning PG, and selected imaging tests to define the surgical anatomy as well as to exclude synchronous or metachronous PG. Preoperative embolization of large, vascular tumors can facilitate surgical treatment. Early excision of cervical PG is recommended to prevent the development of larger, more locally advanced tumors (Shamblin class III) which are associated with a higher incidence of operative nerve injury. Important management principles include selective preoperative angioembolization of large tumors, staged resection of bilateral tumors, maintenance of meticulous vascular surgical technique, and use of subadventitial dissection. An interdisciplinary approach with selective preoperative embolization followed by complete excision by an experienced surgical team provides safe and effective treatment of cervical PG with very low morbidity and excellent outcomes.

148 Southwestern Surgical Congress | 66th Annual Meeting QUICK SHOT ABSTRACTS (cont.)

60. NODAL BASIN RECURRENCE AND ADEQUACY OF RESECTION FOLLOWING LYMPHADENECTOMY FOR MELANOMA CW Kimbrough MD, ME Egger MD MPH, AJ Stromberg PhD, L Hagendoorn MBA, KM McMasters MD PhD Louisville, KY

BACKGROUND: Patients with sentinel lymph node (SLN) positive melanoma should undergo completion lymphadenectomy (CLND) for involved regional nodal basins, but the total number of lymph nodes needed for an adequate dissection has not been firmly established. Recommendations vary, with most derived from expert opinion or retrospective reviews limited to single institutions. For this study, we evaluated patients who underwent CLND to determine the minimum number of lymph nodes associated with both overall survival and recurrence within the dissected nodal basin for axillary, inguinal, and cervical lymphadenectomies.

METHODS: A post hoc analysis was performed of patients with cutaneous melanoma ≥ 1mm thick who underwent CLND as part of a multicenter randomized controlled trial. The indication for CLND was a positive SLN biopsy, and only patients with CLND limited to a single nodal basin were included for analysis. Cutoffs for adequate lymphadenectomy were determined for each nodal basin based on greatest difference in survival, and evaluated using Kaplan-Meier (KM) survival analysis for both overall survival (OS) and recurrence within the dissected nodal basin. Multivariate Cox proportional hazard models were then used to test these cutoffs along with other risk factors for both OS and nodal basin recurrence.

RESULTS: A total of 341 patients who had a CLND were identified, 17 of which had recurrence within the dissected nodal basin. Median follow-up was 59 months. There was no difference in age, Breslow thickness (BT), ulceration, lymphovascular invasion, or tumor regression across nodal groups. Males had a higher percentage of axillary and cervical dissections, while females were more likely to have inguinal disease (p < 0.0001). Total lymph node counts of ≤ 5, 9, and 15 nodes were identified as cutoffs for inguinal, axillary, and cervical dissections, respectively. On KM analysis there was a trend for worse lymph node recurrence free survival in patients below the cutoff values compared to those above (p = 0.054). There was no difference in OS for patients above and below the lymph node cutoffs (p = 0.168). Cox proportional hazard modeling using cutoff levels, ulceration, and BT did not indicate that the cutoffs were an independent predictor for nodal recurrence (RR 2.73, 95% CI 0.87 – 7.42) or for OS (RR 1.38, 95% CI 0.88 – 2.08). Ulceration was the only risk factor significantly associated with nodal recurrence (RR 3.70, 95% CI 1.31 – 12.06). Both ulceration (RR 1.89, CI 1.35 - 2.67) and BT (RR 4.39, 95% CI 1.47- 11.15) were independently associated with OS.

CONCLUSION: Although cutoff levels were not independently associated with overall survival or nodal recurrence following CLND, resected lymph node counts of ≤5, 9, and 15 demonstrate a trend towards increased nodal recurrence that is consistent with published values in the literature. At the very least, CLND should reach these targets. Ulceration is an independent risk factor for nodal recurrence.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 149 QUICK SHOT ABSTRACTS (cont.)

61. PERCUTANEOUS EMBOLIZATION OF THORACIC DUCT INJURY POST–ESOPHAGECTOMY SHOULD BE CONSIDERED INITIAL TREATMENT FOR CHYLOTHORAX BEFORE PROCEEDING WITH OPEN RE-EXPLORATION KJ Marthaller MD, SP Johnson MD, RM Pride MS, ER Ratzer MD, HW Hollis Jr MD Denver, CO

BACKGROUND: Newly developed microcatheter technology facilitates percutaneous treatment of post-esophagectomy thoracic duct disruption and resultant chylothorax with high success and low morbidity compared to traditional thoracotomy and mediastinal ligation. The authors present a small series of post-esophagectomy patients who developed high output chylous fistula and chylothorax that were successfully treated with percutaneous embolization.

METHODS: A retrospective review of all patients who developed chylothorax following esophagectomy in our facility during the last six years was performed. During the study period from 6/1/2007 to 12/31/2012, 5 patients with refractory chylous fistula post esophagectomy were identified. Percutaneous ablation of the fistula was attempted as initial therapy in all cases. The average volume of chyle/24 hours was calculated. Duration of leak was defined as time from operation to intervention. Cumulative chylous output from operation to intervention was recorded and averaged. Evaluation of lymphatic access sites, type of sclerosant and need for adjuvant coil embolization were analyzed. A Pub Med search of all previously reported similar case series is provided with this review.

RESULTS: Successful ablation of the chylous fistula was achieved in 4/5 patients, (80%) in this series. There was one treatment failure. Average time from thoracic duct disruption to treatment was 18.2 days. Average maximal volume of chyle pre-treatment was 1756 mL per 24hrs. Cumulative chylous output from operation to intervention was 28018 mL per patient. Both coils and liquid sclerosants were required to achieve closure in selected instances. Conventional pedal lymphangiography was used in two cases. A novel approach using direct puncture of groin lymph nodes was used in two cases to opacify the thoracic duct via abdominal lymphatics. A detailed description of the technique with images is presented.

CONCLUSION: Percutaneous embolization strategies to treat thoracic duct injuries and following esophagectomy should be considered initial therapy before proceeding with traditional transthoracic mediastinal ligation. Opacification of the thoracic duct to facilitate direct trans-hepatic cannulation can be accomplished with standard pedal lymphangioraphy or by direct lymph node cannulation in the groin. Successful ablation of chylothorax following percutaneous embolization can be predicted in a high percentage of cases (80% in this series) without need for open re-exploration.

150 Southwestern Surgical Congress | 66th Annual Meeting TOP 5 POSTER ABSTRACTS

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 151 TOP 5 POSTER ABSTRACTS (cont.)

1. SYMPTOMATIC CHOLELITHIASIS: IMPACT OF THE TIMING OF CHOLECYSTECTOMY ON LONG-TERM MORTALITY AND COSTS RA Choudhury BA; C Neylan; KR Dumon MD; NN Williams MD; K Murayama MD Philadelphia, PA

BACKGROUND: The current management for symptomatic cholelithiasis suggests that the shorter the time to cholecystectomy, the lower the costs and the lower the mortality/morbidity for patients. The objective of this study will be to estimate the long-term mortality and costs associated with delays to cholecystectomy for patients with symptomatic cholelithiasis.

METHODS: A decision analytic Markov state transition model was designed to simulate the life patients with the diagnosis of symptomatic cholelithiasis. Six patient groups with 10,000 patients each were created. Patient groups were characterized by the time delay before cholecystectomy. Timing groups included 1 week, 1 month, 2 months, 6 months, and 1 year of delay to cholecystectomy, and then one group of patients who only had surgery if they had a major event (i.e. cholecystitis, cholangitis, pancreatitis). Life-expectancy and medical costs were estimated over the duration of the model (15 years). Markov model parameters and cost data were extracted from the literature.

RESULTS: Delay to cholecystectomy was associated with a negative impact on long- term survival: 15 year mortality: 25.899% (short delay - one week) vs. 26.369% (long delay - surgery only after event). Total costs were lower for the group of patients that only had surgery after an event: Total costs: $22,104,852 (long delay) vs. $39,176,649 (short delay). Although costs per case were lower for groups with shorter delays to surgery, those groups had a higher number of total cholecystectomies performed, resulting in higher total costs.

CONCLUSION: For patients with symptomatic cholelithiasis, delay to cholecystectomy is associated with higher long-term mortality. Although shorter delay is associated with reduced costs per case, it is also associated with higher total costs due to a higher number of total cholecystectomies peformed.

152 Southwestern Surgical Congress | 66th Annual Meeting TOP 5 POSTER ABSTRACTS (cont.)

2. NECROTIC VERSUS PERFORATED APPENDIX: CAN CT SCAN DIFFERENTIATE? DOES IT MATTER? JL Regner MD; L Harmon MD; L Chapa MD; DC Jupiter PhD Temple, T X

BACKGROUND: Historically, the progression of simple to complicated appendicitis is thought to occur as a result of full-thickness appendiceal wall necrosis leading to perforation. Currently, in order to minimize post-operative infections, surgeons attempt to perform appendectomy prior to perforation. However, infections still occur. Our goal was to evaluate whether CT scan findings could predict risk of necrosis or perforation. Secondary aim was to determine if these two endpoints affect clinical outcomes.

METHODS: Retrospective cohorts from 2007 to 2012 at an academic tertiary referral center were evaluated. Patients with non-perforated appendicitis by CT scan were stratified based on the operative finding of perforation and pathologic assessment of appendiceal wall necrosis. Demographics, CT findings, operative and pathologic data, time sequence, and post-operative outcomes were included.

RESULTS: Two hundred eighty-one (70%) of 402 patients, age 39.7 +/- 16.25 years (47.5% male) reviewed had uncomplicated appendicitis (no evidence of perforation or necrosis). 121 (30 %) patients had either necrosis of the appendix (42, 10.3%), perforation (48, 12%) or both (31, 7.7%) (p < 0.001). CT scan findings of fecolith (OR 2.31, p= 0.01), pericolic fluid (OR 2.47, p = 0.012), and appendiceal wall thickening (OR 2.41, p=0.02) were risks factors for perforation, but no CT scan findings could significantly predict necrosis. Superficial surgical site infections occurred in 5 of 281 patients (1.8%) with uncomplicated appendicitis versus 8 (6.6%, p = 0.017) in patients with perforation or necrosis. Intra-abdominal abscesses did not occur in simple appendicitis, but occurred in 9 of 121 (7.4% p = 0.0001) patients with perforation or necrosis.

CONCLUSION: While CT scan findings can predict patients at risk for perforation, no specific findings could detect or predict patients at risk of necrosis. Both necrosis and perforation significantly increase the risk of post-operative infections. Therefore, all patients with appendicitis should benefit from prompt surgical intervention.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 153 TOP 5 POSTER ABSTRACTS (cont.)

3. ADVANTAGE OF ADJUVANT RADIATION THERAPY IN OCTOGENARIANS UNDERGOING SURGICAL RESECTION OF RECTAL CANCER D Chauhan MD; AS Burnett MD PHD; TK Rajab MD; P Ernst PHD; DA McCain MD PHD; SA Mokashi MD Hackensack, NJ

BACKGROUND: Radiation in patients with rectal cancer is an important adjuvant therapy. It can be given either pre-operative or post-operative phase or both. However the optimum timing of the radiation in terms of pre-operative or post-op phase remains a question of debate in octogenarian patients as there is lack of enough evidence.

METHODS: In this study we aim to find the optimum time of radiation therapy in octogenarians with rectal cancer undergoing surgical resection. Octogenarians with rectal cancer were selected from surveillance, Epidemiology and End Results (SEER) database collected between 1998 and 2009. The data set contained 4,026 patients with rectal cancer who underwent surgical resection and radiation therapy. They were divided into 3 groups. 1,586 (39%) patients had radiation before the surgery. 66 (2%) patients had radiation before and after the surgery, also called the combination group. 2,347(59%) patients had radiation after the surgery. Taking in the consideration of unequal sample sizes, Tukey-Kramer multiple comparison tests was used to compare the mean survival of the patients in each group.

RESULTS: The mean survival in pre-operative radiation group was 37.7 months, in combination group was 48.41 months and post-operative radiation group was 44.3 months. There was no statistically significant difference in survival time between the combination group and the radiation after surgery group (p-value=0.64). There was marginal statistical significance in survival time between the combination group and the before surgery group (p-value=.05). There was a statistically significant difference in survival time between the radiation after surgery group and the radiation before surgery group (p-value <0.0001).

CONCLUSION: Octogenarian patients with rectal cancer undergoing adjuvant radiation therapy, with or without neoadjuvant radiation, have greater survival than compared to neoadjuvant only radiation. There appears to be survival advantage of postoperative radiation therapy in octogenarian patients with rectal cancer.

154 Southwestern Surgical Congress | 66th Annual Meeting TOP 5 POSTER ABSTRACTS (cont.)

4. A RABBIT HEMORRHAGIC SHOCK MODEL T Feldmann MD; JK Pham BS; D Ngo BS; BT Imayanagita BS; E Steward; AP Kong MD; K NajafI DO; C Barrios MD Orange, CA

BACKGROUND: Establishment of hemorrhagic animal models allows for the development of new interventions by mimicking shock states. Few models have been reported using rabbits to simulate traumatic injuries. A balance must be struck between cost, feasibility, and similarity to human physiology. In order to provide a basis for future studies we established a model of controlled hemorrhage in a rabbit model to confirm its use as an appropriate and economical alternative.

METHODS: Sixteen New Zealand white rabbits between 4.4-5.0 kg were used according to an IACUC approved model. The animals were anesthetized and intubated. An ear vein was cannulated for infusions and the femoral artery was cannulated for hemodynamic monitoring and blood draws. The animals were hemorrhaged over two minutes for a total blood loss of 12 mL/kg. Labs were drawn at baseline prior to hemorrhage and then at 30 minutes, 1 hour, and 6 hours into the protocol. A standard bolus with 20 mL/kg of lactated ringers or normal saline was given to every animal after the 30 minute lab draw to simulate resuscitation. Further fluid boluses were given during the study at a dose of 20mL/kg within the first hour of the experiment and subsequently 10mL/kg for predetermined blood pressure or heart rate triggers, demonstrating evidence of shock. After completion of the protocol the animals were humanely euthanized.

RESULTS: All animals survived to end of experiment. A significant increase was seen in both lactate (1.0 vs 4.4 mg/dL, p<0.01) and creatinine (1.1 vs 2.1 mg/dL, p<0.01) at 6 hours from baseline. Hemoglobin declined significantly over this same time period (11.3 vs 7.0 mg/dL, p<0.01). Base excess showed a decline from 11.1 mEq/L to -0.4 mEq/L (p<0.01).

CONCLUSION: The data obtained from this rabbit model show laboratory values consistent with changes seen in hemorrhagic shock in humans--elevation in lactic acid and creatinine with declining hemoglobin values. A rabbit model can appropriately mimic expected human physiologic changes during hemorrhagic shock. Further studies can use this model as a platform to balance cost, logistics, and similarity to human physiology.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 155 TOP 5 POSTER ABSTRACTS (cont.)

5. THE BARCELONA TECHNIQUE: FOR ILEOSTOMY REVERSAL KW Russell MD; BP O’Holleran MD; MC Mone RN BSE; CL Scaife MD Salt Lake City, UT

BACKGROUND: The Barcelona technique is a method of bowel anastomosis. This technique is not well described in the literature. It is simple technique where the proximal and distal ends of a resection margin are approximated at the antimesenteric side, small enterotomies are made, the GIA stapler is passed into both lumens creating a common channel, and then one additional stapler load is used to create the anastomosis and amputate the specimen. We sought to evaluate this technique as it relates to ileostomy reversal in terms of cost and complications.

METHODS: With IRB approval we reviewed all the ileostomy reversals from 2006- 2013 for a single surgical oncologist who uses the Barcelona technique. We evaluated patient demographics, diagnoses, treatments, complications and hospital charges.

RESULTS: During the study period 19 patients underwent ileostomy reversal using the Barcelona technique. The median age at surgery was 58 years (range: 26- 84 years) and 53% were female. The majority of patients had rectal cancer that was initially treated with low anterior resection and diverting loop ileostomy (75%). Other diagnoses were ulcerative colitis, rectal perforation, and leak after colon resection for dysplastic polyp. The median length of stay after ileostomy reversal was 3 days. Following ileostomy reversal there was a wound infection rate of 5%. There have been no leaks, intra-abdominal abscesses, strictures or readmissions

The Barcelona technique requires only 2 stapler loads. Conventional ileostomy reversal often requires a total of 4 loads and 2 different stapling devices. At our institution the Barcelona technique saves $510 of charges to the patient.

CONCLUSION: The Barcelona technique is a safe and effective technique for ileostomy reversal. It decreases the number of stapler loads needed compared to conventional technique and thus saves significant medical cost. This technique should be considered for ileostomy reversal and other types of bowel anastomosis.

156 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 157 POSTER ABSTRACTS (cont.)

6. SUPERIOR MESENTERIC ARTERY SYNDROME TREATED BY LAPAROSCOPIC DUODENOJEJUNOSTOMY: A CASE REPORT Brian J Pottorf, MD; Farah A Husain, MD Denver, CO

BACKGROUND: First described in the medical literature by Carl Freiherr von Rokitansky in 1861, superior mesenteric artery (SMA) syndrome is a rare pathology that causes compression of the third portion of the duodenum. As more diagnoses of SMA syndrome were made over the next century, it has been defined as compression of the third portion of the duodenum by the superior mesenteric neurovascular bundle anteriorly and the aorta and vertebral column posteriorly. The duodenal compression often manifests as a sense of fullness in the epigastrium, postprandial abdominal pain, early satiety, and intermittent emesis. This constellation of symptoms represents a mechanical duodenal obstruction. Although conservative medical management is often attempted as the initial treatment modality, surgical intervention is occasionally required for bypass of the obstruction. Transabdominal duodenojejunostomy remains the gold standard operation. However, as laparoscopic advances continue, a minimally invasive approach to treating SMA syndrome has proven to be a safe and effective surgical option.

METHODS: Standard laparoscopic ports for gastric bypass were placed. The transverse colon mesentery was retracted cephalad, thereby exposing the ligament of Treitz. The patient’s mesentery was thin from her weight loss, which enabled easy visualization of the SMA. A window was created in the mesocolon, which allowed visualization of the third portion of the duodenum confirming compression by the SMA resulting in proximal duodenal and gastric dilation. A loop of jejunum was brought through the mesocolon, positioned carefully so as to lay comfortably, without tension, on the dilated third portion of the duodenum. Parallel enterotomies were made and the endoscopic linear cutting stapler was inserted and fired thereby creating a widely patent retrocolic duodenojejunostomy. The common enterotomy was closed with an endoscopic linear cutting stapler.

RESULTS: Postoperatively, the patient had an uneventful course and was discharged on post-operative day 2 without recurrence of her abdominal pain.

CONCLUSION: SMA syndrome is a rare cause of chronic duodenal obstruction. The diagnosis is a clinical one which is confirmed by contrast studies demonstrating partial obstruction of the third portion of the duodenum in the vicinity of the SMA. Initial treatment consists of conservative management. If this modality fails, then surgical intervention can be performed. Transabdominal duodenojejunostomy has been considered the gold standard of operative approaches. Currently, advances in minimal access bariatric surgery have demonstrated the safety and low morbidity of laparoscopically created enteric anastomoses. The shorter hospital stay, low morbidity and high success of laparoscopic enteric bypass make this approach favorable to traditional open surgical bypass. We therefore strongly recommend that laparoscopic enteric bypass should be considered the primary treatment modality for patient’s suffering from SMA syndrome.

158 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

7. BILATERAL ADRENAL INJURY IS ASSOCIATED WITH INCREASED RISK OF ADRENAL INSUFFICIENCY COMPARED TO UNILATERAL INJURY SF McLean, MD; A Dwivedi PhD; S Lee MSc; AH Tyroch MD El Paso, TX

BACKGROUND: Adrenal injury (AI) is rare with a reported incidence of 2% (.02), after blunt trauma, with .003% incidence bilateral AI. A sequelae of adrenal injury is relative adrenal insufficiency (RAI). Two studies reported RAI in 1/1120 AI and 5/10 in bilateral AI. We examine the national and local incidence of AI and investigate the relationship with RAI. Our hypothesis is that RAI will occur more frequently in bilateral AI.

METHODS: Retrospective review of new adrenal injuries in a level I trauma center 2005-2012 was used to evaluate the relationship between AI and RAI, whereas the National Trauma Databank (NTDB) 2007-2009 was used to evaluate U.S. incidence. A result of cortisol level below 25 in a critically ill patient or a failure to increase cortisol level after synthetic ACTH stimulation was counted as relative adrenal insufficiency. A CT scan finding or a pathologic or an OR finding of adrenal injury was used to assess injury. Fisher’s exact test was used to compare the proportion of RAI according to the type of AI.

RESULTS: Out of a total 19644 trauma admissions locally 2005-12, 95 (.0048 incidence) had adrenal injury (AI) with 5 bilateral AI (.00026 incidence). AI incidence increased yearly from .0009 to .0071. NTDB incidences increased also from .0040 to .0044 during 2007-2009. Sixty percent (3/5) of the bilateral vs. 5% (6/90) of unilateral had RAI, ( p =.001.). All (100%) of bilateral AI, contrasting with 35.6% (32/90) of unilateral AI had infections. (p=.008). Other data: Mean age=34.6(2-86) yrs. Survival =97%. ISS and LOS data: (mean/ median/range): ISS = 24.3/24/ (1-75), hospital LOS =13.52/8.0/(1-81) days, ICU LOS =10.6/ 7.5/(0-44) days.

CONCLUSION: AI incidence (.0048) was similar to national (.0044). RAI and infections were significantly more common after bilateral AI. Our findings suggest that we test those patients with bilateral adrenal injuries for adrenal insufficiency, and monitor closely for infections.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 159 POSTER ABSTRACTS (cont.)

8. BURNOUT VS.NIRVANA:WHAT IS THE IDEAL TRAUMA ACUTE CARE SURGERY(TACS) MODEL? JL Kashuk MD;P Colvin RN;K Skipper MD;J Joseph MD; A Lipsky MD PhD Dallas, TX

BACKGROUND: Despite continued maturation of the TACS paradigm, recent evidence suggests that burnout rates are amongst the highest of all surgical disciplines. While the reasons for these trends remain poorly defined, an improved understanding of the issues are imperative for the future survival of the specialty. We theorized that our community based, TACS model promotes wellness, career satisfaction, and a low rate of burnout.

METHODS: 32 full time TACS surgeons affiliated with our community based group, working at 10 ACS/state verified trauma centers were sent an anonymous cross sectional survey with 55 questions which included self assessments of training background, preparation for a TACS career, practice patterns, home and family, and the Maslach Burnout Inventory (MBI), a standardized assessment of burnout and quality of life

RESULTS: 69% (22/32) responded; 68% were age 30-49, 32% >49-64.Twenty (91%) were married with 2 children (IQR2-3). Median years worked = 10-15. 86% performed teaching, leadership, committees, professional organizations, and research. Median work/call hrs/wk= 70 (IQR: 60-89); 78 (IQR: 48-84). 64% averaged 8-14 days off/ month. On the MBI, 86% had high personal accomplishment scores compared to 66% in other national surveys (p=.04). Although only 7 (32%) members of the group were noted to be burned out, all 3 women (43%) and 4 (21%) men were in this category (p = 0.02). This compared to 52% in other national surveys (p=.08). Younger surgeons tended to feel burned out more often than older ones (40% vs. 14%, p = 0.35). The greatest predictor of burnout was respondents who felt unable to affect change in their work environment (6 times higher odds, p = 0.07).

CONCLUSION: While our TACS model had high personal accomplishment scores, burnout rates still appear to be a concern, particularly in women and those who felt unable to affect change in the work environment. Further study of burnout in our specialty and the impact of various TACS models are warranted.

160 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

9. SHOOT TO WOUND OR AIM TO KILL: RUBBER BULLETS AS “NON- LETHAL” FORCE JF Byrd MD; ML Maxey MD; RS Smith MD Columbia, SC

BACKGROUND: Rubber bullets are intended to be low-velocity, nonlethal projectiles used by law enforcement to inflict pain and mild injury only. First introduced in the 1970s for riot control in Northern Ireland, rubber bullets are considered relatively safe when aimed from a distance to the lower extremities. Conversely, close range shots to the trunk and head are more likely to cause serious injury. Injury severity is dependent on both firing distance and location of impact. Herein we discuss a case of a serious penetrating abdominal injury sustained from close range firing of a rubber bullet.

METHODS: Case Presentation: A 23-year-old male was transferred to our level I trauma center with a penetrating abdominal injury following an altercation with local law enforcement. In an attempt to apprehend the patient, three rounds of rubber bullets were fired from a 12 gauge shotgun. The third round was fired at close range and entered the patient’s abdomen . CT imaging from the outside hospital showed a foreign body lodged in the left lateral lobe of the liver. The patient underwent laparotomy at our institution where a Grade IV liver injury was found. The rubber bullet was removed from the posterior surface of the liver along with an outer plastic shell. An omental pedicle was fashioned through the defect. Non-segmental debridement of the left lateral lobe was performed during a second-look laparotomy on post-operative day two closely followed by delayed abdominal closure. The remaining hospital stay was uneventful, and the patient was discharged on post-operative day 14.

RESULTS: Not applicable for case report

CONCLUSION: Alternative projectiles, including rubber bullets, were developed as a non-lethal adjunct for crowd control; however, when fired at close range serious injury can occur. This case of intra-abdominal penetration of a rubber bullet with severe liver injury highlights potentially lethal consequences. A re-evaluation of these measures may be warranted to establish guidelines for safe use in law enforcement

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 161 POSTER ABSTRACTS (cont.)

10. A SURGICAL APPROACH TO THE DIAGNOSIS AND MANAGEMENT OF THYROTOXIC HYPOKALEMIC PERIODIC PARALYSIS Brian J Pottorf MD; John T Moore MD; Harris W Hollis Jr MD Denver, CO

BACKGROUND: Thyrotoxic hypokalemic periodic paralysis (THPP) is a life- threatening endocrinopathy rarely encountered in surgical practice. It is associated with uncontrolled hyperthyroidism causing potassium shifts from the extracellular compartment to the intracellular space with resultant myopathy and paralysis. THPP becomes a surgical condition when the disorder is either refractory to medical management or the patient desires operative intervention for compressive symptoms in the neck.

METHODS: This report examines THPP from the surgeon’s perspective. A treatment algorithm for diagnosis and management is presented in conjunction with a detailed case presentation of a young female with recurrent myalgia and weakness resulting from THPP. The typical components of THPP are highlighted. The lack of overt symptoms of hyperthyroidism makes the diagnosis difficult. Clinical requirements and tools for accurate and timely diagnosis are outlined.

RESULTS: A 26 year old female presented with a chief complaint of myalgia and weakness. Her serum potassium was 2.4 mEq/L. She was admitted to the medical service where her hypokalemia was corrected. She was profoundly hyperthyroid with a TSH <0.01 UIU/mL. She denied symptoms of hyperthyroidism. Methimazole and propranolol were initiated. The patient recovered and was subsequently discharged. Eight months later, she presented a second time with weakness, myalgias and a low potassium which eventually dropped to a nadir of 1.2 mEq/L. Paralysis involving all muscles below the neck resulted in dyspnea and an inability to protect her airway. She required emergent intubation. Potassium repletion reversed the paralysis allowing extubation. Her hyperthyroidism remained poorly controlled despite appropriate medical therapy. Radioactive iodine ablation was considered an inferior alternative due to the size of her thyroid and the potential for incomplete ablation. She was referred for thyroidectomy to mitigate the potential of recurrent paralysis and to minimize both the radiation exposure and the time required to complete definitive treatment. She has done well following total thyroidectomy and has no recurrent symptoms.

CONCLUSION: Thyrotoxic hypokalemic periodic paralysis is rare. Prompt intervention to correct electrolyte derangements is paramount for a successful outcome. Control of hyperthyroidism is the ultimate goal. Definitive therapy can be achieved medically or surgically. When the hyperthyroidism is refractory to medical management or radioablation is contraindicated, total thyroidectomy is a reasonable option for the experienced surgeon. Long term results with either modality are excellent. Patient preference, prolonged duration associated with radiotherapeutic ablation, and relief of compressive symptoms warrant consideration of early operative intervention.

162 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

11. CASE REPORT: ASYMPTOMATIC SOLITARY METASTATIC MELANOMA TO THE GALLBLADDER HD Bowker MD; MK Doan MD; JL Cashman MD Phoenix, AZ

BACKGROUND: Metastatic melanoma involves the GI tract in approximately 15% of patients with widespread disease burden and is associated with poor long term survival. Reports of both primary and metastatic gallbladder melanoma appear in the literature, but very few as solitary lesions. When surgically resected, survival rates for solitary metastases can approach 90% at 5 years. Melanoma of the gallbladder may present in both symptomatic (i.e. cholecystitis) and asymptomatic forms, often identified during screening PET CT scan. Data is lacking to assess for differences in outcomes for symptomatic versus asymptomatic gallbladder melanoma.

METHODS: A single case report and review of literature for other reports of isolated metastatic melanoma to the gallbladder.

RESULTS: A 64 year-old man with history of previously treated metastatic melanoma presented to our clinic. Screening PET CT scan demonstrated increased avidity of Couinaud’s segments 4a and 4b of the liver. Right upper quadrant ultrasound was suspicious for chronic cholecystitis. The patient was asymptomatic, and no other disease burden was identified. He underwent diagnostic laparoscopy with subsequent laparoscopic cholecystectomy. No gross pathology was present in the liver or porta hepatis. Gross inspection of the gallbladder demonstrated black, gelatinous excrement within the lumen. Final pathology results indicated isolated gallbladder melanoma, without muscularis invasion and sparing of the cystic duct. The patient was discharged home on post operative day 1 without complication.

CONCLUSION: Melanoma metastases may occur throughout the gastrointestinal tract. When presenting as isolated lesions with the potential for complete resection, surgical intervention is indicated. Overall mortality for isolated lesions is much lower than for widely metastatic GI disease as presented in case series. Because of the paucity of biliary presentations, data regarding this disease process is weak by all standards. However, for low morbidity procedures in otherwise asymptomatic patients, it is our opinion that surgical intervention should be offered in the context of appropriate oncology follow up.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 163 POSTER ABSTRACTS (cont.)

12. THE MANAGEMENT OF SPLENIC TRAUMA IN A REGIONAL TRAUMA REFERRAL SYSTEM PD Colavita MD; PE Fischer MD; H Desai BS; K Jones BS; ML Barringer MD; AB Christmas MD; RF Sing DO Charlotte, NC

BACKGROUND: The goal of an inclusive trauma system is to provide optimal treatment to the injured patient at all echelons of care. Level 3 trauma centers are essential components of this system through the provision of organized care to rural communities. Except in cases where specialized care is required, these centers should provide the same level of service for most traumatic emergencies. The BACKGROUND of this study was to compare the management of splenic injuries at a level 3 vs. a level 1 center within the same trauma system.

METHODS: The trauma registries of the respective level 3 trauma center (TC3) and a level 1 trauma center (TC1) functioning in the same region were queried to identify all splenic injuries from 2006-2011. The TC3 does not have interventional radiology or neurosurgical capabilities. Grade of splenic injury, transfusion requirements, free fluid state, and management data were collected. Outcomes were compared among patients who were managed at TC3, transferred from TC3 to the TC1, and patients directly admitted to TC1.

RESULTS: Overall, 407 patients with spleen injuries were identified; 348 at TC1 and 59 at TC3. Twenty patients were immediately transferred from TC3 to TC1. Compared with the patients who remained at TC3, those transferred had higher injury severity scores (ISS) (mean 29.4 vs 20.3, p=0.016) and had a lower Glasgow Coma Score (GCS) (11.2 vs 14.8, p<0.001) with no difference in age or revised trauma score (RTS). Splenic laceration grades were similar in the two groups who presented to TC3. Comparing patients presenting to TC1 and those who were not transferred from TC3, there was no difference in age, ISS, RTS, or splenic laceration grades. Patients presenting to TC1 had lower GCS scores (12.1 vs 14.8, p<0.001). Of patients presenting to TC3, 28.2% were taken to the OR from the ED vs 18.4% of those at TC1, but 12.9% of patients underwent angiography +/- embolization at TC1 vs. 0% at TC3 (both p<0.05). There was no difference in overall intervention rates. Inpatient mortality rates were equivalent between TC1 and TC3. Rates of home discharge disposition were higher in TC3 (97.4%) vs TC1 (67.3%, p<0.001), and length of stay was shorter (4.9 vs 11.4 days, p=0.002).

CONCLUSION: In this study, patients were likely transferred from TC3 to TC1 for injuries and physiologic derangements beyond their splenic trauma. While LOS and home disposition rates were improved in TC3, this may be confounded by other injury severity factors, including neurosurgical requirements that are not available at TC3. A well-developed level 3 trauma center can effectively manage splenic injuries without the necessity of transfer to a Level 1 Trauma Center.

164 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

13. POSTLOBECTOMY PULMONARY ARTERY AND VEIN STUMP THROMBOSIS: INCIDENCE AND CLINICAL SIGNIFICANCE HA Hopper MD; CN Hopper; MA Smith; RM Bremner; JL Huang Phoenix, AZ

BACKGROUND: The incidence of pulmonary artery (PA) and vein (PV) thrombosis after lobectomy and pneumonectomy is not well reported in the literature. The BACKGROUND of this study was to evaluate the incidence of this entity at a thoracic referral center.

METHODS: After IRB approval, a retrospective review was performed of patients post lobectomy or pneumonectomy from April of 1997 to April of 2012. Data was obtained from operative case database, medical records, and imaging reports. Imaging review was performed by the radiology department; imaging of patients with radiologic reports stating thrombus was re-examined.

RESULTS: One hundred and seventy three patients underwent lobectomy or pneumonectomy. Six were identified to have thrombus: two in the pulmonary vein and four in the pulmonary artery. The average age of the 6 patients was 65 years and three were male. Both pulmonary vein thromboses occurred in men. In 5 of the 6 patients, the average time to identification of thrombus was 8 days. One patient had thrombus identified on day 213. 76 of 173 (43.93%) patients had follow-up CT (computed tomography) scans: 25 (14.45%) had CT angiography; 25 had CT with contrast; and 25 had CT without contrast. Most of these 76 scans were not during the hospitalization but were part of routine post-operative surveillance scans. Of the 6 patients with thrombus, indications for CT included: one for cancer follow-up, two for evaluation of pulmonary embolus, one to rule out abscess, and two for dyspnea. Three of the patients had ultrasounds to evaluate for lower extremity deep vein thromboses. All of the ultrasounds were negative. All 6 patients had lobectomy or bilobectomy. None of the 6 patients that underwent pneumonectomy were identified to have thrombus. Four of the six surgeries involved the right lung. Three of the six thromboses were on the right side. One thrombus was bilateral. Five of the six patients had pathology of adenocarcinoma. One patient had carcinoid type lung cancer. Four of the six patients received chemical deep vein thrombosis prophylaxis during their hospitalization. The average length of the remaining surgical pulmonary artery stump in patients with thrombus was 17.8 mm. This was longer than a randomly selected control group with an average length of 3.9 mm. In patients with pulmonary vein stump thrombus, the average stump length was 16.85mm. This was longer than the same control group with a stump length of 9.1mm.

CONCLUSION: The incidence of thrombus in the PA and PV at our institution after lobectomy or pneumonectomy is 3.4% [PA 2.3% (4 of 173), PV 1.1% (2 of 173)]. Our data suggests there may be an association between stump length and the development of thrombus. No complications from PA/PV thrombus were identified in the immediate postoperative follow-up period. However, there is literature showing possible systemic infarction secondary to embolization of PV thrombus. Further research is required to determine the most appropriate form of treatment.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 165 POSTER ABSTRACTS (cont.)

14. DIAGNOSIS AND CURRENT MANAGEMENT OF GASTRIC PANCREATIC REST TUMORS ST O’Day MD; HW Hollis Jr MD; GE Kimm Jr MD; CC Barnett Jr MD Denver, CO

BACKGROUND: A pancreatic rest tumor is the most common ectopic tissue encountered during operations in the upper abdomen; however the diagnosis and management of these tumors can often be difficult. It is important for surgeons to have clinical awareness of this condition and be familiar with the current methods for accurate diagnosis and treatment.

METHODS: The authors present an illustrative case of a 28-year-old female with abdominal pain caused by heterotopic pancreatic tissue in the gastric antrum. A Pub Med search was performed of all reported cases of pancreatic rest tumors in the past 15 years. These tumors are contrasted to the more common gastrointestinal stromal tumors. The clinical, endoscopic, and radiologic features of pancreatic rest tumors are reviewed. An endoscopic photograph highlights the typical appearance of the lesion. A concise management algorithm for evaluation and treatment of gastric pancreatic rest tumors is included.

RESULTS: Various diagnostic modalities can be used to diagnose gastric submucosal masses and suspected pancreatic rest tumors. These include barium contrast study, computed tomography, magnetic resonance imaging, and endoscopy. Obtaining a histologic diagnosis can be challenging, but is necessary to rule out malignancy in selected cases.

CONCLUSION: Pancreatic rest tumors are relatively uncommon, but should always be included in the differential diagnosis of submucosal lesions in the gastric antrum. There are very specific endoscopic and radiologic features associated with pancreatic rest tumors that can facilitate an accurate diagnosis. Characteristic features of gastric pancreatic rest tumors include: pre-pyloric location, submucosal position with central umbilication and a well-defined round or oval mass with smooth or serrated outline on CT scan. A long diameter to short diameter ratio of greater than 1.4 suggests the presence of heterotopic pancreas. Surgical excision of these tumors is appropriate for symptomatic patients or when malignancy cannot be excluded.

166 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

15. BOUVERET’S SYNDROME CAUSED BY A CHOLECYSTOGASTRIC FISTULA KJ Kalkwarf MD; RD Betzold MD; CL Parnell MD; AT Mancino MD Little Rock, AR

BACKGROUND: Bouveret’s syndrome is a gastric outlet obstruction caused by gallstone impaction. This is an unusual finding most commonly caused by a cholecystoduodenal fistula. While exceedingly rare, a cholecystogastric fistula can also be the cause.

CASE: A 73-year-old man presented to our emergency room with a 4-day history of multiple episodes of emesis, but no abdominal pain. He had no previous abdominal surgeries. A computed tomography (CT) scan from two months prior showed two large gallstones in the gallbladder, but he had never experienced related symptoms. He was afebrile with stable vital signs. Routine laboratory analysis showed no major abnormalities. Physical examination revealed a non-tender and non-distended abdomen. CT scan showed pneumobilia throughout the left lobe of the liver, gallbladder wall thickening with pericholecystic stranding and a communication between the gallbladder and the distal gastric antrum. It also showed a large gallstone in the antrum causing a gastric outlet obstruction and another large gallstone in the second portion of duodenum. After nasogastric tube placement, intravenous fluid resuscitation, and antibiotics, he underwent surgical exploration through a subcostal incision. Upon entering the abdomen, dense adhesions and phlegmonous change were identified near the gallbladder. A large gallstone was palpated near the pylorus and it was extracted through a gastrotomy. A second gallstone was identified in the ileum. It was advanced in a retrograde fashion to an area of the jejunum appropriate for a gastrojejunostomy. The second gallstone was then extracted through an enterotomy used to construct the gastrojejunostomy. The postoperative course was uneventful and he was discharged to home 12 days later.

DISCUSSION: Gallstone ileus occurs when a gallstone enters the gastrointestinal tract through a cholecystoenteric fistula and obstructs the bowel lumen. Eighty percent of the time, these stones pass through the gastrointestinal tract without problem. However, if the stone is greater than 2.5 cm in diameter, it may cause a bowel obstruction or “gallstone ileus.” These obstructions typically occur in the ileum (84%), but can also occur in the distal jejunum (9%), or colon and rectum (3%). Gallstone impaction in the duodenum is also seen, but accounts for only 1-3% of gallstone ileus. This is called Bouveret’s syndrome based on its first description in 1896. Our patient presented with large gastric and duodenal gallstones secondary to a cholecystogastric fistula. This is the least common spontaneous fistula and is a life-threatening complication of cholelithiasis. Although endoscopy can be diagnostic and therapeutic, the dense adhesions and inflammatory changes require surgery in more than 90% of cases.

CONCLUSION: Bouveret’s syndrome continues to be a rare but serious complication of cholelithiasis. In this case, treatment with a gastrotomy for gallstone extraction and a gastrojejunostomy for palliative bypass was both safe and effective.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 167 POSTER ABSTRACTS (cont.)

16. CHYLOUS ASCITES WITH NON-ISCHEMIC SMALL BOWEL MESENTERIC VOLVULUS MK Ruhlman MD; SJ Langenfeld MD Omaha, NE

BACKGROUND: Chylous ascites is the accumulation of lymphatic fluid within the abdominal cavity. It can result from trauma, infection, malignancy, or congenital abnormalities. It can vary greatly in severity and clinical significance. We report the rare finding of chylous ascites resulting from lymphatic obstruction in an otherwise healthy adult presenting with midgut volvulus.

METHODS: A 42 year old woman presented to the University of Nebraska Medical Center emergency department with the acute onset of severe epigastric abdominal pain that began suddenly while swimming. She reported a similar, less severe, episode two years prior which resolved without intervention. She was otherwise healthy, with a surgical history of umbilical hernia repair. On exam, she was non-distressed with stable vital signs. Her abdomen was distended with localized epigastric tenderness but no guarding or rebound tenderness. All laboratory values including CBC, BMP, and lactate were normal. Computed tomography (CT) was performed showing malroatation of the cecum and terminal ileum as well as a mesenteric swirl sign, compression of the superior mesenteric artery and vein, and concern for midgut volvulus. There was no evidence of perforation or pneumatosis. The patient was taken emergently to the operating room for diagnostic laparoscopy.

RESULTS: Intraoperatively, the patient was found to have midgut volvulus involving the entire small bowel and right colon, but no ischemia. The duodenum and left colon were anatomically normal without evidence of congenital malrotation. Over two liters of milky white fluid was found in the abdominal cavity originating from the small bowel mesentery and leaking from the mesenteric border. This was found to be consistent with chyle, having a triglyceride level over 1000 mg/dL. Cytology was negative for malignancy. The bowel was detorsed laparoscopically and resection was not required. The patient tolerated the procedure well and advanced quickly after surgery. She was dismissed home on postoperative day two without incident. Four months later, she is without recurrent episodes.

CONCLUSION: Chylous ascites has been rarely described in the literature. This case reviews a healthy young patient presenting with midgut volvulus which resulted in severe lymphatic obstruction and subsequent massive chyloperitoneum. Interestingly, the patient did not develop bowel ischemia despite the severity of mesenteric congestion and the large amount of chylous fluid found within the abdomen. In this case, early laparoscopy was both diagnostic and therapeutic. It allowed for a quick recovery from a potentially life-threatening disease.

168 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

17. NECESSITY OF REPEAT HEAD CT AFTER ISOLATED SKULL FRACTURE IN THE PEDIATRIC POPULATION AS Hentzen MD; SD Helmer PhD; RJ Nold MD; JM Haan MD Wichita, KS

BACKGROUND: Head injuries are common in the pediatric population, but evaluation and management is highly variable. Skull fracture will prompt computed tomography (CT) of the head. However, when an isolated skull fracture is found there are no guidelines for repeat imaging. This study evaluated the need for repeat head CT in the event of isolated skull fracture in the pediatric population.

METHODS: A 10-year retrospective review was conducted of patients ≤18 years of age with isolated skull fractures at an American College of Surgeons-verified level 1 trauma center from January 1, 2001 to December 31, 2011. Data collected included demographics, injury severity and details, location of skull fracture, clinical indicators of head trauma, development of intracranial hemorrhage, and mortality.

RESULTS: Of the 65 patients in this study, the mean age was 4.2 years, Injury Severity Score was 7.2 and head/neck Abbreviated Injury Severity Score was 2.3. The majority of the patients had a GCS of 15 upon arrival (75.4%). Five patients were level 1 traumas, 48 were level 2’s, and 12 were consults from the emergency department. Mechanism of injury included: falls (69.2%), motor vehicle collisions (23.1%), and animal injuries (3.1%). Abuse was involved in 4.6% of the cases. Frontal fractures were identified in 26.2% of cases, 26.2% were parietal, 15.4% were temporal and 29.2% were basilar. The most common clinical indicators associated with skull fractures were non-frontal scalp hematoma (40.0%), severe mechanism (30.8%), and loss of consciousness (30.8%). Other indicators present were GCS score <15 (23.1%), irritability (20.0%), prolonged vomiting (15.4%), and altered mental status (10.8%). One patient developed intracranial hemorrhage after the initial head CT showed no bleed. She had a non-frontal scalp hematoma, loss of consciousness, altered mental status and nausea on admission. Repeat CT was done on hospital day 4, secondary to intractable nausea, which detected a small subdural bleed. Sixty-three patients were discharged home, 1 to foster care, and 1 to rehabilitation. There were no deaths.

CONCLUSION: Isolated skull fractures in the pediatric population do not necessitate a repeat head CT as long as they do not develop worsening clinical indicators of head injury. There should be a low threshold for repeat imaging if the patient clinically deteriorates.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 169 POSTER ABSTRACTS (cont.)

18. ANALYSIS OF PATIENTS GREATER THAN OR EQUAL TO 65 WITH ISOLATED CERVICAL SPINE FRACTURES LM Poole MD; P Le MS3; RM Drake MEd; SD Helmer PhD; JM Haan MD Wichita, KS

BACKGROUND: Fall injuries are an extremely common and significant cause of morbidity and mortality in the elderly population. Cervical spine fractures frequently result following falls and have a significant mortality rate ranging from 19% to 24%. Few studies have specifically looked at dysphagia in this group and more information is needed regarding the discharge outcomes of survivors. The BACKGROUND of this study was to evaluate elderly patients with isolated cervical spine injury in regards to enteral feeding options, disposition, and mortality.

METHODS: An 11-year retrospective review was conducted of patients ≥ 65 years of age with isolated cervical spine fractures at an American College of Surgeons- verified level 1 trauma center from January 1, 2001 to December 31, 2011. Data included demographics, injury severity/details, cervical spine injury details, sensory and motor deficits, hospitalization details, swallow evaluation, need for naso-gastric tube or Dobhoff tube for enteral nutrition, invasive adjuncts (tracheostomy, open or percutaneous endoscopic gastrostomy), complications, and mortality.

RESULTS: A total of 145 patients met study inclusion criteria. Patients were predominately female (56.6%), with a mean age of 80.2 ± 7.6 years, and a median ISS of 5 and head/neck AIS of 2. Two patients (1.4 %) had a sensory deficit, 4 (2.8%) had a motor deficit, and 4 (2.8%) had both a sensory and motor deficit. Thirteen patients (9.0%) had a naso-gastric tube or Dobhoff tube placed for enteral nutrition. Nearly one-third of patients (n=43, 29.7%) underwent swallow evaluation, and 10 (6.9%) had either an open or percutaneous gastrostomy. Three patients (2.1%) had a tracheostomy. The largest proportion of patients were discharged to a skilled nursing unit (n=52, 35.9%), with the next largest group being discharged to home or to home with home health (n=49, 33.8%). Nine patients (6.2%) died in the hospital and sixteen patients (11%) were made comfort care.

CONCLUSION: Isolated cervical spine injury in the elderly patient can lead to significant consequences. Dysphagia can be a challenging complication following an isolated cervical spine injury in an elderly patient. This raises the question as to whether elderly patients should routinely undergo a swallow evaluation following a cervical spine injury. Just over one-third of affected patients required skilled nursing care following their injury and another 11.8% died or were discharged to hospice during their hospitalization, which is consistent with previously reported data. Physicians need to be cognizant of the potential for these problems in order to counsel patients and their families.

170 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

19. LESSONS LEARNED – MULTIPLE CASUALTIES FROM COLLAPSE OF AN OUTDOOR STAGE J Browne MD; T Pohlman MD; T Hayward MD; G Gomez MD; T Scherer MD; DV Feliciano MD; RL Reed MD Indianapolis, IN

BACKGROUND: Collapse of scaffolding on an outdoor concert stage is an underappreciated cause of multiple casualty incidents (MCIs). Healthcare providers are usually not familiar with forces related to a stage collapse and may not be able to anticipate the types of injuries sustained by victims.

METHODS: This was a retrospective analysis of the electronic medical records and Trauma Registries of 3 Level I Trauma Centers (LITCs: 2 adult, 1 pediatric) serving an urban community following an outdoor stage collapse. Data collected included patient injuries, operations performed, Trauma and Injury Severity Scores (TRISS), and mortality. Reports of similar MCIs associated with collapse of an outdoor stage in the last 10 years worldwide were reviewed for comparison.

RESULTS: The MCI in question resulted from excessive straight-line wind gusts that forced the forward collapse of the scaffolding of a stage onto an awaiting audience at a large concert venue. Responders triaged 44 patients with 145 injures to 3 L1TCs. There were 7 fatalities including 4 deaths on the scene and 3 at a L1TC from traumatic brain injuries. The majority (n=109, 75%) of injuries were located above the diaphragm. Emergency operations were performed for 22 injuries, including 3 immediate decompressive craniectomies. TRISS analysis identified no mortality outliers. To our knowledge, there have been 18 outdoor stage collapses worldwide in the past decade, causing 303 injuries and 15 deaths (mean mortality 2%). The majority (13/18, 72%) of these events were wind-related. The experience reported herein was the most lethal of its kind during this period (mortality 7/48, 15%).

CONCLUSION: Outdoor stage collapses persist despite best-practice engineering guidelines for construction. This has most commonly been due to straight-line wind gusts, which often exceed the engineering specifications required by standards committees. In the experience described above, the falling overhead vector of force during a stage collapse resulted in most of the injuries occurring above the diaphragm. Receiving healthcare providers following similar MCIs should anticipate this injury pattern. Recommendations for civic and healthcare personnel from this experience include the following: 1) municipalities should proactively mandate inspections of stage engineering; 2) concert venues should have emergency evacuation plans; 3) concert management should act early to evacuate crowds in the face of impending severe weather; 4) hospital disaster plans should account for the increased incidence of injuries above the diaphragm, especially to the head and neck, from such incidents.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 171 POSTER ABSTRACTS (cont.)

20. CURRENT MANAGEMENT OF CECAL VOLVULUS FOLLOWING COLONOSCOPY KV Mitchell MD; A Canfield MD; C Frankum MD; HW Hollis MD Denver, CO

BACKGROUND: Cecal volvulus has been reported as a rare but potentially lethal complication following colonoscopy. It can result in large bowel obstruction and compromised colonic perfusion. Cecal ischemia and perforation can lead to catastrophic outcomes if expectant management delays definitive treatment.

METHODS: This report presents an algorithm to be used as a tool for early recognition and expeditious management of cecal volvulus. It serves to focus attention on colonoscopy as a rare but potential etiology of acute cecal volvulus. An illustrative case is presented that exemplifies the typical presentation and clinical course of cecal volvulus following colonoscopy. A Pub Med review of the recent literature accompanies this report.

RESULTS: A 67 yo female became ill after routine screening colonoscopy and sigmoid polypectomy. She experienced pain, nausea and vomiting post procedure. No hematochezia or acute abdomen was identified on initial presentation. She was initially observed for signs of perforation and was discharged only to return with similar symptoms and mild abdominal distention. Contrast CT evaluation revealed cecal dilation consistent with volvulus and intraperitoneal free air. The patient was taken urgently to the operating room where cecal volvulus was confirmed and a laparoscopic assisted right hemicolectomy was performed. The patient’s post-operative course was associated with a mild ileus which resolved without re-intervention and she was discharged on postoperative day 8. She has remained well post resection. The differential diagnosis of persistent abdominal pain following colonoscopy is presented. Recommendations for diagnosis and treatment are discussed, including appropriate imaging and timely surgical intervention. Persistent pain post colonoscopy is abnormal and should prompt the surgeon to consider cecal volvulus in addition to the more typical perforations associated with polypectomy, sigmoid diverticular rupture or transmural electrocautery injury.

CONCLUSION: Cecal volvulus is a rare complication of colonoscopy. Patients typically present within 2 days following the procedure complaining of persistent abdominal pain. The pain is worse with upright position, likely impacted by movement of the mobile cecum. A plain abdominal upright radiograph may demonstrate free air and identify a dilated cecum. CT scan is usually more accurate in demonstrating cecal dilation. Inadequate adhesion of the cecum to the posterior parietal peritoneum predisposes a patient to cecal rotation anteromedially. This is likely precipitated by colonic insufflation during the procedure. The diagnosis of cecal volvulus by contrast enema or CT scan should prompt emergent surgical exploration and right hemicolectomy.

172 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

21. PERSISTENT CONSTIPATION AFTER GASTROENTERIC STIMULATOR PLACEMENT FOR GASTROPARESIS MS Jones MD; M Rivera MD; AE Barber MD Las Vegas, NV

BACKGROUND: Gastrointestinal dysmotility and gastroparesis, whether diabetic or idiopathic, have a varying constellation of associated symptoms. Our practice involves placement of gastroenteric stimulators for symptomatic improvement of nausea and vomiting from gastroparesis in select patients. This group has noticed an anecdotal persistence of lower gastrointestinal symptoms, specifically constipation, in patients with successful gastroenteric stimulator placement. Considering the likely link between dysmotility in the upper gastrointestinal tract and that in the lower gastrointestinal tract, we posit that the majority of our patient population experiences persistent constipation and/or fecal incontinence after gastric stimulator placement.

METHODS: Patients with diabetic and idiopathic gastroparesis were evaluated in this study. A retrospective chart review of 27 patients was conducted. Successful gastroenteric stimulator placement for gastroparesis was defined by an absence of significant nausea and vomiting at follow up examination. Additionally, patient records were evaluated for persistence of constipation, need for regular laxative use, and fecal incontinence.

RESULTS: 72% of patients post gastroenteric stimulator placement for both diabetic and idiopathic gastroparesis experienced persistent constipation. Some members of this group have successfully undergone sacral neuromodulation with decrease in fecal incontinence and constipation.

CONCLUSION: With research to suggest mechanisms associated with gastroparesis may be similar to those involved with chronic constipation in certain patients, this data poses the question: should sacral neuromodulation be attempted in gastroparesis patients with constipation? Given observed treatment successes, should sacral neuromodulation be attempted in patients with fecal incontinence?

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 173 POSTER ABSTRACTS (cont.)

22. INCREASING OIL PRODUCTION: AN UNEXPECTED EXPLOSION IN TRAUMA PATIENTS D Urban MS; JG Ward BA; SD Helmer PhD; JM Haan MD Wichita, KS

BACKGROUND: Increased concern over associated injury patterns following a rise in oil field injuries led to a review of causative factors and treatment outcomes.

METHODS: A retrospective review was conducted of all land-based oil field injury admissions ages 18 and older at an ACS-verified level 1 trauma center from January 2003 through June 2012. Data collected included demographics, injury mechanism, injury type, treatment, and patient outcomes.

RESULTS: A total of 66 patients were admitted during the study period. Patients were all male, with mean age 37.2 years, mean Glascow Coma Scale score of 13.8, and normotensive (one patient in shock). The majority were minimally injured with mean Injury Severity Score of 9.0; however, 23 patients (12.9) required ICU admission, 6 (3.4%) transfusion, and 9 (13.6%) mechanical ventilation. Predominate mode of injury was being struck (15.6%), followed by fall (6.7%), caught in machinery (4.5%), explosion (3.9%), pinned (3.4%), struck and fall (2.2%), and cut (0.6%). Injuries were predominantly head (50%), extremity (39.4%), spine (19.7%), face (13%), pelvic (12.1%), thoracic (16.7%), burn (10.6%), and abdominal (4.5%). Fifty-two patients (78.8%) were discharged home, 11 (16.7%) to rehabilitation, 1 (1.5%) to a nursing home, with 2 deaths (3.0%).

CONCLUSION: Increased domestic oil production will inevitably result in higher numbers of oil field-related traumas. Lower torso protection, securing overhead materials, as well as fall safety precautions and education could lead to a decrease in injury incidence in this growing industry.

174 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

24. “OPERATIONS THROUGH THE SKIN GRAFT -- SEPARATING ABDOMINAL PROCEDURES FROM ABDOMINAL WALL RECONSTRUCTION AFTER DAMAGE CONTROL” DH Livingston MD; DV Feliciano MD Newark, NJ

BACKGROUND: Despite advances in trauma care, a subset of patients surviving damage control laparotomy cannot achieve fascial closure and require split-thickness skin grafting (STSG) of their open abdomen. Controversy exists as to whether reconstruction of the gastrointestinal tract (i.e., takedown stoma, etc.) should be perfomred at the time of abdominal wall reconstruction (AWR) or staged. Many surgeons do not believe that operations through the STSG can be completed safely or without loss of the graft. The advantage of the staged approach is that later AWR can be performed in a “clean field”.

METHODS: Patients were deemed ready for intestinal reconstruction when the STSG could be easily picked up from the underlying viscera. An incision encompassing up to 180 degrees of the circumference of the healed STSG was made within 1 cm of the interface with native skin. Adhesions were lysed only as needed to perform the planned operation, and care was taken not to detach the STSG from underlying omentum or viscera more than necessary. At the completion of the procedure, any devascularized STSG was debrided. The edge of the elevated STSG was then sutured to native skin of the abdominal wall with interrupted sutures of 2-0 nylon. Dry gauze and an abdominal binder were used to minimize traction movement of the previously elevated STSG.

RESULTS: From 1995-2013, 22 patients underwent 25 abdominal operations through the elevated STSG approach at two Level I trauma centers. The mean time between application of the original STSG and the subsequent intra- abdominal operation was 11 months. Operations performed were as follows: 15 takedown of stomas, 3 gastrojejunostomies, and 7 other procedures (antrectomy/ gastrojejunostomy; small bowel repair after blunt trauma; closure of colocutaneous fistula; choledochojejunostomy; Caesarean section; ureteral reimplantation; excision of heterotopic bone). There were 2 complications. One operation could not be completed as planned as the STSG was devascularized, and this patient was closed with full- thickness skin flaps. A 30% loss of the elevated STSG occurred in another patient who developed extensive edema after a prolonged lysis of adhesions. A new STSG was applied 18 days later. All other operations were successfully completed and all other elevated STSG healted completely. There were no intestinal complications, infections or deaths.

CONCLUSION: Major intra-abdominal operations are readily accomplished though the abdominal STSG in almost all patients who have undergone a damage control laparotomy. This staged approach allows for more operative options and decreases the risk of infections following subsequent complicated AWR.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 175 POSTER ABSTRACTS (cont.)

25. AUTOMATED IMPLANTED CARDIOVERTER DEFIBRILLATOR: A RISK FACTOR FOR ADVERSE OUTCOMES FOLLOWING TRAUMA RS Jawa MD; M Altieri MD; J McCormack BSN; E Huang MS; D Rutigliano MD; JA Vosswinkel MD Stony Brook, NY

BACKGROUND: The number of Automated Implanted Cardioverter Defibrillators (AICDs) being implanted is increasing, with demand estimated to rise substantially in the next 20 years. Limited research has been performed on the implications of defibrillators for trauma patients. We hypothesized that while a minority of our trauma patients would have AICDs, they would have significantly higher complications rates.

METHODS: We reviewed the trauma registry for patients admitted to a state designated level 1 trauma center from 2008-2012. To allow for appropriate case matching only admitted patients who were at least 60 yeard old, had at least one National Trauma Databank defined comorbidity, and did not expire in the emergency room were included. Statistical analyses for significance were performed using parameteric and nonparametric tests, as appropriate.

RESULTS: AICD No AICD Patients(n) 82 1675 Gender(%male) 74.4 42.5* Age(mean+SD,years) 79.5+8.3 80.0+9.8 Comorbidity HTN(%) 75.6 75.3 ^On Anticoagulant(%) 71.9 30.2* DM(%) 32.9 22.6* Dementia(%) 15.8 19.1 Mechanism of Injury Fall(%) 85.4 77.4 ISS(mean+SD) 11.5+7.1 10.9+6.8 GCS(median&IQR) 15(15,15) 15(15,15) H.LOS(median&IQR,days) 9(5,14.7) 7(4,11) ICU Stay(%) 29.3 21.6 Unplanned ICU admit(%) 14.6 6.3* Complication: DVT/PE(%) 4.9 4.5 Pneumonia(%) 12.2 7.4 Sepsis(%) 2.4 3.0 AMI(%) 11 4.5* Mortality(%) 13.5 5.7*

*p<0.05 between patients with an AICD and those without AICD. ^Anticoagulant refers to Coumadin or Plavix.

176 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

CONCLUSION: The patients were comparably matched in terms of age, Injury Severity Score (ISS), Glasgow Coma Score (GCS), hypertension (HTN), dementia, and mechanism of injury. However, patients with AICDs were predominantly male, more often diabetic (DM), and more often on anticoagulants. Patients with AICDs had substantially higher unplanned Intensive Care Unit (ICU) admission, acute myocardial infarction (AMI), and mortality rates despite relatively low ISS scores. To our knowledge, this is the first English language report evaluating the association between AICDs and adverse outcomes in trauma. It remains to be determined if these excess adverse outcomes are secondary to the combination of anticoagulant use and AICD. Confirmation of these preliminary findings in a larger study would support the need for earlier, more intense management of these patients.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 177 POSTER ABSTRACTS (cont.)

26. EARLY POSTOPERATIVE COMA IN PATIENT USING ICODEXTRIN FOR PERITONEAL DIALYSIS: A WORD OF CAUTION NR Shah MD; A Ashfaq MD; J Murphy MD; JP Heppell MD Phoenix, AZ

BACKGROUND: Icodextrin (Extraneal®, Baxter Healthcare Corporation, Deerfield, IL) used as peritoneal dialysate can be absorbed and hydrolysized to maltose that are detected as glucose by commonly used point-of-care Accu-chek glucometers. This can lead to factitious hyperglycemia resulting into significant morbidity if not recognized early.

METHODS: A 56 year old male insulin dependent diabetic with known history of HIV and End Stage Renal Disease on peritoneal dialysis underwent examination under anesthesia and excisional biopsy of a suspicious anal lesion. In the recovery room, the patient became progressively comatose. He had no response to narcan, normal blood gases and normal bedside point-of-care blood glucose monitoring by Accu-chek (162, 134, 123, and 152 mg/dL). The patient was transferred to the ICU where a basic metabolic panel revealed severe hypoglycemia (43 mg/dL). After receiving dextrose 50% and continuos dextrose drip his mental status recovered.

RESULTS: He was sent home the next day after receiving peritoneal dialysis.

CONCLUSION: Clinicians should be aware of falsely elevated glucose readings based on Accu-chek particularly in diabetic patients receiving peritoneal dialysis with Icodextrin. Safeguards to prevent this complication have been implemented at our institution by means of using new StatStrip glucosemeter (NovaBiomedical,Waltham,Mass) utilizing glucose oxidase enzyme in test strips.

178 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

27. AN ANALYSIS OF THE OUTCOMES OF PENETRATING GUNSHOT WOUND INJURY BEFORE AND DURING RECESSION J Baalmann MS; JG Ward BA; SD Helmer PhD; JM Haan MD Wichita, KS

BACKGROUND: Previous studies suggest there is a correlation between the incidence of penetrating traumatic injuries and economic depression. In the United States, a prolonged recession began in August 2007. The resultant financial stress may place individuals at increased risk for injury secondary to gun-related crimes. This study evaluated morbidity and mortality associated with gunshot injuries during the recent recession.

METHODS: A 5-year retrospective review was conducted of gunshot wound (GSW) injuries at an ACS-verified level 1 trauma center. Three study groups were created: pre-recessionary (PRC; October 01, 2005 to December 31, 2007); transitional (TR; January 01, 2008 to September 30, 2008); and recessionary (RC; October 01, 2008 to December 31, 2010). Data collected included demographics, injury severity, vitals, treatment, intensive care unit (ICU) admission, patient outcomes, previous violence- related injury (PVRI), weapon type, insurance status, and mortality. Gun mishaps and self-inflicted GSWs were excluded.

RESULTS: Across the 3 study periods a total of 185 patients met inclusion criteria: PRC=87, TR=20, RC=78. Demographic variables, injuries sustained, and complications were similar between PRC and RC, although there was a trend for more head injuries in RC than in PRC (8.0 vs 17.9%, P=0.057). Median ISSs were also similar for PRC and RC (4 vs 9, P=0.610). However, indirect markers of severity, including ICU admission, and intubation prior to arrival increased in the REC. Intensive care unit admission increased from 21.8 to 39.7% (P=0.012). Intubation prior to arrival was significantly higher for PRC vs RC (0.0 vs 39.7%, P<0.001). Injuries resulting in permanent disability increased in the RC from 2.3 to 12.8% (P=0.033). A trend towards decreased GSWs secondary to domestic violence for PRC vs RC was observed (11.5 vs 3.8%; P=0.086), with a concomitant trend for increased violence within a home for RC vs PRC (38.2 vs 56.1%, P=0.064). Previous violence-related injury increased from PRC to RC (5.7 vs 19.2%, P=0.008). Handgun use increased for PRC vs. RC (66.0 and 85.7%, P=0.023) while there was a trend for increased numbers of uninsured patients (55.2 vs 69.2%; P=0.097). There was no significant difference in mortality rates between PRC and RC (18.4% and 14.1%, P=0.457).

CONCLUSION: Typical recessionary markers such as increased domestic violence or uninsured patients did not increase significantly, bringing into question the utility of violence prevention programs in an economic depression. However, during the recent recession injury due to handguns increased, therefore greater handgun regulation may prevent injury during times of economic recession. While its significance is unclear, increased permanent disability was observed with indirect markers of increased severity of injury.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 179 POSTER ABSTRACTS (cont.)

28. THE INCIDENCE AND IMPACT OF DRUG USE AS WELL AS ALCOHOL ON TRAUMA M Fang; JK Pham BS; AP Kong MD; C Barrios MD Orange, CA

BACKGROUND: Recent studies have shown that alcohol and substance abuse increases the likelihood of traumatic injury. While the correlation between alcohol consumption and trauma has been studied extensively, less is known about the outcomes or type of post-injury clinical care necessary for patients who test positive for a combination of alcohol and drug use. The goal of the study is to assess the effect that alcohol as well as drug use have on injury severity, hospital and ICU length of stay, and outcomes.

METHODS: This was a retrospective study at a Level 1 trauma center of patients who underwent a computerized alcohol and drug screening intervention (CADSI). Patients were categorized into four groups: alcohol positive only, drug positive only, a combination of drug and alcohol positive and negative for both. Each patient was tested for the presence of drug and alcohol whenever possible. Hospital and ICU length of stay (LOS), Glasgow Coma score, mortality, and injury severity score (ISS) were analyzed for correlation to alcohol and drug presence. T-test and chi squared were utilized for statistical significance.

RESULTS: The study surveyed 932 ED and inpatients. Patients who were not tested for either alcohol or drugs or both were excluded (124). Those who tested positive for alcohol were also likely to test positive for drugs (88.8%). Patients positive for both alcohol and drugs were significantly more injured (ISS 13.43 vs 9.92, p-value <0.05) than those positive for only alcohol. When compared to patients positive for only alcohol, patients positive for both drugs and alcohol, were not likely to have significantly higher hospital or ICU LOS (7.03 vs 5.36, p=0.26 and 1.66 vs 1.53, p=0.81 respectively). However, by comparing patients who tested negative for both drugs and alcohol to those who tested positive, the difference between their hospital LOS (4.04 vs 5.48, p=0.04) does show a significant increase in the need for use of inpatient resources. Patients who tested positive for both alcohol and drugs were more likely to yield decreased survival rates than those who tested negative for both (94% vs 97% , p-value <0.01).

CONCLUSION: The study suggests that screened patients who are positive for alcohol, are more likely to be positive for drugs as well. Furthermore, findings indicate that a combination of alcohol and drug use is associated with a higher injury severity score, resulting in greater need for treatment and use of resources. Preventative measures such as alcohol screening and intervention have been shown to reduce recidivism in trauma. ED as well as inpatients should be screened for drug use in a similar manner in order to reduce high risk behavior. A study for validating a drug screening tool is warranted.

180 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

29. GEOGRAPHIC PREVALENCE OF TRAUMA MECHANISMS IN AN URBAN SETTING JK Pham BS; P Schuber BS; S Lush MSN; C Barrios MD Orange, CA

BACKGROUND: The consequences of traumatic mechanism injuries remain a major public health problem in urban settings. National hospital-based statistics remain useful. However, they do not provide any insight into the geographic patterns of specific mechanisms. Understanding of geographic variation from these injuries could improve prevention and response.

METHODS: Our BACKGROUND is to identify incidences and outcomes associated with severe traumatic injury across geographic regions of Orange County in order to target resources and injury prevention strategies.

RESULTS: From a total of 2481 patients, 2017 were able to be geolocated. Auto vs. Auto or Motorcycle traumas were prevalent on surface streets. About 38.7% of Auto vs. Pedestrian traumas occurred on major streets and intersections. Assaults were substantially prevalent along freeways. Penetrating traumas (41.8%) concentrated in the large inner city areas. 464 (18.7%) were excluded due to 911 system inputting errors and outdated technology.

CONCLUSION: Our data demonstrated that there are indeed geographic patterns to certain trauma mechanisms in a large urban county. Those patterns allow for targeting resources to specific locations in order to improve injury prevention measures. Furthermore, our analysis demonstrated opportunity for enhanced technology to assist first response personnel in overcoming observed challenges currently faced in data transmission and information sharing. Enhancements would allow better field and hospital preparation and shorter response times.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 181 POSTER ABSTRACTS (cont.)

30. EXTENSIVE PNEUMATOSIS FOLLOWING IRRIGATION OF PELVIC DRAIN WITH HYDROGEN PEROXIDE AA Melin DO; AM Heckman MD; SM Hussain MD; JS Thompson MD Omaha, NE

BACKGROUND: Hydrogen peroxide is a widely available agent used commonly as an irrigation and disinfecting solution. It has been reported, however, to have significant side effects. The severity of these are related to the concentration and method of exposure ranging from nausea and abdominal cramping to portal venous gas, air embolism and death. We present a case of extensive pneumoperitoneum associated with use of hydrogen peroxide.

METHODS: We present the case of an 81 year old male who developed a rectovesicular fistula following radiation for metastatic prostate cancer. He had recurrent bleeding and infections and underwent a pelvic exenteration which was complicated by a persistent pelvic abscess requiring placement of percutaneous drainage catheter. He noted decreased output from his drain over several days and irrigated the catheter with 3% hydrogen peroxide rather than the prescribed saline flushes. He presented later that day to the emergency room with fever, diarrhea and abdominal cramping but no rebound or guarding. CT imaging was obtained which depicted free air in the pre-sacral space extending into the retroperitoneum and diffusely throughout the peritoneum. However no portal venous gas was noted.

RESULTS: The patient was admitted with concern for sepsis and started on antibiotics. He did not appear to have an acute abdomen on examination. Given his clinical exam and upon careful review of the imaging, we assumed his radiographic findings were related to the direct instillation of hydrogen peroxide into his pelvic cavity rather than concern for perforation. He was monitored for several days and his catheter was repositioned for optimal drainage of his persistent collection. He was discharged with an oral antibiotic regimen and resumed flushing his drain with saline. Resolution of free air was noted on subsequent imaging.

CONCLUSION: Instillation of hydrogen peroxide into an intraabdominal cavity resulted in a benign pneumoperitoneum. The radiographic findings were concerning for whether operative exploration was indicated, particularly in a complicated surgical patient. This effect of hydrogen peroxide is a significant and potentially treatment altering radiographic finding.

182 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

31. HEPATIC “BOLSA” : A NOVEL METHOD OF PERIHEPATIC PACKING FOR HEMORRHAGE SF McLean MD; N Ng MD; AH Tyroch MD; M Galeb MD El Paso, TX

BACKGROUND: Perihepatic packing using preformed polyglactin 910 (Vicryl) mesh or mesh which is sutured to the liver has been reported for traumatic hemorrhage. We report a new technique of haptic wrapping case of hepatic bleeding after liver biopsy in a coagulopathic patient. The technique is called the hepatic “BOLSA” (Bag on Liver Supporting Anti-Hemorrhage).

METHODS: A 59 year old male presented in recovery room after liver biopsy, followed by angio-embolization of hepatic mass 9 hours earlier. The patient was acidotic with base deficit 6.5, pH 7.31. He had INR 0f 1.6, PT 17.8 and bladder pressure 25, indicating mild intra-abdominal hypertension. CT showed fluid around the liver. The patient’s coagulopathy was not able to be corrected with multiple transfusions of FFP and cryoprecipitate, and the patient developed abdominal compartment syndrome with bladder pressure of 40, difficulty with ventilation. Patient was taken to OR. The liver mass was located in the dome in segments 7 and 8. The mass was packed, falciform taken down. Patient initially stabilized, then rebled, was taken down to angiography, where a selective Right hepatic artery embolization was performed. The patient returned to OR the same day, and a surface bleeder was ligated, then the patient was repacked. The patient stabilized. He was taken to OR on POD 2.

At the second OR, as soon as the liver packs were removed, the patient resumed bleeding. The following were used to stop bleeding: surgicel, Nu-knit surgicel, Argon beam coagulation, Fibrin sealant, and more packing. These were not successful. A BOLSA was created. Two 12 by 12 cm sheets of polyglactin 910 mesh were sutured together with a running PDS suture creating a long rectangle of mesh. One was knitted, one woven. Then a number 1 PDS was run in a mattress fashion along each of the longer aspects of this rectangle. This formed a bilateral purse string along each long edge. The BOLSA was placed around the right lobe of the liver such that it completely wrapped the liver, leaving the hemostatic agents in the mass. Then the purse strings were tightened. This left the gallbladder in the middle of the purse strings, free. The purse string sutures were tied. There were no sutures to the liver itself. After a cholecystectomy, the patient had a Wittmann patch placed on POD 4. On POD 11 from the initial surgery and POD 9 from the BOLSA placement, the patient returned to OR. The BOLSA was removed, the abdomen closed primarily.

RESULTS: The patient progressed to eating, ambulating. He required drainage of a right pleural effusion, and was discharged home six weeks after the BOLSA was placed.

CONCLUSION: A hepatic BOLSA with lateral purse string sutures is effective in stopping hepatic bleeding in a coagulopathic patient.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 183 POSTER ABSTRACTS (cont.)

32. GUT FAILURE IS A RELIABLE PREDICTOR OF INTRAABDOMINAL ABSCESS SM Kolnik BS; CC Burlew MD; BC Shulman BA; JL Johnson MD; EE Moore MD Denver, CO

BACKGROUND: Fever and leukocytosis in the critically ill trauma patient is typically the harbinger of an infectious complication. Enteral nutrition (EN) tolerance via tube feeds has been suggested to be a screening tool to exclude intraabdominal abscess (IAA) as an etiology for the trauma patient with fever and leukocytosis, although EN tolerance has not been systematically evaluated. The BACKGROUND of this study was to determine the clinical utility of using EN tolerance as a predictor of IAA absence.

METHODS: Data were obtained from a multicenter prospective cohort study of blunt trauma patients with hemorrhagic shock. EN was initiated and advanced by a predetermined study-wide protocol. Patients age ≥ 16 with fever (T ≥ 38.0) or leukocytosis (WBC ≥ 12,000) were included. A logistic regression with repeated measures model was used to assess the association between EN tolerance (defined as ≥ 1,200 kcal/day) and primary IAA.

RESULTS: Out of the 1,563 patients with fever or leukocytosis, 57 IAAs were diagnosed (3.6% prevalence). 36 (75.0%) of these diagnoses were among patients who did not tolerate EN on the previous day; the remaining 12 (25.0%) tolerated EN on the day prior to diagnosis. Patients not tolerating EN were 2.7 times as likely to harbor an IAA. Patients tolerating EN were 63% less likely to be diagnosed with an IAA compared to patients who did not tolerate EN on the prior day (95% CI: 29.6% to 80.9%; p value = 0.0026).

CONCLUSION: The majority of patients with an IAA do not tolerate EN immediately prior to diagnosis. While IAA is uncommon in patients tolerating feeding, EN rate cannot be relied on to completely exclude abdominal infection.

184 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

33. THORACIC EXTRAVASATION: A COMPLICATION OF PARENTERAL NUTRITION ADMINISTERED VIA CENTRAL VENOUS ACCESS RW Day MD; JV Blas MD; KL Harold MD; AB Chapital MD Phoenix, AZ

BACKGROUND: The insertion of central lines and initiation of parenteral nutrition is generally a safe practice. There are many potential complications; however, great vessel perforation can lead to mediastinal extravasation of total parenteral nutrition (TPN).

METHODS: The charts of two patients who had experienced perforation of great vessels by peripherally inserted central catheters and extravasation of total parenteral nutrition were reviewed. The management of this condition is also reviewed.

RESULTS: Patient 1: A sixty-three year old male with severe pancreatitis and associated pancreatic pseudocyst required the initiation of parenteral nutrition. A PowerPICC line was placed and total parenteral nutrition initiated. An esophagoduodonoscopy was attempted to place a post-duodenal feeding tube, this attempt had to be aborted due to patient intolerance. TPN was reinitiated after the procedure and five hours later the patient developed subjective shortness of breath. A chest x-ray showed large bilateral pleural effusions and bilateral thoracentesis was performed. The fluid removed was milky-white in nature and sent for analysis which revealed glucose of 587 and triglycerides of 372. A CT scan of the chest, abdomen and pelvis which showed mediastinal free air, pericardial effusion and bilateral pleural effusions. CT surgery was consulted and the PICC line was removed in the ICU and the patient did well with no further sequelae.

Patient 2: A sixty-four year old male underwent open ventral hernia repair with Gore Bio-A polymer mesh and layered closure. He had a prolonged post-operative ileus and a PowerPICC was inserted and TPN was initiated. Three days after placement, the patient became tachycardic and tachypnic. Physical exam revealed decreased lung sounds at bilateral bases. The patient also had an elevated white blood cell count and a CT scan of chest, abdomen and pelvis was obtained. This CT scan revealed bilateral pleural effusions and an intra-abdominal abscess. Bilateral thoracentesis revealed milky-white fluid with glucose 177, triglycerides of 1184. CT angiogram of the chest showed the PICC line outside the vessel in the mediastinum and it was removed under ICU monitoring. The effusions had recurred at this point and bilateral chest tubes were also placed. The effusions were seen to resolve and the chest tubes removed. The patient had no further sequelae.

CONCLUSION: While great vessel perforation of a central catheter with TPN extravasation is a relatively rare complication precautions including use of single- lumen catheters can be used to decrease this risk. A high index of suspicion should be maintained and TPN stopped during the evaluation of new-onset pleural effusions. If ultimately determined to be due to TPN extravasation, prompt consultation with cardiothoracic surgical services should occur in order to manage potentially fatal conditions which may develop from extravasation or from removal of the inciting catheter.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 185 POSTER ABSTRACTS (cont.)

34. VENOUS THROMBOEMBOLISM UNDER THE MICROSCOPE: ARE WE FOLLOWING OUR OWN GUIDELINES? LG Godat MD; L Kobayashi MD; DC Chang PhD; R Coimbra MD San Diego, CA

BACKGROUND: An increasing emphasis on venous thromboembolism (VTE) rates as a quality improvement measure, and the publication of practice management guidelines has brought prevention of VTE to the attention of most clinicians. Accordingly the number of publications regarding VTE doubled from 1995-2000, and tripled from 2000-2005. We sought to investigate the incidence of VTE in a high risk trauma population, and we hypothesized that rates of VTE would fall over time due to increased emphasis on prophylaxis.

METHODS: This is a population based study of all non-federal hospitals in California using the California Office of Statewide Health Planning and Development database. Inclusion criteria were all patients admitted from 1995 to 2010 with spine fractures with or without cord injury (cervical, thoracic, lumbar and sacral) and pelvic fractures. Patients who died within 48 hours of admission were excluded. Univariate, bivariate and logistic regressions were done to determine institutional factors predictive of in- hospital VTE and mortality. Patient factors studied included; age, gender, calendar year, central line, race, Survival Risk Ratio (a surrogate for ISS), Charlson comorbidity index, insurance status, teaching hospitals and trauma center designation.

RESULTS: 370,761 patients met inclusion criteria. 54% of patients were treated in non-trauma centers. The rate of VTE increased significantly from 1995 with a peak of 3.4% in 2003, p=0.001. After 2003, the rate then decreased back to just below baseline. This trend was consistent across trauma and non-trauma centers, as well as teaching and non-teaching facilities. On multivariate analysis the following were independent predictors of VTE (p<0.05); central line placement, age >35, male gender, increased length of stay and being treated at a teaching hospital or trauma center. In the subgroup hospitalized for >1week, a spine fracture with cord injury was also predictive of VTE. VTE is an independent predictor of mortality in these patients, odds ratio 2.1, p<0.001).

CONCLUSION: The CHEST Guidelines on VTE prophylaxis were published in 2000, followed by the EAST guidelines in 2002. Accordingly a steady decline in VTE rates beginning in 2003 is seen. This decline was consistent throughout all hospital types suggesting attention to VTE prevention was universal over this time period.

186 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

37. DE GARENGEOT HERNIA: A LAPAROSCOPIC APPROACH TO REPAIR E Bedolla MD; JS Bender MD Oklahoma City, OK

BACKGROUND: Femoral hernias represent less than 5 percent of all inguinal hernias. A much more rare occurrence is the presence of a vermiform appendix within a femoral hernia. Rene Jacques Croissant de Garengeot is credited with first describing this condition in 1731. In 2005, Akopian and Alexander proposed that a femoral hernia with an incarcerated appendix or appendicitis be referred to as a “de Garengeot” hernia. This type of femoral hernia is often diagnosed during operative exploration of an erythematous right groin mass. Only rarely is the diagnosis made preoperatively.

METHODS: We present a 65 year-old female with a de Garengeot hernia preoperatively diagnosed by computerized tomography (CT). The patient initially presented to her gynecologist with complaints of one month of right lower quadrant abdominal pain. A CT scan was obtained to exclude gynecologic pathology and the images instead revealed the presence of an incarcerated vermiform appendix within a femoral hernia. A referral to general surgery was made. Without evidence of perforation or systemic disease, the decision was made to perform a laparoscopic repair.

RESULTS: The patient underwent a transabdominal pre-peritoneal (TAPP) hernia repair coupled with a laparoscopic appendectomy. A supra-umbilical 12mm port was used in addition to two 5mm ports placed in the standard position for a TAPP hernia repair. Laparoscopic evaluation of the incarcerated appendix revealed inflammation of the tip of the appendix consistent with chronic appendicitis. There was no evidence of perforation or contamination of the hernia sac and its contents. A piece of Bard 3DMax Mesh was implanted and secured to complete the hernia repair. Laparoscopic appendectomy ensued via the same three ports. The patient’s post-operative course was uncomplicated and she was discharged home after a 24-hour observation period. Short- term follow up has revealed a successful hernia repair without evidence of infectious complications.

CONCLUSION: Laparoscopic repair of a de Garengeot hernia is technically feasible and can be a suitable surgical option in a patient without signs of acute appendicitis, perforation, or abscess formation.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 187 POSTER ABSTRACTS (cont.)

38. TRANSPOSITION OF THE LEFT RENAL VEIN FOR THE TREATMENT OF NUTCRACKER SYNDROME IN CHILDREN BW Ullery MD; N Itoga MD; M Mell MD Stanford, CA

BACKGROUND: Nutcracker syndrome is caused by compression of the left renal vein between the superior mesenteric artery and the aorta. Invasive surgical intervention for this pathologic entity is controversial, particularly in the pediatric population. We aim to describe our early clinical and operative experience with such patients.

METHODS: We report three cases of pediatric patients undergoing successful left renal vein transposition for the treatment of nutcracker syndrome.

RESULTS: All three patients were female (age, 9-17 years) and presented with a mean of 11.7 months of abdominal or left flank pain requiring chronic narcotic analgesia (Table). Initial clinical presentations were associated with either hematuria or proteinuria. Diagnosis of nutcracker syndrome was supported in each case by an elevated renocaval pressure and/or axial imaging demonstrating mesoaortic compression of the left renal vein. All patients underwent an uncomplicated left renal vein transposition, liberation of the ligament of Treitz and associated adhesions, with excision of peri-aortic nodal tissue (mean hospital length of stay, 5.7 days). After mean follow-up of 13 months, all patients report complete resolution of symptoms and hematuria/proteinuria.

CONCLUSION: Transposition of the left renal vein is a safe and effective treatment for nutcracker syndrome in appropriately selected pediatric patients. Further experience and long-term follow-up is warranted to better evaluate the sustained efficacy of this procedure in this unique patient population.

188 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

39. SKIPPED AXILLARY NODE METASTASIS: A REVEIW OF THE LITERATURE AND CASE REPORT Jeffrey Summers BS; Jillian Ciocchetti MD Parker, CO

BACKGROUND: Classically, axillary metastasis with an unknown primary have been treated as breast cancer - even if a primary breast lesion cannot be identified. We present a case of skipped axillary node metastasis of endometrial carcinoma in a 75 year old woman. If not for modern imaging, this patient would have received the incorrect diagnosis and treatment.

METHODS: This is a case report with literature search to examine a case of a 75 year old woman with a skipped axillary metastasis.

RESULTS: The patient was found to have endometrial carcinoma which metastasized to her right axillary nodes. The patient presented with ER/PR positive adenocarcinoma in an axillary node and would have been treated as a breast cancer, if it were not for modern imaging and staging techniques.

CONCLUSION: Axillary node metastasis with an unknown primary should be fully evaluated with PET imaging prior to treating the patient for presumed breast primary. The entity of skipped axillary metastasis or lymphatic failure is real and should be taken into account when treating someone with an occult axillary metastasis.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 189 POSTER ABSTRACTS (cont.)

40. CYSTIC MALIGNANT PHEOCHROMOCYTOMA: AN UNUSUAL TUMOR WITH AN UNUSUAL PRESENTATION A Ghazali, MD; DJ Margolin, MD Kansas City, MO

BACKGROUND: Pheochromocytoma is typically a biochemically active tumor with clinical significance related to symptomatology. It classically presents as a solid adrenal mass in a hypertensive patient with headaches, palpitations and diaphoresis [1]. Malignant pheochromocytomas represent just 10% of cases, and there is a paucity of data on prognosis and outcome of treatment due to the low incidence of reported malignant cases [2]. Diagnosis of malignant disease is based on evidence of locoregional or distant metastasis rather than on histological features of the tumor [1,2].

METHODS: We report a case of a 16cm malignant pheochromocytoma with a cystic structure that presented as a systemic inflammatory response syndrome, without any classical signs or symptoms of catecholamine release. A 43 year old female presented with L rib pain, fatigue, fever, leukocytosis, tachycardia and tachypnea. On physical exam she had a palpable left abdominal mass. A CT scan demonstrated a 16x12x12cm complex cystic retroperitoneal mass that was displacing the spleen. Biochemical work up was diagnostic for pheochromocytoma with elevated 24 hour urine metanephrines and plasma norepinephrine levels. PET scan showed positive uptake in the periphery of the cystic mass.

RESULTS: Intraoperatively a hypervascular adrenal tumor was noted to be invading the tail of the pancreas, the spleen, and the left kidney. The center of the mass was necrotic and contained purulent appearing fluid. The tumor was removed en bloc with the left kidney, distal pancreas, and spleen. Pathology showed a 590g, 15.2 x 10.4 x 8.5cm cystic mass with necrotic center and features consistent with pheochromocytoma. There was microscopic disruption of the renal capsule and splenic capsule by the tumor, suggesting a malignant nature. Eight of eight regional lymph nodes were negative for metastasis.

CONCLUSION: Because there was no evidence of metastasis and margins were widely negative no adjuvant chemotherapy was indicated [6]. The patient’s systemic inflammatory response resolved after tumor resection. Few other cases of structurally similar pheochromocytomas are reported in the medical literature [3, 4, 5]. Even fewer of these are like our patient, asymptomatic in regard to catecholamine release. Because there was no evidence of metastasis and margins were widely negative no adjuvant chemotherapy was indicated [6]. The patient’s systemic inflammatory response resolved after tumor resection. Few other cases of structurally similar pheochromocytomas are reported in the medical literature [3, 4, 5]. Even fewer of these are like our patient, asymptomatic in regard to catecholamine release.

190 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

References 1. Arcos C, et al. Malignant giant pheochromocytoma: a case report and review of the literature (2009) Can Urol Assoc J, 3(6), 89-91 2. Zarnegar R, et al. Malignant pheochromocytoma (2006) Surg Oncol Clin N Am, 15(3), 555-71 3. Soufi M, et al. Giant Malignant Cystic Pheochromocytoma: A Case Report (2012) Indian Journal of Surgery, 74(6), 504-6 4. Erem C, et al. Epinephrine-secreting cystic pheochromocytoma presenting with an incidental adrenal mass: a case report and a review of the literature (2005) Endocrine, 28(2), 225-30 5. Zenggang P, et al. A Giant Cystic Pheochromocytoma of the Adrenal Gland (2008) Endocrine Pathology, 19(2), 133-8 6. Nakane M, et al. Successful treatment of malignant pheochromocytoma with combination chemotherapy containing anthracycline (2003) Ann Oncol, 14 (9), 1449- 1450

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 191 POSTER ABSTRACTS (cont.)

41. TRAUMA REMAINS A SURGICAL DISEASE FROM CRADLE TO GRAVE SN Acker MD; RT Stovall MD; DA Partrick MD; EE Moore MD; CC Cothren- Burlew MD; DD Bensard MD Aurora, CO

BACKGROUND: Nonoperative management of injury has led some to suggest that trauma is no longer a surgical disease. Nonoperative management of many blunt and some penetrating injuries has supplanted operative intervention. We hypothesized that surgical intervention is still often required in both injured children and adults. Moreover, we speculated that there would be distinct patterns of operative intervention based on age.

METHODS: We queried the trauma databases at the two academic level one trauma centers (LIPTC and LIATC/LIIPTC), which serve as referral centers for a multi state region. We reviewed all patients admitted to the trauma service who underwent an in patient operation between 7/1/09 and 6/31/13. We evaluated trends in the operative interventions performed and patient characteristics based on patient age. Patients were divided into the groups by age (years) for data analysis: 0-1; 2-5; 6-12; 13-15; 16- 21; 22-40; 41-50;51-64; >65. To determine operative trauma rates by specialty and age, patients were further divided into four groups (children <15, young adults 15-44, middle aged 45-65, and elderly >65).

RESULTS: During this time period a total of 11,611 patients were admitted to the trauma service, 6334 (55%) of who underwent an inpatient operation. Average Injury severity score among trauma patients requiring an operation was lowest for children and teenagers (<10) but higher in all adults (range 11-14). Less than 10% of children required more than one operation during their hospitalization. In contrast, >20% of adults underwent more than one operation. Survival decreased as age increased, but remained >94% for all patients who underwent an operation. In all age groups, the number of operative interventions increased significantly between those patients with LOS <7 days (1.1) and those with LOS >7 days (2.2; p<0.0001 for all age groups). 8% children, 28% young adults, 39% middle aged, 42% elderly had a LOS > 7 days. Two thirds of operative procedures were orthopedic operations in all age groups except for infants (5%). General surgical intervention was highest in 22-40 years (28%), 16- 21 years (21%), and 41-50 years (21%). Neurosurgical intervention was most often observed in infants age 0-1 (21%) and the elderly (10%). Prolonged LOS was more likely with general surgical and neurosurgical intervention. Orthopedic procedures occurred more frequently in patients with LOS of < 3days.

CONCLUSION: Over half of patients admitted following traumatic injury require operative intervention. The specific interventions performed vary with patient age. Patients with prolonged LOS were more likely to undergo general surgery, neurosurgery, and/or multiple operations. Trauma remains a surgical disease with frequent surgical intervention and excellent survival regardless of age.

192 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

42. MOTORCYCLE RIDERS ARE MORE LIKELY TO HAVE LEFT SIDED INJURIES Y Sun MD; BR Troop MD; AK Srivastava MD; AF Kanne MSN St. Louis, MO

BACKGROUND: Motorcycle crashes account for more than 175,000 injuries a year. Extremity injuries account for a large amount of these injuries. Our study was designed to identify the laterality, right side or left side, of these injuries in both right handed and left handed motorcycle riders. It is estimated that about 10% of the population is left handed.

METHODS: We reviewed the charts of 101 consecutive motorcycle riders who had predominately right sided or left sided injuries and were admitted to our Level 1 Trauma Center. We specifically looked at long bone fractures. Both upper and lower extremity long bone fractures were included. Handedness was determined by occupational therapists. Riders were excluded if their injuries were not predominately right or left sided.

RESULTS: Left sided injuries were identified in 70% of the total. (P=0.023) Among the 101 patients, 90, or 89%, were right handed. These right handers suffered left sided injuries 67% of the time, and right sided injuries 33% of the time. (P=0.004) Eleven of the patients were left handed, and 100% of these suffered left sided injuries. (P=0.022)

CONCLUSION: 1. Motorcycle crash patients are more likely to suffer left sided injuries. 2. Left sided injuries predominate in both right handed and left handed drivers. 3. Left handed motorcylce drivers are more likely to injury their left side than are right handed drivers. 4. Injured motorcycle drivers are represented in the same ratio as left handed and right handed ratio in the population.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 193 POSTER ABSTRACTS (cont.)

43. METASTATIC PAPILLARY GALLBLADDER CARCINOMA WITH A UNIQUE PRESENTATION AND CLINICAL COURSE BC Chapman MD; TS Jones MD; MC McManus MD; RJ Shah MD; C Gajdos Aurora, CO

BACKGROUND: Papillary gallbladder adenocarcinoma (PGA) is a distinct clinical entity that represents about 5% of all malignant gallbladder tumors. There are few reports of metastatic disease; those reported frequently involve lymph nodes or other structures in the hepatoduodenal ligament.

METHODS: N/a

RESULTS: A 59 year old female with right upper quadrant pain and a massively enlarged gallbladder on ultrasound went to the operating for an attempted laparoscopic cholecystectomy. Intraoperatively she was noted to have a segment 4 liver lesion. A biopsy of this lesion showed metastatic adenocarcinoma with a suspected gallbladder primary. Subsequently, she was referred to our hospital and underwent appropriate staging followed by an open cholecystectomy and extended right hepatic lobectomy with portal lymph node dissection. Final pathology demonstrated well-to-moderately differentiated PGA with identical morphology and immunohistochemistry in the liver resection specimen with negative margins. She underwent adjuvant chemotherapy with cisplatin and gemcitabine

Two years later she was found to have increased uptake on surveillance PET scan in the head of the pancreas. Endoscopic ultrasound with fine needle aspiration demonstrated metastatic PGA. She underwent an attempted Whipple operation but due to repeatedly positive pancreatic duct margins, she had a total pancreatectomy and splenectomy. Final pathology showed metastatic PGA along the entire length of the pancreatic duct with only a single focus of tumor invasion into the pancreatic parenchyma. Immunohistochemistry confirmed this tumor to be identical to her previous malignancy. All peripancreatic lymph nodes were negative for cancer.

CONCLUSION: To our knowledge, this is the first report of metastatic PGA recurring along the entire pancreatic duct with disease confined to the pancreas only. We hypothesize that papillary tumor cells spread to pancreatic duct via the common bile duct and remained dormant for several years. Based on our experience, aggressive surgical approach may prolong survival in well selected patients.

194 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

44. ACADEMIC PEDIATRIC SURGICAL PRACTICE AS A MODEL FOR ACUTE CARE SURGERY SN Acker MD; NA Nadlonek MD; DD Bensard MD; FM Karrer MD; DA Partrick MD Aurora, CO

BACKGROUND: Acute care surgery (ACS) aims to provide timely care for patients with emergent general surgical needs. Challenges to the ACS model include surgeon concern about a limited breadth of practice with little opportunity for an elective practice and lack of career satisfaction. We hypothesized that an academic pediatric surgical service can be used as a model of ACS delivery that addresses these physician concerns. The aim of the current work was to profile an academic pediatric surgical practice with a focus on what portion of care would be considered ACS.

METHODS: We reviewed all unique billing encounters performed by the pediatric surgical service during the calendar year 2012. Data were reviewed from a single tertiary care children’s hospital. We stratified data based on where the child was seen and what services were provided. We assessed the number of procedures that were performed and the distribution of urgent or emergent and elective procedures. Urgent or emergent procedures were defined as those procedures, which must be completed within 24 hours of diagnosis.

RESULTS: During 2012, a total of 4804 operative procedures were performed, the majority of which, 3894 (81%), were elective procedures. 2057 (43%) procedures were considered out patient operations; the remaining 2747 (57%) were in patient procedures. Only 910 (19%) procedures performed during the year were urgent or emergent. In addition to surgical procedures, non operative patient encounters also made up a large portion of the clinical responsibilities of the pediatric surgical group. Over half of all patient encounters performed during the year were non operative patient encounters including 3826 out patient clinic visits, 840 emergency department consults not requiring admissions, 2051 in-patient consults and 405 critical care visits. A total of 340 trauma patients were evaluated by the surgical service, 220 of which required in patient admission to the pediatric surgery service (average injury severity score 12.7 ± 10.1). Sixty-six of these trauma patients required a general surgical procedure during their hospital stay.

CONCLUSION: Academic pediatric surgeons provide a wide variety of general surgical care including elective and emergent inpatient and outpatient care. These data demonstrate the success of a well established and balanced ACS service that allows surgeons to maintain specialized elective surgical practices with high physician satisfaction.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 195 POSTER ABSTRACTS (cont.)

45. PRIMARY PULMONARY MELANOMA: A CASE REPORT AND DIAGNOSTIC CRITERIA A Landmann MD; JL Calisto MD; DE Stowell MD; MD Peyton MD Oklahoma City, OK

BACKGROUND: Melanoma is primarily a dermatologic condition diagnosed by physical examination and excisional biopsy. Lesions have been described in mucosal sites such as oral cavity, paranasal sinuses, esophagus, larynx, vagina and anorectal region. (1). Lesions in visceral organs are rare and generally represent metastasis from a cutaneous lesion. Primary melanoma of the lung is extremely rare, with few published case reports in the literature.

METHODS: We present the case of a 61-year-old male with diabetes mellitus type 2 and Sweet syndrome presents with complaints of two months of dyspnea and 25kg unintentional weight loss. On workup, the patient was found to have a right lower lobe mass Pleural fluid analysis demonstrated no malignant cells. CT guided core biopsies were nondiagnostic. PET imaging was inconclusive due to the patients poorly controlled diabetes. Bronchoscopy was performed intraoperatively and no endobronchial lesions were identified. A large mass was encountered invading the fissure and middle lobe necessitating a right pneumonectomy for en bloc resection. Frozen section identified high-grade malignancy. Hilar lymphadenectomy was performed and submitted for pathology. Final pathology revealed a tumor measuring 14 x 12 x 8 cm with findings consistent with malignant melanoma and positive immunohistochemistry markers: pan-melanoma, HMB-45, S-100. All lymph nodes were negative for malignancy. The patient underwent comprehensive dermatologic examination and no cutaneous primary lesion was identified. The post-operative course was complicated by a broncho-plueral fistula necessitating reoperation. The patient is currently recovering well and no additional lesions have been identified on surveillance.

RESULTS: Melanoma is currently one of the fastest growing malignancies, with cutaneous manifestations remaining the most common. Primary lung melanoma is exceedingly rare, with fewer than 25 cases described in the literature. Diagnostic criteria have been proposed for a lesion to be characterized as a primary melanoma.

1. Nesting or junctional changes are present beneath the bronchial epithelium 2. Invasion of the bronchial epithelium by melanoma cells 3. The lesion should be a solitary lung tumor 4. No evidence of cutaneous, mucous membrane or ocular melanoma 5. Absence of any other detectable tumor

CONCLUSION: Treatment of primary pulmonary melanoma includes surgical resection including lymphadenectomy and chemotherapy. Data regarding prognosis and survival is limited due to the scarcity of cases. Patients should be followed for development of cutaneous lesions or metastatic disease.

196 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

46. A FATAL CASE OF DISSEMINATED STRONGYLOIDIASIS IN A CROHN’S DISEASE PATIENT AT Nguyen MD; A Falor MD; D Plurad MD; S Bricker MD; A Neville MD; F Bongard MD; B Putnam MD; DY Kim MD Torrance, CA

BACKGROUND: Strongyloides stercoralis is a parasitic intestinal nematode endemic to tropical areas. While early detection allows for improved treatment, a disseminated infection can develop in immunocompromised patients. We report the case of a Crohn’s disease patient with disseminated strongyloidiasis, and attempted treatment with oral, per-rectal, and subcutaneous Ivermectin.

METHODS: A case report and review of the literature was performed using PubMed and Ovid. The grey literature was also searched. The main search terms used for the literature review were: ‘Strongyloides stercoralis,’ ‘Crohn’s disease,’ ‘immunocompromised,’ ‘inflammatory bowel disease,’ and ‘small bowel.’

RESULTS: A 40-year old female with a history of steroid-dependent Crohn’s disease now presents with one week of vomiting, loose stools, and abdominal pain. The patient was afebrile, with a tachycardia of 124 that improved with resuscitation. Exam showed a diffusely tender abdomen without peritonitis. Labs showed: Sodium 126, Creatinine 0.48, Lactic acid 1.3, and White blood cell 5.0 with 89.3% Neutrophils. Computed- tomographic imaging demonstrated multiple loops of thick-walled small bowel. The patient was started on intravenous antibiotics and corticosteroids. Her hospital course was complicated by tachycardia, hypotension, and hypoxia. On hospital day seven, with a concern for continued sepsis, an exploratory laparotomy was performed. The patient was found to have significant jejunal stricturing and thickening. Sixty- five centimeters of small bowel was resected, and a side-to-side functional end-to-end stapled anastomosis was performed. Post operatively, the patient persisted in sepsis. Specimen pathology revealed Crohn’s disease, as well as small-bowel infestation by Strongyloides stercoralis. Further testing demonstrated the organism in the stool, urine, and pulmonary secretions. Antibiotics were broadened, and the patient was started on nasal-gastric and rectal Ivermectin. A post-operative ileus prevented adequate intake, and the patient failed to improve. Off- label subcutaneous Ivermectin was added to the patient’s therapy. Despite this, the patient became increasingly hypoxemic and acidotic, and succumbed to her disease on post-operative day 19. Though strongyloidiasis itself is not uncommon, there is little data regarding disseminated strongyloidiasis in Crohn’s disease. There is also little data available regarding the parental treatment of strongyloidiasis, as there are no approved non- enteric formulations for human use.

CONCLUSION: Disseminated strongyloidiasis usually occurs in immunocompromised patients. Anti-helminth medications are critical, but the treatments do not have an approved parental form. In our case, enteric access was limited by persistent ileus. Off-label usage of a subcutaneous Ivermectin formulation did not halt disease progression. This patient illustrates the importance of further study of strongyloidiasis treatment options for immunocompromised individuals.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 197 POSTER ABSTRACTS (cont.)

47. PENETRATING CARDIAC INJURIES AT A LEVEL II TRAUMA CENTER: A 15 YEAR REVIEW JS Murry; JR Soto MD; MS Truitt MD; EL Dunn MD Dallas, TX

BACKGROUND: Penetrating injuries to the heart are associated with high morbidity and mortality. Outcomes data for these injuries are usually reported from individual trauma programs most of which are large urban level I centers. Many urban areas are also served by level II trauma centers. There is little data to indicate how these level II centers perform with penetrating cardiac injuries. We sought to evaluate penetrating cardiac injuries at our level II trauma center over the last 15 years and report on our outcomes.

METHODS: Our trauma database was reviewed to identify all patients who presented to our emergency department with a penetrating cardiac injury. Medical records as well as autopsy reports were reviewed. Mechanism of injury, associated injuries and outcomes were evaluated.

RESULTS: From January 1, 1998 through December 31, 2012 we evaluated 135 patients with penetrating cardiac injuries. Average age was 31 years. Males represented 92%. The majority of injuries were related to gunshot wounds (GW) 97/135 (72%). The remaining were from stab wounds (SW) 38/135 (28%). Cardiac injury grade as IV or higher in 108/135 (81%). Overall these patients had a high mortality rate with 96/135 (71%) not surviving past the emergency department (ED). Of those 89/96 (93%) had no signs of life on admission to the ED. Patients that survived past ED admission had a high survival rate 23/39 (59%). Patients with stab wounds had a higher survival rate 16/19 (84%) compared to those with GSW 7/20 (35%). Average length of stay was 10 days for survivors. Most patients had injuries to other organs 117/135(87%). Most patients had a concomitant lung injury(87/117) and more than a third had associated liver injuries (47/117). ED thoracotomies were performed in 15 patients with only 2/15 surviving to OR and only one of these patients surviving to hospital discharge.

CONCLUSION: Penetrating injuries to the heart have a high rate of lethality. Most urban centers will not have a high volume of these injuries. Level II trauma centers will often be involved with this patient population. Our results are very similar to prior data from level I trauma centers. Level II centers must provide resources to provide optimal care and ensure the best patient outcomes comparable to level I centers.

198 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

48. WHAT DETERMINES LATE FAILURE FOLLOWING SUCCESSFUL SUICIDE RESUSCITATIONS: DOES THE MONEY MATTER? O Hasan MD; JG Ward BA; F Dong PhD; G Crawford BA; JM Haan MD Wichita, KS

BACKGROUND: The 2008 economic slowdown resulted in an increase in premature deaths from intentional violence including suicide. Among survivors of traumatic suicide attempt, 92% will remain alive at a mean follow-up of 54 months. This study sought markers to denote resuscitation futility after suicide attempt at 12-month follow-up during a recession.

METHODS: Records for patients who had attempted traumatic suicide were retrospectively reviewed at an American College of Surgeons-verified level I trauma center. Patient records were grouped by date of admission: Pre-recession (Group 1) 10/01/2004-10/01/2007, Transition (Group 2) 10/2/2007-09/30/2008, and Recession (Group 3) 10/01/2008-10/01/2011. Additional grouping by type of documented mental health history was applied: chronic mental illness, substance abuse, and no history. Data collection included demographics, mental health history, injury mechanism, outcomes, date and cause of death (per state death records), and reason for and mechanism of suicide attempt.

RESULTS: During the study period 291 patients were evaluated following attempted suicide. Of these, 217 (74.6%) survived their initial hospitalization and were the focus of this investigation. The majority were male (n = 156, 71.9%) and Caucasian (n = 187, 86.2%). Average age was 34 ± 13 years. Initial suicide attempt mechanism included cutting (36.9%), hanging (27.2%), fall (10.1%), MVA (7.4%), firearms (7.4%), and unknown (11.1%). Seventy-two patients were assigned to Group 1 (33.2%), 26 to Group 2 (12.0%), and 119 to Group 3 (54.8). Among the 21(9.7%) patients who died within 12 months after initial suicide attempt, cause of death was identified as suicide for 12 patients (57.1%). There were no significant differences between post-discharge mortality rates: Group 1 (n = 10, 13.9%), Group 2 (n = 2, 7.7%), and Group 3 (n = 9, 7.6%). There were also no significant differences between mortality rates for those with no history of mental illness (16.1%), a substance abuse history (8.8%) and a history of chronic mental illness (4.7%). Age > 65 (n = 3, 1.4%) was significantly associated with mortality (P = 0.0008).

CONCLUSION: Of note, elderly patients are at higher risk for all-cause suicide-related death within 12 months following traumatic suicide attempt and require more robust follow-up in a recessionary period. Based on this study, there was no difference in the phase of recession period, demographics, mental health history, or mechanism for delayed suicide completion.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 199 POSTER ABSTRACTS (cont.)

49. COMPLICATED DIVERTICULITIS PRESENTING AS A SPIGELIAN HERNIA: A CASE REPORT AND LITERATURE REVIEW IM Cassaday DO; KB Muir MD; KJ Aluka MD El Paso, TX

BACKGROUND: Ventral hernias are a common reason for patients to present in the emergency department. The diagnosis is often made solely on physical examination. Obscure presentations are occasionally evaluated with imaging. On rare occasions, other diagnoses may disguise themselves as ventral hernias.

METHODS: We were presented with a 31 year-old male with an abdominal bulge in his left lower quadrant. The bulge was non-reducible and tender to palpation. An ultrasound was obtained that was interpreted as an abdominal wall defect containing a hernia sac with bowel contents but no evidence of free fluid. The physical examination was concordant. The patient was initially diagnosed with an incarcerated Spigelian hernia.

RESULTS: He was taken to the operating room for a diagnostic laparoscopy with plans for a hernia repair with mesh. Intraoperatively the patient was found to have a thickened sigmoid colon adherent to the anterior abdominal wall as well as scattered diverticuli. Inability to reduce the sigmoid colon resulted in conversion to an exploratory laparotomy. The obscure abdominal mass was found to be the leadpoint for a complex, loculated abdominal wall abscess. The patient was subsequently diagnosed with complicated diverticulitis and a complex abdominal wall abscess.

CONCLUSION: The clinical evaluation alone of a relatively superficial abdominal wall mass is often adequate in providing the correct diagnosis. An abdominal wall mass is generally a hernia until proven otherwise. However, the adage “measure twice, cut once”, applies to this case. In instances when the diagnosis is unclear, a different mode of imaging beyond ultrasonography, such as a CT scan, may be a useful adjunct in differentiating the etiology of the abdominal mass.

200 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

50. CHOLEDOCHOLITHIASIS PRACTICE UNDER ACUTE CARE SURGERY- IDENTIFYING THE STONE PASSERS J Watt MD; N Kulvatunyou MD; RS Friese MD; DJ Green MD; L Gries MD; B Joseph MD; T O’Keeffe MD; AL Tang MD; G Varcruysse MD; P Rhee MD Tucson, A Z

BACKGROUND: Choledocholithiasis (CDL) diagnosis and management can vary and be challenging. Diagnostic approaches can be costly and time-consuming. The study objective was to identify clinical predictors of CDL patients who may pass the stone on their own, the “passer”. We also looked at the diagnostic approach that may best suit for the stone passer.

METHODS: We identified patients with CDL from our prospectively maintained acute care surgery (ACS) data base. Clinical suspicion of CDL was defined as the presence of right upper quadrant abdominal pain, the ultrasonographic finding of choleltihiasis, elevated liver enzymes, and/or evidence of dilatation of common bile duct (CBD) (> 7 millimeter [mm]) with or without evidence of CBD stones. The “passer” was defined as those with suspected CDL who had a negative endoscopic retrograde cholangio-graphy (ERCP), or negative magnetic resonance cholangiography (MRCP), or intraoperative cholangiogram (IOC) with continued normalization of liver enzymes during clinical follow up. We performed multivariate regression analysis to identify clinical factors that were associated with the passer. We also performed outcome comparisons between different practice approaches i.e., LC+IOC, MRCP, or direct ERCP.

RESULTS: During a 3-year study period, 98 patients had suspected CDL. The mean age was 47 + 22 years old; 72% were female. There were 38 (39%) patients who were the passers. The absence of common bile duct (CBD) dilatation was the only significant predictor of the stone may pass. We also found that LC+IOC approach led to a shorter time to the operating room (OR) and a trend toward decreased hospital length of stay and costs in those “passer” CDL patients.

CONCLUSION: For patient who presents with a possible CDL, the absence of CBD dilatation may suggest the stone may have passed, and LC+IOC may be most cost- effective to tackle CDL under our current ACS.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 201 POSTER ABSTRACTS (cont.)

51. INJURIES FROM ALL TERRAIN VEHICLES: AN OPPORTUNITY FOR INJURY PREVENTION E Benham MD; AB Christmas MD; PE Fischer MD; M Mavilla BS; LP Hedrick; RF Sing DO Charlotte, NC

BACKGROUND: All-terrain vehicle (ATV) trauma is an increasing cause of injuries and fatalities among children and adults. However, this form of recreation is not well regulated. Helmet use remains low, and many accidents are associated with alcohol and drug intoxication. This study assesses demographics, behavior, and injury patterns of ATV trauma in an attempt to focus injury prevention efforts.

METHODS: We performed a retrospective analysis of all ATV related injuries (2008- 2012) using the Trauma Registry of a regional Level 1 trauma center. Data collected included patient demographics, associated injuries, helmet use, and alcohol or drug intoxication. Data were analyzed using standard statistical methods.

RESULTS: 404 patients incurred ATV related injuries over the five year study period. Of the 304 patients in whom helmet data was known, only 75 wore a helmet (24.7%, 95% CI 19.9% - 29.9%). Patients who wore a helmet were significantly younger (p=0.0068), had a significantly higher admission Glascow Coma Score (p=0.0011), had a significantly lower injury severity score (p=0.0015), and had significantly shorter intensive care unit (p=0.0014) and hospital length of stay (p=0.0294). The percentage of patients diagnosed with traumatic brain injury was significantly lower in patients who wore a helmet (8.0%) than in those who did not (26.6%) (p=0.0007). Additionally, the percentage of patients admitted to the intensive care unit was significantly lower in patients who wore a helmet (14.7%) than in those who did not (31.4%) (p=0.0047). Blood alcohol levels were obtained from 207 patients. Of these patients, 73 patients were legally intoxicated with a blood alcohol limit greater than 0.08 g/dL. Intoxicated patients were significantly less likely to wear helmets when compared to the non- intoxicated group (6.8% vs. 27.8%) (p=0.001).

CONCLUSION: All-terrain vehicle trauma can lead to significant patient morbidity and mortality. Despite state laws requiring helmet use, compliance remains low, especially among patients with alcohol intoxication. Heightened awareness of these issues regarding helmet use and alcohol intoxication during ATV operation can help to focus future ATV injury prevention initiatives.

202 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

52. OUTCOMES FOLLOWING URGENT OR EMERGENT REPAIR OF INCARCERATED OR STRANGULATED VENTRAL HERNIAS IN THE MORBIDLY OBESE AL Howarth MD; MM Mrdutt MD; JL Regner MD; CL Isbell MD; TS Isbell MD; DC Jupiter PhD; ML Davis MD Temple, T X

BACKGROUND: Thirty-five percent of American adults are obese with a body-mass index (BMI) >30. This segment of the population incurs an estimated $270 billion annual US economic loss due to health care expenditures and lost work days. Ventral hernias (VH) are a common post-surgical complication in the morbidly obese (MO), and surgeon bias may limit the elective repair of these VH. We hypothesized that emergent surgery for incarcerated or strangulated VH would be more prevalent in the MO population with an associated increased incidence of perioperative complications when compared to the non-obese.

METHODS: A retrospective cohort from 2007- 2012 at our academic tertiary referral center was studied. Inclusion criteria were age ≥18 and emergent operative intervention for incarcerated or strangulated VH. Subjects were excluded for cirrhosis, current immunosuppressive treatment, chemotherapy, or pregnancy. Demographics, 30-day, and extended outcome measures, specifically acute kidney injury, deep vein thrombosis, pneumonia, fascial dehiscence, abscess formation, wound infection, sepsis, transfusion, need for re-operation or radiologic intervention, were recorded. Subjects were divided into two groups based on BMI ≥35, MO and BMI<35, non-morbidly obese (NMO). Bivariate analysis was performed on our defined outcomes.

RESULTS: Seventy-one subjects met inclusion criteria of which 46 (65%) were MO and 52 (73%) were women. Current tobacco use and diabetes mellitus were seen in 31% and 42% of the population, respectively. Twenty-four subjects were evaluated at our institution for symptoms related to their VH, but did not undergo elective repair due to prohibitive operative risk. Complication rates were compared between the two groups (NMO vs MO) at 30–days: abscess (8% vs 10%), sepsis (none vs 5%), wound infection (12% vs 26%), and re-operation (4% vs 8%). There were no 30-day mortalities. Post-discharge follow-up data demonstrated even higher rates of complication in the MO: abscess (12% vs 15%), wound infection (12% vs 31%), and re-operation (4% vs 15%). Seventeen of the 71 patients were lost to follow-up at discharge. Although higher rates of complication were observed in MO subjects, findings did not reach statistical significance.

CONCLUSION: The perioperative complication rates in the MO following emergent repair of VH are exceedingly high across all time points. Our study was limited by a small sample size and the number lost to follow-up. However, based on the complication rates in this series of emergent VH repairs, we recommend reconsideration of delaying elective operative intervention in the MO. Further studies will determine the long-term sequelae of delaying VH repair in the obese and should provide insight into the optimal timing of repair.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 203 POSTER ABSTRACTS (cont.)

53. PRE-OPERATIVE SICU ADMISSION DOES NOT IMPROVE CLINICAL PARAMETERS PRIOR TO OPERATIVE DEBRIDEMENT OF NECROTIZING SOFT TISSUE INFECTIONS J Keeley MD; A Kaji MD PhD; C deVirgilio MD; D Kim MD; B Putnam MD; D Plurad MD; S Bricker MD; F Bongard MD; AL Neville MD Torrance, CA

BACKGROUND: Early surgical debridement of necrotizing soft tissue infection (NSTI) is the cornerstone of management of this morbid condition. For patients presenting with NSTI and severe sepsis or septic shock, admission to a surgical intensive care unit (SICU) for goal directed resuscitation may be warranted if surgery must be temporarily delayed. The BACKGROUND of this study was to evaluate whether patients admitted to the SICU for resuscitation prior to surgery would have decreased mortality and improvement in laboratory parameters indicative of end-organ perfusion.

METHODS: We analyzed all patients presenting with an NSTI to our university affiliated county hospital between 2008-2013. Pre-operative admission to the SICU, time to operation, admission and pre-operative laboratory values, and mortality were assessed. Admission laboratory values were compared to pre-operative values for those patients admitted to the SICU prior to surgery.

RESULTS: During the five-year study period, 138 patients were admitted with an NSTI, of which twenty (14.5%) died. Thirty-one patients were admitted to the SICU for resuscitation via a standardized sepsis protocol prior to undergoing therapeutic debridement. Twenty-five (80.6%) of SICU-resuscitated and 51(48%) of those proceeding directly to surgery met criteria for severe sepsis or septic shock (p<0.001). Time from hospital admission to surgery for pre-operative SICU patients was 12.9 + 11 hours. Despite SICU admission, no statistical difference was noted between patients’ admission and pre-operative white blood cell (WBC) count, bicarbonate, creatinine, or lactate levels. Patients admitted to the SICU pre-operatively had higher mortality rates compared to those who proceeded directly to surgery (OR =2.9, 95%CI 1.1-7.8, p=0.03). As the SICU-resuscitated cohort may be inherently more severely ill, a propensity-score adjusted analysis was performed; this supported the expected higher mortality rate in those first resuscitated in the SICU (OR=2.8, 95%CI 1-8.1, p=0.05). As an additional sensitivity analysis, a subgroup including only patients with severe sepsis and septic shock (n=76; pre-operative SICU=25 and direct OR=51) was performed. In this subgroup, there was no difference in mortality (32% versus 20%, p=0.2) or laboratory markers of end-organ perfusion between SICU-resuscitated patients and those that went directly to the operating room.

CONCLUSION: Pre-operative resuscitation in a SICU prior to surgical debridement was not associated with a decrease in mortality or differences in laboratory markers of end-organ perfusion. Our data supports existing literature advocating immediate surgical source control of NSTI.

204 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

54. SARCOIDOSIS PRESENTING WITH A RUPTURED HEPATIC ARTERY ANEURYSM RD Betzold MD; KJ Kalkwarf MD; FR Bentley MD; D Borja-Cacho MD Little Rock, AR

BACKGROUND: Sarcoidosis is a systemic granulomatous disease that involves the eyes, heart, lungs, kidneys and liver. Liver involvement occurs in 10–15% of the patients and is frequently asymptomatic. However, some patients develop progressive cholestasis, portal hypertension and cirrhosis. The most common hepatic vascular manifestations described in sarcoidosis include portal and hepatic venous thrombosis. Extrahepatic sarcoidosis has been associated with bronchial, coronary, aortic and ventricular aneurysms. Hepatic arterial involvement has not been described. The aim of this work is to present the association of sarcoidosis with hepatic artery aneurysms.

METHODS: We present the case of ruptured segment VI hepatic artery aneurysm associated with sarcoidosis.

RESULTS: A 28 year-old African American male without significant past medical history presented to an outside emergency department complaining of diffuse abdominal pain and syncope. After initial fluid resuscitation, the abdominal CT scan demonstrated hemoperitoneum and a large subcapsular hepatic hematoma. The patient was transferred to our institution. An angiogram and subsequent embolization of the right lobe were performed. The patient remained hemodynamically stable. During the initial interrogation at our institution the patient referred the presence of diffuse lymphadenopathy and 6-month 100 lb weight loss. After lymphoma and infectious etiologies were ruled out, he was discharged home to finish his evaluation as an outpatient. However, he developed recurrent severe right upper quadrant abdominal pain, hypotension, and tachycardia 13 days later. His hemoglobin decreased 2 gm and a new CT scan demonstrated interval increase in the amount of hemoperitoneum and a 9 x 5 cm subcapsular liver hematoma. A new angiogram demonstrated the presence of a 1.7 cm pseudoaneurysm in segment VI of the liver. The main feeding vessel was an accessory right hepatic artery. He underwent a second embolization, but during the following days he developed severe abdominal pain, leukocytosis and a progressive anemia. Liver surgery was consulted and a right hepatectomy was performed. The final pathology demonstrated a 9 x 6.5 x 5 cm subcapsular hematoma contiguous to a 1.7 cm pseudoaneurysm and the presence of multiple irregularly shaped non-caseating granulomas. The granuloma distribution and pattern were suggestive of sarcoidosis as was the angiotensin converting enzyme level. Oral prednisone was started and the patient was discharged on postoperative day 5. He has remained asymptomatic.

CONCLUSION: Sarcoidosis is a chronic inflammatory disease that can be associated with visceral artery aneurysms. Hemorrhagic shock in the setting of sarcoidosis should alert the clinician to the possibility of a ruptured aneurysm. Acute management of spontaneous rupture of related aneurysms should include early stabilization and endovascular therapy. Surgical intervention is indicated only if the previous measures fail, but it is durable and definitive.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 205 POSTER ABSTRACTS (cont.)

55. A RARE CASE OF AN ADULT WITH PRUNE - BELLY SYNDROME PRESENTING EMERGENTLY WITH ACUTE ABDOMEN FJ Yanquez MD; LD Butvidas MD; RS Friese MD; JL Wynne MD Tucson, A Z

BACKGROUND: Prune-belly (Eagle-Barrett) syndrome (PBS) is a rare congenital disorder, affecting 1: 40,000 live births and is characterized by a clinical triad involving abdominal muscle deficiency, severe urinary tract abnormalities and bilateral cryptorchidism. Although 50% of cases do not survive the age of two, early diagnosis and therapy can prolong survival. Later in life, predisposition to midgut malrotation and persistence of the embryonic wide mesentery, resulting in mobile coecum, volvulus and elongation of the colon have been documented. Current surgical literature lacks reports of adults with PBS. Herein we report a case of an adult with PBS who presented with an acute abdomen and complete bowel obstruction. The surgical findings, pathology and diagnostic imaging unique to an adult survivor with PBS are reviewed.

METHODS: A 32 years old male with a history of PBS, multiple childhood urological surgeries and undescended testes was transferred from an outside facility (OSF) with a three day history of acute abdominal pain, obstipation and distention. Patient had a HR of 123, RR in the 20’s and a WBC of 18.4 with a suspected abdominal source of sepsis. The patient was admitted, rehydrated and a focused physical exam was performed. The patient appeared cachectic, with a protuberant abdomen, tender out of proportion to examination, with rigidity and guarding. CT scan from OSF revealed free fluid, and swirling of the mesentery. Emergent laparotomy demonstrated a murky and malodorous peritoneal fluid with extensive colonic distension and black thin- walled right and proximal transverse colon; the ischemic segment had twisted on itself and was caught under an adhesive band. There was no evidence of gross perforation. Thus after evaluating the blood supply, an extended right hemicolectomy with a side to side ileocolic anastamosis was performed. After a thorough exploration and wash out, the abdomen was closed.

RESULTS: A 73cm resected colon with attached appendix and a 22cm terminal ileum specimen revealed an abrupt line of demarcation and torsion of the bowel wall having extensive necrotic discoloration. The colonic serosa showed multifocal patchy black granular fibrous adhesions. Microscopy revealed transmural ischemic necrosis. Postoperatively, patient had a slow recovery with prolonged ileus and a negative exploratory laparotomy nine days post initial intervention for leukocytosis and imaging suspicion for anastomosis leak. Along with a history of multiple substance abuse and prolonged use of narcotics, patient was seen multiple times in clinic for recurrent constipation.

CONCLUSION: Although PBS is a rare surgical case in adults, severe bowel obstruction due to redundancy and anatomical variance should receive high consideration in a PBS patient with acute abdomen. Early recognition, understanding of the pathophysiology and careful post-operative care may help physicians to better diagnose and manage this uncommon life threatening emergency.

206 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

56. ACUTE RUPTURED APPENDICITIS PRESENTING AS A COMPLICATION OF UNRESECTED PRIMARY TUMOR IN METASTATIC COLORECTAL CANCER AR Cardenas MD; DJ Cucher MD; IJ Levine MD; M Kowalski MD; MA Rennels MD; RS Krouse MD Tucson, A Z

BACKGROUND: Many patients with colorectal cancer are diagnosed with advanced disease that precludes resection for curative intent. There is some controversy over whether to resect the primary tumor in these patients as prophylaxis against complications such as bleeding, obstruction or perforation. Based on recent evidence, typical current practice is to forego prophylactic resection in such patients.

METHODS: A case report and literature review are presented. A 54-year-old male with a known history of metastatic colon cancer with a primary tumor in the cecum presented with ruptured acute appendicitis and small bowel obstruction. An ileocecectomy was performed.

RESULTS: Pathologic examination of the specimen revealed tumor infiltration at the base of the appendix causing luminal obstruction. The patient’s post-operative course was marked by prolonged respiratory failure requiring ventilation, with eventual discharge to a rehabilitation facility. A review of the literature shows that this is the first reported case of ruptured appendicitis in a non-resected colorectal cancer.

CONCLUSION: Prophylactic resection of advanced colorectal tumors remains controversial. The evidence suggests that the majority of these patients can be safely managed without prophylactic resection. However, in the unusual patient presenting with a cecal tumor, we strongly advocate consideration of prophylactic resection due to the potential complications involved.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 207 POSTER ABSTRACTS (cont.)

57. PHYSIOLOGIC FACTORS ASSOCIATED WITH ED SURVIVAL, HOSPITAL SURVIVAL, AND ORGAN DONATION AFTER TRAUMATIC CARDIOPULMONARY ARREST CR Huntington MD; PE Fischer MD; AB Christmas MD; WE Anderson MS; L Patton BA; RF Sing DO Charlottte, NC

BACKGROUND: The resuscitation of trauma patients following cardiopulmonary arrest remains a controversial issue. We undertook this study to assess outcomes among patients who survived the emergency department (ED), survived to hospital discharge (HD), or survived to organ donation (OD) at a regional Level I Trauma Center.

METHODS: Following IRB approval, a retrospective review of our trauma registry was conducted from 2008-2012. Data collection included demographics, mechanism of injury, pre-hospital resuscitation, ED interventions, hospital length of stay, organ donation rates, and neurologic outcome for survivors. Data were analyzed by standard statistical methods and stratified by ED, HD, and OD survival rates.

RESULTS: Overall, 357 trauma patients experienced a cardiopulmonary arrest either during transport or following arrival to our emergency department. More than half (n=188, 52.8%) survived the emergency department. The overall rate of hospital survival was 18.8% (n=67), and the overall rate of organ donation was 9.8% (n = 35). Positive predictors of ED survival and HD included age < 18, white race, blunt mechanism of injury, tachycardia, higher Glasgow coma scale (GCS), and higher revised trauma scores (RTS). Moderate prehospital crystalloid resuscitation (0.5 to 2L fluid) was associated with ED survival but not survival to HD. Negative predictors of ED survival and HD included CPR in progress on arrival, penetrating trauma, and abnormal pupil exam (asymmetric, dilated, or nonreactive). Gender and results of standard FAST exam did not affect ED survival or HD. Patients who received ACLS medications were more likely to die in the ED than patients who did not receive these medications. OD was associated with white race, abnormal pupil exam, longer pre-hospital CPR time, and location of CPR. No differences were observed in GCS, RTS, ACLS medication usage, mechanism of injury, age, gender, prehospital fluid resuscitation, or blood product usage comparing OD to non OD. An average of 2.4 organs were harvested per organ donor. Asystole or cardiac standstill on ultrasound performed in the trauma bay, was associated with very poor ED (1.0%) and HD survival, but contractility was associated with ED (71%) and HD survival.

CONCLUSION: Age < 18, white race, penetrating trauma, evidence of contractility on cardiac FAST, normal pupil exam, increased GCS, and increased RTS are predictors of not only ED survival, but hospital survival following traumatic arrest. Moderate amount (0.5 to 2L) of crystalloid resuscitation by EMS and increased use of blood products were associated with survival out of the ED, but did not improve overall survival. Our study confirms that ACLS medications have no role in treating traumatic arrest, not even as a bridge to organ donation. We found cardiac ultrasound to be an important tool in trauma resuscitation.

208 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

58. MANAGEMENT OF ANOMALOUS CIRCUMFLEX ARTERY ENCIRCLING THE AORTIC ANNULUS IN AORTIC VALVE REPLACEMENT V Rodriguez MD; I Salas De Armas MD; DA Tolpin MD; NM Lakkis MD; R Gilani MD; MJ Wall Jr MD; KL Mattox MD; S Markan MD and PI Tsai MD Houston, TX

BACKGROUND: Anomalous circumflex artery originating from the right coronary cusp coursing around the aortic annulus posteriorly, becomes significant in the setting of an aortic valve replacement for obvious reasons. In this report, we document the first preoperative identification, and successful management of this anomaly during aortic valve replacement with the use of intraoperative transesophageal echocardiography (TEE) to document avoidance of compression or injury to the anomalous vessel at completion of the operation.

METHODS: A case report with review of the literature

RESULTS: We present the case of a 53 year old Hispanic female with newly diagnosed critical aortic stenosis and preoperative work-up cardiac catheterization demonstrating an anomalous origin of the circumflex artery arising from the right coronary cusp coursing posteriorly around the aortic annulus. Transesophageal echocardiogram (TEE) was performed intraoperatively to confirm a critically stenotic bicuspid aortic valve (AV). The surgery progressed uneventfully with replacement using a 19-mm St. Jude Regent supra-annular valve. After successful separation from the cardiopulmonary bypass, TEE demonstrated a normally functioning prosthetic AV, but with with diastolic flow outside the sewing ring in the area which would correspond to the non-coronary cusp. Immediate concern was raised that this represented a perivalvular leak around the newly placed prosthetic AV. Upon further examination, this abnormal flow was able to be followed to where it originated from the right coronary cusp region consistent with the preoperative cath findings of an anomalous circumflex artery coursing behind the aorta and now appeared directly adjacent to the sewing ring of the prosthetic aortic valve. This was further confirmed in the midesophageal long-axis view where the circumflex artery was visualized in cross section. There was good flow without compromise by the valve ring. The patient’s surgery concluded without incident and she eventually was discharged home after an uneventful recovery.

CONCLUSION: In addition to reviewing preoperative coronary catheterization results for coronary artery disease, proper knowledge of the coronary anatomy by the operative team is vital for all cardiac surgeries to help prevent potential complications and to prevent misinterpreting intraoperative findings. Intraoperative TEE can be used to assess the function of newly placed prosthetic heart valve and rule out perivalvular leaks in the post-cardiopulmonary bypass period. Additionally, intraoperative TEE in this case allowed the surgical team to assess the patency of the at-risk anomalous circumflex artery after placement of the prosthetic aortic valve. This can also be valuable in the setting of prior dissection of the vessel off the aortic annulus to rule out any dissection injury. Finally, this knowledge and TEE guidance would be crucial in a setting of aortic root annular enlargement if necessary.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 209 POSTER ABSTRACTS (cont.)

59. UNUSUAL ISOLATED AZYGOUS VEIN AVULSION FROM BLUNT TRAUMA: CASE REPORT AND LITERATURE REVIEW T NGUYEN MD; I SALAS DE ARMAS MD; MJ WALL JR MD; R GILANI MD; KL MATTOX MD; NM LAKKIS MD; S MARKAN MD; PI TSAI MD Houston, TX

BACKGROUND: Azygous vein injury is uncommon and usually occurs with penetrating trauma. Given the anatomic location, the diagnosis and management remain significantly challenging. We describe an unusual case of isolated blunt trauma injury to the azygous vein from motor vehicle accident with a successful outcome.

METHODS: A case report and literature review of isolated blunt deceleration injury to the azygous vein from a traffic accident.

RESULTS: Patient presented to the emergency room (ER) after involvement in a traffic accident. She was hemodynamically unstable, and a left anterolateral ER thoracotomy was immediately performed with cross clamping of the aorta and no evidence of pericardial tampanade with return of cardiac function. A substernal exploration of the right chest was performed and revealed significant blood return, which prompted transfer of patient to the operating room for a clamshell exploration. After evacuation of the right hemothorax and careful exploration, the only injury noted was an avulsion of the azygous vein over T7-T8 vertebral bodies. Minor venous bleeding on and between the vertebral bodies was controlled with electrocautery and bone wax. The azygous vein was ligated at both avulsed ends. A mini laparotomy demonstrated no other intraabdominal injuries, and the patient tolerated release of the aortic cross clamp and was optimized with blood products. Postoperative course was uneventful and patient was successfully treated and discharged.

CONCLUSION: Azygous vein injuries from blunt trauma are rare, and isolated azygous vein injuries are exceedingly rare due to list location, which also poses a significant challenge for exposure and repair. These injuries should be thought of as great vessel injuries as they also carry a high morbidity and mortality. In our case, as reported in the literature, there was no pathognomonic signs of this except hypotension and need for immediate surgical exploration. Patient, if lucky enough to survive to ER, is exsanguinating and condition would not allow a CXR or CT scan. The usual witnessed hemodynamic collapse, while in ER, would prompt a left thoracotomy and eventual clam shell to identify almost serendipitously this occult injury. This is in contrast to penetrating trauma to the azygous vein, which is usually treated with sternotomy or right thoracotomy because of the trajectory. When managing blunt trauma, one must be aware of this entity and the need for immediate surgical repair so a lethal outcome can be avoided.

210 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

60. CLINICAL, IMAGING, SURGICAL AND PATHOLOGIC CORRELATION OF NON-INVOLUTING CONGENITAL HEMANGIOMAS F Sheikh MD; A Akinkuotu MD; R Ali MSIII; S Pimpalwar MD; A Pimpalwar MD Hosuton, TX

BACKGROUND: Non-involuting congenital hemangiomas (NICH) are are uncommon vascular tumors that can be misdiagnosed as venous malformations and require excision for cosmesis. We evaluated our experience with diagnosing NICH and the surgical excision of these tumors.

METHODS: A chart review of all patients treated for NICH between Novemeber 2011 and October 2013 was performed. Diagnosis was based on clinical findings, imaging and histopathology. Data obtained included the use of preoperative embolization, blood loss, length of stay and duration of surgery.

RESULTS: NICH was diagnosed in 4 patients, ages 5-13. All patients presented with slow-growing, painless masses that failed to regress after birth. The overlying skin had a blue hue with interspersed telangiectasia, peripheral pale halo and prominent surface and peripheral subcutaneous veins. Lesion sizes included 4cm (periareolar), 6.6cm (right flank), 5.2 (anterior neck) and 5.5cm (right forearm). On ultrasound masses were sharply demarcated and hypoechoeic with a subtle lobular pattern and prominent compressible veins. A plethora of small arteries with low resistance waveform was visualized on doppler imaging. Angiography showed multiple hypertrophied arterial feeders and multiple large veins that drained into enlarged adjacent veins without arteriovenous shunting.

All 4 patients underwent surgical resection, 2 of which underwent preoperative embolization, either one day prior to or the morning of surgery. Excision was performed using blunt and sharp dissection around the well-demarcated border of the tumors and serial ligation of feeding vessels. Duration of procedures ranged from 55 to 78 minutes. Blood loss was minimal for three patients ranging from 1 to 10mL, however excision of the pre-embolized forearm tumor resulted in 100mL of blood loss. This patient required a hospital stay of 3 days for pain control while all others were discharged the day of surgery. Histopathology confirmed lobular architecture and a conglomerate of endothelial lined channels (GLUT-1 negative) with a central arteriole and dilated dysplastic veins.

CONCLUSION: NICH has distinctive clinical and imaging characteristics that correlate with the lobular architecture seen on histopathology and the well-demarcated tumor margins observed during surgery. The benefit of preoperative embolization will need to be studied further.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 211 POSTER ABSTRACTS (cont.)

61. “FLESH-EATING” BACTERIA IN AMERICA: NATIONAL TRENDS IN OPERATIVE MORTALITY FROM NECROTIZING FASCIITIS SW Ross MD; M Kim MD; B Oommen MD; AL Walters MS; KT Dacey MHA; VA Augenstein MD; BT Heniford MD; RF Sing DO Charlotte, NC

BACKGROUND: Necrotizing fasciitis is a disease process with high mortality and morbidity, but little is known about risks factors for mortality. Our goal is to examine national level data to elucidate pre-operative risk factors and predictors for mortality.

METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried from 2005-2011 for all cases of necrotizing fasciitis. Patient demographics, comorbidities, operative characteristics, and outcomes were analyzed using standard statistical tests. Procedures were organized by body part and invasiveness: incision and drainage, debridement, fasciotomy, amputation, and radical amputation (hip or shoulder disarticulation). A multivariate model was constructed to identify independent predictors of mortality.

RESULTS: There were 1540 patients with necrotizing fasciitis: 140 had incision and drainage, 1009 debridements, 82 fasciotomies, 153 simple and 20 radical amputations. Procedures involved the skin alone (14.7%), head and neck (0.8%), thorax (1.1%), abdomen (34.8%), perineum and pelvis (26.2%), upper (2.5%) and lower extremity (19.7%). There were 203 deaths (13.2%). Patients that died were older (52.8±13.4vs60.5±14.7 years), had a higher Charlson Comorbidity Index score (1.4±1.9vs2.3±2.5), were more likely to use steroids (5.8%vs11.3%), have a bleeding disorder (12.5%vs31.5%), had chemotherapy (1.8%vs4.9%) or radiation in the last 30 days (0.3%vs2.2%); all p<0.05. However, those that died were less likely to have diabetes (49.1%vs39.9%) or to smoke (38.0%vs27.6%), p<0.05. On average, patients were similar in gender (male: 51.1%vs50.7%) and were morbidly obese (BMI: 35.9±12.7vs35.6±15.5 kg/m2); p>0.05. Those that died were more likely to present in septic shock (22.3%vs60.1%), have a higher ASA classification (ASA 4-5:36.6%vs83.2%), require amputation (10.3%vs17.2%), and have an abdominal site affected (33.8%vs41.4%). When pre-operative labs were analyzed, a creatinine of >2 gm/dL (21.4%vs41.5%), INR of >2 (4.6%vs17.5%), albumin <2.5 gm/dL (62.8%vs74.4%) and platelets of < 100,000 /uL (6.7%vs23.5%) were associated with increased mortality; all p<0.05. However WBC, hematocrit, and sodium were not significantly different. On multivariate regression, non-diabetics, functionally dependent patients and patients with a bleeding disorder, recent radiotherapy, ASA 4 or 5, creatinine >2 gm/dL or platelets <100,000/uL were significantly more likely to die; all p<0.05.

CONCLUSION: Pre-operative risk factors for mortality in necrotizing fasciitis include elevated creatinine, thrombocytopenia, bleeding disorders, and recent radiotherapy. Paradoxically, diabetes was demonstrated to be protective against operative mortality in necrotizing fasciitis, possibly due to prohibitive surgical risk or aggressive progression of disease with early pre-surgical mortality in this population. Further prospective study is required to better characterize this result.

212 Southwestern Surgical Congress | 66th Annual Meeting POSTER ABSTRACTS (cont.)

62. MESH LOCATION IN VENTRAL HERNIA REPAIR: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS DH Nguyen MPH; MT Nguyen MS; SC Hicks PhD; J Davila PhD; LS Kao MD MS; DH Berger MD MHCM; MK Liang MD Houston, TX

BACKGROUND: Mesh repair of ventral hernias has been shown to reduce recurrence rates compared to suture repair. However, there is no consensus on the best location to place mesh with respect to the fascia. This review seeks to identify the mesh location associated with the lowest rate of recurrence following ventral hernia repair.

METHODS: A literature search of Pubmed, Cochrane databases and Embase was conducted using PRISMA guidelines. MINORS was used to assess the methodological quality. A network analysis was performed to show the relationship between the different mesh locations. Primary outcome was hernia recurrence. Secondary outcome was surgical site infection (SSI).

RESULTS: Sixteen studies were identified (n=2,259). The pooled recurrence rate was 12.4% (n=1007) for onlay (mesh placed anterior to anterior rectus fascia), 50% (n=36) for inlay (mesh placed in the hernia defect), 8.9% (n=730) for sublay (retrorectus, retromuscular, Rives Stoppa, or preperitoneal), and 7.2% (n=483) for underlay (IPOM, intraperitoneal). The pooled SSI rate was 15% for onlay, 8.7% for inlay, 7.9% for sublay, and 13.0% for underlay. The network analysis showed that underlay and sublay repairs have the lowest rates of recurrence and SSI.

CONCLUSION:Underlay and sublay placement of mesh demonstrate improved outcomes compared to onlay and inlay repairs; however the quality and level of data remains poor. A randomized controlled trial is needed to validate the findings, in particular comparing underlay and sublay techniques.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 213 POSTER ABSTRACTS (cont.)

63. APPENDICITIS IN MISSISSIPPI: ARE THERE HEALTH CARE DISPARITIES? TS Helling MD, DF Soltys MD, X Zhang PhD Jackson, MS

BACKGROUND: Health care disparities have been shown to affect severity of disease and treatment by health care providers and have been linked to socioeconomic status, including race, gender, and income. This also may apply to treatment of acute appendicitis, a common health care concern across all demographics. This study was intended to determine the effect of socioeconomic factors on the severity, course, and treatment of acute appendicitis in adults at a state referral institution.

METHODS: This was a retrospective single institution study of all adult patients with acute appendicitis treated by appendectomy from 2008-2012. Age (categorized into quarters), gender, race, payer status, median household income estimate by zip code (categorized into quarters), and their effect on type of surgery (open vs. laparoscopic), perforation, duration of symptoms, complications, readmission, length of stay, and hospital charges was determined. Perforation, duration of symptoms, mortality, complications, and need for readmission were used as surrogates for severity of disease.

RESULTS: Of 423 patients identified, 382 had a complete set of data and formed the basis for this study. Most (285, 75%) were younger than 42, and 143 were women. There were 216 non-white patients (57%). Most (55%) were uninsured. One hundred two (27%) were in the lowest income quarter (estimated median income < $27,141). Three hundred thirty-one (87%) had a laparoscopic appendectomy, 20 others were converted to open operations, and 31 had open surgery from the onset. There were 69 patients who had a perforated appendix. Forty-four (12%) had complications and 19 required readmission. There were 21 deaths (5.5%). By multivariate analysis age (upper quarter: OR 3.55, CI 1.04 – 12.14, p = 0.044) and race (non-white versus white: OR 3.69, CI 1.30 – 10.46, p = 0.014) were associated with open surgery; age (upper quarter: OR 4.66, CI 2.10 – 10.37, p < 0.001) and gender (female versus male: OR 0.39, CI 0.20 – 0.75, p = 0.005) were associated with perforation; and age (upper quarter: OR 0.18, CI 0.04 – 12.14, p = 0.036) inversely associated with readmission. There was no association of these variables with duration of symptom, mortality, complications, length of stay, or hospital charges.

CONCLUSION: Of the socioeconomic factors studied, age and race, but not gender, payer status or income level, were associated with open rather than laparoscopic appendectomy. Difficulty in diagnosis may account for the age effect. There is no ready explanation for race effect on type of operation. Age was also associated with higher rates of perforation. Neither race, payer status, nor income levels were associated with perforation, duration of symptoms, mortality, complications, need for readmission, length of stay, or charges. While peculiarities of treatment existed, in this state referral institution there was no discernible effect of socioeconomic factors on the severity or outcome of acute appendicitis in adults

214 Southwestern Surgical Congress | 66th Annual Meeting CONSTITUTION AND BYLAWS

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 215 CONSTITUTION ARTICLE I: NAME ARTICLE V: OFFICERS The name of the organization shall be The Southwestern Surgical Congress. It shall The officers of the Congress shall consist of a President, a President-Elect, a Vice- be incorporated as a non-profit organization under the laws of the state of Oklahoma President, a Secretary-Treasurer and a Recorder who are active Fellows of The unless otherwise directed by action of the members of the Congress. It shall have no Southwestern Surgical Congress. capital stock or shareholders. The President-Elect shall be elected at the Annual Congress Business Meeting to serve for one year. At the expiration of that year, he or she shall become President and shall ARTICLE II: MISSION STATEMENT serve for one year or until his/her successor is elected and installed. If the President- The Southwestern Surgical Congress is an organization that promotes the advancement Elect dies, resigns or becomes otherwise unable to complete the term and succeed of General Surgery by representing the interests of academic, community and rural to President, the Vice President shall assume the position and responsibilities of the surgeons, surgical residents and medical students through education, advocacy, research President-Elect. The Congress shall elect both a Vice-President and President-Elect at and innovation. The goal of the Congress is to promote excellence in patient care and the next Annual Congress Business Meeting. professional development. All other officers shall be elected at the Annual Congress Business Meeting to serve for one year, except for the Recorder and the Secretary Treasurer who shall each be elected ARTICLE III: MEMBERS to serve for a term of 3 years, with a limit of no more than two terms. The members shall be known as Fellows of The Southwestern Surgical Congress. They shall be reputable surgeons and allied specialists residing in the states comprising this Congress, and other areas as approved by the Council of the Congress. Physicians shall ARTICLE VI: MEETINGS be elected to membership according to the Constitution and these Bylaws. When the Meetings of The Southwestern Surgical Congress shall be held and designated as membership of any Fellow in the Congress terminates by resignation, death, or any follows: other manner, all of his or her rights and privileges in the Congress terminate. None of (1) A Fall Council meeting at a site and date designated by the President. the assets or privileges may be used to benefit such person or the representatives of his (2) The Annual Council Meeting which is held immediately prior to the or her estate. Annual Scientific Meeting. (3) The Annual Scientific Meeting for presentation of the education program. ARTICLE IV: COUNCIL (4) The Annual Congress Business meeting during the Annual Scientific There shall be an Executive Committee of the Council composed of the President, the Meeting. President-Elect, the Secretary-Treasurer, the Vice-President, the Recorder and the two (5) The Council Executive Committee Meeting, held at the Annual most recent Past Presidents of the Congress. Scientific Meeting and additionally as needed

There shall be a Council of the Congress consisting of the President, President-Elect, Vice-President, Secretary-Treasurer, Recorder, the two most recent Past Presidents, ARTICLE VII: RULES OF CONDUCT Chairman of the Program Committee, Associate Fellow Representative and all The parliamentary conduct of the Congress and its component committees shall be councilors from each of the states comprising the Congress area. State Councilors and governed by Robert’s Rules of Order (most recent edition). the Associate Fellow Representative shall be appointed by the President-Elect with the approval of the Council of the Congress at the Annual Executive Session. The term of office of each Councilor shall be three years. A Councilor shall not serve more than ARTICLE VIII: FUNDS AND EXPENSES two consecutive terms. Funds may be raised by annual dues and voluntary contributions or in any manner approved by the Council of the Congress. Funds may be appropriated by the Council to defray the expenses of the Congress, to carry on its work and for any other purpose approved by the Council in accordance with 501c3 requirements.

216 Southwestern Surgical Congress | 66th Annual Meeting CONSTITUTION (cont.) ARTICLE V: OFFICERS The officers of the Congress shall consist of a President, a President-Elect, a Vice- President, a Secretary-Treasurer and a Recorder who are active Fellows of The Southwestern Surgical Congress.

The President-Elect shall be elected at the Annual Congress Business Meeting to serve for one year. At the expiration of that year, he or she shall become President and shall serve for one year or until his/her successor is elected and installed. If the President- Elect dies, resigns or becomes otherwise unable to complete the term and succeed to President, the Vice President shall assume the position and responsibilities of the President-Elect. The Congress shall elect both a Vice-President and President-Elect at the next Annual Congress Business Meeting.

All other officers shall be elected at the Annual Congress Business Meeting to serve for one year, except for the Recorder and the Secretary Treasurer who shall each be elected to serve for a term of 3 years, with a limit of no more than two terms.

ARTICLE VI: MEETINGS Meetings of The Southwestern Surgical Congress shall be held and designated as follows: (1) A Fall Council meeting at a site and date designated by the President. (2) The Annual Council eetingM which is held immediately prior to the Annual Scientific eeting.M (3) The Annual Scientificeeting M for presentation of the education program. (4) The Annual Congress Business meeting during the Annual Scientific Meeting. (5) The Council xecutiveE Committee Meeting, held at the Annual Scientific eetingM and additionally as needed

ARTICLE VII: RULES OF CONDUCT The parliamentary conduct of the Congress and its component committees shall be governed by Robert’s Rules of Order (most recent edition).

ARTICLE VIII: FUNDS AND EXPENSES Funds may be raised by annual dues and voluntary contributions or in any manner approved by the Council of the Congress. Funds may be appropriated by the Council to defray the expenses of the Congress, to carry on its work and for any other purpose approved by the Council in accordance with 501c3 requirements.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 217 CONSTITUTION (cont.)

ARTICLE IX: AMENDMENTS CHAPTER 1: MEMBERSHIP Section 1. The Congress, at any Annual Congress Business Meeting of the Fellows, may amend The Council shall judge the qualifications of its applicants for Fellowship. any Article of this Constitution by a 60% vote of the members present, provided that Every reputable and legally-qualified surgeon or allied specialist who has attained a copy of the proposed Amendment has been furnished for each Active and Senior certification by his/her appropriate Specialty Board may be eligible for Fellowship. Fellow at least thirty days in advance of the Annual Congress Business Meeting. Membership shall not be denied because of race, creed, color or sex. The Membership shall consist of Fellows recommended by the Council from the following states: Arizona, Arkansas, California, Colorado, Hawaii, Idaho, Kansas, Missouri, Montana, ARTICLE X: DISSOLUTION CLAUSE Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, South Dakota, Texas, In the event of the dissolution of this organization for any cause, the Council of the Utah, Wisconsin and Wyoming. Congress shall, after satisfying claims, direct the distribution of all funds and assets of The Southwestern Surgical Congress to such scientific, educational, or charitable Qualified and reputable surgeons residing in areas other than those included in The organizations or purposes as two-thirds of the Council approves. No part of the assets Southwestern Surgical Congress area who express a desire to become a member may or funds shall be given to any member or other individual. request an application form from one of the State Councilors who will present the application to the Council for special consideration for membership. Fellows who have paid their dues and now reside in states outside of the area comprising the Congress may continue as Fellows with all duties and privileges.

Domestic: Every reputable and legally-qualified surgeon or allied specialist who has attained certification by his or her appropriate American Surgical Specialty Board (which is a member of the American Board of Medical Specialties) and who has graduated from a Medical School acceptable to The Southwestern Surgical Congress may be eligible for membership.

Foreign: Surgeons requesting membership in The Southwestern Surgical Congress who are foreign medical graduates are eligible if they possess the following qualifications: a) they are able to speak and write English. Application and supporting materials must be completed in English. b) Graduation from a Medical School acceptable to The Southwestern Surgical Congress. c) Certification appropriate to the applicant’s specialty practice by an American Specialty Board acceptable to The Southwestern Surgical Congress or appropriate specialty board certification by the Royal College of Physicians and Surgeons of Canada or documented proof of the completion of a minimum of five years of formal post-doctoral surgical education. d) A full and unrestricted license to practice medicine in the country and in the state or province where they are in practice.

Section 2. New states will be admitted to membership in The Southwestern Surgical Congress in the following manner: A surgeon who meets all of the qualifications for membership in The Southwestern Surgical Congress shall submit an application for the state he/she wishes to have included in The Southwestern Surgical Congress. He/she shall include with his/her application the name of surgeons who meet the qualifications and wish to become active members of the Congress. This application shall be submitted to the Council, and if approved, shall be presented to the Fellows of the Congress at the Annual Congress Business Meeting where a majority vote shall be required for inclusion as a new state.

218 Southwestern Surgical Congress | 66th Annual Meeting BYLAWS CHAPTER 1: MEMBERSHIP Section 1. The Council shall judge the qualifications of its applicants for Fellowship. Every reputable and legally-qualified surgeon or allied specialist who has attained certification by his/her appropriate Specialty Board may be eligible for Fellowship. Membership shall not be denied because of race, creed, color or sex. The Membership shall consist of Fellows recommended by the Council from the following states: Arizona, Arkansas, California, Colorado, Hawaii, Idaho, Kansas, Missouri, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, South Dakota, Texas, Utah, Wisconsin and Wyoming.

Qualified and reputable surgeons residing in areas other than those included in The Southwestern Surgical Congress area who express a desire to become a member may request an application form from one of the State Councilors who will present the application to the Council for special consideration for membership. Fellows who have paid their dues and now reside in states outside of the area comprising the Congress may continue as Fellows with all duties and privileges.

Domestic: Every reputable and legally-qualified surgeon or allied specialist who has attained certification by his or her appropriate American Surgical Specialty Board (which is a member of the American Board of Medical Specialties) and who has graduated from a Medical School acceptable to The Southwestern Surgical Congress may be eligible for membership.

Foreign: Surgeons requesting membership in The Southwestern Surgical Congress who are foreign medical graduates are eligible if they possess the following qualifications: a) they are able to speak and write English. Application and supporting materials must be completed in English. b) Graduation from a Medical School acceptable to The Southwestern Surgical Congress. c) Certification appropriate to the applicant’s specialty practice by an American Specialty Board acceptable to The Southwestern Surgical Congress or appropriate specialty board certification by the Royal College of Physicians and Surgeons of Canada or documented proof of the completion of a minimum of five years of formal post-doctoral surgical education. d) A full and unrestricted license to practice medicine in the country and in the state or province where they are in practice.

Section 2. New states will be admitted to membership in The Southwestern Surgical Congress in the following manner: A surgeon who meets all of the qualifications for membership in The Southwestern Surgical Congress shall submit an application for the state he/she wishes to have included in The Southwestern Surgical Congress. He/she shall include with his/her application the name of surgeons who meet the qualifications and wish to become active members of the Congress. This application shall be submitted to the Council, and if approved, shall be presented to the Fellows of the Congress at the Annual Congress Business Meeting where a majority vote shall be required for inclusion as a new state.

April 13 – 16, 2014 | Westin Kierland Resort, Scottsdale, AZ 219 BYLAWS (cont.)

Section 3. A candidate for Fellowship shall make application in writing on a form (D) Senior Fellows provided by the Congress. The application form shall contain all specific information Upon the recommendation of the State Councilor, the Membership Committee deemed important and pertinent by the Council. The requirement for an accompanying and subsequent approval of the Council, an Active Fellow in good standing who initiation fee is limited to application for active fellowship. The application must be has attained the age of 65 years and remains in active practice may continue as an approved and signed by the applicants State Councilor before consideration by the Active Fellow with all the rights and responsibilities or may request change to senior Council of the Congress. status by applying to the Council. An Active Fellow in good standing who has retired from practice regardless of reason or age and is not using his/her professional Section 4. The Council shall have the right to accept or reject any application for credentials for employment shall be granted Senior Fellowship. Senior Fellows may Fellowship in the Congress. If approved by the Council, each application shall be signed receive the official Journal upon payment of the member’s subscription fee. . by the Chairman of the Membership Committee of the Congress. If disapproved, the initiation fees will be returned. (E) Senior Fellows for Life: Senior Fellow for Life status may be conferred by the Council upon surgeons who Section 5. The membership of this Congress shall be designated as Active, Associate, have retired from active practice and have held Senior Fellow membership status for Honorary, Senior and Inactive Fellows. at least one year. This status is intended for surgeons who wish to retire completely from the association but remain listed in the membership directory. Senior Fellows (A) Active Fellows for Life may neither vote nor hold elective office. Active Fellowship may be conferred upon physicians who have been actively engaged in the practice of surgery for at least one year following the completion (F) Inactive Fellowship of an approved surgical training program, who are of good moral character and Inactive Fellowship may be granted by the Council upon request from Active professional standing, duly licensed and who are certified by the American Board Fellows while they are serving military duty, while engaged in full time post- of Surgery or other appropriate Specialty Board. Extraordinary exceptions to graduate training, while actively engaged in missionary service or for other valid these membership requirements may be recommended by the State Councilor and reasons as accepted by the Council. Upon conclusion of this period the member considered for approval by the Council of the Congress, after careful and complete may resume his/her previous status of Active Fellow. Inactive Fellows are not review and approval by the Membership Committee. required to pay membership dues but they may receive the official Journal upon payment of the members’ subscription fee. They may not vote or hold elective (B) Associate Fellows office. Inactive Fellows must inform the Central Office annually concerning their Associate Fellowship may be conferred upon physicians who are at any level of an current status. Active members while serving active duty will continue to receive the ACGME approved surgical training program, who are of good moral character and Journal without a fee and interruption. professional standing and are duly licensed. Associate Fellowship will be limited to five years. Upon completion of Board Certification, the Associate Fellow is Section 6. Fellows shall be certified by the Congress and their certificates shall be signed eligible for Active Fellowship, after 1 year of practice. Associate Fellows will be by the President and the Secretary-Treasurer of the Congress. entitled to the same privileges as Active Fellows except the privileges of voting and holding office. Associate Fellows will pay no initiation fee but will pay a reduced Section 7. The privilege of holding any elective office and voting in the Congress shall membership fee as set by the Council and regular membership meeting registration be restricted to Active Fellows and Senior Fellows in good standing. Honorary, Inactive, fees. Associate Fellows who apply for Active Fellowship will have the initiation fee Associate Fellows and Senior Fellows for Life shall not vote or hold office. waived and pay the standard membership dues at that time. Section 8. Any member who is suspended from his/her local or state Medical Society, (C) Honorary Fellows the American College of Surgeons, or who otherwise may be disqualified from fellowship Honorary Fellowship may be conferred by the Council upon surgeons who have in this Congress for any good or sufficient cause may have his/her membership in the distinguished themselves by outstanding achievement. Honorary Fellowship may be Congress terminated, following review and agreement by the Council. conferred upon surgeons living in states outside those included in The Southwestern Surgical Congress or upon surgeons living in countries other than the United States. Honorary Fellows shall pay no dues or initiation fees and may not vote or hold elective office. They may receive the official Journal upon payment of the members’ subscription fee.

220 Southwestern Surgical Congress | 66th Annual Meeting BYLAWS (cont.)

(D) Senior Fellows Upon the recommendation of the State Councilor, the Membership Committee and subsequent approval of the Council, an Active Fellow in good standing who has attained the age of 65 years and remains in active practice may continue as an Active Fellow with all the rights and responsibilities or may request change to senior status by applying to the Council. An Active Fellow in good standing who has retired from practice regardless of reason or age and is not using his/her professional credentials for employment shall be granted Senior Fellowship. Senior Fellows may receive the official Journal upon payment of the member’s subscription fee. .

(E) Senior Fellows for Life: Senior Fellow for Life status may be conferred by the Council upon surgeons who have retired from active practice and have held Senior Fellow membership status for at least one year. This status is intended for surgeons who wish to retire completely from the association but remain listed in the membership directory. Senior Fellows for Life may neither vote nor hold elective office.

(F) Inactive Fellowship Inactive Fellowship may be granted by the Council upon request from Active Fellows while they are serving military duty, while engaged in full time post- graduate training, while actively engaged in missionary service or for other valid reasons as accepted by the Council. Upon conclusion of this period the member may resume his/her previous status of Active Fellow. Inactive Fellows are not required to pay membership dues but they may receive the official Journal upon payment of the members’ subscription fee. They may not vote or hold elective office. Inactive Fellows must inform the Central Office annually concerning their current status. Active members while serving active duty will continue to receive the Journal without a fee and interruption.

Section 6. Fellows shall be certified by the Congress and their certificates shall be signed by the President and the Secretary-Treasurer of the Congress.

Section 7. The privilege of holding any elective office and voting in the Congress shall be restricted to Active Fellows and Senior Fellows in good standing. Honorary, Inactive, Associate Fellows and Senior Fellows for Life shall not vote or hold office.

Section 8. Any member who is suspended from his/her local or state Medical Society, the American College of Surgeons, or who otherwise may be disqualified from fellowship in this Congress for any good or sufficient cause may have his/her membership in the Congress terminated, following review and agreement by the Council.

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CHAPTER 2: MEETINGS CHAPTER 3: ELECTION OF OFFICERS Section 1. At the Annual Congress Business Meeting of the Fellows, the President- Section 1. The Congress shall hold an Annual Scientific Meeting. The time, Elect and the Vice-President for the forthcoming year shall be elected. place, and length of the meeting shall be determined by the Council. Appropriate registration fees for the Annual Scientific Meeting will be determined by the Section 2. The Secretary-Treasurer shall be elected every third year, but if he/she is Council. unable to complete his/her term of office, the Executive Committee may appoint a Secretary-Treasurer to serve on an interim basis until the next Annual Meeting, at Section 2. Each individual attending the Annual Scientific Meeting shall register which time his/her successor shall be elected for a three-year term. and secure a badge from the Secretary-Treasurer or designated representative. This badge is required for admittance to the educational program and all other events at The successor to the Secretary-Treasurer shall be elected at the Annual Meeting one the meeting. year in advance of his/her assumption of duties to serve as an understudy to the outgoing Secretary-Treasurer. He/She shall attend all meetings of the Council and the Section 3. During the Annual Scientific Meeting, there shall be an Annual Council Executive Committee without a vote. Congress Business Meeting of the Congress in order to elect officers and to transact other business. The time and place of this Business Meeting shall be announced in Section 3. The Recorder shall be elected every third year, but if he/she is unable to the Program. complete his/her term of office, the Executive Committee may appoint a Recorder to serve on an interim basis until the next Annual Meeting, at which time his/her Section 4. Distinguished individuals who are not Fellows of The Southwestern successor shall be elected for a three-year term. Surgical Congress may be invited by the Program Committee with approval of the Executive Committee to any Annual Scientific Meeting for the purpose of The successor to the Recorder shall be elected at the Annual Meeting one year in participating in the educational programs. advance of his/her assumption of duties to serve as an understudy to the outgoing Recorder. He/She shall attend all meetings of the Council and the Council Executive Section 5. Papers read before the Congress must not have been published or Committee without a vote. presented at a major regional or national scientific meeting prior to presentation at the Congress, except by arrangement with the Program Committee. The abstract Section 4. The report of the Nominating Committee shall be presented at the Annual form of such papers shall be completed and submitted to the Program Committee Congress Business Meeting of the Congress. Additional nominations may be made prior to their deadline in order to be considered for the Program. Such papers from the floor. shall become the property of the Congress and, subject to the approval of both the Publication and Research Committee of the Congress and the Editorial Staff of Section 5. Elections shall be held by ballot, voice vote, or standing vote, as decided the contracted Journal. The papers may be published in the Journal serving as the by the presiding officer. A majority vote of members present shall be necessary for official organ of the Congress. election. In the event no one candidate receives a majority of the votes cast, the one receiving the smallest number of votes shall be dropped, the vote retaken, and the balloting shall proceed in this manner until a candidate receives such majority of the votes cast.

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CHAPTER 3: ELECTION OF OFFICERS Section 1. At the Annual Congress Business Meeting of the Fellows, the President- Elect and the Vice-President for the forthcoming year shall be elected.

Section 2. The Secretary-Treasurer shall be elected every third year, but if he/she is unable to complete his/her term of office, the Executive Committee may appoint a Secretary-Treasurer to serve on an interim basis until the next Annual Meeting, at which time his/her successor shall be elected for a three-year term.

The successor to the Secretary-Treasurer shall be elected at the Annual Meeting one year in advance of his/her assumption of duties to serve as an understudy to the outgoing Secretary-Treasurer. He/She shall attend all meetings of the Council and the Council Executive Committee without a vote.

Section 3. The Recorder shall be elected every third year, but if he/she is unable to complete his/her term of office, the Executive Committee may appoint a Recorder to serve on an interim basis until the next Annual Meeting, at which time his/her successor shall be elected for a three-year term.

The successor to the Recorder shall be elected at the Annual Meeting one year in advance of his/her assumption of duties to serve as an understudy to the outgoing Recorder. He/She shall attend all meetings of the Council and the Council Executive Committee without a vote.

Section 4. The report of the Nominating Committee shall be presented at the Annual Congress Business Meeting of the Congress. Additional nominations may be made from the floor.

Section 5. Elections shall be held by ballot, voice vote, or standing vote, as decided by the presiding officer. A majority vote of members present shall be necessary for election. In the event no one candidate receives a majority of the votes cast, the one receiving the smallest number of votes shall be dropped, the vote retaken, and the balloting shall proceed in this manner until a candidate receives such majority of the votes cast.

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Section 4. Secretary-Treasurer CHAPTER 4: DUTIES OF OFFICERS (A) The Secretary-Treasurer shall be a member of the Council and a member of the Section 1. President Executive Committee of the Council. He/she is an ex-officio member of all committees (A) The residentP shall preside at the Council Meetings, and at the Annual Congress except when designated as a regular member of a specific committee. The Secretary- Business Meeting, and shall perform such duties as custom and parliamentary usage may Treasurer shall be elected for a three-year term and may be re-elected to this office. If he/ require. During the Annual Scientific Meeting, he/she shall deliver an address on such she is unable to complete his/her term of office, the President, with the approval of the matters as he/she shall deem of importance to the Fellows of the Congress. He/she shall Executive Committee or the Council, shall appoint a successor to serve until the next be Chairman of the Executive Committee of the Council, an ex-officio member of all election. other Committees, and may preside over Scientific Sessions. (B) Duties of the Secretary-Treasurer are as follows: (B) He/she shall appoint special committees, as the need for such committees arises. (1) Under direction of the Council, he/she shall supervise the activities of the Congress and facilitate the workings of the various standing committees. He/she (C) At the Annual Congress Business Meeting during the Annual Scientific Meeting, shall insure that minutes are recorded of Council meetings, Executive Committee the President assumes his/her duties as President; he/she shall announce the following meetings, and the annual or special meetings of the members. He/she shall appointments: supervise the maintenance of files and records of the Congress. He/she shall (1) Chairman of the Standing Committees as needed. perform other duties as are incident to such office or as may be assigned to him/she (2) New members to the Standing Committees as needed. The senior member of from time to time by the Council. With the approval of the Council, he/she may each Standing Committee retires from the Committee each year, but may be re- delegate to the Business Manager such duties as he/she deems appropriate. appointed. (2) Under the direction of the Council, he/she shall supervise the financial affairs (3) Regular or acting Councilors and Vice-Councilors as heretofore provided. of the Congress. He/she shall advise the Business Manager concerning billings and collections and management of all funds received by the Congress. Financial (D) The President may, at his/her discretion, call a meeting of the Council or any records and bank accounts shall be under the direction of the Business Manager, Committee for consideration of such business as may properly be brought before it. If who shall render an annual report. The Business Manager will provide the a member of the Council is unable to complete his/her term of office, the President Secretary-Treasurer with an annual report for presentation to the membership at the shall appoint a successor. The President may, by and with the advice and consent of annual business meeting. the Council, relieve any member of any Committee of his/her duties. When a member appointed to serve on any Committee is unable to complete his/her term of duty, the Section 5. Recorder President shall appoint a successor to complete the term. In the event any member of The Recorder shall be a member of Council, the Executive Committee, Chairman of the Council is unable to attend any Council meeting, the President may appoint an Publication and Research Committee, an ex-officio member of the Program Committee alternate to serve for that meeting. and function as the liaison officer between the SWSC and the official journal of the Congress. (E) On the President’s death, disability, resignation, or removal, the President-Elect shall succeed to the Presidency His/her duties will consist of determining with the Chairman of the Program Committee, the maximum number of scientific papers to be submitted for publication, Section 2. President-Elect collecting and editing the manuscripts and discussions at the Annual Scientific Meeting (A) The President-Elect shall serve as a member of the Council of the Congress, and and editing them for publication in the official journal of the Congress. In addition, of its Executive Committee and shall assist the President in the performance of his/her he/she will give a report at both the Council and annual Congress Business meetings duties, and shall preside in his/her absence or at his/her request. regarding the activities of his/her office and of the Publication and Research Committee. Section 3. Vice-President The Vice-President shall serve as a member of the Council of the Congress and its Executive Committee. If the Vice-President is unable to complete his/her term, the President shall appoint his/ her successor to serve until the next election.

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Section 4. Secretary-Treasurer (A) The Secretary-Treasurer shall be a member of the Council and a member of the Executive Committee of the Council. He/she is an ex-officio member of all committees except when designated as a regular member of a specific committee. The Secretary- Treasurer shall be elected for a three-year term and may be re-elected to this office. If he/ she is unable to complete his/her term of office, the President, with the approval of the Executive Committee or the Council, shall appoint a successor to serve until the next election.

(B) Duties of the Secretary-Treasurer are as follows: (1) Under direction of the Council, he/she shall supervise the activities of the Congress and facilitate the workings of the various standing committees. He/she shall insure that minutes are recorded of Council meetings, Executive Committee meetings, and the annual or special meetings of the members. He/she shall supervise the maintenance of files and ecordsr of the Congress. He/she shall perform other duties as are incident to such office or as may be assigned to him/she from time to time by the Council. With the approval of the Council, he/she may delegate to the Business Manager such duties as he/she deems appropriate. (2) Under the direction of the Council, he/she shall supervise the financial affairs of the Congress. He/she shall advise the Business Manager concerning billings and collections and management of all funds received by the Congress. Financial records and bank accounts shall be under the direction of the Business Manager, who shall render an annual report. The Business Manager will provide the Secretary-Treasurer with an annual report for presentation to the membership at the annual business meeting.

Section 5. Recorder The Recorder shall be a member of Council, the Executive Committee, Chairman of Publication and Research Committee, an ex-officio member of the Program Committee and function as the liaison officer between the SWSC and the official journal of the Congress.

His/her duties will consist of determining with the Chairman of the Program Committee, the maximum number of scientific papers to be submitted for publication, collecting and editing the manuscripts and discussions at the Annual Scientific Meeting and editing them for publication in the official journal of the Congress. In addition, he/she will give a report at both the Council and annual Congress Business meetings regarding the activities of his/her office and of the Publication and Research Committee.

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CHAPTER V. GOVERNANCE Section 1: The Council (A) The Council is the governing body of The Southwestern Surgical Congress. It shall authorize the purchase of property, stocks, bonds, and securities, make loans, and authorize and supervise the expenditures of the funds of the Congress.

(B) The Council shall meet as prescribed in Article VII of the Constitution, and as often thereafter as may be necessary. It shall be subject to called meetings as prescribed in Chapter 4, Section 1C of these Bylaws or on petition of five members of the Council.

(C) The President of the Congress shall preside at all meetings of the Council. In his/her absence, the President Elect shall preside. In the absence of the President and President Elect, the Vice-President shall preside. In the event of the absence of the President and President-Elect and Vice President, the Council shall elect a presiding officer. Seven members of the Council shall constitute a quorum.

Section 2. Council Executive Committee The Executive Committee shall study the long-range goals of the Congress and formulate specific recommendations for future operations. This Committee shall represent the Council whenever a full meeting of the Council would not be possible, to consider and act upon such matters as would come before the Council, and report its findings and conclusions to the Council.

The Chairman for the Council Executive Committee shall be the President or the President-Elect in the President’s absence, or any member elected by a majority vote of the members present.

The Council Executive Committee may be called to meet by request of the President or upon written request of three of its members.

Section 3. State Committee Each State Committee shall be composed of the State Councilor and Vice- Councilors. Each may serve up to two three-year terms. The Councilor for each state will recommend the Vice-Councilors. These appointments will be made by the President-Elect at the Annual Meeting of the Council.

The State Councilor must receive and consider all applications for Fellowship from his/her state, and must sign and approve the applications before they are submitted to the Membership Committee for action and referral to the Council for final approval.

The Vice Councilors are responsible for promoting membership within their region and assisting the State Councilor with his/her duties.

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Section 4: Business Manager The Council shall contract with a Business Manager hereinafter. The Business Manager shall be responsible for the operational management of the affairs of the Congress under the direction of the Executive Committee. The Business Manager may be a member of an association management firm. As primary custodian of the Congress’ funds the Business Manager shall be bonded in an amount sufficient to safeguard the financial assets of the Congress.

CHAPTER 5: STANDING COMMITTEES The Standing Committees shall each consist of at least three members who may or may not be members of the Council. One member of each Standing Committee, or more as indicated, shall be appointed or reappointed by the President-Elect at the beginning of his/her term of office at the Annual Congress Business Meeting, to serve a three-year term, except for the Program Committee. The Chairman of each Committee shall be designated by the President-Elect for the following year. At least one former member shall remain on each Committee each year to provide continuity of purpose. Membership on a Standing Committee shall be limited to two consecutive terms.

An annual report shall be submitted by each Standing Committee to the Council, in writing and shall become a part of the minutes of that Council Meeting. A summary of the Committee reports shall be presented by the Chairman at the Annual Congress Business Meeting.

Section 1. Program Committee The duty of the Program Committee is to select and arrange the Educational Program for the Annual Scientific Meeting. The Program Committee shall consist of the President, Recorder and six appointed members. The newly elected Vice President will annually appoint two individuals to serve a three-year term. One of these appointments will be designated to serve as Chairman of the Program Committee when the Vice President serves as President. The other members of the Committee will consist of two members serving their second year, two members serving their third year (one having been selected as Chairman). The Program Committee shall designate a CME Coordinator and obtain CME credit for the annual Congress meeting.

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Section 2. Budget and Finance Committee This Committee will review the financial transactions of the Central Office and suggest any indicated changes to the Council. It will advise the Secretary-Treasurer about financial transactions and investments. It will recommend the amount of the annual membership dues and initiation fees, commensurate with the requirements of the Congress for the ensuing year.

Section 3. Constitution and Bylaws Committee It shall be the duty of this Committee to annually review the Constitution and Bylaws and to recommend any amendments or revisions as indicated.

Section 4. Publication and Research Committee This Committee shall review all manuscripts presented at the Annual Scientific Meeting and select those of highest quality or greatest interest to be forwarded to the official journal for publication. Final selection of papers to be published will be determined by the Journal. The Recorder shall be the Chairman of this Committee. Any scientific surveys or research projects of the Congress membership shall be initiated or approved by this Committee.

Section 5. Nominating Committee The Nominating Committee shall consist of the two living immediate Past Presidents with the most senior acting as Chairman and two members of the Council appointed by the President. They shall nominate candidates for President- Elect, and Vice-President and such other officers as required, and this committee shall report to the Council at the Annual Council Meeting immediately prior to the Annual Congress Business Meeting. Additional nominations may be made from the floor by Active or Senior Fellows during the Annual Congress Business Meeting. The Nominating Committee shall also appoint members to serve in the various Southwestern Surgical Congress representative positions in national organizations.

Section 6. Local Arrangements Committee The chairman of the Local Arrangements Committee will be appointed by the President.

Section 7. Graduate Medical Education Committee It shall be the duty of the Graduate Medical Education Committee to encourage the participation of surgical residents in the various programs of the Southwestern Surgical Congress programs. It shall also be the duty of the committee to encourage the participation and involvement of directors of surgical residencies in member states in the Congress and its various programs.

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Section 8. Membership Committee It shall be the duty of the Membership Committee to solicit from qualified general and specialty surgeons in member states of The Southwestern Surgical Congress applications for Fellowship in the Congress. It shall be the responsibility of the committee to evaluate each application for Fellowship to ensure that the surgeon fulfills the requirements for Fellowship as defined in Section 5 of Chapter 1 of these Bylaws. The committee will make its recommendation regarding Fellowship for each applicant to the Council of the Congress. The Graduate Medical Education Chairman shall serve as a member of this committee.

Section 9. State Councilor Committee The State Councilor Committee shall consist of a State Councilor from each of the states, with both California and Texas having both a North and South representative. It will meet annually at The Southwestern Surgical Congress’ annual meeting. The committee will be responsible for electing the State Councilors-at- Large to serve on the Executive Committee for a two-year term (with a maximum of two consecutive terms allowed to be served). These positions will be staggered to enable one new Councilor-at-Large appointment each year. The Senior Councilor- at-Large shall serve as Chair of the State Committee. The Junior Councilor-at- Large will serve as an assistant. The Congress Vice-President should continue to be available to serve as a resource for this group and attend the State Councilor’s meeting.

CHAPTER 6: ANNUAL MEMBERSHIP DUES

Section 1. Annual membership dues shall be determined by the Council.

Section 2. Any Fellow whose dues remain unpaid for a period of one year shall have his/her membership discontinued. He/she shall be notified at least two months prior to this action. He/she may be reinstated upon payment of both the current and delinquent dues.

Section 3. Membership dues for each year shall be payable in advance, shall become due on December 31 of the preceding year, and shall become delinquent on January 1 of the year in which they apply.

Section 4. Newly elected Fellows of the Congress shall pay an initiation fee approved by the membership, based upon the recommendations of the Budget and Finance Committee and approved by the Council.

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CHAPTER 7: AMENDMENTS Bylaws may be amended at the Annual Congress Business Meeting by a 60% approval vote of the members present.. A copy shall be provided for the voting members at least thirty (30) calendar days in advance.

(Adopted 1949, as amended through March 2012)

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236 Southwestern Surgical Congress | 66th Annual Meeting THE SOUTHWESTERN SURGICAL CONGRESS 67 th Annual Meeting

RN SURGICA TE L ES CO W N H G T ND R U MT E ID S O SD S S WY • • NE NV UT KS MO CA CO

OK AR AZ NM

TX

HI OR 48 GANIZED 19

April 26 – 29, 2015 Monterey, CA | Hyatt Regency Monterey RN SURGICA TE L ES CO W N H G T ND R U MT E ID S O SD S S WY • • NE NV UT KS MO CA CO

OK AR THE SOUTHWESTERNAZ NM SURGICAL CONGRESS TX

HI OR 48 GANIZED 19

Southwestern Surgical Congress 5019 W. 147th Street Leawood, KS 66224

Phone: 913.402.7102 Fax: 913.273.9940 Email: [email protected] Web: swscongress.org