ASC 2024 Searchable Abstracts

R. Sachs1, P. Truche1, J. Lee1, S. Burjonrappa2, A. Thenappan2  1Robert Wood Johnson – UMDNJ, General Surgery, New Brunswick, NJ, USA 2Robert Wood Johnson – UMDNJ, Pediatric Surgery, New Brunswick, NJ, USA

Introduction:  Recent advancements in artificial intelligence (AI) have led to the development of systems capable of passing the USMLE examinations. This suggests a future role for AI in medical education and clinical practice. This role, however, has yet to be defined and its limitations are being explored. This study aims to evaluate the accuracy of AI systems in answering pediatric surgery fellowship-level questions.

Methods:  We assessed the performance of the ChatGPT-4 large language model on pediatric surgery fellowship-level questions. No additional training or input was provided prior to assessment. A total of 419 multiple-choice pediatric surgery fellowship-level questions were obtained from the ACS SCORE curriculum and categorized into Operative/procedural decisions, Diagnostic decision-making, Pharmacology, Embryology/Anatomy, Pathophysiology, and Epidemiology/Statistics. The model's accuracy in identifying the correct multiple-choice answer was calculated as well as compared amongst the different categories.

Results: ChatGPT-4 accurately answered 52.5% of the pediatric surgery fellowship-level questions overall (220/419). The highest accuracy was achieved in the pharmacology category (65% correct), followed by anatomy/embryology (57.5%) and pathophysiology (53.52%). In contrast, the model exhibited lower performance in the diagnostic decision-making (51.85%) and operative/procedural decisions (51.06%) categories.

Conclusion: The performance of AI systems such as ChatGPT-4 was average in answering pediatric surgery fellowship-level questions. It also remains inconsistent across various question categories. Notably it was least successful in categories that primarily require decision making. These results highlight the limitations of AI in replicating the expertise and critical thinking skills of pediatric surgery trainees and surgeons. As such, caution and further investigation is necessary prior to the integration of AI systems into medical education and clinical practice.


C. Meschia1, D. Weigle1, C. Izzo1, J. Zhang1, M. Crandall1, D. Ebler1, T. S. Hester1, J. Humanez1, S. Jain1, M. Kochuba1, T. Husty1, K. Lydon1, F. Madbak1, L. Neumayer1, R. Warner1, C. White1, B. Yorkgitis1, D. Skarupa1  1University of Florida Jacksonville, Surgery, Jacksonville, FL, USA

Critical care is a core component of both inpatient care and resident education in multiple specialties. At this institution, resident supervision was previously provided by an in-house acute care surgeon who also maintained other clinical responsibilities. In effort to provide enhanced attending-level resources and supervision to overnight ICU residents, the critical care resource intensivist (CCRI) program was incorporated, wherein a dedicated ICU attending is present overnight. A previous study was performed to determine the perceptions of general surgery residents on the impact of the CCRI on education and patient care. The goal of this study is to expand this inquiry to multiple resident specialties in the critical care setting, as well as to compare resident experiences preceding versus after implementation of the CCRI model.

The Qualtrics survey platform was utilized to send anonymous surveys to residents within the specialties of anesthesiology (AN), emergency medicine (EM), internal medicine (IM), and general surgery (GS). Demographic information elicited included post-graduate training year (PGY), specialty, and chronological relationship to implementation of CCRI. 4-point Likert Scale and free text questions were included.

Of 138 total residents (16 AN, 46 EM, 51 IM, 25 GS), 82 completed the survey (59.4%). Respondent stratification included 31 PGY-1 (38%), 22 PGY-2 (27%), 17 PGY-3 (21%), 6 PGY-4 (7%), 6 PGY-5 (7%); 11 AN (14%), 18 EM (22%), 29 IM (35%), 24 GS (29%); 7 (9%) only before CCRI, 26 (32%) before and after, and 48 (59%) only after implementation. Composites of strongly agree/agree on positive perception of attending availability (95%), improved patient care (98%), education (87%), and procedural skill (78%) and disagree/strongly disagree on perception of CCRI limiting autonomy (79%) or detracting from education (83%) were noted.

The CCRI model was implemented to enhance both educational and clinical support of residents in the ICU overnight; however, consideration is given to the perceived impact on resident education and autonomy. Across multiple disciplines and post-graduate training years, residents have indicated a favorable perceived impact of the CCRI on education, clinical support, and procedural skill with no significant impairment to autonomy.

P. Ji1,2, S. A. Brimer1,2, H. Li1,2, L. Yu1,2, J. Grande-Allen3, S. Balaji1,2, R. K. Birla1,2, S. Keswani1,2  1Baylor College Of Medicine, TCH Pedi Surgery, Houston, TX, USA 2Texas Children’s Hospital, TCH Pedi Surgery, Houston, TX, USA 3Rice University, Bioengineering, Houston, TX, USA

Introduction: Discrete subaortic stenosis (DSS) is characterized by the development of fibrous membrane tissue in the left ventricular outflow tract (LVOT), leading to an increase in pressure gradient and altered shear flow pattern in the narrowed passage below the aortic valve in the LVOT. Except surgical resection, there are no other treatment options, as the mechanisms of fibrous membrane formation are not known. Further, DSS recurs in some patients, necessitating repeat surgeries. As endocardial endothelial cells (EEC) of the LVOT experience changes in pressure gradient and shear flow, we hypothesized that altered shear forces induce an inflammatory response by EEC, which interact with cardiac fibroblasts to govern a fibrotic phenotype that contributes to the pathophysiology of DSS.


Methods: Cone-and-plate devices were used to generate flow-induced shear stress regimes (6, 15, 35 dynes/cm^2) noted in DSS for 1, 4, 8 and 24 hours on 2D cultures of porcine EECs. Inflammatory cytokine profiles of the shear-conditioned EEC media were analyzed (Luminex Assay) and RNA was isolated and bulk RNA sequencing was performed. Differences in CD31 receptor expression among EECs after shear stress was analyzed using immunofluorescence staining. Shear-conditioned EEC supernatant was then added to cardiac fibroblasts and changes in the fibroblast fibrotic phenotype was assessed using PCR array. Data presented as mean+/-stdev and p values by ANOVA.  


Results: High Shear stresses on EEC led to a significant increase in several inflammatory cytokines including TNF- α, GM-CSF, IL-2, IL-4 and IL-8 (p<0.01). Following bioreactor treatment with varying shear stresses, the expression of CD31 receptors on the porcine EEC membrane was significantly elevated (p<0.05). RNA-seq analysis showed that the inflammatory cell signaling pathway was activated in the EEC. The bioreactor-treated EEC conditioned medium induced fibrosis in porcine fibroblasts at 48 hours after media transfer, and the RT-qPCR data showed that the fibrotic markers (α-SMA, ACTA2, TFG-β1, Col1, SMAD2 & AGTRAP) were significantly altered in porcine fibroblasts, especially under the high shear stress bioreactor treated porcine EEC medium.


Conclusion: The study demonstrates that altered shear forces induce an inflammatory response in EEC, which may lead to their interaction with cardiac fibroblasts that promotes a fibrotic phenotype, thereby contributing to DSS pathophysiology. CD31 has been identified as a crucial player in the mechanical sensing and inflammatory response of EEC. These findings hold significant implications for understanding DSS pathophysiology and pave the way for developing strategies to enhance patient management, ultimately reducing the morbidity and associated costs linked to DSS recurrence in future.

B. Koskulu1,2, R. J. Schwartz3  1Baylor College Of Medicine, Houston, TX, USA 2University Of Houston, Pharmacy, Houston, TX, USA 3University Of Houston, Biochemistry, Houston, TX, USA

Introduction:  A heart injury can cause damage to cardiac muscle tissue, which cannot be repaired due to the low rate of proliferation in cardiac myocytes. A promising approach to healing the cardiac muscle tissue involves inducing cardiomyocyte growth by reactivating the cell proliferation signaling mechanisms. Sphingosine-1-phosphate (S1P), a bioactive lipid molecule, shows promise in inducing cell proliferation. S1P triggers cell signaling through G-protein coupled receptors (S1PRs) and initiates several signaling pathways, including growth, differentiation, migration, and proliferation.

Methods: We utilized the S1P molecule to induce cardiomyocyte-like cells with very low proliferation capacity upon differentiation, mimicking the low proliferating myocardial cells. The effect of S1P on cell proliferation was assessed using a wound healing assay and imaged with a fluorescent microscope to observe nuclear division. Time-course analysis of cell division transcriptomes was conducted using qPCR assays. Subsequently, RNA sequencing of different time points after S1P addition was performed to identify the cellular response to proliferation.

Results: Our research demonstrated that S1P signaling induces cell cycle entry from G1 to S. Fluorescent images revealed that cell division was initiated and nuclei division was completed within 24 hours after S1P addition. Several cell cycle transcript levels changed in response to S1P addition. Data from RNA sequencing indicated that pathways such as Notch, Wnt, Erk, and Hippo, as well as physiological events like cell cycle initiation and wound healing, were regulated. Furthermore, S1P signaling played a key role in telomere preservation and elongation. 

Conclusion: Therefore, S1P is an important signaling molecule for inducing cardiomyocyte growth, proliferation, and other critical cellular processes such as wound healing and telomere maintenance. 


K. Bellam1, D. D. Harris1, M. Broadwin1, S. A. Sabe1, C. Stone1, M. Kanuparthy1, R. Abid1, F. Sellke1  1Brown University School Of Medicine, Cardiothoracic Surgery, Providence, RI, USA

Introduction:  Our recent studies using porcine models have demonstrated that serum-starved extracellular vesicles (EVs) mitigate inflammation in animal models of acute myocardial ischemia/reperfusion and improve blood flow via inducing collateral vessel growth in ischemic myocardium. Previously, our lab demonstrated that EVs have increased abundance of antioxidant, pro-angiogenic, anti-inflammatory, and pro-survival proteins in ischemic tissues, but have yet to be investigated in nonischemic tissues. This study investigates the effect of hypoxia-modified EV therapy on oxidative stress and inflammatory signaling in nonischemic territories in a porcine model of chronic myocardial ischemia. 

Methods:  Human bone marrow-derived stem-cells (HBMSCs) were cultured to 80% confluence before being placed in a humidified hypoxia chamber. The media was collected and the EVs were isolated and characterized with electron microscopy, nanoparticle tracking analysis, and immunoblotting as previously described and published. At 11 weeks of age, Yorkshire swine underwent placement of an ameroid constrictor to the left circumflex artery to induce chronic myocardial ischemia. Two weeks later, the pigs underwent redo-left thoracotomy for an intramyocardial injection of either saline (Control, n = 7) or hypoxia-modified EVs (HEV, n = 7) into the ischemic ventricular territory. Five weeks later, pigs were euthanized, and left ventricular myocardial tissue was harvested.  Areas of ischemic (left circumflex territory) and nonischemic (left anterior descending territory) left ventricular myocardial tissue were determined by microparticle perfusion analysis. Protein expression was measured with immunoblotting. 

Results: Hypoxia-modified EV treatment was associated with increased expression of the anti-inflammatory protein IL-10 and antioxidant proteins p-eNOS, SOD1, and SOD2 in nonischemic myocardial territories compared with the control (all p<0.05). Treatment was also associated with decreased expression of inflammatory protein β-catenin (p=0.003), pro-oxidant protein KEAP-1 (p<0.0001), ERK 1/2 (p=0.002), AKT (p=0.008, and IL-6 (p=0.016). No change was seen in proteins p-AKT, PI3K, total NOS total (all p>0.05).

Conclusion: Nonischemic territories in the hypoxia-modified EV group had increased expression of anti-inflammatory and anti-oxidative stress markers compared to the control saline group in the setting of induced chronic myocardial ischemia. This study provides insights into the local regional effects of EVs in areas adjacent to the injection site, furthering our knowledge of its role as a potential therapeutic in human disease. 

R. Kambli1, R. C. Cockrell1, G. An1  1University Of Vermont College Of Medicine / Fletcher Allen Health Care, General Surgery, Burlington, VT, USA


Sepsis-induced acute kidney injury (SI-AKI) involves a complex interaction of immune, endothelial, and microvascular cells modulated by inflammatory cytokines and molecular mediators. Understanding the mechanistic pathophysiology of SI-AKI can enhance the prediction and potential treatment of multi system organ failure and subsequent mortality. The dynamics of renal impairment can be better understood using a computational model that integrates the known mechanisms of renal tubular epithelial and endothelial cell injury and the effect of heterogenous hypoperfusion of the kidney. Toward this end we developed an agent-based model (ABM) that simulates the renal immune response leading to SI-AKI.  


The Renal Function ABM (RFABM) represents the proximal tubule as the origin of the SI-AKI immune response. It is informed by current literature regarding the renal response to acute inflammation. Cell types include resident renal macrophages, neutrophils, monocytes, dendritic cells, pericytes, microvascular endothelial cells, and tubular endothelial cells. These cells interact through intracellular receptors and inflammatory cytokines present in extracellular milieu. Simulation experiments include influx of pro inflammatory cytokines and heterogenous hypoperfusion seen in septic shock, with the consequent generation of tubular necrosis and impairment of global renal function. Calibration was performed by generating synthetic populations of immune cells and comparing their behavior to published data on cytokine/mediator trajectories and organ-level damage/dysfunction reflected by creatinine clearance.


The RFABM successfully integrates existing knowledge regarding the molecular and cellular interactions leading to SI-AKI. Simulation experiments reproduced the response to septic insult in terms of the dynamics of cellular/molecular mediators (ex. pro-inflammatory cytokines and reactive oxidative species) as well as clinically accessible lab values of renal damage/dysfunction (creatinine) and were able to demonstrate the additional effect of increased heterogenous hypoperfusion differentiating sepsis from septic shock.


The RFABM is an initial computational model that represents and integrates mechanistic knowledge regarding the generation of SI-AKI. The RFABM replicates the primary dynamics of renal injury in response to circulating inflammatory mediators and differential hypoperfusion and has been designed to be integrated with an existing computational model of systemic inflammation and sepsis. Future work will expand and validate the mechanistic details of the RFABM so it can be used as an in silico experimental proxy system for positing novel drug targets and therapeutic strategies to ameliorate the consequences SI-AKI and general renal inflammation.

S. Keshwani1, A. Madrigrano1, C. Ferrigno1, J. M. Velasco1  1Rush University Medical Center, General Surgery, Chicago, IL, USA

Introduction:  Breast cancer is the leading cause of cancer in women. Management of breast cancer often includes image guided lumpectomy and SLNB (sentinel lymph node biopsy). Given the high incidence rate of breast cancer and shortage of fellowship trained specialists, general surgeons are frequently responsible for these patients. Although these procedures are part of the core curriculum of general surgery residency, residents have less operative exposure to breast surgery due to duty hour restrictions and decreased resident autonomy. This study's purpose was to create a simulation-based, novel curriculum designed to teach PGY1 and PGY2 residents how to perform breast lumpectomy and SLNB prior to their clinical experience.

Methods:  All eighteen junior general surgery residents were invited to participate. We chose fresh human donors to represent tissue planes more accurately. We inserted Savi Scout reflectors (Merit Oncology, Inc) in each breast for tumor localization. An olive pit plus 1mL of Methylene blue was inserted in the axilla for SLN identification. For the first session, two attending surgeons discussed proper surgical technique for lumpectomy and SLNB. Residents performed the procedures and received real-time feedback. Trainees returned for a second session two months later where they performed the same operation without any guidance. They were graded on technique by the same attendings present during both sessions. Residents were asked to fill out a voluntary, anonymous post-session Likert-scale based survey to gauge confidence.

Results: Out of 18 total residents, seven PGY1 and six PGY2 residents participated (response rate: 72.2%). 57% of PGY1 and 50% of PGY2 respondents strongly felt that this session improved their understanding of lumpectomies, SLNB, and axillary anatomy. Most residents also felt strongly that their skills improved when compared to the training session, and that these skills were transferable to the operating room. In attending evaluations, PGY1 residents significantly improved in all aspects of the procedures; PGY2 residents showed non-statistically significant improvement in their technique. 

Conclusion: This study aimed to implement a simulation-based program designed to teach the fundamentals of breast surgery by using available instruments. Utilization of fresh cadavers creates ideal conditions for identification of tissue planes and visualization of landmark structures. Our results indicate that residents find these sessions helpful in learning anatomy, improving their confidence and efficiency, and facilitating skill acquisition that is transferable to the operating room. Although long term objective evaluations are needed, we believe this approach should be considered in general surgery training programs. 


C. E. Berry1, A. Z. Fazilat1, C. Lavin1, H. Lintel1, N. Cole1, S. Stingl1, D. Abbas1, L. E. Kameni1, C. Valencia1, D. C. Wan1  1Stanford University, Plastic And Reconstructive Surgery/Surgery/Stanford University School Of Medicine, Palo Alto, CA, USA

Introduction:  With the growing relevance of AI-based patient-facing information, microsurgical-specific online information provided by professional organizations was compared to that of ChatGPT and assessed for accuracy, comprehensiveness, clarity, and readability.

Methods:  Plastic and reconstructive surgeons blindly assessed responses to ten microsurgery-related medical questions written either by ASRM or ChatGPT based on accuracy, comprehensiveness, and clarity. Surgeons were asked to choose which source provided the overall highest quality microsurgical patient-facing information. Additionally, 30 individuals with no medical background (ages 18-81, μ=49.8) were asked to determine a preference when blindly comparing materials. Readability scores were calculated, and all numerical scores were analyzed using the following six reliability formulas: Flesch-Kincaid Grade Level, Flesch-Kincaid Readability Ease, Gunning Fog Index, Simple Measure of Gobbledygook (SMOG) Index, Coleman-Liau Index, Linsear Write Formula (LWF), and Automated Readability Index. Statistical analysis of microsurgical-specific online sources was conducted utilizing paired t-tests.

Results: Statistically significant differences in accuracy (p<0.001), comprehensiveness (p<0.001), and clarity (p<0.05) were seen in favor of ChatGPT (Figure 1A). Surgeons, 70.4% of the time, blindly choose ChatGPT as the source that overall provided the highest quality microsurgical patient-facing information. Laymen intended to represent the patient population 55.9% of the time selected AI-generated microsurgical materials as well (Figure 1B). Readability scores for both ChatGPT and ASRM materials were found to exceed recommended levels for patient proficiency across six readability formulas, with AI-based material scored as more complex.

Conclusion: AI-generated patient-facing materials were preferred by surgeons in terms of accuracy, comprehensiveness, and clarity when blindly compared to online material provided by ASRM. Additionally, surgeons and laymen consistently indicated an overall preference for AI-generated material. A readability analysis suggested that both materials sourced from ChatGPT and ASRM surpassed recommended reading levels across six readability scores. 


H. Trembath1, J. Kearney1, H. Kim1, M. Meyers1, J. Yeh1  1University Of North Carolina At Chapel Hill, Department Of Surgery, Chapel Hill, NC, USA

Introduction: Pancreatic adenocarcinoma (PDAC) is an extremely lethal disease with dismal long term survival. The relationship between diabetes mellitus (DM) and PDAC is multifaceted and better understanding it is a stated NIH research priority. DM is a known PDAC risk factor; there is a subset of PDAC patients with new onset DM (NOD), who are diagnosed with PDAC <2 years after DM diagnosis that is currently under investigation regarding the pathophysiology, demographics, outcomes, as well as a potential group to screen.

There are two molecular subtypes of PDAC, basal and classical, that are prognostic and predictive of chemotherapy response. While subtyping assays have been developed, they are not yet utilized for majority of PDAC patients. We set out to evaluate if presence of NOD correlates with molecular subtype and could be used as a subtype proxy to help guide prognosis and treatment decisions.

Methods: This is a single institution, cohort study using retrospective review of hospital data and RNA sequencing data. To be included in the study, patients had to have PDAC on pathology specimen review, RNA sequencing data from resected specimen for molecular subtyping, and have undergone resection from 2009-2022. Demographic and clinical factors were examined using bivariate and multivariate analysis.

Results: We identified 139 patients that met inclusion criteria: 84 patients with no history of DM, 31 patients with longstanding DM (>2 years), 16 with NOD, and 8 patients with a missing date of DM diagnosis and were thus excluded from the analysis. There were 120 patients with classical subtype and 11 with basal subtype. The demographics between groups were overall similar, however BMI was higher in the group of longstanding DM compared to no DM (M=29.1 SD=5.4, M=25.8, SD=4.8), but not statistically different from NOD. After controlling for age, sex, race, and preoperative weight, NOD was not a significant predictor of PDAC subtype (OR 0.62, 95% CI 0.06, 6.1). Increasing age was associated with slightly decreased odds of having basal subtype (OR 0.91, 95% CI 0.85, 0.98, p value 0.02).

Conclusion: As continued interest in the NOD PDAC patient group mounts, we sought to see if NOD could be used in subtype prediction and hence, aid in prognosis and treatment choices. We are the first, to our knowledge, to show that NOD and PDAC subtype are not associated and NOD cannot be used to predict PDAC subtype at this time. Additionally, we found that sex, race, and preoperative weight are poor predictors of subtype. However, there could be different demographic or clinical factors that may be identified in the future to aid in subtype predication. Further investigation into underlying pathophysiology of the NOD group is still needed.


M. A. Sacks1, F. A. Velcek1  1SUNY Downstate Health Sciences University, Department Of Surgery, Brooklyn, NY, USA


Surgical residents are expected to obtain consent for complicated surgical procedures. Most residents have little training of informed consent prior to residency. Without understanding of the components of consent, the process can be challanging. We proposed a education and simulation workshop to address this issue. The purpose was to assess and improve the communication and consent process for pediatric general surgery cases by surgical residents. 

After internal review board(IRB) committee exemption for quality improvement project, a needs assessment was instituted to gather deficiencies in the communication process for pediatric surgery perioperative discussions. A grand rounds presentation was developed to address deficiencies in communication and highlight areas of improvement for the pediatric surgery consenting process.  Pre/post-tests were developed to assess knowledge and growth after session. General surgery residents were assessed on comfort level for consenting families of patients for pediatric surgery procedures and confidence level in having difficult discussions with families for complex pediatric surgical cases. A grand rounds presentation served as the education session to explain definitions and present opportunities for simulation with feedback. After the session, residents rated their confidence in the above areas.

In this group of grand round attendees, following the session of education for consent components and having senior residents practice obtaining consent from faculty for procedures with open feedback, attendees found the session helpful. Where senior residents(PGY 4-5) gain was negligible, interns showed improvement in confidence having difficult discussion (4.6 -> 6.5) and medical students almost doubled their scores in confidence with obtaining consent (1.8 -> 3.8) and having difficult discussions (2.9 -> 4.2) after just observing the ground rounds session (Figure 1). Where communication errors cost time, money, productivity, and trust of the patient, this assessment and learning session attempted to close the gap for pediatric surgery cases.

There is a need for discussions on consenting of pediatric patients with oversight. Residents lack education on who can consent and resources to improve the consenting process. A single short session is well-received by residents, which improved knowledge, boasted confidence, and provided and opportunity for quality improvement in the consenting process.

S. Balaji1,2, S. Laplante1,2, H. Muaddi3, P. Patel2, N. Rukavina2, C. Shwaartz1,2  1University of Toronto, Toronto, Ontario, Canada 2University Health Network, Toronto, Ontario, Canada 3Mayo Clinic, Rochester, MN, USA

Introduction:  Robotic surgery is rapidly increasing globally and is well-integrated into various Canadian surgical specialties. Despite its significant adoption in general surgery, a formal training program and curriculum for general surgery trainees are currently lacking in Canada compared to urology and OBGYN training programs, where simulation training has been proven to be effective for skill development. Therefore, we designed a comprehensive didactic and hands-on technical training course for general surgery residents and subspecialty fellows at our institution. This study aimed to assess the workshop's impact on enhancing general surgery trainees’ confidence and competence in robotic surgery. 

Methods:  General surgery trainees (i.e., residents and fellows) from our institution were invited to participate in the study. At the beginning of the workshop, participants were asked to report their exposure to robotic surgery and confidence in 20 critical domains of using the technology, such as port placement, instrument handling, and managing collisions, via a self-rated numerical scale. Their competence was assessed using a multiple-choice knowledge test on high-yield concepts. Questionnaires were administered again immediately post-workshop. The paired t-test or Wilcoxon test were used, as appropriate, to compare participants’ responses before and after the workshop.

Results: Seven residents and eight fellows participated in the study. 57% (4/7) of residents and 38% (3/8) of fellows reported having no exposure to robotic surgery in the past year. Participants’ mean self-rated expertise on robotic surgery pre-workshop was 2.5 out of 10. After the workshop, both residents’ and fellows’ confidence increased [(2.0±0.4 vs. 5.7±1.1, p= <0.05) and (3.1±0.3 vs. 6.7±0.7, p= <0.001) respectively]. When tested on their knowledge about robotic surgery, trainees’ competence scores also improved after attending our workshop (residents: 47% vs. 63%, p=0.025 and fellows: 56% vs. 65%, p=0.13). All the participants agreed that the workshop helped reduce their anxiety levels regarding robotic surgery and that they feel safer using the robot in clinical settings after attending the workshop. There was unanimous agreement that they would like to see this course offered again in the future.

Conclusion: Our first-of-its-kind robotic workshop in Canada led to a significant improvement in trainees’ confidence about using robotic surgery. There was an effective improvement in general surgery residents' knowledge after the workshop, but there was not a significant increase in fellow’s competence, which indicates the need to tailor this workshop according to training level of surgical trainees. Our future efforts will focus on incorporating insight from this workshop and exploring different measures of technical competence to ultimately shape a longitudinal robotic curriculum in Canada. 

A. Allahwasaya1, R. Akhund1, S. Balachandra1, R. Wang1, B. Lindeman1, J. Fazendin1, A. Gillis1, J. McMullin1, H. Chen1  1University Of Alabama at Birmingham, Endocrine Surgery, Birmingham, Alabama, USA

Adrenal incidentalomas (AIs) are found in approximately 3–4% of abdominal computed tomography (CT) scans. Evaluating the functional status and malignant potential of AIs in a timely manner is necessary, as this directs appropriate non-operative surveillance or surgical intervention. This study aims to evaluate the adherence of referring services to the American Association of Endocrine Surgeons (AAES)/American Association of Clinical Endocrinologists (AACE) guidelines for the biochemical work-up of AIs at a single tertiary surgical clinic.


We did a retrospective study on 125 patients who were evaluated for AIs at the endocrine surgery clinic between November 2017 and January 2022.Information on patient demographics, referral source, and referral reason was collected. The appropriateness of the initial biochemical work-up conducted by the referring physicians for Cushing's syndrome, Aldosteronoma, and Pheochromocytoma was assessed. The number of days from referral to initial clinic visit and initial clinic visit to surgery was also collected. For statistical analysis chi-square and Kruskal-Wallis were performed. 


Adrenal incidentalomas referrals came from endocrinologists (44.8%), other sub-specialties (31.2%), and primary care physicians (PCPs; 19.2%). Patients referred by endocrinologists were more likely to receive a complete screening biochemical work-up for AIs compared to other sub-specialties and PCPs (76.8% vs. 28.2% vs. 8.3% respectively, P < 0.001). Among the 125 patients, 66 (52.8%) were diagnosed with benign adrenal masses, 20 (16%) with Cushing syndrome, 20 (16%) with pheochromocytoma, 10 (8%) with aldosteronoma, and 5 (4%) with metastatic masses. Out of the 50 patients diagnosed with functional tumors, 23 (46%) were referred to the surgery clinic without having undergone the recommended biochemical work-up for AIs.  Only 11 (55%) of the 20 patients with pheochromocytoma were assessed for elevated catecholamine levels by the referring physician. A total of 83 (66.4%) patients underwent adrenalectomy, and patients referred by endocrinologists were more likely to undergo surgery compared to other sub-specialties and PCPs (81.8%vs57.9%vs52.0%, p<0.05). There was no significant variation in time from referral to initial clinic visit by specialty. 

More than half of the patients with AIs referred to endocrine surgery clinic were by specialists other than endocrinologists. Familiarizing all referring physicians with AAES/AACE recommended screening guidelines for AIs may minimize undiagnosed cases of functional adrenal incidentalomas and facilitate timely surgical management when necessary.

L. J. Hornung1, L. Rivera-Barbosa2, J. E. Johnson3, J. E. Carter2, J. E. Schoen2, H. A. Phelan2  1Louisiana State University Health Sciences Center, School Of Medicine, New Orleans, LA, USA 2Louisiana State University Health Sciences Center, General Surgery, New Orleans, LA, USA 3Wake Forest University School Of Medicine, General Surgery, Winston-Salem, NC, USA

Introduction:  The probability that future battlefields will require prolonged casualty care (PCC) of burn injuries has led the U.S. military to solicit an educational program tailored to the needs of inexperienced burn providers potentially delivering PCC across Roles 2 and Role 3. Here, we performed a needs assessment to determine the essential elements for a curriculum teaching burn care during Large Scale Combat Operations (LSCO) against peer or near-peer adversaries within multi-domain contested combat environments.

Methods: Virtual and face-to-face site visit meetings were conducted with 20 stakeholders at 3 different levels: 1) Subject Matter Experts (SMEs) in prehospital military care of burn casualties at the U.S. Army Institute of Surgical Research (USAISR) Burn Center, the Joint Trauma System (JTS), and the U.S. Army Medical Center of Excellence (US Army MedCoE) in Joint Base San Antonio (JBSA) – Fort Sam Houston, TX; 2) Course Directors, Instructors, Curriculum Innovators and Writers for the Combat Paramedic Branch and the Critical Care Flight Paramedic Program (CCFPP), at JBSA – Fort Sam Houston, TX; and 3) regulatory administrators providing education, research and IRB administration for USAISR and US Army MEDCoEBSA, Fort Sam Houston, TX.? 

Results: The curriculum needs identified after stakeholder engagement consisted of the following terminal learning objectives: training in appropriate burn casualty monitoring according to available resources; principles of burn wound care according to available resources; best practices during PCC for pain, nutrition, and infection control management; specific management of inhalation injuries, chemical, radiation, electrical, pediatric, and mass casualty burn injuries; and procedural skill training for patient decontamination, debridement, dressings, and escharotomy. Additionally, needs were identified for novel technology that provides asynchronous individual learning capabilities using interactive role play simulations, immersive simulation, or virtual reality simulation as well as hands-on procedure simulators.?? 

Conclusion: Stakeholder engagement resulted in the identification of a series of terminal learning objectives that were subsequently used as the basis for a military curriculum we are calling the “Burns for Providers Program” (BP2). Scenario creation, software development, and tabletop simulator design for the BP2 curriculum are currently underway.?? 



S. Prathibha1, S. Bejarano3, A. Z. Molina4, M. Zuniga2, J. Y. Hui1, J. Witt5, S. Marmor1, T. M. Tuttle1  1University Of Minnesota, Surgical Oncology/Surgery, Minneapolis, MN, USA 2One World Surgery, Tegucigalpa, FRANCISCO MORAZÁN, Honduras 3Liga Contra el Cancer, Clinical Oncology/Medicine, San Pedro Sula, CORTES, Honduras 4Hospital San Felipe, Clinical Oncology/Medicine, Tegucigalpa, FRANCISCO MORAZÁN, Honduras 5St. Luke’s Surgical Associates, Duluth, MN, USA

Breast cancer is the leading cause of cancer death in low and middle-income countries (LMIC). Delays to diagnosis and treatment are common in LMICs and result in advanced stage breast cancer and worse survival rates. Previous studies have demonstrated that lack of breast cancer information by primary providers in LMICs can lead to delays in diagnosis. Honduras, a LMIC, lacks robust research on breast cancer. The objective of this study is to survey baseline breast cancer knowledge among Honduran providers, present an educational conference on breast cancer and study possible improvements in knowledge.

A one-day, in-person breast education conference directed towards primary care providers was held in Honduras on March 2023. Lectures, hand-on demonstrations, and tumor boards were included. A knowledge-assessment tool was created by breast cancer experts from Honduras and the United States and evaluated participant knowledge regarding screening, diagnosis, and treatment. Once informed consent was obtained, participants were asked to complete demographic and knowledge surveys before the start of the course. One month after the course, participants completed the survey again. Pre- and post-course scores were calculated, and descriptive statistics were used to analyze the scores.

The initial survey received 86 responses and the 1 month post-course survey received 94 responses. 31% were physicians, 19% were nurses, 44% were other healthcare workers and 6% did not identify their field. Physician status, age, prior educational activities, number of years in practice, and number of breast cancer patient seen per month did not significantly impact initial baseline survey scores. Overall scores significantly improved from 70% at baseline to 80% at 1 month (p<0.0001). Similarly, scores evaluating screening (67% to 76%), diagnosis (82% to 87%), and treatment (62% to 79%) significantly increased from pre-course to 1 month post-course (Table 1).

We found that the implementation of a one-day educational conference in Honduras resulted in significant improvement in knowledge scores regarding breast cancer screening, diagnosis, and treatment. Although further studies are required to understand whether this improvement is retained long term, this strategy may effective in reducing delays to breast cancer diagnosis and treatment in other LMICs.

I. K. Eng1, J. S. Kim1, I. Park2, Y. Kim2, K. Chen3, N. J. Jackson3, M. H. Kwon2  1David Geffen School Of Medicine, University Of California At Los Angeles, Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles, Division Of Cardiothoracic Surgery, Department Of Surgery, Los Angeles, CA, USA 3David Geffen School Of Medicine, University Of California At Los Angeles, Department Of Medicine Statistics Core, Los Angeles, CA, USA


Nontechnical surgical skills are paramount to improving patient safety, as failures in teamwork, leadership, and communication underlie nearly 60% of perioperative complications. The Nontechnical Skills for Surgeons (NOTSS) taxonomy, comprised of situation awareness, decision making, leadership, communication and teamwork, has been validated as a reliable framework for teaching and assessment, but is often costly to implement. Recognizing that the resources to simulate high-fidelity clinical scenarios may not be accessible to all, we sought to pilot a low-cost, low-fidelity NOTSS curriculum within a cardiothoracic surgery training program. 


Four cardiothoracic surgery fellows (PGY6-7) participated in two days of low-fidelity NOTSS simulations separated by three months. On each day, the fellows underwent two distinct scenarios that assessed their cognitive (situation awareness, decision making) and social (communication and teamwork, leadership) skills. Performance in the four NOTSS categories was evaluated by NOTSS-trained course directors. The fellows also completed pre- and post-simulation self-evaluations to assess their confidence levels with respect to the four NOTSS categories. Both measures were scored on a 4-point Likert scale. Between the two days of simulation, fellows attended a formal lecture on the NOTSS taxonomy and were provided self-study materials. NOTSS performance was reported as median with interquartile range and compared across days using a paired t-test. Percent change in fellow confidence score within each day was reported as a mean and compared across days using a mixed-effects linear regression model.


In the low-fidelity NOTSS curriculum, the fellows demonstrated improvement in overall NOTSS scores between the two days (2.62[2.52-2.69] vs 3.17[3.06-3.19], p<0.01). Within the cognitive and social skills scenarios, there was a significant improvement in leadership score (2.33[2.17-2.42] vs 3.00[3.00-3.08], p=0.03), which was not observed in situation awareness, decision making, and communication and teamwork. With regards to fellows’ self-confidence between pre- and post-simulation on each day, there was an increase in confidence levels on day 2 compared to day 1 in the overall NOTSS category (-8.03% vs +5.65%, p=0.07) as well as when divided into cognitive (-13.67% vs +8.22%, p = 0.09) and social (-4.46% vs +3.93%, p=0.49) skills, though it was not statistically significant. 


We have developed a NOTSS curriculum in cardiothoracic surgery with minimal costs and technology requirements that can be formally integrated into surgical training. While improvement in assessment scores was limited to leadership, fellows showed greater confidence across both cognitive and social skills following the curriculum. We thus present a novel, low-fidelity NOTSS framework to teach, assess, and refine trainees’ nontechnical surgical skills regardless of a program’s available resources.


A. Al-Gahmi1, C. P. Jara1, M. A. Carlson1  1University Of Nebraska College Of Medicine, Surgery, Omaha, NE, USA

Introduction:  Despite decades of research, survival from pancreatic cancer (PC) has been minimally impacted. Swine have anatomic, genetic, physiologic, metabolic, and immunologic similarities to humans, making them suitable for PC modeling and for testing novel therapeutics or devices. Our objective was to develop an orthotopic porcine PC model using KRASG12D-transformed ductal cells that also expressed PIDO (fusion protein of PD-L1 and indoleamine dioxygenase) and/or PD-L2. These proteins have been shown to induce immune evasion of allogeneic islet cell implants in immunocompetent mice. We hypothesized that the expression of PIDO/PDL2 in tumorigenic porcine pancreatic ductal cells would produce allograft survival through immune evasion and yield an orthotopic PC model in immunocompetent swine.

Methods:  Anesthetized domestic swine (N = 4; ~42 kg, age 3-4 months) underwent upper midline laparotomy and pancreatic duodenal lobe exposure followed by four pancreatic injections per swine (two anterior and two posterior) of KRASG12D-transformed pancreatic ductal cells (107 in 0.2-1 mL of 5 mg/mL Matrigel) expressing (i) control (mutant KRAS only), (ii) PIDO, (iii) PD-L2, and (iv) PIDO + PD-L2. All swine were euthanized at four weeks and tissue was collected for histopathologic analysis.

Results: Expression of mutant KRAS and PD-1 ligand proteins was confirmed in vitro prior to the in vivo implantations (data not shown). All four swine survived the four-week observation period without negative signs. Pre-implantation vs. necropsy serum studies (including CA 19-9, CAE, AFP) were not different. At necropsy, there was gross evidence of mild fibrosis/inflammation at the injection sites without palpable mass. Peripancreatic lymphadenopathy was present. All four injectate types (control, PIDO, PD-L2, and PIDO + PD-L2) had no microscopic evidence of transformed tumor cells (Fig. 1) at the injection or regional nodes, neither by H&E nor immunohistochemistry. However, each site did have prominent inflammatory infiltrate consisting of neutrophils, macrophages, and T-cells.

Conclusion: In this preliminary study, orthotopic implantation of allogenic KRASG12D-transformed porcine pancreatic ductal cells with various PD-1 ligand protein expression elicited an immune response but did not produce any observable tumor implants. The failure of various PD-1 ligands to promote immune evasion in this allogeneic orthotopic porcine tumor implantation model (in contrast to the previous non-tumor murine studies) may be secondary to inherent differences between swine and mice, inappropriate/inadequate implantation conditions, redundant immune response mechanisms specific to tumors, or other issues. Additional studies are underway to explore these possibilities.


S. J. Soelling1, M. Sulciner1, L. V. Saadat1, S. Wrenn3, R. Gartland2, J. B. Liu1, N. L. Cho1  1Brigham And Women’s Hospital, Boston, MA, USA 2Massachusetts General Hospital, Boston, MA, USA 3Rush University Medical Center, Chicago, IL, USA

While female representation is increasing among general surgery residents over time, gender disparities persist at the faculty and leadership level in academic surgery. Prior studies have reported gender disparity in academic scholarship, award recognition, and leadership representation within the American Association of Endocrine Surgeons (AAES), as well as gender disparities in Accreditation Council for Graduate Medical Education (ACGME) surgical subspecialty fellow enrollment. Given these previous findings, we aimed to evaluate gender representation within the United States AAES fellowship programs at the fellow, faculty, and program leadership levels.

Demographic information was collected for all matched AAES fellows from 2001 to 2023 and for current Endocrine Surgery (ES) faculty, program directors (PDs), and section heads at US programs based on publicly available data. Stated gender was collected from physician clinical biographies, hospital websites, or National Provider Identifier listings. Leadership positions were defined as PDs and section heads. Gender differences between ES fellows, faculty, and leaders were analyzed.

Gender was determined for 381 (99.5%) fellows, 105 (100%) faculty, 25 (100%) PDs, and 25 (100%) section heads. There were 222 (58.3%) female fellows, 53 (50.5%) faculty, and 20 (40%) leaders (PDs and section heads). The proportion of female fellows increased from 2001-2011 (54.6%) to 2012-2023 (59.7%). While there was no significant difference between the proportion of female fellows and faculty (58.3% vs 50.5%, p=0.15), we found a significant difference in the proportion of female leaders relative to fellows (40% vs 58.3%, p=0.01) [Figure 1]. There was also a lower proportion, though not significantly different, of female leaders relative to faculty (40% vs 50.5%, p=0.22).

Female surgeons are well represented among ES fellows and faculty; however, females are disproportionately underrepresented at the leadership level. Further research evaluating factors contributing to this discrepancy is warranted. Intentional efforts to highlight and address disparities in leadership positions is critical to closing the gender gap in academic surgery.

M. Sturdevant1, L. Tien1, N. Owings1, B. Adam1, A. Lee1, A. Abuzeid1, J. Mckenzie1, B. Ange1, C. Blades1, E. Mabes1  1Medical College Of Georgia, Department Of Surgery, Augusta, GA, USA

The instillation of cameras in our trauma bays necessitated development of a tool to analyze resuscitation flow, communication, and systems-based issues. Trauma video reviews have been implemented to guide quality and performance improvement projects, streamlining resuscitations and identifying issues that can be addressed and tracked. To establish a video review tool, inter-rater reliability (IRR) needs to be established across video reviewers. Six trauma attendings reviewed the videos using a standardized survey with both subjective and objective questions, making changes to the tool during a period of “teaching” for the faculty on how to perform the surveys. This pilot study was conducted to establish our IRR as a first step in validating our Trauma Video Review Tool.  

The Trauma Video Review Tool was designed to assess the trauma team's ability to follow our updated institutional guidelines in performing the steps of the primary and secondary surveys in a trauma with consideration for appropriate evaluation adjuncts, clinical decision making, communication, and situational awareness. Survey questions contain validity measurements and use small scales to eliminate ambiguity and improve validity amongst raters. The agreement among rates was evaluated on a scale of poor agreement to good agreement.  

Six videos were reviewed and all were level 1 traumas with the majority (85%) blunt mechanisms. Twenty-eight evaluations were completed. Percent agreement between the six video raters was calculated to determine IRR using Fleiss’ Kappa. All videos had fair to good agreement with the exception of video 2 which scored 0.149 IRR. There was a weakly positive linear progression correlation of the Fleiss Krappa score from videos reviewed over time (figure 1).  

This is a pilot study evaluating the video review tool development and to evaluate IRR among the attending video raters. We expect that evaluation and scoring of videos will guide our program on institutional quality improvement projects in streamlining resuscitations. With implementation of trauma protocols, this review tool will serve as a valuable device to validate the effectiveness of the enforced protocols and provide important information on systems-based issues. 

D. R. Crosby1, J. Creary2, E. Brown1, A. Fields1, M. G. Sharpe3, A. Badrinathan4, V. P. Ho5  1Case Western Reserve University, Department Of Nutritional Biochemistry And Metabolism, Cleveland, OHIO, USA 2Case Western Reserve University, Department Of Biology, Cleveland, OHIO, USA 3Case Western Reserve University School Of Medicine, Cleveland, OH, USA 4University Hospitals Medical Center, Department Of Surgery, Cleveland, OHIO, USA 5MetroHealth Medical Center, Department Of Trauma Surgery, Cleveland, OH, USA

Introduction: Social media is a powerful tool to spread information about trauma surgery. Our prior research found that most of the trauma-related content published via podcasts and YouTube videos was not created by licensed professionals. We sought to evaluate the source of trauma surgery content in extremely short-format social media via Instagram (IG) and TikTok (TK). Further, we wanted to describe the level of public engagement with trauma surgery content on these two platforms.

Methods:  The terms “trauma surgery” and “trauma” were searched in IG and TK. Corresponding profile descriptions, the intended audience, and frequency of posting were recorded. To examine engagement levels, the © HypeAuditor Engagement Rate Calculator was used to collect the average number of likes and comments for IG and the average number of likes and the total number of videos for TK accounts with high engagement. Differences between platforms were compared using a chi-square.

Results: 186 accounts were included (IG=103, TK=83). IG accounts were more likely to focus on psychological trauma (40, 39%) when compared to TK (2, 2%). On both platforms, the included profiles primarily post content daily (48%). The highest number of followers and highest number of likes per post on TK was 812.2K and 22.7K, while on IG it was 9.8K and 13.2K. The IG profiles that focused on physical trauma with high engagement made an average of 642 posts compared to their TK counterparts at 723 videos. 52 TK accounts (63%) were run by medical professionals (residents, doctors, nurses, or physician’s assistants), compared with only 30 IG pages (29%), p<0.001. IG content (39%) was more likely to be designed for medical professional audiences when compared to TK (31%), p<0.01. TK (55%) was more likely to be designed for the general population than IG (30%), p<0.01.

Conclusion: TK has been adopted by more medical professionals than IG to spread information about trauma surgery. TK accounts also have higher user engagement and were targeted to general population audiences. TK and IG are frequently utilized to engage the public about trauma surgery.


E. Lavanga1, A. Zil-E-Ali2, K. Krause1, C. DeHaven1, F. Aziz2  1Penn State College of Medicine, Division Of Vascular Surgery, Hershey, PA, USA 2Penn State Health Hershey Medical Center Heart and Vascular Institute, Division Of Vascular Surgery, Hershey, PA, USA

Introduction: The COVID-19 pandemic altered workflow in hospitals across the United States, requiring vascular surgery resident physicians to adapt their patient care strategies and improve their electronic medical record (EMR) efficiency. The aim of this study was to examine the impact of the pandemic-necessitated changes in surgery program workflow on EMR usage of vascular surgery residents across multiple years of training. 

Methods: Vascular surgery resident EMR usage data was obtained from the Cerner © Advance User Experience from March 2019 to May 2021. Surgical caseloads for each post-graduate year (PGY) were obtained from hospital records. Usage time was tracked from user login to logout. The data was divided into three timepoints: before, during, and after COVID-necessitated workflow alterations and was subdivided into usage categories including total time, chart review, documentation, electronic orders, and messaging time. EMR usage by timepoint, EMR usage by PGY, and EMR usage by both timepoint and PGY were analyzed via Kruskal-Wallis test with significance set at 0.05. 

Results: EMR data from seven residents was included in the study across three timepoints. All day average EMR use decreased from 115.56 ± 97.3 to 89.54 ± 78.6 minutes during COVID workflow disturbances and remained low at 93.56 ± 82.3 minutes following the reinstitution of normal workflow (p-value <0.001). This permanent decline in both daytime and evening EMR usage following workflow alterations was observed for total time, chart review time, and order placement. All day EMR usage decreased with increasing PGY. The most significant decrease was observed from PGY three with an average of 102.28 ± 78.0 minutes per day to PGY four with an average of 56.29 ± 45.5 minutes per day demonstrating a 46-minute decrease in EMR time (p-value <0.001). Analysis of PGY EMR use across the three timepoints demonstrated that PGY one residents were the most influential in the decrease in EMR use following COVID-related workflow changes. Intern EMR usage declined from 204.9 ± 112.1 minutes to 121.10 ± 92.3 and then stabilized at 128.82 ± 125.7 minutes following resolution of normal workflow (p-value <0.001). Surgeries decreased by approximately 22 cases during COVID-19 restrictions.

Conclusion: Vascular surgery interns demonstrated the most significant permanent improvement in EMR efficiency during the COVID-19 pandemic alterations to hospital workflow. The novice status of intern training allowed PGY one residents to easily adapt to the changes in surgical program workflow and optimize the efficiency of their EMR usage to prioritize in person patient care.


M. E. Jones-Carr1, J. Perry1, R. D. Reed1, C. Killian1, G. Baker1, P. Porrett1, D. J. Anderson1, V. Kumar1, A. Shunk2, J. E. Locke1  1University Of Alabama at Birmingham, Heersink School Of Medicine, Department Of Surgery, Division Of Transplantation, Birmingham, Alabama, USA 2Legacy of Hope, Birmingham, ALABAMA, USA

Medical treatments which lack regulatory approval often rely on cell lines or animal models, which can differ substantially from in vivo conditions, and as such a pre-clinical human model is needed. Brain death, defined as irreversible cessation of all functions of the entire brain, including the brain stem, is traditionally a means for organ donation. However, brain-dead decedents are often precluded from organ donation due to various health factors, affording the opportunity to study brain death as a novel preclinical human model for the study of disease treatments particularly non-procurement surgical interventions. Herein, we describe a new pre-clinical human model, the brain-dead decedent: The Parsons Model.  

Brain-dead decedents that were unable to donate their organs for the purposes of transplantation were identified by our local organ procurement organization and subsequently enrolled after family consent. A total of four adult decedents were enrolled; the second decedent was excluded from surgical intervention due to a leukemic blast crisis. Decedents were maintained on the ventilator in a critical care setting. Hemodynamic and physiologic data were recorded. They underwent bilateral native nephrectomies and bilateral porcine kidney xenotransplants.

All decedents were male with ages ranging from 53-66 years. Decedents underwent xenotransplantation 3.9, 4.9, and 5.8 days after their first exam documenting brain death, and were supported for a total of 7.3, 8.1, and 12.8 days after brain death. The first and third decedents were mildly bradycardic pre-operatively. All decedents were on vasopressor infusions pre- and intraoperatively. Postoperatively the first required ongoing vasopressor infusions, as did the third and fourth intermittently. The third and fourth decedents required antihypertensives sporadically throughout their course. All decedents had transient hypertension with xenograft reperfusion. The second decedent was also tachycardic with reperfusion; this quickly subsided with beta blockade.

We report the first series with a novel preclinical human model for the study of surgical interventions, henceforth known as the Parsons Model. Our decedents’ hemodynamics supported major non-procurement surgical interventions in the setting of brain death.  The brain-dead decedent model could facilitate innovation of new medical devices, surgical interventions, or even surgical education.

M. E. Jones-Carr1, R. D. Reed1, P. MacLennan1, J. Perry1, S. D. Fry1, J. E. Locke1  1University Of Alabama at Birmingham, Heersink School Of Medicine, Department Of Surgery, Division Of Transplantation, Birmingham, Alabama, USA

Introduction: Computer programs operating with Artificial intelligence (AI) train themselves with a large amount of pre-existing data and subsequently synthesize and process information in a novel way. However, there is growing concern that these machines generate biased output due to the historically-prejudiced information with which they are programmed. There are known gender discrepancies in the composition of various professions, such as surgery. Surgery and its subspecialties are historically male-dominated, though women are beginning to enter the field in higher numbers. We hypothesize that AI has the potential to thwart workforce diversification. Known biases, which are established in everything from societal norms to published papers, have the potential to profoundly influence the conclusions AI algorithms draw, such as with resume sorting. The ability of AI to magnify existing biases is potentially profound, but has thus far been under studied.  

Methods: Text prompts were entered into the publicly available, web-based AI image generator DALL-E 2 including president, surgeon, scientist, surgeon-scientist, engineer, baker, statistician, transplant surgeon, economist, surgery resident, homemaker, person cooking, nurse, doctor, and secretary. Image output was categorized as male or female. Androgynous and non-humanoid images (9) were excluded from analysis. A total of 172 images were included. Two-sided one-sample binomial tests were performed, with statistical significance at p < 0.05. 

Results: Prompts which returned a majority of male images included president (11 male, 1 female, p = 0.006), surgeon (22, 5, p = 0.001), scientist (6, 2, p = 0.22), surgeon-scientist (12, 4, p = 0.06), engineer (6, 2, p = 0.22), baker (6, 2, p = 0.22), statistician (5, 2, p = 0.33), transplant surgeon (9, 4, p = 0.17), and economist (3, 2, p = 0.63). One prompt, surgery resident, elicited an equal proportion of genders (4, 4, p = 0.54). Conversely, images which were majority female were homemaker (4, 8, p = 0.39), person cooking (3, 8, p = 0.16), nurse (2, 6, p = 0.22), doctor (4, 12, p = 0.06), and secretary (2, 10, p = 0.03). 

Conclusions: The AI we tested consistently produced images for various professions which were not equally-balanced between genders. Statistically significantly male-skewed professions in our sample included president and surgeon. The only significant female-skewed profession was secretary. Interestingly, doctor returned a majority of female images, but was not statistically significant. We urge AI developers to correct these biases before releasing their far-reaching products, as AI in its current state continues to sustain gender stereotypes.  

S. J. Williams-McLeod1, B. Eke1, C. Sodhi1, D. Hackam1  1The Johns Hopkins University School Of Medicine, Pediatric Surgery, Baltimore, MD, USA

Introduction:  Lipopolysaccharide (LPS) is an endotoxin found in the cell wall of gram-negative bacteria that triggers the activation of inflammatory mediators of the innate immune system. Short-chain fatty acids (SCFAs) are metabolites that contain fewer than six carbon atoms. SCFAs have been shown to influence gut-brain communication, especially under conditions of gut dysbiosis such as sepsis. Despite this, the mechanisms underlying this crosstalk are not fully understood. β-hydroxybutyrate (BHB), a four-carbon short chain fatty acid, can exert anti-inflammatory and antioxidant effects in cells treated with LPS. Here, we investigated the effects of a BHB pre-treatment in a brain organoid model of inflammation as well as a mouse model of endotoxemia. 

Methods: In-Vitro LPS Exposure: Pregnant C57/Bl6 mice were anesthetized with isoflurane and cervically dislocated prior to harvest of embryonic tissue. Brains from C57/Bl6 e15 mice were harvested for organoid development. Brain organoids are a novel model system that allow for the study of early brain development at the structural, cellular, and molecular level. Here, organoids were cultured for 21 days in Complete Brain Media (Neurobasal Media Plus – 2% B-27, 1% Glutamax, 0.01 ug/mL BDNF, 0.01 ug/mL GDNF, 1X primocin/gentamycin/penn/strep) before harvest (Fig. 1). Brain organoids were re-suspended in six-well plates at 1.5e6 M cells/well. Organoids were treated with BHB (5 Mm) for a 15-minute pre-treatment prior to treatment with LPS (50 μg). Samples were collected and stored at -80°C. A Qiagen RNeasy kit was used to isolate RNA and generate cDNA for quantitative real-time polymerase chain reaction (qRT-PCR) analysis. In-Vivo Endotoxemia: P10 C57/Bl6 mice were administered BHB (80 mg/kg i.p.) for a 15-minute pre-treatment prior to treatment with LPS (2.5 mg/kg i.p.). All animals were sacrificed six hours after treatment. Tissue samples were collected in liquid nitrogen and stored at -80°C for analysis or were fixed in 4% paraformaldehyde and stored at 4°C for immunohistochemistry. Experiments were performed with six animals per group. Statistical significance was evaluated using student’s t-test and ordinary one-way ANOVA. 

Results: Statistically significant differences were found between LPS and LPS+BHB groups in TLR4 (p= 0.0424) and IL-6 (p= 0.0011) genes. Surprisingly, BHB resulted in elevated expression levels of IL-6, TNF-a, LCN-2, GFAP, and Tubb3 genes as assessed by qRT-PCR, revealing LPS-induced feedback inhibition and the sustained activation of pro-inflammatory cytokines.  

Conclusion: The short chain fatty acid BHB leads to increased LPS signaling in mouse brain, providing insights into the mechanisms by which a dysbiotic microbiome may lead to impaired gut-brain signaling during sepsis.

J. W. Duess1, D. Scheese1, K. Tsuboi1, Z. Raouf1, M. Sampah1, C. Tragesser1, D. Klerk1, H. Moore1, S. Williams-McLeod1, W. B. Fulton1, T. Prindle1, S. Wang1, M. Wang1, P. Lu1, C. P. Sodhi1, D. J. Hackam1  1Johns Hopkins University School Of Medicine, Pediatric Surgery, Baltimore, MD, USA

Introduction: We have previously shown that impaired gastrointestinal dysmotility is a predisposing factor to the development of necrotizing enterocolitis (NEC), explaining in part the early ileus seen in patients with this disease. Importantly, the pathogenesis of impaired motility in NEC remains unknown, impaired signaling in the enteric glia was determined to play a role. The inflammatory gatekeeper A20 has been shown to dampen inflammation in a variety of cells, suggesting a possible role in the enteric glia. We now hypothesize that A20 exerts an inflammatory gatekeeper role in the enteric glia where it could regulate the development of ileus in the pathogenesis of NEC. 

Methods: We first generated mice lacking A20 in the enteric glia by crossing A20loxp mice with Sox10creERT mice, where Sox10cre is activated in the enteric glia at the time of tamoxifen injection. Acute abdominal inflammation was induced at 3-weeks of age in C57Bl/6 and A20?Sox10 mice by intra-peritoneal injection with gram negative bacterial lipopolysaccharide (LPS, 1mg/kg, 6h). A20 expression in the intestinal mucosa in wildtype mice was assessed by qRT-PCR. NEC was induced in newborn C57Bl/6 and A20?Sox10 mice through four days of formular gavage with stool from an infant with severe NEC and intermittent hypoxia. Intestinal motility was measured by oral administration of fluorescent tracer FITC-dextran/30-min before sacrifice. Then, the serial sections from stomach to colon were divided into 1-cm sections to measure motility as a function of the Geometric center (GC). The terminal ileum was harvested to measure pro-inflammatory cytokine (TNF) expression and intestinal histology.  

Results: A20 was successfully depleted from the enteric glia by immunostaining and RT-PCR. A20?Sox10 mice exposed to LPS (1mg/kg) had an extremely distended intestine, severe diarrhea, and lethal mortality. LPS treatment A20?Sox10 mice induced severe intestinal dysmotility (p<0.01) as manifest by impaired passage of dye. Abdominal inflammation by LPS injection resulted in significant sepsis in A20?Sox10 mice as revealed by extreme lethargy and high levels of the proinflammatory mediator Tnf in the intestinal mucosa vs. wild-type mice (p<0.001). A20 expression in the intestinal mucosa was significantly reduced, suggesting a loss of A20 may precede NEC development. Strikingly, and in support of this possibility, mice lacking A20 from Sox10 expressing cells developed severe dysmotility and NEC as revealed by significant mucosal injury, weight loss, and elevated expression of Tnf, confirming that A20 expression on the enteric glia regulates intestinal motility in the pathogenesis of NEC.

Conclusion: We now reveal that A20 regulates intestinal motility in the pathogenesis of NEC. These findings suggest that strategies to maintain A20 expression or signaling on the enteric glia may promote normal intestinal motility and reduce the incidence of NEC.


G. H. Gershner1,2, K. B. Snyder1,2, C. Calkins1,2, C. Dalton1,2, C. J. Hunter1,2  1Oklahoma Children’s Hospital, Division Of Pediatric Surgery, Oklahoma City, OK, USA 2The University of Oklahoma Health Sciences Center, Department Of Surgery, Oklahoma City, OK, USA

Introduction: Despite decades of research and advancement, NEC remains a devastating disease associated with high morbidity and mortality in the neonatal population. GPX enzymes are ubiquitous in the body and previous studies have shown a decrease in glutathione peroxidase 4 (GPX4) in patients with NEC. Those of interest include GPX1 (cytosolic) and GPX2 (intestinal, liver, gallbladder).  Our study examined gene expression of GPX1, GPX2, and glutathione synthetase. We hypothesize that these enzymes will have a decreased expression in NEC, leading to higher amounts of ROS and increased proclivity to NEC.

Methods: Intestinal tissue was collected from premature neonates with and without NEC already undergoing surgical resection. RNA was isolated from the tissue for analysis.  All patients were age-matched at the time of resection for experimentation. RTqPCR was performed to analyze GPX1, GPX2, and glutathione synthetase (GSS) gene expression.  ANOVA was performed for statistical analysis.

Results: Our results showed that GPX2 was significantly elevated across active NEC patients (p<0.01). GPX1 was significantly elevated in one NEC pt (p<0.005), and up-trending in the other.  GSS was marginally significant in one NEC patient (p≤0.05), but significantly decreased in another (0.0002).

Conclusion: Our study showed that GPX2 was significantly elevated in NEC, while GPX1 and GSS were inconsistent. Given a previous study showing that GPX4 had decreased activity in NEC, it appears that the elevation of GPX2 in NEC could be a response to oxidative stress.  While GPX2 mainly targets hydrogen peroxide, it is able to assist in other glutathione-based redox reactions. The inconsistent levels of GPX1 and GSS, and further clarification of GPX2 overexpression warrant further study.