8.10 Clinical Predictors in the Development of Necrotizing Enterocolitis

Posted on December 22, 2014

S. Faisal1, A. G. Cuenca1, S. D. Larson1, D. W. Kays1, S. Islam1  1University Of Florida,Gainesville, FL, USA

Introduction:  The development of prognostic metrics are especially important in the identification of disease states that may rapidly worsen, such as necrotizing enterocolitis (NEC).  While many such predictors have been reported and are thought to be associated with NEC, none have been validated. The purpose of this study was to attempt to create a model that could help predict NEC based on clinical, physiologic, and lab parameters.

Methods:  We retrospectively collected clinical data on 108 patients with NEC as well as 38 age-matched controls from 2000 to 2009. We performed multiple logistic regression and developed receiver operator curves based on the clinical data collected to determine if any metrics that have been reported as well additional parameters including the presence of cardiac or hepatic dysfunction could be important for the development of NEC and further generalized to the age-matched controls. 

Results: Using Univariate analysis, we found significant differences (p < 0.05) in the birth weight, bandemia, sodium concentration, percent lymphocytes, hemoglobin, method of delivery, and mean arterial pressure (MAP), however we did not note differences in pH, absolute neutrophil count, platelet count, presence of cardiac dysfunction (See Table). Logistic regression was then performed on the significant variables. Surprisingly, only bandemia, MAP, and hemoglobin concentration at the time of clinical suspicion of NEC was found to be significant in our population, with OR of 1.29, 1.13 and 0.7, respectively (see Table). It is possible that missing data and selection bias may confound our model. Therefore, ROC were performed on the variables collected. Bandemia, MAP, and hemoglobin concentration were again found to have the greatest areas under the curve, respectively 0.86, 0.79, and 0.72. 

Conclusion: While bandemia is already considered an important clinical variable, these data suggest that we may be able to improve on already recognized clinical parameters by including decreased hemoglobin concentration and elevated MAP in the clinical algorithm currently used for the identification of NEC in at risk patients. Surprisingly, pH, cardiac dysfunction, or ANC were not found to be predictive of NEC in our patient population. This model is to be tested and validated prospectively in the future. 

 

8.11 Analysis of Intestinal Failure in Premature Infants and Premature Infants with Gastroschisis

Posted on December 22, 2014

D. M. Hook-Dufresne1, X. Yu4, A. Olsen1, L. Putnam1, S. D. Moore-Olufemi1  1University Of Texas Health Science Center At Houston,Pediatric Surgery,Houston, TX, USA 4Baylor College Of Medicine,Pediatric Epidemiology,Houston, TX, USA

Introduction: Gastroschisis (GS) is the most common congenital abdominal wall defect and is associated with poor clinical outcomes associated with the development of intestinal failure (IF). GS patients are often born at less than 37 weeks gestational age (GA), classifying them as premature, and are at increased risk for feeding difficulties associated with prematurity. The purpose of this study was to analyze the effect of prematurity on the development of IF in both GS and non-GS patients and analyze IF related outcomes between the two groups.

Methods:  A single institutional database of GS patients born less than 37 weeks GA (N=49) was queried for the following: GA, birth weight, length of stay (LOS), time to initial feeds (TIF), time to full feeds (TFF) and days on total parenteral nutrition (TPN), rate of catheter related blood stream infections (CRBSI) and 30 day mortality.  Control infants (N=343) with no gastrointestinal pathology were 7:1 matched with the GS infants on GA by week. We defined IF as requiring TPN for ≥ 60 days. The Wilcoxon rank sum test and Chi-square test  were used to test the differences between two groups for the continuous and categorical variables respectively.

Results: Premature GS infants had significantly lower birth weight than non-GS premature infants (2145 vs. 2485 gm, p< 0.0007). Premature GS infants had significantly longer LOS, TPN days, TIF and TFF when compared to non-GS premature infants (Table 1). Premature GS infants had significantly higher incidence of CRBSI (20% vs. 0.3%, p<0.0001) and 30 day mortality (4% vs. 0.3%, p<0.04). No patients in the non-GS premature group were diagnosed with IF, while the IF rate in the GS group was 29% (14 of 49).

Conclusion: Premature GS infants have significantly longer LOS, time on TPN and time to inital and full feeds when compared to their non-GS counterparts. Our study demonstrates that the poor nutritional outcomes and the development of IF in premature patients with GS is more likely a function of the intestinal dysfunction associated with GS than of prematurity. Further research into the factors that promote the intestinal dysfunction associated with GS is needed to improve clinical outcomes for these patients.

 

8.12 Elective Over Selective Silo Placement for Gastroschisis Treatment Results in Increased Morbidity

Posted on December 22, 2014

A. R. Raines1, P. C. Mantor1, T. Garwe1,2, P. Motghare2, J. Hunter3, K. Roselius4, A. Adeseye1, R. Letton1  1University Of Oklahoma College Of Medicine,Surgery,Oklahoma City, OK, USA 2University Of Oklahoma College Of Medicine,Biostatistics And Epidemiology,Oklahoma City, OK, USA 3University Of Oklahoma College Of Medicine,Oklahoma City, OK, USA 4University Of Oklahoma College Of Medicine,College Of Public Health,Oklahoma City, OK, USA

Introduction: Active debate exists regarding the use of the primary abdominal closure versus silo placement for gastroschisis treatment.  In 2005, we changed our strategy from primary closure and selective silo placement to elective silo placement with delayed closure. We reviewed our experience with each strategy.

Methods: This retrospective study, evaluating infants born with gastroschisis, used data from a single children’s hospital between 1999 and 2012.  Before 2005, our preferred gastroschisis treatment was primary closure with selective silo placement.  After 2005, our preferred treatment was elective silo placement with delayed closure.  Morbidity outcomes were evaluated based on whether treatment was received before or after 2005 (SELECTIVE SILO and ELECTIVE SILO groups, respectively).  In both groups, there were patients who were not managed with the preferred standard at the time, and two analyses were performed including and excluding these patients.  Morbidity outcomes of interest were total parenteral nutrition (TPN) days, ventilator days, hospital days, infectious complications, and need for unplanned re-operation.

Results: A total of 250 neonates were included (108 and 142 patients in the SELECTIVE SILO and ELECTIVE SILO groups, respectively).  No significant differences (p > 0.05) were observed in gestational age, gender, birth weight, APGARs, delivery type, or rate of complicated gastroschisis (atresia, bowel necrosis, obstruction) between the two groups regardless of whether patients who did not receive the elective treatment of choice for the time period were included or excluded.  The ELECTIVE SILO group had significantly (p<0.05) longer average TPN days (31 vs. 23), hospital days (41 vs. 28), and a higher rate of wound infections (18% vs. 4%) as compared to the SELECTIVE SILO group regardless of whether patients who did not receive the elective treatment of choice were included or excluded.  Overall, the ELECTIVE SILO group experienced significantly (p<0.05) fewer mean ventilation days, however, excluding patients not receiving elective treatment of choice resulted in no significant mean difference.  Unplanned reoperation rates between the two groups were similar, although, there was a trend toward higher reoperation rates in the ELECTIVE SILO group (15% vs 3%; p=0.0792) when excluding patients not receiving elective treatment.

Conclusion: These data suggest that the strategy of elective silo placement and delayed closure in gastroschisis patients significantly increases the total number of hospital days, TPN days, and wound infections as compared to primary closure and selective silo placement. Based on these results, primary abdominal closure should be the recommended approach in managing infants with gastroschisis.  Carefully controlled prospective studies are required to further validate these conclusions.

 

8.13 Gastroschisis: Outcomes of Extremely Premature Infants

Posted on December 22, 2014

T. Nice1, R. Russell1, N. Fineberg2, D. Rogers1, C. Martin1, B. Chaignaud1, S. Anderson1, M. Chen1, E. Beierle1  1University Of Alabama At Birmingham,Pediatric Surgery,Birmingham, AL, USA 2University Of Alabama At Birmingham,School Of Public Health,Birmingham, AL, USA

Introduction:

There has been little information focused on the management of gastroschisis in extremely premature infants.  The purpose of this study was to identify potential differences in treatments and outcomes of gastroschisis in very premature versus later gestational age infants.

Methods:   

A retrospective review of all infants with gastroschisis was performed from October 1999 to December 2012 (IRB # X100817009).  Infants were stratified based on gestational age: group 1 (very premature <32 weeks); group 2 (near-term 32-37 weeks); and group 3 (term > 37 weeks).   Demographic and treatment data were collected.  Complicated gastroschisis included cases with bowel perforation, necrosis, volvulus, or atresia.  Outcome measures included length of stay, TPN days, total operations and non-central venous line (CVL)-related operations, sepsis, necrotizing enterocolitis (NEC), and death.  Analysis was done using Chi square and ANOVA tests with Tukey HSD for post-hoc testing.  (α=0.05)

Results:  

A total of 247 infants were included: 13 very premature, 121 near-term, 113 term.  Demographically the groups differed only by gestational age, birth weight, and lower APGAR scores in group 1.  Treatment was similar across all groups with no statistical difference in operation type, timing, or use of mesh.  Group 3 had a lower risk of complicated gastroschisis [Table 1].  Within the first year of life, non-CVL-related operations were required more often in group 1 (53.8%) compared to group 2 (39.7%) or group 3 (27.4%) [p=0.049].  Group 1 also experienced a longer length of stay (114.9 vs 57.3 vs 46.8), increased incidence of sepsis (53.8% vs 20.7% vs 23.9%) , and increased mortality (38.5% vs 4.1% vs 2.7%) [Table 1].  NEC accounted for a large portion of the sepsis events.  Increased ventilator days (23.8 vs 4.6 vs 4.1, p<0.001) and increased TPN days (88.5 vs 48.4 vs 39.4, p<0.001) were also seen in group 1.

Conclusion:  

Extremely premature infants with gastroschisis underwent similar treatment but required more operations, total parenteral nutrition and ventilator days, and had a higher risk for sepsis and death.  While many did well, survival was markedly lower (62%).  Incidence of necrotizing enterocolitis and mortality in this extremely premature infant population with gastroschisis were higher than previously reported for infants of this gestational age range.  These results can be used to guide future efforts to improve the management of these patients and to improve counseling for their parents.

 

8.14 Giant Cell Tumor of the Bone: Epidemiology and Ouctomes for 281 Pediatric and Adult Patients.

Posted on December 22, 2014

T. K. Woleston1,3, K. Mahendraraj1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2Rutgers University, New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, ST. GEORGE’S, Grenada

Introduction: Giant cell tumors of the bone (GCT) are very rare in the pediatric population, with an incidence of 1.8%-10.6%. GCT are typically benign, although malignant GCTs have been described and are poorly understood based on the few case series published. This study reports the largest cohort of GCT patients from the SEER database to better characterize clinical and pathologic factors associated with pediatric and adult GCT cases.

Methods: Demographic and clinical data on 281 GCT patients was abstracted from the SEER database (1973-2010). Pediatric patients were defined as those aged ≤19. Data was analyzed using the Chi square test, t-test, and multivariate analysis. Kaplan-Meier analysis was used to compare long-term survival between groups.

Results: Among 281 GCT patients, 48 (17%) were pediatric (mean age 18±2), and 233 (82.9%) were adult (mean age 42±16). GCT was significantly more common among pediatric females (58.3% vs. 41.7%, female vs. male, p<0.001), compared to a more evenly distributed adult group (F:M=1:1, p<0.001). While GCT was most common overall among Caucasians (48.9% and 59.6%, p<0.001), it was significantly more common among pediatric Hispanics than adults (33% vs.16.5%, p=0.01). Pediatric GCT was more often well differentiated (22% vs.18.2%), localized (54.5% vs. 46.2%), had size <2 cm (4.5% vs. 0%), and had a lower lymph node positivity rate (0% vs. 1.7%), although none were statistically significant. Surgery was the most common therapy in both groups (75.6% and 63.2%, p=0.07), and was the only treatment associated with significant improvement in both pediatric (36.6±0.9, p<0.001) and adult (28.9 ± 1.3, p<0.001) survival. Cancer-specific mortality was significantly lower in the pediatric group (2.1% vs. 16.8%, p<0.001), and median survival significantly longer (13.9±5.7 years vs. 9.1±5.3 years, p<0.001). Multivariate analysis identified distant metastases (OR 2.6, CI=1.2-5.7) as the only risk factor for increased mortality among pediatric patients, p=0.021.

Conclusions: Pediatric GCT has higher incidence among females and Hispanics compared to adult GCT. Clinicians should consider the possibility of GCT in a symptomatic patient from these populations. Pediatric GCT was observed to be more often well differentiated and localized, with size <2 cm, no lymph node positivity, and significantly longer survial. Surgical resection was the most common treatment and conferred the longest survival advantage in both groups. Resection should be considered in pediatric GCT patients with resectable disease. Adult GCT patients should be considered for clinical trial accrual given their relative rarity, and increased cancer-specific mortality.

8.15 Analysis of Trends Associated with Robotic-Assisted Surgery in Free Standing Children’s Hospitals

Posted on December 22, 2014

J. B. Mahida1,2, J. N. Cooper1, D. Herz3, K. A. Diefenbach2, K. J. Deans1,2, P. C. Minneci1,2, D. J. McLeod1,3  1Nationwide Children’s Hospital,Center For Surgical Outcomes Research,Columbus, OH, USA 2Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA 3Nationwide Children’s Hospital,Division Of Pediatric Urology,Columbus, OH, USA

Introduction: To evaluate current trends in the use and costs associated with robotic surgery at freestanding children’s hospitals.

Methods: We identified all patients less than 18 years of age in the Pediatric Health Information System (PHIS) database who underwent a robotic-assisted surgery between October 2008 and December 2013. After determining the six most frequently performed primary procedures in this group, we identified a cohort of patients who underwent equivalent open or laparoscopic procedures at the same hospitals over the same time period. We analyzed the overall frequencies and trends in the numbers of procedures performed over the study period and compared costs between patients undergoing robotic-assisted surgery and patients not undergoing robotic surgery for each of the six procedures.

Results: The six most common urologic or general surgery robotic-assisted cases performed were correction of ureteropelvic junction (UPJ) obstruction (n=760), ureteral reimplantation (n=351), nephrectomy (n=145), partial nephrectomy (n=56), gastrointestinal antireflux procedure (n=61), and cholecystectomy (n=46). The overall number of robotic-assisted surgeries performed at the 22 included hospitals increased by 19.8% per year (p<0.001); individual analyses of the six most commonly performed procedures revealed that this was primarily driven by significant increases in urologic procedures (17.4%/year, p<0.001). Differences in demographics, clinical characteristics, and length of stay between all patients undergoing robotic and non-robotic procedures are shown in the Table. Total hospital costs tended to be higher for robotic-assisted surgeries than comparable open or laparoscopic procedures (Urologic procedures median costs: robotic $14,583 vs. open $9,388, p<0.001) (General surgical procedures median costs: robotic $13,954 vs. laparoscopic $10,180, p<0.001).

Conclusion: Use of robotic-assisted surgery in pediatrics is increasing, especially in the management of urologic diseases. Costs of robotic-assisted surgery associated admissions were higher than non-robotic surgery associated admissions even though robotic procedures were associated with a shorter length of stay. Further analysis of specific procedure related outcomes and patient reported satisfaction, particularly for procedures that would otherwise be performed open, may be warranted in order to justify the increased cost of robotic surgery in children.

 

8.16 Predictors of Failure of Fish Oil Therapy for Parenteral Nutrition-Associated Liver Disease

Posted on December 22, 2014

P. Nandivada1, S. J. Carlson1, M. I. Chang1, A. A. O’loughlin1, K. M. Gura1, M. Puder1  1Children’s Hospital Boston,Pediatric Surgery,Boston, MA, USA

Introduction:
Parenteral fish oil (FO) therapy is a safe and effective treatment for parenteral nutrition-associated liver disease (PNALD), with successful resolution of cholestasis and avoidance of liver transplantation in 85% of infants. However, patients with PNALD who do not achieve resolution of cholestasis with parenteral FO therapy progress to end stage liver disease requiring liver transplantation or resulting in death.  The purpose of this study is to identify early patient factors that are associated with subsequent failure of parenteral FO therapy to guide prognostication and patient referral guidelines.

Methods:
A retrospective review of prospectively collected data for infants with PNALD treated with at least 4 weeks of parenteral FO at Boston Children’s Hospital (BCH) between January 2006 and January 2012 was performed. PNALD was defined as a direct bilirubin greater than 2 mg/dL. Resolution of cholestasis was defined as a sustained direct bilirubin less than 2mg/dL. Treatment failure was defined as the need for liver or multivisceral transplantation or death as of January 2013. Patient demographics, hospital transfer status, and laboratory values at the time of initiation of therapy were compared between patients who achieved resolution of cholestasis with parenteral FO therapy and those who failed therapy. 

Results:
138 infants with PNALD that were treated with parenteral FO were identified. Twenty-one patients (15.2%) failed therapy, with 32% of the infants failing therapy undergoing liver transplantation and mortality in 68%. There was no significant difference in gestational age, age at diagnosis of PNALD, or birth weight between the patients who responded to parenteral FO therapy and those who failed therapy. The most common diagnosis resulting in short bowel syndrome was necrotizing enterocolitis, followed by gastroschisis, in both groups. However, patients who failed therapy had more advanced liver disease at the time of therapy initiation. Patients who failed therapy had higher direct bilirubin (9.9 vs 6.2 mg/dL, p < 0.01), lower gamma glutamyl transferase (GGT) (85.4 vs 166.8 U/L, p = 0.03), and higher international normalized ratio (INR) (1.4 vs 1.2, p < 0.01) than patients who did not fail therapy. A higher proportion of infants that failed therapy were transfers from outside hospitals (85.7%) when compared to patients who responded to therapy (67.5%). This finding may represent delays in initiation of therapy due to unavailability of parenteral FO at the infants’ home institutions.

Conclusion:
Patients who initiate parenteral FO therapy for treatment of PNALD with biochemical evidence of severe liver disease as defined by bilirubin, GGT and/or INR are at risk for treatment failure.  For infants with PNALD at institutions without access to parenteral FO, earlier referral to centers where parenteral FO therapy is available may further improve response rates.
 

8.17 Mucoepidermoid Carcinoma in Children: A Population-Based Outcomes Study Involving 221 Patients

Posted on December 22, 2014

K. Mahendraraj1, R. S. Chamberlain1,2,3  1Saint Barnabas Medical Center,Department Of Surgery,Livingston, NJ, USA 2New Jersey Medical School,Department Of Surgery,Newark, NJ, USA 3Saint George’s University,Department Of Surgery,Grenada, Grenada, Grenada

Introduction:
Salivary gland carcinomas are rare in adults and children, the most common form being mucoepidermoid carcinoma (MEC). Small cohort studies suggest different clinical characteristics of MEC in adults compared to children. This study sought to analyze demographic and clinical factors which affect outcomes in adult and pediatric patients that may be used to risk stratify patients for treatment and clinical trial accrual. 

Methods:
Demographic and clinical data on 4,234 patients with MEC was abstracted from the Surveillance Epidemiology and End Result (SEER) database (1973-2010). Children were defined as age ≤ 21 and adults as >22. Standard statistical methodology was used.

Results:
Among 4,234 MEC patients, 221 (5.2%) were children and 4,013 (94.8%) were adults. The majority of pediatric MEC occurred in females (55.7%), while most adults MEC patients were male (50.6%), p<0.001. Overall, 71% of MEC occurred in Caucasians, p<0.001. Among African-Americans and Hispanics, there were more pediatric patients than adults (16.3% vs. 10%, and 20.8% vs. 8.3%, respectively; p<0.001). Adults had a higher rate of poorly differentiated disease (12.6% vs. 2.7%) and metastasis (7.7% vs. 3.6%) compared to children, p<0.001. Most children (53.8%) and adults (44.8%) presented with tumor size 2-4 cm. 51.1% of all patients underwent surgery and 41% had combination surgery and radiotherapy. More children underwent primary surgical resection alone (64.3% vs. 50.4%), while more adults had combination surgery and radiotherapy (41.4% vs. 33.0%); p<0.001. Mean overall survival (OS) was significantly longer in children than adults (34.5 vs. 18.7 years), p<0.001. Surgical resection significantly improved OS in children (34.9±0.5 vs. 22.6±0.5 years; p<0.001). Children had a lower overall mortality (3.6% vs. 38.0%) as well as higher 5-year cancer-specific survival (98% vs. 82%). Multivariate analysis identified adults (OR 10.4), tumor size greater than 2 cm (OR 1.9), poor (OR 4.0) or undifferentiated grade (OR 5.0), regional disease stage (OR 1.5), and lymph node invasion (OR 1.6) as associated with increased mortality, p<0.05.

Conclusion:
MEC is an aggressive salivary gland cancer that is predominantly found in Caucasians. It is far more common in adults, and is associated with more advanced stage, poorer grade and worse overall prognosis compared to children. While MEC presented with similar tumor size in both age groups, tumors in children occurred less frequently, were more often localized, well differentiated and had better outcomes. Surgical resection significantly improved OS in MEC patients, particularly among children. Older age and advanced tumor stage were associated with increased mortality.

8.18 Is Routine Postoperative Follow-Up Necessary After Common Pediatric Surgical Procedures?

Posted on December 22, 2014

E. M. Knott1, S. Suh2, B. A. Dalton1, T. A. Wattsman2, S. D. St. Peter1, S. R. Shah1  1Chidren’s Mercy Hospital,Pediatric Surgery,Kansas City, MO, USA 2Virginia Tech Carilion School Of Medicine,Pediatric Surgery,Roanoke, VA, USA

Introduction:
The rate of postoperative complication is extremely low for common pediatric surgical procedures such as hernia repair, circumcision and pyloromyotomy.   However, most surgeons continue to request patients return for routine follow-up after these procedures.  The objective of this study was to evaluate the necessity of routine follow-up by determining the rate of interventions performed during the postoperative period at scheduled clinic follow-ups and emergency department visits.

Methods:
A retrospective review was performed of all patients undergoing inguinal hernia repair, umbilical hernia repair, epigastric hernia repair, circumcision, or laparoscopic pyloromyotomy at two institutions during a 6 month period. Charts were reviewed for postoperative clinic and emergency department visits during the initial 90 days after surgery. An intervention was defined as any laboratory or radiographic workup, prescription of medications, hospital admission, or scheduling further follow-up visits.

Results:
Chart review was performed in 270 patients undergoing the following procedures (n): inguinal hernia repair (76), umbilical hernia repair (42), epigastric hernia repair (9), circumcision (126), laparoscopic pyloromyotomy (10), or some combination of the above (7). Of these, 146 patients (54.1%) were seen in the surgery clinic for follow-up at a mean of 23.7 ± 12.7 days after the procedure. Thirteen of these follow-ups required an intervention: 12 after circumcision (related to wound healing or adhesions) and 1 after laparoscopic pyloromyotomy (for an umbilical granuloma).  Fourteen patients (5.2%) visited the emergency department during the postoperative period at a mean of 8.3 ± 7.1 days (range 2-21 days) after the procedure. Of these, 8 required an intervention:  2 after inguinal hernia repair (pain and cellulitis), 1 after epigastric hernia repair (cellulitis), 3 after circumcision (pain, cellulitis or bleeding), and 2 after pyloromyotomy (irritability and emesis).  No patients required readmission, and one patient required reoperation (for lysis of penile adhesions) during the follow- up period.

Conclusion:
These data demonstrate that patients after inguinal hernia repair, umbilical hernia repair, epigastric hernia repair, circumcision, and laparoscopic pyloromyotomy have a low rate of follow-up.  Of those that are seen in the postoperative period very few require any intervention, and patients having undergone circumcision are the ones that most frequently prompt an intervention.  Based on these data routine postoperative follow-up for select common pediatric surgical procedures may not be necessary and alternatives should be further investigated.  
 

8.19 Frequency of Cardiorespiratory Events in Premature Infants During Observation After Hernia Repair

Posted on December 22, 2014

E. M. Knott1, K. W. Schnell1, B. J. Pieters2, S. D. St. Peter1  1Children’s Mercy Hospital,Pediatric Surgery,Kansas City, MO, USA 2Children’s Mercy Hospital,Department Of Anesthesiology,Kansas City, MO, USA

Introduction:
Wide variation exists in criteria for overnight observation after inguinal hernia repair in former premature infants. We previously compiled retrospective data to demonstrate the risk of overnight apneic events. In order to validate these findings we initiated prospective observational study to capture the true event rates.

Methods:
After institutional review board approval, we have followed all premature infants admitted for overnight observation after inguinal hernia between 7/1/11 to 7/31/14. Children under an adjusted gestational age (AGA) of 60 weeks were admitted for observation. Patients undergoing hernia repair while inpatient in the intensive care nursery were excluded. Demographic data was collected. The lowest heart rate and oxygen saturation after leaving the recovery room were noted. Episodes of apnea, bradycardia and desaturation were recorded. 

Results:
To date, 96 patients have been accrued. AGA was 48.0 ± 5.5 weeks; 88.5% were male with an average weight of 4.7 ± 1.0 kg. Bilateral hernia repair was performed 55.2% of the time; laparoscopic repair was performed in 4.2%. Average length of stay was 24.1 ± 5.3 hours. While no patient had a recorded apneic episode, 1 was readmitted the night on postoperative day 1 for a witnessed episode of apnea after discharge. The 5 patients that had either bradycardia or desaturation are summarized in Table 1. Two of the 5 were on a home monitor. One had neurologic impairment and another had coarctation of the aorta; the remaining 3 had no significant comorbidities. No patient had more than one episode of either bradycardia or desaturation.

Conclusion:
The majority of postoperative episodes of bradycardia or desaturation are seen in infants undergoing inguinal hernia repair at less than 50 weeks adjusted gestational age. These events are short lived, resolve with supplemental oxygen and do not delay discharge. Lowering the AGA to 50 weeks or less for admission after inguinal hernia repair is supported by these data.
 

8.20 Effect of Variation in Non-operative Management of Acute Complicated Appendicitis in Children

Posted on December 22, 2014

A. C. Alder1,2, M. M. Hagopian2, R. I. Renkes1, L. Burkhalter1, R. P. Foglia1,2  1Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA 2University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA

Introduction:
Appendicitis is a common ailment in children. Treatment requires a tremendous allocation of resources especially for complicated cases. Initial non-operative management (NOM) has gained favor in selected cases of complicated appendicitis. Variations in this NOM approach include percutaneous drain placement or aspiration of intra-abdominal abscesses. We set out to review the effects of this variation on our population of patients with complicated appendicitis treated without initial appendectomy.

Methods:
All patients with appendicitis were reviewed between June 2009 and December 2012. Among these patients those who were treated with antibiotics +/- adjuncts and no appendectomy during the initial hospital stay were identified. Demographic and clinical data were collected with specific interest in data related to treatment variation (imaging technique, drain placement, antibiotic type, etc) and clinically relevant outcomes (length of stay (LOS), time to tolerating oral diet, etc). Data were analyzed using univariate and multivariate techniques as well as time to event tests.

Results:
Among 3491 patients found to have appendicitis, 101 patients were noted to have complicated appendicitis and were selected for NOM. All patients were given antibiotics. The mean age was 9 years with a slight majority of female patients. All patients had imaging – either CT, ultrasound or both. Patients with fever had a trend to a longer time to oral intake, a significantly longer time to tolerance of regular diet and no difference in LOS.  Patients with a fecalith had a significantly longer LOS, no difference in first oral intake and a trend toward a longer time to tolerance of a regular diet.  A change in antibiotics, use of TPN and an ICU stay were associated with an increased LOS and a longer time to tolerance of regular diet. Only ICU stays were associated with a longer time to first oral intake. Abscesses were found on imaging in over 90% of all patients. Drains were placed in 74/101 patients.  Placement of a drain was associated with a longer LOS and  prolonged time to tolerance of a regular diet when compared to aspiration and antibiotics alone.  Aspiration was associated with a significantly lower LOS, but no difference in first or tolerance of a diet. Time to event analysis confirmed  that the patients who were drained had a significantly longer time to tolerance of the regular diet but no difference in time to first oral intake.

Conclusion:
In this large series we found it surprising that patients with complicated appendicitis who underwent drainage of an abdominal abscess had a longer LOS. They were as quick to start a diet, but took longer to tolerate a regular diet. This effect may be related to the management style of the surgical team, but may also be related to the intra-abdominal process. This differs from previously published reports which indicate a quicker time to recovery when the abscess was amenable to drainage.  We believe this warrants further research into the best use of resources in the management of complicated appendicitis.
 

9.01 Improving Predictive Value of Trauma Scoring Through Integration of ASA-PS with ISS

Posted on December 22, 2014

D. Stewart1, C. Janowak1, H. Jung1, A. Liepert1, A. O’Rourke1, S. Agarwal1  1University Of Wisconsin,Surgery,Madison, WI, USA

Introduction:  Many methods exist for predicting mortality among adult trauma patients; however, most systems ignore patient co-morbidity, a significant predictor of outcome, in their calculations. The American Society of Anesthesiologists Physical Status (ASA-PS), a well-validated and easy-to-use scale, is an assessment of pre-operative status that has been shown to accurately predict post-operative mortality.  Using the ASA-PS as a marker of cumulative patient comorbidity severity we sought to test whether we would be able to improve the predictive power of the Injury Severity Score (ISS), the most commonly utilized trauma grading system, with respect to mortality, major complication, and discharge disposition.

Methods:  A retrospective review of a prospectively collected and internally validated database at an academic Level I trauma center was performed for consecutive adult admissions between 2009-2013.  Abbreviated Injury Scale (AIS) was measured by region (head/neck, face, thorax, abdomen, extremities, general) and severity of injury (1 to 5). ISS was measured by summing the squares of the three most injured regions [(AIS1)2 + (AIS2)2 + (AIS3)2].  ASA-PS scores were assigned based on patient comorbidities and then integrated with the traditional ISS in a variety of permutations, including adjustments of ASA-PS for patient age >70 and using individual AIS components of ISS.   We assessed these various models for predictive ability with a primary outcome of mortality and secondary outcomes of major complications as per National Trauma Data Bank (NTDB) definitions as well as discharge disposition using receiver operating characteristic (ROC) analysis.  These were compared with the ISS.

Results: All of the ISS/ASA-PS hybrid formulas outperformed ISS alone in predictive power for mortality, major complication, and discharge disposition.  The best overall permutation, (AIS1)2+(AIS2)2+(Age-Modified ASA-PS)2, yielded an ROC of 0.888 for mortality as compared to ISS with an ROC=0.853 (p<0.001).  Similar differences were seen for discharge disposition (Hybrid ROC=0.743; ISS ROC=0.639, p<0.001) and major complication (Hybrid ROC=0.761; ISS ROC=0.719, p<0.001).

Conclusion: Incorporating ASA-PS into calculations of trauma scoring is both simple and more predictive of mortality, major complication, and discharge disposition than the traditional ISS metric.  Replacing ISS with this new method, which takes patient age and comorbid condition into account through adaptation of the ASA-PS improves prognostication of outcomes and enables care providers to prioritize resources for injured patients.

 

9.02 Acute Ethanol Intoxication Inhibits Platelet Function in Healthy Individuals

Posted on December 22, 2014

A. Slaughter1,2, M. P. Chapman1,2, A. Banerjee1, E. Gonzalez1,2, H. B. Moore1,2, E. E. Moore1,2  1University Of Colorado Denver,Surgery,Aurora, CO, USA 2Denver Health Medical Center,Surgery,Aurora, CO, USA

Introduction:  Despite the established effects of moderate, long-term ethanol consumption on platelet function, the impact of acute ethanol exposure based on homotypic platelet aggregometry remains contradictory. Thus the role of acute ethanol intoxication in the pathogenesis of trauma induced coagulopathy has not been elucidated. The development of recent whole blood viscoelastic assays however provides the opportunity to better evaluate the effect of acute ethanol exposure on the hemostatic capacity of platelets. We hypothesized that acute ethanol intoxication will impair platelet function in otherwise healthy individuals.

Methods:  Healthy volunteers (n=7) participated in the study. Baseline venous blood samples for kaolin-activated whole blood thromboelastography (TEG) and platelet mapping (PM) were obtained at the beginning of the study. Additional blood samples were drawn and incubated with ethanol for 1 h (in vitro exposure). Participants then consumed ethanol to legal intoxication, a blood alcohol content of >0.1 g/dL, as monitored by repeated breathalyzer testing. Blood was drawn after 1h of sustained intoxication (in vivo exposure). We then repeated TEG and PM on the post-incubation and post-intoxication samples. Percentage platelet inhibition at the adenosine diphosphate (ADP) and thromboxane A2 (TxA2) receptors following ethanol exposure was calculated. 

Results: The platelet TxA2 receptor, stimulated by arachidonic acid (AA), demonstrated a significant increase median (IQR) percentage inhibition from baseline following in vivo ethanol intoxication, 50.4% (27.9) vs. 75.2% (25.3) (p=0.018). Likewise, the TxA2 receptor demonstrated a significant increase percentage inhibition from baseline following in vitro ethanol incubation, 50.4% (27.9) vs. 75.6% (30.35) (p=0.046).  Platelet ADP channel percentage inhibition comparing baseline and post-intoxication was 40.2% (35.7) vs. 61.3% (35.1) (p=0.398). ADP channel percentage inhibition comparing baseline and post-incubation was 40.2% (35.7) vs. 64.65 (42.6) (p=0.917).

Conclusion: Acute ethanol intoxication significantly impaired platelet function via the TxA2 receptor. Furthermore TxA2 receptor inhibition followed both in vivo and in vitro exposure. Our results therefore suggest that platelet dysfunction could exacerbate coagulopathy in intoxicated trauma victims.  

9.03 BMI is Inversely Proportional to Need for Therapeutic Operation after Abdominal Stab Wound

Posted on December 22, 2014

M. B. Bloom1, E. J. Ley1, D. Z. Liou1, T. Tran1, R. Chung1, N. Melo1, D. R. Margulies1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction:   Several authors have examined the relationship between trauma patient Body Mass Index (BMI) and blunt and polytrauma outcomes.  Less attention has been paid to the need for therapeutic intervention in penetrating trauma.  We sought to determine whether increasing BMI is protective in abdominal stab wounds, and predictive of need for intervention.

Methods:   We conducted a review of all patients presenting with abdominal and flank stab wounds at an urban level I trauma center from January 1, 2000 to December 31, 2012.  Patients were divided into four groups based on their BMI.  Abstracted data includes baseline demographics, physiologic data, and characterization of whether the stab wound had violated the peritoneum, caused intra-abdominal injury, or required an operation that was ultimately therapeutic. Patients who were safely observed without an operation were considered as having no intra-abdominal injuries, but were excluded from the peritoneal violation analysis. The one-sided Cochran-Armitage Trend was used for significance testing of the protective effect.

Results:  Of 281 patients with abdominal stab wounds, 249 had complete data for evaluation, grouped as BMI<18.5(underweight, n=6), BMI 18.5-29.9(normal to overweight, n=195), BMI 30-35(obese, n=38), and BMI>35(severely obese, n=10). There were no statistically significance differences between groups with respect to age, GCS score, SBP, ISS, AIS subtypes, and mortality, but greater BMI was more prevalent in females (p=0.015). All 6 patients with BMI<18.5 had peritoneal violation, and 5/6 (83%) had intra-abdominal injury. The rate of peritoneal violation trended downward as BMI increased (100%, 86%, 77%, 75%; p=0.147). Increasing BMI was associated with a significant decrease in actual visceral injury (83%, 56%, 50%, 30%; p=0.022). Of 6 patients with BMI<18.5, 4 (67%) had intra-abdominal injury requiring an operation that was therapeutic, whereas in BMI>35, only 2/10 (20%) did. The rate progressively decreased as BMI rose (67%, 44%, 39%, 20%; p=0.041).

Conclusion:  Increased BMI protects patients with abdominal stab wounds and is associated with both lower rates of injured viscera and a reduced need for operations. Heavier patients may be more suitable to observation and serial exams, while very thin patients are more likely to require an operation.

 

77.04 Learning Styles Preferences of Surgical Residency Applicants

Posted on December 22, 2014

R. H. Kim1, T. Gilbert2  1Louisiana State University Health Sciences Center – Shreveport,Surgery,Shreveport, LA, USA 2Louisiana State University Health Sciences Center – Shreveport,Academic Affairs,Shreveport, LA, USA

Introduction:

The learning style preferences of general surgery residents have been previously reported; there is evidence that residents who prefer read/write learning styles perform better on the ABSITE. However, little is known regarding the learning style preferences of applicants to general surgery residency and their impact on educational outcomes. In this study, the preferred learning styles of surgical residency applicants were determined. We hypothesized that applicant rank data is associated with specific learning style preferences.

Methods:

The Fleming VARK learning styles inventory was offered to all general surgery residency applicants that were interviewed at a university hospital-based program. The VARK model categorizes learners as: visual (V), aural (A), read/write (R), kinesthetic (K), or multimodal (MM). Responses on the inventory were scored to determine the preferred learning style for each applicant. Applicant data, including USMLE scores, class rank, interview score, and overall final applicant ranking were examined for association with preferred learning styles.

Results:

Sixty-seven applicants were interviewed. Five applicants were excluded due to not completing the VARK inventory or having incomplete applicant data. The remaining 62 applicants (92%) were included for analysis. Most applicants (57%) had a multimodal preference. 69% of all applicants had some degree of preference for kinesthetic learning. There were statistically significant differences between applicants of different learning styles in terms of USMLE Step 1 scores (p=0.001) and USMLE Step 2 CK scores (p=0.01), but not for class ranks (p=0.27), interview scores (p=0.20), or final ranks (p=0.15). Multiple comparison analysis demonstrated that applicants with aural preferences had higher USMLE 1 scores (233.2) than those with kinesthetic (211.8, p=0.005) or multimodal (214.5, p=0.008) preferences, while applicants with visual preferences had higher USMLE 1 scores (230.0) than those with kinesthetic preferences (p=0.047). Applicants with aural preferences also had higher USMLE 2 scores (249.6) than those with kinesthetic (227.6, p=0.006) or multimodal (230.1, p=0.008) preferences.

Conclusion:

Most applicants to general surgery residency have a multimodal learning style preference. Learning style preferences are associated with higher USMLE Step 1 and Step 2 scores, in particular for applicants with aural preferences. Students who performed well in lecture-dominated medical school environments due to their aural preferences could be at a disadvantage in the more independent, reading-focused learning environments of surgical residency.

77.05 At Home on the Road: The Impact of Visiting Student Electives on Match Results

Posted on December 22, 2014

S. C. Daly1, R. A. Jacobson1, J. L. Schmidt1, B. P. Fleming1, A. Krupin1, M. B. Luu1, J. A. Myers1, M. C. Anderson1  1Rush University Medical Center,Chicago, IL, USA

Introduction:  Residency applicants commonly complete visiting student electives (VSEs) away from their home institution. VSEs may benefit applicants through exposure to desired programs, and benefit programs by serving as an extended interview. To date, no study has quantified the impact of VSE completion on the residency application process, stratified by specialty. Consequently, medical students apply to VSEs on incomplete, often anecdotal information. As VSEs involve monetary and opportunity costs to students and administrators, data on their utility is vital for student wellbeing and ultimately, success in the Match. As such, the hypothesis of this study is that completion of VSEs correlates with increased odds of matching at a former host site.

Methods:  This is a retrospective review of VSE completion and Match data from one institution’s graduating classes from 2008-2014. De-identified records were analyzed for medical school GPA, USMLE exam scores, specialty choice, and site of VSEs. Data collected were analyzed using subgroup analysis, stratified by PGY2 specialty. Data was summarized with standard descriptive statistics. 

Results: Students who completed VSEs had higher GPAs and USMLE exam scores than those who did not. Specialty choice had a profound impact on rates of VSE completion. In total, 501 (55.2%) of the 907 records queried showed completion of a VSE, with 0.80 VSEs per applicant. Of these, students who completed one or more VSE matched into a program that had hosted them in 19.6% of cases. General Surgery applicants had a VSE completion rate of 58.8%, with 0.86 VSEs per applicant. 100% of Orthopedic Surgery applicants completed VSEs, with 2.19 per applicant. While General Surgery applicants matched into a host program 16.7% of the time, Orthopedic Surgery applicants matched into a host program at a rate of 44.4%. 

Conclusion: General Surgery applicants applied to a mean of over 25 programs from 2008-2014, thus the odds of matching into any program were 1 in 25. However, VSE completion increased the odds of matching into any of 1-3 host programs to roughly 1 in 6. Accordingly, our data suggest that applicants who completed a VSE were more likely to match into an individual host program than to a non-host. This concept can be extrapolated using Orthopedic Surgery match data: applicants who completed more VSEs were more likely to match into a host program than those who completed fewer. Limitations of this comparison include a different applicant pool. Also, data on applicants’ rank lists, which impact match results, is not available. Ultimately, applicants who complete VSEs may possess improved control over the residency match process by increasing their odds of matching into desired programs. Presently, General Surgery applicants complete VSEs at a rate near the all-specialty average. Encouraging future applicants to complete additional VSEs could improve the application experience and increase match rates at desired programs. 

77.06 Longitudinal Study Defining Students’ Preferences and Factors for Choosing a Surgical Career

Posted on December 22, 2014

J. Giacalone1, A. Berger1, J. Keith1  1University Of Iowa,Carver College Of Medicine,Iowa City, IA, USA

Introduction:  Many factors contribute to an undergraduate medical student’s career choice; these factors are variable and often change throughout one’s education. Importantly for surgical programs and medical education, analysis of longitudinal information will help clarify the considerations that influence career choices at each phase of training.

Methods:  This is the first survey of a longitudinal prospective study of students at the University of Iowa Carver College of Medicine. A self-administered questionnaire was distributed at the start of the first year. The questionnaire will be administered each subsequent year to the same cohort. The questions cover factors such as education related debt, mentorship experiences, healthcare work exposure, participation in research, and career preferences. Residencies classified as surgical include general surgery, neurosurgery, obstetrics-gynecology, ophthalmology, orthopedic surgery, otolaryngology, plastic/reconstructive surgery, and urology.

Results: 143 students responded to the survey. Thirty-six percent of students had a practicing physician in their family.  Of those students with a physician in their family, 31 percent were interested in a surgical career, compared to 22 percent among students without a physician in their family (p=0.32708). While not significant, there does appear to be a trend of increased interest in surgery for students with surgeons in the family (orthopedics, ophthalmology, obstetrics-gynecology, general surgery) compared to medical students with a nonsurgical physician in their family (p=0.126). Some of the most important career-related factors for students interested in surgery include intellectual stimulation, quality of life, patient contact, potential salary, technical skill, and work hours. 85 percent of students had debt. Of those with debt, 39 percent felt it influenced their choice of specialty, although these choices were widely dispersed. Interestingly, only 5 percent of those without debt felt it influenced their specialty choice, reflecting a statistically significant difference between groups (p=0.00104). That said, students who plan to choose a specialty based on debt were significantly less likely to specify a specialty choice at the beginning of medical school, compared to those who did not feel influenced by debt (38.8 percent versus 22.3 percent did not specify a specialty preference, respectively (p=0.037)).

Conclusion: The current information portrays student’s early career preferences. Of the factors assessed, student debt and physicians in the family plays a large role in specialty role. While other factors are not significant at this time, this longitudinal study will uncover influential factors such as family influences, research and mentorship experiences, and specialty-specific expectations.

 

77.07 Medical Students in Laparoscopic Cases: Increased Operative Time and Same Post-Operative Outcomes

Posted on December 22, 2014

M. Mori1, A. Liao1, T. Hagopian2, S. Perez1, J. F. Sweeney1, B. Pettitt1  1Emory University School Of Medicine,Surgery,Atlanta, GA, USA 2University Of Southern California,Plastic And Reconstructive Surgery,Los Angeles, CA, USA

Introduction:
Medical students are increasingly assuming active roles in the operating room (OR) as part of their clerkships. Laparoscopic surgeries offer increasing opportunities for MS participation, including camera driving, teaching through well-visualized operative field, and suturing. The effect of the presence of medical students on the procedure time and post-operative outcomes are unknown. We aimed to characterize the effects of medical student participation in laparoscopic cases.

Methods:
Data from the American College of Surgeons National Surgical Quality Improvement Program was linked to the institutional operative records for non-emergent, inpatient, laparoscopic general surgery cases at our institution from 01/2009 to 01/2013. Cases were grouped into eight distinct procedure categories. Hospital records provided information on the presence of medical students. Demographics, comorbidities, operative time, and postoperative complications were analyzed, using linear regression.

Results:
Of 700 laparoscopic cases reviewed, medical student was present in 38% of the cases. Controlling for wound class, procedure group, and surgeon, multivariate linear regression demonstrated that the presence of medical students in the OR was associated with an additional 30 minutes of total operative time on average (p<0.0001, 95% CI [17-43 mins]). No association between medical students and the number of postoperative complications was observed (0.21 vs. 0.19, p=0.79).

Conclusion:
This is the first study to examine the effect of medical student’s presence during laparoscopic procedures. While it is reassuring that no increase in the complications was observed, the association with increased operative time in laparoscopic cases needs to be examined further, especially given the financial burden incurred by the increased OR time.

77.08 Perceived vs Desired Competence at Procedural Skills in 3rd Year Students Across Two Institutions

Posted on December 22, 2014

J. Carr1, M. Meyers1, A. Deal1, F. Johnson2, T. Schwartz2  1University Of North Carolina At Chapel Hill,Chapel Hill, NC, USA 2St. Louis University,St. Louis, MO, USA

Introduction:  Ensuring that medical students acquire basic procedural skills is increasingly challenging. We previously reported experience and expectations of students over several years at our institution. In this study, we compare students’ experience and expectations at two institutions over two years.

Methods:  With IRB approval, an online survey was conducted at the end of 3rd year in 2013 and 2014 at the University of North Carolina at Chapel Hill (UNC) (n = 76, 91 respectively) and St Louis University (SLU) (n = 54, 55). Opinions were sought as to experience, level of competence and desired level of competence for nine procedural skills (Foley, NG placement, venipuncture, IV placement, arterial puncture, basic suturing, LP, thoracentesis, intubation) using a 4-point Likert scale (1=unable to perform; 2=require major assistance; 3=require minor assistance; 4=independent). Responses were compared by Student’s t-test. 

Results: Gender (UNC 51% male, SLU 46%) and plans to enter a procedural-based specialty (49% vs. 51%) were comparable. No differences were seen in perceived or desired competence for any skill in 2013 or 2014 at either institution. Differences were seen for the mean number of procedures performed between the two schools for Foley (4.2±1.06 at UNC vs 2.98±1.34 at SLU; p<0.0001), IV placement (2.24±1.35 vs 1.55±1.06; p<0.0001), arterial puncture (1.47±.88 vs 2.03±1.13; p<0.0001), LP (1.49±.77 vs 1.30±.63; p=0.037) and basic suturing (4.74±.78 vs 4.42±.90; p=0.002). UNC students reported their self-perceived competence was greater than at SLU for Foley (3.63±0.63 vs 3.15±0.82; p<0.0001), NG tube (2.45±0.88 vs 1.75±0.89; p<0.0001), IV placement (3.08±0.75 vs 2.71±0.84; p=0.0002), arterial puncture (1.67±0.62 vs 1.50±.70; p=0.01) and LP (2.18±0.74 vs 1.69±0.75; p<0.0001). A difference between desired competence between the two schools was observed for Foley (UNC 3.78±0.43 vs SLU 3.65±0.50; p=0.02), NGT (3.38±0.68 vs 3.06±0.75; p=0.0002) and LP (2.84±0.71 vs 2.66±0.75; p=0.045). For all skills at both schools, there was a significant difference in actual vs. desired competence (p<0.0001 for all). 

Conclusions: A significant gap between medical students’ self-assessed competence and their desired competence at performing basic procedural skills persists over years and across institutions. Several differences exist between institutions in self-perceived competence, a finding that may be partially explained by disparities in experience level. Differences in desired competence between institutions is more difficult to explain, and is not influenced by desire to pursue a procedural specialty. These data suggest that despite decreasing student procedural experience, the desire still exists for greater proficiency during medical school.

77.09 Focused Medical Student Intersession Improves Knowledge, Technique, and Interpersonal Interactions

Posted on December 22, 2014

C. M. Freeman1, J. M. Sutton1, D. B. Pettigrew3, P. L. Jernigan1, E. F. Midura1, J. W. Kuethe1, B. R. Davis1,2, K. P. Athota1,2,3  1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA 2University Of Cincinnati,Department Of Surgical Education,Cincinnati, OH, USA 3University Of Cincinnati,Department Of Medical Education,Cincinnati, OH, USA

Introduction:  For the previous century, resulting from the Flexner Report, medical school curricula has consisted of two years of didactics followed by two years of clinical rotations. More recently, the Liaison Committee on Medical Education has mandated a more integrative approach to medical student education. While the value of incorporating clinical activities into the basic science educational years has been previously investigated, the efficacy of integrating basic science modules within the clinical rotations has not been well-studied. 

Methods:  We developed an intensive review course of anatomy via a laparoscopic perspective to reaffirm anatomical and spatial relationships initially taught during gross anatomy. Utilizing fresh, prosected cadavers, medical students entering the third year clerkships underwent a systematic review of anatomic landmarks of intra- and retro-peritoneal organs. Stations were designed to provide overview of the use of the laparoscope and to review abdominal, pelvic and retroperitoneal anatomy. Further discussion regarding differential diagnoses of various clinical scenarios was held to reinforce anatomic relationships of the organs within the abdomen. Medical student perceived interest, knowledge gain, comfort level with surgical instruments, pertinent anatomy and interaction with surgery attending and resident preceptors were assessed via voluntary survey at the conclusion of the session. Statistical analyses were performed using Fischer’s exact test.

Results: Thirty nine medical students participated in the surgical intersession prior to beginning core clerkships with the majority (90.6%) finding the gross anatomy sessions valuable.  Twenty one students returned a detailed voluntary survey regarding their experience with the intersession. A significant improvement in the students’ understanding of anatomy relevant to gallbladder pathophysiology and laparoscopic anatomy was noted (66.7% felt uncomfortable with the topic before vs. 4.8% after the intersession, p <0.0001).   Students also demonstrated a significant improvement in comfort with use of the laparoscope (4.8% before vs. 90.5% after, p <0.0001).  Additionally, students demonstrated decreased sense of anxiety regarding their interaction with surgical attendings and residents after intersession (71.4% before vs. 28.6% after, p <0.01).

Conclusion: A focused intersession integrating pre-clinical knowledge of anatomy and pathophysiology prior to the medical student surgery clerkship can be used to reinforce clinically-relevant anatomic knowledge gained within the initial two years of medical school.  The improved knowledge base and comfort with laparoscopic anatomy, use of the laparoscope, and improved interactions with surgery faculty and residents may translate to an enriched educational experience for medical students throughout their surgical clerkship.

 

 

 

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