63.10 Low Rates of VACTERL Screening in Children with Anorectal Malformations

Posted on January 18, 2016

V. A. Lane1,2, E. J. Ambeba1, J. N. Cooper1, D. L. Lodwick1, M. A. Levitt2,4, D. J. Chisolm3,5,6, R. J. Wood2, P. C. Minneci1, K. J. Deans1 1Nationwide Children’s Hospital,Center For Surgical Outcomes Research,Columbus, OH, USA 2Nationwide Children’s Hospital,Center For Colorectal And Pelvic Reconstruction,Columbus, OH, USA 3Nationwide Children’s Hospital,Pediatrics And Public Health,Columbus, OH, USA 4Ohio State University,Surgery,Columbus, OH, USA 5Ohio State University,Pediatrics,Columbus, OH, USA 6Ohio State University,Public Health,Columbus, OH, USA

Introduction:

The VACTERL (Vertebral, Anal, Cardiac, TracheoEsophageal, Renal, Limb) association is a group of congenital anomalies that often occurs among patients diagnosed with anorectal malformation (ARM). Despite the existence of recommended VACTERL screening practices for ARM patients, it is unclear whether such screening is routinely implemented by clinicians. Missed and delayed diagnoses may delay medical intervention and contribute to increased morbidity. Our objective was to examine VACTERL screening practices throughout the United States in children born with ARM.

Methods:

We conducted a retrospective cohort study using the 2005-2009 Medicaid Analytic eXtract (MAX), a health care utilization database that contains Medicaid enrollment and utilization claims. We included 17 states with claims data usable for research. Patients born between January 1, 2005 and December 31, 2008 who had an ICD-9 diagnosis code for ARM and at least 12 months of continuous enrollment in Medicaid were included. In order to minimize disease misclassification, patients were excluded if there was no record of a definitive ARM procedure within the first year of life. VACTERL screening tests were identified based on ICD-9 and CPT procedure codes and included echocardiogram, spinal radiographs, spinal cord assessment (spinal ultrasound [US] and/or spinal MRI), renal US, and limb radiographs.

Results:

A total of 2,278 children with an ARM diagnosis code were identified, of which 406 children underwent a definitive ARM procedure within the first year of life. Males comprised over half of the cohort (57%). Overall, 6% of children did not have any VACTERL screening test. Eighty percent had 2 or more screening tests; only 3% of the sample had all 5 screening tests. Seventy-seven percent of children had an echocardiogram; 20% had a spinal radiograph; 57% had some type of spinal cord assessment (spinal US only, 30%; spinal MRI only, 14%; both spinal US and spinal MRI, 13%); and 77% had a renal US. In addition, limb (upper and/or lower) radiographs were performed in 16% of children (Table).

Conclusion:

In this population-based study, we identified a low rate of VACTERL screening in patients with ARM, especially for vertebral anomalies. Under-screening for associated anomalies may lead to delayed diagnosis of significant anomalies that may require either medical or surgical intervention; thus improving screening rates could enhance care of children with these conditions.

63.05 The Return of the Bilateral Neck Exploration for the Treatment of Primary Hyperparathyroidism

Posted on January 18, 2016

B. De Rienzo-Madero1, C. Toledo-Toral1, G. Kraus-Fischer1, D. Kajomovitz-Bialostozky1, E. Luque1, E. Moreno1, M. Muñoz1, F. Cordera2, R. Arrangoiz2 1Centro Médico ABC,General Surgery,México, D.F., Mexico 2Centro Médico ABC,Surgical Oncology,México, D.F., Mexico

Introduction:
Primary hiperparathyroidism (PHPT) is a benign disease with malignant potential. It is more common in women in the fifth decade (incidence: 1 in 75). 95% of patients are symptomatic, with the most common symptoms being neuro-psychiatric in nature. Surgery is the gold standard for the management of PHPT. We propose the use of a radio-guided parathyroidectomy with a bilateral neck exploration, biopsy of the 4 parathyroid glands in-vivo, and the evaluation of their functionality ex-vivo in order to determine which should be excised. We describe the feasibility and efficacy of this technique at our hospital in Mexico City.

Methods:
We present a retrospective observational study from a prospectively maintained cohort of 36 consecutive patients with the diagnosis of PHPT who underwent surgical intervention at our institution by two surgeons. The diagnosis was confirmed with serum calcium, 25 OH vitamin D, and parathyroid hormone (PTH) levels. The NIH criteria were used to determine surgical candidates. For the procedure, patients underwent a 99m-Tc sestamibi scan 1 to 2 hours prior to surgery, a bilateral neck exploration through a 2 to 2.5 cm incision in which the 4 parathyroid glands were identified was performed. A biopsy in-vivo was taken from each of the glands and their ex-vivo functionality was evaluated using a gamma probe. The radioactivity of each gland was compared to the basal count taken before the start of the procedure, the hyperfunctioning glands were excised. Additionally, intraoperative PTH was measured in accordance to the Miami criteria. Patients were followed-up clinically and biochemically at 1 week, 3 weeks, 8 weeks and 1 year postoperatively.

Results:
Symptomatic PHPT was diagnosed in 100% of the patients. The average serum calcium was 10.13+0.6 mg/dl, and PTH 93.82+43.45 ng/ml. 52.7% of our patients had a negative 99m-Tc sestamibi scan and 44.4% had a positive scan for a single adenoma. Pathology confirmed that 19.4% of patients had a single adenoma, 36.1% a double adenoma, 33.3% a triple adenoma, and 11.1% hyperplasia. Compared to the gamma probe basal counts in the neck, adenomas presented on average 71%, and hyperplasic glands 20% of the basal value. All patients had a decrease in serum calcium and PTH postoperatively. There was a failure rate (persistent or recurrent PHPT) of 5.5%, and no patient presented with significant associated complications.

Conclusion:
The radio-guided bilateral neck exploration with evaluation of the functionality ex-vivo of the 4 parathyroid glands offers a similar cure rate to the traditional bilateral neck exploration and has a greater cure rate than unilateral parathyroidectomy, with a similar morbidity rate to the latter. We show that this as a safe and effective technique for the management of PHPT and is associated with reduced hospital costs. This technique offers excellent clinical and esthetic results and represents a feasible alternative to the traditional parathryoidectomy.

63.06 Complications Following Pediatric Thyroidectomy are Rare at a High Volume Center

Posted on January 18, 2016

T. M. MADKHALI1, A. I. Salem1, D. F. Schneider1, R. S. Sippel1, H. Chen1,2 1University Of Wisconsin-Hospital & Clinics,Endocrine Surgery,Madison, WI, USA 2University Of Alabama,Surgery,Birmingham, Alabama, USA

Introduction: Thyroid disease requiring surgery is relatively rare in children but can have significant life-long health implications. Published data indicates higher postoperative complications following thyroidectomy when compared to the adult population reaching more than 50%. However, this percentage is much less when thyroidectomy is performed in high volume centers. We sought to assess the incidence of postoperative complications in pediatric patients in a high volume thyroid surgery center

Methods: A retrospective review of patients younger than 19 years who underwent thyroidectomy at our institution between July 1994 and July 2014. The primary outcomes were the incidence of postoperative hypocalcemia, hoarseness, hematoma, and surgical site infection. Hypocalcemia was defines as plasma calcium level < 8 mg/dl, parathyroid hormone level < 10 pg/ml, or the need of oral calcium and activated vitamin D (calcitriol) supplementations to prevent hypocalcemia symptoms

Results: While more than 3,290 thyroidectomies were performed on adult patients in our institution, around 126 pediatric patients underwent 131 thyroid operations in the same time frame. For the latter group, the average age was 13 ± 5 years with female gender predominance (77%). Nodular diseases (37%) and hyperthyroidism (34%) were the most common indications for thyroidectomy in pediatric age group. Subtotal/total thyroidectomy was performed in 97 patients (74%). 33 patients developed 35 complications (27%), mainly due to transient hypocalcemia in 28 patients (21%) and transient hoarseness in 5 patients (4%). Only 1 patient (<1%) experienced permanent hypocalcemia. None of the patients developed permanent hoarseness, hematoma, or surgical site infection

Conclusion: In our institution, thyroidectomy in pediatric patients can be considered as a safe procedure with a low postoperative complication rate

63.07 Surgical Approaches to Achalasia in Children Undergoing Esophagomyotomy: An IPEG Survey

Posted on January 18, 2016

J. Gould1, R. Rentea1, S. St. Peter1 1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA

Introduction: Achalasia is a rare neurodegenerative disorder of the esophagus characterized by dysmotility. Surgical repair consists of esophagomyotomy, often in conjunction with a reflux-reducing procedure. Given the rarity of this surgery in the pediatric population, we sought to determine which surgical techniques and studies are being performed for the surgical treatment of pediatric achalasia.

Methods: Data of surgeon workup and technique preferences treating esophageal achalasia were collected as part of a comprehensive online-based survey sent to members of the International Pediatric Endosurgery Group (IPEG).

Results: The survey was completed by 191 surgeons. Of the 191 surgeons polled, 141 perform esophagomyotomies for achalasia.The number of procedures performed per surgeon were; 1-2 (15%); 3-5 (34%); 6-10 (28%); 11-20 (15%); >20 (8%). The majority of responders approach the operation laparoscopically (90%) while robotic and open approaches were used with equal frequencies at 5% each. None of the surgeons employed peroral endoscopic myotomy. Work up prior to esophageal myotomy most frequently consisted of a diagnostic esophagram (94%) or manometry (73%). Only 60% required an EGD and few requested T cruzi studies.

No preference between circumferential, isolated anterior, or anterior and lateral division of the phrenoesophageal ligament for mobilization of the esophagus was demonstrated. Placement of anchoring sutures between the crus and esophagus after myotomy were performed equally. There was a predominant preference for hook cautery (68%) over harmonic shears (21%), ligasure (13%) and other devices (8%) for muscle division. Intraoperatively 57% had endoscopy and 50% had post operative esophagram prior to initiation of enteral feeding. Fundoplication accomplished by the Thal/Dor approach was performed most frequently (81%) followed by the Toupe (13%) and Nissen (3%). Five percent of patients did not obtain any type of fundoplication to prevent post operative GERD. Diet restrictons were provided in 76% of post-operative patients.

Conclusion: Given the relative infrequency of achalasia in the pediatric population, no established treatment protocol exists. Most existing recommendations are based on those established in the adult population. We have identified current practices as a first step in developing more standard, and ultimately more effective, treatment pathways.

63.03 Intaoperative Parathyroid Hormone Level: Factors Affecting the Drop

Posted on January 18, 2016

B. D. Graffree1, R. Martin1, A. Quillo1 1University Of Louisville School Of Medicine,Surgical Oncology/Surgery/Medicine,Louisville, KY, USA

Introduction: Parathyroid hormone (PTH) monitoring during minimally invasive parathyroidectomy (MIP) has become a staple in optimizing cure by confirmation of the removal of the hyperfunctioning parathyroid tissue. However, insufficient PTH drop within 10 minutes is noted in a number of patients. The aim of this study was to evaluate potential factors affecting the time period in which a fifty percent PTH drop is observed.

Methods: Patients included in this study were those who underwent MIP by a single surgeon between between December 2011 and April 2015 with a single parathyroid gland removed and by definition whose PTH values eventually dropped by 50% and to within normal range. This data was collected under IRB protocol after patient consent in a prospective clinical outcomes database. Patients were then grouped as follows: 1) 50% PTH drop at 10 min after gland excision 2) 50% drop at 15 min 3) 50% drop greater than 15 min. These groups were compared according to pre-operative PTH and calcium, age, glomerular filtration rate (GFR), and weight of adenoma. Statistical analysis was performed by Oneway Anova.

Results: A total of 88 patients fit the selection criteria. There were 62 (70%) patients that experienced a PTH drop at ten minutes; 18 (20%) patients with PTH drop at 15 minutes; and 9 (10%) patients with PTH drop greater than 15 minutes. Of the factors analyzed, statistical significance was only shown in the postoperative PTH values (p=0.001). However, patients with a 50% PTH drop at ten minutes displayed a higher mean GFR than the other groups. This difference approached statistical significance (p=0.0783).

Conclusion: Factors such as age, pre-operative PTH and calcium have no significant effect on the time required for a patients PTH to drop by 50%, indicating a successful operation. Because GFR was near statistical significance, it is plausible to consider GFR levels in deciding how long a surgeon should wait intra-operatively to draw PTH levels. Although postoperative PTH was shown to be statistically significant between the groups, there is very little use for this in recommendations for clinical protocol. Future study should involve a larger patient size in order to provide a more accurate assessment of factors that could cause this difference, if any.

63.04 Encapsulated FVPTC: Are these Tumors Really Benign?

Posted on January 18, 2016

Z. Aburjania3, D. Elfenbein4, E. Weinlander4, C. Montemayor5, R. Lloyd5, D. Schneider4, R. Sippel4, H. Chen3 3University Of Alabama,Department Of Surgery,Birmingham, Alabama, USA 4University Of Wisconsin,Department Of Surgery,Madison, WI, USA 5University Of Wisconsin,Pathology,Madison, WI, USA

Introduction: Follicular variant papillary thyroid cancer (FVPTC) is a well differentiated thyroid cancer thought to be slightly more aggressive than papillary thyroid cancer. Total thyroidectomy is the common treatment for FVPTC. However, recent studies suggest that the encapsulated form of FVPTC (eFVPTC), a subtype reported to behave more like a benign lesion, can be treated with thyroid lobectomy alone. The objective of this study was to determine if the eFVPTC behaves less aggressively than the non-encapsulated variant.

Methods: A prospectively collected endocrine surgery database was reviewed for all patients with either type of FVPTC on surgical pathology between 1999-2012. Histology was re-reviewed by a pathologist to determine if the FVPTC was encapsulated (eFVPTC) versus non-encapsulated (FVPTC).

Results:Of the 68 patients with FVPTC, 27(40%) had eFVPTC while the remaining 41(60%) had FVPTC. The mean age was 48 ± 1.8 years and 63% were female. Sixty-four (94%) underwent total thyroidectomy while the remaining patients had thyroid lobectomy alone. Fifty-four (84%) patients who had a total thyroidectomy received radioactive iodine. In comparing the groups, eFVPTC was more common in females than in males (49% vs. 24%, p=0.043). Five (7%) patients had cervical lymph node (LN) involvement, and the mean age of those patients was 34 ± 2.3 years compared with the patients without (vs 49.9 ± 6.8, p < 0.0001). The eFVPTC group had lower rates of cervical LN involvement (4% vs 10%, p=0.6411). Patients were followed for median of 3 years (range: 0-13). Recurrence occurred in only 2 patients: one with eFVPTC and one with FVPTC. None of the patients had distant metastasis and no patients died of their disease.

Conclusion: Encapsulated FVPTCs appear to have a lower rate of cervical lymph node metastases compared to non-encapsulated tumors, but recurrent disease may be seen in both subtypes of FVPTCs.

62.20 Challenges of Investigating a Learning Curve: Institutional Experience with High Resolution Anoscopy

Posted on January 18, 2016

A. Najafian1, E. B. Schneider1, E. C. Wick2, J. K. Canner1, J. Wolf2, S. H. Fang2 1Johns Hopkins University School Of Medicine,Johns Hopkins Surgery Center For Outcomes Research/ Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Division Of Colorectal Surgery/Department Of Surgery,,Baltimore, MD, USA

Introduction:
Learning curves have been widely used to evaluate the impact of training and experience on performance of a new procedure. However, there are many unmeasurable factors that may influence a learning curve. This study aimed to investigate an approach to the learning curve as an academic institution starts a high-resolution anoscopy (HRA) practice.

Methods:
Following IRB approval, a total of 161 HRAs performed on 103 patients by two surgeons over two years at an academic institution were retrospectively reviewed. The two colorectal surgeons had completed the American Society for Colposcopy and Cervical Pathology (ASCCP) approved colposcopy and HRA course. Anal pap smears were obtained concurrently with each HRA performed and the concordance of HRA and Pap smear was examined, based on both volume and duration of practice.

Results:
The mean age was 45.5 years (range 23-79) and 70 (68.0%) patients were male. Seventy-eight percent (80/103) of the patients were HIV (Human Immunodeficiency Virus)-positive and 11% (11/103) of the patients had CD4 counts less than 200. Fifty-three percent of all HRAs performed were positive for anal dysplasia in the presence of abnormal anal cytology. The concordance of anal cytology and HRA improved as case volume increased (from 60% to 67% for surgeon 1 [p=0.24], and from 70% to 75% for surgeon 2 [p=0.72]) (Fig-1-A). Similar results were seen after evaluating the learning curve based on the duration of practice (from 56% to 64% for surgeon 1 [p=0.37], and from 71% to 75% for surgeon 2 [p=0.97]) (Fig-1-B). Interestingly, the changes in concordance were not consistent over time for surgeon 1, who had a peak of 70% vs. a nadir of 35%.

Conclusion:
Although both surgeons demonstrated a non-statistically significant improvement in HRA-cytology concordance over time, the unusual learning curve pattern for surgeon 1 may hint to some challenges that might have impacted the learning curve, including lack of a gold standard for which to compare HRA results and multiple patient-related factors. In order to better evaluate the learning curve, we need to consider all these limitations and be able to control all the potential patient related factors that may impact the surgeon’s performance.

63.01 The consensus and controversial points of new IPMN guideline

Posted on January 18, 2016

H. Ito1, T. Ochiai1, S. Matsumura1, Y. Mitsunori1, A. Aihara1, D. Ban1, A. Kudo1, M. Tanabe1 1Tokyo Medical And Dental University,Heptobiliary And Pancreatic Surgery,Bunkyo-ku, Tokyo, Japan

Introduction:

International consensus guideline for management of Intraductal Papillary Mucinous Neoplasms (IPMN) was revised and published in 2012. Despite widespread acceptance of this guideline, the validity and problem have not been well-studied. We aim to evaluate the clinical utility of this new?guideline with our cases and make clear consensus and controversial points.

Methods:

This is a retrospective study of 105 patients who were consulted for IPMN from Jan 2006 to Oct 2014 at our department. Diagnosis was performed with dynamic enhanced CT and MRI. Pathological analyses were according to Who Classification of Tumours of the Digestive System 4th edition.

Results:

A total of 15 patients undergoing resection for IPMN with new guideline were identified from Apr2013 to Oct 2014. Of these, 11 patients had a component of MD/Mix-IPMN. Carcinoma was found in 5/11(45%) patients and the following were the details. Invasive carcinoma was found in 4/11(36%) patients and high grade dysplasia in 3/11(27%) patients. We present a case report with noninvasive carcinoma which grew 3mm to 8mm of main pancreatic duct with 16mm cyst at the pancreatic head for one year. Of these, 4 patients had a component of BD-IPMN. Invasive carcinoma was found in only one case with high risk stigmata of jaundice. Our previous study from Jan 2006 to Mar 2013 revealed that invasive carcinoma was found in 6/24(25%) patients and high grade dysplasia in 7/24(29%) patients with MD/Mix-IPMN. While, invasive carcinoma was found in 3/29(10%) patients and high grade dysplasia was found in 5/29(17%) patients with BD-IPMN. Next we investigated 37 patients who were continuously observed. 12 patients of these had a component of MD/Mix-IPMN including 2 cases with high-risk stigmata and 10 cases with worrisome features. The other 25 patients had a component of BD-IPMN including 7 cases with worrisome features. All these observing patients have no aggressive growth of tumor for about two years.

Conclusion:

It was consensus point new guideline made the surgical indication stricter compared to the old one. From now we tend to avoid surgical treatment for IPMN, so another predicting factor of malignancy should be considered through continuous observation.

63.02 Should Vitamin D Deficiency be Corrected Prior to Parathyroidectomy?

Posted on January 18, 2016

R. W. Randle1, C. J. Balentine1, E. Wendt1, D. F. Schneider1, H. Chen2, R. S. Sippel1 1University Of Wisconsin,Department Of Surgery,Madison, WI, USA 2University Of Alabama,Department Of Surgery,Birmingham, Alabama, USA

Introduction:

Vitamin D deficiency is common in patients presenting with hyperparathyroidism (HPT), but the importance of replacement prior to surgery is controversial. We aimed to evaluate the impact of low vitamin D on the extent of resection and post-operative hypocalcemia for patients undergoing parathyroidectomy for primary HPT.

Methods:

We identified patients with primary HPT undergoing parathyroid surgery between 2000 and 2015 using a prospectively maintained database. Patients with normal (30ng/mL or greater) vitamin D (25-OH) levels were compared to those with levels less than 30ng/mL.

Results:

The study included 1015 (54%) patients with normal vitamin D and 872 (46%) patients with low vitamin D undergoing parathyroidectomy for primary HPT. Lower vitamin D was associated with higher preoperative parathyroid hormone (PTH) compared to normal vitamin D (median 90 vs 77pg/mL, p<.001). Calcium (median 10.5 vs 10.4mg/dL, p<.001) was also higher while phosphate (median 2.8 vs 2.9mg/dL, p<.001) was lower in patients with low vitamin D, indicating more severe disease. Despite higher preoperative and baseline PTH levels in the low vitamin D group, 10 and 15 minute post-excision PTH was similar (Figure) resulting in a greater overall drop in PTH (median drop 78 vs 72%, p<.001) and similar post-operative calcium (median 9.3 vs 9.3mg/dL, p=.13) compared with the normal vitamin D group. A subgroup analysis in patients with severely low (≤10ng/mL) vitamin D (n=67) also revealed higher preoperative PTH, similar post-excision PTH, greater drop in PTH (median drop 81 vs 72%, p<.001), and similar post-operative calcium (median 9.3 vs 9.3, p=.39) compared to those with normal vitamin D. To achieve similar cure rates, patients with low vitamin D were less likely to require 4-gland exploration (19 vs 23%, p=.009), conversion from a focused approach to 4-gland exploration (11 vs 15%, p=.01), removal of more than 1 gland (20 vs 30%, p<.001), and subtotal parathyroidectomy (8 vs 12%, p=.003) than patients with normal vitamin D. Despite undergoing a more focused operation, patients with low vitamin D had similar rates of persistent (1.5 vs 2.0%, p=.43) and recurrent (1.7 vs 2.6%, p=.21) HPT. Also, at the time of parathyroidectomy both groups had equally low rates of both transient (2.3 vs 2.3%, p=.97) and permanent (0.2 vs 0.4%, p=.52) hypocalcemia.

Conclusion:

Restoring vitamin D in deficient patients should not delay the appropriate surgical treatment of primary HPT. Even though low vitamin D may be a marker for more severe primary HPT, deficient patients are more likely to be cured with the excision of a single adenoma and no more likely to suffer persistence, recurrence, or hypocalcemia than patients with normal vitamin D.

62.17 Virtual Reality Simulation for Residents: A Trainee Experience in Damage Control Endovascular Skills

Posted on January 18, 2016

W. Teeter1, M. L. Brenner1,2, M. R. Hoehn2, D. S. Stein1, T. Scalea1 1University Of Maryland,Division Of Trauma And Critical Care,Baltimore, MD, USA 2University Of Maryland,Division Of Vascular Surgery,Baltimore, MD, USA

BACKGROUND: The use of catheter-based techniques is increasing in the field of trauma. Virtual reality simulation (VRS) is a well-established means of endovascular skills training, and other simulation skills are now mandatory for board-eligibility in general surgery. Training for emerging endovascular damage control skills in trauma, including resuscitative endovascular balloon occlusion of the aorta (REBOA), may be obtained by residents through VRS.

Methods: Fifteen trainees in either an ACGME-approved General Surgery or Surgical Critical Care Fellowship at one institution received didactic and instructional sessions on REBOA. The subjects performed the procedure 6 times. Subjects were excluded if they had taken a similar endovascular training course, had post-graduate training in endovascular surgery, or had performed the procedure in the clinical setting. Performance metrics were measured on a Likert scale, and included procedural time; accurate placement of guide wire, sheath, and balloon; correct sequence of steps; economy of motion; and safe use of endovascular tools. A pre- and post-course test and questionnaire were completed by each subject.

Results: Fifteen subjects, with a mean PGY level of 4.9 years (SD±0.95) participated in the study. Significant improvements in knowledge (p < 0.0001, CI 95%), as assessed by a standardized exam, were observed at the completion of the course. Procedural task times significantly improved from a mean of 207 seconds (SD ± 19.9) to 107 seconds (SD ± 20.6)[(p < 0.0001, CI 95%] (Fig 1). No correlation was observed with endovascular experience in residency, number of endoluminal catheters placed per week, or other parameters. All trainees strongly agreed that the course was beneficial, and the majority would recommend this training to other trainees.

Conclusion: Damage control endovascular skills can be effectively acquired using VRS. Significant improvements in procedural time and knowledge can be achieved regardless of previous endovascular experience or area of training. Novice interventionalists such as surgical trainees can add a specific skill set (REBOA) to their existing core competencies. Use of this procedure in the clinical setting will determine if VRS for REBOA training confers validation metrics such as transfer of skills.

62.18 Surgical Resident Experience with Ethical Controversy

Posted on January 18, 2016

M. P. Kuncewitch1, J. M. Nicastro1, G. F. Coppa1, W. Doscher1 1North Shore University And Long Island Jewish Medical Center,Surgery,Manhasset, NY, USA

Introduction: Throughout surgical training residents may find themselves in situations in which they disagree with the clinical decision-making of the attending surgeon. We sought to survey the experiences and opinions of surgical residents of all PGY levels at our large surgical residency program with regard to moral and ethical controversy. Our purpose was to understand the frequency of such situations, what role residents believe they play in confronting them, and what recourse residents believe they have to address ethically controversial situations in

Methods: A survey was distributed to the 60 residents in our general surgery residency program. The survey asked our residents to anonymously respond to a questionnaire with 12 multiple-choice questions covering the incidence of ethically controversial situations as well as resident feelings towards these situations and any subsequent action taken by the resident. An additional question asked residents for their PGY year. At the close of the survey residents were given the opportunity to anonymously comment and extrapolate their experience.

Results:Forty-seven out of our 60 residents (78.3% responder rate) completed the survey. Sixty-six percent of residents reported at least one instance in which they faced a moral objection to an attending’s decision to operate (or refuse to operate) on a patient, while 48% reported taking part in intra-operative decision making that they felt clearly deviated from appropriate care. Sixty-one percent of residents said they felt comfortable raising concerns with an attending decision on moral or ethical grounds, however only 27% of residents felt assured that this would not result in any form of retaliation. Sixty-one percent of residents felt that at least half of their attending would be receptive to a resident voicing their patient-care decisions or moral or ethical grounds. A majority of residents (71%) felt that a senior resident was the most appropriate person to consult when they didn’t feel comfortable voicing their concerns with a particular attending.

Conclusion:Surgical residency training can challenge residents with difficult decision-making regarding patient care on both moral and ethical grounds. A majority of residents in our general surgery residency reported facing situations in which they disagreed with an attending on such grounds. Variability exists in how residents chose to respond and the comfort level with which they do so.

62.19 Does Operative Case Volume Affect Surgery In-Training Exam Scores?

Posted on January 18, 2016

C. S. Schoolfield1, G. Nightengale1, R. H. Kim1, N. Samra1, Q. Chu1, W. W. Zhang1, T. Tan1 1Louisiana State University Health Sciences Center,Shreveport, LA, USA

Introduction:
In the era of duty hour restrictions, there is a concern that increased time spent by residents in operative cases could lead to decreased time available for studying and therefore adversely impact their ABSITE scores. The objective of this study is to determine if a residents’ number of operative cases correlates with their American Board of Surgery In-Training Exam (ABSITE) scores and could be used as a predictor of future success.

Methods:
A retrospective review was performed on ABSITE scores and operative case logs from a university hospital-based general surgery residency program from 2008-2015. All preliminary and categorical residents were included. Excluded was any incomplete data or records. The data was grouped as a collaborative ABSITE percent correct score and then in groups who scored above and below the 30th percentile. The data was analyzed using linear regression analysis.

Results:
A total of 125 ABSITE scores from 29 residents were reviewed. The overall mean percent correct was 72.4%. Thirty nine scores were <30th percentile ranking with a mean percent correct score of 66.4%. Overall, there was no correlation between number of operative cases and ABSITE scores (R2=.005, p=.4). When those ≥30th percentile on the ABSITE were grouped together, there was a significant positive correlation in number of case logs and ABSITE scores (p=.02). When data was broken down to groups <30th percentile there was however not a significant correlation between case logs and ABSITE scores (p=.61).

Conclusion:
At an academic medical center, there was not significant correlation between general surgery residents’ operative case numbers and their ABSITE scores. An increase in operative cases, and therefore assumed increased time in the operating room, does not appear to have a negative effect on resident academic performance as measured by ABSITE scores.

62.14 Impact of Hepatopancreatobiliary and MIS Fellowships on General Surgery Resident Experience

Posted on January 18, 2016

R. M. Minter1, B. D. Schirmer2, R. Rosenthal3, M. Arregui4, L. Swanstrom5 1University Of Michigan,Surgery,Ann Arbor, MI, USA 2University Of Virginia,Surgery,Charlottesville, VA, Virgin Islands, U.S. 3Cleveland Clinic Florida,Surgery,Weston, FL, USA 4Nagan, Arregui, And Davis, MD Inc,Surgery,Indianapolis, IN, USA 5The Oregon Clinic,Surgery,Portland, OR, USA

Objective: Evaluate the impact of Fellowship Council(FC) accredited Hepatopancratobiliary(HPB) and Advanced GI Minimally Invasive Surgery(GIMIS) fellowships on General Surgery resident case experience.

Methods: HPB(n=12) and GIMIS(n=53) fellow case volume data were quantified in programs with affiliated residencies 2010-2012. Using ACGME chief resident defined category data for the residencies affiliated with these fellowships, liver and pancreas experience was quantified in programs with HPB fellowships, and basic laparoscopy, complex laparoscopy, upper endoscopy(UEND), and colonoscopy experience in programs with GIMIS fellows. Resident data were benchmarked against national standards.

Results: Data are derived from 12/16(75%) HPB and 53/60(88%) GIMIS FC accredited fellowships. Comparative data for resident performance in institutions with HPB and GIMIS fellowships are shown in the Table. Median UEND and colonoscopy volumes for 2010-12 were 43 and 54 for residents (national average 48.4 UEND; 65 colonoscopy), and 55 and 1 for GIMIS fellows.

Conclusions: HPB fellowships do not have a deleterious impact on affiliated General Surgery residents’ liver and pancreas experience, and resident endoscopy experience is not threatened by the presence of a GIMIS fellow. Resident case volumes in institutions with GIMIS fellows are comparable to the national average within the ACGME complex laparoscopy domain, but lower within the basic laparoscopy domain. As GIMIS fellows are performing few basic laparoscopic cases, this is most likely due to fewer cases being performed in these institutions versus fellow impact.

62.15 Back to Basics—The Importance of Enterostomal Therapy Education for General Surgery Residents

Posted on January 18, 2016

J. J. Tackett1, A. L. Fonseca1, W. E. Longo1 1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA

Introduction:
General surgery residents’ perceived knowledge base and comfort with intestinal stomas and enterostomal therapy are profiled in the results of a national survey.

Methods:
An anonymous survey was distributed to 734 U.S. general surgery residents through permission of their residency program directors. This anonymous survey explored the existence of formal didactics and training in ostomy creation and stomal care, examined residents’ perceived knowledge base of clinical indications for enterostomal care approaches, and elicited residents’ comfort with performing enterostomal surgeries and mitigating complications. Responses were recorded on a Likert scale. Chi squared test was applied when appropriate.

Results:
Surveys were distributed to 734 residents across the U.S. through their program directors. 218/734 respondents completed the survey (30%): 40% from the Northeast, 22% from the Midwest, 22% from the South, 16% from the West, and 82% with direct university affiliation. Only 12% of respondents stated that they had experienced formal enterostomal therapy training and only 15% had attended a lecture on the subject. Most respondents (86%) stated they routinely worked with enterostomal therapists during the care of patients with ostomies. Only 11% of graduating chiefs felt ‘very confident’ in their knowledge base of clinical indications for enterostomal care and just over half (61%) felt ‘very comfortable’ with the surgical procedures of ostomy creation and closure. Overall, a mere 6% of all residents felt ‘very comfortable’ dealing with common ostomy complications.

Conclusion:
In an era of surgical subspecialization and advanced nursing practice in enterostomal therapy, general surgery residents lack confidence in either their knowledge base or comfort when approaching enterostomal therapy and stomal complications. Resident education across the country should be reformed and formalized to enhance training in these principles that are essential to general surgery practice.

62.16 Trends in and barriers to medical students’ surgical education: a global survey

Posted on January 18, 2016

I. H. Marks3, M. Keem2, A. Diaz1, S. L. Seyedian4, G. S. Philipo9, I. Di Salvo7, H. Munir8, T. Pomerani6, N. Peter5, C. Lavy5 1Virginia Commonwealth University,School Of Medicine,Richmond, VA, USA 2University Of Melbourne,Melbourne, , Australia 3Barts And The London School Of Medicine And Dentistry,London, , United Kingdom 4Tehran University Of Medical Sciences,Student Scientific Research Center,,Tehran, , Iran 5University Of Oxford,Oxford, , United Kingdom 6University Of Florence,Florence, , Italy 7University Of Pavia,Lombardy, , Italy 8Allama Iqbal Medical College,Lahore, , Pakistan 9Mwananyamala Regional Referral Hospital,Mwananyamala, , Tanzania

Introduction: Approximately 5 billion people have no access to basic surgical care. The global burden of noncommunicable diseases and injury requiring surgical care has overtaken that of infectious disease, with conditions such as cancer, heart disease and diabetes, increasing dramatically in less-developed countries. Evidence suggest that barriers to accessing surgical care in low- and middle-income countries include difficulty accessing surgical services due to distance, poor roads, and lack of suitable transport; lack of local resources and expertise; and direct and indirect costs related to surgical care. What is less clear is what elements are responsible for influencing medical students in choosing a career in surgery. The goal of this study is to elucidate the reasons why medical students may or may not choose a career in surgery, identify common themes across different regions, genders and income strata.

Methods: In collaboration with the University of Oxford, we developed an electronic, multi-question survey to help elucidate the reasons why medical students may choose or discount surgical careers. Hosted on a web-based survey platform via the University of Oxford, the survey was distributed via multiple mailing lists as well as social media. The study was open to all medical students and was entirely anonymous and confidential.

Results: 499 medical students from 63 countries in six different regions including Africa, Asia, The Americas, Australasia, Eastern Mediterranean and Europe completed the survey (n=499), 43% (216) of which were male. 68%(339) of responders are considering a surgical career comprising 83% (192) female and 68% (147) male responders. Responses were analyzed both collectively and by region. Those from the East Mediterranean region were the most likely to be considering a career in surgery (81%) while those from Europe and Australasia was the least likely (67%). With the exception of Australasia, all regions disagreed with the statement that medical students had good access to undergraduate surgical education. The cost of postgraduate surgical training was expressed as a significant concern only in the African region. Over half the responders from Asia, Africa and the East Mediterranean agreed that surgeons in their countries dedicated the majority of their time to private sector patients. These regions were also the most likely to say that surgeons had poor access to resources. All regions except for Europe perceived surgeons to be overworked.

Conclusion: While the study is not yet adequately powered, trends in elements influencing medical students to choose a surgical career are appearing within our preliminary data. Whilst applications from female surgeons remain low in different regions globally, enthusiasm amongst female medical students appears to be high. Barriers to female students having successful surgical careers may therefore be more influential after completion of medical school.

62.11 Do Trends in Surgical Resident Case Volumes Justify Additional Oncology Fellowship Training?

Posted on January 18, 2016

A. A. Khan1, S. Desai1, J. Mellinger1, S. Ganai1 1Southern Illinois University School Of Medicine,Springfield, IL, USA

Introduction: Resident case volume and complement has changed over the past decade, possibly due to an increase in minimally-invasive procedures and duty hour reform. Subspecialty fellowship training in complex general surgical oncology has recently received approval for board certification and has been advocated as a pathway to improve proficiency in the performance of complex open oncologic cases in addition to providing comprehensive exposure to the multidisciplinary management of cancer. The purpose of this paper is to evaluate trends in resident exposure to complex oncologic cases.

Methods: A retrospective analysis of National Accreditation Council for Graduate Medical Education (ACGME) case log statistical reports from 2000-2013 was conducted to determine resident case volume for selected oncology-relevant procedures. Average yearly case numbers combining both Surgeon Chief and Surgeon Junior categories were analyzed as cases per graduating resident using linear regression assessing for temporal trends, with the null hypothesis assuming an estimated slope of zero. The Spearman rho test was used to estimate correlation of case trends over time.

Results:Linear regression trends for oncology-relevant procedures are summarized in the attached table. Decreasing trends were observed for major lymphadenectomies (rho -0.93, p<0.0001) and modified radical mastectomy (rho -0.86, p=0.007) during the study period. There was no significant change in exposure to total gastrectomy (rho +0.33, p=0.43) and esophagectomy (rho -0.60, p=0.03). An increasing exposure was noted for hepatopancreaticobiliary cases including major hepatic resection (rho +0.93, p <0.0001) and pancreatectomy (rho +0.93, p <0.0001).

Conclusion:While decreases were noted for exposure to soft tissue lymphadenectomy, there were no differences in foregut cases and an increase in hepatopancreaticobiliary cases. The overall case numbers for several of these complex oncologic procedures remain low, justifying a need for further fellowship training depending on independent resident experience.

62.12 Intraoperative Variation and Acquisition of Complex Operative Techniques: Pancreaticoduodenectomy

Posted on January 18, 2016

S. J. Davidson1, M. Rojnica2, A. J. Langerman2 1University Of Chicago,Pritzker School Of Medicine,Chicago, IL, USA 2University Of Chicago,Department Of Surgery,Chicago, IL, USA

Introduction:
Complex procedures often have numerous acceptable approaches; it is unclear how surgical fellows choose between these techniques. We used pancreaticoduodenectomy as a model procedure to catalogue the variability between surgeons within an affiliated health system and investigate the factors that affect fellow’s acquisition of techniques.

Methods:
Semi-structured interviews and operative note analysis were conducted to determine techniques of five attending surgeons, and these data were mapped to identify variations. Identical interviews and subsequent questioning were completed with four recent fellowship graduates whose current practice included pancreaticoduodenectomy.

Results:
All surgeons performed a different operation, both in order and techniques employed. Based on minor variations, there were actually 21 surgical step data points that differed – far more than previously recognized. Four of five surgeons were unable to identify colleagues’ techniques. Fellows reported that they were more likely to adopt techniques from mentors who had regimented techniques, teaching styles they related to, and with whom they frequently operated. Fellows did not feel residency training had a strong influence on their choice of technique, but did report a moderate influence from senior partners after fellowship.

Conclusion:

The true number of variants of pancreaticoduodenectomy based on granular, step-by-step difference is substantially larger than previously described. Results hint that variation may be furthered by the fact that surgeons may not be intimately aware of the techniques employed by colleagues. Interestingly, fellows appear to choose techniques based on factors not directly related to their own outcomes, but rather mentors’ techniques and teaching style. Whether fellows adopt the techniques that will be most optimal given their abilities is worthy of further investigation, as are changes in technique over time. Better codification of surgical variation is needed to facilitate these investigations as well as matching of technical variations to patient outcomes.

62.13 Comparison of Surgical Clerkship Performance between Medical and Physician Assistant Students

Posted on January 18, 2016

N. N. Alamiri1, C. M. Maliska1, H. Chancellor-Macintosh1, G. Sclabas1 1University Of Oklahoma Health Science Center,College Of Medicine In Tulsa – Department Of Surgery,Tulsa, OK, USA

Introduction:
Third year medical students (MS-III) and second year physician assistant students (PA-S) have similar core clinical rotations during their education. Uniquely at our institution, both groups rotate together and are assessed by the same evaluation and grading standards. This study compares the performance of MS-III and PA-S during their combined surgical clerkship rotation.

Methods:
A retrospective analysis on students’ final clerkship grades, individual grades for Clinical Performance Evaluation (CPE), Objective Structured Clinical Examination (OSCE), faculty tutorials, and National Board of Medical Education general surgery examination (NBME) for academic years 2013 and 2014.

Results:
A total of 95 students were included, 51 MS-III and 44 PA-S. Between both groups’ final grades and OSCE scores, there was no significant statistical difference (p > 0.05). However, MS-III as compared to PA-S had significantly higher CPE, NBME, and tutorial scores (p < 0.05). In comparing 2013 to 2014 MS-III classes, no significant difference existed, but the 2014 PA-S class had a significantly higher NBME and tutorial scores as compared to 2013 PA-S class.

Conclusion:
MS-III performed better in tests evaluating medical knowledge, possibly a reflection of a more intense basic science education MS-III receive. No significant difference in clinical performance was found. This could be attributed to similar clinical education both receive as well as PA-S often have a history of prior professional health care experience. Over the time of the study, PA- S basic science education seemed to improve.

62.09 Assessing Pre-Operative Communication Between Attendings and Residents

Posted on January 18, 2016

S. Sullivan1, J. Steiman1, C. Pugh1 1University Of Wisconsin,Madison, WI, USA

Introduction: The operating room (OR) has traditionally been a place of discovery learning. However, prior reports have shown that residents spend less than 15% of their total residency hours in the OR. Furthermore, use and development of new surgical devices and technologies limits residents’ participation in certain procedures as part of their general training. As such, the OR must increasingly become a place of active, focused learning with each experience. Effective communication should occur prior to the operation to identify learning needs. The goal of this study was to investigate pre-operative communication between attendings and residents.

Methods: Categorical surgery residents (n=20) completed a 39-item survey assessing the following related to operative preparation: 1) when they prepare and the amount of time they spend preparing, 2) what they focus on when preparing, 3) interaction with attendings before the operative case 4) resource use to prepare for the operation and 5) identification of perceived case weaknesses. A 5 point Likert scale was used, with 1= Hardly Ever and 5= Almost Always. In the sample, there were 12 males (60%), and the average age was 32. The majority of the residents (6) were in their program year (PGY) 1, with 4 in both PGY 2 and PGY 3, and 3 in both PGY4 and PGY5.

Results: All of the respondents (see Table 1) said that they usually prepare for operative cases. The majority of residents identify the critical steps of an operation prior to the case. Only a small percentage, however, review these with the attending with regularity, and 95% state they do not typically discuss who will perform these critical steps. Fourteen residents (70%) stated that discussion of personal educational goals prior to cases occurs infrequently. The majority of residents typically do not discuss what parts of the case they will do with the attending beforehand (85%). That being said, most residents reported hardly ever asking to do a certain part prior to operating and stated that weakness identification pre-operatively does not generally occur. Finally, only 30% of residents were largely satisfied with the amount of interaction with attendings prior to cases.

Conclusion: We have identified major deficits in communication between residents and attendings. Explicit communication is therefore needed to improve teaching and learning within the OR. Though patient centric, the OR is also a learning environment for surgical residents. Overall, residents would like more opportunities for pre-operative discussions with attendings. Potential targets for these discussions include residents’ case participation and personal educational goals.

62.10 Fate of Abstracts Presented at the 2009 American Transplant Congress and the 2007-2009 AHPBA

Posted on January 18, 2016

J. B. Durinka1, C. Ortiz2, T. Wenzel2, J. Ortiz2 1University Of Buffalo,Buffalo, NY, USA 2University Of Toledo,Surgery,Toledo, OH, USA

Introduction: Oral and poster presentations at major meetings serve to rapidly present and share study results with the scientific community. On the other hand, full-text publication of abstracts in peer-reviewed journals provides dissemination of knowledge. The purpose of this study was to evaluate the publication rate of abstracts presented at the 2009 American Transplant Congress (ATC), and the annual Americas Hepato-Pancreato-Biliary Association (AHPBA) from 2007-2009 to assess the factors influencing publication and determine the impact factor of these journals.

Methods: All abstracts presented at the 2009 ATC and 2007-2009 ABPBA were included in the study. A Pubmed-Medline search was performed to identify a matching journal article. Topics, country of origin, study type, study center and publication year were tabulated. Journals and impact factors of publication were noted.

Results: Out of 2568 abstracts presented, (474)18% were published as full-text articles. Publication rates according to topics of the meeting and country of origin did demonstrate statistical significant differences (p-value<0.05). Single-centered studies had higher publication rates 70.87% (160/190) than multi-centered studies among oral abstracts. Abstracts from multi-centered studies had higher publication rates among poster abstracts (68.09% vs. 31.91%), and the journals they were published in had higher impact factors than single center studies (4.578 vs. 3.897). The median impact factor of the journals was 4.2 (4.8 for oral presentations and 3.627 for poster presentations) that went on to be published as full text manuscripts. When comparing multi-center and single institutions, the difference between 12 month and 24 month publication rates was not statistically significant (p=0.5443 and 0.1134). However, oral and poster abstracts published by study center (multi/single) did demonstrate a statistically significant difference (p < .0001); comparing the type of study, there was also a statistically significant difference between the oral and poster abstract (p < .0001).

Conclusion: Eighteen percent of abstracts presented at both meetings went on to full text publication. The publication rate for these abstracts presented at both meetings was lower than rates from other fields of medicine. Factors leading to failure require elucidation. Encouraging authors to submit their presentations for full-text publication might improve the rate of publication. Authors should be wary of accepting oral and poster abstracts as dogma; authors should refrain from citing them in publications especially if they are from outside United States.

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