57.06 Perceptions of Inappropriate Behavior Among Surgeons and Students Influences Career Choice

Posted on January 26, 2017

J. L. Lazarus2, A. Gibson1, S. Campbell1  1Texas Tech Univeristy Health Science Center,Lubbock, TX, USA 2University Of Michigan,Ann Arbor, MI, USA

Introduction:
Demand for surgeons is increasing and expected to continue.  Though the number of general surgery residency positions has increased accordingly, the number of applicants has not proportionally increased.   Few have investigated the perceptions and behavioral dynamics of medical students and their mentors in regards to student career choice.  Increasing awareness regarding inappropriate behavior of physicians and trainees has led to professionalism included as a core competency in surgical training.  Since perceptions involve cultural and generational differences and are integral in interpersonal relationships, we hypothesize that perceptions of inappropriate behavior vary among medical students and attending surgeons subsequently directing students’ career paths.

Methods:
Medical students were given an evaluation twice during their surgery clerkship: at midpoint and rotation end. From a list, students were asked to select which behaviors they thought were appropriate or inappropriate.  Some behaviors included raising one’s voice, making sexual comments, and using foul language. Students were also asked if they had witnessed or experienced any of these behaviors at the end of the clerkship. Half of the participant’s evaluations were paired from mid to endpoint and specialty choice assessed. Seven attending surgeons participated in a separate survey and selected from a similar list of behaviors and rated them on appropriateness.

Results:
We first investigated whether the students and attending surgeons agreed on what they perceived as inappropriate behavior.  No behavior was completely agreed upon by either group. The following behavior had at least a 20% disparity among groups: use of foul language, ignoring someone, raising one's voice and making sexual comments. We then investigated any change in student’s perception of inappropriate behavior during the clerkship.   Interestingly, most students’ perceptions regarding at least one behavior changed from midpoint compared to the end of the rotation.  Of 41 students, 16 witnessed or experienced behavior they thought was inappropriate.  Three of these 16 students were considering surgery as a specialty at midpoint.  One of these three changed to a non-surgical specialty at the end of the rotation secondary these experiences. 

Conclusion:
Perception of inappropriate behavior varies among individuals, not only between students themselves, but between students and attending surgeons.  Since most students changed their perceptions during the rotation, we can conclude perceptions may be influenced by the interactions during the clerkship itself. Furthermore, witnessing or experiencing perceived inappropriate behavior leads to an undesirable learning environment.  Specific core professionalism training for both attending surgeons and medical students is necessary to ensure an inspiring learning environment fostering positive attitudes towards surgical careers.
 

57.05 Assessment of Desired and Actual Student Procedural Competence Over Time

Posted on January 26, 2017

C. Becker1, M. Meyers1  1University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA

Introduction:   Curriculum guidelines for medical students have changed in recent years associated with American Association of Medical Colleges guidelines published in 2014 deemphasizing procedural skill acquisition.  As such, the average student finishes their training with less procedural experience than in generations past.  We sought to examine whether student opinion has changed over time with regard to their desires for skill acquisition.     

Methods:   Under IRB approval, we conducted a survey of 4th year students over a six-year period (2011-2016) at a single medical school.  Experience, actual and desired levels of competence were measured for nine procedural skills (Table) using a 4-point Likert scale (1=unable to perform; 2= major assistance; 3= minor assistance; 4=independent). Data were compared by Student’s t test.

Results:  134 students (62 men/70 women) responded in 2011 (86% response rate(rr)) and 96 (59 men/37 women) in 2016 (56% response rate).  More students in 2011 were destined for a procedural specialty (57% vs. 28%; p=0.005).  For all skills, there was no difference in the students perceived level of actual competence between 2011 and 2016 except for arterial puncture. (Table) Similarly, for all skills except venipuncture, there was no difference in the desired level of competence between the two years. (Table) In both years, 2016, there was a significant difference between desired and actual competence for all skills (table).   

Conclusion:  No difference in either actual or desired competence was seen between 4th year students over a six year period of time for these nine skills, despite changes in recommendations from the AAMC minimizing expectations for graduating students.  Students in both years desired a significantly greater level of competence than they acquired.  Future recommendations should take into account student desires in evaluating curriculum changes.    

 

57.04 Competitive Advantage of MBA for Physician-Executives: A Systematic Literature Review

Posted on January 26, 2017

A. D. Turner1, S. Stawicki2, W. Guo1  1State University Of New York At Buffalo,Surgery,Buffalo, NY, USA 2St Luke’s University Health Network,Surgery,Bethlehem, PA, USA

Introduction:
In response to systemic challenges facing the U.S. healthcare system, many medical students, residents and practice physicians are pursuing a business degree. One of the most popular options among U.S. trainees is the pursuit of the Master of Business Administration (MBA) or equivalent diploma. The value of such proposition remains poorly defined, with substantial financial and time commitments added to the already expensive and lengthy medical training. The aim of this review is to analyze current literature pertaining to the added value of MBA training for physician-executives (PE). We hypothesized that skills gained by those who supplement their clinical experience with business education provide a significant competitive advantage. 

Methods:
A detailed literature search of four electronic databases (PubMed, SCOPUS, ERIC, and Embase) was carried out. Included were studies published between Jan 2000 – July 2016, focusing specifically on PE. Out of 1,580 non-duplicative titles, we identified 26 relevant articles. Attributes which were found to add value to one’s competitiveness as PE were recorded. A quality index score was assigned to each article in order to minimize bias. Results were tabulated by attributes and by publication.

Results:
We found that competitive advantages deemed to be most important for PE’s in the context of MBA training were leadership (n=19), career advancement opportunities (n=14), and understanding of financial aspects of medicine (n=11).  Among other prominent factors associated with the desire to engage in business education were awareness of public health issues/strategy, increased team building skills, higher salary/income, increased negotiation skills, improvement in work-life balance achieved. Of interest, acquired strategies for reducing malpractice litigation did not appear to be as important as the above-mentioned primary drivers. See Figure 1 for detailed depiction of these results.

Conclusion:
This comprehensive systematic review confirms our hypothesis that a business degree confers a competitive advantage for PEs. It identifies that leadership, career advancement and understanding of finance in medical practice are among the added values of pursuing a business degree for our future PE’s. This Information gained from this review may be beneficial to medical schools designing or implementing combined dual degree curricula. Effective physician executives equipped with a business degree represent a unique and highly valued group that collectively holds the promise of reshaping the landscape of our ailing healthcare systems, many of which await well-rounded, knowledgeable, clinically-trained leaders.
 

57.03 Gender Differences in Academic Surgery Work-Life Balance and Satisfaction

Posted on January 26, 2017

D. Baptiste1, A. M. Fecher1, J. Yoder3, C. M. Schmidt1, M. E. Couch2, D. P. Ceppa1,3  1Indiana University School Of Medicine,Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Otolaryngology, Head & Neck Surgery,Indianapolis, IN, USA 3Indiana University School Of Medicine,Center For Outcomes Research In Surgery,Indianapolis, IN, USA

Introduction: An increasing number of women are pursuing a career in surgery. Concurrently, the percentage of surgeons in dual-profession partnerships is increasing. We sought to evaluate the gender differences in professional advancement, work-life balance and satisfaction at a large academic center.

Methods: All surgical residents, clinical fellows and faculty in the Departments of Surgery, Neurosurgery, Ophthalmology, Orthopedic Surgery, Otolaryngology, and Urology at a single academic medical center were surveyed. The variables collected included gender, academic rank, academic productivity, marital status, family size, division of household responsibilities, and career satisfaction. Student’s t-tests, Fisher’s exact, and Chi-square were used to compare results.

Results: There were 127 faculty and 116 trainee respondents (>80% response rate). Respondents were mostly male (58% of trainees, 77% of faculty, p=0.002); 66% of trainees and 87% of faculty (p=<0.001) were married or in a committed relationship. The proportion of female surgeons increased across the generations (p=0.002), as did the percentage of surgeons in dual-profession partnerships (p=0.03). Women were more likely than men to be married to a professional (80% vs. 37%, p<0.001 for faculty; 82% vs. 42% p=0.001 for trainees). Women were also more likely to have a spouse employed in a full time position (p<0.001). Women were less likely to be on tenure track (p=0.002); there was no difference in academic rank (p=0.09) Female surgeons were less likely to have children (p<0.001) or more likely to have delayed child bearing (p=0.04), and more likely to have younger children (p<0.001). Women faculty compared to male faculty were more likely to be primarily responsible for childcare planning (p<0.001), meal planning (p<0.001), grocery shopping (p<0.001), and vacation planning (p=0.002). Gender neutral responsibilities included financial planning and monthly bill payment. Gender differences in division of household responsibilities were present in surgical trainees to a lesser degree. On a Likert scale, female surgeons scored lower satisfaction in personal life (p=0.02) and work life (p=0.002), but there was no statistically significant difference in the level of satisfaction with overall balance between faculty, trainees or genders.  Surgeons later in their career reported greater satisfaction than surgeons in training or in early/mid-career (p>0.002).

Conclusion: There are an increasing number of women pursuing a career in surgery. Despite equivalent responsibilities at work, women surgeons are more likely to be partnered with a full-time working spouse and to be primarily responsible for managing their households. Additional consideration for improvement in recruitment and retention strategies for this and the next generation of surgeons might address barriers to equalizing these gender disparities.

55.01 Does the Stapler Size Matter?

Posted on January 26, 2017

C. Shwaartz1, B. Cohen1, J. Leanza1, C. M. Divino1  1Icahn School Of Medicine At Mount Sinai,General Surgery,New York, NY, USA

Introduction:
A stapled anastomosis is commonly used during colorectal surgery for different indications. Stapled anastomoses have many advantages such as ease and speed of performance, potentially less manipulations of the anal canal, and more uniformity. The purpose of this study was to determine whether stapler size used at colorectal anastomosis affects outcomes.

Methods: This is a retrospective review of 230 patients that underwent colorectal anastomosis with the use of circular stapler between October 2013 and April 2016 at The Mount Sinai Hospital. Patients were divided into two groups based on size of the circular stapler (stapler size 25-29 mm vs 31-33 mm). Preoperative and postoperative factors including outcomes such as stricture, anastomotic leak, and functional outcomes such as the number of bowel movements per day, and incontinence were recorded and compared between the two groups.  A multivariate statistical analysis was carried out to assess the associations between the stapler size and the outcomes. Patients were then called for follow up in order to assess for functional outcome using the Wexner score along with other measures.

Results:

 230 patients who underwent rectal surgery were identified. 72.2% had an anastomosis performed using a 25 – 29mm circular stapler while 27.8% used a 31 – 33mm stapler. Both groups were comparable in regard to age, sex, comorbidities, smoking history, recent use of immune modulating medications or chemoradiation, procedure, indication, and the presence of bowel diversion. Those in the large stapler group were more likely to have an ASA of 3-5 vs 1-2 (P=0.05), they had a longer mean hospital stay (P=0.04) and those in the small stapler group were more likely to have a lower preoperative albumin (P=0.02). Multivariate analysis revealed that the stapler size did not predict the rate of anastomotic leak or stricture. Patients undergoing a low anterior resection with a colorectal anastomosis, compared to an anterior resection/sigmoidectomy, was significantly associated with anastomotic leaks. Additionally, the presence of bowel diversion significantly predicted stricture formation.
Regarding functional outcomes and quality of life, there was no difference found between the small and large stapler groups concerning number of bowel movements per day, presence of urgency, incontinence, pad use, clustering, need for constipating agents, any change in lifestyle reported, and mean Wexner score. Additionally, functional outcomes did not significantly differ between those asked within 1 year of bowel continuity and those who were asked after 1 year. 

Conclusion:
Different stapler sizes used in rectal surgery are not associated with long term outcomes.

 

47.19 Analysis of Online Fundraising for Pediatric Oncology Patients Using Crowdfunding

Posted on January 26, 2017

I. Schulte4, H. Garrigan3, S. Romo3, P. H. Chang1,2  1University Of Cincinnati,Surgery,Cincinnati, OH, USA 2Shriners Hospitals For Children-Cincinnati,Cincinnati, OH, USA 3Shriners Hospitals For Children-Boston,Boston, MA, USA 4Northeastern University,Boston, MA, USA

Introduction:

Due to the high cost of pediatric oncology care, many people have turned to online fundraising campaign websites, such as GoFundMe.com, to raise additional funds. These websites can be utilized to share the child’s story and recruit donors.  Our group had performed a previous analysis of burn patients on GoFundMe.org and had found several variables that were correlated with increased fundraising using GoFundMe.org.  This study aims to analyze the characteristics assoicated with increased fundraising for pediatric oncology patients on GoFundMe.org.

Methods:
Fifty profiles featuring pediatric oncology patients were accessed via GoFundMe.com. These profiles requested funds for a variety of medical expenses, such as for travel and the cost of dietary supplements for infants. Campaign characteristics such as age, diagnosis, date the fundraiser was posted online, amount of money raised, fundraising goal, and number of donators, Facebook shares, and updates were collected. Simple descriptive statistics were performed.

Results:
Across the 50 profiles, 27 (54%) featured males and 23 featured females (46%). The children featured ranged from ages 3 months to 18 years and were from either the United States or Canada. On average, profiles raised 42% of their goal (range 1.02-115.51%). The fundraising goals ranged from $1,000-100,000, and the average amount raised per day was $13.61 (+$16.05). The average amount raised per Facebook share was $16.21 (+$22.05) and the average Facebook shares per donor recruited was 12.76 (+$11.87) shares. 

Conclusion:
Given the increasing popularity of crowdfunding over the past few years, families of pediatric oncology patients have begun to use crowdsource funding websites to effectively pay for the expenses surrounding pediatric cancer treatment. While some profiles are created by family members, there were some instances where friends or coworkers of the parent started the GoFundMe profile. As seen in this study, these profiles have the potential to raise thousands of dollars by hundreds of independent donors. Understanding factors that lead to successful crowdfunding profiles can help guide future pediatric cancer patients in designing and distributing online campaigns.
 

47.16 Fulminant Clostridium difficile colitis in children: A disease of surgical relevance?

Posted on January 26, 2017

R. B. Interiano1,2, J. Wolf4,5, S. Arnold4, R. F. Williams1,2  1University Of Tennessee Health Science Center,Surgery,Memphis, TN, USA 2St. Jude Children’s Research Hospital,Surgery,Memphis, TN, USA 4University Of Tennessee Health Science Center,Infectious Diseases,Memphis, TN, USA 5St. Jude Children’s Research Hospital,Infectious Diseases,Memphis, TN, USA

Introduction: Clostridium difficile colitis is a common cause of antibiotic-associated diarrhea, with an increased incidence in adults and children over the past two decades.  While colectomy is associated with an increase in mortality in adults, little data exists as to the age-related outcomes for surgery in children with severe C. difficile infections (CDI).

Methods: Laboratory results, surgical interventions, and pathology reports were reviewed for all patients with a positive laboratory result for C. difficile at our two institutions from January 2003 to December 2012.  Thirty-day mortality was evaluated to assess whether the CDI had contributed to the demise of those patients.

Results: Six-hundred fourteen patients with positive laboratory results were identified at a primarily pediatric oncologic research hospital, while 448 patients were identified at an urban level 1 pediatric hospital.  Of these patients, no patients were found to have died within 30 days from the positive test as a result of the infection as assessed by clinical notes and autopsy results when available.  No patients in this study cohort required bowel resection or colectomy as a result of CDI.  Two patients were identified who required exploration – both for ascites causing respiratory insufficiency.  While the colon was noted to be either dilated or inflamed, neither patient required a bowel resection.

Conclusion: Fulminant CDI is a disease associated with a high mortality in the adult population, while the rate of fulminant disease requiring resection appears to be much lower in children.  Efforts to predict which pediatric patients may benefit from any surgical intervention may be hindered by the paucity in cases identified.

 

47.13 Giant Parathyroid Adenoma – Friend or Foe?

Posted on January 26, 2017

D. J. Goldberg1, J. Monchik1, T. Cotton1  1Brown University School Of Medicine,General Surgery,Providence, RI, USA

Introduction:

Giant parathyroid adenomas are poorly defined in the literature. There is limited data regarding preoperative localization and the incidence of multiglandular disease. The purpose of this study is to determine the utility of preoperative localization using ultrasound and sestamibi, as well as the incidence of multiglandular disease, in patients with a giant parathyroid adenoma.

Methods:

A retrospective review identified 870 patients who underwent surgery for primary hyperparathyroidism (PHPT) from January 2003 to September 2013.  A giant parathyroid adenoma, defined as a single gland with a weight >2 grams, was identified in 78 patients. Seven hundred ninety-two patients had adenomas <2 grams and were placed in the non-giant adenoma group.  All patients underwent ultrasound and sestamibi for preoperative localization.  Ultrasound and sestamibi results were compared with operative findings. The criteria for completion of surgery was an intraoperative parathyroid hormone fall of 50% from the highest level and into the normal range 10 minutes following parathyroid gland resection. Accuracy of various localization techniques, as well as the incidence of multiglandular disease, was then compared between groups.

Results:

In the giant adenoma group (>2 grams), surgery identified a single adenoma in 70/78 patients (89.7%) and double adenoma in 8/78 (10.3%).  There was no incidence of four gland hyperplasia.  In the non-giant adenoma group, surgery identified a single adenoma in 683/792 patients (86.2%), double adenoma in 88/792 (11.1%), and 4 gland hyperplasia in 21/792 (2.7%).  Giant adenomas were correctly localized by ultrasound in 60/78 patients (77%) compared to the non-giant adenoma group with 518/780 patients (66%, p=0.07).  Giant adenomas were correctly localized by sestamibi in 72/78 patients (92%) compared to the non-giant adenoma group with localization of 618/785 patients (79%, p=0.002).  Within the giant adenoma group alone, sestamibi was significantly more accurate at localizing the giant adenoma when compared with ultrasound (92% vs 77%, p=0.01).  Of the 8 patients with a double adenoma in the giant adenoma group, 4/8 (50%) correctly localized one of the two adenomas by ultrasound compared to 7/8 (88%) with sestamibi (p=0.28).

Conclusion:

Giant parathyroid adenomas are reasonably common, occurring in 9% of parathyroidectomies for PHPT over a 10 year period.  While 10.3% of giant adenoma patients had a double adenoma, none had four gland hyperplasia.  Patients with a giant adenoma localized better with sestamibi than ultrasound and were more likely to localize with either modality than patients with non-giant adenomas.  

 

47.05 Small Bowel Obstruction in Children

Posted on January 26, 2017

K. L. Weaver1, H. Alemayehu1, B. David1, S. D. St. Peter1, P. Aguayo1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction:
Small bowel obstruction (SBO) remains a significant source of morbidity and accounts for up to 16% of surgical admissions in the US. Despite this prevalence, literature relevant to the management of pediatric SBO is sparse. We reviewed our institutional experience to determine the etiologies, clinical course, management and outcomes of pediatric SBO.

Methods:
With IRB approval, we conducted a retrospective review of all patients <18yrs admitted for SBO from 2008 through 2013. Patients with a history of chronic obstruction, known intestinal dysmotility, colonic obstruction, neonatal SBO, or acute ileocolic intussusception were excluded. Patients with inflammatory bowel strictures were included only if they presented acutely. Both descriptive and comparative analysis was performed. All means reported ± standard deviation.

Results:
There were 156 patients with acute SBO during the study period; 73 male and 83 female. 42 children had 57 recurrent SBOs for a recurrence rate of 27% after a single episode of SBO.   Overall there were 213 episodes of SBO. The mean age at SBO was 8.1 ± 6.0 years. Overall 79% (n=169) underwent operative management. 69% (n=148) of the episodes of SBO had prior abdominal surgery, and 85% (n=126) were managed operatively; adhesions were the most common etiology (n=86). Mean time from previous operation to initial episode of SBO was 33.2 ± 46.1 months. Children without previous abdominal surgery had obstructions due to intestinal strictures (n=11), perforated appendicitis (n=8), Meckel’s Diverticulum (n=7), congenital adhesions (n=7), volvulus (n=1), and other causes (n=9).  Non-operative management with bowel rest and nasogastric tube decompression was attempted in 51% (n=108) of patients.  Non-operative management failed in 59% of these patients, 62% of which had adhesive bowel obstructions. Recurrent SBO after successful non-operative management was 39% which was higher than those who underwent operative management who had a recurrence rate of 19% (p=0.01). 

Conclusion:
Non-operative management of SBOs in children has a higher failure rate than reported in adults.  Further, those who succeed with conservative management have a higher rate of recurrence than those who undergo exploration.
 

45.14 Post Mastectomy Reconstruction Rates:The Effect of Tumor Grade and Radiation Therapy in Younger Women

Posted on January 26, 2017

K. G. Reddy2, P. D. Strassle2,3, K. P. McGuire1,2  1University Of North Carolina At Chapel Hill,Division Of Surgical Oncology,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA 3University Of North Carolina At Chapel Hill,Department Of Epidemiology,Chapel Hill, NC, USA

Introduction: Despite the well-documented psychological benefits and oncological safety of post mastectomy breast reconstruction (PMBR), most breast cancer patients do not undergo PMBR. To better understand patterns of PMBR use, it is important to examine the interactions between patient/cancer factors and rates of reconstruction in the breast cancer population. Our main objectives were to determine the following: if reconstruction rates vary across age, if cancer grade and radiation therapy are associated with breast reconstruction, and if the effects of cancer grade and radiation therapy vary across age. 

Methods:

Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified women ≥ 18 years old who underwent mastectomy for breast cancer diagnosed between 2000 and 2012. Women with inflammatory BC, Stage IV disease, and bilateral BC were excluded. Multivariable logistic regression, adjusting for clinicopathologic variables, was performed. Age was truncated at 30 (i.e. women ≤30 years old were considered 30 years old) and 90  due to small sample sizes in the tails, and modeled as a quadratic variable as determined by functional form assessment.

Results:

Overall, there were 161,255 women who met the inclusion criteria and 34,432 (21.4%) underwent PMBR.  Age was significantly associated with reconstruction, with younger women more likely to undergo PMBR (p<0.0001). Tumor grade and radiation therapy were both significantly associated with PMBR, p=0.05 and p<0.0001, respectively. The effects of tumor grade (p=0.0006.) and radiation ( p=0.001) were also significantly differential across age. Cancer grade only affected PMBR among women <50 years old, with higher grades being associated with increased PMBR. Similarly, while radiation affected PMBR in women <70, the effect was greatest among younger women and was associated with decreased PMBR.

Conclusion:

When compared to their older counterparts, younger breast cancer patients are more likely to undergo post mastectomy breast reconstruction, and have tumor grade and radiation be associated with reconstruction. Further study would be necessary to better elucidate how these factors affect  the clinical decision-making  process. 

45.07 Use of Exonal Mutation Analysis in Surgically-Treated Gastrointestinal Stromal Tumors

Posted on January 26, 2017

H. M. Dohnalek1,2,3, R. Acree1,2,3, D. Bihm1,2,3, K. Pulice1,2,3, H. Quadri1,2,3, N. G. Haddad1,2,3, L. B. Johnson1,2,3, J. Marshall1,2,3, W. Al-Refaie1,2,3  1Georgetown University Medical Center,Surgery,Washington, DC, USA 2MedStar Georgetown University Hospital,Surgery,Washington, DC, USA 3MedStar Georgetown Surgical Outcomes Research Center,Washington, DC, USA

Introduction:  While surgery remains the cornerstone treatment for Gastrointestinal stromal tumors (GIST), imatinib meselate has emerged as an effective targeted tyrosine kinase inhibitor in the adjuvant and advanced/ metastatic settings. Several clinically significant exonal mutations have been discovered in KIT and PDGFRA. Exonal mutational analysis (EMA) can identify such mutations and thus informs a patient’s prognosis and subsequent treatment strategies. Indeed, the National Comprehensive Cancer Network has recommended that patients undergo EMA following resection of high risk tumors (defined as per the Meittinen and Lasota criteria) or prior to initiation of TKI therapy in advanced or metastatic tumors. However, the use of EMA within a comprehensive cancer center remains unknown.  We hypothesize that use of exonal mutation analysis at our comprehensive cancer center is similar to that of published rates of 17.7% (Bischof et al. 2014). 

Methods:  An IRB-approved retrospective cohort study was performed on 59 patients who underwent surgical resection of pathologically-confirmed, biobanked and c-KIT positive GIST from 2006 through 2015. Patient’s electronic health records were accessed and information was then stored in a RedCap cloud-based database. To ensure data collection accuracy, two quality assurance evaluations of a 10% random selection of patients were performed. The NCCN guidelines based on the Meittinen and Lasota criteria for GIST risk stratification were used. 

Results: The most frequent location of GIST within our cohort was in the stomach (71.1%), followed by small bowel (20.3%), pancreas and biliary tract (6.8%) and large bowel (1.7%). Only 15% of our cohort were classified as high-risk tumors and 5% had metastatic or locally advanced tumors. Of our entire cohort of 59 patients, 15% underwent EMA. Only one third of high-risk and metastatic patients underwent EMA. The overall exonal mutational distributions were KIT exon 11 mutations in 78% and PDGFRA exon 18 mutations in 22%. Overall, the use of EMA has shown an increasing trend during the study period [Figure].

Conclusion: This hypothesis-generating exploratory study demonstrates uptake of EMA after resection of high-risk or advanced/metastatic GIST is relatively comparable to published rates. However, these rates are lower than guideline-recommended care. As personalized medicine becomes more common, further studies are needed to uncover reasons behind this low uptake while investigating its impact on outcomes and cost of care. 

 

45.03 OPRT as a Predictor of Benefit from S-1 Adjuvant Chemotherapy for Cholangiocarcinoma Patients

Posted on January 26, 2017

K. Akahoshi1, D. Ban1, R. Kuboki1, S. Matsumura1, Y. Mitsunori1, T. Ochiai1, A. Kudo1, M. Tanabe1  1Tokyo Medical And Dental University,Hepato-Biliary-Pancreatic Surgery,Bunkyo-ku, Tokyo, Japan

Introduction:  To improve the prognosis of cholangiocarcinoma, we investigated biomarkers that can contribute to select the patients who can take benefit from adjuvant chemotherapy after surgical resection.

Methods:  Of 170 consecutive patients who underwent surgical resection for cholangiocarcinoma between 2004 and 2015, 26 patients who received gemcitabine adjuvant chemotherapy (the GEM group), 36 patients who received S-1 adjuvant chemotherapy (the S-1 group) and 103 patients who didn’t receive adjuvant chemotherapy (the NC group) were enrolled in this study. Propensity score matching was performed to adjust for differences in patient characteristics, then 36 patients were selected from the NC group. Immunohistochemical analysis of orotate phosphoribosyltransferase (OPRT) and human equilibrative nucleoside transporter 1 (hENT1) was performed, and the correlation between the expression and cancer recurrence was analyzed.

Results: Before the propensity matching selection, the NC group was associated with higher prevalence of distal cholangiocarcinoma (p=0.03) and higher ASA score (p=0.03) than the GEM and the S-1 groups. After the matching, there were no differences among the GEM(n=26), S-1(n=36) and the NC(n=36) groups. Immunohistochemistry of resected tumor tissues was performed. Of the 98 patients, 46 and 52 showed high OPRT and hENT1 expression, respectively. Distal cholangiocarcinoma was more likely to exhibit high OPRT and hENT1 expression (p<0.01). Among high OPRT patients, the disease free survival(DFS) rates of the GEM, S-1, and NC groups at 5 years were 28.8%, 50.8% and 22.9%, respectively. The DFS of the S-1 group was significantly better than the NC group (p=0.037) and the DFS of the GEM group was similar to the NC group (p=0.85). On the other hand, among low OPRT patients, the DFS rates of the GEM, S-1, and NC groups at 5 years were 23.1%, 18.0% and 27.6%, respectively. There were no significant differences of the DFS among them. The same analysis was performed about hENT1. No significant improve of the DFS was observed by adjuvant chemotherapy in both high and low hENT1 expression patients. Multivariate analysis of all patients (n=98) determined that residual tumor (HR=2.533; 95% CI:1.548-4.144; p=0.001) and lymph node metastases (HR=1.708; 95% CI:1.031-2.830; p=0.038) were independent prognostic factors for cancer recurrence, whereas S-1 adjuvant chemotherapy wasn’t a prognostic factor. However, multivariate analysis of the high OPRT patients (n=46) determined that S-1 adjuvant chemotherapy (HR=0.309; 95% CI:0.120-0.796; p=0.015) and lymph node metastases (HR=2.594; 95% CI:1.099-6.121; p=0.030) were prognostic factors for recurrence.

Conclusion:

S-1 adjuvant chemotherapy for cholangiocarcinoma patients was effective to improve DFS only in the patients who exhibited high tumoral OPRT expression. OPRT is expected to contribute to the optimization and personalization of adjuvant chemotherapy for cholangiocarcinoma.

 

43.15 Impact of Prior Myocardial Infarction on Myocardial Recovery after Transcatheter Aortic Valve Replacement

Posted on January 25, 2017

A. Mantha2, N. Asthana3, G. Vorobiof3, P. Benharash1  1University Of California – Los Angeles,Cardiac Surgery,Los Angeles, CA, USA 2University Of California – Irvine,Orange, CA, USA 3University Of California – Los Angeles,Cardiology,Los Angeles, CA, USA

Introduction:  Transcatheter valve replacement (TAVR) is a definitive, minimally invasive treatment for patients with severe stenosis (AS) and has been shown to improve myocardial remodelling. However, it is unclear whether these changes occur in patients who have a history of myocardial infarction. This study sought to evaluate the impact of TAVR in patients who had previously suffered a myocardial infarction and have undergone PCI or CABG.

Methods:  A review of our prospectively-maintained institutional Society of Thoracic Surgeons database and Transcatheter valve Registry was performed to identify all patients undergoing TAVR from Jan. 2013- Mar. 2016. Chi-square test and regression were used to evaluate differences in patient demographics, readmission rate and length of stay. Repeated measures analysis of variance was used to compare myocardial strain and function among forty-two patients with speckle data through one-month follow-up. 

Results: Of the 172 patients included in the analysis, 62 (36%) had previously experienced a myocardial infarction. 22 (33%) underwent PCI alone, 18 (27%) underwent CABG alone and 9 (13%) underwent both PCI and CABG. Patients who underwent PCI alone had a significantly longer length of stay (7.2 vs 4.4 days, p<0.001) after TAVR and higher proportion of patients readmitted within 30 days (37%, p<0.01). Patients with history of MI had consistently lower magnitudes of strain in the septal (p<0.01), anterior (p<0.02), lateral (p<0.01), and inferior (p<0.01) ventricular walls despite having similar ventricular diameter (p=0.77) and septal thickness (p=0.82). Both cohorts demonstrated significant improvement in global longitudinal strain (-19.0 vs -16.0 in control, -17.1 vs -14.1 in MI, p<0.01) and interaction between history of MI and GLS was not significant.

Conclusion: Patients with history of myocardial infarction benefit similarly from TAVR as control patients with no history of MI despite having poorer pre-operative ventricular contractility. However, management strategy of infarction episode may have differential impact on tissue ischemia leading to increased length of stay and risk of readmission after TAVR.
 

41.18 Comparison of a Modern Cohort to Lund & Browder suggests that Burn Estimate Errors are Operator Error

Posted on January 25, 2017

W. C. Ray1, R. W. Rumpf1, A. Rajab1, S. K. Martinez2, C. G. Gerrard2, N. L. Adolphi2, R. Fabia1  1Nationwide Children’s Hospital,Columbus, OH, USA 2University Of New Mexico HSC,Radiology-Pathology Center For Forensic Imaging,Albuquerque, NM, USA

Introduction:

Effectively treating burns relies on rapidly and accurately assessing the total body surface area (TBSA) and the proportion of skin that was burned (TBSA-B).  Without accurate measurements of TBSA and TBSA-B, the efficacy of treatment is compromised, increasing the potential for medical complications.  As such the burn treatment community requires a rapid and accurate means of assessing the extent and severity of burns.  Unfortunately, even burn experts admit that most initial burn assessments, even those performed by experts themselves, frequently have significant errors.

Current methods for determining TBSA-B rely on tables of average body statistics such as the Lund and Browder tables.  Today’s pediatric population differs in both size and shape from the population used to derive these charts, and estimates based on historical models are assumed to deviate from today’s reality.  In addition to potential errors in the tables themselves, Lund and Browder and similar tables can be procedurally difficult to apply, relying on subjective and relative comparisons that result in significant deviations from the correct value even when the charts themselves are accurate.

Methods:

We initially hypothesized that the preponderance of errors seen in TBSA-B estimates using Lund and Browder were because the chart could not adequately represent a cohort taken from today’s pediatric population.  In order to test this hypothesis, we compared the zone percentages as described in the Lund and Browder chart to actual TBSA percentages as measured using CT scans of human cadavers.  Previous attempts at evaluating the accuracy of the Lund and Browder chart have been self-referential (e.g., comparing the results that different individuals achieve when applying the chart to the same test subject); to our knowledge this is the first study using an empirical approach to evaluating the chart by comparison to an external “gold standard” measurement of surface areas.

Results:

Unexpectedly, the actually-measured zone percentages were in reasonable agreement with Lund and Browder, even with subjects in the 1% tails of the BMI range. The largest deviation was 5.4%, significantly less than the error seen in real-world TBSA-B estimations.  It would appear that while today’s population is morphometrically different from that studied by Lund and Browder, their body-region proportions scale surprisingly well. 

Conclusion:

Our data indicates that, contrary to common assumption, the primary source of error in TBSA-B estimation is in the application of the Lund and Browder table rather than in the contents of the table.

 

41.15 AMD3100: Single-Dose Stem Cell Mobilizing Agent In Vascularized Composite Tissue Allografts In Canine

Posted on January 25, 2017

B. J. Swearingen1,2, S. S. Graves2,3, R. F. Storb2,3, D. W. Mathes1,2  1University Of Colorado Denver,Plastic And Reconstructive Surgery,Aurora, CO, USA 2Fred Hutchinson Cancer Research Center,Clinical Research Division,Seattle, WA, USA 3University Of Washington,School Of Medicine,Seattle, WA, USA

Introduction:
Vascularized Composite Allograft (VCA) transplantation is a clinical reality but limited by toxicities of chronic immunosuppression and rejection. Current clinical tolerance protocols rely on recipient conditioning and donor cell mobilization that limits use to living donor transplants. We sought to design a clinically relevant protocol applicable to cadaveric organs. We modified our existing non-myeloablative stem cell canine VCA transplant model to use AMD3100 (Plerixafor) for stem cell mobilization.

Methods:
5 DLA-haploidentical, related canine recipients [Group I] received conditioning with 350cGy TBI, AMD3100-mobilized donor stem cells and VCA transplantation with a short course of immunosuppression (MMF:56 days/CSP 70 days +/- taper). 4 DLA-haploidentical, related canine recipients [Group II] underwent identical conditioning plus an infusion of Bone Marrow (BM) Aspirate in addition to AMD3100. CD34+ hematopoietic progenitor cells were quantified via flow cytometry. Peripheral blood chimerism was evaluated by PCR techniques weekly. VCA graft survival was followed clinically and histologically.

Results:
All 9 canines tolerated the conditioning regimen. 4 [Group I] and 3 [Group II] were followed long-term. Stem cell engraftment and donor chimerism were seen in all dogs. Median COBE apheresis counts were 6.21×10^8 (Group I) and 3.08×10^8 (Group II) cells/kg, respectively. Bone Marrow aspirate counts were 1.47×10^8 cells/kg (Group II). No acute rejection nor evidence of GVHD was seen.  An unexpected finding of persistent thrombocytopenia that resolved on loss of donor cell chimerism seen in Group I led to addition of BM aspirate for Group II in an attempt to address this.

Conclusion:
This study demonstrates proof of principle for AMD3100 as a single-dose stem cell mobilizing agent for a clinically relevant tolerance protocol. Use of AMD3100 led to stem cell engraftment in all animals transplanted with no evidence of acute rejection in the VCA. Current application of AMD3100 is limited by thrombocytopenia that may be resolved with the addition of BM Aspirate.
 

41.13 Smartphone Camera Viability For Skin Tone Measurement

Posted on January 25, 2017

J. Butts1, R. Seelaus1, D. Morris1  1University Of Illinois At Chicago,Plastic Surgery,Chicago, IL, USA

Introduction:

Accurate color measurement is essential to the plastic surgeon desiring optimal aesthetic outcomes. Variability of human perception and environmental lighting conditions limit observation or swatch-based methods, leading to use of spectrophotometers as the gold-standard for accurate color matching.

Advances in smartphones camera technology and the utilization of device-independent color-spaces may provide an opportunity for replacement of spectrophotometers in resource-limited settings, without significant calibration or processing.

We investigated the utility of a consumer smartphone camera against a spectrophotometer for the evaluation of skin tones in a variety of illuminant environments.

Methods:

Silicone disks pigmented to match a representative skin sample from a fair-skinned subject were created using spectrophotometer measurements in standard fashion. Skin and disk samples were measured with the spectrophotometer and imaged with a smartphone under three illuminant conditions: D65 (simulated daylight), incandescent, and white fluorescent TL84.

Average pixel RGB values of each silicone and skin sample were calculated from each smartphone image. Samples were converted from sRGB to Lab color-spaces, and Euclidian distances (dE) were calculated between matched skin and silicone Lab samples.

Results:

A two-way one sided t-test was performed to assess equivalence between mean spectrophotometer and smartphone values. A magnitude threshold of 1.0 was chosen as a maximally-stringent, just noticeable difference in fair-skinned individuals.

Images taken under D65 were statistically equivalent to the spectrophotometer. Those under incandescent and fluorescent were not, with incandescent providing lower, and fluorescent higher, dE values.

Conclusion:

Equivalence between smartphone and spectrophotometer under simulated sunlight agrees with recommendations for indirect sunlight as an ideal condition for color matching. Although incandescent and fluorescent narrowly-missed equivalence, their precision suggests utility if measurements are taken in consistent lighting conditions or for applications with greater tolerances.

40.16 Expression of Phosphorylated Sphingosine Kinase 1 Is Associated with Invasiveness of Gastric Cancer

Posted on January 25, 2017

T. Hanyu1, H. Ichikawa1, T. Ishikawa1, S. Kosugi2, M. Nakajima1, J. Sakata1, T. Kobayashi1, H. Kameyama1, T. Wakai1, M. Nagahashi1  1Niigata University Graduate School Of Medical And Dental Sciences,Division Of Digestive And General Surgery,Niigata, NIIGATA, Japan 2Uonuma Institute Of Community Medicine Niigata University Medical And Dental Hospital,Department Of Digestive And General Surgery,Minami-Uonuma, NIIGATA, Japan

Introduction:

Sphingosine-1-phosphate (S1P), a pleiotropic bioactive lipid mediator, has been implicated as a key regulatory molecule in cancer through its ability to promote cell proliferation, migration, angiogenesis and lymphangiogenesis. Previous studies suggested that S1P produced by sphingosine kinase 1 (SphK1), which is activated by phosphorylation, plays important roles in progression of disease and metastasis. However, the associations between phospho-SphK1 (pSphK1) and clinical parameters in human gastric cancer have not been well investigated to date.

Methods:

We created pSphK1 expression profiles by immunohistochemical analysis for 136 patients, who underwent surgery for gastric cancer at Niigata University Medical and Dental Hospital between January 2007 and December 2009. pSphK1 expression and clinicopathological factors were compared by univariate and multivariate analyses.

Results:

The univariate analysis revealed that pSphK1 expression was significantly correlated with depth of tumor invasion (P = 0.022), lymph node metastasis (P = 0.040), distant metastasis (P = 0.042), histological differentiation (P = 0.048), and lymphatic invasion (P = 0.004). The multivariate analysis revealed that diffuse type (Odds ratio 2.169, 95% confidence interval 1.014–4.630, P = 0.046) and the presence of lymphatic invasion (Odds ratio 3.401, 95% confidence interval 1.451–8.000, P = 0.005) were independently associated with pSphK1 expression in patients with gastric cancer.

Conclusion:

Our results provide the first evidence that pSphK1 expression is associated with invasiveness of human gastric cancer, suggesting importance of S1P in patients with gastric cancer.

40.04 Detection of Tumor-Specific Mutations in Plasma DNA: A Potential Esophageal Adenocarcinoma Biomarker

Posted on January 25, 2017

M. Egyud1, J. Jackson1, E. Yamada1, A. Stahlberg1,2, P. Krzyzanowski3, V. Litle1, L. Stein3, T. Godfrey1  1Boston University School Of Medicine,Department Of Surgery,Boston, MA, USA 2University Of Gothenburg – Sahlgrenska Cancer Center,Department Of Pathology,Gothenburg, , Sweden 3Ontario Institute For Cancer Research,Toronto, ON, Canada

Introduction: Recent studies have shown that tumor-specific DNA from multiple types of tumors can be detected circulating in plasma and this has raised the possibility of “liquid biopsies” using mutated tumor DNA as a potential diagnostic and prognostic biomarker. Detection of mutations with allele frequencies below 0.1% remains challenging however given that circulating cell-free DNA is highly degraded and in low abundance.  Detection of multiple different mutations in the same sample presents an additional challenge particularly when the mutation panel may change from patient to patient. We have developed a novel approach, called SimSen-Seq, to introduce molecular barcodes into sequencing libraries with DNA inputs as low as 5ng. Barcodes enable differentiation of true mutants from background noise introduced by Taq polymerase errors and permits detection of variant alleles with frequencies below 0.1%. The barcodes are protected from mis-priming using a hairpin structure which permits a high degree of multiplexing and flexibility for detection of multiple mutations from one plasma sample.  We are using this technology to test the utility of liquid biopsy as a biomarker for esophageal adenocarcinoma (EAC) diagnosis and disease monitoring.

Methods: Blood samples were obtained at a single time point from patients with various stages of EAC and longitudinal blood samples were also collected from patients undergoing neoadjuvant therapy followed by surgery. Tumor samples were obtained from biopsy or resection specimens. Tumor DNA was sequenced using a targeted EAC panel to identify mutations in each tumor. SiMSen-Seq assays were designed to identify these mutations in plasma, and hairpin barcodes were attached. Sequencing libraries were generated from circulating DNA, sequenced and analyzed using the barcodes to reduce background noise.

Results: Mutations were identified in tumor samples from 32 patients. To date, 24 patients have had plasma analyzed; 4 stage I, 8 stage II, 9 stage III, and 3 stage IV. Of these 24, the same mutations have been identified in 11 plasma DNA samples (0% stage I, 50% stage II, 67% stage III, 100% stage IV. All mutant alleles were present at <1% frequency and five patients demonstrated multiple mutant alleles in plasma DNA.

Conclusion: SimSen-Seq shows promise as a novel ultra-sensitive, highly multiplexed sequencing method for identifying rare circulating mutations. Possible applications include prognostication in early stage patients and rapid monitoring of therapeutic response and recurrence. Further work is to evaluate this is ongoing.

 

39.07 Evaluation Of Parathyroid Glands With Indocyanine Green Fluorescence Angiography After Thyroidectomy

Posted on January 25, 2017

A. Rudin1, T. McKenzie1, G. B. Thompson1, D. Farley1, M. Richards1  1Mayo Clinic,Division Of General Surgery,Rochester, MN, USA

Introduction:
Hypoparathyroidism is the most common complication after a total or near-total thyroidectomy (T-NT).  Intraoperative evaluation of parathyroid viability has been limited to visual inspection. Parathyroid function has been confirmed with postoperative lab values.  Indocyanine green fluorescence angiography (ICGA) is a new adjunct that has been used in surgical procedures to assess blood flow.  This study evaluated the utility of ICGA compared to visual inspection to predict parathyroid function, guide auto-transplantation and potentially decrease permanent hypoparathyroidism.

Methods:
This was a single center retrospective study of patients who underwent T-NT between January 2015 and June 2016.  All patients were screened for hypercalcemia and those with hyperparathyroidism were excluded. Patients who had ICGA were compared to T-NT patients without ICGA. All patients had a PTH level on postoperative day 1.  Parathyroid blood supply was scored based on ICGA as none, intermediate or normal. Visual blood supply was either viable or non-viable. Glands with no ICGA uptake were auto-transplanted. Data was analyzed to assess the frequency of auto-transplantation and incidence of hypoparathyroidism between groups. ICGA was also compared to visual inspection of the parathyroid glands.

Results:
112 patients underwent T-NT, 25 with ICGA and 87 without. Auto-transplantation was more common in the ICGA group at 36% compared to 13% in the control (p=0.015). The mean postop day 1 PTH in the ICGA group was 22 vs. 21 in the control group (p= 0.30) (normal 15-65 pg/ml). 22 out of 25 patients with intraoperative ICGA had at least one parathyroid gland with normal ICGA uptake, and 3 with intermediate update.  There was no correlation with postoperative PTH levels (p=1.0). 14 of 25 patients with intraoperative ICGA had at least two parathyroid glands with normal ICGA uptake, which correlated to postoperative PTH levels >=15 in 12 patients and PTH <15 in 2. There was no difference when compared to patients with less than 2 normal ICGA glands (n=11, p=0.08)(note: <2 normal includes patients with ICGA intermediate glands). There were 83 parathyroid glands identified in the ICGA group. Visual and ICGA assessment of normal blood flow were 66/84(78%) and 52/84(61%) respectively. There were 8 glands (9%) that would have undergone auto-transplantation based on visual inspection that had adequate blood supply on ICGA. Hypoparathyroidism was present in 32 out of 87 controls (37.5%) and 8 out of 25 (32% in the ICG group).  No cases of permanent hypoparathyroidism were identified in either group.

Conclusion:

ICGA is a novel technique that may improve the assessment of parathyroid gland blood supply compared to visual inspection.  ICGA can guide more appropriate auto-transplantation without compromising postoperative parathyroid function. At least two vascularized glands on ICGA may predict postoperative parathyroid gland function.

 

38.10 Clinical Psychomotor Skills among Left and Right Handed Medical Students.

Posted on January 25, 2017

S. A. Alnassar1, S. A. Alnassar1  1University Of British Columbia,Vancouver, British Columbia, Canada

Introduction: There is a growing perception that the left handed (LH) medical students are facing difficulties while performing the clinical tasks that involve psychomotor skill, although the evidence is very limited and diverse. The present study aimed to evaluate the clinical psychomotor skills among Right-handed (RH) and left-handed (LH) medical students.

Methods: For this study, 54 (27 left handed and 27 right handed) first year medical students were selected. They were trained for different clinical psychomotor skills including suturing, laparoscopy, intravenous cannulation and urinary catheterization under the supervision of certified instructors. All students were evaluated for psychomotor skills by different instructors. The comparative performance of the students was measured by using a global rating scale, each selected criteria was allotted 5-points score with the total score of 25.

Results:There were no significant differences in the performance of psychomotor skills among LH and RH medical students. The global rating score obtained by medical students in suturing techniques was: LH 15.89±2.88, RH 16.15±2.75 (p=0.737), cannulation techniques LH 20.44±2.81, RH 20.70±2.56 (p=0.725), urinary catheterization LH 4.33±0.96 RH 4.11±1.05 (p=0.421). For laparoscopic skills total peg transfer time was shorter among LH medical students compared to RH medical students (LH 129.85±80.87 sec vs RH 135.52±104.81 sec) (p=0.825).  

Conclusion:
Among LH and RH medical students no significant difference was observed in performing the common surgical psychomotor skills. Surgical skills for LH or RH might not be a result of innate dexterity but rather the academic environment in which they are trained and assessed.  
 

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