38.04 Pluralistic Ignorance And Risk Of Attrition Among Residents.

Posted on January 25, 2017

R. Panni1, M. Laurel2, K. Nandagopal3, G. Cohen3, G. M. Walton3, A. Salles1  1Washington University,Surgery,St. Louis, MO, USA 2Washington University School Of Medicine,St. Louis, MO, USA 3Stanford University,Palo Alto, CA, USA

Introduction: Attrition continues to be a major problem in general surgery residencies with an estimated one out of five residents failing to complete training. While there are a number of reasons for this, here we examine one factor, pluralistic ignorance, and its relationship to risk of attrition among surgical residents. The difference between the perception of one's own experience compared to the experiences of those around them is termed pluralistic ignorance. For example, in academic contexts, it is common for people to think that those around them are faring better, whether that be with more success, better grades, or more happiness. This feeling is often more pronounced at times of transition. In this study, we hypothesized that those who experience greater degrees of pluralistic ignorance may be at greater risk for attrition.

Methods:  Junior residents in a single general surgery residency program were surveyed on a voluntary basis for two consecutive years (2011-2012 and 2012-2013). As part of a larger study, residents were administered a questionnaire which included measures of pluralistic ignorance with items such as the number of time per week they made any mistakes, felt down, felt bothered by blaming themselves for things, were satisfied with their performance. The participants were then asked the same questions about a typical resident in their program. We measured risk of attrition with two items, how frequently they thought about leaving residency and how likely they think it is that they will complete their current residency. We examined the correlations among these measures to see whether pluralistic ignorance was related to risk of attrition.

Results:

36 residents participated in the survey (43% response rate). We found that higher degrees of pluralistic ignorance were associated with more frequent thoughts of leaving residency (rs = 0.55, p=0.0006). The less pluralistic ignorance residents experienced, the more likely they were to intend to complete their residency (rs = -0.62, p<0.0001). Thus, pluralistic ignorance was significantly associated with these two measures of risk of attrition. In regression analyses controlling for gender and post-graduate year, pluralistic ignorance was significantly predictive of the frequency of thoughts of leaving residency (B=0.75, t=3.35, p=0.002) and intention to complete residency (B=-0.76, t=-3.25, p=0.003).

 

Conclusion:
To our knowledge, pluralistic ignorance has not been examined in the context of surgical residencies. Our data suggest that this may be a predictor of risk of attrition. Perhaps more importantly, pluralistic ignorance is modifiable. At the institution where this study was performed, each post graduate year group routinely meets with a psychologist. Residents thus have an opportunity to discuss their various struggles together and realize that others are having similar experiences. Interventions such as this may reduce pluralistic ignorance and potentially decrease the risk of attrition.

33.06 Late Relative Lymphopenia is Associated with an Increased Infection Rate in Pediatric Burn Patients

Posted on January 25, 2017

Z. Diltz3,4, R. A. Devine4, K. Wheeler4, J. Shi4, H. Xiang4, R. Fabia1,5, M. W. Hall2,4,6, R. K. Thakkar1,4,5  1Nationwide Children’s Hospital,Department Of Pediatric Surgery,Columbus, OH, USA 2Nationwide Children’s Hospital,Department Of Critical Care Medicine,Columbus, OH, USA 3Ohio State University,College Of Medicine,Columbus, OH, USA 4Nationwide Children’s Hospital,The Research Institute,Columbus, OH, USA 5Ohio State University,Department Of Surgery,Columbus, OH, USA 6Ohio State University,Division Of Pulmonary, Critical Care And Sleep Medicine,Columbus, OH, USA

Introduction:

Burn injury is estimated to be the fourth leading cause of death in children in the United States, according to the World Health Organization, and each year roughly 745,000 children under age 17 require medical attention for burn injuries.  These patients are at high risk for adverse outcomes including infectious complications which remain a leading cause of morbidity for burn patients.  Both increased (leukocytosis, neutrophilia) and decreased (lymphopenia) white blood cell (WBC) counts have been reported in this setting.

We designed a retrospective study to test the hypothesis that abnormalities in WBC counts that are present beyond the first two days of burn injury will be associated with increased nosocomial infection risk.  

Methods:
We used our institution’s trauma registry to identify patients aged 0-18 years old with burns of at least 10% total body surface area (TBSA) from 2005 to 2015.  Demographic data, mechanism of injury, and clinical outcomes including infections were collected and verified through chart review.  Complete blood counts with differentials were recorded through the first week of hospitalization following injury.  Abnormal WBC data were defined as high total WBC count (leukocytosis), high percentage of neutrophils (relative neutrophilia), or low percentage of lymphocytes (relative lymphopenia) according to age-based laboratory norms.  Late abnormalities were defined as those noted on post-burn days 3 – 7. Nosocomial infection was defined as a positive culture plus receipt of a full course of antibiotics. 

Results:

140 burn patients TBSA≥ 10% were identified during the study period. A higher percentage of patients had late relative lymphopenia (67.2%) than late leukocytosis (10.6%) or late neutrophilia (32.0%).  There were no significant differences in age or burn TBSA between subjects with and without late relative lymphopenia.  The group of patients with late relative lymphopenia had a significantly higher nosocomial infection rate (71.8%) than those with normal lymphocyte percentages on or after day 3 (42.1%) (p=0.0287).  This was not true for patients with late leukocytosis (p=0.34) or late relative neutrophilia (p=1.0).

After controlling for age, gender, mechanism of injury, and TBSA with multivariable logistic regression analysis, the adjusted odds of nosocomial infection were significantly lower in subjects without late relative lymphopenia (AOR = 0.18; 95% CI = 0.04-0.81).  Patients with late relative lymphopenia had longer mean hospital and ICU lengths of stay, but the differences were not statistically significant.

Conclusion:

Late relative lymphopenia following severe pediatric thermal injury is associated with the subsequent development of nosocomial infection even when controlling for burn size and other factors. This should be the subject of a future prospective study in a larger sample size. 

30.09 Stromal MZB1 is a Prognostic Factor of Pancreatic Cancer Resected After Chemoradiotherapy

Posted on January 25, 2017

K. Miyake1, R. Mori1, R. Matsuyama1, Y. Homma1, A. Okayama2, Y. Ota1, K. Taniguchi1, H. Hirano2, I. Endo1  2Yokohama City University,Graduate School Of Medical Life Science And Advanced Medical Research Center,Yokohama, KANAGAWA, Japan 1Yokohama City University,Department Of Gastroenterological Surgery,Yokohama, KANAGAWA, Japan

Introduction: Pancreatic ductal adenocarcinoma (PDAC) is classified to three types following the resectability in NCCN Guidelines, namely Resectable, Borderline resectable (BR), and Unresectable. BR cases invade to surrounding major arteries and/or vein. Therefore, it is not easy to achieve R0 resection by straightforward surgery. Recently, several studies have reported that NACRT for BR-PDAC improves prognosis and resectability, and eradicates micro metastases. Furthermore, it is presumed that NACRT induces antitumor immunity, and the accumulation of tumor infiltrating lymphocytes (TILs) correlate with prognosis. In our department, we have started clinical research of NACRT for BR-PDAC from Jan 2009. In fact, we have already reported that high CD8+ TILs might be a predictive marker of long survival for these cases. However, the feature of cases with high CD8+ TILs has not been clarified. In this study, we have performed proteomic analysis to reveal the predictive marker of high accumulation of CD8+ TILs.

Methods: We studied 72 resected BR-PDAC cases with NACRT from Jan 2009 to Mar 2014. Three matched pairs of high CD8+ TILs with good prognosis and low CD8+ TILs with poor prognosis cases were selected. Shotgun proteomics was performed using the cancerous part and tumor stroma which are extracted from formalin-fixed and paraffin-embedded tissue samples. For validation of identified proteins, immunohistochemistry (IHC) was performed. 44 PDAC cases with straight forward surgery from 2006 to 2014 were evaluated for comparison. Relationships between the identified proteins and NACRT, TILs, clinical outcomes were assessed by statistical analysis.

Results: 369 proteins were identified by shotgun proteomics, and there was statistic difference of expression in 6 proteins. From these candidates, we selected one protein; Marginal zone B and B1 cell specific protein (MZB1), which is known for B lineage cell specific protein. MZB1 expression were detected in only tumor stroma, and tumor cells were negative. IHC showed high expression of stromal MZB1 in long survival cases with high CD8+ TILs as with proteomic analysis. In the NACRT group (n=72), high expression of stromal MZB1 was positively correlated with the accumulation of CD8+ TILs (|R|=0.347, p=0.002). Patients with high accumulation of stromal MZB1 (?207) had a longer overall survival (OS) than others (3 year-survival; MZB1 high : low = 60.2% : 28.6%, p=0.014). Regarding the 36 patients with high CD8+ TILs in the NACRT group, there was statistic significant relationship between high expression of stromal MZB1 and OS (3 year-survival; MZB1 high : low = 72.9% : 42.9%, p=0.003). In straight forward group (n=44), there was no significant relationships between stromal MZB1 and accumulation of CD8+ TILs, or OS.

Conclusion: MZB1 might be a predictive marker of the high CD8+ TILs and long term survival of resected BR-PDAC cases after NACRT. Furthermore, MZB1 might have a promotive effect on anti-tumor immunity.

 

16.22 Intraoperative Parathyroid Identification Not Associated with Increased Permanent Hypoparathyroidism

Posted on January 25, 2017

J. Zagzag1, R. Rokosh1, K. S. Heller1, J. Ogilvie1, K. Patel1, A. Kundel1  1New York University School Of Medicine,New York, NY, USA

Introduction:  One major risk of total thyroidectomy is permanent hypoparathyroidism, and this risk may be increased if a central neck dissection is also performed.  This study was undertaken to evaluate whether identification of parathyroid glands intraoperatively during total thyroidectomy (TT) and total thyroidectomy with central neck dissection (TTCND) is related to inadvertent parathyroid gland excision in the final pathologic specimen.  We also assessed the effect of intraoperative and pathologic parathyroid identification on rates of permanent hypoparathyroidism.

Methods:  A retrospective review of all TT and TTCND performed by our endocrine surgery group between 2011 and 2015 was performed. Patients were stratified into two groups, those with 0-2 and those with 3-4 parathyroid glands identified intraoperatively. The presence of any parathyroid tissue in the final pathologic specimen was examined. Intraoperative and pathologic parathyroid identification was correlated with permanent hypoparathyroidism.  Chi-squared test was used for statistical significance.

Results: A total of 496 cases included 351 TT and 145 TTCND. At least 3 parathyroid glands were identified intraoperatively in 63% of cases. 37% of final specimens contained unexpected parathyroid glands. Intraoperative identification  of 3-4 parathyroid glands was inversely related to the number of parathyroid glands identified on pathology in TTCND but not TT (RR 0.34, 95%CI 0.17-0.69, p-value 0.003). Parathyroid gland identification intraoperatively had no relationship to rates of permanent hypoparathyroidism in either group (TT 2.2% vs 3.8%, p-value 0.721, TTCND 4.1% vs 0.0%, p-value 0.213). Parathyroid tissue on final pathology had no relation to rates of permanent hypoparathyroidism (3.3% vs 2.5%, p-value 0.138).

Conclusion: Intraoperative identification of parathyroid glands is associated with a lower incidence of unexpected parathyroid gland excision when performing a total thyroidectomy with central neck dissection. Total thyroidectomy with or without central neck dissection, when performed by experienced endocrine surgeons who routinely identify parathyroid glands, was not associated with increased rates of hypoparathyroidism when fewer than three parathyroid glands were identified intraoperatively or when parathyroid tissue was found on final pathology. The identification of parathyroid glands intraoperatively did not result in permanent hypoparathyroidism.

 

16.17 Defining Intrinsic Operative Risk Separate from Patient Factors for Preoperative Evaluations

Posted on January 25, 2017

J. B. Liu1,4, Y. Liu1, M. E. Cohen1, C. Y. Ko1,3, K. Y. Bilimoria1,2, B. J. Sweitzer2  1American College Of Surgeons,Chicago, IL, USA 2Northwestern University,Chicago, IL, USA 3University Of California – Los Angeles,Los Angeles, CA, USA 4University Of Chicago,Chicago, IL, USA

Introduction:

Surgical-patient care is enhanced by multidisciplinary co-management. While accurate understanding of perioperative risks are a necessary component of care management, this is dependent on both procedure-intrinsic and patient-specific risk factors, both of which can be challenging to assess and to effectively share with non-surgeons. To improve interdisciplinary communication, we sought to describe intrinsic and patient risks for common operations.

Methods:

3,631,160 patients encompassing 2,010 Common Procedural Terminology (CPT) codes between 2010-2015 from the ACS NSQIP database were identified. Hierarchical regression modeling was used to categorize each procedure based upon its risk of death or serious morbidity (DSM) into three (low, medium, and high) risk categories. Procedures comprising 80% of the cases within each category were identified. Risk categories were also created within each surgical specialty. The distribution of risk for each procedure was then examined to illustrate the effect of including patient characteristics.

Results:

The overall rate of DSM was 7.4%. There were 37 commonly performed low, 106 medium, and 78 high risk procedures across all specialties. Shoulder arthroscopy had the lowest intrinsic risk, and Ivor-Lewis esophagectomy the highest. As expected, incorporating patient characteristics revealed variability in risk regardless of intrinsic operative risk. For instance, predicted risk of DSM for shoulder arthroscopy ranged from 0.3-3%, while for Ivor-Lewis esophagectomy ranged from 15-81%.

Conclusion:

Understanding an operation’s intrinsic risk can assist providers when evaluating patients and inform decisions about care. This study compiled a list of the most commonly performed procedures across all and within each specialty and stratified them into low, medium, and high risk categories. Patient factors undoubtedly play a role in the risk evaluation.

16.12 Can Surgeons Still Be Scientists? Productivity Remains High Despite Competitive Funding

Posted on January 25, 2017

A. K. Narahari1, E. J. Charles1, J. H. Mehaffey1, R. B. Hawkins1, A. K. Sharma1, V. E. Laubach1, C. G. Tribble1, I. L. Kron1  1University Of Virginia,Division Of Thoracic And Cardiovascular Surgery, Department Of Surgery,Charlottesville, VA, USA

Introduction:  Obtaining federal funding for scientific research is as competitive as ever. Lung transplant research has been dominated by surgeons ever since the first transplant in 1963 by Dr. James Hardy, but is that still the case? We hypothesized that even in this difficult era of funding, surgeon-scientists have remained among the most productive and impactful researchers in lung transplantation.

Methods:  Grants awarded by the National Institutes of Health (NIH) for the study of lung transplantation between 1985 and 2015 were identified by querying the NIH Research Portfolio Online Reporting Tool Expenditures and Results (RePORTER), an online database that combines NIH project databases, funding records, abstracts, full-text articles, and information from the U.S. Patent and Trademark Office. Five research areas were targeted: lung preservation, ischemia reperfusion, ex vivo lung perfusion, anti-rejection medication, and airway healing. Grants not related to lung transplantation were excluded following a secondary search for “lung transplant” in the description page of NIH RePORTER. Identified papers from each grant were assigned the impact factor (Journal of Citation Reports 2014) for the journal in which it was published. A grant impact metric was calculated for each grant by dividing the sum of impact factors for all associated manuscripts by the total funding for that grant [Σ(Impact factor of each paper in grant) / Funding of grant].  Univariate analysis of grant impact metrics was completed.

Results: One hundred and eight lung transplantation grants were identified, totaling approximately $300 million and resulting in 2,300 papers published in 421 different journals. Surgery departments received $102.5 million over a total of 27 grants, while Internal Medicine departments received $118.8 million over 42 grants. There was no significant difference in the median grant impact metric between Surgery and Internal Medicine departments (4.2 vs. 5.4 per $100,000, p=0.86; Table 1), or between Surgery and Physiology, basic science, or Medicine subspecialty departments (all p>0.05; Table 1). Surgery departments had a significantly higher median grant impact metric compared with private companies (4.2 vs. 0 per $100,000, p<0.0001; Table 1).

Conclusion: Surgeon-scientists in the field of lung transplantation have received fewer grants and less total funding compared to other researchers but have maintained an equally high level of productivity and impact.  The dual-threat academic surgeon-scientist is an important asset to the research community and should continue to be supported by the NIH. 

 

14.20 Ultrasonographic Detection of Occult Inguinal Hernia

Posted on January 25, 2017

C. Shwaartz1, R. S. Lingnurkar2, B. Cohen1, M. Cohen1, H. K. Rosenberg1, C. M. Divino1  1Icahn School Of Medecine At Mount Sinai,General Surgery,New York, NY, USA 2Central Michigan University College Of Medicine,College Of Medicine,Mount Pleasant, MI, USA

Introduction:

In recent years, ultrasonography has gained popularity as an adjunct to physical examination, replacing the now abandoned contrast herniography to detect occult inguinal hernias. Despite pronounced heterogeneity in reported positive and negative predictive values for this modality, the integration of ultrasound in the diagnostic algorithm for inguinal discomfort has been advocated when physical examination alone is inconclusive. The aim of this study is to confirm this recommendation by assessing the diagnostic value of ultrasonography in detecting occult inguinal hernia, and appraise the limits of its detection rate across discrete populations. 

Methods:

We retrospectively reviewed the demography and the outcome of 137 patients presenting with inguinal discomfort between the years 2013 and 2016 in a single surgeon practice. Inclusion criteria were the following: (1) inconclusive physical examination by a single surgeon, and (2) ultrasound and interpretation by a single radiologist following physical examination. Follow up data were collected by either a clinic visit for inguinal hernia repair soon after inguinal ultrasound, or a telephone survey querying for both inguinal hernia repair during the follow up period, and eventual resolution of symptoms. Demographic factors affecting the accuracy of ultrasonography were analyzed.

Results:

137 patients were included in the study, with a median age of 49 years, of which 45% were females. 26 (19%) were tested positive and 111 (81%) were tested negative for occult inguinal hernia. A total of 18 (13%) patients underwent surgery soon after inguinal ultrasound. Of the remaining 119 patients, 101 (85%) were successfully called for follow up. 37 (31%) patients remained symptomatic on follow up, and 4 (3%) patients had undergone inguinal hernia repair during the follow up period. Positive and negative predictive values (PPV and NPV) for ultrasound in detecting occult inguinal hernia were determined to be 79.17%, and 61.05% respectively. Variance across cohort was noted: ultrasound accuracy was influenced by gender (PPV 90.91% in females vs. 69.2 in males), age (PPV 90.91% below 49 and 71.4 above 49), BMI, prior hernia surgery and comorbidities predisposing to hernia formation (lung disease, constipation, prostatism) (PPV of 85.7% with comorbidity vs. 76.4% without).

Conclusion:

Inguinal ultrasonography has a moderately high positive predictive value, but a relatively low negative predictive value for detecting occult inguinal hernia. Our study uniquely stratified these diagnostic values across discrete populations, revealing particularly high positive predictive values for females, patients aged ≤ 49, and patients with predisposing comorbidities.  These findings suggest that ultrasound may be most effective in detecting occult inguinal hernia in representative patients.

 

09.15 Non-Accidental Burns in Kids: What Are the Risk Factors?

Posted on January 25, 2017

R. P. Barker1, K. B. Savoie2, R. C. Passaro1, J. W. Eubanks2, R. F. Williams2  1Univeristy Of Tennessee Health Science Center,College Of Medicine,Memphis, TN, USA 2Univeristy Of Tennessee Health Science Center,Department Of General Surgery And Pediatrics,Memphis, TN, USA

Introduction:
Non-accidental burns account for up to 20% of all non-accidental trauma and have been associated with increased septic complications, longer lengths of stay, more operations, and higher morbidity. Identification of these burns can be difficult; therefore, we sought to identify risk factors associated with non-accidental burns.

Methods:
After institutional review board approval, a retrospective chart study of all patients from 2011-2013 with confirmed or suspected diagnoses of non-accidental burns were identified through the institutional trauma data bank. These patients were then matched 2:1 with burn patients who had no suspicion for abuse based on gender, race, TBSA, and date of burn. Individual charts were reviewed and data was abstracted for basic demographics, injury characteristics, and parameters related to non-accidental trauma. Standard statistical analysis was performed.

Results:
A total of 94 patients were identified; 33 of these were either suspected or confirmed non-accidental cases. The remaining 61 were burn cases with no suspicion for abuse. Non-accidental cases presented at younger ages than accidental cases (median age 1.89 vs 8.42, p <0.0001) and were more likely to present with clinical signs of shock (median SBP 101 vs 124, p = 0.0004, median HR 133 vs 103, p = 0.004, median RR 28 vs 22, p = 0.001). Non-accidental cases were more likely to require ICU admissions (32% vs 7%, p = 0.05). Hospital length of stay was longer for non-accidental cases compared to accidental cases (median days 3 vs. 0, p <0.0001).  A surgery consultation was required for 87.9% of non-accidental cases vs. 50.8% of accidental cases (p <0.0004). Non-accidental cases were more likely to involve the perineum (36.4% vs. 8.2%, p =0.0007) and the feet (42.4% vs. 14.8%, p =0.0033) when compared to accidental burns.  Accidental burns were more likely to involve the upper extremities (37.7% vs. 18.2%, p =0.05) compared to non-accidental burns.  While only 47.5% of accidental cases required admission, 93.9% of non-accidental cases were admitted (p <0.0001). Non-accidental cases were more likely to have underlying social concerns when compared to accidental cases. These included a single parent (45.5% vs. 21.7%, p =0.02) and a previous Department of Children Services (DCS) encounter (27.3% vs. 1.7%, p <0.0001). Trauma activation was initiated in 24% of non-accidental cases and none of the accidental matched cases (p <0.0001).

Conclusion:
Suspected and confirmed non-accidental burn cases are overall more severe than accidental burn cases and require more hospital resources. Younger patients with burns to the perineum or feet who live in a single parent home or have a previous DCS encounter are at increased risk for non-accidental burns and may benefit from early social work consultation or transfer to a burn center for further evaluation. 
 

09.11 Evaluation of Postoperative Fever in Children

Posted on January 25, 2017

K. S. Corkum1, J. E. Grabowski1, C. J. Hunter1, T. B. Lautz1  1Ann & Robert H. Lurie Children’s Hospital Of Chicago,Division Of Pediatric Surgery/Department Of Surgery,Chicago, IL, USA

Introduction: Early postoperative fever is an extremely common occurrence in both adult and pediatric patients. Adult data suggest that fever workup is unnecessary for most patients in the first 24-48 hours after a major operation. Data in the pediatric population is extremely limited, and as a result, many children with early postoperative fever may undergo unnecessary “pan-culturing”. The aims of this study were to describe the incidence of early postoperative fever following elective inpatient operations in children, determine current utilization of laboratory and radiologic tests in these children with fever, and assess the frequency with which early postoperative fever workup yields a positive result.

Methods: A retrospective analysis of all surgical subspecialty patients at our institution undergoing an inpatient or observational stay surgery between 2011 and 2015 was performed using our electronic medical record (EMR). The EMR query identified 18,612 distinct patient operative encounters of which 6,943 met our inclusion criteria of elective admission type, surgery performed on hospital day zero or one, and an identified wound class of I-IV. Of those encounters, 2,128 had a documented postoperative fever (>100.5 F within 0-2 days post procedure). The EMR was also queried for all blood cultures, urinalysis, urine cultures, respiratory viral panels (RVP) and chest radiographs during that time period and the generated data was then cross-referenced against our cohort of patient operative encounters based on medical record number and date of service using IBM SPSS.

Results: 2,128 patients (30.6%) developed an early postoperative fever, including 761 on POD0, 1422 on POD1, and 1157 on POD2. Urinalysis was tested in 450 (21.1%) and was positive in 89 (19.8% of patients tested and 4.2% of all with fever). Urine culture was tested in 479 (22.5%) and was positive in 72 (15.0% of patients tested and 3.4% of all with fever). Of patients with a positive urine culture, 90.2% (65/72) had an indwelling urinary catheter at the time of surgery. Blood culture was performed in 453 (21.2%), but only 3 patients, all with a central venous catheter, had clinically significant positive cultures. Overall, chest radiographs were performed in 853 (40.1%), and 26 (3.0%) were read as concerning for pneumonia, 326 (15.3%) non-infectious, 420 (19.7%) normal, and 81 (3.8%) were obtained to confirm line, tube or hardware placement. RVP was performed in 52 (3.1%) and was positive in 20 (38.5% of patients tested and 1.2% of all with fever).

Conclusion: Similar to adult patients, early postoperative fever is extremely common in the pediatric surgical population, and rarely associated with a positive blood, urine, respiratory culture and/or chest radiograph suggestive of an infectious source. Workup for early postoperative fever in the pediatric surgical population should be applied selectively, based on patient history, severity of illness, and clinical assessment.

 

07.15 Measuring Complete Response After Neoadjuvant Therapy for Rectal Cancer: Do X's Really Equal 0's?

Posted on January 25, 2017

C. T. Ellis1, K. B. Stitzenberg1  1University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA

Introduction: Tumor response to neoadjuvant chemoradiation is increasingly recognized as an important prognostic indicator.  Individuals with a pathological complete response (pCR) to neoadjuvant therapy for rectal cancer have been shown to have greatly improved long-term survival.  Tumor response can be estimated from cancer registry data when both clinical and pathological stage information is reported. Prior studies have presumed ypTXNX is equal to ypT0N0, and thus both are usually grouped together as representing pCR. However, this methodology is unproven. For this study, we sought to determine how pCR-status is best captured for rectal adenocarcinoma patients using cancer registry data.

Methods:   Using the National Cancer Database (NCDB), we included patients with clinical stage II/III rectal adenocarcinoma that underwent neoadjuvant chemoradiation and a proctectomy from 2004 – 2013.  We compared outcomes amongst three goups: those with ypTXNX, those with ypT0N0, and those with ypT>0N>0.  We estimated the difference in OS by treatment received using Kaplan-Meier survival curves and Adjusted Cox proportional hazards models, controlling for patient, tumor, and facility characteristics.

Results:  Overall, 3,700 (13%) and 2,756 (10%) of our cohort (n=27,859) had a pCR as indicated by ypTXNX and ypT0N0, respectively. Over time, there was a decrease in those with ypTXNX and an increase in those with ypT0N0.  In 2004, 28% of our cohort were ypTXNX and 5% were ypT0N0.  In 2013, only 3% were ypTXNX and 14% were ypT0N0.  5-year OS for ypTXNX patients was more similar to that of individuals with an incomplete response than those with ypT0N0; 5-year OS 77%, 73%, and 87%, respectively (Figure).

Conclusion:  Prior studies using the NCDB assumed ypTXNX and ypT0N0 both represented pCR.  This assumption is supported by the increase in ypT0N0 and decrease in ypTXNX over time, consistent with changes in coding practices.  However, survival outcomes suggest otherwise, as long-term survival for the ypTXNX and ypT0N0 groups is different.  Survival for pCR using ypT0N0 alone is most consistent with a true pCR based on previously published survival outcomes.  Registry studies that include ypTXNX in the definition of pCR may not accurately capture the true pCR cases. Additional research is needed to validate this methodology. 

07.12 Factors Associated with Burden of Anal Condyloma and Need for Operative Intervention

Posted on January 25, 2017

H. Foss1, C. Y. Peterson1, K. A. Ludwig1, T. J. Ridolfi1  1Medical College Of Wisconsin,Colorectal Surgery,Milwaukee, WI, USA

Introduction:  Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. An estimated 79 million Americans are currently infected with HPV, and approximately 14 million new infections occur each year. Known risk factors for contracting HPV include high number of lifetime sexual partners, failure to use condoms consistently, history of sexually transmitted infections, immunosuppression, and younger age. Many treatment modalities exist and are largely based on the extent of condyloma present. These treatments may range from simple office based procedures to major full thickness skin resections in those with large volume disease. The aim of this project is to identify risk factors associated with need for surgical intervention as well as extent of disease.

Methods:  A retrospective chart review was completed for patients seen at the Medical College of Wisconsin Anal Dysplasia Clinic from April 2014 to June 2016. Information including demographic information, smoking status, HPV subtype, immune condition, need for surgical intervention, and surgical specimen size was then extracted from the medical record. Descriptive statistics were employed to evaluate the patient population. Logistic regression was used to evaluate for statistically significant covariates in predicting need for surgical intervention. Multiple linear regression analysis was used to evaluate for statistically significant covariates in predicting a log transformation of surgical specimen size. Significance was determined using a p-value equal to or less than 0.05.

Results: 283 patients met inclusion criteria, of which 252 (89.05%) were male, 179 (63.25%) had a smoking history, 232 (81.98%) were HIV positive, and 108 (38.16%) had undergone surgical intervention for anal condyloma. HPV subtyping was completed in 236 (83.39%) patients, of which 76 (32.20%) tested positive for HPV 16, 25 (10.59%) tested positive for HPV 18, and 149 (63.40%) tested positive for other high risk HPV subtypes. Of six covariates analyzed with logistic regression, only male gender significantly predicted the need for surgical intervention (p-value 0.04). Of seven covariates analyzed with multiple linear regression, HPV 18 status (p-value 0.05), smoking history (p-value 0.005), and older age (p-value 0.04) significantly predicted larger specimen size.

Conclusion: 

Male gender is predictive of needing surgical intervention, while HPV subtype 18, smoking history, and older age are associated with greater burden of disease. The only modifiable risk factor in predicting burden of anal condyloma is smoking status with an average increase of 1 cm3 of condyloma burden in those who smoke. Smoking cessation should be strongly encouraged in those who are HPV positive.

 

 

07.03 Surgical Strategy of Hepatic Resection with Inferior Vena Cava Resection for Liver Cancers

Posted on January 25, 2017

T. Ochiai1, D. Asano1, J. Yoshino1, S. Watanabe1, Y. Ishikawa1, N. Chiyonobu1, Y. Mizuno1, T. Sato1, H. Ueda1, Y. Iwao1, H. Ono1, Y. Mitsunori1, S. Matsumura1, D. Ban1, A. Kudo1, S. Tanaka2, M. Tanabe1  1Tokyo Medical And Dental University,Department Of Hepto-Biliary And Pancreatic Surgery,Bunkyo-ku, Tokyo, Japan 2Tokyo Medical And Dental University,Department Of Molecular Oncology,Bunkyo-ku, Tokyo, Japan

Introduction: The prognosis of patients who have liver cancer associated with inferior vena cava tumor thrombus (IVCTT) or inferior vena cava invasion (IVCI) is very poor, and effective treatment modalities are extremely limited. The objective of this study is to determine the efficacy of surgery and appropriate surgical procedures for liver malignancy with IVCTT or IVCI.

Methods: From January 2003 to December 2015, 19 patients with the liver malignancy (eight metastatic tumors, seven hepatocellular carcinomas, three intrahepatic cholangiocarcinomas and one mixed hepatocellular cholangiocarcinoma) underwent hepatectomy with concomitant IVC resection and reconstruction for eight IVCTT and eleven IVCI. We retrospectively analyzed surgical procedures and survival.

Results:Of the 19 patients, 2 underwent trisegmentectomy, 6 underwent bisegmentectomy, 5 underwent segmentectomy and 6 underwent partial hepatectomy. As IVC reconstruction, 13 underwent primary closure, 4 required 20-mm expansive polytetrafluoroethylene (ePTFE) graft and 2 required patch graft using round ligament and epicardium, respectively. During the IVC cross-clamping, 6 required infrarenal abdominal aortic cross-clamping without cardiopulmonary bypass or venous bypass, 3 required extracorporeal circulation assisting device to maintain stable hemodynamics. Median operation time was 515 minutes (range 256 to 918 minutes) and median intraoperative bleeding was 2353 ml (range 740 to 44000 ml). No hospital death was recognized. The median survival time of hepatocellular carcinoma was 27 months (range 4 to 89 months) and of colorectal liver metastases was 22 months (range 2 to 48 months). One out of 3 in intrahepatic cholangiocarcinoma is still alive 60 months after surgery. 

Conclusion:Hepatic resection with IVC resection and reconstruction for liver tumors provided acceptable outcomes in 19 patients. Considering morphology of the tumor and intraoperative hemodynamics, appropriate surgical procedures should be selected.

 

06.12 Use Of Suprahepatic Occlusion Of The IVCFor Resection Of HCC With Tumor Thrombus In The Hepatic Vein

Posted on January 25, 2017

A. Li1, M. Wu1  1Eastern Hepatobiliary Surgery Hospital,SMMU,Shanghai, SHANGHAI, China

Introduction: To investigate the differences in the surgical approaches for resection of hepatocellular carcinoma (HCC) with tumor thrombus was extending into the hepatic vein using occlusion of the suprahepatic inferior vena cava (IVC) with occlusion forceps.

Methods: Between January 2011 and December 2013, 21 patients diagnosed with advanced HCC with tumor thrombi in the hepatic vein underwent hepatectomy and thrombectomy. Peri- and postoperative morbidity and mortality rates were evaluated prospectively and analyzed.

Results:Mean age of the patients was 47 years. Median primary tumor size was 12.0±4.0cm. All HVTT were removed using occlusion of the suprahepatic IVC with Satinsky vascular clamp. Pringle’s maneuver time was 19 minutes (range 15 to 24 minutes). Mean time of occlusion of the suprahepatic IVC was 10 minutes (range 8 to 20 minutes). Mean intraoperative blood loss was 600 mL (range 300 to 2,000 mL). Postoperative complications were seen in 10% of patients (n=2), included pleural effusion (n=2). Median follow-up was 38 months (range 2 to 72 months). The 1- and 2-year overall survival (OS) rates were 57% and 4%, respectively, while the 1- and 2-year recurrence rates were 94% and 96%.

Conclusion: This study showed that using occlusion of the suprahepatic IVC, resection for HCC with tumor thrombi in the hepatic vein can be performed safely and thereby avoid embolus rupture of tumor thrombus and air embolism, and may improve the prognosis of these patients. This method is especially suitable for unexpected, intraoperatively detected hepatic vein tumor thrombus.
 

05.11 Cancer Registration in Resource-Limited Environments – Experience in Lagos, Nigeria

Posted on January 25, 2017

M. Fatunmbi1,2, M. Masika1,2, A. Saunders2, C. Agbakwuru3, B. Chugani3, M. Jimoh3, O. Ilegbune3, A. Adewale3, O. Akinyemiju3, C. Nwogu1,2,3  1State University Of New York At Buffalo,Buffalo, NY, USA 2Roswell Park Cancer Institute,Buffalo, NY, USA 3Lakeshore Cancer Center,Lagos, , Nigeria

Introduction:
There is significant disparity in cancer registration between high income countries (HIC) and low- to middle-income countries (LMIC).  While population-based cancer registries provide a superior sample compared to hospital-based cancer registries, the utility of hospital-based cancer registries has been supported.  Despite great efforts being made by international organizations, such as the World Health Organization (WHO) and its subsidiaries, there is still a great deficit in the number and quality of cancer registries in Africa.  Development of high quality cancer registries has proven challenging for various reasons, including resource limitations restricting population access to healthcare facilities, lack of trained personnel, and inadequate funding for cancer control efforts from all government levels.  In addition, there is an under appreciation of the cancer burden, thus an under appreciation of the role registries play in recognizing and alleviating the burden.  Therefore, there is a recognized need for the establishment of more cancer registries in LMICs.  

Methods:
Lakeshore Cancer Center (LCC) in Lagos, Nigeria sought to establish a hospital-based registry to allow for a proper assessment of the cancer burden of its patient population.  The aim was to begin collection of data, make it accessible to other hospitals and institutions, and ultimately to expand to a regional population-based cancer registry.  A retrospective review of electronic and paper records of patients who presented at LCC from July 2014 to June 2016 was performed.  Patient demographics, diagnoses, stages and treatments were captured, and initially coded in Excel for preliminary review.  Descriptive statistics were analyzed.  CanReg5 (International Association for Cancer Registration, Lyon, France), an open source application, was then customized to capture selected data elements in a hospital-based cancer registry based at LCC. 
 

Results:

Since July 2014, LCC has seen an increase in the number of new cancer cases.  The total number of cases captured was 226.  Evaluation of patients by disease site revealed that the most common cancer site was breast (38%), followed by prostate (12%), colorectal (8%) and cervical (6%).  A combination of gynecological, upper GI, CNS, hematological and renal cancer constituted 25% of diseases sites.  The majority of patients also presented with stage III (24%) or IV (61%) cancers (Figure 1).

 

Conclusions:

These results reflect early hospital-based cancer registry data from a cancer center in an LMIC.  The data reveals that 85% of patients treated at LCC present at later stages.  This highlights a need for developing and strengthening early detection and screening programs.

 

05.03 Lessons Learned from the Implementation of a Trauma Mortality Review in Central Africa

Posted on January 25, 2017

C. A. Thiels1, S. Nigo3, M. Kasumba3, J. A. Brown3, S. M. Wren2  1Mayo Clinic,Rochester, MN, USA 2Stanford Medicine,Palo Alto, CA, USA 3Mbingo Baptist Hospital,Northwest Province, , Cameroon

Introduction:   Trauma remains a leading cause of death in Africa. Mortality reviews aimed at identifying preventable deaths, or deaths which could be avoided if optimal care had been delivered, are underutilized but may provide information to guide improvement at trauma centers. We report our experience with implementing a trauma mortality review process in a rural teaching hospital in Central Africa.

 

Methods: A prospective trauma registry at Mbingo Baptist Hospital, Cameroon from 1/2014-3/2016 (n=1912) identified 36 deaths. Chart review was conducted using a standardized preventable death assessment form to identify demographics, cause of death, physician related factors (e.g. delayed diagnosis), system related factors (e.g. lack of medications), and patient related factors to identify themes for improvement. Preventable deaths were defined using American College of Surgeons criteria.

 

Results: Of the 36 trauma mortalities identified, 30 records were available and included. Median age was 29 years (IQR 19, 46) and 80% were male. Mechanism of injury included 16 road traffic related crashes, 8 thermal injuries, 3 falls, 2 blunt injuries, and 1 firearm injury. Traumatic brain/cord injuries accounted for half (n=15) of the injuries with the remainder being burns (n=8), extremity (n=4), abdominal (n=2), and one patient with tetanus. Fifty percent of patients presented in a delayed fashion (≥ 1-day delay) and 43% were transfers. Two patients died at initial resuscitation, 6 during non-operative management, and 22 after surgery, at median hospital day 2 (IQR 1,5). Causes of death included neurologic (47%), respiratory (33%), multi-organ failure (20%), infection (17%), and bleeding (17%) etiologies. Opportunities for improvement were identified in all cases including 16 preventable or possibly preventable deaths and 14 non-preventable deaths. Physician related issues were identified in 80% of cases with pre-operative (n=13, e.g. suspected under resuscitation in 5/8 burn patients) and post-operative (n=13) factors being the most commonly cited. Systems related issues were cited in 77% of cases including unavailable medications (n=12), lack of ventilator support (n=12) or cross-sectional imaging (n=9), and limited blood product availability (n=5).

 

Conclusion:  Implementation of mortality review at a Central African rural hospital revealed that the majority of trauma deaths resulted from burns or neurologic injuries, with most occurring in the post-operative phase of care. Under resuscitation was noted as a recurring physician related area of improvement in burn patients and was exacerbated by the transfer status of many patients. Lack of cross-sectional imaging was noted as a contributing factor in many of the patients with neurologic trauma. These data may help facilitate quality improvement and allocation of resources while this method of structured review of trauma deaths may help improve the quality of trauma care at other trauma centers in Africa.

04.01 Evidence for Botulinum Toxin in Management of Ventral Hernia: A Systematic Review and Meta-Analysis

Posted on January 25, 2017

J. M. Weissler1, M. A. Lanni1, M. G. Tecce1, M. J. Carney1, V. Shubinets1, J. P. Fischer1  1University Of Pennsylvania,Plastic Surgery,Philadelphia, PA, USA

Introduction:  Incisional hernia (IH) remains a challenging and costly surgical complication with high morbidity and exceptionally high recurrence rates. With nearly 350,000 repairs and a cost burden of $3.2 billion annually, there is a clear need for reparative strategies to thwart recurrence and the dramatic physiologic changes to the abdominal wall musculature after hernia. Botulinum toxin (Botox) injections have recently been identified as a potential preoperative means to counteract abdominal wall tension, reduce hernia size, and facilitate ultimate fascial closure. This systematic review and meta-analysis reviews outcomes after Botox injections in the setting of ventral hernia, and demonstrates the applicability of Botox in abdominal wall reconstruction. 

Methods:  A systematic review of the literature was conducted in accordance with PRISMA guidelines using MeSH terms “ventral hernia”, “herniorrhaphy”, “hernia repair”, and “botulinum toxins.” Relevant studies reporting pre- and post-injection data were included. Outcomes of interest included changes in hernia defect width and lateral abdominal muscle length, recurrence, complications, and patient follow-up. Qualitative findings were also considered to help demonstrate valuable themes across the literature.  

Results: Overall, 164 titles were identified following the initial database search from which 11 articles were reviewed. 3 titles were ultimately included in the quantitative analysis, with a total of 56 patients. The remaining articles were considered qualitative in nature and analyzed the subjective effects of Botox. Meta-analysis revealed significant hernia width reduction (mean= 5.79cm; n=29; p<0.001) and lateral abdominal wall muscular lengthening (mean= 3.33cm; n=44; p<0.001) following Botox injections (Table 1). Mean length of follow-up was 24.7 months (range 9-49). The specific metrics before and after Botox injections for each hemi-abdomen were also included in the analysis. 

Conclusion: While traditional abdominal wall reconstruction approaches have unquestionable benefits, Botox injections of the abdominal wall also offer tremendous potential in managing complex ventral hernias. This minimally invasive “chemical component separation” technique may provide crucial tissue mobility, minimize undue abdominal wall tension, and decrease abdominal muscle contractile force facilitating fascial closure, with a potentially easier postoperative recovery for the patient. Although further studies are needed, there is a significant opportunity to bridge the knowledge gap in preoperative practice measures for ventral hernia risk reduction. 

 

95.16 #ILookLikeASurgeon: A Global Social Media Movement Advocating Diversity and Surgical Culture Change

Posted on January 25, 2017

H. J. Logghe1, M. A. Boeck2, K. A. Hughes4, T. K. Varghese5, N. J. Gusani6, C. D. Jones3  7University Of Colorado Denver,Aurora, CO, USA 1University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA 2New York Presbyterian Hospital,Columbia, Department Of Surgery,New York, NY, USA 3Johns Hopkins University School Of Medicine,Department Of Surgery, Division Of Acute Care Surgery,Baltimore, MD, USA 4Falmouth Hospital,Department Of Surgery,Falmouth, MA, USA 5University Of Utah,Department Of Surgery, Division Of Cardiothoracic Surgery,Salt Lake City, UT, USA 6Penn State Hershey Medical Center,Department Of Surgery, Division Of Surgical Oncology,York, PA, USA

Introduction:  Despite nearly half of US medical students being female, only 15% of general surgeons are women. Additionally, only 5.5% of US physicians identify as African-American and 6.3% as Hispanic. Globally, surgery includes even fewer minorities, challenging recruitment and retention of underrepresented groups in the field. The sparsity of colleagues of similar backgrounds may lead to feelings of isolation. This study sought to examine the methodology and results of the diversity-championing #ILookLikeASurgeon social media movement to describe a novel approach to networking, advocacy, and collaboration.

Methods:  In August 2015, the Twitter hashtag #ILookLikeASurgeon was introduced, accompanied by a blog post detailing the goal of the hashtag and encouraging others to tweet photos using the hashtag #ILookLikeASurgeon in support of diversity in surgery. Dynamic interactions across social media platforms (including Twitter, Facebook, LinkedIn, Instagram, and blogs) encouraged users to post photos depicting practicing and aspiring surgeons. Reposting ensuing messages fostered participation, increased dissemination, and magnified impact. Engagement of traditional media, podcasts, and surgical conferences strengthened the message of inclusion. Data from Symplur Signals about Twitter activity were retrospectively analyzed using descriptive statistics.

Results: In twelve months on Twitter #ILookLikeASurgeon continued to be a multilingual multinational phenomenon, including nearly 250 million impressions, 13,000 participants, and 70,000 tweets, averaging 8 tweets per hour with more than 50% containing photos. Participants included patients, undergraduate and medical students, residents, and attendings across surgical and medical specialities, with posts from personal, organizational, and institutional accounts. The movement received significant traditional media coverage, with newspaper articles in French, Spanish and German, a feature on the NBC Today Show website and audio interviews on the BBC.

Conclusion: The #ILookLikeASurgeon Twitter campaign proved to be a successful method of uniting surgeons from diverse backgrounds from around the world in real time, at no cost, and without travel, thus pioneering a new frontier for surgical discourse. This single hashtag formed a virtual community advancing networking, mentoring, and research collaborations, while simultaneously humanizing the profession, demonstrating that anyone from an extraordinarily diverse group can look like a surgeon. A year after the first tweet, the hashtag continues to foster a virtual community for discussion on issues of gender, diversity, and the evolving culture of surgery.

 

 

01.05 Statins Reduce Thoracic Aortic Aneurysm Growth in Marfan Syndrome Mice

Posted on January 25, 2017

M. P. Fischbein1  1Stanford University,Cardiothoracic Surgery,Palo Alto, CA, USA

Introduction: Systematically dissect the prenylation pathway to better define the mechanism behind the beneficial effect of statins on aneurysm reduction in MFS and anticipate this will help elucidate the pathophysiology of aneurysm formation.  

Methods: Fbn1C1039G/+ mice (4 week old) were treated subcutaneously with either (a) Pravastatin (PS) (HMG-Co Reductase inhibitor) (100 mg/kg per day); (b) Manumycin A (MA) (FPT inhibitor) (2.5 mg/kg/every other day); (c) Perillyl Alcohol (PA) (GGPT-1 and -2 inhibitor) (5.0 mg/kg/every other day); or (d) vehicle control Fbn1C1039G/+ mice from age 4-8 weeks. Aortic dimensions were measured with transthoracic echo.

Results:  PS and MA significantly reduced aneurysm growth compared to vehicle control (PS:1.57 ± 0.03 mm; MA: 1.55 ± 0.06 mm; vehicle: 1.77 ± 0.05 mm, respectively: p < 0.05). There was no significant difference between PS and MA treated groups. In contrast, PA did not significantly decrease aneurysm size (PA: 1.81 ± 0.06 mm). Elastin staining illustrated reduced elastin breakdown in MA treated mice compared to vehicle control treated groups (MA: 2.2 ± 0.3, vehicle: 4.2 ± 0.6, respectively: p < 0.05). After identifying that the Ras pathway is important, we measured the relative expression of pRaf-1 and pErk1/2, downstream enzymes in transforming growth factor- β (TGF-β) signaling pathway with WES. Although elevated in control Marfan mice, both pRaf-1 and pErk 1/2 were significantly reduced in MA treated mice, corresponding with a reduction in aneurysm growth (pRaf-1: MA: 5.1 ± 1.3, vehicle: 8.8 ± 0.8, p = 0.08, pErk1/2: MA: 2.3 ± 0.1, vehicle: 3.2 ± 0.1, p < 0.05, respectively

Conclusion: Statins reduce aortic aneurysm growth in Fbn1C1039G/+ Marfan mice by decreasing both Ras activation and downstream ERK signaling

 

01.07 A Hypothermic Ex-vivo Intestinal Perfusion Unit that limits ischemia reperfusion injury

Posted on January 25, 2017

A. Flores Huidobro1, C. Ibarra1, A. S. Munoz-Abraham1, A. Bertacco1, R. Patron-Lozano1, A. Alkukhun1, R. Morotti1, J. Zinter1, F. D’Amico1, D. Mulligan1, J. Geibel1, M. I. Rodriguez-Davalos1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction: Intestinal function may be compromised for several reasons leading to a high number of adult and pediatric patients with intestinal failure. In an effort to reduce injury we have developed multiple animal and human models for extracorporeal perfusion using our intestinal perfusion unit (IPU). We previously published a feasibility study, here we present a comparison between transportation modalities: cold ischemia times, and a variety of preservation solutions. 

Methods: Twelve human intestines were procured from our two regional organ procurement organizations using our approved IRB protocol. Eight intestines were procured and connected to the IPU on site. Four intestines were procured, packed in static cold preservation and delivered to our institution within an average time of 8 hours and 42 minutes and the intestines were all connected proximally to jejunum and distally to the ileum, as well as to the superior mesenteric artery in a dual pump system (luminal and vascular). The human intestines were connected to the IPU and perfused with UW (University of Wisconsin) solution, HTK (Histidine-tryptophan-ketoglutarate) and a combination of UW + Ringer Lactate. Samples were taken at 8, 10 and 12 hours in hypothermic perfused conditions. Pathological analysis was determined using the Park/Chiu (P/C) scoring system for intestinal injury (0=normal, 8=transmural infarction). 

Results:Histological analysis of intestines shipped and then connected to the IPU showed a P/C score of jejunum (2.3) and for ileum (2.8). Intestines connected to the IPU on-site: P/C score of jejunum (1.85) and for ileum (1.23).. Average cold ischemia time (CIT) for recovered intestines by our team was 2.16 hours and CIT for intestines by other teams was 8.42 hours. Of the 12 total intestines, six were perfused with UW solution, five with HTK and one with UW + RL.  UW perfusion had an average P/C score of 1.6 and 1.77 in ileum and jejunum respectively. HTK had a P/C score average of 1.78 in ileum and 2.27 in jejunum. The combination of UW and RL had the poorest score, 2.33 in both the ileum and jejunum. 

Conclusion:Continuous hypothermic perfusion of intestinal tissue with UW solution proved to be the best source for limiting ischemia reperfusion injury. Lower ischemia injury scores were seen in the Ileum in comparison to Jejunum. This study demonstrates the advances of the IPU project and the variables that can significantly impact the preservation of the intestinal tissue. The results show that if possible, the intestine should be connected at the procuring site in order to achieve maximal preservation. 

 

95.18 Global Collaborative Healthcare: Resource requirements for surgical specialties at a leading AMC

Posted on January 25, 2017

N. ROSSON1, H. HASSOUN1  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA

Introduction:
Historically, global collaborations involving US academic medical centers (AMCs) focused on specific diseases and public health issues in less developed countries. Recently, rapid privatization of healthcare systems, economic development, and a shift in the disease burden have led providers in emerging countries to seek partnerships with AMCs with hopes of improving care to its citizens. This new paradigm is termed Global Collaborative Healthcare, and since 1999 Johns Hopkins Medicine International (JHI) has been at its forefront, facilitating global expansion of the Johns Hopkins Medicine (JHM) mission. We investigated the resource requirements for surgical specialty subject matter expertise (SME) to support the JHI operating model. 

Methods:
The size and scope of JHI’s engagements have increased from consulting to projects of greater complexity and resource requirements, such as affiliations, hospital management and joint ventures, with past engagements in over 50 countries and currently 18 active projects in 16 countries. JHI engages a range of SMEs from the entities that comprise JHM and to facilitate and monitor the use resources, JHI develops work orders that define the terms and services provided which are retained in a JHI database. Data was extracted from this database on a query for all work completed in a 3 year period (Jan, 2013-Dec, 2015), sorted and analyzed to determine total utilization (hours and full time equivalent (FTE) and clinical and non-clinical areas of expertise.   Using the American College of Surgeons definition, 14 surgical specialties were reviewed.  For purposes of this analysis, 1 FTE = 2,080 hours. 

Results:
JHI utilized on average at 21,940 hours annually, or 10.55 FTEs for all faculty and staff SMEs.  The surgical specialties had an average annual utilization of 4,0933 hours or 1.97 FTEs. Within the surgical specialties, Thoracic and General Surgery had the highest utilization, with an annual average 673.49 hours and 605.82 hours respectively followed by Urology and Vascular with 581.86 hours and 427.81 hours respectively. Please refer to Table 1 for the totals and trends in utilization. 

Conclusion:

The global healthcare market is massive and expanding, providing a platform for leading AMCs to enter into collaborative partnerships with healthcare organizations around the world.  In evaluation of the JHI model, we found that surgical specialties play a significant role, providing surgical departments a unique opportunity to successfully engage in these collaborations while continuing to fulfill their core mission and revenue streams.

 

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