99.14 Use of deceased allografts with nephrolithiasis in renal transplantation.

Posted on January 31, 2019

T. Bharani1, J. A. Cagliani1, L. W. Teperman1, E. P. Molmenti1  1North Shore University And Long Island Jewish Medical Center,Surgery,Manhasset, NY, USA

Introduction:  Kidney transplantation is the preferred treatment for end-stage renal disease. Over the past decade, there has been an increase in number of end-stage renal disease patients requiring transplant, without an increase in the availability of allograft kidneys. Donor nephrolithiasis has been considered a relative contraindication due to increased morbidity and graft failure. However, the shortage of kidney allografts has led many centers to consider the possibility of treating donor nephrolithiasis before transplant.

Methods:  We conducted an observational retrospective chart review of patients who underwent renal transplantation to assess the prevalence of ureteral and kidney stones in the donor graft. Kidney stones were removed in the back table before transplantation. Patients aged above 18 years old were included if they received the kidney from a deceased donor. Immediate and long-term complications of the transplanted recipients were recorded. Donors were followed with yearly ultrasonography of the remaining kidney in addition to standard follow-up protocol.

Results: A total of 200 adult deceased donors patients were included in this study. Nephrolithiasis was found in two patients demonstrating an incidence of 1%. This report outlines the clinical management of allograft nephrolithiasis through stone removal before transplantation. There has been no reported post-transplant complications or recurrence of nephrolithiasis in any of the recipients to date.

Conclusion: This study highlights the clinical manifestations of complications due to allograft nephrolithiasis and treatment options available for stone removal. Donor gifted lithiasis should be considered for potential transplantation given the increasing shortage of the allograft pool. Continued long-term follow-up of recipients is still required to ensure the safety of this approach.

 

99.05 Transplant Kidney Graft Arterial And Venous Anatomy And Clinical Outcomes

Posted on January 31, 2019

P. Brady1, W. C. Goggins1, R. S. Mangus1  1Indiana University School Of Medicine,Surgery / Transplant,Indianapolis, IN, USA

Introduction:
There is an increasing shortage of kidney allografts available for transplantation. Each available kidney must be utilized in order to alleviate this shortage. Transplant kidney allografts with multiple renal arteries or veins present added technical complexity when performing the transplant procedure. These grafts may be at higher risk for non-use or for perioperative complications such as graft thrombosis or hematoma. Occasionally, small accessory vessels are ligated which may affect the short- and long-term function of the graft. This study reviews the arterial and venous anatomy for all kidney transplants at a single center over a 17-year period. Outcomes include early graft loss, delayed graft function and long-term graft function.

Methods:
The operative reports for all kidney transplants at a single center between 2001 and 2018 were reviewed. Extracted data included the number of arteries and veins for each graft, as well as type of reconstruction. Ligated vessels were recorded when reported by the surgeon. Delayed graft function was defined as a need for dialysis within 7 days of transplant. Cox regression with a direct entry method was utilized to assess long-term graft function. Operative technique and immunosuppression protocol was similar and consistent for all surgeons during the study period.

Results:
There were 3,504 kidney transplants performed during the study period, 2161 (62%) deceased and 1343 (38%) living donors. Data from 10 surgeons were included (range 10 to 1923 transplants). Donation after circulatory death (DCD) comprised 4% of all donors and 6% of deceased donors. Complete operative reports were available for 98% of grafts. There were 78% of grafts with a single renal artery and 97% with a single renal vein. There was no difference in delayed graft function with grafts that had multiple arteries (2.2% vs 2.5%, p=0.61) or multiple veins (0% vs 2.5%, p=0.16).  Risk of graft loss within 7-days of transplant for single and multiple vessels showed no difference (arterial 1% vs 1%, p=0.96; venous 1% vs 1%, p=0.80). Cox regression analysis demonstrated no difference in graft survival at 15-years based on vessel anatomy (p=0.58). Median graft survival for single and multiple vessels was (arterial) 136 and 137 months (p=0.69) and (venous) 136 and 136 months (p=0.95).

Conclusion:
These results demonstrate remarkably consistent results for kidney grafts with standard or with more complex arterial and venous anatomy. These results suggest that kidney  grafts with complex anatomy should not be excluded from transplant.
 

99.02 Renal Autotransplantation Offers Pain Relief to Patients with Loin Pain Hematuria Syndrome

Posted on January 31, 2019

N. M. Bath1, T. Al-Qaoud1, H. W. Sollinger1, R. R. Redfield1  1University Of Wisconsin,Transplant,Madison, WI, USA

Introduction: Loin Pain Hematuria Syndrome (LPHS) is a rare clinical entity in which patients typically present with severe loin pain. This pain is often debilitating to the point that patients require narcotics for pain control and are often unable to continue employment. Renal autotransplantation is a potential treatment although results are varied. This highlights the importance of patient selection. In order to improve patient selection, we developed the UW-LPHS Test. Here we describe our initial results.

Methods: A retrospective chart review was performed which identified 15 patients with LPHS who underwent renal autotransplantation at a single institution between January 2017 to May 2018. In order to identify patients with LPHS who would likely benefit from autotransplantation, patients underwent bupivacaine injection into the ureter via cystoscopy, known as the UW-LPHS Test. Patients who report pain relief following the UW-LPHS Test are then deemed to benefit from renal autotransplantation. Pre-operative length of pain, pain medications taken pre-operatively, resolution of pain following the UW-LPHS Test, post-operative complications, and return to normal lifestyle were among data points collected.

Results: All patients had previously undergone extensive work-up to determine the etiology of their pain. Nutcracker Syndrome (NCS) was identified as the cause of LPHS in 60% of patients (n=9) with 55.5% of NCS patients (n=5) having undergone previous operative interventions which failed to resolve their pain. Of the 15 patients identified, 93.3% (n=14) underwent the UW-LPHS Test with near or complete resolution of their pain. Two patients not included in this cohort did not have pain relief following the UW-LPHS Test and were later diagnosed with interstitial cystitis. All patients report near complete or complete resolution of their pain post-operatively. 73.3% of patients (n=11) no longer require narcotics for pain control, and 26.7% of patients (n=4) are weaning their narcotic usage. 80% of patients (n=12) have returned to school or employment with 6.7% (n=1) planning to return in the coming months.

Conclusion: Renal autotransplantation for Loin Pain Hematuria Syndrome has been shown to reliably provide pain relief in this patient population; however, it is imperative to properly identify patients who will benefit from autotransplantation. The UW-LPHS Test appears to be an accurate predictor of successful outcomes following renal autotransplantation. Future studies are needed to further clarify the long-term outcomes in patients with LPHS who have undergone renal autotransplantation.

 

96.14 Surgical Outcomes of Gastrostomy Tube Insertion in Children

Posted on January 31, 2019

T. Kuriakose1, F. D. Arias1, Y. Lee1,2  1Rutgers Robert Wood Johnson Medical School,Division Of Pediatric Surgery, Department Of Surgery,Piscataway, NJ, USA 2Robert Wood Johnson University Hospital,Bristol-Myers Squibb Children’s Hospital,New Brunswick, NJ, USA

Introduction:  Gastrostomy tubes can be inserted using percutaneous endoscopic technique (PEG), laparoscopic or open. The choice of technique is usually determined by surgeon preference. The fear of complication has deterred many pediatric surgeons from performing PEG in young children. Evidence supporting this claim is scant. We hypothesize that PEG can be safely performed in children. 

Methods:  We conducted a retrospective review of gastrostomy tube insertion in children age 0-21 at an academic medical center from 1/2014 to 4/2018. Gastrostomy tube insertions were identified by CPT codes. Patients were excluded from analysis if they had prior gastrostomy tube, concurrent major surgery or incomplete records. Data collected included operative time, length of stay from procedure to discharge, rates of conversion to a different technique and complication. Complications are defined as return to emergency department (ED), return to operating room (OR), and hospital readmission within 30 days of procedure. 

Results: 116 gastrostomy tube patients were identified, and after applying exclusion criteria, 83 were analyzed. There were 30 girls and 53 boys. 49 of these patients were younger than 2 years of age. 56 patients underwent PEG placement. The average operative time was 37.1 minutes (95% CI: 31.3-42.8). Average length of stay was 4.67 days (95% CI: 3.19-6.15). 5.4% (3/56) of PEG procedures required conversion to laparoscopic or open. 7.1% (4/56) of these patients visited the ED within 30 days of procedure; 3 of whom required tube replacement. 1.8% (1/56) of these patients had a GI-related readmission (erythema at tube site). 10 patients underwent laparoscopic gastrostomy tube placement. The average operative time was 88.8 minutes (95% CI: 66.9-110.7). The average length of stay was 4.1 days (95% CI: 2.24-5.96). 10% (1/10) required conversion to open. None of laparoscopic group had an ED visit or a GI-related readmission within 30 days of procedure. 17 patients underwent open gastrostomy tube placement. The average operative time was 76.7 minutes (95% CI: 55.1-98.3). The average length of stay was 9.06 days (95% CI: 0.37-17.75). 5.9% (1/17) of these patients visited the ED within 30 days of procedure; none required gastrostomy tube replacement. 5.9% (1/17) of these patients had a GI-related readmission (erythema and drainage at tube site) within 30 days of procedure. In our study, only one case returned to OR within the study period for gastrostomy tube revision, and the initial technique use was open. 

Conclusion: PEG is associated with the shortest operative time of all procedures. Laparoscopic gastrostomy tube insertion is associated with longest operative time but the shortest postoperative length of stay. There is no complication identified in the laparoscopic group. Open gastrostomy tube insertion is associated with the longest postoperative length of stay, and a comparable rate of complication as compared to PEG.

 

96.04 Evaluating severe Haller Indices in postoperative pectus patients with otherwise corrected chest wall

Posted on January 31, 2019

E. Port1, F. Hebal1, C. Hunter1,2, F. Abdullah1,2, B. Malas1, M. Reynolds1,2  1Ann and Robert H Lurie Children’s Hospital of Chicago,Pediatric Surgery,Chicago, IL, USA 2Feinberg School Of Medicine – Northwestern University,Surgery,Chicago, IL, USA

Introduction: Assessment of Pectus Excavatum (PE) deformity in patients undergoing surgery is limited to Haller Index (HI), a preoperative measurement of severity, requiring use of computed tomography (CT). This measure has been used for over 20 years though there is little data validating its accuracy in PE versus non-PE patients. In our clinical experience, patients with normal chest appearance have registered HI beyond 3.25, a threshold frequently used to qualify patients for surgery and insurance reimbursement. A Correction Index (CI) measuring the ratio of the PE defect to a “healthy” chest diameter has been previously proposed as an alternative to HI with promising results. Our prior study demonstrated the accuracy of extrapolating post-operative HI and CI without CT radiation using White Light Scanning (WLS), a novel 3D imaging modality to measure PE deformity parameters. The purpose of this study was to demonstrate that a significant proportion of postoperative PE patients register severe HI despite a normal appearing chest and normal measurements by another validated metric of severity.

Methods: We conducted a prospective study of pre and postoperative WLS scans in PE patients from 2015-2018. HI and CI were measured in these scans and descriptive analysis assessed the postoperative change in severity indices. Patients with postoperative HI beyond 3.25 despite normal chest appearance and normal CI measurements were identified. Postoperative CI <5% was considered normal, and logistic regression was used to determine if other parameters are associated with a severe HI measurement in an otherwise normal chest. Metrics of chest dimensions assessed include mediolateral (ML) diameter, midclavicular anteroposterior (AP) diameter, and circumference at the level of defect.

Results: A total of 41 patients who underwent repair for PE had complete scan data available for analysis. Nine(22%) patients had estimated HI  ?3.25 despite normal CI and chest wall appearance on post-operative scans. Greater chest circumference (OR: 1.04; CI: 1.01-1.07; p<0.02) and shorter midclavicular AP diameter (OR: 0.91; CI: 0.82-0.98; p<0.03) were significant factors associated with a HI >3.25 despite an otherwise normal chestwall. Figure 1 shows pre and postoperative measurements with common thresholds.

Conclusion: This study demonstrates that HI can register a severity warranting surgical intervention in patients with a corrected PE defect and flat appearing chest. In a preoperative cohort these findings represent a potential for mischaracterization of severity in PE patients that could warrant unnecessary intervention. Future studies will examine modifications to HI and alternatives to improve assessment of severity of PE.

 

96.03 Use of Cryoanalgesia for Pain Management for the Modified Ravitch Procedure in Children

Posted on January 31, 2019

M. Pilkington1, C. M. Harbaugh2, R. B. Hirschl1, J. D. Geiger1, S. K. Gadepalli1  2University Of Michigan Medical School,Department Of Surgery,Ann Arbor, MI, USA 1University Of Michigan,Pediatric Surgery,Ann Arbor, MI, USA

Introduction:  Intercostal nerve cryoablation is one component of the pain management armamentarium for post-thoracic surgery analgesia.  It has been shown to reduce length of stay in the minimally invasive Nuss procedure but its role in the Modified Ravitch has not been explored.  This study aimed to determine the effect of cryoanalgesia on length of stay, opioid use, and complications.

Methods:  We performed a retrospective review of all pediatric patients (<21 years) undergoing a Modified Ravitch procedure between January 1, 2015 and July 31, 2018 at our center. Postoperative analgesia included intercostal cryoablation (IC; n = 9), thoracic epidural (TE; n = 19), or noninvasive analgesia alone (NI; n = 14) at the treating team’s discretion.  Length of stay (LOS), complications, parenteral intraoperative opioids, inpatient analgesic use, and outpatient analgesic prescribing were collected.  Opioids were converted to oral morphine equivalents per kilogram (OME/kg) for comparison. Chi-squared analysis was performed for categorical variables and Kruskal-Wallis H test was used for continuous variables.

Results: The groups had similar patient characteristics except age (IC median 15 years [IQR 14-16]; TE 16 [14-17]; NI 17.5 [17-18.8]; p < 0.001) and chest wall profile (dominant defect pectus carinatum versus excavatum; IC 44.4% carinatum, TE 15.8%, and NI 92.9%; p < 0.01). There was no difference in overall complication rate (IC 33.3%, TE 36.8%, NI 28.8%; p = 0.9). Length of stay, OR time, and opioid use are shown in the table below. 

The use of cryotherapy reduced length of stay compared to patients with a thoracic epidural (4 days vs. 6 days, p < 0.01) and did not impact time in the OR (312 minutes vs. 335 minutes, p = 0.3) or operative time (261 minutes vs. 270 minutes, p = 0.4).  Intraoperative parenteral opioid use was lowest in patients with a TE (0.53, p < 0.01) but did not differ between IC and NI (1.10 vs. 0.89; p = 0.2).  The amount of opioid utilized as an inpatient did not differ (IC 1.48 OME/kg, TE 1.04 OME/kg, NI 1.87 OME/kg) nor did the number of outpatient opioids and refills prescribed (IC 3.34 OME/kg and 22.2%, TE 4.87 OME/kg and 15.8%, NI 3.63 OME/kg and 14.3%; p = 0.3 and p = 0.8).

Conclusion: This is the first study on the use of IC in patients who underwent the Modified Ravitch procedure. In pediatric patients that received invasive analgesia, IC reduced length of stay and provides analogous postoperative pain management with similar use of opioids as compared to patients with a thoracic epidural. The use of cryoanalgesia does not prolong length of time in the operating room, surgical time, nor increase complications compared to thoracic epidural. 

96.02 Laparoscopic Common Bile Duct Exploration for Treatment of Choledocholithiasis in Children

Posted on January 31, 2019

R. E. Overman1, L. Hsieh1, T. Thomas1, S. Gadepalli1, J. Geiger1  1University Of Michigan,Pediatric Surgery,Ann Arbor, MI, USA

Introduction:
The treatment of choledocholithiasis in pediatric patients can be challenging, and the optimal approach has not been identified. Laparoscopic intraoperative cholangiogram (IOC) with common bile duct exploration (CBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are the two interventions commonly utilized in the treatment of choledocholithiasis. We compare our experience with these two techniques in our institution. 

Methods:
With the approval of the University of Michigan IRB, we identified 81 pediatric patients under 18 years of age with suspected choledocholithiasis who underwent laparoscopic cholecystectomy (LC) with IOC/CBDE or ERCP from May 1, 2006 to December 31, 2016. Primary outcomes analyzed were success of intervention and complications.

Results:
Of the 81 patients with suspected choledocholithiasis, 23 patients (28%) underwent an endoscopic intervention prior to LC [20 ERCP, 3 endoscopic ultrasound (EUS)]. Of patients who underwent EUS/ERCP first, 17 had stone or sludge cleared endoscopically, while 6 had normal common bile ducts without evidence of stones or obstruction. Of a total of 34 patients who underwent endoscopic intervention, there were 5 with post-ERCP complications, including pancreatitis, bleeding requiring repeat EGD, and retained CBD stone requiring repeat ERCP. Of the 58 (72%) patients who underwent laparoscopic intervention first, 37 had a negative IOC and required no further intervention, 2 could not have IOC completed, and 19 had IOC positive for choledocholithiasis. 15 patients underwent attempted CBDE, 8 of which were successful. None of the patients who underwent a successful CBDE suffered post-operative complications or required further procedures. Of the 7 patients in whom CBDE was unsuccessful, 5 underwent ERCP with stone extraction, 1 underwent ERCP with no evidence of CBD stone, and 1 had choledocholithiasis resolve without intervention.  In our series, 1 patient suffered cystic duct leak after LC (1.2%).

Conclusion:
Patients with choledocholithiasis who underwent laparoscopic intervention first had fewer complications, and many also avoided a second anesthetic associated with the need for ERCP after LC. While our success rate remains moderate, we believe that with increased standardization, availability of the tools needed, and increased volume that the success rate will increase over time. Our evidence suggests that patients with suspected choledocholithiasis should undergo laparoscopic cholecystectomy first with IOC and CBDE if indicated, with ERCP reserved for patients whose ducts cannot be cleared laparoscopically.

96.01 Practice Patterns and Work Environments that Influence Gender Inequality among Pediatric Surgeons in the US

Posted on January 31, 2019

B. Zhang1,2, M. L. Westfal1,2,3, C. L. Griggs1,2,3, Y. Hung2, D. C. Chang1,2, C. M. Kelleher1,2,3  1Harvard Medical School,Boston, MA, USA 2Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 3Massachusetts General Hospital,Department Of Pediatric Surgery,Boston, MA, USA

Introduction:
Anecdotally in surgery, female surgeons have less robust practices and perform less advanced or less sub-specialized surgical cases than their male colleagues. It is unclear whether these anecdotes are isolated incidents or are true of surgeons throughout the system.

Methods:
Analysis of inpatient and ambulatory cases of board-certified pediatric surgeons in the New York Statewide Planning and Research Cooperative System dataset from 2000-2015 was performed. Two measures of surgeon practice patterns were compared by surgeon gender: (1) percent of case volume that is pediatric surgery-specific (% peds) and (2) Herfindahl-Hirschman Index (HHI), a measure of case mix that quantifies each surgeon’s degree of focus within pediatric surgery. Additionally, surgeons’ work environments were assessed in five ways as based on "network" – the group of colleagues who operated at all hospitals in which the surgeon worked that year: (1) total network case volume (2) network pediatric surgery-specific case volume (3) number of surgeon colleagues (4) proportion of network case volume that each surgeon performed and (5) type of hospital at which each surgeon performed the majority of their cases each year, academic or non-academic. 

Results:
51 surgeons were analyzed (10 female, 19.6%) for 461 surgeon-years (64 female, 13.9%), and 94,979 cases (10,151 female, 10.7%). Case mix of female surgeons had significantly fewer pediatric-specific cases (14.1% peds vs 16.7% peds, respectively, p=0.04) and was less focused than that of male surgeons (HHI 0.16 vs 0.20, p=0.03). Female surgeons worked in networks with fewer surgeon colleagues (7.2 vs 12.1, p<0.01) and with lower total case volumes (388 vs 734, p<0.01) and lower pediatric surgery-specific case volumes (83 vs 159, p<0.01) (Fig. 1). In addition, female surgeons performed a greater proportion of all available work within their networks than male surgeons (49% vs 36%, p=0.04), and the percentage of female surgeons operating at academic surgical centers was not different from that of the male cohort (74.2% vs 72.3%, p=0.99).

Conclusion:

Despite achieving the same levels of sub-specialty training as their male peers and maintaining competitive appointments at academic surgical centers in equal proportion, female pediatric surgeons operate in smaller networks with fewer cases and fewer colleagues. Even though female surgeons perform a greater share of all work that is available to them, they have less sub-specialized practices and caseloads with fewer expertise-building, pediatric surgery-specific cases. Gender disparity in professional achievement may be due to lack of sponsorship and access to large physician networks rather than lower female surgeon productivity.
 

95.02 Feasibility of Axillary Lymph Node Localization Using Radar Reflector Localization

Posted on January 31, 2019

S. A. Morris1, D. Henry2, W. Sun2, C. Laronga2, M. C. Lee2  1University Of South Florida College Of Medicine,Tampa, FL, USA 2Moffitt Cancer Center And Research Institute,Breast Surgical Oncology,Tampa, FL, USA

Introduction: Radar reflector localization (RRL) has been identified as an effective means of guiding excision of non-palpable breast lesions compared to traditional wire localization (WL). With increasing data supporting selective or targeted axillary dissection for node positive breast cancer after neoadjuvant chemotherapy (NAC), we sought to evaluate the feasibility of RRL to assist the excision of biopsy-proven or suspected metastatic axillary lymph nodes.

 

Methods: A retrospective chart review of all suspected or biopsy-proven node positive patients who underwent RRL of an axillary lymph node to guide surgical extirpation as a selective axillary nodal excision (SANE), targeted axillary dissection (TAD) or axillary lymph node dissection (ALND) between 1/2017 and 5/2018 was conducted. Clinical and demographic data were collected. Descriptive statistics were performed.

 

Results: A total of 42pts had a radar reflector placed in/adjacent to a biopsy-proven or suspected metastatic axillary lymph node a median of 7.5 days prior to surgery (range: 1-139 days). 33 (79%) nodes had a clip placed at the time of diagnostic biopsy, if one was performed. At the time of surgery, the median pt age was 56 years (range: 21-75 years), with 41 (98%) having ductal histology, 18 (43%) with hormone-positive only breast cancer and 21 (50%) undergoing mastectomy. A total of 9pts (21%) had surgery first, 29pts (69%) after NAC, and 4pts (9.5%) for an axillary recurrence (ipsilateral and contralateral). TAD was performed in 34pts (81%) using dual-tracer sentinel lymph node (SLN) biopsy concurrent with RRL; in 33/34 (97%) specimens the RRL node was also identified as a SLN. One pt failed SLN mapping. Of the remaining pts, 4 (9.5%) underwent ALND alone and 4 (9.5%) underwent RRL SANE. The median number of nodes in a RRL specimen was 1 (range: 1-6). The median number of SLNs removed was 3 (range: 0-9). The radar reflector was recovered in all cases, and surgeons did not report any intraoperative or postoperative complications. The median number of positive nodes in the RRL surgical specimen was 1 (range: 0-3). One pt had a discordant FNA of a suspicious axillary lymph node, final pathology was negative. Of the 29pts having NAC, 29 (100%) RRL nodes were positive or showed treatment effect and 11/29 (38%) had a complete pathologic response.

 

Conclusion: RRL is feasible to guide excision of suspected or biopsy proven lymph nodes in the axilla of a breast cancer patient and can be utilized with minimal risk of complications. Further investigation is warranted to compare RRL to WL.

93.04 Eliminating the learning curve: the case for the recessed video stylette in global surgery.

Posted on January 31, 2019

A. N. Bowder2, R. Amin1, L. McCormick3, S. Siddiqui1,3  1Children’s Hospital Of Wisconsin,Pediatric Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,General Surgery,Milwaukee, WI, USA 3Brio Device,Ann Arbor, MICHIGAN, USA

Introduction: There is a paucity of anesthesia providers worldwide. This severe shortage in the global surgery workforce has left billions of people without access to surgical care. A recent study by the World Federation of Societies of Anesthesiologists surveyed 153 countries and found there to be a limited number of physician anesthesia providers (PAP) in low and middle-income countries (LMICs). In the African and South East Asian Regions alone, there are on average 1.36 and 1.20 PAP. The global community continues to search for innovative solutions aimed at safely decreasing the discrepancy between anesthesia providers and the burden of surgical disease. We propose that the creation of an intuitive and safe intubation tool could be integral to increasing the anesthesia workforce globally.

Methods: We performed an IRB-approved single center prospective comparison of mannequin intubation by medical students using an articulating video stylet (AVS) and the Olympus bronchoscope. The device used first was alternated between consecutive participants to account for any learning effect.  Five successful intubations were completed with each device.  Time to intubation was measured from when the participant picked up the instrument until the tip had passed beyond the vocal cords.  The number of passes to successful intubation was also recorded.

Results:A total of 19 participants were recruited. The learning curve was noted to be less steep with the AVS (Table1). Intubation time was significantly shorter with use of the AVS. The mean intubation time for the AVS was on average 25.2 seconds less than for the bronchoscope (P<0.0001).  Additionally, more than one attempt were only required in 6% of the intubations using AVS compared to 18% with the bronchoscope (P=0.0057).

Conclusions:This study demonstrates the feasibility of creating an intubation device with little to no learning curve when performed in a standardized mannequin. These results merit continued development. We also will need to complete larger research trials aimed at validating our findings and evaluating the clinical safety of this device. If we are able to prove that the AVS is able to safely, decrease the learning curve in the clinical setting it has the potential to address the shortage of anesthesia providers promptly. Over fifty percent of countries surveyed reported 4 or more years of training required for a PAP. If we are able to decrease this training time even slightly we can make great strides towards reducing the overall burden of surgical disease. Furthermore, this innovative technology can be used by the global community as they develop sustainable task shifting models for non-physician anesthesia provide in LMICs

 

89.17 An Easily Reproducible 3D Printed AAA Model Using Open Source Digital Tools

Posted on January 31, 2019

J. Coles-Black1, J. Chuen1  1Austin Health,Department Of Surgery,Heidelberg, VICTORIA, Australia

Introduction:
There has been strong interest in the application of 3D printing to Vascular Surgery. However, consistently major barriers to uptake include the lack of technical expertise amongst surgeons, and the perceived cost of 3D printing technologies. We present a low-cost, low-complexity, easily reproducible CT-to-3D-printed-model workflow developed using open source software packages and inexpensive desktop 3D-printers.

Methods:
Using 3D Slicer (version 4.5; Harvard, US, 2015), abdominal CT aortogram DICOM datasets were automatically segmented using the "Threshold" function. The "Dilate" and “Subtract Scalar Volume” functions were used to generate a 3D hollow vessel. The mural thrombus was isolated using the "Volume Clip" extension. This was subtracted from the luminal contents in order to create a non-intersecting thrombus model. The model was printed on a Filament Fused Deposition Modelling 3D Printer (Makerbot Replicator 2X; Stratasys, Minnesota, USA). The subsequent 3D printed model was shown to experienced vascular surgeons, who rated its utility for the preoperative planning of complex cases.

Results:
The model was well received, with immediate requests for more models. Manual inspection of the physical model was felt to be a valuable addition to standard CT angiogram reconstructions, especially in tortuous or complex aortic aneurysms. Hollow flexible models were deemed particularly useful for rehearsal of endograft insertion and positioning via the iliac arteries, and in predicting the trajectory of guidewires and devices.

Conclusion:
There are clear applications for 3D printing in the field of Vascular Surgery, with positive feedback from the assessed cohort of experienced surgeons that the AAA models would be useful in challenging cases.

89.14 The feasibility of hepatectomy with vascular reconstruction to treat the liver tumor

Posted on January 31, 2019

A. Li1, A. Li1  1Eastern Hepatobiliary Surgery Hospital,Division Of The 2nd Special Treatment,Shanghai, SHANGHAI, China

Introduction:

Radical surgery remains the main treatment for the patients with liver cancer,But resectability rate is low when clinically diagnosed, portal vein,hepatic vein or inferior caval vein invaded by tumors are a few of the  main reasons.How to increase resectability ofliver cancer still is very challenging to the clinician. This study was clone to explore the feasibility of the new surgical approach for the treatment of liver cancer with portal vein,hepatic vein or inferior caval vein invasion. 

 

Methods:

25 patients received hepatectomy with vascular reconstruction between February 2011 and June 2018.  15 patients with ICC underwent hepatectectomy combined with portal vein resection and vascular reconstruction and 5 patients with ICC underwent hepatectomy combined with inferior caval vein resection and vascular reconstruction. 4 patients with HCC underwent hepatectomy combined with inferior caval vein resection and vascular reconstruction, 1 patient with HCC underwent hepatectomy combined with hepatic vein resection and vascular reconstruction.

Results:

There was no surgery related death. After surgery,3 patients died 10 months later, 20 patient died 24 months later, two patients survived for over 3 years and one patient over 4 years.

Conclusion:

Hepatectomy with vascular reconstruction for patients with carcinoma of the liver invading portal vein,hepatic vein or inferior caval vein has been proved to be a safe treatment, it could improve the resectability of the tumor and prolong survival.

 

89.13 The Current Landscape of 3D Printing in Endovascular Intervention

Posted on January 31, 2019

J. Coles-Black1, J. Chuen1  1Austin Health,Department Of Surgery,Heidelberg, VICTORIA, Australia

Introduction:
3D printing has started to establish itself as an adjunct to endovascular procedures, where the ability to visualise complex anatomy with physical 3D models provides better anatomical clarity than can be achieved with 3D reconstructions or 2D imaging modalities.

Methods:
We performed a literature search using Ovid MEDLINE, Ovid EMBASE and PubMed. The search terms used were “Printing, Three-Dimensional” AND “Vascular Surgery” AND “Endovascular”. This resulted in 18 articles, which were independently read in full to identify relevant studies. The findings from these studies were then compared against our own centre’s experiences with the technology.

Results:

Our literature search identified 10 publications reporting on the use of 3D printing in endovascular procedures, of which 3 (30%) related to the planning of fenestrated grafts. In 6 (60%) of the articles, the 3D printed models were used for simulation. The vast majority (80%) of articles utilised the 3D printed models for interventional planning. In addition, in 100% of cases, the 3D printed models developed for the studies did not degrade after simulation or manual interrogation. Despite this, only 3 (30%) of articles involved the use of 3D printed models for trainee education.  Therefore, we highlight the largely untapped potential for these models to be reused for trainee education, which was not explored in the majority of articles.

The studies’ conclusions correlate with our own experiences from our 3D printing lab, where expert vascular surgeons have deemed 3D printed models valuable in the planning of complex cases, such as in cases with short or very angulated

Conclusion:

Vascular Surgery units worldwide, including our own, are starting to explore the applications of 3D printing in endovascular surgery. We attest to the enormous potential for growth in this field, and the ease of adoption of this new technology.

 

89.11 Report of a Single Center Experience of Intrabronchial Valve Placement

Posted on January 31, 2019

S. Gupta1,2, T. L. Demmy1,2, M. Hennon1,2, C. Nwogu1,2, A. Picone1,2, S. Yendamuri1,2, E. U. Dexter1,2  1State University Of New York At Buffalo,Medicine,Buffalo, NY, USA 2Roswell Park Cancer Institute,Thoracic Surgery,Buffalo, NY, USA

Introduction:
Prolonged air leak (PAL), defined as an air leak present for longer than 5 days, occurs in 4-9% of patients following lung resection (LR). Bronchoscopic intrabronchial valve (IBV; Olympus, Redmond, WA) placement is an FDA-approved treatment for PAL after LR.  IBV placement is also used off-label in other conditions such as spontaneous pneumothorax, severe emphysema and bronchopleural fistula. We conducted a retrospective review of our institutional outcomes after IBV placement.

Methods:
Twenty four patients had a total of 28 IBV placements between 8/2013-6/2017. Presence of air leak was determined by measuring air leak flow using a digital chest drainage system or by visual confirmation of bubbling in the water seal chamber of a pleural drainage reservoir. Removal of IBV is performed 6 weeks after air leak resolution. One patient with severe bullous emphysema had no air leak at the time of IBV placement.

Results:
Most patients had 3-5 IBV placed (see Table 1). Twelve patients had IBV placement after LR and 7 patients for spontaneous pneumothorax (n=6) or bullous emphysema (n=1; EMPH). LR included 7 lobectomy, 2 bilobectomy, 2 wedge resection, and 1 exploratory thoracotomy with unplanned wedge resection. Air leak resolution among 11 LR patients occurred at most 1 week after IBV placement for 6 patients, 2 weeks for 2 patients, 1 month for 1 patient, and 2 months for 2 patients. All patients with IBV post LR had chest tube removal prior to discharge (n=2) or management as an outpatient (n=10). Ten patients in the LR group are alive with follow up ranging from 14-59 months. For the two LR patients who died, death occurred 354 days and 389 days following IBV placement. Five EMPH patients were discharged from the hospital with resolved air leak, but only 2 are alive. Among the 5 EMPH patients with PAL resolution, duration of leak post-IBV was at most 1 week for 2 patients, 1 month for 1 patient, and 2 months for 2 patients. Death in the 5 EMPH patients occurred 10, 45, 63, 187 and 487 days following IBV procedure. Patients who had surgery for pleural disease (PD) developed PAL due to intraoperative lung damage. Although there was good resolution of air leak with IBV for PD, like EMPH patients, survival was low. Two patients with bronchopleural fistula associated with empyema had IBV placement of 1 valve each with resultant blockage of the fistula. Both are alive.

Conclusion:
IBV placement has a good success rate in resolving PAL after LR and enabled hospital discharge. The higher death rate in EMPH and PD patients following IBV placement may be impacted by underlying medical disease. In order to identify patients appropriate for IBV placement or factors that influence outcomes after IBV placement, further study is needed.
 

89.08 Implementation of direct transcranial cerebral hypothermia during cardiopulmonary bypass: A feasibility study

Posted on January 31, 2019

M. T. Cain1, S. Greenberg2, P. Pearson1  1Medical College Of Wisconsin,Division Of Cardiothoracic Surgery/ Department Of Surgery,Milwaukee, WI, USA 2University Of Chicago,Department Of Anesthesiology Critical Care,Chicago, IL, USA

Introduction:
Induction of systemic hypothermia is a common technique during cardiac surgery to aid in tolerance of low flow states associated with cardiopulmonary bypass (CPB). Reduced regional blood flow, hemodilution from the CPB circuit, and cerebral hyperthermia during the rewarming phase of CPB all place patients at risk for neurological injury or dysfunction. A simple, practical, and safe intraoperative tool for selective cerebral hypothermia could provide the neuroprotective advantages of systemic cooling without the adverse effects of hyperthermic rebound.  Here we present results on the feasibility of utilizing an external transcranial cerebral cooling device (WElkins Portable Temperature Management System, Welkins,LLC Downers Grove, IL), in conjunction with conventional intraoperative monitors, for cerebral cooling during cardiac surgery requiring CPB.

Methods:
Prospective core and tympanic patient temperature data was collected for all subjects. Patients were fitted with the cooling device after placement of traditional monitors and intraoperative positioning. Cooling was initiated and temperatures were monitored at 20 minute intervals throughout each procedure, and during the first 6 hours of immediate postoperative intensive care unit (ICU) recovery. Systemic cooling procedures via CPB circuit was not adjusted due to device implementation. Outcome variables included device failure rate, cerebral temperature reduction by tympanic probe, resource burden for implementation,  device disruption of standard patient monitoring devices, and adverse device events including alopecia, pressure ulceration, or skin damage.

Results:
A total of 18 patients underwent device placement. Complete data was obtained on 16 patients. There were no device failures, however there were two early device discontinuations related to persistent postoperative hypothermia (11.1%). Mean tympanic temperature reduction was 1.0°C  intraoperatively (0.5-1.6°C) and 1.2°C during ICU recovery (0.5-1.9°C) relative to core temperature.  No harms or interference with standard patient monitoring devices were noted, and device implementation required a mean technician time of 245 minutes intraoperative and 261 minutes postoperatively.

Conclusion:
External transcranial selective cerebral cooling is a feasible technique that can be performed in conjunction with standard patient monitoring devices without evidence of local skin or hair damage, or interference with patient care in this early data series. Expanded use of this device is required to further characterize its benefit on neurological outcomes after cardiac surgery.
 

89.07 A Prototype for the Assessment of Limb Tissue Oxygenation Under Non-pulsatile Conditions

Posted on January 31, 2019

E. O. Cruz1, Y. Sanaiha1, V. Dobaria1, P. Benharash1  1University of California Los Angeles,Cardiac Surgery,Los Angeles, CA, USA

Introduction:
Near infrared spectroscopy (NIRS) is a non-invasive commercially available method for measuring tissue oxygenation. However, cost and reliability have limited its widespread use. Currently, there is no cost-effective method to assess tissue oxygenation under non-pulsatile conditions such as cardiopulmonary bypass. Such a device might improve the reliable detection of limb ischemia and direct interventions to avoid permanent injury. 

Methods:
The device used in this study consisted of a single photodetector and a pair of red (660 nm) and infrared (880 nm) light emitting diodes (LEDs) selected to discriminate between the absorption of oxymyoglobin and deoxymyoglobin at a depth of about 1cm. The LEDs and signals (20 point running average) were multiplexed and recorded at 100 Hz on a PC. Nine healthy volunteers were examined while a blood pressure cuff was used to first disrupt venous (30 mmHg x 90 seconds) and subsequently arterial flow (200 mmHg x 30 seconds). The red/infrared (R/IR) transmission ratio was calibrated and then recorded for each subject. A Wilcoxon-Mann-Whitney test was used to determine the significance of signals during each period of occlusion compared to the baseline noise, using alpha level P<0.05.

Results:
Amongst all volunteers, the amplitude of the average noise, or deviation from the baseline R/IR ratio, was 0.0091 +/- 0.004. At an average of 90 seconds after venous occlusion, the R/IR ratio decreased by 0.033 +/- 0.021 (P=0.01). Venous occlusion resulted in signal depression greater than the noise for that specific trial in 77.8% of participants, and the median signal to noise ratio was 16.49. After an average of 30 seconds of arterial occlusion, the R/IR ratio decreased by 0.035 +/- 0.008 (P<<0.01). All trials produced a signal depression greater than the noise during arterial occlusion, and the median signal to noise ratio was 10.92. In addition, a significant hyperemic rebound was detected following the restoration of arterial flow in 77.8% of trials.

Conclusion:
This simple device appears to successfully detect changes in tissue oxygenation under non-pulsatile settings. Further studies and adjustments to decrease system noise and add additional depths are warranted. The utilization of this simple NIRS system in patients on extracorporeal life support or cardiopulmonary bypass may assist in the early detection of limb ischemia.
 

89.04 Outcomes with Percutaneous Right Ventricular Assist Device following Left Ventricular Assist Device

Posted on January 31, 2019

S. K. Sundararajan1, M. Cain3, B. Badu3, L. Durham3, L. Joyce3, N. Gaglianello2, D. Ishizawar2, M. Saltzberg2, D. Joyce3, A. Mohammed2  1Medical College Of Wisconsin,General Internal Medicine/Medicine/Medical College Of Wisconsin,Milwaukee, WI, USA 2Medical College Of Wisconsin,Cardiology/Medicine/Medical College Of Wisconsin,Milwaukee, WI, USA 3Medical College Of Wisconsin,Cardiothoracic Surgery/Surgery/Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction:
Right ventricular (RV) failure is a frequent complication of left ventricular assist device (LVAD) implantation in patients with end-stage heart failure, impacting 20% of patients. RV failure post LVAD is associated with 40% 1-year mortality. Percutaneous support can be used in this scenario, however data supporting this approach is lacking. 

Methods:
A retrospective review was conducted of all patients who developed severe RV failure requiring use of a right internal jugular placed percutaneous right ventricular assist device (RVAD) following durable LVAD implant at our academic institution between 01/01/2017 and 07/31/2018. Patient demographics were reviewed in addition to key hemodynamic and laboratory values were collected pre-RVAD implantation (immediately prior to cannulation) and at the time of explant (post-RVAD). Pre-RVAD and post-RVAD data was compared using paired T tests. Survival at 30 days or at date of hospital discharge (whichever was longer) was considered as the primary outcome. Patient hemodynamic measures were evaluated as secondary outcomes.

Results:
Of 41 patients who received LVAD, 10 (24%) developed severe RV failure postoperatively. Baseline characteristics include age 51±14.5 years, with 30% females. Incidence of ischemic cardiomyopathy was 20%. Most patients received LVAD as destination therapy (80%). RVAD support via percutaneous cannulation was maintained for a median duration of 15.5 days (Range – 7 to 23 days). Survival at 30 days or to hospital discharge was 100%. RVAD support was successfully weaned in 9 patients (90%), while the remaining 1 patient underwent cardiac transplantation. We observed a reduction in central venous pressure from 17.2±4.5 mm(Hg) to 11±3.1 mm(Hg), p=0.004 and an increase in LVAD flow from 4.5±0.8 l/min to 5.1±0.4 l/min, p=0.018. There was a trend towards increase in mixed venous oxygen saturation from 61.5±11.1% to 67.0±7.0%, p=0.224. Other biochemical parameters collected at the time of percutaneous RVAD support and 24-48 hours after RVAD explant are described in the table below.

Conclusion:
Use of a right internal jugular placed percutaneous RVAD for treatment of severe RV failure after LVAD implantation provides superior early postoperative survival than traditional management techniques. These findings support broader implementation of this technique to further characterize its benefit.

89.02 Algorithm-Based Troubleshooting for Bleeding during Thoracoscopic Anatomic Pulmonary Resections

Posted on January 31, 2019

H. Igai1, R. Yoshikawa1, F. Osawa1, T. Yazawa1, M. Kamiyoshihara1  1Japanese Red Cross Maebashi Hospital,Department Of General Thoracic Surgery,Maebashi, GUNMA, Japan

Introduction: Few studies have reported on the effects of intraoperative complications such as vessel injury during thoracoscopic anatomic pulmonary resections. We evaluated intraoperative vessel injury and assessed troubleshooting methods during thoracoscopic anatomic pulmonary resections.

Methods: Between April 2012 and March 2018, 378 patients underwent thoracoscopic anatomic pulmonary resection, 40 of whom were identified as having intraoperative vessel injury. Significant vessel injury was defined as bleeding that needed compression times of more than 30 seconds for hemostasis. In our department, we treat significant bleeding based on the algorithm shown in Figure 1. We analyzed the injured vessel and the hemostatic procedure employed, then compared the perioperative outcomes in patients with (n=40) or without (n=338) vessel injury. Additionally, we examined the data on a year-by-year basis from April 2012, and perioperative results were compared in each year.

Results: The surgical procedures examined included 32 lobectomies (80%) and 8 segmentectomies (20%). The vessel injured was a branch of the pulmonary artery in 22 cases (55%), a branch of the pulmonary vein in 13 (32.5%), and a different vessel in 5 (12.5%). The procedure was converted into a thoracotomy in five cases (12.5%) to achieve hemostasis. Hemostasis was achieved by applying a thrombostatic sealant in 26 cases (65%), compression with a cotton stick or adjacent lung parenchyma in 10 (25%), and some other way in 4 (10%).
Although patients without vessel injury had a shorter operation time (207 vs 240 min., p=0.0005), less intraoperative blood loss (53 vs 286ml., p<0.0001), and shorter duration of chest tube drainage (3 vs 3.9days, p=0.02), there were no significant differences in the length of postoperative hospitalization (8 vs 13days, p=0.14) or morbidity (15 vs 23%, p=0.25).
The occurrence rate of intraoperative significant bleeding in the last year measured was similar to that in the first year measured (6.8 vs 10.5%, p=0.23), although other perioperative results had significantly improved in that time frame.

Conclusion: Thoracoscopic anatomic pulmonary resection is feasible and safe if the surgeon performs appropriate hemostasis although vascular hazards might be inherent during thoracoscopic anatomic pulmonary resection, regardless of surgeon’s experience. Application of sealants and compression techniques using a cotton stick or adjacent lung parenchyma are important techniques to achieve hemostasis in the event of significant vessel injury during thoracoscopic anatomic pulmonary resection.

 

80.08 Superiority of esophageal reconstruction by pedicled jejunal flap with microvascular augmentation

Posted on January 31, 2019

G. Takiguchi1, T. Nakamura1, H. Hasegawa1, M. Yamamoto1, Y. Matsuda1, S. Kanaji1, K. Yamashita1, T. Oshikiri1, T. Matsuda1, S. Suzuki1, Y. Kakeji1  1Kobe University Graduate School of Medicine,Gastrointestinal Surgery,Kobe, HYOGO, Japan

Introduction: The safe and secure esophageal reconstruction method in patients whose stomach is unavailable is still unsettled issue. Recently, the number of cases using pedicled jejunum flap (PJF) as an alternative conduit are increasing when the stomach is unavailable. The objective of this study is to elucidate advantages of reconstruction by PJF.

Methods: Forty-nine patients whose stomach was unavailable for the conduit following esophagectomy were enrolled in this study: 10 patients underwent ileo-colon (IC) reconstruction after esophagectomy from January 2005 to January 2011; after that 39 patients underwent esophageal reconstruction by PJF with microvascular augmentation from February 2011 to January 2018. Surgical outcomes, complications, perioperative serous albumin levels and postoperative body mass index (BMI) changes were retrospectively reviewed and compared between IC and PJF group.

Results:Anastomotic leakage rate was significantly lower in PJF group than those of IC group (10.3 % vs. 50.0 %, P=0.011). There was no severe diarrhea in PJF group while 30.0 % was observed in IC group. The mean serum albumin level was higher all through the postoperative period in PJF group than IC group. Especially, PJF group showed significant better recovery of serum albumin level compared to IC group at two weeks after operation (2.70 g/dl vs 2.20 g/dl, P=0.003). The mean decrease rate of postoperative BMI was lower in the PJF group than in the IC group. In the IC group, one patient died due to the postoperative pneumonia and brain infarction, but there was no mortality in the PJF group.

Conclusion:The reconstruction by PJF with microvascular augmentation following esophagectomy was superior to reconstruction by IC at the point of anastomotic leakage and severe diarrhea. Also, PJF has an advantage in earlier recovery of postoperative serum albumin level and keeping the body weight than IC. PJF might be a better choice for reconstruction after esophagectomy than IC in patients whose stomach is unavailable.
 

 

79.08 Using Myoglobin as Serum Marker in Administering Renal Protective Therapy in Electrical Burn Patients

Posted on January 31, 2019

J. H. Henderson1, P. Attaluri1, E. He1, J. Kesey1, M. Tan1, J. Griswold1  1Texas Tech University School of Medicine,Department Of Surgery,Lubbock, TEXAS, USA

Intro: Electrical high-voltage contact injuries are the second leading cause of occupational death in the U.S. The electrical surge encounters muscle cells, causing sudden and intense myocyte contraction, releasing intracellular contents such as myoglobin and creatine kinase (CK). The released pigments cause obstruction of renal tubules leading to acute renal failure. Currently, the trauma literature supports use of elevated serum CK to indicate muscle and renal damage. While CK can be a reliable screening method for muscle injury, we believe myoglobin is a more sensitive and specific indicator of risk and severity of renal damage. Our study aims to determine whether elevated CK or elevated myoglobin is more sensitive in predicting the risk of renal injury for electrical burn patients and to define parameters of serum myoglobin for implementing renal protective therapies.

Methods: A retrospective, single institution review was conducted on all patients over the age of 18 years who suffered a high voltage electrical injury (>1,000 volts) admitted to the Burn Center from 2006 to 2017. Patients who had preexisting end stage renal disease, were on dialysis, or died within 48 hours of admission were excluded. Chi-Square Testing was used to compare means in serum myoglobin and serum CK levels collected daily and acute kidney injury (AKI) as defined by the RIFLE criteria, which breaks AKI into three categories Risk, Injury, and Failure. Urine output and fluid resuscitation therapies were collected daily to track the progression of AKI. A Pearson product-moment correlation coefficient was computed to assess the relationship between AKI and serum myoglobin and serum CK. An independent sample mean's test was performed on patients who developed AKI to determine a serum myoglobin threshold for initiation of treatment.

Results: A total of 207 patients were analyzed 2006-2017; 27.1% of patients developed AKI as defined by RIFLE criteria. Mean serum myoglobin in patients with AKI was found to be 2,336.9 vs. no AKI 1,140.14 (P=0.0001). Mean serum CK level in patients with AKI was found to be 10,926 vs. no AKI 8,174 (P=0.132). There was a positive correlation between serum myoglobin levels and developing AKI (r = 0.212, n = 120, p = 0.02), whereas there was no statistically significant correlation between serum CK levels and AKI. Patients with myoglobin level 1,449.52 or above are at high risk of developing AKI (P=0.053) and require renal protective measure.

Conclusion: Serum myoglobin is a more sensitive marker for predicting AKI when compared to serum CK in high-voltage electrical burns. A serum myoglobin threshold of >1500 was associated with increased risk of AKI, indicating the need to start renal protective therapies. Although trauma and rhabdomyolysis patients’ CK may be useful for indication of risk of renal damage, in electrical contact injuries myoglobin must be used to determine risk of renal damage and to direct renal protective therapy.

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