Central Surgical Association PROGRAM

Central Surgical Association

PROGRAM OF THE 70TH ANNUAL MEETING

Omni Amelia Island Plantation Amelia Island, Florida

Thursday, Friday and SaturdayMarch 14–16, 2013

Continuing Medical Education portion by the American College of Surgeons

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The Central Surgical Association wishes to recognize and thank the following companies for

their ongoing support through educational grants:

Ethicon

The following companies will be exhibiting at the 2013 Annual Meeting:

ACell, Inc

Baxter Biosurgery

Cadence

Covidien

Cubist Pharmaceuticals

Karl Storz Endoscopy America

RF Surgical Systems, Inc.

Sanofi Biosurgery

W.L. Gore & Associates

GRANT ACKNOWLEDGEMENT

EXHIBITOR ACKNOWLEDGEMENT

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170TH ANNUAL MEETING 2013

Central Surgical Association

70TH ANNUAL MEETING

Amelia Island, FloridaMarch 14 –16, 2013

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FUTURE MEETINGS

2014 March 6-8 Indianapolis, Indiana2015 March 5-7 Chicago, Illinois2016 March Montreal, Quebec

2 CENTRAL SURGICAL ASSOCIATION

TABLE OF CONTENTS

A Exhibitors 4 Special Notes 6 Officers and Councilors, Society Representatives, Committees

8 Learning Objectives, Accreditation Statement And Disclosure Statement

9 Program and Activities

15 Scientific Program

27 Abstracts

109 “Best Paper by a New Member” Award

112 In Memoriam

113 Elected to Membership at the Annual Meeting in March 2012

115 2013 Membership Listing

241 Geographical Listing

263 Past Officers

271 Constitution and Bylaws


TABLE OF CONTENTS (continued)

287 Central Surgical Association Foundation Board of Directors and Committee Members289 Contributors

295 Enrichment Awards

299 Notice of Change

300 Notice of Death

301 Past Annual Meeting Locations


SPECIAL NOTES

The Omni Amelia Island Plantation Resort will serve as the headquarters for the 2013 CSA Annual Meeting. The registration desk will be open from 3:00 pm to 6:00pm on Wednesday, March 13th and will remain open during the meeting hours on March 14-16. The CSA Registration Desk is located at the Amelia Concierge Desk. All scientific sessions will be held in the Omni Amelia Island Plantation Resort. Continental breakfast will be available for physicians on Thursday-Saturday mornings beginning at 7:00am. Spouses and companions can enjoy breakfast Thursday and Friday mornings from 8:00am-10:00am and on Saturday morning they can join the physicians for breakfast. Meeting registrants are encouraged to visit the tabletop exhibits during breakfasts and refreshment breaks on Thursday and Friday. A Welcome Reception will be held on Thursday, March 14 at Sunrise Beach from 6:30pm-8:30pm. The Annual Reception and Dinner will be held on Friday, March 15 in the Amelia 3,4 from 7:00pm-10:00pm. Members, registered guests and spouses are cordially invited and encouraged to attend. Business or resort attire is recommended for the Welcome Reception and the Dinner Dance is business or black tie optional. Cost for the evening events is included in the registration fee for all physicians and spouses.


SPECIAL NOTES (continued)

The Executive Council reminds its membership the contact information for the Central Surgical Association is:

WEBSITE

www.centralsurg.org

ADDRESS

5019 W. 147th StreetLeawood, KS 66224

PHONE

(913) 402-7102

FAX

(913) 273-1140

EMAIL

[email protected]

PLEASEMAILANYREGISTRATIONORDUESPAYMENTSTO:

Central Surgical Association PO Box 413216 Kansas City, MO 64141


OFFICERS AND COUNCILORS 2012-2013

President Gerald M. Larson 2012-2013

President-Elect Nathaniel J. Soper 2012-2013

Secretary Fred A. Luchette 2012-2015

Treasurer Scott A. Gruber 2011-2013

Recorder W. Scott Melvin 2011-2014

Councilors Herbert Chen 2012-2015Gerald M. Fried 2012-2013Margo C. Shoup 2011-2014 Representatives to the . . .

AmericanBoardofSurgeryChristopher R. McHenry 2012-2018 Cleveland, OH BoardofGovernorsAmericanCollegeofSurgeonsFred A. Luchette 2011-2014 Chicago, IL AdvisoryCouncilforSurgeryAmericanCollegeofSurgeonsTina W.F. Yen 2012-2018 Milwaukee, WI


OFFICERS AND COUNCILORS 2012-2013 (continued)

ProgramCommitteeRonald J. Weigel (Chair) 2012-2013Mark K. Eskandari 2010-2013Timothy A. Pritts 2011-2014P. Marco Fisichella 2011-2014 Robert C.G. Martin 2012-2015 Kenric M. Murayama 2012-2015 Ex Officio Fred A. Luchette W. Scott Melvin MembershipAdvisoryCommitteeM. Ashraf Mansour (Chair) 2010-2013Doug B. Evans 2010-2013Jon C. Gould 2010-2013Scott M. Wilhelm 2010-2013David F. Canal 2011-2014Joseph J. Sferra 2011-2014Betty J. Tsuei 2011-2014Jeffrey D. Wayne 2011-2014L. Michael Brunt 2012-2015 Ex Officio Fred A. Luchette

AuditingCommitteeBenoit Blondeau (Chair) 2012-2013Patrick S. Vaccaro 2012-2013

NominatingCommitteeWilliam D. Turnipseed (Chair) 2010-2013Michael S. Nussbaum 2011-2014Gerald M. Fried 2012-2015K. Craig Kent 2012-2013Merril T. Dayton 2012-2013


EDUCATIONAL OBJECTIVES

LEARNINGOBJECTIVESThis program has been constructed by the Program Committee of the Central Surgical Association and has been selected from abstracts submitted by the membership of the Association. The subject matter selected is a cross-section of the cutting edge of surgical practice today. The intention of the program is to add to the basic knowledge and understanding of surgical disease, to analyze the result of new approaches or techniques for managing disease and to examine new concepts in surgical science.

DISCLOSURESTATEMENTIn compliance with ACCME Accreditation Criteria, the American College of Surgeons, as the accredited provider of this activity, must ensure that anyone in a position to control the content of the educational activity has disclosed all relevant financial relationships with any commercial interest. All reported conflicts are managed by a designated official to ensure a bias-free presentation. Please see the insert to this program for the complete disclosure list. ACCREDITATIONSTATEMENTThis activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the American College of Surgeons and the Central Surgical Association. The American College of Surgeons is accredited by the ACCME to provide continuing medical education for physicians. AMAPRACATEGORY1CREDITS™The American College of Surgeons designates this live activity for a maximum of 15 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Of the AMA PRA Category 1 Credits™ listed above, a maximum of 13.25 credits meet the requirements for Self-Assessment.

American College of SurgeonsDivision of Education


SCHEDULE OF

EVENTS


SCHEDULE OF EVENTS

Wednesday,March13,2013

2:30pm - 3:30pmFoundationBoardMeetingOssabaw B

3:00pm - 6:00pmExhibitSet-UpAmelia 2,3 3:00pm - 6:00pmRegistrationOpenAmelia Foyer

3:30pm - 5:30pmCouncilMeetingOssabaw A

7:00pm - 10:00pmPresident’sDinnerSunrise Café & Terrace

Thursday,March14,2013

6:00am - 7:00amExhibitSet-UpAmelia 2,3

6:30am - 12:30pmCSARegistrationAmelia Foyer


SCHEDULE OF EVENTS (continued)

7:00am - 8:00amContinentalBreakfastforPhysiciansAmelia 2,3

7:00am - 12:30pmExhibitsOpenAmelia 2,3

8:00am - 10:00amSpouse&CompanionBreakfastOceanview Terrace

8:00am - 10:00amCasePresentations:GI/Colorectal;Hepatobiliary;Vascular;EndocrineAmelia 1

10:00am - 10:15amRefreshmentBreak&ExhibitsAmelia 2.3

10:15am - 12:30pmScientificSessionIAmelia 1

12:30pmAfternoonfree

1:15pm - 6:00pmCSAGolfOutingOak Marsh

1:30pmCSATennisOutingOmni Hotel Tennis Courts



1:15pm - 5:00pmCSAOptionalToursOff Property 6:30pm - 8:30pmWelcomeReceptionOceanview Terrace

Friday,March15,2013

7:00am - 5:45pmCSARegistrationAmelia Foyer

7:00am - 8:00amContinentalBreakfastforPhysiciansAmelia 2,3

7:00am - 4:15pmExhibitsOpenAmelia 2,3

8:00am - 10:00amSpouse&CompanionBreakfastOceanview Terrace

8:00am - 9:30amScientificSessionIIAmelia 1

9:30am - 10:00amRefreshmentBreak&ExhibitsAmelia 2,3



10:00am - 11:15amScientificSessionIIIAmelia 1

11:15am - 11:30amCSAFoundationAwardsAmelia 1

11:30am - 12:15pmAddressofthePresidentAmelia 1

12:15pm - 1:15pmPresident’sLuncheonforNewMembersTalbot

1:15pm - 4:00pmScientificSessionIV-AAmelia 1

1:15pm - 4:00pmScientificSessionIV-BAmelia 4

4:00pm - 4:15pmRefreshmentBreakAmelia 2,3

4:15pm - 5:15pmDEBATE:EmploymentModelsforSurgeons—GeneralSurgeonsasHospitalEmployeesAmelia 1

5:15pm - 5:45pmAnnualBusinessMeetingAmelia 1



4:15pmExhibitTeardownAmelia 2,3

7:00pm - 8:00pmReceptionAmelia Foyer

8:00pm - 11:00pmAnnualDinner&DanceAmelia 3,4

Saturday,March16,2013

7:00am - 11:30amCSARegistrationAmelia Foyer

7:00am - 9:00amContinentalBreakfastforPhysicians&SpousesAmelia 2,3

8:00am - 11:30amScientificSessionVAmelia 1


SCIENTIFIC PROGRAM


SCIENTIFIC PROGRAM

Wednesday,March13,2013

3:00pm – 6:00pm CSARegistration Thursday,March14,2013 6:30am – 12:30pm CSARegistration 7:00am – 8:00am ContinentalBreakfastforPhysicians 7:00am – 12:30pm ExhibitsOpen 8:00am – 10:00am CasePresentations 8:00am – 8:30am GI/Colorectal:ManagementofPerforatedDiverticulitis:Laparoscopicvs.LaparotomyModerator: Bradley R. Davis, MD (University of Cincinnati) Panelists: David P. O’Brien, IV, MD (The Oregon Clinic) David A. Margolin, MD (Ochsner Clinical Foundation Hospital) Stephen Barnes, MD (University of Missouri) 8:30am – 9:00am Hepatobiliary:ManagingtheDifficultBileDuctStoneModerator: Gary C. Vitale, MD (University of Louisville) Panelists: Jeffrey W. Hazey, MD (The Ohio State University) Victor Velanovich, MD (University of South Florida) C. Max Schmidt, MD (Indiana University)


SCIENTIFIC PROGRAM (continued)

9:00am – 9:30am Vascular:ThoracicStentGraftingforAcuteThoracicAorticDissectionsModerator: Mark K. Eskandari, MD (Northwestern University) Panelists: James W. Dennis, MD (University of Florida College of Medicine – Jacksonville) Karl Illig, MD (University of South Florida) M. Ashraf Mansour, MD (Spectrum Health Medical Group) 9:30am – 10:00am Endocrine:ParathyroidectomyforAsymptomaticHyperparathyroidismModerator: Sonia Sugg, MD (University of Iowa) Panelists: Scott M. Wilhelm, MD. (University Hospitals – Case Medical Center) Glenda G. Callender, MD (University of Louisville) Christopher McHenry, MD (MetroHealth Medical Center) 10:00am – 10:15am MorningBreak 10:15am - 12:30pm ScientificSessionI:Trauma/CriticalCare&ColorectalModerator: Gerald M. Larson, MD 1. PERCUTANEOUS PIGTAIL CATHETER VERSUS STIFF TUBE THORACOSTOMY FOR PEDIATRIC EMPYEMA: A COMPARISON OF OUTCOMES D Petel, P Li, S Emil McGill University Health Centre



2. ENDOSCOPIC TRANS-ORAL STAPLING VS. OPEN CRICOPHARYNGEAL MYOTOMY FOR CERVICAL (ZENKER’S) ESOPHAGEAL DIVERTICULUM IN A THORACIC SURGICAL PRACTICE MJ Schuchert, DD Odell, A Wallace, PF Ferson, JD Luketich, RJ Landreneau University of Pittsburgh Medical Center 3. SINGLE-INCISION RESULTS IN SIMILAR PAIN AND QUAILTY OF LIFE SCORES WITH BETTER COSMESIS COMPARED TO MULTI-INCISION LAPAROSCOPIC CHOLECYSTECTOMY: A BLINDED PROSPECTIVE RANDOMIZED TRIAL OF 100 PATIENTS MAC Zapf, RS Salabat, D Leung, AK Yetasook, EW Denham, E Barrera, Z Butt, JM Carbray, H Du, MB Ujiki Northshore University HealthSystem 4. SOCIO-ECONOMIC DISPARITIES IN THE SURGICAL MANAGEMENT OF PEPTIC ULCER DISEASE JW Smith, TJ Mathis, GA Franklin, BG Harbrecht, MV Benns, GM Larson University of Louisville 5. ANASTOMOTIC LEAK OR ORGAN SPACE SURGICAL SITE INFECTION: WHAT ARE WE MISSING IN OUR QUALITY IMPROVEMENT PROGRAMS? AS Rickles, JC Iannuzzi, KN Kelly, RN Cooney, DA Brown, JRT Monson, FJ Fleming University of Rochester Medical Center 6. CONSTRUCT VALIDATION AND COMPARISON OF A NOVEL COLORECTAL POSTOPERATIVE QUALITY OF LIFE METRIC AND THE SHORT FORM 36 IN COLORECTAL SURGERY PATIENTS DS Keller, S Goyal, VK Cheruvu, B O’Brien-Ermlich, CP Delaney University Hospitals-Case Medical Center



12:30pm AfternoonFreeGolf,TennisandOptionalTours 6:30pm – 8:30pm WelcomeReception Friday,March15,2013 7:00am – 5:45pm CSARegistration 7:00am – 8:00am ContinentalBreakfastforPhysicians 7:00am – 4:15pm ExhibitsOpen 8:00am – 11:15am ScientificSessionII:EndocrineModerator: Gerald M. Larson, MD 7. THE UTILITY OF ROUTINE PREOPERATIVE CERVICAL ULTRASONOGRAPHY IN PATIENTS UNDERGOING THYROIDECTOMY FOR DIFFERENTIATED THYROID CANCER K O’Connell, TW Yen, F Quiroz, DB Evans, TS Wang Medical College of Wisconsin 8. THE LONG-TERM IMPACT OF ROUTINE INTRA-OPERATIVE NERVE MONITORING DURING THYROID AND PARATHYROID SURGERY TC Lairmore, AK Janicek, BR Sigmond, CM Govednik-Horny, DC Jupiter Scott & White Memorial Hospital



9. DO GIANT PARATHYROID ADENOMAS REPRESENT A DISTINCT CLINICAL ENTITY? PM Spanheimer, AJ Stoltze, G Lal, SL Sugg, JR Howe, RJ Weigel University of Iowa 10. TRENDS AND DISPARITIES IN EDUCATION BETWEEN SPECIALITIES IN THYROID SURGERY: ANALYSIS FROM THE NSQIP DATABASE R Monteiro, JS Mino, AE Siperstein Cleveland Clinic Foundation 9:30am – 10:00am MorningBreak ScientificSessionIII:Oncology10:00am – 11:15am Moderator: Gerald M. Larson, MD 11. MUTATION-NEGATIVE THYROID “FOLLICULAR LESION OF UNDETERMINED SIGNIFICANCE” CYTOLOGY RESULTS: NODULE SIZE PREDICTS MALIGNANCY RS Mehta, SE Carty, PN Ohori, M Tublin, S Hodak, MT Stang, JT Johnson, KL McCoy, M Nikiforova, YE Nikiforov, L Yip University of Pittsburgh 12. EZH2-SHRNA-MEDIATED UP-REGULATION OF P21WAF1/CIP1 AND ITS TRANSCRIPTIONAL ENHANCERS WITH CONCOMITANT DOWN-MODULATION OF MUTANT P53 IN PANCREATIC DUCTAL ADENOCARCINOMA RB Batchu, OV Gruzdyn, AM Qazi, DW Weaver, SA Gruber Wayne State University



13. CLINICAL SCENARIOS ASSOCIATED WITH LOCAL RECURRENCE AFTER LAPAROSCOPIC RFA OF COLORECTAL LIVER METASTASES E Aksoy, S Aliyev, HE Taskin, O Birsen , J Mitchell, A Siperstein, E Berber Cleveland Clinic Foundation 11:15am – 11:30am CSAFoundationAwards11:30am - 12:15pm AddressofPresidentPracticeofSurgeryintheNextDecade:FutureStillBrightforaRewardingCareerGerald M. Larson, MD University of Louisville 12:15pm – 1:15pm President’sLuncheonforNewMembers 1:15pm – 4:00pm ScientificSessionIV-A:GI/HepatobiliaryModerator: Robert C.G. Martin, MD, University of Louisville 14. CLINICAL EVALUATION OF SOMATOSTATIN USE IN PANCREATIC RESECTION: CLINICAL EFFICACY OR LIMITED BENEFIT? R Anderson, E Dunki-Jacobs, G Callender, C Scoggins, K McMasters, N Burnett, RCG Martin University of Louisville 15. CHOLECYSTECTOMY IS EFFECTIVE THERAPY FOR BILIARY DYSKINESIA C Wybourn, R Kitsis, TA Baker, B Degner, S Sarker, FA Luchette Loyola University Chicago



16. USE OF THE GASTROGRAFIN CHALLENGE IN PATIENTS WITH A HISTORY OF ABDOMINAL OR PELVIC MALIGNANCY MA Khasawneh, B Srvantstian, MP Bannon, MD Zielinski Mayo Clinic Rochester 17. SURGICAL OUTCOMES FOLLOWING TOTAL PANCREATECTOMY WITH ISLET CELL AUTOTRANSPLANTATION FOR CHRONIC PANCREATITIS IN PEDIATRIC PATIENTS GC Wilson, JM Sutton, M Salehi, N Schmulewitz, MT Smith, S Kucera, KA Choe, JE Brunner, DE Abbott, JJ Sussman, SA Ahmad University of Cincinnati 18. PREDICTING AGGRESSIVE BEHAVIOR IN NON-FUNCTIONING PANCREATIC NEUROENDOCRINE TUMORS J Cherenfant, S Stocker, M Gage, H Du, T Thurow, M Odeleye, S Schimpke, K Kaul, C Hall, I Lamzabi, P Gattuso, DJ Winchester, R Marsh, D Bentrem, M Baker, RA Prinz, M Talamonti Northshore University HealthSystem 19. RATE OF GROWTH OF PANCREATIC SEROUS CYSTADENOMA BASED ON INITIAL NEOPLASM SIZE AS INDICATION FOR RESECTION KM El-Hayek, N Brown, C O’Rourke, G Falk, G Morris-Stiff, RM Walsh Cleveland Clinic Foundation 20. OBESITY INCREASES MALIGNANT RISK IN PATIENTS WITH BRANCH-DUCT INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM EC Sturm, KM Shaffer, CM Schmidt II, SJ Lee, NJ Zyromski, HA Pitt, JM Dewitt, MA Al-Haddad, JA Waters, CM Schmidt Indiana University School of Medicine



1:15pm – 4:00pm ScientificSessionIV-B:Breast,Cardiothoracic,BasicScience,Education,OutcomesModerator: Timothy Pritts, MD, University of Cincinnati 21. RISK OF PULMONARY EMBOLISM IN TRAUMA PATIENTS NOT ALL CREATED EQUAL NS Germain, A Ong, RS Smith, E Jeremitsky Allegheny General Hospital 22. RADIOGRAPHIC ASSESSMENT OF ELDERLY GROUND LEVEL FALLS: IS THE “PAN-SCAN’ OVER DOING IT? C Dwyer, A Scifres, A Corcos, A Peitzman, T Billiar, K Stahlfeld, J Sperry University of Pittsburgh 23. RETENTION OF SUTURING AND KNOT-TYING SKILLS IN SENIOR MEDICAL STUDENTS AFTER PROFICIENCY-BASED TRAINING VM Gershuni, J Woodhouse, LM Brunt Washington University School of Medicine 24. PREOPERATIVE AXILLARY IMAGING WITH PERCUTANEOUS LYMPH NODE BIOPSY IS VALUABLE IN THE CONTEMPORARY MANAGEMENT OF BREAST CANCER PATIENTS TJ Hieken, BC Trull, JC Boughey, KN Jones, C Reynolds, KN Glazebrook Mayo Clinic Rochester 25. PHARMACOLOGIC STIMULATION OF THE NICOTINIC ANTI-INFLAMMATORY PATHWAY MODULATES GUT AND LUNG INJURY FOLLOWING HYPOXIA-REOXYGENATION INJURY SL Tarras, DM Liberati, K Ginnebaugh, LN Diebel Wayne State University



26. PARTIAL VS. TOTAL SPLENECTOMY IN CHILDREN WITH HEREDITARY SPHEROCYTOSIS AD Seims, F Breckler, KD Hardacker, FJ Rescorla Riley Hospital for Children 27. GASTROESOPHAGEAL REFLUX DISEASE, PROTON-PUMP INHIBITOR USE AND BARRETT’S ESOPHAGUS IN ESOPHAGEAL ADENOCARCINOMA: TRENDS REVISITED MJ Lada , DR Nieman, M Han, P Timratana, C Peyre, CE Jones, TJ Watson, JH Peters University of Rochester Medical Center 4:00pm – 4:15pm AfternoonBreak4:15pm – 5:15pm Debate:EmploymentModelsforSurgeons–GeneralSurgeonsasHospitalEmployeesModerator: Ronald Weigel, MD, PhD Presenters: Jeffrey L. Ponsky, MD (University Hospitals-Case Medical Center) J. David Richardson (University of Louisville) 5:15pm – 5:45pm CSAAnnualBusinessMeeting(Members Only) 7:00pm – 11:00pm AnnualReception&DinnerDanceBusiness Attire or Black Tie Optional



Saturday,March16,2013 7:00am – 11:30am CSARegistration 7:00am – 9:00am ContinentalBreakfastforPhysiciansandSpouses/Guests 8:00am - 11:30am ScientificSessionV:MinimallyInvasive&GeneralSurgeryModerator: Nathaniel J. Soper, MD 28. ACUTE CARE SURGERY PRACTICE MODEL: TARGETED GROWTH FOR FISCAL SUCCESS MS Alexander, CS Nelson, JP Coughenour, SL Barnes University of Missouri 29. REGIONAL COLLABORATION ACROSS HOSPITAL SYSTEMS TO DEVELOP AND IMPLEMENT TRAUMA PROTOCOLS SAVES LIVES WITHIN TWO YEARS JA Claridge, B Patterson,F Degrandis, C Emmerman, D Bronson, A Connors MetroHealth Medical Center 30. PERORAL ESOPHAGEAL MYOTOMY (POEM) AND LAPAROSCOPIC HELLER MYOTOMY PRODUCE A SIMILAR SHORT-TERM ANATOMIC AND FUNCTIONAL EFFECT ON THE ESOPHAGOGASTRIC JUNCTION EN Teitelbaum, S Rajeswaran, R Zhang, RT Sieberg, FH Miller, NJ Soper, ES Hungness Northwestern University


31. PER ORAL ENDOSCOPIC MYOTOMY (POEM): A SHORT-TERM COMPARISON WITH THE STANDARD LAPAROSCOPIC APPROACH AK Yetasook, M Zapf, EW Denham, JG Linn, JM Carbray, M Ujiki NorthShore University HealthSystem 32. PERIOPERATIVE OUTCOMES OF LAPAROSCOPIC TRANSHIATAL ESOPHAGECTOMY WITH ANTEGRADE ESOPHAGEAL INVERSION FOR HIGH GRADE DYSPLASIA AND INVASIVE ESOPHAGEAL CANCER KA Perry, LM Funk, WS Melvin The Ohio State University 33. THE USE OF LAPAROSCOPIC ULTRASOUND IN DIFFICULT CHOLECYSTECTOMY CASES SIGNIFICANTLY DECREASES MORBIDITY EC Gwinn, S Daly, DJ Deziel Rush University Medical Center 34. AUTOMATED ANALYSIS OF ELECTRONIC MEDICAL RECORD DATA REFLECTS THE PATHOPHYSIOLOGY OF SURGICAL COMPLICATIONS J Tepas, III, M Nussbaum, AL Hsiao, JM Rimar University of Florida College of Medicine-Jacksonville 35. ETIOLOGY AND INCIDENCE OF PEDIATRIC GALLBLADDER DISEASE SK Walker, AC Maki, DS Foley, KM Wilson, L Galganski, CA Wiesenauer, SJ Bond University of Louisville 36. PATIENT PERSPECTIVES ON POSTOPERATIVE VISITS WITH GENERAL SURGEONS GP Wright, AM Wolf, G Ambrosi, MB Dull, MH Chung Michigan State University 11:30am MeetingConcludes



ABSTRACTS



ABSTRACTS

1. PERCUTANEOUS PIGTAIL CATHETER VERSUS STIFF TUBE THORACOSTOMY FOR PEDIATRIC EMPYEMA: A COMPARISON OF OUTCOMESD Petel, P Li, S EmilMcGill University Health Centre

PURPOSE: Pediatric empyema is a common cause of respiratory morbidity and hospitalization in children. Recent randomized trials have shown no benefit to thoracoscopic decortication over pleural drainage with fibrinolytic installation. However, the optimal method of pleural drainage is not well defined. We conducted a study to compare outcomes of 8.5 Fr soft pigtail catheters (PC) placed via Seldinger technique to larger calibre stiff chest tubes (12-24 Fr) placed via thoracostomy (TT).

METHODS: A retrospective review of all pediatric patients treated for empyema during a five year period (2006-2011) was conducted. Patients treated by PC were compared to those treated by TT. Data regarding clinical status at presentation, laboratory tests, imaging, procedural details, analgesic and sedative requirements, and outcomes were extracted. Treatment failure was defined as need for another invasive thoracic procedure (second tube or catheter or thoracoscopic decortication) after initial pleural drainage. Continuous data are reported as mean +/- SEM, and compared by student t test, while categorical data were compared by Fischer’s exact test.

RESULTS: Forty three patients were treated, 21 by PC, and 22 by TT. Fibrinolytics were used in 71 % of the PC and 64% of the TT groups. Baseline clinical parameters were not significantly different between the two groups. The attached table shows outcome differences between the groups. Treatment failure was significantly higher in the PC group. When only patients who received fibrinolytics in each group were compared, failure rate was still higher in the PC group, but not statistically significant (40% vs. 14%, p = 0.129), and total illness duration was significantly shorter in the PC group (18.3 +/- 1.0 vs. 25.6 +/- 3.5 days, p=0.048).


ABSTRACTS (continued)

CONCLUSION: Percutaneous pigtail catheters are associated with higher failure rates, but shorter total duration of illness, in the treatment of pediatric empyema. The ideal method for draining pediatric empyema may be a small calibre, stiff chest tube, placed by percutaneous technique.

NOTES

Outcome PercutaneousPigtailCatheter

ChestTubeThoracostomy

P

Treatment Failure (%) 43 14 0.045

Duration of Drainage (days) 4.8 +/- 0.5 6.1 +/- 0.5 0.069

Intravenous antibiotic duration (days) 11.4 +/- 1.6 11.0 +/- 1.4 0.870

Febrile period duration (days) 7.4 +/- 1.1 8.3 +/- 1.4 0.617

Post-procedure duration of narcotic analgesia (days)

3.1 +/- 0.4 4.2 +/- 0.6 0.124

Total post-procedure narcotic dose (mg morphine equivalents / kg)

2.9 +/- 2.1 1.6 +/- 0.5 0.574

Total hospital stay (days) 10.7 +/- 0.8 12.5 +/- 1.4 0.295

Total duration of illness (days) 17.9 +/- 1.0 22.4 +/- 2.4 0.096



2. ENDOSCOPIC TRANS-ORAL STAPLING VS. OPEN CRICOPHARYNGEAL MYOTOMY FOR CERVICAL (ZENKER’S) ESOPHAGEAL DIVERTICULUM IN A THORACIC SURGICAL PRACTICEMJ Schuchert, DD Odell, A Wallace, PF Ferson, JD Luketich, RJ LandreneauUniversity of Pittsburgh Medical Center

PURPOSE: Zenker’s diverticulum is a true pulsion diverticulum forming above the level of the cricopharyngeus, usually secondary to muscular hypertrophy. Treatment is focused on the relief of the functional obstruction via cricopharyngeal myotomy and drainage or excision of the diverticular pouch. In cases with favorable anatomic characteristics (adequate oral aperture, absence of kyphosis, and presence of a sizeable diverticulum) endoscopic trans-oral stapling is preferred. In the absence of these characteristics, open cricopharyngeal myotomy is performed. In this study, we describe our experience and long-term results with both open and endoscopic treatment.

METHODS: A retrospective review of all operations (n=120) performed for Zenker’s Diverticulum over an 11 year period from 6/01-6/12. Patients were separated into 2 groups on the basis of surgical approach: open cricopharyngeal myotomy with or without diverticulectomy or diverticulopexy (OCM, n=28) and trans-oral endoscopic stapling (ES, n=92). Patient demographics, perioperative data, hospital course as well as symptomatic outcomes were analyzed for each group. Durability of treatment was assessed using the Kaplan-Meier method with group comparisons performed by the log-rank test.

RESULTS: Patients undergoing ES were older (76.4 vs. 70.2, p=0.02) and had larger diverticuli (4.0 vs. 2.9 cm, p=0.002) [Table]. ES was associated with reduced perioperative morbidity (10.9% vs. 35.7%, p=0.007). No differences were noted in length of stay (median=2 in each group) or mortality. There was one death in each group (ES - staple line dehiscence and mediastinal sepsis; OCM - Clostridium difficult colitis and sepsis. At a mean follow-up of 18 months, ES was associated with a higher rate of sustained symptomatic improvement compared with OCM (95.7% vs. 78.6%, p=0.01).



CONCLUSION: In properly selected patients, ES is safe and effective with low perioperative morbidity and durable symptomatic improvement. The increased dysphagia rates observed in the OCM group may be due to diffuse pharyngeal dysfunction manifest in the setting of smaller diverticuli. Both ES and OCM approaches should be included in the armamentarium of the esophageal surgeon.

Table: Comparison of Stapled and Open Approaches in the Management of Zenker’s Diverticulum

NOTES

Stapled(n=92) Open(n=28) PValue

Age (years) 76.4 70.2 0.02

Gender (M:F) 39:53 9:19 0.38

Diverticulum Size (cm) 4.0

(Range: 2-8)

2.9

(Range:2-4.5)

0.002

Length of Stay (days) 2

(Range: 1-38)

2

(Range: 1-18)

0.09

Morbidity (%) 10.9 35.7 0.007

Mortality (%) 1.1 3.6 0.41

Symptomatic Improvement (%)

95.7 78.6 0.01



3. SINGLE-INCISION RESULTS IN SIMILAR PAIN AND QUAILTY OF LIFE SCORES WITH BETTER COSMESIS COMPARED TO MULTI-INCISION LAPAROSCOPIC CHOLECYSTECTOMY: A BLINDED PROSPECTIVE RANDOMIZED TRIAL OF 100 PATIENTSMAC Zapf, RS Salabat, D Leung, AK Yetasook, EW Denham, E Barrera, Z Butt, JM Carbray, H Du, MB UjikiNorthShore University HealthSystem

PURPOSE: Our objective was to compare cost as well as perioperative and long-term quality of life between subjects randomly assigned to either single- (SILS) or multi-incision (MILS) laparoscopic cholecystectomy.

METHODS: We conducted an Institutional Review Board-approved, prospective, multi-hospital, multi-surgeon, single-blinded randomized trial. Patients with acute or chronic cholecystitis, gallstone pancreatitis, choledocholithiasis, gallbladder polyps, or biliary dyskinesia were offered participation in the trial. Those who consented were randomized to either SILS or MILS and blinded with four-port bandaging for one week following the procedure. Measures from the Surgical Outcomes Management System were used to quantify pain and other health-related quality of life outcomes. Postoperative analgesic use was recorded in a medication diary. Patients were followed in clinic at 3 weeks, 6 months, one and two years post-cholecystectomy with exams to document hernia formation. All data was entered into a prospective database and monitored by a dedicated research coordinator.

RESULTS: Nine hundred and forty-six patients were offered enrollment in the study over a three year period by three surgeons at three hospitals. One hundred subjects consented for the study and were randomly assigned to SILS (N=50) or MILS (N=50). There was no statistically significant difference in demographics except more females underwent SILS (85% v 66%, p=0.0255). Indications for surgery were equally distributed between the two groups. Operative time was greater for SILS (65.6 +/- 21.5 v 44.8 +/- 24.3 mins, p<0.0001). Five SILS patients required added ports. There was one morbidity (post-operative hemorrhage) in the SILS cohort and none in the MILS group. Hospital stay was equal



between groups, however, cost was significantly higher in the SILS group ($17,723 +/- $13,016 v $14,825 +/- $6,520, p<0.0001). Analgesic use was equal between groups. Both groups reported similar quality of life scores except the SILS group expressed greater satisfaction with cosmesis at one year (SILS 4.0 v MILS 4.5, p<0.05). At an average follow-up of SILS 20.2 +/- 6.7 months and MILS 21.55 +/- 4.7 months, no umbilical hernias have been identified in either group.

CONCLUSION: SILS cholecystectomy results in similar pain and quality of life scores when compared to a standard laparoscopic approach. Cosmesis scores were slightly better for SILS at the expense of longer operative times. NOTES



4. SOCIO-ECONOMIC DISPARITIES IN THE SURGICAL MANAGEMENT OF PEPTIC ULCER DISEASEJW Smith, TJ Mathis, GA Franklin, BG Harbrecht, MV Benns, GM LarsonUniversity of Louisville

PURPOSE: During the last 60 years, there has been a nationwide decrease in the number of operations performed for peptic ulcer disease (PUD). In contrast, the experience at our university based safety net hospital (SNH) was that ulcer operations are still performed relatively frequently. We hypothesized that differences in frequency of PUD operation may occur in hospitals that serve different patient populations. The purpose of this study was to evaluate our experience with PUD and compare it with national trends

METHODS: An IRB approved retrospective study of patients undergoing operation for PUD between 1/2008 and 12/2011 was performed. Patient records at two hospitals [(a private community hospital and a university safety net hospital (SNH)] with similar admission numbers and geographic catchment were examined for PUD risk factors, H. Pylori status, insurance/income status, type of operation and surgical outcomes. A case matched control group of medically treated patients were identified after primary diagnosis of PUD by endoscopy at the safety net hospital. Univariate and multivariate analysis was performed.

RESULTS: The total number of operations for PUD performed at the SNH was significantly higher than those performed at the private hospital from 2008-2011. (142 vs. 24, p<0.001). The private hospital followed national trends over the same time period with reduction of ~93% from 1967 to 2008 (115 to 7.9 nationally, and 119 to 6 at private hospital). (Figure) In contrast to national and private hospital experience, the number of operations for PUD at SNH has increased from 27/year in 1985 to 36/year in 2008. Additionally, 43% of patients at the SNH had no insurance and 61% held residence in the poorest quartile of zip codes compared to the 3% uninsured patient rate at private hospital for a similar group of patients.



At both hospitals, most operations were emergent (range 83%-92%) and treated with omental patch (45%); gastric wedge resection (15%); vagotomy & antrectomy (19%); or vagotomy & pyloroplasty (14%). At the SNH, the H. pylori infection rate was lower (48% vs. 83%, P<0.001) and NSAID use was higher (76% vs. 63%P<0.01) in the 142 surgical patients, compared to the 320 medical controls. Adjusted risk ratios demonstrated insurance status, NSAID use, and lower socioeconomic class were all equally predictive of surgical ulcer disease when compared to medical controls.

CONCLUSION: The number of operations performed in our private hospital for PUD has decreased congruent with national trends but has increased in our local SNH which is, in part, related to socio-economic factors. In addition, H.pylori infection occurred in less than 50% of patients and was not be the dominant etiologic factor in surgical ulcer disease. These factors should be considered in the changing management of surgical ulcer disease in the new millennium. NOTES



5. ANASTOMOTIC LEAK OR ORGAN SPACE SURGICAL SITE INFECTION: WHAT ARE WE MISSING IN OUR QUALITY IMPROVEMENT PROGRAMS?AS Rickles, JC Iannuzzi, KN Kelly, RN Cooney, DA Brown, JRT Monson, FJ FlemingUniversity of Rochester Medical Center

PURPOSE: Panels of expert colorectal surgeons consistently rank anastomotic leak as one of the most important quality metrics for colectomies. Nonetheless, most administrative and clinical databases collect organ space surgical site infections (OSI) as a proxy for anastomotic leak. This study questions the validity of using OSI as a surrogate for anastomotic leak.

METHODS: The Upstate New York Surgical Quality Initiative (UNYSQI) is a collaboration of 9 hospitals in upstate New York that prospectively collect colectomy specific metrics, including anastomotic leak, in addition to data for the National Surgical Quality Improvement Program (NSQIP). Cases with an OSI and/or anastomotic leak were selected from the UNYSQI database from 2010-2011. Cases were separated into groups based on OSI or anastomotic leak. Chi square and student t-test were used to compare patient characteristics and outcomes. A kappa statistic was calculated for agreement between OSI and anastomotic leaks. A p-value <0.05 was considered statistically significant.

RESULTS: Out of 6,151 colectomies in NSQIP in 2010, 2.9% of patients were coded as having an OSI. In the 810 colectomies captured by UNYSQI, 22 (2.7%) patients had an OSI and 32 (4.0%) had anastomotic leaks. Out of those patients coded as having anastomotic leaks in UNYSQI, only 8 (25%) were also coded as having an OSI, leaving 75% (n=24) who were not captured as an OSI in NSQIP. Similarly, of the patients with an OSI, only 8 (36.4%) were coded as an anastomotic leak in UNYSQI (κ=0.272, p=<0.001). When comparing patient characteristics and outcomes, patients with an anastomotic leak were more likely to have an unplanned return to the operating room (75% vs. 27.3%, p=0.001, Table 1). Cases with an OSI had a higher rate of readmissions but the difference was not statistically



significant (54.5% vs. 32.3%, p=0.105). Operations for cancer made up the largest portion of OSI and anastomotic leaks (31.8% and 50.0% respectively) but patients with inflammatory bowel disease had the highest rate of both OSI and anastomotic leaks (14.7% and 9.4% respectively).

CONCLUSION: OSI is a poor surrogate for anastomotic leak, grossly underestimates leak rates, and seemingly represent different pathologic processes. A move towards procedure specific quality measures for colorectal surgery should include anastomotic leaks to have accurate data for use in improving patient care.

NOTES

Table 1. Characteristics and Complication Rates

VariableOrgan Space Infection n=22 (%)

Anastomotic Leak n=32 (%) p-value

Age (mean) 55.5 ±15.4 61.9 ±12.7 0.113

Male (n=374) 13(41.9) 13(40.6) 0.829

Surgical Indication 0.350

Diverticulitis (n=217) 3(13.6) 6(18.8)

Cancer (n=341) 7(31.8) 16(50.0)

IBD (n=34) 5(22.7) 3(9.4)

Other (n=218) 7(31.8) 7(21.9)

Emergent Operation (n=112) 2(9.1) 1(3.1) 0.560

Postop Death 1(5.3) 2(7.1) 1.000

Unplanned Return to OR 6(27.3) 24(75) 0.001*

Readmission within 30 Days 12(54.5) 10(32.3) 0.105

Hospital length of stay (days) 16.0 ±14.9 21.7 ±15.4 0.195

*p-value<0.05 considered statistically significant



6. CONSTRUCT VALIDATION AND COMPARISON OF A NOVEL COLORECTAL POSTOPERATIVE QUALITY OF LIFE METRIC AND THE SHORT FORM 36 IN COLORECTAL SURGERY PATIENTSDS Keller, S Goyal, MF McGee, VK Cheruvu, B O’Brien-Ermlich, CP DelaneyUniversity Hospital-Case Medical Center

PURPOSE: Several questionnaires have been used to measure quality of life (QOL) in colorectal patients. However, existing QoL assessment tools are often complex, require complicated analysis, lack specificity for colorectal surgery, and are not focused on assessment of perioperative care. The postoperative quality of life (PQL) assessment is designed to capture subtle, yet significant QoL factors in an easy tool validated for the colorectal post-operative period. Although internally validated, PQL lacks external validation with a universally accepted QoL metric, such as the Rand Short Form 36 (SF-36). The purpose of this study was to externally validate the PQL metric to the SF-36 for colorectal surgery.

METHODS: PQL was designed using 14 questions ranked on a Likert scale (1-10) with surgeon and patient input. After obtaining IRB approval, 100 consecutive colorectal surgery patients at University-Hospitals, Case Medical Center were prospectively administered baseline and post-operative (2, 4, 8, 12, 30, 60, and 90 days) PQL and SF-36 questionnaires between November 2005 and April 2008. Patients were included if over 18 years old, undergoing major colorectal surgery via an abdominal approach (laparoscopic or open) for benign or malignant disease, and complete records of both PQL and SF-36 at baseline and each post-operative time point were available. Factor analysis was performed to confirm the validity of the study group SF-36 scores across all 8 mental and physical health domains. Spearman’s rank test determined correlations between each of the 8 SF-36 scales and the 14 PQL questions and summary score. Convergent validity was demonstrated using Spearman’s correlation coefficient at domain and scale level. The degree of agreement between PQL and SF-36 was assessed through Bland-Altman plot using standardized scores computed. Pairwise comparisons were made to determine any significant differences between the two scales.



RESULTS: Eighty-eight patients met inclusion criteria, and were included in the analysis. SF-36 factor analysis confirmed comparability between the study group and the general population. All PQL items correlated significantly with all 8 mental and physical health domains in the SF-36 (p-value < 0.0001). Bland-Altman plots demonstrated consistently similar measure for level of agreement between PQL and SF-36 as indicated by the 95% limits of agreement.

CONCLUSION: Our study validates the use of the PQL metric in colorectal surgery. The PQL and SF-36 demonstrated a strong and consistent level of agreement across all 8 domains for pre and post-operative scores in colorectal surgery patients. PQL is also constructually valid in the pre-operative period. Based on our analysis, the novel PQL metric represents a simple, point-of-care alternative to SF-36 for rapid QoL assessment after abdominal surgery. NOTES



7. THE UTILITY OF ROUTINE PREOPERATIVE CERVICAL ULTRASONOGRAPHY IN PATIENTS UNDERGOING THYROIDECTOMY FOR DIFFERENTIATED THYROID CANCERK O’Connell, TW Yen, F Quiroz, DB Evans, TS WangMedical College of Wisconsin

PURPOSE: Preoperative thyroid and cervical lymph node ultrasonography (US) is recommended in all patients with differentiated thyroid cancer (DTC) to evaluate for clinically occult metastatic lymphadenopathy. The purpose of this study was to examine the influence of preoperative US findings on surgical management in patients with DTC.

METHODS: This study was an IRB-approved, retrospective review of 70 patients with biopsy-proven DTC who underwent total thyroidectomy between February 2010 and January 2012 by a single group of endocrine surgeons. All patients underwent preoperative cervical US, which included evaluation of the thyroid, central, and lateral neck lymph node compartments (levels 2-7). Data collected included patient demographics, preoperative physical examination and US findings, fine needle aspiration (FNA) biopsy results, procedure performed, and final pathology.

RESULTS: Palpable lateral neck adenopathy was thought to be present in 5 (7%) of the 70 patients;, however, 2 of the 5 had no sonographic evidence of lymphadenopathy and did not undergo lateral compartment neck dissection (LCND). Of the remaining 65 patients with no palpable lymphadenopathy, 14 (22%) had suspicious lymph nodes identified on preoperative ultrasound; 2 patients with central neck lymphadenopathy, 10 patients with lateral neck lymphadenopathy, and 2 patients with both central and lateral neck lymphadenopathy. Preoperative FNA of suspicious lymph nodes was performed in 8 (57%) of the 14 patients and was positive in 7. All 14 patients underwent total thyroidectomy with therapeutic central compartment neck dissection (CCND), and the 12 patients with lateral compartment lymphadenopathy also underwent LCND. Metastatic disease was confirmed in 13 (93%) of the 14 patients who underwent CCND (median 4.5, range 0-22) and 11 (92%) of the 12 patients who underwent LCND (median 3, range 0-8).



CONCLUSION: Preoperative cervical US changed the operative management in 16 (23%) of 70 patients with DTC in whom thyroidectomy was planned. Clinically occult metastatic lymphadenopathy was detected in 14 (22%) clinically node-negative patients but was also not confirmed in two patients thought to have clinically palpable lymphadenopathy. The results of this study confirm that patients with DTC should undergo a preoperative, focused, high-quality cervical ultrasonography as findings will alter the extent of surgery for one in four patients. NOTES



8. THE LONG-TERM IMPACT OF ROUTINE INTRA-OPERATIVE NERVE MONITORING DURING THYROID AND PARATHYROID SURGERYSK Snyder, BR Sigmond, TC Lairmore, CM Govednik-Horny, AK Janicek, DC JupiterScott & White Memorial Hospital

PURPOSE: Despite increasing use of intra-operative nerve monitoring (IONM) globally as an adjunct to visual identification of the recurrent laryngeal nerve (RLN), published studies have shown little or no benefit. However, no long-term studies exist. The aim of this study was to evaluate the impact of IONM feedback on surgical outcomes over time at a single institution.

METHODS: A retrospective analysis of prospectively gathered data was conducted for 1944 patients including 3426 nerves-at-risk between March 2004 and September 2011. The primary outcome measures included temporary vocal cord palsy and permanent vocal cord paralysis or paresis as determined by intra-operative loss of RLN function and post-operative laryngoscopy. Additional measures included instances where IONM particularly assisted the surgeon’s localization of the RLN.

RESULTS: Of the nerves-at-risk, 140 of 3426 (4.09%) suffered injury overall with 7 having permanent paralysis (0.20%) and 15 having permanent paresis (0.44%). Over time, a statistically significant decrease in RLN injury is seen per successive operative year (OR 0.86, 95% CI 0.76-0.96, p < 0.001) with a stabilization of injury rates after 24 months of continued monitoring use. Assistance with identification of the RLN was seen in 402 nerves (11.73%) or 163 patients (7.73%) involving aberrant anatomy or difficult dissections.

CONCLUSION: With experience, routine use of IONM during thyroid and parathyroid surgery decreases the incidence of recurrent laryngeal nerve injury and provides assistance for RLN identification during challenging operations with compromised visualization.



NOTES



9. DO GIANT PARATHYROID ADENOMAS REPRESENT A DISTINCT CLINICAL ENTITY?PM Spanheimer, AJ Stoltze, G Lal, SL Sugg, JR Howe, RJ WeigelUniversity of Iowa

PURPOSE: The size of abnormal parathyroid glands resected in patients with primary hyperparathyroidism is highly variable. We sought to characterize the clinical characteristics of patients presenting with giant parathyroid glands and whether they represent a distinct clinical entity.

METHODS: An IRB approved retrospective chart review was performed on 300 consecutive patients who underwent parathyroidectomy for primary hyperparathyroidism from April 2008 to September 2011. We compared patients with giant parathyroid glands, which was defined as weight greater than or equal to the 95th percentile, with the remaining group of patients. Statistical calculations were made for continuous data using the two tailed T-test and for categorical data using the two sided Fisher’s exact test.

RESULTS: We enrolled 232 female and 68 male patients with a mean age of 59 years and length of follow up of 6.5 months. Median gland weight was 0.61 grams (range 0.05–29.93). Giant glands were defined as weight ≥3.5 grams which corresponded to the 95th percentile. Patients with giant parathyroid glands had a higher mean preoperative calcium level (11.7 mg/dl vs. 10.9 mg/dl, p<0.001), higher mean parathyroid hormone level (227.6 pg/ml vs. 136.7 pg/ml, p=0.002), and were less likely to have multiglandular disease (7% vs. 31%, p=0.04) compared to the remaining patients. No statistically significant differences were observed in the incidence of osteoporosis (45% vs 46%), nephrolithiasis (20% vs. 16%), or bone, muscle or abdominal pain (20% vs. 28%) in the giant gland group compared to the non-giant group. However, patients with giant glands were more likely to present with clinically asymptomatic disease (53% vs. 25%, p=0.003). No differences were observed in successful localization between the two groups by ultrasound (53% vs. 51%), Tc-99m-MIBI scan (53 % vs 56%), 4D CT (50% vs. 44%), or a combination of modalities (67% vs. 63%). There were no differences in age,



gender, gland location, or the incidence of persistent (0% vs. 2%) or recurrent (0% vs. 1%) hyperparathyroidism between the two groups. Finally, patients with giant glands had an increased incidence of symptomatic post-operative hypocalcemia (13% vs. 2%, p=0.05) including one patient who required rehospitalization following removal of a giant gland.

CONCLUSION: Giant parathyroid glands have a distinct presentation characterized by single gland and clinically asymptomatic disease despite increased levels of serum calcium and parathyroid hormone. Interestingly despite their size, giant parathyroid glands demonstrated no differences in successful preoperative localization. Finally, following resection of a giant gland, patients require close observation and a lower threshold for calcium supplementation due to the increased incidence of symptomatic hypocalcemia. NOTES



10. TRENDS AND DISPARITIES IN EDUCATION BETWEEN SPECIALITIES IN THYROID SURGERY: ANALYSIS FROM THE NSQIP DATABASER Monteiro, JS Mino, AE Siperstein Cleveland Clinic Foundation

PURPOSE: To determine practice patterns in patients undergoing thyroid surgery in the US, and characterize by level of resident involvement and by specialty to determine if surgical outcomes differed based on these parameters.

METHODS: The ACS-NSQIP database was queried from 2005-2010 for patients who underwent thyroid surgery (lobectomy, thyroidectomy, goiter, thyroidectomy with nodal dissection) and analyzed with JMP9. Resident involvement was classified by post-graduate year (PGY) and stratified by specialty (Otolaryngology vs General Surgery).

RESULTS: Of 47,144 patients undergoing thyroid surgery, 90.4% of all cases were performed by General Surgery (GS) vs 9.6% by Otolaryngology (ENT). Attendings alone performed 66% of cases in ENT, while this was true in only 28% for GS. Of GS cases done with housestaff, 42% were done by junior residents, 50% senior, 7.4% fellows; for ENT: 35%, 49.8%, and 15% respectively. Operative time was shorter for GS (116 min) vs ENT (127 min) (p <.0001) with attendings alone decreasing OR time by 20 min compared to cases done with housestaff. With ENT, OR time increased with increasing PGY, but this was not seen for GS. Case complexity, evaluated by proportions of CPT codes performed, was not significantly different between specialties, with roughly equivalent ASA class. Overall, GS had lower complication and return to OR rates compared with ENT, although these values did not appear to be clinically significant. Re-operations were higher with attendings alone or with fellow assistance in both specialties. There was no difference in length of stay for attending alone vs resident-assisted cases in both specialties.



CONCLUSION: While thyroid surgeries are performed by both GS and ENT, 90% of thyroid cases are performed by GS, vs 10% for ENT. There does not appear to be a significant difference in case complexity between both specialties. Overall, a higher percentage of thyroid cases are being performed with resident involvement in GS; this is true in only one-third of cases in ENT. This implies that while thyroid cases are being directed to tertiary hospitals in GS, this trend does not hold true for ENT. Additionally, junior residents perform a significant proportion of cases indicating early exposure to endocrine surgery and that there is balanced operative exposure between junior and senior residents with minimal effect of fellows in GS. In contrast, while juniors also receive significant exposure in ENT, this is diminished by an increased proportion performed by fellows, and this trend is more pronounced with advanced level cases. Neither specialty had a difference in outcomes (LOS, morbidity, mortality) based on resident level except operative time which was higher for ENT at all PGY levels. Reasons for longer case length in ENT cannot be discerned by NSQIP, but do not appear to be related to case complexity. Ultimately, the vast majority of thyroid cases remain in the hands of GS with equal outcomes and lower operating times than their ENT counterparts. NOTES



11. MUTATION-NEGATIVE THYROID “FOLLICULAR LESION OF UNDETERMINED SIGNIFICANCE” CYTOLOGY RESULTS: NODULE SIZE PREDICTS MALIGNANCYRS Mehta, SE Carty, PN Ohori, M Tublin, S Hodak, MT Stang, JT Johnson, KL McCoy, M Nikiforova, YE Nikiforov, L YipUniversity of Pittsburgh

PURPOSE: In thyroid nodule fine needle aspiration (FNA) cytology, the new and often-encountered category of follicular lesion of undetermined significance (FLUS) is associated with a 6-20% risk of cancer. When mutation testing of a FLUS specimen is positive the risk of cancer is reportedly high (85-99%), but negative testing does not exclude malignancy. The study objective was to identify clinical and imaging features that predict thyroid cancer in mutation–negative FLUS thyroid nodules.

METHODS: All patients with mutation-negative FLUS cytology results and thyroid surgery from 4/07-4/09 were identified after IRB approval. Routine testing of FNA cytology was performed for BRAF V600E, NRAS codon 61, HRAS codon 61, KRAS codons 12/13 point mutations, RET/PTC1, RET/PTC3, and PAX8/PPAR-gamma rearrangements. Epidemiologic, clinical, imaging, and histologic data were retrospectively analyzed using independent sample t-test or Mann Whitney U-test to compare means of continuous variables, Chi-square or Fisher’s exact test for associations of variables between groups, and multivariate logistic regression analysis to adjust for covariates.

RESULTS: A total of 230 mutation-negative FLUS nodules in 190 consecutive patients were included. Histologically, 12 (5.2%) nodules were malignant in 11 patients and 218 nodules were benign in 179 patients. Malignancy was not associated with mean age at diagnosis (p=0.07), female sex (p=0.39), history of prior head/neck radiation (p=0.69), family history of thyroid cancer (p=0.3), history of tobacco use (p=0.56), or history of non-thyroid malignancy (p=1.0). The majority of nodules were multifocal (76%) and bilateral (63%) but these variables were not associated with malignancy risk (p=0.31 and p=0.77, respectively). On preoperative imaging, at least 1 of 6 known suspicious ultrasound features was identified in 65% of nodules but again this occurred regardless of histology (p=0.58). However,



malignant mutation-negative FLUS nodules were larger than benign nodules (mean maximum diameter 33.6mm, malignant vs. 24.0mm, benign; p=0.007). In multivariate analysis, nodule size remained an independent predictor of thyroid malignancy (OR 1.044, p=0.018). In ROC analysis, a mutation-negative FLUS nodule size of 18.5mm offered 100% sensitivity and 40% specificity in detecting thyroid malignancy.

CONCLUSION: Although most known clinical and sonographic risk factors do not distinguish thyroid cancer in mutation-negative FLUS nodules, size is an independent predictor of malignancy and the risk of malignancy increased by 4.4% with every millimeter increase in the size of the nodule. We further observed no cancer risk in 88 mutation-negative FLUS nodules <1.85 cm in size. Selected patients with mutation-negative and small FLUS thyroid nodules may be managed with ultrasound surveillance in lieu of thyroidectomy. NOTES



12. EZH2-SHRNA-MEDIATED UP-REGULATION OF P21WAF1/CIP1 AND ITS TRANSCRIPTIONAL ENHANCERS WITH CONCOMITANT DOWN-MODULATION OF MUTANT P53 IN PANCREATIC DUCTAL ADENOCARCINOMARB Batchu, OV Gruzdyn, AM Qazi, DW Weaver, SA Gruber Wayne State University

PURPOSE: Enhancer of zeste homologue 2 (EZH2), a component of the chromatin modification protein complex, is up-regulated in pancreatic ductal adenocarcinoma (PDAC). However, its role in disease progression is poorly understood. Tumor suppressor protein p53 trans-activates the expression of cyclin-dependent kinase inhibitor p21WAF1/CIP1 which in turn promotes cell cycle arrest. p21WAF1/CIP1 is frequently lost while p53 is mutated in the majority of PDAC patients. The purpose of this study is to analyze the expression levels of mutant p53 as well as p21WAF1/CIP1 and its transcriptional trans-activators in response to shRNA-mediated knockdown of EZH2 in PDAC and correlate these levels with in vivo tumor growth.

METHODS: PANC-1 cells were grown in sub-confluent monolayer cultures in DMEM with standard supplements in a CO2 incubator at 37oC. p21WAF1/CIP1, b actin, and various antibodies to p53 were obtained from Oncogene Research Products, Cambridge, MA. Standard protocols were followed for western blot analysis and antibody reactions were visualized using chemiluminescence. Six week old CB17/Cr-SCID mice were injected subcutaneously with PANC-1 cells (3 x 106) transfected with EZH2 shRNA or scrambled shRNA controls into both flanks of mice followed by measurement of tumor growth.

RESULTS: Western blot analysis with antibodies Ab2 and Ab6 that recognize both wild type and mutant p53 did not show significant alteration in band intensity between control and EZH2 knock-down cells (Fig.1A). However, Ab3 that detects only mutant p53 showed a band of significantly lesser intensity with EZH2 knockdown compared with control transfected cells. Western blot analysis further revealed a significant up-regulation of p21WAF1/CIP1. Gene expression profile analysis indicated significantly enhanced transcripts of transcriptional inducers of p21WAF1/CIP1, such as nerve growth factor receptor, platelet-derived growth



factor, tumor necrosis factor, SMAD proteins, and TGF b, along with down-regulation of mutant p53 transcript, corroborating the western blot results in response to EZH2 knockdown (Fig.1B). PANC-1 cells expressing EZH2 shRNA displayed markedly attenuated growth potential in SCID mice (Fig.1C).

CONCLUSION: We provide evidence that the silencing of EZH2 with shRNA may form the basis of a targeted therapeutic approach to PDAC that operates via the down-regulation of mutant p53 with concomitant enhanced expression of p21WAF1/CIP1 and its transcriptional trans-activators.

NOTES



13. CLINICAL SCENARIOS ASSOCIATED WITH LOCAL RECURRENCE AFTER LAPAROSCOPIC RFA OF COLORECTAL LIVER METASTASESE Aksoy, S Aliyev, HE Taskin, O Birsen, J Mitchell, A Siperstein, E Berber Cleveland Clinic Foundation

PURPOSE: Over the last decade, radiofrequency thermal ablation (RFA) has been incorporated into the treatment algorithm of patients with unresectable colorectal liver metastases (CLM). For this population, the local recurrence (LR) rate is a key parameter used to assess the success of RFA. LR is defined as development of new tumor abutting and/or in 1 cm of an ablation zone. The aim of this study is to correlate LR with other hepatic or extrahepatic recurrence and patient survival.

METHODS: Between 2000 and 2011, 252 patients with CLM underwent laparoscopic RFA of 883 lesions. These patients were followed under a prospective protocol with quarterly liver CT scans and blood work, including CEA levels quarterly for the first 2 years and then biannually to detect recurrence in follow up. Clinical scenarios associated with LR were identified and categorized as being “isolated LR”, “LR associated with new liver disease” or “LR associated with systemic disease”. Demographic, clinical and survival data were assessed using t-test, Chi Square and univariate Kaplan Meier analysis. Statistical significance was reached at p < 0.05 level.

RESULTS: One hundred eighteen patients (47%) developed LR after their initial laparoscopic RFA. These were 85 men (72%) and 33 women (28%), with a mean age of 70 ± 8 years. For this cohort, the mean of number of lesions was 3.1 ± 0.2 (range; 1- 11) and dominant tumor size 2.9 ± 0.1 cm (range; 0.7- 6.5 cm) at the time of initial RFA. The LR rate per lesion was 29%. Of the patients who developed treatment failure at the RFA site, this was an isolated LR in 31 (26%) patients, associated with new liver recurrence in 51 (43%) and systemic metastases in 36 patients (31%). When patients with different clinical scenarios associated with LR were compared, no clinical predictors to differentiate these subgroups were identified. At a median follow up of 30



months (range, 3-113), the overall Kaplan-Meier median overall survival (OS) for patients with and without LR were 28 vs 31 months, respectively, p=0.103. The OS for patients whose LR was isolated, associated with new liver and systemic recurrences was 39, 26, and 22 months, respectively, p=0.009.

CONCLUSION: This study shows that although the presence of LR does not negatively impact on survival, the pattern of recurrent disease did. LR after RFA for CLM is most often associated with new liver and systemic recurrences, reflecting the aggressive biology of cancer in patients channeled to this treatment modality. NOTES



14. CLINICAL EVALUATION OF SOMATOSTATIN USE IN PANCREATIC RESECTION: CLINICAL EFFICACY OR LIMITED BENEFIT?R Anderson, E Dunki-Jacobs, G Callender, C Scoggins, K McMasters, N Burnett, RCG MartinUniversity of Louisville

PURPOSE: The benefit of somatostatin for the prevention of pancreatic fistula has been widely debated in the literature. The aim of this study is to evaluate the efficacy of somatostatin in preventing pancreatic fistulas and improving post-surgical outcomes after pancreatic resection.

METHODS: A review was performed of a prospectively collected 2002 patient hepato-pancreatico-biliary database. Patients were included if they underwent pancreatectomy between 10/01/00 and 05/16/2012. Patients received somatostatin prophylactically at the discretion of their surgeon. Data were analyzed using univariate and multivariate analysis to determine if somatostatin had any effect on pancreatic fistula formation, fistula severity, length of stay, and readmission rates.

RESULTS: We identified 510 patients who underwent pancreatectomy. Overall, 30 (5.9 %) patients developed postoperative pancreatic fistulas and 27 (5.3%) fistulas were of clinical significance (grade B or C). Somatostatin was administered prophylactically to 215 (42.2%) patients, 57 (11.2%) patients were readmitted, and the median length of stay was 9 days (2-81). Pancreatic fistula developed in 7 (3.3%) patients who received somatostatin versus 23 (7.8%) patients who did not receive somatostatin (p=0.031). Among patients receiving somatostatin, 6 (2.8%) fistulas were of clinical significance versus 21 (7.1%) fistulas for patients who did not receive somatostatin (p=0.031). Readmission occurred in 27 (12.6%) patients who received somatostatin versus 30 (10.2%) patients who did not receive somatostatin (p=0.398). The median length of stay was 9 days (2-48) for patients who received somatostatin versus 9 days (2-81) for patients who did not receive somatostatin (p=0.462).



CONCLUSION: Somatostatin associated with a statistically significant decrease in both the rate of fistula formation and the number of clinically significant fistulas in our pancreatectomy patients. Somatostatin use post-pancreatic resection is beneficial in preventing pancreatic fistulas and improving some post-surgical outcomes. Continued evaluation of somatostatin use in relation to both intra-operative predictors and cost are needed to better define the population that will gain clinical benefit and cost savings.

Table:Acomparisonofpatientsreceivingprophylacticsomatostatintopatientsnotreceivingprophylacticsomatostatin

NOTES

No Somatostatin Somatostatin p-value

Number 295 (58%) 215 (42%)

Fistula/leak 23 (8%) 7 (3%) 0.031

A 1 (<1%) 2 (1%) 0.999

B 11 (4%) 2 (1%) 0.051

C 10 (3%) 4 (2%) 0.413

B and C 21 (7%) 6 (3%) 0.031

Readmission 30 (10%) 27 (13%) 0.398

LOS 9 (2-81) 9 (2-48) 0.462



15. CHOLECYSTECTOMY IS EFFECTIVE THERAPY FOR BILIARY DYSKINESIAC Wybourn, R Kitsis, TA Baker, B Degner, S Sarker, FA LuchetteLoyola University Chicago

PURPOSE: Biliary dyskinesia (BD) is described as biliary colic in the absence of gallstones. The diagnosis relies on imaging studies and decreased excretion of bile in response to cholecystokinin during scintigraphy. The purpose of this study was to evaluate the success of laparoscopic cholecystectomy (LC) for relieving symptoms in patients diagnosed with biliary dyskinesia and correlate ejection fraction (EF) with symptom relief.

METHODS: A retrospective review was performed at a single institution of all patients who underwent LC for BD from 1/2005 thru 1/2012. The diagnosis of BD was based on a normal gallbladder on ultrasound and cholescintigraphy with a gallbladder EF ≤ 45%. Data collection included demographics, results of imaging studies, comorbid conditions, pathologic diagnosis, and early postoperative pain relief. Patients were contacted by phone after being discharged from the surgeon’s care for evaluation of symptom relief. Data was analyzed using non-parametric statistical methods including: Mann-Whitney U test, receiver operator curve (ROC) characteristic, Fisher’s exact test and Chi-squared. All data are expressed as median and 25th and 75th percentile range.

RESULTS: There were 149 patients who had a LC for BD during the study period. The median biliary ejection fraction was 20% (11-29%). The most common pathologic finding was chronic cholecystitis (n=113, 76%). Median length of immediate postoperative follow up was 11 days (8-17) of which 100 patients (75%) had relief of symptoms. Phone interviews confirmed 75% of patients remained free of pain. There was no difference in the EF among those with resolution of pain 20% (12-30%) compared to patients with persistent pain 21% (12-28%), p= 0.53. ROC characteristic for the association between scintigraphic EF and resolution of postoperative pain demonstrated no association, with an area under the curve equal to 0.47. Sensitivity, specificity, positive and negative predictive values are provided (Table).



CONCLUSION: The majority of patients in this series had resolution of biliary cholic with LC. However, cholescintigraphy EF did not correlate with outcome. Further studies are needed to better identify patients diagnosed with BD who will benefit from LC.

NOTES

Pain (n)PPV NPV

EF Resolved Persistent

45% 113 36 100% 0% 24% 0%

35% 100 34 94% 13% 25% 87%

25% 70 13 36% 38% 12% 65%

15% 35 15 42% 69% 29% 79%

5% 14 4 11% 88% 22% 76%



16. USE OF THE GASTROGRAFIN CHALLENGE IN PATIENTS WITH A HISTORY OF ABDOMINAL OR PELVIC MALIGNANCYMA Khasawneh, B Srvantstian, MP Bannon, MD ZielinskiMayo Clinic Rochester

PURPOSE: The Gastrografin (GG) challenge was developed to predict the need for operative management in patients with small bowel obstruction (SBO). Although clinical trials have demonstrated that it is an effective diagnostic and therapeutic modality, these studies excluded patients with a history of abdominal/pelvic (AP) malignancy. This study aims to examine the outcomes of the GG challenge for patients with a history of AP malignancies.

METHODS: IRB approval was obtained to review all patients admitted with SBO between April 2010 and August 2012. Patients with signs of strangulation or AP surgery within six weeks were excluded. Patients with a history of AP malignancy were compared to those without. Kaplan Meier (KM) analysis was used to determine recurrence and survival rates. Data is reported as means or percentages with significance considered at p<0.05.

RESULTS: In total, 178 subjects were identified all of whom underwent GG challenge; 81 (46%) with a history of AP malignancy and 97 (54%) without. The most common type of malignancy was gastrointestinal (44%) followed by urologic (36%) and gynecologic (25%). There was no difference in sex (51% vs 43% males), prior SBO (41% vs 53%), prior abdominal operations (2.6 vs 2.8),or prior ventral hernia repair (10% vs 20%). Surgical exploration rates during index admission were similar (28% vs 18%), as was the duration from admission to exploration (5.0 vs 3.8 days). Patients with AP malignancy had a significantly higher hospital duration of stay (8.0 vs 5.8) and parenteral nutrition supplementation rate (30% vs 14%). There was no difference in 30 day morbidity (31% vs 22%) or mortality (4% vs 3%); however the KM mortality at 12 months was higher in the AP malignancy group (18% vs 4%). KM recurrence rates were similar at 12 months (24% vs 25%) as was duration of time from index SBO hospital dismissal to readmission (116 vs 102 days). Upon readmission, there was no difference between



operative exploration (58% vs 35%) or strangulation rates (8% vs 0%). There were 26 patients with known active AP malignancy. Of these, there was a similar rate of operative exploration during the index SBO admission (31% vs 21%), but the duration from admission to exploration (8.6 vs. 3.4 days) and hospital stay were longer (9.8 vs 6.2). There was no difference in morbidity (31% vs 25%) or 30 day mortality (3.9% vs 3.3%). While the 12 month KM recurrence was similar (35% vs 24%), there was a significantly greater 12 month KM mortality (43% vs 6%) in those patients with active malignancy.

CONCLUSION: The GG challenge was safe and effective in patients presenting with SBO and a history of AP malignancy. While the hospital duration of stay was longer, the ability to successfully discharge patients without operative exploration despite an active AP malignancy was equal to those patients without active malignancy. As a result, GG has the potential to improve these terminal patients’ quality of life.

NOTES



17. SURGICAL OUTCOMES FOLLOWING TOTAL PANCREATECTOMY WITH ISLET CELL AUTOTRANSPLANTATION FOR CHRONIC PANCREATITIS IN PEDIATRIC PATIENTSGC Wilson, JM Sutton, M Salehi, N Schmulewitz, MT Smith, S Kucera, KA Choe, JE Brunner, DE Abbott, JJ Sussman, SA AhmadUniversity of Cincinnati

PURPOSE: This study aims to review surgical outcomes of pediatric patients undergoing total pancreatectomy with islet cell autotransplantation (TPICT) for the treatment of chronic pancreatitis.

METHODS: All pediatric patients (defined as age 5-18 years) undergoing TPICT over a 10 year period (December 2002 to June 2012) were identified for inclusion in a single center observational cohort study. Retrospective chart review was performed to identify pertinent preoperative, perioperative and postoperative data including narcotic usage, insulin requirements, etiology of pancreatitis, previous surgical interventions, operative times, islet cell yields, length of hospital stay, and overall quality of life. Quality of life was assessed using the SF-36 health questionnaire.

RESULTS: Fourteen pediatric patients underwent TPICT for the treatment of chronic pancreatitis at the University of Cincinnati with a mean age of 15.9 years (range 14-18) and a mean BMI of 21.8. 50% (n=7) (7/14) of the patients were male and 29% had undergone previous pancreatic operations (Whipple n=1, Puestow n=1, Frey n=1, Berne n=1). Etiology of pancreatitis was idiopathic for 57% (n=8) while the remainder had identified genetic mutations predisposing to pancreatitis (CFTR n=4, SPINK1 n=1, PRSS1 n=1). Mean operative time was 532 minutes (range 360-674) with an average hospital length of stay of 16 days (range 7-37). Islet cell isolation resulted in mean islet cell equivalents (IE) of 500,443 in patients without previous pancreatic surgery versus 413,671 IE in patients with prior pancreatic surgery (p=0.12).Median patient follow-up was 6 months from surgery (range 0-36). Preoperatively, patients required on average 33.7 morphine equivalent mg per day (MEQ) which improved to 20.4 MEQ at most recent follow-up. Five patients (36%) were completely



narcotic free and an additional three patients (21%) required intermittent narcotic dosing for break through pain only. None of the patients were diabetic preoperatively. All of the patients were discharged following the operation with scheduled insulin requirements (mean=17 Units/day). This requirement decreased to a mean of 10.4 U/d (p=0.1) at most recent follow-up visit. 21% of patients progressed to insulin independence and 64% of patients require less than 15 U/d. All patients achieved stable glycemic control post-operatively. There was no incidence of “brittle” diabetes in the patient population. Quality of life surveys showed improvement in the physical health component, mental health component, and overall health score (p= 0.18, 0.23, 0.21, respectively)

CONCLUSION: This study represents one of the largest series examining total pancreatectomy with islet cell autotransplantation in the pediatric population. Pediatric patients benefitted from TPICT with a decrease in post-operative narcotic requirements, stable glycemic control, and improved quality of life.

NOTES



18. PREDICTING AGGRESSIVE BEHAVIOR IN NON-FUNCTIONING PANCREATIC NEUROENDOCRINE TUMORS J Cherenfant, S Stocker, M Gage, H Du, T Thurow, M Odeleye, S Schimpke, K Kaul, C Hall, I Lamzabi, P Gattuso, D Winchester, R Marsh, K Roggin, D Bentrem, M Baker, R Prinz, M Talamonti NorthShore University HealthSystem

PURPOSE: The biologic potential of non-functioning pancreatic neuroendocrine tumors (PNET) is highly variable and difficult to predict prior to resection. This study was conducted to identify clinical and pathologic factors that are associated with malignant behavior and death in patients who have these tumors.

METHODS: The databases of four institutions were reviewed to identify patients who have undergone pancreatectomy for PNETs using ICD-9 codes from 1992 to 2011. Functioning PNETs were excluded. Multivariate regression Cox proportional models were constructed to identify clinical and pathologic factors associated with distant metastasis and survival.

RESULTS: The study included 128 patients; 57 females and 71 males. The mean age was 55.±14 years and the mean body mass index (BMI) was 28.±5. Eighty-nine (70%) patients presented with symptoms while 39 (30%) patients had tumors discovered incidentally. The mean tumor size was 3.3±2 cm with 56 (44 %) of the tumors measuring 2 cm or less. Seventy-three (57 %) patients had histologic grade 1 tumors, 37 (29 %) with grade 2, and 18 (14%) with grade 3 disease. Peripancreatic lymph node involvement was present in 31 (24%) patients, absent in 75 (59%), and unknown in 22 (17 %) patients. Distant metastasis occurred in 18 (14 %) patients. There were 12 deaths including 1 perioperative, 8 disease-related, and 3 of unknown cause. The overall 5-year survival was 75% with a median follow up of 33 months. Three patients with tumors ≤ 2 cm developed distant metastasis with 2 disease-related deaths. Multivariate regression analysis identified age >55 (HR 5.89, 95% CI 1.64 to 20.58), grade 3 histology (HR 6.08, 95% CI 1.32 to 30.2) and distant metastasis (HR 8.79, 95% CI 2.67 to 28.9) as risk factors significantly associated with higher risk of death (p<0.05). Sex, race, body mass index, symptoms, lymphovascular and perineural invasion



were not statistically related to metastasis or survival (p >0.05).

CONCLUSION: Age >55, grade 3 histology and distant metastasis were significant risk factors for death in non-functioning PNETs. Tumors < 2 cm can be malignant and should be managed with either short interval surveillance or resection.

NOTES



19. RATE OF GROWTH OF PANCREATIC SEROUS CYSTADENOMA BASED ON INITIAL NEOPLASM SIZE AS INDICATION FOR RESECTIONKM El-Hayek, N Brown, C O’Rourke, G Falk, G Morris-Stiff, RM WalshCleveland Clinic Foundation

PURPOSE: The purpose of this study was to examine the natural history and growth rate of pancreatic serous cystadenomas to determine which factors lead to resection in these benign neoplasms.

METHODS: A prospectively maintained database was retrospectively reviewed, identifying patients diagnosed with serous cystadenomas of the pancreas. The diagnosis was made via a combination of classic imaging features with or without cyst aspiration results consistent with serous cystadenoma: low amylase, CEA < 192 ng/dl, and no extracellular mucin. Wilcoxon’s rank sum test was used to test for differences in continuous variable between surveillance and resection groups. Chi-squared and Fisher’s exact tests were used to compare categorical variables between surveillance and resection groups. Ordinary least squares regression was used to model the log of the ratio of follow-up to initial cyst sizes against time and other features. All analyses were performed in R software (version 2.15.1, Vienna, Austria). A significance level of 0.05 was used for all analyses.

RESULTS: A total of 222 patients were identified and prospectively followed from 1998-2011, 196 in the surveillance group and 24 in the resection group. Mean age for patients undergoing surveillance was 67 years while mean age for those in the resection group was 62 years, and there were 170 (77%) females. A total of 113 patients had at least two follow-up images to document cyst changes (106 in surveillance group and 7 in surgical group). In the surveillance group, the distribution of lesions found in the head, body, tail, and uncinate were 42%, 24%, 17%, and 13% respectively. In the surgical cohort, the distribution of lesions found in the head, body, tail, and uncinate were 71%, 14%, 14%, and 0% respectively (p = 0.78). Initial mean maximum diameter of cysts in the surveillance group and surgical group



were 2.28 cm and 3.97 cm respectively (p = 0.003). Seventeen patients underwent resection early in this series, and seven during surveillance for development of symptoms and/or rapid rate of growth. Modeling to predict rate of growth was performed and showed similar growth patterns across many factors reviewed (age, gender, initial size less than or greater than 4 cm), and none were statistically significant. Rate of growth increased with time, with an estimated doubling time of 10 years.

CONCLUSION: This largest single institution study of serous cystadenoma shows growth patterns are similar for serous cystadenomas of the pancreas regardless of initial size. When doubling time is found to be appreciably faster than 10 years, resection should be considered.

NOTES



20. OBESITY INCREASES MALIGNANT RISK IN PATIENTS WITH BRANCH-DUCT INTRADUCTAL PAPILLARY MUCINOUS NEOPLASMEC Sturm, KM Shaffer, CM Schmidt II, SJ Lee, NJ Zyromski, HA Pitt, JM Dewitt, MA Al-Haddad, JA Waters, CM SchmidtIndiana University School of Medicine

PURPOSE: Obesity is an established risk factor for pancreatic adenocarcinoma. No study has specifically examined the influence of obesity on malignant risk in intraductal papillary mucinous neoplasm (IPMN), a group at significant risk of pancreatic adenocarcinoma. We hypothesize that obesity is associated with a higher frequency of malignancy in patients undergoing resection for IPMN.

METHODS: Retrospective review of a prospectively collected database comprised of patients from a single, university-based hospital undergoing resection for IPMN between 1992 and 2012, was performed. Clinicopathologic, and demographic parameters were examined in patients with complete data regarding preoperative body mass index (BMI). Patients were classified according to WHO categories of BMI. High grade (CIS) and invasive lesions were defined as malignant. Low and moderate grade dysplastic IPMN were defined as non-malignant.

RESULTS: In total, 358 patients underwent resection for IPMN. Of these, 263 had complete data for calculation of body mass index (BMI). 79 (30%) of these were malignant IPMN’s; and 184 (70%) of these were non-malignant. Of 244 patients with BMI <35, 70 (29%) were malignant, whereas in 19 patients with BMI >35, 9 (47%) were malignant (p = 0.11). In branch-duct IPMN’s, in patients with BMI <35, 12 (10%) were malignant, compared to 3 (33%) in obese patients (p = 0.002). Alternatively, in main-duct IPMN, in patients with BMI <35, 22 (21%) were malignant, compared to 4 (50%) in obese patients (p = 0.08).

CONCLUSION: These findings suggest that obesity is associated with an increased frequency of malignancy in branch-duct IPMN. This is a potentially modifiable risk factor which may influence oncologic risk-stratification, patient counseling, and surveillance strategy.



NOTES



21. RISK OF PULMONARY EMBOLISM IN TRAUMA PATIENTS NOT ALL CREATED EQUALNS Germain, A Ong, RS Smith, E JeremitskyAllegheny General Hospital

PURPOSE: Patients with traumatic brain injuries (TBI) are assumed to be at high risk for pulmonary embolism (PE). Delay in the initiation of chemoprophylaxis and prophylactic placement of inferior vena cava filters (IVCF) have been advocated by some due to concern for increased intracranial hemorrhage in the presence of low dose anticoagulants. Surprisingly, some data bases have suggested that the risk of PE is lower in patients with isolated TBI compared to other injuries. We hypothesized that patients with isolated TBI are not at high risk for the development of PE when compared to the general trauma population.

METHODS: Patients from the National Trauma Data Bank (NTDB) from the year 2008 were analyzed. Preexisting conditions (PEC), injury severity (ISS), hospital size, trauma level of designation, length of stay (LOS), intensive care unit days (ICU), prevalence of DVT and PE were extracted. Injuries were also classified into six categories; blunt chest, abdominal solid organ, pelvic fracture, lower extremity fracture, spine fracture and TBI. Three main groups of patients were created, those with and without the mentioned injuries and isolated TBI.

RESULTS: Out of a total of 627,775 injured patients, 2,182 (0.35%) had a documented PE. There were 274,260 patients with none of the studied injuries, 289,248 with the five other injury types (including multiple injured brain injured patients), and 64,267 patients with isolated TBI; their respective PE prevalence for the 3 main groups were 0.12%, 0.59% and 0.25% (p<0.001). Using an age, sex, race, adjusted multivariable model evaluating isolated and multiple injured patients and controlling for interaction with IVCF, we found that isolated TBI was not associated with PE. An additional multivariable analysis was performed for patients that were graded for TBI severity. Again, isolated TBI was not associated with PE.



CONCLUSION: Isolated TBI does not appear to be associated with an increased incidence of PE when compared to other injuries. Patients with multiple injuries clearly carry a higher risk of PE and should receive prophylactic interventions. Patients with isolated TBI may not require aggressive prophylaxis as is the standard for other high risk groups. NOTES



22. RADIOGRAPHIC ASSESSMENT OF ELDERLY GROUND LEVEL FALLS: IS THE “PAN-SCAN’ OVER DOING IT?C Dwyer, A Scifres, A Corcos, A Peitzman, T Billiar, K Stahlfeld, J SperryUniversity of Pittsburgh

PURPOSE: Routine whole body CT imaging (PAN-SCAN) has been shown to identify unexpected injuries and alter the management of the blunt injured patient. Less is known regarding the importance of PAN-SCAN imaging in patients with less acute mechanisms of injury. We sought to characterize the changes in practice overtime and utility of PAN-SCAN imaging in elderly fall patients that require trauma center admission.

METHODS: A retrospective analysis using data derived from a Pennsylvania state wide trauma registry was performed (2007-2010). All hemodynamically stable patients (>65 years) who suffered a ground level fall and were admitted for > 24 hours were selected. ICD-9-CM procedure codes were utilized to characterize the extent of radiographic evaluation and the timing of head, chest and abdominal CT imaging over time. Patients who underwent a combination of all 3 scans within 2 hours of arrival were considered to have underwent PAN-SCAN imaging. Utilization of PAN imaging was assessed over time. Clinical outcomes were compared across PAN-SCAN patients relative to less diagnostic imaging. Logistic regression analysis was used to determine if PAN-SCAN imaging was an independent determinate of mortality.

RESULTS: Over the time period of the study, 13,043 patients met inclusion criteria, had at least a single diagnostic CT performed within 2 hours of arrival (head, chest or abdomen) and constitutes the study cohort. The annual rate of PAN-SCAN imaging following ground level falls has significantly increased over time. (Figure, *= p< 0.05). A significantly lower mortality rate (p=0.004) without any significant change in injury severity score (ISS, p=0.15) was found, over the same time period. After controlling for differences in injury severity, presenting vital signs, and intubation status, PAN-SCAN imaging was not significantly associated with mortality (OR – 1.15, p= 0.10, 95% CI 0.97-1.3). However, PAN-



SCAN patients did have a significantly higher ISS ( 13.7 vs. 12.3, p<0.01 ) compared to those who had head, chest or abdominal imaging in a delayed fashion, outside the initial trauma evaluation. Despite higher injury severity, PAN-SCAN imaging was associated with significantly lower ICU requirements, step down days and a lower overall length of stay.

CONCLUSION: The routine use of whole body CT imaging has important implications for trauma center resource utilization. PAN-SCAN imaging has become more common in elderly ground level fall patients over time. Although PAN_SCAN imaging during initial trauma evaluation was not associated with an independent mortality risk reduction, it was associated with a significantly lower hospital and ICU length of stay. This data suggests that whole body CT imaging may benefit and reduce trauma center resource utilization for patients with ground level falls and less acute mechanisms of injury.

NOTES



23. RETENTION OF SUTURING AND KNOT-TYING SKILLS IN SENIOR MEDICAL STUDENTS AFTER PROFICIENCY-BASED TRAININGVM Gershuni, J Woodhouse, LM BruntWashington University School of Medicine

PURPOSE: Senior medical students (MS4) benefit from skills preparation for internship, but the long-term retention of skills is unclear. We evaluated skills acquisition and retention of outcomes of a proficiency-based suturing and knot-tying curriculum administered at the beginning of 4th-year and 7 months later.

METHODS: MS4 planning to enter a surgical specialty were randomized to a proficiency-based suturing and knot-tying curriculum at the beginning of the 4th year (Intervention, n=10) versus no training (Control, n=9). Tasks included simple interrupted (SI) and subcuticular suturing (SQ), one and two-handed tying, and tying on a pass. Technical proficiency (TP) was determined using Objective Structured Assessment of Technical Skills (OSATS, proficiency = 3) by a senior surgeon blinded to the student group and measurement of task times. Both groups underwent assessment at baseline and again at 7 months. The Intervention curriculum consisted of two training sessions, independent practice, and assessment 8 weeks later. Performance was compared between the Intervention and Control MS4 and with categorical PGY-1 surgical interns who participated in a similar curriculum and had follow-up testing at 4 months of internship. All data are mean ± SD; statistical significance was determined by Student’s t-test or Fisher’s exact test.

RESULTS: Intervention and Control MS4 had similar total task times (848.3 ± 199.1 vs 845.1 ± 209.1 min) and TP scores (1.76 ± .15 vs 1.76 ±.28) at baseline. Intervention MS4 improved their TP scores and total task times significantly from baseline to 8 weeks post-course (p<.001) and maintained their improvement at 7 months despite no further formal training (see Table). In contrast, Control MS4 task times and TP scores at 7 months were not significantly different from baseline. At 7 months, Intervention MS4 TP scores were significantly higher and task times faster compared to Control MS4 (Table, p<.001). Significantly more



Intervention than Control MS4 also reached proficiency targets at 7 months for both suturing tasks (SI: 89% vs. 22%, SQ: 89% vs. 22%; p<.01) and 1-handed knot tying (78% vs. 11%, p<.01), but not for 2-handed knot tying (78% vs. 33%, p=.15) or tying on a pass (67% vs. 22%, p=.15). Compared to PGY-1 at 4-months of internship, Intervention MS4 achieved higher TP scores and faster times, while the Control MS4 had lower TP scores and longer times; however, these differences were not statistically significant. Mean improvement in total time for all 5 tasks from baseline was 300 seconds in the Intervention MS4 group vs 126 sec in the Control MS4 and 172 seconds in the PGY-1 interns.

CONCLUSION: A proficiency-based suturing and knot-tying curriculum for MS4 taught early in 4th-year results in improved performance compared to no training. Moreover, students retained these skills over 7 months of the 4th year and perform at a level comparable to that of PGY-1 interns at 4 months of internship.

NOTES

Group MeanTPScore(±SD)

(≥3=proficiency)

MeanTotalTaskTime(±SD)

(sec)

Baseline Post-course

(8wks)

Follow-up* Baseline Post-course

(8wks)

Follow-up*

InterventionMS4 1.8 ± .15 3.0 ± 1.27 3.3 ± .22 848.3 ± 199.1 537.1 ± 81.6 548.7 ± 79.9

ControlMS4 1.8 ± .28 2.1 ± .31 845.1 ± 209.4 718.9 ± 151.3

PGY1SurgicalInterns 2.1 ± .56 2.7 ± .66 773.4 ± 169.7 601.3 ± 74.4



24. PREOPERATIVE AXILLARY IMAGING WITH PERCUTANEOUS LYMPH NODE BIOPSY IS VALUABLE IN THE CONTEMPORARY MANAGEMENT OF BREAST CANCER PATIENTSTJ Hieken, BC Trull, JC Boughey, KN Jones, C Reynolds, KN GlazebrookMayo Clinic Rochester

PURPOSE: ACOSOG Z11 and other studies showing little benefit to axillary dissection (ALND) for early stage breast cancers with limited nodal disease have led many surgeons to change axillary management of breast cancer patients. Consequently, the value of preoperative axillary imaging ±ultrasound-guided needle biopsy (USNB) of suspicious lymph nodes (LN) is being questioned. Benefits include direct triage to ALND without sentinel lymph node biopsy (SLNB), selection of patients for primary systemic therapy and identification of mastectomy + reconstruction patients likely to need radiation. However data is lacking on the predictive value of preoperative axillary imaging ±USNB in identifying cases that fall outside Z11 guidelines.

METHODS: With IRB approval, from our institutional prospective database we identified 988 consecutive invasive breast cancers in patients undergoing operation including axillary surgery in 2010-2011. DCIS and neoadjuvant therapy patients were excluded. We reviewed preoperative imaging and pathology.

RESULTS: The 988 breast cancers included 793 T1, 246 T2, 35 T3, 4 T4 tumors. Axillary operation was 77% SLNB, 13% SLNB+ALND, 10% ALND. Preoperative axillary ultrasound (AUS) was performed in 92% and breast/axillary MRI in 51%. An USNB, primarily FNA (95%), was done in 245 cases with suspicious LN findings and positive in 82 (33.5%). Regarding nodal status, preoperative AUS, MRI and USNB had negative predictive values of 81%, 80%, 75.2% and positive predictive values of 50.2%, 55% and 100%. Visualizing 1 v multiple abnormal LNs on AUS predicted >2LN+ on final pathology (14.7% v 29.1%, p=0.006). One v multiple abnormal LNs on MRI also predicted >2LN+ (15% v 32%, p=0.009). In preoperative USNB LN+ cases the mean number of +LNs was 6.5±0.7 (1-34) and the mean LN metastasis size was 16.8±0.9mm (0.5-50) -- significantly larger than AUS negative



cases [3.9±1.2mm (0.05-30)] p <0.001. Associations between AUS and MRI with nodal histology are shown in the table. There was no N0 or N0(i+) disease after an USNB +LN and only 3 N1mi cases. Among T1/T2 patients LN+ by USNB, 39/74 (52%) had 1 or 2 +LN; those with multiple abnormal LNs on AUS had ≥3 +LNs in 66% (21/32) of cases v 38% (18/42) with ≥3+LNs with a solitary abnormal LN AUS, p=0.016.

CONCLUSION: In our contemporary series preoperative AUS±USNB proved valuable for surgical planning, permitting ALND without SLNB in 10% of patients. USNB LN+ cases had a greater number and extent of LN involvement. Multiple suspicious LNs on AUS predicted >2 +LNs. Our findings reinforce that neither AUS nor MRI has sufficient negative predictive power to preclude surgical axillary staging based on current standards of care. Two thirds of T1/T2 patients with USNB +LN and multiple suspicious LNs on AUS had ≥3+LNs, suggesting such patients should proceed to ALND despite the results of Z11. Patients undergoing breast conservation who are USNB+ with a single AUS abnormal LN who meet Z11 criteria may be eligible for SLNB and might avoid ALND.



AssociationofPreoperativeAxillaryImagingandUSNBResultsandMRIFindingswithNodalHistologyatSurgeryin988BreastCancerPatients

NOTES

PreoperativeAxillaryUltrasound/USNBResults

NEGATIVE SUSPICIOUS

No USNB

SUSPICIOUS

Negative USNB

SUSPICIOUS

Positive USNB

P Value

LN+ 140/643 (21.8%)

13/33 (39.4%)

46/148 (31.1%) 82/82 (100%) <0.0001

#LN+, median, IQR 0 (0-0) 0 (0-1) 0 (0-1) 3 (1-7) <0.0001

>2 LN+ 23/643 (3.6%) 3/33 (9.1%) 8/148 (5.4%) 42/82 (51.2%) <0.0001

Size of Largest LN Metastasis, mm, median, IQR

2.6 (0.6-6), 6 (0.9-14.8) 2.1 (0.25-6.0) 14 (8.8-24.3) <0.0001

Extranodal extension present

38/133 (28.6%)

4/12 (33.3%) 13/44 (29.6%) 54/74 (73%) <0.0001

PreoperativeAxillaryMRIResults

NEGATIVE SUSPICIOUS

LN+ 80/337 (23.7%) 97/168 (57.7%) <0.0001

#LN+, median, IQR 0 (0-0) 2 (0-3) <0.0001

>2 LN+ 10/337 (3.0%) 42/168 (25%) <0.0001

Size of Largest LN Metastasis, mm, median, IQR

3 (0.2-7.3) 9.5 (6-21.5) <0.0001

Extranodal extension present

27/76 (35.5%) 42/68 (61.8%) <0.0001



NOTES



25. PHARMACOLOGIC STIMULATION OF THE NICOTINIC ANTI-INFLAMMATORY PATHWAY MODULATES GUT AND LUNG INJURY FOLLOWING HYPOXIA-REOXYGENATION INJURYSL Tarras, DM Liberati, K Ginnebaugh, LN DiebelWayne State University

PURPOSE: Preinjury vagal nerve stimulation confers significant protection against gut and lung injury following experimental hemorrhagic shock (HS). This likely occurs via the nicotinic anti-inflammatory pathway and the α7 nicotinic acetylcholine receptor (α7nAChR). Intestinal barrier integrity is dependent on the cytoskeletal elements. We hypothesized that either a nonspecific cholinergic (nicotine) or selective α7nAChR agonist (AR-R17779) would modulate intestinal and pulmonary effects of gut ischemia-reperfusion if used early after HS insult in an in-vitro model.

METHODS: Confluent HT29 intestinal epithelial cells were cocultured with Escherichia coli. Cell cultures were then subjected to 21% O2 (control) or 5% O2 (hypoxia) for 90 minutes followed by reoxygenation. A subset of HT29 cells were treated with nicotine (5µM) or AR-R17779 (4µM) before or immediately after hypoxic insult. HT29 cell culture supernatants were obtained and TNFα and IL-6 levels quantitated. HT29 cell monolayer integrity was determined by measuring permeability (FITC-dextran) and apoptosis. In other experiments, confluent pulmonary microvascular epithelial cells (HMVEC) were cocultured with HT29 supernatants and HMVEC permeability and ICAM-1 expression determined. HT29 cells were subsequently stained for actin microfilaments using rhodamine labeled phalloidin.

RESULTS: See Table. Disruption of HT29 actin microfilaments was demonstrated following hypoxia/reoxygenation (H/R) insult and was abrogated by either nicotine or AR-R17779 agonist. Pretreatment with these agonists did not protect against H/R immunoinflammatory effects as was noted with treatment after the hypoxic insult.



CONCLUSION: Post insult pharmacologic stimulation of the nicotinic anti-inflammatory pathway appears to mimic the protective effect of pre-HS vagal nerve stimulation noted in animal studies. In vivo studies are warranted to confirm the results of this current investigation.

NOTES

HT29cells HT29 control HT29 + H/R HT29 + nicotine(5µM) + H/R HT29 + AR-R17779(4µM) + H/R

TNF (pg/ml) 32.8 ± 2.1 65.4 ± 5.3* 30.4 ± 4.8# 28.3 ± 3.3#

IL-6 (pg/ml) 13.6 ± 1.2 33.8 ± 5.2* 20.8 ± 2.9*# 20.3 ± 3.1*#

Perm. (nmol.cm-2.hr-1) 0.25 ± 0.02 0.52 ± 0.04* 0.30 ± 0.03# 0.28 ± 0.02#

% apoptosis 5.2 ± 0.8 11.4 ± 2.3* 5.6 ± 1.1# 5.3 ± 1.2#

HMVEC

Perm. (nmol.cm-2.hr-1) 0.15 ± 0.02 0.47 ± 0.05* 0.19 ± 0.03# 0.16 ± 0.02#

ICAM-1 (MFI) 7.1 ± 1.5 18.9 ± 2.8* 9.7 ± 1.9# 9.3 ± 1.6#



26. PARTIAL VS. TOTAL SPLENECTOMY IN CHILDREN WITH HEREDITARY SPHEROCYTOSISAD Seims MD, F Breckler Pharm D, KD Hardacker, FJ Rescorla MDSection of Pediatric Surgery, Department of Surgery, Indiana Riley Hospital for Children

PURPOSE: Partial splenectomy is utilized selectively in children with hereditary spherocytosis in order to decrease red cell breakdown while maintaining splenic immune function. The purpose of this study is to compare the outcomes in children undergoing laparoscopic partial splenectomy (LPS) with those undergoing laparoscopic total splenectomy (LTS).

METHODS: After obtaining IRB approval, the records of all children 18 years of age or younger with hereditary spherocytosis undergoing LTS and LPS were reviewed from 2002 to 2012. Wilcoxen rank summary tests were used for comparison of p value of less than 0.05 value was considered significant.

RESULTS: Eighty seven children with hereditary spherocytosis underwent either LTS (71) or LPS (16). The mean age was 5.5 ± 2.8 years for LPS and 7.1 ± 3.6 years for LTS (p=0.14) and gender was comparable between the groups. Accessory spleens were identified in 20% of LTS and 38% LPS (p=0.13). Concomitant cholecystectomy for gallstones was performed in 32% of LTS and 38% of LPS. The operative time was 86.5 ± 33.0 minutes for LTS and 139.9 ± 36 minutes for LPS (p=0.0005). The length of stay was 1.2 ± 0.5 days for LTS and 2.4 ± 1.4 days for LPS (p=0.0003). The preoperative (pre) and postoperative (post) reticulocyte (retic) and hemoglobin (Hgb) levels are listed in the table. Children undergoing LPS had lower preop (p=0.0148) and postop (p<0.0001)Hgb levels than LTS. Three children in the LPS required transfusions (2, 4, and 5 years later) for aplastic crisis with parvovirus infection. No children with LTS have evidence of persistent splenic function or anemia. There was no occurrence of overwhelming post splenectomy infection in any of the children.



CONCLUSION: These data demonstrate that LPS is effective in decreasing hemolysis in children with hereditary spherocytosis although LTS is more effective. In this series children selected for LPS had lower preop Hgb levels indicating more severe hemolysis. LPS has the disadvantage of longer operative time and length of stay which may be balanced by retained immune function for these children.

NOTES

Preop Retic

%

Postop Retic

%

P Preop Hgb

(gm/dl)

Post Hgb

(gm/dl)

P

LPS 14.0 ± 4.5 7.4 ± 4.1 0.0024 8.8 ± 1.9 10.5 ± 1.7 0.0216

LTS 11.0 ± 5.4 2.3 ± 1.1 0.0001 10.2 ± 1.7 13.8 ± 1.1 <0.001



27. GASTROESOPHAGEAL REFLUX DISEASE, PROTON-PUMP INHIBITOR USE AND BARRETT’S ESOPHAGUS IN ESOPHAGEAL ADENOCARCINOMA: TRENDS REVISITEDMJ Lada MD, DR Nieman MD, M Han MD, P Timratana MD, C Peyre MD, CE Jones MD, TJ Watson MD, JH Peters MDUniversity of Rochester Medical Center

PURPOSE: Screening for esophageal adenocarcinoma has not become policy in part over concerns in identifying the high-risk group. It is often claimed that a significant proportion of patients developing esophageal adenocarcinoma do not report pre-existing reflux symptoms or prior treatment for gastroesophageal reflux disease (GERD). As such, our aim was to assess the prevalence of GERD Symptoms, proton-pump inhibitor (PPI) use and Barrett’s esophagus (BE) and their impact on survival in patients undergoing esophagectomy for esophageal adenocarcinoma.

METHODS: The study population consisted of 347 consecutive patients who underwent esophagectomy for esophageal adenocarcinoma between 2000 and 2011 at a university-based medical center. Patients with a diagnosis of esophageal squamous cell carcinoma and those who underwent esophagectomy for benign disease were excluded. The prevalence of pre-operative GERD symptoms, defined as presence of heartburn, regurgitation or epigastric pain, PPI use (> 6 months) and BE were retrospectively collected. Overall long-term and stage-specific survival was compared in patients with and without the presence of pre-operative GERD, PPI use or BE.

RESULTS: The majority of patients (64%, 222/347) had pre-operative GERD symptoms and a history of PPI use (52%, 180/347). Slightly less than half (44%, 152/347) carried a pre-operative diagnosis of BE. Kaplan Meier survival analysis revealed a marked survival advantage in patients undergoing esophagectomy who had pre-operative GERD symptoms, PPI use or BE diagnosis (Figure, p= <0.0001). The survival advantage remained significant in patients with pre-operative BE when adjusted for American Joint Committee on Cancer (AJCC) stage (p= 0.042).



CONCLUSION: These data show that the often quoted statistic that the majority of patients with esophageal adenocarcinoma do not report pre-existing GERD or PPI use is false. Furthermore, a diagnosis of BE is present in a surprisingly high proportion of patients (44%). There is a distinct survival advantage in patients with pre-operative GERD symptoms, PPI use and BE diagnosis which may not be simply due to earlier stage at diagnosis. Screening may affect survival outcomes in more patients with esophageal adenocarcinoma than previously anticipated.



NOTES



NOTES



28. ACUTE CARE SURGERY PRACTICE MODEL: TARGETED GROWTH FOR FISCAL SUCCESSMS Alexander, CS Nelson, JP Coughenour, SL BarnesUniversity of Missouri

PURPOSE: Acute Care Surgery (ACS) remains in its infancy as a defined surgical specialty within hospital systems. Little has been published regarding the financial impact of this care delivery method to hospital systems and departments when combining trauma, emergent, and elective general surgery into a single practice model. We sought to compare hospital and clinical productivity measures of a newly formed university division of acute care surgery based on patient type: trauma, emergent, and elective; to determine the best avenues by which to focus on programmatic growth.

METHODS: Single calendar year retrospective review of hospital system and divisional fiscal productivity (FTE=3) of specific patient visits by patient type (trauma, emergent, or elective) admitted to or discharged by the acute care surgeons. Demographic data, payor mix, patient volumes and operative rates were determined for each patient type. Fiscal contribution by patient type to both hospital and clinical productivity were measured by net revenue and wRVU production respectively. Chi-squared test for independence compared payor mix and analysis of variance (ANOVA) was used for comparison of fiscal performance between patient types.

RESULTS: 1,492 patients were included in the analysis of calendar year 2010; 1,056 trauma (67% male, age 41.9 (range: 0-102)), 346 emergent (53% male, age 44.6 (range: 15-91)), and 90 elective (51% male, age 46 (range: 16-87) patient encounters. There were no significant differences in payor mix between patient types. Significant differences were seen in average per patient encounter hospital net revenue, clinical wRVU production and length of stay (LOS). The ACS team (N=3) operated on 12% of trauma patients compared to 52% of emergent, and 100% of elective surgery encounters. Hospital net revenue per patient was highest for trauma encounters while clinical productivity per patient encounter was highest for emergent patients. Elective encounters



contributed negatively to hospital margins. (See Table I)

CONCLUSION: Per patient hospital system revenue and a majority of clinical wRVU productivity remains highest for the care of injured patients in our ACS practice model while emergent general surgical encounters demonstrate the highest per patient rates of clinical productivity. Targeted growth of the ACS practice model should focus on the injured and acutely ill and focus less on elective surgical practice.

NOTES



29. REGIONAL COLLABORATION ACROSS HOSPITAL SYSTEMS TO DEVELOP AND IMPLEMENT TRAUMA PROTOCOLS SAVES LIVES WITHIN TWO YEARSJA Claridge, B Patterson, F Degrandis, C Emmerman, D Bronson, A ConnorsMetroHealth Medical Center

PURPOSE: The Northern Ohio Trauma System (NOTS) was created with the expressed goal of improving trauma care through collaboration, system wide protocol implementation, and evidence based process improvement. The primary goal of this study was to evaluate the mortality of trauma patients seen across the region after two years of beginning NOTS.

METHODS: Regional data was compared to the two years pre-NOTS (2008 and 2009) to the two years post-NOTS (2010 and 2011). The regional system consisted of two large hospital systems, initially including one level 1 center, 4 level 2 centers, 7 non-trauma hospitals, and local EMS groups. Two level 2 trauma centers closed during the study period. Mortality was the primary outcome for this study. Multivariate logistic regression was also done to evaluate for independent predictors of mortality. An odds ratio (OR) and 95% confidence interval (CI) of survival was determined after adjusting for other factors associated with mortality.

RESULTS: Over the 4 year period 29,890 trauma patients were seen throughout NOTS. The mean age was 44 with a mean ISS of 8. 65% percent of the patients were male. Racial breakdown demonstrated that 64.0% were white, 31.9% were black, and 4.1% were other races. The mean LOS was 3.0 ± 5.2 days and overall mortality was 3.4%. A comparison of pre and post-NOTS mortality is demonstrated in the table. A separate analysis using multivariate logistic regression demonstrated that patients treated in the post-NOTS period was a significant independent predictor for survival when controlling for age, gender, ethnicity, mechanism, and ISS. The OR of survival of Post NOTS was 0.81 (CI = 0.70-0.94) when evaluating all patients. The OR for admitted patients was 0.78 (CI = 0.66-0.94) and 0.76 (0.62-0.95) in patients with ISS >24. There was a significant increase in the percentage of patients seen at the level 1 center in the post-NOTS period, which



was especially demonstrated in patients with higher ISS.CONCLUSION: NOTS contributed to the saving of lives within 2 years of its formation. Regionalized protocols, collaboration, and consolidation resulted in a significant improvement in mortality.

NOTES

Pre-NOTS Post-NOTS

(* p<0.01)

Relative Reduction in Mortality

All Trauma Patients N = 12766 N = 17124

4.4% 2.7%* 38.6%

All Admitted Trauma Patients

N = 10337 N = 10460

3.7% 3.1%* 16.2%

ISS > 14 N = 1774 N = 1816

25.4% 19.3%* 24.0%

Blunt Injuries N = 10892 N = 14968

3.5% 2.2%* 37.1%

Age > 64 N = 2762 N = 3558

7.5% 5.5%* 26.7%

ISS >24 N = 817 N = 725

46.3% 38.6% 16.7%

Black Patients N = 4067 N = 5273

4.4%* 2.6%* 40.9%

Penetrating N = 1480 N = 1749

10.1% 6.5%* 35.6%



30. PERORAL ESOPHAGEAL MYOTOMY (POEM) AND LAPAROSCOPIC HELLER MYOTOMY PRODUCE A SIMILAR SHORT-TERM ANATOMIC AND FUNCTIONAL EFFECT ON THE ESOPHAGOGASTRIC JUNCTIONEN Teitelbaum, S Rajeswaran, R Zhang, RT Sieberg, FH Miller, NJ Soper, ES HungnessNorthwestern University

PURPOSE: Peroral esophageal myotomy (POEM) is a novel endoscopic operation for the treatment of achalasia. In addition to its endoscopic nature, POEM differs from traditional laparoscopic Heller myotomy (LHM) in that only the inner circular muscle layer of the esophagus is divided, the diaphragmatic hiatus is not mobilized, and an antireflux procedure is not performed. The effect of these technical differences in terms of anatomic and functional outcomes at the esophagogastric junction (EGJ) postoperatively is unknown.

METHODS: Patients who had undergone either LHM or POEM at a single-institution in a non-randomized fashion, and had both a pre and postoperative routine timed barium esophagram (TBE), were selected for analysis. TBE was performed using a swallow of 200ml of diluted barium contrast, with radiographs taken at 1, 2, and 5 minutes post-swallow in an upright position. All TBE measurements were made by a radiologist blinded to both procedure type and pre/postop time point. Esophageal contrast column height was measured from the EGJ for each radiograph (1, 2, 5 mins). Maximum esophageal width and the degree of angulation between the esophageal body and the EGJ were measured on the 1 min radiograph. Patients were contacted via telephone to obtain a current Eckardt symptom score.

RESULTS: 17 LHM and 12 POEM patients had undergone both pre and postop routine TBE. There were no baseline differences between groups with respect to gender distribution, age, body mass index, or duration of dysphagia. More LHM patients had undergone prior endoscopic treatment (59% vs. 8%, p<.01) and the mean time from procedure to postop TBE was longer for LHM patients (7 ±4 vs. 2 ±1 months, p<.001). Both LHM and POEM patients had significant decreases in TBE column heights



postoperatively on 1, 2, and 5 min radiographs (LHM: pre 15.6, 12.7, 11.3cm vs. post 3.6, 2.5, 1.8cm; p<.001 and POEM: pre 14.7, 11, 9.4cm vs. post 4.4, 2.5, 1.2cm; p<.001) (See Table). When changes from baseline were compared for column heights, there was no difference between LHM and POEM. Both operations also resulted in a decrease in maximum esophageal width (LHM: 4 vs. 1.9cm; p<.001 and POEM: 3.9 vs. 1.7cm; p<.001) and a less severe angulation between the esophageal body and EGJ (LHM: 48 vs. 35 degrees; p<.001 and POEM: 41 vs. 35 degrees; p=.02). Changes from baseline for width and angle were similar between procedures. Current Eckardt symptom scores decreased from preop baseline for both procedures (LHM: 7 ±3 vs. 1 ±2, scale 0-12; p<.01 and POEM: 7 ±2 vs. 1 ±1) at a mean follow-up interval of 61 months for LHM and 5 months for POEM.

CONCLUSION: POEM and LHM produce a similar short-term anatomic and functional result at the EGJ in terms of decreased column height on TBE. Additionally, POEM results in a similar narrowing and straightening of the esophagus despite the fact that it does not involve hiatal mobilization. The long-term symptomatic and physiologic outcomes of POEM require further study.



LaparoscopicHellerMyotomy(n=17) Preop Postop p-value

Mean column height

at 1 minute (cm) 15.6 ±5.9 3.6 ±2 <.001

Column height at 2 min 12.7 ±6.6 2.5 ±2.3 <.001

Column height at 5 min 11.3 ±5 1.8 ±2 <.001

Mean esophageal width (cm) 4 ±1.6 1.9 ±.7 <.001

Mean angle between esophageal body

and EGJ (degrees) 48 ±20 35 ±16 <.001

PeroralEsophagealMytomy(n=12) Preop Postop p-value

Mean column height

at 1 minute (cm) 14.7 ±4.1 4.4 ±3.4 <.001

Column height at 2 min 11 ±4.3 2.5 ±2.2 <.001

Column height at 5 min 9.4 ±5.3 1.2 ±1.7 <.001

Mean esophageal width (cm) 3.9 ±1.4 1.7 ±1.2 <.001

Mean angle between esophageal body

and EGJ (degrees) 41 ±18 35 ±13 0.02

Comparisonofchangespretopostop LHM POEM p-value

Mean change in column height

at 1 minute (cm) -12 ±6 -10.3 ±6.1 NS

Change in column height at 2 min -10.2 ±7.3 -8.5 ±4.7 NS

Change in column height at 5 min -9.5 ±5.8 -8.2 ±5.6 NS

Change in mean esophageal width (cm) -2.1 ±1.6 -2.2 ±1 NS

Change in mean angle between

Esophageal body and EGJ (degrees) -13 ±10 -7 ±9 NS



NOTES



31. PER ORAL ENDOSCOPIC MYOTOMY (POEM): A SHORT-TERM COMPARISON WITH THE STANDARD LAPAROSCOPIC APPROACHM Ujiki , AK Yetasook, M Zapf, EW Denham, JG Linn, JM CarbrayNorthShore University HealthSystem

PURPOSE: We report our short-term experience with POEM and compare these results to our outcomes with laparoscopic Heller Myotomy for achalasia.

METHODS: Patients from an institutional review board-approved protocol underwent POEM and were followed in a prospective database. Comparisons were made with patients in a prospective esophageal database who underwent laparoscopic Heller myotomy and partial fundoplication between May 1, 2009 and August 24, 2012.

RESULTS: Thirty-two patients underwent a minimally invasive approach (13 POEM, 19 LHM with a partial Dor or Toupet fundoplication). Baseline demographics, pre-operative Eckardt scores, motility data, and prior intervention history were comparable. One perforation occurred in each group, with extended length of stay (LOS) of 24 (POEM) and 20 (LHM) days. Removing these cases, average LOS in days (2.8±1.7 and 2.6±1.5, p=0.75) were not different between the groups and both procedures achieved myotomy length of 10 cm. Operative time was significantly less in minutes with the peroral approach (184±69 in POEM and 328±60 in LHM, p<0.0001). Post-operative pain by visual analog scale scoring was also less (3.8±3.0 in POEM versus 5.7±1.9 in LHM, p<0.05) as well as use of analgesia with morphine-equivalents in mg (12.0±8.4 versus 42.0±54.1, p<0.05) during admission. Eckardt scores in the early postoperative period were similar (0.8±.1.3 in POEM versus 1.6±1.7 in LHM, p=0.66) with comparable average follow-up in days (124±96 in POEM versus 163±182 in LHM, p=0.48).



CONCLUSION: Significantly decreased operative time was found with the peroral approach (POEM). Additionally, this incisionless method to esophagomyotomy may result in significantly less pain in the immediate post-operative period with similar relief of symptoms. Increased experience with POEM through prospective studies is needed.

NOTES



32. PERIOPERATIVE OUTCOMES OF LAPAROSCOPIC TRANSHIATAL ESOPHAGECTOMY WITH ANTEGRADE ESOPHAGEAL INVERSION FOR HIGH GRADE DYSPLASIA AND INVASIVE ESOPHAGEAL CANCERKA Perry, LM Funk, WS MelvinThe Ohio State University

PURPOSE: We sought to examine whether antegrade laparoscopic inversion esophagectomy (LIE), a potential alternative to thoracoscopic-assisted or open transhiatal esophagectomy, is a safe and reliable approach to esophageal resection in patients with high grade dysplasia and distal esophageal cancer.

METHODS: Thirty-six patients underwent LIE with antegrade esophageal inversion between November 2009 and July 2012. Data for all patients were maintained in an IRB-approved prospective database. Outcome measures included operative time, blood loss, adequacy of resection, lymph node harvest, length of hospital stay, and perioperative complications. This series of patients represents our entire experience with this procedure.

RESULTS: Thirty-six patients with an average age of 64 years underwent LIE. Twenty-nine (81%) of the patients were male. Indications for surgery included 32 adenocarcinomas, 2 Barrett’s esophagus with high-grade dysplasia, and 2 squamous cell carcinomas. Eleven patients (31%) underwent neoadjuvant chemotherapy and radiation. LIE was completed successfully in 34 (94%) patients, while 2 required conversion to open transhiatal esophagectomy. LIE required an average of 221 minutes to complete, and there was a median operative blood loss of 100 ml. An R0 resection was achieved in all cases, and the median lymph node harvest was 15.5. Median hospital stay was 8 days with a median intensive care unit stay of 2 days. Postoperative complications included clinically evident anastomotic leak with radiographic confirmation (n=11), atrial arrhythmias (n=5), pneumonia (n=4) and tracheoesophageal fistula (n=2). There was one perioperative death due to multisystem organ failure. Eighteen patients underwent endoscopic dilation for treatment of dysphagia. Compared to patients undergoing primary esophageal resection, those who received neoadjuvant therapy did not have



significantly different operative times, blood loss, hospital stays, lymph node yields, or complication rates.

CONCLUSION: Laparoscopic transhiatal esophagectomy with antegrade esophageal inversion is a safe approach to esophageal resection in patients with high grade dysplasia and distal esophageal cancers. Complete resection with an adequate lymph node harvest can be consistently achieved with relatively short operative times, minimal operative blood loss, low perioperative mortality, and short inpatient hospital stays for primary surgical resection or following neoadjuvant chemotherapy and radiation. NOTES



33. THE USE OF LAPAROSCOPIC ULTRASOUND IN DIFFICULT CHOLECYSTECTOMY CASES SIGNIFICANTLY DECREASES MORBIDITYEC Gwinn, S Daly, DJ DezielRush University Medical Center

PURPOSE: Laparoscopic ultrasound (LUS) is a method for intraoperative bile duct imaging that can be used prior to any potentially hazardous dissection. The purpose of this study was to determine if LUS could permit safe completion of laparoscopic cholecystectomy (LC) and to assess whether this had any impact on clinical outcome.

METHODS: Forty-four patients in whom LUS was considered critical for identification of the extrahepatic bile ducts during cholecystectomy were prospectively identified from a database of 438 patients who had routine LUS performed during cholecystectomy. In these patients, anatomy was obscured due to severe acute (29) or chronic (15) cholecystitis. LC patients were compared, on an intention to treat basis, with a group of forty-one contemporaneous patients with severe cholecystitis who had planned open cholecystectomy (OC) for the indication of anticipated difficult gallbladder dissection. Preoperative, intraoperative, and postoperative variables were analyzed by Fischer exact, Chi-square, and unpaired Student T-test. Significance was defined as p-value ≤ 0.05.

RESULTS: LUS identified the extrahepatic bile ducts in all cases. 40 of the 44 cases, or 91%, were completed laparoscopically. The LC and OC groups had similar age, gender, co-morbidities and preoperative laboratory profiles. LC patients had significantly fewer preoperative percutaneous cholecystostomy tubes (0% vs. 12%) and a lower median ASA classification (2 vs. 3). Intraoperatively, LC patients had significantly less estimated blood loss (30.0 +/- 42.2 cc vs. 150.0 +/- 178.0 cc) and fewer drains placed (27% vs. 76%). There were no differences in operative times or in the rates of intraoperative cholangiography, common bile duct exploration, or subtotal cholecystectomy. Postoperatively, LC patients had a significantly shorter length of stay (1.5 +/- 1.1 vs. 6.0 +/- 6.0 days) and significantly fewer



total complications (14% vs. 44%), Clavien-Dindo grade 1 (7% vs. 24%) and grade 3 (2% vs. 24%) complications, biliary complications (0% vs. 20%), biliary reinterventions (0% vs. 20%), and abdominal reinterventions (0% vs. 17%). In the OC group, there were two patients with bile leaks, one with a major bile duct injury and one death.

CONCLUSION: By allowing identification of the extrahepatic bile ducts during difficult cholecystectomy, LUS results in a high rate of successful laparoscopic completions. Laparoscopic cholecystectomy is associated with better clinical outcomes than open cholecystectomy for patients with severe cholecystitis. NOTES



34. AUTOMATED ANALYSIS OF ELECTRONIC MEDICAL RECORD DATA REFLECTS THE PATHOPHYSIOLOGY OF SURGICAL COMPLICATIONSJ Tepas, III, M Nussbaum, AL Hsiao, JM RimarUniversity of Florida College of Medicine-Jacksonville

PURPOSE: We hypothesized that a novel algorithm using electronic medical record (EMR) data from multiple clinical and biometric sources could provide early warning of organ dysfunction in patients with high risk for postoperative complications and sepsis. Surgical patients undergoing colorectal surgical procedures were evaluated.

METHODS: The Rothman Index (RI) index is a predictive model based on heuristic equations derived from 26 variables related to inpatient care. It integrates clinical nursing observations, bedside biometrics, and laboratory data into a continuously updated, numeric physiologic assessment, ranging from 100 (unimpaired) to -60. The RI can be displayed within the EMR as a graphical trend with decreasing trend warning of physiologic dysfunction. Patients undergoing colorectal procedures between June and October, 2011, were evaluated to determine correlation of initial RI and lowest RI to incidence of complications and/or postoperative sepsis. Patients were stratified by number of complications and presence of sepsis defined by discharge ICD9 codes. Mean direct cost of care was then calculated for each group.

RESULTS: The overall incidence of peri-operative complications in the 124 patient cohort was 51% (n=64patients). The 349 complications sustained by this group represented 82 distinct diagnoses. The ten patients with sepsis (8%) experienced a 40% mortality. Analysis of initial RI for the population stratified by number of complications and/or sepsis demonstrated a risk related difference. With progressive onset of complications, the RI continued to decline, indicating worsening physiologic dysfunction and linear increase in direct cost of care. (Table)



CONCLUSION: These findings demonstrate that EMR data can be automatically compiled into an objective metric that reflects patient risk and changing physiologic state. The automated process of continuous update defines a physiologic trajectory associated with evolving organ system dysfunction indicative of postoperative complications. Early intervention based on these trends will guide preoperative counseling, enhance pre-emptive management of adverse occurrences, and improve cost efficiency of care.

NOTES

NoComplx 1-5Complx >5Complx Sepsis

N 60 47 7 10

Mean initial RI 85.06±10.4 71.43±21.5 56.44±37.4 64.13±21.7

Lowest mean RI ± SE 72.8±2.17 57.7±3.33 23.9±5.62 -1.3±6.71

Mean Dir. Cost ($± SE)$10,289

±5,779

$22,377

±35,408

$44,164

±44,000

$63,099

±48,052



35. ETIOLOGY AND INCIDENCE OF PEDIATRIC GALLBLADDER DISEASESK Walker, AC Maki, DS Foley, KM Wilson, L Galganski, CA Wiesenauer, SJ BondUniversity of Louisville

PURPOSE: Our recent perception is that that the spectrum of pediatric biliary tract disease is changing. Hemolytic disease has remained relatively constant, while the incidence of biliary dyskinesia and non-hemolytic (cholesterol) stones has been increasing. The goal of this study was to examine the causes and comorbidities of pediatric gallbladder disease at our institution.

METHODS: A retrospective chart review was performed on 408 consecutive patients at Kosair Children’s Hospital who underwent cholecystectomy over a 9-year time period ending in 2012. Patient demographic data and prior medical and surgical illness were extracted from the chart. Radiographic studies, operative, and pathology reports were reviewed. Body mass index (BMI) was calculated from height and weight based on the Center for Disease Control (CDC) childhood body mass index-for-age model. The following classifications were used: normal BMI (between 5% and 85% of population), overweight (between 85% and 95% of population), and obese (greater than 95%). Descriptive statistics and student two-tailed unequal distribution t-tests were performed comparing BMI and the indication for cholecystectomy.

RESULTS: Four hundred eight patients comprised the study group. 386 (95%) of cholecystectomies were performed laparoscopically. Average age was 13.3 years and 67.2% were females. Indications for cholecystectomy were gallstones in 257 (63%) and biliary dyskinesia in 135 (33%). Of the patients with gallstones, 59 (23%) children had hemolytic disease. While the number of cholecystectomies for hemolytic disease was relatively stable throughout our study, the incidence of both biliary dyskinesia and non-hemolytic (cholesterol) cholelithiasis rose dramatically by 63% and 216%, respectively. (Figure 1).



Average BMI calculations were as follows: 42% had normal BMI, 12% were overweight and 39% were obese. Average BMI with standard deviation for hemolytic disease was 19.3+4.6, biliary dyskinesia was 24.7+ 6.4, and non-hemolytic disease 28.9+9.5. Average BMI for patients with non-hemolytic (cholesterol) stones and biliary dyskinesia were significantly greater than the average BMI for patients with hemolytic stones (p<0.0001). Also, the average BMI for children with non-hemolytic (cholesterol) stones was statistically greater than the average BMI with biliary dyskinesia (p<0.0001).

CONCLUSION: This study shows that symptomatic gallbladder disease is increasing in our pediatric population over the 8 year time period. Biliary dyskinesia and children with non-hemolytic (cholesterol) stones are responsible for this increase. Average BMI values are lowest for those with hemolytic disease, intermediate for patients those with biliary dyskinesia, and greatest for those with non-hemolytic (cholesterol) stones.



NOTES


NOTES




36. PATIENT PERSPECTIVES ON POSTOPERATIVE VISITS WITH GENERAL SURGEONSGP Wright, AM Wolf, G Ambrosi, MB Dull, MH ChungMichigan State University

PURPOSE: The current standard of care in our community is for routine office follow-up two weeks after general surgical procedures. With low complication rates, however, many common postoperative concerns could be addressed over the phone, saving time and money for both the patient and surgeon.

METHODS: General surgeons at three university-affiliated community hospitals participated. Patient contact information was obtained for procedures over a 6-month time period including: laparoscopic cholecystectomy (LC), appendectomy for uncomplicated appendicitis (AP), and inguinal (IH) or umbilical (UH) hernia repair. Patients were mailed an anonymous survey with self-addressed stamped envelope from a third party institution not directly affiliated with the surgeon’s office. The primary outcome measure was whether or not patients felt their concerns could have been adequately addressed over the phone in place of an office visit.

RESULTS: A total of 1406 surveys were sent to the patients of 22 general surgeons. Completed surveys were received from 339 patients. One hundred seventy-four underwent LC, 83 IH, 41 AP, and 41 UH. One hundred twelve (33.0%) felt their concerns could have been adequately addressed over the phone without an office visit. Patients who spent less than 10 minutes with their doctor (n=223) favored telephone follow-up (p<0.001). There were also significant differences in perspectives between procedures (p<0.001). Patients undergoing IH were less interested in telephone follow-up compared with LC (14.5% vs. 40.8%, p<0.001), AP (14.5% vs. 34.1%, p=0.018), and UH (14.5% vs. 36.6%, p=0.010). There was no significant difference between age or gender groups. Of 66 patients (19.5%) with self-reported complications, 44% sought care from a healthcare provider other than their primary surgeon.



CONCLUSION: One third of patients undergoing common surgical procedures felt that an immediate postoperative visit was unnecessary and that a phone call would have been sufficient to address their concerns. For laparoscopic cholecystectomy alone, this could save over 400 office visits annually in our community. These observations are important for healthcare organizations that are trying to maximize surgeons’ efficiency while improving patient satisfaction.

NOTES


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2011LaparoscopicAntirefluxSurgeryPreventsAspirationofPepsinAfterLungTransplantation P. Marco Fisichella, et al. Loyola University, Chicago, Illinois


“BEST PAPER BY A NEW MEMBER” AWARD (continued)

2012 DysphagiaPost-Fundoplication;MoreCommonlyHiatalOutflowResistancethanPoorEsophagealBodyMotilityCL Wilshire, S Niebisch, et al.


IN MEMORIAM

WilliamF.DonaldsonPittsburgh, PA

RobertL.SchmitzChicago, IL

WilliamJ.SchulteMilwaukee, WI

RobertT.SoperIowa City, IA

HughD.Stephenson,Jr.Columbia, MO


GEOGRAPHICAL LISTING


GEOGRAPHICAL LISTING (continued)

CANADA

ALBERTACalgaryBathe, OliverDixon, ElijahKortbeek, JohnMcKinnon, J. GregoryMcPhedran, N. TaitPasieka, JaniceYilmaz, Serdar

MANITOBAWinnipegDowns, Allan

ONTARIOBellevilleInglis, Frederic

CookstownWatters, Neil

HamiltonKnight, Peter

Mueller, C. Barber

LondonDuff, JohnPassi, Ronald

MansfieldPearson, F. Griffith

OttawaHarris, KennethLewis, Ronald

OwenSoundMullens, J. Edward

TorontoDeitel, MervynKoven, IrvingMcLeod, RobinRosen, IrvingSmith, Andrew

QUEBECMontrealBrown, Rea A.Chiu, Ray Chu-JengEmil, SherifFeldman, LianeFerri, LorenzoFleiszer, DavidFried, GeraldGordon, PhilipHampson, LawrenceHinchey, E. JohnMacLean, LloydMcLean, A. PeterMetrakos, PeterMulder, DavidRosenberg, LawrenceShibata, HenrySigman, HarveyWexler, Marvin

St.LeonardRheault, Marcel



SASKATCHEWANReginaMeiers, Suzanne

SaskatoonKeith, RogerMcFadden, AndrewMiller, Grant

GERMANY

EssenBroelsch, Christoph

GREECE

AthensTsapogas, Makis

ThessalonikiTsoulfas, Georgios

TURKEY

Siali,IstanbulKalayoglu, Munci

UNITEDARABEMIRATES

AbuDhabiHau, Toni

UNITEDSTATESOFAMERICA

ALABAMABirminghamGleysteen, JohnHanaway, MichaelHarmon, Caroll

ARIZONACarefreeMichaelis, Lawrence

GoodyearStaren, Edgar

MesaEckhauser, Marc Lewis

ParadiseValleyHale Jr., Harry

PhoenixJoehl, RaymondLund, DennisMadura, II, James

ScottsdaleDemeure, Michael

TucsonLittle, AlexZollinger, Jr., Robert

CALIFORNIACoronadoKnutson, Carl



DuarteYim, John

ElMaceroAndrews, NeilBerkoff, HerbertWolfman, Earl

LaJollaBergan, John

LarkspurAlfrey, Edward

LosAngelesBenfield, JohnDeMeester, TomFord, HenriGewertz, BruceReber, HowardSenagore, AnthonyUpperman, Jeffrey

OrangeHarness, Jay

RanchoSantaFeGeha, Alexander

RescueFrey, Charles F.

SanDiegoBlock, MelvinMiller, Fletcher

SanFranciscoDoherty, CorneliusWest, Michael

SantaBarbaraDent, ThomasSerkes, Kenneth

SantaRosaJacobson, Lyle F.Peralta, Elizabeth

StudioCityMakowka, Leonard

TorranceMoore, Thomas

COLORADOCarbondaleTowne, Jonathan

DenverHalgrimson, CharlesMoore, Ernest

LoneTreeChae, FrankNorton, Lawrence

LongmontGillespie, Robert

CONNECTICUTHartfordButler, Karyn

NewHavenChagpar, AneesKim, AnthonyLongo, Walter


DELAWARENewarkPetrelli, Nicholas

DISTRICTOFCOLUMBIAWashingtonAl-Refaie, WaddahKirkpatrick, John

FLORIDABartlowEtheredge, Edward

BocaRatonBarron, James

BonitaSpringsFreier, Duane

CaptivaIslandReyes, Hernan

CoralGablesReis, Robert

JacksonvilleNussbaum, MichaelSommer, BruceVolpe, Carmine

JupiterErnst, Calvin

KeyLargoHummel, Robert

LongBoatKeyJudd, Donald

MiamiLew, John

NaplesGonzalez, LuisMason, G. Robert

NokomisWittmann, Dietmar

OcalaMcChesney, Lawrence

OrangeParkUdekwu, Anthony

PalmCityGans, Henry

PlatationMax, Martin

PonteVedraBeachBarnhorst, Donald

SarasotaBoenau, Jack

TampaBandyk, DennisCarey, LarryDawes, LillianFabri, PeterFiror, HughKarl, Richard

VeroBeachWeil, Richard



GEORGIAAtlantaFink, AaronGordon, RobertKnechtle, StuartSweeney, John

SavannahZaren, Howard

ValdostaBeal, JohnILLINOISArlingtonHeightsConway, DanielLoren, Alan

BellevilleWade, Terence

BurrRidgeGamelli, Richard

ChicagoAbcarian, HerandAkhter, ShahabAn, GaryAngelos, PeterBaker, TaliaBaker, RobertBarker, WalterBenedetti, EnricoBernhard, VictorBines, StevenCaicedo, JuanChedrawy, EdgarChoi, EugeneConnolly, Mark

Crandall, MarieDas Gupta, Tapasde Hoyos, AlbertoDeziel, DanielDurham, JosephEskandari, MarkFaber, L. PenfieldFichera, AlessandroFlint, LewisFrancescatti, DariusFry, DonaldFryer, Jonathan P.Hansen, NoraHoyt, DavidHungness, EricHunter, JamesHurst, RogerJeruss, JacquelineKaplan, EdwinKeen, RichardKhan, SeemaKibbe, MelinaMahvi, DavidMassad, MalekMatthews, JeffreyMcCarthy, III, WalterMoss, GeraldNajafi, HassanPatti, MarcoPearce, WilliamPickleman, JackPosner, MitchellPrystowsky, JayPugh, CarlaRichter, HarryRoggin, KevinShapiro, MichaelSkaro, AntonSnow, NormanSoper, Nathaniel



Swaroop, MamtaVanecko, RobertVargish, ThomasVitello, JosephWayne, JeffreyWise, StephenWood, DonaldYao, James

DanvilleCanver, Charles

EvanstonBaker, MarshallJona, JudaPrinz, RichardSener, StephenTalamonti, MarkUjiki, MichaelWinchester, DavidYao, Kathy

GlenviewCaprini, JosephCurtin, JohnPaloyan, Daniel

HighlandParkGould, Steven

HinesSantaniello, JohnSilver, Geoffrey

HinsdaleGreager, JohnSchuler, James

HoffmanEstatesFisher, H. Calvin

ItascaMozes, Martin

KnoxvilleMiller, Joshua

LakeForestWeinberg, Jr., Milton

MaywoodAranha, GerardDe Jong, StevenFisichella, P. MarcoGlynn, LorettoGodellas, ConstantineHolt, DavidKuo, PaulLuchette, FredSankary, HowardSarker, SharfiSlogoff, MicheleTon-That, Hieu

NapervilleFolk, Frank

NilesTrippel, Otto

NorthChicagoZdon, Michael

NorthbrookLeapman, StephenNahrwold, David

OakBrookPaloyan, Edward



ILLINOIScontinuedOakParkBaker, William

ParkRidgeSaletta, John

PeoriaAnderson, RichardBonello, JuliusCrawford, DavidDeBord, JamesEstes, NormanMarshall, J.Pearl, RichardStanfill, Amy

SkokieFrantzides, ConstantineVelasco, Jose

SpringfieldFolse, J. RolandHazelrigg, StephenRakinic, JanRamsey, DonSumner, David

VernonHillsWesley, John

WarrenvilleShoup, Margo

WesternSpringsThomas, Paul

WilmettePrinten, KennethSherman, Joseph

WinnetkaFry, WillardStrauch, Gerald

WoodstockBryan, Douglas

INDIANACarmelJolly, Walter

EvansvilleHeimburger, Irvin

FortWayneReed, Jr., Donald

HobartGalouzis, Tom

IndianapolisBillmire, DeborahBroadie, ThomasCanal, DavidCikrit, DoloresClare, SusanColeman, III, JohnDalsing, MichaelDunnington, GaryEngum, ScottFalimirski, MarkGeorge, VirgilioGrosfeld, JayHayward, III, ThomasHouse, MichaelHoward, ThomasLadd, AlanMadura, JamesMiskulin, Judiann



Munshi, ImtiazNakeeb, AttilaPitt, HenryPohlman, TimothyRescorla, FrederickSawchuk, AlanSchmidt, ChristianSelzer, DonSimons, ClarkTouloukian, ChristopherWest, KarenZyromski, Nicholas

LafayetteMcPherson, RichardRolley, Ronald

MonroviaBennett, JamesYaw, Peter

ValparaisoAnderson, Raymond

WestLafayetteLempke, Robert

IOWADavenportLohmuller, Joseph

IowaCityGurll, NelsonHowe, JamesJochimsen, PeterKatz, DanielMason, EdwardMetcalf, AmandaRossi, NicholasScott-Conner, CarolShaaban, AimenShilyansky, JoelShirazi, SiroosSugg, SoniaUrdaneta, LuisWeigel, Ronald

KeokukCaropreso, Philip KANSASKansasCityJewell, WilliamMammen, JoshuaThomas, James

LakeQuiviraHermreck, ArloPierce, George

LeawoodSchloerb, Paul

PrairieVillageHolder, ThomasThomas, Jr., Christopher



KENTUCKYCovingtonWright, CreightonLexingtonBelin, RobertEndean, EricFerraris, VictorHagihara, PatrickRanjan, DineshSachatello, CharlesSchwarcz, Thomas

LouisvilleBergamini, ThomasCacchione, RobertCheadle, WilliamEdwards, JohnFoley, DavidGaar, EdwinGalandiuk, SusanGarrison, R. NealHarbrecht, BrianLarson, GeraldMartin, RobertMarvin, MichaelMcCafferty, MichaelMcMasters, KellyMiller, Frank B.Polk, Jr., HiramRichardson, J. DavidRodriguez, JorgeScoggins, CharlesSmith, JasonVitale, GaryWrightson, William

ProspectWaterman, Norton

SomersetMays, E. Truman

LOUISIANANewOrleansBuell, JosephMargolin, DavidNichols, Ronald

MAINERomeTarnay, Thomas

MARYLANDAnnapolisPark, Adrian

BethesdaNiederhuber, JohnRice, Charles

CockeysvilleImbembo, Anthony

NottinghamGeis, W. Peter

RockvilleRead, Raymond



MASSACHUSETTSBostonEllis, Jr., F. HenryFernando, HiranFischer, JosefHasselgren, Per-OlofHurst, JamesLevitsky, SidneyLillemoe, Keith

BurlingtonSillin, Lelan

DanversNarra, Vinod

NewtonBecker, James

SpringfieldPatterson, Lisa

WorcesterBozorgzadeh, AdelFiddian-Green, Richard MICHIGANAdaMason, James

AnnArborAnderson, III, HarryArneson, Jr., WallaceBartlett, Robert H.Brandt, MaggieBreslin, TaraBurney, RichardCampbell, DarrellChang, Alfred

Cimmino, VincentCoran, ArnoldGauger, PaulGolladay, EustaceGreenfield, LazarHemmila, MarkHenke, PeterHinshaw, DanielHoshal, Jr., VerneKirsh, MarvinKnol, JamesKonnak, JohnKraft, RichardLindenauer, S. MartinMagee, JohnMerion, RobertMulholland, MichaelOrringer, MarkPark, PaulinePatel, HimanshuPrager, RichardPunch, JeffreyRectenwald, JohnStanley, JamesSung, RandallTeitelbaum, DanielThompson, NormanWahl, WendyWakefield, ThomasWhitehouse Jr., Walter

ChelseaFeller, Irving

DearbornBerkas, Ernest



MICHIGANcontinuedDetroitBaylor, AlfredDiebel, LawrenceDolman, HeatherDulchavsky, ScottFromm, DavidGruber, ScottKlein, MichaelLedgerwood, AnnaLelli, Jr., JosephLucas, CharlesMentzer, Jr., RobertPhillips, EduardoReddy, DanielSteffes, ChristopherStephenson, LarrySugawa, ChoichiTyburski, JamesWeaver, DonaldWhite, MichaelWilson, Robert

DrummondIslandFilo, Ronald

FrankfortOlsen, William

GrandRapidsMansour, M AshrafScheeres, DavidTaber, RodmanWolk, Seth

GrossePointeKelly, AlexanderLloyd, Larry

GrossePointeFarmsJavid, HushangKalamazooSwaniker, Fresca

LansingMcLeod, Michael

MearsRoseman, David

PontiacSilbergleit, Allen

RochesterHillsHinshaw, Keith

RoyalOakKoffron, AlanLucas, RobertShanley, Charles

SouthfieldBodzin, Jason

WarrenHans, SachinderKosir, Mary

WestBloomfieldElliott, Jr., Joseph



MINNESOTADuluthMonge, James

MinneapolisAbrams, JeromeActon, RobertBarke, RoderickBecker, WilliamBeilman, GregoryBuchwald, HenryDelaney, JohnFoker, JohnGoodale, RobertHess, DonavonIkramuddin, SayeedLeonard, ArnoldNajarian, JohnNey, ArthurOdland, MarkSaltzman, DanielShumway, SaraTuttle, ToddVickers, SelwynWard, HerbertZera, Richard

RochesterDevine, RichardFarnell, MichaelGrant, CliveHieken, TinaMcIlrath, DonaldNagorney, DavidSarr, MichaelSterioff, SylvesterWoods, John

St.PaulAhrenholz, DavidLa Fave, JamesMowlem, AlbertRupp, William M.

MISSISSIPPIBrandonTimberlake, Gregory

JacksonAhmed, NaveedHelling, ThomasMerrill, WalterMISSOURIColumbiaBarnes, StephenCurtis, JackDale, PaulHumphrey, LorenMiedema, BrentNichols, W. KirtSilver, DonaldWalls, Joseph

FarmingtonOliver, George

KansasCityAmoury, RaymondBlondeau, BenoitFriedell, MarkGeehan, DouglasHolcomb, III, GeorgeKoontz, Jr., PaulKraybill, WilliamTalboy, GlennVan Way, III, Charles



MISSOURIcontinuedSantaGenevieveHoye, Robert

St.LouisAnderson, CharlesAyvazian, VatcheBrunt, L. MichaelCodd, JohnEberlein, TimothyFerguson, Tomas B.Johnson, FrankKing, HaroldKodner, IraMatthews, BrentPhilpott, GordonShieber, WilliamSicard, GregorioStokes, JamesWarner, Brad

MONTANABillingsMorasch, Mark

NEBRASKAOmahaCarlson, MarkFitzgibbons, Jr., RobertForse, ArmourHodgson, PaulMercer, DavidMittal, SumeetRose, ScottSasson, AaronThompson, Jon

NEWJERSEYNewBrunswickMackenzie, James

NewarkRush,BenjaminSiegel, John

WestOrangeHill, George NEVADAGlenbrookGoldsmith, Harry

NEWMEXICOAlbuquerqueCorson, John

SantaFeSchiller, William

NEWYORKAlbanyBernard, HarveyConti, DavidLeather, RobertShah, Dhiraj

BrainardRoot, Harlan

BrooklynWise, LeslieBuffaloButsch, John



Caty, MichaelCherr, GregoryDayton, MerrilDryjski, MaciejDunn, DavidEdge, StephenEvans, James T.Flynn, Jr., WilliamGlick, PhilipHassett, JamesKulaylat, MahmoudPeer, RichardWilkinson, Neal

DelmarLempert, Neil

DewittParker, Frederick

GreatNeckShons, Alan

NewYorkAckerman, NormanBessey, PalmerEnker, WarrenGreen, RichardMcKinsey, JamesMichelassi, FabrizioReilly, Jr., JamesWallack, Marc

OrchardParkUpson, James

RochesterAdams, JamesAndrus, CarlBankey, PaulDe Weese, JamesEttinghausen, StephenGestring, MarkKashyap, RandeepKrusch, DavidLanzafame, RaymondPeacock, JamesPegoli, Jr., WalterPeters, JeffreySchoeniger, LukeSchwartz, Seymour I.Stewart, Scott

StatenIslandCoil, James

SyracuseClark, Jr., WilliamHassan, MoustafaKittur, Dilip

TeaneckFlancbaum, Louis

WilliamsvilleCaruana, JosephDoerr, RalphDouglass, Jr., Harold



NORTHCAROLINACharlotteGersin, KeithLalka, Stephen

CorneliusStarling, James

DurhamMureebe, LeilaWells, Jr., Samuel

GreenvillePories, Walter

RaleighFarkas, Linda

NORTHDAKOTAGrandForksSauter, Edward OHIOAkronDonovan, DuaneGuyton, DanielLee, Jai HoonParanjape, CharuWilliams, Gary

BeavercreekAdebonojo, Samuel

BellbrookMartin, Lester W.

BratenahlHermann, Robert

ChagrinFallsAnkeney, Jay L.

ChardonKhaitan, Leena

CincinnatiAhmad, SyedAlexander, J. WesleyAzizkhan, RichardBailey, J. KevinBossert, JohnBroderick, TimothyDavis, BradleyDavis, KennethDonovan, Jr., JamesEdwards, MichaelFalcone, Jr., RichardFegelman, ElliottFischer, DavidFlege, Jr., JohnGiglia, JosephHafner, CharlesHeimlich, HenryHelmsworth, JamesHiratzka, LorenJoffe, StephenJohannigman, JayKagan, RichardKempczinski, RichardPritts, TimothyRafferty, JaniceRyckman, FrederickSchreiber, J. TracyShaughnessy, ElizabethSheldon, CurtisSmith, J. MichaelSolomkin, JosephSussman, JeffreyTevar, Amit



Tsuei, BettyVester, SamuelWulsin, John

CirclevilleEvans, William E.

ClevelandAeder, MarkAlexander, J. JeffreyAverbook, BruceBarksdale, Jr., EdwardBerber, ErenBrandt, ChristopherClaridge, JeffreyCmolik, BrianCrowe, JosephDelaney, ConorDifiore, JohnEsselstyn, CaldwellFratianne, RichardGrundfest, SharonHardacre, JeffreyHenderson, J. MichaelHull, TracyKim, JulianLavery, IanMagnuson, DavidMansour, EdwardMarks, JeffreyMcHenry, ChristopherMiller, CharlesNaylor, Jr., DouglasO’Hara, PatrickOnders, RaymondPonsky, JeffreyPriebe, PaulRemzi, FezaRosenblatt, StevenSanabria, Juan

Schauer, PhilipSchulak, JamesShuck, JerrySiperstein, AllanSteiger, EzraStevenson, JeanVogt, DavidWalsh, MatthewWilhelm, ScottYowler, Charles

ColumbusArnold, MarkBloomston, MarkBoles, Jr., E. ThomasBumgardner, GinnyCaniano, DonnaCarson, III, WilliamCrestanello, JuanDas, B. MohanElkhammas, ElmahdiEllison, ChristopherFabia, RenataFalcone, Robert E.Ferguson, Ronald M.Groner, JonathanHazey, JeffreyHenry, MitchellJones, LarryKenney, BrianLindsey, DavidMartin, Jr., EdwardMeckstroth, CharlesMelvin, W. ScottMichalsky, MarcMikami, DeanMiller, MichaelMiller, SidneyMoffatt-Bruce, SusanMoss, R. Lawrence



OHIOcontinuedColumbuscontinuedMuscarella, PeterNeedleman, BradleyNwomeh, BenedictPelletier, RonaldRajab, AmerRuberg, RobertSatiani, BhagwanSchmidt, CarlSmead, WilliamStarr, JeanSteinberg, StevenVaccaro, PatrickVermilion, BlairWilliams, TomYashon, DavidYee, Lisa

DaytonBarney, LindaDunn, MargaretEkeh, A. PeterMcCarthy, MaryRudich, StevenSaxe, JonathanTchorz, Kathryn

GalenaBerggren, Ronald

GreenvilleDutro, John

GroveCityKilman, James

MiddleburghHeightsPlecha, Fred

OregoniaFinley, Jr., Robert

PerrysburgThomford, Neil

PowellCooperman, Marc

ShakerHeightsChung, RaphaelFazio, VictorVogel, Jon

SolonRosen, Michael

SouthEuclidStellato, ThomasSylvaniaSferra, Joseph

ToledoChaudhuri, PrabirJacobs, LloydMerrick, III, HollisWilliams, MalloryZelenock, Gerald

UniversityHeightsStallion, Anthony

YoungstownKavic, Michael



OREGONPortlandMilas, MiraO’Brien, IV, David

PENNSYLVANIAAbingtonWeintraub, William

DanvilleStrodel, William

DowningtownRusso, Pier Antonio

ErieDexter, David

HersheyKauffman, Jr, GordonKoltun, WalterPoritz, LisaSmith, Jr., J. StanleyStewart, DavidWaldhausen, John

LancasterConter, Robert

PhiladelphiaCooper, JoelFry, Robert D.Griffen, WardJain, Ashok KumarLewis, FrankMalangoni, MarkMurayama, KenricRhodes, RobertBell, Richard

PittsburghBartlett, DavidBasu, AmitBilliar, TimothyCarty, SallyCobb, CharlesCourcoulas, AnitaJarrett, FredricLee, KennethMagovern, GeorgeMarsh, JamesMcCloskey, CarolMoorman, DonaldPeitzman, AndrewRams, JamesSchraut, WolfgangSchuchert, MatthewSell, Jr., HarryShapiro, RonSimmons, RichardSingh, MichaelStarzl, ThomasTan, HenkieWebster, Marshall

ReadingLeventhal, Joseph

SaxonburgStremple, John

SayreMeyer, Kenneth

VeronaSieber, William

WexfordLandreneau, Rodney



PENNSYLVANIAcontinued WyndmoorKahng, Kim

RHODEISLANDPortsmouthCloutier, Jr., Charles

ProvidenceEspat, N. JosephHopkins, RobertSax, Harry

SOUTHCAROLINAColumbiaAlmond, CarlSmith, R. Stephen

GreenvilleGauderer, Michael

HiltonHeadIslandCerilli, G. JamesHumphrey, Edward W.Poticha, Stuart

NorthCharlestonFreeman, Joel

TENNESSEEJonesboroughBryant, Lester

NashvilleSmith, RogerSolorzano, Carmen

TEXASAustinErlandson, ErrolLowery, Brian

DallasArenas, JuanNikaidoh, Hisashi

ElPasoSaltzstein, Edward

HoustonWesson, DavidMontgomeryJones, James

TempleLairmore, Terry

TylerKeitzer, Walter

UTAHSaltLakeCityWarden, Glenn

VERMONTBurlingtonDavis, John H.Taheri, Paul

JerichoDrucker, William



VIRGINIAArlingtonMayes, James

CharlottesvilleHallowell, PeterUpchurch, Jr., Gilbert

McLeanWallace, Robert B.

NorfolkLind, James

RichmondMaher, James

RoanokeHaley, Harold

WinchesterLynn, Hugh

WASHINGTONAnacortesRoderick, Heather

BellevueJordan, Jr., Prescott

MosesLakeMartin, Louis

SeattleCondon, Robert

WISCONSINLaCrosseChapman, ScottCogbill, ThomasSkemp, Joseph

MadisonBernhardt, LouisChen, HerbertD’Alessandro, AnthonyFaucher, LeeFoley, EugeneGarren, MichaelHarms, BruceHeise, CharlesHoch, II, JohnKaufman, DixonKennedy, GregoryKent, K. CraigMack, EberhardMatsumura, JonMelnick, DavidRikkers, LaytonSollinger, HansStorm, F. KristianTefera, GirmaToth, SusanTurnipseed, WilliamVega, RolandWeber, Sharon

MilwaukeeBrown, KellieEvans, DouglasGould, JonJohnson, ChristopherLudwig, KirkOldham, KeithOtterson, MaryPappas, Sam



WISCONSINcontinuedMilwaukeecontinuedRoza, AllanSato, ThomasScher, KennethSeabrook, GaryTelford, GordonTermuhlen, PaulaWagner, MarvinWalker, AlonzoWallace, James R.Wang, TracyWeigelt, JohnWilson, StuartYen, Tina

ShorewoodGuice, Karen

WESTVIRGINIACharlestonAburahma, AliBoland, James

HuntingtonHarrah, John

RonceverteCaushaj, Philip

WYOMINGCodyCollicott, Paul



PAST OFFICERS

* Deceased

PRESIDENTRoy D. McClure* 1940-1941Grover C. Penberthy* 1941-1942Roscoe R. Graham* 1942-1946Casper F. Hegner* 1946-1947George M. Curtis* 1947-1948Henry K. Ransom* 1948-1949J. Dewey Bisgard* 1949-1950Walter G. Maddock* 1950-1951B. Noland Carter* 1951-1952R. Kennedy Gilchrist* 1952-1953James T. Priestley* 1953-1954Leon J. Leahy* 1954-1955Rudolf J. Noer* 1955-1956Robert M. Zollinger* 1956-1957Hilger P. Jenkins* 1957-1958William A. Altemeier* 1958-1959Charles D. Branch* 1959-1960Robert T. Tidrick* 1960-1961Chester B. McVay* 1961-1962Angus D. McLachlin* 1962-1963Samuel P. Harbison* 1963-1964Edward S. Judd* 1964-1965Carl E. Lischer* 1965-1966D. Emerick Szilagyi* 1966-1967Fraser N. Gurd* 1967-1968Edwin H. Ellison* 1968-1969E. Lee Strohl* 1969-1970Stanley O. Hoerr* 1969-1970Vallee L. Willman* 1971-1972John M. Beal 1972-1973Charles L. Eckert* 1973-1974William J. Fry* 1974-1975Robert A. Mustard* 1975-1976Charles A. Hubay* 1976-1977Alexander J. Walt* 1977-1978Robert E. Condon 1978-1979John E. Jesseph* 1979-1980

264 CENTRAL SURGICAL ASSOCIATION* Deceased

PAST OFFICERS (continued)

Robert J. Freeark* 1980-1981Seymour I. Schwartz 1981-1982Lloyd D. MacLean 1982-1983Ward O. Griffen, Jr. 1983-1984Lloyd M. Nyhus* 1984-1985George E. Block* 1985-1986Larry C. Carey 1986-1987Daniel W. Elliott* 1987-1988Robert J. Baker 1988-1989Jay L. Grosfeld 1989-1990Jeremiah G. Turcotte 1990-1991Donald Silver 1991-1992Jack. R. Pickleman 1992-1993Folkert Belzer* 1993-1994Roger G. Keith 1994-1995J. Roland Folse 1995-1996Jerry M. Shuck 1996-1997Henry Buchwald 1997-1998David Nahrwold 1998-1999Josef Fischer 1999-2000David Mulder 2000-2001William Baker 2001-2002Jonathan B. Towne 2002-2003Layton F. Rikkers 2003-2004Mark A. Malangoni 2004-2005 Fabrizio Michelassi 2005-2006Thomas Stellato 2006-2007E. Christopher Ellison 2007-2008Richard H. Bell 2008-2009William Turnipseed 2009-2010Michael Nussbaum 2010-2011Gerald Fried 2011-2012Gerald M. Larson 2012-2013



SECRETARYGeorge M. Curtis* 1940-1946Walter G. Maddock* 1946-1949James T. Priestley* 1949-1952Robert M. Zollinger* 1952-1955Charles D. Branch* 1955-1958Angus D. McLachlin* 1958-1961Carl Lischer* 1961-1964Edwin H. Ellison* 1964-1967Vallee L. Willman* 1967-1970William J. Fry* 1970-1973Alexandar J. Walt* 1973-1976Robert J. Freeark* 1976-1979Ward O. Griffen, Jr 1979-1982Larry C. Carey 1982-1985Jay L. Grosfeld 1985-1988Jack R. Pickleman 1988-1991J. Roland Folse 1991-1994David J. Nahrwold 1994-1997William H. Baker 1997-2000Fabrizio Michelassi 2000-2003E. Christopher Ellison 2003-2006Michael S. Nussbaum 2006-2009Nathaniel J. Soper 2009-2012Fred A. Luchette 2012-2015

* Deceased

266 CENTRAL SURGICAL ASSOCIATION* Deceased


TREASURERCharles H. Hubay* 1972-1975John E. Jesseph* 1975-1978Robert P. Hummell 1978-1981Robert J. Baker 1981-1984Donald Silver 1984-1987Jerry M. Shuck 1987-1990Henry Buchwald 1990-1993Josef E. Fischer 1993-1996Layton F. Rikkers 1996-1999Thomas A. Stellato 1999-2002Carol EH Scott-Conner 2002-2005William Turnipseed 2005-2008Christopher McHenry 2008-2011Scott Gruber 2011-2013

RECORDERRobert E. Condon 1972-1977John J. Bergan 1977-1982Jeremiah G. Turcotte 1982-1987Gordon L. Hyde 1987-1992Jonathan Towne 1992-1997Mark Malangoni 1997-2002Richard H. Bell, Jr. 2002-2007 Gerald Larson 2007-2011W. Scott Melvin 2011-2014



REPRESENTATIVETOTHEAMERICANBOARDOFSURGERYLloyd M. Nyhus* 1973-1977William J. Fry* 1977-1982John S. Najarian 1982-1988Jeremiah G. Turcotte 1982-1988Olga Jonasson 1988-1994Richard A. Prinz 1994-2000Michael S. Nussbaum 2000-2006Fabrizio Michelassi 2006-2012Christopher R. McHenry 2012-2018

REPRESENTATIVETOTHEAMERICANCOLLEGEOFSURGEONSADVISORYCOUNCILONSURGERYDaniel W. Elliott* 1982-1985Jay L. Grosfeld 1989-1994Josef E. Fischer 1994-2001Mark Malangoni 2001-2007E. Christopher Ellison 2007-2013Tina W.F. Yen 2012-2018

* Deceased



REPRESENTATIVETOTHEAMERICANCOLLEGEOFSURGEONS BOARDOFGOVERNORSWard O. Griffen, Jr. 1969-1972 1972-1975Melvin A. Block 1975-1978 1978-1981John L. Glover 1981-1984Robert E. Condon 1987-1990 1990-1993Donald Silver 1993-1996 1996-1999Henry Buchwald 1999-2002 2002-2005Layton Rikkers 2005-2011Fred A. Luchette 2011-2014

* Deceased



COUNCILORSEarl B. Smith 1981-1984Lloyd D. MacLean 1983-1984Jay L. Grosfeld 1982-1985Ward O. Griffen, Jr. 1984-1985Peter Cruse 1983-1986Folkert O. Belzer* 1984-1987Lloyd M. Nyhus* 1986-1987Marshall W. Webster 1985-1988George E. Block* 1987-1988Larry C. Carey 1987-1988Marcel J. Rheault 1986-1989Dan W. Elliott* 1988-1989Robert J. Baker 1989-1990Frederic E. Eckhauser 1988-1991Jay L. Grosfeld 1990-1991Roger G. Keith 1989-1992Jeremiah G. Turcotte 1991-1992Josef E. Fischer 1990-1993Donald Silver 1992-1993James S.T. Yao 1991-1994Jack R. Pickleman 1993-1994David S. Mulder 1992-1995Layton F. Rikkers 1993-1996Roger G. Keith 1995-1996Mark A. Malangoni 1994-1997Bruce L. Gewertz 1995-1998Jerry Shuck 1997-1998Marvin Wexler 1996-1999Frank R. Lewis 1997-2000Henry Buchwald 1998-1999David Nahrwold 1999-2000James Madura 1998-2001Josef Fischer 2000-2001David Mulder 2001-2002Gary Dunnington 1999-2002Robert Bower 2000-2003William H. Baker 2002-2003

* Deceased



James Starling 2001-2004Darrell A. Campbell, Jr 2002-2005Layton F. Rikkers 2004-2005Rene Lafreniere 2003-2006Mark Adams* 2004-2007Mark Malangoni 2005-2006Christopher McHenry 2005-2008Fabrizio Michelassi 2006-2007Mary Otterson 2006-2009Thomas Stellato 2007-2008Keith Lillemoe 2007-2010 E. Christopher Ellison 2008-2009Gerald Fried 2008-2011Richard Bell, Jr. 2009-2010Wendy Wahl 2009-2012 Fred Luchette 2010-2011William Turnipseed 2010-2011Michael Nussbaum 2011-2012Margo Shoup 2011-2014Herbert Chen 2012-2015 Gerald M. Fried 2012-2013

* Deceased


CONSTITUTION & BYLAWS


CONSTITUTION & BYLAWS

RESOLUTIONIn view of the desirability of a Surgical Association embracing within its membership surgeons of the central portion of the United States and of the adjacent Canadian provinces, BE IT RESOLVED that such an association be organized by a self-appointed committee of Founders composed of the undersigned forty (40) Fellows of the American Surgical Association; who, at their first meeting, shall (1) elect from their number a President and a President-Elect, each to serve one year; a Secretary to serve a three year term; a Treasurer and a Recorder, each to serve a five year term; and three Councilors each to serve a three year term. The immediate Past President will serve as the fourth Councilor, to serve for one year. The Executive Council will also select members to represent the Association at the American Board of Surgery for a six year term, at the Board of Governors of the American College of Surgeons for a renewable three year term, and at the Advisory Council for Surgery of the American College of Surgeons for a six year term; (2) draw up a suitable Constitution and Bylaws; and (3) invite not more than sixty (60) additional qualified surgeons to become Founder members.


CONSTITUTION & BYLAWS (continued)

CONSTITUTION

ArticleI:Name This society shall be called THE CENTRAL SURGICAL ASSOCIATION. ArticleII:Object The object of this Association shall be to further the practice of Surgery in its various departments, and the study and investigation of surgical problems. ArticleIII:Membership Section 1: The Central Surgical Association shall consist of active, senior, associate, non resident and honorary members (as amended 1977). Section2: The number of active members shall be limited to two hundred fifty (250) (as amended 1948, 1970, 1997). Section3:Senior members shall be founders, founder members or active members in good standing who have reached the age of fifty (50) years, or who have been elected to fellowship in the American Surgical Association, or in one of the other senior societies as determined by the Council. They shall have all the privileges of active members. Senior members shall not be bound by the requirement for attendance at meetings. Upon reaching the age of sixty-five (65), senior members will be relieved of responsibility for paying dues (as amended 1949, 1970, 1977, 1984).

Section4:Retired members shall be those who, having been elected to active or senior membership who have retired from the active practice of surgery. Retired members shall not be bound by the requirement for attendance at meetings and will be relieved of responsibility for paying dues (as amended 2003)



Section:5:Non-resident members shall be those who, having been elected to active or senior membership while a resident within the geographic area accepted by the Council as that of the Central Surgical Association, move elsewhere. Existing non-resident members shall pay dues and shall have all the privileges of active members but shall be relieved of the requirement of attendance at meetings and shall not hold office (as amended 1977).

Section6:Associate Members shall be trainees in the last two years of surgical residency or in a surgical fellowship, as well as new graduates currently in the first two years of surgical practice (prior to American Board of Surgery or equivalent certification). The application process for Associate Membership will be the same as for full membership. Associate Members are not required to pay annual dues. They are not eligible to serve on Central Surgical Association committees and may not attend or vote at the annual business meeting. A complimentary subscription to the journal, Surgery, will not be provided to Associate Members. Associate members who have completed surgical residency are allowed to submit abstracts without the need for sponsorship by a Central Surgical Association member but they are not eligible to act as sponsors for membership or abstract submission. Associate members are encouraged to attend the annual scientific meeting. The maximum term limit for Associate Membership is four (4) years. Upon being granted certification by the American Board of Surgeons, the Associate Member shall notify the membership committee and expedited review of the individual’s application material will be performed to change the applicant’s status to full membership.



Section7:Each candidate for membership must be sponsored by an active or senior member and endorsed by two other active or senior members. To be eligible for active membership each candidate must be certified by the American Board of Surgery or equivalent board or a Fellow of the American College of Surgeons. The Membership Committee must pass on the merits of professional and ethical qualifications of all candidates. The names of the candidates and recommendation of the Membership Committee are submitted to the Council at least one month before the annual meeting. In special circumstances, Council may waive the requirement of certification by the American Board of Surgery or equivalent board or membership in the American College of Surgeons upon recommendation of the Membership Committee by a two-thirds affirmative vote. Names of those surgeons approved by the Council and proposed for election to membership shall be submitted by the Secretary in his/her report at the executive session of the Annual meeting (as amended 1973). If an application fails to be approved for election for three successive years, a new application will be required, but will not be considered until after a minimum of twelve months has elapsed (as amended 1976).

Section8:The number of honorary members shall be limited to ten (10). Proposals for associate, active or honorary membership shall be made in writing to the Council on blanks furnished by the Secretary of the Association, and signed by three members from the active or senior groups.



Section9:Each candidate for membership must be sponsored by an active or senior member and endorsed by two other active or senior members. The Membership Committee must pass upon the merits of professional and ethical qualifications of all candidates. The names of the candidates and the recommendations of the Membership Committee are submitted to the Council at least one month before the Annual Meeting. Names of those surgeons approved by the Council and proposed for election to membership shall be submitted by the Secretary in his/her report at the executive session of the Annual Meeting (as amended 1973). If an application fails to be approved for election for three successive years, a new application will be required but will not be considered until after a minimum of twelve months has elapsed (as amended 1976).

Section10:Following preliminary recommendations by the Council, election to membership shall be determined by ballot of those present at the annual executive meeting of the Association. Favorable ballots to the extent of 75 percent of those cast shall elect. An individual properly proposed for membership and failing to receive election by ballot at three consecutive Annual Meetings shall not be eligible for a second proposal for membership until one year has elapsed from the time of the last Annual Meeting at which the candidate was considered for membership.

Candidates who have received sufficient ballots for election to membership shall attend the next Annual Meeting of the Association unless excused by the Council. At that annual business meeting, each candidate will be introduced to the Association and presented with the Certificate of Membership. Candidates unable to attend the annual meeting shall be mailed the Certificate of Membership and shall forego the privilege of formal introduction to the Association. (as amended 1974, 1975, 1991, 2007).



Section11:The qualifications for active or honorary membership should include:

(a)Certification by the American Board of one of the surgical specialties or by Fellowship in or certification by one of the Royal Colleges or by the American College of Surgeons.

(b)Evidence of participation in activities which have a concern for the welfare of patients and the fostering of the advancement of surgical theory and practice (as amended 1974). Section12:Resignations of members may be acted upon at any annual executive meeting and may be accepted by a majority vote of the members present, providing the member resigning is not in arrears.

Section13:Any member may be expelled for unprofessional or unethical conduct by vote of the Council. Charges of such conduct must be preferred and signed by three members before their consideration by the Council, whose action thereon must take place within one year thereafter. In case the vote of the Council is not decisive, the charges may be dropped by the Council or presented by the Secretary to the Association for action in executive session at which time a three-fourths vote of the members present shall be required for expulsion.

Section14:Any active member who shall have absented him/herself from three (3) consecutive Annual Meetings without acceptable explanation in writing to the Secretary may be dropped from membership in the Association on vote of the Council. His/Her membership may be reinstated by vote of the Council.



ArticleIV:Officers

Section1:The officers of the Association shall consist of a President, a President-Elect, a Secretary, a Treasurer, and a Recorder. These five, together with three Councilors elected at large and the immediate past President, shall constitute the Council. Each Councilor shall serve for three years. A member at large shall be elected annually to replace the outgoing Councilor. Any past President, upon invitation of the President, may be enrolled as a temporary member of the Council to fill a vacancy (as amended 1974).

Section2:The officers, including the members of the Council, shall be nominated by a committee of five (5) members. The Committee shall be composed of the three (3) immediate Past Presidents the most senior of which shall be Chairman of the committee, and two (2) members appointed by the President.

Section3:The election of officers shall take place at the executive sessions of each Annual Meeting. A majority of the votes cast shall constitute an election.

Section4:Any vacancy occurring during the year among the officers of the Association shall be filled by Council.



ArticleV:Committees

Section1:The President shall appoint a Local Committee for Arrangements for the Annual Meeting (as amended 1968).

Section2:There shall be a Program Committee of six members, two appointed annually by the President with the approval of Council, and each to serve three years. Annually, one senior member of the committee is selected by the President in conjunction with Council to act as Chairman of the Committee. The Recorder and the Secretary shall be members of this committee ex-officio. The Program Committee shall select and arrange papers for the Annual Meeting. The Secretary shall employ a competent stenographer to report all discussions of the papers presented before the Association and to assist in keeping the minutes (as amended 1968, 1973, and 1984).

Section3:The Council shall be empowered to select and edit papers read at the Annual Meeting for publication in a surgical journal or inclusion in a Volume of Transactions, if issued. The Council may delegate this power to the Recorder.

Section4:There shall be a Membership Committee of nine members, three appointed annually by the President with the approval of Council and with attention to regional representation. Each appointee will serve three years. The Chairman is selected by the President with Council approval. The Chairman will serve a term of three years. The Secretary shall be a member of the Membership Committee ex-officio. The Membership Committee will carefully evaluate all candidates for membership. The Committee shall convene prior to the Annual Meeting and prepare a list of recommended candidates for membership. This list will then be submitted to the Council for review. The Council then prepares the final approved list to be submitted by the Secretary at the executive session of the Annual Meeting (as adopted 1973).



BYLAWS(revised March 2004)

SectionI:MeetingsThe Association shall meet each year at a time and place designated by vote of the Association at the previous Annual Meeting, following recommendations of the Council and approved by the members of the Association. If change in the time and place becomes necessary between meetings of the Association, the change may be made by the Council. The meeting shall continue for not longer than three (3) days (as amended 1968).

SectionII:QuorumFor transaction of ordinary business, the members present at any meeting shall constitute a quorum. To effect changes in the Constitution and Bylaws, for assessments, appropriations or expenditures of money other than those required in the routine business of the Association, for election of officers and members, or for the expulsion of a member, a minimum of one hundred (100) members shall be required to form a quorum (as amended 1974).

SectionIII:DutiesofOfficers

1.PresidentandPresident-Elect:The President shall preside at the meetings of the Association, preserve order, regulate debates, sign certificates of membership, appoint committees not otherwise provided for, announce results of elections, and perform all other duties legitimately appertaining to his/her office. The President shall prepare an address for the Annual Meeting. In his/her absence, the President-Elect shall preside. In the absence of both, the chair shall be taken by a member elected by those of the Council who are present.

The President-Elect shall substitute for the President as provided above.

No President shall serve for more than one year in that office. The immediate Past-President shall serve for one year on the Council.



2.Secretary:The Secretary shall keep the minutes of the Association and shall issue, at least four weeks prior to the Annual Meeting, a program specifying the time and place of the meeting. The Secretary shall also issue a list of the candidates for proposed membership. The Secretary shall attest all official acts requiring certification, notify officers and members of their election, keep in his/her custody the Seal of the Association and affix it to all documents and papers as the Association may direct, and take charge of all papers not otherwise provided for. He/She shall serve as Secretary and keep minutes of the meetings of the Council and compile a written report to be read at the executive session of the Association to include the recommendation for place of Annual Meeting and the list of candidates proposed for membership, as approved by Council.

3.Treasurer:It shall be the duty of the Treasurer to receive all monies and funds belonging to the Association. The Treasurer shall pay all bills against the Association and shall render all bills for dues and assessments at the conclusion of each meeting, as promptly as possible. A report shall be presented to the Council at each Annual Meeting which includes the names of all members in arrears. The Treasurer shall present an annual account for audit.

4.Recorder:The Recorder shall receive all papers and reports of discussions on papers presented to the Association and shall determine their worthiness for publication. The Recorder shall also be the custodian of the permanent records of the Association (as amended 1968)


5.Council:The Council shall consist of three (3) Councilors elected from the membership at large, together with the President, President-Elect, Secretary, Treasurer, Recorder, and immediate Past President. The term of service of the Councilors elected at large shall be three years. At the annual executive meeting one Councilor shall be elected to take the place of the Councilor whose term expires.

The Council shall be the executive body of the Association. Its stated meetings shall be held at the call of the President and a majority of its members shall constitute a quorum.

The President of the Association shall be Chairman and the Secretary of the Association shall be Secretary of the Council and keep minutes of its proceedings.

SectionIV:CommitteeonArrangementsforAnnualMeetingThe Local Committee on Arrangements for the Annual Meeting shall consist of members appointed by the President, acting together with the President, President-Elect, Secretary and Recorder ex-officio. The duties of this Committee shall be the preparation of the general arrangements for the Annual Meeting.

SectionV:PapersandReportsAll papers and reports read before the Association shall be delivered to the Recorder at the time of their presentation. No paper shall be published in the Transactions or as emanating from the Association which has not been read in full before the Association or presented by Title, nor elsewhere reported unless full credit is given to the Association.

SectionVI:InitiationFeeEvery active member shall, within thirty (30) days after notice of election, pay an initiation fee which includes his/her dues for that year, and by which act he/she acknowledges and accepts the Constitution and Bylaws of the Association (as amended 1952, 1976, 1980).



SectionVII:AnnualDues There shall be an annual assessment on active and senior members as proposed by the Council (as amended 1952, 1976, 1980).

SectionVIII:ArrearageofMembersIt shall be the duty of the Treasurer to notify in writing any member in arrears for one year. After having notified the member by registered mail containing a copy of this section and not having received his/her dues within two months thereafter, it shall be the duty of the Treasurer to notify the Council of such arrearage, which fact shall be entered on the minutes. If reasonable explanation or payment is not forthcoming within one year thereafter, the member’s name may be stricken from the list. The Council may reinstate the member after payment of arrears.

SectionIX:InvitedGuestsAny member may invite guests to a meeting of the Association. The names of all guests shall be entered under a separate head in the list of those attending the meeting. The President may invite guests to participate in the discussion. All guests shall withdraw from the executive session.

SectionX:CertificatesofMembershipEvery member shall be entitled to a certificate of membership signed by the President and the Secretary and bearing the Seal of the Association.



SectionXI:OrderofBusiness

AnnualMeeting

1. Call to order

2. Announcements from the Chairperson of the Local Committee on arrangements

3. Announcements from Secretary

4. Announcements from Recorder

5. Reading of scientific papers and presentations

BusinessMeeting

1. Call to order

2. Introduction of new members

3. Report of the Recorder

4. Report of the Treasurer

5. Report of the Auditing Committee

6. Report of the Secretary

7. Report of the Membership Advisory Committee Chairperson

8. Report of the Program Committee Chairperson

9. Results of the Election of New Members



10. Report of the Society Representative to the American Board of Surgery

11. Report of the Society Representative to the Board of Governors of the American College of Surgeons

12. Report of the Society Representative to the Advisory Council for Surgery of the American College of Surgeons

13. Report of the Executor of the Central Surgical Association Foundation

14. Future Meetings

15. Report of the Local Arrangements Committee for next year’s Annual Meeting

16. Appointment of new committee members for the following year: Membership Advisory Committee, Program Committee, Nominating Committee and Auditing Committee

17. Old business/New business

18. Report of the Nominating Committee

19. Passing of the Gavel

20. Adjournment (revised 2002)



SectionXII:RulesofOrderThe proceedings of the Association shall be conducted under the local parliamentary rules of order.

SectionXIII:AlterationintheConstitutionandBylawsNo part of the Constitution or Bylaws shall be amended, altered or repealed except at an executive session of a regular Annual Meeting. The suggested amendment, alteration or repeal in the Constitution or Bylaws shall have been presented in writing at a previous Annual Meeting, signed by three (3) members and delivered to the Secretary. The adoption of a suggested amendment, alteration or repeal shall be by the vote of three-fourths (3/4) of the members present.



CSAF BOARD OF DIRECTORS AND COMMITTEE MEMBERS2012-2013

OFFICERS

PresidentRichard H. Bell, Jr., MD

1stVice-PresidentWilliam D. Turnipseed, MD

SecretaryMichael S. Nussbaum, MD

TreasurerGerald M. Fried, MD

BoardMembersatLargeMeril T. Dayton, MD David M. Mahvi, MD Susan Moffatt- Bruce, MD Richard A. Prinz, MD

Ex-OfficioMembersGerald M. Larson, MD, President CSA Fred A. Luchette, MD, Secretary CSA



FOUNDATION CONTRIBUTORS


(FOR CONTRIBUTIONS RECEIVED THROUGH DECEMBER 31, 2012)

FOUNDATION CONTRIBUTORS

FOUNDERSTABLETotal Contributions or Pledge over $10,000

Christopher Ellison Anna M. Ledgerwood Charles E. Lucas

PRESIDENTSCIRCLETotal Contributions or Pledge over $5,000 (Presidents Circle Pin and Silver Ribbon)

Robert J. Baker William H. Baker Richard H. Bell James R. DeBord Norman C. Estes J. Roland Folse Jay L. Grosfeld Roger G. Keith Fred A. Luchette Mark A. Malangoni Fabrizio Michelassi David S. Mulder David L. Nahrwold Michael S. Nussbaum Jack R. Pickleman Layton F. Rikkers Thomas A. Stellato Jeremiah G. Turcotte

PATRONS Total Contributions of $1000-$4999 (Blue Ribbon)

James T. Adams Gerard V. Aranha Wallace A. Arneson, Jr. Adel Bozorgzadeh L. Michael Brunt Henry Buchwald John L. Butsch Dolores F. Cikrit John J. Coleman,III Robert E. Condon Anita P. Courcoulas Thomas H. Covey Anthony M. D’Alessandro Michael C. Dalsing Lillian G. Dawes Duane L. Donovan Scott A. Engum Josef E. Fischer Frank A. Folk Gerald M. Fried Susan Galandiuk Tom N. Galouzis Richard L. Gamelli R. Neal Garrison Bruce L. Gewertz Lazar J. Greenfield Mark R. Hemmila Paul E. Hodgson James L. Hoehn Verne L. Hoshal, Jr. Thomas J. Howard Ray J. Joehl Stephen N. Joffe


FOUNDATION CONTRIBUTORS (cont.)

Richard J. Kagan Michael D. Klein Gerald M. Larson Ian C. Lavery Frank R. Lewis Keith D. Lillemoe Katherine J. Liu Robert J. Lucas Lloyd D. MacLean James A. Madura Edward E. Mason Jeffrey B. Matthews Richard C. McPherson Sidney F. Miller Albert Mowlem C. Barber Mueller William O. Myers Hiram C. Polk, Jr. Jeffrey L. Ponsky Kenneth J. Printen Richard A. Prinz Frederick J. Rescorla Hernan M. Reyes James A. Schulak Carol Scott-Conner Anthony J Senagore Stephen F. Sener Gregorio A. Sicard Lelan F. Sillin Donald Silver Herbert E. Sloan Nathaniel J. Soper Edgar D. Staren Jon S. Thompson Gregory A. Timberlake Jonathan B. Towne William D. Turnipseed Jose M. Velasco Wendy L. Wahl Thomas W. Wakefield

Karen W. West Gary B. Williams Stuart D. Wilson James S.T. Yao

DONORS Total Contributions of $300-$999 (Red Ribbon)

Richard C. Anderson Peter Angelos Mark W. Arnold Vatche H. Ayvazian Douglas M. Behrendt Louis C. Bernhardt Timothy R. Billiar Deborah F. Billmire Thomas A. Broadie David F. Canal Scott C. Chapman William R. Clark, Jr. Paul E. Collicott Daniel Conway Paul R. Cunningham Merril T. Dayton Steven A. De Jong Richard M. Devine Daniel J. Deziel John A. Dutro Errol E. Erlandson Calvin B. Ernst Robert J. Fitzgibbons, Jr. Richard B. Fratianne W. Peter Geis Lawrence G. Hampson Sachinder S. Hans Kenneth A. Harris Per-Olof J. Hasselgren Peter K. Henke Robert E. Hermann


George J. Hill George W. Holcomb, III Tracy L. Hull Gordon L. Hyde Jay A. Johannigman Christopher P. Johnson Walter A. Koltun William G. Kraybill Rene Lafreniere Joseph L. Lohmuller David M. Mahvi Jeffrey M. Marks Lester W. Martin Christopher R. McHenry Walter H. Merrill Amanda M. Metcalf Monica Morrow Michael W. Mulholland Richard M. Nedelman W. Kirt Nichols George A. Oliver Mary F. Otterson Edward Paloyan Elizabeth A. Peralta Henry A. Pitt Jay B. Prystowsky Jan Rakinic Feza H. Remzi Lawrence Rosenberg Allan M. Roza John M. Santaniello Jonathan Saxe C. Max Schmidt Harry W. Sell, Jr. Margo C. Shoup Jerry M. Shuck Joseph P. Skemp Norman J. Snow Sylvester Sterioff Gordon L. Telford

James H. Thomas James G. Tyburski Vic Velanovich Brad W. Warner Marvin J. Wexler Katharine Yao

CONTRIBUTORS Total Contributions up to $299 (Green Ribbon)

Jerome H. Abrams Robert D. Acton Syed A. Ahmad David H. Ahrenholz Harry L. Anderson, III Carl H. Andrus John A. Aucar John C. Aust Bruce J. Averbook Richard G. Azizkhan Roderick A. Barke John A. Barrett Robert H. Bartlett Thomas M. Bergamini Jason H. Bodzin John E. Bossert John J. Brems Douglas H. Bryan Richard E. Burney Darrell C. Campbell, Jr. Donna A. Caniano Joseph A. Caruana Frank H. Chae Herbert Chen Susan E. Clare Charles T. Cloutier, Jr. Richard P. Cochran William R. Cole Donald R. Cooney



Conor P. Delaney David W. Dexter Elijah Dixon Cornelius Doherty Scott A. Dulchavsky David L. Dunn Margaret M. Dunn Joseph R. Durham Stephen B. Edge Richard W. Egan Robert E. Falcone Michael B. Farnell Victor W. Fazio Victor A. Ferraris Ronald S Filo Lewis M. Flint William J. Flynn, Jr. David P. Foley Henri R. Ford R. Armour Forse David Fromm Edwin E. Gaar Paul G. Gauger Douglas M. Geehan John J. Gleysteen Jon C. Gould John A. Greager Scott A. Gruber Sharon Grundfest Daniel P. Guyton Peter T. Hallowell Bruce A. Harms Jay K. Harness Thomas Z. Hayward, III J. Michael Henderson Daniel B. Hinshaw John R. Hoch, II Sayeed Ikramuddin Lloyd A. Jacobs Juda Z. Jona

Donald L. Kaminski Dixon B. Kaufman Michael S. Kavic Seema A. Khan John R. Kirkpatrick James A Knol Paul G. Koontz, Jr. John B. Kortbeek Alan P. Ladd Stephen G. Lalka Raymond J. Lanzafame Gary W. Lemmon Nonie Lowry Dennis P. Lund Hugh B. Lynn George J. Magovern James W. Maher Leonard Makowka M. Ashraf Mansour David A. Margolin Walter J. McCarthy Robin S. McLeod Jonathan L. Meakins Frank B. Miller Ernest E. Moore Donald W. Moorman Gerald S. Moss Martin F. Mozes Kenric M. Murayama Kimberly K. Nagy Attila Nakeeb Douglas F. Naylor Ronald L. Nichols Hisashi Nikaidoh Mark D. Odland Patrick J. O’Hara David M. Ota Pauline K. Park Frederick B. Parker Janice L. Pasieka



Lisa A. Patterson James L. Peacock Richard H. Pearl Andrew B. Peitzman Mark D. Pescovitz Jeffrey H. Peters Eduardo Phillips Fred R. Plecha Mitchell C. Posner Paul P. Priebe Jeffrey D. Punch Janice F. Rafferty Stephen C. Rayhill Daniel J. Reddy Donald N. Reed, Jr. Robert L. Ruberg Steven M. Rudich Daniel Ruge William M. Rupp Frederick C. Ryckman Charles R. Sachatello John D. Saletta Michael G. Sarr Bhagwan Satiani Harry C. Sax Philip R. Schauer Kenneth S. Scher Donald J. Scholten Don J. Selzer Joseph J. Sferra Ron Shapiro Elizabeth A. Shaughnessy Joel Shilyansky Allen Silbergleit Geoffrey M. Silver Norman A. Silverman Richard L. Simmons Anton Skaro Ezra Steiger Steven M. Steinberg

Robert J. Stratta Sonia L. Sugg Randall S. Sung Jeffrey J. Sussman Fresca Swaniker Paul A. Taheri Daniel H. Teitelbaum Paula M. Termuhlen Gilbert R. Upchurch, Jr. Patrick S. Vaccaro Charles W. Van Way, III Robert M. Vanecko Roland J. Vega Gary C. Vitale David P. Vogt Marc K. Wallack R. Matthew Walsh Alvin L. Watne Jeffrey D. Wayne Sharon M. Weber Ronald J. Weigel Michael A. West Walter M. Whitehouse Jr. Eric A. Wiebke Thomas E. Williams David P. Winchester Leslie Wise Seth W Wolk Serdar Yilmaz Michael J. Zdon Richard T. Zera Robert M. Zollinger, Jr.

If you have any questions regarding your listing, please contact CSA Foundation at 913-402-7102



CSA FOUNDATION SURGICAL ENRICHMENT AWARDS

1995-2012

1995-FrankE.Johnson,M.D.St. Louis UniversityInternational Traveling Scholarship in Health Outcomes Research

1996-ScottA.Dulchavsky,M.D.Wayne State UniversityRenal Apoptosis During Ischemia Reperfusion Injury

1997-PeterAngelos,M.D.Northwestern UniversitySponsor: Raymond J. Joehl, M.D.The Teaching of Ethics in Surgical Training: The Development of a Curriculum

1997-ScottA.Engum,M.D.Indiana UniversitySponsor: Jay L. Grosfield, M.D.Experimental Assessment of Small Intestinal Sub mucosa as a Pros-thetic Diaphragm Substitute in a Growing Animal Model

1998-RandallS.Sung,M.D.University of MichiganSponsor: Jonathan S. Bromberg, M.D.Cytokine Inhibition in Adenovirus-Mediated Gene Transfer

1999-JeffreyJ.SusmanUniversity of CincinnatiSponsor: Josef E. Fischer, M.D.Modulation of Type 1/Type 2 Tumor Immune Responses to Improve Adoptive Immunotherapy

2000-HenryJ.Schiller,M.D.SUNY Upstate Medical UniversitySponsor: Frederick B. Parker, M.D.Alveolar Mechanics and Ventilator Induced Lung Injury


CSA FOUNDATION SURGICAL ENRICHMENT AWARDS (continued)

2001-TinaR.Desai,M.D.University of ChicagoSponsor: Bruce L. Gewertz, M.D.The Role of IL-6 Hypoxic Endothelial Barrier Dysfunction

2002-ChristianM.Schmidt,M.D.Indiana UniversitySponsor: James Madura, M.D.Role of Cyclooxygenase-2 in Human and Pancreatic Experimental Tumorigenesis

2003-HankC.Hill,M.D.Roswell Park Cancer InstituteSponsor: Boris W. Kuvshinoff II, M.D.Neoadjuvant Tumor Immunotherapy in a Surgical Metastasis Model

2004-MarkR.Hemmila,M.D.University of MichiganSponsor: Darrell A. Campbell, Jr., M.D.Trauma Care Quality Improvement

2005-AndyC.Chiou,M.D.University of IllinoisSponsor: James R. De Bord, M.D.Surgical Resident Rotation in the Office of Human Research Over-sight’s Institutional Review Board

2006-KatharineYao,M.D.Loyola University Medical CenterTraumaList and LoyolaList: A Pilot Project to Improve “Hand Off” Com-munications and Workflow Efficiency

2007-CharlesP.Heise,M.D.University of WisconsinSalmonella Mediated Type III Secretion of Interleukin-10 for Prevention of Th2 Mediated Inflammatory Bowel Disease


2008-CliffordS.Cho,M.D.University of Wisconsin School of MedicineExperimental Manipulation of Melanoma-Induced Immune Suppres-sion

2009-DavidJ.Bentrem,M.D.Northwestern UniversityStudy of 5-Lipoxygenase, an Arachidonic Acid Pathway Enzyme, in Colon Cancer

2010-DavidP.Foley,M.D.University of WisconsinDetermining the Role of Nrf2 in a Murine Model of Hepatic Ischemia Reperfusion Injury

2011-AnthonyVisioni,M.D.University Hospitals Case Medical CenterModulating KLF4 to Target Tumor-Associated Macrophages in Melanoma

2012- JacquelineJeruss,M.D.,Ph.D.Northwestern UniversityCDK Inhibition and Restoration of SMAD3 Signaling in Aggressive Breast Cancer Subtypes

CSA FOUNDATION SURGICAL ENRICHMENT AWARDS (continued)


CSA FOUNDATION TURCOTTE AWARD WINNER

2012-AnkushGosain,M.D.,Ph.DUniversity of WisconsinIdentification and Characterization of Gastrointestinal Mucosal Immune Defects in Hirschsprung’s Disease


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Submitto: Central Surgical Association Telephone: 913-402-7102 5019 W. 147th Street Email: [email protected] Leawood, KS 66224 Fax: 913-273-1140


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Submitto: Central Surgical Association Telephone: 913-402-7102 5019 W. 147th Street Email: [email protected] Leawood, KS 66224 Fax: 913-273-1140


1941 – Ann Arbor1942 - Chicago1943-44-45 – No meetings1946 - Chicago1947 - Chicago1948 - Chicago1949 - Cleveland1950 - Chicago1951 - Chicago1952 - Toronto1953 - Chicago1954 - Detroit1955 - Chicago1956 - Rochester1957 - Chicago1958 - Columbus1959 - Montreal1960 - Chicago1961 - St. Louis1962 - Cincinnati1963 - Chicago1964 - Rochester, MN1965 - Milwaukee1966 - Chicago1967 - Pittsburgh1968 - Cleveland1969 - Chicago1970 - Detroit1971 - Minneapolis1972 - Chicago1973 - Toronto1974 - Cincinnati1975 - Chicago1976 - Rochester, NY1977 - Buffalo1978 - Chicago1979 - Omaha

1980 - St. Louis1981 - Dearborn1982 - Chicago1983 - Milwaukee1984 - Pittsburgh1985 - Montreal1986 - Chicago1987 - Louisville1988 - Columbus1989 - Alberta1990 - Chicago1991 - Indianapolis1992 - Madison1993 - Cincinnati1994 - Chicago1995 - Cleveland1996 - Minneapolis1997 - Chicago1998 - Ann Arbor1999 - St. Louis2000 - Chicago2001 - Tucson2002 - Pittsburgh2003 - Toronto2004 - Chicago2005 - Tucson2006 - Louisville2007 - Chicago2008 - Cincinnati2009 - Sarasota2010 - Chicago2011 – Detroit2012 – Madison2013 – Amelia Island

CSA ANNUAL MEETING LOCATIONS


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CENTRAL SURGICAL ASSOCIATION

March6–8,2014Indianapolis,Indiana

2014 Annual Meeting

SAVE THE DATE

Central Surgical Association5019 W. 147th Street Leawood, KS 66224

Email: [email protected]

Fax: 913-273-1140Telephone: 913-402-7102

Documents

Central Surgical Association PROGRAM