FEBRUARY 14-17, 2014ST. REGIS MONARCH BEACH

DANA POINT, CA

Scientific Program 85th Annual Meeting

Jointly sponsored by the American College of Surgeons and the Pacific Coast Surgical Association.

Pacific Coast Surgical Association

Pacific Coast Surgical Association85th Annual Meeting

SCIENTIFIC PROGRAMFebruary 14-17, 2014

St. Regis Monarch Bay Resort Dana Point, California

TABLE OF CONTENTS2014 Arrangements / Program Committee ............................................................ 1

Council Officers, Members and Representatives .................................................. 2

Program Information ................................................................................................. 3

Scientific Program ...................................................................................................... 4

Program Agenda ....................................................................................................... 6

Scientific Session Agenda ........................................................................................ 8

Scientific Sessions 1-26 ........................................................................................... 13

E-Poster Sessions A ................................................................................................. 50

E-Poster Sessions B ................................................................................................. 64

E-Poster Sessions C ................................................................................................. 77

Founders ................................................................................................................... 91

Past Presidents ......................................................................................................... 92

New Members .......................................................................................................... 98

In Memoriam ..........................................................................................................105

Members Listed Alphabetically ........................................................................... 115

Constitution ............................................................................................................184

Bylaws ......................................................................................................................190

Future Meetings.....................................................................................................195

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2014 ARRANGEMENTS COMMITTEE President and Spouse Fred and Becky Weaver Vice-President Steven Katz Program Chair Jonathan Hiatt Local Chairperson Lawrence Wagman Golf Tournament Edward Phillips Tennis Tournament Ronald Latimer Fun Run/Walk Lawrence Wagman Spousal Hospitality Gail Katz and Becky Weaver

2014 PROGRAM COMMITTEE Program Chair Jonathan Hiatt Members Fred Weaver Quan-Yang Duh J. David Beatty L. Andrew DiFronzo Richard Bold John Vetto

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COUNCIL OFFICERS Fred Weaver, President (2014) Los Angeles, CA William Schecter, President-Elect (2015) San Francisco, CA Steven Katz, Vice-President (2014) Los Angeles, CA John A. Ryan, Jr., Historian Seattle, WA Quan-Yang Duh, Secretary-Treasurer (2016) San Francisco, CA Jonathan R. Hiatt, Recorder (2015) Los Angeles, CA

COUNCIL MEMBERSPresident

President-Elect

Vice-President

Historian

Secretary-Treasurer

Recorder

Sherry M. Wren, Councilor (2014) Northern California Karen E. Deveney, Councilor (2015) Oregon/Hawaii Edward Phillips, Councilor (2017) Southern California Robert Sawin, Councilor (2016) Washington/British Columbia/Alaska

COUNCIL REPRESENTATIVES Mika Sinanan, Seattle, WA (10/2014) Board of Governors, American College of Surgeons John G. Hunter, Portland, OR (6/30/2016) American Board of Surgery Kenneth Waxman, Santa Barbara, CA (12/31/2014)

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Advisory Council for General Surgery, American College of Surgeons

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PROGRAM INFORMATIONOverall Goal and Objectives of the Program The goal of the program is to provide an educational opportunity for the members of PCSA. Members are academic and community surgeons from four caucuses – Northern California, Southern California, Washington/British Columbia/Alaska, and Hawaii/Oregon. Membership is competitive. Attendees represent the leaders of their medical communities.

Learning Outcomes The meeting will provide high quality up-to-date information regarding major areas in general surgery. Attendees will learn the most recent developments in the field of surgery from scientific and clinical leaders. Time will be provided following each presentation for questions and discussion. Moderators will oversee sessions and facilitate discussions.

Accreditation Statement This 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 Pacific Coast Surgical Association. The American College Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

AMA PRA Category 1 Credits™ The American College of Surgeons designates this live activity for a maximum of 12.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure In 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. See the insert to this program for the complete disclosure list.

Disclaimer Attendees voluntarily assume all risks involved in travel to and from the Annual Meeting and in attendance of and participation in the program. PCSA and ACS Association Management Services shall not be liable for any loss, injury, or damage to person or property resulting directly or indirectly from any acts of God, acts of government or other authorities, civil disturbances, acts of terrorism, riots, thefts, or from any other similar causes.

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SCIENTIFIC PROGRAME-POSTER SESSIONSSaturday, February 15 12:20pm – 2:00pmE-Posters will be presented in three groups on Saturday, February 15 during the lunch hour. Each 3-minute oral presentation of the E-Poster will be followed by brief question and discussion. Box lunch will be provided.

PRESIDENT’S PANELSunday, February 16 10:20am – 12:00pmPresident Weaver has convened an elite panel to consider “Effects of Healthcare Reform on American Surgery.” Dr. Steven Stain, Chair of Surgery at Albany Medical College, will serve as moderator and will discuss the perspective of a surgical chair. Dr. David Hoyt, Executive Director of the American College of Surgeons, will present the perspective of the ACS and practicing surgeons. The educational perspective will be reviewed by Dr. John Hunter, Chair of Surgery at Oregon Health Sciences University. Our invited speaker is Dr. Geoffrey Joyce, Director of Health Policy at the Schaeffer Center for Health Policy & Economics and Associate Professor, Pharmaceutical Economics & Policy at the University of Southern California. Dr. Joyce will speak on the topic, “The Impacts of Health Care Reform on Payers, Providers and Patients”, followed by a discussion with participation from the audience.

RESIDENTS’ COMPETITIONThe top-scoring resident papers from each caucus will be presented during the scientific sessions. Presentations will be judged on clarity, focus and scientific relevance to surgical practice. Prizes will be awarded at the President’s Dinner. This year’s residents are:

NICOLAS LANGAN Washington/British Columbia/Alaska Saturday, February 15, 9:00am – 10:15am

ELISE LAWSON Southern California Sunday, February 16, 7:45am – 9:25am

HADIZA KAZAURE Northern California Sunday, February 16, 7:45am – 9:25am

KELLY FAIR Oregon/Hawaii Sunday, February 16, 10:40am – 12:20pm

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INDUSTRY SUPPORTA commercial display of scientific interest will be available during the Annual Meeting, providing an opportunity for attendees to view products and services from various corporations. Continental breakfasts and refreshment breaks will be served in the exhibit area.

PCSA would like to thank the following companies for their support of the 2014 Annual Meeting through an educational grant:

Endologix

Gore & Associates

KCI

PCSA would like to thank the following exhibiting companies:

Abbott Vascular

Acute Innovations

Automated Medical Products

Baxter BioSurgery

Cook Medical

Cubist Pharmaceuticals

Endologix

Genomic Health

Gore & Associates

Hansen Medical

Hitachi Aloka Medical

Novadaq Technologies

Penumbra, Inc.

Philips Healthcare

Strategic Business Holdings

TEI Biosciences

The Medicines Company

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PROGRAM AGENDATHURSDAY, FEBRUARY 13Council Reception* 6:00pm – 7:00pm Club 19

Council Dinner* 7:00pm – 9:00pm Club 19

FRIDAY, FEBRUARY 14Finance Committee Meeting* 7:00am – 8:30am Aegean

Council Meeting* 8:30am – 5:00pm Aegean

Council Lunch with Industry Sponsors* 12:15 pm – 1:15 pm Adriatic

Registration/Hospitality 1:00pm – 6:00pm Pacific Ballroom Promenade

Speaker Ready Room 3:00pm – 6:00pm Sorrento

New Members’ Private Reception* 5:00pm – 6:00 pm Wine Room

Welcome Dinner 6:30pm – 9:30pm Off-Site (Tivoli Too)**

SATURDAY, FEBRUARY 15Continental Breakfast 7:00am – 9:00am Pacific Ballroom 3

Registration/Hospitality 7:00am – 5:00pm Pacific Ballroom Promenade

Speaker Ready Room 7:00am – 5:00pm Sorrento

Industry Sponsors/Exhibitors 7:00 am – 4:00 pm Pacific Ballroom 3

Introduction and President’s Address 8:00am – 9:00am Pacific Ballroom 1 & 2

Scientific Sessions 9:00 am – 10:15 am Pacific Ballroom 1 & 2

Morning Break with Industry 10:15am – 10:40am Pacific Ballroom 3

Scientific Sessions 10:40 am – 12:20 pm Pacific Ballroom 1 & 2

E-Poster Session A 12:20pm – 2:00pm Pacific Ballroom 1 & 2

E-Poster Session B 12:20pm – 2:00pm Adriatic

E-Poster Session C 12:20pm – 2:00pm Aegean

Creativity, Conversation and Confections : 1:00pm – 4:00pm TBD An Afternoon of Jewelry Making

Scientific Sessions 2:05pm – 3:20pm Pacific Ballroom 1 & 2

Afternoon Break with Industry 3:20pm – 3:45pm Pacific Ballroom 3

Scientific Sessions 3:45pm – 4:30pm Pacific Ballroom 1&2

Art Presentation: Pageant of 4:30pm – 5:30pm Pacific Ballroom the Masters: Where Art Comes To Life! and Promenade

Dinner at Leisure 5:30pm

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SUNDAY, FEBRUARY 16Fun Run 6:30am – 7:15am Meet in Hotel Lobby

Continental Breakfast 7:00am – 9:00am Pacific Ballroom 3

Registration/Hospitality 7:00am – 12:00pm Pacific Ballroom Promenade

Speaker Ready Room 7:00am – 12:00pm Sorrento

Industry Sponsors/Exhibitors 7:00am – 11:30am Pacific Ballroom 3

Scientific Sessions 7:45am – 9:25am Pacific Ballroom 1 & 2

Morning Break with Industry 9:25am – 9:50am Pacific Ballroom 3

Historical Vignette 9:50am – 10:20am Pacific Ballroom 1 & 2

President’s Panel 10:20am – 12:00pm Pacific Ballroom 1 & 2

Satellite Symposium 12:30pm – 1:30 pm Pacific Ballroom 1 & 2

Golf Tournament 12:30pm – 5:30pm Monarch Beach Golf Links

Tennis Tournament 1:30pm – 3:30pm Monarch Beach Tennis Club

President’s Reception 6:30pm – 7:15pm Monarch Ballroom Promenade

President’s Dinner 7:15pm – 10:00pm Monarch Ballroom

MONDAY, FEBRUARY 17 Continental Breakfast 7:00am – 9:00am Pacific Ballroom Promenade

Registration/Hospitality 7:00am – 12:00pm Pacific Ballroom Promenade

Speaker Ready Room 7:00am – 12:00pm Sorrento

Scientific Sessions 7:45am – 11:35am Pacific Ballroom 1 & 2

Membership Business Meeting 11:35am – 12:15pm Pacific Ballroom 1 & 2

Meeting Adjourns by 12:15pm

*Invitation only events **Transportation provided

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SCIENTIFIC SESSION AGENDASATURDAY, FEBRUARY 15, 20148:00 – 8:15 Introduction8:15 – 8:45 President’s Address8:45 – 9:00 Introduction of New Members9:00 – 10:15 Scientific Session 1 M. Margaret Knudsen

1 Changing Patterns of In-Hospital Deaths Following Implementation of Damage Control Resuscitation Practices in Forward Combat Facilities

2 Clinical Relevance Of the MRI for Cervical Spine Clearance in the Evaluable Patient: A Prospective Study

3 A Human Factors Sub-Systems Approach to Trauma Care Reduces Disruptions, Treatment Time and Length of Stay

10:15 – 10:40 Morning Break with Industry Support 10:40 – 12:20 Scientific Session 2 Peter Lawrence

4 Increased Volume of Plasma Transfusion is Predictive of Deep Venous Thrombosis in the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study

5 The Origin of Fatal Pulmonary Emboli: A Post Mortem Analysis of 500 Deaths From Pulmonary Embolism in Trauma, Surgical and Medical Patients

6 Comparative Safety of Endovascular Aortic Aneurysm Repair Over Open Repair Using Patient Safety Indicators During Adoption

7 Aortic Morphology and Survival Following TEVAR for Type B Aortic Dissection

12:20 – 2:00 Lunch E-Poster Session A & B & C

Lunch E-Poster Session A Richard Bold & John Vetto1a Axillary Reverse Lymphatic Mapping Reduces Patient

Perceived Incidence of Lymphedema after Axillary Dissection in Breast Cancer

2a Preoperative Axillary Ultrasound (AUS) for Identification of Sentinel Lymph Nodes in Breast Cancer

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3a Prophylactic Mastectomy: Are We Treating The Surgeon or The Patient?

4a Breast Cancer following Ovarian Cancer In BRCA Mutation Carriers: Is Surveillance Justified?

5a Trends in Neoadjuvant Chemotherapy Use for Surgical Breast Cancer Patients in California

6a Abdominal Versus Perineal Surgery for Rectal Prolapse: Is a Perineal Approach Still Relevant in the Laparoscopic Era?

7a Colorectal Enhanced Recovery After Surgery: A Prospective Study in a Community Hospital

8a A Decade of Bariatric Surgery: What Have We Learned?

9a Laparoscopic Versus Open Bowel Resection in Emergent Small Bowel Obstruction: Analysis of the National Surgical Quality Improvement Program Database

10a Minimally Invasive Esophagectomy: Outcomes from 217 Consecutive Patients

11a Statewide Survey of Opinions on Diagnosis and Management of Adhesive Small Bowel Obstruction

12a Lymph Node Count as a Quality Measure for Gastric Cancer: Does CoC Accreditation Matter?

Lunch E-Poster Session B Stephen Katz & Kenji Inaba1b Subclavian Vein Catheterization Using a Perfused Human

Cadaveric Model: Application to Surgical Education

2b A Retrospective Review of Plastic Surgery Consultations to Evaluate the Effect of Web-Based Education on Patient Satisfaction and Consultation Time

3b Role of Imaging in Diagnosis of Hidden Hernias

4b Teaching Hospitals Eliminate Insurance-Based Disparity in the Mortality of Trauma Patients

5b Prospective Evaluation of Open Fractures - Impact Time to Washout

6b Assessment of Pediatric Burn Management in a Tertiary Care Center in Sub-Saharan Africa

7b Impact of Contemporary Military Medicine on Civilian Trauma Care

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8b Age Related Mortality Following Traumatic Brain Injury in the Elderly: When is Care Futile?

9b The Impact of Hydroxyethyl Starch Use in Organ Donors after Neurologic Determination of Death on the Development of Delayed Graft Function in Kidney Transplant Recipients

10b Identification of a High Risk Subset of Patients Undergoing Infrainguinal Bypass Surgery

11b The Role of Preoperative Duplex Scanning in Neurogenic

Lunch E-Poster Session C L. Andrew DiFronzo & Gerald Lipshutz1c Non-Robotic Endoscopic Transaxillary Thyroidectomy:

Early Experience and Outcomes in the United States

2c The NIH Consensus Recommendations in the Management of Primary Hyperparathyroidism Are Not Being Followed. Why Not?

3c Characterization of Endocrine and Exocrine Function After Pancreatic Resection

4c The Drowning Whipple: Perioperative Fluid Balance and Outcomes Following Pancreaticoduodenectomy

5c Operative Time as a Measure of Quality in Pancreaticoduodenectomy: Is Faster Better?

6c Pancreatic Enucleation for Side-Branch Intraductal Papillary Mucinous Neoplasms

7c Current Indications for Surgery of IPMN’s May Overlook Some Patients With Cancer: Recommendations for Change

8c Autologous Islet Transplantation with Remote Isolation after Pancreas Resection for Chronic Pancreatitis

9c Bile Duct Injuries: A Simple Classification Based on Anatomy and Outcome

10c Management of Polycystic Liver Disease with Hepatic Resection

11c Prehepatectomy Novel Assessment Tool to Predict Remnant Liver Function: Correlation Between Expression of Organic Anion Transporting Polypeptides 1/ Multidrug Resistance Protein 2 and Gadoxetic Acid-Enhanced MRI Signal in Cirrhotic Rat Liver

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2:05 – 3:20 Scientific Session 3 Stephen Sener8 Stem Cell Profile in Melanoma Primary Tumors Predicts

Lymph Node Status and Distant Metastases More Accurately Than Tumor Depth or Ulceration

9 Contralateral Breast Cancers Detected Solely By MRI Are Clinically Significant

10 The Underestimated Risk of Cancer in Patients with Non-Functional, Cervical Multi-Nodular Goiters and Benign Preoperative Fine Needle Aspiration

3:20 – 3:45 Afternoon Break with Industry Support3:45 – 4:30 Scientific Session 4 Susan Orloff

11 Reoperative Complications After Primary Orthotopic Liver Transplantation: Predictors and Outcomes

12 The Impact of Meeting Donor Management Goals in Extended Criteria Donors on the Number of Organs Transplanted per Donor: A Prospective Study From the United Network for Organ Sharing Region 5 Donor Management Goals Workgroup

13 Increasing Organ Donation in Hispanic Americans

SUNDAY, FEBRUARY 16, 20147:45 – 9:25 Scientific Session 5 Fred Weaver

14 Comparison of Clinical Registry Versus Administrative Claims Data for Modeling Surgical Quality Measures

15 Long-term Results of a Postoperative Pneumonia Prevention Program for the Inpatient Surgical Ward

16 Effects of Urinary Catheter Removal Per SCIP Guideline in Patients Undergoing Abdominal and Pelvic Operations

17 A Novel Financial Incentive Program Successfully Improved Operating Room Efficiency

9:25-9:50 Morning Break with Industry Support9:50-10:20 Historical Vignette “Surgery 1881-1901: Pistols, Presidents,

and Pancreases: The Assassinations of Garfield and McKinley”: John Ryan and Ronald Meier

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10:20-12:00 President’s Panel “Health Care Reform and American Surgery”

Steven Stain, John Hunter, David Hoyt & Geoffrey Joyce

MONDAY, FEBRUARY 17, 20147:45-9:25 Scientific Session 6 Karen Deveney

18 ACGME Case Logs: A National Review of the Rise of Minimally Invasive Surgery Over Two Decades of General Surgery Resident Training

19 General Surgery Residents Have an Increased Desire to Quit at High Attrition Residencies – A Multi-Institutional Study

20 Pregnancy-Related Attrition in a General Surgery Residency Over 10 Years: Fact or Fiction?

21 Innovative Approach using Multidisciplinary Simulation to Educate Surgical Residents in Technical and Non-Technical Skills in High Risk Clinical Scenarios

9:25-11:35 Scientific Session 7 William Schecter22 Trends in Operative Interventions for Crohn’s Disease

in the Biologic Era

23 Predictors of Therapeutic Re-operation in Necrotizing Soft Tissue Infections

24 Successful Salvage: A 117 Patient Series of Complex Open Abdominal Wall Reconstructions

25 Outcomes of Robotic-Assisted Thoracic Operations in a High-Risk Population

26 Does Laparoscopic Hepatectomy Result in Better Short-Term Outcomes Than Open Hepatectomy?

11:35-12:15 PCSA Membership Business Meeting 12:15 Meeting Adjourned

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Scientific Sessions 1-26

All Scientific Session and E-Poster Presentation authors and presenters are MDs unless otherwise noted.

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Changing Patterns of In-Hospital Deaths Following Implementation of Damage Control Resuscitation Practices in Forward Combat Facilities

Authors: N Langan, M Martin, M EckertInstitution: Madigan Army Medical Center, Tacoma, WAPresenter: Nicholas LanganPrimary Discussant: Ali SalimDiscussion Closed By: Matthew Martin

Importance: Analysis of deaths provides invaluable epidemiologic and quality improvement data for trauma centers and is particularly important under rapidly evolving battlefield conditions.

Objectives: Analyze the evolution of injury patterns, early care, and resuscitation among in-hospital deaths, before and after implementation of damage control resuscitation (DCR) policies.

Design: Review of Joint Theater Trauma Registry (2002 to 2011)

Setting: Forward U.S. combat hospitals

Patients: Patients with vital signs at presentation and subsequent in-hospital death. Cohorts were grouped into two time periods: pre-DCR (before 2006) and DCR (2006-2011).

Main Outcome Measures: Injury types and severity scores (ISS), timing and location of death, resuscitation fluids.

Results: 2,565 in-hospital deaths were identified among 57,179 admissions (4.5%). The majority of patients (74%) were severely injured (ISS>15) and 80% died within 24 hours of admission. DCR policies were widely implemented by 2006 and resulted in a large decrease in mean 24-hour crystalloid (6.1 to 3.2L) and increased FFP use (6.6 to 11.2 units, both p<;0.05). The mean PRBC:FFP ratio changed from 2.6:1 pre-DCR to 1.4:1 with DCR (p<;0.01). There was a significant increase in mean injury severity between groups (ISS 22 pre-DCR vs 27 DCR, p<;0.05) and a marked shift in injury patterns (Figure).

Conclusions: There has been a significant shift in resuscitation practices in forward combat hospitals indicating widespread military adoption of DCR. Patients who died in-hospital during the DCR era were more likely to be severely injured and have a severe brain injury, consistent with a decrease in deaths among potentially salvageable patients.

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Clinical Relevance Of the MRI for Cervical Spine Clearance in the Evaluable Patient: A Prospective Study

Authors: S Resnick, K Inaba, E Karamanos, M Pham, S Byerly, P Talving, S Reddy, D DemetriadesInstitution: University of Southern California, Los Angeles, CAPresenter: Shelby ResnickPrimary Discussant: Martin SchreiberDiscussion Closed By: Kenji Inaba

Importance: A missed cervical spine (CS) injury can have devastating consequences. In patients who cannot be cleared clinically utilizing the NEXUS low risk criteria, due to either a neurologic deficit or pain, the optimal imaging modality for CS clearance remains controversial.

Objective: To investigate the accuracy of CT and MRI for CS clearance

Design: A prospective observational study from 01/01/2010 through 05/31/2011. Initial exams, all CS imaging results, interventions and final CS diagnoses were documented. The gold standard for the sensitivity and specificity calculations was final diagnosis of CS injury at time of discharge.

Setting: Level I Trauma Center

Participants: In total, 830 evaluable adult blunt trauma patients with CS tenderness and/or neurological deficit undergoing CT of the CS Main

Outcome Measure: Clinically significant CS injuries, defined as injuries requiring surgical stabilization or halo placement.

Results: Overall, 164 (19.8%) CS injuries were diagnosed, 23 (2.8%) were clinically significant. All patients with clinically significant injuries had their injury detected by CT. Fifteen patients with a negative CT had a new finding on MRI, however, none required surgical intervention or halo placement. There was no change in management due to MRI findings. The sensitivity/specificity of CT for detecting CS injury was 90.9%/100%. For clinically significant CS injuries, the sensitivity was 100% and specificity was 100%.

Conclusion: CT is effective at detecting clinically significant CS injuries in the evaluable patient with neurologic deficit or CS pain. MRI did not provide any additional clinically relevant information.

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A Human Factors Sub-Systems Approach to Trauma Care Reduces Disruptions, Treatment Time and Length of Stay

Authors: K Catchpole, E Ley, D Wiegmann, J Blaha, D Shouhed, A Gangi, R Blocker, B GewertzInstitution: Cedars Sinai Medical Center, Los Angeles, CAPresenter: Kenneth CatchpolePrimary Discussant: Darren MalinoskiDiscussion Closed By: Bruce Gewertz

Importance: Systems improvement can reduce accidents and improve outcomes. To generate a range of solutions to commonly encountered impediments to ideal care we employed Human Factors Engineering (HFE) principles.

Objective: We targeted the trauma process and hypothesized that implementation HFE principles would reduce flow disruptions, improve time-to-treatment within the trauma ‘golden hour’ and decrease length-of-stay.

Design: Interrupted time series. A multi-disciplinary team of surgeons, human factors experts, and process improvement specialists at identified targeted interventions based upon observed impediments to care. The interventions were: headsets, equipment storage, medication packs, whiteboard, pre-briefing, teamwork training.

Setting: An academic level 1 trauma center

Participants: Trauma patients between August and October 2011 (pre) and 2012 (post).

Main Outcome Measures: flow disruptions (defined as events resulting in a pause during the primary task) with treatment time and length-of-stay secondary outcomes.

Results: Six out of seven interventions were successfully deployed. 86 cases were observed prior to the intervention and 120 post intervention. For high level trauma cases, the mean number of flow disruptions before the intervention implementation was reduced (25.6±17.0 v. 18.8±10.14, p=0.0018). Overall, cases were 11 minutes faster in the post-intervention phase(p=0.0194). Length of stay was significantly reduced for major risk patients (8.0 v. 12.0, p=0.0413).

Conclusions and Relevance: Complex sub-system interventions, based on a detailed human factors analysis of the delivery trauma care, resulted in reduced flow disruptions, care time, and length of stay.

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Increased Volume of Plasma Transfusion is Predictive of Deep Venous Thrombosis in the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study

Authors: K Fair, L Kiraly, M Cohen, H Phelan, E Fox, J Holcomb, M SchreiberInstitution: Oregon Health and Science University, Portland, ORPresenter: Kelly FairPrimary Discussant: Kenji InabaDiscussion Closed By: Martin Schreiber

Objective: To determine whether blood product transfusions are related to the incidence of venous thromboembolism in the PROMMTT study.

Design: A retrospective review of prospectively acquired data from the PROMMTT study. Data were recorded from July 2009-October 2010.

Setting: Ten level I trauma centers in the United States.

Participants: A total of 1245 adult trauma patients were enrolled in the PROMMTT study, all of whom received at least one unit of packed red blood cells (RBCs) within 6 hours of admission.

Interventions: None.

Main Outcome Measures: Rates of deep venous thrombosis (DVT) with respect to blood product transfusion and injury severity.

Results: A total of 57 patients were diagnosed with DVT in the study. Within this group, higher volume of RBC, plasma, platelet, and cryoprecipitate transfusion, as well as higher injury severity score (ISS), and higher extremity abbreviated injury scale score (AIS), were correlated with DVT in a univariate analysis. A multivariate logistic regression was then performed, revealing that extremity AIS greater than 2 (p= 0.014, OR 2.653, CI 1.217-5.784) and greater than 9 units of plasma transfused in 24 hours (p=0.019, OR 2.010, CI 1.121-3.604) were predictive of DVT. However, volume of RBCs, platelets, and cryoprecipitate were not predictive of DVT in this model.

Conclusions: Higher extremity AIS score and greater volume of plasma transfused were independently predictive of deep venous thrombosis in PROMMTT study patients. Although higher ratios of plasma to packed red blood cells have been shown to improve survival, increased plasma transfusion may be associated with an increased DVT rate, flow disruptions, care time, and length of stay.

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The Origin of Fatal Pulmonary Emboli: A Post Mortem Analysis of 500 Deaths From Pulmonary Embolism in Trauma, Surgical and Medical Patients

Authors: M Tadlock, K Chouliaras, M Kennedy, P Talving, O Okoye, H Aksoy, E Karamanos, L Zheng, C Rogers, T Noguchi, D DemetriadesInstitution: University of Southern California, Los Angeles, CAPresenter: Matthew TadlockPrimary Discussant: Matthew MartinDiscussion Closed By: Demetrios Demetriades

Importance: The traditional theory that pulmonary emboli (PE) originate primarily from lower extremity (LE) deep venous thrombosis (DVT) has recently been challenged, especially in victims of blunt trauma.

Objective: To determine the origin of fatal PE in trauma, surgical and medical patients.

Design: Retrospective cohort study

Patients: Five hundred autopsies from the Los Angeles County Forensic Medical Division between 2002-2010 where PE was the cause of death.

Outcomes: Primary outcome was an identified source for the PE.

Results: Venous thromboemboli (VTE) were identified in 491 cases, amniotic embolization in 5, air embolism in 3 and fat embolism in one. Of the 491 VTE PE’s, 36% were surgical and 64% medical. Detailed Venous dissection for clots was performed in 380; the source of the embolus was the LE (70.8%), iliac veins (4.2%), and upper extremity (1.1%). No source was identified in 22.6%. In trauma and non-trauma surgical patients, no PE source was identified in 20% and 29% (p=0.358) respectively. Age (Adjusted Odds Ratio [AOR] 1.04 [1.011-1.071], p=0.06) and Body Mass Index (BMI) (AOR 1.04 [1.008-1.077], p=0.016) were independent predictors for identifying a PE source. A higher Charlson comorbidity index was predictive of finding no PE source (AOR 0.708 [0.555-0.902], p=0.005).

Conclusions: The majority of medical and surgical patients with fatal PE had a LE source, but a significant number had no source identified. Age, and BMI were independently associated with PE source identification, while a higher Charlson comorbidity index was associated with no source for PE found at autopsy.

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Comparative Safety of Endovascular Aortic Aneurysm Repair Over Open Repair Using Patient Safety Indicators During Adoption

Authors: J Rose, C Evans, A Barleben, D Bandyk, S Wilson, D Chang, J LaneInstitution: University of California, San Diego, San Diego, CAPresenter: John RosePrimary Discussant: Paul SudingDiscussion Closed By: John Lane

Objective: In 2003, the Agency for Healthcare Research and Quality (AHRQ) established Patient Safety

Indicators: (PSIs) to monitor preventable adverse events during hospitalizations. This study evaluates the comparative safety of endovascular (EVAR) versus open aneurysm repairs (OAR) of abdominal aortic aneurysm (AAA) by measuring PSIs associated with each procedure over time.

Design: PSIs were calculated using AHRQ Win QI, V4.4. Unadjusted analysis included age, sex, race, year, comorbidity, rupture status, hospital teaching status, and emergent repair. Multivariate analysis was stratified by year for any PSI in EVAR versus OAR. Postoperative mortality was analyzed to control for overall safety.

Patients: Cases of aneurysm repair were extracted from the Nationwide Inpatient Sample, 2003-2010

Outcome Measure: PSIs, mortality

Result: There were 43,385 EVAR and 27,561 OAR; with 1,289 and 3,094 associated PSIs, respectively. The annual percentage of PSIs among all aortic repairs decreased from 7.4% (2003) to 4.4% (2010) while the proportion of total repairs that were EVAR increased from 41% (2003) to 75% (2010). The most common PSIs and percentage decline were Accidental Puncture/Laceration (1,312 total, 44% decline), Foreign Body Left During Procedure (911, 43%), and Postoperative Pulmonary Embolism or Deep Venous Thrombosis (788, 41%). Stratified by year, the odds of a PSI after EVAR was comparatively less likely versus OAR every year except 2007 and the odds of death was comparatively less every year.

Conclusion: PSIs can be used to monitor comparative safety of emerging surgical technologies. Here, EVAR was safer than OAR. Adoption of minimally invasive technology can improve safety of surgical admissions.

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Aortic Morphology and Survival Following TEVAR for Type B Aortic Dissection

Authors: M Sigman, O Palmer, M Cunningham, F WeaverInstitution: University of Southern California, Los Angeles, CAPresenter: Michael SigmanPrimary Discussant: Ronald DalmanDiscussion Closed By: Fred Weaver

Importance: Indications for thoracic endovascular aortic repair (TEVAR) in type B aortic dissections are evolving. Emerging data suggest a survival benefit for TEVAR over medical management in uncomplicated cases.

Objective: To report our experience with TEVAR for type B aortic dissections.

Design: Retrospective review of charts from 2007 to 2013.

Setting: University hospital.

Participants: Patients with type B aortic dissection.

Exposure: Thoracic endovascular aortic repair.

Main Outcome Measures: Aortic morphology and survival.

Results: Thirty TEVARs were performed. Eighty percent (24) were male with an average age of 59. Indications were rupture 10%, refractory pain 20%, mal-perfusion 30%, and aneurysmal degeneration 40%. The average number of aortic zones involved was 7 with all but one involving the abdominal aorta. Mean time from diagnosis to TEVAR was 242 days. At TEVAR, the left subclavian artery was covered in 14 (47%) and re-vascularized in 10. Spinal drainage was performed in 13 (43%). Technical success was 100%. Adverse events included spinal cord ischemia (1), cardiac arrest (1) and hand ischemia (1). Aorta-specific 30-day mortality was 3.3%. With a mean follow up of 19 months, 16 patients demonstrated complete thrombosis of the thoracic false lumen on CT imaging, with 21 patients demonstrating either decreased or stable aortic diameters. One patient required endovascular re-intervention for proximal extension of the dissection. Overall survival was 90% at both 1 and 3 years.

Conclusions: TEVAR is safe and technically feasible. Low perioperative morbidity, favorable aortic remodeling and excellent intermediate survival suggest TEVAR is beneficial for patients with a type B aortic dissection.

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Stem Cell Profile in Melanoma Primary Tumors Predicts Lymph Node Status and Distant Metastases More Accurately Than Tumor Depth or Ulceration

Authors: A Graff-Baker, I White, O Khan, J Alabran, P Muller, R Pommier, A Skinner, J Vetto, S PommierInstitution: Oregon Health and Science University, Portland, ORPresenter: Amanda Graff-BakerPrimary Discussant: Richard EssnerDiscussion Closed By: John Vetto

Objective: Lymph node (LN) status in melanoma predicts prognosis and drives adjuvant therapy. Tumor depth and ulceration prompt lymph node biopsies. Melanoma stem cells (SC) are associated with aggressive disease. The goal of this study was to determine if primary melanoma SC predict nodal status and distant metastases better than tumor depth, ulceration, or immunologic response.

Design: Immunohistochemistry of primary melanomas, associated malignant LN, and metastases were performed. Melanoma cells were identified by SOX10, stem cells by CD271, ABCG2 and CD20, and immunoresponse by CD3, CD4, CD8, CD68 and OX40.

Setting: Surgical oncology laboratory

Patients: Tissues from 15 pathologically-staged patients (7th edition AJCC); two stage 0, 8 stage I/II, and 5 stage III/IV.

Main Outcome Measures: Presence of stem and immunologic cells, stage at diagnosis.

Results: All primary tumors, LN, and distant metastases were Sox10+, CD68+, CD4+, and CD8-. Stage 0 tumors were CD271+, ABCG2- and OX40-. Stage I/II tumors were CD271+ and ABCG2+. Loss of one or both of these cell populations correlated with stage III/IV disease (p<;0.01). OX40 differentiated stage 0 from advanced disease (p<;0.05). CD20, CD68, CD4, or CD8 did not predict LN or metastases. Depth of the primary tumor or ulceration did not significantly correlate with advanced disease. SC nd immunologic profiles in primary tumors differed from associated LN and metastases.

Conclusions: SC profiles in primary tumors predict nodal status and distant metastases. Patients could be selected for nodal dissection and recommended for adjuvant therapy based on markers (ABCG2, CD271 and OX40) derived solely from the primary tumor.

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Contralateral Breast Cancers Detected Solely By MRI Are Clinically Significant

Authors: N Brown, M Chung, M DiNome, S Lavotshkin, J Maxwell, V O’Connor, A BilchikInstitution: John Wayne Cancer Institute, Santa Monica, CAPresenter: Nefertiti BrownPrimary Discussant: Steven ChenDiscussion Closed By: Anton Bilchik

Objectives: The role of magnetic resonance imaging (MRI) in the preoperative evaluation of the newly diagnosed breast cancer patient is controversial because the clinical relevance of discovering an occult contralateral breast cancer is unclear. The objective of this study is to determine the incidence of occult contralateral breast cancers detected by preoperative MRI to describe and compare the histopathology of these lesions to the index cancer to determine if clinical differences exist.

Design: Clinical, histopathologic, and imaging data were reviewed from a prospective database of women who underwent preoperative breast MRI for known unilateral invasive breast cancer from 2005-2013. Characteristics of the index and contralateral breast cancer were analyzed with respect to tumor characteristics and adjuvant systemic therapy used for the index cancer.

Results: Of the 671 women who underwent preoperative MRI evaluation for invasive breast cancer, 26 (3.8%) were found to have an occult contralateral breast cancer. More than half (57.6%) of contralateral cancers were invasive. The mean size of contralateral cancers was 1.53 cm, compared with 1.59 cm for index cancers. Most (65%) contralateral cancers had a worse pathologic stage than index cancers (p=0.0203). Of the 15 contralateral cancers with discordant histology, 7 (46.6%) would not have received adjuvant therapy solely on the basis of the index cancer.

Conclusions: Our datum demonstrates that MRI detected contralateral breast cancers are clinically relevant tumors not related pathologically to the index cancer and require separate adjuvant treatment. Preoperative MRI identifies clinically significant occult contralateral breast cancers.

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The Underestimated Risk of Cancer in Patients With Non-Functional, Cervical Multinodular Goiters and Benign Preoperative Fine Needle Aspiration

Authors: M Campbell, C Seib, L Candell, O Clark, Q Duh, J Gosnell, W ShenInstitution: University of California San Francisco, San Francisco, CAPresenter: Michael J. CampbellPrimary Discussant: Michael YehDiscussion Closed By: Wen Shen

Importance: Ultrasound guided fine needle aspiration (FNA) is an excellent tool for evaluating patients with solitary thyroid nodules, with a false negative malignancy rate of <3%. The utility of FNA in patients with cervical multinodular goiters (MNG) is unknown, because biopsy and surveillance of thyroids with numerous nodules may be impractical.

Objective: To evaluate the incidence and risk factors for unsuspected thyroid cancer in patients with non-functional, cervical MNG who had a benign preoperative FNA and underwent thyroidectomy.

Design, Setting & Participants: Retrospective review of patients with nonfunctional, cervical MNG at a high-volume tertiary referral center between 2005 and 2012.

Main Outcome Measure(s): Incidence of thyroid cancer on surgical pathology.

Results: Of the 134 patients included in the study, 31 (23.1%) were found to have thyroid cancer on final pathology. Twenty-one (15.7%) patients had a microscopic papillary cancer (<1cm) and 10 (7.5%) patients had other forms of thyroid cancer (five follicular, four papillary (>1cm), and one papillary and follicular). On univariate analysis, male gender was associated with non-micropapillary thyroid cancer (p = 0.024). On multivariate analysis, male gender (OR = 10.2, 95% CI 1.4 to 76.8) and FNA cytology not reviewed at our institution (OR = 6, 95% CI 1.2 to 30) were independently associated with non-micropapillary thyroid cancer.

Conclusions and Relevance: The incidence of thyroid cancer in patients with MNG and benign FNA is significant. Surgeons should have an increased index of suspicion in male patients and ensure FNA cytology is reviewed by an experienced cytopathologist.

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Reoperative Complications After Primary Orthotopic Liver Transplantation: Predictors and Outcomes

Authors: J DiNorcia, E Cheng, I Shaik, A Zarrinpar, F Kaldas, H Yersiz, D Farmer, R Busuttil, V AgopianInstitution: David Geffen School of Medicine, Los Angeles, CAPresenter: Vatche AgopianPrimary Discussant: Jorge D. ReyesDiscussion Closed By: Ronald Busuttil

Background: Data on the incidence and impact of reoperative complications after liver transplantation are scarce.

Objective: To identify predictors of reoperative complications after liver transplantation and evaluate outcomes.

Design: Retrospective study

Setting: Single tertiary care institution

Participants: Adult patients who underwent primary orthotopic liver transplantation from January 2004 to July 2012.

Main Outcomes and Measures: Univariate and multivariate analyses of 20 recipient, donor, and operative characteristics on reoperation after liver transplantation and its impact on overall graft and patient survival.

Results: Of 1363 patients, 394 (28.9%) underwent unplanned reoperation. Reasons for reoperation included bleeding (59.6%), intraabdominal sepsis (12.4%), biliary complications (10.9%), and a combination of other reasons (18.4%). Compared to recipients not requiring reoperation, patients who underwent reoperation had higher MELD scores (30 vs. 27, P<;0.001), greater frequency of pretransplant coronary artery disease (10.1% vs. 5.8%, P=0.014), diabetes (31.2% vs. 23.5%, P<;0.005), hospitalization (55% vs. 44%, P<;0.001), dialysis (42.6% vs. 28.5%, P<;0.001), intubation (28.9% vs. 16.4%, P<;0.001), vasopressors (17.6% vs. 9.1%, P<;0.001), and greater operative transfusion requirements (15 vs. 10 units, p<;0.0001) and longer warm ischemia times (43 vs. 41 minutes, P=0.003). There were no significant differences in donor characteristics. Multivariate predictors of reoperation included pretransplant coronary artery disease, dialysis, and vasopressors and cold ischemia time greater than 8 hours (Table). Patients suffering reoperative complications had inferior 1-, 3-, and 5-year graft and patient survival (Figure, P<;0.001).

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Conclusions: Patients who require unplanned reoperation after liver transplantation have high preoperative acuity and inferior post-transplant graft and patient survival. We identified important predictors of reoperation that may help guide perioperative decisions and improve outcomes after liver transplantation.

Multivariate Predictors of Unplanned Reoperation After Liver Transplantation

Variable Odds Ratio 95% CI P Value

Coronary artery disease

2.30 1.37-3.85 0.002

Pre-transplant vasopressor

1.80 1.15-2.84 0.011

Pre-transplant dialysis

1.68 1.21-2.33 0.002

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The Impact of Meeting Donor Management Goals in Extended Criteria Donors on the Number of Organs Transplanted per Donor: A Prospective Study From the United Network for Organ Sharing Region 5 Donor

Management Goals Workgroup

Authors: J Zatarain, D De la Cruz, M Patel, M Sally, T Ewing, M Crutchfield, K Enestvedt, D MalinoskiInstitution: Portland VA Medical Center, Portland, ORPresenter: John ZatarainPrimary Discussant: Ali SalimDiscussion Closed By: Darren Malinoski

Importance: The shortage of organs available for transplantation has led to the utilization of extended criteria donors (ECDs) in order to expand the donor pool. These donors are older and have more comorbidities and efforts to optimize the quality of their organs are needed.

Objective: To determine the impact of meeting a standardized set of critical care endpoints, or Donor Management Goals (DMGs), on the number of organs transplanted per donor (OTPD)

Design: Prospective interventional study from February 2010 to July 2013

Setting and Participants: All ECDs managed by the eight OPOs in the Southwestern United States (United Network for Organ Sharing Region 5)

Intervention: Implementation of nine DMGs as a checklist to guide the management of every ECD. The DMGs represented normal cardiovascular, pulmonary, renal, and endocrine endpoints. DMGs ‘met’ was defined a priori as achieving any 7 of the 9 DMGs and this was recorded at the time of referral to the OPO, at the time of authorization for donation, 12-18 hours later, and prior to organ recovery.

Main Outcome Measure: The primary outcome measure was ≥ 3 OTPD and binary logistic regression was used to identify independent predictors with a p<;0.05

Results: There were 671 ECDs with 2.1 + 1.3 OTPD. 10% had the DMG bundle met at referral, 15% at the time of authorization, 33% at 12-18 hours, and 45% prior to recovery. 43% had ≥ 3 OTPD. Differences between ECDs with < 3 and ≥ 3 OTPD are included in the table. Independent predictors of ≥ 3 OTPD were age (OR=0.95 per year), creatinine (OR=0.73 per mg/dL), DMGs ‘met’ met prior to organ recovery (OR=1.90), and a change in the number of DMGs achieved from referral to organ recovery (OR=1.11 per additional DMG).

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Conclusions: Meeting DMG’s prior to organ recovery in ECDs is associated with more organs transplanted per donor. An increase in the number of critical care endpoints achieved throughout the care of a potential donor, both by the donor hospital as well as the OPO, is also associated with an increase in organ yield.

Table: Univariate analysis of continuous and categorical data associated with ≥3 organs transplanted per donor in extended criteria donors

Univariate Analysis of Continuous and Categorical Data Associated with ≥3 Organs Transplanted Per Donor in Extended Criteria Donors

Variable <3 Organs Transplanted per Donor(n=380)

≥3 Organs Transplanted per Donor(n=291)

P Value

Donor age (yrs) 61 ± 7 59 ± 7 <.001

Creatinine prior to organ recovery 1.89 ± 1.81 1.37 ± 1.12 <.001

DMG bundle "met" at referral 10% 12% 0.387

DMG bundle "met" at time of authorization 13% 17% 0.266

DMG bundle "met" 12-18 hours later 28% 40% 0.001

DMG bundle "met" prior to organ recovery 37% 56% <.001

Individual number of DMGs achieved:

At referral 5.0 ± 1.3 5.2 ± 1.1 0.054

At time of authorization 5.1 ± 1.4 5.2 ± 1.3 0.125

12–18 hrs later 5.7 ± 1.4 6.1 ± 1.3 0.002

Prior to recovery 6.1 ± 1.2 6.6 ± 1.3 <.001

Relative changes in number of DMGs achieved:

From referral to authorization 0.04 ± 1.49 0.03 ± 1.36 0.962

From referral to 12-18 hrs later 0.71 ± 1.60 0.87 ± 1.51 0.198

From referral to prior to recovery 1.11 ± 1.54 1.44 ± 1.49 0.005

From authorization to 12–18 hrs later 0.67 ± 1.61 0.84 ± 1.51 0.164

DMGs, donor management goals. DMGs “met” is defined as meeting any seven or more of the nine DMGs. Data expressed as means with standard deviation or percentage Independent samples T test used for continuous data and chi square for categorical data to calculate p-value

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Increasing Organ Donation in Hispanic Americans

Authors: A Salim, E Ley, C Berry, D Schulman, S Navarro, L Zheng, L ChanInstitution: Cedars Sinai Medical Center, Los Angeles, CAPresenter: Cherisse BerryPrimary Discussant: Darren MalinoskiDiscussion Closed By: Ali Salim

Background: The need for suitable organs for transplantation is especially pronounced in minority populations such as Hispanic Americans (HA) due to disproportionately high rates of diabetes and kidney disease. Considerable barriers exist for HA consent to donation, resulting in significantly lower donation rates compared to non-Hispanic whites.

Objective: To investigate the impact of an aggressive outreach intervention over a 5 year period aimed at improving organ donation rates among HA.

Design: Prospective Observational Study

Setting: Four Southern California neighborhoods with a high percentage of HA

Patients: Organ donors managed at a major metropolitan Level I trauma center that provides the majority of care to the target neighborhoods.

Interventions: Television and radio media campaigns, ‘culturally sensitive’ educational programs implemented at various high schools, churches, and medical clinics residing in the target neighborhoods.

Main Outcome Measures: Consent rates for organ donation tracked over time using Cochrane-Armitage trend tests.

Results: Outreach interventions started in 2007 and were completed by 2012. Of 268 potential donors, 155 total donors (106 HA) were consented during the time period. A significant increase in consent rates was noted among HA (p=0.004), and this increase was not realized among Non-Hispanics (table).

Conclusions: During the study period, there was a significant increase in consent rates among HA, which was not realized among Non-Hispanics. Aggressive outreach programs can narrow the gap between organ supply and organ demand by improving consent rate among HA.

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Comparison of Clinical Registry Versus Administrative Claims Data for Modeling Surgical Quality Measures

Authors: E Lawson, D Zingmond, C KoInstitution: David Geffen School of Medicine, Los Angeles, CAPresenter: Elise LawsonPrimary Discussant: Sara JavidDiscussion Closed By: Clifford Ko

Importance: There is debate regarding the optimal data source for assessing hospital surgical quality for public reporting.

Objective: To compare clinical registry vs administrative claims data for modeling surgical quality measures and to determine the validity of measures that use a hybrid of data types.

Design: Retrospective cohort study

Setting: ACS National Surgical Quality Improvement Program and Medicare inpatient claims, 2005-2008

Patients: Systematic sample of surgical procedures

Main Outcome: National Quality Forum endorsed risk-adjusted measures of hospital performance for 30-day postoperative major complications or death after colectomy, lower extremity bypass (LEB), or all surgical procedures. Measures use hierarchical multivariable logistic regression to identify statistical outliers for better or worse performance. Hospital quality was assessed using clinical data, administrative data, or a hybrid of data types. Kappa statistics assessed agreement between data sources on determinations of hospital quality.

Results: 111,984 patients from 206 hospitals. Agreement between clinical and claims data was poor for hospital risk-adjusted outlier status. Hybrid models using clinical outcomes data had moderate-to-excellent agreement with clinical models on quality determinations, while agreement between clinical models and hybrid models using administrative outcomes data was routinely poor.

Conclusion: Assessments of hospital surgical quality differ substantially when using clinical registry vs administrative claims data. Hybrid measures using clinical outcomes data may be a valid alternative for quality measurement. These findings have implications for policies focused on public reporting of surgical quality.

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Comparison of Hospital Risk-Adjusted Statistical Outlier Classification for 30-Day Postoperative Complications or Death Between a Clinical Surgical Registry (Acs-Nsqip) and Administrative Data From Medicare Inpatient Claims for Three Quality Measures

Model Name

Data Source

Agreement on Hospital Outlier Status Classification Between Clinical Model and Specified Model (weighted kappa)

Risk-adjustment variables

Outcome variables

Colectomy Lower extremity bypass

All surgical procedures

Clinical Clinical registry Clinical registry

(Reference) (Reference) (Reference)

Administrative Administrative claims

Administrative claims

Poor (0.10)

Poor (0.20)

Poor (0.21)

Hybrid 1 Clinical registry Administrative claims

Poor (0.14)

Poor (0.27)

Poor (0.35)

Hybrid 2 Administrative claims

Clinical registry

Moderate (0.52)

Excellent (0.77)

Moderate (0.57)

Clinical Registry: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Administrative claims: Medicare inpatient claims

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Long-term Results of a Postoperative Pneumonia Prevention Program for the Inpatient Surgical Ward

Authors: H Kazaure, S WrenInstitution: Stanford University School of Medicine, Stanford, CAPresenter: Hadiza KazaurePrimary Discussant: Thomas BerneDiscussion Closed By: Sherry Wren

Importance: Postoperative pneumonia (PNA) is a major risk factor for prolonged hospitalization, readmission, death, and high cost of care.

Objective: We previously published the first study to characterize and describe the outcome of a systematic and standardized postoperative PNA prevention program in non-ICU surgical patients introduced in year 2007. We present long-term results of the pilot program (through fiscal year 2012), and compare our post-intervention annual pneumonia rates to those captured in ACS-NSQIP and calculate the cost savings attributable to the program.

Design: Retrospective cohort study

Setting: University-affiliated Veterans hospital

Participants: All non-cardiac surgical patients with ward-acquired PNA

Intervention: A previously described standardized postoperative PNA prevention program

Main Outcome Measure: ward-acquired PNA

Results: Between years 2008-12, there were 18 cases of ward PNA among 4,099 at-risk patients yielding a case rate of 0.48%, which is 38.5% lower than our pre-intervention rate (0.78%). The case rates in all years were lower than the pre-intervention rate (0.25%, 0.5%, 0.57%, 0.6%, and 0.13% in years 2008-12 respectively). The PNA case rate (male, non ICU) in ACS-NSQIP was 2.7% (10,701 cases of PNA among 399,088 at-risk patients), which is 565% higher than the post-intervention rate at our facility. Using a national average of $46,400 in health care cost attributable to one case of postoperative pneumonia, approximately $262,400 attributable cost was saved per year after introduction of the prevention program.

Conclusions and Relevance: Our prevention program achieved substantial and sustained reduction in pneumonia incidence; its wider adoption could improve postoperative outcomes.

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Effects of Urinary Catheter Removal Per SCIP Guideline in Patients Undergoing Abdominal and Pelvic Operations

Authors: C Kin, H Vo, M Jalali, L Welton, K Rhoads, M WeltonInstitution: Stanford University Medical Center, Stanford, CAPresenter: Cindy KinPrimary Discussant: Anthony SenagoreDiscussion Closed By: Mark Welton

Importance: The Surgical Care Improvement Project (SCIP) guidelines mandate urinary catheter removal within 48 hours of surgery to reduce catheter-associated urinary tract infection (UTI) rates. Published series have not demonstrated this desired result, and the urinary retention (UR) rates are undefined.

Objective: To determine whether UR rates increase and UTI rates decrease with earlier catheter removal.

Design: Prospective observational trial (2010-2013). Patients undergoing abdominal and pelvic operations underwent catheter removal by postoperative day (POD) 2 and POD3, respectively. UR was diagnosed by ultrasound. UTI was diagnosed by urinalysis and culture.

Setting: Academic hospital.

Participants: Adults undergoing general surgery operations were eligible; 250 were approached and 181 participated.

Exposure: Early catheter removal.

Main Outcome Measure: UR and UTI rates.

Results: Forty of 181 catheters were not removed for medical reasons. In abdominal cases, catheter removal by POD2 vs after POD2 resulted in higher UR (23% vs 3%, p=0.009). Intravenous fluid volume given on POD1 was greater in abdominal cases with UR (2.5 v 2L, p=0.03). Higher urine output on POD2 and POD3 (2.5 vs 1.6L, p=0.001) was associated with higher UR rates. UTI rates were higher in patients with prolonged catheterization (p<;0.02). Length of stay was longer in patients with UR (8.9 vs 5.4 days, p=0.001). Patients with UR had higher UTI rates.

Conclusion: Adherence to the SCIP measure of early catheter removal resulted in higher UR rates as well as lower UTI rates. Optimization of UR and UTI rates may be achieved by consideration of clinical factors such as perioperative volume status.

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Rates of Postoperative Urinary Retention and Urinary Tract Infection in Patients Undergoing Early vs Late Catheter Removal

N Retention Rate

P Value

UTI Rate

P Value

Abdominal foley for 1-2 days

104 23% 0.009 5% 0.01

foley for 3 or more days

33 3% 18%

Pelvic foley for 2-3 days

37 27% 1 0 0.02

foley for 4 or more days

7 29% 29%

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A Novel Financial Incentive Program Successfully Improved Operating Room Efficiency

Authors: T Scalea, D Carco, Y Fouche, A PollakInstitution: University of Maryland, Shock Trauma Center, Baltimore, MDPresenter: Thomas ScaleaPrimary Discussant: Steven KaminskiDiscussion Closed By: Henry Cryer

Hypothesis: Establishing incentives for OR teams will improve efficiency.

Design: Evaluation of a financial incentive program (FIP) to improve turnaround times (TAT) and first case starts (FCS) in trauma ORs. OR efficiency awareness education was conducted prior to FIP implementation.

Setting: Urban Level 1 trauma center

Participants: All OR team members were included. Each eligible team member achieving a TAT of 60 or less or an on-time FCS was awarded a point. Reports listing individual performances were posted. Pay bonuses were awarded for achieving one of three progressive point totals in any month.

Mean Outcome Measures: TAT was defined as wheels-out to wheels-in and FCS as wheels-in within 6 minutes of scheduled start.

Results: Prior to FIP, mean TAT varied between 77-83 minutes, with only 18% - 26% of TATs less than 60 minutes. FCS averaged 29% - 34%. After FIP implementation, FCS improved from 31.2% to 64% (p<;0.001), and TATs less than 60 minutes increased from 23.8% to 52% (p<;0.001). The two month cost of the FIP was $8340. We saved 13 minutes per TAT for an estimated savings of $177,000. We estimate an additional savings of $33,000 for FCS for a total of $210,000.

Conclusion: A novel FIP improved OR efficiency. Given the small amount of money involved, it seems unlikely this is solely responsible. Effectively communicating the importance of TAT and FCS and publishing individual results more likely increased staff awareness. Teamwork created by linking assignment of points to a team result likely contributed to success.

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ACGME Case Logs: A National Review of the Rise of Minimally Invasive Surgery Over Two Decades of General Surgery Resident Training

Authors: M Richards, J McAteer, F Drake, A Goldin, S Khandelwal, K GowInstitution: University of Washington, Seattle, WAPresenter: Morgan RichardsPrimary Discussant: Kevin ReavisDiscussion Closed By: Kenneth Gow

Importance: One of the most important changes in the field of surgery has been the rise of Minimally Invasive Surgery (MIS); however, its adoption into training programs has not been studied.

Objective: Evaluate changes in general surgery resident operative experience with regard to MIS.

Design, Setting and Participants: Review of Accreditation Council for Graduate Medical Education Case Logs for academic years 1993-94 through 2011-12.

Main Outcomes and Measures: Open and corresponding MIS cases were analyzed using t-tests with statistical significance set at p <;0.05.

Results: Of 6,467,708 operations with sufficient data, 2,393,030 (37%) were performed with the MIS approach. Of all MIS operations performed, the five most common were cholecystectomy (49%), appendectomy (16%), groin hernia repair (10%), abdominal exploration (non-trauma) (4%) and antireflux procedures (4%). During the study period there was a transition from a predominantly open to MIS approach for appendectomy, antireflux procedures, thoracic wedge resection and partial gastric resection. Cholecystectomy is the only procedure for which MIS was more common than the open technique throughout the study period. The open approach is still more common for all other procedures including: pediatric antireflux, thoracic exploration for trauma, lobectomy/segmental lung resection, gastrostomy, groin hernia repair, abdominal exploration (non-trauma), splenectomy (non-trauma), enterolysis, enterectomy, common bile duct exploration and partial colectomy.

Conclusions: MIS has an increasingly prominent role in contemporary surgical therapy for many common diseases. The open approach, however, still predominates in all but five procedures. Therefore, residents today must become facile with multiple approaches for a single procedure, which demands a broader skill set than in the past.

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Percentage of MIS Cases by Period

Procedure Period 1 Period 2 Period 3 Period 4

Cholecystectomy 69.4% 85.6%* 87.8%# 91.2%#

Appendectomy 13.2% 26.0%* 48.9%* 72.9%*

Antireflux – Adult 29.0% 57.5%* 70.5% 78.5%*

Thoracic wedge resection 24.3% 46.0%* 52.1% # 77.0%#

Gastric Resection, partial 1.5% 10.4% 38.5%# 70.2%#

Period 1 includes Academic Year (AY) 1993-94 to 1997-98

Period 2 includes AY 1998-99 to 2002-03

Period 3 includes AY 2003-04 to 2007-08

Period 4 includes AY 2008-09 to 2011-12

* Denotes this percentage is statistically different than prior period

# Insufficient data to perform statistical analysis

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General Surgery Residents Have an Increased Desire to Quit at High Attrition Residencies – A Multi-Institutional Study

Authors: E Gifford, J Galante, A Kaji, M Nelson, R Sidwell, T Hartranft, B Jarman, M Melcher, M Reeves, C Reid, C Are, B Smith, C deVirgilioInstitution: Harbor-UCLA Medical Center, Los Angeles, CAPresenter: Edward GiffordPrimary Discussant: Karen DeveneyDiscussion Closed By: Joseph Galante

Objective: To determine how often categorical general surgery residents seriously consider quitting residency

Design: Anonymous survey of categorical surgery residents and 10 year attrition rates for each program. Responses from high and low attrition rate programs were compared.

Setting: Thirteen residency programs

Participants: 288 categorical surgery residents

Main Outcome Measures: Factors associated with the desire to quit residency

Results: Survey response rate was 77.6%. 58% seriously considered quitting. The most frequent reasons for wanting to quit were sleep deprivation on a specific rotation (50%), an undesirable future lifestyle (46%) and work hours on a specific rotation (41.4%). Factors most often cited that kept residents from quitting were support from family/significant others (65%), support from other residents (63.5%), and feeling better rested (58.9%). Age, gender, PG year, university program, faculty mentor, and AOA were associated with increased desire to quit on univariate analysis. On multivariate analysis only female gender was associated with thoughts of quitting (OR 1.2, p=0.003). There were 86 resident responses from high attrition rate programs and 202 from low attrition programs (26.2% vs. 7.2% 10 year attrition rate, OR 3.9, p<;0.0001). Residents from high attrition rate programs were more likely to want to quit (OR 1.8, P=0.03).

Conclusions: A majority of categorical general surgery residents seriously consider quitting residency. Female residents are more likely to consider quitting. The desire to quit appears to be strongly associated with work conditions on specific rotations rather than overall work hours, and is higher in programs with historically high attrition rates.

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Pregnancy-Related Attrition In A General Surgery Residency Over 10 Years: Fact or Fiction?

Authors: E Brown, J Galante, J Braxton, D FarmerInstitution: University of California Davis, Sacramento, CAPresenter: Erin BrownPrimary Discussant: Jeff GauvinDiscussion Closed By: Joseph Galante

Objective: To determine whether pregnancy increases the risk of attrition from general surgery residency.

Design: Retrospective review of all categorical general surgery (CGS) residents matriculating into a single residency program from 1999 to 2009.

Setting: Academic general surgery residency program.

Participants: All CGS residents matriculating into a single residency program from 1999 to 2009. Main

Outcome Measure(s): Voluntary/involuntary attrition rates, incidence of pregnancy

Results: Eighty-seven residents matched into CGS PGY1 spots from 1999 to 2009. 51 were men (59%); 36 were women (41%). Attrition in the program was 18% (16/87) with only one being involuntary. Seven residents who left were women (44%); this was 19% of all women residents in the program. This was not statistically significant from the proportion of men leaving the program (p=0.83). Among the 87 residents, 9 women experienced 11 pregnancies with only 1 of these residents leaving the program. Sixteen men accounted for 21 pregnancies (none of these men left). The proportion of childrearing in those who did not leave the program was significantly higher than in those who left (p=0.02). In the 25 residents participating in childrearing, 24 finished on time and 1 extended training by 1 month.

Conclusions: Pregnancy does not appear to be a risk factor for attrition. While residents leave the program in search of improved lifestyle, pregnancy does not appear to cause women or men to leave the program.

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Innovative Approach using Multidisciplinary Simulation to Educate Surgical Residents in Technical and Non-Technical Skills in High Risk Clinical Scenarios

Authors: G Nicksa, R Fidler, C Anderson, L StewartInstitution: University of California San Francisco, San Francisco, CAPresenter: Grace NicksaPrimary Discussant: Paul SudingDiscussion Closed By: Lygia Stewart

Objective: ACGME core competencies stress non-technical skills that can be difficult to teach to surgical residents, who also need emergency procedure training. In emergencies, surgeons work in multidisciplinary teams; thus, meaningful simulations need to incorporate this. We used multidisciplinary emergency clinical simulations to educate surgical residents in non-technical and technical skills.

Design/Setting: SimMan(3GS) was used to simulate high-risk clinical scenarios (20 min scenarios, 30 min debrief), in OR, ICU, ER, Ward, or Simulation Center. Oxford Non-Technical Skills (NOTECHS) scale (range 0-4) was used to assess performance; and anonymous online surveys to solicit participant feedback.

Participants: Surgical residents(PGY-1, PGY-2) participated in multidisciplinary clinical scenarios(22 sessions/12 mos), with other health care professionals [nursing, anesthesia, medicine, RT, pharmacy (mean number participants/session 6)]. Clinical scenarios included: PE, pneumothorax, MI, GI bleed, anaphylaxis, PEA arrest.

Main Outcome Measure: Evaluation of resident skills: communication, leadership, teamwork, problem-solving, situation awareness; and ability to perform emergency procedures.

Results: Residents found sessions useful (93%), and reported improved confidence doing procedures (85%). Significant improvement was demonstrated in PGY-2 performance (but not PGY-1), in communication, leadership, teamwork, and procedural ability (P<;0.009).(Table)

Conclusions: Residents found multidisciplinary simulations provided a realistic, invaluable educational experience. Multidisciplinary simulation provides a valuable means of educating surgical residents and evaluating their skills in real-life clinical scenarios.

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Percentage of MIS Cases by Period

Skills

PGY 1 Skill Score

P Value

PGY 2 Skill Score

P Value1st 6 mos

2nd 6 mos

1st 6 mos

2nd 6 mos

Communication 3.38 2.93 0.313 3 3.83 < 0.0001

Leadership 3 2.57 0.346 2.77 3.83 < 0.0001

Teamwork 3.25 3.14 0.785 3.15 3.83 0.001

Problem-solving 2.38 2.43 0.87 3 3.17 0.491

Situation Awareness

2.5 2.79 0.39 2.85 3.33 0.064

Procedural Ability

2.25 2 0.434 2.23 3.33 0.009

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Trends in Operative Interventions for Crohn’s Disease in the Biologic Era

Authors: C Budde, K Lu, B Diggs, K Deveney, K Keyashian, D Herzig, V TsikitisInstitution: Oregon Health and Science University, Portland, ORPresenter: Cristina BuddePrimary Discussant: Raman MenonDiscussion Closed By: Karen Deveney

Objective: Biologic therapies have dramatically changed the way we treat and manage Crohn’s disease. In our study we examined how the rates of inpatient admissions, surgical interventions, and stoma formation have altered from the pre-biologic to the current biologic therapy era.

Design, Setting, and Patients: We reviewed the National Inpatient Sample (NIS) database from the years 1988 to 2011. All patient admissions with the diagnosis of Crohn’s disease were examined.

Main Outcome Measures: Percent of admitted patients who needed any Crohn’s-related operative intervention, percent of admitted patients who required stoma construction and percent of stoma formation over the total number of surgical cases.

Results: A total of 2,844,906 Crohn’s-related patient admissions were analyzed. Number of inpatient admissions rose substantially over the years from less than 70,000 in 1988 to over 205,000 in 2011(Figure1). Despite this rise in admissions, the percent of admissions that included a Crohn’s-related surgical intervention has decreased substantially from 26% in 1988 to 12% in 2011. However, the percent of stoma formation has remained fairly constant over the years, around 2% of Crohn’s admissions. When compared to all Crohn’s surgical cases, the percentage of stoma construction has increased from 14% to 18% of all surgical cases(Figure2).

Conclusions: In the Crohn’s biologic therapy era, there has been a substantial increase in the number of Crohn’s-related inpatient admissions whereas the rate of surgical interventions has decreased. The percent of stoma construction over total admissions remains unaffected. However, when operative intervention is required, stoma construction is more likely to occur.

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Predictors of Therapeutic Re-operation in Necrotizing Soft Tissue Infections

Authors: H Yan, D Kim, A Neville, J Keeley, C de Virgilio, A Kaji, S Bricker, F Bongard, B Putnam, D PluradInstitution: Harbor-UCLA Medical Center, Los Angeles, CAPresenter: Huan YanPrimary Discussant: Darren MalinoskiDiscussion Closed By: Brant Putnam

Importance: Mandatory re-operation in patients with necrotizing soft tissue infections (NSTI) is controversial.

Objective: To identify predictors of therapeutic re-operation (TRO) in patients with NSTI

Design: A 5 year retrospective cohort study of patients undergoing a single therapeutic operation (STO) or TRO. Variables included demographics, clinical presentation, time to operation, admission/post-op labs, pathology, and outcomes.

Setting: A university affiliated County hospital

Participants: One-hundred forty consecutive patients with NSTI

Main Outcome Measures: Therapeutic re-operation defined as surgical debridement of necrotic tissue at a second operation

Results: Eighty-three patients (59%) underwent a STO (including 12 patients who underwent a non-therapeutic ‘second look’) and 57 patients required TRO, yielding a pretest likelihood of 41%. On univariate analysis, patients undergoing TRO were more likely to have blood culture positivity (p=0.0002) and a higher admission and post-op white blood cell (WBC) count, lactate, base deficit, and bandemia (p >0.005). On multivariate analysis, an admission WBC >17 and a post-op lactate >2 were associated with the need for TRO. The sensitivity/specificity for predicting the need for a TRO using these 2 variables were 89%/57% with a NPV/PPV of 89%/59%. Mortality was 28% vs. 4% (p<;0.0001) for patients who underwent a TRO versus a STO.

Conclusions: A large proportion of patients with NSTI do not require mandatory re-operation. This predictive model has the potential to enhance patient safety and resource utilization by minimizing unnecessary return trips to the operating room in patients with NSTI.

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Variable Odds Ratio 95% C.I. P Value

Admission WBC >17 4 2 - 10 0.0003

Postoperative lactate >2 8 2 – 19 0.0003

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Successful Salvage: A 117 Patient Series of Complex Open Abdominal Wall Reconstructions

Authors: S Diamond, H Cryer, P RahgozarInstitution: David Geffen School of Medicine, Los Angeles, CA Presenter: Shawn DiamondPrimary Discussant: Hobart HarrisDiscussion Closed By: Henry Cryer

Importance: This study demonstrates that complex open abdominal wall reconstruction (COR) often requires reoperation but ultimately succeeds most of the time.

Objective: To determine the success and salvage rates of COR as well as elucidate factors which contribute to failure

Design: Retrospective Cohort Analysis

Setting: Single-site University Medical Center

Participants: 117 patients undergoing COR from 2006-2011

Outcome Measures: Operative failure rate for primary and subsequent salvage operations with data analysis

Interventions: Open abdominal wall reconstruction and salvage operations for complications

Results: 117 patients met selection criteria with 47-month average follow-up. Retrorectus mesh with overlying fascial closure was accomplished in 75% of patients and 30% of these required myofascial advancement flaps. Bridge mesh without fascial closure was used in 18% patients and 8% had primary fascial closure alone. The primary operation succeeded in 55.6% (N.64) of patients while 31.3% (N.36) eventually succeeded after salvage maneuvers. Preoperative and technical factors associated with the need for salvage include: contamination (OR 4.1p=0.002), wound infection (OR 7.1p<;0.0001), mesh infection (OR 5.0p=0.01), bridge mesh (OR 4.4p=0.02) and use of biologic mesh (OR 13.0p=0.02). Reoperation and interventions for recurrence, fistula, wound and mesh infection resulted in either salvage or failure at variable rates (Table 1). Fifteen patients (13%) failed despite attempted salvage.

Conclusions: COR ultimately succeeded in 87% of patients but 31% required more than one operation to salvage complications. Risk factors for reoperation were presence of infection or contamination at the time of primary operation and the use of biologic mesh or bridge mesh repair. The use of biologic mesh in contaminated cases requires further evaluation.

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The Clavien-Dindo Classification of Surgical Complications

Intervention Salvaged N (%) Failed N (%)

Total Number Patients 36 (100%) 15 (100%)

Reoperation for Mesh Infection 15 (42%) 3 (20%)

Reoperation for Seroma 9 (25%) 0 (0%)

Reoperation for Wound Infection 7 (19%) 3 (20%)

Biological Mesh Infection 6 (17%) 1 (6.7%)

Reoperation for Recurrence 5 (14%) 4 (27%)

Local Wound Care and Dressings 5 (14%) 1 (6.7%)

Conversion Biologic to Permanent Mesh

4 (11%) 1 (6.7%)

Reoperation for Hematoma 2 (5.5%) 2 (13%)

Interventional Radiologic Procedure 2 (5.5%) 0 (0%)

Capsulectomy 2 (5.5%) 0 (0%)

Panniculectomy 1 (2.7%) 0 (0%)

Reoperation for Fistula 1 (2.7%) 0 (0%)

Clavien-Dindo Classification

IIIb 31 (86%) 13 (87%)

I 5 (14%) 0 (0%)

IIIa 5 (14%) 1 (6.7%)

II 0 (0%) 0 (0%)

IV 0 (0%) 0 (0%)

Table 1. Clavien P A, et al. The Clavien-Dindo Classification of Surgical Complications. Five-Year Experience. Ann Surg. 2009; 250: 187-296

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Outcomes of Robotic-Assisted Thoracic Operations in a High-Risk Population

Authors: A Abolhoda, V Kirkpatrick, M Thein, D Wong, S WilsonInstitution: Veterans Affairs Long Beach Health Care System, Long Beach, CAPresenter: Vincent KirkpatrickPrimary Discussant: Paul SudingDiscussion Closed By: Samuel Wilson

Objective: Robotic-assisted surgery offers a new minimally invasive approach to intrathoracic pathology. This study evaluates short-term outcomes of robotic thoracic surgery in a high-risk veteran population with greater rates of smoking and comorbidities than the general population.

Design: Retrospective study of 30-day postoperative morbidity and mortality.

Setting: Veterans Affairs hospital. Patients: 150 consecutive patients who had robotic thoracic surgery.

Outcome Measures: Thirty-day surgical outcomes including mortality, length of stay, conversion to thoracotomy and readmission.

Results: Of 150 patients, 143 were male and 7 were female. There were 125 pulmonary resections (86 lobectomies, 39 wedge resections) 11 mediastinal procedures, and 14 other procedures. 69% had a malignant pathology. Mean age was 64 (25-91), 13% (20) had a history of alcohol abuse, 17% (26) had a psychiatric disorder, and 44% (66) were active smokers averaging 39 pack-years. Chronic obstructive pulmonary disease was present in 51% (76), 18% (27) had documented coronary artery disease, 19% (29) had diabetes mellitus, and 10% (15) had renal insufficiency. Conversion to thoracotomy was required in 15% (22). Postoperative complications occurred in 33 (22%) (Table). For 128 patients successfully treated robotically without thoracotomy, mean postoperative length of stay was five days. Thirty-day mortality was 0.8% (1) for these 128 patients, and 1.3% (2) overall. Four patients (3%) required hospital readmission overall.

Conclusions: This is the first report of outcomes for robotic thoracic surgery in a high-risk veteran population, which shows low morbidity and mortality comparable to reports for video-assisted thoracoscopic surgery.

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Intraoperative and Postoperative Data for 150 patients

Intraoperative data n %

Conversion to thoracotomy 22 15%

Blood transfusion 4 3%

Death 0 0%

Average estimated blood loss 85 mL

Postoperative data

Atrial Fibrillabion 18 12%

Bronchoscopy 13 9%

Blood Transfusion 9 6%

Prolonged airleak (>7 days) 11 7%

Pneumonia 6 4%

Respiratory failure (reintubation) 3 2%

Reoperation within 30 days 3 2%

Readmission within 30 days 4 3%

Pulmonary embolism 1 0.7%.

Deep vein thrombosis 1 0.7%.

Average chest tube days 3 days

Length of stay 6 days

30-day Mortality 2 1.3%.

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Does Laparoscopic Hepatectomy Result in Better Short-Term Outcomes Than Open Hepatectomy?

Authors: C Franken, A DifronzoInstitution: Kaiser Permanente Medical Center, Los Angeles, CAPresenter: Cara FrankenPrimary Discussant: Thomas BiehlDiscussion Closed By: L. Andrew DiFronzo

Objective: Compare short-term outcomes of laparoscopic (LH) vs open hepatectomy (OH)

Design: Retrospective matched case control study, 2004-2013

Setting: Tertiary referral center

Participants: 52 LH patients matched to 52 OH patients, based on extent of hepatectomy and pre-operative diagnosis

Main Outcome Measure: 30-day mortality and morbidity.

Results: groups were evenly matched with respect to gender, age, indication for resection, extent of hepatectomy, and presence of cirrhosis; only median BMI was higher in the LH group (28 vs 25 in the OH group, p=0.01). Overall mortality was not statistically different between groups (1.9% LH vs 3.8% OH, p=1.0). Overall morbidity was also not significantly different (42% vs 39% LH vs OH, p=0.84), and Clavien grade 3/4 complications were not different (6% LH vs 8% OH, p=1). Pulmonary complications (22% LH vs 17% OH, p=0.8). readmission rate (7.7% LH vs 9.6% OH, p= 0.7), mean operative time (219 min LH vs 198 min OH, p=0.16), and mean length of stay (4.7 days LH vs 5.7 days OH, p=0.13) were not statistically different between groups. There was no significant difference in positive pathologic margins (3.8% LH vs 1.9% OH, p= 1). Mean estimated blood loss was significantly less in patients having LH (237 mL vs 387 mL in the OH group, p=0.05). 1.9% of the patients in each group had an intraoperative blood transfusion.

Conclusions: Patients having LH have similar short-term outcomes to patients having OH. LH results in decreased blood loss compared to OH, although the need for blood transfusion is not different. Pathologic margin status was not compromised by having LH.

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E-Poster: Session A

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Axillary Reverse Lymphatic Mapping Reduces Patient Perceived Incidence of Lymphedema after Axillary Dissection in Breast Cancer

Authors: J Pasko, J Garreau, M Glissmeyer, N JohnsonInstitution: Good Samaritan Hospital, Portland, ORPresented By: Jennifer Pasko

Importance: Axillary reverse mapping (ARM) facilitates identification of lymphatic channels during axillary dissection. It has been suggested that this technique may decrease the incidence of lymphedema.

Objective: To understand whether use of ARM has decreased the subjective incidence of lymphedema.

Design: Survey Setting: Community Hospital Participants: 142 patients who underwent axillary dissection (> than 10 nodes) between 2009 and 2012 were identified. Questionnaires were mailed to those patients. Questions were posed with regard to their upper extremity symptoms following reverse mapping and axillary dissection.

Main Outcome Measures: Incidence of lymphedema; use of compression garment Results: Of the 142 surveys mailed, 30 were returned undelivered. This left 112 mailed with 46 answered for a response rate of 41%. There was a reported incidence of lymphedema of 39% in the overall group. Of the 22 who reported reverse mapping (ARM) the incidence of lymphedema was only 27% versus 50% in the traditional dissection (TD) group. In the ARM group only 4/22 are using a compression garment versus 11/24 in the TD group. Complaints of inner arm numbness were equal in both groups. Numbers did not achieve statistical significance.

Conclusion: ARM may reduce the incidence of patient reported lymphedema. ARM may correlate with reduced use of compression garments suggesting that incidence of clinical lymphedema may be lower in the reverse mapping group. Additional studies with greater patient numbers are warranted.

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Preoperative Axillary Ultrasound (AUS) for Identification of Sentinel Lymph Nodes in Breast Cancer

Authors: S Sener, J Lang, P WehnerInstitution: University of Southern California, Los Angeles, CAPresented By: Stephen Sener

Objective: Published reports have confirmed the ability of AUS to identify axillary lymph node metastases. The purpose of this study was to determine the frequency with which suspicious lymph nodes identified by preoperative AUS were sentinel versus non-sentinel nodes.

Study Design: Patients with invasive breast cancer who were clinically node-negative had breast and axillary ultrasound as part of surgical planning. Ultrasound-guided core biopsies were done using a 16 g spring-loaded core biopsy device (16g MD TECH SuperCore). A retrospective analysis of records from September 2009 through June 2013 was performed for invasive breast cancer patients who had sentinel lymph node biopsy (SLNB) accompanied by wire-localization of suspicious nodes (BIRADS 4 or 5), which had been identified by preoperative AUS and for which there were discordant (i.e., benign) core biopsy results.

Results: The median number of excised sentinel nodes was 3. The wire-localized lymph node was the sentinel node in 34 of 42 patients (sensitivity =0.81). Metastatic cancer was found in the sentinel lymph nodes of 8 (19%) patients, 7 of whom had the sentinel node accurately identified by AUS. For 7 of 8 patients who had neoadjuvant chemotherapy, the node identified by AUS was a sentinel node.

Conclusions: In this preliminary study, AUS identified the sentinel node in the majority of patients. These results, if confirmed in a larger patient sample size, suggest that a clinical trial of preoperative core biopsy guided by AUS and technetium 99m sulphur colloid lymphatic mapping might determine the need for sentinel lymphadenectomy, in patients with benign core biopsies.

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Prophylactic Mastectomy: Are We Treating The Surgeon or The Patient?

Authors: J Recabaren, A LewisInstitution: Huntington Memorial Hospital, Pasadena, CAPresented By: Aaron Lewis

Importance: Despite conservative consensus guidelines, the reported rate of prophylactic mastectomy has significantly increased the last decade, fueled by recent news events. To determine the value of prophylactic mastectomy it is necessary to assess the yield of occult breast cancers.

Objective: To evaluate the incidence of occult breast cancer found at prophylactic mastectomy after modern surveillance and imaging.

Design: IRB approved retrospective study.

Setting: A community teaching hospital.

Participants: All women with unilateral/bilateral prophylactic mastectomy between 1/2010 and 5/2013. Women with bilateral cancers were excluded.

Main Outcome Measures: To establish the incidence of occult breast cancer in patients undergoing prophylactic mastectomy. Demographics, family history, LCIS, BRCA status, tumor profile, and MRI findings were analyzed.

Results: 108 patients had prophylactic mastectomies. 103 patients had an index unilateral breast cancer and five patients had true bilateral prophylactic mastectomies. Preoperative MRI was performed in 86 patients (79.6%) with suspicious contralateral findings in 19 patients (17.8%). These were addressed with pre-operative image guided biopsy. Pathologic evaluation of the true prophylactic breast specimens found two occult cancers (1.9%). One was an invasive lobular carcinoma, one a ductal carcinoma in situ and one a non-malignant LCIS (0.9%).

Conclusions and Relevance: With availability of modern screening and imaging, the incidence of occult breast cancer found by prophylactic mastectomy is extremely low. Our study questions prophylactic mastectomy. Based on our data, we recommend a conservative of approach of surveillance avoiding unnecessary surgeries.

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Breast Cancer Following Ovarian Cancer In BRCA Mutation Carriers: Is Surveillance Justified?

Authors: A Gangi, I Cass, D Paik, C Dang, b karlan, L Andrew, C Walsh, B Rimel, F AmersiInstitution: Cedars Sinai Medical Center, Los Angeles, CAPresented By: Alexandra Gangi

Background: BRCA mutation carriers are at increased risk of developing breast cancer (BC). However, the incidence of BC after a diagnosis of epithelial ovarian carcinoma (EOC), including ovarian, fallopian tube, and peritoneal cancers is not well known. Optimal BC surveillance and detection in these patients has also not been well characterized.

Objective: To determine the incidence of BC after a diagnosis of EOC, and to evaluate the need for BC surveillance in these patients.

Design: Retrospective review of a prospectively maintained database.

Setting: Academic medical center with gynecologic and breast cancer centers.

Participants: 364 patients who had BRCA mutation testing with stage I-IV EOC between 1998 and 2012.

Main Outcome Measures: Incidence of BC and methods of surveillance

Results: Of 364 patients, 135(37%) were found to carry a germline BRCA 1 or 2 mutation. Mean age at the time of diagnosis of EOC was 49.5 years (range 28-89 years). Twelve (9%) patients developed BC. Mean time from diagnosis of EOC to diagnosis of BC was 3.0 years. Of the entire cohort, 63 patients (47%) had a first degree relative with BC, and5 of the 12 (42%) patients who developed BC also had first degree relative with BC. Annual mammography (MMG) was used for surveillance in 59% (80/135) of patients, although MMG was suspended in EOC patients with disease free interval of <;12 months. Annual breast MRI’s were performed in 44% (60/135) of patients. Nineteen (14%) patients used either tamoxifen or aromatase inhibitors for BC prevention for a median of 12 months. Fifty three patients (39%) had consultation by a breast surgeon. Thirteen (10%) patients underwent bilateral prophylactic mastectomy at a median of 23 months following GC diagnosis. BC was most commonly diagnosed with MMG in 7 (58%) patients, 3 (25%) patients had a palpable mass on clinical exam, and 2 (17%) patients had incidental BC found on prophylactic mastectomy. Seven (58%) patients with BC underwent bilateral mastectomy. All patients had early stage breast cancer (Stage 0-II). Eight of 12 (67%) had invasive ductal carcinoma with five (63%) patients with triple negative disease. Three patients (38%) received

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adjuvant chemotherapy. At a median follow up of 43 months (range 2-193 months), 33% (4/12) of patients had died from recurrent EOC after a diagnosis of BC. Median survival of the entire cohort was 78 months.

Conclusions: Metachronous BC in patients with known BRCA mutations with EOC is low. Mammography detected a majority of these BC at an early stage. These results suggest that optimal BC surveillance in patients with BRCA –associated EOC needs to be re-evaluated given the low incidence of BC in these high risk patients.

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Trends in Neoadjuvant Chemotherapy Use for Surgical Breast Cancer Patients in California

Authors: H Schoellhammer, L Goldstein, S ChenInstitution: City of Hope National Medical Center, Duarte, CAPresented By: Hans F. Schoellhammer

Importance: Academic use of neoadjuvant chemotherapy (NAC) for locally-advanced breast cancer has grown, but details regarding adoption regionally are unknown.

Objective: Examine trends in NAC use regionally in California, and to identify predictors for its use.

Design: The Surveillance, Epidemiology, and End Results (SEER) database was queried from 2004-2009. Chemotherapy data is not directly provided in SEER; thus the tumor/node evaluation fields identifying when pathologic assessment was performed relative to systemic treatment were used as a proxy for NAC.

Participants: Surgical breast cancer patients treated in California; characteristics included age, sex, race, tumor size, nodal status, and estrogen/progesterone (ER/PR) status.

Main Outcome Measures: NAC trends across years were assessed overall and by California SEER registry using Jonckheere-Terpstra two-sided test for trend. Univariate and multivariate logistic regression models were analyzed to identify predictors of NAC.

Results: 116,686 patients were identified. Overall, rates of NAC increased from 4.3% in 2004 to 5.4% in 2009 (p<;0.0001). Changes in San Francisco-Oakland (5.0% to 4.6%, p=0.23) and San Jose-Monterey (4.1% to 4.9%, p=0.2) were not significant. Los Angeles showed significant increasing trend (4.4% to 5.1%, p<;0.0001), as did the remainder of California (4.2% to 5.8%, p<;0.0001). NAC predictors include younger age, non-White race, later diagnosis year, larger tumor, ER/PR negativity, nodal status, and region (all p<;0.001).

Conclusion: NAC for surgical breast cancer patients in California increased from 2004 to 2009. Rates of change varied across California regions and years. Further studies to elucidate barriers to NAC use are needed.

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Abdominal Versus Perineal Surgery for Rectal Prolapse: Is a Perineal Approach Still Relevant in the Laparoscopic Era?

Authors: M Young, M Jafari, M Phelan, M Stamos, S Mills, A Pigazzi, J CarmichaelInstitution: University of California, Irvine School of Medicine, Orange, CAPresenter: Monica Young

Importance: Patients with rectal prolapse often have significant comorbidities that lead surgeons to select a perineal resection for treatment despite a known higher recurrence rate over abdominal approaches. There is a lack of data to support this practice in the laparoscopic era.

Objective: To evaluate if risk-adjusted morbidity of perineal surgery for rectal prolapse is actually lower than laparoscopic surgery.

Design: A retrospective review of rectal prolapse cases was conducted from 2005-2011. Outcomes were analyzed according to procedure-type: laparoscopic rectopexy (LR), laparoscopic resection/rectopexy (LRR), open rectopexy (OR), open resection/rectopexy (ORR) and perineal resection (PR). A multivariate logistic regression was used to compare risk-adjusted morbidity and mortality between each procedure.

Setting: Hospitals utilizing the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

Participants: Rectal prolapse patients.

Main Outcome Measures: 30-day morbidity and mortality

Results: Among 3,254 cases sampled, a laparoscopic approach was used in 22%, an open abdominal approach in 30% and PR in 48%. Patients undergoing PR were older (76) and had a higher ASA (3) compared to laparoscopic (58, 2) and open abdominal procedures (58, 2). Risk-adjusted mortality could not be assessed due to a low overall incidence of mortality (0.01%). Overall morbidity was 9.3%. ORR was associated with a higher risk-adjusted morbidity compared to PR (OR: 1.97, p<0.02). There were no significant differences in risk-adjusted morbidity found between LR or LRR compared to PR (OR: 0.4, p=0.14; OR: 1.56, p=0.15). Laparoscopic cases averaged 27 min longer than open cases (p<0.001).

Conclusions: Laparoscopic rectal prolapse surgery has comparable morbidity to perineal surgery. A randomized trial is indicated to validate these findings and to assess recurrence rates.

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Colorectal Enhanced Recovery After Surgery: A Prospective Study in A Community Hospital

Authors: C Budde, A Rotramel, M Whiteford, J FrankhouseInstitution: Oregon Health and Science University, Portland, ORPresented By: Cristina Budde

Objective: Enhanced recovery after surgery(ERAS) colorectal programs often focus primarily on reducing length of stay(LOS). Using core ERAS guidelines, we developed a program of care with the goal of speeding recovery while addressing other important outcomes affecting patient experience and safety.

Design, Setting, and Patients: This is a prospective, single institution study. Our ERAS program is a multidisciplinary effort involving anesthesia, nursing and surgery staff that was initiated in 2010 and in full practice by 2011. We assessed practice patterns and patient outcomes for all elective colectomy cases performed at our community hospital from 2009(prior to ERAS implementation), 2011 and 2012.

Main Outcome Measures: Laparoscopic approach, narcotic use, LOS, 30-day readmission, ileus(defined as re-insertion of nasogastric tube), intra-abdominal infection

Results: From 2009 to 2012, use of laparoscopy increased from 57% to 89%(p<;0.001). LOS decreased significantly(6.66 vs. 3.65 days, p<;0.001), without an increase in readmission(p=NS). Use of patient-controlled narcotic analgesia(PCA) and duration of use decreased(63% vs. 15%,p<;0.001, 67.8hrs vs. 47.1hrs,p<;0.001). Ileus rate decreased from 13% to 3%(p=0.03). Intra-abdominal infection decreased from 7% to 1%(p=NS, limited by sample size)(Table1). Comparing laparoscopic cases alone showed similar results. Length of stay reductions resulted in an estimated cost savings of $3200/patient(2011) and $4816/patient(2012).

Conclusions: Implementation of this patient care-directed enhanced recovery program is associated with decreased LOS without increased readmission, as well as significant decreases in narcotic use, perioperative morbidity, and cost.

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A Decade of Bariatric Surgery: What Have We Learned?

Authors: B Wong, M YamamuraInstitution: Kaiser Permanente – Moanalua, Honolulu, HIPresented By: Brian Wong

The short-term benefits of bariatric surgery are well documented; however, few reports with data beyond 10 years exist. We present our 12-year results in bariatric surgery.

Methods: A retrospective case series of 985 (21%M, 79% F) morbidly obese and super-obese individuals who underwent bariatric surgery between 2000 and 2012. All patients met National Institutes of Health criteria for recommendation for a bariatric procedure.

Intervention: Laparoscopic Roux-en-Y gastric bypass with a hand-sewn gastro-jejunal anastomosis, Laparoscopic Gastric Sleeve, Laparoscopic Adjustable Gastric Band

Main Outcome Measures: Weight loss, HgA1C levels, and complications

Results: A total of 985 patients underwent bariatric surgery from January 2000 to March 2012. The lost to office follow-up rate was 5% at 5 years and 16% at 12 years. RYGB was performed in 765(77%) patients, gastric banding in 91(9%) patients, and gastric sleeve in 129(13%) patients. The mean excess weight loss was 40.9 % at 11 years following gastric bypass. In patients with at least 1 year of follow up, 71% with diabetes experienced and maintained improvement or resolution. Of the 985 bariatric procedures, 117 (13%) had >1 complication during follow-up. 56 (5.6%) patients required operative intervention for complications. The incisional hernia rate was 1.8%. The gastro-jejunal stenosis rate was 3.6%. 16(12%) bands were removed. No surgery-related deaths occurred.

Conclusions: Bariatric surgery is safe and effective in achieving weight loss and improving diabetes. New procedures are being introduced as the demand for bariatric surgery increases. As we move forward, examining long term data is essential in validating the performance of bariatric surgery in the community.

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Laparoscopic Versus Open Bowel Resection in Emergent Small Bowel Obstruction: Analysis of the National Surgical Quality Improvement Program Database

Authors: R Sharma, S Reddy, D Thoman, J Grotts, L FerrignoInstitution: Santa Barbara Cottage Hospital, Santa Barbara, CAPresented By: Rohit Sharma

Importance: Small bowel obstruction (SBO) is commonly encountered by surgeons and has traditionally been handled via an open approach, especially when small bowel resection (SBR) is indicated. Some series show better outcomes with laparoscopic bowel resection versus open (LBR vs OBR).

Objective: To identify risk factors for adverse events after emergent SBR for SBO with emphasis on surgical approach.

Design: Retrospective review utilizing the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Public Use File.

Setting: Hospitals in the NSQIP database.

Patients: 4,669 patients were identified who had emergent SBR with principal diagnosis of SBO from 2006-2010.

Exposure: bowel resection.

Main Outcome and Measures: Mortality and post-operative adverse events.

Results: Of 4,669 patients who had emergent SBR, 152 (3.3%) had LBR. Overall, patients who had OBR were older and had higher ASA scores. There was no difference in duration of surgery (95 vs 93 min, p > 0.05). Postoperative complications were more common in the OBR group compared to LBR and length of stay (LOS) was longer (9 vs 7 days, p <0.001). Using multivariate analysis, perioperative variables age > 70; pulmonary, renal, neurological, and cardiac comorbidities; and pre-operative sepsis were associated with mortality and respiratory adverse events. LBR was associated with overall decreased odds of morbidity and postoperative wound infection (p<;0.05).

Conclusions: Patients undergoing emergency OBR are older and with more comorbidities than patients undergoing LBR, and have an increased odds of wound infection. LBR was associated with equivalent operative time, shorter LOS, less morbidity and equivalent mortality.

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Minimally Invasive Esophagectomy: Outcomes from 217 Consecutive Patients

Authors: M Young, A Gebhart, S Vu, N NguyenInstitution: University of California, Irvine School of Medicine, Orange, CAPresented By: Monica Young

Importance: Minimally invasive esophagectomy (MIE) has been described since the early 1990s; however, there are few large studies reporting more than 100 cases.

Objective: To analyze outcomes of patients undergoing MIE

Design: A retrospective study between 1998-2013

Setting: Academic medical center

Participants: 217 consecutive patients who underwent MIE for esophageal cancer (80.6%), gastric cardia cancer (8.8%), Barrett’s esophagus (3.7%), recalcitrant stricture (5.5%) and gastrointestinal stromal tumor (1.4%).

Main Outcome Measures: Operative techniques, intraoperative outcomes, 90-day morbidity and mortality

Results: The MIE procedures included Ivor Lewis MIE (n=160), MIE with a cervical anastomosis, (n=49), laparoscopic hand-assisted transhiatal esophagectomy (n=6), and laparoscopic proximal gastrectomy (n=2). In the first half of our series Ivor Lewis MIE technique was used in 50% of cases, which increased to 96.5% in the latter half. There were 177 males with a mean age of 65 years. Of 193 cancer cases, 40% had neoadjuvant therapy. Conversion rate to open surgery was 1.8%. Major complications occurred in 12.4% and included leak (10.6%), respiratory failure (3.7%), pulmonary embolism (1.8%), bleeding (0.9%) and myocardial infarction (0.5%). Minor complications occurred in 20.7%, the most common being atrial fibrillation (6.5%). The 90-day mortality was 3.2%. The mean number of lymph nodes retrieved was 18. Surgical pathology included stage 0 (19.2%), stage I (18.1%), stage II (30.6%), stage III (26.9%) and stage IV (5.2%).

Conclusion: In this large series of MIE, we determined that the Ivor Lewis technique is our preferred operative approach and is associated with low mortality and low conversion rate.

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Statewide Survey of Opinions On Diagnosis and Management of Adhesive Small Bowel Obstruction

Authors: P Bilderback, R Smith, J Rose, S HeltonInstitution: Virginia Mason Medical Center, Seattle, WAPresented By: Phillip Bilderback

Importance: New evidence exists to improve the management of adhesive small bowel obstruction (aSBO).

Objective: Gather opinions of surgeons in Washington about their work-up and management of aSBO, hypothesizing there may be opportunities for improvement through education.

Design: A 19-question electronic survey administered via e-mail.

Setting: General surgeons listed on the Washington State American College of Surgeons roster.

Main Outcome Measures: Overall reported usage of water soluble contrast (WSC) and laparoscopic lysis of adhesions (LLA) and opinions regarding the evidence, contraindications, and barriers to each. Factors associated with their use were investigated.

Results: 144 out of 353 respondents completed the survey (41% response). 83% WSC to aid their decision-making; but a third of surgeons were unaware of any evidence to support its diagnostic/therapeutic use. 67% reported using LLA, but did so infrequently (20% of cases). Surgeons whose opinion favored laparoscopy were more likely to use it (50% vs. 10% of cases, p<;0.05). 86% of surgeons were unaware of any evidence demonstrating superior outcomes following LLA compared to open lysis of adhesions. 83% cited distention as a contraindication to LLA for fear of causing an enterotomy.

Conclusions and Relevance: Despite common use, many surgeons are unaware of recent evidence supporting WSC as a diagnostic and therapeutic maneuver. Many surgeons do not perform LLA for reasons that are not supported by the literature, which strongly supports the use of LLA for aSBO. A clear opportunity exists to improve patient outcomes in Washington State by educating surgeons about the merits of WSC challenge and LLA in selected patients with aSBO.

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Lymph Node Count as a Quality Measure for Gastric Cancer: Does CoC Accreditation Matter?

Authors: J Morgan, L Ji, A Cupino, G Friedman, C Dyke, M Senthil, S LumInstitution: Loma Linda University, Loma Linda, CAPresented By: Garrett Friedman

Importance: Accreditation by the American College of Surgeons Commission on Cancer (CoC) and quality measure reporting both purport to improve the quality of cancer care. In May, 2013 the CoC endorsed a new gastric cancer quality measure recommending removal of 15 or more lymph nodes (LN) for all surgically resected, non-metastatic gastric cancer cases.

Objective: To determine 1) if CoC accreditation is associated with compliance with the LN count guideline and 2) the effect of compliance on overall survival.

Design: Retrospective, population-based, cohort review.

Setting: California Cancer Registry.

Participants: Patients treated surgically for Stage I-III gastric adenocarcinoma between January 1, 2004 and December 31, 2010.

Main Outcome Measures: Compliance with removal of 15 LN and overall survival.

Results: Of 3,321 gastric cancer cases identified, 42.3% had >15 LN removed. Hospitals currently CoC-accredited treated 50.5% of cases; hospitals without prior CoC accreditation treated 30.1%. In hospitals without CoC accreditation, 34.8% of patients had >15 LN removed, compared to 44.7% with current CoC accreditation. Removal of >15 LN was associated with current CoC accreditation (vs. never accredited, OR 1.61, 95%CI 1.36-1.91). Cox regression showed that improved survival was predicted by removal of > 15 LN (HR 0.69, 95% CI 0.62-0.76), but not CoC accreditation (HR 0.98, 95% CI 0.87-1.09).

Conclusions and Relevance: While adequate LN retrieval is more likely in CoC-accredited hospitals, survival outcome is associated with LN count rather than CoC accreditation. Fewer than half of cases met the minimum LN requirement, indicating the need for process improvement for all hospitals.

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E-Poster: Session B

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Subclavian Vein Catheterization Using a Perfused Human Cadaveric Model: Application to Surgical Education

Authors: S Varga, J Smith, M Minneti, J Carey, S Zakaluzny, M Sullivan, D Demetriades, P TalvingInstitution: University of Southern California, Los Angeles, CAPresented By: Jennifer Smith

Importance: Complications following medical procedures are a significant cause of patient morbidity and mortality. Recent integration of simulators into surgical training provides a means for residents to practice procedures prior to performing them on patients.

Objective: The purpose of this paper is to present a unique training model using a perfused human cadaver for central line placement training with the ultimate goal of reducing central venous catheter mechanical complications.

Design: The applicability of the fresh tissue cadaver model for central line placement was assessed using a 10 item questionnaire with a 5-point Likert-type scale. Respondents were asked to rate their opinions as strongly agree, agree, neutral, disagree, or strongly disagree.

Setting: All participants received a didactic . This was followed by supervised practice on a commercially available simulator. The students were then relocated to the Fresh Tissue Dissection Laboratory where they practiced subclavian vein catheterization on a fresh, perfused human cadaver.

Participants: Course participants included 87 physicians from various medical specialties at different stages of training.

Main Outcome Measures: The objective of this study was to introduce perfused human cadavers as a new model to be used for teaching central venous catheter placement.

Results: Results of the survey demonstrated that 91% of the participating physicians found the perfused cadaveric model to be a true simulation of conditions that exist in live patients, and 98% reported that the use of this model promoted acquisition of technical skills.

Conclusion: The integration of central line placement training on perfused cadavers into residency and fellowship training provides an unparalleled realistic simulation to participants. Further study is needed to assess whether realistic simulation translates into objective endpoints such as decreased mechanical complications.

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A Retrospective Review of Plastic Surgery Consultations to Evaluate the Effect of Web-Based Education on Patient Satisfaction and Consultation Time

Authors: D Boudreault, C Li, M WongInstitution: University of California Davis, Sacramento, CAPresented By: David Boudreault

Hypothesis: Patients expect a healthcare system that is efficient and provides the highest quality of care. Through an independent survey published by Grote in The McKinsey Quarterly 2007, patients report the quality of education they received regarding their procedure or treatment was the most influential factor in their decision of which hospital or physician they ultimately chose. The implications of an ‘excellent’ versus a ‘very good’ rating had significant affects on this choice. After reviewing 176,000 surveys, Physician Research Consultants noted a significant decrease in patients’ willingness to recommend services to family/friends from those rating their experience as ‘excellent’ vs. ‘very good’ (86% vs. 23%). Many healthcare systems have targeted improved patient education through various educational tools to help improve satisfaction. We hypothesize web-based education prior to consultation will increase patient satisfaction with their consultation and decrease consultation time.

Design: Retrospective chart review

Patients: 767 new plastic surgery patient consultations at a University-based practice (5/2012-8/2013).

Intervention: EmmiEngageTM, a web-based education module, was issued to patients prior to consultation. Patient satisfaction was rated using a 5-point Likert scale (1=excellent, 5=poor). Consult times were obtained from the electronic medical record. Both were assessed in viewers and non-viewers.

Results: Viewers were more satisfied with their experience compared to non-viewers (satisfaction scores, mean±SD: 1.13±0.44 vs. 1.36±0.74; p=0.02) and more likely to rate their experience as excellent (92% vs. 75%; p=0.02). Viewers trended towards longer visits compared to non-viewers (mean±SD: 54±26 vs. 50±35 minutes; p=0.10).

Conclusion: Viewing EmmiEngageTM significantly improved plastic surgery patients’ satisfaction with their consultation, but also trended towards longer consultation times. Our surgeons report that patients who viewed EmmiEngageTM appear to have an increased understanding of their procedure and thus engage in higher-level conversations, possibly leading to longer consultation times.

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Role of Imaging in Diagnosis of Hidden Hernias

Authors: J Miller, M Michael, R Saouaf, S TowfighInstitution: Cedars Sinai Medical Center, Los Angeles, CAPresented By: Joseph Miller

Importance: The term ‘hidden hernia’ refers to a hernia with no mass, bulge, or defect on exam. Patients can present with pain and undergo many tests, yet a diagnosis of hernia may be missed.

Objective: To examine the effectiveness of imaging--ultrasound (US), computerized tomography (CT), and magnetic resonance imaging (MRI)-- in the diagnosis of hidden inguinal hernias.

Design: Retrospective review of patients with hernias, 2008-2013.

Setting: Specialty referral practice.

Participants: Forty-one patients met the following inclusion criteria: a) symptoms suggestive of inguinal hernia, b) no palpable hernia on exam, c) at least one form of imaging preoperatively, and d) an operation for i nguinal hernia.

Main Outcome Measures: Sensitivity, specificity, and predictive values of imaging modalities (US, CT, MRI) of the groin and pelvis for detection of hidden inguinal hernias.

Results: Inguinal hernia was confirmed at time of surgery for 30 of 41 patients. The number, sensitivity, specificity, negative predictive value and positive predictive value of each imaging modality were, respectively: US (N=6, 0.5, 0.6, 0.33, 0.67), CT (N=21, 0.61, 0, 0, 0.79), MRI (N=22, 0.88, 0.17, 0.33, 0.74). Among hidden hernias not detected by CT, 83.3% were visualized by MRI.

Conclusions: Ultrasound is underutilized for diagnosis of hidden hernias and can provide fair results, but with low sensitivity. CT scan is a poor imaging study of the groin. A negative CT scan in a patient with clinical suspicion for hernia should be followed up with an MRI, which provides the most sensitive detection of a hidden hernia.

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Teaching Hospitals Eliminate Insurance-Based Disparity in the Mortality of Trauma Patient

Authors: L Godat, L Kobayashi, D Chang, B Potenza, R CoimbraInstitution: University of California, San Diego, CAPresented By: Laura Godat

Importance: Disparities in healthcare have been observed in many fields of surgery, including trauma. Gender, race, and lack of or limited insurance such as Medical have been associated with poorer outcomes in trauma patients. Awareness of these differences could help identify quality improvement targets and lead to more unbiased care.

Objective: To determine the impact of hospital type as well as the presence of a surgical residency on trauma mortality rates in relation to patient’s insurance status. Design: Analysis of a prospectively collected population database.

Setting: California Office of Statewide Health Planning and Development patient database from 1999-2010, which includes all state certified hospitals.

Participants: 1,738,504 trauma admissions of patients age 18-65, excluding deaths within the first 24 hours.

Main Outcome Measures: Mortality Results: Overall mortality was 0.66%. In non-teaching hospitals mortality was 0.8% for those with limited insurance, defined as self-pay or Medical and 0.5% for those with good insurance, defined as workman’s compensation, Medicare or private insurance. Conversely at teaching hospitals, defined as having a surgical residency program, mortality was 0.8% and 0.9% for limited and good insurance respectively. Compared to patients with good insurance those with limited insurance had higher mortality in non-teaching hospitals [odds ratio (OR) 1.49; p<;0.005]. The presence of a surgical residency program, independently and in combination with trauma center designation, was not associated with disparity in mortality (OR 1.07; p=0.57 and OR 1.06; p =0.61 respectively) (Figure 1).

Conclusions: The presence of a surgical residency program may reduce provider or systems based treatment bias based on insurance status resulting in more equitable care.

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Prospective Evaluation of Open Fractures – Impact of Time to Washout

Authors: M Srour, C Chan, B Schnuriger, D Skiada, K Inaba, O Okoye, L Lam, D DemetriadesInstitution: University of Southern California, Los Angeles, CAPresented By: Marissa Srour

Background: The standard practice of irrigation and debridement (I&D) of open fractures within 6h of injury remains controversial. This study was designed to prospectively evaluate the impact of time to initial I&D on infectious complications.

Methods: Patients admitted with open extremity fractures (06/2009-06/2011) were prospectively enrolled and followed to one-year post discharge. Demographics, mechanism of injury, time to irrigation, operative intervention and incidence of local infectious complications were documented. Patients were stratified into 4 groups based on time of I&D (<;6h, 7-12h, 13-18h, 19-24h). Univariate and multivariate analysis were used to determine the impact of time to I&D on outcomes.

Results: 315 patients were enrolled (Mean age 33.9±16.3, 79% male, 78.4% blunt trauma). The most frequently injured site was the lower extremity (70.2%), and 47.9% of all injuries were Gustilo III. There was no difference in fracture location, degree of contamination, or antibiotic use between groups. All patients underwent I&D within 24h. Overall, 14 patients (4.4%) developed early wound infections while 10 (3.2%) developed late infections (after 30 days). The infection rate was not statistically different on univariate (<;6h [4.7%], 7-12h [7.5%], 13-18h [3.1%], 19–24h [3.6%], p=0.654) or multivariate analysis (<;6h [ref] p=0.654, 7-12h AOR: 2.1[0.4,10.2], p=0.371, 13-18h AOR: 0.8[0.1,4.5], p=0.808, 19-24h AOR: 1.1[0.2,6.2], p=0.899). Time to I&D did not impact the rate of non-union, hardware failure, length of stay, or mortality.

Conclusion: In this prospective analysis, time to I&D did not impact the development of local infectious complications provided it was performed within 24 hours of arrival.

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Assessment of Pediatric Burn Management in a Tertiary Care Center in Sub-Saharan Africa

Authors: D Martins, A Karan, B Johnson, V Amado, D Kulber, A Taela, E Hartford, D DeUgarteInstitution: David Geffen School of Medicine, Los Angeles, CA Presented By: Deborah Martins

Objective: Pediatric burn injuries are one of the leading causes of childhood mortality worldwide and are most prevalent in Sub-Saharan Africa. Identifying challenges in burn management can help focus efforts to decrease the associated morbidity and mortality. Objective is to determine the operative capacity for management of pediatric burns in a referral hospital in sub-Saharan Africa.

Design: Retrospective analysis of pediatric general surgical ward admissions for burns from January to December of 2012.

Setting: Tertiary care referral and teaching hospital in a sub-Saharan African country.

Participants: Patients admitted to the pediatric general surgery ward with a burn diagnosis.

Main Outcome Measures: Rates of skin grafting for documented 3rd degree and deep 2nd degree burns.

Results: Burns were diagnosed in 275 patients and accounted for over 25% of the admissions to the pediatric general surgery ward. The median age was 2.7 years (range 0 to 14 years). The median total body surface area affected was 8% (range 1% to 30%) for those in whom it was recorded. The majority of burns were 2nd degree (76%); the remainders were 3rd degree (5%) or not-specified (19%). A total of 9 burn patients (3%) received operative management. Only 31% of those patients with documented 3rd degree burns and 7% of those with documented deep 2nd degree burns were managed operatively. The median length of stay was 4 days (range 1 to 74 days). Operative block time for general pediatric surgery was limited to 1 ½ days per week. Dermatomes and mesher plates were not available in the operating room.

Conclusions: Burns account for a large percentage of admissions to the general pediatric surgery ward in this sub-Saharan African setting. Prevention efforts may be guided by knowledge that over 50% of pediatric burns were in infants and toddlers. Surgery was infrequently performed in patients with documented

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3rd degree and deep 2nd degree burns. The limited operative block time and inadequate instrumentation may help account for the high rates of non-operative management. These data demonstrate the challenges of pediatric burn management and the need to build local capacity.

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Impact of Contemporary Military Medicine on Civilian Trauma Care

Authors: A Haider, L Powell, E Schneider, N Dhiman, J Orman, F Butler, R Gerhardt, E Haut, D Efron, J Mather, E MacKenzie, D Geyer, J DuBose, T Rasmussen, E Cornwell III, L BlackbourneInstitution: Johns Hopkins School of Medicine, Baltimore, MDPresented By: Adil Haider

Introduction and Objective: Historically improvements in trauma care have been driven by war. Our objective was to determine if advances in military medicine stemming from the post 9/11, Iraq and Afghanistan conflicts have translated to improvements in the management of civilian trauma in the US.

Methods: A database of all trauma directors (TDs) for Level 1 (L1), Level 2 (L2) and Level 3 (L3) trauma centers in the US was created. A 55 item web based, anonymous survey was sent to TDs, who were specifically asked if military data had changed practices at their center in 5 domains of trauma care.

Results: We were able to find contact information for 630 of the estimated 650 L1, L2 and L3 TDs in the US and received 245 completed surveys (108 from L1; 72 from L2; and 65 from L3). Most TD’s believed that military data regarding Damage Control Resuscitation (increased FFP:Plts:PRBC ratios) has significantly altered practice. However, Only 60% TDs felt that other interventions shown to be effective in the battlefield are equally effective in the civilian setting. TDs stated that lack of civilian research regarding tourniquets; new pre hospital interventions and topical hemostatic agents were a barrier to adopting these interventions for civilian use despite their use by the military.

Conclusion: This national survey of TDs suggests that Military data supporting DCR has altered practice. However impact on the four other domains was variable. Also, L1 centers are quicker to adopt Military practices. Interventions to further enhance Military-Civilian translation are needed.

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Age Related Mortality Following Traumatic Brain Injury In the Elderly: When is Care Futile?

Authors: G Tominaga, K Schaffer, I DandanInstitution: Scripps Memorial Hospital La Jolla, La Jolla, CAPresented By: Gail Tominaga

Objectives: To determine: 1) outcomes in elderly patients by decade to examine whether there is an age and Head-Abbreviated Injury Score (H-AIS) combination where ongoing care would be futile, and 2) any differences in mortality rate (MR) by decade of life in the elderly patient sustaining head injury.

Design: Retrospective review over 3 years (2010-2012).

Setting: One Level II Trauma Center.

Participants: All trauma patients admitted to one Level II Trauma Center were stratified by age groups: A=<49 yrs; B=50-59 yrs; C=60-69 yrs; D=70-79 yrs; E=80-89 yrs; F=90+ yrs.

Main Outcome Measures: Hospital length of stay (LOS) and in-hospital mortality were obtained from the Trauma Registry. Data were analyzed using Fishers exact test for categorical data with p<0.05 defined as statistical significance.

Results: There were 4304 trauma patients with 23.2% age 70 or greater. Numbers of deaths and MR within each age group based on H-AIS are noted in the table. For H-AIS 1-4 (mild to moderate brain injury), patients 90+ yrs of age have a low but significantly higher MR than all patients < 90 yrs of age and there is no difference in MR in patients < 49 yrs of age and 50-89 yrs of age. For H-AIS 5 (severe brain injury), patients 60 or higher have a significantly higher MR than those < 60 yrs of age and those 90+ yrs of age had a 100% MR.

Conclusions: Our data shows that those 70-89 yrs of age have similar mortality rates of those 60-69 yrs of age for all H-AIS. Mortality increases significantly in those greater than 50 yrs of age with severe brain injury (H-AIS 5) compared to those < 50 yrs of age. Those 60-89 yrs of age had no difference in mortality compared to those 50-59 yrs of age in the H-AIS 5 group. We had no 90+ yr old survivors of severe brain injury; however, definitive conclusions cannot be made due to the small numbers in this group.

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The Impact of Hydroxyethyl Starch Use in Organ Donors after Neurologic Determination of Death on the Development of Delayed Graft Function in Kidney Transplant Recipients

Authors: M Patel, C Niemann, M Sally, J de la Cruz, J Zatarain, T Ewing, M Crutchfield, K Enestvedt, D MalinoskiInstitution: Massachusetts General Hospital, Boston, MAPresented By: Madhukar Patel

Importance: The use of Hydroxyethyl starch (HES) solutions results in increased rates of acute kidney injury in critically ill patients. The impact of HES on renal function in organ donors after neurologic determination of death (DNDD) and the recipients of their organs has not been evaluated.

Objective: To determine if HES use in DNDDs prior to organ recovery is associated with higher rates of delayed graft function (DGF) in renal transplant recipients.

Design: Prospective observational study from 2011 to 2013 with collection of the data elements listed in the table. Since HES use was provider dependent, critical care variables that predicted the use of HES were identified and an associated propensity to receive HES was derived. Subsequently, a multivariable analysis was performed to identify independent predictors of DGF with a p<;0.05

Setting and Participants: All of the DNDDs managed by a single organ procurement organization.

Main Outcome Measures: Renal DGF (dialysis in the first week after transplantation)

Results: Data were complete for 989 kidneys transplanted from 529 donors. 15% came from ECDs, 41% received HES (1217 ± 528 ml), and 35% developed DGF. The mean Cr was 1.3 + 1.2 mg/dL and CIT was 15.9 + 6.8 hours. Kidneys from DNDDs who received HES had a higher crude rate of DGF (41% vs. 31%, p<;0.001). After accounting for the propensity to receive HES, independent predictors of DGF were age (OR 1.03 per year), CIT (OR 1.04 per hour), Cr (OR 1.49 per mg/dL), and HES use (OR 1.40).

Conclusions and Relevance: HES use during donor management was independently associated with a 40% increase in the risk of DGF in kidney transplant recipients.

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Identification of a High Risk Subset of Patients Undergoing Infrainguinal Bypass Surgery

Authors: T Wu, F Weaver, S KatzInstitution: University of Southern California School of Medicine, Los Angeles, CAPresented By: Tiffany Wu

Objective: To evaluate preoperative risk factors and their relationship to adverse outcomes in patients undergoing open infrainguinal revascularization. The ability to predict either a major adverse limb event (MALE) or major adverse cardiac event (MACE) may help to select patients better served by an endovascular approach.

Design: NSQIP database analysis

Setting & Patients: The National Surgical Quality Improvement Program (NSQIP) database from 2005-2011 was queried. Patients undergoing infrainguinal revascularization by open bypass were identified (n=20,505).

Main Outcome Measures: MALE was defined as deep incisional surgical site infection, graft failure, or return to OR within 30 days. MACE was defined as stroke, MI, cardiac arrest, or death within 30 days. Preoperative risk factors and patient demographics were compared. Those factors found to be significant were placed in a step-wise multivariate Cox proportional hazards regression model to determine their individual significance.

Results: In multivariate analysis, the use of vein as the bypass conduit, diabetes, and OR time >4hrs were significant predictors of MALE (p < 0.05). History of angina, previous cardiac surgery, and transfusion of 4 or more units of pRBCs were significant predictors of MACE (p < 0.05). Dialysis dependence, steroid dependence, emergency operation, and ASA >3 were significant predictors of both MACE and MALE.

Conclusions: Pre-operative risk factors can be used to predict MALE and MACE in patients requiring infrainguinal arterial revascularization. In subgroups of patients at highest risk for either MACE or MALE, endovascular revascularization may be more appropriate as a first line intervention.

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The Role of Preoperative Duplex Scanning in Neurogenic Thoracic Outlet Syndrome Patients Undergoing Operation

Authors: M Orlando, K Likes, S Mirza, Y Cao, A Cohen, Y Lum, J FreischlagInstitution: Johns Hopkins School of Medicine, Baltimore, MDPresented By: Megan Orlando

Objective: To evaluate the role of venous and arterial duplex scanning in neurogenic thoracic outlet syndrome (NTOS) patients who underwent first rib resection and scalenectomy (FRRS).

Design: A retrospective review.

Setting: An academic tertiary care hospital.

Patients: NTOS patients treated with FRRS from 2005 to 2013.

Main Outcome Measures: Abnormal scans were classified as venous compression (VC, >50% decrease in flow in the symptomatic subclavian vein from adduction to abduction), venous ablation (VA, zero flow velocity on abduction), arterial compression (AC, >50% increase or decrease in subclavian artery flow on abduction), or a combination of compression types (VCAC or VAAC).

Results: Of 316 patients treated for NTOS between 2005 and 2013, 166 (78% female, average age 34, range 13-66) underwent complete preoperative duplex scanning. Abnormal scans were seen in 41% of Patients: 18 (11%) had VC, 14 (8.4%) VA, 22 (13%) AC, 9 (5.4%) VC and AC, and 5 (3.0%) VA and AC. 4 patients demonstrated unsuspected chronic venous thrombus. VC patients were more likely to have a preceding trauma (P < .03) and more often experienced a pneumothorax during FRRS (50% vs. 26%, P < .02). AC and VAAC patients were younger (29 and 23, P < .05). On physical exam, a positive Adson’s test frequently predicted compression (76%, N=34). 97% of NTOS patients with venous and/or arterial compression had a successful outcome as compared to 95% of patients scanned without compression.

Conclusions: Duplex scanning has a preoperative role in patients with NTOS as scanning identified venous and/or arterial compression in over 40% of patients, and 4 patients had an unsuspected venous thrombus. The Adson’s test often predicts compression when performed. FRRS is even more successful in patients with preoperative compression as seen by duplex scanning.

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E-Poster: Session C

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Non-Robotic Endoscopic Transaxillary Thyroidectomy: Early Experience and Outcomes in the United States

Authors: M Said, R Owen, B Palmer, K Nam, R Schrier, P Aron, W InabnetInstitution: Kaiser Permanente Medical Center, Los Angeles, CAPresented By: Meena Said

Objective: Evaluate safety of Endoscopic transaxillary thyroidectomy (ETT) in US

Design: Prospective cohort study (pilot study); December 2010-January 2013

Setting: Academic medical center

Patients: Thyroid disease patients undergoing ETT

Intervention: ETT

Main Outcome Measures: Postoperative complications and functional health. Surveys performed at preoperative visit (V1),first postoperative (V2) and second postoperative (V3) visits evaluating voice,shoulder function, pain, physical functioning, role limitations, and energy/fatigue.

Results: 35 patients underwent 38 ETT: 20 lobectomies, 15 total thyroidectomies, 3 completion thyroidectomies performed. 27 patients had thyroid nodules, 4 had Graves’ Disease, and 7 multinodular goiters. 12 lesions were malignant, 26 were benign. Mean age and BMI were 43 years and 23.3 respectively. Mean hospital stay was 9.6 hours. 10 (26% ) parathyroid autotransplantations performed. Mean procedure time was 159 minutes. 2 patients had vocal cord palsies, 1 had transient hypoparathyroidism, 1 had pneumonia. Surveys from 16 patients showed when compared with pre-operative visit, voice worsened at V2 (p=0.004). After 3 months voice improved and no difference between V1 and V3 (p=0.144). The same was observed with shoulder function (p values 0.003 and 0.06). No difference in pain between V1 and V3 (p=0.359). No differences in physical functioning between any visits (p=.083, p=0.398). No difference between the V1 and V3 role limitations or energy/fatigue scores.

Conclusions: Endoscopic transaxillary thyroidectomy is a safe procedure with a low overall complication rates. High recurrent laryngeal nerve injury rate may be related to learning curve. Functional outcomes are favorable.

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The NIH Consensus Recommendations in the Management of Primary Hyperparathyroidism Are Not Being Followed: Why Not?

Authors: A Sharata, T Kelly, Y Rozenfeld, C Hammill, E Schuman, J Carlisle, S Aliabadi-WahleInstitution: The Oregon Clinic, Portland, ORPresented By: Ahmed Sharata

Importance: Poor observance of national guidelines in management of various diseases has been previously established.

Objective: To examine primary care providers’ familiarity with and adherence to National Institute of Health consensus recommendations in treatment of primary hyperparathyroidism (PHPT) as updated in 2009.

Design: A survey examining knowledge of PHPT management was distributed to clinicians of a large primary care group. The medical records of their patients with the diagnosis of PHPT between 2009 and 2011 were then retrospectively reviewed to assess treatment strategies.

Participants: One hundred and nine of 350 physicians responded to the survey. One hundred and twenty four patients with a diagnosis of active PHPT were identified, 86 of whom were observed and the remainder were managed surgically.

Results: Thirty-five percent of clinicians reported using the consensus statement and 31% were familiar with all criteria for intervention in asymptomatic patients with PHPT. Patient chart review demonstrated that 61% of patients met criteria for surgery; however, only 34% of this group had parathyroidectomy. Based on univariate analysis, lower age, higher intact parathyroid hormone level, abnormal urinary calcium excretion and endocrinologist evaluation were associated with surgical intervention.

Conclusion: This study confirms suboptimal adherence with consensus recommendations in management of primary hyperparathyroidism. Only one third of clinicians demonstrated solid familiarity with management strategies of PHPT, paralleling their treatment approach. Educational efforts may improve adherence with national recommendations.

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Characterization of Endocrine and Exocrine Function After Pancreatic Resection

Authors: I Gawlas, I Epelboym, M Winner, J Allendorf, P HaighInstitution: Kaiser Permanente Medical Center, Los Angeles, CAPresented By: Irmina Gawlas

Importance: Endocrine and exocrine insufficiency after pancreatectomy significantly affect cardiovascular health, nutrition and QOL. However, the incidence and predictors of pancreas dysfunction are not well characterized because of small study size and inconsistent definitions.

Objective: Determine the incidence and predictors of pancreas dysfunction after pancreatectomy

Design: Retrospective cohort

Setting: Large population

Participants: Patients undergoing pancreatectomy

Exposure: Pancreatectomy

Main Outcome Measures: Postoperative diabetes (Hgb A1c>6.5 or fasting glucose>125 or hypoglycemic use) and exocrine insufficiency (pancreatic enzyme use)

Results: Of 1174 patients identified, 42% had pre-existing diabetes. Of the remaining 681 patients, 277(40.7%) developed diabetes at a median 3.3 months. Independent predictors of diabetes were increasing Charlson comorbidity index (HR 1.9 for CCI 2+, p=0.003), total pancreatectomy (HR 8.3, p=0.001), and pancreatitis (HR 1.5, p=0.033); benign or malignant neoplasms were not predictors. 445/1174(37.9%) patients developed pancreatic insufficiency at a median 3.5 months. Compared to Whipple, distal pancreatectomy was associated with decreased enzyme use (HR 0.4, p<;0.001), while total pancreatectomy increased enzyme use (HR 5.1, p<;0.001). Other independent predictors were female gender (HR 1.3, p=0.002), Charlson comorbidity index (HR 1.9 for CCI 2+, p=0.005), preoperative BMI>30 (HR 0.67, p=0.046), and Asian ethnicity (HR 0.57, p=0.007).

Conclusions and Relevance: At a population level, pancreatic dysfunction after pancreatectomy is more common than previously reported, and therefore its risk should be given greater relevance in the decision-making for pancreatectomy.

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The Drowning Whipple: Perioperative Fluid Balance and Outcomes Following Pancreaticoduodenectomy

Authors: G Wright, A Davis, T Koehler, M ChungInstitution: Michigan State University School of Medicine, Grand Rapids, MIPresented By: G. Paul Wright

Objective: Pancreaticoduodenectomy (PD) is among the most high-risk surgeries. We sought to assess the impact of perioperative fluid balance on outcomes following PD to identify targets for reducing morbidity.

Design: A retrospective review of PDs performed from 2008-2012 was completed. Cumulative fluid balances were recorded immediately, 24, 48, and 72 hours postoperatively and patients were divided into quartiles. Multivariate analyses were performed accounting for age, gender, diagnosis, ASA class, estimated blood loss, colloid and blood product use, and hemoglobin nadir. Significance was assessed for p<0.05.

Setting: University-affiliated teaching hospital.

Participants: Consecutive PDs.

Main Outcome Measures: The predefined primary outcome measures were morbidity (Clavien grade > III), mortality, and readmission. Secondary outcome measures included hospital and ICU length of stay, delayed gastric emptying, pancreatic fistula, and cardiopulmonary complications amongst others. A priori we hypothesized higher postoperative fluid balance would be associated with unfavorable outcomes.

Results: One hundred sixty-nine PDs were performed during the study period. The 90-day morbidity and mortality rates for the cohort were 40.2% and 3.0%, respectively, while hospital length of stay was 13.6±6.7 days (mean±SD). Greater fluid balance at 48 and 72 hours postoperatively was an independent predictor of morbidity (Table I) and length of stay (48hr: p=0.04, 72hr: p=0.03) on multivariate analysis.

Conclusion: Increasing postoperative fluid balance is associated with higher postoperative morbidity and longer hospital stay following PD. Efforts at maintaining a fluid-restrictive strategy should be emphasized in this population.

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Operative Time as a Measure of Quality in Pancreaticoduodenectomy: Is Faster Better?

Authors: G Garnett, W Limm, L WongInstitution: University of Hawaii, Honolulu, HIPresented By: Gwendolyn Garnett

Background: Case volume has been the metric for determining quality in complex pancreatic surgery, with studies showing better outcomes in surgeons/hospitals with high volumes. However, some surgeons perform fewer cases with good quality.

Objective: To determine whether operative time can provide insight into a surgeon’s ability to perform pancreaticoduodenectomy safely and effectively.

Design/Setting/Patients: The American College of Surgeons NSQIP database was used (2007-2011) to identify 4805 pancreaticoduodenectomy patients. Cases were divided into those with operative time (ORtime) <300 min (n=1459, 30.4%) vs >300 min and ORtime <360 min (n=2431, 50.6%) vs >360 min. Complications and outcome measures were compared between groups and predictors of 30-day mortality were assessed.

Results: Age >65 years, male sex, prior chemotherapy, prior radiation and higher ALT were associated with ORtime >300 min. These factors, diabetes and higher bilirubin were associated with ORtime >360 minutes. Patients with ORtime >300 minutes were more likely to have intra-abdominal infections and bleeding requiring transfusion. Patients with ORtime >360 minutes also demonstrated more intra-abdominal and superficial infections, bleeding requiring transfusion, wound dehiscence, and reintubation. ORtime >300 and 360 min was associated with longer hospital stays and higher 30-day mortality. Predictors of 30-day mortality include ORtime >300 minutes, age > 65, COPD, albumin < 3, hypertension, and protime > 14 seconds.

Conclusions: Shorter operative time for pancreaticoduodenectomy is associated with fewer complications, shorter hospital stay and lower 30-day mortality. Few patient factors correlate with longer operative times, leaving surgical competence and skill as a major contributor to operating time. Operative time may provide insight into surgeon performance.

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Pancreatic Enucleation for Side-Branch Intraductal Papillary Mucinous Neoplasms

Authors: E Thomas, L Matsuoka, S Alexopoulos, F Weaver, MD, R Selby, D ParekhInstitution: University of Southern California, Los Angeles, CAPresented By: Elizabeth Thomas

Objective: The diagnosis of side-branch intraductal papillary mucinous neoplasms (IMPN) is increasingly more common, but their appropriate management is still evolving. We recently began performing laparoscopic enucleation or pancreatic head resection for these lesions with vigilant post-operative imaging.

Design: A retrospective review.

Setting: Tertiary care hospital.

Participants: Twelve patients underwent laparoscopic enucleation and 5 underwent laparoscopic pancreatic head resection for side-branch IPMN from January 1, 2008 to March 30, 2013.

Main Outcome Measures: Patient survival, follow-up and postoperative complications.

Results: The mean age of patients was 64 years old. The most common presenting symptom was abdominal pain. The indication for surgical intervention was growth in the cyst or symptoms in the majority of patients. Fourteen lesions were in the head/uncinate, 2 were in the pancreatic body and 1 was in the tail. Final pathology was consistent with side-branch IPMN in 13 patients (1 with focal adenocarcinoma). Three patients had serous cysts and 1 had a mucinous cyst. Three patients developed pancreatic leaks which were controlled with intraoperative placed drains, while one required additional drain placement. Median time from surgery to latest follow-up imaging is over 2 years. No patients have developed recurrent cysts or adenocarcinoma.

Conclusions: To our knowledge this is the largest reported series of laparoscopic enucleation for side-branch IPMN. Laparoscopic enucleation or pancreatic head resection with close follow-up is a reasonable treatment option for side-branch IPMN lesions, as the risk of malignancy is low and pancreatic function is preserved.

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Current Indications for Surgery of IPMN’s May Overlook Some Patients With Cancer: Recommendations for Change

Authors: A Nguyen, P Toste, B Clerkin, V Muthusamy, R Watson, J Tomlinson, J Hines, H Reber, T DonahueInstitution: David Geffen School of Medicine, Los Angeles, CA Presented By: Andrew Nguyen

Importance: The 2012 Sendai Criteria suggest that patients with 3 cm branch duct intraductal papillary mucinous neoplasms (BD-IPMN) without ‘worrisome features’ may undergo close observation.

Objective: To determine an optimal cyst size cutoff to identify patients who would benefit from resection. Design Retrospective review. Setting University medical center.

Participants: 150 patients with IPMN underwent resection between July 1996 and June 2012. 66 had BD-IPMN.

Main Outcomes and Measures: Pathologic grade was dichotomized into low (low or intermediate grade lesions) or high (high grade, carcinoma in situ or invasive cancers). Fisher’s exact test, t-test, linear regression and receiver operating characteristic (ROC) analyses were performed.

Results: The median cyst size on imaging (IM) was 2.7 cm (range: 0.6-9.6 cm), which correlated with final pathologic size (R²=0.819, p<;0.001). Fifty-one (77%) low grade and 15 (23%) high grade lesions were identified. ROC analysis demonstrated that lesion size (on IM) is a reasonable predictor of grade with an area under the curve of 0.691. Compared with a cutoff of 3 cm, an IM size cutoff of 2.5 cm: (i) correlated better with pathologic grade (p=0.141 vs. p=0.019) and (ii) was associated with higher sensitivity (45.5% vs. 72.7%) for high grade lesions. The negative predictive value of tumor size <2.5 cm was 90.3% vs. 84.2% for cysts <3.0 cm. Three of the 6 high grade cysts <3 cm had neither mural nodules nor atypical cells on cytology. These patients would not have had a resection using currently recommended criteria.

Conclusions: Our data support an optimal size cutoff of 2.5 cm for resection even without the presence of worrisome features.

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– 85 –

Autologous Islet Transplantation with Remote Isolation after Pancreas Resection for Chronic Pancreatitis

Authors: D Tai, N Shen, A Posselt, G Szot, N Feduska, B Clerkin, E Core, R Busuttil, O Hines, H Reber, G LipshutzInstitution: David Geffen School of Medicine, Los Angeles, CA Presented By: Denise Tai

Importance: Autologous islet transplantation (AIT) is an elegant and effective method for preserving euglycemia in patients undergoing total pancreatectomy (TP) for severe chronic pancreatitis (CP). However, few centers worldwide perform this complex procedure, which requires interdisciplinary coordination and access to an islet cell isolating facility.

Objective: To investigate outcomes from a single institutional case series of near-total or TP/AIT using remote islet isolation

Design: Retrospective cohort study from March 2007 to August 2013

Setting: Tertiary academic referral centers

Participants: Eight patients (13-47 years) with CP and reduced quality of life after failed medical management

Intervention: Pancreas resection followed by transport to a remote facility for islet isolation using a modified Ricordi technique; transplantation via portal vein infusion

Outcome Measures: Islet yield; pain assessment; insulin requirement; financial costs; transport time

Results: 7 of 8 patients had successful islet isolation after near-total or TP. 3 of 5 TP patients had islet yields of >5000 IE/kg. 6 patients at 2 months post- op had significantly reduced pain or were pain free; 2 did not require insulin and 2 required low doses. Average transport cost and time were $16,451.32 and 3.5 hours.

Conclusion: Pancreatic resection with AIT for severe CP is a safe and effective final alternative to ameliorate debilitating pain and to help prevent the development of surgical diabetes. Because many centers lack access to islet isolating facilities, we describe our experience using a regional multicenter collaboration as a successful model to remotely isolate cells, with outcomes similar to larger case series.

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– 86 –

Bile Duct Injuries: A Simple Classification Based on Anatomy and Outcome

Authors: M Stapfer, S Alexopolous, A Bui, D Kiran, S Kulkarni, H Ramos, Y Genyk, L Sher, D Parekh, L Matsuoka, R SelbyInstitution: University of Southern California, Los Angeles, CAPresented By: Maria Stapfer

Objective: To offer a simplified classification system of Bile Duct Injuries (BDI) that incorporates arterial injury and correlates with outcome as measured by anastomotic failure, major complications, or eventual need for hepatectomy.

Design: A retrospective study of 183 BDI sustained over a 22 year period was conducted at a major hepatobiliary/liver transplant center from 1990 until 2012. BDI were stratified according to a simplified classification scheme which incorporates combined biliary and arterial injuries.

Setting: Current classification systems are comprehensive but impractical in their complexity. Most systems do not incorporate combined bilio-vascular injuries and none is universally accepted.

Main Outcome Measures: After stratifying BDI into a new anatomic based classification system main outcome measures that were analyzed included anastomotic failure, major complications, and eventual need for hepatectomy.

Results: BDI were stratified into Peripheral (n=44), Low (n=56), High (n=49), and High Combined (n=34)(Figure 1). Vascular injury was unusual in the Peripheral and Low BDI while 41% of High BDI had associated arterial injuries. Anastomotic Failure (p<.02), major complications (p<0.001), and eventual need for hepatectmy (p<0.0001) were significantly higher in patients with High Combined BDI. The ultimate success rate of repair was 97%; Death 3%. Transplanted 2%. Hepatectomy 10%.

Conclusion: A practical BDI classification system is proposed which reflects severity and predicts outcome. High Combined BDI increase major complications, lead to anastomotic failure, and result in the need for hepatectomy in a significant proportion of patients.

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Stapfer Bilio-Vascular Injury Classification Scheme

N Art Inj Anast failure

Major Comp

Liver Rx

P val

Peripheral 44 2% 5% 14% 0% .1

Low 56 4% 2% 11% 0% .1

High 49/81 0% 14% 18% 6% .06

High-Combined Arterial

34/81 100% 38% 53% 47% <.0001

– 88 –

Management of Polycystic Liver Disease with Hepatic Resection

Authors: J Tseng, S OrloffInstitution: Oregon Health and Science University, Portland, ORPresented By: Jennifer Tseng

Objective: Polycystic liver disease (PLD) can cause devastating symptoms due to hepatomegaly. Hepatic resection in lieu of liver transplantation has been recently proposed as a viable treatment option. This case series outlines successful experience with this operative strategy.

Design: A retrospective single-center chart review was performed of PLD patients with normal liver and kidney function who underwent formal liver resection (2 to 4 segments) with or without partial resection, drainage, sclerosis with 70% alcohol, and marsupialization of remaining cysts by one surgeon from June 2001 to June 2013.

Results: Eleven patients were treated with a median duration of follow-up of 32 months (range: 6 to 146 months). All patients described significant improvement in their symptoms and quality of life. No patients required reoperation for symptoms. Complications included incisional hernias, post-operative ascites that resolved with medical therapy, secondary bacterial peritonitis from infected ascites and bile leakage. A subset of patients was maintained on long-acting octreotide post-operatively for large cystic disease burden in the remaining liver.

Conclusions: For PLD patients with preserved liver and renal function, hepatic resection with drainage, partial liver resection, sclerosis, and marsupialization of remaining cysts should be considered a feasible and safe therapy. Post-operative long-acting octreotide has the potential to reduce the growth of remaining cysts and prevents new cysts from developing. Patients managed in this fashion are able to avoid liver transplantation and have improved symptoms and quality of life.

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– 89 –

Prehepatectomy Novel Assessment Tool to Predict Remnant Liver Function: Correlation Between Expression of Organic Anion Transporting Polypeptides 1/ Multidrug Resistance Protein 2 And Gadoxetic Acid-Enhanced MRI Signal in Cirrhotic Rat Liver

Authors: J Kim, T Kim, K Hong, H Moon, I Oh, S Lee, W Foley, D Cronin, J HongInstitution: Medical College of Wisconsin, Milwaukee, WIPresented By: Joohyun Kim

Hypothesis: Prehepatectomy prediction of remnant liver function (RLF) is critical in hepatic surgery. Gadoxetic acid-enhanced magnetic resosnance imaging (GAE-MRI) has been used to predict RLF. However, its clinical utility in cirrhotic liver is unknown. We hypothesize that dynamic signal retention (DSR) ratio, correlates with expression of organic anion transporting polypeptides 1 (OATP1, the importer) and multidrug resistance protein 2 (MRP2, the exporter), and can be used to predict RLF.

Methods: 18 Sprague-Dawley rats were assigned into control (n=6) and liver cirrhosis group (LCG, n=12). Liver cirrhosis was induced by repeated intraperitoneal administration of N-nitrosodimethylamine over a 4 week period. All animals underwent pre-op GAE-MRI for 30 minutes followed by 70% hepatectomy. We analyzed DSR and hepatic tissue mRNA levels for OATP1 and MRP2. The follow up period was 2 weeks. This study was approved by the Institutional Animal Care and Use Committee.

Results: Survival rate was 100% in control versus 0% in LCG (p=0.001). DSR ratio was significantly higher in the LCG (P=0.033). Compared to control group, LCG demonstrated a significantly lower mRNA OATP1 (p=0.004) and MRP2 (0.002), and OATP1/MRP2 mRNA ratio (p=0.032). There was a negative correlation between the DSR and OATP1/MRP2 mRNA ratio for LCG (R=-0.709, P=0.01).

Conclusions: In cirrhotic rat livers, GAE-MRI correlates with the mRNA expressions of OATP1 and MRP2, and hepatic reserve function. GAE-MRI signal analysis has potential clinical applicability in predicting RLF and facilitating patient selection to avoid post-hepatectomy liver failure in cirrhotic patients.

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– 91 –

PCSA FOUNDERS

Harold Brunn Frank Hinman Emmet Rixford

Thomas O Burger W. D. Kirkpatrick Samuel Robinson

Samuel H. Buteau Otis F. Lamson Paul Rockey

S. L. Caldbick A. Stewart Lobinger Hnery Sherk

Robert C. Coffey Charles D. Lockwood Ernst A. Sommer

Walter B. Coffey A.O. Lee Stanley Stillman

John F. Cowan J. Tate Mason Charles T. Sturgeon

Richard B. Dillehunt A. Aldridge Matthews George W. Swift

Sumner Everingham J. B. McNerthney Wallace G. Toland

Charles Fox Wayland A. Morrison Alanson Weeks

Edgar L. Gilcrest Howard C. Naffziger Horace G. Wethrill

Philip K. Gilman Charles E. Phillips

– 92 –

PCSA PAST PRESIDENTS

President Elected Year

Location Meeting Year

Caucus

Fred Weaver 2013 Dana Point, CA 2014 SC

Mika Sinanan 2012 Kauai, HI 2013 WA/BC/AK

James Holcroft 2011 Napa Valley, CA 2012 NC

James Atkinson 2010 Scottsdale, AZ 2011 SC

James J. Peck 2009 Maui, HI 2010 HA/OR

Orlo Clark 2008 San Francisco, CA 2009 NC

Bruce Stabile 2007 San Diego, CA 2008 SC

Michael J. Hart 2006 Kohala Coast, HI 2007 AK/BC/WA

Cornelius Olcott IV 2005 San Francisco, CA 2006 NC

Samuel Eric Wilson 2004 Laguna Nigel/Dana Point, CA

2005 SC

Livingston Wong 2003 Wailea, HI 2004 HA/OR

Thomas R. Russell 2002 Monterey, CA 2003 NC

Theodore X. O'Connell

2001 Las Vegas, NV 2002 SC

John K. MacFarlane 2000 Banff, AB 2001 AK/BC/WA

Robert C. Lim, Jr. 1999 San Francisco, CA 2000 NC

Thomas V. Berne 1998 San Jose del Cabo, Baja

1999 SC

– 93 –

PCSA PAST PRESIDENTS

R. Mark Vetto 1997 Kaanapali Beach, HI 1998 HA/OR

F. William Heer 1996 Napa Valley, CA 1997 NC

Ronald K. Tompkins 1995 San Diego, CA 1996 SC

Meredith P. Smith 1994 Seattle, WA 1995 AK/BC/WA

Norman M. Christensen

1993 Sacramento, CA 1994 NC

Louis L. Smith 1992 Scottsdale, AZ 1993 SC

Clare G. Peterson 1991 Keoneloa Bay at Poipu, Kauai, HI

1992 HA/OR

Allen H. Johnson 1990 Pebble Beach 1991 NC

Eric W. Fonkalsrud 1989 Laguna Nigel, CA 1990 SC

George I. Thomas 1988 Vancouver, BC 1989 AK/BC/WA

John K. Stevenson 1988 Vancouver, BC 1989 AK/BC/WA

F. William Blaisdell 1987 San Francisco, CA 1988 NC

John E. Connolly 1986 Rancho Mirage, CA 1987 SC

Thomas J. Whelan, Jr. 1985 Maui, HI 1986 HA/OR

Roy Cohn 1984 Monterey, CA 1985 NC

Wiley F. Baker 1983 Newport Beach, CA 1984 SC

Hilding H. Olson 1982 Seattle, WA 1983 AK/BC/WA

– 94 –

PCSA PAST PRESIDENTS

David J. Dugan 1981 Napa Valley, CA 1982 NC

William R. Mikkelsen 1980 Coronado, CA 1981 SC

Thomas R. Montgomery

1979 Hawaii 1980 HA/OR

Philip R. Westdahl 1978 Yosemite, CA 1979 NC

William F. Pollock 1977 Newport Beach, CA 1978 SC

Carl R. Schlicke 1976 Palm Springs, CA 1977 AK/BC/WA

Ralph D. Cressman 1975 Monterey, CA 1976 NC

Max R. Gaspar 1974 Scottsdale, AZ 1975 SC

Allen M. Boyden 1973 Kaanapali Beach, HI 1974 HA/OR

Paul C. Samson 1972 Yosemite, CA 1973 NC

Gordon K. Smith 1971 San Diego, CA 1972 SC

Joel W. Baker 1970 Mexico City, Mexico 1971 AK/BC/WA

H. Brodie Stephens 1969 San Francisco, CA 1970 NC

Lyman A. Brewer III 1968 Palm Springs, CA 1969 SC

Matthew McKirdie 1967 Honolulu, HI 1968 HA/OR

Leon Goldman 1966 Monterey, CA 1967 NC

Arthur Pattison 1965 Palm Springs, CA 1966 SC

– 95 –

PCSA PAST PRESIDENTS

Ralph H. Loe 1964 Vancouver, BC 1965 AK/BC/WA

Carleton Mathewson, Jr.

1963 San Francisco, CA 1964 NC

John C. Jones 1962 Palm Springs, CA 1963 SC

John E. Raaf 1961 Portland, OR 1962 HA/OR

Robert A. Scarborough

1960 San Francisco, CA 1961 NC

Clarence J. Berne 1959 Palm Springs, CA 1960 SC

Caleb S. Stone, Jr. 1958 Victoria, BC 1959 AK/BC/WA

H. Glenn Bell 1957 Santa Barbara, CA 1958 NC

William J. Norris 1956 Palm Springs, CA 1957 SC

Louis R. Gambee 1955 Palm Springs, CA 1956 HA/OR

Loren R. Chandler 1954 Yosemite, CA 1955 NC

E. Eric Larson 1953 Santa Barbara, CA 1954 SC

Alexander B. Hepler 1952 Harrison Hot Springs, BC

1953 AK/BC/WA

Alson R. Kilgore 1951 Del Monte, CA 1952 NC

William K. Kroger 1950 Coronado, CA 1951 SC

Eugene W. Rockey 1949 Gearhart, OR 1950 HA/OR

Howard C. Naffziger 1948 San Francisco, CA 1949 NC

– 96 –

PCSA PAST PRESIDENTS

Leroy B. Sherry 1947 Los Angeles, CA 1948 SC

Homer D. Dudley 1946 Victoria, BC 1947 AK/BC/WA

Philip K. Gilman 1945 San Francisco, CA 1946 NC

Philip K. Gilman 1944 No meeting due to WWII

1945 NC

Philip K. Gilman 1943 No meeting due to WWII

1944 NC

Philip K. Gilman 1942 No meeting due to WWII

1943 NC

Philip K. Gilman 1941 No meeting due to WWII

1942 NC

Charles T. Sturgeon 1940 Los Angeles, CA 1941 SC

Richard B. Dillehunt 1939 Pointland, OR 1940 HA/OR

Sumner Everginham 1938 Del Monte, CA 1939 NC

Wayland A. Morrison 1937 Los Angeles, CA 1938 SC

Otis F. Lamson 1936 Vancouver, BC 1937 AK/BC/WA

Harold Brunn 1935 Del Monte, CA 1936 NC

E. C. Moore 1934 Santa Barbara, CA 1935 SC

Ernst A. Sommer 1933 Gearhart, OR 1934 HA/OR

Emmet Rixford 1932 Del Monte, CA 1933 NC

Rea Smith 1931 Santa Barbara, CA 1932 SC

– 97 –

PCSA PAST PRESIDENTS

J. Tate Mason 1930 Victoria, BC 1931

Wallace I. Terry 1929 Del Monte, CA 1930 NC

A. Stewart Lobinger 1928 No info available 1929 No info available

Robert C. Coffey 1927 No info available 1928 No info available

Stanley Stillman 1926 No info available 1927 No info available

Charles D. Lockwood 1925 Del Monte, CA 1926 NC

Founder's Meeting San Francisco, CA 1925

– 98 –

JEFF AVANSINO Caucus: Washington/British Columbia/Alaska

Speciality: Pediatric Surgery

Position/Location: Assistant Professor Pediatric Surgery, Seattle Children’s Hospital, Seattle, Washington

Sponsors: Robert Sawin, John HT Waldhausen, Mika Sinanan

STEVEN CHENSpouse: Sara

Children: Amanda, Jeremy

Caucus: Northern California

Speciality: Surgical Oncology

Position/Location: Associate Professor, General and Oncologic Surgery City of Hope National Medical Center, Duarte,CA

Interests: Eating Out, Tennis, Public Policy Work

Sponsors: Richard J. Bold, Joseph Kim, Brian Smith

JEFF GAUVIN Partner: Dr. Mary Ciotti

Caucus: Southern California

Speciality: General Surgery, Surgical Education

Position/Location: General Surgery and Surgical Education/Cottage Hospital, Santa Barbara, CA

Interests: Sailing, Travel

Sponsors: Ronald Latimer James Holcroft Kathrin Mayer - Troppman

PCSA NEW MEMBERS CLASS OF 2014

– 99 –

KENNETH GOW Spouse: Patricia

Children: Ryan, Amanda

Caucus: Washington/British Columbia/Alaska

Speciality: Pediatric Surgery

Position/Location: Seattle Children’s Hospital, Seattle, WA

Interests: Academic – Pediatric Surgical Oncology, Surgical Education; Personal – Graphic Arts

Sponsors: Robert Sawin, Adam Golden, John Waldhausen

WILLIAM HELTON Spouse: Andrea

Children: Anna Karina

Caucus: Washington/British Columbia/Alaska

Speciality: General Surgery

Position/Location: Virginia Mason Medical Center, Seattle, WA

Interests: International travel, playing with Anna, Golf, Skiing, Surfing

Sponsors: Thomas Biehl, Ravi Modnka, John A. Ryan, Jr.

SARAH JAVID Spouse: Patrick

Children: Iris, Lydia

Caucus: Washington/British Columbia/Alaska

Speciality: General Surgery

Position/Location: University of Washington Medical Center, Seattle, WA

Interests: Family Time, Activities with the kids (nature walks, playground time), Skiing, Ballet, Running

Sponsors: Kristine Calhoun, Carlos Pellegrini, Mika Sinanan

– 100 –

STEPHEN KAMINSKI Caucus: Southern California

Speciality: Trauma/Critical Care

Position/Location: Santa Barbara Cottage Hospital, Santa Barbara, CA

Sponsors: Ronald Latimer, Michael Sige, David Spain

SAURABH KHANDELWAL Spouse: Veena Shankaran MD

Children: Naveen

Caucus: Washington/British Columbia/Alaska

Speciality: Bariatric/Laparoscopy/MIS

Position/Location: University of Washington, Seattle, WA

Sponsors: Karen Horvarth, Mika Sinanan, Brant Oelschlager

JOHN LIPHAM Spouse: Shannon

Caucus: Southern California

Speciality: General Surgery

Position/Location: Keck Medical Center, Los Angeles, CA

Interests: Developing Minimally Invasive Methods of Diagnosing and Treating Gastroesophageal Reflux Disease, Barrett’s, Esophageal Cancer and Gastric Cancer

Sponsors: Tom Berne, Tom DeMeester, Fred Weaver

– 101 –

OTWAY LOUIE Spouse: Waid

Children: Leyton

Caucus: Washington/British Columbia/Alaska

Speciality: Plastic Surgery

Position/Location: University of Washington Medical Center, Seattle, WA

Interests: Spending time with family and most anything outdoors

Sponsors: Kris Calhoun, Brant Oelschlager, Mika Sinanan

DARREN MALINOSKI Spouse: Sehra Sampson

Children: Sophia, Noah

Caucus: Oregon/Hawaii

Speciality: Trauma/Critical Care/Acute Care Surgery

Position/Location: Portland VA Medical Center, Portland, OR

Interests: Tennis, Poker, Skiing, and taking my kids swimming

Sponsors: Cliff Deveney, Karen Deveney, Martin Schreiber

TOSHIO NAGAMOTO Spouse: Beverly

Children: Erika

Caucus: Oregon/Hawaii

Speciality: General Surgery

Position/Location: Good Samaritan Regional Medical Center/Portland

Interests: Vascular disease, Listening to music, Skiing, and Eating

Sponsors: Karen Deveney

– 102 –

MAKOTO OGIHARA Spouse: Megumi

Children: Jo, Hana, Ken

Caucus: Oregon/Hawaii

Speciality: General Surgery

Position/Location: Surgical Associates, Inc., Honolulu, HI

Interests: Healthy Diet, Medical Education, Guitarist and Interpreter at Church

Sponsors: Whitney Limm, Linda Wong, Livingston Wong

KAUSHAL (KEVIN) PATEL Spouse: Elaine

Children: Kamran, Kiran, Kayann

Caucus: Southern California

Speciality: Vascular Surgery

Position/Location: Kaiser Permanente, Los Angeles, CA

Interests: Vascular Disease; Playing basketball and THE LAKERS!

Sponsors: Clarence Cole, L. Andrew DiFronzo, Fred Weaver

KEVIN REAVIS Spouse: Kelly

Children: Nathan

Caucus: Oregon/Hawaii

Speciality: Esophageal and Bariatric Surgery

Position/Location: The Oregon Clinic Division of Gastrointestinal and Minimally Invasive Surgery, Portland, OR

Interests: Soccer, Surfing, Skiing, Hiking, Photography, Travel

Sponsors: Karen Deveney, Brian Smith, Lee Swanstrom

– 103 –

JORGE REYES Caucus: Washington/British Columbia/Alaska

Speciality: Liver Transplantation

Position/Location: University of Washington, Seattle, WA

Interests: Advocacy for children nationally and internationally, developing strategies of care and for organ availability which are the standard today.

Sponsors: Carlos Pelligrini, Mika Sinanan, Robert Sawin

ANTHONY SENAGORE Spouse: Patricia

Caucus: Northern California

Speciality: Colorectal Surgery

Position/Location: Academic Surgeon, Keck School of Medicine, Los Angeles, CA

Sponsors: William Schecter, Vaughn Starness, Michael Stamos

MAHESWARI SENTHIL Spouse: Swamy

Children: Girish, Maya

Caucus: Southern California

Speciality: Surgical Oncology

Position/Location: Academic Surgeon, Loma Linda University, Loma Linda, CA

Interests: Tennis, Hiking, Swimming, Running and Cooking for Family and Friends

Sponsors: Carlos Garberoglio, Kevork Kazanzian, Sharon Lum

– 104 –

PAUL SUDING Spouse: Katharine (Katie)

Children: Madeline, Thomas

Caucus: Northern California

Speciality: Laparoscopic and General Surgery

Position/Location: Community Base Surgeon, First Surgical Consultants, Oakland, CA

Interests: Running and Skiing

Sponsors: Steven Stanten, Russell Williams, Samuel Eric Wilson

GARTH H. UTTER Spouse: Clara K. Paik, MD

Children: Jolie Utter

Caucus: Northern California

Speciality: Trauma/Emergency Surgery

Position/Location: Academic Surgeon, University of California Davis, Sacramento, CA

Interests: Running, Clinical Research

Sponsors: James Goodnight, James Holcroft, Lynette Scherer

– 105 –

IN MEMORIAM Deceased Members

WILEY F. BARKER, MD

MAURICE GALANTE, MD

EDMUND JOHN HARRIS, SR.

LEON MORGENSTERN, MD

DONALD L. MORTON, MD

– 106 –

Wiley F. Barker, MD died on October 13th just days before his 94th birthday. A founding member of the UCLA Department of Surgery at UCLA, Dr. Barker was born in Santa Fe, New Mexico on Oct 16, 1919, raised there, and then moved to Boston for his undergraduate and medical education at Harvard. His surgical residency at Brigham & Women’s hospital was interrupted by WWII, during which time he served as a medical officer in the Navy. Dr. Barker arrived in Los Angeles to complete his residency training, having been personally recruited to the program by our founding Department Chairman, Dr. William P. Longmire, Jr.

As in all aspects of his life, Dr. Barker excelled and completed the residency program ahead of schedule. He accepted an initial appointment at the Wadsworth Veterans Hospital, and shortly after was appointed the first Chief of General Surgery, when the UCLA Medical School building was opened in the fall of 1954. He spent his entire career at UCLA, where he had further roles as the Chief of Vascular Surgery at UCLA and Chief of Surgery at the Sepulveda VA Hospital. He is most widely identified as a pioneer in the development of peripheral vascular surgery. Dr. Barker performed the first endarterectomy on the west coast and wrote the first textbook on peripheral artery disease. He served as the president of the Society for Vascular Surgery, Society for Clinical Surgery, Pacific Coast Surgical Association, and the International Cardiovascular Society.

Several UCLA awards have been created in honor of Dr. Barker, including the Wiley Barker Teaching Award, given annually to an outstanding General Surgery 4th year resident who demonstrates a commitment to teaching, and the Wiley Barker Endowed Chair in Vascular Surgery, established in 2010. Until recently, Dr. Barker continued to participate in the UCLA Department of Surgery and Division of Vascular Surgery as Chief Emeritus. While working in the lab at Harvard, Dr. Barker befriended someone who had an interest in growing orchids, and upon retirement, he also developed an interest in raising orchids, produced many varieties, and has written a book on the subject. Dr. Barker is survived by his beloved wife Nancy, 3 children and 6 grandchildren. His career was distinguished by many contributions to his colleagues, university, patients, and the field of surgery.

- Peter Lawrence, MD

IN MEMORIAM

WILEY F. BARKER, MD

1919-2013

– 107 –

Maurice Galante, the legendary San Francisco surgeon, passed away at the age of 93, on February 5, 2013, surrounded by his family. Maurice was born and raised on the island of Rhodes and spoke fluent Italian, Greek and French in addition to English. He immigrated to the United States in 1938 and obtained his medical degree from Ohio State University in 1944. His immigration was fortunate—many of his family members as well as most of the Jewish Community of Rhodes perished during the Holocaust. Following an internship at Morrisania Hospital in New York City, he began a residency in surgery at the University of California, San Francisco under Dr. Glenn Bell. Except for service in the United States Army in the middle of his residency, he remained at UCSF for his entire career, retiring in 1997.

Maurice was unquestionably the dominant clinical surgeon at UCSF during his tenure. He brought his artistic temperament to the practice of surgery and used his instruments to lovingly and gently reveal the mysteries of the human body. He was a brilliant head and neck, esophageal, and abdominal surgeon. He performed over 300 pelvic exenterations for far advanced cervical cancer offering hope to women with this devastating disease. His special relationship with his patients resulted in the funding of the acclaimed Galante Lecture Series, the Galante Research Fund and the Maurice Galante Distinguished Professorship in Surgery.

Like many icons in surgery, stories about Maurice, some perhaps apocryphal, abound. When testifying in court, Maurice was asked by an attorney whether he was an expert in breast cancer. He turned to the jury and flamboyantly proclaimed in his delightful Italian accent: “My mother had breast cancer!”

During a thyroidectomy, Maurice bumped heads with his resident while searching for the recurrent laryngeal nerve. The resident, with a touch of chutzpah, said: “Ah, a meeting of the minds!” Maurice stopped, peered at him over his mask, and very slowly asked: “Then why do I feel so alone?”

Maurice operated with the Bovie like Monet painted with a brush. He was doing a radical neck dissection when the lights in the room suddenly went out. Legend has it that he continued to skeletonize the carotid artery with the Bovie without missing a beat. He declared to the residents, “See, Bovie makes its own light”.

IN MEMORIAM

MAURICE GALANTE, MD

1919-2013

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A brilliant young UCSF physician developed papillary carcinoma of the thyroid. He went to the library and reviewed the entire literature on the subject. He could quote chapter and verse the many contradictory articles and was as nervous as a cat. Maurice’s pre-operative conference consisted of putting his arm on the young man’s shoulder, looking into his eyes and saying: “Don’t worry. I’m going to cure you’ -- exactly what he needed to hear at that moment.

In 1968, Maurice was rescued from bachelorhood by the beautiful and accomplished Patricia Miyasato. It would be difficult to find a more loving and devoted couple. Their three children Phillip (a banker), Danielle (an artist) and Michel (a composer and musical director) have continued their parents’ devotion to music, the arts and family. The arrival of Phillip and Lori’s daughter Lily and Michel and Carol’s daughter Ondine Eabha brought tremendous joy to the entire family.

Maurice’s legacy lives on in the thousands of lives he saved, the academic programs he fostered, the generations of surgeons he trained, and his remarkable family.

- William Schecter, MD

IN MEMORIAM

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Dr. Edmund John Harris passed away peacefully at home on September 20, 2012, following 5 years of progressive Alzheimer’s dementia at the age of 92. Born to George and Mary Harris in Waltham, Massachusetts, Ed went on to Harvard College (‘42) and Harvard Medical School (‘45). Shortly after graduation, he served in the Army Air Force as a flight Surgeon, at Chanute Field in Illinois. He then completed his surgical training in Boston, at the Massachusetts General Hospital, the West Roxbury VA Hospital, and the Boston Children’s Hospital, and during this training he met a beautiful Chemistry major from Wellesley College, Marilyn Cook, who became his wife and lifelong companion. Upon finishing his training he moved west to Indiana to follow a mentor, but then several years later, he came to San Francisco for the American College of Surgeons meeting, and decided that the Bay Area was the place for his young family.

Although trained as a cardiothoracic surgeon, he was interested in the developing field of vascular surgery and helped shape the growth of vascular surgery as a specialty. He was a charter member of the Western Vascular Society, a founding member and past president of the Northern California Vascular Society, a member of the Pacific Coast Surgical Association and a Distinguished Fellow of the Society for Vascular Surgery.

Ed started his career in the bay area as a solo practitioner on the Peninsula, establishing a practice that encompassed Seton Hospital, Peninsula Hospital, Mills Hospital and Seqouia Hospital. Ed then helped form the Peninsula Vascular Surgery Associates, a group he led until his retirement in 1993. Initially unfulfilled in his new retirement, he was then lured to Stanford by Dr. Christopher Zarins and Ed’s son John, to help the new Division of Vascular Surgery establish a practice in the treatment of venous disorders. Ed worked at Stanford until his second retirement in 2006.

Ed was an all-star hockey player in high school, who was not allowed on the Harvard team because he taught tennis lessons in the summer before his admission to Harvard, and was considered a professional. Ed was an accomplished skier, he continued his love of tennis, he continued to love sailing

IN MEMORIAM

EDMUND JOHN HARRIS SR.

1920-2012

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and briefly maintained a boat on the bay, but his real love was golf. He and Marilyn traveled widely and golf was often the focal point of their trips. He was a long time member of the Peninsula Golf and Country Club, and more recently the Burlingame Country Club. He continued to play golf at Burlingame Country Club twice a week until a month before his death. He is survived by his wife Marilyn, his children Ann C. Harris, Nancy Wyatt (Andrew), E. John Harris, Jr. MD (Leslie) and William G. Harris (Julie), as well as 8 grandchildren .

-E. John Harris, Jr. MD

IN MEMORIAM

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Dr. Leon Morgenstern died on December 23, 2012 at the age of 93. Blessed with a multitude of talents and an extraordinary intellectual curiosity, Dr. Morgenstern spent a rich life as a general surgeon, a surgical scientist, a medical ethicist, and an exceptional human being.

A native of Pittsburgh, PA, Dr. Morgenstern was an AOA graduate of the New York University College of Medicine in 1940 and completed internship at Queens General Hospital in Jamaica, New York. From 1944 to 1946, he served in the Army Medical Corps and was discharged at the rank of Captain. Next came a fellowship in Pathology at Queens General Hospital, followed by residency in general surgery at Queens. On completion of his training in 1953, Dr. Morgenstern joined the staff of Cedars of Lebanon Hospital in Los Angeles, CA, and worked in research and residency training with Dr. David State, who was Cedars’ first Director of Surgery. Dr. State moved to Albert Einstein College of Medicine as Chair of Surgery in 1958, and Dr. Morgenstern joined him there for one year. In 1960, Dr. Morgenstern returned to Cedars as the second full time Director of Surgery.

At Cedars of Lebanon and later the merged Cedars-Sinai Medical Center, Dr. Morgenstern worked to build an academic surgical department. He expanded the residency program, increased the full time staff of his department, and developed of number of distinguished programs by strategic recruitment of eventual leaders in their fields. These included surgical endoscopy with Drs. George Berci and Edward Phillips, cardiac surgery with Dr. Jack Matloff, and surgical critical care with Dr. M. Michael Shabot. Dr. Morgenstern also strengthened the Cedars affiliation with the Department of Surgery at UCLA, where he rose to the rank of full professor.

An excellent technical surgeon with a busy clinical practice, Dr. Morgenstern was a world expert in surgical diseases of the spleen, including splenic preservation and techniques of partial splenectomy. Other lines of investigation that he pursued with his staff included experimental gastric neoplasia, biliary physiology, radiation enteropathy, and anastomotic intestinal healing. He also was an avid and passionate medical historian. He was the author of nearly 300 scientific publications.

IN MEMORIAM

LEON MORGENSTERN, MD

1919-2012

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After 28 years as Director of Surgery at Cedars, Dr. Morgenstern retired from that post in 1988 and began a second and similarly fruitful career as a medical ethicist. In 1995, he established Cedars-Sinai’s Center for Healthcare Ethics, which has grown into a highly recognized and robust program for patients, caregivers, and policy-makers. Dr. Morgenstern served as an adjunct ethics professor at the University of Judaism, Los Angeles, and an advisory board member to the Pacific Center for Health Policy and Ethics at USC.

Dr. Morgenstern was a prominent member of many surgical organizations, including the American Surgical Association. He served as president of the Southern California Chapter of the American College of Surgeons and the Los Angeles Surgical Society.

This accounting of Leon Morgenstern’s medical and surgical career describes only a fraction of the life that he led. He was an avid reader, scholar, and thinker. He was a writer, poet, artist, and musician; more than a musician, he was a builder of violins. His intellect and humanity were infectious. He could be stern but never harsh or vulgar. He held those around him – colleagues, students, staff members, friends -- to his own lofty standards for effort, character, and accomplishment. None of us ever regretted the challenge.

Dr. Morgenstern is survived by his wife, Laurie Mattlin, sons David and Seth, and five grandchildren. His life and career were celebrated at a program at Cedars-Sinai on April 18, 2013. The outpouring of reverence and love was something to behold.

- Jonathan R. Hiatt, MD and Edward Phillips, MD

IN MEMORIAM

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Dr. Donald L. Morton died on January 10, 2014, at the age of 79. An incredible man and outstanding teacher, surgeon, and scientist, Dr. Morton will be missed by members of the Pacific Coast Surgical Association, friends, and colleagues throughout the world.

Dr. Morton was born in a small town in West Virginia. He finished high school in three years and, perhaps because he worked in a drugstore after school, decided to become a doctor. He was the first in his family to go to college and started his education at Berea, a small college in the Appalachian Mountains of Kentucky. Before graduation, he moved with his family to California where he was awarded an academic scholarship to the University of California, Berkeley. He was accepted to medical school after three years at Berkeley and received his Bachelor’s degree after the first year of medical school at the University of California, San Francisco (UCSF). Dr. Morton became an intern in Medicine at UCSF and then a resident in Surgery. During residency, he completed two years of research at the National Cancer Institute (NCI) which firmly solidified his desire to enter the field of cancer research. At the completion of his residency, Dr. Morton returned to the NCI where he was a Senior Investigator of the Surgery Branch and became the Head of the Tumor Immunology Section and Senior Surgeon. He became Board certified in surgery and Board certified in thoracic surgery while at the National Institutes of Health (NIH).

In 1971, he moved with his young family from Bethesda to Los Angeles to become Chief of Surgical Oncology at the University of California, Los Angeles (UCLA). Dr. Morton’s Division of Surgical Oncology at UCLA was one of the first surgical oncology divisions in the nation and became a role model for surgical oncology in other medical schools. In 1991, Dr. Morton left UCLA as Emeritus Professor to establish the John Wayne Cancer Institute at Saint John’s Health Center in Santa Monica where he practiced and performed cutting-edge research until his passing.

Dr. Morton’s pioneering research impacted surgical oncology and surgical practice worldwide. His accomplishments are extraordinary. His early work with BCG for non-specific immunotherapy for melanoma and the intralesional injection of BCG to melanoma metastatic to the bladder laid the

IN MEMORIAM

DONALD L. MORTON, MD

1935-2014

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foundation for the use of intravesical BCG for bladder cancer, the first FDA-approved form of cancer immunotherapy. His work on cancer vaccines led to NIH funding for a large prospective randomized trial of an anti-melanoma vaccine which he developed. Dr. Morton was also a pioneer in limb salvage surgery for soft tissue sarcoma and pulmonary resection for solid tumor metastases. His work examining regional lymphatic drainage for primary cutaneous melanoma, which began in the early 1970’s, led to the introduction of lymphatic mapping and sentinel node biopsy for melanoma. This has become a practice-changing contribution to the field of surgery and to the management of patients with various types of solid tumors, especially melanoma and breast cancer. His work has spared innumerable patients the morbidity of regional lymph node dissection for tumor-free lymph nodes.

Dr. Morton has had few peers in surgery and medicine. In 2003, the Society of Surgical Oncology awarded him the Heritage Award. In 2008, the American College of Surgeons awarded him the prestigious Jacobson Innovation Award for the contribution of sentinel lymph node biopsy to the field of surgery. In 2010, Dr. Morton was voted Alumnus of the Year of the UCSF Medical School. He was an extraordinary clinical investigator who tested his hypotheses rigorously in prospective randomized, highly structured clinical trials which are models of clinical research. During his career, he was elected president of the World Federation of Surgical Oncology Societies, was founder and president of the International Sentinel Node Society, and served as president of the Society of Surgical Oncology.

Don was an extraordinary teacher and mentor who trained over 100 fellows in surgical oncology, most of whom are in leadership roles in academic institutions or major cancer centers. He authored almost 1,000 publications and had competitive research funding from the National Cancer Institute for over 40 consecutive years. In 2000, the journal Science ranked him as the clinical investigator who received the most grant funding from the NIH. Very few surgeons have program projects lasting their entire career, as he did. Dr. Morton’s publications have been cited nearly 20,000 times, and he published over 60 articles which were each cited more than 100 times.

-Armando E. Giuliano, MD

IN MEMORIAM

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ARTICLE I Section 1. The name of this Association shall be THE PACIFIC COAST SURGICAL ASSOCIATION.

ARTICLE II Section 1. The object of the Association shall be to advance the science and practice of surgery.

ARTICLE III Section 1. The Association shall consist of Active, Senior, Honorary, and Non-Resident Fellows Members.

Section 2. Active membership shall be limited to 250 Fellows Members, the number elected each year to be left to the discretion of the Council.

Section 3. No one shall be eligible for membership unless his/her practice is limited to surgery and he/she has established a reputation as a practitioner, author, teacher or original investigator, and has been recommended by the Council. Candidates must be in practice for two years on the West Coast. The candidate shall also have been certified either by the American Board of Surgery, the appropriate specialty Board, or its foreign equivalent. (adopted 2/2007)

Section 4. The Council shall have the power of decision in the consideration of each candidate’s eligibility and its judgment upon such eligibility shall be final. No candidate for membership shall be voted upon at the executive session of the Association unless recommended by the Council.

Section 5. Proposals for membership shall be made by Fellows Members on applications furnished by the Secretary-Treasurer of the Association. The proposal of a candidate for membership shall be supported by letters to the Secretary-Treasurer from each of the three sponsors who shall vouch for his/her character and standing. The application and letters shall be presented to the Council by the Secretary Councilor of the region recommending the candidate.

CONSTITUTION

Proposed Revisions from the 2013 Meeting which will be voted on at the 2014 Meeting: are indicated with a strikethroughProposed New Language from the 2013 Meeting which will be voted on at the 2014 Meeting: is indicated with underlined text

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Section 6. Proposals for membership, properly filled out, accompanied by the necessary endorsements and confidential letters from the sponsors, shall be in the hands of the Secretary-Treasurer at least six months before the date of the annual meeting. Three months before the annual meeting, the Secretary-Treasurer shall send to each member of the Association a list of all candidates for active membership and a printed summary of their qualifications, including educational attainments and professional positions. Members are encouraged to submit to the Council written comments on the candidates’ qualifications for membership. The Council at its annual meeting shall, after full consideration of all information available, recommend to the Association such candidates as are qualified for membership. The Council shall have the power to request from any member of the Association a careful and unbiased investigation of the qualifications of any candidate for election to the Association. Any candidate for active membership may be assigned to a member of the Council for careful investigation as to his/her personal and professional qualifications.

Section 7. After recommendation by the Council, election to fellowship membership shall be by ballot at the executive session of each annual meeting and if three-quarters of the ballots are favorable, the candidate shall be declared elected. Candidates for active membership not brought forward to the Association for election by the Council in the first year after nomination may be reconsidered in the two subsequent years at the request of the Councilor and with support from their region.

Section 8. Candidates who have not been recommended for active membership by the Council three years after nomination, shall be withdrawn and their sponsors notified. This action shall not prevent the reproposal of such candidates for membership. Any candidate for fellowship membership who has been recommended by the Council, but not selected by the Association cannot be proposed again for membership for at least two years.

Section 9. Prospective Fellows Members after election must qualify within three months by the payment of the initiation fee and annual dues to the Secretary-Treasurer and by filing a recent 8x10 photograph with the Association. To become an Active member, the nominee shall be expected to attend the first Annual Meeting after election to be introduced to the Association and to receive the certificate of membership. Should the nominee fail to attend the first subsequent meeting, the second Annual Meeting must be attended. If the nominee is unable to attend the second meeting, membership will not be conferred subject to action by the Council. Fees contingent on membership will not be refunded.

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ARTICLE IV Section 1. Active members shall have a practice that is limited to surgery. and be currently engaged in the surgical care of patients. Candidates for Honorary Fellowship shall be nominated by the Council and elected by ballot at the executive session of the annual meeting. Honorary Fellows shall not be required to pay dues or initiation fee and shall enjoy all the privileges of other Fellows except those of voting and holding office.

Section 2. All Fellows Members automatically shall automatically become Senior Fellows Members at the age of sixty (60) years. They shall pay dues to the age of seventy (70) years or upon retirement from active practice, whichever occurs first. They shall and have the privilege of voting and holding office but are excused from the annual meeting attendance requirement.

Section 3. Active and Senior Members shall be required to pay association dues. They have the privilege of voting and holding office.

Section 34. Members are considered Retired upon reaching the age of seventy five (75) or retirement from active clinical practice, whichever occurs first. They are no longer required to pay Association dues. They have the privilege of voting and holding office. A Non-Resident Fellow shall be a Fellow under the age of sixty who no longer resides in the Pacific Coast geographical area. He/She shall be excused from attendance requirements. He/She may vote at such meetings as he/she attends and enjoy all the privileges of the Association except that he/she may not hold office or membership on standing committees. He/She shall pay annual dues. A request for non-resident status must be submitted in writing to the Secretary and shall be granted only by the Council. Upon written request the Council may restore a Non-Resident Fellow to active status. At its discretion, the Council may terminate membership as a Non-Resident Fellow. A Non-Resident Fellow shall automatically become a Senior Fellow at age sixty.

Section 45. The resignation of a Fellow may be accepted at the discretion of the Council.

Candidates for Honorary Membership shall be nominated by the Council and elected by ballot at the executive session of the annual meeting. Honorary Members shall not be required to pay dues or initiation fees and shall enjoy all the privileges of other Members except those of voting and holding office.

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Section 56. A Non-Resident Member shall be a Member under the age of sixty (60) who no longer resides in the Pacific Coast geographical area. He/She shall be excused from attendance requirements. He/She may vote at such meetings as he/she attends and enjoy all the privileges of the Association except that he/she may not hold office or membership on standing committees. He/She shall pay annual dues. A request for non-resident status must be submitted in writing to the Secretary-Treasurer and shall be granted only by the Council. Upon written request the Council may restore a Non-Resident Member to active status. At its discretion, the Council may terminate membership as a Non-Resident Member. A Non-Resident Member shall automatically become a Senior Member at age sixty (60).

Section 67. The resignation of a Member may be accepted at the discretion of the Council.

ARTICLE V Section 1. The officers of the Association shall be a President, a President-eElect who becomes President one year following election, a President-eElect who becomes President two years following election, a Vice-President, a Secretary-Treasurer, a Recorder, an Historian, and four Councilors. There shall be a Program Committee appointed by the President, consisting of five members, one representing each of the four geographical sections of the Association, and the Recorder, who shall act as Chairman. The Council member and the Program Committee member who resides in the same geographical area as the Recorder shall act as an Advisory Committee to him/her.

Section 2. The Presidents-Elect, the Vice-President, the Secretary-Treasurer, the Recorder, and the Historian shall be elected for one year, and a Councilor shall be elected as provided by the Bylaws. The President shall not be eligible for re-election at any time. The Secretary-Treasurer and Recorder shall not serve more than six years, shall not both be retired in the same year, and shall not be elected from the same region of the Association.

Section 3. All officers shall be nominated by a Committee, appointed by the President, consisting of the three most recent past Presidents, at least three (3) months prior to the annual meeting. Additional nominations may be made from the floor.

Section 4. The election of officers shall take place at an executive session of the annual meeting. A majority of votes cast constitute an election.

CONSTITUTION: PROPOSED REVISIONS

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ARTICLE VI Section 1. It shall be the duty of the President to be present and to preside at all meetings of the Association; to see that the rules of order and decorum are properly enforced in all deliberations of the Association; to sign the certificates of fellowship membership.

Section 2. In the absence of the President, the Vice-President shall preside, and in the absence of the Vice-President, the Secretary-Treasurer shall preside.

Section 3. In the absence of all three, the Association shall elect one of its Fellows Members to preside pro tem.

Section 4. The Secretary-Treasurer shall keep the minutes of the Association and shall issue, at least six weeks prior to the annual meeting, a preliminary notice of the time and place of the meeting, and the business to be transacted. He/She shall issue the final program of the annual meeting and a list of the names of the candidates for Fellowship Membership who are under consideration by the Council. He/She shall attest all official acts requiring certification, in connection with or independent of the President, notify officers and Fellows Members of their election and, keep in his/her custody the Seal of the Association and affix it to all documents and papers that the Association may direct; take charge of all papers not otherwise provided for. He/She shall serve as Secretary-Treasurer and keep minutes of the meetings of the Council. He/She shall, with the President, sign the certificates of Fellowship Membership and receive all monies and funds belonging to the Association. He/She shall pay the bill of the Association, collect all dues and assessments as promptly as possible, report to have, in accordance with the Bylaws, regulating the same, forfeited their Fellowship Membership. It shall be the duty of the President of the Association to appoint an Audit Committee, consisting of two (2) Members of the Association, whose duty it shall be to consult with a Certified Public Accountant, to examine the books of the Secretary-Treasurer, and to report on the same to the membership during the annual meeting. He/She shall annually present a review of the Association’s finances performed by a Certified Public Accountant. A full audit shall be performed as determined by the President and President-Elect in the final year of the Secretary-Treasurer term Council.

Section 5. It shall be the duty of the Historian to assemble and preserve the Archives of the Association for storage and reference. The Archives shall consist of the roster of the members of the Association since its inception, and such

CONSTITUTION: PROPOSED REVISIONS

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photographs as are available. It shall be his/her duty likewise to secure and file a photograph of each new member. At each Annual Meeting of the Association, the Historian shall be called on by the President to give a presentation of historical significance to the membership.

Section 6. The Recorder shall, as Chairman of the Program Committee, assemble the scientific program and forward it to the Secretary-Treasurer at least two months before the annual meeting. The Recorder shall receive all papers and reports of discussion on papers presented before the Association and as the Chairman of the Program Committee take charge of the publication of the papers presented before the Association.

Section 7. It shall be the duty of the President of the Association to appoint an Audit Committee, consisting of two (2) Fellows Members of the Association, whose duty it shall be to examine the books of the Secretary-Treasurer and report on the same during the annual session.

ACTICLE VII Section 1. Vacancies occurring in the offices of the Association shall be filled by appointment by the President until the next meeting. He/She shall also have the authority to appoint all committees not otherwise provided for.

ARTICLE VIII Section 1. The Constitution may be amended at any regular meeting by a written resolution embodying the proposed changes, which shall lie over for one year and which must receive approval by two-thirds of the members present and voting.

ARTICLE IX Section 1. The President, the two Presidents-elect, Vice-pPresident, Secretary-Treasurer, Recorder and Historian shall act as ex-officio members of the Council with the right to vote.

CONSTITUTION: PROPOSED REVISIONS

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CHAPTER I Section 1. The Pacific Coast Surgical Association shall meet annually at such time and place as may be designated by the Council, preferably on President’s Day weekend.

Section 2. There shall be at least one annual executive session of the Association, at which the order of business shall be as follows: (a) reading the minutes of the last meeting; (b) reports of the Secretary-Treasurer, Recorder and Historian; (c) reports of the Council; (d) report of Program Committee; (e) reports of representatives of the Association to the American Board of Surgery and to the American College of Surgeons; (f) unfinished business; (g) new business; (h) report of Auditing Committee; (i) report of Nominating Committee; (j) election of officers; (k) election of Members; (l) induction of new officers; (m) adjournment.

CHAPTER II Section 1. The Members present at any executive session shall constitute a quorum for business.

CHAPTER III Section 1. The annual dues and the initiation fee shall be recommended by the Council and voted upon by the membership each year at the annual meeting. Members may be exempted from payment of dues at the discretion of the Council.

CHAPTER IV Section 1. The usual parliamentary rules (Robert’s Rules) governing deliberative bodies shall govern the business workings of the Association.

CHAPTER V Section 1. All questions before the Association unless otherwise provided shall be determined by a majority vote of the members present and voting except change in the Constitution and Bylaws and the election of new members which require a two thirds (2/3) majority.

BYLAWS

These Bylaws were revised and approved at the 2013 PCSA Business Meeting.

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CHAPTER VI Section 1. The President shall deliver an address at the annual meeting of the Association.

CHAPTER VII Section 1. The Secretary-Treasurer and Recorder of the Association shall receive at each annual meeting a draft from the President for such sum as may be voted by the Council for services rendered the Association, and to this shall be added the necessary expense incurred in the discharge of his/her official duties.

CHAPTER VIII Section 1. Those members submitting titles of essays shall supply the Recorder with the title and an abstract of the proposed essay. The program committee shall have the responsibility for choosing the primary discussant. The discussant shall receive a copy of the essayist’s paper not later than two weeks before the annual meeting. The presenting author and opening discussant shall submit the manuscript and a text of the discussion ready for publication just prior to presentation.

CHAPTER IX Section 1. The Council shall consist of five members, of which four are elected, the fifth member to be the retiring president who automatically serves for one year. The President, President-Elect, Vice President, Secretary-Treasurer, Recorder and Historian shall act as ex-officio members of the Council with the right to vote. One member of the Council shall be elected annually to serve four years. Any member of the Association shall be eligible for membership on the Council, provided that each regional section of the Association shall always be represented on the Council. These regional sections, which may be enlarged at the will of the Association, shall consist, respectively, of the Members residing in 1) Washington, British Columbia and Alaska, 2) Oregon and Hawaii, 3) Northern California to, but not including Santa Barbara and Bakersfield, 4)Southern California including Santa Barbara and Bakersfield. The President shall be notified by any Councilor who is unable to attend a meeting of the Council. Upon such notification, the President shall appoint from the Councilor’s regional section an alternate who shall act as Councilor for that meeting.

Section 2. The President shall preside as Chairman of the Council and the Secretary-Treasurer shall keep record of its proceedings.

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Section 3. The duties of the Council shall be: 1. To investigate candidates for membership and report to the Association the names of such persons as are deemed worthy. 2. To take cognizance of all questions of an ethical, judicial, or personal nature, and upon these, the decisions of the Council shall be final, provided that appeal may be taken from such decision of the Council to the Association under a written protest, which protest shall be voted upon by the Association. 3. All resolutions before the Association shall be referred to the Council before debate, and the Council shall report by recommendation at the earliest hour possible. 4. The Program Committee and the Council shall have power to invite guests to appear on the scientific program. 5. The Council at the invitation of the President shall meet at some date preceding the annual meeting for consideration of matters of importance with reference to the annual meeting and particularly with reference to the eligibility of proposed candidates for admission.

CHAPTER X Section 1. The Council shall have full power to withdraw from submission for publication any paper that may be referred to it by the Association, unless specially instructed to the contrary by the Association, which shall be determined by vote.

CHAPTER XI Section 1. The President shall appoint for the following annual meeting a Committee on Arrangements, and the Program Committee as provided in the Constitution. The Program Committee shall consist of four members representing each of the caucuses and a chairman. A Program Committee member shall serve for three years and shall be eligible for reappointment for one additional term.

CHAPTER XII Section 1. Active membership shall be forfeited by failure to be present at four consecutive meetings. After failure to attend three consecutive meetings, the Secretary-Treasurer will notify the member that a fourth consecutive absence will terminate his/her membership. In cases where the fourth absence was caused by extremely compelling circumstances, the Council may at its discretion, stay the termination of membership. Failure by any member of the Association to pay dues for one year may be considered sufficient cause to drop the member from the membership roll on recommendation of the Council to the

BYLAWS

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Association. Membership also may be forfeited for reasons deemed sufficient by the Association.

Section 2. Attendance at an annual meeting shall be defined as registration with Secretary-Treasurer, payment of the registration fee and attendance at not less than one scientific session. Retired members and those exempt from dues because of illness shall have the privilege of attending the annual meeting at a registration fee determined by the Council.

Section 3. At the discretion of the Council, and for good and sufficient reasons, an Active Member may be transferred to the list of Senior Members.

CHAPTER XIII Section 1. A paper shall not be read before this Association which has been published previously or which does not deal with a subject of surgical importance. The member shall close the discussion.

Section 2. The maximum time allowed essayists shall be 10 minutes, except by permission of the Program Committee. The primary discussant shall be allowed 5 minutes, each subsequent discussant 2 minutes, and final closing discussant 5 minutes.

Section 3. No paper read before this Association shall be published in any medical journal or pamphlet for circulation as having been read before the Association without having received endorsement of the Program Committee.

Section 4. At the discretion of the Program Committee, poster sessions may be held during the scientific meeting. Papers representing work from these poster sessions may be submitted for consideration for publication to the journal of their choice.

CHAPTER XIV Section 1. The Scientific Meetings shall be open to any member of the association in good standing in his/her profession, provided he/she establish his/her identity, or their invited guest. Only an officially invited guest may register and attend functions.

Section 2. Members may request invitations for guests by applying to the Secretary-Treasurer in writing at least one month prior to the first day of the

BYLAWS

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annual meeting. The Council shall determine the number of guests which may be invited. Invitations to guests shall be issued only by the Secretary-Treasurer.

A Member requesting that an invitation be extended to a guest shall assume such financial responsibility as may be determined by the Council for the guest so invited.

The President may invite distinguished members of the profession to be guests of the Association.

Section 3. The Association shall have no financial responsibility for invited guests, except distinguished guests invited by the President.

CHAPTER XV Section 1. Pursuant to Article V, Section 3, of the Constitution, the Nominating Committee shall request some specific information from each of the four regional sections where new candidates are required for the offices of the President-Elect, Secretary-Treasurer, Recorder, and Regional Councilor. An election with written mail ballot shall be held within each regional section involved in selecting candidates for each of these four offices. The Regional Councilors will conduct the balloting and provide the Nominating Committee with a report reflecting the wishes of their caucus. The Nominating Committee may review the ballots if questions arise about the voting process.

Section 2. The candidate for Vice President shall be selected by each President-Elect.

CHAPTER XVI Section 1. These Bylaws may be amended at any annual meeting by a two- thirds vote of the Members present and voting. Proposed amendments shall be made in writing as motions before the Association, and shall then be dealt with in accordance with the provisions of Chapter IX, Section 3, Paragraph 3, of the Bylaws.

BYLAWS

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2015: FEBRUARY 19-22, 2015

Host Northern California Site Marriott Monterey Monterey, California

2016: FEBRUARY 20-23, 2016

Host Oregon/Hawaii Site JW Marriott Ihilani Ko Olina - Oahu, Hawaii

FUTURE MEETINGS

Pacific Coast Surgical Associationc/o ACS Association Management Services

633 N. St. Clair StreetChicago, IL 60611-3211

PHONE: 800-274-9083FAX: 312-267-1782

EMAIL: pcsa@facs.orgWEB: www.pcsaonline.org

Pacific Coast Surgical Association