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Title: The Structure and Biological Function of CREGPresenter Name: Felecia Jinwala & Luiz AraujoPI: Shahua LiCo-authors: Gaby Ghobrial (1), Luiz Araujo (1), Felicia Jinwala (1), Shahoa LIe and Leonard LeeRutgers - RWJ Medical School

Abstract: The cellular repressor of E1A-stimulated genes (CREG) is a 220 amino acid glycoprotein structurally similar to oxidoreductases. However, CREG does not have enzymatic activities because it cannot bind to the cofactor flavin mononucleotide. Although CREG can be secreted, it is mainly an intracellular protein localized in the endocyticlysosomal compartment. It undergoes proteolytic maturation mediated by lysosomal cysteine proteases. Biochemical studies have demonstrated that CREG interacts with mannose-6-phosphate/insulin-like growth factor-2 receptor (M6P/IGF2R) and exocyst Sec8. CREG inhibits proliferation and induces differentiation and senescence when overexpressed in cultured cells. In Drosophila, RNAi-mediated knockdown of CREG causes developmental lethality at the pupal stage. In mice, global deletion of the CREG1 gene leads to early embryonic death. These findings establish an essential role for CREG in development. CREG1 haploinsufficient and liver-specific knockout mice are susceptible to high fat diet-induced obesity, hepatic steatosis and insulin resistance. The purpose of this review is to provide an overview of what we know about the biochemistry and biology of CREG and to discuss the important questions that remain to be addressed in the future.

Published: Frontiers in Cell and Developmental Biology (October, 2018)

Title: Hartmann’s Reversal: To Robot, or Not to Robot? A Single Institution Series Presenter: Kristen DonohuePI: Nell Maloney PatelCo Authors: Donohue, K. D.1; Rossi, A. J.1; Maloney Patel, N.1Institution: 1. Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, UnitedStates. Introduction: The restoration of intestinal continuity after a Hartmann’s procedure remains a procedure that is technically difficult and associated with a high complication rate. The reported morbidity rates range from 3-50% and mortality is quoted as high as 7%, with a mean of 1%. As surgery has evolved, minimally invasive techniques have been implemented in these reversals, as in most fields of surgery, and laparoscopic reversal of a Hartmann’s has been shown to be feasible with comparable outcomes and the benefits of laparoscopic surgery. The natural progression of minimally invasive surgery in the modern era is to involve the robotic platform in assistance, as has been seen in other areas of colorectal surgery. Despite this logical progression, there has been a very limited amount of literature on the use of robotic platforms in colostomy reversals. We seek to characterize our experience with robotic colostomy reversals in a case series at a single institution. Methods: IRB approved retrospective chart review was conducted. 450 patients undergoing robotic surgery by colorectal surgeons at a single institution from January 2013 through October 2017 were reviewed. During this period 14 patients were identified that underwent robotic Hartmann’s reversals from January 2016-October 2017. Variables studied included age, gender, BMI, ASA, OR time, conversion to open procedure, post-operative complication, length of stay, cost and indication for initial operation. Results: 14 patients were identified within the study criteria. One patient had surgery on the Xi platform, all others were operated on by the Xi. All patients also underwent cystoscopy and ureteral stent placement. Indications for initial Hartmann’s procedure included perforated diverticulitis (7), stricture (IBD/diverticular/malignant, (6)) and diverticular colovesicular fistula (1). Median operative time was 317 (+/-90) minutes, and median OR cost $2920.84. Conversion to open procedure occurred in 5/14 cases (35.7%). There were no intraoperative complications and post-operative complications occurred in 2/14 (14.3%). Median length of stay was 4 days (STD 0.83 days) and median total cost $25385.85.

Conclusions/Discussion: The robotic approach to Hartmann’s reversal appears to be a safe and feasible alternative to open or laparoscopic surgery. The known benefits of the robotic platform including improved 3D visualization and wristed instruments are beneficial both in the pelvic dissection and splenic flexure mobilization. It is associated with low morbidity and short hospital stay. Operative times do appear to be longer when compared to the reported open and laparoscopic literature; however, variables such as ureteral stents are not routinely reported/used in other series. Further comparative data is needed to determine cost efficacy.

Title: Endoscopic Versus Laparoscopic Gastrojejunal Revision as Therapeutic Options for Weight Regain after Roux-en-Y Gastric Bypass

Presenter Name: Keith King, MD

Name of PI: Ragui Sadek, MD FACS

Name of Co-authors (in appropriate order): Keith King, MD, Andrew Wassef, Ragui Sadek, MD FACS

Institution (especially if not at RWJUH): RWJUH

Introduction: Revisional surgery is rapidly growing within the field of bariatric surgery, increasing from 6% of all cases in 2013 to 14,1 % of cases in 2017 [5]. This increased incidence of revisional surgery places an additional importance on the revisional technique employed. Inadequate weight loss or weight regain are the most common indication for revision. Endoscopic gastrojejunal revision (EGJR) has been shown to be a safe, effective and less invasive alternative to revisional surgery, with promising weight loss outcomes. However, there is limited data available comparing this technique to similar laparoscopic techniques. We examine the effectiveness of EGJR and laparoscopic gastrojejunal revision for weight regain after Roux-en-Y gastric bypass.

Methods: A retrospective review was conducted of 83 patients who underwent EGJR using interrupted suture technique for weight regain. Weights from pre and post-revision, intraoperative factors, and complications were collected and analyzed. For comparison purposes, a literature search was conducted using PubMed, MEDLINE, to identify peer-reviewed original and review articles using the keywords "gastrojejunostomy revision", "gastric bypass revision", "weight regain", "gastric bypass", “pouch revision”. A total of 649 articles were identified. Selected for articles where revision was done for failure of weight loss or weight regain and the technique performed included laparoscopic revision of the gastrojejunal anastomosis and/or the gastric pouch. Articles were required to report follow up in terms of BMI/%EWL at specific time intervals between 3 months and 24 months.

Results: EGJR were performed in 83 patients (84% female, mean age: 50.6, BMI: 42.5 kg/m2). Technical success (stoma diameter ≤10 mm) was achieved in all cases. No immediate major complications or readmissions were reported. BMIL at 3, 6, and 12 months was 2.8 ± 2.0 (N = 42), 3.1 ± 2.4 (N = 22), 2.1 ± 3.0 (N = 12) kg/m2 respectively (Figure 1). Seven articles met the selection criteria with a total of 112 pooled patients. BMIL at 3, 6, and 12 months was 5.97 ± 1.22, 5.43 ± 1.23, and 7.55 ± 1.19 kg/m2 respectively (Figure 2).

Discussion/Conclusion: RYGB is an effective treatment for class II-III obesity and related comorbidities but is associated with a high incidence of weight regain, reported at 60% after five years [14]. The etiology of weight regain is multifactorial with multiple treatment options available. One option to address weight regain is through reduction of the gastrojejunostomy, a restrictive procedure. Although restriction plays a limited role in the initial weight loss after RYGB given a primarily physiologic, not mechanical mechanism of action, it does play an important role in long-term weight maintenance. In our study, EGJR had a lesser impact on weight loss when compared to laparoscopic gastrojejunostomy revision. However, as a less invasive procedure with fewer complications, EGJR may still be considered as part of the algorithm for addressing weight regain after RYGB.

Conference that the research was submitted or presented at, and/or journal title and date where research was published: ASMBS Obesity Week 2018

Preference of poster vs. podium presentation: Poster

Management of a Rectourethral Fistula After Fournier’s Gangrene: A Case ReportGian-Paul Vidal MD, Kushan Radadia MD, Nick Farber MD, Alexander Rossi MD, Jeremy Sinkin, MD, Urologist MD. Nell Maloney Patel, MD

Introduction: Rectourethral fistulas are a rare condition that are usually iatrogenic or traumatic in nature. Causes include but are not limited to infection, surgery, and radiation, usually in the treatment of prostatic or rectal cancer. The incidence has been reported to be about 1-3%. Case Presentation:The patient is a 43-year-old male with a history significant for morbid obesity and non-insulin dependent diabetes mellitus who initially presented to our institution with Fournier’s Gangrene. He had a prolonged post-operative course requiring multiple surgical perineal debridements. He then formed a rectourethral fistula that required urinary and fecal diversion with a suprapubic catheter and an end colostomy. He later developed a large parastomal hernia as well as a distal urethral stricture that has required after multiple dilatations. After a multidisciplinary discussion with urology, colorectal, and plastic surgery, he was taken to the operating from for a transperineal closure his fistula which included a cystoscopy to visualize the fistula, take down of the fistula with primary closure of both the urethra and rectum, and a pedicled Gracilis interposition flap. Post-operatively, he recovered well. He had the suprapubic catheter removed. He was discharged to rehab with a Foley catheter in place for a month, with plans to evaluate his rectum and possibly reverse his colostomy. Conclusion:Rectourethral fistulas can occur iatrogenically after surgery. Here we described a case where a young man developed a fistula after multiple surgical perineal debridements for Fournier’s Gangrene. He was initially treated with urinary and fecal diversion temporarily and has undergone a closure of the fistula via a transperineal approach with a pedicled gracilis flap.

Indoleamine 2,3-dioxygenase provides adaptive resistance to immune checkpoint

inhibitors in hepatocellular carcinoma.

Zachary J. Brown1,2, Su Jong Yu1,3, Bernd Heinrich1, Chi Ma1, Qiong Fu1, Milan Sandhu1,

David Agdashian1, Qianfei Zhang1, Firouzeh Korangy1, Tim F. Greten1

1 Gastrointestinal Malignancy Section, Thoracic and Gastrointestinal Oncology Branch,

Center for Cancer Research, National Cancer Institute, National Institutes of Health,

Bethesda, MD 20892, USA

2 Rutgers Robert Wood Johnson Medical School, Department of Surgery, New

Brunswick, NJ.

3 Department of Internal Medicine and Liver Research Institute, Seoul National

University College of Medicine, Seoul, Korea

Presenter Name: Zachary J. BrownPI: Tim F. Greten

Introduction:

Hepatocellular carcinoma (HCC) is the second leading cause of cancer related death

worldwide. Immune checkpoint blockade with anti-CTLA-4 and anti-PD-1 antibodies has

shown promising results for treatment of patients with advanced HCC. The anti-PD-1

antibody, nivolumab, is now approved for patients who have had progressive disease on

the current standard of care. However, a subset of patients with advanced HCC have

failed to respond to therapy. Here we provide evidence of adaptive resistance to

immune checkpoint inhibitors through upregulation of indoleamine 2,3-dioxygenase

(IDO) in HCC.

Methods:

The drug 1-methyl-D-tryptophan (1-D-MT) and epacadostat, which have been shown to

inhibit IDO, were utilized alone or in combination with a CTLA-4 or PD-1 blocking

antibody in treatment of mice with subcutaneous and orthotropic HCC. Induction of IDO

RNA in tumor cells was evaluated by quantitative polymerase chain reaction (qPCR).

Results:

Anti-CTLA-4 treatment caused an induction of IDO in resistant HCC tumors but not in

tumors sensitive to immune checkpoint blockade. Using both subcutaneous and hepatic

orthotopic models, we found that the addition of an IDO inhibitor increases the efficacy

of treatment in HCC resistant tumors with high IDO induction. Further, in vivo

neutralizing studies showed that the IDO induction by immune checkpoint blockade was

dependent on IFN-. Similar findings were observed with anti-PD-1 therapy and with the

IDO inhibitor epacadostat.

Conclusion:

These results provide evidence that IDO may play a role in adaptive resistance to

immune checkpoint inhibitors in patients with HCC. Therefore, inhibiting IDO in

combination with immune checkpoint inhibitors may add therapeutic benefit in tumors

which overexpress IDO and should be considered for clinical evaluation in HCC.

Brown ZJ, Yu SJ, Heinrich B, Ma C, Fu Q, Sandhu M, Agdashian D, Zhang Q, Korangy F,

Greten TF. Indoleamine 2,3-dioxygenase provides adaptive resistance to checkpoint

inhibitors in hepatocellular carcinoma. Cancer Immunology, Immunotherapy 2018:1-11.

doi:10.1007/soo262-018-2190-4. PMID: 29959458

Title: Integrating the DiSC® Model into Intramural Leadership Training within General Surgery Residency to facilitate improvement in team communication and dynamics

Authors: William A. Burns MD and Nell Maloney Patel MD

Purpose: Communication skills are now represented in the ACGME core competencies and are recognized as an important part of developing future surgeons. We believe DiSC® training in residency will enhance the communication skills of residents when used as a platform for feedback on team communication using DiSC® comparison reports.

Method: As part of a residency leadership curriculum, we integrated the DiSC® comparison tool during multiple sessions. This tool provides a context for how different communication styles work with each other and identifies areas of possible conflict and areas of like-mindedness. A year in review usability and effectiveness survey was completed at the end of the year.

Results: The needs assessment survey indicated residents felt communication training was important, 64% (18/28) marked Strongly Agree, 36% (10/28) marked Agree. In contrast, only four percent (1/28) marked Strongly Agree and 18% (5/28) marked Agree when asked if they had received adequate training on communication. The year in review survey indicated residents felt DiSC® was useful throughout the year, 60% (17/28) marked Strongly Agree, 36% (10/28) marked Agree. In addition 32% (9/28) marked Strongly Agree, 43% (12/28) marked Agree when asked if they were able to implement what they had learned into practice. Finally, 61% (17/28) marked Strongly Agree and 36% marked Agree for the intended use of DiSC® beyond residency.

Conclusion: DiSC® training provides residents with insight into their communication style and how they may be perceived by others in their interactions. The value of DiSC® is the ability to impact communication styles in variable settings.

Title: Earplug Umbilicoplasty: A Simple Method to Prevent Umbilical Stenosis in a Tummy Tuck

Presenter Name: Milind D. Kachare, MD

PI: Bradon J. Wilhelmi, MD

Co-authors: Swapnil Kachare, MD, Christina Kapsalis, BS, Milind Kachare, MD, Andrea Hiller, BS, Sara Abell, BS, Thomas J. Lee, MD, Bradon J. Wilhelmi, MD

Institution: Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, University of Louisville, Louisville, KY

Introduction: An aesthetically pleasing umbilicus is a vital component of patient satisfactionfollowing an abdominoplasty. An umbilicus that is moderate to small is desiredto achieve the best aesthetic result, but a small umbilicus has potential for stenosis.This article presents a method for umbilical stenting that creates a modest umbilicus,while preventing stenosis.

Methods: All patients underwent abdominoplasty with an umbilical reconstruction using an inverted U-flap method between 2015 and 2017. An earplug was placed into the umbilicus at 2 weeks postoperatively for a total of 4 to 6 week. Patients were evaluated subjectively on the aesthetic outcome.

Results: Twenty one female patients were evaluated 6 weeks postsurgery. In all cases, both the patient andthe surgeon were 100% satisfied with the final size. Umbilical size ranged from 1.8 to2.2 cm.

Discussion/Conclusion: Use of an earplug for umbilical stenting is a simple and reproduciblemethod to create an aesthetically pleasing umbilicus and avoid stenosis.

Published: EPlasty

Title: DaVinci Assisted Take Down of Iatrogenic Rectovaginal Fistula Through a Posterior Vaginectomy.”


PI: Nell Maloney Patel, MD

Co-authors: O. Zumba, M. Kachare, L.R. Rodriguez, N.M. Patel

Institution: RWJUH

Introduction: A rectovaginal fistula (RVF) is an epithelial lined tract between the rectum and vagina. This can result in recurrent urinary tract or vaginal infections, but also creates a significant psychosocial burden for the patient. Unfortunately, due to the individual complexities of these patients, they are difficult to manage despite the numerous surgical options presently described.

Generally RVFs are classified as low, middle or high, due to the location of the rectal and vaginal opening. Due to this, both low and middle RVFs may be approached via anal, perineal or vaginal routes. Where as high RVFs, which have their vaginal opening near the cervix, generally require an abdominal approach for repair.

Traditionally for high RVFs patients underwent open surgery; however, minimally invasive surgery has recently been widely accepted as the preferred approach. Although surgeons are becoming more facile with these approaches, both pelvic surgery and a reoperative abdomen still impose significant technical difficulties. Here, we present the video of a female with a complex surgical history including a hysterectomy, bilateral salpingo-oopherectomy, creation and reversal of a Hartmann’s colostomy as well as a loop ileostomy due to a locally advanced recto-sigmoid cancer, who subsequently developed a rectovaginal fistula and was managed minimally invasively with a multidisciplinary novel approach through a posterior vaginectomy; an approach that utilized the enhanced magnification of the Robot, which improved visualization and allowed access into an uninflamed, virgin plane, resulting in minimal loss of vaginal length.

Methods: Take Down of a Rectovaginal Fistula through a Posterior Vaginectomy using the Da Vinci Robotic System

Results: Intra-operatively it was noted that the patient had two fistulas, a rectovaginal fistula as well as a recto-cervical fistula, which required additional dissection and ultimately a coloanal anastomosis. However, due to the approach, minimal Patient’s post-operative course was uneventful and she was discharged home on post-operative day three.

Discussion/Conclusion: Rectovaginal fistulas are extremely challenging to manage. Currently, there is scant literature on determining the optimal approach due to the intricate nature of this disease. Additionally with the advent of minimally invasive techniques, the decision algorithm has increased in complexity. In this particular case, both Gynecologic Oncology and Colorectal Surgery used the Da Vinci robotic system together in a novel approach towards a high rectovaginal fistula in a complex patient.

Presented at ACS conference 2018

Title: An Anatomical Study to Propose the Necessary Nerve Block to Ensure Adequate Anesthesia to the 5th Digit.



Co-authors: M. Kachare, S. Kachare, L. Meredith, B. Vivace, C. Kapsalis, and B. Wilhelmi.


Introduction: An anatomical study to evaluate the adequacy of a single injection volar block in order to provide anesthesia to the dorsum of the distal phalanx of the fifth digit.

Methods: Dissections were carried out on six different cadaveric upper extremities to locate the terminal digital sensory branches of the fifth digit.

Results: This study found that for five specimens, three had innervation to the dorsum of the distal phalanx of the fifth digit from the digital branches of the dorsal cutaneous branch of the ulnar nerve (DCBUN). The other two specimens had innervation to this area via the proper digital nerves from the superficial branch of the ulnar nerve.

Discussion/Conclusion: Due to the immense variability in sensory distribution of the distal 5th digit, the widely accepted volar block may not be adequate coverage of the dorsum of the distal 5th digit, further requiring either the traditional digital block or a supplemental dorsal block.

Submitted: Plastic Surgery Research Council Annual Meeting

Figure 1: Medial and Lateral branches of the DCBUN

Figure 2: Medial and Lateral branches of the DCBUN

Figure 3: Medial and Lateral branches of the DCBUN with markings for visualization

Title: Posterior Interosseous Nerve Graft: Utilizing a Ratio of Surface Anatomy to Predict Length for Digital Nerve Reconstruction



Co-authors: B. Vivace, S. Kachare, L. Meredith, C. Kapsalis, M. Kachare, and B. Wilhelmi


Introduction: Digital nerves are particularly susceptible to injury and are the most commonly damaged peripheral nerve.1 Several options exist for repair, however autologous nerve grafts remain the superior option.2 Multiple sites for donor nerves exist, yet each carries its own risks. The distal sensory terminus of the posterior interosseous nerve (PIN) provides primary innervation to the dorsal articular capsule of the wrist.3 Harvesting of this nerve leaves no clinically detectable deficit in proprioception of the wrist or sensation of the forearm and is of similar cross sectional area of the distal digital nerves. 2,4

The length of PIN available may vary by patient size. In this study we sought to develop a method to accurately predict the length of PIN in regards to individual patient anthropometry.

Methods: Data Source: Fresh frozen cadaveric upper extremity specimens were obtained from the Acland Fresh Tissue Lab at the University of Louisville.Study: Several anthropometric measurements of the upper extremity were obtained in order to develop a reproducible ratio. Dissection of the radial nerve with isolation of PIN was performed. The nerve was then resected proximally to the last muscular branch and distally to its disappearance in the dorsal wrist capsule in order to obtain accurate length.Statistical Analysis: A Pearson Correlation was performed in order to obtain a reproducible ratio. Once the ratio for PIN length to ulna length was determined to be 0.25, a calculated PIN length was obtained. The measured and calculated PIN lengths were compared using a t-test.

Results:7 specimens, 4 males and 3 females, were dissectedOn average:

Length of the PIN was 6.33 cm (range: 4.9 -9.6 cm) Length of the ulna was 25.8 cm (range: 23.8- 30.6 cm) The ratio of PIN to ulna length was 0.248 with a R = 0.783

Using one-fourth (0.25) the length of ulna, the mean predicted length of the PIN was 6.46 cm (range: 5.92 - 7.65 cm)

On univariate analysis, there was no significant difference between the measured and predicted PIN length, p=0.73

Discussion/Conclusion: Anthropometric ratios predicated on reproducible surface anatomy can be a

viable and useful tool in predicting the available nerve length for potential digital nerve reconstruction in cadaveric specimens.

Using a ratio of one-fourth the length of the ulna, the predicted length of the sensory PIN available for harvest in a cadaver was not significantly different than the actual measured length in a reproducible fashion.

Further studies may prove useful in relating patient anthropometry to predicting the total harvestable length available of other potential donor nerves.

Presented at 2019 American Society for Peripheral Nerve Annual Meeting

Figure 2: Specimen 6: PIN with final branch to extensor

indicis muscleFigure 3: Specimen 6: PIN length

Title: Anthropometric Ratio to Accurately Predict the Injection Site of the Posterior Interosseous Nerve



Name of Co-authors: S. Kachare, B. Vivace, L. Meredith, C. Kapsalis, M. Kachare, and B. Wilhelmi


Introduction: Chronic wrist pain is a debilitating and common ailment with a multifaceted etiology.1 Several treatment options have been developed including partial to total arthrodesis, proximal row carpectomy, and wrist denervation.2 More recently, partial denervation of the PIN alone has shown to be similarly effective at alleviating pain with a single dorsal incision.3

In order to establish potential usefulness of denervation, diagnostic injection of local anesthetic is required. However, it is paramount the injection be accurate to provide adequate blockade of the PIN, or a false negative result may preclude patients from a beneficial procedure.4 A previous anatomical study stated that using a distance of 1cm ulnar to the proximal aspect of Lister’s tubercle can accurately provide injection for the PIN.5 However, no anatomical study exists describing the site of injection accounting for individual wrist width. We sought to develop a reproducible anthropometric ratio utilizing external wrist surface anatomy to predict a safe and accurate injection site for the PIN.

Methods:Data Source: Fresh frozen cadaveric upper extremity specimens were obtained from the Acland Fresh Tissue Lab at the University of Louisville.Study: In specimens 1 and 2, gentian violet dye was placed 1cm ulnar to Lister’s tubercle using modified Seldinger’s Technique. Dissection of the radial nerve with isolation of PIN was performed and intraneural injection was noted in specimen 2. Several anthropometric measurements were obtained in order to develop a reproducible ratio to calculate location of injection. We hypothesized that using ¼ the distance ulnar from proximal aspect of Lister’s tubercle to the radial aspect of ulnar styloid would provide more accurate injection. In specimens 3 - 7, ¼ the distance from Lister’s tubercle to the ulnar styloid was calculated for the site of injection. Following injection, each of the specimens were dissected and location of injection in relation to the PIN was identified.

Results:

7 total cadaver forearms, 4 male and 3 female were dissected. On average, male arms had a greater distal wrist circumference compared to

female arms, 17.9cm vs. 13cm, p=0.0005. Injection at one-fourth the distance ulnar from the proximal edge of Lister’s

tubercle to the radial aspect of the ulnar styloid resulted in 100% accurate perineural injection without intraneural injection.

This calculated ratio was more accurate than using a standard location of 1cm ulnar to the Lister’s tubercle.

Discussion/Conclusion: An anthropometric ratio of ¼ the distance ulnar from the proximal edge of Lister’s tubercle to the radial aspect of the ulnar styloid is able to predict accurate injection sites for the distal PIN in cadaveric specimens of varying anatomical proportions.Further cadaveric and translational studies are necessary to better determine the clinical implications of our findings, as the use of our calculated ratio may mitigate nerve damage via intraneural injection and bolster the sensitivity and specificity of diagnostic PIN block prior to denervation.

Presented at 2019 American Association for Hand Surgery Annual Meeting

Figure 1: Specimen 6:Dissection of PIN with Location of Perineural

Injection

Figure 2: Specimen 6: Location of Perineural

Title: Short-Term Outcomes in Cardiac Surgery with Pre-operative ADP-Inhibitor Use: A Propensity-matched Analysis

Presenter Name: Michael Lee

Name of PI: Leonard Lee

Co-authors: Christopher Bargoud, Hannah Rhee, Anna Olds, Russell Pepe, Viktor Dombrovskiy, M.D., Ph.D, Anthony Lemaire, M.D., Aziz Ghaly, M.D., and Leonard Lee, M.D.

Institution: RWJUH

Introduction: Post-operative bleeding is a persistent problem after cardiac surgery, and has been associated with other significant post-operative complications. While there have been attempts to create bleeding risk scores for these patients, none have established widespread use. Many patients undergoing cardiac surgery are receiving preoperative dual antiplatelet therapy (DAPT) to prevent thrombus formation. Previous studies have demonstrated increased post-operative bleeding in these patients who undergo CABG, but not for other types of cardiac surgeries. In this study we aim to understand whether use of pre-operative DAPT in patients undergoing cardiac surgeries results in increased post-operative bleeding, morbidity and mortality.

Methods: We performed a retrospective cohort study for patients undergoing cardiac surgery at Robert Wood Johnson Medical Center between years 2012-2017. The operations included were divided into 5 categories: CABG (Coronary Artery Bypass Grafting) only, Aortic Valve Replacement (AVR) only, Mitral Valve Replacement (MVR) only, and Valve (AVR, MVR, mitral valve repair) + CABG. Patients who received ADP inhibitors within 5 days prior to surgery were compared to patients who held this therapy 5 days prior to surgery. To account for differences in case mix, propensity matching was utilized. The primary outcomes of interest was post-operative bleeding requiring transfusion, with secondary outcomes including length of stay (LOS), mortality, ventilator time, length of stay in the intensive care unit. Multivariate logistic regression and generalized linear modeling were used to mitigate covariate confounding.

Results: 4935 patients were reviewed in this study. A total of 578 patient underwent ADP inhibitor cessation prior to surgery, and were propensity matched to 578 patients who had received this therapy. There were no intergroup differences for matched characteristics. In our multivariate analysis, the use of ADP-inhibitors within 5 days of surgery was found to be an independent predictor of bleeding requiring transfusion overall [OR = 1.4391 (95% CI: 1.1777 – 1.8827), p = 0.0009]. More specifically, it was independently predictive for CABG procedures [OR = 1.3572 (95% CI: 1.0286 – 1.7909), p = 0.0308], AVR [OR = 2.3913 (95% CI: 1.1958 – 4.7822), p = 0.0129], and MVR [OR = 4.6154 (95% CI: 1.5780 – 13.4991), p = 0.0043], but not Valve + CABG

[OR = 0.6623 (95% CI: 0.2926 – 1.4994), p = 0.3245]. Thirty-day mortality rates in both groups were similar [p = 0.1377] for all surgical subgroups.

Discussion: In this study, we demonstrated that ADP inhibitor prior to cardiac surgery was associated with increased bleeding in multiple types of surgeries, although this ultimately did not affect mortality or other post-operative complications. Because post-operative morbidity and mortality were not affected by pre-operative ADP inhibitor use, the use of ADP inhibitors immediately prior to cardiac surgery may not be considered a highly risky practice.

Does thyromegaly with tracheal deviation or substernal extension pose high risk of acute airway compromise?

Yaqeen Qudah, M.D. and Jessica S. Crystal, M.D., Jason Wade, M.D., Stanley Z. Trooskin, M.D., Tomer Davidov, M.D.

Introduction: Thyromegaly with tracheal deviation and substernal extension is an indication for surgery in part because of concern for acute airway compromise. However, the exact risk is unclear.

Methods: CT scans of the neck or chest from 2009-2017 performed at a single hospital were queried for findings of thyromegaly with substernal extension, tracheal deviation, or tracheal compression. The charts of these patients were retrospectively reviewed to determine whether acute airway compromise with sudden intubation was required.

Results: A total of 682 scans were queried, revealing 209 patients whose scans demonstrated substernal extension or tracheal deviation or compression. Nineteen patients required intubation, of which 18 were emergent. Eighteen of these 19 patients had confounding cardiopulmonary problems. One patient intubated for a suspected substernal goiter was found to have metastatic anaplastic thyroid cancer. No patients required cricothyroidotomy or urgent tracheostomy. There were no mortalities related to sudden airway compromise. Six patients progressed to surgery, one of whom required sternotomy. Of 209 patients, 125 patients (60%) were asymptomatic with CT findings incidentally discovered. Eighty-four patients (40%) presented with symptoms in part related to thyromegaly: dyspnea, dysphagia, chest pain, neck pain, or visible neck mass. Of these 84 patients, 76 (90%) had other confounding cardiopulmonary problems.

Conclusion: While thyromegaly with substernal extension or tracheal deviation may be an indication for thyroidectomy in part to prevent sudden airway compromise, the majority of patients with these CT findings are asymptomatic and only rarely do these patients sustain an airway emergency.

WEIGHT LOSS AFTER SLEEVE GASTRECTOMY IN MICE INVOLVES A LEPTIN-DEPENDENT BUT FXR-INDEPENDENT MECHANISMPIs: Yi-horng Lee & Grace GuoAuthors: Monica Chow, Andrew Wassef, Bo Kong, Laura Armstrong, Justin Schumacher, Daniel Rizzolo, Jianliang Shen, Ragui Sadek, Grace Guo, Yi-horng LeeInstitution: Ernest Mario School of Pharmacy, Department of Pharmacology & Toxicology Introduction: Obesity affects 18.5% of children and adolescents in the United States. Many comorbidities are associated with obesity, such as diabetes and steatohepatitis. Sleeve gastrectomy (SGx) leads to weight-independent improvements in various comorbidities, but via unclear mechanisms. Leptin is an appetite-suppressing hormone secreted by adipose tissue. Farnesoid X receptor (FXR) is a nuclear hormone receptor involved in the regulation of lipid and glucose metabolism. We therefore hypothesized that weight-loss and improvements after SGx may be secondary to an FXR-dependent pathway involving decreased leptin resistance. Methods: Wild type (WT, C57BL/6J) and FXR whole-body knock out (KO) mice were fed either a high fat (HFD) or isocaloric control diet (CD) for 3 months prior to undergoing either a SGx or a sham operation. Postoperative weights were recorded weekly. Mice were euthanized at 1, 2, and 3 months after surgery. Leptin levels were analyzed using a magnetic bead assay. Mann-Whitney U test was used to determine significance (p < 0.05). Results: SGx-CD mice sustained a lower percent weight gain at 3 months postoperatively compared to sham-CD mice (1 versus 23, WT and 4 versus 12, FXR) than SGx-HFD mice compared to sham-HFD mice (33 versus 57, WT and 11 versus 22, FXR). SGx-CD mice had decreased leptin levels compared to sham-CD mice at all postoperative time points. Leptin levels were statistically significant in this cohort at postoperative month 3. SGx-HFD mice had decreased leptin levels compared to sham-HFD mice only at postoperative months 1 and 2. These trends were consistent between both WT and FXR KO mice. Conclusion: Decreased leptin resistance is crucial for sustained weight loss, but FXR does not play a significant role in the improvement of leptin resistance. A sustained HFD after SGx can eliminate decreased leptin resistance acquired after SGx.

Title: A Prospective Cohort Study of a Perioperative Bundle to Reduce Surgical Site Infection following Pancreaticoduodenectomy

Presenter Name: Sharon Lawrence

Name of PI: Peter Allen, MD, FACS

Author list: Sharon Lawrence, Alessandra Pulvirenti, Caitlin Mcintyre, Yuting Chou, Mithat Gonen, Vinod Balachandran, T. Peter Kingham, Michael D’Angelica, Jeffrey Drebin, William Jarnagin, and Peter J Allen

Institution: Memorial Sloan Kettering Cancer Center

Introduction: Pancreaticoduodenectomy is historically associated with incisional surgical site infection (iSSI) rates between 15-20%. Prospective studies have been mixed with respect to the benefit of individual interventions directed at decreasing iSSI. We hypothesized that the application of a perioperative bundle during pancreaticoduodenectomy would significantly decrease the rate of iSSI.

Methods: An initial cohort of 150 consecutive post-pancreaticoduodenectomy patients were assessed within 2-4 weeks of operation to determine baseline iSSI rates. The Centers for Disease Control definition of iSSI was utilized. A four-part perioperative bundle was then instituted for the second cohort of 150 patients. This bundle consisted of a double ring wound protector, gown/glove and drape change prior to fascial closure, irrigation of the wound with bacitracin solution, and a negative pressure wound dressing over the skin closure left in place until postoperative day 7, or day of discharge. 300 patients provided 80% power to detect a 50% risk reduction in iSSI.

Results: Cohorts 1 and 2 were similar with respect to age (68 vs 69 yrs, p=0.92), gender (male, 51% vs 55%, p=0.64), BMI (26 vs 26, p=0.99), neoadjuvant therapy (32% vs 25%, p=0.37), median operative time (222 vs 215 min, p=0.36) and the presence of a preoperative stent (79% vs 62%, p=0.064). The iSSI rate was 22.3% in the initial cohort. This rate was higher than both our institutional database (13%) and NSQIP reporting (11%). Within cohort 2, the iSSI rate decreased significantly to 10.7% (n=15; p=0.01). All four components of the bundle were utilized in 91% of cohort 2 patients.

Conclusion: In this cohort study of 300 consecutive patients who underwent pancreaticoduodenectomy, the implementation of a four-part bundle decreased iSSI from 22% to 11%.

Title: Use of Quantitative Image Analysis and Cyst Fluid Inflammatory Markers to Predict Risk in Intraductal Papillary Mucinous Neoplasms

Presenter Name: Sharon A Lawrence

Name of PI: Amber L. Simpson, PhD

Author List: S.A. Lawrence, MD, J. Chakraborty, PhD, M.A. Al Efishat, MD, M.A. Attiyeh, MD, G. Askan, MD, Y. Chou, BA, A. Pulvirenti, MD, C.A. McIntyre, MD, M. Gonen, PhD, O. Basturk, MD, V.P. Balachandran, MD, T.P. Kingham, MD, M.I. D’Angelica, MD, W.R. Jarnagin, MD, J.A. Drebin, MD, P.J. Allen, MD, R.K. Do, MD, PhD, A.L. Simpson, PhD

Institution: Memorial Sloan Kettering Cancer Center

Background: Intraductal papillary mucinous neoplasms (IPMNs) represent cystic precursor lesions of pancreatic cancer with varying levels of risk for progression to malignancy based on degree of dysplasia. We sought to combine existing tools for identifying lesions with the highest risk of progression into one prediction model that can identify high-risk IPMNs.

Methods: An institutional database was queried for patients with resected branch duct or mixed type IPMN, cyst fluid available for analysis, and high quality preoperative abdominal CT scans. A previously described predictive nomogram combining clinical features with cyst fluid inflammatory marker (CFIM) analysis was applied to patient data. CT scans were analyzed to extract quantitative imaging (QI) features describing variations in CT enhancement patterns known to be predictive of grade of dysplasia in IPMN and previously validated in a larger cohort. The nomogram predictive score and QI model risk score were than combined to build a predictive model.

Results: Thirty-three patients were included in the final analysis, with 21% (n=7) classified as high-risk based on degree of dysplasia, and the remaining 79% (n=26) classified as low-risk. The cohort was 55% male (n=18), and median age at operation was 72 years (IQR 63-76). Worrisome radiographic features were present in 52% of patients (n=17). Combination of the clinical nomogram with CFIMs was predictive of high-risk lesions, with an area under the receiver operating characteristic curve (AUC) of 0.74. The addition of QI features further improved the predictive value of the preoperative model, yielding an AUC of 0.88.

Conclusion: Quantitative imaging combined with clinical features and CFIMs may be developed to reliably predict which IPMNs are high-risk. Although further validation with a larger cohort is needed, this model may represent a highly accurate tool for preoperative patient assessment.

Title: Inhibition of bone morphogenic protein receptor 2 increases mitochondrial permeability and the downregulation of XIAP in lung cancer cells

Presenter: Rachel NeMoyer

Authors (identify in bold the PI/Faculty sponsor for the project): Dr. John Langenfeld

Introduction: Bone morphogenetic protein receptor (BMP) inhibitors have been shown to induce death of lung cancer cells, which involves the downregulation of x-linked inhibitor of apoptosis protein (XIAP). XIAP is a potent inhibitor of executioner caspases that promotes resistance to many chemotherapeutic agents.

Methods: The mechanism by which inhibiting BMP signaling downregulates XIAP has not been elucidated.

Results:We find that the BMP inhibitors JL5 and DMH2 downregulate XIAP and enhances cell death of TRAIL, Taxol, and AEG a Smac mimetic. JL5, which inhibits both type I and type II BMP receptors, enhances cell death of cancer therapeutics by decreasing the expression of XIAP, which leads to an increase in caspase activity. The downregulation of XIAP is mediated by the inhibition of the BMP type II receptor and not the BMP type I receptors. Knockdown of BMPR2 but not the BMP type I receptors increases mitochondrial permeability resulting in the release of cytochrome c and Smac/Diablo into the cytosol.

Conclusions: These studies suggest that the inhibition of BMPR2 increases cytosolic Smac/Diablo that inhibits XIAP enhancing apoptotic cell death of cancer therapeutics.

Title: OncotypeDx risk stratification in early stage breast cancer: when is accelerated partial breast irradiation (APBI) safe?

Presenter Name: Ashley Newman, MD

Name of PI: Laurie Kirstein, MD

Name of Co-authors (in appropriate order): Lior Z. Braunstein, Atif J. Khan, Gulisa Turashvili, Hannah Y. Wen, Emily Zabor, Michelle Stempel, Monica Morrow

Institution (especially if not at RWJUH): Memorial Sloan Kettering Cancer Center

Introduction:Radiation therapy after breast conservation surgery significantly reduces the risk of local recurrence. It is unclear if there is a difference in local recurrence risk in patients who undergo whole breast irradiation vs. APBI. The OncotypeDX Recurrence Score(RS) (TM Genomic Health, Redwood CA) has been shown to be prognostic and predictive for both local and distant recurrence in women with ER+, HER2- breast cancers. The purpose of this study was to determine the relationship between the OncotypeDX RS and short term outcomes in patients undergoing APBI in conjunction with breast conservation therapy.

Methods: After IRB approval, patients at a single institution who underwent APBI between 2010-2015 were retrospectively identified. Patients were typically considered for APBI based on the 2009 ASTRO guidelines, and the final decision for radiation approach was based on patient and physician preference. Patients who had OncotypeDX RS were included in our study. During the study period OncotypeDX RS was routinely obtained on ER+, HER2-, node negative patients with tumors between 0.5cm-5cm in size. Data was collected on patient and tumor characteristics, including tumor size, nodal status, hormone receptor status, and Recurrence Score. The OncotypeDX RS categories used were low risk: <18, intermediate risk: 18-30, and high risk: >30. Categorical variables were compared using Fisher’s exact test.

Results:107 patients were identified, with a mean age of 62 years. All were T1N0, except one patient who was T2N0. Median follow-up time was 3.9 years (range: 0.1 - 7.1). Four patients (3.7%) had high risk, 36 (33.6%) had intermediate risk and 67(62.6%) low risk RS. There were only two ipsilateral in breast recurrences within our cohort, one in the intermediate (at 3 years) and one in the high risk group (at 5 years). Because of the low event rate, a statistical evaluation of the difference in recurrence risk groups could not be performed. Hormone receptor status was the only difference amongst patients of different recurrence scores, with progesterone receptor positivity being more common amongst patients with low and intermediate scores (P<.001).

Discussion/Conclusion:Our experience reveals a low in-breast recurrence rate among patients with early stage, node negative breast cancer who undergo breast conservation and APBI with a low or intermediate OncotypeDX risk score. These results are reassuring for those patients interested in APBI, who exhibit low or intermediate-risk OncotypeDX RS. More data are needed to characterize the implications of APBI among patients with a high OncotypeDX RS.

Conference that the research was submitted or presented at: ASTRO annual meeting 2018.

Title: The Role of the Axillary Impella 5.0 Device on patients with Acute Cardiogenic ShockPresenter name: Saeed TarabichiName of PI: Anthony LemaireName of Co-authors: Aziz Ghaly* MD, David Adekanye BA, Hirohisa Ikegami MD, Leonard Y. Lee MD, and Anthony Lemaire MDInstitution: RWJIntroduction: Acute cardiogenic shock is associated with high mortality rates. The Impella device is a microaxial left ventricular assist device that can be inserted through the axillary artery. The purpose of our study is to determine the role of the Axillary Impella devices on patients with acute cardiogenic shock. Methods: A retrospective chart review was conducted to identify patients who underwent Axillary Impella device placement for acute cardiogenic shock from January 1st 2014 to September 30th 2018 at a single institution. In-patient records were examined to determine duration of device, length of stay (LOS), postoperative complications, and 30-day in-hospital mortality. Results: A total of 40 patients, who were primarily men (N=29) with a mean age of 61.2±10.7 years old, underwent Axillary Impella placement for cardiogenic shock. The primary reasons for implant were (1) required upgraded support from an Impella CP or intra-aortic balloon pump (iabp) to Impella 5.0, (2) to treat left ventricular (LV) distention for patients on extracorporeal mechanical oxygenation (ECMO), and (3) to provide longer term support and allow for mobilization of the patients. Twenty-three of the patients had previous devices already in place including a Femoral Impella CP device or an iabp and 9 patients were on ECMO support. The duration of the device was 21.05±17 days with the LOS of 40.8± 28 days for those patients. Seventeen of the patients went on to additional surgery including (1) Heartmate 3 device placement (N=6), (2) other cardiac procedures such as surgical revascularization (N=9), and orthotopic heart transplantation (N=2). A total of 21 patients of the 40 (52%) died during their hospitalization with 7 patients (17%) having complications related to the Impella device. These complications included right arm ischemia or neuropathy (N=3) and Impella malfunction requiring device replacement (N=4). The majority of these devices were placed in the right axillary artery (N=38) versus the left axillary artery (N=2). Conclusions: A total of 58% (N=23) of the study patients had previous mechanical support and 23% (N=9) were on ECMO demonstrating the severity of disease and accounting for the high mortality. The Axillary Impella device allows for a minimally invasively placed device that is durable with a mean duration of 3 weeks. The Axillary artery Impella 5.0 provides upgraded full cardiac support while allowing for mobilization of the patient. In addition, it treats LV distention in patients on ECMO while avoiding sternotomy. Finally, the Axillary Impella provides time for decision making for additional therapy with either long-term devices or orthotopic heart transplant.Conference: International Society for Minimally Invasive Cardiothoracic Surgery

Title Complicated Gallstone Disease in Pediatric Cholecystectomy Patients Presenter Name Jason Wade Name of PI Yi-Horng Lee Name of Co-authors (in appropriate order) Elizabeth Day, C.R. Cadman, Jason Wade, MD, Yi-Horng Lee, MD Institution Rutgers-RWJ Introduction The incidence of gallstone disease and cholecystectomy in children has been rising over the past 20 years. This can be attributed to improved ultrasound diagnostics, less invasive surgical techniques, and increased prevalence of obesity. Pediatric patients treated with cholecystectomy often have complicated gallstone diseases. The purpose of this study is to determine the incidence and associated risk factors of complicated gallstone disease in pediatric patients undergoing cholecystectomy at a single institution. Methods Pediatric patients (< 19 years old) who have undergone cholecystectomy at a single center between January 1, 2010 and July 30, 2017 were reviewed. 155 patients were identified by querying medical records using CPT codes for cholecystectomy. Associated gallstone diseases were identified by reviewing the medical records, including imaging studies, laboratory values and pathology reports. Patients with a postoperative diagnosis of acute or chronic cholecystitis, cholangitis, gallstone pancreatitis, and choledocholithiasis were considered to have complicated gallstone disease. Mann-Whitney tests were performed to compare age and BMI distribution between uncomplicated and complicated gallstone diseases. Fisher’s exact test was used to analyze gender distribution. Significance is defined as p<0. 05 Results The mean age of pediatric cholecystectomy patients was 14.7 years old. 77% of the patients identified were female. 56 patients (36%) were diagnosed with complicated gallstone disease: 26 acute/chronic cholecystitis, 19 gallstone pancreatitis, and 13 choledocholithiasis. 2 patients were diagnosed with both gallstone pancreatitis and choledocholithiasis and were included in both groups. None had the diagnosis of cholangitis. There were no differences in age and gender distribution. However, there was a difference in the distribution of BMI among those who suffered from complicated gallstone diseases. Discussion/Conclusion The majority of the cholecystectomy patients were female. Neither age nor gender is associated with complicated gallstone disease. However, patients with higher BMI are more likely to be associated with complicated gallstone diseases.

Title: The Layperson’s Perception of Congenital Ear Abnormalities and Non-surgical Ear Molding

Authors: Anthony Azzolini, MD; Stuart Campbell, MD; Dan Mazzaferro, MD; Jordan Swanson, MD; Jesse Taylor, MD; Scott Bartlett, MD

Introduction: Congenital ear deformities lead to corrective Otoplasty in some children. There is a brief window of time following birth when infants are candidates for non-operative ear molding. Early recognition remains a cornerstone of this treatment option. The authors intend to administer surveys using crowdsourcing technology to determine which deformities are recognizable by the layperson, and their opinions ear molding.

Methods: Before and after photographs of congenital ear deformities that were treated with ear molding at our institution were reviewed within our department. Mild, moderate, and severe versions of the following types of ears were selected: constricted, cryptotia, cupped/lopped, helical rim deformity, prominent ears, and Stahl’s. One normal appearing ear was used as a control group. Using Amazon’s Mechanical Turk (MTurk) platform, participants were randomly assigned to see one photograph of either the normal ear, or one of the deformed ears. Participants then answered the first series of questions regarding that photo. They were then shown the ear after treatment, and a second series of questions was asked. Statistical analysis was performed using Stata.

Results:Responses were obtained from 983 participants with a mean age of 34. Participants were 60.4% female (n=594). Patients were further categorized as either parents (56.5%, n=555) or non-parents (43.5%, n=428). After randomly assigning each participant to either the normal ear, or one of the multiple abnormal ears, each group had mean of 52 participants. On a 1-10 scale, participants appropriately distinguished between normal (2.4/10) and abnormal ears (5.5/10) of each type (P<0.001). Further, the least abnormally rated ear deformity (mild Stahl’s, 4.2/10), was still rated significantly more abnormal than the normal ear (P<0.001). Across all types of abnormal ears, participants felt the child was likely or highly likely to be bullied (56.39%), and feel embarrassed (62.3%) due to ear appearance. In the normal ear group, the same responses were 5.88% and 3.9% respectively. 54.35% of participants said the children with abnormal ears were either likely or highly likely to seek treatment due to ear appearance. When participants viewed the photo of the abnormal ear after ear molding therapy, 76.6% responded with satisfied or highly satisfied if it was their child.

Conclusion:Ear molding is a viable non-surgical therapeutic option for congenital ear deformities and it carries a high degree of patient satisfaction. Further, it may prevent childhood

exposure to bullying and negative self-image. While the average person is able to identify congenitally deformed ears as “abnormal,” only about half would be likely to seek treatment. The burden of early identification and referral for treatment still largely relies on healthcare providers.

Title: When Should We Perform Frenulectomy for Tongue Tie?: An Evidence-Based Algorithm of Care

Authors: Anthony Azzolini, MD; Stuart Campbell, MD; Rohil Shekher, MD; Scott Bartlett, MD; Jesse Taylor, MD; Jordan Swanson, MD

Background: Ankyloglossia (or tongue-tie) is characterized by a short or thickened lingual frenulum; without treatment this can be associated with impaired breastfeeding, speech, and dentofacial growth. Yet the indications for performing frenulectomy are unclear.

Methods: A meta-analysis was performed to identify the extent of the benefit from frenotomy in the categories of breastfeeding measures, degree of tongue-tie, and maternal pain during feeding in randomized, controlled trials (RCTs). Further, a structured literature review analyzed the optimal type and timing of repair. An algorithm was developed to incorporate this evidence into a patient management pathway.

Results: Among 424 studies reviewed, 5 RCTs met inclusion criteria for meta-analysis. Frenotomy significantly improved the degree of tongue-tie, with a decrease in Hazelbaker Assessment Tool for Lingual Frenulum Function (HATLFF) score of 4.5 points compared to a decrease of 0 in those who did not undergo frenotomy (p<0.00001). This was associated with improved self-reported breastfeeding (RR 3.48, p<0.00001), and decreased pain (Short-Form McGill Pain Questionnaire, p<0.00001); however, Breastfeeding Self-Efficacy – Short Form and LATCH scores did not significantly improve.

Conclusions: Frenotomy is associated with breastfeeding improvements that vary individually but trend toward significance collectively during a critical time in infant development. Among patients with a severe HATLFF score or difficulty breastfeeding, we conclude that simple frenotomy without anesthetics is generally indicated in infants under 4 months of age and z-frenuloplasty under general anesthesia for those over 4 months of age.

Objectives:

As a result of this presentation, the participants will be able to:

List the most widely accepted indications for frenulotomy based on the current literature

Assess the appropriate age for frenotomy based on the improvements in breastfeeding

Compare and contrast different frenotomy procedures

Show reliable data to new mothers of infants with ankyloglossia. This will help alleviate some of the anxiety associated with poor breastfeeding and the need for a procedure.

Provide some standardization to the existing body of literature for continued exploration of this topic

Title: Cranial Bone Graft Barrier Technique: A New Approach to Large Nasal Septal Perforation Repair

Authors: Anthony Azzolini, MD; Stuart Campbell, MD; Francesco Gargano, MD; Matthew Kaufman, MD

Background: Closure of large nasal septal perforations has presented a unique challenge to Rhinology experts and ENT Surgeons. There is currently no surgical technique that has proven superior in the literature. The cranial bone graft barrier (CBGB) technique is a novel new approach that may improve closure rates.

Methods/Materials: In our case series, 5 consecutive patients with symptomatic nasal septal perforations were treated using the CBGB technique. A description of this technique is presented. Patients were followed clinically to determine the success of repair and symptom relief. Results: In all 5 patients, short term follow up has shown 100% closure rate and symptomatic relief. There have been no reported complications in the follow up period.

Conclusion: The Cranial Bone Graft Barrier technique provides a strong, effective, reliable repair for large nasal septal perforations. This technique provides surgeons with a viable alternative to current approaches. Additional results with higher sample size will continue to be studied.

PHOTOS:

Title: Ventricular Shunt Complications in Patients Undergoing Posterior Vault Distraction Osteogenesis

Authors: Anthony Azzolini, MD; Stuart Campblell, MD; Katherine Magoon, MD; Jordan Swanson, MD; Scott Bartlett, MD; Jesse Taylor, MD

Purpose: The primary objective of this study is to investigate peri- and post-operative morbidity, complication, and shunt revision rates of patients with Shunt Dependent Hydrocephalus (SDH) undergoing Posterior Vault Distraction Osteogenesis (PVDO) compared to patients undergoing conventional Posterior Vault Reconstruction (PVR) The secondary objectives of this study are to determine patient characteristics that predispose to shunt complications following PVDO and to compare the shunt-related adverse event rates post-PVDO to subjects with isolated SDH without coexisting craniosynostosis.

Methods/Description: A retrospective case-controlled cohort analysis of all patients undergoing PVDO and PVR for syndromic or complex craniosynostosis was performed. Patients with SDH who underwent shunt placement at our institution were identified from each group, and a comprehensive review of medical records was conducted which included demographic information, perioperative variables, distraction protocols, and shunt-related complications within 90 days of surgery. Shunt-related complications were defined as infections related to the shunt, surgical site infections, surgical revision of shunt, LOS, and readmission. Statistical analysis was computed using STATA.

Results: Fourteen patients with ventricular shunts who underwent PVDO and eight patients with shunts who underwent PVR were identified. There were no shunt-related complications in the PVR cohort. The shunt-related complication rates were significantly higher with PVDO (n=5, 37.5%, p=0.0093). Among the five patients who suffered complications, the most common were shunt infection (n=4, 80%) , shunt malfunction (n=4, 80%), and wound infections (n=3, 60%). Aside from planned distractor removals, all patients with complications required additional operations for shunt revision and/or replacement. Four patients (80%) required multiple takebacks for such procedures, with an average of three additional procedures per patient.

Conclusion: In complex or syndromic craniosynostosis patients who have previously undergone ventricular shunting, PVDO results in higher shunt-related complications and need for additional procedures when compared to traditional PVR. The benefits and advantages of PVDO in these patients must be weighed against this more unfavorable risk profile, with an eye towards reduction of shunt infections and shunt malfunctions.

Title: Academic Productivity in Craniofacial Surgery: Our Experience with a Clinical Research Fellowship

Authors: Anthony Azzolini, MD; Stuart Campell, MD; Jordan Swanson, MD; Scott Bartlett, MD; Jesse Taylor, MD

Purpose: As research productivity is becoming increasingly emphasized in the curriculum vitae of aspiring craniofacial surgeons, the benefits of a clinical research fellowship cannot be understated. Further, clinical research is imperative to examine the successes and limitations of our evolving discipline. The authors report institutional experiences with their model for a clinical research fellowship since its inception in 2013.

Methods: A critical analysis of research productivity was performed for all clinical research fellows from 2013-2018. Academic productivity was determined for each individual fellow as number of peer-reviewed publications, journal, and academic fate. Additionally, the productivity of the three primary investigators in charge of the fellowship was examined before and after implementation of the research fellowship.

Results: A query of academic productivity for the clinical research fellows yielded 120 peer reviewed publications and 234 podium presentations at national/international meetings. Of the publications, 43 (35.5%) were published in Plastic and Reconstructive Surgery, and 42 (34.7%) in Journal of Craniofacial Surgery between 2013 and 2018. Research fellows appeared as authors on an average of 11.5 publications during their time as a fellow, with an average of 3.5 first authorships. Eight of nine fellows went on to pursue a residency position in Plastic Surgery. Those eight fellows have a 100% match rate into integrated or independent plastic surgery residencies. Primary investigators saw an increase in their annual publications in peer-reviewed from 12 per year to 27 per year.

Conclusion: Implementation of a formalized research fellowship within a craniofacial surgery program increases the academic productivity of an institution in a reproducible fashion. Additionally, a research fellowship provides the fellow with the basic research tools and experience to thrive in the increasingly competitive field of craniofacial surgery.

Title: Using Mobile Devices for Intraoperative Performance Assessment

Presenter Name: Karan Grover MD PharmD

Name of PI: Amin Madani MD PhD

Name of Co-authors (in appropriate order): Karan Grover MD PharmD, Charesa Smith BA, Roman Nowgrod MD, James Lee MD, Amin Madani MD PhD

Institution (especially if not at RWJUH): CUMC

Introduction: Surgical training programs are transitioning from the traditional Halstedian apprenticeship model to a competency-based model. Nevertheless, there has been a paucity of effective methods to measure intraoperative performance, and current assessments are limited by either a narrow applicability or generic language prohibiting formative feedback. A need exists for a robust, comprehensive, universal, and objective assessment tool.

The objective of this study is to: 1) develop a novel assessment that comprehensively evaluates all intraoperative skills and is universally applicable to any procedure; 2) incorporate this assessment into a user-friendly, web-based, mobile application; 3) provide evidence for validity and feasibility for its incorporation into surgical training.

Methods: This is a nonrandomized, cross-sectional, prospective study. Attending surgeons rated surgical residents' operative skills (as either primary surgeon or first assistant) using the Intraoperative Performance Assessment Tool (IPAT) after any surgical procedure. IPAT contains 41-items based on the previously published 5-axis intraoperative performance model, which includes: psychomotor skills, declarative knowledge, interpersonal skills, personal resourcefulness, and advanced cognitive skills. Validity evidence will be obtained with respect to internal structure and relationship to other variables. Scores will also be correlated to years of training and total case numbers for each procedure using the appropriate parametric or non- parametric statistical tests. Internal structure will be evaluated by assessing inter-rater and intra-rater reliability on a random sample of 10 subjects using intra-class correlation coefficient. Feasibility of the IPAT will be evaluated by measuring time to completion and a questionnaire circulated to the raters and surgical trainees.

Results: There were a total of 51 residents and 15 attendings in 1 general surgery residency program, who were invited to participate in this pilot study. One-way analysis of variance (ANOVA) was used to determine whether amount of training and experience (indicated by PGY years in this study) influenced mean global assessment scores (GAS). Between all post-graduate year groups, there was a significant difference detected (F = 3.70, P<0.02).Results from two tailed t-tests demonstrated that the senior residents (PGY4-5) were rated significantly higher than their junior residents (PGY1-3) 3.9 vs. 2.6

(p=0.001), respectively. When comparing each individual PGY group with all other PGYs, the GAS for PGY5 residents were significantly higher from PGY1-3 residents (P<0.027, P<0.008, P<0.016 respectively), but not PGY4 residents (P<0.46). Total case volume and total rated cases showed moderate positive linear correlations with GAS (r=0.6, r=0.5) using the Pearson correlation coefficient.

Discussion/Conclusion: Feedback is an essential element for developing professional expertise. The IPAT can measure intraoperative performance to provide trainees with meaningful information on how to improve their skills. Operative assessments have been studied and incorporated into surgical training programs, especially in the UK. Currently, the ABS requires OPRS to be completed for certification. These assessments are specific to procedures and often paper-based. While the IPAT does not yet show a strongly positive correlation between case volumes and global assessment scores, there exists a clear difference between junior and senior residents. The lack of a clear linear relationship may be attributed to the nonlinear nature of learning as well as the small sample size. Interestingly, PGY3s were found to have the lowest GAS of all the groups, however this finding was not statistically significant. We hypothesize that this is due to the higher level of expectations relative to the junior residents. This is consistent with previously published data. The paucity of data makes it difficult to prove the validity of the tool at this time. Data collection from this ongoing study will help us determine the validity of the tool as well as enable us to practically revise the tool in real time to suit the needs of the training program.

Title: Implementing a training program to improve feedback in a surgical residencyPresenter Name: Michael Scott, MDName of PI: Nell Maloney Patel, MDName of Co-authors: William Burns, MD, Brianna Slatnick, MDInstitution: RWJUH

Introduction: Increasing demands on faculty-level surgeons coupled with stricter work restrictions on surgical residents implores methods to improve efficiency in surgical training. Feedback is an essential and highly effective learning tool in surgical education. We seek to include feedback training in our program to improve the culture of feedback at our institution. We propose the Kirkpatrick model, a framework that assesses workplace training initiatives, to evaluate our strategy.

Methods: We surveyed surgical trainees (n=42) for baseline attitudes on feedback. Training modules were done separately with faculty (n=12) and residents (n=28) and consisted of a 35-minute presentation on the effective use of feedback followed by a workshop modeled after the Association for Surgical Education Committee on Graduate Surgical Education’s “Giving Verbal Feedback” workshop. Participants give and receive feedback using standardized scenarios in front of their peers, which is followed by a debriefing. Analysis of the training model was done using a Kirkpatrick level 1 survey utilizing thirteen 5-point Likert scale questions and Kirkpatrick level 2 pre- and post-training quizzes containing 6 knowledge-based questions analyzed using Student’s t-test.

Results: Among surgical residents, 97.4% agree that feedback is an important part of resident learning. 64.1% do not believe attendings make feedback a priority and only 23.1% of residents believe that attendings provide effective feedback. Residents agree that feedback should be part of faculty training (94.9%) and senior resident training (89.7%) (response rate 93%). 100% of faculty (response rate: 50%) were satisfied with the feedback training module, as well as 100% of residents (response rate 79%). The average score of the pre- and post-training quizzes among faculty improved significantly (63% to 83%, p-value = 0.03). The average score for residents also improved (56% to 77%, p-value = <0.001).

Conclusions: Feedback is an efficient and impactful tool to complement surgical residency training. Our experience demonstrates that surgical trainees feel that feedback is essential to their training and is inadequately provided by their educators. Our training modules were well-accepted by faculty and residents and facilitated learning on techniques for effective feedback.

Title: Factors that predict success with the GI Mentor IITM SimulatorPresenter Name: Michael Scott, MDName of PI: Nell Maloney Patel, MDName of Co-authors: Kurun Oberoi, MD, Viktor Dombrovskiy, MD, Anastasia Kuna, MD,

Aziz Merchant, MDInstitution: RWJUH and NJMS

Introduction: Virtual reality simulation has become an important tool for the surgical trainee. Studies have validated virtual reality (VR) simulation as an effective way to improve surgical skills. Furthermore, passing the Fundamentals of Endoscopic Surgery has become a requirement for surgical trainees to become board certified. However, studies have shown that some individual factors may lead to an advantage in VR simulation, such as gender, video game experience, and hand dominance. These studies are limited to laparoscopic simulation. Therefore, we seek to investigate whether certain characteristics may predict success with the GI Mentor II in order to inform surgical training programs.

Methods: Surgical residents (n=32) in two large academic general surgery programs completed an assessment on the Symbionix GI Bronch-Mentor™ VRS. This included two brief practice modules followed by an “easy” and “difficult” simulated colonoscopy. The simulator recorded several performance parameters. Demographic and individual factors were acquired via a survey and included gender, age, level of PGY seniority, glove size, hand dominance, upper and lower endoscopy experience, history of motion sickness, nausea during testing, video game experience, playing an instrument and history of playing sports. Factors and performance parameters were assessed using Chi-squared and Wilcoxon Rank Sum test analysis as appropriate.Results: For the “easy” colonoscopy, glove size (p=<.01) and history of playing an instrument (p=.02) was correlated with number of times patient was in pain. Total number of clinical endoscopy (p=.02) and history of sports (p=.04) was associated with time to reach cecum. For the “difficult” colonoscopy, childhood video game play was associated with percent of time patient was in pain (p=.03) and percent of time with a clear view (p=<.01). History of motion sickness (p=.05), nausea during testing (p=.04) and childhood video game play (=<.01) was associated with percent of time with clear view. Total number of clinical endoscopy was associated with efficiency of screening (p=.01), time to reach cecum (p=<.01) and total time (p=.03). All other factors, including gender, age, level of seniority and hand dominance did not show significant correlations.

Conclusions: Several factors were associated with success. Larger glove size, history of childhood video game play, and history of sports or instrument use may predict better scores. However, most factors and performance metrics showed no correlation, and more clinical endoscopy experience correlated with better simulation scores. This suggests that the GI mentor may offer only a minor advantage for certain trainees.

Title: Increased Costs of Trauma Activation for Minimally Injured PatientsPresenter Name: Michael Scott, MDName of PI: Matthew Lissauer, MDName of Co-authors: Waleed Abouelela, BA, David Blitzer, MD, Timothy Murphy, MSN,

Gregory Peck, MDInstitution: RWJUH

Introduction: In the era of value-based health care, it is essential to ensure that patients receive the optimal care for every health care dollar spent. This study was designed to compare outcomes and costs for patients with minimal orthopedic injuries stratified by trauma service (TS) involvement versus no TS involvement.

Methods: Retrospective trauma database analysis was performed at a Level 1 trauma center. Over a six-year period, patients sustaining an isolated fracture to the distal upper or lower extremity were identified. Inclusion criteria included age 18-89 and musculoskeletal AIS ≤ 3. Exclusion criteria included amputation and AIS > 1 for all other body areas. Outcomes and costs between patients who received TS care were compared to the non-TS group. Data analyzed included age, gender, operative intervention, payer status, co-morbidities, Emergency Department (ED) and hospital length of stay (LOS), time to operating room (OR), costs and charges. Univariate analysis and propensity score matching were used to compare groups.

Results: 982 patients were enrolled, 145 (14.8%) in the TS care group. On univariate analysis, patients who received TS care had shorter time to OR, but higher costs and charges. Propensity matched cohorts (n=89 for TS care) demonstrated the same findings, but in addition had shorter ED LOS, as well as longer hospital LOS and more complications.

Conclusions: TS involvement for patients with isolated distal orthopedic injuries may not increase value. Although patients who received TS care spent less time in the ED and arrived to the OR sooner, this came at a greatly increased financial cost with worse hospital LOS and more complications. Strategies aimed at reducing unnecessary TS involvement without an increase in undertriage may improve outcomes and costs.

Title: Assessing the Lancet’s Six Surgical Indicators: A Step toward Surgical System Strengthening in ColombiaPresenter Name: Michael Scott, MDName of PI: Gregory Peck, DOName of Co-authors: Joseph S. Hanna MD, PhD, Gabriel E. Herrera-Almario MD, Mónica

Pinilla-Roncancio MA, MSc, PhD, David Tulloch PhD, Sergio Valencia MD, MA, Charles Hamilton MPhil, Shahyan Rehman BS, Ardi Knobel Mendoza BA, Cindy Lorena Chamorro Velasquez BA, Liliana Carolina Gomez Bernal, Maria Alejandra Peña Navarro, Maria Fernanda Moreno Salas BA, Rachel Nemoyer, MD, MPH, Cristian Camilo Paez Cancelado MD, Vicente H. Gracias MD, Carlos Hernando Morales Uribe MD, Oscar Alberto Bernal Acevedo MD, PhD, Dario Londoño MD, PhD

Institution: RWJUH, New Brunswick, New Jersey, United StatesUniversidad de los Andes, La Fundacion de Santa Fe, Bogotá,

ColombiaSan Vicente Fundación, Medellín, Colombia

IntroductionThe Lancet Commission on Global Surgery (LCoGS) recommended six surgical indicators to baseline a situational analysis of surgical system strength in low- and middle-income countries. This analysis is essential to inform the process of National Surgical, Obstetric, Anesthesia Planning in order to achieve universal health coverage. The aim of this study was to collect, interpret, and analyze the six surgical indicators in Colombia.

Methods: Several national databases were queried to obtain aggregate, national-level data from 2016, including RIPS, REPS and DANE. For indicator 1 (i.e., 2-hour access), Bellwether-capable facilities were mapped, and drive-times were calculated using ArcGIS and ESRI. For indicator 2 (i.e., surgeon, anesthesiology, and obstetrician (SAO) density), data was cross-referenced with professional societies to locate providers and calculate density. For indicator 3 (i.e., surgical volume), CUPS codes were used to identify operative procedures. For indicator 4 (i.e., perioperative mortality), data was cross-referenced with mortality statistics. For indicator 5 & 6 (i.e., catastrophic and impoverishing expenditure), data from the 2007 Colombian National Health Survey was used to calculate out-of-pocket expenditure and household income.

Results:15.1% (7.1 million people) of the Colombian population is unable to reach a Bellwether-capable facility within 2 hours. Provider density is estimated to be 16.4 SAO per 100,000 people. Approximately 3069 (SD +/- 1329) operative procedures were performed in an operating room per 100,000 people. POMR is estimated to be 0.73% (SD +/- 0.32%) in 2016. In 2007, 6% (2.8 million people) of Colombians faced impoverishing expenditure

and 21% (9.9 million) faced catastrophic expenditure with direct and indirect costs of surgical care combined.

Discussion/Conclusion:In aggregate, the Colombian surgical system performs well, but falls short of the LCoGS targets for indicators 2, 3, 5 and 6. This baseline situational analysis highlights opportunities for improvement. With needed investment, Colombia will be on track to meet the 2030 LCoGS targets.

Conference that the research was submitted or presented at, and/or journal title and date where research was published: Will be submitted for publication at The LancetPreference of poster vs. podium presentation. Podium (or poster)

Title: Burden of Surgical Disease on Interfacility Ambulance Transfers in a Middle-Income CountryPresenter Name: Paul TrucheName of PI: Gregory PeckName of Coauthors: R. NeMoyer , S. Patiño-Franco2, M. Torres , L.F. Pino, G.L. Peck.Institution: RutgersIntroduction: Middle-income countries (MICs) frequently report a large rate of interfacility ambulance transfers, which remain largely under-investigated and reflect an opportunity to optimize timely and safe definitive surgical treatment. Herein we investigate surgical disease burden among interfacility transfers, differentiate the burden with respect to the public and private sectors, and provide a preliminary cost estimate for a large urban city in a middle income country. Methods: A large retrospective analysis of transfer records from a public emergency medical service was conducted from April 2015 to April 2016 in Cali, Colombia. Comparisons were made and odds ratios calculated comparing diagnosis, transferring service specialty, and facility type. A comparative analysis was performed between public and private healthcare facilities initiating transfer using the public EMS sector. ICD9 codes were subcategorized and compared to transferring service specialty using univariate regression. Cost estimates were performed using the 2016 fee schedule and historical conversion rates.Results: 31,659 patients were transferred over a 13-month period including 21,790 interfacility transfers. 7,808 (34.6%) transfers were surgical disease conditions, with 69.8% of these transfers at a surgeon’s request. Surgical disease conditions accounted for more transfers among public vs. private facilities (33% vs. 15%; p <0.001). Private hospitals transferred to private hospitals 77% of the time, while public hospitals transferred to public hospitals 61% of the time. The most common surgical conditions requiring transfer were fractures (1,227, 5.4%), appendicitis (913, 4.1%), wounds (871, 3.9%), abdominal pain (818, 3.6%), trauma (652, 2.9%), and acute abdomen (271, 1.2%). Total cost of surgical disease related interfacility transfers was estimated to be 943,562 United States Dollar (USD). Conclusion: Surgical disease conditions contributed to nearly half of interfacility ambulance transfers with the majority reflecting basic surgical conditions. Public and private hospitals both utilize the public ambulance service, but contribute unequally to surgical disease related transfer burden with respect to disease type and severity. Conference Presented at: Academic Surgical Congress, Houston Texas Feb 2019

Abstract for Bethune 2019 Conference (Ethics in Global Surgery)

ATLS Protocol Adherence Among Providers of Pediatric Trauma Care in Low- and Middle-Income Countries

Botelho-Filho FM1, Truche P2, Caddell L2, Roa L2, Mooney DP2, Alonso N3, Abib SCV1

1Federal University of Minas Gerais, Brazil, 2Program in Global Surgery and Social Change, Harvard Medical school, 3Department of Plastic Surgery, University of Sao Paulo

Introduction: Efforts towards improving trauma care in LMICs have included advocacy for Advanced Trauma Life Support (ATLS) certification, however the independent effectiveness of ATLS certification has not been evaluated for providers of pediatric trauma care in LMICs. This study seeks to determine adherence to ATLS protocols during pediatric trauma assessment in an LMIC trauma center.

Methods: Trauma assessments for pediatric patients (<14 years) presenting to a level 1 trauma center in Belo Horizonte Brazil were prospectively observed over 6-months by independent observers. Completion of each step of the ATLS assessment was documented and completion was compared between pediatricians, general surgery residents and trauma surgeons acting as the team leader.

Results: Assessments of 64 major trauma patients led by ATLS certified trauma surgeons (32), pediatricians (10) and surgical residents (22) were observed. On average 33% of ATLS steps were performed. Completion rates of ATLS steps did not differ between provider specialties (p=0.821). Lowest rates of performance included C-spine protection, administering oxygen, measuring breathing rate, exposure, and addressing hypothermia. GCS was assessed in 95% of the patients. FAST exam was completed in 23% of patients and chest X-ray in 56%.

Conclusion: ATLS protocol adherence is low for pediatric trauma assessment, even among certified providers. Certification alone may not independently ensure quality pediatric trauma assessments in LMIC settings.

PREDICTING PATIENTS AT RISK OF INACCURATELY REPORTED RACE AND ETHNICITY IN TRAUMA RESEARCH

Ankita Gore BS, Paul Truche MD, Anton Iskerskiy BS, Akshara Kartik BS, Gerardo Lopez BS, Tim Murphy RN, MSN, CEN, TCRN, FAEN, Joseph Hanna* MD,Ph.D., FACS, Gregory Peck* DO, FACS Rutgers Robert Wood Johnson Medical School

Invited Discussant: [discussant]

Introduction: Accuracy of race and ethnicity is important for high quality trauma outcomes research. Identifying patients at risk for inaccurate racial and ethnic reporting can guide process improvement and data collection practices. This study seeks to identify patients at higher risk of inaccurate race and ethnicity reporting to the NTDB.

Methods: Self-identified race and ethnicity was obtained through in-person interviews for patients admitted to a Level I Trauma Center over a six-month period and compared for accuracy to data submitted to the NTDB. Patient characteristics including patient age, race, ethnicity, gender, primary language, insurance status, GCS score, verbal status and injury severity were examined as potential predictors of inaccurate reporting of race or ethnicity using stepwise logistic regression.

Results: 444 patients met inclusion criteria with 135 patients with race or ethnicity inaccuracies. 84 patients (19.1%) had inaccurate race and 51 patients (10.9%) had inaccurate ethnicity reported to the NTDB. Univariate analysis revealed that race, ethnicity, primary language, age and insurance type were associated with higher risk of both inaccurate race and ethnicity reporting. In a multivariable analysis, only ethnicity (P<.0001, [OR 11.1, 95% CI 6.3-19.4]) was a strong independent predictor of patients with inaccurate race/ethnicity.

Conclusion: Hispanic patients are at higher risk for both race and ethnicity misclassifications even when adjusted for socioeconomic factors, language and injury severity. This may suggest confusion in race and ethnicity reporting standards for minority patients or an unconscious bias. Further research is needed to determine best practices for documentation of demographic

information in minority trauma patients with respect to race and ethnicity.

Defining the Influence of Inaccurately Reported Ethnicity on Adjusted Outcomes Models in Trauma Research

Author Block: Ankita Gore, BS, Paul Truche, MD, Akshara Kartik, BS, Anton lskerkiy, BS, Gerardo Lopez, BS, Tim Murphy, MSN RN CEN TCRN FAEN, Joseph Hanna, MD PhD FACS and Gregory Peck, DO FACS. Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, Rutgers School of Graduate Studies, New Brunswick, NJ, Robert Wood Johnson University Hospital, New Brunswick, NJ

Abstract:

Introduction: Racial and ethnic disparities are associated with disparate outcomes after trauma. This study aims to characterize the accuracy of reported patient ethnicity and determine the effect of inaccurately reported ethnicity within adjusted outcomes models.

Methods: Patients admitted to a Level I Trauma Center over a six-month period were interviewed to obtain self-identified or family-reported race, ethnicity and primary language which was then compared to data submitted to the NTDB. Multivariable regression was used to model the independent effect of incorrect ethnicity on length of stay and complication rate after adjusting for patient demographics, insurance status, injury severity, primary language and GCS.

Results: 444 patients were included in the study. 51 patients (11.4%) had inaccurate ethnicity reported to the NTDB with 91% of them Hispanic/Latino. Patients with incorrect ethnicity were younger (P<0.0001), more likely Spanish-speaking (P<0.0001) and more likely uninsured (P=0.0002). Patients with the inaccurately documented ethnicity had an independent effect on mean length of stay (P=0.01), but not on complication rate (P=0.899).

Conclusion: Our findings suggest that inaccurate reporting of ethnicity disproportionately occurs for minority patients. Patients with incorrectly documented ethnicity have an independent effect on length of stay when adjusting for socioeconomic factors and injury severity. This suggests inaccurate data may have a significant effect on large scale trauma outcomes research.

Title: Globalization of National Surgical, Anesthesia, and Obstetric Plans: The Critical Link Between Health Policy and Action in Global Surgery

Authors: Paul Truché (1)*, MD - [email protected]

Haitham Shoman (1), MD, DIC, MPH – [email protected]

Ché L. Reddy (1), MD, MPH - [email protected] Desmond T. Jumbam (1), ( 2) MSGH - [email protected] Joanna Ashby (1, 3), BSc - [email protected]

Adelina Mazhiqi (1) - [email protected]

Taylor Wurdeman (1) - [email protected]

Kee B. Park MD (1) - [email protected]

John G Meara (1)(2), MD, DMD, MBA - [email protected]

(1) Program in Global Surgery and Social Change, Harvard Medical School

(2) Department of Plastic and Oral Surgery, Boston Children’s Hospital

(3) Wolfson School of Medicine, University of Glasgow

Abstract:

Efforts to improve surgical care have evolved from a volunteer mission trip model of surgical delivery in low resource settings to a sustainable health system strengthening approach as private and public stakeholders recognize the enormous health toll and financial burden of surgical disease. The National Surgery, Anesthesia and Obstetrics Plan (NSOAP) has developed as a policy for countries to address the health burden of noncommunicable diseases with respect to surgery, but these plans have not developed in isolation. The national surgical plan has become a phenomenon of globalization as a broad range of actors – individuals and institutions – help in both NSOAP formulation, implementation and financing. As the the nexus between policy and action in the field of global surgery, the NSOAP reflects a special commitment by state actors to make

progress on global goals such as the World Health Organization's Sustainable Development Goals. This requires a continued global commitment that involves genuine partnerships that embrace the collective strengths of both national and global actors to deliver sustained, high quality surgical care for all poor, rural and marginalized peoples.

Keywords: Global Surgery, Essential Surgery, Universal Health Coverage, Global Health, Globalization, Noncommunicable diseases, Global Health Systems, Health Policy

Feasibility of Prehospital Data Collection At Handoff From EMS Providers for Trauma Systems Improvement in LMICs

Paul Truche, Zina Model, Dhaval Mehta, John Dutton, Camilo Cuatin Guttierez, Ramiro Manzano, Luis Fernando Pino, Carlos Ordoñez, Gregory Peck

Objective:

Inclusion of prehospital data in Latin American trauma registries has been proposed as a way to improve outcomes for surgical patients in LMIC settings. Methods to obtain data on EMS transfers remain under-investigated. This study aims to determine feasibility of collecting basic EMS data directly from prehospital providers in LMIC settings.

Methods:

A novel 11 variable prehospital data collection instrument was designed and a process for collecting clinical prehospital data directly from prehospital providers was developed in collaboration with local stakeholders at two large trauma centers in Cali, Colombia. A one-week prospective study at both hospitals was conducted to assess completion rate of a simple EMS hand off form. The percentage of questions successfully completed were recorded and completion rates of recorded clinical vs nonclinical data were compared.

Results:

66 prehospital patients presented to the emergency room via ambulance over the course of one week. Completion rates for the 10 variables included ambulance service name (97%), type of ambulance service (97%), location of emergency (86%), response time (79%), transport time (86%), gender (98%), age (76%), SBP (79%), HR (80%), RR (80%), and mechanism of injury (80%). 80% of clinical variables were recorded and 90% of nonclinical variables were recorded. Nonclinical data was more likely to be recorded than clinical (P=.0164), but both types had high levels of data capture with the design.

Conclusion:

Data collection directly from prehospital is a feasible way to obtain baseline prehospital information in LMIC settings. Clinical

data may be more difficult to obtain than non clinical demographic data.

Identifying Ethnicity Documentation Inaccuracies in a Trauma Registry: A Global Surgery Perspective

Ankita Gore BS1, Paul Truche MD1, Gerardo Lopez BS1, Akshara Kartik BS2, Tim Murphy MSN RN CEN TCRN FAEN3, Anton Iskerskiy BS2, Joseph Hanna MD PhD FACS4, Gregory Peck DO FACS4

Institution Affiliation:

1 Rutgers Robert Wood Johnson Medical School

2 Rutgers School of Graduate Studies

3 Robert Wood Johnson University Hospital

4 Division of Acute Care Surgery - Rutgers Robert Wood Johnson Medical School

Background

Ethnicity is associated with disparate outcomes in trauma patients and is one of a host of socioeconomic factors key to surgical public health research globally. Accurate ethnicity data is needed to inform epidemiologic trauma trends within vulnerable populations. This study aims to characterize the accuracy of patient ethnicity recorded in an urban trauma center with the intent of identifying processes to improve collection of accurate ethnicity data.

Methods

Patients admitted to an urban level I trauma center over a six-month period were interviewed in-person using a standardized questionnaire. Patients’ self-identified or family-reported ethnicity was compared to the recorded ethnicity in the hospital trauma registry. McNemar’s test was used for a comparative accuracy analysis.

Results

444 patients were surveyed with 98 patients (22%) self-identifying as Hispanic/Latino. 48 patients experienced ethnicity inaccuracies which represented a statistically significant difference between self-reported ethnicity and ethnicity recorded in the trauma database

(p<0.001). 44 (91%) discrepant patient records were of Hispanic/Latino patients misclassified as non-Hispanic.

Conclusion

A concerning degree of inaccuracy was observed in ethnicity data with the Hispanic/Latino minority population subject to the majority of the observed discrepancies. These data suggest that ethnicity reporting for minorities may be disproportionately inaccurate, resulting in erroneous reporting to state and national public health databases. Further research is needed to assess the magnitude and causes of inaccurate data collection globally and how this will impact emerging surgical research in the developing world with a focus on approaches to improving epidemiologic data accuracy for public health and policy creation.

Assessment of Interfacility Ambulance Transfers in a Middle-Income Country

P. Truche1 , R. NeMoyer1 , S. Patiño-Franco2 , M. Torres3 , L.F. Pino4 , G.L. Peck1 ; 1Rutgers-Robert Wood Johnson Medical School, Department Of Acute Care Surgery, New Brunswick, NJ, USA; 2Universidad de Antioquia, Facultad De Medicina, Medellín, ANTIOQUIA, Colombia; 3Red de Salud del Centro E.S.E., Cali, VALLE DEL CAUCA, Colombia; 4Hospital Universitario del Valle - Evaristo García, Cali, VALLE DEL CAUCA, Colombia

Introduction: Complex emergency medical systems (EMS) exist in high-income countries to facilitate transfers between hospitals. In Cali, Colombia, under the public insurance paradigm, a single public ambulance service provides transport for most interfacility transfers. Transfers between hospitals in low- and middle-income countries (LMICs) have not been explored, but represent an essential component of providing timely and high quality care. We seek to quantify the number and type of interfacility transfers in a large, MIC city, compare this between public and private hospitals, and provide a cost estimate.

Methods: A retrospective review of a large public, urban EMS was completed for 1-year of interfacility (hospital-to-hospital) transfers. Disease proportions among interfacility transfers were examined and comparisons made between patients being transferred from public to private hospitals and vice versa using fishers exact and/or chi-square tests. ICD9 codes were subcategorized for analyses. Cost estimates were performed using the 2016 ambulance fee schedule.

Results: 31,659 patients underwent transfer, including 21,790 interfacility transfers. Diagnoses for transfer included 55% medical, 34% surgical, and 10% obstetric and gynecological. Pediatric patients were 22% of transfers. The top ten reasons for transfer included fracture (1227, 5.4%), fever (996, 4.4%), appendicitis (913, 4.1%), wounds (871, 3.9%), abdominal pain (818, 3.6%), unspecified medical conditions (776, 3.4%), myocardial infarction (770, 3.4%), pneumonia (751, 3.3%), cerebrovascular disease (690, 3.1%) and trauma (652, 2.9%). These made up 55% of the total transfers for the year. Private

hospitals transferred patients to other private facilities 77%, and had 5.6x the odds of being transferred to a private hospital vs public hospital (CI [5.1-6.0], p<.01). The estimated cost over the year was 2,121,234 USD for all interfacility transfers.

Conclusion: Medical, surgical and obstetric conditions all contribute greatly to the burden of interfacility transfers in Cali, Colombia, with significant cost to the public health system. The major reasons for transfer represent common diseases with the majority being noncommunicable. Public and private hospitals contribute unequally to transfer burden. More research is needed to link outcomes data to patient transfers, determine specific reasons for patient transfer, and optimize triage systems to reduce cost and improve outcomes.

Title: Rare Case of Congenital Pulmonary Airway Malformation (CPAM) in an Adult Female with Mediastinal ShiftAuthors: Lindsay Volk, MPH, MD, Siavash Saadat, MD, John E. Langenfeld, MD, Leonard Y. Lee, MDIntroduction: We present a case of Congenital Pulmonary Airway Malformation (CPAM) that presented as left sided pleuritic chest pain and shortness of breath, with a mediastinal shift and further describe the surgical management of this patient, which included a video-assisted thorascopic upper lobectomy and resulted in relative resolution of the mediastinal shift.Case Description:A 26-year old woman with a history of a left sided pneumothorax presented to the emergency room reporting a sensation of breathlessness, associated with lightheadness and distal paresthesias. She admitted to having similar episodes in the past and underwent placement of a chest tube 6 years prior to presentation at an outside hospital. She denied any other relevant medical or family history. Her exam was significant for decreased breath sounds on the left side. Initial chest x-ray that showed a left sided pneumothorax, blebs, and a mediastinal shift to the right. Patient had a left chest tube placed and a computed tomography scan of the chest showed extensive bullous disease predominantly involving the left upper lobe, suggestive for CPAM. Patient underwent a video-assisted thorascopic upper left lobectomy and a section of the lung was sent for pathologic examination. Macroscopically, the sample revealed multiple thin walled cystic bullous lesions. Microscopic examination confirmed multiple subpleural bullae with areas of granulation tissue and chronic patchy inflammation. A follow up chest x-ray shows relative resolution of the mediastinal shift. Patient recovered without incident and was discharged on hospital day 6.Discussion:It has been proposed that CPAM in adults may present with more complicated radiographic images due to recurrent infections. Our patient was found to have a mediastinal shift on radiographic imaging that resolved with surgical intervention. A mediastinal shift is not widely reported as a radiographic presentation of CPAM. This may be due at least in part to the fact that the majority of cases of CPAM are diagnosed prenatally before air trapping is allowed to occur. The mediastinal shift in this patient most likely is representative of a chronic process which would only be able to occur with an adult presentation of CPAM. Other adult presentations of CPAM do not report a mediastinal shift, but also do not have the extensive pan-lobular presentation that was found in this patient.Conclusion:Although a rare diagnoses in adults, CPAM can present with significant variations in radiographic presentation including a correctable mediastinal shift.

Title: Placement of a sutureless aortic valve in a patient with severely calcified aortic root homograftAuthors: Lindsay Volk, MD, MPH, Justin Elkhechen, Anna Olds, & Leonard Lee, MDAbstract: Significant aortic calcification is a known sequelae of a homograft aortic root replacement and creates a treatment challenge if these patients require cardiac reintervention. The standard surgical option for patients requiring an aortic valve replacement in the setting of a calcified aortic homograft has been a Bentall procedure, which is considered a high-risk procedure with extended cross-clamp, cardiopulmonary bypass and operative times. This is the case of one such patient with a severely calcified aortic homograft who underwent successful aortic valve replacement using an Edwards intuity Elite Aortic Valve leaving the aortic root and arch intact. The sutureless nature of this valve allowed its placement in a heavily calcified annulus using a median sternotomy approach without excision and replacement of the calcified aortic homograft. Using this method, the patient avoided the more extensive re-do aortic root replacement and the accompanying increase in morbidity and mortality. This represents only the fourth reported case of such a method being used, and the first within the United States.Case Description: The patient is a 56-year-old male who had undergone an aortic valve replacement with a homograft aortic root replacement 14 years prior for severe aortic insufficiency. He had done well for several years but then represented with symptoms of worsening shortness of breath. Further workup, including cardiac catheterization and echocardiography, revealed relatively nonobstructive coronary artery disease and severe aortic insufficiency with an ejection fraction of 50%. On preoperative work up he was noted to have extreme calcification of his aortic root including his ascending aorta as a consequence of the prior homograft aortic root replacement. The patient underwent a redo sternotomy, extensive lysis of adhesions, aortic valve replacement with an Edwards Intuity Elite Aortic Valve, and cut down isolation of the right common femoral artery and common femoral vein. Intraoperative findings included dense adhesions within the pericardial space, extensive calcification of his valve in the entire aortic root and extending into his ascending aorta, a dilated left ventricle with relatively preserved biventricular function.A small injury to the right ventricle was created and easily repaired with 4-0 pledgeted prolene sutures. The procedure was conducted on bypass and a standard transverse aortotomy was performed above the prior suture line and area of calcification. The leaflets of the existing valve were excised. Three sutures were placed at the nadir of each leaflet and a 21 mm Intuity Elite sutureless valve was parachuted down and deployed without difficulty. The transverse aortotomy was then closed. He had an uneventful recovery and was discharged home on postoperative day 3. At a follow up appointment, the patient was doing well and reported an improvement in his symptoms.

Discussion: Performing repeat cardiac surgery on patients with calcified aortic roots presents a unique challenge, frequently requiring a more extensive aortic root replacement. There is prior literature suggesting that aortic root replacements carry increased morbidity and mortality over isolated aortic valve replacements. We present a case of one such patient who underwent aortic valve replacement with a sutureless valve allowing us to avoid a redo replacement of his aortic homograft. By eliminating the need for a procedure considered high-risk due to the extended cross-clamp, on-pump, and operative time, we have been able to achieve a successful results without the additional risks.

Title: Does the five-point modified frailty index (mFI-5) predicts surgical outcomes in pancreatic ductal adenocarcinoma patients undergoing pancreaticoduodenectomyAuthors: Volk LE, Chu, QD, Kuo YH, DiSandro K, Randazzo M, Zibari GB, Shokouh-Amiri H, Gibbs JFIntroduction: Models for predicting surgical outcomes have emerged, however, their adoption into practice has been slow. This study evaluates the predictability of a simplified frailty index (mFI-5) in pancreatic cancer patients undergoing pancreaticoduodenectomies (PD).Methods: We conducted a retrospective study of patients undergoing PD for pancreatic ductal adenocarcinoma (PDAC) using the ACS-NSQIP dataset from 2014-2016. Five preoperative factors were examined: functional status, diabetes, history of COPD, history of CHF, and hypertension requiring medication. Patients were then categorized as no, low, intermediate, or severe frailty. Outcomes were length of stay, unplanned return to OR, 30-day readmission, and 30-day mortality.Results: 6040 patients were identified with no (37.5%), low (61.2%), or intermediate frailty (1.3%). A significant age difference was noted between the no (63.1), low (68.2), and intermediate (69.2) frailty groups (p<0.0001). Readmission rates were greater in the intermediate than in the no frailty group (24.7% vs 14.0%, p=0.014). 30-day mortality was greater in the low (2.6%) than in the no frailty group (1.4%). The mFI-5 was predictive of 30-day mortality and Clavien IV complications in univariate analysis. When the mFI-5 was considered in multivariate analysis and age was included, it was no longer predictive of poor outcomes.Discussion: The small subset of preoperative medical co-morbidities included in the mFI-5 significantly predicts differences in postoperative outcomes such as Clavien IV complications, readmission rates, and mortality between frailty groups, but this relationship is not robust when multivariate analysis is used. This suggests that the mFI-5 is while a simple predictor of outcome in PDAC patients undergoing pancreaticoduodenectomy has limited clinical use.

Title: Early and Intermediate Outcomes of Surgical Management of Active Infective EndocarditisAuthors: Lindsay Volk MD, MPH, Nina Verghis MS, Antonio Chiricolo MD, Hirohisa Ikegami MD, Leonard Y. Lee MD, and Anthony Lemaire MDIntroduction: The treatment of active infective endocarditis (IE) presents a clinical dilemma with uncertain outcomes. This study sets out to determine the early and intermediate outcomes of patients treated surgically for active IE at an academic medical center.Methods: A retrospective chart review was conducted to identify patient who underwent surgical invention for IE at our institution from July 1st, 2011 to June 30th, 2018. Demographic characteristics including age and gender were collected. In-patient records were examined to determine etiology of disease, surgical intervention type, postoperative complications, length of stay (LOS), 30-day in-hospital mortality, and 1-year survival. Results: 25 patients underwent surgical intervention for active IE. The average age of the patients was 47±14 years old and the majority of the patients were male (N=15). The etiology varied and included intravenous drug use (IVDU), presence of transvenous catheters, and dialysis. Four patients (16%) developed cerebrovascular accidents postoperatively and 1 patient (4%) required a craniotomy. Five of the 25 patients (20%) returned with recurrent IE and two patients (8%) required redo valvular replacements. The cause of the recurrence was resumed IVDU in all 5 cases. Three of the patients with recurrent disease were treated with IV antibiotics as they were deemed too high risk for redo surgery. The 30-day in-hospital mortality was 0% and the 1-year survival was 80%. The average LOS was 27 days ±15 and the longest LOS was 65 days. None of the patients developed bleeding requiring redo surgery or developed mediastinitis.Conclusions: Surgical management of IE can be difficult and challenging with significant morbidity and mortality. The average LOS is longer than traditional adult cardiac surgery procedures and the recurrence rate of valvular infection is not minimal especially if the underlying etiology is IVDU.

The Use of Native Kidney Biopsy to Predict Renal Dysfunction Following Liver Transplantation

David Walls, MD, Liudmila Muraveika, MD PhD, Deirdre Sawinski, MD, Matthew Palmer, MD PhD, Brendan Keating, PhD, Peter Abt, MD

Background: Acute and chronic kidney injury (AKI and CKI) are a common occurrence for patients with end-stage liver disease and are associated with significant morbidity and mortality. We aimed to determine the utility of native kidney biopsy in conjunction with pre-transplant clinical and laboratory data to predict renal dysfunction following liver transplantation and better characterize pathologic findings on patients with hepatorenal syndrome.

Methods: We performed a prospective observational trial to identify potential predictors of severe renal dysfunction following liver transplantation. A native kidney biopsy was performed at the time of liver transplantation which was reviewed by a single pathologist. The primary outcomes measured were the development of chronic kidney disease (CKD) stage 4 or 5 or death. Immunofluorescence, light microscopy, and electron microscopy findings on the native kidney biopsy were compared among the primary and secondary outcomes.

Results: A total of 89 patients underwent native renal biopsy at the time of liver transplantation. Recipient, transplant, and donor characteristics among the study population are shown in Table 1. 17 patients went on to develop CKD stage 4 or 5 and 15 patients died during the follow-up period (1-5 years, no mortality within 6 month post transplantation). A larger proportion of patients, who either developed CKD stage 4 or 5 or died had >20% interstitial fibrosis and tubular atrophy (IFTA) as compared to those that did not experience either endpoint (p-value = 0.0256). There were no significant differences in glomerulosclerosis (GS) or arterial fibrosis between the two groups (p-value = 0.1781 and 0.3761 respectively).

Conclusions: Stage 4 or 5 CKD after liver transplantation is associated with increased mortality. Cirrhosis of the liver can be accompanied by a variety of microscopic glomerular disorders and interstitial fibrosis (Table 3).

Table 1: Recipient, Transplant, and Donor Characteristics of the Study CohortRecipient Characteristics at Time of Transplant N = 89

Age, Median (IQR) 59 (10.0)Male Gender (%) 63 (70.8)Race (%) White 68 (76.4) Black or African American 14 (15.7) Hispanic/Latino 4 (4.5) Asian 3 (3.4)Cause of ESLD (%) HCV 40 (44.9) Alcohol 16 (18.0) NASH 5 (5.6) Multifactorial 11 (12.4) Cryptogenic 4 (4.5) PSC/PBC 7 (7.9) Other 6 (6.7)Positive HCV Status (%) 48 (53.9)HCC Diagnosis (%) 39 (43.8)History of Hypertension (%) 35 (39.3)History of Diabetes (%) 28 (31.5)Body Mass Index (kg/m2), Mean (SD) 27.4 (5.2)

Transplant CharacteristicsMELD at Transplant, Mean (SD) 24.6 (8.7)Cold Ischemia Time (Hours), Median (IQR) 4.85 (2.0)Donor Liver Type (%) Living 17 (19.1) DBD 71 (79.8) DCD 1 (1.1)

Donor CharacteristicsAge, Median (IQR) 41 (29.0)Male Gender (%) 50 (56.2)Race (%) White 67 (75.3) Black or African American 13 (14.6) Other 9 (10.1)Cause of Death (%) Anoxia 41 (46.1) CVA 16 (18.0) Trauma 18 (20.2)Positive HCV Status (%) 5 (5.6)Body Mass Index (kg/m2), Median (IQR) 25.3 (9.0)

Pathology Characteristics Death or CKD Stage 4/5 (N = 28) No Death and No CKD Stage 4/5 (N = 61) p-value IFTA (%) < 20% 21 (75) 55 (90.2) > 20% 3 (10.7) 0 (0)GS (%) < 20% 18 (64.3) 46 (75.4) > 20% 6 (21.4) 6 (9.8)Arterial Fibrosis (%) Within Normal Limits 4 (14.3) 18 (29.5) Minimal 2 (7.1) 3 (4.9) Mild 6 (21.4) 14 (23.0) Moderate 3 (10.7) 3 (4.9)

Table 2: Comparison of Native Renal Pathological Characteristics Between Patients With and Without Development of CKD Stage 4/5 or Death (N = 89)

0.0256

0.1781

0.3761

Table 3: Pathological Diagnosis

Clinical Diagnosis

Pathological Diagnosis

FSGS MPC MPGN ANS WNL DNHRS 30 3 4 4, 1 IgA 3 12 0Other 79 3 3 3, 1 IgA 11 29 2

FSGS = Focal Segmental GlomerulosclerosisMPGN = Mesanglial Proliferative GlomerulonephritisMPC = Chronic Membranoproliferative ChangesANS = Arterial SclerosisDN = Diabetic NeuropathyWNL = Within Normal LimitsIT = Inadequate Tissue

Title: Kidney Transplant Outcomes from Donation after Circulatory Death Donors of Advanced Age

Presenter: David Walls, MD

PI: Peter Abt, MD

Co-Authors: Grace Lee, MD, MSME, Deirdre Sawinski, MD, Brendan Keating, PhD

Institution: University of Pennsylvania

Introduction: Studies assessing the impact of older donor age on donation after cardiac death (DCD) kidney transplant outcomes have done so as a function of extended-criteria donor status and yielded contradictory results. A direct comparison of kidney transplant outcomes between older DCD and older donation after brain death (DBD) donors has yet to be performed.

Methods: We performed a retrospective cohort study using UNOS/OPTN data. We identified 48,493 DBD and 4,771 DCD recipients from donors >50 years between 1994-2016. Donor age was stratified into 5 groups: 50-54, 55-59, 60-64, 65-69, and >70. Kaplan-Meier analysis was performed to assess differences in graft survival, delayed graft function (DGF), and primary nonfunction (PNF). Multivariable logistic regression models were constructed to identify factors predictive of graft failure.

Results: In the 50-64 donor age groups, the DCD donors had significantly lower creatinine, rates of hypertension, and death from CVA compared to DBD donors. Rates of DGF were significantly greater for DCD kidneys in all groups except >70; however, rates of PNF within each group were similar. Equivalent graft survival was observed in all donor age groups except 65-69. In multivariable analysis, older donor age was associated with graft failure (OR=1.03, 95% CI 1.02-1.03, p<0.0001). DCD status did not independently predict graft failure among donors >50.

Conclusion: Optimal older DCD kidneys, particularly ages 50-64, are a potential means to safely expand the donor pool with PNF and graft survival rates equivalent to that of similar age-matched DBD kidneys.

Conference: ASTS 2019

Title: Application of a Prescription Drug Monitoring Program to Detect Underreported Controlled Substance Use in Patients Evaluated for Liver Transplant

Presenter: David Walls, MD

PI: Peter Abt, MD

Co-Authors: Samantha Halpern, MSN, Anuranita Gupta, BS, Alexa Lustig, MSN, Robert Weinrieb, MD, Matthew Levine, MD, PhD

Institution: University of Pennsylvania

Introduction: Pre-surgical controlled substance use predicts postoperative complications, increased readmissions, and mortality. We aimed to examine if a Prescription Drug Monitoring Program (PDMP) would detect underreported controlled substance use in patients undergoing liver transplant evaluation.

Methods: We performed a retrospective cohort study at a tertiary referral center of patients undergoing liver transplant evaluation in 2017. PDMP reviews were performed on all 360 patients and urine drug screen (UDS) results were reviewed when available to evaluate dispensed controlled substances. These results were compared to the patient’s self-reported medication list at evaluation to identify any underreporting. The primary outcome was the number of self-reported controlled substance discrepancies on the medication list identified by PDMP and UDS at the time of evaluation.

Results: Among the 360 patients, 87 (24%) had a discrepancy where PDMP revealed a controlled substance prescription that the patient did not report on their medication list. 77% (67/87) of these discrepancies involved opiates. 219 (61%) of the 360 patients had a negative UDS, but 70 (32%) of these patients had at least one controlled substance listed on PDMP. A diagram visually representing detection of underreported controlled substance use by UDS and PDMP is shown in Figure 1.

Conclusions: There is a large incidence of underreported controlled substance use among patients evaluated for liver transplant. PDMP is a promising screening tool when used in conjunction with the UDS for detecting underreported controlled substance use in liver transplant candidates.

Conference: ASTS 2019

Figure 1.

Title: Point-of-care ocular ultrasound for real-time intracranial pressure monitoringPresenter Name: David YouName of PI: Dr. Lissauer, Dr. LafonteName of Co-authors (in appropriate order): Dr. Ilker HacihalilogluInstitution (especially if not at RWJUH): •Rutgers Robert Wood Johnson Medical School (RWJMS)-New Brunswick•Robert Wood Johnson University Hospital RWJUH- New Brunswick•Computer Assisted Surgery and Therapy Laboratory, Department of Biomedical Engineering Rutgers University-PiscatawayIntroduction:The recognition and preemptive management of secondary brain injury is paramount as the damage is often irreversible once clinical symptoms manifest. Intracranial pressure (ICP) monitoring is the most widely used modality for recognizing impaired cerebral perfusion and subsequent tissue hypoxia and infarction, which may lead to secondary neurologic injury13. Amongst patients with severe traumatic brain injuries (TBIs), the rate of ICP monitoring in America is 77.4% and 57% in the UK10.Extraventricular drains (EVD) and intraparenchymal devices are the two most commonly used and widely-adopted methods for invasive ICP monitoring. The most common complications are ventriculostomy-associated infections (VAIs). Placement of EVDs are associated with an average infection rate of 8.8% while quoted at 22% in some studies9. These include infected bone flaps, brain abscesses, subdural empyemas, ventriculitis, meningitis, and superficial wound infections11. The second most common complications related to invasive ICP monitoring devices are technical errors. A recent study found that EVDs placed in an ICU setting were sub-optimal 6.5% of the time9. Furthermore, these devices have been found to be inaccurate if intraparenchymal gradients exist between fossas of the skull7.Methods for non-invasive ICP monitoring are continually being investigated, validated, and improved upon, including measurements of optic nerve sheath diameters (ONSD), optical coherence tomography, pupillometry, transcranial doppler ultrasonography (TCD), and tympanometry. The sub-arachnoid space between the dura and white matter of the optic nerve communicates with the sub-arachnoid space of the brain, establishing a linear relationship between peri-optic CSF pressure and ICP6. Thus, measurement of optic nerve sheath diameters using ultrasound have been routinely found in multiple studies to demonstrate the strongest correlation with ICP, with sensitivities of 95% and specificities to 80%1,5. Furthermore, the use of ultrasound is considered non-invasive. There are no known complications in humans, hence why it is routinely used for fetal monitoring. Transcranial doppler ultrasonography is another popular non-invasive ICP monitoring modality. Recent evidence demonstrates overall accuracy ranging around ±12 mmHg when compared to their invasive counterpart, making it a poor comparison to ONSD measurements. Overall, the ability to detect ICP > 20 mmHg (when impaired cerebral perfusion becomes a significant concern) was highest for ONSD1.At this time, ultrasound measurements of optic nerve sheath diameters are not considered to be robust enough as a replacement for traditional invasive techniques for ICP monitoring12. ONSD measurements are often operator-dependent and vary by the

type of ultrasound equipment being used. There is a need to implement high-quality signal processing algorithms to improve accuracy and reliability. Furthermore, this technique is routinely described in environments as more of a screening tool, where insertion of EVDs or intraparenchymal monitors are unlikely, such as emergency departments, ambulatory settings, or in the field. In order for it to also be effective in conventional ICU settings, there needs to be ability for real-time monitoring. This will require fully automatic signal processing methods and miniature transducer elements that are able to be attached to the patient.

ObjectivesAim 1: Compare point-of-care ophthalmic ultrasound measurement of optic nerve sheath and ophthalmic vein diameters with real-time intracranial pressure monitoring (bolts, EVD, etc.) in critically ill patients.Aim 2: Improve the sensitivity and reliability of this methodology by developing automated image processing algorithms, including both 2D and 3D ultrasound scans.Aim 3: Demonstrate the ability for real-time ICP monitoring with low-cost and small-profile ultrasound transducers.

Methods:ImagingUltrasound (US) images will be obtained using a Sonosite Export ultrasound system through RWJUH. The ultrasound probe will obtain images of the optic nerve sheath and ophthalmic vein diameter. Each scan will be obtained using a standard technique (gently running US probe over the eyelid) and will take one minute per scan.Statistical ConsiderationsData will be analyzed by extracting the important anatomical features from the ultrasound images using the developed state of the art image processing methods. The software program that will be used to develop the computational image analysis method is MATLAB (The Mathworks Inc., Natick, MA). MATLAB is a high-level technical computing language and interactive environment for algorithm development, data visualization, and data analysis. It is used in most Universities for algorithm development. Using image intensity information we will develop the image processing method. The generated data will include both two-dimensional (2D) and three-dimensional (3D) surface mesh models. The software program will utilize the images and compute an optic nerve sheath diameter that we will then compare to the actual optic nerve sheath diameter. We will compare the optic nerve sheath diameter results to the patient’s measured ICP as well.

Results/Discussion/Conclusion:Pending results from Dr. Hacihaliloglu from the Computer Assisted Surgery and Therapy Laboratory, Department of Biomedical Engineering Rutgers University-Piscataway

Title: Accessory common bile duct: a rare but important anatomical variant Presenter: Anthony CasabiancaPI: Darren CarpizoCo-author: Mihir Shah, Darren CarpizoInstitutions: RWJMS, CINJ

Introduction: Accessory bile ducts are a rare but recognised part of the literature in biliary surgery. Variations in biliary anatomy occur not infrequently. In this case, we present an 84-year-old man with pancreatic adenocarcinoma who underwent a pancreaticoduodenectomy complicated initially by bile leak and later sepsis secondary to bile stasis originating from a ligated accessory duct. This case emphasises the importance of recognising anatomic variants of biliary anatomy as their lack of recognition can lead to major morbidity in routine hepatobiliary and pancreatic surgical procedures.Methods: During the procedure, a thin, tubular structure that was approximately 3 mm in diameter was encountered lateral to the common bile duct (CBD) within the hepatoduedenal ligament. At the time, it was felt to be a lymphatic vessel and was divided using a vessel sealing device. The procedure was carried on in the usual fashion. A flat Jackson-Pratt (JP) drain was left posterior to the hepaticojejunostomy.Results: An 84-year-old man presented with pancreatic adenocarcinoma. Following neoadjuvant chemoradiation, the patient underwent a pancreaticoduodenectomy, complicated by early bile leak. Re-exploration and intraoperative cholangiogram identified an accessory common bile duct draining segment 5 of the right hepatic lobe, which was then ligated. The patient underwent a complicated postoperative course eventually developing sepsis secondary to biliary stasis. He elected for comfort measures and passed away secondary to complications of sepsisDiscussion: An accessory CBD is an exceedingly rare congenital anomaly of the biliary system in which two separate channels drain bile from the liver in a parallel fashion. The incidence of this anatomical variation is not clear, <50 cases are reported in the literature, most of which originate in Asian populations. Because of its relative rarity, this anatomic variation is difficult to recognize as a source of biliary leak following surgery.It is thought that this duplication of the biliary tree is the result of non-regression of fetal anatomy. In the third week of gestation, the biliary tree contains separate drainage for the right and left lobes of the fetal liver. It is believed that at a later stage of development the bile ducts fuse to form one. ailure of this process to complete can result in an accessory bile duct which may drain an isolated portion of the liver or result in a branch from intrahepatic ducts which communicate with the CBD.Indeed, this embryological origin is consistent with many of the variations described by the classification scheme first proposed by Goor in 1972.4 A modification of this classification scheme exists with five possible variants depending on the origin of the accessory duct and the location of the distal drainage. Type 1 is a large CBD with two channels

divided by a septum distal to the entry of the cystic duct. Type 2 is a large CBD, which branches into two separate channels distal to the cystic duct. Type 3a describes a parallel duct separate from the CBD, which drains an isolated part of the liver. Type 3b also describes a parallel duct, which originates as a branch of the right or left hepatic duct. Type 4 is a branch of the left hepatic duct, which has connections with the CBD and its own separate drainage into the target organ.Typically, one duct will drain into the ampulla while the other duct may fuse at the ampulla or have a separate drainage location.Variations have been described with the accessory duct draining into the stomach as well as into the duodenum and pancreas.The anatomical drainage of the accessory duct has been associated with different types of cancers.For example, accessory ducts that drain into the stomach have been associated with cancers of gastric origin, while ducts draining into the duodenum or pancreas are commonly associated with biliary-related neoplasms.These variations in anatomy are significant also for their role in bile duct injury during cholecystectomy. Injuries to these ducts have been documented and are associated with early bile leak following cholecystectomy. Additionally, the anatomy of the biliary tree must be evaluated for these aberrant ducts to prevent complications associated with liver transplantation.We suspect that our patient developed sepsis secondary to cholestasis with a biliary-enteric anastomosis. This was likely the result of ligating an accessory bile duct, which was the primary drainage for an isolated hepatic segment. The case also highlights the challenges of performing pancreaticoduodenectomy in octogenarians as by the time it was determined that his sepsis could not be controlled with percutaneous catheter drainage, the patient was too ill to be able to survive an attempt to salvage him by resecting the involved liver segment. We hope that this case may demonstrate the important role that these accessory ducts play in biliary anatomy and that understanding their unique anatomy is critical to preventing significant morbidity and mortality in patients undergoing surgery involving the biliary tract. When an accessory duct needs to be divided, or it is divided incidentally, an attempt should be made to reconstruct it, particularly when a biliary-enteric anastomosis is made to the common hepatic duct which seeds the intrahepatic biliary tree with bacteria.

Published: British Medical Journal (BMJ) Case ReportsCasabianca AS, Shah MM, Carpizo DAccessory bile duct: a rare but important anatomical variantCase Reports 2018;2018:bcr-2018-225133

Title: Does Metastatectomy Improve Survival in Gastric Cancer? An analysis of the National Cancer Database.

Presenter: Joshua C. Chao

Primary Investigator: David August

Co-authors: Stephanie H. Greco, Joshua C. Chao, David A. August, H. Richard Alexander.

Introduction/Background:Despite advanced surgical techniques and improvements in surgical survival as well as novel chemotherapy regimen, metastatic gastric cancer continues to have a dismal prognosis, with a median survival of 10 months and a 5-year overall survival rate for patients with metastatic disease is 5.1%. Metastatectomies, defined as resection of both the primary and various metastatic sites, though rare, have been found to improve overall survival in a small subset of those with metastatic gastric cancer. Methods: Data from the years 2004 to 2015 of the National Cancer Database was queried for adult patients with metastatic gastric adenocarcinoma. Patients were classified into those who underwent gastrectomy alone, metastatectomy alone, or both gastrectomy and metastatectomy versus patients who received chemotherapy alone. Propensity score matching was utilized to compare survival in these groups. Results: A total of 18,772 patients met the inclusion criteria: 16,446 (87.6%) patients underwent chemotherapy alone and 2,326 (12.4%) patients underwent either gastrectomy alone (962 patients or 5.1% of total), metastatectomy alone (380 patients or 2.0%), or both gastrectomy and metastatectomy (984 patients or 2.0%). After multivariable adjustment, patients who underwent primary site surgery and metastatectomy had a statistically significant greater overall survival than patients who received only chemotherapy, or underwent only a gastrectomy or metastatectomy (further data analyses pending). Propensity score-adjusted analysis produced findings demonstrating overall survival for patients who underwent primary site resection and metastatectomy was (further data analyses pending), whereas those who underwent chemotherapy only, gastrectomy only, or metastatectomy only had an overall survival of (further data analyses pending). Conclusion: Our data and analysis identify a subset of patients with metastatic gastric cancer for whom metastatectomy may improve overall survival. However, given continued uncertainty, there remains need for future prospective trials to investigate the impact of metastatectomy on overall survival in patients with advanced gastric cancer.

Title: Utility of fractal in plastic and reconstructive surgery

Presenter Name: Omar Elfanagely

Name of PI: Jeremy Sinkin

Name of Co-authors (in appropriate order): Mohammed Attiy, Yousef Elfanagely

Institution (especially if not at RWJUH): RWJ

Introduction: The utility of fractal geometry stems from its ability to characterize the irregular or fragmented shape of natural and complex objects. Physicians and scientists can use fractal analysis as a tool to objectively quantify complex biological surfaces found in plastic surgery. In this study, we categorize and review published literature discussing the application of fractal analysis in the field of plastic surgery.

Methods: A literature search was conducted on PubMed, Science Direct and Web of Science to determine the utility of fractal theory in plastic surgery. A total of 39 articles were found that meet our inclusion requirements. The PubMed, Science Direct and Web of Science databases were searched with the keywords skin, fracture, fractal, hand, wound, injury, oncology, silicone, implants, and analysis. Papers were then divided into seven categories: skin/soft tissue, craniofacial, hands, wounds, breast, microvascular, and implants & devices.

Results:

Of the 50 articles found during the literature review Breast, Wounds and Skin/Soft tissue were the most common topics with 15, 8, and 6 articles, respectively. There was been an increasing trend of fractal utilization in Plastic and Reconstructive surgery. Multiple studies support the potential of fractal and multifractal analyses in monitoring disease evolution, response to medical treatment, and as a diagnostic tool.

Discussion/Conclusion

Fractal analysis shows promise in the diagnosis, characterization, and prognostication of pathologies within the field of Plastic and Reconstructive Surgery. More translational studies are needed to understand the complete depth to which fractal geometry can be incorporated in clinical practice. It is clear, however, that FD can be utilized as a supplement to imaging and other modalities to track severity, progression, and response to treatment.

Title: Magnetic Sphincter Augmentation for Management of Gastroesophageal Reflux Following Laparoscopic Sleeve Gastrectomy: A Single Institution Case Series

Presenter Name: Omar Gonzalez-Vega

Name of PI: Ragui Sadek MD

Name of Co-authors (in appropriate order): Keith King, MD, Omar Gonzalez-Vega, MD, Andrew Wassef, BS, Ragui Sadek, MD FACSIntroduction: Laparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric surgery in the United States. Multiple studies have demonstrated that LSG can worsen pre-operative or result in de novo gastroesophageal reflux disease (GERD). For cases of medically refractory GERD following LSG, surgical options are limited given the absence of the fundus. Magnetic sphincter augmentation (MSA) using the Linx™ Reflux Management System provides an alternative surgical option. However, there is limited data evaluating the efficacy of this technique in post LSG patient population

Methods: A retrospective review was conducted of four patients with a history of LSG for morbid obesity that subsequently underwent laparoscopic LINX® magnetic sphincter device placement for medically refractory GERD between XX and XX. Patient demographic characteristics, operative details, and postoperative outcomes were collected and analyzed. Efficacy was evaluated using a previously validated GERD score questionnaire. Results: Laparoscopic LINX® magnetic sphincter device placement was successfully performed in four patients (XX% female, mean age of XX and BMI of XX kg/m2). All patients were discharged within 24 hours with no reported morbidities or readmissions. The severity and frequency of the patients’ reflux, regurgitation, epigastric pain, sensation of fullness, dysphagia, and cough symptoms were significantly improved postoperatively compared to preoperative evaluation with a reduction of their GERD score from XX to XX. Discussion/Conclusion: Laparoscopic LINX® magnetic sphincter device placement was successfully performed in four patients (XX% female, mean age of XX and BMI of XX kg/m2). All patients were discharged within 24 hours with no reported morbidities or readmissions. The severity and frequency of the patients’ reflux, regurgitation, epigastric pain, sensation of fullness, dysphagia, and cough symptoms were significantly improved postoperatively compared to preoperative evaluation with a reduction of their GERD score from XX to XX.Magnetic sphincter augmentation using the Linx™ Reflux Management System is a safe and effective surgical option for addressing medically refractory GERD in patients with a previous LSG.

Conference that the research was submitted or presented at, and/or journal title and date where research was published: American Society for Metabolic and Bariatric Surgery

Title: Combined open and endovascular management of extent II thoracoabdominal aortic aneurysm and abdominal aortic occlusion. A case report.

Presenter Name: Priya Patel Name of PI: Virendra I. Patel Name of Co-authors: Jahan Mohebali MD MPH, Virendra I Patel MD MPH Institution (especially if not at RWJUH): Massachusetts General Hospital, Columbia University Medical Center

Introduction: Thoracoabdominal aortic aneurysm (TAAA) repair is associated with high risk of post-operative mortality, spinal cord ischemia and renal injury. Endovascular repair combined with open repair in a two-staged approach has lower incidence of mortality and spinal cord ischemia compared to open repair. Here we present a case report of a single-staged hybrid repair of a complex chronic type B aortic dissection with Crawford extent II TAAA in a patient with extensive vascular surgical history.

Method: Our patient’s previous vascular interventions, including an ascending aortic arch reconstruction and axilo-femoro-femoral bypass compounded the difficulty of our operative approach. Her aortic dissection extended to the aortic arch and given her previous distal arch reconstruction her proximal descending aorta was not accessible in the usual manner. We therefore opted to perform a hybrid repair in which a TEVAR procedure would be used to serve as an elephant trunk for a standard open extent II repair. However, she also suffered from infra-renal aortic occlusion with occluded bypassed iliac segments making the TEVAR and open TAAA repair both mutually necessary. Therefore each procedure was performed sequentially.

Discussion/Conclusion: Following the surgical procedure our patient was taken to the surgical intensive care unit for close neurovascular monitoring. In the initial post-operative period she required the use of permissive hypertension to assist with adequate spinal cord perfusion, this was later weaned. She did have an initial rise in creatinine that returned to baseline prior to discharge. These findings are consistent with those reported for staged hybrid aortic aneurysm repair in which patients have had increased rate of acute kidney injury with no long-term renal failure, paralysis or paraplegia. Staged repair distributes the cumulative spinal cord ischemia burden and allows time for vascular remodeling and collateralization. Although our case could not be performed in a staged manner our results were comparable with expected acute kidney injury with no long term renal failure and no post operative paralysis and paraplegia.

Journal: Journal of Vascular Surgery

Title: Incisional Hernia After Percutaneous Endoscopic Gastrostomy Tube Placement: Importance of Avoiding the Linea Alba

Presenter Name: Alexander Rossi, MD

PI: Tomer Davidov, MD

Co-authors: Milind D. Kachare, MD, Alexander J. Rossi, MD, Noah Y. Mahpour, MD, Tomer Davidov, MD

Institution: RWJUH

Introduction: A gastrostomy tube passes from a patient's stomach through the abdominal wall and allows for direct enteral access. An alternative to an open gastrostomy, a percutaneous endoscopic gastrostomy (PEG) is typically favored as it is a less invasive option. However, a thorough understanding of the anatomy involved is paramount in order to prevent complications, regardless of what technique is chosen for placement. We present a case of an incisional hernia, which developed after the removal of a PEG tube placed through the midline of an abdominal wall, which is both a rare and avoidable complication. Placement of a PEG tube lateral to midline and avoiding the linea alba, an inherent weak point, will decrease the incidence of incisional hernias.

Methods/Results: Case Report

Discussion/Conclusion: While the literature is sparse regarding incisional hernias secondary to PEG tubes, we believe that this is an underreported complication of the procedure, and precautions should be taken to reduce the risk of hernia formation. Although this case resulted in a fat containing hernia, the potential for more serious herniation of bowel and strangulation should not be overlooked. While the standard procedure for deciding on placement of the PEG site on the abdominal wall does depend on the specific anatomy of the patient in question, avoiding known weak points of the abdominal wall, such as the linea alba and the paramedian linea semilunaris, could help prevent such complications from occurring. Additionally, in patients with underlying malnourishment, one should consider increasing the time interval between placement and removal from the standard, as wound healing is retarded in this setting. Also, in patients with a prior history of hernias, the specific site of PEG tube placement should be thoroughly considered, and care should be taken to avoid placement of the tube in an area that has high risk for future herniation.

Submitted: American College of Gastroenterology Case Reports Journal

Poster Presentation

Square Knots vs. One Handed Sliding Crossed Knots in #1 Polydioxanone (PDS) SutureB. Slatnick1 , E. Day1 , S. Asghar1 , V.Y. Dombrovskiy1 , T. Davidov1 ; 1Rutgers, Robert Wood Johnson Medical School, General Surgery, New Brunswick, NJ, USA

Introduction: Surgeon preference dominates choice on number of knots and type of suture material for surgical closures. For abdominal wall closures, #1 Polydioxanone suture (PDS) is recommended due its high tensile strength and absorbable nature. While “square knots” on monofilament suture are anecdotally known to be stronger than sliding knots, this is not well quantified. Furthermore, the optimal number and type of knots with PDS suture for abdominal wall closure is poorly defined. Our previous study shows that addition of one-handed sliding crossed knots with PDS suture decreases knot failure rate in a linear fashion. However, even with 12 knots there was a 10% failure rate. This study seeks to determine the mechanical properties of square knots (or two handed knots) on PDS and define the optimal number of knots required to prevent knot failure.

Methods: Square crossed knots were tied with 4, 6, or 8 throws using #1 PDS Suture. A single surgeon hand tied a total of 90 samples in randomized order: 30 samples for each group over 2 sessions to prevent fatigue. Using a tensilometer, knots were tested to the point of knot failure—defined as the knot untying before the suture breaks. The peak force in Newtons (N) was recorded at knot failure. We then compared knot failure rates and peak forces between this model and our previous study. Chi squared analysis, t-test, and general linear modeling was used for intergroup comparisons.

Results: Square knots had decreased knot failure rates compared to one handed sliding crossed knots with the same number of throws. Square knots with 4, 6, and 8 throws had knot failure rates of 90, 0 and 0% respectively. There was no difference in knot failure rates between 4 one handed sliding crossed knots and 4 square knots (P= 0.45); however, with 6 or 8 square knots there were no failures compared to 70% and 43% for one handed sliding crossed knots respectively. At 4 knots, 52 N were required on average for knot failure in the one-handed sliding crossed group vs. 70 N for square knots.

Conclusion: Square knots are superior to one-handed sliding crossed knots using #1 PDS. Square knots with 6 throws are the optimal number to prevent knot failure.

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