NPSA PROGRAM 10/26/15

Underlining denotes presenting authorItalics denotes member

*Asterisk denotes guest author

North Pacific Surgical Association 102 nd Annual Meeting, Portland, OR, November 13-14, 2015 Friday7:30-7:40 Welcome and Introduction: President John T. Vetto, MD

7:40-11:10 First Scientific SessionModerator: Eugene S. Cho, MD, Tacoma, WA

Head/Neck and Oncology By the end of this session, participant will 1) understand how dual-energy computed tomography can help locate parathyroid glands in patients with primary hyperparathyroidism, 2) diagnose axillary web syndrome after a sentinel lymph node biopsy for melanoma, 3) understand the limitations of early mammography for breast cancer surveillance, 4) understand how to prevent capsular contraction after implants reconstruction for breast cancer, 5) learn the prognostic value of length of primary tumor in esophageal cancer, 6) learn the appropriate procedure to treat a duodenal gastrointestinal stromal tumor, 7) learn the nonoperative and operative management of rectal carcinoid, 8) recognize disparities and learn outcomes of anal canal cancer for HIV+ patients

9 Papers (20 min each: 10 min primary, 5 min Discussant, 5 min Closer and questions)

1. 7:40-8:00 Resident Competition PaperDual-energy Computed Tomography: A Promising Novel Preoperative Localization Study That Facilitates Neck Exploration for Treatment of Primary Hyperparthyroidism Seyednejad N*; Healy CF*; Tiwari P*; Vos PM*; Melck A*; Hague CJ*; Wiseman SM (Closer) -- Vancouver, BCDiscussant: Raul Mirande, MD, Klamath Falls, OR

Background: Dual-energy computed tomography (DE-CT) is a novel imaging modality that provides information about how substances behave at different energies and about tissue composition beyond that obtainable with single-energy techniques. DE-CT has not previously been reported for preoperative parathyroid localization in individuals diagnosed with primary hyperparathyroidism (PHP).

Objective: To evaluate the utility of Dual-energy CT for preoperative parathyroid localization in individuals undergoing an initial neck exploration for treatment of PHP.

Methods: A retrospective review of the clinical and biochemical characteristics, imaging tests (Ultrasound (US), Tc-99m sestamibi non-contrast single photon emission CT (CT-MIBI) and DE-CT), operative findings, and patient outcomes was carried out for PHP cases undergoing an initial operation at a single center.

Results: Twenty-four patients made up the study population. The accuracy of each preoperative imaging test, based upon operative findings and pathological confirmation of removal of an abnormal parathyroid from the localized site was: 58% for US, 71% CT-MIBI, and 75% for DE-CT. DE-CT was able to accurately localize an abnormal parathyroid gland in 2 of 6 (25%) cases that CT-MIBI and US were unable to identify. Of the 5 cases with multi-gland disease (4 double adenomas and 1 sporadic 4 gland hyperplasia) DE-CT was able to localize a single abnormal gland. All study patients had normalization of serum calcium and PTH levels postoperatively.

Conclusions: This first report to evaluate DE-CT for preoperative parathyroid localization suggests that this novel imaging test shows promise, may be more accurate then other localization studies (US and CT-MIBI), and warrants further study.

2. 8:00-8:20 Resident Competition PaperAxillary Web Syndrome: an Underappreciated Complication of Sentinel Node Biopsy in MelanomaSchuitevoerder D*; Fortino J*, Vetto JT (Closer) – Portland, ORDiscussant: Timothy Bax, MD, Spokane, WA

Objective: Axillary web syndrome (AWS) is known to occur following axillary dissection, and has been reported following axillary sentinel node biopsy (ASLNB) for breast cancer. However, the incidence and outcomes of AWS following ASLNB for melanoma are unknown.

Methods: A retrospective review of prospectively collected, clinically node negative patients undergoing ASLNB for melanoma at a single institution by a single surgeon during a fourteen-year period was conducted to determine the incidence of AWS. Features pertaining to patients (age, gender), primary tumor (location, Breslow's depth), and nodes (number removed, positive node rate) were correlated with the occurrence of AWS.

Results: Of the 444 patients undergoing ASLNB, 21 (4.7%) developed AWS post-operatively. By comparison the incidence of other complications in this population were: infection 3%, bleeding 1.5%, wound dehiscence 0.8%, lymphocele 5%, and lymphedema 0.4%. There was no statistical difference between patients with or without AWS in terms of tumor thickness, location of primary (UE vs trunk), average number of nodes, positive SLNB rates (10% vs 12%), patient age, or gender. All cases of AWS resolved with expectant management; none required surgical intervention.

Conclusions: Axillary web syndrome (AWS) is a notable complication of ASLNB for melanoma, with an incidence as high or higher than “standard†� complications. AWS should therefore be included in the pre-operative discussion of possible complications of ASLNB. Traditional patient, tumor, and nodal factors are not predictive of AWS. Patients should be counseled that AWS usually responds to symptomatic treatment and resolves with time.

3. 8:20-8:40 Resident Competition PaperThe Role of Early Post-Treatment Mammography after Breast Conservation Therapy Barron M*; Nelson D*; Kuckelman J*; Bingham J*; Sohn V* (Closer) - Tacoma, WADiscussant: Shannon Tierney, MD – Seattle, WA

Background: Current American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines recommend early mammographic evaluation following completion of breast conservation therapy (BCT). However, the clinical utility of these recommendations are not well defined. Our objective was to determine the role of post-treatment mammogram following breast conservation therapy for malignancy.

Methods: A retrospective review at a single tertiary referral institution of all female patients (>18 years old) who underwent BCT for invasive breast cancer was performed.

Results: Between 2004 and 2013, 358 patients met inclusion criteria. Sixty-three (13.3%) patients were excluded due to incomplete data. The mean age of our cohort was 59±12 years. All patients underwent early post-operative mammograms with a mean time from BCT to mammogram of 279±105 days. Twenty-two patients (6%) had findings that prompted biopsy on initial post treatment mammogram. Common findings included abnormal microcalcification patterns (73%) and masses (27%). Of those 22 patients there was 1 (4.5%) patient that had malignancy identified on biopsy. This represents 0.3% of overall patients who underwent mammography in the early post-operative period.

Conclusions: The utility of early mammogram after breast conservation therapy is limited andprompts unnecessary diagnostic procedures. These additional procedures are marginally beneficial. Our data support the discontinued practice of early post-treatment mammography after breast conservation therapy for malignancy.

4. 8:40-9:00Prophylactic Use of Pentoxifylline (Trental) and Vitamin E to Prevent Capsular Contracture after Implant Reconstruction in Patients Requiring Adjuvant Radiation Cook M*, Garreau J*, Zegzula D*, Schray M*, Sorenson L*, Glissmeyer M*, Johnson N (Closer) – Portland, ORDiscussant: Karen Kwong, MD, Portland, OR

Purpose: In the realm of breast reconstruction for breast cancer, a subset of women will require post-mastectomy radiation (PMR) to assure control of their disease. In these cases, the risk of capsular contracture is reported at 40-60% and risk of implant loss at 18%. Pentoxifylline combined with vitamin E has been reported to reduce or reverse radiation fibrosis (RIF) after radiation to preserved breasts. We questioned whether prophylactic use could lower the morbidity of radiation after implant reconstruction.

Methods: Prospective study of 30 women after mastectomy with reconstruction, implants or tissue expanders, that required adjuvant chest wall radiation. Within 4 weeks of radiation completion, subjects began 400 mg Pentoxifylline 3x daily in combination with 400 IU of vitamin E twice daily for 180 total treatment days followed with a twelve-month observational phase.

Results: There were 26 evaluable subjects with 49 reconstructed breasts. Of these, 3 patients required additional procedures. One patient had bilateral implant exchange due to contracture and malposition. Two patients had unilateral revisions. One was due to contracture on the radiated breast, the other was due to malposition in the non-radiated breast. Radiation complication in 2/26 breasts(7.7%). There were no implant losses (0%).

Conclusion: The combination of Pentoxifylline and vitamin E prevented severe contracture in our patient population with no implant losses and only 7.7% of the subjects requiring revisions on the radiated side. This suggest that prophylactic use of Pentoxifylline and vitamin E may allow safe immediate reconstruction in patients who will require PMR

5. 9:00-9:20 Resident Competition PaperIncreasing Tumor Length Is Associated with Node Positivity and Decreased Survival in Esophageal Cancer Haisley, K*, Kunio NR*, Hart K*, Bakis G*, Schipper PH*, Sheppard BC, Hunter JG, Dolan JP (Closer) – Portland, ORDiscussant: Flavio Rocha, MD, Seattle, WA

Background: Depth of tumor invasion is a key factor in determining staging in esophageal cancer. While the effect of tumor length has received less attention, it may be an equally valid prognostic feature for node positivity and survival in esophageal cancer

Methods: Through retrospective review of the esophageal cancer research database (ECRD), esophagectomy patients with either adenocarcinoma or squamous cell carcinoma of the esophagus and documented tumor lengths on final pathology were analyzed. Patients having received neoadjuvant chemoradiation were excluded due to the potential confounding treatment effect on the tumor size. Tumor length was then compared to both node positivity and overall survival through a Cox proportional Hazard Model and linear regression respectively

Results: 101 patients from January of 2000 through July of 2015 met criteria and were included in the analysis. 81% were men with a median age at surgery of 65 (IQR: 58, 73) with 90% of patients having adenocarcinoma and an additional 10% with squamous cell carcinoma. Median tumor length for all patients was 3.0 cm (IQR: 0.9, 4.1). Data analysis showed that each 1-cm increase in tumor length predicted an increase of 0.3 in the count of positive lymph nodes (p<0.001). Additionally, there was a significant decrease in overall survival with increasing tumor length (hazard ratio 1.26 for every 1-cm increase in tumor length, 95% CI 1.14-1.40, p<0.001) independent of node positivity.

Conclusion: The findings of this study suggest an important association between esophageal cancer tumor length and lymph node metastasis as well as overall survival.

9:20-9:50 Break

6. 9:50-10:10 Resident Competition PaperSegmental Duodenal Resection with Duodenojejunostomy for Gastrointestinal Stromal Tumor Crown A*, Biehl T, Rocha F (Closer) – Seattle, WADiscussant: Ronald Wolf, MD – Portland, OR

Duodenal gastrointestinal tumors (GIST) present infrequently and surgical resection remains the mainstay of therapy. However, given the lack of lymphatic and submucosal spread and anatomic location near the bile duct and pancreas, the optimal approach for resection is unknown. Options include local resection, segmental resection, pancreas-sparing duodenectomy and

pancreaticoduodenectomy. This video demonstrates a technique for segmental resection of a GIST in the third portion of the duodenum abutting the uncinate process of the process with a duodenojejunostomy reconstruction. Given the location of the tumor, decision was made to proceed with a segmental duodenal resection to prevent the morbidity of a pancreatic resection and anastomosis from a pancreaticoduodenectomy. An extensive Kocher maneuver was performed to the level of the ligament of Treitz. The tumor was identified and the duodenal mesentery was mobilized. Attachments between the duodenum and the uncinate process of the pancreas were ligated and the duodenum divided proximally and distally to the tumor. A window was created in the transverse colon mesentery and a retrocolic duodenojejunostomy was created after confirmation of patency of the ampulla. Pathology revealed a 2.5 cm GIST with 1 mitotic figure per high power field and negative margins. The patient had an uneventful recovery and was discharged on post-operative day #6. Adjuvant imatinib was not recommended given the low risk features of the tumor. The patient is currently disease-free.

7. 10:10-10:30Preoperative CT Scan to Predict Pancreatic Fistula After Distal Pancreatectomy Using Gland and Tumor CharacteristicsJutric Z*, Johnston C*, Haykin L*, Matthews C*, Harmon L*, Shen J*, Hahn H*, Coy D*, Lasarev M*, Cassera M*, Wolf R, Hansen P*, Hammill C*, Alseidi A, Newell P (Closer) - Portland, ORDiscussant: Andrzej Buczkoswki – Vancouver, BC

Background: Postoperative pancreatic fistula (POPF) remains the dominant cause of morbidity following distal pancreatectomy. Preoperative risk stratification of patients undergoing distal pancreatectomy would be useful for treatment algorithms and clinical trials.

Methods: Risk factors for POPF in 220 consecutive patients undergoing distal pancreatectomy at two major institutions were recorded retrospectively. Gland density was measured on noncontrast CT scans (n=101), and histological scoring of fat infiltration and fibrosis was performed by a pathologist based on H&E staining (n=120). Recursive partitioning was used to construct a decision tree to predict POPF based on eleven variables.

Results: 42 patients (21%) developed a clinically significant POPF (ISGPF Grade B or C) within 90 days. Univariate analysis of age, operative approach, method of gland transection, splenectomy, staple line reinforcement, and pathologic diagnosis in 199 patients showed none were predictive of POPF. Fat infiltration was significantly associated with gland density (p=.0013), but density did not predict POPF (p=0.5). ROC curve analysis did not identify values for gland thickness at the margin that predicted POPF (area under curve = 0.635). Recursive partitioning resulted in a decision tree that predicted POPF in this cohort with a misclassification rate of <15% using gland fibrosis (histology), density (HU), margin thickness (cm), and pathologic diagnosis.

Discussion: This multicenter study shows that no single perioperative factor reliably predicts POPF after distal pancreatectomy. However, a novel decision tree was constructed using recursive partitioning that predicts POPF with >85% accuracy. Further work is required to validate the applicability of this model to clinical practice.

8. 10:30-10:50Surgical Management of Rectal Carcinoids: Trends and Outcomes from the SEER Database (1988-2012) McConnell YJ - Vancouver, BCDiscussant: Liana Tsikitis, MD – Portland, OR

Background: Local excision of small (<10 mm) rectal carcinoids is standard treatment. Full rectal resection is recommended if >10 mm, T2 or more, or N1 or more. Actual patterns of care and outcomes are understudied due to the rarity of this tumor. This study investigated type of surgical procedure for non-metastatic rectal carcinoid, linked with cancer-specific survival.

Methods: SEER database was interrogated for the years 1988-2012, for patients with rectal carcinoid. Demographic, pathologic, surgical, and survival data were exported, collated and analyzed. Chi square testing was used to compare proportions. Kaplan Meier survival analysis was used to compare outcomes.

Results: 11,505 patients with rectal carcinoid were identified - 9,040 of whom had localized disease without evidence of lymph node or distant metastatic involvement. The majority (84%) underwent local excision only. Full rectal resection was performed more frequently for larger (>10 mm) tumors (11.2%) compared to smaller (<10 mm) tumors (4.2-6.3%, p<0.001), as well as for higher T stage (T1: 4.2%, T2: 11.8%, T3: 24.3%, p<0.001). The overall rate of rectal resection did not change over time (4.1-4.7%). Non-operative management was more common after year 2000 (11.1-13.6%) than prior (5.5%, p<0.001). Cancer-specific 5 year survival was similar across time periods and with increasing non-operative management for small, localized disease (98.6-99.5%, NS).

Conclusions: For small, localized rectal carcinoids, local excision remains the standard surgical procedure. Non-operative management of low risk lesions is becoming more common and does not appear to be associated with a worsening of disease-specific survival. Data from large repositories regarding local progression/recurrence are needed.

9. 10:50-11:10 Resident Competition PaperHIV Positivity and Anal Cancer Outcomes: A Single-Center Experience Wieghard N*, Hart KD*, Kelley K*, Hardaker HL*, Herzig DO, Mitin T*, Thomas CR*, Tsikitis VL (Closer) - Portland, ORDiscussant: Megan Cavanaugh, MD – Portland, OR

Background: Anal cancer remains common in HIV-infected patients. Outcomes of chemoradiation regimens have mixed results. We evaluated the impact of HIV on treatment and outcomes at our institution.

Methods: Retrospective data analysis of patients with anal cancer treated from 2000-2013 was performed. Outcomes measured were chemoradiation tolerance, recurrence, and colostomy-free/overall survival. Standard chemotherapy was defined as 5-fluorouracil/mitomycin-C, and non-standard as non-mitomycin-C -based. Tolerance issues specified were unscheduled breaks, toxicities requiring hospitalization, and/or alteration of chemoradiation regimen.

Results: 86 patients (14 HIV-positive, 72 HIV-negative) were treated for anal cancer with median follow-up of 29.2 months. HIV-positive patients were more likely male (100% vs 38%, p < 0.001), but diagnosed

at similar stages (p = 0.49). They were less likely to receive standard chemotherapy (36% vs 86%, p < 0.001). There was no differences in recurrence (p = 0.55), survival time (p = 0.48), or tolerance issues (64% vs 42%, p = 0.15). The HIV-positive cohort had slightly lower colostomy-free survival rates (p = 0.053). Receipt of standard chemotherapy positively predicted recurrence-free and overall survival (HR 0.278, 0.082-0.946; HR 0.32, 0.094-1.096). Tolerance issues were negative predictors for both (HR 5.264, 1.376-20.142; HR 4.181, 1.136 – 15.389). HIV status did not worsen recurrence (HR: 0.78, p=0.71) or overall survival (HR: 0.67, p=0.57). Use of mitomycin-based chemotherapy significantly increased in the post-RTOG-9811 era (p=0.002).

Conclusions: HIV-positive patients received more non-standard chemoradiation, and had slightly lower colostomy-free survival, but equivalent recurrence and overall survival rates. Use of standard chemotherapy significantly increased after 2008.

11:10-11:25 Comments – John Weigelt, MD, Visiting Professor

11:00-11:45 The President’s Lecture Change, Organization and Good ScoutsJohn T. Vetto, MD (no MOC reqested)

11:45 - 12:45 Lunch with speaker History of Powell Books: largest independent used/new bookstore in world

12:45-3:05 Second Scientific SessionModerator: Ryan F. Holbrook, MD

Education/Telemedicine/Pancreatic/TraumaBy the end of this session, participants will 1) understand how to improve medical student/resident cohesion by changing call schedules, 2) learn how to improve single port surgery by using rigid or articulating instruments, 3) learn how a statewide teleradiology program can decrease cost and diminish patient radiation risk, 4) understand a preop model that predicts postop pancreatic fistula, 5) learn how remote teleconferencing can mentor first responders with trauma ultrasounds in the field, 6) understand how to emergently reverse vitamin K antagonist, 7) learn how to better manage severe abdominal sepsis with an open abdomen/negative pressure device technique.

Founder’s Lecture: Maintanence of Certification of General Surgery Boards/SESAPBy the end of the sessions, participants will learn how to more efficiently learn new techniques, outcomes, diagnostic tests, and patient care pathways in an effort to remain current on the field of surgery and be able to recertify for the Board of General Surgery.

7 abstracts (20 min each: 10 min primary, 5 min Discussant, 5 min Closer and questions)

10. 12:45-1:05 Resident Competition PaperAdding Remote Ultrasound "Knobology" Control to Remote Just-In-Time Telementored Trauma Ultrasound: A Randomized Controlled Trial

Kirkpatrick AW (Closer), McKee I*, McKee JL*, Ma IW*, McBeth PB*, Roberts DR*, Wurster C*, Partfitt RJ*, Ball C, Oberg S*, Sevcik B*, Hamilton DR* - Calgary, ABDiscussant: Robert Rush, MD – Tacoma, WA

Introduction: Remote telementored ultrasound (RTMUS) involves novice users being remotely-guided by ultrasound experts using informatic technologies (IT). While technically feasible there is little or no objective evaluations of this technique. We thus evaluated the performance of firefighters to evaluate for simulated hemoperitoneum.

Methods: A prototype RTMUS system providing lap-top computer remote viewing and control of a distant ultrasound machine knobology over the internet was evaluated. Verbal and visual communication was provided by commercial-off-the-shelf teleconferencing technologies (Skype and GoToMeeting). Firefighters in Edmonton (n = 101) were mentored from Calgary, (n=65), Nanaimo (n=19), and Memphis (n=17), to objectively examine the right-upper-quadrant of an ultrasound phantom randomized to free fluid or not. The RTMUS was further randomized to utilize or not a suite of remote control knobology functions (GUIK+ or GUIK-). The primary outcome was diagnostic accuracy.

Results: The RTMUS exam was feasible in all 101 cases recruited, with an overall diagnostic accuracy of 97% (CI = 91-99%), sensitivity of 94 % (CI=83-99%), and specificity of 100 (CI=93-100%) with three false negative (FN) exams and Likelihood ratios of a positive (LR+) and negative (LR-) test being infinity and 0.0625. One FN occurred in the GUIK+ group and 2 in the GUIK- group. There was no statistical difference in test performance characteristics in either group (GUIK+ and GUIK-).

Conclusion: All tasks required longer time to complete in SPAs when compared to a conventional approach. Higher SPAs times are likely due to difficulty in triangulation. Articulating instruments have an increased benefit in SPAs surgery, and additional experience and training may facilitate SPAs utilization.

11. 1:05-1:25Rigid Versus Articulating Instrumentation for Single Port Surgery Task Completion Chow G*, Chiu CJ*, Zheng B*, Panton OMN, Meneghetti A (Closer) – Vancouver, BCDiscussant: Erin Gilbert – Portland, OR

Background: The laparoscopic learning curve results from absence of haptic feedback, loss of 3 dimensional perspective, and need for specialized instrumentation. Single port access surgery (SPAs) may provide benefit when compared to conventional multi-port surgery, but there is likely a steeper learning curve due to greater challenges in triangulation and instrumentation. In this study, we compare the use of traditional in-line rigid instruments with articulating instruments for SPAs.

Methods: A standardized FLS peg transport task was performed by surgeons using a conventional three-port approach or SPAs device. The task was performed using a standard rigid instrumentation, and then repeated using articulating instrumentation in both approaches. Performance was recorded and compared.

Results: 20 surgeons completed all tasks, and average time using a conventional approach was shorter than SPAs (144 ± 54 vs. 198 ± 74 sec, p < 0.001). Use of articulating instruments required longer procedural time when compared to rigid instrumentation (201 ± 66 vs. 141 ± 58 seconds, p < 0.001). In

the conventional model, task time was lower with rigid instruments when compared to articulating instruments (108 vs. 179 sec). Task time in the SPAs model was lower with rigid instruments when compared to articulating instruments (173 vs. 223 sec).

Conclusion: All tasks required longer time to complete in SPAs when compared to a conventional approach. Higher SPAs times are likely due to difficulty in triangulation. Articulating instruments have an increased benefit in SPAs surgery, and additional experience and training may facilitate SPAs utilization.

12. 1:25-1:45 Resident Competition PaperA Statewide Teleradiology System Reduces Radiation Exposure and Charges in Transferred Trauma Patients Watson J*, Moren A.*, Diggs B*, Houser B*, Eastes L*, Brand d*, Bilyeu P*, Schreiber M, Kiraly L -(Closer)– Portland, ORDiscussant: Raj Nair, MD, Salem, OR

Background: Trauma transfer patients routinely receive repeat imaging due to inefficiencies within the radiology system. In 2009 the virtual private network (VPN) telemedicine system was adopted throughout Oregon allowing virtual image transfer between hospitals. The startup cost was a nominal $3,000 per hospital.

Methods: A retrospective review from 2007-2012 included 400 adult trauma transfer patients picked randomly based on a power analysis (200 pre/200 post). The primary outcome evaluated was reduction in repeat CT scans. Secondary outcomes included cost savings, ED length of stay (LOS) and spared radiation. All data were analyzed with Mann-Whitney U and x2 tests. P<0.05 indicated significance. Spared radiation was calculated as a weighted average per body region and savings was calculated using charges obtained from OHSU radiology CPT codes.

Results: Four-hundred patients were included. ISS, age and gender were not statistically different between groups. The percentage of patients with repeat CT scans decreased after VPN implementation: CT abdomen (13.2% v 2.8%, p<0.01) and cervical spine (34.4% v 18.2%, p<0.01). Post VPN, the total charges saved in 2012 for trauma transfer patients was $333,500 while the average radiation dose spared per person was 1.8mSV. Length of stay in the ED for patients with ISS<15 transferring to the ICU was decreased (p<0.05).

Conclusions: Implementation of a statewide teleradiology network resulted in fewer repeat CT scans, significant savings, decrease in radiation exposure, and decreased LOS in the ED for patients transferring to the ICU. The potential for healthcare savings by widespread adoption of a VPN is significant.

13. 1:45-2:05 Resident Competition PaperA Night Float Week in a Surgical Clerkship Improves Student Team Cohesion Connelly CR*, Cook MR*, Moren AM*, Schreiber MA, Kiraly LN (Closer) – Portland, ORDiscussant: Adam Meneghetti, MD - Vancouver

Introduction: Resident duty hour restrictions have increased reliance on night float (NF) teams, however, medical student clerkships often follow traditional call schedules. This discrepancy may result in less valuable overnight clinical experiences and a feeling of disconnect between students and the resident care teams. Additionally, the quality of clerkship mentorship is associated with career choice. The comparative educational value of a student NF model remains unclear. We hypothesize that NF rotations in the third year surgical clerkship improve student learning and perceptions of team cohesion.

Methods: A NF system for third year medical students was implemented during the 2013/14 academic year with each student completing one week of NF with the trauma/emergency general surgery service. We prospectively studied the impact of this intervention on team cohesion, using the Perceived Cohesion Scale, and academic performance, using NBME surgery exam scores. Pre- and post- intervention scores were compared with Student's t-test

Results: We surveyed 70 medical students, 37 traditional call and 33 night float students, with 64 respondents (91% response rate). Student perception of team cohesion increased significantly, with no perceived loss of educational benefit. Pre- and post-intervention exam scores were compared, average scores for night float students were significantly higher than traditional call students (76.0 vs 70.2, p<0.05).

Conclusion: A week long NF experience for medical students significantly improves their perception of team cohesion and is associated with higher shelf exam scores. Overall educational value may be improved with the addition of a dedicated period of NF during the surgical clerkship.

14. 2:05-2:30 Resident Competition PaperEmergent Reversal of Vitamin K Antagonists: Addressing All the Factors Martin D*, Barton CA*, Dodgion C*, Schreiber MA, (Closer) – Portland, ORDiscussant: Matthew Martin, MD – Tacoma, WA

Introduction: Prothrombin complex concentrates (PCCs) rapidly reverse anti-coagulation from vitamin K antagonists (VKA). Prior to 2013, only 3-factor PCCs (3F-PCC) were available in the United States, requiring the use of plasma or activated factor VII (VIIa) to replace all 4 VKA affected procoagulant enzymes. The recent availability of Kcentra®, a 4-factor PCC (4F-PCC) balanced with several anticoagulant enzymes allows replacement of all VKA depleted factors. No direct comparisons between these distinct PCC formulations exist to guide clinical decision-making.

Methods: Retrospective review of a single level 1 academic trauma center. Pharmacy records were queried for all trauma patients who received 4-factor replacement for VKA reversal with either 3F-PCC+VIIa or 4F-PCC. Patient charts were reviewed from admission until discharge from index hospitalization. Primary endpoints were in-hospital mortality and the new diagnosis of DVT.

Results: 78 patients were identified between 2011 and 2015. 53 patients received 3F-PCC+VIIa and 25 4F-PCC. Gender, age, and indication for anticoagulation were similar between groups, as were admission GCS, Injury Severity Scores and INR prior to reversal. In-hospital mortality was significantly increased in the 3F-PCC+VIIa group (9 deaths (17.0%) vs 0 deaths, p=0.05), as was the incidence of new diagnosis of DVT (12 DVTs (22.6%) vs 0 DVTs, p<0.01). The rate of screening duplex ultrasounds was not different between groups.

Conclusion: The use of 4F-PCC for VKA reversal after traumatic injury is associated with lower rates of both in-hospital mortality and post-traumatic DVT when compared to rates in similar patients treated with 3F-PCC+VIIa.

15. 2:30-2:50 Resident Competition PaperOpen Abdomen with Negative Pressure Device Versus Primary Abdominal Closure for the Management of Surgical Abdominal Sepsis: a Retrospective Review Bleszynski MS*, Chan T*, Buczkowski AK (Closer) – Vancouver, BCDiscussant: Marilyn Butler, MD

Background: Staged abdominal reconstruction with temporary abdominal closure has become an alternative option to standard single operation and on demand re-laparotomy for surgical abdominal sepsis (SABS). There is an insufficient amount of data in the literature comparing outcomes of primary abdominal/fascial closure (PAC) and open abdomen with negative pressure dressing (VAC) in a critically ill severe abdominal sepsis/septic shock population. The primary objective was to compare mortality between ICU patients who undergo PAC versus VAC.

Methods: Retrospective review of 211 consecutive ICU admissions from 2006-2010 at a tertiary center. Inclusion criteria: suspected or diagnosed severe abdominal sepsis or septic shock requiring source control laparotomy. APACHE-IV measures of disease severity were calculated using an online calculator following the Cerner protocol. Cases were categorized according to closure method at initial procedure.

Results: 211 patients met inclusion criteria for SABS, consisting of 75 PAC and 136 VAC cases. Overall in-hospital mortality was 28% and APACHE-IV PMR was 45%. Mean PAC and VAC APACHE-IV PMR were both 45%. VAC mortality was 22.8% compared to 38.6% for PAC (p=0.012). Controlling for disease severity, the adjusted odds ratio of mortality for VAC patients was 0.41 95%CI [0.21, 0.81], p=0.01 compared to PAC. Patients who failed PAC had the highest mortality (58.7%) with mean APACHE-IV PMR of 48.6%.

Conclusions: Management of severe abdominal sepsis/septic shock with open abdomen and a negative pressure device is associated with significantly better survival compared to primary fascial closure.

3:05-3:15 Discussion by John Weigelt, MD, Visiting Professor

3:15-3:45 Break

3:45-4:30 Founder’s Lecture: John A. Weigelt, MDMaintenance of Certification: Who is maintaining what?

4:30-5:15 Executive Session – NPSA Members only

Saturday, November 14, 2015Moderator: Allen Hayashi, MD

7:30-10:10 am: Third Scientific Session: Quality/Patient Outcomes/New Techniques/VascularBy the end of this session, participants will 1) learn how fluorescent cholangiography may help achieve the critical view of safety in cholecystectomy, one of the most common general surgery procedures, 2) learn the limitations of intraoperative leak testing for sleeve gastrectomy, 3) learn strategies to decrease the risk of superficial skin infections after colorectal surgery, 4) learn how to improve ostomy teaching and the patient’s length of stay, 5) understand how patient care pathways can decrease length of stay and complications in pediatric G tube patients, 6) understand the safety of using prosthetic mesh in hernia repairs in a more austere environment, 7) learn how 24 hour post discharge follow up can improve patient satisfaction, and 8) learn the new indications of axillofemoral bypass.

8 abstracts (20 min each: 8-10 min primary, 5 min discussant, 5 min questions)

16. 7:30-7:50 Fluorescent Cholangiography in Laparoscopic Cholecystectomy: The initial Canadian Experience Chow G*, Meneghetti A, Zroback C*, Chiu CJ*, Meloche M*, Warnock G*, Panton OMN (Closer) – Vancouver, BCDiscussant: Matthew Macha, MD – Eagle, ID

Background: Laparoscopic cholecystectomy is the most commonly performed general surgical procedure worldwide. Bile duct injury rates have not decreased despite increased rates and training with this procedure. Laparoscopic fluorescent cholangiography using Indocyanine Green (ICG) for real-time intraoperative near infrared (NIR) imaging of the extrahepatic biliary system has potential to help identify anatomy and may possibly decrease rates of inadvertent biliary injury. Here we present the initial Canadian experience with this technique.

Method: An objective analysis of NIR imaging during elective cholecystectomy in the Canada was performed. Patient demographics, intraoperative details, and subjective surgeon data were recorded. The primary endpoint was to identify real-time rates of cystic and common bile duct identification. Survey questions were obtained regarding the functionality, use, and perceived benefit of the technology.

Results: NIR imaging with ICG cholangiography was used in 12 initial cases. The average operative time with 80 +/- 31 minutes. The cystic duct, CBD, and CHD were visualized with NIR in 100%, 83%, and 50% of cases respectively. Use of fluorescent cholangiography incorporated smoothly into the operation in 83% of cases, and facilitated identification of anatomy in a majority of cases. There were no adverse reactions or complications related to the technology.

Conclusions: Fluorescent cholangiography allows for non-invasive real time visualization of the extra-hepatic biliary tree. This technology has not increased operative times and facilitates obtaining a critical view of safety. This technology has received positive feedback in this initial Canadian use and may be a durable adjunct for laparoscopic surgery.

17. 7:50-8:10 Resident Competition PaperImproving Access to Bariatric Surgery: Early Surgical and Patient Focused Outcomes of a Rural Obesity Clinic Chan AW*, Hopkins J*, Gagnon I*, Birch DW - Edmonton, ABDr. Adam Meneghetti, Closer – Vancouver, BCDiscussant: Dr. Christy Dunst – Portland, OR

Background: Bariatric surgery is typically offered in larger healthcare centres, forcing patients to travel long distances to access care. Cost and travel time are barriers. An adult obesity program was established in Whitehorse, Canada based on the multidisciplinary adult bariatric clinic in Edmonton, to alleviate long distance care difficulties. The study objective is to analyze patient and healthcare staff satisfaction and surgical outcomes for this program.

Methods: A survey was administered to 20 patients and 8 healthcare staff in Edmonton and 20 patients and 4 staff in Whitehorse. The Edmonton cohort consisted of out-of-province residents and in-province residents who travelled ≥3 hours one-way to Edmonton. The Yukon cohort consisted of Whitehorse residents who followed up in Whitehorse. All surgeries were performed in Edmonton. Patient charts were reviewed. A multivariate linear regression was performed to predict the effects of travel distance and other clinical covariates on follow-up compliance.

Results: Post-operative body mass index (BMI), operative complications, and 5-point Likert scale satisfaction scores were similar (4.60 vs 4.58); however, Whitehorse patients attended significantly more appointments (85.6% vs 71.1%, p=0.002). Length of hospital stay was a significant covariate on follow-up compliance in the multivariate regression (p=0.046). Respondents identified cost, accessibility and medical specialization as benefits of the outreach clinic.

Conclusions: The Whitehorse Bariatric Program provides obesity and peri-operative care comparable to an urban centre. Surgical outcomes are not compromised. Patient follow-up and satisfaction suggests a highly successful program. This may serve as a model for improving access to obesity services across Canada.

18. 8:10-8:30 Resident Competition PaperRoutine Intraoperative Leak Testing for Sleeve Gastrectomy: Is the Leak Test Full of Hot Air? Bingham J*, Lallemand M*, Barron M*, Kuckelman J* , Carter P, Blair K*, Martin M (Closer) – Tacoma, WADiscussant: Ross McMahon, MD – Seattle, WA

Introduction: Staple line leak after sleeve gastrectomy (SG) is a rare but dreaded complication with a reported incidence of 1 to 10%. Many surgeons routinely test the staple line with an intraoperative leak test, but there is little evidence to validate this practice. In fact, there is a theoretical concern that the leak test may weaken the staple line and increase the risk of a postop leak.

Methods: Retrospective review of all SG performed over a 7-year period. Cases were grouped by whether an intraoperative leak test (IOLT) was performed, and compared for the incidence of postop staple line leaks. The ability of the IOLT for identifying a staple line defect and for predicting a postoperative leak was analyzed.

Results: 542 SG were performed between 2007-2014. 13 patients (2.4%) developed a postop staple line leak. The majority of patients (N=494, 91%) received an IOLT, including all 13 patients (100%) who developed a subsequent clinical leak. There were no (0%) positive IOLTs and no additional interventions were performed based on the IOLT. The IOLT sensitivity and positive predictive value were both 0%. The leak rate was higher when a routine IOLT was performed (2.6%) versus no routine IOLT (0%).

Conclusions: The performance of routine IOLT after sleeve gastrectomy provided no actionable information, and was negative in all patients who developed a postoperative leak. The routine use of an IOLT did not reduce the incidence of postop leak, and in fact was associated with a higher leak rate after SG.

19. 8:30-8:50Minimizing Variance in Pediatric Gastrostomy: Does a Standardized Perioperative Plan Decrease Cost and Improve Outcomes? Sunstrom R *, Lofberg K*, Hamilton N*, Sims, T*, Azarow K (Closer) – Portland, ORDiscussant: Stephanie Acierno, MD – Tacoma, WA

Background: The Division of Pediatric Surgery at OHSU has been standardizing protocols for common pediatric surgical problems. A protocol for laparoscopic gastrostomy placement was implemented which specified perioperative antibiotics, feeding regimens, and discharge criteria. Our hypothesis was that hospital cost could be decreased while at the same time improving or maintaining patient outcomes.

Methods: Patients ≤ 18 years who underwent primary laparoscopic gastrostomy tube placement during study periods were evaluated. Control study period = October 1, 2012 - March 31, 2013; Protocol study period = Sept 1, 2014 -March 31, 2015. We evaluated surgeon compliance, patient outcomes (as defined by 30 day NSQIP complication rates), and cost of initial hospitalization before and after implementation of this protocol.

Results: N = 23 (control group), and 39 (protocol group). Average length of hospitalization was 4.3 days, and 2.3 days respectively, p<0.05. Complication rates were 30.4% and 18% respectively, p<0.05. Tube dislodgement accounted for the largest difference. Surgeon compliance was greater than 95%.

Conclusion: A standard protocol is achievable for perioperative gastrostomy management. A shorter length of stay and decreased complication rate was demonstrated when a standardized protocol was implemented. We are expanding this concept to a variety of other common pediatric surgical procedures.

20. 8:50-9:10Colorectal SSI Reduction Strategies DeHaas D (Presenter?) Aufderheide S*, Gano J*, Weigandt J*, Ries J*, Faust B*– Springfield, ORDiscussant: Daniel Herzig, MD – Portland, OR

Our facility was identified as a high outlier for SSI for all cases and colorectal cases in the NSQIP SAR in January 2012. A best practice bundle to reduce SSI and an ERAS colorectal pathway were concurrently initiated.

A multidisciplinary surgical quality team was established. A hospital-wide hand-washing campaign was initiated. Preoperative and postoperative order sets were revised to include the desired measures.

Preoperative elements included SCIP measure compliance (including correct antibiotic selection, timing, and dosage), chlorhexidine showers, and pre-op chlorhexidine wipes. Surgeons were encouraged to use mechanical bowel prep with antibiotics for patients undergoing colorectal surgery.

Intraoperative measures included continuous normothermia, chlorhexidine surgical prep with reinforcement of correct prep technique, use of wound protectors, use of clean closure trays, and gown/glove changes as appropriate. Antibiotics were re-dosed at appropriate time intervals.

Postoperative measures included standardization of dressing removal, daily chlorhexidine showers, and discontinuation of antibiotics within 24 hours of incision.

A best practice SSI reduction bundle combined with an ERAS colorectal protocol resulted in a dramatic improvement in SSI rates and postoperative morbidity. In NSQIP April 2015 Interim SAR, results show reduction from overall SSI rate for 2011 of 4.87% to 1.71% (1st decile/low outlier status). Colorectal SSI rate was reduced from 17.58% to 5.11% (1st decile/low outlier status).

Multimodal interventions to reduce SSI resulted in significant, sustained improvement in our facility SSI rates. Maintaining gains will require continuous compliance with current measures. Further interventions to consider are full implementation of clean closure procedures, euvolemia, nutritional supplementation, surgical attire requirements, OR traffic reduction, and perioperative glucose control.

9:10-9:40 Break

21. 9:40-10:00 Stoma creation: Does Day of the Week Affect Length of Stay? Long KC*, Hawkins M* - Presenter – Seattle, WADiscussant: John Kortbeek, MD – Calgary, AB

Background: In the current healthcare economy, balancing patient safety with hospital length of stay and associated cost has become more important than ever. Subjective observation suggests that patients undergoing ostomy creation early in the week seem to have a shorter length of stay than those operated on later in the week.

Objective: This retrospective review assesses the postoperative hospital length of stay associated with ileostomy based on timing of the operation by day of the week performed.

Results: Analysis included 39 patients who underwent low anterior resection for rectal cancer with ileostomy on Monday, Tuesday, Wednesday (n = 11), Thursday (n = 10) or Friday (n = 18). All procedures except one were performed laparoscopically or robotically. The initial enterostomal therapist visit was on average postoperative day 1.3, 1.4 and 3.2 for the Monday, Tuesday, Wednesday group, the Thursday group and the Friday group, respectively. The average length of stay for the Monday, Tuesday, Wednesday group was 5.5 days, the Thursday group was 4.9 days and the Friday group was 6.2 days.

Conclusions: In our institution, patients undergoing low anterior resection with ileostomy had an average length of stay one full day shorter when the operation was performed on any day other than Friday. These data suggest that procedures involving stoma creation should be performed on days other than Friday if possible. Contributing factors may be the unavailability of enterostomal therapist teaching over the weekend or physician weekend cross-coverage. Limitations of this study include its retrospective nature and small size.

22. 10:00-10:20 Resident Competition PaperThe Routine Use of Prosthetic Mesh in Austere Environments: Dogma versus Data Kuckelman J*, Blair K*, Martin M (Closer) – Tacoma, WADiscussant: Bruce Ham, MD - Portland

Introduction: Mesh repair has become the standard default in adult hernia repairs. Mesh infection is an uncommon but potentially devastating complication. Currently there is widespread dogma against the use of prosthetic mesh (PM) in deployed or austere environments, but little available data to support or refute this bias.

Methods: Retrospective review of all hernia repairs over 1 year in a forward deployed surgical unit in Afghanistan. Demographics, hernia type, repair performed and mesh type were evaluated. Follow up was completed up to 6 weeks and then as needed, and complications to include infection were recorded.

Results: 68 patients were identified, mean age was 38 (range 3-80) and 98% were male. Single-dose perioperative antibiotics and standard sterile technique were utilized in all cases. The majority (71%) had PM placed. The mean operative time was 54 minutes and mean estimated blood loss was 15cc.The vast majority of our hernias were inguinal (95%) with one ventral and one umbilical hernia. In the PM group, there were no surgical site infections, no mesh infections, and no mesh explantation or reoperation. One patient who received an inguinal repair with mesh developed post-operative pneumonia. There were no recurrences in either group identified at up to 1-year postop. There was no statistically significant difference in any outcome measure between the PM and no-PM groups.

Conclusions: The use of prosthetic mesh for hernia repairs in the austere or forward environment appears safe and did not increase the risk of SSI, mesh infections, or recurrence.

23. 10:20-10:40 Resident Competition PaperCall to Care: The Impact of 24-Hour Post Discharge Telephone Follow-up in the Treatment of Surgical Daycare Patients Daniels S*; Kelly A*; Simeoni L*, Bachand D; Hall C*; Hofer S; Hayashi A (Closer) – Victoria/AlbertaDiscussant: Scott Browning, MD – Portland, OR

The benefits of day surgery are numerous and the number of day procedures performed each year is rising. Patient satisfaction and effective management of post-operative complaints are important factors in determining the success of any outpatient surgery program.

In September 2013 a 24-hour post discharge telephone follow up call (TFU) was initiated by surgical day care nurses at the Royal Jubilee Hospital. This retrospective quality assurance study evaluated the effectiveness of the TFU in identifying and addressing postoperative complaints and determining the level of satisfaction with discharge instructions and care. Our study group was administered a survey where they were asked to evaluate the TFU. Outcomes assessed included: incidence, frequency, severity and type of post-operative complaints; satisfaction with discharge instructions and care; and feedback on the TFU experience.

854 patients underwent a day surgery procedure. Of these TFU group N= 313 (36.7% of sample), Non-TFU group N= 541 (63.3% of sample). Independent samples t-tests revealed that patients who received TFU had significantly fewer post-operative complaints compared to those who had not (0.19 and 0.28 on average, respectively). Patients who received TFU were more satisfied with their discharge care. Participants in the TFU group overwhelmingly rated the TFU as being helpful, and positively impacting their discharge care (93.6% and 84.5%, respectively). The results of this study suggest that telephone follow up is an appropriate tool to address patients’ post-operative complaints, ensure patient satisfaction with discharge care, and assist patients with their concerns in the immediate post-operative period.

24. 10:40-11:00 Resident Competition PaperThe Changing Role of Axillofemoral Bypass in Current Vascular Surgery Practice Landry G (Closer), Perrone K*, Rahman A*, Nguyen K*, Azarbal A*, Liem T*, Mitchell E*, Moneta G – Portland, ORDiscussant: James Peck, MD – Portland, OR

Introduction: Axillofemoral bypass (AFB) has largely been supplanted by endovascular revascularization in modern practice. Its role and outcomes require redefinition. We sought to determine the current role of AFB and whether the changing role affects outcomes.

Methods: All AFB performed at a single institution from 2006-2013 were reviewed for indication, demographics, patency and survival. The current series was compared to prior published series from our group predating widespread use of endovascular techniques (1996-2001).

Results: During the study period 90 AFB (29 axillofemoral, 61 axillobifemoral) were performed. Chronic limb ischemia was the indication in 43(48%), acute limb ischemia 29(32%), graft infection 16(18%), and other 2(2%). In comparison with prior series, chronic limb ischemia procedures were significantly reduced (48% vs 74%,p=0.01), with a significant increase in acute limb ischemia (32% vs 14%,p=0.006)

and comparable rate for infection (18% vs 12%,p=ns). Mean follow up was 13.3±20.2 months. Overall patency at 1 and 2 years was 74.6% and 67.8%. Patency rates were similar for chronic (72.1%,72.1%) and acute (75.8%,50.5%) ischemia, whereas, for infection, patency rates were significantly higher (93.8%,93.8%,p<0.05). Median survival was 40.3 months, with overall survival 67.0% and 54.2% at one and two years. This was similar for all indications (chronic ischemia 73.2%,54.3; acute ischemia 55.9 %,55.9%,; infection 67.7%,58.0%,p=0.25), with patency and survival similar to prior series.

Conclusions: While the use of AFB in chronic limb ischemia is in decline, it remains a vital treatment option for acute limb ischemia and infections. Graft patency and survival remain unchanged despite the shift in indications.

11:00-11:15 Discussion by John Weigelt, MD, Visiting Professor

11:15-11:45 Historian’s lecture - Preston Carter, MDLloyd Nyhus and Rene Stoppa:   Pioneers of the Inguinal Preperitoneum

11:45-12:15 The CAGS President's Listening and Advocacy TourChris deGara, MD, President, Canadian Association of General Surgeons

12:15-1:15 Lunch & Talk: Bridges of Portland with the Bridge Lady -- Sharon Wood Wortman

1:15-1:45 Video Sessions (2 videos, no discussants, questions/answers after each video)

1:15-1:30 1) Trans-anal Laparoendoscopic Surgery (TALES): a novel approach to rectal lesions in childrenHamilton, NA* (Presenter), Krishnaswami S -- Portland, OR

1:30-1:45 2) Video Assisted Pancreatic Debridement for Infected Pancreatic NecrosisKniery K*, Martin M - Closer, Tacoma, WA

1:45-5:00 VirtuOHSU (OHSU surgical simulation program, hands on) 2hr course/1hr travelBy the end of this session, participants will 1) use a colonoscopy, laparoscopic common bile duct exploration, robot-assisted laparoscopic, laparoscopic, and inguinal hernia repair simulators, and 2) learn how to employ these simulators for teaching/remediating surgical skill.