MISSOURI CHAPTER AMERICAN COLLEGE OF SURGEONS, INC.

46th Annual Professional Meeting May 31 - June 2, 2013

Missouri Chapter American College of Surgeons, Inc.

Chartered December 7, 1967

This Program is designed to provide a platform for Associate Fellows and Fellows to share their surgical experiences and techniques and to encourage scientific

participation by resident surgeons.

Accreditation Statement The American College of Surgeons is accredited by the Accreditation Council for

Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

AMA PRA Category 1 CreditsTM

The American College of Surgeons designates this live activity for a maximum of 14.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. University of Missouri Sinclair School of Nursing is an approved provider of continuing nursing education by the Missouri Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation. 7.5 Contact Hours will be awarded. MONA Provider approval number 713-XII.

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Fellowship Pledge Recognizing that the American College of Surgeons seeks to exemplify and develop the highest traditions of our ancient profession, I hereby pledge myself, as a condition of fellowship in the College, to live in strict accordance with its principles and regulations. I pledge myself to pursue the practice of surgery with honesty and to place the welfare and the rights of my patients above all else. I promise to deal with each patient, as I would wish to be dealt with if I was in the patient’s position, and I will set my fees commensurate with the services rendered. I will take no part in any arrangement, such as fee splitting or itinerant surgery, which induces referral or treatment for reason other than the patient’s best welfare. Upon my honor, I declare that I will advance my knowledge and skills, will respect my colleagues, and will seek their counsel when in doubt about my own abilities, in turn, I will willingly help my colleagues when requested. Finally, I solemnly pledge myself to cooperate in advancing and extending the art and science of surgery by my Fellowship in the American College of Surgeons.

Updated 12/14/2012

AMERICAN COLLEGE OF SURGEONS EVALUATION FORM

Member Services Missouri Chapter 46th Annual Professional Meeting; Lake Ozark, MO

May 31 – June 2, 2013 IN ORDER TO RECEIVE A CME CERTIFICATE, PLEASE BRING THIS COMPLETED FORM TO: Registration 7:00am – 3:00pm

As a participant at this educational activity, I attended ________ hours* of sessions.

*1 hour = 1 AMA PRA Category 1 credit™

Please check the box if you are a member of the American College of Surgeons. Your ACS Portal MY CME transcript page will be updated with the credits earned within 3 months of this meeting. Your ACS member number is important to ensure proper transfer of credit. ACS Member # ______________________

PLEASE PRINT NAME_________________________________________email_________________________________________ Please circle the appropriate number for each question

Excellent Very Good Good Fair Poor 1. Overall, how would you rate this educational activity?

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Strongly Agree Agree Neutral Disagree Strongly

Disagree 2. Program topics and content met the stated

objectives. 5

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3

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3. Content was relevant to my educational needs.

5

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3

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4. Educational format was conducive to learning.

5

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5. Acquired knowledge will be applied in my practice environment.

5

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6. I will seek additional information on this subject.

5

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7. Program was fair, objective, and unbiased toward any product or program.

5

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8. Please explain any specific instance(s) of bias or conflict of interest:

______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 9. Please list a minimum of two things you are going to change in your practice as a result of what you have learned at this activity. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 10. Please describe the barriers anticipated when implementing the above changes: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 11. Do you have any suggestions for future topics to support and/or expand on what you have learned at this activity?

______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Additional Comments

______________________________________________________________________________________________________ ______________________________________________________________________________________________________

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(Intentionally Left Blank)

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LEARNING OBJECTIVES

1. Review the preoperative evaluation, operative management and follow-up of

select patient groups with breast cancer.

2. Introduce the audience to relevant issues which need to be considered when evaluating and treating patients with breast cancer.

3. Give more audience awareness of: Indications for SLND, Utilization of

Ultrasound in pre and post op evaluation, Occult breast cancer management, Follow-up of breast cancer patients and patterns of recurrence in high risk patients.

4. Define current recommendations for screening and treatment of blunt

cerebrovascular injury. 5. Express changing concepts of managing acute appendicitis and diverticulitis.

6. Current guidelines for melanoma screening high risk patient.

7. Biopsy techniques

8. Pathologic/prognostic features of melanoma important for surgical management

9. Which patients should undergo a sentinel node biopsy

10. Wide local excision of the primary

11. Adjuvant treatment for deep primary melanomas and node positive disease

12. Adjuvant management of metastatic melanoma.

13. To become familiar with small renal masses (SRMs).

14. To recognize the benefits and risks of nephron-sparing surgery (NSS) versus

radical nephrectomy.

15. To become familiar with the treatment modalities for SRMs.

16. Identify the different types of ventral hernias.

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LEARNING OBJECTIVES (Continued)

17. Describe option of repairs and prevention of hernia recurrence.

18. Explain the surgical approach of the Transcatheter Aoritic Valve Replacement

(TAVR) and Open Aortic Valve (OAR) replacement.

19. Describe the pitfalls of Open AVR and TAVR.

20. Compare the advantages of TAVR and OAR. 21. The attendees will become familiar with databases currently in place and in

development for their surgical practice.

22. Attendees will gain an appreciation for how databases have impacted patient quality measures in certain patient sub-groups.

23. Understand indications for operative intervention for acute perforated

diverticulitis.

24. Understand indications for operative intervention for elective sigmoid resection.

25. Participants will understand the clinical presentation and natural history of severe aortic stenosis.

26. Participants will be able to understand the indications for aortic valve

intervention in patients with severe aortic stenosis.

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2012-2013 OFFICERS

PRESIDENT Stanley M. Augustin, MD, FACS

Kansas City, Missouri

VICE PRESIDENT Julie A. Margenthaler, MD, FACS

Saint Louis, Missouri

SECRETARY – TREASURER Paul S. Dale, MD, FACS

Columbia, Missouri

IMMEDIATE PAST PRESIDENT Mark R. Wakefield, MD, FACS

Columbia, Missouri

COUNCILORS

TERMS EXPIRING JUNE 2013 Stephen H. Colbert, MD, FACS

Columbia, Missouri

John P. Kirby, MD, FACS (Vice President-Elect) Saint Louis, Missouri

TERMS EXPIRING JUNE 2014

Bashar Safar, MBBS, FACS Saint Louis, Missouri

Erik M. Grossmann, MD, FACS

Columbia, Missouri

TERMS EXPIRING JUNE 2015 Benoit Blondeau, MD, FACS

Kansas City, Missouri

G. Brent Sorenson, MD, FACS Kansas City, Missouri

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RESIDENT COUNCILORS Bernard DuBray, MD Saint Louis, Missouri

Jacob R. Hopping, MD Saint Louis, Missouri

Graham Pollock, MD Kansas City, Missouri

Jake Quick, MD

Columbia, Missouri

Dominic E. Sanford, MD Saint Louis, Missouri

GOVERNOR-AT-LARGE

William G. Hawkins, MD, FACS

SPECIAL SOCIETY GOVERNORS James C. Denneny, III, MD, FACS

Bryan F. Meyers, MD, FACS

EDUCATION COMMITTEE Mark R. Wakefield, MD, FACS

Paul S. Dale, MD, FACS Jacob A. Quick, MD

M. Jeanne Shellabarger, MSN, ACNS-BC Julie A. Margenthaler, MD, FACS

ADVOCACY & POLICY COMMITTEE

Glenn E. Talboy, Jr., MD, FACS

ASSOCIATION OF WOMEN SURGEONS REPRESENTATIVE

Debra G. Koivunen, MD, FACS

CANCER COMMITTEE CHAIRMAN Julie A. Margenthaler, MD, FACS

TRAUMA COMMITTEE CHAIRMAN

Bryan R. Troop, MD, FACS

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PAST PRESIDENTS MARK R. WAKEFIELD, MD, FACS – 2011 - 2012 WILLIAM G. HAWKINS, MD, FACS – 2010 - 2011 GLENN E. TALBOY, JR, MD, FACS – 2009 - 2010

WALTER R. PETERS, MD, FACS – 2008-2009 MATTHEW J. CONCANNON, MD, FACS – 2007-2008

JOHN G. ADAMS, JR, MD, FACS – 2006-2007 C. ROBERT WETZEL, MD, FACS – 2004 - 2006 DEBRA G. KOIVUNEN, MD, FACS – 2003-2004

JOHN W. SHOOK, MD, FACS – 2002-2003 DONALD L. JACOBS, MD, FACS – 2001-2002

TODD L. DEMMY, MD, FACS – 2000-2001 BRENT ALLEN, MD, FACS – 1999-2000

MICHAEL BORKON, MD, FACS – 1998-1999 BRENT W. MIEDEMA, MD, FACS – 1997-1998

MARC J. SHAPIRO, MD, FACS – 1996-1997 CHARLES W. VANWAY, MD, FACS – 1995-1996 JOSEPH A. CORRADO, MD, FACS – 1994-1995

GREGORIO A. SICARDO, MD, FACS – 1993-1994 THOMAS S. HELLING, MD, FACS – 1992-1993 DONALD G. SESSIONS, MD. FACS – 1991-1992

JACK J. CURTIS, MD, FACS – 1990-1991 JOHN P CHRISTY, MD, FACS – 1989-1990

JOSEPH A. PINKERTON, JR., MD, FACS – 1988-1989 MICHAEL J. BUKSTEIN, MD, FACS – 1987-1988

ANTHONY E. FATHMAN, MD, FACS – 1986-1987 MARTIN J. BELL, MD, FACS – 1985-1986

EDWIN E. MACGEE, MD, FACS – 1984-1985 CHARLES B. ANDERSON, MD, FACS – 1983-1984

ROBERT S. HUNT, MD, FACS – 1982-1983 BOYD E. TERRY, MD, FACS – 1981-1982

HUGH S. HARRIS, JR., MD, FACS – 1980-1981 WILLIAM SHIEBER, MD, FACS – 1979-1980

RAYMOND A. AMOURY, MD, FACS – 1978-1979 LYNN KRAUSE, JR., MD, FACS – 1977-1978

MAX A. HEEB, MD, FACS – 1976-1977 PAUL G. KOONTZ, JR., MD, FACS – 1975-1976

HUGH E. STEPHENSON, JR., MD, FACS – 1974-1975 HARVEY R. BUTCHER, MD, FACS – 1973-1974 JOHN S. SPRATT, JR., MD, FACS – 1972-1973 ROBERT W. MAHER, MD, FACS – 1971-1972

FREDERICK J. MCCOY, MD, FACS – 1970-1971 CHARLES P. MCGINTY, MD, FACS – 1969-1970

CARL E. LISCHER, MD, FACS – 1968 -1969

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In compliance with ACCME Accreditation Criteria, the American College of Surgeons, as the accredited provider of this activity, must ensure that anyone in a position to control the content of the educational activity has disclosed all relevant financial relationships with any commercial interest. All reported conflicts are managed by a designated official to ensure a bias-free presentation. Please see the insert to this program for the complete disclosure list.

Disclosure Information Missouri Chapter American College of Surgeons

46th Annual Professional Meeting May 31 – June 2, 2013

In accordance with the ACCME’s Accreditation Criteria, the American College of Surgeons must ensure that anyone in a position to control the content of the educational activity has disclosed all relevant financial relationships with any commercial interest. Therefore, it is mandatory that both the program planning committee and speakers complete disclosure forms. Members of the program committee were required to disclose all financial relationships and speakers were required to disclose any financial relationship as it pertains to the content of the presentations. The ACCME defines a ‘commercial interest’ as “any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients”. It does not consider providers of clinical service directly to patients to be commercial interests. The ACCME considers “relevant” financial relationships as financial transactions (in any amount) that may create a conflict of interest and occur within the 12 months preceding the time that the individual is being asked to assume a role controlling content of the educational activity.

The ACCME also requires that ACS manage any reported conflict and eliminate the potential for bias during the session. The planning committee members and speakers were contacted and the conflicts listed below have been managed to our satisfaction. However, if you perceive a bias during a session, please advise us of the circumstances on the session evaluation form.

Please note we have advised the speakers that it is their responsibility to disclose at the start of their presentation if they will be describing the use of a device, product, or drug that is not FDA approved or the off-label use of an approved device, product, or drug or unapproved usage.

The requirement for disclosure is not intended to imply any impropriety of such relationships, but simply to identify such relationships through full disclosure, and to allow the audience to form its own judgments regarding the presentation.

SPEAKERS / MODERATORS/ CHAIRS / DISCUSSANTS

NOTHING TO

DISCLOSE

DISCLOSURE

(As it pertains to the content of the presentation)

Charles H. Andrus, MD, FACS X Ashley Bartels, MD X Lucas Beffa, MD X Elyse Brinkmann X Pamela Bunting, MD X R. Phillip Burns, MD, FACS X Haniee Chung, MD X Leah Conant X Chris Cooper, MD X Jeffrey P. Coughenour, MD, FACS X Paul S. Dale, MD, FACS Speaker: Merck; honorarium

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SPEAKERS / MODERATORS/

CHAIRS / DISCUSSANTS

NOTHING TO

DISCLOSE

DISCLOSURE

(As it pertains to the content of the presentation)

Sara Dehbashi, MD X Sekhar Dharmarajan, MD, FACS X Oluwadamilola M. Fayanju, MD, MPHS X Jacob Frisbie X Christie W. Gooden, MD, MPH X Raja R. Gopaldas, MD, FACS Founder: Cardioptimus, Inc; equity interest Shoshana Hacker, MD X Yassar Hashim, MD X John R. Hornick, MD X Mosharraf Hossain, MD X Burhan Janjua, MD X Bharti Jasra, MD X Jeremy Jensen, MD Investigator/Speaker: Sonosite; equipment loan agreement

of $134,550 Andrew Jung X Adil A. Khan, MD X John P. Kirby, MD, FCCWS, FACS X Coen L. Klos, MD X Jared Konie, MD X Siddarth Kudav, MD X Arun Kumar, MD X Julie A. Margenthaler, MD, FACS X Kari L. Martin, MD X Brian M. Nguyen X Michael B. Nicholl, MD X Dominic E. Sanford, MD Researcher: Pfizer; research grant G. Brent Sorensen, MD, FACS X Lauren Steward, MD X Kurt H. Strom, MD X Mark R. Wakefield, MD, FACS X Jimmy Xu, MD X Amir Zahra, DO X

PLANNING COMMITTEE

NOTHING TO DISCLOSE

DISCLOSURE (All commercial relationships)

Paul S. Dale, MD Speaker: Merck; honorarium National Speakers Bureau: Hologic; honorarium

Julie A. Margenthaler, MD, FACS X Jacob Quick, MD X M. Jeanne Shellabarger, MSN, ACNS-BC X Mark R. Wakefield, MD, FACS X

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Schedule of Events

Thursday, May 30, 2013

6:30 P.M. Council Meeting Dinner (Officers, Councilors, Guests, and Past Presidents)

HK’s Restaurant @ Lodge of Four Seasons Friday, May 31, 2013

Location: Eagles Peak in Season’s Bay Building 7:00 – 8:00 A.M. Continental Breakfast 7:00 – 8:00 A.M. Registration 8:00 A.M. Welcome and Opening Remarks

Julie A. Margenthaler, MD, FACS – Vice President

8:15- 10:00 A.M. Transcatheter Aortic Valve Replacement Moderator: John P. Kirby, MD, FCCWS, FACS

8:15 – 9:00 A.M. Updates In Management Of Severe Aortic Stenosis

Arun Kumar, MD; Assistant Professor of Clinical Medicine, Division of Cardiovascular Medicine & Director, University Hospital Cardiac Intensive Care Unit; University of Missouri; Columbia

9:00 – 9:45 A.M. Surgery For Aortic Valve Disorders: Evolution From Open To Percutaneous Approach.

Raja R. Gopaldas, MD, FACS

Assistant Professor and Director of Research, Division of Cardiothoracic Surgery; University of Missouri; Columbia

9:45 – 10:00 A.M. Q&A

10:00 – 10:30 A.M. Break, Visit Exhibits, and View Posters

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10:30 – 12:00 P.M. Committee on Trauma abstract/paper competition Moderator: Jeffrey P. Coughenour, MD, FACS *Basic Science

**Clinical (10 minute presentations and 5 minutes for questions)

10:30 – 10:45 A.M. **Jiashou Jimmy Xu, MD – Saint Louis University

Epidemiologic Review Of Patients With Methamphetamine-Related Burns.

10:45 – 11:00 A.M. **Jeremy Jensen, MD - University of Missouri-Columbia

Pre-Hospital Ultrasonography For The En Route Identification Of Correctable Thoracic Pathology After Injury: Preliminary Experience.

11:00 – 11:15 A.M. **Haniee Chung, MD - Washington University

Age-Related Outcome Following Blunt Trauma: How Old Is “Old”?

11:15 – 11:30 A.M. **Ashley Bartels, MD - University of Missouri-Columbia

An Early Detection System For Sepsis Based On Infrared Thermography.

11:30 – 11:45 A.M. *Chris Cooper, MD - University of Missouri-Columbia

Electrodermal Activity And Pediatric Endotracheal Intubation Training: A New Frontier In Targeted Simulation Based Training.

11:45 – 12:00 P.M. *Jared Konie, MD - University of Missouri-Columbia

Correlations Of Gene Expression Levels Of TICAM1, TRAF6, And TRAM1 In Hemorrhagic Shock Patients .

12:00 – 12:45 P.M. Lunch –Malaga in Main Building

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12:45 – 2:15 P.M. Location: Eagles Peak in Season’s Bay Building Benign Surgical Disease Paper Session Moderator: Jeffrey P. Coughenour, MD, FACS * Resident/Fellow Paper Competition ** Student Paper Competition

(10 minute presentations and 5 minutes for questions)

12:45 – 1:00 P.M. **Jacob Frisbie - Columbia Surgical Associates

Implementation Of An Aggressive Hemodialysis Access Surveillance Program: Improved Access Patency Rates

1:00 – 1:15 P.M. *Adil A. Khan MD - Saint Louis University

Thrombelastographic Assessment In Chronic Disseminated Intravascular Coagulation (DIC)

1:15 – 1:30 P.M. *Luke Beffa, MD - University of Missouri -Columbia

Insulin Resistance In Diabetic Bariatric Patients Is Associated With Impaired Arteriolar Vasodilation

1:30 - 1:45 P.M. *Coen Klos, MD - Washington University

Obesity Increases Risk For Complications Following Restorative Proctocolectomy

1:45 – 2:00 P.M. *Burhan Janjua, MD - Saint Louis University

An Improved Hemicorporectomy Technique

2:00 – 2:15 P.M. *Bharti Jasra, MD - Saint Louis University

Use Of Biologic Material For Grade 2 Ventral Hernia Repair. Is It Worth The Cost?

2:15 – 2:45 P.M. Ice Cream Break, Visit Exhibits, and View Posters

2:45 – 3:30 P.M. Papers That Should Have Changed Your Practice

Jeffrey P. Coughenour, MD, FACS

Assistant Professor of Surgery and Emergency Medicine

Medical Director, Frank L. Mitchell Jr MD Trauma Center

Associate Medical Director, Staff for Life Helicopter Service

Division of Acute Care Surgery; University of Missouri; Columbia

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3:30 – 4:15 P.M. Injured Patients and Databases: Quality Improvements in Patient Sub-Groups

John P. Kirby, MD, FCCWS, FACS

Associate Professor of Surgery, Division of General Surgery, Acute & Critical Care Surgery Section; Washington University School of Medicine

Medical Director, Wound Care Center; Barnes-Jewish Hospital; Saint Louis

4:15 – 5:00 P.M. The Missouri American College of Surgeons Committee on Trauma Bi-Annual Business Meeting

5:00 – 7:00 P.M. Social Activity - Cloverleaf

President’s Reception & Family Pool Party

Cash bar and light fare

Saturday, June 1, 2013

Location: Eagles Peak in Season’s Bay Building

7:00 – 8:00 A.M. Family Buffet Breakfast 7:00 – 8:00 A.M. Registration 8:00 – 9:00 A.M. Renal Cell Carcinoma Moderator: Julie A. Margenthaler, MD, FACS

8:00 – 8:10 A.M. Introduction of New Challenges in the Management of Renal Cell Carcinoma.

Mark R. Wakefield, MD, FACS

Associate Professor and Urology Division Chief; University of Missouri; Columbia

8:10- 8:30 A.M. Management Options for Small Renal Masses

Kurt H. Strom, MD

Assistant Professor; Division of Urology; University of Missouri; Columbia

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8:30 – 8:50 A.M. Target Therapy

A Mosharraf Hossain, MD, MPH

Assistant Professor of Clinical Medicine; Division of Hematology & Oncology; University of Missouri; Columbia

8:50 – 9:00 A.M. Q&A

9:00 – 9:45 A.M. Update On Surgical Management Of Diverticulitis

Sekhar Dharmarajan, MD, FACS

Assistant Professor of Surgery; Section of Colon & Rectal Surgery; Washington University; St. Louis

9:45 – 10:15 A.M. Break, Visit Exhibits, and View Posters

10:15 – 12:00 P.M. Surgical Oncology: Breast Pathology Paper Session

Moderator: Paul S. Dale, MD, FACS *Resident/Fellow Paper Competition **Student Paper Competition

(10 minute presentations, followed by 5 minutes questions)

10:15 – 10:30 A.M. *Pamela Bunting, MD - Washington University

Sentinel Lymph Node Biopsy During Prophylactic Mastectomy: Is There A Role?

10:30 – 10:45 A.M. **Leah Conant - Washington University

Cancer Anxiety And Patient Selection Of Mastectomy Over Breast Conservation Therapy

10:45 – 11:00 A.M. *Lauren Steward, MD - Washington University

Axillary Ultrasound In Patients With Clinically Node-Negative Breast Cancer: Which Features Are Predictive Of Disease?

11:00 – 11:15 A.M. *Oluwadamilola M. Fayanju, MD, MPHS - Washington University

Geographic And Temporal Trends In The Management Of Occult Primary Breast Cancer: A Systematic Review And Meta-Analysis

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11:15 – 11:30 A.M. **Brian M. Nguyen - Washington University

Post-Treatment Surveillance For Breast Cancer Patients: What Motivates The Experts?

11:30 – 11:45 A.M. *Oluwadamilola M. Fayanju, MD, MPHS - Washington University

Contralateral Prophylactic Mastectomy In Unilateral Breast Cancer Patients: A Systematic Review And Meta-Analysis

11:45 – 12:00 P.M. *Lauren Steward, MD - Washington University

Predictive Factors And Patterns Of Recurrence In Patients With Triple Negative Breast Cancer

12:00 – 1:15 P.M. Location: Malaga in Main Building

Missouri Commission On Cancer Luncheon

Cancer In The Transplant Population

Christie W. Gooden, MD, MPH Abdominal Transplant Surgeon; Henry and Marion Bloch Liver Disease Management and Transplant Center

Clinical Assistant Professor; University of Missouri-Kansas City

Saint Luke's Hospital of Kansas City

1:15 – 2:15 P.M. Location: Eagles Peak in Season’s Bay Building

Current Treatment Of Melanoma: A Case Presentation And Panel Discussion

Moderator: Paul S. Dale, MD, FACS Dermatopathology Kari L. Martin, MD Assistant Clinical Professor of Dermatology; University of Missouri; Columbia Surgery Michael B. Nicholl, MD

Assistant Professor; Division of Surgical Oncology; University of Missouri; Columbia

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Medical Oncology A. Mosharraf Hossain, MD, MPH

Assistant Professor of Clinical Medicine; Division of Hematology & Oncology; University of Missouri; Columbia Panel Discussion to follow

2:15 – 3:30 P.M. Surgical Oncology: GI & Lung Pathology Paper Session Moderator: Mark R. Wakefield, MD, FACS *Resident/Fellow Paper Competition **Student Paper Competition

(10 minute presentation and 5 minutes for questions)

2:15 – 2:30 P.M. *John R. Hornick, MD - Washington University

Multifunctional Sigma-2 Ligands For Targeting Of Pancreatic Cancer Stem Cells

2:30 – 2:45 P.M. *Dominic E. Sanford, MD - Washington University

Inflammatory Monocyte Mobilization Decreases Patient Survival In Pancreatic Cancer: A Role For Targeting The Ccl2/Ccr2 Axis

2:45 – 3:00 P.M. *Yassar Hashim, MD - Washington University

A Novel Therapeutic (Sigma 2-Smac) Conjugate Effectively Target Apoptosis In Pancreatic Adenocarcinoma

3:00 – 3:15 P.M. *Sara Dehbashi, MD – Washington University

The Basis For Immunologic Susceptibility To Lung Cancer In Man

3:15 – 3:30 P.M. *Coen L. Klos, MD - Washington University

Total Lymph Node Yield In N0 Colon Cancer Does Not Predict Recurrence

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3:30 – 4:30 P.M. Moderated Poster Presentations Moderator: Mark R. Wakefield, MD, FACS

7 minute presentations

Amir Zahra, DO - Saint Louis University

Coagulation Management During An Operation On A Uremic Patient

Charles H. Andrus, MD - Saint Louis University

Laparoscopic Repair Of A Parahiatal Hernia

Siddarth Kudav, MD - University of Missouri -Columbia

Successful Intraoperative Management Of Duct Of Luschka Bile Leak

Andrew Jung – Saint Louis University

Chronic Idiopathic Intestinal Pseudo-Obstruction: A Case Report And Literature Review

Bharti Jasra, MD - Saint Louis University

Video Assisted Repair Of A Postoperative Lung Hernia

Bharti Jasra, MD - Saint Louis University

Thymoma Secreting Ectopic Parathyroid Hormone Concomitantly With Tertiary Hyperparathyroidism

Shoshana Hacker, MD - Saint Louis University

Emphysematous Cholecystitis Resulting In Cystic Artery Erosion And Massive Hemoperitoneum In The Setting Of Dabigatran Therapy

Elyse Brinkmann - Saint Louis University

Charcot Spine Secondary To Traumatic Spinal Cord Injury: A Case Report And Differential Diagnosis

5:00 – 7:00 P.M. Social Activity

Lake Cruise Excursion by Tropic Island Cruises, Inc

Families and guests welcome

Cash bar and light fare

Cruise Drop Off at Shady Gators

Enjoy dinner on your own at Shady Gators

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Sunday, June 2, 2013

Location: Sea Chase in Main Building

7:30 – 9:00 A.M. Family Buffet Breakfast

7:30 – 9:00 A.M. Registration

8:00 – 9:00 A.M. Officers and Councilors Meeting

9:00 – 10:00 A.M. American College Of Surgeons Update

R. Phillip Burns, MD, FACS

First Vice-President, American College of Surgeons

Professor & Chairman, Department of Surgery, University of Tennessee College of Medicine and Chairman of the Board of University Surgical Associates; Chattanooga, TN

10:00 – 11:00 A.M. Ventral Hernias, Current Trends

G. Brent Sorensen, MD, FACS

Saint Luke’s Health System and Assistant Professor of Surgery; University of Missouri; Kansas City

11:00 – 12:00 P.M. Business Meeting and Awards

Mark R. Wakefield, MD, FACS

Introductions and Thank-yous

Reports --

Secretary/Treasurer Report

Association of Women Surgeons

Committee on Cancer

Committee on Trauma

Announcements

Nominate Slate and Vote

Awards

Change of the Guard

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EXHIBITORS

BG Medical, LLC

Darvol, Inc

DePuy Synthes CMF

LifeCell Corporation

Merck

Missouri Professionals Mutual

PUBLISHED ABSTRACTS

1. EPIDEMIOLOGIC REVIEW OF PATIENTS WITH

METHAMPHETAMINE-RELATED BURNS Jonathan Pollack, MD, Jiashou Jimmy Xu MD, Michael Smock MD, and Christine Kamp PA-C Saint Louis University

Methamphetamine (Meth) abuse in the US is a significant problem with an estimated 1.2 million Americans >12 years old surveyed in 2010 indicating meth usage the year prior to survey. Meth has been on the forefront in burn care with admissions increasing dramatically over the past 10-15 years. Missouri has consistently ranked at the top of all states regarding clandestine laboratory incidents during this time period accounting for 1985 laboratory seizure incidents or 16% of all nationwide seizures in 2012. A major contributing factor to meth burn admission is the ease of production through everyday household chemicals. The new “one pot” or “shake and bake” technique warrants a real time epidemiological review of methamphetamine related burn injuries. Our study is a retrospective review of the 2011 calendar year of Burn Unit Admissions at Mercy Hospital St Louis. Inclusion criteria was a chart review of patients admitted with a positive urine toxicology screen for amphetamines and/or a patient whose burn occurred while making or using methamphetamine. From January 1, 2011 to December 31, 2011, 31 admissions met inclusion criteria. Of 220 total admissions, this represented 14% of all burn unit admissions in 2011. Most patients, 90%, had a positive toxicology. Age Range was 19-59 (mean 36.6) with 23 Males and 8 females. Average length of stay was 10.4 days with an average 14.3% Total Body Surface Area burns. Of those admissions 19 (63%) required skin grafting and 12 (37%) did not. Insurance coverage at time of admission: 13 (42%) patients had no health insurance, 13 (42%) had some form of state Medicaid, 3 (10%) had Medicare, and 2 (6%) patients were covered by private health insurance. With a very high number of Meth related burn admissions, we continue to recommend to keeping a high level of suspicion. Routine questioning about mechanism of injury, obtaining history from law enforcement, and toxicology screens are imperative for the health care team as pain control, withdrawal symptoms, clinical suspicion for inhalation injuries, and increased fluid resuscitation levels have all been described. Meth related burn injuries, as it were, continue to require heavy resource allocation for burn centers.

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2. PRE-HOSPITAL ULTRASONOGRAPHY FOR THE EN ROUTE IDENTIFICATION OF CORRECTABLE THORACIC PATHOLOGY AFTER INJURY: PRELIMINARY EXPERIENCE

Jeremy Jensen MD, Christopher S. Nelson MD, Salman Ahmad MD FACS, Stephen L. Barnes, MD FACS, Jeffrey P. Coughenour MD FACS University of Missouri-Columbia Objective Use of ultrasound to efficiently evaluate the critically ill and injured was first described nearly 15 years ago,1 and although it is commonly used in the emergency department and intensive care setting, use in the pre-hospital environment remains limited. More recently, thoracic ultrasound has been added to the classic abdominal and pericardial assessment following trauma, with a higher sensitivity and specificity than plain chest radiograph for the detection of pneumothorax.2-4 A growing body of literature also supports use of this modality in the pre-hospital environment by non-physicians, with acceptable image acquisition and interpretation after adequate training.5-8 Ultrasound in uniquely suited for assisting providers in clinical decision-making in the aeromedical setting because of vibration and significant ambient noise. We hypothesized that after a didactic and practical learning program, non-physician air medical crewmembers could successfully use portable ultrasound to evaluate the chest for pneumothorax and/or correct endotracheal tube placement after injury, and accurately interpret the images obtained. Methods Medical flight crew members completed an instructional program on basic thoracic ultrasound. The program consisted of didactic lectures, practical skills instruction, and a simulated case scenario requiring image interpretation. Ultrasound examination of anesthetized swine was also performed during an invasive skills lab to demonstrate normal and abnormal studies. At the conclusion, 90% of crew members rated their knowledge and/or skills as good or excellent (as measured on a five-point Likert scale). Portable ultrasound devices were then deployed on each of the service’s three aircraft.

Patients 18 or over with a history of injury or medical patients requiring endotracheal intubation and mechanical ventilation underwent en flight ultrasound examination (thoracic portion of the E-FAST) by the medical flight crew. The study was repeated by an emergency medicine physician or trauma surgeon on arrival in the emergency center (EC). Providers then completed a blinded questionnaire to document their findings. Admission chest radiograph (CXR) and chest computed tomography (CT) results served as the “gold standard” for each case. Ultrasound images from the field were saved and separately reviewed by two physicians to determine accuracy of the medical crew members’ interpretation.

Results

Fifty (50) patients meeting inclusion criteria underwent en flight thoracic ultrasound. Mean age was 44 (18-94) and 80% of the patients were male. Average ISS was 16.5 (l-43), while average chest AIS was 1.8 (0-5). Adequate imaging of the right and left chest was achieved in 76% of patients examined. Limitations were identified in 24% (12/50) of patients compared to 10% of exams done in the EC. Factors cited included patient access (1), body habitus (3), subcutaneous emphysema (1), and provider skill (7). In only one case was the pre-hospital or aircraft environment cited as a limitation (access).

Pre-hospital US images correlated with the “gold standard” in 90% of cases (45/50). In the remaining five, there was: A small anterior PTX seen on CT but missed by pre-hospital and EC US, a clinical change between pre-hospital imaging and CT (suggesting development of a PTX after en flight US, two misinterpretations of adequate images, and one false positive (apical bullous empysema documented on CT). Using all modalities, four pneumothoraces (8%) were identified. One was correctly identified en flight, one appears to have developed after pre-hospital US (images were correctly interpreted as normal), one was

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captured on en flight imaging but interpreted as normal, and the last was seen only on CT (pre-hospital and EC US correctly interpreted as normal).

Twelve (12) patients were intubated and on mechanical ventilation during transport. Endo-tracheal tube position was interpreted as correct on each. Nine of these patients had ultrasound in the EC, where there was 100% agreement. No malpositioned tubes were identified in any patient on subsequent CXR or CT when obtained. Conclusion

After appropriate instruction, medical flight crew members are able to adequately evaluate the chest for pneumothorax and/or malpositioned endotracheal tubes with > 90% accuracy. Given the unique challenges of the aeromedical environment, thoracic ultrasound is perfectly suited to assist in patient evaluation and medical decision-making prior to arrival to definitive care. Additional experience is necessary to confirm our preliminary findings. References 1. Boulanger BR, McLellan BA, Brenneman FD, Ochoa J, Kirkpatrick AW. Prospective evidence of the

superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. JTrauma 1999 Oct;47(4):632-7

2. Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces. The extended focused assessment with sonography for truama (E-FAST). J Trauma 2004;57: 288-295

3. Wilkerson RG, Stone MD, et al. Sensitivity of bedside ultrasound and supine AP chest radiograph for identification of pneumothorax after blunt trauma. Acad Emerg Med 2010 Jan;17(1): 11-7

4. Rowan KR. Traumatic pneumothorax detection with thoracic ultrasound: Correlation with chest radiograph and CT – initial experience. Radiology 2003 Apr;227(1): 305-6

5. Polk JD, Fallow WF Jr, Malangoni MA, et al. The “Airmedical FAST” for trauma patients – the initial report of a novel application for sonography. Aviat Space Environ Med 2001 May;72(5): 432-6

6. Heegaard W, Hildebrandt D, Spear D, et al. Prehospital ultrasound by paramedics: Results of a field trial. Acad Emerg Med 2010 Jun;17(6): 624-630

7. Madill JJ. In-flight thoracic ultrasound detection of pneumothorax in combat. J Emerg Med 2010 Aug;39(2): 194-7

8. Price DD, Wilson SR, Murphy TG. Trauma ultrasound feasibility during helicopter transport. Air Med J 2000 Oct-Dec;19(4): 144-6

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3. AGE-RELATED OUTCOME FOLLOWING BLUNT TRAUMA: HOW OLD IS “OLD”?

Haniee Chung, MD, Stephanie L. Bonne, MD, Bradley D. Freeman, MD, Julie Nash, RN, Douglas J.E. Schuerer, MD, Grant V. Bochicchio, MD, MPH, Robert D. Winfield, MD Washington University and Barnes-Jewish Hospital Introduction: Effective treatment of trauma patients requires critical evaluation of existing guidelines and a clear definition of triage criteria. With the rapid growth in the geriatric population being treated in trauma centers, the need for prehospital identification of patients at risk of higher morbidity and mortality is becoming increasingly evident. Existing literature has suggested that undertriage of elderly patients to trauma centers exists1 despite evidence that triage to trauma centers and trauma team activation has yielded promising results 2, 3, and that the underutilization of trauma team activation has led to undertreatment and worse outcomes for the geriatric trauma population4. Unfortunately, difficulty in establishing a uniform standard has arisen due to uncertainty regarding the age at which physiologic features predispose to poorer outcomes. Current Eastern Association for the Surgery of Trauma guidelines have established age 65 or greater as the definition of an elderly trauma patient and an algorithm of triaging and trauma team activation based on assessment of comorbid and pre-existing conditions is in place5; however, the primary source literature leading to the recommendation for trauma team activation and aggressive treatment arises from a series in which the elderly were classified using an age cutoff of 70 years6. In both the prehospital setting, in which emergency care providers are often unable to assess comorbidities, and in the emergency department, where this same limitation often exists and where aggressive treatment should be initiated early for optimal outcome, it becomes increasingly important that a concrete age cut off is used that encompasses comorbidities and pre-existing conditions that place patients at increased risk for poor outcome following trauma. We hypothesized that an age could be identified at which point outcome following trauma would worsen, regardless of mechanism or comorbidities, thus clarifying guidelines for trauma triage and trauma team activation. Methods: We evaluated all adults between the ages of 18 and 89 years admitted to our Level I Trauma Center with a history of blunt mechanism of injury from January 1, 2008 to December 31, 2012. Information regarding demographics, comorbidities, injury pattern and severity, interventions, and outcomes were reviewed. For the purposes of analysis, patients were grouped according to several variables: low-energy (same-level fall) and high-energy (motor vehicle collision) mechanism; low (injury severity score <15) and high (injury severity score ≥15) injury severity; healthy (≤ 1 comorbidity) and ill (≤ 2 comorbidities) and age blocks (18-44, 45-49, 50-54, 55-59, 60-64, 65-69, ≥70 years). Outcomes of interest included length of stay (LOS), intensive care unit (ICU) LOS, ventilator days, mortality, and discharge disposition. Univariate analyses were completed between groups utilizing one-way analysis of variance for continuous variables with the Bonferroni correction utilized for multiple comparisons; Chi square test was used to compare proportional variables. Linear regression was performed to evaluate the adjusted risk for the continuous endpoints of LOS, ICU LOS, and ventilator days, taking into account age block, comorbidities, gender, mechanism, and injury severity. In a separate analysis, we utilized discharge disposition as a surrogate marker of morbidity and mortality in our study, grouping patients into two groups: home discharge and discharge to a facility for ongoing care or death. Multinomial logistic regression was then performed to evaluate the adjusted risk for morbidity and mortality, once again taking into account age block, comorbidities, gender, mechanism, and injury severity. A p-value < 0.05 was considered significant in all evaluations. All statistical calculations were performed using SPSS Statistics, version 20 (© International Business Machines Corp., Armonk, New York, USA). This study was reviewed and approved by the Human Research Protection Office and Institutional Review Board of Washington University. Results: Between January 1, 2008 and December 31, 2012, 5,431 patients sustained blunt injury via either same level fall or motor vehicle collision. Information regarding the study population can be seen in Table 1.

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Table 1. Characteristics of Patients with Blunt Injury by Age Group 18-44

(n=1953) 45-49

(n=335) 50-54

(n=409) 55-59

(n=424) 60-64

(n=325) 65-69

(n=349) 70+

(n=1636)

p-value Age

29 ± 8.0 47 ± 1.4 52 ± 1.4 57 ± 1.4 62 ± 1.4 67 ± 1.4 80 ± 5.6 p<0.001 Gender (% male) 67 60 60 60 50 50 37 p<0.001 Mechanism (% Fall) 15 39 46 57 71 71 88 p<0.001 Level (% Level 1) 25 19 12 15 14 10 7 p<0.001 ISS

13 ± 11 12 ± 9 12 ± 10 11 ± 9 9 ± 8 11 ± 7 12 ± 7 p<0.001 Comorbidities (% with ≥ 2)

8 21 29 41 50 54 60 p<0.001 LOS

6 ± 8.2 7 ± 8.5 6 ± 6.4 6 ± 7.2 5 ± 5.3 6 ± 6.1 6 ± 6.2 p=0.019 ICU LOS

2 ± 5.7 2 ± 6.2 1 ± 4.5 1 ± 4.3 1 ± 3.3 2 ± 4.6 1 ± 4.5 p=0.003 Ventilator Days

1 ± 4.5 1 ± 5.1 1 ± 4.0 1 ± 3.0 1 ± 3.5 1 ± 3.2 1 ± 3.9 p=0.005

Facility Discharge (%) 16 25 28 35 41 49 62 p<0.001

Mortality (%) 3 2 3 4 2 4 8 p<0.001

Data are presented as means ± standard deviation or percent with a given condition. Linear regression taking into account age, comorbidities, gender, mechanism, and injury severity revealed significant associations between injury severity and LOS, ICU LOS, and ventilator days (all p<0.001). Motor vehicle collision as a mechanism was associated with longer LOS (p=0.023) and greater comorbidities were associated with both increased ICU (p=0.001) and overall LOS (p<0.001); however, there was no significant association between age and any of these endpoints. Utilizing logistic regression, age ≥ 70 years was found to be associated with increased risk for mortality relative to patients aged 18-44 (OR 3.790, 95% CI 2.449-5.865, p<0.001). No other age group was associated with a significant relationship with mortality after correcting for the covariate factors mentioned previously. In our final logistic regression, we evaluated the effect of age on outcome, demonstrating that relative to blunt trauma victims between the ages of 18 and 44 years, all patient groups show an increased risk of morbidity and mortality. This risk increased significantly at the age of 65 years of age, and dramatically at the age of 70 (Figure 1).

Figure 1

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*=p<0.05 relative to patients aged 18-44. **=p<0.05 relative to patients aged 18-59. ***=p<0.05 relative to patients aged 18-69.

Conclusions: When taking into account comorbidities, gender, mechanism, and injury severity, we confirmed that an age of 70 or greater is associated with an increased trauma-associated mortality relative to young patients. All patients over the age of 44 years are at greater risk for morbidity and mortality when these factors are considered; however, morbidity and mortality shows a more dramatic increase beginning at the age of 65. If prompt and aggressive treatment is expected to improve outcome in these patients, then current recommendations for trauma center evaluation and trauma team activation based on an age of 65 years are appropriate; however, additional work is necessary to determine whether or not increased utilization of resources will improve short and long-term outcomes in these high-risk patients. References: 1. Chang DC, Bass RR, Cornwell EE, Mackenzie EJ. Undertriage of elderly trauma patients to state-

designated trauma centers. Arch Surg. Aug 2008;143(8):776-781; discussion 782. 2. Meldon SW, Reilly M, Drew BL, Mancuso C, Fallon W, Jr. Trauma in the very elderly: a

community-based study of outcomes at trauma and nontrauma centers. J Trauma. Jan 2002;52(1):79-84.

3. Mann NC, Cahn RM, Mullins RJ, Brand DM, Jurkovich GJ. Survival among injured geriatric patients during construction of a statewide trauma system. J Trauma. Jun 2001;50(6):1111-1116.

4. Scheetz LJ. Effectiveness of prehospital trauma triage guidelines for the identification of major trauma in elderly motor vehicle crash victims. J Emerg Nurs. Apr 2003;29(2):109-115.

5. Calland JF, Ingraham AM, Martin N, et al. Evaluation and management of geriatric trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. Nov 2012;73(5 Suppl 4):S345-350.

6. Demetriades D, Karaiskakis M, Velmahos G, et al. Effect on outcome of early intensive management of geriatric trauma patients. Br J Surg. Oct 2002;89(10):1319-1322.

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4. AN EARLY DETECTION SYSTEM FOR SEPSIS BASED ON INFRARED THERMOGRAPHY

Ashley Bartels, MD, Salman Ahmad MD FACS, Mihail Popescu PhD, and Stephen L Barnes MD FACS University of Missouri-Columbia Sepsis represents a considerable healthcare burden—it is common, frequently fatal and costly. The incidence of sepsis and the number of deaths related to sepsis are increasing. There are 751,000 cases of sepsis diagnosed annually in the United States; the incidence is projected to increase by 1.5% per year. Sepsis remains the leading cause of death among patients in non-coronary ICUs and is the eleventh leading cause of death overall in the United States. Those patients who do survive sepsis have a significant reduction in their quality of life. In addition, caring for patients with sepsis results in an economic burden of nearly $17 billion annually in the United States. Prompt diagnosis of infection is essential because the treatment of sepsis within the first six hours is critical. Early, goal-directed resuscitation has been shown to provide a significant benefit in mortality when hemodynamics are optimized within the first few hours of disease presentation. When resuscitation efforts are directed at specified goals in the initial six hours, the 28-day mortality rate is reduced. To provide rapid intervention, establishing an early diagnosis is imperative. Temperature is a well-known indicator of health. Clinicians measure patient body temperature using a variety of modalities. Changes in the core body temperature of more than a few degrees are a clear indicator of a bodily dysfunction. Because infection can be present without fever (in the elderly and debilitated patients), with a normal or low body temperature (in host defense failure) or with increased body temperature, the detection of trends in minute changes in temperature may be more predictive of infection than absolute numbers. Remote-sensing infrared thermography (RSIT) can be used to measure core body temperature that is accurate to three decimals in a centigrade scale. The forward-looking infrared (FLIR) T440 camera—a specific type of RSIT—has the ability to detect subtle temperature differences of <0.045C at 30C. RSIT has the ability to be rapidly mobilized and monitored. It also has the ability to monitor temperature continuously. The FLIR T440 camera has a frame rate of 60 hertz, and thus, will collect unique images at a frequency of 60 frames per second. The combination of these RSIT capabilities allows for real-time monitoring of a patient’s core body temperature using a camera that is highly sensitive to minute changes. Our institutional protocol requires either hourly or continuous monitoring of body temperature in the ICU; all types of body thermometers are utilized. Traditional body thermometers are accurate to one decimal in the centigrade scale. Periodic measurements of patient body temperature using traditional assessment tools may allow small changes in body temperature to be overlooked, are often invasive and are open to operator error. In contrast, RSIT is more sensitive to minute changes in body temperature, is non-invasive and can be installed and calibrated by a master operator to decrease the likelihood of operator error. By detecting early signs of infection among ICU patients, preventive action will be initiated earlier and may lead to a decreased incidence of sepsis among ICU patients. Advancements are currently being made in intelligent design and in the development of computerized clinical decision support (CCDS) technology. CCDS allows for the implementation and refinement of evidence-based guidelines (EBGs) to assist in the complex care of ICU patients. Sucher and colleagues used this technology to develop an automated sepsis-screening tool for the early identification of sepsis and found a significant increase in compliance with recommended interventions, as well as a decrease in mortality associated with sepsis. Our goal of identifying an effective warning system for the detection of sepsis will

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integrate well with CCDS technology. RSIT will provide a non-invasive, mobile tool for detecting minute changes in body temperature and will send real-time data to the automated screening tool. We are currently applying the concept of infrared thermography to remotely, continuously and non-invasively measure the core body temperature of ICU patients. We hypothesize that the high sensitivity of remote-sensing infrared thermography for detecting minute changes in core body temperature will translate into an effective warning system to prevent septic shock in ICU patients.

This work is innovative because it will allow us to investigate the role of non-invasive, remote core body temperature monitoring in the early detection of infection and prevention of septic shock. If our hypothesis is correct, then RSIT may be used in the rapid identification, diagnosis and management of infection in ICU patients. An important, tangible outcome of this research is the resulting dataset that may be used to investigate other medical concerns. For example, this technology may also have the opportunity to serve as an early warning system for wound infections. Capturing images with infrared thermography may allow changes in temperature to be associated with antibiotic use and effectiveness—contributing to the decision-making process of therapy. The capabilities of RSIT may be applied to the intra- and peri-operative settings to detect early signs of temperature decline in the surgical patient—a known risk factor for surgical site infections. Ultimately, the real-time monitoring of core body temperature may integrate well with the current advancements being made in computerized clinical decision support technology.

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5. ELECTRODERMAL ACTIVITY AND PEDIATRIC ENDOTRACHEAL INTUBATION TRAINING: A NEW FRONTIER IN TARGETED SIMULATION BASED TRAINING

Cooper CJ, Stephan CL, Bukoski AD, Bruzzini DB, Barnes SB University of Missouri-Columbia Background Electrodermal activity (EDA) has been shown to reflect activity within the sympathetic nervous system and provides a sensitive and accurate index of alteration in emotion, attention, and cognition. Currently, its clinical use has been limited to applications within psychological and neurological disorders, such as epilepsy, autism, and sleep disorders. This novel instrument may be useful for targeting the most effective training modalities for cognitive and technical proficiency in lifesaving procedures. We examined the differences in EDA between a cohort of medical providers trained in pediatric endotracheal intubation using live tissue or a partial task trainer. Methods A prospective, randomized trial comparing training outcomes and differences in EDA for medical providers trained in pediatric endotracheal intubation was performed at 7 training sessions over a 5 month period. Study participants included medical providers with varying training levels ranging from Emergency Medical Technicians-Basic (EMT-B) to critical care physicians. Those with no medical background or training were excluded from the study. Participants were evaluated before and after training with a cognitive assessment and psychomotor test. Training included didactic and technical, “hands-on,” sessions. For technical training, participants were randomized to either a ferret live tissue model or partial task trainer simulator model. Training across all platforms was standardized. Baseline EDA was established during a 30 minute didactic presentation and compared to measurements obtained during the technical training sessions using an Affective Q Sensor® wristband. Demographic data included age, gender, occupation, clinical experience with intubation, and previous exposure to live tissue or simulator based training. Analysis was completed using Microsoft Excel © with p value less than 0.05 significant. Results 68 medical providers were included in the study with an equal distribution randomized to either live tissue or simulator based training. Mean age was 34 (range 22-60). 56% were males and 38% were active military. There was not a statistical difference between the mean baseline EDA for the live tissue and simulator based training groups (p>0.05). Mean absolute difference between baseline and maximum EDA amplitude during training was 0.43µS higher for the live tissue training group (p>0.05). However, the mean percent change between baseline and maximum EDA was 2540% for the live tissue group and 1052% for the simulator group (p<0.05). The live tissue group also demonstrated a greater improvement in cognitive and technical proficiency from pre-test to post-test when compared to the simulator training group. Conclusion Medical providers trained with live tissue exhibit significantly increased changes in EDA amplitude when compared to providers trained with a partial task trainer in pediatric endotracheal intubation. Live tissue trained providers also demonstrated greater improvement in cognitive and technical proficiency for this lifesaving procedure. Monitoring of EDA is an emerging technology that could have a powerful impact on targeting the most effective environment to train providers in lifesaving procedures. Its application in simulation based training is completely novel and further investigation into its utility is warranted.

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6. CORRELATIONS OF GENE EXPRESSION LEVELS OF TICAM1, TRAF6, AND TRAM1 IN HEMORRHAGIC SHOCK PATIENTS

Jared A. Konie, Robert Calaluce, Michael L. Misfeldt and Stephen L. Barnes University of Missouri-Columbia INTRODUCTION: Toll-like receptors (TLRs) sense invading microbial pathogens and play critical roles in the activation of the immune system. TLR signaling leads to proinflammatory cytokine production and these responses are vital for host defenses against pathogens. These protein receptors were initially found to recognize specific molecular patterns associated with microbes and were collectively termed pathogen-associated molecular patterns (PAMPs). The complex pathways of TLRs are now known to play key roles in sepsis as well as critical illnesses which do not involve infectious agents. Recently, there has been increasing evidence that TLRs respond to endogenous molecules released from stressed or damaged cells, called damage-associated molecular patterns (DAMPs), implying that TLRs can survey danger signals and are associated with sterile inflammation. Ligands binding to TLRs activate multiple signaling cascades leading to induction of genes involved in immune responses. TLRs include an intracellular Toll-interleukin-1 (IL-1) receptor (TIR) domain which interacts with various adapter proteins such as toll-like receptor adapter molecule 1 (TICAM1) or TIR-domain-containing adaptor protein-inducing interferon-beta (IFN-β) (TRIF). TICAM1 mediates protein-protein interactions between TLRs and signal transduction components and induces IFN-β through the activation of nuclear factor kappa-B (NF-κB) to induce apoptosis. Other adapter proteins include: translocation associated membrane protein 1 (TRAM1), found in mammalian endoplasmic reticulum (ER) which influences glycosylation and translocation of secretory proteins across the ER membrane; and tumor necrosis factor receptor associated factor 6 (TRAF6), which responds to proinflammatory cytokines, mediates TNF and TLR signaling, and affects levels of IL-1. TLR signaling, however, requires stringent regulation to avoid major detrimental effects such as tissue damage. Several regulators of the immune response are beginning to be studied in conjunction with TLR pathways such as: suppressor of cytokine signaling 3 (SOCS3), a member of the SOCS family, the only known inducible inhibitors of cytokine signaling; signal transducers and activators of transcription 3 (STAT3), regulators of various cellular processes; and microRNAs (miRNA), short double-stranded RNA molecules that post-transcriptionally down-regulate gene expression of target mRNA sequences. We hypothesized that the expression levels of selected genes and regulators in both the TLR3 and TLR4 pathways in trauma patients with hemorrhagic shock would correlate with clinical parameters. METHODS: Twelve trauma patients in hemorrhagic shock were prospectively enrolled in this IRB-approved study. After transfer to the Surgical Intensive Care Unit, written informed consent was obtained and peripheral whole blood samples were collected at 0, 12, 24, and 48 hours. Age, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) and serial vital signs, pH, BD, crystalloid, blood products, and injury patterns were recorded. Whole blood was stabilized using PaxGene collection tubes. Gene expression levels of SOCS3, STAT3, TLR3, TLR4, myeloid differentiation factor 88 (MyD88), TRAF6, TICAM1, TRAM1 were measured using Custom PCR Arrays. miRNA expression was measured by quantitative RT-PCR utilizing standard miRNA controls. Statistical analysis was performed for each possible pair of markers (gene, miRNA, and clinical parameters) using linear mixed models. RESULTS: Sixteen statistically significant correlations (nine direct and 7 indirect) between genes and miRNAs were found changing over time in all patients. Among our most significant findings were: TICAM1 gene expression levels correlating directly with TRAF6 ( p<0.01) and TRAM1 (p<0.001); TLR3 gene expression correlating directly with TRAM 1 (p<0.001); and TLR4 gene expression levels correlating directly with TRAF6 (p<0.01), and indirectly with miRNAs 146a (p<0.001) and 155 (p<0.001). There were no statistically significant correlations between gene expression and any of the clinical parameters.

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Figure 1. Estimated mean linear relationships between TLR3 and TRAM1, TLR4 and miR-146a, and TLR4 and miR-155 with 95% confidence bands (yellow) and superimposed individual data shows a direct relationship between TLR3 and TRAM1 and indirect relationships between TLR4 and miR-146a and miR-155. CONCLUSIONS: The direct correlations between gene expression levels of TICAM1 and TRAF6 and TRAM1, TLR3 and TRAM1, and TLR4 and TRAF6, as well as the indirect correlations between miRNAS

146a and 155 and TRAF6, are unique findings in sterile inflammation and the whole blood of patients with hemorrhagic shock. Although these findings may suggest regulation by miRNAS 146a and 155, additional studies are warranted. Moreover, a larger study would elucidate the role of miRNA expression and its potential association with outcome following severe injury. The data generated from such studies could guide the development of unique, targeted therapeutic treatment strategies for trauma patients in hemorrhagic shock.

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7. IMPLEMENTATION OF AN AGGRESSIVE HEMODIALYSIS ACCESS SURVEILLANCE PROGRAM: IMPROVED ACCESS PATENCY RATES

Jacob Frisbie, MSIII, Scott A Gard, MD, FACS, Paul W Humphrey, MD, FACS, John G Adams, Jr, MD, FACS Columbia Surgical Associates Introduction: Despite the many advances made in the care of hemodialysis access over the past several years, many patients present with acute thrombosis of their access without warning. These acute events lead to access down time with interruption of timely dialysis treatments, performance of access procedures to restore patency and/or create a new access, and increased cost. Prior to 2009, our group philosophy/management of access problems was best described as “damage control”-- access problems were a low priority in our practice and dealt with only when dialysis was interrupted. We created an Access Center in 2009 and developed a multi-disciplinary approach for the care of dialysis access using protocols developed in conjunction with our Surgical Access Nurses, Nephrologists, and Dialysis Nurses. Herein we report our experience with implementation of our surveillance program and compare that to our experience prior to institution of our surveillance program. Methods: A retrospective study of prospectively collected data was performed on patients with end-stage renal disease referred to our center for a new hemodialysis access. Patients were divided into 2 groups: patients undergoing a newly created access from January 2006 through December 2007 prior to our surveillance program comprised Group A; patients undergoing a newly created access and entered into our surveillance program from January 2010 through December 2011 comprised Group B. Patient demographics, types of access procedures performed, and access patency rates were evaluated for the two groups. Statistical analysis of the data was performed using standard statistics applications. Results: A total of 302 access procedures were performed in Group A, and 975 access procedures were performed in Group B. Significantly more autologous arteriovenous fistulas (aAVF) were created in Group B (p < .05). Sixty-six patients met the criteria for inclusion into Group A; 137 patients were included in group B. The median primary-assisted patency rate for Group A was 20.31 +/- 2.69 months compared to 31.23 +/- 1.19 months for Group B (p < .05). Conclusions: The implementation of an aggressive hemodialysis access surveilence program at our Access Center in 2009 has led to markedly improved access patency rates.

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8. THROMBELASTOGRAPHIC ASSESSMENT IN CHRONIC DISSEMINATED INTRAVASCULAR COAGULATION (DIC)

Adil A. Khan, MD, Jordan M. Jurgens, MD, April A. Hubble, AAS, Charles H. Andrus, MD, FACS Saint Louis University Background: Thrombelastography (TEG), utilized today during acute resuscitations in trauma, liver transplantation, and cardiovascular surgery, necessitates future clinical evaluations in chronic disseminated intravascular coagulation (DIC). Case Study: A 56-year-old male underwent a Dacron graft replacement of the ascending aorta with aortic valve repair for a type A dissection. Postoperatively, he developed a Pseudomonas sternotomy infection treated by debridement and tigecycline. Concomitant with this chronic infection, the patient developed heparin induced thrombocytopenia (HIT), acute renal failure requiring CVVH, and a chronic DIC state characterized by several months of thrombocytopenia, hypofibrinogenemia, D-dimer and fibrin monomer positivity, and prolongation of the PT/INR/PTT. A bilateral pectoral-flap-obliteration of the anterior mediastinum wound was planned. Four units of FFP, 1 unit of platelets, and 1 unit of cryoprecipitate were given to preoperatively address an INR=1.8, a platelet count=71,000/mm3, and a fibrinogen claus=106 mg/dl and TEG Angle a 41.7o, respectively. Immediately on FFP administration, all exposed mediastinal surfaces bled responsive only to mechanical packing/tamponade. A more permanent tamponade was attempted by the planned operation. Results: With significant postoperative bleeding, RBCs (16U), FFP (11U), platelets (24U), and cryoprecipitate (7U) were administered. While the INR and PTT fluctuated, the TEG react-time (in vitro initiation of clot formation) remained within normal limits. Four days postoperative, while the react-time dropped to 4.4 minutes approaching enzymatic hypercoagulability, the INR and PTT spiked to 9 and 128.4 seconds, respectively. Postoperative Angle a’s were normal or in a hyperfibrinogenemic range. While most of the MA (CK)’s were within the normal range, platelet mapping demonstrated severe inhibition to ADP-stimulated aggregation (79%-100% inhibition) in the presence of thrombocytopenia. Conclusion: TEG with platelet mapping in DIC is a better in vitro overall assessment of in vivo coagulation homeostasis than the present use of PT, INR, PTT, platelet counts, and fibrinogen levels.

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9. INSULIN RESISTANCE IN DIABETIC BARIATRIC PATIENTS IS ASSOCIATED WITH IMPAIRED ARTERIOLAR VASODILATION

Luke Beffa, Edgar L Galiñanes, Mark J. Perna, Guiling Zhao, Jorge A. Castorena-Gonzalez, Luis A. Martinez-Lemus, Roger A. DeLaTorre University of Missouri-Columbia Obesity and Type 2 diabetes are commonly associated with vascular disease of which a shared abnormality is the presence of endothelial dysfunction. The mechanisms responsible for endothelial dysfunction are incompletely understood, in particular those leading to aberrant insulin-dependent vascular responses. Because not all obese individuals are diabetic, we hypothesize that a reduced insulin-dependent vasodilatation is a specific endothelial dysfunction independent of obesity that accompanies or precedes the presence of overall insulin resistance. We tested this hypothesis in jejunal submucosal arterioles obtained from samples collected from bariatric patients undergoing Roux en-Y proximal gastric bypass surgery. Patients were 49 ± 2 years old and had a mean body mass index (BMI) of 48.5 ± 2.4 Kg/m2. No significant differences in age or BMI were found between diabetics (n=22) and non-diabetics (n=30). Maximal arteriolar constriction responses to phenylephrine were not significantly different between diabetics (52.9 ± 8.6%) and non-diabetics (60.4 ± 6.2%). Insulin-dependent responses were blunted in diabetics vs. non-diabetics, having a maximal dilation to 10-5 M insulin of 40.4 ± 6.4 vs. 61.9 ± 8.8%, respectively. Constriction and dilation responses to 80 mM KCl, acetylcholine, or sodium nitroprusside were not different between diabetics and non-diabetics. These results suggest that a blunted insulin-vasodilation response is a form of endothelial dysfunction not correlated with BMI in type 2 diabetic patients. As both insulin and acetylcholine induce dilation in part through the production of nitric oxide (NO), the blunted response to insulin occurring in the absence of an abnormal acetylcholine-induced dilation suggest that the mechanism responsible for the blunted insulin response is upstream of NO synthase activation.

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10. OBESITY INCREASES RISK FOR COMPLICATIONS FOLLOWING RESTORATIVE PROCTOCOLECTOMY

Klos CL, Jamal N, Hunt S, Wise P, Birnbaum E, Mutch M, Safar B, Dharmarajan S Washington University Purpose: Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the preferred surgical treatment for most patients with ulcerative colitis (UC). IPAA is a technically complex surgical procedure and overall complication rates range from 30% to 60%. Mirroring the epidemic of obesity in the general population, the proportion of obese patients referred for IPAA is increasing. Accordingly, the aim of this study was to investigate the hypothesis that obesity increases complication rate following IPAA. Methods: This study was conducted as a retrospective review of a prospectively collected database of patients that underwent IPAA between January 1990 and April 2011. Patients were categorized according to body mass index (BMI): BMI<30 (non-obese) and BMI&#8805;30 (obese). Patient characteristics, operative information and complications were recorded through medical record review. The primary outcome measure was cumulative complication rate. Statistical analysis was performed using Student t test and Fisher's exact test with significance set at p<0.05. Results: A random sample of 178 patients undergoing IPAA were selected from the database: 103 (58%) with BMI<30 (median 24, range 16-29) and 75 (42%) with BMI&#8805;30 (34, 30-52). The most common diagnosis was UC in 142 (79%) patients and mean followup after IPAA was 56 months. Obese patients had an increased rate of overall (53% vs. 69%, p=0.04) and pouch related complications (9% vs. 21%, p<0.01) following IPAA, with an increased rate of pouch anastomotic strictures in particular (17% vs. 3%, p< 0.01). Conclusions: While IPAA is technically feasible and safe in patients with BMI&#8805;30, obesity is associated with an increased risk of complications. In particular, the rate of pouch anastomotic strictures is higher in obese patients undergoing IPAA. Obese patients should be informed about these risks during preoperative counseling.

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11. AN IMPROVED HEMICORPORECTOMY TECHNIQUE Burhan Janjua, MD; David C. Crafts, MD; Frank E. Johnson, MD Saint Louis University Introduction The first hemicorporectomy, also known as translumbar amputation (TLA), with survival, was attempted in 1960. The first case with survival of the patient occurred in 1961. It is a life-saving procedure initially designed for carefully selected patients with otherwise terminal cancer. The most common indications now are benign conditions such as chronic osteomyelitis of the pelvis in paraplegic patients. It is the only procedure in which the entire spine is electively divided. The first few attempts featured a one-stage procedure, but it is usually performed in two stages now, if possible. In the two-stage strategy, the first stage entails fecal and urinary diversion and all other procedures deemed useful. The second stage is the amputation. About 58 cases are reported, although others are assumed to exist. Several operative techniques have been described in the medical literature, usually with few details. We report our experience with four patients who had this operation, all done in two stages. Methods We reviewed the current literature using texts and a computer search. We did not consider any reports dealing with a one-stage TLA procedure. We reviewed clinical details of four patients in our series. Results We found 26 references via computer search; 15 described technical features. The anterior approach is familiar to surgeons and suitable for the first stage. Some reports featured an initial anterior approach for the second stage; one featured the decubitus position. We therefore switched to an initial prone position (posterior approach) for the second stage in the next two cases. This allowed us to easily expose and resect the posterior bony elements (which entails minimal blood loss), open the dura, divide the cauda equina, close the dura, and mark the disc to be divided later so that the chosen disc would be visible from the front. Then the operative wound is covered with a sterile dressing, the patient is turned to the supine position, the aorta and vena cava are divided, and the spine is divided through the previously marked disc. The amputation is then completed. Once the amputation is completed, the operative wound is covered with a sterile dressing, the patient is turned again, and the wound is closed. The only complications in our series were minor skin necroses in three cases. All of our patients regained good health soon after the TLA. A custom-made prosthesis enabled wheelchair use. An appropriately modified automobile with hand controls enabled driving. All four patients indicated that they were pleased with the results. Conclusion Hemicorporectomy can be carried out with good results. Our approach decreases operative time for the second stage of a two-stage TLA and minimizes blood loss.

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12. USE OF BIOLOGIC MATERIAL FOR GRADE 2 VENTRAL HERNIA REPAIR. IS IT WORTH THE COST?

Bharti Jasra, MD, Michael Millard, BSc(Hons), Brian L. Holt, MD, Maj, USAF, MC, Eddy C. Hsueh, MD Saint Louis University INTRODUCTION: According to Ventral Hernia Working Group (VHWG) for Grade 2 Ventral Hernia Repair (VHR) due to increased risk of surgical site occurrences (SSO), there is additive risk of synthetic mesh, and possible advantage of using biologic material. To date there is no published controlled clinical study comparing biologic versus synthetic mesh in this group. In this study we reviewed our experience with the biologic material to see if their use is justified in grade 2 VHR given high cost involved. METHODS: Retrospective chart review of patients undergoing VHR between 2004 and 2009 was done. Comparison between the synthetic and the biologic group for the grade 2 VHR was made in terms of recurrences using Kaplan Meier analysis and the SSO using fisher’s exact test. RESULTS: Total 102 patients with grade 2 ventral hernia were identified, 74 of these had synthetic mesh repair and 28 had biologic repair. Interquartile range of follow up was between 0.98 to 18.7months with median of 3.8months. The 24months recurrence rate was 24.7 %( 95%CI 13.3-42.9%) for the synthetic and 40.7 %( 95%CI 13.7-84.3%) for biologic which was not a statistically significant difference (p = 0.408). Similarly there was no statistically significant difference in the SSO with more SSO in the synthetic group 33% compared to 25% in biologic (p=0.477). CONCLUSION(S): In view of high cost involved and no evidence of better outcomes, role of biologic repair material in grade 2 ventral hernia repair is overrated.

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13. SENTINEL LYMPH NODE BIOPSY DURING PROPHYLACTIC MASTECTOMY: IS THERE A ROLE?

Pamela Bunting MD, Amy E Cyr MD, Feng Gao PhD, and Julie A Margenthaler MD Washington University School of Medicine Objective Prophylactic mastectomy (PM) is performed to decrease future breast cancer risk, but there is a 3-5% occult cancer rate on final pathology. Performing a sentinel lymph node biopsy (SLNB) at the time of PM permits axillary staging in the event that an occult cancer is identified. SLNB is not without potential morbidity, and its utility during PM remains unclear. We sought to determine the rate of occult malignancy in patients undergoing PM and whether routine SLNB is justified during PM. Methods A retrospective review of a prospectively maintained database was performed to identify patients undergoing PMs with SLNB from July 2005 to August 2012. Descriptive statistics were utilized for data summary and compared by Fisher’s exact test or ANOVA, where appropriate. A P value of <0.05 was considered significant. Results There were 384 patients identified during the study period who underwent 467 PMs (mean age 45 years, range 20-86). Of the 467 PMs performed, 15 (3.9%) cancers were found on final pathology. All 6 of the invasive cancers identified were T1 (mean 6.3 mm, range 3-10 mm). A total of 682 SLNs were taken for an average of 1.46 SLNs per PM. There were 5 SLNs positive overall (1.1%). Two of the 5 patients with positive SLNs underwent completion axillary lymph node dissection, but no further lymph nodes were positive. Conclusion In 467 PMs performed, 15 (3.9%) cancers were found, and only 5 (1.1%) were associated with a positive SLN. The occult malignancies identified were all T1 and all 5 of the patients with positive SLNs in the PM specimen had contralateral breast cancer which further limited the clinical significance of the occult disease. Based on these results, the routine use of SLNB at the time of PM is unnecessary and does not warrant the morbidity associated with the procedure.

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14. CANCER ANXIETY AND PATIENT SELECTION OF MASTECTOMY OVER BREAST CONSERVATION THERAPY

Leah Conant, Tonya Martin-Dunlap, MD, Carla S. Fisher, MD, and Julie A. Margenthaler, MD Washington University School of Medicine Introduction: Breast conservation therapy (BCT) provides equivalent survival outcomes to mastectomy for women with early-stage breast cancer. Despite this, recent studies have reported increases in the rate of mastectomy and contralateral prophylactic mastectomy. We investigated the indications for mastectomy in a cohort of women. We sought to determine specific patient and clinical characteristics impacting this decision-making process. Methods: A questionnaire was administered to 349 patients who had undergone previous unilateral or bilateral mastectomy for breast cancer during the years 2006 to 2010. The survey queried on demographics, surgical treatment received, and the rationale for those decisions. A retrospective chart review collected clinical characteristics and details surrounding the treatment decision-making process. Descriptive statistics were utilized for data summary. Results: Of 349 patients surveyed, 326 had complete clinical data. Of those, 206 (63%) were not offered BCT and mastectomy was recommended by their physician. Of 206 not offered BCT, clinical data demonstrated BCT contraindications for 171 (83%) with multicentric disease or extent of disease prohibitive of BCT, 25 (12%) who failed BCT secondary to positive margins, and 10 (5%) with recurrence following BCT. The remaining 120 (37%) patients were offered BCT but chose mastectomy. Reasons provided for this decision (patients were allowed to choose more than one reason) included “felt mastectomy would reduce recurrence risk” in 155 (75%), “felt mastectomy would improve survival” in 91 (44%), “avoidance of radiation therapy” in 41 (20%), “felt mastectomy was a better option cosmetically” in 19 (9%), “avoidance of future surveillance imaging” in 6 (3%), and “encouragement by friends/family” in 6 (3%). Conclusion: Nearly two-thirds of the patients undergoing mastectomy for breast cancer in our study were not offered BCT secondary to absolute and/or relative contraindications. For those patients electing mastectomy despite BCT eligibility, the predominant reason for their choice was anxiety over future cancer risk. Prospective studies are needed to determine whether patient education regarding perceived versus actual recurrence risk would alter this decision-making process.

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15. AXILLARY ULTRASOUND IN PATIENTS WITH CLINICALLY NODE-NEGATIVE BREAST CANCER: WHICH FEATURES ARE PREDICTIVE OF DISEASE?

Lauren Steward, MD Leisha Elmore BS, Catherine M. Appleton MD, Julie A. Margenthaler MD Washington University School of Medicine Introduction: Axillary ultrasound is often used in the preoperative evaluation of breast cancer patients in an attempt to identify sub-clinical node-positive disease. The aim of the current study was to identify whether certain radiologic characteristics of axillary lymph nodes correlate with cytology and final pathology in women with breast cancer. Methods: Ultrasound reports of 109 women with clinically node-negative breast cancer were reviewed to extract the radiologic features of lymph nodes that prompted biopsy. Specific characteristics previously shown to be more commonly associated with metastatic involvement were recorded. Lymph node characteristics were compared to cytology obtained from fine-needle aspiration biopsy/needle core biopsy and final pathology. Descriptive statistics were utilized for data summary. Results: Of 109 patients, cytology was positive in 73 (67%) and pathology was positive in 71 (65%). A total of 66 ultrasound reports provided specific nodal characteristics which prompted biopsy. The most common indication was an abnormal lymph node cortex characterized by thickening or eccentric contour (N=40). In this subset of patients, 22 (55%) had malignant cytology, 15 (38%) had benign cytology, and 3 (7%) had indeterminate cytology. The final pathology was malignant in 27 of 40 (68%) and benign in 13 of 40 (32%). Loss of the fatty hilum was described in 17 patients; cytology was malignant in 11 (65%), benign in 4 (24%), and indeterminant in 2 (11%). Final pathology was malignant in 13 of 17 (76%) and benign in 4 of 17 (24%). Nine patients had lymph nodes with both abnormal cortical features and loss of the fatty hilum. Of these, both cytology and final pathology were malignant in 6 (67%) and benign in 3 (33%). Conclusions: Axillary ultrasound is a valuable tool that accurately predicted malignant axillary disease in 65% of patients with clinically node-negative breast cancer. Specific ultrasound characteristics such as lymph node size, cortical features, contour, and hilar fat were not individually predictive of final cytology and pathology in our cohort.

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16. GEOGRAPHIC AND TEMPORAL TRENDS IN THE MANAGEMENT OF OCCULT PRIMARY BREAST CANCER: A SYSTEMATIC REVIEW AND META-ANALYSIS

Oluwadamilola M. Fayanju, MD, MPHS, Carolyn R. T. Stoll, MPH, MSW, Graham A. Colditz, MD, DrPH, Donna B. Jeffe, PhD, Julie A. Margenthaler, MD Washington University School of Medicine Introduction Given increased but disparate breast MRI utilization, we conducted a pooled analysis of occult-primary-breast-cancer (OPBC) patients and a meta-analysis of MRI accuracy in OPBC. Methods A literature review yielded 201 studies. Patient-level data published &#8805;1994 for clinically/radiographically OPBC patients were pooled; regression models examined associations between patient/study data and outcomes including treatments and recurrence. We report adjusted odds ratios (OR) and 95% confidence intervals (CI) (two-tailed p<0.05=significant). MRI meta-analysis included studies with clinically/mammographically OPBC patients who also received MRIs. We report pooled sensitivity and specificity. Results The pooled analysis included 92 patients (15 studies plus Siteman). Being from Asia predicted receiving breast surgery (OR=6.0, 95% CI=2.0-17.7) but not chemotherapy (OR=0.3, 95% CI=0.1-0.8) while US patients were more likely to receive chemotherapy (OR=13.1, 95% CI=2.6-64.8, all p<0.05). Chemotherapy recipients were more likely to have a distant recurrence (OR=9.8, 95% CI=1.1-87.2, p<0.05). Negative MRIs predicted receipt of chemotherapy (p<0.05). In the MRI-accuracy meta-analysis (9 studies, n=250), pooled sensitivity=96% (95% CI=91-98%), specificity=63% (95% CI=42-81%). Conclusion OPBC management varies significantly with geography. Long-term benefit of chemotherapy is unclear, and high MRI sensitivity has not decreased OPBC incidence. We recommend establishing an international OPBC patient registry to facilitate longitudinal study and global treatment standards.

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17. POST-TREATMENT SURVEILLANCE FOR BREAST CANCER PATIENTS: WHAT MOTIVATES THE EXPERTS?

Brian M. Nguyen, Harveshp D. Mogal, Katherine S. Virgo, Julie A. Margenthaler, Ling Chen, Emad Allam, Frank E. Johnson St. Louis University Medical Center Introduction: Breast cancer is the most common cancer among American women, excluding skin cancer. The lifetime chance of a woman developing invasive breast cancer is about 12%. As the number of survivors increases due, in part, to better surveillance methods and treatments for recurrence, more women receive post-treatment surveillance. Despite established guidelines on surveillance strategies, we documented variation in clinical practice. We sought to determine what factors motivate physicians who perform post-treatment surveillance to determine why such variation exists. Methods: A custom-designed survey instrument with eleven questions about potential motivating factors was e-mailed to 3245 members of the American Society of Clinical Oncology (ASCO) who had identified themselves as having breast cancer as a major focus of their practice. Responses were submitted on a 10-level Likert-type scale (1 least important to 10 most important). The percentage of responses for each of the motivating factors was calculated. Ranking was done according to the strongest factor (percentage with score of 10) and weakest factor (percentage with score of 1). Results: There were 1013 responses (31%) submitted. Of these, 723 (73%) were evaluable and included in our analysis. The potential detection of a second primary breast cancer was the strongest motivating factor (53% of responses with a score of 10). The avoidance of medical malpractice lawsuits was the weakest (26% of responses with a score of 1). Conclusions: 1.) Despite evidence-based guidelines, wide variation in the intensity of post-treatment surveillance persists. 2.) Innumerable motivating factors presumably exist. 3.)To our knowledge, this is the first report investigating such factors. 4.) Our data serves to help understand why variability exists and thereby to devise strategies to minimize it.

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18. CONTRALATERAL PROPHYLACTIC MASTECTOMY AFTER UNILATERAL BREAST CANCER: A SYSTEMATIC REVIEW & META-ANALYSIS

Oluwadamilola M. Fayanju; Carolyn R.T. Stoll; Susan Fowler; Graham A. Colditz; Julie A. Margenthaler Washington University School of Medicine Background: Despite limited prospective data and conflicting evidence of survival benefit, contralateral-prophylactic-mastectomy (CPM) rates continue to increase. Here we present a systematic review and meta-analysis of CPM in women with unilateral breast cancer. Methods: We searched PubMed, Embase, Scopus, ClinicalTrials.gov, Cochrane databases and retrieved papers’ bibliographies for articles published through March 2012 reporting outcomes in female CPM recipients with a history of unilateral primary breast cancer. Fixed- and random-effects meta-analyses were conducted based on tests of study heterogeneity. We examined potential confounding via study-level stratification (elevated familial/genetic risk [i.e., BRCA carrier status and/or family history] and country of study publication) and bivariate meta-regression. We report pooled relative risks (RR) and risk differences (RD) with 95% confidence intervals (CI) at two-tailed p<0.05 significance. Results: Of 93 articles reviewed, 14 (mean/median follow-up ≥2 years) were included in meta-analyses. CPM recipients had higher rates of overall survival (RR=1.09 [95% CI 1.06, 1.11]) and lower rates of breast-cancer-specific mortality (RR=0.69 [95% CI 0.56, 0.85]) and distant/metastatic recurrence (RR=0.64 [95% CI 0.51, 0.81]). In the overall analysis, CPM was not associated with an absolute reduction in risk of metachronous contralateral breast cancer (MCBC; RD= -18.0% [95% CI -42.0%, 5.9%, p=0.118]), but among patients with elevated familial/genetic risk, both the relative and absolute risks of MCBC incidence were significantly decreased among CPM recipients (RR = 0.04 [95% CI 0.02, 0.09, p<0.001]; RD = -24.0% [95% CI -35.6%, -12.4%, p=0.013]). Conclusion: CPM is associated with significant decreases in MCBC among high-risk patients, but the decreased rates of mortality and recurrence observed when comparing CPM recipients and non-recipients of all risk levels are likely not attributable to a CPM-derived decrease in MCBC incidence. Unilateral-breast-cancer patients not otherwise at risk for MCBC should not be advised to undergo CPM.

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19. PREDICTIVE FACTORS AND PATTERNS OF RECURRENCE IN PATIENTS WITH TRIPLE NEGATIVE BREAST CANCER

Lauren Steward MD, Leah Conant BS, Feng Gao PhD, Julie A. Margenthaler MD Washington University School of Medicine Objectives: Triple negative breast cancer [(TNBC) = estrogen receptor (ER) negative, progesterone receptor (PR) negative, and Her2 non-amplified] generally portends a poorer prognosis. We sought to describe the outcomes of patients with TNBC in order to determine the patterns of recurrence, time to recurrence, and the impact on overall survival. Methods: We identified 484 patients with initial Stage I-III TNBC who were treated between January 2002 and December 2009. Data included patient and tumor characteristics, surgical, systemic, and radiation treatment received, and breast cancer-specific survival. Patients were divided according to whether or not they experienced a recurrence (either local or distant or both). Data were compared using Chi-square, Fisher’s exact test, and logistic regression. A p value <0.05 was considered significant.Results. The study cohort included 484 patients with a mean age of 53.3 + 12.6 years and a mean follow-up of 29 + 21 months. Of 484 patients, 349 (72%) had no evidence of recurrence while 135 (28%) had recurrent disease, including 26 (19%) with locoregional recurrence, 76 (56%) with distant recurrence, and 33 (24%) with both locoregional and distant recurrence. Of the 59 total locoregional recurrences, 23 (39%) were in the ipsilateral regional nodes, 23 (39%) in the ipsilateral breast, and 13 (22%) in the chest wall post-mastectomy. Of the 109 patients with distant recurrences, lung was the most common site (n=58) followed by bone (n=49), liver (n=48), and brain (n=40). Factors significantly associated with recurrence included race (African American & other), increasing tumor size, positive pathologic nodal status, increasing stage, and type of surgical therapy (mastectomy) (p<0.05 for each). After controlling for all potential confounders in multivariate stepwise regression, only race and increasing p athologic stage were independent predictors of recurrence (p<0.05 for each). At study follow-up, only 7 (5%) of the 135 total patients with recurrence were alive. Conclusions: Nearly 30% of all patients with a TNBC experienced either a locoregional and/or distant recurrence, and African-American patients were at the highest risk. Although bone metastases were common in patients with TNBC, they were more likely to occur with visceral metastases as well. Locoregional and/or systemic recurrence in our cohort of patients with TNBC resulted in 95% breast cancer-specific mortality.

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20. MULTIFUNCTIONAL SIGMA-2 LIGANDS FOR TARGETING OF PANCREATIC CANCER STEM CELLS

John R Hornick and William G Hawkins Washington University School of Medicine Introduction: Pancreatic cancers consist of a heterogeneous population of cells that includes progenitor cells capable of maintaining and repopulating the primary tumor, termed pancreatic cancer stem cells (CSC). These have gained attention because they are thought to contribute to chemoresistance. Sigma-2 receptor/PGRMC1 is a marker of pancreatic cancer that we have targeted using multifunctional ligands to induce apoptosis. We hypothesize that inducing apoptosis in pancreatic CSCs using S2-based compounds will inhibit the regenerative capacity of these cells to repopulate the tumor. Methods: Aspc1 cells were treated with S2/Smac at subtherapeutic (2µM) or therapeutic (4µM) doses over 18 hours prior to staining for ALDH. Flow cytometry gated for ALDHhigh cells which were separated on cell density plots and a percentage compared to ALDHlow cells. In another model, KCM cells were treated with 4µM of S2/Smac for 18 hours and stained for CD44+ and c-met+ which were detected by flow cytometry. Results: We have experimental evidence for pancreatic CSC populations being sensitive to S2/Smac based on shifts in stem cell markers such as c-met and ALDH. Subtherapeutic doses of S2/Smac (2µM) enriched pancreatic ALDHhigh in vitro over 18 hours from 4.96% with vehicle to 10.70%. Therapeutic doses of S2/Smac at 4µM increased from 4.96% with vehicle to only 6.71%. In another model, KCM cells that were treated with 4µM of S2/Smac for 18 hours decreased the CD44+/c-met+ population from 1.68% with vehicle to 0.55%. Conclusions: Cancer stem cell populations have been identified in pancreatic cancer and are hypothesized to contribute to treatment failure. We have identified pancreatic CSCs, and observed changes in this population following treatment with S2/Smac compounds. Therapeutic doses must be used as lower doses appear to enrich for stem cells, similar to the effect seen with other chemotherapies. This finding supports further investigation into targeting pancreatic CSC with S2R.

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21. INFLAMMATORY MONOCYTE MOBILIZATION DECREASES PATIENT SURVIVAL IN PANCREATIC CANCER: A ROLE FOR TARGETING THE CCL2/CCR2 AXIS

Dominic E. Sanford, Brian A. Belt, Roheena Z. Panni, Anjali Deshpande, Allese Mayer, Andrea Wang-Gillam, David G. Denardo, Peter Goedegebuure, and David C. Linehan Washington University Introduction: Macrophages (MAC) are predominant in the tumor microenvironment of pancreatic ductal adenocarcinoma (PDAC), and these cells suppress anti-tumor immunity as well as promote angiogenesis, chemoresistance and tumor invasion. Inflammatory monocytes (IM) express the chemokine receptor CCR2, and these cells are produced and stored in the bone marrow (BM). Under inflammatory conditions, IM are recruited from the BM to the periphery by CCL2, where these cells extravasate into tissues and become MAC. Our objective was to determine the therapeutic role for targeting the CCL2/CCR2 axis in PDAC. Methods: Kaplan-Meier and multivariate analyses were performed to assess for a correlation between blood monocyte levels and survival in PDAC patients undergoing pancreaticoduodenectomy (n=377). IM prevalence in the blood and BM of PDAC patients (n=21) and controls (n=11) was compared by flow cytometry. T cell suppression assays were performed using CCR2+ MAC from PDAC patients. Immunohistochemistry, flow cytometry, and qRT-PCR were performed on PDAC tumors (n=11) and normal human pancreas (n=10). CCR2 blockade was tested in a murine model of PDAC. Results: Pre-operative blood monocyte prevalence correlates inversely with survival, and low monocyte prevalence is an independent predictor of increased survival in resected PDAC patients. IM are increased in the blood and decreased in the BM of PDAC patients compared to controls, suggesting that IM are mobilized from the BM to the bloodstream in this disease. The ratio of IM in the blood versus the BM is a novel predictor of decreased patient survival following tumor resection. Human PDAC tumors produce CCL2, and immunosuppressive CCR2+ MAC infiltrate these tumors. In mice, CCR2 blockade decreases MAC in the primary tumors and premetastatic livers resulting in enhanced anti-tumor immunity, decreased tumor growth, and reduced metastasis. Conclusions: IM recruitment is critical to PC progression, and targeting CCR2 may be an effective immunotherapeutic strategy in this disease.

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22. A NOVEL THERAPEUTIC (SIGMA 2-SMAC) CONJUGATE EFFECTIVELY TARGET APOPTOSIS IN PANCREATIC ADENOCACINOMA.

Yassar Hashim, MD; Dirk Spitzer, PhD; Suwanna Vangveravong, PhD; Robert Mach, PhD; Mary Hornick; William Hawkins, MD Washington University School of Medicine Introduction: Pancreatic cancer is a devastating disease in need of new therapies. Here we deliver novel drugs selectively to pancreatic cancers using sigma-2 ligands and targeting a survival/apoptosis pathway. The drugs are chemically conjugated sigma 2 ligand and SMAC (Second mitochondria-derived activator of caspase). Sigma 2 receptors are found in different organs, but they are unregulated in proliferating tumor cells. We have previously shown that Sigma-2 receptors are highly expressed in pancreatic cancer cells, and sigma 2 ligands are rapidly internalized in vivo and in vitro. SMAC mimetics are small molecules that induce apoptosis by targeting Inhibitors of apoptosis (IAPs) Method: We synthesized novel compounds which conjugate a Sigma-2 ligand with (SMAC) mimetic or a fluorescent label. We tested the compounds on human pancreas cell lines. We applied escalating concentrations of Sigma-2 ligand, SMAC, Sigma-2 ligand/SMAC conjugate, and Sigma-2 Ligand plus SMAC. Viability, caspase and apoptosis assays were performed 24 hours after treatment. In vivo testing was performed on Nude mice with right flank subcutaneous human pancreatic tumor implant which were treated with the compound and vehicle (control) daily for 2 weeks. Results: All the sigma-2 ligands were rapidly internalized by pancreatic cancer cells. The plateau of internal fluorescence intensity was reached in &#8804;5 minutes. There was significant increase in apoptosis level, killing and caspases activities of the conjugated compound compared to controls. Tumor volume was significantly smaller and survival was longer in the mice treated with the conjugate compared to the control group (P value < 0.05). Conclusion: We developed a novel molecular therapeutic based on the concept of cancer selective delivery and inhibition of a survival pathway. This strategy for drug delivery has the potential to expand the therapeutic window for conventional agents and has great clinical implication for pancreas cancer and other malignant tumors.  

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23. THE BASIS FOR IMMUNOLOGIC SUSCEPTIBILITY TO LUNG CANCER IN MAN

Sara Dehbashi, Xue Lin, Higashikubo Ryuji, Stephanie Chang, A. Sasha Krupnick Washington University Background and Hypothesis: It is currently unknown why some individuals with a heavy smoking history do not develop lung cancer, while others with little exposure to tobacco develop the disease. Our group has recently demonstrated, in a murine model, that strain-specific differences in natural killer cells (NK cells) contributes to relative resistance, or susceptibility to lung cancer. Based on this data, we set out to test the hypothesis that individual variations in NK immune responses contribute to susceptibility or resistance to lung cancer in man. Methods: All patients enrolled in this study were treated in the Department of Surgery, Division of Cardiothoracic Surgery of Washington University in St. Louis. Patients with an extensive smoking history (>45 pack years) who were lung cancer-free based on a recent chest CT were classified as lung cancer “resistant”. Patients with a similar smoking who were diagnosed with lung cancer were classified as lung cancer “susceptible”. Twenty milliliters of peripheral blood was collected from individuals using heparinized collection tubes. Peripheral blood lymphocytes (PBLs) were isolated as previously described by adding 10cc of blood to 15cc of ficoll, centrifuging for 30 minutes at 25 degree and then isolating only the white band. Natural killer cells were identified flow cytometrically as CD45+CD56+CD3- using antibodies primarily conjugated to fluorescent dyes. To evaluate lung cancer-specific responses PBLs were co-cultured in vitro with the lung cancer cell line A549 in a two to one ratio. Lung cancer specific immune responses were characterized by production of the cytokines TNF- and IFN- at a single cell level by intracellular staining. All these steps were done based on an IRB approved protocol. Results: Data is summarized in Figure 1. No differences were detectable in the proportion of NK cells in the blood of individuals susceptible or resistant to lung cancer. After stimulation with A549 cancer cell line NK cells from those deemed “resistant” to lung cancer produced higher levels of TNF- and IFN- compared to those deemed “susceptible” to lung cancer. Conclusion: Here we describe for the first time that NK cell reactivity correlates with lung cancer susceptibility. Our data may serve to explain why some individuals with a heavy smoking history do not develop lung cancer while others develop this disease despite limited exposure to tobacco. Since immunotherapy for cancer is rapidly gaining acceptance with translation of experimental protocols into the clinic, our data might act as a foundation for clinical trials focusing on modifying NK cells for lung cancer immunotherapy and immunoprevention.

Figure 1: No differences in the proportion of NK cells were evident between the groups (top panel). Higher levels of TNF- and IFN- are evident by single cell flow cytometry in the “resistant” patients compared to those deemed “susceptible” to lung cancer after overnight stimulation with A549.

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24. TOTAL LYMPH NODE YIELD IN N0 COLON CANCER DOES NOT PREDICT RECURRENCE

Klos, C.L.; Hunt, S.; Mutch, M.; Wise, P.; Safar, B.; Birnbaum, E.; Dharmarajan, S. Washington University School of Medicine Introduction: Lymph node stage is an important independent prognostic factor for recurrence in colon cancer. Complete mesocolic excision with central vascular ligation (CME) has been reported to significantly increase nodal yield in the resected specimen, hence potentially decreasing false negative histopathologic reports of nodal stage. We evaluated if total lymph node yield (TLN) predicts recurrence of right sided colon cancer after curative resection in the absence of metastatic lymph nodes. Methods: Our main colorectal database was queried for patients who had a curative right sided colectomy for colon cancer between January 2003 and January 2007. Histopathologic features and recurrence data were recorded through medical record review. Patients were stratified by AJCC stage (I, II and III) and recurrence status: A) without recurrence, B) with recurrence. Five-year recurrence rates were obtained per Kaplan-Meier method, TLN was compared between groups by t test. Results: 58 stage I, 77 stage II and 57 stage III patients were identified, with a 5-year recurrence rate of 4.5%, 11% and 42.8% respectively. TLN averaged 15.8, 17.4 and 19.8 respectively and significantly increased per advancement of stage (slope 1.94, p<0.01). However, no significant difference was observed when TLN was compared between group A and B within stages. There was merely a tendency among stage III patients in group B to show an increased TLN compared to A (18.4(A) vs 22.8(B), p=0.06). Conclusion: Advanced stage colon cancer correlates with an increased TLN. However, after a rigorous oncologic resection of the right colon, TLN is similar among stage I and II right sided colon cancer patients regardless of whether recurrent disease will develop.

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25. COAGULATION MANAGEMENT DURING AN OPERATION ON A UREMIC PATIENT

Amir Zahra, D.O., Alison J. Witte, M.D., Ryan M. Krampert, M.D., Charles H. Andrus, M.D., F.A.C.S. Saint Louis University School of Medicine Background: Impaired platelet aggregation without thrombocytopenia is well-described in chronically uremic patients. Thrombelastography (TEG) is commonly utilized during acute resuscitations in trauma, liver transplantation, and cardiovascular surgery to direct correction of coagulopathy. Case Study and Methods: A chronically anti-coagulated patient status post aortic and mitral valve replacements, with chronic renal failure now on hemodialysis after a history of peritonitis secondary to peritoneal dialysis, presented with a two day history of vomiting. Computerized axial tomography (CAT) imaging revealed partial small bowel obstruction (SBO) with supportive laboratory abnormalities: hypochloremia, hyperkalemia, uremia, and alkalemia. Initially, she was resuscitated with fluids, electrolytes, and hemodialysis over several days. Her abdominal distension persisted and repeat imaging continued to demonstrate a high-grade partial SBO. She then underwent enterolysis for extensive adhesions and a functional inter-loop herniation of small bowel; a cholecystectomy was also performed. Intraoperatively, it was noted that there was no visible clot formation resulting in a constant ooze of blood from all cut surfaces. With the administration of one unit of platelets, this bleeding resolved. A TEG with platelet mapping was obtained at the start of the case and again after the administration of the platelets.Results: Prior to the case and immediately afterwards, Platelets were 311,000/mm3 and 264,000/mm3; INR was 1.4 and 1.6; and PTT was 33.7 seconds and 34.5 seconds, respectively. The TEG results prior to and after platelet administration demonstrated normal react-times (R) and normal Maximal Amplitudes (MA); a normal post-transfusion alpha angle was noted compared to a slightly elevated initial angle of 73.2o (range 53o-72o). The initial abnormal platelet mapping was significantly improved by platelet administration: %ADP inhibition: 32% - 6.8% and %AA (arachidonic acid) inhibition 8.4% - 0%. Conclusion: TEG with platelet mapping-directed platelet administration effected dramatically clinically-observed bleeding in the presence of uremia and a normal platelet count.

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26. LAPAROSCOPIC REPAIR OF A PARAHIATAL HERNIA Kim-Phung Nguyen, M.D., Keith S. Naunhiem, M.D., F.A.C.S., Charles H. Andrus, M.D., F.A.C.S. Saint Louis University School of Medicine Background: Unlike the paraesophageal hernia, the parahiatal hernia is rare. Case Study: A 68-year-old female was referred with gastroesophageal reflux complaints: chronic daily epigastric pain radiating to chest and postprandial nausea and regurgitation. Barium swallow and EGD documented this to be a type II paraesophageal hernia, and a laparoscopic Nissen fundoplication was recommended. After placement of the five trocars in standard positions, the area of the esophageal hiatus was visualized. Dense adhesions were noted and by blunt dissection, cautery, and harmonic scalpel the adhesions between the hernia sac and the incarcerated stomach were taken down. The stomach, omentum, and hernia sac were reduced from the left chest through the diaphragmatic defect. It was noted that the hernia defect was lateral to the lateral muscle leaflet of the crus in the posterior diaphragm and the distal esophagus was in the proper position in esophageal hiatus. With a muscular bridge between the esophageal hiatus which was located medial and the more lateral diaphragmatic defect, this was a tru e parahiatal hernia. Results: With the hernia sac reduced into the abdomen and then excised, a primary sutured closure with O ethibond of the diaphragmatic defect between the lateral leaflet of the crus and the lateral aspect of the diaphragmatic defect was performed. With this closure, the hernia defect had been transposed into the esophageal hiatus. A posterior portion of fundus was brought through the retroesophageal window which had been dissected and a standard 360o 2-cm Nissen fundoplication was performed over a 56-Fr dilator utilizing three 2-0 ethibond sutures to complete the wrap. Posterior to the esophagus, a posterior crural repair was performed with 2-0 Ethibond. Conclusion: While a parahiatal hernia is a rare diaphragmatic defect, with its primary closure the result hiatal defect can be addressed as a standard fundoplication and crural closure.

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27. SUCCESSFUL INTRAOPERATIVE MANAGEMENT OF DUCT OF LUSCHKA BILE LEAK

Siddharth Kudav,MD, Edgar Luis Galiñanes, MD, Norbert Richardson, MD University of Missouri-Columbia Background: Duct of Luschka leak is rare, occurring in less than 2% of elective laparoscopic cholecystectomies. Diagnosis and management typically involves endoscopic retrograde cholangiopancreatography (ERCP) in the postoperative setting. To the authors’ knowledge there are no reports of successful intraoperative identification and management of a duct of Luschka bile leak in the current body of literature. Method: We present a case of a 30-year-old-female with classic symptomatic cholelithiasis with normal liver function tests that underwent an elective laparoscopic cholecystectomy. Intraoperative cholangiogram (IOCG) was unremarkable. Bilious drainage was noted from the lateral gallbladder fossa, far away from the any biliary anatomy identified on IOCG. A 19-French Blake drain was left in the gallbladder fossa for drainage control. Results: The patient was discharged on postoperative day one with minimal serous fluid from the drain. However, the patient was readmitted for observation to the hospital postoperative day two with increased abdominal pain and bilious drainage. The patient was managed conservatively. The bilious output decreased during her hospital course. The patient was discharged home with the drain in place postoperative day five. She eventually had it removed 13 days postoperatively in clinic without any further sequela. Conclusion: If intraoperative identification is possible, ducts of Luschka bile leaks can be managed without postoperative ERCP, avoiding possible complications such as pancreatitis, bleeding, perforation and late stricture formation. Drainage control can be achieved with a drain placed at the time of surgery and followed postoperatively. We successfully present identification and management of a duct of Luschka bile leak at the time of surgery.

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28. CHRONIC IDIOPATHIC INTESTINAL PSEUDO-OBSTRUCTION: A CASE REPORT AND LITERATURE REVIEW

Andrew Jung BS; Hale Wills MD, MS; Dennis Vane MD, MBA, FACS, FAAP Saint Louis University INTRODUCTION: Intestinal pseudo-obstruction is a syndrome characterized by clinical features of small bowel obstruction without a definitive mechanical obstruction. Most commonly seen in an acute setting, it often follows abdominal surgery. Chronic intestinal pseudo-obstruction can have a myriad of etiologies, encompassing neurologic, infectious, genetic, and smooth-muscle related factors. An idiopathic cause for chronic intestinal pseudo-obstruction accounts for roughly 20% of cases, and currently remains a diagnosis of exclusion. CASE REPORT: A 13 year old male presents with a 31 pound weight loss over 4 months. The weight loss was accompanied with large caliber, foul-smelling stools, intermittent dysphagia, and emesis. Since the neonatal period, the patient has had a history of feeding intolerance, diarrhea, and constipation. Initial work up for cystic fibrosis, celiac, Crohn’s, and Hirschsprung’s was negative. Upper and lower GI endoscopy revealed a dilated stomach and bladder, and an upper GI barium series showed retained contrast after 4 hours, suggestive for gastroparesis and atony. The patient was started on TPN, and underwent numerous unsuccessful feeding trials via nasoduodenal tubes. Further work up for metabolic, neurologic, systemic connective tissue disorders, infectious/inflammatory, mitochondrial, toxic, auto-immune, and malignant causes of gastroparesis was negative. The child underwent a gastrojejunostomy with partial colectomy with back-up ileostomy. The small bowel appears to have some minimal function; howe ver, the stomach remains atonic, as does the bladder. In addition, the colon does not appear to function normally. Grossly, the colonic specimen was substantially dilated. Submucosal edema with dilated blood vessels, thin muscularis mucosae/propria with ganglion cells present, and serosal layer edema were appreciated microscopically. With all other disease processes ruled out, diagnosis is suggestive of chronic intestinal pseudo-obstruction. Following a complication of a dislodged gastrostomy tube the child subsequently underwent a laparotomy with a roux-en-Y jejeunostomy. He is currently tolerating jejeunostomy feedings at a low rate.

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29. VIDEO ASSISTED REPAIR OF A POSTOPERATIVE LUNG HERNIA Bharti Jasra, MD, William F Sasser, MD, FACS. Saint Louis University Hospital Introduction: Lung hernia is a rare entity and should be repaired if it is incarcerated or symptomatic. Open repair can be challenging especially in presence of scarring from previous surgery, proximity to cardiophrenic angle, and difficulty to localize due to overlying breast tissue. Case Study: 57 year old woman presented to Saint Louis University Hospital five years after removal of a benign chest wall tumor. She had recurrent pain at the scar site for over a year. The pain was sharp, severe, episodic, and associated with deep breathing. It was difficult to localize the hernia on physical examination due to the overlying breast tissue but computed tomography (CT) imaging confirmed a left anterior lung hernia close to cardiophrenic angle. She had multiple hospital admissions in the past from symptomatic lung hernia therefore it was decided to repair it. Video assisted thoracoscopic surgery (VATS) was used to localize and reduce the hernia after which a small anterior thoracotomy was made to repair a defect that measured 8 x 6 cm in size. A GORE DUALMESH graft was used for the repair. She was discharged without any complications. Results: After postoperative period patient’s pain completely resolved. Conclusions: Postoperative lung hernia repair close to cardiophrenic angle and posterior to breast tissue can be challenging. Use of VATS along with open approach not only makes it easier and safer but also gives satisfactory results.

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30. THYMOMA SECRETING ECTOPIC PARATHYROID HORMONE CONCOMITANTLY WITH TERTIARY HYPERPARATHYROIDISM

Bharti Jasra, MD, Keith S. Naunheim, MD, FACS, Erin Ely, MD, Charles H. Andrus, MD, FACS Saint Louis University School of Medicine Introduction: A thymoma secreting ectopic parathyroid hormone (PTH) is extremely rare and difficult to differentiate from underlying presumed tertiary hyperparathyroidism secondary to chronic renal disease. Case Study and Methods: A 54 year-old male, status post cadaveric kidney transplant , had been treated with alendronate for hypercalcemia of presumed tertiary hyperparathyroidism (Ca++ = 9.7 +/- 0.5 mg/dl, Phosphorus = 2.7 +/- 0.4 mg/dl, PTH = 169.3 +/- 23.2 pg/ml). Incidentally he was found to have a 1.5cm nodule in the anterior mediastinum on computerized axial tomography (CAT) imaging which was metabolically active on Tc-99m sestamibi parathyroid imaging. Since patient was immunocompromised we decided to remove the nodule rather than observing with serial imaging. As thoracoscopic excision of the nodule showed thymoma on frozen section, total thymectomy was done. During the perioperative hospitalization, serum PTH, Ca++, and phosphorus levels were obtained. Results: After the thoracoscopic excision of the nodule but prior to the conversion to the median sternotomy/total thymectomy, the PTH level was 213 pg/ml (preoperative baseline: 137 pg/ml) and five hours later was 338 pg/ml. Final pathology demonstrates a well-circumscribed, lobulated Type A Thymoma (modified Masaoka Stage I, T1NxMx) without any nests of ectopic parathyroid cells identified. Over the course of the postoperative seven-day hospitalization, the Ca=9.5+0.8, phosphorus=2.9 +/- 1.0, and the intact PTH serum levels declined from 338 pg/ml - 82 pg/ml by a logarithmic decay (average: -1.31 pg/ml / hour) with an R2 =0.92 of the least squares fit of the log(PTH) versus time. Over the course of the next three weeks, a tertiary hyperparathyroidism equilibrium recurred (Ca++ = 10.0 +/- 0.7 mg/dl, Phosphorus = 3.0 +/- 0.3 mg/dl, PTH = 131 pg/ml). Conclusion: While the thymoma was removed and the rate of excretion of the thymoma-derived ectopic PTH was calculated for the postoperative period, the tertiary hyperparathyroidism state was reestablished shortly thereafter.

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31. EMPHYSEMATOUS CHOLECYSTITIS RESULTING IN CYSTIC ARTERY EROSION AND MASSIVE HEMOPERITONEUM IN THE SETTING OF DABIGATRAN THERAPY

Shoshana D. Hacker, M.D., Charles H. Andrus, M.D., F.A.C.S., Jula Veerapong, M.D. Saint Louis University School of Medicine Background: Massive hemorrhage in the setting of gallbladder perforation is a rare entity. Predisposing risks factors such as anticoagulation therapy, renal failure, advanced age, and immunosuppression have been described. We report a case of an emphysematous gallbladder resulting in perforation and massive hemoperitoneum in a patient on direct thrombin inhibitor therapy for atrial fibrillation. Case Report: A 76 year-old woman with Parkinson’s disease, Raynaud’s syndrome, and atrial fibrillation was admitted to the cardiology service for acute chest pain. She was on dabigatran for risk reduction of cardiac-associated embolic events. During admission, laboratory data revealed an acute drop in hemoglobin, normal platelet counts, and normal coagulation parameters. Progression of symptoms to abdominal pain prompted computed tomography which demonstrated hemoperitoneum with active arterial contrast extravasation within the gallbladder lumen and around the duodenum. Additional findings included pneumobilia, pneumoperitoneum, and gallbladder emphysema. She was taken to the operating room for an exploratory laparotomy and 2.5 liters of blood was evacuated. Exploration of the right upper quadrant revealed free gallstones, an edematous gallbladder with a small perforation, and active hemorrhage from the cystic artery. A cholecystectomy was performed. Postoperative recovery was uneventful. Results: Axial imaging accurately identified a constellation of findings that resulted from an erosion of the cystic artery during an acute episode of emphysematous cholecystitis. Pathologic evaluation of the gallbladder demonstrated acute necrotizing cholecystitis with diffuse mucosal necrosis and hemorrhage, a transmural inflammatory infiltrate comprising of neutrophils and lymphocytes, and bacterial overgrowth within the luminal hemorrhagic debris. Conclusion: Hemoperitoneum resulting from emphysematous cholecystitis is a rare occurrence carrying significant morbidity and mortality. A high index of suspicion allows for rapid identification and prompt surgical intervention for high risk patients on anticoagulation therapy despite normal coagulation studies.

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32. CHARCOT SPINE SECONDARY TO TRAUMATIC SPINAL CORD INJURY: A CASE REPORT AND DIFFERENTIAL DIAGNOSIS

Elyse Brinkmann, Scott Vizzi MD, Frank Johnson MD Saint Louis University Charcot spinal arthropathy is a rare, progressive, degenerative disorder involving the vertebral bodies, intervertebral discs, and posterior facets that is caused by impaired innervation of the spine. This disease was historically associated with neurosyphilis, but most present-day cases are consequences of traumatic spinal cord injury. Surgical intervention can result in significant symptomatic relief and increased life expectancy, which makes early recognition critical to management. The radiologic characteristics of Charcot spine can mimic a wide variety of destructive spinal pathologies, including infection, malignancy, and inflammatory arthritis, all of which must be considered during initial evaluation. We encountered a case which illustrates the process of establishing the correct diagnosis. Case Report The patient is a 63 year old Caucasian male with a history of T8 ASIA class A paraplegia secondary to a motor vehicle collision in 1983, managed with multilevel spinal fusion, who presented to our hospital in 2012 after a fall. Lumbar spine imaging obtained during admission revealed post-operative changes from T12 to L3 with massive heterotopic bone formation. CT and needle biopsy confirmed the diagnosis. Conclusion Charcot spine should be included in the differential diagnosis for all patients with a history of traumatic spinal cord injury who present with increasing back pain and new radiographic changes. Diagnosis almost always requires extensive testing including X-ray, biopsy, and CT imaging. Early recognition can be difficult due to the insidious onset of nonspecific symptoms. The slow, chronic progression of the variable symptoms associated with this disease is responsible for the usual delay in definitive diagnosis. Treatment options may be limited by an advanced stage of disease at presentation. We present a representative case of Charcot spine along with spectacular CT images and pathology slides.

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Acknowledgments The Missouri Chapter of American College of Surgeons would like to take this opportunity to thank all of our technical exhibitors for their continued support of our professional meeting. We would also like to give special thanks to those exhibitors who were not only exhibitors but were sponsors and gave (unrestricted) educational grants to provide our fine speakers, activity, and food expenses for this year’s program. The Missouri Chapter of American College of Surgeons is committed to the free exchange of medical education. Inclusion of any presentation in this program, including presentations on off-label uses, does not imply an endorsement by the Missouri Chapter of American College of Surgeons of the uses, products, or techniques presented. When commercial support is received for an educational activity, the conference planning committee maintains complete control over the selection of content and speakers. Acceptance of commercial support does not imply approval or endorsement of any product.