scientific program · the goal of the program is to provide an educational opportunity for pcsa...

February 16-19, 2018Meritage Resort and Spa

Napa, California

Pacific Coast Surgical Association

89th Annual Meeting

SCIENTIFIC PROGRAM

Education jointly provided by the American College of Surgeons and the Pacific Coast Surgical Association.

10931_PCSA_Program2018_Exhibitors.indd 1 2/2/18 8:16 AM

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Pacific Coast Surgical Association89th Annual Meeting

Scientific ProgramFebruary 16-19, 2018

Meritage Resort and SpaNapa, California

2018 Arrangements / Program Committee .................................................................2Council Officers, Members, and Representatives ...................................................2-3 Scientific Program Information ..................................................................................4-5 Scientific Program Details ...........................................................................................6-9Meeting Agenda and Scientific Program ..............................................................11-18 Scientific Sessions 1-26 ............................................................................................19-46 Mini-Podium Session A ...........................................................................................47-61 Mini-Podium Session B ...........................................................................................62-76 Mini-Podium Session C ...........................................................................................77-91 Founders .........................................................................................................................93 Past Presidents ..........................................................................................................94-96 New Members ........................................................................................................97-101 In Memoriam ........................................................................................................102-121 PCSA Constitution ..............................................................................................123-126 PCSA Bylaws .......................................................................................................127-130Future Meetings ..........................................................................................................131

Table of Contents


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2018 Arrangements Committee

President and Spouse Quan-Yang Duh and Ann Comer

Vice-President Wen Shen

Golf Tournament Steven Stanten

Tennis Tournament Amanda Wheeler

Guest and Children’s Activities Michael Campbell

2018 Program Committee

Program Chair and Recorder Christian de Virgilio

Members: Quan-Yang Duh (2018)

Farin Amersi (2020)

Kristine Calhoun (2019)

James Dolan (2018)

Lygia Stewart (2018)

Sherry Wren (2022)

Council Officers

Quan-Yang Duh, President (2018) San Francisco, CA

Wen Shen, Vice-President (2018) San Francisco, CA

John A. Ryan, Jr., Historian Seattle, WA

Sherry Wren, Secretary-Treasurer (2022) Palo Alto, CA

Christian de Virgilio, Recorder (2021) Los Angeles, CA

PCSA 89th Annual Meeting


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Caucus Councilors

Richard Bold, Councilor (2018) Northern California

John Vetto, Councilor (2019) Oregon/Hawaii

L. Andrew DiFronzo, Councilor (2021) Southern California

Lorrie Langdale, Councilor (2020) Washington/ British Columbia/Alaska

Council Representatives

Kevin Billingsley, Portland, OR (2020) Advisory Council for Gen. Surgery, ACS

Armando Giuliano, Los Angeles, CA (2020) Board of Governors, ACS

Kenji Inaba, Los Angeles, CA (2020) American Board of Surgery

PCSA 2018 Publications Committee Members

PCSA 89th Annual Meeting

Farin Amersi

Richard Bold

Cliff Deveney

Jim Dolan

Joe Galante

Jessica Gosnell

Kenji Inaba

Patrick Javid

Sara Javid

Dennis Kim

Greg Landry

Steven Lee

Sharon Lum

Darren Malinoski

Dan Margulies

Samer Mattar

Marc Melcher

Sue Orloff

Marty Schreiber

Brett Sheppard

Areti Tillou

Christian de Virgilio, Chair


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

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

Disclosure In compliance with the ACCME 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. 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.

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

Scientific Program Information


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Scientific Program Information

CONTINUING MEDICAL EDUCATIONCREDIT INFORMATION

Accreditation

This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint provider-ship of the American College of Surgeons and Pacific Coast Surgical Association. The American College of Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

AMA PRA Category 1 Credits™

The American College of Surgeons designates this live activity for a maximum of 14.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participa-tion in the activity.

Of the AMA PRA Category 1 Credits™ listed above, a maximum of 10.25 credits meet the requirements for Self-Assessment.


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PCSA RESIDENT’S COMPETITIONSaturday, February 17, 11:00 AM – 12:30 PMThe top-scoring resident paper from each caucus will be presented during the scientific sessions. Presentations will be judged on clarity, focus and scientific relevance to surgical practice. Prizes will be awarded at the President’s Dinner. This year’s resident contestants are:

Raphael Byrne | Oregon/Hawaii Oregon Health and Science University “Who Undergoes Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy (CRS/PIC) for Appendiceal Cancer?: An Analysis of the National Cancer Database (NCDB)”

Todd Robinson | Washington/British Columbia/AlaskaVirginia Mason Medical Center “Fifty Pheos: A Multidisciplinary Algorithm for the Perioperative Management of Pheochromocytoma”

Brie Nardy | Northern CaliforniaUniversity of California – Davis “Pre Injury Use of Selective Serotonin Receptor Inhibitors are Predictive of Opioid Use 90 Days after Discharge in Trauma Patients”

Azure Adkins Southern California Kaiser Permanente | Los Angeles “Do Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Administered After Pancreatectomy Increase the Risk of a Postoperative Pancreas Fistula or Other Complication?”

PCSA NEW MEMBER PRIZESaturday, February 17, 3:30 PM – 5:15 PMAll New Members are encouraged to submit their abstract for the PCSA New Member Prize Award. The award for the New Member Prize is complimentary registration for the awardee and guest to the Annual Meeting.

Lan Vu | Northern CaliforniaUniversity of California - San Francisco “Outcomes of Sutureless versus Sutured Gastroschisis Closure”

Scientific Program Details


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LUNCH MINI-PODIUM SESSIONS A,B,C Saturday, February 17, 12:35 PM – 1:40 PM Mini-Podium Presentations will be presented on Saturday, February 17 during the lunch hour. Each mini-podium presentation will be followed by brief ques-tions and discussion. A box lunch will be provided.

HISTORIAN PRESENTATION – John Ryan, MDSunday, February 18, 9:15 AM – 9:55 AMPCSA Historian Dr. John A. Ryan will make a presentation, “The Surgeon and the Emperor: Theodor Billroth and Franz Joseph.” After attending this presentation, attendees will have a better knowledge and understanding of the culture during the Austrian-Hungary Empire and its leader Franz Joseph and how this fostered the brilliance of the great 19th Century surgeon Theodor Billroth. The study also explains the state of medical affairs in 1867 along with how and why Billroth was able to make such tremendous advances in surgical treatments.

PRESIDENTIAL KEYNOTE SPEAKER – Dimitri Christakis, MDSunday, February 19, 9:55 AM – 10:25 AMA pediatrician, researcher, and parent, Dimitri Christakis, is the George Adkins Professor of Pediatrics at the University of Washington, Director of the Center for Child Health, Behavior and Development at Seattle Children’s Research Insti-tute, Editor-in-Chief of JAMA-Pediatrics and an attending pediatrician at Seattle Children’s Hospital. Professor Christakis graduated from Yale University and the University of Pennsylvania School of Medicine. He is the author of over 200 original research articles, a textbook of pediatrics and The Elephant in the Living Room: Make Television work for your kids. (September 2006; Rodale). In 2010 he was awarded the Academic Pediatric Association Research Award for outstand-ing contributions to pediatric research over his career. His passion is developing actionable strategies to optimize the cognitive, emotional, and social develop-ment of preschool children. The pursuit of that passion has taken him from the exam room, to the community and most recently to cages of newborn mice. This morning, Dr. Christakis’ talk, “How Early Experiences Shape Brain Development and Cognition” will show his passion in action.



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PRESIDENTIAL KEYNOTE SPEAKER Nicholas Christakis, MD, PhD, MPHSunday, February 19, 10:25 AM – 10:55 AMDr. Christakis is a social scientist and physician who conducts research in the areas of biosocial science, network science, and behavior genetics. He directs the Human Nature Lab at Yale University, and is the Co-Director of the Yale Institute for Network Science. In 2009, Christakis was named by Time magazine to their annual list of the 100 most influential people in the world. In 2009 and in 2010, he was listed by Foreign Policy magazine in their annual list of Top 100 Global Thinkers. Dr. Christakis talk entitled “Doing Experiments with Social Networks to Make the World Better” will share with attendees how ill health, disability, health behavior, health care, emotional states, and death in one person can influ-ence the same phenomena in others in a person’s social network.

PRESIDENT’S FORUMSunday, February 19, 10:55 AM – 12:15 PMFollowing the Presidential Keynote Speakers, the topic of the President’s Forum will be “Diversity and Inclusion: What Does it Mean for the Pacific Coast Surgical Association?” Moderated by Dr. Sherry Wren, Professor of Surgery, Vice Chair for Professional Development and Diversity and Director of Global Surgery, Center for Global Health and Innovation at Stanford University, The panelists will include: Dr. Steve Stain, Chair of Surgery at Albany Medical Center; and Dr. Nadine Caron, Associate Professor of Surgery (Northern Medical Program) and Co-Director of Center for Excellence in Indigenous Health at University of British Columbia and Dr. Sanziana Roman, Director, Endocrine Surgery Fellowship, Professor of Surgery at Duke University.



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Industry Support Displays

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

PCSA would like to thank the Industry Support Committee Members for their time and efforts: Insoo Suh, Chair Jon Carter Dan Azagury Jason Lee Michael Campbell Laurence Yee

PCSA would like to thank the following exhibiting companies:

PCSA would also like to extend their gratitude for the Educational Grant Support from Gore & Associates.

• Allergan• Abbott Vascular• Bard Davol• BK Ultrasound• Cook Medical• Genomic Health• Gore & Associates• Hitachi Healthcare• Intuitive Surgical• (The) JAMA Network• Mallinckrodt Pharmaceuticals• Medtronic• Prescient Surgical• SBH• Teleflex


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Meeting Agenda and Scientific Program

FRIDAY, FEBRUARY 167:00 am – 8:00 am Finance Committee Meeting and Breakfast Carneros F-H8:00 am – 12:00 pm Council Meeting and Breakfast Carneros F-H12:00 pm – 12:15 pm Council Photograph TBD12:15 pm – 1:15 pm Council Lunch Rutherford Terrace1:15 pm – 3:00 pm Executive Session of the PCSA Council Carneros F-H5:00 pm – 6:00 pm New Members Private Reception Carneros Ballroom (C-H)6:00 pm – 7:00 pm Welcome Reception Carneros Ballroom & Oakville Terrace

SATURDAY, FEBRUARY 176:30 am – 7:30 am Women in Surgery Forum Carneros AB7:00 am – 8:00 am Continental Breakfast with Industry Support Meritage 1, 2 & Foyer8:00 am – 8:05 am Introduction by the Recorder Meritage 3-108:05 am – 8:15 am Vice President Introduction of President Meritage 3-108:15 am – 8:45 am President’s Address Meritage 3-108:45 am – 8:55 am Introduction of New Members Meritage 3-10

9:00 am - 10:30 am Scientific Session 1 Meritage 3-10 Moderated by: Andre Campbell

10:30 am – 11:00 am Morning Break with Industry Support Meritage 1, 2 & Foyer

Care Fragmentation and Readmission Outcomes Following Emergency Abdominal SurgeryPresenter: Yen-Yi Juo | Discussant: Joseph Galante | Closer: Peyman Benharash

Mortality in Emergency General Surgery is Frequently TransferredPresenter: Margaret Lauerman | Discussant: David Zonies | Closer: Jose Diaz

Between-Surgeon Variation in Emergency General Surgery: Does It Matter Who Is On Call?Presenter: Rhea Udyavar | Discussant: Steven Stain | Closer: Ali Salim

Industrial Payments by Surgical Device Companies and Conflict of InterestPresenter: Kasra Ziai | Discussant: Samer Mattar | Closer: Brian Smith


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SATURDAY, FEBRUARY 1711:00 am – 12:30 pm Scientific Session 2 Meritage 3-10 Moderated by: Rochelle Dicker

12:35 pm – 1:40 pm Boxed Lunch Mini-Podium Sessions Carneros AB

Resident Prize Finalist – Southern California CaucusDo Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Administered After Pancreatectomy Increase the Risk of a Postoperative Pancreas Fistula or Other Complication?Presenter: Azure Adkins | Discussant: Richard Bold | Closer: L. Andrew DiFronzo

Resident Prize Finalist – Oregon/Hawaii CaucusWho Undergoes Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy (CRS/PIC) for Appendiceal Cancer?: An Analysis of the National Cancer Database (NCDB)Presenter: Raphael Byrne | Discussant: Emily Finlayson | Closer: Vassiliki Tsikitis

Resident Prize Finalist – Northern California CaucusPre Injury Use of Selective Serotonin Receptor Inhibitors are Predictive of Opioid Use 90 Days after Discharge in Trauma PatientsPresenter: Brie Nardy | Discussant: Karen Brasel | Closer: Joseph Galante

Resident Prize Finalist – Washington/Alaska/British Columbia CaucusFifty Pheos: A Multidisciplinary Algorithm for the Perioperative Management of PheochromocytomaPresenter: Todd Robinson | Discussant: Wen Shen | Closer: Thomas Biehl

SESSION AModerated by: Elizabeth Benjamin and Shin Hirose

A1: Management of a Giant Omphalocele with a Narrow Neck Presenter: Candace Haddock

A2: A Negative CT Abdomen/Pelvis Is Sufficient to Safely Discharge Patients with Abdominal Seatbelt Signs from the Emergency Department Presenter: Deven Patel

A3: Pulmonary Sequestration Requiring Prenatal and Postnatal Intervention Presenter: Laura Galganski

A4: Risk of Gastroschisis is Higher in Rural Counties in California: A Population-Based Study from 1995-2012 Presenter: Jamie Anderson


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SATURDAY, FEBRUARY 1712:35 pm – 1:40 pm Boxed Lunch Mini-Podium Sessions Carneros AB

SESSION AModerated by: Elizabeth Benjamin and Shin Hirose

A5: Surgical Management of Omphalocele: Old and New Approaches Presenter: Hunter Oliver-Allen

A6: The Gap Still Exists: Racial Disparities in Outcomes and Costs after Appendectomy Within and Across Hospitals Presenter: Cynthia Tom

A7: Implementation of a Clinical Practice Guideline for Post-Operative Management of Appendicitis Improves Outcomes for Children Presenter: Melissa Vanover

A8: Heparin-Induced Thrombocytopenia (HIT) in Trauma: Association with Bacterial Infection Presenter: Areg Grigorian A9: IBD Serological Immune Markers ASCA and OmpC are Potential Biomarkers for Hirschsprung-Associated Enterocolitis Presenter: Philip Frykman

A10: Impact of Insurance Status on Discharge Disposition in Patients with Mental Illness Presenter: Rebecca Plevin

A11: High Cost of Pediatric Falls from Buildings Presenter: Melissa Vanover

A12: Predictors of Post-operative Length of Stay after Ventral Hernia Repair: An ACS-NSQIP Analysis Presenter: Sandhya Kumar

A13: Early Cholecystectomy is Associated with Decreased Length of Stay and Improved Outcomes in Patients with Mild Gallstone Pancreatitis: An Analysis of the ACS-NSQIP Database Presenter: Emily Dubina


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SATURDAY, FEBRUARY 1712:35 pm – 1:40 pm Boxed Lunch Mini-Podium Sessions Carneros F-H


SESSION BModerated by: Michael Campbell and Beverley Petrie

B1: Laparoscopic versus Open Total Gastrectomy for Gastric Adenocarcinoma: Short- and Long-Term Survival Presenter: Colette Inaba B2: Factors Associated with Readmission after Parathyroidectomy for Renal Hyperparathyroidism Presenter: Eric Kuo

B3: Should Tumor Sidedness Influence Surgical Decision Making in Metastatic Colon Cancer? Presenter: Trang Nguyen

B4: Gene Directed Surgery for Hereditary Diffuse Gastric Cancer: Effect on Survival Presenter: Joseph Forrester

B5: Initial Experience with Telemedicine in an Academic Endocrine Surgery Program Presenter: Ki Wan Park

B6: Faster Discharge after Open Pancreaticoduodenectomy is Not Associated with a Higher Risk of Hospital Readmission Presenter: Jerry Jiang

B7: Patient Frailty, not Just Age, is Associated with Increased Risk of Complications after Adrenalectomy Presenter: Jamie Anderson

B8: Preoperative Neutrophil-to-Lymphocyte Ratio is a Predictor of Recurrence in Patients with Stage II Colon Cancer Presenter: Michael Esparza

B9: The Utility of Immunological Markers in Prognostication of Upfront Resectable Pancreatic Cancer. A Cohort Study from an Academic Community Hospital Presenter: Ephraim Tang


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SATURDAY, FEBRUARY 1712:35 pm – 1:40 pm Boxed Lunch Mini-Podium Sessions Carneros F-H

SESSION BModerated by: Michael Campbell and Beverley Petrie

B11: Current Trends in Breast Surgery: Surgeons, Billing Practices, and Healthcare Disparities in Price of Surgery Presenter: Joshua Tseng

B12: Biopsy-proven Lymph Nodes Predict Presence or Absence of Residual Axillary Nodal Disease Following Neoadjuvant Chemotherapy in Node-Positive Breast Cancer Presenter: Angelena Crown

B13: Delayed Operative Intervention in Traumatic Injury Presenter: Anne Stey

SESSION C Carneros JKModerated by: Rachel Hight and Cindy Kin

C1: The National Inpatient Sample is Not Sufficiently-Powered for Hospital Quality-of-Care Evaluation Presenter: Yas Sanaiha C2: SCIP Measures Have Not Reduced the Incidence and Financial Burden of Complications Following Cardiac Operations Presenter: Yas Sanaiha

C3: Adverse Effects of Computers During Bedside Rounds in a Critical Care Unit Presenter: Navpreet Dhillon

C4: Influences of Antiviral Treatment Era and Etiology of Liver Disease on Early Graft Survival after Liver Transplantation Presenter: Nicholas Parrish

C5: Combined Posterior and Video-Assisted Transaxillary First Rib Resection: A Novel Approach Presenter: Angelena Crown

C6: Aggressive Pre-Operative Continuous Renal Replacement Therapy (CRRT) Improves Outcomes for Orthotopic Liver Transplantation (OLT) Presenter: Brian Nguyen


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SATURDAY, FEBRUARY 1712:35 pm – 1:40 pm Boxed Lunch Mini-Podium Sessions Carneros JK


SESSION CModerated by: Rachel Hight and Cindy Kin

C7: Does Size Matter? An Analysis of the National Cancer Database (NCDB) to Assess Predictive Factors Associated with Conversion from Minimally Invasive to Open Thymectomy Presenter: Douglas Liou

C8: Delayed Video-Based Assessment Provides Similar Results to Immediate Operative Performance Ratings Presenter: Barnard Palmer C9: Robotic Stellate Ganglionectomy and Sympathectomy for Refractory Tachyarrhythmias Presenter: Jane Yanagawa

C10: Under-Treated Medical Conditions, Not Trauma, are Primary Indications for Limb Amputation at a Referral Hospital in Cameroon Presenter: Nikola Teslovich

C11: Simulation Curriculum Increases Learners’ Confidence and Interest in Cardiothoracic Surgery Presenter: Rebekah Macfie

C12: Disparities in Peptic Ulcer Disease: A Nationwide Study Presenter: Joaquim Havens

C13: Effective Augmentation of the Deceased Donor Pool by Utilization of Organs from Small (15 kg) Pediatric Donors with Acute Kidney Injury: Matched-Pair Analysis of 68 Pediatric en Bloc Kidney Transplants Presenter: Christoph Troppmann


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SATURDAY, FEBRUARY 171:45 pm – 3:00 pm Scientific Session 3 Meritage 3-10 Moderated by: Robin Cisco

3:00 pm – 3:30 pm Afternoon Break with Industry Support Meritage 1 & 2, Foyer3:30 pm – 5:15 pm Scientific Session 4 Meritage 3-10 Moderated by: Yuman Fong

5:15 pm – 6:15 pm Council and Industry Support Reception TBD

Surgical Treatment of Biliary Atresia: Time for a Paradigm Shift?Presenter: Sophoclis Alexopoulos | Discussant: Carlos EsquivelCloser: Sophoclis Alexopoulos

Extrahepatic Biliary Ductal Complications in Adult Liver Transplantation: An Analysis of 433 Consecutive High Acuity PatientsPresenter: Fady M Kaldas | Discussant: Johnny Hong | Closer: Ronald Busuttil

Pathologic Response to Pretransplant Locoregional Therapy is Predictive of Patient Outcome after Liver Transplantation for Hepatocellular Carcinoma: Analysis from the US Multicenter HCC Transplant ConsortiumPresenter: Joseph DiNorcia | Discussant: Susan Orloff | Closer: Vatche Agopian

Metastasectomy as First-Line Treatment in the Era of Modern Systemic Therapy for MelanomaPresenter: Daniel W. Nelson | Discussant: Jennifer Garreau | Closer: Mark Faries New Member Prize Awardee – Northern California CaucusOutcomes of Sutureless versus Sutured Gastroschisis ClosurePresenter: Russell Witt | Discussant: Philip Frykman | Closer: Lan Vu

Selective Shave Margins in Patients Undergoing Lumpectomy for Breast CancerPresenter: Nicholas Manguso | Discussant: Janie Grumley | Closer: Farin Amersi

Influence of Intraoperative Findings on Outcomes and Resource Utilization in Children with Complicated Appendicitis: Justifying the Need for SeverityAdjustment in Performance Reporting and Reimbursement PoliciesPresenter: Seema Anandalwar | Discussant: Lan Vu | Closer: Robert Sawin


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SUNDAY, FEBRUARY 186:30 am – 7:15 am Global Surgery Forum Carneros AB7:00 am – 8:00 am Continental Breakfast with Industry Support Meritage 1 & 2, Foyer7:30 am – 8:45 am Scientific Session 5 Meritage 3-10 Moderated by: Edgardo Salcedo

8:45 am – 9:15 am Morning Break with Industry Support Meritage 1 & 2, Foyer9:15 am – 9:55 am Historical Presentation Meritage 3-10

9:55 am – 12:00 pm President’s Forum and Panel Meritage 3-1012:30 pm – 5:30 pm Optional Activities6:30 pm – 7:15 pm President’s Reception Oakville Terrace & Carneros Foyer 7:15 pm – 10:00 pm President’s Dinner Carneros Ballroom


Factors Influencing Career Dissatisfaction in Pregnant General Surgery Residents: Results of a Nationwide SurveyPresenter: Erika Rangel | Discussant: Maureen Tedesco | Closer: Ali Salim

Outcomes of Laparoscopic Cholecystectomy Performed by Surgical Residents Pre- and Post-Implementation of Mandatory Fundamentals of Laparoscopic Surgery (FLS) CertificationPresenter: Emily Dubina | Discussant: Donn Spight | Closer: Dennis Kim

Surgical Rounds: Improving Efficiency and Meeting Expectations Without Compromising CarePresenter: Amanda Sammann | Discussant: Ali Salim | Closer: Mary Knudson

The Surgeon and the Emperor, Theodor Billroth and Franz Joseph: Success or Failure?Presented by PCSA Historian John Ryan, MD, FACS


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MONDAY, FEBRUARY 197:00 am – 8:00 am Breakfast Meritage 1, 2 and Foyer 7:45 am – 9:15 am Scientific Session 6 Meritage 3-10 Moderated by: Matthew Lin

9:15 am – 9:30 am Morning Break Meritage Foyer9:30 am – 11:00 am Scientific Session 7 Meritage 3-10 Moderated by: Robert Sawin

11:15 am – 12:00 pm PCSA Business Meeting (Members Only) Meritage 3-10

Bundled Strong for Surgery (S4S) Optimization Targets StronglyLinked to Surgical OutcomesPresenter: Douglas Liou | Discussant: Lorrie Langdale | Closer: Sherry Wren

Assessing the Quality and Costs of Cholecystectomies in Rural HospitalsPresenter: Erin Howell | Discussant: Benjamin Padilla | Closer: Steven Lee

The Disconnect between Surgeon-Reported Complications and CMS-Required Patient Safety Indicator ReportingPresenter: Jamie Anderson | Discussant: Melinda Maggard-GibbonsCloser: Garth Utter

Immune Thrombocytopenic Purpura Splenectomy in the Contextof New Medical TherapiesPresenter: Tarin Worrest | Discussant: Sherry Wren | Closer: Brett Sheppard

Black Race and Body Mass Index are Risk Factors for Rhabdomyolysis and Acute Kidney Injury in TraumaPresenter: Areg Grigorian | Discussant: Karen Deveney | Closer: Brian Smith

Predictors of ARDS: Lung Injury Persists in the Era of Hemostatic ResuscitationPresenter: Lucy Kornblith | Discussant: Kenji Inaba | Closer: Mitchell Cohen

Hyponatremia and Complex Biliary DiseasePresenter: Michael Zobel | Discussant: Dennis Kim | Closer: Lygia Stewart

Risk Factors for Perioperative Complications and Prolonged Length of Stay after Laparoscopic Adrenalectomy: Size and Diagnosis MatterPresenter: Yufei Chen | Discussant: Michael Yeh | Closer: Quan-Yang Duh


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Scientific SessionsPodium Papers 1-26

All Scientific Session and Mini-Podium Presentation authors and presentersare MDs unless otherwise noted.


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Scientific Sessions: Podium Papers 1-26All Scientific Session and Mini-Podium Presentation authors and presenters are MDs unless otherwise noted.

Session 1 Paper: 1

Care Fragmentation and Readmission Outcomes Following Emergency Abdominal Surgery

Authors: Yen-Yi Juo, Yas Sanaiha, Usah Khrucharoen, Areti Tillou, Erik Dutson, Peyman Benharash

Institution: University of California - Los Angeles

Presenter: Yen-Yi Juo | Discussant: Joseph Galante | Closer: Peyman Benharash

Objective: To examine whether readmission to index hospitals is associated with improved mortality following emergency abdominal surgeries (EAS) Background: Non-index readmissions have been shown to be associated with worse outcomes following complex surgeries, presumably due to fragmentation of care. However, urgent procedures like EAS are commonly performed at low volume hospitals with high failure-to-rescue rates. It is unclear whether index hospitals still represent optimal readmission destination when complications occurred following EAS.

Methods: This is a retrospective study of the 2010-2014 Nationwide Readmissions Database evaluating patients who experienced 30-day readmission following one of six EAS procedures. Propensity score-weighted regressions examined associations between readmission destination volume quartiles and mortality. Low volume centers were defined as hospitals at lowest case volume quartile.

Results: Of the 1,660,034 patients who underwent EAS, 71,584 experienced 30-day readmission, 14% of which occurred at a non-index hospital. Up to 56.3% EAS were performed in low volume centers. Surgery at low volume center (OR 1.30, 95% CI 1.14-1.48), occurrence of complications (OR 1.15, 95% CI 1.03-1.29) and discharge to destination other than home (OR 1.44, 95% CI 1.26-1.65) were all significant risk factors for non-index readmission. Non-index readmission was associated with significantly higher in-hospital mortality rates (4.1 vs 2.4%, p<.001). These associations persisted even after hospital case volume and patient characteristics have been accounted for with propensity-weighted regression analysis.

Conclusions: More than half of EAS were performed in low-volume centers. Following EAS, index readmission was associated with lower in-hospital mortality regardless of the case volume at the index facility.

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Session 1 Paper: 2

Mortality in Emergency General Surgery is Frequently Transferred

Authors: Margaret Lauerman1, Anthony Herrera1, Gordon Smith2, Jennifer Albrecht1, Hegang Chen1, Thomas Scalea1, Ronald Tesoriero1, Brandon Bruns1, Jose Diaz1

Institutions: 1R Adams Cowley Shock Trauma Center, 2West Virginia University

Presenter: Margaret Lauerman | Discussant: David Zonies | Closer: Jose Diaz

Objective: To evaluate rates of transfer of mortality in Emergency General Surgery (EGS). Background: While inter-hospital transfer rates in EGS have been investigated, rates of concurrent transfer of complications to receiving hospitals are unknown due to the difficulty of linking the first and second hospital encounters. With complications occurring after inter-hospital transfer attributed to the second hospital, this may bias pay for performance reporting or measurement of hospital quality if hospitals frequently transfer away complications. Mortality was chosen as a representative complication.

Methods: State hospital data from 2013-2015 was analyzed. Encounters were divided into transfers (TF) and non-transfers (NT). TF were identified from the second hospital to allow measurement of complications after transfer and linked to the first hospital. Transferred mortality represented the percentage of total mortality initially presenting to individual institutions which was subsequently transferred (TF mortalities divided by the sum of NT mortalities and TF mortalities)

Results: Overall there were 370,242 EGS admissions and 17,003 in-hospital deaths. TF encounters encompassed 1,399 deaths (8.2%). Transferred mortality varied widely by hospital (0.8%-35.2%), and was inversely correlated with annual EGS volume for all hospitals (p<0.001, rs-0.52) and high volume hospitals (p=0.004, rs-0.69), but not low volume hospitals (p=0.25, rs-0.32).

Conclusions: Transfer of complications in EGS was a previous undescribed phenomenon. Hospitals transfer a substantial amount of mortality overall, and individual institutions transfer away a broad range of the total mortality initially presenting to their institution. Complications transferred from hospitals in EGS may significantly alter pay-per- performance metrics and measurements of hospital quality.

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Session 1 Paper: 3

Between-Surgeon Variation in Emergency General Surgery: Does It Matter Who Is On Call?

Authors: Rhea Udyavar1, Ali Salim1, Edward E. Cornwell2, Zain G. Hashmi1, Joaquim M. Havens1, John W. Scott1, Daniel Sturgeon1, Pablo Tarsicio Uribe Leitz1, Adil H. Haider1

Institutions: 1Brigham & Women’s Hospital, 2Howard University Hospital

Presenter: Rhea Udyavar | Discussant: Steven Stain | Closer: Ali Salim

Background: Hospital-level variation has been shown to influence outcomes in Emergency General Surgery (EGS). However, whether the individual surgeon plays a role in this variation is unknown. Our objective was to characterize the extent to which outcomes in EGS vary between surgeons across one large state in the U.S.

Methods: Analysis of the Florida State Inpatient Database (SID) (2010-2014), including patients who emergently underwent 1 or more of 7 procedures (laparotomy, adhesiolysis, small bowel resection, colectomy, repair of a perforated gastric ulcer, appendectomy, or cholecystectomy). We used multi-level random effects modeling to quantify the amount of variation in outcomes (mortality, complications, and readmissions) attributable to surgeons. Patient clinical and demographic factors, as well as hospital-level factors, were introduced into the model in a stepwise fashion and the percent of the variation attribut-able to surgeons was derived.

Results: Our study included 1,736 surgeons across 205 hospitals, with a total of 291,497 EGS cases. The overall unadjusted mortality rate was 3.8%, while the complication and readmission rates were 12.7% and 27.7%, respectively. Surgeon-level variation had the greatest impact on mortality. Peptic ulcer disease operations were most susceptible to surgeon-level variation, while appendectomies appeared to be least susceptible to surgeon-level variation.

Conclusion: Surgeon-level variation contributes to a significant portion of mortality in EGS. This variation is most pronounced in surgery for peptic ulcer disease, a high-risk, low-frequency surgical condition. Programs to reduce mortality in EGS should address reducing variability in practice with attention to high-risk, low-frequency procedures.


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Session 1 Paper: 4

Industrial Payments by Surgical Device Companies and Conflict of Interest

Authors: Kasra Ziai, Alessio Pigazzi, Roxana Nouri, Helene Nepomuceno, Joseph Christopher Carmichael, Steven D. Mills, Michael J. Stamos, Mehraneh D. Jafari

Institution: University of California - Irvine

Presenter: Kasra Ziai | Discussant: Samer Mattar | Closer: Brian Smith

Objective: To characterize the association between industrial payments by surgical device companies, self-declared COI, and relevancy of publications amongst the highest paid physicians. Background: Surgical device companies’ association with physicians can increase the potential risk of bias and conflict of interest (COI) in studies.

Methods: The 10 large surgical device companies and the 10 highest paid physicians by each company were identified using the 2015 Open Payment Database (OPD) general payments data. We searched PubMed to specify articles published by each physician in 2016 and their associated COI declaration. Scopus was used to identify bibliometric data. Royalty and license payments were excluded.

Results: A total of $12,446,969 were paid to the 100 top physicians, with median payment of $95,993.07. Of the 100 physicians, 62% were faculty at academic institutions. The mean h-index was 18±18 (range, 0-75) for the authors. A total of 7,362 articles were published by these 100 physicians with a mean of 73±95 (range, 0-431), and median of 37. In 2016, 412 articles were published by these practitioners with a mean of 4±5.54 (range, 0-25) and median of 1. Fifty-four-percent of the 2016 articles were relevant to the general payments received by the authors. However, only 29% of the authors declared the COI in the publication.

Conclusions: We found that high inconsistency exists between self-declared COI and OPD amongst the highest paid physicians by surgical device companies. Such inconsistencies need to be addressed to decrease the risk of potential bias in studies.


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Session 2 Paper: 5

Southern California Caucus Resident Prize Finalist

Do Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Administered After Pancreatectomy Increase the Risk of a Postoperative Pancreas Fistula or Other Complication?

Authors: Azure Adkins, Andrew DiFronzo, Jennifer Lee, Stefanie Sueda

Institution: Kaiser Permanente - Los Angeles

Presenter: Azure Adkins | Discussant: Richard Bold | Closer: L. Andrew DiFronzo

Objective: Compare the rate of POPF and other complications in patients who did and did not receive NSAIDs after pancreatectomy.

Background: NSAIDs have been associated with increased leak rates following colorectal surgery. It is unclear if NSAIDs used following pancreatectomy increase the risk of POPF. Additionally, no prior study has examined the effect of NSAIDs on overall postoperative complications after pancreatectomy. Methods: Retrospective study of patients who had pancreatectomy between 2005-2015, with and without administration of NSAIDs. Primary outcome measures were overall morbidity and development of POPF.

Results: 454 patients underwent pancreatectomy; 159 (35%) received NSAIDs postopera-tively. The most common NSAID was ketorolac. Demographics were similar between the two groups and malignancy was the most common indication for surgery. In 90 patients (20%) there was a documented POPF within 30 days of surgery. POPF occurred in 23% who had received an NSAID, compared to 18% in the non-NSAID group (p=0.27). The rate of POPF was similar in patients having distal pancreatectomy and pancreato-duodenectomy, regardless of NSAID use. Overall morbidity was significantly increased in patients who received an NSAID (73% vs 54%, p<0.0001). Patients who received NSAIDs had higher rates of pneumonia (p=0.01), delayed gastric emptying (p=0.0008), and intra-abdominal abscess (p=0.0092).

Conclusion: This is the largest reported study of POPF rates, complications, and NSAID use in pancreatic surgery. POPF is not increased by the use of NSAIDs following pancre-atectomy. However, overall morbidity does appear to be adversely affected by NSAID use.

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Session 2 Paper: 6

Washington/Alaska/British Columbia Caucus Resident Prize Finalist

Fifty Pheos: A Multidisciplinary Algorithm for the Perioperative Management of Pheochromocytoma

Authors: Todd J. Robinson1, Liv K. Harmon2, Adnan Alseidi1, James Helman1, Thomas Biehl1

Institutions: 1Virginia Mason Medical Center, 2Kaiser Permanente - Seattle

Presenter: Todd Robinson | Discussant: Wen Shen | Closer: Thomas Biehl

Objective: To compare the use of long acting vs. short acting alpha blockade in the perioperative management of pheochromocytoma.

Background: Pheochromocytoma is a catecholamine-secreting tumor primarily managed with surgical resection in appropriately selected patients. Preoperative treatment with alpha blockade and volume repletion, and, if needed beta blockade, minimizes intra- and peri-operative hemodynamic derangements. Previously, phenoxybenzamine, a long-acting non-selective alpha blocker has been used, but many institutions now favor short-acting selective alpha blockers such as prazosin.

Methods: We performed a retrospective chart review of patients who underwent pheochromocytoma resection from 2000 to present day. Patients were identified using CPT codes for adrenalectomy and diagnosis of pheochromocytoma in our pathology database. We compared phenoxybenzamine vs. prazosin and the difference in vasopressor require-ment, length of ICU stay, and length of hospital stay. Results We identified 53 patients who underwent pheochromocytoma resection. Twenty-six were pretreated with long-acting alpha blockers and 22 were treated with prazosin. Five patients were not treated preopera-tively as they had non-functioning tumors that were found to be pheochromocytoma on pathology. Patients receiving prazosin had decreased requirement for vasopressor support (27% vs 38%) and spent less time in the ICU (1.05 vs 1.38 days). Total length of stay was 3.69 vs 3.64 days in the long and short acting groups, respectively. We reviewed the evolution of our management algorithm.

Conclusion: Prazosin is a safe and effective alternative to phenoxybenzamine in the setting of multidisciplinary approach to perioperative management of patients with pheochromocytoma, and minimizes vasopressor use and ICU length of stay.


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Session 2 Paper: 7

Oregon/Hawaii Caucus Resident Prize Finalist

Who Undergoes Cytoreductive Surgery and Perioperative Intraperitoneal Chemotherapy (CRS/PIC) for Appendiceal Cancer?: An Analysis of the National Cancer Database (NCDB)

Authors: Raphael M. Byrne, Elizabeth N. Dewey, Erin W. Gilbert, Kevin G. Billingsley, Daniel O. Herzig, Kim C. Lu, Karen E. Deveney, Vassiliki L. Tsikitis

Institution: Oregon Health and Science University

Presenter: Raphael Byrne | Discussant: Emily Finlayson | Closer: Vassiliki Tsikitis

Objective: The aim of our study is to identify patterns of care for patients with appendi-ceal cancer and identify clinical factors associated with patient selection for multimodality treatment including cytoreductive surgery and perioperative intraperitoneal chemother-apy (CRS/PIC). Background: CRS/PIC is emerging as a beneficial treatment option for appendiceal neoplasms with peritoneal metastasis.

Methods: National Cancer Database (NCDB) data from 2004-2014 of all diagnoses of appendiceal cancers were examined. We examined treatment modalities as well as demographic, tumor-specific, and survival data. A multivariate logistic regression analysis was performed to determine the patient cohort most likely to receive CRS/PIC. Kaplan-Meier was used to estimate survival for all treatment groups. Significance was evaluated at p≤0.05.

Results: We analyzed data on 18,321 patients. 5,860 (32.0%) received surgery and systemic chemotherapy, 1,397 (7.6%) CRS/PIC, and 11,064 (60.3%) only chemotherapy, only surgery, or neither. Significant predictors of receiving CRS/PIC included male sex (OR 1.4, CI:1.1-1.8), white race (OR 1.8, CI:1.2-2.8), non-Hispanic ethnicity (OR: 2.2, CI: 1.1-4.0), private insurance (OR 1.3, CI: 1.0-1.7), and well-differentiated tumors (OR 4.2, CI: 3.1-5.7) (p≤0.05). Lower Charlson-Deyo comorbidity score (OR: 0.8, CI: 0.6-1.0, p=.09) had a suggestive association. The CRS/PIC group had improved 5-year survival for mucinous (65.5% vs. 47.3%) and well-differentiated tumors (74.9% vs. 65.5%) when compared to other treatment modalities (p<0.01).

Conclusions: Patients were more likely to undergo CRS/PIC if they were male, white, privately insured, and with well-differentiated tumors. CRS/PIC was associated with improved survival in patients with mucinous and low-grade tumors.

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Session 2 Paper: 8

Northern California Caucus Resident Prize Finalist

Pre Injury Use of Selective Serotonin Receptor Inhibitors are Predictive of Opioid Use 90 Days after Discharge in Trauma Patients

Authors: Brie Nardy, Jamie Anderson, Christine S. Cocanour, Wendy Ziegler, Joseph M. Galante

Institution: University of California – Davis

Presenter: Brie Nardy | Discussant: Karen Brasel | Closer: Joseph Galante

Objective: To determine risk factors associated with long-term opioid use in trauma patients.

Background: More deaths are related to opioids in the U.S. than motor vehicle collisions and gun violence. Trauma patients may be at particular risk of opioid dependence, however this population often lacks long-term follow-up.

Methods: This is a retrospective cohort study of capitated patients ≥18 years, admitted to a Level 1 trauma center and transferred to their managed care hospital from 2009-2014. Long-term opioid use is defined as use ≥ 0 days post-discharge based on prescription refill date. Multivariable logistic regression evaluated the impact of age; sex; zip code-based median household income; mechanism of injury; operative status; and history of drug, opioid, selective serotonin receptor inhibitor (SSRI) and benzodiazepine use on opioid use 90 days after discharge.

Results: 331 patients were included in the study and 184 (55.6%) were on opioids at 90 days. Median age was 51 years (range 18-95). The predominant mechanism was blunt (89.4%). Nearly half of patients (43.2%) underwent an operation. There was no difference in 90-day opioid use among patients who were on opioids vs. opioid-naïve patients (50.9% vs 56.5%, p=0.444). On multivariable analysis, only pre-admission SSRI use was predictive of narcotic use longer than 90 days after discharge (OR 2.53, p=0.02).

Conclusions: A majority of trauma patients remain on opioids at 90 days. Use of SSRIs and presumably pre-injury depression predispose trauma patients to long-term use of opioids. Recognition of this risk factor may allow surgeons to alter prescribing practices.


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Session 3 Paper: 9

Surgical Treatment of Biliary Atresia: Time for a Paradigm Shift?

Authors: Elyse M. LeeVan1,2, Shu Cao2, Lea Matsuoka2, Sophoclis P. Alexopoulos3

Institutions: 1Huntington Hospital, 2University of Southern California, 3Vanderbilt University

Presenter: Sophoclis Alexopoulos | Discussant: Carlos Esquivel Closer: Sophoclis Alexopoulos

Objective: To compare the survival of patients with biliary atresia (BA) who underwent portoenterostomy/biliary drainage (BD) followed by liver transplant (LT) vs primary LT.

Background: BA is a progressive perinatal disease of the biliary ducts that is fatal unless treated surgically with BD or LT. Most infants are initially treated with BD, but require subsequent LT. However, some infants diagnosed with BA proceed straight to LT.

Methods: Data was obtained from the California Office of Statewide Planning and Development for patients with biliary atresia between 1990-2015. Patients were divided into 3 groups based on management: biliary drainage alone (BD), BD followed by LT (BD+LT), or primary liver transplant (PLT). Analysis included Kruskal-Wallis test or Chi-square test in comparisons between groups, Kaplan-Meier plots and Cox proportional hazards regression in survival analysis.

Results: 626 of 1261 patients had adequate data for analysis: 166 BD, 147 BD+LT, and 313 PLT. Patients undergoing PLT had reduced risk of mortality compared to patients first managed with BD (HR 0.54, p = 0.014) (Figure-1a). Failure of BD requiring subsequent LT (BD+LT) conferred an increased risk of mortality compared to PLT (HR 2.18, p = 0.006) (Figure-1b). The effect of treatment era (pre versus post 2002) on patient survival differed based on procedure, improving for patients undergoing PLT (HR 0.19, p = 0.003).

Conclusions: Although BD remains the gold standard in treatment of newly diagnosed BA, improvement in outcomes for pediatric LT have resulted in superior patient survival when LT is used as the primary treatment modality.


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Session 3 Paper: 10

Extrahepatic Biliary Ductal Complications in Adult Liver Transplantation: An Analysis of 433 Consecutive High Acuity Patients

Authors: Fady M. Kaldas, Islam M. Korayem, Tara Russell, Vatche G. Agopian, Joseph Dinorcia, Douglas G. Farmer, Hasan Yersiz, Ronald W. Busuttil


Presenter: Fady M Kaldas | Discussant: Johnny Hong | Closer: Ronald Busuttil

Objective: To evaluate the rate, predictors, and outcome of extrahepatic biliary ductal complications (EBC) in a maximal acuity liver transplant (LT) patient population. Background: Extrahepatic biliary complications (EBC) comprise the highest percentage of technical complications in LT. Given the ever increasing acuity of LT recipients, identification of factors contributing to EBC is essential to minimize morbidity and optimize outcomes. A detailed analysis in a high acuity patient population is lacking.

Methods: Multivariate logistic regression was used to identify preoperative recipient, donor, and intraoperative factors associated with developing EBC. (Retrospective review, 433 consecutive adult LTs, median MELD 37, 2013-2015, single academic center)

Results: Median follow-up was 25 months. Overall patient and graft survival at 1 year was 91.7%, and 91% respectively. Overall incidence of EBC was 26.8%. T-tubes were used in 176 OLT’s. Anastomotic leak and stricture rates were 4.4% and 15.5% respectively. T-tube exit site leak was 8.1%, T-tube obstruction was 3.2%. 25 patients required surgical bile duct revision. Significant risk factors for EBC included donor anoxia, donor hyper-tension, recipient hepatocellular carcinoma, liver re-transplantation, suture type, and hepatic arterial thrombosis and stenosis.

Conclusions: We report the largest single center analysis outlining physiologically and anatomically significant variables contributing to EBC following LT in a high acuity patient population. Careful consideration of these factors could guide perioperative management and mitigate potentially preventable EBC. This is of particular relevance given the rising level of OLT patient acuity nationally.


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Session 3 Paper: 11

Pathologic Response to Pretransplant Locoregional Therapy is Predictive of Patient Outcome after Liver Transplantation for Hepatocellular Carcinoma: Analysis from the US Multicenter HCC Transplant Consortium

Authors: Joseph DiNorcia1, Sander S. Florman2, Brandy Haydel2, Richard M. Ruiz3, Goran B. Klintmalm3, Srinath Senguttuvan4, David D. Lee5, C. Taner Burcin5, Elizabeth C. Verna6, Karim J. Halazun7, Maarouf Hoteit8, Matthew H. Levine8, William C. Chapman9, Neeta Vachharajani9, Federico Aucejo10, Mindie H. Nguyen11, Marc L. Melcher11, Amit D. Tevar12, Abhinav Humar12, Constance Mobley13, Mark Ghobrial13, Trevor Nydam14, Beth Amundsen15, James F. Markmann15, Jennifer Berumen16, Alan Hemming16, Alan N. Langnas17, Carol A. Carney17, Debra L. Sudan18, Johnny C. Hong19, Joohyun Kim19, Michael A. Zimmerman19, Abbas Rana3, Michael L. Khuet3, Christopher M. Jones20, Thomas M. Fishbein21, Ronald W. Busuttil1, Vatche G. Agopian1

Institutions: 1University of California - Los Angeles, 2Mount Sinai, 3Baylor University, 4Texas A&M University, 5Mayo Clinic – Jacksonville, 6Columbia University, 7Cornell University, 8University of Pennsylvania, 9Washington University, 10Cleveland Clinic, 11Stanford University, 12University of Pittsburgh, 13Houston Methodist, 14University of Colorado – Aurora, 15Harvard University, 16University of California - San Diego, 1

7University of Nebraska, 18Duke University, 19Medical College of Wisconsin,

0University of Louisville, 21Georgetown University

Presenter: Joseph DiNorcia | Discussant: Susan Orloff | Closer: Vatche Agopian

Objective: To evaluate the rate, predictors and impact of complete pathologic response (cPR) to pretransplant locoregional therapy (LRT) in a large, multicenter cohort of hepatocellular carcinoma (HCC) patients undergoing liver transplantation (LT).

Background: LRT is used to mitigate waitlist dropout for patients with HCC awaiting LT. Degree of tumor necrosis found on explant has been associated with recurrence and overall survival.


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Session 3 Paper: 11 (continued)

Methods: Comparisons were made among patients with (n=817) and without (n=2638) cPR, and multivariable predictors of cPR were identified (2002-2013) using logistic regression.

Results: Of 3455 patients, 2752 and 691 were within and beyond Milan criteria, respect-ively; and 817 (23.6%) had cPR on explant. Compared to patients without cPR, cPR patients were younger; had lower MELD scores, neutrophil-lymphocyte ratios (NLR), alpha-fetoprotein (AFP) levels; were more likely to have tumors within Milan criteria and fewer LRT treatments; and had significantly lower 1-, 3-, and 5-year incidence of post-LT recurrence (1.6%, 4.0%, and 5.8% vs. 6.2%, 13.5%, and 16.4%; p<0.001) and superior recurrence-free (91%, 82%, and 72% vs. 87%, 73%, and 64%; p<0.0001) and overall (92%, 84%, and 75% vs. 91%, 78%, and 68%; p=0.0002) survival (Figure). Multivariable predictors of cPR included age, gender, diagnosis, lab MELD, NLR, AFP, radiologic size, and LRT number (Table).

Conclusions: In a large US multicenter study of LT recipients with HCC who had pre-transplant LRT, achieving cPR portends significantly lower posttransplant recurrence and superior survival. Factors predicting cPR are identified, which may help prioritize patients and guide LRT strategies to optimize posttransplant cancer outcomes.

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Session 4 Paper: 12

Metastasectomy as First-Line Treatment in the Era of Modern Systemic Therapy for Melanoma

Authors: Daniel W. Nelson1, Trevan D. Fischer1, Amanda N. Graff-Baker1, Ahmed Dehal1, Stacey Stern1, Anton J. Bilchik1, Mark B. Faries2

Institutions: 1John Wayne Cancer Institute, 2The Angeles Clinic and Research Institute

Presenter: Daniel W. Nelson | Discussant: Jennifer Garreau | Closer: Mark Faries

Objective: To determine the impact of effective medical therapies on metastasectomy in stage IV melanoma.

Background: Resection historically played a prominent role in the treatment of metastatic melanoma, in part due to ineffective medical options. Recent, rapid improvement in systemic treatment has led some to question the role of surgery as first-line therapy.

Methods: Patients with stage IV melanoma in a prospectively-maintained database were stratified by treatment era (1965-2002 or 2003-2015). Metastasectomy-associated factors were examined. Survival analysis compared modern immune/molecularly targeted therapies alone versus surgery followed by these therapies.

Results: Among 2,357 eligible patients, 1,065 (45.2%) underwent surgical treatment. Over the entire period, surgically treated patients had a more than 2-fold longer median melanoma-specific survival (27 vs. 11 months; p<0.0001). Prior to the introduction of modern immune and targeted therapies, metastasectomy was more frequent among patients who were female, had no history of stage III disease, had only 1 organ involved or had M1a (vs. M1c) disease (all p<0.01) In the current era, only age and no stage III history were independent metastasectomy factors (both p<0.01). On match-paired analysis surgery followed by adjuvant systemic therapy was associated with higher 5-year melanoma-specific survival versus systemic therapy alone (58.8% vs 38.9%; p=0.049). Multivariable regression showed, single organ involvement (HR 0.43; CI 0.21-0.90; p=0.02) and first-line surgery (HR 0.47; CI 0.23-0.98; p=0.04) as independently associated with improved melanoma-specific survival.

Conclusions: Patients treated with modern melanoma drugs demonstrated longer survival with initial surgical resection. Prospective evaluation of metastasectomy with adjuvant systemic therapy is warranted.

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Session 4 Paper: 13

New Member Prize Winning Abstract – Northern California Caucus

Outcomes of Sutureless versus Sutured Gastroschisis Closure

Authors: Russell G. Witt, Michael Zobel, Benjamin Padilla, Hanmin Lee, Tippi MacKenzie, Lan Vu

Institution: University of California - San Francisco

Presenter: Russell Witt | Discussant: Philip Frykman | Closer: Lan Vu

Objective: To evaluate clinical outcomes of sutureless gastroschisis repair compared to sutured repair.

Background: Sutureless gastroschisis repair offers an alternative to the traditional sutured method and has been previously shown to decrease intubation time however data is conflicted regarding the effect on time to full enteral feeds and length of stay.

Methods: Single center retrospective chart review was performed of all consecutive patients undergoing gastroschisis repair from February 1st, 2007 until April 30th, 2017. Patient clinical characteristics and outcomes were evaluated including length of stay, time to full feeds, TPN duration, days requiring morphine, days intubated, wound infection rates, antibiotic treatment duration, rate of umbilical hernias that required operative correction and readmission rates.

Results: 97 patients underwent gastroschisis repair during the study time frame. 7 patients were excluded for incomplete charts. There was no statistical difference in length of stay (p=.71), TPN duration (p=.23), time to full enteral feeds (p=.22) and read-mission (p=.36). The sutureless group had a significant decrease in days on antibiotics (sutureless 7.2 vs sutured 12.4, p=.0032), days on morphine (4.2 vs 7.1, p=.0003), and days intubated (2.8 vs 6.8, p=.0001) as well as a significantly greater rate of umbilical hernias requiring surgical repair (5 vs 0, p=.015).

Conclusions: Sutureless repair of gastroschisis is safe and can significantly decrease the amount of time intubated, pain medication requirements and overall days on anti-biotics while increasing the risk of umbilical hernias. The difference may reflect changing management practices in the care of gastroschisis as sutureless repair is increasingly performed.

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Session 4 Paper: 14

Selective Shave Margins in Patients Undergoing Lumpectomy for Breast Cancer

Authors: Nicholas Manguso, Cory Donovan, Alice Chung, Halley Vora, Attiya Harit, James Mirocha, Armando E. Giuliano, Farin Amersi

Institution: Cedars-Sinai Medical Center

Presenter: Nicholas Manguso | Discussant: Janie Grumley | Closer: Farin Amersi

Objective: To determine the impact of selective shave margins (SSM) on lumpectomy outcomes in patients with invasive breast cancer.

Background: The technique of excising the entire lumpectomy cavity, to obtain tumor free margins, has been the standard operating technique. Although this reduces re-excision rates, larger cosmetic defects occur. SSM, where smaller selected portions of the cavity are excised, should decrease re-excision rates without affecting oncologic outcomes.

Methods: Patients undergoing lumpectomy for infiltrating ductal (IDC) or lobular (ILC) breast cancer between 2006-2014 were identified. Survival and oncologic outcomes were compared between patients undergoing SSM and conventional lumpectomy (CL).

Results: 1129 patients with a mean age of 63.9 years and mean tumor size of 1.9 cm were identified. 1002 patients (88.8%) had IDC; 127 (11.2%) had ILC. 399 (35.3%) underwent SSM; 730 (64.7%) had CL. 290 (25.7%) required re-excision (28.8% IDC vs 36.2% ILC, p<0.01). SSM patients had lower re-excision rates (24.3% vs 36.2%, p=0.04) and fewer SSM re-excisions had residual cancer (12.6% vs 34.5%, p<0.01). CL patients had more mastectomies (9.7% vs 5.5%, p=0.02). At median follow-up of 33 months there was no significant difference in patients undergoing SSM and CL in 3-year disease-free (DFS) (p=0.89) or overall survival (OS) (p=0.29). In IDC and ILC individually, there was no significant difference between SSM and CL in DFS (IDC p=0.94; ILC p=0.56) or OS (IDC p=0.31; ILC p=0.71).

Conclusion: Patients undergoing SSM, regardless of histology, have lower re-excision and mastectomy rates with comparable DFS and OS at 3-years to those undergoing CL.

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Session 4 Paper: 15

Influence of Intraoperative Findings on Outcomes and Resource Utilization in Children with Complicated Appendicitis: Justifying the Need for Severity Adjustment in Performance Reporting and Reimbursement Policies

Authors: Seema Anandalwar1, Danielle Cameron1, Dionne Graham1, Patrice Melvin1, Jona-than Dunlap1, Mark Kashtan1, Brian Kenney2, Jacqueline Saito3, Douglas Barnhart4, Shawn Rangel1

Institutions: 1Boston Children’s Hospital, 2Nationwide Children’s, 3St. Louis Children’s Hospital, 4Primary Children’s Hospital

Presenter: Seema Anandalwar | Discussant: Lan Vu | Closer: Robert Sawin

Objective: To examine the influence of intraoperative findings on outcomes and resource utilization in children with complicated appendicitis.

Background: Complicated appendicitis in children represents a continuum of severity, although disease severity is not currently considered in comparative performance reporting and reimbursement policies.

Methods: Retrospective study of 1333 children with complicated appendicitis from 22 hospitals (1/2012-12/2014). Clinical outcomes were obtained from the NSQIP-Pediatric Appendectomy Pilot database and merged with resource utilization data from the Pediatric Health Information System database. NSQIP-Pediatric categorizes appendicitis as complicated if any of the following are present in the operative report: visible hole [H], fibropurulent exudate >2 quadrants [E], abscess [A], or extraluminal fecalith [F]. Multi-variable mixed effects regression was used to predict event rates and outcomes for complications, revisits, LOS, and cost, for all combinations of intraoperative findings (e.g. HA =hole+abscess), adjusting for patient characteristics and clustering.

Results: Multiple findings were present in 44% of cases and associated with higher complication rates (RR:1.66[95%CI1.17-2.36]), revisit rates (RR:1.60[1.15-2.21]), LOS (RR:1.45[1.36-1.55]), and cost (RR:1.35[1.19-1.53]) compared to single findings. Significant differences were also found among combinations of findings for all outcomes, includ-ing a 4.2-fold difference in complication rates (9.6%[E] -40.2%[HEAF],p<0.001,figure), 2.6-fold difference in revisit rates (8.9%[E]-22.9%[HEAF],p=0.001), 2.2-fold difference in LOS (4.0 days[E]-8.9 days[HEAF],p<0.001), and 2.4-fold difference in cost ($13,296[E]-$32,282[HEAF],p<0.001).

Conclusions: More severe presentations of complicated appendicitis are associated with worse outcomes and greater resource utilization. Severity adjustment is needed for fair comparative performance reporting and reimbursement policies, particularly at hospitals treating underserved populations where more severe presentations are common.

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Session 5 Paper: 16

Factors Influencing Career Dissatisfaction in Pregnant General Surgery Residents: Results of a Nationwide Survey

Authors: Erika L. Rangel, Adil H. Haider, Manuel Castillo-Angeles, Gerard M. Doherty, Douglas S. Smink

Institution: Brigham and Women’s Hospital

Presenter: Erika Rangel | Discussant: Maureen Tedesco | Closer: Ali Salim

Objective: To determine factors associated with career dissatisfaction for childbearing residents.

Background: Previous work shows that pregnant surgical residents face unique challenges and many consider leaving residency due to difficulties balancing childbearing with training. Little is known about factors that influence career dissatisfaction in this cohort.

Methods: We performed a national survey of surgeons who delivered ≥1 child during a general surgery residency. Three outcome measures were studied as surrogates for career dissatisfaction:1)considering leaving residency due to challenges surrounding child-bearing;2) if given opportunity to choose again, would prefer a non-surgical career more accommodating of motherhood;3)would advise a female medical student against a surgical career due to difficulties balancing motherhood with the profession. Logistic regression was used to determine the predictors of an affirmative response for each of the three outcomes.

Results: 347 women reported 452 pregnancies. Lack of a formal maternity leave policy was associated with a desire to leave residency. Perceptions of negative stigma during pregnancy were associated with counseling medical students against the profession. Changing subspecialty or fellowship plans due to perceived difficulty balancing mother-hood with the originally chosen subspecialty was associated with all three markers of career dissatisfaction (Table).

Conclusions: Surgery residents who perceived negative stigma during pregnancy, did not have a formal institutional maternity leave policy, or altered their career trajectory due to challenges of childbearing expressed greater career dissatisfaction. Further insight into the complex factors contributing to subspecialty selection, workplace bias, and obstacles to establishment of maternity leave policies are needed to enhance professional fulfillment for childbearing residents.


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Session 5 Paper: 17

Outcomes of Laparoscopic Cholecystectomy Performed by Surgical Residents Pre- and Post-Implementation of Mandatory Fundamentals of Laparoscopic Surgery (FLS) Certification

Author: Emily D. Dubina, Xuan-Binh D. Pham, Hoover Wu, Imani McElroy, Alexander C. Schwed, Jessica A. Keeley, Amy H. Kaji, Dennis Y. Kim, Christian De Virgilio

Institution: Harbor - UCLA Medical Center

Presenter: Emily Dubina | Discussant: Donn Spight | Closer: Dennis Kim

Objective: To examine the effect of FLS certification on residents’ operative performance.

Background: Since 2009 FLS has become a requirement for completion of general surgery residency. Content validity, cost, and impact on surgical outcomes are a few of the issues surrounding mandatory FLS certification. At our institution, laparoscopic cholecystectomy (LC), one of the most common laparoscopic procedures nationwide, is performed primarily by surgical residents with senior resident teaching assistants (TAs). The impact of FLS training on surgical outcomes for patients undergoing LC are unknown.

Methods: A retrospective analysis of all LCs performed at a single university-affiliated hospital was performed. Residents were divided into pre-FLS (2005-2009) and post-FLS (2010-2014) groups. The main outcome measure was the occurrence of intraoperative complications. Secondary outcomes included surgery duration and conversion to open cholecystectomy.

Results: Of 3034 LCs, 1663 (55%) were performed in the pre-FLS era. Overall, there were 17 bile duct injuries (0.56%) and 35 intraoperative complications (1.2%) for the study period. There were no differences in intraoperative complications (1.1% vs. 1.2%, p=0.7), bile duct injuries (0.7% vs. 0.4%, p=0.2), conversion to open cholecystectomy (8.4% vs. 6.8%, p=0.1), or surgery duration (1.6 vs. 1.6 hours, p=1.0) between the pre-FLS and post-FLS groups. On multivariate logistic regression analysis, increasing patient age was the only variable independently associated with operative complications (OR 1.03, 95% CI 1.01-1.06, p=0.006).

Conclusion: LC performed by residents with senior resident TAs is safe. Mandatory FLS certification has not resulted in an improvement in clinical outcomes and its utility warrants further investigation.


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Session 5 Paper: 18

Surgical Rounds: Improving Efficiency and Meeting Expectations Without Compromising Care

Authors: Amanda Sammann, Lara Z. Chehab, Margaret M. Knudson, Rachael A. Callcut


Presenter: Amanda Sammann | Discussant: Ali Salim | Closer: Mary Knudson

Objective: To improve efficiency on daily trauma surgery rounds using human-centered design.

Background: Academic surgical services face complex challenges to meet expectations related to patient care, resident experience and education, work hours and hospital efficiency. We used a novel Human-Centered Design (HCD) approach to understand the barriers to rounding efficiency and employed an iterative HCD process to prototype innovative rounding models.

Methods: HCD is a well-established research methodology that uses ethnographic interviews and in-context observations to identify the challenges and needs facing stakeholders and to iteratively prototype solutions. We performed 22 pre-implementation interviews and observations of inpatient morning rounds. The implementation phase included 4 iterations of prototypes over 3 months. Each iteration was informed by qualitative feedback from key stakeholder meetings. To analyze results, we calculated differences in median intern work hours and performed an unpaired t-test to compare mean discharge order times.

Results: Pre-intervention data from 15 observations revealed that 34.2% of time was spent on ‘non-clinically relevant’ activities. Of the ‘clinically-relevant’ activities, 40.2% of time was spent carrying out the team huddle at bedside, leaving only 21% of time for direct patient contact. Post-intervention data showed a significant decrease (p < 0.05) in discharge order and intern departure times by 58 and 97 minutes, respectively.

Conclusions: HCD is a powerful tool to address complex workflows with diverse interests and competing priorities. By developing prototypes that are informed by key stakeholders, we can iterate rapidly to develop sustainable interventions without xcompromising quality of care, system efficiency or stakeholder satisfaction.

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Session 6 Paper: 19

Bundled Strong for Surgery (S4S) Optimization Targets Strongly Linked to Surgical Outcomes

Authors: Douglas Z. Liou1, Prasha Bhandari1, Sherry M. Wren2, Nell J. Marshall2, Alex Sox-Harris1, Joseph B. Shrager1, Mark F. Berry1, Natalie Lui1, Leah M. Backhus1,2

Institutions: 1Stanford University, 2Palo Alto VA

Presenter: Douglas Liou | Discussant: Lorrie Langdale | Closer: Sherry Wren

Objective: To test the hypothesis that bundled risk factors have a greater impact on perioperative outcomes.

Background: Strong for Surgery (S4S) is a public health campaign of the American College of Surgeons focused on optimizing patient health prior to surgery by identifying evidence-based modifiable risk factors. The potential impact of S4S bundled risk factor optimization on outcomes after major surgery has not been studied.

Methods: The VASQIP database was queried for patients undergoing major general, thoracic, vascular, orthopedic, and urologic surgery between 2008-2015. Patients with complete data pertaining to S4S risk factors, specifically preoperative smoking status, HbA1c level, and serum albumin, were stratified according to number of positive risk factors and outcomes were compared.

Results: 31,285 patients were included, with 16,630 (53.2%) having no S4S risk factors (S4S0), 12,323 (39.4%) having one (S4S1), 2,186 (7.0%) having two (S4S2), and 146 (0.5%) having three (S4S3). In S4S1, 60.3% were actively smoking, 35.2% had HbA1c >7, and 4.4% had albumin <3. In S4S2, 87.8% were smokers, 84.8% had HbA1c >7, and 27.4% had albumin <3. Major complications, reoperations, and 30-day mortality increased progressively from S4S0 to S4S3. S4S3 had the greatest adjusted mortality risk (AOR 5.29, p<0.01) over S4S2 (AOR 2.34, p<0.01) and S4S1 (AOR 1.68, p<0.01).

Conclusions: Smokers with suboptimal nutritional status and poor glycemic control had the greatest risk of postoperative mortality compared to patients with fewer S4S risk factors. Further studies are necessary to determine if interventions aimed at improving S4S risk factors impact outcomes after major surgery.

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Session 6 Paper: 20

Assessing the Quality and Costs of Cholecystectomies in Rural Hospitals

Authors: Erin C. Howell, Cynthia Tom, Scott Friedlander, Steven L. Lee

Institution: Harbor-UCLA Medical Center

Presenter: Erin Howell | Discussant: Benjamin Padilla | Closer: Steven Lee

Objective: Our aim was to characterize differences in cholecystectomy outcomes performed at rural and urban hospitals.

Background: Rural hospitals play a unique role in the healthcare safety net by providing critical access for patients living in remote areas where geography often creates barriers to care. Workforce shortages and financial constraints threaten the viability of rural surgery and query the quality of care delivered in these settings.

Methods: We used the Nationwide Inpatient Sample (NIS) to perform a retrospective cohort analysis of cholecystectomies (n=3,410,500) performed in patients aged 0-69 between 2002-2012. We compared cholecystectomies at urban and rural hospitals based on their NIS designations. Survey weighted bivariate and multivariable regression analyses were performed with primary outcomes including laparoscopy, complications, length of stay (LOS), and cost.

Results: Bivariate analysis showed rural hospitals cared for fewer private patients, less minorities, and more patients older than 50. Rural hospitals utilized less laparoscopy and had higher overall complication rates. Multivariate analysis confirmed lower rates of laparoscopy (OR 0.88, 95%CI 0.87-0.90) and higher complication rates (OR 1.04, 95%CI 1.01-1.07) at rural hospitals. Rural hospitals were also associated with decreased LOS (IRR 0.87, 95%CI 0.86-0.87), but slightly increased cost (log transformed dollar 0.01, 95%CI 0.01-0.02).

Conclusions: Rural hospitals cared for fewer private patients, less minorities, and more older patients. Despite less laparoscopy utilization, rural hospitals performed cholecys-tectomies with minimal differences in morbidity, cost, and LOS. Additional research is needed to refine rural hospital care, improve its quality, and maintain the viability of critical access hospitals.


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Session 6 Paper: 21

The Disconnect Between Surgeon-Reported Complications and CMS-Required Patient Safety Indicator Reporting

Authors: Jamie E. Anderson, Garth H. Utter, Keley Torres, Gregory J. Jurkovich

Institution: University of California – Davis

Presenter: Jamie Anderson | Discussant: Melinda Maggard-Gibbons Closer: Garth Utter

Objective: To examine the role of the surgical morbidity and mortality (M&M) conference in identifying Center for Medicare and Medicaid Services-directed Patient Safety Indicators (PSIs).

Background: Health systems are increasingly accountable for patient outcomes that affect reimbursement. PSIs were established by the Agency for Healthcare Research and Quality, and use inpatient administrative data to identify adverse outcomes. We hypothesized that these outcomes, critical to hospital finance, are not routinely considered in surgical quality improvement programs, including the surgical M&M conference.

Methods: We reviewed all PSIs and M&M reports from a single surgery department including subspecialties at an academic center in 2016, excluding pediatric cases. We compared hospitalizations flagged by ≥1 PSIs 3 and 5-15 (v6.0) with M&M reports submitted by surgery faculty and residents for departmental review to assess the degree of overlap of these two processes.

Results: Among 6,563 surgical hospitalizations, the M&M process reviewed adverse events for 687 patients (10.5%), 434 (6.6%) of which were deemed potentially preventable or preventable. The M&M process identified 74 (1.1%) hospitalizations with ≥1 PSI- defined event, 57 (0.9%) of which were not captured by the PSIs. In contrast, the PSIs identified 32 hospitalizations, 10 of which did not undergo M&M review. The most common PSI-defined event captured via the M&M process but not by the PSIs was hematoma/hemorrhage requiring reoperation (n=16).

Conclusions: The disconnect between hospital-directed quality assurance activities (the PSIs) and surgeon-directed activities identifies an opportunity for alignment of interests and shared resource allocation to capture clinically and financially-relevant quality of care events.


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Session 6 Paper: 22

Immune Thrombocytopenic Purpura Splenectomy in the Context of New Medical Therapies

Authors: Tarin C. Worrest1, Aaron J. Cunningham1, Elizabeth Dewey1, Thomas G. Deloughery1, Erin W. Gilbert1, Brett C. Sheppard1, Laura E. Fischer2

Institutions: 1Oregon Health & Science University, 2The University of Oklahoma

Presenter: Tarin Worres | Discussant: Sherry Wren | Closer: Brett Sheppard

Objective: Examine response, recurrence and complications rates for patients with immune thrombocytopenic purpura (ITP) after splenectomy as second line therapy.

Background: As newer generation medical therapy utilization increases, splenectomy has been relegated to second or third-line therapy for ITP. These medications have well-known associated morbidity. Changes in treatment algorithms may affect response rates and complications in chronic ITP patients.

Methods: Retrospective study of consecutive patients who underwent ITP splenectomy from January 1994 to June 2017 at a US tertiary care center. Non-responders after s plenectomy and those with recurrent disease were compared to complete responders.

Results: The cohort included 84 patients. Median number of agents received prior to splenectomy was 3 (1-6). 11.9% of patients had a medication-related complication, including heart failure, adrenal insufficiency, diabetes mellitus, infection and osteopo-rosis. After splenectomy, 83.5% had a complete response, 7.5% partial response, and 9% no response. Complete response was associated with response to medical therapy prior to surgery (p<0.01). 19% had recurrent disease, which was associated with lower diagnosis platelet count (p<0.01). 37 patients (44.0%) had urgent splenectomies for bleeding or persistently low platelets despite medical therapy. Nine patients had Clavien-Dindo grade II or higher complications (10.7%). Seven of these complications were related to recurrent or refractory ITP.

Conclusions: Many ITP patients have complications related to medication use, and 44.0% required urgent splenectomy despite medical therapy. Earlier splenectomy may avoid treatment-related complications. Splenectomy remains an effective and safe treatment for ITP with complete response rate of 83.5%.

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Session 7 Paper: 23

Black Race and Body Mass Index are Risk Factors for Rhabdomyolysis and Acute Kidney Injury in Trauma

Authors: Areg Grigorian, Viktor Gabriel, Ninh T. Nguyen, Brian Smith, Boris Borazjani, Sebastian Schubl, Victor Joe, Jeffry Nahmias

Institution: University of California – Irvine

Presenter: Areg Grigorian | Discussant: Karen Deveney | Closer: Brian Smith

Objective: We hypothesized that in trauma patients, black race and a higher body mass index (BMI) are associated with risk for rhabdomyolysis and acute kidney injury (AKI).

Background: Obesity has been shown in a single center study to be a risk factor for rhabdomyolysis. More recently, sickle cell trait, known to be more prevalent in blacks, has been shown to be a risk factor for rhabdomyolysis.

Methods: This was a retrospective analysis using the National Trauma Data Bank. All patients 18 years were grouped based on race and their BMI: normal (18.5-24.99kg/m2), obese(30-34.99kg/m2), severely obese(35-39.99kg/m2) and morbidly obese (>40kg/m2). The primary outcome was incidence of rhabdomyolysis and AKI. A multivariate linear regression analysis controlled for significant cofactors.

Results: There were 1,221,990 patients included. There was no difference in ICU stay or ventilator days(p>0.05). Morbidly obese patients had a higher incidence of rhabdomy-olysis(0.1% vs 0.02%), AKI(1.1% vs 0.4%) and mortality(3.1% vs 2.8%). After adjusting for covariates, risk factors for rhabdomyolysis include black race (odds ratio (OR) 1.81, CI 1.17-2.81, p<0.05) and BMI>35kg/m2 (OR 1.44, CI 1.03-2.02, p<0.05). Black race is a risk factor for AKI (OR 1.62, CI 1.45-1.80, p<0.001). Each increase in BMI category, obese (OR 1.32; 1.24-1.41), severely obese (OR 1.73; 1.59-1.87) and morbidly obese (OR 1.80, 1.66-1.94), had an increased OR for development of AKI.

Conclusions: Black race and BMI > 35 kg/m2 are associated with increased risk for rhabdomyolysis and AKI in a large database. These patient populations should be closely monitored to potentially prevent and/or treat these complications.

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Session 7 Paper: 24

Predictors of ARDS: Lung Injury Persists in the Era of Hemostatic Resuscitation

Authors: Lucy Kornblith1, Brittney Redick1, Benjamin Howard1, Carolyn Hendrickson1, Sara Moore1, Anamaria Robles1, Amanda Conroy1, Farzad Moazed1, Carolyn Calfee1, Rachael Callcut1, Mitchell Cohen2

Institutions: 1University of California - San Francisco, 2Denver Health Medical Center

Presenter: Lucy Kornblith | Discussant: Kenji Inaba | Closer: Mitchell Cohen

Objective: Investigate predictors of ARDS in the era of hemostatic resuscitation.

Background: Acute respiratory distress syndrome (ARDS) following trauma is histori-cally associated with crystalloid and blood product exposure. Advances in resuscitation have occurred over the last decade, but their impact on ARDS is unknown.

Methods: Data was prospectively collected from arrival to 28d for 914 consecutive highest-level trauma activations who required intubation and survived >6h from 2005-2016. Patients with PaO2:FiO2 ratio (PF) of ≤300mgHg during the first 8d were identified. Two blinded expert clinicians adjudicated all chest radiographs for bilateral infiltrates in the first 8d. Those with left heart failure detected were excluded. Multivariate logistic regression was used to define predictors of ARDS.

Results: Of the 914 patients, 62% had a PF≤300 and 22% developed ARDS; of these, 43% were diagnosed in the first 24h. ARDS patients diagnosed after 24h were more severely injured (ISS 32 vs. 20, p=0.001) with higher rates of blunt injury (85% vs. 72%, p=0.003), chest injury (58% vs. 36%, p<0.001), and TBI (71% vs. 48%, p<0.001) compared with the no ARDS group. In multivariate analysis, blunt injury, head/chest AIS scores, crystalloid from 0-6h, and platelet transfusion from 7-24h were independent predictors of ARDS developing after 24h.

Conclusions: Blood and plasma transfusion were not independently associated with ARDS. However, platelet transfusion from 7-24h was a significant independent risk factor. The role of platelets warrants further investigation but may be mechanistically explained by lung injury models of pulmonary platelet sequestration with peripheral thrombocytopenia.

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Session 7 Paper: 25

Hyponatremia and Complex Biliary Disease

Authors: Michael J. Zobel, Lygia Stewart


Presenter: Michael Zobel | Discussant: Dennis Kim | Closer: Lygia Stewart

Objective: Describe etiologic associations between hyponatremia and complex biliary disease.

Background: Hyponatremia is associated with complex biliary disease, including gangrenous cholecystitis; but the etiology of this association remains unclear.

Methods: 802 patients with gallstone disease were studied (696 men, 106 women; average age 62). Illness severity was characterized: None (no inflammatory/infectious manifesta-tions), SIRS (fever, leukocytosis, tachycardia), Severe (abscess, cholangitis, empyema), or Sepsis-MODS (hypotension, organ dysfunction/failure, bacteremia). Charlson comor-bidity index(CCI) calculated. Gallstones, bile, and blood (as clinically indicated) were cultured. Pathology reviewed. Univariate and multivariate analyses of factors associated with hyponatremia performed.

Results: Hyponatremia (Na<135 mmol/L) was present in 174(22%) cases. On bivariate analysis, serum sodium was significantly decreased with: worsening illness severity, ascending bacterial infection, gangrenous cholecystitis, elevated CCI, and increasing age(table). On multivariate analysis, all factors (except age) independently correlated with serum sodium(table); and factors were additive.

Conclusion: This unique, large study is the first to explore, with such granularity, relation-ships between complicated biliary disease and hyponatremia. No previous studies have examined specific culture, clinical, and pathologic data (data often not readily available in administrative databases). Our study illustrates an independent correlation between illness severity and serum sodium. Patient comorbidity and presence of gangrene also independently correlated with hyponatremia on multivariate analysis - suggesting hypo-natremia may be a marker for acute/chronic inflammation. Culture data demonstrated Serum Na decreased as bacterial infection ascended from gallstone colonization to bacto-bilia to bacteremia. Finally, serum sodium was significantly lower in patients with more complex biliary infections, including gangrenous cholecystitis, cholangitis, and sepsis.

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Session 7 Paper: 26

Risk Factors for Perioperative Complications and Prolonged Length of Stay after Laparoscopic Adrenalectomy: Size and Diagnosis Matter

Authors: Yufei Chen, Anouk Scholten, Kathryn Chomsky-Higgins, Iheoma Nwaogu, Jessica E. Gosnell, Carolyn D. Seib, Wen T. Shen, Insoo Suh, Quan-Yang Duh


Presenter: Yufei Chen | Discussant: Michael Yeh | Closer: Quan-Yang Duh

Objective: We hypothesize that diagnosis and tumor size independently affect complications and length of stay (LOS) following laparoscopic adrenalectomy.

Background: Laparoscopic adrenalectomy is the gold standard for most adrenal disorders. Current national database analyses and systematic reviews lack granular information on the effect of hormonal function and size on risk of perioperative complications and LOS.

Design/Methods: A retrospective analysis of patients who underwent laparoscopic adrenalectomy between 1993-2017 at a single academic center was performed. Complications with Dindo-Clavien grade ≥2 included in our analysis. Prolonged LOS was defined as >75th percentile of the cohort. Multivariable linear and logistic regression was used to obtain adjusted odds ratios (ORs).

Results: We identified 640 patients who underwent 653 laparoscopic adrenalectomies. 56.7% were female, and mean age was 50.1 (range 5-88). 73 complications with grade ≥2 occurred in 54 patients (8.3%) with post-operative mortality of 0.3%. Median hospital LOS was 1 day (range 0-32). Factors independently associated with increased complications were ASA class 3/4 (OR 3.2, 1.6-6.3, p<0.01), diabetes (OR 2.0, 1.0-4.1, p=0.05), conversion to hand-assist or open (OR 4.0, 1.4-11.4, p=0.01), diagnosis of pheochromocytoma (OR 3.9, 1.3-11.5, p=0.01) and tumor size ≥6cm (OR 2.4, 1.0-5.4, p=0.04). Prolonged LOS was associated with ASA class 3/4, any conversion, diagnosis other than aldosteronoma or non-functional adenomas, and tumor size ≥4cm.

Conclusions: Laparoscopic adrenalectomy remains safe for the majority of adrenal disorders. Patient comorbidities, adrenal pathology, and tumor size impact the risk of complications and LOS, and should all be considered in selecting and preparing patients for surgery.

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Mini-Podium SessionsA


48

Mini-Podium Sessions AAll Scientific Session and Mini-Podium Presentation authors and presenters are MDs unless otherwise noted.

SESSION A

A1: Management of a Giant Omphalocele with a Narrow Neck Presenter: Candace Haddock

A2: A Negative CT Abdomen/Pelvis Is Sufficient to Safely Discharge Patients with Abdominal Seatbelt Signs from the Emergency Department Presenter: Deven Patel

A3: Pulmonary Sequestration Requiring Prenatal and Postnatal Intervention Presenter: Laura Galganski

A4: Risk of Gastroschisis is Higher in Rural Counties in California: A Population-Based Study from 1995-2012 Presenter: Jamie Anderson A5: Surgical Management of Omphalocele: Old and New Approaches Presenter: Hunter Oliver-Allen

A6: The Gap Still Exists: Racial Disparities in Outcomes and Costs after Appendectomy Within and Across Hospitals Presenter: Cynthia Tom

A7: Implementation of a Clinical Practice Guideline for Post-Operative Management of Appendicitis Improves Outcomes for Children Presenter: Melissa Vanover

A8: Heparin-Induced Thrombocytopenia (HIT) in Trauma: Association with Bacterial Infection Presenter: Areg Grigorian A9: IBD Serological Immune Markers ASCA and OmpC are Potential Biomarkers for Hirschsprung- Associated Enterocolitis Presenter: Philip Frykman

A10: Impact of Insurance Status on Discharge Disposition in Patients with Mental Illness Presenter: Rebecca Plevin

A11: High Cost of Pediatric Falls from Buildings Presenter: Melissa Vanover

A12: Predictors of Post-operative Length of Stay after Ventral Hernia Repair: An ACS-NSQIP Analysis Presenter: Sandhya Kumar A13: Early Cholecystectomy is Associated with Decreased Length of Stay and Improved Outcomes in Patients with Mild Gallstone Pancreatitis: An Analysis of the ACS-NSQIP Database Presenter: Emily Dubina


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Mini Podium Session: A # 1

Management of a Giant Omphalocele with a Narrow Neck

Authors: Candace Haddock1, Abdullah Alshehri1, Jugpal Arneja2, Cindy Verchere1, Erik Skarsgard1

Institutions: 1BC Children’s Hospital; 2King Khaled University Hospital

Presenter: Candace Haddock

Giant omphalocele (GO) is a birth defect characterized by solid visceral herniation through a large, amnion covered umbilical defect. Treatment options include surgical fascial closure, or a “paint and wait” approach of amnion escharization/epithelialization followed by compressive visceral reduction. We present a particularly challenging case of GO with an uncharacteristically narrow fascial defect (<5cm), which obstructed attempts at reduction after the amnion was epithelialized. The patient was treated with subcutane-ous tissue expansion followed by the first stage of abdominal wall reconstruction. The skin covered amnion was de-epithelized, the fascial defect was enlarged to a diameter of 14cm by radial incisions, and the fascial margins were advanced circumferentially and su-tured to the preserved amnion, without peritoneal violation or use of mesh. The expanded skin was sufficient to cover the reconstructed abdominal wall. Serial amnion excisions are planned, with an ultimate goal of complete fascial (+/-mesh) coverage over the next 12-18 months.

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A Negative CT Abdomen/Pelvis Is Sufficient to Safely Discharge Patients with Abdom-inal Seatbelt Signs from the Emergency Department

Authors: Deven C. Patel, Navpreet K. Dhillon, Nikhil T. Linaval, Kavita A. Patel, Christos Colovos, Eric J. Ley, Daniel R. Margulies, Galinos Barmparas


Presenter: Deven Patel

Objective: The aim of this study was to determine how a negative CT abdomen/pelvis (A/P) can serve in the safe disposition of patients who present with an abdominal seatbelt sign (ASBS).

Background: The presence of an ASBS following a motor vehicle collision (MVC) is associated with a high risk for occult mesenteric and/or bowel injury prompting imaging studies and a prolonged period of clinical observation. Whether a negative CT A/P can serve to safely rule out these injuries and avoid unnecessary hospitalization remains unknown.

Methods: Patients ≥ 15 years admitted from 01/2014 to 12/2016 were reviewed for the presence of an ASBS. Those who did not undergo a CT A/P were excluded. CT scans were classified as negative if there were no signs of acute vascular, visceral or bony injury. The sensitivity, specificity, positive (PPV) and negative predictive value (NPV) were calculated.

Results: 1,108 were admitted after an MVC. Of those, 196 (17.7%) had an ASBS upon presentation, and 183 (93.4%) underwent a CT A/P. A total of 114 patients (62.3%) had a negative CT A/P. These patients remained hospitalized for a median of 2 (1-35) days with none (0.0%) requiring a laparotomy. The sensitivity of CT in identifying a mesenteric and/or bowel injury was 100.0%, specificity was 94.1%, NPV was 100.0% and the PPV 53.9%. The negative likelihood ratio was 0.0.

Conclusions: For patients with an ASBS following a MVC, a negative CT A/P is sufficient for safe discharge from the emergency department without need for additional clinical observation.


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Pulmonary Sequestration Requiring Prenatal and Postnatal Intervention

Authors: Laura Galganski, Payam Saadai, Jamie Anderson, Shinjiro Hirose

Institution: University of California - Davis

Presenter: Laura Galganski

Background: Pulmonary sequestrations are rare congenital anomalies of nonfunctional lung tissue with aberrant vascular supply. They may be asymptomatic, spontaneously regress or may lead to development of a hydrothorax in utero. This hydrothorax may lead to fetal hydrops, which is fatal without intervention.

Case: We report a patient treated in utero for a hydrothorax causing fetal hydrops. An ultrasound-guided thoracoamniotic shunt placement was performed successfully at 32 weeks of gestation. Follow-up ultrasound on post-operative day three demonstrated improvement in the hydrothorax and hydrops with the identification of a feeding vessel originating from the descending aorta supplying a likely sequestration. Due to prema-ture rupture of membranes, the mother delivered at 33 weeks. The patient required a temporary pigtail thoracostomy tube to drain an ongoing pleural effusion that caused respiratory distress. At age 9 months, computed tomography confirmed the diagnosis of a pulmonary sequestration, and he returned for elective thoracoscopic resection.


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Risk of Gastroschisis is Higher in Rural Counties in California: A Population-Based Study from 1995-2012

Authors: Jamie E. Anderson, Yvonne Cheng, Rebecca A. Stark, Payam Saadai, Shinjiro Hirose


Presenter: Jamie Anderson

Objective: To identify geographic trends in incidence of gastroschisis in California since 1995.

Background: The rate of gastroschisis is increasing worldwide and some hypothesize there is a higher risk in rural or agricultural areas.

Methods: This is a population analysis using data from the Linked Birth Database from the California Office of Statewide Health Planning and Development from 1995-2012. The database links data from the Vital Statistics Birth Data and California Patient Discharge Data. Patients were identified by an ICD-9 procedure code for gastroschisis repair (54.71); ICD-9 diagnosis code for gastroschisis (756.73, available since 2009); or birth certificate designation for gastroschisis (available since 2006). Rural designations for counties were based on 2010 census data. Annual incidence rates of gastroschisis by county were calculated. Multivariable logistic regressions examined influence of county, year, and rural designation on risk of gastroschisis.

Results: The rate of gastroschisis increased from 1.7 cases per 10,000 births in 1995 to 5.3 cases per 10,000 births in 2012. Compared to Los Angeles County, logistic regression found lower odds of gastroschisis in Alameda, Contra Costa, Marin, Orange, and San Francisco Counties (OR 0.34-0.71, p<0.001-0.038), whereas risk was higher in El Dorado, Humboldt, Kern, Lake, Mendocino, Modoc, Monterey, Nevada, Riverside, Sacramento, San Bernardino, San Joaquin, Shasta and Siskiyou Counties (OR 1.31-8.18, p<0.001-0.025). Logistic regression demonstrated an increased odds of gastroschisis in partially-rural and rural counties compared to metropolitan counties (OR 1.60, p<0.001; OR 3.04, p<0.001, respectively).

Conclusions: Gastroschisis incidence is increasing in California and risk is higher in rural counties.

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Surgical Management of Omphalocele: Old and New Approaches

Authors: Hunter S. Oliver-Allen, James T. Ross, Lan T. Vu


Presenter: Hunter Oliver-Allen

Objective: To describe outcomes in omphalocele closure and present a novel method for the surgical repair of giant or ruptured omphalocele.

Background: Omphalocele is a congenital anomaly resulting in a midline defect of the periumbilical abdominal wall with visceral herniation. Defects can be repaired imme-diately or delayed. In order to provide fascial and skin closure without excessive tension or intra-abdominal pressure, temporary or permanent mesh may be used to bridge the defect. We present the largest published single-center experience with omphalocele and describe a novel surgical approach for the management of giant or ruptured omphalocele.

Methods: Retrospective review of patients treated for omphalocele between 1997 and 2017. Patient demographics, timing and method of repair, length of stay, recurrence, and complications were collected and analyzed. Results: Sixty-six patients were treated for omphalocele, of whom 60 were included in the analysis. The most common method of reconstruction was primary repair. The mean age of initial operation was 25 days. 18 patients underwent a staged repair. Mean length of stay was 42 days and overall complication rate was 12%. Two patients with ruptured omphaloceles had initial repair with biologic mesh and vacuum wound dressing. Both patients had subsequent definitive repair at 9 months.

Conclusions: We present our 20-year experience in the management of patients with omphalocele. We describe our novel technique, the ‘Baseball’method, a hybrid of the ‘silo’ and the ‘paint-and-wait’ approaches, that facilitates coverage of large defects while decreasing hospital length of stay and the need for repeated operations.


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The Gap Still Exists: Racial Disparities in Outcomes and Costs after Appendectomy Within and Across Hospitals

Authors: Cynthia Tom, Erin C. Howell, Scott Friedlander, Steven L. Lee


Presenter: Cynthia Tom

Objective: To evaluate whether different hospital types affect racial disparities in patients with appendicitis.

Background: Previous studies demonstrated significant racial disparities in patients with appendicitis. Little is known whether such disparities are reduced or worsened within or across different hospital settings.

Methods: We compared outcomes and costs of appendectomy patients from Nation-wide Inpatient Sample database(2001-2012). Patients were stratified by race and hospital safety-net burden. High-burden hospitals had the highest-quartile of Medicaid/uninsured patients, and low-burden hospitals had the lowest-quartile. The primary outcomes (disease severity, laparoscopy, length of stay(LOS), morbidity, and cost) within and between hospital types were analyzed with multivariate logistic regression.

Results: Overall, high-burden hospitals treated more minorities than low-burden hospitals (63.9% vs 42.9%). Within high-burden hospitals, minorities were associated with higher appendiceal perforation rates(APR), decreased laparoscopy, longer LOS, and increased costs. Conversely, within low-burden hospitals, minorities were associated with lower APR, decreased laparoscopy, increased costs, and increased complications. When comparing high-burden to low-burden hospitals, both high-burden whites and minorities were associated with higher APR, decreased laparoscopy, longer LOS, and increased costs. The greatest disparities existed between high-burden minorities and low-burden whites with higher APR(OR=1.18;95%CI=1.15-1.21;p<0.01), decreased laparoscopy(OR=0.73;95%CI=0.71-0.75;p<0.01), longer LOS(OR=1.15;95%CI=1.14-1.16;p<0.01), and increased costs(ORlog=0.09;95%CI=0.08-0.09;p<0.01).

Conclusions: The large divide between minorities at high-burden hospitals and whites at low-burden hospitals is alarming. These results underscore the significant yet different patterns of racial disparities within and between different hospitals nationwide. Immediate attention is needed to identify the cause of these inequalities and promote future interventions to bridge the gap for this common surgical disease.

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Implementation of a Clinical Practice Guideline for Post-Operative Management of Appendicitis Improves Outcomes for Children

Authors: Melissa Vanover, Shinjiro Hirose, Payam Saadai


Presenter: Melissa Vanover

Objective: Improve post-appendectomy outcomes for children.

Background: Appendicitis is the most common cause for urgent abdominal surgery in children. No consensus currently exists for post-operative management and presents an opportunity for quality improvement endeavors.

Design/Methods: A clinical practice guideline was developed and approved by the Pediatric Surgery Department. Data was collected retrospectively for all pediatric patients who underwent appendectomy by a pediatric surgeon for a year prior to and following implementation. Modifications to the guideline were made after every 3 months of patient data collection following the Plan-Do-Study-Act (PDSA) model.

Results: A clinical practice guideline was developed and presented to the Pediatric Surgery Department. Individual meetings were held with attending surgeons, prompting more detailed feedback. Several portions of the initial guideline were revised prior to unanimous approval. Since implementation, 159 children underwent appen-dectomy. 58 children (36.6%) were found to have complicated appendicitis, which was comparable to pre-implementation (40.6%). Average length of stay decreased for children with both simple (1.5 to 1.1 days) and complicated appendicitis (6.7 to 4.6 days). There was a decrease in the rate of post-operative Emergency Department visits (10.9% to 8.1%), without significant change in the rate of post-operative complications (7.8% to 8.1%) or readmissions (3.5% to 3.7%). There was 93.8% compliance with the guideline.

Conclusions: Presentation of national and local statistics, as well as individual meetings, increased motivation for guideline development and led to a high rate of compliance. Guideline implementation led to decreased length of stay without increase in complica-tion or readmission rate.


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Heparin-Induced Thrombocytopenia (HIT) in Trauma: Association with Bacterial Infection

Authors: Areg Grigorian, Sebastian Schubl, Viktor Gabriel, Cristobal Barrios, Victor Joe, Matthew Dolich, Michael Lekawa, Jeffry Nahmias


Presenter: Areg Grigorian

Objective: We hypothesized trauma patients with Heparin-induced thrombocytopenia (HIT) have a higher incidence of bacterial infection compared to patients without HIT.

Background: HIT has a reported incidence of 0.2% in trauma patients. Recent studies have shown that bacterial infections may induce antibodies reacting with the major HIT antigen leading to an increased incidence of HIT.

Methods: This is a retrospective analysis of the National Trauma Data Bank (NTDB) from 2008-2015 querying for any patient diagnosed with HIT. Propensity scores were calculated to match patients with HIT to patients without HIT in a 1:2 ratio. The primary outcome was infectious complications including bacteremia, colitis, urinary tract infection (UTI) and pneumonia. Analysis was performed using a binary logistic regression model.

Results: There were 120 patients with HIT between 2008-2015 with an incidence <0.003%. The mean age was 54.5 years and mean injury severity score was 15.2. The mean length of stay was 27.4 days with mean ventilator days of 18.5. The most common injury was to the lower extremity (47.5%). Thrombotic complications including deep vein thrombosis, pulmonary emboli and cerebrovascular accident were seen in 35.8% of patients. The mortality rate was 7.5%. The odds ratio for bacterial infection in HIT was 23.36 (confidence interval (CI) 7.99-68.25, p < 0.001), for UTI 10.80 (CI 2.32-50.25, p <0.05) and for pneumonia 5.58 (CI 2.62-11.89, p <0.001).

Conclusions: The incidence of HIT in trauma is significantly lower than previously reported. Bacterial infection is associated with a higher incidence of HIT in trauma.

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IBD Serological Immune Markers ASCA and OmpC are Potential Biomarkers for Hirschsprung-Associated Enterocolitis

Authors: Philip K. Frykman1, Deven Patel1, Sungjin Kim1, Zhi Cheng1, Tomas Wester2, Agneta Nordenskjöld1, Akemi Kawaguchi3, Thomas T. Hui4, Peter F. Ehrlich5, Anna L. Granström2, Carole J. Landers1, The HAEC Collaborative Research Group (HCRG)1

Institution: 1Cedars-Sinai Medical Center; 2Astrid Lindgren’s Children’s Hospital; 3University of Texas; 4University of California – San Francisco; 5C.S. Mott Children’s Hospital

Presenter: Philip Frykman

Objective: The aim of this study was to identify biomarkers to aid in diagnosis of Hirschsprung-associated enterocolitis (HAEC).

Background: HAEC is the most frequent complication in Hirschsprung (HSCR) patients. Currently HAEC is diagnosed clinically, leaving uncertainty in the diagnosis thereby potentially leading to over- or under-treatment of patients.

Methods: From 2012-2017, 43 children with HSCR enrolled in a multi center study, under-went retrospective evaluation of their medical records, and questionnaire-directed parent interviews. HAEC status was determined using HAEC score with cutoff 4 according to Frykman et al. (2017). Plasma was collected and underwent ELISA for the IBD-associated antibodies: ASCA, OmpC, CBir, ANCA. Data were analyzed using t test, univariate, multi-variable and binomial regression models.

Results: Eighteen patients had at least one episode of HAEC, 25 had no HAEC episodes. The HAEC and NO HAEC groups had similar median ages (4.6 years), family histories of HSCR, (see Table for comparison). The HAEC group showed markedly elevated ASCA IgA, IgG, and OmpC antibody levels compared with the NO HAEC group while CBir and ANCA were similar between groups. Both univariate and multivariable analysis revealed higher OmpC antibody levels associated with HAEC (OR 1.39 , CI 1-1.92,p=0.048 ), while univariate analysis identified a trend toward elevated IgA and IgG ASCA levels with HAEC.

Conclusions: Elevated OmpC and ASCA serum antibody levels are associated with HAEC, similar to Crohn’s disease, suggesting shared gut microbial-host immune responses. Further, these antibodies may serve as potential biomarkers for HAEC diagnosis, although prospective study with larger sample size is needed.


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Impact of Insurance Status on Discharge Disposition in Patients with Mental Illness

Authors: Rebecca E. Plevin, Amanda Conroy, Catherine Juillard, Rachael A. Callcut


Presenter: Rebecca Plevin

Objective: Evaluate the impact of insurance status on discharge disposition in trauma patients with mental illness.

Background: Mental illness affects 20% of American adults and is a risk factor for trau-matic injury. These patients are often uninsured. This study investigates the impact of insurance status on discharge resources.

Methods: Patients with mental illness were identified from the 2012 NTDB National Sample Program and stratified by insurance status. Outcomes were compared with logistic regression.

Results: 247,718 patients had mental illness. Insurance distribution was 12% uninsured, 56% public, and 32% private. Injury severity score (ISS) was similar between the groups. Uninsured patients were younger and more often used alcohol, tobacco, or drugs (all, p<0.05). Suicide and assault were common in the uninsured, whereas falls were more common in insured patients. Length of stay was similar between insured and uninsured (6.4 vs. 6.3 days). There was no statistical mortality difference between uninsured, publically, and privately insured (1.3% vs. 3.8% vs. 1.2%). Uninsured patients were less likely to be discharged to another facility (p<0.001) and to receive home services (p<0.001) compared to insured patients. Discharge to skilled nursing facility (SNF) was highest with public insurance (38%) vs. private (6.8%) or no insurance (2.8%, all p<0.05). Public insurance was an independent predictor of disposition to a SNF, controlling for mechanism of injury and comorbidities (p<0.05).

Conclusions: Despite similar ISS, uninsured patients suffering mental illness receive fewer resources upon discharge. This likely creates additive risk for readmission and poor out-of-hospital outcomes that warrant further investigation.

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High Cost of Pediatric Falls from Buildings

Authors: Melissa Vanover


Presenter: Melissa Vanover

Objective: Describe the scope and cost of injuries related to pediatric falls from buildings.

Background: Injuries related to falls from windows decreased dramatically in California in the 1990s, but have plateaued since 2006.

Design/Methods: A single institution database was used to identify children under age 15 admitted between January 2009 and December 2015 with diagnosis code E882 or W13. Patients with a fall height of less than 10 feet were excluded. The California Department of Public Health EpiCenter database was queried for statewide and county specific incidence.

Results: In California, 450-600 ER visits, 150-200 admissions and 0-3 deaths per year were the result of pediatric falls from buildings. The rate of falls per 100,000 population was 8.9 in 2006 and 8.0 in 2014. Counties with the highest per capita rates in 2014 were San Diego (11.9), Fresno (10.4), and Sacramento (10.1). At a pediatric Level 1 trauma center, 202 children were admitted over a 7-year period. Patients were mostly male (62%) and toddlers (75%, mean age 3.8 years). Most incidents occurred at home (90%). Traumatic brain injuries were common (60%), requiring intubation (13%) or ICU admission (33%). Surgery was required for 22% and therapy for 17% of patients. Most were discharged home (93%), though 6% required additional rehabilitation. Average cost of hospitalization was $12,379 and charge $102,008. Most had public health insurance (64%).

Conclusions: Falls from buildings remain a persistent source of childhood injury requiring costly hospitalizations. Increased efforts are needed to raise awareness of prevention methods.


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Predictors of Post-operative Length of Stay after Ventral Hernia Repair: An ACS-NSQIP Analysis

Authors: Sandhya B. Kumar, Soren B. Jonzzon, Matthew Y.C. Lin


Presenter: Sandhya Kumar

Objective: To identify factors associated with prolonged length of stay (PLOS) after ventral hernia repair.

Introduction: Enhanced Recovery After Surgery (ERAS) pathways have been utilized in many subspecialties to improve outcomes and decrease length of stay. Understanding the patient and operative factors associated with PLOS is crucial in the development of ERAS pathways for ventral hernia repair.

Methods: Using the 2011-2015 National Surgical Quality Improvement Program (NSQIP) database, we identified 53,257 patients who underwent ventral hernia repair. PLOS was defined as 75th percentile. Multivariable logistic regression was used to identify factors associated with PLOS.

Results: Mean PLOS was 4.5 days and the 75th percentile was 5 days. 84% were open repairs and 16% were laparoscopic; operative time was 134 and 122 minutes respectively (p<0.001). Multivariate analysis showed that American Society of Anesthesiologists (ASA) Class IV (odds ratio(OR) = 4.1), operative time > 2 hours (OR = 3.2), and concurrent bowel resection (OR = 3.1) had the strongest association with PLOS > 5 days (all p<0.001). ASA Class III, dependent functional status, open operation, need for myocutaneous flap, pre-operative sepsis, and dirty/infected wound class were less strongly associated with PLOS > 5 days.

Conclusions: ASA class IV, operative time > 2 hours, and concurrent bowel resection were the strongest predictors of PLOS after ventral hernia repair and could be targets for reduction of hospital stay in these patients. Additionally, patients with serious comorbidities and those who undergo bowel resection may need to be excluded from ERAS pathways.

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Early Cholecystectomy is Associated with Decreased Length of Stay and Improved Outcomes in Patients with Mild Gallstone Pancreatitis: An Analysis of the ACS-NSQIP Database

Authors: Emily D. Dubina, Christian De Virgilio, Eric R. Simms, Dennis Y. Kim, Ashkan Moazzez


Presenter: Emily Dubina

Objective: To compare length of stay (LOS) and 30-day morbidity in patients with mild gallstone pancreatitis (GSP) undergoing early (<48 hours of admission) versus delayed (≥48 hours) cholecystectomy.

Background: Many institutions delay cholecystectomy for mild GSP until normalization of laboratory values and abdominal pain, for fear that early surgery increases complica-tions. Previous studies have demonstrated that early cholecystectomy (EC) for mild GSP shortens LOS, but were not powered to detect differences in morbidity.

Methods: A review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was performed to identify adults under-going same-admission cholecystectomy for pancreatitis from 2005 to 2014. Patients with preoperative indicators of severe pancreatitis (organ dysfunction) were excluded. Outcome measures including LOS, operative times, and 30-day morbidity were compared between patients undergoing early and delayed cholecystectomy using bivariate analysis.

Results: Of 1938 patients identified, 824 (42%) underwent EC. The EC group had more laparoscopic than open cholecystectomies (95.9% vs. 93.7%, p=0.037) and concurrent CBD interventions (50.8% vs. 37.9%, p<0.001). EC was associated with decreased time from admission to operation (1.5 vs. 4.6 days, p<0.001), operative time (70.1 vs. 78 minutes, p<0.001), and LOS (3.3 vs. 7 days, p<0.001). Overall morbidity (2.9% vs. 5.4%, p=0.008), organ space infection (0.4% vs. 1.6%, p=0.008), and re-operation (0.7% vs. 2.0%, p=0.023) were also decreased in EC.

Conclusions: For mild GSP, EC is associated with decreased LOS and reduced overall morbidity, organ space infection, and re-operation. Therefore, EC should be considered as the preferred approach.

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Mini-Podium SessionsB


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Mini-Podium Sessions BAll Scientific Session and Mini-Podium Presentation authors and presenters are MDs unless otherwise noted.

SESSION B

B1: Laparoscopic versus Open Total Gastrectomy for Gastric Adeno- carcinoma: Short- and Long-Term Survival Presenter: Colette Inaba B2: Factors Associated with Readmission after Parathyroidectomy for Renal Hyperparathyroidism Presenter: Eric Kuo

B3: Should Tumor Sidedness Influence Surgical Decision Making in Metastatic Colon Cancer? Presenter: Trang Nguyen

B4: Gene Directed Surgery for Hereditary Diffuse Gastric Cancer: Effect o n Survival Presenter: Joseph Forrester

B5: Initial Experience with Telemedicine in an Academic Endocrine Surgery Program Presenter: Ki Wan Park

B6: Faster Discharge after Open Pancreaticoduodenectomy is Not Associated with a Higher Risk of Hospital Readmission Presenter: Jerry Jiang

B7: Patient Frailty, not Just Age, is Associated with Increased Risk of Complications after Adrenalectomy Presenter: Jamie Anderson

B8: Preoperative Neutrophil-to- Lymphocyte Ratio is a Predictor of Recurrence in Patients with Stage II Colon Cancer Presenter: Michael Esparza

B9: The Utility of Immunological Markers in Prognostication of Upfront Resectable Pancreatic Cancer. A Cohort Study from an Academic Community Hospital Presenter: Ephraim Tang

B10: Lower Than Expected Completion Thyroidectomy Rate: The Intersection of Clinical Reasoning and Guideline- Based Care Presenter: Kathryn Chomsky-Higgins

B11: Current Trends in Breast Surgery: Surgeons, Billing Practices, and Healthcare Disparities in Price of Surgery Presenter: Joshua Tseng

B12: Biopsy-proven Lymph Nodes Predict Presence or Absence of Residual Axillary Nodal Disease Following Neoadjuvant Chemotherapy in Node-Positive Breast Cancer Presenter: Angelena Crown

B13: Delayed Operative Intervention in Traumatic Injury Presenter: Anne Stey

– Moderators Rachael Callcut and Darren Malinoski


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Mini Podium Session: B # 1

Laparoscopic versus Open Total Gastrectomy for Gastric Adenocarcinoma: Short- and Long-Term Survival

Authors: Colette S. Inaba, Matthew D. Whealon, Christina Y. Koh, Sarath Sujatha-Bhaskar, Marija Pejcinovska, Ninh T. Nguyen


Presenter: Colette Inaba

Objective: To compare outcomes of laparoscopic vs. open total gastrectomy for gastric adenocarcinoma using a national cancer database.

Background: The use of laparoscopic total gastrectomy for gastric cancer remains controversial.

Methods: The National Cancer Database (2010-2014) was analyzed for total gastrectomy cases performed for gastric adenocarcinoma. Patient demographics and surgical outcomes were stratified by stage and compared based on laparoscopic vs. open surgical approach. Primary outcome measures included 30-day and 90-day mortality. Kaplan-Meier curves were used to estimate five-year survival.

Results: There were 2,584 cases analyzed, including 592 (22.9%) stage I, 710 (27.5%) stage II, and 1282 (49.6%) stage III cases. The distribution of laparoscopic vs. open cases were 156 (26.4%) vs. 436 (73.6%) for stage I, 163 (23.0%) vs. 547 (77.0%) for stage II, and 241 (18.8%) vs. 1041 (81.2%) for stage III. For all stages analyzed, there was no difference between laparoscopic vs. open approach for adjusted 30-day mortality (stage I: 2.4 vs. 2.6%, adjusted odds ratio, AOR, 0.52, P =0.75; stage II: AOR 1.36, P =0.99; stage III: AOR 0.46, P =0.29) or 90-day mortality (stage I: AOR 0.46, P =0.99; stage II: AOR 1.17, P =0.99; stage III: 0.57, P =0.29). There was no difference between the 5-year laparoscopic vs. open Kaplan-Meier estimated survival curves for any stage (stage I: P =0.195; stage II: P =0.834; stage III: P =0.456).

Conclusions: Laparoscopic and total gastrectomy have comparable 30-day mortality, 90-day mortality, and five-year survival. Laparoscopic total gastrectomy should be a viable option in the management of gastric adenocarcinoma.


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Factors Associated with Readmission after Parathyroidectomy for Renal Hyperparathyroidism

Authors: Eric J. Kuo, Lin Du, Michael W. Yeh, Masha J. Livhits


Presenter: Eric Kuo

Objective: To evaluate risk factors for readmission in patients undergoing parathyroidec-tomy (PTx) for renal hyperparathyroidism (RHPT). Background : Patients with RHPT are susceptible to major electrolyte fluctuations, which may predispose to early readmission after PTx.

Design/Methods: Patients with renal failure who underwent PTx were abstracted from the California Office of Statewide Health Planning and Development (1999-2012). Multivariable logistic regression was used to identify risk factors for readmission within 30 days of discharge.

Results: The cohort included 4411 patients, of whom 17% were readmitted. Procedures included subtotal PTx (74% of cases) and total PTx with autotransplantation (26%). Median time to readmission was 9 days. Electrolyte disturbances, including hypocalcemia, were present in 36% of readmissions and were the most common diagnoses associated with readmission. Independent risk factors for readmission included Black race (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.1-1.6), Hispanic race (OR 1.4, 95% CI 1.1-1.8), disposition with home health (OR 2.1, 95% CI 1.4-2.9), disposition to a skilled nursing facility (OR 2.5, 95% CI 1.7-3.6), increased initial length of stay (OR 1.01, 95% CI 1.00-1.02), and total PTx with autotransplantation (OR 1.3, 95% CI 1.1-1.6). Advancing age (OR 0.99, 95% CI 0.98-0.99) and surgery at a high-volume hospital (0.6, 95% CI 0.4-0.8) were protective against readmission.

Conclusions: Patients undergoing PTx for RHPT have a high readmission rate, frequently for metabolic complications. Increased post-operative vigilance, which may include outpatient laboratory monitoring, may be indicated in a subset of patients who are at high risk for readmission.


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Should Tumor Sidedness Influence Surgical Decision Making in Metastatic Colon Cancer?

Authors: Ahmed Dehal, Brooke Vuong, Amanda Graff-Baker, Shu-Ching Chang, Annabelle Teng, Trang Nguyen, Anton Bilchik, Melanie Goldfarb

Institution: John Wayne Cancer Institute

Presenter: Trang Nguyen

Background: Recent data showed worse survival in patients with metastatic right-sided colon cancer (mRCC) compared to metastatic left-sided colon cancer (mLCC). However, the impact of tumor sidedness on survival in patients with metastatic colon cancer (mCC) undergoing resection of primary tumor (RPT) or metastatectomy has not been studied.

Objective: To evaluate the impact of tumor sidedness on survival in patients with mCC undergoing RPT or metastatectomy.

Methods: Patients with mCC that had either RPT or metastatectomy and did not die within 90 days of surgery in the 2004-2014 National Cancer Data base were identified. Propensity score matching was used to determine the survival benefit from either RPT or metastatectomy in mRCC and mLCC.

Results: Of 46,785 patients, 36,684 (78%) had a RPT and 10,773 (23%) had a metastatec-tomy. After propensity score matching for demographics, tumor charactristics, and non-surgical treatment, RPT independently conferred a 43% lower risk of death at 2 years in patients with mRCC (p<0.0001) compared to 48% in mLCC (p<0.0001). Similarly, metastatectomy was associated with 33% decreased risk of death at 2 years in mRCC (p<0.001) compared to 41% in mLCC (p<0.001).

Conclusions: Patients with mLCC may derive a larger survival benefit with aggressive surgical therapy compared to those with mRCC. Oncologists should consider this finding when counseling patients with mCC regarding the role of surgical therapy.

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Gene Directed Surgery for Hereditary Diffuse Gastric Cancer: Effect on Survival

Authors: Joseph Forrester1, Geoffrey Krampitz2, James Ford1, Teri Longacre1, Uri Ladabaum1, R Brooke Jeffrey1, Nicolette Chun1, Allison Kurian1, Kerry Kingham1, Sara Fry1, Jeffrey Norton1

Institution: 1Stanford University; 2MD Anderson

Presenter: Joseph Forrester

Objective: To study the role of prophylactic total gastrectomy in patients with CDH1 mutations.

Background: Gastric cancer can be inherited as an autosomal dominant condition in hereditary diffuse gastric cancer (HDGC). The gene associated with HDGC is CDH1, an E-cadherin gene that is responsible for cell adhesion, maturation and movement.

Methods: 43 patients with mutations in the CDH1 gene were studied prospectively including 8 with symptoms and 35 without symptoms. Total gastrectomy was recommended to each. Proportions are compared by Fisher’s exact test. Quality of life is assessed in patients who underwent prophylactic gastrectomy

Results: 13 (30%) patients declined surgery. Total gastrectomy was done in 8 symptom-atic patients and 22 asymptomatic patients of whom only 3 (14%) had endoscopically proven signet ring cell cancer preoperatively while 21 of 22 (95%) had it on final pathology (p=0.05). Each asymptomatic patient was T1, N0; while 7 of 8 symptomatic patients had positive lymph nodes. Median follow-up was 7 years. 5 (63%) symptomatic patients died, while only 1 (95%) prophylactic patient died of non-gastric cancer related causes at 2 years postoperatively (p=0.05). 15 of 15 prophylactic patients who were able to be contacted said that each would do the surgery again, while 6 of 15 had some discomfort from reflux (40%).

Conclusions: HDGC is a malignant form of gastric cancer caused by a CDH1 mutation. Prophylactic gastrectomy is indicated for those who inherent a CDH1 mutation because if they wait until the development of symptoms they have a significantly reduced survival.


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Initial Experience with Telemedicine in an Academic Endocrine Surgery Program

Authors: Feibi Zheng, Ki Wan Park, William J. Thi, Michael W. Yeh


Presenter: Ki Wan Park

Objective: To demonstrate the feasibility of incorporating telemedicine into an academic endocrine surgery program.

Background: Telemedicine is an emerging medium for the delivery of ambulatory care. Telemedicine encounters for low-risk surgical patients may improve access to care and efficiency.

Methods: A retrospective assessment of telemedicine encounters for thyroid and parathyroid conditions at a single institution was performed. Encounters occurring from April 2016 to April 2017 were cross referenced with the electronic health record (EHR). Billing data were extracted from the practice management component of the EHR.

Results: Three-hundred and two telemedicine encounters were conducted, of which 7% were initial consultations, 46% post-operative visits, and 46% follow-up visits. The median patient age was 56 years (range 14 to 83 years). The median round-trip travel distance saved was 122 miles and estimated drive time saved was 2.9 hours per encounter. In 2.1% of cases, a second in-person visit within the 90-day global period occurred after a post-operative telemedicine encounter. Charges were filed for 67 encounters, and the unpaid claims rate was 9.2%. The charge to collection ratio was comparable to that of in-person visits. Over the study period, 70 clinic hours were liberated via the use of telemedicine.

Conclusions: Telemedicine was successfully incorporated as a routine component of patient care for thyroid and parathyroid conditions. Telemedicine encounters were widely accepted by patients as a substitute for in-person visits, yielding the advantages of reduced travel burden and increased clinic availability, while having a similar financial profile to in-person visits.


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Faster Discharge after Open Pancreaticoduodenectomy is Not Associated with a Higher Risk of Hospital Readmission

Authors: Jerry P. Jiang, Alexander M. Upfill-Brown, Amanda M. Dann, Mark D. Girgis, Jonathan C. King, Oscar J. Hines, Howard A. Reber, Timothy R. Donahue


Presenter: Jerry Jiang

Objective: To compare the risks and causes for readmission in patients undergoing open pancreaticoduodenectomies (OP) who were discharged expeditiously or after longer index hospital stays.

Background: Expedient discharge of patients after surgery can reduce costs. However, premature discharge poses a risk for subsequent detection of complications and readmission.

Design/Methods: The American College of Surgeons National Quality Improvement Program (NSQIP) database and targeted pancreatectomy (NSQIP-HPB) database were used to identify 5 174 patients undergoing OP from 2014-2015. Demographics, comor-bidities, perioperative factors, length-of-stay (LOS) and 30-day OP specific and general post-operative complications were recorded.

Results: Patients were stratified into “early” or “late-discharge” groups based on LOS≤7 (n=2544, 49.2%) or LOS>7 (n=2630, 50.8%) days. Rates of readmission were 16.7% for e arly and 19.2% for late groups (p<0.001). Late-discharge patients had more complications during their index hospitalization (31.5% vs 12.2%, p<0.001) particularly surgical site infections (SSI) (11.1% vs 1.8%, p<0.001). Fistula was the index complication most associated with readmission in early (HR: 5.074, p<0.001) and late (HR: 2.354 p<0.001) groups. The causes of readmission did not differ significantly between the two groups, with SSI being the most common cause (LOS≤7: 31.4%, LOS>7: 33.2%). Using propensity score modeling to control for other predictors of readmission, a shorter length of stay was not associated with an increased risk for (HR:1.03, p=0.5) or shorter time (HR:0.25, p=0.07) to readmission.

Conclusions: Shorter LOS after OP does not increase the risk for readmission after controlling for other predictors of readmission, thereby validating the premise for enhanced recovery and discharge programs.

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Patient Frailty, Not Just Age, is Associated with Increased Risk of Complications after Adrenalectomy

Authors: Jamie E. Anderson, Carolyn D. Seib, Michael J. Campbell


Presenter: Jamie Anderson

Objective: To evaluate the impact of age and frailty on outcomes of adrenalectomy.

Background: The incidence of adrenal tumors increases with patient age, but the operative risks of adrenalectomy in older patients and the contribution of patient frailty to morbidity have not been well studied.

Methods: We used the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database from 2005-2011 to compare length of stay (LOS) and 30-day morbidity after adrenalectomy according to age and validated modified frailty index (mFI) score. Multivariable regression examined the impact of age and frailty on outcomes after open and laparoscopic adrenalectomy (OA and LA, respectively).

Results: We identified 4,043 patients who underwent 3,091 LA and 952 OA. LA was protective (OR 0.19, 95% CI 0.15-0.25, p<0.001) against serious complications, but patients with higher mFI scores had longer mean LOS and higher rates of serious post-operative complications regardless of the operative approach. On multivariable analysis, increasing mFI score was independently associated with increased risk of serious complications, with >=3 frailty traits associated with an OR of 5.04 vs. patients with 0 frailty traits (95%CI 3.07-8.27, p<0.001). Age was independently associated with increased complications only when patients were older than 75 (vs. less than 50: OR 2.03, 95%CI 1.30-3.16, p=0.002).

Conclusions: Patient frailty is associated with increased risk of complications following adrenalectomy, independent of age or operative approach. The risks of adrenalectomy in frail patients and those older than 75 must be weighed against the potential benefits to ensure appropriate patient selection.

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Preoperative Neutrophil-to-Lymphocyte Ratio is a Predictor of Recurrence in Patients with Stage II Colon Cancer

Authors: Michael A. Esparza, Howard S. Kaufman, Steven G. Katz, Gabriel Akopian

Institution: Huntington Hospital

Presenter: Michael Esparza

Objective: To determine whether preoperative neutrophil-to-lymphocyte ratio (NTLR) is associated with recurrence in patients with stage II colon cancer who undergo resection.

Background: Adjuvant therapy has demonstrated survival benefit in stage II colon cancer patients with high-risk features. NTLR is a simple, inexpensive marker of inflammation and is a predictor of survival in some cancers.

Methods: Medical records were reviewed for patients with pathologic stage II adenocarcinoma of the colon during a six-year period. Patients who died within 30 days of surgery or those had less than 3 years of follow-up were excluded. Preoperative NTLR was calculated. A NTLR of 4 was chosen as the cut-off based on receiver operator characteristic analysis. Kaplan-Meier estimates and Cox proportional hazards models were obtained.

Results: 100 patients with a median age of 70 underwent resection. The mean follow-up was 48 months. Twelve patients (12%) recurred at a median of 18 months. Of these, 8 (67%) had not undergone adjuvant chemotherapy. NTLR >4 was associated with higher recurrence (21% vs. 8%; p=0.05). Demographics, comorbidities, medications, cancer site, emergency surgery, tumor size and number of lymph nodes examined were not associated with recurrence. Cox proportional hazards identified NTLR >4 as a predictor of recurrence (OR 3.22, 95% CI 1.02-10.16; p=0.05).

Conclusions: NTLR >4 was associated with higher recurrence in stage II colon cancer patients. Preoperative NTLR is an inexpensive, readily available biomarker that identifies patients at high-risk for recurrence who may benefit from adjuvant chemotherapy and closer surveillance.


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The Utility of Immunological Markers in Prognostication of Upfront Resectable Pancreatic Cancer. A Cohort Study from an Academic Community Hospital

Authors: Ephraim S. Tang, Philippa H. Newell, Ronald F. Wolf, Paul Daniel Hansen, Benjamin Cottam, Marka R. Crittenden, Michael J. Gough

Institution: Providence Portland Cancer Center

Presenter: Ephraim Tang

Objective: To determine the prognostic value of peripheral and tumor-infiltrating leukocytes in patients with resectable pancreatic ductal adenocarcinoma (PDAC).

Background: We hypothesized that interplay between lymphoid and myeloid cells i n the blood and tumor affect survival after resection for PDAC.

Methods: We conducted a cohort study of resectable PDAC to determine which immu-nologic parameters have prognostic value. Lymphoid and myeloid populations were quantified in peripheral blood drawn on the day of surgery and first post-op visit with quantitative flow-cytometry. Tumor infiltrating immune cells were quantified by immunohistology/digital image analysis. Primary outcome was overall survival.

Results: 64 Patients were recruited from June 2010 to November 2014. Pre-operative analysis of peripheral blood lymphocytes, monocytes and granulocytes did not reveal c orrelation with survival. Analysis of tumor infiltrate revealed positive correlation between CD3+ infiltrate and overall survival (HR 0.27, 95%CI 0.07-0.96, P<0.05). Post-operative analysis revealed higher ratio of CD3+ cells/monocytes correlated negatively with survival (HR 1.27, 95% CI 1.09-1.49, P<0.005). Multivariate Cox model including AJCC stage and receipt of adjuvant therapy, CD3+tumor infiltrate (HR 0.135, 95%CI 0.02-0.82, P<0.05), and post-op CD3/monocyte ratio (HR 1.43, 95%CI 1.18-1.72, P<0.0001), remained significant.

Conclusions: Pre-operative analysis of peripheral lymphocytes did not predict survival. However, tumor infiltrating CD3+ T-cells are a positive prognosticator, while higher ratios of CD3 + monocytes in post-op blood is a negative one. These data suggest that while peripheral blood immunocytes do not reflect the immune environment of the tumor, it is valuable to consider the systemic immune response during recovery from resection.

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Lower Than Expected Completion Thyroidectomy Rate: The Intersection of Clinical Reasoning and Guideline-Based Care

Authors: Kathryn H. Chomsky-Higgins, Yufei Chen, Iheoma Nwaogu, Jessica E. Gosnell, Carolyn D. Seib, Wen T. Shen, Insoo Suh, Quan-Yang Duh


Presenter: Kathryn Chomsky-Higgins

Objective: We hypothesized that clinical practice patterns following the 2015 American Thyroid Association (ATA) guidelines on management of well-differentiated thyroid cancer (WDTC) would differ from projections.

Background: The 2015 ATA guidelines suggest hemithyroidectomy as an alternative to total thyroidectomy (TT) for selected cases of WDTC. Previous analyses suggest that nearly half of these cases would result in completion thyroidectomy based on final pathology.

Design/Methods: We reviewed our 1-4cm WDTC patients since the release of the ATA guidelines, identifying those eligible for initial hemithyroidectomy. Patients with preoperatively-identified high-risk characteristics were excluded. Clinical practice and pathological outcomes were reviewed to determine the implications of the guidelines on extent of thyroidectomy.

Results: Of 61 patients, 43% had high-risk characteristics on final pathology. Overall, 66% initially underwent TT, whereas 34% had hemithyroidectomy. In those who underwent initial TT, 53% had high-risk pathology. On the other hand, in patients who underwent hemithyroidectomy, only 24% required completion. Multinodularity was positively correlated with both need for completion and choice of initial operation.

Conclusions: Consistent with previous analysis, nearly half of all patients require TT based on final pathology. Actual practice demonstrated that only one-third of those eligible underwent initial hemithyroidectomy, and only one-quarter of these patients required completion. Thus, patients are more often appropriately triaged to initial TT based on factors other than ATA guidelines, such as multinodularity. Our findings suggest that, although guidelines are important for evidence-based best practices, they do not obviate the need for well-applied experience and clinical judgment for management of WDTC.


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Current Trends in Breast Surgery: Surgeons, Billing Practices, and Healthcare Disparities in Price of Surgery

Authors: Joshua Tseng, Emma Ngula, Farin F. Amersi, Rodrigo F. Alban


Presenter: Joshua Tseng

Objective: To better understand the business of breast surgery, we analyzed financial data from the Medicare Fee for Service program, and its relationship to provider characteristics and patient demographics.

Background: Healthcare is a rapidly changing industry that has been widely criticized for its lack of transparency.

Methods: Using the Medicare Provider Fee-For-Service Payment Data Public Use Files from 2014-2015, we identified providers who billed for mastectomies and breast recon-struction. Provider zip codes were matched to census data from the 2011-2015 American Community Survey. Markup ratios (amount charged divided by amount allowable by Medicare) were analyzed in terms of provider and patient demographics.

Results: General surgeons performed 71.7% of mastectomies, while surgical oncologists, gynecologists, and ambulatory surgical centers (ASC’s) performed the rest (16.9%, 1.0%, and 8.9%). General surgeons did 10.6% of breast reconstructions, but billed for “breast reconstruction with other technique). Female surgeons captured the majority of market share for mastectomies (53.1%) in contrast to other common general surgical procedures (4.6%). General surgeons charged prices at lower rates compared to oncologists and gynecologists (2.61 vs 3.21 vs 3.49, p<0.001). There was no difference in payment for partial and simple mastectomies by gender or subspecialty (p=0.962 and p=0.750). ASC’s billed at the highest ratio of 6.51 (p<0.001). Independent predictors of higher charges included surgical subspecialty, higher income, and larger Asian population census.

Conclusions: Though physician fee reimbursements are standardized by Medicare, charges for breast surgery widely vary, and higher prices are associated with surgical subspecialty, median household income, and racial composition.

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Biopsy-proven Lymph Nodes Predict Presence or Absence of Residual Axillary Nodal Disease Following Neoadjuvant Chemotherapy in Node-Positive Breast Cancer

Authors: Angelena Crown, Janie Grumley

Institution: Virginia Mason Medical Center

Presenter: Angelena Crown

Objective: This study evaluates the pathologic response in the biopsy proven node as a predictor of residual axillary disease.

Background: Neoadjuvant chemotherapy has become a standard approach for patients with large breast cancers in hopes of allowing for breast conserving surgery. ACOSOG Z1071 reported the inaccuracy of sentinel lymph node biopsy after neoadjuvant chemo-therapy. Axillary lymph node dissection (ALND) has remained standard of care regardless of clinical response.

Methods: Patients with node-positive breast cancer completing neoadjuvant chemotherapy between March 2014 and March 2017 were evaluated. Radiologic markers were placed in the axillary node at the time of biopsy, before neoadjuvant chemotherapy. All patients underwent ALND at the time of breast surgery. The biopsied node (BN) with the radiologic marker was isolated, and evaluated as a separate specimen. The axillary packet (AP) was evaluated for additional nodal disease.

Results: 25 patients with node positive breast cancer were identified and underwent neoadjuvant chemotherapy between March 2014 and March 2017. All 25 BN were identified. 10 patients had complete pathologic response in the breast. 13 patients had no residual cancer in the BN and no additional disease within the AP. 9 patients with persistent disease in the BN had additional nodal disease in the AP. 3 patients had disease in the BN only.

Conclusions: The biopsied node predicted the presence or absence of residual axillary nodal disease in all patients in this series. Complete pathologic response in the BN may be useful in identifying patients who may not need ALND after neoadjuvant chemotherapy.


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Delayed Operative Intervention in Traumatic Injury

Authors: Anne M. Stey, Tasce Bongiovanni, Amanda Conroy, Rachael Callcut


Presenter: Anne Stey

Objective: To determine the type and impact of delayed abdominal operations for traumatic injury.

Background: Timing of procedural intervention has been identified as a quality metric benchmark for patients undergoing operative intervention following abdominal injury. This study investigates the National trends in delayed intervention.

Methods: The National Trauma Data Bank National Sample Program 2008-2012 weighted file was used to identify patients older than 12 years of age who underwent initial exploratory laparotomy following traumatic injury. Delayed was defined as greater than one day following presentation. Survey weighted univariate analysis compared delayed and non-delayed operative procedure rates, perioperative management, and outcomes.

Results: 2,269 patients underwent a delayed initial exploratory laparotomy. Operative delay rates were similar among all five years ranging from 3.6-6.4%. The most frequent non-delayed procedures were bowel injury repair, 11.1%, and splenectomy, 8.2%. The most frequent delayed procedures were splenectomy, 19.0% and laceration closure, 11.8%. Patients with operative delays were more likely to go to the intensive care unit 28.9% vs. 4.2% or step-down 23.7% vs. 1.3% from the emergency room compared to patients without delays who went directly to the operating room; 90.1% vs. 30.5%. Patients who experienced operative delays had significantly more ventilator days 5.0 vs. 1.3, intensive care days 8.3 vs. 2.3 and total hospitalization days; 15.4 vs. 8.0.

Conclusions: Splenectomy was one of the most frequently performed non-delayed and delayed operative procedures. Patients in the delayed group had increased ventilator days, ICU days and total hospitalization days.


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Mini-Podium SessionsC


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Mini-Podium Sessions CAll Scientific Session and Mini-Podium Presentation authors and presenters are MDs unless otherwise noted.

SESSION C

C1: The National Inpatient Sample is Not Sufficiently-Powered for Hospital Quality-of-Care Evaluation Presenter: Yas Sanaiha C2: SCIP Measures Have Not Reduced the Incidence and Financial Burden of Complications Following Cardiac Operations Presenter: Yas Sanaiha

C3: Adverse Effects of Computers During Bedside Rounds in a Critical Care Unit Presenter: Navpreet Dhillon

C4: Influences of Antiviral Treatment Era and Etiology of Liver Disease on Early Graft Survival after Liver Transplantation Presenter: Nicholas Parrish

C5: Combined Posterior and Video- Assisted Transaxillary First Rib Resection: A Novel Approach Presenter: Angelena Crown

C6: Aggressive Pre-Operative Continuous Renal Replacement Therapy (CRRT) Improves Outcomes for Orthotopic Liver Transplantation (OLT) Presenter: Brian Nguyen

C7: Does Size Matter? An Analysis of the National Cancer Database (NCDB) to Assess Predictive Factors Associated with Conversion from Minimally Invasive to Open Thymectomy Presenter: Douglas Liou

C8: Delayed Video-Based Assessment Provides Similar Results to Immediate Operative Performance Ratings Presenter: Barnard Palmer C9: Robotic Stellate Ganglionectomy and Sympathectomy for Refractory Tachyarrhythmias Presenter: Jane Yanagawa

C10: Under-Treated Medical Conditions, Not Trauma, are Primary Indications for Limb Amputation at a Referral Hospital in Cameroon Presenter: Nikola Teslovich

C11: Simulation Curriculum Increases Learners’ Confidence and Interest in Cardiothoracic Surgery Presenter: Rebekah Macfie

C12: Disparities in Peptic Ulcer Disease: A Nationwide Study Presenter: Joaquim Havens

C13: Effective Augmentation of the Deceased Donor Pool by Utilization of Organs from Small (15 kg) Pediatric Donors with Acute Kidney Injury: Matched-Pair Analysis of 68 Pediatric en Bloc Kidney Transplants Presenter: Christoph Troppmann

– Moderators


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Mini Podium Session: C # 1

The National Inpatient Sample is Not Sufficiently-Powered for Hospital Quality-of-Care Evaluation

Authors: Yas Sanaiha1, Yen-Yi Juo1, Young-Ji Seo1, Esteban Aguayo1, Aditya Mantha2, Peyman Benharash1

Institution: 1University of California - Los Angeles; 2University of California - Irvine

Presenter: Yas Sanaiha

Objective: Efficacy of National Inpatient Sample(NIS) to assess hospital quality-of-care.

Background: Population-based administrative databases such as the National Inpatient Sample (NIS) are increasingly used to benchmark hospital quality. It is unclear whether sufficient case volumes for quality analysis are present after 2012 when the sampling methodology of NIS changed to include 20% of all hospitalizations.

Methods: Patients having any of the six procedures endorsed by the Agency for Health-care Research and Quality (AHRQ) for quality benchmarking were identified from NIS 2012-14. Primary outcome of interest was in-hospital mortality while the case volume threshold to detect a doubling of mortality rate was calculated with a one-sided Student’s t-test using a power of 0.8 and alpha of 0.05.

Results: Among the 9,529 hospitals performing at least one of the eligible procedures, median sampled annual case volume/ hospital ranged from one case for esophagectomy to 27 for coronary artery bypass grafting (CABG). None of the hospitals had adequate volume to exhibit a statistically significant doubling of the national average mortality for pancreatectomies, abdominal aortic aneurysm repairs, esophagectomies, CABG or hip replacements. Only 26.9% hospitals had adequate power to detect a doubling of mortality after craniotomies(p<0.05).

Conclusions: For the six benchmarking surgical procedures, most hospitals within NIS do not have sufficient sampled case volume to allow detection of deviation from national average incidence of mortality or complications. The current NIS algorithm in does not allow valid inferences to be made regarding hospital quality-of-care and alternate method should be further explored.

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SCIP Measures Have Not Reduced the Incidence and Financial Burden of Complications Following Cardiac Operations

Authors: Yas Sanaiha1, Yen-Yi Juo1, Aditya Mantha2, Esteban Aguayo1, Richard J. Shemin1, Boback Ziaeian1, Peyman Benharash1

Institution: 1University of California - Los Angeles; 2University of California - Irvine

Presenter: Yas Sanaiha

Objective: To assess the impact of Surgical Care Improvement Project (SCIP) on rates and costs of complications after cardiac surgery.

Background: Introduced in 2006, SCIP measures have aimed to reduce surgical complica-tions. We postulated a reduction in infectious and cardiovascular complications in cardiac surgery following implementation of SCIP guidelines for glucose control, beta-blockers, and antibiotics. We further aimed to identify complications associated with high resource utilization as targets for quality improvement.

Methods: The National Inpatient Sample was used to identify adults undergoing coronary/valve operations between 2005-2014. The primary outcome of interest was the financial burden of complications including: cardiovascular, respiratory, infectious and renal. Linear regressions were used to calculate risk-adjusted rates of complications and attributable costs.

Results: Of the 3,026,900 identified patients, 45% developed at least one complication. Chronic kidney disease (OR 1.67, CI 1.60-1.74), heart failure (OR 1.19, CI 1.16-1.22), diabetes (OR 1.13, CI 1.11-1.15) and increased Elixhauser comorbidity index were inde-pendently associated with the occurrence of complications. The aggregate complication rate rose significantly over the study period with concomitant increases in cardiovascular, infectious and renal categories (all P<0.01). Respiratory and not infectious complications comprised the largest financial burden ($3.66 billion/year) with significantly increasing costs throughout the study period (FIGURE).

Conclusions: Despite introduction of SCIP, infectious and cardiovascular complications following cardiac operations have increased. While the rapid rise in incidence and resource use for respiratory complications may reflect changes in patient characteristics, the findings of this study warrant further investigation of methods to reduce the burden of this problem.

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Adverse Effects of Computers During Bedside Rounds in a Critical Care Unit

Authors: Navpreet K. Dhillon, Sarah E. Francis, James M. Tatum, Galinos Barmparas, Michelle Keller, Bruce L. Gewertz, Eric J. Ley


Presenter: Navpreet Dhillon

Objective: To assess how “computers on wheels” (COW) impact communication during multidisciplinary rounds (MDR).

Background: MDR, which improve communication and facilitate consensus on the plan of care, often incorporate COW to access the electronic medical record. We hypothesized that COW usage affects communication.

Methods: A prospective, observational study was conducted from March to May 2017 at a 24-bed surgical intensive care unit (SICU) at a tertiary center. MDR include an attending, critical care fellow, residents, a pharmacist, nurses, and a respiratory therapist. Observers trained in human factors analysis recorded the presence of communication barriers, which were defined as simultaneous conversations within the rounding group during a presentation, phone usage during a presentation, nursing or physician interrup-tions, or difficulty hearing. A targeted intervention was implemented where the number of COW was reduced by half. The frequency of communication barriers was compared before and after the intervention.

Results: A total of 229 individual patient presentations were observed before and 200 after the intervention. Reduction in COW was associated with decreases in simultaneous conversations within the rounding group (50.7% vs. 28.5%, p<0.01) and difficulties in hearing the presentation (51.1% vs. 20.0%, p<0.01). Phone use (63.3% vs. 68.5%, p=0.30), nursing interruptions (5.7% vs. 6%, p=0.89), and physician interruptions (5.7% vs. 5.5%, p=0.94) were unchanged.

Conclusions: A reduction in COW resulted in improved communication as reflected in the ability to hear more case presentations and fewer distracting conversations. Optimization of human-computer interactions through alternative technologies may improve care in the SICU.

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Influences of Antiviral Treatment Era and Etiology of Liver Disease on Early Graft Survival after Liver Transplantation

Authors: Nicholas F. Parrish, Irene D. Feurer, Scott A. Rega, Sophoclis P. Alexopoulos

Institution: Vanderbilt University

Presenter: Nicholas Parrish

Objective: Understand how new HCV treatments impact liver transplant outcomes.

Introduction: We hypothesized that with increasingly effective HCV antiviral classes, survival of grafts transplanted for HCV would improve more than for HBV, for which effective antivirals have been available since 1998, or non-alcoholic steatohepatitis (NASH), for which no disease-modifying medications exist.

Methods: We analyzed 22,480 liver transplant recipients with decompensated cirrhosis due to HCV, HBV or NASH from the Scientific Registry of Transplant Recipients (June 2017 release). Antiviral era was stratified as: Interferon (IFN) from 2003 to 2010, protease inhibitors (PI) from 2011 to 2013, and direct-acting antivirals (DAA) since 2014.

Results: Proportions of transplants for HCV decreased (34.9 to 21.5%) and NASH increased (6.5 to 17.2%) with each advancing era (all p<0.05). After adjusting for demo-graphic and clinical covariates, the effect of antiviral era on early graft survival differed by diagnosis (p<0.001). This reflects steadily improving graft survival for HCV with each advancing era, whereas there were no consistent temporal trends for HBV or NASH. There was 40% higher risk of early graft loss for HCV compared to NASH in the IFN era (HR=1.41, 95%CI=1.24-1.59), but not in the DAA era (HR=0.87, 95%CI=0.72-1.07).

Conclusions: Increasing effectiveness of HCV antivirals has corresponded with decreased transplantation for HCV and improved survival of grafts transplanted for HCV cirrhosis, outpacing improvements in survival of grafts transplanted for HBV or NASH cirrhosis. Considering the necessarily limited follow-up available in the DAA era, graft survival for HCV now parallels that for NASH.

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Combined Posterior and Video-Assisted Transaxillary First Rib Resection: A Novel Approach

Authors: Angelena Crown, Jean-Christophe Leveque, Thomas Biehl, Michal Hubka

Institution: Virginia Mason Medical Center

Presenter: Angelena Crown

A 28-year-old female presented with a palpable supraclavicular mass and chest discomfort. A chest CT demonstrated a 10 x 3.2 cm cystic mass largely replacing the right first rib and impinging upon her brachial plexus and subclavian vessels. To minimize morbidity, we offered her a combined posterior and video-assisted transaxillary approach first rib resection. From a lateral decubitus position, the neurosurgery team began the posterior disarticulation on the rib while we mobilized it thoracoscopically through an inframammary incision and from the auscultatory triangle. An axillary incision facilitated dissection of the rib off of the brachial plexus and subclavian vessels. The mass and rib were amputated and liberated through the axillary incision. The patient did well postop-eratively and discharged home on post-op day #5. Final pathology demonstrated a 6.8 cm tumor of fibrous dysplasia. Follow up CT at 4 months showed complete rib resection with no abnormalities.


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Aggressive Pre-Operative Continuous Renal Replacement Therapy (CRRT) Improves Outcomes for Orthotopic Liver Transplantation (OLT)

Authors: Brian M. Nguyen, Alejandro Pita, Rachel Hogen, Kiran Dhanireddy, Damon Clark, J. Perrin Cobb, Subarna Biswas, Kenji Inaba, Aaron Strumwasser

Institution: University of California – Los Angeles

Presenter: Brian Nguyen

Objective: To evaluate the effects of pre-operative CRRT with massive volume removal in pre-OLT patients with volume overload.

Background: End-stage liver disease (ESLD) patients awaiting transplant are often volume overloaded with diuretic resistance, and have marginal hemodynamics from systemic vasodilation. Continuous renal replacement therapy (CRRT) is suggested as a therapy that mitigates the deleterious effects of volume overload, but the amount of volume removal and its impact on outcomes remain uncertain. We hypothesized that pre-operative CRRT may reverse the deleterious effects of ESLD in patients awaiting OLT.

Methods: A total of 100 deceased donor allograft recipients that underwent pre-operative CRRT were analyzed (years 2013-2015). Massive volume removal was defined as patient loss of >10% ideal body weight. After matching for baseline characteristics, outcomes were compared between the massive volume removal patients (n=51) and those that underwent <10% volume removal (n=40). Data is represented as mean [SD] with significance at a p≤0.05.

Results: Groups were matched for age (54[8.1] vs. 54[10.3] y), BMI (27[7.8] vs. 28[6.0]), pre-CRRT MELD (28[8.7] vs. 27[11]) and pre-operative MELD (39[5.4] vs. 38[7.4]). The massive volume removal group had shorter hospitalization (32[16.0] vs. 47[37.5]d, p=0.02), less intra-operative coagulopathy (9.8%vs 43%, p=0.0003), blood loss (4508[2333]ml vs. 7885[5870]ml, p=0.003), and fewer post-operative neurologic complications (6.3% vs. 25%, p=0.02). There was no difference in cardiovascular complications, post-operative renal recovery, mortality and graft survival (p>0.1 for each).

Conclusions: Pre-operative CRRT > 10% IBW may reduce the impact of volume overload associated with ESLD and improve OLT outcomes.

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Does Size Matter? An Analysis of the National Cancer Database (NCDB) to Assess Predictive Factors Associated with Conversion from Minimally Invasive to Open Thymectomy

Authors: Douglas Liou1, Fernando Espinoza-Mercado2, Jerald Borgella2, Taryne A. Imai2, Hrag Bairamian2, Miguel Burch2, Harmik J. Soukiasian2

Institution: 1Stanford University; 2Cedars-Sinai Medical Center

Presenter: Douglas Liou

Objective: Determine risk factors for conversion from minimally invasive to open thymectomy.

Background: Minimally invasive thymectomy (MIT), either VATS or Robotic, may be the initial surgical approach for thymectomy. Risk factors and outcomes for conversion to open resection (COT) are unclear. We hypothesize tumor size and stage are associated with conversion.

Methods: The NCDB was queried for comorbidity adjusted patients with Masaoka stage I-III thymoma who underwent attempted MIT during 2010-2014. Outcomes and 5-year overall survival of successful MIT were compared to COT patients. Multivariable logistic regression was performed to determine factors associated with conversion.

Results: 315 patients underwent attempted MIT. 28(8.9%) were converted to open thymectomy. There were no differences in age, gender, race, Charlson-Deyo comorbidity index, facility type, Masaoka stage, margin status, readmissions, and perioperative mortality between COT and MIT patients. COT had significantly larger tumor size (7.0 vs. 4.5 cm, p=0.002) as well as longer postoperative length of stay compared to MIT (4 vs. 2 days, p=0.003). 5-year survival was similar; 75.2% in COT vs. 88.6% in MIT (p=0.29). Multivariable logistic regression revealed Masaoka stage III did not (adjusted odds radio AOR 1.2, p=0.73) predict conversion to open thymectomy. Only tumor size >7cm (AOR 4.6, p<0.001) was predictive of conversion.

Conclusions: MIT is successful greater than 90% of thymectomies (Masaoka stage I-III tumors). Tumor size was the only variable associated with conversion to open thymec-tomy. Interestingly, Masaoka stage was not a significant factor in conversion. We suggest COT should be considered over MIT for tumors >7cm.

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Delayed Video-Based Assessment Provides Similar Results to Immediate Operative Performance Ratings

Authors: Barnard Palmer, Emily Miraflor, Gregory Victorino


Presenter: Barnard Palmer

Objective: We hypothesized that video-based delayed evaluations would provide similar ratings to those immediately completed.

Background: Evaluator time restraints are a notable obstacle in technical evaluation of resident operative skills. Resident Operative performance ratings (OPRs) completed more than 3 days after observation have been discouraged due to diminished evaluation quality. We aimed to determine whether video-based evaluation could eliminate short-comings of delayed OPRs.

Methods: Thirty-nine laparoscopic cholecystectomies by 23 residents in a single residency were prospectively recorded and assessed using the Operative Performance Rating tool. Single observer evaluations were performed immediately upon procedure completion followed by repeat delayed OPRs at an interval of greater than 30 days using video recordings only. Immediate and delayed OPRs were compared using paired t-tests and analysis of item-to-item variance. Feedback comment number and percentages of global versus specific comments were examined.

Results: Ninety-seven percent of delayed video rating items were within 1 of immediate scores while 55% were identical. There were no statistically significant differences in mean scores of any rating items. Average numbers of comments were 11.8 and 17.2 (p < 0.001 ) while specific comments numbered 8.4 and 12.8 (p<0.001) per operation in immediate and delayed evaluations, respectively. Average item-to-item variation did not statistically differ (8.16 v. 8.06; p = 0.898).

Conclusions: Delayed operative assessment via video-based format offers similar ratings when compared to immediate in-person OPRs. Roles of delayed video ratings have not been determined, but they may serve as an alternative assessment method when immediate evaluations are not feasible.

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Robotic Stellate Ganglionectomy and Sympathectomy for Refractory Tachyarrhythmias

Authors: Jane Yanagawa, Vishal Dobaria, Peyman Benharash


Presenter: Jane Yanagawa

Objective: To establish robot-assisted thoracoscopy as a method of performing bilateral cardiac sympathetic denervation (CSD) in patients with refractory tachyarrhythmias.

Background: Bilateral CSD has been shown to reduce implantable cardioverter- defibrillator (ICD) shocks in patients with refractory ventricular tachyarrhythmias. The robotic approach has not been previously described for this procedure in this patient population.

Methods: A patient with non-ischemic cardiomyopathy and ventricular tachycardia refractory to medical management leading to recurrent ICD shocks was referred for bilateral CSD. He underwent Xi robot-assisted thoracoscopy (using three 8mm robot ports with no additional access or assistant ports required) to perform bilateral partial stellate ganglionectomy/T1-T4 sympathectomy. Approximately 50% of the stellate ganglion was resected on both sides.

Results: The patient tolerated the procedure well. He was discharged home on post- operative day 3 with no intra- or post-operative complications.

Conclusions: Robot-assisted thoracoscopy is a safe method for performing bilateral CSD in patients with refractory tachyarrhythmias.


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Under-Treated Medical Conditions, Not Trauma, are Primary Indications for Limb Amputation at a Referral Hospital in Cameroon

Authors: Nikola T. Teslovich1, Joesph D. Forrester1, Samuel Nigo2, James A. Brown2, Sherry M. Wren1

Institution: 1Stanford University; 2Mbingo Baptist Hospital

Presenter: Nikola Teslovich

Objective: Investigate indications for amputation in low-resource settings and identify factors associated with in-hospital morbidity and mortality.

Background: Historically, 40-70% of amputations are trauma-related in low-resource settings. Yet non-communicable diseases (NCD) like diabetes (DM) and peripheral vascular disease (PVD) are increasingly common. We hypothesized NCDs have overtaken trauma as the primary cause for amputation with post-operative morbidity and mortality driven by un- or under-treated medical conditions.

Methods: Retrospective cohort study of amputations performed at rural referral hospital in Cameroon from May 2014-2015. Patients were identified through operative case logs and perioperative variables from chart review.

Results: One hundred seventy-five amputations were performed including 75 (44%) above-knee, 70 (41%) below-knee, 11 (6%) above-elbow, 8 (5%) transmetatarsal, 3 (2%) below-elbow, 2 (2%) disarticulations and 1 (1%) partial-hand. Median patient age was 58 years (1-95 years) with 105 (63%) males. One hundred twenty-one (71%) amputations were performed for infection, 23 (14%) for PVD, 17 (10%) for cancer, and only 8 (5%) for trauma sequelae. Seventy-four (65%) amputees had known DM prior to admission with 39 (53%) actually receiving diabetic medication pre-admission. One hundred twenty-eight amputees had hemoglobin A1c obtained at admission, 119 (93%) had values >6.5%. There were 29 (17%) in-hospital fatalities; fatality was associated with prolonged anesthesia time (p=0.01) and intraoperative oxygen saturation < 90% (p=0.02).

Conclusions: In Cameroon, infections and vascular disease stemming from un- or under-treated DM and PVD, not trauma, are driving amputations. Improving disease management in these patient populations may decrease frequency, morbidity, and mortality of amputation.

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Simulation Curriculum Increases Learners’ Confidence and Interest in Cardiothoracic Surgery

Authors: Rebekah Macfie1, Sarah Walcott-Sapp1, Justin Watson1, Caleb Haley2, Elizabeth Dewey1, Kenneth Azarow1, Paul Schipper1

Institution: 1Oregon Health & Science University; 2University of Michigan

Presenter: Rebekah Macfie

Objective: To describe the impact of a longitudinal simulation curriculum in cardiothoracic (CT) surgery on learners’ interest and confidence in performing CT surgery.

Background: Simulation in cardiothoracic surgery is an emerging and rapidly progressing field, however best practices have yet to be defined. This study describes a longitudinal, high-fidelity simulation curriculum for trainees of various levels.

Methods: Medical students (n=31), general surgery residents (n=26) and CT fellows (n=15) participated in seven unique, high-fidelity cardiothoracic simulations proctored by CT faculty. Following each simulation participants completed an eleven-question survey evaluating the simulation on a Likert-type scale.

Results: Participation in CT simulation curriculum significantly increased learners’ operative confidence (p<0.0001). Of participants who were not confident prior to participation, 75% increased confidence by at least one level and 39% increased at least two levels. Learners of all levels perceived simulation-based education as being effective. Across the seven experiences 82-100% of participants ranked the simulations as Good or Great in effectiveness and 100% of participants would recommend the curriculum to a colleague. Participation in the simulation curriculum increased participants’ interest in CT surgery; the magnitude of increase was significantly greater for learners early in their training (p=0.0012).

Conclusions: A high-fidelity longitudinal cardiothoracic simulation curriculum significantly increased participant’s operative confidence and interest in a career in CT surgery. Learners are accepting of these methods and would recommend them to colleagues. These findings demonstrate that early implementation of simulation-based training can help attract and train the next generation of cardiothoracic surgeons.

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Disparities in Peptic Ulcer Disease: A Nationwide Study

Authors: Joaquim M. Havens, Manuel Castillo-Angeles, Stephanie Nitzschke, Reza Askari, Deepika Nehra, Ali Salim

Institution: Brigham and Women’s Hospital

Presenter: Joaquim Havens

Objective: To evaluate for disparities in the management and outcomes for peptic ulcer disease in the United States.

Background: Peptic ulcer disease (PUD) requiring intervention still represents a critical source of morbidity and mortality nationally. Racial and socioeconomic disparities have been previously described in the surgical setting, but not in this population.

Methods: We queried the Nationwide Inpatient Sample (2012-2013). All inpatients with a primary diagnosis of PUD were included. Demographics, ulcer location, complication, procedures (esophagogastroduodenoscopy [EGD], surgery and catheter embolization) and outcomes were obtained. The primary outcome was in-hospital mortality. Multivariable regression models were used.

Results: A weighted total of 210,000 PUD admissions were identified. Overall mortality was 2.6%. Hemorrhage was the most common complication (86.67%), and perforation had the highest mortality (5.96%). For hemorrhage and perforation, choice of procedure differed by race (p=0.019 and 0.016, respectively), but didn’t differ by insurance status (p=0.44 and 0.10, respectively). For hemorrhage, Black patients had higher rates of EGD (97.4%vs. 97.1%) and lower rates of surgery (1.9%vs. 2.2%) when compared to White patients (p=0.019). For perforation, Black patients had higher rates of Surgery (97.2% vs. 95.9%) and lower rates of EGD (2.8% vs. 4.1%) when compared to White patients (p=0.016). Being uninsured (OR 1.52, 95% Confidence Interval 1.02-2.26) was a significant predictor of in-hospital mortality.

Conclusions: PUD represents a group of low frequency but highly morbid emergency procedures. While there are racial differences in procedure selection, these differences are small. Unlike other surgical conditions insurance status, not race predicts mortality in PUD.


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Effective Augmentation of the Deceased Donor Pool by Utilization of Organs from Small (15 kg) Pediatric Donors with Acute Kidney Injury: Matched-Pair Analysis of 68 Pediatric en Bloc Kidney Transplants

Authors: Christoph Troppmann, Chandrasekar Santhanakrishnan, Kathrin Troppmann, John McVicar, Junichiro Sageshima, Richard Perez


Presenter: Christoph Troppmann

Objective: To test the hypothesis that acute kidney injury (AKI) in small pediatric kidney donors does not impact long-term transplant outcomes.

Background: Kidneys from small pediatric donors with AKI are frequently discarded due to the perception that AKI adversely impacts outcomes—although the lack of cellular senescence may uniquely predispose these kidneys to recover from their acute injury.

Methods: AKI was defined as terminal donor creatinine [mg/dL] ≥1.5 for donors 0-14 days and ≥1.0 for donors >14 days old. Among 219 pediatric en-bloc transplants from donors ≤15kg performed 11/2003-01/2015 at our institution, we identified 29 AKI grafts that were pair-matched (for donor weight, DCD setting [7%], preservation time) with 29 no-AKI grafts (median overall recipient age, 50.3 [7-76] years). Our standard protocol includes hypothermic pulsatile perfusion pre-implantation, rATG induction, and steroid-free maintenance with tacrolimus and mycophenolate mofetil.

Results: Table 1 shows donor and preservation characteristics. Delayed graft function (first-week-dialysis) was more frequent in AKI (48.3%) vs. no-AKI (13.8%) grafts (p=0.01). Early graft loss (≤90 days) from graft thrombosis or primary nonfunction occurred for 3 (10.3%) AKI vs. 2 (6.7%) no-AKI grafts (p=n.s.). At 1 and 5 years, neither death-censored graft survival (at both time points: 83% [AKI] vs. 89% [no-AKI]; p=0.46) nor graft function were significantly affected by AKI.

Conclusions: Despite slower early function in AKI grafts, long-term graft survival and function were excellent and unaffected by AKI. Our outcomes suggest that AKI in small pediatric donors should not contraindicate donation and that these donors can expand the deceased donor pool.


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93

PCSA Founders

Harold Brunn

Thomas O Burger

Samuel H. Buteau

S. L. Caldbick

Robert C. Coffey

Walter B. Coffey

John F. Cowan

Richard B. Dillehunt

Sumner Everingham

Charles Fox

Edgar L. Gilcrest

Philip K. Gilman

Frank Hinman

W. D. Kirkpatrick

Otis F. Lamson

A. Stewart Lobinger

Charles D. Lockwood

A.O. Lee

J. Tate Mason

A. Aldridge Matthews

J. B. McNerthney

Wayland A. Morrison

Howard C. Naffziger

Charles E. Phillips

Emmet Rixford

Samuel Robinson

Paul Rockey

Hnery Sherk

Ernst A. Sommer

Stanley Stillman

Charles T. Sturgeon

George W. Swift

Wallace G. Toland

Alanson Weeks

Horace G. Wethrill


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PCSA Past Presidents

PRESIDENT ELECTED LOCATION MEETING CAUCUS YEAR YEARJonathan R. Hiatt 2016 Indian Wells, CA 2017 SCKaren Deveney 2015 Kohala Coast, HI 2016 HI/ORWilliam P. Schecter 2014 Monterey, CA 2015 NCFred Weaver 2013 Dana Point, CA 2014 SCMika Sinanan 2012 Kauai, HI 2013 AK/BC/WAJames Holcroft 2011 Napa Valley, CA 2012 NCJames Atkinson 2010 Scottsdale, AZ 2011 SCJames J. Peck 2009 Maui, HI 2010 HI/OROrlo Clark 2008 San Francisco, CA 2009 NCBruce Stabile 2007 San Diego, CA 2008 SCMichael J. Hart 2006 Kohala Coast, HI 2007 AK/BC/WACornelius Olcott IV 2005 San Francisco, CA 2006 NCSamuel Eric Wilson 2004 Laguna Nigel/ 2005 SC Dana Point, CALivingston Wong 2003 Wailea, HI 2004 HI/ORThomas R. Russell 2002 Monterey, CA 2003 NCTheodore X. O’Connell 2001 Las Vegas, NV 2002 SCJohn K. MacFarlane 2000 Banff, AB 2001 AK/BC/WARobert C. Lim, Jr. 1999 San Francisco, CA 2000 NCThomas V. Berne 1998 San Jose del Cabo, Baja 1999 SCR. Mark Vetto 1997 Kaanapali Beach, HI 1998 HI/ORF. William Heer 1996 Napa Valley, CA 1997 NCRonald K. Tompkins 1995 San Diego, CA 1996 SCMeredith P. Smith 1994 Seattle, WA 1995 AK/BC/WANorman M. Christensen 1993 Sacramento, CA 1994 NCLouis L. Smith 1992 Scottsdale, AZ 1993 SCClare G. Peterson 1991 Keoneloa Bay 1992 HI/OR at Poipu, Kauai, HIAllen H. Johnson 1990 Pebble Beach 1991 NCEric W. Fonkalsrud 1989 Laguna Nigel, CA 1990 SCGeorge I. Thomas 1988 Vancouver, BC 1989 AK/BC/WAJohn K. Stevenson 1988 Vancouver, BC 1989 AK/BC/WAF. William Blaisdell 1987 San Francisco, CA 1988 NCJohn E. Connolly 1986 Rancho Mirage, CA 1987 SCThomas J. Whelan, Jr. 1985 Maui, HI 1986 HI/ORRoy Cohn 1984 Monterey, CA 1985 NC


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PRESIDENT ELECTED LOCATION MEETING CAUCUS YEAR YEARWiley F. Baker 1983 Newport Beach, CA 1984 SCHilding H. Olson 1982 Seattle, WA 1983 AK/BC/WADavid J. Dugan 1981 Napa Valley, CA 1982 NCWilliam R. Mikkelsen 1980 Coronado, CA 1981 SCThomas R. Montgomery 1979 Hawaii 1980 HI/ORPhilip R. Westdahl 1978 Yosemite, CA 1979 NCWilliam F. Pollock 1977 Newport Beach, CA 1978 SCCarl R. Schlicke 1976 Palm Springs, CA 1977 AK/BC/WARalph D. Cressman 1975 Monterey, CA 1976 NCMax R. Gaspar 1974 Scottsdale, AZ 1975 SCAllen M. Boyden 1973 Kaanapali Beach, HI 1974 HI/ORPaul C. Samson 1972 Yosemite, CA 1973 NCGordon K. Smith 1971 San Diego, CA 1972 SCJoel W. Baker 1970 Mexico City, Mexico 1971 AK/BC/WAH. Brodie Stephens 1969 San Francisco, CA 1970 NCLyman A. Brewer III 1968 Palm Springs, CA 1969 SCMatthew McKirdie 1967 Honolulu, HI 1968 HI/ORLeon Goldman 1966 Monterey, CA 1967 NCArthur Pattison 1965 Palm Springs, CA 1966 SCRalph H. Loe 1964 Vancouver, BC 1965 AK/BC/WACarleton Mathewson, Jr. 1963 San Francisco, CA 1964 NCJohn C. Jones 1962 Palm Springs, CA 1963 SCJohn E. Raaf 1961 Portland, OR 1962 HI/ORRobert A. Scarborough 1960 San Francisco, CA 1961 NCClarence J. Berne 1959 Palm Springs, CA 1960 SCCaleb S. Stone, Jr. 1958 Victoria, BC 1959 AK/BC/WAH. Glenn Bell 1957 Santa Barbara, CA 1958 NCWilliam J. Norris 1956 Palm Springs, CA 1957 SCLouis R. Gambee 1955 Palm Springs, CA 1956 HI/ORLoren R. Chandler 1954 Yosemite, CA 1955 NCE. Eric Larson 1953 Santa Barbara, CA 1954 SCAlexander B. Hepler 1952 Harrison Hot Springs, BC 1953 AK/BC/WAAlson R. Kilgore 1951 Del Monte, CA 1952 NCWilliam K. Kroger 1950 Coronado, CA 1951 SCEugene W. Rockey 1949 Gearhart, OR 1950 HI/ORHoward C. Naffziger 1948 San Francisco, CA 1949 NC


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PRESIDENT ELECTED LOCATION MEETING CAUCUS YEAR YEARLeroy B. Sherry 1947 Los Angeles, CA 1948 SCHomer D. Dudley 1946 Victoria, BC 1947 AK/BC/WAPhilip K. Gilman 1945 San Francisco, CA 1946 NCPhilip K. Gilman 1944 No meeting due to WWII 1945 NCPhilip K. Gilman 1943 No meeting due to WWII 1944 NCPhilip K. Gilman 1942 No meeting due to WWII 1943 NCPhilip K. Gilman 1941 No meeting due to WWII 1942 NCCharles T. Sturgeon 1940 Los Angeles, CA 1941 SCRichard B. Dillehunt 1939 Pointland, OR 1940 HI/ORSumner Everginham 1938 Del Monte, CA 1939 NCWayland A. Morrison 1937 Los Angeles, CA 1938 SCOtis F. Lamson 1936 Vancouver, BC 1937 AK/BC/WAHarold Brunn 1935 Del Monte, CA 1936 NCE. C. Moore 1934 Santa Barbara, CA 1935 SCErnst A. Sommer 1933 Gearhart, OR 1934 HI/OREmmet Rixford 1932 Del Monte, CA 1933 NCRea Smith 1931 Santa Barbara, CA 1932 SCJ. Tate Mason 1930 Victoria, BC 1931 Wallace I. Terry 1929 Del Monte, CA 1930 NCA. Stewart Lobinger 1928 No info available 1929 No info availableRobert C. Coffey 1927 No info available 1928 No info availableStanley Stillman 1926 No info available 1927 No info availableCharles D. Lockwood 1925 Del Monte, CA 1926 NCFounder’s Meeting San Francisco, CA 1925


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PCSA New Members: Class of 2018

Deanna J. AttaiCaucus: Southern CaliforniaSpecialty: Breast SurgeryHobbies/Interests: Social media for patient education and professional collaboration, organic vegetable gardeningSponsors: Armando Giuliano, Jonathan Hiatt, Joe Hines

Karen BraselCaucus: Oregon/HawaiiSpecialty: General SurgeryHobbies/Interests: Reading, running, skiingSponsors: Karen Deveney, John Hunter, Martin Schreiber

Timothy BrowderCaucus: Northern CaliforniaSpecialty: Trauma and Critical Care SurgerySponsors: Kenji Inaba, Ali Salim, David Spain

Robert M. CahnCaucus: Oregon/HawaiiSpecialty: General SurgerySpouse/Partner: Taryn WheelerHobbies/Interests: Cycling, running, cooking, guitarSponsors: Clifford Deveney, Karen Deveney, Sharon Lum


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Emily FinlaysonCaucus: Northern CaliforniaSpecialty: Colorectal SurgeryHobbies/Interests: nappingSponsors: Quan-Yang Duh, Wen Shen, Madhulika Varma

Philip K. FrykmanCaucus: Southern CaliforniaSpecialty: Pediatric SurgerySpouse/Partner: Channing Frykman, M.D.Children: Ryan and KristenHobbies/Interests: I most enjoy spending time with my wife, Channing, and children at home. I am also passionate about pediatric surgical missions focused on education. My colleagues and I co-founded Global Pediatric Surgical Technology and Education Project (GPSTEP), a nonprofit which developed and deploys low-cost surgical instrumentation for repair of anorectal malformations to resource poor areas around the world. I also enjoy surfing, skiing, cycling and triathlons.Sponsors: Harry Applebaum, Steven Colquhoun, Edward Phillips

Janie GrumleyCaucus: Washington/British Columbia/AlaskaSpecialty: Surgical Breast OncologySpouse/Partner: StephenChildren: Madison, Stephen and MatthewHobbies/Interests: Figure Skating, Travel, CookingSponsors: Thomas Biehl, Flavio Rocha, John Ryan

Hanmin LeeCaucus: Northern CaliforniaSpecialty: Pediatric SurgeryHobbies/Interests: BasketballSponsors: Quan-Yang Duh, Shinjiro Hirose, Wen Shen


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Melinda Maggard-GibbonsCaucus: Southern CaliforniaSpecialty: General SurgerySponsors: Ronald Busuttil, Jonathan Hiatt, Clifford Ko

Samer MattarCaucus: Washington/British Columbia/AlaskaSpecialty: Bariatric SurgerySpouse/Partner: Tallah Children: Omar and Layth Hobbies/Interests: Arts, Cultural eventsSponsors: Clifford Deveney, John Hunter, Bruce Wolfe

Benjamin PadillaCaucus: Northern CaliforniaSpecialty: Pediatric SurgeryHobbies/Interests: Running and gardeningSponsors: Quan-Yang Duh, Shinjiro Hirose, Wen Shen

Beverley A. PetrieCaucus: Southern CaliforniaSpecialty: Colon and Rectal SurgeryHobbies/Interests: RunningSponsors: Christian de Virgilio, Brant Putnam, Bruce Stabile


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Jason PomerantzCaucus: Northern CaliforniaSpecialty: Pastic/Craniofacial SurgerySponsors: Orlo Clark, Quan-Yang Duh, Mary McGrath

Mitchell B. SallyCaucus: Oregon/HawaiiSpecialty: Trauma/Critical Care SurgerySpouse/Partner: Smyth LaiChildren: Sloane and ElizaHobbies/Interests: Reading, general fitness, family travel.Sponsors: Karen Deveney, Darren Malinoski, Jennifer Watters

Shant ShekherdimianCaucus: Southern CaliforniaSpecialty: Pediatric SurgeryHobbies/Interests: Running, travel, global healthSponsors: Vatche Agopian, Harry Applebaum, Daniel DeUgarte

Insoo SuhCaucus: Northern CaliforniaSpecialty: Endocrine SurgeryHobbies/Interests: Hiking, tennis, travelingSponsors: Quan-Yang Duh, Jessica Gosnell, Wen Shen


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Maureen TedescoCaucus: Northern CaliforniaSpecialty: General SurgerySpouse/Partner: Mike LivingstonChildren: Lucy, 10; Anthony, 7; and Rosie, 3Hobbies/Interests: hiking, drinking wine, reading, soul cycle, cookingSponsors: Dan Eisenberg, Tom Krummel, Sherry Wren

Lan Tuyet VuCaucus: Northern CaliforniaSpecialty: Pediatric SurgeryHobbies/Interests: FoodieSponsors: Quan-Yang Duh, Shinjiro Hirose, Wen Shen

Thomas WeiserCaucus: Northern CaliforniaSpecialty: Trauma/Critical CareSpouse/Partner: Iram WeiserChildren: Ismael and ElizaHobbies: Swimming, hiking and bikingSponsors: Jeff Norton, David Spain, Sherry Wren

David ZoniesCaucus: Oregon/HawaiiSpecialty: Trauma/Critical CareSpouse/Partner: Eliesa Ing, MDChildren: Johanna and GwendolynHobbies: Cycling, cooking, hiking, fishingSponsors: Clifford Deveney, Karen Deveney, Martin Schreiber


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IN MEMORIAM


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Thomas Berne

Wilton Doane

Eric Fonkalsrud

Joseph Ignatius

Geoff Nunes

Jeffrey Pearl

Lester Sauvage

William Shoemaker

Lou Smith

W.E. Stern

IN MEMORIAM


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IN MEMORIAM

Thomas Van Cleve Berne1936-2017

Dr. Thomas Van Cleave Berne M.D. passed away peacefully on Friday, October 27, 2017 at the age of 81. He was in good health until the end.

Tom was born on April 8, 1936, in Los Angeles, California, to Clarence J. Berne, M.D., and Esther Van Cleave Berne, Ph.D. His father, Dr. Clarence J. Berne, was Chairman of the Department of Surgery at the University of Southern California (USC) for 28 years. Tom Berne grew up in a section of Silver Lake known as “Pill Hill” because of its proximity to local hospitals. He met his wife Cynthia in high school, proposed on the bank of the Seine in Paris, and they were happily married for 60 years. He loved to spend time with his children, Susan, Kate, and John; and his nine grandchildren.

Tom loved traveling with Cynthia and visiting friends all around the world. He also enjoyed scuba diving, skiing, and USC football. Tom (W6TAG) was a ham radio operator from the time he was a teenager, sharing that passion with his children, grandchildren, and friends. His interest in ham radio and public health and safety led him to coordinate disaster preparedness activities for his neighborhood communities.

Like his father, Tom dedicated his life to surgery, teaching, patient care, and research. After completing undergraduate studies at Pomona College and USC, he graduated from USC Medical School in 1960 and then completed his surgical residency at the now Los Angeles County+USC Medical Center (LAC+USCMC). He served as a Fellow in renal transplantation at Guy’s Hospital in London from 1966-67. Upon his return, Tom established a renal transplant program and performed the first kidney transplant at LAC+USCMC. In an interesting parallel, Dr. Clarence Berne, his father, performed the first surgery at the old L.A. County hospital in 1932 and Thomas Berne performed the first surgery in the new LAC+USC facility in 2008.


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He joined the faculty of USC in 1967, rising to the rank of tenured Professor. He was instrumental in establishing the LAC+USCMC Level 1 Trauma Center and the service of Acute Care Surgery at LAC+USCMC. He served on the staff of not only LAC+USCMC but also Good Samaritan Hospital and, the USC Norris Cancer and University Hospitals. He served as President of several surgical societies, including our own Pacific Coast Surgical in 1998 and the Western Surgical Association.

Tom was an internationally renowned expert in trauma surgery and surgical critical care, but his primary passion was always for the education of students, residents, and fellows. Through his mentorship, Tom was an inspiration to surgeons who now practice their craft throughout the world. He enjoyed teaching so much that he continued to do so right up to the time of his passing. He was a brilliant surgeon, a gentle soul and a man of impecca-ble integrity. He will be missed beyond measure by the surgeons, nurses, staff and patients he touched during his amazing and wonderful surgical career, and fondly remembered by his family and friends for his kindness, generosity of spirit, and love.

-- Submitted by Fred Weaver, MD

IN MEMORIAM


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IN MEMORIAM

Wilton Doane1921-2017

Dr. Doane was born in Mansfield Pennsylvania to a family of doctors-His father, his uncle, and his two brothers. After attending the University of Pennsylvania School of Medicine, he served in WWII as a lieutenant in the Navy. He interned and did his surgical residency at the Pennsylvania Hospital, the first hospital established in the United States and on whose Board of Directors Benjamin Franklin served. While there, Dr. Doane worked with Dr. John Gibbon, who was one of the innovtors of the first heart-lung machine in the country. In 1951, he and his wife Carol moved to Boston where he had been awarded a Fellowship at the Lahey Clinic in thoracic surgery. When war was declared in Korea he was drafted back into the Navy and served on the aircraft carrier Essex for the duration.

Dr. Doane had always wanted to join a multi-specialty medical group. He believed that was the best way to practice medicine, where specialists in every medical discipline could consult with one another in the diagnosis and treatment of patients most effectively. In 1956 he joined the Santa Barbara Medical Clinic, soon became Chairman of the Board of Trustees, helped develop a large multi-speciality organization, and, with legal advice, worked to form a medical foundation, in order to better serve Santa Barbara and environs. He served two terms as Chairman of the Board of the Santa Barbara Medical Foundation Clinic, and worked towards the merger with the Sansum Clinic. He served as Chairman and a member of that Board of Directors for many years.

Dr. Doane was certified by the American Board of Surgery in 1952 and the American Board of Thoracic Surgery in 1959. His reputation as a gifted surgeon is widely known, but he was also an innovator and a leader in medical matters nationally. He helped design the concept of pre-paid medical insurance in an effort to counter federal government single-pay insurance. He was national President of the American Group Practice Association and often went to Washington, D.C. to lobby for that cause.


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IN MEMORIAM

Dr. Doane was the author of many important scientific papers published in medical journals. He was a member of the following professional organizations: The American Medical Association, California Medical Association, Santa Barbara County Medical Association, American College of Surgeons, Pacific Coast Surgical Association, and the Western Thoracic Surgical Association. Other national and local Boards on which he served include Direct Relief, the American Mutual Fund(Capital Group), National Childhood Cancer Foundation, California Blue Cross Medical Policy Committee, Hope Ranch Board of Directors, Montecito Retirement Association, and Senior Warden of All Saints By-the-Sea Episcopal Church.

During all the years of his busy career he never lost the urge to travel to exotic areas. He and his wife Carol camped on the banks of the Nile River, drove from Teheran to Shiraz to Persepolis in southern Iran, were driven up the Indus River from Peshawar Pakistan to Gilgit, to the Chinese border in the Karakorum Himalaya, and in 1968 they went to Kabul Afghanistan to work for Care Medico.

Dr. Doane is survived by his wife Carol, his three children Richard Doane, Nancy Doane Babbott(David Babbott) and John Doane(Kerry Doane), and ten grandchidren- David Babbott-Klein, John Babbott, Ben Skye-Babbott, Wilton Stewart, Elizabeth Stewart, Keenan Doane, Jameson Doane, Jed Doane, Cheney Doane, and Kim Doane, one great-grandchild Zilpha Babbott-Klein, and two grand daughters-in-law Libby Babbott-Klein and Ariana Skye-Babbott. He was predeceased by his daughter Kimberly Doane Stewart.

As busy as he was, he found time to play his beloved trumpet, to learn how to sculpt, to enjoy tennis, skiing, and hiking at the family cabin in Jackson Hole, Wyoming. But his family came first! They all not only adored him but respected him. His patients and his co-workers loved and admired his gentle compassion, as well as his skill as a surgeon. He was a remarkable man, a happy man, a noble man- And he had a remarkable life.

-- Submitted by: Ronald Latimer, MD


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IN MEMORIAM

Eric W. Fonkalsrud1932-2017

Eric W. Fonkalsrud, founding chief of pediatric surgery at UCLA and PCSA President in 1989, died at home on April 6, 2017. Rick, as he was known to many of us, was 84 years of age.

A native of Baltimore, Maryland, Rick grew up in Seattle, Washington. He received a Bachelor of Arts degree from the University of Washington, where he was a member of the national champion crew from 1950-53, and his medical degree from Johns Hopkins University. Following internship and a year of residency at Johns Hopkins, Rick completed surgical residency at UCLA, followed by training in pediatric surgery at Children’s Hospital of Ohio State University. He returned to UCLA in 1965 as chief of pediatric surgery and spent the remainder of his illustrious career in Los Angeles. He became professor of Surgery in 1971 and served as executive vice chair of the Department of Surgery from 1982-88. He retired to emeritus status in 2001 but remained at work until a few months before his passing.

Rick was a busy clinician who performed more than 15,000 operations during his career. He was a world authority on the management of congenital chest wall malformations and gastroesophageal reflux disease in children, neonatal surgery, and management of inflammatory bowel disease in children and adults. Rick had one of the country’s largest clinical experiences with the ileoanal pouch procedure for patients with severe ulcerative colitis. He also initiated liver transplantation at the UCLA Medical Center in 1968, using a heterotopic technique different from the orthotopic approach now in use.


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IN MEMORIAM

An international figure in his field, Rick served as president of the American Pediatric Surgical Association, the Society of University Surgeons, the Association for Academic Surgery, the Pacific Association of Pediatric Surgeons, the Southern California Chapter of the American College of Surgeons, the Los Angeles Surgical Society, and of course the PCSA. He was very devoted to the PCSA, and his absence was certainly felt at our last Annual Meeting. Among his many honors and awards, Rick was a James IV Association Traveling Scholar, and he received the Coe Medal from the Pacific Association of Pediatric Surgeons “for lifelong contributions to the field of pediatric surgery”, the Golden Apple and Golden Scalpel Awards at UCLA, “Man of the Year” from the California Chapter of the Crohn’s and Colitis Foundation of America, and the UCLA Dickson Emeritus Profes-sorship Award in 2014. He was particularly proud of his award as Forest Farmer of Year in Western Washington in 1997.

Rick was a consummate educator and mentor to thousands of students and residents. More than a dozen of his residents and research fellows went on to train in pediatric surgery fellowship programs. He took this role so seriously that he continued weekly teaching conferences with residents and students through his entire retirement and only suspended these a few months ago when his health began to fail. Generations of trainees will remember learning about pediatric patients and their surgical problems from Dr. Fonkalsrud, fortified by popcorn and soda in his office on the 7th floor of the UCLA Health Sciences Center.

Rick lived life to the fullest. He was an avid athlete, indeed a competitive triathlete, and a devoted swimmer. He was thoroughly dedicated to the University of California and the UCLA School of Medicine. His career spanned the period of growth and maturation of our School, and he contributed measurably in many ways that make us the institution we are today.

Rick is survived by his wife Peggy, their four children Eric Jr., Lynn, David and Robb, and six grandchildren. The world has lost a distinguished surgical leader, and many of us have lost a great friend.

--Submitted by Jonathan R. Hiatt, MD


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IN MEMORIAM

Joseph Ignatius1925-2015

Joseph A. Ignatius, M.D. died October 4, 2015 at the age of 90 in Santa Barbara, California.

Born in Glendale, California in 1925, Dr. Ignatius was a first generation American of Armenian heritage and the youngest of three children.

He attended the University of Southern California for two years and then transferred to Stanford University, where he received both undergraduate and graduate degrees. His general surgery residency was interrupted by two years of active duty in the U.S. Navy during the Korean War. Dr. Emile Holman, always sympathetic to the returning veteran, was able to create an opportunity for Dr. Ignatius to complete his surgical residency at Stanford Hospital, then located in San Francisco.

Dr. Ignatius began his clinical practice in Los Altos. During this time, he recognized the enormous challenge of keeping up with the voluminous journal literature. In response, Dr. Ignatius created The Surgical Index, a monthly publication of original abstracts, many including editorial comment by Dr. Ignatius, of the “best of the best” articles in the surgical literature.

The first issue was published in 1972 with Dr. Robert Mitchell as partner. The publication grew to several thousand subscribers. In 1990, Dr. Mitchell ended his participation, and Dr. Ignatius continued alone in writing the monthly issues for the next 10 years.

In 2000, a total of 329 monthly issues spanning 27½ years of uninterrupted publication was coming to a close. At that point, Dr. Thomas Russell, as incoming Director of the American College of Surgeons, started publishing an on-line version of The Surgical Index on the ACS website.

In the 1960s, Dr. Ignatius joined Concerned Physicians and Scientists Against the War and later was appointed by Dr. Phil Lee, then assistant secretary for the Dept. of Health, Education, and Welfare, to help establish one of the first medical clinics to provide care for people in rural communities who had little access to quality medical care.


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IN MEMORIAM

Dr. Ignatius was a Diplomate of the American Board of Surgery, a Fellow of the American College of Surgeons, and an active member of the San Francisco Surgical Society and the Pacific Coast Surgical Association. For many years he served as the Chairman of the State of California Advisory Committee for the ACS and a member of the Committee on Applicants. He was an active contributing editor to the ACS SESAP Program and a member of the Editorial Board of the Archives of Surgery for ten years, the first time a non-academic surgeon had held this position.

In 2011, the Annual Ignatius Lecture in Surgery was established at Stanford University in his honor, acknowledging his contribution to the field of medicine and to the practicing surgeon.

A life-long tennis player, Dr. Ignatius began to compete both nationally and internationally in his 40s. He was ranked #1 in Northern California in both singles and doubles for several years and was a finalist in 14 national senior championships including wins over Bobby Riggs and Tom Brown, both former

Wimbledon finalists. By the end of his competitive career, he had achieved a ranking of number five in the world and had represented the U.S. in multiple international senior Davis Cup-type competitions.

Dr. Ignatius is survived by his wonderful wife Cherie, four children by his first wife Virginia, four grandchildren, seven nieces and nephews, his brother, Paul R. Ignatius, former Secretary of the Navy, and Paul’s wife, Nancy Weiser Ignatius.

-- Submitted by Norm Christensen


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IN MEMORIAM

Geoffrey Nunes1940-2017

Geoffrey Nunes was an active and important member of the PCSA . He died at home on March 3, 2017 at the age of 77. He was born in San Francisco and raised in Alameda, California. His father was Chief Public Defender of Alameda County. He graduated from Stanford University in 1961, and while at Stanford met and married his wife of 55 years, Susan. He received his M.D. degree from the University of California, San Francisco in 1965, and remained there for his surgical training. From 1971 to 1974 he served in the U.S. Army at the 2nd General Hospital in Landstulil, West Germany, attaining the rank of Lieutenant Colonel.

In 1974 he came to Spokane and joined Dr. Richard Ahlquist (PCSA member) in the practice of General Surgery. Geoff became a leader in the surgical community. He was a Fellow of the American College of Surgeons and served as a Governor to the College from 1991 to 1997. He was an active member of the Spokane Surgical Society, the Washington State Chapter of the American College of Surgeons, Western Surgical Association, Pacific Coast Surgical Association, and the North Pacific Surgical Association, in which he served as president in 1994.

He served on the Board of Directors of Medical Service Corporation of Eastern Washington, and subsequently Premera Blue Cross. He was very interested in the history of surgery, and was Historian of the Pacific Coast Surgical Association from 1999 through 2004. His presentations were academically sound, cleverly presented, and had perfect tone and grammar. His talk in 2002 “Kaiser, Garfield, and Permanente” recognized the contributions of a capitalist with vision in health care finance and delivery.

His interests were primarily within surgery, but he greatly enjoyed classical and chamber music, and actively supported the Spokane Symphony and the Spokane String Quartet. In later years he and Susan happily explored many corners of the world on cruises. He leaves his wife Susan, as well as three sons David, Chris, and Rob and seven grandchildren.

--Submitted by John A. Ryan, MD


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IN MEMORIAM

Jeffrey Pearl1944-2017

Dr. Pearl was raised in California, attended UC Berkeley, and earned his MD at the Mount Sinai School of Medicine. His residency training at UCSD in general surgery was with Dr. Marshall Orloff.

Dr. Pearl joined the UCSF faculty in 1981. He began his surgical practice at Mount Zion Hospital where his father Dr. Milton Pearl became Chief of Surgery and Chief of Staff.

Jeff was instrumental in the integration of UCSF and Mt. Zion. He became Associate Dean and Associate Medical Director at the UCSF Medical Center at Mt. Zion where he developed and directed the Northern California Hernia Center at UCSF Mt. Zion. He also created the Central Venous Access Service in conjunction with the Department of Radiology. He held the Fishbon Endowed Chair in Ambulatory Surgery. He served as Vice Chair to the Department of Surgery and oversaw Departmental Finances.

Dr. Pearl was recognized as an outstanding surgeon, committed teacher to medical s tudents and residents, and a valued colleague.

He is survived by his wife Anne, daughter Laura, and two grandchildren, Danny and Lindsay.

--Submitted by John Roberts, MD


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IN MEMORIAM

Lester Sauvage1926-2015

Long time PCSA member Dr. Lester Sauvage, a major innovator, productive researcher and scholar, indefatigable cardiovascular surgeon, and most significantly a man of great faith and compassion, passed away on June 5, 2015 in Seattle.

Lester was born in Wapato, Washington in 1926. An avid athlete, particularly as a baseball player, he attended Gonzaga High School for Boys in Spokane, Washington, then matriculated at Gonzaga University where he continued to play baseball. His devout faith almost directed him to the priesthood, but he ultimately decided to attend medical school and graduated at age 21 from St. Louis University with his M.D. degree. After a tour of duty in the Korean War in 1952, he met and married Mary Ann Marti in 1956. He completed his surgical training at Harvard, including a Chief Residency with Dr. Robert Gross at Boston Children’s Hospital, where he was involved in some of the early days of open heart surgery for congenital heat disease.

Dr. Sauvage came to Seattle and set up practice at both Children’s Orthopedic Hospital (now known as Seattle Children’s Hospital), Providence Hospital and Swedish Hospital. He continued to perform both adult and pediatric cardiac surgery, as well as peripheral vascular surgery for decades. His passion for innovation led to his creation of the Dacron vascular grafts for treatment of aortic and peripheral arterial disease, a significant contri-bution to that field. He also successfully performed Seattle’s first bloodless open heart


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IN MEMORIAM

operation in 1967 at the request of a Jehovah’s Witness patient. His intellectual curiosity and spirit of innovation, ultimately led him to develop a research institute that ultimately became the Bob Hope Heart Institute, and he remained involved with that for the remain-der of his life. During his career, he performed more than 10,000 operations, and published more than 250 papers and books, including his last book, “Opening Hearts” that was published just 2 weeks before his death.

His ability to work extraordinary hours was legendary. He was known as a man who could nap anywhere and at any time, followed quickly by resuming his work at full speed. Despite his busy, professional life, he was widely respected as a devoted family man, who was deeply committed to his faith and his church. That deep faith made him a very compassionate surgeon, who always emphasized the human aspects of medicine.

Dr. Sauvage is survived by his sister, his 8 children and his 31 grandchildren. His legacy of loving surgical care, innovation, and great faith was a great blessing to the entire Pacific Northwest.

-- Submitted by Robert Sawin, MD


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William C. Shoemaker 1923-2016

Dr. William Shoemaker died peacefully at his home on March 14, 2016 at the age of 93. The Pacific Coast Surgical Association lost one of its most prolific members. The world lost a true visionary.

Will Shoemaker was born in Chicago, the second of four sons. After graduating from UCSF medical school (then in Berkeley) in 1946, Will served as a Navy physician, and began his surgical training. Following the war, Will completed his surgical residency at Hahnemann, and then moved to Boston, where he was to spend three fellowship and research years in Surgery and Biochemistry; there he worked closely with Francis Moore, who became a major influence. During these formative years, Will developed a passionate drive to understand the unique physiology of surgical and trauma patients, which would shape his remarkable career.

After Boston, Will moved to Chicago, where he became professor of surgery at the University of Illinois, and where he was instrumental in developing the trauma services at Cook County Hospital. He was then recruited to Mount Sinai Hospital in New York, where he developed one of the first modern multidisciplinary intensive care units. In his work at Mount Sinai, Will envisioned and demonstrated the potential of applying bedside physiologic monitoring to titrate critical care to optimal compensatory endpoints. Will finally returned to California in 1979, where he would serve as professor at UCLA and USC, and continue his groundbreaking work in monitoring and treating patients following operations, trauma, and shock.

IN MEMORIAM


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The importance of Will’s clinical and scientific contributions cannot be overstated. Early in his career, he brilliantly demonstrated how surgical and trauma patients were different from medical patients. He utilized innovative bedside physiologic measurement techniques to prove that to survive trauma and operations, surgical patients needed to achieve supernormal circulatory and metabolic compensatory states. He further developed treatment strategies to monitor and support his patients, and thereby improve survival. In doing so, Will was one of a small group of individuals who defined modern critical care, founding the Society of Critical Care Medicine and its journal, Critical Care Medicine. Will authored over 700 scientific papers and book chapters, many of which are now considered sentinel works in advancing our understanding of shock, trauma, and perioperative care.

Will was a remarkable teacher and mentor. He was warm, caring, and generous with his time, attention, and support. He was fiercely passionate about his beliefs and his principles, and he inspired countless students, residents, and professional colleagues, not only in his own institutions, but throughout the world. In fact, there is arguably no other contemporary American physician as well-known and respected internationally as Will Shoemaker.

Yet, despite his fame, his tireless work ethic, his dedication to his patients, his students, his research, and to his endless travels, Will remained fiercely dedicated to his family, his children, his grandchildren and to Norma, a wonderful and amazingly accomplished woman who was his wife of 63 years. To Will’s loving family, our deepest sympathy.

Though Will was always modest and self-effacing, his life of accomplishment was absolutely astounding, and his legacy profound. History will record Dr. William Shoemaker as one of America’s most influential surgeons. We were all very fortunate to have Will as our colleague in the Pacific Coast Surgical Association.

-- Submitted by Kenneth Waxman, MD

IN MEMORIAM


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Louis L. Smith1925-2016

Louis L. Smith was born May 19, 1925, in College Place, Washington, and died September 9, 2016 in Loma Linda, California.

Dr. Smith was the third of three sons born to parents who were both educators. Because of the mentorship of his surgeon uncle, Wilburn H. Smith, Louis decided to become a surgeon early in life. His premedical studies were completed at Pacific Union College, Angwin, California, and at Walla Walla College, Washington, on an accelerated academic program brought on by World War II. Thereafter, he was accepted to the College of Medical Evangelists, in Loma Linda, California. He completed his clinical years at the Los Angeles County General Hospital. He then entered the surgery residency program at the Los Angeles County General Hospital. His residency was interrupted by the Korean War; he was drafted and served as chief of surgery for two years at the U. S. Air Force Base Hospital in Itazuki, Japan. Following active military duty, he returned to Los Angeles where he completed surgical residency training at the LA County General Hospital. He was awarded a National Institutes of Health research fellowship in 1957, and spent two years in postgraduate study at Harvard University in the laboratory of Dr. Francis Moore, and in working with Dr. Joseph Murray who performed the first successful human organ transplant. Dr. Smith helped in developing CVP access and monitoring techniques, studied the effects of shock, and performed the first surviving mammalian liver transplant while working in Dr. Moore’s laboratory. He established a collaborative relationship with a young Swiss surgeon, Uli Gruber, while at Harvard; they continued their investigative efforts after leaving Boston. Many young Swiss residents subsequently worked with Louis in the laboratory, both at the Los Angeles County General Hospital and at Loma Linda University Medical Center.

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Dr. Smith joined the Loma Linda School of Medicine faculty in 1959. He became one of the first faculty members to make the move from Los Angeles to Loma Linda in 1962 during the consolidation of the Medical School in Loma Linda. He was cofounder of the Walter E. MacPherson Society at Loma Linda University, dedicated to the advancement of medical education and research, serving as president from 1964 to 1967. He was Director of the Surgical Research laboratory at LLU for 25 years. Admired and respected by many of his surgical residents, fellows, and colleagues, Dr. Smith will be remembered as one of the best technical surgeons with whom they worked. In 1967, he performed the first kidney transplant at Loma Linda. He traveled and lectured extensively; in 1983 he traveled to China; while in China, he was called on to repair the aortic aneurysm of the Surgeon General of China. In 1998 he traveled with the LLU heart team to North Korea.

Dr. Smith established the vascular surgical residency program at Loma Linda Univer-sity Medical Center. During his active surgical career, he held numerous leadership and administrative roles, including president of the Pacific Coast Surgical Association (1992), president of the Southern California, chapter of the American College of Surgeons, and president of the Alumni Association of his alma mater where he was also honored as Alumnus of the Year in 2000. He was author of more than 100 articles and 15 book chapters. He trained many young surgeons, including Leonard L. Bailey, pioneer of LLU’s infant heart transplant program, who carry on his legacy. His wife, Marguerite, preceded him in death in 2009. He is survived by his daughter, Patti, and her surgeon husband, Richard Catalano, on the LLU Surgical faculty, two grandchildren, and three great grandchildren.

– Submitted by Ted Mackett, MD

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Walter Eugene Stern1920-2017

W. Eugene Stern, founding chief of neurosurgery and former chair of surgery at UCLA, died on July 27, 2017 in Truckee, California. Dr. Stern was 97 years of age.

A native of Portland, Oregon, Dr. Stern received both Bachelor of Arts and Doctor of Medicine degrees from the University of California. From 1946-48, he served in the Medical Army Corps of the United States, rising to the rank of Captain. Dr. Stern was a clinical clerk in the National Hospital for Paralyzed and Epileptic in London (1948-9) and national research fellow in medical science at Johns Hopkins (1949-50). He completed training in neurological surgery under Howard C. Naffziger at the University of California in 1951.

Dr. Stern joined the UCLA faculty in 1952 as the chief of the division of neurosurgery in the new department of surgery under Dr. William P. Longmire, Jr. and held this position until 1985. During these years he established neurosurgical affiliations with the Wadsworth (now Greater Los Angeles) Veterans Administration Medical Center and with Harbor General Hospital (now Harbor-UCLA Medical Center), and he brought the neurosurgery faculty and residency program to the positions of national prominence that they enjoy today. Dr. Stern led the department of surgery as chair from 1981 to 1987, which also marked the year of his retirement and transition to emeritus status.

A clinician, educator, and scientist, Dr. Stern had particular interests in intracranial mass dynamics, cerebral edema, C.N.S. infectious processes, cranial tumors, and postoperative care of the neurosurgical patient. He was a meticulous teacher who held himself to the same rigorous standards that he expected of his students.

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Among many leadership positions, Dr. Stern served as President of the American Association of Neurologic Surgeons, Western Neurosurgical Society, Society of Neuro-logical Surgeons, and Los Angeles Surgical Society. He was chairman of the editorial board of the Journal of Neurosurgery, vice chairman of the American Board of Neurological Surgery, secretary of the American College of Surgeons, Cushing Medalist of the American Association of Neurologic Surgeons, recipient of the Distinguished Service Award from the California Association of Neurological Surgery, and a member of many other scholarly societies including Phi Beta Kappa, Alpha Omega Alpha, and the James IV Association of Surgeons. Dr. Stern held Honorary Membership in the Society of British Neurological Surgeons and a National Institutes of Health Special Fellowship at the University Labora-tory Physiology in Oxford, England. He became a member of the PCSA in 1959.

Dr. Stern was married to his wife, the former Elizabeth Naffziger, from 1946 until her untimely death in 1989. He is survived by their four children, Eugenia Louise, Geoffrey Alexander, Howard Christian, and Walter Eugene.

Appropriately reflecting Dr. Stern’s legacy, the chair of neurosurgery at UCLA holds the W. Eugene Stern Endowed Chair. Dr. Stern was a key figure in our School of Medicine. He also was a great gentleman, a dedicated teacher, a fine clinician, and a lifelong scholar.

-- Submitted by Jonathan R. Hiatt, MD

IN MEMORIAM


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ARTICLE I

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

ARTICLE II

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

ARTICLE III

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

Section 2. PCSA Council shall have the discretion to increase the number of Active Members in order to maintain the mission of the Association.

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

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

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

Section 6. Proposals for membership, properly filled out, accompanied by the necessary endorse-ments and confidential letters from the sponsors, shall be in the hands of the Secretary-Treasurer at least six four months before the date of the annual meeting. The Council at its annual meeting shall, after full consideration of all information available, recommend to the Association such candidates as are qualified for membership.

The Council shall have the power to request from any member of the Association a careful and unbiased investigation of the qualifications of any candidate for election to the Association. Any candidate for active membership may be assigned to a member of the Council for careful investiga-tion as to his/her personal and professional qualifications.

PCSA Constitution (PCSA’s Constitution Amendments were voted on and approved at the 2017 Annual Business Meeting. According to Article VIII, Section 1, these changes will lie for one year.)


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

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

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

ARTICLE IV

Section 1. Active members shall have a practice that is limited to surgery.

Section 2. All Members shall automatically become Senior Members at the age of sixty (60) years. They shall pay dues and have the privilege of voting and holding office but are excused from the annual meeting attendance requirement.

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

Section 4. Members are considered Retired upon reaching the age of seventy five (75) or retirement from active clinical practice, whichever occurs first. They are no longer required to pay Association dues.

Section 5. Candidates for Honorary Membership shall be nominated by the Council and elected by ballot at the executive session of the annual meeting. Honorary Members shall not be required to pay dues or initiation fees and shall enjoy all the privileges of other Members except those of voting and holding office.

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Section 6. A Non-Resident Member shall be a Member under the age of sixty (60) who no longer re-sides in the Pacific Coast geographical area. He/She shall be excused from attendance requirements. He/She may vote at such meetings as he/she attends and enjoy all the privileges of the Association except that he/she may not hold office or membership on standing committees. He/She shall pay annual dues. A request for non-resident status must be submitted in writing to the Secretary-Treasurer and shall be granted only by the Council. Upon written request the Council may restore a Non-Resident Member to active status. At its discretion, the Council may terminate membership as a Non-Resident Member. A Non-Resident Member shall automatically become a Senior Member at age sixty (60).

Section 7. The resignation of a Member may be accepted at the discretion of the Council.

ARTICLE V

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

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

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

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

ARTICLE VI

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

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

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

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

Section 5. It shall be the duty of the Historian to assemble and preserve the Archives of the As-sociation for storage and reference. The Archives shall consist of the roster of the members of the Association since its inception, and such photographs as are available. At each Annual Meeting of the Association, the Historian shall be called on by the President to give a presentation of historical significance to the membership.

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

ACTICLE VII

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

ARTICLE VIII

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

ARTICLE IX

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

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CHAPTER I

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

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

CHAPTER II

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

CHAPTER III

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

CHAPTER IV

Section 1. The usual parliamentary rules (Robert’s Rules) governing deliberative bodies shall gov-ern the business workings of the Association.

CHAPTER V

Section 1. All questions before the Association unless otherwise provided shall be determined by a majority vote of the members present and voting except changes in the Constitution and Bylaws which require a two thirds (2/3) majority and election of new members require a three fourth (3/4) majority.

CHAPTER VI

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

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

BylawsThese Bylaws were approved at the 2017 PCSA Business Meeting.


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CHAPTER VIII

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

CHAPTER IX

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

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

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

CHAPTER X

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



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CHAPTER XI

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

CHAPTER XII

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

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

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

CHAPTER XIII

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

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

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

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



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CHAPTER XIV

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

Section 2. The Association shall have no financial responsibility for invited guests, except distin-guished guests invited by the President.

CHAPTER XV

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

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

CHAPTER XVI

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



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2019 February 15 - 18, 2019HOST: Washington/Alaska/British Columbia CaucusSITE: JW Marriott Tucson Starr Pass Resort & Spa – Tucson, AZ

2020 February 14 - 17, 2020HOST: Southern California CaucusSITE: Omni La Costa Resort & Spa – Carlsbad, CA

PCSA’s Official Journal is JAMA Surgeryhttps://jamanetwork.com/journals/jamasurgery

Future Meetings


Pacific Coast Surgical Associationc/o American College of Surgeons

633 North Saint Clair StreetChicago, Il 60611

Phone: 800.274.9083Fax: 312.202.5003

Email: [email protected]: http://pcsaonline.org/


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