Cleft Lip Prevalence and Management in a Developing Nation

Saman Ahmad, BDS, Dental/Oral Surgeon, Model Hospital Lajpat Nagar, New Delhi, India

Widespread of this disease in children and the management in the developing Nation like India. Cleft lip is the most common congenital deformity, occurring both de novo and with many syndromes. It affects more than 10 million people worldwide and can lead to difficulty breastfeeding, compromise nutrition in newborns, lead to poor dental development, and significant psychosocial problems. In India, one of the most populous countries in the world, the prevalence of cleft lip has been found to be 1.3 per 1,000 live births, however, these numbers are very underreported, making the true prevalence likely much higher.

In India, a vast majority of those affected are left untreated due to the low socioeconomic status of the families, illiteracy, superstition, lack of awareness, and poverty of their families. Treatment typically involves a multidisciplinary approach including both ENT and dental surgeons, speech pathologists and audiologists. The delay in treatment in India leads to significant health care problems short and long term for those affected. Many receive only surgical repair, often requiring complicated procedure due to their late presentation and forego speech and audiologic help. Without receiving the complete treatment, most continue to suffer from esthetic and psychosocial problems as they age.

Currently in India, there is a huge unmet need existing for treatment of cleft lip and even in treated persons in terms of speech training, esthetic management, and psychosocial wellbeing. Since surgery is perceived to be costly and impairs a huge economic burden on families, delaying treatment is common and leads to substantial morbidity. Public awareness and early management can lead to better esthetics, feeding, speech, and dental growth. This need to aware and educate the Indian people on how to deal with cleft lips can help to improve the huge burden of untreated and unmet needs of this defect.

The World Surgical Foundation, What We Do and the Role of the ICS

Domingo T. Alvear, MD, FICS, FACS, Founder of the World Surgical Foundation, Mechanicsburg, PA

“The best way to find yourself is to lose yourself in the service of others.” – Mahatma Gandhi

Dr. Hafdan Mahler, WHO Director General from 1973 to 1988 stated that surgery has an important role in the global primary healthcare but the vast majority of the world’s population has no access to skilled surgical care. (June 29, 1980, XXII ICS Meeting, Mexico City). There has been little change since then because the Lancet Commission in 2015 states that 5 billion patients cannot access safe surgery when needed. 143 million more surgeries are needed annually at a minimum to take care of the surgical burden of disease which account to 11% of the total.

In 1997, the World Surgical Foundation was founded to help alleviate the surgical burden by:

1. Provide free surgical service to patients in low income and medium income countries utilizing volunteers from the USA, Canada and local counterparts. These surgical procedures are performed for 5 to 7 days in one or 2 locations. Education of the local counterparts is an integral part of the mission by bringing expertise to have long term effect.

2. We donate equipment and supplies to sustain safe and efficient surgery for the local surgeons.

3. We have encouraged the participation of Surgical Residents and Fellows in training from the USA, Canada and local counterparts. They are exposed to surgical diseases not commonly seen by them, they can learn from other surgeons’ different techniques on how to perform surgery safely and efficiently without the availability of equipment and supplies they are familiar with. They are also able to be involved with more “open surgery” and “surgical surprises”.

4. Specialty focused surgery in Pediatric Surgery, Plastic Surgery, Pediatric Urology, Adult Urology, Neurosurgery and Gynecology have participated when available.

5. The WSF new initiative is the formation of Anorectal Malformation Clinics in Honduras and the Philippines to take care of patients with Imperforate Anus and Hirschsprung’s Disease. The goal is to allow these patients to attain continence will be free from the stigma of having a colostomy.

The role of the ICS should be:

1. To be the “Umbrella Organization” for surgical outreach much like the United Way.

2. Educate funders that surgery is essential in reducing the global burden of disease.

3. Educate local surgeons by bringing expertise.

4. Capacity building by donating equipment and supplies to sustain safe and efficient surgery.

5. Encourage Surgical Residents and Fellows and Young Surgeons to get involve in providing service to patients in low income and medium income countries.

Fulminant Myonecrosis from a Minor Puncture Wound. A Rare Case of Clostridial Septicum Gas Gangrene

Saptarshi Biswas, MD, Attending Surgeon, Department of Trauma, Acute Care Surgery and Surgical Intensive Care, Forbes Regional Hospital, Allegheny Health Network, Pittsburgh, PA

Gas gangrene, a spreading infection mediated by toxins released by Clostridium species, is a potentially fatal and physically disabling disease due to its often rapid progression. It carries a high rate of mortality and morbidity. C. perfringens is the commonest species, followed by C. novyi. C. septicum is relatively rare, accounting for only 1.3% of all clostridial infections.

C. septicum represents a novel subtype among clostridial species, and often capable of causing devastating tissue necrosis in the absence of prior trauma, and is able to present distant from the presumed portal of entry resulting in metastatic myonecrosis . Clostridial infections are believed to have a greater prevalence among individuals who have malignant disease.

We present a case of a 60-year-old male who presented to the ED with severe right thigh pain. He recalled stepping on a nail a week back when he was discharged with tetanus toxoid and local dressing.Clinical examination revealed crepitus overlying his right thigh extending upto his pelvis . CT scan showed diffuse subcutaneous air. Intraoperatively, he had extensive necrotic muscle in all thigh compartments, thrombosed vessels, and diffuse gas tracking along the entire femur. A right hip disarticulation was completed.

Cultures of the wound grew out Clostridium septicum.Histology was consistent with significant myonecrosis and an invasive gram positive bacilli infection .

Infection with C. septicum carries a high mortality rate and early detection is the key. The presence of crepitus can be a late finding and absence of this sign should not deter from pursuing this

diagnosis.

Although uncommon, it is of utmost importance that the management be initiated early and include aggressive resuscitation, early systemic antibiotics, hyperbaric oxygen therapy if available, and radical surgical debridement.

Dog Bites - Dogmas and Evidences

Saptarshi Biswas, MD, Attending Surgeon, Department of Trauma, Acute Care Surgery and Surgical Intensive Care, Forbes Regional Hospital, Allegheny Health Network, Pittsburgh, PA

Canine bites present a major public health concern worldwide. Significant dog bites affect tens of millions of people globally each year. In USA, approximately 4.5 million people are bitten by dogs each year . Unfortunately majority of these bites occur in children. In the 1980s and 1990s, the U.S. averaged 17 fatalities per year, while in the 2000s this has increased to 26.77% of dog bites are from the pet of family or friends, and 50% of attacks occur on the dog owner's property. Approximately 900,000 dog bites are treated in United States each year.

Although the majority of dog bites do not result in significant injury, disfigurement, infection or permanent disability approximately 20% of dog bites become infected. The ‘hole and tear’� effect—whereby canine teeth anchor the person while other teeth bite, shear, and tear the tissues—results in stretch lacerations, easily piercing immature cranial bones. The biting force of canine jaws varies with the breed, from 310 kPa to nearly 31?790 kPa in specially trained attack dogs. Large wounds, significant devitalisation, and high mortality can result, with the highest mortality in neonates (six times that in toddlers), who are usually bitten by household pets. 45 % of the attacks are caused by American Pit Bull Terriers. Rottweilers and German Shephards are also known to cause serious damage. According to studies 85% of the dog bites were from animals belonging to the victim. Situations in which dog bites occur include dog fighting , mistreatment, trained dogs acting as guard or military animals, provoked or unprovoked.

Factors that increase risk of infection are Alcoholism (increased susceptibility to Pasteurella infection), Cirrhosis, asplenia (increased risk of Capnocytophaga), Steroid therapy, rheumatoid arthritis, diabetes mellitus, and overall immunocompromised state.

We describe evidence based management protocols and discuss prevailing dogmas and misconceptions.

Mission Medicine (International Surgery)

Gene Bolles, MD, Assoc. Professor Neurosurgery,

Denver Health Medical Center, University of Colorado Health Science Center, Denver, CO

In an era of increasing globalization, the dramatic advances in transportation methods and social media have truly transformed the world into a veritable “global village.� As such, increasing numbers of surgical trainees are seeking to include international experience as a component of their surgical education.

A logical response to these concerns and a more effective means of providing care to a large population is to train the people living in that society.

U.S. surgical training programs need to undergo remodeling to meet the needs of a globalizing world with dramatic health care disparities.

I have observed and experienced mission medicine, now called International Surgery, grow and become ever needed in our world. As physicians we have an opportunity to not only help educate and help our colleagues elsewhere in the world but to be ambassadors for ourselves as human beings, our profession as health care providers, and for our country.

The Lancet Commission has shown the great need and importance of surgical treatment in the less developed countries in our world.

This discussion will involve experiences in many countries of our world i.e., Iraq (Kurdistan), Albania, Mexico and others.

Post-Operative Cognitive Dysfuntion (POCD)

Gene Bolles, MD, Assoc. Professor Neurosurgery,

Denver Health Medical Center, University of Colorado Health Science Center, Denver, CO

Mental dysfunction after surgery as been attributed to anesthesia for past many years, Recent studies are indicating this is not the problem. POCD has been studied by having pre and post operative cognitive testing. It is found that mental dysfunction gets worse over the age of 65 and while most often improves with time there is increasing incidence of permanent dementia. It is being found to be related to inflammatory response affecting the microglial in our brain. The larger the surgery, the more serious and frequent the dysfunction. Therefor this is a surgical complication and should be included in the informed consent.

Traumatic Abdominal Wall Injuries: A Case Series

Beatrice Caballero, MS, Medical Student, Texas Tech University Health Sciences Center, Department of Surgery, Lubbock, TX

Introduction: Traumatic Abdominal Wall Hernias (TAWH) and Morel-Lavallee lesions are a rare consequence of blunt force abdominal trauma. Â They occur when a significant amount of force is applied to a relatively small area of the abdomen causing shearing or tearing of the muscle and/or fascia layers allowing a hernia to develop. The limited number of studies and case reports in the literature has prevented the development of a protocol for the best imaging and treatment modalities. We discuss four cases of traumatic abdominal wall injuries and their management.

Methods: Data was collected on the mechanism of injury, patient presentation, surgical management and patient outcomes via chart review. Four cases of traumatic abdominal wall hernias presented to our level 1 trauma center. All four were due to MVC. CT of the Abdomen and Pelvis was the imaging modality of choice in all four cases. All four hernias were lateral to the rectus muscle. Hernias were repaired with biologic, absorbable mesh in all four instances on the initial exploratory laparotomy. All four hernias had other associated intra-abdominal injuries. ABRA Dynamic Tissue Closure System was used in one instance to bring together the abdominal wall.

Results: All four instances were repaired with mesh with 100% fascial closure. There were no surgical site infections and to date no recurrence of hernias.  All four hernias underwent an exploratory laparotomy for concomitant other injuries. Conclusion: Traumatic abdominal wall injuries secondary to blunt trauma are uncommon.  Although there are no published guidelines it is generally agreed that CT is the best imaging modality for traumatic abdominal wall injuries because of its high sensitivity to detect defects in the abdominal wall as well as injuries to abdominal organs. It is important that TAWHs continue to be investigated until there is empirical evidence supporting standard protocols for treatment based on severity and comorbidities. Until that time, clinicians will have to continue to use their best judgment in each case with which they are presented.

Do Absorbable Mesh Get Integrated in Fascia in Real Life?

Samim Chalabi, MD, Chief of Surgery, Guthrie Towanda Memorial Hospital, Towanda, PA

Need to know if animal studies translate in human and is valable

We only had indirect confirmation by CT scan We assume that absorbable mesh is incorporated in new fascia in human in a way similar to animal model studies I am presenting a case of a 65 Year old woman who had repair of umbilical hernia with polyglycolic acid plug absorbable mesh* and an infraumbilical hernia repaired primarily on 06/2017. After an episode of heavy lifting and a few months of severe coughing she presented with evidence of recurrence of her hernia and was symptomatic. She underwent an exploration and repair of recurrent infraumbilical hernia with Monofilament Polypropylene * on 09/2018. At operation it was noticed that the umbilical hernia repaired with the absorbable mesh was completely healed with integration (see picture) So we can conclude with certainty that there is integration of the absorbable mesh with the new fascia similar to the animal models. We may suspect that primary closure of the hernia even if it was initially small in size may not be recommended in this case but since this is a statistical issue only a large randomized study can confirm this suspicion. * Bio-A mesh, Gore Medical * Ventralex, C R Bard

Damage Control Surgery in Trauma

Akella Chendrasekhar, MD, Clinical Assistant Professor of Surgery , SUNY Downstate; Trauma Medical Director, Richmond University Medical Center, Lake Hopatcong, NJ

Severely injured patients have reduced physiologic reserve to tolerate definitive surgical repair. Damage Control was a term borrowed from the US Navy which was used to refer to special teams that would keep severely damaged ships afloat until they could reach a friendly port for definitive repair. Similarly, damage control surgery refers to immediately attending to life threatening conditions [keeping patient afloat] while definitive management is delayed until appropriate resuscitation can be performed.

Phases of care:

1. Rapid transport and rapid triage for treatment

2. Control hemorrhage, limit contamination and maintain optimal blood flow to vital organs and extremities.

3. Resuscitation to normalize temperature, acidosis, coagulopathy and tissue oxygen delivery

4. Definitive repair typically requires a staged approach to address all the injuries, timing of this definitive treatment is dependent on the physiologic status of the patient.

5. Closure of abdominal wall or soft tissue wounds can be delayed until after complete recovery from associated deep tissue injuries.

While damage control has not been studied prospectively, retrospective data suggests significant reduction in morbidity and mortality. We cover the limitations of damage control as well as the benefits This talk will cover the various aspects of damage control and practical applications in various trauma scenarios

Unique Constellation of Thoracoabdominal Injuries in a High-speed Motor Vehicle Collision

Caroline Chung, BS, BA, Second Year Medical Student, Texas Tech University Health Sciences Center, Lubbock, TX

The seatbelt sign is commonly seen after a high speed motor vehicle collision (MVC). It is a harbinger of potential thoracoabdominal trauma. It is also an important clue in the identification of injury patterns which can include thoracoabdominal trauma and spinal injuries. Among these are Chance fractures, characterized by hyperflexion injuries to the spine. These types of fractures are also commonly associated with intra-abdominal injuries.

Complete transection of the duodenum is rare, reported at less than 5% of all abdominal trauma. Blunt traumatic diaphragmatic injuries are also an uncommon injury, reported at less than 1% of blunt traumatic injuries according to a retrospective study. Bilateral blunt diaphragmatic injuries extremely rare, reported at 0.8% - 8%. This case highlights all three of these rare injuries in a 37-year old woman involved in a high speed MVC.

To our knowledge, there are only a few cases reporting these unique mechanisms of injury. This case highlights them all in one patient. Thorough understanding of the mechanism of injury may help in the early diagnosis of abdominal viscera ruptures and other injuries which might not present as obviously as others.

Imaging Alternatives in Pedicle Screw Placement. Adapting Machine Vision to Spinal Navigation

W Craig Clark, MD, PhD, Staff Neurosurgeon, Greenwood Leflore Hospital, Carrollton, MS

Pedicle screws are widely used for fixation in performing spinal fusions because of their three column support and rigid posterior stabilization. Various studies have reported less than optimal placement rates as high as 70%. The use of intraoperative imaging and computerized navigational techniques have been shown to improve the accuracy of pedicle screw insertion. Despite this, a number of surgeons continue to use standard free hand techniques, citing the increased risks of radiation to themselves, OR staff and the patient, as well as the exorbitant costs of the technology involved. The purpose of this presentation is to review the alternative imaging modalitiescurrently in use for pedicle screw placement and present preliminary results using an innovative, non-radiological imaging system based on machine vision technology.

Treatment of Cardiac Arrhythmia Associated with Subarachnoid Hemorrhage: A Literature and Protocol Review.

Caitlin Clark, MD, Resident, Department of Internal Medicine, Case Western Reserve University at MetroHealth, Cleveland Heights, OH

It is widely known that subarachnoid hemorrhage is associated with co-morbid cardiac arrhythmias, which can place the patient at higher risk of mortality in the acute phase of the hemorrhage. Cardiac Arrhythmias are more commonly seen with Hunt Hess Grade 3 and above hemorrhages, due to the presence of blood and blood products in the cisterns. These blood products have been shown to exert deleterious effects upon the hypothalamus, resulting in massive sympathetic discharge leading to cardiac arrhythmia. We aim to discuss the immediate treatments for cardiac arrhythmia associated with subarachnoid hemorrhage, which, if implemented in a timely fashion, can prevent the patient from degenerating into cardiopulmonary arrest. This study consisted of a review of the literature and relevant protocol management for cardiac arrhythmia. There are only a few arrhythmias which are designated “malignant,� and which can lead to the death of the patient if not definitively addressed in a timely manner. These arrhythmias include Monomorphic Ventricular Tachycardia, Polymorphic Ventricular Tachycardia, and Ventricular Fibrillation. All are considered to be non-perfusing rhythms emanating from the ventricles, and are also designated as Irregular Wide QRS-Complex Tachycardias. Any patient in one of these rhythms is not perfusing their brain, adding insult to an already injured brain. All physicians recognize that the routine management of complex cardiac arrhythmias in critically ill patients such as those with subarachnoid hemorrhage will usually require active participation of our Cardiology and Intensivist colleagues. However, it is critically important, and often life-saving, for the neurological surgeon in the intensive care unit to have a thoughtful and pragmatic approach to early identification of these problems, allowing timely intervention to improve patient safety and outcomes.

Noncardiac Massive Thoracic Bleeding

Raymond A. Dieter Jr., MD, General and Cardiothoracic Surgeon, Glenn Ellyn, IL

Introduction: Clinical bleeding situations are not uncommon. Most such occurrences involve trauma, the GI tract, or surgery. Usually these cases are not associated with intra thoracic bleeding. We have reviewed our experience with intrathoracic bleeding and the results of such.

Material: Review of our surgical practice and consultations has shown a number of patient’s of various ages who have bled massively. These circumstances include past pneumonectomy, post cardiopulmonary bypass patients, post bronchoscopy, congenital pulmonary lesions, and transthoracic esophagectomy patients. Patients with massive trauma to the chest, aortic atrial or ventricular injury, IVC or SVC injury may bleed massively. Young age does not avoid such, for example GSW to the chest or cadillac fin penetration and unsuspected coagulation defects. Findings: Massive noncardiac bleeding was seen in a large number of patients with non aortic (23) and twenty aortic lesions whether per primum or in consultation. Intrathoracic bleeding was the result of trauma (), congenital, acquired pulmonary, tumors, vascular access and surgical complications. Depending on the etiology, control and possible survival was possible in approximately one-half of the patients.

Discussion: Patients of all ages were seen with massive intrathoracic bleeding. Bleeding was related to trauma, surgery, tumors, and aortic disruption. When the blood loss is massive, in an uncontrolled situation, pulmonary or venous in nature successful resuscitation is difficult. Iatrogenic massive bleeding is also difficult to control - even when occurring in the OR.

Treatment of Appendicitis: Do Medicaid and Non-Medicaid Enrolled Patients Receive the Same Care?

Amanda Fazzalari, MD, Resident, University of Massachusetts Medical School, Waterbury, CT

Purpose: Previous studies using national datasets have suggested that insurance type drives a disparity in care delivered to emergency surgery patients. We have recently shown that nationally, Medicaid enrolled patients presenting with acute surgical diagnoses, such as appendicitis, are operated on less frequently, have longer times to surgery (TTS), longer length of hospital stay (LOS) and higher rates of in-hospital morbidity. However, these large databases lack the granularity that smaller single institution series may provide. The goal of this study is to identify socioeconomic and geographic factors that may account for disparities in care between Medicaid and Non-Medicaid enrollees (excluding Medicare) with acute appendicitis in Central Massachusetts.

Methods: This retrospective cohort study included all adult patients with acute appendicitis at two campuses of an academic medical center in Central Massachusetts between 2010-2017. Baseline sociodemographic and clinical characteristics were compared according to Medicaid enrollment status and univariate and multivariate analyses were performed to assess differences in the frequency of surgery performed, TTS, LOS, and rates of readmission between those with and without Medicaid.

Results: The sample consisted of 1,257 patients, with a mean age of 39.4 years old, 46.4% were female and 135 (10.7%) were enrolled in Medicaid. Medicaid enrollees were significantly younger (33.5 vs 40.1 years, p <0.0001), and more likely to be unmarried (73% vs 48.1%, p<0.0001) or Non-White (54.1% vs 24.4%, p <0.0001) when compared to Non-Medicaid enrollees. Medicaid enrollees were more likely to live in a neighborhood that was closer to the hospital (4.0miles vs 8.3miles, p<0.0009), had a lower median annual income ($40,400.00 vs $67,700.00, p<0.0001), had a lower level of formal education (82.9% vs 91.6% with high school diploma, p<0.0001) and were more likely to belong to a racial/ethnic minority (31.0% vs 17.1%, p<0.0001). Medicaid enrollees were also less likely to have diabetes mellitus, hyperlipidemia, or hypertension. There were no significant differences between the number of Medicaid and Non-Medicaid enrollees who presented with perforated appendicitis (28.9% vs 31.2%, p=0.857) or who underwent laparoscopic appendectomy (96.3% vs 90.7%, p=0.081). While LOS (20h:30m vs 22h:38m, p=0.109), and 30-day readmission rates (17.8% vs 14.5%, p=0.683) were similar between the two groups, there was a significant difference in the median TTS, with Medicaid patients waiting longer, even after adjusting for social and clinical characteristics (6h:47m vs 4h:49m, p<0.001).

Conclusions: This study underscores the importance of local data in understanding delivery of care at the institutional level. Despite anticipated population differences between patients with and without Medicaid, the treatment of appendicitis did not differ substantially in this single-institution series. While Medicaid enrollees did experience longer TTS, the explanation for this is unclear. Further studies are needed to investigate factors that may account for this difference. These could include disparities in the household support systems, available social support, system issues within the healthcare system, or bias, all potentially leading to delays to surgery among Medicaid enrollees.

Hospital Hip Fracture Protocol Leads to Improved Outcomes

Kristy Fisher, MBA, MSc, Richmond University Medical Center,

SUNY Downstate, Bellmore, NY

Introduction/Purpose: Hip fractures are frequently occurring injuries amongst high risk populations. The subsequent potential of increased morbidity and mortality can be significantly sensitive to the management provided by the responding health care facility. As an institution dedicated to the quality and success of its patient care and outcomes, Richmond University Medical Center sought to alter its current managerial approach to provide a higher standard of care and therefore, yield more satisfactory results.

Methods: Data from a sample population of 445 hip fracture patients hospitalized for over 24 hours in a level 1 trauma center from 2013 - 2018 was collected from the trauma registry. The sample population was divided into three groups:

A: Antecedent events (no protocol); 1/1/2013 - 8/1/2014

B: Protocol implemented with no enforcement; 8/2/2014 - 8/1/2017

C: Protocol with enforcement and performance improvement tracking; 8/2/2017 - 3/31/2018

The obtained data includes the following parameters for each group: demographic information (age, gender, injury severity score), time to operative fixation, hospital length of stay, ICU length of stay, number of days on the ventilator, DVT prophylaxis appropriateness, and survival to hospital discharge.

Results:

A difference of statistical significance in the mean values amongst the three groups was noted in the following parameters before the protocol and after its implementation and enforcement:

Conclusion: With the formation of the hip fracture protocol and its implementation as a policy, better outcomes for hip fracture patients were achieved. My apologies, the format of the data table was altered. I have emailed a copy of the original as well. Please let me know if any further actions need to be met and I will address it as soon as possible. Thank you and sorry for the inconvenience.

Creation of a Vaginal Canal for De Novo Vaginoplasty and Salvage Vaginal Replacement For Transgender and Cisgender Women: A Proposed Novel Technique

Maurice Garcia, MD, MAS, Associate Clinical Professor, Urology, In Residence Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA

Purpose: Sigmoid Colon and Ileum have been described as alternative sources of graft-tissue for transgender (MtoF) women undergoing gender-affirming vaginoplasty surgery to create a neovaginal canal de novo. The use of Right Colon has never been described for this purpose. Also, to date, there has been no description in the literature about how to perform salvage vaginoplasty (for vaginal canal replacement) in general, for vaginal canal replacement in either transgender or cisgender women. We describe: 1. A novel trans-pelvic and abdominal-laparoscopic surgical technique developed by our group for both de novo creation, and replacement, of a vaginal canal (vaginoplasty) using an intact segment of Right Ascending Colon as a pedicle-flap; 2. Proposed indications for use of intestine (versus alternative graft options) for creation of a vaginal canal in transgender and cisgender women; 3. Constraints specific to the surgical site, human anatomic data, and practical considerations- which all support why this technique is superior to previously described intestinal vaginoplasty techniques using Sigmoid Colon and Ileum; 4. Key elements of the surgical set-up and surgical approach for an inter-disciplinary surgical team consisting of a reconstructive urologist (performing the transpelvic vaginal construction) and a colorectal surgery team (performing the colon-graft harvest); 5. We describe two novel surgical devices designed specifically for intestinal vaginoplasty; and 6. We describe refinements to our technique to minimize risk of complications associated with intestinal vaginoplasty. Methods: Review of surgical indications for vaginal creation/replacement, patient selection criteria, intraoperative surgical-site anatomic measurements, and literature review of documented anatomic variations to the vascular supply of the colon. We present the results of fresh human cadaver studies and radiographic (CT-scan) studies pre and post-vaginoplasty surgery. We present intraoperative photographs from the transpelvic and abdominal-laparoscopic surgical field at all key points of the surgery. Results: The cross-sectional diameter of the lumen of colon is more suitable for creation of a vaginal canal functional for receptive intercourse in comparison to Ileum, which is significantly smaller in diameter and has a lower mean wall-thickness. While availability of intestine is important, given its overall redundancy, availability is rarely a limiting factor. Instead, our experience using both Sigmoid and Right Colon dictates that it is the net length of the vascular pedicle that determines whether any specific colon segment is or is not feasible for use for creation of a vaginal canal. The principal vascular supply to the Right colon is the Ileocolic artery (ICA). In contrast to the arterial supply to the Sigmoid Colon, the ICA is: 1. More constant (re. documented normal human variations), and hence more reliable from a surgical standpoint; 2. Yields a reliably longer vascular pedicle, hence rendering the Right Colon a more favorable graft for vaginal construction. Conclusions: The intact Right Colon pedicle-flap graft we describe is more reliable for de novo vaginal canal creation & salvage-vaginoplasty in transgender and cis-gender women than Sigmoid colon. This technique also yields more favorable post-surgical anatomy for management of potential post-operative complications.

Should We Wait for the Syringomyelia to Occur Before Treating Chiari Malformations?

Shankar Gopinath, MD, Associate Professor of Neurosurgery Baylor College of Medicine, Houston, TX

There is a tendency among practitioners to wait for Chiari malformations to develop complication such as Syringomyelia at which stage, neuronal dysfunction would have occurred. Our case series illustrate the late stage of the disease that could have been prevented by offering treatment much earlier to obtain better functional outcome. Also, our series shows what modality of treatment is best in such conditions. We as neurosurgeons, have an obligation to educate not only the patients and their families but also the referring physicians.

Endobronchial Ultrasound With Transbronchial Needle Aspiration in The Diagnosis of Thoracic Diseases; A Single Center Experience

Dwight Harris II, BS, Medical Student, University of Kentucky College of Medicine, Manchester, KY

Purpose: Lung cancer remains the leading cause of cancer related mortality in the United States, and obtaining a tissue diagnosis and proper staging is an essential part of treatment plan development. Historically mediastinoscopy has been the gold standard for lung cancer diagnosis and staging, but mediastinoscopy has many limitations including: sensitivity, limited number of lymph node levels that can be sampled, and safety. In 2005, the first Endobronchial ultrasound (EBUS) probe capable of guided transbronchial needle aspiration was introduced. Endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA) is a relatively new and less invasive technique being used for lung cancer screening. Many studies have reported that EBUS-TBNA has similar sensitivity and specificity when compared to mediastinoscopy with a significantly lower complication rate. We wanted to determine our institutions experience with EBUS-TBNA, and contribute to the ongoing conversation about the role of EBUS-TBNA vs mediastinoscopy in lung cancer diagnosis and staging.

Methods: With IRB approval we reviewed the last 150 EBUS-TBNA procedures preformed at our institution from August 31, 2017- May 26, 2016 for lung mass evaluation. We selected 10 patients form our institution that had EBUS and 10 that had mediastinoscopy and calculated the cost for both procedures. We also used CPT codes to calculate the 10-year trend in EBUS and mediastinoscopy procedures at our institution.

Results: In total the charts of 150 patients were reviewed. The total number of lymph node stations sampled was 294 with 39 stations read as non-diagnostic. Ninety-eight of the 150 patients had a confirmed diagnosis of malignancy. Thirty-nine patients had a diagnosis other than cancer, and 13 patients had incomplete information or were lost to follow-up. EBUS-TBNA was correct in diagnosing malignancy in 94 of the patients, and EBUS-TBNA or EBUS-TBNA and lab test gave enough information to diagnosis without further invasive testing in 37 of the non-lung cancer patients. Over all the sensitivity, specificity, positive predictive value, and negative predictive values of EBUS where 94.0, 100.0, 100.0 and 91.5 percent respectively. Only three complications were reported intraoperative or at the first follow-up appointment. Two patients suffered minor bleeding, and one suffered major bleeding that resulted in cardiac arrest. Of the 150 patients only eight received mediastinoscopy, and 15 patients received a VATS or thoracotomy. In all eight cases the mediastinoscopy agreed with the results optioned from EBUS-TBNA. Thirteen of the 15 VATS or thoracotomies agreed with the results optioned form EBUS-TBNA. The average net revenue for EBUS-TBNA was 4,136 ± 2,540 (mean ± standard deviation) United States dollars (USD), and the average net revenue for mediastinoscopy was 2,716 ± 1,860 USD.

Conclusions: EBUS-TBNA has a similar sensitivity and specificity to mediastinoscopy, with fewer complications. Compared to mediastinoscopy, EBUS-TBNA is also more cost effective. Because of its reliability, cost effectiveness, and safety, EBUS-TBNA is gradually replacing mediastinoscopy.

Technical Tips to Consider During Laparoscopic Pancreas Surgery

Michael Jacobs, MD, Clinical Professor of Surgery, Michigan State University College of Human Medicine, Associate Chair of Surgery, Ascension Providence and Providence Park, Birmingham, MI

The author will present video vignettes of laparoscopic pancreatic surgery to demonstrate anatomy, exposure, suturing methods, and technical pearls. The demonstration will include laparoscopic distal pancreatectomy and Whipple procedures.

Inguinal Hernia Repair with Mesh-How I do It

Michael Jacobs, MD, Clinical Professor of Surgery, Michigan State University College of Human Medicine, Associate Chair of Surgery, Ascension Providence and Providence Park, Birmingham, MI

The inguinal hernia repair with mesh is a novel technique that is simple, reproducible, and allows for less failure. A video-based educational format will be presented to demonstrate the technique in detail.

Management of Short Neck Infra-Renal Abdominal Aortic Aneurysms With Fenestrated ZFEN Stents: Single Institution Experience

Faisal Jehan, MD, Resident General Surgery, New York Medical College, Westchester Medical Center, Valhalla, NY

The problem / surgical intervention the presentation covers: Abdominal aortic aneurysms (AAAs) have prevalence as high as 8%, depending on the criteria used for diagnosis. The mainstay of AAA repair has been open aneurysm repair which was first described in 1951.

Introduction of endovascular aneurysm repair (EVAR) in 1990 led to a paradigm shift from open aneurysm repair and it is estimated that 75% of AAA are treated with stent graft. Improved mortality, shorter hospital length of stay (LOS) has been achieved with endograft technology.

Although the EVAR provides an attractive alternative to traditional open surgical repair EVAR is limited by patient specific anatomic criteria of the aorta and iliac vessels. Specifically, short, conical and angulated aortic aneurysms represent significant challenge for standard EVAR and may lead to graft failure.

Why the audience needs to know this information: In order to overcome the challenge of the short infrarenal neck and provide patients with optimal and durable results, a fenestrated Zenith device by Cook Medical (Cook Inc., Bloomington, IN) was introduced in 2012. Allowing for creation of custom-made scallops and fenestrations to accommodate renal and mesenteric branch vessels this device showed excellent early and mid-term outcomes in post market surveillance.

The Division of Vascular Surgery at Westchester Medical Center in Valhalla, NY, was an early adapter of this new technology and performed its first ZFEN implantation in 2015. Since then 18 devices have been placed with ongoing active use of the device. This has positioned us among high volume users of this technology in the region. We would like to present short and midterm outcomes of this FDA approved, but still relatively new method of therapy of aortic aneurysm with a short infrarenal neck. What the learner will be able to accomplish after the presentation: After the presentation, the learner should be familiar with the patient selection, preoperative preparation, surgical technique, intraoperative complications and the short and long-term outcomes of patients with short neck infra-renal abdominal aortic aneurysms managed with fenestrated ZFEN stents.

How the audience will benefit from the presentation. The audience will benefit from understanding the challenges and benefits of endovascular approach to the management of short neck infra-renal abdominal aortic aneurysms with fenestrated stent grafts. The experience of a large volume center with this treatment modality and its outcomes will provide the surgeons with information on short and mid-term results in real life clinical setting. It will also provide objective data that will help with patient selection and discussion of the risks and benefits in the management of these complex and challenging patients.

Telemedicine Programs Albania and Cabo Verde: The Tales from Two Continents?

Rifat Latifi, MD, Chair and Professor of Surgery, Director Department of Surgery, Program Director Surgical Critical Care Fellowship, Chief of General Surgery, Westchester Medical Center, New York Medical College, Katonah, NY

This year Telemedicine Program of Kosova (TPK) was inaugurated in 2002. c. Much has changed over these years, but the contribution of TPK continue to be visible both in the infrastructure and academic world and are serving as virtual university classrooms with hundreds of thousands students, doctors, nurses, in addition to providing better access patients in remote side of the countries where program has been adopted. The aim of this paper is to review the international expansion of the model of TPK over last 15 years, particularly clinical telemedicine in Albania and Cabo Verde. Retrospective review of clinical teleconsultation from 2014- January 2018 was performed. Basic demographics of patients and whether patients were transferred to tertiary center of remained in the referring hospital and most common clinical specialties that used telemedicine were analyzed. Thirty telemedicine centers in Albania, Southern Europe and 14 centers in Cabo Verde, Africa, have been established. The majority have been functional since 2014. There were 2366 patients seen via telemedicine in Albania (65% males) and 2158 (male 45%) in Cabo Verde in 29 clinical disciplines. In Albania, teleradiology, teleneurotrauma and telestroke with 677, 638 and 498 patients respectively led the specialties of all teleconsultation, while in Cabo Verde most popular clinical disciplines were neurology 599, cardiology (319), dermatology (173) orthopedic surgery (160), general surgery (124), and urology 108. 1809 (76.45%) patients (Albania) and 1630 (75.53%) (Cabo Verde) were not transferred to tertiary centers of the country.

Conclusion: The model of telemedicine in Albania and Cabo Verde has advanced the quality and availability of necessary medical services. By studying the clinical disciplines that used telemedicine mostly, the countries can predict the healthcare needs in the future.

Complex Abdominal Wall Reconstruction: Practical Approaches

Rifat Latifi, MD, Chair and Professor of Surgery, Director Department of Surgery, Program Director Surgical Critical Care Fellowship, Chief of General Surgery, Westchester Medical Center, New York Medical College, Katonah, NY

With advances in abdominal surgery and the use of Damage Control Surgery (DCS) in the management of major trauma, and patients with abdominal catastrophes, complex abdominal wall defects have become the new surgical disease, and the need for complex abdominal wall reconstruction (CAWR) has increased dramatically. Subsequently, how to reconstruct these large defects has become a new surgical question.

While DCS and open abdomen management (OAM) in trauma and critically ill patients or those who have survived initial catastrophic abdominal event, has been shown to be lifesaving, closing the abdomen and regaining abdominal wall function to avoid severe consequences of DCS and OAM has become modus operando in our department. I will review our most recent experience in CAWR in the Acute Phase of Injury or intra-abdominal catastrophe, using biologic mesh. Furthermore, most recently, biologic mesh has become the new standard in high-risk patients with contaminated and dirty infected wounds. While biologic mesh is the most common tissue engineered used in this field of surgery, level I evidence is needed on its indication and long-term outcomes. Various techniques for reconstructing the abdominal wall have been described, however the long-term outcomes for most of these studies, are rarely reported. In this presentation, I will outline current practical approaches to perioperative management and definitive abdominal reconstruction in patients with complex abdominal wall defects, with or without fistulas, as well as those who have lost abdominal domain and review our experience in almost 300 patients. In our most recent study (unpublished data) we have shown that frailty appears to be a more important predictor of adverse outcomes after CAWR with BM than age. All future studies should assess frailty as a potential predictor of outcomes.

TAVR- a Multi-Disciplinary Model for the Future Structural Heart

Tessa London, MD, MPH, Assistant Professor of Surgery, Cardiothoracic Surgery, University of Kentucky, Lexington, KY

Transcatheter aortic valve replacement (TAVR) has taken the world by storm and may supplant the current standard of care, which is surgical aortic valve replacement (SAVR) for appropriate candidates. This presentation discusses the issue of aortic stenosis and the options for surgical versus transcatheter valve replacement. The abnormalities of aortic valve morphology and function represent the most common cardiac-valve lesion, with relevant implications both for medical and surgical treatment. Over 25% of adults in the US over the age of 65 are affected by aortic stenosis. As the population of the US ages, there is a growing demand for aortic valve replacement and a need for understanding of the treatment options.

Patients considered for TAVR valves must have severe symptomatic aortic stenosis and consider moderate to high risk for surgical valve replacement. Each patient considered for TAVR is placed under a multitude of tests including CT scans, carotid duplexes, and echocardiograms. In addition, consultation with anesthesia, cardiologists and two independent cardiothoracic surgeons is necessary to be considered for TAVR and creates a holistic multi-disciplinary approach to a previously solitary decision.

At the end of the presentation, the audience will be able to describe the preoperative assessment and multi-disciplinary decision-making process involved in assessing a patient’s candidacy for a TAVR versus a SAVR. They will also be able to describe the long-term mortality/morbidity of data of both approaches. Additionally, we will look into the future of TAVR and discuss the possible impacts this has on surgical aortic valve replacements.

Update from the American Board of Surgery

Joshua Mammen, MD, PhD, Associate Professor of Surgery and Vice Chair, Department of Surgery, University of Kansas, Kansas City, KS

I serve as a Director of the American Board of Surgery. Several changes have been implemented over the last year in certification and the audience may benefit from an explanation of the rationale of those changes as well as details of the new continuous certification process.

Update in Total Hip Replacement Advancements and Painful Osteoarthritis of the Hip

Robert Mathews, MD, PhD, Medical Director of Penn Surgery Institute, Millersville, PA

Hip joint pain makes the patient seek relief and led to our study of the anatomical changes seen in the hips of 520 patients of the total joint arthroplasties done at the Nuffield Orthopaedic Center, University of Oxford, England, The New York Orthopaedic Hospital, Columbia University, New York, New York, and at Penn Surgery Institute (PSI) and Barnes Kasson Hospital, Susquehanna, Pennsylvania.

The clinical and laboratory research initiated at Duke University, John Hopkins University, Clemson University, and Oxford University reached fruition at the New York Orthopaedic Hospital, Columbia University, New York, the Pennsylvania State University at Hershey Medical School and the Penn Surgery Institute, Lancaster, Pennsylvania.

In the severely painful osteoarthritic hip joint, the synovium appeared to react to the rigors of joint motion on ambulation. The femoral head debris lost via repetitive microfracture on motion tended to self-perpetuate the inflammatory process and attack mast cells and histiocytes. The inability of the scavenger cells to cope with this degenerative process brought cellular lysosomal enzymic release and cell death in bone which served to self-perpetuate the painful inflammatory process.

We have identified afferent peripheral fibers in the hip joint, tendons, synovium, capsule, periosteum bone, and the scarified tissue near articular cartilage as well as nerves in the bone cortex and cancellous red marrow of human joints.

These nerves supply the capsule, the periosteum and the soft tissue of the hip joint. Nerves appear throughout the bone. The intramedullary, endosteal unmyelinated and myelinated fibers enter the bone through the nutrient foramen with the nutrient artery and travel toward the epiphysis and follow along the traveculae. The myelinated and unmyelinated fibers of the bone were found near the vascular elements. On occasion, a few fibers extended to the endosteal wall of the femoral cortex (Plate I). The anatomic data in our total hip replacement patients was correlated with the clinically evaluated pain before and after surgery. Each patient seen post-operatively had significant relief of pain. In all, we achieved 95 percent hip pain relief in these patients.

Furthermore, other progress by all of us included:

Femoral Prostheseis and Acetabulum

- Polyethylene improved

- collarless femoral prosthetics which decreased stress risers

-cement technique

- titanium porous

- length control

- ceramics

- antibiotics in cement

Updates on the Surgical Management of Breast Cancer

Colleen Murphy, MD, Assistant Professor of Surgery, University of Colorado, Lone Tree, CO

Surgery for breast cancer has greatly changed in the past 10 years. Specifically, for those women requiring or choosing mastectomy, preservation of the entire breast envelope, including the nipple and areola complex has become the standard. For patients who have larger tumors but still desire breast preservation, oncoplastic surgical techniques provide a new option for a large tumor resection with excellent cosmetic results. Finally, axillary dissections are becoming an operation of the past, as patients who are node positive on presentation now have the opportunity to receive systemic therapy prior to surgery, which converts a significant portion of patients to node negative, thereby eliminating the need for axillary node dissection. This talk will update learners to the indications and patient selection criteria for the newest techniques in breast surgery and review the technical aspects of these procedures. The talk will provide learners the skills needed to appropriately offer these procedures in their clinical practice.

The Role of Bariatric Surgery in the Treatment of Diabetes

Sharique Nazir, MD, Associate Professor and Honorary Police Surgeon (NYPD), NYU Langone Medical Center, Staten Island, NY

Diabetes is worldwide disease with no popular surgical treatment. By Doing weight loss surgery we have achieved near to complete remission and perhaps able to cure this metabolic disease .

Will like to present surgical treatment for the diabetes with scientific evidence. Diabetes currently affects 285 million people worldwide, with these number expected to rise to 439 million by 2030. These staggering statistics make diabetes a growing pandemic sweeping the globe. The devastating complications make treating and curing diabetes essential.

Bariatric surgery is widely accepted with the most common procedures being the Roux-en-Y bypass, the sleeve gastrectomy and the laparoscopic banding technique. Case reports from as early as 1955 have shown improvement in diabetes following weight altering surgeries such as these. Studies conducted on patients after Roux-en-Y bypass have shown that all patients have either some improvement or complete normalization of blood glucose following surgery. Diabetic control in these patients can occur within just days of bypass, long before any significant weight loss is even seen. The improvement in diabetes resulting from bariatric surgery can be due to many factors. Firstly, decreased caloric intake leads to changes in incretin stimulation of islet cells. Moreover, hormone changes occur due to re-routing of food thus altering gut secretion (decreasing leptin and insulin, while increasing adiponectin, peptide YY3-36, and GLP-1). Additionally, intestinal malabsorption leads to weight loss, decreased insulin resistance, decreased glucose absorption, and reduced stress on islet cell.

Surgery has proven to be superior to medical treatment in achieving glycemic control and reducing comorbid conditions in the diabetic population . Bariatric surgery induces remission of diabetes and is associated with a significant improvement in metabolic control over medical therapy, both conventional and intensive. Although type 2 diabetes has been the domain of physicians, surgeons may now be able to claim greater success in achieving improved metabolic control.

Trauma Patients in the Rural Setting

Sharique Nazir, MD, Associate Professor and Honorary Police Surgeon (NYPD), NYU Langone Medical Center, Staten Island, NY

Even in the 21st century, rural trauma is still considered a neglected disease. Rural trauma is an injury occurring to a victim who is isolated in terms of geography, population density, weather, distance, availability of resources, or a combo of these. While on 20% of the population lives in rural areas, almost half of motor vehicle deaths occur within this population. Furthermore, the age of people who live in rural areas is much older than those who are in urban areas. This makes trauma relates to falls are common and serious issue. Of the most dangerous and deadly occupation in the US, four of the top five are primarily seen in rural areas (commercial fishing, logging, farming/ranching, mining).

With the deadly impact trauma has on rural settings, providing care and developing plans for treatment are vital to the improving outcomes for trauma patients. Many providers in these areas have less exposure to severely injured patients and rural hospitals have variability in their clinical capabilities, mainly considered level 3 or 4 trauma centers. Thus, caring for trauma patients in rural setting requires not only the same care as would be expected in an urban area but with fewer people, equipment and specialty training.

With all this in mind, developing a system for these hospitals to use to guide stabilizing, resuscitation and further management can help not only ease the process of caring for trauma patients but save lives. The rapid triage and transfer guidelines set forth by the rural committee of the ACS committee on trauma help to mitigate these issues. They create a standard of care for unstable patients at both level 3 and 4 trauma centers. With an emphasis on rapid evaluation, resuscitation, and transfer to higher level center, the decision-making process has become more streamlined and effective.

While courses and protocol are available and becoming integrated in rural hospitals, it still is imperative that high level centers provide the proper education to rural centers (with the RTTDC course being one method of doing so). This will allow rural providers to not only gain valuable life-saving skills but also lead to more effective trauma patient care. The unstable patient in a rural setting can be catastrophic, thus being able to recognize this and have the ability to provide immediate temporizing measures while preparing for transfer is critical. As the rural community grows, making sure these patients have access to skilled trauma providers is a necessity.

Strategies and Management of Concurrent Non-small Cell Lung and Esophageal GIST Cancers

Francis Podbielski, MS, MD, Clinical Professor of Surgery, University of Illinois at Chicago, Riverside, IL

Introduction: Lung cancer is the leading cause of cancer death in men and women in the United States today with an incidence of 55/100,000 with over 154,050 deaths in 2018. Esophageal cancer is much less common with an incidence of 4.2/100,000 and causing 15,850 deaths in 2018. GIST tumors represent less than 1% of all esophageal neoplasms. Management of simultaneous lung cancer and GIST tumor of the esophagus presents a challenging problem to the clinician in terms of operative approach and post-operative care.

It is important for clinicians to understand the variable and non-classic presentation of esophageal GIST tumors to enable them to provide an expeditious and thorough work-up and avoid an unexpected intra-operative finding. Case Summary: The patient is a 65 y/o man who was found on a screening CT scan to have a mass-like consolidation of the left lower lobe measuring 4.9 x 2.3cm and a small hiatal hernia. Flexible bronchoscopy with brushings of the LLL revealed a non-small cell lung cancer. A PET/CT scan showed increase FDG uptake in the medial half of this lung mass with no other evidence of disease.

The patient underwent a left thoracotomy and lower lobe lobectomy for what was found to be a pT1cN0 invasive adenocarcinoma of the lung; all margins of resection were negative for malignancy. At the time of surgery, a freely mobile submucosal lesion was discovered in the distal esophagus while dividing the inferior pulmonary ligament. Frozen section revealed a low grade, spindle cell tumor. The tumor was enucleated without difficulty.

The patient did well post-operatively, and a barium swallow on post-operative day #2 showed no evidence of esophageal leak. Unfortunately on the following day he was noted to have food material draining though his chest tube. He was made NPO and an esophageal stent placed without success. Final pathology on his esophageal lesion was eventually returned as a low grade GIST tumor (<5 mitoses/hpf) measuring 4.0 x 3.2 x 2.7cm, KIT (CD117) +, and with positive margins.

Given his ongoing esophageal leak and his neoplasm, he was returned to the operative room on POD #7 for an Ivor-Lewis esophagogastrectomy; final pathology showed negative margins of resection. He did well after surgery and a barium swallow on POD #7 showed no evidence of leak. Unfortunately, the following day while on a liquid diet he developed drainage of po feedings through his chest tube. He was maintained on a strict NPO regimen with jejunostomy tube feedings for the next eight weeks at which point his remaining thoracic drain was gradually withdrawn and he was started on a liquid diet. Discussion: This case illustrates the challenges faced when encountering a second, unexpected, rare tumor of an adjacent organ in the thorax during standard lung resection. A decision to proceed with immediate esophageal resection versus prolonged drainage was openly debated within the surgical team. Physical, emotional, and family support was critical for patient during a protracted hospital stay.

Nutcracker Syndrome: A New Paradigm in the Diagnosis and Management?

Thomas Pshak, MD, Assistant Professor of Surgery,

Division of Transplant Surgery, Department of Surgery, University of Colorado Denver, Denver, CO

Nutcracker Syndrome is a rare entity, but has debilitating effects on patients. Medically, the left kidney generally remains functional. The difficulty in management of this syndrome is unfortunately chronic opioid addiction. There have been numerous surgical techniques described in the treatment and resolution of the outflow obstruction. Most of these techniques have acceptable surgical results, but very few have reported resolution of pain and narcotic usage. I would like to present a new management strategy aimed at correctly identifying those patients who would benefit from surgical management of the is syndrome while simultaneously getting these patients off narcotics in the post-operative period. This preliminary data suggests a near 100% correlation in identifying those patients that will benefit from a left renal autotransplant with the use a a novel test instilling Marcaine into the renal collecting system. Once validated, these results could change the surgical treatment of Nutcracker Syndrome forever.

Evolution in the Treatment of Distal Radius Fractures

Sudhir Rao, MD, Orthopaedic Surgeon, Big Rapids Orthopaedics, Big Rapids, MI

Distal Radius fractures are amongst the most frequent fractures treated by orthopaedic surgeons. They can result from trivial falls or high impact injuries. The presentation will describe our understanding of the injury and various methods of treatment that have evolved over the years since the fracture was first described in the 1800's to the current state of the art.

Delayed Endovascular Repair of Blunt Traumatic Aortic Injury

Aditya Safaya, MD, Resident, General Surgery, Westchester Medical Centre, New York Medical College, Ossining, NY

Background: Estimated 8000 deaths/year are associated with blunt aortic injury in United States. Blunt thoracic aortic injury (BTAI) is the 2nd most common cause of death in blunt trauma patients. Majority of patients die at the scene from exsanguination, with only 10-15% of patients arriving at the hospital with signs of life. Most common mechanisms of injury is motor vehicle collision, followed by pedestrians struck by motor vehicles and fall. Traditional recommended approach to these injuries was emergent open repair with mortality rates approaching 30%. The advent of endovascular approach with Thoracic Endovascular Aortic repair (TEVAR) offers significantly lower risk of death and spinal cord ischemia in all age groups compared with open surgery. Traditionally early endovascular repair (less than 24 hours) has been advocated for such injuries. However this may pose a challenge in patients with multi organ severe injuries that frequently necessitate emergent repair and is encountered in as many as 40% of these patients.

Objective: At Westchester Medical Center (WMC), a regional level I trauma hospital, delayed TEVAR for BTAI are performed in hemodynamically stable patients after initial resuscitation and treatment of other, possibly life-threatening, injuries. The aim of this study is to review early and long term outcomes of this strategy.

Design/Methods: This study is a retrospective chart review of patients who underwent TEVAR at Westchester Medical Center from January 2006 to September 2018 using the vascular/cardiothoracic/trauma surgery and operating room databases. The patients’ hospital medical records were reviewed to collect data of interest.

Patient inclusion criteria were:

(1) = 18 years old

(2) Blunt aortic injury identified by computed tomography and/or angiography

(3) TEVAR of the aortic injuries performed from January 2006 to September 2018

Exclusion criteria: patients < 18 years old.

Variables of interest include: Age, Gender, Mechanism of injury, Trauma level (I, II or III), Initial heart rate and blood pressure, Glasgow Coma Scale (GCS), Injury Severity Score, Primary diagnosis, Method of diagnosis, type of thoracic aortic injury, site of aortic injury (aortic arch or distal to the left subclavian artery), and time from injury to therapeutic procedure. Intraoperative variables of interest are: American society of Anesthesiologists score (ASA), length of operation, blood transfusions, brand and size of stent used, and coverage of left subclavian artery. Type of thoracic injury will be classified as Grade 1—intimal tear, Grade 2—intramural hematoma, Grade 3—aortic pseudoaneurysm, and Grade 4—free rupture.

Post Operative variables of interest include early (30-day) post operative mortality and morbidity (Endoleaks, stroke, Myocardial Infarction, paraplegia).

Long Term Follow-up data at 6, 12 and 60 months was collected and data was analyzed in terms of variables including long term mortality and morbidity (Endoleaks, Re-Interventions, aortic interventions, cardiac events, neurologic events etc). Results: Outcome of the cohort of patients managed in our center are analyzed and reported as center specific and compared to historical cohorts of open repair of BTAI for variables of interest.

Cost Management in Healthcare

Sibu Saha, MD, MBA, Professor of Surgery, University of Kentucky, Lexington, KY

Healthcare expenditures in the U.S are twice those of other developed countries. Current model is wasteful and expensive! Variabilty in healthcare is thought to be a cause of cost escalation.Cost drivers include cost of drugs and devices,defensive medicine,administrativr costs and moral hazards!

This report will show cost analysis of a surgical practice. The presentation will include system based solutions.

Infection with Spinal Instrumentation: The Current Management Strategies

Asem Salma, MD, Attending Neurosurgeon, Mercy Health St Rita's Medical Center, Lima, OH

The volume of elective spine surgery with integrated instrumentation and fusion has been increased dramatically over the last few years. Spine infection after spinal instrumentation is a devastating event. With every incidence patient morbidity is increased and long-term outcome, as well as and health care costs are adversely affected. The rate of infection ranges from 2% to 20% of all instrumented spinal surgeries.

The aim of this presentation is to provide a comprehensive review and discussion of the pathogenesis, diagnosis, prevention, and management strategies of infection with spinal instrumentation

Non-traumatic Intracerebral Hemorrhage: Surgical Indications and Technical Considerations

Asem Salma, MD, Attending Neurosurgeon, Mercy Health St Rita's Medical Center, Lima, OH

Despite Intracerebral hemorrhage is much less common than ischemic stroke, it is associated with a significantly high mortality and morbidity. Several region of the central nervous system can be affected such as the basal ganglia, thalamus, cerebral lobes, pons, and cerebellum. The causes of the condition vary, however, Hypertension, cerebral amyloid angiopathy, and anticoagulation are major causes of intracerebral hemorrhage. In this presentation different aspects of nontraumatic intracerebral hemorrhage we be reviewed and discussed with focusing on surgical indications and technical considerations.

Up The Creek Without a Paddle: Adventures in Rural Surgery During My First Year

Tracy Sambo, MD, General Surgeon, Poplar Bluff, MO

This is an interactive discussion outlining three difficult cases I encountered in my first year in practice in a rural setting. These cases were made more difficult by lack of resources and geographic isolation. I describe what happened, what I did, and what one could do when facing a similar situation. I then allow for the audience to share their own tips and tricks for getting back down the creek without a paddle.

A New Conception of Oral Potentially Malignant Disorders (PMDs) and Surgical Management of PMDs

Joji Sekine, DDS, PhD, Deputy Director, Nagasaki Diagnostic Pathology Clinic, Nagasaki, Japan

Purpose: Oral squamous cell carcinoma (OSCC) comprises 92-95% of all oral cancers. OSCC sometimes show the features of oral epithelial dysplasia (OED), numerous criteria exist for the diagnosis of epithelial dysplasia, and there is not always a clear-cut distinction between what presents a mild dysplasia consisting only of focal dysplasia, which may represent carcinoma in situ (CIS). OED is usually confirmed to a single tissue compartment and may progress to cancer, but does not always do so. CIS or oral intraepithelial neoplasia (OIN) are lesions that have the morphologic characteristics of cancer, including atypical cells and dysplastic tissue organization, but are confirmed to one tissue component and do not penetrate the basement membrane. Numerous criteria exist for the diagnosis of OED, and there is not always a clear-cut distinction of what represents mild dysplasia— consisting of only focal atypia, moderate dysplasia, and severe dysplasia—which may present as OIN and CIS. Recently, such borderline lesions are called potentially malignant disorders (PMDs). This paper presents how we distinguish PMDs and other lesions as well as surgical management of PMDs.

Method: The study included 114 patients (64 men, 50 women). All participants provided informed consent to participate, following approval of the study protocol (approval no. 996; March 26, 2012) by the ethics committee of Shimane University Hospital. In all patients, biopsy was done, which were formalin fixed, paraffin embedded. Histopathological diagnoses was done by specialist of Pathology in our hospital. There were 67, 10, and 37 patients with OED, CIS, and OSCC, respectively. The expressions of Nucleus accumbens-associated protein 1 (NAC1), cytokeratine 13 and 17, human papilloma virus (HPV) 16, 18, and p16 were examined. Furthermore, c-mic, E-cadherin, vimentin and Ki-67 were also used for distinguishing PMDs.

Results: NAC1 labeling indices (Lis) cut-off values which discriminated between OED and CIS/OSCC were 50%. NAC1 was also available for distinguishing normal and OED with LIs cut-off value of 60%.OED and OIN was distinguished using Ki-67 and c-mic, on the other hands, OIN and OSCC was distinguished by the expression of E-cadherin and vimentin.

Conclusion: PMDs (borderline lesions between normal and malignancy) are very difficult to be diagnosed by routine HE staining. Our approach by various immunohistochemical staining would be feasible to distinguish PMDs from normal and OSCC. Regarding the management of PMDs, surgery should be indicated as some PMDs show features of malignancy. More detailed study would be needed for accurate diagnoses of PMDs.

Transpopliteal GSW Causing an Acute Popliteal Venous Thrombosis and Associated Major Pulmonary Embolus

Grace Shim, Medical Student, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX

Introduction: Common acute complications of lower extremity gunshot wounds (GSW) include major hemorrhage, soft tissue disruption, fractures, acute limb ischemia and neurological injuries. Patients who sustain a GSW may have vascular injuries remote from the visible point of entry and projectile tract. Despite maintaining integrity of the popliteal artery and vein, our case presentation demonstrates a complication that arose from the blast injury effect of a GSW that traversed the popliteal fossa. Case presentation: 65 year old male was admitted as an activated level 2 trauma for an accidental, self-inflicted GSW to the right lower extremity. He has no significant medical comorbidities. Aside from right leg pain, the patient denied any other symptoms; specifically denying any chest pain or shortness of breath. On physical exam, an entry wound was noted right proximal calf posteromedially. No exit wound identified. There was minimal bleeding and the patient was neurovascularly intact with symmetrical ABIs at 0.98.

Plain films identified the bullet located in the soft tissue of the lateral right suprapatellar area. CTA of abdomen, pelvis, and lower extremities revealed no vascular injuries. However, the CTA incidentally revealed acute pulmonary emboli involving the subsegmental right lower lobe pulmonary vasculature.

Due to the incidental finding of pulmonary emboli on the CTA, a dedicated PE protocol CT of the chest was performed. This demonstrated a large pulmonary embolus in the right main pulmonary artery extending into the upper and lower lobe branches as well as small pulmonary emboli within the tertiary branches of the left lower lobe. Bilateral lower extremity venous dopplers were obtained, which revealed an acute right popliteal thrombus. Discussion: Extremity vascular injuries associated with GSWs typically present with either severe hemorrhage or acute critical limb ischemia. It is important to maintain a high level of suspicion for major vascular injuries secondary to the blast injury effect, particularly blast injuries which result in only acute vascular thrombosis. This case demonstrates the extremely subtle presentation of acute popliteal venous thrombosis and associated major pulmonary embolus in what otherwise appeared to be a relatively innocuous lower extremity GSW.

Current State of Acute and Chronic Pain Management: Identifying the Non-Opioid Alternatives!

Vinita Singh, MD, Cancer Pain Director, Assistant Professor of Anesthesiology, Emory University, Atlanta, GA

How to manage pain without opioids in acute peri-op as well chronic pain setting?

In the current era of opioid crisis, it is important to understand and identify non-opioid based methods of pain control.

Understand/identify non-opioid medications, interventions and complementary alternative for pain control.

Be able to provide/identify non-opioid based methods of pain control. Will briefly cover variety of interventional pain procedures, non-opioid medications and complementary alternatives for pain control.

Thinking Outside the Box. Complex Hemodialysis Access, Advanced Approaches and Creative Techniques

Ehab Sorial, MD, Clinical Associate Professor of Surgery, Stanford University, Los Gatos, CA

Hemodialysis access can be challenging due to the patients' comorbidities including central venous occlusions which forbid placement of new access in either upper extremities. - Audience will need to know there are advanced options to perform upper extremity access even with central venous occlusions. Also they will be able to think outside the box and choose other sites for new access placement. - The learner will be able to perform appropriate diagnostic tests and perform adequate evaluation of patients before referral to vascular surgery. Also they will be able to understand when to refer those patient in a timely manner to prevent long term consequences from long lasting dialysis catheters which may lead to systemic sepsis. - Audience will benefit from presentation by knowing about the new technology and by understanding the anatomy of central venous occlusions. Also they will understand how vascular surgeons would tackle these complex issues.

Changing Paradigm in the Treatment of Carotid Artery Disease

Ehab Sorial, MD, Clinical Associate Professor of Surgery, Stanford University, Los Gatos, CA

Carotid disease is the 5th leading cause of stroke in the US. There is changing paradigm in its treatment from Medical to Carotid endarterectomy to Carotid stent. - The audience will need to understand when to use what type of treatment. Also how to perform appropriate medical management for Carotid disease. - The learner will be able to decide which treatment is appropriate for each patient. Also when it is appropriate to refer patient to the vascular surgeon to proceed with surgical management. - The audience will benefit from the presentation by understanding the etiology of stroke due to Carotid disease, treatment paradigm and medical management including lifestyle factor modifications

Contour Mapping of Human Surface Anatomy: Defining Focal Fat Pad Loci and Improving Surgical Outcomes with Anatomically-Guided Adipose Reconfiguration

David Teplica, MD, MFA, Clinical Associate, Section of Plastic and Reconstructive Surgery, Department of Surgery, The University of Chicago, Chicago, IL

Authors: David Teplica, MD, MFA, Brent Robinson, MD, Donald Keith, MBA, Stephen Goudy, and Eileen Jeffers

Purpose: The term ’subcutaneous fat’ is used as though it refers to as a singular anatomic entity. However, given gendered differences in fat enlargement and consistent patterns of focal fatty fullness seen with certain diseases and hormonal shifts, it follows logically that focal fats must exist. Although subcutaneous adipose appears grossly similar body-wide, we surmised that any given focal fat mound might have unique anatomic/physiologic characteristics when compared to neighboring locations. This might provide an explanation for the myriad of body shapes seen and explain patterns of anatomic change occurring over the human lifespan. To test these hypotheses, an anatomic study was designed to measure and visualize full-body focal fatty thicknesses.

Methods: Bilateral paired fat mounds were identified and mapped in lean healthy medical models using contour mapping techniques borrowed from geography and cartography. Loci of subcutaneous fullness were then quantified and tabulated using calipers and pinch-testing protocols. Meta-analysis was accomplished by graphically plotting findings onto the surface of the torsos and limbs of a single lean man and single lean woman.

Results: Paired focal mounds occurred in a consistent curvilinear arrangement running down the anterior surface of the body, coursing from axilla to groin on both sides of the midline. This array was consistent with the locations of mammary ridges seen during embryological development of placental mammals. Posteriorly, analogous paired mounds were found running from posterior axillary folds to buttocks. Focal fat pads were also consistently identified along the medial and lateral aspects of the arms. The legs appeared to have a spiraling arrangement of mounds consistent with rotation of the limb buds that must occur embryologically to permit flexion of the knees for bipedal ambulation. Each subject in the study pool exhibited a different amount of fullness in any given pair of mounds, but the locations of the fat pads were consistent in every subject. None exhibited a fat pad that was not along the described lines, regardless of gender, age, race, hormonal status, sexuality, or states of health.

In addition, use of the same topographic mapping technique in the clinical setting has proven invaluable to provide full-body, anatomically based, and circumferential insights into unwanted shapes. When plotted on the surface of the body just prior to surgery, contour maps facilitated anatomically based, proportionate, and natural-appearing surgical reconfiguration of 3-dimensional form, whether for reconstructive or aesthetic purposes.

Conclusions: The use of pinch-testing and contour mapping has provided basic anatomic insights regarding fat pad distribution body-wide. Although fat pad loci were consistent in every study subject, fullness in any given pair varied by individual, explaining the wide variability of human shapes seen. An improved understanding of baseline anatomy and unwanted focal fat pad fullness can help guide surgical reconfiguration of body shape to improve surgical outcomes and patient satisfaction by improving the likelihood of gender-appropriate, ethnically sensitive, and natural-appearing results.

Further work is also needed to define the physiology of subsets of adipocytes located in each of the newly described, paired, focal mounds of fats. ... the problem / surgical intervention the presentation covers:

The findings provide a better understanding of how to analyze, document, and surgically alter 3-dimensional human anatomy.

... why the audience needs to know this information:

Our data have the potential to help understand the consistent spatial orientation of human form, how it varies by gender, age, disease, sexuality, and ethnicity with a goal to inform and improve medical and surgical care.

... what the learner will be able to accomplish after the presentation:

The learner will be better able to visualize anatomy, recognize patterns of bodily findings, and better prepare for reconstruction or surgical manipulation of body form.

... how the audience will benefit from the presentation:

The audience will be better able to recognize anatomic entities that are genetically-based, to better inform patients about the inborn nature of anatomy, to better plan and prepare for any individual surgical case (whether reconstructive or cosmetic), and to imagine how well-planned and well-mapped surgery may be the best method to deliver natural appearing and gender-appropriate surgical results.

The Dr. Arno Roscher Endowed Lecture:

How to Slow, Stop or Reverse the Aging Process

Ara Tilkian, MD, Director of Cardiology, Providence Holy Cross Medical Center, Mission Hills, CA

The presentation will cover the historical efforts of slowing, stopping and reversing the aging process going back many centuries.

Presentation will review the important drivers of aging, the history of the efforts to slow and stop aging, and discuss the current and future efforts to reverse the aging process.

A Unique Presentation of Traumatic Diaphragmatic Hernia Rupture in a 37-Year-Old Man

Natalie Tully, BS, Medical Student IV, Texas Tech University Health Sciences Center, Austin, TX

Introduction: Hiatal hernias have a prevalence in the general population of 14-84%. Of these, 90-95% are Type I, or sliding hiatal hernias. Traumatic hiatal hernias represent a minority but substantial portion of the hiatal hernia population. Diagnosis of hiatal hernia, especially traumatic hernias, may be difficult, as computed tomography (CT) scan is only diagnostic in an estimated 40-80% of cases.

Case Report: This 37-year-old male presented to an outside hospital two days after he felt a popping sensation in his left upper quadrant while lifting his mother and experienced worsening abdominal pain and bloating. On physical exam he was found to have a firm abdomen with left upper and lower quadrant tenderness. Vital signs and laboratory findings were within normal limits. Chest x-ray revealed high density free fluid in the right lower lobe. A subsequent CT scan of the abdomen showed a large epigastric mass and moderately high density right flank fluid extending into the pelvis.

The patient was transferred to our facility where he was found to have increasing abdominal pain and distension as well as nausea and taken to the operating room. Upon incision for laparoscopy, a large amount of blood was evacuated from the abdomen. After one liter was evacuated, the decision was made to perform a laparotomy. Once the abdomen was open, a large amount of blood was found in the left upper quadrant without an obvious source.

A large, chronic hiatal hernia with a well-formed sac was found. Upon further inspection, the two most cranial short gastric arteries were found to be avulsed but not actively bleeding. They were oversewn and a Stamm gastrostomy tube was placed to serve as a gastropexy. Afterwards, the abdomen was copiously irrigated, suctioned and closed.

The patient was extubated postoperatively returned to the surgical intensive care unit. ?His postoperative recovery was largely uneventful and he was discharged on postoperative day 4 and had his gastrostomy tube removed 6 weeks later.

Discussion: Chronic hiatal hernia is a common medical condition within the general population, of which the vast majority are small, Type I (Sliding) hiatal hernias. Type IV (Complex) hiatal hernias compose <5% of all cases but predispose patients to disproportionate morbidity and mortality.

While the complications generally associated with large hiatal hernias involve incarceration, strangulation and necrosis, this patient was unique in that he presented with a hemorrhagic complication.

This patient presentation is likely to have resulted from a chronic hernia, which was put under an acute increase in intra-abdominal pressure while lifting a significant amount of weight.

While the short gastric arteries had accommodated the gradual tension of hernia expansion, they likely could not tolerate an acute increase in tension during this straining event. Therefore, the stomach herniated through the hiatus during this event, causing the short gastric arteries to shear and bleed into the abdomen.

However, this patient did not continue to bleed- on laparotomy, no active bleeding was found-only large amounts of clotted and old blood. It is well documented in the literature that exsanguination can occur intra or retroperitoneally.

It is likely that the bleeding then tamponaded itself, preventing further blood loss.

However, the patient may have had preexisting risk factors for hypercoagulability. Most notable among these may have been his use of injected testosterone, which can predispose patients to polycythemia and concomitant hypercoagulability.

Management of Tarlov Cysts

William Welch, MD, Chair, Department of Neurosurgery at Pennsylvania Hospital, Philadelphia, PA

Tarlov cysts are commonly identified lesions seen on spinal, pelvic and abdominal studies. They are usually asymptomatic but may cause spinal, radicular, pelvic and abdominal pain as well as neurological dysfunction including bladder, bowel and sexual discomfort. These symptoms frequently overlap specialties including neurosurgery, orthopedic surgery, general surgery, urological surgery and gynecology. I will review the presumed etiology of these lesions, their potential symptoms, overlap with multiple medical and surgical specialties, and management. This work is based on 30 years of experience with these lesions and review of the existing literature. The learner will develop a better understanding of these lesions, how they may impact their patients and the surgical and non-surgical management of this condition.

A 1-year Prospective Time Study of Email Use

William Welch, MD, Chair, Department of Neurosurgery at Pennsylvania Hospital, Philadelphia, PA

Email correspondence has the potential to provide messaging in a concise, efficient manner. This system has not met its potential and has had the effect of consuming important physician time while conveying limited amounts of mission critical information I performed a prospective study over the course of a calendar year as to the amount of time that it took me (university-based academic physician) to open emails. I categorized the emails into multiple clinically and academically relevant subsets and included a category mission critical. Opening emails consumed approximately 1 week (130 hours) of time and yielded minimal mission critical information. This has a significant impact on physician well-being. I will make suggestions as to how email can be better managed.