ABSTRACTS

Presentation Descriptions

International College of Surgeons

United States Section

84^th Annual Surgical Update

And

American Academy of Neurological and Orthopaedic Surgeons

46^th Annual Scientific Meeting

Hilton Palacio Del Rio

San Antonio, Texas

May 4-6, 2023

Giving Back: How to Get Involved in Global Surgery as a Surgical Trainee

Presented in the: Opening Session: Global Surgery 2023 and Featured Lectures

Osaid Alser, MD, MSc (Oxon), General Surgery Resident, Texas Tech University Health Sciences Center, Lubbock, TX

There are growing calls for focused strategies to reduce the gap in surgical safety and access between high-income countries (HIC) and low-to-middle-income countries (LMICs). These calls were amalgamated to form the Lancet Commission on Global Surgery in 2015 with the aim of improving surgical care and disparities, particularly in LMICs. Surgical trainees in HIC have an essential role in supporting their fellow trainees and medical students in LMICs in various ways including academic and clinical aspects. We share our experience from Oxford-Palestine (OxPal) initiative which aims at enhancing medical education in Palestine and other MENA countries by offering medical students and trainees mentorship, research fellowship/journal club, virtual reality curriculum, case-based discussion, and many other activities.

The Value of Surgical Missions in Low and Middle Income Countries to a Surgical Training Program

Presented in the: Opening Session: Global Surgery 2023 and Featured Lectures

Domingo T. Alvear, MD, Chairman and Founder, World Surgical Foundation, Mechanicsburg, PA

Surgical missions in Low and Middle Income Countries can be an asset to a Surgical Resident in training. Several recent trends concerning surgical education have resulted in significant challenges in the preparedness of current graduates. Residency has de facto shortened by nearly 12 months due to duty-hour restrictions. Opportunities for autonomy and independent decision making during residency have become a rarity due to regulatory changes, medico-legal concerns, societal and ethical changes and healthcare financing enforcement. Approximately 80% of graduates choose to pursue fellowship after residency , leaving only 20% who enter surgical practice.

Methods : For 25 years the World Surgical Foundation has provided life saving and life changing surgical procedures in over 12,000 patients. I will be presenting sample cases. I will present surgical residents who benefitted from this program.

Conclusion : Surgical missions can be a great asset to a surgical residency training program. I encourage the International College of Surgeons to embrace this program.

A surgical resident will be exposed to unusual and complex cases during the mission. Open cases will be prevalent. They will be working with Volunteer Surgeons with different background and skills. Career paths of the surgical residents have change after exposure to cases and to expert surgeons.

Cost Comparison of Endovascular versus Open Surgical Revascularization in Popliteal Artery Occlusive Disease

Presented in the: Annual Research Scholarship Competition

Hamza Ashfaq, MPH, OMS-III, University of Pikeville Kentucky College of Medicine, Pikeville, KY

Popliteal Artery Occlusive Disease (PAOD) is a vasculopathy that can lead to claudication and eventually extremity loss. Endovascular repair (EVR) and open surgical repair (OSR) are both currently used in the treatment of PAOD. These two revascularization interventions have been proven efficacious in alleviating pain and salvaging the limb. The choice of treatment modality is primarily determined by severity of disease and degree of involvement. However, the difference in costliness between these procedures hasn’t been explored extensively nor been a factor in clinical decision making. Through this study we aim to provide insight into the cost differences between the two procedures.

A retrospective analysis identified patients who underwent treatment for PAOD over a 6-year period at the University of Kentucky. Cost data was obtained for direct costs including operating room time, anesthesia, surgical services, supplies, and accommodations (non-ICU & ICU) as well as indirect costs.

A total of 67 patients, 48 male and 19 female patients with a mean age of 59 were treated for PAOD. 22 patients underwent OSR and 45 underwent EVR. The contribution margin of OSR was at a loss whereas EVR was profitable (-$515 vs $$3,840). Total indirect costs were also lesser in EVR than OSR ($10,839 vs $12,843). On average, OSR was more costly for operating room time ($3,019 vs $2,149), anesthesia ($1,594 vs $692), supplies ($5,091 vs $4,306), and post-operative accommodations ($6,479 vs $5,340). EVR was only more costly in the utilization of surgical services ($348 vs $271).

These preliminary results demonstrate that EVR is a less costly intervention for the treatment of PAOD as compared to OSR. EVR should be highly considered in patients who are eligible, as the intervention of choice.

How Good Physicians Find Themselves in Bad Situations

Presented in the: Honors Luncheon The Dr. Arno Roscher Endowed Lecture

Ryan Bayley, MD, Founder and Chief Executive Coach, Bayley Coaching Solutions, Assoc. Adjunct Professor, Dept. of Surgery, Duke University; Emergency Physician, Wake Emergency Physicians (WEPPA); EMS Medical Director, Granville County, NC, Chapel Hill, NC

As physicians, we have long enjoyed high levels of status, authority, and deference in the workplace. Historically, this has created a culture where we were rarely challenged or criticized - a culture that is now increasingly at odds with societal expectations around speech and behavior, particularly of those in positions of power. Not surprisingly, the number of physicians accused of poor communication, boundaries issues, or disruptive behavior has skyrocketed over the last 5 years.

Given this, physicians need to be aware that one badly worded conversation or inappropriate behavior can lead to loss of hospital privileges or even loss of medical license. Whereas historically physicians would only be held accountable for more egregious behaviors such as fraud, gross incompetence, or assault, now there is a whole new category of incivility that we need to be aware of.

A subset of unprofessional behavior, incivility encompasses a wide range of low-intensity behaviors around communication and body language that nonetheless can be harmful to those around us and cultivate a toxic work culture. Unfortunately, many of us trained in environments where incivility was common, ignored, and even accepted - further setting us up for failure in today's clinical environment.

In this hour, we will explore this idea of incivility and the changing expectations that our peers and patients have of us now. Drawing upon the real-life experience of the hundreds of physicians that we have worked with, we will identify the communication styles and behaviors that are most likely to create problems, and most importantly, we will impart actionable strategies in navigating today's medical workplace.

Preliminary Experience with DaVinci Single Port (SP) in General Surgery

Presented in the: General Plenary Session

Francesco Bianco, MD, Associate Professor University of Illinois at Chicago, Chicago, IL

The presentation will describe the application of the new robotic single port davinci platform in general surgery. This is an off label application as there is currently no FDA approval and the work is being conducted under an IRB research protocol. The current experience is of 350 cases and include cholecystectyomies, inguinal and ventral hernia repair, sleeve gastrectomies, gastric resections and nissen fundoplications.

Intercostal Nerve Cryo Ablation Provides Effective Analgesia When Used as an Adjunct in Rib Fracture Stabilization: The Recent Evidences.

Presented in the: Trauma and Critical Care Surgery: 2023 Considerations

Saptarshi Biswas, MD, Associate Program Director General Surgery Residency, Director of Surgical Research and Simulation, Grand Strand Medical Center, Myrtle Beach, SC

Traumatic rib fractures occur in approximately 10% of trauma patients often resulting in severe pain, major morbidities such as atelectasis and pneumonia. The pathophysiology centers on pain causing the impairment of adequate pulmonary function and clearance of secretions which attributes largely to the mortality rates of 29%, reported in patients with 7 or more rib fractures.

Prior studies have reported 59% of patients continue to have persistent pain at 2 months after injury. When followed to 6 months, 28% of isolated rib fracture patients still experienced chest wall pain. Most modern analgesia modalities have a short duration of effect (< 72 h) and require repeated doses for effective treatment. In addition, many of these modalities have contraindications for use (i.e., epidural catheters with coagulopathy or spinal fractures and nonsteroidal anti-inflammatory drugs with renal dysfunction or gastrointestinal bleeding).

Recent decade have seen dramatic increases in opioid-related deaths from drug overdose. United States declared a national emergency on August 10, 2017, and emphasis has been placed on limiting the prescriptions of all opioid medication by providers.

The technique of intercostal cryoneurolysis (IC) may be a useful adjunct to provide both short- and long-term analgesia for traumatic rib fracture pain. IC for control of postthoracotomy pain was first described by Nelson et al. in 1974. In terms of efficacy for thoracotomy pain, multiple trials have shown that IC has equal or improved efficacy as compared to intermittent intravenous and oral opioids. Often, IC showed significantly decreased narcotic use, improved pain control, and improved compliance with pulmonary physiotherapy as compared to controls

Direct application of the cryoprobe to a peripheral nerve results in a Sunderland Stage II nerve injury known as axonotmesis. In this circumstance, the nerve axon and myelin sheath are destroyed but the endoneural, perineural, and epineural structures remain intact . This is followed by Wallerian degeneration of the distal nerve resulting in numbness distal to the nerve lesion. Regeneration of the nerve occurs along the remaining perineural structures typically between 1 and 3 mm per day.

With the encouraging results seen in the fields of thoracic and pediatric surgery, Trauma surgeons have began to incorporate IC as an adjunctive analgesic technique when performing surgical stabilization of rib fractures (SSRFs). Since the experience of pain and level of pain tolerance are inherently subjective and can vary widely between individuals, the ability to assess and compare the individual trauma patient's pre-operative (conventional analgesia) and post-operative (cryoneurolysis analgesia) pain levels can minimize confounding variables regarding the efficacy of treatment. IC was safe with minimal long-term adverse outcomes;continuing to recover sensation by 6 months. Finally, IC added no significant increase in the number or magnitude of invasive procedures to the patient's care as it was a simple extension of an already indicated procedure.

Further investigation, including comparative trials, is necessary and warranted to further establish the role of IC in traumatic rib fracture pain.

Harness Hang Syndrome; Death on a rope and Rescue Death. Debunking myths and evidence- based discussion of Suspension Syndrome.

Presented in the: Rural Surgery: Applications and Adaptations for Your Practice

Saptarshi Biswas, MD, Associate Program Director General Surgery Residency, Director of Surgical Research and Simulation, Grand Strand Medical Center, Myrtle Beach, SC

Suspension trauma refers to the pathophysiologic syndrome that occurs when a victim is suspended motionless in a vertical position for an extended period of time. This can occur in sports that use a harness system as well as in various occupational activities including work on high wires or helicopter rescue operations.

The first known mention of deaths while on rope with no obvious cause was in 1972 at the second international conference of mountain rescue doctors in Innsbruck, Austria. Death could not be explained by trauma surgeons. Some climbers had died while suspended, and in a reported case, the victim died immediately after rescue.

Suspension trauma can occur in any activity that uses a body harness system. This includes sports such as mountaineering, rock climbing, parachuting, paragliding, via ferrata, canyoneering, BASE jumping, and spelunking. Occupational activities include work on high wires or rescue operations in hostile environments (mountainous or other difficult terrain, helicopter winching in rescues at sea, etc).

There is a paucity of scientific data about suspension trauma and what little is available consists of case reports and human experimental prospective studies of which only a few are controlled and randomized.

The pathophysiology of suspension trauma is related the human body’s response to the orthostatic position resulting in functional hypovolemia from pooling of blood in the lower extremities. The absence of a muscle pump in an immobilized subject diminishes venous return, accentuating this phenomenon. Symptoms of presyncope (nausea, light-headedness, hot flashes, numbness of the extremities) or unconsciousness result if not treated in an expedited fashion. Different types of body harnesses can exacerbate this situation.

Sports enthusiasts and workers who use a body harness system should never act alone and should not use a simple chest harness. If a victim shows symptoms of presyncope or is unconscious, he should be released from suspension as soon as is safely possible. There is no clear evidence to support the idea that the return to the horizontal position may contribute to the potential risk of rescue death. once a victim has been brought to the ground, rescue professionals should follow the current international prehospital and advanced life support guidelines without modifications.

Update on GERD ACG Guidelines- Medical and Surgical Treatment

Presented in the: Rural Surgery: Applications and Adaptations for Your Practice

Francis Buckley, MD, Associate Professor of Surgery, University of Texas, Dell Medical School, Austin, TX

Will discuss the updated American College of Gastroenterolgy guidelines on GERD management. These guidelines are a major shift forward in terms of utilization of diagnostic testing, limiting medical therapy and expanded role of surgical therapy.

Aging Population in the World and Singapore - New Direction in Surgery?

Presented in the: Opening Session: Global Surgery 2023 and Featured Lectures

Clement Chan, MD, MBA, Honorary Associate Clinical Professor, Hong Kong University; Honorary Associate Clinical Professor, Chinese University of Hong Kong; Adjunct Associate Professor, School of BioMedical Sciences, Chinese University of Hong Kong; Visiting Professor, Cebu Ins, Singapore,

1. Population ageing is a global phenomenon:

Virtually every country has similar ageing population growth. For those aged 65 or above, it was around 6% world population in 1990, rising to703 million (9%) in 2019 and expected to be 1.5 billion (16%) in 2050.

2. Population ageing fastest in Eastern & South-Eastern Asia, and Latin America & Caribbean.

For E & SE Asia, it was around 6% of the population in 1990 rising to 11% in 2019.

For Latin America & Caribbean, it was around 5% in 1990, rising to 9% in 2019

From 2019 to 2050, share of elderly projected increased to 2 folds in E & SE Asia, Central & S Asia, N Africa & W Asia, & Latin Am. & Caribbean.

3. Population ageing will put increased financial pressure on old-age support systems.

4. Population ageing does not lead inevitably to macroeconomic decline—with well-chosen policies, opposite may be true.

5. Singapore:

In Singapore, the increase in life expectancy plus decrease in birth rates leads to an aging population with unfavourable old aged support ratio.

In 2018, Singapore is one of highest life expectancies in world.

In 2017, Singapore showed lowest fertility rate in world (0.83 children/woman)

In 2035, it is estimated that 32 % Singaporeans will be aged 65 or above.

The median age is 39.7 in 2015 increasing to 53.4 in 2050.

The demographic shift in Singaporean society means

a) there is decreased workforce to support the ageing population;

b) there is less support from the family as young generation tends to live away from parents

Problems of Surgery in Elderlies:

While there are many reasons for increased risks of surgeries in terms of mortality, complications, morbidities and long term ill consequences, there are 3 prominent ones

1) Frailty

2) Polypharmacies &

3) Co-Morbidities

New Directions in Surgeries for elderlies:

While the increased risks are well recognized, a good surgical team should never be scared to take up the challenge and adopt an attitude of avoidance. Instead, special and SEPARATE MODE of management should be directed to surgeries in elderlies. The lecture would discuss under 4 areas.

1. PREOPERATIVE OR PEROPERATIVE MANAGEMENT

2. ANAESTHESIA

3. SURGERY

4. POSTOPERATIVE MANAGEMENT

Rural Trauma: The Importance of PreHospitaI Inclusion in Research, Planning, Training and Operations

Presented in the: Rural Surgery: Applications and Adaptations for Your Practice

Will Chapleau, Paramedic, Trauma Nurse Specialist, Director International Pre-Hospital Medicine Institute, Chicago Heights, IL

Rural Trauma presents many challenges that require identifying and utilizing all of the resources available to develop an integrated Trauma System. In this presentation, we will discuss the importance of ensuring the PreHospital Care leaders and providers are involved in the research, planning, training and operations of a high performance Trauma System in a rural setting.

Ensuring the Future of Diabetic Care in the US Features Solid Organ Pancreas Transplantation

Presented in the: Transplantation Session

Matthew Cooper, MD, Chief, Division of Transplantation, Medical College of Wisconsin, Milwaukee, WI

With improved technology including glucose sensors and feedback loops now becoming standard in the care of diabetic patients, the question often asked is the place for solid organ pancreas transplantation with its known risks including surgical and the need for long-term immunosuppression. Data will be presented that will confirm the continued value of solid organ pancreas transplantation for appropriately chosen recipients and the superiority over these technology-driven interventions.

Management of Colorectal Liver Metastases

Presented in the: Surgical Oncology

Colin Court, MD, PhD, Assistant Professor, Division of Surgical Oncology and Endocrine Surgery Mays Cancer Center, UT Health San Antonio - MD Anderson, San Antonio, TX

The management of colorectal liver metastases is an evolving field with numerous systemic and loco regional therapies playing important roles. Long term studies have demonstrated that up to 40% of patients in some centers will have 10 year survival with aggressive management. This presentation will highlight some of the recent advances and treatment techniques in the field as well as the role of the surgeon in helping coordinate and time these various treatment strategies.

Motherhood and Surgery: How to make it work

Presented in the: Women in Surgery Panel Discussion

Tamera Cox, MD, General Surgeon, Atrium Health Cleveland, Shelby, NC

Multiple studies have demonstrated that women in medicine struggle to conceive children and then to stay on as viable members of the surgical work force when they do have children. I will plan to discuss the struggles I have seen with women I have worked with over the years as a medical director for a community general surgery practice and review what seems to work well and what we can do to keep woman happy and engaged both as successful surgeons and involved parents.

Creating Ancillary Income in a Private Surgical Practice - OrthoSculpt

Presented in the: AANOS Annual Scientific Meeting: Neurological and Orthopaedic Surgery Part 1

Steven Cyr, MD, Orthopaedic Surgeon, CYRxMD Cosmetic Surgery, San Antonio, TX

The challenge of maintaining a profitable practice continues to worsen. As private physicians face progressively declining reimbursements and government regulations which limit the ability to generate ancillary revenue, physicians have been leaving private practice. Physicians must think outside the box to grow their practice revenue streams. Dr. Cyr outlines the foray into cash-based medical practice in the Cosmetic Surgery field by outlining his model for creating ancillary revenue for private practice surgeons. He describes the technique to implement Cosmetic Surgery training/techniques as well as ancillary revenue through the implementation of cosmetic surgery and medical spa services such as injections/fillers. As the only fellowship trained orthopedic surgeon and fellowship trained Cosmetic Surgeon by the AACS in the Country, Dr. Cyr outlines opportunities for surgeons to pursue with additional training that can not only increase revenue but also increase one’s length of practice. He is the developer of the surgical procedures using high definition liposculpture, called OrthoSculpt.

This presentation will allow Physicians to understand the potential opportunities that exist to increase one’s financial success while decreasing the stress and risk associated with a practice which relies solely on insurance and government reimbursements. Dr. Cyr will describe how surgical training in multiple specialties, including orthopedic surgery, Gen Surgery, and other fields, lend themselves very well to a practice in Cosmetic Surgery. He will outline opportunities that exist and describe how his surgical background as an orthopedic surgeon allowed him to perform procedures with increased safety and anatomic accuracy.

Popliteal Artery Aneurysm Repair: A Single Center Experience

Presented in the: Annual Research Scholarship Competition

Nicholas Demas, BS, Second Year Medical Student (MS II), University of Kentucky College of Medicine, Lexington, KY

Purpose:

Popliteal artery aneurysm (PAA) is a relatively rare disease diagnosed clinically or with imaging modalities. These aneurysms may present with lower extremity ischemia but can be asymptomatic at the time of discovery. The two current repair methods are endovascular and open repair. Our aim is to review the experience at University of Kentucky Medical Center and compare endovascular versus open repair and their outcomes from January 2010 to December 2019.

Methods:

I have reviewed a total of 79 charts with IRB approval. These charts included 4 females and 75 males ranging in age from 22 to 89 years (mean 63.5). Seventy cases presented with symptoms of lower limb ischemia (88.61%), and nine cases were asymptomatic at the time of aneurysm discovery (11.39%). Endovascular repair was done in 38 cases (48.10%), and open repair was done in 41 cases (51.90%). Four open repair cases used a GoreTex graft, and the remaining 37 open repair cases used vein grafts. Thirteen patients underwent bilateral popliteal artery aneurysm repair (16.46%). Eight cases were diagnosed as popliteal artery pseudoaneurysms (10.13%). Seven of the eight pseudoaneurysm diagnoses received open repair, and the remaining 1 case received endovascular repair. Five pseudoaneurysm cases were due to an infection, one case was from pseudoaneurysms forming after reintervention of a femoral graft, one case was due to trauma from a crush injury, and one case was a focal giant cell reaction with fibrotic vessel wall elements.

Results:

Thirty-four patients were followed for more than 2 years (43.04%). Twelve total cases required surgical reoperation within 30 days of the initial repair (15.19%). 5 endovascular repairs required reoperation, and 7 open repairs required reoperation. Regarding the 5 endovascular repair reoperation cases, one was to fix a thrombosed endovascular stent with open repair, one was a fasciotomy for compartment syndrome, one was debridement of necrotic tissue and fasciotomy for compartment syndrome, one was a balloon angioplasty for a partially occluded stent, and one was debridement of necrotic tissue and a balloon angioplasty. Regarding the 7 open repair reoperation cases, one was evacuation of a leg hematoma, one was evacuation of a leg hematoma and bypass repair for an area of active extract, one was open evacuation for a surgical incision site hematoma, one was for ligation of groin lymphatics and wound vac placement for incision site drainage, one was a balloon angioplasty, one was debridement of necrotic tissue, and one was a fasciotomy with debridement of necrotic tissue. Fourteen total amputations were performed after the initial aneurysm repair (17.72%), with ten involving the knee, one involving the forefoot, and four involving the toes. Eight amputations were performed within 30 days of aneurysm repair, with 7 being above-the-knee (AKA) and 1 being a forefoot amputation. Four amputations were performed within 90 days of aneurysm repair, with 3 being above-the-knee and 1 amputation of four toes. Two amputations were performed after 90 days of aneurysm repair, where one was a transphalangeal amputation and the other a transmetarsal amputation. Three patients died within 30 days of their procedure during their hospital stay (3.80%). One patient died from acute respiratory failure due to cardiac failure; one patient died from a non-ST elevation myocardial infarction; one patient died from respiratory failure.

Conclusions:

Popliteal artery aneurysms are a relatively rare disease, and the current methods of repair include endovascular repair or open repair using either a synthetic or vein graft. In our experience, endovascular repair and open repair had a similar number of reoperations within 30 days. Open repair reoperations were done more often for debridement of necrotic tissues and related to the surgical incision site and hematomas. Endovascular reoperations were done more to fix thrombosed grafts. Endovascular repair had a higher number of amputations within 30 days of aneurysm repair, with 6 amputations compared to the 2 amputations for open repair cases. Endovascular repair is appealing for its shorter hospital stay, especially for asymptomatic cases and when a minimally invasive approach is preferred, but it does have an increased risk of stent thrombosis and amputation from our study findings.

Entrustable Professional Activities in General Surgery Residency

Presented in the: Special Luncheon Lecture

Daniel Dent, MD, Chair, Department of Medical Education; Professor and Vice Chair for Education, Department of Surgery; University of Texas Health San Antonio Long School of Medicine, San Antonio, TX

Our current model of surgical education determines promotion and trainee completion based largely on surrogate measures of competence such as case logs, standardized test performance, faculty evaluations, and a final attestation by the program director. Unfortunately, these surrogate measures do not allow for a demonstration and understanding of trainee performance as they complete their training period, which has led to heterogeneity in readiness for unsupervised practice. Internationally, several other countries have moved rapidly to competency based training model, most notably Canada.

Beginning in July 2023, the American Board of Surgery is launching use of 18 Entrustable Professional Activities (EPAs) for General Surgery in all training programs across the United States. This work builds on a pilot study of 5 at 28 surgical programs from July 2018-June 2020. This pilot demonstrated feasibility of EPA use in addition to providing important lessons to guide next steps. The July 2023 EPA launch will require education and engagement of trainees, faculty, training program and department leadership, all key audiences in attendance at the planned ICS-US Section meeting.

Attendees will learn about the American Board of Surgery plan for implementing Entrustable Professional Activities. This will include: Rationale for implementation Planned timeline EPA content and plan for technologic support

Localizing HCC: A multi-faceted approach to HCC in South Texas

Presented in the: Transplantation Session

Danielle Fritze, MD, Associate Professor,

University of Texas Health San Antonio, San Antonio, TX

Hepatocellular carcinoma (HCC), while widespread globally, is more common in South Texas than anywhere else in the United States. Located in the heart of this HCC hotspot, our transplant center has responded to this observation of local prevalence with a dedicated multi-disciplinary effort to better understand and manage HCC. This presentation reviews these efforts: basic investigation of HCC epigenetics and oncogenesis, translational work on ablative techniques, clinical trials in systemic therapy, assessment of disparities in HCC care, the expansion of surgical offerings including minimally invasive resection and living donor liver transplantation, the creation of the San Antonio Liver Cancer Symposium, and other interventions to educate health care providers and patients. In addition to providing an overview of research relevant to the local prevalence of HCC, this presentation is intended to be viewed as a case study in the impact of one center embracing responsibility for a disease impacting its community.

Cannulation Strategies for OxyRVAD VV ECMO in End Stage Lung Disease

Presented in the: Annual Research Scholarship Competition

Andrew Gorton, MD, Resident Physician, Cardiothoracic Surgery, University of Kentucky, Lexington, KY

To demonstrate the use of oxyRVAD systems and various cannulation strategies in patients with end stage lung disease as a bridge to evaluation for and possible lung transplantation.

From March 2021 to April 2022 at our institution we accepted 23 patients with acute- or acute-on-chronic respiratory failure requiring maximal ventilatory support that were placed on venovenous ECMO support. All patients eventually required oxyRVAD placement for right heart support during the evaluation process for lung transplantation. Of this population 17 patients presented with COVID ARDS, 4 patients with ILD, 1 patient with IPF, and 1 patient with NSIP. 6 patients were listed for and successfully underwent lung transplantation (bilateral transplant in 5 and combined heart-lung transplant in 1). 12 patients expired during the evaluation process or were not candidates and care was withdrawn. 2 patients were successfully weaned from and decannulated from ECMO. 2 patients remain on ECMO support while evaluation proceeds. 1 patient was transferred to a different center for complex transplant evaluation.

Of our cohort, 26% underwent successful lung transplantation, 52% were not candidates or expired during the evaluation process, 8% were weaned from support, 8% remain on oxyRVAD support while being evaluated. 4 of the 6 transplants were in COVID ARDS while the remaining were in ILD and NSIP. The most efficacious cannulation strategy was determined to be via a two-stick approach which provided the best balance of ECMO drainage and flow and ability to rehabilitate the patient.

oxyRVAD ECMO support is a reasonable treatment approach to end stage lung disease while undergoing evaluation for or awaiting lung transplantation. Our preferred cannulation strategy utilized two-sticks via the internal jugular and a femoral vein. This allowed for optimum ECMO function and patient rehabilitation potential.

Rural Surgery in Extremis: Comparison of Independent Rural and International Surgical Residencies

Presented in the: Rural Surgery: Applications and Adaptations for Your Practice

Riley Grogan, MD, General Surgery Resident (PGY-IV), Gundersen Health System, La Crosse, WI

Many surgical challenges and disparities exist, both globally and in the rural US. In my limited experience, there is semblance in these challenges, and as a surgical mentor once told me, global surgery is “Rural Surgery in extremis”. In this presentation, I will briefly share the rich history of rural surgical training at Gundersen Health System, explore the vibrant history of surgical education at AIC Kijabe Hospital in Kijabe, Kenya and review the impact of Gundersen’s international elective (IE) experience on its trainees. Although a world apart, the commonalities that exist between these two unique institutions have provided a sustainable solution for addressing healthcare inequities, both rurally and abroad – the role and importance of surgical education.

A Single Site, Retrospective Chart Review of Renal Transplant Graft Failure and Mortality Rates Pre and Post COVID-19 Pandemic

Presented in the: General Plenary Session

Troy Hollinsworth, MS-3, Medical Student, Sioux Falls, SD

Purpose

Immunosuppressed patients are at increased risk of complications of COVID-19. Despite the morbidity and mortality associated with COVID-19, there is little information regarding its effect on post-transplant patients. Research and clinical data have shown that renal transplant patients are at greater risk for mortality and morbidity due to associated infectious diseases. However, due to the novelty of COVID-19, we have little information regarding its effects on the transplant patient population. This study investigates how COVID-19 effected renal transplant patients in terms of graft failure and mortality at a community based transplant center.

Methods

We identified renal transplant patients using CPT codes from a single institution from 2011-2022. Patients were excluded if under the age of 18 years at time of transplant, were pregnant, were lost to follow up, or experienced mortality within 30 days of transplant. Patient demographics, transplant data, and outcomes were collected by retrospective chart review of the electronic medical record. COVID-19 test results, days from COVID-19 to graft failure and mortality, vaccination status, and COVID-19 treatment regimen were recorded and analyzed. We then compared outcomes and complications in patients who did and did not contract COVID-19.

Results

We identified 254 renal transplant patients who met initial criteria. Of these, 52 patients were excluded. Of the 202 patients that met criteria, 84 were diagnosed with COVID-19. Only one patient diagnosed with COVID-19 had subsequent graft failure after 104 days. The mean duration to mortality after a COVID-19 positive test was 129 days (n=13). The mean duration to mortality after transplant for all COVID-19 positive patients was 2519 days (n=14) compared to those who were COVID negative at 2119 days (n=7). Initial analysis shows no significant difference in complications and mortality for these patients when considering their comorbidities. Full analysis of our database is pending.

Conclusions:

In our community based transplant center, we found that patients with positive COVID-19 test did not have significantly greater complications or mortality than those who never tested positive.

Total Laparoscopic Whipple Procedure - A video case presentation

Presented in the: General Plenary Session

Michael Jacobs, MD, Clinical Professor of Surgery, Michigan State University CHM; Director of HPB Program and HPB Fellowship, Associate Chair of Surgery, Ascension Providence and Providence Park Hospitals, Novi, MI

This video presentation covers a skin to skin Whipple procedure that is accomplished totally laparoscopically.

Because of the complexity in dissection and reconstruction, most Whipple procedures nowadays are still performed in open fashion. Even though some progression is made in minimally invasive surgery, it's most commonly achieved in hybrid form using hand assistance through a mini-laparotomy, while only a few high volume centers nowadays are able to perform this operation in a pure laparoscopic fashion, including both the dissection and reconstruction phase.

In this video presentation, we are sharing a safe and efficient way, including port placement, sequence of dissection, tricks&tips .etc, in performing a total laparoscopic Whipple procudre, with satisfying patient's outcome.

Audience can incorpoarate useful information into their practice of minimally invasive Whipple procedure.

Stoma and Stoma Complications: How to create the perfect stoma

Presented in the: Colorectal Emergencies

John Kidwell, MD, Assistant Professor of Surgery, Texas Tech Health Sciences Center, Colon and Rectal Surgery, Lubbock, TX

Stoma creation is a common surgical procedure. Stoma creation is associated with a significant morbidity. We follow the current ASCRS guidelines in ostomy surgery to improve quality stoma creation and post operative care to reduce that morbidity and improve quality of life..

Obstructed Colorectal Cancer Nightmares from the ER

Presented in the: Colorectal Emergencies

Philip Kondylis, MD, Assistant Professor, University of Central Florida, Kissimmee, FL

The presentation addresses options available in the management of patients presenting acutely with high grade obstruction of the colorectum. There are options available to the surgeon and patient beyond creation of a decompressive stoma. The presentation will focus on more minimally invasive approaches to surgical stoma decompression. The presentation includes a discussion of the relative advantages and disadvantages of these approaches. At the conclusion, participants should have a better understanding of all the treatment options for these patients.

Massive Transfusion in Trauma: Does Payer Status Decrease Futile Transfusion?

Presented in the: Trauma and Critical Care Surgery: 2023 Considerations

Anthony Kopatsis, MD, Ichan Mount Sinai School of Medicine Elmhurst Hospital Center, Elmhurst, NY

Blood shortages are a national crisis creating dangerous scenarios for patients requiring massive transfusion protocol (MTP) in the trauma setting. Judicious use of blood product is critical to rescue salvageable patients while refraining from unnecessary MTP to save precious resources. We evaluate RBC transfusion volume and in-ED deaths relationship to payer status as markers of futility in trauma patients receiving MTP.

Among the 11,098 patients, ED mortality rate was 1.2% (n=132). Injury severity score (ISS) was higher in patients receiving MTP (14.7 vs.7.49, p < 0.01) and patients with penetrating trauma were more likely to receive MTP (32.8% vs. 10.1%, p<0.001). Mean probability of survival was lower in the MTP group (0.73 vs. 0.97, p<0.01). The median age of patients receiving MTP was younger (43.2 years vs. 51.3 years, p< 0.01). There was no difference in MTP status based on gender MTP given (p=0.15), (female 33%, male 67%) vs. MTP not given (female 21.3%, male 78.7%), race (p=0.49), ethnicity (p=0.50), or region, urban vs. rural (p=0.06). MTP was transfused was found to have been transfused more often in the died-in-ED group (7.6% vs. 0.5%, p < 0.001). Patients on Medicaid were more likely to have received MTP (only 37.7% of patients receiving MTP were on Medicaid compared to 62.3% non-Medicaid, p < 0.05); patients on Medicare were less likely to receive MTP (6.6% of patients receiving MTP on Medicare vs. 93.4% non-Medicare; p < 0.05). The discriminatory value for amount of PRBC transfused alone on whether a patient lived or died was high (AUROC 0.604 [95% CI 0.57 to 0.64]).

Patients with penetrating trauma and higher ISS are more likely to receive MTP, regardless of their probability of survival. Patients over the age of fifty years, Medicare recipients, and patients with blunt trauma are less likely to receive MTP. Assessing futility of MTP should be equitable and future transfusion guidelines should consider salvageability in cases with low probability of survival despite age and mechanism.

An urban Level I Trauma Center database was analyzed from 1/1/2017 to 06/30/2022. All patients presenting to the ED as trauma activations were included. RBC transfusion volume during initial resuscitation, as well as baseline patient and trauma event characteristics including region (zip code) and payer status. Patients who received massive blood transfusion (>= 5 units of RBC/24 hours) were compared to those who did not. Multivariate analysis assessed relationships between MTP activations in the ED.

A Novel Technique for Wound Closure using Spanning Sutures to Decrease Graft Size

Presented in the: General Plenary Session

Lior Levy, BA, Medical Student, New York Medical College, New York, NY

Background:

The effective closure of large wounds that cannot be primarily closed presents an ongoing surgical challenge. Current strategies such as the purse-suture technique, gradual suture approximation and dynamic dermatotraction, while useful in some contexts, have their drawbacks. Some examples include incomplete closure or dehiscence, painful and prolonged healing, unfavorable cosmetic appearance and restricting wound shape and depth requirements.

Methods:

We describe the spanning suture technique, a novel strategy for wound closure that addresses many of these limitations. 13 patients of an average age of 47 years old underwent a wound closure surgery using the spanning suture technique with subsequent skin grafting from September 2021 to January 2022 at Westchester Medical Center. Results were analyzed retrospectively. Operation characteristics such as the wound location, pre-operative wound size, postoperative wound size, follow up wound size at 6 weeks, percent decrease in wound size, post-operative complications and pertinent medical problems were examined.

Results:

The grafts demonstrated 100% complete transfer success. The majority of the wounds were located on the extremities. The most common reason for surgery was trauma. On average, the percent decrease in wound size after two weeks was 62.41%. One patient experienced superficial necrosis of muscle requiring loosening of the spanning sutures.

Conclusion: The spanning suture technique is shown to be a promising new strategy for wound closure with frank defect size reduction, competitive cosmetic outcomes and maximal grafting success, all while addressing the disadvantages of other current strategies.

Hybrid Surgical Approach to Atrial Fibrillation

Presented in the: General Plenary Session

Tesssa London-Bounds, MD, MPH, Assistant Professor of Surgery, University of Kentucky, Lexington, KY

We will discuss the growing topic of atrial fibrillation that is affecting more of our aging population and has an untreated 5 yr survival of 50%. We will be discussing the hybrid approach for surgical ablation in conjunction with the electrophysiologists using minimally invasive techniques that do not include stenotomy. This helps build hospital programs, relationships with cardiologists, and optimal care/follow up for patients. The audience will learn about newer approaches to atrial fibrillation and building programs.

Updates in Surgical Oncology

Presented in the: Surgical Oncology

Joshua Mammen, MD, PhD, Professor of Surgery, University of Nebraska, Omaha, NE

The treatment of malignancies continues to evolve as more effective systemic agents are introduced and surgical treatment are de-escalated so as to reduce morbidities. The session will provide the audience an understand of these changes so they can implement them in their practices. The presentation will involve a panel of 4 speakers who describe changes in the field of surgical oncology that are relevant to the audience. The spectrum of disease covered will range from skin malignancies to hepatobiliary malignancies.

The Ethical Concern between Surgeon-Burnout and Patient-Safety

Presented in the: Opening Session: Global Surgery 2023 and Featured Lectures

Peter Johannes Manoppo, MD, Bioethicist, General Surgeon, Wijaya Kusuma University, Surabaya; Indonesian Bioethics Forum, Surabaya, Indonesia

The surgical encounter consists of competent and responsible surgeon as care-giver and vulnerable patient as care-receiver. A harmony of this encounter is needed to provide appropriate surgical care based on proper medical ethics (autonomy, beneficence, nonmaleficence, justice, care ethics), patient-safety and good surgical practice. Sometimes, surgeon-burnout might happen by exhaustion of surgeon mental, physical,social and professional life, or even depersonalisation, that might impact the surgeon quality of life and patient-safety and also might raise ethical concern.

Conclusion: surgeon-burnout might compromise patient-safety and inflict ethical concern.

Key-words: surgeon-burnout, patient-safety, ethical concern.

The Importance of Nutrition in Patients Undergoing Surgery for GIT Tumor

Presented in the: Surgical Oncology

Jiri Matyas, MD, Head of ICU, Surgery Clinic Pardubice, Czech Republic, Pardubice, CZ

Patients undergoing surgery for a tumor of the digestive tract are often at risk for many reasons - polymorbidity, frailty and, among others, malnutrition. Malnutrition is present in 50-60% of patients with tumors of the upper GIT and 60-70% of patients with pancreatic tumors. It often presents a more serious problem than the histological type or the stage of the tumor itself. It negatively affects wound healing, leads to a higher incidence of infectious complications, and increases the cost of treatment. Well-executed nutritional preparation and perioperative nutrition increases the patient's chance of surviving an acute insult, accelerates the induction of anabolism and enables healing of anastomoses. Our findings lead to a clear conclusion: for patients with a GIT tumor, the question is not whether to feed them, but which nutrients, in what dose, and when they should be administered. Each patient needs individual approach, which however does not mean improvisation and it is necessary to abide by a quality system of perioperative care.

In the surgery of the 21st century, we must not be satisfied only with the healing of the anastomosis and surgical wound and with the discharge of the patient. Our goal is to restore the patient’s physical and mental condition, including his ability to work and return to his original style of life. In 2020, our ICU participated in a large European study that investigated the long-term importance of nutrition for ICU patients.

Well-performed surgery is crucial, but just one of many factors that influence the outcome of the patient. In this message, the author emphasizes the importance of nutrition for the recovery of patients. Apart from nutrition, the audience will learn about other procedures applied at our workplace, which are based on the latest knowledge and recommendations of professional companies. Our procedures are applicable and usable in practice in every large and modern workplace. They result in a decrease in mortality and morbidity and in an improved outcome for patients after GIT tumor surgeries.

In this presentation, our own rich experience in caring for patients operated on for GIT tumors will be presented. Our sophisticated system of preoperative and postoperative care will be presented. It includes many aspects, among others nutritional screening, nutritional preparation, operation timing, postoperative care, and rehabilitation. This system is based on up to date findings and the recommendations issued by the ASPEN and ESPEN.

An Update on HIPEC in Appendiceal and Colorectal Malignancy

Presented in the: Surgical Oncology

Tyler Mouw, MD, Assistant Professor Texas Tech University, Department of Surgery, Lubbock, TX

The talk will include historical and recent publications on the topic of HIPEC pertaining to treatment of colorectal and appendiceal tumors involving the peritoneum. This will include a discussion of ongoing trials and new research opportunities.

Blunt Chest Trauma: Past and Present

Presented in the: Trauma and Critical Care Surgery: 2023 Considerations

Petr Nestrojil, MD, PhD, Trauma Clinic, University Hospital Brno, Czech Republik, Brno, Czech Republik

Incidence of blunt chest injuries 12.8% in all traumas, 75% in polytraumas, mortality 25%. Brief history and review of treatment of blunt chest injuries in the past - conservative treatment, accompanied with high mortality x operative treatment with reduced mortality.

Conservative treatment - reduction of chest wall deformity and its stabilization. 1960s - tracheotomy + intermittent ventilation and artificial lung ventilation. 1970s - 1980s - external compression - cingulum - high percentage of complications. 80s - 90s - internal pneumatic splint - UPV - Positive End Expiratory Pressure x operative treatment - rib splints.

Present : - quality of diagnosis: CT + 3D reconstruction of the chest skeleton - extent of chest wall injury - indications for conservative treatment - operative solution - our indications:

- surgical indication - flail chest - floating segment with floor fractures - 3 or more adjacent ribs - chest wall deformity - volume reduction by > 30% - lung injury - anesthetic (Intensive care) indication - mechanical ventilation disorder - decrease in ventilation parameters - ineffective artificial lung ventilation - pulmonary contusion - polytrauma

Material: 2011 - 2021 blunt chest injuries (fractures of 2 or more ribs) - hospitalised: 924 patients, patients with polytrauma : 148 of them - operative solution: 105 patients, with polytrauma and compound injuries 91 and with monotrauma 14 patients

Conclusion : Benefits of the operational solution: - improvement of ventilation mechanics, shortening of artificial lung ventilation length, reduction of complications, occurrence of pneumonia, reduction of mortality of patients with unstable chest wall, reduction of treatment costs, reduction of permanent consequences - operated x conservative = 30 : 60%

Preventing Physician Burnout: Identification and Prevention

Presented in the: Opening Session: Global Surgery 2023 and Featured Lectures

Izi Obokhare, MD, Associate Professor and Associate Dean for Faculty Development; General Surgery, Colon and Rectal Surgery, Advanced Laparoscopic / Robotic Surgery, Department of Surgery, Texas Tech University Health Science Center, Amarillo, TX

The major issue plaguing health care providers today is physician burnout. The etiology is multifactorial, and the results can be devastating and costly. This presentation will be focused on outlining the cause, risk factors, diagnosis, prevention and management of burnout. At the end of the presentation, participants will be able to formulate a concrete action plan to reduce and manage burnout.

Current Management of Complicated Sigmoid Colon Diverticulitis

Presented in the: Colorectal Emergencies

Izi Obokhare, MD, Associate Professor and Associate Dean for Faculty Development; General Surgery, Colon and Rectal Surgery, Advanced Laparoscopic / Robotic Surgery, Department of Surgery, Texas Tech University Health Science Center, Amarillo, TX

Discussion of the various presentations of complicated diverticulitis, diagnosis and the up-to-date management of diverticulitis. At the end of the presentation, participants should be able to comfortably manage complicated diverticulitis.

Normothermic Regional Perfusion for DCD Organ Recovery

Presented in the: Transplantation Session

Christina Papageorge, MD, Assistant Professor of Surgery, University of Virginia, Charlottesville, VA

Normothermic regional perfusion (NRP) is an emerging technique in the United States for recovery of organs from donors after circulatory death (DCD). While it has gained more widespread adoption in parts of Europe, it has been more slowly embraced in the United States, partly due to ethical and legal concerns. Furthermore, the benefits of NRP remain under investigation. The technique involves placement of the donor on ECMO or bypass after declaration of death and ligation of the cerebral blood vessels. The thoracic and abdominal organs are then perfused and oxygenated for a period of 2-4 hours, followed by recovery of the organs.

It is proposed that perfusion of the organs for a period of time after the warm ischemic insult of withdrawal and circulatory arrest will reverse some of the ischemic injury, thereby resulting in improved outcomes for the transplant recipients of these organs compared to standard rapid DCD recovery. Specifically, in the field of liver transplantation, ischemic cholangiopathy has been the achilles heel of DCD organ utilization. There is evidence suggesting a significant reduction in biliary complications following use of NRP compared to standard rapid DCD recovery. There may also be a beneficial reduction in delayed graft function for kidneys recovered from donors undergoing NRP.

As this approach to DCD organ recovery becomes more widely implemented in the United States, it is important for transplant surgeons to be familiar with the process and the expected outcomes and potential benefits. The transplant community will additionally need to be leaders in addressing ethical and legal concerns.

Pulmonary Infarction after Dialysis Catheter Exchange

Presented in the: General Plenary Session

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

Chronic kidney disease affects more than 1 in 7 Americans. Almost 800,000 people in the United States living with advanced stage kidney disease. Of that patient population, 70% require hemodialysis either via catheter based dialysis or an arteriovenous shunt/fistula. Catheter complications range from mild (occlusion and malfunction) to life-threatening (systemic sepsis).

Although extremely uncommon, dialysis catheter embolic phenomenon either from breakage of the tubing or thromboembolic debris to the pulmonary circulation may occur at any stage of their presence in the body and especially during placement and removal.

A more thorough understanding of the potential for occult thromboembolic episodes from these catheters will help all medical personnel provide improved care to patients in terms of prevention and management of their sequelae. The case presented illustrates the challenge in diagnosing and managing a patient who suffered a pulmonary infarction with development of a large pleural effusion after exchange of a hemodialysis catheter.

Dialysis catheters are inserted and managed by a variety of practitioners; general surgeons, vascular surgeons, interventional radiologists all care for these patients at some point during their disease process. It is critical that all of these physician specialists as well as ancillary staff (nurses, and dialysis technicians) be aware of potential complications of use of the catheters and their maintenance.

Robotic Surgery in Transplantation: A Technology Finding an Indication?

Presented in the: Transplantation Session

Thomas Pshak, MD, Assistant Professor of Surgery, University of Colorado, Aurora, CO

By 2030, 30% the United States with be morbidly obese (BMI > 40). Typically, the ESRD population has even higher incidence of morbid obesity. Most transplant centers in the US have BMI cut-offs, typically around 38. Thus, as the population becomes more obese, there will be even more limited access to a life-saving transplant for those with high BMI. Robotic kidney transplant has been shown to have better outcomes than a traditional open surgery in the high BMI population. This presentation will provide background, current state data and glimpse into the future in the world of kidney transplant surgery.

Surgical Mission Trip to Honduras - Hand Surgery Cases

Presented in the: AANOS Annual Scientific Meeting: Neurological and Orthopaedic Surgery Part 1

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

The presentation is based on experience gained in two mission trips. Complex cases are presented and discussed. Treatment challenges in this setting are highlighted

Thoracic Trauma Update 2023

Presented in the: Trauma and Critical Care Surgery: 2023 Considerations

Peter Rhee, MD, MPH, DMCC, Professor of Surgery Uniformed Services University of the Health Sciences and City University of New York, Saint Barnabas Hospital, White Plains, NY

To update on management of Thoracic trauma. Topics will include indications for thoracotomy, Indications for Resuscitative Emergency Department Thoracotomy, Autologous blood transfusion, Sternal fixation, Internal Rib fixations, Indications for VATS, and Thoracic irrigation for hemothorax.

Whole Blood Resuscitation Following Liver Transplantation: Is it Time for Implementation?

Presented in the: Annual Research Scholarship Competition

Ivan Rodriguez, MD, Research Fellow, University of Colorado Anschutz Medical Campus, Aurora, CO

Whole blood (WB) resuscitation reduces antigen exposure and decreases cost compared to blood component resuscitation in massive bleeding. We developed a score to risk stratify patients for intensive care unit needs two-hours following graft perfusion in liver transplantation(LT) that correlates with blood product utilization. We hypothesize that this disposition score can identify patients that would benefit from WB resuscitation.

275 LT were included in the analysis. The score successfully stratified patients in median RBC utilization(3, 7, 11, 19, 28 p<0.001), which also mirrored empiric WB cooler utilization(23%, 47%, 64%, 83%,93% P<0.001). Donor exposure from blood products and estimated costs demonstrate the potential reductions using WB over conventional component-based resuscitation per patient.

WB has a potential role in resuscitating massive bleeding in LT after reperfusion to reduce antigen exposure and cost. LT recipients with a disposition score of 2 or greater are the most likely to benefit from this resuscitation strategy.

LT patients were stratified into five groups based on a disposition score (0,1,2,3,4). A WB unit equates to 1 red blood cell (RBC), 1 plasma, and 1 platelet unit. Patients were evaluated for total transfusion requirements 12 hours from 2-hours following graft reperfusion (time of score). The percent of patients per cohort that would have received a cooler of whole blood (6 units) during this time frame were identified per cohort, in addition to number of donor exposures, and estimated blood bank costs of per patient that could have been reduced with WB.

Pancreas Transplantation Alone in the USA, Where Are We Standing After 20 Years?

Presented in the: Transplantation Session

Reza Saidi, MD, Associate Professor of Surgery, Division Chief of Transplant Services - Kidney Adult and Pancreas, Upstate Medical University, Syracuse, NY

Introduction

The first human pancreas transplant was performed in 1966. A pancreas transplant is the most effective treatment to overcome or even reverse the complications related to diabetes and improve quality of life. Currently, more than 30,000 pancreas transplant procedures have been performed worldwide, with only around 8% of all pancreas transplants having been a pancreas transplant alone.

Material and methods

We performed a retrospective registry analysis utilizing the OPTN/UNOS database for pancreas transplants alone performed in the United States from January 2001 to December 2020 to assess transplant outcomes. The data was collected directly from the de-identified information contained within the database. The study population was divided into two subgroups: patients receiving a pancreas transplant between 2001-2010 and those receiving a pancreas transplant between 2011-2020. Post-transplant outcomes were compared between transplant recipients in these two time periods.

Results

3008 allograft recipients were included in the study. 1778 (59.1%) transplants were done from 2001 to the end of 2010. 1230 (40.9%) transplants were done from 2011 to the end of 2020. Table 1 summarises the demographic characteristics of each group. Although the BMI and recipient sex comparison shows a statistically significant difference, the differences are not clinically significant. The overall 5-year allograft survival rate was 52.17% in the 2001-2010 group, which increased to 58.82% in pancreas transplants alone from 2011 to 2020 (P=0.02). The overall 5-year patient survival rate was 74.52% in the 2001-2010 group, which increased to 74.92% in pancreas transplants alone from 2011 to 2020 (P=0.81).

Conclusion

With all the progress in terms of surgical techniques, organ allocation and preservation, and immunosuppressive regimens, the pancreas transplant alone allograft survival has been improving over the years, which makes it a confident choice for definitive treatment of Diabetes mellitus, both type 1 and 2.

Evaluation of Post-Operative Urinary Retention in Trans-abdominal Pre-peritoneal Inguinal Hernia Repair: Challenges in Chart Review

Presented in the: Annual Research Scholarship Competition

Rachel Schneider, MD, Medical Student, UMass Chan Medical School, Worcester, MA

Post operative urinary retention (POUR) is a known complication of laparoscopic trans-abdominal pre-peritoneal inguinal hernia repair (TAPP) with a prevalence ranging from 0.2% to 35%.(1) Given this prevalence discrepancy, our single-center analysis sought to evaluate the effectiveness of assessing the prevalence of POUR through retrospective chart review.

Using EPIC report workbench and SlicerDicer, we identified 3,477 patients in the past 5 years who have undergone TAPP and queried this population for charges and diagnoses associated with POUR. We used STATA to create a random sample of this population, then manually reviewed the selected 100 patient charts.

3,447 patients were identified having undergone TAPP since 2018, with 47 patients identified with a diagnosis of urinary retention within 6 months post-operation. Only 6 patients (0.014%) had either a foley catheter or bladder scan ordered. Manual chart review of our random sample demonstrated POUR in 6% (95% CI: 5.95-6.05) of this population.

Variability in identifying POUR via manual chart review and EPIC reporting suggests that more consistent methods for documenting POUR after TAPP are needed. POUR can increase length of stay, risk of urinary tract infection, and costs, and should be tracked more efficiently to identify and mitigate risk factors.(2) From a quality informatics perspective, methods to standardize POUR documentation could be implemented to improve EPIC reporting.

References:

1. Hudak KE, Frelich MJ, Rettenmaier CR, et al. Surgery duration predicts urinary retention after inguinal herniorrhaphy: a single institution review. Surg Endosc. 2015;29(11):3246-3250. doi:10.1007/S00464-015-4068-2

2. Drissi F, Gillion JF, Roquilly A, Luyckx F, Duchalais E. Nationwide Analysis of Urinary Retention Following Inguinal Hernia Repair: Results from the National Prospective Hernia Registry. World J Surg. 2020;44(8):2638-2646. doi:10.1007/S00268-020-05538-7

Cross-Training and Supervised Deployment of Surgeons into Critical Care During the COVID19 Health Crisis

Presented in the: Trauma and Critical Care Surgery: 2023 Considerations

Ridwan Shabsigh, MD, Chairman, Department of Surgery, SBH Health System, Professor of Clinical Urology, Weill Cornell Medical School, Bronx, NY

During the health crisis of the COVID19 pandemic in early 2020, huge numbers of critically-ill patients were hospitalized in short time, demanding rapid escalating expansion of intensive care units. Hospital resources became progressively challenged and ultimately overwhelmed. In anticipation of cancellation of elective surgery and need for critical care physicians, surgeons of various specialties were cross-trained in critical care in a well-defined education, shadowing and training program. They were then deployed, under the supervision of a critical care-experienced cardiothoracic surgeon, to be in charge of one of the intensive care units. Using tele-ICU, the supervising surgeon provided 24/7 oversight and guidance to the onsite cross-trained surgeons. The experience was successful, safe and satisfactory. This model of cross-training and supervised deployment of surgeons into critical care provides valuable lessons in health crisis management.

Cardiac Care in Belize: Building a Local, Sustainable Cardiac Surgery Program from Square One

Presented in the: Opening Session: Global Surgery 2023 and Featured Lectures

Eric Skipper, MD, Professor, Cardiothoracic Surgery; Surgical Director, Cardiac Transplantation and Advanced MCS; Surgical Director Structural Heart, Sanger Heart and Vascular Institute, Atrium Health, Charlotte, NC

Belize, formerly British Honduras and the only English-speaking country in Central America, has a population of roughly 400,000. The gross income per capita is $11,900 or less. The Pan American Health Organization reports that one-third of the population lives below the poverty level.

Cardiovascular diseases are rampant, second only to malnutrition and metabolic diseases, comprising about one-third of all registered deaths.

Cardiovascular care is not commonly available in developing countries such as Belize, and many patients have limited or no options regarding health care for such conditions. Karl Heusner Memorial Hospital (KHMH), situated in Belize City, Belize, is the only tertiary care hospital in the country. While it had many shortcomings in the delivery of health care, the most significant was lacking a program for advanced treatment of cardiovascular diseases.

The desire to create such a program led to a collaboration between Heineman-Robicsek Foundation, Inc. (HRF), local leaders, and native Belizean, British trained cardiac surgeon, Dr. Adrian Coye, who had just returned to the country after his residency in the United Kingdom.

HRF procured and installed the first cardiac catheterization laboratory in Belize and subsequently performed the first cardiac catheterization in 2011. After performing a number of cardiac catheterizations, efforts began toward establishing a cardiac surgery program.

In 2012, teams from HRF and the Sanger Heart & Vascular Institute (SHVI) based in Charlotte, North Carolina, working along-side Dr. Coye, performed the first open heart surgeries. Such teams included a supporting cardiac surgeon, perfusionist, OR nurse and critical care specialists.

Subsequently, HRF has donated echocardiographic stations, operating room and intensive care unit equipment, in efforts to insure appropriate infrastructure necessary for a cardiac surgery program.

Free public cardiac screening events began in 2015 and continue annually in rural underserved areas of the country.

Education and training has been provided by HRF for echo and interventional cardiology, cardiac catheterization technology, and nursing, both scrub and critical care. Local nurses have been provided advanced training at Atrium Health, Carolinas Medical Center. Hospitalists and critical care specialists have chosen to go for advanced training abroad.

A “five-year” plan was developed in a collaborative manner regarding the necessary steps to create an independent and locally sustainable cardiovascular center in Belize.

Of note, HRF started a similar program at UNICAR in Guatemala City 45-years ago, which today is the only facility in Central America dedicated to cardiac care. Based on that experience, given a robust five-year plan, we are confident of the future success in Belize.

Firearm Injury and Violence Prevention

Presented in the: Annual Ethics Forum: The Dr. Andre Crotti Lecture

Ronald Stewart, MD, Professor and Chair of Surgery, UT Health San Antonio, San Antonio, TX

The presentation will describe an overview of the magnitude of the health impact of intentional injury and firearm-related injury, death and disability followed by a description of an inclusive model to reduce firearm injury, death, and disability. The model is based on a common narrative focused on understanding and addressing the root causes of violence while simultaneously making firearm ownership as safe as reasonably possible. The presentation will conclude with pragmatic recommendations centered on how best to reduce the burden of firearm-related injury, death and disability.

Effects of Insurance Type and Distance from the Cancer Center on Outcomes After Robotic-Assisted Pulmonary Lobectomy

Presented in the: Surgical Oncology

Eric Toloza, MD, PhD, Cardiothoracic Surgeon, Moffitt Cancer Center, Tampa, FL

Our presentation will cover the problem effects the type of insurance a patient has and the distance they live from a cancer center have on perioperative outcomes after pulmonary lobectomy. The audience needs to know this information so that they can help patients with worse insurance types and longer distances to travel overcome obstacles to healthcare access and improve perioperative outcomes after surgery, such as pulmonary lobectomy. The learner will be able to identify risk factors for worse perioperative outcomes for these patient subpopulations. The audience will benefit from the presentation by learning about these risk factors and their effects on which perioperative outcomes.

Role of Tranexamic Acid in the Management of Chronic Subdural Hematoma

Presented in the: AANOS Annual Scientific Meeting: Neurological and Orthopaedic Surgery Part 2

Roy Torcuator, MD, Neurosurgeon, Insight Institute for Neurosurgery and Neuroscience, Insight Surgical Hospital, Flint, MI

1.To define chronic subdural hematoma and discuss updates on its pathophysiology

2. To elucidate the current recommendations in the management of chronic subdural hematoma

3. To demonstrate representative cases and their management and outcomes

4. To discuss updates and recent literature regarding CSDH and how they can be applied in clinical practice

The Centralization Conundrum - The Challenges of Breast Surgery in Rural Practice

Presented in the: Rural Surgery: Applications and Adaptations for Your Practice

Lee Trombetta, MD, General Surgeon, Gundersen Medical Center, La Crosse, WI, Winona, MN

Review of barriers to conducting breast surgery in rural hospitals. Centralization of breast resources to regional referral centers has made it increasing difficult for general surgeons to offer breast surgery. These resources include breast imaging (Mammography and MRI), medical oncology, radiation oncology, pathology, and plastic surgery. There are significant advantages to providing breast surgery in rural hospitals. With creative collaboration, these barriers can be overcome to great benefit of rural populations.

Rectal Prolapse: Help! My rectum is falling out.

Presented in the: Colorectal Emergencies

Nsikak Umoh, MD, Colon and Rectal Surgeon, The Woodlands Colon and Rectal Associates, Shenandoah, TX

It will focus on diagnosis and surgical management of rectal prolapse. It is a common problem faced by both general surgeons and colorectal surgeons. How to diagnose rectal prolapse, knowledge on important investigations and available management options.

Anterior Lumbar Spine Exposures

Presented in the: AANOS Annual Scientific Meeting: Neurological and Orthopaedic Surgery Part 1

Jon-Cecil Walkes, MD, Chief CV Surgery, St Joseph Medical Center, Houston, TX

Approaches to vascular control when doing anterior spinal surgery. Techniques to minimize risks of bleeding and optimize visualization of the thoracic and lumbar spine

The Power of the Pivot

Presented in the: Women in Surgery Panel Discussion

Jennifer Whittington, MD, PhD, General Surgery, Surgical Oncology, Mount Sinai/Elmhurst Hospital Center, New York, NY

Although medical school classes are graduating classes of greater than 50% women and surgical residencies are graduating more female trainees, there remains a paucity of women in surgical leadership roles. Limitations for these types are leadership positions are even further limited for women who maintain family responsibilities outside of their work. Often, women in surgery must think outside of the box and make pivotal career decisions to obtain leadership roles. Our panel discussion will include detailed discussion on contract negotiations, networking, and finding a seat at the leadership table.

Postsurgical Outcomes with Interspinous Spacers in Lumbar Spinal Stenosis: Clinical Outcomes and Complications

Presented in the: AANOS Annual Scientific Meeting: Neurological and Orthopaedic Surgery Part 2

Mohan YS, MD, Neurosurgeon, Garden City Hospital, Garden City, MI

Introduction:

Lumbar spinal stenosis represents one of the most frequent lumbar pathologies. Multiple management strategies include conservative and surgical options. In the last group of procedures, open and minimally invasive technique do exist to adequately manage these patients. We present a surgical cohort of 50 patients with the use of the interspinous spacers placement along with posterior lumbar decompression and posterolateral fusion.

Material methods:

Fifty patients with diagnosis of spinal stenosis were collected for a retrospective analysis of prospectively collected data. Variables included age, gender, comorbidities, BMI, symptom presentation, length of symptoms, surgical complications, EBL, preop VAS (Visual Analogue Scale), 3 and 12-month VAS.

Results:

Preliminary results showed 50 individuals with varying ages of presentation with long standing claudication symptoms of 2 years approximately. Most patients had an adequate clinical improvement in clinical symptoms/pain and activities of daily living.

Conclusions:

Properly selected patients with lumbar stenosis can safely be treated with a minimally invasive placement of interspinous spacers along with decompression and posterolateral fusion.

This information above was published with limited editing. ICSUS and AANOS are not responsible for any inaccuracy or incorrect information.