International College of Surgeons – United States Section

80th Annual Surgical Update


American Academy of Neurological and Orthopaedic Surgeons

42nd Annual Scientific Meeting


The W Lakeshore Hotel – Chicago, Illinois

April 26-28, 2018


Abstracts and Presentation Descriptions


A Novel Approach to Closure of an Open Abdomen and Lower Extremity Traumatic Wound

Babak Abbassi, MD, MBA, MS, 2nd year Surgery Resident - Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX


Damage control surgery in the management of trauma patients often results in catastrophic open abdomens. Skin and fascial edges are left open to avoid development of an abdominal compartment syndrome, to allow for abdominal reexploration, or as a necessity in the treatment of intra-abdominal sepsis.  Definitive fascial closure is often not feasible.  Vacuum assisted closure (VAC) devices have variable delayed fascial closure rates ranging 33% to 100% and can be associated with long-term VAC therapy. Fascial bridge closures can be done utilizing both biologic and synthetic mesh products but this by definition results in a biomechanically dysfunctional abdominal wall. Lastly, component separation surgery is often limited to degree of myofascial gap (MFG). These prolonged closure techniques are associated with increase rates of enterocutaneous/enteroatmospheric fistula formation. This case demonstrates how mechanical and biologic methods are used to reconstruct the linea alba and achieve primary abdominal myofascial closure. This was achieved in spite of an initial MFG of 14 cm with a visceral extrusion (VE) of 4.5 cm. The same technology was utilized to achieve primary closure of a large circular traumatic wound on the anterior shin with exposed tibia. This unique approach provides the ability to restore a biomechanically functional abdominal wall.


The patient we present is a 40-year-old male who was transferred to our facility after being involved in a high speed motor vehicle collision. He was taken emergently to the OR for a damage control laparotomy. Three mesenteric defects were found and over-sewn, he developed disseminated intravascular coagulation, and his abdomen was packed with thrombin-soaked gelfoam. CT imaging performed post-operatively revealed: sub-arachnoid hemorrhage, intraparenchymal hemorrhage, multi-flap transsection of descending thoracic aorta, multiple splenic and liver lacerations, a pancreatic head laceration, bilateral pneumothoraces, right tibial plateau and fibular head fractures. He necessitated a second look laparotomy due to abdominal hemorrhage. At that time a cholecystectomy, liver laceration repair, and right hemicolectomy were performed. In addition he underwent a TEVAR, exploratory laparotomy with ileocolic anastomosis , open placement of gastrostomy tube and placement of negative pressure wound therapy device (NPWTD). Primary myofascial closure was not feasible. His abdomen had been open for 8 days. We installed an abdominal dynamic tissue system which bridges the myofascial gap with elastomers that allow for dynamic tension. Thus, allowing controlled medialization of the myofascial units without tissue damage. Time from DTS placement to primary myofascial closure was 7 days. At the time of DTS removal, we utilized a porcine urinary bladder matrix to accelerate wound healing through constructive remodeling.


We installed the DTS device on his anterior leg wound which had increased in maximum diameter despite treatment with NPWTD. His wound measured 9 cm x 6.5 cm with a depth of 4.5 cm caused by disruption of interosseous membrane. We re-approximated the tissue on post-device placement day 15.


Complex traumatic wounds of the trunk and extremities are a challenging problem, necessitating exploration of newer technologies. This case series demonstrates a unique and successful combination of mechanical and biological technologies for closure of these challenging wounds.


Empyema from Misplacement of Percutaneous Nephrostomy Tube: A Diagnostic Challenge

Raed Abdulkareem, MD, General Surgery Resident, University of Illinois at Chicago, Chicago, IL


In this case report, we discuss the development of an empyema due to percutaneous nephrostomy tube placement.  In this instance, the nephrostomy tube was found to be traversing the pleural space and diaphragm resulting in bacterial tracking from a chronically infected kidney into the pleural space with resultant empyema. To our knowledge this is the first case report describing such a complication in the literature.


Nephrostomy tube placement is a common procedure employed to manage several different types of ureteral obstruction. The most common causes of obstruction are renal calculi, gynecological malignancy, or narrowing of the ureter due to chronic inflammation. Complications of nephrostomy tube placement are rare, and most commonly include bleeding, sepsis, organ injury, and death.


Multiple reports appear in the literature describing the aforementioned complications observed during nephrostomy tube placement, but based on a literature review, no other cases were found in which a nephrostomy tube traversing the thoracic cavity enroute to the kidney resulted in an empyema. Urinothorax and nephropleural fistula have been reported soon after placement or removal of percutaneous nephrostomy tubes; this complication usually resolved after simple thoracentesis or serial thoracenteses. A similar case from our review is presented by Kumar et al. who described a patient who underwent percutaneous nephrolithotomy (PCNL) for the removal of kidney stones. Several days after the procedure the patient became short of breath, and a pleural effusion was noted on a chest x-ray.  A video-assisted thoracoscopy was eventually performed that revealed an empyema.6. Thus, to our knowledge, the case presented here in our report is the first of its kind to be reported.


Although there are no other cases specifically describing nephrostomy tube placement into the chest, there are many other cases that outline other rare complications of a nephrostomy tube or PCNL. One such article describes two cases where PCNL led to severe venous bleeding. In one of the cases, the nephrostomy catheter was misplaced into the renal vein, and in the second case the catheter was placed into the inferior vena cava (IVC). In both cases, exploratory laparotomies were performed to stabilize the patients, and neither patient experienced any long-term consequences from the hemorrhage.


In conclusion, the main indication for the use of a nephrostomy tube is ureteral obstruction. Tube placement is a useful and simple procedure, but it does have certain complications of which the practitioner must be aware.


Feculent Empyema After Laparoscopic Appendectomy: A Rare Case Report

Raed Abdulkareem, MD, General Surgery Resident, University of Illinois, Chicago, IL


While most commonly secondary to pneumonia or a lung abscess, thoracic empyema can arise in other clinical conditions as well.  Empyema after appendectomy has been previously described.  This case discusses not only the development of empyema several weeks after a laparoscopic appendectomy, but the actual presence of fecal material inside the pleural cavity upon performing video assisted thoracoscopy for the presumptive diagnosis of empyema.


To our knowledge, this is a unique case of documented migration of an appendicolith/fecal matter to the pleural cavity in an adult patient.


Collaborating Care Between Orthopaedic and Plastic Surgery in the Care of Mangled Extremity Injuries

Sonya Agnew, MD, Assistant Professor, Plastic and Reconstructive Surgery, Loyola Medicine, Chicago, IL


Optimal management of patients with mangled extremities requires that surgical and critical care services collaborate and communicate. Recent evidence suggests that shifting the paradigm from "silo care" to "integrated care" where teams communicate regularly results in improved outcomes. This is relevant to all surgical disciplines and given the ease of present day technology, there is no excuse for delayed or absent communication between different disciplines caring for an individual patient. The learner will be able to understand initial management for open fractures, deciding between limb salvage and amputation, options for managing bone loss, managing soft tissue defects, and customizing amputations. The audience should gain a sense of empowerment to collaborate across disciplines, as it is known "The Whole is Greater than the Sum of Its Parts".


Lessons Learned in 20 Years of Service by the World Surgical Foundation: How Do We Measure Success?

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


Service to a patient that requires life changing procedure is important for the individual patient,however long lasting and sustainable care should be the goal. I will take to the journey of WSF in 20 years,how to achieve sustainability and long term care. The new paradigm for missions should be focused care on each specialty. Collaboration with local surgeons,anesthesiologists and OR Nurses is the key to success. Allowing US  and Canadian Surgical Residents and Fellows to participate in missions will propagate the idea for future missions. The secret of success is COLLABORATION.


Total Colonic Aganglionosis; Challenges in Management: Early and Late

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


Total colonic aganglionosis (TCA) occurs in 1 to 5% of patients with Hirschsprung's disease. TCA presents with unique problems including the initial presentation which causes delay in diagnosis,continued controversy in the definitive surgical management, high morbidity (enterocolitis, incontinece ,malnutrition, etc.) and mortality rate at 6 to 10%. Discussion includes the differences between TCA and classic Hirschsprung's disease (presentation and management. Discussion on the surgical management (Swenson, Duhamel, Soave, and their modification). Advantages and disadvantages with each technique will be discussed. Review of 20 cases of TCA managed at the Pinnacle Health System in 40 years will be discussed. Recommendation as to the best surgical option for TCA will be discussed.


Surgical Innovation and the Future of Surgical Practice

Peter Angelos, MD, Linda Kohler Anderson Professor of Surgery and Surgical Ethics Chief, Endocrine Surgery Associate Director, MacLean Center for Clinical Medical Ethics The University of Chicago, Chicago, IL


Surgical progress demands innovative approaches to solving individual patient problems. However, there are multiple ethical issues that arise when surgeons offer innovative operations to solve their patients' problems. We will explore these ethical issues and the challenges with adopting novel surgical options either too early or too late.


Hidden Figures: Making Female Physician Leaders Visible

Vineet Arora, MD, MAPP, Associate Professor of Medicine, Assistant Dean Scholarship & Discovery, Pritzker School of Medicine, Co-Director MERITS Medical Education Fellowship, GME Director of Clinical Learning Environment Innovation, Chicago, IL


1. Describe common barriers faced by women physicians in obtaining leadership roles in academic medicine and medical practice.

2. Identify strategies that women in medicine can use to advance as leaders.

3. Apply one of the discussed techniques for positioning oneself as a physician leader.


Surgical Triage in the Hostile, Low-Resource Environment: Who Gets What?

Samer Attar, MD, Assistant Professor, Orthopedic Surgery, Northwestern Medicine, Chicago, IL


Surgical triage in the hostile, low-resource environment: Who gets what? Cases from Syrian field hospitals under siege and under aerial attack within civilian/residential neighborhoods.


Advances in the Surgical Management of Epilepsy

S. Kathleen Bandt, MD, Assistant Professor of Neurological Surgery, Northwestern University, Chicago, IL


Epilepsy affects 1-2% of the population and only 70% of patients are well controlled with medication. This leaves approximately 1 million Americans with medication-resistant epilepsy which is associated with an 8 fold higher rate of premature death than the general population. Surgery is a proven treatment option for medication-resistant epilepsy. Recent advances in surgical innovation have significantly expanded the number of potential surgical candidates for epilepsy surgery. This presentation will discuss those advances and the benefit of surgery for epilepsy overall.


New Advances in Breast Cancer Therapies, the Surgical Approach

Daphnee Beaulieu, MS4, Medical Student, University of St-George's, Brooklyn, NY


1) The problem / surgical intervention the presentation covers.

Although breast cancer has seen enormous changes in diagnosis and management options, it is still the most common cancer affecting women worldwide. In just two decades, breast cancer management went from requiring only a surgeon to perform a total radical mastectomy with total axillary dissection to requiring a multidisciplinary team approach. The standard of care for breast cancer has shifted dramatically, and it’s imperative that surgeons recognize the various aspects of treatment to contribute to the multidisciplinary breast unit team. The presentation will cover the most important changes in breast cancer management overall, and more specifically the different surgical options.


2) Why the audience needs to know this information.

I believe it is important to know not just the surgical approach to a problem, but also to understand the big picture of a disease. It will provide surgeons with a better appreciation of the various aspects of breast cancer treatment.


3) What the learner will be able to accomplish after the presentation.

Have a better understanding of the comprehensive treatment approach to breast cancer. Be able to better counsel patient on treatment options. Make a significant contribution to the multidisciplinary breast cancer unit team


4) How the audience will benefit from the presentation.

The audience will get an up to date overview of the new treatment options for patients with breast cancer.


Opioid Management in the Trauma Patient

Daphnee Beaulieu, MS4, Medical Student, St-George's University, Brooklyn, NY


The opioid epidemic is a real problem that continues to grow. A new opioid management protocol in trauma patients has recently been studied in a retrospective study. This presentation will shed light on the newest recommendations in pain management for trauma patients. Surgeons will gain a better appreciation of the repercussions opioids can have on their patients, and develop a framework for proper pain management in post-op patients.


Simultaneous Occurrence of Gastric and Duodenal Peptic Perforation: A Rare Encountered Entity

Mohit Bhatia, MBBS, MS, Senior Resident, Department of General Surgery, Safdarjang Hospital, New Delhi, India, Ambala City, Haryana, India


1.  The problem / surgical intervention the presentation covers.

We present a rare case of 50 year old man with synchronous perforations in pre pyloric and anterior wall of 1st part of duodenum owing to its rare incidence of simultaneous perforation this is an interesting case for surgeons worldwide.


2. Why the audience needs to know this information.

So far less than 10 such cases have been reported worldwide.


3. What the learner will be able to accomplish after the presentation.

Although peritonitis is a common encountered clinical condition, but the possibility of synchronous perforations at different sites is a possibility, though rare.


4. How the audience will benefit from the presentation.

sharing such a case at a world wide platform will help budding surgeons to enhance clinical acumen and will make us more vigilant to handle such an unexpected crisis and will enable us to manage it successfully.


Reoperation After Lobectomy: A Retrospective Review

Tessa Cartwright, MD, MPH, Cardiothoracic Surgery Fellow, University of Kentucky, Lexington, KY


The two most common approaches for surgical resection of a lung lobe are open versus video assisted thoracoscopic. The literature reveals multiple studies reporting 30-day survival rates when comparing  approaches; however, it has also been reported that the video-assisted approach is associated with shorter length of stay, lower overall costs, and reduced rates of overall complications.  There have been reports revealing no significant difference in operative times between approaches.  These conclusions have been replicated in many studies; however, there are no studies reviewing the patient population receiving open versus thoracoscopic lobectomies in recent literature.


We reviewed the demographics of patients undergoing either a lobectomy during the calendar years 2012-2015, we reported by the American College of Surgeons National Quality Improvement Program.   We compared clinical risk factors, intraoperative factors, 30-day complications, and related operations for patients undergoing open traditional thoracotomy or video-assisted pulmonary lobar resection.


Of the 19,294 patients undergoing lobar resection, 662 (3.4%) had a related reoperation within 30 days.  Five thousand seven hundred and thirty-seven (29.7%) of lobectomies performed were performed through an open approach whereas 13,557 (70.3%) were thoracoscopically performed.  Patients who underwent open procedures had higher rates of obesity (33.5% vs 31.7%, p< 0.001), smoking (35.8% vs 27.0%, p< 0.001), hypertension (57.6% vs 53.0%, p< 0.001), COPD (26.2% vs 20.7%, p< 0.001) and ASA Class III or greater (84.8% vs 74.5%, p< 0.001).  Unadjusted analysis showed that open procedures had higher rates of 30-day mortality (2.5% vs 1.1%, p< 0.001) along with longer median lengths of stay (6 days vs 3 days, p< 0.001). After adjusting for patient demographics and operative characteristics, open procedures were consistent associated with a statistically significant increase in 30-day mortalities (OR 1.88, p< 0.001), 30-day morbidities (OR 1.85, p< 0.001), and length of hospital stay (beta coefficient of 2.17, p< 0.001).


Consistent with previously published data, our retrospective review of the American College of Surgeons National Quality Improvement Program for 2012-2015 revealed that open procedures are associated with higher rates of related reoperations and mortality.


Use of PRP in Sports Medicine

Naga Suresh Cheppalli, MD, Orthopaedic Surgeon, Florence, SC


Use of platelet rich plasma in sports injuries. This presentation will cover indications of using PRP for tissue healing, and technique of obtaining PRP and technique of delivering and results of PRP injections, literature review. Sports injuries are very common in sports medicine practice and less invasive methods of treating them would be option in some situations. This Information can be used in daily practice.


Management of Cervical and Occipital-Cervical Fractures: Developing an Organized and Algorithmic Approach

W. Craig Clark, MD, PhD, Chairman, AANOS, Carrollton, MS


Recent Board certification examinations for both ABNS and ABCNS reveal that many practicing surgeons have yet to develop a cogent and organized approach to the management of fractures of the occiput and cervical spine. The author draws upon his experience as a developer of MOC exams, primary board certification exams,oral exams and over 30 years of academic and private neurosurgical practice to present one way of looking at this very relevant and timely topic.


Contemporary Legal Update to the Definition of Brain Death

W. Craig Clark, MD, PhD, Chairman, AANOS, Carrollton, MS


Every state's definition of death is based on the Uniform Determination of Death Act (UDDA) which asserts that any determination of death must be made in accordance with accepted medical standards. Recent years have seen an increasing number of controversies associated with determination of death by neurological criteria (DNC).These controversies have centered on issues like 1) the need to obtain consent for the performance of a brain death evaluation; 2)What are the accepted standards for the determination of brain death? 3)When should organ support be continued after determination of brain death? 3) Who bears the costs of continuing organ support after declaration of death based on neurological criteria (DNC)? 4)When is organ support withheld or discontinued when the victim is pregnant? These hot button issues will be discussed, as well as potential solutions and the rationales behind them.


Pitfalls in the Diagnosis of a Limping Child
Maxime Coles, MD, FICS, Orthopaedic Surgeon, Coffeyville, KS

It is primordial to differentiate a normal from an abnormal gait to be able to evaluate a child properly. A Limp is a common complaint among a child seeking medical attention.  A complete history and a physical examination will narrow the causes. Knowledge of orthopedic emergencies like Acute fractures, Septic arthritis, Acute or chronic Osteomyelitis, Vascular compromise, Tumors, Muscular Dystrophies, Compartment Syndrome, Transient Synovitis, Septic arthritis, Slipped Capital Femoral Epiphysis etc. can prevent further complications.




After attending this lecture, the lerner should be able to:


1- Understand well the normal from the abnormal pediatric gait patterns.

2- Distinguish between septic arthritis and toxic Synovitis of the hip.

3- Recognize orthopedic emergencies.

4- Understand and differentiate between the following causes of limp: developmental hip dysplasia, Legg-Calvé-Perthes disease, and slipped capital femoral epiphysis.

6- Diagnose common overuse injuries in children.

7- Formulate a differential diagnosis of the limping child based on the patient’s age.


Rare Occurence of FNH in a Child

Edward Daniele, MD, Texas Tech University Health Sciences Center, Department of Surgery, Lubbock, TX


Focal Nodular Hyperplasia(FNH) is an asymptomatic, benign lesion that originates in the liver.  It is commonly diagnosed in women from the third to fifth decades of life, with rare reports of presentation in children. It is thought to arise from a vascular malformation, which therefore induces a reactive hyperplasia. 


We present an 11-year-old female found to have a symptomatic, ambiguous liver lesion.  She underwent an ultrasound revealing a heterogeneous, hypoechoic ill-defined area measuring 1.5 x 2cm adjacent to the left lobe of the liver. She next had a CT with no clarity shed on this lesion.  Finally, an MRI revealed the lesion in segment 3 of the liver with no evidence of contrast accumulation. It was determined that the imaging appearance was not compatible with focal nodular hyperplasia. The decision was then made to go to the operating room for a diagnostic laparoscopy with intraoperative frozen section.


She was taken to the operating room where a frozen section sample was obtained. Examination by multiple pathologists was inconclusive, and no definitive diagnosis could be made with concern for a possible neoplastic process.  A wedge resection of the lesion with harmonic scalpel was then performed for excisional biopsy.  During the resection, there was no hyper-vascularity noted throughout either the lesion or adjacent parenchyma, something normally consistent with FNH. On final pathology, it was found to be focal nodular hyperplasia.


FNH is almost always asymptomatic (cited as high as 95% of the time) and usually presents as a non-tender abdominal mass incidentally found on physical examination. The best imaging study has been shown to be enhanced magnetic resonance imaging (MRI) with a specificity of 98%.  If unable to diagnose, one case series showed 16 of 19 patients underwent intraoperative frozen sections with a sensitivity of 89% and a specificity of 100%. In our patient we describe, after MRI imaging is incompatible with the diagnosis of FNH, we proceed with an intra-operative frozen section that continues to be inconclusive. In the pediatric population care must be taken to weigh the benefit of performing an aggressive liver operation versus a non-operative approach.  Without a benign diagnosis, the threshold for surgical removal should be low, especially in children. Although there are specific signs on CT that are pathognomonic of FNH, without these signs the diagnosis should still not be ruled out.


Update on GEMINI for the Cure of SCI: Fusogens and Possible Spinal Cord Lavage

Raymond A. Dieter, Jr., MD, Surgeon, Research Service, Hines VA Hospital, Glenn Ellyn, IL


Purpose: Despite more than a century of intensive research, spinal cord injury (SCI) remains an incurable condition; the GEMINI protocol (Canavero, Italy), however, is promising.


Methods: This protocol uses a fusogen, polyethylene glycol (PEG), applied to a complete blade-cut of the spinal cord. PEG is characterized by its effects of rapid fusion of cut neurons, reduction of Wallerian degeneration, increased neurite outgrowth, anti-inflammatory effects, and high lipid solubility.


Results: Studies in rats and dogs with five to eight weeks of SCI recovery have obtained Maximal Basso Beattie Bresnahan Scale (BBB or equivalent) motor scores ranging from 18 to 21 out of 22, whereas control SCI procedures without the addition of PEG only range from 3 to 4 (Kim, South Korea; Ren, China). A more recent study tested a new fusogen, PEGylated Graphene NanoRibbons (PEG-GNR, also known as TexasPEG; Tour, United States) and obtained slightly increased neurite outgrowth compared to PEG (Kim, submitted).


Conclusions: application of the GEMINI protocol for SCI regeneration/fusion is demonstrating very good motor recovery and cellular explanations are being advanced. Further work is underway and includes the development of an advanced fusogen that will combine an antioxidant enzyme with TexasPEG (Tour). Fusogen lavage of the spinal cord (Canavero and Wurster, USA) is also being proposed because of the potential for: (1) extended cord perfusion, (2) minimally invasive surgery for placing a spinal cord tube and pump, and (3) possible early application and use in conjunction with spinal cord decompression (laminectomy), the current standard of care.


Prevention of Lymphedema in Breast Cancer Patients Undergoing Mastectomy and Axillary Lymph Node Dissection

Michelle Djohan, Medical Student, University of Toledo College of Medicine, Toldeo, Ohio


Axillary lymph node dissection (ALND) is a critical component of breast cancer treatment with nodal involvement.  Despite advances in the diagnosis and treatment of breast cancer, there have been very few modifications in the surgical approach for ALND since its original description by Halsted in the sixteenth century. 


In this presentation we will review the technical consideration and innovative process in performing axillary lymph node dissection which allow prophylactic lymphatico-venous bypass procedure. 


The procedure describe on reverse mapping process to identify the lymphatic channels leading to the transition lymph nodes.  The axillary lymph node dissection will proceed with the usual fashion with particular gentle and careful dissection in finding the lymph node and lymphatic channels using loupe magnification.  Once these lymphatic channels are preserved, the remaining axillary contents are carefully removed with particular attention to the preservation of small branching vessels in the axilla to allow the lymphatico-venous bypass procedure to be completed using operating microscope, special ultra-fine micro surgical instruments and 12-0 nylon sutures. 


Once the anastomosis completed, the patency and functional flow of the lymphatico-venous bypass can be confirmed by using near infra-red imaging fluoroscopy and injection of Indo-cyanine green dye.

Detailed surgical description on this process will be described in this presentation.


Eight-Year Follow-Up on the U.S. First Face Transplant and the Longest Living Composite Tissue Facial Allograft Containing Vascularized Bone

Risal Djohan, MD, MBA, Vice Chairman Dept. of Plastic Surgery Cleveland Clinic, Cleveland, OH


The first face transplant in the US was performed more than 8 years ago, with the effort from multi-disciplinary team and detailed planning.  The patient sustained from ballistic injury to her face with destruction of her facial features as well functional capacity to smell, eat normal food, normal speech and social interaction in public.


This presentation will review the multidisciplinary planning for consideration of complex composite tissue allo-transplantation containing vascularized bone, surgical process, rehabilitation and current physical and social condition.  She has been maintaining condition with stable immunosuppression protocol using Mycophenolate Mofetil, Tacrolimus and Prednisone.  There were three rejection episodes occurred post operatively at 47 days, 92 months and 4.5 years, which were treated with short hospitalizations and immunosuppression adjustments. 


The patient continues to demonstrate improvements in anxiety, depression, and social re-integration with close follow up and evaluation by transplant team, psychiatry and plastic surgical team.


Our patient represents the longest follow-up in an individual who received composite transplant including vascularized bone. Despite three acute rejection episodes and several infectious complications, her overall health has been relatively well maintained with continued management via the lowest possible regimen of immunosuppression. Continued objective evaluation of these results both on an institutional and international level can be used as a learning process for every team doctors and patients who are planning and performing such complex surgical procedure.


Cirugia Taurina: Surgery in the Bullfight Ring

Leopoldo Fernandez Alonso, MD, PhD, Division of Vascular Surgery,  Complejo Hospitalario de Navarra, Mutilva, Pamplona, Spain


“Cirugia taurina” is the surgical discipline that treats lesions caused by bull horns.  These lesions have distinct features and are observed both in matadores gored during bullfights in the ring as well as in runners injured during events that take place through streets of towns and cities in Europe and Latin America. Less frequently, they are also observed in other local festivities involving bulls.


The purpose of this presentation is to provide a brief introduction about the “Fiesta de los Toros” (The Festivities of the Bulls), their different forms both inside and outside the rings.  We will describe the minimal requirements needed to staff immediate response units in order to effectively treat these traumatic injuries that are often life-threatening. We will present our experience at the Pamplona bullfight ring and the Navarra Hospital in the management of patients with bull horn inflicted injuries during the famous festivities of “San Fermin” and the “running of the bulls” made famous in the US in part through the novels of Chicago native, Hemingway. We will review the features of these lesions, their frequent anatomic locations and the details of surgical management.


Management of Foramen Magnum Tumors

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


Delay in identifying the high cervical cord compression, especially the foramen magnum region tumors is not uncommon. Surgical treatment requires proper approach and safe tumor removal. Question of whether to instrument the spine after tumor removal does come up frequently. It is imperative to know the nuances of foramen magnum tumor identification and treatment to avoid neurological deterioration.


Caring for the Adult with Congenital Heart Disease

Sarah Hartlage, MD, MS, Assistant Professor; Department of Anesthesiology and Perioperative Medicine; University of Louisville; Louisville, KY


Thanks to advances in surgery and pharmacology, children with severe congenital heart defects are surviving into adulthood in ever-increasing numbers. Although many of these patients continue to receive their cardiac care at specialized pediatric centers, they may present to any facility for noncardiac care, particularly in the setting of urgent interventions. Perioperative care of these patients is complex. This presentation entails a concise review of the challenges presented, including unique anatomic issues, hemodynamic goals, and criteria for referral. Learners will be well-equipped for general care of the adult survivor of congenital heart disease during the non-cardiac perioperative period.


Pulmonary Ossification: An Unusual Solitary Lung Tumor

James Hendele, MD, General Surgery Resident, University of Illinois, Chicago, IL


This presentations details our experience with one patient with a long smoking history and prior CABG with LIMA conduit who presented with weight loss and malaise and was found to have a solitary lung tumor.  Pre-operative workup included axial imaging and a PET scan - which was positive.  A biopsy was consistent with osseous metaplasia without evidence of malignancy.  However, given the patient's history and presenting complaints, the likelihood of malignancy within the tumor was such that we recommended surgical excision.  The patient had an uncomplicated post-operative course after open thoracotomy and lobectomy.  Final pathology again did not show malignancy, but rather pulmonary ossification (PO).


PO is a fairly common pathology, diagnosed very infrequently in life as it remains nearly uniformly asymptomatic.  It occurs more frequently in patients with prior lung insults or coexisting pulmonary pathologies, as in our patient with a history of CABG with LIMA conduit. 


Because PO is so infrequently seen it was not on our pre-operative differential.  It is likely that other practitioners have not seen this pathology in their patients prior.  With this presentation we intend to inform our listeners about this uncommon, benign lung tumor so that they can make informed decisions about patients similar to ours in whom PO should be seriously considered as a pre-operative diagnosis.


Strategic Crisis Response Care

Pastor Michael Henderson, International Critical Incident Foundation, American Association of Christian Counselors, Rocklin, CA


A critical incident is any event or that occurs suddenly, is unexpected, presents a threat, and causes a significant emotional response.  Most people experience a range of responses to a critical incident. There is no predictable pattern to the affects that may be experienced, normal responses which follow can include physical and emotional responses, and changes to behavior and thinking. Understanding normal responses to these unusual events can help you cope more effectively and provide support for others that may experience a critical incident. This important course is for everyone who works with traumatized people. We will explore the Stress Continuum, the levels of stress including eustress (i.e., beneficial, motivating stress), traumatic stress, burnout, compassion fatigue or secondary PTSD, and vicarious traumatization which may occur as a result of helping others. Stress management self-care techniques will be presented, experienced and discussed.


Surgical Correction of Unilateral Nasal Bony Deformity Using Nasal Septum Cartilage Following Treatment For Naso-Orbital-Ethmoid Fractures

Taichi Ide, DDS, Senior Resident, Izumo, Japan


Naso-orbital-ethmoid  (NOE) fractures are fractures that occur in the midface area, at the confluence of the nose, orbits, ethmoid and frontal sinuses, and floor of the anterior cranial base. These facial fractures are common because of the exposed position and thin bony walls of the midface area, and they are frequently encountered by oral and maxillofacial surgeons. Treatment of an NOE fracture is challenging and requires a thorough knowledge of central midfacial anatomy and surgical technique, as well as access to specific tools, to obtain optimal restoration of esthetic form and function.


Here we report on use of a novel secondary surgical correction technique that included augmentation of the para-nasal soft tissue using septal cartilage as a grafting material in a patient with facial asymmetry following repair of fractures in the NOE complex in a 17-year-old Japanese male 6 months after surgical treatment of fractures in the NOE complex. An otorhinolaryngologist harvested the septal cartilage during nasal septoplasty to correct a deviated septum that was planned to coincide with removal of the plates 6 months after the primary surgery. The maxillofacial surgeons then grafted the septal cartilage into the concave area in the right para-nasal region and fixed it with a bioresorbable screw (Biomet Inc., Jacksonville, FL) after removal of the right plate via a transconjunctival approach. The postoperative course was uneventful and the patient was satisfied with the cosmetic outcome after 9 months postoperatively. Our experience with this patient suggests that use of septal cartilage harvested by an otorhinolaryngologist as a graft for reconstruction after NOE fracture is feasible. A septal cartilage graft may be useful for reconstruction of a postoperative midfacial concave deformity.


Intraoperative Indocyanine Green Fluorescence Imaging for Evaluation of Blood Supply in Local Flaps for Reconstruction in Oral Cancer

Masaaki Karino, DDS, Phd, Assistant Professor, Department of Oral and Maxillofacial Surgery, Shimane University, Faculty of Medicine, Izumo, Japan


Introduction: Local flap reconstruction is a useful surgical procedure in head and neck cancer. However, the flaps used may become necrotic because of an unstable blood supply. The blood supply to local flaps can now be determined during head and neck surgery using the fluorescence properties of indocyanine green (ICG). The aim of this study was to investigate the feasibility of intraoperative ICG imaging in patients with head and neck cancer undergoing local flap reconstruction.


Methods: This imaging technique involves intravenous administration of ICG intraoperatively and illumination of the surface of the local flap by an infrared camera. ICG fluorescence can be detected in the near-infrared region as deep as 10 mm from the tissue surface.


Results: Four patients with oral cancer (1 man, 3 women; mean age 67.8 years) were evaluated. The histopathological diagnoses were squamous cell carcinoma, mucoepidermoid carcinoma, myoepithelial carcinoma, and ameloblastic carcinoma. In all cases, the primary tumor was resected and the hard and/or soft tissue defect was reconstructed using a local flap. Three sternocleidomastoid flaps and one temporal muscle flap were used. All the flap reconstructions were successful. Postoperative complications included minor infection and partial skin necrosis.


Conclusion: ICG fluorescence imaging is feasible for intraoperative evaluation of the blood supply of local flaps in patients with head and neck cancer undergoing reconstruction. This imaging method may help to increase the success rate of local flap reconstruction.


TRPV2 is a Potential Novel Target of Esophageal Cancer Stem Cells

Keita Katsurahara, MD, Division of Digestive Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan


Background: Recent evidence suggests that membrane proteins, such as ion transporters, are specifically activated in cancer stem cells (CSCs). Therefore, these molecules are receiving a great attention as new chemotherapeutic targets of malignant tumor. This study aimed to investigate the expression and activity of ion transport-related molecules in CSCs of esophageal squamous cell carcinoma (ESCC).


Methods: Cells with high ALDH1A1 activity were isolated from esophageal cancer cell lines via FACS, and then, CSCs were generated using the sphere formation assay. The gene expression profiles of CSCs were examined using a microarray analysis. Candidate genes of membrane proteins activated in CSCs were selected based on that microarray data. Anticancer effects induced by inhibition of the selected proteins were examined.


Results: ALDH1A1 mRNA and protein levels were certainly upregulated in CSCs compared with non-CSCs. Obtained CSCs were resistant to Cisplatin and had the ability of re-differentiation. The results of the microarray analysis revealed that expressions of 50 genes of plasma membrane proteins were changed in CSCs, and that several genes related to ion channels, including transient receptor potential cation channel subfamily V member 2 (TRPV2), were upregulated. The upregulation of TRPV2 mRNA were also validated in CSCs derived from two types of esophageal cancer cell lines using RT-PCR method. The specific TRPV2 inhibitor, Tranilast, was more cytotoxic at lower concentration in CSCs than in non-CSCs, and effectively decreased the number of tumorspheres. Further, Tranilast significantly decreased the cell population with high ALDH1A1 expression in esophageal cancer cells.


Conclusions: The results of the present study suggest that TRPV2 is involved in the maintenance of CSCs, and that its specific inhibitor, Tranilast, becomes a promising targeted therapeutic agent against ESCC.


Novel Concept of Inducing Chronic Allograft Nephropathy in an Animal Model

Manu Kaushik, MD, Resident Physician, St. John Providence Hospital, Michigan State University, Southfield, MI


Renal transplantation has an established superiority in prolonging the longevity of patients with end stage renal disease. Though impressive advancements have improved the short-term survival of the graft, long-term survival is still a major concern. Chronic allograft nephropathy (CAN) remains to be the leading cause of late allograft loss. We wish to simulate CAN in an animal model, to test our hypothesis that a low flow state in the kidney transplant is the primary etiology behind the manifestation of CAN. If successful, this animal model will be the first of its kind and will allow testing of new treatments and prevention techniques against CAN.


The initial phase of the study involved 7 rabbits in the control group. All 7 subjects underwent right sided nephrectomies. The remaining kidney was given 1 year to adapt and compensate, following which the control group subjects were euthanized and the kidney was harvested. The necropsied kidney were sent for histopathology to determine the adaptive changes that would be expected in the remaining kidney, which would mimic the transplanted kidney. The pilot phase of the study involved 5 rabbits.  All subjects underwent a right nephrectomy under general anesthesia. Postoperative kidney function tests were followed to assess the progressive change in renal physiology. After 4 weeks of adaption period, the second operation was performed which involved clipping of the left renal artery of the left kidney, providing at least 50 % occlusion to the inflow, to mimic the change in diameter from the aorta to the iliac artery. This was done to replicate the decrease in blood flow in the transplanted kidney compared to the native organ. Post operative kidney function was followed in the immediate postoperative period and the kidney functions were trended on day 1,7,14,21 and 28.


Rabbit 1,2 and 4 had renal function within normal limits (creatinine 0.8-1.8 mg/dl) throughout, however rabbit 3 was found to have a significant elevation in creatinine (13.8 mg/dl) on postoperative day two  and had to be euthanized secondary to a post operative stroke. Rabbit 4 had a severe elevation in creatinine on postoperative one with creatinine levels of 14.1. The rabbit expired on postoperative day 2 itself. Histopathology of the pilot study specimens with hemotoxylin and eosin stains did not show any structural changes. By including electron microscopy in our main experiment, we expect to notice substantial pathological changes in the tubulo-interstium of the harvested specimens.


Chronic allograft rejection continues to be a culprit in loss of a kidney transplant. Successful development of an animal model, which simulates chronic rejection will be an essential step in understanding the pathophysiology of the disease process.


A Rare Case of Pseudomonas Meningitis Following Intrathecal Baclofen Pump Placement in a 28-year old Paraplegic Patient

Clementine Laetitia Soraya Koa Affana, MD, Faculty Member, All Saints University School of Medicine, Commonwealth of Dominica


Case Report and Challenges in Risk Factors Reduction.


This report describes a case of Pseudomonas Aeruginosa meningitis from an intrathecal baclofen pump in a paraplegic patient following an Asia A spinal cord injury. Intrathecal baclofen pumps are an effective option for the treatment of spasticity following spinal cord injury. However, they harbor a risk of pseudomonal meningitis that should be considered. Pseudomonal meningitis is a rare yet fatal complication of baclofen pump placement, but to our knowledge, it is underreported in the currently available literature (less than 10 cases reported in the past 10 years). In this article, we discuss the case of a patient developed neurological symptoms 14 days after his pump was placed, and consequently required immediate removal of the pump and aggressive antibiotic treatment. We present the risk factors associated with baclofen pump infections according to the existing literature, and we present the existing data on reduction of risk factors and prevention of such infections.


Baseline Assessment of Pediatric Surgical Care Delivery in Sub-Saharan Africa Using the World Health Organization (WHO) Situational Analysis Tool (SAT)

Clementine Laetitia Soraya Koa Affana, MD, Faculty Member, All Saints University School of Medicine, Commonwealth of Dominica


Access to pediatric surgical care remains poor in sub-Saharan Africa resulting in unnecessary deaths and lifelong morbidity. Our aims were to evaluate pediatric surgical care delivery in sub-Saharan Africa using the WHO SAT, and to compare high volume to low volume facilities to determine factors associated with increased pediatric surgical care delivery.


We performed a retrospective analysis of the WHO SAT administered between 2010 and 2013. We analyzed geographic distributions, facility types, and pediatric surgical volume. We defined low volume facilities as facilities performing =500 procedures annually, and high volume facilities as those performing >500 procedures annually. We compared low and high volume facilities to determine differences in workforce, infrastructure, and neonatal surgical care delivery. We determined significance using student t and Chi square tests.


Three hundred and eighty one facilities from 25 countries in sub Saharan Africa participated; 65% of high volume facilities were general/mission hospitals. Compared to low volume facilities, high volume facilities had more surgeons (means 3.05 vs 1.12, p<0.01); more non surgeon providers (means 5.88 vs 2.14, p<0.01); more anesthesiologists (means 2.56 vs 0.32, p<0.01); more non anesthesiologist providers (means 5.79 vs 1.92,

p< 0.01); more functioning operating rooms (means 5.22 vs 1.65, p< 0.01); and were more likely to perform neonatal cases (odds ratio 8.66, p<0.01).


High volume facilities had significantly more providers and functioning operating rooms. Efforts to improve access to pediatric surgical care should include building a surgical workforce and improving infrastructure.


Comparison of Feeding Jejunostomy via Gastric Tube versus Jejunum after Esophageal Cancer Surgery

Tomoki Konishi, MD, Graduate Student, Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan



Esophageal cancer patients often suffer from preoperative malnutrition. It is very important for them to improve their perioperative nutrition status. In our department, we have adopted jejunostomy after esophageal cancer surgery in almost all cases because it could carry out enteral nutrition management from the early stage. However, sometimes we have experienced catheter related complications via jejunostomy. Recently, several studies reported that gastrostomy via gastric tube might reduce the catheter related complications.

In this study, we compared gastrostomy with jejunostomy as postoperative results and catheter-related complications.



From January 2010 to November 2016, we performed 215 consecutive esophagectomy for esophageal cancer. It was divided 133 cases of gastrostomy group (Group G) and 82 cases of jejunostomy group (Group J). We analyzed problems such as tube-related complications, clinicopathological factors (age, sex, tumor localization, tumor progression degree, preoperative chemotherapy), postoperative results (anastomotic leakage, respiratory complications, recurrent nerve palsy, postoperative hospitalization periods) retrospectively. As a surgical procedure, we pierce the enteral feeding tube from the gastric tube and the edge is placed in the duodenum or jejunum and fixed to the abdominal wall via gastrostomy. On the other hand, we penetrate the enteral feeding tube from the upper jejunum and the edge is placed in the jejunum via jejunostomy.



There were no significant differences between the two groups in clinicopathological factors such as anastomotic leakage and recurrent nerve paralysis, postoperative hospital   periods. 12 cases (9.0%) / 25 cases (30.9%) (p <0.001) of postoperative respiratory complications occurred. Catheter related complications were occurred in 12 cases {G / J 4 (3.0%)/ 8 (9.8%), (p = 0.0384)} and it was significantly less in group G. The details of catheter related complications were classified into group G (tube flexion, duodenal perforation and dislocation) and group J (penetration, intestinal obstruction and intestinal fluid leakage). All of Group G complications were conservatively treated and did not show intestinal obstruction complications. Meanwhile, in Group J, all three cases of intestinal obstruction required surgical treatment.



The catheter related complications rate after esophagectomy via gastrostomy in this study were lower than that via jejunostomy in previous reports. We suggest that the route of enteral nutrition tubes via gastrostomy is better than via jejunostomy with regard to catheter related complications.


Liver Transplantation for Polycystic Liver Disease

Yoshihito Kotera, MD, PhD, Asssistant Professor Surgery, Department of Surgery, Institute  of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan


Polycystic Liver Disease (PLD) is basically benign disease. But Patients sometime suffered dyspnea and decreases strength and the ability to move due to increasing size of cysts. Moreover, infection is occurred in the cyst made liver dysfunction. In these reasons, it is difficult to manage patients with PLD. We had 4 cases of Liver transplantation between 2012 to 2016. In this study, we report a feature of these 4 cases.


2 cases are man and 2 cases are women. Average age is 62 years old (56-67). Living donor liver transplantation were performed in 3 cases. Renal transplantation was performed at the same time in 1 case. Before liver transplantation infection in the cysts were occurred frequently in all cases. Percutaneous abscess drainage was performed in 3 cases.

Clinical Course

3 cases had any complications. Bleeding in after operation occurred in 2 cases. Bacterial peritonitis occurred in 1 case. The complications occurred in these 3 cases needed operation to cure. All cases survived more than one year without any infection or rejection.


Control infection and symptoms are difficult for the patients with PLD especially a patient with cyst infection. LDLT is a one of the option for a patient with PLD even with cyst infection. The vascular complications may be more frequent in patients transplanted for PLD due to the lack of intrinsic coagulopathy in the operative period and the excess space in the abdominal cavity after hepatectomy


Hyperoxia After Cardiac Arrest and In-hospital Mortality: First Do No Harm

Rana Latif, MD, FFA, Associate Prof, Dept of Anesthesiology & Perioperative Medicine, Anesthesiology Critical Care, Education Coordinator, Paris Simulation Center, Office of Medical Education, University of Louisville, Louisville, KY


More than 550,000 patients suffer sudden cardiac arrest in USA each year. Current guidelines emphasize the use of 100% oxygen during cardiopulmonary resuscitation (CPR). Clinicians consider ventilation with 100% oxygen after return of spontaneous circulation (ROSC) as benign and harmless. During this presentation, we will increase general awareness that hyperoxia (PaO2 >300 mm Hg) after ROSC increases morbidity and mortality when compared with normoxia (PaO2 = 75-100 mmHg). After a brief summary of pathophysiological injury caused by whole body ischemia (as in cardiac arrest) and reperfusion (as in ROSC), we will discuss how hyperoxia affects individual organs resulting in increased morbidity and mortality. Finally, we will suggest a plan for maintaining oxygen delivery to the end organs with a goal to achieve normoxia after ROSC.


Novel Approach to Diversion of Enteroatmospheric Fistula

Karla Leal, MD, Surgery Resident, Texas Tech University Health Science Center, Lubbock, TX


Enteroatmospheric fistulas remain one of the most challenging problems colorectal and general surgeons face due to associated high morbidity and mortality rates. An enteroatmospheric fistula is an external opening in the setting of an open wound. Risk factors include history of open abdomen, excessive manipulation to bowel, trauma to abdomen and infections among others. Treatment of enteroatmospheric fistulas remains problematic and treatment is difficult to standardize because each fistula poses unique challenges due to location and size.


We present a 56 year old female patient with extensive abdominal surgeries resulting in a non-healing midline wound. She underwent resection of the necrotizing infected tissue, with mobilization of skin flaps in order to close the patient’s abdomen. On post operative day one, she became tachycardic with a leukocytosis, with concern for sepsis. Operative exploration revealed a 4 cm fascial defect with an enteroatmospheric fistula that had been draining enteric contents into subcutaneous planes. Classic methods of diversion including drainage with a Malencot tube placement were attempted without success. Subsequent interventions called for a more creative approach. A silicone silo bag with chest tube suction ensemble was devised and was sutured to the anterior fascia around the fistula. The chest tube drain was then sutured to end of silo bag and attached to low continuous suction. Enteric contents were successfully diverted while the patient’s medical status improved. This diversion method allowed the patient to successfully improve her sepsis. There are many methods to divert high and low output fistulas in preparation for definitive surgical repair that have proven successful. Given the patient’s location and size of her fistula, our team had to come up with a different approach in order to help the patient. This innovative technique was the ideal temporizing measure as it allowed for diversion of enteric contents while maintaining fascial integrity. This allowed the patient’s medical condition to improve, prior to definitive surgical repair.


Outcomes and Techniques of Transvaginal Anterior Levatorplasty for Intractable Rectovaginal Fistula

Kotaro Maeda, MD, PhD, Executive Director and Professor, International Medical Center, Fujita Health University Hospital, Toyoake, Japan


Background: Rectovaginal fistula is a tough issue for surgeons and gynecologists  to treat due to high recurrent rate and the invasiveness after various procedures. Anterior levatorplasty was added to the excision of the fistula with sutures of the rectum and vaginal wall. Techniques and outcomes are presented herein.


Technique: Adverse T incision is performed at the entrance of the vagina and the dissection of the rectovaginal septum is followed. Rectovaginal fistula is excised and the dissection of rectovaginal septum is forwards about 3 cm proximal to the fistula. Dissection of the rectovaginal septum is continued until bilateral levator muscles are visualized. Rectal wall is closed with sutures and approximation of both levator muscles are performed with 1-0 non-absorbable sutures. Vaginal wall is then closed.


Outcome: Sixteen patients underwent tranavaginal anterior levatorplasy for intractable rectovaginal fistula. Median age was 46 years. Fistulas are originated for birth injury in 7 cases and low anterior resection in 3 cases. Seven patients underwent previous surgery. Nine patients had a stoma before surgery. All patients underwent anterior levatorplasty and three patients additional stoma creation. One case had infection and the other case had a rupture of the closed wound. Both cases had a re-operation in the same fashion and the stomas are closed without recurrence.


Fourteen patients had no recurrence after stoma closure during follow up of median 9 years. Two patients are waiting for stoma closure with the fistula closed.


Conclusion: Transvaginal anterior levatorplasty can be an option for intractable rectovaginal fistula with minimal invasiveness.


The Impact of Postoperative Inflammation on Recurrence in Patients with Colorectal Cancer

Daiki Matsubara, MD, Division of Digestive Surgery,Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan


Postoperative complications have been reported as one of the independent prognostic factors in several types of malignancies, however, the main mechanisms still remain unclear. The aim of this study is to clarify the impact of postoperative CRP levels on prognosis in patients with colorectal cancer.


A total of 636 patients with stage l-lll colorectal cancer (CRC) who underwent surgery in our institution between 2008 and 2015 were retrospectively analyzed.


1) Patients were divided into two groups according to the peak CRP value (max CRP) after surgical resection: low CRP group (<10 mg/dl: n=482) and high CRP group (=10 mg/dl: n=154). Univariate and multivariate analyses were performed to identify independent prognostic factors for recurrence-free survival (RFS). The correlation between max CRP and recurrence patterns were also analyzed.


2) Proliferation assays were performed to investigate the effect of recombinant cytokines (IL-6, TNF-a, IL-1b) on CRC cell (HT29, DLD-1). Additionally, adhesion assays as peritoneal recurrence model using CRC cell and mesothelial cell (Met-5A) with recombinant cytokines were performed to validate its effects on cell adhesion. In these assays, the cell growth or adhesive ability of CRC cell which were treated with cytokines were compared to that of non-treated CRC cell.


1) Patients in high CRP group showed significantly worse RFS than patients in low CRP group. (p=0.004) A multivariate analysis revealed that higher CRP, as well as larger tumor size, high T and N stage, venous invasion, high CEA level, was independent prognostic factors for RFS. (HR: 1.78, 95% CI 1.05-2.97, P=0.0312) The difference in RFS between the low and high CRP groups was not statistically significant in patients with postoperative complications, while, among patients without postoperative complication, high CRP group revealed worse RFS when compared with low CRP group. (p=0.0001) Furthermore, high CRP was significantly associated with peritoneal recurrence both in overall patients and in patients without postoperative complication. (p=0.0006, 0.0052)

2) Proliferation assays and adhesion assays revealed that recombinant cytokines enhanced cell growth and adhesive ability of CRC cell. (p<0.05)

Our study suggested that postoperative inflammation might be one of crucial mechanisms of poor prognosis in patients with colorectal cancer. This risk might be, at least in part, due to adhesive ability of cancer cells which were enhanced by cytokines.


Suprapubic Catheter Placement through Ileal Mesentery Causes Mechanical Small Bowel Obstruction Six Years Later in a Female Patient with Turners Syndrome

Jayne McCauley, MD, General Surgery Resident - Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX



Small bowel injury is a rare but reported complication of percutaneous suprapubic catheter (SPC) placement, with a reported incidence of 2-3%. Delayed presentation of injury or bowel obstruction secondary to SPC placement is rarely reported in the literature.


Case Presentation:

In August 2017, a 65 year-old female with a past medical history of Turner’s Syndrome, heart block, and neurogenic bladder for which a SPC was placed by urology in November of 2011, presented with small bowel obstruction. She presented one time in March of 2017 with a possible small bowel obstruction, that resolved with a gastrograffin small bowel follow through. On the subsequent admission in August 2017 she presented with a small bowel obstruction. She required surgical exploration and the SPC was found to be inserted through small bowel mesentery of the terminal ileum causing a mechanical obstruction with bowel ischemia, which required resection. The urology team was consulted intraoperatively for replacement of the SPC.



To our knowledge, and upon literature review, there are only a handful of cases reporting injuries from SPC to small bowel mesentery causing a small bowel obstruction. An even fewer number of cases are reported as far out as five years. Therefore, in patients with SPC who present with bowel obstructions, it is important to consider placement of SPC through bowel mesentery as a possible etiology of delayed bowel obstruction.


Addiction Medicine Meets Cardiac Anesthesia – An Update on Evidence-Based Treatment for Opioid Use Disorder

J Thomas Murphy, MD, Professor of Anesthesiology, University of Kentucky, College of Medicine, Lexington, KY


Description: Problem the presentation covers: The presentation covers the disease of addiction, which is a chronic brain disease, the treatment of which has long been hampered by stigma and inadequate teaching in medical schools and post-graduate specialty training. The current opioid epidemic in the USA will likely be felt for years to come. The scientific basis of addiction as a brain disease will be reviewed, and a summary of evidence-based treatments will be presented. The author and presenter is a career cardiac anesthesiologist who became interested opioid use disorder (OUD) while providing anesthesia for thoracic surgery, typically valve replacement or empyema secondary to intravenous drug use. After self-education and board-certification in Addiction Medicine, the presenter extended the use of his knowledge from the perioperative environment to the outpatient clinic for follow-up and treatment of post-operative patients with OUD and others. Why the audience needs to know this information: The recognition that addiction is a disease which can be treated and managed in a way similar to other chronic diseases, and that it is not merely the result of a weak will, or moral failing, is important to all physicians. While effective prevention of OUD may require a public health initiative, one-on-one physician-patient interaction and discussion of risk factors may influence perioperative care, pain control, and patient satisfaction. What the Learner will be able to accomplish after the presentation • Explain risk factors for addiction • Identify patients at risk for opioid misuse • State which withdrawal syndromes are life-threatening • Identify when to request a consultation from Addiction Medicine How the audience will benefit from the presentation • Become knowledgeable about the subspecialty of Addiction Medicine


Simulation in Surgical Education: Where Are We In 2018?

Mayur Narayan, MD, MPH, MBA, Associate Professor of Surgery, Weill Cornell Medicine/ New York-Presbyterian Hospital, New York, NY


The use of simulation in surgical education is continuously evolving. This state-of-the-art lecture will highlight the evolution of simulation: where we have been, where we currently are, and where we are heading with respect to simulation and surgical education. This presentation will also highlight low- and high fidelity simulators, team building exercises, health professions education simulation as well as in situ simulations to be used by both local national and international colleagues. Of note, I will also demonstrate the importance of incorporating simulation in the developing world. The audience will benefit from attending this lecture by getting a historical perspective on surgical simulation and new trends in implementing it in their respective institutions. The audience will also benefit from understanding current requirements from the American College of Surgeons Accredited Education Institutes (ACS-AEI), learning about assessment tools and potential challenges in implementing simulation in their local environment.  The lecture will also highlight the impact of Entrustable Professional Activities [EPAs] in documenting competency in general surgery residency training.


Trauma as Disease Process Affecting the Nation

Sharique Nazir, MD, Attending Surgeon, NYU Langone Hospital, New York, Honorary Police Surgeon NYPD, Staten Island, NY


Trauma is one of the major public health issues globally faced, with no other disease impacting society as greatly. It's impact can be seen across all countries regardless of income, leading to high rates of both death and disability.  While trauma remains the major killer of people aged 1-45 worldwide, public perspective still views it as accidental and not as a disease.


One way to analyze the impact that trauma has is by measuring years of potential life lost (YPLL) before the age of 65. When using YPLL, for any given year traumatic injuries impact surpasses those caused by cancer and heart disease. Another way to analyze disease impact is by determining disability adjusted life years (DALY). DALY measures the burden of disease by analyzing total health loss and premature mortality at the population level. DALY is calculated by the years of life lost (YLL) plus the years lived with a disability (YLD). YLL is partly determined by the remaining life expectancy at age of death, thus is can be adjusted based on population. In using DALY, the burden of disease can be compared between different years, helping to guide policy development.


The evolution of trauma's disease process can be analyzed by comparing DALY scores between 1990 and 2013. Road injuries have the largest impacts on society, being the highest DALY for individuals ages 10-24 year old. Other major contributors for all ages include self-harm, falls, drowning, and interpersonal violence. Between 1990 and 2013, DALY scores increased for road injuries, falls, adverse effects of medical treatment, self harm & interpersonal violence, highlighting the increasing impact these have on the disease process itself. While DALYs vary based on socioeconomic status, they tend to be higher for men of all regions and higher in high-income countries.


By trending this data, implementation of systems to decrease the burden of disease is feasible. The organization and implementation of care delivery systems greatly affects trauma as a disease process. While the US has made great progress in decreasing preventable traumatic deaths and increasing trauma care quality; this is not true for most low-, middle-income countries (LMIC). Most LMIC lack developed trauma systems, hospital resources, non-optimized training, and dedicated trauma centers leading to compromised trauma care within overcrowded emergency departments. To advance trauma care delivery, quality of care, and improve outcomes, problems must be addressed throughout LMIC. Adaptation of care systems within LMIC regions can be done to fit the culture and current practices, while also focusing on each regions main burden of disease.  By distinguishing traumatic injury as it’s own disease, systems can be developed to provide organized and comprehensive care adapted for the population of interest, resulting in decreased mortality and reduced burden of disease worldwide.


New Concepts on the Functional Anatomy of the Abdominal Wall

Enrico Nicolo, MD, Emeritus, Department of Surgery, Jefferson Regional Medical Center, Jefferson Hills, PA


The functional anatomy of the abdominal wall is presented in three main aspects.


1- the functional unit of the abdominal wall, muscle-fascia unit.


2- the functional anatomy of all the muscles of the anterior abdominal wall as the ability to actively contract against the intra-abdominal viscera and passively relax to accommodate the intra-abdominal volume.


3- the functional interrelationship of the anterior abdominal wall with the other walls of the abdomen, especially with the diaphragm for the determination of the intra-abdominal pressure that fallows the physical law of the parallelogram, and not the physical law of Pascal.


Novel Nodal Metastatic Index as a Combined Indicator of Nodal Counts and Stations in Gastric Cancer

Keiji Nishibeppu, MD, Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan


Background: In 14th Japanese classification of gastric carcinoma (JCGC), the indicator for node staging was changed from nodal stations to counts as same as TNM classification. This study was designed to investigate the usefulness of nodal metastatic (NM) index, which reflects both nodal counts and stations in gastric cancer.


Methods: We retrospectively analyzed 455 consecutive gastric cancer patients, who underwent curative gastrectomy with radical lymphadenectomy from 2008 through 2012. The NM index was calculated by the total of nodal counts score using 14th JCGC (N0:0, N1:1, N2:2, N3:3) and highest metastatic nodal stations score (D1 area:1, D2 area:2, D3 area:3).


Results: 1) The NM index of 5 was proved to be the best cut-off value to stratify the prognosis of patients into two groups (P < 0.0001; NM index <5 vs =5), and patients were correctly classified into four groups: (i) 0 (5-year survival rate 96.7%), (ii) 1-<3 (81.5%), (iii) 3-<5 (67.1%) and (iv) =5 (22.7%). 2) Compared with patients with the NM index <3, those with the NM index =3 had a significantly undifferentiated type, deep tumor depth and presence of lymphatic invasion and venous invasion. Multivariate analyses revealed that tumor size, T-stage, venous invasion, and the NM index (P = 0.002, HR=3.68) were independent prognostic factors. Specifically, patients with pN3 or pStage III could be definitely stratified by the NM index.


Conclusion: The NM index is useful to stratify the prognosis and may enable to identify those who need meticulous treatments and follow-up in patients with gastric cancer.


Compliance and Variance in Teaching Assistant Experience during Surgical Residency

Mitesh Patel, MD, Providence Hospital and Medical Centers--Michigan State University, Southfield, MI


Purpose: Starting in the 2014-2015 calendar year, the American Council for Graduate Medical Education (ACGME) and the American Board of Surgery (ABS) have made it a requirement, that a graduating surgical resident must complete at least 25 cases acting as a teaching assistant (TA) during residency training. The ACGME allows a resident to log a case as a TA during the 4th or 5th years of residency, whereas the ABS allows only a 5th year resident to act in a TA capacity. The definition of teaching assistant may vary from program to program. Also the types of cases that chief residents are performing as TA as well as the setting in which they are performed differs amongst various programs. The purpose of this study was to gain insight as to how many cases graduating chief residents are logging as TA, the setting in which they are done, as well as the types of cases that are being performed.


Methods: An online survey consisting of 21 questions was sent via email to all general surgery program directors across the nation between August and October of 2015. Questions regarding number of cases performed as a TA, types of cases performed as a TA, the setting in which they were performed, as well as the level of resident supervised by a TA were asked.


Results: Of the 200 surveys that were delivered, we received 88 responses (44%). Fifty-two percent of programs stated that their graduating residents generally log more than 25 cases as TA upon graduating. Thirty-six percent of programs stated that a PGY4 could act as a TA, however 31% of programs stated that they had no specific level of training requirement for a resident to act as a TA. Fifty-two percent of programs stated that a junior resident needed to perform more than 50% of a case in order for a senior resident to log a case as a TA. All 88 respondents (100%) stated that their senior residents acted as a TA in the operating room, 59% acted as TA in the clinic, 66% on the surgical floors, and 70% in the emergency room. Fourty-eight percent stated that residents were logging cases as TA in both open and laparoscopic operations and also that they perform cases in both the elective and emergent setting.


Conclusions: The definition of a teaching assistant differs amongst programs. Also, the types of cases that residents log as a TA varies amongst programs because there are no clear guidelines set by the ACGME and ABS as to what constitutes a TA case. Nonetheless, in most programs, senior residents are performing more than 25 TA cases upon graduation based upon our results.


Surgery: Past, Present and Future

Prof. Adel Ramzy, MD, ICS World Past President, Professor of Surgery, Cairo University, Cairo, Egypt


Chirurgiae in latin means hand work. Celsius described surgery as curing by the hand. Past Surgery: - Egypt: the oldest surgical procedure was transplantation 2750 BC in Egypt. Imhotep was the Egyptian God of medicine 2700 BC. The Edwin Smith papyrus was the oldest textbook of surgery 2700 BC. - India founded the basic principles of plastic surgery: flaps and rhinoplasty. - China pioneered acupuncture. - Greece Hippocrates 460-370 BC laid the Hippocratic oath. Herophilos 335-280 BC founded the great Alexandria school of medicine. - Greco roman Galan 129-199 AD wrote books on surgery and described many operations. - Persia and Arabic: Alrazi 865-925 author of Alhawi, and pioneer in neurosurgery and ophthalmology Al Zahrawi specialized in cauterization and surgical instruments Ibn Sina 980-1037 introduced experimental medicine. - France: Ambroise Pare 1510-1590 treated hemorrhage by ligature and made progress in obstetrics. Dominique Lary 1768-1842 introduced the concept of triage for casualities. - England and Scotland: John Hunter 1728-1783 introduces the Hunterian Society of London and Ashley Cooper 1788-1841 worked on mammary glands and hernia. - Prussia: Theodor Billroth 1829-1894 had done oesophagectomy and gastrectomy. - Infection Control started by Ignaz Simmelweis 1847 and advanced by Pasteur and Josef Lister - Blood groups allowed blood transfusion early 20th.

Century Anesthesia started by ether and chloroform (John Snow) and later nitrous oxide (P Priestly) The 20th century marked great studies in surgery all over the world headed by USA, England, France and Germany.


Surgery at present - Organ transplantation started by cornal 1905 – to double organ transplantation 1984. - Implantable devices replaced many disordered functions e.g. pacemakers, artificial heart, cochlear, shunts (ventriculocaval, peritoneocacal etc), and devices for incontinence and impotence. - Robotic surgery open and laparoscopic allowed more precision but expensive. - Nano biochemical engineering. - Gene therapy in oncology and vascular problem. - Stem cell therapy for spinal, cardiac and periodontal regeneration. - Laser of different types for many purposes. - Telemedicine allowed surgery at distance especially for underdeveloped areas. - Advances in endoscopic surgery, staplers, harmonic scalpels, etc.


Surgery in the future will receive many subspecialties, minimally invasive, Hi and Nanotechnology, better genetic engineering. It is difficult to foretell the dreams and unpredictable surgical advances.


Double Peritoneal Cavity Cause of Post Prandial Abdominal Pain, Reflux Esophagitis, Small Bowel Obstruction and Mesenteric Ischemia

Biagio Ravo, MD, Professor, Rome American Hospital, Rome, Italy


Double peritoneal cavity is a new anatomical finding not described before in the medical literature.  A presentation of such a finding will be described with a theory of its embryological development and its impact on the abdominal structures and clinical importance.


Managing Your Stress and Moving Beyond Burnout

Stephen Robinson, MA & Elizabeth Robinson, MA, Founders, EVENPULSE: The Science of Human Resilience, Boulder, CO


This workshop presentation is built for surgeons to engage with tools that will support their practice and physiologic response to stress. They will learn to alter their autonomic system, to facilitate a relaxation response, and guide them to work with a mindful brain both in and outside of the OR. Building from a knowledge base founded on both a review of literature and peer review studies as well as numerous trials and as a result of field implementations, through learning autonomic self-regulation and the effective use of attention, this workshop will teach relevant information that will strengthen the surgeon's self-control, peer and patient relationships.


You will learn how to pace yourself internally and meet the outer demands to reduce escalation of the physiologic response to stress and anxiety and mitigate the tendency to burn out. Participants will learn a model that has been scientifically-grounded and tested with 6,000 deploying combat soldiers and which has been used across the US Special Operations Command. This program is particularly beneficial to surgeons who provide trauma and/or disaster outreach intervention.


The take-aways include understanding and the application of regulating the autonomic nervous system, managing the mind and brain's response to stress and anxiety, directing imagination, implementing simulations, and managing energy. The underlying theme is centered around mastering the ability to rest and recover in order to maximize your physiologic response to the world and situations that unexpectedly arise. You will learn how to give yourself this gift daily, weekly, monthly, quarterly, and annually, dropping down into a moment-to-moment presence. You will become maximally effective and efficient in daily tasks. The skills you will learn are applicable across the spectrum of your work and decision making processes, from patient relations to administration to surgical interventions.


The gap this workshop fills is providing relevant information to surgeons that allows them to de-stress rather than distress and do so within the context of their busy jobs and lives. The gap is preventing burnout and mitigating negative stressors through effective physiologic self-regulation, which is not something that physicians are routinely taught and would only access typically by going to individuals or organizations outside their usual professional sphere for training and information.


Complications after Femoropopliteal Bypass: Vein vs. Prosthetic Graft Utilizing Data from the NSQIP Database

Peter Rodgers-Fischl, MD, Resident Physician, Cardiothoracic Surgery, University of Kentucky, Lexington, KY


Infrainguinal femoropopliteal bypass grafting is the recommended for the treatment for peripheral arterial disease (PAD) with a long occlusion of the superficial femoral artery (SFA). However, currently there is a debate about the types of graft materials utilized. Some studies have demonstrated superiority with the saphenous (SV) conduits whilst others have shown nearly equal potency rates. The aim of our study is to compare the complication rate amongst prosthetic vs saphenous vein grafts utilizing the NSQIP database for surgical centers within the United States.


The NSQIP database was used to compare any morbidity within 30 day of surgery for femoralpopliteal bypass procedures with primary CPT code 35556 for veinous grafts or 35656 for prosthetic grafts. These included any SSI (superficial, deep, or organ space), wound dehiscence, pneumonia, transfusion, UTI, extended ventilation, sepsis, septic shock, renal failure or insufficiency.  Propensity score matching was done to minimize the effects of confounding from non-randomized data.


During the study period there for 13,027 femoralpopliteal bypass surgeries conducted.  The saphenous vein was utilized as a conduit 6,483 times vs. 6,544 prosthetic grafts.  There was a significant difference between the ASA class and clean vs. clean/contaminated wound classification utilized before propensity matching.  After propensity matching, the only statistically different 30-day morbidity was in the number of patients requiring transfusion (16.4% in the venous group vs. 19% in the prosthetic group, p = 0.003).


With the exception of number of patients requiring transfusion, there was no statistical significant difference after propensity score matching in the number or type of complications between venous vs. prosthetic graft conduit.


Violence Seen Through a Public Health Lens

Selwyn Rogers, MD, MPH, Professor of Surgery, University of Chicago Medicine, Chicago, IL


Intentional violence and clinical care to address trauma are largely focused on crime and punishment and biomedical response to physiological derangements. I will explore examination of violence through a public health lends. Through delineation of protective and risk factors for violence, potential solutions will be discussed. The impact of violence is far reaching and affects not just the person who dies from trauma but his/her family and all of their contacts. If we are to improve the health of the population, we have to address the wider social determinants of health such as poverty, unemployment, lack of education, and opportunities that increase the risk of violence in communities.


Trends in Surgical Practice: Challenges and Opportunities

Sibu Saha, MD, MBA, Professor of Surgery and Bioengineering, University of Kentucky, Chief & Program Director, CT Surgery, University of Kentucky, Lexington, KY


Increasing number of surgeons are employed by hospitals. Health care systems are bringing hospitals under one management. Service line management is spreading to reduce costs and improve outcome.

Fee for service will be replaced by bundle payment,value based payment etc. Surgeons are not trained in negotiation and/or business of surgical practice


Bilateral Mastectomies in Breast Cancer Patients: Does Single vs Double Surgeon Affect Outcomes?

Arsalan Salamat, MD, Breast Surgery Fellow, University of Pittsburgh Medical Center, Pittsburgh, PA


Background: There has been a rise in elective contralateral prophylactic mastectomy (CPM) concurrently with a total mastectomy (TM).1,2 The rate of CPM nationwide increased from 4% to 13% since 200 and tripled from 10% to 33% for women <45 years of age. 1;2 Surgical complications rates are reported to be increased when a bilateral mastectomy (BM) is performed compared to a unilateral mastectomy (UM), particularly with immediate reconstruction.3


Methods: In this study with retrospectively analyzed 583 patients who underwent mastectomy at a single academic institution without immediate reconstruction. The 3 groups included: 1. Bilateral mastectomy with 2 surgeons (N=230) 2. Bilateral mastectomy with single surgeon (N=20) 3. Unilateral mastectomy with single surgeon (N=333). We compared rate of complications such as hematoma, seroma, need for reoperation, skin ischemia, and skin necrosis as well as operative time (OT) amongst the 3 groups. Statistical analysis was performed using SPSS to calculate chi-square and one-way ANOVA. A p-value <0.05 was considered statistically significant.


Results: There was a significant difference in OT between groups 1 and 2. There were no significant differences in the rate of hematomas, seromas, infection, re-operation, or flap ischemia between the 3 groups (P<0.01).


Conclusions: Bilateral mastectomies w/o immediate reconstruction can be safely performed with 2 surgeons operating simultaneously w/o increased risk of complications.


Current Surgical Training and Preparation for a Career in Rural Surgery:

An Individual Perspective

Tracy Sambo, MD, Vidant General Surgery - Edenton, Edenton, NC


This presentation addresses current surgical training as it applies to preparing for going into a rural surgery practice upon graduating residency.  This information is important because it will shed light on how sufficient our current training guidelines are and where we may be lacking.  This may help shape what we want to do with our surgical training programs in the future.


Prevention of Bowel Anastomotic Leak:  Reinforcement using Biologic Mesh

Larry S. Sasaki, MD, Colorectal Surgeon, Bossier City, LA


Anastomotic leaks are a dreaded post-operative complication.  The literature is replete with studies that report leak rates from 0.5 to 12%.  Low colorectal anastomoses have higher leak rates reported as high as 15%.  Preliminary analysis has confirmed a reduction of anastomotic leaks using a biologic mesh wrap.  An extracellular matrix derived from porcine urinary bladder was applied and sutured to the anastomosis.  The functional intent of this mesh was to facilitate a constructive remodeling process with restoration of normal site-appropriate tissue.  One hundred, eighty-nine(189) patients with bowel anastomoses were reinforced with a porcine biologic mesh wrap.  Bowel anastomoses included entero-enterostomy, ileo-colic, ileo-rectal, ileo-anal, colo-colostomy, colo-rectal, and colo-anal anastomoses.  Preliminary analysis has indicated a statistically significant reduction of anastomotic leak.  This presentation will discuss the technique for application, and these preliminary findings.


Therapeutic Misadventures

Lakshmanan Sathyavagiswaran, MD, Professor of Medicine and Pathology at USC, Keck School of Medicine, Los Angeles, CA



Attendees will understand the Coroner's role in evaluating possible therapeutic misadventures.

Attendees will report suspected fatal therapeutic misadventures to the Coroner.

Attendees will understand likely sources of therapeutic misadventures in clinical practice.


It shall be the duty of the coroner to inquire into deaths known or suspected as resulting in whole or in part from or related to accident or injury either old or recent (California Government Code Section 27491).

We ask that hospitals report deaths during surgery or within 24 hours afterwards.


Misadventure -  A mischance or accident; a casualty caused by the act of one person and inflicting injury upon another. Homicide by misadventure is where a man, doing a lawful act without any intention of hurt, unfortunately kills another.


In Civil (Malpractice) Cases: The Coroner gives a medical opinion about cause and manner of death.

An interested party brings a civil suit.

The plaintiff must prove, with a preponderance of evidence:

The defendant had a duty to the plaintiff

The defendant breached that duty

The plaintiff suffered damages

The breach of duty caused the damages

The Coroner is a neutral party in litigation.

The Coroner Reports poor medical care to the Medical Board of California. If such care is felt to be gross negligence and resulted in death


Peri Procedural Deaths:

Malfunction of (or defective) medical device, tool or diagnostic/therapeutic agent, e.g., internal short circuit in cauterizing device causing electrocution. Rarely occurring complication with recognized untoward potential, e.g., INH related hepatic damage. Incorrect use of a medical device, tool, diagnostic or diagnostic / therapeutic agent, e.g., esophageal intubation during an elective procedure administering wrong dose.


Unanticipated complication, e.g., leaving a surgical towel in abdomen incomplete ligation of vessel.

In 2.9-3.7% of hospital admissions there is an injury caused by medical management.

The most common cause is adverse drug events (2%)


Coroner’s Statistics: 511 cases 2003-2012. 76 (15%) adverse medication effects. Most common drugs involved are coumadin and radiographic contrast. 423 (83%) unintentional cut, puncture or perforation.


Humanitarian Surgery from ICSUS and Europe: What are the Options?

Frank P. Schulze, MD, Chief of Surgery, St. Marien-Hospital, Mulheim, Germany


Introduction: In 2018 the world population is more than 7.6 billion people. However, up to 5 billion people cannot access safe, affordable, and timely surgery each year. More than 234 million operations are performed worldwide per year. Yet, there is an estimated need of more than 320 million surgeries annually. Thus, closing the gap requires an additional 100 million procedures worldwide each year. In this presentation, the current situation to surgical access is analyzed and discussed, with a special focus on a possible future humanitarian option and contribution from ICS-US and Europe. A potential transatlantic cooperation of the respective ICS sections with the WHO is discussed and suggested.


Methods: The existing missions and projects for humanitarian surgery of the International Federation of Red Cross and Red Crescent Societies (IFRC), Médicins Sans Frontières / Doctors Without Borders (MSF) and the World Health Organization (WHO) and further NGOs were analyzed and reviewed for possible integration with the resources of surgical expertise within the North-American and Western European Sections of the International College of Surgeons (ICS).


Results: Humanitarian surgery of the IFRC focuses on combat and war zones. Typical surgical diagnoses and treatments are open bone fractures, wound infections, amputations, gun shots, stabbing injuries, blast injuries, and Caesarean sections. A minimum of 3 month service blocks are expected from each participating doctor.


MSF also mainly operates in war and conflict areas. The spectrum of treatment is similar to that of IFRC. A minimum of 6 weeks to 3 months service blocks are required from volunteer doctors.


In 2015 the WHO founded the Emergency Medical Team (EMT) initiative. The WHO EMT initiative assists organizations and member states to build capacity and strengthen health systems by coordinating the deployment of quality assured medical teams in emergencies. EMTs must strive for self-sufficiency, meet minimum standards, and have to undergo a Global Classification Process to become an EMT classified team.


Conclusion: The WHO Emergency Medical Team (EMT) initiative offers a potential platform on which to build a North American and Western-European “Transatlantic Essential Surgical Support Actiongroup” (TESSA) of the respective sections of the ICS. Details have yet to be discussed with the participating ICS sections and the WHO.


Surgical Management of Bile Duct Injury after Cholecystectomy

Frank P. Schulze, MD, Chief of Surgery, St. Marien-Hospital, Mulheim, Germany


Introduction: Cholecystectomy for symptomatic gallstones is one of the most common procedures in general surgery in North-America and Western Europe. The incidence of bile duct injury (BDI) associated with open cholecystectomy is reported to be around 0.2%. Recent publications show BDI to occur in more than 0.5 % of the laparoscopic cholecystectomies. Severe consequences of BDI are peritonitis, sepsis, hepatic failure, or even death. In the long term, BDI may result in chronic cholangitis, bile duct stenosis, cirrhosis, the development of cancer, and the necessity for complex surgery. An overview on the classification and the therapeutic options to manage BDI is presented.


Methods: PubMed, the Cochrane Library, and further literature sources were searched for available data and current publications on the incidence, management, and outcome of “bile duct injuries”. In addition to this review of the literature, own cases of BDI and their clinical management and outcome are presented as examples.


Results: The incidence of bile duct injury after cholecystectomy is reported to be between 0.1 - 0.3% in open surgery and 0.4 - 0.8% after laparoscopic cholecystectomy. A consensus from expert surgeons on appropriate surgical techniques to avoid BDI has been published. Different classifications of BDI like Bismuth, Hannover, Steward-Way, and Strasberg are in use. An early and accurate diagnosis of iatrogenic bile duct injury after cholecystectomy has significant influence on the outcome of the respective patients. Endoscopic diagnostics and stenting of a bile duct lesion is the Gold Standard. However, in patients with complete dissection or obstruction of the bile duct, surgical reconstruction is essential in most cases. While the Roux-Y hepatico-jejunostomy is the most common form of reconstruction, a long-term risk for the development of cholangitis, stenosis or cholangiocellular carcinoma exists. If possible, an early primary anastomosis of the bile duct may be the better option and may be considered. Reconstruction of the bile duct with umbilical vein as a new surgical procedure has been reported lately.


Conclusion: Bile duct injury after cholecystectomy remains a severe complication which should be prevented by highest awareness and caution during cholecystectomy. While the prevention of BDI during cholecystectomy should be a major effort of the performing surgeon, early diagnosis of BDI and a precise and effective complication management are the keys to successful damage control. In the patient’s and the responsible surgeon’s own interest, support from a specialized hepatobiliary surgeon and/or transfer to a HPB referral center may be considered.


Management of Atypical Trigeminal Neuralgia

Maura Segura, MD, PhD, Medical Director, Department of Neurological Surgery, Hospital Angeles Morelia, Morelia, Mexico (Presented by: Octavio Carranza Renteria, MD)



Atypical trigeminal neuralgia (Type II) can be defined as the  one that does not have fixed trigger zones or stimuli, causes persistent pain on top of the paroxysmal attacks of the trigeminal neuralgia and is accompanied with sensory abnormalities of the face.


Patients affected with this variant of the disease have a bad prognosis and are refractory to most of the treatments available.


The reason why this patients have a clinical presentation so aggressive is yet unknown.



The aim of this research is to expose our experience in the management of Atypical Trigeminal Neuralgia and its relationship with the presence of Arachnoiditis and Fibrosis in the meninges.


Patients and Methods: 

A retrospective recollection of information from all the cases of trigeminal neuralgia seen in our clinic from 2014-2017 was done. Patient’s age, sex, diagnostic, side of the face affected, branch of the trigeminal nerve causing pain and treatment were registered. From 241 cases of Trigeminal Neuralgia, we only included in this analysis those patients whose Trigeminal neuralgia could be classified as atypical (n=37). 19 patients underwent Microvascular Decompression of the Trigeminal Nerve; biopsies of the surrounding meninges of the patients were obtained. The biopsies were analyzed through optic microscopy with a simple Hematoxilin-Eosin dye.  The two main findings were Arachnoiditis and Fibrosis with Microcalcifications of the meninges.



Of 241 cases of Trigeminal neuralgia in our database, 37  (16%) were atypical. We observed a predominance of women (70%) . The average age of these patients was 43 years. 51% of the patients had pain on the left side of the face, 36% on the right and 12% of the cases were bilateral.  Of the 19 patients operated with MVD, 6 had pain after the surgery and in the other 13 cases the pain disappeared. 4 of these 13 patients had recurrence of the pain in the following 3 years. After 3 years 10 of the patients continued to have pain to a certain degree (53%) and 9 did not (47%).  Biopsies were obtained the cases operated. The main histological findings were Arachnoiditis (n= 7) and Fibrosis with Microcalcifications (n=6)



More studies with bigger samples are needed to determine if these pathological findings have any relationship with the likelihood of success of MVD Surgery. We propose that MVD offers a favorable alternative to the relief of pain in certain cases of atypical trigeminal neuralgia. The data in our study suggests that there may be an association between the pathological findings of arachnoiditis and fibrosis with the recurrence or persistence of pain. Our observations are not statistically significant but we propose that these two pathological features might be associated in the pathophysiology of Atypical Trigeminal Neuralgia.



MVD may be considered an option for the treatment of patients with atypical trigeminal neuralgia with an expectative for the effective relief of pain in this group of patients. As much as half of the patients with this variant of the disease can find relief of pain after surgery.


Role of VAC Therapy in Wound Management in India

Rajesh C. Shah, Prof. Dr., Professor of Surgery and Medical Superintendent, Sheth L.G. Municipal General Hospital and Ahmedabad Municipal Corporation Medical Education Trust Medical College, Ahmedabad, India


Vaccum assisted closure (vac) therapy is one of the modality used for wound management in India, it is frequently used with great results. Present study will present role of vac therapy for wound management.


En-bloc Mediastinal Lymph Node Dissection Using a Laparoscopic Transhiatal Approach for Esophageal Cancer

Atsushi Shiozaki, MD, PhD, Assistant Professor, Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan


Purpose: The procedure for middle and lower mediastinal lymph node dissection using a laparoscopic transhiatal approach (LTHA) has not been established because of the difficulties associated with this surgery. We developed a novel and simple technique for their dissection.

Methods: The esophageal hiatus was opened and CO2 was introduced into the mediastinum. Pericardial adipose tissue was divided, and the pericardium was exposed. The posterior plane of the pericardium was extended, and the anterior side of the subcarinal, main bronchial, thoracic paraaortic and pulmonary ligament lymph nodes were separated. The posterior side of these lymph nodes was then separated. Finally, while lifting these lymph nodes like a membrane, they were resected from bilateral mediastinal pleura, main bronchi and tracheal bifurcation. The treatment outcomes of 100 patients with esophageal cancer who underwent middle and lower mediastinal lymph node dissection by LTHA were compared with those of 75 patients who underwent their dissection by the right thoracotomy.


Results: The total operative time and bleeding were significantly decreased by LTHA. The number of resected middle and lower mediastinal lymph nodes in the two groups was not significantly different. Postoperative respiratory complications occurred in 13.0% of patients treated with LTHA and 25.3% of those treated without it (p<0.05).


Conclusions: Our surgical procedure resulted in a good surgical view of the mediastinum, and en-bloc dissection of middle and lower mediastinal lymph nodes was performed safely. Further, our procedure significantly decreased postoperative respiratory complications.


Retrospective, Single Site Study to Evaluate the Analgesic Effectiveness of Exparel (Liposomal Bupivacaine) Mixed with Bupivacaine hcl Versus ON-Q Pain Pump for Renal Transplant Recipient Incisions

Elizabeth Tacl, MD, Resident, Sanford University of South Dakota Medical Center, Sioux Falls, SD


The primary objective is to determine if liposome bupivacaine with bupivacaine HCl can reduce the maximum pain levels observed post-surgery more than the standard analgesia methods, ON-Q pain pump, for donor nephrectomy and recipients as determined by an 10 point pain scale during inpatient recovery stay. Secondary objectives include to evaluate whether ON-Q pain pump versus Exparel require longer times until need for first narcotic dose, difference in post operative nausea or vomiting requiring intervention, time to first mobilization (time out of bed), total narcotic need, use of other pharmacologic pain adjunct needs (Flexeril, Tylenol, etc. ), and total length of hospital stay.


Methods: Charts of 40 patients were reviewed over a 14-month period. Patients either received ON-Q pain pump with standard post operative pain control or intraoperative periincisional Exparel. The following assessments will also be evaluated: 10 point pain scale, narcotic usage, data regarding use of antiemetic and other pharmacologic pain adjuvant medications, first mobilization and total length of stay.


Effective postoperative pain control is an essential component for the surgical patient. Data available indicates that an afferent neural blockade with local anesthetics is the most effective analgesic technique.


Liver Segmentation Based on the Surgical Anatomy

Ken Takasaki, MD, PhD, Professor Emmeritus of Surgery, Institute of Gastroenterology, Tokyo Women’s Medical University, Tokyo, Japan


We cannot locate any artery, vein, or bile duct in the liver parenchyma, but only fibroid bundle. I named these fibroid bundles as Glissonean Pedicle.


Every branch of Glissonean pedicles wrap an artery, vein and bile duct.


A part of hepatoduodenal ligament forms the primary branch of the Glissonean pedicle. The primary branch diverges into three secondary branches at the port of the liver. Each secondary branch invades in the liver and feeds one segment. Then the liver is now separated into three segments: right anterior segment, right posteriol segment and left segment. There is one additional area called the caudate area, which is nourished directly from the primary branch. The three segments are almost the same size, each accounting for about 30% of the total volume with the remaining 10% occupied by the caudate area.


Each of secondary branches branched into several tertiary branches at the inside of the liver. The area fed by one tertiary branch is called a cone unit”. The base of each cone unit lies on the surface of the liver and the apex lies in the direction of the hepatic hilum. Then each three segments are composed of six to eight cone units. Procedures of hepatic resection are done by transection of corresponded Glissonean pedicles.


The procedures of hepatic resection are divided into two types; that is segment resection and cone unit resection.


The first step of the procedure of hepatic segment resection is transection of corresponding segmental branch at the hilum of the liver.


The first step of the procedure of hepatic cone unit resection is transection of some number of tertiary branches selectively through hilum approach or parenchymal approach.


Management of Abdominal Cerebrospinal Pseudocyst in a Hostile Abdomen

Anand Tarpara, MD, PGY-4, General Surgery, Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX


Ventriculoperitoneal shunt placement is a common neurosurgical procedure. Abdominal cerebrospinal pseudocyst is a rare complication of ventriculoperitoneal shunt placement. Management of this complication varies depending on patient presentation. Our purpose for this case presentation is to illustrate a minimally invasive approach to manage abdominal cerebrospinal pseudocyst in a hostile abdomen.



Perform a literature review on abdominal cerebrospinal pseudocyst incidence and review management strategies. Describe our case and our approach to manage abdominal cerebrospinal pseudocyst in a hostile abdomen.

The abdomen was entered with a Hasson trocar at the umbilicus. Intraoperative images were captured highlighting the extent of intraabdominal adhesions. Lysis of adhesions with a harmonic scalpel provided adequate exposure to the right upper quadrant. The pseudocyst was entered with the harmonic scalpel, allowing drainage and successful repositioning of the catheter tip.



A literature review demonstrates an incidence of cerebrospinal abdominal pseudocyst ranging from 0.25% to 10%. Management of the pseudocyst varied based on patient presentation. Management options described included shunt externalization, drainage and repositioning of distal catheter, interventional radiology-guided drainage, and non-operative management.



Surgical management of cerebrospinal abdominal pseudocyst includes image-guided drainage, laparoscopic versus open drainage procedures, as well as shunt externalization. Due to complex surgical history of our patient we describe a successful laparoscopic approach to drain and reposition the distal catheter in a hostile abdomen.


An Anatomic Analysis of Monozygotic Twins:  Direct or Mirrored Concordance of Skin Features, Facial Shape, and Body Asymmetries

David Teplica, MD, MFA, Clinical Associate, Section of Plastic & Reconstructive Surgery University of Chicago, Chicago, IL


Purpose: Although the public and most academicians believe that environment changes anatomy over time, the literature lacks a carefully designed study to assess the impact of environmental influence on anatomic expression. 


Methods: Over the past 28 years, the faces of more than 225 pairs of Monozygotic (MZ) Twins have been analyzed using highly standardized photographs and novel digital mapping strategies. The application of image analysis software allowed visualization and quantification of findings.  Extreme concordance of skin features was identified in the cohort, but mirroring of findings was recognized in a subset of subjects, confounding the analysis.  To cross-check the findings, image-overlay and digital subtraction techniques were devised which established the presence or absence of mirroring of facial shape, which agreed with skin findings in each case and confirmed the diagnosis of concordance or mirrored-concordance in all twin pairs studied.  Inherent lateralization was established and confirmed. Separately, all recognizable skin features on both sides of the faces of both members of twin pairs were tabulated. Handedness was correlated blindly after analysis of anatomic features was complete. Body shape analysis was performed on a separate smaller cohort of MZ twins using standardized frontal torso images and similar digital subtraction techniques.


Results: The Mirror Phenomenon was present in the faces of 64% of male pairs and 23% of female pairs in a subset of 32 pairs with confirmed zygosity and known handedness.  The presence or absence of mirroring of facial shape was identified and agreed in every case with mirrored or direct concordance of skin features. The probability that skin features could align as either concordant or mirrored by random chance varied from p = 0.000267 to p = 2.04 x 10[-9], even though the twins often had very different environmental exposures. Combining the findings in the first two pairs of twins alone (one pair with direct concordance and the second with mirrored agreement), 59 patterns of interest were found among 66 occurrences, giving a p-value of 1.19 x 10[-11].  The chance that these two separate sets of events could happen spontaneously is virtually nil, negating the idea that the environment plays any significant role in the development of skin characteristics.


In addition, skin findings matched the lateralization of asymmetries of body shape in every case studied to date and correlated strongly (p = 0.016) with handedness, suggesting hemispheric brain dominance is lateralized in concert with the superficial structures of ectodermal origin as well as with fat, muscle, and bony anatomy.


Conclusions: Identical twins exhibit direct concordance or anatomic mirroring for nearly all features studied, strongly supporting a new concept of anatomic predetermination. As our data applies to twins of all ages, the timing of anatomic expression must also be genetically based. Human anatomy is inborn spatially and temporally to a level never previously recognized, with little to no evidence that average environmental exposures have any permanent effect on anatomic findings.


... the problem / surgical intervention the presentation covers:

The findings provide a better understanding of 3-dimensional human anatomy


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

Our data has the potential to help understand the spatial orientation of some disease and aging patterns and therefore may inform and improve medical and surgical care in the future.


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

The learner will be better able to visualize anatomy and recognize patterns of bodily findings.


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

The audience will be better able to recognize anatomic entities that are genetically-based and to better inform patients about the inborn nature of anatomy and the lack of evidence that environmental manipulation (e.g. diet, exercise, lotions, and potions) will be able to effect desired change. Unlike trauma or disease, surgery may therefore be the only positive vehicle to effect anatomic alteration.


Management of Stage III Pancreatic Adenocarcinoma with Irreversible Electroporation (IRE) in a Community Setting: Single Center Experience

Thav Thambi-Pillai, MD, Associate Professor of Surgery, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD


The patients with locally advanced pancreatic adenocarcinoma have limited options and the outcomes are poor. Surgery is key component to have a chance at curative option for these patients and in addition it's equally important to obtain clear margins at the time of operative resection.


Irreversible Electroporation (IRE) provides an opportunity for these small minority of patients with borderline resectable pancreatic cancer patients.


I'll be discussing the role and technique of IRE and our limited experience in a community setting.


Management of Low-Grade Gliomas and Insular Tumors

Jose Valerio, MD, MBA, Chair of Neurosurgery, Palmetto General Hospital; CEO Biscayne Plaza Surgical Center, Weston, FL


This presentation explains the different neurosurgical concept to define low-grade gliomas and the clinical sign and symptoms that increase the risk for malignancy. We explain all the different surgical approaches for resection of low-grade gliomas in the insular region, the application of new technology like navigation and the correlation with the vascular components we show different clinical scenarios and we also show the correlation between surgical resection using awake craniotomies vs general anesthesia. In this presentation, we show the surgical anatomical approach based on the anatomical location of the tumor and the possible complication of these approaches.


In conclusion, we show the advantage of using navigation with the integration of the surgical anatomical are the possibility of tumor resection in areas of difficult access with good results, more safety, and accuracy in the tumor resection.


Teaching Basic and Laparoscopic Techniques and Academic Pursuits  in a Teaching Hospital in Sri Lanka

Siva Vithiananthan, MD, Associate Professor of Surgery, Clinician Educator Brown University Alpert Medical School, Chief of Minimally Invasive and Bariatric Surgery - The Miriam Hospital, Providence, RI


Presentation describes effort by Surgeon as an individual and as part of a team, teaching laparoscopy over 2 visits. Teaching house staff and attending surgeons in a region that has suffered from 30 years of civil war In Sri Lanka brings certain challenges and joys. This describes local collaboration and also setting up a program to include many practicing surgeons to help with their MIS techniques .


Ethical Considerations in Plastic Surgery Missions

Thomas D. Willson, MD, UCLA David Geffen School of Medicine, Division of Plastic and Reconstructive Surgery, Section of Craniofacial and Pediatric Plastic Surgery, Los Angeles, CA


Ethical dilemmas are intrinsic to the sporadic practice of surgery in locations where certain treatment options may not otherwise be available. While these dilemmas are unpleasant, they are unavoidable for surgeons choosing to practice in these environments. This talk will attempt to address commonly encountered problems and discuss potential solutions. In particular, will address (1) the need to triage patients and understanding the limits of the practice environment; (2) the limits of informed consent; and (3) ensuring adequate post-operative care and acceptable surgical results.


Spondylectomy for En Bloc Resection of Tumors of the Mobile Spine - Indications and Technique

Jean-Paul Wolinsky, MD, Professor of Neurosurgery and Orthopedic Surgery, Northwestern University, Chicago, IL


The audience will be exposed to the indications for en bloc resection for tumors of the spine. The technique of spondylectomy will be discussed in detail and how to plan such surgeries to achieve the best oncologic outcome.


Clinical Trial of Regenerative Medicine Using Autologous Adipose Derived Stem Cell (ADSC) Cultured by Serum Free Medium

Hisakazu Yamagishi, MD, PhD, Professor, Kyoto Prefectural University of Medicine, Kyoto, Japan


Clinical use of autologous adipose derived stem cells (ADSC) cultured by serum free medium for ALS was performed to five patients.


These ADSC showed cell-surface expression of CD 90, CD105 and CD73 positive, but lack of CD45, CD34, CD14, CD79 and HLA-DR. And these ADSC produced multi cytokines, such as GH, HGF, NGF, G-CSF, GM-CSF and VEGF.  Additionaly these ADSC has trilineage differentiation potential (osteogenic, chondrgenic and adiposogenic ). Five ALS patients has got autologous ADSC transfusion 3times, every two month. Four patients out of five have got good results.


Surgical Outcomes After Anatomical Hepatectomy for Patients with Hepatocellular Carcinoma

Masakazu Yamamoto, MD, PhD, Professor of Surgery, Department of gastroenterology, Tokyo Women's Medical University, Tokyo, Japan


Background: Anatomical hepatectomy is known to be effective treatment in patients with hepatocellular carcinoma (HCC). However, anatomical hepatectomy is classified as one of the high-level HBP surgeries and the 30-day and the 90-day mortality rate in NCD is 2% and 4%, respectively. We evaluated the morbidity and mortality after anatomical hepatectomy for patients with HCC in our institute.


Methods: Between 1968 and 2016, 5053 patients with HCC underwent hepatectomy at our institute. Of those, 1920 patients who underwent anatomical hepatectomy were evaluated. Anatomical hepatectomy is defined as trisectionectomy, right and left hepatectomy, and sectionectomy. Glissonean pedicle approach was introduced for anatomical hepatectomy since 1985. The morbidity and mortality were evaluated every 5 years.


Results: The mean ICGR15 did not differ among groups. The median operation time did not differ among groups. The median blood loss was decreased recently (Group’85-‘89: 1.8L, ‘90-‘94: 1.4L, ‘95-‘99: 1.4L,’00-‘04: 1L, ‘05-‘09: 0.9L, ‘10-‘14: 0.7L). The morbidity rate was decreased (Group’85-‘89: 39%, ‘90-‘94: 24%, ‘95-‘99: 30%, ’00-‘04: 20%, ‘05-‘09: 23%, ‘10-‘14: 14%). The mortality rate was decreased (Group’85-‘89: 5%, ‘90-‘94: 3%, ‘95-‘99: 2%, ’00-‘04: 1%, ‘05-‘09: 0.5%, ‘10-‘14: 0.5%).  Long-term surgical outcomes (5 year survival rate) has been improved (Group’85-‘89: 43%, ‘90-‘94: 55%, ‘95-‘99: 64%, ’00-‘04: 64%, ‘05-‘09: 60%, ‘10-‘14: 76%), and recent 5 years survival rate was better than the national record (5 year survival rate 57%) by Liver Cancer Study Group of Japan.


Conclusion: The short-term outcomes after anatomical hepatectomy for patients with HCC have improved every 5 years. The long-term survival rates are considered to be improving owing to better short-term outcomes after surgery.


Applicability of Buccal Fat Pad Grafting for Oral Reconstruction

Aya Yoshino, DDS, PhD, Assistant professor, Shimane University, Izumo, Japan


Introduction: Pedicled buccal fat pad (BFP) fills an anatomical gap consisted of the buccinator muscle, the masseter muscle, and the ramus of the mandible. It has a sufficient blood supply from the surrounding arteries. We have been using BFP grafting for oral defects induced by ablative surgery for a tumor, an ankylosis of the temporomandibular joint and so on. This study sought to evaluate the applicability of pedicled BFP grafting with a higher number of cases than our previous report in 2015.


Methods: We retrospectively evaluated 67 graftings of 66 cases (34 men, 33women; mean age, 71.7 years). They received pedicled BFP grafting 10 year 4 month-period from June 2007 to September 2017 in our department. The grafts were applied for the defects of the palate (n= 10), the upper gingiva (n=17), the buccal mucosa (n=11), the lower gingiva (n=22), the oral floor (n=1), maxillary sinus mucosa (n=1), the temporomandibular joint (n=1), the coronoid process of mandible (n=1), and the mandibular bone defect induced by a gap arthroplasty of the mandible (n=3).  Besides, by means of gene expression microarray analysis, we have investigated genes which are potential targets for epithelialization of BFP.


Results: Complete epithelialization of the BFP occurred within 4 weeks in most of the graftings. Four weeks post-operation, no complications occurred in most of the graftings.


Conclusion:  BFP grafting appears to be feasible for the reconstruction of surgical defects in the oral region.