International College of Surgeons - United States Section
78th Annual Surgical Update - Somerset Inn, Troy, Michigan
June 16-18, 2016

Abstracts and Presentation Descriptions

Left Atrial Appendage Rupture Due to Blunt Trauma
Hassan Ahmed, MD, FICS, Chief Resident, Texas Tech University Health Sciences Center, Lubbock, TX

Purpose: Cardiac rupture secondary to blunt trauma is associated with high mortality rate. Patients that survive often have a delay in diagnosis due to distracting, non-cardiac injuries.  Herein we describe a 38 year-old man who was involved in a motorcycle collision which resulted in left atrial rupture and subsequent cardiac tamponade.

Case Report: 38 year-old motorcycle rider crashed into a truck and then presented to our Level 1 Trauma Bay with hypotension and hemodynamic instability. Noteworthy was a severe deformity of his left thigh. Extended Focused Assessment of Sonography in Trauma (eFAST) revealed fluid around the heart consistent with hemopericardium. Blood pressures responded favorably to volume resuscitation, and he was taken to the operating room. Sub-xiphoid pericardiotomy was made with return of frank blood.  Median sternotomy revealed rapid bleeding, which was controlled with manual pressure on the left atrial appendage. A vascular load staple was fired across the appendage with cessation of all bleeding. The staple line was reinforced with a pledgeted 5-0 Prolene suture.

Results: The patient was discharged on hospital day 7 after repair of his femur.  He progressively recovered, and during his last clinic visit the patient mentioned that he was going to buy a new motorcycle.

Conclusions: Several forces may perpetuate blunt cardiac injury including shearing from rapid deceleration and compression of the heart between the spine and sternum.  6-10% of patients who suffer blunt chest injury also have cardiac rupture.

The case herein underscores the importance of rapid identification of this patient’s blunt traumatic cardiac rupture, enabled by expert use of the eFAST. It is also crucial to avoid inordinate attention to deformed extremity fractures. High index of suspicion and prompt identification using eFAST are key components of this patient’s successful outcome.

Coil Embolization Of Bleeding Ileal Conduit Varices
Hassan Ahmed, MD, FICS, Surgery Resident, Texas Tech University Health Sciences Center, Lubbock TX

Ileal conduit stomal varices are rare and prone to significant, life threatening bleeding. There is no established standard treatment modality to mange this condition. Varices are a common complication of liver cirrhosis with portal hypertension. Typically, they are found in the gastro-esophageal region. Peristomal varices represent ectopic portosystemic shunts due to portal hypertension. Ectopic bypasses such as stomal varices cause only 1-5% of all variceal bleeding episodes. The site of bleeding is usually located at the vulnerable mucocutaneous junction of the stoma, between the high-pressure portal system and the low-pressure systemic venous system. Since the first report of peristomal hemorrhage in 1968, different therapies such as sclerotherapy, embolization, transjugular intrahepatic portocaval shunt (TIPS), or liver transplantation has been used to treat and prevent variceal bleeding. The scarce case reports in the literature of patients with ureteroileal conduit, liver cirrhosis and ectopic variceal bleeding unanimously recommend TIPS to prevent further bleeding. However, portocaval shunting reduces the hepatic clearance of ammonia leading to hepatic encephalopathy with neurocognitive impairment, stupor, and coma in extreme cases. To our knowledge there is only one case reported with percutaneous transhepatic endovascular embolization (PTEE) without the use of TIPS.

Case report with literature review. We present the case of a 55-year-old woman with copious, recurrent ileal conduit bleeding from stomal varices. Bleeding was successfully managed by PTEE. In view of absence of clinically significant other varices or ascites, attempts were made to visualize the peristomal varices with an 8-12 MHz linear array ultradsound probe Even though the presence of varices around the stoma where established they were not accessible for cannulation. A percutaneous transhepatic access to the right porta hepatis using AccuStick Kit was obtained. This led access to the portal vein and from there to the superior mesenteric vein. Venography confirmed the position of the varices, which then were coil embolized successfully using Tornado coils time 6.

After the successful coil emboiization, she was observed post procedure in the hospital for 2 days, did not require additional blood transfusion. She was discharged from the hospital in much better condition. The patient did not have further bleeding or ischemic complications and has been event free for the last 4 months.

Although rare, when a patient with ileal conduit stoma, hepatic dysfunction, and recurrent episodes of “macrohaematuria”�, bleeding peristomal varices should be considered. Percutaneous transhepatic endovascular embolization is a reasonably good approach.

Primary CNS Lymphoma: Analysis Of Treatment By Gamma- Knife Radiosurgery And Chemotherapy In A Prospective, Observational Study
Andres M. Alvarez-Pinzon, MD, MSc, , Clinical Research Fellow, Neurological Surgery Department, Miami Neuroscience Center, Larkin Community Hospital, Plantation, FL

AANOS Scholarship Honorable Mention

Background: Primary central nervous system lymphomas (PCNSL) include 4% of all primary brain-tumors. The dilemma posed by PCNSL treatment is the choice between strategies designed to intensify therapy and strategies to avoid neurotoxicity. The replacement of radiotherapy with other treatment modalities is an alternative approach that has also been well studied. This is a clinical study reporting the Gamma knife radiosurgery-(GKRS) experience in patients with Primary CNS lymphoma.

Methods:  Prospective, observational study evaluating the radio-surgical treatment of PCNSL. Strict inclusion and exclusion criteria were employed. Primary outcomes were the presence or absence of a lesion in a previously treated zone.  Secondary outcomes were survival rate, patients’ satisfaction and quality of life (QOL). 

Results: Between January 1998 and January 2015 thirty-four patients were treated with doses ranging from 12 Gy to 26 Gy (median:13.8Gy).  Fifty percent isodose line (range:45-85). Treatments in   14 of the 34 patients had failed chemotheraphy prior to GKRS; 4 patients were managed with only biopsy and GKRS. None of the patients showed any deterioration in their QOL related to the treatment and no complications were reported after the procedure. All lesions showed a complete response when evaluated using magnetic resonance imaging 3-8 weeks (mean range 6.3 weeks). Median survival was 46.3months from the initial diagnosis and 42months after GKRS.

Conclusions: The use of GKRS is non-invasive, safe, and shows rapid success, improving the prognosis and QOL of the patient.  This noninvasive treatment modality should be considered as an option for patients with Primary CNS lymphoma.

Surgical Mission Surprises - Honduras 2015
Domingo Alvear, MD, FICS, Pediatric Surgeon, Pinnacle Health System, Harrisburg, PA

When participating in surgical missions in Low Income Countries,we are confronted wilth difficult problems that require quick solutions in the absence of imaging studies that we are familiar with to make the correct decisions. The conditions we encounter during the surgical procedure itself is less than ideal but to save a life you have to use what is available at your disposal. In this paper I will be presenting 5 cases for discussion. Audience participation is essential. 1. One day old infant female born at home presents with respiratory distress,abdominal distension,unable to feed,short right arm,small omphalocele,and no visible anus. What to do? 2. Three day old male with bilious vomiting and abdominal distension. Plain radiograph shows a high intestinal obstruction,no contrast study available. What to do? 3. 6 year old male with lye burn of the esophagus,has a esophagostomy and gastrostomy. What are the options to replace the esophagus? 4. 13 year old male who presented with vominting and abdominal pain. C.T. Scan shows blockage of the 3rd and 4th portion of the duodenum. What to do? 5. 11 year old girl with a massive tumor of the right arm. Disarticulation vs. preservation?

Obstruction From A Meckel's Diverticulum - 35 Years Experience
Domingo Alvear, MD, FICS, Pediatric Surgeon,Pinnacle Health System, Harrisburg, PA

 Meckel's Diverticulum is found in 2% of the population worldwide. Symptomatic cases can occur in 5% lifetime occurence. Complications include hemorrhage in 32%,obstruction in 30%,diverticulitis in 22%,umbilical lessions in 10% and miscellaneous in 6%. Our experience in the last 35 years will review obstructions from a Meckel's Diverticulum which includes intussusception (inverted Meckel's) prenatally to 16 years of age,umbilico-ileal ban or meso-diverticular band causing volvulos,or from diverticulitis, or in a subtle omphalocele. Cases will be discussed including pre-op findings,testing,etc.,surgical findings and results

CT Guided Placement of high Activity, Low Dose Rate (HALDR) Brachytherpay Seeds
Hassan Anbari, MD, Radiology Resident, Providence Hospital, Southfield, MI

Pancreatic cancer is expected to be the second deadliest malignancy. The majority of patients present with metastatic disease, only 15-20% are surgically resectable. Of those who undergo surgery, greater than 80% suffer disease relapse. The median survival for untreated advanced disease is approximately 3 and 1/2 months. Following treatment this increases to 6 months. Brachytherapy for advanced pancreatic cancer is described in the literature by placing isotopes directly into tumors at the time of surgery or through laparoscope. With image guided needle based therapies becoming commonplace in interventional radiology practices, High Activity, Low Dose Rate (HALDR) Brachytherapy is another option. We employed such therapy as palliative measure for heavily pretreated patients with high grade, recurrent solid tumors with good clinical and radiographic follow up results. We treated two patients with HALDR brachytherapy. The first patient is a 66 year old male with prostate cancer with metastatic disease in the tail of the pancreas. At time of diagnosis, PET/CT imaging revealed FDG-avid disease with an SUV of 10.5. Following insertion of radioactive seeds, one year follow up exam demonstrated no FDG-avid disease. The integration of EBRT following brachytherapy with incorporation of the implant dose into the external beam IMRT calculation is another possible synergistic approach described by Soto et al. Brachytherapy also reduces the risk of malignant cells to proliferate between EBRT treatments, which help maintain local control. HALDR brachytherapy is minimally invasive with a nominal side effect profile. The procedure employs CT or ultrasound guidance to deliver radioactive pellets through small gauge needles. The treatment is performed in an outpatient setting and requires less visits compared to EBRT. The procedure is generally well tolerated and is accessible to appropriate patients in need

Yttrium-90 Radioembolization For Non-Resectable Primary And Metastatic Liver Cancer
Hassan Anbari, MD, Radiology Resident at Providence Hospital, Southfield, MI

Radioembolization is a minimally invasive procedure that combines embolization and radiation therapy to treat liver cancer. Tiny glass or resin micro beads filled with radioactive isotope yttrium (Y-90) are placed inside the blood vessels that feed a tumor. This blocks the supply of blood to the cancer cells and delivers a high dose radiation to the tumor while sparing healthy liver parenchyma due to its preferential blood supply from portal venous blood. This technique has proven useful for the majority of patients with HCC as most of them present in advanced stage, beyond potentially curative options, and unresectable metastatic colorectal cancer. The technique has also shown effective in terms of extending time to progression of disease and also providing survival benefits. The published experience with radioembolization for the treatment of cholangiocarcinoma is narrow. A systematic review and pooled analysis by Al-Adra et al. showed a median survival of 15.5 months from the initiation of Y-90 microsphere therapy for unresectable ICC. The study has also showed surgical benefits for previously inoperable disease occurred in seven patients in three different studies. In 2015, after fierce process of approvals that lasted for two years, we incorporated this method to treat four patients. Two presented with unresectable HCC, and the other two with metastatic CRC, and inoperable ICC. The process involved a multidisciplinary team of IR, Rad-Onc., Surgery, Oncology, anesthesiologists, and radiation physicist. Coordination and timing are so crucial to insure that the precise dose is on hand, and the sophisticated delivery system is functional. Although it is not a cure, Y-90 radioembolization can shrink liver tumors, relieve painful symptoms, improve the quality of life, and extend survival. It has been done in our hospital as an outpatient procedure with promising outcome.

Morbidity and Mortality in Adults Undergoing Resection of  Supratentorial Meningioma
Ahmed Awad, MD, Post-doc Research Associate, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY

AANOS Scholarship Grand Prize Winner

Introduction: Meningioma is the most common benign brain tumor. In this study, we focus on the morbidity and mortality associated with supratentorial meningioma surgeries in adults.

Methods: A retrospective study of a prospectively collected data utilizing the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database. Inclusion criteria were adult patients (= 18 years) who underwent resection of supratentorial meningioma between years 2005 to 2012.

Results: A total of 1,568 patients were identified. The morbidity and mortality rates were 21.2% and 1.7%, respectively. The most common morbidity complications were; peri-operative blood transfusion (POBT), on ventilator >2 days, urinary tract infections (UTIs), DVT/thrombophlebitis, stroke/CVA, unplanned intubation, pulmonary embolism (PE), sepsis, and wound complications. Cardioplumonary and CNS complications, UTIs, POBT, DVT/PE and sepsis were all significant (P<0.05) predictors of mortality. On the other hand, return to OR, extended hospital stay (>30 days), unplanned reoperations and admissions were all significant (P<0.0001) predictors of morbidity. On multivariate analysis, age (>50 years), functional status prior to surgery, were all significant (P<0.05) predictors of both morbidity and mortality. In addition, pulmonary and renal comorbidities, recent weight loss, pre-operative blood transfusion, and operative time >4 hours were significantly (P<0.05) associated with high risk of morbidity.

Conclusions: Meningioma resection is associated with relatively high risks of morbidity and mortality. Patients >50 years should be given special consideration. Maintaining operative time <4 hours and decreasing pre-operative blood transfusion may decrease the risk of morbidity.

Minimizing Ionizing Radiation in Pediatric Emergency Department Patients with Suspected Appendicitis
Liisa Bergmann, MD, Radiology Resident, PGY-3 / R2, Royal Oak, MI

Mounting evidence suggests that the ionizing radiation associated with computed tomography (CT) in pediatric patients is also associated with long-term negative health sequelae.  Our immediate purpose is to evaluate changes in ordering frequency of ultrasonographic examination (US) and CT in pediatric emergency department (PED) patients with suspected appendicitis in a community setting.  This is within the context of the long-term goal of attaining ionizing radiation “as low as reasonably achievable.”� (ALARA)

Retrospective review of all PED patients who underwent abdominal US and/or CT Abdomen / Pelvis (CTAP) was performed.  Charts were reviewed for one year prior to and one year following the implementation of an electronic medical record (EMR) prompt reminding physicians ordering CT Abdomen / Pelvis in PED patients with suspected appendicitis to first order US.  Multivariate regression analysis was performed.

Preliminary results suggest that although the likelihood a US examination would be performed on a PED patient with suspected appendicitis increased to nearly 100% after the implementation of the EMR prompt, CT was also ordered for nearly all patients.

It is well known that US is highly user dependent and the appendix is frequently not visualized on US examination.  Our data suggest that US examination alone does not preclude the need for additional information for diagnosis, nor does US examination significantly reduce ionizing radiation exposure in PED patients with suspected appendicitis.   Our findings support development of a standardized physical exam protocol developed and accepted by surgeons and emergency physicians in order to achieve ionizing radiation ALARA.

Stent-Retriever Endovascular Treatment of Ischemic Stroke
W. Craig Clark, MD, PhD, FICS, AANOS Interim Chairman, Attending Neurosurgeon, Greenwood-Leflore Hospital, Greenwood, MS

The results of the MR CLEAN trial completed in the Netherlands showed reduced disability among patients with ischemic stroke who were treated with endovascular thrombectomy in addition to the standard TPA. Previous studies had failed to show any significant benefit of the addition of endovascular therapy. Potential reasons for this futility include relatively low rates of demonstrated angiographic reperfusion, delays in achieving reperfusion and the lack of patient selection using advanced imaging techniques to demonstrate vessel occlusion and salvageable brain tissue. Advances in the device technology improved the speed and efficacy of recanalization, and CT perfusion imaging could show the extent of irreversibly injured brain in the ischemic core and hypoperfused but potentially salvageable ischemic penumbra. Furthermore, CT perfusion imaging has now evolved, allowing fully automated, standardized volumetric processing to be achieved in the context of routine clinical practice. This then set into motion a series of clinical trials occurring simultaneously in the U.S., Australia and Europe that were reported simultaneously. This presentation will present the results of the MR CLEAN, EXTEND-1A and SWIFT-PRIME trials along with the implications this information may have for clinicians managing ischemic stroke.

Minimally Invasive Surgical(MIS) Techniques for the Management of Spinal Metastases
W. Craig Clark, MD, PhD, FICS, AANOS Interim Chairman, Attending Neurosurgeon, Greenwood-Leflore Hospital, Greenwood, MS

Metastatic disease to the spine is an increasingly common clinical condition given improved cancer care and overall mortality trends. The majority of patients who die of cancer have vertebral metastases at autopsy. An estimated 20,000 patients per year in the United States have symptomatic epidural spinal cord compression and a much greater number have symptomatic vertebral metastases. The clinical burden in other areas of the world is likely similar. The major indications for surgery in these patients is usually related to either spinal instability or progressive neurological deficits. Rarely is surgical resection for cure a viable option, with most procedures carried out with palliation in mind. These patients are usually already weakened and/or immunocompromised as a result of chemotherapy or radiotherapy.

Open surgical treatment has a well- established track record in the treatment of these patients. More recent advancements in surgical technique, instrumentation and imaging modalities have evolved into minimally invasive surgical (MIS) techniques that have now been adapted to the treatment of metastatic disease to the spine. It is felt that the use of MIS may minimize the overall degree of physiological insult to the already compromised patients, and may allow quicker adjuvant chemotherapy or radiotherapy than would have otherwise been possible with the more established open procedures. The current study reviews the techniques currently used in MIS of metastatic disease to the spine, and attempts to delineate the more appropriate (or inappropriate) application of these techniques.

Management of Newer Anticoagulants for the Surgeon
Edward Danielle, MD, PhD, FICS, Resident, Texas Tech University Health Sciences Center, Lubbock, TX

Purpose: Surgeons are increasingly challenged by patients taking non-Vitamin K antagonist anticoagulants for cardiac arrhythmias and thromboembolism prevention. These newer oral anticoagulants consist of Factor Xa inhibitors and direct thrombin inhibitors. Compared to Warfarin, these medications decrease risk for stroke, embolism, hemorrhagic stroke, major bleeding, and death. Unfortunately, these newer agents often have no antidote, sometimes posing significant threat to the patient. Herein we summarize anticoagulant medications and their mechanisms, antidotes and duration of action.

Methods: Three major trials have prompted increased use of the newer anticoagulants, including the ARISTOTLE trial, the RE-LY trial, and the ROCKET-AF trial. Herein we review these studies and their application to the surgical patient.

Results: Regardless of the class of anticoagulant, the first step is to stop the medication immediately. For patients who have ingested the anticoagulant within the previous two hours, the next step is activated charcoal. The third step depends upon the drug consumed.  If the patient is taking a direct thrombin inhibitor, 1g of tranexamic acid (TXA) may be given. Additionally, the patient should be aggressively hydrated since only 35% is protein bound and the drug is excreted primarily through the kidneys.  Hemodialysis may be performed.  In the setting of unstable hemorrhage, FEIBA (Factor 8 inhibitor bypass activity) may be given. FEIBA is the only clinically approved activated PCC (prothrombin complex concentrate).

Patients on Rivaroxaban should receive 4-Factor PCC. If refractory bleeding persists, FEIBA may be used.  A similar protocol can be followed if the patient ingested a factor Xa inhibitor.

Conclusions: The number of patients taking new anticoagulants will continue to increase.  The surgeon's knowledge of mechanism, duration of action and reversal strategies are crucial for successful treatment.

Vaccinations for Health Care Professionals
Vilma Drelichman, MD, FACP, FIDSA, Clinical Professor Wayne State University, Detroit, Michigan, Southfield, MI

Healthcare workers are at increased risk of contracting infections at work, and further transmit them to colleagues and patients.

The audience needs to know that protecting themselves act as a barrier against the spread of infections and maintain healthcare delivery during outbreaks.

The audience will learn why mandatory vaccination policies are occasionally implemented by healthcare authorities and how to implement such policies.

The audience will learn the importance of HCW vaccination, in particular those working with high risk individuals.

Impact of Medical or Surgical Admission on Outcomes of Patients with Acute Cholecystitis: A Multivariate Regression Model
Joseph Eid, MD, General Surgery resident, Providence Hospital and Medical Center, Michigan, Southfield, MI

PURPOSE:  Acute cholecystitis (AC) is a surgical disease. Nevertheless, these patients are often admitted to the medical service. This may lead to delay in surgery, which may affect outcomes.

METHODS: Between July 2010 and March 2013, 329 consecutive patients younger than 70 years old presented to a community-based academic tertiary care hospital with AC. Primary outcomes included hospital length of stay (LOS), time to cholecystectomy, hospital costs, readmission and mortality rates.

RESULTS: Two hundred fifteen patients (65.3%) were admitted to the medical service during the study period. Patients admitted to the surgical service were significantly younger (41.5 years ± 12.9 vs. 47.9 years ±13.1, p<0.001). On multivariate logistic regression analysis controlling for patient’s characteristics, the patients under the medical service had longer LOS (4.4 days ± 3.7 vs. 2.9 days ± 2.1, p=0.03), waiting time to cholecystectomy (1.8 days ± 2.6 vs. 0.86 days ± 1.1, p=0.007) and increased hospital costs ($5654.79 ± $3282.28 vs. $4323.53 ± $2498.64, p=0.03) as compared to surgical group. Readmission and mortality rates were not significantly different between groups.

CONCLUSIONS: Patients younger than 70 years old with AC undergoing cholecystectomy admitted to a medical service had a longer time to operation, LOS and increased hospital costs compared to those admitted to a surgical service. Admission to a surgical service for patients with a surgical diagnosis needs to emphasized to reduced cost and improved quality.

Intrauterine Cleaning After Placental Delivery At Cesarean Section: A Randomized Controlled Trial
Ahizechukwu Eke, MD, MPH, FICS, PGY4 Obstetrics & Gynecology Resident, Clinical Instructor, Michigan State University, Lansing, MI

To test the hypothesis that omission of intrauterine cleaning during cesarean sections does not increase intraoperative and postoperative complications

We randomized 206 women undergoing primary elective cesarean deliveries to cleaning (103 women) or omission of cleaning (103 women) of the uterine cavity after placental delivery. Spontaneous rupture of membranes prior to cesarean section, chorioamnionitis, poorly controlled diabetes mellitus, patients on chronic steroid therapy and patients with immunosuppressive disorders were excluded. Primary outcome measure was postpartum endomyometritis. Secondary outcomes were postpartum hemorrhage, mean surgical time, retained products of conception, quantitative blood loss, length of hospital stay, return of gastrointestinal function, repeat surgery and hospital readmission rates. Analysis followed the intention-to-treat principle.

There were no statistically significant differences in the rate of endomyometritis between those who received intrauterine cleaning and those who did not (2.0 vs. 2.9%; RR = 0.60; 95% CI 0.40-1.32). No retained products of conception occurred in either group, and there were no statistically significant differences in postpartum hemorrhage (5.8% vs 7.7%, RR 0.75, 95% CI 0.6-1.2), hospital readmission rates (2.9% vs 3.8%, RR 0.75, 95% CI 0.8-1.5), mean surgical time, hospital length of stay, return of gastrointestinal function, repeat surgery, and quantitative blood loss between both groups.

Our randomized controlled trial provides evidence suggesting that in women at low risk for infection, omission of intrauterine cleaning during cesarean deliveries does not increase intraoperative or postoperative complications.

Updates in the Current Management of Stroke
Richard Fessler, MD, Chairman, Department of Surgery, St. John Hospital & Medical Centers
Medical Director, Ascension of Michigan Telemedicine Oversight Committee, Detroit, MI

Stroke is the fourth leading cause of death and the number one cause of adult disability in North America.  In-hospital and peri-procedural stroke is a common occurence. Up to 40% or more of in-hospital strokes may occur in patients on surgical or other procedural services. 

Delivery of care for victims of stroke is time dependent.  Thus, it is important that the practicing surgeon or proceduralist recognize signs of stroke and be aware of new modalities for the potential treatment of patients suffering an in-hospital ischemic event. 

After participating, the audience will: 

1) be able to discuss the latest interventional treatment techniques for acute stroke;
2)  learn the most common causes of acute stroke;
3) generate a potential differential diagnosis for peri-procedural stroke;
4) be able to discuss the recent major studies regarding acute stroke treatment;
5) recognize their local resources for management of acute stroke.

Complex Hepatobiliary and Pancreas Surgery in a Minimally Invasive Era
Michael Jacobs, MD, FICS, Associate Chair of Surgery, HPB Program and HPB Surgery Fellowship Director
St. John Providence and Providence Park Hospitals, Southfield and Novi, MI

Aim:  To provide knowledge and innovative technical exposure based on 15-years of experience in the field of HPB Surgery through video-based education.

Background:   Hepatobiliary and pancreas surgery involves complex learning curves.  Traditionally, an open technique was used, but laparoscopic HPB surgery is gaining wider acceptance.   Complex laparoscopic  HPB surgery provides all of the advantages of laparoscopic techniques without compromising the outcome.  This lecture reviews the indications, contraindications, and technical approach through a video-based education format, enabling the viewer an opportunity to understand the various technical pearls and pitfalls.

Materials and Methods:  The cases presented will demonstrate the laparoscopic approach to common HPB problems based upon the authors experience.  Clinical vignettes will be used to review pertinent data that focus on anatomic approximation of relevant structures and suitability for a laparoscopic approach. 

Results:    The technical video demonstrates the totally laparoscopic complex HPB Surgery.  Selected highlighted procedures, pearls, and pitfalls are reviewed.  The postoperative outcomes  will be reviewed.

Conclusion:   Totally laparoscopic HPB surgery is technically feasible and affords the patient all of the benefits of laparoscopic surgery without compromising the outcome.

Efficacy and Cost Effectiveness of Iliac Stenting in the Operating Room and Cath Lab
Sooyeon Kim, BS, Medical Student, University of Kentucky, Lexington, KY

Iliac arterial stenting is routinely performed both in the operating room (OR) and in the catheterization lab (CL). To date, no analysis has been conducted to compare efficacy and resource utilization between these locations.

Consecutive patients (N=105) treated between 2006 and 2013 at a single center were retrospectively analyzed. Patients included adults with chronic, symptomatic iliac artery stenosis with a minimum Rutherford Score (RS) of 3. Patients were treated with stents of the unilateral or bilateral external iliac, internal iliac, or aortoiliac arteries. Exclusion criteria were prior stenting, acute ischemic presentation, or major concomitant procedures. Patient demographics, procedure details, hospital course, physician billings, and actual procedure room and total costs were recorded, the latter from the hospital cost accounting system. All variables were compared by procedure location. Multivariable regression was used to adjust costs by demographic and perioperative cost drivers. Immediate outcomes included technical success, length of stay, same-stay reintervention, and major complications. Two-year outcomes included reintervention, death, or loss to follow-up.

Fifty-one procedures (49%) were performed in the OR and 54 (51%) in the CL. Mean age was 57 and 44% were female. Diabetes (DM) was more prevalent in OR patients (49 vs. 26%, p=0.016), and hyperlipidemia (HLD) in CL patients (80 vs. 57%, p=0.020). DM and elevated creatinine were associated with increased total costs; HLD with increased procedure room costs. Severe cases (RS = 4) were more often performed in the OR (42 vs. 11%, p<0.001) and were associated with increased total costs (p<0.01). OR procedures more often utilized additional stents (stents = 2; 61 vs. 46%, p=0.214), thrombolysis (12 vs. 0%, p=0.011), cut-down approach (8 vs. 0%, p=0.052), and endotracheal anesthesia (80 vs. 0%, p<0.001): these were all associated with increased costs (p<0.05). There was no difference in procedure room costs (OR median $7,700 vs. $8,300, p=0.445) but OR procedures were associated with increased total hospital costs (OR median $13,500 vs $9,100, p<0.001). OR procedures also resulted in increased hospital length of stay (LOS > 1 day; 41% vs. 17%, p<0.01) and more often required admission to the ICU (37 vs. 2%, p<0.001). Subsequent multivariable regression revealed that OR location was not a predictor of either procedure room or total costs, but was associated with increased professional fees (exponentiated coefficient for log-transformed procedure room costs 0.95, 95% CI 0.89-1.02; total costs 1.09, 95% CI 0.98-1.21; physician billings 1.31, 95% CI 1.13-1.51). Same-stay reintervention (4.8%) and reintervention after discharge (33%, median follow-up 13 mos.) did not vary by location.

Stenting performed in the OR resulted in increased LOS, more frequent ICU admission, and ultimately increased total costs. However, patients brought to the OR had more severe disease at presentation and therefore often required more aggressive intervention. After controlling for these differences, procedure venue per se was not associated with increased costs but the OR was associated with increased professional fees. Given the similar outcomes between venues, it would therefore seem reasonable to perform most stenting in the CL, while judiciously sparing the OR for more severe cases.

Treatment Of Large Acoustic Neuromas
Michael LaRouere, MD, President, Michigan Ear Institute, Director of Neurosciences, Providence Hospital and Medical Center, Clinical Associate Professor, Wayne State University,
Clinical Professor, Michigan State University, Clinical Professor William Beaumont/Oakland University, Farmington Hills, MI

The treatment of large acoustic tumors is very challenging. Preservation of facial nerve function in tumors measuring 3 cm or greater has averaged 49% following surgical removal over the past few decades. Utilizing a staged approach to tumor removal has resulted in a 79% chance at good facial nerve function  postoperatively. A retrospectiver eview of 2875 acoustic neuroma patients over a 10 year period was undertaken. One hundred fifty three large (>3cm) AN patients who were operated upon were identified.Staged surgical patients were compared to those undergoing single stage surgery with or without adjuvant stereotactic radiosurgery with respect to post treatment facial nerve function. Eighty one percent of patients in the staged surgical resection group had HB grade I-II facial functioncompaired with 75% in the single stage group Overall 79% of patients had good (HB I-II) facial function compaired to those studies in the literature showing 49% good facial function following resection of AN tumors over 3 cm. The audience will learn our  methods, including staged resection, the use of facial nerve monitoring and a team approach to skull base surgery which have led to improved outcomes with these challanging cases.

Iatrogenic Brachial Plexus Injury Secondary to Inappropriate Positioning Among Adults
Rana Latif, MD, FCAI, FICS, Associate Prof., Dept of Anesthesiology & Perioperative Medicine, Anesthesiology and Neuroscience Critical Care, University of Louisville, Louisville, KY

The prevalence of iatrogenic brachial plexus injury (BPI) has been estimated at 0.02-0.06%, represents 23% of nerve injuries claims but 35% received substandard care. The BPI is caused by stretching and compression of nerve leading to ischemia of the nerve adding postoperative morbidity. The positioning of the patient in the operating room can be divided into four stages with different physician responsible for correct position. These stages are (1) preoperative: anesthesiologist; (2) intraoperative: surgeon; (3) intraoperative change of positioning: surgeon and (4) postoperative: anesthesiologist. A team approached is required with respect to positioning of these patients. The first step is to identify the high risk patients for BPI preoperatively. These include patients with diabetes mellitus, hypertension, pre-existing neuropathy, peripheral vascular disease, obesity, arthritis, smoking with COPD, cervical rib, deformity of the shoulder region (e.g. post trauma) and anomalous origin of brachial plexus. Intraoperative causes included prolonged operating time, median sternotomy, hypothermia and hypotension. The certain positioning can increase the risk of BPI including excessive abduction of the arm (> 90?), steep Trendelenburg with shoulder braces, external rotation of the arm, excessive rotation of the head and dorsal extension at shoulder.  The surgical units should develop written positioning standard, communicate them to different specialties, professionals and staff. They should have sufficient padding and positioning materials for surgeries. It is important to document that during the surgery, the positioning standard were maintained. If BPI occurs, determine the extent of injury with sensory and motor deficit. Develop plan of care with involvement of patient, patients’ family, neurologist and physiotherapist. The patient should be followed up with documentation of neurological recovery. Fortunately, in most of the cases, the recovery is complete.

Minimally Invasive Outpatient Treatment of Degenerative Spine Pathology
Miguel Lis-Planells, M.D., Neurosurgeon, The Bonati Spine Institute, Hudson, FL

The Bonati Spine Institute in Hudson, Florida has been a center of excellence in the growing field of outpatient minimally invasive spine surgery for over 20 years, pioneered by its founder Dr. Alfred Bonati. This vast experience allows us to offer our patients a success rate of over 95%, measured as significant reduction or elimination of pain, with a complication rate of less than 1% for the treatment of a large variety of pathology affecting the spine.  Collectively, our techniques have been known as the Bonati Procedures.

In our presentation, The Bonati Procedures for the outpatient treatment of spinal pathology using minimally invasive surgical techniques will be discussed, which include the following aspects:

- Careful patient selection.
- Customized surgical plan specifically designed for each patient.
- Meticulous, state of the art, minimally invasive surgical procedures that involve the use of patented instruments, surgical and anesthesia techniques that have been developed at our Institute.
- Methodic perioperative care provided to our patients, ensuring an optimal surgical outcome.

An overview of the main indications and contra-indications for the application of the Bonati  Procedures will be presented.  Illustrative cases of patients treated at the Institute will be discussed and surgical outcomes will be shown, including early return to work , minimal use of post operative narcotic medication and shortened recovery and return to activities of daily living.

In conclusion, The Bonati Procedures utilize state of the art, minimally invasive patented surgical technology that proves to be safe and effective for the treatment of degenerative spinal pathology in the outpatient setting and offers our patients high surgical success, low post-operative complication rate and improved patient outcomes.

Post-Bariatric Complications
Sharique Nazir, MD, FICS, Surgery Attending, NYU Lutheran Medical Center, New York, NY

Weight loss surgeries  are one of the fastest growing hospital procedures performed in the United States. It is estimated that 220,000 weight-loss surgeries were performed in 2008 .

Complications following surgical treatment of severe obesity vary based upon the procedure performed and can be as high as 40 percent . Due to the high surgical volume, improving the safety of these operations has become a high priority, leading to the development of strict criteria for center accreditation, guidelines for safe and effective bariatric surgery, and careful monitoring of surgical outcome.

Bariatric or metabolic surgery is the only proven long term approach to reduction of obesity comorbidities and significant weight loss. It is however a relatively new branch of surgery one that has complex and variable anatomy that some general surgeons may not be familiar with. The number of bariatric surgeries performed has remained stable yet the incidence of complications is rising due to a rising percentage of the population that are former bariatric patients. The risk of complications does not diminish as the time from the index operation passes and as it becomes more remote the chances that they will present emergently to a non-bariatric center for care of by a general surgeon increases. There is also a rise in surgical tourism for low cost weight loss surgery which can result in visits very soon post operatively and without full knowledge of what was done or the quality of the work. The general surgeon's needs to be familiar with the varied complications of bariatric surgery so that he can triage which patients need urgent intervention  and which patients need referral to a bariatric center. After this presentation the audience will familiar with the common complications of bariatric surgery, how they present, their proper workup and radiological presentation and their common treatments.

The audience should be familiarized so they can diagnose and manage symptoms.

Cutting Seton For High Anal Transsphincteric  Anal  Fistula-Our Experience
Petar Petricevic, MD. PhD, FICS, Consultant Colon and Rectal Surgery, Zrenjanin, Serbia

INTRODUCTION: No single procedure for high anal transsphincteric  fistula delivers a high cure rate while also completely protecting sphincter function. Our aim is to present our experience  and results with thightening  ligation of intersphincteric fistula track procedure.

METHODS:  Between 1995 and 2011 year we are operated twenthy patients  with high cryptoglandular fistulae  when more than one-third of the sphincter is involved and we treat these patients  in mayority in nineteen patients with ligation of intersphincteric fistula track (LIFT) or cutting seton.

RESULTS:  In one patient  with recurrence after fistulotomy, which was  first operated on a second surgeon , after our operation (LIFT), we have  had completely healing, but the patient received minor soiling  incontinence. In small number of three femail patients , in two cases we are treated with thightening  cutting  seton (LIFT) procedure and in one femail patient   with fistulae on anterior commissure,  we are treated with primary repair of external sphincter,  and in all three femail cases we are not notice problems with healing, continence and FIQL.  In other 16 male patients  we have had one patient of this 16 patients with  supralevator extension and other one patient had extrasphincteric  fistula secondary to transsphincteric  fistula. In all 16 cases we used  to put thightening cutting seton and  in this group of patients, we have had satisfied healing without recurrence, continence,  patient-perceived overall change in bowel control and FIQL.

SUMMARY: Cutting  seton  for high anal fistula achieved excellent healing, good continence in majority, particularly in males, and high level of patient satisfaction.

The Management Of Patients With Colorectal Cancer And Synchronous Liver Metastasis Or Indeterminate Liver Lesions: A Retrospective Review
Sunu Philip, MD, FICS, General Surgery Resident, Providence Hospital and Medical Centers, Southfield, MI

Between a third to one-half of patients with colorectal cancer develop liver metastases . Approximately 15-25% of these patients present with one or more liver metastases at the time of diagnosis. The management of patients with synchronous colorectal metastases limited to the liver remains controversial with much of thedata published from highly specialized academic centers. We proposed to review the management and outcomes of patients with colorectal cancer and synchronous liver metastases at a community teaching hospital.

In this institutional review board approved retrospective study, the medical records of all patients with a diagnosis of colorectal cancer identified in the cancer registry of the hospital were reviewed. The review was conducted over a five year period from 2008-2013. The study sample included all patients with a primary diagnosis of colorectal cancer and synchronous liver metastases who had undergone a colon or rectal resection. We also reviewed the records of all patients who had an indeterminate lesion noted on preoperative staging and then progressed to have liver metastases on follow up imaging after their colon resection. A total of 811 patients with colon or rectal cancer were entered in the cancer registry over the study period. Ninety patients met the criteria for inclusion in the study. This sample was divided into three subgroups based on the pattern of their liver metastases. Patients with diffuse bi-lobar disease were classified as multiple, those with a finite number of metastatic deposits were classified as discrete. Finally those those patients with indeterminate lesions that progressed to cancer were classified as indeterminate.

Of the 90 patients, 50(55%) had diffuse metastatic disease at diagnosis. Twenty five patients (27%) had discrete lesions and 15 (16%) had indeterminate lesions. Twenty seven patients in the diffuse group had presented with intestinal obstruction and had emergent colon surgery. Only 4 patients in this group were treated with primary chemotherapy. One patient in this group had a resection of hepatic metastases. In the discrete group, the number of liver secondaries ranged between 1 and 4 lesions with a size ranging between 0.9 and 7 cm. Ten of the 25 patients in this group had liver resections of which 4 were done synchronously at the time of their colon surgery. Only two patients in the group with indeterminate lesions had a liver resection. The time to liver resection in those patients who staged procedures ranged from 4 months to two years from their colon surgery. Progression of disease was noted in all patients with diffuse disease on serial imaging and in a large number of patients with discrete and indeterminate lesions who were treated without hepatic resection.

Only a small proportion of patients with synchronous colorectal liver metastases are candidates for a potentially curative resection. In this series only a small proportion of patients with diffuse unresectable metastatic disease were treated with primary chemotherapy.  Patients with localized disease should be evaluated early for synchronous or early staged resection. Patients with suspicious indeterminate lesions may benefit from evaluation of these at the time of their of colon resection or alternatively will need careful followup imaging.

Factors Associated With Treatment Failure After An Index Episode Of Acute Diverticulitis
Sunu Philip, MD, FICS, Resident, General Surgery, Providence Hospital and Medical Centers, Southfield, MI

Recurrence after a first episode of diverticulitis are reported to occur in up to 40% of patients. Sigmoid resection has traditionally been recommended after 2 episodes of uncomplicated diverticulitis. Factors that have been reported as associated with recurrence are a prior history of diverticulitis, abscess and corticosteroid medication use. Recurrence occurs at any time period after successful resolution of the index episode. We have however observed patients who do not completely recover from their index episode. This purpose of this study was to investigate the factors associated with treatment failure after an index episode of acute diverticulitis.

A retrospective review of all patient readmitted to hospital within 120 days of an index episode of Hinchey stage 1 and 2 diverticulitis was conducted over a period from 2008-2014. Demographic data, important co-morbidities, body mass index(BMI) and outcome at most recent available followup were recorded. Data on antibiotic type and duration, percutaneous drainage and progression of disease based on repeat computed tomography (CT) imaging was also recorded on those patients were this data was available. Important inclusion criteria were the presence of an index episode of Hinchey stage 1 or 2 diverticulitis based on CT imaging and a readmission or emergency room visit within a 120 days with repeat CT imaging documenting persistent or progressive disease.

One hundred patients were identified who met criteria for inclusion in the study.  Sixty seven (67%) were female and 33 (33%) were male. The average age of the population was 63 (33-91) with a median of 60 years. Seventy seven patient (77%) had Hinchey stage 1 diverticulitis at their index presentation while 23 (23%) had stage 2 disease with a pericolic abscess. Twelve patients (12%) had been treated with oral antibiotics prior to their presentation to hospital. Fifteen patients (15%)  received  drainage or aspiration of a pericolic abscess during their index admission. The median time to readmission was 30 days (3-120 days). Thirty one patients (31%) were smokers and the median body mass index (BMI) of this sample was 30kg/m2 with an average of 31.2kg/m2. Sixty two patients (62%) had progression of their disease based on repeat imaging. Seventy one (71%) patients  had a sigmoid colectomy in this series.

At least 50% of patients in this series who had persistent diverticulitis after their index admission had a BMI higher than 30kg/m2. In addition over 70% of patients with persistent disease received a sigmoid colon resection. The findings of this study suggest that obesity may be associated with treatment failure after an index episode of uncomplicated diverticulitis and that persistent disease despite adequate medical therapy is associated with the need for eventual sigmoid resection.

The Disturbingly High Cost of Your Career in Surgery:
The Business of Medicine in 2016 from the Perspective of a Tax Attorney, Business Owner, and Doctor Advocate
Victoria Powell, JD, LLM (taxation), Medical Education Speaker's Network:  Victoria J. Powell JD, LL.M LLC, owner;  Powell Heymann LLC, partner, Scottsdale, AZ

Per Becker’s Hospital Review, surgeons occupy fifteen out of the top 25 earning medical specialties, with Orthopedic and Neurosurgeons ranking first and second,  according to Merritt Hawkins’ 2014 Review of Physician and Advanced Practitioner Recruiting Incentives. These statistics rank surgeons among the “top 1%” of all US income earners - a space they share with the wealthiest families in America, but unlike those families (whose money earns money), surgeons earn ordinary income and pay tax at the highest rates. While this income level is a tremendous career accomplishment, not surprisingly, many surgeons do not have sufficient knowledge, experience or skills to understand that they may inadvertently be losing money in not being prepared to fully address practice management issues and risks, especially in a fast-changing financial environment, in overpaying taxes year after year, and in investing in complex retirement or insurance plans, or medical real estate without adequate business analysis tools.  This seminar will help close that educational gap, not only by providing a tax attorney’s perspective on these issues, but also by learning from those that have actually lost money by discussing de-identified client case studies.  Background information on the tax laws, health care law, Treasury regulations, IRS enforcement patterns and case law that govern highly compensated individuals and corporate entities will lay the foundation for the discussion.  Case studies will be presented as ‘what not to do’ examples.  Lastly, ‘what to do’ strategies and tactics will be presented on practice management concepts and coordination of professional service providers, how to use the health care and tax regulations for better results, and  how to control ‘controllable’� risks to help keep more hard earned money, as well as how to recover and improve the surgeon’s autonomy in practice, employment and even, perhaps,  politics.

Management of Inguinal Hernias in Premature Infants - Pre or Post discharge? - What is best?
Farda Qayyum, MD, Surgical Resident, Pinnacle Health System, Harrisburg, PA

Purpose: The purpose of this retrospective study is to determine the optimal management of inguinal hernias in premature infants, including timing of repair as well as type of anesthesia. Premature Infants of both sexes have a higher incidence of inguinal hernia than full term infants. They are being discharge from the hospital as long as they are feeding and have no respiratory issues. Their weight upon discharge has been between 2 to 2.5 kg. We have proven that hernia repair under regional anesthesia (spinal or caudal) is safer than general anesthesia. Infants can be discharged within 24 to 48 hours post operatively. Sending them home post repair will prevent the potential complications of inguinal hernias including incarceration or strangulation and feeding difficulties.

Hypothesis: Premature infants undergoing inguinal hernia repair during initial hospitalization with caudal blocks will have a smaller recurrence rate as well as fewer complications. 

Methods: A retrospective chart analysis will be performed on premature infants who have undergone inguinal hernia repair in a 20-year period at our institution. Hernia repairs at our institution are generally performed during the sentinel hospitalization. An open technique is employed with regional anesthesia (spinal or caudal). Complications including hernia recurrence, wound complications and anesthesia complications will be assessed. We will compare out complication rates with those cited in current literature. 

Results: Current data cites 5% vs 31% recurrence rate in hernias repaired at the initial hospitalization vs. delayed repair. Recurrence rate in our patients is close to zero. Anesthesia complications are cited to be as high as 5-12%. In our patients, we have found no complications with regional anesthesia.

Conclusions: Inguinal hernia repair in premature infants is safe to perform under regional anesthesia. Potential complications can be minimized by operating before discharging the patients home.

Posterior Interosseous Nerve Palsy: Case Report And Review Of Radial Nerve Palsy
Sudhir Rao, MD, Orthopaedic Surgeon, Big Rapids Orthopaedic PC and Premier Hand Center, Big Rapids, MI

Radial and posterior interosseous nerve palsy is the most frequently encountered nerve palsy in the upper limb.  Accidental trauma is the leading cause but iatrogenic injury is not uncommon.  The case illustrates posterior interosseous nerve injury following an orthopaedic procedure.

Neuromuscular anatomy and surgical technique are highlighted to get a better understanding of the challenge at hand.

Various clinical presentations are discussed. Treatment of radial nerve palsy is reviewed

This paper draws attention to a serious and sometimes preventable nerve injury.  The audience will be able to suspect, diagnose and offer treatment guidelines on the basis of this presentation

Clinical Transplantation And Tolerance: Are We There Yet?
Reza Saidi, MD, FICS, Assistant Professor of Surgery, Alpert Medical School of Brown University, Rhode Island Hospital
Department of Surgery, Division of Organ Transplantation, Providence, RI

Organ transplantation is not only considered as the last resort therapy but also as the treatment of choice for many patients with end-stage organ damage. Recipient-mediated acute or chronic immune response is the main challenge after transplant surgery. Nonspecific suppression of host immune system is currently the only method used to prevent organ rejection. Lifelong immunosuppression will cause significant side effects such as infections, malignancies, chronic kidney disease, hypertension and diabetes. This is more relevant in children who have a longer life expectancy so may receive longer period of immunosuppressive medications. Efforts to minimize or complete withdrawal of immunosuppression would improve the quality of life and long-term outcome of pediatric transplant recipients.

Unusual Non-Lung Primary Malignancies Presenting In The Lung Parenchyma
Tracy Sambo, MD, MS, FICS (Jr), Surgical Resident - Presence St. Joseph Hospital, Chicago, IL

Only a small minority of lung cancer patients present with parenchymal malignancies that are not either standard histology lung cancers (i.e., non-small cell/small cell) or metastatic lesions from primary cancers elsewhere in the body.  Surgical practitioners need to be cognizant of these types of neoplasms to provide a thorough and expeditious evaluation of patients with these tumors.  This presentation will illustrate the scenarios in which different types of non-standard primary lung tumors present, thus enabling the learner to recognize the possibility of non-traditional lung cancer during evaluation of a pulmonary mass or infiltrate.  The intended audience will gain a better understanding of the pathophysiology of these disease processes which will translate into more cost effective delivery of care and improvements in patient survival.

Enterobacter Cloacae Sepsis With Multiple Brain Abscesses
Francis Gregory Samonte, MD, Assistant Professor, Neurophysiology, De Lasalle University, Philippines, San Diego, CA

A case of a 30 year male with Enterobacter cloacae diagnosed following a 4 week history of headache, nausea and vomiting. Patient was initially managed conservatively with antibiotic medications for 2 weeks. The patient continued to deteriorate and later presented with dense right sided weakness, which prompted a head CT scan imaging study. Initial interpretation was notable for cerebrovascular insult. However the multiple brain mass was reportedly unequivocal. Following an initial consult with neurologist a brain MRI was obtained which revealed multiple confluent abscesses in the entire cerebral hemisphere. Blood culture grew Enterobacter cloacae (sensitive only to Levofloxacin) and Staph aureus. Patient was managed with intravenous antibiotics, steroids and supportive treatment. He continued to show remarkable improvement until 12 hospital days when he suffered a massive intraparenchymal hemorrhage. Family refused further neurosurgical intervention. Patient expired 3 days later.

Enterobacter is a clinically significant Gram-negative, anaerobic, rod-shaped bacterium. In recent years, E. cloacae has emerged as one of the most commonly found nosocomial pathogen in neonatal units, with several outbreaks of infection being reported (J. Hosp. Infect.70,7-14 (2008). This microorganism may be transmitted to neonates through contaminated intravenous fluids, total parenteral nutrition solutions and medical equipment. However, there has been very few cases (if any) reported of this infection complicating brain abscess in adults.

It is an important case not only because of the rarity of this infection in the setting of brain abscess, but also because the need to further understand and elucidate the possible relationship between this gut flora and the pathogenesis which may have influenced the brain abscesses formation.

Laparoscopic Cholecystectomy in Portal Vein Thrombosis and Cavernous Transformation
Frank P. Schulze, MD, FICS, Surgeon-in-chief, St. Marien-Hospital, ICS European Federation Secretary, ICS Past-President of the German Section
Mülheim an der Ruhr, Germany

Introduction: Laparoscopic cholecystectomy is the Gold-standard in the therapy of symptomatic gallstones. However, in patients with portal vein thrombosis the perioperative risk is significantly increased and a cavernous transformation is a special challenge for the performing surgeon. Only few cases have been reported.

Methods: A 51 year old male patient suffered for more than 8 years from symptomatic gallstones. 2 years prior to cholecystectomy he developed a biliary pancreatitis with a long-term hospital stay following diabetes mellitus und chronic exocrine pancreas dysfunction. A complete portal vein thrombosis with cavernous transformation developed. The patient suffered from weekly colics. Preoperative ultrasound and MRI showed a complete portal vein thrombosis with a cavernous transformation of the hepatoduodenal ligament including Calot’s triangle. A laparoscopic cholecystectomy was performed. The positions of the trocar sites were chosen carefully under respect of the umbilical vein and visible collaterals. Preparation was performed under highest respect to the cavernous transformation and under generous use of vascular clips. The cavernous transformation was preserved.

Results: The total operating time was 87 minutes. Intraoperative blood-loss was minimal. Postoperative Doppler ultrasound showed the collaterals of the cavernous transformation open and with good flow. The postoperative laboratory findings were identical to preoperative. The patient was dismissed at day 3 after surgery.

Conclusion: The indication for cholecystectomy in patients with known complete portal vein thrombosis and cavernous transformation should be restrictive due to the overall increased perioperative risks. However, if a patient suffers from frequent colics in short intervals laparoskopic cholecystektomy is an justifiable option. With respect to the special anatomy and an increased risk for bleeding the operation should be performed by an experienced HBP-surgeon.

Delayed Gastric Emptying: Pylorus-Preserving Versus Non-Pylorus-Preserving Pancreaticoduodenectomy - Systemic Review And Meta-Analysis
Awinderpreet Singh, MD, Fellow Hepato-Biliary Program, Providence Hospital, Southfield-MI

Purpose: Pancreaticoduodenectomy (PD) is the procedure of choice for periampullary benign and malignant lesions. Delayed gastric emptying (DGE) is one of the most common complications following PD. The benefit of pylorus preservation has been the subject of numerous studies, however practice still varies widely.

Methods: A systemic literature search was performed using PubMed and EMBASE databases to identify randomized controlled and retrospective series comparing PPPD (pylorus-preserving pancreaticoduodenectomy) and NPPPD (non-pylorus preserving pancreaticoduodenectomy).A  Meta-analysis was performed using Review Manager 5.0,  and heterogeneity was measured with I2 statistic. A fixed or random effects model was used when there heterogeneity was observed. DGE was the primary outcome.

Results: A total of 377 abstracts were evaluated and 24 articles (9 randomized controlled trials-RCT, 11 retrospective studies and 2 prospective studies) were deemed eligible for analysis. DGE was significantly increased in PPPD (357 out of 1874, 19.1%) compared to NPPPD (193/1101, 17.5%) with  an odds ratio of 1.81, 95% CI, 1.18-2.77, p=0.007) ( Figure 1). This finding was also observed in the subset analysis of RCT (PPPD, 26.8% vs NPPPD, 16.6%; p=0.01)

Conclusion: These findings suggest that pylorus preservation is associated with an increased rate of DGE as compared to non-pylorus preserving pancreaticoduodenectomy.

Long-Term Outcomes of the Bilaminar Repair Sandwich Technique" for" Closure of Large, Complex Abdominal Wall Defects
Lauren Spoo, MD, OB-GYN Resident, Baylor College of Medicine, Houston, TX

Purpose: Complex ventral hernias occur in up to 15% of patients undergoing abdominal surgery. Management of these large ventral hernias remains challenging due to complex operative conditions, intense post-operative pain, potential respiratory compromise and lateral muscle traction predisposing to early recurrence. Despite recent advances in technique and materials, the overall recurrence rate can be unacceptably high, with reported recurrence rates varying between 15-21% for open repair within 36 months.The author first introduced his variation of Guarnieri’s “sandwich technique”� in 2011, which combines CST with both a biologic mesh underlay and overlay. The purpose of this study is to report long-term outcomes of the author’s original newly-proposed bilaminar repair “Sandwich technique”� with the aim to raise awareness of this technique among various specialties.

Methods: Medical records were reviewed from patients who underwent ventral hernia repair using two layers of biologic mesh with or without CST from 2005 to 2014.  The primary outcome that we will be reporting is hernia recurrence rate. Secondary outcomes will include early and late complications and mortality.

Results: There were approximately 150 patients who fit our criteria with a follow-up period of up to nine years. We will analyze the data collected to report the total number of patients who fit our search criteria, the median age, median follow-up time, and patient demographics, including co-morbidities. We will report on the type of hernias present, the type of surgery performed, including whether or not additional procedures such as dermolipectomy were performed, the type and rate of complications observed, and the recurrence rate to-date.

Conclusion: We hypothesize based on our clinical observations that the bilaminar repair “sandwich technique”� using dual-layer biologic mesh and CST is a superior technique with low recurrence rates for repair of large, complex, and recurrent ventral hernias.