Ann Surg Research Articles

Review of “Leadership in American Surgery: Women Are Rising to the Top” by Pories SE in Ann Surg 269:199–205, 2019

Journal of Craniofacial Surgery: October 2019 - Volume 30 - Issue 7 - p 2294-2295 doi: 10.1097/SCS.0000000000005455

LARGE VENTRICULAR SEPTAL DEFECT CAUSED BY AN ACUTE INFERIOR ST ELEVATION MYOCARDIAL INFARCTION

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Septal rupture is an uncommon, but fatal, complication of myocardial infarction (MI) which usually occurs 3-5 days after an acute MI, however, in rare instances it may develop within the first 24 hours or as late as 2 weeks. It is associated with a tremendously high mortality rate (41-80%) which has been unchanged during the last few decades [1]. We hereby report one such rare instance when this complication occurred within 48 hours following MI. CASE PRESENTATION: A 59 year old male with a history of coronary artery disease status post percutaneous coronary intervention in 2011 presented to the emergency room with chest pain for 1 hour prior to admission. Initial electrocardiogram showed acute inferior ST elevation MI. Emergent cardiac catheterization showed occlusion of the right coronary artery and a drug eluting stent was placed. The patient was transferred to intensive care unit for close monitoring, however, 5 hours later he developed sudden increasing shortness of breath. Physical examination revealed a new systolic murmur and an echocardiogram was performed showing a large ventricular septal defect (VSD) (Image-1). Overnight he developed atrial fibrillation and became hemodynamically unstable with a systolic blood pressure in the 60's. He was then cardioverted without success and amiodarone was bolused followed by a continuous infusion. The decision was made for emergent coronary artery bypass grafting and repair of the VSD the next day. The defect was successfully closed with a Dacron patch after timely and prompt correction of atrial fibrillation. DISCUSSION: There are 3 life threatening complications of acute MI which include rupture of the left ventricular free wall, rupture of the interventricular septum and development of severe mitral regurgitation. One study compared 225 patients who had a first MI and experienced one of the mechanical complications to 1012 patients without complications to analyze the reason behind these complications. They reported that delayed hospitalization (>24hours), excessive in-hospital physical activity and recurrent ischemia as some of the risk factors for rupture [2]. Early retrospective studies noted lower mortality rates in patients undergoing surgical repair > 6 weeks after infarction than those who went in earlier, however these studies had selection bias as patients with normal ejection fraction and smaller defects survived to become low risk surgical candidates [3]. Hence, optimal approach varies with the clinical presentation. In patients like ours who develop cardiogenic shock, death is inevitable without urgent surgical intervention. CONCLUSIONS: This case is an unusual scenario where this fatal complication occurred within 48 hours following MI even after prompt revascularization. It is unique because it was further complicated with atrial fibrillation, which can further reduce survival probability, yet he survived and defied the odds. Reference #1: Saplaouras A1, Sakellaropoulou A1, Mililis P1, Bazoukis G1, Kolokathis AM1, Konstantinidou E1, Anagnostou A1, Panagopoulou N1, Vlachos K1, Lakoumentas I1, Sideris A1. Ventricular septal rupture following myocardial infarction: A potentially fatal complication. Clin Case Rep. 2019 Jan 9;7(2):397-400 Reference #2: Figueras J, Cortadellas J, Calvo F, Soler-Soler J. Relevance of delayed hospital admission on development of cardiac rupture during acute myocardial infarction: study in 225 patients with free wall, septal or papillary muscle rupture. J Am Coll Cardiol 1998; 32:135. Reference #3: Daggett WM, Guyton RA, Mundth ED, et al. Surgery for post-myocardial infarct ventricular septal defect. Ann Surg 1977; 186:260 DISCLOSURES: No relevant relationships by John Mikhail, source=Web Response No relevant relationships by Mohammed Shariff, source=Web Response

PRIMARY CARDIAC ANGIOSARCOMA INVADING BIOPROSTHETIC MITRAL VALVE

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Primary cardiac tumors have an occurrence rate of 0.0001% - 0.03% on large autopsy series. The angiosarcoma variety are locally aggressive, however there are no previous reports of invasion of a bioprosthetic mitral valve. This may be partially due to the predisposition of malignant cardiac tumors to be right sided. CASE PRESENTATION: We present a 52-year-old female with a past medical history of rheumatic heart disease that came to the hospital for worsening shortness of breath and chest pain. She had undergone a surgical mitral valve replacement 5 years prior. To evaluate for possible endocarditis a trans-esophageal echocardiogram was performed which showed a large mass overlying the mitral annulus and significant bioprosthetic stenosis. This mass protruded across the mitral valve and extended into the left atrial appendage. During removal of the compromised bioprosthetic mitral valve a significant amount of foreign material was noted in and around the valve and a large tumor-like mass involving part of the interatrial septum was resected. A 27 mm Perimount Magna Mitral Ease valve was seated in the supra-annular position. The interatrial septum was reconstructed using a 2 cm bovine pericardium patch. Initial pathology of the mass revealed foci of high-grade malignant neoplasm, organizing thrombi and mesenchymal tissue. Final pathology was consistent with a high-grade epithelioid angiosarcoma. This patient is currently undergoing chemotherapy and radiation therapy. DISCUSSION: Overall survival of patients with primary cardiac angiosarcoma is approximately 1 year. Patients that undergo surgical resection of the tumor have a greater survival than those treated with chemotherapy and radiation alone. Surgical resection is technically difficult due to proximity to important vascular structures. Improvement in overall survival rates has been difficult due to the rarity of the condition. CONCLUSIONS: Primary cardiac angiosarcoma is a rare condition with very poor outcomes. Surgical resection is the cornerstone of treatment, however survival is poor regardless. Reference #1: Lam KY, Dickens P, Chan AC. Tumors of the heart. A 20-year experience with a review of 12,485 consecutive autopsies. Arch Pathol Lab Med. 1993;117(10):1027-31. Reference #2: Patel SD, Peterson A, Bartczak A, et al. Primary cardiac angiosarcoma - a review. Med Sci Monit. 2014;20:103-9. Published 2014 Jan 23. https://doi.org/10.12659/MSM.889875 Reference #3: Look hong NJ, Pandalai PK, Hornick JL, et al. Cardiac angiosarcoma management and outcomes: 20-year single-institution experience. Ann Surg Oncol. 2012;19(8):2707-15. DISCLOSURES: No relevant relationships by Raul Alonso, source=Web Response No relevant relationships by Daryoosh Derakhshan, source=Web Response No relevant relationships by Christopher Foth, source=Web Response No relevant relationships by Marc Iskandar, source=Web Response No relevant relationships by Vy Nguyen, source=Web Response No relevant relationships by Josue Rizo, source=Web Response

Review of “Global Surgery: Effective Involvement of US Academic Surgery” by Mock C et al in Ann Surg 268:557–563, 2018

Journal of Craniofacial Surgery: September 2019 - Volume 30 - Issue 6 - p 1920 doi: 10.1097/SCS.0000000000005238

Review of “Key Components of the Safe Surgical Ward: International Delphi Consensus Study to Identify Factors for Quality Assessment and Service Improvement” by Hassen YAM et al in Ann Surg 269:1064–1072, 2019

Journal of Craniofacial Surgery 31(2):p 594-595, March/April 2020. | DOI: 10.1097/SCS.0000000000005867

Review of “Leading From the Front: An Approach to Increasing Racial and Ethnic Diversity in Surgical Training Programs” by Butler PD in Ann Surg 269:1012–1015, 2019

Review of “Leading From the Front: An Approach to Increasing Racial and Ethnic Diversity in Surgical Training Programs” by Butler PD in Ann Surg 269:1012–1015, 2019

Review of “Resident Autonomy in the Operating Room: How Faculty Assess Real-time Entrustability” by Chen X et al in Ann Surg 269:1080–1086, 2019

Review of “Resident Autonomy in the Operating Room: How Faculty Assess Real-time Entrustability” by Chen X et al in Ann Surg 269:1080–1086, 2019

Review of “An Economic Evaluation of the National Surgical Quality Improvement Program (NSQIP) in Alberta, Canada” by Thanh NX et al in Ann Surg 269:866–872, 2019

Review of “An Economic Evaluation of the National Surgical Quality Improvement Program (NSQIP) in Alberta, Canada” by Thanh NX et al in Ann Surg 269:866–872, 2019

Review of “Surgical Consultation as Social Process” by Clapp JT in Ann Surg 269:446–452, 2019

Review of “Surgical Consultation as Social Process” by Clapp JT in Ann Surg 269:446–452, 2019

Reconstruction of Complex Hemipelvectomy Defects: A 17-year Single-institutional Experience With Lower Extremity Free and Pedicled Fillet Flaps

PURPOSE: Hemipelvectomy procedures result in massive soft tissue defects.1,2 The standard reconstructive approach is to reconstruct the defect with anterior or posterior hemipelvectomy flaps; however, certain oncologic situations can preclude the use of local tissue flaps.3,4 In such cases, a suitable alternative to provide sufficient soft tissue coverage is the use of fillet flaps, which are defined as pedicled or free flaps harvested from amputated parts.5 The purpose of this study is to present our institution’s experience with using both pedicled and free fillet flaps to reconstruct hemipelvectomy soft tissue defects. METHODS: The authors performed a retrospective chart review of patients who underwent hemipelvectomy followed by fillet flap reconstruction from 2001 to 2018. Patient demographics, clinical and surgical characteristics, postoperative outcomes, and complications were reviewed. RESULTS: Ten patients were identified and included. Mean age was 51 ± SD 12.4 years. Six patients (60%) underwent standard external hemipelvectomy, and 4 patients (40%) extended external hemipelvectomy. Seven (70%) lower extremity fillet flaps were performed as free tissue transfers, and 3 (30%) were pedicled flaps. Mean flap size was 1,153 ± SD 1,137 cm2. Mean follow-up was 5 months (range, 1–24 months). Five patients developed postoperative complications; none of them required operative intervention. There were no partial or total flap losses postoperatively. CONCLUSION: Reconstruction with either pedicled or free lower extremity fillet flaps is a valuable reconstructive modality for managing acquired soft tissue defects following hemipelvectomy. This useful technique mitigates donor site morbidity, while simultaneously delivering adequate soft tissue coverage with an acceptable complication profile. REFERENCES: 1. Senchenkov A, Moran SL, Petty PM, et al. Soft-tissue reconstruction of external hemipelvectomy defects. Plast Reconstr Surg. 2009;124:144–155. 2. Tashiro K, Arikawa M, Fukunaga Y, et al. Free latissimus dorsi musculocutaneous flap for external hemipelvectomy reconstruction. Microsurgery. 2019;39:138–143. 3. Senchenkov A, Moran SL, Petty PM, et al. Predictors of complications and outcomes of external hemipelvectomy wounds: account of 160 consecutive cases. Ann Surg Oncol. 2008;15:355–363. 4. Houdek MT, Andrews K, Kralovec ME, et al. Functional outcome measures of patients following hemipelvectomy. Prosthet Orthot Int. 2016;40:566–572. 5. Bibbo C, Newman AS, Lackman RD, et al. A simplified approach to reconstruction of hemipelvectomy defects with lower extremity free fillet flaps to minimize ischemia time. J Plast Reconstr Aesthet Surg. 2015;68:1750–1754.

Validation and educational impact study of the NANEP high-fidelity simulation model for open preperitoneal mesh repair of umbilical hernia.

The aim of the study was to develop, validate and analyze the educational impact of a high-fidelity simulation model for open preperitoneal mesh repair of an umbilical hernia. The number of surgical simulators available for training residents is limited. Primary for ethical reasons and secondary for the emerging pay-per-quality policies, practicing-on simulators rather than patients is considered gold standard. Validated full-procedural surgical models will become more and more important in training residents. Such models may assure that evidence-based standards regarding technical aspects of the procedures become integral part of the curriculum. Furthermore, they can be employed as a quality control of residents' skills (Fonseca et al. in J Surg Educ 70:129-137, 2013). In a repeated measures design, medical students, residents in their last year of training and attending surgeons performed an open preperitoneal mesh repair on the NANEP model [NANEP stands for the German acronym Nabelhernien-Netzimplatation-Präperitonal (English: Umbilical hernia mesh implantation preperitoneal)]. Subjects were categorized as "Beginners" (internship students) or "Experts" (residents and surgeons). Content validity was analyzed by criteria of subject-matter-experts. Blinded raters assessed surgical skills by means of the Competency Assessment Tool (CAT) using the online platform "CATLIVE". Differential validity was measured by group differences. Proficiency gain was analyzed by monitoring the learning curve (Gallagher et al. in Ann Surg 241:364-372, 2005). Post-operative examination of the simulators shed light on criterion validity. The NANEP model-proofed content and construct-valid significant Bonferroni-corrected differences were found between beginners and experts (p < 0.05). Beginners showed a significant learning increase from the first to the second surgery (p < 0.05). Post-operative examination data confirmed criterion validity. The NANEP model is an inexpensive, simple and efficient simulation model. It has highly realistic features, it has been shown to be of high-fidelity, full-procedural and benchtop-model. The NANEP model meets the main needs of surgical educational courses at the beginning of residency.

Review of “The Current State of Surgical Ergonomics Education in U.S. Surgical Training-A Survey Study” by Epstein S et al in Ann Surg 269:778-784, 2019

Journal of Craniofacial Surgery 31(1):p 326, January/February 2020. | DOI: 10.1097/SCS.0000000000005690

Review of "A Structured Compensation Plan Improves But Does Not Erase the Sex Pay Gap in Surgery" by Morris M, Chen H, Heslin MJ, Krontiras H in Ann Surg 268: 442-448, 2018.

Review of "A Structured Compensation Plan Improves But Does Not Erase the Sex Pay Gap in Surgery" by Morris M, Chen H, Heslin MJ, Krontiras H in Ann Surg 268: 442-448, 2018.

Abstract SY23-01: Blood-borne tumor cell dissemination in cancer patients

Abstract SY23-01: Blood-borne tumor cell dissemination in cancer patients

The diagnosis and management of intraductal papillary mucinous neoplasms of the pancreas: has progress been made?

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are premalignant mucin-producing epithelial tumors that arise from the pancreatic ductal system. These cystic tumors represent 15-30% of cystic lesions of the pancreas [Basturk et al. in Am J Surg Pathol 39(12):1730-1741, 1; Ferrone et al. in Arch Surg (Chicago, Ill: 1960) 144(5):448-454, 2, Kosmahl et al. in Virchows Arch Int J Pathol 445(2):168-178, 3; Spinelli et al. in Ann Surg. 239(5):651-657, 4]. It is believed that IPMN can progress from low-grade dysplasia to high-grade dysplasia to invasive cancer, and this pathway of progression accounts for 20-30% of pancreatic cancer [Adsay et al. in Am J Surg Pathol 28(7):839-848, 5; Tanaka et al. in J Gastroenterol 40(7):669-675, 6; Wu et al. in Sci Transl Med 3(92):92ra66, 7]. Furthermore, it is also widely believed that IPMN represent a field defect of the pancreas in which the entire ductal system is at risk of developing invasive carcinoma, not only in the area of radiographically detectable IPMN, and thus the remaining gland should undergo surveillance after partial pancreatectomy [Salvia et al. in Ann Surg 239(5):678-685, 8; Izawa et al. in Cancer 92(7):1807-1817, 9; Yamaguchi and Tanaka in Jpn J Clin Oncol 41(7):836-840, 10]. Increasingly, surgeons are faced with the dilemma between recommending highly complex resections-that have significant morbidity and mortality-in patients who may have low-risk IPMN (low-grade dysplasia), or alternatively, recommending observation for those who could possibly be harboring a radiographically occult malignancy. Given the complexity of the management decisions for patients with IPMN, the purpose of this paper is to review the current literature and to provide a summary of how accurate we are currently with the identification of high-grade dysplasia or progression to carcinoma in patients who present with IPMN.

Review of “How Many Observations Are Needed to Assess a Surgical Trainee's State of Operative Competency?” by Williams RG et al in Ann Surg 269:377–382, 2019

Review of “How Many Observations Are Needed to Assess a Surgical Trainee's State of Operative Competency?” by Williams RG et al in Ann Surg 269:377–382, 2019

Review of “Pilot Study to Evaluate the Safety, Feasibility, and Financial Implications of a Postoperative Telemedicine Program” by Nikolian VC et al in Ann Surg 268:700–707, 2018

Review of “Pilot Study to Evaluate the Safety, Feasibility, and Financial Implications of a Postoperative Telemedicine Program” by Nikolian VC et al in Ann Surg 268:700–707, 2018

Review of “Impact of the Affordable Care Act (ACA) Medicaid Expansion on Cancer Admissions and Surgeries” by Eguia E et al in Ann Surg 268:584–590, 2018

Review of “Impact of the Affordable Care Act (ACA) Medicaid Expansion on Cancer Admissions and Surgeries” by Eguia E et al in Ann Surg 268:584–590, 2018

Review of “Toward a Consensus on Centralization in Surgery” by Vonlanthen R et al in Ann Surg 268

Review of “Toward a Consensus on Centralization in Surgery” by Vonlanthen R et al in Ann Surg 268

Review of “Assessing the Safety of Overlapping Surgery at a Childrenʼs Hospital” by Hyder JA et al in Ann Surg 268

Review of “Assessing the Safety of Overlapping Surgery at a Childrenʼs Hospital” by Hyder JA et al in Ann Surg 268