Poster Wall

2020 Annual Clinical Assembly of Osteopathic Surgeons (ACA)

A VIRTUAL ASSEMBLY, Virtual, California

October 20 – 23, 2020 (Tuesday – Friday)

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A Case of Benign Colonic Spasm Masquerading as Colorectal Carcinoma 1439228 Tanya Odisho DMC Sinai Grace Hospital A Case of Benign Colonic Spasm Masquerading as Colorectal Carcinoma General Surgery Introduction/Purpose: Introduction: If not comprehensively characterized, etiologies presenting as apple core lesions on imaging can be mistaken for malignancy and thus, an extensive surgical approach may be untaken unnecessarily. Methods or Case Description: Case presentation: An 81-year-old female presented with significant weight loss over a month, abdominal pain, distension, diarrhea, and flatulence. CT abdomen was concerning for a large bowel obstruction, secondary to possible primary colon carcinoma, for which Surgery was consulted. A double contrast barium enema was completed which was originally interpreted as an abnormal core type lesion involving the sigmoid colon. Colonoscopy was subsequently completed showing spastic colon without mass or mechanical obstruction. Careful review of the original barium study demonstrated apparent resolution of the area of previously suspected constriction, reducing the likelihood of a fixed neoplastic stenosis. The patient was discharged home with an antispasmodic for symptomatic relief. She returned two months later with recurrent symptoms. Operative management was undertaken with low anterior resection of the colonic stricture. Pathology was reported as diverticulosis with focal pericolic fibrosis, negative for malignancy.Outcomes: Discussion: Colonic carcinoma is usually detected on colonoscopy or barium enema for evaluating vague abdominal symptoms. Haustral spasms are transient in nature and when caught on imaging can demonstrate a narrow, focal ring appearance that is uniformly constricted, appearing as an apple core lesion. Although acute attacks of diverticulitis can cause transient episodes of partial obstruction, recurrent inflammatory attacks can eventually lead to marked fibrosis of the colonic wall and stricture formation, causing partial or complete obstruction. Conclusion: Conclusion: Thorough evaluation of colonic obstruction utilizing a multitude of imaging modalities for definitive diagnosis prior to surgical resection of bowel is crucial to avoid unnecessary surgery and related complications.

A Rare Case of Abdominal Wall Abscess containing a Gallstone Secondary to Cholecystocutaneous Fistula 1439255 Cecilia Nguyen St. John's Episcopal Hospital Sohayla Rostami St. John's Episcopal Hospital Hobin Kang St. John's Episcopal Hospital Narinder Grewal St Johns Episcopal hospital A Rare Case of Abdominal Wall Abscess containing a Gallstone Secondary to Cholecystocutaneous Fistula General Surgery Introduction/Purpose: A cholecystocutaneous fistula is an abnormal epithelial tract that allows communication between the gallbladder and the skin. In some cases the communication is spontaneous due secondary to iatrogenic causes. Spontaneous cholecystocutaneous fistula is a rare condition.Methods or Case Description: A 71-year-old female presented to ED with history of right sided abdominal wall mass with associated abdominal pain. She presented mass in right hypogastrium, tender, erythematous, warm and no drainage. Next we underwent incision and drainage of right abdominal wall abscess. Outcomes: On postoperatively day 3, patient had penrose removed without complications. Pathology revealed bile pigmented crystallin structure with surface acute inflammatory cells suggestive of biliary calculus. Patient informed of pathology results and instructed to have a HIDA scan to evaluate gallbladder morphology and function if possible repeat of CT.Conclusion: Cholecystocuteanous fistulas are increasingly rare. In spontaneous cholecystocutaneous fistula, the abscess is walled off by the abdominal wall and eventually it progressively penetrates its. The fistula usually occurs via fundus of the gallbladder and in this case has not progressed enough for fistula to have drainage onto the skin. With the increase in surgical treatment of gallbladder calculus disease the incidence of cholecystocutanous fistula has fallen dramatically . A literature review of case published between 1961 and 2013 identified 50 cases. While external biliary fistula is rare and can be a post-operative complication of liver and biliary tract surgery, they can also be traumatic, therapeutic, spontaneous. While cholecystocutaneous fistula is rare occurrence, we can consider this as a rare complication of gallbladder disease.

A Rare Case of Chest Wall Hidradenocarcinoma: A Case Report 1439271 Kayla Brown Nova Southeastern University Kiran C. Patel College of Osteopathic Medicine Matthew Nier Peconic Bay Medical Center Garrett Tibbets Peconic Bay Medical Center Steven Ouzounian Peconic Bay Medical Center A Rare Case of Chest Wall Hidradenocarcinoma: A Case Report General Surgery Introduction/Purpose: Hidradenocarcinoma is an extremely rare eccrine gland tumor that comprises less than 0.001% of all tumors, and less than 0.01% of cutaneous tumors. The most common locations for hidradenocarcinoma include the head, upper extremity, and the superior trunk above the nipple line-T4 dermatome, presenting either as solid or cystic subcutaneous nodules with associated pruritus or ulceration. With fewer than 50 cases reported in the United States, a minority of these select cases involve lesions located within the chest and pectoral regions.Methods or Case Description: We present an extremely rare case of a right anterior inframammary chest wall hiradenocarcinoma in a 52-yo female, not otherwise described in literature. Following surgical removal and pathological identification, the patient was referred to oncology to complete a PET/CT and tumor marker analysis. At three month follow up she remains disease free.Outcomes: A number of tumor markers have been assessed, however there is a wide variation of prevalence without correlation to accurately recommend treatment plans or recurrence probability. There are no definitive studies or data to support specific treatment of this disease. However, due to moderately high local recurrence rates and lymphatic metastasis, a commonly followed treatment includes wide surgical excision with adjuvant chemotherapy.Conclusion: Each individual case of hidradenocarcinoma, regardless of location, must be identified and evaluated on a case-by-case basis for appropriate treatment and management planning. Further research should be conducted to identify a more cohesive classification of hidradenocarcinoma subsets with detailed delineation of genetic mutations and tumor markers. From this collection and categorization of information we may then be able to draw more appropriate conclusions regarding appropriate treatments and management based on hidradenocarcinoma location, severity, and propensity for metastasis and recurrence.

A Rare Case of Left Sided Acute Appendicitis in a Patient With Asymptomatic Malrotation 1439223 Phillip Nahirniak Henry Ford Macomb Liz Ekkel Henry Ford Macomb Shivana Prakash Henry Ford Macomb A Rare Case of Left Sided Acute Appendicitis in a Patient With Asymptomatic Malrotation General Surgery Introduction/Purpose: Midgut malrotation is a disease process that is often cared for by pediatric surgeons but is not often seen in the adult population. It is often repaired with a Ladd's procedure to treat or prevent a torsion. We present an interesting case of 28 year old male who presented with left sided acute appendicitis due to his previously undiagnosed malrotation.Methods or Case Description: Our patient is a 28 year old healthy male who presented to the emergency department with periumbilical and left sided abdominal pain which had been ongoing for 2 days. While in the emergency department, workup was significant for CT abdomen/pelvis with IV contrast which showed malrotation of the bowel and the appendix was located in the left lower quadrant with surrounding acute inflammation. The patient was taken to the operating room. While there the abdomen was explored, with the findings of malrotation that were known from the pre operative CT scan. The appendix was located in the left lower quadrant. The appendectomy was completed without any issue. We elected to leave the malrotation alone as it had not caused the patient any symptoms in the past.Outcomes: Our patient did very well. Post operatively he was observed in the hospital overnight and discharged home on post operative day one after tolerating a regular diet. He was seen for a two week post operative visit and was doing extremely well at that time.Conclusion: It is important to review all imaging prior to surgery as it can greatly impact surgical planning. In our case, we altered position of our laparoscopic ports significantly to be able to complete our operation.

A Rare Case of Simultaneous Cecal and Sigmoid Volvulus in an Elderely Female 1439218 Karlbuto Alexandre Detroit Medical Center - Sinai Grace An King Ang Detroit Medical Center Huron Valley Urvi Rana Michigan State University College of Osteopathic Medicine A Rare Case of Simultaneous Cecal and Sigmoid Volvulus in an Elderely Female General Surgery Introduction/Purpose: Volvulus is an acute surgical emergency that involves the twisting of a segment of the gastrointestinal tract around the mesentery, it can lead to acute closed-loop bowel obstruction and ischemia. The sigmoid colon is the most common site of volvulus occurring 80% of the time, followed by the cecum occurring 15%. In the United States, large bowel obstruction due to cecal volvulus is rare. Simultaneous cecal and sigmoid volvulus is exceedingly rare.Methods or Case Description: Here, we report a case of a 70-year-old female patient who presented with abdominal pain, nausea, and vomiting. Abdominal computed tomography revealed sigmoid volvulus, and the patient underwent decompressive colonoscopy. The patient initially reported improved symptoms but developed abdominal distension the next day. The patient was taken for an exploratory laparotomy and was found to have both cecal and sigmoid volvulus.Outcomes: To address the cecal volvulus, a right hemicolectomy with primary ileal-transverse colon anastomosis was performed. Next, our attention was brought to the sigmoid volvulus, in which a sigmoidectomy with primary colorectal anastomosis was performed. The patient subsequently regained bowel function on POD#5. She was subsequently discharged on POD#12. Conclusion: Colonic volvulus, involving both the cecum and sigmoid colon is extremely rare and to our knowledge, this is the sixth reported case to have developed both conditions simultaneously.

A Rare Presentation of Encapsulating Peritoneal Sclerosis 1439250 Julia Porter St John's Episcopal Hospital Jame Ren St John's Episcopal Hospital Jackie Battista St. Johns Episcopal Hospital Youstina Assad St John's Episcopal Hospital A Rare Presentation of Encapsulating Peritoneal Sclerosis General Surgery Introduction/Purpose: Encapsulating peritoneal sclerosis is a grave complication, which entails the intra abdominal contents being encased by a fibrinous capsule. This is usually a complication of peritoneal dialysis that develops over an extended period of time. There have been few cases reported of patients with no history of peritoneal dialysis.Methods or Case Description: A 53 year old female presented to the ED after recent discharge from the same institution for spontaneous bacterial peritonitis. She had complaints of continued nausea, vomiting and abdominal pain since discharge. On exam she had a large fluid wave and was diffusely tender to palpation. CT findings were consistent with pneumoperitoneum. The patient was taken to the OR for an exploratory laparotomy and was found to have encapsulating peritoneal sclerosis. The fibrinous capsule encasing the intra abdominal contents was entered and an extensive lysis of adhesions was performed on the small bowel. The patient expired post operatively.Outcomes: Encapsulating peritoneal sclerosis is a grave disease. This is a clinical diagnosis associated with recurrent bowel obstructions. This has classically been associated with long term peritoneal dialysis. The exact causes of peritoneal leading to EPS are unknown. Many patients present with non specific GI complaints and in later stages of the disease, obstruction and perforation is common. Imaging can be non specific to the disease process and the gold standard of diagnosis is laparatomy, which is both diagnostic and therapeutic.Conclusion: Early diagnosis and treatment in patients found to have encapsulating peritoneal sclerosis is key. Optimization before surgery helps decrease morbidity and mortality rates, as usually these patients are not ideal surgical candidates. This was a complicated presentation with concern for bowel perforation, in which this was not possible.

A Rare Primary Osteogenic Sarcoma of the Prostate and Bladder 1439234 Jesse Rockmore Mclaren Macomb Gregory McIntosh Michigan Institiute of Urology A Rare Primary Osteogenic Sarcoma of the Prostate and Bladder Urological Surgery Introduction/Purpose: Malignant mesenchymal tumors comprise less than 1% of urinary bladder malignancies. An estimated 35 cases of osteosarcoma of the bladder have been reported. The prognosis of osteosarcoma of the bladder is poor and the course is aggressive. Our case describes a rare finding of osteosarcoma of the bladder and prostate from initial diagnosis, through treatment, progression, and demise.Methods or Case Description: A 72-year old man with a history of prostate cancer treated 12 years prior with radiation presented with hematuria. Cross-sectional imaging and office cystoscopy revealed what was thought to be bladder calculi. Rigid cystoscopy revealed an obstructing calcified bladder mass that was resected. Pathology confirmed at the Cleveland Clinic revealed osteosarcoma. The patient subsequently underwent radical cystoprostatectomy. Pathology revealed osteosarcoma replacement to the prostate with extension into the bladder, negative margins, and a single node positive for osteosarcoma. He experienced distant metastatic disease 3 months following the procedure despite adjuvant chemotherapy. His prognosis was deemed poor and he chose palliative care.Outcomes: Our case demonstrates a rare sequela of radiation therapy. In addition, as our institution had yet to encounter this histological variant, outside evaluation with a national cancer center was necessary to confirm the diagnosis. The patient received standard surgical and oncological care yet experienced rapid progression and demise.Conclusion: Osteosarcoma of the prostate and bladder is rare. In this case, the disease progressed despite surgical and oncological treatment. Prostate cancer is a common disease treated with radiation. Rare secondary malignancies resultant from prior radiation treatment reveal the long term sequelae of radiation therapy. Our case highlights a need to counsel patients on long-term potential adverse effects of radiation therapy for prostate cancer.

A Review of Orthopedic Implant Failures due to Metallosis and the Methods Utilized to Minimize and Address this Condition 1439226 Brynn Hentschel Edward Via College of Osteopathic Medicine- Auburn Campus Chris Horn Edward Via College of Osteopathic Medicine- Auburn Campus Dr. David Stephen D.O. Edward Via College of Osteopathic Medicine A Review of Orthopedic Implant Failures due to Metallosis and the Methods Utilized to Minimize and Address this Condition General Surgery Introduction/Purpose: Metallosis is a common cause of adverse reactions to total joint arthroplasties that result in a complicated revisional procedure and a lengthy recovery process. Through the progression of both procedures and prosthetics, the incidence of metallosis as a cause for total joint failure has markedly decreased. The prevalence of metal on metal joints has become less common, however even with the discontinuation of metal-on-metal implants, metallosis still occurs due to complications of modern OTS (on-the-shelf) implants.Methods or Case Description: Through the review of 18 research articles regarding metallosis and total joint arthroplasty prosthetics. Three studies highlighted the incidence of metallosis in joints excluding total knees and total hips, 3 studies reviewing metallosis in total joint failures, 3 studies on adverse reactions to total joint replacements, 2 studies on diagnostic findings/complications, and 7 studies on the future of total joint procedures. Further results were reviewed within discussion with current Orthopedic surgeons.Outcomes: Some studies attributed total joint failures to either an attributed infection only, metallosis only, or specific allergic reactions to metals causing adverse reaction. In addition a few recognized gender specific total knee replacements of importance of custom prosthetics.Conclusion: Although metallosis incidence overall is decreasing because fewer metal on metal implants are being inserted, metallosis is still an issue in non metal implants due to the suggested increase in wear, leading to loosening prosthetics or improperly placed prosthetic pieces. The studies above highlight many reasons for why metallosis still occurs but there still lacks a body of sound and conclusive evidence as to why. This indicates the necessity for more studies to better illuminate the risk factors that can be directly traced to total joint procedures.

Acute Calyceal Obstruction In an Adolescent with Infundibulopelvic Dysgenesis 1439236 Chase Cavayero Mclaren Macomb Hospital Gregory Mcintosh Mclaren Macomb Hospital Donald Nguyen Dayton Children's Hospital Acute Calyceal Obstruction In an Adolescent with Infundibulopelvic Dysgenesis Urological Surgery Introduction/Purpose: Infundibulopelvic dysgenesis is an obstructive process of the renal collecting system that is associated with a variety of congenital malformations such as multicystic dysplastic kidney (MCDK), infundibulopelvic stenosis, and calyceal diverticula. While some patients remain asymptomatic, others may experience flank pain, depending on the degree of obstruction. Our case describes a 14-year-old adolescent, found to have severe hydrocalycosis and pain secondary to acute obstruction of a stenotic infundibulum.Methods or Case Description: A 14-year-old male presented to the emergency department with a chief complaint of acute onset nausea, vomiting, and flank pain. Ultrasound and contrasted CT scan revealed a massively dilated central renal calyx. An antegrade nephrostogram was performed and revealed no communication between the dilated calyx and the true collecting system. A Nephrostomy tube was placed for relief. The patient underwent cystoscopy with diagnostic uretero-renoscopy. Intraoperative pyelogram revealed a dilated megaureter and a grossly abnormal collecting system. There was an abnormal renal pelvis with multiple stenotic infundibular segments. A punctate calculus was encountered at the entrance of a stenotic calyx, and fragmented with a laser lithotripter. Methylene blue, injected through the nephrostomy tube was immediately seen emanating from this stenotic calyx. Post-procedure pyelogram suggested continuity between the two systems was re-established. A double J ureteral stent was placed.Outcomes: Repeat nephrostogram was performed, which confirmed resolution of the obstruction. The patient recovered and has remained asymptomatic.Conclusion: This case highlights the unusual presentation of acute stone obstruction of a stenotic infundibulum in a patient with infundibulopelvic dysplasia. This is a rare presentation, as such cases of stenotic infundibuli are generally asymptomatic. This case serves to present management strategies for this atypical presentation.

An Uncommon cause of Small Bowel Obstruction in a Pediatric Female Patient 1439231 Kyle Lange Henry Ford Macomb Jeffrey Christian Dayton Children's Hospital An Uncommon cause of Small Bowel Obstruction in a Pediatric Female Patient General Surgery Introduction/Purpose: General surgeons are often asked to evaluate and manage small bowel obstructions. We become comfortable in our training in managing the common causes of small bowel obstructions such as adhesions, hernias, and malignancies. In the pediatric population we may think of congenital malformations as an exotic cause for an obstruction, but this case demonstrates an example of another rare cause of obstruction primarily seen in the pediatric population.Methods or Case Description: A 13 year old female presented with abdominal pain, distension, constipation for three days. Abdominal xrays demonstrated dilated loops of small bowel with air fluid levels. She had no previous surgeries, was a healthy pubescent female with no developmental delays. She was made NPO and given IV fluids. The next morning her pain had increased, appeared more distended, and denied passing flatus or having a bowel movement. A follow-up xray showed increased small bowel distension. The decision was made to take the patient for exploratory laparotomy. On exploration a mass was palpated in the lumen of the mid ileum. An enterotomy was made, and a trichobezoar was removed.Outcomes: She was discharged on post-operative day 3 after tolerating a diet. She denied a previous history of trichotillomania, although did admit to sucking on her hair. Trichobezoars make up approximately 6% of all bezoars in one study, and are usually found in the stomach or the duodenum with extension into the stomach.Conclusion: This case demonstrates a rare but very possible cause of small bowel obstruction in a pediatric patient. Once again the importance of clinical examination and maintaining a high index of suspicion with a wide differential, in order to have a good outcome are evident in this case.

Bilateral Orchitis and Testicular Enlargement 1439254 Paul Spore University of North Texas Health Science Center Cara Fisher University of North Texas Health Science Center Connie Ly University of North Texas Health Science Center Lauren West University of North Texas Health Science Center Joel Mathews University of North Texas Health Science Center Bilateral Orchitis and Testicular Enlargement General Surgery Introduction/Purpose: The testes develop in the abdominal cavity of the fetus and descend through the processus vaginalis in the abdominal wall before birth. The testis is covered by the tunica albuginea and the tunica vaginalis, and, along with the ductus deferens, testicular artery, pampiniform plexus, and the genitofemoral nerve, are surrounded by the internal spermatic fascia.Methods or Case Description: During a routine dissections of a 76-year-old male cadaver, bilateral orchitis, bilateral testicular enlargement, a left-sided varicocele, and a right-sided indirect inguinal hernia were discovered.Outcomes: The right testis was measured at 10 cm and the left testis was measured at 11 cm. Removal of the outer layers of the scrotum revealed solidified green, yellow, and grayish purulent exudate. The left testis was easily compressible and had a large varicocele, while the right testis was turgid and, when dissected, contained a large hematoma. The inferior pole of the left testis had extensive fibrous scarring at the epididymal-testis junction and the anterior surface of left testis had two small nodular plaques protruding from the tunica albuginea. An indirect inguinal hernia was identified within the right spermatic cord. Conclusion: If the processus vaginalis does not close completely, this can increase the susceptibility of an indirect hernia occurring. The donor could have had congenital bilateral patent processus vaginalis, which would make him more susceptible to indirect inguinal hernias. Physicians should consider the possibility of unilateral or bilateral patent processus vaginalises when treating patients with a history of indirect inguinal hernias or cryptorchidism.

Breast Implant Associated - Anaplastic Large Cell Lymphoma of Rapid Onset Intra-Capsular Seroma 1439257 John Bates Beaumont Royal Oak Farideddin Nossoni Beaumont Royal Oak Breast Implant Associated - Anaplastic Large Cell Lymphoma of Rapid Onset Extra-Capsular Seroma Plastic and Reconstructive Surgery Introduction/Purpose: Breast Implant Associated - Anaplastic Large Cell Lymphoma is a newer T-Cell Lymphoma effecting textured breast implants. These implant were used heavily in Europe and the United States recent years. As this body of literature continues to grow we describe a patient with rapid onset extra-capsular fluid collection with cytology proven anaplastic large cell lymphoma following breast reconstruction.Methods or Case Description: we review the course of care for a 60 year old female who underwent breast reconstruction after left lumpectomy in 2004. She had her implants exchanged in 2015 after rupture. She was diagnosed with BIA-ALCL in 2020 after 3 weeks of swelling on her left breast. She was evaluated in multidisciplinary fashion according to guidelines and underwent removal of implants and En bloc resection of bilateral implant capsules. Pathological analysis post-operatively found no malignancy in her capsule but it was present in the periprosthetic fluid collection. Outcomes: Following implant removal and bilateral en bloc capsulectomy with pathological evaluation, she falls into the early stages of BIA-ALCL and is currently symptom free.Conclusion: She is being followed with serial physical examination; however the role of radiological studies like MRI, PET scan for surveillance remains unclear. Further studies are required to develop further long term surveillance guidelines for patients with different stages of the disease.

Cardiothoracic and Vascular Surgery Podium Presentation: Hypoplastic Aortoiliac Syndrome Causing Severe Claudication 1439229 Tanya Odisho DMC Sinai Grace Hospital Cardiothoracic and Vascular Surgery Podium Presentations Cardiothoracic and Vascular Surgery Introduction/Purpose: Hypoplastic aortoiliac syndrome (HAS) is a rare condition largely described in young women of small stature with a significant smoking history. Angiography is the gold standard of diagnosis. The treatment of choice remains surgical revascularization.Methods or Case Description: A 48-year-old woman presented with intermittent claudication in her bilateral lower extremities since 1 year previously with worsening symptomology with extended periods of walking. CT angiography revealed moderate and severe segments of stenosis at the infrarenal abdominal aorta with the worst area of involvement at the aortic bifurcation. Based on the patient’s presentation and radiographic findings, she was diagnosed with HAS. We performed an aortoiliac bypass grafting with a bifurcating graft graft via an open transabdominal approach. After surgery, the patient was administered clopidogrel and aspirin on post operative day 1. She has remained free of claudication since her operation.Outcomes: In contrast to arteries of aortoiliac occlusive disease, the arteries in HAS may have little if any atherosclerotic changes such as stenosis, kinking or calcification. These arteries, however, have distinct anatomic findings that define the syndrome, including high bifurcation of the abdominal aorta, straight course of the iliac arteries without the normal characteristic bowing, acute angle of the aortic bifurcation (20°–30°), aortic diameter of 14 mm or less, and iliac artery diameter of 7 mm or less. As a result of these stenotic features, patients with HAS present most commonly with intermittent claudication and hypertension. Most patients need to be surgically managed, with aortofemoral bypass being the most commonly used grafting technique.Conclusion: As HAS increases the risk for aortoiliac occlusive disease and severe complications of hypertension, it is imperative to identify these patients early and treat them accordingly. Upon completion, participants will be able to clearly define hypoplastic aortoiliac syndrome or small aorta syndrome, identify patients most at risk for this syndrome, and the symptomology associated with this disease process. Upon completion, participants will be able to effectively work-up a patient suspected of having hypoplastic aortoiliac syndrome, with respect to ordering the appropriate imaging modality.Upon completion, participants will be able to discuss different treatment approaches to hypoplastic aortoiliac syndrome.Upon completion, participants will be able to identify key surveillance measures and follow-up requirements in patients with hypoplastic aortoiliac syndrome.

Cardiothoracic and Vascular Surgery Podium Presentation: Leadership Positions Held Among Osteopathic Female and Male Cardiothoracic Surgeons 1439276 Chi Chi Do-Nguyen Philadelphia College of Osteopathic Medicine Elizabeth Norton Creighton University School of Medicine Jessica Figueredo Nova Southeastern University, Dr. Kiran C. Patel College of Osteopathic Medicine Alejandra Castro-Varela Tecnologico de Monterrey, School of Medicine and Health Sciences Julie Qiu Philadelphia College of Osteopathic Medicine Sarah Miter Department of Surgery, Inova Health System Cardiothoracic and Vascular Surgery Podium Presentations Cardiothoracic and Vascular Surgery Introduction/Purpose: Osteopathic physicians make up the minority of surgeons in cardiothoracic surgery (CTS). With the Accreditation Council for Graduate Medical Education (ACGME) one accreditation system, we investigated the current status of female and male osteopathic surgeons in CTS, comparing metrics associated with career advancement.Methods or Case Description: Seventy-eight CTS programs, including integrated, 4+3, and traditional fellowships, were identified using the ACGME public programs database. Data, including faculty demographics and institutional characteristics, were collected using institutional websites, the 2019-2020 United States News & World Report medical school rankings by research ranking, and ctsnet.org.Outcomes: Of 1208 CTS teaching faculty members, only 14 are DO physicians (1.2%) and of those, 64.3% are male. More men acquired PhD degrees, compared to women (11.1% vs. 0.0%). Similar proportions of men and women acquired other degrees (22.2% and 20.0%, respectively). Collectively, few surgeons advanced to professorship, with 92.9% as assistant, 7.1% as associate, and 0.0% as full professors. However, more women advanced to professorship compared to men, with 80.0% as assistant and 20.0% as associate professors (vs. 100.0% and 0.0%, respectively). Only 1 male physician held a leadership position in CTS as division chief. No physicians held the leadership positions of program director nor chairperson.Conclusion: Factors associated with academic ranking, such as advanced degrees, are similar between male and female osteopathic CTS faculty members. However, osteopathic surgeons continue to collectively make up a minority of senior faculty and leadership positions nationally, with a majority serving as assistant professors and only one physician serving in a leadership role. Upon completion, participant will be able to assess the prevalence of osteopathic cardiothoracic surgery faculty members among cardiothoracic surgery faculty across the nation.Upon completion, participant will be able to investigate the advancement of osteopathic cardiothoracic surgery faculty members to higher academic ranking and leadership positions within the field.Upon completion, participant will be able to demonstrate the need for diversity and inclusion in the recruitment of cardiothoracic surgery faculty positions in the United States.

Cardiothoracic and Vascular Surgery Podium Presentation: Survival after distal esophageal rupture: a case report of prolonged intrathoracic complications after conversion from Mallory Weiss tear to Boerhaave’s syndrome during a pandemic. 1439241 Rachel Kaczynski St. John's Episcopal Hospital Eloise Rogers St. John's Episcopal Hospital Jazlyn Amador-Jimenez St. George's University, School of Medicine Cardiothoracic and Vascular Surgery Podium Presentations Cardiothoracic and Vascular Surgery Introduction/Purpose: This report details a case of a right pleural effusion after esophageal rupture with a protracted course ultimately leading to successful patient discharge.Methods or Case Description: We present a 42 year-old male with chronic alcoholic cirrhosis who was admitted to the intensive care unit during the COVID-19 pandemic with altered mental status, agonal respirations, and hematemesis. He was a person under investigation for COVID-19 with gastroenterology evaluation of reported retching with hematemesis. There was no evidence of ongoing bleed and endoscopy was deferred in the setting of his critical condition. A large right pleural effusion was identified and initially drained 2 liters of “dirty dishwater” fluid via a pigtail thoracostomy tube. Over three weeks, the patient had pigtail catheter exchanged for a larger chest tube as the effusion became empyema. Once the patient was stabilized and downgraded from the ICU, he was transitioned to an oral liquid diet, which was observed to drain into his chest tube.Outcomes: The patient underwent endoscopy with covered stent placement, venting percutaneous endoscopic gastrostomy tube placement, and eventual jejunostomy feeding tube placement. Nearly 3 months after initial admission, he underwent thoracotomy with decortication and washout, after which he recovered well and was discharged home on liquid diet.Conclusion: This case is uniquely interesting given our patient's remarkable outcome despite the significant published mortality of Mallory Weiss tear conversion to Boerhaave’s syndrome in a patient with Child-Pugh class B cirrhosis and critical condition at presentation, superimposed on the significantly altered resource profile available during the height of the COVID-19 pandemic. Upon completion, participants will be able to recognize confounding symptoms which may represent esophageal rupture in a chronically ill alcoholic.Upon completion, participants will be able to identify distinct differences in symptoms and pathology when an outlier (COVID-19) clouds the diagnosis.Upon completion, participants will have a greater understanding of a positive outcome after delay in diagnosis of Boerhaave's syndrome despite current literature indicating a higher incidence of fatal outcome.

Cardiothoracic and Vascular Surgery Podium Presentation: Ruptured Congenital Abdominal Aortic Aneurysm in an 11-Year-Old with Multiple Peripheral Artery Aneurysms 1439240 Christopher Tanga University at Buffalo Cardiothoracic and Vascular Surgery Podium Presentations Cardiothoracic and Vascular Surgery Introduction/Purpose: Congenital abdominal aortic aneurysms (AAA) are rarely encountered in clinical practice. The combination of a congenital AAA in a patient with multiple peripheral artery aneurysms is even more rare. We report the management of an 11-year-old male who presented with a ruptured congenital AAA who also had multiple peripheral arterial aneurysms. Methods or Case Description: This 11-year old male collapsed after complaining of severe abdominal pain. A computed tomography (CT) scan was obtained demonstrating an 11 cm ruptured AAA. He was taken emergently for an exploratory laparotomy. The retroperitoneal hematoma was evacuated while the supraceliac aorta was compressed. The proximal aortic aneurysm neck was dissected and the suprarenal aorta was clamped. The aneurysm was repaired with a bifurcated tube graft. He survived and recovered well but had a prolonged hospital course secondary to a prolonged ileus.Outcomes: At 2-month follow up, a CT was obtained that demonstrated the development of new internal iliac artery aneurysms, an axillary and brachial artery aneurysm, and interosseous aneurysms. These were repaired with coil embolization of the internal iliac aneurysms, and thrombin injection of the interosseous aneurysms. The axillary artery aneurysms will be surveilled with duplex ultrasonography.Conclusion: We report an 11-year-old male with no known genetic abnormalities who presented with a ruptured 11 cm AAA which was successfully repaired with an open bifurcated aortic graft. Additionally, the patient had multiple peripheral artery aneurysms. The internal iliac artery, left brachial artery, and left ulnar interosseus arteries have all been successfully repaired. The left axillary artery aneurysm is being closely surveilled. Describe the presentation and management of a ruptured abdominal aneurysm in the pediatric patient.Describe the differential diagnosis of potential etiologies of pediatric abdominal aortic aneurysm.Understand the workup involved in pediatric abdominal aortic aneurysm.

Cardiothoracic and Vascular Surgery Podium Presentation: Symptomatic Esophageal Duplication Cyst in a 65-year-old Male 1439272 Jane Ohde AHN Esophageal Institute Vilok Vijayanagar St. John Macomb-Oakland Hospital James Martin Ascension Macomb-Oakland David Siegel Ascension Macomb-Oakland Neil Kleman Ascension Macomb-Oakland Rachel Cohen Ascension Macomb-Oakland Cardiothoracic and Vascular Surgery Podium Presentations Cardiothoracic and Vascular Surgery Introduction/Purpose: Esophageal duplication cysts are rare congenital anomalies of the gastrointestinal tract most commonly presenting in childhood. When found in adults they are most often symptomatic. There are rare reports of malignant transformation.Methods or Case Description: This is a 65-year-old male who presented with increasing dysphagia to solid foods. He was evaluated with computed tomography (CT) of the chest which showed a 4.5 x 4.3 x 3 cm exophytic mass arising from the right lateral aspect of the lower esophagus. The patient underwent an upper endoscopy with endoscopic ultrasound (EUS) for further workup of this mass. The ultrasound showed a 4.6 x 2.1 cm hypoechoic heterogeneous mass lesion with septations around the distal esophagus. FNA was performed which was nondiagnostic. A positron emission tomography (PET) scan was then performed which showed increased uptake in the lower portion of the thoracic esophagus. It was recommended the patient undergo surgical resection. Outcomes: A right posterolateral thoracotomy was performed with complete excision of the cyst. The cyst was inadvertently entered during dissection and purulent fluid was encountered. This was sent for cultures which showed mixed respiratory flora with rare yeast likely a result of infection introduced from the FNA. Pathology of the specimen revealed an esophageal duplication cyst with chronic inflammation and abscess formation with no evidence of malignancy. Conclusion: Esophageal duplication cysts are rare and usually present in childhood however our patient presented in late adulthood with a symptomatic cyst. The cyst likely became infected secondary to the FNA performed during his workup. Esophageal duplication cysts typically have a characteristic appearance on EUS and do not need biopsy for diagnosis. The mainstay of treatment is surgical which is now increasing performed minimally invasively. Describe the presentation and diagnostic workup for an esophageal duplication cyst.Recognize typical radiographic and endoscopic findings.Discuss the various therapeutic interventions and their indications.

Case Presentation: Treatment Emergent Small Cell Neuroendocrine Cancer of the Prostate 1439239 Kevin Carocci MSU McLaren Macomb Urology Gregory McIntosh MSU McLaren Macomb Case Presentation: Treatment Emergent Small Cell Neuroendocrine Cancer of the Prostate Urological Surgery Introduction/Purpose: Our case describes a 74-year-old male with treatment emergent small cell neuroendocrine prostate cancer (t-SCNC). He was initially treated with neoadjuvant ADT and radiation, subsequently progressing to m-CRPC. We look at the diagnosis and treatment guidelines of t-SCNC in patients with m-CRPC.Methods or Case Description: A 74-year-old male with a history of hemochromatosis and non-metastatic castrate resistant prostate cancer (nm-CRPC) presents to the Emergency Department with gross hematuria and clot retention. His history is significant for T3bN0M0 intermediate-risk prostate cancer, Gleason 4+3, and PSA 4.4 at diagnosis. He was treated with radiation in 2014 and subsequently progressed to nm-CRPC treated with initial Eligard in 2017 and the addition of Erleada was added in 2018. Patient underwent cystoscopy with clot evacuation and transurethral resection of prostate (TURP). Pathology revealed small cell carcinoma. A follow-up CT PET showed prostate cancer recurrence. Patient was then started on chemotherapy and completed 4 cycles of carboplatin and etoposide.Outcomes: t-SCNC is thought to arise with therapeutic resistance to androgen receptor targeted therapy with an ensuing transformative impact on the cell histology to a more aggressive variant. Treatment includes chemotherapy +/- monoclonal antibodies. Our patient seems to have responded favorably with a follow up PET CT demonstrating a near complete resolution of previously seen periprostatic extension and retroperitoneal/iliac chain lymphadenopathy as well as absence of new metastatic disease.Conclusion: Small cell carcinoma of the prostate (SCCP) is a rare malignancy that affects

Chronic Ischemic Monomelic Neuropathy after Arteriovenous Fistula Creation: A Unique Presentation of Vascular Steal. 1439242 Rachel Kaczynski St. John's Episcopal Hospital Youstina Asaad St. John's Episcopal Hospital Chronic Ischemic Monomelic Neuropathy after Arteriovenous Fistula Creation: A Unique Presentation of Vascular Steal. General Vascular Surgery Introduction/Purpose: We discuss a case of a 58 year old male who presented for left upper extremity steal syndrome including ischemic monomelic neuropathy (IMN) 1.5 months after arteriovenous fistula creation.Methods or Case Description: He presented after three surgical attempts to salvage his fistula with rest pain, complete loss of function with contracture of the 4th and 5th digits, and loss of sensation in the ulnar distribution for more than three weeks. At our institution, he underwent surgical ligation of the distal fistula and creation of new fistula proximally, resulting in complete resolution of his vascular steal symptoms almost immediately despite the chronicity prior to surgical presentation.Outcomes: Our patient provides a unique perspective regarding dialysis access salvage versus patient quality of life.Conclusion: The patients’ functional status and pain levels should take precedence over salvage of an arteriovenous access site, and early ligation of the access should be completed prior to chronic IMN development. However, if a patient presents late along the IMN course, we recommend strong consideration of access ligation in order to attempt to regain full neurovascular function of the extremity as we experienced in our patient.

Comparative Analysis On The Effects, Costs, And Clinical Indications For Autograft, Allograft, And Bone Graft Substitutes In The Setting Of Orthopedic Trauma Surgery 1439215 Ariel Kidron Kiran C. Patel Nova Southeastern University College of Osteopathic Medicine Hiep Nguyen Kiran C. Patel Nova southeastern University College of Osteopathic Medicine Tianyi Liu Kiran C. Patel Nova southeastern University College of Osteopathic Medicine Jack Bayer Kiran C. Patel Nova southeastern University College of Osteopathic Medicine Comparative Analysis On The Effects, Costs, And Clinical Indications For The Use Of Autograft, Allograft, And Bone Graft Substitutes In The Setting Of Orthopedic Trauma Surgery General Surgery Introduction/Purpose: When determining the graft of choice, osteoconductivity, osteoinductivity, ostegenicity, graft price, and morbidity should all be considered. Subsequent sterilization techniques and technology have provided surgeons promising allograft options. Furthermore, synthetic options have been introduced in an attempt to decrease the morbidity of autografts and decrease the transmission of disease during allograft procedures.Methods or Case Description: A systematic literature review of PubMed and UpToDate databases was conducted. A total of seventy-five articles, published in 2010-2020, were selected for the initial review. After examining each article, a total of thirty studies met inclusion criteria.Outcomes: Autografts displayed the highest compatibility and desired properties within orthopedics, including optimal osteoconductivity, osteoinductivity, and osteogenicity. Autografts also include the least cost but at a greater risk of morbidity to the patient. Allografts demonstrated slightly less osteoconductive properties, less potential osteoinductive properties, and no osteogenic potential. However, allografts spare the patient of donor site morbidity. Synthetic biologics such as bone matrix proteins (BMP) exhibit osteoinductive potential and share similar costs to allografts.Conclusion: Effective bone healing rests upon the judicious usage of bone grafts, bone substitutes, and synthetic factors. The determination is based on the ability to foster osteogenesis, osteoconduction, and osteoinduction while considering the associated costs and complications. Autograft remains the “gold standard” in regard to histocompatibility and osteointegration properties albeit posing donor site morbidity. Allografts and structural synthetics have reduced osteogenic and osteoinductive potentials in but pose less donor morbidity risks. The use of BMP successfully increased osteoinductive effects through signaling pathways in osteoblastic differentiation and osteogenesis involving TGF-beta. The development of different bone graft modalities may spearhead rapid bone healing with increasing clinical effectiveness, safety, and narrower indications.

Complex Nasal Reconstruction: Methods to Avoid a Forehead Flap 1439262 Mickel Voigt Philadelphia College of Osteopathic Medicine Kayla Humenansky Philadelphia College of Osteopathic Medicine Complex Nasal Reconstruction: Methods to Avoid a Forehead Flap Plastic and Reconstructive Surgery Introduction/Purpose: Approximately 4.7 million people are bitten by dogs every year, of which 44,000 were facial injuries.1 Facial dog bite injuries can include damage to the soft tissues but the unique architecture and lack of tissue for mobilization make closure of nasal defects challenging. We demonstrate how nasolabial flaps can be used in place of forehead flaps for reconstruction of multiple nasal subunits including the tip and columella .Methods or Case Description: A 26-year-old male presented following a facial dog bite in which he sustained a large soft tissue avulsion involving multiple nasal subunits. Options for nasal reconstruction including the forehead flap were discussed with him. To limit additional visible, scarring coverage was provided with a nasolabial flap.Outcomes: In general, a paramedian forehead flap offers coverage of all the nasal subunits, at the expense of a vertical forehead scar. For patients wishing to avoid a vertical scar, the nasolabial flap is an excellent choice. Historically, the nasolabial flap is described for resurfacing of alar defects; however, as presented here it can be used to resurface other nasal subunits as well. One of the major benefits of a nasolabial flap is the ability to camouflage the scar within the nasolabial fold. The flap is also durable, allowing for coverage of cartilage reconstruction. Conclusion: The nasolabial flap is an excellent option of nasal reconstruction; however, there are some limitations of the nasolabial flap. While we have proven its ability to resurface the ala, nasal tip, and columella, it is unlikely that it will reach the dorsum. As seen in this case presentation, the nasolabial fold should not be discounted as an excellent option for reconstruction of multiple nasal subunits.

Cryptorchidism and Small Bowel Obstruction, An Incidental Finding During Incarcerated Inguinal Hernia Repair 1439249 Alexander Gonzalez-Jacobo St. John's Episcopal Hospital Julia Porter St. Johns Episcopal Hospital Narinder Grewal St Johns Episcopal hospital Cryptorchidism and Small Bowel Obstruction, An Incidental Finding During Incarcerated Inguinal Hernia Repair General Surgery Introduction/Purpose: Cryptorchidism is a common congenital abnormality. An undescended testicle should be repaired by six months of age. One of the main risks of leaving an undescended testicle is malignancy. Here we present a case of a 65 year old male with an undescended testicle that presented with incarcerated right inguinal hernia causing SBO.Methods or Case Description: We present a case of a 65 year old male with PMH of right sided undescended testicle who presented to the emergency room with an incarcerated right inguinal hernia. Upon exam the patient had a right incarcerated inguinal hernias, the right side was tender to palpation. It was also noted that the patient only a left testicle. The patient was taken to the operating room for a right inguinal hernia repair and the contents of the hernia included viable small bowel and an undescended right testicle. Inguinal hernia was repaired with mesh and orchiectomy was performed.Outcomes: Hernia sac and testicle was sent for pathology. The pathology of the testicle was found to be benign and patient was discharged on POD 1.Conclusion: Cryptorchordism is a common congenital abnormality that is seen in young males, but is rare in adults. The relative risk of neoplastic changes in undescended testes is 40 times higher. After puberty the loss of functionality, and fertility rates do not improve after postpubertal repair this orchiectomy. After orchiectomy, repair should be performed by completely closing the inguinal canal after hernia defect is repair. Mesh and inguinal canal no longer need a channel for cord structures since they have been removed. This is an interesting case that is not readily encountered but one should know how to manage if encountered intraoperatively.

CT-guided drainage of numerous abscesses 1439216 Grant Myres Nova Southeastern University College of Osteopathic Medicine Chad Richards Nova Southeastern University College of Osteopathic Medicine CT-guided drainage of numerous abscesses General Surgery Introduction/Purpose: Acute bouts of appendicitis are the most common surgical emergency; unaddressed, serious complications will occur. This case will discuss the care for a ruptured appendicitis in a pediatric patient and how to properly diagnose appendicitis, thus preventing untoward outcomes.Methods or Case Description: The patient is a 7-year-old female with no past medical history who presents to the emergency department with her parents for a 2-3 week history of fever, abdominal pain, and non-bloody diarrhea. Patient presented to the emergency department 3 weeks prior and was diagnosed with the flu and discharged. At home, the abdominal pain persisted until patient returned. CT and US imaging were taken in the ED after initial supportive treatment. CT imaging showed advanced perforated appendicitis with formation of numerous abscesses.Outcomes: Patient was admitted and underwent CT-guided percutaneous abscess drainage. Despite surgical drainage and IV antibiotics, patient’s abscess and peritonitis complications persisted for 10 days until patient was able to be discharged. After the inflammation had subsided, patient had an uncomplicated follow-up appendectomy, resulting in resolution of symptoms.Conclusion: When the patient initially presented to the ED, the diagnosis of influenza lead to deleterious outcomes. A more comprehensive approach may have lead to the correct diagnosis of appendicitis before it ruptured, causing sepsis and abscess formation and necessitating surgical intervention. Ultimately, drainage and appendectomy lead to the patient’s fortuitous outcome. Recognizing the varied presentation of pediatric appendicitis prevents these complications.

Delayed Diagnosis of Urethral Straddle Injury 1439233 Hailey Eisner McLaren Macomb Delayed Diagnosis of Urethral Straddle Injury Urological Surgery Introduction/Purpose: The urethra accounts for only 4% of all genitourinary trauma. The bulbar urethra is the most common location of injury and typically results from a straddle type fall or direct blow to the perineum. Patients will classically present with a butterfly hematoma, blood at the urethral meatus and an inability to void. We present the rare case of a 69 year-old male with delayed diagnosis of a urethral straddle injury. Methods or Case Description: A 69 year-old male presented 4 days after falling onto a ceramic flower pot and sustaining blunt perineal trauma. Since the incident he experienced severe swelling, pain and ecchymosis throughout the entire groin and upper thighs. He had not urinated since prior to the trauma. He was evaluated by his PCP the day following injury and sent home with pain medications but no further work-up was obtained. Initial urological work-up revealed a significantly elevated serum creatinine of 10 and an anterior urethral injury with contrast extravasation into the perineum, scrotum and inguinal soft tissues. Primary urethral realignment and catheter placement via cystoscopy was unsuccessful. Urinary drainage was subsequently obtained with CT guided suprapubic catheter placement. Outcomes: The patient had significant improvement after successful urinary drainage with normalization of all labs. He was subsequently discharged home with plans for further evaluation and management to be done outpatient. Conclusion: Although it is common for patients to initially present with complications years after partial urethral injuries, patients who are unable to void after perineal trauma tend to present immediately. It is important to report this case of delayed diagnosis of a urethral straddle injury to better understand the rare presentation and potential consequences.

Delayed Retrieval of Resectoscope Beak Requiring Holmium Laser Fragmentation 1439256 Anthony Bonzagni McLaren Macomb Delayed Retrieval of Resectoscope Beak Requiring Holmium Laser Fragmentation Urological Surgery Introduction/Purpose: Equipment malfunction is a common occurrence in surgery. It places the surgeon in a difficult position having to devise an innovative solution to safely complete the surgery. If time permits, one may rely on expert opinion to navigate these situations. We present a case of equipment failure in a patient undergoing a bladder tumor resection. Methods or Case Description: 78-year-old male with a history of CRPC. He had a cystoscopy done in the office, which revealed a tumor on the lateral wall of the bladder. The patient was taken to the OR for a TURBT. Entrance into the bladder with the resectoscope was difficult secondary to a peno-membranous stricture. Once in the bladder, the ceramic beak of the scope detached and was seen in the lumen. Multiple attempts were made to remove the beak with the equipment at hand, however we were unsuccessful and the procedure was aborted. The patient was brought back to the OR for a 2nd attempt to retrieve the beak and complete the TURBT. Once the resectoscope beak was identified in the bladder, a 1000 micron laser fiber was used to laser the beak in half. Removal of all fragments was confirmed with repeat cystoscopy and fluoroscopy. The TURBT was then completed and the patient had an uncomplicated postoperative course.Outcomes: We were able to safely remove the resectoscope beak in a staged procedure using the holmium laser and we were able to resect the patient’s bladder tumor. Conclusion: Equipment malfunction is well documented in literature, however as each procedure is highly variable the solution requires improvisation. Our two-staged procedure demonstrates the creativity necessary to obtain the safest and best outcome for the patient.

Diversion Colitis Resulting in Perforation and Abscess Formation 1439273 Benjamin Hart Henry Ford Macomb Hospital Diversion Colitis Resulting in Perforation and Abscess Formation General Surgery Introduction/Purpose: Diversion colitis is a well described condition in patients after colostomy in which the de-functioned segment of colon undergoes microscopic or macroscopic inflammatory changes. Symptoms are typically only present in one third of patients and include bleeding per rectum, abdominal pain, and tenesmus. This is the first reported case of perforation and abscess involving a de-functioned segment of colon.Methods or Case Description: A 67 year-old male with a past surgical history significant for end colostomy with mucous fistula creation secondary to severe diverticular disease presented to ER with abdominal pain and fever. CT abdomen and pelvis demonstrated a retroperitoneal abscess communicating with the adjacent de-functioned descending colon.Outcomes: The patient was treated conservatively with antibiotics and CT guided drainage. One week later, the drain was interrogated and demonstrated resolution of the fluid collection with no communication to the retroperitoneum. The drain was subsequently removed.Conclusion: While symptomatic diversion colitis occurs in up to one third of patients with de-functioned colon, the phenomenon of perforation and abscess formation has never been described prior to this case report.

Effect of Demographics on EQ in Military Medical Students 1439261 Mackenzie Berry Amanda Sniadach Rocky Vista University of Osteopathic Medicine Jacob Doyle Rocky Vista University Sunjin Oh Rocky Vista University Effect of Demographics on EQ in Military Medical Students General Surgery Introduction/Purpose: OBJECTIVE: The purpose of this study was to assess the differences in emotional quotient during a high stress military trauma simulation of RVU military students by measuring different demographics including race, marital status, and sex in the medical students.Methods or Case Description: METHODS: The study consisted of 103 students (78 male, 25 female; 85 Caucasian, 11 Asian, 6 Mixed; 66 single, 37 married) attending RVU from three sessions (2017, N=30; 2018, N=32; 2019, N=41). All participants were contracted with the U.S. military, and placed in a hyper-realistic mass-trauma simulation to induce stress. • Participants filled out EQ questionnaires before and after the training using the Veracity TouchScreener® tablet, which records significant psychophysiological responses. • All the responses were pooled across 2017, 2018, and 2019. Contingency tables were analyzed for marital status, gender and race using a CochranMantel-Haenszel test for Nonzero Correlation.Outcomes: RESULT: Emotional quotient (EQ) data for race, gender, and marital status was not found to be significantly different among the demographics tested across the years.Conclusion: CONCLUSION: Medical students have similar emotional quotients during high stress regardless of marital status, gender and race. In other words, medical students have a consistent response that is unlikely to conflict with their performance. Although our study cannot disprove the existence of EQ results during stress, it does suggest a small correlation. In future studies we would like to compare emotional quotient data across different professions such as physician assistants, nurses, first responders and social workers.

Entero-cutaneous fistula presenting as an insect bite: A case report 1439252 Matt Schultzel SHARP and Scripps Hospital systems Nelli Ghazaryan Des Moines University Entero-cutaneous fistula presenting as a bug bite: A case report General Surgery Introduction/Purpose: Enterocutaneous fistulas that develop between the colorectal anastomosis and the skin are usually a late manifestation of an unrecognized anastomotic leak. The prevalence of enterocutaneous fistulas in the general population is not known. There are very few reports in the literature of fistulas that include the gluteal region or lower limb. Methods or Case Description: 61 year old woman with a history of rectal cancer, status port TaTME treatment with subsequent radiation therapy. She was lost to follow-up and presented 1 year later at an outside hospital, complaining of what she thought was a bug bite along the posterior of her distal thigh. The "bite" formed an abscess which burst, yet stool and undigested food started draining from the wound. This created suspicion for a colocutaneous fistula. Outcomes: At the time of I&D, her White Blood Count (WBC) was 32K. She became septic upon opening of the posterior compartment of the thigh despite her high WBC. She underwent end colostomy and multiple I&D of thigh to decompress the abscess and stop the fistula with eventual primary closure.Conclusion: Colocutaneous fistulas occur almost exclusively as a complication of previous resection for diverticulitis, or from percutaneous drainage of diverticular abscesses. The patient herein described had a previous history of rectal cancer, s/p TaTME with subsequent radiation therapy. TaTME is associated with improved local control and better survival, as well as decreased postoperative genitourinary dysfunction due to pelvic autonomic nerve preservation. However, long-term oncologic outcomes of TaTME have not been reported. This case study shows the diversity with which an enterocutenous fistula may present and is an example of an atypical patient with different risk factors than would normally be expected.

Exploring Gender Differences in Emotional Intelligence Variables on Stress Habituation During High Intensity Trauma Simulation Training 1439267 Susan Roberts Rocky Vista University Anthony LaPorta Rocky Vista University Rebecca Ryznar Rocky Vista University Exploring Gender Differences in Emotional Intelligence Variables on Stress Habituation During High Intensity Trauma Simulation Training General Surgery Introduction/Purpose: This pilot project explored the relationship between emotional intelligence variables on the habituation process for military medical students involved in a high stress trauma simulation exercise. Identifying training differences would allow for more targeted training and improve learning and performance outcomes. Methods or Case Description: Second year Rocky Vista University military medical students completed the Intensive Surgical and Trauma Skills Course in San Diego, CA. Throughout the week, 50 increasingly intense mass casualty incident scenarios were simulated in Emergency and Operating Rooms. Throughout the course, salivary cortisol was measured as an indicator of stress response and habituation. Students completed the Emotional Quotient-Inventory 2.0, developed by Multi-Health Systems Inc. before and after the course. Emotional Intelligence inventory was correlated with varying levels of habituation throughout the exercise.Outcomes: Greater habituation was found in females with a greater sense of reality testing (pConclusion: Medical simulation training exercise coupled with high stress training is essential and effective for learning and performance improvement. Engaging in high stress ED and OR mass casualty scenarios may improve the habituation process and result in greater learning outcomes and individual performance. The outcomes of this project offer insight into targeting improved training for personnel in high stress simulation environments, with emphasis on gender differences.

From Sea to Air: Surgical Simulation in Extreme Environments 1439268 Anthony LaPorta Rocky Vista University Christopher Brazell Rocky Vista University College of Osteopathic Medicine Bryan Eldreth From Sea to Air: Surgical Simulation in Extreme Environments General Surgery Introduction/Purpose: BACKGROUND: In this three-phase experiment, the U.S. Navy assessed the feasibility of placing modular resuscitation and operation rooms aboard small, mobile ships to reduce the time between battlefield injury and life-saving surgical care. Methods or Case Description: METHODS: Three surgical teams were formed from 15 active duty military members. Simulated surgeries were performed aboard the USNS Brunswick using “Cut Suit” technology developed by Strategic Operations Inc to simulate four common battlefield injuries. Participants were fitted with individual monitors to assess dynamic and kinematic motion tracking and Motion Sickness Assessment Questionnaires (MSAQ) were given to participants. Each surgery was graded by subject matter experts on a Likert-type scale from zero to five with four or five deemed successful. Outcomes: RESULTS: 112 operations were performed in phase III and 89% were deemed successful with 46% completed at the roughest conditions tested. MSAQ scores revealed low motion sickness scores throughout most of the study and MSAQ positively correlated with sea state conditions (p. The only significant predictor for patient outcome scores was surgeon/team performing operations. Conclusion: CONCLUSIONS: Surgical performance scores provide evidence that ship motion does not adversely affect surgical outcomes. Our next investigation tests the previous procedures in non-traditional aircraft such as the V-22, a vertical take-off and landing tiltrotor aircraft currently used by the U.S military for casualty evacuation. Future research should also investigate the potential implications in the civilian sector for surgical stabilization in certain motion-induced trauma evacuation settings where immediate intervention is necessary.

Gastroesophageal Reflux Disease: A Historical Perspective of Surgical Innovation and Evolution 1439217 Kayla Strandberg Lake Erie College of Medicine - Bradenton Gastroesophageal Reflux Disease - A Historical Perspective of Surgical Innovation General Surgery Introduction/Purpose: The first documented evidence of esophagitis due to reflux dates back to 1855, however, it took over a century to pursue surgical intervention for gastroesophageal reflux disease (GERD). In 1951, Phillip Allison established a physiological relationship between hiatal hernias and gastroesophageal reflux disease - a concept that springboarded the advancement of anti-reflux procedures. Rudolph Nissen adopted Allison’s technique for diaphragmatic hernia repair, combining anatomical and physiological principles. Despite experimentation with multiple procedures, Nissen remained dissatisfied with symptom recurrence, prompting the development of new surgical approaches.Methods or Case Description: Relevant articles were first identified via database search (primarily PubMed) with a list of keywords that were used in various combinations without restrictions on the year of publication. Full-length articles were obtained and used to create a timeline from the first anti-reflux procedures to modern approaches.Outcomes: In 1936, Nissen performed a modified fundoplication in which he employed the Witzel technique (a technique used for gastrostomies) to treat an esophageal ulcer that was penetrating the patient’s pericardium. Sixteen years later, the patient was re-examined and there was no evidence of esophagitis. The success of this operation led to the development of “gastroplication,” the procedure now known as Nissen’s fundoplication. Many individuals have since modified this procedure to improve symptom resolution. Moreover, there were many alternative procedures to the Nissen fundoplication developed, but these techniques were found to be less effective and did not withstand the test of time.Conclusion: As medicine advances, surgical approaches to GERD are changing in order to increase safety and efficacy. The surgical history of GERD emphasizes the importance of long-term follow-up with these new techniques and provides a strong basis of comparison for quality of improvement.

General Surgery Podium Presentation: A Rare Case of Cocaine Induced Biliary Tree Constriction in a Middle Aged Male 1439221 Karlbuto Alexandre Detroit Medical Center - Sinai Grace Christopher Husko DMC Sinai Grace Hospital James Hebden Michigan State University College of Osteopathic Medicine John Barnwell DMC Sinai Grace Hospital General Surgery Podium Presentations General Surgery Introduction/Purpose: This is a case of a 62 year old male with a history of extensive cocaine use and cholecystectomy that presented to the emergency department with abdominal pain, urobilia, nausea, and vomiting. The patient had elevated total bilirubin (5.2) and direct bilirubin (3.7). CTA subsequently showed a mass in the gallbladder fossa measuring 3.8 x 2.1 cm. MRCP showed a 4.9 x 3.0 cm mass at the porta hilium with dilated proximal biliary ducts and abrupt transition at the porta hilium. Methods or Case Description: ERCP was performed with brush biopsy which showed predominantly benign ductal epithelium with rare atypical cells. CA 19-9 levels were mildly elevated at the time, only 94.3. Interventional radiology placed an internal-external biliary drain. The patient was discharged and told to obtain endoscopic ultrasound (EUS) as an outpatient, and return for follow-up. The patient was eventually re-admitted and discharged for other issues several times. He never followed up outpatient to receive EUS. On last admission to the hospital CT scan showed no biliary tree obstruction which was further confirmed on removal internal external biliary drain. Outcomes: The patient never followed for outpatient EUS to further rule out malignancy. We suspect the patient's initial symptoms and radiographic findings of biliary tree constriction may have been induced by cocaine use. Evidence in the literature states that cocaine use can precipitate Sphincter of Oddi dysfunction leading to obstructive jaundice. This is a rare case that has not been described in the literature.Conclusion: At this present time there is no direct correlation between cocaine use and biliary tree constriction. We highly suspect that this patient's obstructive jaundice and biliary tree constriction was caused by underlying cocaine use. Learn the effects of cocaine on the natural physiology of the body. Learn the effect of cocaine on the gastrointestinal tract and how this can affect the general surgeron. Discuss the different theories we have with regards to why our patients pathology disappeared.

General Surgery Podium Presentation: Hepatopancreaticobiliary Surgery Fellowship Selection Process: the Impact of Being a DO Candidate 1439259 Joseph Lim Medical City Arlington / TCU-UNTHSC SOM Terence Jackson Cleveland Clinic Akron General Edward Cho Methodist Health System Houssam Osman Methodist Health System Rohan Jeyarajah Methodist Health System General Surgery Podium Presentations General Surgery Introduction/Purpose: Doctors of Osteopathic Medicine (DO) candidates have an uphill climb in terms of matching into the field of General Surgery when compared to their Doctor of Medicine (MD) counterparts, as evident in the match rates between US MD Seniors and US DO seniors with similar USMLE scores. However, there has not been any study exploring the impact of being a DO applicant when applying to Hepatopancreaticobiliary (HPB) fellowship.Methods or Case Description: Survey was sent out to 52 faculty members and programs directors involved in HPB fellowship candidate selection. It consisted of cases where respondents had to pick a preferred candidate between on 2 abridged, fictional HPB fellow applications and give an open-ended response as to why they picked that candidate. The applications were nearly identical with one notable characteristic of interest such as candidate’s medical background (MD or DO). Faculty members were then asked to input their demographic information, followed by open-ended questions asking for their factors of interest when selecting a fellow. Program directors additionally provided demographic information of their past 5 fellows.Outcomes: The demographic survey of the faculty members and past fellows consisted of all MDs (both US and foreign). In the case-based portion of the survey, 50% of respondents explicitly stated that they preferred the MD candidate over their DO counterpart because of their degree. However, the most important factors included motivation, passion, work ethic, collegiality, professionalism, academic productivity, and technical skill; medical degree was not mentioned by any respondents.Conclusion: Being a DO candidate may provide to be a disadvantage when applying to HPB surgery fellowship program. However, there are more significant factors when selecting an HPB surgery fellow. Upon completion, participants will be able to describe the effect of a DO degree during the HPB fellowship selection process.Upon completion, participants will be able to list the most desired characteristics during the HPB fellowship selection process.Upon completion, participants will be able to describe the educational background of current HPB faculty members and HPB fellows.

General Surgery Podium Presentation: Integration of Ultrasound Examinations of Thoracic and Abdominopelvic Anatomy Increases Student Confidence of Associated Anatomical and Clinical Concepts 1439238 janelle Lopez Midwestern University, Arizona College of Osteopathic Medicine General Surgery Podium Presentations General Surgery Introduction/Purpose: Ultrasound addition to gross anatomy curriculum in medical schools has great success. Students are more interested in anatomy, perform better, and have positive experiences. Fall 2017, Midwestern University Arizona College of Osteopathic Medicine (AZCOM) and Arizona School of Podiatric Medicine (AZPOD) integrated ultrasound to the anatomy curriculum.Methods or Case Description: Ultrasound workshops provide students the ability to visualize anatomy in real-time, appreciate anatomical relationships, and understand the use of ultrasound for point of care assessment. Osteopathic and podiatric students enrolled in the 2017-2018 and 2018-2019 gross anatomy course utilized ultrasound to appreciate anatomical and physiological relationships of the heart during thoracic anatomy unit, gallbladder and aorta during abdominal unit and bladder and kidneys during posterior abdominal wall/perineum anatomy unit. After the conclusion of the course, students were emailed an anonymous survey to gauge their perceptions of whether the ultrasound experience enhanced their anatomical knowledge. Likert style questions were converted to numerical values and averages were compared using independent t-tests utilizing SPSS software.Outcomes: Males more strongly agreed the ultrasound workshops for the gallbladder and posterior abdominal wall enhanced their anatomical and clinical comprehension and their ability to orient to the anatomical space than females (p p > 0.05). Osteopathic and podiatric students both “strongly agreed” all workshops enhanced their anatomical and clinical comprehension, promoted further independent investigation into the anatomical relationships in the scanned region, and improved their ability to orient within the scanning area. Conclusion: Integration of ultrasound workshop to anatomy curriculum of fall 2017 showed subjectively increased anatomical comprehension academically and clinically, stimulation of student curiosity, and improved anatomic orientation. understand alternative teaching modalities used in undergraduate medical education. understand the effect on students by implementing the use of ultrasound into the medical school cirriculum.comprehend the importance of ultrasound in understanding anatomical relationships.

General Surgery Podium Presentation: Morbidity, Mortality, and Disability After Unhelmeted Motorcycle Accidents are Greater Than Their Helmeted Counterparts 1439248 Edward Skicki PennMedicine - Lancaster General Hospital Lucas Phi Arnot Health Loann Mai PCOM Mitchell Meagher Arnot Health Madison Morgan PennMedicine - Lancaster General Health General Surgery Podium Presentations General Surgery Introduction/Purpose: In 2003, Pennsylvania (PA) repealed its universal motorcycle helmet law and there has been a subsequent increase in motorcyclist fatalities. We sought to evaluate the demographics and outcomes of motorcycle crashes (MCC) in Pennsylvania since the law’s repeal. We hypothesized that MCC trauma patients who did not wear a helmet would have a higher mortality and more morbidities and disabilities than their helmeted counterparts.Methods or Case Description: The Pennsylvania Trauma Outcome Study (PTOS) database was retrospectively queried from 2003-2018 for all adult (age ≥15) trauma patients admitted to trauma centers in Pennsylvania for motorcycle crashes (MCC) and divided into helmeted and unhelmeted groups. Patient demographics, comorbidities, and clinical variables were compared between both groups to determine potential differences.Outcomes: From the PTOS query, 23,289 patients were identified. Unhelmeted MCC patients were more likely to be male, younger, intoxicated, black and of Hispanic ethnicity. Prehospital data showed unhelmeted MCC were more likely to have worse field GCS and were more likely to be intubated. They were then more likely to require admission, ICU/step-down care, and operative interventions. The mean ISS (16.47 vs. 14.57, pConclusion: Unhelmeted MCC result in a higher morbidity, mortality and disability. This study indicates that further sub-analyses need to be performed to identify individual populations in need of injury prevention programs. Upon completion, the participant will be able to understand the mortality differences between patients in unhelmeted motorcycle crashes compared to those who were helmeted.Upon completion, the participant will be able to understand the morbidity differences between patients in unhelmeted motorcycle crashes compared to those who were helmeted.Upon completion, the participant will be able to understand the post injury disability differences between patients in unhelmeted motorcycle crashes compared to those who were helmeted.

General Surgery Podium Presentation: Adopting Single-Incision Laparoscopic Appendectomy in Children: Is It Safe During the Learning Curve? 1439213 Shawn Chakraborty Alabama College of Osteopathic Medicine General Surgery Podium Presentations General Surgery Introduction/Purpose: Laparoscopic appendectomy is the gold standard for treatment of acute appendicitis. However, there is minimal data on the outcomes during the adoption of this technique in the era of wide laparoscopic experience in training and practice. This study evaluates the learning curve of contemporarily trained surgeons adopting SILS appendectomy, and more specifically, the safety of the operation during the early portion of this learning curve.Methods or Case Description: A retrospective review of 974 consecutive pediatric patients who underwent an appendectomy at the Children’s Hospital of Illinois from 2005 to 2018 was performed. A subgroup analysis was then performed for the technique of single incision laparoscopy; a total of 438 were included. The adoption of this technique by new partners in the group was evaluated. Outcomes measured included length of operation, length of anesthesia time, and complication rate (surgical site infection).Outcomes: A trend to faster operative times was observed for all surgeons as case numbers increased. Based on a 95% confidence band using a Loess smoothing method and this experienced time as the standard, we expect adopting surgeons to reach this experienced level after 51 cases. During this early SILS appendectomy learning curve, there was no significant difference in complication rate when compared to conventional multi-port laparoscopy.Conclusion: As expected, the more single incision cases performed, the shorter the operative times. More importantly, we did not find an increase in complications during this learning stage of single incision appendectomies in either perforated or non-perforated appendicitis. We conclude that the adoption of SILS appendectomies is safe even in the learning curve of the technique given contemporary minimally invasive training/practice. recognize the need for further research and evaluation as to the safety of SILS in pediatric surgical candidates.define the advantages to performing SILS rather than traditional laparoscopy. asses the importance of the learning curve in newly trained surgeons. illustrate the concept that SILS is a variation in approach and not a variation in technique. evaluate the need for more general surgery residency programs to incorporate single-incision training into their program

Improving Practice Patterns in Patients with Newly Diagnosed Bladder Masses Treated with Transurethral Resection 1439251 Daniel Drach Midwestern University Joseph Zanghi Franciscan Health James Siegert Franciscan Health Improving Practice Patterns in Patients with Newly Diagnosed Bladder Masses Treated with Transurethral Resection Urological Surgery Introduction/Purpose: Presence of muscle on initial transurethral resection of bladder tumor (TURBT) specimen and performing a restaging transurethral resection (reTUR) within 6 weeks in high risk non-muscle invasive bladder cancer (NMIBC) aid in accurate staging and, therefore, guide proper treatment. The purpose of this study was to assess and improve TURBT quality by making surgeons aware of their practice patterns and setting improvement goals. Methods or Case Description: Patients undergoing TURBT for a newly diagnosed bladder mass were analyzed during the 9 months before and after intervention. Primary endpoints were the presence of muscle on initial TURBT, and whether a reTUR was performed when clinically indicated. Initial results were presented to the physicians and a second dataset was then collected to assess for changes in practice patterns. Analysis was performed using Fisher's exact test to determine differences in categorical data. POutcomes: After comparing the TURBT results before and after our quality improvement intervention, we found a significant improvement in the number of patients receiving a reTUR with 5/13 (38%) before compared to 15/19 (79%) after, P=0.03. The number of specimens on initial TURBT with muscle present were not significantly different with 38/52 (73%) before and 33/49 (67%) after. The average time to reTUR before and after QI intervention was 32.4 days and 42.4 days, respectively. Conclusion: Our data suggests critical analysis of practice patterns and setting improvement goals can significantly impact clinical practices. Future studies will be performed to determine the impact these changes have on oncologic outcomes.

Is there a need for lap chole with hyperkinetic gallbladders? 1439224 Martin Hardy St. Marys Medical Center, KCU Consortium Christie Brock St. Marys Medical Center, KCU Consortium Adam Kramer St. Marys Medical Center, KCU Consortium Is there a need for lap chole with hyperkinetic gallbladders? General Surgery Introduction/Purpose: Classic biliary dyskinesia has been defined as an ejection fraction less than 35% during hepatobiliary scan with cholecystokinin. There are a subset of patients who present with symptoms of biliary colic and what appears to be biliary hyperkinesia, or an ejection fraction greater than 75%. There is little data concerning these patients with elevated ejection fraction, and resolution or recurrence of their symptoms in the postoperative period.Methods or Case Description: A retrospective chart review was completed on all patients >18 years, who had symptoms consistent with biliary colic, an ejection fraction >/= 75% on hepatobiliary scan and underwent a laparoscopic cholecystectomy between August 1, 2015 and October 31, 2019. The total number of patients identified was 60. Patients with gallstones were excluded from the study.Outcomes: All 60 patients in our review had pathology consistent with chronic cholecystitis, and 18 of those showed chronic cholecystitis with cholesterolosis. We retrospectively chart reviewed the post-operative information concerning resolution of preoperative symptoms. We were able to confidently identify 45 out of 60 patients (75%) that reported complete resolution of symptoms. 14 out of 60 had partial resolution and 1 patient reported no resolution. With this data, 59 out of 60 patients reported noticeable improvement in their pre-operative symptoms.Conclusion: According to the data from our study, we would conclude that there is indication for laparoscopic cholecystectomy in patients with hyperkinetic gallbladders. The range we used was >75% which is an easy cutoff for use in practice. Surgery would be an adequate option to offer patients presenting with biliary colic and EF >75%, especially in the setting of other negative diagnostic workup.

Medical Error Recognition by Medical Students during Simulated Asystole: Benefits from Teamwork and Assertiveness Training Techniques Used in Aviation 1439222 Alexander Lee Liberty University College of Osteopathic Medicine Andrew Behnke Liberty University College of Osteopathic Medicine Margaret Chi Liberty University College of Osteopathic Medicine Nakeia Hall Liberty University College of Osteopathic Medicine Mitch Morrison Liberty University Timothy Hodge Liberty University College of Osteopathic Medicine Medical Error Recognition by Medical Students during Simulated Asystole: Benefits from Teamwork and Assertiveness Training Techniques Used in Aviation General Surgery Introduction/Purpose: Our purpose was to determine if a teamwork lecture with first-year medical students using aviation-based methods would yield a perceptible increase in error recognition and intervention.Methods or Case Description: We recruited first-year medical students without current CPR training and provided American Heart Association certification in CPR techniques. The students were divided into a control group (n=10) and intervention group (n=11). The intervention group received a 90-minute session on aviation-based teamwork and error recognition and two role-playing exercises, including error assessment, just culture, and intervention strategies.Outcomes: The time (in seconds) in the intervention group was lower as compared to the control group (9.56 +/-2.47, 15.86 +/- 11.19, p=0.11). Forty-two percent of intervention group participants spoke up within a critical 10 second time period, compared to 30% from the control group. We videotaped the simulated exercises, recorded the debriefing sessions, and transcribed both for analysis. Using a combination of manual and NVivo-aided coding, we aggregated the interview results into three thematic clusters: Stress, Real-Life, and Speak Up.Conclusion: These results indicate the benefit of aviation-based team training and error recognition during simulated scenarios early in medical education.

Medical students immersed in a hyper-realistic surgical training environment leads to improved measures of emotional resiliency by both hardiness and emotional intelligence evaluation 1439265 Andrew Kimber Rocky Vista University Anthony LaPorta Rocky Vista University Medical students immersed in a hyper-realistic surgical training environment leads to improved measures of emotional resiliency by both hardiness and emotional intelligence evaluation General Surgery Introduction/Purpose: Burnout is experienced by medical students, residents, and practicing physicians at significant rates. Individuals may be protected against developing burnout symptoms if they have higher levels of Hardiness and Emotional Intelligence. Previous studies have shown that both Hardiness and Emotional intelligence protect against the detrimental effects of stress, however there is limited research on how training programs affect both simultaneously. This study defines the association of Hardiness and Emotional Intelligence and their potential improvement through hyper realistic immersion simulation training in military medical students.Methods or Case Description: A total of 68 second year medical students enrolled in the US military scholarship program from five United States medical schools participated in this study. During a six day hyper-realistic surgical simulation training course, students rotated through different roles as part of a medical team and responded to several mass-casualty scenarios. Hardiness and Emotional Intelligence were assessed using the Hardiness Resilience Gauge (HRG) and the Emotional Quotient Inventory (EQ-I 2.0) respectively, at two time points: on arrival (pre-event) and after completion of the course (post-event). Outcomes: Hardiness and emotional intelligence scores and sub scores consistently improved from pre-event and post-event assessments. No difference in training benefit was observed between genders but were observed by age where age was more often associated to Emotional Intelligence. In addition, factor analysis indicated that the HRG and EQ-I 2.0 assessment tools measured predominately different traits although they share some commonalities in some components. Conclusion: Hardiness and Emotional Intelligence scores can be improved through immersion training in military medical students. Results from this study support the use of training course interventions and prompt the need for long term evaluation of improvement strategies on ameliorating burnout symptoms.

Need for Increased Awareness of International Circumcision Variations and Associated Complications 1439230 Ryan Margolin Touro College of Osteopathic Medicine Christine Lomiguen Lake Erie College of Osteopathic Medicine Need for Increased Awareness of International Circumcision Variations and Associated Complications Urological Surgery Introduction/Purpose: Male circumcision is a prevalent and straightforward procedure. Cultural, religious, and/or social factors impact the decision for circumcision, with method of circumcision and patient age varying accordingly. Safety also varies when performed by non-medically trained (traditional) practitioners, endemic internationally. Complications associated with traditional practitioner performed circumcision warrants further consideration by physicians with patients from international areas. A thorough initial approach with at-risk patients or genitourinary-focused visits can foster open discussion and better understanding of complications attributable to circumcisions.Methods or Case Description: A systemic literature search yielded 24 manuscripts assessed and incorporated into this review.Outcomes: Circumcision complications include: bleeding, infection, pain, incomplete foreskin removal, glans amputation, glans necrosis, skin bridge formation, meatal stenosis, or death. Rates vary based on patient age, practitioner training, and method of circumcision. Increased complications are evident from circumcisions after the neonatal period and into adolescence, due to bleeding from increased foreskin vascularity. Cultures which utilize traditional practitioners and untrained volunteers, with varying skill levels, often do not perform circumcisions until a patient has reached adolescence. Surgical settings can vary in equipment and medication availability and sterility. Complication rates from traditional practitioners are difficult to ascertain due to lack of record taking.Conclusion: Circumcision is a widely performed procedure with risks. Considering varying methods, conditions, and age at which patients undergo circumcision, it is important to emphasize circumcisions are not identical. Heightened clinical suspicion of long-term complications, including meatal stenosis, iatrogenic phimosis, skin bridges, and undesirable appearance, are recommended. When obtaining a clinical history, urologically focused questioning should determine not only if a circumcision was performed but also details, including age, method, and procedure location, to better guide clinicians.

Neurofibroma Cholecystitis, a Rare Manifestation in Neurofibromatosis Type 1: A Case Report 1439264 Kayla Brown Nova Southeastern University Kiran C. Patel College of Osteopathic Medicine Grace Mele Peconic Bay Medical Center, Stony Brook Southampton General Surgery Residency Program Rachel Grinnan Peconic Bay Medical Center Steven Ouzounian Peconic Bay Medical Center Neurofibroma Cholecystitis, a Rare Manifestation in Neurofibromatosis Type 1: A Case Report General Surgery Introduction/Purpose: Neurofibromatosis Type 1 (NFT-1) is one of the most common inherited disorders. It is due to spontaneous genetic mutations of the NF-1 gene coding for the tumor suppressor gene Neurofibromin. The incidence and prevalence of NFT-1 is among the highest for an inherited disorder with nearly 100% penetrance. Patients with NFT-1 have a higher rate of morbidity and mortality due to the development of malignancies and complications as compared to the general population.Methods or Case Description: Our patient presented with gastrointestinal manifestations relating to NFT-1, which is an exceedingly rare occurrence. A cholecystectomy was performed for his clinically deteriorating hepatobiliary pathology secondary to a neurofibroma tumor not seen on preoperative imaging.Outcomes: Gastrointestinal manifestations are rare, and as a result are nearly always undiagnosed. They are usually discovered only after causing severe life-threatening symptoms such as obstructive or hemorrhage which requires emergent intervention. GI tumors in NFT-1 are usually found once they are large, obstructive, or causing bleeding which by definition leads to difficulty in treatment and subsequently high morbidity and mortality rates.Conclusion: Advanced imaging of NFT-1 patients may increase detection and aid in appropriate early treatment, of patients with occult gastrointestinal neoplasms. Currently there is a clear lack of standardized screening and treatment algorithms which might otherwise allow for the more proactive identification and surgical treatment of the intra-abdominal tumors associated with patients with NFT-1. In the interim physicians should maintain a high index of clinical suspicion, in both monitoring and treating these complex patients. More study is needed to decrease the associated morbidity and mortality in this group of patients, especially in light of the fact that the median survival from this disease is only age 31.

Neurological Surgery Podium Presentation: Geographic Disparities in County-Level Prevalence of Allopathic, Osteopathic, Non-Surgical, and Surgical Residency Programs in the United States 1439220 Dario Marotta Alabama College of Osteopathic Medicine (ACOM) Larry Armstrong Northwest Arkansas Neuroscience Institute Matthew Heard Sara Buckley Telyn Peterson Andrew Nam Abigail Jackovic Brittany Cuff Mackenzie Fowler Stephen Aita Victor Del Bene Neurological Surgery Podium Presentation Neurological Surgery Introduction/Purpose: Physician shortage is a well-documented contributor to inequitable medical care access in rural and underserved communities. Residency prevalence may contribute to this shortage. Therefore, we aimed to characterize the distribution and socioeconomic profiles of U.S counties with residency programs by residency type.Methods or Case Description: Medical residencies (n=4,882) were compiled from the Accreditation Council for Graduate Medical Education (ACGME) and American Osteopathic Association residency databases. Programs were categorized by type (allopathic, osteopathic, non-surgical, surgical). County frequencies were merged with 19 county-level variables from the U.S. Census Bureau American Community Survey 5-Year Estimates (2013-2018). The Rural-Urban Continuum Code (RUCC) was used as a measure of rurality.Outcomes: Allopathic and osteopathic programs differed significantly in frequency and geographic distribution yet were independently consistent with most census variable mean values of the general U.S. population. Comparisons between counties with exclusively allopathic and osteopathic programs revealed osteopathic residencies served less populous and educated counties with [mean(SD)]: lower incomes [$52,152($12,022)], older age [39.8(4.8)], higher percentage of disabled persons [15.8%(4.1%)], and higher percentage of veterans [9.3%(2.5%)]. Logistic regression revealed that for every 1-unit RUCC increases, there was a 50% decreased odds of finding a residency program, 40% decreased odds of finding an allopathic program, and 25% decreased odds of finding an osteopathic program. Post-accreditation unification reduced the prevalence of surgical and non-surgical residencies in 36 counties. Fifty percent of osteopathic neurosurgical residencies were eliminated despite having an average existence of 26.9(18.5) years, thereby impacting four counties.Conclusion: Osteopathic residencies are distributed in more rural and underserved counties. Post-accreditation unification may reduce access to surgical and non-surgical care. ACGME accreditation efforts toward improving access to care through residency distribution should incorporate osteopathic strategies. Summarize the impact of medical residencies in rural and underserved communitiesCharacterize socioeconomic profiles of U.S. counties with medical residency programsCompare and contrast the frequency and distribution of counties with allopathic, osteopathic, non-surgical, and surgical programsDiscuss the potential impacts of reduced medical residency prevalence resulting from post-accreditation unificationPropose accreditation strategies to support the establishment of residency programs in rural and underserved counties

Penile Amputation with Primary Reanastomosis and Post-Operative Leech Therapy 1439232 Adam Peterson Mclaren Macomb Urological Surgery Scott Sircus Mclaren Macomb Urologic Surgery Penile Amputation with Primary Reanastomosis with Post-Operative Leech Therapy Urological Surgery Introduction/Purpose: To date self-amputation of the penis remains a rarity. There is little evidence to support the best management strategies and is typically left to relying upon expert opinion. Our case describes a 28-year-old male under immense psychological stress amputating his penis, and management with primary microscopic reanastamosis.Methods or Case Description: a 28-year-old male with a history of depression presents to the emergency department after penile self-amputation. Upon presentation the penis was unavailable, however, was delivered within 4 hours of the inciting event. After amputation an approximately 5 mm urethral stump remained. After discussion with family, social work, and the urologic team the decision was made for primary microscopic anastomosis, given the success reported by expert opinion. Post-operatively the patient required leech therapy to aid with venous pooling and survivability. Throughout his post-operative course ultrasound demonstrated good arterial flow throughout the penis, however due to venous pooling and poor blood flow to the penile skin the skin, the foreskin and penile skin began sloughing. The patient then elected to proceed with formal penectomy opposed to skin grafts placement. which would lead to a more difficult and tedious recovery, with unknown success rates.Outcomes: We were able to demonstrate good arterial flow throughout the penis. Good arterial flow with poor venous outflow led to significant venous pooling requiring leach therapy. After approximately 6 weeks the patient elected for penectomy instead of proceeding with further management with penile skin grafts.Conclusion: In conclusion, penile amputation remains a rarity in urology. Undertaking expert opinion primary reanastomisis is possible and time sensitive. Major challenges arrive not with the initial surgery but post-operative complications f many times leading to eventual penectomy despite best surgical efforts.

Percutaneous Balloon Compression Technique using Intraoperative DynaCT for the Treatment of Trigeminal Neuralgia: Technical Note 1439275 Aakangsha Jain Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine Assad Ali Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine Percutaneous Balloon Compression Technique using Intraoperative DynaCT for the Treatment of Trigeminal Neuralgia: Technical Note Neurological Surgery Introduction/Purpose: Percutaneous balloon compression (BC) is a well- established technique that can provide immediate therapeutic relief to patients suffering from trigeminal neuralgia (TN). The general procedure of BC uses fluoroscopy imaging to guide the needle through the foramen ovale (FO). The aim of this study was to describe our experience with a novel technique using intraoperative DynaCT as an adjunct for more accurate guidance of the needle to the FO.Methods or Case Description: In this study, DynaCT was used to perform BC in 14 TN cases. The three-dimensional path of the needle was pre-planned using DynaCT and the FO was accessed with needle-guided bi-plane fluoroscopy. DynaCT was used for confirmation of the final position of the needle prior to insertion of the balloon as well as for confirmation of the position of the balloon after inflation.Outcomes: DynaCT-guided percutaneous BC allowed for precise placement and positioning of the needle. It facilitated easier cannulation of the FO by providing three-dimensional images for needle guidance. The clinical results were good, and all patients had a quick postoperative recovery. There were no complications.Conclusion: The advantages of the DynaCT-guided technique include a single precise needle pass, less trauma, and avoidance of vessel injury. Precise placement of the balloon into different aspects of the foramen ovale can target trigeminal branches more selectively and allow for a better outcome.

Perioperative Multimodal Anesthetic Care Incorporating Transversus Abdominis Plan Block Is Associate With Reduced Narcotic Use in Laparoscopic Sleeve Gastrectomy 1439225 Sean Martin UPMC Pinnacle Perioperative Multimodal Anesthetic Care Incorporating Transversus Abdominis Plan Block Is Associate With Reduced Narcotic Use in Laparoscopic Sleeve Gastrectomy General Surgery Introduction/Purpose: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgery performed in North America. As our knowledge of the importance in limiting narcotic use in postoperative patients increases, we sought to evaluate the effect of transversus abdominis plan blocks (TAP) on inpatient narcotic use in patients undergoing LSG. Methods or Case Description: A retrospective review of LSG performed at a single institution by three bariatric surgeons was performed. All cases over a fifteen-month period were included and anesthesia records were reviewed to stratify patients those that received a TAP block and those that did not. Demographic, as well a surgical outcomes were collected for all patients. Narcotic utilization, as reported in morphine equivalents (ME), was evaluated between the two groupsOutcomes: 384 LSG patients were identified of which 37 (9.6%) received a TAP block. There was no statistically significant difference in postoperative morbidity, length of stay or readmission between groups. Average total hospitalization narcotic utilization in patients with TAP blocks was 49 ME (IQR 14.5-89) to 83 ME (IQR 58.5-110) in the no TAP group (pConclusion: Patients that received a TAP block as a part of their perioperative anesthetic care utilized less in hospital narcotics than those patients that did not receive a TAP block. TAP blocks may be a useful pain control adjunct in patients that undergo LSG.

Plastic and Reconstructive Surgery Podium Presentation: An Innovative Approach To Mini Abdominoplasty Procedures Using Exclusively Local Anesthesia 1439260 Ian Zelko Midwestern University Zach Zylstra Midwestern University Plastic and Reconstructive Surgery Podium Presentation Plastic and Reconstructive Surgery Introduction/Purpose: Mini abdominoplasties with liposuction have long been performed in hospitals under general anesthesia. In our study we aim to evaluate the patient’s peri-operative experience of performing this procedure using only tumescent anesthesia.Methods or Case Description: Fifty mini abdominoplasties with liposuction, using tumescent anesthesia, were performed between 2017-2019 in an ambulatory setting. The tumescent fluid infused was comprised of 50 mL of 2% plain lidocaine, 1mL of 1:1000 epinephrine, 10 mL of 8.4% sodium bicarbonate, and 1000 mL of 0.9% normal saline. Liposuction and tissue excision were completed with the patient conscious. Patients were seen in the office for post-operative visits 1, 2, 4, and 12 weeks after surgery. A survey was completed by patients to gather subjective data.Outcomes: All participants were female with a mean age of 53 years old. All procedures were safely completed without any intra-operative complications. The mean amount of fluid aspirated with liposuction was 2462 mL. The average dimensions of excised tissue were 50.6 cm in length and 11.6 cm in height. Based on a 1-10 scale, with 10 being the worst pain, intra- and post-operative pain was rated on average as 1.9 and 3.9 respectively. Mean patient satisfaction was 4.3, based on a scale from 1 – 5, with 5 being excellent satisfaction. Twenty-eight patients rated their satisfaction as excellent. There were no major or minor complications. Nine patients had some form of revision performed, of which five were scar revisions.Conclusion: The study results demonstrate that this procedure can be safely performed with tumescent anesthesia, with minimal pain for the patient and without compromising the aesthetic outcome or complication rate. Upon completion, participant will be able to describe the instruments used and general procedural instructions for a mini-abdominoplasty under exclusively local anesthesia. Upon completion, participant will be able to list the components of the tumescent utilized for fully awake liposuction and mini-abdominoplasty, as well as understand its concentration limits. Upon completion, participant will be able to appreciate that the procedure mentioned can be safely and effectively performed out-patient without the need for general anesthesia.

Plastic and Reconstructive Surgery Podium Presentation: Plastic Surgery During the COVID-19 Pandemic for Improved Mental Health and Quality of Life 1439237 Makayla Gologram Lake Erie College of Osteopathic Medicine Christine Lomiguen Lake Erie College of Osteopathic Medicine Justin Chin Lifelong Medical Care Plastic and Reconstructive Surgery Podium Presentation Plastic and Reconstructive Surgery Introduction/Purpose: Plastic surgery, a largely elective specialty, involves remodeling the body for functional and/or cosmetic purposes. Elective plastic surgery reportedly increases mental and physical health and quality of life by enhancing physical features. Growth in number of procedures was expected in 2020; however, the COVID-19 pandemic derailed this surge as procedures were deemed non-essential. Considering benefits of elective cosmetic procedures, this research aims to raise awareness of implications plastic surgery and COVID-19 have on mental health, quality of pre- and post-surgical care, and demand for aesthetic surgery in a “new normal” society. Methods or Case Description: A search was conducted on Google Scholar and National Library of Medicine’s MEDLINE/PubMed databases. The following terms were queried: “plastic surgery,” “aesthetic surgery,” “COVID-19” and “coronavirus” in conjunction with “mental health,” “social media,” and “quality of life”. Outcomes: A total of 39 manuscripts were assessed and incorporated into this review. Evidence reports decreased overall surgical procedures performed during the pandemic, due to public health and safety mitigations, limited healthcare workers, and patient fear of the virus. With less procedures, there is opportunity to increase quality of pre- and post-surgical care (e.g., additional infection prevention measures). Safely resuming plastic surgery can improve mental health and quality of life, especially in patients with body dissatisfaction, and can lead to increased comfort with and demand for aesthetic surgery.Conclusion: Since the initial climb of COVID-19 cases, restrictions on elective procedures have begun to relax, along with public health guidelines. The mental health and quality of life benefits of safely resuming plastic surgery may result in positive and measurable secondary outcomes. A spike in COVID-19 cases may, once again, cause restrictions among elective surgeries to be enforced. Understand the growth in cosmetic plastic surgery proceduresAssociate cosmetic procedures with their benefits to mental health and quality of life.Understand the hardships the surgical subspecialty has endured during the COVID-19 pandemic.Learn the benefits of implementing plastic surgery resumption during the COVID-19 pandemic with the associated preventative measures.Explain the risks of proceeding with elective plastic surgery during COVID-19.

Positional hepatic outflow obstruction alleviated by breast implant during orthotopic liver transplantation 1439253 Christine Kolwitz NYU Winthrop Positional hepatic outflow obstruction alleviated by breast implant during orthotopic liver transplantation General Surgery Introduction/Purpose: The purpose of this case report is to describe a technique to alleviate hepatic outflow obstruction during a deceased donor orthotopic liver transplantation, caused by compression of the retrohepatic IVC when the liver was released to its position of rest. This technique utilizes a traditional silicone breast implant placed deep to the liver to elevate the liver off of the retroperitoneum, preventing compression of the IVC.Methods or Case Description: This case describes a 66 year-old male patient with cirrhosis and liver failure secondary to hepatitis C infection, complicated by hepatocellular carcinoma which was minimally responsive to Yittrium-90 radioablation. The patient underwent a successful deceased donor liver transplant, however, was found to have hepatic outflow obstruction causing hemodynamic instability and decompensation prior to leaving the operating room. In order to take the patient to the ICU, laparotomy pads were placed behind the liver to elevated it away from the IVC, and the patient was left with an open abdomen. Upon return to the OR 48hours later, the lap pads were removed and replaced with a silicone breast implant.Outcomes: This technique improved the venous outflow obstruction and prevented hemodynamic instability and decompensation, allowing the patient to leave the hospital in good condition.Conclusion: Although an off label use, breast implants are readily available at most institutions, and an acceptable and effective way to help position a transplanted liver and alleviate venous outflow obstruction.

Primary Malignant Melanoma of the Urinary Bladder 1439246 Elizabeth Snajdar McLaren Macomb Primary Malignant Melanoma of the urinary bladder Urological Surgery Introduction/Purpose: Primary malignant melanoma to the urinary bladder accounts for 0.2% of all cases. To date, there are 28 reported cases of primary malignant melanoma of the bladder in the literature, making it an exceedingly rare lesion. We present the case of a 78-year-old female, with no prior history of melanoma, who presented with incontinence and gross hematuria. Subsequent workup led to cystectomy revealing histology and immunohistochemistry consistent with primary malignant melanoma. Extensive investigation with PET/CT did not reveal a melanotic tumor on metastatic work up.Methods or Case Description: A 78-year-old female presented with incontinence and gross hematuria. CT urogram was performed and revealed a bladder mass along with left hydroureteronephrosis. Patient subsequently underwent transurethral resection of the bladder tumor with concurrent left ureteral stent placement. The tumor was unamenable to complete resection due to tumor size and location. She then underwent treatment consisting of radical cystectomy with ileal conduit, bilateral pelvic lymph node dissection, hysterectomy with bilateral salpingoopherectomy, and excision of anterior vaginal wall. Surgical margins as well as lymph nodes were all negative at the time of resection. Patient was unfortunately not a candidate for adjuvant therapy given her comorbidities.Outcomes: The patient developed evidence of retroperitoneal, mesenteric metastasis, and pulmonary metastasis approximately 12 months after diagnosis. The patient subsequently succumbed to her metastatic disease sixteen months after her initial diagnosis.Conclusion: Primary malignant melanoma of the bladder is exceedingly rare, yet poses great risk given its lethality with a mean survival time of 20 months. Due to the limited number of reported cases, it is essential to publish such cases as to better understand and characterize its behavior and histology in an effort to better serve our patients.

SAFE! Successful Nonoperative Management of a Sport-Induced Grade V Hepatic Injury 1439258 Karin Gunther Ascension Macomb-Oakland Hospital Joseph Buck Ascension Michigan St. John SAFE! Successful Nonoperative Management of a Sport-Induced Grade V Hepatic Injury General Surgery Introduction/Purpose: In the United States, blunt liver injury is most commonly caused by a motor vehicle collision. Methods or Case Description: We present a case of a 17 year old male who had the unusual presentation of hepatic vein injury after collision with another baseball player.Outcomes: Despite his high American Association for the Surgery of Trauma grade injury, he was able to be treated conservatively without operative management or blood transfusion.Conclusion: This case highlights the evolving management of hepatic injury towards non-operative therapies, even for high grade V hepatic injuries.

Salvage Of Chronically Resistant Bilateral Charcot Foot Osteoarthropathy With Signs Of Osteomyelitis 1439244 Ariel Kidron Kiran C. Patel Nova Southeastern University College of Osteopathic Medicine Hiep Nguyen Kiran C. Patel Nova southeastern University College of Osteopathic Medicine Tianyi Liu Kiran C. Patel Nova southeastern University College of Osteopathic Medicine Ananya Pathak University of Guelph-Humber Nghi Nguyen Kiran C. Patel Nova southeastern University College of Osteopathic Medicine Enjolina Iqbal Kiran C. Patel Nova southeastern University College of Osteopathic Medicine Salvage Of Chronically Resistant Bilateral Charcot Foot Osteoarthropathy With Signs Of Osteomyelitis General Surgery Introduction/Purpose: Charcot foot osteoarthropathy is a rare, degenerative, and painless condition involving disease around joints caused by diabetes. The patient presented with ulcerations, inflammation, and redness bilaterally. Chronic diabetic ulcers related to Charcot deformity are a high risk to develop osteomyelitis and are 12x more likely to result in amputation. However, this patient was able to avoid amputation by undergoing midfoot exostectomy and adopting novel therapeutic modalities.Methods or Case Description: A 73-year-old female with a history of Type II diabetes, hemoglobin A1c =5.6%, neuropathy, and arthritis presented to the clinic with significant difficulty in walking and Achilles tightness with worsening bilateral foot ulcerations. The ulceration showed resistance to healing despite using a variety of off-loading modalities. X-ray imaging demonstrated severe rocker-bottom flatfoot with end-stage midfoot osteoarthropathy. Wound culture of the midfoot prior to surgery detected proteus bacterial infection.Outcomes: Preoperatively the soft tissue infection was treated with a combination of Doxycycline and Augmentin followed by operative midfoot resection of exostosis bone overgrowth, as well as bilateral Achilles tendon lengthening. During the operation, an Integra graft was utilized to regrow new skin with minimal scarring. An Adaptic sterile dressing with a fiberglass posterior splints were applied bilaterally. X-rays demonstrated clean resectioning of bone without any signs of infection. Conclusion: Surgical resection of the midfoot bone growth/exostosis helped taking pressure off the skin and allowed the wound to heal without recurrence. Lengthening of the Achilles tendon helped destress the forces on the midfoot and minimized the potential for further breakdown and progression of the flatfoot. Postoperatively the weekly dressing changes and treatment of the ulcerations with Silvadene antibiotic cream, Adaptic sterile dressing, and fiberglass posterior splint, kept the tissue healthy and viable.

Simulating Early Clinical Experiences with Surgical Procedures in the Anatomy Lab 1439247 Tayler Gant VCOM-Auburn Harrah Chiang VCOM-Auburn Simulating Early Clinical Experiences with Surgical Procedures in the Anatomy Lab General Surgery Introduction/Purpose: There is evidence to suggest that early exposure to clinical experiences could bolster a medical student’s education and preparation to tackle the problem-based learning encountered during clinical rotations1,2. We hypothesized that incorporating common surgical procedures into the gross anatomy lab during preclinical years, students would have an enhanced anatomical learning experience. The incorporation of these procedures would not be disruptive to the normal conduct of the anatomy lab, nor result in exorbitant costs or extraordinary faculty skills. Methods or Case Description: Seven common surgical procedures, including intraosseous needle insertion, venous cut down, chest tube insertion, surgical cricothyroidotomy, core needle liver biopsy, appendectomy, and hysterectomy, were taught as a part of this study. Video instructions on each of the surgical procedures were provided before each corresponding lab. Surveys were provided to study participants to measure their satisfaction of the procedures and how it was incorporated into the allotted lab time.Outcomes: Both students and faculty who were sampled in the study reported that they were satisfied with the procedures (96.5% and 100%, respectively), that the procedures did not interfere with lab times (96% and 100%), and that the procedures facilitated clinical learning (98% and 100%).Conclusion: This study demonstrates that providing a novel surgical teaching program to medical students is beneficial to their education and non-disruptive to the conventional anatomy curriculum. This exercise further facilitates an osteopathic education by displaying how structure and function organize surgical practice.

The Effect of Hyper-Realistic Trauma Training on Emotional Intelligence in Second Year Military Medical Students 1439263 Rebecca Ryznar RVU Erin West The Effect of Hyper-Realistic Trauma Training on Emotional Intelligence in Second Year Military Medical Students General Surgery Introduction/Purpose: This project demonstrated that: -Hyper-realistic trauma training increases emotional intelligence in second year medical students -Increased emotional intelligence is correlated with improved physician wellness and less burnout -No significance difference was seen based on gender This project expanded upon previous exploration of emotional intelligence during the habituation for military second year medical students undergoing high-stress simulation with trauma and surgical skill training. The objective was to interpret emotional intelligence data before and after hyper-realistic immersion trauma training and to include a larger sample size than previously investigated.Methods or Case Description: Fifty increasingly intense mass casualty scenarios with simulated Emergency Department (ED) and Operating Room (OR) procedures were performed while students lived as if deployed in an Afghan village. Students rotated through a variety of roles in both the ED and the OR throughout the weeklong program. Second year medical students completed the EQ-i 2.0 Model for Emotional Intelligence on the first and last day of the intensive surgical skills week. Outcomes: Total emotional intelligence significantly improved from pre to post scores as well as each of the five domains and most subdomains. Scores improved an average of 4 points after only a 5-day training course. Conclusion: Hyper-realistic trauma training significantly improves emotional intelligence in second year medical students. This has wide implications for the future of medical and surgical training. This training philosophy can develop emotionally intelligent physicians who can perform well under stress and be more resistant to burn out which is something the medical community desperately needs.

The Effect of Immersion Trauma Training on Resiliency and Hardiness in Military Medical Personnel 1439269 Anthony LaPorta Rocky Vista University Sarah Sysbist Mckenzie Zeman Rocky Vista University Andrew Kimber Rocky Vista University The Effect of Immersion Trauma Training on Resiliency and Hardiness in Military Medical Personnel General Surgery Introduction/Purpose: “Hardiness” is a generalized mode of functioning that influences one’s interpretation of the world and helps to make sense of their experiences. It consists of three components: Challenge, Control, and Commitment. Together, these components facilitate a flexible, confident, and passionate approach to life that ensures a strong degree of resiliency. We believe these components, measured in conjunction with immersion trauma training, are important in the development of military medical students and their ability to respond and optimally perform in highly stressful and unexpected situations.Methods or Case Description: We now have the results of participants from immersion training during the Intensive Surgical Skills Course. In this exercise students rotated through scenarios of increasing stress. Students took the Hardiness Resilience Gauge (HRG), a 28-item measure of hardiness, before and after the course. This measure results in a Total Hardiness score, along with scores on each of the Challenge, Control, and Commitment subscales. Outcomes: On average, at both time points students scored in the Mid (90-110) to High (110-130) range for Total Hardiness, Challenge, Control, and Commitment. 2018 and 2019 scores were nearly identical. The average Total Hardiness scores increased from 112 to 117, p=0.00237. The average Challenge scores increased from 111 to 116, p=0.0192. The average Control scores increased from 112 to 117, p=0.0206. The average Commitment scores increased from 111 to 116, p=0.00322.Conclusion: This study demonstrates the effectiveness of immersion-based training exercises in increasing one’s resiliency and hardiness. These types of exercises can increase first responder readiness by training military units and medical personnel to perform their functions more effectively in active chaotic environments. The MHS Hardiness score is a first of its kind score verified in the US military.

The Effect of Marriage and Gender in Regard to Honestly Reporting Stress 1439266 Mackenzie Berry Amanda Sniadach Rocky Vista University of Osteopathic Medicine Sunjin Oh Jacob Doyle Rocky Vista University The Effect of Marriage and Gender in Regard to Honestly Reporting Stress General Surgery Introduction/Purpose: OBJECTIVE: The purpose of this study was to assess the likelihood of providing false answers to questions asking about the level of stress while measuring different demographics. Methods or Case Description: METHODS: 103 students (78 male, 25 female; 85 Caucasian, 11 Asian, 6 Mixed; 66 single, 37 married) attending Rocky Vista University from three sessions (2017, N=30; 2018, N=32; 2019, N=41). • hyper-realistic mass-trauma simulation to induce stress and the data was collected using the Veracity TouchScreener® tablet • Contingency tables were analyzed for Marital status, Gender and Race using a Cochran-Mantel-Haenszel test for Nonzero Correlation. Outcomes: RESULTS: Single people more likely to truthfully admit being stressed • Neither group is more likely to be dishonest • Gender showed a significant effect for stress data, but no specific trends • Non-significant trend could be observed with females being more likely to admit stress • Non-significant trend of males being more likely to lie than females. Conclusion: CONCLUSION: Single participants were more likely to admit being stressed when compared to married participants. This data will enable us to identify populations that are more susceptible to stress in order to provide them with resources and training to further improve their mental health and readiness. Future studies will include data from another session in 2020; this may solidify the trend shown in Gender demographic by increasing the sample size

Urological Surgery Podium Presentation: Stopping the Flow: A Peculiar Case of Enlarged Prostate, Kidney Injury, Cardiac Dysfunction, and Colonic Polyps 1439274 Sydney Pekarek Midwestern University Chicago College of Osteopathic Medicine Miranda Schmidt Midwestern University Chicago College of Osteopathic Medicine Anis Rauf Midwestern University Chicago College of Osteopathic Medicine Suha Moten Loyola University of Chicago Urological Surgery Podium Presentation Urological Surgery Introduction/Purpose: Waldenstrom Macroglobulinemia is a rare form of Non-Hodgkin's lymphoma. Surgical management of such condition is poorly documented; however, surgical biopsy is key to making the diagnosis. The following case illustrates a peculiar case of Waldenstrom Macroglobulinemia complicated by immunoglobulin light chain amyloidosis.Methods or Case Description: A 70-year old male presented with acute kidney injury and was found to have proteinuria secondary to prostatic enlargement. Urologic management included a workup for prostatic cancer as well as benign prostatic hypertrophy. The patient underwent a transurethral resection of the prostate (TURP). Following this management, proteinuria persisted without an identifiable cause. The decision was made to biopsy the kidneys at this time; results showed deposition of amyloid. Although no biopsy was performed, we suspect the prostate contained amyloid depositions. The patient had failure to thrive secondary to decreased oral intake; esophagogastroduodenoscopy was completed with biopsy of the esophageal and gastric tissue. Concurrently, the patient’s cardiac function appeared to deteriorate. Upon echocardiogram, specific hypertrophy of the left ventricle was found and an endomyocardial biopsy was completed. Combined biopsy results alluded to systemic light chain amyloidosis; further workup identified Waldenstrom Macroglobulinemia as the underlying cause.Outcomes: The patient underwent successful kidney, endomyocardial, gastric, and esophageal biopsies as well as a TURP. Subsequent percutaneous endoscopic gastrostomy tube was placed for nutritional management. Medical management included chemotherapy, kidney function monitoring, and nutritional status evaluation secondary to decreased absorption capabilities. The surgical team continues to follow the patient for possible resection of tissues as needed.Conclusion: Waldenstrom Macroglobulinemia requires a high index of suspicion. This case illustrates an uncommon presentation of light chain amyloidosis. Diligent evaluation of prostatic enlargement and decreased kidney function is required. Upon completion, participants will be able to recognize when further investigation of prostatic biopsy is suggested. Upon completion, participants will be able to recognize the misleading nature of BPH presentation. Upon completion, participants will be able to identify the associated symptoms of systemic amyloidosis.

Urological Surgery Podium Presentation: The Impact of Low Pressure Pneumoperitoneum in Robotic Assisted Radical Prostatectomy: A Prospective, Randomized, Double Blinded Trial 1439214 Matthew Rohloff Metro Health: University of Michigan Health Urological Surgery Podium Presentation Urological Surgery Introduction/Purpose: Robotic surgery has revolutionized postoperative outcomes across surgical specialties. However, the use of pneumoperitoneum comes with known risks given the change in physiological parameters that accompany its utilization. A recent internal review found a 7% decrease in postoperative ileus rates when utilizing a pneumoperitoneum of 12 mmHg over the standard 15 mmHg in robotic assisted radical prostatectomies (RARP). The purpose of this study is to prospectively evaluate the utility of lower pressure pneumoperitoneum by comparing 8 mmHg and 12 mmHg during RARP.Methods or Case Description: Patients were randomly assigned to undergo robotic assisted radical prostatectomy at a pneumoperitoneum pressure of 12 mmHg or 8 mmHg. The primary outcome was development of postoperative ileus and secondary outcomes were length of operation, estimated blood loss and positive surgical margin status.Outcomes: A total of 201 patients were analyzed; 96 patients at 8 mmHg and 105 patients at 12 mmHg. The groups were adequately matched as there were no differences between demographic parameters or medical comorbidities. There was a decrease in postoperative ileus rates with lower pneumoperitoneum pressures; 2% at 8 mmHg and 4.8% at 12 mmHg. There were no clinically significant differences in estimated blood loss, total length of operative time and positive margin status.Conclusion: Lower pressure pneumoperitoneum during robotic assisted radical prostatectomy is non-inferior to higher pressure pneumoperitoneum levels and likely infers a decreased rate of postoperative ileus. The experienced surgeon may safely perform this operation at 8 mmHg and take advantage of the proposed benefits of this pressure setting. understand the importance of lower pressure pneumoperitoneum and its physiologic effectsdefine the benefits of lower pressure pneumoperitoneum on ileus ratesrecognize the differences in varying pneumoperitoneum pressures during a robotic assisted radical prostatectomy

Warm Zone Care: Lessons Learned from the Large-Scale Active Shooter Training Prior to the STEM School Shooting 1439270 Alissa Lenz Rocky Vista University WARM ZONE CARE - Lessons Learned From Large-Scale Active Shooter Training Prior to the Stem School Scooting General Surgery Introduction/Purpose: The amount of horror produced by an active shooter in a school or a church or for that matter anywhere cannot be overstated. Newly developed techniques include stopping the bleed, developing better logistics scenarios, timing and transportation scenarios along with activities within the accepting hospital. This large-scale training event provided in valuable information as to all of the areas in need of improvement. Methods or Case Description: 910 including dispatchers, law enforcement, firefighters, paramedics, and hospitals trained in 18 events at 3 churches and Schools The active shooter drill was then initiated at the point of injury with 7 injured simulated patients all wearing a “CUT-Suit” simulation. Evaluation was from point of injury to and including care in the Operating Room. Allowing evaluation of real time and system logistics. Outcomes: A total of 112 simulated patients received 480 medical procedures. Central to this exercise, law enforcement established a "WARM ZONE". EMS was able to move into the facility, locate casualties, extract the first victim within minutes and move them to a casualty collection point and transported to safety within nine minutes. Six months later “The Real” event happened at Stem School in Colorado. Nine students were out by 16 minutes. By comparison it was 47 minutes before the first fireman entered Columbine in 1999.Conclusion: Strengths and weaknesses were identified among the participating groups, both pre-hospital and in-hospital care. These include what roles agencies play if a true event and specific timing in establishing areas such as the warm zone itself, casualty collection point, transportation and at the accepting hospitals themselves.

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