Quickshot – Basic Science Abstracts and Case Reports 2021

Basic Science Abstracts

  • Abstracts are listed in order of presentation
Abstract Number Abstract Title Presenter
3829 Unique microRNA Expression Patterns in Hematopoietic Stem and Progenitor Cells after Hemorrhagic Shock and Polytrauma in Young and Old Adult Mice Darden
3508 Comparison of Operative Characteristics and Outcomes after Infected Endovascular and Open-Surgical Abdominal Aortic Graft Excision Small
3712 Effects of Beta-Blockade on the Expression of Regulatory microRNAs following Severe Trauma and Chronic Stress Apple
3751 ADAMTS8 Locus associated with Abdominal Aortic Aneurysms in the UK Biobank Pruitt
3793 An immune-modulatory strategy to mitigate hepatic ischemia/reperfusion injury in a murine model Duarte
3817 Mechanistic insights of nicotine receptors in exacerbation of TAAD formation by nicotine Chun
3835 A Pilot Study of a Point-of-Care Wound Bed Assay to Predict Graft Take Barrios
3847 Resolution of inflammation via the FPR2 receptor pathway in abdominal aortic aneurysms Filiberto

Surgery Day Abstract Submission 2021 : Entry # 3829
ABSTRACT TITLE
Unique microRNA Expression Patterns in Hematopoietic Stem and Progenitor Cells after Hemorrhagic Shock and Polytrauma in Young and Old Adult Mice
ABSTRACT BODY
Introduction: Elderly mice are unable to sufficiently upregulate and sustain emergency myelopoiesis after severe injury, in part due to inadequate emergency myelopoietic response by bone marrow (BM) hematopoietic stem and progenitor cells (HSPCs) and circulating myeloid cells. There has been growing evidence of microRNA (miR) control of HSPC self-renewal and differentiation. Our main objective was to compare BM HSPC miR responses of old and young mice in a clinically relevant murine model of severe trauma and shock.
Methods: C57BL/6 adult male mice aged 8-12 weeks (young) and 18-24 months (old) underwent a model of polytrauma and hemorrhagic shock (PT) that engenders an injury severity score of 18. Pseudomonas pneumonia was induced in a separate polytrauma cohort (PT+PNA) of young and old adult mice. miR expression patterns were calculated from lineage-negative enriched BM HSPCs isolated from PT mice at 24 hours and PT+PNA mice at 48 hours post-injury. Genome-wide expression analyses and Ingenuity Pathway Analysis (IPA) were also performed on bronchoalveolar lavage (BAL) leukocytes.
Results: miR expression patterns were significantly different among all conditions (p<0.05), except for old-naïve vs old-injured (PT or PT+PNA) mice, suggesting an inability of old mice to mount a robust early response to severe shock and injury. Among the miRs with the highest differential expression between young and old PT +/- PNA mice were miR494-3p, miR-223, miR196b-5p, miR-17-5p, miR-145a-5p, miR-132-3p, and miR-125a-5p, which have been demonstrated to be important for renewal, expansion, or differentiation of myelopoietic stem cells. Additionally, young adult mice had significantly more cells obtained from their BALs and were determined to have more PMNs compared to old mice (59.8% vs 2.2%, p=0.0069); however, there was no significant difference in the percentage of activated macrophages (6.0% vs 6.8%, p=0.89). Interestingly, the old adult murine BAL leukocytes demonstrated a more dysfunctional transcriptomic response to PT+PNA than young adult murine BAL leukocytes, as reflected in IPA predicted upstream functional analysis with 119 pathways altered in young adult BAL leukocytes versus only 96 pathways in old adult BAL leukocytes.
Conclusion: Using our murine model of polytrauma and hemorrhagic shock, which emulates severe human trauma, we determined that the miR expression pattern in BM HSPCs after PT (+/-PNA) is significantly dissimilar in old versus young adult mice. In the acute phase, old adult mice are unable to mount a robust miR response in HSPCs following injury. HSPC miR expression in old PT mice reflects a diminished functional status as well as a blunted capacity for terminal differentiation of myeloid cells, demonstrated by the decreased percentage of PMNs and dysfunctional gene expression pattern in the BAL leukocytes of old mice. This is important as miR expression is a modifiable epigenetic cellular component that could improve outcomes.

PRESENTING AUTHOR NAME
Dijoia Darden
PRESENTING AUTHOR EMAIL ADDRESS
dijoia.darden@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Other
SENIOR AUTHOR/MENTOR NAME
Philip Efron

RESEARCH CATEGORY
Basic Science
RESEARCH DISCIPLINE
Acute Care/Trauma/Sepsis


Surgery Day Abstract Submission 2021 : Entry # 3508
ABSTRACT TITLE
Comparison of Operative Characteristics and Outcomes after Infected Endovascular and Open-Surgical Abdominal Aortic Graft Excision
ABSTRACT BODY
Introduction: National rates of open aortic repair(OAR) are declining due to endovascular procedures(EVAR); however, both strategies can present with aortic graft infection(AGI). AGI is a devastating complication associated with significant morbidity and mortality. To date, no studies compare infected EVAR to OAR graft removal. Therefore, we sought to analyze our experience with AGI and assess differences in patient characteristics, operative strategies, and short-term outcomes between infected EVAR and OAR graft excision.

Methods: A single-center, retrospective review of all AGI procedures was performed(2004-2020). The primary end-point was 30-day mortality. Secondary end-points included complications, re-infection, aorta-related death, and survival.

Results: 142 AGI explants were examined: infected EVAR-27%(n=38), OAR-73%(n=104). Demographics and comorbidities were similar between groups, but tobacco exposure(P=.032) and peripheral artery disease(P<.001) were more prevalent among OAR patients. Gram-negative/anaerobic infection was significantly more common with infected EVAR(53% vs. OAR-22%;P=.001). Infected EVAR removal was more likely to employ either an aorto-aortic or aorto-bi-iliac reconstruction configuration(EVAR-68% vs. OAR-9%;P<.001). There was no difference in the frequency of single vs. multi-stage or in-situ vs. extra-anatomic repair strategies. In contrast, conduit selection was significantly different with rifampin-soaked Dacron being used most frequently with infected EVAR(42% vs. OAR-13%;P<.001) while autogenous/non-autogenous biologic allograft use was more common with infected OAR(68% vs. EVAR-31%;P<.001).
The overall 30-day mortality rate was 21% and was not different between cohorts(EVAR-21% vs. OAR-20%;P=1). Similarly, there were no differences in overall complication incidence, but infected EVAR patients had a higher rate of gastrointestinal complications(34% vs. OAR-17%;P=.040). Freedom from major adverse limb events was lower after infected OAR management(1-year: 63±6% vs. EVAR-85±7%;log-rank P-value=.06). Life-long suppressive antibiotic therapy was prescribed more commonly after infected EVAR operations(28% vs. 11%;P=.048). However, one-year freedom from re-infection was similar(OAR 76±6% vs. 88±6%;log-rank P=.6). Correspondingly, there were no differences in aorta-related death or survival.

Conclusions: Infected EVAR is now a common cause of AGI and is associated with more virulent microbiology and increased postoperative gastrointestinal morbidity compared to infected OAR graft excision. Despite significant differences the in technical conduct of the operations, similar short-term outcomes can be anticipated for both infected EVAR and OAR graft removal operations. Differential use of suppressive life-long antimicrobial prophylaxis and incidence of adverse limb events in follow-up support utilization of different surveillance strategies.

PRESENTING AUTHOR NAME
Coulter Small
PRESENTING AUTHOR EMAIL ADDRESS
colt.pauzar@ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Medical Student
SENIOR AUTHOR/MENTOR NAME
Samir Shah

RESEARCH CATEGORY
Basic Science
RESEARCH DISCIPLINE
Vascular


Surgery Day Abstract Submission 2021 : Entry # 3712
ABSTRACT TITLE
Effects of Beta-Blockade on the Expression of Regulatory microRNAs following Severe Trauma and Chronic Stress
ABSTRACT BODY
Introduction: Beta-blockade administration following lung contusion, hemorrhagic shock and chronic stress has been shown to improve bone marrow function, decrease hypercatecholaminemia and reduce inflammation. MicroRNAs (miR) are critical biologic regulators and we sought to expand our understanding of the molecular mechanisms underlying the reduced inflammatory response following the administration of beta blockade in our rodent trauma model.

Methods: Male Sprague-Dawley rats aged 8-9 weeks (n=4/group) were randomized to lung contusion, hemorrhagic shock with daily restraint stress (LCHS/CS) ± propranolol (LCHS/CS+BB). Restraint stress occurred 2 hours daily following LCHS. Propranolol (10 mg/kg) was given IP daily until sacrifice on day 7. Bone marrow and liver were harvested. Total RNA & miR were isolated from CD34+ cells and genome-wide miR expression patterns were assayed. MiRs with significant expression differences were found using BRB Array Tool (p<0.001, t-test). Liver TNF- expression was performed with qPCR. Significance *p<.05 LCHS/CS vs LCHS/CS+BB by two-tailed unpaired t-test.

Results: There were marked differences in expression of 24 miRs in the LCHS/CS+BB group when compared to the LCHS/CS group, when using a p<0.001. Rno-miR-27a (associated with decreased production of inflammatory cytokines) was upregulated 4.8* fold following LCHS/CS+BB when compared to LCHS/CS alone. Liver TNF- expression was found to be significantly decreased following LCHS/CS+BB when compared to LCHS/CS alone (23±6* vs. 52±10 DNA/β-actin).

Conclusions: The use of beta blockade following trauma may help mitigate persistent inflammation by increasing expression of rno-miR-27a and reducing expression of TNF- in those who remain critically ill.

PRESENTING AUTHOR NAME
Camille Apple
PRESENTING AUTHOR EMAIL ADDRESS
camille.apple@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Surgery Resident
Post-Graduate Year (PGY) – for Surgery Residents Only
PGY 6
SENIOR AUTHOR/MENTOR NAME
Alicia Mohr

RESEARCH CATEGORY
Basic Science
RESEARCH DISCIPLINE
Acute Care/Trauma/Sepsis


Surgery Day Abstract Submission 2021 : Entry # 3751
ABSTRACT TITLE
ADAMTS8 Locus associated with Abdominal Aortic Aneurysms in the UK Biobank

ABSTRACT BODY
Introduction: Abdominal Aortic Aneurysms (AAA) remain a leading cause of death in elderly males. The multigenic nature of the diseases remains poorly understood. Recent meta-analyses have identified several loci involved in disease development, but the UK Biobank (UKB) is an untapped resource for gene discovery. We hypothesized there are additional genetic variants associated with AAA and tested this through a GWAS within the UKB.

Methods: AAA patients were identified using ICD and procedure codes. Thoracoabdominal aneurysms, thoracic aneurysms, dissection with aneurysm and connective tissue disorders were excluded. The remaining UKB participants with GWAS data were included in the referent group. Logistic regression allowed estimation of the OR and 95% CI adjusting for age, gender and hypertension. Meta-analysis was performed on the previously reported top loci.

Results: GWAS was performed on 1,189 patients with AAA and 457,926 referent patients with European ancestry. ADAMTS8 was identified as a novel locus (1.3×10-8) with OR of 0.77 and 95% CI of 0.71-0.85. ADAMTS8 codes for a metalloproteinase expressed in macrophage rich areas of atherosclerotic plaques and may effect extracellular matrix remodeling. The Genotype-Tissue Expression (GTEx) database indicates lower expression with the minor allele of this SNP. Two previously reported loci also reached GWAS significance: 9p21 CDKN2B-AS1 (5.9*10-9) and CELSR2 (2.4*10-8) allowing for an updated meta-analysis.

Conclusion: While replication is still needed, this UKB GWAS presents ADAMTS8 as a novel locus and potential insight into matrix remodeling associated with AAA pathogenesis. We also further support the association between AAA development and CDKN2B-AS1 and CELSR2 loci.

PRESENTING AUTHOR NAME
Eric Pruitt
PRESENTING AUTHOR EMAIL ADDRESS
Eric.Pruitt@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Surgery Resident
Post-Graduate Year (PGY) – for Surgery Residents Only
PGY 5
SENIOR AUTHOR/MENTOR NAME
Yan Gong PhD

RESEARCH CATEGORY
Basic Science
RESEARCH DISCIPLINE
Vascular


Surgery Day Abstract Submission 2021 : Entry # 3793
ABSTRACT TITLE
An immune-modulatory strategy to mitigate hepatic ischemia/reperfusion injury in a murine model

ABSTRACT BODY
Introduction: Hepatic ischemia/reperfusion injury (IRI) is the leading cause of early graft dysfunction and contributes to the shortage of donor liver grafts. However, despite its clinical importance, there are no effective therapies to prevent or treat this condition. Indoleamine 2,3-dioxygenase (IDO) is an intracellular enzyme that catalyzes the catabolism of the essential amino acid tryptophan to the product kynurenine. It is well known for inducing a powerful immunosuppressive metabolic programming. To date, studies have mostly focused on prolonging graft survival by overexpressing IDO in the transplanted tissue. PEGylation of therapeutic proteins reduces their immunogenicity and extends systemic circulation time. Here, we PEGylate IDO and evaluate the efficacy and safety of this IDO delivery strategy to control the local hepatic inflammatory response in a mouse model of warm hepatic IRI.

Methods: We used a well-established mouse model of partial hepatic IRI. Partial hepatic ischemia was produced in the left and median lobes for 90 minutes followed by 6 hours reperfusion. Male 8-12 week old Balb/c mice were separated into 3 cohorts; PEGylated-IDO (PEG-IDO), IDO, and phosphate buffered saline (PBS) intravenously administered 48 hours prior to inducing ischemic injury.

Results: PEGylated-IDO significantly improved hepatic IRI; plasma levels of aspartate aminotransferase and alanine aminotransferase at 6 hours after reperfusion were significantly lower in the PEG-IDO group, when compared with those in PBS group (P<0.05). Histological analysis showed significantly less congestion, necrosis, and vacuolization in the PEG-IDO group compared with those in PBS groups (P<0.05) as assessed by Suzuki score. The presence of IDO also suppressed hepatocellular apoptotic death as measured the number of TUNEL+ hepatocytes, when compared to PBS treated mice. Furthermore, PEG-IDO therapy decreased localized hepatic infiltration of inflammatory cells such as T cells, neutrophils, and macrophages, and resulted in reduced expression of proinflammatory cytokines (IL-6, TNF-, IL-1 and IFN-) and chemokines (CXCL-10) after 6 hours of hepatic IRI.

Conclusion: The results in this study indicate that PEG-IDO preconditioning protects livers from local inflammation and liver damage induced by hepatic IRI. This metabolic immune-modulatory approach may be a new therapeutic strategy against innate immunity-dominated liver tissue damage.

PRESENTING AUTHOR NAME
Sergio Duarte
PRESENTING AUTHOR EMAIL ADDRESS
sergio.duarte@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Assistant Professor
SENIOR AUTHOR/MENTOR NAME
Ali Zarrinpar

RESEARCH CATEGORY
Basic Science
RESEARCH DISCIPLINE
Transplant/Hepatopancreatobiliary (non-cancer)


Surgery Day Abstract Submission 2021 : Entry # 3817
ABSTRACT TITLE
Mechanistic insights of nicotine receptors in exacerbation of TAAD formation by nicotine
ABSTRACT BODY
Hypothesis: Presence of nicotine triggers differential expression of subunits in nicotine acetylcholine receptors (nAChRs), resulting in exacerbation of TAAD formation.

Background: Tobacco smoke is a strong risk factor for exacerbation of TAAD formation in humans. High dose of nicotine treatment to tgfb2 knockout mice resulted in exacerbation of TAAD. A major biologically-active constituent of tobacco smoking products is nicotine. There are 17 distinct isoforms of the subunits in nAChRs, which form homomeric or hetromeric complexes. Among the subunits, α1, α7, δ, ε have been identified in a variety of non-neuromuscular cell types such as vascular ECs, vascular SMCs, smooth muscle specific α-actin positive myofibroblasts, T- lymphocytes, and macrophages. It has been shown that nAChR α1 and α7 had participated in the pathological processes of athrosclerosis and angiogenesis. In this study, we assessed differential expression of nAChR subunits in presence or absence of nicotine to investigate mechanistic role of their contributions to exacerbation of TAAD formation.

Methods: Exacerbation of TAAD formation were induced by treatment of BAPN in drinking water and mini-pump implantation of nicotine free base in Tgfb2 knockout mice. Post 14 days treatment, aortas were harvested from nicotine treated and control groups. qPCR was performed and expression of nAChR subunits was quantitated.

Results: Treatment of nicotine free base 45mg/kg/day (NEB 45mg) exacerbated TAAD formation in tgfb2 induced knockout mice. mRNA levels of nAChR subunits determined in skeletal muscle and descending thoracic aorta (DTA). While α1, α7, α9, β1, β2, δ, and ε subunits were detected in skeletal muscle, α1 and α7 were detected in aortas. NFB 45mg treatment decreased the mRNA levels of α1 subunit but increased that of α7 subunit.

Conclusion: Our findings indicate that NEB 45mg exposure promotes differential expression of nAChR subunits in aortas and suggests that this regulation may play an essential role in the exacerbation of TAAD formation by smoking.

PRESENTING AUTHOR NAME
Changzoon Chun
PRESENTING AUTHOR EMAIL ADDRESS
chang.chun@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Other
SENIOR AUTHOR/MENTOR NAME
Zhihua Jiang

RESEARCH CATEGORY
Basic Science
RESEARCH DISCIPLINE
Thoracic/Cardiac


Surgery Day Abstract Submission 2021 : Entry # 3835
ABSTRACT TITLE
A Pilot Study of a Point-of-Care Wound Bed Assay to Predict Graft Take

ABSTRACT BODY
Introduction:
Deciding when to graft a burn wound is instrumental in acute burn reconstruction. A diagnostic technology capable of predicting autograft success would be tremendously helpful in determining the optimal timing for initial debridement and grafting. In prior work, members of our team developed a point-of-care proteinase assay capable of predicting delayed wound healing in chronic wounds. In the work reported here, we seek to quantify these proteolytic enzymes in acute burn wounds in an effort to ultimately determine whether a quantitative assessment of proteinase activity in a burn wound might predict successful healing of split-thickness autograft.

Methods:
Eight burn patients were taken to the operating room for autografting. Tissue samples were obtained, as well as swabs of wounds pre- and post-excision. A point-of-care proteinase activity assay determined initial rate of fluorescence, which correlates to the amount of proteolytic enzyme activity. Autograft was then applied to the excised wound bed. Each autograft was assessed after two weeks, with ≥50% take considered successful, and <50% take deemed unsuccessful. Initial rates of fluorescence were then compared between pre- and post-excision sites. These groups were analyzed using two-sided student’s t tests, with p<0.05 identified as significant.

Results:
The pre-excision group initial rate was significantly higher than the post-excision group (p=0.0006). The tissue group initial rate was also significantly higher than the post-excision group (p = 0.0028). We also looked at pre-excision initial rates of enzymatic activity between autografts that were successful (n=10, 18.34±20.90) compared to autografts that ultimately failed (n=5, 4.32±4.62) with p = 0.169.

Conclusions:
In this pilot study, multiple findings indicate the potential of this fluorochrome-based point-of-care assay to differentiate wound beds with differing levels of proteolytic activity. Pre-excision tissue beds contained significantly higher initial rates of proteolytic enzymatic activity compared to excised and debrided tissue beds (p = 0.0006). This is consistent with unexcised burn wound morphology, as proteolytic enzymes function to debride damaged tissue and promote angiogenesis in the acute setting. Interestingly, the initial rates of proteolytic enzyme activity in pre-excised wounds of autografts that ultimately succeeded trended towards significance (p = 0.169) compared to autografts that ultimately failed, suggesting that these proteolytic enzymes reflect an overall healthy wound bed, the presence of which could portend a heightened chance for autograft success. This pilot study confirms the presence of proteolytic enzymatic activity in acute burn wounds utilizing a point-of-care test. Future work will investigate whether this test can ultimately assist physicians in predicting whether acute burn wounds are amenable to autografting.

PRESENTING AUTHOR NAME
Evan Barrios MD
PRESENTING AUTHOR EMAIL ADDRESS
evan.barrios@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Surgery Resident
Post-Graduate Year (PGY) – for Surgery Residents Only
PGY 2
SENIOR AUTHOR/MENTOR NAME
Joshua Carson MD

RESEARCH CATEGORY
Basic Science
RESEARCH DISCIPLINE
Burns/Plastic Surgery


Surgery Day Abstract Submission 2021 : Entry # 3847
ABSTRACT TITLE
Resolution of inflammation via the FPR2 receptor pathway in abdominal aortic aneurysms

ABSTRACT BODY
Introduction: The endogenous pro-resolving lipid mediator Resolvin D1 (RvD1) is derived from the ω-3 polyunsaturated fatty acid docosahexanoic acid and is involved in the resolution phase of acute inflammation. Specifically, RvD1 has been shown to have a beneficial effect in a diverse group of inflammatory disease models, although few studies have described the mechanism mediating those effects. The aim of this study was to decipher the role of RvD1 by means of the formyl peptide receptor 2 (FPR2) in a murine AAA model and to provide translational implications of these findings in samples derived from patients undergoing surgery for AAA.

Methods: Eight to 12 week-old male FPR2 knockout out (KO) and C57BL/6 (wild type (WT)) mice underwent treatment with either topical elastase (5ul) (n=5-8/group) or heat-inactivated elastase (n=4/group; controls). Aortic tissue was harvested on day 14 for evaluation of aortic diameter. WT mice underwent treatment with either topical elastase (n=5/group) or heat-inactivated elastase (n=5/group; controls). Aortic tissue was harvested on day 7, 14 and 21 and quantified for FPR2 expression. FPR2KO and WT mice (n=10) underwent topic elastase (day 0) and treatment with either RvD1 (100ng/mouse I.P.) or normal saline (control) daily until harvest on day 14. Additionally, aortic tissue from human AAAs (n=10/group) and from organ transplant donors (n=6/group; controls) were analyzed for quantification of FPR2 expression. The relative quantification of gene expression was analyzed using the ΔΔCT method with β-actin (mice) and GAPDH (humans) as the endogenous reference. Statistical analysis was performed using GraphPad Prism 7. Groups were analyzed using Mann-Whitney test for phenotype and Wilcoxon test for gene expression data. Data is presented as mean ± SEM for aortic dilation.

Results: FPR2KO mice exhibited larger aortic diameters as compared with WT group (200% ± 29% vs. 135% ± 13%; p=0.22). C57BL6 mice had higher FPR2 expression as compared with respective controls on days 7 (n=5/group p=0.125), days 14 (n=5/group p=0.06), days 21 (n=5/group p=0.06). RvD1 mediated protection against AAA formation was obliterated in FPR2KO mice (WT + RvD1: 56% ± 10% vs. FRP2KO + RvD1: 121% ± 8% (n=9/group p<0.0001). Male human patients with AAA had lower FPR2 expression as compared with respective controls (n=6-10/group, p=0.02).

Conclusion: This study identifies the state of failure in the resolution of inflammation by means of decreased expression of the pro-resolving receptor FPR2 in human AAAs. Mimicking this condition by genetic deletion of the murine ALX/FPR2 ortholog in C57BL6 mice exacerbated the aortic dilation induced by topical elastase. Additionally, the RvD1 mediated protection against AAA formation was obliterated in FPR2KO mice. In conclusion, this study established the role of pro-resolving signaling by means of the FPR2 receptor in aneurysms and vascular inflammation.

PRESENTING AUTHOR NAME
Amanda Filiberto
PRESENTING AUTHOR EMAIL ADDRESS
amanda.filiberto@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Surgery Resident
Post-Graduate Year (PGY) – for Surgery Residents Only
PGY 5
SENIOR AUTHOR/MENTOR NAME
Gilbert Upchurch Jr.

RESEARCH CATEGORY
Basic Science
RESEARCH DISCIPLINE
Vascular


Case Reports

  • Abstracts are listed in order of presentation
Abstract Number Abstract Title Presenter
3736 Adenocarcinoma of prior ureterosigmoidostomy site in a patient with a history of bladder exstrophy and remote ileal conduit reconstruction Mazirka
3598 Pseudomonal Meningoencephalitis With Ventriculitis Secondary to Bacteremia in a Burn Patient: A Novel Case McKean
3610 Intraductal Oncocytic Papillary Neoplasm of the Pancreas Munley
3637 Relapsing acute pancreatitis caused by a mucinous cystic neoplasm Ladd
3766 Robotic Preperitoneal Repair of a Traumatic Flank Hernia: A Case Report Brazel
3778 High Grade Neuroendocrine Tumor of the Presacral Space Invading the Rectum and Pelvic Sidewall Cadavid
3799 Cherubism: A Case Report of Pre-Pubertal Surgical Intervention in a 10-Year-Old Male Covey
3802 Donor Derived Cell Free DNA Testing for the Early Detection of Graft-versus-Host Disease in Solid Organ Transplantation: A Case Study Lewis
3805 Complex Multi-Specialty Management of an Iatrogenic Recto-Spinal Fistula Freeman
3832 Venous Bullet Embolus Following Gunshot Wound to Axilla Krebs
3853 Near-complete transection of stomach due to gastric band erosion leading to sepsis Vozzola
3856 Case Report: Incisional Hernia Repair with Biological Mesh McCracken
3850 Post-Infarction Left Ventricular Wall Rupture Presenting in the Setting of Blunt Traumatic Injury Carpenter

 

Surgery Day Abstract Submission 2021 : Entry # 3736
ABSTRACT TITLE
Adenocarcinoma of prior ureterosigmoidostomy site in a patient with a history of bladder exstrophy and remote ileal conduit reconstruction.

ABSTRACT BODY
Introduction: Carcinogenicity of ureterosigmoidostomy has been well established in the literature however the development of colon cancer in such patients remains a rare event. Exposure of colonic mucosa to urine is thought to be the cause of increased cancer risk but the exact pathophysiology is still unknown. Theories of increased nitrite and N-nitroso compounds, phagocyte activation response, and increased production of free radical oxygen species that result in DNA damage have all been suggested as underlying causes, but none proven with certainty. There appears to be a latent period after the creation of diversion and cancer occurrence with a median age of 31 years if diversion is still in place and 21 years after initial ureterosigmoidostomy that was followed by a re-diversion. Here we present a case of adenocarcinoma occurrence at the site of ureterosigmoidostomy 70 years after original surgery and more than 40 years after reconstruction to an ileal conduit.

Methods: A case study of a single patient was performed with a thorough review of the patient’s history and current medical status. A review of published literature was also performed in a non-systematic fashion.

Case presentation: A 72-year-old woman presented with abdominal pain, blood per rectum dark stool, and found to have a near-obstructing sigmoid colon adenocarcinoma on evaluation and biopsy. The mass was necrotic, large, and non-traversable on colonoscopy despite the patient being up to date on screenings with the last colonoscopy less than 10yrs before the presentation. Her history was significant for bladder exstrophy requiring neonatal Mainz II Pouch ureterosigmoidostomy diversion which was revised to the ileal conduit in her 20s, as well as cardiomyopathy, right-sided aortic arch, aberrant left subclavian artery, and Kommerells diverticulum, all requiring numerous vascular and cardiothoracic interventions. She underwent successful resection of the disease at our center, with mass noted to be at the Mainz II Pouch site demonstrating invasion into the retroperitoneum. The patient is currently recovering from the procedure.

Conclusion: Patients with a history of urinary diversion are at increased risk of colon cancer development due to exposure of mucosa to urine. Cancer can occur many decades after the diversion, even if there was a re-diversion procedure. Routine screenings may not be sufficient in timely diagnosis and patients likely need more frequent surveillance due to their increased risk to avoid late-stage diagnosis and obstruction.

PRESENTING AUTHOR NAME
Pavel Mazirka MD
PRESENTING AUTHOR EMAIL ADDRESS
pavel.mazirka@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Surgery Resident
Post-Graduate Year (PGY) – for Surgery Residents Only
PGY 1
SENIOR AUTHOR/MENTOR NAME
Thomas Read MD

RESEARCH CATEGORY
Case Report
RESEARCH DISCIPLINE
Oncology


Surgery Day Abstract Submission 2021 : Entry # 3598
ABSTRACT TITLE
Pseudomonal Meningoencephalitis With Ventriculitis Secondary to Bacteremia in a Burn Patient: A Novel Case

ABSTRACT BODY
Introduction
Burn patients with large burn surface area involvement are at increased risk of infection due to the presence of large wounds, multiple surgeries, prolonged intensive care unit admission, and immunosuppression. Pseudomonas aeruginosa (P. Aeruginosa) is the most commonly isolated organism in this population. Even with frequent infections in the burn population, meningitis and encephalitis are rare, and ventriculitis is exceptional.

Methods
We report the case of a 66-year-old woman who developed P. Aeruginosa bacteremia during her hospital course, causing secondary meningoencephalitis with ventriculitis.

Results
She was admitted for partial and full thickness burns affecting the neck, chest, abdomen, upper medial arms, and bilateral anteromedial thighs for an estimated 20% total body surface area burn. She met sepsis criteria and broad-spectrum antimicrobial coverage was initiated. Magnetic resonance imaging of the brain, performed for altered mental status, revealed meningitis and ventriculitis. Cerebrospinal fluid analysis demonstrated findings consistent with bacterial meningitis, with cultures positive for P. Aeruginosa. Serial neuroimaging with computerized tomography revealed new areas of ischemia concerning for septic emboli.

Conclusions
In the presence of altered mental status and fever of unknown origin, workup should remain broad. Even in the presence of another source, it is important to keep an open mind for the rarer intracerebral infection as it requires different management, including urgent evaluation of antibiotic selection and dosing to ensure central nervous system penetration, and neurosurgical evaluation.

PRESENTING AUTHOR NAME
Jordan McKean MD
PRESENTING AUTHOR EMAIL ADDRESS
jordan.mckean@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Surgery Resident
Post-Graduate Year (PGY) – for Surgery Residents Only
PGY 1
SENIOR AUTHOR/MENTOR NAME
Joshua Carson MD

RESEARCH CATEGORY
Clinical/Translational
RESEARCH DISCIPLINE
Burns/Plastic Surgery


Surgery Day Abstract Submission 2021 : Entry # 3610
ABSTRACT TITLE
Intraductal Oncocytic Papillary Neoplasm of the Pancreas

ABSTRACT BODY
Intraductal oncocytic papillary neoplasm (IOPN) of the pancreas has historically represented a rare subtype of intraductal papillary mucinous neosplasms (IPMN) but is now considered a distinct entity with an improved prognosis compared to IPMN subtypes. It is a precursor to invasive carcinoma and is characterized by complex, thick, arborizing papillae with layers of oncocytic epithelial cells and distinct cancer-related fusion genes. Our case report describes a patient with a multiloculated cystic pancreatic mass with main pancreatic duct dilation found incidentally on imaging. Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic ultrasound (EUS) and fine needle aspiration revealed fragments of epithelium with papillary structures and high grade dysplasia. He underwent laparoscopic distal pancreatectomy, regional lymphadenectomy, and splenectomy without complication. Final surgical pathology revealed a 2.6cm intraductal onocytic neoplasm with high grade dysplasia, negative margins, twelve negative lymph nodes and background chronic pancreatitis. He has no evidence of disease recurrence after fourteen months and has not required adjuvant treatment. Surgeons should be aware of given its unique genetic characteristics; further studies are needed to characterize the disease as well as recurrence-free and disease-free survival rates.

PRESENTING AUTHOR NAME
Jennifer Munley MD
PRESENTING AUTHOR EMAIL ADDRESS
jennifer.munley@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Surgery Resident
Post-Graduate Year (PGY) – for Surgery Residents Only
PGY 3
SENIOR AUTHOR/MENTOR NAME
Ryan M. Thomas MD

RESEARCH CATEGORY
Clinical/Translational
RESEARCH DISCIPLINE
Oncology


Surgery Day Abstract Submission 2021 : Entry # 3637
ABSTRACT TITLE
Relapsing acute pancreatitis caused by a mucinous cystic neoplasm

ABSTRACT BODY
Introduction: Most cystic lesions of the pancreas are pseudocysts, a sequela of acute pancreatitis. These benign lesions must be differentiated from mucinous cystic neoplasm (MCN) and intraductal papillary mucinous neoplasm (IPMN) because MCNs and IPMNs have malignant potential: 6-36% diagnosed as invasive mucinous cystadenocarcinoma with 20-60% 5-year survival rates. These cystic neoplasms can cause symptoms, but their potential to induce pancreatitis is not well characterized.

Methods: case report

Results: We report a 47 year old female who initially presented with abdominal pain in 1994 and was diagnosed with pancreatitis in the setting of pancreatic divisum and a pseudocyst. In 2008, she had recurrent left upper quadrant abdominal pain and a serum lipase of 113 IU. Endoscopic ultrasound (EUS) at that time showed a 1.3 x 0.8 cm non septated, thin walled cystic lesion in the pancreatic body without associated mass and was diagnosed as a pseudocyst based on fluid amylase >50,000 IU and CEA of 6.1 ng/ml. Continued monitoring of the lesion over the subsequent 10 years showed increased cyst growth and complexity. The patient presented in early 2018 with worsening abdominal pain and the cyst had increased to 2.5 x 2.6 x 2.1 cm. EUS revealed an enlarged, multi-compartment, septated cyst at the junction of the pancreatic body and tail that measured 3.2 x 1.8 cm; the main pancreatic duct measured 1.2 mm. Cytology showed no malignant cells, degenerated amorphous debris, calcification in a background of acute and chronic inflammatory cells, and CEA of 300.6 ng/ml. Laparoscopic distal pancreatectomy with intraoperative ultrasound guidance, splenectomy, and cholecystectomy was performed. Pathology revealed a mucinous cystic neoplasm with low-grade dysplasia, confirmed by ER and inhibin immunostaining, 2 cm in greatest dimension; negative for high-grade dysplasia or invasive carcinoma.

Conclusions: Initial presentation of pancreatic mucinous cystic neoplasms can mimic acute pancreatitis and may lack characteristic imaging or biochemical features of these neoplasms with malignant potential. In this case, this error in diagnosis perpetuated mismanagement for nearly 20 years.

PRESENTING AUTHOR NAME
Alexandra Ladd MD
PRESENTING AUTHOR EMAIL ADDRESS
alexandra.ladd@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Surgery Resident
Post-Graduate Year (PGY) – for Surgery Residents Only
PGY 3
SENIOR AUTHOR/MENTOR NAME
Steven Hughes MD

RESEARCH CATEGORY
Clinical/Translational
RESEARCH DISCIPLINE
Oncology


Surgery Day Abstract Submission 2021 : Entry # 3766
ABSTRACT TITLE
Robotic Preperitoneal Repair of a Traumatic Flank Hernia: A Case Report
ABSTRACT BODY
Introduction
A 39-year-old male was referred to the clinic for a painful, left-sided flank bulge. He was involved in a motorcycle accident in June 2018 which resulted in left clavicle fracture requiring open reduction and internal fixation, left sided rib fractures, and left hemothorax requiring chest tube placement. He was otherwise healthy, and he did not take any medications. On physical exam, he had a reducible ovoid softball-sized bulge at the left flank just above the iliac crest. His pre-operative CT showed a left-sided flank hernia containing descending colon without evidence of bowel compromise. There was a full thickness, 6 by 7 cm defect consistent with avulsion of the three lateral abdominal muscles from the iliac crest. Robotic surgical repair was offered.

Methods
Three robotic trocars were placed along a vertical line just to the left of the midline and an assistant trocar was placed at the right upper quadrant just to the right of the midline. The patient was placed in the right lateral decubitus position, and the table was flexed. First, the peritoneal flap was created, and the hernia sac reduction was performed. There was significant scarring between the hernia sac and the abdominal wall making the dissection difficult. Once the hernia sac was reduced, the posteromedial region was dissected until the psoas muscle was exposed to create room for mesh overlap. Hemostasis was confirmed.

Next, the defect was measured to be 8 by 10 cm. Using a multiple simple running stitch of #0 V-Loc sutures, the defect was closed by approximating the lateral abdominal muscles to the fascia covering the iliac crest and to the erector spinae muscle. Lowering the insufflation pressure and using small bite technique allowed approximation of this large defect. A 16 x 16 cm piece of mesh was fashioned from a larger mid-weight polypropylene mesh. The mesh was secured in place with a few simple interrupted 2-0 Vicryl sutures avoiding fixation to the psoas muscle in order to avoid injury to the retroperitoneal nerves, such as the ilioinguinal and iliohypogastric nerves. The peritoneal flap was then closed with 3-0 V-Loc suture.

Results
His immediate postoperative course was uneventful. At postoperative follow-up three weeks after his surgery, his preoperative symptoms had improved. He had developed mild left groin pain and numbness that improved on further follow-up. Dermatomal mapping suggested involvement of the ilioinguinal/iliohypogastric region.

At postoperative follow-up seven weeks after his surgery, he continued to have persistent left flank bulge with some induration. He was informed that this bulge may improve but is unlikely to completely resolve. However, his preoperative pain had resolved, and he was content with the outcome.

Conclusions
Robotic repair of chronic traumatic flank hernias is feasible. Neuropathic symptoms and persistent bulge may develop as a result and should be discussed with the patient preoperatively.

PRESENTING AUTHOR NAME
Morgan Brazel BA
PRESENTING AUTHOR EMAIL ADDRESS
brazemor@ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Medical Student
SENIOR AUTHOR/MENTOR NAME
Mazen Al-Mansour MBBS

RESEARCH CATEGORY
Case Report
RESEARCH DISCIPLINE
General Surgery


Surgery Day Abstract Submission 2021 : Entry # 3778
ABSTRACT TITLE
High Grade Neuroendocrine Tumor of the Presacral Space Invading the Rectum and Pelvic Sidewall

ABSTRACT BODY
Introduction: Neuroendocrine tumors are neoplasms that can be found anywhere in the body. They are most commonly found in the gastrointestinal tract followed by the bronchopulmonary tree. This case report describes a neuroendocrine tumor of the presacral space which is rarely reported.

Methods: Patient is a 70-year-old female that initially presented with a 5 month history of pelvic pain, pressure, and constipation. CT imaging of the abdomen/pelvix showed a presacral mass measuring 6 x 3 x 4.5 cm. On imaging, the mass was found to be abutting the rectum. Colonoscopy was performed without any findings of intra-luminal colonic or rectal masses. On digital exam, there was an extra-rectal mass that was palpable posteriorly and seemed adherent to the sacrum. CT guided biopsy was completed and pathology demonstrated high grade neuroendocrine carcinoma. Stage was estimated to be cT3N0M0 due to adherence to presacral fascia. The case was presented at a multidisciplinary tumor board conference, and it was recommended she undergo neoadjuvant radiotherapy given her high grade pathology. After completion of radiation, she endorsed some improvement in her symptoms, and interval MRI demonstrated decrease in the size of the mass. A PET CT Dotatate scan did not show any evidence of metastasis. A week after radiation, she was taken to the operating room. Intra-operative findings included a bulky tumor in the deep pelvis which invaded much of the mesorectum, pelvic sidewall and pelvic floor on the right side. Resection was completed from an abdominal approach but required excision of most of her levator ani complex on the right. In addition, the majority of her rectum and sigmoid colon were resected with creation of an end colostomy. The presacral tissues down to the periosteum were taken but no sacrectomy was performed as the periosteum appeared to be without gross tumor involvement.

Results: Final pathology showed poorly differentiated neuroendocrine carcinoma with tumor involving the outer surface of the rectum. The specimen contained 21 lymph nodes with only one lymph node involved by direct extension of tumor. Margins were pathologically negative. Given the adherence to the right pelvic sidewall, it was recommended she undergo boost radiotherapy to the presacral space. She was also treated with adjuvant chemotherapy consisting of carboplatin and etoposide due to high expression of Ki67.

Conclusions: Neuroendocrine tumors of the presacral space are rare and those that have been reported have been mostly found within the sacrum. In this case, the pathology showed tumor involving the outer surface of the rectum and invading into the muscularis propria. This pattern of invasion and location of her tumor intra-operatively make it unlikely that the intestinal tract was the primary site of origin. Despite a unique pathology, a multidisciplinary team and approach has led to a favorable response thus far.

PRESENTING AUTHOR NAME
Analucia Cadavid MD
PRESENTING AUTHOR EMAIL ADDRESS
analucia.cadavid@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Surgery Resident
Post-Graduate Year (PGY) – for Surgery Residents Only
PGY 3
SENIOR AUTHOR/MENTOR NAME
Thomas Read MD

RESEARCH CATEGORY
Case Report
RESEARCH DISCIPLINE
Oncology


Surgery Day Abstract Submission 2021 : Entry # 3799
ABSTRACT TITLE
Cherubism: A Case Report of Pre-Pubertal Surgical Intervention in a 10-Year-Old Male

ABSTRACT BODY
Introduction: Cherubism is a rare, autosomal dominant fibro-osseous condition that primarily causes facial disfiguration via bilateral swelling of the mandible and maxilla, malocclusion, and secondary edentulism. It is usually found before the age of 5-years-old, with a male:female ratio of 2:1. Because the disease has been observed to regress during or after puberty, the general consensus for treatment has been watchful waiting, with surgical intervention reserved for disease that persists post-pubertally.

Case Description: A 10-year-old prepubescent Caucasian boy presented to the Plastic Surgery clinic with cherubism and worsening facial disfiguration characterized by intermittent growth and regression of the bony and soft tissues of his bilateral cheeks and mandible complicated by secondary edentulism. He had previously been diagnosed with cherubism via genetic testing after he presented for evaluation of cheek and jaw cysts at two years of age. He was initially treated with watchful waiting while being followed by a multidisciplinary pediatric craniofacial clinic. However, by age 10, the disfigurement, loss of dentition, and subsequent emotional duress prompted prepubertal surgical intervention. The patient underwent debulking of the mandible with bilateral osteotomies at the buccal aspects, curettage of mandibular fibro-osseous cysts, and application of bone graft and ViviGen to mandibular defects. The patient presented to his post-operative clinic visit with worsening purulent discharge and concern for bilateral mandibular infection. He was taken to back to the operating room for irrigation and debridement of the mandible. In his following clinic appointments, the patient was doing exceptionally well with no complaints. Subsequent CT images showed stable results. Overall, two years post-operatively, the patient and his parents continue to be pleased with the outcome of the surgical intervention.

Discussion: The treatment for patients with cherubism depends on the extent of the lesions and their effects on the patient’s emotional well-being. The current literature supports a watchful waiting method, as the lesions have been observed to regress after puberty. However, cherubism can also cause severe deformities that can affect the airway, cause proptosis, and cause significant psychological damage. In our case, due to the worsening facial distortion, a debulking of the mandibular disease was performed and the cystic space was filled with bone autograft, which resulted in an excellent and stable cosmetic outcome for the patient.

Conclusion: This case of cherubism in a 10-year-old boy demonstrates that surgical intervention in the prepubescent period is an effective intervention to create a stable cosmetic outcome with little evidence of lesion regrowth and should be considered as the specifics of each patient’s case is evaluated.

PRESENTING AUTHOR NAME
Sarah Covey MD, MPH
PRESENTING AUTHOR EMAIL ADDRESS
sarah.covey@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Surgery Resident
Post-Graduate Year (PGY) – for Surgery Residents Only
PGY 2
SENIOR AUTHOR/MENTOR NAME
Jessica Ching MD

RESEARCH CATEGORY
Case Report
RESEARCH DISCIPLINE
Burns/Plastic Surgery


Surgery Day Abstract Submission 2021 : Entry # 3802
ABSTRACT TITLE
Donor Derived Cell Free DNA Testing for the Early Detection of Graft-versus-Host Disease in Solid Organ Transplantation: A Case Study

ABSTRACT BODY
Introduction: Graft-versus-host disease (GVHD) is a rare but devastating event occurring in 0.5-2% of all solid organ transplants within the first year of transplant. It is difficult to diagnose both due to its rarity and the overlap of presenting symptoms and signs of other more common post-transplant events such as infection, rejection, surgical complications, and drug toxicities. The mortality rate of GVHD after orthotopic liver transplantations (OLT) can be upwards to 85% due at least in part to lack of early detection and treatment options. Here, we look at the use of donor-derived cell free DNA (dd-cfDNA) in early detection of GVHD.

Methods: Kidney, liver, and simultaneous liver-kidney transplant recipients at the University of Florida are recruited into an observational study investigating the variability and utility of routine surveillance measurement of dd-cfDNA within the first 6 months after transplantation. Within this study dd-cfDNA is also measured when patients are admitted for infection and rejection episodes.

Case Study/Results: A 50-year-old man with a history of alcoholic cirrhosis was enrolled in the study after undergoing OLT. He was re-admitted on postoperative day 34 with tachycardia, hypotension, and diffuse generalized skin sloughing. Liver enzyme levels were within normal limits. After several days of treatment with antibiotics, multiple skin and endoscopic biopsies were consistent with both GVHD and disseminated fungal infection. GVHD was further confirmed by Short Tandem Repeat (STR) DNA fingerprinting. Despite aggressive treatment with steroids and a JAK1/2 inhibitor, his condition deteriorated and he was transitioned to comfort care prior to his death. Blood samples drawn at the time of his readmission, as well as subsequent to treatment contained more than 25% dd-cfDNA (normal < 1%). These results were available prior to the clinical diagnosis.

Conclusions: When comparing these values to other OLT patients enrolled in our infection arm, we can conclude that dd-cfDNA in its extreme amounts can potentially indicate early signs of GVHD, especially in the setting of normal transaminase levels. The routine use of dd-cfDNA to monitor graft and immune function should be implemented within the first year of transplantation, its beneficial results can improve the quality and preservation of the organ. It can further provide an opportunity to improve and expand the diagnostic tools to monitor and detect these types of unrecognized risk

PRESENTING AUTHOR NAME
Duncan Lewis
PRESENTING AUTHOR EMAIL ADDRESS
duncanlewis@ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Other
SENIOR AUTHOR/MENTOR NAME
Ali Zarrinpar MD, PhD

RESEARCH CATEGORY
Case Report
RESEARCH DISCIPLINE
Transplant/Hepatopancreatobiliary (non-cancer)


Surgery Day Abstract Submission 2021 : Entry # 3805
ABSTRACT TITLE
Complex Multi-Specialty Management of an Iatrogenic Recto-Spinal Fistula

ABSTRACT BODY
Intro: Colorectal-spinal fistulas are an extremely rare entity, the most common etiologies being complications following colectomy, ruptured appendicitis, diverticulitis and post-radiation necrosis. The problem and its treatment are associated with substantial risk of morbidity, mortality and reoperation. Herein, we present a case of a recto-spinal fistula following iatrogenic injury during pelvic lymphadenectomy for recurrent prostate cancer, and describe the subsequent multi-specialty treatment required.

Case Presentation: A 67-year old man underwent prostatectomy and radiotherapy for prostate adenocarcinoma in 2003. In 2018 he underwent robotic retroperitoneal lymph node dissection for nodal recurrence at an outside institution. There were unrecognized thermal injuries to the left common iliac artery and sigmoid. Ten days postoperatively, the patient suffered acute massive gastrointestinal hemorrhage. At operation, he was found to have a left common iliac to sigmoid colon fistula requiring left common iliac ligation, right to left femoral-femoral bypass and Hartmann resection of the sigmoid. Two months later he developed persistent bleeding from the rectal stump related to an intraabdominal phlegmon presumably from persistent infection from the aortic bifurcation with fistula to the rectal stump. He was then transferred to our institution and underwent a temporizing aorto-uni-iliac (AUI) Cook stent graft to his right internal iliac artery with coil embolization of his left common, internal and external iliac system to effectively isolate his left hemipelvis.

He did well over the next several months but then started complaining of severe low back pain and fevers. CT angiogram revealed gas around his left common iliac artery and rectum tracking to his spine. A recto-spinal fistula was suspected due to occult rectal stump blowout. He was treated with intravenous antibiotics and ultimately underwent extra-anatomic bypass (right ax-fem) with AUI graft explantation and aortic ligation. He was found to have a chronic blowout of the rectal stump eroding into the L5-S1 disc space. With the assistance of neurosurgery the disc space was debrided and the rectal stump was resected to the mid-rectum and reclosed. The patient recovered without acute incident. His back pain resolved though he suffers from mild left leg claudication.

Discussion: As illustrated in this case, management of acute arterial-colonic fistula, and subsequent recto-spinal fistula can be complex. Colorectal-spinal fistulas are rare and of diagnostic interest. With a multidisciplinary approach in a tertiary care center, morbidity may be minimized and a good outcome may be achieved.

PRESENTING AUTHOR NAME
William Freeman MD
PRESENTING AUTHOR EMAIL ADDRESS
William.Freeman@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Surgery Resident
Post-Graduate Year (PGY) – for Surgery Residents Only
PGY 2
SENIOR AUTHOR/MENTOR NAME
Thomas Read MD

RESEARCH CATEGORY
Case Report
RESEARCH DISCIPLINE
Colorectal (non-cancer)


Surgery Day Abstract Submission 2021 : Entry # 3832
ABSTRACT TITLE
Venous Bullet Embolus Following Gunshot Wound to Axilla

ABSTRACT BODY
Background
A 20-year-old male presented as a trauma alert after sustaining gunshot wounds to the right upper extremity and axilla. The patient was hemodynamically stable on arrival. CT demonstrated a right lobe liver injury and a retained bullet in either the pericardium or within the heart. The patient was taken to the operating room for emergent exploration. Pericardial window was performed and was without a
palpable bullet. Abdominal exploration demonstrated a Grade II right lobe liver laceration with an associated hematoma and a 1cm diaphragmatic injury that was primarily repaired. Median sternotomy
with cardiopulmonary bypass was then performed. A metallic foreign body was identified in the distal lumen of the right ventricle and removed. A patent foramen ovale was incidentally identified and
repaired primarily. The patient was admitted to the Trauma ICU and extubated on post-operative day one. Pleural and mediastinal chest tubes were removed on post-operative days three and four, respectively.
The patient was additionally found to have a nondisplaced radial shaft fracture from an upper extremity injury that was managed nonoperatively. Recovery was otherwise uneventful and patient was
discharged home on post-operative day six.

Summary
We hypothesize that the retained bullet embolized from the hepatic parenchyma through the right hepatic vein, inferior vena cava, and right atrium before its final location in the trabecular meshwork of
the right ventricle.

Conclusions
Bullet embolization is a rare sequela of penetrating trauma. When it occurs the right ventricle and pulmonary artery are the most common destinations of embolized fragments. Management options include serial imaging, percutaneous retrieval, and open retrieval. A large bullet fragment with patent foramen ovale favored retrieval in this case. We present the case of bullet embolization from the hepatic parenchyma to the right ventricle that was extracted via median sternotomy.

PRESENTING AUTHOR NAME
Jonathan Krebs
PRESENTING AUTHOR EMAIL ADDRESS
jonathan.krebs@surgery.ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Surgery Resident
Post-Graduate Year (PGY) – for Surgery Residents Only
PGY 2
SENIOR AUTHOR/MENTOR NAME
R Stephen Smith

RESEARCH CATEGORY
Case Report
RESEARCH DISCIPLINE
Acute Care/Trauma/Sepsis


Surgery Day Abstract Submission 2021 : Entry # 3853
ABSTRACT TITLE
Near-complete transection of stomach due to gastric band erosion leading to sepsis

ABSTRACT BODY
Introduction:
A 73-year-old female was admitted with a fall history after 3-weeks of nausea, abdominal pain, and PO intolerance. She had an older generation 10.0 gastric band placed in Mexico 7 years before presentation. After which, she never followed up with a bariatric surgeon. CT scan with IV contrast showed fluid buildup along the gastric band catheter with two rim-enhancing regions concerning for multiple abscesses. On physical exam, she was tender to palpation over the port site, but there was no erythema or drainage. Endoscopy was performed, which showed evidence of a partially eroded lap band best seen at the retroflexion. Clinically, the patient had a fever and white count elevation to 15.

Methods:
Intra-operatively, we found multiple pockets of frank pus surrounding the gastric band catheter. When we removed the band, we found a significant gastrotomy due to the erosion (approximately 270 degrees) just distal to the GE junction. We dissected the crus to get to healthy esophageal tissue proximal to the GE junction to repair the gastrotomy. This was repaired in 2 layers, and then the hiatus was repaired. A bubble test with endoscopy was performed without evidence of a leak, and a drain was placed in the LUQ. An UGI study was completed the next day, also without a leak.

Results/Conclsuion:
She was discharged three days following surgery. She was admitted to the hospital 1-week later for fatigue and dehydration. At her 1-month follow-up, she was doing well with no new complaints. Normally, eroded gastric bands are easily removed without evidence of gastronomy. The 270-degree gastronomy was an additional complication. Gastrectomy was not needed because we were able to fix the hole with healthy tissue proximal to the GE junction.

PRESENTING AUTHOR NAME
Amanda Vozzola
PRESENTING AUTHOR EMAIL ADDRESS
avozzola@ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Medical Student
SENIOR AUTHOR/MENTOR NAME
Jeffrey Friedman

RESEARCH CATEGORY
Case Report
RESEARCH DISCIPLINE
General Surgery


Surgery Day Abstract Submission 2021 : Entry # 3856
ABSTRACT TITLE
Case Report: Incisional Hernia Repair with Biological Mesh

ABSTRACT BODY
Introduction:
Surgical mesh is commonly placed in incisional hernia repair as an adjunct to primary fascial closure and has been shown to reduce hernia recurrence. Synthetic mesh is used most widely, with biological meshes typically reserved for use in contaminated cases or in high-risk patients. Biological meshes are fully-resorbable, biologically derived extracellular matrices. The role of biological mesh in abdominal wall reconstruction has not been adequately researched and still needs to be defined. This case demonstrates a case in which biologically-derived was used to repair an abdominal wall defect.

Methods:
In this case report, we describe the laparoscopic repair of two large ventral abdominal wall defects using biological mesh in a clean-contaminated setting following a roux-en-y gastric bypass in a high-risk, obese patient.

Results:
Both ventral abdominal wall defects were successfully repaired and reinforced with biological mesh. The patient experienced favorable post-surgical outcomes without hernia recurrence, post-operative infection, or readmission.

Conclusions:
Biological mesh is a successful and feasible option for abdominal wall reconstruction in contaminated cases or in high-risk patients. More research is warranted to determine the efficacy of biological mesh versus that of synthetic mesh as well as to compare the likelihood of post-operative complications or recurrence.

PRESENTING AUTHOR NAME
Johanna McCracken
PRESENTING AUTHOR EMAIL ADDRESS
jmccracken@ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Medical Student
SENIOR AUTHOR/MENTOR NAME
Jeffrey Friedman

RESEARCH CATEGORY
Case Report
RESEARCH DISCIPLINE
General Surgery


Surgery Day Abstract Submission 2021 : Entry # 3850
ABSTRACT TITLE
Post-Infarction Left Ventricular Wall Rupture Presenting in the Setting of Blunt Traumatic Injury

ABSTRACT BODY
Introduction: Left ventricular free wall rupture (LVFWR) is a notoriously fatal diagnosis associated with acute myocardial infarction. Herein, we describe a case in which LVFWR inconspicuously presented in a blunt trauma patient, ultimately diagnosed via cardiac catheterization and successfully repaired with emergent surgical intervention.

Methods: We report the case of 66 year old man with history of untreated hypertension who initially presented as a Level 2 Trauma alert to the trauma center at University of Florida Health. He was involved in a motor vehicle accident in which he was the restrained driver who lost consciousness and collided with a tree. Of note, he described a two-day history of chest pain after vigorous yard work five days preceding the event. On arrival in the trauma bay, he was awake, alert, and conversant; however, his vital signs were concerning with tachycardia of 140 beats per minute and hypotension to 60mmHg systolic with narrowed pulse pressure. His electrocardiogram (EKG) demonstrated ST elevation. Bedside focused assessment with sonography for trauma revealed pericardial effusion. Computerized tomography showed large pericardial effusion without aortic injury. Due to EKG changes and unclear source of the pericardial effusion, he was taken promptly to the cardiac catheterization suite, where coronary angiography revealed occlusion of a large obtuse marginal branch and LVFWR was identified on ventriculography.

Results: The patient was emergently taken to the operating room and underwent median sternotomy, cardiopulmonary bypass, and identification and repair of LVFWR. He was extubated on postoperative day 1, remained inpatient for eight days, and was ultimately discharged to home in good condition.

Conclusions
With this case report, we describe a presentation of LVFWR diagnosed amidst trauma evaluation, ultimately clarified by cardiac catheterization and definitively managed with surgical intervention. We assert that this case presentation will assist cardiothoracic surgeons, cardiologists, and trauma teams in identifying rare causes of pericardial effusion such as post-infarction LVFRW in the setting of blunt thoracic injury.

PRESENTING AUTHOR NAME
Anne-Marie Carpenter MD
PRESENTING AUTHOR EMAIL ADDRESS
acarpenter@ufl.edu
PRESENTING AUTHOR ACADEMIC RANK
Surgery Resident
Post-Graduate Year (PGY) – for Surgery Residents Only
PGY 3
SENIOR AUTHOR/MENTOR NAME
George Arnaoutakis MD

RESEARCH CATEGORY
Clinical/Translational
RESEARCH DISCIPLINE
Thoracic/Cardiac


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