Most residents at present do not do the lectures. Improved mon-itoring and proactive approach with possible incentives will needto be developed to improve compliance with online education.

QS329. A DECISION-DELPHI TO EVALUATE INJURY CON-TROL CURRICULA IN CANADIAN HEALTH PRO-FESSIONAL SCHOOLS: OPINIONS OF TRAUMA EX-PERTS. Shaifali Sandal1, Avery Nathens2, Najma Ahmed2;1St George University, St George’s, Grenada; 2University ofToronto, Toronto, ON, Canada

Introduction: Injury constitutes a major public health problemresponsible for about 5.8 million deaths worldwide. It is the lead-ing cause of potential years of life lost between the ages of 1-44. Ina landmark document in 1966, the American Association for theSurgery of Trauma reported that the vast majority of injurieswere preventable. Recently, the American Association of MedicalColleges identified physicians as having a pivotal role in educationabout injury control; despite this, a review of literature shows thatinjury prevention is poorly covered in medical and nursingschools. The purpose of the present study was to create an instru-ment to capture the thoughts and experiences of trauma careproviders and opinion leaders about the desired content, mode ofdelivery and evaluation of a standardized curriculum in injurycontrol. Methodology and Results: A thorough review of theliterature was used to create a preliminary instrument to capturequantitative and qualitative elements. Using feedback from thepreliminary pilot testing phase, in conjunction with a review ofthe literature, we created a unique 8 page 31 item instrument.Readability, appropriateness of content, validity and reliabilitywere informally tested with local experts. This instrument wasmailed to 170 trauma specialists across Canada, including traumaphysicians, surgeons, nurses, data analysts and clinical epidemi-ologists whose area of research is injury. Participants were alsogiven the option of completing the instrument on-line. Quasi-anonymity was obtained by ensuring that consent for participa-tion and all further communications with the experts was main-tained by the research assistant. A Decision-Delphi methodologywas used to determine the opinions of the Trauma Experts aboutcurricula in three different areas; firstly, their educational back-ground and experiences on injury control, secondly, their knowl-edge and opinions about the current curricular content in healthprofessional schools, and finally, what the ideal injury controlcurriculum should include and how it should be delivered andevaluated. Conclusions: The quantitative analysis will help tounderstand what, when and how an injury control curriculumshould be constructed. Iterative coding analysis of the qualitativecomments will uncover themes, which will help deepen our un-derstanding of why injury control subjects are under-representedin health professional curricula. The results of this study will alsoinform the design of a Test Question Analysis tool to assess theknowledge and capture the experiences of student bodies in thehealth professions. Collectively, this body of work will help createa standard inter-professional curriculum for injury control amongthe health professional schools in North America.

QS330. A CASE OF RIGHT MIDDLE LOBE SYNDROME INMARFAN’S DISEASE. Shirong Chang1, Hector Saucedo1,Kenneth Lloyd2, Matthisa Loebe1; 1Baylor College of Medi-cine, Houston, TX; 2The Methodist Hospital, Houston, TX

Background: Right middle lobe syndrome (RMLS) is character-ized by chronic or recurrent right middle lobe atelectasis that canlead to pulmonary infection. Pulmonary abnormalities have beenreport in patients with Marfan’s syndrome; however, the associa-tion with RMLS has never been documented. Case Report: A68-year old male patient with a diagnosis of Marfan’s syndromeand history of a small right lung mass vs. scar tissue since child-

hood was admitted to the hospital after several weeks of produc-tive cough and constitutional symptoms that were treated unsuc-cessfully with both intravenous and oral antibiotics. A computedtomography (CT) scan of the chest revealed a 9.7 � 6.7 cm rightmiddle lung mass. A right lateral thoracotomy was performedwhich revealed a large abscess. The patient subsequently under-went a right middle lobe lobectomy that led to resolution ofsymptoms. Conclusion: Right middle lobe syndrome is chronic orrecurrent collapse of right middle lobe due to extrinsic compres-sion or intrinsic abnormalities of bronchus. In Marfan’s syndromepatients, the abnormal collagen cross-link caused by mutate fibril-lin molecule produced a reduced tensile strength of pulmonaryconnective tissue. Therefore, Marfan’s syndrome patient hashigher propensity for collapse of right middle lung that can lead toinflammation and pneumonia under certain insults. High level ofsuspicion with prompt diagnosis and aggressive treatment withantibiotics may be effective. However, surgical resection becomenecessary when medical management fails.

QS331. MANAGEMENT OF VASCULAR INJURIES ASSOCI-ATED WITH KNEE DISLOCATIONS IN THE OBESEPATIENT. Jennifer Rogers1, David Han2; 1Penn State Col-lege of Medicine, Hershey, PA; 2Penn State Hershey MedicalCenter, Hershey, PA

Introduction: The management of injuries to the popliteal arterythat occur as a result of traumatic knee dislocation focuses on timelyrestoration of arterial flow and stabilization of the orthopedic injury.In some cases, determining the order of repair can be challenging,especially when complex vascular and/or orthopedic injuries exist. Inthe obese patient, repair can be more complex and time-consuming,which can increase the chance for subsequent complications. CaseReport: A 40-year-old obese male presented with severe pain in theright knee after twisting it while exiting a golf cart. Orthopedicevaluation revealed a displaced tibial plateau fracture dislocation.Initial evaluation revealed a palpable right dorsalis pedis pulse, butover the ensuing hours the pulse could no longer be felt. Motor andsensory examination were limited due to pain, but were grosslyunremarkable. The ankle-brachial index was 0.54. Preoperative ar-teriography demonstrated occlusion of the popliteal artery at theknee joint, with reconstitution of the tibial vessels and patent runoffbeyond the ankle. In the operating room, the knee dislocation wasreduced, and the joint stabilized with an external fixator. During thistime, the greater saphenous vein was harvested from the left thigh.The patient was then placed prone, and through a posterior ap-proach, the popliteal artery injury was repaired with an interpositiongraft of saphenous vein. Completion arteriography showed a patentrepair with three vessel runoff. The patient had a subsequent un-eventful recovery. Discussion: Because different degrees of severityof ischemia occur, popliteal artery injuries can be difficult to diagno-sis as well as variable in the urgency of repair. Various algorithmsexist for the role of arteriography, but in many cases, the level ofischemia is severe and revascularization should proceed withoutdelay. In determining the sequence of repair, consideration must begiven to the severity of each injury. In cases where vascular repair isperformed first, the graft may be in jeopardy during orthopedicmanipulation. When the orthopedic stabilization is performed first,the external hardware can impair the ability to adequately exposethe vessels, especially in the obese patient. A posterior approach tothe arterial injury can allow optimal timing of both repairs. Harvest-ing the vein during orthopedic stabilization addresses the difficultyof harvesting vein with the patient prone during a posterior ap-proach. Additionally, the posterior approach is typically away fromthe placement of the external fixator, and technically easier in theobese patient. Conclusion: This case suggests an approach that canprovide optimal timing of concomitant orthopedic and vascular re-pair of popliteal artery injuries that result from traumatic knee

398 ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS

dislocation. The posterior approach can be used for repair of suchlocalized injuries, and may be the desired approach in the obesepatient.

QS332. A QUALITATIVE STUDY OF FACTORS WHICH IN-FLUENCE PATIENT CHOICE BETWEEN OPEN ANDENDOVASCULAR ABDOMINAL AORTIC ANEU-RYSM REPAIR. Margaret L. Schwarze, Nancy Pandhi,Matthew Swedlund, Deborah Gawin, David Vanness, Mau-reen Smith; University of Wisconsin, Madison, WI

Background: For patients who are eligible for open AAA repair andendovascular stent grafting, the choice of procedure likely involvesweighing certain factors and a complicated decision making process.How patients view these options and which factors influence theirdecision making is poorly understood. Methods: This is a qualitativestudy using content analysis methodology. Researchers selected andinterviewed a purposive sample of ten patients with AAA who werecandidates for both open and endovascular procedures and had con-sented to undergo repair via one specific approach. Both pre-operative and post-operative patients were included. Audiotapes ofthe interviews were transcribed and analyzed using open and axialcoding schemes. Results: Patients described a broad range of decid-ing factors. Patients recognized obvious trade offs between morbidityand mortality, recovery time and post-operative surveillance. Thedesire to not have to return for follow up and the anxiety that theywould require additional surgery were common concerns. Patientsalso mentioned less apparent influences such as the their currenthealth status, concern about stents raised by recent news reportsregarding coronary procedures, pressure from family members andthe opinion of their surgeon as major deciding factors. Patients’ability to describe the characteristics of the surgery ranged broadlyfrom “running something up through the groins,” “wrapping theaneurysm” and “the easy temporary way” versus “the hard perma-nent way” though all patients were correctly able to identify theoptions of both the open and endovascular repair. Conclusions:While most patients who are candidates for both endovascular andopen AAA repair cite obvious concerns about each procedure as partof the decision making process, nearly all patients raised concernsabout less apparent or misunderstood aspects of the procedure whichfactored into their decision making. Surgeon knowledge of this rangeof factors which may influence their patient’s choice is important todispel misperceptions and assist patients to choose the repair mostconsistent with their preferences.

QS333. GASTRECTOMY FOR GASTRIC CANCER IN PA-TIENTS WITH VENTRICULOPERITONEAL SHUNTS.Edel Doorley1, K. S. Virgo2, Anil Bahadursingh2, R. A. Au-disio1, Frank E. Johnson2; 1University of Liverpool, Liver-pool, United Kingdom; 2Saint Louis University, St. Louis,MO

Background: Ventriculoperitoneal (VP) shunts have afforded manypatients with hydrocephalus relatively normal life expectancies.Some patients may require further abdominal surgery unrelated totheir shunt, such as a gastrectomy. Much of the published literatureregarding gastrointestinal surgery in people with VP shunts con-cerns children. It indicates that complications of surgery are com-mon. We hypothesized that adults with shunts undergoing surgeryfor gastric cancer would have a similarly high rate of adverse out-comes, particularly shunt infection and meningitis. We also hypoth-esized that intraabdominal shunt-related adhesions and/or othertechnical difficulties would occur frequently. Methods: NationwideDepartment of Veterans Affairs (DVA) databases were searched toidentify patients with International Classification of Diseases, 9thRevision, Clinical Modification (ICD-9-CM) codes for VP shunt wholater developed gastric cancer and were treated with gastrectomyduring fiscal years 1994-2003. Charts on these patients were re-

viewed to determine whether gastrectomy was more difficult becauseof the VP shunt, how the VP shunt was managed intraoperatively,and whether intraabdominal infection, shunt infection, meningitis,or shunt malfunction occurred during the hospital stay. Results:There were 2,213 patients with ICD-9-CM procedure codes for gas-trectomy for gastric cancer. Five had codes for preexisting VP shuntand three were deemed evaluable. Record review revealed no intra-operative technical problems attributable to the shunt. There wereno infectious complications or instances of postoperative shuntmalfunction. Conclusions: This is the first report on this topic.Gastrectomy for gastric cancer in adult patients with a preexistingVP shunt does not appear to be associated with an increased com-plication rate, as compared to that experienced by otherwise similarpatients without a VP shunt in the general population. VP shuntscan be successfully managed intraoperatively with simple maneu-vers such as administering preoperative antibiotics and treatingpreexisting infections before surgery.

QS334. OUTCOMES OF CURATIVE INTENT TREATMENTFOR COLORECTAL CANCER AMONG PATIENTSWITH TOTAL VISUAL IMPAIRMENT. Richard A. Sea-grave III, Katherine S. Virgo, Frank E. Johnson, Ryan M.McEnaney, Stephen S. Feman; Saint Louis UniversitySchool of Medicine, Saint Louis, MO

Objective: Many studies have examined the effects of melatoninlevels in blind patients and its effect on the development of certaincancers. However, no study has assessed the impact of melatoninlevel on outcomes after curative intent treatment for cancer. Theaim of this study was to compare outcomes in patients withnormal vision versus total visual impairment after curative intentsurgery for colorectal carcinoma. We hypothesized that individu-als with total visual impairment would have better outcomescompared to individuals with normal vision, due to the visuallyimpaired patients’ increased and sustained high serum levels ofmelatonin. Method: A nationwide study was conducted of allveterans with a diagnosis of total visual impairment (no lightperception) who subsequently developed colorectal carcinoma.The Department of Veterans Affairs Patient Treatment File (PTF)was used to extract data during 1994-2003. Univariate analysiswas performed for demographic, medical history, pre-operativetests, clinical examination, and 30-day morbidity and mortalityrates. These results were compared to previously published dataof patients with normal or near-normal vision who underwentcurative intent treatment for colorectal carcinoma. Results: Therewere 28 patients identified with computer codes for both totalvisual impairment and subsequent colorectal carcinoma; threewere deemed evaluable after applying predetermined exclusioncriteria. There were no complications, compared to the expectedrate of about five percent. The five-year survival rate (33%) wasalso lower than the expected rate (64.4%). Conclusion: This is thefirst report on this topic to our knowledge. Our limited datasuggest that blind patients who develop colorectal carcinoma andreceive curative intent surgery have different outcomes than pa-tients who have normal vision. This result must be further studieddue to the small number of patients who met the inclusion crite-ria. We encourage future investigation with larger populations.

QS335. OUTCOMES OF CURATIVE INTENT LUNG CANCERSURGERY IN TOTALLY VISUALLY IMPAIRED PA-TIENTS. Colby L. Parks1, Robert Wong1, Robert Miller2,Katherine S. Virgo1, Frank E. Johnson1, Stephen Feman1;1Saint Louis University, St. Louis, MO; 2Department of Vet-erans Affairs Medical Center, St. Louis, MO

Objective: Several reports have suggested that increased mela-tonin level may retard some cancer growth. Although blind pa-tients have increased serum melatonin levels, no study has as-

399ASSOCIATION FOR ACADEMIC SURGERY AND SOCIETY OF UNIVERSITY SURGEONS—ABSTRACTS