Leading the Way Newsletter

LEADING THE WAY SUMMER 2020 • VOLUME 12, NUMBER 2 DEPARTMENT OF #MCWMedicalMoments @MCWSurgery SURGERY iHeartRadio: The Word on Medicine MCWSurgery www.mcw.edu/surgery From the Chair | Douglas B. Evans, MD The 2019-2020 Chief Residents who will continue to lead the way at many great institutions across the country. What a fantastic edition of “Leading the Way” — research on everything from large databases to basic science and Chief Residents Charles Fehring, MD quality — to best practices and new intraoperative devices – and (and their future plans) Ascension Columbia Saint the stimulating contribution by David and Lyle Joyce on innova- Chad Barnes, MD Mary’s Hospital tion, discovery and commercialization. What characterizes all of Complex General Surgical Milwaukee, WI the contributions to this edition is the authors’ passion for their Oncology Fellowship Kaleb Kohler, MD topic – the characteristic of medicine which makes it so excit- City of Hope Cancer Center Vascular Surgery Fellowship ing. The anticipation of new knowledge and the fun of becoming Duarte, CA University of Kentucky immersed in a disease site or a perplexing clinical problem are Nicholas Berger, MD Lexinngton, KY indescribable. The thrill of having that intense effort and inves- Colorectal Surgery Fellowship Rebecca Marcus, MD tigation result in a favorable patient outcome is invaluable for Cleveland Clinic Complex General Surgical the patient, their family and the treating physicians and scientific Cleveland, OH Oncology Fellowship team. We are working on a way to bottle and commercialize the Michael Cain, MD John Wayne Cancer Institute excitement and joy in discovery which is palpable in the Joyce ar- Cardiothoracic Surgical Santa Monica, CA ticle — you will be the first to hear of this when it comes to mar- Fellowship Rebecca Mitchell, MD ket! Perhaps one of the unintended consequences of the world University of Colorado Surgical Critical Care with Coronavirus has been a bit more time for reading, writing Denver, CO and Acute Care Surgery and investigation. I suspect that a few of your many recent con- Lindsey Clark, MD Fellowship ference calls (when the phone was on mute) may have provided General and Trauma Surgery MCW additional time for personal discovery? CONTINUED ON PAGE 2 Holston Valley Medical Center Kingsport, TN Fellows Jacob Wood, MD (and their upcoming positions) Assistant Professor of Surgery Maria Linnaus, MD Division of Vascular Surgery Senior Associate Consultant University of North Carolina General and Bariatric Surgery Chapel Hill, NC Mayo Clinic Health System Ali El Mokdad, MD Eau Claire, WI General Surgery Rebecca Y. Kim, MD, MPH Dallas, TX Assistant Professor of Surgery Joshua Pearl, MD University of Utah Acute Care Surgery Fellowship Salt Lake City, UT Children’s Wisconsin Katherine Flynn-O’Brien, MD, Amy E. Murphy, DO MPH Co-Director, Trauma Center Assistant Professor of Surgery West Chester Hospital Division of Pediatric Surgery Cincinnati, OH MCW IN THIS ISSUE: Predictors of Mortality After Trauma: A Novel Outcome Score..2 The Utility of Vessel-Sealing Devices in Thyroid Surgery........ 10 Do You Match? Double Your Donation Today!...................... 18 De-escalation in Breast Cancer Surgery: When Less Becomes Road Construction Ahead................................................... 12 Leading the Way................................................................. 19 More.....................................................................................4 MCW/Froedtert General and Vascular Surgery Semiannual Faculty Listing.................................................................... 21 Inclusion, Diversity, and Equity in Healthcare and the Workplace Report............................................................................... 14 Mark Your Calendars.......................................................... 22 ............................................................................................6 Detection of Germline Variants Using Expanded Multigene Panels M C W S u r ge r yEvolving Treatment Options for Type B Aortic Dissections........8 in Patients with Localized Pancreatic Cancer....................... 16 knowledge changing & saving life

From the Chair Predictors of Mortality After CONTINUED FROM PAGE 1 Rachel S. Morris, MD trauma centers. Patient-level data were obtained from the NTDB from January While we all are Assistant Professor enveloped in the blan- Division of Trauma & Acute Care 1, 2007 through December 31, 2013 for ket of SARS-CoV2, and Surgery the derivation dataset and January 1, many are working 2014 through December 31, 2015 for the tirelessly to make our validation dataset. The 2007- 2013 NTDB data set was medical environment Trauma is the fourth leading utilized to derive the Elderly Mortality After Trauma safe while balancing cause of death for Americans, (EMAT) score. The NTDB data dictionary’s definition the needs of those costing the United States roughly and NTDB data fields were used to collect variables who do and do not $671 billion each year in medical including demographics (insurance status, age, race, have COVID-19, the expenses.1 Patients presenting sex), comorbidities (myocardial infarction within six practice of medicine with urgent and emergent months, steroid use, chronic obstructive pulmonary and surgery goes on. conditions are increasingly disease [COPD], obesity, current smoker, diabetes The thrill of discovery older with more medical mellitus, dementia, disseminated cancer, functionally and the quest for new comorbidities.2,3 Trauma patients dependent health status, cirrhosis, chronic renal failure, knowledge remain ex- aged 65 or older have a higher congestive heart failure [CHF], and stroke with residual hilarating and are two risk for mortality after trauma.4 deficits), injuries (rib fractures [1-6 rib fractures, greater of the reasons why than 7 rib fractures and flail chest], hemopneumothorax, we have the greatest Survival in elderly trauma hip dislocation, traumatic brain injury, pelvic fracture, job on planet earth. patients is significantly affected femur fracture, solid organ injury [kidney, liver spleen], Even the greatest job by pre-existing disease and injury humerus fracture, facial fracture, cervical spine fracture, can be more difficult pattern. Predictive models should thoracic/lumbar spine fracture, great vessel injury in the setting of per- and bowel/pancreas injury), mechanism of injury sonal and family isola- take these factors into account.5 (blunt, penetrating), and most aberrant ED physiologic tion and social unrest Elderly patients may also undergo parameters (SBP, pulse, intubation in the ED, temperature, — please know how interventions that are ineffective Glasgow Coma Scale [GCS] and respiratory rate). For much we appreciate in achieving the desired goals.6 injuries, the corresponding the many extra ef- Multiple factors affect treatment ICD-9 codes were used. forts of everyone who decisions in these patients, such has delivered the best as differences in prognostic To derive the EMAT possible care to our estimates among surgeons, score, a univariate analysis patients and worked inadequate data about post- of in-hospital mortality was tirelessly in support performed using available of the missions of the trauma quality of life, and time variables (demographics, Department of Sur- constraints.7 injuries, physiologic gery and MCW. There is a critical need to parameters and co- provide accurate, timely, and morbidities). Variables with Hopefully baseball prognostic information to a p < .05 were then included will return soon – so facilitate shared decision-making in multiple stepwise many metaphors im- and guide treatment decisions. logistic regression models portant for life – none In order to match the treatment to identify independent better than the at- plan with individual patient predictors of in-hospital titude needed for a goals, improved and more timely mortality. Ultimately, successful at-bat; em- predicators of elderly trauma least absolute shrinkage bracing the moment mortality are needed. and selection operator no matter how dif- The data source for this (LASSO) method with p ficult and striving for study was the National Trauma < .05 as the cut-off for success (home run) Data Bank (NTDB) (2007-2015), statistical significance was rather than being mo- the largest trauma registry in chosen for factor selection tivated simply by the the United States.8 It includes based on calibration and fear of failing (striking patient and hospital data on discrimination analysis. out). traumatic injuries and clinical Based on the relative outcomes of more than 700 impact of each identified Figure 1 2 | Medical College of Wisconsin Department of Surgery

Trauma: A Novel Outcome Score predictor (e.g., -coefficient), a two-tiered scoring system are infrequently utilized and surgeons have expressed to predict in-hospital mortality was developed: a quick that lack of prognostic data may lead to potentially non- elderly mortality after trauma (qEMAT) score for use within beneficial interventions.7 EMAT is available earlier in the the first hour of presentation and a full EMAT (fEMAT). The hospitalization than GTOS and offers higher discrimination coefficients were rounded to the nearest half integer to than all prognostic models tested. EMAT is independent develop a score that would be easier to use. of ISS and can specifically account for body region-based injury patterns. This information provides a useful adjunct A mobile application supporting Android version 4.4+ when counseling family and patients regarding prognosis. (Google, Mountain View, CA) and iOS version 8.0+ (Apple, Cupertino, CA) was developed to facilitate usability (Figure FOR ADDITIONAL INFORMATION on this topic, see 1). 840,294 patients met the inclusion criteria, 6.6% of references, visit mcw.edu/surgery, or contact Dr. Morris which resulted in in-hospital mortality. All injury types at [email protected]. were significantly different in survivors vs non-survivors except for hip dislocation. Blunt was the most common REFERENCES mechanism of injury in both cohorts (>98%). 1. Jurkovich GJ, Rivara FP, Johansen JM, Maier RV. Centers The fEMAT and qEMAT predict in-hospital mortality for Disease Control and Prevention injury research using readily available metrics and represent a potentially agenda: identification of acute care research topics valuable tool in shared decision-making. This method of interest to the Centers for disease Control and outperforms Geriatric Trauma Outcome Score (GTOS) and Prevention--National Center for Injury Prevention and age + ISS and does not require calculation of ISS for use. Control. J Trauma. 2004;56(5):1166-1170. EMAT can be used to provide prognostic information early 2. Hashmi A, Ibrahim-Zada I, Rhee P, et al. Predictors of in the hospital course when critical treatment decisions mortality in geriatric trauma patients: a systematic are being discussed. review and meta-analysis. J Trauma Acute Care Surg. 2014;76(3):894-901. The elderly trauma population is expanding and 3. Wilson MS, Konda SR, Seymour RB, Karunakar MA, experiences worse mortality rates and poorer functional Carolinas Trauma Network Research G. Early Predictors outcomes than younger patients.9 These patients are of Mortality in Geriatric Patients With Trauma. J Orthop medically complex and generate many ethical and financial Trauma. 2016;30(9):e299-304. questions. There are multiple benefits to developing an 4. Perdue PW, Watts DD, Kaufmann CR, Trask AL. elderly predictive mortality model. Prognosis is the first Differences in mortality between elderly and younger step in communication prior to a goals of care discussion.10 adult trauma patients: geriatric status increases risk of Shared decision-making is “an approach where clinicians delayed death. J Trauma. 1998;45(4):805-810. and patients share the best available evidence when faced 5. Kirshenbom D, Ben-Zaken Z, Albilya N, Niyibizi E, Bala with the task of making decisions, and where patients M. Older Age, Comorbid Illnesses, and Injury Severity are supported to consider options to achieve informed Affect Immediate Outcome in Elderly Trauma Patients. J preferences.”11 Structured conversations facilitate shared Emerg Trauma Shock. 2017;10(3):146-150. decision-making in these extremely stressful situations 6. Cardona-Morrell M, Kim J, Turner RM, Anstey M, for the physician, patient and family.10 ICU physicians’ Mitchell IA, Hillman K. Non-beneficial treatments in and nurses’ clinical accuracy in predicting six-month hospital at the end of life: a systematic review on extent outcomes is highly varied.12 Providers are placed in the of the problem. Int J Qual Health Care. 2016;28(4):456- difficult position of informing patients of their prognosis 469. with limited data-driven information. Similarly, families 7. Morris RS, Ruck JM, Conca-Cheng AM, Smith TJ, Carver and patients must make treatment decisions without an TW, Johnston FM. Shared Decision-Making in Acute accurate prognosis. Armed with the ability to prognosticate, Surgical Illness: The Surgeon’s Perspective. J Am Coll palliative care consultation could be obtained earlier in the Surg. 2018;226(5):784-795. hospitalization, avoiding late, symptom-based palliative 8. Haider AH, Saleem T, Leow JJ, et al. Influence of the care utilization.13 EMAT shows that previous limitation of National Trauma Data Bank on the study of trauma care with DNR in place, hypotension, cirrhosis, chronic outcomes: is it time to set research best practices renal failure, and traumatic brain injury are highly to further enhance its impact? J Am Coll Surg. associated with in-hospital mortality. 2012;214(5):756-768. 9. Jacobs DG. Special considerations in geriatric injury. EMAT features a tiered calculator incorporating a quick Curr Opin Crit Care. 2003;9(6):535-539. score based on immediately available factors at initial patient presentation and a full score which requires imaging CONTINUED ON PAGE 19 results and medical history. Other prognostic models Leading the Way | Summer 2020 | 3

De-escalation in Breast Cancer Surgery: Chandler Cortina, MD received systemic chemotherapy. After 20 years, amongst Assistant Professor all treatment arms, there was no difference in DFS, DDFS, Division of Surgical Oncology and OS. However, in patients who underwent lumpectomy and received RT, the local regional recurrence (LRR) The surgical management of breast cancer has was 14% compared to 39% for those who underwent undergone a substantial evolution over the past lumpectomy alone (p< .001).6 This trial, along with several century, largely due to the contributions of innovative others, established breast conservation therapy as a surgeons and brave patients. By performing less invasive surgical option for select patients. More recently, data procedures, surgeons have been able to provide from the Cancer and Leukemia Group B (CALGB) 9343 optimal care while simultaneously improving patient study allows for RT omission in patients over 70 with small quality of life and minimizing long-term side effects (T1 and T2), node-negative, hormone-receptor positive such as lymphedema and upper-extremity neurological tumors, who take anti-endocrine therapy for five years, dysfunction.1 Surgical de-escalation coincides with with no difference in OS at 10 years.7 substantial advancements in both radiation therapy and systemic medical therapy and emphasizes the Given that less than 35% of women who present with significance of the multidisciplinary approach to treating a clinically normal axilla will subsequently have evidence breast cancer. of axillary disease on surgical pathology, surgeons sought to evaluate if performing less axillary surgery was safe. Dr. Prior to the late 1800s, breast cancer was considered Armando Giuliano largely championed this by establishing a uniformly lethal disease until Dr. William Halsted the role of sentinel lymph node biopsy (SLNB) in breast began performing the radical mastectomy (RM).2 In this cancer in the mid-1990s.8 SLNB is a technique where the operation, the entire breast, axillary lymph nodes (ALN), initial draining lymph nodes of the breast are identified and and pectoralis major muscle are surgically excised. This pathologically assessed for cancer involvement. Assessing operation became the only therapy for breast cancer, if the SLN demonstrated metastasis could potentially allow but was fraught with long-term physical limitations and the remaining ALN to forego removal, thus minimizing the sequala. By the mid-20th century, physicians developed risks for lymphedema and neurological dysfunction of the a better understanding of the pathophysiology of breast upper extremity. cancer. This scientific understanding led the oncology community to question if such radical and morbid surgery The development of the SLNB technique led to the was necessary. These inquiries served as the catalyst in NSABP-B32 trial, which evaluated if SLNB offered equal developing critical breast surgical oncology clinical trials. survival benefit compared to ALND in clinically node- negative patients. If patients had a positive SLN, they In the 1970s, the National Surgical Adjuvant Breast underwent axillary lymph node dissection (ALND); and Bowel Project (NSABP) B-04 clinical trial evaluated if however, if the SLN was negative, no further axillary the modified radical mastectomy (MRM) (removal of the surgery was performed. At the 10-year follow-up, there breast tissue and ALN only) was adequate surgical therapy was no significant statistical difference in the OS and DFS compared to the conventional RM that Halsted instituted. between the two groups, but there was significantly less Patients were divided into two cohorts based upon their morbidity among the SLN-only group.9 clinical nodal status, and the role of radiation therapy (RT) was also evaluated.3 After 25 years, amongst all treatment With improving RT techniques, a growing number of arms, there was no difference in the disease-free survival systemic therapy options, and the knowledge that in NSABP (DFS), distant-disease-free survival (DDFS), and overall B-04 there was no difference in OS or DFS for patients who survival (OS).4 This trial confirmed that the MRM was underwent ALND, the role of ALND in pathologically node- equivalent to the RM. positive (but clinically negative) patients came under question. This led to the development of the American Around the same time as NSABP B-04 was conceived, College of Surgeons Oncology Group (ACOSOG) Z0011 breast conservation therapy (BCT) had a growing following (Z11) trial. This non-inferiority trial aimed to evaluate if with several case-series published on the “lumpectomy” patients with small (T1 and T2) tumors who were clinically- technique. This led to the development of NSABP B-06: node negative, underwent lumpectomy and RT, and had A clinical trial that compared lumpectomy with ALN with 1-2 pathologically positive sentinel nodes, had improved or without RT compared to MRM in patients with tumors survival rates through ALND.10 Patients who were found that were 4 cm or less.5 If patients had ALN disease, they to have positive sentinel nodes were randomized to no further surgery or ALND. Notably, all patients received 4 | Medical College of Wisconsin Department of Surgery RT after surgery. At the 10-year follow-up, there was no difference in OS between the two groups and the

When Less Becomes More ALND group had higher rates of both lymphedema and mastectomy, total mastectomy, and total mastectomy neurological dysfunction.11 followed by irradiation. N Engl J Med. 2002; 347:567– 75. Simultaneously with Z11, the European Axillary 5. Fisher B, Bauer M, Margolese R, et al. Five-year Radiotherapy, or Surgery in Early Breast Cancer (EORTC results of a randomized clinical trial comparing total AMAROS), trial was being conducted to evaluate the role mastectomy and segmental mastectomy with or of dedicated axillary RT compared to ALND. Similar to without radiation in the treatment of breast cancer. N Z11, AMAROS required patients to have clinically-small Engl J Med. 1985; 312:665–73. (T1-T2) tumors and be clinically node-negative; however, 6. Fisher B, Anderson S, Bryant J, et al. Twenty-year AMAROS also allowed patients who were undergoing follow-up of a randomized trial comparing total lumpectomy or mastectomy. Over 90% of the cohort had mastectomy, lumpectomy, and lumpectomy plus three or less positive SLNs.12 The 10-year follow-up data irradiation for the treatment of invasive breast cancer. was presented at the 2018 San Antonio Breast Cancer N Engl J Med. 2002; 347:1233–41. conference and revealed no difference in OS or DFS.13 The 7. Hughes KS, Schnaper LA, Bellon JR, et al. Lumpectomy rate of lymphedema was halved in those patients who plus tamoxifen with or without irradiation in women underwent RT compared to those who underwent ALND. age 70 years or older with early breast cancer: long- term follow-up of CALGB 9343. J Clin Oncol. 2013 Jul While these clinical trials demonstrate the feasibility 1;31(19):2382-7. to de-escalate surgery in clinically node-negative patients, 8. Giuliano AE, Kirgan DM, Guenther JM, Morton DL. there are both parallel and on-going clinical trials Lymphatic mapping and sentinel lymphadenectomy evaluating similar surgical techniques for clinically node- for breast cancer. Ann Surg. 1994, 220: 391-398. positive and locally-advanced breast cancer. These trials 9. Krag DN, Anderson SJ, Julian TB, et al. Sentinel-lymph- highlight the progression of breast cancer surgery and the node resection compared with conventional axillary- significant role of the multidisciplinary oncology team in lymph-node dissection in clinically node-negative advancing breast cancer care. patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet FOR ADDITIONAL INFORMATION on this topic, see Oncol. 2010 Oct;11(10):927-33. references, visit mcw.edu/surgery, or contact Dr. 10. Giuliano AE, Hunt KK, Ballman KV, et. al. Axillary Chandler Cortina at [email protected]. dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: REFERENCES a randomized clinical trial. JAMA. 2011 Feb 1. McLaughlin SA, Wright MJ, Morris KT, et al. Prevalence 9;305(6):569-75. 11. Giuliano AE, Ballman KV, McCall L, et al. Effect of of lymphedema in women with breast cancer 5 Axillary Dissection vs No Axillary Dissection on 10-Year years after sentinel lymph node biopsy or axillary Overall Survival Among Women With Invasive Breast dissection: objective measurements. J Clin Oncol. Cancer and Sentinel Node Metastasis: The ACOSOG 2008, 10;26(32):5213-9 Z0011 (Alliance) Randomized Clinical Trial. JAMA. 2. Halsted W. The Results of Operations for the Cure of 2017 Sep 12;318(10):918-926 Cancer of the Breast Performed at the Johns Hopkins 12. Donker M, van Tienhoven G, Straver ME, et al. Hospital from June 1889, to January 1894. Ann Surg Radiotherapy or surgery of the axilla after a positive 1894. 20:497-555. sentinel node in breast cancer (EORTC 10981-22023 3. Fisher B, Montague E, Redmond C, et al. Comparison AMAROS): a randomised, multicentre, open-label, of radical mastectomy with alternative treatments for phase 3 non-inferiority trial. Lancet Oncol. 2014 primary breast cancer. A first report of results from Nov;15(12):1303-10. a prospective randomized clinical trial. Cancer. 1977; 13. Rutgers EJ, Donker M, Poncet C, et al. Radiotherapy 39:2827–39. or surgery of the axilla after a positive sentinel node 4. Fisher B, Jeong JH, Anderson S, et al. Twenty-five-year in breast cancer patients: 10 year follow up results of follow-up of a randomized trial comparing radical the EORTC AMAROS trial (EORTC 10981/22023). San Antonio Breast Cancer Symposium. December 2018. Abstract GS4-01. Leading the Way | Summer 2020 | 5

Inclusion, Diversity, and Equity in Tracy S. Wang, MD, MPH MCW DEPARTMENT OF SURGERY’S PLEDGE Professor We pledge to achieve and maintain equity Division of Surgical Oncology and diversity among faculty and staff, to reinforce professional workplace standards, Andrew S. Kastenmeier, MD and to optimize patient care and health Associate Professor equity. Division of General Surgery #IWILLMCW #WEWILLMCW The field of surgery is more diverse and inclusive than ever before, but true equity remains elusive. The coworkers, the way that we recruit, the way that we composition of the workforce in surgery is not reflective of hire, the way that we promote, the way that we allocate the demographics seen in the medical student population resources, the way that we select leaders, the way that or the population in general. According to 2019 data from we delegate tasks, the way that we teach, the way that the Association of American Medical Colleges (AAMC), we mentor, and the work environment that surrounds us. for the first time ever, women comprise the majority of The outcome of these behaviors is that equally qualified enrolled medical students in the United States. Yet women individuals are unintentionally perceived as more or less represent only 39% of medical school faculty, and they deserving of advancement or accolades based on non- only represent 24% of full professors. Only 3% of medical conscious biases of those who are making the decisions. school faculty are Black and only 4% identify as Hispanic or Latino. 1,2 Much attention has been directed at disparities in health care outcomes. Disparities in socioeconomic Just as concerning is the lack of women and status and education have been highlighted as underlying underrepresented in medicine (URM) physicians in causes, but there is growing evidence that implicit bias leadership positions, advanced academic ranks, and as in the physician-patient relationship is a factor that is recipients of professional awards. Despite equivalent increasingly recognized as contributing to disparate health qualifications, female physicians have been shown to have care outcomes.4,5 received lower salaries, lower Medicare reimbursements, fewer invitations to serve as expert speakers, and fewer There is a single reason why addressing implicit bias professional awards.2 Female surgeons earn 8% less has such great potential in our effort to create a more annually than male surgeons after controlling for specialty, inclusive, diverse, and respectful environment: Everyone age, faculty rank, and metrics of clinical and research has implicit biases. In fact, people of underrepresented productivity. For those women who do enter a surgical groups can have implicit biases about a group to which career, overcoming bias and discrimination requires social they belong. Men and women both implicitly associate and physical adaptation that has been shown to result in men with career orientation and women with family fatigue, stress, and job dissatisfaction that tests the limits orientation.2 The keys to combating the impact of implicit of even the most resilient individuals.3 bias are understanding that implicit bias exists, working to determine what implicit biases one holds, identifying Advancement of women and underrepresented how you may be acting on implicit bias in your daily life, minorities in medicine – and academic surgery, specifically and then working to mitigate the impact of these biases. – may be hindered by stereotype-confirming thoughts, This takes self-reflection, something to which busy people known as implicit bias. Implicit biases are mental often hesitate to devote ample time. associations outside of conscious awareness or control that influence one’s interactions with others. Implicit Last year, the Medical College of Wisconsin Center for biases are stereotypes that we attribute to certain groups, the Advancement of Women in Science launched IWill and these stereotypes stem from perceptions reinforced MCW, a community-wide campaign that encourages by culture, media, and personal experiences. Ultimately, dialogue to create shared language, understanding, implicit biases may lead people to act in ways that are not and positive action. Support for equity across gender, in line with their explicit beliefs or values, and physicians ethnicity, sexuality, and parental choice drives this are not immune to harboring implicit biases.1,4 campaign. This grass-roots initiative focuses on individual action – people pledge to act, and then ask others to Implicit bias can impact the way that we treat our join them in this movement. The Department of Surgery created a collective pledge and implemented an action 6 | Medical College of Wisconsin Department of Surgery plan to increase awareness of our own implicit biases. We have asked the 367 faculty, staff, fellows, and residents to

Healthcare and the Workplace participate in implicit association testing (IAT), via Project REFERENCES Implicit. Results are anonymous and reported only to the 1. Torres MB, Salles A, Cochran A. Recognizing and individual. We also asked for voluntary completion of an anonymous survey to those who took the IAT to determine Reacting to Microaggressions in Medicine and if there are implicit bias themes across our department Surgery. JAMA Surg. 2019 Jul 10. PMID: 31290954. that represent opportunities for further action. 2. Salles A, Awad M, Goldin L, Krus K, Lee JV, Schwabe MT, Lai CK. Estimating Implicit and Explicit Gender Implicit bias represents a significant contributor to our Bias Among Health Care Professionals and Surgeons. collective shortfall in successfully promoting diversity, JAMA Netw Open. 2019 Jul 3;2(7):e196545. PubMed inclusion, and equity. It creates obstacles to success for PMID: 31276177. women and minorities. Implicit bias also impacts the 3. Barnes KL, McGuire L, Dunivan G, Sussman AL, patient care that we provide and contributes to less McKee R. Gender Bias Experiences of Female Surgical successful health care outcomes for certain groups. The Trainees. J Surg Educ. 2019 Nov - Dec;76(6):e1-e14. ubiquitous nature of implicit bias means that we each have doi:0.1016/j.jsurg.2019.07.024. Epub 2019 Oct 7. a role in creating a solution. This can be accomplished by PubMed PMID: 31601487. taking responsibility to investigate our own implicit biases 4. Chapman EN, Kaatz A, Carnes M. Physicians and taking action to minimize the impact of implicit bias in and implicit bias: how doctors may unwittingly environment. Each of us has a role to play in understanding perpetuate health care disparities. J Gen Intern our own implicit biases. Med. 2013 Nov;28(11):1504-10. doi: 10.1007/ s11606-013-2441-1. Epub 2013 Apr 11. Review. We realize that the IAT is an imperfect tool, and the PubMed PMID: 23576243; PubMed Central PMCID: results do not predict the behavior of any particular PMC3797360. individual. But as a whole, it suggests how groups of 5. Maina IW, Belton TD, Ginzberg S, Singh A, Johnson people may respond, and why we felt it was important TJ. A decade of studying implicit racial/ethnic bias in to have a department-wide effort for this initiative of healthcare providers using the implicit association increasing awareness of the implicit biases. test. Soc Sci Med. 2018 Feb;199:219-229. doi: 10.1016/j.socscimed.2017.05.009. Epub 2017 May We would like to invite anyone who has interest to 4. Review. PubMed PMID: 28532892. participate in implicit-association testing in an effort to identify personal biases. The IAT is completely PROJECT IMPLICIT anonymous and is for your personal and professional development (https://implicit.harvard.edu/implicit/). IMPLICIT-ASSOCIATION TEST If you participate, we would love to hear your thoughts and impressions by completing our survey Non-profit organization with a goal to educate the (bit.ly/2W4I0ZT). public about hidden biases and to provide a “virtual laboratory” for collecting data on the internet. FOR ADDITIONAL INFORMATION on this topic, see Implicit-Association Test: measures the strength of references, visit mcw.edu/surgery, or contact Dr. Tracy associations between concepts and evaluations or Wang at [email protected]. stereotypes. https://implicit.harvard.edu/implicit/ Available Implicit Association Tests Weight IAT Age IAT Religion IAT Presidents IAT Gender-Science IAT Gender-Career IAT Native IAT Asian IAT Disability IAT Weapons IAT Race IAT Skin-tone IAT Arab-Muslim IAT Sexuality IAT Leading the Way | Summer 2020 | 7

Evolving Treatment Options for Type B Joseph Hart, MD, MHL For cases without Associate Professor an early surgical Division of Vascular and Endovascular or interventional Surgery indication, medical management is the Epidemiology mainstay therapy. Blood pressure and The epidemiology of a Type B (or descending heart rate control thoracoabdominal) aortic dissection (TBAD) is unique is initiated on all from a Type A dissection. In TBAD, the dissection occurs TBAD patients, both beyond the left subclavian artery (Figure 1), whereas a medical and surgical Type A dissection occurs in the ascending aorta. While management groups, emergency surgery is recommended for type A dissections, immediately upon medical management is the primary treatment for TBAD. diagnosis. Heart rate Figure 1: A schematic diagram Surgery for a Type A dissection carries a 10% to 20% control is an essential of a typical entry tear of a Type-B operative mortality, whereas uncomplicated TBADs have first step as afterload Aortic Dissection (TBAD), beyond an 80% one-year survival when treated with medical reduction alone, the origin of the left subclavian management alone. artery. Etiology The most common cause of an aortic dissection is in the presence of uncontrolled hypertension. Cystic medial necrosis of the tachycardia, may increase shearing forces on the wall of aortic wall is the typical pathologic finding. Connective the aorta. After an intravenous beta-blocker is initiated to tissue disorders such as Marfan syndrome, Ehlers-Danlos control tachycardia and hypertension, additional agents syndrome, and Loeys-Dietz syndrome are risk factors for can be added as needed. Close blood pressure monitoring developing an aortic dissection. Fibrillin gene mutations, with an arterial line is crucial. as well as genetic mutation clusters within families, highlight the importance of genetic testing to better Treatment understand the pathophysiology of aortic dissections. Until recent years, aortic surgery for repairing any Diagnosis visceral malperfusion or rupture was the only option The diagnosis of aortic dissection is expedited by CT available. More recently, thoracic endovascular aneurysm angiography (CTA). If a coronary etiology is ruled out in repair (TEVAR) devices made endovascular or hybrid a patient presenting with chest pain, a CTA can quickly approaches feasible. TEVAR is much less invasive and confirm or exclude the diagnosis of TBAD in most cases. In continues to evolve to make treatment safer and more other instances, an aortic dissection is diagnosed when a tolerable to larger subsets of patients. CT scan is performed for a different clinical concern, such as a pulmonary embolism. Additional useful modalities In addition to conventional covered TEVAR devices, a in the diagnosis of TBAD include transesophageal novel system has recently become available.4 This approach echocardiography (TEE), magnetic resonance angiography involves a combination of covered and uncovered stents (MRA), intravascular ultrasound (IVUS), and catheter allowing treatment of the central aorta by re-expanding angiography. The latter two are primarily useful as the dissected true lumen, while preserving antegrade intraprocedural imaging for stent grafting. flow into essential visceral branches. The current Management system that is commercially available is the Cook Zenith Dissection Endovascular System stent (Figure 2). The first The algorithm for the initial management of these component is a relatively standard covered TEVAR device. patients includes assessment for evidence of rupture or The remaining, more distal components are uncovered to significant organ ischemia.1-3 The severity of TBADs are allow persistent perfusion into important renal, visceral, assessed to identify or exclude malperfusion of renal, intercostal and lumbar branches of the central aorta.5-12 mesenteric, or lower extremity circulation. If there is evidence of critical visceral organ or lower extremity Other treatments on the horizon for TBADs with malperfusion, early interventional or surgical treatment complications include branched or fenestrated EVAR is required. devices and physician-modified endovascular grafts (PMEGs). These approaches may play an important role in 8 | Medical College of Wisconsin Department of Surgery management of long-term complications of patients with TBADs, such as chronic aneurysms.

Aortic Dissections REFERENCES 1. Fattori R, Cao P, De Rango P, Czerny M, Evangelista A, Complications Complications of TBADs can be numerous, subtle to Nienaber C, Rousseau H, Schepens M. Interdisciplinary expert consensus document on management of type B identify early, and potentially fatal. Acute and chronic aortic dissection. J Am Coll Cardiol. 2013;61(16):1661- complications include aneurysm formation, rupture, 78. spinal cord ischemia with paraplegia, stroke, malperfusion 2. Bannazadeh M, Tadros RO, McKinsey J, Chander R, syndrome of the central aorta with visceral and/or renal Marin ML, Faries PL. Contemporary Management of ischemia, and extremity ischemia. Malperfusion, persistent Type B Aortic Dissection in the Endovascular Era. Surg pain, or less commonly rupture, are the drivers of early Technol Int. 2016;28:214-21. urgent intervention or surgery. Aneurysm formation and 3. Tadros RO, Tang GHL, Barnes HJ, Mousavi I, Kovacic progression beyond threshold size is the dominant driver JC, Faries P, Olin JW, Marin ML, Adams DH. Optimal of delayed interventional treatment. Treatment of Uncomplicated Type B Aortic Dissection: Follow-Up/Surveillance Monitoring JACC Review Topic of the Week. J Am Coll Cardiol. 2019;74(11):1494-1504. Ongoing surveillance is vital for patients with TBADs, 4. Spanos K, Kölbel T. Device profile of the Zenith regardless of whether treated with a repair or medically Dissection Endovascular System for aortic dissection. managed. Following an interventional repair, CTA is useful Expert Rev Med Devices. 2019;16(7):541-548. to monitor for branch vessel stenosis, progressive endoleak, 5. Lombardi JV, Gleason TG, Panneton JM, Starnes BW, or aneurysmal enlargement. In medically managed cases, Dake MD, Haulon S, Mossop PJ, Seale MM, Zhou surveillance with CTA is also a mainstay of care. The other Q; STABLE II Investigators. STABLE II clinical trial on previously noted modalities, such as MRA, TEE, or catheter endovascular treatment of acute, complicated type angiography, may each also be useful in specific situations. B aortic dissection with a composite device design. J Vasc Surg. 2020;71(4):1077-1087.e2. FOR ADDITIONAL INFORMATION on this topic, visit 6. Sobocinski J, Dias NV, Hongku K, Lombardi JV, Zhou Q, mcw.edu/surgery or contact Dr. Joseph Hart at Saunders AT, Resch T, Haulon S. Thoracic endovascular [email protected]. aortic repair with stent grafts alone or with a composite device design in patients with acute type B aortic dissection in the setting of malperfusion. J Vasc Surg. 2020;71(2):400-407.e2. 7. Lombardi JV, Cambria RP, Nienaber CA, Chiesa R, Mossop P, Haulon S, Zhou Q; STABLE I Investigators. Five-year results from the Study of Thoracic Aortic Type B Dissection Using Endoluminal Repair (STABLE I) study of endovascular treatment of complicated type B aortic dissection using a composite device design. J Vasc Surg. 2019;70(4):1072-1081.e2. 8. Sobocinski J, Lombardi JV, Dias NV, Berger L, Zhou Q, Jia F, Resch T, Haulon S. Volume analysis of true and false lumens in acute complicated type B aortic dissections after thoracic endovascular aortic repair with stent grafts alone or with a composite device design. J Vasc Surg. 2016;63(5):1216-24. CONTINUED ON PAGE 11 Figure 2: A schematic of central aortic involvement of the visceral branches in TBAD, treated with the novel dissection endovascular treatment system. A covered stent is deployed proximally to exclude and seal the primary entry tear; the uncovered stent component(s) deployed more distally to re- expand the true lumen, help achieve false lumen thrombosis (closure), and preserve critical distal branches to the renal and mesenteric circulation. The left subclavian artery can be covered (as seen here) and is tolerated by most patients with normal vertebral artery anatomy, due to robust collateral flow to the arm. Interval carotid-subclavian bypass can be added in the early post-op period when needed. Leading the Way | Summer 2020 | 9

The Utility of Vessel-Sealing Devices Sophie Dream, MD “I have pondered the question for many years and Assistant Professor conclude that the explanation probably lies in the Division of Surgical Oncology operative methods of the two illustrious surgeons. Kocher, neat and precise, operating in a relatively Tracy S. Wang, MD, MPH bloodless manner, scrupulously removed the en- Professor tire thyroid gland doing little damage outside its Division of Surgical Oncology capsule. Billroth, operating more rapidly and, as I recall, with less regard for the tissues and less In 1909, Emil Theodor Kocher won the Nobel Prize in concern for hemorrhage, might easily have re- “Physiology or Medicine” for his work on the physiology, moved the parathyroids or at least have interfered pathology, and surgery of the thyroid gland.2 Throughout with their blood supply, and have left fragments his career, he performed over 5,000 thyroid operations of the thyroid.” and reported a mortality rate of 0.5%.3 In the modern era of surgery, mortality after thyroidectomy is extremely —William Stewart Halsted, 19191 unlikely; however, at the beginning of Dr. Kocher’s career, thyroidectomy carried a 41% mortality rate.3 As the to avoid making a hasty conclusion about the durability Father of Thyroid Surgery, Kocher’s ability to reduce the of VSDs. The first of which being that the NSQIP Thyroid mortality rate after thyroid surgery was attributed to Procedure-Specific Database does not address surgeon- his adoption of aseptic technique, his understanding of volume, which has been shown to be a significant factor thyroid physiology, and his meticulous surgical technique in postoperative complication rate in thyroidectomies.5,7 which resulted in minimal blood loss.3,4 Additionally, many thyroid surgeons who report using a VSD will use CH techniques throughout their operations, Hemostasis is of particular concern in thyroid surgery, which is problematic when trying to ascribe post operative as postoperative neck hematoma can be a life-threatening outcomes to one hemostatic method over. complication. Dr. Kocher demonstrated that surgical technique is second-to-none in preventing mortality due Many ex-vivo studies have been performed since the to hemorrhage during thyroid surgery. Today, the rate advent of VSDs to evaluate their ability to effectively seal of postoperative hematoma after thyroidectomy is less vessels. In a prospective study evaluating fresh porcine than 1% in the hands of experienced surgeons.5 With the arteries, Tharakan et al. compared ten vessel-sealing advent of vessel-sealing devices, the surgeon is faced with methods (including four VSDs, three staplers, suture deciding which of the available tools can aid in minimizing ligation, and clips).8 They measured the average burst surgical complications. pressure in each vessel, placing a catheter in the open end secured with a purse-string suture and then, infusing A recent study published in JAMA Surgery6 aimed saline through the catheter, the pressure at which the to compare the rate of neck hematoma in patients vessel leaked was noted to be the burst pressure. They undergoing thyroidectomy using conventional hemostasis found the highest average burst pressure to be in suture- (CH) techniques (tying or clipping of vessels) versus vessel- base methods and the lowest burst pressures in stapling sealing devices (VSD), using the Thyroid Procedure-Specific methods. However, they noted that all vessel sealing Database of the National Surgical Quality Improvement methods had average burst pressures above 250 mmHg, Program (NSQIP). When comparing 6,522 propensity- which is above physiological relevance.8 score matched patients (3,261 in whom VSD was used and 3,261 in whom CH was used), the authors concluded that It is of the utmost importance that, when adopting a CH was associated with higher odds of a neck hematoma, technology in surgery, the surgeon be familiar with the while VSD usage was associated with shorter length of functionality of the device, as well as any potential pitfalls stay. They did not identify any differences in recurrent or limitations. It is also crucial that the surgeon does not laryngeal injury or operative times between the two see advances in surgical technology as a replacement methods.6 Scan the QR code to read While the above study was well-designed and well- “Implementation of Vessel- powered, there are many factors that one must consider Sealing Devices in Thyroid Surgery,” by Drs. Sophie Dream 10 | Medical College of Wisconsin Department of Surgery and Tracy Wang, published in JAMA Surgery.

in Thyroid Surgery FOR ADDITIONAL INFORMATION on this topic, visit mcw.edu/surgery or contact Dr. Sophie Dream at for meticulous surgical technique and experience. While [email protected]. vessel-sealing devices may provide some advantage in the operating room, the most significant reduction in 9. Harold KL, Pollinger H, Matthews BD, Kercher KW, mortality and morbidity related to thyroid surgery only Sing RF, Heniford BT. Comparison of ultrasonic came after Dr. Kocher demonstrated value in the core energy, bipolar thermal energy, and vascular clips for principle of hemostasis. the hemostasis of small-, medium-, and large-sized arteries. Surg Endosc. 2003;17(8):1228-1230. REFERENCES 1. Halsted WS. The Operative Story of Goitre. The CONTINUED FROM PAGE 9 9. Lombardi JV, Cambria RP, Nienaber CA, Chiesa Author’s Operation. JAMA. 1920;74(10):693-694. 2. Theodor Kocher – Facts. https://www.nobelprize.org/ R, Mossop P, Haulon S, Zhou Q, Jia F; STABLE investigators. Aortic remodeling after endovascular prizes/medicine/1909/kocher/facts/. Published 2020. treatment of complicated type B aortic dissection Accessed March 1, 2020, 2020. with the use of a composite device design. J Vasc 3. Becker WF. Presidential Address: Pioneers in Thyroid Surg. 2014;59(6):1544-54. Surgery. Ann Surg. 1977;185(5):493-504. 10. Lombardi JV, Cambria RP, Nienaber CA, Chiesa R, 4. Sakorafas GH. Historical Evolution of Thyroid Surgery: Teebken O, Lee A, Mossop P, Bharadwaj P; STABLE From the Ancient Times to the Dawn of the 21st investigators. Prospective multicenter clinical Century. World Journal of Surgery. 2010;34(8):1793- trial (STABLE) on the endovascular treatment of 1804. complicated type B aortic dissection using a composite 5. Adam MA, Thomas S, Youngwirth L, et al. Is There a device design. J Vasc Surg. 2012;55(3):629-640.e2. Minimum Number of Thyroidectomies a Surgeon 11. Melissano G, Bertoglio L, Rinaldi E, Civilini E, Tshomba Should Perform to Optimize Patient Outcomes? Ann Y, Kahlberg A, Agricola E, Chiesa R. Volume changes Surg. 2017;265(2):402-407. in aortic true and false lumen after the “PETTICOAT” 6. Siu J, McCarthy J, Shekhar G, et al. The Association procedure for type B aortic dissection. J Vasc Surg. of Vessel-Sealant Devices Compared to Conventional 2012;55(3):641-51. Hemostasis with Post-operative Neck Hematoma after 12. Melissano G, Bertoglio L, Kahlberg A, Baccellieri Thyroid Operations. JAMA surgery. D, Marrocco-Trischitta MM, Calliari F, Chiesa R. 7. Sosa JA, Bowman HM, Tielsch JM, Powe NR, Gordon Evaluation of a new disease-specific endovascular TA, Udelsman R. The importance of surgeon device for type B aortic dissection. J Thorac Cardiovasc experience for clinical and economic outcomes from Surg. 2008;136(4):1012-8. thyroidectomy. Annals of sSrgery. 1998;228(3):320- 330. 8. Tharakan SJ, Hiller D, Shapiro RM, Bose SK, Blinman TA. Vessel sealing comparison: old school is still hip. Surg Endosc. 2016;30(10):4653-4658. To refer a patient or request a transfer/consultation, please use the references below: ADULT PATIENTS Clinical Cancer Center PEDIATRIC PATIENTS All Non-cancer Requests Referrals: 866-680-0505 Referrals/Transfers/ Referrals: 800-272-3666 Transfers/Consultations: Consultations: 800-266-0366 Transfers/Consultations: 877-804-4700 Acute Care Surgery: 877-804-4700 414-266-7858 mcw.edu/surgery Leading the Way | Summer 2020 | 11

Road Construction Ahead Lyle Joyce, MD, PhD “Roads? Where we’re going, we don’t need roads.” Professor — Doctor Emmett Brown, “Back to the Future” Chief, Section of Adult Cardiac Surgery (1985) Division of Cardiothoracic Surgery David Joyce, MD Of course, those of us who rely on the expertise of human Associate Professor radiologists on a daily basis undoubtedly have a different Division of Cardiothoracic Surgery view. As cardiac surgeons, we have a unique appreciation for the greatly exaggerated claims about our own demise. Radiology. Ophthalmology. Anesthesiology. That said, it is undeniable that disruption is already Dermatology. Medical students were often told that here. Remember learning how to perform a fundoscopic it would be ill-advised to consider any other specialty examination as a medical student? How good were you options given the work/life balance and favorable at picking out diabetic retinopathy? How would you like compensation packages to be found along this “road to go head-to-head against Google AI’s Optical Coherence to happiness.” In the world after Waze, an alternative Tomography platform (which can also correctly determine nagivation app, this course seems a bit more treacherous. age, biological sex, smoking history, hemoglobin A1c, BMI, On February 11, 2017, Alphabet’s Google Brain released and systolic blood pressure)? Soon you will be able to its second-generation proprietary machine learning download an app on your iPhone that is more accurate in system. It didn’t take much of an imagination to figure detecting a melanoma than 21 of the best dermatologists out that if TensorFlow could reliably identify a cat within a at Stanford.2 As surgeons who are “leading the way,” we YouTube video, artificial intelligence could easily quantify should find these trends inspiring. How can we be the the cancer risk associated with a mass on a CT scan.1 ones to lead innovation, as opposed to becoming roadkill Professor Geoffrey Hinton, godfather of neural networks, ourselves? went so far as to put it this way: “I think that if you work as a radiologist you are like Wile E. Coyote in the cartoon. Ed Roberts, the David Sarnoff Professor of Management You’re already over the edge of the cliff, but you haven’t Technology at MIT, has given us a framework for yet looked down. There’s no ground underneath. It’s just understanding this opportunity in mathematical terms:3 completely obvious that in five years deep learning is going to do better than radiologists.” INNOVATION = INVENTION + COMMERCIALIZATION The first variable in this equation is something that is Health-e was one of two startups from the Chicago cohort that was selected to compete in the Global New Venture already hard wired into our DNA as surgeons, thanks to Challenge finals. frequent visits by innovation’s mother (necessity) to our 12 | Medical College of Wisconsin Department of Surgery operating rooms every day. In more complex versions of this type of problem solving, our efforts at invention have resulted in grant funding, abstract presentation, and manuscript publication in various societies and medical journals across the globe. Dr. Gwen Lomberk’s Division of Research in the Department of Surgery is a virtual assembly line of good ideas that are on their way to changing medical practice. But it is the second variable in the equation that is often overlooked in an academic medical institution. Medical school curricula generally don’t include topics like market segmentation, customer acquisition costs and development of a value proposition. Even in the rare cases in which genius and life experience have bestowed upon an individual the gifts of entrepreneurship (we’re looking at you, Drs. Mike and Aoy Mitchell), success requires the assembly of a team. This past year I (Dr. David Joyce) had the opportunity to assemble a diverse group of business executives and technology partners to compete in the University of Chicago Booth School of Business/

Polsky Center’s Global New Venture Challenge. Mentored by some of the best economists in the startup world, we developed a strategy to use the data from wearable devices to train an artificial intelligence algorithm that could predict adverse events such as early hospital readmission in heart failure patients. Our team was selected to compete against cohorts from London and Hong Kong in the final round of competition later this spring, and with a little luck and some traction with a Venture Capital firm, we hope to launch this product by the end of the year. Throughout this process, we couldn’t help imagining what might happen if everyone in our department had the same opportunity to partner with a team that offered such diverse talents. Professor Frederick Terman was considered the “Father of Silicon Valley” because he encouraged engineering students like William Hewlett and David Packard to not just develop good ideas, but to commercialize them. What would happen if our department applied this same approach within the health care industry and developed a The current technology pipeline features a heavy emphasis on artificial intelligence division to streamline the innovation and machine learning platforms.This presents a unique opportunity to solve many of process? By taking a systematic and the problems that arise in the surgical specialties. purposeful approach, it seems likely that we could identify FOR ADDITIONAL INFORMATION on this topic, visit projects with the right development horizon and total mcw.edu/surgery, contact Dr. David Joyce at djoyce@ addressable market size to qualify for angel and venture mcw.edu, or read Drs. Lyle and David Joyce’s new money in addition to the usual sources of grant funding. book “Mechanical Circulatory Support: Principals and When you consider that only 19 of the existing 326 Applications.” unicorns were launched from the $3.65 trillion health care sector and that the growth rate of health care data has been approximately 878% since 2016, hitching our domain expertise with the right data science and management team could turn out to be a road trip worth taking. REFERENCES “Mechanical 1. Ardila, D., et al., End-to-end lung cancer screening with Circulatory Support: Principals and three-dimensional deep learning on low-dose chest Applications” can computed tomography. Nat Med, 2019. 25(6): p. 954- be purchased on 961. Amazon and is 2. Esteva, A., et al., Dermatologist-level classification of available in both skin cancer with deep neural networks. Nature, 2017. print and eBook 542(7639): p. 115-118. formats. 3. Roberts, E.B., Managing invention and innovation. Research-Technology Management, 2007. 50(1): p. 35-54. Leading the Way | Summer 2020 | 13

General and Vascular Surgery Semiannual Emma Gibson, MD doing better than expected. The semiannual report in- General Surgery Resident cludes the model name (for example “General Surgery Sur- PGY 3 gical Site Infection”), total number of cases contributed to Jon Gould, MD the model, the observed number of events, the observed Alonzo P. Walker Professor and Chief event rate, predicted observed rate, expected rate, OR, the Division of General Surgery lower limit of the confidence interval, the upper limit of Background: the confidence interval, outlier status, decile rank, adjusted percentile, adjusted quartile, and performance assessment. The ACS National Surgical Quality Improvement Program (NSQIP) is a risk-adjusted, outcomes-based Results are reported in table format and using site- program that aims to measure and improve the quality specific bar plots. These bar plots provide a graphical de- of surgical care. The information collected and reported scription of the information contained in the site summary enables participating hospitals to make a valid comparison report. When interpreting the bar plots, it is important of its outcomes with those of other hospitals and, as a to remember that the bottom and top of the background result, determine where it needs to make improvements. bar for each model indicates the value of the smallest and Froedtert Hospital is one of 10 hospitals in Wisconsin largest OR for sites in the model. In other words, the back- participating in ACS NSQIP.1 ground bar gives the range of site ORs for all sites in the model. The lines within each background bar identify se- A Semiannual Report (SAR) is released to participating quential adjusted quartile ranges in the site ORs (0%, 25%, hospitals every 6 months, which includes data from the 50%, 75%, and 100% of sites). For each model, the site previous year. This most recent report includes 30-day odds ratio is represented by a point and the numerical val- outcomes from July 1, 2018 to June 30, 2019. During the ue of the site OR is reported near the top of the plot. The reporting period, 718 sites submitted data for inclusion in confidence interval for the site OR is represented by a verti- this SAR, with outcomes measured for more than 1 million cal line segment containing the site OR. Horizontal line seg- cases. Data collected includes preoperative demographics, ments cap the top and bottom of the confidence interval. laboratory variables, intraoperative variables, A site is a high outlier if their confidence interval is entirely complications, and most importantly, 30-day outcomes. above the orange, horizontal reference line, and the site is a low outlier if their confidence interval is entirely below the orange, horizontal reference line. ‘1’ and ‘4’ indicate that the site is in the first or fourth adjusted quartile, re- spectively (Fig. 1). A representative bar plot from our most recent semi-annual report is displayed in Figure 2. Outcomes Figure 1: Semi-annual report bar plot overview. NSQIP outcomes are adjusted us- ing a robust risk-adjustment meth- odology that takes into account mul- tiple clinical variables. Risk adjusted, 30-day morbidity and mortality out- comes are computed for each par- ticipating hospital and reported as odd ratios (ORs) that represent the odds of a complication happening at our hospital, compared to the odds of that event happening at a model estimated average ACS NSQIP hos- pital, if that hospital were to do the same procedures on the same mix of patients. An OR of 1.0 means the hospital is doing as expected. A number greater than 1.0 means the hospital is doing worse than expected and a number less than 1.0 means the hospital is 14 | Medical College of Wisconsin Department of Surgery

Report Discussion NSQIP data allows us to take the complexity of our patients and procedures into account as we determine where we need to focus our quality improvement efforts. When an opportunity is identified, the NSQIP database allows us to quickly determine specific patients in each model to experience a complication of interest in order to conduct a more detailed analysis. Outcome-Specific Heat Maps are another tool that allows us to focus QI efforts. This provides participants with a visual overview of their performance. Adjusted percentiles are used to determine the fill/pattern for a particular Figure 2- General/Vascular surgery outcomes. model category and height is proportional to the overall case volume submitted by the hospital. Hovering over a model category displays additional model summary information. An example of an Outcome- Specific Heat Map is provided in Figure 3. One drawback of the semi-annual report is that cases performed up to 18 months previously are included and the most recent cases were performed 6 months previously. NSQIP provides an on demand, risk-adjusted and smoothed rates report for the different models as well. This allows for real time tracking of outcomes in order to track the impact of QI interventions and to monitor evolving issues. Figure 3 – NSQIP Outcome Specific Heatmap. We use NSQIP for many other purposes factors and trends in rare events, and for our researchers as well. NSQIP data is shared regularly with the department, to perform outcomes research using large numbers of hospital, clinical programs, and multidisciplinary unit-based patients with robust and reliable data to reflect outcomes. accountable care teams. Resident-specific outcomes data is provided through the Quality In Training Initiative. This The NSQIP program is a key element to our departmental increases surgery resident engagement and awareness and hospital approach to improve the safety and quality of of quality and outcomes, and fulfills the ACGME Clinical the surgical care we provide. We continue to look for new Learning Environment Review (CLER) requirement to provide ways to use this program and our data to do even more. residents with data to reflect their clinical outcomes. We participate in the Hepatobiliary and Pancreas Surgery FOR ADDITIONAL INFORMATION on this topic, visit mcw. Collaborative through NSQIP. This is a multi-institutional edu/surgery or contact Dr. Jon Gould at jgould@mcw. collaborative intended to improve the quality of care in edu. hepatobiliary and pancreatic surgery by working together to investigate opportunities to improve outcomes. Sites that participate in NSQIP have access to the Participant Use File (PUF). The PUF is a HIPAA-compliant REFERENCE data file containing patient-level, aggregate, de-identified 1. ACS NSQIP Semiannual Report: Site Summary, Froedtert data. The 2016 PUF contains more than one million cases. This allows our clinicians opportunities to examine risk Memorial Lutheran Hospital: 07/01/2018-06/39/2019. Provided by courtesy of Dr. Jon Gould. Leading the Way | Summer 2020 | 15

Detection of Germline Variants Using Expanded Multigene Ashely Krepline, MD pancreatic cancer at Froedtert and the Medical College General Surgery Research Resident of Wisconsin. In our analysis, we identified 510 patients PGY 4 with localized pancreatic cancer who were treated from 2009-2018; 163 (32%) of whom were referred for genetic Susan Tsai, MD, MHS counseling and 127 (78%) of the 163 patients referred Associate Professor to genetic counseling underwent commercially available Director, LaBahn Pancreatic Cancer genetic testing. There were no differences in gender, Program age at diagnosis, race, or clinical stage between patients Division of Surgical Oncology with an identified genetic variant and those without a variant identified. Of 163 patients who were seen by a Pancreatic cancer is projected to be the second leading genetic counselor, nine (6%) were of Ashkenazi Jewish cause of cancer-related deaths in the United States by descent, eight of whom underwent genetic testing with 2030.1 While carcinogenesis is typically due to acquired no genetic variants identified. There were no differences genetic mutations, approximately 5-10% of patients with in personal history of other cancers, first-degree, or any- pancreatic cancer have an inherited genetic variant that is degree relative with pancreatic cancer, between patients thought to play a role in carcinogenesis. The most common with a genetic variant identified or those without a genetic genetic variants identified in patients with pancreatic variant identified. (Table 1). cancer include: BRCA1, BRCA2, PALB2, ATM, and CDKN2A.2 Current consensus guidelines from the American College Most commonly, patients did not undergo genetic of Medical Genetics and Genomics (ACMG) recommend testing due to lack of family history warranting testing germline testing in patients with a strong family history (n=12, 33%) or lack of insurance coverage or prohibitive of pancreatic cancer, breast cancer, ovarian cancer or copay (n=10, 28%), and some patients declined testing aggressive prostate cancer and melanoma. Testing is also (n=6, 17%). Of the 127 patients who underwent genetic recommended in patients of Ashkenazi Jewish ancestry testing, clinically actionable genetic variants were identified or a family history suggestive of Peutz-Jeghers or Lynch in 20 (16%) patients. The most common variants identified syndromes.3 With a selective approach to germline testing, include variants in ATM (n=7, 35%), genes associated with genetic variants are identified in 10-19% of patients with hereditary breast and ovarian cancer syndromes (BRCA1 pancreatic cancer.4-6 In 2018, the National Comprehensive n=2, BRCA2 n=1, PALB2 n=2, combined 25%), and CHEK2 Cancer Network (NCCN) released updated guidelines (n=3, 15%). The remaining five patients had a variant in a for germline testing to include genetic counseling in all variety of genes (Figure 1). patients with pancreatic cancer, rather than selective germline testing.7 In addition to the changes in genetic Between 2009 and 2013, genetic testing was performed testing guidelines put forth by the NCCN, genetic testing using targeted variant analysis, full gene sequencing techniques have changed over the years. Genetic testing analysis, and/or large rearrangement analysis for BRCA1, had previously been performed on targeted genes thought BRCA2, and PALB2. Following 2013, a variety of multigene to be associated with pancreatic cancer, notably BRCA1, panels have been utilized with an increasing number of BRCA2, and PALB2, or targeted mutation testing in BRCA1 genes being tested over time, with patients now routinely and BRCA2 associated with Ashkenazi Jewish descent. receiving 60-70-gene panels. Between 2009 and 2012, With the advent of next generation no genetic variants were identified, however this has sequencing (NGS), patients are now increased to 40% of patients having a genetic variant routinely receiving a non-selective identified in 2016, with the use of 34-gene panel testing panel testing of over 70 genes. and the proportion of variants identified when the panels expanded to 60-70 genes stayed the same. In July 2018, We analyzed the frequency after the release of new NCCN guidelines recommending of germline variants identified using all patients with pancreatic cancer be seen by a genetic commercially available germline testing in patients with localized 16 | Medical College of Wisconsin Department of Surgery

Panels in Patients with Localized Pancreatic Cancer counselor, the proportion of patients with clinically REFERENCES actionable variants identified dropped to 10% (Figure 2). 1. Rahib L, Smith BD, Aizenberg R, et al. Projecting Cancer In conclusion, clinically actionable germline Incidence and Deaths to 2030: The Unexpected variants were identified in 16% of patients with localized Burden of Thyroid, Liver, and Pancreas Cancers in the pancreatic cancer who underwent genetic testing. The United States. Cancer Research. 2014; 74(11):2913- presence of a germline variant was not predicted by 2921. younger age, personal history of a prior cancer, or family 2. Klein AP. Genetic susceptibility to pancreatic cancer. history of pancreatic cancer. The increased utilization of Mol Carcinog. 2012;51(1):14-24. larger genetic panel testing identified a higher proportion 3. Hampel H, Bennett RL, Buchanan A, et al. A practice of germline variants than targeted gene testing, including guideline from the American College of Medical the identification of low penetrance genetic variants. The Genetics and Genomics and the National Society expansion of genetic testing to all patients with pancreatic of Genetic Counselors: referral indications for cancer requires an infrastructure to counsel and interpret cancer predisposition assessment. Genet Med. genetic testing results which may not currently be feasible 2015;17(1):70-87. at most institutions. 4. Salo-Mullen EE, O’Reilly EM, Kelsen DP, et al. Identification of germline genetic mutations in patients FOR ADDITIONAL INFORMATION on this topic, visit with pancreatic cancer. Cancer. 2015;121(24):4382- mcw.edu/surgery or contact Dr. Susan Tsai at stsai@ 4388. mcw.edu. 5. Lowery MA, Wong W, Jordan EJ, et al. Prospective Evaluation of Germline Alterations in Patients With Exocrine Pancreatic Neoplasms. Journal of the National Cancer Institute. 2018;110(10):1067-1074. 6. Grant RC, Selander I, Connor AA, et al. Prevalence of germline mutations in cancer predisposition genes in patients with pancreatic cancer. Gastroenterology. 2015;148(3):556-564. 7. NCCN Clinical Practice Guidelines in Oncology. Pancreatic Adenocarcinoma. Version 2.2019 Available at https://www.nccn.org/professionals/physician_ gls/pdf/pancreatic.pdf. Accessed June 25, 2019. Leading the Way | Summer 2020 | 17

Do You Match? Double Your Donation Today! By Meg M. Bilicki, Director of Development, Department of Surgery Thanks to the generosity of the family of Robert E. Condon, MD, the Medical College of Wisconsin Department of Surgery is pleased to announce a $100,000 matching gift challenge for the Resident Research Fund. Donate before December 31, 2020, and your gift will be matched dollar-for-dollar, up to $100,000. Dr. Robert E. Condon was a gifted, compassionate physician, as well as an inspirational educator and mentor to generations of aspiring physicians. He served as the Chair of the Department of Surgery from 1979 to 1997. His passion for teaching will be remembered through the Resident Research Fund, which will benefit resident medical education and research. The Resident Research Fund gives surgical residents an opportunity to initiate and complete research projects related to their professional interests. The objective is to create opportunities for residents to gain a foundational understanding of clinical and translational research methods and evidence- based medicine skills, and to inspire them to pursue opportunities for “Time in the research lab gives career development as Dr. Robert E. Condon poses with a the resident a chance to become investigators. cardboard cutout of himself. an expert in something, to read in depth, to question authorities The Resident Research and to present. In the middle of a Fund bolsters the Department of Surgery’s existing programs with very busy residency, it gives them dedicated laboratory experiences that expose residents to the process time to reconnect with family and of translating scientific knowledge from bench to bedside. It provides friends.” residents the opportunity to initiate and complete research projects related to their professional interests. — Robert E. Condon, MD The goal of this challenge is to provide faculty and alumni with a special giving opportunity to increase their effect on a program area which may have shaped their own medical career. Most former residents realize their residency experience at MCW was invaluable and the pinnacle of their medical and surgical training. “The matching gift challenge is an exciting way for donors to see their investment double and to make a great impact,” Resident Research Fund Committee Chair Mary Otterson, MD ’84, GME ’90, said. “We are most grateful for the Condon family who offered such a strategic gift.” You can participate in furthering science and advancing the field of surgery by giving our residents the skills they need to be tomorrow’s outstanding physicians and scientists. This is the first time that a matching gift challenge has been issued strictly for the Resident Research Fund. Thank you, Meg! IF YOU WISH TO HAVE YOUR GIFT MATCHED, After 11 years of simply make a gift now through December 31, unprecedented loyalty 2020. You can make a gift online at and commitment to the www.mcw.edu/surgery or call 414-955-1841. Department of Surgery, Gifts can also be mailed to: Meg M. Bilicki has Medical College of Wisconsin accepted a position with Office of Development the Neuroscience Service 8701 Watertown Plank Road Line. We are forever Milwaukee, WI 53226 grateful for everything Meg has done for the Department of Surgery. 18 | Medical College of Wisconsin Department of Surgery

The Word on Medicine Predictors of Mortality After Trauma COVID-19 episodes: CONTINUED FROM PAGE 3 The Word on Medicine aired a series of weekly special broadcasts that 10. O’Connell K, Maier R. Palliative provided accurate information from physicians caring for patients every care in the trauma ICU. Curr day. We explained how this virus was transmitted from animals to humans Opin Crit Care. 2016;22(6):584- in China, how human-to-human transmission occurred, the challenges 590. with testing and treatment, and much more. 11. Elwyn G, Laitner S, Coulter A, The Word on Medicine would like to thank and Walker E, Watson P, Thomson R. gratefully acknowledge Drs. Joyce Sanchez, John Implementing shared decision Fangman, Mary Beth Graham (Department of making in the NHS. BMJ. Medicine, Division of Infectious Diseases) and 2010;341:c5146. Nate Ledeboer (Department of Pathology) for their many contributions during our six-part 12. Detsky ME, Harhay MO, series devoted to COVID-19. Bayard DF, et al. Discriminative Accuracy of Physician and Nurse Scan the barcode to the right or visit ihr.fm/2LeatGc to check out The Predictions for Survival and Word on Medicine podcast. Functional Outcomes 6 Months After an ICU Admission. JAMA. 2017;317(21):2187-2195. 13. Morris RS, Gani F, Hammad AY, et al. Factors associated with palliative care use in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. J Surg Res. 2017;211:79-86. Leading the Way | Summer 2020 | 19

LEADING THE WAY NEW FACULTY DIVISION OF TRAUMA AND ACUTE CARE SURGERY Mary Elizabeth Schroeder, MD Johnson University Hospital. Dr. Schroeder joined the faculty of George Washington University after her fellowship training prior Mary Elizabeth (Libby) Schroeder, MD, to joining the faculty at Rutgers Robert Wood Johnson University. Assistant Professor of Surgery, joined the She recently completed the OASIS Women in Leadership Program Department of Surgery faculty in June from at Rutgers University. She also holds the title of Associate Director Rutgers Robert Wood Johnson University in of the Global Surgery Program within the Division of Trauma and New Brunswick, New Jersey where she was Acute Care Surgery. Dr. Schroeder and Dr. Chris Dodgion co-lead Assistant Professor of Surgery and attending the research workgroup for the American College of Surgeons’ surgeon at Robert Wood Johnson University collaboration with Hawassa University in Ethiopia, designing Hospital. Dr. Schroeder also served as the research curriculum for faculty and residents as well as providing hospital’s Associate Director of Pediatric Trauma. She earned her mentorship as they develop a research infrastructure. Dr. medical degree from Michigan State University College of Human Schroeder provides clinical care to patients of the Trauma, Acute Medicine in East Lansing. Dr. Schroeder completed general Care Surgery and Critical Care services at all sites covered by the surgical residency training followed by a critical care fellowship Division. at George Washington University in Washington, DC. She then completed an acute care surgery fellowship at Robert Wood Patrick B. Murphy, MD, MSc, MPH, Assistant Professor of Patrick B. Murphy, MD, MSc, MPH Surgery, will join the Department of Surgery faculty in July following completion of a two-year acute care surgery and Surgery degree from Western University and trauma fellowship at Indiana University in Indianapolis. He a Master of Public Health degree in Quality, earned his medical degree from Queen’s University in Kingston, Patient Safety and Outcomes Research from Ontario, Canada and completed general surgical residency Johns Hopkins University in Baltimore. Dr. training at Western University in London, Ontario. During Murphy will provide clinical care to patients residency training, Dr. Murphy attained a Master of Science in of the Trauma, Acute Care Surgery and Critical Care services at all of the sites covered by the Division. DIVISION OF TRANSPLANT SURGERY Francisco A. Durazo, MD Francisco A. Durazo, MD, joined the completed fellowship training in gastroenterology and liver Department of Surgery in February as disease at USC and advanced training in pancreato-biliary Professor and Chief, Transplantation endoscopy in Germany and France. Hepatology; Chief, Transplantation He is board certified in Internal Medicine, Gastroenterology Medicine; and Medical Director of Adult and Transplant Hepatology and his clinical expertise includes Live-Donor Liver Transplantation. He is also the full scope of general and transplant hepatology with a focus Senior Medical Director of the Adult Liver on liver transplantation, non-alcoholic fatty liver disease, drug Transplantation Program at Froedtert and the induced liver injury, liver cancer (hepatocellular carcinoma Medical College of Wisconsin. He holds a secondary appointment and cholangiocarcinoma), and biliary diseases. Dr. Durazo also in the Department of Medicine, Division of Gastroenterology performs therapeutic endoscopy of the pancreas and biliary tract and Hepatology. Prior to joining the faculty at MCW, Dr. Durazo (i.e. ERCP) and liver biopsies. served as Medical Director of Adult Liver Transplantation at the Dr. Durazo’s research focus is on the treatment of hepatocellular University of California Los Angeles (UCLA) and Chief of Transplant carcinoma, acute liver failure, and liver transplantation. He Hepatology in the Division of Liver and Pancreas Transplantation, served as principal investigator of National Institute of Health Department of Surgery at UCLA. (NIH) –funded research studies on drug-induced liver injury, co-investigator for other NIH-funded clinical trials, as well as Dr. Durazo earned his medical degree from the State of Mexico investigator for other peer-reviewed, funded research projects. University, Mexico City. After a research fellowship, he completed internal medicine residency training at the University of Southern California (USC) in Los Angeles. Following residency, Dr. Durazo 20 | Medical College of Wisconsin Department of Surgery

THE MEDICAL COLLEGE OF WISCONSIN DEPARTMENT OF SURGERY FACULTY BY SPECIALTY Bariatric and General Surgery, continued Surgical Oncology– Trauma/ACS, continued Minimally Invasive Surgery Jon C. Gould, MD, MBA Endocrine Surgery Anuoluwapo F. Elegbede, MsC, Matthew I. Goldblatt, MD Rana M. Higgins, MD Sophie Dream, MD* MD Jon C. Gould, MD, MBA Andrew S. Kastenmeier, MD Douglas B. Evans, MD* Joshua C. Hunt, PhD, MA Rana M. Higgins, MD Tammy L. Kindel, MD, PhD Tracy S. Wang, MD, MPH* Christina Megal, DNP, APNP, Andrew S. Kastenmeier, MD Kathleen Lak, MD* Tina W.F. Yen, MD, MS FNP-C, CWON-AP, CFCN Tammy L. Kindel, MD, PhD David J. Milia, MD* David J. Milia, MD* Kathleen Lak, MD Patrick B. Murphy, MD, MSc, Surgical Oncology– Rachel S. Morris, MD Cardiac Surgery MPH Hepatobiliary and Patrick B. Murphy, MD, MSc, G. Hossein Almassi, MD Todd A. Neideen, MD Pancreas Surgery MPH Lucian A. Durham III, MD, PhD Philip N. Redlich, MD, PhD Kathleen K. Christians, MD Todd A. Neideen, MD Viktor Hraska, MD, PhD Libby Schroeder, MD Callisia N. Clarke, MD, MS Libby Schroeder, MD David L. Joyce, MD, MBA Lewis B. Somberg, MD* Douglas B. Evans, MD* Lewis B. Somberg, MD, MSS* Lyle D. Joyce, MD, PhD Jill R. Streams, MD T. Clark Gamblin, MD, MS, MBA Jill R. Streams, MD Takushi Kohmoto, MD, PhD, Travis P. Webb, MD, MHPE Karen E. Kersting, PhD, LCP Colleen Trevino, MSN, FNP, PhD Susan Tsai, MD, MHS Travis P. Webb, MD, MHPE MBA* Pediatric General and Vascular and Endovascular R. Eric Lilly, MD* Thoracic Surgery Surgical Oncology– Surgery Michael E. Mitchell, MD* John J. Aiken, MD* Regional Therapies Shahriar Alizadegan, MD* Paul J. Pearson, MD, PhD Casey M. Calkins, MD* Callisia N. Clarke, MD, MS Kellie R. Brown, MD* Chris K. Rokkas, MD Brian T. Craig, MD T. Clark Gamblin, MD, MS, MBA Joseph P. Hart, MD, RVT, RVPI Ronald K. Woods, MD, PhD* John C. Densmore, MD* Harveshp Mogal, MD Brian D. Lewis, MD Mona S. Li, MD* Colorectal Surgery Katherine T. Flynn-O’Brien, MD, Thoracic Surgery Michael J. Malinowski, MD* Jed F. Calata, MD MPH Mario G. Gasparri, MD* Neel Mansukhani, MD Kirk A. Ludwig, MD David M. Gourlay, MD* David W. Johnstone, MD* Peter J. Rossi, MD* Mary F. Otterson, MD, MS Tammy L. Kindel, MD, PhD Paul L. Linsky, MD* Abby Rothstein, MD* Dave R. Lal, MD, MPH* Gary R. Seabrook, MD Carrie Y. Peterson, MD, MS* Keith T. Oldham, MD* Affiliated Institution Timothy J. Ridolfi, MD, MS Thomas T. Sato, MD* Transplant Surgery Program Directors Francisco A. Durazo, MD Gary T. Sweet Jr., MD Jack G. Schneider, MD* Calvin M. Eriksen, MD Aspirus Wausau Hospital Community Surgery Sabina M. Siddiqui, MD Johnny C. Hong, MD James Rydlewicz, MD Robert J. Brodish, MD Kyle Van Arendonk, MD, PhD Christopher P. Johnson, MD Aurora–Grafton T. Clark Gamblin, MD, MS, MBA Amy J. Wagner, MD* Joohyun Kim, MD, PhD Nicholas Meyer, MD Dean E. Klinger, MD Columbia St. Mary’s Hospital Kaizad Machhi, MD Priyal Patel, MD (9/20) Joseph C. Battista, MD Kevin V. Moss, MD Research Faculty Terra R. Pearson, MD St. Joseph’s Hospital Eric A. Soneson, MD Mohammed Aldakkak, MD Jenessa S. Price, PhD John G. Touzious, MD Mark A. Timm, MD John E. Baker, PhD Allan M. Roza, MD Waukesha Memorial Hospital General Surgery Young-In Chi, PhD Motaz A. Selim, MBBCh, MSC, Chief Surgical Residents Marshall A. Beckman, MD, MA* Mats Hidestrand, PhD MD (2020-2021) Thomas Carver, MD Gwen Lomberk, PhD Melissa Wong, MD Jacqueline Blank, MD** Kathleen K. Christians, MD Angela J. Mathison, PhD Stephanie Zanowski, PhD Kayla Chapman, MD Panna Codner, MD Aoy T. Mitchell, PhD Michael A. Zimmerman, MD Kathryn Haberman, MD Christopher S. Davis, MD, MPH Kirkwood Pritchard, Jr., PhD Trauma/ACS Elizabeth Traudt, MD** Raul A. Urrutia, MD K. Hope Wilkinson, MD, MS Marc A. de Moya, MD Surgical Oncology– Marshall A. Beckman, MD, MA* ** Administrative Chiefs Christopher Dodgion, MD, MSPH, Breast Surgery Thomas Carver, MD MBA Chandler S. Cortina, MD Panna A. Codner, MD Anuoluwapo F. Elegbede, MsC, Amanda L. Kong, MD, MS* Christopher S. Davis, MD, MPH MD Caitlin R. Patten, MD* Marc A. de Moya, MD Matthew I. Goldblatt, MD Tina W.F. Yen, MD, MS Terri A. deRoon-Cassini, PhD Christopher Dodgion, MD, MSPH, MBA LEARN MORE AT MCW.EDU/SURGERY | @MCWSurgery * Participates in Community Surgery/Off-Campus Locations. Leading the Way | Summer 2020 | 21

Department of Surgery 8701 Watertown Plank Road Milwaukee, WI 53226 2020 SURGICAL Department of Surgery ONCOLOGY SYMPOSIUM Dedicated to Clinical Care, Research, and Education OCTOBER 23, 2020 • Cardiothoracic Surgery Virtual Symposium • Colorectal Surgery • Community Surgery FEATURED TOPICS: Breast Oncology, Endocrine Neoplasias, Gastrointestinal • Surgical Education Oncology, Pancreatic Tumors, and Cutaneous Malignancies • General Surgery Email [email protected] for more information. • Pediatric Surgery • Research Check out our website for a current list of upcoming events! • Surgical Oncology www.mcw.edu/surgery • Transplant Surgery • Trauma/ACS 22 | Medical College of Wisconsin Department of Surgery • Vascular & Endovascular Surgery Leading the Way is published three times yearly by The Medical College of Wisconsin – Department of Surgery, 8701 Watertown Plank Road, Milwaukee, WI 53226 ©2020 Editors: Rana Higgins, MD Heidi Brittnacher, 414-955-1831 or [email protected] Designer: Liz Chen, [email protected] Leading the Way is written for physicians for medical education purposes only. It does not provide a complete overview of the topics covered and should not replace the independent judgment of a physician about the appropriateness or risks of a procedure for a given patient.