Medicine and Health Sciences Commons^™

Comparison Of Sternal Pain And Narcotic Requirement After Cardiac Surgery Between New Rigid Closure And Conventional Wire Closure: Follow-Up Results Of 50 Randomizations., Jeevan Kuman, Bs, James T. Diehl, Md, Hitoshi Hirose, Md, Phd

Department of Surgery Faculty Papers

To investigate if rigid closure reduces sternal pain.

Presented at Chest 2013.Chicago IL.October 26-31, 2013.

Two-Vessel Off-Pump Coronary Artery Bypass Grafting By Left Thoracotomy In A Complex Redo Case, Shinya Unai, Md, Hitoshi Hirose, Md, Phd, Gary A. Cook, Pa-C, Nicholas C. Cavarocchi, Md, John W..C. Entwistle Iii, Md, Phd

Department of Surgery Faculty Papers

Introduction:

The left thoracotomy approach is an alternative technique for coronary revascularization to avoid complications associated with re-sternotomy, such as injury to patent grafts, right ventricle, aorta, during re-sternotomy. Situations such as calcification of the ascending aorta and previous mediastinitis favor the use of the left thoracotomy approach. Revascularization of the circumflex territory via a lateral thoracotomy has been reported previously. However, reports of revascularization of the LAD combined with circumflex artery territory via left thoracotomy approach are rare. We successfully performed an off-pump CABG by left thoracotomy in a complex redo case to revascularize the LAD and obtuse marginal …

Edoardo Bassini (1844-1924): Father Of Modern-Day Hernia Surgery., Wei Phin Tan, B.S., Harish Lavu, Md, Ernest L. Rosato, Md, Charles J. Yeo, Md, Scott W. Cowan, Md

Department of Surgery Gibbon Society Historical Profiles

According to Roman scripture, it was Celsus who attempted the first inguinal hernia repair in history during the first century A.D. His attempts were unsuccessful and resulted in an early recurrence of the hernia, which eventually led to the patient’s death.1 Over the next two millennia, little understanding was gained regarding the anatomy of the inguinal canal. It was only in the last 100 years that major advancements in herniorrhaphy were established, thanks in large part to the work of Edoardo Bassini, who revolutionized the surgical treatment of the inguinal hernia with a technique which has become the basis of …

Abdominal Intercostal Hernia: A Rare Complication After Blunt Trauma., Phi D Nguyen, B.A., Michael J. Pucci, Md, Jay S. Jenoff, Md, Scott W. Cowan, Md

Department of Surgery Gibbon Society Historical Profiles

Abdominal intercostal hernia (AIH) is uncommonly reported in the literature with only 20 cases reported to date.1–3 We report a case of a delayed incarcerated AIH secondary to blunt trauma from a motor vehicle accident in which the colon and diaphragm herniated through an associated chest defect that was repaired successfully through a transabdominal approach using primary repair of the defect in combination with onlay porcine patch reinforcement.

Case Series On Veno - Venous Extracorporeal Membrane Oxygenation (Vv-Ecmo) As A Bridge To Complete Recovery In Influenza Type A Related Refractory Ards, Renganaden Sooppan, Md, Nicholas C. Cavarocchi, Md, Harrsion Pitcher, Md, Qiong Yang, Md, Michael Baram, Md, Hitoshi Hirose, Md, Phd

Department of Surgery Faculty Papers

Introduction:

Influenza A sequelae range from mild symptoms to acute respiratory distress syndrome (ARDS), which can be refractory to conventional ventilator therapy. We present a case series of three non-H1N1 Influenza patients with ARDS, who completely recovered after VV-ECMO.

Case Presentation:

In January and February 2013, we experienced three cases of Influenza A induced ARDS that failed conventional ARDS ventilator therapy. All three patients presented with typical flu-like symptoms, which deteriorated over several days, requiring intubation. They were all treated with oseltamivir. They had bilateral chest infiltrates on chest x-rays. After a few days of failing conventional treatment these patients …

Sternal Wound Infection Caused By Mycobacterium Chelonae., Shinya Unai, Joseph Miessau, Pawel Karbowski, Gurjyot Bajwa, Hitoshi Hirose

Department of Surgery Faculty Papers

INTRODUCTION: Sternal wound infection caused by Mycobacterium chelonae, a member of the rapidly growing nontuberculous mycobacteria (NTM), is rare and may present without signs and symptoms of systemic infection.

METHODS: We present a patient who had a M. chelonae infection of the sternum following excision of a left atrial myxoma and conducted a review of the literature from 1976 to 2013.

RESULTS: Seventy cases of NTM sternal wound infection after cardiac surgery were identified, including six outbreaks and ten sporadic cases including the present case. Thirty-four cases were isolated coronary artery bypass grafting (CABG) surgery, 16 cases were isolated valve …

Does Skin Pigmentation Effect Readings Of Cerebral Oximeter Devices While On Cardiopulmonary Support?, Christine Feldmeier, Md, Harrsion Pitcher, Md, Qiong Yang, Md, Nicholas C. Cavarocchi, Md, Hitoshi Hirose, Md, Phd

Department of Surgery Faculty Papers

Introduction:

Cerebral oximetry is utilized as a non-invasive method to ensure adequate cerebral perfusion. In a review of our clinical experience, it was noted that there were consistent inaccurate values from normal utilizing relative (INVOS, Covidien, Mansfield, MA) cerebral oximetry as opposed to absolute (FORESIGHT, CAS medical, Branford, CT) cerebral oximetry in darker skin patients.

Presented 24th Annual ELSO Conference. Philadelphia, PA. Sep 19-21, 2013.

Proggene: Gene Expression Based Survival Analysis Web Application For Multiple Cancers., Chirayu Pankaj Goswami, Harikrishna Nakshatri

Department of Surgery Faculty Papers

BACKGROUND: Identification of prognostic mRNA biomarkers has been done for various cancer types. The data that are published from such studies are archived in public repositories. There are hundreds of such datasets available for multiple cancer types in public repositories. Wealth of such data can be utilized to study prognostic implications of mRNA in different cancers as well as in different populations or subtypes of same cancer.Description: We have created a web application that can be used for studying prognostic implications of mRNA biomarkers in a variety of cancers. We have compiled data from public repositories such as GEO, EBI …

A Cost Reducing Ecmo Model: A Single Institutional Experience., En Yaw Hong, Suzanne Wallace, Amy Tropea, Jaime Byrne, Msn, Rn, Hitoshi Hirose, Md, Phd, Harrsion Pitcher, Md, Nicholas C. Cavarocchi, Md

Department of Surgery Faculty Papers

Background: The demand for ECMO support has grown. Its provision remains limited due to several factors (high cost, complicated technology, lack of expertise) which increase healthcare cost. Our goal was to assess if an ICU run ECMO model (without continuous bedside perfusion) would decrease costs while maintaining patient safety and outcomes.

Method: We performed a retrospective review that analyzed the cost and safety benefits of a newly implemented ICU-run ECMO unit from 2011-2012. The program consisted of a dedicated ICU involving multidisciplinary providers (ICU RN, mid-level providers and intensivists). In year one, we introduced an education platform, new technology and …

The Impact Of A New Ecmo Program On Clinical Outcomes Of Patients With Acute Myocardial Infarction Complicated By Cardiogenic Shock., Shinya Unai, Md, Harrsion Pitcher, Md, Qiong Yang, Md, Nicholas Ruggiero, Md, Hitoshi Hirose, Md, Phd, Nicholas C. Cavarocchi, Md

Department of Surgery Faculty Papers

Objective:

To investigate if a new ECMO program will improve the outcome of patients who had acute myocardial infarction complicated with cardiogenic shock.

Presented 24th Annual ELSO Conference. Philadelphia, PA. Sep 19-21, 2013.

Mrsa Sepsis And Acute Respiratory Distress Syndrome During Veno-Arterial Extracorporeal Membrane Oxygenation (Ecmo)., Philip Hsiao, Bs, Joseph Miessau, Bs, Harrsion Pitcher, Md, Qiong Yang, Md, Michael Baram, Md, Nicholas C. Cavarocchi, Md, Hitoshi Hirose, Md, Phd

Department of Surgery Faculty Papers

Presentation:

A 39 year old female African American presented with respiratory distress two days after ERCP for pancreatitis.

The patient quickly deteriorated, required intubation, and developed severe hypotension requiring vasopressors.

VA-ECMO was initiated for ARDS and SIRS due to on-going pancreatitis.

Pre ECMO ABG: PH 7.01, PaCO2 70, PaO2 70 with FiO2 100% with PEEP 15

Profound hypotension, required 2 pressors

Preliminary results of cultures were negative at the time of ECMO placement.

Presented 24th Annual ELSO Conference. Philadelphia, PA. Sep 19-21, 2013.

Left Ventricular Thrombus Found In A Patient With Ards And Stress-Induced Cardiomyopathy Requiring Veno-Arterial Ecmo., Shreya Gupta, Bs, Joseph Miessau, Ms, Harrsion Pitcher, Md, Michael Baram, Md, Nicholas C. Cavarocchi, Md, Hitoshi Hirose, Md, Phd

Department of Surgery Faculty Papers

Presentation:

68 year-old male with a history of acute leukemia with complete remission after bone marrow transplant 4 months ago, coronary disease s/p LAD stents about 14 years ago with no chronic anti-platelet medication, and repeated episode of DVT despite appropriate anti-coagulation, presented with viral pneumonia (rhinovirus).

Allograft Reconstruction For Digital Nerve Loss., John S Taras, Nirav Amin, Nimit Patel, Lucy A Mccabe

Department of Orthopaedic Surgery Faculty Papers

PURPOSE: To investigate the outcomes of digital nerve repairs using processed nerve allograft for defects measuring 30 mm or less.

METHODS: Seventeen patients with 21 digital nerve lacerations in the hand underwent reconstruction with processed nerve allograft. Outcome data for 14 patients with 18 digital nerve lacerations were available for analysis. Postoperative outcome data were recorded at a minimum of 12 months and an average of 15 months. The average nerve gap measured 11 mm (range, 5-30 mm). Outcome measures included postoperative sensory examination as assessed by Semmes-Weinstein monofilaments and static and moving 2-point discrimination. Pain was graded using a …

Samuel D. Gross, M.D. (1805-1884): An Innovator, Even In Death., Peter R. Bucciarelli, B.S., John C. Kairys, Md, Ernest L. Rosato, Md, Charles J. Yeo, Md, Scott W. Cowan, Md

Department of Surgery Gibbon Society Historical Profiles

Dr. Samuel Gross' contributions to the field of surgery are well known and range from numerous clinical advances to pioneering scholarship and professional activities. Dr. Gross was ceaselessly ambitious and even remarked in his autobiography that his ‘‘conviction has always been that is far better for a man to wear out than to rust out.’’1 It is through this frame of motivation that Dr. Gross lived his life.

Antithrombin Iii Deficiency In A Patient Requiring Extracorporeal Membrane Oxygenation., Jonathan R. Sarik, Md, Shinya Unai, Md, Harrsion Pitcher, Md, Qiong Yang, Md, Hitoshi Hirose, Md, Phd, Nicholas C. Cavarocchi, Md

Department of Surgery Faculty Papers

Introduction:

Antithrombin or antithrombin III (ATIII) is a vitamin K-independent, natural anticoagulant that is the major inhibitor of thrombin. With the binding of heparin, a conformational change in antithrombin occurs that increases the inactivation of thrombin by antithrombin by 4000-fold. Antithrombin deficiency can be hereditary or acquired; the acquired form is frequently encountered in patients requiring mechanical circulatory support.

Formulation of clots within the circuit of extracorporeal membrane oxygenation (ECMO) is a life-threatening emergency and requires emergent intervention. Decreased ATIII is associated with a hypercoagulable state, which can lead to dangerous complications for patients requiring mechanical circulatory support.

We Came, We Saw, We Cannulated?, Hitoshi Hirose, Md, Phd, Kumar Gaurav, Md, Nicholas C. Cavarocchi, Md, Vanjul Agarwal, Md, Roselle Almeida, Md, Andrew Toscano, Md, Urvashi Vaid, Md, Ms, Bharat K. Awsare, M.D., Fccp, Michael Baram, Md

Department of Surgery Faculty Papers

Introduction: Despite advances in management of patients with severe acute respiratory distress syndrome (ARDS), mortality due to ARDS still remains high. In patients with refractory gas-exchange abnormalities, extracorporeal membrane oxygenation (ECMO) is considered as salvage therapy that aims to decrease ventilator induced lung injury and provide lung rest. injury and provide lung rest.

Methods: We conducted a retrospective study of patients diagnosed with ARDS from October 2010 to September 2012. The aim of the study was to describe the population of patients placed on ECMO for ARDS in our institution. All patients placed on ARDSnet protocol were identified in the …

Failure Patterns In Resected Pancreas Adenocarcinoma: Lack Of Predicted Benefit To Smad4 Expression., Jordan M. Winter, Laura H. Tang, David S. Klimstra, Weiguo Liu, Irena Linkov, Murray F. Brennan, Michael I. DʼAngelica, Ronald P. Dematteo, Yuman Fong, William R. Jarnagin, Eileen M. OʼReilly, Peter J. Allen

Department of Surgery Faculty Papers

OBJECTIVE: To determine whether SMAD4 expression is associated with recurrence pattern after resection for pancreatic ductal adenocarcinoma (PDA).

BACKGROUND: SMAD4 expression status has been reported to be associated with patterns of failure in PDA, but studies have not examined recurrence patterns after resection.

METHODS: A tissue microarray was constructed including 127 patients with resected PDA and either short-term (<12 >months) or long-term (>30 months) survival. SMAD4 expression was evaluated by immunohistochemistry and categorized as present or lost in tumor cells. Conventional pathologic features (lymph node metastases, positive resection margin, poor grade, and tumor size) were recorded, and disease-specific outcomes …

An Old Problem With A New Therapy: Gastrointestinal Bleeding In Ventricular Assist Device Patients And Deep Overtube-Assisted Enteroscopy., Konrad Sarosiek, Linda J Bogar, Mitchell I Conn, Brendan O'Hare, Hitoshi Hirose, Md, Phd, Nicholas C. Cavarocchi, Md

Department of Surgery Faculty Papers

Conventional algorithms for diagnosis and treatment of gastrointestinal bleeding (GIB) in patients with nonpulsatile ventricular assist devices (VADs) may take days to perform while patients require transfusions. We developed a new algorithm based on deep overtube-assisted enteroscopy (DOAE) to facilitate a rapid diagnosis and treatment. From 2004 to 2012, 84 patients who underwent VAD placement in our institution, were evaluated for episodes of GIB. Our new algorithm for the management of GIB using DOAE was evaluated by dividing the episodes into three groups: group A (traditional management without enteroscopy), group B (traditional management with enteroscopy performed >24 hours after presentation), …

Predictors Of Treatment Outcomes In Geriatric Patients With Odontoid Fractures: Aospine North America Multi-Centre Prospective Gof Study., Michael G Fehlings, Ranganathan Arun, Alex R. Vaccaro, Paul M Arnold, Jens R Chapman, Branko Kopjar

Department of Orthopaedic Surgery Faculty Papers

STUDY DESIGN: Multicenter prospective cohort study.

OBJECTIVE: To identify patient and treatment characteristics associated with treatment success or failure in the management of odontoid fractures.

SUMMARY OF BACKGROUND DATA: Odontoid fractures are the most common cervical spine fractures in the elderly and represent a significant management challenge with widely divergent views regarding operative versus nonoperative management.

METHODS: A total of 159 patients 65 years and older with radiographically confirmed type II odontoid fractures were enrolled at 10 sites in the United States and 1 site in Canada between January 2006 and May 2009. Subjects were followed at 6 and 12 …

Extracorporeal Membrane Oxygenation For Bridge To Decision And To Recovery., Hitoshi Hirose, Md, Phd, Shingeki Tabaka, Md, James Diehl, Md, Nicholas C. Cavarocchi, Md

Department of Surgery Faculty Papers

Extracorporeal life support has advanced from its humble beginnings over 3 decades ago, with the first description of its success in a patient with Acute Respiratory Distress Syndrome (ARDS), going as far back as 1971. The indications for extracorporeal membrane oxygenation (ECMO) therapy include refractory respiratory and/or cardiac failure, and ECMO is now being increasingly used in adult patients. In this case report, we present a patient who had traveled from India to the United States, where she developed acute decompensated biventricular failure and shock, requiring ECMO placement as a bridge to a decision. During her first few days on …

Multimodal Endovascular Management Of Acute Ischemic Stroke In Patients Over 75 Years Old Is Safe And Effective., George M Ghobrial, Nohra Chalouhi, Lana Rivers, Samantha Witte, Justin Davanzo, Richard Dalyai, Michelle L Gardecki, Pascal Jabbour, Fernando Gonzalez, Aaron S Dumont, Robert H Rosenwasser, Stavropoula Tjoumakaris

Department of Neurosurgery Faculty Papers

INTRODUCTION: Greater attention has been directed to endovascular recanalization of acute ischemic stroke in septuagenarians and above.

TECHNIQUE: A retrospective chart review was conducted to include patients treated for acute ischemic stroke from 2006 to 2012. All patients underwent initial neurological assessment and non-contrast head CT. Patients treated from 2009 to 2012 additionally received emergent CT angiogram and CT perfusion. 51 patients met the clinical and radiographic criteria and underwent multimodal endovascular revascularization for acute ischemic events.

RESULTS: All patients underwent cerebral angiography and met angiographic criteria for endovascular thrombolysis. 34 patients (67%) were older than 80 years of age. …

Chevalier Jackson, M.D. (1865-1958): Il Ne Se Repose Jamais., Phi D Nguyen, B.A., Scott W. Cowan, Md, Charles J. Yeo, Md, Nathaniel R. Evans Iii, M.D.

Department of Surgery Gibbon Society Historical Profiles

In the final year of the American Civil War, 1865, Chevalier Jackson was born on the 4th of November just outside Pittsburgh, Pennsylvania. The eldest of three sons of a poor, livestock-raising family, Jackson was raised in a period of social and political unrest. He was perhaps an even more unrestful boy. The description of his childhood days from his father’s father—Il ne se repose jamais, ‘‘He never rests’’—would ultimately reflect the man, doctor, and evangelist Jackson would later become.1 Indeed, he never did rest, Jackson would tirelessly pave the way for modern bronchoscopy and endoscopy as a whole; bringing …

Completely Steroid-Free Immunosuppression In Liver Transplantation: A Randomized Study., Carlo B. Ramirez, Md, Cataldo Doria, Md, Phd, Adam M. Frank, Md, Stephen T. Armenti, Ignazio R. Marino, Md

Department of Surgery Faculty Papers

INTRODUCTION: Corticosteroids (CS) have been standard immunosuppression to prevent and treat rejection. However, CS are associated with increased risk of infection, obesity, hypertension, hyperlipidemia, diabetes, and accelerated hepatitis C virus (HCV) recurrence post-orthotopic liver transplantation (OLT). This study assesses the safety and efficacy of CS-free immunosuppressive regimen in adult OLT.

METHODS: A two-yr, prospective, randomized study of CS with delayed withdrawal (CS) or CS-free regimen with basiliximab, tacrolimus, and enteric-coated mycophenolate sodium (EC-MPS) was performed in 39 patients (CS=20; CS-free=19). CS group received intra-operative methylprednisolone weaned by six months. HCV patients had HCV PCR pre-OLT and 0.5, one, three, and …

John Chalmers Dacosta (1863-1933): Restoration Of The Old Operating Table., Madalyn G. Peters, Md, Adam C. Berger, Md, Gordon Schwartz, Md, Mba, Facs, Charles J. Yeo, Md, Scott W. Cowan, Md

Department of Surgery Gibbon Society Historical Profiles

John Chalmers DaCosta was an influential chairman and the first Samuel D. Gross Professor of Surgery at Jefferson Medical College in Philadelphia. He was well known throughout the field as a skilled surgeon, passionate speaker, and exceptional writer. In addition to countless accomplishments during his career, DaCosta was deeply dedicated to the preservation and commemoration of surgical history. This ideology was exemplified when he set out on a mission to recover the old wooden operating table used by many of his iconic mentors including Samuel D. Gross, Joseph Pancoast, and William W. Keen. This table was originally used for surgical …

Preparation And Technical Considerations For Percutaneous Cannulation For Veno-Arterial Extracorporeal Membrane Oxygenation., Kathleen Lamb, Hitoshi Hirose, Nicholas C. Cavarocchi

Department of Surgery Faculty Papers

BACKGROUND: The most frequent limb complications from peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are limb ischemia and localized bleeding. To minimize these risks, perfusion of the distal limb with peripheral percutaneous cannulation was done.

TECHNIQUE: Percutaneous cannulation with a distal perfusion port was performed in all patients. During the VA-ECMO, distal limb perfusion was monitored using near-infrared spectroscopy to assess tissue oxygenation. At the decannulation, patch angioplasty was performed to prevent the development of narrowing of the artery at the cannulation site.

CONCLUSIONS: Using our standard technique, we have not experienced any limb loss related to ischemia or bleeding.

Management Of Upper Aerodigestive Tract Bleeding On Extracorporeal Membrane Oxygenation., Hitoshi Hirose, Md, Phd

Department of Surgery Faculty Papers

Introduction: Bleeding complications on extracorporeal membrane oxygenation (ECMO) are often encountered. In a review of our own series, it was found that upper aero digestive tract bleeding was common and management was often difficult. We propose an algorithm to help manage upper aero digestive tract bleeding in the anticoagulated, ECMO patient.

Methods: A retrospective chart review was performed of the patients who underwent veno-venous or veno-arterial ECMO at our institution between July 2010 and July 2012. The patients that had upper aero digestive tract bleeding that required an otolaryngology consultation were identified. They were further investigated to determine location …

Management Of Upper Aerodigestive Tract Bleeding In Patients On Ecmo., Hitoshi Hirose, Md, Phd, Meredith Harrison, Md, Adam I. Baker, Md, Nicholas C. Cavarocchi, Md

Department of Surgery Faculty Papers

Introduction: Bleeding complications on Extracorporeal Membrane Oxygenation (ECMO) are often encountered. In a review of our own series, it was found that upper aero digestive tract bleeding was common and management was often difficult. We propose an algorithm to help manage upper aero digestive tract bleeding in the anticoagulated, ECMO patient. Hypothesis: Once an ECMO patient fails conservative management for upper aero digestive bleeding, more aggressive measures will prove successful, which will provide benefit to the patient. Methods: A retrospective chart review was performed of the patients who underwent venovenous or veno-arterial ECMO at our institution between July 2010 and …

Major Perioperative Morbidity Does Not Affect Long-Term Survival In Patients Undergoing Esophagectomy For Cancer Of The Esophagus Or Gastroesophageal Junction., Brent T Xia, Ernest L Rosato, Karen A Chojnacki, Albert G. Crawford, Benny Weksler, Adam C. Berger

Department of Surgery Faculty Papers

INTRODUCTION: The incidence of cancer of the esophagus/GE junction is dramatically increasing but continues to have a dismal prognosis. Esophagectomy provides the best opportunity for long-term cure but is hampered by increased rates of perioperative morbidity. We reviewed our large institutional experience to evaluate the impact of postoperative complications on the long-term survival of patients undergoing resection for curative intent.

METHODS: We identified 237 patients who underwent esophagogastrectomy, with curative intent, for cancer between 1994 and 2008. Complications were graded using the previously published Clavien scale. Survival was calculated using Kaplan-Meier methodology and survival curves were compared using log-rank tests. …

Assessment Of Nutritional Adequacy In Patients On Extracorporeal Membrane Oxygenation., Hitoshi Hirose, Md, Phd, Joseph Miessau, Pa-C, Evanthia Foliou, Rd, Pawel Karbowski, Pa-C, Ms, Melanie K. Sion, Md, Christine Feldmeier, Md

Department of Surgery Faculty Papers

Introduction: Nutrition is a key element of recovery from the state of critical illness. Little is known about nutritional adequacy in patients supported on extracorporeal membrane oxygenation (ECMO) for severe cardio-respiratory dysfunction. A study was performed whether or not early nutrition support improve outcomes of the patients on ECMO.

Methods: A retrospective IRB approved review was conducted of all patients supported on ECMO from 7/10 to 6/12. The patients were divided into 2 groups, survivors and non-survivors. Age, sex, preoperative comorbidities, type and duration of ECMO, day to initiation and goal feeding, caloric intake, weekly biomarkers (pre-albumin, albumin, …

William Edwards Ladd, M.D. (1880-1967): The Description Of His Bands., Pei-Wen Lim, Md, Niels D. Martin, Md, Barry A. Hicks, Md, Charles J. Yeo, Md, Scott W. Cowan, Md

Department of Surgery Gibbon Society Historical Profiles

In the early 20th century, an established surgical specialty catering to pediatric surgery did not exist, and pediatric surgical ailments were operated on by general surgeons. With his devotion to childhood diseases and his unique thinking in surgical development, William E. Ladd would become a leading figure in America by pioneering the field of pediatric surgery.