College of Surgeons – United States Section
82nd Annual Surgical Update
of Neurological and Orthopaedic Surgeons
44th Annual Scientific Meeting
June 24-26, 2021 – Minneapolis, Minnesota
Abstracts and Presentation Descriptions
(Published as submitted with very limited edits)
World Surgical Foundation Philippines: A Success Story
Domingo T Alvear, MD, FICS, Retired Chief of Pediatric Surgery, UPMC
The World Surgical Foundation was formed in 1997 to help the surgical burden of disease in low income countries. We have provided service in the Philippines, Honduras, India, Thailand, Ecuador, Haiti, Ethiopia and Nigeria. Our main goal is to help our local counterparts to be able to provide surgical services to the patients in need of life changing and sometimes life saving surgical procedures throughout the year. We help train them by bringing expertise during our surgical missions and by supporting them attend postgraduate courses in the USA. We provide them with
equipments such Portable Anesthesia Machines, Electrosurgical Units, Harmonic Scalpels, Cryostat and sterile supplies. WSF Philippines was formally formed in 2018. They have their own set of officers and Board of Directors. Before the Covid foundation they have conducted surgical outreach in 6 to 10 times a year. They have affiliation with the Philippine College of Surgeons, Philippine Society of Pediatric Surgeons, Philippine Society of Anesthesia and OR Nurses Association of the Philippines. They have support of SM Foundation, Ansell Gloves, Pharmaceutical Companies and other companies such as Sun Life, etc. Before the Pandemic they had plans to build a 50 Bed Pediatric Surgery Hospital and all from donated funds. This hospital will be training hospital for South East Asia. They had partner with Americares and LifeBox to distribute Pulse Oximeters and introduce Safe Surgery initiated in 330 Hospitals throughout the country.
WSF Philippines is now a part of the SURE Commission of the Philippine College of Surgeon to train physicians from remote areas of the Philippines basic emergency surgery to help obviate the needs of their community. They will also study the surgical needs of each community. In this paper, I will discuss how this was achieved.
Definitive Closure of a Ballistic Shotgun Injury with Extensive Soft Tissue Loss to the Right Thigh using ABRA Adhesive Dynamic Tissue System (DTS) and Porcine Urinary Bladder Matrix (PUBM)
Rohan Anand, MBA, Medical Student, Texas Tech University School of Medicine
Buckshot ballistic injuries have unique wounding characteristics, resulting in especially formidable and destructive wounds at close range. The pellets cause an anatomic defect with necrotic tissue and heavy bacterial contamination. The ABRA adhesive Dynamic Tissue System (DTS) closure device provides noninvasive closure of retracted skin defects. Porcine urinary bladder matrix (PUBM) is an acellular matrix product derived from the inner lining of the porcine urinary bladder that imparts constructive remodeling and possible antimicrobial properties.
We present a case of a 37-year old male who sustained a close-range shotgun wound to the right lateral thigh. Definitive wound closure was achieved using a combination of dynamic tension and a biologic xenograft. Data and information were collected via chart review of EMR at University Medical Center from the initial ER visit, intrahospital course, and post-operative care.
A 37-year old male with no past medical history sustained a close-range shotgun wound to the right lateral thigh. There was extensive soft tissue loss, but no bony, major vascular, or neurologic injuries. The patient was immediately taken to the OR for extensive debridement of nonviable skin, fascia, and muscle. A negative pressure wound therapy (NPWT) device was applied.
Postoperatively despite narcotics, the patient was in worse pain than at the initial time of presentation, likely due to the NPWT. Thus he was returned to the OR on post injury day (PID) 2 for removal of the NPWT, additional debridement of soft tissue, and installation of the ABRA adhesive DTS closure device (6 elastomers). After installation, the width decreased from 8 to 2 cm, and the muscle extrusion decreased from 2 cm above the skin to 1 cm below the skin. The 21 cm length and 9 cm blast injury cavity depth remained unchanged.
On PID 6, examination of the wound in the OR revealed a maximum width of 1 cm, and it was deemed feasible to proceed with definitive wound closure. Micromatrix 500 mg was implanted into the blast cavity, along with a portion of the Cytal wound matrix sheet. The remainder of the wound matrix sheet was implanted throughout the bidirectional vertical mattress dermal closure. The patient was discharged home on PID 7.
Close range ballistic buckshot injuries cause extensive local tissue destruction. In addition to the pellets, wadding, gunpowder, and foreign bodies such as wood or cloth can be blasted into the wound. The ABRA adhesive DTS closure device utilizes elastomers to create dynamic tension across the soft tissue defect, resulting in decreased wound volume dimensions. The PUBM extracellular matrix is a substrate that serves as the site for cell attachment, migration, proliferation, and differentiation, allowing for deposition of host site-appropriate tissue.
This case highlights a particularly extensive ballistic buckshot soft tissue injury. Due to the patient’s intolerance of the NPWT, the combination of the ABRA adhesive DTS closure device and PUBM allowed for definitive closure of this complex wound in four days. Further research into impact on length of stay, overall cost savings, and long-term patient outcomes are warranted.
Online Survey Among Doctors of Nepal on Re-utilization of Surgical Tools from Developed Nations
Shrinit Babel, College Freshman, Pre-Med Student at the University of South Florida, Judy Genshaft Honors College
Surgery has a key role in healthcare globally: a third of the world’s burden of disease comes from surgically treatable conditions. Nepal is an underdeveloped country with a primitive healthcare sector, lacking tools for basic procedures along with financial and accessibility constraints. The Nepalese have been deprived of their right to basic surgical and medical healthcare, contributing to the global burden of disease. The sophisticated tools and supplies, if available, are largely concentrated in urban areas. However, these tools lack efficiency and are not up-to-date with international standards. Various international agencies have tried to uplift healthcare in underserved areas by medical device donation. The purpose of this online web-based survey was to obtain the knowledge of procurement of such commodities at their workplace among doctors, how this has facilitated in their healthcare delivery activities, what the real necessities are and how can such donations be made cost effective and the underserved sections of the community be benefitted.
After approval by the Nepal Health Research Council, the BLJ Pass-A-Tool Not-For-Profit Foundation sent out a structured web-based questionnaire which included 28 questions designed via SurveyMonkey and was disseminated among doctors of Nepal via social media and personal emails. The responses were recorded in the online platform and results were tabulated.
There were 256 respondents with an average completion rate of 52%. Among them, 41% were surgeons, 39% were medical doctors, and 18.3% worked in rural areas while 36% worked at urban places. Around 28% responded that their institute has received medical supplies or devices in the past. Most of the donations and supply came from the United States followed by China and Japan. Commodities received as supplies included surgical masks, Personal Protective Equipment (PPE), surgical sutures, laparoscopic sets, mesh, dialysis machines, MRI machines etc. Most of the respondents believe that such donations are beneficial for their daily practices. 23.74% responded that they reuse such tools quite often. However, 34% said that they do not communicate with the donors while only 15% communicated. Around 40% mentioned that such supplies fit the need that has been defined by the health care facility. Around 37% believed that such donations meet the national regulations and policies. 40% mentioned that trained personnel are available to operate donated devices and 53% believed that such donations have improved the health care delivery of their institute. Most of the responders felt that higher regulatory healthcare agencies, such as ICS or world congresses, in developed countries should serve as a liaison between donating agencies and consumer groups to foster transparency, regular monitoring, training, and safe surgical practices, which would eventually reduce the global burden of disease and allow recipient countries to be benefitted.
LMICs like Nepal can be benefited with the medical/surgical donations from the developed countries. However, proper scrutinization and follow up is required regarding appropriate use of the supplies and its impact upon the consumer group.
Surgical Challenges: A Surgeon’s Perspective from the Developing World
Suman Baral, MD, Assistant Professor,
Lumbini Medical College and Teaching Hospital Ltd
Nepal is a country situated in South East Asia with a population of 28.2 million with low human development index of 0.574 ranking 148th of 187 countries worldwide. The health status of the country is still in a primitive state and many of the needy people are striving for surgical health. Though, there has been increased awareness about global surgery and unmet needs of surgical facilities especially in the under developed countries, still there has been a tremendous gap between two parts of the world. A 10 year long internal conflict claimed 17,000 lives along with the April 2015 earthquake that killed more than 9000 people injuring more than 23,000 lives had great impact on healthcare delivery of the country. The author had this experience of the earthquake and could still feel the havoc and loss of lives owing to lack of adequate trained personnel, resources and logistics alongside the unpreparedness of the possible natural disasters that can happen at any instant of time. As a practicing surgeon in the developing community at rural part of the country, the author is trying to justify the inadequacy of surgical health care, its impact upon the general public, fallacies of the health care system, challenges while working on the floor and requirement of global surgery needs. Cultural (acceptability), structural (accessibility) and most importantly financial( affordability) status of the people in the community are the prime determining factors that ensues surgical health delivery. However, recently, the government of Nepal has initiated health insurance project which is applicable only in few districts and the impact of the scheme could be seen in various hospitals as increase in the number of patients seeking surgical services that has increased dramatically since previous years which justifies affordability issue. As most of the health personnel are men, female group of patients are not willing to seek medical and surgical attention. Lack of trust in treating individual and cultural taboo is the next issue that is often encountered. Accessibility is the most common determining factor that predisposes inadequacy of surgical health delivery as most of the people needed to come from Himalayas and places with difficult geographical diversity where roadway inaccessibility and financial constraints play a key role. Lack of trained personnel in surgery, less number of surgeons willing to stay at rural community due to lesser incentives, lack of equipped operating rooms and anesthesia facility and low number of health care delivery centers are some issues that need to be addressed in order to ensue proper surgical service in the community. These shortcomings can be overcome with facilitation of training opportunities to local man powers, missionary visits from international faculties and exchange programs between two academic institutes, playing key role for facilitation in surgical logistics from developed communities and overall creating a bridge in order to work in hand on hand together to achieve the special goals of global surgery. Finally, the author believes that the International college of Surgeons (ICS) could be the most important platform to achieve the above perspectives.
Integrating Pain Related Interventional Procedures in a Spine Practice
Amit Bhandarkar, MD, AANOS, Orthopedic Spine Surgeon, St. Mary's Hospital Centralia
This presentation talks about integrating the pain related interventional procedures in Spine practice to help patients with early diagnosis and early treatment especially in rural areas. Knowing where the pain is coming from and its early treatment helps to prevent the Opioid use related problems in these patient populations.
The Harsh Reality of the Lockdown: Increased Domestic Violence During the Early Peak Phase of COVID 19 pandemic. A Rural Level 1 Trauma Center Experience
Saptarshi Biswas, MD, FICS, Attending Trauma Surgeon, Department of Trauma, Acute Care Surgery and Surgical Critical Care, Grand Strand Medical Center
Myrtle Beach, SC
As the early peak phase of the novel coronavirus outbreak has intensified, individuals identified as nonessential were advised to remain home to prevent community transmission of the disease. The stay at home mandates further escalated isolated environments such as school closures, social distancing, travel restrictions, closure of public gathering spaces, and business closures. As citizens were forced to stay home during the pandemic, the crisis created intensifying stressors and isolation, which fostered an environment for increased domestic violence.
A retrospective review of all emergency department (ED) patients that presented to an American College of Surgeons (ACS) verified rural level one trauma center with associated diagnostic coding for assault was conducted during the Coronavirus 2019 (COVID-19) lockdown, integral dates March 16, 2020, to April 30, 2020. In particular, the identification of proportional assaults presented to the ED after school closures (March 16, 2020) was compared to the previous year (March 16, 2019, to April 30, 2019). The data collected included patient characteristics, grouping by mechanism, grouping by a specific mechanism, and domestic violence perpetrators.
A statistically significant (p = 0.01) increase in assaults was found during the COVID-19 lockdown, particularly during school closures.
Despite overall reductions in trauma volume during the COVID-19 stay at home mandates, a significant increase in domestic violence assaults was observed. The assaults were perpetrated mainly against white men by partners and unspecified non-family members, which were predominantly penetrating injuries.
Trauma Recidivism in a Rural ACS Level 1 Trauma Center. Has the Paradigm Shifted? Are Elderly Adults More at Risk?
Saptarshi Biswas, MD, FICS, Attending Trauma Surgeon, Department of Trauma, Acute Care Surgery and Surgical Critical Care, Grand Strand Medical Center
Myrtle Beach, SC
Repeated episodes of trauma, particularly in older adults, results in increased morbidity and mortality. This study investigates trauma recidivism at a rural Level I trauma center, in order to identify which older adult patients in our region are more likely to become recidivists.
Materials and Methods:
This 4-year retrospective study (2013 to 2017) examines all patients ≥ 18 years of age with multiple hospital admissions for trauma, comparing patients ages ≥ 65 (older adults) to those ages 18-64 (younger adults). Exclusion criteria consisted of age <18 and home zip code outside of the study region. Data included admission demographics, injury characteristics, and other clinical metrics.
240 younger adult and 182 older adult trauma recidivists were included (10,920 trauma patients total). 4% of all patients were recidivists, with significantly higher rates of recidivism among older adults (OR: 1.94 [1.59 – 2.36], p <0.001). Older adult recidivists were more likely to be female (OR: 4.28 [2.82 – 6.51], p <0.001) and suffer blunt trauma secondary to a fall (OR: 5.36 [3.91 – 7.35], p <0.001). Trauma recidivism in older adults also correlated with a higher Injury Severity Score, longer length of stay, and an increased proportion of patients requiring discharge home with organizational help or to a rehabilitation facility.
Trauma can be recurrent and associated with poor health outcomes, particularly in older adults. Recidivists in the studied region were significantly older, with the most at-risk population consisting of females suffering blunt injury secondary to fall. Improved prevention strategies are needed for this population.
Disclaimer: This research was supported (in whole or in part) by HCA and/or an HCA affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA or any of its affiliated entities.
Global Surgery – The Jamaican Map
B'jorn Blackwood, MBBS, Medical Officer, Kingston and St. Andrew Health Department, Ministry of Health and Wellness
Surgery has been referred to as the “forgotten step-child” of global health. For a long time, it has not been included in the discussion of how healthcare could be improved worldwide, especially in rural and remote parts of the world. Global surgery is a term which is used to describe the rapid development of a multidisciplinary field which is geared towards providing improvement in surgical care in health systems around the world. It comprises a multitude of features which surrounds the treatment of surgical diseases and equitable access to surgical services across health systems globally. The Lancet Commission on Global Surgery (LCoGS) in 2015 recommended six parameters to facilitate the measurement of a country's accessibility and delivery of surgical care. These parameters were accepted by the World Bank for inclusion in World Development Indicators. The objective of this project is to map the global surgical indicators across the Caribbean island of Jamaica. After obtaining these parameters, it will be possible to implement future strategic decisions in order to improve the quality and delivery of surgical care in the healthcare sector.
Local collaborators including the Ministry of Health and Wellness, Jamaica, the Statistical Institute of Jamaica and personnel at the various public hospitals across Jamaica were invited to participate in this research effort. These partnerships yielded data on (i) the volume of general surgical procedures across the island, (ii) the surgical workforce and (iii) the island’s population distribution in relation to Bellwether capable hospitals.
Jamaica’s surgical volume was reported at 77374 procedures in 2018. The majority of cases were done in the General Surgery specialty. The South Eastern Region had majority cases across all specialties totalling 67,064 procedures. The bulk of these cases, totalling 26,498 were done in the Kingston Public Hospital which is the largest type A hospital on the island. Spanish Town Hospital, a type B hospital, had the second highest number in the region with a total of 20,864 cases across the specialties. UHWI, also a type A hospital, had a total of 11,688 cases. UHWI, KPH and STH are all situated within the corporate area of Jamaica where the majority of the population reside. The overall surgical workforce in Jamaica is reported to be 322 surgical specialists [11 per 100,000], which falls short of the recommended 20 per 100,000 to be achieved by 2030 as set out by the Lancet Commission on Global Surgery. Cornwall Regional Hospital, a public type A hospital, is situated in the second city of Montego Bay, St. James. It is located in the Western Regional Health Authority area which has a population of 477,571 as of 2018. The case numbers, totalling 14,708 at the Cornwall Regional Hospital should be almost triple the amount given the average case numbers in previous years. This is due to the problems facing the hospital’s infrastructure since 2016. This has led to decreased access to healthcare and a shifting of surgical procedures to several Type B hospitals in the region. There are twelve (12) Bellwether-capable hospitals across the island, which confer 100% coverage of the island’s population within a 2-hour radius of essential surgical services. However, with specificity towards Neurosurgery, there is approximately 16% of the Jamaican populace that is located more than 2 hours away from a center with neurosurgical capacity. This is likely due to the lack of neurosurgical services in any of the hospitals located in the North-East or Southern Regional Health Authorities. Based on an estimated average case load of 223 cases/year there should be an additional 2,449 neurosurgical procedures being conducted across the island.
This research offers novel information regarding the characterization of global surgical capacity in the Caribbean. Future research efforts will seek to expound on this preliminary data and interrogate the effects of the current landscape of surgical services.
Plagues and People
Frank Bongiorno, MD, MPS, FICS, Adventures in Learning, Community Education
This presentation presents human history in light of the epidemic diseases that have developed along with and influenced the course of civilization. The development of multiple life forms together over time rendered a conflict of natural development inevitable especially since the micro life forms presented millions of years before Homo Sapiens. Thence developed the clash of People VS Plagues .
This talk will be both medical and secular history.
Risk Factors for Failure of Non-Operative Management in Patients with Intracranial Hemorrhage and Blunt Splenic Injury
Nicole Boswell, BS, Medical Student, University of South Carolina School of Medicine
There is limited literature evaluating failure of NOM in blunt splenic injuries and its effects on outcomes in TBI patients. Poor oxygen delivery and hypotension are well known risk factors for poor outcomes in TBI patients, both of which can occur in the setting of hemorrhage from failure of NOM in blunt splenic trauma. This is an institutional review of risk factors associated with failure of NOM of blunt splenic injury in patients with concomitant TBI.
This is a retrospective chart review of patients in the trauma registry at Greenville Memorial Hospital from March 2013 to July 2019. We reviewed 562 charts of patients with the diagnosis of blunt splenic trauma, of which 107 had a diagnosis of intracranial hemorrhage. We used Chi square analysis and student’s T-test to extrapolate risk factors for failure of NOM.
555 patients of the 562 met inclusion criteria into the study. Eighty-nine of those were admitted for NOM, 45 of which failed NOM. Fifteen of those 45 that failed NOM had a concomitant intracranial hemorrhage (ICH). Elevated heart rate (p=0.007), elevated ISS (p=<0.001), decreased GCS (p=<0.001), and presence of mechanical ventilation (p=0.002) were risk factors for failure of NOM with associated intracranial hemorrhage. Of those with ICH that failed NOM, 86.7% (n=13) were male. Mortality rates were increased in those with ICH who underwent NOM compared to those without ICH (p= 0.005). CT blush, hemoperitoneum, and other abdominal injuries were less frequently seen in the NOM group since most of those patients entered the operative management group.
Overall, elevated heart rate, elevated ISS, decreased GCS, and presence of mechanical ventilation were seen more frequently in patients with ICH that underwent NOM for blunt splenic trauma. Patients who underwent NOM with ICH had higher mortality rates than those without ICH.
The Expansion of Surgical Care Services is Essential in Improving Health Equity
Kathryn Campos, BA, Independent Student Researcher, University of Washington, School of Medicine - Dept. of Surgery, Harborview Injury Prevention Program
5 billion people lack safe, timely and affordable access to surgical care. Global surgical and Anesthesia care is widely considered to be a neglected area of global health. Surgical care expansion is critical for the strengthening of healthcare systems worldwide and the effort to effectively reduce surgical disease associated global burden of disease conditions. The purpose of this narrative review is to identify, evaluate and summarize pertinent literature on global surgery, health equity, surgical disease, and scaling up universal coverage of essential surgery.
Initial database systems that were researched were PubMed, Embase and WHO Database for systematic reviews. The search terms used were Global Surgery Healthcare Equity and Essential Surgery/Surgical Care, Healthcare Equity and Universal Coverage/LMIC Global Surgery and Essential Surgery/Surgical Telemedicine and Essential Surgery. Studies included had to be focused on surgical care, health equity, global surgery and surgical telehealth.
After examining the abstracts, 311 studies were excluded for various reason, mainly most lacked a focus on global surgical care. 41 articles were considered for review. After reviewing the full articles an additional 23 were excluded due to a lack of relevance pertaining to a broad basis of global surgical care. Search outcome, a total of 17 articles are included in this review.
Scaling-up surgical and anesthesia care is an effective public health tool. Global surgery is essential in addressing, identifying and improving the expansion of surgical care access and health equity, collaboration and capacity building, data collection, monitoring and evaluation processes, research and training opportunities, economic productivity, enhanced primary and healthcare system efficiency, and the reduction of associated mortality and DALY rates.
According to The World Health Organization (WHO), 5 billion people around the world lack safe, timely, and affordable access to surgical care. Treatment for surgical conditions include a broad range of diseases that represent approximately 30% of the global burden of disease and span 100% of disease sub-categories, remains out of reach for the majority of the world’s population. With a rise of global conflict, increasing rates of displaced persons, detrimental worldwide shortages of healthcare providers, risk of natural disasters and famine the need for surgical care is essential. Access to safe, affordable, surgical and anesthesia care is required in order for the global burden of disease to be adequately addressed in the 21st century.
Quality healthcare delivery in any nation requires the establishment of sustainable surgical systems. Despite its well-founded presence as a primary area constituting the overall global burden of disease, surgical and anesthesia care remains arguably one of the most under-served and under-represented areas of global health.
The goal of this literature review is to identify, evaluate and summarize pertinent published literature on global surgery and healthcare equity specifically in the context of surgical disease as it relates to the global burden of disease, current barriers to surgical care in LMICs vs. HIC’s, essential surgery and approaches to scaling up surgical and anesthesia care worldwide.
A number of literature reviews and systematic studies have been undertaken on the topic of global surgery care and health care equity. This literature review seeks to describe, evaluate, and summarize pertinent published material contained in the inclusion studies provided in this study. The Essential Surgery Report states “New opportunities exist to address health-care inequity and to reset the global health agenda to meet present and new health challenges. These include global commitments to the achievement of UHC, greater strategic investments in health, and the launch of a new set of SDGs, which aim to end poverty, promote sustainable economic growth, and ensure health for all at all ages by tackling infectious diseases, noncommunicable diseases, and injuries. The full realization of these promises will only be possible by strengthening of health services and health systems, including strengthening of the delivery of safe, affordable, and timely surgical care ”.
The intention of this review is to identify studies and credible/ governing resources from the literature focused on global surgical care and health equity, scaling up surgical and anesthesia care accessibility, surgical systems, the economic impact of surgical care, addressing barriers to surgical care, and the utilization of technological innovation that provide information potentially leading to closing gaps to surgical care intervention. The aim of this review is therefore to evaluate the current gaps that exist within the field of global surgical care, analyze the impact of surgical care interventions on limited resource settings, and address potential opportunities for the enhancement of surgical care expansion as it pertains to health equity, innovation and global health engagement.
Initial database systems that were researched were PubMed, Embase and WHO Database for systematic reviews. The search terms used were Global Surgery Healthcare Equity and Essential Surgery/Surgical Care, Healthcare Equity and Universal Coverage/LMIC Global Surgery and Essential Surgery/Surgical Telemedicine and Essential Surgery. Additional primary literature papers accessed from reference tracking include The Essential Surgery Disease Control Priority DCP3 website (http://www. dcp-3.org/surgery) and The Lancet Global Surgery 2030 Report (https://www.thelancet.com/journals/lancet/article/PIIS01406736(15)60160-X/fulltext). Analysis was performed by a single researcher over an 8-week period. Each citation co
Know your Plastic (Orthopedics)
Naga Suresh Cheppalli, MD, FICS, AANOS, Asst. Professor of UNM, Albuequrque; Staff Orthopedic Surgeon VA Hospital
In Orthopedics, Plastics has been an integral part of joint replacement. Different companies use different plastics. In this topic, we present various steps involved in plastic processing to delivery, including sterilization. I would like to discuss with clinical results of various types of High-density Polyethylene used in total knee and what we can expect in the future.
Incision and Surrounding Soft Tissue Management of the Breast Using Closed Incision Negative Pressure Therapy with Full-Coverage Dressings
Anthony N. Dardano, Jr., DO, FICS, Associate Professor of Surgery, Florida Atlantic University, Chief of Plastic Surgery Trauma, Delray Medical Center
Boca Raton, FL
For patients undergoing breast surgery, incisional management can have a significant impact on healing outcomes and patient satisfaction. Closed incision negative pressure therapy (ciNPT) using a novel foam dressing that covers breast incisions, the nipple-areolar complex, and surrounding tissues*, creates a barrier against external contaminants, removes fluid and infectious materials, reduces edema, and bolsters the breast by holding the incisional edges together. We report the outcomes of 7 patients undergoing breast surgery followed by ciNPT with full-coverage dressings.
The patients comprised 1 male and 6 females aged 21 to 49 years old. Patient medical history included weight loss greater than 50 pounds, fibromyalgia, polycystic ovarian disease, endometriosis, and smoking. Body mass indices were 25.6 to 32.4 kg/m2. Surgery types included breast reduction (n=3), breast augmentation (n=2), implant exchange (n=1), and bilateral mastectomy for male gynecomastia (n=1). Incision lengths ranged from 23 to 40 (mean: 32.9) cm, and all were closed using buried subcuticular sutures. Patients received prophylactic antibiotics and ciNPT with full-coverage dressings at -125 mmHg. Four patients were immediately discharged for outpatient care, 2 patients were discharged on postoperative Day (POD) 1, and 1 patient was discharged on POD 2. On POD 7, ciNPT was discontinued, and all incisions remained closed. Within the 30-day follow-up period, 1 patient experienced a minor dehiscence of the left breast and another patient developed a small seroma on POD 15, but there were no signs of infection and no intervention was required. Upon follow-up 3 to 5 months post-surgery, we observed an overall reduction in swelling, less pain, improved range of motion, and improved scar appearance
In this patient population, we report that ciNPT with full-coverage dressings provided support for incision healing after breast surgery by protecting the incisional environment and moving fluid away from the surgical site. This surgical dressing is beneficial in improving surgical outcomes in both breast reconstruction as well as aesthetic breast surgery.
Management of Soft Tissue Edema in the Lower Extremity using Circumferential Negative Pressure Wound Therapy: A Case report
Anthony N. Dardano, Jr., MD, FICS, Associate Professor of Surgery, Florida Atlantic University, Chief of Plastic Surgery Trauma, Delray Medical Center
Boca Raton, FL
Problem: The patient underwent open reduction and internal fixation of tibial plateau fracture, the the incision was closed with surgical staples (Figure 1). The patient was placed in a standard postoperative splint with a soft cotton wrap. On postoperative Day (POD) 7, the surgical dressing was removed, and 300 cc of seroma fluid was aspirated from the left knee (Figure 2). The patient was then placed in a knee immobilizer. The patient complained of severe left leg edema. Clinical assessment found no indication of deep vein thrombosis or compartment syndrome. Dorsalis pedis and posterior tibial pulses were 2+. There was no open wound, and the incision was healing well, but concern for edema remained.
Solution: Application of ACTIV.A.C.™ Therapy System: The decision was made to apply incisional negative pressure therapy over the left lower extremity from the mid-thigh down to the ankle incorporating the entire soft tissue in the lower extremity. The skin was protected with Xeroform® Occlusive Petrolatum Dressings (Figure 3), followed by V.A.C.® GRANUFOAM™ Dressings applied circumferentially (Figure 4). A seal was created over the dressings using V.A.C.® Drape and Ioban™ 2 Antimicrobial Incise Drape. Negative pressure was applied at -125 mmHg using an ACTIV.A.C.™ Therapy System (Figure 5). During therapy, the distal circulatory status was monitored (eg, distal pulses were palpated) to ensure uncompromised perfusion.
Results: After 5 days, incisional negative pressure therapy was discontinued. Compared to measurements taken on POD 7, the leg circumference at POD 12 had decreased 4 cm at the calf and 4 cm at the thigh (Figure 6). Within 2 weeks of discontinuing incisional negative pressure therapy, the edema in the left leg had subsided and it was similar in dimensions to the uninjured right leg
Conclusion: Use of incisional negative pressure therapy is a beneficial tool for controlling soft tissue edema following surgery. There was no apparent disruption of normal perfusion to the distal aspect of the leg when applied circumferentially, and there were no postoperative complications."
Clinical Characteristics, Management, and Outcomes of Patients with Primary Cardiac Angiosarcoma: A Systematic Review
Gabriel De la Cruz Ku, MD, AANOS, Resident Physician, General Surgery, Mayo Clinic
Purpose/Background: Primary cardiac tumors have a prevalence of approximately 0.001% to 0.03%. 25% of primary cardiac tumors are malignant, and of these, 30% are angiosarcomas. Primary cardiac angiosarcomas (PCA) are highly aggressive and have poor prognosis regardless of the type of treatment. Here we conducted a systematic review in order to assess clinical characteristics, management, and outcomes of patients with PCA.
Methods: Using PRISMA guidelines, we performed a systematic review utilizing the following databases: PubMed, Scopus and EBSCO, without exclusion for language or publication date. Inclusion criteria were cross-sectional studies, case-control studies, cohorts, and case series that reported the clinical characteristics, management, and outcomes of patients with PCA. In addition the exclusion criteria were duplicated studies, articles and case reports. We assessed the risk of bias using the Newcastle-Ottawa Scale.
Methods: We reviewed 2,397 records, and after the screening and eligibility, 6 studies were included. PAC patients were found to have a mean age of 45 [SEM=1.66], while 54.15% [SEM=6.23] were male. The most frequent clinical manifestations were chest pain, dyspnea and pericarditis/pericardial effusion. Tumors were most commonly located in the right atrium and ranged in diameter from 5.8 to 7.2 cm. In the included studies, 47.6 to 94.4% and 33.3 to 100% of the patients were treated with surgery and chemotherapy, respectively. Two studies reported the use of radiotherapy. Moreover, more than half of patients presented with metastasis at diagnosis, most commonly to the lung. Mortality ranged from 64% to 90% with a median overall survival that ranged from 5 to 26 months. Furthermore, three analyses reported that surgery improved the main outcomes, indeed, fewer patients with distant metastasis and a higher median time of overall survival.
Conclusions: PCA are rare and symptoms are mainly nonspecific, often resulting in late diagnosis. The most frequently location is the right atrium and usually in male sex. Most of PCAs have metastasizes at initial presentation and high mortality; however, surgery with adjuvant chemotherapy may enhance the average overall survival as well as decrease the percentage of distant relapses. Further studies are needed to better compare the efficacy of surgery, chemotherapy, and radiotherapy.
Metastatic Melanoma-Long Term Survival
Raymond A. Dieter, Jr., MD, MPH, FICS, Adjunct-Olivet/Visiting Researcher U of I
Glen Ellyn, IL
Melanoma is a highly malignant tumor.When the tumor is metastatic the prognosis is grim. Two patients with multiple distant metastases and recurrent surgical interventions over a number of years are living 25 and 32 years later.
Paper #2. A board certified active thoracic and cardiovascular surgeon answered a request by a North Dakota physician for a locum tenons to cover his practice in a community of 1500 people and to cover the hospital as the only physician for 60 miles.General medicine,OB.trauma, and surgery was performed. Lasting friendships were made with a very pleasant community.The experience will be discussed
Surgical Learning Requires....Assessment!
David R. Farley, MD, Emeritus Professor of Surgery, Mayo Clinic
While all of us as surgical caregivers teach students, residents, patients, and co-workers the nuances of our trade, there is NO guarantee that learners will actually LEARN the material or patients will comprehend our instructions. Indeed, good teaching does NOT guarantee good learning. In an era with a shortage of time to teach our surgical trainees, we must efficiently deliver surgical wisdom and create an environment where surgical learning can occur. The key to successful learning lies within each surgical learner - learning is an active process and takes individual effort. Our job to convert good teaching to good learning involves making sure our learners put forth the effort...typically through testing, quizzing, coaching and challenging them. The audience will learn that comprehension can not be assured unless assessment is involved.
Early and Late Postoperative Complications of Mandible Reconstruction: Osseous Versus Soft Tissue Flaps
Jake Goldstein, Medical Student, Medical Student, Loyola University Chicago Stritch School of Medicine
Forest Park, IL
Flap reconstruction has expanded a physician's ability to treat patients with complex mandible defects. This study compared complication rates between the current gold standard, osseous free flaps (OFF), and the alternative, soft tissue flaps with a reconstruction bar (STF).
Retrospective chart review of patients who underwent mandible reconstruction with OFF or STF at Loyola University Medical Center from 2007 to 2017. Early complications (EC) occurred within thirty days of surgery and late complications (LC) thereafter.
Twenty-eight patients were reconstructed with STF and 100 with OFF. Thirty-three patients had an EC (25.8%) and 31 had a LC (32.6%). In the group of patients that received an OFF, 25 experienced an EC (25.0%) and 27 experienced a LC (36.0%). In the group of patients that received a STF, 8 experienced an EC (28.6%) and 4 experienced a LC (14.3%). Eleven patients had multiple early complications (8.6%) and 19 had multiple late complications (32.6%). In the patients who received an OFF, 9 patients experienced multiple early complications (9.00%) and 17 experienced multiple late complications (18.7%). In the patients who received a STF, 2 patients experienced multiple early complications (7.1%) and 2 patients experienced multiple late complications (7.7%). Of the 100 patients reconstructed with an OFF, 14 were readmitted (14.0%), 6 of which were flap-related (42.9%) and 8 for other medical indications (57.1%). Of the 28 patients reconstructed with a STF, 4 were readmitted (14.3%), 1 of which was flap-related (25.0%) and 3 of which were not related to their flap (75.0%).
STF did not show higher rates of complications.
Management of Post-Hepatectomy Biliary Complications
Michael J. Jacobs, MD, FICS, Clinical Professor of Surgery, Michigan State University CHM
Bloomfield Hills, MI
Post-hepatectomy biliary complications are inherent risks that face surgeons. Knowledge of the management is necessary to prevent and treat this challenging complication. A review of management options will provide the learner with the necessary tools to enhance the care of patients who develop biliary complications.
Cerebellar Arteriovenous Malformations: Treatment Strategy
Muhammad Janjua, MD, FICS, Clinical Instructor Neurosurgery, University of Illinois Chicago
Poplar Grove, IL (Presented by: Jesseca R. Pirkle, BS)
Cerebellar Arteriovenous malformations (AVMs) are abnormalities of unknown origin in arterial vasculature that comprise less than 15% of all neurological AVMs. Unlike the more common cerebral AVMs, they have a unique presentation, hemorrhagic tendencies and outcomes. However, due to their rarity, there has been little opportunity to investigate the unique qualities and challenges of cerebellar AVMs and their subsets. Our main objective is to study the presentation, and current diagnostic and treatment modalities of these complex vascular malformations.
Literature search was conducted to study any published case reports of studies on cerebellar arteriovenous malformations (AMVs). The diagnostic and treatment modalities are further discussed. The authors also report a case of 79-year-old female who presented in an obtunded state. The patient was diagnosed to have bilateral cerebellar hemispheric AVMs and small AV dural fistula. Treatment strategy has been discussed.
Diagnostic imaging with MRI/MRA of the brain with and without contrast is the first step, followed by preoperative digital subtraction (DSA) to diagnose these vascular malformations. Dural fistulas are typically embolized first, followed by embolization of arterial feeders to the parenchymal infratentorial AVMs if possible. Due to the emergent presentation of non-communicating hydrocephalus, co-existing cerebellar hemorrhage with edema, and further risk of re-bleeding, surgery is a recommended option after first stabilization. Treatment rationale with its own case example has been discussed in detail.
Diagnostic radiological imaging, followed by emergent CSF diversion, are the first step in the stabilization of these symptomatic vascular lesions. DSA, followed by embolization, is helpful when performed in a stepwise fashion. Preoperative embolization helps to decrease the intraoperative blood loss. Considering an inherent risk of rebleed, surgical resection can be offered to resect these lesions and to avoid the associated morbidity that may occur if the lesions are left untreated.
Lung Cancer in Young Adults: A Single Center Experience
Stuart Jones, BS, Medical Student, University of Kentucky
Lung cancer is relatively uncommon in young people. The purpose of this study is to review our experience in the diagnosis, treatment, and outcome of lung cancer in young adults at Markey Cancer Center.
This is an IRB-approved retrospective study of lung cancer in adult patients with non-small cell lung cancer (NSCLC) who were between age 18 and 40 at diagnosis. These patients were diagnosed in the years 2012 through 2018 and were diagnosed and/or treated at Markey Cancer Center. The final cohort consisted of 36 patients.
Among 36 cases, the majority (23; 63.88%) presented at advanced stage of disease (Stage III or IV). Our cohort consisted of a strong majority of female patients (25; 69.44%). The most common type of NSCLC was adenocarcinoma (14; 38.89%). The five-year survival rate was 48% among our cohort.
Lung cancer is rare in young patients; when present, it often presents at advanced stage. Despite many diagnostic tools and treatment modalities available, long-term survival remains poor.
The Economic Effects on Acute Care Surgery in a New York City Public Hospital During the COVID Pandemic
Anthony Kopatsis, MD, Senior Staff, ICAHN School of Medicine at Mount Sinai
There is evidence that surgical procedures like appendectomies and cholecystectomies are among the most frequently performed surgeries in the United States. They also incur high yearly hospital costs and fall among the procedures that generate greater amounts of revenue for hospitals. With the emergence of the COVID-19 crisis and New York (NY) arguably suffering the greatest impact in the United States, New York hospitals prioritized COVID-19 patients and this has resulted in the decrease in the volume of surgical procedures carried out especially at Elmhurst Hospital Center which turned out to be the epicenter of the crisis. This a retrospective study comparing numbers of appendicitis and cholecystitis cases seen at Elmhurst Hospital Center (EHC) from March to May between the years 2019 and 2020. This study aims to identify a marked reduction in these cases in 2020 compared to 2019 and also determine the amount of revenue lost in those 3 months as a result of the reduction in these cases. This study stems from the knowledge that these conditions require surgical interventions which generate huge hospital costs, thereby contributing largely to the revenue of hospitals. Patients will be obtained from EPIC via the Electronic Medical Record (EMR) system from the years described above. We have included all patients 5 years and older with the diagnosis of appendicitis and cholecystitis and the intervention as needed. (Data points to be collected will include age, sex, race, ethnicity, insurance status, ICD-10/diagnosis, comorbidities, surgical procedure/CPT, citizenship status.
A retrospective data analysis of three (3) months during the first COVID 19 pandemic surge of 2020 in comparison to the similar three months in 2019. All patients were included with no age, sex or racial exclusions. In addition, the financial department was utilized to tally results in monetary reimbursement for the months and years in question. The data will be obtained from the EPIC electronic records in Health and Hospital Elmhurst Hospital Center in New York City.
There were a total of 314 patients who presented with either appendicitis or cholecystitis to EHC from March to May of 2019 and 2020. 76% (239) presented in 2019 which is >3 times th number seen in 2020 (75), p=0.823. In March 2019, a larger proportion of patients were seen (64%) compared to March 2020 (36%), while > 10 times the number of patients seen in April 2020 (8%) were seen in April 2019 (92%), and May 2019 (78%) also had > 3 times the number of patients seen in May 2020 (22%), p=0.00. In the 3 months of 2019 that included all insurances for laproscopic appendectomy and laparoscopic cholecystectomies, the hospital collected $680,730.55. For the similar three months in the COVID surge of 2020, the hospital collected $162, 594.87. There is almost 4 fold decrease in revenue for the two surgeries in the COVID surge of the three months. This was seen in every payor from Medicare, commercial and self-pay a universal decrease in revenue collected 2019 to 2020 (Table 2)
During the surge of the COVID pandemic we have seen great disruptions in our daily surgical activity. In acute care surgery we see an abundances of cases daily and certain cases can be seasonal. During the pandemic hospitals had to shut down on elective surgery and remain open for acute surgical emergencies and traumas. Some areas like EHC had to divert their Level 1 trauma patients to other institutions that weren’t hit as hard. It would seem reasonable that acute care cases would not be effective from a respiratory disease such as COVID. But EHC did see and extreme reduction in cases during this period. Unlike more affluent neighborhoods, the Elmhurst community does not have the luxury to travel to a different hospital for their ailments. With that being said, we noticed a great reduction in appendicitis and cholecystitis patients with a respectful reduction in surgeries. EHC has a commitment to the community to take care of all emergency needs but we have seen a great reduction not in the treatment because of resources but no patients were admitted with presenting symptoms. In addition, we did not see any complications of untimely presentations of appendicitis or cholecystiitis, ie peforations, abscess’ In addition to the reduction of treatment for the patient and eventual training for the surgical program for these cases, there was a clear reduction in revenue. As physicians we like tto not think of the monetary investment of hospitals but in any hospital especially a public hospital, the revenue from these admissions and procedures are of paramount importance to the viability of the instution in a public health format. We had seen a four fold decrease in the revenue collected by the hospital.In addition, on evaluation of Table 3 that show an absolute reduction in cases as expressed in Lap appy and Lap chole. Although we only critically examined three months, it can be seen that this reduction in cases and eventually occurred for months after the surge of pandemic. These results did not normalize and still did not normalize with the advancement of the “second” surge in NYC. As we compared the individual insurances In every payor there was a universal decrease in revenue as shown by variance.
We saw almost three times less cholecystitis and appendicitis as during the surge. In addition, the hospital loss over four times the amount of revenue in the same period. Additional review needs to determine the decrease of these acute care cases and time will only tell on the impact of decrease revenue for a public hospital will mean.
Surgical Techniques to Achieve Safety Laparoscopic Cholecystectomy in Severe Cholecystitis
Kung-Kai Kuo, MD, PhD, FICS, President of ICS-Taiwan Section; Professor in Surgery, University of Kaohsiung Medical University
Laparoscopic cholecystectomy is one of the most common procedures for the general surgeon. However, how to minimize the mortality and major complications (such as common hepatic duct (CHD) severance, duodenum or colon injuries, postoperative hemorrhagic shock --- etc) remains an important clinical issue. Any major complications might cause legal liability to the staff, increase hospital stay with cost, and damage program’s reputation.
During the past three years, near two thousand five hundred cases underwent (urgent or elective) laparoscopic cholecystectomy (three trocars in majority but single incision LC is increasing) by a group of HBP specialists in our institution, which is a tertiary care University hospital. We had no mortality and very few major complications from this procedure.
Our crucial experiences for operating cases with severe cholecystitis include: meticulously dissecting out the Calot’s triangle is important; “99% assumed” cystic duct might not be the true cystic duct, so only divide “100% confirmed” cystic duct; when applying clips, relaxing and avoid excessive traction of gallbladder; over usage of energy device in the Calot’s triangle should be avoided; dome-down circumferential dissection of gallbladder neck, partial or subtotal cholecystectomy then transcystic approach, intraoperative cholangiography study, 3D image are all techniques or equipment to increase the operative safety.
Preoperative images analysis is very important which provide crudes implying operative difficulty such as thickened GB wall, Mirrizi like picture (figure A), pneumobilia, which indicates possible bilioenteric fistula or gallstones ileus. CT/MRI coronary view can be used to examine whether Calot’s triangle is obliterated by impacted stone in the Harmann’s pouch, which overlaid upon the common hepatic duct (figure B). In this situation, the cystic duct usually is short and runs forward, ventrally to the CHD, not right side, laterally to the CHDn (figure C). Sagittal view can provide whether cystic duct runs ventrally or dorsally into the CBD. They are warning signs for high risk of bile duct injury and require tremendous patience in dissection. Single incision LC should be avoided in these difficult cases for the early beginners.
Building a culture of safety by effective education, self-reflection and mutual sharing experience, in addition to a clear identification of cystic structure may minimize the major complications from laparoscopic cholecystectomy.
Systematic Review of Procedural Healthcare Simulation in Low- and Middle-Income Countries
Sarah Lund, MD, FICS, Resident, Mayo Clinic
Procedural simulation in healthcare is frequently used in high income countries and has demonstrated effectiveness in the acquisition of procedural skills. With the known benefits of using simulation in health professions education and the link to improved patient outcomes, low- and middle-income countries (LMICs) have also adopted healthcare simulation training. Researchers have increasingly investigated the efficacy of simulation at improving procedural skills in LMICs. To guide such efforts and prioritize research questions, the scope of the current simulation research in LMICs must be better understood. Therefore, we aim to summarize the current state of procedural skills healthcare simulation in LMICs, including the cost, cost-effectiveness, and overall sustainability of these simulation programs.
A systematic review was performed of original research articles that assessed procedural simulation for healthcare professionals and students in LMICs. Databases queried included MEDLINE®, Embase, Cochrane, Scopus, and African Index Medicus. Additionally, grey literature was included from thematically related systematic reviews. Two researchers independently screened titles and abstracts to determine eligibility. After articles were selected for full text review, articles were divided between authors who, in teams of two, independently reviewed and coded information from their subset of articles. Paired authors reached consensus through discussion when discrepancies existed. Information extracted from each article included country, study design, simulation type, discussion of simulation cost or cost effectiveness, discussion of sustainability, and outcomes studied. Research outcomes in each study were characterized by whether the outcome measured learner performance in simulated settings or in real clinical settings and whether the outcomes measured were related to knowledge, time, the process of performing a skill, and/or the end-product of skill performance.
From a pool of 4,106 articles published up to November 2019, 423 were considered for full-text review after title and abstract screening. After full text review, 190 articles were included in this review. Of those, 39 articles (21%) were randomized controlled trials and 151 were observational cohort studies (79%), of which the vast majority were a pre-, post-test experimental design. Obstetrics and neonatal medicine were the area of simulation most studied (74 articles, 39%), followed by general surgery (31 articles, 16%) and Basic Life Support (BLS) (25 articles, 13%). The majority of studies (149 articles, 78%) compared simulation to no intervention or pre-existing educational activities. The majority of outcomes measured were knowledge-based. The overwhelming conclusion was that simulation is a superior educational methodology when compared to no intervention in LMIC settings. Several studies mentioned cost (72 articles, 38%), cost-effectiveness (4 articles, 2%), or sustainability (64 articles, 34%) in the article text. However, few articles included monetary cost (20 articles, 11%) and no studies analyzed sustainability efforts or cost-effectiveness as research outcomes.
Simulation as a means of education and training works in LMICs. Not surprisingly, simulation shows significant benefits in most domains of healthcare training. The authors would argue that given the positive effects of simulation on learning, future studies in LMICs should focus on comparing different simulation techniques or questions directed at sustainability and cost-effectiveness of simulation in LMICs.
Success Factors for Retirement: What to Know If Years Away or in Retirement Today
David Mandell, JD, MBA, Partner, OJM Group; Attorney
Achieving a comfortable retirement that meets one’s lifestyle goals and timeline is the #1 financial goal for most surgeons. This is evidenced by independent physician studies and our own experience in working with well over 1,000 physicians. In this lecture, Mr. Mandell will discuss three long-term strategies that are crucial for a physician to implement while in practice:
• implementing a wealth management plan and monitoring it
• making sure the plan is comprehensive
• building flexibility into the plan
Mr. Mandell will also explain three shorter-term tactics to consider when approaching, or already in, the retirement years:
• developing an accurate retirement budget
• de-risking investments
• designing a retirement withdrawal strategy
Management of Sternoclavicular Joint Infection: A Single Center Experience
Thomas Marsden, MD, Resident, University of Kentucky
Sternoclavicular (SC) joint infections are an uncommon form of septic arthritis. Several articles have been published regarding these infections, however there is no consensus guidelines regarding the optimal management of this disease.
We performed a retrospective review of 41 patients at the University of Kentucky with sternoclavicular joint infections between December 1st, 2014 and December 1st, 2018. Twenty four patients (58.5%) underwent surgery and 17 patients (41.5%) had no operation and were treated conservatively without surgical intervention. Procedures performed included 14 incision and drainages, 16 joint debridements, 12 excision of SC joints, 3 interventional radiology procedures, 2 muscle flaps and 14 negative pressure wound therapy placements.
Pain (82.9%) was the most common presenting symptom in these patients, followed by swelling (53.7%), fever (29.3%) and erythema (24.4%). The most common bacteria isolated in cultures was MRSA in 10 patients. No association between the various characteristics analyzed and need for surgical intervention were identified. Fourteen patients had to be readmitted to the hospital with complications from their initial sternoclavicular joint infection treatment. Two patients that were initially treated conservatively required surgical intervention during rehospitalization. Five patients that underwent either incision and drainage of the sternoclavicular joint or sternoclavicular joint resection required repeat surgical intervention at their rehospitalization.
Treatment of this rare form of septic arthritis depends on the extent of infection. The majority of patients in this series required surgical intervention. Negative pressure wound therapy is an excellent adjunct following debridement or excision of the sternoclavicular joint.
Providing Pathology Expertise for Capacity Building and Cancer Care
Yasodha Natkunam, MD, PhD, FICS, Ronald F. Dorfman Endowed Professor in Hematopathology, Stanford University School of Medicine
1. Understand the importance of precision diagnostics and capacity building in pathology
2. Discuss how optimizing pathology services can improve clinical management including surgical decision making and management
3. Understand how training of medical workforce at all levels in pathology and laboratory medicine impacts global cancer care
Perioperative Mortality Rate in a Low Resource, Non-Governmental Organization Hospital.
Yuki Ng, MBBS, Junior Doctor, Sarawak General Hospital
Kuching, Sarawak, Malaysia
Seventy per cent of the global population do not have access to safe and affordable surgical and anaesthesia care, and 90% of them are found in the low and middle-income countries. The World Health Organization deemed perioperative mortality rate as a gross indicator for access to safe and affordable surgical and anaesthesia care. India is the second-largest country by population and the World Bank considers India to be a low-middle income country. This predisposes the Indian population to not have access to safe and affordable surgical care. We aimed to descriptively assess the perioperative mortality rate of a low resource non-governmental organization hospital in India.
We performed a retrospective clinical audit from January 2016 to February 2020. We collected the operation volume from the operation theatre registry, all recorded deaths in relation to surgery during the timeframe of data collection and investigated each death. We also investigated patients who were discharged against medical advice to have a holistic view of the perioperative mortality of the hospital. The data was then analysed descriptively with Microsoft excel.
The operation theatre registry recorded 1860 patients who underwent major operations with sedation. The perioperative mortality was 3 (0.16%). Mortality was found in general surgery (n=2) and obstetrics and gynaecology (n=1) department. The case-mix done under obstetrics and gynaecology was at 1046 (56.2%), general surgery at 614 (33.0%) and orthopaedics at 200 (10.8%). There were 388 (20.8%) emergency cases recorded. This was persistent with every year that was recorded with emergency cases ranging from 18-22%. We found that our average surgical volume per year was 448 (excluding the year 2020), this was consistent with previous years after extrapolating the surgical volume.
Vivekananda Memorial Hospital is a non-governmental organization (NGO) hospital that serves 300 thousand population from 4 districts in the state of Karnataka with 100 beds. Among these 300 thousand population, there are multiple hospitals serving this population. Within this hospital, there were 4 obstetrician, 1 orthopaedic surgeon and 1 general surgeon. The attending paediatrician, task shifts to becoming the attending anaesthesiologist for all cases in the hospital. There is 1 ICU bed for both adults and children, and 1 post-operative recovery bed. There is 1 operation theatre for general surgery and orthopaedics cases and 1 operation theatre for obstetrics and gynaecological cases. This hospital can provide open laparotomy and caesarean section delivery. Using the bellwether procedures as a benchmark, this hospital can provide most of the essential procedures needed. With limited human resource and hospital resources, the hospital is still able to perform better than the global standard of operative safety with a perioperative mortality rate of 0.16%. However, by interviewing the surgeons, there were a few patient data that was not captured although a rigorous process was performed to attempt to capture all patient data. Case selection to undergo safe surgery in low resource hospitals are imperative. Wisdom paired with clinical experience must guide referrals to larger hospitals with the appropriate capacity to provide safe surgical care. This audit shows that access to safe and affordable surgical care is achievable in a low resource NGO setting.
According to the Lancet Commission on Global Surgery, it describes access to safe and affordable surgical and anaesthesia care includes financial safety. Perioperative mortality does not capture this. It captures a general understanding of the access to a health facility, and the safety and capacity of surgical and anaesthesia care. We took the liberty to further assess the fiscal charges of the health services provided. Almost all services provided in this hospital charged cheaper services in comparison to the other hospitals. Tribal groups receive 50% off on top of the usual charges and if they cannot pay the 50% reduced hospital charges, healthcare can be made pro bono on a case by case basis. This further strengthens our study that access to surgical and anaesthesia care is achievable even in a low-resource setting.
Outcomes of Pancreatic Cyst: Analysis of 90,958 Patients from Nationwide Inpatient Sample Database.
Kenji Okumura, MD, FICS, Resident, Department of Surgery, Westchester Medical Center and New York Medical College
Acute pancreatitis (AP) may be associated with serious complications. While the management of AP has improved in past decades, complications of pancreatic pseudocyst in major databases have not been studied. The purpose of this study was to investigate the nationwide outcome of hospitalization for pancreatic pseudocyst.
A retrospective review was conducted using data from the 2005 - 2014 National Inpatient Sample. Adults (age, ≥ 18 years) with a diagnosis of cyst/pseudocyst, as defined by ICD-9-CM codes, were included in analysis and adults with a diagnosis of pancreatic benign tumor or malignancy were excluded. Patients were divided into two groups: Early Phase (EP), 2005 - 2009, and Later Phase (LP), 2010 - 2014. Differences in outcomes including mortality, length of stay (LOS), and total cost of hospital care were assessed using multivariable regression models.
90,958 patients were admitted in the study period [39,249 (43%) EP, and 52,078 (57%) LP]. The mean age was younger in EP than that in LP (57.0 vs. 58.0, p<0.001). The mortality was significantly higher in EP than that in LP (2.3% vs. 1.3%, p<0.001). Compared to EP, LP showed that the total cost of care was significantly higher, however, LOS was significantly shorter ($58k vs. $67k, respectively, p<0.001; 9.8 vs. 8.3 days, respectively, p<0.001). After adjustment of demographics, LP showed better survival than EP (Odds Ratio 0.75; 95% Confidence Interval 0.67-0.83, p<0.001).
Our study showed the trend of the treatment of pancreatic pseudocyst. The outcome of pseudocyst had improved compared to before.
Stem Cell Therapies: Facts or Fiction?
Tobias Raabe, PhD, Research Assistant Professor of Genetics, Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania
Some new stem cell treatments are now being offered in major hospitals, such as the Mayo Clinic, and the Cleveland Clinic, although most such treatments are still done by smaller clinics, especially autologous treatments. This is not a coincidence as autologous stem cell treatments do not carry the risk of immunogenicity or tumor formation, do not require FDA approval, and there is a great need for treatment of intractable chronic diseases such as rheumatoid arthritis, Parkinsons disease, Alzheimers disease, and also acute diseases such as stroke and spinal cord injury.
Unfortunately there is often a wide gap between what is actually known about a given stem cell treatment and what some stem cell clinics advertise as ‘proven’ treatments.
I will review select stem cell treatments that are currently accepted among clinicians and the scientific community to be proven effective and safe, and compare them to other stem cell treatments that are much more based on hope and hype.
My 20 years of research on a wide variety of mouse and human stem cells including adult stem cells will guide me to select the most relevant examples while being mindful of the audience which mostly consists of surgeons.
During the past three years I have been collaborating with the Chief Transplant Surgeons Drs. Abraham Shaked and Kim Olthoff at the University of Pennsylvania to use human adult liver derived stem cells that form 3D organoids, for disease modeling. We have posted a preprint of the above topic at: https://www.biorxiv.org/content/10.1101/791467v1?rss=1. We also have submitted our work to Hepatology and were invited to resubmit with changes.
Most recently we have shown that organoids from cirrhotic liver patients are more permissive to SARS-CoV-2 infection than organoids from healthy human liver. This may in part explain why preexisting chronic liver disease is associated with increased risk for severe COVID-19 outcome.
Neurosurgical Thoracolumbar Wound Complicated by CSF Fistula Open for 29 Days, Achieved Definitive Sutureless Closure Within 12 Days After Implantation of Porcine Urinary Bladder Matrix
Jasmin Rahesh, MS, MBA, Medical Student, Texas Tech University School of Medicine
Porcine urinary bladder matrix (PUBM) is a xenograft used for surgical reinforcement and management of soft tissue wounds at high risk of poor wound healing. PUBM is an acellular matrix product derived from the inner lining of porcine urinary bladder that imparts constructive remodeling and possible anti-microbial properties. We present a challenging case of a thoracolumbar wound secondary to laminectomy complicated by a cerebral spinal fluid (CSF) fistula managed successfully with PUBM.
We present a case of a 23-year-old white female with achondroplasia who initially underwent laminectomy for a World Health Organization (WHO) grade I ependymoma extending from thoracic vertebrae 10 to sacral segment 1. After initial laminectomy the patient was returned to the operating room by neurosurgery 19 days after the index operation for a wound infection and cerebrospinal fluid fistula.
The patient was taken to the operating room for wound debridement and implantation of PUBM 3 days after surgical wound care consultation (29 days after initial wound issues were documented). Examination of the wound revealed areas of fat necrosis, fibrinous exudate, and dermal dehiscence. The resulting common defect measured 22 cm in length with maximum width of 4 cm, a depth of 2 cm cephalad, which progressed to a maximum depth of 6.5 cm near the caudad portion of the wound. There was clear fluid emanating from the sacral area. The porcine urinary bladder matrix was implanted first with 500 mg of MicroMatrix, followed by a three-layer Cytal 10 x 15 cm wound sheet. No sutures were used in the dermal closure, the skin edges were apposed with strips of vac drape tape only.
This case highlights definitive closure of a chronic 29-day old wound with a CSF fistula within 12 days of PUBM implantation and sutureless skin edge apposition. Presence of a CSF fistula increases the risk of meningitis, excludes the use of negative pressure wound therapy, often requires prolonged antibiotic therapy and hospitalization. Early intervention with this technique in future cases could potentially decrease length of stay and greatly reduce healthcare costs.
This case highlights the efficacy of PUBM with an active CSF fistula in a large chronic thoracolumbar surgical wound. This material accelerated wound healing and facilitated discharge 3 days after implantation.
Diffuse Idiopathic Skeletal Hyperostosis (DISH) and Acute Cervical Spinal Cord Injury: Is There a Need for Surgical Intervention?
Gazanfar Rahmathulla, MBBS (MD), Clinical Assistant Professor of Neurosurgery and Medical Director of Neurosurgery Trauma, University of Florida
Introduction: Diffuse idiopathic skeletal hyperostosis (DISH), is characterized by the ossification of the entheses (i.e., enthesopathy). It is a known clinical entity that is often asymptomatic. DISH reduces flexibility of the spine, predisposing patients to higher morbidity and mortality from trivial traumatic events. There is an increased risk of developing spinal cord injury and patients present with variable neurological findings.
Material & Methods: Literature review identifying 29 relevant articles to DISH and cervical spine fractures and spinal cord injuries. Majority of studies were case reports or retrospective case series comprising less than 10 patients with no definitive guidelines to enable decision making amongst surgeons for this group of elderly patients.
Results: We discuss our experience and relevant literature and outcomes, radiological findings of relevance and identifying and discussing risk to optimize outcomes. Paucity of evidence in regards to best practices results in surgeons having no criteria to direct medical versus surgical management. We present representative cases with DISH and as we see a greater number of ageing patients in our practice with DISH, we stress the need for an aggressive surgical management strategy.
Conclusion: As our patient population ages, we are seeing more acute cervical spine fractures in patients with DISH. These patients represent unique spinal injuries usually from low impact trauma. Surgical indications are largely based on SLIC score, surgeon’s preference and experience with all types of cervical spine fractures. Surgical intervention can result in good outcomes in carefully selected patients
Analyzing Disparities in Trauma Care: A Heavy Burden with Minimal Resource
Alexandra Reitz, MD, Resident Physician, Department of Surgery, Emory University
Purpose: To improve trauma systems, hospitals in low-middle income countries (LMICs) are compared to low resource settings in affluent countries. Utilizing implemented registries, a safety-net level one US trauma center (L1) was compared to a Bolivian tertiary referral center (TRC). The purpose of this study was to investigate hospital, patient, and system attributes that impact trauma care. We hypothesized that, despite resource limitations in both settings, contextual barriers as well as healthcare disparities exist between centers.
Methods: Our cohort consisted of patients presenting to the institutions with trauma-related injuries from 10/01/2015 to 12/01/2018 prospectively registered into the hospital databases. Demographics including age, mechanism, and pre-hospital transport were evaluated. Statistical methods included tests and two sample independent t-tests in SAS v9.4. These comparisons allowed for the analysis of similarities, differences, and recommendations for improvement.
Results: The L1 registry consisted of 14,371 patients with 3,830 patients included in TRC registry. 70% of patients (70.47% L1 vs. 70.16% TRC) were male. The average age of victims was 42.8 years at L1 compared to 38.6 years at TRC (p <.001). Regarding mechanism, 22.68% sustained penetrating injuries at L1 compared to 12.53% at LMIC while 77.29% had blunt injuries at L1 compared to 82.87% at TRC (p<.001). Average time from injury to hospital was 0.447 +/- 0.379 days at L1 compared to 1.054 +/- 5.650 days at TRC (p<.001). 85% of patients at L1 arrived by ground ambulance while 71.56% at TRC arrived by public or private transportation (p<.001).
Conclusion:Despite resource limitations in both settings, prehospital trauma systems differ between institutions as evident by disparities in time to presentation and mode of transportation. Delays to trauma care have been linked to worse patient outcomes. Adapting existing prehospital system models such as those used in US L1 trauma centers could potentially enhance coordination and improve patient care globally.
Colon Cancer Care in the Rural Community: Are We Good Enough?
Michael Sarap, MD, Clinical Instructor, Department of Surgery, Wright State University Boonshoft College of Medicine, Dayton Ohio; Outgoing Chair, American College of Surgeons Advisory Council for Rural Surgery
Colon cancer is the second leading cause of cancer death in the United States with over 150,000 new cases and nearly 60,000 deaths per year. Americans with colon cancer receive care in a variety of settings and from a variety of specialists. Recent studies have focused on disparities of cancer diagnosis and cancer care related to location, socioeconomic levels, racial and ethnic groups, availability of local resources and expertise and the inability to seek care at remote cancer centers.
The critical components of high quality medical care were defined by the Institute of Medicine many years ago and the recent addition of cost analysis helps to define the actual value of the care delivered to a population. Academic and lay articles suggest that cancer care in small facilities is less optimal than care provided in larger tetiary and academic centers. Much of this disparity relates to the inability of smaller facilities to adequately document their care and their results and benchmark it to other centers. Smaller centers participating in the American College of Surgeons Commisssion on Cancer (CoC) Quality Programs have proven that high quality cancer care can and is being provided in local settings and that the care can be significantly less costly and of high value. Other small and remote centers, even if they do not have the resources to become fully accredited, can use the readily available CoC tools and standards to document and benchmark their results to other centers. Use of information from quality programs can elevate the care of colon cancer patients across the spectrum of clinical settings. The presentation highlights an example of a high quality colon cancer screening and treatment program in a rual setting.
Addressing the Shortfalls of Current General Surgical Training for Rural Surgery Practices
Brian Schneider, MD, Associate Professor of Surgery, Texas Tech University Health Science Center
The needs of many rural general surgery practices are not being met by current general surgery residency training. Available resources, need to perform a wide range of procedures, and availability of expertise all contribute to differences in rural practices. These differences are not well-addressed at many surgical training programs. However, some training programs are beginning to address these needs in a variety of ways. This presentation will review specific areas that need to be addressed to better prepare graduates for rural general surgery practice. It will also review what is being done currently in various programs to fulfill these needs. Lastly, challenges to meeting needs of rural general surgery will be addressed, including a review of current proposals and suggestions for moving forward. Audience members attending the presentation will be aware of specific rural general surgery needs as they differ from a more traditional general surgery practice, how these needs are being addressed currently, and how still-existing shortcomings to rural surgery needs may be addressed. The presentation will help participants provide guidance and resources to those seeking a rural surgery practice. The presentation will also illuminate areas of training for rural general surgery that still need to be addressed, with the hope that this will better prepare future graduates for the unique practice challenges they face.
Improving Communication Between Critical Access Hospitals and Regional Trauma Centers
Brian Schneider, MD, Associate Professor of Surgery, Texas Tech University Health Science Center
In many areas of the country, initial access to trauma care is provided by smaller critical access hospitals. These facilities face significant problems related to obtaining appropriate and timely care for trauma patients. These problems include proper assessments, recognition of problems that require a higher level of care, communicating findings with regional trauma centers, coordinating transport for patients, and implementing meaningful quality improvement programs. These issues have been exacerbated during the Covid-19 pandemic, when many hospitals are at capacity. While some programs have made great strides in improving trauma care, many improvements can still be made. This presentation seeks to review current practice as it relates to the relationship between critical access hospitals and regional trauma centers. Research related to regional trauma care coordination will be reviewed. Specific areas will be identified that could improve timely decision-making and care. Further discussion will address possible methods of improvement of communication between these smaller hospitals and trauma programs. Participants will better understand the challenges faced by critical access hospitals and the centers to which they refer patients. They will also become aware of new innovations for improving these relationships, as well as areas that still need to be addressed. Participants will be able to apply these methods in order to improve trauma care in their own regions.
A Closed Loop Clinical Audit on Surgical Safety Checklist
Akatya Vidushi Sinha, MBBS, Medical Student,
MGM Medical College
Introduction : The WHO Surgical Safety Checklist aims to decrease errors ,adverse events, and thus increase teamwork and communication in surgery. The checklist ensures the safety of patients during surgery. The aim is to complete an audit on the level of compliance to the WHO surgical safety checklist in surgical operating theatres at MGM Hospital.
Method : The data was collected retrospectively , where in the first part of the study only 20 general surgery case files were studied to cross-check its compliance with the WHO Surgical safety checklist. The place of audit was at the MGM Operation theatres and was conducted for a period of 1 month during November 2020. Interventions were carried out by a series of meetings and discussions with the medical and the nursing staff. Results were re-audited after 2 weeks in all surgical departments to cross-check and compare the compliance in other allied surgical departments as well.
Results : In the first part of the study , 60% of the compliance was reported in all three stages of the checklist for General surgeries. After the re-audit , the compliance observed in General surgery , Orthopedic , ENT , CVTS ,Urology , Neurosurgery were 90% , 90% , 90% , 90% ,95% and 90% respectively.
Discussion : Compliance is seen to be greater in major surgeries than in minor surgeries. The compliance with all items in the checklist and active participation by all medical and nursing staff is mandatory for successful implementation of the Surgical safety checklist.
Case Report of Azygous Vein Injury from Blunt Force Trauma: Surgical Management and Literature Review
Annie Snitman, Medical Student, Texas Tech University School of Medicine
Azygous vein injury from blunt chest trauma is an uncommon injury with little data on its management. As such, we describe an unusual case and management of a 44 year old female involved in a highway speed motor vehicle accident. She sustained multiple injuries; we will be focusing on the near-complete circumferential transection of the azygous vein. Included is a thorough literature review and discussion of operative management of this rare injury.
Management of Lower Extremity Tibial Arterial Disease: Where Are We and Where Are We Heading?
Ehab Sorial, MD, FICS, Associate Professor of Surgery
Los Gatos, CA
Tibial disease is a challenging problem in the vascular surgery discipline especially in patients with end stage renal disease and in diabetics.
Multiple modalities for therapy have been used in the management of these patients, including open and Endovascular surgery.
We describe current therapy modalities, changes that have been implemented in our practice and our future vision of tibial disease management.
Surgical Training Programs Across Rural Africa Better Prepare Surgeons for Humanitarian Disasters than US-Based Training
Michael Traynor, MD, MPH, Resident, Mayo Clinic
Purpose: There is great need for more surgeons to provide quality care for patients impacted by humanitarian disasters and for the millions of people in rural Africa who lack access. However, prior literature suggests surgeons trained in resource-rich environments, such as those from the United States in Accreditation Council for Graduate Medical Education (ACGME) programs, are ill-equipped to navigate challenges in humanitarian crises.2,3 Faith-based hospitals have been training general surgeons locally in rural and sub-Saharan Africa for 25 years1. We aimed to investigate whether surgeons training in sub-Saharan Africa were more specifically equipped than those in resource rich countries to care for populations impacted by humanitarian disasters.
Methods: Operative procedures were categorized and validated from a cohort of twenty Pan-African Association of Christian Surgeons (PAACS) graduates from five training programs in four countries. Public reports of ACGME experience were utilized. Comparisons were made to the reported experience of Médecins Sans Frontières (MSF) in humanitarian disasters2.
Results: Humanitarian disasters require broad surgical experience, notably essential general surgery, orthopedics, urology, and obstetrics and gynecology. For such procedures, PAACS trainees performed more major cases than ACGME graduates in the categories of gynecology & obstetrics (p=0.0001), orthopedics (p=0.0003), operative trauma (p=0.0003), and urology (p=0.0001). While ACGME graduates performed more cases than PAACS graduates for abdomen (p=0.002), breast (p=0.04), thoracic (p=0.0001), laparoscopy (p=0.0001), and vascular categories (p=0.0002), these were not as relevant to the experience of essential surgery required in humanitarian disasters.
Conclusion: Compared to ACGME residents, PAACS trainees perform and acquire competence in more operations that are relevant to the experience of MSF in humanitarian disasters. Training surgeons in low-resource settings who are well-equipped to address humanitarian disasters should be a priority.
The Role of 3D Printing in Hepatobiliary Surgery: Challenges and Opportunities
Georgios Tsoulfas, MD, PhD, FICS, Associate Professor of Surgery, Department of Transplantation Surgery, Aristotle University
The advent of 3D printing represents an excellent example of how technological advancements can potentially change surgical practice. In the short time period since the first applications, it has been possible to see the effect that it has had and continues to have allowing surgeons to simulate the operation planned, improving the education of surgical trainees and helping patients and their families better understand the upcoming surgery and the risks involved. At the Aristotle University School of Medicine, there is a program involving 3D Printing of Hepatobiliary primary and metastatic tumors.
Based on the patient's multiphasic CT scan, and with a program created by the Polytechnic School of the University, the data is electronically transferred to a 3D printer, where a model of the patient's liver with the lesion is printed. This is subsequently evaluated for a) obtaining informed consent, b) student, and resident training and c) effect on surgical efficiency (OR time, estimated blood loss,complications etc).
A Novel Modification of the Endorectal Advancement Flap for Complex Anal Fistulas: Surgical Technique and Outcomes
Rebekah Wood, MD, General Surgery Resident
Sioux Falls, SD
Fistula-in-ano is a common problem encountered by surgeons which can be classified as either simple or complex. Complex fistulas (CF) cause higher morbidity and are much more challenging to treat. Although numerous treatment options are available for CF, none are proven to be 100% effective. The endorectal advancement flap (EAF) procedure was developed as an alternative to conventional surgical treatments for CF. Herein, we describe a novel modification of the EAF procedure along with surgical outcomes in terms of recurrence, fecal incontinence and factors associated with flap failure.
A retrospective review of patients with CF who underwent EAF between 2004-2019 was done.
The conventional EAF procedure was modified by performing transverse imbrication of the internal sphincter over the internal fistula opening. The incidence of post-operative recurrence and fecal incontinence were calculated from chart documentation at the last available date of followup.
With a median follow-up of 6.6 months (range: 3.3-24 months), 99 patients with CFs underwent a modified EAF. Of these, 93% (92/99) had a successful procedure, 7% (7/99) experienced recurrence and 1% (1/99) experienced new-onset fecal incontinence.
Systemic steroid or immunomodulatory therapy use (p=0.001) and patients with diagnosedinflammatory bowel disease (p<0.0001) were associated with increased rate of recurrence.
EAF with transverse imbrication of the internal opening using interrupted, absorbable suture is an effective technique to treat complex or recurrent anal fistulas. It is associated with a low risk of recurrence (7%) and fecal incontinence (1%) and a valid treatment option for CFs.