Opening Session: Global Surgery 2022 and Featured Lectures

Quality of Life of Patients After Colorectal Cancer Surgery in Soba University Hospital, Sudan.

Mohammed Adam, MBBS, MHPE, Teaching Assistant, University of Khartoum, Khartoum, Sudan

Background: Colorectal surgery is reported to have a significant effect on patients, both physically and psychologically. On the other hand, infections are found to be major risk factors in Sudan and Sub-Saharan Africa such as intestinal Schistosoma colitis, especially those presenting with sigmoid colonic adenocarcinoma.

Aim of the study: To assess the quality for patients after colorectal cancer surgery and the effect of the stoma and on their life.

Methods: A descriptive cross-sectional hospital-based study at Soba University Hospital was done. A sample of 92 patients with colorectal cancer who had undergone colorectal surgery was Fully covered and interviewed using the SF-36 Quality of life standard questionnaire.

Results: The sample size was 72. The mean age was 51 years. 79% were married, 70% were working, with free business being the most encountered occupation (36.1%). However, only 48.6% were still employed at the time of surgery. Regarding the mental health component, there was a significant difference in social functioning domain mean scores between patients who were employed and patients who were unemployed. Where the physical functioning and role physical domains were found to differ significantly with the different educational attainment of patients. Patients who did not undergo radiation therapy reported higher mean scores of role limitation due to physical problems, compared to patients who received radiation therapy.

Conclusion: The quality of life was affected negatively in terms of the level of pain and presence of colostomy with sexual activity affection but the other parameters were not strongly affected.

Building Collaborative Partnerships with an Eye Towards Equity

Barnabas Alayande, MBBS, PgDTh, MBA, FACS, West African College of Surgeons, Senior Registrar

Global Surgery Fellow, University of Global Health Equity, Kigali, Rwanda

The problem / surgical intervention the presentation covers:

While there has been substantial growth and progress in the growth of global surgery as a field and the recognition of partnerships as an effective mechanism - this is a field with colonial and racist roots. White privilege and white supremacy are still present today. Dismantling this system is necessary for justice and also to maximize the positive impact of global health work for vulnerable patients who need care.

What the learner will be able to accomplish after the presentation:

The learner should be able to identify the framework for equitable partnerships and describe an ideal partnership.

Identify specific practices in global surgery that reflect poor collaborations, generally, but particularly with partners in low-income settings.

Reflect on personal professional and institutional relationships, self-assess, and identify the shortfalls in equity.

Come to terms with pervasive structural racism and power imbalances, and mitigate the likelihood of permitting these systems.

Be able to initiate difficult discussions (constructively confront), ask forgiveness (humble vulnerability), and change practice (sensitive accompaniment).

How the audience will benefit from the presentation:

This will help practically improve partnerships and the audience will learn from reflections on a unique framework for identifying collaborative partnerships. Ultimately, this will lead to best practices in care for vulnerable patients and populations.

Why the audience needs to know this information:

It is easy to remain oblivious of, or even ignore, structural imbalances in partnerships. True win-win equitable partnerships can only be achieved by deliberate reflection, training, and accountability.

WSF Honduras is now a Reality: It took 20 years but it is worth the effort!

Domingo T Alvear, MD, Chairman, World Surgical Foundation, Mechanicsburg, PA

Honduras is in Central America and has a population of over 10 million. It is considered a low income country by the World Bank with $600.00 per capita income per year. 66% are living under poverty line. WSF was invited in 1980 because they needed a Pediatric Surgeon with US Training to come and introduce different techniques in treating patients with Hirschsprung's Disease and Imperforate Anus. Since then they requested many more specialist to come including Plastic Surgeons to care for Microstia and skin tumors, General Surgeons to train them for Laparoscopy, Vascular Surgeons for A/V shunts and Neurosurgeons for Hydrocephalus. Severe chronic cholecystitis need our expertise. Pediatric Surgery has made a large dent in Colorectal Malformation and Colon Interposition to replace esophagus. Hand surgery is also needed.

WSF Honduras have volunteer surgeons, anesthesiologists and nurses who are willing to perform surgical missions all year round. When the Pandemic is over we plan to resume our surgical mission twice a year.

Conclusion : WSF Honduras is now a reality because our local counterparts agree with our mission and goals to help reduce the surgical burden of disease. We have the support of the locals and the government.

Pediatric Injuries During Wartime Require Efforts to Support Pediatric Surgical Trainings

Kathryn Campos, BA, MSc, Independent/Academic Student Researcher, University of Washington School of Medicine Dept. of Surgery and Harborview Injury Prevention Program, Seattle, WA

Pediatric Injuries During Wartime Require Strengthened Efforts to Support Pediatric Surgical Training Activities Among Local Providers, A Systemic Review

Background: Pediatric injuries account for a notable portion of casualties in modern conflict. Pediatric medical care is often disrupted by the impact of conflict and insecurity during wartime however the implementation and accessibility of relevant pediatric surgical skill training for local clinicians residing in conflict settings have not been specifically investigated.

Methods: We conducted a systemic review of databases including PubMed, Embase and Google Scholar to identify records that described pediatric surgical care trainings for local clinicians during wartime.

Results: A total of 1,192 records. 7 eligible reports were selected for review. Each of the reports described pediatric injuries, evaluation of patient outcomes, access to pediatric surgical care and pediatric surgery training in conflict settings. While general accounts of pediatric injury types, pediatric surgical interventions and patient outcomes were discussed few records provided quantitative data or qualitative accounts assessing the implementation of pediatric surgical care trainings among local clinicians residing in conflict.

Conclusions: Currently few reports describing pediatric surgical training activities in conflict settings are available. Efforts to improve access to pediatric surgical skill training activities for local clinicians residing within conflict settings is imperative in order to reduce pediatric mortality and improve patient outcomes during wartime.

Keywords: Pediatric Surgery AND Pediatric Injuries AND Armed Conflict AND Pediatric Surgery Access AND Pediatric Surgery Training

The Global Evolution of Kidney Paired Donation for Patients with ESRD

Matthew Cooper, MD, Professor of Surgery, Georgetown University School of Medicine; Director, Kidney and Pancreas Transplantation; Director, Transplant Quality, Medstar Georgetown Transplant Institute, Washington, DC

Kidney Transplantation is the optimal intervention for individuals with CKD and ESRD providing an increased life span and improved overall quality of life. As the data supporting transplantation continue to grow and reach more individuals the waiting list has grown to over 100,000 patients with an expected waiting time averaging 5-8 years depending upon blood type and geography. Conversely, living donor transplantation has proven to result in much shorter waiting times and increased graft and patient survival compared to matched deceased donors. With modern day immunosuppression, HLA-matching is no longer a restriction for living kidney donation yet incompatibilities of both of blood type and HLA exist. The emergence of Kidney Paired Donation (KPD) has been revolutionary in providing living donor opportunities to many recipients around the world with volumes over 1300 cases/year in the US alone. Participants will be made aware of the initial efforts that spawned KPD two decades ago, the volumes of KPD transplants around the world, and many of the new and excited recent advances in KPD including Advanced and Family Donation, and paired molecular matching and the Kidney for Life Program via the National Kidney Registry.

InciSioN; The Future of The Operating Room

Katayoun Madani, MS, MD, Global Surgery Fellow, Sadanah Trauma and Surgical Initiative, Chicago, Paradise Valley, AZ

In 2015 Lancet Commission on Global Surgery report indicated over five billion people across the globe lack access to safe, timely and affordable surgical care when needed, a significant gap in health care delivery which has further widened over the course of the COVID-19 pandemic. InciSioN is a network of over 5000 students, trainees, and early career physicians who are passionate about creating just access to surgical healthcare. In addition to an international team working on a global scale, on a local level InciSioN has a network of over 50 established national working groups spanning all World Health Organization regions.

InciSioN’s work rests on three pillars of advocacy, education, and research in global surgery. The organization initiated Global Surgery Day in 2015 and has advocated for neglected surgical patients and strengthening of surgical healthcare systems from local campaigns, to targeted events alongside the United Nations General Assembly. With the aim of training the future generation of global surgery, InciSioN has developed internal capacity building workshops, compiled educational resources and is currently in the process of developing an e-learning course. InciSioN contributed to collection of surgical indicators for World Data Indicators in 2016, and following the launch of its research proposal program in 2017 created a robust research infrastructure leading to multiple internal and external collaborations. Combining all three pillars, InciSioN hosts the largest global surgery focused conference in the world known as InciSioN Global Surgery Symposium (IGSS). The fourth edition of this conference, IGSS2021, was attended by over 1300 people from 97 countries, featured five days of panel discussions, a full scientific program, and seven workshops bringing together over 100 international expert speakers.

This presentation will shine a light on the impact of InciSioN over its five year history and the role of students and trainees in global surgery. It will provide information on how to collaborate with InciSioN and further highlight the importance of supporting the development of the future of the operating room.

Development of Czech Medicine and Surgery and its Current Status

Karel Novák, MD, PhD, Professor of Surgery (pensioner), Charles University Prague; Medical Faculty Pilsen,

Palacky University Olomouc; West Bohemian University, Pilsen; Kliniken Nordoberpfalz, Weiden, Germany (Univ. Regensburg), Rokycany, Czech Republic

The presentation is a survey of the historic development of Czech medicine and surgery since Middle ages to 21st century. There are presented important persons and their discoveries and priorities. Czech republic is a small country, 10.7 milion inhabitans only, but its additon to world medicine and surgery is large.

The activities of Czech section of ICS are large, starting through Prof. Arnold Jirýsek, one from five co-founders of the ICS in Geneve in 1935, the first World president of ICS 1936 – 1938 and finishing in activities after anticommunistic revolution in 1989, e.g. two European cengresses, one World kongres in 2015 in Prague and in Pilsen and 27 Czech- Japan surgical symposiums in the period 2001 – 2018.

Building Collaborative Partnerships with an Eye Towards Equity

Robert Riviello, MD, MPH, Associate Professor, Harvard Medical School, Boston Kletjian Distinguished Chair of Global Surgery, Brigham and Women's Hospital, Boston, Boston, MA

The learner should be able to identify the framework for equitable partnerships and describe an ideal partnership. Identify specific practices in global surgery that reflect poor collaborations, generally, but particularly with partners in low-income settings. Reflect on personal professional and institutional relationships, self-assess, and identify the shortfalls in equity. Come to terms with pervasive structural racism and power imbalances, and mitigate the likelihood of permitting these systems. Be able to initiate difficult discussions (constructively confront), ask forgiveness (humble vulnerability), and change practice (sensitive accompaniment).

Leadership in Surgery: Lessons Learnt (and still learning)

Georgios Tsoulfas, MD, PhD, Professor of Transplantation Surgery, Chief Department of Transplantation Surgery, Aristotle University School of Medicine, Thessaloniki, Greece

The goal of this presentation is to describe what is leadership, types of leadership, characteristics and shaping of leadership and then to explore the role of leadership in surgery. Additionally, lessons learnt from personal experience will be presented as an example of things to do and not to do. The goal of this presentation is to help the audience understand the elements of leadership, as well as strong relationship with surgical life and practice.

Transplantation Surgery: Global Perspectives

Abdominal Transplant Surgery Fellowship: A pot-pourri of domestic and international trainees

Megan Adams, MD, Assistant Professor of Surgery, University of Colorado Hospital, Aurora, CO

Discussion of how the fellowship training of transplant surgeons has changed over the years

Transplant Oncology: An Evolving International Field

Kristopher Croome, MD, MS, Professor of Surgery, Mayo Clinic Florida, Jacksonville, FL

Presentation will cover transplant as an option for patients with unresectable colorectal liver metastases, intrahepatic cholangiocarcinoma, hilar cholangiocarcinoma and down-staged HCC.

-These patients were historically treated palliatively if surgical resection was not an option. transplant has emerged as a curative option for selected patients with These cancers.

Donation After Circulatory Death: The International Transplant Community Leaving the USA Behind

Trevor Nydam, MD, Associate Professor of Surgery, University of Colorado School of Medicine, Aurora, CO

Transplantation worldwide continues to struggle from profound donor shortages. Donation after cardiac death (DCD) provides some relief but efforts to address the associated allograft injury and early dysfunction are needed. We will review the ongoing efforts to increase access to DCD donors and the recent methods that promise to improve outcomes. The transplant centers in Europe continue to lead the way in advancing allograft preservation and viability assessment.

Is Xenotransplantation the Future of Organ Transplantation?

Reza Saidi, MD, Associate Professor of Surgery, SUNY Upstate Medical University, Manlius, NY

The increasing life expectancy of humans has led to a growing numbers of patients with chronic diseases and end-stage organ failure. Transplantation is an effective approach for the treatment of end-stage organ failure; however, the imbalance between organ supply and the demand for human organs is a bottleneck for clinical transplantation. Therefore, xenotransplantation might be a promising alternative approach to bridge the gap between the supply and demand of organs, tissues, and cells; however, immunological barriers are limiting factors in clinical xenotransplantation. Thanks to advances in gene-editing tools and immunosuppressive therapy as well as the prolonged xenograft survival time in pig-to-non-human primate models, clinical xenotransplantation has become more viable. In this review, we focus on the evolution and current status of xenotransplantation research, including our current understanding of the immunological mechanisms involved in xenograft rejection, genetically modified pigs used for xenotransplantation, and progress that has been made in developing pig-to-pig-to-non-human primate models. Three main types of rejection can occur after xenotransplantation, which we discuss in detail: (1) hyperacute xenograft rejection, (2) acute humoral xenograft rejection, and (3) acute cellular rejection. Furthermore, in studies on immunological rejection, genetically modified pigs have been generated to bridge cross-species molecular incompatibilities; in the last decade, most advances made in the field of xenotransplantation have resulted from the production of genetically engineered pigs; accordingly, we summarize the genetically modified pigs that are currently available for xenotransplantation. Next, we summarize the longest survival time of solid organs in preclinical models in recent years, including heart, liver, kidney, and lung xenotransplantation. Overall, we conclude that recent achievements and the accumulation of experience in xenotransplantation mean that the first-in-human clinical trial could be possible in the near future. Furthermore, we hope that xenotransplantation and various approaches will be able to collectively solve the problem of human organ shortage.

The Role of Technology in Transplantation Surgery

Georgios Tsoulfas, MD, PhD, Professor of Transplantation Surgery, Chief Department of Transplantation Surgery, Aristotle University School of Medicine, Thessaloniki, Greece

The role of technology in the transplantation surgery will be presented, including the use of 3D-printing, augmented reality and artificial technology. The potential applications of these technologies will be discussed through specific examples, while at the same time they will be evaluated in terms of advantages and disadvantages. Finally, the role of surgical education, so that surgeons are well positioned to understand and use this technology, and potential applications for global surgery will be discussed.

Advances in Neurological and Orthopaedic Surgery

Outpatient Anterior Total Hip Replacement

Eric Cohen, MD, Assistant Professor of Orthopedic Surgery, Brown University, East Providence, RI

There is an increased interest in outpatient or same-day anterior total hip arthroplasty. This presentation will discuss the preoperative, intraoperative and postoperative protocols to perform successful outpatient anterior total hip arthroplasty. This will include patient selection, preoperative education, anesthesia and medications, surgical techniques , and postoperative home care and followup. The outpatient arthroplasty literature will also be reviewed and discussed.

Endoscopic Cubital Tunnel Release

Manuel F. DaSilva, MD, Associate Professor, Director Medical Student Education, Department of Orthopedic Surgery, Rhode Island Hospital, Alpert Medical School at Brown University, East Providence, RI

The problem / surgical intervention the presentation covers - Cubital Tunnel syndrome is the 2nd most common nerve compression condition in the upper extremity. This presentation will provide an historical perspective from 90 years ago to cutting edge treatment options used today.

Why the audience needs to know this information - Any surgeon that sees patients with peripheral nerve problems should be knowledgeable of all treatment options including minimally invasive techniques.

What the learner will be able to accomplish after the presentation - at the very least learner will be aware of minimally invasive options for the treatment of cubital tunnel syndrome and if more knowledge is needed, learner will know where to find more information

How the audience will benefit from the presentation - Nearly all surgical problems have or will benefit from the development and integration of Minimally invasive techniques. At the very least, the learner should be aware of the different possibilities of treatment.

Better, Stronger, Faster: Intraoperative Methodological Computerized Surgeon Assessment

Saikiran Murthy, DO, MA, Assistant Professor of Neurosurgery and Orthopedics, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY

There are several mechanisms utilized by health systems to evaluate and enhance operating room efficiency. However, there has not been a widely accepted and uniform assessment program that can be tailored to analyzing intraoperative surgical efficiency across a wide range of surgical specialties.

We have developed and applied a computer based program that interfaces with the surgeon during an operation. The operation is divided into a series of sequential steps or components. Each component is reviewed in detail and uploaded to the program prior to surgery. During surgery, every step is timed until effective completion. An instructional module interfaces with the surgeon during each step.

This mechanism utilizes time as both a quantitative and qualitative metric. It allows for structured and methodological preparation as well rehearsal of surgery. It has been used as an intraoperative tool for neurosurgical resident education and real-time intraoperative skills training with close oversight. It can be used as a method for continued surgical refinement for all levels of surgical experience as well as a means of maximizing surgical effectiveness and operating room efficiency.

Advances in Endoscopic Spine Surgery

Albert Telfeian, MD, PhD, Professor and Vice Chair Quality Assurance, Department of Neurosurgery; Director, Center for Minimally Invasive Endoscopic Spine Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI

Endoscopic spine surgery is an awake, minimally invasive surgical option for treating many spine pathologies.

The learner will be able to describe novel surgical options for diverse spine pathology after the presentation.

The audience will benefit from the presentation by increasing awareness of awake spine surgical options for patients

Honors Luncheon

Physician Financial Wellness: Understanding How Financial Advisors Work & Conflicts to Avoid

Andrew Taylor, CFP, Wealth Advisor/Partner, OJM Group, LLC, Cincinnati, OH

In numerous studies, the #1 financial goal for physicians and surgeons of all specialties is reaching a comfortable retirement on that doctor's terms. A physician's perception that they are on track for such a goal can be a significant element of a doctors' mental wellness. For most doctors, in order to reach this, and other financial goals (like paying for children's education), they will employ a financial advisor.

This lecture will shed light on the area - allowing attendees to learn about the various business models financial advisors may follow. Further, it will dive into the curcial distinction between advisor held to the fiduciary standard and one held to a suitability standard. The goal of the talk is to educate surgeons so they can make better decisions when employing a financial professional in their quest to reach financial wellness.

Despite this, few physicians truly understand how financial professionals are credentialed, make money, owe professional duties and more. Many doctors can even accurately identify an advisor who has a fiduciary duty to them, versus one who does not. This is often by design, as financial firms have a history of using opaque terminology and complex legal discolsures.

Rural Surgery: A Global View

Surely the appendicitis did not go away! Acute appendicitis during the Covid lockdown. A rural hospital perspective and discussion of comparable effects in Europe and Asia.

Saptarshi Biswas, MD, Attending Surgeon, Department of General Surgery, Trauma and Surgical Critical Care, Associate Program Director, General Surgery Residency, Grand Strand Medical Center, Myrtle Beach, SC

The coronavirus disease 2019(COVID-19) rapidly spread across the globe and eventually was declared global public health emergency by the WHO on January 30th2020 were ordered. The initiation of stay at home mandates and other strategies were ordered to prevent the increased transmission, health system overload, and increased mortality. However there were concerns that patients were not going to seek necessary health care because of lockdown mandates.

To examine the effect of COVID-19 on hospital admissions unrelated to SARS-CoV-2 virus, the volume of ED presentations and hospital admissions for acute appendicitis were evaluated. Appendicitis was chosen as it is the commonest ED presentation that is managed by general surgeons representing 4.5% of all cases of abdominal pain resulting in over 250,000 yearly appendectomies in the United States .Acute appendicitis is believed to be caused by obstruction of the appendicular lumen, either by fecalith or lymphoid hyperplasia, leading to eventual ischemia and bacterial overgrowth. The standard of care for decades has been appendectomy, with newer literature suggesting the safety of antibiotics for uncomplicated acute appendicitis. As appendicitis is unlikely to improve without medical and/or surgical intervention, question arises whether covid-19 and its effects on our social norms and behavior might impact the disease process and the incidence rate of acute appendicitis. We demonstrated a significant decrease in overall appendicitis presentations to our community hospital during april of the early phase of the COVID-19. Potential explanations include: an overall decrease in incidence of appendicitis related to adjustments in social behaviors associated with COVID -19; patients utilized primary care physicians/ urgent care/telehealth services to receive antibiotics therapy for presumed appendicitis.; appendicitis was over treated or over diagnosed prior to COVID-19 emergence in the US or patients misdiagnosed with COVID-19 associated gastrointestinal symptoms. To attempt to answer these querries was beyond the capabilities of this research.

Our analysis showed that uninsured patients represented a small portion of the total acute appendicitis admissions. We present a retrospective cohort study on prospectively collected emergency department data of acute appendicitis patients admitted to an ACS verified level 1 Rural trauma center in south Carolina inclusive years 2018-2020 between the particular timeframes march 15-22. Three years of data were collected with groupings according to patient characteristics (age, race, gender) and primary outcomes (acute appendicitis).Continuous variables will be compared using the Wilcoxon signed rank test, whereas categorical variables will be compared using Pearsonâ€™s chi-square test of proportion, as appropriate in SPSS software. We also site similar impact of the COVID-19 pandemic on volume, management of acute appendicitis in different parts of Europe and Asia during the similar time frame.

The Value of Global Surgery and Rural Surgery Training in Urban Academic Centers

Edie Chan, MD, Associate Professor of Surgery, Rush University Medical Center, Chicago, Chicago, IL

This presentation covers how both global surgical and rural surgical training benefits the entire surgical landscape for surgeons. This affects the surgical audience by identifying how this additional training creates more well rounded surgeons and leads to future opportunities to help build partnerships with academic centers to enhance this training. The will be able to describe how global surgery and rural surgery training prepares surgeons for their future careers regardless if it's in an urban, community or rural setting. The audience will benefit from learning how these additional forms of training will create a stronger surgical community.

Surgical Philanthropy - How to Operate

Ravi Kothuru, MD, MBA, Residency Program Director, Chief, Division of Thoracic Surgery, Associate Chairman Department of Surgery; The Brookdale University Hospital and Medical Center, Brooklyn, NY

How to start a surgical philanthropic organization. I cofounded Operational International after participating in surgical missions during my residency. We faced many problems in organizing the missions thru other non profit organizations due to lack of finances, control over time, place of mission etc. This led to the formation of Operation International and the structure we used in its set-up to encourage young surgeons to participate early on in their careers. I would share the details of this organizational structure that is amenable for residents and young faculty to be more involved and form their own organizations. The need for global surgery far exceeds the supply and we should do everything in our power to increase and facilitate the participation of our residents and graduates in this endeavor.

General Plenary Session

Management of Abdominal Wall Hernias

Anthony N. Dardano, DO, Chief of Plastic Surgery, Trauma Associate Professor of Surgery, Florida Atlantic University, Boca Raton, FL

Presentation will give review of abdominal wall hernias and defects as well as mesh product updates, and tips for optimizing outcomes utilizing Botox, SPY imaging for tissue perfusion and ciNPWT for dressings

Emerging Personalized Treatments for Liver Cancer

Tobias Raabe, PhD, Research Assistant Professor, Director, Translational Medicine Laboratory University of Pennsylvania, Philadelphia, PA

This presentation will review emerging strategies to prevent both the emergence and the recurrence of liver tumors after surgical removal. The talk will emphasize the increasing importance of collaboration between surgeons, stem cell biologists and hepatologists for best patient outcome and will highlight both the chances and potential pitfalls of the emerging treatments.

I will compare the pros and cons of liquid biopsy vs direct tumor biopsy. I will briefly describe the emerging techniques of genomics, transcriptomics and tumor organoid growth/ personalized drug screening, using representative examples. Importantly, these novel techniques also have many additional potential applications in medicine beyond the liver and thus may be of general interest to the audience.

My presentation will include examples of transcriptomics of patient liver derived stem cells my lab has been working with, although this will only be about 1/4th of the talk - mostly it will be a review.

Because the described novel technologies are not only relevant for liver surgery but for surgery in general, I believe the talk would greatly benefit from an allotted time of 15min.

The incidence of liver cancer is rising worldwide and no satisfactory treatments are available, in part because liver tumors are heterogenous in nature, making personalized treatments necessary. Emerging personalized treatments include the use of both liquid biopsies and tumor biopsies. The latter allow not only tumor genome and transcriptome profiling to identify potential patient specific drug targets but also allow growing the tumor in the lab for personalized drug screening.

Central Venous Occlusion's Impact on Patients on Hemodialysis

Ehab Sorial, MD, Associate Professor of Surgery, Stanford University, Los Gatos, CA

Central venous occlusions in hemodialysis patients have an impact on patients' lifestyle. These issues impact their need for long term upper extremity hemodialysis access. Due to multiple IJ catheterizations central venous occlusions are common.

The listeners will learn about this new available technology and how it works.

They will learn about our institution's results for the past 3 years.

Also the listeners will obtain knowledge about the impact of this morbidity on patient's lifestyle and longevity

A novel technique of right sided central venous canalization is now available using what we call The Surfacer device.

Once the right central venous system gets recanalized, we are able to advance a HeRO graft and establish a long term hemodialysis access in the right upper extremity.

Trauma and Critical Care Surgery in 2022

Trauma Care in a Tertiary Care Hospital in India

Ahmad Abdul Hai, MS, Former Professor and HoD Surgery, Patna Medical College, Director General Surgery, Paras HMRI Hospital, Bailey Road, Patna, Bihar, India

Trauma is becoming the leading cause of death worldwide and sadly 20% of these deaths are occurring in India. Our paper gives a brief glimpse of how we are managing these cases at our tertiary care super speciality hospital in northern India. It is however by no means representative of trauma care being given throughout the country. Being a private hospital only the financially privileged few (2-3%) can avail of these facilities. Although many hospitals exist we are the only comprehensive trauma care facility in the private sector in the entire state with population of 127 million (Bihar census). During the years 2016 to 2020 our total hospital admission was 79834 of these the number of severe trauma was approx. 7600 cases (9.52%). Breakdown of the trauma cases reveals that Poly-trauma formed the largest group followed by isolated orthotrauma, neurotrauma, general surgical trauma (abdominal and uro), plastic trauma, gunshot wounds, and burns (electrical). Road traffic accidents (RTA) was the commonest cause, others being fall from height, violence and physical assault, firearm injuries, stab injuries, assault and electrocution. Of these cases approx. 35% required ICU care and ventilatory support. The mean age of patients was 34.54* years and overall mortality was approximately 30%*. Males accounted for 77% of the patients. The point of care investigations included CBC, KFT, Blood Gas evaluation [Sr. Lactate, Base deficit, SOB Pack (BNP)], X-ray’s, CT, MRI, and ECG. RTPCR was included only in 2020. To improve the survival prospects we strongly feel that reducing the time from accident site to the trauma centre, ensuring prompt and adequate oxygenation with effective transfusion during transport can certainly improve the survival rate. The use of arterial blood gas analysis (Sr. Lactate and Base deficit) are relatively simple, easily preformed, cost effective tests which have helped us in assessing the damage severity, evaluate the efficacy of therapy and give a clue to the outcome. Bihar being a large state transportation is mostly through ill-equipped ambulances and for the patient to reach our centre may take up to 8 to 10 hours â€“ a loss of very valuable time. During this transport period most of the patients pass through hospitals of various standards and care. At some of these sites the gross misuse of antibiotics including Imipenem, Cilastatin, Teicoplanin and the latest antifungals Caspofungin & Anidulafungin by unregistered practicenors of medicine and drug availability over the counter without a legal prescription further adds to the problem. By the time the patients reach us most of them have received at-least 2 to 3 higher antibiotics in grossly inappropriate dosage and schedule. The high mortality rate is basically due to poor transport, (no ATLS ambulances), poor compliance of traffic rules, poor first aid facilities in the primary site, lack of trained personal, political rivalry and the price to be paid for being the largest democracy in the world with a huge uneducated population. Based on this experience and being fully aware of their financial and administrative limitations we have been making certain recommendations to our Government here with the hope that it will help in improving the scenario of trauma care in our state.

*Subject to some modification after re-visiting our records.

Trauma Care During The COVID 19 Pandemic

Robert Davis, MD, Director of Trauma/ Surgical Critical Care, Harlem Hospital Center, New York, NY, Elmsford, NY

The COVID 19 pandemic placed a significant added burden on our healthcare system, and nowhere was it more felt than in the delivery of emergency care, including Trauma. This presentation will look at the impact on trauma care in an urban trauma center. We review the trends in the injury pattern and the impact of the pandemic on resources to care for the injured patient. Hopefully we can learn from this unprecedented strain on our Emergency/Trauma Services in order to be better prepare for the next pandemic. It's not a question of if it will happed but of when. Will we be ready?

Thoracic Trauma

Loren Harris, MD, Clinical Associate Professor of Surgery, SUNY Downstate College of Medicine, Staten Island, NY

The diagnosis and care for patients with thoracic trauma

This information is vital for any physician caring for trauma patients

After the presentation, the learner will be able to identify and treat a variety of thoracic traumatic injuries

The audience will benefit from the presentation by acquiring knowledge that will help them with the management of thoracic trauma patients

Mechanism of Injury in Intoxicated Trauma Patients by Sex and Age Over Time

Anthony Kopatsis, MD, Senior Surgical Staff, ICAHN School of Medicine at Mount SInai/Elmhurst, New York, NY

We sought to investigate mechanism of injury in intoxicated trauma patients by age and sex and investigate if see if there was any change over time.

Multivariate analysis using logistic regression was used to investigate tends of mechanism of injury in intoxicated trauma patients by sex and age during 2007-2015 using TQP database.

We found 915,797 intoxicated trauma patients who were brought to emergency room and had a detectable alcohol in blood during 2007-2015 in TQP database.

Overall, the most common mechanism of injury was motor vehicle accident (MVA) (40.1%) following by assault (24.2%) and fall (21.7%). However, we observed a decrease in the rate of assault (26.1% for 2007 vs. 20.8% for 2015) and increase in the rate of fall (15.5% for 2007 vs. 24.1% for 2015) over 9 years of the study (Figure 1).

The rate of fall for intoxicated trauma patients increased by increasing in age (81% for older than 86 vs. 18.2% for younger than 65, P<0.01) and rate of suicide (0.6% vs. 2.7%, P<0.010) and assault (0.9% vs. 25.2%, P<0.01) decreased in older ages (Figure 2).

Overall, most of intoxicated patients were men (79%). However, the rate of intoxicated women increased with increasing in age and reached to 52.7% for older than 85 years (P<0.01) (Figure 3). Also, we observed a gradual increase in rate of intoxicated women from 18.9% for 2007 to 22.2% for 2015.

When comparing different sexes, the rate suicide was higher in women compared to men (3% vs. 2.5%, P<01). Although overall rate of suicide had minimal change during 2007-2015 (2.7% vs. 2.5%), the rate of suicide increased in intoxicated women overtime (2.7% for 2007 vs. 3.1% for 2015).

The most common mechanism of trauma in intoxicated patient is MVA followed by assault and fall. However, fall is replacing assault over time. The rate of trauma for intoxicated women increasing over time especially in elderly. Most of the intoxicated patients are men in younger ages. However, the rate of intoxicated women increases with increase in age and in elderly ages most of the intoxicated patients are women. In this line intoxicated women have higher rate of suicide compared to men which increasing over time. Further studies need to investigate reasons and develop preventive strategies.

Blast Injury

LTC Robert Madlinger, DO, MPH, Chief of Trauma, Acute and Surgical Critical Care, Mohawk Valley Health System, Utica, NY; Commander 1st Forward Resusitative Surgicalteam USAR USARC, Washington, NJ

Blast injury its effects on mechanism, injury types, military, terror and inicdental/occupational blast sources and clinical sequale , military prehospital triage tactics ,historical events and public health repercussions and surgical surge capacity.

What's Old is New: Geriatric Trauma in 2021

Leslie Tyrie, MD, Trauma Medical Director, Division Chief, Acute Care Surgery, Clinical Assistant Professor of Surgery, NYU Grossman School of Medicine, NYU Langone Hospital, Brooklyn, NY

All surgeons regardless of background care for elderly patients. In our level 1 trauma hospital in New York City, we have started a geriatric trauma program to meet the needs of our community and better capture this unique population of patients. As a result, we project we will evaluate over 2000 geriatric trauma patients in 2021. In this presentation I will review some of our own trauma experience including a review of the common trauma mechanisms and resultant injuries we treat. I will review the unique needs of the geriatric trauma population and emergent treatments/trends regarding care. I will also talk about the multimodality treatment teams and increased resources required for best practices for the treatment of geriatric patients both at the time of admission as well as at discharge and for ongoing care. The audience will learn the differences between adult and geriatric adult trauma surgery. The learner will be able to understand the unique challenges of caring for elderly injured patients. Target audiences will include those in trauma systems who are facing challenges to meet the needs of our aging populations and also all surgeons treating elderly patients in the setting of an acute surgical crisis as injury parallels this patient population. The audience will be able to describe both the challenges and best practices as it relates to elder surgical care.

Annual Research Scholarship Competition

Outcomes and their State-Level Variation in Patients Undergoing Surgery with Perioperative SARS-CoV-2 Infection in the USA: A Prospective Multicenter Study

Osaid Alser, MD, MSc (Oxon), General Surgery Resident, Texas Tech University Health Sciences Center, Lubbock, TX

Uncertainty regarding the postoperative risks of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) exists. Therefore, we aimed to report the 30-day outcomes of patients with perioperative SARS-CoV-2 infection undergoing surgery in the USA.

As part of the COVIDSurg multicenter study, all patients aged â‰¥17 years undergoing surgery between January 1 and June 30, 2020 with perioperative SARS-CoV-2 infection in 70 hospitals across 27 states were included. The primary outcomes were 30-day mortality and pulmonary complications. Multivariable analyses (adjusting for demographics, comorbidities, and procedure characteristics) were performed to identify predictors of mortality.

A total of 1,581 patients were included; more than half of them were males (n= 822, 52.0%) and older than 50 years (n=835, 52.8%). Most procedures (n=1,261, 79.8%) were emergent, and laparotomies (n= 538, 34.1%). The mortality and pulmonary complication rates were 11.0 and 39.5%, respectively. Independent predictors of mortality included age â‰¥70 years (OR 2.46, 95% CI [1.65-3.69]), male sex (2.26 [1.53-3.35]), ASA grades 3-5 (3.08 [1.60-5.95]), emergent surgery (2.44 [1.31-4.54]), malignancy (2.97 [1.58-5.57]), respiratory comorbidities (2.08 [1.30-3.32]), and higher Revised Cardiac Risk Index (1.20 [1.02-1.41]). While statewide elective cancelation orders were not associated with a lower mortality, a sub-analysis showed it to be associated with lower mortality in those who underwent elective surgery (0.14 [0.03-0.61]).

Patients with perioperative SARS-CoV-2 infection in the United States have a significantly high risk for postoperative complications, especially elderly males. Postponing non-emergent surgery and adopting non-operative management, when reasonable, should be considered in the USA during the pandemic peaks.

Chlorhexidine Gluconate Wound Irrigation and Surgical Site Infections in Renal Transplant Patient

Michael Burt, MD, General Surgery Resident, University of South Dakota, Sioux Falls, SD

Healthcare associated infections remain a common complication of inpatient hospital care. Among surgical patients, surgical site infections (SSI) are the most common hospital-acquired infection and are associated with increased length of stay, morbidity, and mortality. This is especially true in immunocompromised patients. SSIs remain a challenging problem for renal transplant patients with incidence rates ranging from 5-20%. In this population SSIs are associated with significant morbidity in including graft failure and may increase risk of mortality. Chlorhexidine gluconate (CHG) 0.05% containing solution used as an intraoperative subcutaneous wound irrigation has been proposed as a possible intervention to reduce the risk of SSI. Previous studies have been performed in a variety of patient populations and have demonstrated possible benefit of this intervention on reducing SSI rates. To date, there have been no prior studies specifically evaluating the efficacy of wound irrigation with CHG solution in prevention of SSI in renal transplant patients.

This study is a single center, single surgeon, retrospective analysis of patients who received either a deceased or living donor renal transplant at our institution within the last 10 years. SSI rates within 30 days of operation were compared between patients who received 0.05% CHG irrigation solution versus standard subcutaneous irrigation with warm saline.

Preliminary analysis of 95 renal transplant patients demonstrates overall SSI rate of 15.7% consistent with current literature. SSI rate in non-CHG saline irrigation patients was 19.6% (10/51) versus 11.4% (5/44) in the CHG irrigation group. Final analysis, matching, and results to be presented at conference.

Intraoperative subcutaneous incisional irrigation with CHG containing solution may be associated with decreased rates of SSI in renal transplant patients and should be further investigated by prospective randomized clinical trials.

Abdominal Perforation as a Complication of Tocilizumab use in COVID-19 positive patients

Maaria Chaudhry, BS, Saint Louis University, New Castle, DE

The purpose will be to examine a specific case of abdominal perforation in an a COVID+ patient treated with Tocilizumab. There have been few recorded cases looking at the relationship between tocilizumab use in COVID+ patient and abdominal perforation.

This patient was examined upon admission, treatment and followup. He was initially prescribed tocilizumab. However, he soon developed bilateral lower abdominal fullness and subcutaneous emphysema; a CT of the abdomen was ordered. It showed diffuse colonopathy of sigmoid colon with a large amount of extraluminal air and fluid in the left retroperitoneum, tracking through the left perirenal space into the left upper quadrant abdomen. He underwent CT guided drainage of pelvic abscess. He then underwent an anterior resection, diverting loop ileostomy, open appendectomy, drainage of pelvic accesses, omental pedicle flap, and Jackson-Pratt drain placement. He was transferred to the SICU post operatively due to a loss of blood (around 400 ccs) and then was taken into surgery to for exploratory laparotomy to control the hemorrhage from inferior mesenteric artery stump.

The patient ultimately recovered and was sent home.

If a seriously ill COVID-19 patient receives Tocilizumab and suffers from either persistent abdominal pain or new-onset subcutaneous emphysema, then gastrointestinal perforation needs to be ruled out.

A SIR Mathematical Model of Previous COVID-19 Strains to Analyze Delta Variant Spread

Alexandra Close, Student, University of Maryland, College Park, Olney, MD

The SIR Model has previously been used to model epidemics, and in the past year has been applied to the SARS-CoV-2 COVID-19 outbreak in various geographical areas. Given the virulent transmissibility of the current Delta strain, understanding the impact of containment measures is pertinent. In this paper we focus on Miami-Dade, Florida, where robust data is available and where containment measures have evolved from one outbreak to the next. Using the SIR model to compare containment strategies between the Wuhan, Alpha, and Delta strains will allow us to conclude that better preventative measures would be beneficial in tempering another variant outbreak.

We propose to use the SIR Model to gauge the effectiveness of containment measures against the initial strains of the SARS-CoV-2 (Wuhan and Alpha strain) outbreaks by creating a hypothetical "worst-case" scenario with no interventions (Î² = 2, Î³ = 1/14, N = 2,717,000). We then analyzed the Delta (B.1.617.2.) variant in Miami-Dade, Florida. We used official transmission and recovery rate parameters for the original SARS-CoV-2 strand and compared them against those yielded from data collected from the Johns Hopkins University COVID-19 database (Ensheng Donga, 2020). Assumptions made from this comparison were applied to our prediction for the Delta variant spike, where we assessed how containment measures and vaccinations may be influencing the SIR parameters.

We found that the SIR Model is still a useful tool in analyzing COVID-19 outbreaks and insights can be found regarding the quality of intervention strategies. From the modelling, we saw that strict containment measures used for the first peak were the most effective. While the transmission rate improved between the Wuhan and Alpha outbreaks, the size of the susceptible population increased by a proportion of 15. We attributed this to the lessening of previous restrictions that allowed for closer contact between infected and susceptible populations for the Alpha outbreak. When restrictions were reapplied to contain the second peak (Alpha) on July 2nd, it initiated a decline in cases 12 days later. Our model implied that the Delta outbreak was significantly worse, in rate of transmission (Î² = 0.87) and susceptible population (N = 60,000), than the Wuhan strain (Î² = 0.5, N = 750). The susceptible population of the Delta variant was five times that of the Alpha variant (N = 11,000), even though vaccination rates rose by 20%. These parameters were still far lower than that of the â€œworst-case scenarioâ€, meaning that the containment measures used in all cases were successful but not necessarily optimal.

The SIR Model is a useful tool in epidemiologically monitoring a pandemic. Our modelling validates the importance of intensive containment measures in any highly contagious epidemic.

Outcomes and Efficacy of MRI-compatible Sacral Nerve Stimulator for Management of Fecal Incontinence

Binit Katuwal, MD, Surgery Resident, Providence Hospital, Royal Oak, MI

Fecal incontinence (FI) is an involuntary passage of fecal matter due to an inability to control the discharge of bowel contents. It can have a significant impact on patientâ€™s quality of life. The InterStim was limited by MRI incompatibility. Given the increased need of MRI for diagnostics, MRI compatible InterStim was needed for widespread usage. Medtronic MRI compatible InterStim was FDA-approved in August 2020. Given the recent FDA approval, no large data or literature exists. This is the first study of pooled multi-institutional data to study the efficacy, outcomes and complications of the MRI compatible Interstim.

Pooled data of patients who underwent MRI compatible Interstim placement at UPMC WIlliamsport, University of Minnesota, University of Illinois, University of Wisconsin-Madison was analyzed which involved multiple surgeons and evaluated for the patient details, techniques, complications and outcomes.

A total of 73 patients underwent the implantation. Mean age of patients was 63.29Â±12.2 years, 57 (78.1%) were females. 42(57.5%) were diabetics. All had fecal incontinence, 23.3% had additional diarrhea, fecal urgency in 58.9% and concomitant urinary incontinence in 21(28.8%). N = 15 (20.5%) underwent Peripheral Nerve Evaluation (PNE) before implant. 32(43.8%) underwent rechargeable Interstim placement. 3(4.1%) had their implants removed. External lead connection migration was observed in 7(9.6%) patients after stage I procedure. Following this, a change in technique was done and recommended by Medtronic that the lead be secured to subcutaneous tissue. 1 patient had infection and implant was removed. 7(9.6%) had complications which included nerve pain, hematoma, infection, lead fracture and bleeding. Mean follow up was 6.62Â±3.5 months. During follow up, 68(93.2%) reported significant improvement of symptoms.

This study being the first to evaluate the MRI compatible Interstim shows promising results with significant symptom improvement, good efficacy, good patient outcomes with low complication rates in patients with FI. Further long-term follow-up and future studies with larger patient population is recommended.

Mortality Risk Factors in Patients Admitted with Tracheostomy Complications

Lior Levy, BA, New York Medical College, Valhalla, NY

Purpose: Tracheostomy is a procedure commonly conducted in patients undergoing emergency admission and require prolonged mechanical ventilation. In the present study, the aim was to determine the prevalence and risk factors of mortality among emergently admitted patients with tracheostomy complications, during the years 2005-2014.

Methods: This was a retrospective cohort study. Demographics and clinical data were obtained from the National Inpatient Sample, 2005-2014, to evaluate elderly (65+ years) and non-elderly adult patients (18-64 years) with tracheostomy complications (ICD-9 code 519) who underwent emergency admission. Multivariable generalized additive model and multivariable logistic regression model with backward elimination were used to identify association of predictors and in-hospital mortality.

Results: A total of 4,711 non-elderly and 3,315 elderly patients were included. Females included 44.5% of the non-elderly patients and 47.6% of the elderly patients. 181 (3.8%) non-elderly died of which 48% were female and 163 (4.9%) elderly died, of which 48% were female. The mean (SD) age of the non-elderly patients was 49.62 (12) years old and elderly patients was 74.30 (7) years old. The mean (SD) age at the time of death of non-elderly patients was 53.36 (9) years old and for elderly patients 75.32 (7) years old. In adults and elderly patient groups, 1,348 and 737 were operated on, respectively. Mean (SD) HLOS in adult patients was 9.51 (14.17) days in patients who had operation vs. 5.46 (7.70) days in those who did not (P<0.001). In elderly patients, mean (SD) HLOS was 9.07 (10.49) days in patients who had operation vs. 5.81 (7.70) in patients who did not (P<0.001). In the final multivariable regression model for patients with operation, time to operation, age and modified frailty index score stayed in the model but none of them were significant whereas time to operation (OR=1.068, 95%CI: 1.019-1.119, p=0.006) was the principle risk factor for elderly. In the final multivariable regression model for patients with no operation, hospital length of stay (OR=1.022, 95%CI: 1.008-1.036, p=0.003) and age (OR=1.032, 95%CI: 1.013-1.151, p=0.001) were the main risk factors of mortality in adults whereas only hospital length of stay (OR=1.028, 95%CI: 1.012-1.045, p=0.001) was the risk factor for elderly. Application of an invasive diagnostic procedure (OR=0.557, 95%CI: 0.356-0.870, p=0.01) was a protective factor for adults who did not undergo an operation.

Conclusions: Delayed operation was a significant risk factor of mortality for elderly patients who were operated on. Every day delay in time to operation in elderly patients that were operated on, increased the odds of mortality by 6.8% in elderly. Increased length of stay was a significant risk factor of mortality for all patients who were not operated on. Every day of longer stay in hospital in patients that were not operated on, increased the odds of mortality by 2.2% in adults and 2.8% in elderly.

Mortality in GI Adhesions with Obstruction: A 10-year Study of 115,012 Patients

Akash Thaker, MS, Medical Student, New York Medical College, Valhalla, NY

Patients admitted emergently for obstructions caused by intraabdominal adhesions have high rates of complications, including morbidity and mortality. The goal of our study was to assess risk factors associated with in-hospital mortality for patients with the primary diagnosis of intestinal or peritoneal adhesions with obstruction.

Emergently admitted patients with the primary diagnosis of intestinal or peritoneal adhesions with obstruction were analyzed using the National Inpatient Sample database, 2005-2014. Demographics, clinical data, and outcome were gathered for the current retrospective cohort study. The relationship between mortality and the predictors was assessed using stratified analysis and backward elimination multivariable logistic regression model. Odds ratios (ORs) and the corresponding 95% confidence intervals (95% CIs) were used to present the findings of regression models.

A total number of 54,386 adult and 60,626 elderly patients (age 65+ years) were included. 60.8% of adult and 62.9% of elderly patients were female. Mean (SD) age was 55 (8) years for deceased and 49.5 (11) years for surviving patients in the adults, and 81.7 (7.6) years for deceased and 77.3 (7.6) years for surviving patients in the elderly sample. Mean (SD) hospital length of stay (HLOS) was 16.7 (18.5) days for deceased and 7.8 (8.1) days for surviving patients in the adults, and 13.7 (13.5) days for deceased and 9.2 (8) days for surviving patients in the elderly sample. Mean (SD) time to operation was 3.7 (4.9) days for deceased and 2.2 (3) days for surviving patients in the adults, and 3.4 (3.8) days for deceased and 2.7 (3) days for surviving patients in the elderly sample. In regression model of adult patients with operation, time to operation (OR=1.07, 95% CI: 1.05-1.09, p<0.001), invasive diagnostic procedure (OR=1.58, 95% CI: 1.17-2.13, p<0.001), and age (OR=1.06, 95% CI 1.05-1.08, p<0.001) were the main risk factors for mortality. Female sex was associated with reduced mortality (OR=0.706, 95% CI 0.64-0.77, p<0.012). In the final multivariable regression model for adult patients with no operation, age (OR=1.09, 95% CI: 1.04-1.15, p<0.001), and HLOS (OR=1.09 95% CI: 1.06-1.12, p<0.001) were the main risk factors for mortality. In the final multivariable regression model for elderly patients with operation, time to operation (OR=1.059, 95% CI 1.046-1.071, p<0.001), and age (OR= 1.077, 95% CI: 1.070-1.084, p<0.001) were the main risk factors for mortality. Female sex was associated with reduced odds of mortality (OR=0.706, 95% CI: 0.643-0.776, p<0.001). In the final multivariable regression the final multivariable model for elderly patients with no operation, HLOS (OR=1.05, 95% CI: 1.03-1.07, p<0.001), and age (OR=1.10, 95% CI: 1.09-1.12, p<0.001) were the main risk factors for mortality. Female sex was associated with reduced odds of mortality (OR=0.70, 95% CI 0.56-0.87, p=0.001).

Delayed operation, extended hospital length of stay, invasive diagnostic procedure, age, and male sex are significant risk factors for in-hospital mortality in emergently admitted patients with intestinal or peritoneal adhesions with obstruction.