2017 Scholarship Winners
New Technique: Minced Edge Transposition Graft (MET Graft)
Scott Moradian, DO, Surgical Resident, Larkin Community Hospital, Miami, Fl
Purpose: Develop a tissue salvage technique to reconstruct acute wounds in patients with associated co-morbidities that allotted them high risk for the OR.
Methods: 11 acute full thickness wounds in series varying in size and complexity (10 cm2 to 144 cm2). Patients aged 51 to 96 years old, each with complex medical histories allotting for high risk for general anesthesia.
Results: 100% closure with epithelialization. No failures or infections. Healing Time to Closure: 10-15 days dependent on size of initial wound.
Conclusion: The MET Graft is an easy to master, low cost, bedside technique for the wound care surgeon. MET has become our primary technique to expedite wound closure in patients presenting with unsalvageable tissue and high operative risk secondary to comorbidities
Esophageal Stents: a Single-Center Retrospective Review of Surgical Experience
Tessa Cartwright, MD, MPH, FICS, Cardiothoracic Fellow, University of Kentucky, Lexington, KY
Background: Esophageal stenting methods have been the mainstay of treatment of palliative therapy of esophageal cancer. Through advancement in stent technology, indications of stent placement have expanded to include treatment of non-malignant esophageal disorders such as refractory stricture, tracheoesophageal fistula, iatrogenic esophageal perforation, or leak. Known complications of esophageal stents are aspiration, malposition, dislodgement, perforation, bleeding, fistula formation, and migration. The purpose of our study was to review our experience at University of Kentucky utilizing esophageal stents in both malignant and benign esophageal disease, indications, patient characteristics, morbidity and mortality, and need for re-intervention.
Methods: We undertook a retrospective analysis of the electronic medical records from our University Cardiothoracic Surgery Division to evaluate the experience of esophageal stent placements using codes 43219 and 43212 between January 2000 to December 2014. A review of the literature was also performed. Data was analyzed using SPSS statistical software v. 23 (IBM Corp., Armonk, NY).
Results: One hundred procedures were identified for 56 patients, including two pediatric patients receiving 11 stent procedures for TEF. Twenty-five patients had two or more consecutive procedures. The median age at time of procedure was 57.5 years (range 2.6-85) and almost two-thirds of procedures were performed in males (36/56, Table 1). Sixty-four percent of patients had a history of esophageal or lung cancer. Indications for the 100 surgeries included fistula (30%), dysphagia (25%), perforation (23%), stricture (15%) and leak (7%). Stents included 20 proximal, 24 middle and 56 distal esophagus placements.
Morbidities included 24 stent migrations, 2 displacements, 2 obstructions, 8 esophageal leaks, 4 fistulas, and one each of pneumonia, airway compression, dysphagia, and hemoptysis (Table 2). A statistically significantly greater stent migration complication was noted for stents placed proximally (55%) as compared with distal (19.6%) and middle (8.3%) (p<0.01). The morbidity rate for benign indication was 48% versus 41% for malignant indication (p = .548). Among procedures performed on adults only (N=89), the morbidity rate for benign indication was 64.5% versus 41.4% for malignant indication (p = .047).
Of the 56 patients, 12 were lost to follow-up such that their mortality status is unknown. In the remaining 44 patients 30 (68%) died at a median 107 days (range 2-2383) after their first or only stent placement. Known mortality was 90% (26/29) in malignant indications vs. 27% (4/13) for benign indications (p < .001). 30-day death only occurred in the malignant group (7/29, 24%). Of the 54 patients, 12 were lost to follow-up such that their mortality status is unknown. In the remaining 42 patients 30 (71%) died at a median 107 days (range 2-2383) after their first or only stent placement. Mortality was 72% (26/29) in malignant indications vs. 22% (4/13) for benign indications (p = .001). 30-day death only occurred in the malignant group (7/29, 24%).
Conclusions: Esophageal Stents are commonly used for palliation and for contained leaks. Perioperative mortality is low for benign indications; however, the morbidity rate was significantly higher for those with benign indications as compared to malignant. The overall mortality was significantly higher for malignant indications as compared to benign. The most common indication for stent placement was fistula followed by dysphagia, perforation, stricture and leak. A statistically significantly greater stent migration complication was noted for stents placed proximally (55%) as compared with distal (19.6%) and middle (8.3%). Lastly, we did not find a statistically significant difference in complication stent placed for benign as compared with a malignant etiology.
Exploring the Relationship Between Surgical Care Capacity and Output in Ghana: The Hidden Roles of Non-Material Structures and Processes
Barclay Stewart, MD MscPH, Surgical Resident, University of Washington, Seattle, WA
Objective: Capacity assessments have served as surrogates for surgical output (i.e., number of operations performed annually) in low- and middle-income countries (LMICs) in lieu of system-wide registries. We sought to explore the relationship between capacity and output in Ghana to improve our interpretation of capacity assessments and, ultimately, better inform targeted health system strengthening initiatives.
Methods: A standardized surgical capacity assessment was performed at 37 hospitals nationwide (25 first level, 9 referral, and 3 tertiary hospitals) using World Health Organization guidelines; availability of 25 essential resources and capabilities was used to create a composite capacity score that ranged from 0 (no availability of essential resources) to 75 (constant availability of essential resources) for each hospital. Data on number of essential operations performed over one year, surgical specialties available, hospital beds, and functional operating theaters at each hospital was also collected. The relationship between capacity and output was explored with negative binomial regression modeling.
Results: The median surgical capacity score was 37 [interquartile range (IQR) 29 – 48; range 20 - 56]. All hospitals had medical officers who performed some operations; 5 hospitals had one surgical specialty available (14%); 11 had two specialties available (30%); and 8 had three or more specialties available (22%). The median number of essential operations per year was 1,480 (IQR 736 – 1,932) at first level hospitals; 1,545 operations (IQR 984 – 2,452) at referral hospitals; and 11,757 operations (IQR 3,769 – 21,256) at tertiary hospitals. There was not evidence for correlation between capacity and output (p>0.05).
Conclusion: Contrary to current understanding, surgical capacity assessments may not accurately reflect surgical output. To improve the validity of surgical capacity assessments and facilitate maximal use of available resources, other factors that influence output should also be considered, including: a) demand side factors -- population awareness of surgical need, accessibility of care, ease of healthcare navigation; b) supply-side factors -- structure elements – policies, protocols, incentivization structures; and process elements – service delivery, compliance with guidelines; and c) health administration and management factors -- enabling work environment, emotional infrastructure, financing schemes.
Early Experience Implementing an Enhanced Recovery Protocol in a Community Hospital Setting
Nancy Panko, MD, Surgical Resident, Presence Saint Joseph Hospital, Forest Park, IL
Background: The common course of postoperative care in the cohort of patients undergoing colon and rectal surgery in the US and Europe is changing. As the benefits of optimizing pre and postoperative nutrition, early ambulation, avoidance of narcotics, and maintaining optimal fluid balance have been documented, the ‘Fast Track’ or ‘Enhanced Recovery’ era has emerged. We describe our early experience with implementing an Enhanced Recovery protocol for patients undergoing colon and rectal surgery in a community hospital setting.
Methods: A literature review was conducted using PubMed search for ‘Enhanced Recovery’ and ‘Enhanced Recovery After Surgery.’ The search results were used to devise an enhanced recovery protocol suiting the practice model of the surgeons performing colorectal surgery at a 200-bed community hospital. The protocol was implemented by creating a standardized pre-operative, intraoperative, and postoperative care plan. Surgical residents, pre-op nursing, anesthesiologists, PACU nursing, and floor nursing staff were all educated on the protocol. Data were prospectively collected in Microsoft Excel for the first 10 patients undergoing colorectal procedures in the three-month period since implementation.
Results: Of the 10 patients on whom data was available, nine had been using a preoperative nutritional supplement at least once a day for the five days preceding surgery. All 10 patients received intravenous acetaminophen and oral gabapentin prior to surgery start. Patients received an average of 6.4cc/kg/hr of fluid intraoperatively and just over half (n=6) still received some amount of opioids. There was one patient who suffered an intraoperative complication that would alter their adherence to the protocol. Additionally, postop management on the inpatient floor was poorly implemented with several patients failing to have interventions completed according to the study protocol. Therefore only half the study patients had post-operative data collected. Of those available, 50% were discharged on postop day 2.
Conclusion: Standardizing an enhanced recovery protocol has many pitfalls and close attention to detail and implementation can result in successful adherence leading to cost savings and decreased morbidity and mortality long term. Our data did show that this protocol may lead to shorter length of stay and potentially decreased morbidity. However, we also found that our preoperative counseling and post-operative floor management were the areas with the most variability. These deviations for protocol plans may be prevented with continued nursing education, an EMR based order set, and improved preoperative patient counseling.