39.03 Is the operative autonomy granted to a resident consistent with the operative performance quality?

Posted on January 18, 2018

J. P. Fryer4, B. C. George1, B. D. Bohnen2, S. L. Meyerson4, M. C. Schuller4, A. H. Meier5, L. Torbeck3, S. P. Mandell6, J. T. Mullen2, D. S. Smink7, J. G. Chipman8, E. D. Auyang9, K. P. Terhune10, P. E. Wise11, J. N. Choi3, E. F. Foley13, M. A. Choti12, C. Are15, N. J. Soper4, K. D. Lillemoe2, J. B. Zwischenberger14, G. L. Dunnington3, R. G. Williams3  1University Of Michigan,Ann Arbor, MI, USA 2Massachusetts General Hospital,Boston, MA, USA 3Indiana University School Of Medicine,Indianapolis, IN, USA 4Northwestern University,Department Of Surgery,Chicago, IL, USA 5State University Of New York Upstate Medical University,Syracuse, NY, USA 6University Of Washington,Seattle, WA, USA 7Brigham And Women’s Hospital,Boston, MA, USA 8University Of Minnesota,Minneapolis, MN, USA 9University Of New Mexico HSC,Albuquerque, NM, USA 10Vanderbilt University Medical Center,Nashville, TN, USA 11Washington University,St. Louis, MO, USA 12University Of Texas Southwestern Medical Center,Dallas, TX, USA 13University Of Wisconsin,Madison, WI, USA 14University Of Kentucky,Lexington, KY, USA 15University Of Nebraska College Of Medicine,Omaha, NE, USA

Introduction. Surgical residency training should produce surgeons capable of performing core procedures competently and independently. As residents’ operative performances improve, faculty should allow greater autonomy. In this study we seek to identify and define situations where the operative autonomy levels granted to residents was inconsistent with their operative performance.

Methods.  Surgical faculty provided operative performance ratings for PGY1-5 residents from 14 U.S. general surgery residency programs using the SIMPL smartphone app. For each procedure the supervising surgeon assessed the resident’s operative performance and indicated the level of autonomy that the resident was granted during that procedure. Performance was assessed using an ordinal operative performance scale and autonomy was characterized using the Zwisch autonomy scale. Concordance between performance and autonomy scores was defined as concurrent scores of either “practice ready (performance) or above and meaningful autonomy” (Zwisch) [aka PR/MA] or “not practice ready or above and not meaningfully autonomous” [NPR/NMA]. Discordant scores were “practice ready or above and not meaningfully autonomous” (PR/NMA) as well as “not practice ready or above and meaningfully autonomous” (NPR/MA). The supervising surgeon also indicated the patient-related complexity of the case. Multiple variables were investigated to determine their impact on resident operative autonomy including: resident performance, PGY level, patient-related case complexity, procedure-related complexity, procedure frequency, core vs. specialty procedures.

Results. During the study period 10964 SIMPL assessments that included both a performance score and an autonomy score were collected from 493 different surgeons assessing 615 different residents. 80% of assessments were concordant; including 39% rated as PR/MA and 41% as NPR/NMA. Of the 20% of discordant assessments, most (14.4%) were NPR/MA while the remaining 5.6% were PR/NMA. NPR/MA was the predominant discordant rating in PGY1-4 residents. In PGY5 residents PR/NMA ratings (8.9%) were slightly more frequent than NPR/MA ratings (8.2%). All but 7 surgical attendings (1.4%) provided opportunities for meaningful autonomy on at least one occasion. High volume and easy cases were more frequently performed under meaningfully autonomous circumstances. Operative performance quality accounted for 74% of the variance in the faculty surgeons’ decisions about the level of autonomy allowed (F=341.84; p<0.05).

Conclusions. Faculty autonomy granted to surgical residents was concordant with resident performance in most cases. When discordant, faculty most commonly provided meaningful autonomy when the performance was less than practice ready, a combination to be expected on occasion during training. Few surgical attending surgeons provided no opportunities for autonomous resident operative performance.

38.02 Gender Differences in Residency: Duty Hour Utilization, Burnout and Psychological Wellbeing

Posted on January 18, 2018

A. R. Dahlke1, J. K. Johnson1,3, C. C. Greenberg4, R. Love1, L. Kreutzer1, D. B. Hewitt1,5, C. M. Quinn1, K. Engelhardt1,6, K. Y. Bilimoria1,2  1Northwestern University- Feinberg School Of Medicine, Surgical Outcomes And Quality Improvement Center (SOQIC),Department Of Surgery,Chicago, IL, USA 2American College Of Surgeons,Chicago, IL, USA 3Northwestern University-Feinberg School Of Medicine,Center For Healthcare Studies In The Institute For Public Health And Medicine,Chicago, IL, USA 4Wisconsin Surgical Outcomes Research (WiSOR) Program,Department Of Surgery,Madison, WI, USA 5Thomas Jefferson University Hospital,Department Of Surgery,Philadelphia, PA, USA 6Medical University Of South Carolina,Department Of Surgery,Charleston, SC, USA

Introduction: As the number of women in surgical residency programs continues to increase, there is a growing recognition that women and men may enter, experience, and even leave residency programs differently. Recent studies have shown that up to 65% of surgical residents experience some amount of burnout and challenges to their wellbeing. Our objective is to (1) assess differences in how male and female general surgery residents utilize duty hour regulations and experience burnout and psychological wellbeing and (2) examine reasons why women and men may have differing experiences with duty hours, aspects of burnout, and issues with psychological wellbeing.

Methods: 7,395 surgical residents completed a survey (99% response rate) regarding how often and why they exceeded 2011 standard duty hour limits, as well as about aspects of burnout and psychological wellbeing. Hierarchical logistic regression models were developed to examine the association between gender and each of the resident outcomes. 98 semi-structured interviews were completed with 42 faculty and 56 residents. Transcripts were analyzed thematically using a constant comparative approach. 

Results: Female residents reported more frequently staying in the hospital >28 hours or violating the 80 hour work week maximum ≥3 times in a month, as well as more frequently feeling fatigued and burned out from their work (P<0.001). Females also reported less frequently treating patients as “impersonal objects” or “not caring” what happens to patients (P<0.001). Women reported more often: losing sleep due to worry, being unable to make decisions, feeling constantly under strain, being unable to overcome difficulties, feeling unhappy or depressed, feeling a loss of self-confidence, or thinking of themselves as worthless (P<0.01). In adjusted analyses, all associations remained significant. Themes identified in the qualitative analysis as possible contributory factors to gender differences in residency include: lack of mentorship/leadership roles by women surgeons, dual role responsibilities (surgeon and family), the inability of co-workers to understand gender differences (gender blindness), and gender-based differences regarding pressures and challenges, as well as in approaches to patient care.

Conclusion: Our study found that women report working extended shifts more often than men and experience worse contributing factors to burnout and poor psychological wellbeing. This mixed-methods study adds to the existing literature on resident wellbeing, and calls for a closer look into how gender schemas drive the differences in the way male and female surgeons work, behave, and ultimately cope during residency. Focusing future research on the differences in how women and men navigate residency and their social, emotional, and mentoring needs may help us develop policy recommendations as well as specific programmatic or cultural interventions.

 

38.01 Are General Surgery Residents Being Coerced to Exceed Duty Hour Limits? A FIRST Trial Analysis.

Posted on January 18, 2018

E. Blay1, K. E. Engelhardt1, B. Hewitt1, C. Quinn1, A. R. Dahlke1, A. D. Yang1, K. Y. Bilimoria1  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA

Introduction: As of July 1, 2017, the Accreditation Council for Graduate Medical Education (ACGME) has instituted duty hour limit flexibility by waiving caps on daily shift lengths, while maintaining the 80-hour-per-week cap. Importantly, residents can only stay after a 24-hour call if it is their choice to stay longer.  Our objectives were to understand how often and why residents in the Flexible Arm of the FIRST Trial were working longer than standard duty hour limits and whether this was due to coercion by attendings and senior residents or a voluntary decision made by the individual resident to stay longer.

Methods: All clinical General Surgery residents taking the 2017 American Board of Surgery In-Training Examination (ABSITE) were surveyed. This analysis was limited to residents in the Flexible Arm of the FIRST Trial. The main outcome was number of times the resident exceeded 2011 duty hour limits in a typical month dichotomized into 0 or ≥ 1 event.  If residents indicated that their duty hours exceeded limits in a typical month, they were asked additional questions about duty hour expectations and coercion on a 5-point Likert scale from “Strongly Agree” to “Strongly Disagree.” Rates were compared and regression models were developed to (1) identify resident and program factors associated with exceeding standard duty hour limits and (2) identify predictors of coercion to stay longer.

Results: In the Flexible Arm of the FIRST trial, 1838/1838 (100%) of clinical residents in 58 programs responded to the survey. Of 68% (n=1258) residents who exceeded duty hour rules, 22% (n= 273) of residents said their programs expected them to stay longer than standard duty hour limits.  When residents stayed longer than standard duty hour limits, 78% (n= 983) responded that they voluntarily stayed longer, while 7% (n=93) reported coercion from attendings and 9% (n=117) reported coercion from senior residents. Although females (OR 1.89, 95% CI [1.52-2.34]), interns (OR 4.47, 95% CI [3.32-6.03]) and junior residents (OR 1.43, 95% CI [1.14-1.81]) were more likely to report exceeding standard duty hour limits, there were no significant resident or program characteristics associated with coercion by attendings or senior residents to exceed duty hour limits.

Conclusion: When duty hour flexibility was utilized in the Flexible Arm of the FIRST Trial, it was generally due to the residents choosing to stay voluntarily; however, there was some coercion by attendings and senior residents. As duty hour rules transition into an era of flexibility, programs should be cognizant of ensuring residents are staying for clinical and educational purposes of their own accord and are not being coerced to break ACGME duty hour regulations unnecessarily.

 

31.08 Online Information on Surgery for Pancreatic Cancer is Often Inadequate for Shared Decision-Making

Posted on January 18, 2018

C. Zhang1, A. Yang1, A. Halverson1  1Northwestern University,Chicago, IL, USA

Introduction:
Decision making regarding surgery for pancreatic cancer may be difficult for patients as surgery can improve survival but can also negatively impact quality of life. In order to more actively participate in decision making, patients often seek information on the Internet. The aim of this project was to assess the quality of publicly available online information regarding surgery for pancreatic cancer.

Methods:
This study was a cross-sectional survey of patient-centered websites that address surgery for pancreatic cancer. Two search engines (Google, Bing) were queried with the terms “pancreatic cancer treatment”, “pancreatic cancer surgery”, “Whipple procedure”, and “pancreaticoduodenectomy” to identify websites of interest. Each website was evaluated using the DISCERN instrument (www.discern.org.uk), a validated questionnaire developed to analyze written consumer health information on treatment choices. An additional questionnaire was used to evaluate website content specifically for pancreatic cancer surgical treatment. Two healthcare providers (surgeon, medical student) reviewed each website independently and inter-rater reliability (IRR) was calculated. In addition, one pancreatic cancer patient and one family member analyzed a randomly selected subgroup of study websites using the DISCERN instrument.

 

Results:

We identified 93 distinct websites; 45 met inclusion criteria. Website affiliations included: health care organizations (44%), non-profit organizations (22%), open-access general information (22%), and government/professional websites (11%). Using DISCERN, the two healthcare providers identified that only 24% of the websites had clear aims, 31% had identifiable references, and 36% noted the publication date (Figure). Overall, 4 websites (9%) were identified as excellent, and nine (20%) were of poor quality. In regard to pancreatic cancer surgery, 62% of websites discussed postoperative complications, 56% addressed quality-of-life (QOL) issues, and 53% acknowledged the surgery volume-outcome relationship. IRR was 0.75 for the 2 professional assessors on the overall rating. DISCERN assessment by patient/family evaluators demonstrated 83% agreement with the results by medical professionals. Major areas of disagreement included QOL and website bias.

Conclusion:

The quality of patient-centered online information on pancreatic cancer treatment is highly variable. Websites frequently lack updated information and references, and often do not provide adequate information for patients to make well-informed treatment decisions. However, patients and family members demonstrated the ability to learn strategies to critically evaluate online health information.

25.08 Regulation of Neointimal Hyperplasia by the Short Chain Fatty Acid Butyrate

Posted on January 18, 2018

M. Nooromid1, L. Xiong1, K. Wun1, T. Jiang1, E. Chen1, O. Eskandari1, K. J. Ho1  1Northwestern University,Surgery,Chicago, IL, USA

Introduction:  The short chain fatty acids (SCFA) acetate, propionate and butyrate are produced primarily by the gut microbiome from metabolism of dietary fiber. SCFA serve as a source of energy but also act as signaling molecules. Our prior work in a rat model has demonstrated that butyrate potentially ameliorates neointimal hyperplasia development after arterial injury. To expand our understanding of how butyrate modulates neointimal hyperplasia, we utilized a mouse model of carotid artery ligation, dietary supplementation with butyrate, and knockout mice lacking free fatty acid 3 (FFAR3), a G protein-coupled receptor activated by butyrate. 

Methods:  21-week-old male C57BL6 mice were given drinking water supplemented with butyrate (.5 mg/mL) or control water for four weeks prior to undergoing left carotid artery ligation. Serum butyrate concentration was assessed by gas chromatography. Four weeks later, mice were sacrificed and bilateral carotid arteries were harvested for morphometric analysis. A separate cohort FFAR3 knockout mice also underwent left carotid artery ligation and similar morphometric vessel analysis. 

Results: Post-ligation common carotid arteries from butyrate-treated mice developed significantly less neointimal hyperplasia development than control-treated mice (neointima area .047 ± .008 mm2 control vs. .019 ± .005 mm2  butyrate; P=.03), which correlated inversely with changes in serum butyrate levels (2.3 ± .63 mg/mL control vs. 1.2 ± .12 mg/mL butyrate; P<.001). Interestingly, FFAR3 knockout mice demonstrated significantly decreased neointimal hyperplasia compared to wild-type mice (P=.03). 

Conclusion: Butyrate has a protective effect on neointimal hyperplasia development after carotid ligation, but the role of FFAR3 on mediating this effect is unclear and likely complex. Future studies will focus on validating these findings in alternative murine models and exploring FFAR3 signaling in ex vivo studies. 

 

25.01 Human Venous Valve Disease Caused By Mutations In FOXC2 And GJC2

Posted on January 18, 2018

O. Lyons1, P. Saha1, C. Seet1, A. Kuchta2, A. Arnold2, S. Grover4, V. Rashbrook1, A. Sabine5, G. Vizcay-Barrena3, A. Patel1, F. Ludwinski1, S. Padayachee2, T. Kume6, B. Kwak7, G. Brice8, S. Mansour8, P. Ostergaard9, P. Mortimer9, S. Jeffery9, N. Brown10, T. Makinen11, T. Petrova5, B. Modarai1, A. Smith1  1King’s College London,Academic Department Of Surgery, Cardiovascular Division, BHF Centre Of Research Excellence,London, LONDON, United Kingdom 2Guy’s & St Thomas’ NHS Foundation Trust,Ultrasonic Angiology,London, LONDON, United Kingdom 3King’s College London,Centre For Ultrastructural Imaging,London, LONDON, United Kingdom 4Division Of Hemostasis And Thrombosis,Beth Israel Deaconess Medical Centre,Boston, MA, USA 5Ludwig Institute For Cancer Research And Division Of Experimental Pathology,Department Of Fundamental Oncology, Centre Hospitalier Universitaire Vaudois And University Of Lausanne, Epalinges, Switzerland,Lausanne, LAUSANNE, Switzerland 6Feinberg Cardiovascular Research Institute,Northwestern University School Of Medicine,Evanston, IL, USA 7Department Of Pathology And Immunology,University Of Geneva,Geneva, GENEVA, Switzerland 8South West Thames Regional Genetics Service,St George’s Hospital,London, LONDON, United Kingdom 9Cardiovascular And Cell Sciences Institute,St George’s Hospital,London, LONDON, United Kingdom 10Institute Of Medical And Biomedical Education,St George’s Hospital,London, LONDON, United Kingdom 11Rudbeck Laboratory,Department Of Immunology, Genetics And Pathology, Uppsala University,Uppsala, UPPSALA, Sweden

Introduction:

Venous valves (VVs) prevent blood reflux that can give rise to chronic venous hypertension and ulceration. Patients with mutations in the genes encoding the transcription factor Foxc2 and gap junction protein, connexin47 (Cx47), have venous reflux. We sought to examine VV phenotypes in these patients and to use a murine model to elucidate the function of these proteins in VV development.

Methods:

Human VV number and length were quantified by ultrasound. Murine VV phenotype (marked by expression of Prox1) was examined using confocal microscopy, in wild-type and mice with complete or conditional deletion of genes expressing transcription factors and connexins.

Results:

Patients with Foxc2/Cx47 mutations had reduced valve number (P<0.0005) and shorter valves (P<0.0005). VV initiation in mice was marked by elongation/reorientation of Prox1hi endothelia by postnatal day 0. Expression of Foxc2 and Nfatc1, and the gap junction proteins, Cx47, Cx43 and Cx37, were temporo-spatially regulated during this process. Combined Foxc2 deletion with calcineurin-NFAT inhibition disrupted endothelial organisation, suggesting co-operative Foxc2-NFATc1 patterning. Deletion/knockout of each of the connexins also disrupted endothelial organisation. Specific deletion of endothelial Foxc2 had no effect on VV maintenance.

Conclusion:

Patients with mutations in Foxc2 and Cx47 have globally reduced VV numbers and shorter VV leaflets. Foxc2 and Nfatc1 likely cooperate to organise the initial ring of VV-forming cells. Connexins are critical for early organisation of valve-forming cells at P0 and failure of this process may underlie abnormal VVs identified in patients with mutated Cx47. Foxc2, in endothelia, is not required for valve maintenance.  

21.06 CCR2+ Monocytes Mobilized from Spleen Cause Neutrophil Extravasation During Lung Reperfusion Injury

Posted on January 18, 2018

R. Fernandez1, M. Akbarpour1, S. F. Chiu1, H. Sun1, A. Misharin1, G. S. Budinger1, A. Bharat1  1Northwestern University,Thoracic Surgery,Chicago, IL, USA

Introduction: Lung ischemia reperfusion injury (LIRI) is the primary cause of graft failure and mortality after lung transplant. LIRI is mediated by neutrophils. Neutrophil depletion ameliorates LIRI but is not clinically applicable due to their importance in pathogen clearance. Accordingly, we focused on elucidating trafficking of neutrophils. We identified a novel subset of bone marrow derived classical monocytes (CM) which, upon mobilization from the spleen, mediates neutrophil extravasation during LIRI in mice and humans.

Methods: LIRI was induced in mice by hilar clamping for 60 mins followed by 2 hours of reperfusion. Splenectomy and heterotopic spleen transplant were performed using standard techniques. Multipanel flow cytometry was used to quantify myeloid cell populations in tissues. Human lung samples were taken from lung grafts before and after reperfusion. Student’s t-tests and ANOVA were used for statistical analysis.

Results:LIRI induced an influx of CCR2+CM into the lung (29.3±4.7 vs. 3.9±0.7 cells/mg lung; p<0.001) which was associated with neutrophil extravasation into the alveoli compared to a resting state (16.0±3.1 vs. 2.3±0.3% extravasated, p<0.001). Depletion of all intravascular monocytes with clodronate-liposomes suppressed neutrophil extravasation compared to control (4.5±0.9 vs. 9.1±1.6%; p=0.03). Specific depletion of CM with anti-CCR2 antibody abrogated neutrophil extravasation compared to isotype control (15.4±1.4 vs. 20.7±1.8%; p=0.04). LIRI in Nr4a1-/- mice, which lack only non-classical monocytes, showed no difference in neutrophil extravasation. Splenectomy impaired neutrophil extravasation (6.8±0.6 vs. 16.6±2.2%; p=0.001) and reduced CM lung trafficking after LIRI (13.5±3.2 vs. 53.8±14.0 cells/mg lung; p=0.01). Heterotopic spleen transplant after native splenectomy restored CM trafficking (Figure 1A) (195.3±73.7 vs. 13.5±3.2 cells/mg lung; p=0.008) and neutrophil extravasation (Figure 1B) (14.1±1.2 vs. 6.8±0.6%; p<0.001) compared to spleen-lacking mice. Recipient bone marrow derived CCR2+CM repopulated the heterotopic spleen grafts and were recruited to the lungs during LIRI. Reconstitution with CCR2+CM did not restore neutrophil extravasation in splenectomized mice. Human lung allografts demonstrated over 2-fold increase in CCR2+CM influx immediately after reperfusion which showed linear correlation with neutrophil recruitment (p<0.001).

Conclusion:CCR2+ CM are responsible for neutrophil extravasation after LIRI but must pass through the spleen to mediate their function. As CCR2+CM are short-lived and replenished rapidly by the bone marrow, transient depletion using anti-CCR2 antibodies can ameliorate LIRI without affecting host pathogen response.

 

 

21.04 Are General Surgery Residents Being Coerced to Exceed Duty Hour Limits? A FIRST Trial Analysis.

Posted on January 18, 2018

E. Blay1, K. E. Engelhardt1, B. Hewitt1, C. Quinn1, A. R. Dahlke1, A. D. Yang1, K. Y. Bilimoria1  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA

Introduction: As of July 1, 2017, the Accreditation Council for Graduate Medical Education (ACGME) has instituted duty hour limit flexibility by waiving caps on daily shift lengths, while maintaining the 80-hour-per-week cap. Importantly, residents can only stay after a 24-hour call if it is their choice to stay longer.  Our objectives were to understand how often and why residents in the Flexible Arm of the FIRST Trial were working longer than standard duty hour limits and whether this was due to coercion by attendings and senior residents or a voluntary decision made by the individual resident to stay longer.

Methods: All clinical General Surgery residents taking the 2017 American Board of Surgery In-Training Examination (ABSITE) were surveyed. This analysis was limited to residents in the Flexible Arm of the FIRST Trial. The main outcome was number of times the resident exceeded 2011 duty hour limits in a typical month dichotomized into 0 or ≥ 1 event.  If residents indicated that their duty hours exceeded limits in a typical month, they were asked additional questions about duty hour expectations and coercion on a 5-point Likert scale from “Strongly Agree” to “Strongly Disagree.” Rates were compared and regression models were developed to (1) identify resident and program factors associated with exceeding standard duty hour limits and (2) identify predictors of coercion to stay longer.

Results: In the Flexible Arm of the FIRST trial, 1838/1838 (100%) of clinical residents in 58 programs responded to the survey. Of 68% (n=1258) residents who exceeded duty hour rules, 22% (n= 273) of residents said their programs expected them to stay longer than standard duty hour limits.  When residents stayed longer than standard duty hour limits, 78% (n= 983) responded that they voluntarily stayed longer, while 7% (n=93) reported coercion from attendings and 9% (n=117) reported coercion from senior residents. Although females (OR 1.89, 95% CI [1.52-2.34]), interns (OR 4.47, 95% CI [3.32-6.03]) and junior residents (OR 1.43, 95% CI [1.14-1.81]) were more likely to report exceeding standard duty hour limits, there were no significant resident or program characteristics associated with coercion by attendings or senior residents to exceed duty hour limits.

Conclusion: When duty hour flexibility was utilized in the Flexible Arm of the FIRST Trial, it was generally due to the residents choosing to stay voluntarily; however, there was some coercion by attendings and senior residents. As duty hour rules transition into an era of flexibility, programs should be cognizant of ensuring residents are staying for clinical and educational purposes of their own accord and are not being coerced to break ACGME duty hour regulations unnecessarily.

 

21.01 Are Residents Really Burned Out? A Comprehensive Study of Surgical Resident Burnout and Well-Being

Posted on January 18, 2018

B. Hewitt1, J. W. Chung1, A. R. Dahlke1, A. D. Yang1, K. E. Engelhardt1, E. Blay1, J. T. Moskowitz2, E. O. Cheung2, F. R. Lewis3, K. Y. Bilimoria1  1Northwestern University,Surgical Outcomes And Quality Improvement Center,Chicago, IL, USA 2Northwestern University,Osher Center For Integrative Medicine,Chicago, ILLINOIS, USA 3American Board Of Surgery,Philadelphia, PENNSYLVANIA, USA

Introduction:  Despite great interest in resident wellness, little is known about actual rates of resident burnout as current data are limited by poor response rates, small sample sizes, or use of non-validated measures. Surgical residents are hypothesized to be at particular risk for burnout and poor well-being. We used novel national survey data with responses from nearly all U.S. general surgery residents to (1) examine burnout and poor well-being prevalence and (2) identify factors associated with burnout and well-being.

Methods:  All general surgery residents were surveyed (99% response rate) at the time of the January 2017 American Board of Surgery In-Training Examination (ABSITE) regarding wellness, duty hour violations, preparation for residency, and occupational safety. The main resident wellness outcomes were burnout (abbreviated Maslach Burnout Inventory – 6 items) and psychiatric well-being (General Health Questionnaire-12 which identifies those at risk for non-psychotic psychiatric illness). Hierarchical logistic regression analyses were performed to examine resident and program factors associated with burnout and well-being.

Results: Of 7,441 residents offered the survey, 7,387 residents (99.3%) in 260 surgical residency programs completed all items related to resident wellness. Overall, burnout was reported in 23.8% (n=1,756) of residents and poor psychiatric well-being in 44.3% (n=3,270). From the burnout assessment, 16.0% (n=1,184) of residents responded that they “do not really care what happens to some patients” at least a few times a month, and 18.1% (n=1,337) of residents responded that they daily “feel fatigued in the morning having to face another day on the job.” In multivariable models, burnout was more likely among male residents (OR 1.15 [95% CI 1.01-1.31]), those who felt unprepared for residency (OR 1.65 [95% CI 1.44-1.90]), and those who violated the 80 hour weekly average duty hour limit (violations in 1-4 of the past 6 months: OR 1.54 [95% CI 1.35-1.77]; violations in ≥5 months: OR 2.35 [95% CI 1.80-3.07]) compared to no violations. Burnout was not significantly associated with post graduate year (PGY). Poor psychiatric well-being was associated with similar factors with the exception of female residents (OR 1.25 [95% CI 1.12-1.38]) and PGY 1 residents (OR 1.19 [95% CI 1.04-1.35]) compared to PGY 4/5 residents who were more likely to report poor psychiatric well-being. There was no significant difference in burnout or psychiatric well-being between the Flexible and Standard arms of the FIRST Trial.

Conclusion: In this national survey including 99% of clinically active surgical residents in the U.S., burnout and poor psychiatric well-being were prevalent in surgical residents and more likely in residents who reported feeling unprepared for residency and those who violated duty hour limits. Solutions to improve resident wellness are needed and should address these associated factors.

 

19.06 CCR2+ Monocytes Mobilized from Spleen Cause Neutrophil Extravasation During Lung Reperfusion Injury

Posted on January 18, 2018

R. Fernandez1, M. Akbarpour1, S. F. Chiu1, H. Sun1, A. Misharin1, G. S. Budinger1, A. Bharat1  1Northwestern University,Thoracic Surgery,Chicago, IL, USA

Introduction: Lung ischemia reperfusion injury (LIRI) is the primary cause of graft failure and mortality after lung transplant. LIRI is mediated by neutrophils. Neutrophil depletion ameliorates LIRI but is not clinically applicable due to their importance in pathogen clearance. Accordingly, we focused on elucidating trafficking of neutrophils. We identified a novel subset of bone marrow derived classical monocytes (CM) which, upon mobilization from the spleen, mediates neutrophil extravasation during LIRI in mice and humans.

Methods: LIRI was induced in mice by hilar clamping for 60 mins followed by 2 hours of reperfusion. Splenectomy and heterotopic spleen transplant were performed using standard techniques. Multipanel flow cytometry was used to quantify myeloid cell populations in tissues. Human lung samples were taken from lung grafts before and after reperfusion. Student’s t-tests and ANOVA were used for statistical analysis.

Results:LIRI induced an influx of CCR2+CM into the lung (29.3±4.7 vs. 3.9±0.7 cells/mg lung; p<0.001) which was associated with neutrophil extravasation into the alveoli compared to a resting state (16.0±3.1 vs. 2.3±0.3% extravasated, p<0.001). Depletion of all intravascular monocytes with clodronate-liposomes suppressed neutrophil extravasation compared to control (4.5±0.9 vs. 9.1±1.6%; p=0.03). Specific depletion of CM with anti-CCR2 antibody abrogated neutrophil extravasation compared to isotype control (15.4±1.4 vs. 20.7±1.8%; p=0.04). LIRI in Nr4a1-/- mice, which lack only non-classical monocytes, showed no difference in neutrophil extravasation. Splenectomy impaired neutrophil extravasation (6.8±0.6 vs. 16.6±2.2%; p=0.001) and reduced CM lung trafficking after LIRI (13.5±3.2 vs. 53.8±14.0 cells/mg lung; p=0.01). Heterotopic spleen transplant after native splenectomy restored CM trafficking (Figure 1A) (195.3±73.7 vs. 13.5±3.2 cells/mg lung; p=0.008) and neutrophil extravasation (Figure 1B) (14.1±1.2 vs. 6.8±0.6%; p<0.001) compared to spleen-lacking mice. Recipient bone marrow derived CCR2+CM repopulated the heterotopic spleen grafts and were recruited to the lungs during LIRI. Reconstitution with CCR2+CM did not restore neutrophil extravasation in splenectomized mice. Human lung allografts demonstrated over 2-fold increase in CCR2+CM influx immediately after reperfusion which showed linear correlation with neutrophil recruitment (p<0.001).

Conclusion:CCR2+ CM are responsible for neutrophil extravasation after LIRI but must pass through the spleen to mediate their function. As CCR2+CM are short-lived and replenished rapidly by the bone marrow, transient depletion using anti-CCR2 antibodies can ameliorate LIRI without affecting host pathogen response.

 

18.18 Do Residents Know Duty Hour Limits? How Communicating and Interpreting Duty Hours Impacts Compliance

Posted on January 18, 2018

R. R. Love3, A. Dahlke3, L. Kreutzer3, D. B. Hewitt2,3, K. Y. Bilimoria3, J. K. Johnson3  2Thomas Jefferson University,Surgery,Philadelphia, PA, USA 3Northwestern University,Surgical Outcomes And Quality Improvement Center (SOQIC),Chicago, IL, USA

Introduction: The Accreditation Council for Graduate Medical Education (ACGME) recently revised requirements to allow programs and residents the flexibility to establish and adhere to duty hours in a manner that optimizes patient safety, resident well-being, and education.  This study used qualitative research methods to explore Program Directors (PDs), Program Coordinators, and faculty members’ understanding of duty hour regulations and how they communicate those regulations to their residents.

Methods: Semi structured interviews were conducted with a total of 98 general surgery PDs, residents, and attending surgeons from institutions enrolled in the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial. Interviewees were asked about their understanding of duty hour regulations and how that information was communicated at their institution. Interviews were recorded, transcribed verbatim, and analyzed thematically using a constant comparative approach. This study was a sub-analysis of a larger study that examined implications of duty hour policies on resident wellbeing.

Results: Several themes related to knowledge of duty hour regulations were identified in our study such as interpreting, communicating, reporting, and compliance. Respondents reported differing levels of knowledge and understanding of duty hour regulations. Communication about duty hours occurs both formally (i.e., official correspondence given to residents and faculty from PDs or Program Coordinators regarding duty hour regulations) and informally (i.e., unofficial discussions of duty hours and implicit expectations among residents or faculty). These communications were thought to have a direct impact on how residents interpret their duty hours and how they report them. Residents who were unable to correctly identify duty hour policies may be more likely to violate those policies, which has an impact on reporting and ultimately compliance to duty hour policies.

Conclusion: Inconsistent communication of duty hours from faculty, PDs, and other residents contributes to a general lack of knowledge regarding ACGME duty hours. If residents are unaware of specific duty hour regulations, then violations seem more likely. Programs should use both formal and informal communication methods to systematically reinforce the message about duty hour regulations.

17.04 National evaluation of adherence to quality measures in esophageal cancer

Posted on January 18, 2018

A. Adhia1, J. Feinglass1, K. Engelhardt1, M. DeCamp1, D. Odell1  1Northwestern University,Chicago, IL, USA

Introduction: Esophageal cancer is the leading cause of death among GI malignancies and the incidence of the disease is rising faster than any other solid organ tumor. Patients frequently present with locally advanced disease (stage III), contributing to challenges in treatment decision making.  Our objective was to assess adherence to four novel quality measures in patients with stage III esophageal cancer.

Methods:  18,555 patients diagnosed with stage III esophageal cancer were identified from the National Cancer Database (NCDB) between 2004 and 2014.  Four quality measures were defined from NCCN guidelines: administration of induction therapy, >15 lymph nodes sampled at resection, surgery within 120 days of neoadjuvant treatment, and R0 resection.  The association of patient demographic and treatment variables (age, sex, location of lesion, histology, income, education, race and ethnicity and year of diagnosis) with measure adherence was assessed using logistic regression. Risk of all-cause mortality was assessed comparing adherent and non-adherent cases using Cox modeling.  Kaplan-Meier survival estimates of groups that adhered to none, one of four, two of four etc. quality measures were performed.

Results: Adherence was high for three of the quality measures: neoadjuvant treatment (92.7%), timing of surgery (82.5%) and completeness of resection (91.5%).  However, nodal evaluation was adequate in only a minority of patients (20.0%). Advanced age, Medicaid insurance status, lower level of education and Black or Hispanic ethnicity were all associated with statistically significant increased odds of non-adherence for all measures.  Adherence improved in the more recent time period, with cases after 2008 having improved adherence in administration of induction therapy (OR = 2.58 in 2012-2014 period) and adequate nodal staging (OR = 2.49 in 2012-2014).  Achieving adherence was associated with a statistically significant decrease in all-cause mortality for administration of induction therapy (HR = 0.70 [0.62, 0.78]), nodal staging (HR = 0.67 [0.63, 0.70]), and R0 resection (HR = 0.48 [0.43, 0.53]), but not for timing of surgery (HR = 0.93 [0.85, 1.02]).  Survival improved as the number of quality measures an individual patient adhered to increased (Figure).

Conclusion: Adherence to quality measures in the care of patients with stage III esophageal cancer is associated with improved survival.  Understanding variability in measure adherence may identify potential targets for cancer quality improvement initiatives.

12.16 Utility of Liver Biopsy in the Evaluation of TPN Cholestasis

Posted on January 18, 2018

C. Buonpane1,2, G. Ares1, G. Englert3, I. Helenowski3, F. Hebal1, C. Hunter1,3  1Ann & Robert H. Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 2Geisinger Medical Center,General Surgery,Danville, PA, USA 3Northwestern University,Chicago, IL, USA

Introduction:
Cholestasis is a common and serious complication of total parenteral nutrition (TPN) in neonates, however the pathogenesis is poorly understood.  Approximately 50% of infants requiring long-term TPN develop hepatic dysfunction.  The diagnosis is made when there is development of cholestasis and an absence of other causes such as biliary obstruction, viral hepatitis, drug toxicity, and other metabolic disorders.  Liver biopsies may be requested to assess the severity of cholestasis and fibrosis; however, the impact on treatment strategies and patient outcomes has not been defined.  We hypothesize that liver biopsies in the evaluation of TPN cholestasis do not lead to changes in management or improved patient outcomes.

Methods:
This study is a single institution retrospective review of infants diagnosed with TPN cholestasis from January 2008 to January 2016.  Primary outcomes were length of stay (LOS), 30-day readmission, complication after biopsy, change in management after biopsy (Omegavan and Ursodiol) and mortality.  Univariate analysis was performed using Fisher’s exact test.

Results:

Ninety-five patients with TPN cholestasis were identified, of which 27 (28%) underwent a liver biopsy.  Nineteen (73%) patients had concurrent abdominal surgery for other indications at the time of liver biopsy. Sixty percent of patients with TPN cholestasis had short bowel syndrome and 78% of patients that had a liver biopsy had short bowel syndrome (P=0.036).  There was a significant difference in race (P=0.047) between neonates that had liver biopsies versus those that did not.  Forty eight percent of patients who underwent liver biopsy were African American.

Liver biopsy was associated with a significant change in medical management, including the initiation of Omegavan or Ursodiol.  Eleven (41%) patients were started on medical therapy as a result of liver biopsy, thirteen (48%) patients were on medical therapy prior to biopsy and three patients (11%) were unchanged. 

Patient total bilirubin levels normalized within 6 months of stopping TPN in 92% of cases, with or without liver biopsy.  There was no difference in LOS or mortality in patients with liver biopsy versus without; however, patients with liver biopsy had a higher rate of 30-day re-admission (40% vs 19%, P=0.04).  Five (19%) patients had complications after liver biopsy including bleeding requiring transfusion, need for additional procedures and apnea after anesthesia.

Conclusion:
Liver biopsy in patients with TPN cholestasis was associated with an increase in utilization of medical therapy but did not result in improved patient outcomes.   

11.05 High Mitotic Rate Predicts Sentinel Lymph Node Involvement in Thin Melanomas

Posted on January 18, 2018

K. E. Engelhardt1,2, O. Kutlu3, W. Lancaster1, K. Staveley-O’Carroll4, E. Kimchi4, A. M. Abbott1, E. R. Camp1  1Medical University Of South Carolina,Charleston, Sc, USA 2Northwestern University,Chicago, IL, USA 3University Of Miami,Miami, FL, USA 4University Of Missouri,Columbia, MO, USA

Introduction:
Current recommendations by the National Comprehensive Cancer Network are for consideration of sentinel lymph node biopsy (SLNB) for patients with melanoma <1mm. Clinicians may use presence of ulceration, mitotic rate (MR), and tumor depth to aid in decision making. Low MR has been associated with high false positive rates, however, it is unknown at what value MR becomes a significant predictor of SLN positivity. We hypothesized that higher MR would strongly predict tumor biology in thin melanomas and, therefore, predict SLN involvement.

Methods:
We queried the Surveillance Epidemiology and End Results database for all patients diagnosed with trunk and extremity cutaneous melanoma ≤1mm depth from 2010 to 2013 who underwent SLNB to determine whether MR was an independent predictor of SLN. Patient demographics and tumor characteristics (depth, mitotic rate, ulceration, and tumor location were evaluated). MR was dichotomized at multiple cut-points and estimated multiple stratified logistic regression models were used to identify the ideal cut point for MR as a predictor of SLN status. After determination of the ideal cut-point, we then estimated a hierarchical multivariable logistic regression model to determine the association between high MR and SLN+. We also performed a subset analysis for melanoma at the upper limit of thin categorization (0.75-1mm).

Results:
patient cohort was 51.7% male (n=2,246) with mean patient age of 55.6 years (range 18-85). We identified 4 or more mitosis per high power field as the ideal cut point for dichotomization of MR into high and low risk groups. In our final regression model, MR≥4 (OR 3.67 95%CI 2.66-5.05; p<0.001) and ulceration (OR 2.32 95%CI 1.62-3.31; p<0.001) were significantly associated with SLN+. In a subset analysis of 0.75-1mm melanomas, MR≥4 (OR 4.61 95%CI 2.77-7.66; p<0.001) and ulceration (OR 2.29 95%CI 1.37-3.82 p=0.002) were associated with SLN+. The SLN+ rate of the entire cohort of 0.75-1mm patients was 5.6% (n=122/2184); this number increased to 14.4% (n = 20/139) when the cohort was sub-selected for MR ≥4. Interestingly, depth was not an independent predictor of SLN+ rate in the overall cohort or the 0.75-1mm subset.

Conclusion:
In our analysis, MR≥4 was the strongest independent predictor of SLN+ in thin melanoma. In patients with thin melanoma we found that MR and ulceration, not tumor depth, were independent predictors of SLN involvement. When evaluating patients with thin melanoma for SLNB, MR and ulceration may aid in decision-making analysis more than tumor depth alone.
 

10.15 Development of a Universal Minimum Data Set for Perioperative Care in the Global Setting.

Posted on January 18, 2018

O. Yerokun3, L. M. Baumann1,2, P. Jani5, P. Frykman12, I. Ibanga9, K. Asuman8, S. Krishnaswami10, K. Nguyen18, E. O’Flynn16, B. Onajin-Obembe13, M. Ratel15, S. Bruce6, E. Stieber7, M. Swaroop2, N. Wetzig17, J. Wood11, A. Zeidan14, M. Meheš19, B. Allen19, F. Abdullah1,2, A. Latif4  1Ann & Robert H. Lurie Children’s Hospital,Division Of Pediatric Surgery,Chicago, IL, USA 2Northwestern University,Department Of Surgery,Chicago, IL, USA 3Johns Hopkins Bloomberg School Of Public Health,General Preventative Medicine,Baltimore, MD, USA 4Johns Hopkins University School Of Medicine,Anesthesiology And Critical Care Medicine,Baltimore, MD, USA 5The College Of Surgeons Of East, Central And Southern Africa,Arusha, ARUSHA, Tanzania 6Pan African Academy Of Christian Surgeons,Linden, NC, USA 7Smile Train,New York, NY, USA 8African Agency For Integrated Development,Kampala, KAMPALA, Uganda 9Pro-Health International,Edwardsville, IL, USA 10Oregon Health And Science University,Pediatric Surgery,Portland, OR, USA 11IVUMed,Salt Lake City, UT, USA 12Global Pediatric Surgical Technology And Education Project,Irvine, CA, USA 13Nigerian Society Of Anesthetists,Lagos, LAGOS, Nigeria 142nd Chance Association Reconstructive Surgery For Life Reconstruction,Meyrin, GENEVA, Switzerland 15Korle-Bu Neuroscience Foundation,Langley, BC, Canada 16Royal College Of Surgeons Of Ireland,Dublin, LEINSTER, Ireland 17HEAL Africa,Gisenyi, RUBAVU, Rwanda 18Mending Kids,Burbank, CA, USA 19G4 Alliance,New York, NY, USA

Introduction:
With increased awareness of the global burden of surgical disease and severe disparity in access to care, emergency and essential surgical care and anesthesia are recognized as a core component of universal health coverage. Achieving global improvement requires a universal language for accurate analysis and exchange of information. While examples of large-scale data systems exist, many registries in low- and middle-income countries (LMICs) are limited in scope. The Global Alliance for Surgical, Obstetric, Trauma and Anesthesia Care (G4 Alliance) is a coalition of organizations advocating for improved access to safe surgical and anesthesia care. The development of a universal, global operative data platform can allow for improved quality, structure, and process in areas with the most need.

Methods:
A comprehensive review of existing regional and international perioperative databases and surgical registries was performed.  Information commonly collected in the perioperative period was identified.  A list of surgical procedures considered to be essential procedures in any global setting was created based on existing standards (Bellwether procedures, Disease Control Priorities 3 for Essential Surgery) and expert consensus. These measures were compiled into a collection tool that was disseminated broadly to a multinational group of surgical, anesthesia, trauma, and obstetric experts as part of a working group for the G4 Alliance.  Feedback was collected both electronically and in-person during semi-annual board meetings using a modified Delphi approach and used as the basis for developing a final draft tool for the minimum operative case log.

Results:
A total of 14 experts provided critique via email or during in-person review of data parameters and procedures.  Following completion of three Delphi rounds, a consensus was reached for 38 data parameters and 74 operative procedures to include in the final draft tool. The parameters were categorized by general, demographic, preoperative, intraoperative, and postoperative information (Table 1).  Highly specialized procedures were excluded from the procedure set. All critical demographic and operative parameters were included independent of perceived collection practice in LMICs.

Conclusion:
In order to properly address the gap in delivery of safe surgical care, data-driven quality improvement is necessary.  This requires a robust data system that communicates standardized information from disparate settings across the globe. The development of a minimum operative dataset will further efforts to understand the resources currently utilized for surgical care, and help take a systematic approach to eliminate the unnecessary morbidity and mortality related to surgically treatable disease.
 

10.13 A Golden Hour? Assessing Time to Hospital Presentation for Trauma Patients in Santa Cruz, Bolivia

Posted on January 18, 2018

M. A. Boeck1, S. South2, E. Foianini3, L. Jauregui4, O. Morales Guitierrez3, G. Toledo5, J. Camacho Mansilla6, P. Mercado7, A. Haider8, M. Swaroop2  1New York Presbyterian Hospital-Columbia,Department Of Surgery,New York, NY, USA 2Feinberg School Of Medicine – Northwestern University,Division Of Trauma/Critical Care,Chicago, IL, USA 3Clinical Foianini,Santa Cruz De La Sierra, SANTA CRUZ, Bolivia 4Hospital De Niños Mario Ortiz Suarez,Santa Cruz De La Sierra, SANTA CRUZ, Bolivia 5Hospital San Juan De Dios,Santa Cruz De La Sierra, SANTA CRUZ, Bolivia 6Hospital Japones,Santa Cruz De La Sierra, SANTA CRUZ, Bolivia 7Hospital Municipal Plan 3000,Santa Cruz De La Sierra, SANTA CRUZ, Bolivia 8Center For Surgery And Public Health,Brigham And Women’s Hospital,Boston, MA, USA

Introduction:  The critical first hour post-injury, when patient care impacts survival most, is considered the “Golden Hour” in trauma. In Bolivia and other lower-resource settings, access to trauma care is difficult due to the absence of an integrated trauma system. This study sought to assess time to hospital presentation after injury and associated factors using hospital-based trauma registries from Santa Cruz, Bolivia.

Methods:  Injured patients presenting to one of five participating hospital emergency rooms (ER) were entered into a trauma registry. Data were assessed from October 2015 to February 2017. Inclusion criteria required the date and time of both the injury event and hospital presentation, and that the injury preceded hospital arrival.

Results: Of the N=6,449 registered trauma patients, N=5,113 were included for analysis. Median time to hospital presentation was 2.0 hours (IQR 0.83, 9.7). Most injuries occurred at home (37.1%) or in the street (30.5%). Median patient age presenting to the hospital ≤1 hour from the injury event was 24 years (10, 39) vs. 26 years (13, 43) for those arriving >1 hour, with a majority of men in both groups (≤1 hour: 62.1% vs. >1 hour: 64.2%). Patients who arrived >1 hour since the injury were more likely to be referred/transferred than those who arrived sooner (26.5% vs. 8.1%, p<0.001). Only the second-level, public hospital located in the city’s periphery reported a slight majority of patients arriving ≤1 hour (51.7%). Transport factors affecting time of arrival are shown in Table 1, which indicates potentially quicker hospital arrival by private car or taxi versus ambulance or public transport. Vital signs and Glasgow Coma Scale scores on hospital arrival did not clinically significantly differ between the two patient groups. A majority of patients in both groups were discharged home from the ER, however a greater proportion of patients presenting >1 hour from their injury were admitted to the hospital versus those presenting ≤1 hour (23.3% vs. 14.5%, p<0.001).

Conclusion: One-third of trauma patients reached the hospital within an hour of injury, usually by private car or taxi, suggesting a moderate level of access to timely care in this sprawling urban area in Bolivia. Ambulance transport and certain hospitals were associated with later arrival. It is imperative to identify, isolate, and mitigate elements that impede prompt medical attention, and monitor the effect of corrective interventions on patient outcomes for effective trauma system development.

10.11 Global Experience With Implementation Of A Minimum Universal Operative Case Log.

Posted on January 18, 2018

L. M. Baumann1,2, O. Yerokun10, P. Jani5, N. Wetzig6, L. Samad9, K. Park7, K. Nguyen8, M. Meheš4, B. Allen4, F. Abdullah1,2, A. Latif3  4G4 Alliance,New York, NY, USA 5The College Of Surgeons Of East, Central And Southern Africa,Arusha, ARUSHA, Tanzania 6HEAL Africa,Gisenyi, WESTERN PROVINCE, Rwanda 7World Federation Of Neurosurgical Societies,Phnom Penh, PHNOM PENH, Cambodia 8Mending Kids,Burbank, CA, USA 9Indus Hospital,Pediatric Surgery,Karachi, SINDH, Pakistan 10Johns Hopkins Bloomberg School Of Public Health,General Preventative Medicine,Baltimore, MD, USA 1Northwestern University,Department Of Surgery,Chicago, IL, USA 2Ann & Robert H. Lurie Children’s Hospital,Division Of Pediatric Surgery,Chicago, IL, USA 3Johns Hopkins University School Of Medicine,Anesthesiology And Critical Care Medicine,Baltimore, MD, USA

Introduction:
Emergency and essential surgical and anesthesia care are a core component of universal health coverage. The Global Alliance for Surgical, Obstetric, Trauma and Anesthesia Care (G4 Alliance) is a coalition of >80 organizations advocating for access to safe surgical and anesthesia care for all. A critical part of this mission is the development of a minimum operative case log tool that can be used to build a robust global surgical registry. Accurate data is essential for the evaluation and improvement of surgical outcomes, health infrastructure, and operating room processes. This pilot study aimed to assess the utility of the G4 Alliance operative case log in a global setting.

Methods:
A multidisciplinary and multinational team of experts was assembled from amongst G4 member organizations. A review of potential data measures was conducted with development of a 38 variable minimum operative data set over three rounds of a modified Delphi approach from March to December 2016. The tool was piloted by members at 6 sites in low- and middle-income countries (LMICs) across 4 WHO regions from March to June 2017. Data was collected for up to 6 weeks, and the tool was available in paper, electronic PDF, and Microsoft Access formats to facilitate collection according to local resources. 

Results:
A total of 534 cases were logged between 3 local hospitals (89%) and 3 medical missions (11%). The majority of cases were financed through donation/aid (56%) followed by self-pay (31%). Compliance with data collection for individual variables ranged from 25-100% across all sites (Table 1). The largest variability in compliance was seen with date of birth, which was recorded for 97% of cases during mission trips, but for only 16% of cases at local hospitals. Similarly, weight was recorded for 92% of cases during mission trips but only 68% of cases at local hospitals. In feedback from local staff, >90% were satisfied with the information collected and 100% would like to continue using the tool. Less than 50% of sites currently had an operative data collection system in place.

Conclusion:
Most key operative variables were easily collected across a variety of global settings. Predictably, there was poorer compliance with data that need to be collected at a separate time point such as discharge. Surprisingly, basic demographic data was amongst the most difficult to collect. These results may be reflective of systematic differences in the culture regarding data in LMICs as evidenced by the disparity between locally staffed hospitals and foreign medical missions. Successful integration of a global data system must utilize a locally feasible tool with an emphasis on accurate collection and reporting of data in order to improve surgical care.
 

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