10.19 Using mHealth Technology to Assist CHWs in Identifying Surgical Site Infections in Rural Rwanda

Posted on January 18, 2018

M. Gruendl1,2, F. Kateera1, K. Sonderman2,3, T. Nkurunziza1, A. Matousek3, E. Nahimana1, G. Ntakiyiruta4, E. Gaju5, C. Habiyakare5, E. Nihiwacu1, B. Ramadhan1, R. Riviello2,3, B. Hedt-Gauthier2  1Partners In Health, Clinical/ Research,Kigali, CITY OF KILGALI, Rwanda 2Harvard School Of Medicine,Department Of Global Health And Social Medicine,Brookline, MA, USA 3Brigham And Women’s Hospital,Boston, MA, USA 4Ejo Heza Surgical Center,Kigali, CITY OF KIGALI, Rwanda 5Ministry Of Health,Kigali, CITY OF KIGALI, Rwanda

Introduction:  

Surgical site infections (SSIs) are a significant cause of morbidity and mortality worldwide, particularly in low- and middle-income countries, where the rates of SSI can reach up to 30%. In Rwanda, post-operative follow-up for surgical patients is not routine. Therefore, there are often significant delays in presentation for patients who develop SSIs. Community Health Workers (CHWs) have been integral in maternal and child healthcare at community level and could prove an essential frontline care provider for postoperative surgical patients. The aim of this study was to develop a SSI screening protocol that a CHW could administer through a mobile health application to identify and refer SSIs back to formal health care.

Methods:  

In this prospective cohort study, we enrolled all discharged patients, 18 years or older, who underwent a cesarean section between 22 March and 22 July 2017 at Kirehe District Hospital in Rwanda. Patients from a nearby refugee camp were excluded as well as patients that did not return for a follow-up screening, scheduled at the 10th postoperative day (+/- 3 days). At the screening visit, patients were first evaluated by a CHW and then by a General Practitioner (GP), both of whom administered a 9-question SSI screening protocol: increased pain or fever since discharge, erythema, induration, edema, dehiscence, and/or drainage from the wound (with discoloration or smell). The GPs assessment of the patient wound and SSI diagnosis was considered the gold standard for our analyses. A classification and regression tree (CART) process was used to identify the most predictive questions and we evaluated the reduced algorithm based on sensitivity and specificity.

Results: 

A total of 303 patients met inclusion criteria. 31 (10.2%) were diagnosed with a SSI by the GP. Based on the GP responses to questions there were two combinations of questions that were most predictive of SSI: 1) purulent drainage, wound dehiscence or fever, which had a sensitivity of 96.8% and specificity of 86.8% or 2) purulent drainage, fever, or increasing pain, which had a sensitivity of 96.8% and specificity of 85.7%. Based on the CHW responses to questions there was one combination of questions that were most predictive of SSI which included purulent drainage, fever, or increasing pain, which had a sensitivity of 87.1% and specificity of 73.9%.

Conclusion:
Study results suggest that the optimal reduced SSI protocol is a 3-question algorithm: purulent drainage, pain, and fever. Our next steps are to evaluate the sensitivity and specificity of this protocol on an independent sample of cesarean section patients.
 

11.01 Outcomes after CRS-HIPEC by Facility: Do Higher Volumes Matter?

Posted on January 18, 2018

K. N. Partain1, E. Gabriel1, K. Attwood2, C. Powers3, M. Kim3, S. P. Bagaria1, S. N. Hochwald3  1Mayo Clinic – Florida,Department Of Surgery, Section Of Surgical Oncology,Jacksonville, FL, USA 2Roswell Park Cancer Institute,Department Of Biostatistics,Buffalo, NY, USA 3Roswell Park Cancer Institute,Department Of Surgical Oncology,Buffalo, NY, USA

Introduction:  Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) offers favorable outcomes for select patients with appendiceal and colorectal cancer (CRC). Studies have suggested that this procedure should be performed at high-volume centers, which can limit access to treatment. The purpose of this study was to determine the association between treatment volume and outcomes for CRS-HIPEC.

Methods: This was a retrospective analysis using the National Cancer Data Base, 2004-2013. CRS-HIPEC treatment centers were stratified by low-volume (<10 cases/decade), middle-volume (11-20), and high-volume (>20). Patients who received any systemic chemotherapy were excluded. The primary, long-term outcome was overall survival (OS). Secondary, short-term outcomes included the number of lymph nodes examined in the surgical specimen, post-operative hospital length of stay (LOS), unplanned readmission rate, and 30- and 90-day mortality. 

Results: A total of 749 cases were identified: 303 at low-volume, 138 at middle-volume, and 308 at high-volume centers. Carcinomatosis of appendiceal origin was present in 84.5% of cases, with the remainder of CRC origin. Table 1 summarizes the baseline demographic and clinical characteristics among the three types of centers. Overall, the cases treated among different centers were similar with respect to age, race, insurance status, and comorbid status (as reported by the Charlson-Deyo comorbidity score). The average distance traveled was highly variable (low: 54.5 miles, middle: 238.3 miles, high: 364.1 miles; p<0.001). There was no difference in the average number of lymph nodes examined (low: 13.7, middle: 14.0, high: 12.4; p=0.33), readmission rates (low: 8.7%, middle: 8.9%, high 6.7%; p=0.87), 30-day morality (low: 0.9%, middle: 0.8%, high:1.8%; p=0.59), or 90-day mortality (low: 4.1%, middle: 3.4%, high:4.7%; p=0.83). There was a difference in the average hospital LOS (low: 13.9 days, middle: 17.3 days, high: 19.2 days; p=0.008). The median follow-up for OS was 48.3 months (range 0.5 – 101.8 months). There was no significant association between case volume and median OS (low: 45.8 months, middle: 58.4 months, high: 59.4 months; p=0.43).

Conclusion: Contrary to the push for centralization of CRS-HIPEC, this data suggests that CRS-HIPEC can be completed at lower volume performing centers to achieve similar short- and long-term outcomes compared to higher performing centers. Development of CRS-HIPEC programs in geographic areas of need may be beneficial for patients located far from centralized facilities.

11.02 History of Blistering Sunburn and Molecular Profile in Melanoma

Posted on January 18, 2018

I. Soliman1, N. Goel1, K. Loo1, M. Renzetti1, T. Li1, H. Wu1, B. Luo1, A. Olszanski1, S. Movva1, M. Lango1, S. Reddy1, J. Farma1  1Fox Chase Cancer Center,Philadelphia, PA, USA

Introduction:  Next Generation Sequencing (NGS) has opened the door to investigating the underlying genetic components of cancer, in the hopes of improving diagnostic and treatment efforts. At our institution, NGS is used to detect specific mutations from a targeted cancer panel of 50 genes. The objective of this study is to analyze the molecular profiles of patients with malignant melanoma (MM) and correlate specific gene mutations and mutation burden in patients with and without a history of blistering sunburn.

Methods:  Patients with melanoma of all stages who were asked about their history of blistering sunburn (yes/no) were included in the study. Using NGS, mutations were identified in targeted regions of 50 cancer-related genes. Clinical and pathologic data were collected retrospectively and evaluated using Fisher’s exact and Wilcoxon tests.

Results: The analytic cohort consisted of 91 patients with MM, 1 excluded from analysis due to insufficient DNA. Median age at diagnosis was 63 (range 21-89) and 66% were male (n=60).  66% of the patients had a history of blistering sunburn (n=60), while 34% did not have a history of blistering sunburn (n=31). Of the 89 patients with staging data, 8% were stage I (n=7), 30% were stage II (n=27), 58% were stage III (n=52), and 3% were stage IV (n=3). A total of 136 mutations were identified, affecting 29 unique genes. The most common mutation in patients with a history of blistering sunburn was NRAS (45%), while the most common mutation in patients without a history of blistering sunburn was BRAF V600E (32%). Patients with a history of blistering sunburn had an overall mutation burden of 1.7, compared to patients without a history of blistering sunburn who had an overall mutation burden of 1.2 (p=0.028). 

Conclusion: Using our NGS platform, we identified the most prevalent mutations and the overall mutation burden in melanoma patients with and without a history of blistering sunburn. There is a statistically significant association between overall mutation burden and a history of blistering sunburn. Additionally, the study revealed that the most common mutation in patients with blistering sunburn was NRAS, compared to BRAF V600E in those without a history of blistering sunburn. These findings motivate further investigation with a larger sample size and may provide prognostic value.
 

10.17 Surgery Availability in Malawi: A Geospatial Analysis of Existing and Potential Population Coverage

Posted on January 18, 2018

A. G. Ramirez1,2, A. E. Giles2,3, M. G. Shrime4,5  1University Of Virginia,Charlottesville, VA, USA 2Harvard School Of Public Health,Boston, MA, USA 3McMaster University,Hamilton, ONTARIO, Canada 4Harvard School Of Medicin, Program In Global Surgery And Social Change,Boston, MA, USA 5Massachusetts Eye And Ear Infirmary,Otolaryngology,Boston, MA, USA

Introduction:
Access to essential surgical services is receiving increased recognition in global health with the WHO recognition of surgical provision as integral to universal health care. Using available data, a composite measure of commonly measured inputs was developed that estimates likelihood of surgical availability at a facility level, allowing for assessment of current surgical provision and progress over time using geospatial methods.

Methods:
Geospatial analysis was used to model the current percentage of the population with access to a surgically capable hospital in Malawi, the expansion of all Malawian hospitals to surgery-ready capacity, and the access gain upon optimization of five select hospitals. Data sources include the Demographic and Health Surveys Program Service Provision Assessment, a facility-based survey completed in 2013-2014 in Malawi containing geocoded data on all health facilities in the country, gadm.org for national and subnational district administrative boundaries, and WorldPoP for population density based on 2015 projections. Distance to facility was varied between 10, 20, and 30 kilometers to account for different modes of available transportation.  For the optimization scenario, the hospitals were selected based on largest predicted catchment population after accounting for existing surgically capable hospitals. 

Results:
48 of the 116 hospitals in Malawi were identified as capable of providing surgery: 4 Central Hospitals, 22 District Hospitals, and 22 Community/Other Hospitals. The present population covered by surgical services in Malawi is 5,129,191 (31.7%), 9,802,621 (60.6%), and 12,847,661 (79.4%) at 10, 20, and 30 kilometers, respectively. Enhancing surgical capacity to all hospitals would increase surgical provision to 7,510,353 (46.4%), 13,013,934 (80.4%), and 15,282,611 (94.5%) of the population at 10, 20 and 30 kilometers, respectively, an increase of 14.7-19.8% of the population.  Targeted optimization of five select hospitals showed a summative population coverage size increase of 1,530,660 (3.4%) and 1,947,799 (4.9%) of the population at 20 and 30 kilometers, respectively. All five hospitals were urban community or rural community hospitals located in the southern half of the country. 

Conclusion:
Current coverage of surgical availability in Malawi is inadequate. Given resource constraints, it is prudent to select hospitals to optimally maximize surgical services based on population coverage added. Our model provides an optimization algorithm that demonstrates that the addition of surgical capability to only five targeted facilities would expand surgical access for up to 2 million people. Improvement of additional facilities could be conducted on this same strategic basis.
 

10.18 Quantitative Evaluation of Surgical, Obstetric, and Anesthetic Capacity in Ethiopia

Posted on January 18, 2018

K. Iverson1,2, I. Citron2, O. Ahearn2, K. Garringer2, S. Mukhodpadhyay2,7, D. Burssa5, A. Teshome5, A. Bekele5, S. Workneh5, M. Shrime2,4, J. Meara2,3  1University Of California – Davis,Sacramento, CA, USA 2Harvard School Of Medicine,Program In Global Surgery And Social Change,Boston, MA, USA 3Children’s Hospital Boston,Plastic Surgery,Boston, MA, USA 4Massachusetts Eye & Ear Infirmary,Boston, MA, USA 5Federal Ministry Of Health,Addis Ababa, AA, Ethiopia 7University Of Connecticut,Storrs, CT, USA

Introduction:  As global surgery gains international attention, there is limited data in low- and middle-income countries on the capacity to provide surgical and anesthesia care. The objective of this study was to quantify the availability of surgical, obstetric, and anesthetic services in Ethiopian public hospitals.

Methods: A Harvard-WHO validated survey tool was adapted for the Ethiopian context, in collaboration with the Ethiopian Federal Ministry of Health. A total of 29 public hospitals were surveyed in three of eleven regions of Ethiopia, including 24 first-level, 3 second-level, and 2 third-level hospitals that self-reported performing surgery. The tool was administered in-person to senior administrators and surgical team members. 363 quantitative and qualitative questions were asked spanning eight categories: (1) General Information, (2) Infrastructure, (3) Surgical Sets, (4) Human Resources, (5) Interventions, (6) Emergency and Essential Surgical Care Equipment and Supplies, (7) Financing, and (8) Information Management. The answers were then validated with a hospital walkthrough and operative logbook review. 

Results: All facilities surveyed performed surgical procedures despite the unreliability of basic infrastructure: 66% of facilities reported consistent running water, 55% had uninterrupted electricity, and 96% had a continuous oxygen supply. There were on average 0.87 fully-trained surgeons, anesthesiologists, and obstetricians per 100,000 population in the hospitals’ catchment areas (20-40 SAOs/100,000 recommended by the Lancet Commission on Global Surgery). This was supplemented by 4.08/100,000 non-specialist surgical or anesthesia providers. In first-level hospitals, 96% provided cesarean sections, 79% provided laparotomies, and 0% provided open fracture repairs. A lack of supplies was also a common theme at several first-level hospitals, with only 46% reporting consistent availability of needles and sutures and 71% local anesthesia. 

Conclusion: Severe shortages exist in infrastructure, human resources, and emergency and essential surgical supplies in the Ethiopian facilities surveyed. These deficits limit procedures provided by these hospitals, particularly orthopedic surgery. The data from this study can inform future interventions designed to strengthen the Ethiopian surgical system.
 

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.
 

10.16 The Uptake of Technology and Social Media (SM) Among West African Surgeons

Posted on January 18, 2018

E. O. Abara1, J. O. Olatosi2, N. Abara3, H. Y. Angate4  1Northern Ontario School Of Medicine,Clinical Sciences,Sudbury, ONTARIO, Canada 2University Of Lagos,College Of Medicine,Lagos, LAGOS, Nigeria 3University Of Texas Medical Branch,Department of Family Medicine,Galveston, TX, USA 4University Of Abidjan,College Of Medicine,Abidjan, ABIDJAN, Cote d’Ivoire

Introduction:
The use of technology, including Social media(SM) among physicians has been reported widely. Most of the usage is for personal reasons and at conferences. There is paucity of such reports in the West African sub-region. This study will help us understand how surgeons (physicians) in this sub-region perceive and use technology and SM.

Methods:

Paper questionnaire survey was administered to consenting attendees at the 2015 WACS 55 Congress in Abidjan, Ivory Coast.Questionnaire were in English (100) and French(100). Data were compiled in aggregate protecting the confidentiality of our respondents. Data will be stored for one year. Data analysis was by Excel soft ware Ethics approval was from the Ethics Review Board of the Lagos University Teaching Hospital, Nigeria

Results:

of 200 , 74 (37%) questionnaires fully completed were from: Nigeria(60.8%);Cote D’Ivoire (20.3%); Benin Rep (5.4%);Mali (2.7%); Ghana, Senegal &Sierra Leone (1.4%) each and Non identified location (6.8%).45% were men; 31.5% women and 13.5% no response. Use of social media for personal reasons was more prevalent than for professional work. Use of various types of cell phones, daily internet use, texting. Email and various apps was common. Attitudes on the use of social media in health care ,’friending patients’ were varied Most physicians were not aware of any guidelines and/or legislation regarding online practices and privacy issues. Most physicians reported great value of SM during conferences. Overall, physician engagement in the social media services was 82.4% while 17.6% do not use them at all. More than 75% had computer, internet, cellular phone for their office practice. Fax machines, land phone lines, telemedicine and electronic health records (EHR) were rare <2%.

Conclusion:

The uptake of technology and social media is prevalent and bound to grow. Judicious adoption of technology and SM among physicians may result in strengthening the quality of health care in West Africa. Workshops and Development of Guidelines among physicians are recommended. Future efforts will focus on Urology and subspecialty surveys and increasing participation by the French speaking physicians

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.

10.14 Outcomes in Pediatric Patients with Congenital Colorectal Diseases in Sub-Saharan Africa

Posted on January 18, 2018

L. N. Purcell1, J. Gallaher1, B. Cairns1, A. Charles1  1University Of North Carolina At Chapel Hill,General Surgery,Chapel Hill, NC, USA

Introduction:
In sub-Saharan Africa, there is a high burden of pediatric surgical conditions, particularly traumatic injury. There is a paucity of data regarding outcomes in children with congenital colorectal disease, including imperforate anus and Hirschsprung Disease, especially in sub-Saharan Africa.

Methods:
A retrospective, descriptive analysis of children (≤  18 years) presenting to Kamuzu Central Hospital in Lilongwe, Malawi from February 2012 to October 2015 was performed. Utilizing a pediatric acute care surgery surveillance database, patients diagnosed with congenital colorectal disease that had and did not have surgery were compared with univariate and bivariate analysis.  

Results:

During the study period, 133 pediatric patients with congenital colorectal disease presented to KCH, 82 had Hirschsprung disease (M 70.7%, F 29.3%, 2.4 ± 2.7 years) and 51 had imperforate anus (M 41.2%, F 58.8%, 1.8 ± 2.4 years).

Of those with imperforate anus, 51.0% underwent surgery (M 42.2%, F 57.7%, 1.5 ± 2.5 years, median 0.8 years) and 49.0% had non-operative management (M 40.0%, F 60.0%, 1.9 ± 2.4 years, median 1.0 years). The most common operation performed was exploratory laparotomy with colostomy (57.7%, n = 15), followed by posterior sagittal anorectoplasty (23.1%, n = 6) and dilation (11.5%, n = 3). The average time to the operating room was 12.7 ± 15.7 days.

An equal number (n = 41) with Hirschsprung disease underwent surgery (77.3% M, 33% F, 2.7 ± 3.1 years, median 1.2 years) and had non-surgical management (63.2% M, 36.8% F, 2.2 ± 2.3 years, median 1.4 years). Of those who underwent surgery, the majority had an exploratory laparotomy (41.5%, n = 17), followed by biopsy (34.1%, n = 14), and definitive pull-through operation (19.5%, n = 8). Overall the average time to operating room was 11.7 ± 13.8 days.  

Conclusion:
Surgical access limitations, including limited pediatric surgeons (2 in Malawi) and general surgeons uncomfortable operating on pediatric patients, are highlighted by lack of surgical management and high percentage of colostomies for congenital colorectal diseases. Training general surgeons in pediatric surgery and improving postoperative follow up to increase definitive surgical therapy will improve patient outcomes.

10.12 The Impact of Increasing Surgical Capacity at a Tertiary Hospital in Southern Haiti.

Posted on January 18, 2018

L. E. Ward1, M. M. Padovany1, A. N. Bowder1,2, T. Jean-Baptiste1, R. Patterson1,3, C. M. Dodgion2  1Saint Boniface Hospital,General Surgery,Fond Des Blancs, , Haiti 2Medical College Of Wisconsin,General Surgery,Milwaukee, WI, USA 3Tufts University School Of Medicine,Boston, MA, USA

Introduction: It is estimated over 5 billion people lack access to surgery worldwide. This is often caused by a lack of surgical infrastructure and a paucity of surgical providers. St. Boniface Hospital (SBH), a 124-bed facility on Haiti’s southern peninsula, plays a critical role in providing safe, accessible surgery. SBH has grown its surgery program through three phases; Phase 1 (P1) general surgeries were performed by visiting surgical teams, Phase 2 (P2) general surgery was performed by a full-time surgeon in a single operating suite, Phase 3 (P3) the opening of a surgical center with three operating suites staffed by two general surgeons and surgical residents. We examine the impact of increasing surgical capacity at a rural hospital in Southern Haiti on case volume, patient complexity and mortality.

Methods: We conducted a retrospective review of all surgical cases performed on patients over the age of 18 at SBH between 2015 and 2017. Procedural data and patient demographics were recorded in operative logbooks at the time of the procedure. Postoperative mortality was defined by in-hospital deaths divided by the number of procedures performed.

Results:1507 adult general surgical cases were done at SBH between February 2015 and August 2017. The volume of surgical procedures performed each month increased with stepwise growth in surgical capacity (Figure 1). The average number of surgeries per week were 3.1 with visiting surgical teams (P1), 10.4 with a single general surgeon (P2), and 20.1 with two full time surgeons and residents (P3). This represents a threefold increase in surgical volume between P1 and P2, and a twofold increase between P2 and P3. As the number of surgeries increased so did the complexity of patients. The percentage of patients with ASA scores of 1, 2, 3 and 4 during P2 was 81.3%, 17.3%, 4.2%  and 1.0% respectively. In P3 the percentage of cases with an ASA score of 1,2,3, and 4 was 68.5%, 29.3%, 11.4%, and 1.3%. Surgical mortality during Phase 3 was 1.81% which compares favorably to to other surgical centers in Haiti.

Conclusion: Increasing resources and surgical staff at St. Boniface Hospital allowed for the greater delivery of safe surgical care. The increase in patient complexity represented by ASA scores suggests a greater referral base as a reputation was established. This study highlights the significant impact investments to improve surgical capacity can have in areas of great surgical need.

 

10.10 Development and Validation of a Composite Surgery Availability Score in Malawi

Posted on January 18, 2018

A. E. Giles1,2, A. G. Ramirez1,3, M. G. Shrime4,5  1Harvard School Of Public Health,Boston, MA, USA 2McMaster University,Surgery,Hamilton, ONTARIO, Canada 3University Of Virginia,Surgery,Charlottesville, VA, USA 4Harvard School Of Medicine,Program In Global Surgery And Social Change,Boston, MA, USA 5Massachusetts Eye And Ear Infirmary,Otolaryngology,Boston, MA, USA

Introduction:
Availability of surgery is gaining increasing importance in global health, yet few nationally representative surveys incorporate surgery-relevant indicators. We sought to derive a composite score that predicts surgery availability from existing population-level survey data, and validate it against known surgical data.

Methods:
The Demographic and Health Surveys Program Service Provision Assessment (SPA) survey from Malawi was used to construct a composite score. Sensitivity analysis was conducted to identify an appropriate weighting scheme. Validation was performed through re-creation of the composite score in Kenya’s Access, Bottlenecks, Costs, and Equity (ABCE) Project data and comparison of the score against actual facility surgical volume. Performance of the score was also compared to that of using cesarean section availability as the sole indicator, against an a priori set of surgical volumes as the basis of comparison. 

Results:
Based on the sensitivity analysis, the final composite score was: 0.25[Caesarian Section] + 0.25[Physician Present] + 0.20[Anesthetist Present] + 0.15[Ketamine Available] + 0.15[Transfusion Capability]. A total of 52 facilities (of the 1,060 health care facilities) were identified as providing surgical care in Malawi: 4 central hospitals, 22 district hospitals, 22 community hospitals, and 4 urban clinics. Community hospitals displayed the widest variation in ability to provide surgery. The composite score correlated well with surgical volume when applied to the Kenyan data (beta 1,378, p<0.001). Using a cutoff of 50 or more operations annually to define a facility providing surgery, the score outperformed provision of caesarean section alone with a sensitivity of 97% and specificity of 92%, versus 84% and 95%, respectively (Figure 1).

Conclusion:
The composite surgery availability score is both sensitive and specific for predicting surgical service capability. Implications for adoption of such a score include standardized evaluation of population access to surgical services and monitoring progress over time at the subnational, national, and multinational levels. The proposed methodology may make available time-sensitive findings to inform relevant policy change and investment of resources for surgery as part of achieving universal health coverage.
 

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.
 

10.07 The Global Availability of Cancer Registry Data

Posted on January 18, 2018

A. H. Siddiqui2, S. Zafar1  1University Of Maryland,Department Of Surgery,Baltimore, MD, USA 2Aga Khan University Medical College,Medical College,Karachi, Sindh, Pakistan

Introduction:

The availability of cancer registries has significantly enhanced cancer research, especially that related to cancer epidemiology, survival and outcomes. However, this data is not consistently available in all parts of the world. In an attempt to understand surgical outcomes related to cancer we first attempted to determine the availability of cancer registry data on a global level. We also aimed to test the association of cancer registry data with metadata such as country income and cancer related policy.

Methods:

The World Health Organization (WHO) International Agency for Research on Cancer (IARC) and Global Cancer Observatory (GCO) was queried to extract data on the availability and scope of cancer registries in each of the 190 WHO countries. Policy related data, country profiles, and GDP were also extracted. Information on country income classification and expenditure on health was collected from the World Bank database. 

We used the chi square and t-tests to determine associations between the availability of cancer registry data and each countries income level, per capita health expenditure, and cancer control policy.  Results were tabulated and depicted as choropleth maps using eSpatial. SPSS version 19 was used for data management and statistical analysis.

Results:

Figure 1 shows the global variation in the availability of cancer registry data. Of the 190 countries 20% did not have any kind of cancer registry. The availability of registry data varied by country income status with only 61% in low income countries (LIC) and 95% in high income countries (HIC). Of the low-income countries that did have a cancer registry, only 50% were population based of which 64% had subnational coverage. An overall 60% of countries had a national cancer policy which ranged from 31% in LICs to 79% in HICs. The availability of having registry data was not associated with country income level (p=0.306). However, countries with a national cancer policy were more likely to have a cancer registry in place (p<0.001). Furthermore, countries with high mean per capita health expenditure were more likely to have a national cancer policy (p=0.023), and a population based (p=0.003) cancer registry with national coverage (p<0.01).

Conclusion:

Country level cancer registry data is inconsistent. Low and lower-middle income countries have the least cancer registry data. The availability of data is related to the mean per capita health expenditure of these countries and presence of a national cancer control policy.

10.08 Prevalence and Predictors of Surgical Site Infections After Cesarean Delivery in Rural Rwanda

Posted on January 18, 2018

T. Nkurunziza1, F. Kateera1, R. Riviello2,3, K. Sonderman2,3, A. Matousek2, E. Nahimana1, G. Ntakiyiruta4, E. Nihiwacu1, B. Ramadhan1, M. Gruendl3, E. Gaju5, C. Habiyakare5, B. L. Hedt-Gauthier3  1Partners In Health,Clinical/ Research,Kigali, CITY OF KIGALI, Rwanda 2Brigham And Women’s Hospital,Boston, MA, USA 3Harvard School Of Medicine,2. Department Of Global Health And Social Medicine,Brookline, MA, USA 4Ejo Heza Surgical Center,Kigali, CITY OF KIGALI, Rwanda 5Ministry Of Health,Kigali, CITY OF KIGALI, Rwanda

Introduction:
Surgical site infections (SSIs) are the most common healthcare-related infections, and can cause considerable morbidity or mortality if untreated. For cesarean deliveries in sub-Saharan Africa, most mothers are discharged 3 days postoperatively, and SSIs in most cases, develop following discharge and are left undetected. Therefore, there are few unbiased estimates of the prevalence of cesarean section related SSIs in sub-Saharan Africa. The aim of this study was to estimate the prevalence and predictors of SSIs following cesarean section at Kirehe District Hospital (KDH) in rural Rwanda.

Methods:
This prospective cohort study included women who underwent cesarean section over a 4 month study period (March – July 2017) at KDH. At discharge, consenting mothers provided their demographic information and were given a voucher to return to the hospital within a time frame of 7-13 days post operatively. At the return visit patients were examined by a physician, who evaluated for an SSI and other postoperative complications.  Patients who were still admitted or readmitted to the hospital at 10 postoperative days were included and screened in the hospital on that day. A bivariate analyses assessing possible risk factors, such as patient demographics (age, occupation, education, income level, insurance, distance to health center and marital status) or clinical care variables (pre-morbidity, weight, smoking, skin preparation, ASA class, cadre of provider, surgery indication, type of anesthesia, duration of surgery and antibiotic therapy), were performed using Fisher’s exact test.

Results:
During the study period, there were 384 cesarean deliveries at KDH, of which 347 were eligible for the follow up and 307 (88.5%) were screened by the physician. Of these, 7 (2.3%) were still admitted at the hospital when they underwent screening. The majority (56.7%, n=174) were between 21 and 30 years old. 83.6% (n=168) received preoperative antibiotics within an hour of incision and 96.1 % (n=295) received at least one dose of postoperative antibiotics. The 10 postoperative day SSI prevalence was 10.3% (n=31). In the bivariate analysis, the only significant risk factor for surgical site infection was time for the patient to travel from home to the nearest health center to have dressing change.  Patients who traveled more than one hour had greater risks of SSI (p=0.028). Interestingly, neither having had preoperative antibiotic nor postoperative antibiotic were significant for a SSI (both with p>0.999).

Conclusion:
The SSI prevalence was 10% which is consistent with the current literature throughout sub-Saharan Africa. Patients who travel farther distances have a greater risk of SSI development. The etiology of this increased risk is unclear and warrants further study.
 

10.09 A Novel Survey-Based Metric for Assessing Injury Severity in Population Studies

Posted on January 18, 2018

S. A. Christie1, D. C. Dickson1, T. Nana1, P. M. Stern1, R. A. Dicker2, A. Chichom-Mefire3, C. Juillard1  1University Of California – San Francisco,Center for Global Surgical Studies,San Francisco, CA, USA 2University Of California – Los Angeles,Los Angeles, CA, USA 3University Of Buea,Department Of Surgery And Obstetrics- Gynecology, Faculty Of Health Sciences,Buea, SOUTHWEST REGION, Cameroon

Introduction:
Population-based injury data are critical for developing trauma systems, particularly in low- and middle-income countries (LMIC) where many patients do not present to formal medical care. Determining injury severity in population studies would greatly aid risk stratification and policy planning. However, severity surrogates like disability outcomes are confounded by treatment access, while anatomic and physiologic scores cannot be ascertained in the community setting. As part of an 8065 subject community-based study on injury in Cameroon, we designed a novel series of 4 survey questions intended to estimate injury severity. Outcomes of subjects with and without severity indicators were compared.

Methods:
Three-stage cluster sampling was used to select 36 enumeration areas in Southwest Cameroon. Household representatives at each site reported all family injuries in the past 12 months that resulted in death, loss of routine activity, or required medical attention. Loss of consciousness, post-injury disorientation, event amnesia, or cessation of breathing on the day of injury were considered severity indicators. Presence of severity indicators was correlated to data on injury outcomes. 

Results:
Among 503 injuries reported in a sample of 8065 subjects, 16.5% resulted at least one severity indicator. Specifically, 8% lost consciousness, 9.4% were disoriented, 1.8% had event amnesia, and 0.4% had respiratory arrest at the scene. All study subjects who died from their injuries had one or more severity indicator. Among subjects who presented to formal care, those with severity indicators had higher rates of hospitalization (50% vs. 26.5%, p=0.004) and longer admissions (11.6 vs. 2.9 hospital nights, p=0.03). Excluding injury deaths and recent injuries, subjects with severity indicators were more likely to report ongoing disability at the time of the survey (OR 1.9, p=0.004). In multiple linear regression adjusted for age and formal care use, presence of severity indicators independently predicted increased disability days (OR 23, p=0.02).

Conclusion:
Survey-based severity indicators were present in all injury deaths and predicted longer hospital stays and increased disability after injury. This novel metric shows promise as a means of estimating severity in population studies, which will improve risk stratification for policy and prevention planning. Prospective hospital-based studies should evaluate correlation of survey-based indicators with conventional severity scoring algorithms.

10.05 Establishing a context-appropriate trauma registry for Uganda using the local providers' perspective

Posted on January 18, 2018

J. A. Igu1, C. Haasbroek1, O. C. Nwanna-Nzewunwa1, I. Feldhaus1, M. Carvalho1, M. M. Ajiko2, F. Kirya2, J. Epodoi2, R. Dicker1, C. Juillard1  2Soroti Regional Referral Hospital,Department Of Surgery,Soroti, , Uganda 1University Of California – San Francisco,Center For Global Surgical Studies,San Francisco, CA, USA

Introduction:  

Trauma registries (TR) are key components of primary trauma data collection in developing countries. TR implementation can fail if stakeholder involvement is not prioritized. Stakeholder input, is required to create a context-appropriate TR that aptly captures trauma in developing countries. We sought to identify the key components of a context-appropriate prospective TR in a Ugandan Regional Referral Hospital and elicit the determinants of success and sustainability in implementing such a TR.

Methods:

Focus group discussions were held with all cadres of clinicians involved in trauma care delivery at the hospital to identify context-appropriate TR variables. These results informed the design of a TR, which was then implemented. After a one-week pilot of the TR form, we obtained providers’ views on the utility of the TR form by generating a satisfaction score (the average score derived from a five-point Likert scale) for each question.

Results:

Five focus groups consisting of 14 providers (4 intern doctors, 3 Ear-Nose-Throat care providers, 3 general surgeons, 2 orthopedic officers and 2 eye care providers) identified 47 context-appropriate TR variables. Variable categories included: demographics, history and physical exam, injury characteristics, prehospital care, prehospital transportation, investigations, interventions, diagnosis, outcome/discharge status, and consent. These providers listed five barriers to TR implementation: the perception that TRs are time-consuming and increase workload, difficulties following-up admitted patients, lack of personnel, lack of equipment and other resources to gather data, and participation and cooperation issues. They also cited the availability of TR forms distinct from patient forms, TR forms at the point of care, a TR point person, a local TR committee, a good file storage system, and provider TR awareness as facilitators of TR implementation. Providers identified lack of finances, motivation, and salary incentive, and loss of momentum of the TR project as barriers to sustainability. They named the creation and proper training of a local TR team, periodic project evaluation, efficient project resource allocation, creating a research culture, and foreign partnership(s) as facilitators of sustainability. The post-pilot survey captured the perceptions (Figure) of 29 providers (intern doctors, surgeons, clinical officers, nurses) who implemented the TR. Providers were mostly satisfied with the TR form and its implementation.

Conclusion:

Local providers’ perspectives are key to creating context-appropriate and sustainable TRs developing countries, and TR user satisfaction. Having dedicated resources, well-trained local TR staff, and local ownership of the TR is central to TR success.

10.06 Policy Implications of Road Traffic Injury in Cameroon; Results from a Population-Based Study

Posted on January 18, 2018

S. A. Christie1, D. C. Dickson1, T. Nana1, P. M. Stern1, A. Mbiarikai1, R. A. Dicker2, A. Chichom-Mefire3, C. Juillard1  1University Of California – San Francisco,Center For Global Surgical Studies,San Francisco, CA, USA 2University Of California – Los Angeles,Los Angeles, CA, USA 3University Of Buea,Department Of Surgery And Obstetrics- Gynecology, Faculty Of Health Sciences,Buea, SOUTHWEST REGION, Cameroon

Introduction:
Road traffic injury (RTI) is believed to be a major contributor to death and disability in sub-Saharan Africa. Existing data are predominantly derived from hospital or police records, leading to underreporting in areas where many people do not access formal care. To fill this epidemiologic gap and inform prevention policy, we conducted a community-based survey to identify the yearly incidence, patterns, and impact of road traffic injury in Southwest Cameroon. 

Methods:
Three-stage cluster sampling with selection probability proportionate to population was used to select 36 enumeration areas in Southwest Cameroon. Household representatives at each site were asked to report all injuries in the preceding 12 months that resulted in death, loss of routine activity, or required medical attention. Data on injury mechanism, care-seeking behavior, cost of treatment, disability and economic impact were collected.

Results:
Road traffic injury was the largest single-mechanism contributor to trauma-related death and disability. [Figure] Among 8065 individuals in 15 rural and 18 urban areas, 133 RTI were identified for a total incidence of 16.5 RTI /1000 person-years (95CI 14-20). Incidence of fatal RTI was 37/100,000 person-years (95CI 13-105). Although RTI rates were higher in urban areas (18 vs 11/1000 person-years), incidence of RTI death was higher in rural or semirural regions (60 vs 20/100,000 person-years).  Commercial transport vehicles were involved in 78% of RTI but few commercial drivers participated in first-aid or victim transport (7.5%). Seatbelts and helmets were very rarely utilized (7.6% and 8.7% respectively). Signs of severe injury including loss of consciousness, confusion, amnesia, or respiratory arrest at the scene occured in 34% of RTI. Formal medical services were sought for 79% of road traffic injuries; among those, 45% were admitted to inpatient care and 8.9% underwent at least one operation. Overall, RTI led to 480 disability days/1000 person-years with 24% of injuries resulting in ongoing disability at the time of the survey. Cost of RTI care was more than double the cost for non-RTI injury mechanisms (64,000 vs. 28,000 CFA, p<0.001) and 46% of RTI resulted in the affected household being unable to afford basic necessities.

Conclusion:
RTI occurs commonly in Southwest Cameroon and results in considerable physical and economic disability. As road safety prevention measures are rarely employed, policy modifications including increased monitoring of seatbelt and helmet compliance and offering first-aid training for commercial vehicle operators represent areas of potential opportunity to reduce disability and injury mortality in Cameroon.
 

10.03 Local Impact of General Surgery Task-Sharing in Rural Sierra Leone: A District Hospital Experience.

Posted on January 18, 2018

P. F. Johnston1, S. Jalloh2, A. Samura3, J. A. Bailey1, M. Brittany4, Z. C. Sifri1  1Rutgers New Jersey Medical School,Surgery,Newark, NJ, USA 2College Of Medicine And Allied Health Sciences,Freetown, WESTERN, Sierra Leone 3Kabala Government Hospital,Kabala, KOINADUGU, Sierra Leone 4University Of Maryland – Mercy Medical Center,Baltimore, MD, USA

Introduction:
There exists a disproportionally large burden of surgical disease in low income countries (LICs) but few immediate answers. In Sierra Leone, a handful of trained surgeons serve a country of over 6 million, leaving an excess of surgical burden, particularly in rural regions. This excess burden is borne by non-surgeon physicians and surgically-trained clinical officers (COs). In Sub-Saharan Africa, task-sharing models of CO training have shown some success in the context of caesarian sector. However, limited data exists regarding the contribution of surgical training programs towards tackling the general surgery burden of disease. The aim of this study is to examine the impact of one surgically trained CO on surgical capacity in a district hospital in rural Sierra Leone.

Methods:

Kabala Government Hospital (KGH) is a 100-bed district hospital in the rural Koinadugu district of Sierra Leone serving a population of approximately 325,000. The surgical team consists of one non-surgeon physician, one nurse anesthetist, and a handful of COs with various levels of training in surgery and anesthesia. One CO has been trained to perform basic, yet essential, surgery by a non-profit organization operating within Sierra Leone.

Case logs from the KGH operating theater over a 14 month period were reviewed to examine this CO’s contribution to hospital’s surgical output. Two-sided Pearson Chi-square test was performed to determine statistical differences between cases with a physician versus a CO as the primary surgeon. 

Results:

In total 394 procedures were performed on 375 patients at KGH over the 14 month period examined. The patient population was primarily male (75%) with a mean age 33.9 ± 18.8. The most common procedures performed were inguinal hernia repair (71%), appendectomy (12%), and hydrocelectomy (9%).  Anesthesia was most commonly spinal (50%). The CO was involved in 264 procedures (67%) and primary surgeon for 207 (53%). All cases in the series had a satisfactory immediate surgical outcome as reported in the case logs. No long-term data was available for study.

Physician primaries performed significantly more laparotomies (12% vs. 2%; p = 0.02) than CO primary, but otherwise case types were similar in terms of age, gender, surgery and anesthesia types. 

Conclusion:

A surgically-trained CO can significantly enhance the surgical capacity of a district hospital in rural Sierra Leone, performing over half of all operations with satisfactory results. Top down approaches to scaling surgical workforce and infrastructure are costly and will take time, while a large, immediate need exists. Surgical task-sharing programs may be an easily scalable and effective interim solution in areas of excessive burden and limited-resources. Limitations in the complexity of cases performed are expected and likely appropriate.

Long-term and more complete data is needed to ensure quality and safety of surgery performed by graduates of CO training programs.

10.04 Pre-Op Bowel Prep With Oral Antibiotic Reduces Morbidity After Emergent Colectomy for Diverticulitis

Posted on January 18, 2018

M. Hamidi1, M. Zeeshan1, N. Kulvatunyou1, T. O’Keeffe1, A. Jain1, A. Tang1, E. Zakaria1, L. Gries1, B. Joseph1  1University Of Arizona,Tucson, AZ, USA

Introduction:
The role of preoperative mechanical bowel (MBP) and oral antibiotic preparation (OAP) in elective colectomy has been studied extensively. However, its role is still unknown in patients undergoing emergent colectomy (EC) for acute diverticulitis. The aim of our study was to determine the association between preoperative MBP and OAP and 30-d outcomes after EC for acute diverticulitis.

Methods:
We analyzed patients from the 2012-15 colectomy-targeted NSQIP database who underwent EC for the indication of acute diverticulitis. Patients were stratified into 1 of the 4 group based on type of preoperative preparation [MBP+OAP, MBP only, OAP only, and no bowel preparation (NBP)]. Multivariate regression analysis was performed to analyze the association between preoperative bowel preparation and 30-d postoperative outcomes. 30-d outcomes were anastomotic leaks requiring intervention, surgical site infections (SSI), hospital length of stay (h-LOS), readmission and mortality.

Results:
3004 patients included. Mean age was 61±14y, and 53% were females. 11% (n=339) patients received preoperative bowel preparation [MBP+OAP (17%), MBP only (38%), and OAP only (45%)]. Most common indication for EC was perforation. Figure 1 demonstrates multivariate regression analysis for 30-d outcomes. Patients who underwent OAP only had lower adjusted rates for anastomotic leaks (OR: 0.7[0.5-0.9]), SSI (0.6 [0.3-0.9]), and readmission (0.6 [0.5-0.7]) compared to NBP. However, patients who received MBP (OR: 1.6 [1.3-2.1]) and MBP+OAP (OR: 1.3 [1.1-1.6]) were more likely to develop postoperative ileus.

Conclusion:
Bowel preparation with oral antibiotics only results in a significantly lower incidence of anastomotic leakage, incisional surgical site infection, and hospital readmission when compared to no bowel preparation. In addition, mechanical bowel preparation might be harmful and reduces the protective effect of oral antibiotic preparation.
 

10.02 Does Insurance Protect Individuals from Catastrophic Payments for Surgical Care in Ghana?

Posted on January 18, 2018

J. S. Okoroh1,4, S. Essoun3, R. Riviello2, H. Harris1, J. S. Weissman2  1University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA 3University Of Ghana,Korle-Bu Teaching Hospital/ Department Of Surgery,Accra, GREATER ACCRA, Ghana 4Fogarty International Center,UcGloCal Consortium,Bethesda, MD, USA

Introduction:
According to the WHO, essential surgery should be recognized as integral to achieving Universal Health Coverage. We previously reported that surgical conditions were commonly included in national health plans, yet catastrophic health expenditures persist. Insurance is associated with a reduction in maternal mortality and improved access to essential medications in Ghana, but whether it eliminates financial barriers to care for surgical patients is unknown. We sought to describe amounts and payments for general surgical conditions included under Ghana’s national health insurance scheme, and test the hypothesis that insurance protects surgical patients against financial catastrophe. 

Methods:
We interviewed patients admitted to the general surgery wards of Korle-Bu Teaching Hospital between February 1 – June 30, 2017 to obtain demographic data, annual income, occupation, household expenditures and insurance status. Surgical diagnoses and procedures, procedural fees, anesthesia fees, medicines and all other costs incurred were collected through chart review. The data was collected on a Qualtrics platform and analyzed in STATA. T-tests and chi-square tests were used to compare insured and uninsured groups. Threshold for financial catastrophe was defined as >10% of annual household expenditures, >40% of non-food expenditures, or >20% of individual income. 

Results:
Among 107 enrolled patients, demographic characteristics did not significantly differ between the insured and uninsured except the insured were slightly older [mean 49 years vs 40 years P<0.05.] and more likely to be female [65% vs 40% p<0.05]. The most common surgical procedures for both groups were laparotomy, inguinal hernia repair and appendectomy. Insurance paid on average 40% of the total cost of surgical care, thus protecting some patients from financial catastrophe. However, 50% of the insured patients experienced financially catastrophic payments and almost all reported out-of-pocket payments in addition to hospital payments for medicines and laboratory tests. 

Conclusion:
This study—the first to evaluate the impact of insurance on financial risk protection for surgical patients in a resource-limited setting—shows that despite its benefits, about half of insured surgical patients are not protected from financial catastrophe under the Ghanaian national health insurance scheme due to out-of- pocket payments. Government-specific strategies to enroll uninsured individuals at the point of care and to increase the proportion of cost covered are crucial to protecting individuals from financial catastrophe due to surgical care in Ghana thus achieving Universal Health Coverage. 
 

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