05.19 Identifying essential components of surgical care delivery: An updated Hospital Assessment Tool

Posted on January 25, 2017

Y. Lin1,2, N. Raykar1, S. Saluja1, S. Mukhopadhyay1, S. Sharma1, B. Frett1, S. Enumah1, J. Meara1, M. Shrime1  1Harvard School Of Medicine,Program In Global Surgery And Social Change,Brookline, MA, USA 2University Of Colorado Denver,Department Of Surgery,Aurora, CO, USA

Introduction:
Over 5 billion people do not have access to timely, safe, and affordable surgical care, a cost-effective intervention with major public health impact. Fortunately, the overwhelming unmet surgical need has led to a rising interest in the scale-up of these services globally. Few tools exist, however, that provide comprehensive guidance to health systems planners on the infrastructure, workforce, service delivery, information management and financing elements necessary to build strong surgical systems. We aimed to critically review available guidelines and expert consensus to create an encompassing tool for local, national, regional and international surgical systems planning.

Methods:
PubMed and Google Scholar were searched to identify published documents cataloguing supply, equipment, and/or infrastructure elements for provision of surgical care. An expert panel was convened by The Lancet Commission on Global Surgery during its inaugural meeting in Boston in January 2014 which, among its other tasks, identified and obtained additional documents that were inaccessible through the published literature but part of the operating guidelines for global medical and surgical organizations. This panel consisted of clinicians, researchers, and public health experts from six countries of low-income, middle-income, and high-income country groupings. A comprehensive list of items was generated from these documents, and items with a reported frequency of >30% were included in the initial draft of the Hospital Assessment Tool.  This tool was modified based on the Lancet Commission on Global Surgery’s (LCoGS) National Surgical Plan (NSP) framework.  Adhering to Delphi methodology for survey validation, the updated tool was sent to providers working in low and middle income settings to create an expert-endorsed Hospital Assessment Tool.

Results:
Fifteen surgical tools were identified, containing a total of 216 unique elements related to surgical care delivery. Using the NSP framework, all elements were catalogued within infrastructure (n=152), service delivery (n=49), and workforce (n=15); no elements were identified within the domains of information management or financing. 18 individuals identified as expert providers participated in two rounds of Delphi validation. The final tool consisted of 160 items in the following domains: infrastructure (n=82), service delivery (n=35), workforce (n=21), information management (n=10), and financing (n=12).

Conclusion:
A careful, systematic approach to planning is critical to ensure successful scale-up of surgical services.  Our analysis shows that existing guidance in this arena is varying in advice on the essential components of surgical care delivery.  The Hospital Assessment Tool critically aggregates core elements across the five domains of surgical systems strengthening while allowing for adaptation to local context.
 

05.18 Safety and Effectiveness of the Transverse Abdominal Plane Block in Low to Middle Income Countries

Posted on January 25, 2017

A. J. Scholer1, A. Hashemi2,3, Z. C. Sifri1, M. Gajewski2  3University Of Miami,Anesthesia,Miami, FL, USA 1New Jersey Medical School,Surgery,Newark, NJ, USA 2New Jersey Medical School,Anesthesiology,Newark, NJ, USA

Introduction

Advances in technology have allowed innovation and rapid deployment of these discoveries to spread throughout the developed world. In low to middle income countries (LMICs) a dearth of resources prevents a similar advancement of medical progress. Resources such as opioid medications are difficult to obtain and make pain control one of the many difficult aspects of surgical care in LMICs.  To provide adequate pain control in these countries, surgical teams must implement alternate modes of analgesia, and often their ingenuity, to make surgery a possibility. During short term surgical missions (STSMs), implementation of the transverse abdominal plane (TAP) block was used as an adjuvant to control pain in lieu of narcotics. The primary objective of our study was to determine the TAP block’s safety, feasibility and effectiveness in decreasing opioid use and controlling postoperative pain in LMICs. 

 

Methods

A retrospective chart review was conducted of patients who underwent a hysterectomy (23 patients) during STSMs from 2008 to 2015. Patients were divided into two groups, general anesthesia (GETA) and spinal anesthesia (5 patients, control group) vs. GETA and spinal anesthesia with a TAP block (5 patients). The primary endpoints of our study included Visual Analog Scale (VAS) pain scores at rest (30 minutes – 2 hours postop); intravenous (IV) narcotic doses administered, and complications from TAP block. Secondary endpoints included hospital length of stay (LOS); time to rescue medication, and initial pain score in the PACU.  Baseline characteristics were identified and included age, comorbidities, and the American Society of Anesthesiologists (ASA) class.

 

Results

Mean pain scores significantly increased at each time interval in TAP group than the control group (Table 1) while the mean dose of postoperative narcotics given was similiar in both groups (17 μg fentanyl [0 – 40 μg], control vs. 15 μg fentanyl [5 – 30ug], TAP). The total dose of intraoperative narcotics was lower in the TAP group compared to the control group (95 μg fentanyl [5 – 230 μg] vs. 237 μg fentanyl [0 – 440 μg], respectively, p-value = not significant). No complications from the TAP block were reported.

 

Conclusion

This study demonstrated that a TAP block is a safe opioid alternative, however, resulting in higher initial VAS pain scores post-hysterectomy in LMICs.  Availability of TAP blocks is dependent on trained anesthesia staff and availability of ultrasound equipment which may be limited during STSMS.  In conclusion, if narcotics are scarce during a STSM and trained anesthesia staff is available, TAP blocks are safe and effective in preventing escalation of pain postoperatively in LMICs.

05.17 Global Initiative for Children’s Surgery: Initial experience

Posted on January 25, 2017

L. F. Goodman1, G. Jensen1, S. Greenberg6, K. Lakhoo7, E. Ameh10, D. Poenaru2, D. Ozgediz4, B. Ure8, K. Oldham5, D. Farmer1, S. Bickler3  1University Of California – Davis,Surgery,Sacramento, CA, USA 2McGill University,Pediatric Surgery,Montreal, QC, Canada 3University Of California – San Diego,Pediatric Surgery,San Diego, CA, USA 4Yale University School Of Medicine,Pediatric Surgery,New Haven, CT, USA 5Children’s Hospital Of Wisconsin,Milwaukee, WI, USA 6Medical College Of Wisconsin,Surgery,Milwaukee, WI, USA 7John Radcliffe Children’s Hospital Of Oxford,Oxford, OX, United Kingdom 8Hannover Medical School,Pediatric Surgery,Hannover, NS, Germany 10National Hospital,Pediatric Surgery,Abuja, ., Nigeria

Introduction:  Access to surgical care is limited for five billion people worldwide and children comprise one-third of the world population. Injury and congenital anomalies are increasingly important causes of death and disability, and are often treatable with surgery. Surgeons, anesthetists, and critical care providers in resource-limited settings are most familiar with factors that limit access to quality surgical care for children. This initiative sought to bring together diverse providers to generate a common set of priorities and coordinate efforts for all children to have access to timely and quality surgical care.

Methods:  Ten children’s surgeons and trainees met bi-weekly starting in October 2015. An online survey was sent to invitees to determine the meeting agenda, which included presentations of specialty- and region-specific experiences, followed by working groups.  Thirty-seven surgical care providers, including 27 providers from 18 low- and middle-income countries (LMICs), participated in a two-day working meeting in London in May 2016. The working groups (infrastructure, service delivery, training, and research) identified solutions and created priority lists.  The groups were self-selected, but participants were encouraged to switch between sessions. Summaries were prepared and presented by one group member at the end of each session. At the conclusion of the London meeting, a 16-question paper survey was completed.

Results: Thirty-two physicians completed a pre-meeting survey. Thirteen were females and 22 had completed specialty training in the care of children. Workforce issues were the greatest challenge identified, followed by facilities, patient factors, and the health system. Agreed-upon priorities in each of four areas are shown in Table 1. Outputs determined by the group included needs assessments and a consensus statement on optimal resources for children’s surgical care, both of which are completed. Two training partnerships, between the Royal College of Surgeons of England and India, and between Uganda and South Africa, also began. There were 27 responses to the post-meeting survey. Sixteen found the breakout groups to be the most useful part of the meeting, while four preferred the closing summary action session. Twenty-six found the meeting very useful and thought it should be repeated.

Conclusion: GICS is an innovative forum allowing LMIC providers to share ideas and develop priorities for the improvement of surgical care for children. The group has successfully identified needs and generated specific solutions for the improvement of surgical capacity. The group will continue to catalyze LMIC-centric collaboration by generating tools and knowledge and matching resources to needs.

 

05.15 Limitations to Laparoscopic Cholecystectomies in Guatemala

Posted on January 25, 2017

T. D. Madni1, A. Ochoa2, C. Ortiz2, B. Mijangos2, J. B. Imran1, J. Herrejon1, S. Huerta1  1University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA 2Hospital Nacional De San Benito,Peten, , Guatemala

Background: Over the past  20 years laparoscopic cholecystectomy (LC) has become the standard of care for acute cholecystitis and symptomatic cholelithiasis in the United States. However, in third world countries open cholecystectomies (OC) are still often performed given the relative lack of resources, expertise, and/or training. We have previously shown that over 50% of elective cholecystectomies in rural Guatemala are performed via an open approach.  We hypothesize that the reasons for the scarcity of laparoscopic cholecystectomies is the result of the following factors: (1) deficiency of surgical training in laparoscopy; (2) lack of funding (government); (3) lack of equipment, maintenance, and replacement parts (i.e. trocars, verses needles, general anesthesia).  This study was undertaken to outline factors that lead to the limitations of LC at the major referral hospital in Peten, Guatemala. 

Methods: We reviewed 9402 cholecystectomies performed over 14 years by seven surgeons at the main referral county hospital in Peten, Guatemala  (Hospital Nacional de San Benito: HNSB).  We conducted personal interview with all the surgeons who perform cholecystectomies at HNSB  to determine why OC were more often performed..  All data is expressed at means +/- standard deviation.  Differences between LC vs OC were analyzed by Fisher’s exact test or X2.  Statistical significance was established at a p<0.05 (two-sided). 

Results:  The average age of the surgeon involved was 43±12.1 yo with an average years in practice 14.1±9.9. Total number of cholecystectomies performed were 9402 [8440 (90%) OC, 962 (10%) LC]. The average number of cholecystectomies performed per surgeon were 1341.1±1244.9, OC 1205.7±1194.9, LC 137.4±188.0. The average number of LC performed during training were 262.8±263.9.  Lack of formal training in laparoscopy was identified by 57% of surgeons.  71% of surgeons stated there was a lack of government funds to implement a laparoscopic program (29% felt there were insufficient ancillary staff, and 29% noted poor allocation of hospital funding to purchase laparoscopic equipment/training).  Insufficient laparoscopic equipment was identified by 71% of surgeons.  Of note, 57% preferred to perform LC if possible,  29% preferred OC, 14% did not have a preference. With regards to patient predilection: 14% of surgeons felt patients preferred LC, another 14% felt patients preferred OC, 43% felt that patients were split, and 29% did not feel their patients were educated enough to make this decision. 43% did not think the anesthesia providers were appropriately trained for general anesthesia required for LC.

Conclusion:  Ninety-percent of cholecystectomies performed by these surgeons continue to be OC.  The major limitation is the lack of funding to provide sufficient equipment or ancillary staff.  The majority of surgeons preferred to perform LC if these problems could be addressed. 

05.16 Adult Trauma Mortality Characteristics: Pre-hospital versus In-hospital Deaths

Posted on January 25, 2017

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

Introduction:  In sub-Saharan Africa, trauma is a leading cause of mortality in people less than 45 years old. Injury mechanism and cause of death is difficult to characterize in the absence of pre-hospital care and a trauma surveillance database. Pre-hospital deaths (PHD) and in-hospital deaths (IHD) were compared to elucidate comprehensive mortality injury characteristics.  

Methods:  A retrospective, descriptive analysis of adults (≥ 18 years) presenting to Kamuzu Central Hospital in Lilongwe, Malawi from 2008 to 2013 was performed. Utilizing an emergency department-based trauma surveillance database, patient and injury characteristics of pre-hospital and in-hospital deaths were compared with univariate and bivariate analysis.

Results: 54,504 adult trauma patients presented to KCH between 2008 and 2013. Of those patients, 587 and 473 were BID and DIH, respectively. The majority were men with a mean age of 32.4 ± 12.6 and 38.8 ± 15.2 years, BID and IHD respectively. Head injuries (48.9% vs. 46.4%) due to motor vehicle crash (MVC, 47.4% vs. 60.4%) were the leading cause of death in both groups (BID vs. IHD). Transportation to the hospital was primarily via police (56.5%) for PHD and private vehicle (45.8%) for IHD, with ambulance services transporting less than 7% of patients for both groups. The average time to presentation to the hospital for PHD and IHD was 0.5 ± 1.1 and 1.2 ± 1.7 hours, respectively. The mean time to mortality for IHD was 1.9 ± 2.4 days.

Conclusion: Head injury from MVC is the leading cause of PHD and IHD in Malawi. The majority of patients are transported via police for PHD and private vehicle for IHD, which is consistent with the absence of a pre-hospital care system in Malawi. Improving pre-hospital care, with a special focus on head injury and strategies for vehicular injury prevention within a trauma system, will improve adult trauma mortality in Malawi.

 

05.14 Surgical Volume and Post-Operative Mortality Rate at a Referral Hospital in Western Uganda

Posted on January 25, 2017

G. A. Anderson1,5, L. Ilcisin5, L. Abesiga4, R. Mayanja4, N. Portal Benetiz2, J. Ngonzi4, P. Kayima2, M. Shrime5  1Massachusetts General Hospital,Surgery,Boston, MA, USA 2Mbarara University Of Science And Technology,Surgery,Mbarara, WESTERN, Uganda 3Havard Medical School,Global Health And Social Change,Boston, MA, USA 4Mbarara University Of Science And Technology,Obstetrics And Gynecology,Mbarara, WESTERN, Uganda 5Harvard School Of Medicine,Global Health And Social Medicine,Brookline, MA, USA

Introduction:  The Lancet Commission on Global Surgery (LCoGS) recently recommended that every country report its surgical volume and post-operative mortality rate. Little is known about the numbers of operations performed and the post-operative mortality rate (POMR) in low and middle-income countries (LMIC’s). Additionally, there is little guidance from the literature regarding the most accurate method for collecting these metrics in low resource settings.

Methods:  During two, 2-week periods, every patient who underwent an operation at a medium sized hospital in Western Uganda (MRRH) was observed and recorded. These patients were then followed until discharge or for 30 days. The types of operations were recorded, as were the outcomes of all patients. Prospective data were compared with data obtained by looking at logbooks and patient charts to determine the validity of using retrospective methods for collecting these metrics

Results: Surgical volume at this regional hospital in Uganda is 8,515 operations per year, significantly higher than the 4,000 operations/year reported in the only other paper on volume at a referral hospital in Uganda. The POMR at this hospital is 2.4% (6% for when OBGyn cases are excluded), similar to the 2.1% POMR reported from MSF hospitals (22) and the non-obgyn POMR is nearly identical to the 6% reported at a referral hospital in Rwanda. Finding patient files in the medical records department was time consuming and ultimately yielded only 62% of the needed files. Furthermore, a comparison of missing versus found charts revealed that the missing charts are significantly different from the found charts. Logbooks, on the other hand, found 99% of the operations and 94% of the deaths.

Conclusion: The LCoGS recommends that every country begin annual reporting of surgical volume and POMR. Our results describe a simple, reproducible, accurate and inexpensive method for collection of these variable using logbooks that are already exist in the operating theatres and on the wards of most hospitals in low resource settings. While some have suggested using risk-adjusted POMR as a more equitable variable our data suggests that only a limited amount of risk adjustment is possible given the limited resources in hospitals such as MRRH

05.13 The Effect of a Centralized Blood Banking Policy on Blood Product Availability in Sub-Saharan Africa

Posted on January 25, 2017

J. R. Gallaher1, G. Mulima2, C. G. Shores1, A. G. Charles1,2  1University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA 2Kamuzu Central Hospital,Surgery,Lilongwe, , Malawi

Introduction:
Surgical bleeding can result in substantial morbidity and mortality in the absence of blood transfusion services. Unfortunately, these services remains largely unavailable, unreliable, and unsafe in low-resource countries, especially sub-Saharan Africa. The World Health Organization has addressed these shortages with a policy emphasizing blood safety using centralization and donor restriction. This study sought to characterize the availability of blood products over time for patients with acute hemorrhage at a tertiary center in sub-Saharan Africa, using upper gastrointestinal (UGI) bleeding as a proxy.

Methods:
This is a prospective observational study of adults presenting to Kamuzu Central Hospital (KCH) in Lilongwe, Malawi with clinical signs of acute UGI bleeding over two years (2011-2013). KCH is a resource-poor public, tertiary hospital. We used linear regression modeling to analyze the change in blood product utilization per patient over time, adjusted for presenting hemoglobin. 

Results:
293 adult patients with UGI were enrolled with a mean age of 41.8 years (SD 15.8) and a male preponderance (61.4%). The mean presenting hemoglobin level was 7.2 (SD 3.4) g/dL with 56.1% of patients having a hemoglobin <7 g/dL. A majority (71.3%) of patients received at least one unit of whole blood and the mean number of blood units received was 2.3 (SD 1.4). Only 50.2% of patients received their first transfusion on the day of admission. There was a linear relationship between presenting hemoglobin and the number of units of blood transfused as patients with a lower hemoglobin level received more blood. Over the two-year study period, the mean number of units transfused decreased linearly from 2.5 units (95% CI 2.1, 2.9) at the beginning of the study to 1.3 units (95% CI 0.9, 1.7) at the end, when adjusted for presenting hemoglobin (p=0.0014). 

Conclusion:
At a tertiary center in sub-Saharan Africa, the availability of blood products for acute hemorrhage appears to have decreased over time in the context of substantial policy changes over the last decade. We cannot make substantial progress on the reduction of surgical morbidity and mortality in the absence of a rational blood banking policy that balances both safety and supply.

05.12 Treating Pediatric Hydrocephalus in Sub-Saharan Africa: Outcomes After Shunt Placement

Posted on January 25, 2017

S. Scarlet1, J. Gallaher1, A. Charles1  1University Of North Carolina At Chapel Hill,Acute Care Surgery/General Surgery,Chapel Hill, NC, USA

Introduction:  The prevalence of hydrocephalus is greatest in developing countries, where access to neurosurgical care is limited. Hydrocephalus is the most common indication for pediatric neurosurgery worldwide. Untreated disease is associated with severe neurological disability and a high mortality rate. Additionally, there is paucity of data regarding the long-term outcomes of children following ventriculoperitoneal (VP) shunt placement. 

Methods:  We completed a retrospective review of all children diagnosed with hydrocephalus from March 2015 until June 2016 at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi.

Results: Hydrocephalus was diagnosed based on clinical exam, ultrasound, and measurement of intracerebral pressure via ventricular aspiration in 100 children (45% female). All children underwent VP shunt placement during the 17-month study period. Average age at diagnosis was 4.9 months (SD 5). Presenting signs were enlarged head circumference (94%), seizure disorder (22%), irritability (26%) and meningitis (24%). At the time of surgery, mean weight was 6.3 kg (SD 2.5) and mean head circumference was 52.1 cm (SD 8.6). Mean post-operative length of stay was 27 days (SD 14). Crude in-hospital mortality was 4%. Five children required shunt revision for exposed shunt (n=4) and occluded shunt (n=1). 43 patients had follow-up at home within six months of VP shunt placement. 22 children (51%) died within the six-month follow-up period. Among children who had follow-up, a higher mean head circumference (cm) to weight (kg) ratio was associated with late mortality, 10.2 vs. 7.5 (p=0.01).

Conclusion: In sub-Saharan Africa, the high prevalence of pediatric hydrocephalus is attributed to higher birth rates, poor prenatal care, and increased likelihood of meningitis in the perinatal and neonatal period. In our study, the follow-up mortality rate was very high, especially for patients with a high head circumference to weight ratio. More research is needed to determine the appropriate patient population and optimal time for VP shunt placement in a resource-poor setting.

 

05.11 Cancer Registration in Resource-Limited Environments – Experience in Lagos, Nigeria

Posted on January 25, 2017

M. Fatunmbi1,2, M. Masika1,2, A. Saunders2, C. Agbakwuru3, B. Chugani3, M. Jimoh3, O. Ilegbune3, A. Adewale3, O. Akinyemiju3, C. Nwogu1,2,3  1State University Of New York At Buffalo,Buffalo, NY, USA 2Roswell Park Cancer Institute,Buffalo, NY, USA 3Lakeshore Cancer Center,Lagos, , Nigeria

Introduction:
There is significant disparity in cancer registration between high income countries (HIC) and low- to middle-income countries (LMIC).  While population-based cancer registries provide a superior sample compared to hospital-based cancer registries, the utility of hospital-based cancer registries has been supported.  Despite great efforts being made by international organizations, such as the World Health Organization (WHO) and its subsidiaries, there is still a great deficit in the number and quality of cancer registries in Africa.  Development of high quality cancer registries has proven challenging for various reasons, including resource limitations restricting population access to healthcare facilities, lack of trained personnel, and inadequate funding for cancer control efforts from all government levels.  In addition, there is an under appreciation of the cancer burden, thus an under appreciation of the role registries play in recognizing and alleviating the burden.  Therefore, there is a recognized need for the establishment of more cancer registries in LMICs.  

Methods:
Lakeshore Cancer Center (LCC) in Lagos, Nigeria sought to establish a hospital-based registry to allow for a proper assessment of the cancer burden of its patient population.  The aim was to begin collection of data, make it accessible to other hospitals and institutions, and ultimately to expand to a regional population-based cancer registry.  A retrospective review of electronic and paper records of patients who presented at LCC from July 2014 to June 2016 was performed.  Patient demographics, diagnoses, stages and treatments were captured, and initially coded in Excel for preliminary review.  Descriptive statistics were analyzed.  CanReg5 (International Association for Cancer Registration, Lyon, France), an open source application, was then customized to capture selected data elements in a hospital-based cancer registry based at LCC. 
 

Results:

Since July 2014, LCC has seen an increase in the number of new cancer cases.  The total number of cases captured was 226.  Evaluation of patients by disease site revealed that the most common cancer site was breast (38%), followed by prostate (12%), colorectal (8%) and cervical (6%).  A combination of gynecological, upper GI, CNS, hematological and renal cancer constituted 25% of diseases sites.  The majority of patients also presented with stage III (24%) or IV (61%) cancers (Figure 1).

 

Conclusions:

These results reflect early hospital-based cancer registry data from a cancer center in an LMIC.  The data reveals that 85% of patients treated at LCC present at later stages.  This highlights a need for developing and strengthening early detection and screening programs.

 

05.10 Assessing the costs of a short-term surgical mission in rural Guatemala

Posted on January 25, 2017

M. M. Esquivel1, J. Chen1, N. Siegler1, T. Uribe-Leitz1, D. Siegler2, T. G. Weiser1, G. Yang1,3  1Stanford University,General Surgery,Palo Alto, CA, USA 2Santa Clara Valley Medical Center,Obstetrics And Gynecology,Santa Clara, CA, USA 3Palo Alto VA Health Care System,General Surgery,Palo Alto, CALIFORNIA, USA

Introduction:  Essential surgical conditions account for 18% of the Global Burden of Disease. Short-term surgical missions help address these needs, but there are concerns about appropriate resource allocation. The costs of visiting teams can be significant, and some have questioned whether that money would be better spent expanding local resources. We examined the costs of a short-term surgical mission in rural Guatemala as an approach to conducting a cost comparison of different monetary allocation strategies.

Methods:  We gathered diagnostic and therapeutic information on patients presenting to general, pediatric, plastic, ophthalmologic, and obstetric and gynecologic (Ob/Gyn) clinics from July 27 to August 6, 2015 at a free-standing clinic and surgery center in rural Guatemala. We also obtained information on patient costs and local provider salaries. Separately, we obtained data on the costs of running a 2-week surgical mission, including administrative fees, local staff salaries, travel, and supplies.

Results: The total cost for delivering the 2-week surgical mission was $105,050. Administrative costs, consumables, and salaries for local hospital staff (including the 3 Guatemalan primary care providers) were $26,940. Travel costs for the visiting surgical team (which included surgeons, operating room scrubs, techs, and nursing staff) were $48,110. The majority of surgical supplies and medications were donated, although some were purchased; the total value was estimated at $30,000. Total fees of $27,310 were collected from patients, of which $4,950 was for 1067 clinic visits and $22,360 was for operations performed on 258 patients. Had local Guatemalan surgical providers for those specialties (specifically 2 obstetricians and gynecologists, 1 general surgeon, 1 pediatric surgeon, 1 plastic surgeons, 3 ophthalmologists, and 4 anesthesiologists) performed these procedures in place of the visiting team, their costs would have been an estimated $26,670.

Conclusion: Local fees covered all the local costs generated by the provision of care, but only 26% of the total costs of surgical care provided. If local surgical providers were substituted in place of the visiting team, it would cost over half of the equivalent to what was spent on travel. The visiting team expanded service coverage, provided nearly equivalent resources in purchased and donated supplies and medications, and supported an extended range of specialty care. Recruiting and retaining similar capacity is difficult given the lack of local human resources and does not include the numerous scrub techs, nursing and support staff required during the surgical mission. Until such resources are available locally, combining surgical missions with local capacity-building extends access to primary and specialty surgical care.

 

05.09 Emergency and Essential Surgical Procedures for Children at the Primary Referral Hospital

Posted on January 25, 2017

M. Piacquadio2, E. Ward6, L. Goodman3, A. Wang5, E. Ameh4, S. W. Bickler1  1Rady Children’s Hospital/ UC San Diego,Department Of Pediatric Surgery,San Diego, CA, USA 2Western University Of Health Sciences College Of Osteopathic Medicine Of The Pacific,Pomona, CA, USA 3UC Davis Medical Center,Department Of Surgery,Davis, CA, USA 4National Hospital,Division Of Pediatric Surgery,Abuja, FCT, Nigeria 5Naval Medical Center San Diego,Department Of Surgery,San Diego, CA, USA 6UC San Diego,Department Of Surgery,San Diego, CA, USA

Introduction:  An estimated 2 billion children worldwide do not have access to safe surgical care. To begin addressing this critical gap in surgical care, a consortium of providers, institutions and other stakeholders formed the Global Initiative for Children’s Surgery (GICS) in 2016.  GICS is in the process of identifying optimal resources for children’s surgical care for different types of facilities in low- and middle-income countries (LMICs).  An important unanswered question is which procedures should be done at different levels of care. The goal of this research was to create a list of emergency and essential children’s surgical procedures that can be preformed safely at the primary referral hospital level in LMICs, and to estimate the impact this limited list of procedures might have on the overall surgical need. 

Methods:  To identify a list of emergency and essential children’s surgical procedures we reviewed Surgical Care For Children: A Guide For Primary Referral Hospitals (Macmillan Publishers, 2011). This handbook includes life saving and/or commonly performed procedures that are not complex, and that can be safely performed by medical officers or general surgeons after brief training. To estimate the impact this list of procedures might have on the total need for children’s surgical care we compared the Macmillan generated list to the surgical procedures recorded in comprehensive children’s surgical database from The Gambia (West Africa). This prospective database contains detailed information on all children aged less than 15 years who were treated for surgical conditions at a government referral hospital in Banjul over a 29-month period (Bull WHO 2000; 78:1330-6). 

Results: Surgical Care for Children describes 39 emergency and essential surgical procedures.  Procedures on this list treat a wide spectrum of childhood surgical conditions—including the most common injuries (e.g., burns and fractures), selected congenital anomalies (e.g., inguinal hernia and clubfoot), and infections requiring surgery (e.g., abscesses, osteomyelitis and septic joints).  The Macmillan generated list of emergency and essential surgical procedures covered 496 of the 798 (62.2%) surgical procedures recorded Gambian surgical database. 

Conclusion: Our data suggests that the majority of childhood surgical conditions in LMICs could be treated by a limited number of emergency and essential surgical procedures delivered at the primary referral hospital level.  Improving surgical care for children at primary referral hospitals could improve access for children with surgical conditions; decrease the burden at higher levels of care, and likely decrease cost. Future research should focus on the economic and public health impact of providing a pediatric focused package of children’s surgical care at primary referral hospitals in LMICs, and the best strategy for implementation. 

05.08 Trauma system assessment in Mongolia: INTACT evaluation and recommendations for improvement

Posted on January 25, 2017

S. Lombardo1,2, B. Unurbileg4, J. Gerelmaa4, L. Bayarbaatar4, E. Sarnai4, R. Price2,3  1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA 2University Of Utah,Center For Global Surgery,Salt Lake City, UT, USA 3Intermountain Medical Center,Department Of Surgery,Salt Lake City, UT, USA 4Mongolia National University Of Medical Sciences,Department Of Surgery,Ulaanbaatar, UB, Mongolia

Introduction:  Injury is the third leading cause of death in Mongolia. Mongolians have enjoyed two decades of economic growth, resulting in greater availability of medical care and increased motorization. This same period saw a 29% increase in motor vehicle fatalities.  More than half the population lives outside the urbanized capital of Ulaanbaatar, where access to care may be limited by inefficient organization and/or inadequate local resources. This study evaluates and describes the trauma system in Mongolia, and makes recommendations for improvements.

Methods:  A survey instrument was created to collect hospital-level data to calculate an International Assessment of Capacity for Trauma (INTACT) score (0-10).  INTACT is a validated measure for objective evaluation of trauma capacity of facilities in developing countries based on resource availability; a score of 10 reflects ideal staffing and equipment to provide advanced trauma care.  The survey was administered to key staff members (surgeons, emergency and critical care physicians, nurses, statisticians) at 10 hospitals in February and March 2016.  Following on-site interviews, researchers visually confirmed hospital resources.  An INTACT score was calculated for each hospital and compared to expected INTACT scores based on the World Health Organization (WHO) Guidelines for Essential Trauma Care (ETC) recommendations.

Results: Trauma care in Ulaanbaatar includes a centralized prehospital transportation service and two tertiary hospitals adequately resourced to care for the injured patient (Table 1).  Outside of the capital city there are limited tertiary facilities with similar capabilities.  Secondary-level hospitals are staffed and resourced at levels consistent with WHO guidelines.  Most primary care centers, however, fall below these recommended standards. In all but two instances, INTACT scores were within the expected range by WHO guidelines for facility level (Table 1). Outside of Ulaanbaatar, prehospital transport is hospital-based.  There are no national standards for the prehospital care provider, and no universally accepted criteria to guide patient triage or transfer.  There are no public outpatient rehabilitation facilities within Mongolia.

Conclusion: The Mongolian trauma system utilizes regionalized care to provide emergency services to its diverse population.  Among surveyed hospitals, all except the most basic facilities have resources that meet the WHO recommendations for essential trauma care.  Areas for improvement include better resourcing of primary facilities, development of a cohesive prehospital system outside of Ulaanbaatar, adoption of universal policies and standards for patient triage, management, and transfer, and creation of post-acute rehabilitation facilities.

05.07 Assessing Burns Etiology and Distribution Nationally in Brazil

Posted on January 25, 2017

J. R. Amundson1,2, I. Citron2, S. Saluja2,8, H. Jenny2, A. G. Guilloux9, M. Scheffer9, M. Shrime2,3, N. Alonso4,5  8Weill Cornell Medical College,Department Of Surgery,New York, NY, USA 9Universidade De São Paulo,Departamento De Medicina Preventiva, Faculdade De Medicina,São Paulo, SÃO PAULO, Brazil 1University Of Miami,Miller School Of Medicine,Miami, FL, USA 2Harvard School Of Medicine,Program In Global Surgery And Social Change,Boston, MA, USA 3Massachusetts Eye And Ear Infirmary,Department Of Otology And Laryngology And Office Of Global Surgery,Boston, MA, USA 4Universidade De São Paulo,Craniofacial Surgery Unit, Division Of Plastic Surgery, Department Of Surgery, Faculdade De Medicina,São Paulo, SÃO PAULO, Brazil

Introduction:  Burns are a significant public health issue in Brazil, accounting for $13.06 million in spending and 2500 deaths annually. Although Brazil is considered an upper middle-income nation, it is one of the most wealth disparate countries in the world. Healthcare disparities are also prevalent, with state of the art burns care available in the Southeast and no dedicated burns units in the North. To date, there has been no systematic nationwide study assessing the epidemiology of burns and burns mortality in Brazil. Our goal is to assess the epidemiology of burns in Brazil to both quantify the problem and inform the strengthening of existing burns networks, a system shown to benefit burns care.

Methods:  Data regarding deaths due to burns, place of residence and admitting facility for patients burned via mechanisms of scald, flame, electrical and contact injury from 2008 through 2014 were extracted for each of Brazil’s 27 Federal Units from DATASUS, the electronic national data reporting system for Brazil. Admissions and death registry data were extracted using ICD-10 codes corresponding to the evaluated mechanisms of injury. Pediatric patients were defined as less than 15 years of age. Population data was taken from IBGE 2014 projections, based on the 2010 census. Geographic distributions were mapped using DATASUS and ArcGIS software.

Results: There were, on average, 18,551 burns admissions and 514.7 (SE 20.59) inpatient deaths per year, a 2.77% mortality rate. Pediatric burns account for a third of all burns admissions (33.72%) and 9.35% of inpatient burns mortalities. Regarding mechanism of burn, flame burns made up 44.00% of admission, scalds 28.52%, contact burns 15.67%, and electrical burns 11.82%, with significant regional disparities in mechanism of burns. Both Goiás and Paraíba reported greater than 60 scalds admissions per 100,000 residents. Flame burns predominated in Paraná, with an admission incidence of 87 per 100,000. Overall burn admissions were highest in Goiás with greater than 200/100,000 population, followed by Paraná and Paraíba, with over 100/100,000 population. There was also significant regional variation in inpatient mortality, with 5.16% mortality in Rio de Janeiro and 0.31% mortality in Amazonas. During the same period of 2008-2014, there were an average of 2,459 burns deaths registered per year under the same ICD-10 codes, indicating 79% of burns mortality occurring out of hospital.

Conclusion: This epidemiologic study of burns in Brazil describes significant regional discrepancies in mechanism of injury and inpatient mortality rates. The differences in inpatient mortality between urban and rural states, considered alongside the percentage of burns deaths occurring outside of hospitalization reflects a lack of access to inpatient burns care in rural areas. Further studies are needed to evaluate which addressable factors correlate with burns care outcomes across Brazil.
 

05.06 Safe Surgery Checklist: What Are the Reasons Behind Non-Adherence?

Posted on January 25, 2017

M. Jindal1,2, S. Cane3, C. Zheng2, L. M. Boyle1,3, S. A. Krevat3,4, W. B. Al-Refaie1,2,3  1Georgetown University Medical Center,Washington, DC, USA 2MedStar-Georgetown Surgical Outcomes Research Center,Washington, DC, USA 3MedStar Health,Washington, DC, USA 4MedStar Health Research Institute,Washington, DC, USA

Introduction: Despite extensive evidence emphasizing adherence to Safe Surgery Checklist (SSC), compliance among surgery team members varies widely. A greater understanding of providers’ expectations and outlook on the different components of SSC (including anesthesia sign-in, surgical timeout, and team debrief) is needed to gain deeper insights into non-adherence. The purpose of our study is to examine providers’ perception of SSC at a major metropolitan academic teaching hospital.     

Methods: A SSC-focused questionnaire was developed by a multidisciplinary operating room (OR) safety committee and distributed to 154 providers including attending surgeons, anesthesiologists and certified nurse anesthetists via an online survey tool. The questionnaire had 14 questions in the form of multiple choice complemented with a comment box. Responses were collected anonymously for over a month. Questions inquired team members’ opinions about the importance and compliance of the individual components of the checklist, their perception of barriers to completion of checklists, and their training on performing the timeouts.

Results:The overall response rate was 40% (61/154). Among our respondents, 66% were surgeons, 63% were 30-50 years old, and 69% reported that they always completed all pertinent components of the SCC correctly. Although it is recommended for providers to be present for all three components of the SSC, only 36% reported adhering to this, while 46%, 5% and 19% reported being absent for anesthesia sign-in, surgical timeout, and team debrief, respectively. Majority of those absent from anesthesia sign-in were surgeons (27/29) and from team debrief were anesthesiologists (10/12).

When inquired about previous training on how to complete the SSC, 20% reported receiving no training on this subject at all, 43% only received informal training through observing other providers; an overall 35% believed there was a lack of education/information on this subject. Regarding barriers to completing SSC, 34% identified lack of time, 21% lack of training, 21% lack of awareness of the importance of SSC, and 16% lack of cue/reminders.

Conclusion:Our survey on a multi-specialty OR team found that providers’ perception of SSC may contribute to improved compliance. Among the leading causes of non-adherence were time constraints, lack of formal training in performing and awareness of the importance of SSC. These findings point to initiatives to address these causes as potential solutions to improve compliance. 

05.05 Injury Characteristics, Risk Factors and Outcomes Following Falls in Sub-Saharan Africa

Posted on January 25, 2017

B. E. Haac1,4, J. Gallaher3,4, A. Geyer5, L. Banza2, A. Charles2,3  4UNC Project,Lilongwe, LILONGWE, Malawi 5Air Force Institute Of Technology,Statistics,Wright-Patterson AFB, OHIO, USA 1University Of Maryland Medical Center,General Surgery,Baltimore, MD, USA 2Kamuzu Central Hospital,Surgery,Lilongwe, , Malawi 3University Of North Carolina At Chapel Hill,General Surgery,Chapel Hill, NC, USA

Introduction:   Fall-related injuries are a leading cause of Years Lived with Disability (YLDs) worldwide, yet there remains a dearth of research on predictors of outcomes for falls in low- and middle-income countries. We aimed to further delineate risk factors and outcomes related to fall-related injuries in a Sub-Saharan African cohort.

Methods: We examined the trauma registry at an urban tertiary-care hospital in Malawi for patients presenting after a fall from 2010 to 2014. Categorical and continuous variables were compared with chi-squared and student t-tests, respectively. Logistic and linear regressions were then conducted to assess for the magnitude of effect and control for confounders. A p-value <0.05 was considered significant. 

Results: Over the study time period, 73,267 patients presented with trauma. Falls were the most common mechanism of injury (28.9%), followed by traffic accidents (25.6%), and assault (24.3%). Children (age<18yo; OR 5.10), elderly (age>60yo; OR 1.16), and female (OR 1.57) patients had the highest risk of fall (p<0.001).

The three most severe injuries on presentation and the most common operations differed significantly between patients with falls compared to those suffering from other injury mechanisms (p<0.01). Those with falls had more fractures (aOR 1.82), contusions (aOR 1.86), and dislocations (aOR 2.26), and underwent more open reduction internal fixations and other orthopaedic surgeries (p<0.01).

Patients with falls had a longer mean length of stay (14.8 vs. 12.9 days, p<0.001) and lower mortality (0.4% vs. 3.9%, p<0.01). They were also less likely to be admitted to the hospital (14.4% vs. 18.8%, p<0.001).

Of patients who presented after fall, those who died were older, had higher fall heights, and lower GCS on presentation (p<0.001). Males (p<0.001) and patients who were transferred from another health care facility (p=0.002) had a higher death rate. Patients with flank/abdominal (p<0.001) or head injuries (p<0.001) or those requiring tracheostomy (p<0.001), external-fixation (p=0.042) or amputation (p<0.001) were also more likely to die. In multivariate logistic regression analysis, occupation of peasant farmer (aOR 18.91) or housekeeper/gardener/guard (aOR 16.11) and injuries occurring during the hot dry season (aOR 3.56) were associated with increased death when controlled for confounding in patients who were alive on presentation (p<0.05). Head injury (aOR19.70, p<0.001) was also associated with increased death rates when including patients who were brought-in-dead.

Conclusion: Risk factors for fall include age, sex, occupation, and season. The longer length of stay and lower mortality may be predictive of falls being a significant cause of YLDs after discharge. Age, injury pattern and season were predictive of need for surgery and hospital outcomes including death. Interventions to reduce fall-risk, and improve fall outcomes should focus on these areas.

05.04 Emergency General Surgery in Rwandan District Hospitals: Spectrum, Management, and Outcomes of Care

Posted on January 25, 2017

C. Mpirimbanyi4,5, A. Nyirimodo4,5, Y. Lin3, B. Hedt1,5, J. Odhiambo5, T. Nkurunziza5, J. Havens1,2, R. Riviello1,2  1Harvard School Of Medicine,Surgery,Brookline, MA, USA 2Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA 3University Of Colorado Denver,Department Of Surgery,Aurora, CO, USA 4University Of Rwanda,Department Of Surgery,Kigali, KIGALI, Rwanda 5Partners In Health,Boston, MA, USA

Introduction:
Over 5 billion people do not have access to timely, safe and affordable surgical care. An important way to address this need is to improve the capacity to provide these procedures in district hospitals. Currently, there is limited information on emergency general surgical conditions in district hospitals in Sub-Saharan Africa.  Therefore, this study aims to describe clinical presentations, management, and outcomes associated with emergency general surgical conditions presenting at three rural district hospitals in Rwanda.

Methods:
This is a retrospective study conducted in three rural district hospitals in Rwanda. All patients presenting with emergency general surgical conditions, defined as non-traumatic and non-obstetric acute care surgical conditions, between January 1st 2015 to December 31st 2015 were included. Patient demographics, clinical characteristics, management and outcomes were measured and compared between district hospitals.

 

Results:
During the study period, 356 patients presented with emergency general surgery conditions.  The majority of patients were male (57.2%) and adults aged 15-60 years (54.5%). The most common emergency general surgery diagnosis was soft tissue infections (71.6%), followed by acute abdomen (14.3%). Median length of symptoms prior to diagnosis differed by diagnosis type: acute abdomen 4 days (interquartile range (IQR): 2-7), complicated hernia 17.5 days (IQR: 1-208), soft tissue infections 10 days (IQR: 6-21), and urological emergencies 1.5 days (IQR: 1-6).  Of patients presenting with emergency general surgery diagnoses, 52.8% benefited from operation by a surgeon or general practitioner at the district hospital.  Patients were more likely to receive surgery if they presented to a hospital with a surgeon compared to a hospital with only general practitioners (75% vs. 43%).  73.3%  of operated patients did not get any complications.  The mortality rate of patients undergoing surgery was 1.7%.  The most common postoperative complications were surgical site infections (13.8%) and unplanned reoperation (4.8%).

Conclusion:
In most reports from low and middle income countries, acute abdominal conditions are the majority of presenting diagnoses. Our findings that soft tissue infections are the most common could represent a true difference in epidemiology.  Alternatively, this could be due to an under-diagnosis of acute abdominal conditions in rural district hospital, where such conditions are often under-recognized. Patients were more likely to receive an operation in a hospital with a surgeon as opposed to a general practitioner.  This suggests a need to increase the surgical workforce in district hospitals in order to increase surgical availability for patients.

05.03 Lessons Learned from the Implementation of a Trauma Mortality Review in Central Africa

Posted on January 25, 2017

C. A. Thiels1, S. Nigo3, M. Kasumba3, J. A. Brown3, S. M. Wren2  1Mayo Clinic,Rochester, MN, USA 2Stanford Medicine,Palo Alto, CA, USA 3Mbingo Baptist Hospital,Northwest Province, , Cameroon

Introduction:   Trauma remains a leading cause of death in Africa. Mortality reviews aimed at identifying preventable deaths, or deaths which could be avoided if optimal care had been delivered, are underutilized but may provide information to guide improvement at trauma centers. We report our experience with implementing a trauma mortality review process in a rural teaching hospital in Central Africa.

 

Methods: A prospective trauma registry at Mbingo Baptist Hospital, Cameroon from 1/2014-3/2016 (n=1912) identified 36 deaths. Chart review was conducted using a standardized preventable death assessment form to identify demographics, cause of death, physician related factors (e.g. delayed diagnosis), system related factors (e.g. lack of medications), and patient related factors to identify themes for improvement. Preventable deaths were defined using American College of Surgeons criteria.

 

Results: Of the 36 trauma mortalities identified, 30 records were available and included. Median age was 29 years (IQR 19, 46) and 80% were male. Mechanism of injury included 16 road traffic related crashes, 8 thermal injuries, 3 falls, 2 blunt injuries, and 1 firearm injury. Traumatic brain/cord injuries accounted for half (n=15) of the injuries with the remainder being burns (n=8), extremity (n=4), abdominal (n=2), and one patient with tetanus. Fifty percent of patients presented in a delayed fashion (≥ 1-day delay) and 43% were transfers. Two patients died at initial resuscitation, 6 during non-operative management, and 22 after surgery, at median hospital day 2 (IQR 1,5). Causes of death included neurologic (47%), respiratory (33%), multi-organ failure (20%), infection (17%), and bleeding (17%) etiologies. Opportunities for improvement were identified in all cases including 16 preventable or possibly preventable deaths and 14 non-preventable deaths. Physician related issues were identified in 80% of cases with pre-operative (n=13, e.g. suspected under resuscitation in 5/8 burn patients) and post-operative (n=13) factors being the most commonly cited. Systems related issues were cited in 77% of cases including unavailable medications (n=12), lack of ventilator support (n=12) or cross-sectional imaging (n=9), and limited blood product availability (n=5).

 

Conclusion:  Implementation of mortality review at a Central African rural hospital revealed that the majority of trauma deaths resulted from burns or neurologic injuries, with most occurring in the post-operative phase of care. Under resuscitation was noted as a recurring physician related area of improvement in burn patients and was exacerbated by the transfer status of many patients. Lack of cross-sectional imaging was noted as a contributing factor in many of the patients with neurologic trauma. These data may help facilitate quality improvement and allocation of resources while this method of structured review of trauma deaths may help improve the quality of trauma care at other trauma centers in Africa.

04.01 Evidence for Botulinum Toxin in Management of Ventral Hernia: A Systematic Review and Meta-Analysis

Posted on January 25, 2017

J. M. Weissler1, M. A. Lanni1, M. G. Tecce1, M. J. Carney1, V. Shubinets1, J. P. Fischer1  1University Of Pennsylvania,Plastic Surgery,Philadelphia, PA, USA

Introduction:  Incisional hernia (IH) remains a challenging and costly surgical complication with high morbidity and exceptionally high recurrence rates. With nearly 350,000 repairs and a cost burden of $3.2 billion annually, there is a clear need for reparative strategies to thwart recurrence and the dramatic physiologic changes to the abdominal wall musculature after hernia. Botulinum toxin (Botox) injections have recently been identified as a potential preoperative means to counteract abdominal wall tension, reduce hernia size, and facilitate ultimate fascial closure. This systematic review and meta-analysis reviews outcomes after Botox injections in the setting of ventral hernia, and demonstrates the applicability of Botox in abdominal wall reconstruction. 

Methods:  A systematic review of the literature was conducted in accordance with PRISMA guidelines using MeSH terms “ventral hernia”, “herniorrhaphy”, “hernia repair”, and “botulinum toxins.” Relevant studies reporting pre- and post-injection data were included. Outcomes of interest included changes in hernia defect width and lateral abdominal muscle length, recurrence, complications, and patient follow-up. Qualitative findings were also considered to help demonstrate valuable themes across the literature.  

Results: Overall, 164 titles were identified following the initial database search from which 11 articles were reviewed. 3 titles were ultimately included in the quantitative analysis, with a total of 56 patients. The remaining articles were considered qualitative in nature and analyzed the subjective effects of Botox. Meta-analysis revealed significant hernia width reduction (mean= 5.79cm; n=29; p<0.001) and lateral abdominal wall muscular lengthening (mean= 3.33cm; n=44; p<0.001) following Botox injections (Table 1). Mean length of follow-up was 24.7 months (range 9-49). The specific metrics before and after Botox injections for each hemi-abdomen were also included in the analysis. 

Conclusion: While traditional abdominal wall reconstruction approaches have unquestionable benefits, Botox injections of the abdominal wall also offer tremendous potential in managing complex ventral hernias. This minimally invasive “chemical component separation” technique may provide crucial tissue mobility, minimize undue abdominal wall tension, and decrease abdominal muscle contractile force facilitating fascial closure, with a potentially easier postoperative recovery for the patient. Although further studies are needed, there is a significant opportunity to bridge the knowledge gap in preoperative practice measures for ventral hernia risk reduction. 

 

01.07 A Hypothermic Ex-vivo Intestinal Perfusion Unit that limits ischemia reperfusion injury

Posted on January 25, 2017

A. Flores Huidobro1, C. Ibarra1, A. S. Munoz-Abraham1, A. Bertacco1, R. Patron-Lozano1, A. Alkukhun1, R. Morotti1, J. Zinter1, F. D’Amico1, D. Mulligan1, J. Geibel1, M. I. Rodriguez-Davalos1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA

Introduction: Intestinal function may be compromised for several reasons leading to a high number of adult and pediatric patients with intestinal failure. In an effort to reduce injury we have developed multiple animal and human models for extracorporeal perfusion using our intestinal perfusion unit (IPU). We previously published a feasibility study, here we present a comparison between transportation modalities: cold ischemia times, and a variety of preservation solutions. 

Methods: Twelve human intestines were procured from our two regional organ procurement organizations using our approved IRB protocol. Eight intestines were procured and connected to the IPU on site. Four intestines were procured, packed in static cold preservation and delivered to our institution within an average time of 8 hours and 42 minutes and the intestines were all connected proximally to jejunum and distally to the ileum, as well as to the superior mesenteric artery in a dual pump system (luminal and vascular). The human intestines were connected to the IPU and perfused with UW (University of Wisconsin) solution, HTK (Histidine-tryptophan-ketoglutarate) and a combination of UW + Ringer Lactate. Samples were taken at 8, 10 and 12 hours in hypothermic perfused conditions. Pathological analysis was determined using the Park/Chiu (P/C) scoring system for intestinal injury (0=normal, 8=transmural infarction). 

Results:Histological analysis of intestines shipped and then connected to the IPU showed a P/C score of jejunum (2.3) and for ileum (2.8). Intestines connected to the IPU on-site: P/C score of jejunum (1.85) and for ileum (1.23).. Average cold ischemia time (CIT) for recovered intestines by our team was 2.16 hours and CIT for intestines by other teams was 8.42 hours. Of the 12 total intestines, six were perfused with UW solution, five with HTK and one with UW + RL.  UW perfusion had an average P/C score of 1.6 and 1.77 in ileum and jejunum respectively. HTK had a P/C score average of 1.78 in ileum and 2.27 in jejunum. The combination of UW and RL had the poorest score, 2.33 in both the ileum and jejunum. 

Conclusion:Continuous hypothermic perfusion of intestinal tissue with UW solution proved to be the best source for limiting ischemia reperfusion injury. Lower ischemia injury scores were seen in the Ileum in comparison to Jejunum. This study demonstrates the advances of the IPU project and the variables that can significantly impact the preservation of the intestinal tissue. The results show that if possible, the intestine should be connected at the procuring site in order to achieve maximal preservation. 

 

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