83.16 Coeliosurgery Indications in Gynecology at Panzi General Hospital in DR Congo

Posted on January 18, 2018

M. Ntakwinja1, B. Cadiere1, D. Mukwege1  1Panzi Hospital,Gynecology-Obstetric,Bukavu, SOUTH KIVU, Congo

Introduction: The reduction of parietal and peritoneal trauma that characterizes coeliosurgery is associated with immediate post-op pain reduction, shorter hospital admission and convalescence. The objective of this study was to report the coeliosurgery indications in gynecological problems which are being taken care in Gynecology-obstetric department at Panzi General Hospital.

Methods: This is a retrospective study pertaining 44 patients received in the department for different gynecological problems and who went for coeliosurgery with or without conversion to conventional surgery between January 2013 and October 2015. The data were collected from patient files, entered on Excel 2013 2010 and analyzed by EPI-Info software version 7.2.

Results:The patients’ average age is 39 years. The mainly problems observed are pelvic masses and pelvic algies (59.1%) followed by primary sterility (11.3%). The surgery procedure consisted of an adhesiolysis (22.7%) or a myomectomy (13.6%). A conversion was necessary in 9.09% of the cases, motivated by the importance of the adhesions and the large myomas (3 cases). The average period of hospital admission is 2 days.

Conclusion:Coelioscopy is a technique to be integrated and developed in gynecology department of developing countries considering its diagnostic and therapeutic advantages, especially in the management of tubal infertility due to infection.

 

83.17 Review of the Current State of Orthopedic Specialists in Japan

Posted on January 18, 2018

Y. Yatabe1, k. Ikeda1  1Ichihara Hospital,Dept. Of Orthop. Surg.,Tsukuba, IBARAKI, Japan

?Background and Purpose? To date, academic medical society was responsible for certifying its members as specialists in their respective fields; however, the Japanese Medical Speciality Board has now been established, and it was decided that it would handle specialist certification. Meanwhile, the Japanese Orthopaedic Association (JOA) has been training specialists for over 30 years. This study examined the current situation of orthopedic surgeons in comparison with other specialists. ?Methods? In August 2016, we examined the number of existing academic societies and specialists, with respect to 18 basic areas of medicine requiring specialists, according to the guidelines of the Japanese Medical Speciality Board, and compared the information. ?Results? The number of members with respect to the 18 basic areas of the Japanese Medical Speciality Board was 3,032 to 108,232 (average: 18,597.1), the number of specialists was 666 to 21, 275 (average: 8,567.4), and the acquisition rate was 14.0% to 79.7% (average: 56.0%). Meanwhile, JOA had 24,443 members and 18,489 specialists, with 79.7% of the members having acquired a specialist designation. ?Discussion? It is estimated that the demand for orthopedic medical treatment will increase at an exponential rate in Japan, which is amassing a super-aged society unparalleled elsewhere in the world. To do this, an orthopedic surgeon who understands diseases related to exerciser disease, and who has high level of practical ability, is indispensable. Currently, the number of members, the number of specialists, and the acquisition rate in academic societies exceed the average specified according to the 18 basic regions. Among them, for the specialist acquisition rate, about 80% of the total number of members of the JOA have acquired a specialist designation, the highest acquisition rate among the basic 18 areas put forth by the Japanese Medical Speciality Board. In the future, it is considered necessary to maintain the current number of specialists during the transition to following the specialist guidelines of the Japanese Medical Speciality Board. ?Conclusion? In order to improve orthopedic practice in Japan, it seems necessary to maintain the current number of orthopedic specialists.

83.14 Standardized Wound Management In Kenya: A Survey Of Junior Doctors In 20 Counties

Posted on January 18, 2018

W. C. Wanjau1, N. R. Gitau4, J. K. Wanjeri3, A. L. Kushner1, S. M. Wren2  1Johns Hopkins University School Of Public Health,International Health,Baltimore, MARYLAND, USA 2Stanford University,Center For Innovation In Global Health,Palo Alto, CA, USA 3University Of Nairobi,Department Of Surgery,Nairobi, NAIROBI, Kenya 4Embu County Referral Hospital,Surgery,Embu, EMBU, Kenya

Introduction:  Inadequate treatment of wounds leads to avoidable complications and extended healing time.  First line management is most often provided by junior doctors in Kenya. We assessed baseline knowledge of standardized wound care practices and wounds to identify opportunities for improvement.

 

Methods:  

A qualitative cross sectional study using a wound treatment questionnaire was administered by telephone to medical officers in 20 of 47 counties in Kenya between  11th and 25th August 2015. Medical Officers and Medical Officer interns working in outpatient and surgery departments in the different counties were randomly surveyed; total of 20 doctors; 1 per county. Verbal consent was obtained. Variables collected included wound cleaning solution used, availability of advanced dressings, use and duration of antibiotics, cosmetic consideration when managing wounds, knowledge on the existence of standardized guidelines, and the definition of a chronic wound. 

 

Results: The treatment of wounds varied widely across all assessed variables. Povidine Iodine was used at 80% of facilities to clean wounds, saline in 43% of the facilities and peroxide in 9.5%. Only 45.5% of facilities had advanced wound care material apart from gauze. Advanced dressings used included: Impregnated gauze, vacuum dressing and antimicrobial laced dressing. A total of 65% of doctors gave antibiotics to treat wounds all of the time. Only 30% of doctors considered cosmetics all the time when managing wounds, with 60% some of the time, and 10% never considering it. Only 9.1% were aware of standardized international guidelines for wound care management. None were aware of standardized guidelines for treatment of wounds in their facility. Using a standard definition of 4 weeks to classify a chronic wound,  55% classified the chronic wounds correctly at 4 weeks , 30%  at less than 4 weeks and 15 % after more than 4 weeks.

 

Conclusion: There is wide variability in wound care management and no standardized guidelines across Kenya. Wound management and patient care could be improved by adoption and dissemination of countrywide guidelines. Evidence based care for wound management is needed to avoid preventable morbidity and mortality. 
 

83.15 Quality and Safety Initiatives at the Volta River Authority Hospital in Akosombo, Ghana

Posted on January 18, 2018

K. E. Smiley1, L. Ofori3, C. Spangler1, R. Acquaah-Arhin3, D. Deh2, J. Enos2, S. Manortey2, F. Baiden2, S. R. Finlayson1, R. R. Price1, M. McCrum1  1University Of Utah Health Sciences,Department Of Surgery,Salt Lake City, UT, USA 2Ensign College Of Public Health,Kpong, EASTERN REGION, Ghana 3Volta River Authority Hospital,Akosombo, Eastern Region, Ghana

Introduction:  The Volta River Authority (VRA) Hospital is the healthcare component of a large public works project and functions as a district hospital in Akosombo, Ghana. The VRA hospital has a reputation regionally for patient safety and high quality care. We hypothesized that this stems from standardized processes and an underlying culture of safety typical of high-risk engineering environments. We therefore sought to evaluate the degree of perioperative process variability, as well as staff and patient perceptions of safety and quality of care.

Methods:  Perioperative observations of general surgery, obstetrics and gynecology procedures were used to generate process maps, which were analyzed for process variability and presence of waste steps. The Safety Attitudes Questionnaire (SAQ) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys were used to evaluate staff and patient perceptions of safety culture and quality in a cross-sectional study. The SAQ was analyzed for proportion of respondents with a categorical score ≥75/100, indicating an overall positive perception. HCAHPS results were analyzed with standard “top-box” methods, calculating the proportion of patients selecting the most favorable response to each question.

Results: Fifteen elective surgical procedures were observed. Process map analysis demonstrated streamlined operative processes with little process variation between cases (Figure 1). There was 100% adherence to the World Health Organization Safe Surgery Checklist and no waste steps consistently identified. 31 SAQs were administered with Cronbach’s alpha of 0.84 for teamwork and 0.74 for safety climate, reflecting acceptable internal consistency. 83.9% of workers held positive perceptions of teamwork [median score 91.67, IQR 83.3 – 95.8], while 77.4% held positive perceptions of safety culture [median score 85.71, IQR 79.2 – 92.9]. 15 HCAHPS surveys of surgical inpatients showed 90% of patients giving highest possible scores for pain management and 84.4% for nurse communication, while only 31.3% and 55.6% of patients gave highest possible scores for medication communication and discharge information respectively. The median overall HCAHPS hospital rating was 10 [IQR 8.5 – 10] on a 10-point scale.

Conclusion: Perioperative process mapping displayed low levels of variability and waste and is a useful tool for evaluating standardization of care. Staff and patient surveys suggest an institutional commitment to safety with strong teamwork culture and patient communication. Targets for improvement include medication counseling and discharge planning. VRA Hospital demonstrates the feasibility of delivering high standards of perioperative care in a low-resource setting. 

83.13 Developing Trauma Audit Filters for Regional Referral Hospitals in Cameroon: A Mixed-Methods Approach

Posted on January 18, 2018

N. Wu1, T. C. Nana1, R. Dicker1, M. Carvalho1, O. Nwanna-Nzewunwa1, G. Motwani1, S. A. Christie1, A. Chichom Mefire1, C. Juillard1  1Center For Global Surgical Studies,University Of California, San Francisco,San Francisco, CA, USA

Introduction:  Injuries are a leading cause of death and disability worldwide.  Developing countries account for 90% of injury-related deaths globally. Trauma audit filters can facilitate trauma quality improvement initiatives and reduce the injury burden. Little is known about context-appropriate trauma audit filters for developing countries like Cameroon. This study aimed to (1) develop context-appropriate trauma audit filters for the setting of a regional referral hospital in Cameroon and (2) to assess the barriers and facilitators to their implementation.

Methods:  Feasible audit filters were identified by a panel of Cameroonian surgeons using the Delphi technique. A Likert scale (1 to 5, with 5 as “Most Useful”) was used to rank the filters for utility in a regional referral hospital setting, analyzed using median and interquartile range. Semi-structured interviews were conducted with 16 healthcare providers from three hospital facilities to explore their perceptions of supervision and support they receive from hospital administration, availability of resources, their work environment, and potential concerns and impacts of trauma audit filters. Interviews were coded and thematically analyzed.  

Results: Within a panel of seven surgeons, 18 out of 40 trauma audit filter variables met majority consensus criteria. Sixteen of these, comprising mostly of primary survey and basic resuscitation techniques, had a median score of ≥ 4. Filters meeting consensus include, but are not limited to: vitals obtained, breathing assessment made, and two large bore IVs established – within 15 minutes of arrival; patient with open fracture receives IV antimicrobials within one hour or arrival; patients with suspected spine injury are immobilized and given x-ray. The provider interviews revealed that the barriers to providing quality care were limited human and material resources and patients’ inability to pay. Regular staff training in trauma care and the belief that trauma audit filters would potentially streamline work practices and improve the quality of care were cited as promoters of successful implementation. 

Conclusion: Primary survey and basic resuscitative techniques are key elements of context-appropriate audit filters in Cameroon. Such audit filters may not be costly or require complex infrastructure or equipment that exceed the site’s capabilities. Proper staff orientation and participation in the use of trauma audit filters as quality improvement tools are key to local buy-in and implementation success. 

83.10 Improving Patient Satisfaction with Same Day as Clinic Pediatric Surgery

Posted on January 18, 2018

C. N. Criss1, J. Brown1, J. Gish1, S. K. Gadepalli1, R. B. Hirschl1  1C.S.Mott Children’s Hospital,Pediatric Surgery,Ann Arbor, MI, USA

Introduction
Same Day Surgery (SDS) as clinic programs allow common surgical procedures to be performed the same day as the initial clinic evaluation. Implementation of an SDS program may improve efficiency but patient satisfaction is unclear.   We sought to assess the feasibility and overall patient satisfaction at our institution.

Methods
After IRB approval, pediatric patients presenting for SDS between 1/1/2014-12/31/2016 were carefully followed.   Patient families who did and did not choose SDS were contacted to perform a telephone survey focusing on their overall satisfaction and to obtain feedback.

Results
Twenty-seven patients received SDS, with inguinal hernia repair (30%) and umbilical hernia repair (26%) being the most common. Of the sixteen (59%) patients that agreed to the telephone survey, all parents (16/16) agreed the instructions were easy to understand, 81% (13/16) indicated that it decreased overall stress/anxiety, 75 % (12/16) stated that SDS allowed for less time away from work, and 94% (15/16) agreed to pursue SDS again if offered.  The most common negative feedback was an unspecified OR start-time (19%). There were no significant postoperative complications.

Conclusion
This study demonstrates the feasibility of performing both initial evaluation and surgical intervention on the same day for common pediatric procedures. Overall, patient families were satisfied with the program, reporting value from decreased anxiety and less time away from work. 
 

 

83.11 The Utility of PEEK Implants Adjacent to Sinus Cavities after Craniofacial Trauma

Posted on January 18, 2018

V. Suresh1, R. Anolik1, D. Powers1  1Duke University Medical Center,Durham, NC, USA

Introduction:  Poly(aryl-ether-ether-ketone) (PEEK) implants have become increasingly popular for use in trauma, orthopedic, and reconstructive procedures. PEEK’s utility is derived from chemical and mechanical properties such as temperature stability, water-resistance, and an elastic modulus that is close to that of human cortical bone. Additionally, both in vivo and in vitro studies have shown that PEEK exhibits good biocompatibility and generates minimal inflammatory responses after implantation. As the utilization of PEEK becomes more ubiquitous in the field of craniomaxillofacial trauma and reconstructive surgery, it is imperative to understand the potential consequence of employing this biomaterial in anatomic sites that may pose a risk of infection. Specifically, the use of PEEK in reconstruction of the walls of paranasal sinus cavities is not well documented in the literature. The primary aim of this study is to examine the rate of post-operative complications, namely surgical site infection and implant loss, in patients who have undergone craniomaxillofacial procedures with sinus cavity wall reconstruction using PEEK implants.

Methods: This study is a single center case series. All patients that underwent craniomaxillofacial reconstruction with a custom made PEEK implant in intimate contact with a functional paranasal sinus from June 1, 2013 to May 31, 2017 were included in this study. Baseline characteristics were collected via retrospective chart review. Mechanism of injury, operation time (measured from time of incision to closure), anatomic site of implant, size of implant, perioperative/post-operative antibiotic regimens, follow-up time, and post-operative complications (surgical site infection, readmission within 30 days of procedure, bleeding complications, loss of implant, and/or death) were recorded.

Results: A total of 8 patients were included in this case series. The average age of these patients were 45.75 ± 19.36 years old. Mechanisms of injury ranged from self-inflicted gunshot wounds to facial trauma following an explosion. Average follow-up duration was 300 ± 263 days. The mean operative time for PEEK implantation was 214.13 ± 66.03 minutes and implants ranged in size from approximately 5 sq cm to nearly 100 sq cm. One patient underwent explantation of his PEEK implant secondary to breakdown of the overlying skin due to coagulase-negative S. epidermis infection. No patients were diagnosed with acute or chronic sinusitis after implantation of their custom-designed PEEK implants.

Conclusions: A review of the literature indicates that this is the largest case series reported to date documenting the use of PEEK implants in reconstruction of the walls of the paranasal sinuses.  The authors conclude that PEEK implants may be safely utilized in craniomaxillofacial procedures that involve paranasal sinus cavities without increasing the risk of infection and need for explant.

83.12 Efficacy of a Surgical Site Infection Scorecard for Quality Improvement in Haiti

Posted on January 18, 2018

J. A. Codner1, A. Farrell1, C. Brownfield1, C. Haack1, J. Srinivasan1, J. Sharma1  1Emory University School Of Medicine,Atlanta, GA, USA

Introduction:  Surgical site infections (SSI) are one of the main complications to arise after any type of surgery. These complications are compounded in low resource settings, where patients have less follow up care, and hospitals have less means to deal with the sequelae of surgical wound infections. SSI can contribute to more severe complications including sepsis and mortality. For these reasons, it becomes even more important to prevent the development of a SSI in low and middle income countries (LMIC). The WHO produced a “Safe Surgery Checklist” for the prevention of SSI for global surgery. Our goal with this project was to track the risk factors specified by the WHO in our patients over a 4-week surgical mission trip to Pignon, Haiti by using an SSI scorecard system. The scorecard was used to stratify each patient’s risk of SSI, and overall variable incidence data was then used to evaluate quality improvement steps for the prevention of SSI on subsequent trips to Haiti.

Methods:  An eleven-element SSI scorecard was completed for each operative patient (n= 54), General Surgery (n=32), Urology (n=10), and Head & Neck (n=12). The cumulative value of the scorecard was used to risk stratify each patient for development of SSI. (0-2)-Low Risk (n=18), (3-4)- Intermediate Risk (n=30), (>4)- High Risk (n=6). We then calculated the incidence of each variable for the entire study population.

Results: Follow-up was performed in 41 patients with a mean follow up of 8.6 ± 4.9 days. We had 2 patients with an SSI in our cohort (4.8% n=41). These patients with SSIs had scores of 3 and 5, a perineal incision and a prostatectomy, respectively. Mean score of the scorecard was 2.9 ± 1.2 (n=54). Variable Incidence (n=54): Age >50 (30%), Malnutrition (BMI <18.5) (17%), Pre-op Antibiotics (Abx) not indicated (22%), Surgery time > 1 hr (54%), Clean Contaminated (39%), Contaminated (4%), Drain Indicated and not placed (9%) (n=11), No Post-op Abx (54%).

Conclusion: Implementation of scorecards can help stratify SSI risk and guide antibiotic stewardship preoperatively and postoperatively in LMIC. SSI risk is highly variable and should be assessed for individual patients undergoing surgery.

83.07 Oil Tanker Truck Explosions 1997-2017: A Global Review of the Literature

Posted on January 18, 2018

C. Ewbank1, S. Gupta5,8, B. Stewart3,4, A. L. Kushner5,6, A. Charles2,7  1University Of California San Francisco – East Bay,Department Of Surgery,Oakland, CA, USA 2University Of North Carolina,Gillings School Of Global Public Health,Chapel Hill, NC, USA 3University Of Washington,Department Of Surgery,Seattle, WA, USA 4Stellenbosch University,Department Of Interdisciplinary Health Sciences,Cape Town, , South Africa 5Surgeons OverSeas,New York, NY, USA 6Johns Hopkins Bloomberg School Of Public Health,Center For Humanitarian Health,Baltimore, MD, USA 7University Of North Carolina,School Of Medicine,Chapel Hill, NC, USA 8Shock Trauma,Baltimore, MD, USA

Introduction: Oil tanker truck explosions have been reported worldwide, but the circumstances, potential causes, and health effects have not been well-described. To address this gap, identify prevention targets, and highlight the tanker truck-related health burden, we performed a review of literature to better understand this recurrent public health problem.

Methods: PubMed, WHO Global Health Library, Google, and Lexis Uni databases were systematically searched and records were reviewed. All records that reported information about civilian oil tanker truck spills, fires, and explosions occurring between January 1, 1997 and August 12, 2017 were included.

Results: The search yielded 4,713 Lexis Uni records and 1 PubMed record that met inclusion criteria; 932 records met inclusion criteria (19.8% of records reviewed). The Google and WHO Global Health Library searches yielded no previously unreported events. The reports described 224 oil tanker truck explosions. Most of these events took place in the U.S. (54), Pakistan (37), Nigeria (27), India (23), and Afghanistan (14). At least 2,141 people died at the scene as a result of these 224 events, and 2,761 additional people were hospitalized. Explosions in low and middle-income countries (LMIC) resulted in a mean of 12.0 fatalities per event, while in high income countries (HIC), this rate was only 1.1 fatalities per event. This disparity was largely due to “scooping,” the practice of collecting spilled oil for resale from disabled tanker trucks. Scooping contributed to 1,303 of fatalities (60.9%), and was exclusively reported in LMIC.

Conclusion: This review highlights the frequency and associated significant health burden of oil tanker truck explosions. Most of these events began as collisions or rollovers, but the majority of fatalities involved scooping. The findings suggest that it is imperative to promote tanker truck road safety (e.g., mandatory maintenance, tanker truck-specific speed limits, driver regulations), and improve features of oil tanker trucks and safety and security protocols to prevent mass casualty incidents related to siphoning, scooping, and poaching of fuel from crashed or disabled tanker trucks. 

 

83.08 You pray to your God: qualitative analysis of challenges in the provision of surgical care in Uganda

Posted on January 18, 2018

K. Albutt1,2, R. R. Yorlets2, M. Punchak2,3, P. Kayima4, D. B. Namanya5,6, G. A. Anderson1,2, M. G. Shrime2,7  1Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 2Harvard Medical School,Program In Global Surgery And Social Change,Boston, MA, USA 3David Geffen School Of Medicine, University Of California At Los Angeles,Los Angeles, CA, USA 4Mbarara University Of Science And Technology,Department Of Surgery,Mbarara, MBARARA, Uganda 5Ministry Of Health,Planning Division,Kampala, KAMPALA, Uganda 6Uganda Martyrs University,Nkozi, NKOZI, Uganda 7Massachusetts Eye And Ear Infirmary,Department Of Otolaryngology,Boston, MA, USA

Introduction:  Five billion people lack access to safe, affordable, and timely surgical and anesthesia care. Significant challenges remain in the provision of surgical care in low-resource settings. Uganda is no exception. 

Methods:  From September to November 2016, we conducted a mixed-methods countrywide surgical capacity assessment at 17 randomly selected public hospitals in Uganda (Figure 1). Researchers conducted 35 semi-structured interviews with key stakeholders to understand factors related to the provision of surgical care. The framework approach was used for thematic and explanatory data analysis.

Results: The Ugandan public sector continues to face significant challenges in the provision of safe, timely, and affordable surgical care. These challenges can be broadly grouped into preparedness and policy, service delivery, and the financial burden of surgical care. Providers reported challenges including: (1) significant delays in accessing surgical care, compounded by a malfunctioning referral system; (2) critical workforce shortages; (3) operative capacity that is limited by inadequate infrastructure and overwhelmed by emergency and obstetric volume; (4) supply chain difficulties pertaining to provision of essential medications, equipment, supplies, and blood; (5) significant, variable, and sometimes catastrophic expenditures for surgical patients and their families; and (6) a lack of surgery-specific policies and priorities. Despite these challenges, innovative strategies are being used in the public sector to provide surgical care to those most in need.

Conclusion: Barriers to the provision of surgical care are cross-cutting and involve constraints in infrastructure, service delivery, workforce, and financing. Understanding current strengths and shortfalls of Uganda’s surgical system is a critical first step in developing effective, targeted policy and programming that will build and strengthen its surgical capacity. The public sector, as the provider of care for the majority as well as the most impoverished, must champion the surgical agenda in Uganda. Further research is warranted to better understand the impact of surgical capacity building interventions as they are undertaken in LMICs. 

83.09 Implementation of a Standardized Data-Collection System for Comprehensive Appraisal of Cleft Care

Posted on January 18, 2018

P. Bittar2, A. Carlson1, A. Mabie3, J. Marcus1, A. C. Allori1  1Duke University Medical Center,Plastic Surgery,Durham, NC, USA 2Duke University School Of Medicine,Durham, NC, USA 3Duke University Medical Center,Otolaryngology & Communication Sciences,Durham, NC, USA

Introduction:  Long-term outcomes research for cleft lip and/or palate has been challenging. In 2016, a “standard set” of outcome measures for appraisal of cleft care was proposed by the International Consortium for Health Outcomes Measurement (ICHOM); however, this conceptual framework must be translated into a practical framework customized for specific constraints that exist in each center. Our objective is to describe the process of adapting a conceptual framework into a practical toolkit for one cleft team.

Methods:  This is a single-arm implementation study in a single institution. Implementation took place in a mid-sized multidisciplinary team operating a weekly clinic for patients with cleft lip and/or palate from urban/suburban and rural areas across North Carolina and neighboring states. Eligible subjects were patients from English-speaking families with cleft lip and/or palate receiving treatment at our center. Our intervention was the implementation of a prospective data-collection system based on the ICHOM standard set of outcome measures for cleft lip and/or palate. Implementation was accomplished in multiple stages. Patient- and clinician-reported forms and protocols for gathering data were created. Team members were then trained and the system was tested; finally, the system was deployed. 

Results: Success of the implementation was appraised using the RE-AIM framework to assess reach, effectiveness, adoption, implementation, and maintenance. 98% of eligible patients and all cleft team members agreed to participate. 94% of required standard set data points were captured. Adaptations to friction points were made; specifically, visible reminders were affixed to charts, primary clinicians were required to assume data-entry responsibility, and email reminders were instituted. Development cost for the system was $7707, and average time cost per clinician was 21 minutes/week.

Conclusion: All conceptual frameworks for outcomes studies must first be tailored to suit the environment; otherwise, they cannot be practically implemented and sustained. In this paper, we present this process for a cleft team using the ICHOM standard set. The process may help other teams in implementing the standard set or other conceptual frameworks within their own hospitals.

 

83.05 Delayed Diagnosis and Treatment of Pediatric Colorectal Conditions in Uganda

Posted on January 18, 2018

A. Yap2, A. Muzira3, D. Ozgediz2, T. N. Fitzgerald1  1Duke University Medical Center,Surgery,Durham, NC, USA 2Yale University School Of Medicine,Surgery,New Haven, CT, USA 3Mulago Hospital,Pediatric Surgery,Kampala, KAMPALA, Uganda

Introduction:   Children in sub-Saharan Africa lack access to surgical care and few studies have documented the state of congenital colorectal surgery in low-income countries.  Delay in diagnosis and treatment of these conditions is associated with significant morbidity and mortality.

Methods: A retrospective chart review was completed for children with anorectal malformations (ARM) and Hirschsprung’s Disease (HD) presenting to Mulago Hospital in Kampala, Uganda.  Primary outcomes were prevalence of disease, presentation delay and surgical delay. These conditions are treated in 3 stages in this setting (colostomy formation, definitive surgery and colostomy takedown) and Mulago Hospital was the sole provider of definitive surgery in Uganda during this time frame. Definitive surgery was defined as receiving a PSARP or anorectal pull-through procedure and surgical completion was achieved with colostomy takedown.

Results:  92 patients were included over a 2-year period.  54 patients (59%) were male.  Most patients came from the tribes of Ganda (n=32, 35%) and Soga (n=18, 20%), while these tribes make up only 16% and 9% of the population, respectively.  81 (88%) patients presented initially to a pediatric surgery referral center for colostomy placement, while the remainder presented to local hospitals.  There were 20 (22%) patients with HD and 72 (78%) patients with ARM.  Patients with ARM presented late for colostomy (median 5 days, [1 day – 1 year]), but late presentation for HD was more severe (median 1 year, [4 days – 7.6 years]).  The median wait time for definitive surgery was 37 weeks [0 days – 7 year]).  The median wait time for surgical completion was 2 years [23 weeks to 13 years].   40 (43%) children are still waiting for definitive surgery and 59 (64%) waiting for surgical completion.  The most common complication was neo-anal or anastomotic stenosis, occurring in 8 patients (9%).

Conclusion:  Children with HD and ARM lack access to timely surgical care in Uganda.  When accounting for misplaced medical records and children who do not present for care, this study likely represents a fraction of the burden of congenital colorectal disease in Uganda.

 

83.06 Burden, Backlog, and Economic Consequences of Pediatric Surgical Conditions in Uganda: A Pilot Study

Posted on January 18, 2018

A. Godier-Furnemont1, M. Cheung2, N. Kakembo3, A. Nabirye3, H. Nambooze3, A. Yap1, P. Kisa3, A. Muzira3, J. Sekabira3, D. Ozgediz2  1Yale University,Medical School,New Haven, CT, USA 2Yale University,Department Of Surgery,New Haven, CT, USA 3Makerere University, Mulago Hospital,Department of Surgery,Kampala, Uganda

Introduction:  The substantial backlog of pediatric surgery in resource-limited settings and associated economic consequences have not been measured but have been proposed as metrics for unmet need to aid capacity-building programs. We analyzed surgical conditions and access to definitive care at the national referral hospital, one of two centers with a dedicated pediatric surgery unit in Uganda. Secondarily we assessed economic burden of access to care on families.

Methods:  A survey tool was designed, piloted, and validated. This was used to conduct a prospective study of children age 0-18 years presenting to the Mulago Hospital Pediatric Surgery Outpatient Clinic (PSOPC) and Ward June 1- August 31 2016 using convenience sampling.

Results: 313 PSOPC visits represented 263 unique patients (pts), and 81 inpatient visits were recorded. Median age of PSOPC pts was 1.5 yrs. 51% of pts previously visited another facility (Table 1). 36% of these made ≥2 visits before being referred to Mulago. 75% of PSOPC pts and 28% of Ward pts came from 2 surrounding districts. Median round-trip costs, travel time, and burden costs for pts are summarized in Table 1.

80% of PSOPC pts presented with a new concern; 12% for the next part of a staged surgery; 9% for post-operative follow-up. The most frequently seen conditions in the PSOPC were umbilical and inguinal hernias (13.7% and 12.9%, respectively), anorectal malformations (10.6%), masses (9.1%) and Hirschsprung’s disease (6.1%). Median time caregivers were aware of an inguinal hernia at the time of PSOPC presentation was 18 months. Median age of pts with inguinal hernias was 2.5 yrs; of pts awaiting anoplasty: 1 yr; awaiting colostomy closure: 1.8 yrs.

Of 240 PSOPC pts with a new issue or scheduled for surgery, 10% were admitted and 54% of these pts recovered or received surgery; surgery was postponed for 37.5%. The most cited reason for denial of admission from PSOPC was full ward capacity; pts were instructed to return to the PSOPC in a median of 4 wks.

Ward pts travelled further than PSOPC (median 1 vs. 2.5 hrs, p=0.003). 18% and 53% of PSOPC and ward pts, respectively, borrowed money for transport; 6% and 28%, respectively, sold assets for transport.

Conclusion: A minority of outpatients receive needed surgery at their first presentation to the PSOPC. Ward pts have a significantly higher transport cost burden and come from significantly farther away than outpts. Age at first presentation to the PSOPC, and at the time of surgery represent significant delays in accessing and receiving definitive care. Resource shortages such as limited operating space for elective cases contribute to significant backlogs. Infrastructure and capacity development are necessary to make progress in these areas.
 

83.04 Access to trauma and surgical care in rural Northeastern Uganda—a mixed methods study

Posted on January 18, 2018

N. Lin1,2, O. Nwanna-Nzewunwa1, M. Carvalho1, A. M. Margaret3, A. E. Wange3, G. Motwani1, L. Gwynn2, R. A. Dicker1, C. Juillard1  1University Of California – San Francisco,Center For Global Surgical Studies,San Francisco, CA, USA 2University Of Miami,Miami, FL, USA 3Soroti Regional Referral Hospital,Soroti, SOROTI, Uganda

Introduction:  Delayed access to surgical care leads to increased mortality and disability, disparately affecting low- and middle- income countries. The Lancet Commission on Global Surgery (LCoGS) defines 2 dimensions of access to surgical care: 1) reaching a surgical provider within 2 hours and 2) receiving appropriate care from that provider.  This study aims to evaluate trauma care access as defined by these dimensions in the catchment area of the regional referral hospital (RRH) in Northeastern Uganda. Understanding local barriers and delays can inform contextual public health strategies and resource allocation to strengthen access.

Methods:  We 1) evaluated trauma care capacity and resources at first-level district health facilities in the region using the WHO’s Tool for Situational Analysis to Assess EESC, and 2) surveyed a consecutive sample of trauma patients upon arrival at the RRH to obtain demographic, geographical, temporal, and clinical information about their injury and access to trauma care.  A Wilcoxon rank-sum test was used to compare time taken to reach 1) 1st care site and 2) RRH with LCoGS threshold.

Results:  The study region had eight public district hospitals with an average of 85.3 beds, 0.38 surgeons, 1.88 general doctors, 0.88 anesthetic care providers, and 7.8 paramedics/midwives per facility. Few facilities consistently had a working anesthesia machine (37.5%), oxygen supply (37.5%), running water (25%), electricity and/or generator (12.5%).  All facilities could provide basic resuscitation and first aid, but none could do advanced trauma care procedures.  None had a blood bank or intensive care unit. Frequent shortages of supplies (gloves, gauze) occurred.  Five facilities had an ambulance.

We surveyed 131 trauma patients at RRH age 1-81 years. Falls (43%), road traffic accidents (33%), blunt force (17%), penetrating trauma (5%), and burns (2%) were the mechanisms of injury. First responders were relatives (46%), bystanders (39%), and friends (12%). Transportation to care site was via motorcycle/taxi (64%), ambulance/police (13%) and private car (10%). Median time to reach 1st care site, 1h [IQR 0.6 – 2h], was less than LCoGS threshold (p< 0.0001). However, median time to reach RRH, 6h [IQR 1 – 65h], was more than LCoGS threshold (p<0.0001) and time to reach 1st care site (p<0.0001). Median cost of patient navigation to RRH was $2.28 [IQR $0.56 – 8.33]. 19.8% of patients sought care at a primary care site and 13.7% at a district hospital before reaching RRH.

Conclusion:  District hospitals in Northeastern Uganda lack staff, resources, and transport for adequate surgical trauma care. Many patients experience time delay when accessing trauma care at RRH. Proper resource allocation, increased training, and quality improvement efforts at the district level may improve timely access and availability for trauma patients in this region.

83.03 Determinants of Surgical Burden and Access to Care in Trujillo, Peru

Posted on January 18, 2018

P. F. Johnston1, J. Badach4, F. Muñoz Córdova3, R. A. Cisneros2, Z. C. Sifri1  1Rutgers New Jersey Medical School,Surgery,Newark, NJ, USA 2Universidad Nacional De Trujillo,Trujillo, LA LIBERTAD, Peru 3Universidad Privada Antenor Orrego,Trujillo, LA LIBERTAD, Peru 4Cooper University Hospital,Surgery,Camden, NJ, USA

Introduction:
In Peru, free health insurance is available to impoverished citizens via the Seguro Integral de Salud (SIS) program. However, significant barriers to accessing care exist, with many relying on Humanitarian organizations for surgical care. The aim of this study is to describe the disease burden and barriers to care faced by Peruvian patients presenting to an international organization for surgery.

Methods:

The International Surgical Health Initiative (ISHI) performs yearly humanitarian general surgical missions to Trujillo, Peru, caring for suitable patients prescreened by local healthcare teams.

On missions in 2016 and 2017, patients referred to ISHI were given paper surveys in Spanish. The survey asked basic demographics, insurance status, barriers to care as well as duration of symptoms and disability associated with the patients’ condition. Survey results were examined for differences in disease burden and barriers to care based on having no insurance versus SIS.

Results:

Sixty-seven out of a total 72 patients receiving care by ISHI completed surveys. The mean age was 46 ± 14 years and 52% were female. Just over half of patients had no insurance (54%), while 40% had SIS, and 6% had other insurance. The most common conditions were gallbladder disease (39%), ventral/umbilical hernia (28%), and inguinal hernia (25%). Mean duration of symptoms was 3.3 ± 5.3 years. Patients averaged 3.4 ± 2.9 doctor/hospital visits prior to presenting to ISHI. Sixty percent reported a limited ability to work, 40% had taken time off school or work, and 51% reported constant pain. A majority of patients (79%) reported cost followed by backlogs (17%) as the major barrier to surgical care.

Patients with no insurance were significantly more likely to have symptoms lasting for longer than 1 year compared to those with SIS. Those enrolled in SIS had more doctor/hospital visits and more commonly reported backlogs as a barrier to care (Table). Age, gender, diagnosis, and disability were not significantly different between the groups.

Conclusion:

Despite SIS being overtly available to all poor Peruvians, over half of the patients presenting to ISHI had no insurance, impeding access to care, resulting in longer duration of symptoms. Those with SIS had greater access to healthcare but still faced barriers to surgical care related to expenditure and backlogs. As a result, common general surgical diseases go untreated for years, resulting in pain, disability, and potential complications.

A larger data set is needed to further examine the extent of the surgical disease burden and shed light on the barriers faced by the impoverished Peruvians. This information may assist ministries of health with the scaling of surgical capacity.

82.19 Lipomatous Mass with Highrisk Radiographic Features:Is Routine Corebiopsy Warranted before Excision?

Posted on January 18, 2018

V. Satyananda1, C. Dauphine1, D. Hari1, K. Chen1, J. Ozao-Choy1  1Harbor UCLA Medical Center,General Surgery,Los Angeles, CALIFORNIA, USA

Introduction:  

Lipomatous masses are the most frequent non-cutaneous soft tissue masses encountered in clinical practice. Benign Lipomas comprise the majority,however,it is necessary to differentiate these from malignant lesions for which adequate surgical margins are important. In the abscence of suspicious clinical features, such as overlying skin changes,rapid growth,pain and firmness on examination, radiographic features have traditionally been to determine which patients should undergo core needle biopsy (CNB) prior to excision. We sought to examine whether CNB should be routinely performed in all lipomatous masses that demonstrate high -risk radiographic features

Methods:
A retrospective chart review of all patients who underwent excision of extremity or truncal lipomatous masses at a single institution between October 2014 to July 2017. Patients were divided into three groups-those who did not undergo pre-operative imaging or CNB(Group 1), those who underwent imaging (ultraosund, CT or MRI)without  CNB (Group 2) and those who underwent both imaging and CNB(Group 3). High risk radiographic features were defined as size > 5 cm , intramuscular location, presence of septationa (either < 2mm or > 2mm) and presence of areas of non -fat nodularity within the lesion. the number of high risk features present, pathologic results of surgical excision were evaluated to determine the subset of patients most likely to benefit from CNB.

Results:
In the 58 month study period, 182 patients underwent excision of lipomatous mass. Of these, 57 patients (Group1) had no preoperative imaging or CNB, and all were found to have benign lipotamous masses. In the remianing 125, 70 had imaging only(Group 2) and 55 had both imaging and CNB performed (Group 3). Overall, 2 patients (1.1%) were found to have atypical or malignant lipomatous lesions. Both had > 3 high risk features (thick/thin septations, intramuscular location, size >5cm)and both had undergone CNB( Table 1).

Conclusions:
Few recommendations exist regarding management of lipomatous masses; current guideline suggest imaging and CNB should be performed on large (> 5cm ) and /or high risk radiological features. Nonetheless, the rate of malignancy in these lesions appears to be low. Only 1% of our patients had an atypical or malignant final pathology. Our data suggests that patients who have small lipomatous masses (< 5 cm) may undergo excisional biopsy without further imaging or CNB. in additiona, our study suggests that routine performance of CNB based upon size alone is not warranted , but presence of 3 or more high-risk radiographic features should indicate pre operative CNB to ensure proper surgical approach at the time of excision. 

83.01 What is Your Piece of the Pie? A Survey of Surgeons’ Perceptions on Scope of Practice

Posted on January 18, 2018

A. Nayyar1, K. Patterson2, M. C. Roughton2, C. Wu2  1University Of North Carolina At Chapel Hill,Lineberger Comprehensive Cancer Center,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,Plastic And Reconstructive Surgery,Chapel Hill, NC, USA

Introduction:
Plastic and reconstructive surgery (PRS) has evolved into a very broad field, encompassing reconstructive and aesthetic procedures of the head/neck, breast, body and extremities. Such diversity in our scope of practice may be confusing for patients and referring providers, who may not be aware of the full breath or depth of our discipline. Further contributing to the confusion are other specialties with overlapping clinical expertise: neurosurgery (N), otolaryngology/head and neck surgery (OHNS), oral maxillofacial surgery (OMFS), general surgery (GS), orthopedic surgery (O), OB-GYN, urology (U), vascular surgery (V), cardiothoracic surgery (CT), pediatric surgery (P), transplant surgery (T) and dermatology (D). Previous studies have shown variable understanding amongst patients and primary care physicians about plastic surgery scope of practice, however, referral patterns from other surgeons have not been explored. We seek to understand national trends of referring surgeons’ perceptions of plastic surgery scope of practice.

Methods:
An anonymous, web-based survey was administered to members of American College of Surgeons with members of all surgical specialties. Respondents were asked to choose the surgical specialty they would consult for a variety of reconstructive and aesthetic problems.

Results:
Of 890 responses, 376 (42%) complete responses were received. The majority were general surgeons (40.7%), followed by plastic surgeons (13.6%) and otolaryngologists (10.7%). Referring surgeons considered plastic surgeons the expert in 12/35 (34.3%) reconstructive problems with the exception of head/neck cancer defects (OHNS), craniosynostosis (N), myelomeningocele (N), skin cancer (GS/D), hand fractures (O), upper extremity tendon lacerations (O), carpal tunnel syndrome (O), tissue biopsies (GS), hernia repair (GS), perineal defects (GS), lower extremity soft tissue defects/fractures (O), exposed spinal hardware (N), hidradenitis (GS), acute burns (GS) and chronic lower extremity wounds (GS) (Figure 1). For most aesthetic problems, referring surgeons considered plastic surgeons the expert with the exception of deviated septum (OHNS), hirsutism (D) and discolored skin patches (D).

Conclusion:

Referring surgeons consider plastic surgeons the expert for most aesthetic problems. However, ambiguity exists over the best management of a variety of reconstructive procedures with considerable overlap with orthopedics, OHNS, general surgery and neurosurgery. In an era of increasing surgical specialization, plastic surgeons risk losing these important reconstructive fields to other surgical subspecialties. Increased physician outreach and education of plastic surgeon’s breadth of practice may increase referrals in these areas.

83.02 Burns: Epidemiology, Treatment, and Outcomes at a Regional Referral Hospital In Uganda

Posted on January 18, 2018

K. Albutt1,2, M. Tungotyo3,4, G. Drevin1, S. Ttendo3,4, J. Ngonzi3,4, P. Firth5, D. Nehra1,6  1Harvard Medical School,Program In Global Surgery And Social Change,Boston, MA, USA 2Massachusetts General Hospital,Department Of General Surgery,Boston, MA, USA 3Mbarara Regional Referral Hospital,Mbarara, MBARARA, Uganda 4Mbarara University Of Science And Technology,Mbarara, MBARARA, Uganda 5Massachusetts General Hospital,Department Of Anesthesia, Critical Care And Pain Medicine,Boston, MA, USA 6Brigham And Women’s Hospital,Department Of Surgery,Boston, MA, USA

Introduction:  Burn injuries contribute significantly to the global burden of disease with an annual incidence of 33 million cases, of which approximately 95% occur in lower- and middle-income countries. Despite this, there is a lack of high-quality data in this context. The aim of this study was to study the epidemiology, treatment, and outcomes of burn injury amongst patients presenting to a regional referral hospital in Uganda.

Methods:  We conducted a retrospective observational study of all patients who were admitted with a burn injury to Mbarara Regional Referral Hospital (MRRH) in western Uganda between August 2013 and January 2017. Patient records were abstracted from the Surgical Services QUality Assurance Database (SQUAD), a validated electronic surgical database that currently enrolls all admitted surgical patients at MRRH. Descriptive statistics were used to characterize the population and multivariable logistic regression was used to identify factors associated with mortality.

Results: During the study period, a total of 375 patients were admitted to MRRH with a burn injury, accounting for 3.4% of surgical and 6.2% of trauma admissions to MRRH. Most burn patients were children, with 59.2% under the age of 5 years (x? = 11.5 years / M = 3.0 years). The average total burn surface area (TBSA) burn was 22.7±15.6%, ranging from 2-100%. The majority of burns were partial thickness / second degree (197, 52.5%) followed by superficial / first degree (26, 6.9%), full thickness / third degree (24, 6.4%), and fourth degree (4, 0.8%). Overall, 47.5% of patients underwent bedside wound care alone whereas 28.0% underwent operative intervention. The most common operations were debridement (87, 60.4%), skin grafting (33, 22.9%), and escharotomy/fasciotomy (6, 4.2%). The average length of stay was 11.7 days. While most patients were discharged (204, 54.4%), others absconded (70, 18.7%), died (44, 11.7%), or were referred (14, 3.7%). Inconsistent record keeping was apparent with a number of records missing TBSA (156, 41.6%), burn depth (125, 33.3%), and burn type/mechanism (204, 54.4%). Burn mortality was significantly predicted by TBSA when controlling for confounders including age, gender, burn depth, and operative intervention (p< 0.001). Notably, mortality was not associated with burn mechanism, anatomic location, or length of stay. 

Conclusion: In Uganda, burns contribute significantly to the surgical burden of disease, morbidity and mortality. A detailed understanding of burn injury epidemiology, treatment, and outcomes is essential in facilitating primary prevention, targeting interventions to strengthen capacity, and facilitating provision of safe, timely, and affordable burn care. There is a clear need to improve burn education and standardize reporting given inconsistent record keeping. Burn injury must become a public health priority in Uganda and other low-resource settings. 

 

82.17 Impact of Prescription Drug Monitoring System on Prescribing Practices after Out Patient Procedures

Posted on January 18, 2018

J. L. Philip1, J. R. Imbus1, J. S. Danobetia1, N. Zaborek1, D. F. Schneider1, D. M. Melnick1  1University Of Wisconsin,Madison, WI, USA

Introduction:

The opioid epidemic continues. Overprescribing of opioids contributes to excess opioid supply for diversion and abuse. Recent data demonstrates wide variation in prescribing and significant over-prescribing following outpatient general surgery procedures. Many states have implemented prescription drug monitoring programs (PDMP) as a tool to help prevent and monitor prescription drug misuse and abuse. Beginning on April 1, 2017 Wisconsin law requires prescribers to review the WI electronic PDMP (ePDMP) prior to issuing most controlled substance prescriptions to their patients. Our aim was to investigate trends in opioid prescription amounts and to evaluate the impact of the ePDMP requirement on surgeon prescribing practices.

Methods:

We collected prescription data retrospectively for three months before and after implementation of the law, as well as for two months one year prior. Eligible procedures included outpatient inguinal hernia repair, umbilical hernia repair, laparoscopic cholecystectomy, and breast lumpectomy +/- sentinel lymph node biopsy.  All opioid prescriptions were converted to standard morphine milligram equivalents (MME).  We compared mean MMEs prescribed for different time periods. To estimate the effect of mandatory ePDMP review in Wisconsin on weekly mean MMEs prescribed, we performed an interrupted time-series analysis using an autoregressive integrated moving average (ARIMA) model with weekly intervals.

Results:

In January-March of 2017, the mean MME prescribed following outpatient operations was 135 ± 4.0 (~27 5mg hydrocodone pills). The amount in January 2016 was significantly higher (216 ± 10.2, ~43 5mg hydrocodone pills, p<0.001).  There was a significant decrease in the mean MME prescribed in the three months following the implementation of the ePDMP requirement (114 ± 3.6 MME, ~23 5mg hydrocodone pills, p<0.001 vs. January-March 2017 & vs. January 2016).  There was no difference in the procedure make-up across time periods. Figure 1 demonstrates a downward trend of opioids prescribed over time. Time-series analysis did not reveal a significant intervention effect (intervention parameter -1.84, t-value = -0.99, p = 0.335) for the implementation of the mandatory ePDMP review.

Conclusion:

We demonstrate a decrease in the amount of opioids prescribed by general surgeons for outpatient operations from January to June 2017 and a significant decrease compared to 2016. The implementation of mandatory ePDMP requirements for opioid prescribers does not appear to have had an effect on the amount of opioid prescribed in the early post-intervention period suggesting that additional factors have contributed to decreased prescription amounts. 

 

82.18 Assessing Coding Practices for Surgical Operations over Time in the United States

Posted on January 18, 2018

F. Gani1, A. Z. Paredes2, J. K. Canner1, F. M. Johnston1, E. B. Schneider2, T. M. Pawlik2  1Johns Hopkins University School Of Medicine,Surgery,Baltimore, MD, USA 2Ohio State University,Surgery,Columbus, OH, USA

Introduction:  Variations in hospital billing practices may reflect differences in patient risk or may represent the “up-coding” of patients in response to payer incentives / polices. Given that modifications in hospital billing practices remain largely unknown for surgical services, the current study sought to assess whether coding practices on claims for surgical services have changed over time. 

Methods:  Patients >18 years undergoing a general surgery operation (colorectal, hepato-pancreatico-biliary or upper gastrointestinal surgery) were identified using the Nationwide Inpatient Sample from 2002-2011. Coding practices were compared by hospital and patient characteristics over time.

Results: A total of 1,339,654 patients were identified who met inclusion criteria. Among all patients, the mean number of billing codes was 8.8 codes/record (SD=4.6) with the number of “up-coded” patients (≥9 codes/record) increasing from 41.5% in 2001 to 63.4% in 2011 (p<0.001). While greater patient comorbidity, elective surgery and being enrolled in Medicare were all associated with a greater proportion of up-coded patients (all p<0.001), an increase in the number of “up-coded” patients was also observed among patients presenting without comorbidity who underwent an elective operation. This pattern in coding practices was also observed when this sub-population of patients was stratified by the primary payer (Figure). Coding practices were also observed to be variable by hospital characteristics, with the proportion of up-coded patients consistently higher at non-teaching hospitals compared with rural and teaching hospitals (both p<0.001). Median total charges were 61.1% higher among patients who were up-coded (mean number of codes/record: ≥9 vs. <9: $43,905 [23,259-86,992] vs. $27,247 [16,925 vs. 44,019]).

Conclusion: The number of “up-coded” patients was observed to increase with time; this increase was not explained by patient severity and was associated with higher total charges among patients.

 

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