11.13 How Well Does the Surgical Apgar Score Predict Risk of Serious Complications After Cancer Surgery?

Posted on January 18, 2018

S. M. Manstein1, N. Goel1, W. H. Ward1, L. Demora1, E. A. Ross1, S. S. Reddy1, M. C. Smaldone1, J. M. Farma1, C. S. Chu1, A. Kutikov1, D. Y. Chen1, M. N. Lango1, R. Viterbo1, J. A. Ridge1, A. Karachristos1, R. G. Uzzo1, N. F. Esnaola1  1Fox Chase Cancer Center,Surgical Oncology,Philadelphia, PA, USA

Introduction:
Major cancer surgery is associated with significant risks of perioperative morbidity and mortality, resulting in delayed adjuvant therapy, higher recurrence rates, and worse overall survival. Previous retrospective studies have promoted use of the Surgical Apgar Score (SAS) for preoperative risk assessment. This study prospectively evaluated the predictive value of SAS to predict serious complication (SC, as defined by the American College of Surgeons National Surgical Quality Improvement Program) in cancer patients undergoing elective major surgery.

Methods:
Demographic, comorbidity, procedure, and intraoperative data was collected prospectively for 405 cancer patients undergoing elective major surgery at a single NCI-designated comprehensive cancer center between 2014-17. The SAS was calculated immediately postoperative and outcome data was collected prospectively. Rates of SC according to SAS risk category were compared using Cochran-Armitage trend test. As a measure of discrimination, receiver operator characteristic (ROC) curves were generated and area under the ROC curves (AUC) and 95% confidence intervals (CI) were calculated.

Results:
The median age was 64 years of age (range, 23-86); 44.0% of patients were female, 12.8% were non-Caucasian, 2.5 % were Latino. 77.8% of patients were ASA status classification 1-2, while 22.2% were ASA status classification 3 or greater. The distribution of patients who underwent head and neck, upper gastrointestinal/hepatico-pancreatico-biliary, colorectal, gynecologic, urologic, or reconstructive is shown in Table 1. 80.0%, 17.3%, and 2.7% of patients were deemed to be at low (SAS 7-10), intermediate (SAS 5-6), or high risk (SAS 0-4) for SC based on their immediate postoperative SAS. Forty-six patients (11.4%) ultimately experienced a SC within 30 days; 3.7% returned to the operating room, 3.7% experienced a urinary tract infection, 3.2% experienced a respiratory complication, 2.7% experienced a wound complication, and 1.2% experienced a cardiac complication. Overall, 9.3%, 18.6%, and 27.3% of patients with SAS 7-10, 5-6, or 0-4 experienced a SC, respectively (P=.005). The overall discriminatory ability of the SAS, however, was modest (AUC 0.661; 95%CI, 0.582-0.740).

Conclusion:
The majority of patients who underwent elective major cancer surgery in our cohort were deemed to be at low risk for adverse events based on their immediate postoperative SAS. Although there was an overall association between SAS and higher risk of subsequent postoperative SC in our cohort, the ability of the SAS to accurately predict risk of postoperative SC at the patient-level was limited.
 

11.12 Fecal Diversion Is Rarely Necessary In Cytoreduction And Hyperthermic Intraperitoneal Chemotherapy

Posted on January 18, 2018

L. M. Cohen1, J. Baumgartner1, J. Veerapong1, A. Lowy1, K. J. Kelly1  1University Of California – San Diego,Surgical Oncology,San Diego, CA, USA

Introduction: There is currently no consensus on when stoma creation for temporary fecal diversion is indicated during cytoreduction and hyperthermic intrapertioneal chemotherapy (CRS/HIPEC). The aim of this study was to evaluate the indications for and outcomes following fecal diversion in CRS/HIPEC at a high volume center where stoma creation is used infrequently.

Methods:  A retrospective review of a prospectively maintained database of patients with peritoneal surface malignancy was performed to identify those who underwent complete CRS/HIPEC between 2007 and 2017.

Results: Of 416 patients who underwent complete CRS/HIPEC during the time period, 226 had at least one bowel resection and anastomosis and were included in the analysis. In total, 17 patients (8%) had a stoma created at the time of CRS/HIPEC. Six  (3%) had end colostomy and 11 (5%) had ileostomy meant for temporary fecal diversion. All patients with ileostomy creation underwent proctectomy. Additional factors associated with ileostomy creation included: Body mass index (BMI), prior systemic chemotherapy, operative time, and peritoneal carcinomatosis index (PCI) (Table). In all patients and in the subset that underwent low anterior resection (LAR) (n = 38), there were no differences in anastomotic leak rate (0% vs 3%, p=0.543), inpatient morbidity (64% vs 65%, p=0.945), or length of stay (median 11 days in both groups, p=0.926), but 60-day readmission rate was higher in patients with ileostomy (55% versus 25%, p=0.031). All patients with ileostomy underwent reversal. The median time to reversal was 98 days (range 62 to 567).

Conclusion: The main indication for diverting ileostomy in CRS/HIPEC was LAR. Diverting ileostomy was not associated with decreased anastomotic leak rate when considering all patients or the subset of patients that underwent LAR, but was associated with increased rates of 60-day readmission. These data suggest that the use of temporary fecal diversion in CRS/HIPEC is rarely required, including in patients who undergo LAR. 

 

11.11 A 15-year Experience of Anal Carcinoma in a Veteran Population Comparing HIV vs Non-HIV Patients

Posted on January 18, 2018

E. Vo1, B. A. Kimbrough1, S. S. Awad1,2, N. S. Becker1,2, L. W. Chiu1,2, L. Gillory1,2, D. S. Lee1,2, K. Makris1,2, G. Chen1,2, N. N. Massarweh1,2,3, H. S. Tran Cao1,2, C. Y. Chai1,2  1Baylor College Of Medicine,Houston, TX, USA 2Michael E. DeBakey Veterans Affairs Medical Center,Houston, TX, USA 3VA HSR&D Center For Innovations In Quality, Effectiveness And Safety, Michael E. DeBakey VA Medical Center,Houston, TEXAS, USA

Introduction: The incidence of anal cancer in the US has been steadily increasing since the 1970s. Of the known risk factors for anal carcinoma including HIV, HPV infection, history of anogenital warts, organ transplant, and tobacco use, HIV status poses the greatest risk but has not been clearly defined as a prognostic indicator. The objective of our study was to evaluate the clinical differences between HIV and non-HIV patients with anal carcinoma over the past 15 years at our institution.

Methods: We performed a retrospective review of an institutional tumor registry for all patients with histologically confirmed diagnosis of anal carcinoma from 2000-2015. Baseline demographic and clinical data including gender, age at diagnosis, histologic type, HIV status, treatment history and stage at initial diagnosis were collected. Descriptive and univariate analyses were performed to compare HIV vs non-HIV patients. Cancer-specific survival was calculated using Kaplan-Meier method.

Results: A total of 77 patients were included in our review (43% with HIV). The majority of our patients were male (92%), white (73%), with invasive squamous cell carcinoma (66%). HIV patients were diagnosed at a younger age (51 vs. non-HIV 60 years, p<0.01) and earlier stage 0-1 (63% vs. non-HIV 36%, p=0.01). Local excision was offered at a higher rate for HIV patients (52% vs. non-HIV 30%, p=0.05) with less receiving chemoradiation (42% vs. non-HIV 66%, p=0.04) and salvage APR (6% vs. non-HIV 16%, p=0.29). No statistically significant difference in cancer-specific 5-year survival was noted between HIV vs. non-HIV patients (p=0.64).

Conclusion: Although HIV patients are likely to be diagnosed with anal carcinoma at a younger age and at an earlier stage due to awareness of HIV as a risk factor, there was no difference in cancer-specific 5-year survival between HIV and non-HIV patients. Further study is warranted to examine factors which may influence survival in HIV patients in the era of effective antiviral therapy, and a high suspicion for anal cancer remains key to early detection in patients with anal or perianal lesions or symptoms.

11.09 Patient Characteristics and Outcomes among BRAF-mutated Colorectal Cancers: A Retrospective Review

Posted on January 18, 2018

J. Purchla1, W. H. Ward1, F. Lambreton1, N. Nweze1, T. Li2, N. Goel1, S. Reddy1, E. Sigurdson1, J. M. Farma1  1Fox Chase Cancer Center,Department Of Surgical Oncology,Philadelphia, PA, USA 2Fox Chase Cancer Center,Philadelphia, PA, USA

Introduction: Colorectal adenocarcinoma is a disease with varying causative molecular mechanisms, where chromosomal instability leads to gene specific mutations in proto-oncogenes and tumor suppressors. Among the most well-known mutations, the BRAF gene is associated with decreased disease-free and overall survival. This investigation strives to characterize patient and disease-related outcome measures among patients with BRAF-mutated colorectal adenocarcinoma.

Methods: A retrospective study was performed using molecular profiling (MP) data of 35 colorectal patients of any stage who were treated at our tertiary cancer center between 2006 and 2017. Those who did not undergo molecular profiling or those with incomplete data were excluded. If completed, additional genetic analyses performed within or external to our institution were also included. Demographic, clinical, and pathological data were collected and analyzed. Recurrence free survival was assessed using Kaplan-Meier estimation method.

Results: Out of 481 colorectal patients, 35 (7.3%) were identified as having a BRAF mutation. The median age at diagnosis was 73 years old (range 36-90), 25 (71%) were female, and 29 (82.9%) were white. There were 29 (82.9%) colon primary sites, 16 (55.2%) of those right-sided, and 6 (17.1%) rectal. 9 (25.7%) were stage IV, 15 (42.9%) were stage III, 7 (20.0%) were stage II, and 4 (11.4%) were stage I. A majority of patients (77.1%) exhibited more than just a BRAF mutation, with 15 (42.9%) positive for defective mismatch repair/microsatellite instability (dMMR/MSI), 10 (28.6%) with a P53 mutation, 4 (11.4%) SMAD4, 3 (8.6%) APC, and 3 (8.6%) PIK3CA. A total of 5 (14.3%) patients had a prior history of other cancer types. From this cohort, 29 (82.9%) had surgery, and 23 (79.3%) achieved an R0 resection. A total of 19 (54.3%) patients underwent adjuvant therapy. Targeted therapy with EGFR inhibitor was administered in 10 (28.6%) patients. Recurrence occurred in 10 (28.6%) patients, with the median time to recurrence 22.2 months. The recurrence free survival rate to 1 year was 74.5% and to 2 years was 37.1%. The overall survival rate to 1 year was 89.6%, and to 2 years was 56.8%.

Conclusions: In this cohort, patients with BRAF mutated colorectal cancer were generally older, white and female, and more likely to present with advanced disease. Of those who relapsed, more than 60% of patients did so within 2 years of diagnosis. Overall survival decreased substantially after 1 year. Tumors were primarily in the colon, specifically right-sided colon, with a MP likely to show more than 1 mutation. Our investigation shows that this cohort of BRAF-mutated tumors exhibits a poorer prognosis. To better characterize these patients and their disease-related outcomes, further investigation with a larger cohort is warranted. 

11.10 Postoperative Morbidity and Mortality of Neoadjuvant Therapy after Pancreaticoduodenectomy

Posted on January 18, 2018

K. S. Cools2, H. J. Kim2, J. J. Yeh2, H. K. Sanoff3, K. B. Stitzenberg2  2University Of North Carolina At Chapel Hill,Department Of Surgery,Chapel Hill, NC, USA 3University Of North Carolina At Chapel Hill,Department Of Medicine,Chapel Hill, NC, USA

Introduction:
Although surgical resection remains the only potentially curative treatment for pancreas cancer, neoadjuvant chemotherapy and/or radiation therapy has been increasingly employed to try to downstage patients with borderline resectable tumors. Still, there is a paucity of literature examining outcomes at the population level, for patients who do and do not receive neoadjuvant therapy. The existing studies highlight single/few center experiences, with mixed results. The aim of this study was to compare on a population level, the postoperative morbidity and mortality after pancreaticoduodenectomy (PD) in patients undergoing neoadjuvant therapy versus initial surgery for pancreatic ductal adenocarcinoma (PDA).

Methods:
Using the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) Targeted Pancreatectomy data, we identified patients who underwent a PD for PDA between 2014 and 2015. This database consists of pancreas-specific outcomes from 106 centers in the United States. Patients were grouped based on having received neoadjuvant therapy within 90-days of PD. We used bivariable and multivariable analyses to compare postoperative outcomes between the groups.

Results:
A total of 3,758 patients with PDA underwent PD; 930 (24.7%) received neoadjuvant therapy (13.5% chemotherapy only, 0.8% radiation only, and 10.4% chemoradiation). Those in the neoadjuvant group were more likely to have preoperative biliary stenting (66.2% vs 61.8%, p=0.015), a major vein resection (35.8% vs 17.5%, p<0.001), and longer operating time (413 min vs 364 min, p<0.001). At the time of surgery, those in the neoadjuvant group also had more T1 tumors (10.9% vs 5.1%, p<0.001) and fewer nodes positive (N0 49% vs 28%, p<0.001). There were no differences in 30-day postoperative mortality (1.7% vs 2%, p=0.616) or overall complications (55.9% vs 55.2%, p=0.689). On multivariate analysis, patients who received neoadjuvant therapy had a lower likelihood of pancreatic fistula (OR 0.67, 95% CI 0.49-0.92, p<0.001). On multivariate analysis to identify factors associated with pancreatic fistulas, independent predictors included having initial surgery (OR 1.44, 95% CI 1.07-1.95), preoperative biliary stenting (OR 1.3, 95% CI 1.02-1.7), soft pancreatic tissue (OR 2.96, 95% CI 2.32-3.78), longer operative times (OR 1.06, 95% CI 1.0-1.12), and a normal preoperative albumin (OR 1.41, 95% CI 1.08-1.85).

Conclusion:
Using the robust NSQIP database of over 100 centers, we found that neoadjuvant therapy does not increase the overall postoperative morbidity or mortality of a PD for PDA. There is a decreased likelihood of pancreatic fistulas in patients that receive neoadjuvant therapy.

11.07 Mesoappendix Based Vascularized Lymph Node Transfer for the Surgical Treatment of Lymphedema

Posted on January 18, 2018

D. Ruter1, W. Chen4, R. Garza5, D. Eiferman3, R. Skoracki2  1The Ohio State University College Of Medicine,Columbus, OH, USA 2The Ohio State University College Of Medicine,Department Of Plastic Surgery,Columbus, OH, USA 3The Ohio State University College Of Medicine,Department Of General Surgery,Columbus, OH, USA 4The Ohio State University College Of Medicine,Department Of Pathology,Columbus, OH, USA 5PRMA Plastic Surgery,San Antonio, TX, USA

Introduction: Lymphedema is an accumulation of lymph fluid in the interstitial space that is most commonly due to surgical resection of lymph nodes secondary to malignancy. Standard of care compression and mechanical drainage based treatments are time intensive and provide limited long term relief. Autologous lymph node transfer (ALNT) is a microsurgical treatment in which a vascularized lymph node flap is harvested with its blood supply and transferred to the affected extremity to improve clearance of lymph fluid. A number of donor sites, including the groin, axilla, submental, and supraclavicular regions have been described as potential donor sites for vascularized lymph node containing free flaps. An ideal donor site minimizes the risk of iatrogenic lymphedema while being easily accessible with few potential complications. Previously, our group has utilized intraabdominal jejunal mesentery lymph nodes and omentum flaps for ALNT. We hypothesized that the mesoappendix could be harvested minimally invasively as an expendable "spare part" and would be ideal for transplantation if vessel size is adequate and a reliable number of vascularized lymph nodes can be included.

Methods: In this IRB approved study, 25 mesoappendix specimens (22 appendectomy and 3 right hemicolectomy) resected for benign disease underwent gross pathologic examination for determination of the presence of lymph nodes and measurement of the appendicular artery and vein caliber and length.

Results: A single lymph node was present in two of twenty-five (8%) specimens. Mean artery and vein calibers at the point of ligation were 0.87 and 0.86 mm, with mean lengths, as measured from the appendix mesentery to the ligated vessel end, of 1.70 and 1.84 cm, respectively. The two measurable right hemicolectomy specimens had an artery diameter of 1.2 mm, and vein diameters of 1.1 and 2.2 mm.

Conclusion: Mesoappendiceal lymph nodes were inconsistently present. The artery and vein calibers of 46% of the specimens were greater than 0.8 mm, the minimum caliber we prefer for microsurgical anastomosis. Maximal vessel caliber determination was limited by the site of vessel ligation chosen by the operating surgeon, and thus may be underestimated by our study. The exact role of the lymph node itself is not exactly delineated in the treatment of lymphedema, but evidence suggests that greater numbers of lymph nodes transplanted seem to have greater efficacy in removing lymph fluid. The mesoappendix, while it contains few or no lymph nodes is attached to the appendix, which contains a great number of lymphoid follicles in the submucosa. The uncertain role of this tissue in the treatment of lymphedema will require further investigation as a potential solution. However, for patients suffering from lymphedema, the mesoappendix can easily be explored and evaluated for the presence of lymph nodes and sufficiency of the vascular pedicle if planning to do an abdominal based lymph node transfer. 

11.08 Neutrophil To Lymphocyte Ratio Predicts Outcomes After Chemoembolization for Neuroendocrine Tumors

Posted on January 18, 2018

S. M. McDermott1, N. Saunders3, E. M. Schneider2, D. Strosberg2, J. Onesti4, G. Davidson2, M. Bloomston5, M. Dillhoff2, C. R. Schmidt2, L. A. Shirley2  1Ohio State University,College Of Medicine,Columbus, OH, USA 2Ohio State University,Department Of Surgery,Columbus, OH, USA 3Emory University School Of Medicine,Department Of Surgery,Atlanta, GA, USA 4Mercy Health,Department Of Surgery,Grand Rapids, MI, USA 521st Century Oncology,Ft Myers, FL, USA

Introduction: The neutrophil to lymphocyte ratio (NLR) is predictive of outcomes in various cancers, including neuroendocrine tumors (NETs), as well as response to cancer related treatments, including transarterial chemoembolization (TACE). However, the role of NLR in patients with NET treated with TACE is incompletely understood. We hypothesized that, in patients with liver metastases from NETs, a lower NLR value pre-TACE, as well as post-procedure, would correlate with improved long-term outcomes.

Methods:

After IRB approval, we reviewed 262 patients who underwent TACE for metastatic NET at a single institution. NLR was calculated from the pre-TACE CBC drawn the day of the procedure and the post-TACE CBC drawn approximately one day, one week, and six months after initial treatment. NLR levels were then correlated with overall survival from the time of TACE.

Results:The median post-TACE survival of the entire cohort was 30.1 months. Mean NLR for patients who survived less than 3 years was 4.4 while the mean NLR for patients who survived more than 3 years was 3.3. Median overall survival of patients with a pre-TACE NLR < 4 was 33.3 months vs 21.1 months for patients with a pre-TACE NLR > 4 (p = 0.005). The median survival for patients with post-TACE NLR higher than pre-TACE NLR was 21.4 months vs 25.8 months for patients with post-TACE NLR less than or equal to pre-TACE NLR (p = 0.007) (Figure). NLR values from one day and one week post-TACE did not correlate with outcome.

Conclusion:

An elevated NLR pre-TACE, as well as an NLR value that has not returned to its pre-TACE value several months after the TACE, are associated with worse survival in patients with NET and liver metastases. This value can easily be calculated from the CBC routinely obtained from patients as part of their pre-procedural and post-procedural care. Calculating and trending NLR values for these patients may impact treatment strategies.

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

Posted on January 18, 2018

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

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

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

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

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

11.06 Timing of Radiation Improves Margin Status but Not Limb-Salvage Rates in Deep Extremity Sarcoma

Posted on January 18, 2018

R. D. Shelby1, L. Suarez-Kelly1, P. Y. Yu1, T. M. Hughes1, C. G. Ethun2, T. B. Tran3, G. Poultsides3, D. M. King7, M. Bedi7, T. C. Gamblin7, J. Tseng4, K. K. Roggin4, K. Chouliaras5, K. Votanopoulos5, B. A. Krasnick6, R. C. Fields6, R. E. Pollock1, J. H. Howard1, K. Cardona2, V. P. Grignol1  1Ohio State University,Columbus, OH, USA 2Emory University School Of Medicine,Atlanta, GA, USA 3Stanford University,Palo Alto, CA, USA 4University Of Chicago,Chicago, IL, USA 5Wake Forest University School Of Medicine,Winston-Salem, NC, USA 6Washington University,St. Louis, MO, USA 7Medical College Of Wisconsin,Milwaukee, WI, USA

Introduction:  The addition of radiation to surgery has improved limb-salvage rates for deep extremity sarcomas. Timing of delivery in a neo-adjuvant (NA) vs adjuvant strategy remains an area of study.  We sought to evaluate the effect of NA radiation on patients with deep extremity sarcomas from a multi-institutional database. 

Methods:  A retrospective review of all adult patients with deep extremity sarcomas who underwent surgical resection at 7 U.S institutions from 2000-2016 was performed. Categorical variables were compared using chi-square test. Continuous variables were compared using two-sample t-tests. To assess the impact of radiation on recurrence free survival (RFS) and overall survival (OS) Cox proportional hazard regression models were used. Multivariate analysis was performed for all statistically significant categories to evaluate association with OS and RFS. 

Results: 1483 patients with surgically resected deep extremity sarcomas were identified. Average tumor size was 15cm; the most common histology was undifferentiated pleomorphic sarcoma. 723 (50%) patients had surgery only, 419 (29%) had NA radiation and 311(21%) had adjuvant radiation. Most patients who received radiotherapy had grade 3 tumors (82% NA vs 81% adjuvant vs 60% surgery, p<0.0001). Patients receiving NA radiation were more likely to have a history of radiation (7% NA vs 2% adjuvant vs 4% surgery, p=.0060) and undergo core biopsy for diagnosis (67% NA vs 31% adjuvant vs 34% surgery, p<0.0001) than those who had surgery first. More patients in the NA and surgery alone group underwent radical resection (92% NA vs 83% surgery vs 78% adjuvant p<0.0001). The radiotherapy groups had significantly more limb-sparing operations (98% adjuvant vs 94% NA vs 87% surgery, p<0.0001). NA radiation increased post-operative complications (34% NA vs 24% surgery vs 16% adjuvant, p<0.0001) and the need for tissue flap reconstruction (38% NA vs 24% surgery vs 22% adjuvant, p<0.0001). NA radiotherapy led to more negative margins on frozen (87%% NA vs 79% surgery vs 72% adjuvant, p<.0001) and final pathology (90% NA vs 79% surgery vs 75% adjuvant, p<.0001). There were significantly fewer local recurrences in the NA group (14% vs 17% adjuvant vs 27% surgery, p=0.001). The surgery only group had the fewest metastatic recurrences (52% vs 72% NA vs 62% adjuvant, p=0.001). OS and RFS were better in the groups receiving radiation, although not statistically significant. On multivariate analysis there was no factor independently associated with survival. 

Conclusion: In this large multi-institutional study, radiotherapy (adjuvant and NA) improves limb salvage rates. NA radiation improves margin status and local recurrence rates, however with increased post-operative complications. There were no other differences related to timing of radiotherapy. Our findings are consistent with other smaller studies. 

11.04 Soft Tissue Sarcomas in the Elderly: Are we Overtreating or Undertreating this Patient Population?

Posted on January 18, 2018

A. Gingrich1, S. Bateni1, R. Bold1, A. Kirane1, A. Monjazeb3, M. Darrow4, S. Thorpe2, R. Canter1  1University Of California – Davis,Surgery,Sacramento, CA, USA 2University Of California – Davis,Orthopedics,Sacramento, CA, USA 3University Of California – Davis,Radiation Oncology,Sacramento, CA, USA 4University Of California – Davis,Pathology,Sacramento, CA, USA

Background: The surgical management of elderly cancer patients is a topic of increasing attention, especially as the population ages. Although disparities in access to care and outcomes are a key focus of health services research, few studies have examined differences in patterns of care and outcomes among elderly cancer patients, especially in soft tissue sarcoma (STS).  Our objective was to analyze and compare the clinical, pathologic, and treatment characteristics for elderly STS patients to younger patients, hypothesizing that elderly STS patients represent a distinct cohort of patients for whom more age-specific algorithms are indicated.

Methods: Using the National Cancer Database (2004-2012), we identified 33,859 adult patients (18 -99 years) with non-metastatic STS. We defined “elderly” patients as ≥ 74 years (top quartile of age, n=8,504). We compared patient demographics, tumor characteristics, types of treatment and outcomes among the “elderly” to the non-elderly cohort. We also analyzed survival in the elderly undergoing surgery versus no surgery. Cox proportional hazard analysis was used to analyze multivariate predictors of overall survival among elderly patients.

Results: Age, tumor size, geographic location, rural/urban, and receipt of radiotherapy (RT) were similar between non-elderly and elderly patients. However, significant differences were observed in histologic grade, histologic subtype, and facility type (P<0.05). Elderly patients were less likely to be black (5.8 vs 12.3%, P = 0.001), more likely to have higher comorbidity scores (26.5 vs. 15.2%, P=0.001), and less likely to undergo R0 resection (59.7 vs. 70%, P = 0.001). 90-day mortality was also 3.5 times greater in elderly patients (4.3% vs. 1.2%, P = 0.001). Yet, among elderly patients undergoing surgery, median survival was 43.8 months versus 15.4 months in those who did not undergo surgery (P = 0.001). On Cox proportional hazard analysis of the elderly cohort, predictors of superior survival were comparable to non-elderly patients, including younger age, female sex, lower Charlson-Deyo score, histologic subtype, lower grade, smaller tumor size, surgical resection, R0 resection and receipt of radiation therapy (p<0.05). Chemotherapy did not offer survival benefit (p>0.05).  

Conclusions: Key clinical, pathologic, and treatment differences exist in elderly patients with STS. Although elderly patients have worse rates of R0 resection and 90-day mortality, surgery remains associated with superior long term survival. Better understanding of these important differences in the presentation and management of STS in the elderly are important in the context of the aging population, including the narrower benefit to risk ratio with surgical management of localized disease. 

11.03 A Phase II Trial of Cytoreduction and HIPEC for Advanced Adrenocortical Carcinoma

Posted on January 18, 2018

W. Lo1, T. Beresnev1, M. Merino3, M. Mulquin1, Y. Shutack1, D. Zlott1, J. Hernandez1, J. Davis1, M. Hughes2  1National Cancer Institute,Thoracic And GI Oncology Branch,Bethesda, MD, USA 2Eastern Virginia Medical School,Surgical Oncology,Norfolk, VA, USA 3National Cancer Institute,Pathology,Bethesda, MD, USA

Introduction:  Adrenocortical carcinoma (ACC) is an aggressive disease with 5-year survival estimated at 10-15%. While definitive therapy is complete surgical resection, recurrence occurs in up to 85% of patients. Systemic chemotherapy and molecular-targeted therapy have had minimal benefit for patients with advanced disease. The purpose of this study is to evaluate cytoreduction and HIPEC for safety in patients with advanced ACC confined to the peritoneal cavity, as well as evaluate the strategy for peritoneal progression-free survival.

Methods:  This single-institution, phase 2 clinical trial enrolled patients from April 2013 through September 2016. Eligible patients had histologically confirmed ACC and peritoneal disease deemed resectable by the operating surgeon and preoperative imaging. Comprehensive cytoreductive surgical resection was performed. Patients achieving CCR 0 or 1 proceeded with HIPEC using the closed-abdomen technique. Intraperitoneal cisplatin at 250 mg/m2 was circulated at 40°C for 90 minutes. Primary outcome was peritoneal progression-free survival (PFS). Secondary outcomes included overall survival (OS), adverse events, and treatment toxicity.

Results: Nine patients underwent cytoreduction and HIPEC. Mean operative time was 689 minutes (range 577 – 894 min). Median estimated blood loss was 500 mL (range 100 – 2000 mL). Median length of hospital stay after resection was 11 days. There were no perioperative mortalities or immediate reoperations. No treatment-related toxicities, grade 3 or 4 complications were observed. Thirty percent (n = 3) experienced infection-related complications. During a median follow-up period of 23.2 months, seven patients experienced peritoneal progression of disease and two patients died due to ACC. Median peritoneal PFS was 18.9 months from cytoreductive surgery and HIPEC. Median OS from date of initial diagnosis was 4.23 years. On univariate analysis, prior treatment with mitotane was associated with improved peritoneal PFS and OS. Tumor stage, initial disease-free interval after index resection, tumor functional status, type of initial resection, and prior treatment with etoposide, doxorubicin, and cisplatin (EDP) had no impact on peritoneal PFS or OS.

Conclusion: Recurrent ACC is an aggressive disease, and effective treatment strategies remain undefined. This study demonstrates that cytoreduction and HIPEC can be safely performed for patients with advanced ACC, and may result in a survival advantage for patients with disease confined to the peritoneum after receipt of adjuvant mitotane.  

 

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

Posted on January 18, 2018

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

Introduction:  

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

Methods:  

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

Results: 

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

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

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

Posted on January 18, 2018

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

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

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

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

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

11.02 History of Blistering Sunburn and Molecular Profile in Melanoma

Posted on January 18, 2018

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

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

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

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

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

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

Posted on January 18, 2018

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

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

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

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

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

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

Posted on January 18, 2018

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

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

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

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

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

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

Posted on January 18, 2018

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

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

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

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

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

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

Posted on January 18, 2018

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

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

Methods:

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

Results:

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

Conclusion:

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

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

Posted on January 18, 2018

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

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

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

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

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

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

Posted on January 18, 2018

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

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

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

Results:

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

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

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

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

« Previous Page
Next Page »