90.10 Disparities in Surgical Intervention for Colorectal Cancer: A SEER Analysis from 2000-2015

Posted on January 31, 2019

M. Liu1, M. Miller1, J. Bhattacharya1, C. Kin1, A. Morris1  1Stanford University,School Of Medicine,Palo Alto, CA, USA

Introduction:
Colorectal cancer is the 3rd leading cause of cancer mortality in the United States. Black patients with colorectal cancer have higher rates of overall and disease-specific mortality than white patients. Surgical intervention can be curative for colorectal cancer if patients have access to and receive the care. Our goal was to compare the rates of surgical intervention among black and white patients. We hypothesized that black colorectal cancer patients undergo less surgical intervention compared to white patients.

Methods:
The National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) Registry was used to identify patients over age 18 years diagnosed with incident Stage I-IV from 2000-2015. We performed logistic regressions to determine surgical intervention among black and white patients stratified by stage, adjusting for sex, age, and insurance status. STATA was the statistical software used. Significance was set at a p value less than 0.05.

Results:
A total of 297,555 patients met inclusion criteria. In a logistic regression analysis, black patients had a significantly decreased odds of undergoing surgical intervention compared to white patients [unadjusted OR 0.76 (95% CI 0 .74 – 0 .78) p< 0.0001] and [adjusted OR 0.83 (95% CI 0 .79- 0.86) p<0.0001]. When stratified by stage, black patients were significantly less likely than white patients to undergo surgical intervention at Stage I [adjusted OR 0.74 (95% CI 0.66 – 0 .83) p<0.05] and Stage II [unadjusted OR 0.88 (95% CI 0.78 -0 .998) p<0.05], although not statistically significant when adjusted [OR 0.94 (95% CI 0.81-1.08) p > 0.05]. There was no significant difference in surgical intervention between white and black patients diagnosed with advanced Stages III-IV.

Conclusion:
We found that black patients with curable early-stage colorectal cancer had nearly 17% decreased odds of undergoing surgical intervention compared to white patients. Although our data does not permit us to identify an underlying mechanism for this disparity, further work with an enriched dataset could help to determine the relative contribution of hospital, provider, and patient-level factors.
 

90.09 Head and Neck Surgical Capacity in Rural Haiti

Posted on January 31, 2019

R. Patterson1,2, M. Wilson2, A. Bowder2,3, C. Dodgion3, L. Ward2, M. Padovany2  1Tufts University School of Medicine,Boston, MA, USA 2St. Boniface Hospital,General Surgery,Fond-des-Blancs, SUD, Haiti 3Medical College of Wisconsin,General Surgery,Milwaukee, WI, USA

Introduction:

Surgery is a neglected component of global health, and surgical subspecialty care is particularly absent in low- and middle-income countries (LMICs). Worldwide, head and neck (H&N) conditions contribute to 375,000 deaths per year. Typically managed by otolaryngologists in high-income countries, access to specialists is severely limited in LMICs.

Currently, Haiti has 16 practicing otolaryngologists for a population of 11 million. Thus, many general surgeons manage H&N conditions. In southern Haiti, surgical care at St. Boniface Hospital (SBH) is provided by two Haitian general surgeons and one rotating resident who manage a breadth of surgical disease including H&N conditions. Since 2015, SBH surgical capacity has grown in three distinct phases. Here, we examine the ability of SBH general surgeons to care for H&N conditions by analyzing the volume, complexity, and mortality of cases traditionally treated by otolaryngologists.

 

Methods:
A retrospective review was performed of all H&N surgical cases at SBH between February 2015 and August 2017. These procedures were divided into three phases correlating to increasing level of general surgery capacity: phase 1 (P1) with visiting surgical teams, phase 2 (P2) with one full-time general surgeon, and phase 3 (P3) with a surgical center, two general surgeons, and residents. Diagnosis, procedure details, and patient demographics were recorded in the surgical logbook.

Results:
SBH surgeons performed 2,068 surgical procedures, including 165 (8%) H&N procedures. No H&N procedures were performed in P1, but there were 73 in P2 and 92 in P3, with a monthly average of 4.6 and 10.6 in P2 and P3, respectively. Most cases were thyroidectomies (30.3%), excisions of unspecified head and neck masses (26.7%), and facial plastics procedures (9.7%). The transition from P2 to P3 allowed for increased rates of more complex surgery like H&N mass resections (mean of 1.1 to 2.3 per month, [range of 0-8]), Sistrunk procedures (0.1 to 0.8, [0-2]), and Ludwig’s Angina procedures (0.1 to 0.6, [0-2]). Few specialized procedures of the ear, nose, or throat were performed. There were no recorded mortalities of H&N patients.

Conclusion:
Building general surgery capacity contributed to SBH’s ability to care for H&N disease. SBH’s experience suggests that general surgeons can safely fill gaps in settings with limited subspecialty care. National surgical plans and otolaryngology training should prioritize general surgery cross-training to build on existing H&N surgical skills. This approach should be combined with strengthening referral networks and subspecialty H&N capacity at tertiary centers in order to maximize the availability of specialized care.

90.08 Reasons for Surgical Referral in Rural Ethiopian Hospitals

Posted on January 31, 2019

K. Garringer1, O. Ahearn1, J. Incorvia1, L. Drown1, K. Iverson1,3, D. Burssa2, S. Esseye2,6, V. Smith4, J. Meara1,5, A. Beyene1,7, A. Bekele1,7, S. Bari1  1Harvard School Of Medicine,Program In Global Surgery And Social Change,Brookline, MA, USA 2Federal Ministry of Health, Ethiopia,Addis Ababa, ADDIS ABABA, Ethiopia 3University Of California – Davis,Department Of Surgery,Sacramento, CA, USA 4Assist International,Safe Surgery 2020,Ripon, CA, USA 5Children’s Hospital Boston,Department Of Pediatric Plastic And Oral Surgery,Boston, MA, USA 6Jhpiego,Safe Surgery 2020,Addis Ababa, ADDIS ABABA, Ethiopia 7Addis Ababa University,School Of Medicine, Department Of Surgery,Addis Ababa, ADDIS ABABA, Ethiopia

Introduction: In Ethiopia, the Safe Surgery 2020 initiative is a collaborative effort of partner organizations that implement innovative programs to improve the surgical system. This initiative directly supports the Federal Ministry of Health’s national surgical planning effort that aims to improve access to surgical and anesthesia care in hospitals at all levels of the health system.

Surgical referrals are common within health systems in low- and middle-income countries, where high-quality surgical services are often only available at referral and specialized hospitals located in urban areas. It is important to understand the specific reasons for referrals that are being made for surgical services. This will lend insight to gaps in surgical care and will serve to strengthen primary hospital capacity and reduce the referral burden on higher level hospitals. This study intended to determine the most common reasons for referrals from primary-level hospitals to general and specialized-level hospitals in the Amhara region of Ethiopia.

Methods:  Data on surgical referrals and specific reasons for referral were recorded by surgical team members using newly designed and implemented clinical registries at five primary-level hospitals in the Amhara region of Ethiopia. A descriptive, cross-sectional study was conducted by reviewing the reasons for all emergency and elective surgical referrals that were made to higher-level hospitals during the month of May 2018.

Results: A total of 327 surgical referrals were recorded in the month of May among five primary-level hospitals included in this study (Table 1). The monthly median number of referrals was 70 referrals (IQR 65 – 70). The majority of the referrals (89.9%) were attributed to a ‘lack of specialist care’ at the referring hospitals. The next most common reasons for referral were: a ‘lack of diagnostic equipment’ (3.1%), a ‘lack of drugs’ (1.8%) and ‘patient preference’ (1.8%).

Conclusion: There is a substantial need for specialized surgical care in the Amhara region of Ethiopia, as there is a limited capacity to perform advanced surgical procedures in primary-level hospitals. This finding reiterates the importance of increasing the specialist surgical workforce in Ethiopia, in line with recommendations made by the Lancet Commission on Global Surgery in 2015. A lack of necessary equipment, supplies, and resources in these hospitals also leads to referrals. Results indicate that further consideration of referral reasons among hospitals throughout the country could help to identify focus areas for Safe Surgery 2020 programs and future Ministry of Health interventions meant to increase surgical capacity at the primary-hospital level.

90.07 Burden of Surgical Disease on Interfacility Ambulance Transfers in a Middle-Income Country

Posted on January 31, 2019

P. Truche1, R. NeMoyer1, S. Patiño-Franco2, M. Torres3, L. F. Pino4, G. L. Peck1  1Rutgers-Robert Wood Johnson Medical School,Department Of Acute Care Surgery,New Brunswick, NJ, USA 2Universidad de Antioquia,Facultad De Medicina,Medellín, ANTIOQUIA, Colombia 3Red de Salud del Centro E.S.E.,Cali, VALLE DEL CAUCA, Colombia 4Hospital Universitario del Valle – Evaristo García,Cali, VALLE DEL CAUCA, Colombia

Introduction:   Surgically treatable conditions account for thirty percent of the global burden of disease. Access to timely and safe surgical care has gained increasing priority in low- and middle-income countries (LMICs). MICs frequently report a large rate of interfacility ambulance transfer, which remains largely under-investigated, reflecting an opportunity to optimize timeliness and safety of definitive surgical treatment. Herein, we investigate surgical burden within interfacility transfers, differentiate the burden with respect to the public and private sectors, and provide a preliminary cost estimate for a large urban city in a middle-income country.

 

Methods:   A large retrospective review was conducted on transfer records for a public emergency medical service in Cali, Colombia. Comparisons were made between public and private healthcare facilities initiating transfer. Chi squared analysis was performed and odds ratios calculated comparing diagnosis, transferring specialty, and facility type. ICD9 codes were subcategorized and compared to transferring specialty using pairwise comparisons with a Bonferroni correction. Cost estimates were performed by comparing collected data with the 2016 ambulance fee schedule.

 

Results:  31,659 patients were transferred over a 1-year period including 21,790 interfacility transfers. 7,808 (34.6%) of transfers were for surgical conditions with 69.8% of these transfers at a surgeon’s request. Surgical conditions accounted for more transfers among public vs. private facilities (33% vs. 15%; p <.001). Private hospitals transferred to private hospitals 77% of the time, while public hospitals transferred to public hospitals 61% of the time. The most common surgical conditions requiring transfer were fractures (1,227, 5.4%), appendicitis (913, 4.1%), wounds (871, 3.9%), abdominal pain (818, 3.6%), trauma (652, 2.9%), and acute abdomen (271, 1.2%). The odds of transfer originating from a public facility were 4.4x higher in patients with appendicitis (OR=4.4, CI [3.3-5.8times]) and 7.5x higher with wounds (OR= 7.5, CI [5.2-10.8] P<.001]), but not statistically different for fractures (OR = 1.2, CI [0.99-1.3 P<0.06], abdominal pain (OR = 0.99, CI [0.8-1.2] P<0.63), or trauma (OR=0.99, CI [0.8-1.2] P<0.92). Total cost of surgical interfacility transfers was estimated to be 719,420 USD.

 

Conclusion:  Surgical disease contributed to roughly one-third of interfacility ambulance transfers. The most common reasons for transfer reflect basic surgical disease with a significant cost burden to the public health system. Public and private hospitals contribute unequally to transfer burden and tend to transfer to public and private hospitals, respectively. More research is needed to determine the true cost to Colombia’s health system and correlate clinical outcomes to transfer burden to assess and inform implications this may have on infrastructure, workforce, finance, and national surgical system strengthening.

90.06 Evaluating Disease Biology and Incidence of Rectal Cancer in Young People in Kentucky

Posted on January 31, 2019

M. B. Holbrook1, N. Bhutiani1, B. Huang2, Q. Chen2, T. C. Tucker3, S. Galandiuk1, R. W. Farmer1  1University of Louisville,Surgery,Louisville, KY, USA 2University of Kentucky,Biostatistics,Lexington, KY, USA 3University of Kentucky,Markey Cancer Center,Lexington, KY, USA

Introduction: Multiple studies have demonstrated an increase in rectal cancer among young people, a trend reflected in the most recent colorectal cancer screening guidelines.  Despite significant improvement in screening and education, young rectal cancer patients have emerged as a burgeoning health crisis in Kentucky.  This study sought to compare the incidence of rectal cancer and tumor biology among patients <40 years old in Kentucky and the United States. 

Methods: The Kentucky Cancer Registry (KCR) and the National Cancer Database (NCDB) were queried for patients diagnosed with cancer of the rectum or rectosigmoid junction between 2004 and 2014.  Demographics, tumor characteristics, and annual proportional incidence in patients <40 years old and those ≥ 40 years old were compared. 

Results:Patients in Kentucky and nationally had a similar distribution between rectal junctional and true rectal malignancy (p=0.13).  There was no difference in stage at diagnosis (p=0.17), gender (p=0.57), and KRAS mutational status (p=0.46).  However, a greater proportion of patients in Kentucky had undifferentiated tumors compared to the NCDB (7.5% KCR vs. 1.8% NCDB, p<.001).  Five-year overall survival was no different between groups (~70%).  Linear regression of incidence demonstrated an annual increase in Kentucky of twice the national rate (0.13% per year vs 0.05% per year) with a sharp increase in 2014 (Figure). 

Conclusion:While similar to the national cohort, young rectal cancer in Kentucky displays variation in tumor grade and incidence suggesting difference in tumor biology.  These data reinforce recent changes to screening guidelines, with potential extension to younger patients. 

 

90.05 Stuck with the Consequences: The Prevalence of Untreated Hernias in Southwest Cameroon

Posted on January 31, 2019

W. T. Chendjou3, S. A. Christie1, M. M. Carvalho1, T. Nana4, E. Wepngong3, D. Dickson1, R. Dicker2, A. Chichom Mefire3, C. Juillard1  1University Of California – San Francisco,Department Of Surgery,San Francisco, CA, USA 2University Of California – Los Angeles,Department Of Surgical Critical Care,Los Angeles, CA, USA 3University of Buea,Faculty Of Health Sciences,Buea, SOUTHWEST, Cameroon 4Regional Hospital Limbe,Department Of Surgery,Limbe, SOUTHWEST, Cameroon

Introduction:  Hernias are one of the most commonly encountered surgical conditions, and every year, more than 20 million hernia repairs are performed worldwide. The surgical management of hernia, however, is largely neglected as a public health priority in developing countries, despite its cost-effectiveness. To date, the prevalence and impact of hernia has not been formally studied in a community setting in Cameroon. The aim of this study was to determine the prevalence and characteristics of untreated hernia in the Southwest region of Cameroon.

Methods:  This study was a sub-analysis of a cross-sectional community-based survey on injury in Southwest Cameroon. Households were sampled using a three-stage cluster sampling method. Household representatives were asked to identify all untreated hernias occurring in the past year. Data on socio-economic factors, hernia symptoms – including the presence of hernia incarceration- and treatment attempts were collected between January 2017 and March 2017.

Results: Among 8065 participants, 73 persons reported symptoms of untreated hernia, resulting in an overall prevalence of 7.4 cases per 1000 persons (95% CI: 4.98-11.11). Groin hernias were most commonly reported (n=49, 67.1%) and predominant in young adult males. Over half of persons with untreated hernia reported having symptoms of incarceration (52.1%, n=38), yet 42.1% of these participants did not receive any surgical treatment. Moreover, 21.9 % (n=16) of participants with untreated hernias never presented to formal medical care, primarily due to the high-perceived cost of care. Untreated hernias caused considerable disability as 21.9 % of participants were unable to work due to their symptoms and 15.1% of households earned less money.

Conclusion: Hernia is a significant surgical problem in Southwest, Cameroon. Despite over half of persons with unrepaired hernias reporting symptoms of incarceration, home treatment and non-surgical management was common. Costs associated with formal medical services are a major barrier to obtaining consultation and repair. Greater awareness of hernia complications and cost restructuring should be considered to prevent disability and mortality due to hernia. 

 

90.04 Did the Affordable Care Act Accelerate Utilization of Minimally Invasive Colon Cancer Surgery?

Posted on January 31, 2019

T. Seykora1,2, A. Zeymo2, M. Bayasi3, T. DeLeire4, N. Shara5,6, W. Al-Refaie2,3, R. Essig3, K. Chan2  4Georgetown University,McCourt School Of Public Policy,Washington, DC, USA 5MedStar Health Research Institute,Washington, DC, USA 6Georgetown-Howard Universities Center for Clinical and Translational Science,Washington, DC, USA 1Georgetown University Medical Center,Georgetown University School Of Medicine,Washington, DC, USA 2MedStar Health Research Institute,MedStar Georgetown Surgical Outcomes Research Center,Washington, DC, USA 3Georgetown University Medical Center,MedStar Georgetown University Hospital,Washington, DC, USA

Background: Despite growing evidence supporting clinical benefits of minimally invasive surgery (MIS) for colon cancer, this approach is less likely utilized for patients with lower income and Medicaid or no health insurance. It is unclear whether the Affordable Care Act (ACA) affected MIS utilization for colon cancer across various patient socio-demographic characteristics.

Methods:  Data on surgical approach and patient characteristics for 193,474 colorectal cancer cases were queried from National Cancer Database for 2011-15. Separate multivariable logistic regression models were used to determine odds of receiving MIS, controlling for patient and clinical characteristics. An interaction term was added to each model to examine the relationship between the post-ACA period and each patient variable (race, insurance, patient zipcode income, education, rurality).

Results: Laparoscopic (LS) and robotic-assisted (RAS) surgery for colon cancer increased over time (Fig. 1). Odds significantly increased (all p<0.001) post-ACA for LS (OR range=1.37-1.46) and RAS (OR range=2.77-3.03) across all models. For LS, Blacks had lower odds (0.90, 0.87-0.94) than Whites, while Asians had higher odds (1.08, 1.01-1.15). The odds of RAS did not differ by race. Uninsured and Medicaid patients had lower odds for LS (0.55, 0.51-0.59; 0.70, 0.65-0.74) and RAS (0.33, 0.25-0.42; 0.63, 0.52-0.76). Patients from higher income zipcodes had greater odds of receiving LS (OR range=1.09-1.34 for 2nd– 4th vs 1st income quartile, all p<0.001) and RAS (1.16, 1.03-1.30, 3rd vs 1st quartile). Similarly, patients from higher education zipcodes had greater odds of LS (1.17, 1.12-1.23, 4th vs 1st quartile) and RAS (3rd: 1.14, 1.02-1.29; 4th: 1.40, 1.23-1.59; vs 1st quartile). More rural areas had lower odds of LS (OR range=0.84-0.89, all p<0.001) with even smaller odds for RAS (OR range=0.47-0.71, all p<0.001). Examining the same variables with a post-ACA interaction term revealed increased odds for Hispanics (1.19, 1.10-1.30), while Blacks had lower odds post-ACA (0.83, 0.72-0.95). There was a further increase in LS odds for higher income (3rd: 1.07, 1.01-1.13; 4th quartile: 1.06, 1.00-1.13; vs 1st) although there were no significant effects for RAS. Post-ACA, non-metro areas had a further reduction in odds for LS (0.90, 0.84-0.96) while small metro increased in odds for RAS (1.13, 1.02-1.25). There were no significant post-ACA effects for insurance or education (LS and RAS).

Conclusion: Utilization of MIS increased substantially 2011-15. However, this reflects underlying trends in overall utilization rather than ACA implementation. Post-ACA, race and insurance disparities generally persisted while pre-ACA differences increased for lower income and non-metro patients.

 

90.03 Hernia Repair in a Mobile Surgical Unit

Posted on January 31, 2019

M. Gurakar1,2, E. Kwon2, B. Guzhnay1, A. L. Vicuna3,4, H. B. Perry2, S. P. Jayaraman1, M. B. Aboutanos1, E. B. Rodas1,3  1Virginia Commonwealth University,Program For Global Surgery, Department Of Surgery,Richmond, VA, USA 2Johns Hopkins Bloomberg School of Public Health,Baltimore, MD, USA 3CINTERANDES Foundation,Cuenca, Ecuador 4Universidad del Azuay,Cuenca, Ecuador

Introduction:

Hernias are one of the leading causes of morbidity in low and middle-income countries. Herein, we describe the results of a Mobile Surgical Unit (MSU) performing hernia repairs for remote and underserved populations in Ecuador.

Methods:
A retrospective review from 2013 to 2017 of all patients undergoing hernia repair by a non-profit foundation (CINTERANDES). Data was extracted from medical records and a database was constructed in Excel.

Results:
In a five-year period, MSU carried out 260 hernia repairs on 233 patients. Thirty-one took place in the home base city of Cuenca and 202 in other small towns and rural settings. Female 49% and male 51%; mean age 46.7 ± 15.3 years, mean BMI 26.1 ± 3.9 kg/m2. Hernia repair with mesh was the most common form of repair (59.2%). Repairs included 122 inguinal hernias (46.9%), 98 umbilical (37.7%), 26 epigastric (10.0%), and 14 incisional (5.4%). Patients underwent local (51.0%), spinal (33.0%), or general anesthesia (15.9%). Mean operative time was 62.6 ± 33.3 min. Intraoperative and post-operative complications encountered include wound infection (5), dehiscence (3), hematoma formation (2), and one infection requiring mesh explant at six months. Follow-ups were conducted at one week for 182 patients (78.1%) via videoconference (42.8%), telephone (36.3%), and in-person interview (20.9%).

Conclusion:

Hernia repair can be safely performed in a MSU with low complication rates comparable to hospital-based surgery. Using Mobile Surgery to supplement existing healthcare infrastructure can expand the availability of hernia repair to those in isolated communities.
 

90.02 The Epidemiology of Mass−Casualty Incident Patients Presenting to a Malawian Tertiary Hospital

Posted on January 31, 2019

J. Kincaid1,3, G. Mulima3, N. Rodriguez-Ormaza2, A. Charles2, R. Maine2  1Thomas Jefferson University,Surgery,Philadelphia, PA, USA 2University Of North Carolina At Chapel Hill,Surgery,Chapel Hill, NC, USA 3Kamuzu Central Hospital,Surgery,Lilongwe, Malawi

Introduction:  There is a dearth of information regarding mass-casualty incidents (MCIs) in low resource settings like Malawi. Most literature describes single catastrophic events that expose the fragility of a trauma system and its limited ability to handle the sudden increase in patients. However, in low resource environments, events that can stress the hospital care delivery system are more common than large disasters. We aim to describe the frequency and characteristics of mass casualty events at a tertiary hospital in Malawi.

Methods:  We retrospectively analyzed trauma registry data at a tertiary hospital in Malawi from January 1, 2012 through December 31, 2016. We defined MCI as ≥4 trauma patients presenting simultaneously. We present descriptive statistics and a bivariate analysis comparing patient, trauma mechanism, and outcome characteristics for MCI and non-MCI trauma patients. Categorical variables were compared with chi-squared or Fisher’s exact test and continuous variables were compared using the t-test or the Wilcoxon rank sum test. Statistical significance was defined as p?0.05.

Results: From 2012 to 2016, 75,278 trauma patients arrived at the casualty department; 2,227 patients (3%) arrived as part of an MCI. A total of 341 occurred during five years, an average of 1.1 per week. Most MCIs involved between 4 and 6 people. More women were part of an MCI, 35% vs. 27% for non-MCI. MCI victims were older than non-MCI patients (29±15 vs. 23±14 years). The most common mode of transportation overall was private vehicles for both MCI (52%) and non-MCI (35%) respectively. The median time to hospital presentation is shorter for MCI patients (1hr vs. 4hrs, p<0.0001). More of the MCI patients presented between 6pm and 6am (41% vs. 25%, p<0.0001), when staffing at the hospital is the lowest. Vehicle-related trauma was the most common mechanism for MCI, 77%, compared to 25% for non-MCI (p<0.0001). MCI patients were also admitted to the hospital more frequently (20% vs. 16%). A higher proportion of MCI victims were brought in dead (3% vs. 1%, p<0.0001). While overall mortality was higher among MCI victims (4% vs. 2%, p<0.0001), in-hospital mortality was 5.6% for both MCI and non-MCI patients.

Conclusion: In Malawi, MCIs occur frequently, and most MCIs arrive between 6pm and 6am when staffing is most limited. Hospital and public health efforts should address staff capacity for MCIs and efforts to decrease road traffic crashes. While overall mortality is higher in MCI, MCI patients who arrive at the hospital alive, have an equal chance of survival to discharge rate as admitted non-MCI patients. Establishing pre-hospital care and an organized trauma system to improve triage could improve post MCI survival.

90.01 A Field Survey of Peruvian Healthcare Workers: Access, Barriers and Solutions to Surgical Care

Posted on January 31, 2019

F. Lema1, C. Flores1, V. Padmanaban2, P. F. Johnston2, F. R. Muñoz Córdova3, Z. C. Sifri2  1New Jersey Medical School,Newark, NJ, USA 2University Of Medicine And Dentistry Of New Jersey,Surgery,Newark, NJ, USA 3Universidad Privada Antenor Orrego (UPAO),Trujillo, Peru

Introduction:

The Peruvian government offers Seguro Integral de Salud (SIS), a free health insurance program, to any citizen below a defined poverty level. Despite the ostensible availability of this coverage, many patients lack access to surgical care. Local healthcare workers involved in surgical care may provide additional insight into this problem. We conducted a survey to investigate the perceptions of local healthcare workers on access and barriers to surgical care in Trujillo, Peru.

Methods:

A qualitative survey was issued on paper in Spanish to healthcare workers (HCWs) in the urban center of Trujillo, Peru at three main hospitals. The survey asked providers questions regarding health services in Peru with emphasis on access, barriers and potential solutions to surgical care delivery. Data on basic demographics, medical role and specialty, and years of clinical experience was collected.

Results:

Forty-seven HCWs who completed surveys averaged 35 ± 15 years of age and 9.5 ± 13 years employed in the Peruvian healthcare system. Fifty-five percent of participants included 26 physicians: 7 general surgeons, 1 trauma surgeon, 1 anesthesiologist, 12 interns, 1 pediatrician, 1 gynecologist, and 3 in rural medicine.

The majority of study participants either disagreed (45%) or strongly disagreed (6%) when asked if they believe health services are accessible to every Peruvian regardless of their economic situation. Seventy-four percent of HCWs agreed that there is a problem with access to surgical care in Trujillo and furthermore, this perception by HCW was the same regardless of medical role, gender, years of clinical service, and hospital sites.

Factors that HCWs cited as barriers to surgical care included inadequate funding, deficits in surgical infrastructure, long wait times, lack of qualified surgeons and a lack of surgical resources. Participants elaborated that the lack of surgical resources is a stimulus for patients’ out-of-pocket expenditures, precluding the most impoverished Peruvian patients. Additionally, HCWs agree (47%) and strongly agree (53%) that surgical international humanitarian organizations are an important part of the care for Peru’s poorest patients.

Conclusion:

Notably, the majority of healthcare workers surveyed believe there exists a problem with access to both health services in Peru and surgical care in Trujillo. Furthermore, all participants consider that international surgical teams are a necessary part of the local healthcare system, especially for the care of the poorest citizens. Given that participants were able to name several of these organizations, indicated that their belief is supported by experience. Further study to identify long-term sustainable solutions is warranted.

89.18 Chest Radiograph After Thoracic Surgery: Is It Necessary?

Posted on January 31, 2019

E. D. Porter1, R. M. Hasson1, T. M. Millington1, D. J. Finley1, C. V. Angeles1, J. D. Phillips1  1Dartmouth-Hitchcock Medical Center,Lebanon, NH, USA

Introduction: Overutilization of radiographic imaging continues to drive up medical costs.  In thoracic surgery, patients routinely undergo a chest radiograph (CXR) following surgery and chest tube (CT) removal. However, recent literature has questioned the utility of such practice in the pediatric population. We sought to investigate our institution’s CXR ordering practice following adult thoracic surgery and subsequent CT removal and its impact on clinical decision-making.

Methods: Retrospective cohort study at a single academic center. All adult general thoracic surgery patients with an intraoperative CT placed from April to June, 2018 were selected. Patients discharged with a CT or whom underwent pleurodesis were excluded. Indications for CT removal included absence of an airleak and drainage < 400cc’s in 24 hours. We reviewed patient charts for demographics, comorbidities, procedural data, post-operative CXR orders and results, and 30-day outcomes. Our institution defines a ‘small’ pneumothorax (PTX) as <15% of the hemi-thorax space. For the purpose of this study, any PTX >15% was termed ‘sizable’.

Results: In our study period, 55 patients met inclusion criteria and underwent thoracic surgery with an intraoperative CT placed. Surgical procedures included primary lung or pleura (42), mediastinum (6), diaphragm (5), and esophagus (2). The average number of CXRs performed per day was 2.1 (max 4.0). All patients received a CXR immediately following surgery, with 62% resulting in normal/expected findings, 18% a small PTX, 18% a sizable PTX, and 9% other abnormal results (consolidation or effusion). No patients experienced a change in care secondary to this CXR (Fig. 1). All patients received a post CT removal CXR. These CXRs resulted in 36% normal findings, 44% a small PTX, 5% a sizable PTX, and 15% other abnormal results (effusion and/or hydropneumothorax). A change in care ensued in only 2 patients (4%), which consisted of continued observation with a repeat CXR (Fig. 1). Within patients who had an abnormal finding on their post CT removal CXR, 65% were discharged the same day. Three patients were readmitted, of which two had a CT placed. On review, both patients had abnormal findings on their post CT removal CXR prior to discharge.

Conclusion: Routine immediate post-operative and post CT removal CXRs occurred in all adult thoracic surgery patients at our institution. Despite the majority of CXR’s resulting in abnormal findings, no patient underwent a procedural intervention during initial hospitalization. Routine immediate post-op and post CT removal CXRs without clinical indication are overutilized and interventions to reduce this practice should be further investigated.

89.17 An Easily Reproducible 3D Printed AAA Model Using Open Source Digital Tools

Posted on January 31, 2019

J. Coles-Black1, J. Chuen1  1Austin Health,Department Of Surgery,Heidelberg, VICTORIA, Australia

Introduction:
There has been strong interest in the application of 3D printing to Vascular Surgery. However, consistently major barriers to uptake include the lack of technical expertise amongst surgeons, and the perceived cost of 3D printing technologies. We present a low-cost, low-complexity, easily reproducible CT-to-3D-printed-model workflow developed using open source software packages and inexpensive desktop 3D-printers.

Methods:
Using 3D Slicer (version 4.5; Harvard, US, 2015), abdominal CT aortogram DICOM datasets were automatically segmented using the "Threshold" function. The "Dilate" and “Subtract Scalar Volume” functions were used to generate a 3D hollow vessel. The mural thrombus was isolated using the "Volume Clip" extension. This was subtracted from the luminal contents in order to create a non-intersecting thrombus model. The model was printed on a Filament Fused Deposition Modelling 3D Printer (Makerbot Replicator 2X; Stratasys, Minnesota, USA). The subsequent 3D printed model was shown to experienced vascular surgeons, who rated its utility for the preoperative planning of complex cases.

Results:
The model was well received, with immediate requests for more models. Manual inspection of the physical model was felt to be a valuable addition to standard CT angiogram reconstructions, especially in tortuous or complex aortic aneurysms. Hollow flexible models were deemed particularly useful for rehearsal of endograft insertion and positioning via the iliac arteries, and in predicting the trajectory of guidewires and devices.

Conclusion:
There are clear applications for 3D printing in the field of Vascular Surgery, with positive feedback from the assessed cohort of experienced surgeons that the AAA models would be useful in challenging cases.

89.15 A Qualitative Analysis of Provider Attitudes About and Experiences with Smoking Cessation

Posted on January 31, 2019

A. Radakrishnan1, J. K. Johnson1, J. Coughlin1, R. Love1, D. Odell1  1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA

Introduction:  Tobacco use is the greatest preventable cause of death and disease in the United States, representing a large medical and financial burden nationally. Despite recommendations from the Centers for Disease Control and Prevention (CDC), the United States Preventive Services Task Force, and major professional societies that all providers provide smoking cessation counseling, the delivery and efficacy of these interventions is inconsistent. We conducted a series of standardized interviews with providers caring for patients with lung cancer to identify important barriers and facilitators to the delivery of smoking cessation counselling.

Methods:  We performed a series of interviews with members of the thoracic oncology program at our institution. A total of fourteen interviews were conducted, ranging from 15 minutes to 45 minutes in duration, with provider stakeholders including thoracic surgeons (n=3), interventional pulmonologists (n=1), medical oncologists (n=3), radiation oncologists (n=2), and nurses from the various clinics (n=5). Interviews surveyed providers about the details of their role within care teams, smoking cessation interventions currently offered in their clinics, the providers’ perspectives on barriers to successful smoking cessation, as well as opportunities for improvement. Transcripts and audio recordings were qualitatively analyzed for themes to establish the most important domains to consider when creating a successful and feasible smoking cessation program.

Results: Providers emphasized 5 main domains that impact their delivery of smoking cessation counseling: time pressure, clinical history, resource knowledge, lack of provider education, and inadequate follow-up. All interview participants spend time discussing smoking cessation with their patients and realize the great importance of a smoking cessation counseling, but describe a need for a brief intervention. Providers also noted the diagnosis of lung cancer provided a powerful motivation for the patient to quit smoking. Further, those participants whose practice involved procedural interventions felt that obtaining the procedure was particularly motivating.

Conclusion: All providers recognize the need for more efficient and consistent smoking cessation counseling intervention. All agreed that a brief intervention can be successfully delivered and would be welcomed in their respective clinics.

89.14 The feasibility of hepatectomy with vascular reconstruction to treat the liver tumor

Posted on January 31, 2019

A. Li1, A. Li1  1Eastern Hepatobiliary Surgery Hospital,Division Of The 2nd Special Treatment,Shanghai, SHANGHAI, China

Introduction:

Radical surgery remains the main treatment for the patients with liver cancer,But resectability rate is low when clinically diagnosed, portal vein,hepatic vein or inferior caval vein invaded by tumors are a few of the  main reasons.How to increase resectability ofliver cancer still is very challenging to the clinician. This study was clone to explore the feasibility of the new surgical approach for the treatment of liver cancer with portal vein,hepatic vein or inferior caval vein invasion. 

 

Methods:

25 patients received hepatectomy with vascular reconstruction between February 2011 and June 2018.  15 patients with ICC underwent hepatectectomy combined with portal vein resection and vascular reconstruction and 5 patients with ICC underwent hepatectomy combined with inferior caval vein resection and vascular reconstruction. 4 patients with HCC underwent hepatectomy combined with inferior caval vein resection and vascular reconstruction, 1 patient with HCC underwent hepatectomy combined with hepatic vein resection and vascular reconstruction.

Results:

There was no surgery related death. After surgery,3 patients died 10 months later, 20 patient died 24 months later, two patients survived for over 3 years and one patient over 4 years.

Conclusion:

Hepatectomy with vascular reconstruction for patients with carcinoma of the liver invading portal vein,hepatic vein or inferior caval vein has been proved to be a safe treatment, it could improve the resectability of the tumor and prolong survival.

 

89.13 The Current Landscape of 3D Printing in Endovascular Intervention

Posted on January 31, 2019

J. Coles-Black1, J. Chuen1  1Austin Health,Department Of Surgery,Heidelberg, VICTORIA, Australia

Introduction:
3D printing has started to establish itself as an adjunct to endovascular procedures, where the ability to visualise complex anatomy with physical 3D models provides better anatomical clarity than can be achieved with 3D reconstructions or 2D imaging modalities.

Methods:
We performed a literature search using Ovid MEDLINE, Ovid EMBASE and PubMed. The search terms used were “Printing, Three-Dimensional” AND “Vascular Surgery” AND “Endovascular”. This resulted in 18 articles, which were independently read in full to identify relevant studies. The findings from these studies were then compared against our own centre’s experiences with the technology.

Results:

Our literature search identified 10 publications reporting on the use of 3D printing in endovascular procedures, of which 3 (30%) related to the planning of fenestrated grafts. In 6 (60%) of the articles, the 3D printed models were used for simulation. The vast majority (80%) of articles utilised the 3D printed models for interventional planning. In addition, in 100% of cases, the 3D printed models developed for the studies did not degrade after simulation or manual interrogation. Despite this, only 3 (30%) of articles involved the use of 3D printed models for trainee education.  Therefore, we highlight the largely untapped potential for these models to be reused for trainee education, which was not explored in the majority of articles.

The studies’ conclusions correlate with our own experiences from our 3D printing lab, where expert vascular surgeons have deemed 3D printed models valuable in the planning of complex cases, such as in cases with short or very angulated

Conclusion:

Vascular Surgery units worldwide, including our own, are starting to explore the applications of 3D printing in endovascular surgery. We attest to the enormous potential for growth in this field, and the ease of adoption of this new technology.

 

89.11 Report of a Single Center Experience of Intrabronchial Valve Placement

Posted on January 31, 2019

S. Gupta1,2, T. L. Demmy1,2, M. Hennon1,2, C. Nwogu1,2, A. Picone1,2, S. Yendamuri1,2, E. U. Dexter1,2  1State University Of New York At Buffalo,Medicine,Buffalo, NY, USA 2Roswell Park Cancer Institute,Thoracic Surgery,Buffalo, NY, USA

Introduction:
Prolonged air leak (PAL), defined as an air leak present for longer than 5 days, occurs in 4-9% of patients following lung resection (LR). Bronchoscopic intrabronchial valve (IBV; Olympus, Redmond, WA) placement is an FDA-approved treatment for PAL after LR.  IBV placement is also used off-label in other conditions such as spontaneous pneumothorax, severe emphysema and bronchopleural fistula. We conducted a retrospective review of our institutional outcomes after IBV placement.

Methods:
Twenty four patients had a total of 28 IBV placements between 8/2013-6/2017. Presence of air leak was determined by measuring air leak flow using a digital chest drainage system or by visual confirmation of bubbling in the water seal chamber of a pleural drainage reservoir. Removal of IBV is performed 6 weeks after air leak resolution. One patient with severe bullous emphysema had no air leak at the time of IBV placement.

Results:
Most patients had 3-5 IBV placed (see Table 1). Twelve patients had IBV placement after LR and 7 patients for spontaneous pneumothorax (n=6) or bullous emphysema (n=1; EMPH). LR included 7 lobectomy, 2 bilobectomy, 2 wedge resection, and 1 exploratory thoracotomy with unplanned wedge resection. Air leak resolution among 11 LR patients occurred at most 1 week after IBV placement for 6 patients, 2 weeks for 2 patients, 1 month for 1 patient, and 2 months for 2 patients. All patients with IBV post LR had chest tube removal prior to discharge (n=2) or management as an outpatient (n=10). Ten patients in the LR group are alive with follow up ranging from 14-59 months. For the two LR patients who died, death occurred 354 days and 389 days following IBV placement. Five EMPH patients were discharged from the hospital with resolved air leak, but only 2 are alive. Among the 5 EMPH patients with PAL resolution, duration of leak post-IBV was at most 1 week for 2 patients, 1 month for 1 patient, and 2 months for 2 patients. Death in the 5 EMPH patients occurred 10, 45, 63, 187 and 487 days following IBV procedure. Patients who had surgery for pleural disease (PD) developed PAL due to intraoperative lung damage. Although there was good resolution of air leak with IBV for PD, like EMPH patients, survival was low. Two patients with bronchopleural fistula associated with empyema had IBV placement of 1 valve each with resultant blockage of the fistula. Both are alive.

Conclusion:
IBV placement has a good success rate in resolving PAL after LR and enabled hospital discharge. The higher death rate in EMPH and PD patients following IBV placement may be impacted by underlying medical disease. In order to identify patients appropriate for IBV placement or factors that influence outcomes after IBV placement, further study is needed.
 

89.10 Drivers of Value in Coronary Artery Bypass Grafting

Posted on January 31, 2019

A. A. Brescia1, J. V. Vu1, C. He1, J. Li1, S. D. Harrington2, M. P. Thompson1, E. Norton1, S. Regenbogen1, R. L. Prager1, D. S. Likosky1  2Henry Ford Health System,Detroit, MI, USA 1University Of Michigan,Ann Arbor, MI, USA

Introduction: While healthcare reform efforts have focused on optimizing value (defined as outcomes divided by cost), few studies have focused on identifying how high-value hospitals achieve their performance (i.e., through optimizing quality or cost). We linked clinical and financial data from centers performing coronary artery bypass grafting (CABG) to assess determinants of high-value care.

Methods: Isolated CABG episodes between June 1, 2014 and June 1, 2016 were identified from a statewide administrative database of commercial and government payers (n=2,573 episodes in 33 hospitals) and linked through patient-level data to a clinical registry (used for risk adjustment and clinical outcomes ascertainment). We derived a National Quality Forum endorsed standard composite adverse clinical outcome composed of any of the following: deep sternal wound infection, renal failure, prolonged ventilation, stroke, reoperation, or operative mortality. Hospital value scores were calculated as the proportion of cases without an adverse outcome divided by mean risk-adjusted and price-standardized episode payments. The primary outcome was mean 90-day episode payments (via administrative claims), comprised of index hospitalization, professional, readmission, and post-discharge payment components. We compared total episode payments by value tercile among all patients, and separately among those not developing an adverse outcome.

Results: Among 2,573 patients, mean episode payments were $47,749 and 272 (10.6%) patients experienced an adverse outcome. Percentage of Medicare CABG patients, teaching hospital status, and urban location did not differ between hospital terciles. Hospitals in lowest value tercile (T1) compared to highest value tercile (T3) had longer mean length of stay (LOS) [10.3 vs 8.6 days, p=0.031]. Episode payments were higher in T1 than T3 ($51,194 vs $44,117, p<0.001), driven by $3,212 higher index hospitalization (p<0.001), $1,132 higher professional (p=0.004), and $1,996 higher readmission payments (p=0.016). After stratifying patients who did not experience an adverse outcome, episode payments remained higher in T1 as compared to T3 ($48,014 vs $43,107, p=0.004) [Figure], driven by $722 higher professional services (p=0.024) and $1,408 higher post-discharge payments (p=0.023).

Conclusions: High value hospitals achieved lower episode spending both by optimizing use of potentially discretionary care, in addition to preventing adverse clinical outcomes. Among patients without an adverse outcome, high-value centers had lower total episode, professional, and post-discharge payments. These findings identify sources of modifiable payment variation and may inform approaches to bundled payments and value-based reimbursement.  

89.09 Risk Factors and Outcomes for Unplanned Reintubation Following Esophagectomy

Posted on January 31, 2019

A. Ninh1, A. Bui1, M. B. Yammine2, A. Kaufman2, I. Leitman1  1Icahn School of Medicine at Mount Sinai,Surgery,New York, NY, USA 2Icahn School of Medicine at Mount Sinai,Thoracic Surgery,New York, NY, USA

Introduction: Esophagectomy is a complicated surgical operative procedure, which has been associated with respiratory complications sometimes requiring unplanned reintubation. The purpose of this study is to identify risk factors and adverse postoperative outcomes associated with unplanned intubation following esophagectomy.

Methods: The American College of Surgery National Surgical Quality Improvement Program (ACS-NSQIP) participant user database was queried from 2012 to 2015. Patients who underwent total or partial esophagectomy were identified and demographic data, intraoperative variables, and postoperative outcomes were collected. The primary outcome was unplanned intubation following esophagectomy. Multivariate analyses (logistic and linear regression) were performed to assess for risk factors and adverse outcomes associated with unplanned intubation.

 

Results: Of the 4,938 patients that underwent esophagectomy, 614 patients (12.4%) required unplanned reintubation following surgery. Risk factors for unplanned reintubation following esophagectomy include age greater than 60 (OR=1.58, 95% CI=1.28-1.94), active smoking (OR=1.36, 95% CI=1.11-1.66), morbid obesity defined as BMI>40 or BMI≥35 with hypertension or diabetes (OR=1.58, 95% CI=1.20-2.07), history of chronic obstructive pulmonary disease (OR=2.40, 95% CI=1.86-3.09), history of congestive heart failure (OR=5.15, 95% CI=1.78-14.85), and history of bleeding disorders (OR=1.90, 95% CI=1.30-2.79).Total esophagectomy increases the risk of unplanned reintubation (OR=1.30, 95% CI=1.09-1.54) when compared to partial esophagectomy. Additionally, patients requiring unplanned reintubation experienced longer operations, averaging 21.65 extra minutes (95% CI=10.05-33.26). Patients requiring unplanned reintubation were associated with an increased risk of pneumonia (OR=13.62, 95% CI=11.16-16.61), cerebral vascular accidents (OR=6.61, 95% CI=2.73-16.01), cardiac arrest (OR=11.42, 95% CI=11.30-11.55), and myocardial infarction (OR=6.29, 95% CI=3.58-11.05) when compared to patients that did not require unplanned reintubation. Of those that underwent reintubation following esophagectomy, 72 (13.4%) expired within 30 days, compared to 59 (1.38%) who did not undergo unplanned reintubation (p<0.001). Unplanned intubation following esophagectomy is associated with increased risk of 30-day mortality (OR=9.33, 95% CI=6.44-13.51) and return to operating room (OR=5.76, 95% CI= 4.75-6.98). Hospital length of stay is increased by an average of 11.50 days (95% CI=10.46-12.54). 

 

Conclusion: Patients requiring unplanned reintubation following esophagectomy are at significant risk for adverse postoperative morbidity and mortality. The findings of this study can help to identify patients at increased risk for unplanned reintubation, and serve to guide physician-patient discussion about the risk of significant postoperative complications in at-risk patients following esophagectomy.
 

89.08 Implementation of direct transcranial cerebral hypothermia during cardiopulmonary bypass: A feasibility study

Posted on January 31, 2019

M. T. Cain1, S. Greenberg2, P. Pearson1  1Medical College Of Wisconsin,Division Of Cardiothoracic Surgery/ Department Of Surgery,Milwaukee, WI, USA 2University Of Chicago,Department Of Anesthesiology Critical Care,Chicago, IL, USA

Introduction:
Induction of systemic hypothermia is a common technique during cardiac surgery to aid in tolerance of low flow states associated with cardiopulmonary bypass (CPB). Reduced regional blood flow, hemodilution from the CPB circuit, and cerebral hyperthermia during the rewarming phase of CPB all place patients at risk for neurological injury or dysfunction. A simple, practical, and safe intraoperative tool for selective cerebral hypothermia could provide the neuroprotective advantages of systemic cooling without the adverse effects of hyperthermic rebound.  Here we present results on the feasibility of utilizing an external transcranial cerebral cooling device (WElkins Portable Temperature Management System, Welkins,LLC Downers Grove, IL), in conjunction with conventional intraoperative monitors, for cerebral cooling during cardiac surgery requiring CPB.

Methods:
Prospective core and tympanic patient temperature data was collected for all subjects. Patients were fitted with the cooling device after placement of traditional monitors and intraoperative positioning. Cooling was initiated and temperatures were monitored at 20 minute intervals throughout each procedure, and during the first 6 hours of immediate postoperative intensive care unit (ICU) recovery. Systemic cooling procedures via CPB circuit was not adjusted due to device implementation. Outcome variables included device failure rate, cerebral temperature reduction by tympanic probe, resource burden for implementation,  device disruption of standard patient monitoring devices, and adverse device events including alopecia, pressure ulceration, or skin damage.

Results:
A total of 18 patients underwent device placement. Complete data was obtained on 16 patients. There were no device failures, however there were two early device discontinuations related to persistent postoperative hypothermia (11.1%). Mean tympanic temperature reduction was 1.0°C  intraoperatively (0.5-1.6°C) and 1.2°C during ICU recovery (0.5-1.9°C) relative to core temperature.  No harms or interference with standard patient monitoring devices were noted, and device implementation required a mean technician time of 245 minutes intraoperative and 261 minutes postoperatively.

Conclusion:
External transcranial selective cerebral cooling is a feasible technique that can be performed in conjunction with standard patient monitoring devices without evidence of local skin or hair damage, or interference with patient care in this early data series. Expanded use of this device is required to further characterize its benefit on neurological outcomes after cardiac surgery.
 

89.07 A Prototype for the Assessment of Limb Tissue Oxygenation Under Non-pulsatile Conditions

Posted on January 31, 2019

E. O. Cruz1, Y. Sanaiha1, V. Dobaria1, P. Benharash1  1University of California Los Angeles,Cardiac Surgery,Los Angeles, CA, USA

Introduction:
Near infrared spectroscopy (NIRS) is a non-invasive commercially available method for measuring tissue oxygenation. However, cost and reliability have limited its widespread use. Currently, there is no cost-effective method to assess tissue oxygenation under non-pulsatile conditions such as cardiopulmonary bypass. Such a device might improve the reliable detection of limb ischemia and direct interventions to avoid permanent injury. 

Methods:
The device used in this study consisted of a single photodetector and a pair of red (660 nm) and infrared (880 nm) light emitting diodes (LEDs) selected to discriminate between the absorption of oxymyoglobin and deoxymyoglobin at a depth of about 1cm. The LEDs and signals (20 point running average) were multiplexed and recorded at 100 Hz on a PC. Nine healthy volunteers were examined while a blood pressure cuff was used to first disrupt venous (30 mmHg x 90 seconds) and subsequently arterial flow (200 mmHg x 30 seconds). The red/infrared (R/IR) transmission ratio was calibrated and then recorded for each subject. A Wilcoxon-Mann-Whitney test was used to determine the significance of signals during each period of occlusion compared to the baseline noise, using alpha level P<0.05.

Results:
Amongst all volunteers, the amplitude of the average noise, or deviation from the baseline R/IR ratio, was 0.0091 +/- 0.004. At an average of 90 seconds after venous occlusion, the R/IR ratio decreased by 0.033 +/- 0.021 (P=0.01). Venous occlusion resulted in signal depression greater than the noise for that specific trial in 77.8% of participants, and the median signal to noise ratio was 16.49. After an average of 30 seconds of arterial occlusion, the R/IR ratio decreased by 0.035 +/- 0.008 (P<<0.01). All trials produced a signal depression greater than the noise during arterial occlusion, and the median signal to noise ratio was 10.92. In addition, a significant hyperemic rebound was detected following the restoration of arterial flow in 77.8% of trials.

Conclusion:
This simple device appears to successfully detect changes in tissue oxygenation under non-pulsatile settings. Further studies and adjustments to decrease system noise and add additional depths are warranted. The utilization of this simple NIRS system in patients on extracorporeal life support or cardiopulmonary bypass may assist in the early detection of limb ischemia.
 

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