Sustainable surgical resource initiative for Haiti: the SSRI-Haiti project.

In response to the 2010 earthquake and subsequent cholera epidemic, St Luke's Medical Center was established in Port-au-Prince, Haiti. Here, we describe its inception and evolution to include an intensive care unit and two operating rooms, as well as the staffing, training and experiential learning activities, which helped St Luke's become a sustainable surgical resource. We describe a three-phase model for establishing a sustainable surgical centre in Haiti (build facility and acquire equipment; train staff and perform surgeries; provide continued education and expansion including regular specialist trips) and we report a progressive increase in the number and complexity of cases performed by all-Haitian staff from 2012 to 2022. The results are generalised in the context of the 'delay framework' to global health along with a discussion of the application of this three-phase model to resource-limited environments. We conclude with a brief description of the formation of a remote surgical centre in Port-Salut, an unforeseen benefit of local competence and independence. Establishing sustainable and collaborative surgery centres operated by local staff accelerates the ability of resource-limited countries to meet high surgical burdens.

Prevalence of SARS-CoV-2 Antibodies in a Multistate Academic Medical Center.

OBJECTIVE: To estimate the seroprevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies in health care personnel. METHODS: The Mayo Clinic Serology Screening Program was created to provide a voluntary, two-stage testing program for SARS-CoV-2 antibodies to health care personnel. The first stage used a dried blood spot screening test initiated on June 15, 2020. Those participants identified as reactive were advised to have confirmatory testing via a venipuncture. Venipuncture results through August 8, 2020, were considered. Consent and authorization for testing was required to participate in the screening program. This report, which was conducted under an institutional review board-approved protocol, only includes employees who have further authorized their records for use in research. RESULTS: A total of 81,113 health care personnel were eligible for the program, and of these 29,606 participated in the screening program. A total of 4284 (14.5%) of the dried blood spot test results were "reactive" and warranted confirmatory testing. Confirmatory testing was completed on 4094 (95.6%) of the screen reactive with an overall seroprevalence rate of 0.60% (95% CI, 0.52% to 0.69%). Significant variation in seroprevalence was observed by region of the country and age group. CONCLUSION: The seroprevalence for SARS-CoV-2 antibodies through August 8, 2020, was found to be lower than previously reported in other health care organizations. There was an observation that seroprevalence may be associated with community disease burden.

Pleuroperitoneal (Denver) Shunt for Recurrent Nonmalignant Breast Seroma in a Metastatic Breast Cancer Patient.

Pleuroperitoneal (Denver) shunts have been used primarily for palliation of refractory malignant and chylous peritoneal and pleural collections.1-5 We used a pleuroperitoneal (Denver) shunt for a recurrent, nonmalignant breast seroma in the palliation of metastatic breast cancer as a novel use of this shunt.

Ultrasound-Enabled Noninvasive Management of Inadvertent Carotid Cannulation.

INTRODUCTION: Despite ultrasound use, accidental carotid cannulation is possible during placement of a central venous catheter (CVC), requiring operative repair of the carotid artery and removal of the catheter. CASE PRESENTATION: We report 2 cases-a 59-year-old Hispanic man and an 86-year-old white man-of inadvertent placement of a CVC into the left common carotid artery, removed via a pull-and-pressure technique under real-time ultrasound guidance. No complications occurred and follow-up imaging was negative for fistula creation, hematoma, or cerebral infarcts. DISCUSSION: Prior cases have reported accidental carotid cannulations that required operative repair. Our discussion focuses on the complications of removal of CVCs from the common carotid, and the utility, feasibility, and safety of using real-time ultrasound guidance in the removal. CONCLUSION: While operative removal of CVCs accidentally placed in the carotid is recommended, an ultrasound-enabled pull-and-pressure technique may prevent complications and avoid need for surgical repair in critically ill patients.

Disparate outcomes of global emergency surgery - A matched comparison of patients in developed and under-developed healthcare settings.

INTRODUCTION: Access to surgical care is an essential element of health-systems strengthening. This study aims to compare two diverse healthcare settings in South Asia and the United States (US). METHODS: Patients at the Aga Khan University Hospital (AKUH), Pakistan were matched to patients captured in the US Nationwide Inpatient Sample (US-NIS) from 2009 to 2011. Risk-adjusted differences in mortality, major morbidity, and LOS were compared using logistic and generalized-linear (family gamma, link log) models after coarsened-exact matching. RESULTS: A total of 2,244,486 patients (n = 4867 AKUH; n = 2,239,619 US-NIS) were included. Of those in the US-NIS, 990,963 (42.5%) were treated at urban-teaching hospitals, 332,568 (14.3%) in rural locations. Risk-adjusted odds of reported mortality were higher for Pakistani patients (OR[95%CI]: 3.80[2.68-5.37]), while odds of reported complications were lower (OR[95%CI]: 0.56[0.48-0.65]). No differences were observed in LOS. The difference in outcomes was less pronounced when comparing Pakistani patients to American rural patients. CONCLUSION: These results demonstrate significant reported morbidity, mortality differences between healthcare systems. Comparative assessments such as this will inform global health policy development and support.

How does a concurrent diagnosis of cancer influence outcomes in emergency general surgery patients?

BACKGROUND: A significant proportion of hospital admissions in the US are secondary to emergency general surgery (EGS). The aim of this study is to quantify outcomes for EGS patients with cancer. METHODS: The Nationwide Inpatient Sample (2007 to 2011) was queried for patients with a diagnosis of an EGS condition as determined by the American Association for the Surgery of Trauma. Of these, patients with a diagnosis of malignant cancers (ICD-9-CM diagnosis codes; 140-208.9, 238.4, 289.8) were identified. Patients with and without cancer were matched across baseline characteristics using propensity-scores. Outcome measures included all-cause mortality, complications, failure-to-rescue, length of stay, and cost. Multivariable logistic regression analyses further adjusted for hospital characteristics and volume. RESULTS: Analysis of 3,625,906 EGS patients revealed an 8.9% prevalence of concurrent malignancies. The most common EGS conditions in cancer patients included gastro-intestinal bleeding (24.8%), intestinal obstruction (13.5%), and peritonitis (10.7%). EGS patients with cancer universally had higher odds of complications (odds ratio [OR] 95% confidence interval [CI]: 1.20 [1.19 to 1.21]), mortality (OR [95% CI]: 2.00 [1.96 to 2.04]), failure-to-rescue (OR [95% CI]: 1.52 [1.48 to 1.56]), and prolonged hospital stay (OR [95% CI]: 1.69 [1.67 to 1.70]). CONCLUSIONS: EGS patients with concurrent cancer have worse outcomes compared with patients without cancer after risk-adjustment.

Spontaneous, Postpartum Coronary Artery Dissection and Cardiogenic Shock with Extracorporeal Membrane Oxygenation Assisted Recovery in a 30-Year-Old Patient.

Coronary artery dissection is an infrequent cause of acute coronary syndrome in the general population. There is, however, a greater incidence of spontaneous coronary artery dissection (SCAD) in young women, especially in the peripartum period. However, the majority of cases have favorable outcomes with medical management or percutaneous coronary intervention; coronary artery bypass grafting (CABG) and transplantation are utilized in severe cases. This case is a one of a 30-year-old postpartum female with multivessel SCAD requiring CABG with subsequent biventricular failure and inability to wean from bypass. We believe this is the first reported case in which venoarterial extracorporeal membrane oxygenation (VA-ECMO) was used in the management of biventricular heart failure in a postpartum patient with SCAD.

Never giving up: outcomes and presentation of emergency general surgery in geriatric octogenarian and nonagenarian patients.

BACKGROUND: Aging of the population necessitates consideration of the increasing number of older adults requiring emergency care. The objective of this study was to compare outcomes and presentation of octogenarian and/or nonagenarian emergency general surgery (EGS) patients with younger adults. METHODS: Based on a standardized definition of EGS, patients in the 2007 to 2011 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample were queried for primary EGS diagnoses. Included patients were categorized into older (≥80 years) vs younger (<80 years) adults based on a marked increase in mortality around aged 80 years. Using propensity scores, risk-adjusted differences in major morbidity, mortality, length of stay (LOS), and cost were compared. RESULTS: Of 3,707,465 included patients, 17.2% (n = 637,588) were ≥80 years. Relative to younger adults, older patients most frequently presented for gastrointestinal-bleeding (odds ratio [95% confidence intervals]: 2.81 [2.79 to 2.82]) and gastrostomy care (2.46 [2.39 to 2.53]). Despite higher odds of mortality (1.67 [1.63 to 1.69]), older adults exhibited lower risk-adjusted odds of morbidity (.87 [.86 to .88]), shorter LOS (4.50 vs 5.14 days), and lower total hospital costs ($10,700 vs $12,500). CONCLUSIONS: Octogenarian and/or nonagenarian patients present differently than younger adults. Reductions in complications, LOS, and cost among surviving older adults allude to a "survivorship tendency" to never give up, despite collectively higher mortality risk.

Safety and Feasibility of Laparoscopic Abdominal Surgery in Patients With Mechanical Circulatory Assist Devices.

Objectives Increasing number of mechanical circulatory assist devices (MCADs) are being placed in heart failure patients. Morbidity from device placement is high and the outcome of patients who require noncardiac surgery after, is unclear. As laparoscopic interventions are associated with decreased morbidity, we examined the impact of such procedures in these patients. Methods A retrospective review was conducted on 302 patients who underwent MCAD placement from 2005 to 2012. All laparoscopic abdominal surgeries were included and impact on postoperative morbidity and mortality studied. Results Ten out of 16 procedures were laparoscopic with 1 conversion to open. Seven patients had a HeartMate II, 2 had Total Artificial Hearts, and 1 had CentriMag. Four patients had devices for ischemic cardiomyopathy and 6 cases were emergent. Surgeries included 6 laparoscopic cholecystectomies, 2 exploratory laparoscopies, 1 laparoscopic colostomy takedown, and 1 laparoscopic ventral hernia repair with mesh. Median age of the patients was 63 years (range, 29-79 years). Median operative time was 123 minutes (range, 30-380 minutes). Five of 10 patients were on preoperative anticoagulation with average intraoperative blood loss of 150 mL (range, 20-700 mL). There were 3 postoperative complications; acute respiratory failure, acute kidney injury and multisystem organ failure resulting in death not related to the surgical procedure. Conclusion The need for noncardiac surgery in post-MCAD patients is increasing due to limited donors and due to more durable and longer support from newer generation assist devices. While surgery should be approached with caution in this high-risk group, laparoscopic surgery appears to be a safe and successful treatment option.

Analgesic Access for Acute Abdominal Pain in the Emergency Department Among Racial/Ethnic Minority Patients: A Nationwide Examination.

BACKGROUND: Prior studies of acute abdominal pain provide conflicting data regarding the presence of racial/ethnic disparities in the emergency department (ED). OBJECTIVE: To evaluate race/ethnicity-based differences in ED analgesic pain management among a national sample of adult patients with acute abdominal pain based on a uniform definition. RESEARCH DESIGN/SUBJECTS/MEASURES: The 2006-2010 CDC-NHAMCS data were retrospectively queried for patients 18 years and above presenting with a primary diagnosis of nontraumatic acute abdominal pain as defined by the American Association for the Surgery of Trauma. Independent predictors of analgesic/narcotic-specific analgesic receipt were determined. Risk-adjusted multivariable analyses were then performed to determine associations between race/ethnicity and analgesic receipt. Stratified analyses considered risk-adjusted differences by the level of patient-reported pain on presentation. Secondary outcomes included: prolonged ED-LOS (>6 h), ED wait time, number of diagnostic tests, and subsequent inpatient admission. RESULTS: A total of 6710 ED visits were included: 61.2% (n=4106) non-Hispanic white, 20.1% (n=1352) non-Hispanic black, 14.0% (n=939) Hispanic, and 4.7% (n=313) other racial/ethnic group patients. Relative to non-Hispanic white patients, non-Hispanic black patients and patients of other races/ethnicities had 22%-30% lower risk-adjusted odds of analgesic receipt [OR (95% CI)=0.78 (0.67-0.90); 0.70 (0.56-0.88)]. They had 17%-30% lower risk-adjusted odds of narcotic analgesic receipt (P<0.05). Associations persisted for patients with moderate-severe pain but were insignificant for mild pain presentations. When stratified by the proportion of minority patients treated and the proportion of patients reporting severe pain, discrepancies in analgesic receipt were concentrated in hospitals treating the largest percentages of both. CONCLUSIONS: Analysis of 5 years of CDC-NHAMCS data corroborates the presence of racial/ethnic disparities in ED management of pain on a national scale. On the basis of a uniform definition, the results establish the need for concerted quality-improvement efforts to ensure that all patients, regardless of race/ethnicity, receive optimal access to pain relief.

Emphysematous gastritis in a patient with coxsackie B3 myocarditis and cardiogenic shock requiring veno-arterial extra-corporeal membrane oxygenation.

INTRODUCTION: Emphysematous gastritis is a rare condition in which gas accumulates in the stomach lining usually due to an infectious source. CASE PRESENTATION: We present a 16 year old female with viral myocarditis and cardiogenic shock transferred to our hospital on extracorporeal membrane oxygenation (ECMO) who developed emphysematous gastritis. After listing the patient for heart transplant, patient underwent Bi-VAD placement requiring veno-venous ECMO support. Subsequently, she developed worsening abdominal distention. CT of abdomen/pelvis showed the stomach to be diffusely edematous, thick-walled, containing intramural gas collections, consistent with emphysematous gastritis. Patient underwent nonoperative management and two weeks later had complete resolution of the gastritis. Unfortunately, her overall condition deteriorated in the subsequent days and support was withdrawn. DISCUSSION: Management of emphysematous gastritis usually revolves around supportive care, broad spectrum antibiotics and bowel rest. Our patients' gastritis resolved with non-operative management, albeit, she succumbed to multiorgan failure due to other causes. CONCLUSION: We believe, this is a unique case of a veno-arterial ECMO causing emphysematous gastritis.

Chronic subclinical perforation of a duodenal ulcer presenting with an abdominal abscess in a patient with seronegative rheumatoid arthritis.

Peptic ulcer disease has been a major problem since the turn of this century with high morbidity and mortality. Perforation is less common, with an estimated incidence of 7-10 per 100 000. We present a young woman with rheumatoid arthritis presenting with anaemia. On work up, she was found to have a chronic abdominal abscess secondary to subclinical perforation of a duodenal ulcer. After undergoing percutaneous drainage, she became haemodynamically unstable and was taken for surgical washout and jejunostomy tube placement. A week later she had a decrease in the size of the abscess and was discharged home with drain and tube feeds. At her follow-up a few weeks later, she was tolerating goal tube feeds.

Changing trends in abdominal surgical complications following cardiac surgery in an era of advanced procedures. A retrospective cohort study.

BACKGROUND: Abdominal complications following cardiopulmonary bypass (CPB) procedures may have mortality rates as high as 25%. Advanced procedures such as ventricular assist devices, artificial hearts and cardiac transplantation are being increasingly employed, changing the complexity of interventions. This study was undertaken to examine the changing trends in complications and the impact of cardiac surgery on emergency general surgery (EGS) coverage. METHODS: A retrospective review was conducted of all CPB procedures admitted to our ICU between Jan. 2007 and Mar. 2010. The procedures included coronary bypass (CABG), valve, combination (including adult congenital) and advanced heart failure (AHF) procedures. The records were reviewed to obtain demographics, need for EGS consult/procedure and outcomes. RESULTS: Mean age of the patients was 66 ± 8.5 years, 71% were male. There were 945 CPB procedures performed on 914 patients during this study period. Over 39 months, 23 EGS consults were obtained, resulting in 10 operations and one hospital death (10% operative mortality). CABG and valve procedures had minimal impact on EGS workload while complex cardiac and AHF procedures accounted for significantly more EGS consultations (p < 0.005) and operations (p < 0.005). The majority of consultations were for small bowel obstruction/ileus (n = 4, 17%), cholecystitis (n = 3, 13%) and to rule out ischemia (n = 2, 9%) CONCLUSIONS: In the era of modern critical care and cardiac surgery, advanced technology has increased the volume of complex CPB procedures increasing the EGS workload. Emergency general surgeons working in institutions that perform advanced procedures should be aware of the potential for general surgical complications perioperatively and the resultant nuances that are associated with operative management in this patient population.

An unusual case of biliary bezoar causing small bowel obstruction in a patient with ampullary diverticulum and stapled gastroplasty.

Primary small bowel bezoars constitute 0.44% of small bowel obstructions (SBO). We report a case of a man with a history of gastroplasty who presented with lower abdominal pain. Initial examination revealed leucocytosis and serum lipase. CT of the abdomen/pelvis was consistent with pancreatitis, cholelithiasis and a stable, 3.8 cm, ampullary diverticulum, without obstruction of the pancreatic/common bile duct. Considering this was the patient's first episode of pancreatitis with evidence of cholelithiasis, it seemed prudent that he would benefit from cholecystectomy but not diverticulectomy. Post-cholecystectomy he represented to the hospital with biliary emesis. CT of the abdomen/pelvis revealed postsurgical changes. Owing to non-resolution of the symptoms, 48 h later a small bowel follow-through was obtained that suggested partial SBO. Ultimately, the patient was taken for exploratory laparoscopy and small bowel resection, after a large intramural mass was encountered in the small bowel. Final pathology revealed a 3 cm biliary bezoar causing obstruction and stercoral ulceration.

Emergency management of complicated jejunal diverticulosis.

Jejunal diverticulosis is a rare condition that is usually found incidentally. It is most often asymptomatic but presenting symptoms are nonspecific and include abdominal pain, nausea, diarrhea, malabsorption, bleeding, obstruction, and/or perforation. A retrospective review of medical records between 1999 and 2012 at a tertiary referral center was conducted to identify patients requiring emergency management of complicated jejunal diverticulosis. Complications were defined as those that presented with inflammation, bleeding, obstruction, or perforation. Eighteen patients presented to the emergency department with acute complications of jejunal diverticulosis. Ages ranged from 47 to 86 years (mean, 72 years). Seven patients presented with evidence of free bowel perforation. Six had either diverticulitis or a contained perforation. The remaining five were found to have gastrointestinal bleeding. Fourteen of the patients underwent surgical management. Four patients were successfully managed nonoperatively. As a result of the variety of presentations, complications of jejunal diverticulosis present a diagnostic and therapeutic challenge for the acute care surgeon. Although nonoperative management can be successful, most patients should undergo surgical intervention. Traditional management dictates laparotomy and segmental jejunal resection. Diverticulectomy is not recommended as a result of the risk of staple line breakdown. The entire involved portion of jejunum should be resected when bowel length permits.

High-fidelity, low-cost, automated method to assess laparoscopic skills objectively.

BACKGROUND: We sought to define the extent to which a motion analysis-based assessment system constructed with simple equipment could measure technical skill objectively and quantitatively. METHODS: An "off-the-shelf" digital video system was used to capture the hand and instrument movement of surgical trainees (beginner level = PGY-1, intermediate level = PGY-3, and advanced level = PGY-5/fellows) while they performed a peg transfer exercise. The video data were passed through a custom computer vision algorithm that analyzed incoming pixels to measure movement smoothness objectively. RESULTS: The beginner-level group had the poorest performance, whereas those in the advanced group generated the highest scores. Intermediate-level trainees scored significantly (p < 0.04) better than beginner trainees. Advanced-level trainees scored significantly better than intermediate-level trainees and beginner-level trainees (p < 0.04 and p < 0.03, respectively). CONCLUSIONS: A computer vision-based analysis of surgical movements provides an objective basis for technical expertise-level analysis with construct validity. The technology to capture the data is simple, low cost, and readily available, and it obviates the need for expert human assessment in this setting.

Increased risk of neoplasm in appendicitis treated with interval appendectomy: single-institution experience and literature review.

Appendicitis is a common diagnosis encountered by the acute care surgeon. Management of complicated appendicitis is controversial and often involves initial nonoperative therapy with interval appendectomy. This study reviews single-institutional experience with management of complicated appendicitis with interval appendectomy and addresses an unusually high occurrence of incidental appendiceal malignancies observed with a review of relevant literature. A retrospective review of all diagnoses of appendicitis was performed over 5 years at a tertiary care center. Patient demographics, time to surgery, operative technique, pathologic diagnosis, and clinical outcomes were examined. Three hundred fifteen patients were diagnosed with acute appendicitis. Of these, 24 (7.6%) were deemed complicated and did not undergo immediate appendectomy, and 18 ultimately underwent appendectomy at our institution and were included in analysis. There were no statistical demographic or symptomatic differences between the immediate and interval appendectomy patients. Ninety-nine per cent of the immediate appendectomy patients were treated laparoscopically; 78 per cent of the interval group underwent attempted laparoscopic treatment with 56 per cent completed without conversion to open (P < 0.01). Neoplasms were discovered in 1 per cent of the acute appendectomy group and 28 per cent of the interval appendectomy group (P < 0.0001). Two of the three neoplasms in the acute group were carcinoid, whereas three of the five neoplasms in the interval group were adenocarcinoma. Surgeons should consider appendiceal or colonic neoplasms in cases of complicated appendicitis when nonoperative management is considered. This is most important in patients older than 40 years, in those who forego interval appendectomy, or in those who could be lost to follow-up.

Laparoscopic management of acute small bowel obstruction: evaluating the need for resection.

BACKGROUND: Acute small bowel obstruction (SBO) is a common condition encountered by the on-call emergency surgeon. The role of laparoscopy in the management of SBO continues to be defined. This modality can be limited by dilated bowel and inadequate assessment of compromised tissue. This review was undertaken to determine the reliability of laparoscopic evaluation and the subsequent need for bowel resection. METHODS: A retrospective review of all patients surgically managed for acute SBO between July 2005 and September 2010 was conducted. The clinical presentation, computed tomographic findings, indications for surgery, type of intervention, need for reoperation, length of stay (LOS), and outcomes were all abstracted. RESULTS: A total of 119 patients were surgically managed for acute SBO during this period, 63 with initial laparoscopy and 56 with an open procedure. Twenty-five (40%) of the laparoscopy patients were converted to open, leaving 38 completed laparoscopically. Of the completed group, three patients underwent bowel resection compared with 16 in the converted group (8% vs. 64%, p < 0.0001). No patients in the completed group required a subsequent procedure for bowel resection. Twenty-three (41%) patients in the open cohort required a resection. LOS was significantly reduced in the completed group (7.7 days) compared with the converted (11.0 days, p = 0.01) and open groups (11.4 days, p = 0.002). CONCLUSIONS: Overall, 32% of acute SBOs were managed solely with laparoscopy. No patients requiring a bowel resection were missed using this method of evaluation. Laparoscopic management should be considered as safe and effective initial therapy in most cases of acute SBO.

Trauma activations and their effects on non-trauma patients.

BACKGROUND: Trauma patients consume many resources in the emergency department (ED), but what effect their care may have upon other patients seeking care is unclear. OBJECTIVE: We sought to determine whether the presentation of trauma patients to the ED diverts staff and resources away from non-trauma patients. We hypothesized that the admission of trauma patients to the ED would result in longer times to physician evaluation and completion of laboratory and imaging studies, as well as a longer length of stay in the ED. METHODS: This retrospective study reviewed and compared the charts of two groups of non-trauma ED patients. The group affected by trauma arrived up to 30 min after a trauma activation. The group unaffected by trauma arrived >3 h before or 3 h after a trauma activation. Times from arrival to initial MD evaluation, X-ray study, and computed tomography (CT) scan were documented. Median times from order to completion of laboratory results and imaging were compared, as well as total ED lengths of stay (LOS). RESULTS: Median time from arrival to MD evaluation for patients affected by a trauma activation was almost twice as long as for unaffected patients (42 vs. 23 min, respectively; p < 0.001). Times from arrival to X-ray study, CT scan order, and laboratory results were all significantly greater for patients affected by a trauma activation (p < 0.001). For patients who required admission to the hospital, the affected group had a median LOS that was increased by 16 min (224 vs. 208 min, respectively) when compared to unaffected patients (p = 0.04). CONCLUSION: In the setting studied, the arrival of a trauma patient delayed physician evaluation and diagnostic testing. It only modestly increased the ED LOS for patients needing hospital admission.