Bilateral trauma case conferences: an approach to global surgery equity through a virtual education exchange.

Purpose: With increased interest in international surgical experiences, many residency programs have integrated global surgery into their training curricula. For surgical trainees in low- and middle-income countries (LMICs), physical exchange can be costly, and laws in high-income countries (HICs) prevent LMIC trainees from practicing surgery while on visiting rotations. To enrich the educational experience of trainees in both settings, we established a monthly virtual trauma conference between surgery training programs. Methods: General surgery teams from two public institutions, a public university with two surgical training programs in Kenya and a public university with two level I trauma centers in the United States, meet monthly to discuss complex and interesting trauma patients. A trainee from each institution presents a clinical case vignette and supplements the case with pertinent peer-reviewed literature. The attendees then answer a series of multiple-choice questions like those found on surgery board exams. Results: Monthly case conferences began in September 2017 with an average of 24 trainees and consultant surgeons. Case discussions serve to stimulate dialogue on patient presentation and management, highlighting cost-conscious, high-quality care and the need to adapt practice patterns to meet resource constraints and provide culturally appropriate care. Conclusion: Our 5-year experience with this virtual case conference has created a unique and robust surgical education experience for trainees and surgeons who have withstood the effects of the pandemic. These case conferences have not only strengthened the camaraderie between our departments, but also promoted equity in global surgery education and prioritized the learning of trainees from both settings.

Uncomplicated gastroschisis care in the US and Kenya: Treatment at two tertiary care centers.

BACKGROUND: Gastroschisis is a common birth defect with < 5% mortality in high income countries, but mortality in sub Saharan Africa remains high. We sought to compare gastroschisis management strategies and patient outcomes at tertiary pediatric referral centers in the United States and Kenya. METHODS: This retrospective chart review examined uncomplicated gastroschisis patients treated at Riley Hospital for Children in Indianapolis, USA (n = 110), and Shoe4Africa Children's Hospital in Eldoret, Kenya (n = 75), from 2010 to 2018. Analyzed were completed using Chi square, Fisher's exact, and independent samples t tests and medians tests at the 95% significance level. RESULTS: Survival in the American cohort was double that of the Kenyan cohort (99.1% vs 45.3%, p< 0.001). Sterile bag use for bowel containment was lower in Kenya (81.3% vs 98.1%, p< 0.001), but silo use was comparable at both institutions (p = 0.811). Kenyan patients had earlier median enteral feeding initiation (4vs 10 days, p< 0.001) and accelerated achievement of full enteral feeding (10vs 23 days, p< 0.001), but none received TPN. Despite earlier feeding, Kenyan patients displayed a higher prevalence of wound infections (70.8% vs 17.1%, p< 0.001) and sepsis (43.9% vs 4.8%, p< 0.001). In Kenya, survivors and non survivors displayed no difference in sterile bag use, hemodynamic stability, all cause infection rates, or antibiotic free hospital days. Defect closure (p< 0.001) and enteral feeding initiation (p< 0.001) were most predictive of survival. CONCLUSION: Improving immediate response strategies for gastroschisis in Kenya could improve survival and decrease infection rates. Care strategies in the US can center on earlier enteral feeding initiation to reduce time to full feeding. LEVEL OF EVIDENCE: Level III.

Gender Differences in Insurance, Surgical Admissions and Outcomes at a Kenyan Referral Hospital.

INTRODUCTION: Gender is an important factor in determining access to healthcare resources. Women face additional barriers, especially in low- and middle-income countries. Surgical costs can be devastating, which can exacerbate engendered disparities. Kenya's National Hospital Insurance Fund (NHIF) aims to achieve universal coverage and protect beneficiaries from catastrophic health expenditures. We examine gender differences in NHIF coverage, health-seeking behavior, and surgical outcomes at a tertiary care hospital in Eldoret, Kenya. MATERIALS AND METHODS: All patients ≥13 years admitted to the general surgery service at Moi Teaching and Referral Hospital from January 2018-July 2018 were enrolled. Health records were retrospectively reviewed for demographic data, clinical parameters, NHIF enrollment, and cost information. Descriptive analyses utilized Wilcoxon Rank Sum, Pearson's Chi-square, and Fisher's Exact tests. RESULTS: 366 patients were included for analysis. 48.6% were enrolled in NHIF with significant female predominance (64.8% versus 37.9%, P < 0.0001). Despite differing coverage rates, male and female patients underwent surgery and suffered in-hospital mortality at similar rates. However, women only comprised 39.6% of admissions and were significantly more likely to delay care (median 60 versus 7 days, P < 0.0001), be diagnosed with cancer (26.6% versus 13.2%, P = 0.0024), and require a palliative procedure for cancer (44.1% versus 13.0%, P = 0.013). CONCLUSION: Many financial and cultural barriers exist in Kenya that prevent women from accessing healthcare as readily as men, persisting despite higher rates of NHIF coverage amongst female patients. Investigation into extra-hospital costs and social disempowerment for women may elucidate key needs for achieving health equity.

Use of a Novel Trigger Tool to Identify Palliative Care Needs in Surgical Patients at a National Referral Hospital in Kenya: A Pilot Study.

Background: Addressing unmet palliative care needs in high-risk surgical patients in low- and middle-income countries must include innovative approaches to limitations in personnel and culturally acceptable assessment modalities. Objectives: We assessed the utility of a novel seven-item "Step-1" trigger tool in identifying surgical patients who may benefit from palliative care. Design: All adult patients (≥18 years) on general surgery, neurosurgery, and orthopedic surgery wards were enrolled over a four-month period. Setting/Subjects: This study took place at Moi Teaching and Referral Hospital (MTRH), one of two Kenyan national referral hospitals. Measurements: The "Step-1" trigger tool was administered, capturing provider estimates of prognosis, cancer history, social barriers, admission frequency, hospice history, symptom burden, and functional decline/wasting. A cut-point of ≥3 positive factors was selected, indicating a patient may benefit from palliative care. Results: A total of 411 patients were included for analysis. Twenty-five percent (n = 102) of patients had scores ≥3. The cut-point of ≥3 was significantly associated with identifying high-risk patients (HRP; χ2 = 32.3, p < 0.01), defined as those who died or were palliatively discharged, with a sensitivity and specificity of 63.9% and 78.9%, respectively. Survey questions with the highest overall impact included: "Would you be not surprised if the patient died within 12 months?," "Are there uncontrolled symptoms?," and "Is there functional decline/wasting?" Conclusions: This pilot study demonstrates that the "Step-One" trigger tool is a simple and effective method to identify HRP in resource-limited settings. Although this study identified three highly effective questions, the seven-question assessment is flexible and can be adapted to different settings.

Partial splenectomy in children: Long-term reoperative outcomes☆.

PURPOSE: Partial, or subtotal, splenectomy (PS) has become an accepted alternative to total splenectomy (TS) for management of hematologic disorders in children, but little is known about its long-term outcomes. Here, we present our institutional experience with partial splenectomy, to determine rate of subsequent TS or cholecystectomy and identify if any factors affected this need. METHODS: All patients who underwent partial splenectomy at a single tertiary children's hospital were retrospectively reviewed from 2002 through 2019 after IRB approval. Primary outcome of interest was rate of reoperation to completion splenectomy (CS) and rate of cholecystectomy. Secondary outcome were positive predictor(s) for these subsequent procedures. RESULTS: Twenty-four patients underwent PS, at median age 6.0 years, with preoperative spleen size of 12.7 cm by ultrasound. At median follow up time of 8.0 years, 29% of all patients and 24% of hereditary spherocytosis (HS) patients underwent completion splenectomy at median 34 months and 45 months, respectively. Amongst HS patients who did not have a cholecystectomy with or prior to PS, 39% underwent a delayed cholecystectomy following PS. There were no significant differences in age at index procedure, preoperative splenic volume, weight of splenic specimen removed, transfusion requirements, preoperative or postoperative hematologic parameters (including hemoglobin, hematocrit, total bilirubin, and reticulocyte count) amongst patients of all diagnoses and HS only who underwent PS alone compared to those who went on to CS. There were no cases of OPSS or deaths. CONCLUSION: Partial splenectomy is a safe alternative to total splenectomy in children with hematologic disease with theoretical decreased susceptibility to OPSS. However, families should be counseled of a 29% chance of reoperation to completion splenectomy, and, in HS patients, a 39% chance of delayed cholecystectomy if not performed prior to or with PS. Further studies are needed to understand predictors of these outcomes.

Is resident assistance equivalent to fellows during hepatectomy?

OBJECTIVE: Hepatectomy is a complex operative procedure frequently performed at academic institutions with trainee participation. The aim of this study was to determine the effect of assistant's training level on outcomes following hepatectomy. METHODS: A retrospective review of a prospective, single-institution ACS-NSQIP database was performed for patients that underwent hepatectomy (2013-2016). Patients were divided by trainee assistant level: hepatopancreatobiliary (HPB) fellow versus general surgery resident (PGY 4-5). Demographic, perioperative, and 30-day outcome variables were compared using Chi-Square/Fisher's exact, Mann-Whitney U test, and multivariable regression. Cases involving a senior-level general surgery resident or HPB fellow as first assistant were included (n = 352). Those with a second attending, junior-level resident, or no documented assistant were excluded (n = 39). RESULTS: Patients undergoing hepatectomy with an HPB fellow as primary assistant had more frequent preoperative biliary stenting, longer operative time, and more concomitant procedures including biliary reconstruction, resulting in a higher rate of post-hepatectomy liver failure (PHLF) (15% vs. 8%, P = 0.044). However, trainee level did not impact PHLF on multivariable analysis (OR 0.60, 95% CI [0.29-1.25], P = 0.173). Fellows assisted with proportionally more major hepatectomies (45% vs. 31%; P = 0.010) and resections for hepatobiliary cancers (31% vs. 19%, P = 0.014). On stratified analysis of major and minor hepatectomies, outcomes were similar between trainee groups. CONCLUSION: Fellows performed higher complexity cases with longer operative time. Despite these differences, outcomes were similar regardless of assistant training level. Resident and HPB fellow participation in operations requiring liver resection provide comparable quality of care.

Role of Mechanical Bowel Preparation and Perioperative Antibiotics in Pediatric Pull-Through Procedures.

BACKGROUND: There are no clear guidelines for the use of mechanical bowel preparation and postoperative antibiotics in children undergoing elective colorectal pull-through surgery. The objective of this study was to determine whether preoperative bowel preparation administration or duration of postoperative antibiotics impacted the rate of complications after elective pediatric pull-through surgery. MATERIALS AND METHODS: Patients aged <18 y who underwent a pull-through procedure between 2011 and 2017 were retrospectively identified. Patient data included diagnosis, procedure, administration of mechanical bowel preparation, and duration of perioperative intravenous (IV) antibiotics. Outcomes of interest included surgical site infections and anastomotic complications. RESULTS: A total of 180 patients met inclusion criteria, of which 47.2% received mechanical bowel preparation. The combined rate of infectious and anastomotic complications was 12.2%. There was no significant difference in combined complication rate among those receiving bowel preparation compared with those who did not (14.1% versus 10.5%, P = 0.46). Administration of bowel preparation in the perineal anoplasty subgroup was associated with higher rates of wound infection (33.3% versus 3.3%, P = 0.05). One hundred five patients (58.3%) received perioperative IV antibiotics for ≤24 h. This group had similar rates of complications (13.3%) compared with those receiving IV antibiotics for longer than 24 h (11.6%, P = 0.74). CONCLUSIONS: Although mechanical bowel preparation did not affect the overall complication rate for pull-through procedures, it was associated with more wound infections in those undergoing perineal anoplasty. Duration of postoperative IV antibiotics was not significantly associated with the rate of wound and anastomotic complications.

Risk Factors for Development and Progression of Scoliosis After Pediatric Cardiothoracic Operations.

BACKGROUND: The purpose of this study was to determine the incidence and risk factors for the development and rate of progression of scoliosis and moderate/severe scoliosis in patients undergoing cardiothoracic operations (CTOs). METHODS: Included were patients aged younger than 12 years who underwent CTOs in 1995 to 2006 with a preoperative chest roentgenogram (CRG) and a CRG at least 8 years after CTOs. Scoliosis and moderate/severe scoliosis were defined as a Cobb angle of 10 degrees or more and an angle of 25 degrees or more or the need for surgical intervention, respectively. Risk factors were analyzed using nonparametric and parametric survival analyses. For patients that developed scoliosis, progression rate was analyzed using linear regression models for repeated measures using CRG at 6-month intervals. RESULTS: The study included 871 patients (380 girls [44%]). Median CRG follow-up was 11 years (interquartile range, 9 to 13 years). Overall 10-year incidence of scoliosis and moderate/severe scoliosis was 12% and 3%, respectively. Independent predictors for scoliosis included female sex (hazard ratio [HR], 1.7; 95% confidence interval [CI], 1.2 to 2.5), syndrome (HR, 1.9; 95% CI, 1.3 to 2.8), and isolated developmental delay (HR, 2.4; 95% CI, 1.4 to 4.2). For development of moderate/severe scoliosis, independent risk factors included female sex (HR, 2.8; 95% CI, 1.4 to 5.8), syndrome (HR, 3; 95% CI, 1.5 to 6.1), isolated developmental delay (HR, 3.1; 95% CI, 1 to 9.2]), and prematurity for neonates/infants (HR, 2.3; 95% CI, 1 to 5.2). Rate of angle progression was 0.17 times the current angle per year. Age, syndrome, and developmental delay were risk factors for angle progression. CONCLUSIONS: Patients that undergo pediatric CTO, regardless of the operative approach, are at increased risk for development of scoliosis and moderate/severe scoliosis. Long-term follow-up of these patients is warranted, in particular for girls and patients with genetic syndromes or developmental delay.