- Email: [email protected]
Impact of Delayed Care on Surgical Management of Patients with Gastric Cancer in a Low-Resource Setting
Vol. 225, No. 4S1, October 2017
Scientific Forum Abstracts
S103
METHODS: In order to offer front line providers an IO fluid delivery system that ensures safe and successful establishment of IO access without prior training and minimal instructions, we utilized the external placement guide called Tib-FinderTM. Developed in response to USAID’s Fighting Ebola: A Grand Challenge for Development, the Tib-FinderTM is a new alignment guide to ease utility of the Arrow EZ-IO system without extensive training or practice.
reciprocity integrity is initially subjective, and system strengthening may not be concurrently as demonstrable as the HIC fellow operative training experience. This may highlight a need to apply implementation science to assure reciprocity models in global surgery, and build upon unique academic partnerships to achieve academic sustainability and collaboratively address global injury burden.
RESULTS: Even with appropriate training, providers may not reliably be able to place an IV in a patient with conditions associated with difficult vascular access including obesity, chronic illness, hypovolemia, intravenous (IV) drug abuse, and vasculopathy.
How to Use Global Surgery Indicators in a Low-Resource Setting: Experience from the Line Islands, Kiribati John Tekanene, Teraria Bangao, MBBS, Baranika Toromon, MBBS, Adam L Kushner, MD, MPH, FACS, Lydia Lam, MD Ronton Hospital, Kiritimati, Kiribati; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Kirk School of Medicine, University of Southern California, Los Angeles, CA
CONCLUSIONS: In this case-controlled study, we demonstrate significant reduction in rate of failure to establish IO access for emergency resuscitation in human cadavers, the superiority of using the Tib-FinderTM to the standard practice of using anatomic landmarks for nonmedically trained personnel, and its noninferiority relative to the gold standard for medically trained professionals. Global Learning Opportunity Through Burden Education (GLOBE): An Example of Formalized Latin America Middle-Income Country Acute Care Surgery Training Capacity Gregory L Peck, DO, FACS, David N Blitzer, MD, Rachel E NeMoyer, MD, Paul Truche, MD, Erin M Scott, Mary E Schroeder, MD, Jurek Kocik, MD, Luis L Pino, MD, Vicente Gracias, MD, FACS, Carlos Ordonez, MD Rutgers Robert Wood Johnson, New Brunswick, NJ, Universidad del Valle, Cali, Columbia INTRODUCTION: Academic reciprocal paradigms are necessary to address regional specific global injury burden. Paradigms that uphold high-income country (HIC) and low- and middle-income country (LMIC) reciprocity will more effectively address disparities in injury education, training, and care worldwide. METHODS: An acute care surgery (ACS) paradigm was used to assess an MIC and HIC injury burden training paradigm’s reciprocity integrity over 1 year. A Memorandum of Understanding (MOU) and Research Innovation Fellowship Program (RIFP) defined structure pertaining to clinical, teaching, and funding reciprocity expectations. To ensure bidirectional integrity, both the HIC and the MIC were examined. RESULTS: An HIC ACS fellow completed a predominantly operative injury rotation at an MIC public hospital, with 1-year immediate measurable benefit (1- and 12-month intervals exceeded the HIC injury training volume). Trauma program and systems strengthening implementation by the HIC in the MIC was not qualitatively or quantitatively demonstrated with respect to balanced reciprocity after 1 year, but instead after year 3, and such reciprocity was demonstrated. CONCLUSIONS: ACS faculty and fellowships attempt to demonstrate a reciprocal benefit to both MIC and HIC within an injury and systems education and training construct. Without an analytical method to measure HIC systems implementation in the MIC, the
INTRODUCTION: In the central Pacific Ocean country of Kiribati, surgical care for the 8,800 inhabitants of the Line Islands (Kiritimati population 5,115, Tabuaeran population 2,539, and Teraina population 1,155) is provided at the Ronton Hospital. In addition to a local staff, international teams assist with care. We sought to determine if global surgery indicators, such as the cesarean deliver to total operations ratio (C/O ratio) and number of operations per 100,000 population per year, were useful. METHODS: Using the operating room logbook, total number of operations, operations by local and international surgeons, and number of cesarean deliveries were recorded for the years 2013 to 2016. Calculations were done for total operations and operations only by local staff using the C/O ratio, and number of operations per 100,000 population per year. RESULTS: Over the 4-year period, a total of 461 operations were performed including 81 cesarean deliveries. Local staff performed 244 procedures. The C/O ratio total was 17.6% and the C/O ratio local only was 33.2%. Only 5,233 operations were performed per 100,000 population per year and this dropped to 2,770 for local-only procedures. CONCLUSIONS: An unmet need for surgical care exists in the Line Islands of Kiribati. Global surgery indicators were useful to quickly and easily document the magnitude of the problem. The indicators also helped show the advantage of international surgical teams. Aside from providing additional resources for surgical care, a next step would be to identify other factors that may limit access to care. Impact of Delayed Care on Surgical Management of Patients with Gastric Cancer in a Low-Resource Setting Allison N Martin, MD, MPH, Allison Silverstein, Robinson Ssebuufu, Joseph Lule, Pacifique Mugenzi, MD, Alexandra E Fehr, MPH, Tharcisse Mpunga, Lawrence Shulman, Paul H Park, Ainhoa Costas-Chavarri, MD, FACS Rwanda Military Hospital, Kigali, Rwanda; University Teaching Hospital of Butare, Butare, Rwanda; Partners In Health/Inshuti Mu Buzima, Butaro, Rwanda
S104
J Am Coll Surg
Scientific Forum Abstracts
INTRODUCTION: Gastric cancer is the fifth most common cancer in Eastern Africa. Diagnostic delays result in advanced disease presentation. Limited availability of chemotherapy and radiation in low- and middle-income countries ensures that surgery remains the primary treatment modality. We describe the presentation and current surgical management of gastric cancer in Rwanda.
Impact of Prehospital Time on Trauma-Related Mortality in an Upper Middle-Income Country Alberto F Garcia, MD, Alvaro I Sanchez Ortiz, MD, PhD, Maria I Guiterrez, MD PhD, Jorge Paredes, MD, Juan Carlos Puyana, MD Universidad Del Valle, Cali, Columbia
METHODS: A retrospective review of hospital records at 3 Rwandan hospitals was performed to identify cases of gastric adenocarcinoma from January 2012 to June 2016. Variables collected included demographic factors, diagnostic and therapeutic management, tumor grade, and symptom duration. Descriptive and bivariate analysis was performed using Stata v.14.
INTRODUCTION: Access to timely essential surgery within 2 hours in underserved areas is considered a major indicator toward developing surgical capacity, according to the Lancet Commission on Global Surgery. However, this threshold is not applicable to areas with high incidence of penetrating injuries. We studied prehospital time and its association with in-hospital mortality for trauma patients from an upper middle-income country (UMIC).
RESULTS: Final analysis included 229 patients with pathologically or surgically confirmed disease. Median age was 58 years (interquartile range [IQR] 49e65) and 50.2% were male (n ¼ 115) (Table). Patients reported symptoms (ie weight loss, epigastric pain) for median of 12 months (IQR 7.5e24). On presentation, 18.7% (n ¼ 43) had gastric outlet obstruction, and 13.5% (n ¼ 31) had a palpable mass. Fifty-one percent (n ¼ 117) underwent any operative procedure. Of these, 71% (n ¼ 83) underwent palliative bypasses (ie gastrojejunostomy) or were inoperable. Twenty (8.7%) were referred for palliative care or chemotherapy and did not undergo an operation. Tumor grade was reported in 96 patients, 51.0% were diffuse/undifferentiated, and 49.0% were intestinal/well-differentiated. Only 26 (11.3%) received H. pylori testing and 65.4% tested positive (n ¼ 17). Table. Characteristics of Patients Undergoing Surgery vs No Surgery (n ¼ 230) Variable
Age, median (IQR) Female sex, n (%) Self-reported weight loss, n (%) Palpable abdominal mass, n (%) Gastric outlet obstruction, n (%) Symptom duration (mo), median (IQR)
Surgery (n ¼ 117)
No surgery (n ¼ 113)
p Value*
58 (50e64) 58 (50)
59 (48e67) 56 (50)
0.457 0.948
37 (36)
16 (20)
0.018
13 (11)
18 (16)
0.285
39 (33)
4 (3.5)
<0.001
18 (8e36)
12 (6e12)
0.015
METHODS: We did a prospective cohort study of trauma patients admitted to 4 hospitals in a city with high homicide rates, in a UMIC. Demographics, trauma mechanisms, severity scores, and prehospital time were registered. Prehospital time was categorized according to frequency distribution, to better characterize the mortality risk according to intervals of prehospital time. In multilevel logistic regressions, mortality rates were compared among prehospital time intervals. RESULTS: Study cohort comprised 917 patients; 802 (87.5%) were males. Median age was 28 years (interquartile range 22e40). Penetrating injuries occurred in 65% of patients. Overall mortality was 15.5% (142 patients). The Table shows mortality by prehospital time intervals. Compared with prehospital time <24 minutes, mortality odds increased significantly in trauma patients with prehospital time between 24 and 59 minutes (odds ratio [OR] 3.55, 95% CI 1.17e10.80). There were no significant differences in prehospital time intervals >59 minutes. Table. Effect of Prehospital Times on Mortality in Trauma Patients Prehospital time (min) <24 24e59 60e119 120e360 No data Total
Trauma patients, n 90 362 271 272 12 917
Deaths, n 14 78 44 17 3 142
Mortality, % 15.6 21.5 16.2 6.3 25.0 15.5
Odds ratio 1 3.55 2.26 1.23 e e
95% CI e 1.17e10.80 0.72e7.12 0.36e4.27 e e
IQR, interquartile range *p < 0.05 considered significant.
Multilevel logistic regression adjusted for Trauma and Injury Severity Score (TRISS)-PS and a random effect for hospitals.
CONCLUSIONS: Gastric cancers in Rwanda are often inoperable or are only amenable to palliative surgery. Further research into H. pylori epidemiology and gastric cancer in East Africa is required. Given limited treatment modalities, increased awareness may improve diagnostic delays without significantly affecting outcomes.
CONCLUSIONS: In 4 urban hospitals from a UMIC, mortality risk increased significantly in the second half of the golden hour for these trauma patients. The 2-hour access indicator from the Lancet Commission on Global Surgery is not applicable to ensure adequate access to emergency surgical care in areas with high incidence of penetrating injuries.
Scientific Forum Abstracts
S103
METHODS: In order to offer front line providers an IO fluid delivery system that ensures safe and successful establishment of IO access without prior training and minimal instructions, we utilized the external placement guide called Tib-FinderTM. Developed in response to USAID’s Fighting Ebola: A Grand Challenge for Development, the Tib-FinderTM is a new alignment guide to ease utility of the Arrow EZ-IO system without extensive training or practice.
reciprocity integrity is initially subjective, and system strengthening may not be concurrently as demonstrable as the HIC fellow operative training experience. This may highlight a need to apply implementation science to assure reciprocity models in global surgery, and build upon unique academic partnerships to achieve academic sustainability and collaboratively address global injury burden.
RESULTS: Even with appropriate training, providers may not reliably be able to place an IV in a patient with conditions associated with difficult vascular access including obesity, chronic illness, hypovolemia, intravenous (IV) drug abuse, and vasculopathy.
How to Use Global Surgery Indicators in a Low-Resource Setting: Experience from the Line Islands, Kiribati John Tekanene, Teraria Bangao, MBBS, Baranika Toromon, MBBS, Adam L Kushner, MD, MPH, FACS, Lydia Lam, MD Ronton Hospital, Kiritimati, Kiribati; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Kirk School of Medicine, University of Southern California, Los Angeles, CA
CONCLUSIONS: In this case-controlled study, we demonstrate significant reduction in rate of failure to establish IO access for emergency resuscitation in human cadavers, the superiority of using the Tib-FinderTM to the standard practice of using anatomic landmarks for nonmedically trained personnel, and its noninferiority relative to the gold standard for medically trained professionals. Global Learning Opportunity Through Burden Education (GLOBE): An Example of Formalized Latin America Middle-Income Country Acute Care Surgery Training Capacity Gregory L Peck, DO, FACS, David N Blitzer, MD, Rachel E NeMoyer, MD, Paul Truche, MD, Erin M Scott, Mary E Schroeder, MD, Jurek Kocik, MD, Luis L Pino, MD, Vicente Gracias, MD, FACS, Carlos Ordonez, MD Rutgers Robert Wood Johnson, New Brunswick, NJ, Universidad del Valle, Cali, Columbia INTRODUCTION: Academic reciprocal paradigms are necessary to address regional specific global injury burden. Paradigms that uphold high-income country (HIC) and low- and middle-income country (LMIC) reciprocity will more effectively address disparities in injury education, training, and care worldwide. METHODS: An acute care surgery (ACS) paradigm was used to assess an MIC and HIC injury burden training paradigm’s reciprocity integrity over 1 year. A Memorandum of Understanding (MOU) and Research Innovation Fellowship Program (RIFP) defined structure pertaining to clinical, teaching, and funding reciprocity expectations. To ensure bidirectional integrity, both the HIC and the MIC were examined. RESULTS: An HIC ACS fellow completed a predominantly operative injury rotation at an MIC public hospital, with 1-year immediate measurable benefit (1- and 12-month intervals exceeded the HIC injury training volume). Trauma program and systems strengthening implementation by the HIC in the MIC was not qualitatively or quantitatively demonstrated with respect to balanced reciprocity after 1 year, but instead after year 3, and such reciprocity was demonstrated. CONCLUSIONS: ACS faculty and fellowships attempt to demonstrate a reciprocal benefit to both MIC and HIC within an injury and systems education and training construct. Without an analytical method to measure HIC systems implementation in the MIC, the
INTRODUCTION: In the central Pacific Ocean country of Kiribati, surgical care for the 8,800 inhabitants of the Line Islands (Kiritimati population 5,115, Tabuaeran population 2,539, and Teraina population 1,155) is provided at the Ronton Hospital. In addition to a local staff, international teams assist with care. We sought to determine if global surgery indicators, such as the cesarean deliver to total operations ratio (C/O ratio) and number of operations per 100,000 population per year, were useful. METHODS: Using the operating room logbook, total number of operations, operations by local and international surgeons, and number of cesarean deliveries were recorded for the years 2013 to 2016. Calculations were done for total operations and operations only by local staff using the C/O ratio, and number of operations per 100,000 population per year. RESULTS: Over the 4-year period, a total of 461 operations were performed including 81 cesarean deliveries. Local staff performed 244 procedures. The C/O ratio total was 17.6% and the C/O ratio local only was 33.2%. Only 5,233 operations were performed per 100,000 population per year and this dropped to 2,770 for local-only procedures. CONCLUSIONS: An unmet need for surgical care exists in the Line Islands of Kiribati. Global surgery indicators were useful to quickly and easily document the magnitude of the problem. The indicators also helped show the advantage of international surgical teams. Aside from providing additional resources for surgical care, a next step would be to identify other factors that may limit access to care. Impact of Delayed Care on Surgical Management of Patients with Gastric Cancer in a Low-Resource Setting Allison N Martin, MD, MPH, Allison Silverstein, Robinson Ssebuufu, Joseph Lule, Pacifique Mugenzi, MD, Alexandra E Fehr, MPH, Tharcisse Mpunga, Lawrence Shulman, Paul H Park, Ainhoa Costas-Chavarri, MD, FACS Rwanda Military Hospital, Kigali, Rwanda; University Teaching Hospital of Butare, Butare, Rwanda; Partners In Health/Inshuti Mu Buzima, Butaro, Rwanda
S104
J Am Coll Surg
Scientific Forum Abstracts
INTRODUCTION: Gastric cancer is the fifth most common cancer in Eastern Africa. Diagnostic delays result in advanced disease presentation. Limited availability of chemotherapy and radiation in low- and middle-income countries ensures that surgery remains the primary treatment modality. We describe the presentation and current surgical management of gastric cancer in Rwanda.
Impact of Prehospital Time on Trauma-Related Mortality in an Upper Middle-Income Country Alberto F Garcia, MD, Alvaro I Sanchez Ortiz, MD, PhD, Maria I Guiterrez, MD PhD, Jorge Paredes, MD, Juan Carlos Puyana, MD Universidad Del Valle, Cali, Columbia
METHODS: A retrospective review of hospital records at 3 Rwandan hospitals was performed to identify cases of gastric adenocarcinoma from January 2012 to June 2016. Variables collected included demographic factors, diagnostic and therapeutic management, tumor grade, and symptom duration. Descriptive and bivariate analysis was performed using Stata v.14.
INTRODUCTION: Access to timely essential surgery within 2 hours in underserved areas is considered a major indicator toward developing surgical capacity, according to the Lancet Commission on Global Surgery. However, this threshold is not applicable to areas with high incidence of penetrating injuries. We studied prehospital time and its association with in-hospital mortality for trauma patients from an upper middle-income country (UMIC).
RESULTS: Final analysis included 229 patients with pathologically or surgically confirmed disease. Median age was 58 years (interquartile range [IQR] 49e65) and 50.2% were male (n ¼ 115) (Table). Patients reported symptoms (ie weight loss, epigastric pain) for median of 12 months (IQR 7.5e24). On presentation, 18.7% (n ¼ 43) had gastric outlet obstruction, and 13.5% (n ¼ 31) had a palpable mass. Fifty-one percent (n ¼ 117) underwent any operative procedure. Of these, 71% (n ¼ 83) underwent palliative bypasses (ie gastrojejunostomy) or were inoperable. Twenty (8.7%) were referred for palliative care or chemotherapy and did not undergo an operation. Tumor grade was reported in 96 patients, 51.0% were diffuse/undifferentiated, and 49.0% were intestinal/well-differentiated. Only 26 (11.3%) received H. pylori testing and 65.4% tested positive (n ¼ 17). Table. Characteristics of Patients Undergoing Surgery vs No Surgery (n ¼ 230) Variable
Age, median (IQR) Female sex, n (%) Self-reported weight loss, n (%) Palpable abdominal mass, n (%) Gastric outlet obstruction, n (%) Symptom duration (mo), median (IQR)
Surgery (n ¼ 117)
No surgery (n ¼ 113)
p Value*
58 (50e64) 58 (50)
59 (48e67) 56 (50)
0.457 0.948
37 (36)
16 (20)
0.018
13 (11)
18 (16)
0.285
39 (33)
4 (3.5)
<0.001
18 (8e36)
12 (6e12)
0.015
METHODS: We did a prospective cohort study of trauma patients admitted to 4 hospitals in a city with high homicide rates, in a UMIC. Demographics, trauma mechanisms, severity scores, and prehospital time were registered. Prehospital time was categorized according to frequency distribution, to better characterize the mortality risk according to intervals of prehospital time. In multilevel logistic regressions, mortality rates were compared among prehospital time intervals. RESULTS: Study cohort comprised 917 patients; 802 (87.5%) were males. Median age was 28 years (interquartile range 22e40). Penetrating injuries occurred in 65% of patients. Overall mortality was 15.5% (142 patients). The Table shows mortality by prehospital time intervals. Compared with prehospital time <24 minutes, mortality odds increased significantly in trauma patients with prehospital time between 24 and 59 minutes (odds ratio [OR] 3.55, 95% CI 1.17e10.80). There were no significant differences in prehospital time intervals >59 minutes. Table. Effect of Prehospital Times on Mortality in Trauma Patients Prehospital time (min) <24 24e59 60e119 120e360 No data Total
Trauma patients, n 90 362 271 272 12 917
Deaths, n 14 78 44 17 3 142
Mortality, % 15.6 21.5 16.2 6.3 25.0 15.5
Odds ratio 1 3.55 2.26 1.23 e e
95% CI e 1.17e10.80 0.72e7.12 0.36e4.27 e e
IQR, interquartile range *p < 0.05 considered significant.
Multilevel logistic regression adjusted for Trauma and Injury Severity Score (TRISS)-PS and a random effect for hospitals.
CONCLUSIONS: Gastric cancers in Rwanda are often inoperable or are only amenable to palliative surgery. Further research into H. pylori epidemiology and gastric cancer in East Africa is required. Given limited treatment modalities, increased awareness may improve diagnostic delays without significantly affecting outcomes.
CONCLUSIONS: In 4 urban hospitals from a UMIC, mortality risk increased significantly in the second half of the golden hour for these trauma patients. The 2-hour access indicator from the Lancet Commission on Global Surgery is not applicable to ensure adequate access to emergency surgical care in areas with high incidence of penetrating injuries.