Abstracts and Presentation Descriptions

International College of Surgeons –United States Section

85^th Annual Surgical Update

And

American Academy of Neurological and Orthopaedic Surgeons

47^th Annual Scientific Meeting

Philadelphia, PA - - April 25-27, 2024

Wyndham Historic District Hotel

The following is presented with minimal editing. Special characters and formating may not display properly.

Cerebral protection strategies in TAAD surgeries: a network meta-analysis

Abdullah K. Alassiri, MBBS, Senior Medical Student, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia, Jeddah, Saudi Arabia

Type A aortic dissection (TAAD) is a life-threatening medical condition resulting from a tear in the innermost layer of the aorta, allowing blood to flow into the middle layer and creating a false lumen. Surgical management of TAAD carries a significant risk of neurologic complications, like strokes and cognitive dysfunction. To mitigate these risks, cerebral protection during aortic arch surgery is crucial. Cerebral protection techniques during surgery vary; thus, our network meta-analysis (NMA) seeks to provide a comprehensive overview of the available evidence, assisting clinicians in making informed decisions regarding cerebral protection strategies in TAAD surgeries.

Multiple databases, including PubMed, Embase, Cochrane Library, Web of Science, and SCOPUS, were searched for randomized controlled trials (RCTs) and observational studies comparing cerebral protection techniques during surgical management of Type A aortic dissection. Our NMA was performed using a Bayesian framework to compare the effectiveness of each cerebral protection technique while accounting for direct and indirect treatment comparisons. All statistical analyses were conducted using the R software with the netmeta package.

Our study includes 18 cohort studies and one RCT. The total sample size ranges from 48 to 1558 participants. Regarding our efficacy outcomes, compared to DHCA, all the following cerebral protection techniques showed no significant difference in terms of aortic clamp time, cardiopulmonary bypass time, circulatory arrest time, and ICU and hospital length of stay. However, compared to DHCA, both DHCA/ACP and DHCA/RCP showed a significantly lower 30-day mortality rate [RR =0.6 (95% CI, 0.37–0.98), P = 0.76], and [RR =0.63 (95% CI, 0.41–0.96), P = 0.69], respectively. Moreover, DHCA was not significantly different from any of the cerebral protection techniques in terms of the incidence of atrial fibrillations or the rate of hospital mortality. Multiorgan dysfunction showed no preference for cerebral protection technique over the others, as well as permanent and temporary neurological damage and stroke.

All included cerebral protection techniques were comparable except DHCA/ACP and DHCA/RCP, which showed a significantly lower risk than others in decreasing the risk of 30-day mortality and atrial fibrillation.

Differential Heparin Neutralization Studies Using Protamine Sulfate and a Novel Synthetic Peptide

Andrew Alcazar, BS, Research Associate, Loyola University Medical Center, Chicago, IL

Purpose

Heparin is a critical drug employed in surgical procedures to prevent thrombotic events. The mechanism of heparin relies on its ability to bind to antithrombin III (AT) via electrostatic interactions and consequently increasing its coagulation factor-inhibiting activity. The lingering presence of heparin after procedures has made its safe use also dependent on reversal. Currently in the US, the protamine sulfate protein is employed as a heparin antagonist in the clinical setting. Protamine prevents binding of heparin to AT by forming a stable complex with heparin using its positively charged residues. The high reliance of US medicine on one single reversal drug makes investigation of alternative compounds with similar reversal capabilities of high research interest. Herein, the reversal effects of a small positively charged synthetic peptide marketed as HEPA-Remove and protamine sulfate are compared and presented.

Methods

Normal human plasma was obtained from Loyola University Medical Center and pooled. All plasma was frozen and thawed for approximately 15-20 minutes prior to use. Aliquots of plasma were treated with concentrations of reversal (protamine and HEPA-Remove) ranging from 0 – 10 μg/mL. Peak thrombin concentrations were compared with varying concentrations of both reversals and 2.50 μg/mL of unfractionated bovine, porcine, or ovine heparin or normal saline alone (control) in triplicate using thrombin generation assays. Applicable statistical analysis was then conducted using R. A significant difference is defined to be a p-value less than 0.05.

Results

Both HEPA-Remove and protamine sulfate produced significant increases in peak thrombin activity with increasing concentration of reversal. In the presence of bovine and ovine heparin, Tukey’s honestly significant difference test did not show any significant difference in peak thrombin activities between samples treated with equivalent concentrations of each reversal. In the presence of porcine heparin, however, protamine sulfate did produce a higher peak thrombin than HEPA-Remove at 5 μg/mL (p = 0.011) with peak thrombin activities of 144.25 ± 3.90 nM and 68.25 ± 14.88 nM, respectively (activity ± SD). Protamine sulfate seemed to lower peak thrombin in plasma treated with saline, however no statistical significance was found; both HEPA-Remove and protamine sulfate did not significantly affect peak thrombin activities in the presence of normal saline nor showed any significant differences from one another.

Conclusion

HEPA-Remove shows promising results in vitro in comparison to protamine sulfate. Comparable reversal effects were observed for bovine and ovine heparins. HEPA-Remove seemed to display a lower potency in plasma samples treated with porcine heparin, compared to protamine sulfate. Despite this, adjusting HEPA-Remove for potency may provide equivalent reversal activity as protamine sulfate. Future studies will seek to model the effects of each reversal on bovine, ovine, and porcine heparins in vitro to provide a more robust statistical comparison. Reversal studies will also be conducted on low molecular-weight heparins.

Clinical and Surgical Management of Cavernous Sinus Meningiomas: Guidelines and Surgical Perspectives

Paolo Alimonti, MD, Postdoctoral Research Fellow, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA

Cavernous sinus meningioma (CSM) are rare, mostly benign entities that may adopt a particularly morbid behavior due to the abundance of crucial neurovascular structures of the cavernous sinus. Diagnostic imaging plays a pivotal role in differentiating CSM from other tumor identities.

The mainstay of the management of CSM aims to limit the surgical treatment, whenever appropriate and feasible, to the extracavernous portion of CSM, and address any intracavernous remains with radiation treatment. A wait-and-watch approach with serial MRIs is offered to patients with stable disease or those who are too old or unfit for any form of treatment. Surgery for CSM requires technical expertise and careful consideration of the patient’s clinical status and potential postoperative neurological impairment.

As per the EANS guidelines, asymptomatic lesions, or symptomatic lesions less than 2.5 cm in diameter, or large lesions with intracavernous extension should undergo radiation treatment, best in the form of stereotactic radiation. Fractionated regimens should be used in cases of close proximity (<3mm) to the optic apparatus.

On the other hand, surgical treatment for these lesions is deemed appropriate for large (>2.5 cm), symptomatic tumors with preferentially outward growth from the lateral wall of the CS. Aggressive surgery with CS exenteration is attaempted to those cases characterized by complete visual loss and/or complete ophthalmoplegia, as well as aggressive behaviour/histology and recurrence after radiation. Rapidly symptomatic lesions and unusual radiology findings should prompt decompressive intervention or biopsy through the foramen lacerum.

In those cases where surgical management of CSM is indicated, the anatomical complexity of the cavernous sinus region constitutes a main limiting factor to both the extent of resection and the feasibility of the surgery itself. A plethora of skull base approaches has been developed over the last 40 years, enabling surgeons to tailor the approach to the specifics of each case. While the surgical approach to CSM is limited and reserved for specific symptomatic cases, recent insights from the literature have reported the use of combined skull-base approaches to tackle these lesions. While being underappreciated, combined approaches represent valuable and innovative tools to the surgical armamentarium against CSM. This presentation aims to review the mainstay of the clinical management of CSM while critically appraising the latest reports of advanced skull base surgical approaches to the cavernous sinus.

Through this presentation, the best practices of CSM management will be reviewed, and the audience will gain valuable insight into advanced surgical approaches for CSM, hoping to expand the knowledge of surgical options available for patients with these complex skull base lesions.

Prolapsed Colostomy: Revise or Proceed with Reconstructive Surgery?

Domingo T. Alvear, MD, Chairman, World Surgical Foundation, Mechanicsburg, PA

An 8 month old Filipino boy presented during a surgical mission with a severe prolapse of a transverse colostomy. He was suspected to have Hirschsprung's Disease following birth because he presented with a bowel obstruction based on a plain abdominal radiograph. No biopsy was performed during the performance of the colostomy. He underwent takedown of the colostomy and multiple biopsies confirmed that he had long segment Hirschsprung's Disease up to the ascension colon. He underwent a reconstructive pull through procedure. The ascending colon was tapered and anastomosed to the anal area. He did well and sent home 10 days later. He continues to to well 3 years later, stooling and good bowel control.

Prolapsed colostomy is commonly seen in patients with Hirschsprung's disease ( HD ) and Imperforate Anus ( IA ). Creation of a stoma is commonly employed in low income countries for HD and IA after birth. Prolapse is common as a consequence of the location and improper technique. I will discus reasons for the prolapse and how to diminish the incidence. Reconstructive surgery for Hirschsprung's disease without a diverting colostomy during a mission is feasible if certain principles are followed such as bowel prep, use of staples to minimize leakage, minimize blood loss withe the use of the Ultrasonic device and appropriate antibiotic coverage.

Pullthrough procedure for Hirschsprung's disease without a colostomy can be performed safely beyond the newborn period. This philosophy can be advantageous in low income countries since such procedures are prohibitive and follow up of patients can be difficult.

Creating a Surgical Foundation: How to measure success!

Domingo T. Alvear, MD, Chairman, World Surgical Foundation, Mechanicsburg, PA

The World Surgical Foundation was founded in 1997 to provide free surgical care to low income countries. We have provided over 13,000 surgical procedures in 8 low income countries. We now have a branch in the Philippines and Honduras. The WSF Philippines has provided over 4,000 such service in many, locations . We have provided them with Portable Anesthesia Machines, Electrosurgical Units, Portable Headlights, Surgical Instruments and supplies. They have created a Mobile Surgical Team who can go to remote areas and provide safe and quality surgery. The have collaborated with the Philippine College of Surgeons, Philippine Pediatric Surgical Society, Philippine Society of Anesthesiologists and OR Nurses Association.

We have been going to Honduras for 25 years. According to Dr. Olban Coello, the retired Chairman of Pediatric Surgery, we have elevated the standard of care in Pediatric Surgery. The current crop of new Pediatric Surgeons have recognized our contribution to care of children with complex anomalies and have adopted the surgical management that they learned from us. One such case was demonstrated in our last mission to Honduras in September 2023 when a male infant with Imperforate Anus had an Anoplasty without a colostomy. They also performed 2 Colon Interposition for long gap esophageal atresia with precision.

Surgical Missions are successful if the local counterparts can continue to provide quality and safe surgical care when the Surgical Mission Team has left. We have to provide with equipment and supplies. We have to teach new principles and techniques . A great example is when the Chief of Plastic Surgery, Dr. Carlos Cerrato reminds me that he learned to perform Hernia Repairs in Infants 21 years ago from me. He has performed thousands of repair since that time.

Navigated Atlas Osteosynthesis for Unstable Jefferson Fractures

John Arena, MD, Neurosurgery Resident, University of Pennsylvania, Philadelphia, PA

Purpose:

Jefferson burst fractures of the atlas are typically considered “stable� or “unstable� based upon integrity of the transverse ligament. Whereas stable Jefferson fractures can be treated non-operatively, unstable fractures with mid-substance rupture (Dickman Type I) or bony avulsion (Dickman Type II) of the transverse ligament often require surgical intervention. Atlas osteosynthesis has been proposed as a motion-preserving alternative to atlantoaxial fusion.

Methods:

Cases of unstable Jefferson fractures treated with atlas osteosynthesis at a single Level I Trauma Center were identified and retrospectively reviewed. Clinical and radiographic presentation, surgical management and post-operative outcomes were assessed.

Results:

Seven patients (5 males, 2 females; median age 49.5 years, range 24-64 years) underwent atlas osteosynthesis for unstable Jefferson fractures between 2015 and 2023. All cases demonstrated injury to the transverse ligament (Dickman Type I (n=1), Type II (n=5), and mixed Type I/II (n=1)). Bilateral C1 lateral mass screws were placed with assistance of intraoperative CT guided navigation. Screws were connected to each other using a single 3.5mm rod and fractures reduced. Patients were maintained in a rigid cervical collar following surgery (median duration 12 weeks, range 6-20 weeks). All seven patients were followed with serial upright radiographs demonstrating preserved alignment. Five patients obtained outpatient follow-up CT, all of which demonstrated evidence of osseous union across fractures without hardware complication. None developed post-operative occipital-cervical or atlantoaxial instability requiring additional fusion. Median follow-up 11.5 months (range 2-91 months).

Conclusions:

Atlas osteosynthesis is an attractive motion-preserving surgical approach to the treatment of unstable Jefferson fractures, avoiding the morbidity of atlantoaxial fusion. Intraoperative navigation can be particularly useful for screw placement in the setting of traumatically distorted anatomy with lateral mass displacement. Classically reserved for Jefferson fractures with Dickman Type II transverse ligament injury, atlas osteosynthesis may also be a viable option for Type I transverse ligament injuries.

Safe Cholecystectomy On A Global Scale

Domenech Asbun, MD, Hepatopancreatobiliary and Gastric/Mixed Tumor Surgical Oncologist Miami Cancer Institute; Clinical Assistant Professor, Florida International University, Herbert Wertheim College of Medicine, Florida International University, Miami, Coral Gables, FL

Laparoscopic cholecystectomies are one of the most commonly abdominal operations procedures worldwide. However, bile duct injuries continue to be a significant complication associated with the procedure. Extensive work has been done to elucidate safe practices during laparoscopic cholecystectomy. These practices are not uniformly and widely adopted. However, there is potential for global initiatives to further disseminate this information and ultimately lead to improved clinical outcomes across the world.

The presentation will review the above shortcomings in cover global adoption of safe practices during laparoscopic cholecystectomy, as well as illustrative examples of these techniques. The audience will be introduced to a specific educational program organized by the speaker that aims to eliminate world-wide gaps of knowledge, especially as they affect low- and middle-income countries.

Too Old to Plate! Surgical Rib Stabilization in the Octagenerian and Nonagenerian. Do the evidences add up?

Saptarshi Biswas, MD, Associate Program Director General Surgery Residency; Director Surgical Research & Surgical Simulation;

Grand Strand Medical Center (HCA), Myrtle Beach, SC

Rib fractures in elderly patients, compared with their younger counterparts, are associated with markedly increased morbidity and mortality. Poor outcomes following rib fractures in this age group are likely due to a combination of factors, including diminished pulmonary reserve, increased prevalence of comorbidities (particularly cardiopulmonary and orthopedic), increased use of anticoagulant/antiplatelet medications, and increased sensitivity to the side effects of analgesics, both systemic (narcotics /benzodiazepines) and locoregional (thoracic epidural catheters).

Historical treatment options were limited to conservative management with multimodal analgesia, aggressive pulmonary toilet, oxygen support, and waitful watch for the healing process. With the development of plating systems for rib fracture fixation and chest wall stabilization, the practice paradigm for rib fracture management is shifting, as a viable operative intervention now exists to improve clinical outcomes.

Previous studies of SSRF in the elderly have included a relatively broad age range, generally in the 60-80 years age groups. Previous initial reluctance to perform SSRF in octogenarians due to a presumed increased operative risk, is changing slowly. Restoration of chest wall stability may be particularly important in this age group due to both poor pain tolerance and diminished pulmonary reserve.

A recent multicenter, retrospective cohort study 80 years or older rib fracture patients, SSRF was associated with an independent, decreased risk of mortality as compared with nonoperative management. However, there was increased risk of pneumonia, ventilator days, and ICU days, potentially due to survival. SSRF did not affect discharge disposition, but were able to decrease narcotics use on discharge.

We evaluate the changing trend of operative surgical stabilization of ribs in the octagenerian and nonagenarian age group patients. Studies are sparse bur benefits are visible in selected groups. More future studies are warranted.

Delirium and Frailty in the Perioperative Period in an Ageing Rural Community. A broad look at recent evidences.

Saptarshi Biswas, MD, Associate Program Director General Surgery Residency; Director Surgical Research & Surgical Simulation; Grand Strand Medical Center (HCA), Myrtle Beach, SC

Frailty and delirium are among the most common geriatric syndromes, their association or their independent and combined effects on perioperative morbidity, falls, ICU stay and mortality post discharge warrants discussion.

Delirium is a serious acute-onset neuropsychiatric condition characterized by impaired attention and awareness, a fluctuating course, and global cognitive dysfunction. Despite its high prevalence, often remains under-recognized, misdiagnosed and inadequately managed.

Frailty is defined as a state of vulnerability to physiologic insults, state of decreased functional reserve and resistance to stressors— characterized as both a phenotype and as a state of accumulated deficits. It is common in community dwelling older persons (prevalence 4.0–17.0%). It is estimated to be higher in geriatric surgical patients, and associated with poorer postoperative outcomes, increased mortality, length of stay, discharge to skilled care, readmission, and complications. Postoperative delirium (POD) is a particularly suspected to be associated with preoperative frailty. It is crucial to assess for POD risk because of its independent association with increased length of stay, complications, institutionalization and mortality. Quantification of the relationship between preoperative frailty and POD could enhance perioperative decision making, potentially mitigating unnecessary morbidity and mortality associated with POD

We evaluate the prevalence and outcomes of delirium among patients admitted to perioperative care settings (i.e. acute hospital wards, ICU facilities and post-discharge facilities). We discuss recent systematic reviews and meta-analyses; various frailty indices and explore the independent relationship between frailty and delirium. Future studies are required to determine whether perioperative interventions focused on improving frailty can reduce the risk of POD and improve outcomes in this rapidly growing cohort of patients.

Retrospective Analysis of Pancreatic Injuries and Treatment Outcomes

Lindsey Braden, MD, Resident, Harbor-UCLA Medical Center, University California, Los Angeles, Long Beach, CA

It is estimated that about 4% of patients who suffer abdominal injuries also experience pancreatic trauma. Whether blunt or penetrating, delayed identification and proper treatment often lead to adverse patient outcomes including the development of pancreatic pseudocysts and fistulas, secondary infection, wound dehiscence, anastomotic breakdown, and death [1]. This is particularly true in resource-poor areas with high rates of violence, as evidenced by the experience of our community hospital. In this manuscript, we present the experience of a level 2 trauma center in managing pancreatic trauma over 5.5 years as well as the morbidity and mortality associated. Our manuscript aims to provide a valuable contribution to the literature on pancreatic trauma management by sharing our best practices and key insights.

This retrospective cohort study utilized Kern Medical’s trauma registry to identify patients who were hospitalized at Kern Medical Center (KMC) following tier 1 and 2 trauma activations for penetrating or blunt trauma and suffered pancreatic injury between October 2017 and February 2022. Each case was categorized by mechanism of gunshot wound (GSW), stab wound (SW), or blunt injury incited by motor vehicle accidents. Overall injury severity was assessed with injury severity score (ISS). Grading of pancreatic trauma was determined by American Association for the Surgery of Trauma (AAST) Organ Injury Scaling (OIS). Data were analyzed, organized, and evaluated by the associated injuries, initial management, and outcomes.

Our study found that 31 patients met the inclusion criteria. The most common mechanism of injury in patients suffering pancreatic trauma was GSWs (48.4%), followed by blunt injury (35.5%) and lastly SWs (16.1). Thirty patients suffered associated intra-abdominal injuries. GSWs were found to hold a significantly higher number of associated intrabdominal injuries than either SWs or blunt injury. The spleen was the most commonly associated intrabdominal injury to accompany pancreatic trauma. Grade 1 and 3 pancreatic injuries were the most frequent. Morbidity and mortality rate correlated with pancreatic injury severity. The mortality rate for grade 1 injuries was 10.0%, increasing to 50.0% for grade 4 injuries. Distal resection with closed suction drainage of the pancreas was the most frequent procedure performed. Reoperation was required in 70.4% of patients. Furthermore, an increasing trend between the grade of pancreatic injury and the number of complications was appreciated. Nine patients died with the majority of deaths occurring within 48 hours of admission secondary to hemorrhagic shock or severe associated injuries.

Our study highlights the complexities of managing pancreatic trauma. Management of pancreatic injuries varies based on anatomic location and associated injuries. Utilizing pancreatic injury severity grading in correlation with ISS is advisable and prompt routine drainage is recommended even in the setting of suspected pancreatic injury. The high morbidity and mortality associated with these injuries necessitate a collaborative and multidisciplinary approach that can further investigate nonoperative approaches to treatment.

Empowering Equity in Surgical Care Requires Efforts to Address Surgical Workforce Strengthening in Austere Environments Head-On; A Systemic Review

Kathryn Campos, BA, Independent Researcher: University of Washington Dept. of Surgery & Harborview Injury Prevention Program, Graduate Researcher: Kings Centre for Conflict and Health, Seattle, WA

In austere environments, civilian injuries constitute a significant portion of casualties. However, access to safe surgical care is often hindered by factors such as armed conflict, natural disasters, and humanitarian crises, which strain health systems. While global efforts have sought to prioritize surgical workforce strengthening, limited research and incentives have focused on equitable and sustainable surgical system strengthening in austere settings. In this presentation, we will delve into the critical problem of unequal access to surgical care in austere environments, the need to address this issue, what learners can achieve, and how the audience will benefit from the insights shared.

The Problem/Surgical Intervention: The heart of the issue lies in the fact that access to surgical care in austere environments is far from equitable. To address this problem, our research conducted a systematic review, combing through databases like PubMed, Embase, and Google Scholar, to identify records documenting surgical system-strengthening activities and interventions in austere environments. Our analysis revealed a staggering 2,577 records, but only 21 of them were eligible for review. These selected reports described various aspects of surgical care access, training interventions, and efforts to improve surgical systems in austere settings. However, the majority of these reports lacked quantitative data or qualitative accounts assessing equitable surgical access and workforce strengthening. This gap in knowledge hampers our ability to create effective solutions.

Why You Need to Know: The audience, including healthcare professionals, policymakers, and researchers, needs to understand the gravity of the issue. Austere environments are prone to crises, and the inequity in surgical care access directly affects patient outcomes, provider capabilities, facility functionality, and overall health system performance. By addressing these challenges, we can enhance the resilience of healthcare systems in austere environments, ensuring that essential surgical care is available to all populations, regardless of their geographical location or the circumstances they face.

What You Will Accomplish: After this presentation, learners will have a comprehensive understanding of the disparities in surgical care access in austere environments. They will be equipped with insights into the existing challenges and the potential interventions required to bridge the gap. Additionally, they will gain knowledge about the importance of quantitative and qualitative assessments in evaluating the impact of surgical system strengthening efforts.

Benefits to the Audience: Informed Decision-Making: Healthcare professionals will gain valuable insights into the challenges faced in austere environments and be better prepared to make informed decisions when working in such settings.

Policy Impact: Policymakers will be equipped with data and evidence to advocate for policies that prioritize equitable surgical access and workforce strengthening in austere environments, ultimately saving lives and improving healthcare systems.

Research Opportunities: Researchers will identify gaps in the existing literature and avenues for further investigation, encouraging the development of evidence-based interventions.

Global Health Impact: Understanding and addressing the issue of surgical care access in austere environments is vital for promoting global health equity. By strengthening surgical systems in these settings, we can extend the reach of safe and high-quality surgical care to vulnerable populations worldwide.

Conclusion: The presentation will shed light on the pressing need to bolster equitable surgical capacity building in austere environments. It will emphasize the importance of including surgical system strengthening in humanitarian contexts and advocate for prioritizing equitable surgical workforce strengthening, civilian surgical access, and overall surgical system strengthening. By addressing these issues, we can move closer to the goal of providing safe, accessible, and high-quality surgical care for all populations, both locally and globally, even in the most challenging environments.

Forging a Path to Healing: Bridging Gaps in Burns Surgery Access Amidst Adversity

Kathryn Campos, BA, Independent Researcher: University of Washington Dept. of Surgery & Harborview Injury Prevention Program, Graduate Researcher: Kings Centre for Conflict and Health, Seattle, WA

In this presentation, we address a pressing global issue - the challenges of providing access to burns surgery and burns care in austere environments. The problem at hand is multifaceted, as burn injuries account for a significant portion of casualties in austere settings. These environments, often characterized by rural settings, armed conflict, natural disasters, and humanitarian crises, pose formidable barriers to delivering safe and timely burns surgical care. The consequences are devastating, with limited access leading to unnecessary suffering and loss of life.

Why does this matter, you may ask? The answer lies in the dire need for equitable and sustainable solutions. This presentation is essential for healthcare professionals, policymakers, and humanitarian organizations alike, as it sheds light on the critical importance of increasing access to burns care in austere environments. By understanding the challenges and potential interventions discussed here, the audience can actively contribute to reducing the burden of burn injuries and improving the overall health and well-being of affected populations.

After attending this presentation, learners will be equipped with a comprehensive understanding of the problem at hand, the methods employed to investigate it, the results of relevant research, and the conclusions drawn from these findings. Specifically:

Purpose: We will delve into the purpose of our research, which is to highlight the significant disparities in burns surgical care access in austere environments. We will discuss why this problem demands our attention, emphasizing the impact on vulnerable populations and the need for immediate action.

Methods: Our systematic review, which combed through databases like PubMed, Embase, and Google Scholar, will be detailed. We will explain the rigorous methods employed to identify and select relevant records, providing insights into the research process itself.

Results:The heart of the presentation lies in the results section, where we share our findings from the review of 1,232 records. We will discuss the 16 eligible reports that shed light on access to burns surgical care, training initiatives, and interventions in austere environments. Importantly, we will explore the challenges and gaps in achieving equitable burns training access and workforce strengthening.

Conclusions: In the final segment, we will draw conclusions from our research, emphasizing the urgent need to prioritize burns surgical care in humanitarian contexts. We will underscore the significance of efforts dedicated to strengthening the burns surgical workforce and enhancing access to surgical services in austere settings. By addressing these challenges, we can achieve safe, accessible, and high-quality surgical care for all, from local to global levels.

By the end of this presentation, the audience will be empowered with knowledge and insights to advocate for change, contribute to humanitarian efforts, and drive policy decisions that prioritize burns care in austere environments. Furthermore, attendees will benefit from a deeper understanding of the critical role that healthcare professionals and organizations play in addressing this global health challenge.

In conclusion, Forging a Path to Healing: Bridging Gaps in Burns Surgery Access Amidst Adversity is a presentation that not only educates but also inspires action. It equips learners with the knowledge to make a difference in the lives of those affected by burn injuries in the most challenging circumstances. Together, we can pave the way towards a future where burns surgical care is accessible to all, regardless of the adversities they face.

Background: Burn injuries constitute a substantial proportion of casualties in austere environments. Disparities in access to secure burns surgical care are frequently exacerbated by the disruptive impact of armed conflicts, natural disasters, and humanitarian crises on healthcare systems. While recent initiatives have aimed to enhance access to burns care, prioritize injury prevention, and bolster advocacy efforts on a global scale, there remains a notable absence of comprehensive research investigations and incentives dedicated to addressing equitable and sustainable enhancements in burns care within austere environments.

Methods: We conducted a systematic review of various databases, including PubMed, Embase, and Google Scholar, to identify pertinent records documenting activities and interventions aimed at strengthening burns surgery in austere environments.

Results: A total of 1,232 records were identified, from which 16 eligible reports were selected for review. Each of these reports delineated endeavors related to access to burns surgical care, burns surgical training initiatives, and interventions to augment the quality of surgical care in austere environments. While some reports discussed general aspects of civilian access to surgical services, training interventions, and incentives for improving surgical quality, a scarcity of records provided quantitative or qualitative assessments of efforts directed towards achieving equitable surgical access and workforce reinforcement, with the ultimate goal of enhancing outcomes at the patient, provider, facility, organizational, and health system levels.

Conclusions: Presently, there is a paucity of comprehensive reports detailing initiatives aimed at fortifying burns surgical care and training programs in austere environments. It is imperative that the advocacy and promotion of increased access to burns surgical care on a global scale include a deliberate prioritization of burns care in the humanitarian context. Furthermore, the paramount importance of efforts dedicated to enhancing the burns surgical workforce, civilian access to burns surgical services, and overall burns care strengthening within austere environments cannot be overstated. These endeavors are critical in advancing the provision of safe, accessible, and high-quality surgical care for all populations, from the local to the global level.

Pelvic Organ Prolapse through a Global Health Lens

Danielle Carr, MD, Harvard Medical School,

Mount Auburn Hospital,

Beth Israel Deaconess Medical Center, Cambridge, MA

The incidence of pelvic organ prolapse (POP) worldwide varies across regions and populations. While it is challenging to provide a precise global incidence due to underreporting and variations in healthcare accessibility, it is estimated that up to 50% of women will experience this condition during their lifetime.

Several factors contribute to the development of POP, including childbirth, aging, obesity, and genetic predisposition. Regions with higher fertility rates and limited access to obstetric care may experience a higher incidence of POP.

In resource-limited settings, the impact of pelvic organ prolapse (POP) extends beyond physical health and significantly impacts the overall well-being of affected individuals. Women dealing with POP in these settings often face heightened challenges due to a confluence of factors, including limited access to healthcare facilities, scarcity of skilled professionals, and cultural stigmas surrounding pelvic health issues. The condition can lead to profound physical discomfort, affecting daily activities and productivity, while also contributing to psychological distress and diminished quality of life. Furthermore, the economic repercussions are notable as the chronic nature of POP may impede the ability of affected women to engage in productive work.

The treatment of pelvic organ prolapse involves a multidimensional approach aimed at alleviating symptoms, improving quality of life, and addressing the specific needs of each patient. Options range from conservative measures to surgical management. Resource limitations often hinder the effective management of prolapse. This presentation discusses the different treatment options for pelvic organ prolapse with an emphasis on surgical interventions designed to address POP in resource-limited settings.

Advancements in Endoscopic Ear Surgery: A Decade of Evolution in Otologic Practice among Surgeons in Taiwan

Chin-Kuo Chen, MD, PhD, Chang Gung University,

Communication Enhancement Center, Chang Gung Memorial Hospital,

Department of Otolaryngology, Chang Gung Memorial Hospital, Keelung, Taiwan, Tao-Yuan, Taiwan

Abstract: Minimally invasive surgical techniques have witnessed a paradigm shift in contemporary medical practice, with a concerted effort to achieve superior outcomes with reduced morbidity. While the da Vinci robotic system stands as a technological marvel, its prohibitive costs and logistical challenges have spurred a focused exploration of alternative methodologies. Within the field of otology, endoscopic surgery has emerged as a promising avenue, offering a cost-effective and versatile approach to various otologic procedures.

This present delves into the nuanced landscape of endoscopic ear surgery in Taiwan, specifically within the domains of myringoplasty, tympanoplasty, cholesteatoma surgery, benign neoplasms of the middle ear, stapedectomy, and neuro-otological procedures. The strategic incorporation of endoscopic techniques seeks not only to minimize surgical invasiveness but also to optimize patient outcomes. A distinctive emphasis is placed on the meticulous preservation of normal middle ear mucosa, with observed benefits extending to improved mastoid cavity reaeration and enhanced hearing outcomes.

In a global context where the endoscope is still a nascent tool for otologists, Taiwan stands as a trailblazer, having embraced totally endoscopic tours over a decade ago. This presentation articulates the transformative impact of endoscopy on both diagnostic and therapeutic dimensions within otologic surgery. The endoscope's ability to provide diverse perspectives and angles has not merely altered procedural approaches but has significantly contributed to a deeper understanding of anatomical intricacies.

The relentless progression of endoscopic techniques, coupled with the continual refinement of advanced monitoring systems, underscores an ongoing trajectory of research and development. Numerous instruments and smaller devices are currently under scrutiny by research entities and medical technology firms alike. Within Taiwan, endoscopic ear surgery has garnered substantive interest and adoption among otologists, leading to commendable strides in anatomical studies, 3D endoscopic ear surgery, cochlear implants, stapes surgeries, and rigorous comparative analyses between endoscopic and microscopic methodologies.

This presentation endeavors to distill our experiences in the application of endoscopy to ear surgeries, delineating its profound impact on the landscape of clinical otologic practice. By offering insights into the nuanced evolution of endoscopic ear surgery, this discourse not only serves as a substantive guide for its integration among surgical practitioners but also contributes to the broader scholarly discourse surrounding the refinement of this innovative surgical approach.

An Overview of 2013 Lower Extremity Angioplasty from Singapore General Hospital

Tec Chong, MBBS, Professor, Head & Senior Consultant, Department of Vascular Surgery, Singapore General Hospital, Singapore,

From 2019 to 2022, 2013 lower limb angioplasties were performed at Singapore General Hospital. 83.4% of the patients were for critical limb ischemia. The mean WIFi score is 3.94 representing 59.6% of patients having a moderate or high risk of amputation. 73.3% of procedures done were for treatment of multi level disease. 92.1% technical success with 12 month clinically driven target vessel Revascularization rates of 76.7%, 12 month major amputation rate of 11.4% and 12 month mortality rate of 24.5%. These data represent a real world picture of treatment of complex peripheral arterial disease with high comorbidities at Singapore General Hospital

An Update: ACS-HOPE Collaboration in Lusaka, Zambia

Muriel Cleary, MHS, MD, Assistant Professor of Surgery,

UMass Chan School of Medicine, Worcester, MA

This talk will focus on the building of a collaborative partnership between the University Teaching Hospital in Lusaka, Zambia and the American College of Surgeons: Health Outreach Program for Equity (ACS-HOPE).

Achieving Global Health Equity

Sasha Corbin, MBBS, General Surgery Resident, PGY-2

Morehouse School of Medicine, Atlanta, GA

This presentation will discuss the present status of global health equity in surgery, including social, political, and environmental determinants of health. It will also discuss ongoing initiatives and propose solutions to achieve health equity.

Machine Learning Applications for Predicting ICU Stay Following Posterior Spinal Fusion in Adult Spinal Deformity

Mert Marcel Dagli, MD, Research Fellow, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

The presentation explores the role of machine learning (ML) in predicting the length of stay (LOS) in the Intensive Care Unit (ICU) following posterior spinal fusion (PSF) surgeries for adult spinal deformity (ASD). This surgical intervention is known for its complexity and the critical postoperative care required, particularly in the ICU setting.

Understanding the application of ML in this context is crucial for healthcare professionals involved in the surgical treatment of ASD. This knowledge can lead to more accurate predictions of ICU LOS, enabling better resource allocation and potentially improving patient outcomes.

Additionally, the methodology employed could be applicable or provide inspiration across various specialties and types of surgical procedures.

Attendees will gain the ability to: 1) Recognize the importance of ML in predicting ICU LOS post-PSF or any other surgery. 2) How to approach the identification of key predictors.

Harnessing Pre- and Intra-Operative Predictors to Predict Postoperative Complications in Spine Deformity: Development of a Prognostic Artificial Intelligence Clinical Prediction Model

Mert Marcel Dagli, MD, Research Fellow, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

This presentation addresses the application of Artificial Intelligence (AI) in predicting postoperative complications in posterior spinal fusion (PSF) surgeries for adult spinal deformity (ASD). PSF, a procedure with inherent complexities, often results in a range of postoperative complications that can significantly affect patient outcomes.

Surgeons, clinicians, and healthcare professionals will gain an understanding of how AI models can predict postoperative complications using preoperative and intraoperative data. This knowledge is crucial for enhancing preoperative planning and postoperative care.

After attending this presentation, participants will be able to: 1) Recognize the potential of AI in improving surgical outcomes. 2) Understand the process of developing AI models using preoperative and intraoperative predictors. 3) Understand the process of eventually reaching clinical application with their models.

An Introduction to Artificial Intelligence Clinical Prediction Models in Surgery

Mert Marcel Dagli, MD, Research Fellow, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

This presentation provides an introduction to the realm of artificial intelligence (AI) clinical prediction models in medicine, with a specific focus on their application in neurosurgery. It addresses the problem of enhancing predictive accuracy in medical diagnoses and interventions. In an era characterized by an explosion of healthcare data, harnessing the power of AI/machine learning (ML) has become crucial to developing more accurate prediction models. Attendees will gain insights into the significance of AI in improving healthcare outcomes and the need for clinician scientists to actively engage in this evolving field. The audience will find this presentation invaluable as it bridges the gap between traditional medical approaches and the transformative potential of AI prediction models. By the end of the presentation, learners will acquire a foundational understanding of AI prediction models, their methodological development, performance benchmarks, implications for clinical practice, and future directions. Armed with this knowledge, attendees will be better equipped to harness the capabilities of AI to enhance patient care, diagnostic accuracy, and treatment outcomes.

Correction of Animation Deformity of the Breast

Anthony Dardano Jr., DO, Professor of Plastic Surgery,

Florida Atlantic University;

Chief, Plastic Surgery Trauma,

Delray Medical Center, Boca Raton, FL

Animation deformity of the breast is the unsightly complication following subpectoral implant placement for breast reconstruction or augmentation, characterized by implant displacement with pectoralis muscle contraction.

Estimated to occur in 75-100% subpectoral recons and 15% of breast augmentations

This presentation provides a review of literature, classification, and a how to repair this deformity in breast reconstruction patients.

WALANT Outcomes in a Hospital Procedure Room

Michaela Derby, Medical Student, University of South Dakota Sanford School of Medicine, Sioux Falls, SD

Purpose: The objective of this study was to evaluate patient satisfaction and postoperative complications from wide-awake local anesthesia with no tourniquet in a hospital procedure room.

Methods: A total of 786 patients underwent 948 elective hand procedures in a hospital procedure room. At the conclusion of their surgeries, the patients were surveyed regarding their satisfaction. Postoperatively, patients were evaluated for postoperative complications including infections. The trend in postoperative infection rates across eight age groups was analyzed using a Cochran-Armitage test in R.

Results: The overall infection rate was 6.2% (n=59). All infections were superficial. Carpal tunnel had the highest number of infections (n=25), followed by trigger finger (n=8), and the combination trigger finger with carpal tunnel (n=7). All infections were managed with antibiotics and/or soaks. Ninety-nine percent of patients said the procedure room experience was better or the same as going to the dentist, would recommend wide-awake anesthesia to a friend or family member, and would undergo the procedure again.

Conclusions: Information obtained from this study reflects similar observations to other WALANT clinical procedure room studies and adds to the literature suggesting that minor hand surgery performed specifically in a hospital procedure room is safe with minimal infection risk and high patient satisfaction. Additionally, this study provides results across several different procedure types with a large sample size.

Advanced Bio-Technology Medicine in Burn and Wound Healing

Steven Dominguez, MD, MPH, Bella Milagros Clinic, Huntington Beach, CA

Advanced wound healing BioTechnology options in Burns and Wounds. Key is the use of biotechnology at the bedside without the use of flaps or suction devices. Topics covered include PRP, Stem Cells, Exosomes, and autologous fat grafting. Bedside application including IM, SC, and Topical solutions or gels. In-depth discussion of growth factors inherent in each and action resulting in accelerated biotechnology induced tissue growth and wound healing.

Neurosurgery in Honduras - Experiences Operating in a Third World Country

Jeffrey Epstein, MD, Spine Surgeon, Babylon, NY

The difficulty in performing complex brain and spine surgery in a country which has very limited resources and equipment makes it tremendously challenging.. I will show examples of the pathology that I encountered during my week in Honduras, including verbal descriptions of the surgeries, MR/CT pictures of the various procedures with some intra-op photos as well, and discussions regarding the limitations for performing the surgery as compared to performing the same procedure in the US.

Peace Corps to Surgical Mission: Same Lessons, 30 years

Erika Fellinger, MD, Assistant Professor of Surgery, Harvard Medical School, General and Minimally Invasive Surgery and Surgical Endoscopy, Cambridge Health Alliance, Somerville, MA

This presentation will describe the critical lessons learned during her initial years in the Peace Corps in Benin, West Africa doing village-based health care in the effort to eradicate Guinea Worm, and Burundi, East Africa for AIDS education and prevention, and the continued application of those lessons in her surgical career and to surgical mission work abroad in Peru, Haiti, and Honduras. The lessons learned involve channeling good intentions (the desire to help) into patience, respect, curiosity, collaboration, and skill-building and resource access.

This information is important for the audience to know because the International College of Surgeons is a self-selected group of health care providers who value an international perspective on surgical problems and want to know how they can get involved and contribute productively to improving global surgical care.

After the presentation, the learner will better know what questions to ask when considering doing health-related work in an unfamiliar environment, international or domestic setting, and what kinds of organizational and collaborative benchmarks must be met to have a chance of being truly sustainable and successful.

The audience will benefit from the presentation by listening and hearing the lessons learned (sometimes the hard way) in 30 years of experience working in unfamiliar or international environments and be able to apply those lessons to their own work.

My Journey as a Global Robotic Surgery Proctor

Jacques P. Fontaine, MD, Senior Member - Dept. of Thoracic Surgery, Moffitt Cancer Center; Professor - University of Florida, Tampa, FL

Since 2015, I have had the opportunity to proctor and mentor over 50 thoracic surgeons as they first adopt robotic technology. My experiences and the relationships I have formed over the years with these surgeons in the US and overseas has taught me invaluable lessons as a teacher, a student and mentor working in an academic setting. I will be describing the lessons I have learned and how they impacted me as a clinical educator in an ACGME teaching institution.

Lessons Learned from The Global Travel Fellowship of a Thoracic Surgeon

Jacques P. Fontaine, MD, Senior Member - Dept. of Thoracic Surgery, Moffitt Cancer Center; Professor - University of Florida, Tampa, FL

Globalization is occurring in every field - industry, trade, geo-politics as well as healthcare. Although the human body and surgical pathologies are universal, the way we provide healthcare and manage our healthcare system differ. Through my observations as a travelling surgical fellow in various centers of excellence across the globe, I have concluded that there is a trend towards homogenization and globalization. I will review my observations and discuss my predictions as to the future of our healthcare system based on the lessons I have learned.

Ethics of Artificial Intelligence in Surgery

Sabha Ganai, MD, PhD, MPH, Associate Professor of Surgery, University of North Dakota School of Medicine and Health Sciences, Fargo, ND

Burgeoning use of artificial intelligence technologies has brought questions on the ethics of use, including concerns on disclosure of use, justice considerations, autonomy, privacy, quality, and safety.

Trauma: A Forgotten Epidemic

Thayasivam Gobyshanger, MD, MBBS, MRCS (Edin), MS, FCSSL, Jaffna, Sri Lanka

This study was carried on patients admitted to hospital with the history of trauma to the Northern part of Srilanka to the Trauma care centres. The data were collected through electronic format which includes, the accident scenario, pre hospital care and transfers, injury details and socio economic impact due to the injuries. the aim is to develop a Trauma Registry.

Introduction:

Globally, non -communicable diseases have become a major contributor for morbidity and mortality. Trauma was not a top cause of death at the beginning of the millennia but now has become the 10th cause of death worldwide and 9th in Sri Lanka in the last ten years. Road traffic accidents (RTA) account for majority of trauma cases.

Sri Lanka is an island nation in the Indian ocean with a population of 22 million people with an area of 25,000 square miles (similar in size to the state of West Virginia). In Sri Lanka, the number of cases reported per year with Dengue fever and RTA are similar at about 30,000. The number of deaths due to Dengue is around 300 whereas the traumatic deaths due to road traffic accident is 3,000 annually. The health authorities spend more resources in Dengue than in Trauma.

Trauma registries are not only useful in quality assessment but also helpful in creating injury prevention, policy making and assessment of impact of trauma to a population. There is no trauma registry available in Sri Lanka and the socio-economic impact of the trauma of the population has not been studied. The implementation of a trauma registry is important to create preventive strategies and implement policies to control trauma.

Objective:

Establishing a trauma registry in northern Sri Lanka to study the pattern of injuries and evaluate the impact of trauma in that part of the island.

Methodology:

A prospective electronic format of data collection was carried out in all major hospitals of all five districts of the Northern province of Sri Lanka. Data of all patients with RTA from January 1, 2022 to December 31, 2022 were collected. Injury mechanism, State of the accident site, type of transport to hospital, injury pattern, socio economic impact to the victims and outcome of the sustained injury were analyzed.

Results:

Of the data collected of 6,275 RTA victims, most of the victims are Tamils as this was done in Northern part of Sri Lanka (91%). Majority of victims are males (75%) and they are motorcyclist (59%). Commonest age group was 20-39 years (50%). Very few of them were covered with insurance (0.6%) and 28% of them were professionals or highly skilled and skilled workers. Majority of them were involved in a motorcycle accident (28%) and 27% of victims collided with another motorcycle. Of the victims, 0.8% were under the influence of alcohol and other illicit drugs during the accident. Majority of the transport modality after the motor traffic crash was a three-wheeler (37%) followed by motorcycle (31%). Only 22% of victims were transferred with an ambulance. In only 22% of victims, all precautions were taken during the transport. Orthopaedic related injuries were common among victims (64%). Average salary of SLRs 30,000 to 45,000 (US$ 1 = SLRs 320) monthly earning capacity group was the most affected (55%) by the road traffic accidents. Among them 36%, had lost their earning capacity after the road traffic crash.

Conclusion:

Establishing a trauma registry is an utmost important need for our country. The trauma registry will be useful in studying the risk factors for trauma, outcome after trauma, assess the impact of the trauma on the society and importantly can be used as a policy making tool to decrease RTAs and an education tool for the community to decrease the incidence of trauma.

Minimally Invasive Treatment of Severe Thoracolumbar Trauma

Cristian Gragnaniello, MD, PhD, Assistant Professor of Neurosurgery and Otolaryngology, UT Health San Antonio, San Antonio, TX

Lateral spondyloptosis of the thoracic spine and burst fractures of the thoracolumbar spine pose unique challenges to the surgeon and often are treated with very large and morbid interventions. We present a case series with rationale to minimally invasive treatment of some challenging lesions.

Staged versus Same-Day Circumferential Fusion in Treating Adult Spinal Deformity: A Comparative Systematic Review and Meta-Analysis

Jaskeerat Gujral, Research Scholar, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

This presentation investigates surgical approaches for adult spinal deformity (ASD), focusing on the comparison between staged and same-day circumferential spinal fusion. Considering the complexity and the significant variation in surgical practices, understanding the optimal surgical strategy is essential for improving patient outcomes.

Healthcare professionals involved in spinal surgeries need to understand the nuances and outcomes associated with different surgical approaches to ASD. This knowledge is pivotal for surgical planning, patient counseling, and setting realistic expectations for recovery and outcomes.

Participants will be able to: 1) Identify the difference in outcomes between staged and single-stage circumferential spinal fusion. 2) Understand the methodology of conducting a systematic review and meta-analysis according to PRISMA-P (Protocol) & PRISMA guidelines.

Clinical Insights: The Role of Turmeric as a Nutritional Adjunct in Surgical Recovery

Shivani Gupta, PhD, Professor of Ayurvedic Sciences, Hindu University of America, Deerfield Beach, FL

Nutritional deficiencies are a well-recognized long-term complication following many types of surgery. The presence of preoperative deficiencies has been shown to be predictive of postoperative deficiencies.

Nutrition plays a crucial role in the recovery and overall outcome of surgical patients. Adequate nutrition can help ensure proper wound healing, maintain muscle mass, and reduce the risk of infections. Among various nutrition supplements that have been considered beneficial for surgical patients, turmeric, specifically its active compound curcumin, has gained attention.

Potential benefits for surgical patients include anti-inflammatory effects, antioxidant properties, pain management, wound healing, infection prevention, and immune support.

The bioactive compounds, pharmacokinetics, and mechanisms of action of curcumin show promising science for curcumin in surgical patients. There are clinical trials showing curcumin’s effects on inflammatory markers including CRP, TNF-α, and IL-6 in postoperative patients. There is research on curcumin's positive effects on collagen synthesis, tissue remodeling, and angiogenesis, and exponentially more science on this topic.

The learner will understand the applications of curcumin to the surgical practice, dosage, and administration, quality and purity, as well as surgical timing. The incorporation of curcumin into surgical care can significantly impact patient well-being.

Building a Trauma Care System in LMICs: The Process Behind the TRAIN Trauma India Symposium Consensus

Radzi Hamzah, MD, MPH, Paul Farmer Research Fellow, Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA

Background:

Trauma is a leading cause of morbidity and mortality worldwide, particularly in low- and middle-income countries (LMICs) like India. Addressing the challenges of establishing an efficient trauma care system in such settings is crucial for reducing preventable deaths and improving patient outcomes. This presentation outlines the collaborative efforts and processes involved in developing consensus recommendations for enhancing trauma care in LMICs, with a focus on India.

Purpose:

The primary aim of this presentation is to detail the methodology and collaborative approach undertaken by the Transdisciplinary Research, Advocacy, and Implementation Network for Trauma in India (TRAIN Trauma India) Symposium in formulating actionable recommendations for trauma care systems in LMICs. This initiative highlights the significance of a comprehensive and coordinated approach to trauma care, from pre-hospital to post-discharge services.

Methods:

A transdisciplinary method was employed, assembling experts from various sectors of trauma care to participate in the TRAIN Trauma India Symposium. The process involved establishing five working groups, each focusing on a specific aspect of trauma care: pre-hospital care, in-hospital resuscitation and training, trauma systems, and trauma registries. Through extensive literature reviews and a Delphi consensus method, the symposium aimed to synthesize robust recommendations that are both practical and impactful for LMIC settings.

Results:

The collaborative effort resulted in a series of consensus recommendations that address the entire spectrum of trauma care. These recommendations were classified based on their implementation feasibility and potential impact, covering key areas such as standardized training protocols, the establishment of designated trauma care facilities, and the development of cost-effective trauma registries. The process underscored the value of incorporating diverse expert opinions and evidence-based strategies in crafting comprehensive solutions for trauma care challenges in LMICs.

Conclusion:

The TRAIN Trauma India Symposium's consensus-building process highlights the critical need for collaborative, multidisciplinary efforts in developing effective trauma care systems in LMICs, aimed at significantly reducing trauma-related morbidity and mortality.

The Use of Virtual Reality in Reducing Intraoperative Patient Anxiety

Kyler Hardie, Medical Student, University of South Dakota Sanford School of Medicine, Harrisburg, SD

Our presentation explores the use of virtual reality (VR) in wide-awake local anesthesia no tourniquet (WALANT) hand surgery and its effect on reducing patient anxiety. The use of local-only anesthesia during wide-awake surgery has become increasingly popular in minor hand procedures and studies have demonstrated reduced risk for patients by avoiding sedation. However, some providers and patients are uncomfortable with the idea of wide-awake surgery, particularly in the setting of an anxious patient. Our presentation aims to promote awareness of how VR can be used during wide-awake, local-only hand surgeries, underscore the benefits, and examine the application of VR across other specialties. In addition, we highlight our own experience and data utilizing VR during WALANT procedures for hand surgery. Our goal is to inform the audience that VR during WALANT procedures is safe and can result in higher patient satisfaction, lower patient anxiety, and be cost-effective, with the potential to be utilized across many areas of medicine and surgery.

Burn Injury and Burn Care in Rural Kenya

Mary Hunter, MD, MA, ScM, Assistant Professor of Surgery, University of Michigan, Ann Arbor, MI

Burn injuries remain a significant source of disability and mortality throughout the world, however the burden of burn injuries disproportionately affects people in resource-limited areas. Low-and-middle-income countries have higher incidences of burn injury as well as higher levels of disability and mortality, compared with high-income countries. Studies have shown that factors at each level of injury prevention contribute to the disparities in burn injury: primary prevention (eliminate the event), secondary prevention (diminish the effect), and tertiary prevention (improve outcomes).

In order to better understand burn injury and burn care in a resource-limited setting a mixed-methods research project was undertaken at a 300-bed faith-based, teaching hospital in southwest Kenya. The hospital provides primary care for a rural population of about 800,000 people; the majority of whom live below the international poverity line. The hospital also serves as a referral center for surgical sub-specialties including trauma and burn. The research project was conducted as part of an partnership between institutions in the US and Kenya and included survey, qualitative and quantitative methods. This presentation will discuss the results of the mixed-method assessment of burn injury and burn care at a hospital in rural Kenya and will address the process and challenges of conducting international research.

CrashSavers Comprehensive Hemorrhage Control Training in Guatemala

Rashi Jhunjhunwala, MD, MA, General Surgery Resident, Beth Israel Deaconess Medical Center, Boston, MA, Jamaica Plain, MA

Background: Hemorrhage is the leading cause of preventable death after trauma. In high-income countries first responders are trained in hemorrhage control techniques but this is not the case for developing countries like Guatemala. We present a low-cost training model for tourniquet application using a combination of virtual and physical components.

Methods: The training program includes a mobile application with didactic materials, videos and a gamified virtual reality environment for learning. Additionally, a physical training model of a bleeding lower extremity is developed allowing learners to practice tourniquet application using inexpensive and accessible materials. Validation of the simulator occurred through content and construct validation. Content validation involved subjective assessments by novices and experts, construct validation compared pre-training novices with experts. Training validation compared pre and post training novices for improvement.

Results: Our findings indicate that users found the simulator useful, realistic, and satisfactory. We found significant differences in tourniquet application skills between pre-training novices and experts. When comparing pre- and post- training novices, we found a significantly lower bleeding control time between the groups.

Conclusion: This study suggests that this training approach can enhance access to life-saving skills for prehospital personnel. The inclusion of self-assessment components enables self-regulated learning and reduces the need for continuous instructor presence. Future improvements involve refining the tourniquet model, validating it with a larger sample size and expanding the training program to include other skills.

Associations Between Body Surface Area and Perioperative Outcomes after Robotic-Assisted Pulmonary Lobectomy

Sunny Kahlon, , Medical Student, University of South Florida Health Morsani College of Medicine, Tampa, Florida, Tampa, FL

Purpose:

In previous literature, small body habitus (i.e., low body surface area [BSA]) has been associated with surgical outcomes. This study investigated the effects of low BSA on perioperative outcomes following robotic-assisted pulmonary lobectomy (RAPL).

Methods:

We analyzed 729 consecutive patients who underwent RAPL over 11.8 years by one surgeon. Patients were grouped as having BSA ≤1.65 m2 (Group 1) or as having BSA >1.65 m2 (Group2). Estimated blood loss (EBL), skin-to-skin operative times, postoperative complications, hospital length of stay (LOS), in-hospital mortality, and overall survival were compared, with significance at p≤0.05.

Results:

Group 1 had 135 patients (BSA 1.25–1.65 m2), and Group 2 had 594 patients (BSA 1.66–2.86 m2). Median [Q1, Q3] skin-to-skin operative times were 162 [135, 205] min for Group 1 and 176 [146.75. 215] min for Group 2 (p=0.030). Group 1 had median [Q1, Q3] EBL of 100 [50, 250] mL compared to 150 [58.75, 250] mL for Group 2 (p=0.200). Postoperative complications occurred in 38.5% in Group 1, compared to 38.2% in Group 2 (p=0.950). In-hospital mortality rate was 0.0% for Group 1 and 2.2% for Group 2 (p=0.222). Median overall survival time for Group 1 was 117.5 months, while median overall survival time for Group 2 was 78.1 months (p=0.379).

Conclusions:

Patients with BSA ≤1.65 m2 had shorter skin-to-skin operative times than patients with BSA >1.65 m2. Otherwise, both groups had similar conversion-to-thoracotomy rates, postoperative complication rates, and other perioperative outcomes. Thus, robotic-assisted pulmonary lobectomy is feasible and safe in patients with small body habitus.

Providing Remote Aid During a Humanitarian Crisis

Lewis Kaplan, MD, Professor of Surgery,

Perelman School of Medicine, University of Pennsylvania, Division of Trauma, Surgical Critical Care and Emergency Surgery, Philadelphia, PA

This presentation describes a method of providing robust remote aid that includes surgical telementoring during a humanitarian crisis. Enablers, barriers, and outcomes are presented that are scalable to other venues and leverage advances in telecritical care.

The UAB Community Network: Tackling the Rural Surgery Crisis

Manu Kaushik, MD, Assistant Professor of Surgery, Department of Gastro-intestinal Surgery, Department of Surgery,

University of Alabama at Birmingham, Vestavia Hills, AL

Almost 60 million Americans live in rural areas with only 10 % of general surgeons available to provide them care. Presence of a general surgeon not only provides surgical support to these older with lower education and less insured patients but also positively impacts the socio-economic issues in the community. 162 Rural hospitals have closed since 2005 and >30% of rural hospitals have negative cash flow margins. With the declining rural surgery force, there is a need to supplement these hospitals with surgical support to provide care to the population and generate revenue to keep the hospitals open.The Dept of Gastro-intesinal surgery at the University of Alabama at Birmingham (UAB) has worked towards establishment of a surgery network across Alabama and development of research around rural surgery. Alabama has 67 counties and 28 of them lack surgical support. UAB has targeted 4 of such counties (Marengo, Butler, Tallapoosa, Marion), and provided a full-time general surgeon in 4 different hospitals. These surgeons are supported by 14 other UAB surgeons to assist in call coverage, preoperative planning, intra-operative assistance as needed. The Hospital systems were assisted with clinical resources, staffing/recruitment and UAB representation on the hospital boards.

Between the financial years 2020-2022, a total of 1350 general surgery procedures were performed at the Russell Medical center (130 beds, 8 OR, 1 endo suite) in Tallapoosa County. Majority of these cases were performed minimally invasively with the robot. 1000 general surgery procedures were performed at the regional medical center (72 beds) in Butler County) and 1407 procedures at Whitfield Regional hospital (99 beds,2 OR, 1 Endo suite) between 2020 and 2022. The case complexity ranged from cholecystectomies, hernia repairs to minimally invasive colectomies. There was an overall increase in charges and total revenue generated at all centers.

Rural Surgery practices need support from academic institutions to provide care to the community and to the rural surgeon. Connecting a surgeon to an academic hub provides clinical and academic support, opportunities to the surgeon and may even reduce burnout making rural jobs more appealing to the graduating residents. There is a need to monitor surgical outcomes in the community and determine an appropriate scope of practice to eventually develop more rural surgery training programs.

This presentation will help understand various ways how tertiary academic centers can help Rural populations and will be an important aspect of surgical care to discuss with the other fellows and rural surgeons in the room.

Graduate Medical Education Reform in Vietnam through HAIVN (Partnership for Health Advancement in Vietnam)

Tara Kent, MD, Associate Professor of Surgery, Harvard Medical School; Vice Chair for Education, BIDMC Dept. of Surgery; Program Director, BIDMC General Surgery Residency, BIDMC Division of Surgical Oncology, Boston, MA

The presentation will describe work that I am involved with as the Medical Education Program Senior Advisor - UME & GME (Surgery) for the IMPACT MED Alliance (USAID grant, PI Lisa Cosimi MD). In this program, we work with local faculty in medical universities across Vietnam, providing technical advisement on revision of their graduate medical education program. I will discuss the program's objectives, intersection with health and health education policy in Vietnam, methods of program reform, and interim outcomes as well as barriers.

Using Artificial Intelligence to Bridge Global Surgical Inequities

Divya Kewalramani, MD, Research Fellow, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA

we focus on harnessing artificial intelligence (AI) to tackle one of the most pressing issues in global health: surgical inequities. While affluent nations are advancing with AI for predictive healthcare solutions, the imperative shifts toward deploying AI for reactive solutions in low- and middle-income countries (LMICs). This approach aims to bridge the significant gap in surgical access and quality that disproportionately affects these regions.

The talk will explore various innovative strategies for utilizing AI to enhance surgical care accessibility. These include optimizing surgical supply chains, improving patient triage systems, reducing administrative burden and facilitating remote diagnosis and consultation services. By leveraging AI's power, the goal is to develop scalable, cost-effective solutions that can adapt to the diverse challenges faced by healthcare systems in LMICs.

This talk aims to inspire action and collaboration among the global surgical community, highlighting the critical role of AI in transcending geographical and economic barriers to healthcare. By prioritizing reactive AI solutions in LMICs, we can make significant strides toward universal access to essential surgical care, underscoring the belief that where you live should not determine if you live.

Digital Health and Surgical Outcomes: Hacking Healthcare in Singapore and Qatar

Ayesha Khalid, MD, MBA, Assistant Professor, Harvard Medical School, Cambridge, MA

Healthcare hackathons present a unique opportunity to bring together clinicians, surgeons, engineers and designers to develop digital health tools and medical devices with rapid iteration to utilize in the operating room. Globally, these communities present a mechanism to really improve care as the hackathons in Singapore and Indonesia provided surgeons with multiple digital health tools that were developed and tried in the healthcare setting and set the stage for further work bring done with the government.

Acute Management of Morel-Lavallee Lesion with closed incision negative pressure therapy (ciNPWT) subcutaneous drain placement and SPY fluorescence imaging

Laila Khoury, MD, Resident, Florida Atlantic University, Delray Beach, FL

PURPOSE: The Morel-Lavallée lesion is a post-traumatic degloving soft tissue injury. First described in 1863 by French physician Maurice Morel-Lavallée in a man who developed persistent fluid collection after falling from a train. It is commonly caused by blunt force trauma in which an acute shearing force creates a separation of the skin and subcutaneous tissue from the underlying fascia. The injury may be a closed or an open one. A potential space is created which often accumulates lymph, serous fluid or blood. If not recognized or treated acutely; persistent soft tissue deformity, fluid collection, secondary infection or necrotizing fasciitis can occur.

A 23-year-old male presented to our level one trauma center after being struck by a train. Clinical exam demonstrated multiple contusions of the trunk and right thigh along with a 20cm laceration in the right groin. CT imaging revealed abdominal subcutaneous emphysema and grade 3 liver laceration. Patient was taken to the operating room for management of the groin injury, where he was noted to have extensive undermining of the abdominal subcutaneous tissue from the groin to the right rib cage.

METHODS: Fluorescent SPY imaging was used to evaluate tissue viability. All devitalized tissue was excised, and the wound was irrigated with pulse lavage. A #19-Blake drain was placed in the subcutaneous tissue. The laceration was closed with 3-0 nylon in an interrupted fashion. Closed incision negative pressure device was placed over the groin incision and a larger surface ciNPWT device over the abdominal flap. Patient was placed on bed rest for 5 days.

RESULTS: POD #7 the dressings were removed, and the tissue was noted to be completely viable. The incision was intact and there were no acute fluid collections noted. Pt was discharged home with JP in place.

CONCLUSIONS: We present a safe and effective technique for acute management of Morel-Lavallée utilizing closed incision negative pressure wound therapy, drain placement, and fluorescent SPY imaging.

Leveraging Large Language Models and Agentic AI in Surgery

Anai Kothari, MD, MS, Assistant Professor of Surgical Oncology, Medical College of Wisconsin, Milwaukee, WI

The emergence of large language model (LLM)-based agentic AI systems, such as OpenAI's ChatGPT, has led to significant interest in ways to leverage these tools to improve surgical care. This presentation will equip surgeons with (1) an understanding of how large language models are developed, (2) how agentic AI systems are used in non-surgical settings, (3) existing and novel ways LLM and agentic AI systems can be used in surgical practice.

Dilemmas in Surgical Practice:

Level III Mesopancreas Dissection for PDAC

Kung-Kai Kuo, MD, PhD, Professor in Surgery,

Division of General and Digestive Surgery,

Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan

Mesopancreas dissection is a critical aspect of the pancreaticoduodenectomy (PD) procedure, influencing cancer clearance, accurate staging, and potentially the long-term survival of patients with pancreatic head cancer. Complete removal of the mesopancreas is essential to achieve negative (R0) surgical margins, a critical factor in reducing the risk of cancer recurrence. Precise mesopancreas dissection is technically required to avoid damage to these structures and to minimize the risk of postoperative complications like bleeding or vascular injury.

Inoue described 3 different levels (Levels I ~ III) of mesopancreas dissection in PD.

A Level 3 meso-pancreas dissection includes removal of the nerve plexus of the pancreas head (both PLphI and PLphII), and is characterized by hemi-circumferential removal of the right and posterior nerve plexus around the SMA (PLsma). However, the important drawback of this procedure is the increased rates of posoperative diarrhea.

Whether or when we should perform a Level 3 meso-pancreas dissection for pancreatic head cancer is controversial. Further investigation is needed to achieve balance between radicality, true oncological outcomes and quality of life.

Here we present cases with pancreatic head cancer, levels of dissection are based on the extent of tumor or lymph nodes spread, and vascular encasement. Specific literature review on this topic will be presented too.

Eyelid Reconstruction Following Excision of Eyelid Cancers and Eyelid Trauma

Geoffrey Kwitko, MD, Clinical Assistant Professor of Ophthalmology, University of South Florida, Tampa, FL

Eyelid reconstruction following excision of eyelid cancers and eyelid trauma can be quite challenging. Both functional and cosmetic considerations need to be addressed. Numerous techniques will be discussed including flaps and grafts in order to preserve visual function as well as producing an acceptable cosmetic result. The audience needs to be made aware of the various treatments available and best how to advise their patients on how to proceed once a cancer diagnosis is made or eyelid trauma has occurred.

Robotic Pancreaticoduodenectomy in a Community Setting: Early Experience and Outcomes

McDaniel Lang, MD, General Surgery Resident, Sanford Health, Sioux Falls, SD

Purpose:

Robotic pancreaticoduodenectomy offers several benefits to both patients and surgeons when compared to the traditional open approach including less morbid incisions, decreased intraoperative stress response, and a technical advantage with improved visualization and wrist articulation. Sanford Health is one of the first community-based institutions to offer robotic pancreaticoduodenectomy. Here, we report our experiences thus far, as well as early outcome data.

Methods:

Twelve robotic Whipple procedures performed on Davinci Xi robot at Sanford USD Medical Center in Sioux Falls, SD by two surgeons. Variables examined include patient age, gender, BMI, diagnosis, complications, EBL, length of surgery, length of hospital stay, lymph node harvest, and resection margins.

Results:

Patient characteristics: 12 patients (5 female, 7 male)

Mean age: 60.6 years

Average BMI: 30.8

30- & 90-day mortality: 0 %

Average lymph node harvest for oncologic resection: 19.5 nodes

Positive margin on final pathology: 1/12

Complication rate: 3 out of 12 (25%; 2 pancreatic leaks, 1 pseudoaneurysm)

Conversion to open operation rate: 2 out of 12 (17%)

Average EBL: 223 mL

Mean length of surgery: 9 hours

Mean length of hospital stay: 5.8 days

Conclusions:

Robotic pancreaticoduodenectomy is feasible in a community setting with acceptable outcomes.

Adenotonsillectomy Significantly and Persistently Modifies Gut Microbial Taxonomy and Function in Children with Obstructive Sleep Apnea

Li-Ang Lee, MD, MSc, PhD, Professor, Department of Otorhinolaryngology - Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan

Purpose:

Obstructive sleep apnea (OSA) is associated with gut dysbiosis. The impact of adenotonsillectomy, the primary treatment for childhood OSA, on the relationship between disease severity and the gut microbiome in affected children is yet to be fully understood.

Methods:

In this prospective observational study, we enrolled 55 children diagnosed with OSA. They underwent standard in-lab polysomnographies and stool microbiome analyses to identify the OSA-associated gut microbiome alterations and to document any post-operative changes in both the polysomnographic metrics and gut microbiome.

Results:

Following adenotonsillectomy, the apnea-hypopnea index (AHI) and other polysomnographic parameters exhibited significant improvement at both 3- and 12-months post-surgery. Baseline α- and β-diversity metrics remained consistent across different OSA severity levels. AHI was found to negatively correlate with Lachnospiraceae NK4A136 group, Ruminococcaceae UCG-002, Ruminococcaceae UCG-014, Alloprevotella, Christensenellaceae R-7 group, and Ruminococcaceae UCG-005. Postoperative changes in the α- and β-diversities of the gut microbiota and certain predictive functional pathways were evident. Notably, AHI level changes positively correlated with the Chao 1 index, observed species, and specific bacterial taxa (Enterobacter, Parasutterella, Akkermansia, Roseburia), while exhibiting negative correlations with the Simpson index, several bacterial taxa (Fusicatenibacter, Bifidobacterium, UBA1819, Ruminococcus gnavus group), and functional pathways (purine metabolism, transcription, type II diabetes mellitus).

Conclusion:

Our results shed light on the transformative influence of adenotonsillectomy on the gut microbiome of pediatric OSA patients. Acknowledging the potential detrimental effects of gut dysbiosis in OSA, along with the therapeutic efficacy of interventions such as adenotonsillectomy, emphasizes the need for sustained research in this arena.

Surgeons Shaping Global Surgery Policy

Katayoun Madani, MS, MD, MD Anderson Fellow in Global Surgery Policy and Advocacy, Baylor College of Medicine Michael E Dubakey Department of Surgery and Baker Institute for Public Policy , Rice University, Houston, TX; Past President of InciSioN, Sin Trudin, Belgium, Paradise Valley, AZ

Efforts in improving access to surgical health care in lower resource communities can be traced back to the 1600s. First recognized advocacy effort on a global scale to draw attention to disparities in access to surgical care, was the address by then Director General of the World Health Organization Dr. Mahler at the Congress of the International College of Surgeons in 1980. Yet, the first global policy focused on access to surgical care; the World Health Assembly resolution 68.15 was passed in 2015. The history of evolution of the field of global surgery shows a significant expansion over the last decade. During this time the role of surgeons as advocates and their involvement in policy development has also evolved.

Infrastructure development and building surgical healthcare systems requires funding and resources that are only driven by policy. Policy is only developed when an issue is brought to the attention of the policy makers and made a priority on their agenda. To create such political will advocacy is crucial. By virtue of their leadership role in surgical care delivery, surgeons have a unique vantage point to the needs of a surgical healthcare system and neglected surgical patients. Historically surgeons have taken the matter into their own hands by forming non governmental organizations, partnering with existing organizations and communities and carrying out missions. While missions can be very impactful and assist in building capacity over time, infrastructure building on national scale needs further resources.

The success and future of global surgery necessitates interested surgeons to have an understanding of tools of advocacy and language of policy. Here we share a historical perspective and current landscape of available educational opportunities and gaps in resources and training for future surgeon advocates and policy specialists.

InciSioN's Role in Global Education and Mentorship of the Future of the Operating Room

Katayoun Madani, MS, MD, MD Anderson Fellow in Global Surgery Policy and Advocacy, Baylor College of Medicine Michael E DeBakey Department of Surgery and Baker Institute for Public Policy, Rice University, Houston, TX;

Past President of InciSioN, Sin Trudin, Belgium, Paradise Valley, AZ

Over the past decade there has been a significant rise in interest in global surgery amongst students and trainees around the world. The International Student Surgical Network known as InciSioN is a trainee lead organization spanning over 50 countries. Since its inception in 2015 InciSioN has not only taken an active role in the global surgery community but also has served as a medium of education and development for future global surgery leaders. From internal capacity building workshops, to COVID webinar series, research mentorship and education programs to landmark sessions in ethics, and advocacy, InciSioN leadership has continuously created educational content for their members and public at large. The impact of InciSioN programs and culture of peer mentorship is visible across research publications, advocacy campaigns and professional strides taken by InciSioN alumni.

InciSioN, the ICS US section, and the Association of Academic Global Surgery have together embarked on a novel mentorship program in global surgery. Through this program we are bringing together decades of experience in global surgery to mentor passionate students and trainees. The program focuses on individual goals and aspirations of mentees, and provides a tangible tracking system for outcomes. Here we present both the efforts of InciSioN in educating and developing the future generation as well as the plan and progress of the novel mentorship program we are collaborating on. We hope to highlight the spirited efforts of trainees, and to invite all to participate in our collaborative mentorship program.

Correlation of IL-6 And C-Reactive Protein Levels with the Stage, Differentiation and Types of Colorectal Cancer - A Cross- Sectional Study

Mohamed Shafi Mahboon Ali, MD, Advanced Medical and Dental Institute, Georgetown, Malaysia

PURPOSE

Interleukin-6(IL-6) and CRP have been involved in anti-inflammatory reactions and autoimmune diseases. Interleukin is known for enabling cancer growth and is essential for tumour-directed immune response. CRP modulates inflammatory responses and stimulates platelet and leukocyte responses associated with acute phase responses to tumour growth. Its accumulation in blood is associated with a low-level inflammatory response and is indicative of advancing disease, as occurs in cancer

METHODS

This is a prospective cohort study conducted at the Advanced Medical and Dental Institute(AMDI). 46 patients with newly diagnosed colorectal cancer (CRC) were recruited. The sample size was derived from 2.0 Arifin (2017).5cc of the patient’s venous blood sample was taken and centrifuged for 5 minutes at 4500RPM in the lab. The serum was extracted and divided into two aliquots. One aliquot for the CRP while another for the IL6.CRP values were read using Quick Read Go CRP while IL6 levels were read using Elisa. Data were analysed using IBS SPSS 26. A p-value of < 0.05 was considered statistically significant

RESULTS

Data obtained were expressed as mean and standard deviation (SD) for numerical variables and frequency (n) with percentage (%) for the categorical variables. The mean value for IL-6 was 132.59pg/ml while CEA was 214.04ng/ml and most of the subjects have rectal cancer compared to colon cancer at stage 4. There was a significant correlation between IL-6 and the CRP. The highest median value of CRP was found in the well-differentiated cancer group with a median of 96.00 and an Interquartile (IQR) range of 89.00

CONCLUSIONS

Most of the subjects were diagnosed with stage 4 colorectal cancer and the level of IL-6 increases as the stage increases. There was a significant correlation between IL-6 and the mean value of CRP. Thus, CRP and IL-6 values can be used as a tool to screen for early colon cancer

Global Surgery: Specialty Evolution and the Future of Collaboration

Zoe Maher, MD, Associate Professor of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA

The presentation covers the history of global surgery as a specialty, the evolution of the specialty as it relates to globalization and virtual learning, and the current pathways by which faculty integrate global surgery into practice. It is relevant because in order to achieve equity in healthcare globally, addressing the specific challenges and opportunities in global surgery will be key. The learner should be able to

Describe:

1. Global Surgical Care as Part of Global Health Agenda

2. Advancements in Global Surgery Partnerships for Training

3. Integration of Global Surgery in Surgical Practice

Disparity in cost spent on vasectomies and tubectomies done in public health centers in India in 2019-20.

Sharvari Mande, MBBS, Medical Student, Rajarshee Chhatrapati Shahu Maharaj Government Medical College, Kolhapur.

Intern, Association for Socially Applicable Research, Pune, India., Pune, India

The Indian government has consistently demonstrated a strong political will for family planning. However, the burden of family planning in the country has been disproportionately higher on females as opposed to males. The extent of gender-based disparity in family planning roles is such that female sterilizations continues to be the most common method of contraception in India. Our primary aim was to quantify the differences in uptake and cost spent on tubectomies and vasectomies in India. We have also estimated the financial benefit of scaling up the vasectomies to match the tubectomy rate in India.

A retrospective analysis was conducted on data on the total number of tubectomies and vasectomies performed, and failure and mortality counts due to these procedures obtained from the Health Management Information System (HMIS), 2019-20. The male and female sterilization rates, calculated as the number of sterilizations per 10,000 men and women of reproductive age (RA) group (15-49 years), respectively, and female-to-male ratios were used to assess gender-based disparities in sterilization uptake. State-specific costs of tubectomy, vasectomy, and compensations for the failure and death due to procedures in public health facilities were extracted using government data and research studies. The state-wise costs for tubectomies and vasectomies were calculated by adding the amount spent on procedures and compensations. To estimate the cost-benefit of scaling up vasectomies, the cost of increasing the rate of vasectomy to 50% of the total sterilization rate was calculated. The failure rates, death rates, and percentage of laparoscopy and open sterilization procedures were assumed to be constant in order to calculate the revised numbers of vasectomies, tubectomies, and associated complications. Costs were written after conversion and adjusting inflation to USD.

HMIS reported 3,452,780 surgical sterilizations in 2019-20. The national female and male sterilization rates were 9.0 and 1.3, respectively with the national female-to-male sterilization ratio of 61.5. The cost per tubectomy procedure was 3.5 times that of vasectomy ($89.06 vs. $25.28). The total national cost spent on surgical sterilization ranged from $315,066,920 to $321,735,148, out of which 99.2–99.4% was spent on tubectomies. The cost spent on compensation for the failure of tubectomies was 38 times that of vasectomy failure ($1396982.11 vs. $37023.84). The cost spent on compensations for the death due to tubectomies ranged from $29899 - $119596 while due to vasectomies was $1272 - $ 5089. Thus spending on death compensations due to tubectomies was about 23 times that of vasectomies. A range of $2,728,736- $24,369,595 will be saved if the vasectomy rate was increased to match the tubectomy rate in India while keeping the total sterilization rate constant. It will also result in a reduction in total deaths by 62.4%. There is estimated to be a rise in total failures by 42%.

The uptake of tubectomy is higher than vasectomy in India even after the cost-effectiveness of vasectomy. Our calculation shows that there will be a cost reduction if we scale up vasectomies, as well as a reduction in deaths following sterilization. Further studies investigating the causes of gender-based disparities in surgical sterilization and advocating solutions to minimize these disparities are strongly called for.

Endplate Technology: The Future of Fusion?

John Mangan, MD, Spine Surgeon, Rothman Orthopaedics, Assistant Professor of Orthopaedic Surgery at Thomas Jefferson University Hospital, Glen Mills, PA

Review of new implant technology as it relates to spinal fusion. Advancement in these technologies may greatly impact our ability to achieve fusion.

Chronical Anticoagulant Therapy and its Impact on Surgery

Jiri Matyas, MD, Head of ICU, Surgery Clinic, General Hospital, Pardubice, Czech Republic, Pardubice, Czech Republic

There is an increasing number of people using anticoagulant therapy in the population and many of them have to undergo surgery. Surgeons often find themselves in difficult situations - to decide on discontinuation of this treatment and whether or not to administer antidotes. The situation is especially difficult when the operation is acute or even urgent.

We were studying the occurrence of bleeding complications in patients taking long-term anticoagulant therapy and also we were monitoring the occurrence of thromboembolic complications after their withdrawal or after administration of antidots.

One group consisted of patients undergoing planned (elective) surgery and the second of patients undergoing acute and emergency surgery

We develop specific recommendations for individual situations in elective and acute surgery. These recommendations are specified both according to the urgency of the operation and according to the type of anticoagulant drug used. These recommendations are in line with the recommendations of the professional societies of hematology, surgery, and intensive care.

This lecture is very useful for all surgeons - general, abdominal, endosurgery, and also traumatologists, neurosurgeons, and intensivists

Conditioned Recurrence-Free Survival Following Gross Total Resection of Non-Functioning Pituitary Adenoma

Jesse McClure, MD, PhD, General Surgery Intern, Florida Atlantic University, Boca Raton, FL

Neurosurgeons often remove pituitary tumors with clinical and radiologic evidence of gross total resection. However, non-functioning pituitary adenomas often recur even decades after resection. This presentation follows over 100 patients at a single center who had gross total resections of their non-functioning pituitary adenomas over a decade. The rate of and time to recurrence is analyzed. Risk factors for recurrence are studied and presented. The recommended length of time to follow a patient with regular MRI brain after gross total resection is discussed and demonstrated objectively. The audience can benefit from the presentation by now knowing that even patients with gross total resections of their non-functioning pituitary adenomas should be followed with imaging for at least 15 years, and likely for the rest of their lives. By the end of the presentation, the audience should also know that recurrences are rare, and when they do occur, they may be managed successfully with conservative therapy.

Objective: The authors sought to determine the time to recurrence after achieving a gross total resection of non-functioning pituitary adenomas in adult patients. The authors also sought to determine the rate of recurrence after increasing years of recurrence-free imaging.

Methods: The authors performed a retrospective chart review of all adult patients who underwent gross total resection of non-functioning pituitary adenomas between September 2004 and January 2018 by the senior surgeon. The primary outcome of the study was time to recurrence, defined by imaging and/or clinical criteria.

Results: The median follow-up time for the 148 patients meeting inclusion criteria was 91 months; 12 of these patients (8.1%) had a recurrence. Median time to recurrence was 80 months. The range of time for these recurrences was 36-156 months. The probability of remaining recurrence-free at 180 months post gross total resection of an NFPA with 12-, 36-, 60-, 84-, or 120-months of recurrence-free imaging was 0.82, 0.84, 0.86, 0.88, and 0.93, respectively. The year-over-year odds of a recurrence increased linearly by 1.07%. There was no difference in recurrence-free imaging when patients were stratified by Knosp grade or tumor subtype. None of the patients with recurrence underwent repeat resection. When identified, patients were managed either conservatively or with radiosurgery.

Conclusions: Increased intervals of recurrence-free imaging were not associated with a decrease in risk of recurrence which suggests that patients require life-long periodic imaging. If followed with periodic imaging, recurrences can be discovered before clinically symptomatic and successfully treated without repeat surgery.

Global Health Footprints: A US Resident Perspective

Olajumoke Megafu, MD, General Surgery Resident, University of Massachusetts, Worcester, MA

Description:

Explore the landscape of global health opportunities available to resident physicians, examining access, time commitment, financial support, and mentorship. Learn how to identify areas where you can both contribute and learn from global health initiatives, and understand the crucial role of dedicated faculty in supporting resident involvement.

Audience Relevance:

This presentation is essential for resident physicians interested in engaging with global health but facing uncertainties regarding access, time management, financial support, and mentorship. Understanding these factors is vital for making informed decisions and maximizing the impact of global health involvement. This presentation will also benefit programs that may currently offer global health opportunities or wish to provide for their residents in the future.

Learning Objectives:

1. Evaluate the accessibility of global health programs for resident physicians, including an overview of available opportunities.

2. Compare the time commitment required for engaging in global health, balancing research time with dedicated rotations.

3. Understand the importance of financial backing from programs to support residents participating in global health initiatives.

4. Identify areas where resident physicians can contribute to and learn from global health efforts, leveraging their skills and expertise.

5. Recognize the need for dedicated faculty in global health to mentor and support resident physicians in their involvement.

Benefits to the Audience:

Attendees will gain insights into the accessibility, time commitment, financial support, and mentorship available for resident physicians interested in global health. By understanding these factors and the role of dedicated faculty, physicians can navigate global health opportunities more effectively, maximizing their contributions and learning experiences in this growing field.

Beyond the Ice Age - Machine Perfusion of the Liver

Babak Movahedi, MD, PhD, Assistant Professor of Surgery, UMass Chan Medical School, Worcester, MA

Liver transplantation is the primary curative option for individuals with end-stage liver disease or specific liver malignancies. Unfortunately, due to the scarcity of suitable deceased donor organs thousands of patients die each year while waiting for a transplant. To address this issue, the transplant community has explored the use of marginal organs, such as livers from donors after circulatory death (DCD), livers with significant steatosis, etc. However, the use of these organs has been associated with risks like primary non-function, early graft dysfunction, and various biliary and other complications.

Recognizing the need for a reliable method to assess graft viability and function before transplantation and simultaneously resuscitate the organ to reduce the associated risks, there has been renewed interest in ex vivo perfusion of liver grafts. While static cold storage (SCS) was the standard (and the only) preservation method until recently, it has limitations drawbacks, including cellular energy depletion, cytosolic electrolyte alterations, and the accumulation of reactive oxygen species (ROS) contributing to ischemia-reperfusion injury.

A variety of approaches have been studied in animal models and clinical setting, but based on the temperature at which the organ is being preserved, two main strategies for machine perfusion have emerged: hypothermic machine perfusion (HMP) and normothermic machine perfusion (NMP). Hypothermic oxygenated perfusion (HOP) aims to restore mitochondrial energy stores and reduce ROS release by perfusing and oxygenating the organ at 4-8 °C. Clinical trials since 2010 have demonstrated that recipients of HMP grafts experience lower post-transplant liver function test abnormalities, reduced hyperkalemia, and fewer biliary complications.

In contrast, normothermic preservation mimics the physiological environment by perfusing the organ with a blood-based, oxygenated solution at body temperature. This approach allows for the study of different biomarkers to assess graft viability and function, enabling the selection of well-functioning organs and reducing the risk of post-transplant complications. NMP also allows for safe extension of organ preservation time, overcoming SCS limitations. Clinical trials using NMP have shown a decreased risk of post-reperfusion syndrome, early allograft dysfunction, and ischemic biliary complications.

Despite being in its early stages, machine perfusion holds promise for transforming liver transplantation. It offers expanded donor pool, safer transplants, improved logistics, and better outcomes. Machine perfusion is likely to replace SCS as the standard of care in liver transplantation.

C Sections in Resource-Limited Settings

Victoria Mui, MD, Assistant Professor in Obstetrics and Gynecology, Director of the Women's Global Health Fellowship,

University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA

The Lancet Report on Global Surgery identified Cesarean delivery as one of the three Bellweather Procedures, surgical procedures that should be provided at minimum by a functional health system. The ability to safely provide this surgery is has been shown to directly correlate with the strength of a first-level hospital in low- and middle- income countries to provide other broad services.

The ability to perform a Cesarean delivery also predicts the burden of disease of that population. Approximately 15% of pregnancies result in complications that require emergency obstetric care; however, the study estimates that 951 million women are without access to emergency OB care. In addition, only 2-5% of expected direct OB complications were actually treated due to lack of access.

Given that cesarean deliveries continue to be the most commonly performed surgery among women globally, peri-operative outcomes depend on the quality of care provided. 17% of women experience a complication from cesarean delivery, with high rates of iatrogenic injury identified.

This presentation will look at the current state of Cesarean deliveries, the quality of care, and the areas for improvement.

AOM will enhance utilization of MBS

Sharique Nazir, MD, Director of Bariatric/Robotic Surgery NYCHHH; Assistant Professor Columbia University, Irwing Medical Center, NY, Milltown, NJ

Perioperative complications following bariatric surgery (BS) have been poorly analysed and their management is not clearly assessed. The associated frequency of ICU admission is difficult to estimate. Among surgical complications, digestive perforations are the most frequent. The most common postoperative complications of sleeve gastrectomy are fistulas, but bleeding on the stapling line is also commonly reported. Complication rates are higher after Roux-en-Y gastric bypass, mainly due to anastomotic leaks. Medical complications are mainly thromboembolic or respiratory complications. All these surgical and medical complications are not easily detected; clinical signs can be atypical or insidious, often resulting in delayed management. Respiratory signs can be predominant and lead erroneously to pulmonary or thromboembolic diseases. Diagnostic criteria are based on minor clinical signs, tachycardia being probably the most frequent one. Lately, complications are revealed by haemodynamic instability, respiratory failure or renal dysfunction and radiographic findings. Management decision according to these abnormal signs is based on a combined multidisciplanary approach including surgical and/or endoscopic procedures and medical care, depending on the nature and severity of the surgical complication. Medical management is based on supportive ICU care of organ dysfunctions, curative anticoagulation if required, nutritional support, and appropriate anti-infective therapy. Pharmacological data are limited in morbidly obese patients and the appropriate doses are debated, especially for anti-infective agents. Complicated BS cases have a poor outcome, probably largely related to delayed diagnosis and reoperation.

Being Part of the Solution

Patricia J. Numann, MD, Lloyd S. Rogers Professor of Surgery Emerita, SUNY Health Science Center, Syracuse, NY

Lecture will discuss the role ICS and individuals can play in increasing access to surgical care in low resource areas. The provision of specialty care will be considered. The role of new technology will be discussed.

Learning objectives:

· Assess current programs to increase access to surgical care

· Design programs to deliver specialty care

· Develop a long term organizational and person plan for involvement

Creating a Sustainable Global Surgery Program

Ikenna Okereke, MD, Vice Chairman, Department of Surgery, System Director, Thoracic Surgery, Professor of Surgery, Michigan State University, Henry Ford Health System, Detroit, MI

Global surgery ventures are impactful for several reasons, including a need for basic and complex surgical services in underserved communities across the world. Many surgery groups who perform these trips do so for a maximum of 1-2 weeks per year. While valuable, the local communities are left without services for the bulk of the year. Our team has coordinated efforts to have surgery services available for most of the year. We will detail our efforts in establishing an ongoing and sustained surgery service in an underserved community.

Artificial Intelligence in Surgery: Ensuring the Promise and Managing the Risks

Rocco Orlando, MD, Senior Vice President and Chief Academic Officer, Hartford Health Care; Professor of Surgery, University of Connecticut, Hartford, CT

Artificial Intelligence has exploded in medicine and public awareness during the past two years. Despite the new attention, AI has been in use in health care for at least 10 years. AI is rapidly becoming ubiquitous in medicine - supporting finance, clinical operations, imaging and most recently patient facing interactions. All AI is not created equal - and different types of AI come with different risks. This discussion will review the different types of AI and how they are relevant to surgical practice now and in the future. The risks and promise of natural language processing and large language models (Chat GPT and its relatives) will be explored along with the emerging regulatory climate for healthcare AI. Finally, the discussion will make recommendations about how introduce AI into clinical practices safely and thoughtfully.

Medical Tourism is good for patients and is here to stay

Rodolfo Oviedo, MD, Professor of Surgery, University of Houston Tilman J. Fertitta Family College of Medicine; Professor of Surgery, Sam Houston State University College of Osteopathic Medicine; Medical Director, Nacogdoches Center for Metabolic & Weight Loss Surgery, Nacogdoches, TX

The panel discussion will cover important topics on global metabolic and bariatric surgery including medical tourism. It will be relevant to participants from around the world who dedicate themselves to care for patients who suffer from severe obesitiy and associated diseases.

Efficacy of Intravenous Tranexamic Acid in Reducing Perioperative Hemorrhage and Transfusion in Complex Spinal Fusions: Insights from a Standardized Inverse Probability Weighted Analysis

Ali Ozturk, MD, Professor of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

This presentation addresses the application of intravenous tranexamic acid (TXA) in multi-level thoracolumbosacral posterior spinal fusion (PSF), a complex and high-risk surgical intervention. As adult spinal deformity (ASD) surgeries increase, optimizing perioperative outcomes, including minimizing blood loss and transfusion requirements, is paramount.

Surgeons, anesthesiologists, and perioperative care teams must be informed about interventions that can improve surgical outcomes and patient safety. Understanding the role of TXA in spinal surgery is essential for enhancing patient care protocols and optimizing resource utilization in complex spinal procedures.

Attendees will learn to: 1) Assess the impact of TXA on blood loss and transfusion needs in PSF.

2) Interpret the significance of standardized inverse probability weighting in evaluating perioperative interventions.

Healthcare professionals will benefit from evidence-based insights into TXA's role in reducing perioperative complications, which can lead to the adoption of improved protocols for managing patients undergoing PSF for ASD.

Experience in Percutaneous Surgery in Paraguay

Guido Parquet, MD, Professor of Surgery and Anatomy, School of Medical Sciences, National University of Asuncion; Chief Service of Minimally Invasive Surgery, Institute of Social Welfare, Paraguay, Asuncion, Paraguay

Percutaneous Surgery is a type of minimally invasive surgery which through minimal incisions and guided by radiological images performs different types of diagnostic or therapeutical procedures. it is also known as Interventional Radiology and in various countries of the world it is performed by radiologists. In Paraguay a group of surgeons started to do these procedures in several institutions. Our group has been doing this for more than 15 years. In this presentation we show our numbers and results. We discuss all the advantages we found as surgeons in performing ourselves these procedures. We even think these procedures should be included in the surgery residence program.

Percutaneous Management of Complicated Severe Acute Pancreatitis

Guido Parquet, MD, Professor of Surgery and Anatomy, School of Medical Sciences, National University of Asuncion; Chief Service of Minimally Invasive Surgery, Institute of Social Welfare, Paraguay, Asuncion, Paraguay

Complication of the acute severe pancreatitis is mainly infectious. When this occurs mortality increases a lot. Mayor surgery has high mobimortality. Minimally invasive techniques have been used recently to treat these patients with less morbidity and mortality reported. Our group adopted a protocol proposed by tthe Neatherlands Pancreas study group, the Step-Up approach. In this presentation we show the epidemiology, technique used and the results we had using this protocol. Our results strongly suggest that this management strategy should be used to treat these patients.

Postoperative albumin drop as a predictor for clinical outcome in emergency surgery

Nabin Paudyal, MD, General Surgery Resident, Kathmandu University, Nobel Medical College Teaching Hospital, Biratnagar., Biratnagar, Nepal

Surgical procedures elicit stress responses in the body, impacting postoperative recovery. Monitoring early postoperative changes aids in anticipating and mitigating complications. Albumin, vital for fluid balance and wound healing, becomes crucial. Post-surgery albumin level shifts can forecast complications, aiding surgeons in proactive recovery management. This research aimed to scrutinize postoperative serum albumin level changes post-emergency surgery. Specific goals were two-fold: 1) Assess if post-surgery albumin drop could predict overall outcomes in emergency surgery patients, and 2) Explore postoperative albumin levels' potential as a predictor for adverse outcomes in emergency surgery.

A prospective study was carried out at the Department of General and Laparoscopic Surgery at Nobel Medical College Teaching Hospital. Ethical clearance was done before conducting the study with IRC reference number: 484/2021. Using pre-set inclusion and exclusion criteria, data collection was done. Demographic variables were noted. Factors affecting the postoperative outcomes (diagnosis at the time of presentation, duration of surgery, peri-operative blood loss, presence of comorbidities) were noted. Pre-operative and postoperative serum albumin levels were noted. Postoperative albumin was measured at four-six hours following surgery, the first postoperative day, the third postoperative day, and the fifth postoperative day. The trend of serum albumin change pre-operatively and postoperatively was noted. Change in the level of albumin was correlated against postoperative complications using Clavien-Dindo grading. Logistic regression analysis was done to identify the correlation. ROC was constructed to predict the usefulness of albumin in determining postoperative complications.

Involving 84 patients, primarily within the 15-30 age range, with a mean age of 41.57±18.01 years and a male-to-female ratio of 2.65:1, this study examined postoperative changes. Most patients displayed normal BMI, and the key reason for ER visits was non-traumatic hollow viscus perforation requiring urgent laparotomy. Complications occurred in 41.667%, notably Grade I Clavien-Dindo complications due to surgical site infections. Mortality was 7.14%, primarily from hollow viscus perforation. Pre-op albumin averaged 3.576±0.633 g/dL, unrelated to complications or hospital stay duration. Significant correlations appeared between post-op albumin drop and complications on days 1, 3, and 5, strongest on day 1. Albumin drop also linked to longer hospital stays. Logistic regression tied day 1 albumin drop to a 38.24% increased risk of complications with a 10g/L drop, while ROC analysis showed albumin's acceptable predictive value. Age predicted adverse outcomes and no strong links existed between adverse outcomes and comorbidities, blood loss, or surgery duration.

This study investigated using serum albumin as a predictor of postoperative complications and prolonged hospital stay after emergency surgery. The degree of albumin decrease after surgery showed stronger predictive value than preoperative levels. The rapid decline in albumin levels reflected the stress response to surgery. Monitoring early postoperative albumin changes could aid in predicting adverse outcomes and guide early intervention for better patient care. Serum albumin shows promise as a practical and reliable marker for predicting clinical outcomes following emergency surgery.

Surgical Management of Ectopic Pregnancy

Analeta Peterson, MD, Calvert Health Medical Center, Baltimore, MD

This presentation will review the prevalence, risk factors, and different types of ectopic pregnancy. Diagnostic testing including imaging and lab testing will be reviewed. Finally, minimally invasive and traditional surgical interventions will be reviewed.

The audience needs to know this information because this condition is a medical emergency and can be easily misdiagnosed. It also contributes to maternal mortality. This presentation is beneficial as it will review some rare forms of ectopic pregnancy and explain how to proceed with the diagnosis is not clear.

Chatbot Use in Thoracic Surgery Clinical Scenarios

Joseph Platz, MD, Assistant Professor of Thoracic Surgery, Saint Louis University, St. Louis, MO

Chatbot use in medicine is growing and concerns have been raised as to accuracy and reliability. Reports have suggested effectiveness as a tool when dealing with simplistic medical question but there is less information regarding chatbot use with complex clinical decision making, as might be used by a physician. We assessed the performance of four common chat bots in management of thoracic surgery clinical scenarios over three separate runs.

Spondylodiscitis: Delayed Diagnosis and the Role of Obesity

Pavel Poczos, MD, PhD, Assistant Professor, Charles University, Department of Neurosurgery, University Hospital Hradec Kralove; Assistant Professor, Charles University, Department of Anatomy, Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic

Purpose: The indolent nature of spondylodiscitis often leads to its delayed diagnosis, which is based on clinical, radiological, laboratory, and microbiological findings. The prognosis of spondylodiscitis without accompanying neurological deficits is good if adequate therapy is initiated promptly. The aim of the study was to point out the main risk factors, the presence of frequent delay in diagnosis and the role of early recognition of typical initial clinical signs of spondylodiscitis.

Methods: A retrospective study was conducted at the Department of Neurosurgery of the University Hospital, Hradec Králové, in which 94 spondylodiscitis cases were identified. The clinical presentation, the risk factors, the results of etiologic and radiological methods of diagnosis, the delayed diagnosis and the treatment approaches were analyzed. Concerning the obesity/overweight patients were divided into two groups with BMI less respectively more then 25 kg/m2.

Results: Over a period of 6 years, 94 patients fulfilled the inclusion criteria of the study. The median age of the entire cohort, comprising 35 women and 59 men, was 66 years with an interquartile range (IQR) of 61.25 to 72 years. Regarding the delay, between the first sign (subjective or objective) and diagnosis, we identified an average of 22.7 days (median of 7 days, IQR of 7 to 28 days), with back pain being the predominant symptom. The median BMI was 29.55 kg/m2 (IQR of 25.78 to 34.75 kg/m2) and 73 patients (77.66%) have a BMI more than 25 kg/m2. Overall, 81 patients (86.17%) had an etiologic diagnosis. Staphylococcus aureus was the most common pathogen, in 52 patients (p=0.129). Blood cultures were positive in 35 (67.31%) from 52 patients, where this examination was performed. 20 patients underwent a computed tomography (CT)–guided biopsy (positive in 15 patients [75%]). 76 patients underwent a surgical procedure with positive cultivation in 82.89%. In 78 cases (82.97%), the MRI confirmed the graphical presence of spondylodiscitis. Spinal stabilization (early or delayed) was indicated in 28 patients (75% was performed in patients with BMI>25 kg/m2).

Conclusions: Spondylodiscitis often escapes from an early diagnosis. Obesity seems to be one the most important risk factors for the development of spondylodiscitis. It has also an impact to the level (localization) of the infection, the presence of paravertebral or spinal epidural abscess, and mechanical stability of the spine. The microbial species should always be identified. Molecular biological investigations (polymerase chain reaction [PCR]) can be used to further identify the pathogen in the case of negative cultures. Sooner the diagnosis is done, quicker adequate treatment may be implemented.

Deformity Correction in the Hand. Simple to complex. A case based presentation

Sudhir Rao, MD, Orthopaedic Surgeon, Big Rapids, MI

A deformity in the hand can be mild to severe and affect hand function in a varying manner. Successful correction of deformity and restoration of function may require simple or complex procedures. This presentation will illustrate numerous techniques in a case based approach

Temporary Colostomy an Outmoded procedure? Primary Resection and Anastomosis for Complicated Colonic Diverticulitis: A 25yrs Experience.

Biagio Ravo, MD, Prof. Inc Digestive Surgery Universita Campus Biomedico Rome Italy, Past Director Trauma Service Winthrop University Hospital NY, ICS European Federation Secretary, Roma, Italy

Stoma formation and stoma reversal procedure have high complication rates. Two stage procedure with/without colostomy, laparoscopic lavage or peritoneal drainage are still used for local or generalized purulent or fecal peritonitis secondary to perforated diverticulitis.

A 25yrs review was undertaken to evaluate the feasibility and safety of single stage Primary Resection and Anastomosis( PRA) for complicated diverticulitis in 148 patients with or without Ravo intracolonic bypass (RIB ).The age ranged from 34-89yrs (mean, 67 years), with 88 males and 60 females. The severity of acute divertic ulitis in 129 patients was classified according to the Hinchey classification(Hs), and 19 patients had obstruction and fistulae.. with or without Ravo intracolonic bypass (RIB )

RESULTS: 148 pts treated: 122(82%) had PRA with RIB (Hs2-52,Hs3-44,Hs4-14,obstruction 8, fistula 4), 24(16%) PRA without RIB (Hs2-17,fistulae7), 2(1.3%) PR, and Hartman (Hs4-2). Mortality: Two patients (1.3%) one had anastomotic leakage secondary to an ischemic colon and one had a myocardial infarction. Morbidity: 43 (29%): anastomotic leakage, 1 (0.06%); pulmonary infection, 18(12%); wound infection, 15 (10%); myocardial infarction, 2 (1.3%); right colon perforation 1(0,01%); peritoneal hemorrhage 1 (0,01%); head and back decubitus, 2 (1.3%); and incisional hernia 3 (0,02%). The postoperative Hospital stay was 8-32days; the tubes passed spontaneously between 2-3 weeks

CONCLUSIONS: The review of the literature and present data confirms that the one-stage procedure with RIB can prevent anastomotic leakage in perforated diverticulitis and eliminate all the morbidity and cost associated with colostomy formation, it is safe and effective, and the mortality and morbidity are comparable to those of a multicenter randomized trial treating diverticulitis with /without primary anastomosis reported in the literature.

Management of Soft Tissue Edema in the Lower Extremity using Complete Circumferential Closed Incision Negative Pressure Wound Therapy: A Case report

Omer Sadeh, MD, General Surgery Resident, Florida Atlantic University, Boca Raton, FL, Panama City Beach, FL

Extremity soft tissue edema resulting post-injury or postoperatively can lead to a significant delay in wound healing and subsequent complications that can result in a variable and extended course. We present the successful application of circumferential negative pressure wound therapy (NPWT) over the closed incision and soft tissue to manage severe lower extremity edema following orthopedic surgery without compromising distal extremity perfusion.

52-year-old male status post open reduction internal fixation (ORIF) of closed tibial plateau fracture of the left lower extremity resulting from a motorcycle accident. Postoperative (POD) dressing used initially was a standard splint with soft cotton wrap (Jones bandage). POD7 surgical dressing was removed, and extensive edema was noted in the lower extremity. Circumferential NPWT was applied from mid-thigh to ankle at -125mHg with periodic distal circulatory status monitoring to ensure uncompromised perfusion.

NPWT was removed POD12 and circumferential measurements of the lower extremity at the thigh and calf were compared between prior to circumferential NPWT application (POD 7) and removal (POD 12). Calf circumference decreased 4cm and thigh decreased 4 cm post removal of circumferential NPWT. Within one week of discontinuing NPWT, the left lower extremity edema had subsided and maintained similar dimensions to the uninjured right leg.

Use of incisional negative pressure therapy is a simple and noninvasive tool for controlling soft tissue edema following surgery. This method can facilitate edema resolution and diminish high rates of wound complications in the lower extremity. There were no apparent disruption of normal perfusion to the distal aspect of the leg when applied circumferentially, and there were no postoperative complications.

Pancreas After Kidney Transplantation Outcomes Over the Past 20 Years in the USA

Reza Saidi, MD, Associate Professor of Surgery, Chief of Transplantation, Director Kidney Transplant Program; Surgical Director of Kidney Transplantation, Division of Transplant Services, Department of Surgery, SUNY Upstate Medical University, Syracuse, NY

The number of pancreas transplants performed each year has been variable since 1988 when the Organ Procurement Transplant Network (OPTN)/Scientific Registry of Transplant Recipients (SRTR) began tracking transplant data. The most recent OPTN/SRTR data shows a 9.1% increase in pancreas after kidney (PAK) transplants.

We performed a retrospective registry analysis utilizing the OPTN/UNOS database for pancreas transplants after kidney transplants performed in the United States from January 2001 to December 2020 to assess transplant outcomes. The data was collected directly from the de-identified information contained within the database. Pancreas transplants without outcomes data were excluded.

3706 allograft recipients were included in the study. 2892 (78 %) transplants were done from 2001 to the end of 2010. 814 (22%) transplants were done from 2011 to the end of 2020. Although the BMI and recipient sex comparison shows a statistically significant difference, the differences are not clinically significant. The overall 5-year allograft survival rate was 55.95% in the 2001-2010 group, which significantly increased to 63.67% in the 2011-2020 group (P=0.001). The allograft survival difference increased significantly after 10 years of follow-up (39.58% vs. 51.41%, P<0.001). The overall 5-year patient survival rate was 83.12% in the 2001-2010 group, which increased to 84.88% in the pancreas after kidney transplants from 2011-2020 (P=0.41). The 10-year patient survival rate was 61.37% in the 2001-2010 group, and 67.76% in the 2011-2020 group (P=0.14)

With all the progress in terms of surgical techniques, organ allocation and preservation, and immunosuppressive regimens, the pancreas after kidney transplant allograft survival has been improving over the years. However, PAK utilization has decreased despite significant survival improvements over the years. Therefore, PAK is a great considerable option of choice for uremic recipients with diabetes.

Keynote Lecture: International Medicine Initiatives - A New Opportunity for Your Institution?

Harry Sax, MD, Professor and Executive Vice Chair, Department of Surgery, Associate Dean for International Programs, Cedars-Sinai Medical Center, Los Angeles, CA

Surgeons have traditionally viewed international programs with a focus of travel to underserved environments. Although this is an important part of our lives as physicians, there are other opportunities that can benefit both the physician and their institution. This lecture will discuss the multiple aspects of an Internation Medicine service line at a large Academic Medical Center. This includes recruitment of international patients to be treated at the home institution, development of multisite research protocols, resident and faculty exchanges, and hospital management consulting abroad.

Technology in Surgery: A Global Endeavor in Vascular Surgery

Andres Schanzer, MD, Cutler Distinguished Chair and Professor, Division of Vascular Surgery;

Director, UMass Memorial Center for Complex Aortic Disease;

Director, UMass Memorial Heart and Vascular Center; University of Massachusetts Medical School, Southborough, MA

Advances in fenestrated branched endovascular aneurysm repair

Developing a Medical Legal Neurosurgical and Spine Practice

Nirav Shah, MD, Medical Director,

Princeton Brain, Spine, and Sports Medicine, Lane, PA

Developing and maintaining a medical legal practice with both plaintiff and defense expert work, patient care. The goal will be to educate on navigating the medical legal system, developing a back office operations, discussing marketing strategies, writing reports and scaling the practice.

Spontaneous fistulization of a giant pancreatic pseudocyst into the duodenum following acute pancreatitis

Bikash Kumar Shah, MBBS, Medical Student, Maharajgunj Medical Campus, Kathmandu, Nepal, Kathmandu, Nepal

Introduction:

A pancreatic pseudocyst is defined as a fluid collection that is more than 3 weeks old and is surrounded by a fibrous wall, as per the Atlanta Symposium. Pseudocysts are thought to arise secondary to insults to pancreatic ducts either due to pancreatitis or some other trauma. The incidence of these pseudocysts in adults is 0.5–1/100.000 per year, but it rises in those with acute or chronic pancreatitis, and the incidence has been rising because of the newer imaging techniques. Despite the risk of malignancy being greater in symptomatic cysts, up to 47% of the incidental cysts can be malignant or premalignant. Pancreatic pseudocysts account for 15% to 30% of these cysts, which can appear as single or multiple lesions and present with a variety of clinical symptoms based on the major diameter, pancreatic pseudocysts are classified into four sizes in the literature: small (2 cm), medium (>6 cm), large (>6 cm), and giant ones (>10 cm).

USG, computed tomography (CT) scan, or magnetic resonance imaging(MRI) are the imaging techniques employed to diagnose the condition. To start with transabdominal ultrasonography should be done and a high-sensitivity diagnostic high-resolution endoscopic ultrasound (EUS) with the potential to detect cystic lesions even less than 2 cm, can be opted for.

Depending on where it drains, a pancreatic pseudocyst fistula must be managed. If it drains into the duodenum or colon, surgery might be necessary. Surgical intervention or endoscopic clipping of bleeding vessels are both options for controlling active bleeding. An alternative intervention in cases of bleeding is endoscopic embolization which is guided by radiological or ultrasound technology.

Case Presentation:

A 40-year male, with a history of alcohol consumption, was admitted to our hospital with a one-month-long history of abdominal pain. He was diagnosed with acute pancreatitis then and managed conservatively. He was discharged and advised for a follow-up after 6 weeks. In the meantime, he left consuming alcohol and switched to a normal diet. However, after just 4 weeks, he experienced upper abdominal discomfort followed by, epigastric fullness, abdominal discomfort, early satiety, nausea, and on-and-off vomiting, and came back to the hospital immediately. On admission, his vitals were stable. On examination, there was a cystic swelling over the epigastric region around 7 cm × 5 cm with mild tenderness. The rest of the physical and systemic examination was unremarkable. Hemoglobin was 13 g/dL (normal range, 12-16 g/dL), serum amylase level was 339 U/L; lipase, 415 U/L and other laboratory parameters have been shown in the Table 1. On admission, USG revealed a large cystic lesion at the region of the pancreas compressing the nearby structure, and computed tomography (CT) of the abdomen (Figure 1) revealed a giant pancreatic pseudocyst measuring 22 cm × 12 cm arising from the body compressing the stomach upward and duodenum laterally. The patient was hemodynamically stable and with no complications, so it was managed conservatively.

After 5 days, he had multiple episodes of severe abdominal pain followed by dark coffee-colored vomiting. Repeat CT showed a decreased size of pseudocyst and suggested a pancreatic pseudocyst with a spontaneous cystoduodenal fistula (Figure 1C). UGI endoscopy showed a pancreatic pseudocyst producing compression in duodenum upward with the leakage of pancreatic juice in the duodenal lumen (Figure 2). Because the patient was hemodynamically stable again, he was conservatively managed. After a period of 6 weeks, a followup CT revealed a completely resolved pseudocyst and no surgery was indicated.

Discussion:

Pancreatic pseudocysts are histopathologically distinct from true cysts as they have a fibrous-granulomatous wall as opposed to an epithelial lining. They are further subdivided into four types by the Atlanta classification system: acute fluid collection, acute pseudocysts, chronic pseudocysts, and pancreatic abscess. The majority of pancreatic pseudocysts are asymptomatic, but can occasionally present with pain abdomen, weight loss, early satiety due to gastric outlet and intestinal obstruction, or jaundice due to biliary obstruction considering the mass effect. Fistulization is known to occur in less than 3% of the pseudocysts and the biliary tract, stomach, duodenum, renal collecting system, colon, and bronchial tree might all be affected by the spontaneous rupture pancreatic pseudocyst.

Only 5% of pancreatic pseudocysts are complicated by hemorrhage, but this condition has a 40% mortality rate. Diagnosis is established on the basis of imaging showing an intra- or peri-pancreatic fluid collection in a background of chronic pancreatitis or in a patient recovered from acute pancreatitis. Since the cyst is clearly defined, homogenous, and devoid of calcifications and mural nodules, pancreatic cystic neoplasms can be ruled out as the cause based on the results of the CT imaging .

It is extremely uncommon to have a pancreatic pseudocyst of this size, as was the case in this patient. It may be uncommon to have a pancreaticoduodenal fistula large enough to be seen on CT scans, but in this patient, a ruptured pseudocyst with an air bubble on a repeat CT scan indicates a pancreaticoduodenal fistula. Moreover, this patient presents an unusual way of pancreatic pseudocyst resolution via internal fistulization into the duodenum, which occluded spontaneously without a surgical indication, making this a unique case.

We present a case of a patient who had a giant non-malignant pancreatic pseudocyst as a complication of acute pancreatitis, which spontaneously fistulized into the duodenum and was discovered on a CT scan, which is quite unusual. It resolved secondary to the formation of the fistula without the need for surgical treatment. Giant pancreatic pseudocysts are extremely uncommon, with only a few documented cases.

Use of radiofrequency ablation in the cervical and lumbar spine and current concepts and devices.

Saqib Siddiqui, MD, Orthopedic Spine Surgeon, San Antonio, TX

This is a presentation showing the brief history of the use of radiofrequency ablation in the spine for facet mediated pain. There will be an overview of the clinical indications and the surgical anatomy and pathophysiology and technique for needle and probe placement. There will also be a discussion on first generation devices and how they differ to the newer and superior second generation device type.

Overcoming Challenges During International Surgical Trips: Lessons Learned and Strategies for Success

Ziad Sifri, MD, Professor of Surgery, Rutgers - New Jersey Medical School, Jersey City, NJ

International surgical trips can provide valuable and immediate surgical care to underserved populations. However, they come with many challenges and pitfalls.

The attendee will learn critical lessons from over a decade of International surgical trips. They learn to recognize many of the unforeseen challenges and pitfalls intricately linked to international trips. They will understand the benefits of collaboration, follow-up, teaching, sustainability, and capacity building. These lessons will significantly enhance surgical resilience by highlighting practical solutions to navigate obstacles faced during international surgical trips.

The ultimate goal of the session is to benefit the patient, the surgeon, and the healthcare system working to assist the underserved community.

Acute Kidney Injury (AKI) After Isolated Coronary Bypass (CABG) Surgery

John Slaughter, BS, Medical Student, University of Kentucky College of Medicine, Lexington, KY

Results: In 1068 isolated CABG patients, mean age was 62.9 years (SD 10.1), 74.6% were male and 95.3% were white. Fourteen patients experienced renal failure (1.3%). The STS national reported rate for renal failure in isolated CABG in 2023 was 1.9%.

Choledocholithiasis: New Approaches

Francisco Suarez Anzorena, MD, Professor of Anatomy, Universidad del Salvador. Career Director of Minimal Invasive Surgery, University of Buenos Aires. Chief Service of Interventional Radiology, Hospital de Clínicas José de San Martín, UBA, Buenos Aires, Argentina

Choledocholithiasis . New treatments using videocholedochoscope and Holmium laser.

This novel technique has very good results in complex cases.

The learner will get to know new approaches to treat complex cases of choledocholitiasis and the technique used

Going beyond Global Surgery 2030: Developing a Renal Transplant Center in a LMIC

Thav Thambi-Pillai, MD, Professor and Vice Chair of Surgery, Program Director General Surgery Residency, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD

The presenter will discuss his 20-year journey into developing a Renal transplant Center in Northern part of Sri Lanka, an island nation in the Indian ocean about 20 miles south of the tip of India. The challenges and opportunities for future growth will be discussed as well as early outcomes.

End Stage Ankle Arthritis

Michael Theodoulou, DPM, Assistant Professor of Surgery, Harvard Medical School, Cambridge, MA

The challenges of end-stage ankle arthritis - ankle replacement versus ankle fusion. What does the current study suggest and the value proposition of care.

Medical Tourism, is it safe for patients? Should it be limited?

Aley Tohamy, MD, Clinical Assistant Professor of Surgery Drexel University College of Medicine.

Chair of Department of Surgery Crozer Chester Medical Center

Director of Minimally Invasive and Bariatric surgery, Phoenixville, PA

Surgeons are experiencing the return of patients from travel after performing procedures seeking follow up at local practices or seeking help with complications. Difference in protocols, pathways, techniques of surgeries and different surgical supplies and implants. Even approved surgical procedures different from one country to another.

Development of the National Surgical, Obstetric, and Anesthesia Plan in Ecuador: Situational Analysis - Phase One

Carolina Torres Perez-Iglesias, MD, General Surgery Resident - Beth Israel Deaconess Medical Center, Boston, MA

Purpose:

National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) were developed as a tool to assist nations develop a framework to evaluate, prioritize, and plan the strengthening of their surgical health system. These plans are designed for integration into national health policies. Ecuador is the first country in the Latin American region to start the NSOAP process, led by the Ministry of Health and Vice-presidency with technical assistance of the Program in Global Surgery and Social Change. In this abstract, we describe the process and results of the first phase of the NSOAP development.

Methods:

A situational analysis was conducted between October and December 2022 to assess the capacity of Ecuador’s public surgical health system. The areas addressed during this analysis included the six key health system components of the NSOAP: infrastructure, service delivery, information management, workforce, financing, and governance. The information for the situational analysis was collected via a survey adapted from the World Health Organization’s Surgical Assessment Tool to facilities providing surgical services and via semi-structured interviews with medical staff at geographically representative facilities. The information collected was presented at the first stakeholder meeting in December 2022 in Quito and discussed in working groups composed of multisectoral stakeholders. A 3-round modified Delphi methodology was conducted to establish high-priority themes that would be included in the final NSOAP draft.

Results:

All facilities providing surgical services in Ecuador’s public health system (n=131) responded to the survey. Surgical indicators were calculated using the information collected during the situational analysis. We identified that Ecuador’s public health system provides surgical care to over 80% of the country’s population (n = 14,847,595), with a workforce density of 19 surgical, obstetric, and anesthesia (SOA) providers per 100,000 inhabitants. General hospitals had the greatest bed and operating room capacity among all facility levels. Across the entire system, only 72.5% of operating rooms were reported to be functional. The main barriers identified for meeting the surgical demand were supply deficits, inefficient resource distribution among facilities, and staff deficits. Despite offering universal health coverage, patients often incur out-of-pocket expenses due to supply deficiencies. After the presentation and discussion of the information collected during the situational analysis at the stakeholder meeting, a total of 100 high-rank priorities were identified for incorporation into the national policy plan, including 25 for infrastructure, 20 for service delivery, 25 for the workforce, 12 for information management and 18 for financing.

Conclusions:

The situational analysis provides a comprehensive evaluation of the capacity of the surgical healthcare system, including its challenges and priorities. Engagement of diverse stakeholders across multiple sectors is fundamental for developing comprehensive and sustainable healthcare policies that meet the needs of the population and can be integrated into the NSOAP along with clear deliverables for the implementation part and financing strategies for low- and middle-income countries.

Carpal Tunnel Syndrome in 2024: What's New

Robert Van Demark, MD, Clinical Professor of Orthopedic Surgery, University of South Dakota Sanford School of Medicine, Sioux Falls, SD

Carpal tunnel syndrome (CTS) is the most common compressive neuropathy of the upper extremity. Approximately 400,000 to 600,000 carpal tunnel releases are done yearly in the United States. Historically, electrodiagnostic studies (EDS) have been used to diagnosis CTS. Recently, other testing modalities have been shown to be reliable for preoperative testing.

We will review the other diagnostic tests that are both accurate and cost-effective for diagnosing CTS.

Lacertus Syndrome: The Other Median Nerve Diagnosis

Robert Van Demark, Jr, MD, Clinical Professor of Orthopedic Surgery, University of South Dakota Sanford School of Medicine, Sioux Falls, SD

Carpal Tunnel Syndrome is the most common compressive neuropathy of the upper extremity. First described in 1951, Lacertus Syndrome (LS) or Proximal Median Nerve Entrapment( PMNE) is caused by compression of the median nerve at the elbow. It has been reported that both LS and carpal tunnel can present in 6-13% of patients with carpal tunnel. Because of the similarities in presentation, he presence of untreated LS might be one cause of unsatisfactory results in carpal tunnel surgery.

Our goal is to review he anatomy, pathology and treatment outcomes of the Lacertus Syndrome

Expect the Unexpected and be Ready to Adapt: A Thoracic Surgeon's Perspective of International Voluntary Medical Services

Wickii Vigneswaran, MD, MBA, James A Haley VA Hospital, Tampa, FL

As a Thoracic Surgeon I had the the privilege to organize and travel to different parts of the world to provide medical services, many under the auspices of the ICS. The opportunities to work covered different continents that included Asia, Middle East, Africa, Central and South America. Each offered me a very interesting and unique experience, some very unexpected. I hope and believe briefly sharing my experience will be helpful to someone contemplating specialist voluntary medical missions, and perhaps preparing them adequately on their desire to give back to the community around the world.

Innovative Posterior Rectus Sheath Flap for Superior Paraesophageal Hernia Repair

Yalini Vigneswaran, MD, MPH, Director of Esophageal Diseases, Assistant Professor of Surgery, University of Chicago, Chicago, IL

Although highly experienced foregut surgeons are heavily invested in the repair of complex and large paraesophageal hernias (PEH), recurrence rates are as high as 50%. We have developed a durable surgical solution with exceptionally low recurrence rates using the unique advantages of the robotic platform. This approach uses the patient’s abdominal wall strength to repair PEH by harvesting a posterior rectus sheath flap for hiatal augmentation (PoRSHA). Our striking results with PoRSHA have caught the attention of surgeons nationally and internationally due to the lack of an alternative durable approach. Our early experience using rigorous objective criteria, has demonstrated PoRSHA is not only a safe, feasible and adoptable procedure, but is also a remarkably durable repair with zero recurrences at 2 years postoperatively on routine imaging.5 These results provides significant optimism for the early adoption of PoRSHA for an otherwise challenging surgical problem with high rates of failure. We hope to share our results and technique with the audience providing them a durable approach to these difficult cases. Lastly we hope members of the audience who would like to adopt this procedure will also join multi centered efforts to continue to study this approach.

Atrial Fibrillation after Lung Surgery (Open vs VATS): A single center experience

Amie Woolard, BS, Medical Student, University of Kentucky College of Medicine, Lexington, KY

Atrial fibrillation (AF) is a well-known complication after lung surgery. The purpose of this study was to measure the incidence and impact of AF after open thoracotomy versus video-assisted thoracoscopic surgery (VATS) procedures at an academic medical center.

With IRB approval, the charts of 1499 patients who had lung surgery from January 2005 to December 2021 were reviewed. Of these, 420 underwent an open thoracotomy and 1079 underwent a VATS procedure. The VATS procedures that were converted to an open thoracotomy were considered open procedures. Patients with a pre-operative diagnosis of AF were excluded, leaving 1408 patients in the study. Of these, 396 underwent an open thoracotomy and 1012 underwent a VATS procedure. The average age between the patients with POAF (67+9.2) and the patients without POAF (60+13) were significantly different (P<0.001). The percentage of male patients in with POAF (53.7%) and male patients without POAF (48.3%) were not significantly different (P=0.339).

The overall incidence of AF after lung surgery was 6.7% There was a significant difference between the incidence of AF after an open thoracotomy and VATS procedure (12.6% open, 4.4% VATS, P<0.001). Risk factors for developing POAF included age (P<0.001) and history of coronary artery disease (P=0.018). Of note, hypertension could potentially increase the risk of developing POAF (P=0.067). For patients with and without post-operative AF (POAF), the most common complications were atelectasis (92.6% POAF, 72.0% no POAF), pneumonia (20.0%, 7.0%), respiratory failure (23.2%, 5.8%), and ARDS (23.2%, 4.0%). The average number of complications per patient was significantly higher for patients with POAF compared to those without POAF (1.88 POAF, 1.02 no POAF, P<0.001). There was no significant difference in the in-hospital mortality rate for patients with POAF and patients without POAF (2.1% POAF, 0.9% no POAF, P=0.24). Patients with POAF had a significantly longer average length of stay in the hospital compared to those without POAF (9.72 POAF, 4.84 no POAF, P<0.001). The same is true for the average length of stay in the ICU (4.24 POAF, 1.95 no POAF, P<0.001) and the total time spent in the ICU (6.53 POAF, 2.42 no POAF, P<0.001). After surgery, POAF significantly increased the risk of post-operative mechanical ventilation (10.5% POAF, 1.4% no POAF, P<0.001), reintubation (10.5% POAF, 1.2% no POAF, P<0.001), and return to the operative room (18.9% POAF, 5.0% no POAF, P<0.001).

The incidence of POAF in patients who underwent an open thoracotomy was significantly larger than those who underwent a VATS procedure. Important risk factors for developing POAF include age and history of coronary artery disease. In the end, POAF greatly impacted a patient’s risk of post-operative complications, as well as length of hospital and ICU stay.

Peroneal Nerve Dysfunction for Spine Surgeons

Demian Yakel, DO, Orthopedic Spine Surgeon, Asheville, NC

This presentation is an overview of peroneal nerve dysfunction and how it can be confusing in clinical decision-making for spine surgeons.

I will discuss perineal, nerve problems, how to clinically diagnose, and how to surgically treat.

As a spine surgeon, my understanding of peroneal nerve dysfunction was historically minimal. As I began to understand it, I found multiple patients suffering from it, and benefiting from peroneal nerve decompression.

I feel this is a topic that is rarely discussed, and is much more common than recognized.

I think the audience would benefit from an understanding of this neurological issue and keeping it in their differential diagnosis and treatment options.

Holomedicine: Novel Innovation to Global Perspective

Zachery Yeo, MD, Deputy Program Director of Holomedicine, Singapore,

I will introduce the revolutionary concept of Holomedicine, a field that merges mixed reality technology with medical applications, emphasizing its potential to bring about a global transformation in healthcare practices.

The initial segment of the presentation will focus on the innovative application of the Hololens 2 for surgical planning and intervention. We will explore how this technology is utilized for meticulous pre-surgical planning, where holograms generated from patient-specific scans are used to strategize surgical approaches. This approach enables surgeons to prepare more thoroughly by visualizing the surgical area in three dimensions before the actual procedure. During the surgery itself, these holograms are overlaid into the surgeon's field of vision, enhancing precision and improving patient outcomes through less invasive techniques.

Furthermore, we will delve into the Hololens 2's role in teleproctoring. This segment will highlight how surgeons from various global locations can engage in real-time collaboration, discussing and planning complex surgical procedures. This capability not only fosters international collaboration and the exchange of expertise but also plays a crucial role in elevating surgical standards by pooling global knowledge.

The presentation aims to illuminate how Holomedicine is not merely a theoretical innovation but a practical, impactful tool that is reshaping medical procedures and education on a global scale. It is a glimpse into the future of healthcare, where advanced technology and clinical practice converge to improve patient care world.

Evaluation of Large Language Models in Responding to Surgical Patient Inquiries: A Cross-Sectional Study

Jang Yoon, MD, Professor of Neurosurgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

The presentation focuses on the utilization of Large Language Models (LLMs) in addressing patient inquiries within the realm of surgical interventions. It explores the challenges patients face in understanding the nature of their surgeries, pre-and post-operative concerns.The audience, comprised of healthcare professionals, needs to know this information to understand the evolving role of Artificial Intelligence (AI) in enhancing patient communication. Upon completing this presentation, learners will be able to: 1) Recognize the potential of AI, specifically LLMs, in improving patient communication. 2) Evaluate the proficiency of various LLMs in providing accurate, relevant, and emotionally sensitive responses.