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81: Environmental impact and life cycle financial cost of hybrid (reusable/ single-use) instruments versus single-use equivalents in laparoscopic cholecystectomy
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Posted 12 Mar 2021

Environmental impact and life cycle financial cost of hybrid (reusable/ single-use) instruments versus single-use equivalents in laparoscopic cholecystectomy
213 downloads medRxiv surgery

Chantelle Rizan, Mahmood F Bhutta

Background Hybrid surgical instruments contain both single-use and reusable components, potentially bringing together advantages from both approaches. Methods We used Life Cycle Assessment to evaluate environmental impact of hybrid laparoscopic clip appliers, scissors and ports used for a laparoscopic cholecystectomy, comparing these with single-use equivalents. We modelled this using SimaPro to determine 18 midpoint environmental impacts including the carbon footprint, and three aggregated endpoint impacts. We also conducted life cycle cost analysis, taking into account unit cost, decontamination, and disposal costs. Findings The environmental impact of using hybrid instruments for a laparoscopic cholecystectomy was lower than single-use equivalents across 17 midpoint environmental impacts, with mean average reductions of 60%, and costing less than half that of single-use equivalents (GBP 131 versus 282). The carbon footprint of using hybrid versions of all three instruments was around one-quarter of single-use equivalents (1,756 g versus 7,194 g CO2e per operation), and saved an estimated 1.13 e-5 DALYs (disability associated life years, 74% reduction), 2.37 e-8 species.year (loss of local species per year, 76% reduction), and US $ 0.6 in impact on resource depletion (78% reduction). Scenario modelling indicated environmental performance of hybrid instruments was better even given low number of reuses of instruments, decontamination with separate packaging of certain instruments, decontamination using fossil-fuel rich energy sources, or changing carbon intensity of instrument transportation. Interpretation Adoption of hybrid laparoscopic instruments could play an important role in meeting carbon reduction targets for surgery, whilst saving money. Funding This work was funded by Surgical Innovations Ltd who manufacture hybrid laparoscopic instruments.

82: Racial and Ethnic Inequities in Mortality During Hospitalization for Traumatic Brain Injury: A Call to Action
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Posted 09 Apr 2021

Racial and Ethnic Inequities in Mortality During Hospitalization for Traumatic Brain Injury: A Call to Action
210 downloads medRxiv surgery

Emma A Richie, Joseph G Nugent, Ahmed M Raslan

The health disparities which drive inequities in health outcomes have long plagued our already worn healthcare system and are often dismissed as being a result of social determinants of health. Herein, we explore the nature of these inequities by comparing outcomes for racial and ethnic minority patients suffering from traumatic brain injury (TBI). We retrospectively reviewed all patients enrolled in the Trauma One Database at the Oregon Health & Science University Hospital from 2006 to October 2017 with an abbreviated injury scale (AIS) scale for the head or neck greater than 2. Racial and ethnic minority patients were defined as non-White or Hispanic. A total of 6,352 patients were included in our analysis with 1,504 in the racial and ethnic minority cohort vs. 4,848 in the non-minority cohort. A propensity score (PS) model was generated to account for differences in baseline characteristics between these cohorts to generate 1,500 matched pairs. The adjusted hazard ratio for in-hospital mortality for minority patients was 2.21 (95% Confidence Interval (CI) 1.43-3.41, p<0.001) using injury type, probability of survival, and operative status as covariates. Treating patients under our care is our greatest privilege and responsibility as physicians. As such, we have a societal duty to recognize and accept that the effects of structural racism have taken hold of our patients health long before they arrive in our trauma bays, ICU beds, and operating tables. These disparities permeate our society and contribute to inequitable health outcomes, and we must take action to identify the factors which perpetuate this disproportionate suffering. Simply treating the minority of patients who require surgical intervention or clinical consultation is not enough. Our roles demand that we recognize these larger social factors acting upstream on our patients before they enter our fractioned healthcare system which often fosters the very mistrust that hides them from our otherwise watchful eyes in the first place. What shape, if any, these health inequities take among other nations will enable us to better understand the root of these problems in our society and allow us to work together toward equitable healthcare for all victims of traumatic injury.

83: Tissue Stress from Laparoscopic Grasper Use and Bowel Injury in Humans: Establishing Intraoperative Force Boundaries
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Posted 23 Feb 2021

Tissue Stress from Laparoscopic Grasper Use and Bowel Injury in Humans: Establishing Intraoperative Force Boundaries
207 downloads medRxiv surgery

Amanda Farah Khan, Matthew Kenneth MacDonald, Catherine Streutker, Corwyn Rowsell, James Drake, Teodor Grantcharov

BackgroundInappropriate force in laparoscopic surgery can lead to inadvertent tissue injury. It is currently unknown however at what magnitude of compressive stress trauma occurs in gastrointestinal tissues. MethodsThis study included 10 small bowel and 10 colon samples. Each was compressed with pressures ranging from 100 kPa to 600 kPa by a novel device to induce compressive "grasps" to simulate those of a laparoscopic grasper. Experimentation was performed ex-vivo, in-vitro. Grasp conditions of 0 to 600 kPa for a duration of 10 seconds were utilized. Two pathologists who were blinded to all study conditions, performed a histological analysis of the tissues. Patients were eligible if their surgery procured healthy tissue margins for experimentation (a convenience sample). 26 patient samples were procured; six samples were unusable. 10 colon and 10 small bowel samples were tested for a total of 120 experimental cases. No patients withdrew their consent. Two metrics of damage were quantified: an intestinal layer thickness calculation where the serosa layer was measured in the area of compression and compared to a local control and a histological scoring scale for tissue trauma. ResultsSmall bowel (10), M:F was 7:3, average age was 54.3 years. Colon (10), M:F was 1:1, average age was 65.2 years. All 20 patients experienced a significant difference (p<0.05) in serosal thickness post-compression at both 500 and 600 kPa for both tissue types. A logistic regression analysis with a sensitivity of 100% and a specificity of 84.6% on a test set of data predicts a safety threshold of 329-330 kPa. ConclusionA threshold was discovered that corresponded to both significant serosal thickness change and a positive histological trauma score rating. This "force limit" could be used in novel sensorized laparoscopic tools to avoid intraoperative tissue injury.

84: Outcomes following out-of-hours cholecystectomy: A systematic review and meta-analysis
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Posted 05 Feb 2021

Outcomes following out-of-hours cholecystectomy: A systematic review and meta-analysis
207 downloads medRxiv surgery

Sameer Bhat, Chris Varghese, William Xu, Ahmed W.H. Barazanchi, Bathiya Ratnayake, Gregory O'Grady, John A. Windsor, Cameron I. Wells

Background: Cholecystectomy is one of the most commonly performed abdominal operations. Demands on acute operating theatre availability have led to out-of-hours (evenings, nights, or weekend) cholecystectomy being performed, although it is not known whether outcomes differ between out-of-hours and in-hours (daytime on weekdays) cholecystectomy. Objective: This systematic review and meta-analysis aimed to compare outcomes following out-of-hours versus in-hours urgent cholecystectomy. Methods: MEDLINE, EMBASE and Scopus databases were systematically searched from inception to December 2020 for studies comparing outcomes from out-of-hours and in-hours urgent cholecystectomy in adults. The outcomes of interest were rates of bile leakage, bile duct injury (BDI), overall post-operative complications, conversion to open cholecystectomy, specific intra- and post-operative complications, length of stay (LOS), readmission and mortality. Sensitivity analysis of adjusted multivariate results was also performed. Results: In total, 194,135 urgent cholecystectomies (30,001 out-of-hours; 164,134 in-hours) from 11 studies were included. Most studies were of high (64%) or medium (18%) quality. There were no differences between out-of-hours and in-hours cholecystectomy for rates of bile leakage, BDI, overall post-operative complications, conversion to open cholecystectomy, operative duration, readmission, mortality, and post-operative LOS. Higher rates of post-operative sepsis (odds ratio (OR) 1.58, 95% CI: 1.04-2.41; p=0.03) and pneumonia (OR 1.55, 95% CI: 1.06-2.26; p=0.02) were observed following out-of-hours cholecystectomy on univariate meta-analysis but not on adjusted multivariate meta-analysis. Conclusions: There was no increased risk or difference in specific complications associated with out-of-hours compared with in-hours urgent cholecystectomy.

85: Recent trends in postoperative mortality after liver resection- A systemic review and metanalysis of studies published in last 5 years and metaregression of various factors affecting 90 days mortality.
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Posted 29 Mar 2021

Recent trends in postoperative mortality after liver resection- A systemic review and metanalysis of studies published in last 5 years and metaregression of various factors affecting 90 days mortality.
198 downloads medRxiv surgery

BHAVIN VASAVADA, hardik patel

Aim: The aim of this systemic review and meta-analysis was to analyse 90 days mortality after liver resection, and also study various factors associated with mortality via univariate and multivariate metaregression. Methods: PubMed, Cochrane library, Embase, google scholar, web of science with keywords like liver resection, mortalit, hepatectomy. Weighted percentage 90 days mortalities were analysed. univariate metaregression was done by DerSimonian-Liard methods. Major hepatectomy, open surgery, cirrhotic livers, blood loss, hepatectomy for hepatocellular carcinoma, hepatectomy for colorectal liver metastasis were taken as moderators in metaregression analysis. We decided to enter all co-variants in multivariate model to look for mixed effects. Heterogeneity was assessed using the Higgins I2 test, with values of 25%, 50% and 75% indicating low, moderate and high degrees of heterogeneity. Cohort studies were assessed for bias using the Newcastle-Ottawa Scale to assess for the risk of bias. Publication bias was assessed using funnel plot. Funnel plot asymmetry was evaluated by Egger test. Results: Total 29931 patients data who underwent liver resections for various etiologies were pooled from 41 studied included1257 patients died within 90 days post operatively. Weighted 90 days mortality was 3.6% (95% C.I 2.8% -4.4%). However, heterogeneity of the analysis was high with I2 94.625%.(p<0.001). We analysed various covariates like major hepatectomy, Age of the patient, blood loss, open surgery, liver resections done for hepatocellular carcinoma or colorectal liver metastasis and cirrhotic liver to check for their association with heterogeneity in the analysis and hence 90 days mortality. On univariate metaregression analysis major hepatectomy (p<0.001), Open hepatectomy (p<0.001), blood loss (p=0.002) was associated with heterogeneity in the analysis and 90 days mortality. On multivariate metaregression Major hepatectomy(p=0.003) and Open surgery (p=0.012) was independently associated with higher 90 days mortality, and liver resection for colorectal liver metastasis was independently associated with lesser 90 days mortality (z= -4.11,p<0.01). Residual heterogeneity after all factor multivariate metaregression model was none (I2=0,Tau2=0, H2=1) and nonsignificant (p=0.49). Conclusion: Major hepatectomy, open hepatectomy, and cirrhotic background is associated with higher mortality rates and colorectal liver metastasis is associated with lower peri operative mortality rates.

86: Management Algorithm of External Fixation in Lower Leg Arterial Injury for Limb Salvages
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Posted 03 Mar 2021

Management Algorithm of External Fixation in Lower Leg Arterial Injury for Limb Salvages
193 downloads medRxiv surgery

Lei Jin, Song Zhang, Motao Liu, Yuxuan Zhang, Xin Lin, Dehong Feng, Kejia Hu

PurposeThe purpose of this study was to review the roles of using external fixation to rescue the patients who sustained arterial injuries in the lower legs. MethodsDemographics, surgical treatment and outcomes in 88 patients with lower leg arterial injuries treated by external fixation at two trauma centers from 2009 to 2018 were reviewed. The primary outcome was the rate of successful lower leg salvage, while secondary outcomes were complications and functional recovery. Results80 patients (90 legs) maintained a successful lower leg salvage. The patients were followed up for an average of 15.5{+/-}5.5 months. 6 patients (8 pins) experienced pin-tract infection, pins loosening happened in 2 patients (4 pins), 7 patients (7 legs) developed wound superficial infection, 3 patients (3 legs) with a deep infection developed osteomyelitis, 16 patients (17 legs) suffered the bone nonunion or bone defect. The average healing time of fracture was 5.6{+/-}4.3months. The maintain of external fixation average time was 5.8{+/-}3.6 months. ConclusionWith correctly judging the condition of limb ischemia, mastering reasonably the operation indications, and preventing complications, good clinical effects can be achieved when external fixation is used. Level of evidenceRetrospective cohort, level IV.

87: Postoperative morbidity after liver resection- A Systemic review, meta-analysis, and metaregression of factors affecting them.
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Posted 09 Apr 2021

Postoperative morbidity after liver resection- A Systemic review, meta-analysis, and metaregression of factors affecting them.
176 downloads medRxiv surgery

BHAVIN VASAVADA, HARDIK PATEL

Aim of the study: This systemic review and meta-analysis aimed to analyze post-operative morbidity after liver resection, and also study various factors associated with mortality via metaregression analysis. Material and Methods: PubMed, Cochrane Library, Embase, google scholar, web of science with keywords like liver resection; mortality; hepatectomy. Weighted percentage post-operative morbidities were analyzed. Meta-analysis and meta-regression were done by the DerSimonian-Liard random effect model. Heterogeneity was assessed using the Higgins I2 test. Publication bias was assessed using a funnel plot. Funnel plot asymmetry was evaluated by Eggers test. Morbidity was defined as any postoperative morbidity mentioned. Results: A total of 46 studies was included in the final analysis. Total 45771 patients underwent liver resections. 16111 patients experienced complications during the postoperative period. Weighted post-operative morbidity was 30.2% ( 95 % C.I. 24.8-35.7%). Heterogeneity was high with I2 99.46% and p-value <0.01. On univariate analysis, major liver resections were significantly associated with heterogeneity. (p=0.024). However, residual heterogeneity was still high with I2 98.62%, p<0.001. So, multifactor metaregression analysis major hepatectomy (p<0.001), Open hepatectomy (p=0.001), cirrhotic liver (p=0.002), age (p<0.001), blood loss (p<0.001), and colorectal metastasis (p<0.001) independently associated with postoperative morbidity. Residual heterogeneity was moderate I2= 39.9% and nonsignificant p=0.189. Conclusion: Liver resection is associated with high postoperative morbidity and various factors like major hepatectomy, Open hepatectomy, cirrhotic liver, blood loss, and colorectal metastasis were associated with morbidity and responsible for heterogeneity across the studies.

88: Impact of Systemic Arterial Pressure, Collateral Vascular Resistance and Degree of Carotid Stenosis on Cerebral Blood Flow, Reserve Blood Flow, Critical Carotid Stenosis, Cerebral Ischemia and Carotid Hemodynamics
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Posted 26 Feb 2021

Impact of Systemic Arterial Pressure, Collateral Vascular Resistance and Degree of Carotid Stenosis on Cerebral Blood Flow, Reserve Blood Flow, Critical Carotid Stenosis, Cerebral Ischemia and Carotid Hemodynamics
170 downloads medRxiv surgery

Joseph P Archie

IntroductionCarotid artery stenosis related stroke is a major health care concern. Current risk management strategies for patients with asymptomatic carotid stenosis include ultrasound surveillance and occasionally an estimate of cerebral blood flow reserve. Other patient specific hemodynamic variables may be predictive of ischemic stroke risk. This study, based on a cerebral blood flow hemodynamic model, aims to investigate the impact of systemic arterial pressure, collateral vascular resistance and degree of carotid stenosis on cerebral ischemic risk, cerebrovascular blood flow reserve, critical carotid artery stenosis, carotid artery blood flow and carotid stenosis hemodynamics. MethodsThis study uses a three-component (carotid, collateral, brain) energy conservation cerebrovascular fluid mechanics model in combination with the Lassen cerebral blood flow autoregulation model that predicts cerebral blood flow in patients with carotid stenosis. It is a two-phase model, zone A when regional cerebral blood flow is autoregulated at normal values and zone B when cerebral blood flow is below normal and dependent on collateral perfusion pressure. The model solution with carotid artery occlusion defines collateral vascular resistance, with patient specific values calculated from clinical pressure measurements. In addition to cerebral blood flow the model predicts critical stenosis values and carotid and collateral blood flows as a function of systemic arterial pressure and percent diameter stenosis. Carotid stenosis blood flow velocities and energy dissipation are predicted from carotid blood flow solutions. ResultsThe model defines patient specific collateral vascular resistance, cerebral vascular resistance and critical carotid stenosis. It predicts carotid vascular resistance to be non-linearly proportional to area carotid stenosis. Solutions include reserve cerebral blood flow, the carotid and collateral components of cerebral blood flow, criteria for cerebral ischemia and carotid stenosis hemodynamics. Critical carotid stenosis is determined by mean systemic arterial pressure and the Lassen autoregulation threshold cerebral perfusion pressure. Critical stenosis values range from 61% to 76% diameter stenosis when mean systemic arterial pressures are 80mmHg to 120mmHg and the cerebral autoregulation pressure threshold is 50mmHg. When carotid stenosis is less than critical, cerebral blood flow is maintained normal and the ratios of carotid blood flow to collateral blood flow are inversely proportional to the carotid to collateral vascular resistance ratios. At stenosis greater than the critical, carotid blood flow is not adequate to maintain normal cerebral blood flow, cerebral blood flow is primarily collateral flow, all reserve blood flow is collateral and prevention of cerebral ischemia requires adequate collateral flow. Patient specific collateral vascular resistance values less than 1.0 predict normal cerebral blood flow at moderate to severe stenosis. Values greater than 1.0 predicts cerebral ischemia to be dependent on the magnitude of collateral vascular resistance. Systemic arterial pressure is a major determinant of carotid stenosis hemodynamics. Carotid blood flow velocities increase with carotid stenosis and have progressively higher variance depending on collateral blood flow as predicted by collateral vascular resistance. Turbulent flow energy dissipation intensity is similarly inversely proportional to collateral vascular resistance at severe carotid stenosis. ConclusionsCerebral, collateral and carotid blood flow solutions are determined by systemic arterial pressure, collateral vascular resistance and degree of stenosis. Critical carotid stenosis, systemic arterial pressure and collateral vascular resistance are primary determinants of cerebral ischemic risk in patients with significant carotid stenosis.

89: Unplanned Hospital Visits after Ambulatory Surgical Care
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Posted 12 Mar 2021

Unplanned Hospital Visits after Ambulatory Surgical Care
169 downloads medRxiv surgery

Tasce Bongiovanni, Craig Parzynski, Isuru Ranasinghe, Michael A. Steinman, Joseph S Ross

Objectives: We sought to assess the rate of unplanned hospital visits among patients undergoing ambulatory surgery. Summary Background Data: The majority of surgeries performed in the United States now take place in outpatient settings. Post-discharge hospital visit rates have been shown to vary widely, suggesting variation in surgical or discharge care quality. Complicating efforts to address quality, most facilities and surgeons are unaware of their patients' hospital visits after surgery since patients may present to a different hospital. Methods: We used state-level, administrative data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project from California to assess unplanned hospital visits after ambulatory surgery. To compare rates across centers, we determined the age, sex, and procedure-adjusted rates of hospital visits for each facility using 2-level, hierarchical, generalized linear models using methods similar to existing Centers for Medicare and Medicaid Services measures. Results: Among a total of 1,260,619 ambulatory same-day surgeries from 440 surgical facilities, the risk adjusted 30-day rate of unplanned hospital visits was 4.8%, with emergency department visits of 3.1% and hospital admissions of 1.7%. Several patient characteristics were associated with increased risk of unplanned hospitals visits, including increased age, increased number of comorbidities (using the Elixhauser score), and type of procedure (p<0.001). Conclusions: The overall rate unplanned hospital visits within 30 days after same-day surgery is low but variable, suggesting a difference in the quality of care provided. Further, these rates are higher among specific patient populations and procedure types, suggesting areas for targeted improvement.

90: Place of preperitoneal pelvic packing in severe pelvic traumatisms: About 20 cases performed in a French military level one trauma center
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Posted 15 Feb 2021

Place of preperitoneal pelvic packing in severe pelvic traumatisms: About 20 cases performed in a French military level one trauma center
168 downloads medRxiv surgery

Hardy Julie, Coisy Marie, Monchal Tristan, Bourguoin St├ęphane, Long Depaquit Thibaut, Chiron Paul, Mickael Cardinale, Hornez Emmanuel, Balandraud Paul, Savoie Pierre-Henri

BackgroundThe overall mortality of hemodynamically unstable pelvic fractures is high. Hemorrhage triggers off the Moore lethal triad. Hemostatic management during the golden hour is essential. Combined with pelvic stabilisation, preperitoneal pelvic packing (PPP) is proposed to control venous and bony bleeding, while arterioembolisation can stop arterial bleeding. No international consensus has yet prioritized these procedures. The aim of this study was to analyse a serie of PPP in a military level one trauma center and propose an algorithm for hemodynamically unstable pelvic traumas regardless of the military facility. MethodFrom January 2010 to December 2020, every patient from our military institution with a hemodynamically unstable pelvic fracture underwent PPP combined with pelvic stabilisation. Before 2012 data were retrospectively collected from database (PMSI), after 2012 data were prospectively recorded in our polytrauma database and retrospectively analysed. The care algorithm applied focused on hemodynamic status of polytraumatised patients on admission. Primary criteria were early hemorrhage-induced mortality (<24h) and overall mortality (<30d). Secondary criteria were systolic blood pressure (SBP) and red blood cells (RBC) units administered. Results20 patients with a pelvic fracture had a PPP. Mean age was 49,65 +/-23,97 years and median ISS was 49 (31; 67). The decrease of blood transfusion and increase of SBP between pre- and postoperative values were statistically significant. Eight patients (40%) had postoperative arterial pelvic blush and 7 patients were embolised. The early mortality by refractory hemorrhagic shock was 25% (5/20). Overall mortality at 30 days was 50% (10/20). ConclusionPPP is a quick, easy, efficient and safe procedure. It can control venous, bony and sometimes arterial bleeding. PPP is part of damage control surgery and we propose it in first line. Angio-embolization remains complementary. Besides, PPP is the only means available in precarious conditions of practice, notably in military forward units.

91: A comparative analysis of the health, financial, equity, and cost-effectiveness impacts of maxillofacial surgery in Guinea
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Posted 26 Mar 2021

A comparative analysis of the health, financial, equity, and cost-effectiveness impacts of maxillofacial surgery in Guinea
142 downloads medRxiv surgery

Mirjam Hamer, Dennis Alcorn, Ibrahima Diallo, Fatoumata B Y Bah, Alhassane Conde, Lancine Traore, Etienne Faya Millimouno, Chelsea Peacock, Chris Glasgo, Peter E Linz, Mark G Shrime, Omar Raphiou Diallo

Background: Non-governmental organizations (NGOs) play a substantive role in the delivery of surgical services in in low- and middle-income countries (LMICs). Assessment of their outcomes, especially as they relate to outcomes of surgery done in country, remains limited. Methods: A prospective analysis of maxillofacial surgery in Guinea. Outcomes of interest were changes in patient health, subjective well-being, and financial status; hardship financing and catastrophic expenditure; equitable distribution of surgical access; and cost-effectiveness. Results: We followed 569 patients requiring maxillofacial surgery in Conakry, Guinea, 114 of whom got care at local university hospitals, and 455 of whom got their care with Mercy Ships, a surgical NGO. Patients were followed for between three months (local) and one year (NGO). All patients reported significant improvement in objective and subjective measures of health and in financial status. Approximately half had to borrow and sell to get care, with NGO patients borrowing less, on average. However, NGO patients faced more risk of catastrophic expenditure (41.2% vs. 28.1%, p < 0.001). NGO patients were significantly poorer, whether financial status was measured by asset wealth (p = 0.014) or monthly income (p < 0.001). Finally, surgical care by the NGO was cost effective. Conclusions: In a prospective analysis of surgical patients in an LMIC, we find that surgery improves health and financial well-being. NGOs may be able to reach patients who would not be able to get care through their local system; however, this comes at a cost of increased initial financial risk. Finally, NGO-based surgical care is cost-effective.

92: Internal Neurolysis for the Treatment of Trigeminal Neuralgia: Systematic Review
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Posted 26 May 2021

Internal Neurolysis for the Treatment of Trigeminal Neuralgia: Systematic Review
126 downloads medRxiv surgery

Victor Sabourin, Pascal Lavergne, Jacob Mazza, Fadi Al-Saiegh, Jeffrey Head, Tony Stefanelli, Michael Karsy, James Evans

Introduction Trigeminal neuralgia remains a challenging disease with significant debilitating symptoms and variable efficacy in terms of treatment options, namely microvascular decompression (MVD), stereotactic radiosurgery (SRS), and percutaneous rhizotomy. Internal neurolysis (IN) is an alternative treatment that may be provide patient benefit but has limited understanding. We performed a systematic review of IN treatment of trigeminal neuralgia. Methods Studies from 2000 to 2021 that assessed IN in trigeminal neuralgia were aggregated and independently reviewed. Weighted averages for demographics, outcomes and complications were generated. Results A total of 520 patients in 12 studies were identified with 384 who underwent IN (mean age 53.8 years, range 46-61.4 years). A mean follow-up time of 36.5 months (range 12-90 months) was seen. Preoperative symptoms were present for about 55.0 months before treatment and pain was predominantly in V2/3 (26.8%) followed by other distributions. An excellent to good outcome (Barrow Neurological Institute Pain Score [BNI-PS] I-III) was seen in 83.7% of patients (range 72-93.8%). Pain outcomes at 1 year were excellent in 58-78.4%, good or better in 77-93.75% and fair or better in 80-93.75% of patients. On average facial numbness following IN was seen in 96% of patients however at follow-up remained in only 1.75-10%. The vast majority of remaining numbness was not significantly distressing to patients. Subgroup comparisons of IN vs. recurrent MVD, IN vs. radiofrequency ablation, the impact of IN during the absence of vascular compression as well as IN with and without MVD were also evaluated. Conclusions IN represents a promising approach for surgical treatment of trigeminal neuralgia in the absence of vascular compression or in potential cases of recurrence. Complications were limited in general. Further study is required to evaluate the impact of IN via higher quality prospective studies.

93: Research priorities for lower limb amputation in patients with vascular disease
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Posted 24 May 2021

Research priorities for lower limb amputation in patients with vascular disease
81 downloads medRxiv surgery

David Bosanquet, Sandip Nandhra, Kitty Wong, Judith Long, Ian Chetter, Robert Hinchliffe, The VSGBI Amputation Special Interest Group James-Lind Alliance Priority Setting Partnership Group

Introduction Lower limb amputation is a life-changing event for patients and can be associated with high mortality and morbidity rates. Research into this critical part of vascular surgery is limited. The Vascular Society of Great Britain and Ireland (VSGBI) in partnership with the James Lind Alliance (JLA) process, aimed to identify and develop key research priorities for amputation. Methods A modified JLA Priority Setting Partnership was undertaken, encompassing all vascular practice. Two separate Delphi processes to identify research topics were undertaken with healthcare professionals, patients and carers, led by the VSGBI. The priorities were then ranked by the same participants and amalgamated to produce a list for final prioritisation. The final consensus meeting was attended by patients, carers and healthcare professionals from a variety of backgrounds involved in the care of people with amputation. Using a nominal group technique, the top ten research priorities were identified. Results A total of 481 clinicians submitted 1231 research questions relating to vascular surgery in general. 63 amputation-specific research questions were combined into 5 final clinical questions. 373 patients or carers submitted 582 research questions related to vascular surgery in general. Nine amputation-specific research questions were identified after combining similar questions. Amalgamating both the clinician and patient questions, 12 questions were discussed at the final prioritisation meeting and the top 10 identified. These related to amputation prevention, supporting rehabilitation, improving clinical outcomes following amputation (preventing/treating pain including phantom limb pain and improving wound healing) and research into information provision for patients undergoing amputation. Conclusion The top 10 research priority areas in vascular amputation provide guidance for researchers, clinicians, and funders on the direction of future research questions that are important to both healthcare professionals and patients.

94: Impact of Asian and black donor and recipient ethnicity on the outcomes after deceased donor kidney transplantation in the United Kingdom
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Posted 07 May 2021

Impact of Asian and black donor and recipient ethnicity on the outcomes after deceased donor kidney transplantation in the United Kingdom
80 downloads medRxiv surgery

Abdul Rahman Hakeem, Sonal Asthana, Rachel Johnson, Chloe Brown, Niaz Ahmad

Background: Patients of Asian and black ethnicity face disadvantage on the renal transplant waiting list in the United Kingdom, because of lack of HLA and blood group matched donors from an overwhelmingly white deceased donor pool. This study evaluates outcomes of renal allografts arising from Asian and black donors. Methods: The UK Transplant Registry was analysed for adult deceased donor kidney only transplants performed during January 2001 to December 2015. Results: Asian and black ethnicity patients constituted 12.4% and 6.7% of all deceased donor recipients but only 1.6% and 1.2% of all deceased donors, respectively. Across all recipients, and unsurprisingly given the predominantly white recipient pool, HLA matching was superior for grafts from white donors than from Asian and black donors (p less than 0.0001). Unadjusted survival analysis demonstrated significantly inferior long-term allograft outcomes associated with Asian and black donors, compared to white donors (7 year graft survival 71.9%, 74.0% and 80.5%; log rank p 0.0007, respectively). On Cox regression analysis, Asian donor (HR 1.37 for Asian donors vs. white donors as baseline) and black recipient (HR 1.21 for black recipients vs. white recipient as baseline) ethnicities were associated with poorer outcomes than white counterparts, and on ethnicity matching, compared with the white donor to white recipient baseline group and adjusting for other donor and recipient factors, 5 year graft outcomes were significantly poorer for black donor to black (HR 1.92 (1.11 to 3.32), p 0.02), Asian donor to white recipient (HR 1.56 (1.09 to 2.24), p 0.016) and white donor-black recipient (HR 1.22 (1.05 to 1.42), p 0.011) combinations in decreasing order of worse unadjusted 5 year graft survival. Conclusions: Increased deceased donation among ethnic minority communities would benefit the entire recipient pool by increasing the numbers of available organs and may specifically benefit the Asian and black recipients by increasing the numbers of blood group and HLA compatible grafts for allocation but may not improve allograft outcomes.

95: Effects of Acute Normovolemic Hemodilution on Post-Cardiopulmonary Bypass Coagulation Tests and Allogeneic Blood Transfusion in Thoracic Aortic Repair Surgery: An Observational Cohort Study
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Posted 03 Jun 2021

Effects of Acute Normovolemic Hemodilution on Post-Cardiopulmonary Bypass Coagulation Tests and Allogeneic Blood Transfusion in Thoracic Aortic Repair Surgery: An Observational Cohort Study
63 downloads medRxiv surgery

Domagoj Mladinov, Kyle W Eudailey, Luz A Padilla, Joseph B Norman, Benjamin Leahy, Jacob Enslin, Keli L Parker, Katherine F Cornelius, James E Davies

Background and Aim: Perioperative blood transfusion is associated with increased morbidity and mortality. Acute normovolemic hemodilution (ANH) is a blood conservation strategy associated with variable success, and rarely studied in more complex cardiac procedures. The study aim was to evaluate whether acute ANH improves coagulopathy and reduces blood transfusions in thoracic aortic surgeries. Methods: Single-center observational cohort study comparing ANH and standard institutional practice in patients who underwent thoracic aortic repair from 2019 to 2021. Results: 89 patients underwent ANH and 116 standard practice. There were no significant differences between the groups in terms of demographic or major perioperative characteristics. In the ANH group coagulation tests before and after transfusion of autologous blood showed decreased INR and increased platelets, fibrinogen, all with p<0.0005. Coagulation results in the ANH and control groups were not statistically different. The average number of transfused allogeneic products per patient was lower in the ANH vs control group: FFP 1.1 +/-1.6 vs 1.9 +/-2.3 (p=0.003), platelets 0.6 +/-0.8 vs 1.2 +/-1.3 (p=0.0008), and cryoprecipitate 0.3 +/-0.7 vs 0.7 +/-1.1 (p=0.008). Reduction in RBC transfusion was not statistically significant. The percentage of patients who received any transfusion was 53.9% in ANH and 59.5% in the control group (p=0.42). There was no significant difference in major adverse outcomes. Conclusions: ANH is a safe blood conservation strategy for surgical repairs of the thoracic aorta. Laboratory data suggests that ANH can improve coagulopathy after separation from CPB, and significantly reduce the number of transfused FFP, platelets and cryoprecipitate.

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