Day 1 :
University of Miami, USA
Time : 10:00-10:30
Background: Intraoperative peritoneal carcinomatosis index (I-PCI) and completeness of cytoreduction surgery (CRS) are predictors of survival in patients with peritoneal surface malignancy (PCM) from multiple gastrointestinal malignancies. However, I-PCI is not a reliable predictor in patients with PCM from appendiceal origin. We sought to analyze the impact of postoperative radiological PCI (PR-PCI) on survival rates in this population.
Methodology: From August 2002 to January 2015, 29 consecutive patients with PCM from appendiceal origin undergoing CRS/HIPEC (hyperthermic intraperitoneal chemotherapy) were included in the analysis. Patient demographics, tumor characteristics and perioperative outcomes were collected. Kaplan- Meier survival analysis and Cox proportional hazards model evaluated factors associated with increased mortality. PCI cutoff of 16 was used for both PR-PCI and I-PCI.
Results: Tumor characteristics, intraoperative variables (including PCI, HR 2.41, 95% CI 0.49-11.77) and postoperative complications were not identified as predictors of survival. Mean I-PCI and PR-PCI were 19.1±11.3 and 6.6±10.4 (p<0.001), respectively. PR-PCI <16 was associated with increased survival rates (HR 4.53, 95% CI 1.10-18.69, p=0.030)
Conclusions: PR-PCI seems to be a more reliable predictor of survival than conventional I-PCI in patients with PCM from appendiceal origin undergoing CRS/HIPEC, likely due to a superior correlation with completeness of resection.
The First Affiliated Hospital of Guangzhou University of Chinese Medicine, China
Keynote: Hepatic resection versus TACE in UICC stage T3 Hepatocellular carcinoma patients: A propensity scores matching study
Time : 10:30-11:00
Chong Zhong, MD, PhD has his expertise in surgical oncology and minimally invasive surgery in hepatobiliary and pancreatic surgery in the Department of Surgery at The First Affiliated Hospital of Guangzhou University of Chinese Medicine, China. His clinical interest is hepatobiliary and pancreatic surgery. He has been involved in cancer research for more than ten years. His researches focus on liver cancer and epithelial-mesenchymal transition and signal transduction pathway. His researches received supports from National Natural Science Foundation of China.
The aim of this study is to compare the clinical outcomes following hepatic resection (HR) versus transarterial chemoembolization (TACE) for UICC (the Union for International Cancer Control) stage (7th) T3 HCC (hepatocellular carcinoma). From 2005 to 2013, 1179 patients who underwent HR or TACE were divided into two groups, HR (n=280) or TACE (n=899). The propensity model matched 244 patients in HR and TACE group, respectively, for further analyses. After matching, medium overall survival, 1, 3, and 5-year OS (overall survival) rates in TACE group were 11.8 months (95%CI, 9.9, 13.7), 49.6%, 16.5%, and 8.4%, respectively, whereas HR group were 17.8 months (95% CI, 14.8-20.8), 63.1%, 33.3%, and 26.4%, respectively; (P<0.01). Patients in HR group were more likely to developed pleural effusion. Multivariate analysis indicated that PT, tumor size, tumor numbers, UICC stage, and initial treatment were independent prognostic factors. This study revealed hepatic resection was safe and yielded a survival benefic compared with TACE in UICC stage T3 HCC patients. HR seemed to represent the optimal therapy strategy and should be recommended as a preferable treatment for the management of UICC stage T3 HCC.
Tulane University School of Medicine, USA
Keynote: Anesthesia practice: US and international trends in anesthesiology manpower and practice management
Time : 11:00-11:30
Gary Haynes is a practicing Anesthesiologist, Professor, and the Merryl and Sam Israel Chair in Anesthesiology at Tulane University School of Medicine in New Orleans, Louisiana. He is a Graduate of Illinois College (BS), the University of Cincinnati (MS), and Case Western Reserve University (PhD and MD) and had US Residency Training in Anesthesiology at the Medical University of South Carolina. He is a Diplomat of the American Board of Anesthesiology. Prior to becoming Chair at Tulane, he was Professor of Anesthesiology at the Medical University of South Carolina, Professor and Chair of Anesthesiology and Critical Care at Saint Louis University, and a Medical Director with a US national anesthesia practice management company. His interests include resuscitation, blood transfusion and management of acquired bleeding disorders, department administration, and quality management.
Statement of the Problem: Anesthesia practice management requires the availability of well-trained medical professionals who can enter, and be retained in practice settings. Estimating both the needed, and the available professional personnel, and aligning educational programs to meet those needs is a tremendous challenge. Several studies conducted in the US during the past 25 years failed to assess correctly future manpower requirements. During this same period the US healthcare system experienced continuing growth despite major efforts made to reshape the national healthcare system. Coupled with numerous financial challenges, practice management must evolve with the growth of medical education, advances in anesthetic and surgical care, and growing demands for anesthesia services outside the traditional operating room environment. The problem of aligning anesthesia clinicians with demand is a major issue in the United States; however, it is likely an even greater international problem.
Methodology & Theoretical Orientation: Analyzing anesthesia manpower is a longitudinal problem that requires combining information over the span of decades. Analysis of published manpower studies, surveys, institutional and government reports provides the basis for practice management forecasting.
Findings: Past efforts to estimate future anesthesia manpower needs consistently underestimated the actual requirement for anesthesia personnel. Multiple factors including incorrect study assumptions, evolving demographic trends in patient populations, expansion of medical education, changing characteristics in anesthesia professionals, and growth in the use of anesthesia services outside the traditional operating room environment provide some of the explanations for the unexpected results.
Conclusion & Significance: Developed countries will likely have a continuing need for anesthesia professional staff for many years. The need is far greater in many areas of the world. New technological solutions and changes in the delivery of perioperative care will be sought as alternative solutions to the constraints of anesthesia professionals.
- General Surgery | Oncology and Surgery| Plastic Surgery | Anesthesia and Anesthesiology | Airway Management | Microsurgery | Nursing and Surgery
Location: Lucan Suite
Tulane University School of Medicine, USA
Choro Athiphro Kayina
All India Institute of Medical Sciences, India
The First Affiliated Hospital of PLA General Hospital, China
Title: The strategies of repairing the defects or deformities in superficial tissues and organs with skin flaps
Time : 15:40-16:00
Jiake Chai has his expertise in diagnosis and treatment of burn sepsis, destructive tissue defects, research and applications of wound repair materials, and management of critical national and military health emergencies. He Executive Committee Member, Regional Representative of South East Asia for International Society for Burn Injuries (ISBI), and a past Chairman of the Chinese Society of Burn Surgery. He has been invited to be the associate managing editor, member editor, and reviewer of 20 respected medical journals. He was invited as keynote speaker or as an overseas faculty member at many international academic conferences, giving speeches 11 times, followed by recognition from international colleagues.
Statement of the Problem: The repair of the defects or deformities in superficial tissues and organs caused by burns, trauma, tumor or infection, which seriously influence the functions and appearances, is a significant clinical complain.
Purpose: The purpose of this study is to describe that skin flaps should be the preferred choice to recovery of both function and appearance.
Methodology & Theoretical Orientation: Local flap, axial pattern skin flap, island pattern skin flap, pre-expanded skin flap and free skin flap in our department was widely used in clinical intervention. The principals of repairing the defects or deformities of superficial tissues and organs, the indications and cautions in application of skin flaps were discussed. As an important part, use of tissue expansion in preparing pre-expanded skin flap was also shown.
Conclusion & Significance: Personalized repairing depending on the age, sex, whole body condition and subjective demand of the patients was emphasized. I hope our experiences would improve the development of repairing of defects or deformities in superficial tissues and organs.
Jersey General Hospital, UK
Title: Early versus delayed cholecystectomies in patient with acute cholecystitis: A prospect from jersey
Time : 16:00-16:20
Muhammad Aleem has completed his Fellowship in General Surgery from Royal College of Surgeons Edinburgh (UK) and Dublin (Ireland). He has completed his basic and higher surgical training in Republic of Ireland and England. He has special interest in laparoscopic colorectal surgery. He is currently working as a General Surgeon at the Jersey General Hospital Channel Island of UK
Introduction: A continued debate exists regarding the timescale management of cholecystectomies; early versus delayed. On the contrary, delaying a procedure increases the risk of future gallstone related complications and perhaps re-admissions.
Aim of Study: This study looks to identify whether or not cholecystectomy procedures are undertaken using the most recent guidelines available and what this effect has on primary care: Our aim is: to see what proportion of patients are operated on during the initial emergency presentation and how this influences any re-admissions, complications, conversion to open cholecystectomy and total number of bed nights occupied; to examine the local effects of cholecystectomy procedures on primary care. The study will examine waiting times and effects of delayed cholecystectomies in multiple GP attendances.
Methodology: The study identified 100 patients who had undergone a cholecystectomy at Jersey General Hospital. Patients were identified using clinical coding on discharge summaries and operating theatre lists. 91 patients were admitted with cholelithiasis, 72 underwent cholecystectomies. (Reviewed discharge summary and investigations individually). Of all patients presented with acute cholecystitis 47% (17/36) were managed ‘hot’ gall bladders. After exclusions (frail/comorbid, patient choice): the remaining 63% i.e. 4/36 (11%) lap cholecystectomy for acute cholecystitis converted to open- All ‘hot’ gallbladders
Results: No statistical difference in those who developed bile duct injury, conversion to open procedure, operative length, quality of life or significant examples of mortality or morbidity.”
Total hospital stay reduced by 4 days in the early intervention group. Cost saving: £293 per early cholecystectomy. All acute cholecystitis presentations should be managed on initial presentation with laparoscopic/open cholecystectomy. Early laparoscopic surgery vs delayed should have a no-inferior rate of operative complications.
Conclusions: Doing more hot gall bladders in Jersey, which reduces re-presentations. Dedicated emergency list for performing acute (hot) gallbladder.
Muhammad Zeeshan Baig is an Oral Surgeon and an Assistant Professor Oral and Maxillofacial Surgery Department Islamabad Medical and Dental College Islamabad, Pakistan.
An 18-year boy reported with a painless swelling on the left side of his lower face for three months. On clinical examination, facial deformity was observed with a swelling of 4cm x 2cm which extended from #32 to #34. The swelling was non-tender, firm and non-fluctuant with no difficulty in mouth opening. #38 and #33 were missing, #73 was retained but displaced. Aspiration revealed straw colored fluid. Enucleation, along with extraction of #33 and #73 followed by curettage was done. Histopathology determined it as calcifying cystic odontogenic tumor. Patient was followed up on 7th day, 4th week, 6th month and 1 year, which revealed adequate healing and no signs of reoccurrence noted. Endodontic treatment of #36 was done. CCOT (calcifying cystic odontogenic tumor) is a rare developmental odontogenic cyst thought to arise from the odontogenic epithelial remnants within the jaw bones or gingival tissue. It may be infiltrative or malignant intraosseous or extra-osseous. An equal distribution in the jaws is seen mostly in the anterior area with a strong predilection for second decade of age. No gender dominance is seen. It presents as a painless slow growing mass unless secondarily infected. When located in the maxilla, it is associated with headaches, epistaxis and nasal congestion. Radiographic evaluation is facilitated with occlusal, OPG and CT scan. Associated dentition may show root resorption, divergence and impactions. The lesion can be well defined uni-locular or multi-locular. The capsule is fibrous having 4 to 10 cells in thickness. Basal cells are cuboidal or columnar with an overlying loosely arranged epithelium mimicking the stellate reticulum in ameloblastomic lesions. Enucleation and curettage is recommended for the cystic variant as tumor debris can lead to reoccurrence. Excision is well-thought-out as treatment of choice for solid variants. The reported prognosis is excellent with less chances of recurrence. All this was seen with the present case.
Prince Sultan Military Medical City, Saudi Arabia
Title: Hole detected in goal directed fluid therapy: The challenge of fluid challenge to optimize stroke volume
Time : 16:40-17:00
Muhammad Saleh Bahadeg has completed his MBBS, King Saud University, Riyadh, Saudi Arabia from Saudi Board of Anesthesiology, Prince Sultan Military Medical City. He is interested in Anesthesia for Transplant Surgeries and Regional Anesthesia.
Goal directed fluid therapy (GDFT) includes augmentation of cardiac output to improve tissue perfusion that may decrease postoperative complications. GDFT is incorporated into surgical and critical care and is based on fluid responsiveness using stroke volume (SV), pulse pressure (PP), and systolic pressure (SP) variation to a fluid challenge. Dynamic parameters (SVV, PPV, and SPV) are used to replace static parameters as central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), and mean arterial pressure (MAP) to guide fluid volume therapy. GDFT is becoming part of multidisciplinary approaches to enhance recovery after surgery (ERAS). However, recent studies suggest that benefits of GDFT might be less pronounced than previously believed and there are evidences that SV optimization strategies could be harmful by increasing volume overload, and that modality does not provide the benefits previously described. If patient’s position is on the steep part of the Frank-Starling curve it may benefit from a further fluid challenge; a theory which is almost an oversimplification of complex intraoperative hemodynamics as painful surgical stimuli accompanied by endogenous catecholamine levels, vasodilator effects of neuraxial blockade, and anesthesia may vary considerably such that it is impossible to be sure about optimum stroke volume at a particular moment. The presence of a hole in goal directed fluid therapy is due to the following facts; A) Dynamic monitors (derived and not measured variables) are poor at distinguishing absolute hypovolemia from apparent hypovolemia due to low systemic vascular resistance induced by anesthetic medications; B) Pharmacodynamics of crystalloids indicates that their temporary effect in circulation is limited to 20–30 minutes and redistribution to interstitial space will create tissue oedema that will be translated to post-operative complications. If we check fluid responsiveness after 45 minutes, we will be seriously misled. Anesthesia is as much an art as science; our aim is to use perioperative body weight as an important vital sign to implement “zero fluid balance” rather than the change from liberal to restrictive fluid therapy. The dynamic monitoring should be interpreted cautiously within the overall context of the hemodynamics of the patient and consider anesthetic vasodilator effect combined with surgical stimulation that change the stressed blood volume without change in total blood volume, so that vasopressor is needed rather than volume overload. We should consider the hole in goal directed fluid management as well as the limitation of stroke volume optimization so that every attempt can be made to avoid volume overload.
Augusta University Medical Center, USA
Time : 15:20-15:40
L Renee Hilton, MD, is a Board Certified General Surgeon and is a Fellowship trained in both bariatric and minimally invasive surgery. She is the Director of Bariatric Surgery and the Center of Obesity and Metabolism at Augusta University Medical Center. She is an Assistant Professor at the Medical College of Georgia. She completed her general surgery residency at Jackson Memorial Hospital and then fellowship in bariatric and minimally invasive surgery at Yale University. She has been involved in numerous research projects involving obesity and foregut motility and is currently serving as the Principal Investigator on two trials at Augusta University Medical Center. She specializes in laparoscopic procedures for obesity, including gastric bypass, sleeve gastrectomy, and revisions of prior bariatric surgery. She is dedicated to helping individuals with morbid obesity reach healthier weights and improve their quality of life.
Gallstone disease is one of the most prevalent disease processes being managed by general surgeons across the country; in some studies as high as 15% of the population will be diagnosed with cholelithiasis annually. Cholelithiasis is even more prevalent in the bariatric patient population due to rapid weight loss and is seen in 30-71% of patients. Both the increase in bariatric procedures being performed each year along with the change in practice at most institutions of no longer performing cholecystectomy at the time of initial surgery presents us with a new surgical problem; how should we manage bariatric patients who present with gallstone disease? Diagnosis of gallstone disease in bariatric patients can be a difficult challenge due to many possible etiologies of abdominal pain; however, like the general population, the most common presenting symptoms of gallstone disease are post-prandial right upper quadrant or epigastric abdominal pain and mild nausea with or without vomiting. Evaluation is similar to that of the general population and includes laboratory testing and multiple imaging modalities. Management of gallstone disease in post-operative bariatric patients largely depends on the type of surgery that they have had and whether their foregut anatomy is altered. The purpose of this paper is to review the current literature as well as our own experience to provide a standard for both diagnosing and managing gallstone disease in patients who have had bariatric surgery. Lastly, it is our opinion and recommendation that any patient with gallstone disease and altered foregut anatomy be managed at a tertiary center where a multidisciplinary team is available. The surgeon involved in the case should be an experienced laparoscopic surgeon in either hepatobiliary or bariatric surgery. These cases are technically challenging and adequate knowledge of the surgical foregut anatomy is required to surgically manage these patients safely.
All India Institute of Medical Sciences, India
Title: Confirmation of endotracheal tube placement: Comparison of ultrasound based versus conventional methods-An exploratory study
Time : 12:00-12:20
Choro Athiphro Kayina is working as a Senior Resident Doctor, Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Delhi, India. She graduated from the Regional Institute of Medical Sciences, Imphal, India, and was awarded a gold medal for her Excellence in Obstetrics and Gynecology. She received her MD (Anesthesia) in 2016 from the University College of Medical Sciences, Delhi. Her interest is in Airway Management and Obstetric Anesthesia.
Statement of the Problem: Correct positioning of endotracheal tube (ETT) is necessary to ensure adequate ventilation. Various methods are used for this purpose. Ultrasonography (USG) is a useful, quick and non-invasive method for identification of ETT placement. Three USG methods have been described in literature viz., direct USG visualization of ETT in trachea, “sliding lung sign” and diaphragmatic dome movement. However, the time taken for each of these methods to correctly identify the ETT position has not been previously studied. This study is designed to compare the time taken and the accuracy of detection of position with the three USG methods, conventional auscultation and capnography techniques.
Methodology & Theoretical Orientation: This prospective, randomized controlled trial was conducted on ninety ASA I/II patients, 18–60 years requiring general anesthesia (GA) with tracheal intubation. Patients were randomized on the basis of a computer generated table into three groups depending upon the USG probe position: Group T (tracheal), Group P (pleural) and Group D (diaphragmatic). The time taken for confirmation of ETT placement was recorded.
Findings: Time taken to identify ETT placement was significantly less in Group T compared to the other two groups (p=0.000). The time taken in Group P and Group D was less than that required for confirmation by capnography but was more compared to auscultation.
Conclusion & Significance: All three USG techniques could accurately confirm ETT placement. Real time passage of ETT through the trachea was the fastest amongst the three USG techniques. It was faster than conventional auscultation and capnography techniques. We recommend the use of real time USG visualization of trachea for confirmation of ETT placement especially in trauma victims and patients who are at high risk of aspiration, as it does not require ventilation and hence avoids gastric insufflations in case of accidental esophageal intubation.
Alicia Huff Vinyard is a Board Certified General Surgeon and Fellowship Trained Breast Surgical Oncologist at the Georgia Cancer Center in affiliation with the Augusta University Medical Center in Augusta, Georgia, USA. She attended UNC-Chapel Hill where she completed her pre-medical degree. She completed medical school in 2011 at the Georgia Campus of Philadelphia College of Osteopathic Medicine, Pennsylvania, USA. She completed general surgery training at Augusta University. She decided to specialize in breast surgical oncology to help other breast cancer survivors like herself with a special interest in young breast cancer patients and the obstacles they face. She obtained a fellowship in breast surgical oncology at the University of Miami-Miller School of Medicine in Miami, Florida, USA. She is now employed by the Georgia Cancer Center to lead the breast cancer program as the primary breast surgeon.
Background: Lymphedema (LE) is a serious complication of axillary lymph node dissection (ALND) with an incidence rate of 16%. Lymphatic microsurgical preventing healing approach (LYMPHA) has been proposed as an effective adjunct to ALND for the prevention of LE. This procedure however requires microsurgical techniques.
Aim: The aim of this study was to assess the efficiency of simplified-LYMPHA (SLYMPHA) in preventing LE in a prospective cohort of patients.
Methodology: All patients, undergoing ALND with or without SLYMPHA between January 2014 and December 2016 were included in the study. SLYMPHA is a slightly modified and simplified version of LYMPHA. It is performed by the operating surgeon performing the ALND. One or more lymphatic channels identified by reverse arm mapping are inserted using a sleeve technique into the cut end of a neighboring vein. During follow-up visits, tape-measuring limb circumference method was used to detect clinical LE. Demographic, clinical, surgical and pathologic factors were recorded. The incidence of clinical LE was compared between ALND with and without SLYMPHA. Univariate and multivariate analysis were used to assess the role of other factors in the appearance of clinical LE.
Results: 406 patients were included in the study. SLYMPHA procedure was attempted in 81 patients and was completed successfully in 90% of patients. Early complication rates were similar between patients who underwent SLYMPHA and who did not (4% vs. 4.13%; p=0.948). Median follow-up time was 15±13.73 [1-32] months. Patients, who underwent SLYMPHA, had a significantly lower rate of clinical LE both in univariate and multivariate analysis (3% vs 19%; p=0.001; OR 0.12 [0.03-0.5]). Excising >22 lymph nodes and a co-diagnosis of diabetes were also correlated with higher clinical LE rates on univariate analysis, but only excising >22 lymph nodes remained to be significant on multivariate analysis.
Conclusions: SLYMPHA is a safe and relatively simple method, which decreases incidence of clinical LE dramatically. It should be considered as an adjunct procedure to ALND for all patients during initial surgery.
SMG-SNU Boramae Medical Center, South Korea
Time : 12:40-13:00
Young Jun Chai is an Assistant Professor of Surgery at Seoul Metropolitan Government-Seoul National University Boramae Medical Center since 2013. He was educated and trained at Seoul National University. He is a Managing Editor of Journal of Endocrinology (JES), Secretary of Korea Intraoperative Neural Monitoring Society (KINMoS), and Korean Society of Head and Neck Oncology (KSHNS). He is also an Editorial Board of Clinics in Oncology Journal - Head and Neck Oncology; an active Member of International Society of Oncoplastic Endocrine Surgeons (ISOPES), and Intraoperative Neural Monitoring Study Group (IONMSG). His major interest is endocrine surgery of thyroid, parathyroid, and adrenal glands. He is also interested in molecular biology of thyroid cancer and gave oral presentation at the annual meeting of American Association of Endocrine Surgeons (AAES) in 2014 and 2016 respectively. He has published more than 40 SCI(E) papers and 3 textbooks.
Background: Fine needle aspiration (FNA) is the procedure of choice for evaluating thyroid nodules and FNA may be required even for nodules with very low suspicion of malignancy if they are larger than 2 cm. However, avoiding unnecessary FNA is important to reduce complications related to FNA and to reduce medical expenses. In this study, we developed an image analysis model using deep learning algorithm and evaluated if the algorithm could predict which nodules would have benign FNA results.
Methodology: Ultrasonographic images of thyroid nodules with FNA cytology or surgical pathologic results were retrospectively collected at Boramae Medical Center, Seoul, Republic of South Korea. The images of the nodules were put into the Inception-V3 network model, pre-trained with ImageNet database for fine-tuning. A total of 1,358 images of the nodules (670 benign, 688 malignant) were used for the algorithm development, and the algorithm was trained to predict a nodule as benign or malignant.
Results: Total 55 nodules (34 benign, 21 malignant) from SMG-SNU Boramae Medical Center, and 100 nodules (50 benign, 50 malignant) from Kuma Hospital, Kobe, Japan were used for internal and external test sets. For internal test set, of the 21 FNA malignant nodules, 20 were predicted as malignant by the algorithm (sensitivity, 95.2%). Of the 22 nodules algorithm called benign, 21 were FNA benign (negative predictive value, 95.5%). For external test set, of the 50 FNA malignant nodules, 47 were predicted as malignant by the algorithm (sensitivity, 94.0%). Of the 31 nodules algorithm called benign, 28 were FNA benign (negative predictive value, 90.3%).
Conclusions: The deep learning algorithm had a high sensitivity and negative predictive value despite an unrealistically high percentage of FNA suspicious for malignancy nodules tested. Using deep learning algorithm may assist clinicians in selecting those nodules that are most likely to be benign and avoid unnecessary FNA.
Shalini Nalwad is a Director and Co-founder ICATT International Health Solutions Pvt Ltd, India. Graduated from Mysore University and obtained Fellowship in anaesthesia from College of Anaesthetist Ireland and Membership from Royal College of Anaesthetist. She is associated with Europe’s leading Air ambulance company, has retrieved patients from 5 countries, 2 continents in 72 hours and has undeterringly air-lifted patients from Libya in midst of the turmoil. She has started ICATT an air ambulance company in India in 2014. Has set up guidelines and protocols for the organ air-lifting and has been extensively involved in the organ air-lifting operations. She has made International and National presentations on HEMS, ECMO, Aviation Medicine at Doha, Cairo, Singapore. She is an ECMO specialist from Leicester Glenfield hospital UK June 2015.
Aeromedical transfers are exponentially increasing worldwide. Aeromedical transfers are expensive and potentially dangerous (to the patient and the team) and should not be undertaken unless necessary indications could be for the specialist intervention, on-going support not available at the referring hospital, investigations, lack of staffed intensive care beds or repatriation to the home country or town. All transfers are done on intensive care society guidelines UK/ AAGBI (Association of Anesthetist Great Britain Ireland) All transfers are done bed to bed. Our team lands a night before and assesses the patient and takes over the ICU care, intervene and optimize the patient for air lifting. Despite these transfers are being inter-facility they are more like primary transfers or may be even pre-hospital depending on the referring hospital. Our transfers are both domestic and International. Types of transfers are level 0 to level 4, and we do organ, patient, surgical team, surgical instruments or any medical related transfers.
We do get involved in the end to end logistics for the organ air-lift from deciding the retrieval time to the cross-clamping to creating the green corridors. We have been involved in the International ECMO transfer and was presented in the SWAC 2017 Doha and published in the Qatar medical journal.
Qualities and the talents of the aeromedical team are many, decision making at 40,000 feet, with limited support, out of comfort zone, crisp communication, possibly multi-linguistic, rapport with the aviation team, team work, role sharing, multi-tasking and out of box thinking along with the other factors like jet-lag, exhaustion, boredom.
Conclusion: Each transfer is perplexing due to the diverse factors involved like the pre-transfer condition of the patient, cultural variation, financial, immigration clearance, tarmac clearance, language, relatives, and equipment. Knowledge cannot be limited to medical only and cannot always be conventionally adhered to the AAGBI or Intensive Care Society UK guidelines.
Prince Sultan Military Medical City, Saudi Arabia
Title: Time to stop chaos and confusion about perioperative fluid infusion: Current conceptions need correction
Time : 14:05-14:25
Muhammad Saleh Bahadeg has completed his MBBS, King Saud University, Riyadh, Saudi Arabia from Saudi Board of Anesthesiology, Prince Sultan Military Medical City. He is interested in Anesthesia for Transplant Surgeries and Regional Anesthesia.
Perioperative fluid management is a key component in the care of surgical patients, and each additional litre given in the operating room would cause a 32% increase in the risk of postoperative complications, length of hospital stay, and costs. Thus the anesthesiologist’s practice can make the difference. Current practice of fluid infusion should be re-evaluated, as major abdominal surgery with minimal blood loss can be given any amount of fluid from (700 ml–5400 ml) in four hours, simply because it’s according to an individual provider habits that are hard to justify and continuous apathy is unaccepted. After prolonged preoperative fasting, healthy patients remain euvolemic, and insensible perspiration is shown to be 0.5–1 ml/kg/hour. Even during large abdominal surgery, excessive volumes are infused to compensate loss to the third space, which does not exist. Currently taught methods of intraoperative management in which intravenous fluids are given, based on generalized formula relying on body weight per unit time and modified by perceived magnitude of surgical trauma are not supported by physiological principals. The heart is an endocrine gland that secretes atrial natriuretic peptide (ANP) and the circulating blood volume is only 25–30% of total blood volume as well as 0.8–1.2 of the plasma volume is lining the blood vessels and forms the endothelial glycocalyx that can be distorted by ANP released by hypervolemia. Urine output should not be the driving force of fluid administration. During induction of anesthesia, a starting bolus volume is necessary to compensate for both hypovolemia of the fasting patient and vasodilatation. This has been considered as a good practice for years, but may be inappropriate and the foundation to postoperative complication even before surgery starts. Increased mortality and morbidity was associated with the most commonly used normal saline due to hyperchloraemic acidosis. There is no rational to replace 1 ml blood loss by 3–4 ml of crystalloid infusion. Our aim is to discuss the current conceptions that need urgent correction so that fluid infusion can support the patients’ physiological parameters and improve patients’ outcome.
Fabiano Calixto Fortes de Arruda pursued MBA in Health Management, a Master’s Degree in Health Sciences and works in Goiania, Goias, Brazil as Chief of Department of Plastic Surgery and Burn Unit of Hugol. He has his expertise in plastic surgery, working with academic and practice. He is interested in plastic surgery aesthetic and reconstructive surgery. He has done studies in the areas of plastic surgery development. He has many chapters of books and scientific articles and has published books on financial aspects.
Statement of the Problem: The theme quality of life is commonly studied by surgeons, but the quality of life of surgeons is not so well known. Long work hours, technical challenges and high stakes outcomes are hard practice that become worse quality of life and development of burnout. A study from American College of Surgeons suggests that 40% of surgeons experience burnout and 30% experience symptoms of depression.
Methodology & Theoretical Orientation: An electronic search encompassing MEDLINE, SCiELO, Embase databases were completed using search terms: quality of life, burnout, surgeon, surgical specialty. Inclusion criteria: full manuscript in English, Spanish and Portuguese, from January 1987 to December of 2017, with surgical medical specialties related with quality of life and burnout. Studies with students or residents were excluded.
Findings: The majority of studies in this area are cross sectional. Some studies are associating female sex with increased risk of burnout, depression and lesser career satisfaction, but not found statistically significant difference for poorer quality of life. We found some studies with 16 surgery fields. Hours worked per week were statistically significant predictor of surgeon burnout, psychiatric morbidity, diminished career satisfaction and decreased work life balance. Some studies found inverse relationship between income and attending burnout.
Conclusions & Significance: Studies about burnout and quality of life are not so common but it shows us that changes in lifestyle is needed to conquest heath and quality. Burnout and Quality of life vary across all specialties, so it is necessary to know each field adequately for a surgeon to increase an optimized quality of life.
Sapienza University of Rome, Italy
Time : 14:45-15:05
Alberto Montori MD Emeritus Prof. of General Surgery University of Roma “Sapienza” Italy. FACS ( HON) ISS/SIC (HON) FASGE. G.BERCI, SAGES lifetime achievement, EAES lifetime achievement. IFSES recognition. Former president of SIED, SICE ESGE, EAES, UEG. His main interets in clinical practice is surgical digestive activities, new technology applied to surgery, minimally invasive surgery. Former professor and chairman of 3rd surgical clinic at University of Roma “Sapienza” visiting professor at Thomas Jefferson Medical School College (Philadelphia). He has received many awards and recognitions from scientific associations all over the world.
The Surgical Art is a discipline based on performing technical procedures following the anatomy-surgical principles! However, it is my opinion that the new tools represent a tremendous educational mean in surgical practice and training. Any “image” obtained by so many instruments and the possibility to perform many operations through the instruments (even robotically in to the scope) etc. can be done by surgical hands which knows better than other specialists the surgical principles. In addition to that we must consider all the advanced endoscopic procedures were invented by Surgeons and they are surgical procedures: this is the term which must be used and not “operative” or “therapeutic” used by some specialist who have nothing to do with surgery. The general surgery will change the way to operate (using different instrumentations) remain in my mind, even in the future, Surgery Never Die! I am convinced about this not because I am Surgeon ( trained in a surgical environment) even if I was one of the Surgeon who believed in new technologies applied to Surgery and practically used them every day in O.R. in my last 50 years of clinical practice.The development of Surgery during the last three millennium was tremendous! We had many surgical input from Chinese Surgery, Indian, Jewish, Egyptian, and Mesopotamian; I was particularly linked to the Mycenae-Greek-Roman culture but I never forget that the Surgery was officially recognized by the King of the Assiro- Babylonians, Hammurabi who lived between 1948-1905 B.C.After all these amount of years Surgery became an Art and today represent one the most important Academic Sciences and its importance is recognized from everyone involved in Medicine. There is someone who try to define Surgery mechanical manipulation of tissue the Surgeons are not interested in screening just treatment! This is not true!