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Surgical care is now recognized as a fundamental component of universal health coverage. Unfortunately, most of the world is still without access to safe and timely surgical care, including 9 out of 10 people living in low- and middle-income countries (LMICs). Additionally, even in LMICs with sustainable surgical programs, surgical outcomes continue to lag behind those in high-income countries. In this article, we will provide a brief history and introduction to global surgery, an overview of the existing literature on global surgical outcomes, and a discussion surrounding the challenges to building surgical capacity and improving surgical outcomes in LMICs. In addition, we will discuss the existing frameworks for building surgical care into national universal healthcare plans and initiatives striving improve surgical outcomes in LMICs.

Multimodal, narcotic-sparing analgesic strategies are an important part of enhanced recovery after surgery protocols. Within such protocols, regional anesthetics have proven to be superior to narcotics.This study aimed to evaluate the impact of the transversus abdominis plane block within an enhanced recovery after surgery protocol on length of stay.A retrospective analysis of patients who underwent colorectal surgery in 2015 to 2016 was completed. The primary end points for this analysis were total length of stay and total narcotics consumed during hospitalization. Length of stay and total narcotic use were compared for patients who received a transversus abdominis plane block versus those that did not.The data were obtained from the data warehouse of a university teaching hospital.This study took place at a university teaching hospital.The patients were 18 years or older.The primary outcomes measured were length of stay and the total narcotics used.A total of 347 patients underwent colorectal procedures under the enhanced recovery protocol. Among these, 186 (54%) received a transversus abdominis plane block. Overall, the mean length of stay was 5.8 days (SD ±5.6), and median length of stay was 4 days. These values compare to a mean length of stay of 9.6 days and median length of stay of 7 days before implementing the enhanced recovery protocol. Patients who received a transversus abdominis plane block had a mean length of stay of 5.1 days compared to 6.6 days for those who did not receive one (p0.01). Patients who received a transversus abdominis plane block consumed 736.5 morphine milligram equivalents of opioids compared to 1150.3 morphine milligram equivalents of opioid consumed by those without a transversus abdominis plane block (p0.05), a 36% decrease in opioid use. When comparing patients who had a mean length of stay of 4 days with those whose length of stay was4 days, there was an 80% decrease in opioid use. The readmission rate was 7.8%.The lack of randomization of patients was a limitation of this study.The use of transversus abdominis plane block in the setting of a well-structured enhanced recovery protocol was associated with a statistically significant decrease in length of stay by 1.5 days and a 36% decrease in narcotic use. See Video Abstract at http://links.lww.com/DCR/B432.ANTECEDENTES:La estrategia analgésica multimodal que consume poco medicamento de tipo narcótico es parte importante en los protocolos de recuperación mejorada postoperatoria. Dentro de dichos protocolos, los anestésicos regionales han demostrado ser superiores a la administración de medicamentos narcóticos.OBJETIVO:Estudiar el impacto del bloqueo del plano muscular de los transversos del abdomen sobre la duración de la estadía dentro de un protocolo de recuperación mejorada postoperatoria.DISEÑO:Se realizó un análisis retrospectivo de los pacientes que se sometieron a cirugía colorrectal entre 2015-2016. Los criterios principales de valoración en el presente análisis fueron la duración total de la estadía y el total de medicamentos narcóticos consumidos durante la hospitalización. Se comparó la duración de la estadía y el uso total de narcóticos en los pacientes que recibieron un bloqueo anestésico del plano muscular de los transversos del abdomen con los que no lo recibieron.FUENTE DE DATOS:Banco de datos de un hospital universitario docente.AMBIENTE:Hospital Universitario Docente.PACIENTES:Adultos desde los 18 años o mayores.PRINCIPALES MEDIDAS DE RESULTADO:Duración de la estadía, cantidad total de medicamentos narcóticos administrados.RESULTADOS:Un total de 347 pacientes se sometieron a procedimientos colorrectales bajo el protocolo ERAS. Entre ellos, 186 (54%) recibieron un bloqueo del plano muscular de los transversos del abdomen. En la globalidad, la duración media de la estadía fué de 5,8 días (DE ± 5,6) y la duración media de la estadía fué de 4 días. Estos resultados fueron comparados con la estadía media de 9,6 días y una estadía media de 7 días antes de implementar el protocolo ERAS. Los pacientes que recibieron un bloqueo del plano muscular de los transversos del abdomen tuvieron una estadía media de 5,1 días en comparación con los 6,6 días de los que no recibieron el mencionado bloqueo (p0,01). Los pacientes que recibieron el bloqueo del plano muscular consumieron 736,5 miligramos de morfina o su equivalente en opioides, comparados con los 1150,3 de aquellos sin bloqueo del plano muscular (p0,05) lo que significó una disminución del 36% en la administración de opioides. Al comparar los pacientes que tuvieron una estadía media de 4 días con aquellos cuya estadía fue mayor a 4 días, se evidenció una disminución en el 80% de la administración de opioides. La tasa de reingreso fue del 7,8%.LIMITACIONES:Estudio sin sin aleatorización de pacientes.CONCLUSIÓN:El bloqueo anestésico del plano muscular de los transversos del abdomen dentro un contexto protocolar tipo ERAS o de recuperación mejorada bien estructurada, se asoció con la disminución estadísticamente significativa de la duración de la estadía en 1,5 días y una disminución del 36% en la administración de medicamentos narcóticos. Consulte Video Resumen en http://links.lww.com/DCR/B432.

Background The vast majority of women with breast cancer in sub-Saharan Africa present with advanced stage disease, due primarily to the lack of opportunities for early detection and treatment. As part of a larger effort to increase access to diagnostic and therapeutic services for women’s cancers in the Democratic Republic of Congo (DRC), we implemented a curriculum to train the local workforce and a program to build the supportive infrastructure for the diagnosis and treatment of breast cancer at a private sector health facility (Biamba Marie Mutombo Hospital) in Kinshasa. Study design After onsite trainings in the DRC by a US breast surgeon (RT), Congolese surgeons, general physicians, physician assistants, and nurses used the Phillips Lumify smart-phone ultrasound device to perform and interpret the results of whole breast ultrasound on symptomatic women. Surgeons were trained to perform ultrasound-guided core needle biopsy on those who met the criteria for tissue diagnosis, after which they trained nurses to do the same. Results Over 3 years, 5,211 patients were identified as having a breast abnormality on clinical breast examination. Ultrasound abnormalities were noted in 1,493 (27%) patients, of which 632 (42%) met the criteria for ultrasound-guided core needle biopsy or fine needle aspiration. Pathology reports were available on 368 (58%) patients who underwent biopsy, of which 164 were malignant and 204 benign. Conclusions We demonstrated how the “ability to look” using smart technology can be successfully used to augment clinical breast exam and triage patients for biopsy in a resource-constrained African setting.

Electronic health records (EHRs) or electronic medical records (EMRs) contain a vast amount of clinical data that can be useful for multiple purposes including research. Disease registries are collections of data in predefined formats for population management, research, and other purposes. There are differences between EHRs and registries in the data structure, data standards, and protocols. Proprietary EHR systems use different coding systems and data standards, which are usually kept secret. For EHR data to flow seamlessly into registries, there is the need for interoperability between EHR systems and between EHRs and registries. The levels of interoperability required include functional, structural, and semantic interoperability. EHR data can be manually mapped to registry data, but that is a tedious, resource-intensive endeavor. The development of data standards that can be used as building blocks for both EHRs and registries will help overcome the problem of interoperability.

Background Sacral tumors present a significant challenge to the spine surgeon. As new techniques have evolved in recent years, these lesions have become more amenable to aggressive surgical treatment. Although sacral tumors make up only a small minority of spinal tumors, their surgical management warrants special consideration. Methods Based on our experience, we highlight 3 important surgical nuances specifically for the treatment of sacral tumors: preservation and maximization of neurologic function, protection of ventral abdominal and pelvic structures, and lumbopelvic fixation. Results Two cases of patients with sacral tumors treated at our institution are presented to illustrate these points. Both patients had successful postoperative courses, and remained pain free, well-fixated, and neurologically intact at 3–4 month follow-up. They had no evidence of biomechanical instability. Conclusions To ensure a successful outcome, a goal-directed, methodical approach is required.

To test the efficacy of a community-based intervention, Empowering Communities for Life (EC4L), designed to increase colorectal cancer (CRC) screening through fecal occult blood test (FOBT) in rural underserved communities in a randomized controlled trial. Participants were randomized into 3 groups (2 interventions and 1 control). Interventions were delivered by community lay health workers or by academic health professionals. The main outcome of interest was return rate of FOBT screening kit within 60 days. Participants included 330 screening-eligible adults. The overall return rate of FOBT kits within 60 days was 32%. The professional group (Arm 2) had the highest proportion of returned FOBTs within 60 days at 42% (n = 46/110), a significantly higher return rate than the lay group (Arm 1) [28%(n = 29/103);P = 0.0422] or control group (Arm 3) [25%(n = 29/117);P = 0.0099]. Thus, one arm (Arm 2) of our intervention produced significantly higher CRC screening through FOBT. Community-based participation partnered with academic health professionals enhanced CRC screening among rural and poor-resourced communities.

Precision public health requires research that supports innovative systems and health delivery approaches, programs, and policies that are part of this vision. This study estimated the effects of health insurance mandate (HiM) variations and the effects of physician utilization on moderating colorectal cancer (CRC) screening rates. A time-series analysis using a difference-in-difference-in-differences (DDD) approach was conducted on CRC screenings (1997–2014) using a multivariate logistic framework. Key variables of interest were HiM, CRC screening status, and physician utilization. The adjusted average marginal effects from the DDD model indicate that physician utilization increased the probability of being “up-to-date” vs. non-compliance by 9.9% points (p = 0.007), suggesting that an estimated 8.85 million additional age-eligible persons would receive a CRC screening with HiM and routine physician visits. Routine physician visits and mandates that lower out-of-pocket expenses constitute an effective approach to increasing CRC screenings for persons ready to take advantage of such policies.

Introduction. African Americans (AAs) have a colorectal cancer (CRC)-based health disparity. However, AAs had higher screening test usage than non-Hispanic whites (NHWs) in Arkansas in 2016. Additionally, CRC is of interest in Arkansas because geographic areas such as the Delta regions in Arkansas remain mortality hotspots. Also, certain lifestyle factors such as diet, alcohol and tobacco use, and physical activity have been associated with CRC risk. Our goal is to examine the association between colorectal health, diet, and sociodemographics related to access to adequate food, to understand the factors involved in the CRC health disparity among AAs. Method. We are recruiting participants who have recently (2019-2021) received a colonoscopy. These participants are filling out surveys related to their demographics, socioeconomic status, health, family history, lifestyle, and diet, as well as collecting a stool sample at home for our future untargeted metabolomic analysis. For this preliminary analysis, we have focused on self-report survey data to determine which factors are associated with colorectal health and race. Results. We used t-tests with Bonferroni correction and chi-square test with statistical significance at p Citation Format: Jonathan A. Laryea, Eryn K. Matich, Ping-Ching Hsu, Joseph Su. Associations between diet and food security with colorectal cancer-based health disparity among African Americans [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-160.

There is no single formula or reason for becoming involved in the American Society of Colon and Rectal Surgeons (ASCRS) or any other national organization. With so many organizations and opportunities available, often it is difficult to know which ones to choose, particularly in medicine. There are several key factors in deciding to join an organization, and the level of involvement. Reasons may include professional development, continuing education, networking, or community service. Whatever the reason, one must make a plan to get involved, utilize various resources available to promote involvement (mentors, senior partners, social media), and most importantly, follow through. There are common missteps that one must avoid in order to be successful: find balance, be sure to network, and do not be afraid to contribute.

Rectal prolapse is a debilitating condition with a complex etiology. Symptoms are most commonly prolapse of the rectum and pain with bowel movements or straining, with worsening fecal incontinence over time due to progressive stretching of the anal sphincters. Physical findings are fairly consistent from patient to patient—most notably diastasis of the levator ani muscles, deep pouch of Douglas, redundant sigmoid colon, a mobile mesorectum, and occasionally a solitary rectal ulcer. Evaluation includes a physical exam or imaging demonstrating the prolapse, and evaluating for other causes of pelvic floor dysfunction. Multiple surgical repairs are available, but treatment must be individualized based on patient symptoms and the presence or absence of constipation or other pelvic floor disorders. Mesh repairs have shown promising results, but carry the added risks of mesh erosion, infection, and mesh migration. The optimal repair has not been clearly demonstrated at this time.

Mixed epithelial stromal tumor (MEST) is rare and typically benign renal cystic neoplasm that cannot be clinically distinguished from cystic renal cell carcinoma. Its mainstay course of diagnosis and treatment remains surgical excision. Recurrence and malignant transformation is rare but has previously been described. To our best knowledge, we present the first case of peritoneal seeding resulting in a paracolonic MEST following incomplete resection in a patient with benign MEST. This signifies a new pathological behavior for MEST, predominantly, a benign kidney tumor. In addition, documentation with more cases of MEST is needed to further understand its pathogenesis, clinical behavior, malignant potential, and optimal management.

Fiber bundle microendoscopic imaging of colorectal tissue has shown promising results, for both qualitative and quantitative analysis. A quantitative image quality control and image feature extraction algorithm was previously designed for quantitative image feature analysis of proflavine-stained ex vivo colorectal tissue. We investigated fluorescein as an alternative topical stain. Images of ex vivo porcine, caprine, and human colorectal tissue were used to compare microendoscopic images of tissue topically stained with fluorescein and proflavine solutions. Fluorescein was shown to be comparable for automated crypt detection, with an average crypt detection sensitivity exceeding 90% using a combination of three contrast limit pairs.

BACKGROUND Racial disparity exists in colorectal cancer outcomes. The reasons for this are multifactorial. OBJECTIVE The aim of this study was to evaluate the role of equal treatment of blacks and whites in the elimination of racial disparity in colorectal cancer outcomes. DESIGN A retrospective cohort study of 878 patients with colorectal cancer diagnosed between 1998 and 2008 was done at a University tertiary referral center. Demographic variables including age, sex, and race were abstracted. Tumor-specific variables including American Joint Committee on Cancer stage, anatomic tumor location, vital status, and survival were obtained. Treatment-specific variables including surgery, chemotherapy, radiotherapy, and follow-up were also obtained. Racial differences in these variables were studied and their effect on overall survival was determined by using univariate and multivariate analyses. The findings were then compared with previous data from our institution. SETTING University tertiary referral center. MAIN OUTCOME MEASURES The primary outcomes measured were overall survival and cancer-specific mortality. RESULTS A total of 878 patients met the inclusion criteria, 186 (21.2%) of whom were black. Blacks were significantly younger at diagnosis in comparison with whites, with a median (quartiles) age of 55 years (28-87) compared with 59 years (23-94) (p = 0.0012). Equal proportions of blacks (78.5%) and whites (79.2%) underwent surgery (p = 0.84), similar proportions of blacks (55.4%) and whites (60.8%) received chemotherapy (p = 0.18), and similar proportions of blacks (17.2%) and whites (20.5%) received radiation therapy (p = 0.31). There was no difference in overall survival or cancer-specific mortality between the 2 racial groups. Univariate analysis showed American Joint Committee on Cancer stage and surgery as the only statistically significant factors for overall survival. On multivariate analysis, stage, surgery, and chemotherapy were the only statistically significant factors. Race was not an independent determinant of survival. CONCLUSIONS There were no differences in overall survival and cancer-related mortality between blacks and whites, and this may have resulted from identical treatment. The previously noted disparities in treatment and overall survival at our institution have disappeared.

We tested the hypothesis that racial differences that exist in the distribution of ABO blood type would partially explain the racial disparity in overall survival seen in colorectal cancer.retrospective analysis of the cancer registry of a university hospital for patients treated for colorectal cancer between 1996 and 2008. Demographic, tumor-specific, and treatment-specific variables were abstracted. We also obtained ABO blood group data. The primary end point was overall survival. We divided patients into two groups based on where they underwent surgery: the University of Arkansas for Medical Sciences (UAMS) or outside facilities.Of 833 patients, 182 (21.8%) were black. There was no difference in overall survival between blacks and whites for the entire group (P = 0.61). There was a statistically significant difference in overall survival between patients at the UAMS and outside facilities (P0.0001). For the outside facilities group, there was a statistically significant difference in overall survival between blacks and whites (hazard ratio, CI: 1.48 [1.06-2.00]; P = 0.012); no race difference existed for the UAMS group. The ABO blood group had no effect on overall survival. On stage-stratified univariate and multivariate analyses, chemotherapy and surgery were the only statistically significant determinants of survival.In this study, racial differences in ABO blood group distribution had no effect on overall survival.

Magnetic resonance imaging has become more frequently utilized for staging, preoperative planning, and post-neoadjuvant evaluation of rectal cancer. It offers detailed resolution of the layers of the rectal wall, visualization of the mesorectal fascia, and identification of locoregional nodal involvement. Many advances have been made since the original protocols and include the use of phased-array coils, orthogonally obtained images and 3-dimensional sequences, the use of diffusion-weighted and perfusion protocols to better evaluate the tumor before and after neoadjuvant therapy, and the development of techniques to better evaluate metastatic nodes. Magnetic resonance imaging shows similar accuracy to endorectal ultrasound when staging and offers a less invasive technique that is not limited by patient discomfort or decreased luminal size. This article is meant to provide an update on the recent advances in rectal cancer imaging while addressing the controversial issues that exist in staging, technique, and imaging protocol.

Qualitative screening for colorectal polyps via fiber bundle microendoscopy imaging has shown promising results, with studies reporting high rates of sensitivity and specificity, as well as low interobserver variability with trained clinicians. A quantitative image quality control and image feature extraction algorithm (QFEA) was designed to lessen the burden of training and provide objective data for improved clinical efficacy of this method. After a quantitative image quality control step, QFEA extracts field-of-view area, crypt area, crypt circularity, and crypt number per image. To develop and validate this QFEA, a training set of microendoscopy images was collected from freshly resected porcine colon epithelium. The algorithm was then further validated on ex vivo image data collected from eight human subjects, selected from clinically normal appearing regions distant from grossly visible tumor in surgically resected colorectal tissue. QFEA has proven flexible in application to both mosaics and individual images, and its automated crypt detection sensitivity ranges from 71 to 94% despite intensity and contrast variation within the field of view. It also demonstrates the ability to detect and quantify differences in grossly normal regions among different subjects, suggesting the potential efficacy of this approach in detecting occult regions of dysplasia.

The primary goal of fast track protocols is to enhance postoperative recovery by decreasing morbidity, mortality, length of stay, and return to full function. An important component of limiting postoperative morbidity and mortality is evaluating and assessing preoperative risk. The underlying medical conditions of patients as well as their functional status form a big component of preoperative risk, which in turn is a determinant of postoperative outcomes. The preoperative history and physical examination form the backbone of preoperative risk assessment. This will direct which further tests are necessary to complete the preoperative evaluation. The underlying conditions that pose the greatest risk include cardiovascular disease, pulmonary disease, diabetes mellitus, underlying immunosuppression, incident infections, and functional status. There are various disease-specific risk assessment tools and indexes that help to risk-stratify patients in each disease category. Based on these indexes, several algorithms have been developed to help determine what preoperative testing is required, if any. The accurate evaluation and assessment of preoperative risk will ensure that patients are optimized before surgery to decrease the incidence of postoperative morbidity and mortality, and thereby enhance recovery.

Given that most global surgery efforts have focused on service rather than education, there is very little written about educational research in the global surgery setting. As the focus of global surgery rotations shift from a purely volunteerism-driven effort to an educational experience for surgical trainees as well as providers in host institutions, there is a need to evaluate different ways education initiatives can be tailored and adapted to meet the needs of both sides. Academic institutions can partner with institutions in resource-limited countries to facilitate bridging the gap in surgical workforce, as well as help with training needs of these countries. It is in this educational environment that educational research can flourish.

Colorectal cancer is the second leading cause of cancer deaths in the United States, affecting more than 130,000 Americans every year1. Determining tumor margins prior to surgical resection is essential to providing optimal treatment and reducing recurrence rates. Colorectal cancer recurrence can occur in up to 20% of cases, commonly within three years after curative treatment. Typically, when colorectal cancers are resected, a margin of normal tissue on both sides of the tumor is required. The minimum margin required for colon cancer is 5 cm and for the lower rectum 2 cm. However, usually more normal tissue is taken on both sides of the tumor because the blood supply to the entire segment is removed with the surgery and therefore the entire segment must be removed. Anastomotic recurrences may result from inadequate margins. Pathologists look at the margins to ensure that there is no residual tumor and this is usually documented in the pathology report. We have developed a portable, point-of-care fiber bundle microendoscopy imaging system for detection of abnormalities in colonic epithelial microstructure. The system comprises a laptop, a modified fiber bundle image guide with a 1mm active area diameter and custom Lab VIEW interface, and is approved for imaging surgically resected colon tissue at the University of Arkansas for Medical Sciences. The microendoscopy probe provides high-resolution images of superficial epithelial histology in real-time to assist surgical guidance and to localize occult regions of dysplasia which may not be visible. Microendoscopy images of freshly resected human colonic epithelium were acquired using the microendoscopy device and subsequently mosaicked using custom post-processing software. Architectural changes in the glands were mapped to histopathology H&E slides taken from the precise location of the microendoscopy images. Qualitatively, glandular distortion and placement of image guide was used to map normal and dysplastic areas of the colonic tumor and surrounding region from microendoscopy images to H&E slides. Quantitative metrics for correlating images were also explored and were obtained by analyzing glandular diameter and spatial distribution as well as image texture.

Since the development of the stapled intestinal anastomosis, efforts have been aimed at reducing complications and standardizing methods. The main complications associated with stapled anastomoses include bleeding, device failure, and anastomotic failure (leaks and strictures). These complications are associated with increased cost of care, increase in cancer recurrence, decreased overall survival, poor quality of life, and in some cases the need for further procedures including a diverting ostomy. Reducing these complications therefore has important implications. To this end, techniques to reduce the incidence of anastomotic complications have been the focus of many investigators. In this review, we summarize the current staple line reinforcement technology as well as other adjunctive measures, and specifically discuss the role of biologic materials in this realm.

Biologic immune modulators such as ipilimumab have demonstrated the efficacy against metastatic melanoma. We present a recent case of a 52-year-old male who initially developed mild colitis following the initiation of ipilimumab treatment for metastatic melanoma. Despite initial improvement with immediate cessation of drug and initiation of high-dose steroid therapy his clinical condition worsened and the patient presented to our facility in extremis from colonic perforation. Following an extended right hemicolectomy his postoperative period was extended due to continued symptomatic enteritis. After 3 weeks colonoscopy revealed that the autoimmune event had begun to subside; his condition improved, resulting in discharge. We discuss this particular side effect with respect to ipilimumab adjuvant therapy in melanoma.

Venous thromboembolism (VTE) can occur after major general surgery. Pulmonary embolism is recognized as the most common identifiable cause of death in hospitalized patients in the United States. The risk of deep venous thrombosis (DVT) and pulmonary embolism (PE) is higher in colorectal surgical procedures compared with general surgical procedures. The incidence of venous thromboembolism in this population is estimated to be 0.2 to 0.3%. Prevention of VTE is considered a patient-safety measure in most mandated quality initiatives. The measures for prevention of VTE include mechanical methods (graduated compression stockings and intermittent pneumatic compression devices) and pharmacologic agents. A combination of mechanical and pharmacologic methods produces the best results. Patients undergoing surgery should be stratified according to their risk of VTE based on patient risk factors, disease-related risk factors, and procedure-related risk factors. The type of prophylaxis should be commensurate with the risk of VTE based on the composite risk profile.

Fiber bundle microendoscopy has shown promise as a point-of-care imaging system for epithelial dysplasia visualization. Here we present the use of this technology as a means to characterize lesions in colorectal cancer.