Preoperative telemedicine evaluation of surgical mission patients: Should we use it routinely?

Latifi - Figure 1a

Figure 1. Medweb ™ SAFT screens 1A. Home page

Latifi - Figure 1b

Figure 1. Medweb ™ SAFT screens 1B. Consult screen

Latifi - Figure 1c

Figure 1. Medweb ™ SAFT screens 1C. Ultrasound image

Latifi - Figure 1d

Figure 1. Medweb ™ SAFT screens 1D. Intraoperative and postoperative view of a patient that underwent thyroidectomy.

Latifi - Figure 2

Figure 2. 2A. Phyllodes tumor 2B. Giant goiter 2C. Large lipoma

Latifi - Figure 3

Figure 3. Flank mass, undiagnosable via SAFT

Latifi - Figure 4

Figure 4. Bilateral giant goiter

As most surgeons know, medical care is insufficient or nonexistent in many regions of the world.1 The lack of access to surgical care accounts for a high number of disability-adjusted life years (DALYs), defined as years of healthy life lost.2 DALYs have been launched by the World Bank and by the World Health Organization (WHO) as a measure of the global burden of disease. WHO estimates that 2 billion people have no access to basic surgical care and that surgery could be used to cure 11 percent of the global burden of disease.3

Surgical humanitarian missions, including those outreach efforts arranged through the American College of Surgeons’ Operation Giving Back program, have become a viable method of providing surgical care to patients in underserved areas.4 Many other organizations around the world facilitate such missions as well, which typically involve a broad spectrum of surgical disciplines.

Preoperative evaluation of surgical mission patients is a complex, time-consuming, and often chaotic process. Typically, these evaluations require intense work by the operating team on the day of arrival at the mission site. On-site screening, unfortunately, precludes many patients from receiving surgical treatment due to the identification of last-minute medical issues, such as comorbidities or the lack of necessary test results. Many of these patients wait for years to obtain surgical care only to be told they are inappropriate candidates for the surgical care that will be provided through the mission. It is unclear how many patients are disqualified from participation during on-site screening worldwide for any of the aforementioned reasons, but it is likely that the number is considerable.

The mission

For the last seven years, the Association of Filipino Physicians of Southern Illinois has organized a team of surgeons, anesthesiologists, nurses, and other health care professionals to deliver surgical care in Tagbilaran, the capital city of the island province of Bohol in the Philippines. Since 2012, this mission has been called Bohol Operation Giving Back. From year to year, with some exceptions, the all-volunteer surgical team comprises general surgeons with different subspecialty interests, otolaryngology surgeons, plastic surgeons, obstetrics-gynecology surgeons, anesthesiologists, certified registered nurse anesthetists, and/or other health care practitioners. During these annual one-week surgical missions, the team has performed an array of general surgery operations, including thyroidectomies for advanced goiters and thyroid cancer, hernia repairs, hysterectomies, oophorectomies, and other operations.

Over the last five years of this mission, surgeon volunteers and their teams have performed 446 operations: 168 thyroidectomies, 75 hysterectomies/oophorectomies, 69 cleft lip and palate repairs, 66 hernia repairs, 19 superficial tumor removals, 17 breast operations (from lumpectomies to mastectomies), 16 cholecystectomies, and 16 other procedures.  They operated on 299 female and 147 male patients with the mean age of 34. All year long, in advance of the one-week surgical mission, the nongovernmental organization Gift of Life Foundation for the Philippines and the local medical team see patients and identify those in need of surgery. On the day of our surgical team’s arrival, many surgical candidates are screened—sometimes more than 200 in a single day. After evaluating patients, each surgeon will schedule four to seven operations a day for six operative days.

Exploring telemedicine for evaluation

To assess the applicability of telemedicine in advance of short-term surgical missions, our team conducted a study comparing the use of store-and-forward telemedicine (SAFT) with in-person, on-site preoperative evaluations of surgical mission patients. The institutional review board (IRB) at the University of Arizona, Tucson, approved this study.

The local medical team identified patients in need of various operations, including thyroid gland/mass resection, inguinal hernia repair, myoma resection, ovarian cyst resection, breast tumor resection, gallbladder removal, cleft lip/palate repair, and superficial soft-tumor resection or parotid gland/mass resection. We excluded from the study all patients in need of obstetrics-gynecology or plastic surgery.

One of the authors of this article, Francisco Mora, MD, a second-year general surgery resident, was deployed to Tagbilaran one week before the surgical mission in February 2012. Using a laptop and basic Internet connection, Dr. Mora transferred the upcoming surgical mission patients’ data and images to a secure server via SAFT software. The software featured specially designed screens (see Figure 1).

The data and images transferred included:

  • Patients’ demographic characteristics (age and gender)
  • Preoperative diagnosis
  • Biopsy results (when available)
  • Duration of disease
  • Results of radiologic imaging studies

For patients with goiter, hernia, and other conditions showing visible pathology, digital photos taken with a standard digital camera also were included.

One of the mission surgeons, Rifat Latifi, MD, FACS, a co-author of this article, reviewed all of the data and images from a remote location and made the decision whether to operate and what type of operation was required. On the day the surgical team arrived at the site, the operating surgeon examined each patient in person preoperatively and made the final decision regarding whether to proceed with the operation. Any changes in the originally uploaded plans were recorded.

Results

Table 1. Patients evaluated via SAFT

Condition Number of patients SAFT diagnosis and opinion rendered Confirmation by in-person evaluation (%)
Thyroid mass (mostly, giant goiter) 52 52 100
Inguinal hernia 14 12 86
Gallbladder disease 7 7 100
Superficial soft-tissue tumor 7 5 86
Breast tumor 9 8 89
Parotid mass 4 4 100
Total 93 88 95

In all, 93 general surgery patients were evaluated using SAFT applications (see Table 1). Preoperative SAFT diagnosis leading to a surgical opinion was possible in 88 (93 percent) patients. Figure 2, features samples of three conditions evaluated via SAFT.

In five patients (less than 5 percent), the remote surgeon required more information or better images (see Table 2) to render an opinion. Of those five patients, during the on-site in-person evaluation, the surgical team found that two had a lipoma, two had an inguinal hernia, and one patient had a breast mass. Figure 3, is a photo of one of these conditions, a mass on the patient’s flank that turned out to be a lipoma.

Table 2. Conditions unable to render an opinion via SAFT

Condition N
Lipoma 2
Inguinal hernia 2
Breast mass 1
Total 5

The remote surgeon, using SAFT, preliminarily decided against an operation in five (less than 5 percent) of the patients: two had severe hyperthyroidism and required medical therapy before surgery; one had been misdiagnosed by the local medical team as having an inguinal hernia but, per SAFT, did not; one had a lipoma that did not require removal; and one patient had a breast tumor that appeared suspicious for cancer that required further evaluation and staging (see Table 3).

Table 3. Patients deemed non-operative candidates via SAFT

SAFT diagnosis N Reason
Goiter 2 Severe hyperthyroidism; medical therapy required
Inguinal hernia 1 Misdiagnosis by local team; no indication for surgery
Lipoma 1 No indication for excision
Breast tumor 1 Further evaluation and staging required

The correlation rate between SAFT and in-person preoperative evaluations was 98 percent. Only two operations preliminarily arranged based on the SAFT evaluations were canceled after an in-person on-site consult, both due to a lack of indication for surgery. Overall, preoperative telemedicine evaluation decreased the on-site screening time significantly over what it would have been, as compared with previous missions.

Effective evaluation method

Several studies have shown that telemedicine is a safe and reliable method for evaluating surgical patients preoperatively and postoperatively.5-11 However, the infrastructure for using low-cost telemedicine technologies has yet to become ubiquitous worldwide.12 Most studies have used one of the two main techniques: SAFT or live teleconsultation. For the most part, live telemedicine consultation requires advanced infrastructure and technology, but low bandwidth telemedicine for intraoperative consultations in the jungles of Ecuador has been reported.9,12 Subsequently, Merrell and colleagues in Richmond, VA, used remote screening to evaluate 51 patients in Kenya using e-mails and attachments containing patient data and images. In this study, 33 patients (65 percent) were deemed poor candidates for operative care for various reasons. The rest of the patients underwent successful surgical procedures.10 Although a large number of patients were considered non-candidates for surgical services, the real number of patients that typically are disqualified from receiving care on surgical missions has never been reported.

In our study, the number of patients who did not receive operative care was much lower; however, this high acceptance rate may reflect careful patient selection by the Gift of Life Foundation for the Philippines and past experience. Other studies have reported good results in the use of preoperative screening using telemedicine for patients treated in the Amazon basin.11

Like many other reports, this study demonstrated that the use of SAFT immediately before such missions is safe and reliable. We were unable to render an opinion in advance of our surgical mission via SAFT only for a small number of patients. Additional information that was unobtainable remotely (for example, from maneuvers during in-person physical examinations) was required. The development of standardized SAFT techniques for surgical mission and additional live telemedicine consultation protocols may be a solution to this problem. Some studies have established guidelines for capturing radiologic images for telemedicine patients.13,14

Future applications

Similar studies are needed to assess the quality of other imaging methods for telemedicine patients with superficial soft-tissue tumors and hernias, to name just two conditions. Videos showing surgical mission patients’ pathology tests and physical examinations also are needed.

The authors believe that videos obtained by smartphones or other video equipment would help to remotely identify such conditions as thyroid lobe goiter with greater precision (differentiating, for example, between involvement by one lobe versus both lobes), especially in patients with a bilateral giant goiter, as depicted in Figure 4. Sometimes, massive goiters are difficult to evaluate even in an anesthetized patient on the operating table.

Although involvement of surgery residents and surgical fellows may be admirable in these missions, training a local nurse or physician—someone who lives year-round in the underserved area—to perform preoperative evaluations and forward the data and images to the mission’s surgical team is advisable. Having a local nurse or physician participate in this meaningful manner would strengthen the on-site surgical mission and aid in the development of sustainable health care teams. Perhaps most importantly, this local involvement would facilitate long-term postoperative follow-up care for all surgical mission patients.

Summary

Low-cost telemedicine is a viable and secure tool for preoperative evaluation of surgical mission patients. It increases efficiency and optimizes the use of existing resources. More specifically, it helps ensure an accurate assessment of patients before the surgical team arrives, reduces on-site prescreening time, and decreases the number of surgical candidates on the waiting list. Routine use of telemedicine in surgical missions most likely would reduce preoperative times and the number of operations canceled at the last minute. Moreover, it may be effectively used for long-term follow-up care, including the management of any postoperative complications.


Acknowledgments

The authors thank all the members of Borja Family Hospital in Tagbilaran, Philippines, and all members of Bohol Operation Giving Back 2013 for their support and assistance with this project, as well as the Medweb team for their generous technical support, and Ronald Merrell, MD, FACS, professor, Virginia Commonwealth University, Richmond, VA, for his valuable editorial comments and review of the manuscript.


Editor’s note
Dr. Mora’s participation was funded by the International Virtual e-Hospital Foundation


References

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