Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development

Does the reduction in obstetric hospitals result in an unintended decreased in-hospital delivery utilisation? A causal multilevel analysis in China

Introduction

China's progress towards achieving Sustainable Development Goals for maternal health is largely attributed to a reduction in maternal mortality rates, driven by increased in-hospital delivery services utilisation. However, recent reductions in the number of obstetric hospitals have raised concerns about compromised access to these services. This study investigates the impact of reduced obstetric hospitals on spatial accessibility and the utilisation of in-hospital delivery services.

Methods

Data from 2016 to 2020 were collected from a densely populated province with approximately 83 million residents. Directed Acyclic Graph was applied to identify a minimally sufficient set of confounders, including residential characteristics and transportation-related factors. Multilevel regression models were employed to analyse the causal effects, with sensitivity analysis using fixed effect and quantile regression models.

Results

Between 2017 and 2020, the number of obstetric hospitals decreased by 21.3% (from 1209 to 951), leading to a decline in the proportion of pregnant women covered within a 2-hour driving radius (from 97.4% to 97.1%) and an increase in the maximum of shortest driving time within county (from 117.2 to 121.0 min). Multilevel regression models, adjusted for confounders, showed that a 1 percentage point increase in the proportion of pregnant women covered within a 2-hour driving radius was associated with a 13 percentage point (95% CI: 11.4 to 14.7) increase in in-hospital delivery rates, especially in areas with lower coverage and in-hospital delivery rates.

Conclusions

The reduction in obstetric hospitals increased travel distances, negatively impacting in-hospital delivery utilisation. Expanding the proportion of pregnant women covered within a 2-hour driving radius may be more effective than reducing the maximum of shortest travel distance within a county when optimising obstetric hospital locations. These findings provide insights for optimising obstetric facility locations in similar low- and middle-income countries. While improving spatial accessibility is important, the potential quality gains from centralising obstetric resources should also be considered.

Cultivating a "Feminine" Surgical Culture: Lessons from Indonesia

BACKGROUND

Although the number of female physicians in the United States has been increasing, most practicing surgeons in the United States are men. By contrast, Indonesia has achieved notable gender parity among surgeons, with the number of women practicing as plastic surgeons projected to soon surpass that of men. Achieving greater female representation in plastic surgery is important for delivering high-quality care, especially in the face of physician shortages and high burnout rates.

METHODS

This survey study was conducted at the 26th annual scientific meeting of the Indonesian Association of Plastic Reconstructive and Aesthetic Surgeons, in Manado, Indonesia, in August 2023. Respondents were asked about their perceptions of plastic surgery, mentorship, career motivations, and caregiving responsibilities. Responses were scored using a 3-point Likert scale of agreement with statements (disagree, neutral, or agree); χ 2 and Fisher exact tests were performed to assess differences in responses by sex.

RESULTS

In this validated survey of 175 plastic surgeon trainees and attendings, there were no significant differences between sexes in the perception and roles of mentorship in preparing for a career in plastic surgery. Respondents from both sexes espoused optimistic views on work-life balance items, including time for family and friends and flexibility of work schedules.

CONCLUSIONS

Indonesia can serve as a model for encouraging greater gender parity in plastic surgery. Community-level interventions, such as family leave policies, childcare provisions, and initiatives to promote an inclusive culture, will create a more supportive workplace to increase women's representation in plastic surgery in the United States and around the world.

Successful task shifting: a mixed-methods cross-sectional evaluation of an emergency obstetric care program to increase access to cesarean sections in rural Nepal

BACKGROUND

Direct obstetric causes of maternal mortality account for approximately 86% of all global maternal deaths. In Nepal, 12% of all deaths of women of reproductive age are due to preventable obstetric complications in significant part due to the limited distribution and skill level of human resources.

OBJECTIVES

To address this, the Advanced Skilled Birth Attendant (ASBA) task-shifting initiative was developed to train medical officers to perform Cesarean sections (CSs) and manage obstetric emergencies in Nepal. Until now, there has been limited study of the program's efficacy.

METHODS

A survey targeting all 234 ASBA graduates resulted in 93 usable surveys for multivariate regression. Additionally, seven rural government hospitals with ASBA graduates were selected for 13 in-depth interviews and 6 focus group discussions. Results were then triangulated.

RESULTS

Immediately after training, 92.7% of ASBA graduates reported performing CSs, with the majority (65.6%) continuing to perform CSs today. Of the ASBAs not performing CSs, 51.7% could be explained by the lack of a functional operating theater, despite being at hospitals expected to provide CSs. ASBAs were significantly more likely to be performing CSs with a family physician or another ASBA present (p < 0.001; p < 0.001). Their work was perceived to increase the use of services, improve access, reduce out-referrals, and reduce the burden of CSs on any one staff member.

CONCLUSIONS

The ASBA program successfully reduces human resource shortages, expands the provision of life-saving Cesarean section, and improves the working conditions in rural hospitals within the LMIC setting.

Tranexamic acid in hip and spine surgery for children with cerebral palsy - a PRISMA-compliant scoping review

Many children with cerebral palsy (CP) are frail and require major hip and/or spine surgeries associated with substantial blood loss. Tranexamic acid (TXA) is commonly used to reduce blood loss, but there is uncertainty around the optimal dose and timing of administration. There have been reviews in sub-populations and specific dosing regimens, but a broad overview of the available literature is lacking. The aim of this review was to map available evidence on TXA in hip and spine surgery for children with CP. Given the heterogeneous literature, a prospectively registered scoping review was conducted. Eligibility criteria were broad. Three screeners were involved, with the senior author consulted when disagreements were not resolved through discussion.Titles and abstracts of 14,609 records were screened, with 52 records included. Two additional records were obtained from grey literature and citation searching. Cohort studies (50.0%) were the most common. Most records (76.9%) were on spine surgery. TXA dose varied widely. Loading doses range from 5 to 100 mg/kg and intraoperative infusions from 1 to 10 mg/kg/h. Dose was not reported in 35.2% of records. Primary outcome measures included blood loss and transfusion requirements. TXA was generally reported to be safe. None of the included records reported postoperative TXA administration.While TXA is generally considered safe, there was mixed evidence on efficacy. Much of the evidence was drawn from studies in which TXA was used in patients at higher risk of bleeding or with reduced physiological reserve. There was no evidence for TXA being used postoperatively, when a large proportion of transfusions occur.

Methods families use to raise funds for anorectal malformation treatment at a single public referral hospital in Southwestern Uganda

Background

In Uganda, only two public hospitals provide pediatric surgery services. With less than 10 pediatric surgeons serving approximately 20 million children in Uganda, most patients with anorectal malformations (ARMs) must make several trips to the hospital before undergoing surgery. As a result, households borrow money, sell assets, or solicit contributions from friends and relatives to meet healthcare expenses. We used a cross-sectional study to examine methods families use to raise funds for the treatment of ARMs at a single institution in Southwestern Uganda.

Methods

This cross-sectional study was conducted in the pediatric surgery unit at a Regional Referral Hospital/University Teaching Hospital in Southwestern Uganda from June 2021 to July 2023. Participants included caretakers of children presenting with ARMs for treatment at our referral hospital.

Results

A total of 157 participants were enrolled. Mothers were the main caregivers (77.9%) present at the hospital. Out of a median monthly household income of UGX200 000 (US$51.68), families spent a median of UGX50 000 (US$12.92) to travel to the hospital. To raise funds for healthcare expenses, 68% of households reported selling assets.

Conclusion

Families sell household assets to afford ARMs treatment in Southwestern Uganda. Financial protection by the government through a national child health insurance policy would shield families from substantial health-related expenditures and decrease this burden. In addition, targeted policy to strengthen pediatric surgical capacity through workforce expansion and skills training such as the Pediatric Emergency Surgery Course, may minimize costs, improve timeliness of care, and prevent case cancellations.

Global surgery is stronger when infection prevention and control is incorporated: a commentary and review of the surgical infection landscape

Incorporating infection prevention and control (IPC) is crucial for strengthening global surgery, particularly in low- and middle-income countries (LMICs). This review article highlights the critical role IPC plays in ensuring equitable and sustainable surgical care, aligning with the Sustainable Development Goals (SDG) 3 and 10, which aim to promote health and reduce inequalities. Surgical site infections (SSIs) and other healthcare-associated infections (HAIs) disproportionately affect LMICs, where IPC infrastructure is often underdeveloped. Without robust IPC measures, surgeries in these regions can result in higher morbidity, mortality, and healthcare costs, exacerbating disparities in healthcare access and outcomes. Despite global efforts, such as the World Health Organization (WHO) Guidelines on the Prevention of Surgical Site Infections, IPC integration in surgical practices remains inconsistent, particularly in resource-constrained settings. More widespread adoption and implementation are necessary. By embedding IPC within global surgery frameworks, health systems can improve surgical outcomes, reduce costs, and enhance the resilience of healthcare systems. Effective IPC reduces extended hospital stays, limits the spread of antimicrobial resistance, and increases trust in surgical services. Moreover, the cost savings from preventing SSIs are substantial, benefiting both healthcare systems and patients by reducing the need for prolonged care and antibiotic treatments. This review article calls for greater integration of IPC measures in global surgery initiatives to ensure that surgical interventions are both life-saving and equitable. Strengthening IPC is not optional but essential for achieving the broader goals of universal health coverage and improving public health outcomes globally.

Simulation-Based Education of Health Workers in Low- and Middle-Income Countries: A Systematic Review

INTRODUCTION

Simulation-based education (SBE) is increasingly used to improve clinician competency and patient care and has been identified as a priority by the World Health Organization for low- and middle-income countries (LMICs). The primary aim of this review was to investigate the global distribution and effectiveness of SBE for health workers in LMICs. The secondary aim was to determine the learning focus, simulation modalities, and additional evaluation conducted in included studies.

METHODS

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta Analysis guidelines, searching Ovid (Medline, Embase, and Emcare) and the Cochrane Library from January 1, 2002, to March 14, 2022. Primary research studies reporting evaluation at Level 4 of The Kirkpatrick model were included. Studies on simulation-based assessment and validation were excluded. Quality and risk-of-bias assessments were conducted using appropriate tools. Narrative synthesis and descriptive statistics were used to present the results.

RESULTS

A total of 97 studies were included. Of these, 54 were in sub-Saharan Africa (56%). Forty-seven studies focused on neonatology (48%), 29 on obstetrics (30%), and 16 on acute care (16%). Forty-nine used mannequins (51%), 46 used scenario-based simulation (47%), and 21 used synthetic part-task trainers (22%), with some studies using more than 1 modality. Sixty studies focused on educational programs (62%), while 37 used SBE as an adjunct to broader interventions and quality improvement initiatives (38%). Most studies that assessed for statistical significance demonstrated at least partial improvement in Level 4 outcomes (75%, n=81).

CONCLUSION

SBE has been widely applied to improve outcomes in a variety of contexts across LMICs. Modalities of simulation are typically low-technology versions. However, there is a lack of standardized reporting of educational activities, particularly relating to essential features of SBE. Further research is required to determine which approaches are effective in specific contexts.

Integrating political prioritisation into national surgical planning: a scoping review of surgical, obstetric and anaesthesia care in Cameroon

BACKGROUND

Surgical diseases contribute substantially to death and disability in Cameroon. Strategic planning for surgical, obstetric and anaesthesia (SOA) care in low-income and middle-income countries (LMICs) requires consideration of the policy environment in addition to the issue severity. We aimed at the current landscape of SOA care in Cameroon, incorporating a framework for political prioritisation.

METHODS

A scoping review of published and grey literature was performed. Literature specific to Cameroon, published between 2010 and 2020 and written in either English or French, was included. Abstracts and full texts were screened for discussion of SOA policy context, care and delivery conditions, and issue characteristics. Data extraction and analysis were performed using the Shiffman and Smith framework for political prioritisation accounting for actors, ideas, political context and issue characteristics.

RESULTS

121 articles were included. By specialty, 83 articles were specific to surgery, 45 to obstetrics and 6 to anaesthesia. Policy environment was discussed by 20% (n=25) articles; 30% (n=37) discussed actor power; 22% (n=27) discussed ideas in SOA care and 93% discussed issue characteristics. Core challenges to political prioritisation of SOA care in Cameroon are limited actor support, a lack of consensus definitions, gaps in capacity and a need for systematic data collection on surgical diseases. Policy opportunities include leveraging existing multilateral partnerships to unify SOA actors, conducting national assessments of SOA care capacity, formalisation of task shifting to build capacity, defining essential SOA procedures, including surgical care in future health coverage, and defining and including SOA benchmarks in strategic planning.

CONCLUSIONS

Integrating a framework for political prioritisation into a situational analysis of SOA care is critical to understanding an LMIC's policy context and actors, in addition to issue severity. Such an approach can serve as a baseline for analysis in evidence-informed policy-making for SOA care, even in the absence of centralised, country-wide data.

Economic evaluation of expanding inguinal hernia repair among adult males in Sierra Leone

Sierra Leone faces a substantial backlog of patients with inguinal hernia in need of repair due to a shortage of surgical providers. The current mitigation strategy includes task-sharing with associate clinicians and non-specialist medical doctors, and the economic impact of this approach needs assessment for potential scale-up. This study aimed to assess the cost-effectiveness of open mesh repair of inguinal hernias by associate clinicians and non-specialist medical doctors in adult males (>18 years) compared to no treatment, as well as between the two provider types and to estimate the budget impact of clearing the backlog in Sierra Leone. A Markov model was constructed to calculate the cost per disability-adjusted life year (DALY) averted over 10 years for operations by different providers. Subsequently, the costs of reducing the backlog through accelerated repair rates via task-sharing were assessed under two scenarios, with or without a budget limit. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the uncertainty of input values. Associate clinicians and non-specialist medical doctors achieved USD 250 and USD 411 per DALY averted, respectively, which is below the GDP per capita of USD 1,427. Associate clinicians delivered comparable health outcomes at lower costs than non-specialist medical doctors. A budget of USD 108 million was projected to clear the entire backlog over 10 years. Hernia repair by both associate clinicians and non-specialist medical doctors in Sierra Leone is highly cost-effective. Associate clinicians, with quality training and supportive supervision, are more cost-effective than non-specialist medical doctors. Task-sharing, especially with associate clinicians, is promising for optimizing access to surgical services.

Scalable policy adoption and sustainable implementation of surgical care in the Americas

On September 29, 2023, the Republic of Ecuador convened a meeting to address surgical system strengthening and urge political leaders to invest in surgical infrastructure. The meeting included experts in health diplomacy, innovative financing, implementation strategy and national surgical plans. The event occurred in parallel with the Sixtieth Directing Council of the Pan American Health Organization, Seventy-fifth session of the World Health Organization Regional Committee for the Americas. The meeting centered around four major areas: (i) building surgical capacity as a means to develop universal health care and emergency preparedness; (ii) developing policies and strategies for strengthening surgical systems; (iii) developing models for financing, sustaining, and improving surgical systems in low- and middle-income countries; and (iv) evaluating implementation strategies for funding these endeavors. National surgical plans represent a critical opportunity to build resilient health care systems by establishing comprehensive and sustainable policies. This article highlights the key messages from the event, which focused on Latin America, to inform the broader global health community.

Brain health: A concern for anaesthesiologists and intensivists

Damage to the brain can have disastrous and long-lasting consequences. The European Society of Anaesthesiology and Intensive Care (ESAIC) is aware of the importance of taking good care of the brain, both of patients and of anaesthesia and intensive care unit (ICU) caregivers, and has organised a complete learning track on brain health to bring this concern to the attention of practitioners. This learning track included an online Focus Meeting on Brain Health (November 25, 2023). We here provide readers with a digest of the information that was delivered during that meeting in an opinion paper driven by the authors' own reading of the literature. It is divided according to the meeting's sessions, including how to improve the health of an injured brain, how to keep a young or old brain healthy, how to keep a healthy adult brain unimpaired, how monitoring can impact brain health in the operating room and in the intensive care unit, and how to keep the anaesthesia and ICU caregivers' brain healthy. Each part is a brief and focused summary. The main delivered messages are that the management of injured brain patients involves an adequate choice of sedation, adequate brain monitoring, and focused attention to specific points depending on the underlying pathology; that several measures can be undertaken to protect the brain of the very young needing anaesthesia; that it is possible to detect older patients at risk of postoperative neurocognitive disorders, and that dedicated perioperative management by a multidisciplinary expert team may improve their outcomes; that apparently healthy adult brains may suffer during anaesthesia; that the electroencephalogram may track peri-operative brain dysfunction, and that female patients should be given special care in this respect; that multimodal brain monitoring helps to detect pathological processes and to maintain brain homeostasis; and that burnout in anaesthesiologists can be effectively fought using personal, organisational, managerial and legal approaches.

Barriers to accessing appendectomy in the public sector health system in the Western Cape Province, South Africa

Background

Appendectomy is the surgical treatment for acute appendicitis and barriers to timely care can lead to morbidity and mortality. In South Africa, patients experience delays during the stages of seeking, reaching, and receiving care. This study explored the perceptions and experiences of barriers to accessing appendectomy among patients, caregivers, and surgeons employed at selected public hospitals in the Western Cape, South Africa.

Methods

A qualitative study was conducted through semi-structured in-depth interviews. Study sites comprised four public hospitals. The interviews were audio recorded, transcribed, and translated verbatim. Excerpts in the qualitative data were systematically categorised and themes were generated using inductive thematic analysis according to Braun and Clarke's methodology.

Findings

The following themes were generated from the analysis 1) barriers related to late presentation to a healthcare facility and 2) barriers related to healthcare facility delays. Identified barriers were perceptions of appendicitis-like symptoms, the influence of beliefs, customs and culture on healthcare-seeking behaviour, personal and social positions and values, lack of knowledge of the health system, transport accessibility and affordability, delayed ambulance response time, and proximity of healthcare facilities. Key barriers experienced after presentation to a healthcare facility related to inter-facility transfers, surgical capacity, and the diagnostic and management capabilities of facilities.

Conclusion

Participants in the study experienced, and perceived similar delays to accessing appendectomy to that reported in other African countries. Improved health literacy in communities could lead to timely healthcare-seeking behaviour for appendicitis and other emergency conditions. Efforts are needed to ensure access to affordable and available transport options, and healthcare facilities need to be better equipped to diagnose and treat appendicitis. This can be achieved through upskilling and augmenting human and other resources, which will require the support of the government and other relevant stakeholders.

Effect of inspiratory oxygen fraction during driving pressure-guided ventilation strategy on pulmonary complications following open abdominal surgery: A randomized controlled trial

STUDY OBJECTIVE

The aim of the present study was to determine the effect of 30 % fraction of inspired oxygen (FIO2) compared with 80 % FIO2 in the context of driving pressure-guided ventilation strategy on pulmonary complications following open abdominal surgery.

DESIGN

A single-center, prospective, randomized controlled trial.

SETTING

Tertiary university hospital in China.

PATIENTS

514 adult patients, ASA I-III and scheduled for major open abdominal surgery under general anesthesia.

INTERVENTIONS

Patients were randomly assigned to receive either 30 % or 80 % FIO2 during the intraoperative period. All patients received driving pressure-guided ventilation strategy, including low tidal volume and individualized PEEP set at lowest driving pressure.

MEASUREMENTS

The primary outcome was the incidence of a composite of pulmonary complications within the 7 days postoperatively. The severity of pulmonary complications, extrapulmonary complications, and other secondary outcomes were also assessed.

MAIN RESULTS

Of 1553 patients assessed for eligibility, 514 patients were randomly assigned and analyzed with intention-to-treat principle. Patients receiving 30 % FIO2 had a significantly lower incidence of postoperative pulmonary complications (PPCs) compared to those receiving 80 % FIO2 (46.3 %vs. 64.6 %; RR, 0.72; 95 % CI, 0.61-0.84; P < 0.001). The severity score of PPCs was significantly reduced in the 30 % FIO2 group compared with that in the 80 % FIO2 group within the 7 postoperative days (P < 0.001). Dynamic compliance was significantly greater in 30 % FIO2 group at the end of surgery (56 [48-66] vs. 53 [46-62], P = 0.027). More patients in the 80 % FIO2 group developed oxygen desaturation (SpO2 < 94 %) on air intake during PACU stay (18.5 %vs. 30.4 %; RR, 0.61; 95 % CI, 0.44-0.84; P = 0.002; 30 % FIO2 group vs.80 % FIO2 group).

CONCLUSIONS

In patients undergoing open abdominal surgery, using a 30 % FIO2, compared with 80 % FIO2, in context of driving pressure-guided ventilation strategy, intraoperatively reduced the incidence and severity of pulmonary complications within the first 7 postoperative days.

Trends in Specialty Training and National Institutes of Health Funding Among Surgeon-Scientists

Purpose

To determine if dual-degree training [ie, completion of a National Institutes of Health (NIH)-funded MD/PhD program], among other professional development and demographic variables, predicted academic productivity (eg, K-to-R conversion, number of publications, etc.) among early-career surgeon-scientists.

Methods

We analyzed publicly available data from the National MD/PhD Program Outcomes Study and the Association of American Medical Colleges Graduate Medical Education Track database to identify trends in the number and proportion of MD/PhD graduates pursuing surgical specialties. NIH Research Portfolio Online Reporting Tool Expenditures and Results was interrogated to identify a cohort of early-career academic surgeon-scientists receiving K-awards from 2011 to 2021.

Results

The total number of MD/PhD program graduates completing Graduate Medical Education training increased each decade after the Medical Scientist Training Program was established by the National Institute of General Medical Sciences, but the proportion completing surgical specialties did not change significantly (P = 0.96) from 1965 to 2014. More recent residency match trends demonstrate an increase in both the proportion and number of MD/PhD graduates entering surgical specialties, with 21.5% entering surgical residency training in 2020. Among 476 early-career academic surgeon-scientists receiving K-awards at 70 institutions, 27% were faculty members at only 4 universities, suggesting that federally funded surgeon-scientists are concentrated at a small number of institutions. Although MD/PhD graduates represented only 2.3% of active surgical residents from 2011 to 2020, they constituted a much higher fraction of K-awardees (29%). Of 296 surgeon-scientists who completed K-awards, 35% successfully obtained an R01-equivalent award.

Conclusions

These findings emphasize the need for comprehensive career development and institutional resources to support early-career surgeon-scientists.

Nurse-surgeons in the Australian public health system: A descriptive quantitative survey

Background

With over five billion people worldwide lacking access to surgery, innovative solutions are vital to address the global surgical crisis. Nurse-surgeons present a promising innovation. Considering their contribution worldwide and impact on surgical care in Australia, an exploration of these advanced practice nurses is timely.

Objective

To investigate the roles, training, education, and perceptions of career prospects and support received by practicing nurse-surgeons in the Australian public health system.

Design

Non-experimental descriptive national survey.

Methods

The target population was nurse-surgeons practicing within the Australian public health system. The survey questionnaire comprised of four sections containing questions on nurse-surgeon demographics, roles, training, and perceptions of career prospects and support received. Data collection was conducted through emailing of public hospitals, crowdsourcing, and snowballing. Descriptive analysis was used to report the findings.

Results

Twenty-eight nurse-surgeons participated in the study, 22 females and six males. Most commonly, participants (n = 10) held master's degrees and trained to become nurse-surgeons for an average of 2·27 years (95 % CI [1·47,3·07]). Training programs varied but were all surgical specialty-specific, and usually included a practical component, theoretical component, and competency assessment prior to independent practice. Participants rated employment prospects for nurse-surgeons as poor to average due to limited work opportunities, politics, and strong pushbacks from Australian medical societies. The support received from nurses, surgeons and management was rated by participants as good providing reasons such as supportiveness, value recognition, jealousy, and resentment. The participants were very likely (95 % CI [7.436 - 9.364] to continue practicing due to positive job satisfaction but recommended the standardising of training and practice to ensure role futureproofing.

Conclusions

Nurse-surgeons have been practicing in Australia for decades, yet no standard training and credentialing pathway exist for them. This study identified the various roles, non-standard training, and perceptions of nurse-surgeons in the Australian public health system. The findings of this study will have an impact on policymakers and stakeholders to develop standard national credentialing pathway for nurse-surgeons in Australia to enhance clinical practices and ensure a consistent framework for recognition and development of these advanced practice nurses.

Establishment of Mongolia's first independent and sustainable minimally invasive general thoracic surgery program: A Mongolian-Canadian initiative

Objective

The advent of video-assisted thoracoscopic surgery in Mongolia has faced funding and accessibility challenges, leading to languid adoption. A Mongolian-Canadian collaboration was inaugurated to support the development of a self-sustainable, self-governed minimally invasive thoracic surgery (MITS) program in Mongolia.

Methods

A multidisciplinary Canadian thoracic surgery team collaborated with the National Cancer Center of Mongolia Thoracic Surgery service from 2016 to 2023. The team engaged in patient rounds, MITS procedures, and service education. Program and patient outcomes were reviewed.

Results

Thirty-four patients underwent MITS procedures as part of the Mongolian-Canadian collaboration. Median age was 51 years (range, 16-76 years), and 41% (14 out of 34) were men. Lung, esophageal, and mediastinal procedures composed 50% (17 out of 34), 21% (7 out of 34), and 21% (7 out of 34) of procedures, respectively. Conversion rate, median operative time, and hospital length of stay were 0%, 172.5 minutes, and 8 days, respectively. The complication rate was 9% (3 out of 34) with 3% (1 out of 34) being Clavien-Dindo >3 requiring re-operation. Thirty-day mortality was 0%. Mongolia's thoracic surgery team progressed from surgical assists to primary operators and a self-governed program. In 2023, the National Cancer Center of Mongolia's thoracic surgery service independently conducted 72% (50 out of 69) of esophagectomies and 91% (48 out of 53) of pulmonary resections via minimally invasive technique compared with 0% in 2015.

Conclusions

The Mongolian-Canadian collaboration demonstrated successful transfer of MITS proficiency through global noncolonialist surgical partnership, consequentially shifting the national thoracic surgical paradigm. Continued collaboration will focus on sustainability and supporting local surgeons in regional dissemination of MITS proficiency with the aim of globalizing thoracic surgical excellence.

Education and Training in Global Neurosurgery: The Quest for Diversity and Equitable Collaborations

Education and training are essential components of global neurosurgery because they provide a sustainable solution to address the workforce deficits in the neurosurgical burden of disease. Neurosurgery training programs and opportunities exist in most areas of the world, but some countries still lack formal mechanisms to train future generations. In this special article, we review the neurosurgical workforce deficit, characterize factors influencing the absence or inadequacy of neurosurgical training, and identify strategies that could facilitate global efforts in building a stronger workforce. We summarize the key neurosurgical training models worldwide and the factors influencing the standardization of neurosurgical education by region. In addition, we evaluate the "brain drain" issue in the larger context of the healthcare workforce and propose solutions to mitigate this phenomenon in neurosurgical practice. Future generations of neurosurgical trainees depend on our efforts to intensify and expand education and training in this new virtual era. As we look to the future, we must prioritize education to strengthen the future neurosurgeons who will lead and shape the frontiers of our field.

Establishing a Microsurgical Practice in a Limited Resource African Setting: The Kapsowar Hospital Experience

Background

Microsurgical technique is still not readily available in many low- and middle-income countries. Few works in the scholarly literature describe the establishment of microsurgical practice on the African continent, and there are virtually no descriptions of the financial aspects of free flap performance by locally staffed teams in sub-Saharan Africa. The Kapsowar Hospital is a hospital in rural Kenya with 2 plastic and reconstructive surgeons certified by the American Board of Plastic Surgery and has recently expanded clinical practice to include microsurgical procedures.

Methods

A retrospective chart review was conducted on patients who received a free flap at the Kapsowar Hospital in 2022-2023. Captured parameters included age, sex, relevant medical history, etiology of wound, flap performed, intraoperative time, complications, surgical revisions, and length of stay. Billing information for all domestic patients who received free flaps were audited, and disability-adjusted life years was calculated.

Results

Nineteen free flaps were performed on 17 patients. The most common flap performed was the anterolateral thigh flap (n = 11). Flap survival rate was 94.7%. The surgical cost associated with performing an anterolateral thigh flap was $548 ± $35. The total cost associated with other free flap performances was $863 ± $269. The cost per disability-adjusted life years averted was $121, indicating that the procedure was very cost-effective.

Conclusions

Despite obstacles, microsurgical practices can be safely established in limited-resource African settings. Free flaps can be performed with greater cost-efficiency when performed by local teams. Surgical mission trips should emphasize educational components and ultimately transition care to local surgeons.

Effect of perioperative rehabilitation exercise on postoperative outcomes in patients aged ≥65 years undergoing gastrointestinal surgery: A multicenter randomized controlled trial

STUDY OBJECTIVES

This study aimed to assess the effect of perioperative rehabilitation exercise, initiated shortly after hospital admission, on postoperative outcomes in elderly patients.

DESIGN

A prospective, multicenter, randomized, controlled, open-label, and assessor-blinded clinical trial.

SETTING

Hospital wards.

PATIENTS

Elderly patients (≥65 years, n = 160) scheduled for gastrointestinal surgery between June 2021 and November 2022 were enrolled and randomly assigned to the intervention or control group.

INTERVENTIONS

Patients were divided into two groups base on whether they had received a specific type of exercise program initiated after hospital admission and continued until 30 days after surgery.

MEASUREMENTS

The primary outcome was the Comprehensive Complications Index (CCI) measured at 30 days after surgery. Secondary outcomes were the rate of complications, number of complications, patient satisfaction, hospital readmission, postoperative length of stay, gastrointestinal function recovery, postoperative quality of life and psychological status. Intention-to-treat (ITT) and per-protocol (PP) analyses were conducted.

MAIN RESULTS

ITT analysis showed a significantly lower 30-day CCI in the intervention group (β: -6.31; 95 % Confidence Interval [CI], -11.26 to -1.37, P = 0.013). Compared to controls, the intervention group had a decreased rate of hospital readmission (Odds Ratio: 0.00; 95 % CI, 0.00 to 0.32, P = 0.022), less number of complications (β: -0.57; 95 % CI, -1.03 to -0.11, P = 0.016), as well as lower rate of postoperative anxiety (β: -0.74; 95 % CI, -1.42 to -0.06, P = 0.033) and depression scores (β: -1.13; 95 % CI, -0.97 to -1.30, P = 0.008). Additionally, the intervention group reported higher satisfaction (β: 0.98; 95 % CI, 0.33 to 1.64, P = 0.004) and Euro quality of life-Visual Analogue Scale scores (β: 8.88; 95 % CI, 2.48 to 15.28, P = 0.007). Similar results were found in the PP analysis.

CONCLUSION

Perioperative rehabilitation exercise has a positive impact on postoperative complications, quality of life and psychological well-being in elderly patients undergoing gastrointestinal surgery, even when implemented after hospital admission.

The Role of Telemedicine in Enhancing Surgical Care Delivery in Africa: A Literature Review

Background and Aims

In Africa, telemedicine holds great potential to revolutionize surgical care delivery, especially in areas where access to quality treatment is scarce. Data about the use of these services in African countries is, however, limited. To outline the present issues in surgical care delivery, as well as the significant role of telemedicine in advancing surgical care delivery in Africa. This review will also discuss the challenges behind telemedicine utilization in Africa, and recommend targeted measures to address those barriers while promoting the enhanced integration of telemedicine into surgical care delivery.

Methods

A comprehensive online literature search was conducted using several search engines, including PubMed, ScienceDirect, and Google Scholar to assess the potential advantages of telemedicine over traditional surgical practices in Africa, as well as to identify the challenges hindering its implementation. The literature review examined the role of nongovernmental organizations in promoting telemedicine adoption across various African countries. Literature search terms include "countries of Africa," "impact of telesurgery and telemedicine in Africa," and "current situation of telemedicine in intervention." Only articles written in English were considered, and inclusion criteria included relevance to our research objectives and countries in Africa.

Results

The potential for telesurgery in Saharan and sub-Saharan countries is still a milestone to be unlocked, but already telemedicine implementation has shown great results. Although hindrances like trust, lack of infrastructure, and lack of trained personnel in the field of telecommunication have been issues. There is a rise in the use of telemedicine in areas of interest like postsurgical care, doctor-patient consultation, and tele-monitoring. Various schemes and plans implemented by public organizations have also peaked since the pandemic. A telemedicine establishment requires multifactorial development occurring in a step-by-step manner. Although complexity in development and barriers faced in countries in Africa are concerns, the outcomes of using telemedicine are considerably better. The rising population and lack of medical specialists have led to a gap in access to approachable surgical care, and telemedicine has shown promising potential to overcome it.

Conclusion

Telemedicine implementation has changed the method of intervention in clinics all over the world. Implementation of parts of telemedicine like telesurgery and tele-monitoring has the potential to overcome the concern of a rising population, but there is still a long way to go.

Technological Advancements in Augmented, Mixed, and Virtual Reality Technologies for Surgery: A Systematic Review

Recent advancements in artificial intelligence (AI) have shown significant potential in the medical field, although many applications are still in the research phase. This paper provides a comprehensive review of advancements in augmented reality (AR), mixed reality (MR), and virtual reality (VR) for surgical applications from 2019 to 2024 to accelerate the transition of AI from the research to the clinical phase. This paper also provides an overview of proposed databases for further use in extended reality (XR), which includes AR, MR, and VR, as well as a summary of typical research applications involving XR in surgical practices. Additionally, this paper concludes by discussing challenges and proposed solutions for the application of XR in the medical field. Although the areas of focus and specific implementations vary among AR, MR, and VR, current trends in XR focus mainly on reducing workload and minimizing surgical errors through navigation, training, and machine learning-based visualization. Through analyzing these trends, AR and MR have greater advantages for intraoperative surgical functions, whereas VR is limited to preoperative training and surgical preparation. VR faces additional limitations, and its use has been reduced in research since the first applications of XR, which likely suggests the same will happen with further development. Nonetheless, with increased access to technology and the ability to overcome the black box problem, XR's applications in medical fields and surgery will increase to guarantee further accuracy and precision while reducing risk and workload.

Examining the surgical backlog due to COVID-19 in Latin America and the Caribbean: insights from a scoping review

This scoping review assessed the surgical backlog in Latin America and the Caribbean (LAC) due to COVID-19 and identified mitigation strategies. We searched seven databases for citations from December 2019 to December 2022, focusing on LAC patients with cancelled or postponed procedures. We registered our protocol at Open Science Framework (https://osf.io/x2nd8) and adhered to PRISMA-ScR guidelines. We included 83 citations covering 23 LAC countries and 19 surgical specialities, with Brazil (67%, 56/83) and transplant surgery (24%, 20/83) being the most documented. Surgical backlogs were mainly reported at the hospital (44%, 37/83) and national levels (38%, 32/83). We identified 58 citations that reported a total of 42 strategies to mitigate the backlog, the most cited being establishing prioritisation criteria for surgical cases (41%, 24/58). Our findings highlight challenges across differing healthcare systems in LAC, including disparities in data availability, surgical capacity, and resource allocation. For instance, while countries like Brazil had extensive data on national surgical backlogs, others lacked comprehensive national-level data. Our review can help inform policymakers and healthcare stakeholders to implement targeted interventions to prepare LAC-based surgical systems for future health emergencies.

See one, teach yourself one, do one: Barriers and opportunities in self-administered training and assessment for global surgical education

Objective

We aimed to determine the most important perceived barriers to the implementation of self-administered training and assessment in surgical education according to subject matter experts. With these findings, design thinking was used to explore possible interventions and develop a theory of change for overcoming identified barriers. Specifically, implementation was focused on expanding the surgical skills of associate clinicians (ACs) in low-to-middle-income countries (LMICs).

Methods

A qualitative study with 10 field experts representing surgeons, educators, and engineers from the US, South America, and East and West Africa was conducted. Interviewees were selected through purposeful snowball sampling until thematic saturation. Semi-structured interviews were conducted over video conference or in-person. Open-ended responses were synthesized, coded, and used to identify key barriers for scaling simulation-based learning and self-administered training and assessment in low-resource settings.

Results

We identified four major barriers to widespread implementation of self-administered training and assessment: demonstration of the safety and quality of surgical care provided after self-administered training; validation of the principle of self-administered training and assessment; translation of simulation skills to surgical knowledge; and integration into existing task shifting and task sharing legal landscapes.

Discussion

Increasing surgical capacity in LMICs is an urgent need that could be expanded with carefully developed self-administered training and assessment for ACs. The implementation process will be variable depending on local culture and regulations but is dependent on an international community of local champions to first produce a common body of evidence supporting the technology's utility and then to generate local excitement for its integration into existing systems.

An Evaluation of the Transfer of Skills and Knowledge from Two World Federation of Societies of Anaesthesiologists Fellowship Programs

BACKGROUND

Subspecialist training is an important part of developing human resources for health and for some learners, may require taking place in another, higher-resourced country. Despite effective learning of skills and knowledge in a different, more highly resourced context, transfer of these skills and knowledge back to a more poorly resourced context can be a challenge. We aimed to evaluate the transfer of skills and knowledge in 2 World Federation of Societies of Anaesthesiologists (WFSA) fellowship programs.

METHODS

This qualitative program evaluation study, guided by Guskey's evaluation framework, used in-depth interviews of both faculty and graduates of the 2 fellowship programs. Interviews were conducted remotely, transcribed verbatim, and analyzed using qualitative content and pattern analysis.

RESULTS

We interviewed 2 administrators, 10 faculty members, 17 graduated fellows, and 3 graduated fellows now in the role of faculty member in that fellowship. Key themes were barriers and enablers to the transfer of skills, including workplace and staffing, resources, mentorship, the interprofessional team, and leadership. Graduated fellows were able to have an impact on returning home in the areas of practice and service development, research, and teaching.

CONCLUSIONS

Our study found that the 2 fellowship programs had variable success in the transfer of learned skills and knowledge back to the fellows' "home" institutions. Contextual differences between the fellowship institution and the home institution were the main source of barriers to transfer, and fellows from different countries had diverse needs. Supporting the transfer of knowledge and skills should be an explicit goal of these fellowship programs, and as such, should be considered in the recruitment of fellows, curriculum development, and in how the success of a fellowship is evaluated. Curricula should not just focus on medical knowledge and skills, but also skills in leading change and in education.

Current Management of Locally Recurrent Rectal Cancer

Locally recurrent rectal cancer (LRRC), which occurs in 6-12% of patients previously treated with surgery, with or without pre-operative chemoradiation therapy, represents a complex and heterogeneous disease profoundly affecting the patient's quality of life (QoL) and long-term survival. Its management usually requires a multidisciplinary approach, to evaluate the several aspects of a LRRC, such as resectability or the best approach to reduce symptoms. Surgical treatment is more complex and usually needs high-volume centers to obtain a higher rate of radical (R0) resections and to reduce the rate of postoperative complications. Multiple factors related to the patient, to the primary tumor, and to the surgery for the primary tumor contribute to the development of local recurrence. Accurate pre-treatment staging of the recurrence is essential, and several classification systems are currently used for this purpose. Achieving an R0 resection through radical surgery remains the most critical factor for a favorable oncologic outcome, although both chemotherapy and radiotherapy play a significant role in facilitating this goal. If a R0 resection of a LRRC is not feasible, palliative treatment is mandatory to reduce the LRRC-related symptoms, especially pain, minimizing the effect of the recurrence on the QoL of the patients. The aim of this manuscript is to provide a comprehensive narrative review of the literature regarding the management of LRRC.

Effectiveness of primary repair for low anorectal malformations in Uganda

BACKGROUND

Anorectal malformations (ARMs) have an incidence of up to 1 in 4000 live births and can require immediate neonatal surgery due to associated intestinal blockage. Due to limited surgical access, Ugandan children present late and undergo three separate staged operations: (1) initial colostomy formation; (2) repair of the ARM (called anoplasty); and (3) colostomy closure. Three operations result in long treatment duration, potential complications with each procedure, delays in care, and stigmata associated with colostomies. By offering primary repair for ARMs in a resource-limited setting, we expect to: reduce healthcare expenditure by families, length of treatment, length of hospital stay, frequency of hospital visits, and social rejection.

MATERIALS AND METHODS

A pragmatic clinical trial was performed examining the effectiveness of primary repair (prospective arm) and comparing it with the three-stage repairs (retrospective arm).

RESULTS

Of the 241 patients included for analysis-157 patients had a three-stage repair, whereas 84 patients had one- or two-stage repair. The median [IQR age at the last surgery (days) was 730.0 (365.0, 1460.0) vs 180.0 (90.0, 285.0)] in three-stage and one- or two-stage repairs, respectively. There was no difference in postoperative complications compared to patients who had three-stage repair. Patients who had a two-stage repair had less time with colostomy than those with three-stage repair. Non-inferiority analysis demonstrated that the primary repair approach was non-inferior to the three-stage approach.

CONCLUSIONS

Primary repair for ARM is effective in low-income settings. It allows for less time with colostomy with no difference in post-operative complications. The decision on approach for treatment depends on the surgeon's experience and clinical judgment.

Surgery and the first 8000 days of life: a review

The first 8000 days of life, from birth to adulthood, encompasses critical phases that shape a child's health and development. While global health efforts have focused on the first 1000 days, the next 7000 days (ages 2-21) are equally vital, especially concerning the unmet burden of surgical conditions in low- and middle-income countries (LMICs). Approximately 1.7 billion children globally lack access to essential surgical care, with LMICs accounting for 85% of these unmet needs. Common surgical conditions, including congenital anomalies, injuries, infections, and pediatric cancers, often go untreated, contributing to significant mortality and disability. Despite the substantial need, LMICs face severe workforce and infrastructure shortages, with most pediatric surgical conditions requiring specialized skills, equipment, and tailored healthcare systems. Economic analyses have shown that pediatric surgical interventions are cost-effective, with substantial societal benefits. Expanding surgical care for children in LMICs demands investments in workforce training, infrastructure, and health systems integration, complemented by innovative funding and equitable global partnerships. Prioritizing surgical care within national health policies and scaling up children's surgery through initiatives like the Optimal Resources for Children's Surgical Care can improve health outcomes, align with Sustainable Development Goals, and foster equity in global health. Addressing the surgical care gap in LMICs will reduce preventable mortality, enhance quality of life, and drive sustainable growth, emphasizing surgery as an essential component of universal health coverage for children.

The Access to Oncology Medicines Coalition: Enhanced in-Country Coordination for Sustainable Access

The disparity in access to essential cancer medicines between less and more affluent countries is a major source of inequities in access to cancer care. In May 2022, the Union for International Cancer Control (UICC) launched a new initiative, the Access to Oncology Medicines Coalition (ATOM Coalition), bringing together over 40 organisations from the private and civil society sectors to cooperate and combine resources to address key barriers of access to cancer medicines in low- and lower-middle income countries. While the ATOM Coalition is engaged in global efforts to make cancer medicines more accessible, the initiative also includes a country-level support programme to enhance coordinated locally-led action and accelerate access. This is supported by a transparent governance and organisational structure as well as a working framework with governments and other key stakeholders to assess the current capacity and develop tailored responses that can lift and/or relax some of the identified barriers through joint collaborations with ATOM Coalition partners.

Responding to the challenges of Global Children Surgery: a unique program in Burkina Faso

PURPOSE

The challenges are immense when it comes to enhancing the development of pediatric surgery in low- and middle-income countries in line with current recommendations for holistic and sustainable approaches. The Pediatric surgery development plan in Burkina Faso was started in 2020. This paper reports on our unique experience, focusing on the main actions and indicators monitored.

METHODS

The program was developed based on the core principles of the Global Initiative for Children's Surgery, employing a comprehensive health system-strengthening strategy. Our approach aimed to address the pediatric surgical ecosystem through partnerships, research, and interventions at all levels of the healthcare system.

RESULTS

Significant actions were implemented across various domains, including infrastructure, quality of care, workforce, community awareness, research, and advocacy. These efforts have led to a substantial strengthening of the pediatric surgical ecosystem in the country, achieving major milestones and outcomes in each of these areas.

CONCLUSION

This program has not only helped to create a major impulse for the expansion of pediatric surgery in Burkina Faso, but also enriched the community of interest with a robust implementation program to confirm the main challenge to succeed: integrating this most essential discipline into the wider framework of global health.

Voices From the Frontline: A Reflexive Thematic Analysis Illuminating Perioperative Practice Realities in Southern Ethiopian Teaching Hospitals

Despite national efforts, gaps persist in Ethiopian perioperative care. This reflexive thematic analysis aimed to investigate the contextual challenges faced in delivering perioperative care. In-depth interviews were conducted with 20 healthcare professionals, including anesthetists, nurses, and surgeons, to gain a frontline perspective of perioperative practice realities. The analysis revealed eight interconnected themes: systemic infrastructure vulnerabilities, workforce expansion uncertainties, workforce demoralization, fragile perioperative safety culture, hierarchical structures and communication barriers, financial barriers to care, fragmented information systems, and fragile governance with sociopolitical instability. Local deficiencies in resources and equipment were amplified by global challenges, creating a precarious care environment. While workforce numbers increased, concerns persisted about competency and training quality. Systemic pressures and unmet professional needs contributed to staff demoralization. Inconsistent safety practices and top-down quality improvement initiatives hindered sustainable progress. Rigid hierarchies and departmental silos impeded effective teamwork and resource coordination. Financial constraints created significant barriers to care access and ethical dilemmas for providers. Incomplete digitalization and inconsistent documentation practices compromised continuity of care and data-driven improvements. Overarching sociopolitical instability and weak governance cascaded into healthcare system disruptions. The findings underscore the need for a multifaceted approach to strengthen perioperative care, including improving infrastructure, enhancing workforce development, fostering a culture of safety, breaking down hierarchical barriers, addressing financial accessibility, implementing robust information systems, and building resilient governance structures amidst adversity.

Neurological Surgery Manpower Training and Density in Islamic Republic of Iran: A Population Study

BACKGROUND AND OBJECTIVES

Significant disparities in worldwide neurosurgical training and workforce distribution are prominent primarily in low-income and middle-income countries. Although Iran is considered a lower middle-income country, neurosurgical density and distribution in Iran has surpassed the recommended ratio of 1 neurosurgeon for every 100 000 population. The objective was to determine neurological surgery density and distribution in Iran and the factors significant in the relative success in training and allocation of neurosurgeons in Iran.

METHODS

Review of PubMed and administration of site surveys of multiple data sources including Neurosurgical Society of Iran, Iranian Board of Neurological Surgery, Medical Council of Islamic Republic of Iran, Universities of Medical Sciences in Iran, and Ministry of Health and Higher Education of Iran.

RESULTS

Over the 72-year period from 1952 to 2024, 1200 neurosurgeons have been trained and distributed in 31 provinces in Iran, attaining a ratio of 1.4/100 000 population. All but 40 neurosurgeons were trained after 1981, which coincided with the Iran-Iraq War. Decentralization of medical and neurosurgical residency training programs, resolving the immediate need for neurosurgeons managing penetrating traumatic brain and spinal cord injuries during the 1980 to 1988 Iran-Iraq War, and active participation of legislative and executive branches of government in solving health care disparities were major factors in meeting the needs of the country. At the present time, more than 555 neurosurgeons are practicing in Tehran Province, a proportion of 3.8 neurosurgeons for every 100 000 population, which indicates an element of disparity in density distribution across Iranian land.

CONCLUSION

Legislative initiatives and government support of public health care delivery and decentralization of medical and residency training programs after the Iran-Iraq War and introduction of the Ministry of Health and Medical Education are considered the main reasons for the relative success in meeting the neurosurgical demand and manpower density. Still, further adjustment of distribution of manpower is needed.

The Pan-African Surgical Healthcare Forum: An African qualitative consensus propagating continental national surgical healthcare policies and plans

Access to equitable, safe, affordable, timely, and quality surgical healthcare in Africa remains limited. Few African countries have surgical healthcare plans or policies. Where these exist, there are significant gaps in dissemination, funding, and implementation. A Pan-African Surgical Healthcare Forum (PASHeF) was initiated to address this. The inaugural forum was a two-day consensus conference of technocrats from African Ministries of Health hosted by the Honorable Minister for Health of Rwanda in Kigali. Through coordinated discussions, plenary sessions, working groups, and technocrat networking, they charted the path forward for national surgical healthcare policies and plans. Discussions were sparked by country experiences, and working groups focused on curated context-specific, face-validated questions. Documentation involved field notes, audio recordings, and artificial intelligence transcription. Data was coded using a constant comparative method to itemize delegates' observations, declarations, and recommendations, with member checking. A consensus statement was generated using an inclusive decision-making model. Thirty-two Ministries of Health were represented by 42 delegates who drafted and unanimously adopted the PASHeF 2023 Consensus Statement. This was a 50-point consensus addressing country commitment, leadership, financing, stakeholder mobilization, monitoring and evaluation, partnerships, and other aspects of national surgical healthcare planning in Africa. This consensus is the African roadmap and emphasizes implementation, the need for flexibility in policy development, and current opportunities and barriers. It emphasizes that community involvement and sustainability should undergird this planning, in addition to a focus on the entire spectrum of surgical healthcare, including prevention and rehabilitation. Delegates endorsed PASHeF as an annual event with a secretariat and recommended the creation of a Pan-African Surgical Healthcare Policy monitoring system, and that issues of surgical healthcare should be escalated as an agenda item on African Union and sub-regional ministerial meetings. African nations have embraced surgical healthcare policy as an imperative on their journey towards Universal Health Coverage.

Inteligencia artificial como herramienta de la cirugía global en América Latina

Introducción. América Latina presenta un problema de desigualdad en el acceso a los servicios de salud en relación con el contexto sociocultural de la población, que se acentúa en relación con las actividades quirúrgicas. Ante esta situación, la cirugía global busca soluciones que permitan zanjar la brecha. Métodos. Planteamos el uso de la inteligencia artificial (IA) como una herramienta con gran potencial para expandir el alcance de los cirujanos a las poblaciones más desatendidas de esta región. Resultados. Las potenciales aplicaciones de la IA son innumerables. En este contexto, los recursos educacionales (chatbots) y las plataformas de telemedicina podrían acercar al profesional de la salud a donde es más necesario. Los algoritmos de seguimiento postoperatorio podrían alertarnos de factores de riesgo y posibles complicaciones. Los sistemas de análisis de información facilitarían la asignación de recursos humanos y materiales para brindar una atención más oportuna. La digitalización de las labores burocráticas y administrativas reduciría la carga para el cirujano, permitiendo dedicar este tiempo a la atención de los pacientes. Conclusiones. Pese a que existen limitaciones, como el acceso a la tecnología, la inversión requerida y la barrera idiomática, si los gobiernos, los profesionales de la salud y los desarrolladores tecnológicos apuestan por aplicar esta herramienta en el campo de la cirugía, podríamos estar cerca de una revolución de la atención de salud.

Assessment of transfer-time and time-to-surgery as risk factors to survival in Gastroschisis (GS) in a LMIC; an eight-year review

BACKGROUND

The management of Gastroschisis in LMICs continues to be a challenge and is associated with very poor outcomes in contrast with HICs where survival rates near 100%. The purpose of this work is to provide an overview of survival over the past 8 years in a high-flow tertiary centre in Africa. It also investigates the effect of transfer-time and time-to-surgery on outcome.

METHODS

Retrospective case note review of all GS admissions. The variables assessed were gender, gestational age, weight, type of GS, transfer time, time to surgery and type of surgery. The primary outcome was survival.

RESULTS

A total of 171 GS cases were identified: 148 simple, 23 complex. Seven died before surgery. The median age at surgical intervention was 8.5 h (range, 0-48). Closure options ranged from single-staged (primary fascial, skin, umbilical flap and sutureless closure) or a staged (silo) closure. Overall survival was 34.5%. Cases transferred under 8 h had a 46% survival. Surgery under 12 h of life had highest survival, 45%. Simple GS survived better than complex GS (40% vs 10%). Primary closure had a significantly better survival compared to staged closure (51% vs 18%).

CONCLUSIONS

Transfer-time < 8 h plays a vital role in survival of GS cases. Surgical intervention within 12 h of birth showed a statistically significant improvement in outcome. Primary closure was associated with better survival rates.

LEVEL OF EVIDENCE

Level III.

Building resilient surgical systems that can withstand external shocks

When surgical systems fail, there is the major collateral impact on patients, society and economies. While short-term impact on patient outcomes during periods of high system stress is easy to measure, the long-term repercussions of global crises are harder to quantify and require modelling studies with inherent uncertainty. When external stressors such as high-threat infectious disease, forced migration or climate-change-related events occur, there is a resulting surge in healthcare demand. This, directly and indirectly, affects perioperative pathways, increasing pressure on emergency, critical and operative care areas. While different stressors have different effects on healthcare systems, they share the common feature of exposing the weakest areas, at which point care pathways breakdown. Surgery has been identified as a highly vulnerable area for early failure. Despite efforts by the WHO to improve preparedness in the wake of the SARS-CoV-2 pandemic, measurement of healthcare investment and surgical preparedness metrics suggests that surgical care is not yet being prioritised by policy-makers. Investment in the 'response' phase of health system recovery without investment in the 'readiness' phase will not mitigate long-term health effects for patients as new stressors arise. This analysis aims to explore how surgical preparedness can be measured, identify emerging threats and explore their potential impact on surgical services. Finally, it aims to highlight the role of high-quality research in developing resilient surgical systems.

Trends in Timely Access to High-Quality and Affordable Surgical Care in the United States

OBJECTIVE

To quantify recent trends in access to timely, high-quality, affordable surgical care in the US.

BACKGROUND

Insufficient access to surgical care remains an ongoing concern in the US. Previous attempts to understand and quantify barriers in access to surgical care in the US lack a comprehensive, policy-relevant lens.

METHODS

This observational cross-sectional study evaluates multiple domains of access to surgical care across the US from 2011-2015 and 2016-2020. Our stepwise model included timeliness (<60-minute drive time), quality (surgically capable hospital with ≥3 CMS stars), and affordability (neither uninsured nor underinsured) of access to surgical care using a novel combination of data from the American Hospital Association, Medicare claims, CMS's Five-Star Quality Rating System, the American Community Survey, and the Medical Expenditure Panel Survey.

RESULTS

The number of Americans lacking access to timely, high-quality, affordable surgical care increased from 97.7 million in 2010-2015 to 98.7 million in 2016-2020. Comparing these two periods, we found improvements in the number of Americans lacking access due to being uninsured (decrease from 38.5 to 26.5 million). However, these improvements were offset by increasing numbers of Americans for whom timeliness (increase from 9.5 to 14.1 million), quality (increase from 3.4 to 4.9 million), and underinsured status (increase from 46.3 to 53.1 million) increased as barriers to access. Multiple sensitivity analyses using alternative thresholds for each access domain demonstrated similar trends. Those with insufficient access to care tended to be more rural (6.7% vs. 2.0%, P<0.001), lower income (40.7% vs. 30.0%, P<0.001), and of Hispanic ethnicity (35.9% vs. 15.8%, P<0.001).

CONCLUSIONS

Nearly one-in-three Americans lack access to surgical care that is timely, high-quality, and affordable. This study identifies the multiple actionable drivers of access to surgical care that notably can each be addressed with specific policy interventions.

Cost effectiveness and return on investment analysis for surgical care in a conflict-affected region of Sudan

The delivery of healthcare in conflict-affected regions places tremendous strains to health systems, and the economic value of surgical care in conflict settings remains poorly understood. Our aims were to evaluate the cost-effectiveness, societal economic benefits, and return on investment (ROI) for surgical care in a conflict-affected region in Sudan. We conducted a retrospective study of surgical care from January to December 2022 at the Mother of Mercy-Gidel Hospital (MMH) in the Nuba Mountains of Sudan, a semi-autonomous region characterized by chronic and cyclical conflict. We collected data on all patients undergoing surgical procedures (n = 3016), including age, condition, and procedure. We used the MMH budget and financial statements to measure direct medical and non-medical expenditures (costs) for care. We estimated the proportion of expenditures for surgical care through a survey of surgical vs non-surgical beds. The benefits of care were calculated as averted disability-adjusted life-years (DALYa) based on predicted outcomes for the most common 81% of procedures, and then extrapolated to the overall cohort. We calculated the average cost-effectiveness ratio (CER) of care. The societal economic benefits of surgical care were modeled using a human capital approach, and we performed a ROI analysis. Uncertainty was estimated using sensitivity analysis. We found that the CER for all surgical care was $72.54/DALYa. This CER is far less than the gross domestic product per capita in the comparator economy of South Sudan ($585), qualifying it as very cost-effective by World Health Organization standards. The total societal economic impact of surgical care was $9,124,686, yielding a greater than 14:1 ROI ratio. Sensitivity analysis confirmed confidence in all output models. Surgical care in this conflict-affected region of Sudan is very cost-effective, provides substantial societal economic benefits, and a high return on investment.

Neurosurgery in Pakistan: Past, Present, and Future

BACKGROUND AND OBJECTIVES

Since its independence from India in 1947, Pakistan has struggled with economic crises such as global debt, corruption, constant regime change, and a decades-long war against terrorism. The resulting socioeconomic barriers have stymied efforts to develop a comprehensive and equitably accessible healthcare system, especially regarding safe, timely, and affordable surgical care. This article evaluates neurosurgery's development, current state, and prospects in Pakistan, a lower-middle-income country.

METHODS

We performed a literature search using PubMed and analyzed relevant articles to better understand the state and landscape of neurosurgery in Pakistan. Moreover, we conducted ecological research by querying the databases of the World Bank and the Institute of Health Metrics and Evaluation to evaluate the neurological and neurosurgical disease burden in the Pakistani population.

RESULTS

The neurosurgical workforce in Pakistan has demonstrated rapid growth over the past two decades, with approximately 450 neurosurgeons and a neurosurgeon-per-100 000 population density of 0.114. Nonetheless, access to essential neurosurgical procedures for the treatment of diseases such as stroke has been difficult to ensure, which likely contributes to Pakistan's stroke burden, ie, stroke was still the third most common cause of death in 2019, causing 21.7% of all deaths.

CONCLUSION

While Pakistan's political and economic instability has adversely affected the development of neurosurgery, the field has still made great strides and demonstrates a promising future in providing equitable neurosurgical care to all Pakistan's people.

Global Health Inequities in Orthopaedic Care: Perspectives Beyond the US

PURPOSE OF REVIEW

The burden of musculoskeletal disease is increasing globally and disproportionately affecting people in low and middle income countries (LMIC). We sought to review global access to orthopaedic care, burden of trauma, research infrastructure, impact of surgical mission trips, implant availability, and the effect of COVID-19 upon the delivery of orthopaedic care worldwide.

RECENT FINDINGS

The majority of people in LMIC do not have access to safe, quality surgical care, and there are few fellowship-trained orthopaedic traumatologists. Road traffic accidents are the leading cause of long bone fractures in LMIC and result in significant morbidity and mortality. Of the orthopaedic literature published globally in the last 10 years, less than 15% had authors from LMIC. There has been growth in surgical mission trips to LMIC, but few organizations have established bidirectional partnerships. Among the challenges to delivering quality musculoskeletal care in LMIC is timely access to quality orthopaedic implants. Implant options in LMIC are more limited and subjected to less rigorous testing and regulation than high income countries (HIC). The COVID-19 pandemic dramatically reduced elective surgeries but saw the increase in telemedicine utilization which has prevailed in both HIC and LMIC. Awareness of global inequities in orthopaedic care is growing. Much can be learned through collaborations between orthopaedic surgeons from HIC and LMIC to advance patient care worldwide. There is a need for high quality, accurate data regarding incidence and prevalence of musculoskeletal disease, care utilization/availability, and postoperative outcomes so resources can be allotted to make orthopaedic care more equitable globally.

Achieving Equity Through Global Neurosurgery Research

Since the release of the Lancet Commission on Global Surgery report in 2015, there has been an increase in the number of published papers on global neurosurgery, gaining widespread support from major neurosurgery journals. However, there remains no consensus on what may be considered part of global neurosurgery literature. Here, we propose that global neurosurgery research encompasses all scholarly work that measure, explore, or address inequity in the care of neurosurgical disease. We describe the growth of global neurosurgery research, cite landmark papers, and discuss barriers to participation, particularly among neurosurgeons in low- and middle-income countries. We introduce the 3Rs framework, advocating for global neurosurgery research that is rigorous, responsive, and responsible. This narrative review aims to guide young neurosurgeons and other researchers interested in the field, and to provide a framework through which global neurosurgery practitioners and advocates can evaluate previously accomplished work, paving the way toward neurosurgery that is timely, safe, and affordable to all.

Simulation-based education in the Pacific Islands: educational experience, access, and perspectives of healthcare workers

BACKGROUND

The World Health Organization (WHO) recommends simulation-based education (SBE) to acquire skills and accelerate learning. Literature focusing on SBE in the Pacific Islands is limited. The aim of this study was to determine Pacific Island healthcare workers' experiences, perspectives, and access to SBE.

METHODS

This was a cross-sectional survey of Pacific Island healthcare workers. We designed an online questionnaire based on existing literature and expert consultation. The questionnaire included Likert scales, multiple-choice, multi-select and open-ended questions. Participants were healthcare workers recruited from professional networks across the region. Descriptive statistics and relative frequencies summarized data, and comparative testing included unpaired t-tests, Mann-Whitney U, Chi-squared and Fisher's exact tests. Free-text responses were presented to illustrate findings.

RESULTS

Responses from 56 clinicians working in 11 Pacific Island countries were included. Fifty were medical doctors (89%), including 31 (55%) surgeons. Participants reported experience with scenario-based simulation (73%), mannequins (71%), and simulated patients (61%). Discrepancies were identified between previous simulation experience and current access for simulated patients (P = 0.002) and animal-based part-task trainers (P = 0.002). SBE was seen as beneficial for procedural skills, communication, decision-making and teamwork. Interest in further SBE was reported by most participants (96%). Barriers included equipment access (59%), clinical workload (45%) and COVID-19 restrictions (45%).

CONCLUSION

Some Pacific Island healthcare workers have experience with SBE, but their ongoing access is predominantly limited to low-technology modalities. Despite challenges, there is interest in SBE initiatives. These findings may inform planning for SBE in the Pacific Islands and may be considered prior to programme implementation.

Lived experience of burnout and fatigue in perioperative healthcare professionals in Rwanda: a qualitative study

BACKGROUND

There is a lack of qualitative data on the negative effects of workplace stressors on the well-being of healthcare professionals in hospitals in Africa. It is unclear how well research methods developed for high-income country contexts apply to different cultural, social, and economic contexts in the global south.

METHODS

We conducted a qualitative interview-based study including 64 perioperative healthcare professionals across all provinces of Rwanda. We used an iterative thematic analysis and aimed to explore the lived experience of Rwandan healthcare professionals and to consider to what extent the Maslach model aligns with these experiences.

RESULTS

We found mixed responses of the effects on individuals, including the denial of burnout and fatigue to the points of physical exhaustion. Responses aligned with Maslach's three-factor model of emotional exhaustion, decreased personal accomplishment, and depersonalisation, with downstream effects on the healthcare system. Other factors included strongly patriotic culture, goals framed by narratives of Rwanda's recovery after the genocide, and personal and collective investment in developing the Rwandan healthcare system.

CONCLUSIONS

The Rwandan healthcare system presents many challenges which can become profoundly stressful for the workforce. Consideration of reduced personal and collective accomplishment, of moral injury, and its diverse downstream effects on the whole healthcare system may better represent the costs of burnout Rwanda. It is likely that improving the causes of work-based stress will require a significant investment in improving staffing and working conditions.

"I've yet to meet anyone who's not keen for simulation" - a qualitative study of simulation-based education in the Pacific Islands

BACKGROUND

Simulation-based education (SBE) has been increasingly used to train healthcare workers in low-resource settings and has been endorsed by the World Health Organization (WHO). Consideration of the educational and cultural context is important to maximize the effectiveness of SBE. Despite its demonstrable benefits, there have been no studies of the general approach in the Pacific Islands. This study aimed to determine the factors that influence the uptake and success of SBE in the Pacific Islands.

METHODS

In this qualitative study, participants were recruited via professional networks to contribute to focus groups. Questions focused on participants' previous experiences and perspectives on SBE. Data were manually transcribed before thematic analysis. The reporting of the research was guided by the Standards for Reporting Qualitative Research (SRQR). Human Research Ethics Committee approval was obtained.

RESULTS

Two focus groups were conducted with 16 participants from six Pacific Island countries. Six themes and 15 subthemes were conceptualized from the data. Uptake of SBE is challenged by resource availability, clinical workloads and geographic remoteness. However, locally-driven solutions and positive attitudes towards SBE facilitate its success.

CONCLUSION

This study reveals the complexity of factors affecting the uptake and success of SBE in the Pacific Islands. These findings can serve to optimize the impact of existing and future SBE programmes and may be considered by educators prior to programme implementation.

Surgical Capacity Assessment and Leverage in the Palestinian Land (SCALPEL-I) Study: The First Nationwide Plastic Surgery Capacity Evaluation in Palestine

Background

Access to surgical care in low-to-middle-income countries (LMICs), especially in war-torn areas such as the occupied Palestinian territory (oPt), is a global health priority. The plastic surgical capacity in the oPt has not been evaluated. This study provides the first systematic evaluation of plastic surgical capacity in the oPt.

Methods

A cross-sectional study conducted between December 2022 and February 2023 included facilities providing plastic surgery services in the oPt, except private centers run by nonsurgeons. A modified PIPES (personnel, infrastructure, procedures, equipment, and supplies) tool was used. Data were analyzed for geographic and private/public disparities.

Results

Eleven facilities were included; 6 (54.5%) were in the West Bank and 5 (45.5%) in Gaza. The majority were private hospitals (n = 6, 54.5%). The mean PIPES score was personnel = 4.3 (4.03), infrastructure = 18.4 (2.4), procedures = 9.8 (3.8), equipment = 19.2 (3.6), and supplies = 22.4 (1.9). Hospital beds, operating rooms, and plastic surgeons per 100,000 people were 33.5, 1.0, and 0.5, respectively. There were 8 board-certified plastic surgeons. No facilities had a plastic surgery residency program. Key deficiencies included: 8 facilities (72.2%) not performing microsurgical free tissue transfers (none in Gaza), 5 (45.5%) lacking a system to identify complications, and 7 (63.3%) not offering regular educational courses. Average power supply was 8.0 hours/day in Gaza and 24.0 hours/day in the West Bank.

Conclusions

Plastic surgical capacity in the oPt shows significant deficiencies, especially in Gaza. These findings should inform stakeholders to address disparities, develop training programs, and improve access to safe plastic surgery.

Human Capital and Productivity in Surgery Research Across the Globe: A Big Data Analysis Using Artificial Intelligence

INTRODUCTION

No investigation of each nation's contribution to knowledge production and human capital in surgery currently exists. Previous studies explored country-level research productivity only in few surgical subspecialties. To identify current and future leaders in surgery research, we conduct a retrospective observational study of each country's human capital and research productivity.

METHODS

A web-scraping algorithm was deployed on PubMed to retrieve information on the first and senior author of every publication in all PubMed-indexed surgery outlets-a total of 388 journals-between 2010 and 2022, according to the SCImago classification. Each country's human capital is proxied by the number of first and senior authors.

RESULTS

A total of 665,668 publications from 110 countries were reviewed. The number of publications rises over time. The United States represents 30.78% and 31.32% of global publications based on first and senior authors, respectively. Other leading contributors include the United Kingdom (5.57% and 5.69% of global first and senior author publications, respectively), China (8.84% and 8.74%), Japan (7.14% and 7.10%), and Italy (4.54% and 4.46%). The number of publications per 100K people ranges between 0.04 and 86.01, suggesting widely varying levels of research productivity relative to the population.

CONCLUSIONS

Our findings underscore the US dominance in surgery research. Countries with a higher share of first or senior authors may have greater capacity to expand their future research output. As big data research expands, we expect studies deploying artificial intelligence methodologies, such as web scraping, on data repositories to guide healthcare provision and health policy decisions to become mainstream.