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

Access to healthcare: waiting time until the surgical procedure

BACKGROUND

Understanding the determinants that limit the population's access to surgical care in health services is highly relevant in order to provide data to support political interventions.

OBJECTIVE

This study aimed to evaluate the time between diagnosis and elective surgery in adult patients with the longest waiting lists in Brazil; identify the determinants that interfere with access to the health service to perform surgery; and analyze the quality of life after the indicative diagnosis of surgical intervention.

METHODS

A cross-sectional study was conducted with adult patients treated at three hospitals in the Southeast, North and South regions of Brazil, from October 2020 to October 2022. Data collection included socio-demographic data and assessment of quality of life using the WHOQOL-Bref instrument in the immediate postoperative period and one month after surgery.

RESULTS

A total of 250 patients participated in the study, 55.6% patients from the Southeast, 20.4% patients from the North and 24% patients from the South, with a mean age of 51.86 (SD = 14.27) years and clinical history such as arterial hypertension (p < 0.001). The longest mean waiting time for surgery identified was 26.23 (SD = 17.62) months in the South region, with a significant difference between the evaluated institutions (p = 0.02). Differences were observed between the first place of care of the evaluated patients (p < 0.001). There was a difference in the perception of quality of life between the immediate and late postoperative periods (p = 0.007) and in the physical domain, with an increase in scores among older patients (p = 0.004) and previous clinical history (p = 0.03).

CONCLUSION

Access to the health system varies by region and does not meet the standards proposed by the Brazilian health system. In addition, it seems that longer waiting times for surgery more perceptibly affect the quality of life of older adults and those with other associated diseases.

Paucity of rhinological services and training in sub-Saharan Africa

PURPOSE OF REVIEW

The aim of this review was to evaluate the current information available on the provision of rhinological services in sub-Saharan Africa and discuss the challenges and opportunities for improving care.

RECENT FINDINGS

We found that there were very little data available. Some information had been gathered as part of ENT surveys and there were some local and regional reports looking at rhinological care.

SUMMARY

Despite the lack of data, it is clear that specialist rhinological services in sub-Saharan Africa are generally very poor, particularly in rural areas. There are exceptions in some major cities but there exists a huge unmet need in this part of the world. We discussed the importance of the availability of endoscopy for evaluation and management of diseases of the nose and sinuses. We also look at ways of providing training. Partnership and collaboration with high income countries offer benefits for all. Fellowships are particularly valuable in developing specialist services. The availability of the internet provides a powerful way of imparting knowledge through lectures, guidance, courses and educational material such as open access journals and books. It is incumbent on high income countries to help develop healthcare services in areas of greatest need.

Perioperative lung expansion and pulmonary outcomes after open abdominal surgery versus usual care in the USA (PRIME-AIR): a multicentre, randomised, controlled, phase 3 trial

BACKGROUND

Postoperative pulmonary complications (PPCs) are a leading cause of morbidity, death, and increased use of health-care resources. We aimed to determine whether a perioperative lung expansion bundle including individualised intraoperative management reduces PPC severity in patients undergoing major open abdominal surgery compared with usual care.

METHODS

In this multicentre, randomised controlled phase 3 trial (PRIME-AIR), we enrolled adult patients (age ≥18 years) scheduled for an elective open abdominal surgery that would last at least 2 h, who were at intermediate or high risk for PPCs on the basis of their Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score (a score of ≥26), and who had a BMI below 35 kg/m2 at 17 academic hospitals across ten states in the USA. Participants were randomly assigned (1:1), using permuted block randomisation (a mixture of blocks sizes of 2 and 4; in a 1:2 ratio), stratified by centre, to either usual care or a lung expansion bundle. The bundle comprised preoperative education on PPCs, intraoperative protective ventilation with individualised positive end-expiratory pressure (PEEP) to maximise respiratory system compliance, intraoperative neuromuscular blockade administration and reversal based on patient's weight and neuromuscular transmission monitoring, and postoperative supervised incentive spirometry and mobilisation encouragement. Anaesthesiologists at each site were also randomly assigned to either the intervention bundle group or usual care group, and at each site, at least one unmasked and one masked investigator was designated for each participant. Assessors were masked to treatment assignment. The primary outcome was the highest severity (grade 0-4) of a composite of PPCs by postoperative day 7, including hypoxaemia, respiratory symptoms, atelectasis, bronchospasm, respiratory infection, hypercapnia, pneumonia, pleural effusion, pneumothorax, and ventilatory dependence. The primary endpoint and safety were assessed in the modified intention-to-treat (mITT) population (ie, all participants randomly assigned to treatment who received surgery, and did not withdraw consent or verbal agreement, and excluded those found to be ineligible after randomisation, or for whom consent was not obtained for other reasons). This study is registered with ClinicalTrials.gov, NCT04108130, and is now complete.

FINDINGS

Between Jan 24, 2020, and April 5, 2023, we screened 1462 patients, of whom 794 were enrolled and randomly assigned to treatment. The mITT population included 751 participants, of whom 379 (50%) were in the intervention bundle group and 372 (50%) were in the usual care group. Mean age was 61·8 years (SD 12·8); 360 (48%) of 751 patients were female and 391 (52%) were male; 572 (76%) were White, 44 (6%) were Black, 35 (5%) were Asian, and ten (1%) were other races or more than one race. Adherence to bundle components was high (72-98%). Patients in the intervention bundle group received higher mean PEEP (7·5 cmH2O [SD 2·5] vs 5·6 cmH2O [1·4]) and more frequent per-protocol dosing of neuromuscular blockade (334 [88%] of 379 vs 214 [58%] of 372) and reversal (322 [86%] of 375 who received reversal medication vs 250 [70%] of 358) than did those in the usual care group. By postoperative day 7, the most common PPC severity was grade 2 (211 [56%] of 379 in intervention bundle group vs 225 [60%] of 372 in the usual care group). Mean PPC severity was similar in both groups (1·60 [SD 0·94] vs 1·53 [0·93]; mean difference 0·07 [95% CI -0·03 to 0·18]; p=0·19). Occurrence of serious adverse events was similar in both groups. At 7 days postoperatively, one (<1%) patient in the intervention bundle group and two (1%) in the usual care group had died; at 30 days, cumulatively, one (<1%) patient and four (1%) patients had died; and at 90 days, cumulatively, six (2%) patients and five (1%) patients had died, respectively. Adverse events occurred in 71 (19%) of 379 patients in the intervention bundle group and 54 (14%) of 372 in the usual care group, and 35 (9%) patients in each group had serious adverse events.

INTERPRETATION

In patients with a BMI of less than 35 kg/m2 who are at moderate-to-high risk of PPCs and undergoing prolonged major open abdominal surgery, a perioperative lung expansion bundle did not reduce PPC severity compared with usual care provided at US academic hospitals.

FUNDING

US National Institutes for Health National Heart, Lung, and Blood Institute.

Predicting red blood cell transfusion for primary hip and knee arthroplasty: Designing a hub and spoke high-volume arthroplasty model

Background

Waiting lists for elective surgery are at record levels. Consolidating elective care into superhubs where high-volume surgery can be undertaken efficiently is an attractive solution. These pathways should be safe but also efficient and convenient for patients.We undertook this study to develop a model that would reliably predict healthy (American Society of Anaesthesiologists [ASA] class 1 and 2) patients who could be treated on a streamlined pathway and who would reliably not require red blood cell transfusion during their inpatient admission.

Methods

We retrospectively identified all patients undergoing primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) at our centre over a five-year period. We used binary logistic regression to develop a predictive model based on these variables.

Results

We identified 13-preoperative candidate variables from our literature search and used these to construct our predictive model. The final validated model was highly effective in predicting those patients who would not need a red blood cell transfusion (area under curve = 0.945).

Conclusion

Our model reliably predicts those healthy (ASA 1 or 2) patients undergoing primary THA or TKA surgery who will not require a red blood cell transfusion during their admission. These patients are suitable for this streamlined pathway without the need for unnecessary preoperative patient tests and travel.

Level of evidence

III.

Generation of preoperative anaesthetic plans by ChatGPT-4.0: a mixed-method study

BACKGROUND

Recent advances in artificial intelligence (AI) have enabled development of natural language algorithms capable of generating coherent texts. We evaluated the quality, validity, and safety of this generative AI in preoperative anaesthetic planning.

METHODS

In this exploratory, single-centre, convergent mixed-method study, 10 clinical vignettes were randomly selected, and ChatGPT (OpenAI, 4.0) was prompted to create anaesthetic plans, including cardiopulmonary risk assessment, intraoperative anaesthesia technique, and postoperative management. A quantitative assessment compared these plans with those made by eight senior anaesthesia consultants. A qualitative assessment was performed by an adjudication committee through focus group discussion and thematic analysis. Agreement on cardiopulmonary risk assessment was calculated using weighted Kappa, with descriptive data representation for other outcomes.

RESULTS

ChatGPT anaesthetic plans showed variable agreement with consultants' plans. ChatGPT, the survey panel, and adjudication committee frequently disagreed on cardiopulmonary risk estimation. The ChatGPT answers were repetitive and lacked variety, evidenced by the strong preference for general anaesthesia and absence of locoregional techniques. It also showed inconsistent choices regarding airway management, postoperative analgesia, and medication use. While some differences were not deemed clinically significant, subpar postoperative pain management advice and failure to recommend tracheal intubation for patients at high risk for pulmonary aspiration were considered inappropriate recommendations.

CONCLUSIONS

Preoperative anaesthetic plans generated by ChatGPT did not consistently meet minimum clinical standards and were unlikely the result of clinical reasoning. Therefore, ChatGPT is currently not recommended for preoperative planning. Future large language models trained on anaesthesia-specific datasets might improve performance but should undergo vigorous evaluation before use in clinical practice.

Risk-Adjustment of Perioperative Mortality Rate Measurement in a Low-Income Country

BACKGROUND

The health care systems in low-income countries have extremely limited capacity to treat surgical diseases. The perioperative mortality rate has been suggested as a key quality metric to guide the expansion of care, but there is little information on how to risk-adjust this outcome measure.

METHODS

We did a 42-month observational cohort study of surgical operations at a Ugandan secondary referral hospital. We examined factors associated with in-hospital 30-day perioperative mortality outcomes. The aim of the study was to suggest a suitable indicator metric for comparative health service research in low-income countries.

RESULTS

The 30-day perioperative mortality rate was 5.3 % (n = 381/7170). The adjusted odds ratios (95% confidence interval) of variables associated with mortality were as follows: procedure (P < .001; laparotomy 2.6 [1.6, 4.3], P < .001; cranial surgery 2.8 [1.6, 4.9], P < .001); American Society of Anesthesiologists (ASA) rating 3.1 (2.6, 3.6), P < .001; HIV serostatus (P < .001; positive 2.7 [1.5, 4.8], P < .001); procedure urgency (urgent/emergent) 1.7 (1.2, 2.3), P = .003; home district location (P = .015; distant referral 1.4 [1.0, 1.9], P = .027); and age decile 1.1 (1.0,1.2, P = .001). Laparotomy was the commonest procedure performed (n = 2361) and was associated with 56.3% (n = 216/381) of deaths.

CONCLUSIONS

Laparotomy had a strong independent association with mortality at a Ugandan secondary hospital. The laparotomy perioperative mortality rate may be a suitable outcome measure for comparative health service research in low-income countries.

Comparing the socio-economic and emotional implications of management of a hypoplastic cleft maxilla with distraction osteogenesis or orthognathic surgery in a developing country

Management of a hypoplastic maxilla can be addressed through distraction osteogenesis (DO) or orthognathic surgery (OS), with DO being preferred for severe deformity due to the increased stability of its long-term outcomes. This study aims to compare the economic and emotional implications of DO versus OS at an Indian institute. A total of 20 patients who underwent maxillary DO were compared with 20 patients who underwent orthognathic Le Fort I osteotomy. Sourced from the GSR Institute of Craniofacial Surgery database, patients completed a telephone questionnaire, via a translator, which investigated: return travel costs to hospital, length of hospital stay, Likert scales gauging mood and impact on daily life before, during, and after treatment. There was a marked increased mean length of hospital stay associated with rigid external device (RED) in comparison with OS by 70.5%. This is also associated with a greater mean total cost of hospital stay per patient, also by 70.5%. The mean number of visits to hospital postoperatively was over twice the number of visits for RED in comparison with OS, associated with a staggering 859.9% increase in financial burden on RED patients compared with OS with regards to mean total return travel costs to hospital. There was a 36.8% percentage change in impact on daily life scores for RED patients compared with 25.0% percentage change associated with OS. While DO appears advantageous, its economic drawbacks emphasise the necessity for a comprehensive evaluation of clinical and economic outcomes in low-resource settings. Limitations included challenges due to various regional languages and absence of pre-existing maxillary deficiency data.

Pediatric Surgical Outreach: An Underutilized Resource for Increasing Children's Surgical Capacity in Canada

BACKGROUND

Wait times for children's hospital-based surgical services are at unprecedented levels. Opportunities to increase most children's hospital-based service capacity are sparse, and community-based services are a potential patient-centered alternative. The aim of this study was to understand the current state of pediatric surgical outreach in Canada as an option to address these challenges.

METHODS

An electronic survey was sent to all (n = 18) Canadian children's hospital surgical leaders inquiring about "outreach services" defined as inpatient/outpatient services provided by pediatric surgeons outside of children's hospitals. Descriptive analysis of outreach included facility type/location (by postal code), nature and frequency of service, and participation of other specialties.

RESULTS

18 survey respondents (100 %) reported that pediatric surgical outreach services were available in 7 out of 10 provinces, but only 8/18 (44 %) of Canadian children's hospitals. Services include: i) inpatient coverage at 2 sites in 2 provinces; ii) outpatient surgery at 6 sites in 3 provinces (median distance 69 km, range 6-1881 km from home children's hospital); and iii) outpatient ambulatory clinics at 19 sites in 4 provinces (median distance 18 km, range 4-1448 km from home children's hospital). Median frequencies of outreach surgical slates and clinics were 1 per week and 1 per month, respectively.

CONCLUSION

Less than half of Canadian children's hospitals have developed outreach programs as a strategy to increase capacity for children's surgical services. To promote improved surgical care for all Canadian children, efforts targeting expansion of outreach capacity could increase access for geographically remote children.

TYPE OF STUDY

Cross sectional Retrospective Survey.

LEVEL OF EVIDENCE

Level IV.

A novel tool for assessing psychomotor proficiency in laparoscopic cholecystectomy using simulation-based training

INTRODUCTION

Laparoscopy is underutilized in lower- and middle-income countries (LMICs) due to limited access to training opportunities. Laparoscopic cholecystectomy is the gold standard for treating gallbladder disease in high-income countries (HICs), yet the open approach predominates in LMICs. A low-cost, simulation-based educational module for teaching laparoscopic cholecystectomy was developed by an international collaboration. A novel tool for verifying proficiency (CHOLE-VOP), incorporating a procedural checklist, a global rating scale (GRS), and a final competency rating, was designed and piloted to evaluate psychomotor skill acquisition in laparoscopic cholecystectomy.

METHODS

Fifty-two users completed the learning module, submitted a video recording of their performance on the tool, and performed self- and peer-assessment of videos using the CHOLE-VOP. A Kruskal-Wallis test was used to assess the CHOLE-VOP's ability to differentiate psychomotor performance across three experience levels [novice (no laparoscopic experience), intermediate (1-30 cases), and expert (> 30 cases)] and between settings (LMICs vs. HICs). Inter-rater agreement was measured between self-assessment and peer-assessment, across reviewer reviewer experience levels.

RESULTS

Among users [novices (14), intermediates (18), experts (17), unknown (3)], checklist scores significantly increased from novice (M = 28.16) to intermediate (M = 31.33) and expert (M = 32.66), P < 0.001. Both GRS and final ratings effectively discriminated between experience levels, P < 0.001. LMIC users had higher checklist scores (32.41 vs. 29.35, P = 0.008) and GRS scores (17.54 vs. 15.14, P = 0.002). Inter-rater agreement between self- and peer-assessments was moderate (ICC = 0.52), with poor agreement for novices (ICC = 0.24), who tended to overestimate their performance, and good agreement for intermediate users (ICC = 0.79).

CONCLUSION

The CHOLE-VOP successfully discriminated between experience levels in a simulated laparoscopic cholecystectomy training module. LMIC users outperformed HIC users in select skill parameters. Self-assessments, particularly among novices, showed limited concordance with peer-assessments.

Evaluating Access Improving Interventions: An Economic Evaluation of Surgical Task-Shifting for C-Sections in Sierra Leone

BACKGROUND

Access to safe, timely and affordable surgical care is lacking globally. Less than 6% of all surgical operations are carried out in low- and middle-income countries, where over a third of the world's population lives. CapaCare, an NGO operating in Sierra Leone, have developed a surgical training programme (STP) for Associate Clinicians based on principles of task-shifting to improve access. Interventions to increase healthcare access have the same value evidence requirements as new technologies but their evaluation presents methodological challenges as access is not routinely incorporated explicitly in economic evaluations.

OBJECTIVE

To evaluate the cost-effectiveness of surgical task-shifting in Sierra Leone, implemented through the CapaCare STP, to increase provision of caesarean section (C-section).

METHODS

We evaluated the impact of the STP on the provision of C-section and subsequent maternal and child outcomes, measured in disability-adjusted life-years (DALYs), relative to the costs using a healthcare system perspective and decision-tree model parameterised using data from surgical logbooks, national data, and the literature.

RESULTS

Results indicate that the surgical task-shifting programme in Sierra Leone would be considered cost-effective in increasing provision for C-section. It is cost saving (USD - 16.77) and results in 2.14 DALYs averted, per women with an indication for C-section, due to avoidance of maternal and child deaths as well as reduced complications.

CONCLUSION

Investment in surgical task-shifting initiatives should be considered by policymakers as a potentially cost-effective way to increase access to quality surgical services. Future evaluations of access-increasing interventions should seek to capture the distributional impact of this strategy and system benefits.

Contextual challenges and impacts on the surgical ecosystem in Chiapas, Mexico: A qualitative study

Chiapas is a state in southern Mexico that faces significant challenges in healthcare delivery. Strengthening the surgical system requires a comprehensive understanding of all health system domains and the contextual factors that influence care delivery. This study used qualitative methods to identify factors related to both gaps and successes in surgical care in Chiapas, Mexico. Semi-structured interviews were conducted with 23 participants at 15 public and private hospitals. Participants consisted of nurses, physicians, surgeons, and hospital administrators. Interviews were transcribed, and a codebook was developed and applied to all interviews. Recurring themes were identified and described using thematic analysis. Four themes characterizing the challenging context through which care is delivered were identified: referral system challenges, workforce shortages, insufficiencies in perioperative and nonoperative care, and waste and mismanagement of resources. Three themes related to innovations and workarounds were identified: efforts to maximize resources and reduce waste, strategies to reduce language barriers, and planning to account for clinical needs in situations of limited access and emergencies. Gaps and challenges within the surgical system of Chiapas lead to challenges in care delivery across all domains of the health system. However, several solutions have emerged among local providers. Insight into these factors can be used in planning efforts to improve access to safe and effective surgical care.

Complicated appendicitis in low- and lower-middle-income countries: a systematic review and meta-analysis

BACKGROUND

Acute appendicitis is a common surgical emergency worldwide, with significant variations in prevalence, presentation and outcomes between high-income countries (HIC) and low- and middle-income countries (LMIC). Complicated appendicitis has significant implications for low- and lower-middle-income countries due to limited healthcare resources. While there is extensive evidence for HICs, the evidence for low- and lower-middle-income countries is lacking. This systematic review aimed to compare the prevalence of complicated appendicitis between low-income countries (LICs) and lower-middle-income countries (LoMICs).

METHODS

A systematic review was conducted following PRISMA guidelines (PROSPERO CRD42024526007). Observational studies and randomized controlled trials published in PubMed, MEDLINE, Embase and Scopus (1990-2024) were retrieved. A grey literature search of Google Scholar and the Cochrane Library was also performed to identify existing reviews on the topic. The primary outcome investigated was the incidence of complicated appendicitis.

RESULTS

Eighty-seven articles with 25 582 participants were included. Meta-analyses of outcomes comparing LICs to LoMICs identified an increased pooled proportion of complicated appendicitis (34% (95% CI 27%-41%) vs. 23% (95% CI 19%-27%) P < 0.001), increased post-operative morbidity (19% (95% CI 13%-27%) vs. 13% (95% CI 8%-20%): P < 0.01) and mortality (OR 2.36).

CONCLUSION

Appendicitis remains a major burden in LICs and LoMICs with higher rates of morbidity and mortality. These findings highlight critical deficiencies in surgical access and delivery, underscoring the need for targeted interventions to improve outcomes in these settings.

Incidence and predictors of perioperative mortality in Ethiopia: a systematic review and meta-analysis

INTRODUCTION

The Lancet Commission on Global Surgery highlights perioperative mortality rate (POMR) as a key indicator of a nation's surgical system effectiveness. While POMR is often measured in high-income countries, it is less studied in low- and middle-income countries (LMICs). This study aims to assess the POMR and its predictors in Ethiopia.

METHODS

We conducted a thorough literature search across PubMed/MEDLINE, Embase, Web of Science, Scopus, and Google Scholar for studies from Ethiopia between 2019 and 2023 reporting POMR for various surgical procedures. Data were extracted in duplicate from eligible studies. We used random-effects meta-analysis to pool estimates of POMR and its predictors.

RESULTS

The meta-analysis revealed a POMR of 5.36%. Identified predictors of perioperative mortality in Ethiopia included older age, comorbidities, ICU admission, and an ASA physical status classification of III or higher and emergency surgeries.

CONCLUSION

Ethiopia's perioperative mortality rate is significantly high. Improving surgical care quality and safety, along with expanding access to surgical services, is crucial for bettering surgical outcomes in the country.

Global Barriers to Otolaryngology Care

Importance

Understanding the global barriers to otolaryngology-head and neck surgery (OHNS) care is crucial in addressing disparities in access to care, particularly in low-income and middle-income countries (LMICs).

Objective

To characterize barriers to comprehensive otolaryngology care across World Bank income groups.

Design, Setting, and Participants

Using an online cross-sectional survey that was administered by the Global OHNS Initiative via international and national professional societies, personal contacts, and social media, this study captured the perceptions of otolaryngologists regarding barriers to OHNS care at the levels of the country, health sector, clinician, and patient. Participants included otolaryngologists from the 194 World Health Organization member states and Taiwan. Eligibility criteria included a medical degree and specialized training in managing conditions of the ear, nose, and throat. The nonresponse rate was not recorded. The data collection period spanned from October 2022 to June 2023.

Exposures

Exposures included World Bank income group classification.

Main Outcomes and Measures

The primary outcomes were Likert scale responses regarding frequency of barriers to OHNS care. The a priori hypothesis was that LMICs would report more frequent barriers to OHNS care.

Results

The study involved 146 otolaryngologists (47 female individuals [32%]), with 69 (47%) from high-income countries and 77 (53%) from LMICs. Male individuals represented 45 high-income country respondents (65%) and 54 LMIC respondents (70%). Barriers were reported across income groups at all levels of the health system, with a higher frequency in LMICs. Several barriers were reported to be more substantial in LMICs, such as the national volume and distribution of otolaryngologists, financial compensation for clinicians, and patient stigma, and others were common across income settings, such as the availability of operating rooms and inflexible working hours. Common concerns included national and health sector barriers: OHNS workforce, referral networks, government support; clinician barriers: excessive clinician workloads, understaffing, poor administration support; patient barriers: distance to health care facilities, financial burdens such as medical costs and foregone wages, stigma, and health literacy.

Conclusions and Relevance

The results of this cross-sectional study suggest that there are barriers to otolaryngology care globally that affected all levels of the health care system. This work may inform prioritization of otolaryngology within research and policy, and it emphasizes the need for effective strategies to expand access to otolaryngology care, particularly in lower-income settings.

Omentum transplantation for malignant tumors: a narrative review of emerging techniques and clinical applications

Omentum transplantation has emerged as a versatile and effective technique across various surgical disciplines due to its unique properties of immunological surveillance, anti-inflammatory effects, and wound healing promotion. In breast cancer surgeries, it has been utilized to manage locoregional issues and immediate reconstruction, providing satisfactory cosmetic outcomes and minimal complications, particularly in patients who had previously undergone irradiation. For esophageal cancer, omental reinforcement has significantly reduced anastomotic leak rates and postoperative complications, supporting its use in esophagectomy and complex cardiothoracic surgeries. In gynecological surgeries, the use of omental flaps has shown excellent results in neovaginal reconstruction following pelvic exenteration, offering distinct advantages over myocutaneous flaps by reducing morbidity and preserving sexual function. Additionally, omental transposition has proven beneficial in reducing surgical morbidity following radical abdominal hysterectomy and in managing vaginal cuff dehiscence through vaginal approaches. Robotic-assisted omental flap harvesting has enhanced precision and reduced complications in reconstructive surgeries, making it a promising minimally invasive approach in regenerative surgery and complex reconstructions, such as for facial skeleton reconstruction. The omentum has also been beneficial in laparoscopic procedures for pudendal nerve decompression and in managing thoracic aortic graft infections, demonstrating its versatility and effectiveness in various clinical settings. These studies collectively highlight the omentum's significant role in improving surgical outcomes, reducing complications, and enhancing the quality of life for patients, solidifying its place as a valuable tool in modern surgical practice. This article provides a comprehensive narrative review of omentum transplantation in oncology, discussing its current applications and future potential as a standard treatment modality.

The role of NGOs and humanitarian organizations in enhancing surgical capacity in Africa: lessons learned and future directions-a narrative review

INTRODUCTION

Significant inequities exist in surgical care accessibility across marginalized African communities. Non-governmental organizations (NGOs) and humanitarian groups are vital in supporting Africa's surgical infrastructure. This narrative review explores the current status of surgical care in Africa, highlighting NGO initiatives, past challenges, and future opportunities.

METHODS

A narrative review was conducted using PubMed/Medline, ScienceDirect, and other relevant organizational websites.

RESULTS

Over 90% of patients in Africa lack access to proper surgical care due to funding shortages, inadequate resources, and a lack of skilled personnel. NGOs have addressed these gaps through successful initiatives, including fundraising and training, although past failures emphasize the need for clearer objectives and sustainable strategies.

DISCUSSION

Future efforts should prioritize addressing cultural sensitivities, setting realistic goals, and leveraging telemedicine. NGOs and humanitarian organizations will remain critical to improving surgical care for underserved populations in Africa.

Epidemiology of surgical site infections post-cesarean section in Africa: a comprehensive systematic review and meta-analysis

BACKGROUND

Surgical site infections (SSIs) are among the most common postoperative complications following cesarean section, particularly in Africa. These infections pose maternal health risks, including prolonged hospitalization, increased healthcare costs, and mortality. This systematic review and meta-analysis aimed to evaluate the epidemiology, pooled prevalence, and risk factors for SSIs after cesarean section in Africa.

METHODS

A systematic search of PubMed/MEDLINE, Scopus, and Web of Science databases was conducted to identify studies published between January 2000 and December 2023. The review followed PRISMA 2020 guidelines, and 41 studies spanning 18 African countries met the inclusion criteria. Data on SSI prevalence and risk factors were extracted, and the quality of studies was assessed using the Newcastle-Ottawa Scale. A random-effects model was used to estimate pooled prevalence, with subgroup analysis, sensitivity analyses, and meta-regression exploring variations across study characteristics. Publication bias was assessed using funnel plots.

RESULTS

The pooled prevalence of SSIs after cesarean section was 11% (95% CI: 9-12.9%) with substantial heterogeneity (I2 = 97%, < 0.001). Regional variations were observed, with the highest prevalence in Tanzania (34.1%) and Uganda (15%), and the lowest in Tunisia (5%) and Egypt (5.3%). Temporal trends revealed a peak in prevalence (16%) during 2011-2015, declining to 9.8% by 2016-2020. Prolonged rupture of membranes (PROM) was the most frequently reported risk factor (OR: 4.45-13.9), followed by prolonged labor (> 24 h) (OR: 3.48-16.17) and chorioamnionitis (OR: 4.37-9.74). Potential publication bias indicated by asymmetrical funnel plots.

CONCLUSION

SSIs following cesarean section remain a burden in Africa, with wide regional variations and multiple preventable risk factors. The findings highlight the need for targeted interventions, including improved infection control practices, antenatal care, and timely management of obstetric complications.

Assessment of applicability of Ganga Hospital Score in the management of open tibia fracture

Aims

Open fractures of the tibia encompass a wide spectrum of injuries, posing multiple challenges for treating surgeons. This study evaluates the Ganga Hospital Open Injury Severity Score (GHOISS) in predicting the outcomes of open tibia fractures in Rwanda, focusing on its ability to guide wound management choices and assist in decision-making between preservation and amputation.

Methods

This was a prospective cohort study conducted between March and September 2022 in Kigali, Rwanda, involving patients aged 18 years and older with open tibial fractures. The GHOISS was calculated, and the patients were organized into three groups: Group I: score 1 to 13; Group II: score 14 to 16; and Group III: score ≥ 17. Outcome data were collected at one and six months of follow-up. The predictive validity of the GHOISS was determined through sensitivity, specificity, and predictive values. Correlation and analysis of variance (ANOVA) tests were also conducted to compare groups. Ethical considerations were respected, and institutional review board approval was obtained.

Results

The study involved 111 participants, with a mean age of 34 years (18 to 80) and a male-to-female ratio of 3.44:1. The amputation rate was 10 (9.0%), with a mean hospital stay of 30.55 days (SD 34.09). The infection rate was 54.05%, and the need for soft-tissue reconstruction was 36.9%. The GHOISS in predicting the amputation showed high sensitivity of 100% and sensitivity of 96.03%, with a positive predictive value of 71.4% and negative predictive value of 100%. ANOVA revealed significant differences between the groups (F (2,108) = 21.12; p < 0.001), and a strong positive correlation was found between the covering tissue score and the need for soft-tissue reconstruction.

Conclusion

The GHOISS demonstrated a remarkable ability to predict amputation and salvage in open tibia fractures and the potential for predicting related outcomes. The GHOISS subscore, which assesses skin and covering injuries, has shown a significant ability to predict the need for soft-tissue reconstruction.

Global Collaborative Trends in Otolaryngology Research: U.S. Partnerships With Low-, Middle-, and Other High-Income Countries

OBJECTIVE

Otolaryngology-related conditions impose a significant burden on low-income countries (LICs), lower-middle-income countries (LMICs), and, at times, upper-middle-income countries (UMICs), where health care resources are limited. International research collaboration with high-income countries (HICs), like the United States, can address these disparities by advancing global health knowledge. As such, the underlying objective was to define trends of collaborative otolaryngology publications among the United States and LICs, LMICs, UMICs, and other HICs as well as assess the global distribution of these publications by region.

STUDY DESIGN

A retrospective database review.

SETTING

Scopus.

METHODS

A bibliometric analysis of 163 collaborative publications (2018-2024) across 9 prominent US otolaryngology journals was conducted. Collaborations were categorized by country income level using the World Bank classification. Authorship positions, specialty classifications, and publication metrics were analyzed to assess representation across income groups.

RESULTS

Publications involving LICs and LMICs were limited. LICs contributed 0.82% of authors, with no representation in significant positions, while LMICs contributed 2.07%, with 0.94% in significant positions. HICs dominated authorship, accounting for 92.54% of authors and 94.36% of significant positions. Collaborations with LICs and LMICs were mainly concentrated in specific regions, with Uganda and Egypt, respectively, being the top contributors from these categories. The majority of publications from LICs and LMICs appeared in Otolaryngology-Head and Neck Surgery and JAMA Otolaryngology.

CONCLUSION

This is the first study to examine US-LIC/LMIC collaborations in otolaryngology, revealing limited inclusion of authors from these regions in key roles. Strengthening equitable partnerships is crucial to advancing global health equity in the field.

Volunteering: The Life You Save Might Be Your Own: The Wellness Benefits of Social Beneficence

A common form of beneficence is volunteering especially for those in health care. Research shows that volunteering has beneficial effects, not just for the recipients but also for the volunteers. Studies have shown that volunteering results in improved physical health, mental health, cognitive function, social connections, and in some cases career and life achievements. The strongest effects are in the areas of decreased mortality and increased functioning. Meeting certain volunteering thresholds increases the derived benefits. Additionally, there are benefits to recipient communities and society as a whole, which in turn are a benefit back to the individual.

Changing patterns in joint replacement surgery in the hand in Sweden: a population-based study of 5382 patients

Over a 16-year period (2008-2023), data from the Swedish National Patient Register reveal shifting trends in operation for hand joint replacements linked to demographic, healthcare and surgical advances. Among 5382 identified cases, 63% were women, with the incidence peaking in the 65-74 age bracket, highlighting a marked gender gap in middle and older age groups. Regional analyses indicate significant disparities, as Örebro and Halland had rates exceeding 10 per 100,000, while Stockholm and Blekinge fell below 5 per 100,000. The adoption of total prostheses without cement declined by 22%, reflecting changing surgical preferences. Predictive modelling anticipates an overall decline in incidence by 2035, with gender-specific rates converging over time. These findings highlight the need for targeted healthcare policies that address inequities and minimize unwarranted variations in treatment. Standardized care programmes that support evidence-based surgical decision-making could reduce the incidence of both over- and under-treatment.Level of evidence: III.

Anesthesiology competencies in undergraduate medical education: a comparative study of curriculum frameworks in Brazil, Spain, and the United Kingdom

OBJECTIVES

Medical education is crucial for meeting local needs and achieving global standards, especially in anesthesiology. Key competencies, such as airway management, mechanical ventilation, and sedation, are essential for managing critically ill patients, maintaining surgical and intensive care services, and preventing deaths from surgically treatable conditions. This study evaluated anesthesiology competencies in the curricula of medical schools in Brazil, Spain, and the United Kingdom (UK), highlighting the importance of integrating these skills to prepare for critical situations and support global surgery efforts.

METHODS

Educational frameworks from medical schools in Brazil, Spain, and the UK were analyzed by two independent researchers, who blindly assessed the program structures retrieved from the websites of medical schools and government sources to determine the presence of anesthesiology competency topics, which were organized into the respective disciplines within their academic programs.

RESULTS

A total of 466 medical schools were analyzed, with Brazil accounting for the majority (n = 374), followed by the UK (n = 48) and Spain (n = 44). Most medical schools in Brazil are private (229, 61.2%), whereas public institutions are predominant in Spain (32, 72.7%) and the UK (46, 95.8%). Anesthesiology courses were present in 24 (54.5%) Spanish schools, 128 (34.2%) Brazilian schools, and 9 (18.7%) British schools. Spanish institutions showed the highest incorporation of anesthesiology competencies in their curricula: acute pain management (52.3%), chronic pain management and preoperative evaluation (50.0%), treatment of shock, fluid replacement, and blood transfusion (47.7%), and cardiopulmonary resuscitation (45.5%). In Brazil, the most frequent competencies were preoperative evaluation (17.9%) and cardiopulmonary resuscitation (17.4%), while all other competencies were present in fewer than 15% of schools. In the UK, despite 95.8% of institutions having accessible curriculum frameworks, specific anesthesiology competencies were minimally represented. Multidisciplinary teamwork was identified in only 6.3% of institutions, airway management in 4.2%, and the following competencies in just 2.1%: acute and chronic pain management, cardiopulmonary resuscitation, monitoring, local anesthesia, treatment of shock, fluid replacement, blood transfusion, and vascular access.

CONCLUSIONS

The results highlight the need to show more explicitly competencies within undergraduate medical curricula public websites, particularly in Brazil and the UK. This study emphasizes Spain's more organized curricular structure, which facilitates the clearer identification of competencies, including those related to anesthesiology.

The Serotonergic Dorsal Raphe Promotes Emergence from Propofol Anesthesia in Zebrafish

The mechanisms through which general anesthetics induce loss of consciousness remain unclear. Previous studies have suggested that dorsal raphe nucleus serotonergic (DRN5-HT) neurons are involved in inhalational anesthesia, but the underlying neuronal and synaptic mechanisms are not well understood. In this study, we investigated the role of DRN5-HT neurons in propofol-induced anesthesia in larval zebrafish (sex undetermined at this developmental stage) using a combination of in vivo single-cell calcium imaging, two-photon laser ablation, optogenetic activation, in vivo glutamate imaging, and in vivo whole-cell recording. We found that calcium activity of DRN5-HT neurons reversibly decreased during propofol perfusion. Ablation of DRN5-HT neurons prolonged emergence from 30 µM propofol anesthesia, while induction times were not affected under concentrations of 1, 3, and 30 µM. Additionally, optogenetic activation of DRN5-HT neurons strongly promoted emergence from propofol anesthesia. Propofol application to DRN5-HT neurons suppressed both spontaneous and current injection-evoked spike firing, abolished spontaneous excitatory postsynaptic currents, and decreased membrane input resistance. Presynaptic glutamate release events in DRN5-HT neurons were also abolished by propofol. Furthermore, the hyperpolarization of DRN5-HT neurons caused by propofol was abolished by picrotoxin, a GABAA receptor antagonist, which shortened emergence time from propofol anesthesia when locally applied to the DRN. Our results reveal that DRN5-HT neurons in zebrafish are involved in the emergence from propofol anesthesia by inhibiting presynaptic excitatory glutamate inputs and inducing GABAA receptor-mediated hyperpolarization.

Identification of essential topics and procedural skills for inclusion in a contextualised undergraduate anaesthesia and critical care clerkship in Rwanda: results of a modified Delphi process

INTRODUCTION

Low anaesthesia workforce numbers contribute to shortfalls in access to surgical care globally. Investment in contextualised education and training can help address this issue by inspiring graduates to enter into training and imparting important knowledge and skills to non-specialists. We undertook a modified Delphi study to identify physician anaesthesiologist consensus on themes, topics, and skills for inclusion in undergraduate anaesthesia and critical care (ACC) medical school curricula in sub-Saharan Africa (SSA) and Rwanda.

METHODS

A list of ACC topics/skills was compiled through grey literature review, guiding survey development for a 3-round Delphi process. The first two rounds solicited responses from physician anaesthesiologists across SSA. The final round included only Rwandan physician anaesthesiologists. Respondents rated topics/skills on a 4-point Likert scale from 1 ("exclude from the curriculum") through 4 ("essential for inclusion"). Item-level Content Validity Index (I-CVI, the proportion of respondents rating a topic/skill as 3 or 4) was used for stratification. A first-round I-CVI threshold of 80% and 70% for subsequent rounds was used to define consensus for inclusion. Excluded topics/skills were considered for re-inclusion in subsequent rounds; 50% agreement was set as threshold for re-inclusion. The first round also sought consensus regarding aims, objectives, and delivery methodology.

RESULTS

A total of 147 topics/skills across 12 domains were identified for initial survey inclusion. Fifty-one respondents from 12 countries completed round one. Ninety-six (65.3%) topics/skills met consensus threshold. One additional skill ("pain assessment") was incorporated into round two following suggestions from respondents. The clerkship outcome ranked as most important and achievable was to 'inspire students to undertake anaesthesia specialty training' (n = 25, 49.0% and n = 26, 51.0% respectively). Thirty-six respondents from 12 countries completed round two. Eighty (82.5%) topics/skills met consensus threshold. Seventeen Rwandan specialists completed round three. Seventy-eight (97.5%) topics/skills met consensus threshold. From 67 previously excluded topics/skills, 14 (20.9%) met re-inclusion threshold.

DISCUSSION AND CONCLUSION

A modified Delphi process identified 92 essential topics/skills for inclusion in a Rwandan undergraduate ACC clerkship. Experts prioritised 'inspiring students' over 'achieving clinical competence' for undergraduates. A similar Delphi approach may be useful for educational content development in other settings across the African continent and for other specialties.

TRIAL REGISTRATION

Not applicable (study described is not a clinical trial). UGHE IRB protocol number: 194.

Delayed Surgery Increases the Rate of Infection in Closed Diaphyseal Tibial and Femoral Fractures

BACKGROUND

Although delays in musculoskeletal care in low- and middle-income countries (LMICs) are well documented in the open fracture literature, the impact of surgical delays on closed fractures is not well understood. This study aimed to assess the impact of surgical delay on the risk of infection in closed long-bone fractures treated with intramedullary nailing in LMICs.

METHODS

Using the SIGN (Surgical Implant Generation Network) Surgical Database, patients ≥16 years of age who were treated with intramedullary nailing for closed diaphyseal femoral and tibial fractures from January 2018 to December 2021 were identified. Infection was diagnosed based on the assessment by the treating surgeon. A logistic regression model, adjusting for potential confounders, was used to analyze the association between delays to surgery (in weeks) and infection.

RESULTS

Of the 9,477 closed fractures that were included in this study, 58% were femoral fractures and 42% were tibial fractures. The mean age was 35 years, and 76.2% of the patients were men. The mean delay to surgery was 10.5 days, and the median delay to surgery was 6 days. The overall infection rate was 3.1%. The odds of developing an infection increased by 9.2% with each week of delayed surgical treatment (odds ratio,1.092; 95% confidence interval, 1.042 to 1.145). Increasing delays were also associated with longer surgery duration and higher rates of open reduction.

CONCLUSIONS

Surgical delays in LMICs were associated with an increased risk of infection in closed long-bone fractures. This study quantified the increased risk of infection due to delays in receiving care, highlighting the importance of timely surgery for closed fractures in LMICs.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Orienting global surgery initiatives toward advancing minimally invasive surgery in Africa: a commentary based on continent-wide reviews

Surgical care has advanced with the introduction of minimally invasive surgery (MIS) techniques, which have resulted in a reduced length of hospital stay and improved patient outcomes with regard to morbidity, mortality, and aesthetics. Implementation in Africa remains limited due to economic, infrastructural, and training-related issues. Our previous reviews show that adoption of MIS in Africa has been highly variable. Only Egypt and South Africa, for example, have significantly reported robotic surgery programs. Despite present challenges, recent developments show that progress is being made. Advantages of MIS in resource-limited settings include fewer postoperative complications and shorter hospital stays, crucial for African patients who cannot afford unexpectedly extensive postoperative care and are also reliant on daily earnings. In the future, tele-robotic surgery can improve access to surgical care in under-served regions of the continent. Implementation barriers include the high cost of equipment, inadequate healthcare infrastructure, and limited training opportunities. Investment in the development of low-cost innovations, such as MIS equipment suited for resource-limited settings, local manufacturing or assembly of MIS equipment, and the establishment of training programs within the continent, is necessary to overcome these challenges. Policies supporting the integration of MIS into national healthcare plans are also required. The development of more robust MIS programs in Africa will not only enhance surgical care but will also contribute to the improvement of healthcare and economic outcomes across the continent. We present this commentary on the current state, challenges, and opportunities for the wider adoption of MIS across Africa, based on recent continent-wide reviews.

Bacterial air contamination and the protective effect of coverage for sterile surgical goods: A randomized controlled trial

BACKGROUND

There is limited knowledge regarding how long prepared sterile goods can wait before becoming contaminated. We investigated whether surgical goods could be prepared the day before surgery and kept sterile overnight in the operating room, if protected by sterile covers.

METHODS

Sterile surgical goods for open-heart surgeries (n=70) were randomized to preparation on the morning of the operation or on the previous evening. Exposure time was the total time between preparation and use. Primary outcome was bacterial growth reported as colony forming units (cfu), isolated on 840 agar plates. The protocol was registered with ClinicalTrials.gov (NCT05597072).

RESULTS

When the agar plates were protected with sterile covers, exposure time had no impact (intervention group: 7 cfu, control group: 17 cfu). Without protection, longer exposure time was associated with more cfu (P=.016). A total of 499 cfu were isolated, displaying 59 different types of bacteria including 13 resistant Staphylococcus epidermidis, 6 (46%) of which were multidrug resistant.

CONCLUSIONS

Sterile goods could wait in the operating room for at least 15 hours before use without increased risk of bacterial air contamination, if protected with sterile covers. However, if the goods were not covered, bacterial air contamination occurred over time.

Establishing a Competency Based Medical Education Curriculum for International Medical Graduates Pursuing Pediatric Surgery Training in High-income Countries

PURPOSE

Canada's Royal College of Physicians and Surgeons established a competency-based medical education (CBME) training in pediatric surgery in 2021. Specialty-specific Entrustable Professional Activities (EPAs), foundational to CBME, were created within this framework as tools to assess fellow progression. We aimed to determine which of these EPAs were appropriate for assessment of international medical graduates (IMGs) from Low and Lower-Middle-Income Countries (LMICs) training in pediatric surgery in Canada.

METHODS

Subject matter experts (SMEs) were defined as surgeons with experience in global pediatric surgical education. SMEs were invited to complete a survey tool to assess the relevance of the EPAs for IMG fellows. Each item was rated on a 5-point Likert scale, and narrative comments were collected along with demographic data from respondents. An EPA was determined to be relevant if more than 80 % of SMEs rated it at 4 or higher.

RESULTS

Six SMEs completed the survey. The average duration of experience training pediatric surgery fellows was 13 years, and all SMEs had previously used EPAs for fellow assessment. The average duration of experience supporting LMIC environments was 16 years. Relevance criteria were met for 20 of the 38 EPAs. EPAs not meeting relevance criteria included redundant EPAs, activities not applicable to the LMIC environment, and non-technical skills.

CONCLUSION

EPAs remain a valuable tool for fellow assessment. However, not all the EPAs seem relevant for IMGs training in Canada. Context-relevant education and training programs for LMIC trainees in pediatric surgery are critical to fortifying the global surgical workforce.

Prevalence of surgery in Indigenous people with cancer: a systematic review and meta-analysis

Background

As cancer incidence increases globally, so does the prevalence of cancer among Indigenous peoples. Indigenous peoples face significant barriers to healthcare, including access to and uptake of surgery. To date, the synthesis of access to and uptake of surgery for Indigenous peoples living with cancer has not yet been reported.

Methods

We conducted a systematic literature review and meta-analysis of access to and uptake of surgery for Indigenous peoples in Canada, Australia, New Zealand, and the United States. Five databases were searched to identify studies of Indigenous adults with cancer and those who received surgery. The Joanna Briggs Institute critical appraisal tools were used to assess the quality and inclusion of articles. Random effect meta-analyses were conducted to estimate the pooled prevalence of surgery in Indigenous people with cancer.

Findings

Of the 52 studies in the systematic review, 38 were included in the meta-analysis. The pooled prevalence of surgery in Indigenous people with cancer was 56.2% (95% confidence interval (CI): 45.4-66.7%), including 42.8% (95% CI: 36.3-49.5%) in the Native Hawaiian population, 44.5% (95% CI: 38.7-50.3%) in the Inuit and 51.5% (95%CI: 36.8-65.9%) in Aboriginal and Torres Strait Islander people. Overall, Indigenous people received marginally less cancer surgery than non-Indigenous people (3%, 95% CI: 0-6%). Indigenous people were 15% (95% CI: 6-23%) less likely to receive surgery than non-Indigenous people for respiratory cancers. Remoteness, travel distance, financial barriers, and long waiting times to receive surgery were factors cited as contributing to lower access to surgery for Indigenous people compared to non-Indigenous people.

Interpretation

Efforts to improve access and use of cancer services and surgery for Indigenous peoples should be multilevel to address individual factors, health services and systems, and structural barriers. These determinants need to be addressed to expedite optimal care for Indigenous peoples, especially those living in outer metropolitan areas.

Funding

The Research Alliance for Urban Goori Health (RAUGH) funded this project. GG was funded by an NHMRC Investigator Grant (#1176651).

Public health meets global surgery: a synergistic approach to better outcomes

Background

Global surgery (GS) aims to improve access to timely, quality, and affordable surgical care worldwide, yet it remains underrepresented in public health education.

Objective

This cross-sectional study assessed the awareness and knowledge of GS among 242 public health professionals.

Methods and results

Data collected via a self-structured questionnaire using SPSS 25 revealed significant gender and age diversity, with the majority being young professionals (76.4% aged 20-29). Most participants (71.5%) held a master's degree, and 55% had 1-5 years of public health experience. While 60% were familiar with the term "Global Surgery," a considerable portion lacked a comprehensive understanding. Participants emphasized the need to integrate GS into public health curricula through faculty development, practical training, scholarships, and research collaborations.

Conclusion

These strategies aim to bridge the knowledge gap and enhance the role of surgical care in global health. Despite being essential for addressing a significant portion of the global disease burden, surgical care remains inaccessible to many in LMICs due to systemic barriers. This study underscores the importance of fostering international partnerships and promoting a multidisciplinary approach to improve surgical care access, ultimately contributing to better health outcomes globally.

Patient outcomes after surgery in 17 Latin American countries (LASOS): a 7 day prospective cohort study

BACKGROUND

Access to safe surgical treatment across Latin America is limited by underfunded and fragmented health systems. Epidemiological data are required to describe surgical activity and patient outcomes.

METHODS

We did this 7 day prospective cohort study in 17 Latin American countries, collecting data describing inpatient surgery in adults (aged ≥18 years). The primary outcome was in-hospital postoperative complications within 30 days after surgery. Secondary outcomes were in-hospital mortality, duration of hospital stay, and admission to critical care within 30 days after surgery. This study is registered with ClinicalTrials.gov, NCT05169164.

FINDINGS

Between June 1, 2022, and April 30, 2023, we included 22 126 patients (mean age 49·7 years [SD 18·2]; 9260 [41·9%] male and 12 866 [58·1%] female; 10 180 [46·0%] White) from 284 hospitals. Of the 22 126 patients, 657 (3·0%) patients for the outcome of complications and 380 (1·7%) patients for mortality had missing data. Most patients were low risk (American Society of Anesthesiologists [ASA] grade I or II: 17 311 [78·7%] of 21 979 patients), undergoing non-major surgery (14 944 [68·0%] of 21 986 patients), and on an elective basis (14 837 [67·5%] of 21 988 patients). Despite this low-risk profile, 3163 (14·6%) of 21 632 patients developed postoperative complications resulting in 477 (2·2%) deaths. The most frequent complication category was infection, affecting 1795 (8·2%) patients. The high mortality from complications (failure to rescue) of 15·1% (477 deaths in 3163 patients with complications) suggests significant problems with postoperative care. 2978 (13·6%) patients were admitted to a critical unit immediately after surgery, but 180 (37·7%) of 477 patients who died never received critical care. Patients with complications had a median hospital stay of 8 days (IQR 3-18), compared with 2 days (1-3) for patients without complications. Postoperative mortality and complications were strongly associated with increasing ASA grade, urgency of surgery, and grade of surgery (intermediate and major).

INTERPRETATION

Patients receiving inpatient surgery in Latin America experienced high mortality rates, likely relating to standards of ward care after surgery. Given the rising demand for surgical treatments, resource-efficient measures are urgently needed to improve patient outcomes after surgery across Latin America.

FUNDING

None.

TRANSLATIONS

For the Spanish and Portuguese translations of the abstract see Supplementary Materials section.

Advocacy for Children With Surgical Diseases in Nigeria: National Policy Status, Gaps, and Solutions

INTRODUCTION

An estimated 1.7 billion children, mostly in low- and middle-income countries, lack access to surgical care. Increased focus on, and investment in, children's surgery requires the deliberate and strategic inclusion of children's surgery in healthcare policies. Here we evaluate the status of children's surgical diseases in Nigeria's healthcare policies.

METHODS

Key Nigerian policy documents referring to child and adolescent health were identified and analyzed using Collins' 8-step framework for health policy analysis. The search for evidence (3rd step in Colin's framework) included a combination of directed (DCA) and conventional content analysis (CCA). DCA was based on 4 categories (workforce, service delivery, infrastructure and financing) obtained from the surgical systems development framework developed by the Lancet Commission on Global Surgery.

RESULTS

Seven policy documents with child and adolescent health contents were reviewed: the National Child Health Policy (NCHP), National Policy on Development of Adolescents and Young People in Nigeria (NPDAYPN), Nigeria Every Newborn Action Plan (NENAP), Community Health Influencers Promoters and Services Programme (CHIPS), National Surgical Obstetrics Anaesthesia and Nursing Plan (NSOANP), National Guidelines for Comprehensive Newborn Care (NGCNC) and National Strategic Health Development Plan (NSHDP). Only the NSOANP had surgeons involved in its development, comprehensively addressed children's surgical conditions across all categories, and included surgical stakeholders in its implementation.

CONCLUSION

Children's surgery is not prioritized for specific inclusion within Nigeria's healthcare policies. There is a need for greater collaboration and integration into key healthcare policies. Prioritizing deliberate and strategic inclusion of children's surgery will ensure unmet surgical needs is addressed.

General surgeon workforce density is not associated with treatment-incidence ratios at the county or hospital service area level in North Carolina

BACKGROUND

General Surgeon Workforce Density (WFD) is used to approximate surgical access. Treatment-incidence ratios (TIR) provide a novel measure of care access. TIR's association with General Surgeon WFD has not been evaluated.

STUDY DESIGN

Retrospective cohort study of North Carolina inpatient discharges (2016-2019). The association between county and Hospital Service Area (HSA) TIRs for general surgical diseases was analyzed using adjusted linear and logistic regression.

RESULTS

When adjusting for pertinent covariates, county General Surgeon WFD and TIR (-0.0009, 95 ​% CI -0.028,0.026; p 0.95) and HSA General Surgeon WFD and TIR (0.008, 95 ​% CI -0.021,0.037; p ​0.58) were not statistically significantly associated. The odds of a county 0.91 (95 ​% CI 0.42,1.97; p 0.82) or HSA (OR 0.93, 95 ​% CI 0.43,2.04; p 0.86) having a high TIR was not associated with WFD.

CONCLUSION

General Surgeon WFD is not associated with disease-specific procedural rates of common surgical conditions at the county or HSA level.

Incident Food Insecurity and Associated Risk Factors After Surgical Trauma

INTRODUCTION

Food insecurity, defined as a lack of access to adequate nutrition, impacts approximately 30% of the global population. Despite clear evidence regarding the benefit of proper nutrition on clinical outcomes, the burden of incident food insecurity after surgical intervention in previously food secure patients is unknown. The goal of the study was to quantify incident food insecurity post operatively and to identify associated risk factors.

METHODS

A multicenter, prospective, longitudinal study was conducted among adult surgical trauma patients at tertiary care public and private hospitals in India. The primary outcome was new food insecurity from initial admission for traumatic injury to 6 mo post operatively. Cox proportional hazards models were used to evaluate associations between clinical and sociodemographic variables and incident food insecurity.

RESULTS

Of 774 patients enrolled, 20% were food insecure at baseline. During the follow-up period, 21% of patients who were food secure at baseline experienced new food insecurity. Incident food insecurity was associated with longer length of stay (hazard ratio (HR): 3.76, 95% confidence interval (CI): 1.62-8.74; P = 0.002), intensive care unit admission (HR: 1.87, 95% CI: 1.05-3.31; P = 0.032), receiving welfare support (HR: 2.00, 95% CI: 1.00-3.98; P = 0.049) and daily wage, rather than salaried, employment (HR: 2.95, 95% CI: 1.24-7.06; P = 0.015). Higher total household income was associated with maintaining food security (HR: 0.24, 95% CI: 0.13-0.44; P < 0.001). Hospitalization-related financial toxicity was significantly associated with incident food insecurity (HR: 3.07, 95% CI: 2.09-4.50; P < 0.001).

CONCLUSIONS

High levels of incident food insecurity were observed among surgical trauma patients. This highlights the need for serial food insecurity assessment post discharge. In lieu of serial follow-up, risk factors associated with incident food insecurity can be used to identify high-risk patients prior to discharge to facilitate connection to food insecurity interventions such as food prescription programs, monetary support, and nutritional welfare policies.

Pyridoxine Prevents Postoperative Nausea and Vomiting in Gynecologic Laparoscopic Surgery: A Double-blind Randomized Controlled Trial

BACKGROUND

Postoperative nausea and vomiting are common complications after gynecologic laparoscopic surgery. Pyridoxine has been recommended as a first-line drug to prevent and treat nausea and vomiting during pregnancy; however, its efficacy in preventing postoperative nausea and vomiting remains unclear.

METHODS

Patients of 18 to 65 yr old who received elective gynecologic laparoscopic surgery under general anesthesia were randomized into either the pyridoxine group or the control group. The pyridoxine group received 0.2 g of vitamin B 6 before anesthesia induction, and the control group received normal saline intravenously. Both groups received a similar regimen of combined intravenous and inhalation general anesthesia. All patients received dexamethasone (intravenous) after anesthesia induction and ondansetron (intravenous) before surgery completion. Postoperative nausea and vomiting occurrence was recorded according to the patients' self-reported data. Other clinical data were collected from hospital system, and concentrations of blood interleukin-6 and substance P were measured by enzyme-linked immunosorbent assay.

RESULTS

A total of 442 patients were screened, and 240 patients were equally randomized to the pyridoxine or control group. The incidence of postoperative nausea and vomiting was statistically significant lower in the pyridoxine group than in the control group (16.7% [20 of 120] vs . 35.8% [43 of 120]; relative risk = 0.47 [95% CI, 0.29 to 0.74]; absolute risk reduction = 0.20 [95% CI, 0.08 to 0.30]; P = 0.001), and pyridoxine decreased the incidence of postoperative nausea (12.5% [15 of 120] vs . 35% [42 of 120]; relative risk = 0.36 [95% CI, 0.21 to 0.61]; absolute risk reduction = 0.23 [95% CI, 0.12 to 0.33]; P < 0.001). There were no statistical differences in postoperative vomiting, time to the first postoperative nausea and vomiting occurrence, pain, serum interleukin-6 and substance P, and leukocyte and neutrophil counts.

CONCLUSIONS

In this single-center randomized trial, pyridoxine plus dexamethasone and ondansetron reduced the incidence of postoperative nausea and vomiting in patients undergoing elective gynecologic laparoscopic surgery under general anesthesia. These findings need to be validated in multicenter studies in diverse populations to ensure generalizability.

Transitioning to Office-based Transperineal Prostate Biopsy-A Case Study From a Regional New Zealand Hospital in Economic and Environmental Sustainability

OBJECTIVE

To explore the effects of the transition to office-based transperineal prostate biopsy (TPPB) on the interconnected domains of profit, planet, and people. Sustainability, encompassing environmental, social, and economic dimensions, is increasingly significant in health care. Urology, as a surgical specialty, presents unique opportunities to implement sustainable practices. This article outlines a case study detailing the transition of TPPB from the operating theater to an office-based setting.

METHODS

This study utilized a multi-phase approach, integrating retrospective and prospective data analyses. Changes in clinical workflows, financial savings, environmental impacts, and accessibility to care were assessed. Life cycle analysis evaluated carbon emissions associated with TPPB, while clinical outcomes, including infection rates and procedural efficiency, were monitored. Patient satisfaction and equity in health care access were explored through geographic accessibility studies and procedural adaptations.

RESULTS

Transitioning TPPB to an office-based setting resulted in: 1. Profit: Annual cost reductions of $302,000 NZD, increased procedural capacity, and elimination of hospital admissions due to transrectal ultrasound-guided-related sepsis. 2. Planet: Reduction in greenhouse gas emissions to 70 kgCO2e per biopsy, with significant contributions from reusable equipment packs and virtual consultations. 3. People: Enhanced patient comfort through fewer biopsy cores, reduced health care worker burden, and improved access for Māori populations via proposed mobile biopsy units.

CONCLUSION

This case study underscores the potential for sustainable innovations in urology to achieve cost-effective, environmentally responsible, and socially equitable health care delivery. It serves as a model for integrating sustainability into clinical practice, reinforcing the need for data-driven decision-making and collaborative leadership in the medical field.

A Systematic Comparison of Age, Comorbidity and Frailty of Two Defined ICU Populations in the German Helios Hospital Group from 2016-2021

Background/Objectives: The demographic change raises concerns about the provision of adequate, long-term healthcare. Our study was driven by the decision to test other studies' findings about how patients' age and comorbidities are significantly increasing in German intensive care units (ICUs) over time. The goal of this study was to analyze the age and age-related characteristics, e.g., comorbidities and frailty, in ICU populations from 86 hospitals in the German Helios Group over a period of 6 years. Methods: For this retrospective observational study, we derived two different definitions of ICU cases, with (i) CodeBased ICU cases being defined by typical ICU procedures (e.g., OPS 8-980, 8-98f and/or duration of ventilation > 0 h) derived from the German administrative dataset of claims data according to the German Hospital Remuneration Act and (ii) BedBased ICU cases being based on the actual presence of a patient on a designated ICU bed; this was taken from the Helios hospital bed classification system. For each ICU definition, the size of the respective ICU population, age, Elixhauser Comorbidity Index (ECI) and Hospital Frailty Risk Score (HFR) were analyzed. Further patient characteristics, treatments and outcomes are reported. Trends in cases with and without COVID-19 were analyzed separately. Results: We analyzed a total of 6,204,093 hospital cases, of which 281,537 met the criteria for the CodeBased ICU definition and 457,717 for the BedBased ICU definition. A key finding of our study is that a change in age in absolute and relative terms is observable and statistically significant: the mean age of CodeBased ICU cases, 68.7 (14.4/-0.06), is marginally decreasing, and that of BedBased ICU cases, 69.1 (15.9/0.07) (both with a p-value of <0.001), is marginally increasing. Age analysis excluding COVID-19 cases does not change this key finding. A longitudinal analysis shows a continuously decreasing number of ICU admissions and a marginally positive trend of patients who are 60-69 and ≥80 years old: CodeBased ICU, 1.04/1.02; BedBased ICU, 1.03/1.03, all with a p-value of <0.001. A severity analysis based on the ECI and HFS shows that both are higher in CodeBased ICU cases (2021 ECI:18.0 (12.9); HFS: 10.7 (7.3); both p-values < 0.001) than in BedBased ICU cases (2021 ECI: 12.3 (12.4); HFS: 7.4 (7.1); p-values of 0.3 and 0.12). Further testing results per definition are reported. Conclusions: The observed age-related trends suggest that there has been a further increase in demand for intensive care from a frailer population. We recommend further studies to critically evaluate the increasing frailty within the ICU population and to test the associated presumed need for increased ICU capacities.

Non-technical error leading to patient fatalities in the Australian surgical population

INTRODUCTION

Many surgical adverse events are due to errors in non-technical skills (NTS); consequently, improving NTS is a priority. However, evidence to guide NTS improvement activities is lacking. This study aimed to investigate the incidence and characteristics of non-technical errors linked to fatalities in a large, representative surgical-patient population to guide future NTS improvement.

METHODS

All fatality cases with known or suspected adverse events reported to the Australian and New Zealand Audit of Surgical Mortality (ANZASM) between 2012 and 2019 were retrospectively assessed using a validated tool developed by the study authors. Outcomes included the incidence of non-technical errors linked to death (overall and by NTS domain), the identification of non-technical error predictors through multivariate analysis, and change in non-technical error incidence over time using statistical process control charts.

RESULTS

Some 30 971 cases of surgical fatality were reported between 2012 and 2019, of which 3829 met the inclusion criteria. Due to insufficient information, 134 were excluded, leaving 3695 for analysis. Non-technical errors associated with patient death were identified in 63.7%. Of these, 58.4% had Decision-Making errors, 56.4% had Situational Awareness errors, 15.2% had Communication/Teamwork errors, and 5.44% had Leadership errors. Statistically significant predictors of Communication/Teamwork, Decision-Making, and Situational Awareness errors were identified. The incidence of overall non-technical errors decreased significantly between 2012 and 2019 and periods of significant decrease in Communication/Teamwork and Leadership errors were demonstrated. No significant decrease in Decision-Making or Situational Awareness errors were demonstrated.

CONCLUSION

The incidence of non-technical errors associated with surgical mortality rate is high. Future NTS improvement efforts should be targeted towards Decision-Making and Situational Awareness errors.

Pitfalls and Strategies for Implementing and Sustaining an Otolaryngology Perioperative Registry in Mekelle, Ethiopia

BACKGROUND

Surgical registries have been widely adopted in high-income countries to improve patient outcomes. However, similar data-driven initiatives are still scarce in low- and middle-income countries (LMICs).

AIMS

This study aimed to address the challenges of implementing a perioperative registry for otolaryngology-head and neck surgery (OHNS) in Mekelle, Ethiopia, and to assess strategies for ensuring its long-term sustainability.

METHODS

The registry was developed using REDCap, through a collaborative effort between otolaryngologists in the United States and Ethiopia, ensuring its relevance to the local context. On-site training sessions were conducted for 13 OHNS residents and four senior surgeons to facilitate their use of the registry. A Wi-Fi router was installed in the operating room to enable real-time data entry. Continuous support was provided through remote communication between the local team and the U.S. research team. Sustainability strategies focused on fostering local ownership, integrating the registry into existing workflows, and maintaining continuous data monitoring.

RESULTS

Despite facing challenges like intermittent internet connectivity and issues with workflow integration, the local team successfully integrated the registry into routine clinical and surgical practices. Key strategies included providing dedicated Wi-Fi routers, modifying registry fields for improved efficiency, and emphasizing the registry's value to the institution. Ongoing collaboration between the local team and the U.S. team enabled continuous optimization and data collection.

CONCLUSION

The successful implementation of this perioperative registry underscores the importance of engaging local stakeholders and integrating sustainable workflows. This initiative serves as a model for other LMICs seeking to establish surgical registries that enhance data-driven decision-making at both the patient and institutional levels.

Time trends in spine surgery in Italy: a nationwide, population-based study of 1,560,969 records of administrative health data from 2001 to 2019

BACKGROUND AND PURPOSE

 The use of spinal implants has increased substantially. Their widespread use raises public health concerns. We aimed to study spinal surgery trends in Italy from 2001 to 2019 and present a mapping for ICD9-CM codes potentially related to spinal diagnoses and procedures.

METHODS

 ICD9-CM codes of interest were selected and mapped to clinically meaningful spinal diagnostic categories and procedure classes. The Italian National Hospital Discharge Records database was then browsed according to these codes. Surgical volumes and trends were described. Population incidence rates (IR) were estimated and provided with 95% confidence intervals (CI). Variations in IRs were reported in terms of incidence rate ratio. The statistical significance of counts and IR time series trends was assessed by using the Cox-Stuart test.

RESULTS

 1,560,969 spinal procedures were extracted from 209,818,966 admissions registered nationally. The annual number of spinal procedures increased significantly by 67%, from 58,369 in 2001 to 97,636 in 2019 (P < 0.002). 1,040,326 (67%) procedures did not include implants, while 590,643 (33%) used implants, 395,450 (25%) associated with fusions and 125,193 (8%) with non-fusions. Population IRs increased from 100.9 (CI 100.1-101.7) to 163.2 (CI 162.2-164.3) episodes per 100,000 inhabitants. Surgical volumes for non-implant-related procedures remained stable, while implant-related procedures increased significantly, by 420% over the 19 observed years (P = 0.002).

CONCLUSION

Spinal surgical procedures and their population incidence rates increased significantly. Fusions and other implant-related procedures increased substantially for most diagnostic categories. An ICD9-CM mapping for spinal diagnoses and procedures as a reproducible tool for further explorations was presented.

Mapping Perioperative Care Randomized Controlled Trials in Sub-Saharan Africa: A Scoping Review

The World Health Organization has recognized surgical and anesthesia care as integral components of universal health coverage. In sub-Saharan Africa (SSA), 93% of the population lacks access to essential surgical services. Postsurgery mortality in Africa is double the global average. The involvement of anesthesia providers is crucial for improved outcomes. Perioperative research can produce context-specific solutions to challenges faced in the perioperative period. SSA conducts fewer randomized controlled trials (RCTs) than high-income countries, limiting its contribution to global evidence. Our primary objectives were to document the geographical distribution of included RCTs, describe their characteristics, and evaluate the reporting quality using the Consolidated Standards of Reporting Trials (CONSORT)-2010 checklist. We followed the PRISMA Scoping Reviews (PRISMAScR) Checklist. We searched MEDLINE, the Cochrane Library, and Scopus. We identified perioperative care RCTs within SSA published from 2000 to 2022. Two independent reviewers screened potential studies and extracted data in duplicate, with disagreements resolved through consensus or a third reviewer. Quantitative analysis was done with STATA 16, and data were summarized narratively. We compared RCT quality pre-CONSORT-2010 to post-CONSORT-2010, using Pearson's χ2 test or Fisher exact test (as applicable), considering P < .05 as statistically significant. Of 3319 records, 169 eligible RCTs were identified, randomizing 45,376 participants, with a mean sample size of 98. Between the years 2000 and 2022, there was an exponential trend towards an increasing number of RCTs in SSA (y = 1,5619e0,1051x). The RCTs were from 16 countries in SSA. Most studies were single-country, single-center, led by authors from Nigeria (63/169, 37.3 %) and South Africa (41/169, 24.3%). Most interventions were conducted intraoperatively (n = 125/169, 74%). Pharmacotherapy interventions were most investigated (n = 64/169, 37.9%), followed by analgesic interventions (n = 42/169, 24.9%). The surgical discipline most investigated was obstetrics (n = 51/169, 30.2%). The reporting quality was generally poor, with most RCTs not adhering to CONSORT guidelines and failing to register on a trial registry. This scoping review provides a comprehensive overview of perioperative care RCTs in SSA, highlighting limitations such as small sample sizes, under-representation of high surgical burden disciplines, and poor outcome reporting. Clinical trial capacity is limited to a few countries and institutions, and methodological quality remains poor despite reporting guidelines. There is an opportunity to enhance context-appropriate RCTs in SSA by prioritizing high-quality research through collaborative efforts. Our findings serve as a resource for researchers, funders, and policymakers in perioperative care research in Africa to improve future RCT designs and reporting.

The characteristics of surgical site infection with class I incision in neurosurgery

OBJECTIVE

Surgical site infections (SSIs) were recognized to be the most common complication of neurological surgery, with substantial life quality threats to patients and additional cost burdens to healthcare facilities. This study sought to expound the infection characteristics of class I incision and provide clinical indication for the prevention and treatment of SSIs.

METHODS

A 2-year retrospective analysis was conducted according to patients who performed neurological surgery with class I incision in a tertiary comprehensive hospital in Shaanxi Province, China. Case mix index (CMI)-adjusted and national nosocomial infection surveillance (NNIS) risk index-adjusted SSI rate were utilized for analytical standardization. The SSIs were specifically analyzed according to various departments, surgeons, and surgical classifications.

FINDINGS

6046 surgical cases were finally included in our study. The majority of the American Society of Aneshesiologists (ASA) score and NNIS risk index of surgeries were allocated in level 2 and score 1. Our study found 121 SSI cases, with the crude infection rate of 2.00%. 95.04% were organ/space infection. The most of the infection were found in the surgeries with score 1 (68.60%) of the NNIS risk index. The main surgical classification was resection of space occupying lesions (61.96%). The highest crude and NNIS risk index adjusted infection were individually found in hybrid operation (11.67%) and endoscopy-assisted resection of space occupying lesions (13.33%). 21 of 54 surgeons were found to have SSIs. We found the main pathogenic bacteria was Staphylococcus epidermidis (22.81%), and the commonly prophylactic used antibiotics was Cefazolin (51.95%).

CONCLUSION

Our study found the main infection was among surgeries with score 1 of NNIS risk index and the surgical classification of endoscopy-assisted resection of space occupying lesions. We indicated specific attention should be paid to the surgeon and surgical classification with highest infection rate to control and prevent SSIs.

Perioperative outcomes at three rural Rwandan district hospitals: a 28-day prospective observational cohort study

INTRODUCTION

The paucity of data on perioperative outcomes in low- and middle-income countries complicates the design and implementation of targeted interventions to improve the delivery of safe, affordable, accessible and timely surgical and anaesthesia care services. We assessed perioperative outcomes of patients undergoing surgical care at three Rwandan rural hospitals-Butaro District Hospital, Kirehe District Hospital and Rwinkwavu District Hospital-supported by Partners In Health/Inshuti Mu Buzima-an international non-governmental organisation.

METHODS

We conducted a 6-month prospective observational cohort study at the three district hospitals. A validated electronic-based perioperative assessment tool was adapted for our setting to capture demographics and clinical information. Descriptive and logistic regression analyses were performed using Stata V.15.1.

RESULTS

A total of 3289 major surgeries were performed from January to September 2020 at the three hospitals. Overall, 3204 surgeries (97.5%) were performed on women; the median age was 27 years (IQR: 23-33), and emergency cases constituted 86.8% of all cases. Cases with the American Society of Anesthesiologists (ASA) status of 3 or above had higher odds of having surgical or anaesthesia complications compared with cases with ASA status 1 (OR: 11.1, 95% CI: 2.7 to 45.8). Furthermore, emergency cases had 1.8 times higher odds of having a composite outcome (developing complications, surgical site infections or death) compared with elective cases (95% CI: 1.1 to 3.0).

CONCLUSION

Our findings highlight the need for improving surgical capacity, reinforcing infection prevention and control measures and leveraging electronic data capture for quality improvement to ensure safer surgery and anaesthesia care in rural Rwanda.

Global cardiothoracic surgery: outcomes from a survey on current worldwide training programmes

OBJECTIVES

There are significant disparities in global access to cardiothoracic surgery. Training a diverse cohort of global cardiothoracic surgeons is a critical step. However, little is known about training pathways globally, and there is a lack of standardization in training.

METHODS

The Global Thoracic Surgery Residents' Association developed a 25-item survey covering the five domains of country of origin, access to cardiothoracic surgical training, variations in training, barriers and facilitators to training, and future plans of cardiothoracic surgery trainees. The survey was disseminated electronically and over social media platforms.

RESULTS

A total of 73 responses from trainees in 21 countries were received. Wide variations were found in training programmes, including length of training, operative autonomy, reliance on simulation, trainee supervision and minimum case requirements. Common barriers included discrimination, separation from family and inadequate supervision and volume. Facilitators included participation in global rotations and mentorship. The majority (78%) of trainees plan on additional training.

CONCLUSIONS

There is a lack of standardization of trainee experience with extreme variations in global cardiothoracic training programmes in terms of length of training, reliance on simulation, supervision, research opportunities and minimum case requirements. These variations are opportunities to think forward in terms of collectively working on standardization of trainee experience, developing innovative modalities to increase supervision of trainees and recognizing trainee interest in research. There is a clear demand for increased global collaboration and the transfer of knowledge and techniques in addition to trainee recognition of need for further training.

Preoperative nutrition intervention program increases cleft surgery eligibility in the low- and middle-income country setting

BACKGROUND

Children with cleft lip and/or palate (CL/P) are highly susceptible to malnutrition, which may restrict surgery eligibility and delay repair. Preoperative nutrition programs for children with unrepaired CL/P are an effective treatment to overcome malnutrition for safe surgical intervention in high-resource settings; however, the effectiveness of such programs has not been demonstrated in the setting of low- and middle-income countries (LMICs). We studied the impact of a preoperative nutrition program on improving nutritional status and achieving surgical eligibility for children with CL/P.

METHODS

A retrospective review of patients treated by the Operation Smile (OS) Durgapur Cleft Centre in India from March 2021 to December 2022 was conducted. Patient gender, weight, age, cleft type, parental demographics, and income were recorded. The patients' malnutrition status was categorized as "mild", "moderate", or "severe" based on the Indian Academy of Pediatrics (IAP). Patient IAP classifications were noted at multiple timepoints, where change in nutrition status overtime served as the primary outcome of this study. Whether the child became eligible for surgery was assessed as a secondary outcome. Descriptive statistics used t-tests for continuous variables and chi-squared tests for categorical variables. P-values < 0.05 were considered significant.

RESULTS

The study included 236 patients who presented for nutritional intervention after being deemed ineligible for surgery. Initial IAP malnutrition classifications were 36.9% (n = 87) mild, 42.8% (n = 101) moderate, and 20.3% (n = 48) severe malnutrition. After intervention, 179 (75.8%) patients improved in IAP nutrition status, 49 (20.7%) maintained baseline status, and only eight (3.4%) declined. Final improvement levels were significantly associated with younger age at intake (p < 0.001) and maternal education background (p = 0.011). At study end, a total of 183 (77.5%) patients were eligible for cleft repair while 53 (22.5%) patients were malnourished and remained enrolled in the program. A total of 162 (68.6%) patients underwent surgery.

CONCLUSION

Malnutrition prevents children with CL/P from receiving surgical care in LMICs. This nutrition intervention enabled 228 (96.6%) patients to improve or maintain baseline nutrition and 183 (77.5%) to become surgically eligible who would not have been eligible otherwise. Preoperative nutrition programs offer a promising solution to addressing malnutrition as a barrier to timely, safe cleft repair in resource-constrained settings.