Adaptation and validation of the Children's Surgical Assessment Tool for Rwandan district hospitals

BACKGROUND/AIMS

Paediatric surgical care is a critical component of child health and basic universal health coverage and therefore should be included in comprehensive evaluations of surgical capacity. This study adapted and validated the Children's Surgical Assessment Tool (CSAT), a tool developed for district and tertiary hospitals in Nigeria to evaluate hospital infrastructure, workforce, service delivery, financing, and training capacity for paediatric surgery, for use in district hospitals in Rwanda.

METHODS

We used a three-round modified Delphi process to adapt the CSAT to the Rwandan context. An expert panel of surgeons, anaesthesiologists, paediatricians, and health systems strengthening experts were invited to participate based on their experience with paediatric surgical or anaesthetic care at district hospitals or with health systems strengthening in the Rwandan context. We used the Content Validity Index to validate the final tool.

RESULTS

The adapted tool had a final score of 0.84 on the Content Validity Index, indicating a high level of agreement among the expert panel. The final tool comprised 171 items across five domains: facility characteristics, service delivery, workforce, financing, and training/research.

CONCLUSION

The adapted CSAT is appropriate for use in district hospitals in Rwanda to evaluate the capacity for paediatric surgery. This study provides a framework for adapting and validating a comprehensive paediatric surgical assessment tool to local contexts in LMICs and used in similar settings in sub-Saharan Africa.

The public's perspective on the amount of time surgeons spend operating

BACKGROUND

As waiting lists for elective surgery grow, there seems to be a disconnect between the public's expectations on the amount of time surgeons spend operating compared with reality. On average, a surgeon in the NHS spends one day a week performing elective surgery. We aimed to investigate the public's perception on the amount of time surgeons spend performing elective surgery and what they would desire.

METHODS

Members of the public in the UK were approached randomly either on-line or in-person to complete an anonymised 6-question survey. The questionnaire included demographic details, surgical history, occupational experience in the healthcare sector, the number of days a week they believe and wish for surgeons to be performing elective surgery.

RESULTS

252 members of the public responded to the survey (150 females, 102 males). 38.5% have experience working in the healthcare sector and 58.5% have had surgery in the past. 83.7% believe surgeons spend at least 3 days a week performing elective surgery [3-4 days (43.2%), 5-7 days (40.5%)]. 45.7% of respondents want their surgeon to operate between 5 and 7 days per week.

CONCLUSION

The public appears to overestimate the amount of time that surgeons spend performing elective surgery and have unrealistic expectations of how much they want their surgeons to operate.

History and Current State of Neurosurgery in The Gambia

BACKGROUND

Despite global efforts to improve surgical care access, many low and middle-income countries, especially in neurosurgery, face significant shortages. The Gambia exemplifies this, with only one fully qualified neurosurgeon serving its population of 2.5 million people. This scarcity results in higher morbidity and mortality.

OBJECTIVE

We aim to document the history and current state of neurosurgery in The Gambia to raise awareness and promote neurosurgery development.

METHODS

The study reviews The Gambia's healthcare system, infrastructure, neurosurgical history, workforce, disease burden, and progress, with information derived from reference sources as well as author experience and interviews with key partners in Gambian healthcare.

RESULTS

Neurosurgery in The Gambia began in the 1970s, facing constraints due to competing healthcare demands. Significant progress occurred much later in the early 2010s, marked by the initiation of Banjul Neuro-Missions and the establishment of a dedicated neurosurgery unit.We report significant progress with neurosurgical interventions in the past few years showcasing the unit's dedication to advancing neurosurgical care in the Gambia. However, challenges persist, including a lack of trained neurosurgeons, equipment shortages such as ventilators and diagnostic imaging. Financial barriers for patients, particularly related to the costs of CT scans, pose significant hurdles, impacting the timely diagnosis and intervention for neurological conditions.

CONCLUSION

Neurosurgery in Gambia is progressing, but challenges like equipment scarcity hinder further progress. We emphasize the need for addressing cost barriers, improving infrastructure, and fostering research. Engaging the government and international collaborations are vital for sustained development in Gambian neurosurgery.

Evaluating Global Surgery Partnerships From Low and Middle Income Country Perspectives

INTRODUCTION

Little is known about perceptions of low-income and middle-income country (LMIC) partners regarding global surgery collaborations with high-income countries (HICs).

METHODS

A survey was distributed to surgeons from LMICs to assess the nature and perception of collaborations, funding, benefits, communication, and the effects of COVID-19 on partnerships.

RESULTS

We received 19 responses from LMIC representatives in 12 countries on three continents. The majority (83%) had participated in collaborations within the past 5 y with 39% of collaborations were facilitated virtually. Clinical and educational partnerships (39% each) were ranked most important by respondents. Sustainability of the partnership was most successfully achieved in domains of education/training (78%) and research (61%). The majority (77%) of respondents reported expressing their needs before HIC team arrival. However, 54% of respondents were the ones to initiate the conversation and only 47% said HIC partners understood the overall environment well at arrival to LMIC. Almost all participants (95%) felt a formal process of collaboration and a structured partnership would benefit all parties in assessing needs. During the COVID-19 pandemic, 87% of participants reported continued collaborations; however, 44% of partners felt that relationships were weaker, 31% felt relationships were stronger, and 25% felt they were unchanged.

CONCLUSIONS

Our study provides a snapshot of LMIC surgeons' perspectives on collaboration in global surgery. Independent of location, LMIC partners cite inadequate structure for long-term collaborations. We propose a formal pathway and initiation process to assess resources and needs at the outset of a partnership.

James Warden and the Global Alliance Partnership: A Pediatric Surgery Giant and His Enduring PAPS Landmark

The discipline of pediatric surgery has honored many of the early giants through programs that bear their names. One of those programs is the M. James Warden Global Alliance Partnership, a landmark program celebrated at each annual meeting of the Pacific Association of Pediatric Surgeons since 1989. This article describes James Warden and his legacy as a surgeon and humanitarian and provides an update on the past, present, and future of the Global Alliance Partnership that bears his name. LEVEL OF EVIDENCE: 5.

Towards universal access: A review of global efforts in ear and hearing care

Hearing loss affects 1.6 billion people worldwide and disproportionately affects those in low- and middle-income countries. Despite being largely preventable or treatable, ear and hearing conditions result in significant and lifelong morbidity such as delayed language development, reduced educational attainment, and diminished social well-being. There is a need to augment prevention, early identification, treatment, and rehabilitation for these conditions. Expanded access to hearing screening, growth of the hearing health workforce, and innovations in ear and hearing care delivery systems are among the changes that are needed. To that end, the World Health Organization has prioritized ear and hearing care as a component of Universal Health Coverage, and recent publications have advanced the priority for ear and hearing care. Efforts are underway at the national levels around the world, as evidenced by countries like Zambia and Nigeria that have integrated ear and hearing care within national health strategies. While significant strides have been made in improving access, a critical need remains for additional research, advocacy, and intervention to ensure that no one is left behind in the goal to achieve universal access to ear and hearing care.

Essential surgery delivery in the Northern Kivu Province of the Democratic Republic of the Congo

INTRODUCTION

Surgical services are an essential part of a functional healthcare system, but the Lancet Commission of Global Surgery (LCoGS) indicators of surgical capacity such as perioperative workforce and surgical volume are unknown in many low- and middle-income countries (LMICs) including the Democratic Republic of Congo (DRC). We aimed to determine the surgical capacity and its associated factors within the DRC.

METHODS

Hospitals were assessed in the North Kivu province of the DRC. Hospital characteristics and surgical rates were determined using the WHO-PGSSC hospital assessment tool and operating room (OR) registries. The primary outcome of interest was the number of Bellwether operations (i.e. Caesarean sections, laparotomies, and external fixation for bone fractures) per 100,000 people. Univariate and multiple linear regressions were performed. Primary predictors were the number of trained surgeons, anaesthesiologists, and obstetricians (SAOs) and the number of perioperative providers (including clinical officers and nurse anaesthetists) per 100,000 people.

RESULTS

Twenty-eight hospitals in North Kivu were assessed over one year in 2021; 24 (86%) were first-level referral health centres while 4 (14%) were second-level referral hospitals. In total, 11,176 Bellwether procedures were performed in the region in one year. Rates per 100,000 people were 1,461 Bellwether surgical interventions, 1.05 SAOs, and 13.1 perioperative providers. In univariate linear regression analysis, each additional SAO added 239 additional cases annually (p = 0.023), while each additional perioperative provider added 110 cases annually (p < 0.001). In our multiple regression analysis adjusting for other hospital services, the association between workforce and Bellwether surgeries was no longer significant.

CONCLUSIONS

The surgical workforce in DRC did not meet the LCoGS benchmark of 20 SAOs per 100,000 people but was not an independent predictor of surgical capacity. Major investment is needed to simultaneously bolster healthcare facilities and increase surgical workforce training.

Development of an International Virtual Multidisciplinary Tumor Board for Breast Cancer in Mongolia

INTRODUCTION

Breast cancer is the most diagnosed cancer among Mongolian women and mortality rates are high. We describe a virtual multi-institutional and multidisciplinary tumor board (MTB) for breast cancer created to assist the National Cancer Center of Mongolia.

MATERIALS AND METHODS

A virtual MTB for breast cancer was conducted with participation of two United States and 1 Mongolian cancer centers. A standardized template for presentations was developed. Recommendations were summarized and shared with participants. Collected data included patient demographics, tumor characteristics, stage, imaging and treatments performed, and recommendations. Questions were categorized as treatment, diagnosis, or palliative questions.

RESULTS

Fifteen patients were evaluated. Median age was 39 y. 86.7% of breast cancers were invasive ductal cancers and 13.3% were metaplastic carcinomas. 53.3% were estrogen and progesterone receptor positive (ER+/PR+), 60% were HER2+, 13.3% were triple negative, and 26.7% were recurrent. 40% of patients were evaluated with mammography. 6% received positron emission tomography scans for metastatic evaluation. 66.7% of surgical patients received neoadjuvant chemotherapy. Herceptin was administered to 55.6% of patients with Her2+ cancers. Modified radical mastectomy was most commonly performed and reconstruction was rare. Sentinel lymph node biopsy was not performed. 66.7% of ER+/PR+ patients received endocrine therapy. 6.7% of patients received radiation. 75% of MTB questions pertained to treatment. Recommendations were related to systemic therapy (40%), surgical management (33.3%), pathology (13.3%), and imaging (13.3%).

CONCLUSIONS

This study illustrates the development of an international, virtual, multi-institutional breast cancer MTB and provides insight into challenges and potential interventions to improve breast cancer care in Mongolia.

Bilateral Exchange: Enteral Nutrition Clinical Decision Making in Pediatric Surgery Patients

INTRODUCTION

Evidence-based medicine guides clinical decision-making; however, promoting enteral nutrition has historically followed a dogmatic approach in which patients graduate from clear liquids to full liquids to a regular diet after return of bowel function. Enhanced recovery after surgery has demonstrated that early enteral nutrition initiation is associated with shorter hospital stays. We aimed to understand postoperative pediatric nutrition practices in Kenya and the United States.

METHODS

We completed a prospective observational study of pediatric surgery fellows during clinical rounds in a pediatric referral center in Kenya (S4A) and one in the United States (Riley). Fellow-patient interactions were observed from postoperative day one to discharge or postoperative day 30, whichever happened first. Patient demographic, operative information, and daily observations including nutritional status were collected via REDCap.

RESULTS

We included 75 patients with 41 (54.7%) from Kenya; patients in Kenya were younger with 40% of patients in Kenya presenting as neonates. Median time to initiation and full enteral nutrition was shorter for the patients at Riley when compared to their counterparts at S4A. In the neonatal subgroup, patients at S4A initiated enteral nutrition sooner, but their hospital length of stays were not significantly different.

CONCLUSIONS

Studying current nutrition practices may guide early enteral nutrition protocols. Implementing these protocols, particularly in a setting where enteral nutrition alternatives are minimal, may provide evidence of success and overrule dogmatic nutrition advancement. Studying implementation of these protocols in resource-constrained areas, where patient length of stay is often related to socioeconomic factors, may identify additional benefits to patients.

A needs assessment for simulation in African surgical education

INTRODUCTION

There is a critical need for comprehensive surgical training in African countries given the unmet surgical burden of disease in this region. Collaborative and progressive initiatives in global surgical education will have the greatest impact on trainees. Little is known about surgical education needs from the perspective of practicing surgeons and trainees in low-middle-income countries (LMICs). Even less is known about the potential role for simulation to augment training.

METHODS

A modified Delphi methodology with 2 rounds of responses was employed to survey program directors (PD) and associate program directors (APD) of Pan-African Association of Christian Surgeons (PAACS) general surgery residency programs across eight low-middle-income countries in Africa. 3 PD/APDs and 2 surgical residents participated in semi-structured interviews centered around the role of simulation in training. Descriptive analysis was performed to elicit key themes and illustrative examples.

RESULTS

The survey of program directors revealed that teaching residents the psychomotor skills need to perform intracorporeal suturing was both high priority and desired in multiple training sites. Other high priority skills were laparoscopic camera driving and medial visceral rotation. The interviews revealed a specific desire to perform laparoscopic surgery and a need for a simulation curriculum to familiarize staff and trainees with laparoscopic techniques. Several barriers to laparoscopic surgery exist, such as lack of staff familiarity with the equipment, lack of public buy in, and lack of generalizable and adaptable educational modules. Trainees saw utility in the use of simulation to optimize time in the operating room and sought opportunities to improve their laparoscopic skills.

CONCLUSION

Faculty and surgical trainees in LMICs have interest in learning advanced surgical techniques, such as laparoscopy. Developing a simulation curriculum tailored to the trainees' local context has the potential to fill this need.

The Impact of Colonialism on Surgical Training Structures in Africa Part 1: Contextualizing the Past, Present, and Future

Since the first African country attained independence from colonial rule, surgical training on the continent has evolved along 3 principal models. The first is a colonial, local master-apprentice model, the second is a purely local training model, and the third is a collegiate intercountry model. The 3 models exist currently and there are varied perceptions of their relative merits in training competent neurosurgeons. We reviewed the historical development of training and in an accompanying study, seek to describe the complex array of surgical training pathways and explore the neocolonial underpinnings of how these various models of training impact today the development of surgical capacity in Africa. In addition, we sought to better understand how some training systems may contribute to the widely recognized "brain drain" of surgeons from the African continent to high income countries in Europe and North America. To date, there are no published studies evaluating the impact of surgical training systems on skilled workforce emigration out of Africa. This review aims to discover potentially addressable sources of improving healthcare and training equity in this region.

"Problems you can live with" versus emergencies: how community members in rural Ethiopia contend with conditions requiring surgery

BACKGROUND

98% of people with surgical conditions living in low- and middle-income countries (LMICs) do not receive safe, timely and affordable surgical and anesthesia care. Research exploring barriers to receiving care has tended to be narrow in focus, often facility-based and ignoring the community beliefs, experiences and behaviours that will be an essential component of closing the gap in surgical care. Using qualitative methods, we captured diverse community perspectives in rural Ethiopia: exploring beliefs, perceptions, knowledge and experiences related to surgical conditions, with the overall aim of (re)constructing explanatory models.

METHODS

Our study was nested within a community-based survey of surgical conditions conducted in the Butajira Health and Demographic Surveillance Site, southern Ethiopia, and a follow-up study of people accessing surgical care in two local hospitals. We carried out 24 semi-structured interviews. Participants were community members who needed but did/did not access surgical care, community-based healthcare workers and traditional bone-setters. Interviews were conducted in Amharic, audio-recorded, transcribed, and translated into English. We initially carried out thematic analysis and we recognized that emerging themes were aligned with Kleinman's explanatory models framework and decided to use this to guide the final stages of analysis.

RESULTS

We found that community members primarily understood surgical conditions according to severity. We identified two categories: conditions you could live with and those which required urgent care, with the latter indicating a clear and direct path to surgical care whilst the former was associated with a longer, more complex and experimental pattern of help-seeking. Fear of surgery and poverty disrupted help-seeking, whilst community narratives based on individual experiences fed into the body of knowledge people used to inform decisions about care.

CONCLUSIONS

We found explanatory models to be flexible, responsive to new evidence about what might work best in the context of limited community resources. Our findings have important implications for future research and policy, suggesting that community-level barriers have the potential to be responsive to carefully designed interventions which take account of local knowledge and beliefs.

How much time do surgeons spend operating?

BACKGROUND

Worldwide, there is significant variation in the amount of time surgeons spend performing elective surgery. The degree of variation is unknown. The aim of this study was to assess the variation in amount of time that surgeons spend operating worldwide.

METHODS

An anonymised electronic survey was sent via email to members of The Upper Gastrointestinal Surgeons (TUGS) and shared via social media. The questionnaire consisted of demographic details (age, gender, country of practice), scope of practice (full time/less than full time; private/public sector), experience and average number of days the surgeon spends performing elective surgery.

RESULTS

A total of 225 predominantly general/upper GI surgeons from 47 countries responded. Worldwide, the median number of days that surgeons spend performing elective surgery is 2 days a week. There was significant variation across countries/continents: UK 1 day; North America 2.5 days; Europe 3 days; Asia 2 days; Africa 2 days; South America 1 day; Oceania 1 day (p < 0.0001). All surgeons worldwide preferred to spend 3 days a week performing elective surgery except UK surgeons who desired 2 days a week.

CONCLUSION

There is significant variation in the amount of time that surgeons spend performing elective surgery worldwide. Results of this study could inform public expectations and trainee surgeons on ideal opportunities for training. Reasons for the wide variation could be explored.

Patient-Centered Surgical Care for Children in Low and Lower-Middle Income Countries (LMICs) - A Systematic Scoping Review of the Literature

PURPOSE

Studies exploring patient-centered care (PCC) in pediatric surgery have been disproportionately concentrated in high-income countries. This review aims to characterize the adoption of key PCC domains in low and lower-middle income countries (LMICs).

METHODS

Seven databases were searched from inception until January 2023 to retrieve relevant articles in pediatric surgery in LMICs. We focused on six key PCC domains: patient-reported outcomes (PROs), patient-reported experiences (PREs), shared decision-making (SDM), patient/parent education, patient/parent satisfaction, and informed consent.

RESULTS

Of 8050 studies screened, 230 underwent full-text review, and 48 were finally included. Most were single-center (87.5%), cross-sectional studies (41.7%) from the South-East Asian (35.4%) and Eastern Mediterranean regions (33.3%). Studies most frequently focused on postoperative care (45.8%) in pediatric general surgery (18.8%), and included 1-3 PCC domains. PREs (n = 30), PROs (n = 16) and patient/parent satisfaction (n = 16) were most common. Informed consent (n = 2) and SDM (n = 1) were least studied. Only 13 studies directly elicited children's perspectives. Despite all studies originating in LMICs, 25% of first and 17.8% of senior authors lacked LMIC affiliations.

CONCLUSION

The adoption of PCC in LMICs appears limited, focusing predominantly on PROs and PREs. Other domains such as informed consent and SDM are rarely addressed, and the voice of children and young people is rarely heard in their care. Opportunities to enhance PCC in LMICs abound, with the potential to improve the surgical care of children in resource-limited settings.

LEVEL OF EVIDENCE

III.

Global Neurosurgery at the 76th World Health Assembly (2023): First Neurosurgery-Driven Resolution Calls for Micronutrient Fortification to Prevent Spina Bifida

Since 2018, a neurosurgery delegation has been actively engaged and consistently present at the World Health Assembly. Recognizing the growing impact of neurosurgical diseases, the neurosurgery delegation participated in the 76th World Health Assembly in May 2023, advocating for timely, safe, and affordable global neurosurgical care. The delegation focused on forging new collaborations, strengthening the World Health Organization-World Federation of Neurosurgical Societies official relations, and actively supporting resolutions that impact the neurosurgical patients. However, there is a long advocacy journey ahead to address unmet neurosurgical needs. Patient-centered advocacy is an inherent task of our profession and the essence of the Global Neurosurgery Bogota Declaration of 2016. The highlight of the 76th World Health Assembly was the adoption of the first neurosurgery-driven resolution calling for micronutrient fortification to prevent spina bifida and other micronutrient deficiencies. For the last 4 years, the Global Alliance for Prevention of Spina Bifida, a group spearheaded by neurosurgeons, advocated for spina bifida prevention. This Alliance collaborated with many stakeholders, notably, the Colombian government to promote the resolution: "Accelerating efforts for preventing micronutrient deficiencies and their consequences, including spina bifida and other neural tube defects, through safe and effective food fortification." This is a proud milestone for the neurosurgical profession. There are many strategies available for neurosurgeons, when working together with elected leaders, other stakeholders, and allied professionals, to implement initiatives that can prevent future cases of spina bifida and other neurological disorders and reduce the burden of neurosurgical disease.

The Impact of Colonialism on Surgical Training Structures In Africa Part 2: Surveying Current and Past Trainees

BACKGROUND

As a result of gradual independence from colonial rule over the course of the past century, Africa has developed and evolved 3 primary surgical training structures: an extracontinental colonial model, an intracontinental college-based model, and several smaller national or local models. There is consistent evidence of international brain drain of surgical trainees and an unequal continental distribution of surgeons; however there has not, to date, been an evaluation of the impact colonialism on the evolution of surgical training on the continent. This study aims to identify the etiologies and consequences of this segmentation of surgical training in Africa.

METHODS

This is a cross-sectional survey of the experience and perspectives of surgical training by current African trainees and graduates.

RESULTS

A surgeon's region of residence was found to have a statistically significant positive association with that of a surgeon's training structure (P <0.001). A surgeon's professional college or structure of residency has a significantly positive association with desire to complete subspecialty training (P = 0.008). College and structure of residency also are statistically significantly associated with successful completion of subspecialty training (P < 0.001).

CONCLUSIONS

These findings provide evidence to support the concept that the segmentation of surgical training structures in Africa, which is the direct result of prior colonization, has affected the distribution of trainees and specialists across the continent and the globe. This maldistribution of African surgical trainees directly impacts patient care, as the surgeon-patient ratios in many African countries are insufficient. These inequities should be acknowledged addressed and rectified to ensure that patients in Africa receive timely and appropriate surgical care.

Barriers and Motivations for Health Insurance Subscription Among Health-Care Users in Cameroon

INTRODUCTION

Surgical care is a significant component of the overall health expenditure in low- and middle-income countries. In Cameroon, out-of-pocket payments for surgical service are very high with many patients declining potentially curative surgical procedures. Less than 2% of the population is enrolled in a health insurance scheme leading to a propensity for catastrophic health expenses when accessing care. To assess the perceived barriers and motivations for health insurance subscription among health-care users in Cameroon.

METHODS

This was a cross-sectional community-based qualitative study conducted in the Center Region of Cameroon. A total of 37 health-care users (health insurance subscribers and nonsubscribers) were purposively identified. Four focused group discussions and thirteen in-depth interviews were conducted. All anonymized transcripts were analyzed using a thematic analysis approach.

RESULTS

The six major themes identified as barriers to health insurance subscription were lack of trust in the existing health insurance schemes, inadequate knowledge on how health insurance works, premiums believed to be too expensive, the complexity of the claims processing system, minimal usage of health-care services and practice of self-medication. Motivational factors included the knowledge of having access to quality health services even without money in the event of an unforeseen illness and having a large family/household size. The importance of mass sensitization on the benefits of health insurance was noted.

CONCLUSION

Health insurance is still very underutilized in Cameroon. This results in significant out-of-pocket payment for health services by Cameroonians with catastrophic consequences to households. With most Cameroonians in the informal sector and underemployed, it is imperative to put in place a national strategic plan to overcome existing barriers and increase health insurance coverage especially among the poor. This has the potential to significantly increase access to safe, quality, timely and affordable surgical care.

Impact of Bowel Coverage and Resuscitation Protocol on Gastroschisis Mortality in Low-Income Countries: Experience and Lessons From Uganda

BACKGROUND

Gastroschisis causes near complete mortality in low-income countries (LICs). This study seeks to understand the impact of bedside bowel reduction and silo placement, and protocolized resuscitation on gastroschisis outcomes in LICs.

METHODS

We conducted a retrospective cohort study of gastroschisis patients at a tertiary referral center in Kampala, Uganda. Multiple approaches for bedside application of bowel coverage devices and delayed closure were used: sutured urine bags (2017-2018), improvised silos using wound protectors (2020-2021), and spring-loaded silos (2022). Total parental nutrition (TPN) was not available; however, with the use of improvised silos, a protocol was implemented to include protocolized resuscitation and early enteral feeding. Risk ratios (RR) for mortality were calculated in comparison to historic controls from 2014.

RESULTS

368 patients were included: 42 historic controls, 7 primary closures, 81 sutured urine bags, 133 improvised silos and 105 spring-loaded silos. No differences were found in sex (p = 0.31), days to presentation (p = 0.84), and distance traveled to the tertiary hospital (p = 0.16). Following the introduction of bowel coverage methods, the proportion of infants that survived to discharge increased from 2% to 16-29%. In comparison to historic controls, the risk of mortality significantly decreased: sutured urine bags 0.65 (95%CI: 0.52-0.80), improvised silo 0.76 (0.66-0.87), and spring-loaded silo 0.65 (0.56-0.76).

CONCLUSION

Bedside application of bowel coverage and protocolization decreases the risk of death for infants with gastroschisis, even in the absence of TPN. Further efforts to expand supply of low-cost silos in LICs would significantly decrease the mortality associated with gastroschisis in this setting.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

III (Retrospective Comparative Study).

Management of Postoperative Discitis with Debridement and Novel Technique of Local Antibiotic Instillation: Functional Outcomes from a Resource-Limited Setting

BACKGROUND

Patients in low- and middle-income countries (LMICs) have substantial treatment abandonment and non-adherence with outpatient oral medications. This work sought to investigate outcomes of postoperative discitis treated with debridement and a novel technique focused on reducing outpatient antibiotic requirement in an LMIC setting.

METHODS

This study, conducted and reported following STROBE guidelines, reviewed outcomes of all patients with postoperative discitis who had been debrided by 1 neurosurgeon in a resource-limited setting during 2008-2020. Patients had undergone single-level L4-L5 or L5-S1 discectomy elsewhere, later developing magnetic resonance imaging-confirmed discitis. After non-response or deterioration following intravenous antibiotics, patients underwent early debridement, followed by in-patient antibiotic instillation into disc space for 2 weeks via drain. Study outcomes were modified Kirkaldy-Willis Grade, Japan Orthopaedic Association (JOA) score, and visual analog scale (VAS) score, all assessed at 1 year.

RESULTS

Twelve patients were included, 10 male and 2 female, with median age of 46 (IQR 3.5) years. Debridement was done after median 82.5 (IQR 35) days and took median time of 105 (IQR 17.5) minutes. VAS scores (mean ± SD) decreased from 9.25 ± 0.75 preoperatively to 0.67 ± 0.89 1 year postoperatively (mean difference 8.58, 95% CI 8.01-9.15, P < 0.001). JOA scores (mean ± SD) improved from 4.5 ± 2.94 to 26.42 ± 1.31 1 year postoperatively (mean difference 21.92, 95% CI 20.57-23.26, P < 0.001). Kirkaldy-Willis grade was excellent in 6 (50%) patients, good in 5 (41.7%), and fair in 1 (8.3%). Patients became ambulatory within 2 weeks, with no major complications during 4.15 (IQR 3.45) years of median follow-up.

CONCLUSIONS

In LMICs, patients with medically refractory postoperative discitis potentially have good outcomes after debridement plus 2-week local antibiotic instillation.

Feasibility of Gastrografin Use for Adhesive Small Bowel Obstruction in Low-Income Countries

INTRODUCTION

Small bowel obstruction (SBO) is one of the most common causes for hospital admission in Ethiopia. The use of water-soluble contrast agents (WSCAs) such as Gastrografin to manage adhesive SBO can predict nonoperative resolution of SBO and reduce decision time to surgery and length of hospital stay. However, nothing is known about practice patterns and Gastrografin use in low-income settings. We sought to characterize current management practices, including use of WSCAs, as well as outcomes for patients with SBO in Addis Ababa, Ethiopia.

METHODS

We conducted a mixed-methods study consisting of a survey of surgeons throughout Ethiopia and a retrospective record review at five public, tertiary care-level teaching hospitals in Addis Ababa.

RESULTS

Of the 76 surgeons who completed the survey, 63% had heard of the use of WSCAs for SBO and only 11% used oral agents for its management. Chart review of 149 patients admitted with SBO showed the most common etiology was adhesion (39.6% of admissions), followed by small bowel volvulus (20.8%). Most patients (83.2%) underwent surgery during their admission. The most common diagnosis in patients who did not require surgery was also adhesion (68.0%), as well as for those who had surgery (33.9%), followed by small bowel volvulus (24.2%).

CONCLUSIONS

The etiology of SBO in Ethiopia may be changing, with postoperative adhesions becoming more common than other historically more prevalent causes. Although a Gastrografin protocol as a diagnostic and potentially therapeutic aid for SBO is feasible in this population and setting, challenges can be anticipated, and future studies of protocol implementation and effectiveness are needed to further inform its utility in Ethiopia and other low-income and middle-income countries.

Perioperative medicine: challenges and solutions for global health

The emerging field of perioperative medicine has the potential to make significant contributions to global health. Perioperative medicine aims to help reduce unmet surgical need, decrease variation in quality and systematically improve patient outcomes. These aims are also applicable to key challenges in global health, such as limited access to surgical care, variable quality and workforce shortages. This article describes the areas in which perioperative medicine can contribute to global health using case studies of successful care pathways, risk prediction tools, strategies for effective grassroots research and novel workforce approaches aimed at effectively using limited resources.

Barriers and challenges to achieving equity in global children's surgery: A call to action

CHALLENGES

A Call to Action.

Gaps and priorities in innovation for children's surgery

Lack of access to pediatric medical devices and innovative technology contributes to global disparities in children's surgical care. There are currently many barriers that prevent access to these technologies in low- and middle-income countries (LMICs). Technologies that were designed for the needs of high-income countries (HICs) may not fit the resources available in LMICs. Likewise, obtaining these devices are costly and require supply chain infrastructure. Once these technologies have reached the LMIC, there are many issues with sustainability and maintenance of the devices. Ideally, devices would be created for the needs and resources of LMICs, but there are many obstacles to innovation that are imposed by institutions in both HICs and LMICs. Fortunately, there is a growing interest for development of this space, and there are many examples of current technologies that are paving the way for future innovations. Innovations in simulation-based training with incorporated learner self-assessment are needed to fast-track skills acquisition for both specialist trainees and non-specialist children's surgery providers, to scale up access for the larger population of children. Pediatric laparoscopy and imaging are some of the innovations that could make a major impact in children's surgery worldwide.

Rethinking referral systems in rural chiapas: A mixed methods study

Background

Despite the assurance of universal health coverage, large disparities exist in access to surgery in the state of Chiapas. The purpose of this study was to determine the effectiveness of the surgical referral system at hospitals operated by the Ministry of Health in Chiapas.

Methods

13 variables were extracted from surgical referrals data from three public hospitals in Chiapas over a three-year period. Interviews were performed of health care workers involved in the referral system and surgical patients. The quantitative and qualitative data was analyzed convergently and reported using a narrative approach.

Findings

In total, only 47.4% of referred patients requiring surgery received an operation. Requiring an elective, gynecological, or orthopedic surgery and each additional surgery cancellation were significantly associated with lower rates of receiving surgery. The impact of gender and surgical specialty, economic fragility of farmers, dependence upon economic resources to access care, pain leading people to seek care, and futility leading patients to abandon the public system were identified as main themes from the mixed methods analysis.

Interpretation

Surgical referral patients in Chiapas struggle to navigate an inefficient and expensive system, leading to delayed care and forcing many patients to turn to the private health system. These mixed methods findings provide a detailed view of often overlooked limitations to universal health coverage in Chiapas. Moving forward, this knowledge must be applied to improve referral system coordination and provide hospitals with the necessary workforce, equipment, and protocols to ensure access to guaranteed care.

Funding

Harvard University and the Abundance Fund provided funding for this project. Funding sources had no role in the writing of the manuscript or decision to submit it for publication.

Anatomy and lessons of partnerships in global pediatric surgery

Partnerships in Global Surgery have evolved over several decades and continue to do so based on reports from different experiences and collaborations. These should be characterised by their objectives, leadership and "championship," communication, ethics and equity. Partnerships take the form of academic collaborations or clinical support whose details vary with the different stakeholders involved. Over time, these have evolved based on challenges, successes, and failures. Recently, quality improvement activities have been increasingly initiated with locally derived information. This has come from local databases in low and middle income country (LMIC) settings whose maintenance and analysis have been done through academic collaborations. For many sites in LMICs, there would be very little advance in paediatric surgery without collaborations. Despite this, problems still arise from collaborations due to failure to learn from past problems, lack of local championship, poor communication, and externally driven objectives. For success and longevity, the collaboration must pay attention to unique the needs of the site, champions and equity.

Indexing blood banking performance in India: A retrospective cross-sectional analysis of states and districts

Background

Multiple international assessments have highlighted gaps in blood banking globally. However, there is a dearth of subnational assessments. We applied a thematic framework with multiple composite indices to assess blood bank performance across Indian states and districts.

Methods

In this retrospective cross-sectional analysis, data for 2493 blood banks in 35 states/union territories (UTs) and 616 districts was extracted from the National Blood Transfusion Council for 2016. The framework involved seven themes (accreditation, ownership, safety, volume, infrastructure, regulation, and workforce) with several indicators nested under them. Composite thematic indices and an overall index (0-100, with 100 being the best performance) were constructed using the adjusted Mazziotta-Pareto index method that can provide composite indices that are partially non-compensatory and easily interpretable.

Results

The state-level median [interquartile range] value of the overall index was 59.61 [46.35, 71.67]. Chandigarh had the highest values for safety, regulation, workforce, and ownership indices, Maharashtra for volume and infrastructure indices, and Manipur for accreditation index. Districts in southern and western states performed well on the overall index with inter- and intra-state variations for themes. District-level correlations depicted positive associations among indices with the strongest correlation between ownership and accreditation indices (n=616, R=0.92, p<0.001).

Conclusion

Blood banking in India is fragmented, with variations in themes across geographies. The northern and northeastern states require more attention for volume, accreditation, infrastructure, and ownership. While the southern and western-central regions need to prioritize safety. The framework with thematic indices, when applied to routine data, can be useful for monitoring and evaluation to decide local policies and resource allocations.

Much room for change: access to surgical care for stateless individuals in Pakistan

BACKGROUND

As developing countries take steps towards providing universal essential surgery, ensuring the equitable distribution of such care for underrepresented populations is a vital function of the global surgery community. Unfortunately, in the context of the global "stateless", there remains much room for improvement.

KEY ISSUES

Inherent structural deficiencies, such as lack of adequate population data on stateless communities, absent health coverage policies for stateless individuals, and minimal patient-reported qualitative data on barriers to surgical service delivery prevent stateless individuals from receiving the care they require - even when healthcare infrastructure to provide such care exists. The authors therefore propose more research and targeted interventions to address the systemic issues that prevent stateless individuals from accessing surgical care.

CONCLUSION

It is essential to address the aforementioned barriers in order to improve stateless populations' access to surgical care. Rigorous empirical and qualitative research provides an important avenue through which these structural issues may be addressed.

Determinants of Access to Essential Surgery in the Democratic Republic of Congo

INTRODUCTION

In the Democratic Republic of Congo (DRC), the determinants and barriers of essential surgical care are not well described, hindering efforts to improve national surgical programs and access.

METHODS

A cross-sectional study evaluated access to essential surgery in the Butembo and Katwa health zones in the North Kivu province of DRC. A double-clustered random sample of community members was surveyed using questions derived from the Surgeons OverSeas Surgical Needs Assessment Survey, a validated tool to determine the reasons for not seeking, reaching, or receiving a Bellwether surgery (i.e., caesarean delivery, laparotomy, and external fixation of a fracture) when needed.

RESULTS

Overall, 887 households comprising 5944 community members were surveyed from April to August 2022. Six percent (n = 363/5944) of the study population involving 35% (n = 309/887) households needed a Bellwether surgery in the previous year, 30% (n = 108/363) of whom died. Of those who needed surgery, 25% (n = 78) did not go to the hospital to seek care and were more likely to find transportation unaffordable (P = 0.042). The most common reasons for not seeking care were lack of funds for hospitalization, prior poor hospital experience, and fear of hospital care.

CONCLUSIONS

Access and delivery of essential surgery are drastically limited in the North Kivu province of the DRC, such that a quarter of households needing surgery fails to seek surgical care. Poor access was predominantly driven by households' inability to pay for surgery and community distrust of the hospital system.

Remote training and teleproctoring in gastrointestinal endoscopy for practicing surgeon in rural Uganda

BACKGROUND

There is a significant, unmet need for endoscopy services in rural Uganda. With limited diagnostic and therapeutic interventions, patients in these communities often present with advanced disease. Practicing surgeons must continually adapt to new techniques to meet the needs of their patient populations. Here, we present a remotely proctored endoscopy training program for a surgeon practicing in an area devoid of endoscopic capabilities.

METHODS

This was a retrospective case series conducted between February 2020 and December 2022 at Kyabirwa Surgical Center (KSC). After a 1-week in-person training camp, one surgeon performed endoscopy under guidance of a remote proctor. Patient data and outcomes were collected retrospectively.

RESULTS

The previously endoscopic naïve practicing Ugandan surgeon was remotely proctored for 139 endoscopic cases and he subsequently independently performed 167 diagnostic colonoscopies and 425 upper endoscopies. Therapeutic endoscopy was conducted under remote guidance after proficiency in diagnostic endoscopy. A total of 43 therapeutic procedures were performed, including 29 esophageal stent placements, 5 variceal bandings, and 9 foreign body retrievals. All procedures were completed without complication.

CONCLUSION

Our center developed a remotely proctored endoscopy program that allowed for training of practicing surgeons in an area lacking endoscopic services. Despite its limitations, remotely proctored endoscopy serves as a unique but highly valuable method of expanding access to endoscopy, particularly in areas that lack adequate training opportunities.

A single-center, single-blinded, randomized, parallel-group, non-inferiority trial to compare the efficacy of a 22-gauge needle versus a 15 blade to perform an Achilles tendon tenotomy in 244 clubfeet-study protocol

BACKGROUND

Achilles tendon tenotomy is an integral part of the Ponseti method, aimed at correcting residual equinus and lack of dorsiflexion after correction of the adductus deformity in clubfoot. Percutaneous tenotomy using a number 15 scalpel blade is considered the gold standard, resulting in excellent results with minimal complications. The use of a large-bore needle to perform Achilles tendon tenotomies has been described in literature, but a large-scale randomized controlled trial is currently lacking. In this trial, we aim to show the non-inferiority of the needle tenotomy technique compared to the gold standard blade tenotomy technique.

METHODS

We will randomize 244 feet into group A: needle tenotomy or group B: blade tenotomy. Randomization will be done using a block randomization with random block sizes and applying a 1:1 allocation to achieve an intervention and control group of the exact same size. Children will be evaluated at 3 weeks and 3 months post-tenotomy for primary and secondary clinical outcomes. The primary clinical outcome will be the range of dorsiflexion obtained the secondary clinical outcomes will be frequency of minor and major complications and Pirani score. The non-inferiority margin was set at 4°, and thus, the null hypothesis of inferiority of the needle technique will be rejected if the mean difference between both techniques is less than 4°. The statistical analysis will use a multi-level mixed effects linear regression model for the primary outcomes and a multi-level mixed effects logistic regression model for the secondary clinical outcomes. The physician performing the evaluations post-tenotomy will be the only one blinded to group allocation.

TRIAL REGISTRATION

This trial was registered prospectively with ClinicalTrials.gov registration number: NCT04897100 on 21 May 2021.

Global liver transplantation: emerging trends and ethical challenges

PURPOSE

Liver transplant (LT) is the only definitive treatment for end-stage liver disease (ESLD). This review aims to explore current global LT practices, with an emphasis on challenges and disparities that limit access to LT in different regions of the world.

METHODS

A detailed analysis was performed of present-day liver transplant practices throughout the world, including the etiology of liver disease, patient access to transplantation, surgical costs, and ongoing ethical concerns.

RESULTS

Annually, only 10% of the patients needing a liver transplant receive an organ. Currently, the USA performs the highest volume of liver transplants worldwide, followed by China and Brazil. In both North America and Europe, nonalcoholic fatty liver disease is becoming the most common indication for LT, compared to hepatitis B and C in most Asian, South American, and African countries. While deceased donor liver transplant remains the most performed type of LT, living donor liver transplant is becoming increasingly popular in some parts of the world where it is often the only option due to a lack of well-developed infrastructure for deceased organ donation. Ethical concerns in liver transplantation fundamentally revolve around the definition of a deceased donor and the exploitation of living donor liver donation systems.

CONCLUSION

Globally, liver transplant practices and outcomes are varied, with differences driven by healthcare policies, inequities in healthcare access, and ethical concerns.

Assessment of essential surgical and anaesthesia care capacity: a cross-sectional study in five Pacific Island Countries

Background

Pacific Island Countries (PICs) face unique challenges in providing surgical care. We assessed the surgical care capacity of five PICs to inform the development of National Surgical, Obstetric and Anaesthesia Plans (NSOAP).

Methods

We conducted a cross-sectional survey of 26 facilities in Fiji, Tonga, Vanuatu, Cook Islands, and Palau using the World Health Organization - Program in Global Surgery and Social Change Surgical Assessment Tool.

Findings

Eight referral and 18 first-level hospitals containing 39 functioning operating theatres, 41 post-anaesthesia care beds, and 44 intensive care unit beds served a population of 1,321,000 across the five countries. Most facilities had uninterrupted access to electricity, water, internet, and oxygen. However, CT was only available in 2/8 referral hospitals, MRI in 1/8, and timely blood transfusions in 4/8. The surgical, obstetric, and anaesthetist specialist density per 100,000 people was the highest in Palau (49.7), followed by Cook Islands (22.9), Tonga (9.9), Fiji (7.1), and Vanuatu (5.0). There were four radiologists and 3.5 pathologists across the five countries. Surgical volume per 100,000 people was the lowest in Vanuatu (860), followed by Fiji (2,247), Tonga (2,864), Cook Islands (6,747), and Palau (8,606). The in-hospital peri-operative mortality rate (POMR) was prospectively monitored in Tonga and Cook Islands but retrospectively measured in other countries. POMR was below 1% in all five countries.

Interpretation

Whilst PICs share common challenges in providing specialised tertiary services, there is substantial diversity between the countries. Strategies to strengthen surgical systems should incorporate both local contextualisation within each PIC and regional collaboration between PICs.

Funding

None.

Current Implementation of Quality Measures on American Society for Surgery of the Hand Touching Hands Project Outreach Trips

PURPOSE

As hand and upper extremity outreach trips increase, guidelines for assessing quality of care are being established. The Global Quality in Upper Extremity Surgery and Training investigators have published validated quality measures deemed to be essential for outreach trips to low and middle-income countries (LMICs). The purpose of this study was to assess baseline implementation of these quality measures across nine international hand surgery outreach sites to LMICs. Additionally, we investigated barriers and facilitators to implementing quality measures and documentation of their implementation.

METHODS

We included nine of 12 scheduled 2019 Touching Hands Project trips, excluding independent outreach and teaching mission trips without surgical logs. The team leader from each site received an online questionnaire assessing the documentation and implementation of all 22 quality measures, as well as educational efforts.

RESULTS

A total of 350 surgeries were performed in 2019 with seven reported minor complications and no major complications or mortalities. For analysis, 20 of 22 quality measures were included. Of 20 included validated quality measures, 10 were implemented across all surgical outreach sites. Two sites (Bolivia, Nepal) implemented all of the validated quality measures. Quality measures with the lowest implementation rates included ensuring availability of continuous electricity and oxygen supply with associated documentation of a backup plan. All outreach sites reported formal educational efforts.

CONCLUSIONS

Implementation of validated quality measures across surveyed outreach sites is variable, indicating an opportunity for improvement. Standardizing documentation of quality measure implementation for each site, confirming availability of resources, increasing accountability by the visiting teams, and fostering stronger relationships with local health care, may increase quality measure implementation and improve quality health care delivery and patient safety in LMICs.

CLINICAL RELEVANCE

Benchmarking the implementation of validated quality measures across hand surgical outreach trips provides an opportunity to improve the quality of health care delivered during future hand surgical outreach efforts.

Assessing the impact of anaesthetic and surgical task-shifting globally: a systematic literature review

The global shortage of skilled anaesthesiologists, surgeons and obstetricians is a leading cause of high unmet surgical need. Although anaesthetic and surgical task-shifting are widely practised to mitigate this barrier, little is known about their safety and efficacy. This systematic review seeks to highlight the existing evidence on the clinical outcomes of patients operated on by non-physicians or non-specialist physicians globally. Relevant articles were identified by searching four databases (MEDLINE, EMBASE, CINAHL and Global Health) in all languages between January 2008 and February 2022. Retrieved documents were screened against pre-specified inclusion and exclusion criteria, and their qualities were appraised critically. Data were extracted by two independent reviewers and findings were synthesized narratively. In total, 40 studies have been included. Thirty-five focus on task-shifting for surgical and obstetric procedures, whereas four studies address anaesthetic task-shifting; one study covers both interventions. The majority are located in sub-Saharan Africa and the USA. Seventy-five per cent present perioperative mortality outcomes and 85% analyse morbidity measures. Evidence from low- and middle-income countries, which primarily concentrates on caesarean sections, hernia repairs and surgical male circumcisions, points to the overall safety of non-surgeons. On the other hand, the literature on surgical task-shifting in high-income countries (HICs) is limited to nine studies analysing tube thoracostomies, neurosurgical procedures, caesarean sections, male circumcisions and basal cell carcinoma excisions. Finally, only five studies pertaining to anaesthetic task-shifting across all country settings answer the research question with conflicting results, making it difficult to draw conclusions on the quality of non-physician anaesthetic care. Overall, it appears that non-specialists can safely perform high-volume, low-complexity operations. Further research is needed to understand the implications of surgical task-shifting in HICs and to better assess the performance of non-specialist anaesthesia providers. Future studies must adopt randomized study designs and include long-term outcome measures to generate high-quality evidence.

Identifying critical gaps in research to advance global surgery by 2030: a systematic mapping review

Progress on surgical system strengthening has been slow due to a disconnect between evidence generation and the information required for effective policymaking. This systematic mapping review sought to assess critical research gaps in the field of global surgery guided by the World Health Organisation Health Systems building block framework, analysis of authorship and funding patterns, and an exploration of emerging research partnership networks. Literature was systematically mapped to identify, screen, and synthesize results of publications in the global surgery field between 2015 and March 2022. We searched four databases and included literature published in seven languages. A social network analysis determined the network attributes of research institutions and their transient relationships in shaping the global surgery research agenda. We identified 2,298 relevant studies out of 92,720 unique articles searched. Research output increased from 453 in 2015-16 to 552 in 2021-22, largely due to literature on Covid-19 impacts on surgery. Sub-Saharan Africa (792/2298) and South Asia (331/2298) were the most studied regions, although high-income countries represented a disproportionate number of first (42%) and last (43%) authors. Service delivery received the most attention, including the surgical burden and quality and safety of services, followed by capacity-building efforts in low- and middle-income countries. Critical research in economics and financing, essential infrastructure and supplies, and surgical leadership necessary to guide policy decisions at the country level were lacking. Global surgical systems remain largely under-researched. Knowledge diffusion requires an emphasis on developing sustainable research partnerships and capacity across low- and middle-income countries. A renewed focus must be given to equipping countries with tools for effective decision-making to enhance investments in high-quality surgical services.

Fostering interdisciplinary working within global surgery at an undergraduate level: A hackathon based approach

Objective

To investigate the effectiveness of a virtual hackathon in fostering interdisciplinary working amongst undergraduate students in global surgery.

Methodology

In this study, we developed a 3 day event consisting of guest lectures, a documentary screening and a hackathon supported by academics and experts in the field, to provide students with the opportunity to learn more about and work in interdisciplinary teams within global surgery. Students had the option to attend just the lectures or both the lectures and hackathon. Quantitative and qualitative results were collected through a pre and post session survey.

Results

A total of 21 responses were received for the hackathon and 26 responses for the general event (response rate for event = 26 %, response rate for hackathon = 24.7 %). There was a significant improvement in understanding of interdisciplinary working in global surgery between the pre and post-session survey, with an increase in median from 3 (IQR = 2-3.5, n = 21) to 4 (IQR = 4-5, n = 21) (p < 0.05). Respondents noted that the benefits of a hackathon were that it was very engaging, and brought in diversity of thought and expertise. The drawbacks to the hackathon were that it was fast-paced, required prior knowledge and the virtual platform it was hosted on.

Conclusion

Our study demonstrates that hackathons are an effective, inclusive and equitable way for students to engage in and learn about interdisciplinary working. It is important that as institutions recognise and develop global surgery courses, these courses reflect the interdisciplinary nature of the field.

Closed-globe injury due to metallic foreign body in an elderly worker: A case report

INTRODUCTION AND IMPORTANCE

Cases of ocular trauma in developing countries are often found with more severe conditions due to increased socioeconomic burden, inadequate safety measures, lack of optimal treatment facilities, and poor education. Here we present a case on an elderly worker in a developing country, showing the importance of prompt treatment albeit in a resource-limited setting.

CASE PRESENTATION

A 61-year-old male metalworker presented with closed globe injury after metal debris impact during his work shift 3 h ago. Physical examination showed left eye visual acuity of 1/60, conjunctival injection, corneal blood and fibrovascular tissue, a small foreign body, relative afferent papillary defect, and lens opacities. Ultrasound confirmed vitreous cavity abnormalities. Surgical removal of a foreign body and scleral suturing were performed after an 8-hour delay due to limited staff during night shift. Postoperative follow-up indicated improved vision acuity to 3/60. While the overall prognosis was favorable, the patient did not attend subsequent outpatient follow-up appointments, possibly due to financial barriers, raising concerns regarding long-term management.

CLINICAL DISCUSSION

Ocular trauma remains a significant contributor to visual impairment and avoidable blindness, carrying potential long-term implications for quality of life. This case presentation serves as a poignant reminder of the socioeconomic repercussions of ocular injuries, particularly among workers in resource-constrained environments of the developing world.

CONCLUSION

The notable delays in timely surgical intervention, coupled with financial limitations underline the multifaceted nature of barriers faced.

Emanuel Olatunde Alaba Olanrewaju Odeku (1927-1974): First African Neurosurgeon Trained in the United States and Establisher of the National and West African Postgraduate Medical Colleges

BACKGROUND

In this comprehensive historical account, the authors delve into the remarkable trajectory of Dr. Latunde E. Odeku, a pioneering figure in neurosurgery.

METHODS

The inspiration for this project was ignited by the discovery of the original scientific and bibliographic materials of Latunde Odeku, a renowned Nigerian neurosurgeon and the first African neurosurgeon in history. Following a thorough review of the literature and information available on Dr. Odeku, we have compiled a comprehensive and detailed analysis of his life, work, and legacy.

RESULTS

This paper begins by introducing his childhood and early education in Nigeria, highlights his journey through medical school and residency in the United States, and follows his career and role in establishing the first neurosurgical unit in West Africa. We celebrate the life and legacy of Latunde Odeku, a trailblazing neurosurgeon whose contribution has inspired generations of medical professionals in Africa and around the world.

CONCLUSIONS

This article sheds light on the remarkable life and achievements of Dr. Odeku and his trailblazing work for generations of doctors and researchers.

Availability of laparoscopic surgery in Mexico's public health system: a nationwide retrospective analysis

Background

Laparoscopic surgery remains limited in low-resource settings. We aimed to examine its use in Mexico and determine associated factors.

Methods

By querying open-source databases, we conducted a nationwide retrospective analysis of three common surgical procedures (i.e., cholecystectomies, appendectomies, and inguinal hernia repairs) performed in Mexican public hospitals in 2021. Procedures were classified as laparoscopic based on ICD-9 codes. We extracted patient (e.g., insurance status), clinical (e.g., anaesthesia technique), and geographic data (e.g., region) from procedures performed in hospitals and ambulatories. Multivariable analysis with random forest modelling was performed to identify associated factors and their importance in adopting laparoscopic approach.

Findings

We included 97,234 surgical procedures across 676 public hospitals. In total, 16,061 (16.5%) were performed using laparoscopic approaches, which were less common across all procedure categories. The proportion of laparoscopic procedures per 100,000 inhabitants was highest in the northwest (22.2%, 16/72) while the southeast had the lowest (8.3%, 13/155). Significant factors associated with a laparoscopic approach were female sex, number of municipality inhabitants, region, anaesthesia technique, and type of procedure. The number of municipality inhabitants had the highest contribution to the multivariable model.

Interpretation

Laparoscopic procedures were more commonly performed in highly populated, urban, and wealthy northern areas. Access to laparoscopic techniques was mostly influenced by the conditions of the settings where procedures are performed, rather than patients' non-modifiable characteristics. These findings call for tailored interventions to sustainably address equitable access to minimally invasive surgery in Mexico.

Funding

None.

Strategic planning to improve surgical, obstetric, anaesthesia, and trauma care in the Asia-Pacific region: introduction

Surgical, obstetric, and anaesthesia care are required to treat one-third of the global disease burden. They have been recognised as an integral component of universal health coverage. However, five billion people lack access to safe and affordable surgical care when required. Countries in the Asia-Pacific region are currently developing strategies to strengthen their surgical care systems. The Strategic Planning to Improve Surgical, Obstetric, Anaesthesia, and Trauma Care in the Asia-Pacific Region meeting is a three-part virtual meeting series that brought together Ministries of Health, intergovernmental organisers, funders, professional associations, academic institutions, and nongovernmental organisations in the Asia-Pacific region. The meeting series took place over three virtual sessions in February and March 2021. Each session featured framing talks, panel presentations, and open discussions. Participants shared lessons about the challenges and solutions in surgical system strengthening, discussed funding opportunities, and forged strategic partnerships. Participants discussed strategies to build ongoing political momentum and mobilise funding, the implications of the COVID-19 pandemic and climate change on surgical care, the need to build a broad-based, inclusive movement, and leveraging remote technologies for workforce development and service delivery. This virtual meeting series is only the beginning of an ongoing community for knowledge sharing and strategic collaboration towards surgical system strengthening in the Asia-Pacific region.

Strategic partnerships to improve surgical care in the Asia-Pacific region: proceedings

Emergency and essential surgery is a critical component of universal health coverage. Session three of the three-part virtual meeting series on Strategic Planning to Improve Surgical, Obstetric, Anaesthesia, and Trauma Care in the Asia-Pacific Region focused on strategic partnerships. During this session, a range of partner organisations, including intergovernmental organisations, professional associations, academic and research institutions, non-governmental organisations, and the private sector provided an update on their work in surgical system strengthening in the Asia-Pacific region. Partner organisations could provide technical and implementation support for National Surgical, Obstetric, and Anaesthesia Planning (NSOAP) in a number of areas, including workforce strengthening, capacity building, guideline development, monitoring and evaluation, and service delivery. Participants emphasised the importance of several forms of strategic collaboration: 1) collaboration across the spectrum of care between emergency, critical, and surgical care, which share many common underlying health system requirements; 2) interprofessional collaboration between surgery, obstetrics, anaesthesia, diagnostics, nursing, midwifery among other professions; 3) regional collaboration, particularly between Pacific Island Countries, and 4) South-South collaboration between low- and middle-income countries (LMICs) in mutual knowledge sharing. Partnerships between high-income countries (HIC) and LMIC organisations must include LMIC participants at a governance level for shared decision-making. Areas for joint action that emerged in the discussion included coordinated advocacy efforts to generate political view, developing common monitoring and evaluation frameworks, and utilising remote technology for workforce development and service delivery.

Financing surgical, obstetric, anaesthesia, and trauma care in the Asia-Pacific region: proceedings

Surgical, obstetric, and anaesthesia care saves lives, prevents disability, promotes economic prosperity, and is a fundamental human right. Session two of the three-part virtual meeting series on Strategic Planning to Improve Surgical, Obstetric, Anaesthesia, and Trauma Care in the Asia-Pacific Region discussed financing strategies for surgical care. During this session, participants made a robust case for investing in surgical care given its cost-effectiveness, macroeconomic benefits, and contribution to health security and pandemic preparedness. Funding for surgical system strengthening could arise from both domestic and international sources. Numerous strategies are available for mobilising funding for surgical care, including conducive macroeconomic growth, reprioritisation of health within government budgets, sector-specific domestic revenue, international financing, improving the effectiveness and efficiency of health budgets, and innovative financing. A wide range of funders recognised the importance of investing in surgical care and shared their currently funded projects in surgical, obstetric, anaesthesia, and trauma care as well as their funding priorities. Advocacy efforts to mobilise funding for surgical care to align with the existing funder priorities, such as primary health care, maternal and child health, health security, and the COVID-19 pandemic. Although the COVID-19 pandemic has constricted the fiscal space for surgical care, it has also brought unprecedented attention to health. Short-term investment in critical care, medical oxygen, and infection prevention and control as a part of the COVID-19 response must be leveraged to generate sustained strengthening of surgical systems beyond the pandemic.

The current status of surgical care in the Asia-Pacific region and opportunities for improvement: proceedings

The World Health Assembly resolution 68.15 recognised emergency and essential surgery as a critical component of universal health coverage. The first session of the three-part virtual meeting series on Strategic Planning to Improve Surgical, Obstetric, Anaesthesia, and Trauma Care in the Asia-Pacific Region focused on the current status of surgical care and opportunities for improvement. During this session, Ministries of Health and World Health Organization (WHO) Regional Directors shared country- and regional-level progress in surgical system strengthening. The WHO Western Pacific Regional Office (WPRO) has developed an Action Framework for Safe and Affordable Surgery, whilst the WHO South-East Asia Regional Office (SEARO) highlighted their efforts in emergency obstetric care, workforce strengthening, and blood safety. Numerous countries have begun developing and implementing National Surgical, Obstetric, and Anaesthesia Plans (NSOAPs). Participants agreed surgical system strengthening is an integral component of universal health coverage, pandemic preparedness, and overall health system resilience. Participants discussed common challenges, such as the COVID-19 pandemic, climate change, workforce capacity building, and improving access for hard-to-reach populations. They generated and shared common solutions, including strengthening surgical care capacity in first-level hospitals, anaesthesia task-shifting, remote training, and integrating surgical care with public health, preventive care, and emergency preparedness. Moving forward, participants committed to developing and implementing NSOAPs and agreed on the need to raise political awareness, build a broad-based movement, and form intersectoral collaborations.

Population health and sociodemographic variables as predictors of access to cardiac medicine and surgery in Haiti

BACKGROUND

In Haiti, cardiovascular disease is a leading cause of morbidity and mortality, with congenital and rheumatic heart disease comprising a large portion of disease burden. However, domestic disparities in cardiac care access and their impact on clinical outcomes remain poorly understood. We analyzed population-level sociodemographic variables to predict cardiac care outcomes across the 10 Haitian administrative departments.

METHODS

This cross-sectional study combined data from a 2016-17 Haitian national survey with aggregate outcomes from the Haiti Cardiac Alliance (HCA) database (n = 1817 patients). Using univariate and multivariable regression analyses, the proportion of HCA patients belonging to each of three clinical categories (active treatment, lost to follow-up, deceased preoperatively) was modeled in relation to six population-level variables selected from national survey data at the level of the administrative department.

RESULTS

In univariate analysis, higher department rates of childhood growth retardation were associated with a lower proportion of patients in active care (OR = 0.979 [0.969, 0.989], p = 0.002) and a higher proportion of patients lost to follow-up (OR = 1.016 [1.006, 1.026], p = 0.009). In multivariable analysis, the proportion of department patients in active care was inversely associated with qualified prenatal care (OR = 0.980 [0.971, 0.989], p = 0.005), and child growth retardation (OR = 0.977 [0.972, 0.983]), p = 0.00019). Similar multivariable results were obtained for department rates of loss to follow-up (child growth retardation: OR = 1.018 [1.011, 1.025], p = 0.002; time to nearest healthcare facility in an emergency: OR = 1.004 [1.000, 1.008, p = 0.065) and for preoperative mortality (prenatal care: OR = 0.989 [0.981, 0.997], p = 0.037; economic index: OR = 0.996 [0.995, 0.998], p = 0.007; time to nearest healthcare facility in an emergency: OR = 0.992 [0.988, 0.996], p = 0.0046).

CONCLUSIONS

Population-level survey data on multiple variables predicted domestic disparities in HCA clinical outcomes by region. These findings may help to identify underserved areas in Haiti, where increased cardiac care resources are required to improve health equity. This approach to analyzing clinical outcomes through the lens of population-level survey data may inform future health policies and interventions designed to increase cardiac care access in Haiti and other low-income countries.

Evaluating the status of the Lancet Commission on Global Surgery indicators for India

For universal surgical, obstetric, trauma, and anesthesia care by 2030, the Lancet Commission on Global Surgery (LCoGS) suggested tracking six indicators. We reviewed academic and policy literature to investigate the current state of LCoGS indicators in India. There was limited primary data for access to timely essential surgery, risk of impoverishing and catastrophic health expenditures due to surgery, though some modeled estimates are present. Surgical specialist workforce estimates are heterogeneous across different levels of care, urban and rural areas, and diverse health sectors. Surgical volumes differ widely across demographic, socio-economic, and geographic cohorts. Perioperative mortality rates vary across procedures, diagnoses, and follow-up time periods. Available data suggest India falls short of achieving global targets. This review highlights the evidence gap for India's surgical care planning. India needs a systematic subnational mapping of indicators and adaptation of targets as per the country's health needs for equitable and sustainable planning.

Global dissemination of minimally invasive living donor hepatectomy: What are the barriers?

Minimally invasive donor hepatectomy (MIDH) is a relatively novel procedure that can potentially increase donor safety and contribute to faster rehabilitation of donors. After an initial period in which donor safety was not effectively validated, MIDH currently seems to provide improved results, provided that it is conducted by experienced surgeons. Appropriate selection criteria are crucial to achieve better outcomes in terms of complications, blood loss, operative time, and hospital stay. Beyond a pure laparoscopic technique, various approaches have been recommended such as hand-assisted, laparoscopic-assisted, and robotic donation. The latter has shown equal outcomes compared to open and laparoscopic approaches. A steep learning curve seems to exist in MIDH, mainly due to the fragility of the liver parenchyma and the experience needed for adequate control of bleeding. This review investigated the challenges and the opportunities of MIDH and the barriers to its global dissemination. Surgeons need expertise in liver transplantation, hepatobiliary surgery, and minimally invasive techniques to perform MIDH. Barriers can be categorized into surgeon-related, institutional-related, and accessibility. More robust data and the creation of international registries are needed for further evaluation of the technique and the acceptance from more centers worldwide.

Evaluating the potential impact of spinal anesthesia use in lumbar surgery on global healthcare cost and climate change

Introduction

Despite recent evidence demonstrating its safety and efficacy, spinal anesthesia remains a seldom-utilized anesthetic modality in lumbar surgical procedures. In addition, numerous clinical advantages, such as reduced cost, blood loss, operative time, and inpatient length of stay have been consistently demonstrated with spinal anesthesia over general anesthesia.

Research question

In this report we aim to examine the differences between spinal anesthesia and general anesthesia with regard to accessibility and climate impact and determine whether wider adoption of spinal anesthesia would have a meaningful impact on the global population. Materials and Methods: The climate impact of spinal fusions performed under spinal and general anesthesia were obtained from recent studies published in the literature. Cost of spinal fusions was obtained from an unpublished study performed at our institution. Volume of spinal fusions performed in several countries were ascertained from published reports. Data on cost and carbon emissions were extrapolated based on volume of spinal fusions in each of the nations.

Results

In the U.S., use of spinal anesthesia for lumbar fusions would have resulted in savings of 343 million dollars in 2015. A similar reduction in cost was seen with each country studied. Additionally, spinal anesthesia was associated with 12,352 ​kg carbon dioxide equivalents (CO₂e) while general anesthesia produced 942,872 ​kg CO₂e. Similar reduction in carbon emissions was seen with each country studied.

Discussion and conclusion

Spinal anesthesia is safe and effective for both simple and complex spine surgeries, it reduces carbon emissions, permits lower operative times, and decreases cost.

Retrospective review of antimicrobial use for gastroschisis patients in Kigali, Rwanda: can improved stewardship reduce late inpatient deaths?

Gastroschisis mortality is 75-100% in low-resource settings. In Rwanda, late deaths are often due to sepsis. We aimed to understand the effect of antimicrobial use on survival. We conducted a retrospective review of gastroschisis patients at a tertiary hospital in Kigali, Rwanda between January 2016-June 2019. Demographics, antimicrobial use, microbiology, and outcomes were abstracted. Descriptive and univariate analyses were conducted to assess factors associated with improved survival. Among 92 gastroschisis patients, mortality was 77%(n = 71); 23%(n = 21) died within 48 h. 98%(n = 90) of patients received antibiotics on arrival. Positive blood cultures were obtained in 41%(n = 38). Patients spent 86%(SD = 20%) of their hospital stay on antibiotics and 38%(n = 35) received second-line agents. There was no difference in age at arrival, birth weight, gestational age, silo complications, or antimicrobial selection between survivors and non-survivors. Late death patients spent more total hospital days and post-abdominal closure days on antibiotics (p < 0.001) compared to survivors. There was no difference in the proportion of hospital stay on second-line antibiotics (p = 0.1).

CONCLUSION

We identified frequent late deaths, prolonged antibiotic courses, and regular use of second-line antibiotic agents in this retrospective cohort of Rwandan gastroschisis patients. Future studies are needed to evaluate antimicrobial resistance in pediatric surgical patients in Rwanda.

WHAT IS KNOWN

• Global disparities in gastroschisis outcomes are extreme, with <4% mortality in high-income settings and 75-100% mortality in low-income settings. • Antimicrobial surveillance data is sparse across Africa, but existing evidence suggests high levels of resistance to first-line antibiotics in Rwanda.

WHAT IS NEW

• In-hospital survival for gastroschisis was 23% from 2016-2019 and most deaths occurred late (>48hrs after admission) due to sepsis. • Rwandan gastroschisis patients received prolonged courses of antibiotics and second-line antibiotics were frequently used without culture data, raising concern for antimicrobial resistance.