Chemotherapy-associated pneumoperitoneum in cancer patients: a scoping review

Background

The presence of air in the peritoneal cavity (pneumoperitoneum) is often secondary to perforated viscus. Emergent operative intervention is typically warranted in non-cancer patients. Cancer patients present a unique challenge as they have an increased risk of pneumoperitoneum due to local tumour invasion, radiation therapy, and frequent endoscopic procedures. There is a paucity of literature on the management of patients undergoing chemotherapy who present with pneumoperitoneum. The authors conducted a scoping review to identify and synthesize preliminary evidence on the presentation, management, and outcomes of this patient population.

Materials and methods

A scoping review of cases of pneumoperitoneum in cancer patients from 1990 to 2022 was conducted using the Arksey and O'Malley five-stage approach. Inclusion criteria were a known diagnosis of cancer, chemotherapy within 6 months of presentation, and imaging confirmation of pneumoperitoneum. The authors' exclusion criteria were cancer diagnosis at the time of presentation, perforation secondary to local cancer invasion, and last chemotherapy session greater than 6 months prior to presentation.

Results

Thirty-four cases (8 paediatric, 26 adults) were identified. The median time from the last chemotherapy treatment to presentation with pneumoperitoneum was 14 days. Twenty-one patients were managed operatively, and 13 were managed non-operatively. The most common source of perforation was multiple sites along the bowel. Thirty-day mortality was 33.3% for the operative cohort and 23.1% for the non-operative group.

Conclusions

Pneumoperitoneum in cancer patients remains a highly morbid condition with a mortality rate of approximately 30%, regardless of the treatment approach. Non-operative management should be pursued whenever possible.

Interests and Barriers to Medical Students Participation in a Dedicated Global Surgery Curriculum

INTRODUCTION

Despite many institutions establishing global surgery (GS) programs to support clinical care and education in resource-limited settings, few have established a specific curriculum in GS. This study's objective was to assess medical student interest in such a curriculum and prospects for future careers in GS/global health (GH), and to define the barriers to pursuing an international rotation.

METHODS

We conducted an anonymous online survey of all 495 medical students at a major academic medical center in the mid-South that collected demographic data, country of origin, interest in a GS/GH elective, and barriers to pursuing a GS/GH rotation abroad. The data were analyzed using SPSS software.

RESULTS

Prior international experience increased the likelihood of a student's involvement in GS/GH and more preclinical (years 1 & 2) students (90%) than clinical students. (years 3 & 4) (70%) felt strongly about the value of a GS/GH experience. Of the 163 students who completed the survey, 80% expressed interest in a GS/GH elective, with preclinical students expressing more interest (90%) than clinical students (71%). This interest strongly correlated with an interest in pursuing a career in GH (94%) and/or GS (100%). Identified barriers to engagement in a GS/GH experience abroad included financing (74%), scheduling (58%), family obligations (23%), and personal safety (19%).

CONCLUSIONS

The students we surveyed were very interested in a GS/GH curriculum that included a rotation abroad, especially if they were to receive financial support. Preclinical students expressed more willingness to self-fund such experiences. The findings of this survey further strengthen the need to incorporate GS/GH in medical school curricula.

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.

A scoping review on the availability and utilization of essential opioid analgesics in Sub-Saharan Africa

BACKGROUND

Management of acute, post-operative, and chronic pain requires access to and availability of opioids. While often oversupplied in high-income countries, significant shortages exist in low- and middle-income countries. We conducted a scoping review on availability and usage of opioids in Sub-Saharan Africa (SSA).

METHODS

The five-stage approach of Arksey and O'Malley (2005) was used. MEDLINE via PubMed, EMBASE, and SCOPUS were search and results categorized into themes: 1) Local/regional availability and supply, 2) Consumption patterns, 3) Legislation and policy, 4) Costs and financing, 5) Knowledge and cultural beliefs, and 6) Education and training.

RESULTS

6923 studies were identified from which 69 (1%) met inclusion criteria. Five key findings were: 1) Significant shortages exist, especially in rural areas, 2) Non-opioid analgesics commonly used as first-line acute pain management, 3) Barriers to market entry and bureaucratic processes prevent local production, 4) Significant knowledge gaps/myths exist amongst healthcare practitioners on opioid use, and 5) Continuous education and short courses will be critical.

CONCLUSIONS

Major challenges significantly limit availability and utilization of essential opioids in SSA. Reforms needed to upscale training and education, increase uptake by professionals, and increase market entry.

Hospital Detention for the Inability to Pay: A Qualitative Study of Patient Experiences in Cameroon

INTRODUCTION

Equitable access to quality surgical care and low-cost healthcare services for all segments of the population remains a big problem in many African health systems. In Cameroon, it is very common to find medically discharged patients who have received surgical treatment and are unable to pay the resulting bills. These patients can be held in detention in hospitals until payments are complete. Even the corpses of patients who die with unpaid medical bills can be withheld until their family members pay off the debt. While this practice has been ongoing for many y, there remains very little scholarship on the issue reported in the literature. The main objective of this study was to uncover the lived experiences of discharged patients residing in hospital detention for being unable to pay their medical bills.

METHODS

In-depth interviews, focus group discussions, and observations were conducted with purposefully selected patients living in detention in 2 rural private hospitals in the Fundong Health District in Cameroon. A thematic framework technique was used to analyze the transcribed data. The study was ethically approved by the Cameroon Bioethics Initiative, and informed consent was obtained from all participants.

RESULTS

Living in hospital detention after receiving treatment constitutes an economic, social, and psychological burden for patients. Economically, it exacerbated poverty for the patients unable to purchase food, medications, and clothing due to lack of jobs and financial support. Socially, many of these individuals suffered from isolation, loneliness, shame, stigma, risk of contracting other diseases, and precarious sleeping conditions. The psychological burden was comprised of stress, depression, trauma, nightmares, and suicidal thoughts.

CONCLUSIONS

The experiences of discharged patients in hospital detention suggest that they live in very deplorable conditions. There is a need for a functional healthcare protection mechanism, such as universal health coverage, to reduce the cost of healthcare services and surgical operations. Alternative payment mechanisms should also be considered.

Management and outcomes of chemotherapy-associated pneumoperitoneum in cancer patients: a scoping review protocol

Introduction

Pneumoperitoneum - free air within the peritoneal cavity - is often the result of bowel perforation, though other causes include residual postprocedural or postoperative air and barotrauma. In non-cancer patients, operative intervention is often required. Cancer patients, on the other hand, present a unique set of challenges as they usually have elevated risk of pneumoperitoneum from local radiation therapy, frequent endoscopic procedures, and tumor invasion. Factors such as malnutrition, neutropenia, chemotherapy, and steroid use make emergent surgery tenuous in cancer patients. There is a paucity of published literature on the management of pneumoperitoneum in patients actively undergoing chemotherapy. The main objective of this scoping review is to assess the presentation, management, and subsequent outcomes of this unique patient population.

Materials and Methods

The authors will utilize the framework for performing scoping reviews as outlined by Arksey and O'Malley. They will perform the search for articles in three electronic databases (i.e. SCOPUS, PubMed, Embase) and relevant gray literature. Only articles available in English and published between 1999 and 2022 will be included. Inclusion criteria will be a known diagnosis of cancer, chemotherapy within 6 months of presentation, and imaging confirmation of pneumoperitoneum. Exclusion criteria will be cancer diagnosis at the time of presentation, perforation secondary to cancer itself, and chemotherapy greater than 6 months prior to presentation. A tailored extraction frame to extract relevant information from published articles that meet our inclusion criteria. The data using both descriptive statistics and thematic analysis of the main study questions.

Ethics and Dissemination

Since the authors will not be collecting primary data, formal ethical approval is not required. They study findings will be disseminated through abstracts, conference presentations, and peer-reviewed publications.

A framework to improve retention of Black surgical trainees: A Society of Black Academic Surgeons white paper

Attrition is high among surgical trainees, and six of ten trainees consider leaving their programs, with two ultimately leaving before completion of training. Given known historically and systemically rooted biases, Black surgical trainees are at high risk of attrition during residency training. With only 4.5% of all surgical trainees identifying as Black, underrepresentation among their peers can lend to misclassification of failure to assimilate as clinical incompetence. Furthermore, the disproportionate impact of ongoing socioeconomic crisis (e.g., COVID-19 pandemic, police brutality etc.) on Black trainees and their families confers additional challenges that may exacerbate attrition rates. Thus, attrition is a significant threat to medical workforce diversity and health equity. There is urgent need for surgical programs to develop proactive approaches to address attrition and the threat to the surgical workforce. In this Society of Black Academic Surgeons (SBAS) white paper, we provide a framework that promotes an open and inclusive environment conducive to the retention of Black surgical trainees, and continued progress towards attainment of health equity for racial and ethnic minorities in the United States.

Community participation for reproductive, maternal, newborn and child health: insights from the design and implementation of the BornFyne-prenatal management system digital platform in Cameroon

Introduction

Across communities in low-middle income countries, digital health is currently revolutionizing the delivery of health services, particularly in the field of reproductive, maternal, newborn, and child health (RMNCH) services. While studies have shown the effectiveness of mHealth in delivering RMNCH services, there is little information about factors that enhance mHealth services utilization in low-cost settings including stakeholders' level of influence on the implementation of digital health intervention in sub-Saharan Africa. This paper seeks to describe important lessons on the levels of stakeholders' direct or indirect influence on the design and implementation of the BornFyne-PNMS digital health platform to support RMNCH services.

Methods

A participatory research (PR) design approach was employed to explore stakeholders' perspectives of a new initiative, through direct engagement of local priorities and perspectives. The process of introducing the digital application called the BornFyne-PNMS for district health delivery system and the community, and integrating it within the district health delivery system was guided by research-to-action, consistent with the PR approach. To explore stakeholders' perspectives through a PR approach, we conducted a series of stakeholder meetings fashioned after focus group discussions.

Results

Issues around male involvement in the program, sensitization and equity concerns arose. Emergent challenges and proposed strategies for implementation from diverse stakeholders evidently enriched the design and implementation process of the project intervention. Stakeholder meetings informed the addition of variables on the mobile application that were otherwise initially omitted, which will further enhance the RMNCH electronic data collection for health information systems strengthening in Cameroon.

Discussion

This study charts a direction that is critical in digital health delivery of RMNCH in a rural and low-income community and describes the important iterative stakeholder input throughout the study. The strategy of stakeholders' involvement in the BornFyne PNMS implementation charts a direction for ownership and sustainability in the strengthening of Cameroon's health information system.

Cholecystoappendiceal Fistula From Appendiceal Adenocarcinoma Requiring a Right Hemicolectomy With Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy

Bilioenteric fistulae are rare and difficult to manage complications of chronic cholecystitis. While cholecystoduodenal and cholecystocolic fistulae are more common, a cholecystoappendiceal fistula is an extremely rare finding. We report the presentation and operative management of a 59-year-old male with cholecystoappendiceal fistula and associated abscess in the gallbladder fossa. The patient was appropriately resuscitated, the abscess drained by interventional radiology, and after a complete workup, underwent a laparoscopic appendectomy and cholecystectomy. Pathology revealed moderately differentiated appendiceal adenocarcinoma requiring a right hemicolectomy with cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC). He has recovered well postoperatively with no complications. This case highlights the importance of having a very high index of suspicion for underlying malignancy when managing a fistula of any kind. To the best of our understanding, this is only the second reported case of a cholecystoappendiceal fistula.

Availability and Use of Essential Opioid Analgesics in Sub-Saharan Africa: A Scoping Review Protocol

Introduction

The treatment of acute, peri-operative, and chronic pain by healthcare practitioners and health systems requires appropriate access to and availability of essential opioid medications. While opioids are often oversupplied and overprescribed in high-income countries, there are significant inequities as many low- and middle-income countries (LMICs) experience severe shortages. In fact, while the richest 10% in the world reside in countries receiving almost 90% of all available opioids, 50% of the poorest in the world reside in countries receiving just 1% of all available opioids.Understanding the social, economic, cultural, and regulatory barriers to access essential opioid analgesics in LMICs is critical in delineating and prioritizing appropriate interventions. We aim to conduct a scoping review on the availability and usage of essential opioid analgesics in LMICs, specifically in sub-Saharan Africa, to identify barriers, themes, and knowledge gaps.

Materials and Methods

We will utilize the framework for conducting scoping reviews by Arksey and O'Malley. We will perform the search for articles in 3 electronic databases (i.e., SCOPUS, PubMed, Embase) and relevant gray literature. Only articles in English will be included. There will be no restriction on the publication period. All articles will directly involve either the availability and/or the use of essential opioid analgesics. Studies will be restricted to focus on sub-Saharan Africa. We will use a tailored extraction frame to extract relevant information from published articles that meet our inclusion criteria. We will analyze the data using both descriptive statistics and thematic analysis on the main study questions.

Ethics and Dissemination

Since we will not be collecting primary data, formal ethical approval is not required.Our study findings will be disseminated through abstracts, conference presentations, and peer-reviewed publications.

Highlights

50 percent of the poorest in the world reside in countries receiving just 1 percent of all available opioidsThere is a paucity of data analyzing the inequitable distribution of essential opioid analgesics worldwideOur scoping review will identify barriers, themes, and knowledge gaps on the availability and use of essential opioids in SSAIt will identify areas for further research and potential policy initiatives.

Alectinib-associated pneumoperitoneum in stage IV non-small cell lung cancer - A case report

Introduction and importance

Alectinib, a highly potent, highly selective, brain-penetrant anaplastic lymphoma kinase (ALK) inhibitor is now the first line therapy for patients with metastatic ALK-positive non small cell lung cancer (NSCLC).

Case presentation

We report a rare case of pneumoperitoneum following alectinib initiation for metastatic non small cell lung cancer in a 74-year-old African American female. Patient developed abdominal pain approximately 2 weeks after starting alectinib. She was hemodynamically stable, and imaging revealed pneumoperitoneum. Patient was successfully managed non-operatively.

Clinical discussion

Gastrointestinal perforation presenting as pneumoperitoneum is a very rare complication of alectinib. To our knowledge our patient is only the second case to be reported in the literature since its approval. The complication is likely attributable to the rapid tumor regression in the gastrointestinal tract. Non-operative management should be attempted if possible.

Conclusion

Oncologists should be aware of the risk of gastrointestinal perforation when initiating cytotoxic chemotherapy on patients with metastatic NSCLC. A multidisciplinary approach is critical in appropriately individualizing care in this patient population.

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Alectinib is currently first line treatment for patients with metastatic ALK-positive non small cell lung cancer.

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Gastrointestinal perforation is a very rare complication of alectinib use.

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Patients with pneumoperitoneum require a multidisciplinary approach with non operative management preferred if possible.

Beware of the shrunken gallbladder – Case report of intraoperatively diagnosed gallbladder agenesis

Introduction and importance

Gallbladder Agenesis, the congenital absence of the gallbladder, is a very rare biliary anomaly found in 13 to 65 people per 100,000. Symptomatic patients usually present with abdominal pain, nausea, and emesis, and are often misdiagnosed with gallbladder pathologies leading to unnecessary operations.

Case presentation

We report the case of a 63-year-old Caucasian female patient who presented with recurrent right upper quadrant pain (RUQ) and found to have a contracted gallbladder on ultrasonography (US). A hepatobiliary iminodiacetic acid (HIDA) scan was positive, and the patient was misdiagnosed with chronic cholecystitis. No gallbladder was found on laparoscopy and patient was diagnosed intraoperatively with gallbladder agenesis. Normal biliary anatomy was confirmed intraoperatively using the Firefly technique and there was no ectopic gallbladder on computed tomography (CT) scan obtained postoperatively. Patient currently doing well on conservative pain management.

Clinical discussion

Patients with gallbladder agenesis and normal bile ducts often have symptoms similar to that of usual gallbladder problems. Accurately diagnosing these patients preoperatively remains a challenge.

Conclusion

Symptomatic patients with agenesis of the gallbladder are often diagnosed intraoperatively despite major advances in diagnostic imaging techniques. In these cases, minimizing the risk of injury to the biliary tree is crucial. As our case demonstrates, it is critical for surgeons to become increasingly aware of this rare and important congenital anomaly. A very high index of suspicion is warranted in patients with a shrunken or contracted gallbladder. When in doubt, obtain cross-sectional imaging.

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Gallbladder agenesis is a very rare congenital anomaly with symptoms similar to biliary pathologies.

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GA is often misdiagnosed on ultrasound as a shrunken, contracted gallbladder.

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Cross-sectional imaging with CT or MRI is needed if gallbladder is not clearly visualized on ultrasound.

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If diagnosed intraoperatively, minimize risk of biliary injury and abort procedure.

Retrograde intussusception of jejunojejunostomy after Roux-En-Y gastric bypass leading to small bowel obstruction – Case report of a rare and serious complication

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Retrograde intussusception post RYGB is a very rare complication usually presenting with vague abdominal symptoms.

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Female patients who experience very good weight loss post RYGB are most prone.

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Operative intervention should not be delayed after appropriate resuscitation.

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Resection of the jejunojejunostomy with two anastomoses recreation has least likelihood of recurrence.

Gallbladder volvulus with gangrenous cholecystitis - A case report

INTRODUCTION AND IMPORTANCE

Gallbladder torsion (volvulus) is a very rare pathology that occurs when the gallbladder rotates on the cystic duct/cystic artery axis, resulting in blockage of bile drainage and blood flow.

CASE PRESENTATION

We present the case of an elderly 87-year-old female who experienced acute gallbladder torsion. The patient presented with acute left chest pain that radiated to the patient's back and nausea but no emesis. A thorough physical examination, serologic studies, abdominal ultrasound, and computed tomography scan revealed gallbladder dilation, a thickened wall, enlarged common bile duct (approximately 1 cm), and the presence of pericholecystic fluid, all of which were consistent with acute cholecystitis. Laparoscopic cholecystectomy led to an intraoperative diagnosis of completely gangrenous gallbladder volvulus (GBV) with a 360-degree counter clockwise rotation. The pathology led to a final diagnosis of acute necrotizing cholecystitis without evidence of malignancy.

CLINICAL DISCUSSION

GBV (gallbladder torsion) is typically observed in elderly patients at a female-to-male ratio of 4:1 and a median age at presentation of 77 years. Few advancements have been made in accurate diagnosis of GBV using clinical findings or the results of radiographic imaging, leading to accurate preoperative diagnoses in only 25 % of patients.

CONCLUSION

Though GBV usually presents with right upper quadrant pain, our patient had the rare presentation of left sided chest pain mimicking acute coronary syndrome. GBV is an uncommon condition that occurs frequently in the elderly, particularly in women. Accurate preoperative diagnosis remains daunting, since clinical, laboratory, and radiographic findings often lead to an incorrect diagnosis of acute cholecystitis. Prompt diagnosis necessitates a high level of suspicion, and laparoscopic cholecystectomy is the recommended treatment/management.