Surgery In Low- And Middle-income Countries Research Articles

The Ecuador Pediatric Spine Deformity Surgery Program: An SRS-GOP Site, 2008–2016

Study DesignRetrospective case series. ObjectivesThe purpose of this study is to (1) describe the development of our Spinal Deformity Program; (2) assess the surgical outcomes, including health-related quality of life (HRQOL), radiographic measures, and complications; and (3) explore predictors for HRQOL outcomes. Summary of Background DataThe Scoliosis Research Society (SRS) is very interested in international program site development to provide safe surgical care for children in low- and middle-income countries (LMICs). There is a need for reporting program development and outcomes from these sites. After several years of building local relations and infrastructure, our program started performing spine surgery in 2008. MethodsAll operations were performed at Roberto Gilbert Elizalde Children's Hospital in Guayaquil, Ecuador. At a minimum of two years and average of four years postoperatively, patients received a clinical evaluation, radiographs, and the Spanish SRS-22r questionnaire. ResultsTwenty-eight (74%) of the 38 children who received spine surgery between May 2008 and 2015 are included in this study. Twenty-three (82%) were female with an average age of 14 years at the time of surgery and 18 years at follow-up. The mean total SRS-22r score was 4.3 and mean percentage major curve correction was 57%. Curve location was found to be a significant predictor of postoperative SRS-22r scores with double curves having poorer scores (p = .004). Two complications were pseudarthrosis and postoperative delayed paraplegia, both of which resolved after revision surgery. No infections or other long-term complications have occurred. ConclusionsThe development of equitable surgical care for all children is a primary goal of the SRS. Undertaking the task to perform surgery in LMIC comes with the responsibility to monitor and maintain the highest quality. Our program was safely developed to address the surgical needs of children with good midterm HRQOL outcomes, adequate radiographic curve correction, and no permanent complications. Level of EvidenceLevel IV.

Prioritizing research for patients requiring surgery in low- and middle-income countries.

The National Institute for Health Research Global Health Research Unit on Global Surgery is establishing research Hubs in low- and middle-income countries (LMICs). The aim of this study was for the Hubs to prioritize future research into areas of unmet clinical need for patients in LMICs requiring surgery. A modified Delphi process was overseen by the research Hub leads and engaged LMIC clinicians, patients and expert methodologists. A four-stage iterative process was delivered to prioritize research topics. This included anonymous electronic voting, teleconference discussions and a 2-day priority-setting workshop. In stage 1, Hub leads proposed 32 topics across six domains: access to surgery, cancer, perioperative care, research methods, acute care surgery and communicable disease. In stages 2 and 3, 40 LMICs and 20 high-income countries participated in online voting, leading to identification of three priority research topics: access to surgery; outcomes of cancer surgery; and perioperative care. During stage 4, specific research plans to address each topic were developed by Hub leads at a priority-setting workshop. This process identified three priority areas for future research relevant to surgery in LMICs. It was driven by front-line LMIC clinicians, patients and other stakeholders representing a diverse range of settings. The results of the prioritization exercise provide a future framework for researchers and funders.

Tetralogy of Fallot Repair in Developing Countries: International Quality Improvement Collaborative

Isolated reports from low- and middle-income countries (LMICs) for surgical results in tetralogy of Fallot (TOF) are available. The International Quality Improvement Collaborative for Congenital Heart Disease (IQIC) seeks to improve surgical results promoting reductions in infection and mortality in LMICs. All cases of TOF in the IQIC database performed between 2010 and 2014 at 32 centers in 20 LMICs were included. Excluded from the analysis were TOF with any associated lesions. A logistic regression analysis was performed to identify risk factors for in-hospital mortality after surgery for TOF. A total of 2,164 patients were identified. There were 1,839 initial primary repairs, 200 with initial systemic-to-pulmonary artery shunt, and 125 underwent secondary repair after initial palliation. Overall mortality was 3.6% (78 of 2,164), initial primary repair was 3.3% (60 of 1,839), initial systemic-to-pulmonary artery shunt was 8.0% (16 of 200), and secondary repair was 1.6% (2 of 125; p= 0.003). Major infections occurred in 5.9% (128 of 2,164) of the entire cohort. Risk factors for death after the initial primary repair were oxygen saturation less than 90% and weight/body mass index for age below the fifth percentile (p < 0.001). The initial primary repair occurredafter age 1 year in 54% (991 of 1,839). Older age at initial primary repair was not a risk factor for death (p= 0.21). TOF patients are often operated on after age 1 year in LMICs. Unlike in developed countries, older age is not a risk factor for death. Nutritional and hypoxemic status were associated with higher mortality and infection. This information fills a critical knowledge gap for surgery in LMIC.

Laparoscopic surgery for gynecologic cancer in low- and middle-income countries (LMICs): An area of need

Over 90% of people living in low- and middle-income countries (LMICs) do not have access to surgical care. In the absence of appropriate surgical care, there is high morbidity and mortality from surgically curable diseases, such as cervical cancer. Laparoscopic surgery for gynecologic cancer in LMICs is extremely limited. The benefits of laparoscopy over open surgery are even more pronounced in LMICs than in resource-rich countries. Barriers to implementation of laparoscopic surgery in LMICs should be identified and addressed in order to improve global cancer care and the lives of women worldwide.

Practice, training and safety of laparoscopic surgery in low and middle-income countries

Surgical management of diseases is recognised as a major unmet need in low and middle-income countries (LMICs). Laparoscopic surgery has been present since the 1980s and offers the benefit of minimising the morbidity and potential mortality associated with laparotomies. Laparotomies are often carried out in LMICs for diagnosis and management, due to lack of radiological investigative and intervention options. The use of laparoscopy for diagnosis and treatment is globally variable, with high-income countries using laparoscopy routinely compared with LMICs. The specific advantages of minimally invasive surgery such as lower surgical site infections and earlier return to work are of great benefit for patients in LMICs, as time lost not working could result in a family not being able to sustain themselves. Laparoscopic surgery and training is not cheap. Cost is a major barrier to healthcare access for a significant population in LMICs. Therefore, cost is usually seen as a major barrier for laparoscopic surgery to be integrated into routine practice in LMICs. The aim of this review is to focus on the practice, training and safety of laparoscopic surgery in LMICs. In addition it highlights the barriers to progress in adopting laparoscopic surgery in LMICs and how to address them.

Financial contributions to global surgery: an analysis of 160 international charitable organizations.

BackgroundThe non-profit and volunteer sector has made notable contributions to delivering surgical services in low-and middle-income countries (LMICs). As an estimated 55 % of surgical care delivered in some LMICs is via charitable organizations; the financial contributions of this sector provides valuable insight into understanding financing priorities in global surgery.MethodsDatabases of registered charitable organizations in five high-income nations (United States, United Kingdom, Canada, Australia, and New Zealand) were searched to identify organizations committed exclusively to surgery in LMICs and their financial data. For each organization, we categorized the surgical specialty and calculated revenues and expenditures. All foreign currency was converted to U.S. dollars based on historical yearly average conversion rates. All dollars were adjusted for inflation by converting to 2014 U.S. dollars.Results One hundred sixty organizations representing 15 specialties were identified. Adjusting for inflation, in 2014 U.S. dollars (US$), total aggregated revenue over the years 2008–2013 was $3·4 billion and total aggregated expenses were $3·1 billion. Twenty-eight ophthalmology organizations accounted for 45 % of revenue and 49 % of expenses. Fifteen cleft lip/palate organizations totaled 26 % of both revenue and expenses. The remaining 117 organizations, representing a variety of specialties, accounted for 29 % of revenue and 25 % of expenses. In comparison, from 2008 to 2013, charitable organizations provided nearly $27 billion for global health, meaning an estimated 11.5 % went towards surgery.ConclusionCharitable organizations that exclusively provide surgery in LMICs primarily focus on elective surgeries, which cover many subspecialties, and often fill deep gaps in care. The largest funding flows are directed at ophthalmology, followed by cleft lip and palate surgery. Despite the number of contributing organizations, there is a clear need for improvement and increased transparency in tracking of funds to global surgery via charitable organizations.

A day in the life of a paediatric surgeon

Objectives This study aimed to create a snapshot picture of the global workload of paediatric surgeons and identify differences between countries. Methods Surgeons from 13 paediatric surgical units in different countries across the world were asked to record the number and type of admissions to the paediatric surgery service over a 24-h period from 8 a.m. on 23 May 2012. Results Data were recorded for 13 units from 13 countries: 11 low and middle income countries (LMICs) and two high-income countries (HICs). Dar es Salaam, Tanzania, had the greatest number of admissions. Two units in HICs had the lowest number of admissions, other than the Nigerian unit, which only had three admissions due to a hospital strike on the day surveyed. The percentage of emergency admissions ranged from 38 to 83%. Those units with the highest number of total admissions tended to also have the highest proportion of emergencies. Trauma was the most frequently reported admission reason, accounting for 18% of admissions. However, there were no cases of trauma in HIC units. Conclusion The spectrum of paediatric surgery differs between countries, in particular between LMICs and HICs. Units in LMICs tend to have a greater number of admissions, including a wider variety of conditions and a higher proportion of emergency work. Paediatric surgery in LMICs faces many challenges. This highlights the importance of training specialist paediatric surgeons in these countries. Further data are still needed to fully outline the burden of disease in paediatric surgery, especially in LMICs. Keywords : epidemiology, global surgery, paediatric surgery

Surgical Non-governmental Organizations: Global Surgery's Unknown Nonprofit Sector.

Charitable organizations may play a significant role in the delivery of surgical care in low- and middle-income countries (LMICs). However, in order to quantify their collective contribution, to account for the care they provide in national surgical plans, and to maximize coordination between organizations, a comprehensive database of these groups is required. We aimed to create such a database using web-available data. We searched for organizations that meet the United Nations Rule of Law definition of non-governmental organizations and provide surgery in LMICs. We termed these surgical non-governmental organizations (s-NGOs). We screened multiple sources including a listing of disaster relief organizations, medical volunteerism databases, charity commissions, and the results of a literature search. We performed a secondary review of each eligible organization's website to verify inclusion criteria and extracted data. We found 403 s-NGOs providing surgery in all 139 LMICs, with most (61%) incorporating surgery into a broader spectrum of health services. Over 80% of s-NGOs had an office in the USA, the UK, Canada, India, or Australia, and they most commonly provided surgery in India (87 s-NGOs), Haiti (71), Kenya (60), and Ethiopia (55). The most common specialties provided were general surgery (184), obstetrics and gynecology (140), and plastic surgery (116). This new catalog includes the largest number of s-NGOs to date, but this is likely to be incomplete. This list will be made publicly available to promote collaboration between s-NGOs, national health systems, and global health policymakers.

Current challenges to urological training in sub-Saharan Africa.

estimates of lower urinary tract symptoms, overactive bladder, urinary incontinence and bladder outlet obstruction. BJU Int 2011; 108: 1132–8 11 Grimes CE, Henry JA, Maraka J, Mkandawire NC, Cotton M. Costeffectiveness of surgery in lowand middle-income countries: a systematic review. World J Surg 2014; 38: 252–63 12 Gosselin RA, Thind A, Bellardinelli A. Cost/DALY Averted in a small hospital in Sierra Leone: what is the relative contribution of different services? World J Surg 2006; 30: 505–11 Correspondence: Nicholas J. Campain, Exeter Surgical Health Services Research Unit – Urology, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, Devon EX2 5DW, UK.

Surgically avertable burden of obstetric conditions in low- and middle-income regions: a modelled analysis.

To quantify the burden of maternal and neonatal conditions in low- and middle-income countries (LMICs) that could be averted by full access to quality first-level obstetric surgical procedures. Burden of disease and epidemiological modelling. LMICs from all global regions. The entire population in 2010. We included five conditions in our analysis: maternal haemorrhage; obstructed labour; obstetric fistula; abortion(1) ; and neonatal encephalopathy. Demographic and epidemiological data were obtained from the Global Burden of Disease 2010 study. We split the disability-adjusted life years (DALYs) of these conditions into surgically 'avertable' and 'non-avertable' burdens. We applied the lowest age-specific fatality rates from all global regions to each LMIC region to estimate the avertable deaths, assuming that the differences of death rates between each region and the lowest rates reflect the gap in surgical care. Deaths and DALYs avertable. Of the estimated 56.6 million DALYs (i.e. 56.6 million years of healthy life lost) of the selected five conditions, 21.1 million DALYs (37%) are avertable by full coverage of quality obstetric surgery in LMICs. The avertable burden in absolute term is substantial given the size of burden of these conditions in LMICs. Neonatal encephalopathy constitutes the largest portion of avertable burden (16.2 million DALYs) among the five conditions, followed by abortion (2.1 million DALYs). Improving access to quality surgical care at first-level hospitals could reduce a tremendous burden of maternal and neonatal conditions in LMICs.

The establishment of a follow-up clinic to monitor patient outcomes for a short-term surgical trip to Haiti

INTRODUCTION: International organizations perform a large volume of surgery in lowand middle-income countries (LMIC) but very few report outcomes data. Among groups performing shortterm humanitarian surgery interventions, complication rates are unknown due to a lack of patient follow-up. As part of a one month Global Surgery Elective, we performed urologic and general surgery procedures at Hospital St. Therese (HST) in Hinche, Haiti. The purpose of this study is to determine if a short-term follow-up clinic is adequate to collect surgical outcomes data that would lead to improvements in patient outcomes.

Charitable platforms in global surgery: a systematic review of their effectiveness, cost-effectiveness, sustainability, and role training.

ObjectiveThis study was designed to propose a classification scheme for platforms of surgical delivery in low- and middle-income countries (LMICs) and to review the literature documenting their effectiveness, cost-effectiveness, sustainability, and role in training. Approximately 28 % of the global burden of disease is surgical. In LMICs, much of this burden is borne by a rapidly growing international charitable sector, in fragmented platforms ranging from short-term trips to specialized hospitals. Systematic reviews of these platforms, across regions and across disease conditions, have not been performed.MethodsA systematic review of MEDLINE and EMBASE databases was performed from 1960 to 2013. Inclusion and exclusion criteria were defined a priori. Bibliographies of retrieved studies were searched by hand. Of the 8,854 publications retrieved, 104 were included.ResultsSurgery by international charitable organizations is delivered under two, specialized hospitals and temporary platforms. Among the latter, short-term surgical missions were the most common and appeared beneficial when no other option was available. Compared to other platforms, however, worse results and a lack of cost-effectiveness curtailed their role. Self-contained temporary platforms that did not rely on local infrastructure showed promise, based on very few studies. Specialized hospitals provided effective treatment and appeared sustainable; cost-effectiveness evidence was limited.ConclusionsBecause the charitable sector delivers surgery in vastly divergent ways, systematic review of these platforms has been difficult. This paper provides a framework from which to study these platforms for surgery in LMICs. Given the available evidence, self-contained temporary platforms and specialized surgical centers appear to provide more effective and cost-effective care than short-term surgical mission trips, except when no other delivery platform exists.

Ratio of Cesarean Deliveries to Total Operations and Surgeon Nationality Are Potential Proxies for Surgical Capacity in Central Haiti

The World Health Organization has a standardized tool to assess surgical capacity in low- and middle-income countries (LMICs), but it is often resource- and time-intensive. There currently exists no simple, evidence-based measure of surgical capacity in these settings. The proportion of cesarean deliveries in regard to the total operations (C/O ratio) has been suggested as a way to assess quickly the capacity for emergency and essential surgery in LMICs. This ratio has been estimated to be between 23.3 and 41.5 % in LMICs, but the tool's utility has not been replicated. We reviewed operative logbooks for the Partners In Health/Zanmi Lasante hospital in Cange, Haiti. We recorded data on all consecutive surgical patients from July 2008 to 2010 and calculated the C/O ratio by dividing the number of cesarean deliveries by the total number of operations performed. We also analyzed surgical data by surgeon nationality to provide additional information about local surgical capacity. A total of 3,641 operations were performed between 2008 and 2010. The C/O ratio decreased significantly between 2008-2009 and 2009-2010 (13.4 vs. 10.7 %, p = 0.001) as the surgical volume and resources increased. Nationality analysis demonstrated that Haitian surgeons were able to provide a spectrum of general and specialist surgical care. In its inherent relation to essential surgical procedures and to the overall rate of cesarean deliveries in the region, the C/O ratio can provide an accessible assessment of regional surgical resources. In Haiti, the change in the C/O ratio demonstrated a relative increase in surgical capacity from 2008 to 2010. An additional analysis of surgeon nationality ensured that C/O ratio estimates more accurately reflect local practitioner activity, but deficiencies in the regional capacity to address the local burden of surgical disease may still exist.

The burden of surgical conditions and access to surgical care in low- and middle-income countries

Surgery is an essential component of health systems but has generally been neglected within global public health. This is despite growing evidence documenting the cost-effectiveness of essential surgical care in low- and middle-income countries (LMICs).1 The overall burden of disease that may be cured, palliated or treated with surgical intervention is large and (probably) rapidly growing, and this concept must therefore be revisited. There are major gaps in knowledge related to surgery in LMICs. What exactly is the burden and distribution of surgical conditions in LMICs? What is the unmet surgical need? What resources (human, financial, physical) are required to improve access to surgical care? What impact would this have on global health disparities, and how does this compare with other interventions? How can essential surgical services be integrated into health systems’ surveillance and evaluation? This paper outlines a research agenda and argues that enough is already known to justify accelerated action.