Surgery In Sub-Saharan Africa Research Articles

The outcomes of paediatric cataract surgery with intraocular lens insertion in sub-Saharan Africa: a systematic review

ImportanceCataract is one of the leading causes of childhood blindness in Africa. The management of this condition requires timely surgical extraction of the cataractous lens with immediate optical correction and long-term follow-up to monitor visual improvement and manage complications that may arise. This review provides an opportunity to benchmark outcomes and to shed light on the reasons for those outcomes.ObjectivesTo review the published literature and report on the outcomes of paediatric cataract surgery with intraocular lens insertion in sub-Saharan Africa.Data sourceThe EMBASE, PubMed, Scopus, and Web of Science were searched for relevant articles.Study selectionWe included all published primary studies from sub-Saharan Africa on cataract surgery outcomes in children aged 0–16 years with primary intraocular lens implantation conducted between 1990 and 2020. Eligible studies were those published in English or for which an English translation was available. In addition, reviewers screened the reference lists of all studies included in the full-text review for eligible studies. During the review, studies fitting the inclusion criteria above except for having been conducted in middle and high-income countries were tagged and placed in a comparison arm.Data extraction and synthesisStudy eligibility was determined by two independent reviewers, and data extraction was conducted by one reviewer with entries checked for accuracy by another reviewer. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for data synthesis were followed. The Joanna Briggs Institute (JBI) critical appraisal checklist was used for quality appraisal of the studies. The statistical software R was used in the analysis, and data were pooled using a random-effects model. Forest plots were generated using the R package ‘metafor’.Main outcomes and measuresThe primary outcome was visual acuity (VA) after cataract surgery and the proportions of eyes that achieved good, borderline, or poor visual outcome according to the World Health Organisation (WHO) categorisation of post-operative visual acuity. The secondary outcome measures reported included lag time to surgery, rates of follow-up, and rate of complications.ResultsEight out of 4763 studies were eligible for inclusion in this review, and seven were included in the quantitative analysis. There was a male preponderance in the study population, and the mean age at the time of cataract surgery ranged from 3.4 to 8.4 years. Visual outcomes were available for short-term visual outcomes (1 to 6 months) as the studies had a significant loss to follow-up. The pooled proportion of eyes that achieved a good visual acuity (i.e. equal to or greater than 6/18) in the short-term period was 31% (CI, 20–42). The comparative studies from middle and high-income countries reported proportions ranging from 41 to 91%, with higher thresholds for good visual acuity of 6/12 and 6/15.Conclusion and relevanceThis review reports that there is a lower proportion of eyes with good outcomes after undergoing paediatric cataract surgery in sub-Saharan Africa than in middle- and high-income countries. Furthermore, this review states that there is a high proportion of patients lost to follow-up and suboptimal refractive correction and amblyopia treatment after paediatric cataract surgery.

Risk factors associated with surgical site infection following orthopaedic surgery in South Africa and Sub-Saharan Africa: a scoping review protocol.

The objective of the scoping review will be to understand and describe risk factors associated with surgical site infection (SSI) in an orthopaedic surgery population in Sub-Saharan Africa and South Africa. This paper describes the protocol that will be used for the scoping review. A comprehensive literature search will be conducted using MEDLINE (PubMed), CINAHL (EBSCO), Embase and Cochrane Libraries to identify articles meeting the inclusion criteria, including both published and grey literature, in order to provide a broad overview of the reported risk factors associated with patients who have undergone an orthopaedic surgery with an outcome of SSI within 90 days of a procedure. Additional studies will be sourced by exploring the reference list of included eligible studies. By using a combination of the Population, Exposure, Outcome framework, terms and synonyms related to each category, in different variations, along with Boolean operators (AND, OR, NOT) in the search strategy, identified comprehensive and relevant literature for the scoping review. It is anticipated the results will provide a baseline of risk factors that will inform the development of a risk assessment tool for clinical use. This protocol will inform the development of a scoping review to describe factors associated with SSIs following orthopaedic surgery in Sub-Saharan Africa and South Africa.

Metagenomic sequencing of the skin microbiota of the scalp predicting the risk of surgical site infections following surgery of traumatic brain injury in sub-Saharan Africa.

Surgical site infections (SSI) are a significant concern following traumatic brain injury (TBI) surgery and often stem from the skin's microbiota near the surgical site, allowing bacteria to penetrate deeper layers and potentially causing severe infections in the cranial cavity. This study investigated the relationship between scalp skin microbiota composition and the risk of SSI after TBI surgery in sub-Saharan Africa (SSA). This was a prospective cohort study, enrolling patients scheduled for TBI surgery. Sterile skin swabs were taken from the surrounding normal skin of the head and stored for analysis at -80°Celcius. Patients were monitored postoperatively for up to three months to detect any occurrences of SSI. 16S rRNA sequencing was used to analyze the skin microbiota composition, identifying different taxonomic microorganisms at the genus level. The analysis compared two groups: those who developed SSI and those who did not. A total of 57 patients were included, mostly male (89.5%) with a mean age of 26.5 years, predominantly from urban areas in Uganda and victims of assault. Graphical visualization and metagenomic metrics analysis revealed differences in composition, richness, and evenness of skin microbiota within samples (α) or within the community (β), and showed specific taxa (phylum and genera) associated with either the group of SSI or the No SSI. Metagenomic sequencing analysis uncovered several baseline findings and trends regarding the skin microbiome's relationship with SSI risk. There is an association between scalp microbiota composition (abundancy and diversity) and SSI occurrence following TBI surgery in SSA. We hypothesize under reserve that the scalp microbiota dysbiosis could potentially be an independent predictor of the occurrence of SSI; we advocate for further studies with larger cohorts.

The Impact of the COVID-19 Pandemic on Reconstructive Surgery and Training Programs in Sub-Saharan Africa: A Cross-Sectional Survey.

In Sub-Saharan Africa, which already faces challenges due to a lack of surgeons and facilities, the COVID-19 pandemic could significantly disrupt surgical activities and training programs. "2nd Chance", a non-governmental organization providing training program to enhance local reconstructive surgery capacity in this region since 2015, could play a crucial role in addressing these issues. We aimed to investigate the impact of the COVID-19 on the activity of sub-Saharan African reconstructive surgeons collaborating with "2nd Chance" organization and evaluate its effect on the organization's training programs. In the course of 2022, an online cross-sectional survey was conducted among reconstructive surgeons working in sub-Saharan African countries and collaborating with "2nd Chance". The survey consisted of 57 questions covering demographics, impacts of COVID-19 on personal life, clinical and training activities. Of 469 surgeons eligible for the study, 240 were included and 51 responded. The impact of COVID-19 was felt personally in terms of health and stress. Clinical activities were severely affected, with some reporting higher mortality due to surgical cancellations and delays. Regarding training, there was a shift from practical to theoretical learning, though overall impact was moderate. One-third of participants were able to attend "2nd Chance" workshops. Among the 17 planned workshops, 9 were successfully conducted, and 4 of them exclusively featured African trainers. The COVID-19 pandemic had substantial consequences on reconstructive surgery in sub-Saharan Africa, impacting more clinical practices than training programs. Collaboration between African and European trainers proved essential during the pandemic. In future pandemics, South-South collaborations should be prioritized.

Out-of-pocket costs and catastrophic healthcare expenditure for families of children requiring surgery in sub-Saharan Africa

BackgroundOut-of-pocket healthcare costs leading to catastrophic healthcare expenditure pose a financial threat for families of children undergoing surgery in Sub-Saharan African countries, where universal healthcare coverage is often insufficient. MethodsA prospective clinical and socioeconomic data collection tool was used in African hospitals with dedicated pediatric operating rooms installed philanthropically. Clinical data were collected via chart review and socioeconomic data from families. The primary indicator of economic burden was the proportion of families with catastrophic healthcare expenditures. Secondary indicators included the percentage who borrowed money, sold possessions, forfeited wages, and lost a job secondary to their child’s surgery. Descriptive statistics and multivariate logistic regression were performed to identify predictors of catastrophic healthcare expenditure. ResultsIn all, 2,296 families of pediatric surgical patients from 6 countries were included. The median annual income was $1,000 (interquartile range 308–2,563), whereas the median out-of-pocket cost was $60 (interquartile range 26–174). Overall, 39.9% (n = 915) families incurred catastrophic healthcare expenditure, 23.3% (n = 533) borrowed money, 3.8% (n = 88%) sold possessions, 26.4% (n = 604) forfeited wages, and 2.3% (n = 52) lost a job because of the child’s surgery. Catastrophic healthcare expenditure was associated with older age, emergency cases, need for transfusion, reoperation, antibiotics, and longer length of stay, whereas the subgroup analysis found insurance to be protective (odds ratio 0.22, P = .002). ConclusionA full 40% of families of children in sub-Saharan Africa who undergo surgery incur catastrophic healthcare expenditure, shouldering economic consequences such as forfeited wages and debt. Intensive resource utilization and reduced insurance coverage in older children may contribute to a higher likelihood of catastrophic healthcare expenditure and can be insurance targets for policymakers.

Critical shortage of capacity to deliver safe paediatric surgery in sub-Saharan Africa: evidence from 67 hospitals in Malawi, Zambia, and Tanzania.

Paediatric surgical care is a significant challenge in Sub-Saharan Africa (SSA), where 42% of the population are children. Building paediatric surgical capacity to meet SSA country needs is a priority. This study aimed to assess district hospital paediatric surgical capacity in three countries: Malawi, Tanzania and Zambia (MTZ). Data from 67 district-level hospitals in MTZ were collected using a PediPIPES survey tool. Its five components are procedures, personnel, infrastructure, equipment, and supplies. A PediPIPES Index was calculated for each country, and a two-tailed analysis of variance test was used to explore cross-country comparisons. Similar paediatric surgical capacity index scores and shortages were observed across countries, greater in Malawi and less in Tanzania. Almost all hospitals reported the capacity to perform common minor surgical procedures and less complex resuscitation interventions. Capacity to undertake common abdominal, orthopaedic and urogenital procedures varied-more often reported in Malawi and less often in Tanzania. There were no paediatric or general surgeons or anaesthesiologists at district hospitals. General medical officers with some training to do surgery on children were present (more often in Zambia). Paediatric surgical equipment and supplies were poor in all three countries. Malawi district hospitals had the poorest supply of electricity and water. With no specialists in district hospitals in MTZ, access to safe paediatric surgery is compromised, aggravated by shortages of infrastructure, equipment and supplies. Significant investments are required to address these shortfalls. SSA countries need to define what procedures are appropriate to national, referral and district hospital levels and ensure that an appropriate paediatric surgical workforce is in place at district hospitals, trained and supervised to undertake these essential surgical procedures so as to meet population needs.

Unheard voices of global surgery – trauma services in sub-Saharan Africa: a correspondence

Dear Editor, According to the 2015 Global Burden of Disease (GBD) study, an estimated 4.8 million people die as a result of trauma each year, accounting for 8.5% of global deaths1. As a result, it is estimated that more than 90% of these deaths occur in low-income and middle-income countries2. Road traffic injuries account for ~7.7% of all disability-adjusted life years, with sub-Saharan Africa (SSA) having the highest rate of accident-related mortality2. For example, in 2019, Ethiopia, Uganda, Zimbabwe, and South Africa had the highest proportion of injury-related deaths2. At least one-third of these deaths are attributable to a lack of access to trauma surgery, which results in avoidable mortality, morbidity, and lost productivity in the region, perpetuating the vicious cycle of socioeconomic inequity3. Since Farmer and Kim4 described surgery in 2008 as a “neglected stepchild of global public health,” global surgery has become a field of immense interest and landmark research. Although SSA bears the brunt of trauma cases, there has been significant progress in trauma case management in recent years. This can be seen in the establishment of a partnership program between trauma care instructors from the United Kingdom and trauma care trainees from nine different SSA countries5. The program was called COSECSA-Oxford-Orthopedic-Link (COOL) which trained 540 doctors, 260 nurses, 119 clinical officers, and 111 medical students in primary trauma care in SSA5. Furthermore, the World Health Organization (WHO), in collaboration with the International Society of Surgery (ISS) and the International Association for Trauma Surgery and Intensive Care (IATSIC), has made significant efforts to develop quality improvement programs for better trauma management, particularly in low-resource settings6. Despite widespread recognition and efforts, trauma services in SSA continue to be underrepresented on the international stage, as their needs go unmet7. There is little research on trauma surgery in SSA resulting in a scarcity of data in the field to critically assess its needs. More so, SSA had the lowest authorship contribution per article in collaboration on surgical research, with trauma surgery being the least represented specialty within global surgery7,8. While disparities with high-income countries are acknowledged, internal disparities should also be noted. In SSA, trauma care is distributed inequitably. Access to high-quality trauma care is readily available in urban areas and among populations with a higher socioeconomic status, whereas rural and lower-class regions have limited or no access despite a higher demand for trauma care in these rural areas2. These disparities are caused by differences due to socioeconomic status, sex, age, physical disability, sexual orientation, and geographic location2. The underdeveloped trauma care management in SSA is primarily due to a lack of infrastructure and a skilled health workforce. In addition, limited trauma care training and education, insufficient funds and poor health insurance schemes, a lack of necessary logistics and equipment, and a high brain drain of trauma care personnel are all factors impeding trauma care progress in SSA2. In view of the foregoing, it is crucial to imply strategies to improve trauma care services in SSA. Of note, is the need for improved investment in updating the current health infrastructure as the limited availability of trauma personnel and resources often impedes access to life-saving care. SSA could consider establishing specialized trauma centers that offer comprehensive care to trauma patients. Besides, training the primary care team to manage basic trauma cases can considerably help reduce morbidity and mortality from injuries and trauma in SSA, especially in areas with limited availability of trauma surgeons. Establishing international partnerships and collaborations with trauma centers worldwide can further improve visibility and open opportunities for educational and vocational training. These measures can considerably improve trauma workforce capacity, a step towards standardized trauma care delivery in SSA. In addition, regular quality monitoring audits can help identify relevant (international, national, and local) issues faced in everyday trauma practice, as well as guide potential solutions to improve care provision locally. Results obtained by these audits and quality improvement surveys can promote public health policy reform and ultimately up-to-date clinical practice guidelines that address the current trauma needs of the SSA region. Therefore, identifying and addressing the unique challenges faced in trauma care provision is of paramount significance in reducing morbidity and mortality from otherwise treatable injuries in the SSA region. Ethical Approval and Consent to Participate Not applicable Funding None. Authors’ Contributions A.M.: Conceptualization ideas: All authors were involved in data curation, writing of initial draft, review and editing, final draft. Conflicts of Interest Statement Authors declare no conflict of interest. Consent for publication Not applicable. Availability of supporting data No new data generated. Research Registration Unique Identifying Number (UIN) None. Conflicts of interest The authors declare that they have no financial conflict of interest with regard to the content of this report. Guarantor Wireko Andrew Awuah.

Inguinal hernia surgery learning curves by associate clinicians

BackgroundOpen inguinal hernia repair is the most commonly performed procedure in general surgery in sub-Saharan Africa, but data on its learning curve are lacking. This study evaluated the learning curve characteristics to improve surgical training and enable scaling up hernia surgery in low- and middle-income countries.MethodsLogbook data of associate clinicians enrolled in a surgical training program in Sierra Leone were collected and their first 55 hernia surgeries following the Bassini technique (herniorrhaphies) were analyzed in cohorts of five cases. Studied variables were gradient of decline of operating time, variation in operating time, and length of stay (LOS). Eleven subsequent cohorts of each five herniorrhaphies were investigated.ResultsSeventy-five trainees enrolled in the training program between 2011 and 2020 were eligible for inclusion. Thirty-one (41.3%) performed the minimum of 55 herniorrhaphies, and had also complete personal logbook data. Mean operating times dropped from 79.6 (95% CI 75.3–84.0) to 48.6 (95% CI 44.3–52.9) minutes between the first and last cohort, while standard deviation in operating time nearly halved to 15.4 (95% CI 11.7–20.0) minutes, and LOS was shortened by 3 days (8.5 days, 95%CI 6.1–10.8 vs. 5.4 days, 95% 3.1–7.6). Operating times flattened after 31–35 cases which corresponded with 1.5 years of training.ConclusionsThe learning curve of inguinal hernia surgery for associate clinicians flattens after 31–35 procedures. Training programs can be tailored based on this finding. The recorded learning curve may serve as a baseline for future training techniques.

Adult groin hernia surgery in sub-Saharan Africa: a 20-year systematic review and meta-analysis.

To realize a systematic review to evaluate groin hernia surgery for adults in sub-Saharan Africa. We conducted a systematic review and meta-analysis, the primary objective of which was to determine the surgical techniques used for unilateral groin hernia surgery in sub-Saharan Africa. Studies published in the last 20years were considered. A meta-analysis estimated the pooled prevalence with 95% confidence interval (CI) of mortality, chronic pain and recurrence. A subgroup analysis compared the rate of complications between complicated or uncomplicated hernia. We included 113 articles. The most used technique was Bassini in 40.1%, followed by Lichtenstein in 29.9% and Shouldice in 12.6%. The overall mortality rate was 0.6% (95% CI 0.4-0.9). The pooled recurrence rate was 1.4% (95% CI 1.05-1.9). The pooled rate of chronic pain was 2.7% (95% CI 1.9-3.7). We found that mortality rate for complicated hernias (6.4%) was higher compared to uncomplicated hernias (0.2%). This difference was statistically significant [p ≤ 0.001; OR = 47.7; 95 CI (27.2-83.47)]. This review showed that pure tissue repairs are the most used techniques with Bassini and Shouldice as leading procedures. The post-operative rates of recurrence and chronic pain are low. However, there is a high heterogeneity between studies than can underestimate these pooled prevalences. The consultation at complication stage remains frequent and associated with a higher mortality. Futures studies should focus on improving the quality of studies in terms of design and follow-up to increase the degree of evidence.

The true costs of cesarean delivery for patients in rural Rwanda: Accounting for post-discharge expenses in estimated health expenditures

IntroductionWhile it is recognized that there are costs associated with postoperative patient follow-up, risk assessments of catastrophic health expenditures (CHEs) due to surgery in sub-Saharan Africa rarely include expenses after discharge. We describe patient-level costs for cesarean section (c-section) and follow-up care up to postoperative day (POD) 30 and evaluate the contribution of follow-up to CHEs in rural Rwanda.MethodsWe interviewed women who delivered via c-section at Kirehe District Hospital between September 2019 and February 2020. Expenditure details were captured on an adapted surgical indicator financial survey tool and extracted from the hospital billing system. CHE was defined as health expenditure of ≥ 10% of annual household expenditure. We report the cost of c-section up to 30 days after discharge, the rate of CHE among c-section patients stratified by in-hospital costs and post-discharge follow-up costs, and the main contributors to c-section follow-up costs. We performed a multivariate logistic regression using a backward stepwise process to determine independent predictors of CHE at POD30 at α ≤ 0.05.ResultsOf the 479 participants in this study, 90% were classified as impoverished before surgery and an additional 6.4% were impoverished by the c-section. The median out-of-pocket costs up to POD30 was US$122.16 (IQR: $102.94, $148.11); 63% of these expenditures were attributed to post-discharge expenses or lost opportunity costs (US$77.50; IQR: $67.70, $95.60). To afford c-section care, 64.4% borrowed money and 18.4% sold possessions. The CHE rate was 27% when only considering direct and indirect costs up to the time of discharge and 77% when including the reported expenses up to POD30. Transportation and lost household wages were the largest contributors to post-discharge costs. Further, CHE at POD30 was independently predicted by membership in community-based health insurance (aOR = 3.40, 95% CI: 1.21,9.60), being a farmer (aOR = 2.25, 95% CI:1.00,3.03), primary school education (aOR = 2.35, 95% CI:1.91,4.66), and small household sizes had 0.22 lower odds of experiencing CHE compared to large households (aOR = 0.78, 95% CI:0.66,0.91).ConclusionCosts associated with surgical follow-up are often neglected in financial risk calculations but contribute significantly to the risk of CHE in rural Rwanda. Insurance coverage for direct medical costs is insufficient to protect against CHE. Innovative follow-up solutions to reduce costs of patient transport and compensate for household lost wages need to be considered.

Goiter surgery recommendations in sub-Saharan Africa in humanitarian cooperation.

BackgroundThe standard treatment for endemic goiter is usually total thyroidectomy. In low‐ and middle‐income countries, the management of thyroid disease, which is commonplace in fully developed countries, is not always possible. The purpose of this study is to establish a treatment algorithm to calculate the extent of thyroidectomy based on the risk factors of each patient.MethodsThis is a retrospective observational study conducted during the period between 2017 and 2019. A total of 287 patients with thyroid pathology were treated in Maragua Hospital (Kenya). The results of surgical treatment were analyzed after the implementation of an individualized treatment protocol.ResultsOne hundred and sixty patients with different types of goiter underwent surgery: solitary nodule (54.4%), multi‐nodular goiter (30.6%), diffuse goiter (10.6%), and intrathoracic goiter (3.8%). The techniques used were hemithyroidectomy (78.8%), Dunhill thyroidectomy (9.4%), bilateral subtotal thyroidectomy (6.9%), and total thyroidectomy (3.1%). There was no mortality. The surgical morbidity rate was 16% (only one major complication (3b)). Two cases of dysphonia were resolved in the first week. There were three cases of symptomatic hypocalcaemia, two of which resolved in the first week and the other of which was definitive. The follow‐up at 6 months was 67%. The cancer rate found in the resection specimens was 5%.DiscussionThe implementation of individualized surgical protocols for thyroid surgery in sub‐Saharan Africa can improve outcomes. The cooperation projects can increase access to complex surgical treatment for patients with limited resources in low‐ and middle‐income countries.

The expected indications for video-assisted thoracoscopic surgery in Sub-Saharan Africa

Video-assisted thoracoscopic surgery (VATS) in Sub-Saharan Africa (SSA) is still an evolving surgical procedure that can be used for well-selected patients to treat various pathologies such as pleural disease, lung pathology, esophageal disease, diaphragmatic pathology, mediastinal disease, and other conditions. From the review of literature, over the years, for which VATS has been in use showed that SSA with a good sizeable population has still not embraced the surgical procedure. This is so despite the wide spectrum of diseases and clinical conditions in the region for which VATS can conveniently be applied in other to improve post-operative outcome and reduce post-operate mortality rate. Thus, this review should be a wakeup call for the region and to stimulate the desire in them to make consistent efforts by training doctors and putting the necessary infrastructures in place to ensure the adoption of this method of medical and surgical practice as it decreases post-operative complications and post-operative mortality rates.

Delays to essential surgery at four faith based hospitals in rural Sub-Saharan Africa.

Data regarding delays for emergency surgery in Sub-Saharan Africa is limited. We have therefore decided to undertake an evaluation of delays in patients seeking care, reaching care and receiving care for emergency surgery at four rural faith-based hospitals in this region over a 3 month period. This is a cross-sectional, multi-center, international study at four rural faith-based hospitals in Madagascar, Gabon, Cameroon and Burundi. All patients presenting at these hospitals between 10 February and 1 May 2020 for one of the three Bellwether procedures (caesarean delivery, emergency laparotomy, management of open fracture) were to be enrolled in this study. Data was collected in the form of a questionnaire administered to the patient or the patient's caregiver within 24 h of admission to the hospital. After analysis of data for 148 patients, we found that the median [quartiles] delay in seeking care overall was 3.5 [0.5, 17.6] h, in reaching care 7.6 [2.3, 33.6] h and in receiving care 3.6 [1.7, 6.8] h. In 72% (107/148) of cases, the second delay was more than 2h. Sixty-five percent of patients who were delayed reported that their delay was because care was sought elsewhere before arrival at one of our Bellwether-capable sites. Our results suggest that the majority of patients needing emergency surgical care in the rural areas of Sub-Saharan Africa where our study was conducted are frequently delayed, with the largest delay being in reaching care. Further investigations into the reasons for these delays should be conducted.

Narrative review in pediatric and congenital heart surgery in sub-Saharan Africa: challenges and opportunities in a new era

Narrative review in pediatric and congenital heart surgery in sub-Saharan Africa: challenges and opportunities in a new era

Large Post-Surgical Incisional Hernias: Case Reports and a Review of Barriers Against Early Presentation and Refusal to Consent to Surgery

Incisional hernias, otherwise known as postoperative ventral hernias, are post-surgical fascial defects in the abdominal wall through which fat and viscera protrude. They are preventable causes of morbidity and mortality commonly encountered in our environment. Only a few patients with incisional hernia seek medical advice and only a handful of them consent to a surgical repair, even in the presence of complications, due to the high cost of treatment and disappointment from previous surgery. In this case series, two patients with complicated large long-standing post-surgical incisional hernias, who declined surgical repairs are presented, and the barriers to early presentation and factors responsible for refusal to consent to surgery in sub-Saharan Africa reviewed.

Is abdominal hysterectomy still the surgery of choice in sub‐Saharan Africa?

A trend toward minimally invasive surgery is increasing worldwide. However, reports on the extent and the role of vaginal or laparoscopic hysterectomy in benign gynecologic surgery in sub-Saharan Africa are scarce. Our commentary aims to highlight the existing gaps and potential barriers to implementation of vaginal or laparoscopic hysterectomy and suggests how to introduce and expand minimally invasive gynecologic surgery in this region. Little documentation exists in the literature to account for the role of minimally invasive surgery in the sub-Saharan Africa. Hysterectomy for benign reasons is commonly performed by the abdominal approach. This approach is accompanied by significant complications, prolonged hospitalization, and longer recovery duration. Our commentary highlights the importance of investigating region-specific barriers to the practice of minimally invasive gynecologic surgery in sub-Saharan Africa.

Open-Heart Surgery in Low-Income Settings: The Experience of <i>Salam</i> Centre for Cardiac Surgery in Sudan (2007–2019)

Background: Despite the need for cardiac surgery in Sub-Saharan Africa, access is still very limited. Active since 2007, the Salam Centre for Cardiac Surgery, run by EMERGENCY NGO and co-financed by the Sudanese government, offers heart surgery free of charge. Methods: Retrospective cohort study of 8369 consecutive patients undergoing open-heart surgery between 2007 and 2019, from Sudan (81%) and from neighbouring countries (19%). Findings: Rheumatic heart disease (RHD) was prevalent in 80% of adults (median age 28, Q1-Q3 20-37); with 43% isolated mitral, 11% aortic and 46% multiple valve procedures. Out of the 1396 (17%) patients with congenital heart disease (CHD), 74% were children (< 15 years). Continuity over the years and the low hospital/ 30 days mortality (2·9% RHD; 3·4% CHD) reflect the quality of in-hospital care. Outpatient and oral anticoagulation clinics ensured care after discharge, leading to a 5-years loss-to-follow-up for RHD patients of 18% and a 5-years overall survival of 89.6% (95% CI: 88.9-90.3), with values over 90% for MV and AV surgeries . The programme has also provided training for more than 400 local healthcare workers (2013–2019). Interpretation: The overall favorable results strongly support the original hypothesis that quality, gratuity, and long-term commitment represent the key elements in the collaboration between a humanitarian independent NGO and institutional actors, paving the way for wider, sustainable developments. Funding: The SALAM Centre is funded by EMERGENCY-NGO and by the Sudanese Government. The average Government Contribution in 2007-2019 amounts to 32% of the project’s overall costs, reaching 50% in 2014-2017. Declaration of Interest: We declare no competing interests. Ethical Approval: The institutional ethics board of the University of Milan have approved this study and, due to the nature of retrospective chart reviews, waived the need for informed consent from individual patients.

Challenges in healthcare financing for surgery in sub-Saharan Africa.

One-third of the global burden of disease is attributed to surgical conditions yet, 5 billion people globally, lack access to surgery. The Lancet Commission on Global Surgery, Obstetrics, and Anesthesia (LCOGS) published guidelines for improving access by reducing catastrophic health expenditures (CHEs) by 2030. This is especially important in sub-Saharan Africa (SSA) where 90% of the extreme poor reside. In this paper, we provide a narrative review of four studies on CHEs for surgical care in SSA published since 2015. We discuss healthcare financing in the countries and summarize the authors’ key findings of out-of-pocket payments (OOP) and CHEs. Briefly, the studies enrolled 130 to 300 patients and collected direct OOPs via chart review of health costs or patient interviews. Indirect costs were calculated from lost wages and transportation costs. CHEs were defined as health costs exceeding 10% of the GDP per capita or the household income. Despite healthcare being reported as free in all studies, 60%-90% of surgical patients had CHEs with all costs considered. OOPs persists for medicines and anesthesia that should be covered under any health insurance scheme. In some cases, indirect costs associated with transportation and wages were major drivers of CHEs for surgery. Without addressing these gaps in coverage, more people will risk impoverishment in seeking surgical care in SSA.

Developing an African cardiothoracic surgery database

Purpose: There is a paucity of dependable clinical data in most countries performing heart surgery in sub-Saharan Africa, making it difficult therefore to adequately identify and address challenges that may contribute to poor outcomes. The article aims at creating awareness and advocating for collaborative efforts for developing database for measuring cardiovascular surgical activities in Africa. Developing an African cardiothoracic surgery database with pooled datasets similar to the practice in other continents may help mitigate against these challenges and improve clinical outcomes. Methods: Through concerted efforts by electronic communication the authors working in six sub-regions of Africa have supported this initiative by providing their data on surgery of congenital and rheumatic heart diseases for evaluation. Results: 213 heart centres from 27 countries of Africa (6 sub-regions: North Africa (including the Maghreb- Algeria, Morocco and Tunesia), East Africa, The Horn, Central Africa, West Africa and Southern Africa) were identified. Of these 75 heart centres including 35 congenital and paediatric cardiac units in sub-Saharan Africa (SSA) excluding South Africa were performing heart procedures independently or with support from visiting charity heart missions. Six selected countries of SSA (population of 147,8 million) with six paediatric cardiac units performed 660 open heart surgeries (OHS) for congenital and rheumatic heart diseases in 2019 which project a ratio of 4.5 OHS/per million. In comparison to reported PASCaTS data from 2014, valve repair has increased from 10-30% and the rate of valve replacement has decreased from 90% to 70%. Conclusion: The AfriCaTS database initiative is a wake-up call for joint efforts to develop the most needed south-south cooperation for sharing cardiovascular surgical data and outcomes. A continuing educational program (online or on-site) for the personnel engaged in this project at the African centres will be necessary to achieve efficiency and sustainability. The project will positively impact on patient care, outcomes, capacity building programs, inspire reskilling in complex procedures and research. Membership to the AfroCaTS database working group is open to all heart centres in Africa.

Best Buy in Public Health or Luxury Expense?: The Cost-effectiveness of a Pediatric Operating Room in Uganda From the Societal Perspective.

To determine the cost-effectiveness of building and maintaining a dedicated pediatric operating room (OR) in Uganda from the societal perspective. Despite the heavy burden of pediatric surgical disease in low-income countries, definitive treatment is limited as surgical infrastructure is inadequate to meet the need, leading to preventable morbidity and mortality in children. In this economic model, we used a decision tree template to compare the intervention of a dedicated pediatric OR in Uganda for a year versus the absence of a pediatric OR. Costs were included from the government, charity, and patient perspectives. OR and ward case-log informed epidemiological and patient outcomes data, and measured cost per disability adjusted life year averted and cost per life saved. The incremental cost-effectiveness ratio (ICER) was calculated between the intervention and counterfactual scenario. Costs are reported in 2015 US$ and inflated by 5.5%. In Uganda, the implementation of a dedicated pediatric OR has an ICER of $37.25 per disability adjusted life year averted or $3321 per life saved, compared with no existing operating room. The ICER is well below multiple cost-effectiveness thresholds including one times the country's gross domestic product per capita ($694). The ICER remained robust under 1-way and probabilistic sensitivity analyses. Our model ICER suggests that the construction and maintenance of a dedicated pediatric operating room in sub-Saharan Africa is very-cost effective if hospital space and personnel pre-exist to staff the facility. This supports infrastructure implementation for surgery in sub-Saharan Africa as a worthwhile investment.