Surgery In Sub-Saharan Africa Research Articles

Initial Experience with Open Heart Surgery in Sub-Saharan Africa: Challenges in Mali with Minimum Standards for Practice

Introduction: There has been limited experience with Open Heart Surgeries (OHS) in Sub-Saharan Africa. In west Africa especially in Mali, most fledgling centers are unable to overcome the myriad of challenges encountered in establishing OHS though there is a high prevalence of surgically correctable heart diseases. The aim of this paper is to review our initial experience of our first cases in developing OHS program and discuss the challenges and prospects that need to be overcome to further develop it. Methods: A total of 6 patients who underwent OHS during the first “cardiac mission” in July 2016 were included in this retrospective study. The medical records of the patients were examined and data on age, sex, diagnosis, EuroSCORE, type of surgery, cardiopulmonary bypass details, complications and length of hospital stay were extracted. Results: Six patients with a male to female ratio of 1, ages ranging between 12 and 35 years (mean of 22.5 ± 12 years) were studied. The mean of EuroSCORE was 6 ± 41. Pericardial patch closure of isolated atrial septal defect was performed in one patient. One patient had mitral valve repair for rheumatic mitral regurgitation consisting of chordal shortening with a tricuspid valvuloplasty. Three patients had mitral valve replacement with tricuspid valvuloplasty. Four patients had mitral valve replacement. Sixty-day mortality was 0%. Conclusion: Safe conduct of open heart surgery in Mali Hospital setting is feasible. Grant financial aid is required for rapid growth of Open-Heart Surgery in this part of Sub-Saharan Africa.

Rehabilitation and Reintegration Programming Following Female Genital Fistula Surgery: A Scoping Review

Aims: To examine the range of rehabilitation and reintegration services provided as adjunct to genital fistula surgery, map the existing programming and outcomes, and identify areas where additional research is necessary.
 Methods: Our scoping review is informed by existing methodological frameworks and conducted in accordance with PRISMA guidelines.The search strategy was designed in collaboration with a medical librarian and is applied to nine biomedical, public health, and social science databases. Grey literature is identified through targeted searches and relevant organizational websites. Two primary reviewers independently screened titles and abstracts of all articles, followed by full-text screening and standardized data extraction. Eligible articles will discuss research or programmatic efforts around service provision in adjunct to surgery.
 Results: The literature review is currently underway and preliminary results including summary tables and narrative will be available to share at the ISOFS conference.
 Conclusions: The results of this scoping review will help in understanding and describing what is known and unknown about rehabilitation and social reintegration of women following genital fistula surgery in sub-Saharan Africa and may be useful in developing and evaluating social reintegration projects.

Universal Access to Surgical Care and Sustainable Development in Sub-Saharan Africa: A Case for Surgical Systems Research Comment on "Global Surgery - Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa".

National level experiences, lessons learnt from the Millennium Development Goal (MDG) era coupled with the academic evidence and proposals generated by the Lancet Commission on Global Surgery (LCoGS) together with the economic arguments and recommendations from the World Bank Group’s "Essential Surgery" Disease Control Priorities (DCP3) publication, provided the impetus for political commitments to improve surgical care capacity at the primary level of the healthcare system in low- and middle-income countries (LMICs) as part of their drive towards universal health coverage (UHC) in the form of World Health Organization (WHO) Resolution A68.15. This global commitment from governments must be followed up with development of a Global Action Plan and a global coordination mechanism supported by regional implementation frameworks on the part of the WHO in order for the organisation to better coordinate all stakeholders and sustain the technical support needed to develop and implement national surgical health policy in the form of National Surgical Obstetric and Anaesthesia Plans (NSOAPs). As expounded by Gajewski et al, data and research output on surgical care is essential to informing policy development and programme implementation. This area still remains a challenge in sub-Saharan Africa (SSA) but it is envisaged that countries will include this key component in their ongoing national surgical healthcare policy development and programme implementation. In the Zambian case study, research in the area of Global Surgery investment-the surgical workforce scale-up is used to demonstrate the important role of implementation research in the development and implementation of the Zambian NSOAP as well as the need for international collaborations to this end. Scale-up reviews informed by implementation research to evaluate progress on the commitments contained in Resolution A68.15 and Decision A70.22 are essential to sustain the momentum and to help maintain focus on the gaps in all countries. There are opportunities for non-state actors especially local sub-regional academic institutions, non-governmental organizations (NGOs) and private sector to play a key role in surgical healthcare policy development and implementation research. Collection of and better information management of standardised surgical care indicators is essential for such research, for bi-annual WHO progress reporting and for demonstration of impact to justify and encourage further investments in surgical care.

The National Surgical, Obstetric, and Anesthesia Plan (NSOAP): Recognition and Definition of an Empirically Evolving Global Surgery Systems Science Comment on "Global Surgery - Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa".

In 2015, the Lancet Commission on Global Surgery (LCoGS) working groups developed a National Surgical, Obstetric, and Anesthesia Plan (NSOAP) framework to guide national surgical system development globally predicated on six data points (indicators) which can assess surgical systems. Zambia as well as other subSaharan Africa (SSA) countries have forged ahead in designing and implementing interventions based on LCoGS indicators collected to inform NSOAP. Concurrently, the Zambian team and others have recognized the need for rigorous scientific inquiry to assess and iteratively improve upon the NSOAP process and outputs. Based on the Zambian experience, as well as that of ours in Colombia, we have identified "core principles" through convergent works which inform a scientific framework through which NSOAP can be evaluated. We propose that when contextualized, participatory action research (PAR) and dissemination and implementation science are methodologies upon which a robust framework can be developed to achieving objective and iterative NSOAP evaluation, and ultimately universal health coverage as envisioned by the World Health Organization (WHO).

Global Surgery – Redirecting Strategies for a Global Research Agenda Comment on "Global Surgery – Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa"

More than three years have passed since the publication of the Lancet Commission on Global Surgery and its recommendations on scaling up surgery in sub-Saharan Africa (SSA). An important gap, the voice of the districts as well as lack of contextualized research, has been noted in its support of national surgical plans that run the risk of being at best, aspirational. Moreover, a ‘one-size-fits-all approach’ may not adequately address country-specific challenges on the ground. There is a need to redirect attention, effort, and funding in creating a global mechanism to gather baseline country information documenting every single district level government health facility’s ability and readiness to provide safe surgical, obstetric, trauma, and anesthesia care using the World Health Organization (WHO) Service Availability and Readiness Assessment (SARA) tool to aid in directing country-specific efforts in surgical systems strengthening and ensuring that a basic package of essential surgical and anesthesia services is made available to each citizen with adequate financial protection by 2030. This global mechanism will enable benchmarking, accountability, and streamlining of the work of the global surgical community to achieve true progress in scaling up surgery not only in SSA, but for the rest of the developing world.

Progress in Global Surgery Comment on "Global Surgery - Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa".

Impressive progress has been made in global surgery in the past 10 years, and now serious and evidence-based national strategies are being developed for scaling-up surgical services in sub-Saharan Africa. Key to achieving this goal requires developing a realistic country-based estimate of burden of surgical disease, developing an accurate estimate of existing need, developing methods, rigorously planning and implementing the plan, and scaling-up essential surgical services at the national level.

Local Research Catalyzes National Surgical Planning Comment on "Global Surgery - Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa".

In 2015 the Lancet Commission on Global Surgery (LCoGS) argued that surgical care is important to national health systems along with the economic viability of countries. Gajewski and colleagues outlined how the Commission’s blueprint has been implemented in sub-Saharan Africa, including two funded research projects that were integrated into national surgical plans. Here, we outline how the five processes proposed by Gajewski and colleagues are critical to integrate research, policy, and on-the-ground implementation. We also propose that, moving forward, the most pressing adjunct in many low- and middle-income countries (LMICs) may be a better characterization of rural surgical practices through rigorous research along with models that enable lessons to inform national policy.

Patient Safety in Surgery in Sub-Saharan Africa: A Multi-Method Evaluation of Perioperative Practice and Safety Culture at AaResource-Poor Rural Hospital

Patient Safety in Surgery in Sub-Saharan Africa: A Multi-Method Evaluation of Perioperative Practice and Safety Culture at AaResource-Poor Rural Hospital

Cardiac surgery in sub-Saharan Africa: a report of 3-year experience at the Douala General Hospital

Background: Cardiac surgery was started at the Douala General Hospital since 2012 as a result of a North-South collaboration between Cameroon and Belgium. Five cardiac surgery missions have been carried out since then. This work aimed at assessing three years of this initial experience. Methods: We carried out a cross-sectional descriptive study between November 2012 and March 2016. We reviewed the case records of all patients with heart disease, and with an indication for surgery. Results: A total of 45 patients with heart diseases who had an indication for surgery were retained for this study. There were 23 women and 22 men. Of these, 27 patients benefited from surgical intervention. Their mean age was 41±18 years (range, 14 to 85 years). The most common physical sign was heart murmur in 29 (64.4%) patients. Valvular Heart diseases were the most frequent in 32 (71.1%) patients, which were predominantly rheumatic heart diseases (RHD) in 25 (55.6%) patients. The most frequent surgical procedures were valve replacement with prosthesis, followed by repairs of congenital abnormalities. Mechanical prosthesis were mostly used (8/12 cases). Short-term intra-hospital mortality was 7.4%. The main cause of death was acute ventricular failure. Conclusions: The pilot phase of the cardiac surgery program at the General Hospital of Douala (DGH) was successful. Patients could be operated at a lower cost locally. Efforts must be made for the creation of an autonomous local team.

Abstract 3260: Training for cancer surgery in Sub Saharan Africa

Abstract BACKGROUND: Low- and middle-income countries (LMICs) face both training and infrastructural challenges for surgical care, particularly for cancer. Practitioners charged with caring for these patients have few options for basic or advanced training. OBJECTIVES: To describe the training options for cancer surgery in Sub Saharan Africa METHODS: The different methods of training are described and the advantages and limits of each methods is highlighted. RESULTS: Training during residency and onsite fellowship are a good option but requires an appropriate number and capacity of training programme. International fellowships have the limitation of readjustment back home for the trained fellow. Onsite International training missions like IVUmed’s missions have the advantage of “Teach One, Reach Many” outcome where a whole team in trained in accordance of local needs and the participation of all stakeholders. CONCLUSIONS: Long-term program commitments; effective communication; and a shared vision among the program site, the coordinating nongovernmental organization, and supporting organizations facilitate the development of thriving surgical teaching programs capable of serving local communities and conducting outreach training. Citation Format: Mohamed Jalloh, Serigne Magueye Gueye. Training for cancer surgery in Sub Saharan Africa [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3260. doi:10.1158/1538-7445.AM2017-3260

What are the priorities for improving cataract surgical outcomes in Africa? Results of a Delphi exercise

PurposeThe quality of cataract surgery delivered in sub-Saharan Africa (SSA) is a significant constraint to achieving the elimination of avoidable blindness. No published reports from routine SSA cataract services attain the WHO benchmarks for visual outcomes; poor outcomes (<6/60) often comprise 20% in published case series. This Delphi exercise aimed to identify and prioritise potential interventions for improving the quality of cataract surgery in SSA to guide research and eye health programme development.MethodsAn initial email open-question survey created a ranked list of priorities for improving quality of surgical services. A second-round face-to-face discussion facilitated at a Vision 2020 Research Mentorship Workshop in Tanzania created a refined list for repeated ranking.ResultsSeventeen factors were agreed that might form target interventions to promote quality of cataract services. Improved training of surgeons was the top-ranked item, followed by utilisation of biometry, surgical equipment availability, effective monitoring of outcomes of cataract surgery by the surgeon, and well-trained support staff for the cataract pathway (including nurses seeing post-operative cases).ConclusionImproving the quality of cataract surgery in SSA is a clinical, programmatic and public health priority. In the absence of other evidence, the collective expert opinion of those involved in ophthalmic services regarding the ranking of factors to promote quality improvement, refined through this Delphi exercise, provides us with candidate intervention areas to be evaluated.

Pancreatic Pseudocyst: a Case Report

The pseudocyst of the pancreas is a rare affection. The authors report a case of pancreatic pseudocyst treated and show the importance of scanner in the diagnosis and justify the superiority of classic surgery in sub-Saharan Africa.

Anesthesia for Ambulatory Pediatric Surgery in Sub-Saharan Africa: A Pilot Study in Burkina Faso.

Long surgical wait times and limited hospital capacity are common obstacles to surgical care in many countries in Sub-Saharan Africa (SSA). Introducing ambulatory surgery might contribute to a solution to these problems. The purpose of this study was to evaluate the safety and feasibility of introducing ambulatory surgery into a pediatric hospital in SSA. This is a cross-sectional descriptive study that took place over 6 months. It includes all patients assigned to undergo ambulatory surgery in the Pediatric University Hospital in Ouagadougou, Burkina Faso. Eligibility criteria for the ambulatory surgery program included >1 year of age, American Society of Anesthesiologists (ASA) 1 status, surgery with a low risk of bleeding, lasting <90 minutes, and with an expectation of mild to moderate postoperative pain. The family had to live within 1 hour of the hospital and be available by telephone. During the study period, a total of 1250 patients underwent surgery, of whom 515 were elective cases; 115 of these met the criteria for ambulatory surgery; 103 patients, with an average age of 59.74 ± 41.57 months, actually underwent surgery. The principal indications for surgery were inguinal (62) and umbilical (47) hernias. All patients had general anesthesia with halothane. Sixty-five percent also received regional or local anesthesia consisting of caudal block in 79.23% or nerve block in 20.77%. The average duration of surgery was 33 ± 17.47 minutes. No intraoperative complications were noted. All the patients received acetaminophen and a nonsteroidal anti-inflammatory drug in the recovery room. Twelve (11.7%) patients had complications in recovery, principally nausea and vomiting. Eight (7.8%) patients were admitted to the hospital. No serious complications were associated with ambulatory surgery. Its introduction could possibly be a solution to improving pediatric surgical access in low-income countries.

Global general pediatric surgery partnership: The UCLA–Mozambique experience

Background/purposeThere has been increasing recognition of the disparities in surgical care throughout the world. Increasingly, efforts are being made to improve local infrastructure and training of surgeons in low-income settings. The purpose of this study was to review the first 5-years of a global academic pediatric general surgery partnership between UCLA and the Eduardo Mondlane University in Maputo, Mozambique. MethodsA mixed-methods approach was utilized to perform an ongoing needs assessment. A retrospective review of admission and operative logbooks was performed. Partnership activities were summarized. ResultsThe needs assessment identified several challenges including limited operative time, personnel, equipment, and resources. Review of logbooks identified a high frequency of burn admissions and colorectal procedures. Partnership activities focused on providing educational resources, on-site proctoring, training opportunities, and research collaboration. ConclusionThis study highlights the spectrum of disease and operative case volume of a referral center for general pediatric surgery in sub-Saharan Africa, and it provides a context for academic partnership activities to facilitate training and improve the quality of pediatric general surgical care in limited-resource settings. Level of evidenceLevel IV.

Cheetah noninvasive cardiac output: A viable alternative to arterial line and pulmonary artery catheter cardiac output techniques after cardiac surgery in Sub-Saharan Africa

Objective: The objective of the study is to determine the utility and practicality of Cheetah noninvasive cardiac output monitoring (NICOM) as a means of hemodynamic monitoring of adult patients after open heart surgery (OHS) in Sub-Saharan Africa (SSA). Materials and Methods: This was a single-institutional prospective study of eight adult patients undergoing OHS with cardiopulmonary bypass between August 2015 and April 2016. Cardiac output (CO) was calculated utilizing three measuring techniques; (1) Cheetah NICOM through skin electrodes, (2) FloTrac Vigileo through an arterial line, and (3) Vigilance through an oximetry Swan Ganz catheter (pulmonary artery catheter). CO readings were grouped into four intervals; precardiopulmonary bypass, postcardiopulmonary bypass, and first 24 h and second 24 h in Intensive Care Unit (ICU). The CO recordings from the three techniques were then compared for correlation between the noninvasive and two invasive techniques. Results: The mean patient age was 46.3 ± 15.7 years and 4 (50.0%) were males. Seven (87.5%) patients had acquired heart disease and 1 (12.5%) congenital heart disease. Three (37.5%) patients had severe pulmonary hypertension and 2 (25.0%) patients required intra-aortic balloon pump postoperatively. Correlation was highest in the ICU after patients were fully warm. Correlation coefficients were r = 0.56, bias 0.39 ± 2.34 between NICOM and Vigileo and r = 0.53, bias 1.43 ± 2.26 between NICOM and Vigilance within the first 24 h in ICU. In subsequent second 24 h in ICU, r = 0.84, bias − 0.16± −1.81 between NICOM and Vigileo and r = 0.29, bias 5.68 ± 1.55 between NICOM and Vigilance were the correlation coefficients. There was either none or poor correlation between NICOM and both the Vigileo or Vigilance pre- and post-cardiopulmonary bypass as most patients were still relatively hypothermic. Conclusion: NICOM reliably calculated CO in normothermic patients after OHS, showing average-to-high positive correlations with the Vigileo and Vigilance. Its easy applicability and cheaper cost make it more readily adaptable in SSA with limited finances and skilled healthcare workforce.

Acute kidney injury following cardiopulmonary bypass surgery: Challenges of acute kidney injury after open heart surgery in Sub-Saharan Africa

Acute kidney injury following cardiopulmonary bypass surgery: Challenges of acute kidney injury after open heart surgery in Sub-Saharan Africa

Noninvasive cardiac output: A viable alternative to arterial line and pulmonary artery catheter cardiac output techniques after cardiac surgery in Sub-Saharan Africa

Noninvasive cardiac output: A viable alternative to arterial line and pulmonary artery catheter cardiac output techniques after cardiac surgery in Sub-Saharan Africa

Challenges of acute kidney injury after open heart surgery in Sub-Saharan Africa

Challenges of acute kidney injury after open heart surgery in Sub-Saharan Africa

Hemodynamic monitoring after open heart surgery in Sub-Saharan Africa

Hemodynamic monitoring after open heart surgery in Sub-Saharan Africa

Humanitarian Cardiology and Cardiac Surgery in Sub-Saharan Africa: Can We Reshape the Model?

In recent decades, humanitarian cardiology and cardiac surgery have shifted toward sending short-term surgical and catheter missions to treat patients. Although this model has been shown to be effective in bringing cardiovascular care to the patients' environment, its effectiveness in creating sustainable service is questioned. This study reports the barriers to contribution of missions to effective skill transfer and possible improvements needed in the future, from the perspective of both the local and overseas teams. We reviewed the mission-based activities in the Children's Heart Fund Cardiac Center in the past six years. We distributed questionnaires to the local surgeons and the lead surgeons of the overseas teams. Twenty-six missions visited the center 57 times. There were 371 operating days and 605 surgical procedures. Of the procedures performed, 498 were open-heart surgeries. Of the operations, 360 were congenital cases and 204 were rheumatic. Six local surgeons and 18 overseas surgeons responded. Both groups agree the current model of collaboration is not optimal for effective skill transfer. The local surgeons suggested deeper involvement of the universities, governmental institutions, defined training goals and time frame, and communication among the overseas teams themselves as remedies in the future. Majority of the overseas surgeons agree that networking and regular communication among the missions themselves are needed. Some reflected that it would be convenient if the local surgeons are trained by one or two frequently visiting surgeons in their early years and later exposed to multiple teams if needed. The current model of collaboration has brought cardiac care to patients having cardiac diseases. However, the model appears to be suboptimal for skill transfer. The model needs to be reshaped to achieve this complex goal.