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Background: In recent years, surgical education has increased its focus on the non-technical skills such as communication and interpersonal relationships while continuing to strive for technical excellence of procedures and patient care. An awareness of the ethical aspects of surgical practice that involve non-technical skills and judgment is of vital concern to surgical educators and encompasses disparate issues ranging from adequate supervision of trainees to surgical care access., Methods: This bibliographical research effort seeks to report on ethical challenges from a sub-Saharan Africa (SSA) perspective as found in the peer-reviewed literature employing African Journals Online, Bioline, and other sources with African information as well as PubMed and PubMed Central. The principles of autonomy, non-maleficence, beneficence, and justice offer a framework for a study of issues including: access to care (socioeconomic issues and distance from health facilities); resource utilization and decision making based on availability and cost of resources, including ICU and terminal extubation; informed consent (both communication about reasonable expectations post-procedure and research participation); research ethics, including local projects and international collaboration; quality and safety including supervision of less experienced professionals; and those religious and cultural issues that may affect any ethical decision making. The religious and cultural environment receives attention because beliefs and traditions affect medical choices ranging from acceptance of procedures, amputations, to end-of-life decisions., Results and Conclusions: Ethics awareness and ethics education should be a vital component of non-technical skills training in surgical education and medical practice in SSA for trainees. Continuing professional development of faculty should include an awareness of ethical issues.

Introduction: Global surgery is increasingly recognized as a vital component of international public health. Access to basic surgical care is limited in much of the world, resulting in a global burden of treatable disease. To address the lack of surgical workforce in underserved environments and to foster ongoing interest in global health among US-trained surgeons, our institution established a residency rotation through partnership with an academic hospital in Kijabe, Kenya. This study evaluates the perceptions of residents involved in the rotation, as well as its impact on their future involvement in global health., Materials and Methods: A retrospective review of admission applications from residents matriculating at our institution was conducted to determine stated interest in global surgery. These were compared to post-rotation evaluations and follow-up surveys to assess interest in global surgery and the effects of the rotation on the practices of the participants., Results: A total of 78 residents matriculated from 2006 to 2016. Seventeen participated in the rotation with 76% of these reporting high satisfaction with the rotation. Sixty-five percent had no prior experience providing health care in an international setting. Post-rotation surveys revealed an increase in global surgery interest among participants. Long-term interest was demonstrated in 33% (n = 6) who reported ongoing activity in global health in their current practices. Participation in global rotations was also associated with increased interest in domestically underserved populations and affected economic and cost decisions within graduates' practices.

Background: International elective experiences are becoming an increasingly important component of American general surgery education. In 2011, the Residency Review Committee (RRC) approved these electives for credit toward graduation requirements. Previous surveys of general surgery program directors have established strong interest in these electives but have not assessed the feasibility of creating a national and international database aimed at educational standardization. The present study was designed to gain in-depth information from program directors about features of existing international electives at their institution and to ascertain interest in national collaboration., Methods: This cross-sectional study of 253 United States general surgery program directors was conducted using a web-based questionnaire program., Results: Of the program directors who responded to the survey, twelve percent had a formal international elective in place at their institution, though 80% of these did not have a formal associated curriculum for the rotation. Sixty percent of respondents reported that informal international electives existed for their residents. The location, length, and characteristics of these electives varied widely. Sixty-eight percent of program directors would like to participate in a national and international database designed to facilitate standardization of electives and educational exchange., Conclusions: In a world of increasing globalization, international electives are more important than ever to the education of surgery residents. However, a need for standardization of these electives exists. The creation of an educational consortium and database of international electives could improve the academic value of these electives, as well as provide increased opportunities for twinning and bidirectional exchange.

Despite diligent efforts by the World Health Organization and the governments of developing world countries, tetanus persists as a global health problem. This retrospective study was undertaken to assess the outcome for victims of tetanus presenting to the Baptist Medical Centre in Ogbomoso, Nigeria and to develop better management techniques for future patients. Sixty patients (46 males, 14 females) with nonneonatal tetanus were seen over a 5-year period (1995-1999). The mean age was 26 years, and 74% were 30 years or younger. All patients were treated with antitetanus serum, antibiotics, wound débridement (when a wound was identified), and antispasmodics. No patients underwent tracheostomy or gastrostomy. The mortality rate was 44%. Factors significant for predicting mortality were age greater than 14 years, occupation as a farmer, short incubation period, short symptom duration, high degree of severity on presentation, and high temperature during hospital care. The best hope for improvement in the treatment of tetanus in our institution is more conscientious titration of antispasmodics to control spasms without causing significant respiratory depression. The only real hope for reducing the global mortality for tetanus, however, lies in renewed immunization efforts by all health care providers in developing world countries, not just community health workers.

This study was undertaken to assess the degree of ubiquity of umbilical hernias (UHs) in Nigerians and to determine if a laissez faire approach to the presence of UHs is justified. A prospective evaluation was conducted of the umbilical area of 4052 Nigerians living in the vicinity of the Baptist Medical Centre (BMCO) in Ogbomoso, Nigeria. The diameter of the fascial defect was measured with the subject supine and the protrusion of the umbilical skin with the subject erect. Subjects were divided into three groups: group 1 (1 month to 18 years old); group 2 (older than 18 years); and group 3 (pregnant women in an antenatal clinic). "Outies" (defined as any protrusion of the umbilical tip past the periumbilical skin) were present in 92% of group 1, 49% of group 2, and 90% of group 3 subjects. UHs (defined as protrusion of at least 5 mm and diameter of at least 10 mm) were present in 23% of group 1, 8% of group 2, and 15% of group 3 subjects. Spontaneous closure of UHs seems to occur until age 14. A retrospective analysis identified 11 patients undergoing emergency operations for UH-related problems during the past 15 years. With a low incidence and 0% mortality rate associated with management of these emergencies, a policy of prophylactic repair is not justified at BMCO. Because most of the children we examined had outies, repair for cosmetic reasons is rarely requested. The only logical indication for repair of UHs at BMCO is incarceration, and this rarely occurs.

Povidone-iodine (PI) is a scarce and expensive item for some hospitals in developing countries. This prospective, randomized study was performed at Baptist Medical Centre (BMCO) in Ogbomoso, Nigeria to determine if the use of PI for preoperative skin preparation would result in a lower postoperative wound infection rate and to identify other factors influencing the infection rate. Two hundred patients undergoing inguinal hernia repair were randomized to receive skin preparation with either: (1) locally available, inexpensive market soap and methylated spirit or (2) imported PI. The two groups were equally stratified. The overall postoperative wound infection rate was 5.5%, and there was no significant difference between the groups (5.1% vs. 5.9%). Factors that did not affect the infection rate included gender, age, type of anesthesia, type or duration of the operative procedure, and number of breaks in optimal technique. There were eight abscesses and three cases of cellulitis without suppuration diagnosed an average of 10 days postoperatively. Staphylococcus was the only bacterium identified on Gram stain or culture. The expense of procuring PI is not justified at BMCO. Available funds may better be used for preoperative antibiotics or for improvement in hospital infrastructure, which should result in fewer breaks in optimal operating room technique.

This study was a retrospective analysis of 75 children with perforated typhoid enteritis treated at the Baptist Medical Centre in Ogbomoso, Nigeria over a 4-year period. The mean age was 11.4 years. The usual symptoms were fever and abdominal pain, with a mean duration of 10.5 days. The diagnosis of perforation was usually based on the history and physical examination alone. The time interval from hospital presentation to operation was 11 hours, during which intravenous crystalloid and antibiotics were administered. Among the 75 children, 53 (71%) had a single perforation, and 22 had multiple perforations. Débridement and two-layered closure was performed in 71 (95%) and resection with anastomosis in 4 (5%). Ileus resolution was usually not complete until the eighth postoperative day, and the mean time until the surviving children were afebrile was 10 days. Complications other than death occurred in 7 (9%) children, and there were 15 deaths (20% mortality). All deaths were attributed to overwhelming sepsis, and all but one of the deaths occurred during the first 72 postoperative hours. The only factor statistically significant as a predictor of mortality was the duration of abdominal pain. Improvement in perioperative management including intensive care nursing and more effective antibiotics, although expensive, could result in decreased mortality. A significant decrease in mortality can occur only when the prevention of typhoid fever becomes a higher priority than its treatment.

Fifty consecutive cases of children with intussusception treated at a hospital in a developing country were compared with 50 consecutive cases treated at an American inner city children's hospital and 50 consecutive cases treated at an American referral children's hospital. The plan was to recommend ways of improving the treatment of children with intussusception in the developing world. Nonoperative reduction was attempted in the two American hospitals but was not available in the developing world hospital where all children were treated operatively. Children in the developing world hospital had a significantly longer duration of symptoms, an increased incidence of nonviable bowel, and a mortality of 18%. There were no deaths in either American hospital. The poorer outcome for developing world children was related to delay in treatment, the higher incidence of nonviable bowel, and the lack of adequate nursing care for acutely ill children. The use of nonoperative reduction would not have significantly improved the mortality rate among the developing world children. The mortality can best be reduced by: (1) earlier recognition and treatment of the intussusception; and (2) improvement in the postanesthetic care with better monitoring leading to prompt recognition and treatment of postoperative complications.

Immune competence was evaluated in cured patients who had been treated by irradiation for carcinoma of the laryngopharynx, and compared with that of similar patients treated by surgery alone, and normal controls. Cellular immunity was determined by quantitation of in vitro phytohemagglutinin (PHA)-induced lymphocyte reactivity and peripheral blood thymus-dependent lymphocyte (T cell) levels. Humoral immunity was assessed by measurement of serum immunoglobulin levels and by the effect of serum on in vitro normal lymphocyte reactivity to PHA. In 21 patients who were studied for 4-23 years (mean 8.4) after surgical treatment alone for laryngopharyngeal carcinoma, neither cellular nor humoral immunity differed from that of 44 controls. In contrast, 14 patients who had been irradiated and subsequently cured for 4-15 years (mean 9.0) prior to evaluation displayed significantly impaired cellular immune competence when compared to normals and patients treated by surgery alone. Since previous determinations of the effects of radiation therapy have been in patients who received irratiation to the thymic region or large area of bone marrow, this study indicates that radiation therapy for cancer administered via portals that encompass a minimal area of the immune system may be associated with prolonged impairment of cellular immunity.