Search

Background As surgical systems are forced to adapt and respond to new challenges, so should the patient safety tools within those systems. We sought to determine how the WHO SSC might best be adapted during the COVID-19 pandemic. Methods 18 Panelists from five continents and multiple clinical specialties participated in a three-round modified Delphi technique to identify potential recommendations, assess agreement with proposed recommendations and address items not meeting consensus. Results From an initial 29 recommendations identified in the first round, 12 were identified for inclusion in the second round. After discussion of recommendations without consensus for inclusion or exclusion, four additional recommendations were added for an eventual 16 recommendations. Nine of these recommendations were related to checklist content, while seven recommendations were related to implementation. Conclusions This multinational panel has identified 16 recommendations for sites looking to use the surgical safety checklist during the COVID-19 pandemic. These recommendations provide an example of how the SSC can adapt to meet urgent and emerging needs of surgical systems by targeting important processes and encouraging critical discussions.

BACKGROUND፡ Surgical Site Infection (SSI) and wound dehiscence are two early complications of laparotomy causing significant morbidity and mortality. This study was conducted to determine the prevalence and risk factors of SSI and wound dehiscence in pediatric surgical patients.METHODS: We performed a prospective observational study of all pediatric surgical patients who underwent laparotomy at Tikur Anbessa Specialized Hospital, Ethiopia, from December 2017 to May 2018. Data collected included demographics, operative indication, nutritional status, prophylactic antibiotics administration, and duration of operation. Primary outcome was SSI; secondary outcomes were hospital stay and other postoperative complications, including wound dehiscence and mortality. Data were analyzed using SPSS, Version 23. Fisher’s exact and Chi-squared tests used to report outcomes. Multivariable logistic regression was used to identify variables associated with SSI, wound dehiscence and other outcomes.RESULTS: Of 114 patients, median age was 46 months [range: 1day-13years]; 77(67.5 %) were males. Overall SSI rate was 21.05%. Nine (7.9%) developed wound dehiscence while 3(2.6%) had abdominal contents evisceration. Overall mortality rate was 2.6%. In multivariate analysis, prophylactic antibiotics administration (AOR=13.05, (p=0.006)), duration of procedure (AOR=8.62, (p=0.012)) and wound class (AOR=16.63, (p=0.034)) were independent risk factors for SSI while SSI was an independent predictor of prolonged hospital stay, >1 week (AOR=4.7, p=.003,) and of wound dehiscence (AOR=33. 96,p=0.003). Age (p=0.004) and malnutrition (p1 hour before surgery and operative time >2 hours are independent predictors of SSI.

Background The expansion of local training programmes is crucial to address the shortages of specialist paediatric surgeons across Sub-Saharan Africa. This study assesses whether the current training programme for paediatric surgery at the College of Surgeons of East, Central and Southern Africa (COSECSA) is exposing trainees to adequate numbers and types of surgical procedures, as defined by local and international guidelines. Methods Using data from the COSECSA web-based logbook, we retrospectively analysed numbers and types of operations carried out by paediatric surgical trainees at each stage of training between 2015 and 2019, comparing results with indicative case numbers from regional (COSECSA) and international (Joint Commission on Surgical Training) guidelines. Results A total of 7,616 paediatric surgical operations were recorded by 15 trainees, at different stages of training, working across five countries in Sub-Saharan Africa. Each trainee recorded a median number of 456 operations (range 56–1111), with operative experience increasing between the first and final year of training. The most commonly recorded operation was inguinal hernia (n = 1051, 13.8%). Trainees performed the majority (n = 5607, 73.6%) of operations recorded in the eLogbook themselves, assisting in the remainder. Trainees exceeded both local and international recommended case numbers for general surgical procedures, with little exposure to sub-specialities. Conclusions Trainees obtain a wide experience in common and general paediatric surgical procedures, the number of which increases during training. Post-certification may be required for those who wish to sub-specialise. The data from the logbook are useful in identifying individuals who may require additional experience and centres which should be offering increased levels of supervised surgical exposure.

BACKGROUND Nonsyndromic orofacial clefts (NSOFCs) represent the most common congenital anomalies in the head and neck region. Multiple factors contribute to the occurrence of this anomaly. The etiology of NSOFCs in the Ethiopian population has not been investigated prior to this study. AIMS OF THE STUDY To assess the role of maternal environmental factors in the occurrence of NSOFCs in the Ethiopian Population. METHODS The authors used unmatched case control study design and evaluated the role of environmental factors to the occurrence of NSOFCs in the Ethiopian population. The participants were recruited from the same institution (Yekatit 12 Hospital Medical College). The authors studied 760 mothers (359 mothers of children born with NSOFCs and 401 mothers of children born without any congenital anomalies). Univariate and multivariate logistic regression analyses were used to calculate relative risk by odds ratio and 95% confidence interval. RESULTS Mothers who gave history of bronchial asthma and mothers who were admitted for threatened abortion had a higher risk of delivering a child with NSOFCS P value=0.013; AOR=0.194, 95% CI [0.053-0.712], P value

Workye Tigabie,1 Woubedel Kiflu,2 Fisseha Temesgen,2 Hanna Getachew,2 Tihitena Nigussie,2 Belachew Dejenie,2 Amezene Tadesse,2 Miliard Derbew2 1Department of Surgery, St. Peter Specialized Hospital, Addis Ababa, Ethiopia; 2Department of Surgery, Pediatrics Surgery Unit, Tikur Anbessa Hospital, Addis Ababa, EthiopiaCorrespondence: Workye Tigabie, Email workye62@gmail.comBackground: Inguinal hernia is one of the most frequent reasons for referral to the pediatric surgery unit. The incidence ranges from 1% to 5% in the pediatric population. Surgery for inguinal hernia is among the most commonly performed procedures, with good overall outcomes and few complications.Objective: The study aimed to evaluate the pattern and outcome of inguinal hernia surgery in children.Methodology: This retrospective 5-year cross-sectional study was conducted on all pediatric patients with inguinal hernia (age < 13 years) operated on between September 1, 2014, and August 31, 2019, in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.Results: The male to female ratio of inguinal hernia was 19:1. It was slightly more predominant on the right side and bilaterality occurred in about 10.6% of cases. The mean age at presentation was 15 months, and the average waiting time for patients to be operated on was 5 months. The overall incarceration and strangulation rates were 24% and 3.8%, respectively. Infants had a higher risk of incarceration/strangulation than other children. Among patients who underwent elective surgery, 63% (53/84) of operations were carried out as day-case surgery. The overall mortality, complication rate, and recurrence risk following surgery were 0.9%, 11.5%, and 9.6%, respectively. Bilaterality increased the occurrence of late postoperative complications.Conclusion: All inguinal hernia cases were indirect hernias operated on by standard open surgical techniques. Our study showed increased incarceration rates, recurrences, and complications after surgery. This is because of the delayed presentation of patients and delayed intervention for patients. Therefore, early and timely intervention with proper surgical techniques should always be considered.Keywords: inguinal hernia, incarceration, outcome, pattern, day-case surgery

This quality improvement study evaluates the sustainability of Clean Cut, a surgical infection prevention program implemented at hospitals in Ethiopia.

Background Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define—for the first time—the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally. Methods and findings The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries—who only made up 21% of the total attendees. Conclusions To track global progress towards timely access to quality SAO care, these indicators—at the basic level—should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies., Justine Davies and colleagues discuss the development of updated indicators to support global achievement of access to safe surgical, anaesthetic, and obstetric care.

Pediatric age groups constitute more than 50% of the Sub-Saharan African, SSA, population. Very poor socioeconomic conditions and rare and advanced pathologies are the major health challenges of the region. Despite the overwhelming burden of diseases in the region, the health workforce and infrastructure are underdeveloped. The overall poverty, poor hygiene and sanitation, and widespread infectious disease with very limited infrastructures (road, health institutions) on top of lack of government commitment to improve the health of their people are some of the drawbacks that fail to address the unmet needs of pediatric health in SSA. Complications of surgical care have become a major cause of morbidity and mortality with significant implications for public health. These issues are magnified in developing countries, especially sub-Saharan Africa. The challenge is even more prominent in pediatric surgery, where the population is larger, and there is a shortage of specialists. In this lecture, I describe the difficulties faced from the East African and Ethiopian perspective as well as the role of colleges from high income countries to support SSA to address the unmet pediatric surgery needs.

IntroductionAs childhood mortality from infectious diseases falls across sub-Saharan Africa (SSA), the burden of disease attributed to surgical conditions is increasing. However, limited data exist on paediatric surgical outcomes in SSA. We compared the outcomes of five common paediatric surgical conditions in SSA with published benchmark data from high-income countries (HICs).MethodsA multicentre, international, prospective cohort study was undertaken in hospitals providing paediatric surgical care across SSA. Data were collected on consecutive children (birth to 16 years), presenting with gastroschisis, anorectal malformation, intussusception, appendicitis or inguinal hernia, over a minimum of 1 month, between October 2016 and April 2017. Participating hospitals completed a survey on their resources available for paediatric surgery.The primary outcome was all-cause in-hospital mortality. Mortality in SSA was compared with published benchmark mortality in HICs using χ2 analysis. Generalised linear mixed models were used to identify patient-level and hospital-level factors affecting mortality. A pResults1407 children from 51 hospitals in 19 countries across SSA were studied: 111 with gastroschisis, 188 anorectal malformation, 225 intussusception, 250 appendicitis and 633 inguinal hernia. Mortality was significantly higher in SSA compared with HICs for all conditions: gastroschisis (75.5% vs 2.0%), anorectal malformation (11.2% vs 2.9%), intussusception (9.4% vs 0.2%), appendicitis (0.4% vs 0.0%) and inguinal hernia (0.2% vs 0.0%), respectively. Mortality was 41.9% (112/267) among neonates, 5.0% (20/403) in infants and 1.0% (7/720) in children. Paediatric surgical condition, higher American Society of Anesthesiologists score at primary intervention, and needing/receiving a blood transfusion were significantly associated with mortality on multivariable analysis.ConclusionMortality from common paediatric surgical conditions is unacceptably high in SSA compared with HICs, particularly for neonates. Interventions to reduce mortality should focus on improving resuscitation and timely transfer at the district level, and preoperative resuscitation and perioperative care at paediatric surgical centres.

ObjectivesThe optimal size of the health workforce for children’s surgical care around the world remains poorly defined. The goal of this study was to characterise the surgical workforce for children across Brazil, and to identify associations between the surgical workforce and measures of childhood health.DesignThis study is an ecological, cross-sectional analysis using data from the Brazil public health system (Sistema Único de Saúde).Settings and participantsWe collected data on the surgical workforce (paediatric surgeons, general surgeons, anaesthesiologists and nursing staff), perioperative mortality rate (POMR) and under-5 mortality rate (U5MR) across Brazil for 2015.Primary and secondary outcome measuresWe performed descriptive analyses, and identified associations between the workforce and U5MR using geospatial analysis (Getis-Ord-Gi analysis, spatial cluster analysis and linear regression models).FindingsThere were 39 926 general surgeons, 856 paediatric surgeons, 13 243 anaesthesiologists and 103 793 nurses across Brazil in 2015. The U5MR ranged from 11 to 26 deaths/1000 live births and the POMR ranged from 0.11–0.17 deaths/100 000 children across the country. The surgical workforce is inequitably distributed across the country, with the wealthier South and Southeast regions having a higher workforce density as well as lower U5MR than the poorer North and Northeast regions. Using linear regression, we found an inverse relationship between the surgical workforce density and U5MR. An U5MR of 15 deaths/1000 births across Brazil is associated with a workforce level of 5 paediatric surgeons, 200 surgeons, 100 anaesthesiologists or 700 nurses/100 000 children.ConclusionsWe found wide disparities in the surgical workforce and childhood mortality across Brazil, with both directly related to socioeconomic status. Areas of increased surgical workforce are associated with lower U5MR. Strategic investment in the surgical workforce may be required to attain optimal health outcomes for children in Brazil, particularly in rural regions.

Heteropagus (parasitic) twin is a type of conjoined twinning in which a partially formed defective twin is attached to an otherwise normal twin. It is an extremely rare anomaly. In this paper, we describe five cases we encountered over the past 9 years. Except one, all presented early within a few days of birth. None of them shared an organ but two had bony/visceral connections. All surgeries were successful, and we only encountered wound complications. To the best of our knowledge this is the largest compilation of original cases in a parasitic twin report. Keywords: Conjoined twin, Parasitic twin, Heteropagus twin, Ethiopia

BACKGROUND: Hypospadias repair is one of the problematic issues in pediatric surgery. As a result of the multiple complications following the procedure, a variety of techniques have been used and newer methods continue to emerge. There is still controversy regarding the best method of repair. We aimed to determine the outcome of surgery and factors contributing to unfavorable outcomes in children with hypospadias.MATERIALS AND METHODS: This is a retrospective review undertaken from September 2009 to August 2014. The research was conducted at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. All children who underwent hypospadias repair and had regular follow-up were included in the study.RESULTS: A total of 202 boys aged less than 13 years were assessed. Most surgeries (80.3%) were performed in children older than 18 months. Transverse incised plate urethroplasty (TIP) was frequently performed for distal hypospadias (71.2 %), while transverse ventral preputal flap (TVPF) was the most common procedure done for proximal hypospadias (62.8 %). Overall success rate for first surgery was 55.9 %. There was a high rate of major post-operative complications (44.1%) of which urethrocutaneous fistula (UCF) was the most common (31.2%) followed by meatal stenosis and glans breakdown (7.4 % each). These complications were found to be higher in those who were operated at a later age and those with proximal hypospadias (p=0.03 and p=0.01 respectively). There was also a significant difference among the type of procedures with TIP and TVPF having the least complications (p

Over the past decade, assessments of surgical capacity in low- and middle-income countries (LMICs) have contributed to our understanding of barriers to the delivery of surgical services in a number of countries. It is yet unclear, however, how the findings of these assessments have been applied and built upon within the published literature.A systematic literature review of surgical capacity assessments in LMICs was performed to evaluate current levels of understanding of global surgical capacity and to identify areas for future study. A reverse snowballing method was then used to follow-up citations of the identified studies to assess how this research has been applied and built upon in the literature.Twenty-one papers reporting the findings of surgical capacity assessments conducted in 17 different LMICs in South Asia, East Asia and Pacific, Latin America and the Caribbean, and sub-Saharan Africa were identified. These studies documented substantial deficits in human resources, infrastructure, equipment, and supplies. Only seven additional papers were identified which applied or built upon the studies. Among these, capacity assessment findings were most commonly used to develop novel tools and intervention strategies, but they were also used as baseline measurements against which updated capacity assessments were compared.While the global surgery community has made tremendous progress in establishing baseline values of surgical capacity in LMICs around the world, further work is necessary to build upon and apply the foundational knowledge established through these efforts. Capacity assessment data should be coordinated and used in ongoing research efforts to monitor and evaluate progress in global surgery and to develop targeted intervention strategies. Intervention strategy development may also be further incorporated into the evaluation process itself.

After decades on the margins of primary health care, surgical and anaesthesia care is gaining increasing priority within the global development arena. The 2015 publications of the Disease Control Priorities third edition on Essential Surgery and the Lancet Commission on Global Surgery created a compelling evidenced-based argument for the fundamental role of surgery and anaesthesia within cost-effective health systems strengthening global strategy. The launch of the Global Alliance for Surgical, Obstetric, Trauma, and Anaesthesia Care in 2015 has further coordinated efforts to build priority for surgical care and anaesthesia. These combined efforts culminated in the approval of a World Health Assembly resolution recognizing the role of surgical care and anaesthesia as part of universal health coverage. Momentum gained from these milestones highlights the need to identify consensus goals, targets and indicators to guide policy implementation and track progress at the national level. Through an open consultative process that incorporated input from stakeholders from around the globe, a global target calling for safe surgical and anaesthesia care for 80% of the world by 2030 was proposed. In order to achieve this target, we also propose 15 consensus indicators that build on existing surgical systems metrics and expand the ability to prioritize surgical systems strengthening around the world.

In East, Central and Southern Africa accurate data on the current surgeon workforce have previously been limited. In order to ensure that the workforce required for sustainable delivery of surgical care is put in place, accurate data on the number, specialty and distribution of specialist-trained surgeons are crucial for all stakeholders in surgery and surgical training in the region. The surgical workforce in each of the ten member countries of the College of Surgeons of East, Central and Southern Africa (COSECSA) was determined by gathering and crosschecking data from multiple sources including COSECSA records, medical council registers, local surgical societies records, event attendance lists and interviews of Members and Fellows of COSECSA, and validating this by direct contact with the surgeons identified. This data was recorded and analysed in a cloud-based computerised database, developed as part of a collaboration programme with the Royal College of Surgeons in Ireland. A total of 1690 practising surgeons have been identified yielding a regional ratio of 0.53 surgeons per 100,000 population. A majority of surgeons (64 %) practise in the main commercial city of their country of residence and just 9 % of surgeons are female. More than half (53 %) of surgeons in the region are general surgeons. While there is considerable geographic variation between countries, the regional surgical workforce represents less than 4 % of the equivalent number in developed countries indicating the magnitude of the human resource challenge to be addressed.

Academic partnerships between high- and low/middle-income countries can improve the quality of surgical education and health care delivery in each setting. We report the perceived needs related to collaborative surgical education in a resource-limited setting.We used qualitative methods to elicit the opinions of surgical faculty members and surgical residents and quantitative methods to outline surgical procedure type and volume.Ethiopian faculty members identified the management of trauma and emergency surgical care as a priority. They identified supervision in the operating room (OR), topic-specific lectures and supervising resident assessments in the clinic as appropriate roles for partners. Residents were in agreement with faculty members, highlighting a desire for supervision in the OR and topic-specific lectures.We present specific experiences and needs of a surgical teaching unit in a low-income country, paving the way to form a meaningful and responsive relationship between 2 surgical departments in 2 universities.Les partenariats universitaires entre pays riches et pays à revenus faibles ou moyens peuvent améliorer l’enseignement de la chirurgie et la prestation des soins de santé dans chaque contexte. Nous faisons état des besoins perçus en matière de collaboration pour la formation en chirurgie dans un milieu aux ressources limitées.Nous avons utilisé des méthodes qualitatives pour sonder l’opinion des professeurs et des résidents en chirurgie, ainsi que des méthodes quantitatives pour faire le point sur les types d’opérations et leur volume.Les professeurs éthiopiens ont établi comme priorités la traumatologie et les soins chirurgicaux d’urgence. Ils ont évoqué la supervision au bloc opératoire, les conférences sur des thèmes précis et la supervision de l’évaluation clinique des résidents comme rôles appropriés pour les partenaires. Les résidents ont été du même avis que les professeurs et ont confirmé leur souhait d’être supervisés au bloc opératoire et d’entendre des conférences sur des thèmes précis.Nous présentons les expériences et les besoins particuliers d’une unité d’enseignement de la chirurgie dans un pays à faible revenu, et nous pavons ainsi la voie pour l’établissement d’un lien de collaboration important et pertinent entre les départements de chirurgie de 2 universités.

Information regarding surgical capacity in the developing world is limited by the paucity of available data regarding surgical care, infrastructure, and human resources in the literature. The purpose of this study was to assess surgical and anesthesia infrastructure and human resources in Ethiopia as part of a larger study by the Harvard Humanitarian Initiative examining surgical and anesthesia capacity in ten low-income countries in Africa. A comprehensive survey tool developed by the Harvard Humanitarian Initiative was used to assess surgical capacity of hospitals in Ethiopia. A total of 20 hospitals were surveyed through convenience sampling. Eight areas of surgical and anesthesia care were examined, including access and availability, access to human resources, infrastructure, outcomes, operating room information and procedures, equipment, nongovernmental organization delivery of surgical services, and pharmaceuticals. Results were obtained over a 1-month period during October 2011. There is wide variation in accessibility, with hospital-to-population ratios ranging from 1:99,010 to 1:1,082,761. The overall physician to population ratio ranges from 1:4715 to 1:107,602. The average hospital has one to two operating rooms, 4.2 surgeons, one gynecologist, and 4.5 anesthesia providers—although in all but three hospitals anesthesiology was provided by nonphysician personnel only (i.e., a nurse anesthetist). Access to continuous electricity, running water, essential medications, and monitoring systems is very limited in all hospitals surveyed, although such access did vary across regions. This survey of Ethiopia’s hospital resources attempts to identify specific areas of need where resources, education, and development can be targeted. Because the major surgical mortality comes from late presentations, increasing accessibility through infrastructure development would likely provide a major improvement in surgical morbidity and mortality rates. Infrastructure limitations of electricity, water, oxygen, and blood banking do not prove to be significant barriers to surgical care. The increasing number of physicians is promising, although efforts should be directed specifically toward increasing the number of anesthesiologists and surgeons in the country.