Surgical capacity is disaster preparedness: A scoping review of how surgery and anesthesiology departments responded to COVID-19

OBJECTIVE

This study evaluated how surgical and anesthesiology departments adapted their resources in response to the coronavirus disease 2019 (COVID-19) pandemic.

DESIGN

This scoping review used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews protocol, with Covidence as a screening tool. An initial search of PubMed, Embase, Web of Science, Global Index Medicus, and Cochrane Systematic Reviews returned 6,131 results in October 2021. After exclusion of duplicates and abstract screening, 415 articles were included. After full-text screening, 108 articles remained.

RESULTS

Most commonly, studies were retrospective in nature (47.22 percent), with data from a single institution (60.19 percent). Nearly all studies occurred in high-income countries (HICs), 78.70 percent, with no articles from low-income countries. The reported responses to the COVID-19 pandemic involving surgical departments were grouped into seven categories, with multiple responses reported in some articles for a total of 192 responses. The most frequently reported responses were changes to surgical department staffing (29.17 percent) and task-shifting or task-sharing of personnel (25.52 percent).

CONCLUSION

Our review reflects the mechanisms by which hospital surgical systems responded to the initial stress of the COVID-19 pandemic and reinforced the many changes to hospital policy that occurred in the pandemic. Healthcare systems with robust surgical systems were better able to cope with the initial stress of the COVID-19 pandemic. The well-resourced health systems of HICs reported rapid and dynamic changes by providers to assist in and ultimately improve the care of patients during the pandemic. Surgical system strengthening will allow health systems to be more resilient and prepared for the next disaster.

The Implementation of Simulation-Based Learning for Training Undergraduate Medical Students in Essential Surgical Care Across Sub-Saharan Africa: a Scoping Review

Much surgery in sub-Saharan Africa is provided by non-specialists who lack postgraduate surgical training. These can benefit from simulation-based learning (SBL) for essential surgery. Whilst SBL in high-income contexts, and for training surgical specialists, has been explored, SBL for surgical training during undergraduate medical education needs to be better defined. From 26 studies, we identify gaps in application of simulation to African undergraduate surgical education, including lack of published SBL for most (65%) World Bank-defined essential operations. Most SBL is recent (2017-2021), unsustained, occurs in Eastern Africa (78%), and can be enriched by improving content, participant spread, and collaborations.

A national perspective on exposure to essential surgical procedures among medical trainees in Nigeria: a cross-sectional survey and recommendations

BACKGROUND

In sub-Saharan Africa, recent graduates from medical school provide more direct surgical and procedural care to patients than their counterparts from the Global North. Nigeria has no nationally representative data on the procedures performed by trainees before graduation from medical school and their confidence in performing these procedures upon graduation has also not been evaluated.

METHODS

We performed an internet-based, cross-sectional survey of recent medical school graduates from 15 accredited Federal, State, and private Nigerian medical schools spanning six geopolitical zones. Essential surgical procedures, bedside interventions and three Bellwether procedures were incorporated into the survey. Self-reported confidence immediately after graduation was calculated and compared using cumulative confidence scores with subgroup analysis of results by type and location of institution. Qualitative analysis of free text recommendations by participants was performed using the constant comparative method in grounded theory.

RESULTS

Four hundred ninety-nine recent graduates from 6 geopolitical zones participated, representing 15 out of a total of 44 medical schools in Nigeria. Male to female ratio was 2:1, and most respondents (59%) graduated from Federal institutions. Students had greatest practical mean exposure to bedside procedures like intravenous access and passing urethral foley catheters and were most confident performing these. Less than 23% had performed over 10 of any of the assessed procedures. They had least exposures to chest tube insertion (0.24/person), caesarean Sect. (0.12/person), and laparotomy (0.09/person). Recent graduates from Federal institutions had less procedural exposure in urethral catheterization (p < 0.001), reduction (p = 0.035), and debridement (p < 0.035). Respondents that studied in the underserved North-East and North-West performed the highest median number of procedures prior to graduation. Cumulative confidence scores were low across all graduates (maximum 25/60), but highest in graduates from Northern Nigeria and private institutions. Graduates recommended prioritizing medical students over senior trainees, using simulation-based training and constructive individualized non-toxic feedback from faculty.

CONCLUSION

Nigerian medical students have poor exposure to procedures and low confidence in performing basic procedures after graduation. More attention should be placed on training for essential surgeries and procedures in medical schools.

Global Access to Cardiac Surgery Centers: Distribution, Disparities, and Targets

BACKGROUND

Global data on cardiac surgery centers are outdated and survey-based. In 1995, there were 0.7 centers per million population, ranging from one per 120,000 in North America to one per 33 million in sub-Saharan Africa. This study analyzes the contemporary distribution of cardiac surgery centers and proposes targets relative to countries' cardiovascular disease (CVD) burdens.

METHODS

Medical databases, gray literature, and governmental reports were used to identify the most recent post-2010 data that describe the number of centers performing cardiac surgery in each nation. The 2019 Institute for Health Metrics and Evaluation Global Burden of Disease Results Tool provided national CVD burdens. One-third of the CVD burden was assumed to be surgical. Center targets were proposed as the average or half of the average of centers per million surgical CVD patients in high-income countries.

RESULTS

5,111 cardiac surgery centers were identified across 230 nations and territories with available data, equaling 0.73 centers per million population. The median (interquartile range) number of centers ranged from 0 (0-0.06) per million in low-income countries to 0.75 (0-1.44) in high-income countries. Targets were 612.2 (optimistic) or 306.1 (conservative) centers per million surgical CVD incidence. In 2019, low-income, lower-middle-income, and upper-middle-income countries possessed 34.8, 149.0, and 271.9 centers per million surgical CVD incidence.

CONCLUSION

Little progress has been made to increase cardiac surgery centers per population despite growing CVD burdens. Today's global cardiac surgical capacity remains insufficient, disproportionately affecting the world's poorest regions.

The safe introduction of robotic surgery in a free-standing children's hospital

The aim of this study is to report the experience of implementing a pediatric robotic surgery program at a free-standing pediatric teaching hospital. A database was created to prospectively collect perioperative data for all robotic surgeries performed by the pediatric surgery department. The database was queried for all operations completed from October 2015 to December 2021. Descriptive statistics were used to characterize the dataset, using median and interquartile ranges for continuous variables. From October 2015 to December 2021, a total of 249 robotic surgeries were performed in the department of pediatric surgery. Of the 249 cases, 170 (68.3%) were female and 79 (31.7%) were male. Across all patients, there was a median weight (IQR) of 62.65 kg (48.2-76.68 kg) and a median (IQR) age of 16 years (13-18 years). The median (IQR) operative time was 104 min (79.0-138 min). The median console time was 54.0 min (33.0-76.0 min) and the median docking time was 7 min (5-11 min). The majority of procedures were performed on the biliary tree (52.6%). In the 249 procedures, there were no technical failures of the robot and only two operations (0.8%) were converted to open procedures and one (0.4%) to laparoscopic. This study highlights the ability to successfully integrate a pediatric robotic surgery program into a free-standing children's hospital with a low conversion rate. Additionally, the program extended across multiple surgical procedures and offered real-time exposure to advanced surgical techniques for current and aspiring pediatric surgery trainees.

Developing a Surgical Simulation Curriculum for the Rwandan Context

OBJECTIVE

We report on the development and implementation of a surgical simulation curriculum for undergraduate medical students in rural Rwanda.

DESIGN

This is a narrative report on the development of scenario and procedure-based content for a junior surgical clerkship simulation curriculum by an interdisciplinary team of simulation specialists, surgeons, anesthesiologists, medical educators, and medical students.

SETTING

University of Global Health Equity, a new medical school located in Butaro, Rwanda.

PARTICIPANTS

Participants in this study consist of simulation and surgical educators, surgeons, anesthesiologists, research fellows and University of Global Health Equity medical students enrolled in the junior surgery clerkship.

RESULTS

The simulation training schedule was designed to begin with a 17-session simulation-intensive week, followed by 8 sessions spread over the 11-week clerkship. These sessions combined the use of high-fidelity mannequins with improvised, bench-top surgical simulators like the GlobalSurgBox, and low-cost gelatin-based models to effectively replace resource intensive options.

CONCLUSIONS

Emphasis on contextualized content generation, low-cost application, and interdisciplinary design of simulation curricula for low-income settings is essential. The impact of this curriculum on students' knowledge and skill acquisition is being assessed in an ongoing fashion as a substrate for iterative improvement.

Simulation-Based Breast Biopsy Training Using a Low-Cost Gelatin-Based Breast Model in Rwanda

BACKGROUND

An interdisciplinary team of healthcare providers and simulation specialists adopted and modified a protocol for the creation of a low-cost, gelatin-based breast model for teaching ultrasound-guided breast biopsy and assessed first-time user experience.

METHODS

An interdisciplinary team of healthcare providers and simulation specialists adopted and modified a protocol for the creation of a low-cost, gelatin-based breast model for teaching ultrasound-guided breast biopsy for approximately $4.40 USD. Components include medical-grade gelatin, Jell-O™, water, olives, and surgical gloves. The model was used to train two cohorts comprising 30 students total during their junior surgical clerkship. The learners' experience and perceptions on the first Kirkpatrick level were evaluated using pre- and post-training surveys.

RESULTS

Response rate was 93.3% (n = 28). Only three students had previously completed an ultrasound-guided breast biopsy, and none had prior exposure to simulation-based breast biopsy training. Learners that were confident in performing biopsies under minimal supervision rose from 4 to 75% following the session. All students indicated the session increased their knowledge, and 71% agreed that the model was an anatomically accurate and appropriate substitute to a real human breast.

CONCLUSIONS

The use of a low-cost gelatin-based breast model was able to increase student confidence and knowledge in performing ultrasound-guided breast biopsies. This innovative simulation model provides a cost-effective and more accessible means of simulation-based training especially for low- and middle-income settings.

Determining Critical Topics for Undergraduate Surgical Education in Rwanda: Results of a Modified Delphi Process and a Consensus Conference

Background Developing a contextually appropriate curriculum is critical to train physicians who can address surgical challenges in sub-Saharan Africa. An innovative modified Delphi process was used to identify contextually optimized curricular content to meet sub-Saharan Africa and Rwanda's surgical needs. Methods Participants were surgeons from East, Central, Southern, and West Africa and general practitioners with surgical experience. Delphi participants excluded or prioritized surgical topic areas generated from extensive grey and formal literature review. Surgical educators first screened and condensed identified topics. Round 1 screened and prioritized identified topics, with a 75% consensus cut-off based on the content validity index and a prioritization score. Topics that reached consensus were screened again in round 2 and re-prioritized, following controlled feedback. Frequencies for aggregate prioritization scores, experts in agreement, item-level content validity index, universal agreement and scale-level content validity index based on the average method (S-CVI/Ave) using proportion relevance, and intra-class correlation (ICC) (based on a mean-rating, consistency, two-way mixed-effects model) were performed. We also used arithmetic mean values and modal frequency. Cronbach's Alpha was also calculated to ascertain reliability. Results were validated through a multi-institution consensus conference attended by Rwanda-based surgical specialists, general practitioners, medical students, surgical educators, and surgical association representatives using an inclusive, participatory, collaborative, agreement-seeking, and cooperative, a priori consensus decision-making model. Results Two-hundred and sixty-seven broad surgical content areas were identified through the initial round and presented to experts. In round 2, a total of 247 (92%) content areas reached 75% consensus among 31 experts. Topics that did not achieve consensus consisted broadly of small intestinal malignancies, rare hepatobiliary pathologies, and transplantation. In the final round, 99.6% of content areas reached 75% consensus among 31 experts. The highest prioritization was on wound healing, fluid and electrolyte management, and appendicitis, followed by metabolic response, infection, preoperative preparation, antibiotics, small bowel obstruction and perforation, breast infection, acute urinary retention, testicular torsion, hemorrhoids, and surgical ethics. Overall, the consistency and average agreement between panel experts was strong. ICC was 0.856 (95% CI: 0.83-0.87). Cronbach's Alpha for round 2 was very strong (0.985, 95% CI: 0.976-0.991) and higher than round 1, demonstrating strong reliability. All 246 topics from round 4 were verbally accepted by 40 participants in open forum discussions during the consensus conference. Conclusions A modified Delphi process and consensus were able to identify essential topics to be included within a highly contextualized, locally driven surgical clerkship curriculum delivered in rural Rwanda. Other contexts can use similar processes to develop relevant curricula.

Pediatric Single-Incision Robotic Cholecystectomy: A 6-Year Update from a Single Institution

Introduction: In children, gallbladder disease has become more common due to the rise in childhood obesity and subsequent shift in etiology. While the gold standard of surgical management remains a laparoscopic technique, there has been increasing interest in robotic-assisted techniques. The aim of this study is to report a 6-year update on the experience of treating gallbladder disease with robotic-assisted surgery at a single institution. Materials and Methods: A database was created to prospectively collect patient demographic and operative variables at the time of operation from October 2015 to May 2021. Descriptive analysis of select available variables was performed using median and interquartile ranges (IQRs) for all continuous variables. Results: In total, 102 single-incision robotic cholecystectomies and one single-port subtotal cholecystectomy were performed. From available data, 82 (79.6%) patients were female, median weight was 66.25 kg (IQR: 58.09-74.24 kg), and median age was 15 years (IQR: 15-18 years). Median procedure time was 84 minutes (IQR: 70.25-103.5 minutes) and median console time was 41 minutes (IQR: 30-59.5 minutes). The most frequent preoperative diagnosis was symptomatic cholelithiasis (79.6%). One (0.97%) operation was converted from a single-incision robotic approach to open. Conclusion: Single-incision robotic cholecystectomy is a safe and reliable technique for the treatment of gallbladder disease in the adolescent population.

Exploring the distribution of risk factors for drop-out from Ponseti treatment for clubfoot across Bangladesh using geospatial cluster analysis

Clubfoot is a congenital anomaly affecting 1/1,000 live births. Ponseti casting is an effective and affordable treatment. About 75% of affected children have access to Ponseti treatment in Bangladesh, but 20% are at risk of drop-out. We aimed to identify the areas in Bangladesh where patients are at high or low risk for drop-out. This study used a cross-sectional design based on publicly available data. The nationwide clubfoot program: 'Walk for Life' identified five risk factors for drop-out from the Ponseti treatment, specific to the Bangladeshi setting: household poverty, household size, population working in agriculture, educational attainment and travel time to the clinic. We explored the spatial distribution and clustering of these five risk factors. The spatial distribution of children <5 years with clubfoot and the population density differ widely across the different sub-districts of Bangladesh. Analysis of risk factor distribution and cluster analysis showed areas at high risk for dropout in the Northeast and the Southwest, with poverty, educational attainment and working in agriculture as the most prevalent driving risk factor. Across the entire country, twenty-one multivariate high-risk clusters were identified. As the risk factors for drop-out from clubfoot care are not equally distributed across Bangladesh, there is a need in regional prioritization and diversification of treatment and enrolment policies. Local stakeholders and policy makers can identify high-risk areas and allocate resources effectively.

The Epidemiology and Outcome of Pericardial Effusion in Hospitalized Children: A National Database Analysis

OBJECTIVES

To describe the epidemiology of pericardial effusion in hospitalized children and evaluate risk factors associated with the drainage of pericardial effusion and hospital mortality.

STUDY DESIGN

A retrospective study of a national pediatric discharge database.

RESULTS

We analyzed hospitalized pediatric patients from the neonatal age through 20 years in the Kids' Inpatient Database 2016, extracting the cases of pericardial effusion. Of the 6 266 285 discharged patients recorded, 6417 (0.1%) were diagnosed with pericardial effusion, with the highest prevalence of 2153 patients in teens (13-20 years of age). Pericardial effusion was drained in 792 (12.3%), and the adjusted risk of pericardial drainage was statistically low with rheumatologic diagnosis (OR, 0.485; 95% CI, 0.358-0.657, P < .001). The overall mortality in children with pericardial effusion was 6.8% and 10.9% of those who required pericardial effusion drainage (P < .001). The adjusted risk of mortality was statistically high with solid organ tumor (OR, 1.538; 95% CI, 1.056-2.239, P = .025) and pericardial drainage (OR, 1.430; 95% CI, 1.067-1.915, P = .017) and low in all other age groups compared with neonates, those with cardiac structural diagnosis (OR, 0.322; 95% CI, 0.212-0.489, P < .001), and those with rheumatologic diagnosis (OR, 0.531; 95% CI, 0.334-0.846, P = .008).

CONCLUSION

The risk of mortality in hospitalized children with pericardial effusion was higher in younger children with solid organ tumors and those who required pericardial effusion drainage. In contrast, it was lower in older children with cardiac or rheumatologic diagnoses.

Early discharge on postoperative day 1 following lobectomy for stage I non-small-cell lung cancer is safe in high-volume surgical centres: a national cancer database analysis

OBJECTIVES

Shortening hospital length of stay after lobectomy for stage I non-small-cell lung cancer (NSCLC) remains a challenge, and the literature regarding factors associated with safe early discharge is limited. We sought to evaluate the safety of postoperative day (POD) 1 discharge after lobectomy and its correlation with institutional caseload using the National Cancer Database, jointly sponsored by the American College of Surgeons and the American Cancer Society.

METHODS

We identified patients with stage I NSCLC (tumour ≤4 cm, clinical N0, M0) in the National Cancer Database who underwent lobectomy from 2010 to 2015. Hospital surgical volume was assigned based on total surgical volume for lung cancer. The cohort was divided into 2 groups: POD 1 discharge [length of stay (LOS) ≤ 1] and the standard discharge (LOS > 1). Outcome variables were compared in propensity matched cohorts, and the multivariable regression model was created to assess factors associated with LOS ≤ 1 and the occurrence of adverse events (unplanned readmissions, 30- and 90-day deaths).

RESULTS

A total of 52 830 patients underwent lobectomy for stage I NSCLC across 1231 treating facilities; 3879 (7.3%) patients were discharged on day 1 (LOS ≤ 1), whereas 48 951 (92.7%) were discharged after day 1 (LOS > 1). Factors associated with LOS ≤ 1 included male sex, higher socioeconomic status, right middle lobectomy, minimally invasive surgery and high-volume centres. The risk of adverse events was higher for LOS ≤ 1 in low [odds ratio (OR): 1.913, 95% confidence interval (CI) 1.448-2.527; P < 0.001] and median quartiles (OR: 2.258; 95% CI 1.881-2.711; P < 0.001), but equivalent in high-volume centres (OR: 0.871, 95% CI 0.556-1.364; P = 0.54).

CONCLUSIONS

The safety and efficacy of early discharge on POD 1 following lobectomy are associated with lung cancer surgical volume. Implementation of 'enhanced recovery' protocols is likely related to safe early discharges from high-volume centres.

Resource Mobilization for Global Surgery: Lessons Learned From US Government Appropriations Advocacy

The US Agency for International Development (USAID) receives directives and funding through the appropriation process, though until recently, global surgery was not included in its mission. Nevertheless, an estimated five billion people lack access to safe, timely, and affordable surgical care, in large part due to lack of economic resources. Using coalition-based advocacy, the G4 Alliance successfully developed and submitted language that was incorporated into the 2020 Appropriations report language, directing USAID to financially support global surgery. This has significant implications for global surgical investment, yet few advocates are aware of the 2020 Appropriations language, let alone how they can utilize it now to advance global surgery in their respective countries. Here, we describe how advocates navigate the US appropriations process and the ways USAID funds are obtained for the purposes of global health. We also highlight the importance of coalition-based advocacy and provide guidance in how to increase success.

Initial Experience with Robotic Inguinal Hernia Repair in the Adolescent Population

Purpose: There is no one standard procedure encompassing the needs and differences of the entire pediatric population for inguinal hernia repair (IHR). Several techniques can be used, including open repair, laparoscopic, and robotic-assisted laparoscopic repair. This is a report of a single pediatric hospital's experience performing robotic-assisted IHRs in an adolescent population. Methods: Robotic IHRs performed by the pediatric surgery department were prospectively captured and reviewed. The operation performed was a modified robotic transabdominal preperitoneal approach with ProGrip mesh. Results: Between January 2016 and August 2020, 11 robotic-assisted IHRs occurred. All patients were male, median weight interquartile range (IQR) was 76.6 kg (67.425-90.4 kg) and median age (IQR) was 17 years (17-18.5). All together median (IQR) total operative time was 111 (97.5-126) minutes, median (IQR) total console time was 60 (55.5-75.5) minutes. There were no complications or conversions, with all patients discharged on the day of the operation. Conclusion: This study demonstrates a safe and reliable approach to repairing inguinal hernias using robotics through a small initial case series. Robotic-assisted IHR should be considered a viable technique to optimize the surgical care of adolescents.

Investments in surgical systems contribute to pandemic readiness and health system resilience

Safe surgical care, including anesthesia, obstetrics, and trauma, is an essential component of a functional health system, yet five billion people lack access to high-quality, timely and affordable surgical care. As health decision makers are grappling with how to make appropriate investments for crisis readiness and resilience, investments in surgical care should be considered for their compounding benefits to meet a country's diverse health goals. National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) are developed through global partnerships and multi-stakeholder consensus and provide a dynamic framework for surgical scale-up that also improves the resilience of the larger health system. Our paper applies principles from the literature on health system resilience to surgical systems and examines the unique capabilities of the surgical workforce and infrastructure to be redeployed during times of crisis, using examples from the current pandemic.