Publications & Literature

2010 Burden of Surgical Disease Bibliography

Highlights of 2009-2010

1. Bemudez, L., V. Carter, et al., “Surgical Outcomes Auditing Systems in Humanitarian Organizations.” World J Surg. 2010; 34(3):403-10.

Operation Smile developed a cleft surgery outcomes database and evaluation system using pre- and post-operative photographs that were reviewed by independent evaluators. Twenty percent of patients returned for one-year postoperative visits, which were completed by local foundations, and their photographs were sent to the organization’s international headquarters. Outcomes data was returned to the mission teams and individual surgeons about the patients on whom they had operated one-year prior. Five hundred eighty procedures were evaluated and feedback reports were provided to 134 volunteer surgeons. The authors note that this method enabled evaluation of cosmetic outcomes, but not outcomes involving feeding, breathing, or hearing.

2. Bickler, S., D. Ozgediz, et al. “Key concepts for estimating the burden of surgical conditions and the unmet need for surgical care.” World J Surg. 2010; 34(3): 374-80.

The paper proposes key terminology for analyzing surgical care from a public health perspective and outlines a conceptual framework for estimating the burden of surgical conditions and need for surgical care. Cummulative surgical Disability Adjusted Life Years (DALYs), which measure the burden of surgical conditions, can be calculated using disability weights (DW) and values for surgical care (VSC), accounting for age-specific cumulative risk of surgical disease. The impact of surgical care, or “met need,” is determined as surgical DALYs averted.

3. Bickler, S. W. and D. Spiegel “Improving surgical care in low- and middle-income countries: a pivotal role for the world health organization.” World J Surg. 2010; 34(3): 386-90.

The WHO has expanded its interest in surgical care and is strategically placed to promote and develop safe and timely surgical care. The authors propose two steps to move the surgical agenda forward: 1. A World Health Assembly amendment confirming the critical role of emergency and essential surgery within the health system, and 2. Promotion of “structured collaborations” between WHO and other stakeholders in the form of sponsored WHO fellowships, research, and involvement in Emergency and Essential Surgical Care (EESC) workshops in low and middle-income countries (LMICs).

4. Chu, K., P. Rosseel, et al. “Surgeons Without Borders: A Brief History of Surgery at Médicins Sans Frontières.” World J Surg. 2010; 34(3):411-14.

Médicins Sans Frontières (MSF) began in 1981 by providing humanitarian aid to war refugees. One of the organization’s strengths is its supply chain, by which it has the ability to set up major operating facilities within 48 hours in remote areas using large pre-packaged surgical kits. MSF surgeons perform vascular, obstetrical, orthopaedic, and other specialized surgical procedures. MSF also provide surgical care in post-conflict contexts and occasionally trains local practitioners in anesthesia and basic surgery to build local capacity. The organization acknowledges that the long-term solution to alleviating the global burden of surgical disease lies in building a domestic surgical workforce and infrastructure; however, the organization plays a critical role in providing relief during acute emergencies.

5. Corlew, D. S. “Estimation of Impact of Surgical Disease Through Economic Modeling of Cleft Lip and Palate Care.” World J Surg. 2010; 43(3):391-6.

The economic impact of cleft repair in a developing country is modeled using data from 568 patients receiving surgical cleft care by the NGO Interplast in Katmandu, Nepal. Using Gross National Income (GNI) per capita, cleft repair added $856-$6,598 (cleft lip) and $2,293-$17,278 (cleft palate) to lifetime individual income. Using the more liberal Value of a Statistical Life, potential economic gains were $56,919-$143,363 (cleft lip) and $152,372-$375,412 (cleft palate). The cost of care per DALY averted was $29-73 USD.

6. Dubowitz, G., S. Detlefs, et al. “Global Anesthesia Workforce Crisis: A Preliminary Survey Revealing Shortages Contributing to Undesirable Outcomes and Unsafe Practices.” World J Surg. 2010; 34(3):438-44.

A pilot Internet-based survey was conducted to estimate per-capita anesthesia providers in low and middle income countries. Based on responses from workers in 14 countries, most low and low middle income countries have less than 1 anesthesia provider per 100,000 people, ranging from Yemen with 0.07 providers/100K to Swaziland with 1.41/100K.

7. Gosselin, R. A., A. Maldonado, et al. “Comparative Cost-Effectiveness Analysis of Two MSF Surgical Trauma Centers.” World J Surg. 2010; 34(3): 415-9.

Cost-effectiveness of surgical care provided by MSF in two of their surgical trauma hospitals (Teme hospital in Nigeria and La Trinite Hospital in Haiti) during a three-month period was evaluated using the Global Burden of Disease methodology. The costs were $172 (Nigeria) and $233 (Haiti) per DALY averted. These values are compared with cost-effectiveness analyses for surgical and non-surgical services in other countries.

8. Kushner, A. L., M. N. Cherian, et al. “Addressing the millennium development goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries.” Arch Surg. 2010; 145(2): 154-9.

A survey of 132 district-level health facilities in 8 LMICs was conducted to assess the availability of infrastructure, supplies, and procedures relating to surgical and anesthetic interventions for the reduction of child mortality (MDG 4), improvement of maternal health (5), and reduction in HIV/AIDS transmission (6). The surveys included site visits, on-site inspections, and interviews with key personnel. Most facilities demonstrated shortfalls in basic infrastructure (water, electricity, oxygen) and functioning anesthesia machines. Less than half were capable of performing modest-complexity operations including cesarean sections and appendectomies or life-saving emergency surgical procedures such as cricothyroidotomy and chest tube insertion. Few facilities consistently had appropriate protective attire for operating room staff.

9. Magee, W. P., R. Vander Burg, et al. “Cleft Lip and Palate as a Cost-effective Health Care Treatment in the Developing World.” World J Surg. 2010; 34(3):420-7.

The cost-effectiveness of cleft lip and palate repairs by the nonprofit organization Operation Smile is analyzed using two methods. Using the Disease Control Priorities Project (DCP1) Life Tables, which suggest that the entire burden of a cleft lip/palate is incurred within the first 4 years of life, the cost per DALY averted range from $278-$1827. Based on the observation that older children with clefts suffer from teasing, poor self-esteem, and decreased educational opportunities, the authors propose a modification to the Life Tables that reflects disability associated with these deformities for the entire life span, yielding a cost per DALY averted of $8-$96.

10. McQueen, K. A., J. A. Hyder, et al. “The provision of surgical care by international organizations in developing countries: a preliminary report.” World J Surg. 2010; 34(3): 397-402.

This article describes an Internet-based survey of International Organizations (IOs) delivering surgical care in developing nations. Forty-six organizations (response rate 46%) provided 223,425 cases per year. Most organizations routinely collect data on surgical volume, case mix, and outcomes. The majority of IOs integrate with the referral patterns of local providers, incorporate these practitioners into their organization’s delivery of care, and have provisions for follow-up care in place. Eighty-nine percent reported that they incorporate education and training into their missions.

11. McQueen, K. A., P Parmar, et al. “Burden of Surgical Disease: Strategies to Manage an Existing Public Health Emergency – Report of the 2009 Humanitarian Action Summit Working Group.” Prehospital and Disaster Medicine. 2009; 24(4): 228-31.

Proceedings of a Burden of Surgical Disease Working Group meeting during the 2009 Harvard Humanitarian Initiative’s Humanitarian Action Summit (HHI/HAS). The group discussed results of an online surgery of 100 International Organizations (IOs) that provide surgical services globally. They made the following recommendations for improved surgical service delivery by humanitarian organizations: 1. Understand the local needs and resources; 2. Incorporate best practices into ongoing delivery of surgical care including infrastructure, safety checklists, and appropriate follow-up; and 3. Integrate routine collection of data on surgical conditions and outcomes.

12. Mock, C., M. Cherian, et al. “Developing priorities for addressing surgical conditions globally: furthering the link between surgery and public health policy.” World J Surg. 2010; 34(3): 381-5.

The authors propose preliminary methods for defining global priorities in surgical care and suggest examples of surgical conditions that may fit in each priority group. Priority 1 surgical conditions have a large public health burden for which there is a highly successful surgical procedure that is cost-effective and globally feasible. The authors assert that identification of priority surgical conditions could inform and direct national and international public health efforts. They caution against vertical approaches to addressing specific surgical conditions, instead promoting comprehensive surgical capacity-building.

13. Newton, M. and P. Bird “Impact of Parallel Anesthesia and Surgical Provider Training in Sub-Saharan Africa: A Model for a Resource-poor Setting.” World J Surg. 2010; 34(3): 445-52.

A training program for surgeons and anesthesia providers was developed in rurally-located Kijabe Hospital in Kenya to meet the surgical needs of rural Kenyan patients. The anesthesia program emphasizes obstetric, trauma, pediatric, and regional anesthesia based on the epidemiology of surgical conditions and available resources in rural Africa. In the past 10 years, 18 RNs have been recruited from rural health centers, trained as nurse anesthetists in a 15-18-month program at Kijabe Hospital, and returned to their rural communities. Fifty-five intern-level surgeons have been trained in the specialities of general surgery, obstetrics/gynecology, and orthopedics. During this time the surgical caseload at Kijabe Hospital has increased four-fold, and case complexity has subjectively increased.

14. Nthumba, P. M. “”Blitz surgery”: redefining surgical needs, training, and practice in sub-saharan Africa.” World J Surg. 2010; 34(3): 433-7.

The author argues that reconstructive operations performed during surgical “blitzes” (short trips by individuals and organizations to developing countries) have poorer outcomes than local, in-hospital procedures, primarily because of inadequate preoperative and postoperative care. The “blitz” approach neglects a significant majority of the population and promotes community dependence on unsustainable services. The author envisions a new reconstructive surgical service tailor-made for Africa that is affordable and sustainable yet able to deliver quality surgical care to the remotest villages through involvement of local communities and the training and retention of local surgeons.

15. Perkins, R. S., K. M. Casey, et al. “Addressing the Global Burden of Surgical Disease: Proceedings from the 2nd Annual Symposium at the American College of Surgeons.” World J Surg. 2010; 34(3):371-3.

The article introduces the GBoSD Working Group and highlights papers presented during the 2009 ACS Clinical Congress in Chicago.

16. Riviello, R., D. Ozgediz, et al. “Role of Collaborative Academic Partnerships in Surgical Training, Education, and Provision.” World J Surg 2010; 34(3):459-65.

Six partnerships between North American academic medical centers and teaching hospitals in developing countries are discussed. Drawing from these examples, the authors emphasize the importance of relationship-building, mutual learning, support of local “advocates,” prioritizing local training needs over expatriate training needs, research collaborations, adaptation of the mission to locally expressed needs, multidisciplinary approaches, and measurement of outcomes.

17. Rosseel, P., M. Trelles, et al. “Ten years of experience training non-physician anesthesia providers in Haiti.” World J Surg. 2010; 34(3): 453-8.

Authors discuss Medicine Sans Fronteir’s (MSF’s) nurse anesthetist (NA) training program, which graduated 24 students between 1998 and 2008. The program was 15-18 months long and was coordinated by expatriate anesthesiologists. Of graduates, 79% continue to work as NAs in Haiti (63% in private hospitals, 26% public, 16% mixed). Challenges to this program include lack of sustainability due to the NGO funding and administering the program, lack of acceptance by Haitian anesthesiologists and medical professional societies, and inadequate renumeration for NAs working in the public sector.

18. Taira, B. R., M. N. Cherian, et al. “Survey of emergency and surgical capacity in the conflict-affected regions of Sri Lanka.” World J Surg. 2010. 34(3): 428-32.

Forty-seven hospitals in the conflict affected areas of northern and eastern Sri Lanka were surveyed using the WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care (EESC). The data set was further limited to the thirty-one respondents from district and base hospitals (first level of care). Most facilities had water and about half had consistent electricity. Forty-eight percent had an OR and 57% had medical officers trained to perform basic surgical procedures. There were two surgeons and two OB/Gyn physicians among all 31 hospitals surveyed. All first-level facilities referred patients requiring laparotomy and most referred for hernia repair. Twenty-four percent referred for incision and drainage, usually because of lack of supplies. Forty-five percent of facilities did not have supplies to start an intravenous infusion.

19. Weiser, T. G., M. A. Makary, et al. “Standardised metrics for global surgical surveillance.” Lancet. 2009; 374(9695): 1113-7.

WHO’s Safe Surgery Saves Lives initiative developed measures for assessing structure, volume, and outcome of surgical services at a national level, which included the following: number of operating rooms, number of operations, number of accredited surgeons, number of accredited anaesthesia professionals, day-of-surgery death ratio, and postoperative in-hospital death ratio. One hospital in each of eight different countries was asked to provide this information retrospectively. All hospitals were able to report on each of these measures, although they had most difficulty reporting the outcome measures, as this often required cross-referencing of death registries with surgical records.

Spotlight on Haiti

1. Devi, S. “Helping earthquake-hit Haiti.” Lancet. 2010; 375(9711): 267-8.

The author discusses medical priorities immediately after the quake, which included triage, stabilization of the wounded, and referrals for surgical needs. Accordingly, organizers sought assistance from trained surgeons with experience working in war or disaster zones.

2. Ivers, L. C. and K. Cullen “Coordinating and Prioritizing Aid in Haiti.” N Engl J Med. 2010; 362(7):e21 (Epub).

The authors remind readers that in addition to persistent surgical needs in Haiti, particularly for advanced orthopedic care, the international community should also anticipate intermediate and long-term needs, which will include postoperative care, physical therapy, prosthetics, and mental health interventions.

3. Pape, J. W., W. D. Johnson, Jr., et al. “The Earthquake in Haiti — Dispatch from Port-au-Prince.” N Engl J Med. 2010; 362(7): 575-7.

The authors from the Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), whose clinic became a US Department of Health and Human Services field hospital, assert that more than 95% of the medical problems seen in the first week after the quake were trauma-related. They expressed concerns related to security, availability of supplies, and the need for an inventory of hospital-capacity as well as a way to inform the population of what services are available and what hospitals.

4. Sullivan, S. R., H. O. Taylor, et al. “Surgeons’ Dispatch from Cange, Haiti.” N Engl J Med. 2010; 362(7):e19 (Epub).

A surgeon working in Cange’s free clinic (run by Partners in Health and Zanmi Lasante) describes his team’s efforts to provide surgical care in the aftermath of the earthquake. The team of five surgeons and local staff performed 122 operations in their first 9 days. The most common injuries requiring surgical care included crush injuries, fractured limbs, compartment syndromes, and massive wounds. Heparin prophylaxis protocols and dialysis services were established after several cases of pulmonary emboli and renal failure secondary to rhabdomyolysis were identified. The author notes that months to years of ongoing surgical and postoperative care will be needed to deal with the injuries inflicted by this disaster.

Training (The Workforce in Developing Countries)

1. Cameron, B. H., M. Rambaran, et al. “International surgery: the development of postgraduate surgical training in Guyana.” Canadian J Surg. 2010; 53(1): 11-6.

The University of Guyana developed a 2.5 year surgical training program in collaboration with the Canadian Association of General Surgeons (CAGS), who assisted with needs assessment, curriculum development, Ministry of Health (MOH) approval, funding, and creation of an evaluation system for residents-in-training. Residents were trained by Guyanese and visiting Canadian surgical faculty coordinated through CAGS.

2. Degiannis, E., G. J. Oettle, et al. “Surgical education in South Africa.” World J Surg. 2009; 33(2): 170-3.

Key features of surgical training in South Africa are outlined. After completing undergraduate training, students do a two-year internship in an accredited hospital, followed by one year of community service in a rural hospital where they function independently. They can then train as residents in general surgery for 4-6 years. Trainees are required to take a series of written and oral examinations, keep a logbook of their cases, and achieve first authorship on a publication in a peer-reviewed journal. They can then choose to do two years of subspecialty training. Systemic challenges identified include non-uniform examinations, tension regarding the state Department of Health’s role in employing clinical academics, and “brain drain” to other countries and the private sector.

3. Ezeome, E. R., S. O. Ekenze, et al. “Surgical training in resource-limited countries: moving from the body to the bench–experiences from the basic surgical skills workshop in Enugu, Nigeria.” Trop Doct. 2009; 39(2): 93-7.

Basic surgical skills training (BSS) was introduced into a Nigerian teaching hospital via a collaboration between surgical organizations and a corporate sponsor. The project leaders assert that with a dedicated team of local faculties, giving the local medical trainers a short introduction to the practicalities of organizing and conducting BSS is enough to jump start such a program in resource-poor countries.

4. Luboga, S., M. Galukande, et al. “Recasting the role of the surgeon in Uganda: a proposal to maximize the impact of surgery on public health.” Trop Med Int Health. 2009; 14(6): 604-8.

The authors argue that the clinical and educational role played by surgeons in developing countries must be redefined, with the surgeon assuming a greater role in leadership, management, and public health advocacy by documenting the unmet need for surgery and the resources required to improve access to care.

5. Monjok, E. “The neglect of the global surgical workforce: experience and evidence from Uganda.” World J Surg. 2009; 33(1): 150-1; author reply 152-3.

This general practitioner and administrator shares a possible solution employed in Mozambique. Through short postgraduate training programs (18 months), the country trains “tecnicos de cirurgica,” to increase surgical services in rural populations.

6. Riviello, R., D. Ozgediz, et al. “Role of Collaborative Academic Partnerships in Surgical Training, Education, and Provision.” World J Surg 2010; 34(3):459-65.

7. Sani, R., B. Nameoua, et al. “The impact of launching surgery at the district level in Niger.” World J Surg. 2009; 33(10): 2063-8.

This article describes and evaluates an initiative to provide surgery in district hospitals via a 12-month basic surgery training program for rural general practitioners. After implementation of the program, 544 operations were done in one year in three district hospitals located in the same region. Thirty-eight percent were emergent (70% were cesarean sections and 8% were done for uterine rupture) and 62% were elective (81% were hernia repairs). Transfers to the regional hospital were reduced from 82% to 52% one year post-intervention, after which most transfers were for fractures and abdomino-thoracic trauma. There were no deaths from elective surgery at the district level and the morbidity rate was comparable to the regional hospital. All physicians trained in the program remained at their posts at the time of publication.

Access to Surgical Care

1. Carson, P. J. “Providing specialist services in Australia across barriers of distances and culture.” World J Surg. 2009; 33(8):1562-7.

The author describes provision of specialist surgical services to patients in the geographically and culturally isolated Northern Territory of Australia. In lieu of transporting patients long distances to provide subspecialty surgical care, general surgeons in these remote areas receive additional training in a breadth of surgical subspecialties, and also maintain ongoing communication with specialist surgeons residing in the more populous southern area of the country.

2. Ryan, S. M., P. Milsom, et al. “Travelling surgeons–a clinical audit of laparoscopic cholecystectomy procedures in Northland, New Zealand.” N Z Med J. 2009; 122(1305): 34-40.

Laparoscopic cholecystectomy (LC) in remote Northland, New Zealand is performed by traveling surgeons. A retrospective audit of 149 LCs using this model revealed low complication rates commensurate with international standards.

Training (US Residents/Fellows)

1. Jayaraman, S. P., A. L. Ayzengart, et al. “Global health in general surgery residency: a national survey.” J Am Coll Surg. 2009; 208(3): 426-33.

This reports on a nationwide survey of US residency program directors regarding the nature and scope of their programs’ involvement in global surgery. Of the 73 programs that responded, 33% offered educational activities in global health, most of which consisted of clinical rotations. Expressed goals of the programs were to prepare residents for careers in global health and working with underserved communities and to improve resident recruitment. Fifty-seven percent with no current program expressed interest in global surgery programs and cited time constraints, lack of approval from the ACGME or RRC, and funding as barriers to developing such programs. Sixty-seven percent of those with programs reported that there was no active reciprocal relationship with their partner institutions.

2. Ozgediz, D., J. Wang, et al. “Surgical training and global health: initial results of a 5-year partnership with a surgical training program in a low-income country.” Arch Surg. 2008; 143(9): 860-5; discussion 865.

The article discusses the global health activities of surgical residents and faculty from UCSF before and after development of a formalized relationship with Makerere University in Kampala, Uganda in 2003. Before 2003, 4 faculty and 1 resident made overseas trips. Since establishment of the program, 10 residents and 12 faculty members have been involved with the Ugandan training program. Challenges to increased involvement are discussed – these include limited funding, lack of a clear faculty advancement pathway, and lack of RRC approval for resident clinical activities overseas.

Metrics, Quality, & Outcomes

1. Bemudez, L., V. Carter, et al., “Surgical Outcomes Auditing Systems in Humanitarian Organizations.” World J Surg. 2010; 34(3):403-10.

2. Bickler, S., D. Ozgediz, et al. “Key concepts for estimating the burden of surgical conditions and the unmet need for surgical care.” World J Surg. 2010; 34(3): 374-80.

The paper proposes key terminology for analyzing surgical care from a public health perspective and outlines a conceptual framework for estimating the burden of surgical conditions and need for surgical care. Cummulative surgical DALYs, which measure the burden of surgical conditions, can be calculated using disability weights (DW) and values for surgical care (VSC), accounting for age-specific cumulative risk of surgical disease. The impact of surgical care, or “met need,” is determined as surgical DALYs averted.

3. Corlew, D. S. “Estimation of Impact of Surgical Disease Through Economic Modeling of Cleft Lip and Palate Care.” World J Surg. 2010; 43(3):391-6.

4. Fuglistaler-Montali, I., C. Attenberger, et al. “In search of benchmarking for mortality following multiple trauma: a Swiss trauma center experience.” World J Surg. 2009; 33(11): 2477-89.

The authors propose establishing the NTDB-TRISS as an international standard for measuring outcomes of multiple trauma. Based on their analysis of multiple scoring systems for prediction of mortality in prospectively-collected data from a Swiss university hospital, the NTDB-TRISS combines the highest statistical precision with the highest benchmark level in the prediction of 30-day mortality.

5. Gosselin, R. A., A. Maldonado, et al. “Comparative Cost-Effectiveness Analysis of Two MSF Surgical Trauma Centers.” World J Surg. 2010; 34(3): 415-9.

6. Juillard, C. J., C. Mock, et al. “Establishing the evidence base for trauma quality improvement: a collaborative WHO-IATSIC review.” World J Surg. 2009; 33(5): 1075-86.

A review of the effectiveness of trauma quality improvement (QI) programs was conducted in preparation for developing Guildines for Trauma Quality Improvement Programmes. Thirty-six articles evaluated the effect comprehensive and issue-specific QI programs on mortality and various other outcomes, including cost. All but two of the 36 articles noted significant improvement in the measured outcome after implementation of a QI program. Several also noted cost-savings. Of note, 34/36 articles were from high income countries. The other two were from the same institution in Thailand, and both reported trauma QI processes that resulted in decreased mortality.

7. Magee, W. P., R. Vander Burg, et al. “Cleft Lip and Palate as a Cost-effective Health Care Treatment in the Developing World.” World J Surg. 2010; 34(3):420-7.

8. Mayer, E. K., A. Chow, et al. “Appraising the quality of care in surgery.” World J Surg. 2009; 33(8): 1584-93.

This article discusses the need for a structured framework to measure quality of surgical care that incorporates both clinical pathway measures (structure of care, process of care, outcome of care, and economic measures of care) and patient-reported measures (patient-reported treatment outcomes, health-related quality of life measures, and patient satisfaction). Combining these measures to create an overall composite quality score can be made feasible only if it is supported by the use of robust statistical methodology.

9. McQueen, K. A., W. Magee, et al. “Application of outcome measures in international humanitarian aid: comparing indices through retrospective analysis of corrective surgical care cases.” Prehosp Disaster Med. 2009; 24(1): 39-46.

This article presents outcomes of operations performed during Operation Smile surgical missions. The study exemplifies the importance of collecting, analyzing, and reporting measures of effectiveness in all surgical settings.

10. Weiser, T. G., M. A. Makary, et al. “Standardised metrics for global surgical surveillance.” Lancet. 2009; 374(9695): 1113-7.

WHO’s Safe Surgery Saves Lives initiative developed measures for assessing structure, volume, and outcome of surgical services at a national level, which included the following: number of operating rooms, number of operations, number of accredited surgeons, number of accredited anaesthesia professionals, day-of-surgery death ratio, and postoperative in-hospital death ratio. One hospital in each of eight different countries was asked to provide this information retrospectively. All hospitals were able to report on each of these measures, although the outcome measures were most difficult, as this often required cross-referencing of death registries with surgical records.

Communication & Telemedicine

1. Augestad, K. M. and R. O. Lindsetmo. “Overcoming distance: video-conferencing as a clinical and educational tool among surgeons.” World J Surg. 2009; 33(7): 1356-65.

The authors review the literature pertaining to telemedicine in surgery and report their own experiences establishing telemedicine in Norway. Telemedicine has been used for intraoperative consultation and telementoring, didactic training in surgery clerkship, oversight of traumas in rural areas informing need for referral, and post-operative follow-up. A majority of the population in several developing countries, including South Africa, Nigeria, and Uganda, have access to 3G bandwidth, which is one theoretical means for data transmission.

2. Paige, J. T., D. L. Aaron, et al. “Improved operating room teamwork via SAFETY prep: a rural community hospital’s experience.” World J Surg. 2009; 33(6): 1181-7.

A preoperative briefing protocol implemented at a rural US community hospital was evaluated by querying 10 members of the OR staff pre- and post-intervention using a teamwork assessment scale. Teamwork was improved post-intervention based on 20 pre- and 16 post-intervention cases. Additionally, there was a trend toward shorter procedure times post-intervention based on assessment of operating times for 4 categories of matched cases.

3. Tamariz, F., R. Merrell, et al. “Design and implementation of a web-based system for intraoperative consultation.” World J Surg. 2009; 33(3): 448-54.

A web-based system was designed and piloted for real-time intraoperative teleconsultation between surgeons in the US and consultants in Moscow and Russia. Fifteen thyroidectomies and parathyroidectomies were studied to confirm by teleconsultation the identity of 22 recurrent laryngeal nerves (RLN). Consultants were able to review the entire case via a secure, web-based portal, position a remote consultant-directed camera in the OR, and converse with the surgeon in real-time, while looking at the anatomy. All RLNs were successfully identified in an average of 6 minutes (including review of case footage) and there was no interruption in Internet connection.

Surgery in Conflict Settings

1. Chu, K., M. Trelles, et al. “Rethinking surgical care in conflict.” Lancet. 2010; 375(9711): 262-3.

There is a lack of reliable data on the burden of surgical disease in conflict settings. While increases surgical caseloads in these settings are typically attributed to violent injury, they may also result from underlying infrastructure needs that are no longer met and from consequences of malnutrition and infectious disease (eg. bowel perforation secondary to typhoid fever, soft-tissue abscesses), which are more prevalent in conflict settings. Surgical caseloads in conflict settings are roughly comprised by interventions for violent injury (20%), obstetric emergencies (30%), accidental injury and tropical infections (30%).

2. Contini, S., A. Taqdeer, et al. “Emergency and essential surgical services in Afghanistan: still a missing challenge.” World J Surg. 2010; 34(3): 473-9.

Seventeen Afghan health facilities outside Kabul were queried using the WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care. Shortages of continuous electricity, running water, and oxygen were noted in 30-66% of health facilities. Certified surgeons and anesthesiologists were present in 64% and 27% of facilities, respectively. Lifesaving procedures were not performed in 17-42% of peripheral hospitals; 24% of peripheral hospitals did not have emergency obstetric services.

3. Taira, B. R., M. N. Cherian, et al. “Survey of emergency and surgical capacity in the conflict-affected regions of Sri Lanka.” World J Surg. 2010. 34(3): 428-32.

Anesthesia

1. Dubowitz, G., S. Detlefs, et al. “Global Anesthesia Workforce Crisis: A Preliminary Survey Revealing Shortages Contributing to Undesirable Outcomes and Unsafe Practices.” World J Surg. 2010; 34(3):438-44.

2. Jacob, R. “Anesthesia for thoracic surgery in children in developing countries.” Paediatr Anaesth. 2009; 19(1): 19-22.

Common reasons that children in developing countries may require thoracic surgery include repair of tracheoesophageal fisutulas, pyogenic infections, foreign body aspiration, chest injuries, and accidental ingestions. The author describes innovative techniques for lung isolation and postoperative pain management using inexpensive equipment and a minimal number of trained personnel.

3. Jochberger, S., F. Ismailova, et al. “A survey of the status of education and research in anaesthesia and intensive care medicine at the university teaching hospital in Lusaka, Zambia.” Archives of Iranian Medicine. 2010; 13(1): 5-12.

The author describes the status of anaesthesia-related patient care, education, and research at Zambia’s teaching hospital. Anesthetic equipment, medical supplies, drugs, and consumables are in limited supply. The institution does not have a postgraduate training program; resultingly, anaesthesia is taught as a subspecialty of surgery and few Zambian medical students become interested in pursuing anaesthesia. No recent research efforts have been made by the department of anaesthesia.

4. Newton, M. and P. Bird “Impact of Parallel Anesthesia and Surgical Provider Training in Sub-Saharan Africa: A Model for a Resource-poor Setting.” World J Surg. 2010; 34(3): 445-52.

5. Rosseel, P., M. Trelles, et al. “Ten years of experience training non-physician anesthesia providers in Haiti.” World J Surg. 2010; 34(3): 453-8.

6. Thoms, G. M., G. A. McHugh, et al. (2007). “The Global Oximetry initiative.” Anaesthesia. 2007; 62 Suppl 1: 75-7.

Global Oximetry (GO) was an initiative launched by the World Federation of Societies of Anaesthesiologists (WFSA) in Uganda, India, the Philippines, and Vietnam in 2007 with the overall aims of promoting oximetry utilization and reducing oximetry costs in lower income countries. Specific long-term objectives included created new policy, influencing, oximetry design, and setting new global standards for safer monitoring.

7. Walker, I. A., A. F. Merry, et al. “Global oximetry: an international anaesthesia quality improvement project.” Anaesthesia. 2009; 64(10): 1051-60.

This article describes processes and results of pilot projects in Uganda, India, the Philippines, and Vietnam to increase the use of oximetry in operative and acute care settings. The oximetry gap (difference between observed and expected number of pulse oximeters) in these countries ranged from 14% in acute care settings in the Philippines to 76% in ORs of Vietnam’s Binh Dinh province. Two types of oximeter were donated to select hospitals and providers were trained in appropriate use. Providers documented desaturation events in logbooks (incidence of events 12-16%) and all providers documented appropriate responses to these events. Qualitatively, providers commented that oximeters improved their anesthetic techniques and several said they are now reliant upon the tool. Two types of oximeter were evaluated, and providers were queried regarding the optimal characteristics of an oximeter. Rechargeable batteries were identified as a key feature of an oximeter for low and low middle income countries. At the end of the study period (9-15 months use), 73% and 81% of the two different oximeters, respectively, were in excellent working condition. Lack of money and systems for repair and replacement of non-functional oximeters were identified as significant barriers to global, sustainable oximetry use.

General Surgery

1. Kopelman, D. “Perforated peptic ulcer: “developing” world versus “developed” world.” World J Surg. 2009; 33(1): 86-7.

Complicated peptic ulcer disease remains a significant problem in developing countries. The author notes that most patients in this cohort were young men, many of whom were active smokers and alcohol users. High mortality and complication rates (10% and 30%) are emphasized.

2. Manning, R. G. and A. Q. Aziz. “Should laparoscopic cholecystectomy be practiced in the developing world?: the experience of the first training program in Afghanistan.” Ann Surg. 2009; 249(5): 794-8.

A retrospective review of 137 consecutive cholecystectomies (102 laparoscopic, 35 open) was done in a hospital in Kabul, Afghanistan, a developing country devastated by 3 decades of war and lacking standardized surgical training programs and infrastructure. Six percent of LC patients suffered major complications, which was higher than rates reported in other developed and developing countries. The authors cite lack of ERCP, inability to do intraoperative cholangiography, and non-standard surgeon-training programs as major challenges to doing safe laparoscopic cholecystectomies in this environment.

3. Shah, S. P., H. Epino, et al. “Impact of the introduction of ultrasound services in a limited resource setting: rural Rwanda 2008.” BMC Int Health Hum Rights. 2009; 9:4.

Ultrasound services were introduced at two rural Rwandan district hospitals. Obstetrical scanning was the most frequently used application. Ultrasound changed management plans in 43% of patients scanned, and the most common change was the plan a surgical intervention. There was 96% concordance between interpretations by Rwandan physicians and a blinded, ultrasound fellowship trained emergency medicine physician reviewer from the United States.

Obstetrics/Gynecology

1. Wylie, B. J. and F. G. Mirza. “Cesarean delivery in the developing world.” Clin Perinatol. 2008; 35(3): 571-82, xii.

The WHO advocates an optimal national Cesarean Delivery (CD) rate of 5-15%. Ninety-two percent of the least developed countries have CD rates lower than 5%, with the average rate of CD being 2% in these countries. In both least developed countries and countries with “emerging economies,” urban CD rates are significantly higher than rural rates. An estimated 75% of hospitals providing obstetric care in Africa do not have the ability to perform CD. In low-income countries, neonatal and maternal mortality rates are inversely associated with CD rates. However, CD is emerging as a cultural norm in more advanced developing nations in Latin America and East Asia, where rates are as high as 77% in the richest segments of these populations. CD rates are not associated with maternal or neonatal mortality in these countries, and negative maternal outcomes (wound infections, increased transfusion requirements, prolonged hospitalization) are highlighted.

Otolaryngology

1. Fagan, J. J. and M. Jacobs. “Survey of ENT services in Africa: need for a comprehensive intervention.” Glob Health Action. 2009 Mar 19; 2. doi: 10.3402/gha.v2i0.1932.

Citing the contribution of ear, nose, and throat disorders to the global burden of disease, this article describes results of a survey of ENT surgeons in 18 sub-Saharan African countries regarding availability of ENT, audiology, and speech therapy services and training. The authors find a paucity of ENT services and training opportunities in low-income African nations.

Plastic and Reconstructive Surgery

1. Aziz, S. R., S. T. Rhee, et al. “Cleft surgery in rural Bangladesh: reflections and experiences.” J Oral Maxillofac Surg. 2009; 67(8): 1581-8.

The authors describe three brief surgical missions to repair clefts in Bangladesh, primarily aboard Impact Foundation Bangladesh’s “Boat of Life.” Twenty-three percent of their patients were adult-size and posed unique challenges due to wider clefts, requiring more extensive soft tissue dissection, increased transfusion requirements, and occasionally the use of dermal biomaterials for tension-free repair. The authors note that despite their operative successes, supportive care (genetic counseling, dental specialty care, speech pathology, audiology) is often lacking in these rural environments. They emphasize the importance of training local practitioners during their missions and they highlight two oral and maxillofacial surgery training programs in the country.

2. Bemudez, L., V. Carter, et al., “Surgical Outcomes Auditing Systems in Humanitarian Organizations.” World J Surg. 2010; 34(3):403-10.

3. Corlew, D. S. “Estimation of Impact of Surgical Disease Through Economic Modeling of Cleft Lip and Palate Care.” World J Surg. 2010; 43(3):391-6.

4. Hodges, S., J. Wilson, et al. “Plastic and reconstructive surgery in Uganda–10 years experience.” Paediatr Anaesth. 2009; 19(1): 12-8.

This group with affiliations with St. George’s Hospital in London describes their work addressing cleft lip/palate and burns contractures though subsidized up-country visits by specialists to serve the rural poor and the establishment of a specialist unit at Mengo Hospital in Kampala. Because of high rates of malnutrition and death associated with cleft lip and palate, this group offers nutritional support and repair in affected babies as early as 6 weeks old. The authors also highlight the need for improved anesthesia equipment and services in developing countries.

5. Magee, W. P., R. Vander Burg, et al. “Cleft Lip and Palate as a Cost-effective Health Care Treatment in the Developing World.” World J Surg. 2010; 34(3):420-7.

Surgical Oncology

1. Agarwal, G., P. Ramakant, et al. “Breast cancer care in developing countries.” World J Surg. 2009; 33(10): 2069-76.

This article summarizes presentations at the symposium titled “Breast Cancer Care in Developing Countries,” held as part of the Breast Surgery International program at the International Surgical week 2007 in Montreal, Canada. Presenters discuss breast cancer epidemiology, care, and outcomes in India, Mexico, and Croatia.

2. Chirdan, L. B., F. Bode-Thomas, et al. “Childhood cancers: challenges and strategies for management in developing countries.” Afr J Paediatr Surg. 2009; 6(2): 126-30.

The authors summarize the most common cancers affecting children in developing countries, many of which are amenable to surgical intervention, and they describe barriers to care, which include lack of awareness, lack of specialists and cancer care centers, and reliance on traditional healers. They propose potential solutions including training of cancer care specialists, establishment of standardized treatment protocols, and creation of pediatric cancer units, potentially in collaboration with centers in developed countries that could work together on research, patient care, training, and public awareness endeavors.

Trauma/Burn/Critical Care

1. Atiyeh, B. S., M. Costagliola, et al. ”Burn prevention mechanisms and outcomes: pitfalls, failures and successes.” Burns. 2009; 35(2): 181-93.

Ninety percent of fatal fire-related burns occur in low and middle income countries, with half of these occurring in South-East Asia. Primary burn prevention in LMICs is emphasized in this article. Risk factors for burns include overcrowding, lack of water supply, and low income. LMIC-specific etiologies include homemade kerosene lamps and malfunctioning kerosene pressure stoves, dwellings made of highly combustible materials (treated/painted woods and plastics), and women cooking at floor level or over an open fire while wearing loose fitting clothing made from non-flame retardant fabric. The authors propose that prevention should include educational campaigns as well as legislative efforts to regulate dwellings, products, and handling/transportation of highly-flammable materials.

2. Fuglistaler-Montali, I., C. Attenberger, et al. “In search of benchmarking for mortality following multiple trauma: a Swiss trauma center experience.” World J Surg. 2009; 33(11): 2477-89.

3. Juillard, C. J., C. Mock, et al. “Establishing the evidence base for trauma quality improvement: a collaborative WHO-IATSIC review.” World J Surg. 2009; 33(5): 1075-86.

A review of the effectiveness of trauma quality improvement (QI) programs was conducted in preparation for developing Guildines for Trauma Quality Improvement Programmes. Thirty-six articles evaluated the effect comprehensive and issue-specific QI programs on mortality and various other outcomes, including cost. All but two of the 36 articles noted significant improvement in the measured outcome after implementation of a QI program. Several also noted cost-savings. Of note 34/36 articles were from high income countries. The other two were from the same institution in Thailand, and both reported trauma QI processes that resulted in decreased mortality.

4. Nakahara, S., S. Saint, et al. “Evaluation of trauma care resources in health centers and referral hospitals in Cambodia.” World J Surg. 2009; 33(4): 874-85.

This study evaluated available equipment and knowledge for trauma care at health centers (HC) and referral hospitals (RH) in rural Cambodia through a survey of 85 HCs and 17 RHs. Criteria for essential equipment and knowledge was adapted from the WHO’s Guidelines for Essential Trauma Care (EsTC). Most HCs had equipment for managing shock but not airway and breathing. Many HC providers did not have basic life-saving knowledge/skills regarding airway management, neck protection, and pelvic wrapping, and some HCs did not have essential equipment including needles, stethoscopes, or blood pressure cuffs. Most RHs had appropriate knowledge and equipment for managing airway, breathing, and circulation, but lacked CT scanners, chest tube and central venous line equipment, knowledge of pelvic wrapping for pelvic fractures, and ability to perform burr holes. Equipment availability was correlated with number of staff. Knowledge and skills were correlated with population density and inversely-correlated with distance to a higher level of care.

5. Samuel, J. C., A. Akinkuotu, et al. “Epidemiology of injuries at a tertiary care center in Malawi.” World J Surg. 2009; 33(9): 1836-41.

Data was collected on injured patients presenting to the major referral hospital for central Malawi over a 5-month period. The sample of 1,474 patients was largely male (76%) with a bimodal age distribution (<5yo and 26-30 yrs). Road-traffic injuries and assault were the most common reasons for treatment (43% and 24% respectively). Most patients arrived by private vehicle (44%), which was the fastest means of transportation (avg 120 minutes). The hospital admission rate was 27%. There were 25 mass casualties leading to 102 admissions, and seven were associated with a fatality.

Editorials & Opinions

1. Gostin, L. O. and E. A. Mok. “Grand challenges in global health governance.” Br Med Bull. 2009; 90:7-18.

This article discusses current challenges to global health governance and proposes solutions for improved global health in our era of globalization. The current response by multiple actors, each with their own narrowly defined goals, often results in misdirected, fragmented, and duplicated efforts. The authors argue for an increased role of WHO in establishing global health priorities, coordinating the efforts of interested parties, and increasing transparency, accountability, and monitoring of outcomes.

2. Kingham, T. P., A. Muyco, et al. “Surgical elective in a developing country: ethics and utility.” J Surg Educ. 2009; 66(2): 59-62.

The author describes his experiences as a surgical resident on an elective rotation at a large referral hospital in Malawi. Benefits of such an experience include case variety, heavy reliance on history and physical examinations for diagnoses, need for ingenuity in resource-poor settings, and reinforcement of common principles in safe surgery. He highlights concerns of such experiences, which include the challenge of adapting clinical decision-making to the country’s resources, inadequate supervision, and risk of transmission of communicable diseases to visiting residents.

3. Kopelman, D. “Perforated peptic ulcer: “developing” world versus “developed” world.” World J Surg. 2009; 33(1): 86-7.

4. Luboga, S., M. Galukande, et al. “Recasting the role of the surgeon in Uganda: a proposal to maximize the impact of surgery on public health.” Trop Med Int Health. 2009; 14(6): 604-8.

5. Monjok, E. “The neglect of the global surgical workforce: experience and evidence from Uganda.” World J Surg. 2009; 33(1): 150-1; author reply 152-3.

6. Nthumba, P. M. “”Blitz surgery”: redefining surgical needs, training, and practice in sub-saharan Africa.” World J Surg. 2010; 34(3): 433-7.

Guidelines

1. World Health Organization. “Guidelines for trauma quality improvement programmes.” 2009. http://whqlibdoc.who.int/publications/2009/9789241597746_eng.pdf. Accessed February 18, 2010.

Proceedings

1. McQueen, K. A., P Parmar, et al. “Burden of Surgical Disease: Strategies to Manage an Existing Public Health Emergency – Report of the 2009 Humanitarian Action Summit Working Group.” Prehospital and Disaster Medicine. 2009; 24(4): 228-31.

2. Perkins, R. S., K. M. Casey, et al. “Addressing the Global Burden of Surgical Disease: Proceedings from the 2nd Annual Symposium at the American College of Surgeons.” World J Surg. 2010; 34(3):371-3.

Volunteerism & Experiences

1. Aziz, S. R., S. T. Rhee, et al. “Cleft surgery in rural Bangladesh: reflections and experiences.” J Oral Maxillofac Surg. 2009; 67(8): 1581-8.

The authors describe three brief surgical missions to repair clefts in Bangladesh, primarily aboard Impact Foundation Bangladesh’s “Boat of Life.” Twenty-three percent of their patients were adult-size and posed unique challenges due to wider clefts requiring more extensive soft tissue dissection, increased transfusion requirements, and occasionally the use of dermal biomaterials for tension-free repair. The authors note that despite their operative successes, supportive care (genetic counseling, dental specialty care, speech pathology, audiology) is often lacking in these rural environments. They emphasize the importance of training local practitioners during their missions and they highlight two oral and maxillofacial surgery training programs already existing in Bangladesh.

2. Chu, K., P. Rosseel, et al. “Surgeons Without Borders: A Brief History of Surgery at Médicins Sans Frontières.” World J Surg. 2010; 34(3):411-14.

3. Eberlin, K. R., K. L. Zaleski, et al. “Quality assurance guidelines for surgical outreach programs: a 20-year experience.” Cleft Palate Craniofac J. 2008; 45(3): 246-55.

Participants in Medical Missions for Children (MMFC) outline quality assurance guidelines for surgical outreach missions, including recommendations for pre-trip planning, perioperative concerns, and follow-up care..

4. Hodges, S., J. Wilson, et al. “Plastic and reconstructive surgery in Uganda–10 years experience.” Paediatr Anaesth. 2009; 19(1): 12-8.

5. Lee, D. K. and S. Weinstein. “International public health in third world country medical missions: when small legs walk, we all stand a little taller.” J Am Podiatr Med Assoc. 2009; 99(4): 371-6.

The authors share a compilation of their long-term experience and outcomes from international medical and surgical pediatric mission trips to Latin American countries.

6. McQueen, K. A., J. A. Hyder, et al. “The provision of surgical care by international organizations in developing countries: a preliminary report.” World J Surg. 2010; 34(3): 397-402.

7. McQueen, K. A., W. Magee, et al. “Application of outcome measures in international humanitarian aid: comparing indices through retrospective analysis of corrective surgical care cases.” Prehosp Disaster Med. 2009; 24(1): 39-46.

This article presents outcomes of operations performed during Operation Smile surgical missions. This study exemplifies the importance of collecting,analyzing, and reporting measures of effectiveness in all surgical settings.

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