Global Surgery: The Challenges and Strategies to Win a War That Must Be Won.

Background: Modern science has conquered seas, land, and space. Although great strides have been made in technology and infectious diseases, global surgery, which was reborn in 2015, has not made much progress. The burden of surgical disease in low- and middle-income countries remains seemingly unconquerable, and its growth unstoppable. The myriad challenges in meeting the surgical needs of 5 billion people has intrigued the author. Methods: The author collected the views of plastic surgeons on sources and impediments to the scale-up of plastic surgery in low- and middle-income countries, as well as potential strategies for overcoming these obstacles. The author then performed a literature search reviewing the topics that arose from those discussions. The author proposes a strategy using plastic surgery as a model surgical discipline. Results: A root-cause analysis suggests that the Alma Ata Declaration, with its focus on primary healthcare, is the probable genesis of global surgery (GS) woes. The absence of a clear GS community leader and the fragmented nature of GS advocates who operate in multiple silos, without a clear unified goal, are the primary reasons GS advocates have achieved so little on the ground. Conclusions: Global surgery requires a business model to sustainably meet the surgical needs of the 5 billion people globally. The proposed and implemented strategies must meet rigorous criteria to ensure sustainability, as quick-fix solutions are counterproductive. The development of centers of excellence offers a viable solution to problems that must be addressed successfully.

The State of Surgical Research in Sub-Saharan Africa: An Urgent Call for Surgical Research Trainers.

Background: Surgery in low- and middle-income countries (LMICs) is poorly developed because of years of neglect. Sustained research on global surgery led to its recognition as an indivisible and indispensable part of primary healthcare in 2015. However, this has had little visible effect on surgical ecosystems within LMICs, especially in sub-Saharan Africa (SSA). SSA surgical research systems strengthening, which includes skills transfer, with local priority setting driving the research agenda, is needed to propel global surgery into the future. Methods: The authors performed a literature review of the state of surgical research within SSA and also report the initial efforts of two research training nonprofits to empower young African surgeons with research skills. Results: Surgical research in SSA is disadvantaged even before it is birthed, facing monumental challenges at every stage of development, from research agenda determination to funding, study execution, and publication. Compared with a global output of 17.49 publications per 100,000 population, SSA produces 0.9 (P < 0.0001). The Surgeons in Humanitarian Alliance for Reconstructive, Research, and Education and Enabling Africa Clinical Health Research programs are involved in the longitudinal research mentorship of surgical residents within SSA; the improved quality of research and successful publications by participants suggest nascent steps in growing young surgical scientists. Conclusions: In the absence of an existing surgical research infrastructure within LMICs, global surgery research trainers should link up and collaborate to help develop a surgical research community that will provide the local data required to help transform the SSA surgical ecosystem.

Glomus Tumors: A Systematic Review of the Sub-Saharan Africa Experience.

Background: Glomus tumors are rare benign tumors that were first described in 1812 by Wood. They arise from normal glomus apparatus, usually located in the reticular dermis of the body. Although glomus tumors are universal in occurrence, the sub-Saharan Africa experience has not been well documented. Methods: The authors performed a systematic literature review of eligible studies between 1960 and August 2023, using the terms "glomus," "tumor," "glomangioma," "glomangiomyoma," and "Africa." We also performed a search of the AIC Kijabe Hospital pathology department database of about 140,000 records, covering 30 years, for the terms "glomus tumor," "glomangioma" and "glomangiomyoma." Results: The systematic literature search and institutional database search produced a total of 74 patients who had glomus tumors. These patients had a lag of between 3 months and 20 years from symptom development to definitive treatment. Conclusions: There are very few reports of glomus tumors from sub-Saharan Africa in the current literature: the authors' histopathology database of 140,000 specimens had 46 glomus tumors (0.03%), and only 28 additional patients were found in literature from sub-Saharan Africa. The low numbers of African patients may indicate racial differences in the occurrence of glomus tumors, although this may also be due to failure of clinicians to recognize glomus tumors. The prolonged lag period between symptom development and definitive treatment for glomus tumors indicates the need for diligence in the diagnosis and treatment of a simple problem that is otherwise the cause of incapacitating pain and misery.

Safety and Sustainability: Optimizing Outcomes and Changing Paradigms in Global Health Endeavors.

Background: The need to address inequities in global surgical care has garnered increased attention since 2015, after the Lancet Commission on Global Surgery underscored the importance of ensuring safe, accessible, affordable, and timely surgical and anesthetic care. The vast unmet global plastic surgery needs make plastic surgery care essential in reducing the global burden of disease. In the past, many nonprofit organizations undertook humanitarian activities within low- and middle-income countries that were primarily service-provision oriented. The Lancet Commission on Global Surgery report prompted a shift in focus from direct patient care models to sustainable global surgical models. The realization that 33% of deaths worldwide were due to unmet surgical needs led to a global shift of strategy toward the development of local systems, surgical capacity, and a focus on patient safety and quality of care within international global surgery partnerships. Methods: In this report, the authors explore some of the primary components of sustainable international global surgical partnerships discussed in a recent panel at the American Society of Plastic Surgeons Plastic Surgery The Meeting 2022, titled "Safety and Sustainability Overseas: Optimizing Outcomes and Changing Paradigms in Global Health Endeavors." A literature review elaborating the topics discussed was performed. Results: This report focuses on cultural competence and humility, international collaboration, and the use of technology and innovation, all of which are needed to promote sustainability and patient safety, within global surgery efforts. Conclusions: The adoption of these components into international surgical collaborations will lead to greatly enhancing the development and sustainability of mutually beneficial relationships.

Successful Shoulder Disarticulation under Local Anesthesia in the COVID-19 Era.

The use of the wide-awake local anesthesia no tourniquet, a tumescent local anesthetic technique in recent years, emerged as a powerful tool primarily in hand surgery. It has been adopted in many low- and middle-income countries where it was applied to an increasingly broad group of procedures. We report the case of an older patient with an arm liposarcoma for which surgery under general or regional anesthesia was deemed unsafe, but was successfully managed with a curative right shoulder disarticulation using tumescent local anesthesia.

Correction: Academic global surgical competencies: A modified Delphi consensus study.

[This corrects the article DOI: 10.1371/journal.pgph.0002102.].

Academic global surgical competencies: A modified Delphi consensus study.

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively.

Surgical Antibiotic Prophylaxis in Children Undergoing Surgery: A Systematic Review and Meta-Analysis.

Background: To establish the role of surgical antibiotic prophylaxis (SAP) in the prevention of surgical site infection (SSI) in children undergoing surgery. Design: A systematic review and meta-analysis of six databases: MEDLINE (PubMed), EMBASE, CINAHL Plus, Cochrane Library, Web of Science, and Scopus. Study Selection: Included studies (irrespective of design) compared outcomes in children undergoing surgery, aged 0 to 21 years who received SAP with those who did not, with SSI as an outcome, using the U.S. Centers for Disease Control and Prevention (CDC) definitions for SSI. Data Extraction: Two independent reviewers applied eligibility criteria, assessed the risk of bias, and extracted data. Results: A total of six randomized control trials and 26 observational studies including 202,593 surgical procedures among 202,405 participants were included in the review. The pooled odds ratio of SSI was 1.20; (95% confidence interval [CI], 0.91-1.58) comparing those receiving SAP with those not receiving SAP, with moderate heterogeneity in effect size between studies (τ2 = 0.246; χ2 = 69.75; p < 0.001; I2 = 57.0%). There was insufficient data on many factors known to be associated with SSI, such as cost, length of stay, re-admission, and re-operation; it was therefore not possible to perform subanalyses on these. Conclusions: This review and metanalysis did not find a preventive action of SAP against SSI, and our results suggest that SAP should not be used in surgical wound class (SWC) I procedures in children. However, considering the poor quality of included studies, the principal message of this study is in highlighting the absence of quality data to drive evidence-based decision-making in SSI prevention in children, and in advocating for more research in this field.

Correction: Engineering an adhesive based on photosensitive polymer hydrogels and silver nanoparticles for wound healing.

Correction for 'Engineering an adhesive based on photosensitive polymer hydrogels and silver nanoparticles for wound healing' by Qinqing Tang et al., J. Mater. Chem. B, 2020, 8, 5756-5764, DOI: 10.1039/d0tb00726a.

Engineering an adhesive based on photosensitive polymer hydrogels and silver nanoparticles for wound healing.

Hemostasis, wound closure and prevention of infection are critical to wound healing after an injury. Skin adhesives have been used to seal incisions, thus aiding primary wound healing, as well as creating a barrier to microbes. We constructed a skin adhesive with antibacterial and hemostatic activities (AHAs) for wound management. The adhesive was made by using methacrylated hyaluronan-polyacrylamide (MHA-PAAm) hydrogels, integrated with silver nanoparticles (AgNPs) and bonded to gelatin. Because of the three-dimensional network structure of the hydrogels, nanoscale particles can be encapsulated into their voids; the AgNPs, through sustained delivery of silver ions, endow the adhesives with sustained broad-spectrum antibacterial activity. Furthermore, due to the introduction of MHA which can be crosslinked by visible light, the polyacrylamide hydrogel matrix can be formed through photo crosslinking. In addition, gelatin can be bonded to both the hydrogel matrix and host tissues because of the interaction between carboxyl and amino-moieties. Our animal studies demonstrated that the AHAs which possess tissue adhesive and antibacterial properties were easy to stretch, and were able to stop bleeding in rat tail amputation and liver injury models. AHAs enhance wound granulation tissue formation, vascular tissue formation, and collagen formation, as well as alleviate inflammation. These properties promoted wound closure in rat wound infection models, promising great potential for applying AHAs in clinical uses.

Incorporation of a Global Surgery Rotation into an Academic General Surgery Residency Program: Impact and Perceptions.

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

Burns in sub-Saharan Africa: A review.

OBJECTIVE: Burns are important preventable causes of morbidity and mortality, with a disproportionate incidence in sub-Saharan Africa. The management of these injuries in sub-Saharan Africa is a challenge because of multiple other competing problems such as infectious diseases (HIV/AIDS, tuberculosis and malaria), terrorist acts and political instability. There is little investment in preventive measures, pre-hospital, in-hospital and post-discharge care of burns, resulting in high numbers of burns, high morbidity and mortality. Lack of data that can be used in legislation and policy formulation is a major hindrance in highlighting the problem of burns in this sub-region. METHODS: An online search of publications on burns from sub-Saharan countries was performed. RESULTS: A total of 54 publications with 32,862 patients from 14 countries qualified for inclusion in the study. The average age was 15.3 years. Children aged 10 years and below represented over 80% of the burn patient population. Males constituted 55% of those who suffered burns. Scalds were the commonest cause of thermal injuries, accounting for 59% of all burns, while flame burns accounted for 33%. The burn mortality averaged 17%, or the death of one of every five burn victims. CONCLUSIONS: These statistics indicate the need for an urgent review of burn policies and related legislation across the sub-Saharan region to help reduce burns, and provide a safe environment for children.

Glomus tumor presenting as complex regional pain syndrome of the left upper limb: a case report.

BACKGROUND: Glomus tumors of the hand are rare, benign but debilitating neoplasms arising from the neuromyoarterial glomus body. They may present a diagnostic dilemma, and take years with multiple consultations and investigations before an appropriate diagnosis is made, but once a diagnosis is made, surgical excision is curative. CASE PRESENTATION: This is a case presentation of a 35-year-old African man who presented with complex regional pain syndrome of his left upper extremity, whose genesis was found to be a glomus tumor of the pulp of his left middle finger. Surgical excision resulted in resolution of the chronic regional pain syndrome and a return to a normal lifestyle. Chronic regional pain syndrome is a rare presentation of a glomus tumor, which has only been previously reported in patients with neurofibromatosis type 1, and one patient who did not have neurofibromatosis. CONCLUSIONS: Patients with glomus tumors may spend many years in pain and distress because of misdiagnosis. Sensitization and education of both the public and health care workers will help in early diagnosis and treatment of this otherwise potentially disabling pathology for which surgical excision is curative.

Palliative reconstructive surgery: contextualizing palliation in resource-poor settings.

Introduction. Palliative care in Kenya and the larger Sub-Saharan Africa is considered a preserve of hospices, where these exist. Surgical training does not arm the surgeon with the skills needed to deal with the care of palliative patients. Resource constraints demand that the surgeon be multidiscipline trained so as to be able to adequately address the needs of a growing population of patients that could benefit from surgical palliation. Patients and Methods. The author describes his experience in the management of a series of 31 palliative care patients, aged 8 to 82 years. There were a total of nine known or presumed mortalities in the first year following surgery; 17 patients experienced an improved quality of life for at least 6 months after surgery. Fourteen of these were disease-free at 6 months. Conclusion. Palliative reconstructive surgery is indicated in a select number of patients. Although cure is not the primary intent of palliative surgery, the potential benefits of an improved quality of life and the possibility of cure should encourage a more proactive role for the surgeon. The need for palliative care can be expected to increase significantly in Africa, with the estimated fourfold increase of cancer patients over the next 50 years.

Traumatic tracheostomy and spent bullet aspiration after a gunshot injury: a case report.

Penetrating tracheal injuries are rare. Even rarer is the finding of intrabronchial foreign bodies caused by penetrating objects. We report a patient who experienced a gunshot injury to the trachea and mandible. The tracheal wound was debrided and used as a tracheostomy; a spent bullet in the bronchial tree was missed on initial evaluation but later successfully retrieved bronchoscopically. Spent bullet aspiration is a very rare occurrence. A careful examination of radiographs is essential to aid with the diagnosis. Flexible bronchoscopy is the best means of bullet retrieval. Management of any associated injuries is made easier after the airway is secured.

Use of the osteomuscular dorsal scapular flap in the reconstruction of mandibular defects.

The gold standard for mandibular defect reconstruction is the fibular free flap. Nevertheless, the pedicled osteomuscular dorsal scapular flap as a reconstructive tool offers promise for mandibular defect reconstruction and could be the first choice in certain circumstances. Its use in resource-limited settings offers an excellent solution to otherwise difficult reconstructive problems of the mandible. In 8 patients, mandibular defects resulting from the excision of benign tumors (6), trauma (1), and chronic osteomyelitis (1) were reconstructed using the pedicled osteomuscular dorsal scapular flap; these defects included the central segment of the mandible. The pedicled osteomuscular dorsal scapular flap is an excellent choice for mandibular reconstruction; it may serve as the primary choice in patients with vascular pathology that precludes free tissue transfer, as well as in resource-limited environments, as a secondary choice after a failed free flap reconstruction.