The Impact of Global Collaboration on the Academic Focus of the West African College of Surgeons: Are Worldwide Efforts Aligning with Local Priorities?

BACKGROUND: Global collaboration has the potential to induce a shift in research focus away from the priorities of those in low- and low-middle-income countries (LICs and LMICs). This study quantified international collaboration among surgery publications by Fellows of the West African College of Surgeons (WACS) and investigated if collaboration with upper-middle-income and high-income countries (UMICs and HICs) decreases the homophily of research focus. METHODS: Publications by WACS surgery Fellows from 1960 to 2019 were characterized as local WACS publications, collaborative publications without UMIC/HIC participation, or collaborative publications with UMIC/HIC participation. Research topics were determined for each publication, and topic percentages were compared between collaboration groups. RESULTS: We analyzed 5065 publications. Most (3690 publications, 73%) were local WACS publications, while 742 (15%) were collaborative publications with UMIC/HIC participation and 633 (12%) were collaborative publications without UMIC/HIC participation. UMIC/HIC collaborations contributed to 49% of the increase (378 out of 766 publications) from 2000 to 2019. Topic homophily was significantly lower between local WACS publications and collaborations with UMIC/HIC participation (differed in nine research topics) than it was between local WACS publications and collaborations without UMIC/HIC participation (differed in two research topics). CONCLUSIONS: Publications without international collaboration comprise most WACS research, but the rate of UMIC/HIC collaborations is rapidly increasing. We found that UMIC/HIC collaborations decreased the homophily of topic focus in WACS publications, indicating that global collaborations need to have greater emphasis on the priorities of those in LICs and LMICs.

The History and Evolution of the West African College of Surgeons/Jos University Teaching Hospital Trauma Management Course.

BACKGROUND: Inadequate trauma care training opportunities exist in Low- and Middle-Income Countries. Jos University Teaching Hospital and the West African College of Surgeons (WACS) have synergized, over the past 15 years, to introduce a yearly, certified, multidisciplinary Trauma Management Course. We explore the history and evolution of this course. METHODS: A desk review of course secretariat documents, registration records, schedules, pre- and post-course test records, post-course surveys, and account books complemented by organizer interviews was carried out to elaborate the evolution of the Trauma Management Course. RESULTS: The course was started as a local Continuing Medical Education program in 2005 in response to recurring cycles of violence and numerous mass casualty situations. Collaborations with WACS followed, with inclusion of the course in the College's yearly calendar from 2010. Multidisciplinary faculty teach participants the concepts of trauma care through didactic lectures, group sessions, and hands-on simulation within a one-week period. From inception, there has been a 100% growth in lecture content (from 15 to 30 lectures) and in multidisciplinary attendance (from 23 to 133 attendees). Trainees showed statistically significant knowledge gain yearly, with a mean difference ranging from 10.1 to 16.1% over the past 5 years. Future collaborations seek to expand the course and position it as a catalyst for regional emergency medical services and trauma registries. CONCLUSIONS: Multidisciplinary trauma management training is important for expanding holistic trauma capacity within the West African sub-region. The course serves as an example for Low- and Middle-Income contexts. Similar contextualized programs should be considered to strengthen trauma workforce development.

Surgical subspecialists in West Africa: Workforce size, training opportunities, and contributing factors.

BACKGROUND: The global burden of disease treatable by surgical subspecialists remains an outstanding area of need, and yet little is known about the subspecialist workforce worldwide, especially in sub-Saharan Africa. This study aims to quantify the subspecialty surgical workforce and number of subspecialty training programs in West Africa and to identify socioeconomic factors predicting the number of subspecialists in West African countries. METHODS: West African subspecialists and accredited fellowship training programs in 17 West African countries were quantified using membership data from the West African College of Surgeons and compared with publicly available workforce data from the United States, the United Kingdom, and East, Central, and Southern Africa. Spearman's coefficients were calculated to identify socioeconomic predictors of subspecialist surgical workforce. RESULTS: Of 2,181 surgeons, 712 (32.6%) were surgical subspecialists. Three (18%) of 17 West African countries had greater than 11 subspecialists. There were 174 subspecialty training programs in the region, though 13 countries (76%) had no programs. The number of subspecialists correlated most strongly with the number of subspecialty training programs (rS = 0.68, P = .003) but also correlated significantly with gross population and number of medical schools (rS = 0.50-0.52, P ≤ .05). CONCLUSION: Subspecialist surgeons represent one third of surgeons in West Africa, though most countries have fewer than 12 providers. The number of subspecialists is significantly correlated with the number of subspecialty training programs, and yet many West African countries lack accredited programs. These results suggest that investing in training programs is the most valuable potential strategy to address the shortage of surgical subspecialists in West Africa.

Surgical site infection in children: prospective analysis of the burden and risk factors in a sub-Saharan African setting.

BACKGROUND: Surgical site infections (SSI) add substantially to the morbidity of surgical patients. Our hypothesis was that the SSI rate is high in our setting, but there were no data regarding the prevalence and risk factors. METHODS: Three hundred twenty-two children who had surgery (elective 144, emergency 178) between January, 2001 and September, 2005 were studied prospectively. All patients with clean-contaminated, contaminated, and dirty incisions received prophylactic antibiotics. Data were collected using a tool that captured demographics, diagnosis, co-morbid conditions, type of surgical incision, nature of surgery, type of anesthesia, use of perioperative antibiotics, and duration of surgery. Information also was collected postoperatively on the development of SSI, type of infection, associated signs, the day the infection was identified, the findings in cultures of swabs from infected incisions, duration of hospital stay, and outcome. The chi-square test for categorical variables was used to test for significance of association. The p value for significance was set at 0.05. RESULTS: Seventy-six patients (23.6%) consisting of 40 boys and 36 girls developed SSI. The median age was nine months (range, 2 days-12 years) for those who developed SSI and 15 months (range, 1 day-13 years) for those who did not. The SSI rate was 14.3% in clean incisions, 19.3% in clean-contaminated incisions, 27.3% in contaminated incisions, and 60% in dirty incisions (p < 0.05). The infection rate was 25.8% in emergency procedures and 20.8% in elective procedures (p > 0.05). The infection rate was 31% in operations lasting >or= 2 h and 17.3% in operations lasting < 2 h (p < 0.05). Infection was detected before the eighth postoperative day in 56 of the patients (74.6%) with SSI, and bacteria were cultured from the incision in 32 patients (42.7%). The average length of stay was 26.1 days (range, 8-127 days) in patients with SSI and 18.0 days (range, 1-99 days) in those without SSI (p < 0.05). The mortality rate of patients with SSI was 10.5%, with six of the eight deaths related directly to the SSI, compared with a mortality rate of 4.1% in patients without SSI (p < 0.05). CONCLUSION: The burden of SSI in this setting is high. The degree of incisional contamination and a long duration of surgery (>or= 2 h) are important risk factors.

Colostomy in children--an evaluation of acceptance among mothers and caregivers in a developing country.

BACKGROUND: Colostomy is a common procedure performed in children, mostly for anorectal malformation and Hirschsprung's disease. However, acceptance by parents in developing countries is thought to be poor. METHODS: A prospective evaluation was done to determine the acceptability of colostomy among parents and caregivers, and their attitude towards colostomy in their children. RESULTS: During the period January 1999 - January 2004 a structured questionnaire was administered to 57 parents and caregivers of children with colostomies (41 boys and 16 girls). The indication for colostomy was anorectal malformation in 28 children and Hirschsprung's disease in 29. The length of time the children had the colostomy ranged from 3 weeks to 8 years. Forty-four respondents (77%) found the colostomy and its management acceptable. Thirteen (23%) found the colostomy unacceptable, mainly because of a feeling of social isolation. Problems the respondents complained of included disturbing smell (17, 30%), frequent change of the cloth napkin used as colostomy appliance (15, 26%) and intermittent bleeding from the stoma (4, 7%). CONCLUSIONS: Colostomy in children is acceptable to most parents in our environment. Although some parents found it unacceptable, adequate explanation and counselling may modify their view.

Outcome of primary closure of abdominal wounds following laparotomy for peritonitis in children.

BACKGROUND: Primary wound closure following laparotomy for peritonitis is generally believed to be associated with wound complications and long hospital stay. Open wound management has long been the most common practice after laparotomy for peritonitis. Primary closure (PC), however, has recently been advocated to reduce cost and morbidity. This study determined the incidence and severity of wound complications and their impact on hospital stay and overall outcome when PC of abdominal wounds is done following laparotomy for peritonitis. PATIENTS AND METHODS: A prospective review of patients who had PC of abdominal wounds following laparotomy for peritonitis over a 6-year period. RESULTS: Fifty-six children were analysed (35 boys and 21 girls), aged 11 months to 13 years (median: 8 years). The indication for laparotomy was typhoid intestinal perforation 47 (83.9%), perforated appendicitis 4 (7.1%), complicated cholecystitis 3 (5.3%) and penetrating abdominal injury with bowel perforation and intestinal obstruction with bowel perforation, 1 (1.8%) each, respectively. Postoperatively, 34 patients had wound complications. Nine patients (16.1%) had superficial wound infection alone, 12 (21.4%) had superficial wound infection with partial wound dehiscence, 6 (10.7%) had deep wound infection, 7 (12.5%) had deep wound infection with complete wound dehiscence, whereas 22 (39.3%) had no wound complication. Overall, wound complications in 13 (23.2%) patients were considered to be severe, but none resulted in mortality. Hospital stay in patients who developed wound complications was 8-37 days (median: 25 days) and 6-22 days (median: 10 days) in patients who had no wound complications (P = 0.02). CONCLUSION: The rate of wound complications following PC of dirty abdominal wounds remain but PC is safe and gives good healing outcomes.

Symptomatic vitelline duct anomalies in children.

A wide variety of anomalies may occur as a result of the vitelline duct (VD) failing to obliterate completely. Most reports on symptomatic VD focus on Meckel's diverticulum, while other anomalies are given little attention. A retrospective review was conducted at our institution. According to the records 18 symptomatic children with VD anomalies were seen over 22 years, including 10 boys and 8 girls aged 11 days -14 years (median 7.5 months). Twelve patients aged below 10 years (median 28 days) had patent vitelline ducts (PVDs), 3 children aged 13 months, 13 years and 14 years respectively had Meckel's diverticulum (MD), presenting as inflammation, tapeworm incarceration and volvulus respectively. Two patients, both 8 years old, had umbilical sinus, and a 3-year-old had a vitelline cyst. Only 1 patient with PVD had an associated anomaly (intestinal malrotation). The diagnosis of PVD was obvious clinically, but in 1 patient the fistula was demonstrated by fistulogram. The diagnosis of MD was intraoperative in all 3 patients. Treatment was by various types of resection for PVD and MD and excision for umbilical sinuses and cysts. One patient with PVD developed postoperative intestinal obstruction from adhesions, requiring re-laparotomy and adhesiolysis. Two patients with PVD died from sepsis and anaesthetic-related complications, respectively. Although MD is the most commonly VD anomaly, PVD is the most common symptomatic presentation in our environment.

Perceived role of the journal clubs in teaching critical appraisal skills: a survey of surgical trainees in Nigeria.

BACKGROUND: Critical appraisal skills allow surgeons to evaluate the literature in an objective and structured manner, with emphasis on the validity of the evidence. The development of skills in critical acquisition and appraisal of the literature is crucial to delivering quality surgical care. It is also widely accepted that journal clubs are a time-honored educational paradigm for teaching and development of critical appraisal skills. The aim of this study is to determine the perceived role of journal clubs in teaching critical appraisal skills amongst the surgical trainees in Nigeria. MATERIALS AND METHODS: The West African College of Surgeons and the National Postgraduate College of Nigeria have mandated that all residency programs teach and assess the ability to develop critical appraisal skills when reviewing the scientific literature. Residents at the revision course of the West African College of Surgeons in September 2012 evaluated the role of journal clubs in teaching critical appraisal skills using a 17-item questionnaire. The questionnaire addressed four areas: Format, teaching and development of critical appraisal s kills, and evaluation. RESULTS: Most of the journal clubs meet weekly [39 (59%)] or monthly [25 (38%)]. Thirty-nine residents (59%) perceived the teaching model employed in the development of critical appraisal skills in their institutions was best characterized by "iscussion/summary by consultants" and "emphasis on formal suggestion for improvement in research." Rating the importance of development of critical appraisal skills to the objectives of the residency program and practice of evidence-based medicine, majority of the residents [65 (98%)] felt it was "very important." The commonest form of feedback was verbal from the consultants and residents [50 (76%)]. CONCLUSION: The perceived importance of journal clubs to the development of critical appraisal skills was rated as very important by the residents. However, residents indicated a need for a formal evaluation of the journal clubs. It is our hope that the results of this survey will encourage postgraduate coordinators to evaluate the quality of their journal clubs in the development of skills in critical appraisal of the literature.

Role of damage control enterostomy in management of children with peritonitis from acute intestinal disease.

BACKGROUND: Intestinal anastomosis in severely ill children with peritonitis from intestinal perforation, intestinal gangrene or anastomotic dehiscence (acute intestinal disease) is associated with high morbidity and mortality. Enterostomy as a damage control measure may be an option to minimize the high morbidity and mortality. This report evaluates the role of damage control enterostomy in the treatment of these patients. MATERIALS AND METHODS: A retrospective review of 52 children with acute intestinal disease who had enterostomy as a damage control measure in 12 years. RESULTS: There were 34 (65.4%) boys and 18 (34.6%) girls aged 3 days-13 years (median 9 months), comprising 27 (51.9%) neonates and infants and 25 (48.1%) older children. The primary indication for enterostomy in neonates and infants was intestinal gangrene 25 (92.6%) and perforated typhoid ileitis 22 (88%) in older children. Enterostomy was performed as the initial surgery in 33 (63.5%) patients and as a salvage procedure following anastomotic dehiscence in 19 (36.5%) patients. Enterostomy-related complications occurred in 19 (36.5%) patients, including 11 (21.2%) patients with skin excoriations and eight (15.4%) with hypokalaemia. There were four (7.7%) deaths (aged 19 days, 3 months, 3½ years and 10 years, respectively) directly related to the enterostomy, from hypokalaemia at 4, 12, 20 and 28 days postoperatively, respectively. Twenty other patients died shortly after surgery from their primary disease. Twenty of 28 surviving patients have had their enterostomy closed without complications, while eight are awaiting enterostomy closure. CONCLUSION: Damage-control enterostomy is useful in management of severely ill children with intestinal perforation or gangrene. Careful and meticulous attention to fluid and electrolyte balance, and stoma care, especially in the first several days following surgery, are important in preventing morbidity and mortality.

Early oral feeding following intestinal anastomoses in children is safe.

BACKGROUND: Oral feeding following intestinal anastomoses is frequently delayed. In settings with limited utilisation of parenteral nutrition, this policy is problematic. This report evaluates the safety of early oral feeding following intestinal anastomoses in children. MATERIALS AND METHODS: A prospective study including 64 children aged ≤ 12-year-old who had intestinal anastomoses for varying surgical indications over a 6-year period. Oral feeding was started within 72 hours following surgery, if there was no contraindication. RESULTS: There were 41 (64.1%) boys and 23 (35.9%) girls aged 6 hours to 12 years (median, 6 years). The indication for surgery was perforated typhoid enteritis (33, 51.6%), intestinal atresia (8, 12.5%), colostomy closure for anorectal anomaly (8, 12.5%), intussusception (3, 4.7%) and ileostomy closure (3, 4.7%). Type anastomoses were 39 (60.9%) ileoileal, 4 (6.3%) colocolic, 8 (12.5%) jejunoileal and 4 (6.3%) ileocolic. Oral feeding was commenced in 17 (26.6%) of the patients within 48 hours, 36 (56.3%) by third day and 45 (70.3%) before fifth day post-operative. Feed-related complication occurred in 5 (7.8%) patients, 3 (8.3%) of which was in patients fed within 72 hours post-operative and 2 (7.1%) in those fed after 72 hours. Full oral feed was achieved by fifth and seventh day post-operative in 42 (65.6%) and 61(95.3%), respectively. Two (6.1%) patients had oral feeding stopped and recommenced at seventh day post-operative due to feed-related complications. CONCLUSION: Early oral feeding following intestinal anastomoses in children is safe, particularly in the setting of limited availability of parenteral nutrition.

Anorectal malformation coexisting with Hirschsprung's disease: a report of two patients.

Anorectal Malformation (ARM) and Hirschsprung's Disease (HD) are common causes of congenital intestinal obstruction in children. Simultaneous occurrence of both conditions is rare. Few have been reported in Europe and Asia, but we have no knowledge so far of such report from Nigeria. We present two patients managed in our centre to highlight the challenges of management of this uncommon coexistence. The first patient was a 5-year-old girl who was referred to us with intestinal obstructive symptoms despite an apparently adequate sized ectopic anus. She had colostomy and rectal biopsy, which confirmed HD. She had corrective surgery performed through a posterior sagittal approach. She did well post operatively. The second patient was a 3-year-old girl who presented with features of intestinal obstruction, had laparatomy and was also referred to us. It was observed in the referral hospital during laparatomy, to have features of HD and rectal atresia intraoperatively. She had colostomy done and rectal biopsy performed at the same time, which confirmed the diagnosis of HD. She had simultaneous correction of both conditions through a posterior sagittal approach. She was in good condition at follow up. It was therefore recommended that a high index of suspicion of HD, should be entertained while managing patients with anorectal malformation.

Congenital vaginal obstruction in neonates and infants: recognition and management.

BACKGROUND: Congenital vaginal obstruction commonly presents after puberty and presentation in infancy is uncommon. Due to lack of awareness, diagnosis may be missed in infants, sometimes with disastrous consequences. METHOD: A retrospective review of 9 neonates and infants treated for congenital vaginal obstruction in 16 years. RESULTS: The patients were aged 2 days to 4 months (median 28 days) at presentation. The main presenting feature was a lower abdominal mass, producing intestinal and urinary obstruction in 7 patients. In 2 patients, other conditions were suspected and diagnosis made only intraoperatively and in one patient, diagnosis was incidental during treatment for another condition. The cause of vaginal obstruction were low transverse vaginal septum 6, imperforate hymen 2, high transverse vaginal septum one. Associated anomalies were present in 5 patients (persistent cloaca 3, Hirschsprung disease 1, polydactyly 1). Low vaginal septum was treated by incision and drainage of hydrometrocolpos, imperforate hymen by hymenotomy and drainage of hydrometrocolpos and high vaginal septum by excision. There was recurrence of hydrometrocolpos in one patient who had low vaginal septum, requiring repeat surgery. One patient, in whom diagnosis was missed, died from overwhelming infection. Short term follow-up was good. CONCLUSION: Congenital vaginal obstruction is an uncommon presentation in this setting. Missing the diagnosis can lead to disastrous consequences. A high index of suspicion is required for prompt recognition and treatment.

One-day bowel preparation in children with colostomy using normal saline.

BACKGROUND: Colonic and colorectal surgery frequently requires bowel preparation. This is an evaluation of the use of normal saline for one-day bowel preparation in children with colostomy. PATIENTS AND METHODS: A prospective study of 55 children with colostomy who had one-day bowel preparation for colonic and colorectal surgical procedures in a 3-year period. The information, along with clinical data was recorded on a structured proforma. Data were analysed using SPSS version 11.0. RESULTS: There were 33 boys and 22 girls. The median age was 4 years (range, one month - 13 years). The primary diagnosis were as follows: Anorectal malformation, 24 (44%); Hirschsprung`s disease, 24 (44%); Faecal incontinence- post-abdominoperineal pull-through, 2 (4%); Penetrating rectal injury, 1 (2%); others, 4(8%). Intraoperative bowel luminal fluid cleanliness was assessed as clear in 36 (62%) and contaminated in 21 (38%). Overall, postoperatively, superficial surgical site infection occurred in 6 (10.9%) patients (2 had clean intraoperative colonic fluid, 5.9%. CONCLUSION: One-day bowel preparation using normal saline is effective and safe in children with colostomy.

Colostomy for high anorectal malformation: an evaluation of morbidity and mortality in a developing country.

Colostomy is a life-saving procedure in newborns with high anorectal malformations (ARM). However, the procedure may be attended by complications, particularly in resource limited settings. This is an evaluation of the morbidity and mortality following colostomy for ARM in newborns in two paediatric teaching centres in a developing country. A retrospective review of 61 neonates who had colostomy for high ARM in 4 years is conducted. The babies were categorised into Group A (weight at presentation < 2.5 kg) and Group B (weight at presentation > 2.5 kg). There were 47 boys and 14 girls aged 18 h to 28 days (median 6 days). There were 23 babies in Group A; 18 had colostomy under local anaesthetic (LA), 5 of whom died while 5 had the procedure done under general anaesthetic (GA), 3 of whom died (mortality 8/23, 34.78%). Group B consisted of 38 babies, 18 had colostomy under GA, 3 died, while in 20 the procedure was under LA, 1 of who died (mortality 4/38, 10.5%). The difference in mortality between groups A and B was statistically insignificant (p < 0.056). There were no significant differences in outcome between the two groups when the type of anaesthesia or types of colostomy were considered. Surgical site infection was the most common 12/61, 19.7%. Of the 12 babies that died, 7 were due to overwhelming infections, 4 respiratory insufficiencies and 1 cyanotic heart disease. The overall procedure related mortality was therefore 7 (11.5%). None of the centres had adequate neonatal intensive care services during the period of this report. Morbidity and mortality following colostomy for ARM in newborns is still high in this setting, due largely to infective complications, particularly in babies < 2.5 kg.