Gender Disparities in Complications, Costs, and Mortality After Emergency Gastrointestinal Surgery in Kenya.

INTRODUCTION: Little is known about the impact of gender on emergency surgery within Kenya. Therefore, we aimed to investigate the association of gender on outcomes of postoperative complications, health care costs, and mortality. METHODS: We evaluated an established cohort of patients undergoing emergency gastrointestinal surgery in rural Kenya between January 1st, 2016 and June 30th, 2019. Utilizing logistic regression, we examined the association between self-reported patient gender and the outcomes of postoperative complications and mortality. A generalized linear model was created for total hospital costs, inflation-adjusted in international dollars purchasing power parity, to examine the impact of gender. Confounding factors were controlled by Africa Surgical Outcomes Study Surgical Risk Score. RESULTS: Among 484 patients reviewed, 149 (30.8%) were women. 165 (34.1%) patients developed complications, with women experiencing more than men (40.9% versus 31.0%; P = 0.03) and longer hospital stays (median 6 days (4-9) versus 5 (4-7); P = 0.02). After controlling for Africa Surgical Outcomes Study Surgical Risk Score, odds of developing complications for women were 1.67 (95% confidence interval: 1.09-2.55; P = 0.019) times higher than men, and the odds of death were 2.38 (95% confidence interval: 1.12-5.09; P = 0.025) times greater for women than men, despite similar failure-to-rescue rates and intensive care unit utilization. Total hospital costs were increased for women by 531 international dollars purchasing power parity (117-946; P = 0.012) when compared to men, attributed to longer lengths of stay. CONCLUSIONS: These findings demonstrate that a discrepancy exists between men and women undergoing emergency gastrointestinal surgery in our setting. Further exploration of the underlying causes of this inequity is necessary for quality improvement for women in rural Kenya.

Laparoscopy experience in East, Central, and Southern Africa: insights from operative case volume analysis.

BACKGROUND: With the primary objective of addressing the disparity in global surgical care access, the College of Surgeons of East, Central, and Southern Africa (COSECSA) trains surgeons. While sufficient operative experience is crucial for surgical training, the extent of utilization of minimally invasive techniques during COSECSA training remains understudied. METHODS: We conducted an extensive review of COSECSA general surgery trainees' operative case logs from January 1, 2015, to December 31, 2020, focusing on the utilization of minimally invasive surgical procedures. Our primary objective was to determine the prevalence of laparoscopic procedures and compare this to open procedures. We analyzed the distribution of laparoscopic cases across common indications such as cholecystectomy, appendicitis, and hernia operations. Additionally, we examined the impact of trainee autonomy, country development index, and hospital type on laparoscopy utilization. RESULTS: Among 68,659 total cases, only 616 (0.9%) were laparoscopic procedures. Notably, 34 cases were conducted during trainee external rotations in countries like the United Kingdom, Germany, and India. Gallbladder and appendix pathologies were most frequent among the 582 recorded laparoscopic cases performed in Africa. Laparoscopic cholecystectomy accounted for 29% (276 of 975 cases), laparoscopic appendectomy for 3% (76 of 2548 cases), and laparoscopic hernia repairs for 0.5% (26 of 5620 cases). Trainees self-reported lower autonomy for laparoscopic (22.5%) than open cases (61.5%). Laparoscopy usage was more prevalent in upper-middle-income (2.7%) and lower-middle-income countries (0.8%) compared with lower-income countries (0.5%) (p < 0.001). Private (1.6%) and faith-based hospitals (1.5%) showed greater laparoscopy utilization than public hospitals (0.5%) (p < 0.001). CONCLUSIONS: The study highlights the relatively low utilization of minimally invasive techniques in surgical training within the ECSA region. Laparoscopic cases remain a minority, with variations observed based on specific diagnoses. The findings suggest a need to enhance exposure to minimally invasive procedures to ensure well-rounded training and proficiency in these techniques.

Implementation of a Surgical Critical Care Service Reduces Failure to Rescue in Emergency Gastrointestinal Surgery in Rural Kenya.

OBJECTIVE: We aimed to evaluate the implementation of a dedicated Surgical critical care service (SCCS) on failure to rescue (FTR) rates in rural Kenya. SUMMARY BACKGROUND DATA: FTR adversely impacts perioperative outcomes. In the resource-limited contexts of low- and middle-income countries, emergency gastrointestinal surgery carries high morbidity and mortality rates. Quality improvement initiatives that decrease FTR rates are essential for improving perioperative care. METHODS: All patients who underwent emergency gastrointestinal surgery between January 2016 and June 2019 at Tenwek Hospital in rural Kenya were reviewed. Critical care capabilities were constant throughout the study period. A supervised surgical resident was dedicated to the daily care of critically ill surgical patients beginning in January 2018. The impact of the SCCS initiation on the outcome of FTR was evaluated, controlling for patient complexity via the African Surgical Outcomes Study Surgical Risk Score. RESULTS: A total of 484 patients were identified, consisting of 278 without and 206 with an active SCCS. A total of 165 (34.1%) patients experienced postoperative complications, including 49 mortalities (10.1%) yielding an FTR rate of 29.7%. The FTR rate decreased after SCCS implementation from 36.8% (95% CI: 26.7%-47.8%) to 21.8% (95% CI: 13.2%-32.6%) ( P = 0.035) despite an increase in the average patient African Surgical Outcomes Study score from 14.5 (95% CI, 14.1-14.9) to 15.2 (95% CI, 14.7-15.7) ( P =0.03). CONCLUSIONS: The implementation of an SCCS in rural Kenya resulted in decreased rates of FTR despite an increase in patient complexity and severity of critical illness.

Implementation of a Smartphone-Based Platform for Operative Feedback at Tenwek Hospital in Kenya: A Mixed Methods Study.

BACKGROUND: The SIMPL operative feedback tool is used in many U.S. surgical residency programs. However, the challenges of implementation and benefits of the web-based platform in low- and middle-income countries are unknown. The aim of this study was to evaluate implementation of SIMPL in a general surgery residency training program in Kenya. METHODS: SIMPL was pilot tested at Tenwek Hospital from January through December 2021. Participant perspectives of SIMPL were elicited through a survey and semi-structured interviews. Descriptive statistics were used to analyze survey data. Inductive qualitative content analysis of interview responses was performed by two independent researchers. RESULTS: Fourteen residents and six faculty (100% response rate) were included in the study and completed over 600 operative assessments. All respondents reported numerical evaluations and dictated feedback were useful. Respondents felt that SIMPL was easy to use, improved quality and frequency of feedback, helped refine surgical skills, and increased resident autonomy. Barriers to use included participants forgetting to complete evaluations, junior residents not submitting evaluations when minimally involved in cases, and technological challenges. Suggestions for improvement included expansion of SIMPL to surgical subspecialties and allowing senior residents to provide feedback to juniors. All respondents wanted to continue using SIMPL, and 90% recommended use at other programs. CONCLUSION: Residents and faculty at Tenwek Hospital believed SIMPL were a positive addition to their training program. There were a few barriers to use and suggestions for improvement specific to the training environment in Kenya, but this study demonstrates it is feasible to use SIMPL in settings outside the U.S. with the appropriate resources.

Operative Case Volumes and Variation for General Surgery Training in East, Central, and Southern Africa.

BACKGROUND: Operative experience is a necessary part of surgical training. The College of Surgeons of East, Central, and Southern Africa (COSECSA), which oversees general surgery training programs in the region, has implemented guidelines for the minimum necessary case volumes upon completion of two (Membership) and five (Fellowship) years of surgical training. We aimed to review trainee experience to determine whether guidelines are being met and examine the variation of cases between countries. METHODS: Operative procedures were categorized from a cohort of COSECSA general surgery trainees and compared to the guideline minimum case volumes for Membership and Fellowship levels. The primary and secondary outcomes were total observed case volumes and cases within defined categories. Variations by country and development indices were explored. RESULTS: One hundred ninety-four trainees performed 69,283 unique procedures related to general surgery training. The review included 70 accredited hospitals and sixteen countries within Africa. Eighty percent of MCS trainees met the guideline minimum of 200 overall cases; however, numerous trainees did not meet the guideline minimum for each procedure. All FCS trainees met the volume target for total cases and orthopedics; however, many did not meet the guideline minimums for other categories, especially breast, head and neck, urology, and vascular surgery. The operative experience of trainees varied significantly by location and national income level. CONCLUSIONS: Surgical trainees in East, Central, and Southern Africa have diverse operative training experience. Most trainees fulfill the overall case volume requirements; however, further exploration of how to meet the demands of specific categories and procedures is necessary.

Operative Self-Confidence, Hesitation, and Ability Assessment of Surgical Trainees in Rural Kenya.

BACKGROUND: The education of surgical trainees is ideally designed to produce surgeons with both confidence and competence. This involves the development of autonomy in the operating room. Factors associated with autonomy and entrustment have been studied in high-resource settings. In a resource-limited context, where autonomy is solely at the discretion of faculty, and there are fewer external constraints to restrict it, we hypothesized that assessment of a trainee's performance would be dependent upon reported confidence levels of both faculty and trainees in those trainees' abilities. MATERIALS AND METHODS: At a teaching hospital in rural Kenya, operative experience surveys were administered to eleven general surgery trainees (PGY1-5) and six faculty paired dyads immediately following operative procedures in May 2016 to elicit self-reported assessments of confidence, hesitation, and ability as measured by the Zwisch Scale. We examined factors related to learning and used dyadic structural equation models to understand factors related to the assessment of ability. RESULTS: There were 107 paired surveys among 136 trainees and 130 faculty evaluations. Faculty scrubbed into 76 (72%) cases. In comparison to trainees, faculty were more likely to give a higher average score for confidence (4.08 versus 3.90; P value: 0.005), a lower score for hesitation (2.67 versus 2.84; P value: 0.001), and a lower score for the ability to perform the operation independently (2.73 versus 3.02; P value: 0.01). Faculty and trainee perceptions of hesitation influenced their ability scores. Trainee hesitation (OR 12.1; 1.2-127.6, P = 0.04) predicted whether trainees reported experiencing learning. CONCLUSIONS: Between trainees and faculty at a teaching program in rural Kenya, assessment scores of confidence, hesitation, and ability differ in value but remain fairly correlated. Hesitation is predictive of ability assessment, as well as self-reported learning opportunities. Focus upon identifying when trainees hesitate to proceed with a case may yield important educational opportunities.

Gastrointestinal endoscopy experience of surgical trainees throughout rural Africa.

BACKGROUND: Gastrointestinal endoscopy (GIE) is not routinely accessible in many parts of rural Africa. As surgical training expands and technology progresses, the capacity to deliver endoscopic care to patients improves. We aimed to describe the current burden of gastrointestinal (GI) disease undergoing GIE by examining the experience of surgical training related to GIE. METHODS: A retrospective review was conducted on GIE procedures performed by trainees with complete case logs during 5-year general surgery training at Pan-African Academy of Christian Surgeons (PAACS) sites. Cases were classified according to diagnosis and/or indication, anatomic location, intervention, adverse events, and outcomes. Comparisons were performed by institutional location and case volumes. Analysis was performed for trainee self-reported autonomy by post-graduate year and case volume experience. RESULTS: Twenty trainees performed a total of 2181 endoscopic procedures. More upper endoscopies (N = 1,853) were performed than lower endoscopies (N = 325). Of all procedures, 546 (26.7%) involved a cancer or mass, 267 (12.2%) involved a report of blood loss, and 452 (20.7%) reported pain as a component of the diagnosis. Interventions beyond biopsy were reported in 555 (25%) procedures. Esophageal indications predominated the upper endoscopies, particularly esophageal cancer. Trainees in high-volume centers and in East Africa performed more interventional endoscopy and procedures focused on esophageal cancer. Procedure logs documented adverse events in 39 cases (1.8% of all procedures), including 16 patients (0.8%) who died within 30 days of the procedure. Self-reported autonomy improved with both increased endoscopy experience and post-graduate year. CONCLUSIONS: GIE is an appropriate component of general surgery residency training in Africa, and adequate training can be provided, particularly in upper GI endoscopy, and includes a wide variety of endoscopic therapeutic interventions.

Cecal volvulus in rural Kenya: delayed presentation contributes to high mortality.

BACKGROUND: Cecal volvulus, which is a torsion involving the cecum, terminal ileum, and ascending colon around its own mesentery, results in a closed-loop obstruction. It is a rare reported cause of adult intestinal obstruction. This study aimed to review the clinical presentation, management, and outcomes at a rural, resource-limited referral center. METHODS: We performed a retrospective review of all patients with a diagnosis of cecal volvulus between January 1st, 2009 and December 31st, 2019 at Tenwek Hospital in Bomet, Kenya. The outcome of survival was compared by the time to presentation. Mortality was also compared with prior reports of intestinal obstruction at our institution. RESULTS: Thirteen patients were identified with a mean age of 52 years and a mean symptom duration of 5 days. All patients presented with abdominal pain and distension. Seven patients (54%) presented with perforation, gangrene, or gross peritoneal contamination. Identified risk factors were Ladds bands with malrotation, adhesions, and a sigmoid tumor. Procedures included primary resection and anastomosis (7), damage control (3) with anastomosis on second-look in 2 of these, simple surgical detorsion (1), and surgical detorsion and cecopexy (2). There were four mortalities (31%), of which all had delayed presentation with perforation and fecal contamination. Delays to presentation were associated with mortality (p = 0.03). Cecal volvulus resulted in increased perioperative mortality compared to all intestinal obstructions presenting to the institution (p < 0.0001). CONCLUSIONS: Cecal volvulus carries a high risk of mortality. A high index of suspicion and early consideration in the differential diagnosis of intestinal obstruction should be considered to reduce the mortality associated with the delay in preoperative diagnosis.

A retrospective cohort study of endoscopic therapy and esophagectomy for stage 1 esophageal cancer: less is more.

BACKGROUND AND AIMS: Current guidelines recommend consideration of endoscopic therapy (ET) when treating select stage I esophageal cancers. The proportion of esophageal cancers treated with ET compared with esophagectomy has increased over time. Overall and cancer-specific survival have not been shown to be superior with ET in prior population-based studies. We thus evaluated cancer-specific survival comparing patients treated with ET and esophagectomy. METHODS: We performed a retrospective cohort study using the Surveillance, Epidemiology, and End Results database from 2004 to 2015 of patients with node-negative, superficial (T1a/T1b), esophageal cancer treated with ET or esophagectomy. Competing-risks models were used to compare cancer-specific survival. Cox proportional hazards models were used to assess overall survival. Subgroup analysis was performed comparing time periods 2004 to 2009 and 2010 to 2015. RESULTS: Of 2133 included individuals, 772 (36.2%) underwent ET and 1361 (63.8%) underwent esophagectomy. Unadjusted 5-year survival for cancer-specific death was 87.7% (95% confidence interval [CI], 84.2-90.5) for ET and 82.4% (95% CI, 80.0- 84.5) for esophagectomy (P = .002). Within the adjusted competing-risk model, cancer-specific survival was superior in patients treated with ET compared with esophagectomy (subdistribution hazard ratio [SHR], 1.92; 95% CI, 1.35-2.74; P < .001). From 2004 to 2009, the SHR for esophagectomy was 1.68 (95% CI, 1.07-2.66; P = .024); whereas from 2010 to 2015, the SHR for esophagectomy was 2.02 (95% CI, 1.08-3.76; P = .027). CONCLUSIONS: ET was associated with improved cancer-specific survival compared with esophagectomy in stage I esophageal cancer. This advantage was more pronounced for patients treated after 2009, potentially because of increasing clinician expertise in performing ET and patient selection.

Necrotizing Fasciitis: A Predictable Burden in Rural Kenya.

BACKGROUND: Necrotizing fasciitis (NF) is a devastating disease with substantial morbidity and mortality. Poor outcomes are attributed to delayed diagnosis and management. Tenwek Hospital, a teaching and referral center in rural Kenya, manages many cases despite variable resources. We aimed to understand the burden of NF. METHODS: All patients with admission NF diagnosis who presented in 2017 were reviewed for demographics, investigations, treatment, and outcomes. The primary outcome was unfavorable outcome defined as in-hospital mortality or amputation. Secondary outcomes were discharge diagnosis of NF and cost. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was calculated. Logistic regression models were utilized to assess the impact of risk factors. RESULTS: Sixty-seven patients were identified with an average age of 49.2 (±21) years. Medical comorbidities were present in 48% and history of trauma in 58%. Discharge diagnosis of NF occurred in 61% (N = 41). Overall, mortality occurred in 10% (N = 7) of patients with an initial NF diagnosis. At discharge, patients without NF had favorable outcomes in 96% (N = 25) compared to 78% (N = 32) with NF (p = 0.043). Final NF diagnosis costs 122,098 Kenyan Shillings more (95% confidence interval 36,142-208,054) than non-NF diagnosis (p value = 0.006). Factors associated with unfavorable outcome include diabetes mellitus, any comorbidity, increased heart rate, fever, hyperglycemia, anemia, and discharge NF diagnosis. Increased LRINEC score was associated with discharge NF diagnosis (p = 0.0006) and unfavorable outcome (p = 0.0157). CONCLUSIONS: Patients with NF in rural Kenya experience delays to presentation, unfavorable outcomes, and substantial costs. Certain factors, including LRINEC score, help predict diagnosis and outcome.

Assessing Post-operative Pain with Self-reports via the Jerrycan Pain Scale in Rural Kenya.

BACKGROUND: Perioperative pain management is an essential component to improving patient outcomes. Measurement and description of pain are challenging and vary in different contexts. The objective of this study was to assess the utility of self-reporting via visual analogue scales using the Jerrycan visual analogue scale in the assessment of post-operative pain and to validate the use of this novel scale compared to standard pain scales. MATERIALS AND METHODS: Two hundred and forty-one inpatients who underwent surgical procedures were prospectively assessed for post-operative pain over a 12-month period from February 2016 to January 2017. Participants included patients who underwent general surgery, orthopedic and obstetrics/gynecology procedures. On post-operative day one, four scales were assessed: Verbal scale, Hands scale, Faces scale and Jerrycan scale, each ranging from 0-5. Scores for each scale were recorded, and agreements between scales were calculated using kappa values and Spearman's rank coefficients. RESULTS: The mean age was 34.8 years and more female subjects were evaluated (68%). The majority received spinal anesthesia (61%). The mean pain score was 2.5 for all scales. The Jerrycan (0.50) and Faces scales (0.43) had moderate agreements with the Verbal scale. Participants preferred the Jerrycan Pain Scale. CONCLUSION: The Jerrycan pain scale had comparable scores and reasonable agreement with 3 other pain scales among a cohort of post-operative patients. Patient preference and ease of use of the Jerrycan scale may impact assessment and management of pain in a rural African setting. This scale may be adapted for use in similar resource settings for post-operative pain management.

Operative Case Volume Minimums Necessary for Surgical Training Throughout Rural Africa.

BACKGROUND: Resident operative case volumes are an important aspect of surgical education, and minimums are required in Accreditation Council for Graduate Medical Education (ACGME) programs. Minimum operative case volumes for training do not exist in rural Africa. Our objective was to determine the optimal minimum operative case volume necessary for general surgery training in rural Africa. METHODS: A cross-sectional census electronic survey was conducted among faculty (N = 24) and graduates (N = 56) of Pan-African Academy of Christian Surgeons training programs. Three equally weighted exposures (median minimum case volume suggested by participants, operative experience of prior graduates, and comparisons with ACGME minimums), adjusted from responses to targeted questions, were utilized to construct an optimal minimum operative case volume for training. RESULTS: Sixty-four surgeons were contacted and 40 (13 faculty, 24 graduates, and 3 graduates who became faculty) participated. All participants thought operative case minimums were necessary, and the majority (98%) felt current training adequately prepared surgeons for their setting. Constructed optimal case volumes included 1000 major cases with fewer required cases than ACGME in abdomen, breast, thoracic, vascular, endoscopy, and laparoscopy and more required cases than ACGME for alimentary tract, endocrine, operative trauma, skin and soft tissue, pediatric, and plastic surgery. Other categories (gynecology, orthopedics, and urology) were deemed necessary for surgical training, with regional differences. Prior graduates satisfied the overall, but not category-specific, proposed minimums. CONCLUSIONS: The surveyed surgeons highlighted the need for diverse surgical training with minimum exposures. They described increased need for cases reflecting regional variations with a desire for more experience in categories less common at their institutions.

Surgical Training Throughout Africa: A Review of Operative Case Volumes at Multiple Training Centers.

BACKGROUND: Adequate surgical training is paramount to produce competent surgeons to address the global burden of surgical disease. The Pan-African Academy of Christian Surgeons (PAACS) has general surgery training programs in eight countries. Operative case volumes have been positively associated with improved trainee performance and patient outcomes. For certification in the USA, 850 total operations are required from defined case categories. Yet, little is known about the operative experience of surgical trainees throughout Africa. METHODS: Operative procedures were reviewed, categorized, and validated from a cohort of PAACS graduates and compared to graduates from Accreditation Council for Graduate Medical Education (ACGME) programs. The primary and secondary outcomes were total case volumes and cases within ACGME-defined categories. Regional variations were explored. RESULTS: Twenty PAACS trainees, from five programs in four countries, performed 38,267 unique procedures. ACGME reports on 1211 residents from 251 programs. PAACS graduates logged more major cases (median 1448) than ACGME graduates (median 993) (p value = 0·0001). PAACS graduates performed more gynecology and obstetrics, orthopedics, head and neck, urology, endocrine, operative trauma, pediatric surgery, plastic surgery, and skin and soft tissue cases. US graduates performed more cases in abdomen, alimentary tract, breast, thoracic, and vascular categories. Comparison between regions demonstrated volume and category variations between Kenya and Gabon, Ethiopia, and Cameroon. CONCLUSION: PAACS trainees perform more operations than ACGME trainees with differences in distribution. This experience can serve as a model for regional educational programs seeking to address the broad and largely unmet burden of surgical disease.

Curative Surgery Improves Survival for Colorectal Cancer in Rural Kenya.

BACKGROUND/AIMS: Colorectal cancer (CRC) is increasing in low- and middle-income countries. Surgical care is essential for the treatment. Many patients do not have access to curative surgery for colorectal cancer in rural Kenya. To better understand the impact of surgical care on colorectal cancer in a resource-limited setting, we compared the experience of patients undergoing operations to those who did not. METHODS: All patients with histologically confirmed CRC at Tenwek Hospital from January 1, 1999, to December 31, 2017, were reviewed. Demographic and clinical data were extracted from records when available. The exposure was either curative operation, palliative operation, or no operation. The primary outcome was survival at 5 years, assessed with Cox proportional hazard analysis after propensity-score matching for age, sex, tumor site, time period, and stage. RESULTS: One hundred and sixty-five patients were identified on chart review. Survival information was available for 150 patients with a median follow-up of 319 days. Fifty-two percent had colon cancer and 48% had rectal cancer. At diagnosis, the mean age was 55.4 years (SD: 16.7) and the male to female ratio was 1.1:1. Thirty-nine percent underwent curative operations, 25% palliative operations, and 36% no operations. One-year survival was estimated to be 98% for curative surgery, 73% for palliative surgery, and 83% for no surgery (p = 0.0005). On crude analysis, 5-year survival improved with curative operation in comparison to no operation with a hazard ratio of 0.30 (CI: 0.14-0.64) (p = 0.002). After propensity matching, the hazard ratio for curative operation versus no operation remained significant, 0.34 (CI: 0.14-0.80) (p = 0.01). CONCLUSIONS: Curative surgery improves survival in our resource-limited environment. Although various factors contribute to the use of surgical treatment, the survival advantage persists after adjusted analysis. Barriers exist for access to prompt surgical evaluation and treatment. Surgical care should be a priority to address the increasing burden of CRC in resource-limited settings.

Burr-Hole Craniostomy for Chronic Subdural Hematomas by General Surgeons in Rural Kenya.

INTRODUCTION: Chronic subdural hematoma (cSDH) is a common condition that causes significant morbidity and mortality. In rural sub-Saharan Africa, there are very few neurosurgeons. Yet, cSDH is treatable by relatively simple surgical intervention with potential for rapid clinical improvement. METHODS: We conducted a retrospective chart review of all patients with cSDH who underwent burr-hole trephination at Tenwek Hospital, Kenya, between July 2014 and July 2016. We extracted and compared the clinical presentation, risk factors, operative details, and outcomes. RESULTS: A total of 119 patients were identified with a mean age of 61.3 years. The majority were men (80%). The main predisposing factors were trauma (54.6%) and alcohol intake (34.4%). Patients were generally managed with two burr-holes, irrigation, and a subdural drain, remaining for a median of 2 days. Operations were assisted by general surgery residents under direct supervision of senior residents (46), general surgeons (65), and neurosurgeons (8). Complications included recurrence (5.2%), subdural empyema (2.5%), postoperative seizures (3.4%), and mortality (6.7%). Improvement of symptoms was noted in 91% of all patients. CONCLUSION: Operative management of cSDH can be safely performed in rural facilities by general surgeons familiar with the procedure and with the institutional resources. The majority of patients had satisfactory outcomes.

Strategies and Challenges of a Safe Fireplace Program in Rural Kenya: A Qualitative Study.

There is a lack of information on effective burn prevention strategies. The objective of this study was to examine a safe fireplace program, as a method of burn prevention, in a resource-limited setting. We conducted a qualitative, phenomenological study at a community health and development program for a rural population in Kenya. Semi-structured, in-depth interviews were conducted with a purposive sample of community health workers involved with the safe fireplace program. Data were reviewed iteratively and coded independently by two researchers using NVivo 12. The study included five participants. Reflections from participants fell into three main domains: (1) effective methods of education, (2) strategies to incorporate stakeholders, and (3) implementation challenges. The results of this study emphasize the importance of community engagement in implementing a successful burn injury prevention program in a resource-limited setting. The participants involved in this study reported that rather than focusing on resources outside the community, effective methods of education and strategies for incorporating stakeholders depended on involving peers and community leaders. The challenges to the program were similarly specific to community concerns about resources and maintenance. These findings provide information to guide future community health programs in creating successful models for burn prevention strategies in resource-limited areas.

Trainee autonomy and surgical outcomes after emergency gastrointestinal surgery.

BACKGROUND: Operative meaningful trainee autonomy is an essential component of surgical training. Reduced trainee autonomy is frequently attributed to patient safety concerns, but this has not been examined within Kenya. We aimed to assess whether meaningful trainee autonomy was associated with a change in patient outcomes. METHODS: We investigated whether meaningful trainee autonomy was associated with a change in severe postoperative complications and all-cause in-hospital mortality in a previously described cohort undergoing emergency gastrointestinal operations. Each operation was reviewed to determine the presence of meaningful autonomy, defined as "supervision only" from faculty. Comparisons were made between faculty-led cases and cases with meaningful trainee autonomy. Multilevel logistic regression models were created for the outcomes of mortality and complications with the exposure of meaningful trainee autonomy, accounting for fixed effects of the Africa Surgical Outcomes Study Risk Score and random effects of discharge diagnoses. RESULTS: After excluding laparoscopy (N = 28) and missing data (N = 3), 451 operations were studied, and 343 (76.1%) had meaningful trainee autonomy. Faculty were more involved in operations with older age, cancer, prior complications, and higher risk scores. On unadjusted analysis, meaningful trainee autonomy was associated with mortality odds of 0.32 (95% confidence interval: 0.17-0.58) compared with faculty-led operations. Similarly, the odds of developing complications were 0.52 (95% confidence interval: 0.32-0.84) with meaningful trainee autonomy compared with faculty-led operations. When adjusting for Africa Surgical Outcomes Study Score and clustering discharge diagnoses, the odds of mortality (odds ratio 0.58; 95% confidence interval: 0.27-1.2) and complication (odds ratio 0.83; 95% confidence interval: 0.47-1.5) were not significant. CONCLUSION: Our findings support that increasing trainee autonomy does not change patient outcomes in selected emergency gastrointestinal operations. Further, trainees and faculty appropriately discern patients at higher risk of complications and mortality, and the selective granting of trainee autonomy does not affect patient safety.

CT without borders: Comparison of diagnoses for abdominal pain from a teaching hospital in rural Kenya and a US academic medical center.

PURPOSE: Radiology global health opportunities are expanding as more hospitals in low- and middle-income countries utilize CT. This creates opportunities for global health program building, education, service, and research. This study determines the diagnostic yield and variety of abdominopelvic CT diagnoses for abdominal pain in a US academic medical center (UW) compared to a rural Kenyan teaching hospital (Tenwek). METHODS: A retrospective, cross-sectional sequential sample of 750 adults from both hospitals who underwent abdominopelvic CT for abdominal pain from February 2019 through July 2020 was obtained. Exclusion criteria were trauma, cancer staging, and recent hospitalization or surgery. Patient age, sex, comparison studies, use of contrast, known cancer diagnosis, and CT diagnoses were compared. Negative exam rate, acute abdomen diagnosis, and new cancer diagnosis were recorded. Statistical analysis was performed using R. RESULTS: 750 UW patients met inclusion criteria (mean age 53.3 ± 20 years; 442 women) and 750 Tenwek patients met inclusion criteria (mean age 52.5 ± 18 years; 394 women). 72% of UW patients had comparison imaging compared to 6% of Tenwek patients. 11% (83/750) of UW patients had a known cancer diagnosis compared to 1% (10/750) of Tenwek patients. 39% of UW patients had a negative exam compared to 23% of Tenwek patients (p < 0.001). 58% of UW patients had an acute abdomen diagnosis compared to 38% of Tenwek patients (p < 0.001). 10 of the 15 top acute abdomen diagnoses were shared, but in different order of frequency. Diagnoses unique to UW were diverticulitis, constipation, stercoral colitis, and epiploic appendagitis. Diagnoses unique to Tenwek were tuberculosis and hydatidosis. 3% of UW patients received a new cancer diagnosis (7/19 metastatic), compared to 40% of Tenwek patients (153/303 metastatic) (p < 0.001). CONCLUSION: For adults undergoing CT for abdominal pain, there are differences in the prevalence of abdominal pain diagnoses, new cancer diagnosis, and negative exam rate between the rural Kenyan teaching hospital and the US academic medical center.

The costs of complications after emergency gastrointestinal surgery in Kenya.

BACKGROUND: The financial burden of surgery is substantial worldwide. Postoperative complications increase costs in high-resource settings, but this is not well studied in other settings. Our objective was to review the financial impact of postoperative complications. METHOD: Patients undergoing emergency gastrointestinal operations at a center in Kenya were reviewed between January 2017 and June 2019. In a cost analysis, we ascertained the outcome of total hospital costs, adjusted for inflation, and converted to international dollars using purchasing power parities. Costs were analyzed for their association with a postoperative complication, defined using standardized criteria. We calculated the Africa Surgical Outcomes Study surgical risk scores and clustered for discharge diagnosis in a mixed-effects generalized linear model accounting for confounding factors related to costs and complications. RESULTS: A total of 361 individuals had cost data available. The cohort had 251 men (69.5%) and 110 women (30.5%) with a median age of 41 years (interquartile range: 29-57 years). A total of 122 (33.8%) patients experienced a postoperative complication with an overall all-cause mortality rate of 10.5%. The median total cost of hospitalization was 1,949 (interquartile range: 1,516-2,788) international dollar purchasing power parities. When controlling for patient factors and diagnoses, patients who did not develop complications had costs of 2,119 (95% confidence interval 1,898-2,340) compared to costs of 3,747 (95% confidence interval 3,327-4,167) for patients who developed a postoperative complication, leading to a 77% increase of 1,628 international dollar purchasing power parities for patients with complications. CONCLUSION: Our findings demonstrated a substantial financial burden generated by postoperative complications in patients undergoing emergency gastrointestinal operations. Reducing complications could allow cost savings, an important consideration in variable-resource settings.