Assessment of Acute Burn Management in 32 Low- and Middle-Income Countries.

BACKGROUND: The purpose of this study is to ascertain whether acute burn management (ABM) is available at health facilities in low- and middle-income countries (LMICs). METHOD: The study used the World Health Organization situational analysis tool (SAT) which is designed to assess emergency and essential surgical care and includes data points relevant to the acute management of burns. The SAT was available for 1413 health facilities in 59 countries. RESULTS: A majority (1036, 77.5 %) of the health facilities are able to perform ABM. The main reasons for the referral of ABM are lack of skills (53.4 %) and non-functioning equipment (52.2 %). Considering health centres and district/rural/community hospitals that referred due to lack of supplies/drugs and/or non-functioning equipment, almost half of the facilities were not able to provide continuous and consistent access to the equipment required either for resuscitation or to perform burn wound debridement. Out of the facilities that performed ABM, 379 (36.6 %) are capable of carrying out skin grafts and contracture release, which is indicative of their ability to manage full thickness burns. However the magnitude of full thickness burns managed was limited in half of these facilities, as they did not have access to a blood bank. CONCLUSION: The initial management of acute burns is generally available in LMICs, however it is constrained by the inability to perform resuscitation (19 %) and/or burn wound debridement (10 %). For more severe burns, an inability to perform skin grafting or contracture release limits definitive management of full thickness burns, whilst lack of availability to blood further compromises the treatment of major burns.

The impact of feedback of surgical outcome data on surgical performance: a systematic review.

BACKGROUND: Increasing patient demands, costs and emphasis on safety have led to performance tracking of individual surgeons. Several methods of using these data, including feedback have been proposed. Our aim was to systematically review the impact of feedback of outcome data to surgeons on their performance. STUDY DESIGN: MEDLINE, Embase, PsycINFO, AMED and the Cochrane Database of Systematic Reviews (from their inception to February 2013) were searched. Two reviewers independently reviewed citations using predetermined inclusion and exclusion criteria. Forty two data-points per study were extracted. RESULTS: The search strategy yielded 1,531 citations. Seven studies were eligible comprising 18,632 cases or procedures by 52 surgeons. Overall, feedback was found to be a powerful method for improving surgical outcomes or indicators of surgical performance, including reductions in hospital mortality after CABG of 24% (P = 0.001), decreases of stroke and mortality following carotid endarterectomy from 5.2 to 2.3%, improved ovarian cancer resection from 77 to 85% (P = 0.157) and reductions in wound infection rates from 14 to 10.3%. Improvements in performance occurred in concert with reduced costs: for hepaticojejunostomy, implementation of feedback was associated with a decrease in overall hospital costs from $24,446 to $20,240 (P < 0.01). Similarly, total cost of carotid endarterectomy and following management decreased from $13,344 to $9548. CONCLUSIONS: The available literature suggests that feedback can improve surgical performance and outcomes; however, given the heterogeneity and limited number of studies, in addition to their non-randomised nature, it is difficult to draw clear conclusions from the literature with regard to the efficacy of feedback and the specific nuances required to optimise the impact of feedback. There is a clear need for more rigorous studies to determine how feedback of outcome data may impact performance, and whether this low-cost intervention has potential to benefit surgical practice.

Comparison of off-clamp partial nephrectomy and on-clamp partial nephrectomy: a systematic review and meta-analysis.

OBJECTIVE: To compare peri- and postoperative variables, surgical complications, oncological outcomes and renal outcomes of off-clamp partial nephrectomy (PN) and on-clamp PN. METHODS: A systematic search of the electronic databases, including MEDLINE, Embase and Cochrane Library, was performed. The pooled estimates of tumour size, operative time, estimated blood loss, length of stay, overall complications, transfusion rates, urinary leaks, positive surgical margins and eGFR were calculated. RESULTS: 14 studies were included. There was no significant difference between off-clamp PN and on-clamp PN in terms of tumour size, operative time, estimated blood loss, length of stay, overall complications, transfusion rates, urinary leaks, and positive surgical margins. However, a non-statistically significant trend towards increased blood loss (p = 0.12) and transfusion rates (p = 0.07) in those undergoing off-clamp PN was noted. Off-clamp PN was associated with a significantly lower reduction in eGFR than on-clamp PN (standardised weighted mean difference 0.27, 95% CI 0.14, 0.40, p < 0.0001). CONCLUSIONS: Off-clamp PN may be associated with improved long-term renal outcomes when compared to on-clamp PN with no difference in in peri- and postoperative variables, surgical complications and oncological outcomes. However, the meta-analysis was limited by the design of the underlying studies, and hence further work is necessary.

The impact of feedback of intraoperative technical performance in surgery: a systematic review.

OBJECTIVES: Increasing patient demands, costs and emphasis on safety, coupled with reductions in the length of time surgical trainees spend in the operating theatre, necessitate means to improve the efficiency of surgical training. In this respect, feedback based on intraoperative surgical performance may be beneficial. Our aim was to systematically review the impact of intraoperative feedback based on surgical performance. SETTING: MEDLINE, Embase, PsycINFO, AMED and the Cochrane Database of Systematic Reviews were searched. Two reviewers independently reviewed citations using predetermined inclusion and exclusion criteria. 32 data-points per study were extracted. PARTICIPANTS: The search strategy yielded 1531 citations. Three studies were eligible, which comprised a total of 280 procedures by 62 surgeons. RESULTS: Overall, feedback based on intraoperative surgical performance was found to be a powerful method for improving performance. In cholecystectomy, feedback led to a reduction in procedure time (p=0.022) and an improvement in economy of movement (p<0.001). In simulated laparoscopic colectomy, feedback led to improvements in instrument path length (p=0.001) and instrument smoothness (p=0.045). Feedback also reduced error scores in cholecystectomy (p=0.003), simulated laparoscopic colectomy (p<0.001) and simulated renal artery angioplasty (p=0.004). In addition, feedback improved balloon placement accuracy (p=0.041), and resulted in a smoother learning curve and earlier plateau in performance in simulated renal artery angioplasty. CONCLUSIONS: Intraoperative feedback appears to be associated with an improvement in performance, however, there is a paucity of research in this area. Further work is needed in order to establish the long-term benefits of feedback and the optimum means and circumstances of feedback delivery.

Endometrioma contained within the broad ligament.

We present a rare case of an endometrioma present within and firmly adherent to the broad ligament in a patient who experienced an episode of acute abdominal pain. The endometrioma was excised laparoscopically and the broad ligament repaired.