Determinants of Access to Essential Surgery in the Democratic Republic of Congo.

INTRODUCTION: In the Democratic Republic of Congo (DRC), the determinants and barriers of essential surgical care are not well described, hindering efforts to improve national surgical programs and access. METHODS: A cross-sectional study evaluated access to essential surgery in the Butembo and Katwa health zones in the North Kivu province of DRC. A double-clustered random sample of community members was surveyed using questions derived from the Surgeons OverSeas Surgical Needs Assessment Survey, a validated tool to determine the reasons for not seeking, reaching, or receiving a Bellwether surgery (i.e., caesarean delivery, laparotomy, and external fixation of a fracture) when needed. RESULTS: Overall, 887 households comprising 5944 community members were surveyed from April to August 2022. Six percent (n = 363/5944) of the study population involving 35% (n = 309/887) households needed a Bellwether surgery in the previous year, 30% (n = 108/363) of whom died. Of those who needed surgery, 25% (n = 78) did not go to the hospital to seek care and were more likely to find transportation unaffordable (P = 0.042). The most common reasons for not seeking care were lack of funds for hospitalization, prior poor hospital experience, and fear of hospital care. CONCLUSIONS: Access and delivery of essential surgery are drastically limited in the North Kivu province of the DRC, such that a quarter of households needing surgery fails to seek surgical care. Poor access was predominantly driven by households' inability to pay for surgery and community distrust of the hospital system.

Use of mobile health technologies for postoperative care in paediatric surgery: A systematic review.

INTRODUCTION: Mobile health (mHealth) is the use of mobile communication devices such as smartphones, wireless patient monitoring devices and tablet computers to deliver health services. Paediatric surgery patient care could potentially benefit from these technologies. This systematic review summarises the current literature on the use of mHealth for postoperative care after children's surgery. METHODS: Seven databases were searched by a senior medical librarian. Studies were included if they reported the use of mHealth systems for postoperative care for children <18 years old. Data extraction and risk of bias assessment were performed in duplicate. RESULTS: A total of 18 studies were included after screening. mHealth use was varied and included appointment or medication reminders, postoperative monitoring and postoperative instruction delivery. mHealth systems included texting systems and mobile applications, and were implemented for a wide range of surgical conditions and countries. DISCUSSION: Studies showed that mHealth systems can increase the postoperative follow-up appointment attendance rate (p < 0.001), decrease the rate of postoperative complications and returns to the emergency department and reliably monitor postoperative pain. mHealth systems were generally appreciated by patients. Most non-randomised and randomised studies had many methodological problems, including lack of appropriate control groups, lack of blinding and a tendency to devote more time to the care of the intervention group. mHealth systems have the potential to improve postoperative care, but the lack of high-quality research evaluating their impact calls for further studies exploring evidence-based mHealth implementation.

Surgical Repair of Orofacial Clefts in North Kivu Province of Eastern Democratic Republic of Congo (DRC).

BACKGROUND: There is a high prevalence of orofacial clefts in low- and middle-income countries with significant unmet need, despite having 50% of the population younger than 18 years in countries such as the Democratic Republic of Congo (DRC). The purpose of this article is to report on the experience of general surgeons with orofacial clefts at a single institution. METHODS: This is a retrospective study of patients treated for cleft lip/palate in the province of North Kivu, DRC between 2008 and 2017. RESULTS: A total of 1112 procedures (122/year) were performed. All procedures were performed by general surgeons following training by an international nongovernmental aid organization. A total of 59.2% of patients were male and the median age was 3.4 years (interquartile range: 0.7-13 years). Average distance from surgical center to patient location was 242.6 km (range: 2-1375 km) with outreach performed for distances >200 kms. A majority (82.1%) of patients received general anesthesia (GA) with significant differences in use of GA, age, weight, and length of stay by major orofacial cleft category. Of the 1112 patients, 86.1% were reported to have cleft lip alone, 10.5% had cleft lip and palate, and 3.4% cleft palate alone. Despite this, only 5.3% of patients underwent surgical repair of cleft palate. CONCLUSIONS: Multiple factors including malnutrition, risk of bleeding, procedural complexity, and cosmetic results may contribute to the distribution of procedures performed where most cleft palates are not treated. Based on previously published estimates, unmet needs and social burden of cleft lip and palate are high in the DRC.

Neurosurgical management of hydrocephalus by a general surgeon in an extremely low resource setting: initial experience in North Kivu province of Eastern Democratic Republic of Congo.

PURPOSE: Evaluate the management of hydrocephalus in pediatric patients in the Eastern Democratic Republic of Congo by a general surgeon. METHODS: Retrospective review of a single institution in the province of North Kivu. Patient charts and surgical notes were reviewed from 2003 to 2016. RESULTS: 116 procedures were performed for an average of 8.9 per year. 51.7% of surgeries were on female patients with an average age of 13.6 ± 22.7. The average distance traveled from home to hospital was 153.7 km but ranged from 5 to 1420 km. The majority of hydrocephalus was due to neonatal sepsis (57%); 33.6% were classified as congenital; 9.5% of cases followed myelomeningocele closure. 97.4% had a ventriculoperitoneal (VP) shunt placed. Endoscopic third ventriculostomy combined choroid plexus cauterization (ETV/CPC) was performed in 2.5% of patients. Shunt infection occurred in 9.5% of patients, shunt dysfunction or obstruction in 5.2% and shunt exteriorization in 1.7%; no complications occurred in patients who underwent ETV/CPC. CONCLUSION: VP shunt is the predominant management for hydrocephalus in this environment with increasing use of ETV/CPC. Further research is needed to evaluate variability by etiology, short and long-term outcomes of procedures performed by neurosurgeons and general surgeons, and regional epidemiologic variability.

Operations for Suspected Neoplasms in a Resource-Limited Setting: Experience and Challenges in the Eastern Democratic of Congo.

INTRODUCTION: Surgery is an essential component of a functional health system, with surgical conditions accounting for nearly 11-15% of world disability. While communicable diseases continue to burden low- and low-middle-income countries, non-communicable diseases, such as cancer, are an important cause of morbidity and mortality worldwide. Preliminary data on malignancies in low- and middle-income countries, specifically in Africa, suggest a higher mortality compared to other regions of the world, a difference partially explained by limited availability of screening and early detection systems as well as poorer access to treatment. OBJECTIVE: To evaluate the diagnosed tumor burden in the Eastern Democratic Republic of Congo (DRC) and review literature on existing and suspected barriers to accessing appropriate oncologic care. METHODS: This is a retrospective study carried out at Healthcare, Education, community Action, and Leadership development Africa, a 197-bed tertiary referral hospital, in the Province of North Kivu, along the eastern border of the DRC from 2012 to 2015. Patient charts were reviewed for diagnoses of presumed malignancy with biopsy results. RESULTS: A total of 252 cases of suspected cancer were reviewed during the study period; 39.7% were men. The average age of patients was 43 years. Amongst adult patients, the most common presenting condition involved breast lesions with 5.8% diagnosis of fibrocystic breast changes and 2.9% invasive ductal carcinoma of the breast. 37.3% of female patients had lesions involving the cervix or uterus. The most common diagnosis amongst male adults was prostate disease (16.7% of men). For pediatric patients, the most common diagnoses involved bone and/or cartilage (27.3%) followed by skin and soft tissue lesions (20.0%). All patients underwent surgical resection of lesions; some patients were advised to travel out of country for chemotherapy and radiation for which follow-up data are unavailable. CONCLUSION: Adequate and timely treatment of malignancy in the DRC faces a multitude of challenges. Access to surgical services for diagnosis and management as well as chemotherapeutic agents is prohibitively limited. Increased collaboration with local clinicians and remote specialist consultants is needed to deliver subspecialty care in resource-poor settings.

Characterizing pediatric surgical capacity in the Eastern Democratic Republic of Congo: results of a pilot study.

PURPOSE: Characterize pediatric surgical capacity in the eastern Democratic Republic of Congo (DRC) to identify areas of potential improvement. METHODS: The Pediatric Personnel, Infrastructure, Procedures, Equipment, and Supplies (PediPIPES) survey was used in two representative eastern DRC provinces to assess existing surgical infrastructure and capacity. We compared our results to previously published reports from other sub-Saharan African countries. RESULTS: Fourteen hospitals in the eastern DRC and 37 in 19 sub-Saharan African (SSA) countries were compared. The average PediPIPES index for the DRC was 7.7 compared to 13.5 for SSAs. The greatest disparities existed in the areas of personnel and infrastructure. Running water was reportedly available to 57.1% of the hospitals in the DRC, and the majority of hospitals (78.6%) were dependent on generators and solar panels for electricity. Only two hospitals in the DRC (14.3%) reported a pediatric surgeon equivalent on staff, compared to 86.5% of facilities sampled in SSA reporting ≥ 1 pediatric surgeon. CONCLUSIONS: Significant barriers in personnel, infrastructure, procedures, equipment, and supplies impede the provision of adequate surgical care to children. Further work is needed to assess allocation and utilization of existing resources, and to enhance training of personnel with specific attention to pediatric surgery.