Hepato-pancreato-biliary surgery in West Africa: a timely capacity assessment.

BACKGROUND: West Africa has among the highest rates of hepato-pancreato-biliary (HPB) malignancies in the world. Although surgery is critical for treatment, the availability of HPB surgery in Africa is unknown. This cross-sectional study investigated the current HPB surgical capacity of West African hospitals. METHOD: The Surgeons OverSeas Personnel, Infrastructure, Procedure, Equipment, and Supplies (PIPES) survey was modified to include HPB-specific parameters and quantify capacity. The survey was completed by consultant surgeons from West Africa. A PIPES index was calculated, and a higher score corresponded to greater HPB surgical capacity. RESULTS: The HPB PIPES survey was completed by 35 institutions from The Gambia, Ghana, Ivory Coast, and Nigeria. Most institutions (94.2%) were tertiary referral centres; five had an HPB-trained surgeon. The most commonly available procedure was an open cholecystectomy (91.4%), followed by gastric bypass (88.6%). Major hepatic resections (14.3%) and the Whipple procedure (17.1%) were rare. ICU capabilities were present at 88.6% of facilities while interventional radiology was present in 25.7%. CONCLUSIONS: This is the first HPB capacity assessment in Africa. This study showed the limited availability of HPB surgery in West Africa. These results can be used for regional quality improvement initiatives and as a baseline for future capacity assessments.

The management and outcomes of hepatocellular carcinoma in sub-Saharan Africa: a systematic review.

BACKGROUND: Hepatocellular carcinoma (HCC) is a leading cause of mortality in sub-Saharan Africa (SSA). This systematic review aimed to appraise all population-based studies describing the management and outcomes of HCC in SSA. METHODS: A systematic review based on a search in PubMed, PubMed Central, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), AfricaWide and Cochrane up to June 2023 was performed. PRISMA guidelines for systematic reviews were followed. The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (registration no: CRD42022363955). RESULTS: Thirty-nine publications from 15 of 48 SSA countries were identified; 3989 patients were studied. The majority (74%) were male, with median ages ranging from 28 to 54 years. Chronic Hepatitis B infection was a leading aetiology and non-cirrhotic HCC was frequently reported. Curative treatment (liver resection, transplantation and ablation) was offered to 6% of the cohort. Most patients (84%) received only best supportive care (BSC), with few survivors at one year. CONCLUSION: The majority of SSA countries do not have data reporting outcomes for HCC. Most patients receive only BSC, and curative treatment is seldom available in the region. Outcomes are poor compared to high-income countries.

Treatment of hepatocellular carcinoma in sub-Saharan Africa: challenges and solutions.

Most patients who develop hepatocellular carcinoma reside in resource-poor countries, a category that includes most countries in sub-Saharan Africa. Age-standardised incidence rates of hepatocellular carcinoma in western, central, eastern, and southern Africa is 6·53 per 100 000 inhabitants to 11·1 per 100 000 inhabitants. In high-income countries, around 40% of patients are diagnosed at an early stage, in which interventions with curative intent or palliative interventions are possible. By contrast, 95% of patients with hepatocellular carcinoma in sub-Saharan Africa present with advanced or terminal disease. In high-income countries, targets of 30-40% that have been set for intervention with curative intent are regularly met, with expected 5-year overall survival rates in the region of 70%. These outcomes are in sharp contrast with the very small proportion of patients in sub-Saharan Africa who are treated with curative intent. Primary prevention through the eradication and reduction of risk factors is still suboptimal because of logistical challenges. The challenges facing primary prevention, in combination with difficult-to-manage historic and emerging risk factors, such as ethanol overconsumption and metabolic dysfunction-associated liver disease, mandates secondary prevention for populations at risk through screening and surveillance. Although the increased treatment needs yielded by screening and surveillance in high-income countries are manageable by the incremental expansion of existing interventional resources, the lack of resources in sub-Saharan Africa will undermine the possible benefits of secondary prevention. An estimate of the projected effect of the introduction and expansion of screening and surveillance, resulting in stage migration and possibilities for active interventions for hepatocellular carcinoma, would facilitate optimal planning and development of resources.