Magnesium and Esophageal Pain After Peroral Endoscopic Myotomy of the Esophagus: A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Postoperative esophageal pain occurs in 67% of patients after peroral endoscopic esophageal myotomy (POEM). Magnesium can act as a smooth muscle relaxant. This study investigated whether intraoperative magnesium can reduce postoperative esophageal pain in patients undergoing POEM. METHODS: In this double-blind, placebo-controlled trial, 92 patients were randomized to receive either magnesium sulfate as a 50 mg.kg-1 (total body weight) bolus followed by an infusion at 25 mg.kg-1.hr-1, or 0.9% saline. Intraoperative analgesia was standardized in all patients. The primary outcome was the score from a validated, modified Esophageal Symptoms Questionnaire (ESQ) in the postanesthesia care unit (PACU). Pain scores, opioid requirements, and questionnaire scores were collected through postoperative day 1. RESULTS: ESQ scores were significantly lower in the magnesium group in the PACU (median [25th-75th], 24 [18-31] vs 35 [28-42]; median difference [95% confidence interval, CI], 10 [6-13]; P < .0001) and on postoperative day 1 (16 [14-23] vs 30 [24-35]; P < .0001). Less opioids were needed in the magnesium group in the PACU (mean ± standard deviation [SD] [99% CI], 4.7 ± 10 [1-9] mg vs 29 ± 21 [21-37] mg; P < .0001) and on postoperative day 1 (1 ± 3.7 [0-2.5] mg vs 13 ± 23 [4-23] mg; P = .0009). Pain scores were lower in the magnesium group in the PACU (0 [0-3] vs 5 [5-7]; P < .0001) and on postoperative day 1 (0 [0-2] vs 4 [3-5]; P < .0001). CONCLUSIONS: Patients undergoing POEM randomized to receive intraoperative magnesium had sustained reductions in esophageal discomfort severity and opioid requirements 24 hours after surgery.

Using AI and computer vision to analyze technical proficiency in robotic surgery.

BACKGROUND: Intraoperative skills assessment is time-consuming and subjective; an efficient and objective computer vision-based approach for feedback is desired. In this work, we aim to design and validate an interpretable automated method to evaluate technical proficiency using colorectal robotic surgery videos with artificial intelligence. METHODS: 92 curated clips of peritoneal closure were characterized by both board-certified surgeons and a computer vision AI algorithm to compare the measures of surgical skill. For human ratings, six surgeons graded clips according to the GEARS assessment tool; for AI assessment, deep learning computer vision algorithms for surgical tool detection and tracking were developed and implemented. RESULTS: For the GEARS category of efficiency, we observe a positive correlation between human expert ratings of technical efficiency and AI-determined total tool movement (r = - 0.72). Additionally, we show that more proficient surgeons perform closure with significantly less tool movement compared to less proficient surgeons (p < 0.001). For the GEARS category of bimanual dexterity, a positive correlation between expert ratings of bimanual dexterity and the AI model's calculated measure of bimanual movement based on simultaneous tool movement (r = 0.48) was also observed. On average, we also find that higher skill clips have significantly more simultaneous movement in both hands compared to lower skill clips (p < 0.001). CONCLUSIONS: In this study, measurements of technical proficiency extracted from AI algorithms are shown to correlate with those given by expert surgeons. Although we target measurements of efficiency and bimanual dexterity, this work suggests that artificial intelligence through computer vision holds promise for efficiently standardizing grading of surgical technique, which may help in surgical skills training.

Laparoscopic Heller Myotomy and Toupet Fundoplication.

Esophageal achalasia is a primary motility disorder of unknown origin. The goal of treatment is to eliminate the resistance caused by a non-relaxing lower esophageal sphincter, therefore allowing passage of food and liquid from the esophagus into the stomach. A myotomy with a partial fundoplication (anterior Dor or posterior Toupet) is considered the standard of care for patients with achalasia. In the following review, we describe the indications and technique for a posterior partial fundoplication (Toupet).

Impact of COVID-19 on presentation, management, and outcomes of acute care surgery for gallbladder disease and acute appendicitis.

BACKGROUND: The ongoing coronavirus disease 2019 (COVID-19) pandemic has significantly disrupted both elective and acute medical care. Data from the early months suggest that acute care patient populations deferred presenting to the emergency department (ED), portending more severe disease at the time of presentation. Additionally, care for this patient population trended towards initial non-operative management. AIM: To examine the presentation, management, and outcomes of patients who developed gallbladder disease or appendicitis during the pandemic. METHODS: A retrospective chart review of patients diagnosed with acute cholecystitis, symptomatic cholelithiasis, or appendicitis in two EDs affiliated with a single tertiary academic medical center in Northern California between March and June, 2020 and in the same months of 2019. Patients were selected through a research repository using international classification of diseases (ICD)-9 and ICD-10 codes. Across both years, 313 patients were identified with either type of gallbladder disease, while 361 patients were identified with acute appendicitis. The primary outcome was overall incidence of disease. Secondary outcomes included presentation, management, complications, and 30-d re-presentation rates. Relationships between different variables were explored using Pearson's r correlation coefficient. Variables were compared using the Welch's t-Test, Chi-squared tests, and Fisher's exact test as appropriate. RESULTS: Patients with gallbladder disease and appendicitis both had more severe presentations in 2020. With respect to gallbladder disease, more patients in the COVID-19 cohort presented with acute cholecystitis compared to the control cohort [50% (80) vs 35% (53); P = 0.01]. Patients also presented with more severe cholecystitis in 2020 as indicated by higher mean Tokyo Criteria Scores [mean (SD) 1.39 (0.56) vs 1.16 (0.44); P = 0.02]. With respect to appendicitis, more patients were diagnosed with a perforated appendix at presentation in 2020 [20% (36) vs 16% (29); P = 0.02] and a greater percentage were classified as emergent cases using the emergency severity index [63% (112) vs 13% (23); P < 0.001]. While a greater percentage of patients were admitted to the hospital for gallbladder disease in 2020 [65% (104) vs 50% (76); P = 0.02], no significant differences were observed in hospital admissions for patients with appendicitis. No significant differences were observed in length of hospital stay or operative rate for either group. However, for patients with appendicitis, 30-d re-presentation rates were significantly higher in 2020 [13% (23) vs 4% (8); P = 0.01]. CONCLUSION: During the COVID-19 pandemic, patients presented with more severe gallbladder disease and appendicitis. These findings suggest that the pandemic has affected patients with acute surgical conditions.

A protected time policy to improve dental health among resident physicians.

BACKGROUND: Resident physicians underuse preventive dental health services. The authors assessed the barriers to and need for oral health care among residents and piloted a program to enhance dental health care among house staff. METHODS: Participants from 5 residency programs received 2 hours of protected time during business hours for visits to a nearby dental office. The authors surveyed participating residents before and after the visits about barriers to seeking oral health care and their experiences with the program. The authors recorded dental findings for each participant. RESULTS: A total of 35 of 243 eligible residents (14.4%) participated in the study; 71.4% reported delaying or skipping preventive dental examinations during residency. Lack of time and norms and peer perceptions were important barriers; 28.6% of residents had dental findings requiring further management. CONCLUSIONS: Residents neglect preventive oral health care because of work obligations. More than one-quarter of residents had clinically significant dental findings. Providing protected time addressed common barriers and was well received. PRACTICAL IMPLICATIONS: Resident physicians have unmet oral health care needs. Collaborations between residency programs and dental practices to provide protected time for residents to seek oral health care could address common barriers to care.

Surgical deserts in California: an analysis of access to surgical care.

BACKGROUND: Areas of minimal access to surgical care, often called "surgical deserts", are of particular concern when considering the need for urgent surgical and anesthesia care. We hypothesized that California would have an appropriate workforce density but that physicians would be concentrated in urban areas, and surgical deserts would exist in rural counties. METHODS: We used a benchmark of six general surgeons, six orthopedists, and eight anesthesiologists per 100,000 people per county to define a "desert". The number and location of these providers were obtained from the Medical Board of California for 2015. ArcGIS, version 10.3, was used to geocode the data and were analyzed in Redivis. RESULTS: There were a total of 3268 general surgeons, 3188 orthopedists, and 5995 anesthesiologists in California in 2015, yielding a state surgeon-to-population ratio of 7.2, 6.7, and 10.2 per 100,000 people, respectively; however, there was wide geographic variability. Of the 58 counties in California, 18 (31%) have a general surgery desert, 27 (47%) have an orthopedic desert, and 22 (38%) have an anesthesiology desert. These counties account for 15%, 25%, and 13% of the state population, respectively. Five, seven, and nine counties, respectively, have none in the corresponding specialty. CONCLUSIONS: Overall, California has an adequate ratio of surgical and anesthesia providers to population. However, because of their uneven distribution, significant surgical care deserts exist. Limited access to surgical and anesthesia providers may negatively impact patient outcome in these counties.

Why do patients receive care from a short-term medical mission? Survey study from rural Guatemala.

BACKGROUND: Hospital de la Familia was established to serve the indigent population in the western highlands of Guatemala and has a full-time staff of Guatemalan primary care providers supplemented by short-term missions of surgical specialists. The reasons for patients seeking surgical care in this setting, as opposed to more consistent care from local institutions, are unclear. We sought to better understand motivations of patients seeking mission-based surgical care. METHODS: Patients presenting to the obstetric and gynecologic, plastic, ophthalmologic, general, and pediatric surgical clinics at the Hospital de la Familia from July 27 to August 6, 2015 were surveyed. The surveys assessed patient demographics, surgical diagnosis, location of home, mode of travel, and reasons for seeking care at this facility. RESULTS: Of 252 patients surveyed, 144 (59.3%) were female. Most patients reported no other medical condition (67.9%, n = 169) and no consistent income (83.9%, n = 209). Almost half (44.9%, n = 109) traveled >50 km to receive care. The most common reasons for choosing care at this facility were reputation of high quality (51.8%, n = 130) and affordability (42.6%, n = 102); the least common reason was a lack of other options (6.4%, n = 16). CONCLUSIONS: Despite long travel distances and the availability of other options, reputation and affordability were primarily cited as the most common reasons for choosing to receive care at this short-term surgical mission site. Our results highlight that although other surgical options may be closer and more readily available, reputation and cost play a large role in choice of patients seeking care.

The prevalence of psychiatric diagnoses and associated mortality in hospitalized US trauma patients.

BACKGROUND: We hypothesized that psychiatric diagnoses would be common in hospitalized trauma patients in the United States and when present, would be associated with worse outcomes. MATERIALS AND METHODS: The Nationwide Inpatient Sample (NIS, 2012) was used to determine national estimates for the number of patients admitted with an injury. Psychiatric diagnoses were identified using diagnosis codes according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. RESULTS: A total of 36.5 million patients were admitted to hospitals in the United States in 2012. Of these, 1.3 million (4%) were due to trauma. Psychiatric conditions were more common in patients admitted for trauma versus those admitted for other reasons (44% versus 34%, P < 0.001). Trauma patients who had a psychiatric diagnosis compared to trauma patients without a psychiatric diagnosis were older (mean age: 61 versus 56 y, P < 0.001), more often female (52% versus 50%, P < 0.001), and more often white (73% versus 68%, P < 0.001). For ages 18-64, drug and alcohol abuse predominated (41%), whereas dementia and related disorders (48%) were the most common in adults ≥65 y. Mortality was lower for trauma patients with a psychiatric diagnosis compared to those who did not in both unadjusted and adjusted analysis (1.9% versus 2.8%; odds ratio: 0.56, P < 0.001). CONCLUSIONS: Psychiatric conditions are present in almost half of all hospitalized trauma patients in the United States; however, the types of conditions varied with age. The frequency of psychiatric conditions in the trauma population suggests efforts should be made to address this component of patient health.

A geospatial evaluation of timely access to surgical care in seven countries.

OBJECTIVE: To assess the consistent availability of basic surgical resources at selected facilities in seven countries. METHODS: In 2010-2014, we used a situational analysis tool to collect data at district and regional hospitals in Bangladesh (n = 14), the Plurinational State of Bolivia (n = 18), Ethiopia (n = 19), Guatemala (n = 20), the Lao People's Democratic Republic (n = 12), Liberia (n = 12) and Rwanda (n = 25). Hospital sites were selected by pragmatic sampling. Data were geocoded and then analysed using an online data visualization platform. Each hospital's catchment population was defined as the people who could reach the hospital via a vehicle trip of no more than two hours. A hospital was only considered to show consistent availability of basic surgical resources if clean water, electricity, essential medications including intravenous fluids and at least one anaesthetic, analgesic and antibiotic, a functional pulse oximeter, a functional sterilizer, oxygen and providers accredited to perform surgery and anaesthesia were always available. FINDINGS: Only 41 (34.2%) of the 120 study hospitals met the criteria for the provision of consistent basic surgical services. The combined catchments of the study hospitals in each study country varied between 3.3 million people in Liberia and 151.3 million people in Bangladesh. However, the combined catchments of the study hospitals in each study country that met the criteria for the provision of consistent basic surgical services were substantially smaller and varied between 1.3 million in Liberia and 79.2 million in Bangladesh. CONCLUSION: Many study facilities were deficient in the basic infrastructure necessary for providing basic surgical care on a consistent basis.

Perceived Value of a Program to Promote Surgical Resident Well-being.

OBJECTIVE: The demands of surgical residency are intense and threaten not only trainees' physical wellness, but also risk depression, burnout, and suicide. Our residency program implemented a multifaceted Balance in Life program that is designed to improve residents' well-being. The purpose of this study was to evaluate the program utilization and perceived value by residents. DESIGN, SETTING, PARTICIPANTS: Residents (n = 56, 76% response rate) were invited to participate in a voluntary survey from December 2013 to February 2014 regarding utilization, barriers to use, and perceived value of 6 program components (refrigerator, After Hours Guide, psychological counseling sessions, Resident Mentorship Program, Class Representative System, and social events). They were also asked questions about psychological well-being, burnout, grit, and sleep and exercise habits before and after implementation of the program. RESULTS: The most valued components of the program were the refrigerator (mean = 4.61) and the psychological counseling sessions (mean = 3.58), followed by social events (mean = 3.48), the Resident Mentorship Program (mean = 2.79), the Class Representative System (mean = 2.62), and the After Hours Guide (mean = 2.10). When residents were asked how they would allocate $100 among the different programs, the majority was allocated to the refrigerator ($54.31), social events ($26.43), and counseling sessions ($24.06). There was no change in psychological well-being or burnout after the program. Residents had higher levels of grit (ß = 0.26, p < 0.01) and exercised (ß = 1.02, p < 0.001) and slept (ß = 1.17, p < 0.0001) more after the program was implemented. CONCLUSIONS: This study demonstrated that a multifaceted program to improve the well-being of trainees is feasible, highly valued, and positively perceived by the residents. Further research is needed to quantify the effectiveness and longitudinal impact such a program has on resident depression, burnout, and other psychological factors.

The American College of Surgeons Needs-Based Assessment of Trauma Systems: Estimates for the State of California.

BACKGROUND: In 2015, the American College of Surgeons Committee on Trauma convened a consensus conference to develop the Needs-Based Assessment of Trauma Systems (NBATS) tool to assist in determining the number of trauma centers required for a region. We tested the performance of NBATS with respect to the optimal number of trauma centers needed by region in California. METHODS: Trauma center data were obtained from the California Emergency Services Authority Information Systems (CEMSIS). Numbers of admitted trauma patients (ISS > 15) were obtained using statewide nonpublic admissions data from the California Office of Statewide Health Planning and Development (OSHPD), CEMSIS, and data from local emergency medical service agency (LEMSA) directors who agreed to participate in a telephone survey. Population estimates per county for 2014 were obtained from the U.S. Census. NBATS criteria used included population, transport time, community support, and number of discharges for severely injured patients (ISS > 15) at nontrauma centers and trauma centers. Estimates for the number of trauma centers per region were created for each of the three data sources and compared to the number of existing centers. RESULTS: A total of 62 state-designated trauma centers were identified for California: 13 (21%) Level I, 36 (58%) Level II, and 13 (11%) Level III. NBATS estimates for the total number of trauma centers in California were 27% to 47% lower compared to the number of trauma centers in existence, but this varied based on urban/rural status. NBATS estimates were lower than the current state in 70% of urban areas but were higher in almost 90% of rural areas. All data sources (OSHPD, CEMSIS, local data) produced similar results. CONCLUSION: Estimates from the NBATS tool are different from what is currently in existence in California, and differences exist based on whether the region is rural or urban. Findings from the current study can help inform future iterations of the NBATS tool. LEVEL OF EVIDENCE: Economic, level V.

Prevalence and predictors of depression among general surgery residents.

BACKGROUND: Recent resident suicides have highlighted the need to address depression among medical trainees. This study sought to identify the prevalence and predictors of depression among surgical residents. METHODS: Surgical residents at a single institution were surveyed. Depression and personal traits were assessed using validated measures; participant demographics were also obtained. RESULTS: 73 residents completed the survey (response rate 63%). 36% met criteria for at least mild depression, of which 20% met criteria for moderate to severe depression. In multivariate linear regression analyses controlling for demographic factors, trait emotional intelligence alone was a significant inverse predictor of depression (ß = -0.60, p < 0.001). CONCLUSIONS: Depression is prevalent among general surgery residents. Identifying protective factors and at-risk populations may allow for effective initiatives to be developed to address depression, and optimize the mental health of trainees.

Grit as a predictor of risk of attrition in surgical residency.

BACKGROUND: Grit, a measure of perseverance, has been shown to predict resident well-being. In this study we assess the relationship between grit and attrition. METHODS: We collected survey data from residents in a single institution over two consecutive years. All residents in general surgery were invited to participate (N = 115). Grit and psychological well-being were assessed using validated measures. Risk of attrition was measured using survey items. RESULTS: 73 residents participated (63% response rate). Grit was positively correlated with general psychological well-being (r = 0.30, p < 0.05) and inversely correlated with depression (r = -0.25, p < 0.05) and risk of attrition (r = -0.37, p < 0.01). In regression analyses, grit was positively predictive of well-being (B = 0.77, t = 2.96, p < 0.01) and negatively predictive of depression (B = -0.28 t = -2.74, p < 0.01) and attrition (B = -0.99, t = -2.53, p < 0.05). CONCLUSIONS: Attrition is a costly and disruptive problem in residency. Grit is a quick, reliable measure which appears to be predictive of attrition risk in this single-institution study.

Regional block via continuous caudal infusion as sole anesthetic for inguinal hernia repair in conscious neonates.

PURPOSE: The use of general anesthesia in young children has come under increasing scrutiny due to its potential long-term neurotoxic effects. Meanwhile, regional anesthesia for surgical procedures in neonates has many advantages, including preservation of respiratory status and faster return to feeding. We describe the successful use of 3% 2-chloroprocaine administered via continuous caudal infusion as the sole anesthetic agent during elective surgical procedures in infants. METHODS: A retrospective chart review of all patients who underwent elective surgical procedures under continuous caudal regional anesthetic at a single institution was performed. Thirty patients (27 males, three females) were identified: 28 patients underwent inguinal hernia repairs. Caudal anesthesia was established via continuous infusion of 3% 2-chloroprocaine through an indwelling catheter. RESULTS: Successful analgesia by regional block alone was achieved in all patients for the duration of each surgical procedure without need for rescue anesthesia. Mean operative time was 49 min. Patients were able to return to feeding immediately after surgery and were ready for discharge home within that day. CONCLUSION: Continuous caudal infusion of chloroprocaine is a safe and effective way to maintain adequate analgesia for elective surgeries in infants. This successful regional approach obviates the use of general anesthetic which reduces post-operative recovery time and avoids concerns for neurotoxicity.

Effects of mechanism of injury and patient age on outcomes in geriatric rib fracture patients.

BACKGROUND: Patients older than 65 years have 2-5 times higher mortality if they sustain ≥2 rib fractures compared to younger adults. As a result, our level I trauma center guidelines suggest that older adults with rib fractures be admitted to the intensive care unit for the first 24 hours. In this study, we evaluated the outcomes associated with these guidelines. METHODS: We retrospectively reviewed all patients aged ≥65 years in our Trauma Registry who sustained rib fractures from January 2008 to March 2015. Data included demographics, comorbidities, injuries, length of intensive care and hospital stay (LOS), ventilator days, analgesic used, morbidity, mortality, and disposition. RESULTS: 97 patients aged ≥65 years with at least one rib fracture and an Abbreviated Injury Score of ≤2 for other regions were admitted. Falls caused 58% of the injuries, while motor vehicle collisions (MVC) accounted for 33%. Overall mortality was 4%. Patients who fell had a median hospital LOS that was 0.5 to 1 day longer than in those who suffered other mechanisms of injury or were involved in an MVC respectively. Patients aged ≥70 years had a median LOS of 4 days, twice that of those aged 65 to 69 years. Of the 87 patients with more than one rib fracture, 59 (68%) were not admitted directly to the intensive care unit (ICU) from the emergency department as recommended by our guidelines. 6 of these 59 patients (9%) were later transferred to the ICU and 2 of these patients expired. CONCLUSIONS: Although overall compliance with the geriatric rib fracture guideline was low, both mortality and hospital LOS were low in this group. This suggests that the guideline could be modified to reduce ICU resource usage without compromising patient outcomes. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Mapping Disparities in Access to Safe, Timely, and Essential Surgical Care in Zambia.

Importance: Surgical care is widely unavailable in developing countries; advocates recommend that countries evaluate and report on access to surgical care to improve availability and aid health planners in decision making. Objective: To analyze the infrastructure, capacity, and availability of surgical care in Zambia to inform health policy priorities. Design, Setting, and Participants: In this observational study, all hospitals providing surgical care were identified in cooperation with the Zambian Ministry of Health. On-site data collection was conducted from February 1 through August 30, 2011, with an adapted World Health Organization Global Initiative for Emergency and Essential Surgical Care survey. Data collection at each facility included interviews with hospital personnel and assessment of material resources. Data were geocoded and analyzed in a data visualization platform from March 1 to December 1, 2015. We analyzed time and distance to surgical services, as well as the proportion of the population living within 2 hours from a facility providing surgical care. Main Outcomes and Measures: Surgical capacity, supplies, human resources, and infrastructure at each surgical facility, as well as the population living within 2 hours from a hospital providing surgical care. Results: Data were collected from all 103 surgical facilities identified as providing surgical care. When including all surgical facilities (regardless of human resources and supplies), 14.9% of the population (2 166 460 of 14 500 000 people) lived more than 2 hours from surgical care. However, only 17 hospitals (16.5%) met the World Health Organization minimum standards of surgical safety; when limiting the analysis to these hospitals, 65.9% of the population (9 552 780 people) lived in an area that was more than 2 hours from a surgical facility. Geographic analysis of emergency and essential surgical care, defined as access to trauma care, obstetric care, and care of common abdominal emergencies, found that 80.7% of the population (11 704 700 people) lived in an area that was more than 2 hours from these surgical facilities. Conclusions and Relevance: A large proportion of the population in Zambia does not have access to safe and timely surgical care; this percentage would change substantially if all surgical hospitals were adequately resourced. Geospatial visualization tools assist in the evaluation of surgical infrastructure in Zambia and can identify key areas for improvement.

Size and distribution of the global volume of surgery in 2012.

OBJECTIVE: To estimate global surgical volume in 2012 and compare it with estimates from 2004. METHODS: For the 194 Member States of the World Health Organization, we searched PubMed for studies and contacted key informants for reports on surgical volumes between 2005 and 2012. We obtained data on population and total health expenditure per capita for 2012 and categorized Member States as very-low, low, middle and high expenditure. Data on caesarean delivery were obtained from validated statistical reports. For Member States without recorded surgical data, we estimated volumes by multiple imputation using data on total health expenditure. We estimated caesarean deliveries as a proportion of all surgery. FINDINGS: We identified 66 Member States reporting surgical data. We estimated that 312.9 million operations (95% confidence interval, CI: 266.2-359.5) took place in 2012, an increase from the 2004 estimate of 226.4 million operations. Only 6.3% (95% CI: 1.7-22.9) and 23.1% (95% CI: 14.8-36.7) of operations took place in very-low- and low-expenditure Member States representing 36.8% (2573 million people) and 34.2% (2393 million people) of the global population of 7001 million people, respectively. Caesarean deliveries comprised 29.6% (5.8/19.6 million operations; 95% CI: 9.7-91.7) of the total surgical volume in very-low-expenditure Member States, but only 2.7% (5.1/187.0 million operations; 95% CI: 2.2-3.4) in high-expenditure Member States. CONCLUSION: Surgical volume is large and growing, with caesarean delivery comprising nearly a third of operations in most resource-poor settings. Nonetheless, there remains disparity in the provision of surgical services globally.

Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data.

BACKGROUND: Surgical interventions occur at lower rates in resource-poor settings, and complication and death rates following surgery are probably substantial but have not been well quantified. A deeper understanding of outcomes is a crucial step to ensure that high quality accompanies increased global access to surgical care. We aimed to assess surgical mortality following three common surgical procedures--caesarean delivery, appendectomy, and groin (inguinal and femoral) hernia repair--to quantify the potential risks of expanding access without simultaneously addressing issues of quality and safety. METHODS: We collected demographic, health, and economic data for 113 countries classified as low income or lower-middle income by the World Bank in 2005. We did a systematic review of Ovid, MEDLINE, PubMed, and Scopus from Jan 1, 2000, to Jan 15, 2015, to identify studies in these countries reporting all-cause mortality following the three commonly undertaken operations. Reports from governmental and other agencies were also identified and included. We modelled surgical mortality rates for countries without reported data using a two-step multiple imputation method. We first used a fully conditional specification (FCS) multiple imputation method to establish complete datasets for all missing variables that we considered potentially predictive of surgical mortality. We then used regression-based predictive mean matching imputation methods, specified within the multiple imputation FCS method, for selected predictors for each operation using the completed dataset to predict mortality rates along with confidence intervals for countries without reported mortality data. To account for variability in data availability, we aggregated results by subregion and estimated surgical mortality rates. FINDINGS: From an initial 1302 articles and reports identified, 247 full-text articles met our inclusion criteria, and 124 provided data for surgical mortality for at least one of the three selected operations. We identified 42 countries with mortality data for at least one of the three procedures. Median reported mortality was 7·9 per 1000 operations for caesarean delivery (IQR 2·8-19·9), 2·2 per 1000 operations for appendectomy (0·0-17·2), and 4·9 per 1000 operations for groin hernia (0·0-11·7). Perioperative mortality estimates by subregion ranged from 2·8 (South Asia) to 50·2 (East Asia) per 1000 caesarean deliveries, 2·4 (South Asia) to 54·0 (Central sub-Saharan Africa) per 1000 appendectomies, and 0·3 (Andean Latin America) to 25·5 (Southern sub-Saharan Africa) per 1000 hernia repairs. INTERPRETATION: All-cause postoperative mortality rates are exceedingly variable within resource-constrained environments. Efforts to expand surgical access and provision of services must include a strong commitment to improve the safety and quality of care. FUNDING: None.