A plea for urgent action: Addressing the critical shortage of cardiothoracic surgical workforce in the COSECSA region.

BACKGROUND: The College of Surgeons of East, Central, and Southern Africa (COSECSA) comprises 14 countries, many of which currently grapple with an increasing burden of cardiothoracic surgical (CTS) diseases. Health and economic implications of unaddressed CTS conditions are profound and require a robust regional response. This study aimed to define the status of CTS specialist training in the region (including the density of specialists, facilities, and active training posts), examine implications, and proffer recommendations. METHODS: A desk review of COSECSA secretariat documents and program accreditation records triangulated with information from surgical societies was performed in May 2022 and September 2023 as part of education quality improvement. A modified nominal group process involving contextual experts was used to develop a relevant action framework. RESULTS: Only 6 of 14 (43%) of COSECSA countries offered active training programs with annual intake of only 18 trainees. Significant training gaps existed in Burundi, Botswana, Malawi, Rwanda, South Sudan, Zambia, and Zimbabwe. Country specialist density ranged from 1 per 400,000 (Namibia) to 1 per 8,000,000 (Ethiopia). Overall, the region had 0.2 CTS specialists per million population as compared with 7.15 surgeons per million in High-Income Countries. Surgical education experts proposed an action framework to address the training crisis including increasing investments in CTS education, establishing regional centers of excellence, retention incentives and opportunities for women, and leveraging international partnerships. CONCLUSION: Proactive investments in infrastructure, human resources, training, and collaborative efforts by national governments, regional intergovernmental organizations, and international partners are critical to expanding regional CTS training.

Implementing surgical mentorship in a resource-constrained context: a mixed methods assessment of the experiences of mentees, mentors, and leaders, and lessons learned.

BACKGROUND: A well-qualified workforce is critical to effective functioning of health systems and populations; however, skill gaps present a challenge in low-resource settings. While an emerging body of evidence suggests that mentorship can improve quality, access, and systems in African health settings by building the capacity of health providers, less is known about its implementation in surgery. We studied a novel surgical mentorship intervention as part of a safe surgery intervention (Safe Surgery 2020) in five rural Ethiopian facilities to understand factors affecting implementation of surgical mentorship in resource-constrained settings. METHODS: We designed a convergent mixed-methods study to understand the experiences of mentees, mentors, hospital leaders, and external stakeholders with the mentorship intervention. Quantitative data was collected through a survey (n = 25) and qualitative data through in-depth interviews (n = 26) in 2018 to gather information on (1) intervention characteristics including areas of mentorship, mentee-mentor relationships, and mentor characteristics, (2) organizational context including facilitators and barriers to implementation, (3) perceived impact, and (4) respondent characteristics. We analyzed the quantitative and qualitative data using frequency analysis and the constant comparison method, respectively; we integrated findings to identify themes. RESULTS: All mentees (100%) experienced the intervention as positive. Participants perceived impact as: safer and more frequent surgical procedures, collegial bonds between mentees and mentors, empowerment among mentees, and a culture of continuous learning. Over 70% of all mentees reported their confidence and job satisfaction increased. Supportive intervention characteristics included a systems focus, psychologically safe mentee-mentor relationships, and mentor characteristics including generosity with time and knowledge, understanding of local context, and interpersonal skills. Supportive organizational context included a receptive implementation climate. Intervention challenges included insufficient clinical training, inadequate mentor support, and inadequate dose. Organizational context challenges included resource constraints and a lack of common understanding of the intervention. CONCLUSION: We offer lessons for intervention designers, policy makers, and practitioners about optimizing surgical mentorship interventions in resource-constrained settings. We attribute the intervention's success to its holistic approach, a receptive climate, and effective mentee-mentor relationships. These qualities, along with policy support and adapting the intervention through user feedback are important for successful implementation.

Nonmalignant tracheal stenosis: presentation, management and outcome in limited resources setting.

BACKGROUND: Nonmalignant tracheal stenosis is a potentially life threatening conditions that develops as fibrotic healing from intubation, tracheostomy, caustic injury or chronic infection processes like tuberculosis. This is a report of our experience of its management with tracheostomy, rigid bronchoscopic dilation and surgery. METHODS: Retrospective study design was used. 60 patients treated over five years period were included. RESULTS: Mean age was 26.9 ± 10.0 with a range of 10-55 years. Majority (56 patients (93.3%)) had previous intubation as a cause for tracheal stenosis. Mean duration of intubation was 13.8 days (range from 2 to 27 days). All patients were evaluated with neck and chest CT (Computed Tomography) scan. Majority of the stenosis was in the upper third trachea - 81.7%. Mean internal diameter of narrowest part was 5.5 ± 2.5 mm, and mean length of stenosed segment was 16.9 ± 8 mm. Tracheal resection and end to end anastomosis (REEA) was the most common initial modality of treatment followed by bronchoscopic dilation (BD) and primary tracheostomy (PT). The narrowest internal diameter of the tracheal stenosis (TS) for each initial treatment category group was 4.4 ± 4.3 mm, 5.1 ± 1.9 mm and 6.7 ± 1.6 mm for PT, tracheal REEA and BD respectively, and the mean difference achieved statistical significance, F (10,49) = 2.25, p = 0.03. Surgery resulted in better outcome than bronchoscopic dilation (89.1% vs. 75.0%). DISCUSSION AND CONCLUSION: Nonmalignant tracheal stenosis mostly develops after previous prolonged intubation. Surgical resection and anastomosis offers the best outcome.

Patterns of mediastinal tumors operated at the Tikur Anbessa Hospital, Addis Ababa, Ethiopia over a six years period.

BACKGROUND: The mediastinum is the space that lies between the two pleural cavities containing many vital structures in it. When tumors or cysts arise in the mediastinum they can be either asymptomatic or present as space occupying lesions causing symptoms and signs by their effect on the neighboring organs. Though mediastinal tumors are routinely treated at the study center, there are no studies in Ethiopia concerning the patterns, and modes of treatments of Mediastinal space occupying lesions. OBJECTIVE: To review all the primary mediastinal tumors and cysts operated upon at the Tikur Anbessa Teaching Hospital, Addis Ababa University over a six year period, from August 2005-2011. METHODOLOGY: Clinical retrospective review. RESULTS: In the six years, 73 patients were operated, 49 (67.1%) were males, the and male to female ratio being 2.04:1. The mean age of patients was 35.9 +/- 10.5 years (range 14 to 74). Forty-five (61.6%) had lesions of the anterior mediastinum, 23 (31.5%) in the posterior mediastinum and 5 (6.8%) in the middle. The commonest anterior mediastinal tumors were thymic origin (24/45), and thymic lesions were found more common in females (17:7 ratio). From the 23 patients with posterior mediastinal tumors, 18 had benign neurogenic tumors (4 of which were dumbbell tumors). Chest pain and shortness of breath (dyspnea) were the two most common symptoms in 31 (42.4%) of the patients. Twenty three patients (31.5%) were asymptomatic, and all had benign lesions. None of the malignant lesions were asymptomatic. Eleven (15%) patients; eight with anterior and three with posterior mediastinal masses, had undergone pre-operative tissue diagnosis procedure by image guided FNAC. Fifty-nine (80.8%) patients were operated with intent of therapeutic surgical procedures. There were 28 (38.5%) midline sternotomies, 40 (54.7%) thoracotomies, four underwent a left sided mediastinotomies and one mediastinoscopy performed. The rate of malignancy in this study was 24 (32.8%), of which 19 (79.1%) were in the anterior compartment. A total of 13 (17.8%) patients had complications in the hospital and four (5.4%) of the patients died CONCLUSION: Primary mediastinal tumors are not so rare in the setting. We would also like to recommend further large scale prospective studies which also included long-term outcome so that we can further understand the situation in the country.

Biliopleural fistula after penetrating thoracoabdominal injury: A case report.

INTRODUCTION: Biliopleural fistula is a rare complication of thoraco-abdominal injury. Due to its rarity, the experience of any one surgeon is minimal, there is a paucity of literature regarding optimal treatment. This case report can be an addition to the existing reports to guide surgeons in better understanding and management of such cases. CASE PRESENTATION: A 30 yrs old male patient presented 2 weeks after he sustained gunshot injury over the right posterior chest. He was referred to our hospital because there was bilious chest tube output. Thoracotomy was done and finding was 10 cm right diaphragmatic defect with lacerated liver oozing bile and subcapsular hematoma that herniated into chest. Clotted blood had trapped the lung with pleural peel. Clot evacuation, decortication, biliary leak and liver laceration repair was done. The diaphragmatic defect was then closed. Patient had smooth postoperative course. DISCUSSION: Patients with BPF after thoracoabdominal injury can present with shortness of breath, bile output through chest tube and pleural effusion. Since bile has corrosive effect on lung with subsequent complications like empyema and bronchobiliary fistula, early diagnosis and treatment are imperative. BPF after thoracoabdominal injury can be effectively managed with thoracotomy, decortication and closure of diaphragmatic defect. CONCLUSION: Biliopleural fistula is uncommon after penetrating thoraco-abdominal injury and high index of suspicion and early diagnosis are of paramount importance to prevent complication. Surgery is best treatment option to stop biliary leak, close the diaphragmatic defect, manage further injuries in the chest and release trapped lung.

High Gastrointestinal Colonization Rate with Extended-Spectrum ß-Lactamase-Producing Enterobacteriaceae in Hospitalized Patients: Emergence of Carbapenemase-Producing K. pneumoniae in Ethiopia.

We investigated the gastrointestinal colonization rate and antibiotic resistance patterns of Extended-Spectrum Beta-Lactamase (ESBL)- producing Escherichia coli and Klebsiella pneumoniae in hospitalized patients admitted at Ethiopia's largest tertiary hospital. Fecal samples/swabs from 267 patients were cultured on chrome agar. ESBL. Bacterial species identification, verification of ESBL production and antibiotic susceptibility testing were done using Vitek 2 system (bioMérieux, France). Phenotype characterization of ESBL-E.coli and ESBL- K.pneumoniae was done using Neo-Sensitabs™. ESBL positivity rate was much higher in K. pneumoniae (76%) than E. coli (45%). The overall gastrointestinal colonization rate of ESBL producing Enterobacteriaceae (ESBL-E) in hospitalized patients was 52% (95%CI; 46%-58%) of which, ESBL-E. coli and K.pneumoniae accounted for 68% and 32% respectively. Fecal ESBL-E carriage rate in neonates, children and adults was 74%, 59% and 46% respectively. Gastrointestinal colonization rate of ESBL-E.coli in neonates, children and adults was 11%, 42% and 42% respectively. Of all E. coli strains isolated from adults, children and neonates, 44%, 49% and 22% were ESBL positive (p = 0.28). The prevalence of ESBL-K.pneumoniae carriage in neonates, children and adults was 68%, 22% and 7% respectively. All K. pneumoniae isolated from neonates (100%) and 88% of K. pneumoniae isolated from children were ESBL positive, but only 50% of K.pneumoniae isolated from adults were ESBL positive (p = 0.001). Thirteen patients (5%) were carriers of both ESBL-E.coli and ESBL-KP. The overall carrier rate of ESBL producing isolates resistant to carbapenem was 2% (5/267), all detected in children; three with E.coli HL cephalosporinase (AmpC), resistant to ertapenem and two with K. pneumoniae Carbapenemase (KPC) resistant to meropenem, ertapenem and impenem. We report a high gastrointestinal colonization rate with ESBL-E and the emergence of carbapenems-resistant K. pneumoniae in Ethiopia. Urgent implementation of infection control measures, and surveillance are urgently needed to limit the spread within healthcare facilities and further to the community.

Experience of surgical therapy in 72 patients with thoracic hydatidosis over a 10-year period.

OBJECTIVE: This review aims to evaluate retrospectively 72 patients diagnosed to have thoracic hydatid disease and treated surgically in Tikur Anbessa Hospital between December 1993 and November 2003. DESIGN: Retrospective Analysis hospital records. SETTINGS: Tikur Anbessa Hospital, Department of Surgery, Medical Faculty, Addis Ababa University, Addis Ababa, Ethiopia. PATIENTS AND METHODS: Medical records and Operation theater registers of seventy-two Patients operated on for Thoracic hydatidosis were evaluated retrospectively. Chest Roentgenogram was the main diagnostic tool used Main surgical techniques employed were evacuation in 44 (52.4%) cysts, cystotomy in 30 (35.7%) cysts, and enucleation in 10 (12%) cysts. Additional palliative procedures (such as pericystectomy and Capitonnage) and radical procedures (such as resection of the lung) were also employed. RESULTS: forty of the patients were male and thirty-two female with a mean age of 31.4 years. The most Common presenting symptoms were cough in 60 (83.3%) patients, expectoration in 47 (65.3%) patients and chest pain in 38 (52.8%) patients. Chest radiography revealed a round opacity or shadow in 58 (80.6%) patients. All patients were treated surgically. The mean hospital stay was 38.3 days. Major postoperative Complications occurred in 12 (16.9%) patients; pneumonia, pleural effusion and prolonged air leak were the complications in order of their frequency. There was one postoperative death and one recurrence at 6-months follow-up period. CONCLUSION: Surgical excision of pulmonary hydatidosis with maximum preservation of lung parenchyma is possible in the majority of patients and should remain the mainstay of surgical treatment.