Surgical training programmes in the South Pacific, Papua New Guinea and Timor Leste.

BACKGROUND: There is a surgical workforce shortage in Papua New Guinea (PNG), the Pacific and Timor Leste. Previously, Pacific Island specialists who trained overseas tended to migrate. METHODS: A narrative review was undertaken of the training programmes delivered through the University of Papua New Guinea and Fiji National University's Fiji School of Medicine, and support provided through Australian Aid and the Royal Australasian College of Surgeons (RACS), including scholarships and visiting medical teams. RESULTS: The Fiji School of Medicine MMed programme, which commenced in 1998, has 39 surgical graduates. Sixteen of 22 Fijians, nine of ten Solomon Islanders and four of five in Vanuatu currently reside and/or work in-country. Surgical training in PNG began in 1975, and now has 104 general surgical graduates, 11 of whom originate from the Pacific Islands or Timor Leste. The PNG retention rate of local graduates is 97 per cent, with 80 per cent working in the public sector. Twenty-two surgeons have also undertaken subspecialty training. Timor Leste has trained eight surgical specialists in PNG, Fiji, Indonesia or Malaysia. All have returned to work in-country. The RACS has managed Australian Aid programmes, providing pro bono visiting medical teams to support service delivery and, increasingly, capacity building in the region. The RACS has funded scholarships and international travel grants to further train or sustain the surgical specialists. CONCLUSION: The local MMed programmes have been highly successful in retaining specialists in the region. Partnerships with Australian Aid and RACS have been effective in ensuring localization of the faculty and ongoing professional development.

Who gets Hartmann's reversed in a regional centre?

BACKGROUND: Many patients who undergo a Hartmann's procedure do not have their stoma reversed. We analysed parameters and co-morbidity scales to assess their accuracy in predicting likelihood of undergoing reversal. MATERIAL AND METHODS: Retrospective analysis of 165 patients from a prospective colorectal database who were discharged home following a Hartmann's procedure at Barwon Health (Geelong, Australia), a regional centre, between 2002 and 2010. Parameters measured included age, sex, time to reversal, ICU admission and pathology results were recorded. Patients' ASA, POSSUM and Elixhauser co-morbidity scales were retrospectively analysed. RESULTS: Reversal of Hartmann's was performed in 74/165 (45%) patients after a median of 294 days (range 70-902). Age (mean 58.5 vs 72.9 years, p < 0.001), ICU stay (34/74 vs 66/91, p < 0.001), ASA (p < 0.002), Elixhauser co-morbidity count (mean 1.14 vs 1.92, p < 0.002) and a malignant diagnosis (9/74 vs 31/91, p < 0.002) were all associated with a decreased reversal rate on univariate analysis. Age was the only parameter found to be significant on multivariate analysis. The complication rate was 23/74, with 7/74 noted to have major complications (Clavian-Dindo III-IV). Reasons for not reversing patients included age and co-morbidities, patient refusal, and malignant disease progression. CONCLUSIONS: More than half the patients undergoing a Hartmann's procedure did not proceed to a closure of their stoma. Age was the only parameter significant in predicting those patients undergoing reversal.

A clinical sickness score for the critically ill in Central Africa.

Scoring systems provide a means for comparing results, ensuring consistent standards and evaluating changes in therapy. The APACHE II system depends partly on the results of laboratory tests which are not normally available in Central Africa. The aim of this study was to develop a scoring system based only on clinical observations. Six hundred and twenty-four consecutive admissions to the intensive care unit (ICU) were allocated a clinical sickness score (CSS) according to pulse rate, blood pressure, respiration rate, urine output, Glasgow Coma Scale, temperature and age. CSS was significantly associated with outcome, there being no significant difference between actual and predicted outcomes calculated by logistic regression analysis. There was a significant difference between mean scores for survivors and non-survivors in all diagnostic groups except diabetes. The proportional change in score from admission was also significantly associated with outcome on each subsequent day in ICU. The CSS provides an objective measure of illness severity for critically ill patients in Africa.

Role of ultrasound in the management of thyroid nodules.

One hundred twenty patients undergoing thyroid surgery for thyroid nodules or goiter were examined by preoperative ultrasound and fine needle aspiration (FNA) cytology. In the determination of whether a lesion was malignant, FNA had sensitivity, specificity, and positive predictive values of 86%, 85%, and 58%, respectively. Ultrasound had sensitivity, specificity, and positive predictive values of 74%, 83%, and 51%, respectively. The different types of thyroid pathology showed different ultrasonic features in most cases, although no single feature was pathognomonic. Malignant lesions tended to be solid and hypoechoic without a halo, but there was a cystic element in 26% of the lesions and calcification in 37%. Ultrasound was superior to FNA in diagnosing nodular goiter with sensitivity, specificity, and positive predictive values of 70%, 93%, and 92%, respectively, compared with 55%, 86%, and 83%, respectively. The two modalities are complementary.

Epidural abscess complicating Swenson procedure: a case report and a review of the literature.

A case is reported in which an anastomotic leak following the Swenson procedure for Hirschsprung's disease was complicated by the development of a pelvic abscess that communicated freely with the epidural space. The child presented with signs and symptoms of an epidural abscess, but his myelogram was normal. The diagnosis was made by urografin enema. The child was treated by defunctioning colostomy and drainage of the pelvic abscess by enlarging the defect at the anastomosis site digitally. The epidural space drained freely to the pelvis and therefore laminectomy was not required. The possible etiology of such a communication is discussed.

Rising incidence of breast cancer in Papua New Guinea.

BACKGROUND: Three previous reports have shown the incidence of breast cancer in Papua New Guinea (PNG) to have risen in the 30 years between 1958 and 1987. In the present report the incidence and pathology of breast cancer in the decade 1989-1998 are described. METHODS: This was a retrospective review of all histopathology specimens in PNG from 1989 to 1998. During this period the female population grew from 1 640 000 to more than 2 000 000. RESULTS: There were 790 cases of breast cancer. The age of the patient was not known in 221 cases (26%). The age-standardized incidence was 6.9 per 100 000. The incidence of breast cancer has been steadily rising in the 40 years since cancers were recorded in PNG. The incidence has risen in all four regions, most notably in the islands. The peak incidence was in the 45-54-year-old age group (18.4/100 000); 83.9% of women with breast cancer were aged 54 or less. Fifteen per cent were under 35 years old and 55.7% were under 45. The incidence fell in the elderly. The tumours tended to be advanced. The actual size was recorded in only 163 cases (20.7%) but there were only three T1 tumours in this group. Clinical signs of advanced breast cancer were recorded in 206 cases: ulceration of skin (91 cases), peau d' orange (69 cases), nipple retraction (43 cases) and lymphoedema of the upper extremity (three cases). Axillary nodes were positive in 185 of 247 patients (75%) in whom they were sampled. CONCLUSIONS: The incidence of breast cancer in PNG women has steadily risen over the past 40 years and the highest age-specific incidence occurs in the 35-54 age group. Tumours present late at an advanced stage. Clinical information on pathology request forms is poor and a prospective clinical audit is needed. Strategies need to be developed to detect breast cancer earlier in this population of women.

Surgical capability and surgical pathology in Papua New Guinea in the year 2000.

BACKGROUND: Papua New Guinea (PNG) is a country of 4.5 million people with an annual health budget of only 96 million Kina (1K = US$0.35). There are 19 hospitals in the country and national surgeons are now staffing most of these hospitals. This review aims to describe the surgical pathology in the year 2000 and the capability of PNG surgeons to manage it. METHODS: A review of publications, reports and surgical audit data on surgery in PNG was conducted. Surgical audit has been computerized for over 5 years. The review also draws on personal experience and data from MMed theses submitted to the University of Papua New Guinea. RESULTS: Surgical pathology Surgical practice in PNG remains very general. Late presentation and advanced disease are common. Trauma, infection, malignancy and congenital anomalies dominate the surgical scene. The pattern of disease is different from what is found in the West. Western diseases are emerging with the incidence of appendicectomy rising from 5/100,000 to 75/100,000 in the past 30 years. The incidence of diabetes and gallstones has also risen. Osteoporosis, Colles' and neck of femur fractures are rare. Surgical capability The standard of surgical care is acceptable with a low wound infection rate for clean and clean-contaminated abdominal surgery of 0.9% and an anastomotic leak rate of 1.6%. Transurethral prostatectomy is also being performed to a satisfactory standard for head injuries admitted with a Glasgow Coma Score of 6-8 and a good outcome is achieved in over 70% of cases. Hospital mortality for surgical admissions is 3.7%. Subspecialties in orthopaedics, urology and head and neck surgery have been established. Neurosurgery, paediatric and cardiac surgery are being developed. Priorities for the next decade Papua New Guinea needs to continue to develop surgical subspecialties, particularly paediatric and neurosurgery, while maintaining a broad competence in general surgery. Services for burns, spinal injuries, rehabilitation and oncology need to be improved. Surgeons need to be more involved in rural health and teaching basic skills to primary health-care workers. Acquisition, maintenance and repair of surgical equipment needs to be improved so that PNG's well-trained surgeons can have the right tools for their trade. CONCLUSIONS: Papua New Guinea offers a wide range of surgical pathology. The standard of surgery in PNG is reasonable but there are many areas that need development during the period of the next national health plan, 2001-2010. Australasian surgery has many opportunities to assist surgeons in PNG to achieve their objectives.

Outcome of mechanical ventilation in Central Africa.

The outcome of mechanical ventilation is reported in a prospective series of 200 patients managed in an intensive care unit in Zambia. Fifty two patients survived (26%), and 46 patients were subsequently discharged from hospital (23%). Ten patients died in whom a complication of ventilation was a factor. Patients not expected to survive by the authors had a 96.3% mortality whereas patients with a chance of survival had a mortality rate of 58.8%. Two diagnostic groups were found to have a high mortality: head injury (85.1%) and non-traumatic coma (76.4%). This series is compared with similar series from developed countries and recommendations are made for the institution of mechanical ventilation in the developing world.

The appendix stump: should it be invaginated?

In a prospective trial of 103 patients undergoing appendicectomy, one group of patients had the appendix stump treated by ligation alone and the other group underwent ligation and invagination. The two groups of patients were similar with respect to age, sex, incision and degree of inflammation of the appendix. Perforated appendices were excluded and in neither group were drains used or antibiotics given. No significant difference between the two methods of treatment of the appendix stump was noted, either with respect to wound infection or postoperative stay in hospital.

Non-traumatic coma in Zambia.

A series of 170 patients with non-traumatic coma seen over a 16-month period is reported. The Glasgow coma scale significantly correlated with outcome (P less than 0.001). The diagnosis was also important in determining outcome. Hospital mortality was lowest in patients with cerebral malaria (22.7%), eclamptic coma (36.4%), and organophosphorous poisoning (30.4%). A diagnostic approach to non-traumatic coma is outlined and the management of the different causes is discussed. Most hospitals in tropical Africa should be able to diagnose up to 90% of cases with non-traumatic coma and simple therapy is likely to be effective in the majority of cases.

Central venous pressure monitoring for the critically ill in Zambia.

The safety and value of central venous pressure (CVP) monitoring in 100 critically ill patients in Zambia was studied prospectively. There were six complications related to insertion, the only serious one being a hydrothorax which was recognized and treated. One patient developed catheter-related septicaemia. CVP measurement altered proposed fluid management in 19 cases, determined management in 31 in whom fluid status was uncertain and confirmed fluid therapy in 50. Additional benefits of central venous catheterization were drug infusion in 33 patients and venous access in 53. Technical problems during monitoring occurred in 54 cases and were due to kinking of the catheter, blockage or inadvertent removal. In our circumstances the risks of cannulation of central veins seem justified in selected patients but good nursing supervision of patients is necessary.

Quality assurance in surgery: surgical audit in the developing world.

Surgical audit is an essential component of quality assurance in surgery, particularly in the developing world, where resources and skills are limited. The structure, process and outcome of care can be measured. With regard to structure, in developing countries the delivery of care is influenced by lack of resources and access to surgical skills. The number of operations not being done needs to be estimated as well as the throughput of surgery. With regard to process, ward rounds and writing in case-notes are daily activities which affect the process of care. The use of investigations, particularly ones which are expensive or have risks, should be audited to ensure there is maximum cost-benefit to both the patient and the health care system. Surveys of patient perception of quality are also important. With regard to outcome, surgeons measure quality by auditing complications and mortality. Audit and mortality meetings should be held to discuss problems and how they can be avoided. The factors responsible for 34 deaths at Port Moresby General Hospital are presented. To be reliable, mortality audits should grade illness severity, for example, by using the Glasgow Coma Scale to grade the severity of a head injury. Where mortality rates are low, for example, in patients with fractures, long-term follow-up of disability may be a more appropriate measure of outcome and quality than mortality rates.

Surgery, surgical pathology and HIV infection: lessons learned in Zambia.

HIV (human immunodeficiency virus) infection is prevalent in many areas of sub-Saharan Africa. Seropositivity rates reach 10-15% in urban adults, 21% in critically ill adults and 30% in surgical inpatients aged 21-40 years. AIDS (acquired immune deficiency syndrome) is a multisystem disease which presents to the surgeon with a wide range of pathologies including Kaposi's sarcoma, lymphadenopathy and sepsis. The more common sites for sepsis are the female genital tract, anorectum, pleural cavity, soft tissues (necrotizing fasciitis) and bone and joints. To prevent iatrogenic HIV infection more use should be made of autologous blood. Occupational exposure to HIV infection can be minimized by double-gloving, protecting the eyes when operating and ensuring that theatre gowns are waterproof. The risk of HIV infection from a needlestick injury is 0.4%. Although contact with blood during a surgical procedure is common, the risk is lower than for a hollow needlestick injury.

PIP: In Zambia, 10-15% of urban adults are reported HIV positive, as are over 80% of prostitutes. The HIV seroprevalence rate in a Lusaka hospital's intensive care unit was 21% (27% for surgical and 18% for trauma admissions). HIV-infected patients could be clinically recognized by risk factors or symptoms and signs: weight loss, chronic cough, chronic diarrhea, sepsis, septic arthritis, subacute hematogenous osteomyelitis, a history of sexually transmitted diseases (STDs), death of a spouse or of a child under age 2, recent pregnancy unable to go to term, poor quality or thin hair, appearance of aging beyond years, mental slowness, persistent or unexplained fever, lymphadenopathy, aggressive atypical Kaposi's sarcoma, oral thrush, hairy leukoplakia of the tongue, shingles scars, and scars of maculopapular dermatitis. Common sites for HIV-related sepsis are the female genital tract, anorectum, pleural cavity, soft tissues (e.g., necrotizing fascitis), and bone and joints. Autologous blood transfusion and use of donor blood screened for HIV antibodies, preferably limited to emergencies, would reduce the likelihood of iatrogenic HIV transmission. Surgeons should wear two pairs of gloves, a waterproof gown, and goggles to protect themselves from HIV transmission. If they have skin rashes, cuts, or abrasions on the hands or arms, they should not perform operations. Proper cleaning and disinfection of endoscopes are required. The risk of infection from a needle stick is small ( 0.4%).

Trauma in Papua New Guinea: what do we know and where do we go?

Trauma is a major health problem in Papua New Guinea. Injuries are the commonest cause of death in the productive age group of 15-44 years. Trauma is the leading cause of surgical death in Port Moresby General Hospital. The common causes of injury are road traffic accidents, domestic violence, criminal assault, tribal fights, accidents at home and at work, burns and falls. This review summarizes what has been published on the different causes of trauma in Papua New Guinea. Though much has been written little has been done to implement the recommendations made. Papua New Guinea needs a spinal unit and it needs burns units in its major hospitals. There should be better facilities for rehabilitation. Little has been done to curb tribal fighting and domestic violence. Road traffic fatalities have at least remained static in the last decade and wearing seat belts is now compulsory, but the law must be enforced. Driving after drinking alcohol must be stopped and protective roll bars or cages must be fitted to all open-back utility vehicles which carry passengers. Progress requires vision and commitment by surgeons, leaders in public health, hospital administrators and politicians.

Abdominal trauma in urban Papua New Guinea.

BACKGROUND: Trauma is the commonest cause of surgical admission in Papua New Guinea, accounting for around 30% of cases in Port Moresby and over 40% in the highlands. The abdomen is traumatized in about 10-15% of trauma cases. In malarial endemic areas the enlarged spleen is particularly prone to rupture although earlier studies showed that this injury can often be managed conservatively. AIM: To determine the pattern and outcome of abdominal injury in the two largest cities, Port Moresby and Lae, in the 1990s. METHODS: A retrospective study of 213 adult admissions for abdominal trauma in Port Moresby and a prospective study of 98 adult abdominal trauma patients in Lae. In both centres malaria is endemic. Statistical analysis where appropriate was made using the chi2 test. RESULTS: Abdominal trauma was more likely to affect men outside the home and women in the home. Assault was responsible for 72% of cases of abdominal trauma. Women were assaulted by their husbands in two-thirds of cases. The spleen was the most likely organ to be injured, particularly in blunt trauma. Road traffic accidents caused only 10% of admissions with abdominal trauma. Most patients were admitted with a single injury. Splenic injury was managed nonoperatively in over 60% of cases. The negative laparotomy rate was 7% in Port Moresby and 20% in Lae, but negative laparotomy did not cause any deaths or extra morbidity. 17 patients (5.5%) died, the highest case fatality rate being 29% in a group of 31 patients with an injury severity score of 25 or greater. CONCLUSION: The pattern of abdominal trauma reflects the culture of Papua New Guinea and the different spectrum of risks to men and women. Once patients reach hospital they tend to do reasonably well although there is room for improvement, particularly with early assessment of the extent of the injury. The enlarged spleen is prone to injury and in those cases requiring laparotomy it is difficult to conserve. Many cases of ruptured spleen can be treated nonoperatively.

Head injuries in Papua New Guinea.

Head injuries are the commonest cause of death in the surgical wards in Port Moresby and the commonest cause of death in road accidents. Three prospective and retrospective studies performed over the last decade aimed to determine the pathology and outcome in 274 head injuries admitted to Goroka in 1988-1991 (4 years) and Port Moresby in 1984-1985 and 1992-1993 (total 2.5 years). Head injuries were managed by general surgeons without CT scanning or intracranial pressure monitoring. There were 196 adults and 78 (28%) children; 195 were male and 79 female. Assaults (32%), motor vehicle accidents (49%) and falls (17%) were the commonest modes of injury. The case fatality rate was 21% (57 of 274 cases). Six of the deaths were avoidable. The fatality rates for admission Glasgow Coma Scores of 3-5, 6-8 and over 9 were 81%, 21% and 3% respectively. Two patients died of infection complicating open depressed fractures. The case fatality rate for extradural haematoma was 20% and subdural haematoma 67%. Nine patients died of associated abdominal injuries. Most of the deaths were unavoidable because of the severity of primary brain injury. The speed of diagnosis and quality of care could have been improved but the most important area is management of the airway. General surgeons properly trained in trauma care (which includes emergency airway management) are well able to cope with the majority of head-injured patients in Papua New Guinea.

Traumatic false aneurysms in Port Moresby.

BACKGROUND: Trauma is responsible for about 30% of surgical admissions in Port Moresby. Vascular injuries are frequently missed due to inadequate assessment by primary health care workers and often present late with large aneurysms which are difficult to manage. The aim of this study was to identify the patterns of morbidity associated with traumatic false aneurysms complicating vascular injuries in Port Moresby General Hospital from January 1995 to July 1999. METHODS: A surgical database with 11,004 records was used to identify patients with a diagnosis of false aneurysm. Charts of patients with gunshot wounds, knife wounds and compound fractures were also reviewed to identify further cases with vascular injury. RESULTS: 51 patients were found to have had documented evidence of vascular injury requiring surgical repair within the study period. 21 patients with traumatic false aneurysm presented to Port Moresby General Hospital. 17 of the 21 patients were aged 11 to 40 years. There was only one female patient. Stab wounds (50%) were the commonest mode of injury followed by lacerations (23%) and fish bites (14%). The calf (42%), forearm (13%) and the head (13%) were the commonest sites involved. The time from insult to admission varied from 4 days to 11 years with the modal time being 14 days. Most patients presented with hard signs of false aneurysms (94%) and 81% of the patients were treated within five days. Ligation (67%) was the commonest operation, followed by excision (43%) and vascular repair (19%). There were no deaths or amputations in any of the patients with false aneurysms. CONCLUSION: False aneurysms are a not infrequent complication of vascular injuries. Greater awareness of the possibility of vascular injury is needed. Patients in Port Moresby often present after considerable delay. However, the diagnosis can be made clinically and the results of surgical exploration are good. Although colour Doppler ultrasound is a useful investigation it sometimes fails to identify the aneurysm because it requires blood flow to be present in the aneurysm.

Dumbbell schwannoma causing acute spinal cord compression: case report.

A case is presented of acute spinal cord compression by a thoracic dumbbell spinal schwannoma in a young woman with neurofibromatosis type 1 (NF-1). A successful outcome was achieved with total excision of the lesion and decompression of the spinal cord. Greater recognition of the reversibility of spinal cord compression in the developing world is necessary to reduce major permanent morbidity.