Essential surgery: the way forward.

INTRODUCTION: Very little surgical care is performed in low- and middle-income countries (LMICs). An estimated two billion people in the world have no access to essential surgical care, and non-surgeons perform much of the surgery in remote and rural areas. Surgical care is as yet not recognized as an integral aspect of primary health care despite its self-demonstrated cost-effectiveness. We aimed to define the parameters of a public health approach to provide surgical care to areas in most need. METHODS: Consensus meetings were held, field experience was collected via targeted interviews, and a literature review on the current state of essential surgical care provision in Sub-Saharan Africa (SSA) was conducted. Comparisons were made across international recommendations for essential surgical interventions and a consensus-driven list was drawn up according to their relative simplicity, resource requirement, and capacity to provide the highest impact in terms of averted mortality or disability. RESULTS: Essential Surgery consists of basic, low-cost surgical interventions, which save lives and prevent life-long disability or life-threatening complications and may be offered in any district hospital. Fifteen essential surgical interventions were deduced from various recommendations from international surgical bodies. Training in the realm of Essential Surgery is narrow and strict enough to be possible for non-physician clinicians (NPCs). This cadre is already active in many SSA countries in providing the bulk of surgical care. CONCLUSION: A basic package of essential surgical care interventions is imperative to provide structure for scaling up training and building essential health services in remote and rural areas of LMICs. NPCs, a health cadre predominant in SSA, require training, mentoring, and monitoring. The cost of such training is vastly more efficient than the expensive training of a few polyvalent or specialist surgeons, who will not be sufficient in numbers within the next few generations. Moreover, these practitioners are used to working in the districts and are much less prone to gravitate elsewhere. The use of these NPCs performing "Essential Surgery" is a feasible route to deal with the almost total lack of primary surgical care in LMICs.

Flatulence on airplanes: just let it go.

Flatus is natural and an invariable consequence of digestion, however at times it creates problems of social character due to sound and odour. This problem may be more significant on commercial airplanes where many people are seated in limited space and where changes in volume of intestinal gases, due to altered cabin pressure, increase the amount of potential flatus. Holding back flatus on an airplane may cause significant discomfort and physical symptoms, whereas releasing flatus potentially presents social complications. To avoid this problem we humbly propose that active charcoal should be embedded in the seat cushion, since this material is able to neutralise the odour. Moreover active charcoal may be used in trousers and blankets to emphasise this effect. Other less practical or politically correct solutions to overcome this problem may be to restrict access of flatus-prone persons from airplanes, by using a methane breath test or to alter the fibre content of airline meals in order to reduce its flatulent potential. We conclude that the use of active charcoal on airlines may improve flight comfort for all passengers.

Bilateral ovarian metastases from carcinoma of the gallbladder.

BACKGROUND: Metastasis of carcinoma of the gallbladder to other intra-abdominal organs is recognised, but is rare. Ovarian metastases can mimic the clinical and morphological appearances of primary ovarian tumours, making the diagnosis difficult particularly when the primary source is not apparent. CASE: A patient presented with abdominal pain and was found to have gallstones and bilateral ovarian masses. Tumour markers were all normal. The patient developed jaundice and was subsequently operated on for the gallstones and ovarian masses. Histology showed these to be metastases from a gallbladder carcinoma. CONCLUSION: Presentation of ovarian metastases can cause diagnostic difficulty. Careful evaluation of the digestive tract should be considered in patients presenting with ovarian masses of uncertain origin.