Biliary atresia in Uganda: Current ethical challenges and advancement of public policy.

Biliary atresia is a progressive cholangiopathy in neonates, which often results in liver failure. In high-income countries, initial treatment requires prompt diagnosis followed by Kasai portoenterostomy. For those with a late diagnosis, or those in whom Kasai portoenterostomy fails, liver transplantation is the only lifesaving treatment. Unfortunately, in low- and middle-income countries, timely diagnosis is a challenge and liver transplantation is rarely accessible. Here, we discuss the ethical dilemmas surrounding treatment of babies with biliary atresia in Uganda. Issues that require careful consideration include: risk of catastrophic health expenditure to families, ethical dilemmas of transplant tourism, medical risks of maintaining the transplant in a low-resourced health system, and difficult decisions encountered by the surgeon caring for these patients. Four distinct models of the patient-physician relationship are applied to biliary atresia in Uganda. These models describe differences in patient and physician roles, and patient values and autonomy. Solid organ transplantation is a rapidly evolving segment of healthcare in Uganda and ongoing policy advancements may shift ethical considerations in the future.

Contemporary trends in choledochal cyst excision: An analysis of the pediatric national surgical quality improvement program.

BACKGROUND: Choledochal cysts are rare congenital anomalies of the biliary tree that may lead to obstruction, chronic inflammation, infection, and malignancy. There is wide variation in the timing of resection, operative approach, and reconstructive techniques. Outcomes have rarely been compared on a national level. METHODS: We queried the Pediatric National Surgical Quality Improvement Program (NSQIP) to identify patients who underwent choledochal cyst excision from 2015 to 2020. Patients were stratified by hepaticoduodenostomy (HD) versus Roux-en-Y hepaticojejunostomy (RNYHJ), use of minimally invasive surgery (MIS), and age at surgery. We collected several outcomes, including length of stay (LOS), reoperation, complications, blood transfusions, and readmission rate. We compared outcomes between cohorts using nonparametric tests and multivariate regression. RESULTS: Altogether, 407 patients met the study criteria, 150 (36.8%) underwent RNYHJ reconstruction, 100 (24.6%) underwent MIS only, and 111 (27.3%) were less than one year old. Patients who underwent open surgery were younger (median age 2.31 vs. 4.25 years, p = 0.002) and more likely underwent RNYHJ reconstruction (42.7% vs. 19%, p = 0.001). On adjusted analysis, the outcomes of LOS, reoperation, transfusion, and complications were similar between the type of reconstruction, operative approach, and age. Patients undergoing RNYHJ had lower rates of readmission than patients undergoing HD (4.0% vs. 10.5%, OR 0.34, CI [0.12, 0.79], p = 0.02). CONCLUSIONS: In children with choledochal cysts, most short-term outcomes were similar between reconstructive techniques, operative approach, and age at resection, although HD reconstruction was associated with a higher readmission rate in this study. Clinical decision-making should be driven by long-term and biliary-specific outcomes.

Idiopathic Megaduodenum in a Teenager: A Case Report.

Megaduodenum is a rare clinical syndrome characterized by significant duodenal dilation, elongation, and hypertrophy. Given its rarity and nonspecific clinical manifestations, megaduodenum may be misdiagnosed, leading to delays in surgical care and increased morbidity. We describe a case of idiopathic megaduodenum in a teenage Caucasian female, who presented with a five-year history of halitosis, recurrent belching, bloating, nausea and vomiting, and postprandial epigastric abdominal pain. She was diagnosed with megaduodenum by dramatic findings on contrast radiography. She developed a duodenal volvulus necessitating emergency exploratory laparotomy, during which a duodenal plication and a side-to-side duodenojejunostomy were performed. Exploratory laparotomy and histopathological analysis were unrevealing of any definitive abnormalities to explain her megaduodenum. Postoperatively, she developed two early small bowel obstructions, both from subsequent adhesions requiring repeat laparotomy with adhesiolysis. She has subsequently recovered without incident. Diagnosis and accurate classification of megaduodenum requires surgical exploration with a full-thickness biopsy and subsequent histopathologic analysis to rule out obstructive or functional disorders of the duodenum. Treatment of megaduodenum depends on the underlying cause and degree of duodenal distention. It is crucial that clinicians are knowledgeable of the various surgical options, their indications, and the potential postoperative complications that may arise.

Gaps and priorities in innovation for children's surgery.

Lack of access to pediatric medical devices and innovative technology contributes to global disparities in children's surgical care. There are currently many barriers that prevent access to these technologies in low- and middle-income countries (LMICs). Technologies that were designed for the needs of high-income countries (HICs) may not fit the resources available in LMICs. Likewise, obtaining these devices are costly and require supply chain infrastructure. Once these technologies have reached the LMIC, there are many issues with sustainability and maintenance of the devices. Ideally, devices would be created for the needs and resources of LMICs, but there are many obstacles to innovation that are imposed by institutions in both HICs and LMICs. Fortunately, there is a growing interest for development of this space, and there are many examples of current technologies that are paving the way for future innovations. Innovations in simulation-based training with incorporated learner self-assessment are needed to fast-track skills acquisition for both specialist trainees and non-specialist children's surgery providers, to scale up access for the larger population of children. Pediatric laparoscopy and imaging are some of the innovations that could make a major impact in children's surgery worldwide.

Evaluation of Analgesic Practice Changes Following the Nuss Procedure in Pediatric Patients.

INTRODUCTION: Pectus excavatum repair by the Nuss procedure results in severe postoperative pain. Regional blocks and intercostal nerve cryoablation (INC) have emerged as potential strategies to manage analgesia. This study compares pain-related outcomes following these perioperative interventions. METHODS: We reviewed charts of patients <18 y who underwent the Nuss procedure at Duke Children's Hospital from July 2018 to June 2022. Patients were divided into three groups by analgesic strategy: no block, regional catheters, or INC, representing the chronologic change in our practice. The primary outcome was total and daily in-hospital opioid utilization measured by oral morphine equivalents (OMEs). Secondary outcomes included average daily pain scores, length of stay, opioid refills after discharge, and complications. RESULTS: Twenty-one patients were included and analyzed: no block (n = 6), regional catheters (n = 7), and INC (n = 8). INC-treated patients required significantly lower total postoperative, in-hospital OMEs (64 ± 47 [mean ± standard deviation]) than those with no block (270 ± 217, P = 0.04) or those with regional catheters (273 ± 176, P = 0.03). INC was associated with longer average operative times (161 ± 36 min) than no block (105 ± 21 min, P = 0.005) or regional catheters (90 ± 11 min, P < 0.001). INC-treated patients had shorter hospital length of stays (median 68 h) than those with regional catheters (median 74 h, P = 0.006). CONCLUSIONS: INC was associated with longer operative times but decreased in-hospital OMEs when compared to bilateral regional block catheters and multimodal analgesia alone.

Prioritization of surgical, obstetric, trauma, and anesthesia care in India over seven decades: A systematic analysis of policy documents.

Improving access to surgical care in India requires policy-level prioritization of surgical, obstetric, trauma, and anesthesia (SOTA) care. We quantified SOTA care prioritization in the last seven decades by analyzing India's national policy and programmatic documents. Forty documents of national importance over seven decades (1946-2017) were screened for a set of 52 surgical and 6 non-surgical keywords. The number of mentions per keyword was used as a proxy for surgical prioritization. For thematic analysis, surgical mentions were further classified into five domains: Infrastructure, Workforce, Service Delivery, Financing, and Information Management. The total number of mentions was 4681 for the surgical keywords and 2322 for non-surgical. The number of mentions per keyword was 90.02 for surgical keywords and 387 for non-surgical. The older committee reports showed relatively higher SOTA care prioritization compared to the years after 2010. Among the domains, Service Delivery (897) had the maximum number of mentions followed by Infrastructure (545), Workforce (516), Financing (98), and Information Management (40). National Health Policy 2017, the most recent high-level policy, grossly neglected SOTA care. SOTA care is inadequately prioritized in Indian national health policies, especially in the documents after 2010. Concerted efforts are necessary to improve the focus on financing and information management. Prioritization can be improved through a stand-alone national plan for SOTA care along with integration into existing policies.

Evaluating the status of the Lancet Commission on Global Surgery indicators for India.

For universal surgical, obstetric, trauma, and anesthesia care by 2030, the Lancet Commission on Global Surgery (LCoGS) suggested tracking six indicators. We reviewed academic and policy literature to investigate the current state of LCoGS indicators in India. There was limited primary data for access to timely essential surgery, risk of impoverishing and catastrophic health expenditures due to surgery, though some modeled estimates are present. Surgical specialist workforce estimates are heterogeneous across different levels of care, urban and rural areas, and diverse health sectors. Surgical volumes differ widely across demographic, socio-economic, and geographic cohorts. Perioperative mortality rates vary across procedures, diagnoses, and follow-up time periods. Available data suggest India falls short of achieving global targets. This review highlights the evidence gap for India's surgical care planning. India needs a systematic subnational mapping of indicators and adaptation of targets as per the country's health needs for equitable and sustainable planning.

With equity in mind: Evaluating an interactive hybrid global surgery course for cross-site interdisciplinary learners.

There is limited understanding of the role of transcultural, cross-site educational partnerships for global surgery training between high- and low- or middle-income country (LMIC) institutions. We describe the development, delivery, and appraisal of a hybrid, synchronous, semester-long Global Surgical Care course by global health collaborators from widely different contexts, and evaluate the equity of the collaboration. The course was collaboratively modified by surgical educators and public health professionals with emphasis on collaboration ethics. Faculty from high-income and LMICs were paired to deliver lectures. To collaborate internationally, students and faculty participated either onsite or online. Perceptions and knowledge gained were quantitatively evaluated through participant and faculty cross-sectional surveys, using Likert scales, prioritization rankings, and free text responses analysed qualitatively. Equity was assessed using the Fair Trade Learning rubric and additional probes. Thirty-five learners from six institutions participated. Teams produced mock National, Surgical, Obstetric, and Anaesthesia Plans (NSOAPs) for selected LMICs, and reported a 9% to 65% increase in self-reported global health competencies following the course. Online learners had favourable perceptions of learning, but experienced connectivity challenges. Barriers to effective group work included time differences and logistics of communication for dispersed team members. Individuals taking the course for academic credit scored significantly higher than other learners in peer assessments of participation (8.56±1.53 versus 5.03±3.14; p<0.001). Using the Fair Trade Rubric, 60% of equity indicators were ideal, and no respondents perceived neo-colonialism in the partnership. Blended, synchronous, interdisciplinary global surgery courses based on "North-South" partnerships with a focus on equity in design and delivery are feasible but require careful and deliberate planning to minimize epistemic injustice. Such programs should address surgical systems strengthening, and not create dependency. Equity in such engagements should be evaluated and monitored in an ongoing fashion to stimulate discussion and continuous improvement.

KeyLoop retractor for global gasless laparoscopy: evaluation of safety and feasibility in a porcine model.

BACKGROUND: Many surgeons in low- and middle-income countries have described performing surgery using gasless (lift) laparoscopy due to inaccessibility of carbon dioxide and reliable electricity, but the safety and feasibility of the technique has not been well documented. We describe preclinical testing of the in vivo safety and utility of KeyLoop, a laparoscopic retractor system to enable gasless laparoscopy. METHODS: Experienced laparoscopic surgeons completed a series of four laparoscopic tasks in a porcine model: laparoscopic exposure, small bowel resection, intracorporeal suturing with knot tying, and cholecystectomy. For each participating surgeon, the four tasks were completed in a practice animal using KeyLoop. Surgeons then completed these tasks using standard-of-care (SOC) gas laparoscopy and KeyLoop in block randomized order to minimize learning curve effect. Vital signs, task completion time, blood loss and surgical complications were compared between SOC and KeyLoop using paired nonparametric tests. Surgeons completed a survey on use of KeyLoop compared to gas laparoscopy. Abdominal wall tissue was evaluated for injury by a blinded pathologist. RESULTS: Five surgeons performed 60 tasks in 15 pigs. There were no significant differences in times to complete the tasks between KeyLoop and SOC. For all tasks, there was a learning curve with task completion times related to learning the porcine model. There were no significant differences in blood loss, vital signs or surgical complications between KeyLoop and SOC. Eleven surgeons from the United States and Singapore felt that KeyLoop could be used to safely perform several common surgical procedures. No abdominal wall tissue injury was observed for either KeyLoop or SOC. CONCLUSIONS: Procedure times, blood loss, abdominal wall tissue injury and surgical complications were similar between KeyLoop and SOC gas laparoscopy for basic surgical procedures. This data supports KeyLoop as a useful tool to increase access to laparoscopy in low- and middle-income countries.

Met and Unmet Need for Pediatric Surgical Access in Uganda: A Country-Wide Prospective Analysis.

INTRODUCTION: Children's surgical access in low and low-middle income countries is severely limited. Investigations detailing met and unmet surgical access are necessary to inform appropriate resource allocation. MATERIALS AND METHODS: Surgical volume, outcomes, and distribution of pediatric general surgical procedures were analyzed using prospective pediatric surgical databases from four separate regional hospitals in Uganda. The current averted burden of surgical disease through pediatric surgical delivery in Uganda and the unmet surgical need based on estimates from high-income country data was calculated. RESULTS: A total of 8514 patients were treated at the four hospitals over a 6-year period corresponding to 1350 pediatric surgical cases per year in Uganda or six surgical cases per 100,000 children per year. The majority of complex congenital anomalies and surgical oncology cases were performed at Mulago and Mbarara Hospitals, which have dedicated pediatric surgical teams (P < 0.0001). The averted burden of pediatric surgical disease was 27,000 disability adjusted life years per year, which resulted in an economic benefit of approximately 23 million USD per year. However, the average case volume performed at the four regional hospitals currently represents 1% of the total projected pediatric surgical need. CONCLUSIONS: This investigation is one of the first to demonstrate the distribution of pediatric surgical procedures at a country level through the use of a prospective locally created database. Significant disease burden was averted by local pediatric and adult surgical teams, demonstrating the economic benefit of pediatric surgical care delivery. These findings support several ongoing strategies to increase pediatric surgical access in Uganda.

Crucial Business Model Elements for Medical Device Startup Companies in Emerging Markets.

OBJECTIVES: Medical devices that suit the needs and challenges of low- and middle-income countries are desperately needed. To provide sustainable access to such devices, business approaches must be developed to meet the demands of individual economic, healthcare, and innovation ecosystems. Currently, there is a gap in the literature regarding business models for medical devices in low- and middle-income countries. METHODS: A multimodal approach using literature review and key informant interviews was performed to determine critical components of business models for medical device organizations operating in LMICs, specifically focusing on models in emerging markets. RESULTS: The search resulted in 4,674 articles, of which 31 were determined to be relevant and were reviewed. Additional sources included 1 government website, 5 nongovernmental organization websites, 2 private enterprises, and 6 publicly available, non-peer reviewed websites and 1 video. From these sources, four major criteria were found to be necessary for successful development of medical device business models in emerging markets: value proposition, partnerships, strategic pricing, and funding models. CONCLUSIONS: Innovators must custom tailor their business model when implementing these elements to the regulatory, cultural, and economic landscapes of each setting. This will improve access to safer, affordable medical care and successfully bring innovative technologies to emerging markets.

Low Cost Gastroschisis Silo for Sub-Saharan Africa: Testing in a Porcine Model.

BACKGROUND: Gastroschisis mortality in sub-Saharan Africa (SSA) remains high at 59-100%. Silo inaccessibility contributes to this disparity. Standard of care (SOC) silos cost $240, while median monthly incomes in SSA are < $200. Our multidisciplinary American and Ugandan team designed and bench-tested a low-cost (LC) silo that costs < $2 and is constructed from locally available materials. Here we describe in vivo LC silo testing. METHODS: A piglet gastroschisis model was achieved by eviscerating intestines through a midline incision. Eight piglets were randomized to LC or SOC silos. Bowel was placed into the LC or SOC silo, maintained for 1-h, and reduced. Procedure times for placement, intestinal reduction, and silo removal were recorded. Tissue injury of the abdominal wall and intestine was assessed. Bacterial and fungal growth on silos was also compared. RESULTS: There were no gross injuries to abdominal wall or intestine in either group or difference in minor bleeding. Times for silo application, bowel reduction, and silo removal between groups were not statistically or clinically different, indicating similar ease of use. Microbiologic analysis revealed growth on all samples, but density was below the standard peritoneal inoculum of 105 CFU/g for both silos. There was no significant difference in bacterial or fungal growth between LC and SOC silos. CONCLUSION: LC silos designed for manufacturing and clinical use in SSA demonstrated similar ease of use, absence of tissue injury, and acceptable microbiology profile, similar to SOC silos. The findings will allow our team to proceed with a pilot study in Uganda.

Social injustice symposium: Urban, rural, and global disparities in access to care.

BACKGROUND: Barriers in access to pediatric surgical care are common in low- and middle-income countries (LMICs), but also exist in high-income countries, particularly in urban and rural areas. METHODS: This article describes "Disparities in Access to Care"-held within the Social Injustice Symposium at the 2020 American Pediatric Surgical Association (APSA) Annual Meeting. RESULTS: This symposium outlined disparities in access to care, illustrated by examples from pediatric trauma and neonatal surgery in U.S. urban, U.S. rural, and non-U.S. global locations (LMICs). Geographic and financial challenges were common to families from the rural U.S. and LMICs. In contrast, families in U.S. urban settings generally do not face geographic barriers, but are often economically and racially diverse and many face complex societal factors leading to poor outcomes. Systemic processes must be changed to improve pediatric surgical health outcomes. CONCLUSION: A comprehensive health system with an equal emphasis on supportive care and surgery is required in all settings. Global collaboration and partnerships can provide an avenue for advocacy and strategic innovation to improve quality of care. LEVEL OF EVIDENCE: Ⅴ.

The Evolving Landscape of Global Surgery: A Qualitative Study of North American Surgeons' Perspectives on Faith-Based and Academic Initiatives.

Faith-based missions have played a large role in surgical care delivery in low- and middle-income countries (LMIC). As global surgery is now an academic discipline, this pilot study sought to understand how different faith ideologies influence surgeon motivations and subsequent culture of the global surgery landscape. Interviews were conducted with North American surgeons who pursue global surgery significantly in their career. Points of discussion included early influences, obstacles, motivations, philosophy and approach to global surgery work, and experiences with faith-based (FBO) and non-faith-based organizations (NFBO). Notes were transcribed and thematic analysis performed. Sixteen surgeons were interviewed (11 men, 5 women, ages 39-75 years-old). Surgeons had worked in 32 countries with FBO and NFBO in intermittent or long-term capacity. Religious upbringing and current affiliations included Atheism, Protestant Christianity, Catholicism, Hinduism, Judaism, Mormonism, Islam, and nonreligious spirituality. Early influences included international upbringing (n = 7), emphasis on service (n = 9), and exposure to the religious mission concept (n = 6). The most common core motivation among all participants was addressing disparities (n = 10). Some believed that FBO and NFBO have different goals (n = 4), and only surgeons identifying with Christianity believed the goals are similar (n = 3). Participants expressed that FBO are exclusive (n = 4) and focused on proselytization (n = 6) while NFBO are humanitarian (n = 3) but less integrated into the community (n = 4). Global surgeons have shared early influences, obstacles, and desire to address disparities. Perceptions of FBO and NFBO differed based on religious background. This pilot study will inform future studies regarding the collaborations of FBO and NFBO to improve global surgical care.

KeyLoop: Mechanical Retraction of the Abdominal Wall for Gasless Laparoscopy.

Background. Despite favorable outcomes of laparoscopic surgery in high-income countries, its implementation in low- and middle-income countries (LMICs) is challenging given a shortage of consumable supplies, high cost, and risk of power outages. To overcome these barriers, we designed a mechanical retractor that provides vertical tension on the anterior abdominal wall. Methods. The retractor design is anatomically and mathematically optimized to provide exposure similar to traditional gas-based insufflation methods. Anatomical data from computed tomography scans were used to define retractor size. The retractor is constructed of biocompatible stainless steel rods and paired with a table-mounted lifting system to provide 5 degrees of freedom. Structural integrity was assessed through finite element analysis (FEA) and load testing. Functional testing was performed in a laparotomy model. Results. A user guide based on patient height and weight was created to customize retractor size, and 4 retractor sizes were constructed. FEA data using a 13.6 kg mass (15 mm Hg pneumoperitoneum) show a maximum of 30 mm displacement with no permanent deformation. Physical load testing with applied weight from 0 to 13.6 kg shows a maximum of 60 mm displacement, again without permanent deformation. Retraction achieved a 57% larger field of view compared to an unretracted state in a laparotomy model. Conclusions. The KeyLoop retractor maintains structural integrity, is easily sterilized, and can be readily manufactured, making it a viable alternative to traditional insufflation methods. For surgeons and patients in LMICs, the KeyLoop provides a means to increase access to laparoscopic surgery.