How to isolate and manage a colo-atmospheric fistula in a wound requiring negative pressure dressing: a novel technique using a plastic syringe.

We describe the management of a colo-atmospheric fistula following extensive debridement for abdominal wall necrotising fasciitis. This was a novel technique performed with VAC dressing and a plastic syringe to isolate the fistula from the surround tissue.

Access delays to essential surgical care using the Three Delays Framework and Bellwether procedures at Timor Leste's national referral hospital.

OBJECTIVES: Our objectives were to characterise the nature and extent of delay times to essential surgical care in a developing nation by measuring the actual stages of delay for patients receiving Bellwether procedures. SETTING: The study was conducted at Timor Leste's national referral hospital in Dili, the country's capital. PARTICIPANTS: All patients requiring a Bellwether procedure over a 2-month period were included in the study. Participants whose procedure was undertaken more than 24 hours from initial hospital presentation were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES: Data pertaining to the patient journey from onset of symptoms to emergency procedure was collected by interview of patients, their treating surgeons or anaesthetists and the medical records. Timelines were then calculated against the Three Delays Framework. RESULTS: Fifty-six patients were entered into the study. Their mean delay from symptom onset to entering the anaesthesia bay for a procedure was 32.3 hours (+/-11.6). The second delay (4.1+/-2.5 hours) was significantly less than the first (20.9+/-11.5 hours; p<0.005) and third delays (7.2+/-1.2 hours; p<0.05). Additionally, patients with acute abdominal pain (of which 18/20 ultimately had open appendicectomy and two emergency laparotomies) had a delay time of 53.3 hours (+/-21.3), significantly more than that for emergency caesarean (22.9+/-18.6 hours; p<0.05) or management of an open long-bone fracture (15.5+/-5.56 hours; p<0.05). CONCLUSIONS: Substantial delays were observed for all three stages and each Bellwether procedure. This study methodology could be used to measure access and the three delays to emergency surgical care in low/middle-income countries, although the actual reasons for delay may vary between regions and countries and would require a qualitative study.

The surgical burden of disease and perioperative mortality in patients admitted to hospitals in Victoria, Australia: a population-level observational study.

OBJECTIVES: Comprehensive reporting of surgical disease burden and outcomes are vital components of resilient health systems but remain under-reported. The primary objective was to identify the Victorian surgical burden of disease necessitating treatment in a hospital or day centre, including a thorough epidemiology of surgical procedures and their respective perioperative mortality rates (POMR). DESIGN: Retrospective population-level observational study. SETTING: The study was conducted in Victoria, Australia. Access to data from the Victorian Admitted Episodes Dataset was obtained using the Dr Foster Quality Investigator tool. The study included public and private facilities, including day-case facilities. PARTICIPANTS: From January 2014 to December 2016, all admissions with an International Statistical Classification of Diseases-10 code matched to the Global Health Estimates (GHE) disease categories were included. PRIMARY AND SECONDARY OUTCOME MEASURES: Admissions were assigned a primary disease category according to the 23 GHE disease categories. Surgical procedures during hospitalisations were identified using the Australian Refined Diagnosis Related Groups (AR-DRG). POMR were calculated for GHE disease categories and AR-DRG procedures. RESULTS: A total of 4 865 226 admitted episodes were identified over the 3-year period. 1 715 862 (35.3%) of these required a surgical procedure. The mortality rate for those undergoing a procedure was 0.42%, and 1.47% for those without. The top five procedures performed per GHE category were lens procedures (162 835 cases, POMR 0.001%), caesarean delivery (76 032 cases, POMR 0.01%), abortion with operating room procedure (65 451 cases, POMR 0%), hernia procedures (52 499 cases, POMR 0.05%) and other knee procedures (47 181 cases, POMR 0.004%). CONCLUSIONS: Conditions requiring surgery were responsible for 35.3% of the hospital admitted disease burden in Victoria, a rate higher than previously published from Sweden, New Zealand and the USA. POMR is comparable to other studies reporting individual procedures and conditions, but has been reported comprehensively across all GHE disease categories for the first time.

Collecting data for global surgical indicators: a collaborative approach in the Pacific Region.

In 2015, the Lancet Commission on Global Surgery (LCoGS) recommended six surgical metrics to enable countries to measure their surgical and anaesthesia care delivery. These indicators have subsequently been accepted by the World Bank for inclusion in the World Development Indicators. With support from the Royal Australasian College of Surgeons and the Pacific Islands Surgical Association, 14 South Pacific countries collaborated to collect the first four of six LCoGS indicators. Thirteen countries collected all four indicators over a 6-month period from October 2015 to April 2016. Australia and New Zealand exceeded the recommended LCoGS target for all four indicators. Only 5 of 13 countries (38%) achieved 2-hour access for at least 80% of their population, with a range of 20% (Papua New Guinea and Solomon Islands) to over 65% (Fiji and Samoa). Five of 13 (38%) countries met the target surgical volume of 5000 procedures per 100 000 population, with six performing less than 1600. Four of 14 (29%) countries had at least 20 surgical, anaesthesia and obstetric providers in their workforce per 100 000 population, with a range of 0.9 (Timor Leste) to 18.5 (Tuvalu). Perioperative mortality rate was reported by 13 of 14 countries, and ranged from 0.11% to 1.0%. We believe it is feasible to collect global surgery indicators across the South Pacific, a diverse geographical region encompassing high-income and low-income countries. Such metrics will allow direct comparison between similar nations, but more importantly provide baseline data that providers and politicians can use in advocacy national health planning.

Back to basics: managing gunshot injuries in East Timor.

BACKGROUND: The management of patients following severe trauma requires a combination of skills. Among these are accurate clinical assessment, basic resuscitation measures, basic general surgical skills and techniques, good decision making and team leadership. More technically advanced imaging and investigations are often useful and can enhance clinical assessment but should not replace the basic elements. In situations where more advanced investigations are not available good outcomes can be achieved by application of the basic principles in trauma management and surgery. This article describes a mass casualty situation of gunshot wounds managed with limited resources and the outcomes. METHODS: A series of gunshot wounds managed in a single day at Dili National Hospital, Dili, East Timor is described. The presentation of the patients, initial assessment of injuries and haemodynamic stability are detailed in addition to the subsequent surgical treatment, complications and outcomes. The information was obtained from hospital records and personal recollection of the treating doctors. All injuries were documented with digital photography. All patients were managed by two surgeons who also supervised their postoperative course and reported on their outcomes. Surgical procedures on all of the patients were performed by the named two consultant surgeons and one basic surgical trainee. RESULTS: Fourteen patients were treated for gunshot injuries. All were single bullet injuries. Six trajectories involved the thoracic or abdominal cavity (one trajectory traversed both). Eight injuries were to limbs or soft tissue of the pelvis and included four compound fractures. Surgical intervention was needed for all patients ranging from emergency laparotomy for haemodynamic instability through to wound debridements. Thirteen patients survived and were discharged from hospital within 3 weeks. One patient died of uncontrolled haemorrhage. CONCLUSIONS: In the present series of gunshot injuries managed with limited resources a good outcome was achieved with the application of basic principles. The present series emphasizes the importance of basic trauma management as outlined in courses such as Emergency Management of Severe Trauma and the use of basic surgical techniques as taught during the Advanced Surgical training program.