Assessment of essential surgical and anaesthesia care capacity: a cross-sectional study in five Pacific Island Countries.

Background: Pacific Island Countries (PICs) face unique challenges in providing surgical care. We assessed the surgical care capacity of five PICs to inform the development of National Surgical, Obstetric and Anaesthesia Plans (NSOAP). Methods: We conducted a cross-sectional survey of 26 facilities in Fiji, Tonga, Vanuatu, Cook Islands, and Palau using the World Health Organization - Program in Global Surgery and Social Change Surgical Assessment Tool. Findings: Eight referral and 18 first-level hospitals containing 39 functioning operating theatres, 41 post-anaesthesia care beds, and 44 intensive care unit beds served a population of 1,321,000 across the five countries. Most facilities had uninterrupted access to electricity, water, internet, and oxygen. However, CT was only available in 2/8 referral hospitals, MRI in 1/8, and timely blood transfusions in 4/8. The surgical, obstetric, and anaesthetist specialist density per 100,000 people was the highest in Palau (49.7), followed by Cook Islands (22.9), Tonga (9.9), Fiji (7.1), and Vanuatu (5.0). There were four radiologists and 3.5 pathologists across the five countries. Surgical volume per 100,000 people was the lowest in Vanuatu (860), followed by Fiji (2,247), Tonga (2,864), Cook Islands (6,747), and Palau (8,606). The in-hospital peri-operative mortality rate (POMR) was prospectively monitored in Tonga and Cook Islands but retrospectively measured in other countries. POMR was below 1% in all five countries. Interpretation: Whilst PICs share common challenges in providing specialised tertiary services, there is substantial diversity between the countries. Strategies to strengthen surgical systems should incorporate both local contextualisation within each PIC and regional collaboration between PICs. Funding: None.

International consensus recommendations for the optimal prioritisation and distribution of surgical services in low-income and middle-income countries: a modified Delphi process.

OBJECTIVES: To develop consensus statements regarding the regional-level or district-level distribution of surgical services in low and middle-income countries (LMICs) and prioritisation of service scale-up. DESIGN: This work was conducted using a modified Delphi consensus process. Initial statements were developed by the International Standards and Guidelines for Quality Safe Surgery and Anesthesia Working Group of the Global Alliance for Surgical, Obstetric, Trauma and Anesthesia Care (G4 Alliance) and the International Society of Surgery based on previously published literature and clinical expertise. The Guidance on Conducting and REporting DElphi Studies framework was applied. SETTING: The Working Group convened in Suva, Fiji for a meeting hosted by the Ministry of Health and Medical Services to develop the initial statements. Local experts were invited to participate. The modified Delphi process was conducted through an electronically administered anonymised survey. PARTICIPANTS: Expert LMIC surgeons were nominated for participation in the modified Delphi process based on criteria developed by the Working Group. PRIMARY OUTCOME MEASURES: The consensus panel voted on statements regarding the organisation of surgical services, principles for scale-up and prioritisation of scale-up. Statements reached consensus if there was ≥80% agreement among participants. RESULTS: Fifty-three nominated experts from 27 LMICs voted on 27 statements in two rounds. Ultimately, 26 statements reached consensus and comprise the current recommendations. The statements covered three major themes: which surgical services should be decentralised or regionalised; how the implementation of these services should be prioritised; and principles to guide LMIC governments and international visiting teams in scaling up safe, accessible and affordable surgical care. CONCLUSIONS: These recommendations represent the first step towards the development of international guidelines for the scaling up of surgical services in LMICs. They constitute the best available basis for policymaking, planning and allocation of resources for strengthening surgical systems.

Amoebic Liver Abscesses in Fiji: Epidemiology, Clinical Presentation and Comparison of Percutaneous Aspiration and Percutaneous Catheter Drainage.

BACKGROUND: Amoebic liver abscess (ALA) is a common clinical problem in tropical countries related to poor sanitation. The epidemiology and clinical presentation of ALA in Fiji has not been previously described. It is unclear whether percutaneous aspiration (PA) or percutaneous catheter drainage (PCD) has better outcomes. PURPOSE: The aims were to describe the epidemiology and clinical presentation of ALA in Fiji and to compare the outcomes of PA and PCD for treatment of ALA. METHODS: A retrospective case note review of patients treated with either PA or PCD between 2010 and 2015 was performed. Indications for intervention were ALA > 5 cm, ALA in the left lateral lobe, risk of imminent rupture and failure to respond to medical treatment. RESULTS: There were 262 patients, 90% were male, 92.9% I-Taukei ethnicity and 86.2% regular recreational kava drinkers. Most presented with upper abdominal pain and fevers. The majority (90.3%) had a single abscess with 87.8% being in the right lobe. 174 (66.4%) had LA and 88 (33.6%) had PCD. There was an unintended selection bias for PA in abscess with a volume of <1 litre. PA was associated with a more rapid resolution of fever and shorter hospital stay, more rapid resolution of the cavity and no morbidity. PCD had five complications, one bleed and four bile leaks. There was no mortality in either group. CONCLUSIONS: ALA in Fiji occurs in I-Taukei males who drink kava. PA appears to offer equivalent if not better outcomes for treatment of ALA.

Sigmoid volvulus in pregnancy: case report and review of literature.

Sigmoid volvulus in pregnancy is a very rare condition. Despite this, clinicians should have a high index of suspicion of this condition if they encounter a pregnant woman with symptoms suggestive of bowel obstruction. Incorrect diagnosis may be catastrophic, resulting in major complications, including fetal and maternal death.

Management of malignant pleural effusions by talc pleurodesis.

Since July 2002, the Cardiothoracic Surgical team started talc pleurodesis with or without surgical assisted video thorascopy. This paper reports a retrospective review of medical records of 6 patients who received talc pleurodesis from July 2002 to March 2003, three males and three females. The primary malignancy was proven histological in five patients. All the six patients presented with dyspnoea. Two patients received thoracocentesis 2 or 3 times while 4 had formal chest drains till pleurodesis. The total amount of fluid drained before pleurodesis ranged from 2 to 7 litres. One patient died from metastasis 1 month after pleurodesis with a Blake drain in situ. The pleurodesis success rate was 100% for the 5 patients that lived. All the patients had MPE as a consequence of metastatic malignancy. The patients were discharged home after pleurodesis with a Blake drain and grenade. The complete pleurodesis rate was 5/5. Pain was the most common complication of tetracycline and doxycycline pleurodesis. Talc pleurodesis is a relatively cheap and safe procedure undertaken at Cardiothoracic Surgical Unit, Christchurch Public Hospital. Chemical pleurodesis using talc is an important consideration.