Care of surgical infections by Médecins Sans Frontières Operations Centre Brussels in 2008-14.

BACKGROUND: Surgical infections represent a substantial yet undefined burden of disease in low-income and middle-income countries (LMICs). Médecins Sans Frontières (MSF) provides surgical care in LMICs and collects data useful to describe the operative epidemiology of surgical need that would otherwise be unmet by national health services. We aimed to describe the experience of MSF Operations Centre Brussels surgery for infections during crisis; aid effective resource allocation; prepare humanitarian surgical staff; and further characterise unmet surgical needs in LMICs. METHODS: We reviewed all procedures undertaken in operating theatres at facilities run by the MSF Operations Centre Brussels between July, 2008, and June, 2014. Projects providing only specialty care were excluded. Procedures for infections were quantified, related to demographics and reason for humanitarian response was described. FINDINGS: 96 239 operations were undertaken at 27 MSF Operations Centre Brussels sites in 15 countries. Of 61 177 general operations, 7762 (13%) were for infections. Operations for skin and soft tissue infections were the most common (64%), followed by intra-abdominal (26%), orthopaedic (6%), and tropical infections (3%). The proportion of operations for skin and soft tissue infections was highest during natural disaster missions, intra-abdominal infections during hospital support missions, and orthopaedic infections during conflict missions. Most procedures for skin and soft tissue infections were minor (76%), whereas most operations for intra-abdominal infections were major (98%). INTERPRETATION: Surgical infections are among the most common causes for operation in LMICs. Although many procedures were minor, they represent substantial use of perioperative resources. Growing evidence shows the need for improved perioperative capacity to aptly care for the volume and variety of conditions comprising the global burden of surgical disease. FUNDING: Médecins Sans Frontières.

One stage emergency resection and primary anastomosis for sigmoid volvulus.

OBJECTIVE: To evaluate the safety of single stage resection and primary anastomosis (RPA) in cases of viable sigmoid volvulus, in terms of anastomotic healing and complications. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Surgical Unit, Hayatabad Medical Complex (HMC), Postgraduate Medical Institute, Peshawar, from November 2006 to October 2008. METHODOLOGY: Study included all patients presented and admitted in Surgical Unit, HMC, with sigmoid volvulus during the above mentioned period. Resection and primary anastomosis was done without defunctioning stoma formation or on-table colonic lavage. Manual decompression was carried out pre-operatively. Patients excluded, had serious co-morbid conditions in whom colostomy was done instead of primary anastomosis. Patients were followed-up for one month after surgery. RESULTS: A total of 30 patients were admitted during the study of 2 years duration, out of which there were 21 male and 09 female patients, with male to female ratio of 2.4:1. Only 1 patient had anastomotic leak while 4 patients had superficial wound infection. One patient died due to comorbid condition. Abdominal wound dehiscence or postoperative abdominal abscess was not observed in any case. CONCLUSION: Single stage resection and primary anastomosis is a reliable current treatment modality for the emergency surgical management of sigmoid volvulus and has low morbidity and mortality. On-table colonic lavage and proximal defunctioning colostomies are unnecessary with this technique.

Outcome of acute traumatic extradural hematoma.

OBJECTIVE: To assess the surgical outcome of acute extradural hematoma in terms of neurological recovery and survival. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Postgraduate Medical Institute, Neurosurgery Unit, Hayatabad Medical Complex, Peshawar, from January to October 2006. METHODOLOGY: All patients admitted and operated for acute traumatic extradural hematoma during the study period were included. Demographic data, history, mode of trauma, examination findings, investigations and outcome were recorded. Glasgow coma scale was used for initial assessment and Glasgow outcome scale was applied to assess outcome in terms of neurological recovery in all patients. The follow-up period was 3 months. RESULTS: A total of 30 patients were operated during the period of 10 months including 22 males and 8 females. Patients were in the age range of 20-30 years comprised 30% of all. Most common causes were road traffic accident (50%), fall from height (33%) and assault (17%). Patients were divided according to the initial Glasgow Coma Score (GCS) after resuscitation. The GCS was 3-8 in 6 patients, 9-12 in 7 patients, 13-15 in 17 patients. Twenty-four patients had good outcome, one patient had moderate disability in the form of left sided weakness, one patient remained in vegetative state, while 3 (10%) patients died. Chi-square test was significant for good outcome in patients with GCS 13-15 (p=0.01) and for death in patients with GCS 3-8 (p=0.01). CONCLUSION: Extradural hematoma in head injuries affected young males more commonly. The outcome was better when the initial GCS was in the higher range.

Surgery for children in low-income countries affected by humanitarian emergencies from 2008 to 2014: The Médecins Sans Frontières Operations Centre Brussels experience.

PURPOSE: Pediatric surgical care is deficient in developing countries disrupted by crisis. We aimed to describe pediatric surgical care at Médecins Sans Frontières-Brussels (MSF-OCB) projects to inform resource allocation and define the pediatric-specific skillset necessary for humanitarian surgical teams. METHODS: Procedures performed by MSF-OCB from July 2008 to December 2014 were reviewed. Project characteristics, patient demographics and clinical data were described. Multivariable logistic regression was performed to determine predictors of perioperative death. RESULTS: Of 109,828 procedures, 26,284 were performed for 24,576 children (22% of all procedures). The most common pediatric operative indication was trauma (13,984; 57%). Nine percent of all surgical indications were due to violence (e.g., land mines, firearms, gender-based violence, etc.). The majority of procedures (19,582; 75%) were general surgical, followed by orthopedic (4350; 17%), and obstetric/gynecologic/urologic (2135; 8%). Perioperative death was low (42; 0.17%); independent predictors of death included age <1year, use of general anesthesia with a definitive airway, and operation during conflict. CONCLUSION: Surgical care for children comprised nearly a quarter of all procedures performed by MSF-OCB between 2008 and 2014. Attention to trauma surgery and infant perioperative care is particularly needed. These findings are important when resourcing projects and training surgical staff for humanitarian missions.

Surgery for Conditions of Infectious Etiology in Resource-Limited Countries Affected by Crisis: The Médecins Sans Frontières Operations Centre Brussels Experience.

BACKGROUND: Surgery for infection represents a substantial, although undefined, disease burden in low- and middle-income countries (LMICs). Médecins Sans Frontières-Operations Centre Brussels (MSF-OCB) provides surgical care in LMICs and collects data useful for describing operative epidemiology of surgical need otherwise unmet by national health services. This study aimed to describe the experience of MSF-OCB operations for infections in LMICs. By doing so, the results might aid effective resource allocation and preparation of future humanitarian staff. METHODS: Procedures performed in operating rooms at facilities run by MSF-OCB from July 2008 through June 2014 were reviewed. Projects providing specialty care only were excluded. Procedures for infection were described and related to demographics and reason for humanitarian response. RESULTS: A total of 96,239 operations were performed at 27 MSF-OCB sites in 15 countries between 2008 and 2014. Of the 61,177 general operations, 7,762 (13%) were for infections. Operations for skin and soft tissue infections were the most common (64%), followed by intra-abdominal (26%), orthopedic (6%), and tropical infections (3%). The proportion of operations for skin and soft tissue infections was highest during natural disaster missions (p<0.001), intra-abdominal infections during hospital support missions (p<0.001) and orthopedic infections during conflict missions (p<0.001). CONCLUSION: Surgical infections are common causes for operation in LMICs, particularly during crisis. This study found that infections require greater than expected surgical input given frequent need for serial operations to overcome contextual challenges and those associated with limited resources in other areas (e.g., ward care). Furthermore, these results demonstrate that the pattern of operations for infections is related to nature of the crisis. Incorporating training into humanitarian preparation (e.g., surgical sepsis care, ultrasound-guided drainage procedures) and ensuring adequate resources for the care of surgical infections are necessary components for providing essential surgical care during crisis.

An Analysis of Cesarean Section and Emergency Hernia Ratios as Markers of Surgical Capacity in Low-Income Countries Affected by Humanitarian Emergencies from 2008 - 2014 at Médecins sans Frontières Operations Centre Brussels Projects.

BACKGROUND: Surgical capacity assessments in low-income countries have demonstrated critical deficiencies. Though vital for planning capacity improvements, these assessments are resource intensive and impractical during the planning phase of a humanitarian crisis. This study aimed to determine cesarean sections to total operations performed (CSR) and emergency herniorrhaphies to all herniorrhaphies performed (EHR) ratios from Médecins Sans Frontières Operations Centre Brussels (MSF-OCB) projects and examine if these established metrics are useful proxies for surgical capacity in low-income countries affected by crisis. METHODS: All procedures performed in MSF-OCB operating theatres from July 2008 through June 2014 were reviewed. Projects providing only specialty care, not fully operational or not offering elective surgeries were excluded. Annual CSRs and EHRs were calculated for each project. Their relationship was assessed with linear regression. RESULTS: After applying the exclusion criteria, there were 47,472 cases performed at 13 sites in 8 countries. There were 13,939 CS performed (29% of total cases). Of the 4,632 herniorrhaphies performed (10% of total cases), 30% were emergency procedures. CSRs ranged from 0.06 to 0.65 and EHRs ranged from 0.03 to 1.0. Linear regression of annual ratios at each project did not demonstrate statistical evidence for the CSR to predict EHR [F(2,30)=2.34, p=0.11, R2=0.11]. The regression equation was: EHR = 0.25 + 0.52(CSR) + 0.10(reason for MSF-OCB assistance). CONCLUSION: Surgical humanitarian assistance projects operate in areas with critical surgical capacity deficiencies that are further disrupted by crisis. Rapid, accurate assessments of surgical capacity are necessary to plan cost- and clinically-effective humanitarian responses to baseline and acute unmet surgical needs in LICs affected by crisis. Though CSR and EHR may meet these criteria in 'steady-state' healthcare systems, they may not be useful during humanitarian emergencies. Further study of the relationship between direct surgical capacity improvements and these ratios is necessary to document their role in humanitarian settings.