Providing care to children from low and middle-income countries with complex surgical problems: An 18 year review

PurposeThe burden of surgical disease in children from low and middle-income countries (LMICs) is becoming more recognized as significant and undertreated.  We recently reviewed our health system's experience with providing quaternary-level surgical care to children from LMICs through a partnership with World Pediatric Project (WPP), a not-for-profit organization.MethodsA retrospective review was performed of all WPP-sponsored patients who received surgical care at our children's hospital from LMICs in the Caribbean and Central America from July 2000 to August 2018.ResultsTwo hundred and fifty-five patients (average age: 5.9 ± 5.3 years; range: <1–18 years) from 14 countries received a total of 371 moderately to significantly complex operations from 10 pediatric surgical subspecialties, with cardiac, neurosurgery, craniofacial and general/thoracic surgical subspecialties being the most common. The average length of hospital stay was 10.7 ± 18.9 days.  All patients had the opportunity to follow-up with local providers and/or visiting WPP-sponsored surgical teams. 227 patients (93.8%) were seen by WPP providers or released to an in-country physician partnering with WPP. There were 21 (8.2%) total, minor and major, postoperative complications.  Five deaths (2.0%) occurred at our institution and 7 from disease progression, after returning to their home country.ConclusionsProviding complex surgical care to LMIC children in the US may help address a significant global burden.  This care can be provided by multiple subspecialists with excellent outcomes, good follow-up, and low complication and mortality rates.  Having a supportive health care system, volunteer surgeons, and an organization that manages logistics and provides financial support is essential.Type of StudyClinical research, retrospective reviewLevel of EvidenceLevel IV     

Experience with a novel laparoscopic gynecologic curriculum in Haiti: lessons in implementation

An estimated one-third of the world’s burden of disease requires surgical treatment. In many high-income nations, a large proportion of critical surgical procedures are performed laparoscopically due to a number of advantages the technique offers. There is forward progress in the global surgery field to increase access to laparoscopic techniques in low and middle-income settings (LMIC), with potential benefits to both patients and surgeons. A week long laparoscopic surgery curriculum for surgeons and hospital staff was designed and implemented in a low-resource setting. An iterative design was used to adapt the curriculum on the ground. The local laparoscopic team was able to independently perform two laparoscopic procedures since the course was administered. Implementing laparoscopic surgery programs may be feasible in many LMIC settings. Access to this care may benefit patients. Lessons learned for the global laparoscopist are described.     

The burden of pediatric surgical conditions in low and middle income countries: A call to action

Recently, the role of surgery in global health has gained greater attention, although pediatric surgery has received little specific emphasis. This paper highlights pediatric surgical conditions as a part of global public health, and identifies gaps in knowledge and possible areas of action for the global pediatric surgical community. The burden of disease concept is discussed with examples of its application to pediatric surgery, and further information required to improve measurement of the global burden of pediatric surgical conditions. In addition, selected tools to measure access to surgical care and the unmet need for surgery in low and middle-income countries (LMICs) are reviewed, with recent innovative approaches and other possible adaptations to pediatric surgery. Finally, some of the strategies used to improve access to care for pediatric surgical conditions are discussed, with possible future directions.     

Motivations and impact of international rotations in low- and middle-income countries for orthopaedic surgery residents: Are we on the same page?

BackgroundDespite interest among North American orthopaedic residents to pursue rotations in resource-limited settings, little is known regarding resident motivations and impact on host surgeons.MethodsSurveys were distributed to North American orthopaedic surgeons and trainees who participated in international rotations during residency to assess motivations for participation and to orthopaedic surgeons at partnering low- and middle-income country (LMIC) institutions to assess impact of visiting trainees.ResultsResponses were received from 136 North American resident rotators and 51 LMIC host surgeons and trainees. North American respondents were motivated by a desire to increase surgical capacity at the LMIC while host surgeons reported a greater impact from learning from residents than on surgical capacity. Negative aspects reported by hosts included selfishness, lack of reciprocity, racial discrimination, competition for surgical experience, and resource burdens.ConclusionsThe motivations and impact of orthopaedic resident rotations in LMICs need to be aligned. Host perceptions and bidirectional educational exchange should be incorporated into partnership guidelines.     

Taking time out of training: a Malawi experience

There has been increased focus on global surgery in low-income and middle-income countries (LMICs) since the Lancet commission on global surgery was published in 2015. Interest from surgical trainees in overseas placements during their training is high with a number of motivating factors to engage in overseas work. In this article, we outline the overseas experience of a UK-based orthopaedic trainee during their time out of training in Malawi from both the trainee and training program director perspectives. Overseas LMIC placements during orthopaedic training are encouragingly becoming more established and are supported by a growing body of literature showing widespread benefits to the individual volunteer, donor and host institutions.

     

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

BackgroundBarriers 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.MethodsThis article describes “Disparities in Access to Care”—held within the Social Injustice Symposium at the 2020 American Pediatric Surgical Association (APSA) Annual Meeting.ResultsThis 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.ConclusionA 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 evidenceⅤ     

Shortage of Doctors, Shortage of Data: A Review of the Global Surgery, Obstetrics, and Anesthesia Workforce Literature

Introduction

The global surgery workforce is in crisis in many low- and middle-income countries (LMICs). The shortage of surgery, obstetrics, and anesthesia providers is an important cause of the unmet need for surgical care in LMICs. The goal of this paper is to summarize the available literature about surgical physicians in LMICs and to describe ongoing initiatives to supplement the existing surgical workforce data.

Methods

We performed a systematic search and literature review of the English-language literature regarding the number of surgeons, obstetrician–gynecologists, and anesthesiologists practicing in LMICs.

Results

Literature describing the number of surgeons, obstetricians, and anesthesiologists practicing in LMICs represents a small minority of LMICs, and indicates consistently low levels of surgical physicians. Our literature search yielded comprehensive data for only six countries. No national data were found for 23 of the 57 countries considered by the World Health Organization (WHO) to be in health workforce ‘crisis.’ Across LMICs, general surgeon density ranged from 0.13 to 1.57 per 100,000 population, obstetrician density ranged from 0.042 to 12.5 per 100,000, and anesthesiologist density ranged from 0 to 4.9 per 100,000. Total anesthesiologist, obstetrician, and surgeon density was significantly correlated with gross domestic product (GDP) per capita (r ² = 0.097, p = 0.0002).

Conclusion

The global surgery workforce is in crisis, yet is poorly characterized by the current English-language literature. There is a critical need for systematically collected, national-level data regarding surgery providers in LMICs to guide improvements in surgery access and care. The Harvard Global Surgery Workforce Initiative and the WHO global surgical workforce database are working to address this need by surveying Ministries of Health and surgical professional organizations around the world.     

Challenges of training and delivery of pediatric surgical services in Africa

Background

The practice of pediatric surgery in Africa presents multiple challenges. This report presents an overview of problems encountered in the training of pediatric surgeons as well as the delivery of pediatric surgical services in Africa.

Methods

A returned structured self-administered questionnaire sent to pediatric surgeons practicing in Africa was reviewed and analyzed using SPSS version 11.5 (SPSS, Chicago, IL).

Results

Forty-nine (57%) of 86 questionnaires were returned from 8 countries. Great variability in the requirements and training of pediatric surgeons, even within the same country, was found. Many surgical colleges are responsible for standardization and board certification of pediatric surgeons across Africa. There were 6 (12%) centers that train middle level manpower. Twenty-six (53%) participants have 1 to 2 trainees, whereas 22 (45%) have irregular or no trainee. A pediatric surgical trainee needs 2 to 4 (median, 2) years of training in general surgery to be accepted for training in pediatric surgery, and it takes a trainee between 2 to 4 (median, 3) years to complete training as a pediatric surgeon in the countries surveyed. The number of pediatric surgeons per million populations is lowest in Malawi (0.06) and highest in Egypt (1.5). Problems facing adequate delivery of pediatric surgical services enumerated by participants included poor facilities, lack of support laboratory facilities, shortage of manpower, late presentation, and poverty.

Conclusion

The training of pediatric surgical manpower in some African countries revealed great variability in training with multiple challenges. Delivery of pediatric surgical services in Africa presents problems like severe manpower shortage, high pediatric surgeon workload, and poor facilities. Standardization of pediatric surgery training across the continent is advocated, and the problems of delivery of pediatric surgical services need to be addressed urgently, not only by health care planners in Africa but by the international community and donor agencies, if the African child is to have access to essential pediatric surgical services like his or her counterpart in other developed parts of the world.     

Surgeon Migration Between Developing Countries and the United States: Train, Retain, and Gain from Brain Drain

Background

The critical shortage of surgeons in many low- and middle-income countries (LMICs) prevents adequate responses to surgical needs, but the factors that affect surgeon migration have remained incompletely understood. The goal of this study was to examine the importance of personal, professional, and infrastructural factors on surgeon migration from LMICs to the United States. We hypothesized that the main drivers of surgeon migration can be addressed by providing adequate domestic surgical infrastructure, surgical training programs, and viable surgical career paths.

Methods

We conducted an internet-based nationwide survey of surgeons living in the US who originated from LMICs.

Results

66 surgeons completed the survey. The most influential factors for primary migration were related to professional reasons (p ≤ 0.001). Nonprofessional factors, such as concern for remuneration, family, and security were significantly less important for the initial migration decisions, but adopted a more substantial role in deciding whether or not to return after training in the United States. Migration to the United States was initially considered temporary (44 %), and a majority of the surveyed surgeons have returned to their source countries in some capacity (56 %), often on multiple occasions (80 %), to contribute to clinical work, research, and education.

Conclusions

This study suggests that surgically oriented medical graduates from LMICs migrate primarily for professional reasons. Initiatives to improve specialist education and surgical infrastructure in LMICs have the potential to promote retention of the surgical workforce. There may be formal ways for LMICs to gain from the international pool of relocated surgeons.     

Impact of new dedicated pediatric operating rooms on surgical volume in Africa: Evidence from Nigeria

BackgroundThere is a large unmet children's surgical need in low- and middle-income countries (LMICs). This study examines the impact of installing dedicated pediatric operating rooms (ORs) on surgical volume at National Hospital Abuja, a hospital in Abuja, Nigeria.MethodsA Non-Governmental Organization installed two pediatric ORs in August 2019. We assessed changes in volume from July 2018 to September 2021 using interrupted time series analysis.ResultsTotal surgical volume increased by 13 cases (p = 0.01) in 1-month post-installation, with elective operations making up 85% (p = 0.02) of cases. There was an increase in elective volume by about 1 case per month (p = 0.01) post-installation and the difference between pre-and post-trends was 1.23 cases per month (p = 0.009). The baseline volume of neonatal surgeries increased by 9 cases per month (p < 0.001) post-installation and this difference between pre- and post-trends was statistically significant (p = 0.001). Similarly, one-month post-installation, the cases classified as ASA class >2 increased by 14 (p < 0.001). There was no significant difference between pre-and post-installation mortality rate at about 2% per month.ConclusionsThere were significant changes in surgical volume after OR installation, primarily composed of elective operations, reflecting an increased capacity to address surgical backlogs and/or perform more specialized surgeries. Despite a significant increase in volume and higher ASA class, there was no significant difference in mortality. This study supports the installation of surgical infrastructure in LMICs to strengthen capacity without increasing postoperative mortality.     

CAPS at 50: Now comfortably seated with the grownups

The Canadian Association of Pediatric Surgeons was established 50 years ago, with 30 founding members. Since then, the CAPS membership has grown nearly 10-fold and has developed a global presence with representation from 15 countries. CAPS has 8 pediatric surgery training programs which contribute not only to the North American workforce, but also to profoundly underserved low and middle income countries, particularly in Africa.On the occasion of our 50th Anniversary meeting, we celebrate our diversity and inclusivity as we reflect on our past, on the contributions of our Founding Members, the Women of CAPS, and others who have had a transformational impact on the practice of pediatric surgery. We look forward to our future, which while unknown, holds great promise for future generations of pediatric surgeons and the children and families in need of their care.     

Minimal invasive surgery techniques for patients with adolescent idiopathic and early onset scoliosis

ObjectiveProvide an update on minimal invasive surgery (MIS) techniques for surgical management of pediatric spine.MethodsMinimal Invasive surgery for pediatric spine deformity has evolved significantly over the past decade. We include updated information about the surgical management of patients with adolescent idiopathic and Early Onset Scoliosis through MIS techniques. We take into consideration the implementation of this technique in Low-to-Middle Income Countries (LMICs).ResultsAlthough MIS began as a technique in adult and degenerative spine, recent publications on MIS in pediatric spine cases report benefits of decreased blood loss and infection incidence, and cosmetic advantages from fewer incision numbers. Adoption of MIS techniques in pediatric spine can be facilitated with pre- and intraoperative use of pertinent medical systems.ConclusionWith appropriate considerations and training, MIS is a safe procedure for pediatric spine correction surgery and can be applicable in LMICs.     

PASS-A course in Pediatric Acute Surgical Support to build pediatric surgical emergencies capacity in developing countries

ObjectivesThe burden of pediatric trauma and emergency, including pediatric surgical emergencies in low middle income countries (LMIC) is high. The goal of Pediatric Acute Surgical Support (PASS) course is to prepare caregivers in LMIC for the acute management of life-threatening pediatric surgical emergencies. We aim to show the feasibility of its initial deployment.MethodsPASS was developed in 2016 with LMIC faculty from a teaching children hospital CH. The course contents consisted of a mix of didactic materials for serious general neonatal and pediatric surgery modified PALS/ATLS, in-person multidisciplinary team-based skill stations, interactive clinical scenarios and simulated trauma cases. The course was subsequently revised and delivered to 92 learners in four classes of 2.5-days sessions at two CHs between 2017 and 2019. Learners’ demographics, written exams, team-based case performance, and post-course survey data were prospectively collected and retrospectively analyzed.ResultsPhysician (60%) and nurse learners (40%) from pediatric critical care (36%), surgery (23%), emergency medicine (20%) and anesthesiology (9%) had 3.6 +/- 3.6 years of clinical practice; pre- and post-course written exam score of 55.4+/-15.5% vs 71.6+/-12.8%, team-based trauma scenario management 22.6 ± 7.8% vs 54.7 ± 16.6% and team-based dynamic scores 17+/- 10% vs 53.3+/- 15.5%, respectively (p<0.0001). Self-reported satisfaction scores were ≥ 95% for course method, level of difficulty, clinical applicability, and quality of instructors.ConclusionPASS is well-received by LMIC learners, with short-term improvement in knowledge-, team-based management of acute pediatric surgery emergencies; and has the potential to be a model of horizontal capacity building for pediatric surgery in LMIC.Level of evidenceII     

Global surgical electives in residency: The impact on training and future practice

Background

The purpose of this study was to evaluate perceptions regarding the value of global surgical electives (GSEs) and pursuit of a career in global surgery amongst residents and surgeons.

The Pediatric Surgical Team: a Model for Increased Surgeon Index Case Exposure

Background/PurposeHigh surgical volume for both surgeons and hospital systems has been linked to improved outcomes for many surgical problems, yet case volumes per pediatric surgeon are diminishing nationally in complex pediatric surgery. We therefore sought to review our experience in a geographically isolated setting where a surgical team approach has been used to improve per-surgeon exposure to index pediatric surgical cases.MethodsAs a surgical group, we incorporated a surgical team approach to complex pediatric surgical cases in 2010. We obtained institutional review board approval to review our pediatric surgeon index case volume experience. We then compared our surgeon experience to published surgical volumes for complex pediatric surgical cases.ResultsA surgical team approach (2 or 3 board certified pediatric surgeons/urologists working as co-surgeons or assistant surgeon) was used in the majority of cases for tracheoesophageal fistula/esophageal atresia (77%), congenital pulmonary airway malformation (73.5%), cloaca (75%), anorectal malformation (43.6%) biliary atresia (77.8%), Hirschsprung's disease (51.9%), congenital diaphragmatic hernia (67.6%), robotic choledochal cyst (100%), and complex oncology (adrenal tumors, neuroblastoma, Wilms tumor and Hepatoblastoma surgery) (85–100%). Over the 5-year period, surgeon index case exposure for all index pediatric surgical cases was above the published national median for pediatric surgeons, except for in splenic operations when contrasted to published experience.ConclusionsA surgical team approach to complex pediatric surgery may help maintain exposure to adequate index case volumes. This model may be useful for maintaining competence in geographically-isolated practice settings and low-volume pediatric hospitals that provide surgical care; the model has implications for systems development and workforce allocation within pediatric surgery.Level of Evidence4     

Demand and capacity to integrate pelvic organ prolapse and genital fistula services in low-resource settings

Introduction and hypothesis

There is a need for expanded access to safe surgical care in low- and middle-income countries (LMICs) as illustrated by the report of the 2015 Lancet Commission on Global Surgery. Packages of closely-related surgical procedures may create platforms of capacity that maximize impact in LMIC. Pelvic organ prolapse (POP) and genital fistula care provide an example. Although POP affects many more women in LMICs than fistula, donor support for fistula treatment in LMICs has been underway for decades, whereas treatment for POP is usually limited to hysterectomy-based surgical treatment, occurring with little to no donor support. This capacity-building discrepancy has resulted in POP care that is often non-adherent to international standards and in non-integration of POP and fistula services, despite clear areas of similarity and overlap. The objective of this study was to assess the feasibility and potential value of integrating POP services at fistula centers.

Methods

Fistula repair sites supported by the Fistula Care Plus project were surveyed on current demand for and capacity to provide POP, in addition to perceptions about integrating POP and fistula repair services.

Results

Respondents from 26 hospitals in sub-Saharan Africa and South Asia completed the survey. Most fistula centers (92%) reported demand for POP services, but many cannot meet this demand. Responses indicated a wide variation in assessment and grading practices for POP; approaches to lower urinary tract symptom evaluation; and surgical skills with regard to compartment-based POP, and urinary and rectal incontinence. Fistula surgeons identified integration synergies but also potential conflicts.

Conclusions

Integration of genital fistula and POP services may enhance the quality of POP care while increasing the sustainability of fistula care.

     

Adaptations in pediatric anesthesia care and airway management in the resource‐poor setting

The need for safe and quality pediatric anesthesia care in low‐ and middle‐income countries (LMICs) is huge. An estimated 1.7 billion children do not have access to surgical care, and the majority are in LMICs. In addition, most LMICs do not have the requisite surgical workforce including anesthesia providers. Surgery is usually performed at three levels of facilities: district, provincial, and national referral hospitals. Unfortunately, the manpower, equipment, and other resources available to provide surgical care for children vary greatly at the different level facilities. The majority of district level hospitals are staffed solely by non‐physician anesthesia providers with variable training and little support to manage complicated pediatric patients. Airway and respiratory complications are known to account for a large portion of pediatric perioperative complications. Management of the difficult pediatric airway pathology is a challenge for anesthesia providers regardless of setting. However, in the low‐resource setting poor infrastructure, lack of transportation systems, and crippled referral systems lead to late presentation. There is often a lack of pediatric‐sized anesthesia equipment and resources, making management of the local pathology even more challenging. Efforts are being made to offer these providers additional training in pediatric anesthesia skills that incorporate low‐fidelity simulation. Out of necessity, anesthesia providers in this setting learn to be resourceful in order to manage complex pathologies with fewer, less ideal resources while still providing a safe anesthetic.