Emergency-to-Elective Surgery Ratio: A Global Indicator of Access to Surgical Care

Background

Surgical care is essential to health systems but remains a challenge for low- and middle-income countries (LMICs). Current metrics to assess access and delivery of surgical care focus on the structural components of surgery and are not readily applicable to all settings. This study assesses a new metric for surgical care access and delivery, the ratio of emergent surgery to elective surgery (Ee ratio), which represents the number of emergency surgeries performed for every 100 elective surgeries.

Methods

A systematic search of PubMed and Medline was conducted for studies describing surgical volume and acuity published between 2006 and 2016. The relationship between Ee ratio and three national indicators (gross domestic product, per capital healthcare spending, and physician density) was analyzed using weighted Pearson correlation coefficients (r _w) and linear regression models.

Results

A total of 29 studies with 33 datasets were included for analyses. The median Ee ratio was 14.6 (IQR 5.5–62.6), with a range from 1.6 to 557.4. For countries in sub-Saharan Africa the median value was 62.6 (IQR 17.8–111.0), compared to 9.4 (IQR 3.4–13.4) for the United States and 5.5 (IQR 4.4–10.1) for European countries. In multivariable linear regression, the per capita healthcare spending was inversely associated with the Ee ratio, with a 63-point decrease in the Ee ratio for each 1 point increase in the log of the per capita healthcare spending (regression coefficient β = ?63.2; 95% CI ?119.6 to ?6.9; P = 0.036).

Conclusions

The Ee ratio appears to be a simple and valid indicator of access to available surgical care. Global health efforts may focus on investment in low-resource settings to improve access to available surgical care.

     

Early Closure of Defunctioning Loop Ileostomy: Is It Beneficial for the Patient? A Meta-analysis

World Journal of Surgery - To perform a meta-analysis to answer the question, whether early closure (EC) of defunctioning loop ileostomy may be beneficial for patient as compared with late closure...     

Critical Care Management of Peritonitis in a Low-Resource Setting

Background

Management of critically ill patients is challenging in a low-resource setting. In Rwanda, peritonitis is a common surgical condition where patients often present late, with advanced disease. We aim to describe critical care management of patients with peritonitis in Rwanda.

Methods

Data were collected at a tertiary referral hospital in Rwanda on patients undergoing operation for peritonitis over a 6-month period. Data included epidemiology, hospital course and outcomes. Patients requiring admission to the intensive care unit (ICU) were compared with those not requiring ICU admission using Chi-square and Wilcoxon rank-sum test.

Results

Over a 6-month period, 280 patients were operated for peritonitis. Of these, 46 (16.4%) were admitted to the ICU. The most common diagnoses were intestinal obstruction (N?=?17, 37.0%) and typhoid intestinal perforation (N?=?6, 13.0%). Thirty-nine (89%) patients had sepsis. The median American Society of Anesthesiologist score was 3 (range 2–4), and the median Surgical Apgar Score was 4 (range 0–6). Twenty-four (52.2%) patients required vasopressors, with dopamine and adrenaline being the only vasopressors available. Patients admitted to the ICU, compared with non-critically ill patients, were more likely to have major complications (80.4 vs. 14%, p?<?0.001), unplanned reoperation (28 vs. 10%, p?<?0.001) and death (72 vs. 8%, p?<?0.001).

Conclusion

Patients with peritonitis admitted to the ICU commonly presented with features of sepsis. Due to limited resources in this setting, interventions are primarily supportive with intravenous fluids, intravenous antibiotics, ventilator support and vasopressors. Morbidity and mortality remain high in this patient population.