Michael Cotton

The Amsterdam Declaration on Essential Surgical Care

On behalf of the supporting organisations and all participants of the international symposium ‘Surgery in Low Resource Settings’, November 2014, in Amsterdam, we present the ‘Amsterdam Declaration on Essential Surgical Care’. The situation with regard to a lack of surgical capacity in LMICs is untenable, and urgent action is required to alleviate the situation. Many thousands of patients are dying unnecessarily every day because there is no one trained to operate on them. As a consequence, the death toll of surgical conditions in low resource settings currently outnumbers the death toll of HIV, malaria and TB combined. Rarely has there been such unanimity in the field of global surgery, and there is urgent action needed. The lack of surgical care will be on the agenda during the World Health Assembly in May 2015. We solicit international health policy makers to support the initiative towards a WHA resolution on ‘Strengthening Emergency and Essential Surgical Care and Anaesthesia as a component of Universal Health Coverage’. We need to make the world realize that we completely forgot something: Surgery should be part of the United Na-

Essential Surgery: The Way Forward

IntroductionVery little surgical care is performed in low- and middle-income countries (LMICs). An estimated two billion people in the world have no access to essential surgical care, and non-surgeons perform much of the surgery in remote and rural areas. Surgical care is as yet not recognized as an integral aspect of primary health care despite its self-demonstrated cost-effectiveness. We aimed to define the parameters of a public health approach to provide surgical care to areas in most need.MethodsConsensus meetings were held, field experience was collected via targeted interviews, and a literature review on the current state of essential surgical care provision in Sub-Saharan Africa (SSA) was conducted. Comparisons were made across international recommendations for essential surgical interventions and a consensus-driven list was drawn up according to their relative simplicity, resource requirement, and capacity to provide the highest impact in terms of averted mortality or disability.ResultsEssential Surgery consists of basic, low-cost surgical interventions, which save lives and prevent life-long disability or life-threatening complications and may be offered in any district hospital. Fifteen essential surgical interventions were deduced from various recommendations from international surgical bodies. Training in the realm of Essential Surgery is narrow and strict enough to be possible for non-physician clinicians (NPCs). This cadre is already active in many SSA countries in providing the bulk of surgical care.ConclusionA basic package of essential surgical care interventions is imperative to provide structure for scaling up training and building essential health services in remote and rural areas of LMICs. NPCs, a health cadre predominant in SSA, require training, mentoring, and monitoring. The cost of such training is vastly more efficient than the expensive training of a few polyvalent or specialist surgeons, who will not be sufficient in numbers within the next few generations. Moreover, these practitioners are used to working in the districts and are much less prone to gravitate elsewhere. The use of these NPCs performing “Essential Surgery” is a feasible route to deal with the almost total lack of primary surgical care in LMICs.

Impact of Surgical Resection for Subdiaphragmatic Paragangliomas

BackgroundSubdiaphragmatic paraganglioma is a rare neuroendocrine tumor for which scarce data exist regarding long-term patient outcome following resection. The aim of this study was to determine the association of surgical resection with survival.MethodsA retrospective study at a tertiary care center was performed. Demographics, genetics, histology, and operative details were reviewed. Patients were grouped according to margin status (R0, R1, or R2) and survival calculated.ResultsA total of 50 patients with subdiaphragmatic paragangliomas underwent primary resection from 1999 to 2012. Median age at operation was 46 years, with a median tumor size of 6.0 cm. Of these patients, 30 (60 %) had a R0 resection, 11 (22 %) had a R1 resection, and 9 (18 %) had a R2 resection. There was no operative mortality, and 17 (34 %) patients had metastatic disease. Six (12 %) patients died, four (8 %) of whom had metastatic disease. Univariate analysis identified that age >50 years (p = 0.02) and undergoing a R2 resection (p = 0.03) were associated with a shorter overall survival (OS). Those with metastases at some point after their initial diagnosis had a shorter disease-free survival (DFS) than those without metastases (p = 0.04). Of 27 patients tested, 12 (44 %) had a germline succinyl dehydrogenase B (SDHB) mutation. SDHB immunohistochemistry identified 18 patients (of 27 who underwent staining) who had loss of SDHB expression in which 7 of 11 patients (63 %) who underwent genetic testing had a genetic mutation.ConclusionsSurgical resection of subdiaphragmatic paraganglioma is safe. Survival was longest in patients who were younger, with no metastases, or had a R0 or R1 resection. Patients who test negative for a germline mutation should undergo SDHB immunostaining to identify potential hereditary carriers missed by current genetic testing.

Five years as a flying surgeon in Zimbabwe.

Abstract. Surgical services in the developing world are often based on a Western model where the patient has to seek out the surgeon. A reverse policy was instituted to overcome severe logistical problems. Funding was obtained for air flights to 10 distant rural hospitals and a program of visits advertised in advance. Patients were selected by the resident doctor and seen either as in- or outpatients. A list was drawn up and patients were operated on that day and if necessary the following day when earlier postoperative cases were reviewed. More than 500 operations were performed of varying complexity, and complications were reported in fewer than 10. A scheme where the surgeon visits the rural patient in his or her home area is cost-effective, popular, and beneficial to the hospital staff. It obviates the need for distant referral where there may be language difficulties and where visits from relatives are precluded. It also reduces the workload of overstretched referral centers. It provides the means to teach the local resident doctor rudiments of surgical practice, and it provides regular contact between the outstation and the referral center.

Single-port cholecystectomy and quality of life.

I was intrigued by the article by Wagner et al. [1] in theMay 2013 issue of the World Journal of Surgery. Theauthors’ conclusions, inter alia, state that single-port cho-lecystectomy results in a better quality of life (QoL) score.This is based on a survey of the 222 patients in the study.Information on QoL is garnered from 131 completedquestionnaires. This figure represents 59 % (not 69 %) ofthe patients. Thus, 91 did not reply or gave inadequateinformation. This figure is sufficiently large to make theconclusion based on the remaining questionnaires dubiousat best.Furthermore, single-port access (SPA) cholecystectomywas performed by consultant surgeons, whereas the stan-dard laparoscopic approach was used by several surgeonsof varying experience, including those below consultantstatus. The SPA procedure took longer even though per-formed by senior surgeons. Presumably, if performed byless experienced operators, it would logically take evenlonger and therefore prove even more expensive. Thus, twoplanks of the conclusion in the aforesaid article areremoved. It therefore appears to be in danger of tottering.Reference

The Academic Discipline of Tropical Surgery

Over 2 billion people, more than a third of the world’s population, live in the tropics and sub-tropics. In most of the countries of these regions, the risks of injury or death from trauma is hugely greater than in the affluent West. Furthermore, obtaining surgery for eminently curable conditions is difficult, expensive, and often hazardous. An estimate has been given that approximately 11% of the global burden of disease is surgically treatable [1]. Simple procedures that could transform a young person’s life (for example, club foot manipulation or even simple childhood inguinal herniotomy) have the potential, at minimal cost, of transforming a life. To change a young person’s crippled existence to full participation in society has the cost–benefit potential of decades rather than years or months. Such analysis appears self-evident for many healthcare workers with first-hand experience in resource-poor countries. Twenty years as a general surgeon in Zimbabwe made this abundantly clear to me. Policy makers, however, do need statistics, and it is a welcome sign that more and more data are emerging to demonstrate that surgery is indeed cost-effective. The World Health Organization (WHO) has recognized the need to roll out surgery for the masses in the developing world [2], noting en passant the dire consequences of trauma, which has reached almost epidemic proportions in many places. Trauma remains largely maltreated or untreated. Its effective treatment is, by definition, surgical. Until recently, surgery was considered an expensive luxury for enthusiasts, but major improvements in care have been shown to be achievable without huge cost inputs [3]. Real medical impact in the tropics was initially sought by dealing with global problems of gastroenteritis, malaria, malnutrition, and, more recently, human immunodeficiency virus (HIV). Immunization programs removed poliomyelitis from the world scene; spraying limited the advance of malaria, and many exotic tropical diseases once endemic have been virtually eliminated. The World Health Organization introduced its highly effective essential drugs program and the World Bank launched its essential clinical package. A Caesarean section is the only surgical intervention within this package, and it remains the commonest necessary surgical procedure worldwide. Nonetheless it is becoming manifestly apparent that a basic list of surgical procedures could be drawn up that would cater to the needs of 90% of cases. The skills of a senior specialized surgeon have been shown in one study to be unnecessary in 86.4% of cases [4]. However, the attitude toward surgery is changing. We may call this surgery for the under-resourced 2 billion of the world ‘‘Tropical Surgery,’’ for want of a better term. But who will direct this new focus on Tropical Surgery? Who will direct its path? Where will the surgeons for the WHO recommendations, for example, for circumcision to diminish the incidence of HIV disease, be found and trained? Training programs in many countries are wedded to oldfashioned Western models that are now inadequate to deal with the exigencies of the demand. The pursuit of specialization leads to well-qualified experts willing only to practice in specifically equipped centers of excellence, usually in private practice. Their contribution to the global surgical need is minimal, and yet they cost their countries vast sums in terms of educational input. Initiatives, such as M. H. Cotton (&) Service de Chirurgie Viscerale, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland e-mail: mikeytha@gmail.com

Essential Surgery: The Way Forward: Reply.

To the Editor, We thank Monjok, E. for his comments on our article [1] regarding essential surgical training in Sub-Saharan Africa [2]. Indeed, the character and type of training; i.e., 3 versus 5 years, focused versus comprehensive, and rural versus urban posting; should remain within the purview of the local training institution which has the best gauge of the surgical needs of their community. Training patterns in high-income countries should merely serve as guides, but should not be expected to account for the contextual realities in lowand middle-income countries. Training general practitioners (GPs) or family medicine physicians (FPs) in surgery is not a novel phenomenon. GPs who underwent a 6-month training program in Ethiopia were found to be able to provide life-saving surgical care at a modest cost. [3] The challenge, however, lies in ensuring appropriate quality training with adequate delineation of scopes of competence and responsibility and ability to recognize the need to refer patients when needed, but also to recognize when referral itself may prove deleterious because of local conditions. There is a balance to be made on the amount of training and supervision provided for GPs, FPS, and non-physician clinicians (NPCs), as well as adequate incentives to encourage retention. We accept the feedback on the terminology ‘Non-surgeon Physician’ and agree that ‘Surgical Medical Officer’ is a viable option. However, many countries will wish to retain their own nomenclature. As validating a cadre of health worker necessitates political buy-in, Ministers of Health and other members of the health community need to be included in these discussions to achieve appropriate endorsement and legalization to achieve the ultimate goal of providing access to safe, quality, essential surgical care for all.

Cost-effectiveness of Dental Surgery Procedures: A Call for Strengthening the Evidence: Reply

We thank Benzian and Neiderman [1] for their comments regarding the lack of evidence for the cost-effectiveness of dental surgery in the literature in their response to our article [2]. Indeed, neglect of cases requiring immediate dental extraction is an important cause of sepsis in lowand middleincome countries (LMICs) which can ultimately be life threatening. As part of the International Collaboration of Essential Surgery, we believe that essential surgical procedures, defined as simple interventions that save lives and prevent disability, should be available and accessible to all, and that includes dental extraction for neglected caries. We agree with their call for more cost-effectiveness studies to be done on tooth extraction to dispel the myths that surgical interventions are costly. We also call again for more studies to be done on the cost-effectiveness of other neglected simple surgical interventions for common disabling and life-threatening surgical conditions. We note an increasing interest in atraumatic restorative treatment for dental caries, which removes the need for drills, electricity, or running water and which has been specifically developed for LMICs [3]. Studies on comparative costs and benefits of this technique are also apposite. We join with Benzian and Neiderman in calling for the inclusion of basic oral surgery in the armamentarium of Essential Surgeons.

Adhesive Bowel Obstruction: Letter to the Editor

Dear Sir, I read with interest the article by Butt et al. [1] regarding the rare but possible relevance of de novo adhesional bowel obstruction, i.e., cases of small bowel occlusion arising without previous abdominal surgery. In a study performed in Bulawayo, Zimbabwe [2], the pattern of small bowel obstruction changed with cases caused by postoperative adhesions becoming much more frequent than those due to inguinal hernia. However, a significant number of cases of small bowel obstruction in young women was found to be due to previous pelvic sepsis (PID) treated conservatively with antibiotics. This remains a considerable problem in resource-poor countries. An important impression was that de novo small bowel obstruction in men warranted early exploration because significant pathology was found in almost all cases. This message remains important in those circumstances where access to sophisticated scanning methods is unavailable. Of course, it goes without saying that even more careful inspection of the abdomen is necessary in today’s patient who may have had laparoscopic surgery with hardly any external scarring. Moreover, pervaginal or pergastric surgery leaves entirely no trace, thus forcing the examiner to rely on the patient’s own recollection or records or those of his relatives.