PURPOSESurgery provides vital services to diagnose, treat, and palliate patients suffering from malignancies. However, despite its importance, there is little information on the delivery of surgical oncology services in Tanzania.METHODSOperative logbooks were reviewed at all national referral hospitals that offer surgery, all zonal referral hospitals in Mainland Tanganyika and Zanzibar, and a convenience sampling of regional referral hospitals in 2022. Cancer cases were identified by postoperative diagnosis and deidentified data were abstracted for each cancer surgery. The proportion of the procedures conducted for patients with cancer and the total number of cancer surgeries done within the public sector were calculated and compared with a previously published estimate of the surgical oncology need for the country.RESULTSIn total, 69,195 operations were reviewed at 10 hospitals, including two national referral hospitals, five zonal referral hospitals, and three regional referral hospitals. Of the cases reviewed, 4,248 (6.1%) were for the treatment of cancer. We estimate that 4,938 cancer surgeries occurred in the public sector in Tanzania accounting for operations conducted at hospitals not included in our study. Prostate, breast, head and neck, esophageal, and bladder cancers were the five most common diagnoses. Although 387 (83%) of all breast cancer procedures were done with curative intent, 506 (87%) of patients with prostate and 273 (81%) of patients with esophageal cancer underwent palliative surgery.CONCLUSIONIn this comprehensive assessment of surgical oncology service delivery in Tanzania, we identified 4,248 cancer surgeries and estimate that 4,938 likely occurred in 2022. This represents only 25% of the estimated 19,726 cancer surgeries that are annually needed in Tanzania. These results highlight the need to identify strategies for increasing surgical oncology capacity in the country.

Introduction: Gastric cancer (GC) is the third leading cause of global cancer-related mortality. Despite the shifting burden of GC to low-and middle-income countries, the data regarding incidence, treatment, and outcomes in these settings are sparse. The primary aim of this systematic review was to aggregate all available data on GC in sub-Saharan Africa (SSA) to describe the variability in incidence across the region. Methods: Studies reporting population-based primary data on GC in SSA were considered. The inclusion was limited to primary studies published between January 1995 and March 2022 which comprised of adult patients in SSA with GC. Studies without accessible full text in either French or English language were excluded. Unadjusted GC incidence rates with their standard errors for each study were recalculated from the crude numerators and denominators provided in individual studies. Results: A total of 5,626 articles were identified in the initial search, of which, 69 studies were retained. Reported incidence rates ranged from a high of 5.56 GC cases per 100,000 in Greater Meru Kenya to a low of 0.04 GC cases per 100,000 people in Benin City Nigeria. The overall crude pooled incidence was 1.20 GC cases per 100, 000 (95%CI 1.15-1.26) with a variability of 99.83% (I-2 p < 0.001). From the 29 high-quality population-based registry studies the crude pooled incidence was 1.71 GC cases per 100,000 Conclusion: This systemic review demonstrates that GC incidence is highly variable across SSA. The limited data on GC treatment, mortality, and survival presents a significant challenge to providing a complete epidemiologic description of the burden of GC in SSA. There is a need for further robust data collection, exploration, and research studies on cancer care in SSA, with continued assessment of primary data availability.

Systemic chemotherapy improves the survival of patients who undergo pancreatectomy, but whether chemotherapy should be delivered before or after surgery remains debated. At The University of Texas MD Anderson Cancer Center, localized pancreatic ductal adenocarcinoma (PDAC) has been preferentially treated with preoperative therapy—a practice supported by a robust history of institutional and national trials. In the following review, we discuss the historical use of perioperative therapy, our experience with it at MD Anderson Cancer Center and internationally, and the future of treatment and trials for PDAC.

BACKGROUND:The Lancet Commission on Global Surgery recommended 5000 operations/100,000 persons annually, but did not define condition-specific guidelines. New Zealand, Lancet Commission on Global Surgery's benchmark country, documented 1158 trauma operations/100,000 persons, providing a benchmark for trauma surgery needs. We sought to determine Ghana's annual trauma operation rate compared with this benchmark.METHODS:Data on all operations performed in Ghana from June 2014 to May 2015 were obtained from representative sample of 48/124 district (first level), 8/11 regional, and 3/5 tertiary hospitals and scaled up for nationwide estimates. Trauma operations were grouped by hospital level and categorized into "essential" (most cost-effective, highest population impact) versus "other" (specialized) as per the World Bank's Disease Control Priorities Project. Ghana's annual trauma operation rate was compared with the New Zealand benchmark to quantify current met needs for trauma surgery.RESULTS:About 232,776 operations were performed in Ghana; 35,797 were for trauma. Annual trauma operation rate was 134/100,000 (95% UI: 98-169), only 12% of the New Zealand benchmark. District hospitals performed 62% of all operations in the country, but performed only 38% of trauma operations. Eighty seven percentage of trauma operations were deemed "essential". Among specialized trauma operations, only open reduction and internal fixations had even modest numbers (3483 operations). Most other specialized trauma operations were rare.CONCLUSIONS:Ghana has a large unmet need for operative trauma care. The low percentage of trauma operations in district hospitals indicates an even greater unmet need in rural areas. Future global surgery benchmarking should consider benchmarks for trauma and other specialties, as well as for different hospital levels.

The Lancet Commission on Global Surgery proposed 5000 operations/100,000 people annually as a benchmark for developing countries but did not define benchmarks for different age groups. We evaluated the operation rate for elderly patients (≥65 years) in Ghana and estimated the unmet surgical need for the elderly by comparison to a high-income country benchmark. Data on operations performed for elderly patients over a 1-year period in 2014-5 were obtained from representative samples of 48/124 small district hospitals and 12/16 larger referral hospitals and scaled-up for nationwide estimates. Operations were categorized as essential (most cost-effective, highest population impact) versus other according to The World Bank’s Disease Control Priority project (DCP-3). Data from New Zealand’s National Minimum Dataset were used to derive a benchmark operation rate for the elderly. 16,007 operations were performed for patients ≥65 years. The annual operation rate was 1744/100,000 (95% UI 1440–2048), only 12% of the New Zealand benchmark of 14,103/100,000. 74% of operations for the elderly were in the essential category. The most common procedures (15%) were for urinary obstruction. 58% of operations were performed at district hospitals; 54% of these did not have fully-trained surgeons. Referral hospitals more commonly performed operations outside the essential category. The operation rate was well beneath the benchmark, indicating a potentially large unmet need for Ghana’s elderly population. Most operations for the elderly were in the essential category and delivered at district hospitals. Future global surgery benchmarking should consider specific benchmarks for different age groups.

Importance Surgeons are increasingly interested in using mobile and online applications with wound photography to monitor patients after surgery. Early work using remote care to diagnose surgical site infections (SSIs) demonstrated improved diagnostic accuracy using wound photographs to augment patients’ electronic reports of symptoms, but it is unclear whether these findings are reproducible in real-world practice. Objective To determine how wound photography affects surgeons’ abilities to diagnose SSIs in a pragmatic setting. Design, Setting, and Participants This prospective study compared surgeons’ paired assessments of postabdominal surgery case vignettes with vs without wound photography for detection of SSIs. Data for case vignettes were collected prospectively from May 1, 2007, to January 31, 2009, at Erasmus University Medical Center, Rotterdam, the Netherlands, and from July 1, 2015, to February 29, 2016, at Vanderbilt University Medical Center, Nashville, Tennessee. The surgeons were members of the American Medical Association whose self-designated specialty is general, abdominal, colorectal, oncologic, or vascular surgery and who completed internet-based assessments from May 21 to June 10, 2016. Intervention Surgeons reviewed online clinical vignettes with or without wound photography. Main Outcomes and Measures Surgeons’ diagnostic accuracy, sensitivity, specificity, confidence, and proposed management with respect to SSIs. Results A total of 523 surgeons (113 women and 410 men; mean [SD] age, 53 [10] years) completed a mean of 2.9 clinical vignettes. For the diagnosis of SSIs, the addition of wound photography did not change accuracy (863 of 1512 [57.1%] without and 878 of 1512 [58.1%] with photographs). Photographs decreased sensitivity (from 0.58 to 0.50) but increased specificity (from 0.56 to 0.63). In 415 of 1512 cases (27.4%), the addition of wound photography changed the surgeons’ assessment (215 of 1512 [14.2%] changed from incorrect to correct and 200 of 1512 [13.2%] changed from correct to incorrect). Surgeons reported greater confidence when vignettes included a wound photograph compared with vignettes without a wound photograph, regardless of whether they correctly identified an SSI (median, 8 [interquartile range, 6-9] vs median, 8 [interquartile range, 7-9]; P < .001) but they were more likely to undertriage patients when vignettes included a wound photograph, regardless of whether they correctly identified an SSI. Conclusions and Relevance In a practical simulation, wound photography increased specificity and surgeon confidence, but worsened sensitivity for detection of SSIs. Remote evaluation of patient-generated wound photographs may not accurately reflect the clinical state of surgical incisions. Effective widespread implementation of remote postoperative assessment with photography may require additional development of tools, participant training, and mechanisms to verify image quality.

Capacity assessments serve as surrogates for surgical output in low- and middle-income countries where detailed registers do not exist. The relationship between surgical capacity and output was evaluated in Ghana to determine whether a more critical interpretation of capacity assessment data is needed on which to base health systems strengthening initiatives.

Objective: To evaluate the operation rate in Ghana and characterize it by types of procedures and hospital level. Background: The Lancet Commission on Global Surgery recommended an annual rate of 5000 operations/100,000 people as a benchmark at which low- and middle-income countries could achieve most of the population-wide benefits of surgery, but did not define procedure-type benchmarks. Methods: Data on operations performed from June 2014 to May 2015 were obtained from representative samples of 48 of 124 district-level (first-level) hospitals, 9 of 11 regional (referral) hospitals, and 3 of 5 tertiary hospitals, and scaled-up to nationwide estimates. Operations were categorized into those deemed as essential procedures (most cost-effective, highest population impact) by the World Bank's Disease Control Priorities Project versus other. Results: An estimated 232,776 [95% uncertainty interval (95% UI) 178,004 to 287,549] operations were performed nationally. The annual rate of operations was 869 of 100,000 (95% UI 664 to 1073). The rate fell well short of the benchmark. 77% of the estimated annual national surgical output was in the essential procedure category. Most operations (62%) were performed at district-level hospitals. Most district-level hospitals (54%) did not have fully trained surgeons, but nonetheless performed 36% of district-level hospital operations. Conclusion: The operation rate was short of the Lancet Commission benchmark, indicating large unmet need, although most operations were in the essential procedure category. Future global surgery benchmarking should consider both total numbers and priority levels. Most surgical care was delivered at district-level hospitals, many without fully trained surgeons. Benchmarking to improve surgical care needs to address both access deficiencies and hospital and provider level.

PURPOSE:Urgent appendectomy has long been the standard of care for acute appendicitis. Six randomized trials have demonstrated that antibiotics can safely treat appendicitis, but approximately 1 in 4 of these patients eventually requires appendectomy. Overall treatment success may be limited by complex disease including perforation. Patients׳ success on antibiotic therapy may depend on preoperative identification of complex disease on imaging. However, the effectiveness of computed tomography (CT) in differentiating complex disease including perforated from nonperforated appendicitis remains to be determined. The purpose of this study was to assess the preoperative diagnostic accuracy of CT in determining appendiceal perforation in patients operated for acute appendicitis.METHODS:We performed a retrospective review of pathology and radiology reports from consecutive patients who presented to the emergency department with suspicion for acute appendicitis between January 2012 and May 2015. CT scans were re-reviewed by abdominal imaging fellowship-trained radiologists using standardized criteria, and the radiologists were blinded to pathology and surgical findings. Radiologists specifically noted presence or absence of periappendiceal gas, abscess, appendicolith, fat stranding, and bowel wall thickening. The overall radiologic impression as well as these specific imaging findings was compared to results of pathology and operative reports. Pathology reports were considered the standard for diagnostic accuracy.RESULTS:Eighty-nine patients (65% male, average age of 34 years) presenting with right lower quadrant pain underwent CT imaging and prompt appendectomy. Final pathology reported perforation in 48% (n = 43) of cases. Radiologic diagnosis of perforation was reported in 9% (n = 8), correctly identifying perforation in 37.5% (n = 3), and incorrectly reporting perforation in 62.5% of nonperforated cases per pathology. Radiology missed 93% (n = 40) of perforations postoperatively diagnosed by pathology. There was no secondary finding (fat stranding, diameter >13mm, abscess, cecal wall thickening, periappendiceal gas, simple fluid collection, appendicolith, and phlegmon) with a clinically reliable sensitivity or specificity to predict perforated appendicitis. Surgeon׳s report of perforation was consistent with the pathology report of perforation in only 28% of cases.CONCLUSIONS:The usefulness of a CT for determining perforation in acute appendicitis is limited, and methods to improve precision in identifying patients with complicated appendicitis should be explored as this may help for improving risk prediction for failure of treatment with antibiotic therapy and help guide patients and providers in shared decision-making for treatment options.

IMPORTANCE Clinician miscommunication contributes to an estimated 250 000 deaths in US hospitals per year. Efforts to standardize handoff communication may reduce errors and improve patient safety. OBJECTIVE To determine the effect of a standardized handoff curriculum, UW-IPASS, on interclinician communication and patient outcomes. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized stepped-wedge randomized clinical trial was conducted from October 2015 to May 2016 at 8 medical and surgical intensive care units at 2 hospital systems within an academic tertiary referral center. Participants included residents, fellows, advance-practice clinicians, and attending physicians (n = 106 clinicians, with 1488 handoff events over 8 months) and data were collected from daily text message-based surveys and patient medical records. EXPOSURES The UW-IPASS standardized handoff curriculum MAIN OUTCOMES AND MEASURES The primary aim was to assess the effect of the UW-IPASS handoff curriculum on perceived adequacy of interclinician communication. Patient days of mechanical ventilation, intensive care unit length of stay, reintubations within 24 hours, and order workflow patterns were also analyzed. Mixed-effects logistic regression was used to compute odds ratios and confidence intervals with adjustment for location, time period, and clinician. RESULTS A total of 63 residents and advance practice clinicians. 13 fellows, and 30 attending physicians participated in the study. During the control period, clinicians reported being unprepared for their shift because of a poor-quality handoff in 35 of 343 handoffs (10.2%), while UW-IPASS-period residents reported being unprepared in 53 of 740 handoffs (7.2%) (odds ratio, 0.19; 95% CI, 0.03-0.74; P = .03). Compared with the control phase, the perceived duration of handoffs among clinicians using UW-IPASS was unchanged (+5.5 minutes; 95% CI, 0.34-9.39; P = .30). Early morning order entry decreased from 106 per 100 patient-days in the control phase to 78 per 100 patient-days in the intervention period (-28 orders; 95% CI, -55 to -4; P = .04). Overall, UW-IPASS was not associated with any changes in intensive care unit length of stay, duration of mechanical ventilation, or the number of reintubations. CONCLUSIONS AND RELEVANCE The UW-IPASS standardized handoff curriculum was perceived to improve intensive care provider preparedness and workflow. IPASS-based curricula represent an important step forward in communication standardization efforts and may help reduce communication errors and omissions.

Background and ObjectivesOutcome data after surgery for cancer in Sub‐Saharan Africa are insufficient. We aimed to describe the presentation and outcomes of patients with solid cancers managed at a tertiary hospital in Ghana.MethodsRecords of cancer patients admitted to Komfo Anokye Teaching Hospital general surgery wards from 2013 to 2016 were reviewed for data on presentation, staging, management, and mortality. Patients discharged alive were followed‐up by biannual telephone calls to establish their postdischarge status. Survival analysis was performed for patients with pathologic or radiologic confirmation of cancer and adequate staging.ResultsA total of 343 patients were included. Of these, 76% were female. The most common diagnoses were breast 136 (40%), foregut 70 (20%), and colorectal 63 (18%) cancers. Cancer diagnosis was confirmed by pathology or radiology in 281 (82%) patients, but only 112 (40%) had adequate staging. Seventy‐four (66%) patients were stage IV. Two‐year overall survival for all 343 patients was 22% to 69%, depending on cancer site. Among those with adequate staging who were alive after postoperative 90 days, 3‐year survival was similar for curative compared with palliative operations (P = 0.64).ConclusionsImproved capacity for both therapeutic and palliative cancer care is needed to achieve better outcomes by more appropriate allocation of surgery with respect to the goal of treatment.

PURPOSE:The burden of breast cancer continues to increase in low- and middle-income countries (LMICs), where women present with more advanced disease and have worse outcomes compared with women from high-income countries. In the absence of breast cancer screening in LMICs, patients must rely on self-detection for early breast cancer detection, followed by a prompt clinical diagnostic work-up. Little is known about the influence of religious beliefs on women's perceptions and practices of breast health.METHODS:A cross-sectional survey was administered to female members of Islamic and Christian organizations in Ghana. Participants were asked about their personal experience with breast concerns, knowledge of breast cancer, performance of breast self-examination, and experience with clinical breast exam.RESULTS:The survey was administered to 432 Muslim and 339 Christian women. Fewer Muslim women knew someone with breast cancer (31% v 66%; P < .001) or had previously identified a concerning mass in their breast (16% v 65%; P < .001). Both groups believed that new breast masses should be evaluated at clinic (adjusted odds ratio [AOR], 1.08; 95% CI, 0.58 to 2.01), but Muslim women were less likely to know that breast cancer can be effectively treated (AOR, 0.34; 95% CI, 0.23 to 0.50). Muslim women were less likely to have performed breast self-examination (AOR, 0.51; 95% CI, 0.29 to 0.88) or to have undergone clinical breast exam (AOR, 0.48; 95% CI, 0.27 to 0.84).CONCLUSION:Muslim women were found to be less likely to participate in breast health activities compared with Christian women, which highlights the need to consider how religious customs within subpopulations might impact a woman's engagement in breast health activities. As breast awareness initiatives are scaled up in Ghana and other LMICs, it is essential to consider the unique perception and participation deficits of specific groups.

Background: Cigarette smoking increases the risk of postoperative complications nearly 2fold. Preoperative smoking cessation programs may reduce complications as well as overall postoperative costs. We aim to create an economic evaluation framework to estimate the potential value of preoperative smoking cessation programs for patients undergoing elective colorectal surgery.Methods: A decision-analytic model from the payer perspective was developed to integrate the costs and incidence of 90-day postoperative complications and readmissions for a cohort of patients undergoing elective colorectal surgery after a smoking cessation program versus usual care. Complication, readmission, and cost data were derived from a cohort of 534 current smokers and recent quitters undergoing elective colorectal resections in Washington State's Surgical Care and Outcomes Assessment Program linked to Washington State's Comprehensive Hospital Abstract Reporting System. Smoking cessation program efficacy was obtained from the literature. Sensitivity analyses were performed to account for uncertainty.Results: For a cohort of patients, the base case estimates imply that the total direct medical costs for patients who underwent a preoperative smoking cessation program were on average $304 (95% CI: $40-$571) lower per patient than those under usual care during the first 90 days after surgery. The model was most sensitive to the odds of recent quitters developing complications or requiring readmission, and smoking program efficacy.Conclusions: A preoperative smoking cessation program is predicted to be cost-saving over the global postoperative period if the cost of the intervention is below $ 304 per patient. This framework allows the value of smoking cessation programs of variable cost and effectiveness to be determined. (C) 2017 Elsevier Inc. All rights reserved.

Gaskill, Cameron E. MD; Gyedu, Adam MD, MPH; Stewart, Barclay T. MD; Boakye, Godfred; Donkor, Peter; Quansah, Robert MD, PhD; Mock, Charles N. MD, PhD, MPH Author Information

Introduction Many low- and middle-income countries (LMICs) have a high prevalence of unmet surgical need. Provision of operations through surgical outreach missions, mostly led by foreign organizations, offers a way to address the problem. We sought to assess the cost-effectiveness of surgical outreach missions provided by a wholly local organization in Ghana to highlight the role local groups might play in reducing the unmet surgical need of their communities. Methods We calculated the disability-adjusted life years (DALY) averted by surgical outreach mission activities of ApriDec Medical Outreach Group (AMOG), a Ghanaian non-governmental organization. The total cost of their activities was also calculated. Conclusions about cost-effectiveness were made according to World Health Organization (WHO)-suggested parameters. Results We analyzed 2008 patients who had been operated upon by AMOG since December 2011. Operations performed included hernia repairs (824 patients, 41%) and excision biopsy of soft tissue masses (364 patients, 18%). More specialized operations included thyroidectomy (103 patients, 5.1%), urological procedures (including prostatectomy) (71 patients, 3.5%), and plastic surgery (26 patients, 1.3%). Total cost of the outreach trips was $283,762, and 2079 DALY were averted; cost per DALY averted was 136.49 USD. The mission trips were “very cost-effective” per WHO parameters. There was a trend toward a lower cost per DALY averted with subsequent outreach trips organized by AMOG. Conclusion Our findings suggest that providing surgical services through wholly local surgical mission trips to underserved LMIC communities might represent a cost-effective and viable option for countries seeking to reduce the growing unmet surgical needs of their populations.

LaGrone, Lacey N. MD, MPH; Parent, Brodie MD; Keller, Jonathan M. MD; Serina, Peter T. MD, MPH; Gaskill, Cameron E. MD; Albirair, Mohamed T. MBBS, MPH; Cuschieri, Joseph MD; Kritek, Patricia A. MD; Langdale, Lorrie A. MD, FACS Author Information

BACKGROUND: Postoperative surgical site infections (SSI) are common and costly. Most occur post discharge, and can result in potentially preventable readmission or unnecessary urgent evaluation. Mobile health approaches incorporating patient-generated wound photos are being implemented in an attempt to optimize triage and management. We assessed how adding wound photos to existing data sources modifies provider decision making. STUDY DESIGN: We used a web-based simulation survey using a convenience sample of providers with expertise in surgical infections. Participants viewed a range of scenarios, including surgical history, physical exam, and description of wound appearance. All participants reported SSI diagnosis, diagnostic confidence, and management recommendations (main outcomes) first without, and then with, accompanying wound photos. At each step, participants ranked the most important features contributing to their decision. RESULTS: Eighty-three participants completed a median of 5 scenarios (interquartile range 4 to 7). Most participants were physicians in academic surgical specialties (n = 70 [84%]). The addition of photos improved overall diagnostic accuracy from 67% to 76% (p < 0.001), and increased specificity from 77% to 92% (p < 0.001), but did not significantly increase sensitivity (55% to 65%; p = 0.16). Photos increased mean confidence in diagnosis from 5.9 of 10 to 7.4 of 10 (p < 0.001). Overtreatment recommendations decreased from 48% to 16% (p < 0.001), and undertreatment did not change (28% to 23%; p = 0.20) with the addition of photos. CONCLUSIONS: The addition of wound photos to existing data as available via chart review and telephone consultation with patients significantly improved diagnostic accuracy and confidence, and prevented proposed overtreatment in scenarios without SSI. Post-discharge mobile health technologies have the potential to facilitate patient-centered care, decrease costs, and improve clinical outcomes. ((C) 2016 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Gaskill, Cameron E. MD; Lordon, Ross; Cooper, Julie B. MPA; Lober, William MD; Evans, Heather L. MD, FACS Author Information