Artificial Intelligence and its role in surgical care in low-income and middle-income countries

ObjectiveThis systematic review aims to provide a summary of the use of real-time telementoring, telesurgical consultation and telesurgery in surgical procedures in patients in low/middle-income countries (LMICs).DesignA systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Collaboration published guidelines.Data sourcesEMBASE, MEDLINE, Cochrane, PubMed and Google Scholar were searched for original articles and case reports that discussed telementoring, telesurgery or telesurgical consultation in countries defined as low-income or middle-income (as per the World Banks’s 2021–2022 classifications) from inception to August 2021.Eligibility criteria for selecting studiesAll original articles and case reports were included if they reported the use of telemedicine, telesurgery or telesurgical consultation in procedures conducted on patients in LMICs.ResultsThere were 12 studies which discussed the use of telementoring in 55 patients in LMICs and included a variety of surgical specialities. There was one study that discussed the use of telesurgical consultation in 15 patients in LMICs and one study that discussed the use of telesurgery in one patient.ConclusionThe presence of intraoperative telemedicine in LMICs represents a principal move towards improving access to specialist surgical care for patients in resource-poor settings. Not only do several studies demonstrate that it facilitates training and educational opportunities, but it remains a relatively frugal and efficient method of doing so, through empowering local surgeons in LMICs towards offering optimal care while remaining in their respective communities.

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Innovative financing to fund surgical systems and expand surgical care in low-income and middle-income countries

BMJ Global Health ◽

10.1136/bmjgh-2020-002375 ◽

2020 ◽

Vol 5 (6) ◽

pp. e002375 ◽

Cited By ~ 1

Author(s):

Ché L Reddy ◽

Alexander W Peters ◽

Desmond Tanko Jumbam ◽

Luke Caddell ◽

Blake C Alkire ◽

...

Keyword(s):

Health Systems ◽

Low Income ◽

Critical Role ◽

Scale Up ◽

Surgical Care ◽

Healthcare Intervention ◽

Strengthen Health System ◽

Middle Income ◽

Middle Income Countries ◽

Fiscal Space

Strong surgical systems are necessary to prevent premature death and avoidable disability from surgical conditions. The epidemiological transition, which has led to a rising burden of non-communicable diseases and injuries worldwide, will increase the demand for surgical assessment and care as a definitive healthcare intervention. Yet, 5 billion people lack access to timely, affordable and safe surgical and anaesthesia care, with the unmet demand affecting predominantly low-income and middle-income countries (LMICs). Rapid surgical care scale-up is required in LMICs to strengthen health system capabilities, but adequate financing for this expansion is lacking. This article explores the critical role of innovative financing in scaling up surgical care in LMICs. We locate surgical system financing by using a modified fiscal space analysis. Through an analysis of published studies and case studies on recent trends in the financing of global health systems, we provide a conceptual framework that could assist policy-makers in health systems to develop innovative financing strategies to mobilise additional investments for scale-up of surgical care in LMICs. This is the first time such an analysis has been applied to the funding of surgical care. Innovative financing in global surgery is an untapped potential funding source for expanding fiscal space for health systems and financing scale-up of surgical care in LMICs.

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Perioperative mortality rates in low-income and middle-income countries: a systematic review and meta-analysis

BMJ Global Health ◽

10.1136/bmjgh-2018-000810 ◽

2018 ◽

Vol 3 (3) ◽

pp. e000810 ◽

Cited By ~ 19

Author(s):

Joshua S Ng-Kamstra ◽

Sumedha Arya ◽

Sarah L M Greenberg ◽

Meera Kotagal ◽

Catherine Arsenault ◽

...

Keyword(s):

Systematic Review ◽

Surgical Procedures ◽

Low Income ◽

Meta Analysis ◽

Surgical Care ◽

Low Income Countries ◽

Perioperative Mortality ◽

Middle Income ◽

Middle Income Countries ◽

Wide Range

IntroductionThe Lancet Commission on Global Surgery proposed the perioperative mortality rate (POMR) as one of the six key indicators of the strength of a country’s surgical system. Despite its widespread use in high-income settings, few studies have described procedure-specific POMR across low-income and middle-income countries (LMICs). We aimed to estimate POMR across a wide range of surgical procedures in LMICs. We also describe how POMR is defined and reported in the LMIC literature to provide recommendations for future monitoring in resource-constrained settings.MethodsWe did a systematic review of studies from LMICs published from 2009 to 2014 reporting POMR for any surgical procedure. We extracted select variables in duplicate from each included study and pooled estimates of POMR by type of procedure using random-effects meta-analysis of proportions and the Freeman-Tukey double arcsine transformation to stabilise variances.ResultsWe included 985 studies conducted across 83 LMICs, covering 191 types of surgical procedures performed on 1 020 869 patients. Pooled POMR ranged from less than 0.1% for appendectomy, cholecystectomy and caesarean delivery to 20%–27% for typhoid intestinal perforation, intracranial haemorrhage and operative head injury. We found no consistent associations between procedure-specific POMR and Human Development Index (HDI) or income-group apart from emergency peripartum hysterectomy POMR, which appeared higher in low-income countries. Inpatient mortality was the most commonly used definition, though only 46.2% of studies explicitly defined the time frame during which deaths accrued.ConclusionsEfforts to improve access to surgical care in LMICs should be accompanied by investment in improving the quality and safety of care. To improve the usefulness of POMR as a safety benchmark, standard reporting items should be included with any POMR estimate. Choosing a basket of procedures for which POMR is tracked may offer institutions and countries the standardisation required to meaningfully compare surgical outcomes across contexts and improve population health outcomes.

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Double standards in healthcare innovations: the case of mosquito net mesh for hernia repair

BMJ Innovations ◽

10.1136/bmjinnov-2020-000535 ◽

2020 ◽

pp. bmjinnov-2020-000535

Author(s):

Mark Skopec ◽

Alessandra Grillo ◽

Alvena Kureshi ◽

Yasser Bhatti ◽

Matthew Harris

Keyword(s):

Hernia Repair ◽

Low Income ◽

Low Cost ◽

Surgical Care ◽

Biomechanical Properties ◽

Double Standard ◽

Healthcare Sector ◽

Mosquito Net ◽

Middle Income ◽

Middle Income Countries

With over two decades of evidence available including from randomised clinical trials, we explore whether the use of low-cost mosquito net mesh for inguinal hernia repair, common practice only in low-income and middle-income countries, represents a double standard in surgical care. We explore the clinical evidence, biomechanical properties and sterilisation requirements for mosquito net mesh for hernia repair and discuss the rationale for its use routinely in all settings, including in high-income settings. Considering that mosquito net mesh is as effective and safe as commercial mesh, and also with features that more closely resemble normal abdominal wall tissue, there is a strong case for its use in all settings, not just low-income and middle-income countries. In the healthcare sector specifically, either innovations should be acceptable for all contexts, or none at all. If such a double standard exists and worse, persists, it raises serious questions about the ethics of promoting healthcare innovations in some but not all contexts in terms of risks to health outcomes, equitable access, and barriers to learning.

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Geospatial mapping to estimate timely access to surgical care in nine low-income and middle-income countries

The Lancet ◽

10.1016/s0140-6736(15)60811-x ◽

2015 ◽

Vol 385 ◽

pp. S16 ◽

Cited By ~ 15

Author(s):

Nakul P Raykar ◽

Alexis N Bowder ◽

Charles Liu ◽

Martha Vega ◽

Jong H Kim ◽

...

Keyword(s):

Low Income ◽

Surgical Care ◽

Middle Income ◽

Middle Income Countries ◽

Timely Access ◽

Geospatial Mapping

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Systematic Review of Barriers to Surgical Care in Low-Income and Middle-Income Countries

World Journal of Surgery ◽

10.1007/s00268-011-1010-1 ◽

2011 ◽

Vol 35 (5) ◽

pp. 941-950 ◽

Cited By ~ 179

Author(s):

Caris E. Grimes ◽

Kendra G. Bowman ◽

Christopher M. Dodgion ◽

Christopher B. D. Lavy

Keyword(s):

Systematic Review ◽

Low Income ◽

Surgical Care ◽

Middle Income ◽

Middle Income Countries

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Surgical care by non-surgeons in low-income and middle-income countries: a systematic review

The Lancet ◽

10.1016/s0140-6736(15)60837-6 ◽

2015 ◽

Vol 385 ◽

pp. S42 ◽

Cited By ~ 25

Author(s):

Marguerite Hoyler ◽

Lars Hagander ◽

Rowan Gillies ◽

Robert Riviello ◽

Kathryn Chu ◽

...

Keyword(s):

Systematic Review ◽

Low Income ◽

Surgical Care ◽

Middle Income ◽

Middle Income Countries

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Developing a Sustainable Program for Volunteer Surgical Care in Low-Income and Middle-Income Countries

Oral and Maxillofacial Surgery Clinics of North America ◽

10.1016/j.coms.2020.04.003 ◽

2020 ◽

Vol 32 (3) ◽

pp. 471-480

Author(s):

Vennila Padmanaban ◽

David Hoffman ◽

Shahid R. Aziz ◽

Ziad C. Sifri

Keyword(s):

Low Income ◽

Surgical Care ◽

Middle Income ◽

Middle Income Countries

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Improving outcomes for neonates with gastroschisis in low-income and middle-income countries: a systematic review protocol

BMJ Paediatrics Open ◽

10.1136/bmjpo-2018-000392 ◽

2018 ◽

Vol 2 (1) ◽

pp. e000392 ◽

Cited By ~ 5

Author(s):

Naomi J Wright ◽

Monica Langer ◽

Irena CF Norman ◽

Melika Akhbari ◽

Q Eileen Wafford ◽

...

Keyword(s):

Systematic Review ◽

Low Income ◽

Grey Literature ◽

Surgical Care ◽

Length Of Hospital Stay ◽

Review Literature ◽

Sub Saharan Africa ◽

Cochrane Library ◽

Middle Income ◽

Middle Income Countries

IntroductionThere is a significant disparity in outcomes for neonates with gastroschisis in high-income countries (HICs) compared with low-income and middle-income countries (LMICs). Many LMICs report mortality rates between 75% and 100% compared with <4% in HICs.AimTo undertake a systematic review identifying postnatal interventions associated with improved outcomes for gastroschisis in LMICs.Methods and analysisThree search strings will be combined: (1) neonates; (2) gastroschisis and other gastrointestinal congenital anomalies requiring similar surgical care; (3) LMICs. Databases to be searched include MEDLINE, EMBASE, Scopus, Web of Science, ProQuest Dissertations and Thesis Global, and the Cochrane Library. Grey literature will be identified through Open-Grey, ClinicalTrials.gov, WHO International Clinical Trials Registry and ISRCTN registry (Springer Nature). Additional studies will be sought from reference lists of included studies. Study screening, selection, data extraction and assessment of methodological quality will be undertaken by two reviewers independently and team consensus sought on discrepancies. The primary outcome of interest is mortality. Secondary outcomes include complications, requirement for ventilation, parenteral nutrition duration and length of hospital stay. Tertiary outcomes include service delivery and implementation outcomes. The methodology of the studies will be appraised. Descriptive statistics and outcomes will be summarised and discussed.Ethics and disseminationEthical approval is not required since no new data are being collected. Dissemination will be via open access publication in a peer-reviewed medical journal and distribution among global health, global surgery and children’s surgical collaborations and international conferences.ConclusionThis study will systematically review literature focused on postnatal interventions to improve outcomes from gastroschisis in LMICs. Findings can be used to help inform quality improvement projects in low-resource settings for patients with gastroschisis. In the first instance, results will be used to inform a Wellcome Trust-funded multicentre clinical interventional study aimed at improving outcomes for gastroschisis across sub-Saharan Africa.PROSPERO registration numberCRD42018095349.

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Lessons from developing, implementing and sustaining a participatory partnership for children’s surgical care in Tanzania

BMJ Global Health ◽

10.1136/bmjgh-2019-002118 ◽

2020 ◽

Vol 5 (3) ◽

pp. e002118 ◽

Cited By ~ 2

Author(s):

Godfrey Sama Philipo ◽

Shobhana Nagraj ◽

Zaitun M Bokhary ◽

Kokila Lakhoo

Keyword(s):

Low Income ◽

Surgical Care ◽

Health Coverage ◽

Middle Income ◽

Hospital Capacity ◽

Middle Income Countries ◽

Global Partnerships ◽

Poor Access ◽

Surgical Conditions ◽

Global Population

Global surgery is an essential component of Universal Health Coverage. Surgical conditions account for almost one-third of the global burden of disease, with the majority of patients living in low-income and middle-income countries (LMICs). Children account for more than half of the global population; however, in many LMIC settings they have poor access to surgical care due to a lack of workforce and health system infrastructure to match the need for children’s surgery. Surgical providers from high-income countries volunteer to visit LMICs and partner with the local providers to deliver surgical care and trainings to improve outcomes. However, some of these altruistic efforts fail. We aim to share our experience on developing, implementing and sustaining a partnership in global children’s surgery in Tanzania. The use of participatory methods facilitated a successful 17-yearlong partnership, ensured a non-hierarchical environment and encouraged an understanding of the context, local needs, available resources and hospital capacity, including budget constraints, when codesigning solutions. We believe that participatory approaches are feasible and valuable in developing, implementing and sustaining global partnerships for children’s surgery in LMICs.

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