A Huge Peritoneal Inclusion Cyst Mimicking Peritoneal Tuberculosis: A Case Report

A Huge Peritoneal Inclusion Cyst Mimicking Peritoneal Tuberculosis: A Case Report
Simeon MaraDepartment of Internal Medicine, College of medicine and health sciences, Hawassa University, Hawassa, Ethiopia
, Yegzeru BeleteSchool of Medicine , College of medicine and health sciences, Hawassa University, Hawassa, Ethiopia
ybtmeat.1@gmail.com
, Abebaw AmareDepartment of Pathology, College of medicine and health sciences, Hawassa University, Hawassa, Ethiopia.
, Tinsae AmsaluKibru primary Hospital, Hawassa, Ethiopia
, Kifle AlamirewKibru primary Hospital, Hawassa, Ethiopia
, Eyasu EliasDepartment of General Surgery, Adare General Hospital, Hawassa, Ethiopia

Eastern Africa Ethiopia General surgery

Keywords: Cyst excision, peritoneal tuberculosis, peritoneal inclusion cysts, inflammatory disease of the pelvis
SUBMITTED: 19.05.2024 PEER REVIEWED IN: India, Zambia ACCEPTED: 17.06.2024 PUBLISHED: 19.06.2024
15 MEMBERS OF THE COMMUNITY CONTRIBUTED $76 TO MAKE THIS ARTICLE OPEN ACCESS FOR EVERYONE! THANK YOU
ABSTRACT
Peritoneal inclusion cysts are uncommon abdominopelvic cysts seen in middle aged women who have abdominopelvic surgery or inflammatory disease of the pelvis. Here, we present a case of a 35 -year-old male patient with a huge peritoneal inclusion cyst which mimicked and treated as tuberculosis for two and half months after he presented with progressive abdominal distention of 2-month duration with dull aching abdominal pain and early satiety. Later, diagnosis was made and treated with cyst excision by laparotomy and has no recurrence at nine months of follow up. A Peritoneal inclusion cyst can occur in a middle-aged male with no history of abdominal surgery or trauma. Peritoneal inclusion cysts are worthy to note in the differential diagnosis of abdominal mass and ascites.

Introduction

Peritoneal inclusion cysts (PICs) are benign multi-locular cysts that consist of reactive fluid localized between intra-peritoneal adhesions (1) . Although the pathogenesis of PICs is not well understood, they are thought to arise secondary to intra-abdominal inflammation and subsequent cyst formation. They usually present in women in the third and fourth decades of life with a history of prior pelvic or abdominal surgery and one statistical study showed peritoneal inclusion cysts occur in 2-6% of gynecologic operations (2).

Peritoneal inclusion cysts have no malignant potential, but there is a high rate of recurrence (1-3). They are uncommon in male patients, rather inclusion cysts do occur commonly in women of reproductive age (4). Here we report a rare huge peritoneal inclusion cyst in a middle-aged male patient who has neither history of abdominal surgery nor abdominal trauma.

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Case report

A 35-year-old male patient presented to our medical outpatient department with progressively increasing abdominal distention over a duration of two months, accompanied by dull, aching abdominal pain and early satiety. He reported easy fatigability and decreased appetite. For these complaints, he visited a nearby health facility where he was started on anti-tuberculosis medications, which he took for two weeks. Due to persistent and worsening abdominal distention and tenseness, he visited another nearby health facility, where he was started on spironolactone and furosemide, considering chronic liver disease. Upon presentation to our hospital, he had discontinued the anti-TB medication and was taking spironolactone and furosemide. He complained of low-grade fever with increased sweating and weight loss. He was a social alcohol drinker but not to the extent of getting drunk. He discontinued alcohol consumption since the onset of the abdominal distention and pain. He has no known diagnosed medical illnesses previously, has had no abdominal surgery, and has no history of significant abdominal trauma. He is not a smoker and does not have a cough.

On physical examination, vital signs were stable. The patient had conjunctival pallor but no jaundice. Lung and cardiovascular examinations were normal. The remarkable physical finding was symmetrically tense abdominal swelling with flank fullness and dullness on percussion. A fluid thrill was positive. There was no peripheral edema or facial puffiness, but there was palmar pallor with preserved palmar creases.

His laboratory and imaging test results are as follows:

CBC showed moderate anemia, hemoglobin of 7.8 g/dl with an MCV of 75.3 fL, a platelet count indicating thrombocytosis of 542K/mL, and a WBC count of 6.2K/mL with normal differential percentages. ESR was 40, RBS was 118 mg/dL, ALT was 22 IU/ml, AST was 19 IU/ml, ALP was 163 IU/ml, total bilirubin was 0.8 mg/dL, direct bilirubin was 0.14 mg/dL, serum albumin was 5.56 g/dl, and serum total protein was 8.79 g/dl. Renal function tests were normal, and tests for HBV surface antigen and HCV antibody were negative. Serology for the HIV test was also negative. Urinalysis was negative for infection and proteinuria. Stool examination was normal, and the stool occult test for blood was negative. Peritoneal fluid analysis was performed, and the results are shown in Table 1.

Peritoneal fluid cytology showed a hemorrhagic background containing few mesothelial cells with admixed inflammatory cells. No foreign or malignant cells were seen.

Abdominopelvic ultrasound, conducted by a radiologist, concluded marked intraperitoneal free fluid collection with echo debris, multiple septations, and smooth peritoneal thickening. No enlarged abdominal lymph nodes were detected. The liver, spleen, and other solid organs were normal. The bowel loops and pelvic organs appeared normal.

With the ultrasound findings and peritoneal fluid analysis, which showed high protein and highly cellular fluid, and considering the high prevalence of tuberculosis in the locality, anti-TB treatment was continued. Three liters of hemorrhagic fluid were drained by paracentesis, and iron sulfate 325 mg, one tablet daily, was started. The patient was sent home with a one-month follow-up appointment.

On the second visit, the patient was taking anti-TB medication with pyridoxine and iron sulfate adherently. Repeat CBC showed improvement in hemoglobin to 10.2 g/dl, a mild subjective decrease in abdominal distention, and abdominal examination revealed a slight decrease in abdominal distention. A repeat abdominopelvic ultrasound showed findings similar to the previous scan. Anti-TB treatment was continued, and the patient was scheduled for another follow-up in one month.

On the third visit, the abdominal swelling had decreased slightly compared to previous visits and was localized to the periumbilical area. On physical examination, there was a large cystic swelling palpable in the center of the abdomen, as shown in Figure 1. The flanks were free, and shifting dullness was negative.

A repeat abdominopelvic ultrasound showed a large (24x15x22 cm) thick-walled intra-abdominal cystic mass with diffuse low-level internal echoes and multiple septations. The mass abutted the small bowel loops. There was no free peritoneal fluid collection. The recommendation was to perform an abdominopelvic CT scan with contrast.

A contrast-enhanced abdominopelvic CT scan showed a 23.2×13.8×18.8 cm well-defined, thin-walled, homogenous, near-water attenuating central abdominal intraperitoneal unilocular cystic mass lesion with internal septae but no calcification or solid component. There was no septal or wall enhancement. The mass had pushed the small bowel loops peripherally (see Figure 2).

With these findings, a surgical consultation was made. After obtaining patient consent, surgery was planned.

Under general anesthesia, through a midline vertical incision, the peritoneal cavity was entered, revealing a large intra-peritoneal cystic mass, as shown in Figure 3. The mass had some adherence to the walls of the small and large bowel and adhesions between the omentum and the cystic mass. There was no attachment to the pancreas. The adhesions were released, and the cyst was excised (see Figure 4) with sharp and blunt dissection. There was some leakage of the cyst content after removal. The specimen was sent for histopathology examination. The patient was discharged on the 4th postoperative day with no complications.

Microscopic examination showed the cyst was lined by flattened mesothelial cells with bland nuclei (see Figure 6), and there were scattered inflammatory cells in the edematous stroma between individual cysts (see Figure 7). The cyst wall examination showed scattered lymphocytes in collagenous stroma (see Figure 8).

With the above gross and microscopic examinations consistent with a peritoneal inclusion cyst, there was no evidence of malignancy.

On follow-up visits at 1 month, 6 months, and 9 months after surgery, the patient had no new complaints, and physical and ultrasound examinations were normal.

Table 1: Table 1- Peritoneal fluid analysis report
Parameter Result Normal range
Appearance Hemorrhagic Clear, pale yellow
Triglycerides 39 gm/dl < 50 mg/dl
LDH 1288 gm/dl < 200 U/L
Protein 6.54 gm/dl < 3.0 gm/dl
WBC 1400/mm3, N-69% and L-31% < 300/mm3
RBC 360/mm3 None
AFB Negative Sterile
Gram stain Negative Sterile
Figure 1: Centrally located abdominal mass, photo taken on the OR table patient lying on supine position.
Figure 2: (A)Axial (B)Coronal and (C) Sagittal contrast-enhanced abdominopelvic CT scan shows 23.2 x 13.8 x18.8 cm well-defined thin walled fluid attenuating central abdominal intra-peritoneal unilocular cystic mass lesion with internal septae (white arrows) but has no solid component
Figure 3: Intra-operative image of the mass.
Figure 4: Cystic mass after excision
Figure 5: 5A - Gross appearance of the excised cyst measuring 17x14x10cm unilocular cyst, 5B - Cut section of the resected cyst revealing turbid hemorrhagic fluid content and multiple septations projecting in to the lumen of the cyst.
Figure 6: Cyst lined by flattened mesothelial cells with bland nuclei (H&E-100X)
Figure 7: Scattered inflammatory cells in edematous stroma between individual cysts (H&E-40X)
Figure 8: Scattered lymphocytes are present in collagenous stroma of the cyst wall. (H&E-200X)
Discussion

Peritoneal inclusion cysts (PICs) are benign multilocular cysts that consist of reactive fluid localized between intraperitoneal adhesions (1). They usually present in women in the third and fourth decades of life with a history of prior pelvic or abdominal surgery, especially months to 20 years ago (2). PICs are complications after pelvic inflammatory disease, endometriosis, and radiotherapy, which allow the creation of adhesions. Also, trauma to the abdomen or inflammatory bowel disease can be a reason for peritoneal inclusion cysts(1). In one study, a history of insult to the peritoneum was found in 70.6% of patients with peritoneal inclusion cysts (3). Para-ovarian cysts, hydrosalpinx, and low-grade cystic mesothelioma are usually considered in the differential diagnosis of PICs in female patients (5).

There are case reports where peritoneal inclusion cysts mimicked malignant tumors like ovarian tumor (6). Peritoneal inclusion cysts are not common in male patients but they do occur(4) (7). Diagnosis can be difficult as symptoms are non-specific. Typical patient complaints include diffuse abdominal pain and pressure symptoms(4). Here we reported a huge peritoneal inclusion cyst which was misdiagnosed as peritoneal tuberculosis in a middle-aged Ethiopian male patient who has no history of abdominal surgery and has no reported trauma to the abdomen. Peritoneal tuberculosis is one of the extrapulmonary tuberculosis (EPTB) and accounts for about 4.8% of EPTB (8, 9). The clinical manifestations of peritoneal tuberculosis include progressive abdominal pain and distention with constitutional symptoms and weight loss, imaging tests can reveal particulate ascites with peritoneal thickening, intra-abdominal lymphadenopathies and ascitic fluid examination usually reveals lymphocytic dominant fluid with high protein level (10, 11). The diagnosis of peritoneal tuberculosis is always challenging because microbiologic and molecular test are not sensitive; studies showed the sensitivity of Ziehl Neelsen stain for acid-fast bacilli (AFB) from ascitic fluid is 0-6% (12). And that of gene X-pert MTB/RF ranges 8-50% (13). Because of the diagnostic challenges diagnosis and treatment of peritoneal tuberculosis rely on correlation of clinical presentation, imaging evidence, fluid analysis, ruling out other differential diagnoses and treatment response with empirical anti-tuberculosis therapy (14).  In our patient, the initial clinical presentation with progressive abdominal distention, pain and constitutional symptoms, particulate ascites on the abdominal ultrasonography, high protein content of the peritoneal fluid analysis (table 1) and the high prevalence of tuberculosis in the region lead to the empirical diagnosis of peritoneal tuberculosis and anti-tuberculosis medication initiation. But on the third follow-up visit, the physical examination showed localized abdominal swelling more in the center of the abdomen, and ultrasound and abdominal CT showed a large cystic mass with septations.

In this regard, the possibility of a spontaneously ruptured cyst filling the peritoneal cavity, which might have been resorbed later, might be the explanation for the initial physical findings and ultrasonography findings; but this remains speculation. Or the other way peritoneal tuberculosis can be the preceding event for formation of the peritoneal inclusion cyst and this needs further study.

Peritoneal inclusion cysts have negligible malignant potential, but there is a high rate of recurrence(1, 4). They can enlarge to significantly large size and can lead to intestinal obstruction (15). The studies available on PICs showed treatment is individualized based on the size of the cysts, patient desire and available interventions. Treatments include observation for small cysts, aspiration, and hormonal therapies for female patients and the definitive treatment is surgical excision either by laparoscopy or laparotomy (3)(6). Our patient is treated with an open laparotomy excision, and after 9 months of follow-up, there is no recurrence. This case report shows peritoneal inclusion cysts can be misdiagnosed as peritoneal tuberculosis and cross-sectional images have significant role in the diagnosis of PICs.

Conclusion

Even though PICs are encountered in adult female patients with previous abdominal surgery, trauma or inflammatory diseases of the pelvis, they are not common cause of abdominal swelling in male patients. Here we reported a case of a huge PIC in a middle-aged male patient who has no history of abdominal surgery or trauma. What makes our patient’s presentation unique include the initial finding of huge ascites which lead to wrong diagnosis as peritoneal tuberculosis and the huge size of the inclusion cyst compared to previous reports.

We described the clinical presentation, radiologic findings and histopathologic findings of a peritoneal inclusion cyst. Peritoneal inclusion cysts are worthy to note in the differential diagnosis of abdominal mass and ascites and further studies are required to confirm the mechanism of ascites formation in peritoneal inclusion cyst other than our hypothesis as rupture in to the peritoneal cavity with subsequent resorption.


REFERENCES
1. Natkanska A, Bizon-szpernalowska MA, Milek T, Sawicki W. Peritoneal inclusion cysts as a diagnostic and treatment challenge. 2021;92(8):583–6. [crossref]
2. Vallerie AM, Lerner JP, Wright JD, Baxi L V. Peritoneal Inclusion Cysts A Review. 2009;64(5). [crossref]
3. Chua HKA, Goh SYC, Upamali V, Seet MJ, Wong PCA, Phoon WLJ. Case Reports in Women ’ s Health Subserosal adenomyotic cysts and peritoneal inclusion cysts – Unusual differential diagnoses of multicystic pelvic masses : A review of two cases. Case Reports Women’s Heal [Internet]. 2020;27:e00193. [crossref]
4. Killoran C, Badri D, Walton A, Perry-keene J, Copertino N. International Journal of Surgery Case Reports Peritoneal inclusion cysts in a young male : A case report. Int J Surg Case Rep [Internet]. 2023;106(April):108248. [crossref]
5. Altamimi JO, Alzahrani EA, Fallatah A, Alhakami LA, Bokhari BE. Peritoneal Inclusion Cyst in a Young Patient With a Long History of Abdominal Surgeries : A Case Report Case Presentation. 2023;15(2):1–7. [crossref]
6. Singh A, Sehgal A, Mohan H. Multilocular peritoneal inclusion cyst mimicking an ovarian tumor : A case report. 2015;6(1):39–40. [crossref]
7. Maria A, Rapisarda C, Cianci A, Caruso S, Giovanni S, Valenti G, et al. Benign multicystic mesothelioma and peritoneal inclusion cysts : are they the same clinical and histopathological entities ? A systematic review to find an evidence ‑ based management. Arch Gynecol Obstet [Internet]. 2018; [crossref]
8. Peto HM, Pratt RH, Harrington TA, et al. Epidemiology of extrapulmonary tuberculosis in the United States, 1993-2006. Clin Infect Dis 2009;49:1350–7 [crossref]
9. Sophia De Saram JSF. Gastrointestinal and Peritoneal Tuberculosis. In: ASaH E, ed. Extrapulmonary tuberculosis. 1 ed. Springer International Publishing, 2019: 25–42
10. Sanai FM, Bzeizi KI. Systematic review: tuberculous peritonitis--presenting features, diagnostic strategies and treatment. Aliment Pharmacol Ther 2005;22:685–700 [crossref]
11. Kedar RP, Shah PP, Shivde RS, et al. Sonographic findings in gastrointestinal and peritoneal tuberculosis. Clin Radiol 1994;49:24–9 [crossref]
12. Uygur-Bayramicli O, Dabak G, Dabak R. A clinical dilemma: abdominal tuberculosis. World J Gastroenterol 2003;9:1098–101 [crossref]
13. Sharma SK, Kohli M, Chaubey J, et al. Evaluation of Xpert MTB/RIF assay performance in diagnosing extrapulmonary tuberculosis among adults in a tertiary care centre in India. Eur Respir J 2014;44:1090–3 [crossref]
14. Koff A, Azar MM. BMJ Case, Rep 2020;13:e233131. doi:10.1136/bcr-2019-23313
15. Ganesh VM. Peritoneal inclusion cyst resulting in intestinal obstruction: rare case report. Int Surg J 2016; 3:2341-2 [crossref]
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Built To Last: A Scoping Review Of Surgical Capacity Building Approaches In Conflict-affected Settings

Built To Last: A Scoping Review Of Surgical Capacity Building Approaches In Conflict-affected Settings
Kayla Pfeiffer-Mundt
, Sofia Wagemaker
, Alaa Ismail
, Lynette Dominguez
, Adam L Kushner
, Christopher Hooper Lane
, Kristin Long
longk@surgery.wisc.edu

Global General surgery | Other | Public health | Trauma and orthopaedics

Keywords: surgery, humanitarian, conflict, capacity
SUBMITTED: 01.03.2024 PEER REVIEWED IN: United Kingdom, Singapore, United States ACCEPTED: 22.03.2024 PUBLISHED: 22.03.2024
A PEER REVIEWER FOR THIS ARTICLE DONATED THEIR $10 BITCOIN CASH STIPEND TO Children's Surgical Centre, Cambodia!
6 MEMBERS OF THE COMMUNITY CONTRIBUTED $76 TO MAKE THIS ARTICLE OPEN ACCESS FOR EVERYONE! THANK YOU
ABSTRACT
Background: Access to safe surgery is a critical need in settings affected by armed conflict. Humanitarian organizations can temporarily fill gaps in facilities, supplies, and trained providers. However, it is critically important to build sustainable national surgical capacity as nations emerge from conflict and reconstruct society. We conducted a scoping review to synthesize the evidence on surgical capacity-building in conflict-affected settings with the goal of identifying gaps in the literature to better enable future international humanitarian organizations to support national partners in building capacity and promoting access to care. Materials and Methods: A systematic search of PubMed and Scopus was conducted, along with a review of grey literature published by surgical non-governmental organizations using keywords related to surgery, humanitarian work, and conflict settings. Results and Discussion: The literature search identified articles describing projects in general surgery, trauma, obstetrics and gynecology, cardiothoracic, vascular, ophthalmology, and reconstructive surgery across 32 countries. Capacity-building interventions identified included: one-off training sessions, on-the-job training, task-shifting, long-term skill-building projects, dedicated postgraduate training programs, and infrastructure support. Conclusions: Understanding which interventions are most effective for building long-term surgical capacity in conflict settings will require better data collection, evaluation, and sharing. The current literature does not reflect the full scope of work being conducted in the field. Organizations should ensure alignment with local needs via surgical needs assessments. Reporting on outcomes of capacity-building work was extremely limited, impeding future efforts to build surgical capacity in conflict-affected regions.

Introduction

As of 2019, approximately 80 million people were displaced from their homes due to conflict and 1.8 billion people lived in states prone to conflict. [1,2] Conflict has a profound impact on the health of a population, including death and disability, destruction of health infrastructure, and wide-spread displacement. [3] Acute surgical needs in conflicts include treatment of injuries and emergency procedures like C-sections.[4] In addition, baseline population surgical needs often go unmet and may become more complex due to delays in seeking care. Local health systems are unable to cope with demands for myriad reasons: surgical capacity is often low at baseline, existing facilities face threats of direct attack, infrastructure and supply chains are disrupted, and medical personnel may be killed or displaced.

In these settings, humanitarian organizations provide much-needed supplies, infrastructure, and human resources for surgical care. While these organizations are key for supplementing capacity acutely, they do not offer a long-term solution for limited surgical capacity. Funding is often for short-term projects and there is little local accountability. Disruptions in services are common when instability forces evacuation of international personnel. When humanitarian organizations leave due to instability or the end of the project, the burden of providing follow-up care and meeting ongoing population needs falls back upon the local health system.

While both humanitarian organizations and local actors play a key role in providing surgical care to populations affected by conflict, only local actors have a long-term role. Successful rebuilding of society post-conflict depends on a functioning local health care system. Basic surgical capability saves lives, improves quality of life, and is a cost-effective intervention in low-income contexts. [5] Determining the most effective methods of building surgical capacity in conflict-affected settings is undoubtedly complex, but has important long-term implications for populations affected by war.   Recognizing that there is a demonstrable gap in evidence on surgical capacity-building in conflict-affected settings and to identify gaps in the literature to direct future research, we sought to answer two distinct questions:  What models have been employed for partnership between international humanitarian organizations and local partners to improve the ability to provide surgical services in conflict-affected settings, and what evidence exists on the effectiveness of these partnerships in building capacity?

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Methodology

Search strategy

A systematic search was conducted using Pubmed and Scopus using keywords related to surgery, humanitarian work, and conflict settings. The search included all obtainable titles from 1990 to 2021.  One author (KPM) reviewed all titles and abstracts. Potentially relevant articles were sought for retrieval, and titles and abstracts of all articles cited in or citing these articles were also reviewed. Two authors (KPM and SW) independently read the full-text of all retrieved articles for inclusion (Table 1). All disagreements were resolved by consensus. A search of grey literature sources was also conducted, including Reliefweb, Medicines Sans Frontiers (MSF), and the International Committee of the Red Cross (ICRC) according to their website functionality.

Search Terms used for the review included the following:

Scopus: ((relief  W/3  work )  OR  humanitarian OR (capacity W/3 building)) AND  (surgical OR surgery OR surgeon OR  c-section OR cesarian OR cesarean OR caesarean) AND ((conflict*  W/3  setting*) OR warfare OR “armed conflict” OR “conflict zone” OR “war zone” OR “post-conflict” OR “post conflict”) – 1002 total (112 unique)

PubMed: (“relief work” OR  humanitarian OR “capacity building”) AND  (surgical OR surgery OR surgeon OR  c-section OR cesarian OR cesarean OR caesarean) AND ((conflict* AND setting*) OR warfare OR “armed conflict” OR “conflict zone” OR “war zone” OR “post-conflict” OR “post conflict”) – 165 (110 unique)

Study selection and definitions

The inclusion criteria were as follows: 1) the setting is a geographic area with ongoing or recent conflict or a population displaced by such a conflict, 2) the article must include an international nonmilitary organization providing humanitarian assistance, and 3) there must be local capacity-building related to surgical care. Only articles in English were included.

Articles were excluded if they were not written in English, could not be retrieved, were not set in a known conflict area, or did not include non-military organizations providing assistance to build local capacity specific to surgical care provisions.

Surgical care was defined as those procedures that occurred in an operating room with anesthesia. Capacity-building was defined based on the World Health Organization as:

“the development of knowledge, skills, commitment, structures, systems, and leadership to enable effective health promotion. It involves … advancement of knowledge and skills among practitioners [and] expansion of support and infrastructure for health promotion…” [6]

Two broad categories of capacity-building were identified: human capacity-building and infrastructure support. Human capacity-building included training related to surgery or surgical management, and infrastructure included providing non-disposable equipment, along with building or renovating hospitals and operating rooms.

While military organizations often provide surgical care in conflict, they were excluded because resources available are different and military objectives differ from humanitarian objectives. In describing the location as active conflict, post conflict, or displaced settings, descriptions from included articles were relied upon. However, it is important to note that there is often overlap as the line between active conflict and post-conflict is often blurred, and settings with refugee and internally displaced populations often experience considerable insecurity.

Analysis

Each article that met the inclusion criteria was read in its entirety and the following elements were extracted: humanitarian organization providing care, country, year published, author, title, setting (active conflict, post-conflict, or displaced), type of surgical services being provided, type of capacity-building, and measurements of impact.

Figure 1: Figure 1 – Search Results
Table 1: Locations and types of capacity-building by organization
Organization Contexts Locations Types of capacity-building Surgical Specialties
ICRC Active conflict, Displaced, Post-conflict Afghanistan, Chad, Columbia, DRC, Guinea, Lebanon, Egypt, Guinea-Bissau, Iraq, Jordan, Kenya, Libya, Mali, Myanmar, Nigeria, Palestine, Philippines, Russia, South Sudan, Syria, Somalia, Thailand War Surgery Seminars, On-the-job training (nurses, ancillary surgical staff, and doctors), postgraduate modules of war surgery training for residents, Infrastructure support (surgical equipment, operating theatres, a war surgery training center) Trauma, General, Orthopedic, Vascular
QRCS Active conflict Palestine Short training seminars (endoscopy and minimally invasive surgery), On-the-job training and supervision of physicians and, nurses, International postgraduate surgery training, Infrastructure support (medical equipment, specialized surgery building) General, Cardiothoracic, Urology, Vascular Surgery, Oncology
MSF Active Conflict, displaced Afghanistan, DRC, Chad, Liberia, Somalia, Angola, Haiti, Syria On-the-job training of physicians and nurses, task-shifting, Infrastructure support (building or renovating trauma center and O.R.s,) Trauma, general, obstetric, orthopedic
American University of Beirut Active Palestine Short-term training using telemedicine - virtually scrubbing with a portable tablet and providing real-time video and audio guidance Hand surgery
Operation Smile International Active Jordan Short-term training - transported Iraqi surgeons to view cleft lip/palate surgeries for educational purposes Plastic surgery - cleft lip / palate deformity corrective surgery
WHO Active Somalia Short-term training of doctors, nurses and midwives Trauma and OB
Columbia university mailman school for public health consortium Active Bosnia and Hergozovenia, Kenya, Liberia, Pakistan, Sierra Leone, Southern Sudan, Tanzania, Thailand, Uganda Short-term training of physicians, surgical technicians, and medical officers, Infrastructure improvements Obstetric
Medical Aid for Palestinians Active Lebanon Short-term training of doctors and nurses Trauma
Leonard Cheshire Centre of Conflict Recovery and Humar Charity Center Displaced Azerbaijan Training in management of surgical program with handover to local NGO General, obstetrics and gynecology, ENT, Ophthalmology
Shoklo malaria research unit/ aide medicale internationale Displaced Thailand Infrastructure - Establishment of a surgical service in a refugee camp Non-acute general and Ob/Gyn surgery
BethanyKids Displaced Kenya Passing expertise on to national pediatric surgeons through a disability-focused accredited pediatric surgery program Pediatric congenital and acquired surgical conditions (club foot, VP shunt, cleft lip, hypospadias, colostomy, dressing changes, contracture release)
American physicians sponsored by AHPBA, IHPBA, WSF, American Kurdish Medical Group Post Iraq Training of local surgeons including competency assessment, organization of academic surgical symposium, creation of renal transplant fellowship program, resourcing ang training on laparoscopic surgery, support of medical journal, General surgery including laparoscopic procedures, ob/gyn, renal transplant surgery, neurosurgery, oncology
Australian Aid / Royal Australian College of Surgeons Post Timor-Leste Local postgraduate training, specialty training outside country (via provision of foreign docs and scholarships), 15 years of sustained presence of resident surgeon to provide training and mentoring, training of returned specialists to be medical educators -> teaching hospital and ability of national university to provide postgraduate medical education Training by general surgeon, orthopedic, Ob/Gyn
Fred Hollows foundation new zealand, vision 2020/australian aid Post Timor-Leste International training (masters degree in medicine) and visiting specialist teams + expat advisor focused on training of local tertiary surgical staff. Also building an ophthalmology center and equipping it. Training of 20 mid-level eye care workers and 5 refractionists - mixture of cataract surgeons and general ophthalmologists Ophthalmologic - Eye / cataract surgery
German NGO Kindernothilfe, Deutche Diakonie, Nonprofit civil society group Health for the caucasus Post Russia Initial training of 2 surgeons in Germany , local surgeons assisted during in-country surgical trip - teams of two with additional surgeons observing. Seminars and hands-on training. The local surgeons progressively took on more responsibility so that 4 surgeons were enabled to perform and teach microsurgery interventions such as myringoplasties independently. Also purchase of specific equipment - operation microscope and other specialized equipment Plastic reconstructive surgery - Otologic microsurgery
Results

Search Results

The search in Scopus and PubMed resulted in 13 articles meeting inclusion criteria, and reference review yielded 11 additional articles. Forty-seven documents were identified from grey literature sources. Articles represented 32 different countries across Africa, the Middle East, Eurasia, Southeast Asia, Southeastern Europe and the Caribbean. See image 1 for a map.

The majority of sources (55) were active conflict settings, with 4 displacement settings (refugees or internally displaced), 8 post-conflict settings, and 4 articles with multiple groups represented. Surgical specialties included general, trauma, obstetrics and gynecology, cardiothoracic, vascular, urology, ophthalmology, otologic microsurgery, and reconstructive surgery.  See table 1 for locations and types of capacity-building by organization.

Types of Capacity-Building Interventions

Capacity-building interventions were classified as short-term training, long-term training, or infrastructure improvement. Humanitarian organizations often used a combination of capacity-building modalities based on context and project needs.

Short-term training

Short-term strategies used in humanitarian settings consisted of seminars or training workshops, on-the-job training, and task-shifting. A well-developed example of training seminars are War Surgery Seminars conducted by the ICRC. These are short (typically 3 day) courses focused on trauma surgery and treatment of war-wounded patients conducted in over 20 countries every year. [7] Training seminars have also been reported by other organizations in general surgery, emergency obstetric care, and endoscopy. [8–10]

Another short-term strategy employed by humanitarian organizations is on-the-job training as part of surgical outreach trips. Multiple organizations including the ICRC and Medical Aid for Palestinians have taught trauma management skills to doctors and nurses. [11–19] Medicines Sans frontiers (MSF) has trained local community members in basic surgical nursing skills, and Operation Smile International invited local Iraqi surgeons to observe cleft lip surgeries. [20,21] One notable example of on-the-job training was a collaboration between the American University of Beirut and a hospital in Gaza, Palestine in which virtual reality technology used to remotely ‘scrub-in’ to a complex hand reconstruction surgery and provide real-time audio and video guidance. [22]

A final modality used to build capacity in the short-term is task-shifting. Task-shifting redistributes activities from higher-level to lower-level clinicians and helps with appropriate human resource allocation. Both MSF and the ICRC have supported task-shifting of basic surgical services like wound debridement to non-surgeon physicians or nurses. [7,20,23] In addition, MSF has also relied on surgical nurses to perform emergency cesarian sections in conflict settings. [20]

Long-term projects focused on capacity

Long-term capacity-building efforts have occurred either in the context of dedicated training projects or in collaboration with accredited postgraduate training programs. Training as part of projects typically includes initial training in surgical skills and management practices with progressively increasing levels of responsibility. Seven projects focused on one surgical specialty including: general surgery, trauma surgery, orthopedic fracture management, otologic microsurgery, ophthalmology, and emergency obstetric care. [24–32] In contrast, two projects conducted integrated capacity-building broadly across many surgical specialties, and one project focused solely on management by training a local NGO to coordinate visiting doctors and surgical referrals from camp settings to secondary or tertiary care institutions. [33–35]

Organizations measured success in varying ways. Many reported that they handed day-to-day project management over to local counterparts, while only a few reported quality of care or other outcome measures. Only MSF reported patient outcomes, with continued low peri-operative mortality rates in Somalia even without in-person presence, and a decrease in amputation rates on orthopedic projects in the DRC and Afghanistan. [26,27] Two projects reported new access to specific surgical services. In the Russian North Caucuses, training in otologic microsurgery increased the number of surgeons in the region able to perform and teach microsurgery interventions from zero prior to the project to four afterwards. [28,29] Obstetric training in Ugandan and Tanzanian refugee settings resulted in the capacity to consistently perform C-sections where this service had not previously been available. [30] One project reported on cost-effectiveness, with Aide Medicale Internationale in Thailand demonstrating that providing non-urgent procedures like hernias, mass excisions, and elective sterilizations in camp settings can be more cost effective than referrals out-of-camp. [32]

Postgraduate training programs

A few organizations also supported accredited training programs. In-country training programs included: a fellowship program in transplant surgery in Iraqi Kurdistan, disability-focused pediatric surgical training in Kenya, and ICRC postgraduate war surgery training in sub-Saharan Africa, Columbia, Lebanon, Egypt, Syria, and Gaza. [7,33,36] Other programs funded accredited training conducted partially or fully in neighboring countries. The Qatari Red Crescent Society funded Palestinian doctors for 4-5 years of postgraduate studies in general surgery in Qatar or Jordan. [37] In ophthalmology, the Royal Australasian College of Surgeons and Fred Hollows Foundation of New Zealand worked with national actors in Timor-Leste to establish a postgraduate diploma of ophthalmology at the national university, with supplemental training in Australia, Fiji, and Nepal. [31] Also in Timor-Leste, Australian Aid and the Royal Australian College of Surgeons supported international training in general and orthopedic surgery in Papua New Guinea, Fiji, Indonesia, or Malaysia, with an eventual transition to developing and supporting new postgraduate courses at the national university. [38]

Infrastructure support

Infrastructure and equipment support is also important, as any previously existing infrastructure may have been destroyed by conflict or may have become unusable due to lack of repairs. A number of organizations provided infrastructure such as trauma centers, operating rooms, and specialized surgical equipment. [12,14,17,23,25,39–46] It is also critical to ensure that organizations ensure proper training to use specialized equipment that may be donated, and that necessary repairs can happen locally.

Figure 2: Fig 2: Geographic range of articles
Discussion

Current gaps in the literature

This review identified three key gaps in the literature to address in future surgical capacity-building work. One gap is a scarcity of needs assessments. With limited time and financial resources of humanitarian organizations, it is important to ensure that training and infrastructure are relevant to the needs of the population and skill level of healthcare workers. Nine articles reported conducting a needs assessment prior to starting projects to determine where gaps existed. [28–34,46,47] While additional projects may have conducted such assessments without reporting on it, it is entirely possible training provided in certain contexts is dependent on the experience of the organization rather than needs of the population. Greater clarity on context-specific needs would allow for better resource utilization.

Another gap is that published literature represents only a fraction of capacity-building work conducted in the field. Even when organizations report training efforts, the descriptions are vague and others are unlikely to be able to replicate activities. None of the articles in this review reported specific curricula used in training workshops or other activities. The lack of available information on project activities means there is potential for duplication of efforts between organizations. Making training efforts and curriculum content available would be beneficial for other organizations conducting similar work. Remedying this lack of available information will require commitment from organizations involved in the humanitarian response and mechanisms to share across contexts, likely facilitated by the World Health Organization or UN Humanitarian Cluster system.

A third issue is a lack of consensus on how to measure impact of capacity-building and a scarcity of evaluations. In the short-term, training workshops and seminars have an important role in continuing the medical education of providers, but take time away from clinical practice, so it is important to ensure trainings are needed and useful. While many projects reported on the number of healthcare workers attending trainings, only two projects mentioned competency assessment following such courses. [33,48] In reviewing these efforts, we propose that one-off workshops and short training courses have clearly stated learning objectives, aim to integrate with broader capacity-building strategies when possible, and evaluate and publish training results.

Since the limitations on travel imposed during the COVID pandemic, numerous strategies have been proposed to support local programs.  These include, but are not limited to, efforts such as open educational resources, synchronous/asynchronous support, and formal evaluations of local surgical team expertise.  There is very little data reported on the optimal use of any of these strategies, and ongoing research in this area is paramount for both academic institutions and non-governmental organizations.

For longer-term projects, there is also a lack of clarity on key outcomes. The ability to hand over to local staff is certainly important and was mentioned in a number of articles, however only two projects reported on patient quality of care outcomes following this handover. In addition, there were no capacity-building outcomes reported that were common across projects, which limits the ability for future projects to learn from successes and setbacks. We propose the development of common data metrics between organizations in the following domains, with the recognition that measures could certainly be expanded depending on project goals:

  1. Availability of surgical procedures in project region, particularly those that should be standard at the primary healthcare level. The ability of hospitals to perform cesarian deliveries, laparotomy, and treatment of open fractures (Bellweather Procedures) have previously been proposed for monitoring essential services in low and middle-income countries, and are likely applicable to many conflict-affected settings. [49]
  2. Patient outcome measurements including infection rates, intraoperative and post-operative mortality rates.
  3. Local project ownership and integration with any national training programs.
  4. Retention of trained staff in healthcare sector in country, given that brain-drain is a recognized challenge in many contexts.

There are a number of limitations of this scoping review. First, the limited literature available in peer-reviewed journals led to a reliance on grey literature. Grey literature sources are commonly published by humanitarian organizations who may be hesitant to report negative project outcomes. In addition, only articles explicitly describing the setting as conflict-related were included. This means there were likely interventions in countries experiencing conflict, recovering from a conflict, or hosting displaced populations that were not identified. The scarcity of interventions in post-conflict and refugee settings underlines the huge need for additional research in these settings, even compared to available literature on active conflict settings. Additionally, the language was limited to English and there may be other articles in French, Arabic, or other languages that would add to findings.

Conclusion

Various strategies have been used for capacity-building in conflict-affected settings, including short-term seminars, on-the-job training, task-shifting, dedicated long-term capacity projects, and formal accredited educational degrees. The majority of the available literature focuses on capacity-building in active conflict, although critical gaps remain for understanding the impact of such interventions. This review outlines three key gaps that must be addressed for more effective capacity-building work. First, organizations should ensure training programs align with local needs via surgical needs assessments. Second, greater publishing of capacity-building work and training methodologies would allow for greater collaboration and reduce duplication of efforts. Finally, common evaluation metrics would allow for learning from successes across projects. As instability and conflict continues to increase globally, international organizations must prioritize effective local capacity-building to ensure that those who need surgery are able to receive it.


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A Comparative Study of Ripasa Scoring System and Ultrasonography in the Clinical diagnosis of the Acute Appendicitis in Resource Limited Settings

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

A Comparative Study of Ripasa Scoring System and Ultrasonography in the Clinical diagnosis of the Acute Appendicitis in Resource Limited Settings

Warad Nikhil , Devani Kavin
Lokmanya Tilak Municipal Medical College, Mumbai, India

Background: Acute appendicitis is the commonest cause of acute abdominal pain in the surgical practice. Correct clinical diagnosis prevents unnecessary surgeries and complications. Various scoring systems are there to aid clinical diagnosis of the acute appendicitis.

Methods: A prospective observational study was carries out at the Department of Surgery, Lokmanya Tilak Municipal Medical College, Mumbai from February 2018 to December 2018. Demographic, clinical and laboratory investigations’ data was collected from consenting patients. The gold standard for the diagnosis was histopathological examination. The data was analyzed by IBM SPSS Statistics (2015). Sensitivity, specificity, accuracy and negative predictive value and positive predictive value (= precision) were compared.

Results: Majority of the patients with right iliac fossa pain were operated. RIPASA scores better than USG on all the 4 attributes viz. sensitivity (0.90 against 0.84), specificity (0.30 against 0.20), accuracy (0.80 against 0.73) and positive predictive value (= precision) (0.87 against 0.84). Conclusion: RIPASA is not only less reliant on the technology and skill but also better in guiding the prognosis. Thus, a useful tool in resource limited settings.

A New Innovation in Yogasan (A new Yogasan for quick relief of tension and sleeplessness)

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

A New Innovation in Yogasan (A new Yogasan for quick relief of tension and sleeplessness)

K C Sharma , Uma Sharma
Serv Sidhi Nursing Home, Udhampur, India

For relaxation of body & mind “SHAV ASAN” & “BALASAN” (Vishram Asan) have been well described & practiced. In today’s fast moving life, people want to put themselves to sleep quickly so that they relax fully & awake fresh for next work. Therefore to meet this requirement a modified Valasan has been introduced which quickly puts the body into complete relaxation followed by deep sleep in just 8 – 10 minutes at normal body & surrounding atmospheric temp depending upon weather. With deep sleep tension is obviously relieved.

Method: With appropriate routine pillow under the head, person lies down in Rt. Or left lateral position, flex the upper leg partially, and keep lower leg almost straight. Perineum is directed towards the bed. Weight of the Chest, abdomen & pelvis must fall anteriorly towards the bed. Keep neck on same side & face touching the bed, lower arm flexed at elbow & keep near the face resting on the bed, the upper hand be kept straight but relaxed just behind the greater trochanter of the femur i.e. highest point of hip in this position. Coordinate this position with mind and take one or two deep breath to go to sleep see photo I, II, III.

Expressed breast milk: Awareness and opinion on storage and utilization among mothers in tertiary health care center, Belagavi

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

Expressed breast milk: Awareness and opinion on storage and utilization among mothers in tertiary health care center, Belagavi

Reewen George D Silva
Belagavi Institute of Medical Sciences, Belagavi, India

Introduction: For newborns and infants, breast milk is the best source of nutrition. To achieve optimal growth & development and health, the infants should be exclusively breastfed for the first six months of life [1, 2]. Various pieces of research show that the first time mothers and working mothers become a prey for formula feeds due to structural functional limitations.

Methodology: Cross sectional study was conducted by recruiting 200 subjects through Nonprobability purposive sampling from a tertiary health care center in Belagavi. A Gravid women between age group of 18-45 yrs attending IPD, OPD & follow up care and able to read & write were recruited. The data was collected post Institutional Ethical committee clearance and individual subject consent using a questionnaire. It constituted sections such as Knowledge, Attitude, Practice and Opinion regarding EBM.

Results: The mean age of subjects 28.79 (± 7.02) years. About 119 (59.5%) have not heard about EBM. About 162 (81%) had no idea of storage. 50.2% expressed requirement of professional help. 117(57.9%) said that Expressing will increase the milk production. Opinion on acceptance and need, 126 (63%) were willing to donate EBM, 160 (80%) expressed a need for EBM Bank, 166 (83%) expressed need for availability at every hospital. However 159 (79.5%) said creating awareness and making it a reality is a need of the hour. A χ2 computed shows that there was a significant association with age p <0.032, religion p <0.001, educational level p<0.001, learned on usage of EBM p <0.001 and idea on how to store and utilize EBM p<0.001.

Discussion: A similar study which was conducted by Rai S. concluded that 36% of participants had adequate knowledge[3]. The study by Prabhu P et al also reported that the knowledge about methods of breast milk expression and storage was not satisfactory[4]. An educated woman had higher scores, which was also reported by Ekambaram M et al., [5] there was a significant difference among religion, age, educational level which was statistically significant, which might be attributed to social and multifactorial constraints.

Reverse Innovation in Healthcare from India

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

Reverse Innovation in Healthcare from India

Muthu Singaram
HTIC, IIT Chennai, Chennai, India

Introduction: This review paper explores the innovations in healthcare arising from India and how many of these can be applied to the theory of reverse innovation This study demonstrates how Indian researchers can play a major role in reverse innovation application in healthcare. What is reverse innovation also as Trickle-up Innovation? This was first coined by two Dartmouth University Professors Vijay Govindarajan and Chris Trimble and GE’s Jeffrey R. Immelt. Later Vijay Govindarajan and Chris Trimble published the book Reverse Innovation (2012), these are innovations first arising in the developing countries which are later introduced in the western or developed markets.

Methodology: This study is based on scholarly publication in major journals we have studies over 100 articles and selected 50 for the purpose of our study. We have built nine case studies based on these articles and reliable publicly available data. These case studies shows us that if these success stories are applied lot more of the innovation coming out of India can fall into the reverses innovation from frugal innovation by apply the three box framework which would lead to a larger usage of these innovations and further hence Indian innovations and economic.

Results: The review paper would describe 14 Indian reserve innovations and their benefits to the world at large. Discussion This review paper looks at reverse innovation targeted at providing goods and services to the poorest people in the world and this would fall in the area of strategy-based innovation. This review paper makes a case for the fastest-growing new markets and entrepreneurial opportunities being found among the billions of people `at the bottom of the income pyramid’. BOP proposes that there are tremendous benefits for multi-national companies who prefer to serve these markets in ways aware of their needs.

Keywords: Reverses Innovation, Healthcare, Frugal Innovations, Three-box Framework, Rural health, Process Innovation, Product Innovation, Strategy Innovation, Service Innovation

System Innovation in Laparoscopic Simulation Training for intra-corporeal tissue re-approximation, knot tying and suturing technologies

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

System Innovation in Laparoscopic Simulation Training for intra-corporeal tissue re-approximation, knot tying and suturing technologies

Murugankutty Gopalan
Amrita Institute of Medical Sciences, Kerala, India

Minimally invasive procedures rule the domain of surgery worldwide. The simulator-based training in psychomotor skills necessary for doing ‘Intra-corporeal tissue re-approximation’ remains, the hardest obstacle, the greatest challenge and barrier for all the budding laparoscopic surgeons across the globe; especially in the areas of knot tying and suture placement techniques. As a solution to this issue, we offer our newly developed- hustle free, “trainee end- tool kit- with direct 3D vision as well as the 2D camera vision, with which one can have their psychomotor skills up- gradation within the comforts of their own home.

“Learn from Home” is the proposed system innovation here: As a practical solution to address the above issues, we have developed ‘Learn from Home Gear’ consisting of a Box Simulator + 24 x7 hours of web-based mentorship in combination. The new simulator box is foldable, lightweight, with no cables attached. And a web-based self-monitoring system, consisting of easy to-follow instructions, and well-defined checkpoints for easy self mentoring. These teaching contents shall be circulated to the registered trainees as short video clips.

We have started this training program since the last 6 years, on “one to one basis”- in our Amrita Clinical Skill simulation center and found to be very effective. We would like to diffuse and scale up to the maximum by opening an avenue for sharing this knowledge to the surgical fraternity all over the world taking advantage of the advancement in information- technology, which in turn will result in enhancing the healing power for the patients even at the remotest corner of the globe. With this we could achieve our aim to establish the easiest , simplest, remote skill learning with checkpoint aided self mentoring – the proposed system innovation –“Learn from Home Gear in Laparoscopic Simulation ”

Music as an adjunct cost-effective therapeutic innovation for Management of Pain in Trauma Patients: A Systematic Review and Meta-analysis

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

Music as an adjunct cost-effective therapeutic innovation for Management of Pain in Trauma Patients: A Systematic Review and Meta-analysis

Pratyush Kumar , Oshin Puri, Yogesh Bahurupi
Dr Baba Saheb Ambedkar Medical College and Hospital, New Delhi, India; AIl India Institute of Medical Sciences, Rishikesh, India

Introduction: Music therapy reduces pain perceived, alleviates mood and promotes relaxation, regular breathing and rest. Being a readily available and inexpensive therapy, its efficacy for Management of Chronic Pain, such as that experienced by Trauma patients needs further exploration in low resource settings.

Objective: To determine the effectiveness of Music Therapy as an adjuvant therapeutic intervention in trauma patients of adult and pediatric age group in the pre and post procedural period.

Method: PubMed (n=175), Trip Medical Database (n=278) and ClinicalTrials.Gov (n=28) were searched for ‘Trauma’, ‘Music’ & ‘Pain’. Studies identified from inception were imported to EndNote X9 Library and duplicates removed. Only completed RCTs (Pubmed; n-16, TMD; n=2, CT.Gov; n=6) were screened using Title, Abstract and full text (n=41). Data extracted from 12 studies, was analyzed in Review Manager 5.4.

Result: Due to significant heterogeneity (Chi² = 365.17, P < 0.00001; I² = 97%), inverse variance random effect meta-analysis was done. Scores of the various pain measurement scales from a total of 852 patients from 12 studies revealed a pooled Standard Mean Difference of 0.31 [-0.61, 1.22]. Test for overall effect Z = 0.66 (P = 0.51) indicates that there is no significant difference in pain outcomes between Music Adjuvant therapy (MAT) Vs. Conventional Analgesic care. Subgroup analysis reveals a significant favor [Z = 1.18 (P = 0.24)] to MAT in patients of non-malignant pain of traumatic origin while in burn trauma patients it has no significant benefit [Z = 2.23 (P = 0.03)]. Similarly, as per pooled evidence, MAT is highly effective in the pediatric age group [Z = 1.00 (P = 0.32)] while no significant benefit in the adult age group [Z = 1.11 (P = 0.27)].

Conclusion: The pooled evidence suggests that both interventions significantly improve pain outcomes but Music therapy does not have any significant benefit over conventional therapy when compared as a whole. Although, in patients of non-malignant pain of traumatic origin, MAT has significantly high benefit while for Burn trauma patients, MAT has no proven significant benefit over conventional therapy. Evidence from the meta analysis indicates high efficacy of MAT in children while non such benefit can be proven in adult age group. Therefore, MAT could be a potential inexpensive therapeutic adjuvant in non-malignant pain of traumatic origin (for example post fracture reduction, post operative pain, etc.) and for pain management in children.

Designing Global Surgical Technology: Benefits of a Participatory Design Approach for the Surgeon

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

Designing Global Surgical Technology: Benefits of a Participatory Design Approach for the Surgeon

Tim Ho , Millie Marriot-Webb, William Bolton, Noel Aruparayil, Peter Culmer
University of Leeds, Leeds, United Kingdom

Introduction: Participatory Design (PD) is an approach to technology development that aims to improve outcomes through close and equal involvement of stakeholders in the development process. This approach is increasingly prevalent in medical technology development – particularly in Global Surgery and low-resource healthcare interventions, where understanding of the clinical context is vital to design. It has been argued that PD projects should prioritize participant outcomes alongside project objectives to ensure project longevity and success, yet there is a paucity of research regarding the impacts on clinical stakeholders, and how to optimise their collaboration. Better understanding of the benefits for clinical stakeholders will help facilitate these aims and promote better collaborations.

Methodology: Clinical stakeholders, involved in the development of the “RAIS” (Retractor for Abdominal Insufflation-less Surgery) device, were identified for interview. Semi-structured interviews were conducted with each participant to ascertain their personal motivations, experiences of multidisciplinary and international collaboration, and to explore any opportunities or skills that were developed. Personal frustrations and barriers to collaboration were identified and solutions to these concerns explored.

Results: Stakeholders unanimously prioritised clinical results over personal enrichment as the primary motivation for participation, though academic and career opportunities were recognised as key benefits. A non-hierarchical relationship between clinical and design teams allowed the clinicians to contribute and influence the design process to meet their specific needs as the device’s intended users. The geographical distance between teams and the lengthy design process were major sources of frustration. However, effective communication channels, and integration into design considerations, reduced miscommunication and enhanced contributions from the surgical team who were able to provide more detailed and valuable feedback.

Discussion: This study aims to catalyse further research to determine the ideal participant and project outcomes and the optimal approach to facilitate these. Key considerations for innovators considering using a PD approach include:
Project Conception:
1. Prioritize input from a variety of stakeholders based in LMIC’s in the initial design phase
2. Collaborate with local stakeholders throughout the design process to ensure continuity
3. Establish stakeholder-specific goals as part of the project’s objectives
Communication:
4. Communicate interactively to understand the context and form collaborative relationships with stakeholders
5. Espouse an ethos of equal stakeholdership to facilitate bi-directional information flow, encourage feedback and ensure participant motivations
6. Validate interventions with stakeholders in the contextual environment
Sustainability:
7. Support the development of innovation networks and capacities within LMIC’s
8. Empower stakeholders to innovate, collaborate and disseminate their knowledge
9. Employ formal PD frameworks to guide long-term and sustainable stakeholdership

Lumbar Disc Degeneration, A Transdifferentiation Process-An Electron Microscopic Observation

1st International Congress for Innovation in Global Surgery
ABSTRACT FIRST PRESENTED: 20.04.2022

Lumbar Disc Degeneration, A Transdifferentiation Process-An Electron Microscopic Observation

Prashant B Lakhe
GIPMER, New Delhi, India

Introduction: Lumbar disc degeneration (LDD)is a common condition which affects quality of life. Repeated trauma, ageing and stress predispose to LDD. However exact mechanism is not fully understood. Transdifferentiation refers to a process where a one mature cell switches its phenotype and function to that of another mature differentiated cell type. Such mechanisms have been described in repair following fracture of bones. In order to understand it better, we conducted an electron microscopic study to analyze if LDD is a transdifferentiation process.

Methodology: After institutional ethics committee approval, patients who presented with LDD were subjected to preoperative MRI. Failure of medical management, and occurrence of neurological deficits formed the indication for surgery. Discoidectomy was done by standard microscopic techniques and the disc material was examined under electron microscopy. The disc material was collected and labelled according to proximity to adjoining osteophyte formation. The electron microscopic findings were correlated with clinical and radiological observations.

Results: Study was conducted from Jan 2020 – Dec 2021. A total of 50 patients with 28 males ,22 females with a mean age of 47 years were studied. Majority of the patients(26) had a prolapse at L4- 5 level with the mean duration of symptoms being 12 months. 80 % of patients had a VAS score of 7 and 8. Maximum (72 %) patients showed a Pfirrmann grade 4 of degeneration on MRI and type 2 Modic changes (64 %). Ten patients(20%) showed presence of posterior osteophytes. Electron microscopy showed chondrocyte clustering in 92 % patients, collagen abnormalities in 66% and intracellular inclusions in 60%. Chondrone formation was seen in 12 patients. Patients with higher pain severity and longer duration of symptoms showed increased chondrocyte clustering. Osteophyte formation was seen in patients with longer duration of symptoms. All the patients with osteophytes showed presence of chondrones.

Discussion: LDD is a process which can be explained on electron microscopy. Higher VAS score and longer duration of symptoms results in more chondrocyte clustering. In addition, formation of osteophytes was always associated with chondrone formation. These findings support our hypothesis that lumbar disc degeneration is a transdifferentiation process.

Keywords: lumbar disc degeneration, transdifferentiation, chondrocyte clustering, chondrone