Undergraduate Surgical Education: a Global Perspective

Undergraduate surgical education is failing to prepare medical students to care for patients with surgical conditions, and has been significantly compromised by the COVID-19 pandemic. We performed a literature review and undertook semi-structured reflections on the current state of undergraduate surgical education across five countries: Egypt, Morocco, Somaliland, Kenya, and the UK. The main barriers to surgical education at medical school identified were (1) the lack of standardised surgical curricula with mandatory learning objectives and (2) the inadequacy of human resources for surgical education. COVID-19 has exacerbated these challenges by depleting the pool of surgical educators and reducing access to learning opportunities in clinical environments. To address the global need for a larger surgical workforce, specific attention must be paid to improving undergraduate surgical education. Solutions proposed include the development of a standard surgical curriculum with learning outcomes appropriate for local needs, the incentivisation of surgical educators, the incorporation of targeted online and simulation teaching, and the use of technology.

Neurosurgery in Egypt from ancient Egyptians to Modern Neurosurgery, African Perspective

Neurosurgery has been practiced for more than 12,000 years worldwide. Cranial and transnasal approaches to the brain have been practiced for variable religious, mystical, or therapeutic purposes in ancient civilizations of Africa and specifically in Egypt (1). Ancient Egyptian medicine is documented in the paintings on the walls of temples and numerous papyri (figure 1) (2-4).

Ancient Egyptian medicine dates to 3500 BC when Athotis (Hor-Aha), the second king of the first dynasty, was found to have in his tomb the first “Book of the Dead” that was later quoted with modifications till it reached “Practical Medicine and Anatomic Book” in Ani’s papyrus

Postpartum infection, pain and experiences with care among women treated for postpartum hemorrhage in three African countries: A cohort study of women managed with and without condom-catheter uterine balloon tamponade

We aimed to determine the risk of postpartum infection and increased pain associated with use of condom-catheter uterine balloon tamponade (UBT) among women diagnosed with postpartum hemorrhage (PPH) in three low- and middle-income countries (LMICs). We also sought women’s opinions on their overall experience of PPH care.

This prospective cohort study compared women diagnosed with PPH who received and did not receive UBT (UBT group and no-UBT group, respectively) at 18 secondary level hospitals in Uganda, Egypt, and Senegal that participated in a stepped wedge, cluster-randomized trial assessing UBT introduction. Key outcomes were reported pain (on a scale 0–10) in the immediate postpartum period and receipt of antibiotics within four weeks postpartum (a proxy for postpartum infection). Outcomes related to satisfaction with care and aspects women liked most and least about PPH care were also reported.

Among women diagnosed with PPH, 58 were in the UBT group and 2188 in the no-UBT group. Self-reported, post-discharge antibiotic use within four weeks postpartum was similar in the UBT (3/58, 5.6%) and no-UBT groups (100/2188, 4.6%, risk ratio = 1.22, 95% confidence interval [CI]: 0.45–3.35). A high postpartum pain score of 8–10 was more common among women in the UBT group (17/46, 37.0%) than in the no-UBT group (360/1805, 19.9%, relative risk ratio = 3.64, 95% CI:1.30–10.16). Most women were satisfied with their care (1935/2325, 83.2%). When asked what they liked least about care, the most common responses were that medications (580/1511, 38.4%) and medical supplies (503/1511, 33.3%) were unavailable.

UBT did not increase the risk of postpartum infection among this population. Women who receive UBT may experience higher degrees of pain compared to women who do not receive UBT. Women’s satisfaction with their care and stockouts of medications and other supplies deserve greater attention when introducing new technologies like UBT.

Completeness of Medical Records of Trauma Patients Admitted to the Emergency Unit of a University Hospital, Upper Egypt

Trauma records in Egyptian hospitals are widely suspected to be inadequate for developing a practical and useful trauma registry, which is critical for informing both primary and secondary prevention. We reviewed archived paper records of trauma patients admitted to the Beni-Suef University Hospital in Upper Egypt for completeness in four domains: demographic data including contact information, administrative data tracking patients from admission to discharge, clinical data including vital signs and Glasgow Coma Scale scores, and data describing the causal traumatic event (mechanism of injury, activity at the time of injury, and location/setting). The majority of the 539 medical records included in the study had significant deficiencies in the four reviewed domains. Overall, 74.3% of demographic fields, 66.5% of administrative fields, 55.0% of clinical fields, and just 19.9% of fields detailing the causal event were found to be completed. Critically, oxygen saturation, arrival time, and contact information were reported in only 7.6%, 25.8%, and 43.6% of the records, respectively. Less than a fourth of the records provided any details about the cause of trauma. Accordingly, the current, paper-based medical record system at Beni-Suef University Hospital is insufficient for the development of a practical trauma registry. More efforts are needed to develop efficient and comprehensive documentation of trauma data in order to inform and improve patient care.

Temporal trends in childhood cancer survival in Egypt, 2007 to 2017: A large retrospective study of 14 808 children with cancer from the Children’s Cancer Hospital Egypt

Childhood cancer is a priority in Egypt due to large numbers of children with cancer, suboptimal care and insufficient resources. It is difficult to evaluate progress in survival because of paucity of data in National Cancer Registry. In this study, we studied survival rates and trends in survival of the largest available cohort of children with cancer (n = 15 779, aged 0‐18 years) from Egypt between 2007 and 2017, treated at Children’s Cancer Hospital Egypt‐(CCHE), representing 40% to 50% of all childhood cancers across Egypt. We estimated 5‐year overall survival (OS) for 14 808 eligible patients using Kaplan‐Meier method, and determined survival trends using Cox regression by single year of diagnosis and by diagnosis periods. We compared age‐standardized rates to international benchmarks in England and the United States, identified cancers with inferior survival and provided recommendations for improvement. Five‐year OS was 72.1% (95% CI 71.3‐72.9) for all cancers combined, and survival trends increased significantly by single year of diagnosis (P < .001) and by calendar periods from 69.6% to 74.2% (P < .0001) between 2007‐2012 and 2013‐2017. Survival trends improved significantly for leukemias, lymphomas, CNS tumors, neuroblastoma, hepatoblastoma and Ewing Sarcoma. Survival was significantly lower by 9% and 11.2% (P < .001) than England and the United States, respectively. Significantly inferior survival was observed for the majority of cancers. Although survival trends are improving for childhood cancers in Egypt/CCHE, survival is still inferior in high‐income countries. We provide evidence‐based recommendations to improve survival in Egypt by reflecting on current obstacles in care, with further implications on practice and policy.

Compliance and Barriers Facing Nurses with Surgical Site Infection Prevention Guidelines

Background: Surgical Site Infection (SSI) is defined as infection that occurring within 30 days after surgical procedure or within a year of implantation of prosthesis. Surgical Site Infection can happen in up to 30% of surgical procedures and records for up to 14% of Hospital Acquired Infection (HAIs). Aim of the Study: The aim of this study was to assess levels of nurse’s Compliance; knowledge and practice regarding prevention of surgical site infection Guidelines and identify the barriers facing nurses’ compliance with surgical site infection prevention Guidelines. Design: Cross sectional descriptive study design self-reported survey. Settings: Data was collected from surgical departments from selected Menoufia Governorate Hospitals, Egypt. Sample: A large convenience sample of 450 nurses was selected. Initially 600 questionnaires were distributed, of which only 400 returned completed, a response rate of 66.6%. Tools: was comprised of the: 1) Pre-designed structured questionnaire to assess nurses’ socio-demographic characteristics’ and Nurses’ knowledge, 2) Likert-scale: to assess nurses’ compliance, nurses’ practice and nurses’ barriers facing nurses with surgical site infection prevention guidelines. Study period: The study was conducted from July to November 2019 in the selected hospitals. Results: nurses’ compliance mean scores were in low level with a mean of 13.01, it is clear that most of the nurses have poor knowledge, most of the nurses have poor practice about surgical site infection, concerning the most barriers of compliance facing nurses with surgical site infection prevention guidelines, were lack of a professional model, having no enough time, and some measures for the prevention of surgical site infection are not nurses’ responsibilities. Conclusions: Nurses working in the surgical related wards reported a low level of knowledge, practice and compliance regarding the prevention of surgical site infection guidelines. The most barriers of compliance with surgical site infection prevention guidelines that reported by nurses were, lack of a professional model, nurses do not have enough time, and some measures for the prevention of surgical site infection are not nurses’ responsibilities. Recommendations: Evaluation of nurses’ and hospitals’ application of the guidelines is important to improve the quality of care. Education and training program should be conducted to improve nurses’ knowledge and practice in some areas using evidence-based practice.

Vulvar cancer: surgical management and survival trends in a low resource setting

This study aims to analyze risk factors, clinical profiles, treatment protocols, and disease outcomes in histologically proven resectable vulvar cancer (VC) patients according to tumor stage. This is a retrospective analysis of a prospectively collected database of 20 VC patients from May 2014 to June 2019.

The mean age of VC diagnosis was 55 years, with a range of 38–84 years. The incidence was four cases per year. The disease incidence was significantly more in post-menopausal (65%) and multiparous (90%) women. According to FIGO staging of vulvar cancer, stages I, II, and III were assigned to 6, 1, and 11 patients respectively. Two patients suffered from stage IVa vulvar melanoma. All patients had undergone surgical interventions. Patients treated with only nonsurgical (chemotherapy/radiotherapy/chemo-radiotherapy) treatment modalities were excluded from the study. Fifteen patients were treated with wide local excision (WLE), bilateral inguinofemoral dissection (B/L IFLND), and primary repair. Four and one patients were treated with radical vulvectomy (RV) and modified radical vulvectomy (MRV) [with or without B/L IFLND and PLND] respectively. Reconstruction with V-Y gracilis myocutaneous and local rotation advancement V-Y fasciocutaneous flaps were done in two patients. Therapeutic groin nodal dissection was performed in 19 patients except in one patient who was treated by palliative radical vulvectomy. In the final histopathology reports, tumor size varies from 0.5 to 6.5 cm (mean 3.35 cm) with the predominance of squamous cell carcinoma (18 out of 20 patients). Only 10 out of 18 eligible patients received adjuvant treatment. Poor patient compliance has been one of the major reasons for adjuvant treatment attrition rate. Systemic and loco-regional metastasis occurred in 3 patients each arm respectively. Poor follow up of patients is the key limitation of our study.

Vulvar cancer incidence was significantly high in post-menopausal and multiparous women. The most important prognostic factors were tumor stage and lymph node status. Oncological resection should be equated with functional outcome. The multidisciplinary team approach should be sought for this rare gynecological malignancy.

Neurosurgical Education in Egypt and Africa

Objective: Africa still significantly lags in the development of neurosurgery. Egypt, located in North Africa, is well-developed in this specialty, with the largest number of neurosurgeons among all African countries. This article provides insight into neurosurgical training in Egypt, the challenges African neurosurgeons are facing, and the requirements needed to enhance neurosurgical education and build up the required neurosurgical capacity in Africa.

Methods: The information presented in the current work was collected from databases of the Egyptian Society of Neurological Surgeons and the World Federation of Neurosurgical Societies.

Results: There are two types of neurosurgical certification in Egypt. The first type is granted by the universities (MD), and the second is awarded by the Ministry of Health (Fellow of Neurosurgery). The program in both types ranges from 6 to 9 years. The number of qualified neurosurgeons in Egypt constitutes one-third of the total number of African neurosurgeons. There is a significant shortage of neurological surgeons in Africa, and the distribution is entirely unbalanced, with the majority of neurosurgeons concentrated in the North and South regions. The most important challenge facing neurosurgery in Africa is lack of resources, which is considered to be the main obstacle to the development of neurosurgery. Other challenges include the limited number of neurosurgeons, lack of training programs, and lack of collaboration among the different regions.

Conclusions: Proper collaboration among the different regions within the African continent regarding neurosurgical education will enhance African neurosurgical capacity and make neurosurgery an independent specialty. The definite functional polarity among different regions, regarding both the number of qualified neurosurgeons and the neurosurgical capacity, is an important factor that could help in the development of neurosurgery in this continent

Cardioprotective Effects of Propofol-Dexmedetomidine in Open-Heart Surgery: A Prospective Double-Blind Study

Myocardial protection in cardiac surgeries is a must and requires multimodal approaches in perioperative period to decrease and prevent the increase of myocardial oxygen demand and consumption that lead to postoperative cardiac complications including myocardial ischemia, dysfunction, and heart failure.
Study design
Prospective, controlled, randomized, double-blinded study.
This study aims to study the effect of propofol-dexmedetomidine continuous infusion cardioprotection during open-heart surgery in adult patients.
Materials and methods
Sixty adult patients of both sexes aged from 30 to 60 years old belonging to the American Society of Anesthesiologists III or IV undergoing open-heart surgery were randomly divided into two equal groups: Group P (control group) received continuous infusion of propofol at a rate of 2 mg/kg/h and 50 cc 0.9% sodium chloride solution infused at a rate of 0.4 μg/kg/h (used as a placebo) and Group PD received continuous infusion of propofol at a rate of 2 mg/kg/h and dexmedetomidine 200 μg diluted in 50 cc 0.9% sodium chloride solution infused at a rate of 0.4 μg/kg/h. Infusion for all patients started immediately preoperative till skin closure. Hemodynamic measurements of heart rate (HR), invasive mean arterial pressure, and oxygen saturation were recorded at baseline before induction of anesthesia, immediately after intubation, at skin incision, at sternotomy and every 15 min in the 1st h then every 30 min during the prebypass period then every 15 min in the 1st h then every 30 min after weaning from CPB till the end of the surgery. Serum biomarkers; cardiac troponin (cTnI) and creatine kinase-myocardial bound (CK-MB) samples were measured basally (T1), 15 min after unclamping of the aorta (T2), immediate postoperative (T3), and 24 h postoperative (T4). Intraoperative data were also recorded including the number of coronary grafts, aortic cross-clamping duration, duration of cardiopulmonary bypass (CPB), duration of surgery, and rhythm of reperfusion. Fentanyl requirement, extubation time, and length of intensive care unit (ICU) stay were also recorded for every case.
There was no statistically significant differences as regard to demographic data between the studied two groups. HR and blood pressure recorded was lower in the PD group than the control group, and this difference was noted to be statistically significant. Furthermore, the PD group showed lower levels of myocardial enzymes (cTnI and CK-MB), decreased total fentanyl requirement, earlier postoperative extubation, and shorter ICU stay than the P(control) group.
The use of propofol-dexmedetomidine in CPB surgeries offers more cardioprotective effects than the use of propofol alone.

Blood Transfusion and Lung Surgeries in Pediatric Age Group: A Single Center Retrospective Study

Blood transfusion is not without harm, and recent studies suggest association between transfusion and poor outcome in critically ill patients. Although it is prescribed for many reasons based on the firm belief that blood transfusion improves oxygen carrying capacity, it carries notable adverse hazards. Importantly, lung surgeries are counted as moderate to high-risk operations and take a significant risk of blood loss.
This study aims to reveal the association between blood transfusion and poor clinical outcomes and characterize the epidemiology of blood transfusion after pediatric chest surgery.
Settings and design
Retrospective cohort study, done throughout 3 years.
Materials and methods
A total of 248 patients who underwent open thoracotomy and lung surgery and aged ≤18 years were classified according to the need of intraoperative or postoperative blood transfusion into two groups: Group I (non-transfused = 130) and Group II (transfused = 118).
Statistical analysis
SPSS v25 was used for analysis.
Transfusion probability ranged between 42.8% and 50% according to type of surgery. As regard to postoperative variables, there was no significant difference between both groups regarding the duration of analgesia, allergic reactions, need of re-operation and in-hospital mortality. However, transfused group showed significant increase in duration of antibiotic, persistent postoperative fever, time to remove chest drains, ICU stays, hospital stay and pneumonia. Incidence of pneumonia had a relative risk 1.82 with transfused compared to non-transfused group.
Transfusion group in pediatrics undergoing lung surgeries in our study was more prone to adverse outcomes such as pneumonia, delayed time to remove chest drains, prolonged ICU stay, and hospital stay.