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.

eHealth for service delivery in conflict: a narrative review of the application of eHealth technologies in contemporary conflict settings

The role of eHealth in conflict settings is increasingly important to address geographic, epidemiologic and clinical disparities. This study categorizes various forms of eHealth usage in conflict and aims to identify gaps in evidence to make recommendations for further research and practice. The analysis was carried out via a narrative hermeneutic review methodology. Articles that fulfilled the following screening criteria were reviewed: (1) describing an eHealth intervention in active conflict or ongoing insurgency, (2) an eHealth intervention targeting a conflict-affected population, (3) an e-learning platform for delivery in conflict settings and (4) non-interventional descriptive reviews relating to eHealth in conflict. Of the 489 papers eligible for screening, 46 merited final inclusion. Conflict settings described include Somalia, Sudan, Afghanistan, Syria, Iraq, Pakistan, Chechnya, Gaza and the Democratic Republic of Congo. Thirty-six studies described specific eHealth initiatives, while the remainder were more generic review papers exploring general principles. Analysis resulted in the elucidation of three final categories of current eHealth activity in conflict-affected settings: (1) eHealth for clinical management, (2) e-learning for healthcare in conflict and (3) eHealth for information management in conflict. Obvious disparities in the distribution of technological dividends from eHealth in conflict are demonstrated by this review. Conflict-affected populations are predominantly subject to ad hoc and voluntary initiatives delivered by diaspora and civil society organizations. While the deployment of eHealth technologies in conflict settings is increasingly normalized, there is a need for further clarification of global norms relating to practice in this context.

Delivery Mode for Prolonged, Obstructed Labour Resulting in Obstetric Fistula: A Retrospective Review of 4396 Women in East and Central Africa

Objective: To evaluate the mode of delivery and stillbirth rates over time among women with obstetric fistula.

Design: Retrospective record review.

Setting: Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia and Ethiopia.

Population: A total of 4396 women presenting with obstetric fistulas for repair who delivered previously in facilities between 1990 and 2014.

Methods: Retrospective review of trends and associations between mode of delivery and stillbirth, focusing on caesarean section (CS), assisted vaginal deliveries and spontaneous vaginal deliveries.

Main outcome measures: Mode of delivery, stillbirth.

Results: Out of 4396 women with fistula, 3695 (84.1%) delivered a stillborn baby. Among mothers with fistula giving birth to a stillborn baby, the CS rate (overall 54.8%, 2027/3695) rose from 45% (162/361) in 1990-94 to 64% (331/514) in 2010-14. This increase occurred at the expense of assisted vaginal delivery (overall 18.3%, 676/3695), which declined from 32% (115/361) to 6% (31/514).

Conclusions: In Eastern and Central Africa, CS is increasingly performed on women with obstructed labour whose babies have already died in utero. Contrary to international recommendations, alternatives such as vacuum extraction, forceps and destructive delivery are decreasingly used. Unless uterine rupture is suspected, CS should be avoided in obstructed labour with intrauterine fetal death to avoid complications related to CS scars in subsequent pregnancies. Increasingly, women with obstetric fistula add a history of unnecessary CS to their already grim experiences of prolonged, obstructed labour and stillbirth.

Diagnosis and management of 365 ureteric injuries following obstetric and gynecologic surgery in resource-limited settings.

Ureteric injuries are among the most serious complications of pelvic surgery. The incidence in low-resource settings is not well documented.This retrospective review analyzes a cohort of 365 ureteric injuries with ureterovaginal fistulas in 353 women following obstetric and gynecologic operations in 11 countries in Africa and Asia, all low-resource settings. The patients with ureteric injury were stratified into three groups according to the initial surgery: (a) obstetric operations, (b) gynecologic operations, and (c) vesicovaginal fistula (VVF) repairs.The 365 ureteric injuries in this series comprise 246 (67.4%) after obstetric procedures, 65 (17.8%) after gynecologic procedures, and 54 (14.8%) after repair of obstetric fistulas. Demographic characteristics show clear differences between women with iatrogenic injuries and women with obstetric fistulas. The study describes abdominal ureter reimplantation and other treatment procedures. Overall surgical results were good: 92.9% of women were cured (326/351), 5.4% were healed with some residual incontinence (19/351), and six failed (1.7%).Ureteric injuries after obstetric and gynecologic operations are not uncommon. Unlike in high-resource contexts, in low-resource settings obstetric procedures are most often associated with urogenital fistula. Despite resource limitations, diagnosis and treatment of ureteric injuries is possible, with good success rates. Training must emphasize optimal surgical techniques and different approaches to assisted vaginal delivery.