Surgical site infection (SSI) is the commonest postoperative complication in abdominal surgery. SSI causes patients to experience pain and delays return to normal activities such as work. Additional SSI-related health costs can cause financial hardship, particularly for the most vulnerable patients in LMICs. Treatment of SSI is increasingly challenging due to the rise of antibiotic resistance, which occurs in up to 46% of LMIC patients. This places a strong focus on preventing SSI from occurring in the first place.

We have worked with surgeons representing 13 LMICs to collaboratively adapt existing high income country guidance to produce a guideline that reflects the challenges of delivering surgery in LMICs, and allows health providers to prioritise implementation of key interventions that are most likely to benefit patients.

The ‘Global Surgery Guideline for the Prevention of Surgical Site Infection’, published in BJS, has identified practical steps that all hospitals should urgently take to both reduce avoidable infections and the spread of antimicrobial resistance. In addition, a further three ‘desirable’ recommendations are made in the guideline. It is recognised that worldwide some hospitals may lack the necessary resources to immediately implement these interventions, in which case they should plan strategies to introduce these interventions in the future.

Global Guidance for surgical care during the COVID-19 pandemic

Surgeons worldwide urgently need guidance on how to deliver surgical services safely and effectively during the COVID-19 pandemic. The key outcomes from a scoping search conducted to identify published articles relating to management of surgical patients during pandemics are published in the BJS and outlined in the poster below.

STARFISH STUDY

SToma cARe For Improvement reSearcH (STARFISH): Epidemiologic study of stoma cases in Lower- and Middle-Income Countries and qualitative research on the challenges on stoma care.

The STARFISH study uses a mixed methods approach to assess the burden and challenges of stoma care in low and middle income settings.

Based at the Unit’s Centre in the Philippines and led by Dr Maria Carmela Lapitan at the University of the Philippines in Manilla, Starfish comprises 3 separate sub-studies:

1. A survey at selected healthcare facilities to collect data on stoma incidence, types, indications and complications.

2. Focus groups and one-to-one interviews with patients, carers and health care providers involved in stoma care

3. Development of a questionnaire for stoma patients in low and middle income settings to collect standardised data on stoma care

TIGER STUDY

TIGER (Task shifting Inguinal hernia Repair between surgeons and technicians): development of a randomised trial in low and middle income countries

Can technicians perform mesh inguinal hernia repair safely and cost-effectively in rural surgical settings in low and middle income countries?
This pilot trial aims to investigate delivery of a standardised, measurable training programme for technicians to perform a mesh inguinal hernia repair.

Educational Visits

As part of the pump-priming funding stream, the Global Surgery Unit is supporting educational visits between our international partners, sharing knowledge and experience.

Honey wound dressings for the management of chronic wounds in Ghana

Honey is well documented to have anti-bacterial and anti-fungal properties, however there is currently insufficient evidence to demonstrate that honey wound dressings are effective in the treatment of chronic wounds.

Medical grade honey is currently available but not yet in use in Ghana. This project funded an educational trip for Dr Edwin Yenli and Dr Etch Ighohwo from the NIHR Global Surgery Unit hub in Ghana to visit colleagues at our South African hub in order to observe wound care at specialised units.

To read a full report on Dr Yenli and Dr Ighohwo’s visit please click here.

The WHO Surgical Safety Checklist

In the 10th anniversary year of the WHO Surgical Safety Checklist (WHO SSC), this project aims to determine usage and compliance with the WHO SSC in referral and district hospitals in Rwanda and Malawi.

Led in partnership by Dr JC Allen Ingabire from The NIHR Global Surgery Unit hub in Rwanda and Dr Vanessa Msosa at Kamuzu Central Hospital in Malawi, the study will audit knowledge and usage of the WHO SSC amongst approximately 1000 theatre users at 24 rural and district hospitals in Rwanda and 10 in Malawi.

During a defined 3-day data collection period, operations taking place in general surgical and obstetrics & gynaecology theatres will be audited to investigate if the WHO SSC is available to the whole surgical team and being used to record key variables during every operation performed.

LION STUDY

LION (LaparoscopIc Versus Open Appendectomy): Cost comparison in a lower- middle income setting

This study aims to compare the outcome and cost of conventional open and laparoscopic appendectomy for clinically confirmed, uncomplicated, acute appendicitis in a low resource setting. Although the cost effectiveness of laparoscopic surgery has been investigated previously in high human development index (HDI) countries, similar studies are lacking in low and middle HDI countries.

Led by Dr Adewale Adisa at the NIHR hub in Nigeria, this study will compare outcomes following open and laparoscopic appendectomy in approximately 150 patients at 3 hospitals in Nigeria.

Burns Care

Burns are a significant contributor to the burden of disease in low- and middle-income countries (LMIC). Although current guidelines recommend treatment in specialised treatment centres, such centres are few or non-existent in many LMIC settings.

Led by Dr Chikwendu Ede and Dr Rachel Moore from the NIHR Global Surgery Unit hub in South Africa, this is a prospective observational study comparing outcomes of burns treatments between non-specialised and specialised burns units. Information on 90 day mortality will be collected over a 6 month period at up to 9 non-specialised hospitals treating adult burns patients and compared to outcomes for patients at a dedicated burns unit at Chris Hani Baragwanarth Academic Hospital in Soweto, Johannesburg.

Wound dressing practices to decrease Surgical Site infections in low and middle income countries

Led by Dr Faustin Ntirenganya and Dr Christophe Mpirimbanyi from the NIHR Global Surgery Unit hub in Rwanda, this mixed methods study assesses knowledge, attitudes and practices around surgical wound dressing amongst nurses, general practitioners and surgeons in Rwanda.

The study, conducted at 3 hospitals in Rwanda, will determine types of commonly used dressings and indications for dressing change, evaluate cost implications of wound dressings, and investigate patients’ and health professionals ‘beliefs / perspectives’ regarding the feasibility of a future RCT.

Primary outcome measure will be surgical site infection at 30 days; secondary outcome measures will include length of hospital stay, dressing costs, patient satisfaction and complication rates.

Abdominal Tuberculosis in children – pattern and treatment outcomes

This study led by the NIHR Global Surgery Unit hub in India examines the pattern of abdominal tuberculosis in children and investigates the effectiveness of various treatment regimens, exploring the response of paediatric patients to medical intervention alone, to a surgical approach alone, and to a combined approach.

This involves a retrospective and follow up study of all abdominal tuberculosis cases treated as in-patients in the departments of paediatrics and paediatric surgery at the Christian Medical College & Hospital, Ludhiana from 1st August 2007 to 31st July 2017. Anonymised data on these patients is being studied from medical records and includes information related to demographics, socioeconomic and nutritional status, clinical findings, investigations, radiological findings and treatment related data. Further approaches such as patient interviews are being employed to supplement the available data.

Patients diagnosed with COVID-19 who need surgery are a challenging group. Capturing real-world data and sharing international experience will inform the management of this complex group of patients who undergo surgery throughout the COVID-19 pandemic, improving their clinical care.

Primary aim

• To determine 30-day mortality in patients with COVID-19 infection who undergo surgery. This will inform future risk stratification, decision making, and patient consent.

Any centre performing elective cancer surgery affected by COVID-19 could participate in this study. Investigators could choose one or more cancer types from their centre from which to upload data. This study could be performed prospectively, retrospectively or using a mixed model, dependent on the phase of COVID-19 infection in that team’s hospital.

Primary aim

• To evaluate the 30-day postoperative pulmonary complication rate following elective cancer surgery during the COVID-19 pandemic.

CovidSurg Week is an international multi-centre prospective cohort study in which patients from all specialities undergoing a surgical procedure done in an operating theatre could be included (any SARS-CoV 2 status).

Primary aim

• To determine the optimal timing for surgery following SARS-CoV-2 infection.

With the emergence of the Omicron SARS-CoV-2 variant of concern, there is currently little evidence regarding disease severity in both vaccinated and unvaccinated patients (including in surgical patients), nor is there data to guide patient risk stratification during Omicron COVID-19 waves.

This new study aims to provide renewed rapid data to guide global practice during Omicron COVID-19 waves.

CovidSurg-3 has two separate components:

• Patient-level component: Collection of outcome data for patients with peri-operative SARS-CoV-2.
• Hospital-level component: Collection of aggregated case-mix data. Hospitals in countries with low community SARS-CoV-2 infection rates can contribute towards this component.

Primary aim

• To determine 30-day mortality in patients with peri-operative SARS-CoV-2 infection. This will inform future risk stratification, decision making, and patient consent.

Key Documents

• Study Protocol can be accessed here
• Study Protocol appendix can be accessed here 
• Data collection sheet (patient level) can be accessed here 
• Data collection sheet (hospital level) can be accessed here 

Key Documents for Patients

A range of documents for patients who may be either planning for or about to undergo an operation during the COVID-19 pandemic can be accessed here.

WHO CAN JOIN?

We welcome surgeons, residents, students, researchers, allied health professionals, nurses, community workers, social workers.

WHAT WILL WE DO?

We plan to direct and recruit research from and towards rural areas. In so doing we hope to permit access of rural health providers into academic studies, and recruit the participation of patients from rural areas. Through high quality research addressing needs and concerns of the majority of populations worldwide, we hope to address health needs, build capacity and eventually influence health policy.

You can subscribe to this network here via REDCap.