Manual Colostomy Reversals Following Wide Colorectal Resections at Poorly Equipped Surgical Facilities

Background: The decision for colostomy reversal is usually not easy and often reflects patient’s desire, fully analyzed and agreed by the surgeon. The unavailability of mechanical suturing devices considerably increases this challenge. This study was aimed at sharing our experience with manual colostomy reversals (MCR) techniques after wide colorectal resections (WCRR) as well as documenting related early outcomes and complications.Methods: This retrospective study was carried out between 1st January 2007 and 31st December 2009, at the Lusaka University Teaching Hospital and The Lubumbashi University Clinics. Data were collected from operating lists, clinical records of in-patients and out-patient clinic records. Only fully documented cases with consistent targeted parameters including demography, indication for the colostomy, colostomy type, reversal technique, complications, hospital stay and discharge were considered for statistically analyze.Results: A total of 124 colostomies were performed during the study period; 98 were temporary. Thirty six of these 98 resections were wide and of which the MCR was achieved as follows: simple colon mobilization (56%); additional symphysiotomy (28%), trans-sacral approach (11%) and the use of an ileo-colo-rectal transplant (6%). There was no significant difference in sex and age distribution. Causes of WCRR were: sigmoid colon volvulus (58%); colorectal cancer: (17%); perforated sigmoid  diverticulitis (11%), amoebic perforations (18%) and rectal cancer (6%). All 36 patients (100%) got discharged after successful management of the following complications: a faecal fistula in two patients, a surgical abdominal site infection in 3 patients and pelvic pain and discomfort..Conclusion: The MCR after WCRR is feasible in selected and well prepared patients with a perfect technique. Constraints for cancer resections and patient’ per operative safety shall be observed. The acquisition of colorectal stapling devices should remain the ideal.Key words: colostomy, colorectal resection, Hartmann technique

Policy options for surgical mentoring: lessons from Zambia based on stakeholder consultation and systems science

Background Supervision by surgical specialists is beneficial because they can impart skills to district hospital-level surgical teams. The SURG-Africa project in Zambia comprises a mentoring trial in selected districts, involving two provincial-level mentoring teams. The aim of this paper is to explore policy options for embedding such surgical mentoring in existing policy structures through a participatory modeling approach. Methods Four group model building workshops were held, two each in district and central hospitals. Participants worked in a variety of institutions and had clinical and/or administrative backgrounds. Two independent reviewers compared the causal loop diagrams (CLDs) that resulted from these workshops in a pairwise fashion to construct an integrated CLD. Graph theory was used to analyze the integrated CLD, and dynamic system behavior was explored using the Method to Analyse Relations between Variables using Enriched Loops (MARVEL) method. Results The establishment of a provincial mentoring faculty, in collaboration with key stakeholders, would be a necessary step to coordinate and sustain surgical mentoring and to monitor district-level surgical performance. Quarterly surgical mentoring reviews at the provincial level are recommended to evaluate and, if needed, adapt mentoring. District hospital administrators need to closely monitor mentee motivation. Conclusions Surgical mentoring can play a key role in scaling up district-level surgery but its implementation is complex and requires designated provincial level coordination and regular contact with relevant stakeholders

Surgical capacity, productivity and efficiency at the district level in Sub-Saharan Africa: A three-country study

INTRODUCTION: Efficient utilisation of surgical resources is essential when providing surgical care in low-resources settings. Countries are developing plans to scale up surgery, though insufficiently based on empirical evidence. This paper investigates the determinants of hospital efficiency in district hospitals in three African countries. METHODS: Three-month data, comprising surgical capacity indicators and volumes of major surgical procedures collected from 61 district-level hospitals in Malawi, Tanzania, and Zambia, were analysed. Data envelopment analysis was used to calculate average hospital efficiency scores (max. = 1) for each country. Quantile regression analysis was selected to estimate the relationship between surgical volume and production factors. Two-stage bootstrap regression analysis was used to estimate the determinants of hospital efficiency. RESULTS: Average hospital efficiency scores were 0.77 in Tanzania, 0.70 in Malawi and 0.41 in Zambia. Hospitals with high efficiency scores had significantly more surgical staff compared with low efficiency hospitals (DEA score<1). Hospitals that scored high on the most commonly utilised surgical capacity index were not the ones with high surgical volumes or high efficiency. The number of surgical team members, which was lowest in Zambia, was strongly, positively correlated with surgical productivity and efficiency. CONCLUSION: Hospital efficiency, combining capacity measures and surgical outputs, is a better indicator of surgical performance than capacity measures, which could be misleading if used alone for surgical planning. Investment in the surgical workforce, in particular, is critical to improving district hospital surgical productivity and efficiency