In low- and middle-income countries (LMICs), at least 60 percent of the surgical operations performed are for emergencies. Contrary to widespread belief, it has been shown that the provision of treatment, which is often lifesaving for these patients, can be inexpensive. The staff and equipment required at first-level facilities for all categories of surgical emergency, including trauma (chapter 3) and obstetrics (chapter 5), are essentially the same. Accordingly, the treatment of general surgical emergencies requires little additional cost and should be part of the services offered at first-level facilities. This chapter
The annual death rate from acute abdominal conditions in the United States in 1935 was 38 per 100,000 population, or 3 percent of all deaths in that year. General practitioners performed most surgeries; formal surgical training did not begin until 1937, when the American Board of Surgery was formed. By 1990, the death rate for acute abdominal conditions had fallen to 4 per 100,000 (CDC 1990; U.S. Department of Commerce 1935). The 90 percent reduction in mortality was due to increased access to operations, made possible by new facilities and more skilled staff in combination with the availability of antibiotics for infection, safer anesthesia, and blood for transfusions. The operations were not complicated. They are available today in LMICs, as are low-cost antibiotics, competent anesthesia, and blood; however, as in the United States in 1935, access to these operations is very limited. In the United States and in many other high-income countries (HICs) in 1935, all general surgical emergencies were responsible for 3 percent to 5 percent of deaths. This estimate may be as good as any other estimate of the burden of disease from these causes in LMICs, where there is little or no available surgical treatment.
Fortunately, early treatment with incision and drainage, in combination with a regimen of antibiotics for one to two weeks, is generally successful in locations with limited resources. In late-presenting cases, deaths from sepsis are usually preventable, but bone and joint infections, in particular, can require long-term treatment and subsequent surgery. Because acute infections are common, often occur in children, and do not require complicated surgery, this treatment option is an important and very cost-effective part of the work of a first-level hospital (King and others 1986; WHO 2003). Surgical infections are covered in more detail in chapter 3.
Congenital surgical emergencies are covered in detail in chapter 8. Some of these, especially pyloric stenosis and colostomy for imperforate anus, are completely within the competence of a well-trained general surgeon in a first- or second-level hospital, although it is rare to find a general surgeon who does these operations.
Almost all of the conditions listed in box 4.1 can be treated in first-level hospitals (see table 4.1), although many of these facilities would refer most or all of these patients to a higher level. The public quickly comes to know if referral is likely and learns to bypass the closer hospital and go directly to a larger center. If bypassing is not possible, patients simply stay home. Patients often do not reach the higher-level hospitals to which they are referred, usually for economic reasons (Urassa and others 2005). The important factor limiting the capacity of first-level hospitals is training (Abdullah and others 2011). The shortage of qualified surgeons and anesthetists can be corrected in the short term by training general practitioners, nonphysician clinicians, and nurses to care for most of the common conditions; in the long term, the shortage can be corrected by training appropriate specialists. Approaches to these options are discussed briefly in this chapter and in more detail in chapters 12 and 17.
The Global Health Estimates do not specifically identify general surgical emergencies, but by combining the estimates for three categories (peptic ulcer disease, appendicitis, other digestive diseases) out of the 163, in which death or disability usually results from a general surgical emergency, an estimate of the worldwide rate of DALYs lost from these conditions can be created. At 596 per 100,000 population, this constitutes 1.5 percent of DALYs from all causes, in all parts of the world (table 4.3). The estimates for injuries, maternal, neonatal, and three general surgical emergencies in LMICs were considerably higher than those in HICs.
The overall survival rates of higher than 95 percent cited for most of the four common categories of emergencies in table 4.2 are based on reports from hospitals in LICs, primarily in Sub-Saharan Africa. These results have been achieved despite the late arrival of many patients and the high prevalence of comorbid conditions, such as malaria and HIV infection. Médecins Sans Frontières reported on 16,377 major operations in LMICs, most performed for emergencies in the very basic, first-level hospitals they operated, with a hospital mortality rate of 0.2 percent (Chu, Ford, and Trelles 2010). Staff without formal surgical training performed many of these operations, but trained surgeons were almost always available for consultation and assistance. A report of 1,976 operations for acute abdominal conditions in a Sub-Saharan African public hospital finds a hospital mortality rate of less than 10 percent (Ohene-Yeboah 2006). A small Sub-Saharan African hospital with no trained surgeon on staff and very limited capacity for referral reports a hospital mortality rate of 10 percent for 173 patients with acute abdominal emergencies (McConkey 2002). The operations were performed by general practitioners.
The cost and effectiveness of first-level hospitals, the systems to support them, and the role of surgery within them is discussed in chapters 12, 18, and 19. First-level hospitals have been shown to best serve the needs of the population and to be cost-effective. Their surgical services are usually the most effective component (Debas and others 2006; Gosselin, Thind, and Bellardinelli 2006; McCord and Chowdhury 2003). At first-level facilities, the same staff can provide services for most general surgical, obstetric, and trauma emergencies. With minor adjustments, the same structure, equipment, and supplies can serve all three components at very low cost. At higher referral levels, increasingly specialized services combined with other inefficiencies can increase costs enormously.
Although several types of operations can be done in less-than-ideal conditions, the availability of basic facilities and supporting systems makes procedures simpler, safer, and more efficient. Controlling cost and making optimal use of resources are important everywhere, especially in LMICs. Hence, it is essential to define the basic needs for a functioning surgical system. Fortunately, these essentials do not need to be expensive. Some hospitals in LMICs provide good, lifesaving service for a total cost of less than US$50 per patient day, compared with more than US$1,000 per patient day for hospitals in HICs (Kruk and others 2010). A well-equipped operating theater can be created in LMICs for less than the cost of a small diner or restaurant in a HIC.
Training. Effective training programs for staff members are essential. It is not realistic to expect that all surgical staff will be fully qualified specialists or certified operating room nurses; general practitioners, nonphysician clinicians, and nurses can be trained to manage most of the surgical emergencies seen in first-level hospitals. Variation in surgical capability is an important factor that can limit the number of general surgical emergencies treated, as well as the quality of the outcomes.
Because first-level facilities need to perform emergency obstetrical and trauma surgery, training programs should create the capacity to manage all three categories of surgical emergencies: general surgical, traumatic, and obstetric. Programs in Sub-Saharan Africa and elsewhere have demonstrated that training can be done at low cost and without stationing qualified specialists at every location (Mkandawire, Ngulube, and Lavy 2008; Nyamtema and others 2011; Sani and others 2009; van Amelsfoort and others 2010).
Most LMICs partially resolve this problem by sending recent medical graduates to staff first-level hospitals (general practitioner surgeons), training nurses or other staff to administer anesthesia, and staffing operating rooms with nurses or others without special training. A few countries have trained nonphysician clinicians to perform surgery (see chapters 17 and 19). Because 90 percent or more of the essential operations are within the potential competence of a general practitioner or nonphysician clinician surgeon with a nonphysician anesthetist, short-course training before assignment and periodic skills improvement courses can greatly improve the quantity and the quality of surgical treatment in these places. Regular visits by supervising specialists will serve to maintain and expand the skills, as well as to evaluate quality through audits. Regular supervision of this sort is extremely rare in LMICs.
The shortage of trained staff members results in costly inefficiency in facilities that are working at less than capacity (Kruk and others 2010). Many very poor countries are only beginning to train doctors to qualify as surgeons and anesthetists. General practitioner and nonphysician clinician surgeons in first-level hospitals usually become competent at managing obstetrical emergencies with nurse-midwives and nurse-anesthetists. However, they are less confident with general surgical emergencies and trauma, so that these patients are often referred. Because of financial and other barriers, this practice often means that the patients do not receive the treatment they need (Cannoodt, Mock, and Bucagu 2012; Grimes and others 2011).
Two trends in the revolution in operative surgery in the past decade are particularly noteworthy. First is a general move to more conservative procedures to treat infections, malignancies, and biliary, vascular, and other diseases. Second, innovation and new technologies have facilitated this conservative trend. The intensive use of potent antibiotics has reduced the need for surgery. Video-assisted surgery and stapled suturing have simplified surgical techniques. Ultrasound, computerized radiographic technology, magnetic resonance imaging, and endoscopy have improved preoperative diagnoses; in some cases, they have eliminated the need for surgery. 153554b96e