Publications by authors named "Nasser Kakembo"

26 Publications

  • Page 1 of 1

Improving Surgical Research Capacity in Low and Middle Income Countries: Can Episodic Data Collection Reliably Estimate Perioperative Mortality?

Ann Surg 2021 Jul 29. Epub 2021 Jul 29.

Department of Surgery, Yale University School of Medicine, New Haven, CT Department of Surgery, Mulago Hospital, Kampala, Uganda Department of Anesthesia, Mulago National Referral Hospital, Kampala, Uganda Department of Surgery, Massachusetts General Hospital, Boston, MA Department of Surgery, University of California San Francisco, San Francisco, CA.

Objective: The aim of this study was to empirically determine the optimal sample size needed to reliably estimate perioperative mortality (POMR) in different contexts.

Summary Background Data: POMR is a key metric for measuring the quality and safety of surgical systems and will need to be tracked as surgical care is scaled up globally. Continuous collection of outcomes for all surgical cases is not the standard in high-income countries and may not be necessary in low- and middle-income countries.

Methods: We created simulated datasets to determine the sampling frame needed to reach a given precision. We validated our findings using data collected at Mulago National Referral Hospital in Kampala, Uganda. We used these data to create a tool that can be used to determine the optimal sampling frame for a population based on POMR rate and target POMR improvement goal.

Results: Precision improved as the sampling frame increased. However, as POMR increased, lower sampling percentages were needed to achieve a given precision. A total of 357 eligible cases were identified in the Mulago database with an overall POMR rate of 14%. Precision of ±10% was achieved with 34% sampling, and precision of ±25% was obtained at 9% sampling. Using simulated datasets, a tool was created to determine the minimum sample percentage needed to detect a given mortality improvement goal.

Conclusions: Reliably tracking POMR does not require continuous data collection. Data driven sampling strategies can be used to decrease the burden of data collection to track POMR in resource-constrained settings.
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http://dx.doi.org/10.1097/SLA.0000000000005105DOI Listing
July 2021

Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals.

Surgery 2021 Jun 12. Epub 2021 Jun 12.

Department of Surgery, University of California, San Francisco, CA. Electronic address:

Background: Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children's surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity.

Methods: Two years of a prospective clinical database of children's surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered.

Results: From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society.

Conclusion: This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.
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http://dx.doi.org/10.1016/j.surg.2021.05.007DOI Listing
June 2021

Implementation of a contextually appropriate pediatric emergency surgical care course in Uganda.

J Pediatr Surg 2021 Apr 14;56(4):811-815. Epub 2020 Oct 14.

University of California San Francisco, San Francisco, CA.

Background: Low- and middle-income countries like Uganda face a severe shortage of pediatric surgeons. Most children with a surgical emergency are treated by nonspecialist rural providers. We describe the design and implementation of a locally driven, pilot pediatric emergency surgical care course to strengthen skills of these providers. This is the first description of such a course in the current literature.

Methods: The course was delivered three times from 2018 to 2019. Modules include perioperative management, neonatal emergencies, intestinal emergencies, and trauma. A baseline needs assessment survey was administered. Participants in the second and third courses also took pre and postcourse knowledge-based tests.

Results: Forty-five providers representing multiple cadres participated. Participants most commonly perform hernia/hydrocele repair (17% adjusted rating) in their current practice and are least comfortable managing cleft lip and palate (mean Likert score 1.4 ± 0.9). Equipment shortage was identified as the most significant challenge to delivering pediatric surgical care (24%). Scores on the knowledge tests improved significantly from pre- (55.4% ± 22.4%) to postcourse (71.9% ± 14.0%, p < 0.0001).

Conclusion: Nonspecialist clinicians are essential to the pediatric surgical workforce in LMICs. Short, targeted training courses can increase provider knowledge about the management of surgical emergencies. The course has spurred local surgical outreach initiatives. Further implementation studies are needed to evaluate the impact of the training.

Level Of Evidence: V.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.10.004DOI Listing
April 2021

Ugandan Medical Student Career Choices Relate to Foreign Funding Priorities.

World J Surg 2020 Dec 20;44(12):3975-3985. Epub 2020 Sep 20.

Department of Surgery, Duke University School of Medicine, DUMC, Box 3815, Durham, NC, 27710, USA.

Introduction: The surgical workforce in sub-Saharan Africa is insufficient to meet population needs. Therefore, medical students should be encouraged to pursue surgical careers and "brain drain" must be minimized. It is unknown to what extent foreign aid priorities influence medical student career choices in Uganda.

Methods: Medical students in Uganda completed an online survey examining their career choices and attitudes regarding career opportunities and funding priorities. Data were analyzed using descriptive statistics, and responses among men and women were compared using Fisher's exact tests.

Results: Ninety-eight students participated. Students were most influenced by inspiring role models, employment opportunities and specialty fit with personal skills. Filling an underserved specialty was near the bottom of the influence scale. Women placed higher importance on advice from mentors (p = 0.049) and specialties with lower stress burden (p = 0.027). Men placed importance on opportunities in non-governmental organizations (p = 0.033) and academia (p = 0.050). Students expressed that the most supported specialties were infectious disease (n = 65, 66%), obstetrics (n = 15, 15%) and pediatrics (n = 7, 7%). Most students (n = 91, 93%) were planning a career in infectious disease. Fifty-three students (70%) indicated plans to leave Africa for residency. Female students were more likely to have a plan to leave (p = 0.027).

Conclusion: Medical students in Uganda acknowledge the career opportunities for physicians in specialties prioritized by the Sustainable Development Goals. In order to avoid "brain drain" and encourage students to pursue careers in surgery, career opportunities including surgical residencies must be prioritized and supported in sub-Saharan Africa.
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http://dx.doi.org/10.1007/s00268-020-05756-zDOI Listing
December 2020

Multidisciplinary Development of a Low-Cost Gastroschisis Silo for Use in Sub-Saharan Africa.

J Surg Res 2020 11 6;255:565-574. Epub 2020 Jul 6.

Department of Surgery, Duke University, Durham, North Carolina; Duke Global Health Institute, Duke University, Durham, North Carolina. Electronic address:

Background: Gastroschisis silos are often unavailable in sub-Saharan Africa (SSA), contributing to high mortality. We describe a collaboration between engineers and surgeons in the United States and Uganda to develop a silo from locally available materials.

Methods: Design criteria included the following: < $5 cost, 5 ± 0.25 cm opening diameter, deformability of the opening construct, ≥ 500 mL volume, ≥ 30 N tensile strength, no statistical difference in the leakage rate between the low-cost silo and preformed silo, ease of manufacturing, and reusability. Pugh scoring matrices were used to assess designs. Materials considered included the following: urine collection bags, intravenous bags, or zipper storage bags for the silo and female condom rings or O-rings for the silo opening construct. Silos were assembled with clothing irons and sewn with thread. Colleagues in Uganda, Malawi, Tanzania, and Kenya investigated material cost and availability.

Results: Urine collection bags and female condom rings were chosen as the most accessible materials. Silos were estimated to cost < $1 in SSA. Silos yielded a diameter of 5.01 ± 0.11 cm and a volume of 675 ± 7 mL. The iron + sewn seal, sewn seal, and ironed seal on the silos yielded tensile strengths of 31.1 ± 5.3 N, 30.1 ± 2.9 N, and 14.7 ± 2.4 N, respectively, compared with the seal of the current standard-of-care silo of 41.8 ± 6.1 N. The low-cost silos had comparable leakage rates along the opening and along the seal with the spring-loaded preformed silo. The silos were easily constructed by biomedical engineering students within 15 min. All silos were able to be sterilized by submersion.

Conclusions: A low-cost gastroschisis silo was constructed from materials locally available in SSA. Further in vivo and clinical studies are needed to determine if mortality can be improved with this design.
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http://dx.doi.org/10.1016/j.jss.2020.05.037DOI Listing
November 2020

Burden of emergency pediatric surgical procedures on surgical capacity in Uganda: a new metric for health system performance.

Surgery 2020 03 20;167(3):668-674. Epub 2020 Jan 20.

Department of Surgery, Yale University School of Medicine, New Haven, CT.

Background: The significant burden of emergency operations in low- and middle-income countries can overwhelm surgical capacity leading to a backlog of elective surgical cases. The purpose of this investigation was to determine the burden of emergency procedures on pediatric surgical capacity in Uganda and to determine health metrics that capture surgical backlog and effective coverage of children's surgical disease in low- and middle-income countries.

Methods: We reviewed 2 independent and prospectively collected databases on pediatric surgical admissions at Mulago National Referral Hospital and Mbarara Regional Referral Hospital in Uganda. Pediatric surgical patients admitted at either hospital between October 2015 to June 2017 were included. Our primary outcome was the distribution of surgical acuity and associated mortality.

Results: A combined total of 1,930 patients were treated at the two hospitals, and 1,110 surgical procedures were performed. There were 571 emergency cases (51.6%), 108 urgent cases (9.7%), and 429 elective cases (38.6%). Overall mortality correlated with surgical acuity. Emergency intestinal diversions for colorectal congenital malformations (anorectal malformations and Hirschsprung's disease) to elective definitive repair was 3:1. Additionally, 30% of inguinal hernias were incarcerated or strangulated at time of repair.

Conclusion: Emergency and urgent operations utilize the majority of operative resources for pediatric surgery groups in low- and middle-income countries, leading to a backlog of complex congenital procedures. We propose the ratio of emergency diversion to elective repair of colorectal congenital malformations and the ratio of emergency to elective repair of inguinal hernias as effective health metrics to track this backlog. Surgical capacity for pediatric conditions should be increased in Uganda to prevent a backlog of elective cases.
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http://dx.doi.org/10.1016/j.surg.2019.12.002DOI Listing
March 2020

Long term bowel function after repair of anorectal malformations in Uganda.

J Pediatr Surg 2020 Jul 11;55(7):1400-1404. Epub 2019 Dec 11.

Mulago National Referral Hospital, Department of Surgery, P.O.BOX 7072, Kampala, Uganda. Electronic address:

Background: Anorectal malformations (ARMs) are common congenital anomalies cared for at Mulago Pediatric Surgery Unit (PSU), similar to other sites in the region. All patients undergo staged repairs and complete treatment at older ages compared to high-income countries (HICs). This is the first study to examine long-term bowel function in our patients and compare with HICs.

Methods: A retrospective cohort study was conducted of all children 3-12 years old with ARMs who had repair between January 2012 and June 2017 and who completed surgical repair at least 6 months prior to the study. Bowel function was measured using the fecal continence scoring system derived from Rintala and Lindahl (1995). As in prior studies, patients were classified by score into four categories: Poor (6-9); Fair (9-11); Good (12-17); and Normal (18-20).

Results: Median follow up was 2 years post stoma closure. Long-term bowel function was Normal/Good in 65% (C.I 27, 45), and Fair/Poor 35% (C.I 55, 73), with soiling in 49% (C.I 40, 59), constipation in 23% (C.I 16, 32); and incontinence in 39% (C.I 30, 39). There was no statistically significant association between bowel function and multiple demographic, social, and clinical factors. Median age at completion of treatment (stoma reversal) was 2.3 years old, and median duration of colostomy (interval between stoma placement and takedown) was 1.8 years.

Conclusion: Despite definitive repair at older age and almost two years of living with a stoma, our patients achieve fair long-term bowel function. Nonetheless, improved follow up and timely management of complications may improve outcomes soiling, incontinence and constipation.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.11.015DOI Listing
July 2020

Comparison of Ugandan and North American Pediatric Surgery Fellows' Operative Experience: Opportunities for Global Training Exchange.

J Surg Educ 2020 May - Jun;77(3):606-614. Epub 2019 Dec 18.

Duke University Medical Center, Department of Surgery, Durham, North Carolina.

Objective: North American pediatric surgery training programs vary in exposure to index cases, while controversy exists regarding fellow participation in global surgery rotations. We aimed to compare the case logs of graduating North American pediatric surgery fellows with graduating Ugandan pediatric surgery fellows.

Design: The pediatric surgery training program at a regional Ugandan hospital hosts a collaboration between Ugandan and North American attending pediatric surgeons. Fellow case logs were compared to the Accreditation Council for Graduate Medical Education Pediatric Surgery Case Log 2018 to 19 National Data Report.

Setting: Mulago National Referral Hospital in Kampala, Uganda; and pediatric surgery training programs in the United States and Canada.

Results: Three Ugandan fellows completed training and submitted case logs between 2011 and 2019 with a mean of 782.3 index cases, compared to the mean 753 cases in North America. Ugandan fellows performed more procedures for biliary atresia (6.7 versus 4), Wilm's tumor (23.7 versus 5.7), anorectal malformation (45 versus 15.7), and inguinal hernia (158.7 versus 76.8). North American fellows performed more central line procedures (73.7 versus 30.7), cholecystectomies (27.3 versus 3), extracorporeal membrane oxygenation cannulations (16 versus 1), and congenital diaphragmatic hernia repairs (16.5 versus 5.3). All cases in Uganda were performed without laparoscopy.

Conclusions: Ugandan fellows have access to many index cases. In contrast, North American trainees have more training in laparoscopy and cases requiring critical care. Properly orchestrated exchange rotations may improve education for all trainees, and subsequently improve patient care.
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http://dx.doi.org/10.1016/j.jsurg.2019.12.001DOI Listing
June 2021

Analysis of management decisions and outcomes of a weekly multidisciplinary pediatric tumor board meeting in Uganda.

Future Sci OA 2019 Sep 19;5(9):FSO417. Epub 2019 Sep 19.

Department of Pediatrics, Uganda Cancer Institute, Kampala, Uganda.

Aim: To evaluate the efficacy of a pediatric multidisciplinary tumor board (MTB) in Uganda.

Patients & Methods: We documented the discussion of cases presented at a pediatric MTB and subsequently, though retrospective chart review, determined the degree to which decision were implemented.

Results: 95 patients were discussed. In total, 129 of 226 (57%) distinct management decisions reached during the MTBs were implemented. Of these, 15 resulted in changes in diagnosis and 53 were classified as major changes in management. Decisions on chemotherapy were the most likely to be successfully enacted (51/58), followed by radiotherapy (18/30) and surgery (12/21). Labs/consults were less likely to be implemented.

Conclusion: Key improvements, specifically in the documentation and implementation of management decisions, are needed to improve the MTB's efficacy.
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http://dx.doi.org/10.2144/fsoa-2019-0070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6787502PMC
September 2019

Burden and Outcomes of Neonatal Surgery in Uganda: Results of a Five-Year Prospective Study.

J Surg Res 2020 02 25;246:93-99. Epub 2019 Sep 25.

Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.

Background: Ninety-four percent of congenital anomalies occur in low- and middle-income countries. In Uganda, only three pediatric surgeons and three pediatric anesthesiologists serve more than 20 million children. This study estimates burden, outcomes, coverage, and economic benefit of neonatal surgical conditions in Uganda.

Methods: A prospectively collected database was reviewed for neonatal surgical admissions from January 1, 2012, to December 31, 2017, at the only two sites with specialist pediatric surgical coverage. Outcomes were compared with high-income countries. Met and unmet need were estimated using disability-adjusted life years. Economic benefit was estimated using a value of statistical life-year approach.

Results: For 1313 neonatal admissions, the median age of presentation was 3 d, overall mortality was 36%, and median distance traveled was 40 km. Anorectal malformations were most common (18%). Postoperative mortality was 24%. Mortality was significantly associated with surgical intervention (P < 0.0001). Met need was 4181 disability-adjusted life years per year, which corresponds to a $3.5 million net economic benefit to Uganda, with a potential additional benefit of $153 million if unmet need were fully addressed. Approximately 2% of the total need is met by the health care system.

Conclusions: Neonatal surgery is associated with improved survival for most conditions. Despite increases in workforce and infrastructure, a limited proportion of the need for neonatal surgery is currently being met. This is multifactorial, including lack of access to surgical care and severe shortages of workforce and infrastructure. Current and potential economic benefit to Uganda appears substantial.
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http://dx.doi.org/10.1016/j.jss.2019.08.015DOI Listing
February 2020

Burden of Surgical Infections in a Tertiary-Care Pediatric Surgery Service in Uganda.

Surg Infect (Larchmt) 2020 Mar 27;21(2):130-135. Epub 2019 Sep 27.

Department of Surgery, Duke University School of Medicine, Durham, North Carolina.

Delayed presentation of surgical disease often leads to infection in low- and middle-income countries (LMICs). In addition, many primary infections require surgical intervention. The burden of infection in children's surgery in LMICs is poorly defined and may tax the limited availability of surgical resources. A prospective surgical database was reviewed for all children presenting to a Ugandan tertiary referral hospital from January 2012 to August 2016. All patients presenting with infection were included and analyzed by operative intervention and survival. Of the 3,494 children admitted over the time period, 712 (20.4%) presented with infection. A total of 455 patients (64%) with an infection underwent an operation, with an in-hospital mortality rate of 12.5%. Operations involving infections represented 20% of the volume of the children's surgery department. Common conditions were abscesses (n = 308; 43.4%), typhoid intestinal perforations (n = 85; 12.0%), appendicitis (n = 78; 11.0%) and perforated bowel caused by ileocolic intussusception (n = 37; 5.2%). Patients with esophageal atresia presenting with aspiration pneumonia had an in-hospital mortality rate of 78.6%, those with abdominal sepsis a 67% mortality rate, and neonatal infants with necrotizing enterocolitis a 50% mortality rate. There is a high volume of infection in children requiring surgery, contributing to a high mortality rate. Resource allocation for children's surgical care in LMIC should be directed toward timely diagnosis and surgical intervention of these conditions.
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http://dx.doi.org/10.1089/sur.2019.045DOI Listing
March 2020

Correction to: Epidemiology and mortality of pediatric surgical conditions: insights from a tertiary center in Uganda.

Pediatr Surg Int 2019 Nov;35(11):1291

Department of Surgery, Yale University School of Medicine, 330 Cedar Street, FMB 107, New Haven, CT, 06510, USA.

In the original publication, the family name of one of the authors was spelt incorrectly. The correct name should read as Nensi Ruzgar.
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http://dx.doi.org/10.1007/s00383-019-04550-wDOI Listing
November 2019

Pediatric intussusception in Uganda: differences in management and outcomes with high-income countries.

J Pediatr Surg 2020 Mar 15;55(3):530-534. Epub 2019 Jul 15.

Department of Surgery, Makerere University, Mulago Hospital, Kampala, Uganda.

Purpose: In high-income countries the presentation and treatment of intussusception is relatively rapid, and most cases are correctable with radiographically-guided reduction. In low-income countries, many delays affect outcomes and surgical intervention is required. This study characterizes the burden and outcome of pediatric intussusception in Uganda.

Methods: Prospective case series of intussusception cases from May 2015 to July 2016 at a tertiary referral hospital in Uganda.

Results: Forty patients were included in the study. Male to female ratio was 3:2. Average duration of symptoms before presentation was 4.5 days. Median duration of symptoms in referred patients was 4 days and 2 days in non-referred patients (P value 0.0009). All 40 patients underwent surgical treatment: 25% had resection and enterostomy, 15% had resection and primary anastomosis, 2.5% had resection, primary anastomosis and enterostomy and 57.5% underwent manual reduction. Mortality was 32% and febrile patients on admission were 20 times more likely to die (P value 0.040).

Conclusion: Intussusception carries a high operative and mortality rate in Uganda. Referred patients presented later than non-referred patients to health facilities. Fever on examination at admission was positively associated with mortality. This disease remains a target for quality metrics in global pediatric surgery.

Type Of Study: Diagnostic study.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.07.003DOI Listing
March 2020

Epidemiology and mortality of pediatric surgical conditions: insights from a tertiary center in Uganda.

Pediatr Surg Int 2019 Nov 19;35(11):1279-1289. Epub 2019 Jul 19.

Department of Surgery, Yale University School of Medicine, 330 Cedar Street, FMB 107, New Haven, CT, 06510, USA.

Introduction/purpose: The burden of pediatric surgical disease is largely unknown in low- and middle-income countries such as Uganda where access to care is limited.

Methods: Implementation of a locally led database in January 2012 at a Ugandan tertiary referral hospital, and review of 3465 prospectively collected pediatric surgical admissions from January 2012 to August 2016.

Results: 2090 children (60.3%) underwent surgery during admission. 59% were male and 41% female. 28.6% of admissions were in neonates and 50.4% were in children less than 1 year old. Congenital anomalies including Hirschsprung's, anorectal malformations, intestinal atresias, omphalocele, and gastroschisis were the most common diagnoses (38.6%) followed by infections (15.0%) and tumors (8.6%). Mortality rates were substantially higher than those of high-income countries; for example, gastroschisis and intussusception had mortality rates of 90.1% and 19.7%, respectively. Post-operative mortality was highest in the congenital anomalies group (15.0%).

Conclusion: There is a high burden of infant congenital anomalies with higher mortality rates compared to high-income countries. The unit performs primarily specialized procedures appropriate for a tertiary center. We hope that these data will facilitate evaluation of ongoing quality improvement and capacity-building initiatives.
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http://dx.doi.org/10.1007/s00383-019-04520-2DOI Listing
November 2019

Barriers to Pediatric Surgical Care in Low-Income Countries: The Three Delays' Impact in Uganda.

J Surg Res 2019 10 11;242:193-199. Epub 2019 May 11.

Department of Surgery, Yale School of Medicine, New Haven, Connecticut.

Background: We sought to understand the challenges in accessing pediatric surgical care in the context of the "three delays" model at the Pediatric Surgery Outpatient Clinic (PSOPC) at a tertiary hospital in Kampala, Uganda.

Materials And Methods: An outpatient database was established at the weekly PSOPC. A survey regarding prior healthcare visits and barriers to care was additionally administered to clinic patients and inpatients.

Results: Patients first sought healthcare a median of 56 d before the current visit to the PSOPC. A majority (52%) of patients first sought care at another health facility, and 17% of those surveyed had presented to the PSOPC three or more times for their current medical issue. Of 240 patients with a new issue or due for their next surgery, 10% were admitted to the ward, with only 54% receiving definitive care. Included in the most commonly needed surgeries for PSOPC patients were herniotomy (16% inguinal; 14.9% umbilical), orchiopexy (6.3%), posterior sagittal anorectoplasty (6.3%), and colostomy closure (4.4%), with the range of patient ages at the time of presentation reflecting delays in care. Patient expenditures associated with travel to the hospital showed inpatients coming from significantly further away, with higher costs of travel and need to borrow or sell assets to cover travel costs, when compared with PSOPC patients.

Conclusions: Patients face significant delays in accessing and receiving definitive surgical care. Associated burdens associated with these delays place patients at risk for catastrophic health expenditures. Infrastructure and capacity development are necessary for improvement in pediatric surgical care.
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http://dx.doi.org/10.1016/j.jss.2019.03.058DOI Listing
October 2019

Best Buy in Public Health or Luxury Expense?: The Cost-effectiveness of a Pediatric Operating Room in Uganda From the Societal Perspective.

Ann Surg 2021 02;273(2):379-386

Department of Surgery, Yale University School of Medicine, New Haven, CT.

Objective: To determine the cost-effectiveness of building and maintaining a dedicated pediatric operating room (OR) in Uganda from the societal perspective.

Background: Despite the heavy burden of pediatric surgical disease in low-income countries, definitive treatment is limited as surgical infrastructure is inadequate to meet the need, leading to preventable morbidity and mortality in children.

Methods: In this economic model, we used a decision tree template to compare the intervention of a dedicated pediatric OR in Uganda for a year versus the absence of a pediatric OR. Costs were included from the government, charity, and patient perspectives. OR and ward case-log informed epidemiological and patient outcomes data, and measured cost per disability adjusted life year averted and cost per life saved. The incremental cost-effectiveness ratio (ICER) was calculated between the intervention and counterfactual scenario. Costs are reported in 2015 US$ and inflated by 5.5%.

Findings: In Uganda, the implementation of a dedicated pediatric OR has an ICER of $37.25 per disability adjusted life year averted or $3321 per life saved, compared with no existing operating room. The ICER is well below multiple cost-effectiveness thresholds including one times the country's gross domestic product per capita ($694). The ICER remained robust under 1-way and probabilistic sensitivity analyses.

Conclusion: Our model ICER suggests that the construction and maintenance of a dedicated pediatric operating room in sub-Saharan Africa is very-cost effective if hospital space and personnel pre-exist to staff the facility. This supports infrastructure implementation for surgery in sub-Saharan Africa as a worthwhile investment.
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http://dx.doi.org/10.1097/SLA.0000000000003263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6752983PMC
February 2021

Unifying Children's Surgery and Anesthesia Stakeholders Across Institutions and Clinical Disciplines: Challenges and Solutions from Uganda.

World J Surg 2019 06;43(6):1435-1449

Department of Paediatrics and Child Health, Makerere University School of Medicine, Kampala, Uganda.

Background: There is a significant unmet need for children's surgical care in low- and middle-income countries (LMICs). Multidisciplinary collaboration is required to advance the surgical and anesthesia care of children's surgical conditions such as congenital conditions, cancer and injuries. Nonetheless, there are limited examples of this process from LMICs. We describe the development and 3-year outcomes following a 2015 stakeholders' meeting in Uganda to catalyze multidisciplinary and multi-institutional collaboration.

Methods: The stakeholders' meeting was a daylong conference held in Kampala with local, regional and international collaborators in attendance. Multiple clinical specialties including surgical subspecialists, pediatric anesthesia, perioperative nursing, pediatric oncology and neonatology were represented. Key thematic areas including infrastructure, training and workforce retention, service delivery, and research and advocacy were addressed, and short-term objectives were agreed upon. We reported the 3-year outcomes following the meeting by thematic area.

Results: The Pediatric Surgical Foundation was developed following the meeting to formalize coordination between institutions. Through international collaborations, operating room capacity has increased. A pediatric general surgery fellowship has expanded at Mulago and Mbarara hospitals supplemented by an international fellowship in multiple disciplines. Coordinated outreach camps have continued to assist with training and service delivery in rural regional hospitals.

Conclusion: Collaborations between disciplines, both within LMICs and with international partners, are required to advance children's surgery. The unification of stakeholders across clinical disciplines and institutional partnerships can facilitate increased children's surgical capacity. Such a process may prove useful in other LMICs with a wide range of children's surgery stakeholders.
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http://dx.doi.org/10.1007/s00268-018-04905-9DOI Listing
June 2019

From Procedure to Poverty: Out-of-Pocket and Catastrophic Expenditure for Pediatric Surgery in Uganda.

J Surg Res 2018 12 25;232:484-491. Epub 2018 Jul 25.

Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.

Background: Financial protection from catastrophic health care expenditure (CHE) and patient out-of-pocket (OOP) spending are key indicators for sustainable surgical delivery. We aimed to calculate these metrics for a hospital stay requiring surgery in Uganda's pediatric population.

Methods: A survey was administered to family members of postoperative patients in the pediatric surgical ward at Mulago Hospital. Cost categories included direct medical costs, direct nonmedical costs, indirect costs, plus money borrowed and items sold to pay for the hospital stay. CHE was defined as spending greater than 10% of annual household expenditure. Costs were reported in Ugandan shillings and US dollars.

Results: One hundred and thirty-two patient families were surveyed between November 2016 and April 2017. Median direct costs were $27.55 (IQR 18.73-183.69) for diagnostics, $18.36 (IQR 9.52-41.33) for medications, $26.63 (IQR 9.19-45.92) for transportation, and $32.60 (IQR 12.85-64.29) for food and lodging. Forty-four percent of respondents were employed, and median indirect cost from productivity loss was $95.52 (IQR 55.10-243.38). Eighteen percent (16/87) borrowed money, and 9% (8/87) sold possessions to pay for the hospital stay. Total median OOP cost for patient families per hospital stay was $150.62 (IQR 65.21-339.82). Sixteen percent (21/132) of families incurred CHE from direct costs, and the proportion rose to 27% (32/132) when indirect cost was included.

Conclusions: Although pediatric surgical services in Uganda are formally provided for free by the public sector, families accrue substantial OOP expenditure and almost a third of households incur CHE for a pediatric surgical procedure. This study suggests that broader financial protection must be established to meet Sustainable Development Goal targets.
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http://dx.doi.org/10.1016/j.jss.2018.05.077DOI Listing
December 2018

A Cost-Effectiveness Analysis of a Pediatric Operating Room in Uganda.

Surgery 2018 11 23;164(5):953-959. Epub 2018 May 23.

Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.

This study examines the cost-effectiveness of constructing a dedicated pediatric operating room (OR) in Uganda, a country where access to surgical care is limited to 4 pediatric surgeons serving a population of over 20 million children under 15 years of age.

Methods: A simulation model using a decision tree template was developed to project the cost and disability-adjusted life-years saved by a pediatric OR in a low-income setting. Parameters are informed by patient outcomes of the surgical procedures performed. Costs of the OR equipment and a literature review were used to calculate the incremental cost-effectiveness ratio of a pediatric OR. One-way and probabilistic sensitivity analysis were performed to assess parameter uncertainty. Economic monetary benefit was calculated using the value of a statistical life approach.

Results: A pediatric OR averted a total of 6,447 disability-adjusted life-years /year (95% uncertainty interval 6,288-6,606) and cost $41,182/year (UI 40,539-41,825) in terms of OR installation. The pediatric operating room had an incremental cost-effectiveness ratio of $6.39 per disability-adjusted life-year averted (95% uncertainty interval of 6.19-6.59), or $397.95 (95% uncertainty interval of 385.41-410.67) per life saved based on the country's average life expectancy in 2015. These values were well within the WHO guidelines of cost-effectiveness threshold. The net economic benefit amounted to $5,336,920 for a year of operation, or $16,371 per patient. The model remained robust with one-way and probabilistic sensitivity analyses.

Conclusion: The construction of a pediatric operating room in Uganda is a cost-effective and worthwhile investment, endorsing future decisions to enhance pediatric surgical capacity in the resource-limited settings of Sub-Saharan Africa.
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http://dx.doi.org/10.1016/j.surg.2018.03.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6399742PMC
November 2018

The socioeconomic impact of a pediatric ostomy in Uganda: a pilot study.

Pediatr Surg Int 2018 Apr 24;34(4):457-466. Epub 2018 Jan 24.

Department of Surgery, Duke University, Box 3815, DUMC, Durham, NC, USA.

Introduction: Multiple pediatric surgical conditions require ostomies in low-middle-income countries. Delayed presentations increase the numbers of ostomies. Patients may live with an ostomy for a prolonged time due to the high backlog of cases with insufficient surgical capacity. In caring for these patients in Uganda, we frequently witnessed substantial socioeconomic impact of their surgical conditions.

Methods: The operative log at the only pediatric surgery referral center in Uganda was reviewed to assess the numbers of children receiving ostomies over a 3-year period. Charts for patients with anorectal malformations (ARM) and Hirschsprung's disease (HD) were reviewed to assess delays in accessing care. Focus group discussions (FGD) were held with family members of children with ostomies based on themes from discussions with the surgical and nursing teams. A pilot survey was developed based on these themes and administered to a sample of patients in the outpatient clinic.

Results: During the period of January 2012-December 2014, there was one specialty-certified pediatric surgeon in the country. There were 493 ostomies placed for ARM (n = 234), HD (N = 114), gangrenous ileocolic intussusception (n = 95) and typhoid-induced intestinal perforation (n = 50). Primary themes covered in the FGD were: stoma care, impact on caregiver income, community integration of the child, impact on family unit, and resources to assist families. Many patients with HD and ARM did not present for colostomy until after 1 year of life. None had access to formal ostomy bags. 15 caregivers completed the survey. 13 (86%) were mothers and 2 (13%) were fathers. Almost half of the caregivers (n = 7, 47%) stated that their spouse had left the family. 14 (93%) caregivers had to leave jobs to care for the stoma. 14 respondents (93%) reported that receiving advice from other caregivers was beneficial.

Conclusion: The burden of pediatric surgical disease in sub-Saharan Africa is substantial with significant disparities compared to high-income countries. Significant socioeconomic complexity surrounds these conditions. While some solutions are being implemented, we are seeking resources to implement others. This data will inform the design of a more expansive survey of this patient population to better measure the socioeconomic impact of pediatric ostomies and guide more comprehensive advocacy and program development.
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http://dx.doi.org/10.1007/s00383-018-4230-8DOI Listing
April 2018

Disparity in access and outcomes for emergency neonatal surgery: intestinal atresia in Kampala, Uganda.

Pediatr Surg Int 2017 Aug 4;33(8):907-915. Epub 2017 Jul 4.

Department of Pediatric Surgery, Yale School of Medicine, New Haven, USA.

Background/aim: Intestinal atresia is one of the leading causes of neonatal intestinal obstruction (NIO). The purpose of this study was to analyze the presentation and outcome of IA and compare with those from both similar and high-income country settings.

Patients And Methods: A retrospective review of prospectively collected data from patient charts and pediatric surgical database for 2012-2015 was performed. Epidemiological data and patient characteristics were analyzed and outcomes were compared with those reported in other LMICs and high-income countries (HICs). Unmet need was calculated along with economic valuation or economic burden of surgical disease.

Results: Of 98 patients, 42.9% were male. 35 patients had duodenal atresia (DA), 60 had jejunio-ileal atresia (JIA), and 3 had colonic atresia. The mean age at presentation was 7.14 days for DA and 6.7 days for JIA. Average weight for DA and JIA was 2.2 and 2.12 kg, respectively. All patients with DA and colonic atresia underwent surgery, and 88.3% of patients with JIA had surgery. Overall mortality was 43% with the majority of deaths attributable to aspiration, anastomotic leak, and sepsis. 3304 DALYs were calculated as met compared to 25,577 DALYs' unmet.

Conclusion: Patients with IA in Uganda present late in the clinical course with high morbidity and mortality attributable to a combination of late presentation, poor nutrition status, surgical complications, and likely underreporting of associated anomalies rather than surgical morbidity alone.

Level Of Evidence: Level IV, Case series with no comparison group.
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http://dx.doi.org/10.1007/s00383-017-4120-5DOI Listing
August 2017

Not gastroschisis or omphalocele or anything in between: a novel congenital abdominal wall defect.

Pediatr Surg Int 2017 Jul 7;33(7):813-816. Epub 2017 Mar 7.

Yale-New Haven Hospital, New Haven, CT, USA.

Congenital abdominal wall defects occur when normal embryonic development is interrupted and most commonly results in gastroschisis or omphalocele. Other entities, such as ruptured omphalocele, vanishing gastroschisis, and patent omphalomesenteric ducts with prolapse, have also been described and can create a confusing picture. This case of a newborn with a midline abdominal defect and a mass that was intestine-like and arose from the bowel cannot be classified, and no similar reports were found. This suggests a previously undescribed abdominal wall defect with an aberrant colonic appendage.
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http://dx.doi.org/10.1007/s00383-017-4076-5DOI Listing
July 2017

Gastroschisis in Uganda: Opportunities for improved survival.

J Pediatr Surg 2016 Nov 27;51(11):1772-1777. Epub 2016 Jul 27.

Makerere University School of Medicine, Kampala, Uganda.

Purpose: Neonatal mortality from gastroschisis in sub-Saharan Africa is high, while in high-income countries, mortality is less than 5%. The purpose of this study was to describe the maternal and neonatal characteristics of gastroschisis in Uganda, estimate the mortality and elucidate opportunities for intervention.

Methods: An ethics-approved, prospective cohort study was conducted over a one-year period. All babies presenting with gastroschisis in Mulago Hospital in Kampala, Uganda were enrolled and followed up to 30days. Univariate and descriptive statistical analyses were performed on demographic, maternal, perinatal, and clinical outcome data.

Results: 42 babies with gastroschisis presented during the study period. Mortality was 98% (n=41). Maternal characteristics demonstrate a mean maternal age of 21.8 (±3.9) years, 40% (n=15) were primiparous, and fewer than 10% (n=4) of mothers reported a history of alcohol use, and all denied cigarette smoking and NSAID use. Despite 93% (n=39) of mothers receiving prenatal care and 24% (n=10) a prenatal ultrasound, correct prenatal diagnosis was 2% (n=1). Perinatal data show that 81% of deliveries occurred in a health facility. The majority of babies (58%) arrived at Mulago Hospital within 12h of birth, however 52% were breastfeeding, 53% did not have intravenous access and only 19% had adequate bowel protection in place. Four patients (9%) arrived with gangrenous bowel. One patient, the only survivor, had primary closure. Average time to death was 4.8days [range<1 to 14days].

Conclusion: The mortality of gastroschisis in Uganda is alarmingly high. Improving prenatal diagnosis and postnatal care of babies in a tertiary center may improve outcome.
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http://dx.doi.org/10.1016/j.jpedsurg.2016.07.011DOI Listing
November 2016

Colonic polyposis in a 15 year-old boy: Challenges and lessons from a rural resource-poor area.

Ann Med Surg (Lond) 2016 May 29;7:75-8. Epub 2016 Mar 29.

Department of Surgery, College of Health Sciences Makerere University, Uganda.

Introduction: Colorectal polyps usually present with rectal bleeding and are associated with increased risk of colorectal carcinoma. Evaluation and management in resource-poor areas present unique challenges.

Presentation Of Case: This 15 year-old boy presented with 9 years of painless rectal bleeding and 2 years of a prolapsing rectal mass after passing stool. He had 3 nephews with similar symptoms. On clinical assessment and initial exam under anesthesia, an impression of a polyposis syndrome was made and a biopsy taken from the mass that revealed inflammatory polyps with no dysplasia. He was identified during a pediatric surgical outreach to a rural area with no endoscopy, limited surgical services, and no genetic testing available, even at a tertiary center. He subsequently had a three-stage proctocolectomy and ileal pouch anal anastomosis with good outcome after referral to a tertiary care center. The surgical specimen showed many polyps scattered through the colon.

Discussion: In the absence of endoscopic surveillance and diagnostic services including advanced pathology and genetic testing, colorectal polyposis syndromes are a significant challenge if encountered in these settings. Reports from similar settings have not included this surgical treatment, often opting for partial colectomy. Nonetheless, good outcomes can be achieved even given these constraints. The case also illustrates the complexity of untreated chronic pediatric surgical disease in rural resource-poor areas with limited health care access.

Conclusion: Polyposis syndromes in children present unique challenges in rural resource-poor settings. Good outcomes can be achieved with total proctocolectomy and ileal pouch anastomosis.
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http://dx.doi.org/10.1016/j.amsu.2016.03.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4840396PMC
May 2016

Outcomes and unmet need for neonatal surgery in a resource-limited environment: estimates of global health disparities from Kampala, Uganda.

J Pediatr Surg 2014 Dec 1;49(12):1825-30. Epub 2014 Oct 1.

Makerere University, Kampala, Uganda.

Purpose: Reported outcomes of neonatal surgery in low-income countries (LICs) are poor. We examined epidemiology, outcomes, and met and unmet need of neonatal surgical diseases in Uganda.

Methods: Pediatric general surgical admissions and consults from January 1, 2012, to December 31, 2012, at a national referral center in Uganda were analyzed using a prospective database. Outcomes were compared with high-income countries (HICs), and met and unmet need was estimated using burden of disease metrics (disability-adjusted life years or DALYs).

Results: 23% (167/724) of patients were neonates, and 68% of these survived. Median age of presentation was 5days, and 53% underwent surgery. 88% survived postoperatively, while 55% died without surgery (p<0.001). Gastroschisis carried the highest mortality (100%) and the greatest mortality disparity with HICs. An estimated 5072 DALYs were averted by neonatal surgery in Uganda (met need), with 140,154 potentially avertable (unmet need). Approximately 3.5% of the need for neonatal surgery is met by the health system.

Conclusions: More than two thirds of surgical neonates survived despite late presentation and lack of critical care. Epidemiology and outcomes differ greatly with HICs. A high burden of hidden mortality exists, and only a negligible fraction of the population need for neonatal surgery is met by health services.
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http://dx.doi.org/10.1016/j.jpedsurg.2014.09.031DOI Listing
December 2014

Pediatric surgical camps as one model of global surgical partnership: a way forward.

J Pediatr Surg 2014 May 22;49(5):786-90. Epub 2014 Feb 22.

British Columbia Children's Hospital, Vancouver, Canada.

Background/purpose: A uniquely Ugandan method of holding surgical "camps" has been one means to deal with the volume of patients needing surgery and provides opportunities for global partnership.

Methods: We describe an evolved partnership between pediatric surgeons in Uganda and Canada wherein Pediatric Surgical Camps were organized by the Ugandans with team participation from Canadians. The camp goals were to provide pediatric surgical and anesthetic service and education and to foster collaboration as a way forward to assist Ugandan health delivery.

Results: Three camps were held in Uganda in 2008, 2011, and 2013. A total of 677 children were served through a range of operations from hernia repair to more complex surgery. The educational mandate was achieved through the involvement of 10 Canadian trainees, 20 Ugandan trainees in surgery and anesthesia, and numerous medical students. Formal educational sessions were held. The collaborative mandate was manifest in relationship building, an understanding of Ugandan health care, research projects completed, agreement on future camps, and a proposal for a Canadian-Ugandan pediatric surgery teaching alliance.

Conclusion: Pediatric Surgical Camps founded on global partnerships with goals of service, education, and collaboration can be one way forward to improve pediatric surgery access and expertise globally.
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http://dx.doi.org/10.1016/j.jpedsurg.2014.02.069DOI Listing
May 2014
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