This study supports the benefit for simulation in surgical training in LMICs. Skill improvements were limited to junior-level trainees. This work provides justification for investment in simulation-based curricula in Rwanda and potentially other LMICs.

Background Surgical disease burden falls disproportionately on individuals in low- and middle-income countries. These populations are also the least likely to have access to surgical care. Understanding the barriers to access in these populations is therefore necessary to meet the global surgical need. Methods Using geospatial methods, this study explores the district-level variation of two access barriers in Ghana: poverty and spatial access to care. National survey data were used to estimate the average total household expenditure (THE) in each district. Estimates of the spatial access to essential surgical care were generated from a cost-distance model based on a recent surgical capacity assessment. Correlations were analyzed using regression and displayed cartographically. Results Both THE and spatial access to surgical care were found to have statistically significant regional variation in Ghana (p < 0.001). An inverse relationship was identified between THE and spatial access to essential surgical care (β −5.15 USD, p < 0.001). Poverty and poor spatial access to surgical care were found to co-localize in the northwest of the country. Conclusions Multiple barriers to accessing surgical care can coexist within populations. A careful understanding of all access barriers is necessary to identify and target strategies to address unmet surgical need within a given population.

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Background There currently is no consensus on how to accurately predict early rebleeding and death after a major variceal bleed. This study investigated the relative predictive performances of the original Child-Pugh (CP), model for end-stage liver disease (MELD) and a four-category recalibrated Child-Pugh (rCP). Methods This prospective study included all adult patients admitted to Groote Schuur Hospital with acute esophageal variceal bleeding secondary to alcoholic cirrhosis, between January 2000 and December 2017. CP and rCP grades and MELD score were calculated on admission, and the predictive ability in discriminating in-hospital rebleeding and death was compared by area under receiver-operating characteristic (AUROC) curves.Results During the study period, 403 consecutive adult patients were treated for bleeding esophageal varices of whom 225 were secondary to alcoholic cirrhosis. Twenty-four (10.6%) patients were CP grade A, 88 (39.1%) grade B and 113 (50.2%) grade C on hospital admission. MELD scores ranged from 6 to 40. Thirty-one (13.8%) patients rebleed, and 41 (18.2%) patients died. There was no difference in the discriminatory capacity of the CP (AUROC 0.59, 95% CI 0.50-0.670) and MELD (AUROC 0.62, 95% CI 0.51-0.73) to predict rebleeding (p = 0.72), or between the Child-Pugh (AUROC 0.75, 95% CI 0.71-0.81) and MELD (AUROC 0.71, 95% CI 0.62-0.80) to predict death (p = 0.35). The rCP classification (A-D) had a significantly improved discriminatory capacity (AUROC 0.83 95% CI 0.77-0.89) compared to the CP score (A-C) and MELD to predict death (p = 0.004). Conclusion A recalibrated Child-Pugh score outperforms the original Child-Pugh grade and MELD score in predicting in-hospital death in patients with bleeding esophageal varices secondary to alcoholic cirrhosis.

Laparoscopic colectomy: trends in implementation in Canada and globally T he first study of laparoscopic colectomy (LC) was published in 1991. 1 Throughout the 1990s, adoption of the technique was hampered by concerns regarding oncologic safety and effectiveness. 2,3 This concern led to further studies and, by 2004, randomized controlled trial evidence clearly showed that LC accelerated patients' postoperative recovery and reduced length of hospital stay (LOS) while providing equivalent oncologic outcomes compared with open colectomy (OC). 4 Fewer postoperative complications and shorter LOS imply cost savings to the health care system, which is of considerable importance in an era of rising health care expenditures across all of Canada. 5 Comparisons with other high-income countries suggest a lower adoption rate of LC in Canada. 6-9 The Canadian Association of General Surgeons (CAGS) formed a task force to evaluate the barriers to adoption of laparoscopic colon surgery and to propose potential intervention strategies to enhance the use of the procedure. As an initial step, the task force was asked to complete a literature review of existing publications on this topic to identify patterns of implementation and barriers to adoption in Canada and other countries. Uptake of laparoscopic colectomy in canada Population-based data from Ontario show that between 2002 and 2009, the proportion of elective LC increased from 13% to 37%. 10 In British Columbia, the proportion of patients with colon cancer undergoing LC increased from 2% to 25% between 2003 and 2008. 11 Using population-level data, Hoogerboord and colleagues 12 showed that from 2004 to 2014, the pan-Canadian rate of LC for elective surgeries increased from 9% to 52%. Provincial utilization rates ranged from 11% in Newfoundland to 60% in British Columbia. 12 The rate of LC in Canada was lower than in South Korea, the Netherlands and the United States, but higher than in the United Kingdom, Norway and Sweden (Fig. 1). 6-9 predictors of Uptake of laparoscopic colectomy Compared with OC, the laparoscopic approach is technically more difficult because of the absence of tactile feedback, operating with 2-dimensional vision, and limited degrees of manoeuvrability of instruments. The number of cases required to complete the learning curve for LC varies between 30

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Background: Hundreds of international projects are implemented all over the world. Sustainability of such projects is always questioned. The objective of this study was to analyze landmarks of successful collaboration in global surgical issues between Ukrainian and Canadian institutions from 2006 to 2013. Methods: We completed a descriptive analyses of 3 international projects. Results: In collaboration with Ukrainian obstetrics and gynaecology associations and the Society of Obstetricians and Gynecologists of Canada, an initiative seeking to improve emergency obstetrical care using the Advances in Labour and Risk Management International Program (AIP) was conducted in Ukraine. From 2006 to 2009, 912 providers participated in 18 AIP trainings. Since project termination, 10 AIP training with 435 participants were conducted by a national team. Training is now institutionalized into the Donetsk National Medical University (DNMU) curricula. Since 2010 in collaboration between the University of Toronto, and the DNMU, the Donetsk Telesimulation Satellite Center was established. A telesimulation program has been applied to introduce the Fundamentals of Laparoscopic Surgery course, with the objective to standardize the technical skills of Ukrainian professionals. In total, 137 participants from 11 sites have completed the course. Since 2011, a collaboration between the McGill University and the DNMU to improve disaster management and trauma care has been established. A risk assessment tool geared speci fically toward the European Football Championship Euro 2012 was developed. Trauma training has been conducted and the creation of a database of injury epidemiology. Conclusion: Sustainable partnerships is important to ensure long-term interest in an initiative either funded or not. Capacity building based on bottom-up approaches with the initiative coming from national professionals to ensure national ownership and leadership with long-term commitment is essential. 2. COSECSA, achievements and challenges in improving global surgery. P.G. Jani.

The rare (&lt;2%) development of calcium deposits in soft tissue, known as dystrophic calcification (DC) with the use of Stimulan® (Biocomposites Ltd, Wilmington, NC) absorbable, calcium sulfate antibiotic beads (CSABs) in the setting of orthopedic surgery has previously been described. However, the use of CSAB in hernia repair is relatively novel and its association with the development of DC in this setting has not been previously reported. We describe a case where DC following abdominal wall reconstruction with CSAB was misinterpreted on CT imaging as an enteric fistula and almost resulted in an unnecessary emergency surgical procedure.