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Research Areas - Global Surgery

Desirable features of innovations, new methods and practices in LMIC are that they are low-cost, high quality, setting-appropriate and sustainable. The intended projects are clinically oriented and designed to fulfil these criteria.

Groin Hernia

220 million people worldwide live with groin hernia.

Groin hernia repair is the most commonly performed general surgical procedure worldwide. In high income settings, the lifetime prevalence of groin hernia repair in men is 27% and in women it is 3%. The prevalence of groin hernia in men is around 10% and 2-3% in women. Hernia repair is the most commonly performed general surgical procedure worldwide. Using mesh to achieve a tension-free inguinal hernia repair is golden standard in hernia repair as it significantly reduces the risk of hernia recurrence in men. A commercial mesh costs over 100 USD and is therefore too costly for patients and health care systems in low income countries. A mosquito mesh has been found to be a safe and effective alternative to commercial mesh for elective inguinal hernia repair. The mesh initially studied is not available any longer and a new mesh from a reliable source has to be produced instead. The conclusion that mesh hernia repair is effective and safe also in low income settings stands.

The next question is therefore who should perform the operations and how the training of these individuals should be designed. Task-sharing of surgical procedures is practiced in many African countries. In sub-Saharan Africa, non-surgeon physicians and Non-Physician Clinicians (NPCs) commonly perform inguinal hernia repair.

In high income settings women account for less than 10% of all adult groin hernia patients. In some low-income settings, however, women constitute up to 40% of patients undergoing hernia surgery. Women are more often operated on as emergencies than men and face higher risks of adverse events including death following groin hernia surgery. In contrast to men, the evidence for open hernia repair in women is poor and more research is needed.

Project 1. Outcomes after low cost mesh repair of inguinal hernia performed by surgeons and non-surgeons in Ghana

In this prospective cohort study, surgeons and non-surgeon medical doctors proficient in inguinal hernia repair using sutured techniques have been trained in mesh hernia repair by consultant surgeons. After passing a hands-on examination, they have operated 242 patients. The patients have been followed up after 2 weeks and after 1 year. The manuscript is due for publication. Follow up after 3 years is planned.

Endpoints: recurrence (primary), postoperative complications, chronic pain, self assessed health status and patient satisfaction (secondary).

Trial registration: https://doi.org/10.1186/ISRCTN63478884

Project 2. Training and task sharing in groin hernia surgery in men in Sierra Leone

In this single blinded, randomised trial, non-surgeon medical doctors and non-physician clinicians proficient in inguinal hernia repair using sutured techniques have been trained in mesh hernia repair by consultant surgeons. After passing a hands-on examination, they have operated 230 patients. The patients have been followed up after 2 weeks. One year follow up is due in February 2019. Follow up after 3 years is also planned.

Endpoints: recurrence (primary), postoperative complications, chronic pain, self assessed health status and patient satisfaction (secondary).

Trial registration: https://doi.org/10.1186/ISRCTN63478884

Project 3. Methods in mesh hernia repair in women – a double blinded randomised trial in Uganda

In this double blinded, randomised trial two methods of open mesh hernia repair in women will be compared. Training of international and Ugandan surgeons in the two techniques will begin in March 2019. Thereafter, 440 patients will be operated within this study.

Endpoints: recurrence (primary), postoperative complications, chronic pain, self-assessed health status and patient satisfaction (secondary).

Trial registration: Submitted to ISRCTN

Paediatric surgery

In low income countries, children constitute a large proportion of the populations and a considerable part of all surgical conditions affect children. A survey in Uganda, Sierra Leone, Rwanda and Nepal found that 19% of the children (0-18 years) had a surgical need and that it was not met in 62% of the cases. The estimated lifetime prevalence of surgical conditions in children in Uganda is 14.0 % . Many of these childhood surgical conditions could be treated successfully with surgery. Injuries and congenital anomalies are two groups of conditions that account for a large proportion of paediatric surgical cases and if they go untreated contribute to lifelong disability and a considerable burden of disease. In addition, several studies show high mortality rates after paediatric surgery.

There is a dire shortage of knowledge regarding paediatric surgery in low and middle income countries. Lack of knowledge of the epidemiology of these conditions makes accurate planning, capacity building and resource allocation impossible.

The first PhD student enrolled within the group Global Surgery at Karolinska Institutet, Dr Mary Margaret Ajiko, is a general surgeon with interest in paediatric surgery. The PhD projects are related to epidemiology of paediatric surgical conditions and to what extent the need for surgical procedures is meet in Uganda. Further on, a qualitative study investigates perceptions of and barriers to surgical care among caregivers. Finally, a prospective cohort study will investigate outcome after paediatric surgery and test one or two interventions to reduce the risk of morbidity and mortality postoperatively. Combined, the paediatric surgery research will provide evidence that can be used to increase and improve paediatric surgical services in Uganda and other countries facing similar challenges.

Breast cancer

With half a million deaths annually, breast cancer is a mass killer in women. In low income countries such as Uganda and Ethiopia, women present at young age with advanced disease when cure is not possible. The consequences to their families and society in general are immense. This research will investigate the prevalence of BRCA 1 and 2 mutations in young women and men with diagnosed breast cancer and their first degree relatives in Ethiopia. This has not been done before and the scientific contribution will be important. Identifying families at increased risk and target screening activities at them is a better option than population wide screening for breast lesions in women in LMIC where financial resources are extremely limited. The research will also investigate the understanding of breast cancer and its treatment, in particular surgical treatment, to better be able to design breast cancer prevention and treatment. This research has potential to lead to cost effective, risk based screening and treatment as well as improved outcomes in the worlds poorest countries where most breast cancer mortality occurs.