Global Surgery: We Are Looking at The Moon, But Our Feet Are Still On the Earth

The article “The double-lumen irrigation-suction tube in the management of incisional surgical site infection after enterocutaneous fistula excisions: An observational study” investigates the effect of a double-lumen irrigation-suction tube (DLIST) in the management of surgical site infections and compares that to delayed primary closure for superficial Surgical Site Infections (SSIs) and to vacuum-assisted closure (VAC) in the case of deep SSIs [1]. Surgical Site Infections are the result of surgical interventions and they have been shown consistently to play a significant role in increasing morbidity and mortality, extending the length of stay in the hospital by requiring complicated wound management and, especially in the current environment of global financial stress, increasing the treatment costs by billions of dollars [2,3]. Technology, as in most areas in surgery, has come to the rescue with the use of negative pressure wound therapy (NPWT). Originating from the former Soviet Union in the 1980s, then in the early 1990s in Western Europe and finally in the US by 1997, the technique has managed to lead to impressive reductions in wound size and increased wound healing, thus improving the clinical outcome and expediting the transition to home for these patients [4,5]. However, as with all good things in life, there is always a catch. In the case of NPWT, its initial success led to an expanding market which in 2013 was valued globally at 1.5 billion dollars, and with a projected further growth [6]. The increasing demand and the continued success of the product also meant that the prices remained high, and possibly prohibitively so when we consider that we leave in a world where hospital budgets and national health system budgets are being increasingly pressured. That together with the importance, severity and relative frequency of the problem of SSIs, has led to an interest in identifying more cost-conscious care alternatives, without affecting the quality of the provided care.

In the article by Zao et al., the authors investigated the effect and cost of DLIST in the management of incisional SSIs after enterocutaneous fistula (ECF) excisions [1]. Part of the value of the article is based on two facts: a) the first one is that the authors have chosen to test their concept in a very difficult clinical problem, that of enterocutaneous fistulas, which is known to present clinicians with significant challenges, and b) the second one is that the authors represent the experience of a national referral center for such cases, which means that the patients that are involved in this study are some of the most challenging cases. These two facts add significant weight to the findings of this article.

Despite the limitations of a retrospective study, which the authors readily acknowledge, in an otherwise well-designed study they are able to show that placing DLIST is an efficient and cost-effective method to treat superficial SSIs after ECF excision, whereas in the case of deep SSIs, although the cost of DLIST is lower, the effect of VAC remains better. The message in this article is that we can provide effective care to our patients, even in some of the more challenging clinical situations, in a cost-conscious manner. However, at the same time we should be careful not to draw too many conclusions, or at least not too far-fetched ones. Specifically, this article does NOT tell us that we do not need technology or that we should place cost-efficiency above quality. The success of the DLIST technique, as we can see in the case of the deep SSIs, does not make VAC obsolete, as the latter remains the more successful technique; it just provides us with an alternative that can be used in situations with limited financial and other means, such as in developing countries where a majority of the global population resides (over 80% of the world population). The concept of Global Surgery became a key discussion point with the help of the World Health Organization (WHO). Specifically, the World Health Assembly with Resolution WHA68.15 “Strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage” in 2015 brought to the forefront the issue that basic surgical care is instrumental in saving lives and it is not a luxury [7]. An important part of this emergency and essential surgical care is dealing with SSIs, and as such finding ways to address them in a manner that will benefit the vast majority of our global patients is a step forward.

In conclusion, this article provides us with evidence that good surgical care can be delivered in a cost-conscious manner, so as to benefit a wider part of the global population. However, at the same time we should not ignore the vast potential of technological progress, as in essence this will provide us with the necessary tools to improve the quality and breadth of patient care. The challenge lies in identifying ways to deliver technological progress in a manner that will not make it prohibitive for the vast majority of the global population, as we need to remember that even if we end up traveling into space, our feet will still be on this earth.

Disclosure statement

The author has no competing interests to declare.