General surgery under limited conditions on the Syrian border

Aim: People living in the countryside are less to have access to health care than those

Living in the city center. In addition to this, when migrants are added, it becomes more difficult to use health services. Although 20% of the US population lives in rural areas, only 9% of physicians work in these areas, and general surgeons seem to be inadequate in small rural towns. This study was planned to determine the general surgical procedures performed in the district state hospital.

Methods: The study was carried out in the Ceylanpinar State Hospital with 50 beds, located approximately 150 km far from the city center of Sanliurfa. İn 2018, patient files were reviewed for general surgery polyclinic. Elective and urgent procedures were recorded and their results were evaluated. Patients who were operated for trauma were not included in the study

Results: During the study, 9576 patients were seen in the outpatient clinic. The total number of working days in 2018 was 228 and 42 patients per day. 424 major operations were performed during the study period. 84 appendectomies, 36 anal fissures, 17 hemorrhoids, 109 hernia, 35 laparoscopic cholecystectomy, 30 umbilical hernias, mesh repair in 8 patients with an incisional hernia, 101 pilonidal sinuses, 2 goiter and 2 cases omentum resection and hernia repair surgery was performed.

Conclusion: Especially in rural areas such as Şanlıurfa, where the population of rural areas and the number of refugees is high, the surgeon working in rural areas may need adequate infrastructure and experienced teams to provide a good health service.

Introduction

The health services of rural areas in developing countries are limited due to the insufficient and irregular distribution of human resources [1,2]. This unequal distribution of health workers further increases health disparities in rural areas [3,4]. Although 50% of the population is in rural areas, less than 25% of physicians and 38% of nurses are in these areas. The attrition of health care workers is an important problem in rural areas. In 2010, the World Health Organization proposed policies to keep health workers in tourist areas and rural areas. Recommendations include the recruitment of rural staff in rural areas, including rural health needs in the curriculum and the use of rural services in a rural area [5]. Şanlıurfa is a province where the population of rural areas is high and about half of the population lives in towns and villages. Due to the Syrian war, 22% of the population is refugees. The same applies in Ceylanpınar. Our hospital serves the refugees together with residents. This study was planned to determine the general surgical procedures performed in the district state hospital.

Materials and Methods

Informed consent was not obtained because the study was retrospective. The descriptive retrospective cohort study was designed. Research, World Health Organization Declaration of Helsinki "Involving Human Subjects Ethical Principles for Medical Research" was conducted according to the principles. The patients who applied to the general surgery clinic of Ceylanpınar State Hospital in 2018 were included in this study. All operations recorded. This rural hospital has a capacity of 50 beds during its working period and is 150 km and 1.5 hours away from Şanlıurfa province. There were two general surgeons about 6 months, one general surgeon for the other 6 months. The blood bank and most radiological studies were not available. There was a 7/24 emergency service in the hospital. In this study, non-traumatic general surgery clinic applications and results will be presented. Statistical analysis Variables are expressed as mean ± standard deviations (SD) or median (range) depending on their distribution. Categorical variables were expressed as frequency and percentage.

Result

During the study, 9576 patients were seen in the outpatient clinic. 2890 of these patients were refugees. 30% of our patients were refugees. The total number of working days in 2018 was 228 and 42 patients per day. 424 major operations were performed during the study period. 84 appendectomies, 36 anal fissures, 17 hemorrhoids, 109 inguinal hernias, 35 laparoscopic cholecystectomy, 30 umbilical hernias, mesal repair in 8 patients with an incisional hernia, 101 pilonidal sinuses, 2 goiter and 2 patients with omentum resection and hernia repair surgery was performed. The female/male ratio was 0.94 (4648/4928), in 164 cases general anesthesia was applied and in others, regional anesthesia was applied. Biopsy subcutaneous mass excision, 637 minor surgery was performed. Operations were sent to the pathology clinic of another hospital. Malignant pathology was not detected in any of the samples. Due to the patient's preference, some of them were transferred to the hospital in Sanliurfa.

Discussion

It shows that surgery in rural areas can be an important part of health services but is limited due to some shortcomings. In our hospital, a surgeon carried out only 424 major and 637 minor operations in one year due to the lack of surgical devices with new technology, the absence of blood bank and the patient’s preference as not choosing the hospital.

Most hospitals in the countryside consider providing surgical services very important for their hospitals. However, the inadequacy of surgeons and facilities limits this service. Concerning the rustic surgical workforce, the expanding period of specialists joined with the way that less broad surgery occupants are honing in rural proposes that the lack will just intensify in coming years [6,7]. Considering that the rate and severity of injury in rural areas is higher than in urban areas, the need for specialists will increase further [8,9]. The reason for the low number of experts in the health facilities in rural areas is that they resign before the workforce matures and new experts arrive [10].

The constant change of employees in rural hospitals is one of the biggest obstacles to the development and institutionalization of these hospitals. Some precautions can be taken to prevent this situation. It is possible to improve the financial situation of small clinics and increase their motivation with money to keep experts in rural areas. Some future specialists may be picked not to rehearse rustically to some degree since they feel deficiently arranged to go up against the various caseloads that numerous provincial specialists experience in their training [11,12]. There are a few preparing programs for situating in rural or provincial preparing track. Increasing the amount of general surgical specialty programs that offer knowledge of rustic preparation is a way to address the shortage of labor in the country's surgery [10]. To prevent this situation in our country, financial support is provided to the experts working in the countryside.

There are some possible limitations to the study. Our data only includes cases that applied to Ceylanpınar State Hospital. Patients who were brought to the hospital but could not be operated due to technical insufficiency were not included in the study. The number of operations was not very low compared to rural hospitals. The reason for this is that the district is far from the center and that refugees tend to solve their health problems instead of going to the city center. These results may not apply to all rural areas.

Ethics Committee Approval: Ethics committee approval was not received for this study because of the retrospective design.

1. Lehmann U, Dieleman M, Martineau T (2008) Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention. BMC Health Serv Res 8:19. Link: http://bit.ly/33bKTJQ
2. Appiagyei A, Kiriinya RN, Gross JM, Wambua DN, Oywer EO, et al. (2014) Informing the scale-up of Kenya's nursing workforce: a mixed-methods study of factors affecting pre-service training capacity and production. Hum Resour Health 12: 1-10. Link: http://bit.ly/2GHUiPG
3. Serneels P, Montalvo JG, Pettersson G, Lievens T, Butera JD, et al. (2010) Who wants to work in a rural health post? The role of intrinsic motivation, rural background, and faith-based institutions in Ethiopia and Rwanda. Bull World Health Organ 88: 342-9. Link: http://bit.ly/2YyxZWL
4. Buchan J (2010) Reviewing the benefits of health workforce stability. Human Resources for Health 8: 29 Link: http://bit.ly/2YjrSGt
5. (2010) Increasing access to health workers in remote and rural areas through improved retention. World Health Organization. Link: http://bit.ly/2Yz6Hj3
6. Thompson MJ, Lynge DC, Larson EH, Tachawachira P, Hart LG (2005) Characterizing the general surgery workforce in rural America. Arch Surg 140: 74-9. Link: http://bit.ly/2T38cRb
7. Zuckerman R, Doty B, Gold M, Bordley J, Dietz P, et al. (2006) General surgery programs in small rural New York State hospitals: A pilot survey of hospital administrators. J Rural Health 22: 339-42. Link: http://bit.ly/2ZtC2kk
8. Kwakwa F, Jonasson O (1997) The general surgery workforce. Am J Surg 173: 59-62. Link: http://bit.ly/2KiqiuA
9. Jonasson O, Kwakwa F, Sheldon GF (1995) Calculating the workforce in general surgery. JAMA 274: 731-4. Link: http://bit.ly/2OCYVks
10. Başak F (2018) General surgery service with limited feasibility in a rural hospital; Retrospective cohort study. J Surg Med 2: 236-238. Link: http://bit.ly/2YHLAuN
11. Ritchie WP, Rhodes RS, Biester TW (1999) Workloads and practice patterns of general surgeons in the United States, 1995-1997: A report from the American Board of Surgery. Ann Surg 230: 533-42. Link: http://bit.ly/2KeaPNd
12. Landercasper J, Bintz M, Cogbil TH, Bierman SL, Buan RR, et al. (1997) Spectrum of general surgery in rural America. Arch Surg 132: 494-6. Link: http://bit.ly/2Kl3MBb