Global economic burden of unmet surgical need for appendicitis

BJS, 2022, 109, 995–1009 https://doi.org/10.1093/bjs/znac195 Advance Access Publication Date: 26 July 2022 Original Article Global economic burden of unmet surgical need for appendicitis Anna Reuter1,2 , Lisa Rogge1,3, Mark Monahan4, Mwayi Kachapila4, Dion G. Morton4, Justine Davies5,6,7,* and Sebastian Vollmer1,* on behalf of NIHR Global Surgery Collaboration 1 *Correspondence to: (J.D.) Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK (e-mail: [email protected]); (S.V.) Department of Economics & Centre for Modern Indian Studies (CeMIS), University of Goettingen, Waldweg 26, 37073 Göttingen, Germany (e-mail: svollmer @uni-goettingen.de) Members of the NIHR Global Surgery Collaboration are co-authors of this study and are listed under the heading Collaborators. Abstract Background: There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and $73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and $75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially. Background It has been estimated that, each year, 143 million additional surgical procedures need to be done in low- and middle-income countries to prevent disability and reduce mortality1. The associated loss of economic productivity has been estimated at $12.3 trillion for the interval 2015–20301. In addition to insufficient access to surgery, it has been recognized that outcomes of surgery can be suboptimal for many patients in low- and middle-income countries. This is reflected in the higher rate of perioperative mortality and surgical-site infections experienced by patients undergoing surgery in lowand middle-income countries compared with those in high-income countries2,3. This high-level evidence has been insufficient to prompt large-scale policy change and substantial investment in surgery. The cost to a given society of not providing adequate surgical care for specific conditions might provide direct evidence that more targeted investment in surgical services could be cost-effective. Surgery is a treatment for many diverse conditions4. Although the magnitude of lack of access to quality surgical care has been estimated, developing a health service to provide such holistic surgical care for all conditions may not currently be attainable. It should, however, be within the reach of many countries to provide services to treat some conditions that are otherwise fatal and require a fairly simple procedure5. Appendicitis is a common condition, with an incidence of around 17 700 000 in 20196. Although it leads to death or disability if not treated, timely surgical treatment results in a rapid return to normal function. It disproportionally affects younger populations, who are generally economically productive. Hence, lack of access to surgical treatment for appendicitis is likely to have substantial economic consequences for individuals and societies. Received: January 20, 2022. Revised: April 27, 2022. Accepted: May 12, 2022 © The Author(s) 2022. Published by Oxford University Press on behalf of BJS Society Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/bjs/article/109/10/995/6650196 by guest on 07 October 2022 Department of Economics & Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany 3 Institute of Economics, Department of Health Economics, Friedrich-Alexander-Universität Erlangen-Nürnberg, Germany 4 Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK 5 Institute of Applied Health Research, University of Birmingham, Birmingham, UK 6 Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa 7 Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa 2 996 | BJS, 2022, Vol. 109, No. 10 a Adverse events resulting from not providing surgery to the local standard Incidence of appendicitis (LMICs) Pn P op oop No operation Operation a 82% 15.5% Minor adverse events Successful Deaths: 0% Days lost: 4 10% 2.5% Reoperation Mild cases Deaths: 0.6% Days lost: 24 68.5% % Moderate cases Severe cases Deaths: 10% Days lost: 15 Deaths: 19% Days lost: 60 Deaths: 0% Days lost: 4 Deaths: 0.6% Days lost: 60 b 21.5 Pnoop∗ (b – a) b Adverse events resulting from not providing surgery to the highest standard A B Incidence of appendicitis (LMICs) Pn P op Operation 82% Successful C 15.5% Operation 2 1.5 10% 8 7% % 68.5% Minor Reoperation adverse events Mild cases Deaths: 0% Deaths: 0.6% Deaths: 0.6% Deaths: 0% Days lost: 7 Days lost: 24 Days lost: 60 Days lost: 4 0% 10 0 % No operation 2.5% Moderate cases Severe cases Deaths: 10% Deaths: 19% Days lost: 15 Days lost: 60 D Incidence of appendicitis (HICs) oop Sucessful 10.5% Minor adverse events No operation . n.a. n.a. 2.5% n.a Reoperation Mild cases Moderate cases Severe cases n.a. n.a. n.a. Deaths: 0% Deaths: 0.1% Deaths: 0.1% Days lost: 4 Days lost: 15 Days lost: 60 Rationale: Which adverse events occur because the care provision (quantity and quality) in LMICs is worse than in HICs? (A + B) – (C + D) (A + B) – C† Fig. 1 Calculation of expected mortality risk and number of absent days a Resulting from not providing surgery to the local standard, and b resulting from not providing surgery to the highest standard. *Non-fatal cases. †Assuming that all patients with appendicitis undergo surgery in high-income countries (HICs), such that D = 0. LMICs, low- and middle-income countries; n.a., not applicable. Table 1 Key statistics by WHO region Africa Americas No. of countries 44 29 Incidence per 100 000, 184.27 (72.21) 359.73 (185.64) mean (s.d.)* Surgical volume per 1167 (1305) 5635 (5158) 100 000, mean (s.d.)† No. of appendicectomies 74.17 (62.19) 213.05 (236.18) per 100 000 (approach 2), mean (s.d.)‡ Unmet need (%) (approach 76.65 (26.10) 24.59 (28.75) 1), mean (s.d.)‡ Unmet need (%) (approach 60.24 (27.19) 33.64 (32.62) 2), mean (s.d.)‡ Wage per capita, mean 6544 (7450) 17 609 (12 994) (s.d.)§ Total population 979.14 974.59 (millions)¶ Eastern Mediterranean 18 264.86 (47.48) 3305 (2243) 112.63 (73.14) Europe South-East Asia Western Pacific World 50 10 19 170 232.25 (45.75) 517.36 (526.16) 234.50 (111.59) 262.05 (177.08) 7890 (4463) 1784 (1878) 181.78 (137.17) 107.49 (87.45) 4637 (6365) 4557 (4767) 132.88 (97.81) 142.10 (142.65) 35.48 (35.73) 8.20 (18.18) 67.21 (29.96) 40.23 (36.02) 38.65 (38.14) 31.08 (31.57) 5.21 (15.18) 58.19 (36.95) 20.36 (28.37) 31.85 (34.15) 18 437 (12 664) 28 174 (16 895) 6288 (3694) 659.54 913.32 1921.74 20 689 (19 966) 17 618 (16 056) 1844.54 7301.06 Approach 1 calculates unmet need for appendicitis assuming that the proportion of this unmet need is equivalent to the unment need for all conditions requiring surgery. Approach 2 calculates unmet need as the relative difference of estimated appendicectomies (calculated as World Bank income group-specific share of surgical volume) to the number of appendicitis cases. *Institute for Health Metrics and Evaluation Global Burden of Disease. †Holmer et al.10. ‡Detailed description available in supplementary material S.3. §Organisation for Economic Co-operation and Development, International Labour Organization (harmonized to 2015 US dollar purchasing power parity). ¶World Bank World Development Indicators. Country-specific inputs are shown in supplementary material Table S9 and graphs of unmet need by region and income group in Fig. S8. Downloaded from https://academic.oup.com/bjs/article/109/10/995/6650196 by guest on 07 October 2022 Rationale: Which adverse events (mortality share/number of working days lost*) occur per case of appendicitis because the quantity of operations is insufficient in LMICs? Reuter et al. | 997 a Unmet need in 2015 (approach 1) 0, 0.2 0.2, 0.4 0.4, 0.6 0.8, 1 No data b Unmet need in 2015 (approach 2) Fig. 2 Estimated share of unmet need in 2015 by country Calculated using a approach 1 and b approach 2. Approach 1 calculates unmet need for appendicitis assuming that the proportion of this unmet need is equivalent to the unment need for all conditions requiring surgery. Approach 2 calculates unmet need as the relative difference of estimated number of appendicectomies (calculated as World Bank income group-specific share of surgical volume) to the number of appendicitis cases. Effective treatment of appendicitis requires appropriate and timely surgery, necessitating ready access to acute services7, unlike planned procedures that can be referred to a tertiary centre. Appendicitis can vary in severity from self-limiting infection to life-threatening peritonitis, depending on the development of irreversible, but unpredictable, gangrene. The safest treatment is, therefore, early surgery. Effective surgery for appendicitis is also reflective of local and district surgical services8, and improved delivery is likely to have additional benefits for other common surgical conditions. Estimates are available for the global incidence of appendicitis6, the unmet need for surgery1, and of harm from lack of access to quality surgery, including procedures for appendicitis2. However, there has been no previous estimation of the global economic burden associated with failure to provide access to quality care for appendicitis. Given that access to surgical treatment for appendicitis reflects local surgical care provision, such information is needed to inform discussions on the investment case for provision of surgical care at country, regional, and international levels1,9. This study assessed the economic burden (from loss of income) associated with unmet or delayed or substandard surgical care in low- and middle-income countries. The study focused on two types of indirect cost: lost income owing to premature death and lost income due to absenteeism and/or sick days. Methods This study calculated the economic burden in two scenarios: that resulting from not providing surgery at local standards in low- and middle-income countries; and that resulting from not providing surgical care in these countries at the standard available in high-income countries, which, based on the literature3, was assumed to reflect optimal (high-quality) care. Downloaded from https://academic.oup.com/bjs/article/109/10/995/6650196 by guest on 07 October 2022 0.6, 0.8 998 | BJS, 2022, Vol. 109, No. 10 Table 2 Economic burden estimates No. of countries Mortality-related income losses Not providing surgery to local standard Approach 1 Approach 2 Approach 2 Absenteeism-related income losses Not providing surgery to local standard Approach 1 Approach 2 Not providing surgery to highest standard Approach 1 Approach 2 Total economic burden Not providing surgery to local standard Approach 1 Approach 2 Not providing surgery to highest standard Approach 1 Approach 2 US $ (millions) % of GDP US $ (millions) % of GDP US $ (millions) % of GDP US $ (millions) % of GDP US $ (millions) % of GDP US $ (millions) % of GDP US $ (millions) % of GDP US $ (millions) % of GDP US $ (millions) % of GDP US $ (millions) % of GDP Americas Eastern Mediterranean Europe South-East Asia Western Pacific World 44 29 18 50 10 19 170 6219 9777 7808 1415 29 186 36 627 91 031 0.1781 4445 0.0352 13 316 0.1232 6819 0.0050 889 0.2602 24 040 0.1337 22 476 0.0870 71 984 0.1273 0.0479 0.1076 0.0031 0.2144 0.0820 0.0688 6305 9969 7919 1619 29 419 37 151 92 383 0.1806 4532 0.0359 13 508 0.1249 6930 0.0057 1094 0.2623 24 273 0.1356 23 000 0.0883 73 336 0.1298 0.0486 0.1093 0.0038 0.2164 0.0840 0.0701 95 154 122 23 446 622 1461 0.0027 69 0.0006 206 0.0019 107 0.0001 14 0.0040 372 0.0023 389 0.0014 1157 0.0020 0.0007 0.0017 0.0001 0.0033 0.0014 0.0011 165 318 214 206 631 1086 2622 0.0047 141 0.0011 367 0.0034 200 0.0007 198 0.0056 561 0.0040 863 0.0025 2330 0.0040 0.0013 0.0032 0.0007 0.0050 0.0032 0.0022 6314 9931 7929 1437 29 631 37 249 92 492 0.1808 4515 0.0358 13 521 0.1251 6925 0.0051 903 0.2642 24 411 0.1360 22 865 0.0884 73 141 0.1293 0.0487 0.1093 0.0032 0.2177 0.0835 0.0699 6470 10 287 8133 1825 30 050 38 238 95 004 0.1853 4672 0.0370 13 875 0.1283 7130 0.0064 1291 0.2680 24 834 0.1396 23 863 0.0908 75 666 0.1338 0.0500 0.1125 0.0045 0.2214 0.0871 0.0723 US dollars are expressed in 2015 purchasing power parity. Absolute costs are the sum of the respective country-level costs by region; relative costs are absolute costs divided by the sum of country gross domestic product (GDP) by region. Approach 1 calculates unmet need as the relative difference of surgical volume to the minimum surgical volume proposed by the Lancet Commission on Global Surgery. Approach 2 calculates unmet need as the relative difference of estimated appendicectomies (calculated as World Bank income group-specific share of surgical volume) to the number of appendicitis cases. Country-specific results can be found in supplementary material Fig. S10, Fig. S11, and Table S11; intermediate results by region and income group in supplementary material Fig. S9; and sex-specific results by region in supplementary material Fig. S12 and Fig. S13. The economic burden attributed to scenario 1 could be avoided by increasing the coverage of operations to all who require them while keeping the standard of care in each country the same as it is currently. Scenario 2 involves increasing the coverage of operations to all who require them while increasing the standard of care in each country to be equivalent to that seen in high-income countries. Additionally, the study estimated the total economic burden experienced owing to the current state of care across countries, that is the consequences of providing surgical care of local standard to the proportions of people who currently receive care, and providing no surgical care to those who do not. Supplementary material S.2 provides a detailed description of the method, and details of the data sources and indicator construction can be found in supplementary material S.3. The main analysis was conducted at country level, although some data inputs were available only at the level of country-income groups. The results are presented aggregated to WHO region in the main Downloaded from https://academic.oup.com/bjs/article/109/10/995/6650196 by guest on 07 October 2022 Not providing surgery to highest standard Approach 1 US $ (millions) % of GDP US $ (millions) % of GDP Africa Reuter et al. Africa Local standard (1) Local standard (2) Mortality Highest standard (1) Highest standard (2) Americas | 999 Absenteeism Local standard (1) Local standard (2) Highest standard (1) Highest standard (2) Eastern Mediterranean Local standard (1) Local standard (2) Europe Local standard (1) Local standard (2) Highest standard (1) Highest standard (2) South-East Asia Local standard (1) Local standard (2) Highest standard (1) Highest standard (2) Western Pacific Local standard (1) Local standard (2) Highest standard (1) Highest standard (2) 10 20 30 US $ (billions) Fig. 3 Composition of economic burden Economic burden is expressed in 2015 US dollar purchasing power parity. Approach 1 calculates unmet need as the relative difference of surgical volume to the minimum surgical volume proposed by the Lancet Commission on Global Surgery. Approach 2 calculates unmet need as the relative difference of estimated number of appendicectomies (calculated as World Bank income group-specific share of surgical volume) to the number of appendicitis cases. text. The estimates are presented for the year 2015 as this was the latest year for which data from most sources were available. Unmet surgical need All scenarios required information on the number of individuals with appendicitis who do not receive any surgical care. For this, estimates of the incidence of appendicitis for a given country and 5-year age group in 2015 from the Global Burden of Disease project were used6. Data on numbers of appendicectomies performed (or the shortage of appendicectomies) were not available for most countries. Thus, the unmet need was estimated using the following two approaches. The first approach assumed a need for surgical volume of 5000 operations per 100 000 people, for all conditions that should be treated surgically, following the Lancet Commission on Global Surgery1. Using data on a country’s total surgical volume delivered from Holmer et al.10, the gap between surgical need and volume was defined as the unmet need. It was assumed that the proportion of unmet need for appendicitis is equivalent to that for all conditions requiring surgery. The second approach assumed that appendicectomies comprise a certain share of surgical volume, with that share varying depending on characteristics of the country. This approach was taken based on the knowledge that lower-income countries perform a larger volume of emergency and gastrointestinal procedures (such as appendicectomy), relative to total surgical volume, than high-income countries11. Given that data on volume of appendicectomies to surgical volume were not available for most countries, several steps were taken to derive these estimates. First, information on the ratio of appendicectomies to gastrointestinal surgery from 116 countries was taken from the COVIDSurg Collaborative, GlobalSurg Collaborative database12. Second, information on the share of gastrointestinal surgery relative to total surgical volume in lowand middle-income countries was taken from multiple publications identified in a systematic search of the literature, as listed in the supplementary material Table S2. Data from England’s Hospital Episode Statistics were used as a proxy for data from high-income countries. Data from low-, middle-, and high-income countries are shown in the supplementary material to illustrate how the ratio of gastrointestinal surgery to total surgery varies between World Bank income groups. Although these data were used to calculate the predicted number of appendicectomies for high-income countries, it was assumed that there is no unmet need in such countries; thus, the resulting figures were not included in the estimation. Third, a Downloaded from https://academic.oup.com/bjs/article/109/10/995/6650196 by guest on 07 October 2022 Highest standard (1) Highest standard (2) 1000 | BJS, 2022, Vol. 109, No. 10 combination of these sources was used to predict the number of appendicectomies for each country based on its surgical volume from Holmer et al.10. The gap between a country’s incidence of appendicitis and the predicted number of appendicectomies was then defined as the unmet need. For both approaches, it was assumed that all patients with appendicitis in high-income countries receive surgical treatment. Organisation for Economic Co-operation and Development (OECD) data for 25 high-income countries in 2015 showed that, for most countries, the number of cases of appendicitis was very close to the number of appendicectomies performed13,14. Economic burden estimation Results Table 1 shows the key statistics used to calculate the economic burden of unmet surgical need by WHO region. The estimated share of unmet need was higher using the first approach than the second for all regions except the Americas. This was also evident at country level (supplementary material Fig. S8). Country-specific shares of unmet need are shown in Fig. 2, which allows a more detailed comparison of the two approaches. For most countries, approach 1 yielded a higher unmet need than approach 2, whereas the reverse applied mostly to Latin American countries (supplementary material Fig. S8). Discussion This study has identified a substantial absolute and relative economic burden associated with failure to provide adequate or Downloaded from https://academic.oup.com/bjs/article/109/10/995/6650196 by guest on 07 October 2022 This study focused on two types of income loss: that resulting from early death and that associated with absenteeism. In the first step, the mortality and absenteeism outcomes of surgical treatment in low- and middle-income countries were estimated using surgical treatment at a standard received in low- and middle-income countries and that in high-income countries (as highest available standard), and outcomes of no surgical treatment at all (described in detail in the supplementary material Section S2). Estimates of the probabilities and mortality or absenteeism (days lost) outcomes were based on adverse events of surgically treated appendicitis from the GlobalSurg Collaborative database3,15 (exact definitions are available in supplementary material Table S2). The outcomes of not surgically treating appendicitis in low- and middle-income countries rely on the literature summarized in the supplementary material Table S6. Multiplied by the share of unmet surgical need, this gave the expected mortality risk and the number of days absent from employment resulting from not providing surgery to the local or highest standard to an individual with appendicitis (Fig. 1). In the next step, the expected mortality risk was multiplied by the age-specific incidence of appendicitis to obtain the total number of expected deaths for a given country and age group. The associated income losses were calculated by multiplying the number of expected deaths by the earnings the individuals were expected to have received if they had not died. Similarly, the expected number of absent days was multiplied by the share of unmet surgical need and the incidence of appendicitis to obtain the total number of expected lost working days for a given country. Absenteeism-related income losses were calculated by multiplying the lost working days by the average daily wage. Estimates of the average annual wage for each country were extracted from the International Labour Organization16,17 and OECD18 databases, and all costs were expressed in US dollar purchasing power parity (PPP), deflated to the year 2015. All costs were aggregated by WHO region to display the main results. Country-level results are available in the supplementary material Fig. S16, Table S11. As an intermediate outcome, excess mortality resulting from not providing surgery to local standards was estimated at 4185 per 100 000 patients with appendicitis using approach 1 and 3448 per 100 000 using approach 2 across the whole sample (supplementary material Table S10). The rate was highest in Africa (8299 per 100 000 for approach 1 and 6522 per 100 000 for approach 2) and South-East Asia (7277 and 6301 per 100 000, respectively). The mortality rate from not providing surgery at the highest standard was slightly higher, on average 4237 per 100 000 (approach 1) and 3500 per 100 000 (approach 2) across the sample. The resulting income loss estimates are shown in Table 2. Mortality-related income losses resulting from not providing surgery to the current local standard of care amounted to $91 031 million (2015 PPP) for all countries using approach 1, ranging from $1415 million for Europe and $36 637 million for Western Pacific. Using approach 2, the mortality-related income losses totalled $71 984 million, ranging from $889 million in Europe to $24 040 million for South-East Asia. Expressed as a percentage of gross domestic product (GDP), the economic burden ranged from 0.0050 per cent of GDP in Europe to 0.2602 per cent of GDP in South-East Asia using approach 1, and from 0.0031 per cent of GDP in Europe to 0.2144 per cent in South-East Asia using approach 2. The mortality-related income losses associated with not providing surgery to the highest standard of care were slightly higher, but very similar to the income losses of not providing surgery to local standards. Similar to the mortality-related income losses, absenteeism-related income losses associated with not providing surgery to local standards were lowest in Europe and highest in Western Pacific when estimated using either approach. In Europe, income losses were $23 million for approach 1 and $14 million for approach 2; in Western Pacific, losses were $622 million and $389 million respectively. However, the difference between income losses of not providing surgery to local versus highest standards was much larger than for the mortality estimates. For South-East Asia, the economic burden increased by about 50 per cent, for all other regions except Europe between 75 and 120 per cent, and for Europe it increased 8-fold (approach 1) or 13-fold (approach 2). Combining mortality and absenteeism-related income losses, the global economic burden of not providing surgery to local standards amounted to $92 492 million using approach 1 and $73 141 million using approach 2. The additional economic burden of not providing surgery to the highest standard was $2512 million for approach 1 and $2525 million USD for approach 2. The economic burden of unmet access to surgical care at local standards comprised between 87 and 97 per cent of the total economic burden in all regions except Europe (supplementary material Fig. S15). Absenteeism-related income losses contributed to a small fraction of the economic burden of unmet surgical need for appendicitis, irrespective of the approach employed or benchmark (Fig. 3). The absolute economic burden was highest in South-East Asia and Western Pacific, but the difference between the two approaches was large for both regions. However, even the lower estimates for both regions yielded some 1.5–2-fold higher absolute costs than most other regions. Reuter et al. (which is particularly important in the emergency setting). It could also enable increased efficiency of theatre utilization. Improved access to emergency appendicectomy will thereby provide benefits in surgical care that reach beyond the treatment of appendicitis. Although training surgical providers comes at a cost, if countries can raise revenue from earnings forgone as a result of morbidity or mortality associated with lack of access to quality care for appendicitis, and invest 5 per cent of this into improving services, as a recommended minimum share of public spending on health28, this could easily cover the costs of training. These findings can be put into perspective by taking India as an example. According to Global Burden of Disease data, India had an incidence rate of appendicitis of 121 per 100 000 in 2015 (world median 240 per 100 000), or about 765 000 cases in the age group 20–64 years, for which the economic burden was calculated. The present study estimated an unmet need for 653 000 people (85 per cent) in approach 1, and 418 000 people (55 per cent) in approach 2. Total costs for not providing surgery to a local standard amounted to $14 086 million in approach 1 and $9017 million in approach 2. In contrast, total care costs were 3616 rupees or $69.5 for an appendicectomy at a tertiary care hospital in India in 2010–201129. If India could invest 5 per cent of the foregone earnings (for example, extracted through taxation) in surgical care, this would free up resources to provide 10.1 million (approach 1) or 6.5 million (approach 2) additional appendicectomies, thus closing the gap in surgical need. Such service development would inevitably provide wider benefits, particularly in emergency surgical care, as no service is provided in isolation. Measuring the societal impact of such an investment would be expected to demonstrate substantial additional improvements in care and associated societal benefits. Although the results as a whole are striking, there are some nuances within the findings that are worthy of explanation. The economic burden, relative to GDP, of unmet surgical need was highest in South-East Asia, followed by Africa. Africa and South-East Asia had the greatest economic burden as both had a comparatively high share of unmet surgical need according to the estimates. For South-East Asia, a large contributor to the economic burden was the high incidence rate in Nepal, Bhutan, and Bangladesh according to the Global Burden of Disease data. Without these outliers, South-East Asia would have ranked second after Africa. The ranking differed between economic burden relative to GDP and absolute economic burden of unmet surgical need. The absolute economic burden was highest in Western Pacific and South-East Asia, followed by the Americas, Eastern Mediterranean, and Africa. For Western Pacific, relatively high wages led to higher income losses, whereas the high unmet need and the extreme incidence rates contributed further to the high economic burden for South-East Asia. For most regions, the income losses were higher using approach 1 compared with approach 2; the reverse was, however, true for the Americas, and was also evident at the country level. This seemed to be driven by a combination of comparatively high surgical volume with an even higher incidence rate. For the first approach, the gap between actual surgical volume and the need to achieve a surgical volume of 5000 per 100 000 was considered to estimate the unmet need. As the surgical volume was quite high in the Americas, this resulted in a reasonably low unmet need when using approach 1. Still, the surgical volume was not high enough to counterbalance the very high incidence rate, such that the estimate of unmet need in approach 2 exceeded the estimate of approach 1. There are limitations to this study. The main constraint is the availability of data on appendicitis incidence, outcomes, and Downloaded from https://academic.oup.com/bjs/article/109/10/995/6650196 by guest on 07 October 2022 quality surgical services for the treatment of acute appendicitis. This economic burden, although substantial for any low- or middle-income country, varied by more than 50-fold across different geographic regions. Reduction in mortality and morbidity, and thus reduction in patient’s income losses, through provision of surgery requires that surgical care can be accessed and that care, once accessed, is of high quality. The Lancet Global Health Commission on High Quality Health Systems19 has suggested that lack of quality care is a greater contributor to lives lost than lack of access. In the present analysis, the economic burden was calculated both in terms of improving access to local quality of care and improving access to care at the best global standard. This was done with the aim of teasing apart the relative contributions of lack of access and lack of quality to the economic burden. It is notable that, for treatment of appendicitis, major improvements can be achieved by improving access to care delivered at local standards, and that the additional benefits from meeting the care standards of high-income countries, which were taken to be reflective of high quality, are relatively marginal. This suggests that most benefit can be gained by improving access to care at standards already attained within a geographic region. At first glance, this stands in contrast to the findings of a previous study20 that calculated the unmet surgical need of digestive diseases in low- and middle-income countries in terms of disability-adjusted life-years (DALYs). It was found that 45 per cent of the current surgically avertable burden in terms of DALYs could be avoided with scaled up access to higher-quality surgical care (defined by a lower case fatality rate). This may be explained in part by differences in methodology, but most likely relates to the impact of surgery on mortality from different digestive diseases. Simple emergency surgery for appendicitis has a substantial effect on mortality, maximizing the impact of reduced access. Appendicectomy was selected because it is an emergency procedure required worldwide, and for which every surgeon receives training. Unlike specialist procedures, accessing any surgically ready facility should enable appropriate care. For more complex procedures, lack of appropriate surgical expertise is more likely to influence outcomes adversely. The present study found that improving access to appendicectomy at current local standards of care can substantially decrease mortality. This shows that, despite calls for improved quality, access should not be neglected, especially for the most common emergency procedures. Although they did not compare outcomes resulting from lack of access versus lack of quality, other studies21,22 have shown that lack of access to surgical care is a huge issue in low- and middle-income countries, particularly for emergency conditions7. Access is a multidimensional problem, encompassing service availability, and geospatial, financial, and sociocultural considerations. Solutions therefore require engagement of multiple stakeholders23,24. Although dimensions of geospatial, financial, and sociocultural considerations certainly need to be addressed, they offer complex challenges25. However, given the relative simplicity of surgery for appendicitis, it may be that service availability issues can be addressed more readily by task-shifting or sharing, to compensate for the worldwide shortage of surgeons10. Task shifting or sharing has been applied successfully to caesarean section and inguinal hernia in some contexts26,27. Increasing the availability of technicians could grow surgical services more rapidly than can possibly be achieved through traditional training. This solution could enable out-of-hours surgery in local hospitals and also release surgeons to provide increased diagnostic and perioperative care | 1001 1002 | BJS, 2022, Vol. 109, No. 10 Collaborators National Institute for Health Research (NIHR) Global Surgery Collaboration: AA Essam, Abd Elkhalek Sallam, Abd Elrahman Elshafay, Abd El-Rahman Hegazy Khedr, Abdalla Gamal Saad, Abdalla Gharib, Abdalla Kenibar, Abdallah Salah Elsherbiny, Abdalrahman Adel, Abdelaziz Abdelaal, Abdelaziz Osman Abdelaziz Elhendawy, Abdelfatah Hussein, Abdelkader Belkouchi, Abdelmalek Hrora, Abdelrahman Adelshone, Abdelrahman Alkammash, Abdelrahman Assal, Abdelrahman Geuoshy, Abdelrahman Haroun, Abdelrahman Mohammed, Abdelrahman Sayed, Abdelrahman Soliman, Abdelrhman Essam Elnemr, Abdelrhman KZ Darwish, Abdelrhman Osama Elsebaaye, Abdul Khalique, Abdul Rehman Alvi, Abdul Wahid Anwar, Abdulaziz Altwijri, Abdullah Al-Mallah, Abdullah Almoflihi, Abdullah Altamimi, Abdullah Daqeeq, Abdullah Dwydar, Abdullah Gouda, Abdullah Hashim, Abdulmalik Altaf, Abdulmalik Huwait, Abdulrahman Abdel-Aty, Abdulrahman M. Altwigry, Abdulrahman Sheshe, Abdulrasheed A Nasir, AbdulRazzaq Oluwagbemiga Lawal, Abdulshafi Khaled Abdrabou, Abdurrahaman Sheshe, Abdussemiu Abdurrazzaaq, Abebe Bekele Zerihun, Abeer Al-shammari, Abeer El Gendy, Abeer Esam, Abeer Marey, Abhishek Mittal, Abiboye Yifieyeh, Abid Bin Mahamood, Abidemi Adesuyi, Abouelatta Khairy Aly, Abrar Nawawi, Adam Gyedu, Ade Waterman, Adedapo Osinowo, Adedeji Fatuga, Adel Albiety, Adel B Hassanein, Adel Denewar, Adeleke Adekoya, Ademola Adebanjo, Ademola Adeyeye, Ademola Popoola, Adesina Adedeji, Adesoji O Ademuyiwa, Adesoji Tade, Adewale Adeniyi, Adewale O Adisa, Adham Tarek, Adomas Ladukas, Adrian F. Palma, Afifatun Hasanah, Afizah Salleh, Afnan Abdelfatah, Afnan Altamimi, Afnan Altamini, Agazi Fitsum, Agboola Taiwo, Ahamed Hassan, Ahed Ghaben, Ahmad Abdel Fattah, Ahmad Abdel Razaq Al Rafati, Ahmad Aboelkassem Ibrahem, Ahmad Aldalaq, Ahmad Ali, Ahmad Almallah, Ahmad Alrifaie, Ahmad Ashour, Ahmad Bakr, Ahmad Bani-Sadar, Ahmad Bin Adnan, Ahmad Elbatahgy, Ahmad Faraz, Ahmad Gudal, Ahmad Hasan, Ahmad Khaled Sabe, Ahmad Khoja, Ahmad Nashaat, Ahmad Qaissieh, Ahmad Sabe, Ahmad Saber Sleem, Ahmad Sakr, Ahmad Shalabi, Ahmad Uzair Qureshi, Ahmed Aamer, Ahmed Abd El Galeel, Ahmed Abd Elmoen Elhusseiny, Ahmed Abd Elsameea, Ahmed Abdelkareem, Ahmed Abdelmotaleb Ghazy, Ahmed Abo El Magd, Ahmed Abo Elazayem, Ahmed Adamu, Ahmed Adel, Ahmed Afandy, Ahmed Ahmed, Ahmed Alghamdi, Ahmed Ali, Ahmed Al-khatib, Ahmed Altibi, Ahmed Alzahrani, Ahmed Ata, Ahmed Badr, Ahmed Dahy, Ahmed Diab, Ahmed El Kashash, Ahmed El Kholy, Ahmed Elgaili Khalid Musa, Ahmed Elgebaly, Ahmed Elkelany, Ahmed Elkholy, Ahmed El-Sehily, Ahmed Essam, Ahmed Fahiem, Ahmed Farag, Ahmed Fawzy, Ahmed Fouad, Ahmed Gad, Ahmed Ghanem, Ahmed Gheith, Ahmed Gomaa, Ahmed Hafez El-Badri Kotb, Ahmed Hammad, Ahmed Hassan, Ahmed Hossam Eldin Fouad Rida, Ahmed Ismail, Ahmed Karim, Ahmed Khyrallh, Ahmed Lasheen, Ahmed M. Rashed, Ahmed Magdy, Ahmed Mahmoud Abdelraouf, Ahmed Menshawy, Ahmed Meshref, Ahmed Mohamed Afifi, Ahmed mohamed Ibrahim, Ahmed Mohameden, Ahmed Mohammed, Ahmed Mokhtar, Ahmed Mosad, Ahmed Moustafa, Ahmed Moustafa Saeed, Ahmed Negida, Ahmed Rabeih Mohammed, Ahmed Rabie Mohamed, Ahmed Ragab Nayel, Ahmed Ragab Soliman, Ahmed Raslan, Ahmed Raza, Ahmed Refaat, Ahmed Rslan, Ahmed Sabry, Ahmed Sabry El-Hamouly, Ahmed Safwan Marey, Ahmed Saidbadr, Ahmed Sakr, Ahmed Samir, Ahmed Shahine, Ahmed Sheta, Ahmed Soliman, Ahmed Tammam, Ahmed Tarek Abdelbaset Hassan, Ahmed W. Shamsedine, Ahmed Zaki, Ahmed Zaki Eldeeb, Ahmed Zohair, Ahmedali M Kandil, Ahmedglal Elnagar, Ahsan Zil-E-Ali, Aijaz Jabbar, Ailsa Claire Snaith, Ainhoa Costas-Chavarri, Aiste Austraite, Ajayesh Mistry, Akin Olaolorun, Akinlabi E Ajao, Al Faifi Jubran, Ala Shamasneh, Alaa Abouelnasr, Alaa Al-Buhaisi, Alaa Bowabsak, Alaa El Jamassi, Alaa Elazab, Alaa Elhadad, Alaa Fergany, Alaa Habeebullah, Alaa Hassan, Alaa Shabkah, Alaa Shaheen, Alaba Adesina, Alan Baird, Alan Grant, Alasdair Ball, Alban Cacurri, Albert Mohale Mphatsoe, Alberto Realis Luc, Alejandro Matheu, Alejandro Munera, Alemayehu Ginbo Bedada, Alessandro Favero, Alessio Maniscalco, Alexander Canta Calua, Alexander J Fowler, Alexandra Gerosa, Alexandre Horobjowsky, Alexandre Venancio De Sousa, Alexia Farrugia, Alexis Pierre Arnaud, Alfio Alessandro Russo, Alfredo Gulielmi, Ali Ababneh, Ali Abo El Dahab, Ali Amin Ahmed Ata, Ali Khan Niazi, Ali Kiasat, Ali Mohamed Hammad, Ali Zardab, Ali Zeynel Abidin Balkan, Aliaa Gamal Toeema, Aliaa Sadek, Aliaksandr Filatau, Aliang Latif, Alibeth Andres Baquero Suarez, Alice Faure, Alice Niragire, Alina Robledo-Rabanal, Aline Broch, Alireza Hasheminia, Alisdair Macdonald, Aliyu Ndajiwo, Allan Novak, Alphonse Zeta Mutabazi, Alvaro Enrique Mendoza Beleño, Alvin Ee Zhiun Cheah, Aly Abd Elrazek, Aly Nasr, Aly Sanad, Alyaa Halim Elgendy, Alyne Daltri Lazzarini Cury, Amal Ibrahim, Amandine Downloaded from https://academic.oup.com/bjs/article/109/10/995/6650196 by guest on 07 October 2022 appendicectomies in low- and middle-income countries. The Global Burden of Disease project provides country-level estimates of the incidence of appendicitis, but these diverge from administrative data in high-income countries, probably owing to different data sources (see appendix S.3). Still, the Global Burden of Disease data are the only nationally comparable and comprehensive incidence data available. Additionally, there are large gaps in the surgical outcomes data, particularly in the emergency setting. Uniquely, this study benefited from accessing the raw data in the COVIDSurg Collaborative and GlobalSurg Collaborative studies which provided global prospectively collected outcomes data. The extrapolation to all low- and middle-income countries might not be accurate for the context of every country, and might obscure variations between certain countries. Similarly, there are no reliable global data to distinguish outcomes by age or sex. As the extrapolation is based on comparable data from several lowand middle-income countries, the results should yield reasonable estimates. Furthermore, because of uncertain and conflicting data on appendicectomies, two analyses were provided in an attempt to provide two different angles on unmet need. The assumption is that the approaches give a reasonable second-best option in the absence of data on appendicectomies performed. Finally, the models are static, in the sense that feedback mechanisms were not incorporated. For example, the models do not account for changes in surgical quality if the access to surgical care increases. Yet, the direction of such feedback mechanisms is likely to depend on many different factors, so any assumptions regarding such mechanisms would be highly debatable. This study has shown that, for many low- and middle-income countries, investment in the provision of emergency surgery for appendicitis can be cost-effective by substantially reducing the economic burden of the illness. Development of local and district surgical services could have a positive knock-on effect, enabling access to care for other surgical emergencies and even elective procedures. This additional benefit will need to be evaluated in prospective studies, but might be substantial. Reuter et al. 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Herrera Puma, Clare M Rees, Clare Morgan, Claudia Reali, Claudio Arcudi, Claudio Fermani, Claudio Gabriel Fermani, Clemens Nawara, Clement Onuoha, Clodagh Mangan, Colleen Sampson, Collins Nwokoro, Colombani Jean-Francois, Constantinos Marinos, Cornelius Mukuzunga, Corrado Bottini, Craig Gouldthorpe, Crislee Elizabeth Lopez, Cristina Fernandes, Crystal Yern Nee Chow, Cutting Edge Manipal, Dale Vimalachandran, Dalia Alkhabbaz, Dalia Hemeda, Damien Brown, Damir Ljuhar, Dan L Deckelbaum, Dana Jaradat, Danelo Du Plessis, Daniel Ardian Soeselo, Daniel Cox, Daniel Dabessa, Daniel Estuardo Marroquín Rodríguez, Daniel Hamill, Daniel Nel, Daniel Youssef, Daniela Magri, Daniele Angelieri, Daniele Gui, Danilo Herrera Cruz, Danjuma Sale, Dansou Gaspard Gbessi, Dario Andreotti, Darius Kazanavicius, Darragh McCullagh, David Mcnish, David Merlini, David Monterroso Cohen, Davide De Boni, Davide Rossi, Dayang Nita Abdul Aziz, DC Grobler, Debora Schivo, Deborah Chiesa, Deimante Mikuckyte, Deividas Dragatas, Demi Gray, Diaa Eldin Abdelazeem Amin Elsorogy, Diaa Moustafa Elbendary Elsawahly, Diaaaldin Zahran, Diana Duarte Cadogan, Diana Sanchez, Dickson Bandoh, Diego Alonso Romani Pozo, Diego Antezana, Diego Coletta, Diego Romani, Diego Sasia, Dietmar Öfner, Dieudonne Duhoranenayo, Dimitri Aristotle Raptis, Dimitrios Balalis, Dimitrios K Manatakis, Dimitrios Karousos, Dimitrios Korkolis, Dimitrios Kyziridis, Dimitrios Lytras, Dimitrios Papageorgiou, Dimitrios Sfougaris, Dimitris-Christos Zachariades, Dina Al-Marakby, Dina Faizatur Rahmah, Dina Gamal, Dina Tarek, Dineshwary Periasammy, Diogo Vinicius dos Santos, Dion Morton, Diya Mirghani, Djifid Morel Seto, DM Cocker, Dmitri A Raptis, Dmitri Nepogodiev, Dmitri Raptis, Doaa Downloaded from https://academic.oup.com/bjs/article/109/10/995/6650196 by guest on 07 October 2022 Martin, Amani Althwainy, Amany Abouzahra, Amany Eldosouky Mohammed, Amar Kourdouli, Amel Hashish, Amerdip Birring, Amgad Al Meligy, Amina Abdelhamid, Aminah Hanum Haji Abdul Majid, Aminu Mohammad, Amir Ait Kaci, Amira Atef Omar, Amira Elsawy, Amira Hassan Bekhet, Amira Reda, Amjad Abu Qumbos, Amjad Elmashala, Ammar Gado, Amna Mamdouh Mohamed, Amna Mohamed, Amoudtha Rasendran, Amr Ahmed Saleh, Amr Fadel, Amr Hasan, Amr Hassaan, Amr Hossameldin, Amr Muhammad Elkorashy, Amr Tarek Hafez, Amreen Faruq, Amro Aglan, Ana Cecilia Manchego Bautista, Ana Lucia Contreras-Vergara, Ana Maria Sandoval Barrantes, Ana Vega Carreiro De Freitas, Ana Vega Freitas, Anam Rashid, Anan Rady Abdelazeam, Anand Kirishnan, Anass Majbar, Anastasia Bamicha, Anastasios Stefanopoulos, Anders Thorell, Andre Das, Andre Dubois, Andre L Mihaljevic, Andre Navarro, Andrea Allegri, Andrea Armellini, Andrea Belli, Andrea Bondurri, Andrea Echevarria Rosas Moran, Andrea Natili, Andrea Ruzzenente, Andrea Simioni, Andreass Haloho, Andrei Tanase, Andrej Kolosov, Andrejus Subocius, Andrew G N Robertson, Andrew Kirby, Andrew Mcguigan, Andrew Spina, Andrey Litvin, Andrius Burmistrovas, Andrius Strazdas, Andy Arenas, Aneel Bhangu, Anele Rudzenskaite, Angel David Pérez Rojas, Angela Dell, Angelica Genoveva Vergara Mejia, Angeline Charles, Angelo Antoniozzi, Angelo Benevento, Angelos Tselos, Angham Solaiman El-Ma’doul, Anjana Sreedharan, Ankur Bhatnagar, Ann Kjellin, Anna Lasek, Anna Maffioli, Anna Powell, Anna Rinaldi, Anna Watts, Annalisa lo Conte, Annamaria Bigaran, Annelisse Ashton, Annisa Dewi Fitriana Mukin, Antanas Gulbinas, Antanas Zadoroznas, Anthonius Santoso Rulie, Anthony Ajiboye, Anthony Avoka, Anthony Chuk-Him Lai, Anthony Davor, Anthony Sander, Antje Oosterkamp, Antoinette Bediako-Bowan, Antonella La Brocca, Antônio Leal, Antonio Nocito, Antonio Ramos-De La Medina, Antonio Taddei, Anwar Atiyeh, Anyomih Theophilus Teddy Kojo, Aoife Driscoll, Apar Shah, Apostolos Vlachogiorgos, April Camilla Roslani, Aram Abdelhaq, Arazzelly del Pilar Paucar, Arcangelo Picciariello, Areej Tarek, Arezo Kanani, Ari Leppäniemi, Arianna Birindelli, Arij Ibrahim, Arjun 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Maghrabi, Ashraf Morsi, Ashrarur Rahman Mitul, Asmaa Abdelgelil, Asmaa Abdel-Rahman Al-Aarag, Asmaa Rezq, Asmaa Salah, Aspasia Papailia, Assmaa Badwy, Astrid Leusink, Ata Khan, Ataa Ahmed, Athanasia Bamicha, Athar Eysa, Athirah Zulkifli, Atif Mahdi, Attia Attia, Attia Mohamed Attia, Audrey Clarissa, Audrius Dulskas, Audrius Parseliunas, Augusto Zani, Aung Kyaw Tun, Aurel Mironescu, Aurel Sandu Mironescu, Aurelien Scalabre, Aurora Mariani, Aurore Haffreingue, Aurore Thollot, Ausrine Usaityte, Austė Skardžiukaitė , Awais Raza, Aya Abdel Fatah Ibraheem, Aya Aboarab, Aya Adel Elsharkawy, Aya El-Sawy, Aya Elwaey, Aya Firwana, Aya Hagar, Aya Hammad, Aya Mohamed Fathy, Aya Reda, Aya Yehia Ata, Ayah Hamdan, Ayat Hassaan, Ayman And Taher, Ayman Elwan, Ayman Nabawi, Ayman Salman, Ayman Shwky, Ayokunle Ogunyemi, Azher Herebat, Azmina Verjee, Babajide Adenekan, Babatunde Odeyemi, Badr Eldin Adel, Badreldin Adel Tawfik, Bahar Busra Ozkan, Bakeer Mohamed, Bakhtiar Nighat, Bandar Albeladi, Bárbara Málaga, Barbara Mijuskovic, Barbara Pereira Silvestre, Basant Kumar, Basem Sieda, Bashir Bello, Basim Alghamdi, Basma Magdy, Basma Mahmoud, Basmah Alhassan, Bassant Mowafy, Beatrice | 1003 1003a | BJS, 2022, Vol. 109, No. 10 Samir El Sayed, Gehad Tawfik, Gemma Humm, Genoveffa Balducci, George Christian Manrique Sila, George Ihediwa, George Manrique Sila, Georges Azzie, Georgette Marie Camilleri, Georgios Gemenetzis, Georgios Gkiokas, Georgios Karabelias, Georgios Kyrou, Georgios Tzikos, Gerardo Perrotta, Gerfried Teufelberger, Germain Ahlonsou, German Minguez, Geta Maharaj, Gezim Galiqi, Ghada Elhoseny, Ghada Saied Nagy, Ghiath Al Saied, Ghina Shamim Shamsi, Giacomo Nastri, Giacomo Pata, Gianfranco Cocorullo, Gianluca Curletti, Gianluca Pagano, Gianluca Pellino, Gianmaria Confalonieri, Gianpiero Gravante, Giedrius Lauzikas, Giles Dawnay, Gintaras Simutis, Giorgio Vasquez, Giovanni Landolfo, Giovanni Lazzari, Giovanni Luca Lamanna, Giovanni Pascale, Giovanni Pesenti, Giovanni Sgroi, Giridhar H Devadasar, Gisele Moreira, Giuliano Borda-Luque, Giuseppe Clerico, Giuseppe Rotunno, Giuseppe Salamone, Giuseppe Sammarco, Gokhan Lap, Greg Padmore, Gregorio Tugnoli, Gregory Kouraklis, Greta Mclachlan, Greta Wood, Greta Žiubrytė , Guillaume Podevin, Guillermo Sanchez Rosenberg, Guo Liang Yong, Gurdeep Singh Mannu, Gurpreet Singh Banipal, Gustavo Miguel Machain Vega, Gustavo Peixoto Soares Miguel, Gustavo Pereira Fraga, Gustavo Recinos, Gustavo Rodolfo Pertersen Servin, Haaris A. 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Sii, Samuel Sani Ali, Sandip Kumar, Sandra Ahlqvist, Sandrine Kwizera, Sandro Pasquali, Sani Ali Samuel, Sanju Sobnach, Santiago Villalobos, Sara Abd Elmageed Barakat, Sara Ahmed, Sara Al-saqqa, Sara Amr Mohamed Farouk, Sara Arafa, Sara Ayad, Sara Elhamouly, Sara Etienne, Sara Ghanem, Sara Kharsa, Sara Mahmoud Abdel-Kader, Sara Mamdouh Matter, Sara María Contreras Mérida, Sara Mehrez, Sara Mohammed, Sara W Al-Saqqa, Sarah Abdelghany, Sarah Antar, Sarah Benammi, Sarah Braungart, Sarah Hafez, Sarah Rayne, Sarah Sahel, Sarah Samy, Saraibrahim Ahmed, Saskia Highcock, Saud Aljohani, Saulius Bradulskis, Saulius Mikalauskas, Savino Occhionorelli, Savni Satoskar, Sawsan Adel Awad, Sayed Sarwary, Sayeda Nazmum Nahar, Sayeeda Aktar Tori, Sayinthen Vivekanantham, Scott K D’amours, Sean Mizzi, Sebastian Bernardo Shu Yip, Sebastian King, Sebastian Shu, Sebastian Sierra, Sebastien Gaujoux, Sebestian Shu, Sefeldin Mahdi, Selina Chiu, Selina Man Yeng Chiu, Semay Desta, Serena Manfreda, Serge Kapenda Tshisola, Sergio Estupinian, Sergio Ribaldi, Sergio Zegarra, Servio Tulio Torres Rodriguez, Shadid Al Amin, Shadid Alamin, Shady Elhadry, Shady Hussein, Shady Mahmoud, Shagorika Talukder, Shahadatul Shaharuddin, Shahinaz Alaa El-Din, Shaimaa Aql, Shalon Guevara Torres, Shamsudeen Aliyu, Sharad Karandikar, Sharon Koh, Shaza Rabie Mohamed, Shereen Elsheikh, Sherif Shehata, Sherif Tariq, Shimaa Gamal, Shimaa Said Elkholy, Shireen Gaafar, Shirish Tewari, Shiva Dindyal, Shivanee Tharmalingam, Shorouk El Mesery, Shpetim Ymeri, Shravan Nadkarni, Shruti Ayyar, Shu Ning Kong, Shuang Yi Teo, Shyam Gokani, Shyang Yee Lim, Silje Holte, Silvia Basilicò, Silvia Boni, Silvia De Franciscis, Simon George Gosling, Simon Gosling, Simon Ng, Simon Stock, Simona Juciute, Simona Kasputyte, Simone Conci, Simone Sandler, Simone Targa, Sir Young Yam, Siti Mohd Desa Asilah, Siti Nur Alia Kamarulzamil, Sivasuriya Sivaganesh, Siyaka Itopa Suleiman, Siyi Chung, Soaad Elsobky, Sofia Mouttalib, Soha Abushamleh, Sohaila Elmihy, Soliman Magdy Ahmed, Sondos Turkustani, Sophian Hmila, South Africa, Srinivas Pai, Sriram Bhat, SS Prasad, Stassen Paul, Stavros Parasyris, Stefan Botes, Stefan Breitenstein, Stefan Zammit, Stefano Berti, Stefano Cucumazzo, Stefano M.M Basso, Stefano Roncali, Stella Binna Kim, Sten Saar, Stephanie Hiu-wai Kwok, Stephanie Van Straten, Stephen Dias, Stephen J Chapman, Stephen Kache, Stephen Mcaleer, Stephen R Knight, Stephen Tabiri, Steponas Petrikenas, Stuart J Fergusson, Styliani Parpoudi, Stylianos Germanos, Sudipta Roy, Sukrit Suresh, Sule Burger, Suleiman Baba, Sultan Almuallem, Sung-Hee Kim, Sunil Kumar, Suparna Das, Suraya Bahar, Susan Aviles, Susan Limache, Susan Wndy Mathew, Susana Yrma Aranzabal Durand, Svetlana Doris Brincat, Swantje Kruspi, Swapnil Roy, Syed Abdul Wahhab Eusoffee Wan Ali, Syed Altaf Naqvi, Syed Asaat ul Razi, Sylvia Batista Lemaire, Sylvie Mochet, Syrine Rekhis, T Ariani Widiastini, Tagang Ebogo Ngwa, Taha Yusufali, Taher Al-taher, Tahir Muhammad Yaseen, Tahir Yaseen, Tahira Naqvi, Taiwo Akeem Lawal, Taiwo Lawal, Tan Arulampalam, Tanzeela Gala, Tapan Kumar, Tara Grima, Tarek Ezzat, Tarek Razek, Tasneem Idress, Tasnia Hamid Kanta, Tatsiana Shachykava, Taufiq Khan, Tebian Hassanein Ahmed Ali, Tessa Fautz, Tewodros Worku, Thamer Nouh, Thays Brunelli Pugliesi, Thea Dimech, Thelma Tembo, Thelma Xerri, Theodore Pezas, Theodosios Theodosopoulos, Thiago Fernandes Giuriato, Thierry Alihonou, Thomas Feidantsis, Thomas Fozard, Thomas G Weiser, Thomas M Drake, Thomas Olagboyega Olajide, Thomas Pinkney, Thomas Prudhomme, Thomas Sherman, Thomas Tetens Moe, Thuraya Alzayat, Thusitha Sampath Hettiarachchi, Tien Seng Bryan Lee, Downloaded from https://academic.oup.com/bjs/article/109/10/995/6650196 by guest on 07 October 2022 Panchali Sarmah, Pandi Eduard, Panu Mentula, Paola Salusso, Paola Violi, Paolino De Marco, Paolo Aonzo, Paolo Silvani, Paolo Ubiali, Patrizio Mao, Paul Kielty, Paul Sutton, Paul Ugalde, Paul Witherspoon, Paul Wondoh, Pauline Gastaldi, Paulius Karumnas, Paulius Kondrotas, Paulo Alves Bezerra Morais, Pedro Angel Toribio Orbegozo, Peep Talving, Pei Ying Koh, Per Weber, Per-Olof Lundgren, Peter Deutschmann, Peter Labib, Peter Wiel Monrad-Hansen, Petras Višinskas, Phebe Anggita Gultom, Philip Alexander, Philip Choi, Philip Mshelbwala, Philip Taah Amoako, Philippe Buisson, Phoebe De Bono, Phumudzo Ndwambi, Pier Paolo Grandinetti, Piergiorgio Danelli, Pierpaolo Sileri, Pietra Ligure, Pietro Mingrone, Pigeneswaren Yoganathan, Piotr Major, Poddevin Francois, Povilas Ignatavicius, Povilas Mazrimas, Prasad Pitigala Arachchi, Pratik Jain, Prince Kwakyeafriyie, Prisca A.L. Har, Pui Xin Chin, Puneet Malik, Puyearashid Nashidengo, Qinyang Liu, Quentin Alimi, Quentin Ballouhey, Quinn Ellison, R. Goh Ern Tze, Rachel King, Rachel Moore, Radhian Amandito, Radin Mohd Nurrahman Radin Dorani, Rafael Araujo, Rafael Soley, Rafał Roszkowski, Raffaele Galleano, Ragavan Narayanan, Ragnar Herikstad, Rahma Kamil, Rajeev Satoskar, Rakan Kabariti, Ralph F Staerkle, Ram Nataraja, Ramadan Oumer, Ramadan Shaker, Ramdan Shaker, Ramesh Jonnalagadda, Ramon Alvarado Jaramillo, Ramón Augusto Melo Cardozo, Rana Mamdouh, Rana Saadeh, Raquel Rodríguez-Uría, Raquillet Claire, Rasha Abdelhamed, Razvan-Matei Bratu, Reda Žilinskienė , Redouane Mammar Bennai, Reem Alyahya, Reem Fakher, Reem Husseiny, Reem Khreishi, Reem Mohammed Hassan Balila, Rehab Elashry, Reham Alaa El-Din, Reham Alshareef, Reham Saad, Renato Melo, Reuban D’cruz, Reuben Goh Ern Tze, Reynu Rajan, Rezaul Karim, Ricardo Velasquez, Richard Gilbert, Richard Lilford, Richard Opoku-Agyeman, Richard Spence, Richard William Gilbert, Richmond Hagan, Rifan Alyami, Riinu Ots, Ritauras Rakauskas, Roaa Khan, Robert George, Robert Karlo, Robert Kerley, Robert Mcintyre, Robert Morton, Robert Parker, Robert Tyler, Roberta Bugeja, Roberta Tutino, Roberta Villa, Robertas Baltrunas, Robertas Pranevicius, Roberto Cautiero, Roberto Cirocchi, Roberto Faccincani, Roberto Klappenbach, Roberto Macchiavello, Roberto Peltrini, Roberto Schiavone, Robinson Mas, Roel Matos-Puig, Rofida Elsemelawy, Roger Lawther, Roger Schmid, Rohan Ardley, Rohi Shah, Rokas Rackauskas, Rokayah Julaihi, Rokia Sakr, Roland Osuoji, Romeo Guevara, Romeo Lages Simoes, Romualdas Riauka, Ronald Coasaca Huaraya, Ronald Renato Barrionuevo Ojeda, Ronan Cahill, Rony Camacho, Rory Callan, Rosario Sacco, Rose Khreishi, Rosie Mcdonald, Ross Bowe, Ross Coomber, Rowida Elmelegy, Roxanne Chenn, Roy Quek, Rubén Balmaceda, Rubén Darío Arias Pacheco, Ruben Rivas, Ruben Santiago Restrepo Giraldo, Rudy Gunawan, Rula Zaa’treh, Ruqaya Kadhim Mohammed Jawad Al-Hasani, Ruta Mazelyte, Ruth Blanco, Ruth Gratton, Ruth Scicluna, Ryan Adams, Ryan Choon Kiat Tan, Ryan Mcintosh, S.V. Kinnera, Saad Al Awwad, Sabbir Karim, Sabine Irtan, Sabrina Asturias, Sabrina Dardenne, Sabry Mohy Eldeen Mahmoud, Safia Ali, Safwat Al-Nahrawi, Saged Elsherbiney, Sahar Abdoun Ishag Idris, Sahar Jaber, Sahlu Wondimu, Saiba Abdul-Latif, Said Alyacoubi, Sakhaa Hanoun, Saleem El-Rabaa, Saleh A. Alnuqaydan, Saleh Alqahtani, Salim Anderson Khouri Ferreira, Sally Elshanwany, Sally Hallam, Salma Magdy, Salma Mansour, Salma Said Elkolaly, Salman Aldhafeeri, Salomone Di Saverio, Salwa Khallaf, Sam Arman, Sam Debrah, Sam Seisay, Samaa Mahmoud Al Attar, Samah Afana, Samantha Corro-Diaz Gonzalez, Samar Abdelhady, Samar Adel Ismail, Samar Saad, Samar Soliman, Sameer Kushwaha, Sameh Emile, Sameh Sarsik, Sami Martin Sundstrom, Samson Olori, Samuel Essoun, Samuel | 1003d 1003e | BJS, 2022, Vol. 109, No. 10 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Funding The NIHR Global Surgery Unit received an unattributed medical education grant from Intuitive to support global surgery studies. 14. 15. Disclosure. 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What is the financial burden to patients of accessing surgical care in Sierra Leone? A cross-sectional survey of catastrophic and impoverishing expenditure. BMJ Open 2021; 11:e039049 23. Odland ML, Whitaker J, Nepogodiev D, Aling’ CA, Bagahirwa I, Dushime T et al. Identifying, prioritizing and visually mapping | 1003f d EUROPEA N E NGR SS CO 2022 ov l an 28 N LORECTAL CO –1 D ec · S t. G all e n · S wi tz er European Colorectal Congress 28 November – 1 December 2022, St.Gallen, Switzerland Monday, 28 November 2022 Tuesday, 29 November 2022 Wednesday, 30 November 2022 09.50 Opening and welcome Jochen Lange, St.Gallen, CH 9.00 CONSULTANT‘S CORNER Michel Adamina, Winterthur, CH 10.00 It is leaking! Approaches to salvaging an anastomosis Willem Bemelman, Amsterdam, NL 10.30 COFFEE BREAK 9.00 Advanced risk stratification in colorectal cancer – choosing wisely surgery and adjuvant therapy Philip Quirke, Leeds, UK 10.30 Predictive and diagnostic markers of anastomotic leak Andre D‘Hoore, Leuven, BE 11.00 SATELLITE SYMPOSIUM 11.45 Of microbes and men – the unspoken story of anastomotic leakage James Kinross, London, UK 12.15 LUNCH 13.45 Operative techniques to reduce anastomotic recurrence in Crohn’s disease Laura Hancock, Manchester, UK 14.15 Innovative approaches in the treatment of complex Crohn Diseases perianal fistula Christianne Buskens, Amsterdam, NL 14.45 To divert or not to divert in Crohn surgery – technical aspects and patient factors Pär Myrelid, Linköping, SE 09.30 Predictors for Postoperative Complications and Mortality Ronan O‘Connell, Dublin, IE 11.00 SATELLITE SYMPOSIUM 11.45 Trends in colorectal oncology and clinical insights for the near future Rob Glynne-Jones, London, UK 12.15 LUNCH 14.15 SATELLITE SYMPOSIUM 11.30 SATELLITE SYMPOSIUM 15.00 COFFEE BREAK 15.30 The unsolved issue of TME: open, robotic, transanal, or laparoscopic – shining light on evidence and practice Des Winter, Dublin, IE Jim Khan, London, UK Brendan Moran, Basingstoke, UK 16.30 SATELLITE SYMPOSIUM 17.30 EAES Presidential Lecture - Use of ICG in colorectal surgery: beyond bowel perfusion Salvador Morales-Conde, Sevilla, ES 18.00 Get-Together with your colleagues Industrial Exhibition 12.00 Less is more – pushing the boundaries of full-thickness rectal resection Xavier Serra-Aracil, Barcelona, ES 12.30 LUNCH 14.00 Management of intestinal neuroendocrine neoplasia Frédéric Ris, Geneva, CH 14.30 Poster Presentation & Best Poster Award Michel Adamina, Winterthur, CH 17.15 Lars Pahlman lecture Søren Laurberg, Aarhus, DK 16.15 SATELLITE SYMPOSIUM 17.00 Outcomes of modern induction therapies and Wait and Watch strategies, Hope or Hype Antonino Spinelli, Milano, IT 10.30 COFFEE BREAK 11.00 Incidental cancer in polyp - completion surgery or endoscopy treatment alone? Laura Beyer-Berjot, Marseille, FR 13.45 VIDEO SESSION 15.15 COFFEE BREAK 15.45 Appendiceal neoplasia – when to opt for a minimal approach, when and how to go for a maximal treatment Tom Cecil, Basingstoke, Hampshire, UK 10.00 Segmental colectomy versus extended colectomy for complex cancer Quentin Denost, Bordeaux, FR 15.00 SATELLITE SYMPOSIUM 15.45 COFFEE BREAK er 2022 ecemb ay, 1 D d s r u urgery h T rectal S lo o C class in y Master logy Da Procto 16.15 Reoperative pelvic floor surgery – dealing with perineal hernia, reoperations, and complex reconstructions Guillaume Meurette, Nantes, FR 16.45 Salvage strategies for rectal neoplasia Roel Hompes, Amsterdam, NL 17.15 Beyond TME – technique and results of pelvic exenteration and sacrectomy Paris Tekkis, London, UK 19.30 FESTIVE EVENING Information & Registration www.colorectalsurgery.eu