The Lancet Commission and World Health Organization (WHO) found that across the world around 5 billion people lack access to affordable and safe surgical and anaesthetic care – especially those in low- and middle-income countries (LMICs) where 9 out of 10 people lack access to basic surgical services. 

Research has shown that around 4.2 million people will die every year within 30 days following a surgical procedure, and half of these deaths occur in LMICs.

To address these global surgical challenges, in 2017 the NIHR Global Health Research Unit on Global Surgery (GSU) was set up in partnership at the Universities of Birmingham and Edinburgh. Led by the University of Birmingham and working with international partners, the GSU has since established research hubs across Southern, Central and Western Africa, Central and South America, and South Asia. 

The GSU is unique in the type of research it conducts. It acknowledges the environments in which its hubs are located and develops, launches and rapidly delivers a variety of research studies that are globally yet locally relevant.

It originally set out with five priority areas, aiming to reduce surgical site infection after surgery; reduce morbidity and mortality after high-risk surgery; increase capacity for routine surgery; improve access to surgery; and develop research across rural surgery networks.

During the COVID-19 pandemic a sixth priority area was added: providing data to support recovery of surgical services affected by the COVID-19 pandemic. Towards it the ‘CovidSurg’ platform was launched to collect prospective patient data to support surgeons’ globally in conducting safe surgery and protect patients from COVID-19 infection. The WHO has since adopted the evidence from the data in their guidance.

Professor Dion Morton OBE, Barling Professor of Surgery at the University of Birmingham and Director of the GSU, stressed the importance of conducting research into improving surgical care in LMICs. “Surgical care is one of the major unmet needs in global health care today,” Professor Morton commented.

“With the University of Birmingham as the lead UK higher education institution, the GSU has been set up in collaboration with the University of Edinburgh (in the UK), who provides additional expertise in research training to train the future research leaders in our partner LMIC centres.”

The framework that GSU has adopted is that of a ‘hub-and-spoke’ model. The research hubs are launched in large, typically urban hospitals and support the delivery of surgical research at its own and other hospital spokes across the country, some in rural and/or remote locations. To date seven research hubs have been established in Ghana, Rwanda, South Africa, Mexico, India, Benin and Nigeria all supporting the delivery of surgical care research, through a global network of more than 70 hospitals.

Before the launch of the GSU, community engagement for surgical research in LMICs was relatively unheard of. Through the network of hubs and local hospital spokes, research projects that the GSU’s undertakes are informed by engaging with the local community and finding out how the research could positively affect them and what they would find the most value in being a part of.

Professor Peter Brocklehurst, Director of Research and Development in the University of Birmingham’s Clinical Trials Unit and Co-Director of the GSU, commented upon the importance of developing patient-facing materials, such as online case studies and leaflets available on the GSU’s website: “With face-to-face meetings unable to take place in current circumstances, it has been vital to carry on the conversation online with international webinars to reach the wider surgical community.”

The GSU also delivers holistic training for surgeons, research staff and allied health professionals, enabling them to take up their own research. A major training package for research leaders, researchers and research managers has been developed, building sustainable surgical research and its management capacity. There are also ambitions to develop a surgical research skills programme to provide postgraduate training as well as plans to deliver targeted data management and research management training.

The scale of the developed surgical network is hugely impactful for reaching international partners. All hub countries participate in large cohort studies that addresses a variety of evidence gaps within surgery. Besides conducting clinical trials and other interventional studies, health economics is embedded within the various research studies to test, for example, the cost-effectiveness of the interventions used, cost to the society for an untreated condition, etc.

Professor Brocklehurst remarked on the scale of the research by the GSU: “Over the past three years, the infrastructure the GSU has built is unique. It has enormous potential for patients. More than 8,000 patients have been recruited onto various trials to test new surgical interventions and collected outcomes from 160,000 patients undergoing surgery from across the world.”

In 2018, the GSU launched its first multinational randomised controlled trial, FALCON, testing interventions aiming to reduce wound infections following abdominal surgery. This trial was conducted across seven countries (recruiting >5500 patients), and was completed within 20 months (including during the COVID-19 pandemic period) from trial set up to finishing data collection.

The second international trial launched was CHEETAH in June 2020, amidst all the hardships of the pandemic. The aim of this next study was to assess whether the using separate sterile gloves and instruments to close wounds at the end of surgery compared to current routine hospital practice can reduce surgical site infection at 30-days post-surgery for patients undergoing clean-contaminated, contaminated or dirty abdominal surgery.

A third pilot trial, PENGUIN, began in October 2020 and aims to reduce SSI and pneumonia following abdominal surgery in LMICs. PENGUIN is in addition to the GSU’s 12 other active studies, which range from taking place at a local level to multinational.

Commenting on planned research for future, Professor Morton commented: “We are now looking to improve access to safe emergency surgery, as there is strong evidence to suggest people in LMICs with conditions requiring urgent surgical care experience considerable delay in accessing health services. For example, we are also looking to at how to reconfigure services post-pandemic, review workforce development as well as understanding how to meet the needs of rural surgical locations and the different challenges they face.”

In March 2020, the GSU launched new global guidelines to reduce surgical site infections (SSI) – the most common complication following abdominal surgery – and antimicrobial resistance. The aims of the guidelines are to standardise care and improve surgery. SSI affects 9% of patients in high-income countries compared to 17% of patients in LMICs and causes patients to experience unnecessary pain and delays return to normal activities such as work. GSU has launched other guidelines, including one on surgery in COVID-19 conditions.

The researchers are optimistic for the future. “While we have achieved great work already, there is still a long way to go in making surgery safer for the millions of patients in LMICs,” Professor Morton remarked upon the achievements of the GSU.

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