Beyond short-term surgical missions:On the role of surgeons from high-income settings to help improve surgical care in resource-limited settings

This dissertation provides data collected during the development and implementation of an alternative approach to short-term surgical missions. These missions have been the traditional strategy for surgeons from high-income settings to help to improve surgical care in resource-limited settings. This dissertation presents an alternative approach. During the Amsterdam-based international symposium, ‘Surgery in Low Resource Settings,’ held in November 2014, the urgency for collaborative solutions became more evident. On behalf of 65 international organizations and all participants of the symposium, the “Amsterdam Declaration on Essential Surgical Care” was published in April 2015. Chapter 2 describes that the number of people dying from surgical conditions outnumbers the death toll of HIV, malaria, and tuberculosis combined. Surgery should be a part of the United Nations’ post-2015 sustainable development goals. The aim of Chapter 3 is to present baseline information on surgical burn care in sub-Saharan Africa, and establish methods of process and care improvement. A systematic review provides a critical analysis of the available literature on basic surgical care of burn injuries in sub-Saharan Africa, including timing of excision, grafting, and wound dressing techniques. The results show that essential information—such as depth of burns, TBSA, timing of grafting and wound treatment—are unreported in many of the studies. Future studies should include uniform definitions and parameters such as depth of burns, TBSA, timing of grafting, and wound treatment. The aim of Chapter 4 is to present research insights into ‘access to surgical burn care’ in LMICs. Theoretically, the study is guided by investigating timeliness, surgical capacity, and affordability. In conclusion, the study shows that patients face critical barriers to receiving timely and affordable surgical care in the catchment area of Haydom Lutheran Hospital, Tanzania. To assure timely, safe, and affordable burn care for patients in LMICs, support is also needed beyond hospital management on regional and national levels. Short-term reconstructive plastic surgical missions are a well-established routine method of addressing surgical conditions. Chapter 5 provides a systematic review that assessed the effectiveness of short- term reconstructive surgical missions in LMICs. Original studies of short- term reconstructive surgical missions were included, which reported data on patient safety measurements, health gains of individual patients, and sustainability. Studies with a low follow-up quality could potentially be under-reporting complication rates and overestimating the positive impact of missions. It was concluded that evidence on the patient outcomes of reconstructive plastic surgical missions is scarce and of limited quality. The recommendations were supported by experienced health workers in the field of surgical missions, as recorded in a survey study on surgical missions (Chapter 6). The results showed that training activities were considered most impactful, and reporting on outcome/s, along with long-term follow-up was strongly recommended. According to 94 percent of the participants, the future focus should be on establishing collaborative practices with local actors, and encouraging strategic, long-term changes, under their leadership. Chapter 7 presents insights into the effects of basic reconstructive plastic surgical training activities on participants. The study demonstrates that surgical skills of the participants can improve, and it strengthens the recommendation that training is a key strategy for the much-needed goal of sustainable solutions to meeting the global burden of surgical disease. The larger goal of training activities for health care providers is to obtain a higher standard of care for the patients in need. In the last study, the focus lies on the outcome of post-burn contracture release surgery during the trainings. Based on the results, it can be concluded that contracture release surgery performed during surgical trainings in LMICs can be safe and effective in the long-term

Strategies Following Free Flap Failure in Lower Extremity Trauma: A Systematic Review

ABSTRACT: Background: Free flap reconstructions are an important reconstructive option for soft tissue defects in mangled lower extremities. Microsurgery facilitates soft tissue coverage of defects that otherwise would result in amputation. However, the success rates of traumatic lower extremity free flap reconstructions remain lower than those in other locations. Nevertheless, post-free flap failure salvage strategies have rarely been addressed. Therefore, the current review aims to provide an overview of post-free flap failure strategies in lower extremity trauma and their subsequent outcomes. Methods: A search of Pubmed, Cochrane, and Embase databases was performed on June 9, June 2021 using the following medical subject headings (MeSH) search terms: ‘lower extremity’, ‘leg injuries’, ‘reconstructive surgical procedures’, ‘reoperation’, ‘microsurgery’ and ‘treatment failure’. This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Partial and total free flap failures after traumatic reconstruction were included. Results: Twenty-eight studies with a total of 102 free flap failures fulfilled the eligibility criteria. Following the total failure, a second free flap is the predominant reconstructive strategy (69%). In comparison to the failure rate of a first free flap (10%), the fate of a second free flap is less favorable with a failure rate of 17%. The amputation rate following flap failure is 12%. The risk of amputation increases between primary and secondary free flap failures. After partial flap loss, the preferred strategy is a split skin graft (50%). Conclusion: To our knowledge, this is the first systematic review on the outcome of salvage strategies after free flap failure in traumatic lower extremity reconstruction. This review provides valuable evidence to take into consideration in the decision-making regarding post-free flap failure strategies

Impact of short-term reconstructive surgical missions: A systematic review

Introduction Short-term missions providing patients in low-income countries with reconstructive surgery are often criticised because evidence of their value is lacking. This study aims to assess the effectiveness of short-term reconstructive surgical missions in low-income and middle-income countries. Methods A systematic review was conducted according to PRISMA guidelines. We searched five medical databases from inception up to 2 July 2018. Original studies of short-term reconstructive surgical missions were included, which reported data on patient safety measurements, health gains of individual patients and sustainability. Data were combined to generate overall outcomes, including overall complication rates. Results Of 1662 identified studies, 41 met full inclusion criteria, which included 48 546 patients. The overall study quality according to Oxford CEBM and GRADE was low. Ten studies reported a minimum of 6 months' follow-up, showing a follow-up rate of 56.0% and a complication rate of 22.3%. Twelve studies that did not report on duration or follow-up rate reported a complication rate of 1.2%. Fifteen out of 20 studies (75%) that reported on follow-up also reported on sustainable characteristics. Conclusions Evidence on the patient outcomes of reconstructive surgical missions is scarce and of limited quality. Higher complication rates were reported in studies which explicitly mentioned the duration and rate of follow-up. Studies with a low follow-up quality might be under-reporting complication rates and overestimating the positive impact of missions. This review indicates that missions should develop towards sustainable partnerships. These partnerships should provide quality aftercare, perform outcome research and build the surgical capacity of local healthcare systems. PROSPERO registration number CRD42018099285

Access to burn care in low-and middle-income countries:an assessment of timeliness, surgical capacity, and affordability in a regional referral hospital in Tanzania

This study investigates patients’ access to surgical care for burns in a low- and middle-income setting by studying timeliness, surgical capacity, and affordability. A survey was conducted in a regional referral hospital in Manyara, Tanzania. In total, 67 patients were included. To obtain information on burn victims in need of surgical care, irrespective of time lapsed from the burn injury, both patients with burn wounds and patients with contractures were included. Information provided by patients and/or caregivers was supplemented with data from patient files and interviews with hospital administration and physicians. In the burn wound group, 50% reached a facility within 24 hours after the injury. Referrals from other health facilities to the regional referral hospital were made within 3 weeks for 74% in this group. Of contracture patients, 74% had sought healthcare after the acute burn injury. Of the same group, only 4% had been treated with skin grafts beforehand, and 70% never received surgical care or a referral. Together, both groups indicated that lack of trust, surgical capacity, and referral timeliness were important factors negatively affecting patient access to surgical care. Accounting for hospital fees indicated patients routinely exceeded the catastrophic expenditure threshold. It was determined that healthcare for burn victims is without financial risk protection. We recommend strengthening burn care and reconstructive surgical programs in similar settings, using a more comprehensive health systems approach to identify and address both medical and socioeconomic factors that determine patient mortality and disability

The Effectiveness of Burn Scar Contracture Release Surgery in Low- And Middle-income Countries

Background: Worldwide, many scar contracture release surgeries are performed to improve range of motion (ROM) after a burn injury. There is a particular need in low- and middle-income countries (LMICs) for such procedures. However, well-designed longitudinal studies on this topic are lacking globally. The present study therefore aimed to evaluate the long-term effectiveness of contracture release surgery performed in an LMIC. Methods: This pre-/postintervention study was conducted in a rural regional referral hospital in Tanzania. All patients undergoing contracture release surgery during surgical missions were eligible. ROM data were indexed to normal values to compare various joints. Surgery was considered effective if the ROM of all planes of motion of a single joint increased at least 25% postoperatively or if the ROM reached 100% of normal ROM. Follow-ups were at discharge and at 1, 3, 6, and 12 months postoperatively. Results: A total of 70 joints of 44 patients were included. Follow-up rate at 12 months was 86%. Contracture release surgery was effective in 79% of the joints (P < 0.001) and resulted in a mean ROM improvement from 32% to 90% of the normal value (P < 0.001). A predictive factor for a quicker rehabilitation was lower age (R 2= 11%, P = 0.001). Complication rate was 52%, consisting of mostly minor complications. Conclusions: This is the first study to evaluate the long-term effectiveness of contracture release surgery in an LMIC. The follow-up rate was high and showed that contracture release surgery is safe, effective, and sustainable. We call for the implementation of outcome research in future surgical missions

The Effectiveness of Burn Scar Contracture Release Surgery in Low- And Middle-income Countries

Background: Worldwide, many scar contracture release surgeries are performed to improve range of motion (ROM) after a burn injury. There is a particular need in low- and middle-income countries (LMICs) for such procedures. However, well-designed longitudinal studies on this topic are lacking globally. The present study therefore aimed to evaluate the long-term effectiveness of contracture release surgery performed in an LMIC. Methods: This pre-/postintervention study was conducted in a rural regional referral hospital in Tanzania. All patients undergoing contracture release surgery during surgical missions were eligible. ROM data were indexed to normal values to compare various joints. Surgery was considered effective if the ROM of all planes of motion of a single joint increased at least 25% postoperatively or if the ROM reached 100% of normal ROM. Follow-ups were at discharge and at 1, 3, 6, and 12 months postoperatively. Results: A total of 70 joints of 44 patients were included. Follow-up rate at 12 months was 86%. Contracture release surgery was effective in 79% of the joints (P < 0.001) and resulted in a mean ROM improvement from 32% to 90% of the normal value (P < 0.001). A predictive factor for a quicker rehabilitation was lower age (R 2= 11%, P = 0.001). Complication rate was 52%, consisting of mostly minor complications. Conclusions: This is the first study to evaluate the long-term effectiveness of contracture release surgery in an LMIC. The follow-up rate was high and showed that contracture release surgery is safe, effective, and sustainable. We call for the implementation of outcome research in future surgical missions

Access to Burn Care in Low- and Middle-Income Countries: an Assessment of Timeliness, Surgical Capacity, and Affordability in a Regional Referral Hospital in Tanzania.

This study investigates patients' access to surgical care for burns in a low- and middle-income setting by studying timeliness, surgical capacity, and affordability. A survey was conducted in a regional referral hospital in Manyara, Tanzania. In total, 67 patients were included. To obtain information on burn victims in need of surgical care, irrespective of time lapsed from the burn injury, both patients with burn wounds and patients with contractures were included. Information provided by patients and/or caregivers was supplemented with data from patient files and interviews with hospital administration and physicians. In the burn wound group, 50% reached a facility within 24 hours after the injury. Referrals from other health facilities to the regional referral hospital were made within 3 weeks for 74% in this group. Of contracture patients, 74% had sought healthcare after the acute burn injury. Of the same group, only 4% had been treated with skin grafts beforehand, and 70% never received surgical care or a referral. Together, both groups indicated that lack of trust, surgical capacity, and referral timeliness were important factors negatively affecting patient access to surgical care. Accounting for hospital fees indicated patients routinely exceeded the catastrophic expenditure threshold. It was determined that healthcare for burn victims is without financial risk protection. We recommend strengthening burn care and reconstructive surgical programs in similar settings, using a more comprehensive health systems approach to identify and address both medical and socioeconomic factors that determine patient mortality and disability

Improving patient care by virtual case discussion between plastic surgeons and residents of Uganda and the Netherlands

Introduction: Traditional on-site missions of plastic surgeons from “high-income countries” in “low- and middle-income countries” are often limited in time and lack proper follow-up. Regular digital collaboration could lead to a more impactful and durable exchange of knowledge for plastic surgeons and residents in both settings. Aims: The aim of this study was to evaluate the satisfaction of the first twelve months of weekly digital meetings, explore advantages/disadvantages, and to provide tools for similar initiatives. Methods: Weekly meetings started from August 2021. An encrypted digital connection allowed residents and plastic surgeons from Uganda and the Netherlands to discuss cases for educational purposes, where treatment options were considered. After twelve months, a survey was sent to participants from both countries to indicate the meetings’ strengths, weaknesses, and possible improvements. Results: A total of 18 participants responded to the questionnaire (ten plastic surgeons, six residents, and two researchers). The strengths of the meetings were the accessibility of the meetings, knowledge exchange and practice for residents’ final exams. Possible improvements included having a clear format for patient discussion, a session moderator and better internet connectivity. Moreover, a database to assess the impact of the given intervention on the patient cases by evaluating postoperatively (e.g. three months), could further improve clinical care. Conclusions: Virtual patient discussions subjectively contributed to medical education at both locations. Improved digital infrastructure and a collaborative database could further maximize learning capacity. Furthermore, digital proctoring is a promising way to establish sustainable collaborations between high- and low-resource countries.</p