Abstract
Surgical missions to the developing world have been criticized for their lack of outcome analysis. Reported studies indicate a high rate of postoperative complications. An integrated pathway developed for surgical missions and a report of its performance in action is presented herein. Patients were optimized for surgery by a medical team from the UK for a minimum of 14 days preoperatively. They were then transferred to hospital for surgery and returned when stable. At the completion of the mission a junior doctor remained behind for 3 weeks to chart the patients’ progress. Thirty case patients were treated over a 2-week period. The complication rate at 3 weeks postoperatively was 7/30. Twenty-two operations were classified as complex (over 1 h with more than one flap) and eight as simple (under 1 h with minimal flaps). Of those undergoing the simple operations, 2/8 encountered complications at an average of 5 days postoperatively (range 3–7 days). Many medical teams depart in an elevated atmosphere of accomplishment, which without an outcome analysis gives a false impression of their positive impact. Outcome analysis is essential to honestly appraise the effect of surgical missions.
Surgical missions to the developing world, although organized by an expanding group of charities and non-governmental organizations (NGOs), all have two fundamental aims. First, and perhaps the easiest to achieve, is patient care with the aim of improving long-term quality of life for patients otherwise unable to access medical care. Second is to help the transfer of skills to medical professionals in the host country. This second aim is often forgotten in the rush to treat as many patients as possible during a surgical mission, typically only 2 weeks in duration; however it is crucial to fostering good relations with host hospitals and ultimately trying to foster a medical system that is less reliant on foreign aid.
Despite these good intentions surgical missions to the developing world have been criticized for the lack of outcome analysis. The few reported studies indicate a high rate of postoperative complications. There is therefore a need to plan missions to maximize benefit for patients. Traditionally, missions have dealt with well-defined cohorts of patients, such as cleft lip and palate or noma surgery. However a case load with a wider range of facial reconstruction poses additional problems that need to be anticipated to achieve good surgical outcomes in challenging conditions. The object of this article is to report on an integrated care pathway developed for surgical missions and its performance in action. This pathway has been developed over the course of 5 years of missions to Ethiopia.
Methods
Project Harar has been resident in Ethiopia since 2001. Its primary role is the identification of patients with facial deformity through resident medical officers in the state of Harar in eastern Ethiopia. The patients are transported to the capital Addis Ababa for treatment by either local teams, for the cleft lip and palate programme, or by teams from overseas, as part of complex facial reconstruction missions. Since 2010 the charity has run its own missions and has developed a care pathway attuned to local needs.
Patient selection
Patients were identified in the field and photographed. Cleft lip and palate cases were managed in a separate programme. Complex cases requiring staged reconstruction were directed to charities that ran two or three missions a year and could provide continuity of care. Photographs of cases that could be treated in a single course of surgery were relayed to the charity headquarters and circulated to the surgical team. The principle that was adopted was to accept all cases of benign disease. Malignant cases were not considered due to the complexity posed by multi-modality therapy that had to be provided once the team had departed. Forty patients met these criteria.
Team selection
The mission took place in Yekatit 12 Hospital, which provided 10 beds and two operating theatres. The operative team was based on two surgeons per case, ideally a maxillofacial surgeon and a plastic surgeon. Two anaesthetists were required due to the presence of difficult airways and the need for awake fibreoptic intubation. A team of junior doctors organized the pre-assessment, supervised care during the mission, and remained behind to assess and record outcomes.
Mission plan
The patient load was too great to be housed in the hospital. Facilities were provided at Cheshire Home (a care centre for polio victims) 20 km outside of Addis Ababa. Patients were transferred within 14 days of surgery. Two large wards were created and overseen by five Ethiopian nurses. A small medical team from the UK arrived to optimize the patients for surgery. This involved hygiene, nutrition, and medical assessments including chest X-ray (CXR), orthopantomogram (OPG), and computed tomography (CT) scans if there was a clinical need. All were available at a modest cost. Patients were transferred to Yekatit 12 Hospital the evening before surgery. Postoperatively, patients were returned back to Cheshire Home once their condition was stable. The patients were always accompanied by medical personnel (doctor or nurse). At the completion of the mission a junior doctor remained behind for 3 weeks to chart the patients’ progress and obtain a photographic record of the results.
Results
The total complication rate at 3 weeks postoperative was 23% (7/30). Cases were separated into simple and complex. Simple was defined as a case completed in 1 h with minimal flaps; complex cases took over 1 h to complete and involved more than one flap or reconstruction with rib or auricular cartilage. Complications were classified as major (life-threatening), intermediate (hospital stay more than a week longer than anticipated), and minor (discharged within a week of expectation).
In the surgical mission in April 2012, a total of 40 patients were transferred to Addis Ababa for treatment, of whom 36 were considered suitable for surgery (four patients were excluded due to a requirement for staged surgery, surgery at an older age, pregnancy, and patient refusal), giving 36/40 for the original cohort. An additional 10 patients arrived unsolicited, of whom four were listed for surgery, giving a total patient number of 40 out of 50 assessed (see Table 1 ).
| Diagnosis | Number | Complexity |
|---|---|---|
| Lip reconstruction | 8 | Complex |
| Biopsy | 5 | – |
| Nasal reconstruction | 5 | Complex |
| Haemangioma * | 3 | – |
| Trismus | 2 | Simple |
| Dental cyst | 2 | Simple |
| Reconstruction post-trauma | 2 | Complex |
| Ameloblastoma | 2 | Complex |
| Neurofibromatosis | 2 | Simple |
| Epiphora † | 1 | – |
| Giant cell lesion | 1 | Complex |
| Debridement of necrotic mandible | 1 | Simple |
| Lipoma | 1 | Complex |
| PSA parotid | 1 | Complex |
| Scar revision | 1 | Complex |
| Noma | 1 | Complex |
| Tongue lesion and bony skull lesion | 1 | Simple |
| Encephalocele ‡ | 1 | – |
| Total | 40 |
* All cases referred to visiting vascular surgeon for sclerosant injections.
Preoperative assessment demonstrated haemoglobin ranging from 7.6 to 16.3 g/dl (average 12.9 g/dl). The age of patients ranged from 6 to 45 years (average 24 years), but most children were small for their age, with two 6-year-old patients presenting at 7 and 10 kg, respectively. A total of eight CT scans, 12 CXR, five OPG, one magnetic resonance imaging (MRI) scan, and one echocardiogram were organized preoperatively. Two patients were suspected of having pulmonary tuberculosis (TB) and three patients were positive for hepatitis B virus surface antigen (HBSAg). No patients were positive for the human immunodeficiency virus (HIV).
A total of 40 cases were treated within a 2-week period, including five onward referrals (three haemangiomas, one encephalocele, and one lacrimal duct obstruction) and five biopsies (four malignancies and one undetermined leishmaniasis/cutaneous TB). Microvascular surgery was avoided and operations restricted to 3 h (see Discussion).
Those accepted for surgery are listed by diagnosis in Table 1 . Quality of care was judged by immediate (≤2 weeks) and late complications (2–5 weeks). Immediate complications occurred in 4/30 and included one intraoperative complication with blood loss of 1 l during resection of a giant cell lesion (blood transfusion was difficult to procure) and one return to theatre (third day postoperative) for evacuation of a haematoma following resection of a neurofibroma, which would not be unexpected even in the developed world. Two patients had wound healing problems (dehiscence following upper lip reconstruction, and partial necrosis of part of a submental flap – inferior border, 1 cm from the edge).
The total complication rate at 3 weeks postoperatively was 7/30 (23%). Three late complications were encountered: an external pin fixation of the mandible had to be replaced, and two patients developed partial necrosis of flaps (submental flap, medial border, 2 cm from the edge; and nasolabial flap, inferior border, 1 cm from the edge).
There were four wound-related complications, one of wound dehiscence and three of partial flap necrosis. One patient required a return to theatre for debridement (submental flap, medial border, 2 cm from the edge) and one was debrided under local anaesthetic on the ward (submental flap, inferior border, 1 cm from the edge). All were treated with a 7-day course of antibiotics and complications had resolved before team departure. These were therefore assumed to be caused by bacterial infections rather than an incorrect choice of flap. There were no cases of flap failure.
Of the total 30 operations performed, 22 were classified as complex and eight as simple (see Table 1 ). Of those undergoing the simple operations, 2/8 encountered complications at an average of 5 days postoperative (range 3–7 days). Both complications were minor (patient discharge within a week of expectation). The complication rate in the complex cases was 5/22, with complications occurring at an average of 8 days postoperatively (range 0–18 days). One complication was minor, three were intermediate (hospital stay more than a week longer than expected), and one was major – an acute blood loss of 1 l that was judged to be life-threatening (see Table 2 ).
