Challenges in global microsurgery: A six year review of outcomes at an East African hospital

How to Start and Build Microsurgery Practice-Topics on Success and Sustainability: Global/International

Many young microsurgeons begin their careers at established hospitals where microsurgery resources are limited. This article shares the authors' experiences in overcoming challenges and establishing a microsurgery practice in a new hospital. Due to the lack of equipment, limited support from colleagues, absence of discussion partners, fear of failure, and unpredictable situations, many aspiring microsurgeons lose their motivation. The purpose of this article is to guide future microsurgeons by describing the author's actions and suggesting improvements for their first free flap case. Key factors for building a successful, sustainable, and enjoyable microsurgery practice include remembering your training and mentors, acquiring fundamental knowledge of microsurgery, creating a supportive ecosystem, and having fun.

Results of a Pilot Virtual Microsurgery Course for Plastic Surgeons in LMICs

Background

The Plastic Surgery Foundation's Surgeons in Humanitarian Alliance for Reconstruction, Research and Education (SHARE) program seeks to expand surgical capacity worldwide through mentorship and training for local plastic surgeons. This study aims to define the need for microsurgery training among SHARE global fellows and describe results of a pilot course.

Methods

Ten participants of the SHARE Virtual Microsurgical Skills Course were asked to complete an anonymous survey. Pre- and post-course response rates were 100% and 50.0%, respectively.

Results

There was a high incidence of microsurgical problems encountered in the clinical setting. Resource availability was varied, with high access to loupes (100%), yet limited access to microsurgery instruments (50%), medications (40%), operating microscope (20%), skilled nursing (0%) and appropriate peri-operative care settings (0%). Participants identified vessel preparation, instrument selection, and suture handling as priority learning objectives for a microsurgery skills course. Post-course satisfaction with learning objectives was high (60% "very good," 40% "excellent"). Participants reported high levels of improvement in suture handling (Likert 4.60±0.55), end-to-end anastomosis (4.40±0.55), instrument selection (4.20±0.45), vessel preparation (4.20±0.45), and economy of motion (4.20±0.45).

Conclusions

This study demonstrates a high frequency of reconstructive problems encountered by global fellows yet low access to appropriate resources to perform microsurgical procedures. Initial results from a pilot virtual microsurgery course demonstrate very high satisfaction and high self-rated improvement in key microsurgical skills. The virtual course is an effective and accessible format for training surgeons in basic microsurgery skills and can be augmented by providing longitudinal opportunities for remote feedback.

Bone transport in the management of post-osteomyelitis femoral defects in children: A case series with a minimum of 10-year follow-up in Uganda

PURPOSE

The aim of this study was to evaluate the long-term outcomes of the bone transport technique in the management of post-infectious segmental femoral bone defects in children in a low-income country.

METHODS

Eleven children were included in this case series. All had a femoral defect secondary to osteomyelitis managed with the internal bone transport technique using an external fixator alone. Bone and functional results were evaluated and complications recorded after a minimum follow-up period of 10 years (range: 10-16).

RESULTS

The mean age of the patients was 7.8 years, and the average size of the bone defect was 10.8 cm. At the latest follow-up, bone results were excellent in three, good in five, and fair in three, while the functional results were excellent in three, good in four, fair in three, and poor in one. Limb length discrepancy was observed in 10 cases while hip and/or knee joint disorder was recorded in six cases. At the last follow-up, only one patient had a recurrence of infection.

CONCLUSION

The bone transport technique has proven to be a valid option for eradicating infection and filling large bone defects in children. However, it is a technically difficult and lengthy procedure that is prone to unique complications.

LEVEL OF EVIDENCE

IV-Case series.

Clinical application and outcomes of reconstructive microsurgery in Africa: A systematic review and meta-analysis

BACKGROUND

Reconstructive microsurgical free flap techniques are often the treatment of choice for a variety of complex tissue defects across multiple surgical specialties. However, the practice is underdeveloped in low- and middle-income countries. The aim of this systematic review was to evaluate the clinical application and outcomes of reconstructive microsurgery performed in Africa.

METHODS

Seven databases (PubMed, Web of Science, MEDLINE, CINAHL, Academic Search Complete, Embase, and Google Scholar) were searched for studies reporting microsurgical procedures performed in Africa. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools and quality of evidence using the GRADE approach. Meta-analysis was performed using a random effects model to estimate the pooled proportion of events with 95% confidence intervals. The primary outcome was free flap success rate, and the secondary outcomes were the complication and flap salvage rates.

RESULTS

Ninety-two studies were included in the narrative synthesis and nine in the pooled meta-analysis. In total, 1376 free flaps in 1327 patients from 1976 to 2020 were analyzed. Head and neck oncologic reconstruction made up 30% of cases, while breast reconstruction comprised 2%. The pooled flap survival rate was 89% (95% CI: 0.84, 0.93), complication rate 51% (95% CI: 0.36, 0.65), and free flap salvage rate was 45% (95% CI: 0.08, 0.84).

CONCLUSION

This meta-analysis showed that the free flap success rates in Africa are high and comparable to those reported in high-income countries. However, the comparatively higher complication rate and lower salvage rate suggest a need for improved perioperative care.

REVIEW REGISTRATION

Registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 25th September 2020, ID: CRD42020192344.

Outcomes of microsurgical free tissue transfer performed on international surgical collaborations in low-income and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Microsurgical free tissue transfer is the gold standard for reconstruction of significant soft tissue and bony defects following cancer resection and trauma. Many reconstructive units in low-income and middle-income countries (LMICs) do not yet have access to the resources or training required to perform microsurgical procedures. Long-term international collaborations have been formed with annual reconstructive programmes conducting microsurgery.

AIMS

To critically analyze outcomes of microsurgical free tissue transfer performed on international reconstructive collaborations in LMICs.

METHODS

PRISMA-compliant systematic review and meta-analysis of outcomes for free tissue transfer performed during international collaborations in LMICs using an inverse variance model. The study protocol was published prospectively and registered with PROSPERO (ID: CRD42021225613).

RESULTS

Seven studies, included 290 flaps on 284 patients. The most common sites requiring reconstruction were Head and neck (53% (n = 153)) and lower limb (7.9% (n = 23)) were lower limb reconstruction. The most common free flaps were radial forearm (22%; n = 64) and anterolateral thigh (18%; n = 51). Total Flap Failure rate was 3.8% (n = 13; 95% confidence interval (CI) = 1.9-6.3%) Overall complication rate was 38% (95% CI =27-48%), with 19% of flaps requiring emergency return to theatre (95% CI =14-26%). Flap salvage was successful in 52% of take-backs (95% CI =15% - 88%).

CONCLUSIONS

Free flaps performed during international surgical collaborations in LMICs have comparable failure rates to those performed in higher-income settings. However, there are higher complication and take-back rates. This should be taken into account when planning international collaborations. These results should help preoperative counselling and the consent process.

Vascularized fibula flap in the management of segmental bone loss following osteomyelitis in children at a Ugandan hospital

Background: Hematogenous osteomyelitis is commonly observed in the pediatric population across sub-Saharan Africa. This retrospective case series was designed to evaluate the complications and outcomes of treatment using a vascularized fibula flap (VFF) to fill segmental bone defects secondary to osteomyelitis in children in a low-resource setting in CoRSU Rehabilitation Hospital, Uganda. Methods: Clinical notes and radiographs of children with a diagnosis of osteomyelitis that subsequently underwent a VFF procedure between October 2013 and December 2017 were reviewed. All patients were clinically and radiographically evaluated in 2019. Results: Forty-four children, with an average bone defect of 10.5 cm, were included. Eighty-four percent of children had successful VFF limb reconstruction. Integration of the graft was radiologically sound in 20.8 weeks on average. The postoperative phase was uneventful in 29 % of patients. Complications were observed in the remaining patients, including flap failure (6), donor leg neurapraxia (3), cutaneous paddle necrosis (11), graft fracture (2), skin graft loss (6), fixator failure (1) and non-union (2). Functional outcomes were rated as excellent in 13 patients, good in 14, fair in 9 and poor in 8. There was no recurrence of the bone infection in any of the enrolled children. Conclusion: Despite being a complex and demanding procedure, VFF is a good option for reconstructing post-osteomyelitis bone defects, particularly when associated with loss of soft tissue envelope. Considering the more than satisfactory functional and clinical outcomes, this procedure should be kept in mind for these complex pediatric cases of bone and soft tissue loss, even in a low-resource setting.

The University of Pennsylvania Flap Course Enters Virtual Reality: The Global Impact

The purpose of this study was to evaluate participants from the in-person Penn Flap Course (PFC) and virtual PFC to determine if the virtual PFC increased diversity in culture, sex, education, and surgical specialties internationally and within the United States. Our hypothesis is that the virtual PFC increases diversity internationally and within the United States.

Methods

A retrospective descriptive comparison was performed between participants from the in-person PFC from the years 2017 to 2019 and virtual PFC in 2020. Frequency maps were generated to determine differences in participation of cultures, sexes, education, and specialties internationally and within the United States. Net Promoter Scores (NPSs) were used to assess participant satisfaction with the virtual course.

Results

The in-person PFC included 124 participants from the years 2017 to 2019, whereas the virtual PFC included 770 participants in the year 2020. Compared to the in-person course, the virtual course included more cultures (countries: 60 versus 11; states: 35 versus 22), women (countries: 38 versus 7; states: 23 versus 9), students/researchers (countries: 24 versus 0; states: 9 versus 0), residents (countries: 44 versus 5; states: 26 versus 15), fellows (countries: 21 versus 2; states: 21 versus 9), attendings (countries: 34 versus 8; states: 16 versus 11), plastic surgery (countries: 54 versus 9; states: 31 versus 18), orthopedic surgery (countries: 12 versus 5; states: 11 versus 9), and other specialties (countries: 19 versus 1; states: 8 versus 2). Our overall NPS for the virtual PFC totaled 75%, categorized as "world class" based on global NPS.

Conclusion

A virtual interface for a flap course increased participation and diversity of culture, sex, education, and specialties internationally and within the United States with "world class" participant satisfaction.

Predicting risk factors that lead to free flap failure and vascular compromise: A single unit experience with 565 free tissue transfers

BACKGROUND

Even though the benefit of free tissue transfer is uncontested in complex reconstructive cases, vascular compromise and/or flap failure remain a challenge for the surgeon and identification of possible risk factors can aid in the preoperative planning. The aim of this study was to identify the individual risk factors leading to flap failure and/or vascular compromise in free tissue transfers in a single institution over a period of 10 years and to create an index predicting these problems, as well as finding predictors of other postoperative complications.

METHODS

Data from all the patients undergoing free tissue transfers between 2009 and 2018 were retrospectively analyzed (demographics, comorbidities, flap failure, vascular compromise, and other complications). The results from the univariate and multivariate analyses were used to create an index.

RESULTS

A predictability index with three classes (low, moderate, and high risk) was calculated for each patient, based on defect etiology and the presence of coronary heart disease, diabetes, smoking, peripheral arterial vascular disease, and arterial hypertension. A patient with moderate-risk index had 9.3 times higher chances of developing vascular compromise than those in the low-risk group, while a high-risk index had 18.6 higher odds (p=0.001). American Society of Anesthesiologists (ASA) classification was found to be a predictor of complications in free tissue transfer (p=0.001).

CONCLUSION

If patients at a high risk of vascular compromise could be identified preoperatively through this predictability index, patient counseling could be improved and the surgeon might adapt the reconstructive plan and choose an alternative reconstructive strategy.

Challenges of Setting up a Lower Extremity Reconstruction Practice in a Constrained Environment

BACKGROUND

 Microsurgical lower extremity reconstruction remains challenging, especially when resources are limited such as lack of proper equipment, human resources, administrative support, and located in a remote area far from tertiary care. Nevertheless, reconstructive solutions are required, especially when in urgent trauma situations. In this article, we evaluate ways of overcoming challenges and issues that should be considered in a newly established unit by sharing our initial lower extremity reconstruction experience.

METHODS

 We report a local hospital's initial lower extremity reconstruction experience in February 2017 to January 2018. Through a total of seven patients, we tried to enhance the environment, instruments, nurses' contribution, and perspective of the peers and community in terms of factors related to the surgeon, hardware, environment, supporting faculty, reimbursement, and patients.

RESULTS

 Four patients underwent reconstruction with a freestyle propeller flap and three with an anterolateral thigh flap; in one case, a superficial circumflex iliac artery perforator flap was chosen to salvage partial flap necrosis. Increased experience of the surgeon, new equipment, continuing nurse/patient education, and collaborating with other departments allowed us to choose more challenging flaps and be more meticulous while decreasing the operation time and hospital stay.

CONCLUSION

 To start a lower extremity reconstruction practice in a resource-poor environment, the surgeon needs to evaluate the relevant factors; moreover, he or she should continuously improve them until a working methodology is achieved. Despite all the challenges, the adaptations learned at this center can be applied to other local hospitals around the world to set up a lower extremity reconstruction practice and improve its outcomes.

Review of the First 108 Free Flaps at Public Health Concern Trust-NEPAL Hospitals: Challenges and Opportunities in Developing Countries

BACKGROUND

Free tissue transfer is one of the most important and essential techniques in reconstructive surgery. The underlying complexity, steep learning curve, high cost, and fear of failure make it very difficult to establish as a regular service in developing countries such as Nepal.

METHODS

A retrospective cohort study design was used to analyze the challenges with and opportunities for reconstructive surgery in Nepal. Medical records were reviewed for patient demographics, indications, types of free flaps, hospital stay, complications, and involvement of a microsurgery teaching workshop.

RESULTS

A total of 16 microsurgical workshops were carried out by 3 international organizations over the study period (2007-2017). Altogether 108 free flaps in 103 subjects were reviewed during the study period at different hospitals of the Public Health Concern Trust-NEPAL (phect-NEPAL) and National Trauma Center. Of 103 patients, 60 were males and 43 were females with an average age of 34.5 years (range, 8-73 years). The most common indications for microsurgical reconstruction were tumor, trauma, and burns. Radial artery forearm flap, anterolateral thigh flap, and free fibular flap were the most common types of flaps. Ten different types of flaps were performed. Four cases needed more than 1 flap; one of them needed 3 flaps. Flap success rate approached 90%. Four patients died in the hospital postoperatively.

CONCLUSION

Reconstructive microsurgery is challenging in Nepal and more generally in developing settings. However, persistent technical support such as training and workshops can make it feasible.

Challenges in global reconstructive microsurgery: The sub-Saharan african surgeons' perspective

Background

Microsurgery is an essential element of plastic surgery practice. However, it remains unavailable or rudimentary in several developing countries, especially in sub-Saharan Africa. This study presents the local plastic surgeons experience, while focusing on specific challenges encountered and methods to improve the sub-Saharan global microsurgery practice.

Methodology

An online survey was sent to all plastic surgeons registered with the College of Surgeons East Central and Southern Africa and respective national plastic surgical societies in the east central and southern Africa regional community. A total of 57 questionnaires were sent. Surgeons' country of practice, years of experience and rate of performing microsurgical procedures were considered.

Results

The survey response rate was 56% (n = 32). Most participants believed microsurgery was essential in the region. The leading challenge was inadequate perioperative care, mainly attributed to shortage of support staff (n = 29, 91%). Others were lack of surgical expertise and resources. Interestingly, public unawareness of the benefits of microsurgery was also noted as a critical hindrance. The foremost suggestion on improvement (n = 19, 59%) was to enhance training with a multidisciplinary team-building approach. Others included increased advocacy, publications and funding.

Conclusion

The Plastic surgeons' perspective recognizes the needs of Global Reconstructive Microsurgery in sub-Saharan Africa. However, inadequate perioperative care, insufficient expertise, lack of equipment and lack of public awareness were major hindrances. Finally, there is a need to improve microsurgery in the region through advocacy, training and multidisciplinary team building.

Reconstructive considerations in low and middle-income countries

PURPOSE OF REVIEW

Surgical mission trips in head and neck surgery are common. There are an increasing number of surgical groups performing complex reconstructions in low and middle-income countries (LMIC). Consideration of reconstructive options that are location and patient specific are critical for optimum patient care and local physician education.

RECENT FINDINGS

The pectoralis muscle regional flap is a versatile and reliable option and has been shown to reconstruct defects in nearly every head and neck subsite. Additional regional flap options described are the supraclavicular island flap and submental island flap. There are 15 published case series describing experience with performing microvascular reconstructions in LMIC. The average success rate was 87.1%. Both loupe and microscope magnification are used.

SUMMARY

Complex reconstructions are successfully being performed in LMIC. Although microvascular reconstruction is being utilized by some groups, local and patient-specific factors should be carefully considered, as many regional and local flap options available provide the same reconstruction benefit while minimizing operating room time, resources, and postoperative care needs.

Outcomes and Disability After Massive Proximal Upper Extremity Reconstruction in a Resource-Limited Setting

BACKGROUND

At Ganga Hospital in Coimbatore, India, a unique approach is applied to treat massive upper limb injuries. However, long-term outcomes of complex reconstruction performed in the resource-limited setting are not known. This hinders understanding of outcomes and disability from these injuries and prevents systematically addressing care delivery around upper extremity trauma in the developing world. This project aims to analyze the details of the unique Ganga Hospital reconstruction experience and use patient-reported outcome measures for the first time in this patient population to evaluate post-injury recovery and disability .

METHODS

Forty-six patients were evaluated 6 months or more after massive proximal upper extremity reconstruction at Ganga Hospital. Patients completed functional tests, Jebsen-Taylor test (JTT), and patient-reported outcomes (PROs)-Michigan Hand Questionnaire (MHQ), Disability of Arm, Shoulder, and Hand questionnaire (DASH), and Short-Form 36 (SF-36). Correlations between metrics were assessed with Pearson's correlation coefficients. Linear regression modeling evaluated associations between severity, reconstruction, and outcomes.

RESULTS

MHQ and DASH results correlated with functional test performance, JTT performance, and SF-36 scores (Pearson's coefficients all ≥0.33, p ≤ 0.05). In this cohort, mean MHQ score was 79 ± 15 and mean DASH score was 13 ± 15, which are not significantly different than scores for long-term outcomes after other complex upper extremity procedures. The following factors predicted PROs and functional performance after reconstruction: extent of soft tissue reconstruction, multi-segmental ulna fractures, median nerve injury, and ability for patients to return to work and maintain their job after injury.

CONCLUSIONS

Complex proximal upper extremity salvage can be performed in the resource-limited setting with excellent long-term functional and patient-reported outcomes. PRO questionnaires are useful for reporting outcomes that correlate to functional and sensory testing and may be used to assess post-traumatic disability.