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de Berker HT, Čebron U, Bradley D, Patel V, Berhane M, Almas F, Walton G, Eshete M, McGurk M, Martin D, Honeyman C. Outcomes of microsurgical free tissue transfer performed on international surgical collaborations in low-income and middle-income countries: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2022; 75:2049-2063. [PMID: 35490120 DOI: 10.1016/j.bjps.2022.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 02/19/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Henry T de Berker
- Department of Plastic Surgery, Royal Preston Hospital, Preston, United Kingdom.
| | - Urška Čebron
- Department of Hand, Plastic, Reconstructive and Burn Surgery, University of Tübingen, Tübingen, Germany
| | - Daniel Bradley
- King's College London, Faculty of Dentistry, Oral and Craniofacial Sciences, Guy's Tower, Guy's Hospital, London, United Kingdom
| | - Vinod Patel
- Oral Surgery Department, Guy's Dental Institute, Guy's & St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Meklit Berhane
- Department of Plastic and Reconstructive Surgery, ALERT Hospital, Addis Ababa, Ethiopia
| | - Fernando Almas
- Department of Cranio-Maxillofacial and Reconstructive Surgery, Saint Judes General Hospital, Federal Hospital of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gary Walton
- Department of Head and Neck Surgery, University Hospitals Coventry and Warwickshire, United Kingdom
| | - Mekonen Eshete
- Department of Surgery, School of Medicine, College of Health Sciences Addis Ababa University, Addis Ababa, Ethiopia
| | - Mark McGurk
- Department of Head and Neck Surgery, University College London Hospital, London, United Kingdom
| | | | - Calum Honeyman
- Canniesburn Plastic Surgery and Burns Unit, Glasgow, Scotland, United Kingdom
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Honeyman CS, Patel V, Bakhiet A, Bradley DR, Almas F, Martin D, McGurk M. The impact of the COVID-19 pandemic on international reconstructive collaborations in Africa. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021; 45:469-474. [PMID: 34629757 PMCID: PMC8491751 DOI: 10.1007/s00238-021-01892-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/17/2021] [Indexed: 11/21/2022]
Abstract
Background The SARS-CoV-2 (COVID-19) pandemic has catalysed a widespread humanitarian crisis in many low- and middle-income countries around the world, with many African nations significantly impacted. The aim of this study was to quantify the impact of the COVID-19 pandemic on the planning and provision of international reconstructive collaborations in Africa. Methods An anonymous, 14-question, multiple choice questionnaire was sent to 27 non-governmental organisations who regularly perform reconstructive surgery in Africa. The survey was open to responses for four weeks, closing on the 7th of March 2021. A single reminder was sent out at 2 weeks. The survey covered four key domains: (1) NGO demographics; (2) the impact of COVID-19 on patient follow-up; (3) barriers to the safe provision of international surgical collaborations during COVID-19; (4) the impact of COVID-19 on NGO funding. Results A total of ten reconstructive NGOs completed the survey (response rate, 37%). Ethiopia (n = 5) and Tanzania (n = 4) were the countries where most collaborations took place. Plastic, reconstructive and burns surgery was the most common sub-speciality (n = 7). For NGOs that did not have a year-round presence in country (n = 8), only one NGO was able to perform reconstructive surgery in Africa during the pandemic. The most common barrier identified was travel restrictions (within country, n = 8 or country entry-exit, n = 7). Pre-pandemic, 1547 to ≥ 1800 patients received reconstructive surgery on international surgical collaborations. After the outbreak, 70% of NGOs surveyed had treated no patients, with approximately 1405 to ≥ 1640 patients left untreated over the last year. Conclusions The COVID-19 pandemic has placed huge pressures on health services and their delivery across the globe. This theme has extended into international surgical collaborations leading to increased unmet surgical needs in low- and middle-income countries. Level of evidence: Not gradable. Supplementary Information The online version contains supplementary material available at 10.1007/s00238-021-01892-4.
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Affiliation(s)
- Calum S Honeyman
- Department of Plastic, Reconstructive and Burns Surgery, Ninewells Hospital, James Arrott Drive, Dundee, DD2 1SG Scotland UK
| | - Vinod Patel
- Oral Surgery Department, Guys Dental Institute, Guys & St Thomas NHS Foundation Trust, London, England UK
| | - Abdelwakeel Bakhiet
- Department of Plastic, Reconstructive and Burns Surgery, Ninewells Hospital, James Arrott Drive, Dundee, DD2 1SG Scotland UK
| | - Daniel R Bradley
- Department of Head and Neck Surgery, The Royal Marsden Hospital, London, UK
| | - Fernando Almas
- Department of Cranio-MaxilloFacial and Reconstructive Surgery, Saint Judes General Hospital, Federal Hospital of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Mark McGurk
- Department of Head and Neck Surgery, University College London Hospital, London, England UK
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de Berker HT, Čebron U, Bradley D, Patel V, Berhane M, Almas F, Walton G, Eshete M, McGurk M, Martin D, Honeyman C. Protocol for a systematic review of outcomes from microsurgical free-tissue transfer performed on short-term collaborative surgical trips in low-income and middle-income countries. Syst Rev 2021; 10:245. [PMID: 34496948 PMCID: PMC8427880 DOI: 10.1186/s13643-021-01797-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 08/23/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In many units around the world, microsurgical free-tissue transfer represents the gold standard for reconstruction of significant soft tissue defects following cancer, trauma or infection. However, many reconstructive units in low-income and middle-income countries (LMICs) do not yet have access to the resources, infrastructure or training required to perform any microsurgical procedures. Long-term international collaborations have been formed with annual short-term reconstructive missions conducting microsurgery. In the first instance, these provide reconstructive surgery to those who need it. In the longer-term, they offer an opportunity for teaching and the development of sustainable local services. METHODS A PRISMA-compliant systematic review and meta-analysis will be performed. A comprehensive, predetermined search strategy will be applied to the MEDLINE and Embase electronic databases from inception to August 2021. All clinical studies presenting sufficient data on free-tissue transfer performed on short-term collaborative surgical trips (STCSTs) in LMICs will be eligible for inclusion. The primary outcomes are rate of free flap failure, rate of emergency return to theatre for free flap salvage and successful salvage rate. The secondary outcomes include postoperative complications, cost effectiveness, impact on training, burden of disease, legacy and any functional or patient reported outcome measures. Screening of studies, data extraction and assessments of study quality and bias will be conducted by two authors. Individual study quality will be assessed according to the Oxford Evidence-based Medicine Scales of Evidence 2, and risk of bias using either the 'Revised Cochrane risk of bias tool for randomized trials' (Rob2), the 'Risk of bias in non-randomized studies of interventions' (ROBINS-I) tool, or the National Institute for Health Quality Assessment tool for Case Series. Overall strength of evidence will be assessed according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. DISCUSSION To-date the outcomes of microsurgical procedures performed on STCSTs to LMICs are largely unknown. Improved education, funding and allocation of resources are needed to support surgeons in LMICs to perform free-tissue transfer. STCSTs provide a vehicle for sustainable collaboration and training. Disseminating microsurgical skills could improve the care received by patients living with reconstructive pathology in LMICs, but this is poorly established. This study sets out a robust protocol for a systematic review designed to critically analyse outcomes. SYSTEMATIC REVIEW REGISTRATION PROSPERO 225613.
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Affiliation(s)
- Henry T de Berker
- Department of Burns and Plastic Surgery, Wythenshawe Hospital, Southmoor Road, Manchester, UK.
| | - Urška Čebron
- Department of Hand, Plastic, Reconstructive and Burn Surgery, University of Tübingen, Tübingen, Germany
| | - Daniel Bradley
- King's College London, Faculty of Dentistry, Oral and Craniofacial Sciences, Guy's Tower, Guy's Hospital, London, UK
| | - Vinod Patel
- Oral Surgery Department, Guy's Dental Institute, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Meklit Berhane
- Department of Plastic and Reconstructive Surgery, ALERT Hospital, Addis Ababa, Ethiopia
| | - Fernando Almas
- Department of Cranio-Maxillofacial and Reconstructive Surgery, Saint Judes General Hospital, Federal Hospital of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gary Walton
- Department of Head and Neck Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Mekonen Eshete
- Department of Surgery, School of Medicine, College of Health Sciences Addis Ababa University, Addis Ababa, Ethiopia
| | - Mark McGurk
- Department of Head and Neck Surgery, University College London Hospital, London, UK
| | | | - Calum Honeyman
- Department of Plastic, Reconstructive and Burns Surgery, Ninewells Hospital, Dundee, Scotland, UK
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The potential use of digital health technologies in the African context: a systematic review of evidence from Ethiopia. NPJ Digit Med 2021; 4:125. [PMID: 34404895 PMCID: PMC8371011 DOI: 10.1038/s41746-021-00487-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 06/24/2021] [Indexed: 02/08/2023] Open
Abstract
The World Health Organization (WHO) recently put forth a Global Strategy on Digital Health 2020–2025 with several countries having already achieved key milestones. We aimed to understand whether and how digital health technologies (DHTs) are absorbed in Africa, tracking Ethiopia as a key node. We conducted a systematic review, searching PubMed-MEDLINE, Embase, ScienceDirect, African Journals Online, Cochrane Central Registry of Controlled Trials, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform databases from inception to 02 February 2021 for studies of any design that investigated the potential of DHTs in clinical or public health practices in Ethiopia. This review was registered with PROSPERO (CRD42021240645) and it was designed to inform our ongoing DHT-enabled randomized controlled trial (RCT) (ClinicalTrials.gov ID: NCT04216420). We found 27,493 potentially relevant citations, among which 52 studies met the inclusion criteria, comprising a total of 596,128 patients, healthy individuals, and healthcare professionals. The studies involved six DHTs: mHealth (29 studies, 574,649 participants); electronic health records (13 studies, 4534 participants); telemedicine (4 studies, 465 participants); cloud-based application (2 studies, 2382 participants); information communication technology (3 studies, 681 participants), and artificial intelligence (1 study, 13,417 participants). The studies targeted six health conditions: maternal and child health (15), infectious diseases (14), non-communicable diseases (3), dermatitis (1), surgery (4), and general health conditions (15). The outcomes of interest were feasibility, usability, willingness or readiness, effectiveness, quality improvement, and knowledge or attitude toward DHTs. Five studies involved RCTs. The analysis showed that although DHTs are a relatively recent phenomenon in Ethiopia, their potential harnessing clinical and public health practices are highly visible. Their adoption and implementation in full capacity require more training, access to better devices such as smartphones, and infrastructure. DHTs hold much promise tackling major clinical and public health backlogs and strengthening the healthcare ecosystem in Ethiopia. More RCTs are needed on emerging DHTs including artificial intelligence, big data, cloud, cybersecurity, telemedicine, and wearable devices to provide robust evidence of their potential use in such settings and to materialize the WHO’s Global Strategy on Digital Health.
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