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Prasad K, Peterson N, Nolen D, Macharia C, Mannion K, Rohde S, Sinard R. Building a sustainable free flap program in a resource-limited setting: A 12-year humanitarian effort. Head Neck 2024; 46:1051-1055. [PMID: 38233973 DOI: 10.1002/hed.27640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 01/01/2024] [Accepted: 01/02/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND We present a sustainable complex reconstructive program built through 12 years of surgical outreach work at Kijabe Hospital in Kenya. METHODS Retrospective chart review and anecdotal experiences. RESULTS In 2011, surgeons from a US-medical center performed Kijabe Hospital's first 3 successful free flap surgeries. Since then, they have returned 7 times, performing a total of 31 tumor excisions with microvascular reconstruction. One flap failure occurred that was reconstructed on a subsequent trip. In 2013, a US-trained missionary surgeon and a Kenyan-trained general surgeon began working with the visiting team with the goal of performing these surgeries independently. In 2016 they performed their first independent free flap reconstruction and have since performed 32 independent cases with only three flap losses. Establishing infrastructure, staff education, selective patient criteria, and continuous communication are the factors that enabled the success of this program. CONCLUSIONS Establishing a successful microvascular reconstruction program in a resource-limited setting is feasible.
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Affiliation(s)
- Kavita Prasad
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Nathaniel Peterson
- Department of Otolaryngology - Head and Neck Surgery, Loma Linda University, Loma Linda, California, USA
| | - David Nolen
- Austin Ear, Nose, and Throat Clinic, Austin, Texas, USA
| | - Chege Macharia
- Department of Head and Neck Oncologic and Trauma Surgery, AIC Kijabe Hospital, Kijabe, Kenya
| | - Kyle Mannion
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Sarah Rohde
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Robert Sinard
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee, USA
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Okerosi S, Nkya A, Fagan J, Xu MJ. Realities and challenges of head and neck free flap reconstruction in sub-Saharan Africa. Curr Opin Otolaryngol Head Neck Surg 2023; 31:438-440. [PMID: 37820268 DOI: 10.1097/moo.0000000000000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
PURPOSE OF REVIEW With an increased need to decentralize and train more head and neck ablative and reconstructive surgeons in sub-Saharan Africa, we assess the realities and challenges of free flap reconstruction in sub-Saharan Africa to provide context of its use as a reconstructive option. RECENT FINDINGS Head and neck free flap reconstruction has been performed by local teams as well as visiting teams in Sub Saharan Africa with good results. Free flap success rates are similar to high income regions at 89% vs. 85-100%. However, flap salvage rates are significantly lower (45% compared to 64.1% reported in high income regions). This has been attributed to resource constraints. SUMMARY With increasing efforts to increase free flap reconstructive capacity in sub-Saharan Africa, these efforts need to be in the context of available healthcare resources including infrastructure and workforce outside of the surgical team. As training of head and neck ablative and reconstructive surgeons is expanded, reconstructive training needs take the healthcare resource availability into account.
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Affiliation(s)
- Samuel Okerosi
- ENT Department, Kenyatta National Hospital, Nairobi, Kenya
| | - Aslam Nkya
- Department of Otorhinolaryngology, Muhimibili National Hospital, Dar es Salaam, Tanzania
| | - Johan Fagan
- Division of Otolaryngology, University of Cape Town, Cape Town, South Africa
| | - Mary Jue Xu
- Department of Otolaryngology-Head and Neck Surgery, University of California San Francisco, San Francisco, California, USA
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Ciudad P, Escandón JM, Llanos E, Ludeña J, Manrique OJ, Castro J, Rossi R. Inexpensive Materials for Microsurgery in Middle- and Low-Income Countries. Arch Plast Surg 2023; 50:121-124. [PMID: 36755642 PMCID: PMC9902198 DOI: 10.1055/s-0042-1758640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 08/04/2022] [Indexed: 02/08/2023] Open
Abstract
With the continuous incorporation of new technologies and advancements in surgical technique, microsurgical procedures around the world have generated a higher success rate and innovative procedures are now possible. In this setting, limitations regarding accessibility and acquisition of medical resources and equipment for these types of operations may be difficult in developing countries. We believe the dexterities of surgeons go beyond the surgical technique, meaning that we are able to use everyday materials to re-create affordable solutions that can be used during surgery in a safe way. This manuscript presents our experience with different surgical instruments and gadgets, developed out of necessity, to improve microsurgical interventions in developing countries.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru,Academic Department of Surgery, Hipolito Unanue School of Medicine, Federico Villarreal National University, Lima, Peru,Address for correspondence Pedro Ciudad, MD, PhD Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital 46170LimaPeru
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York
| | - Edgar Llanos
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Juan Ludeña
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, New York
| | - Jorge Castro
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Rafael Rossi
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
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Banda CH, Wilson E, Malata CM, Narushima M, Ogawa T, Hassanein ZM, Shiraishi M, Okada Y, Ghorra DT, Ishiura R, Danno K, Mitsui K, Oni G. Clinical application and outcomes of reconstructive microsurgery in Africa: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2022; 75:2035-2048. [PMID: 35643598 DOI: 10.1016/j.bjps.2022.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/20/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Chihena H Banda
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan; Department of Surgery, Arthur Davison Children's Hospital, Ndola, Zambia.
| | - Emma Wilson
- Division of Epidemiology and Public Health, The University of Nottingham, Nottingham, United Kingdom
| | - Charles M Malata
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom; Anglia Ruskin University, School of Medicine, Chelmsford, Cambridge, United Kingdom
| | - Mitsunaga Narushima
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Tomoko Ogawa
- Department of Breast Surgery, Mie University, Tsu, Japan
| | - Zeinab M Hassanein
- Division of Epidemiology and Public Health, The University of Nottingham, Nottingham, United Kingdom
| | - Makoto Shiraishi
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Yoshimoto Okada
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Dina T Ghorra
- Department of Plastic and Reconstructive Surgery, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, United Kingdom; Department of Plastic and Reconstructive Surgery, Alexandria University, Alexandria, Egypt
| | - Ryohei Ishiura
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Kanako Danno
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Kohei Mitsui
- Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, 2-174 Edobashi, Tsu, 514-8507, Japan
| | - Georgette Oni
- Nottingham Breast Institute, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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Wood CB, Yancey KH, Okerosi SN, Wiggleton J, Seim NB, Mannion K, Netterville JL. Ultrasound Training for Head and Neck Surgeons in Rural Kenya: A Feasibility Study. JOURNAL OF SURGICAL EDUCATION 2020; 77:866-872. [PMID: 32146136 DOI: 10.1016/j.jsurg.2020.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/10/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To determine the feasibility of training otolaryngologists to perform head and neck ultrasound in low- and middle-income countries over a short timeframe. DESIGN Prospective cohort evaluating an ultrasound training course for otolaryngologists in low- and middle-income countries. SETTING Surgical training camp for otolaryngologists in semirural Kenya. METHODS Participants were prospectively recruited to participate in an ultrasound training course during a 2-week surgical training camp. They performed baseline ultrasound exams (9-item test, 5-point scale) with no assistance, followed by didactic sessions teaching ultrasound techniques. Participating surgeons then performed head and neck ultrasound exams on patients in clinic or in the operating room with direct supervision. Postcourse ultrasounds were performed, and the results of these tests were compared to baseline exams. RESULTS Eight surgeons were enrolled out of a total of 13 (62%). Three were attending surgeons (37.5%), 1 enrollee was a head and neck surgery fellow, and 4 were senior residents (50%). Six of 8 surgeons were from Kenya. The mean precourse test score was 25 (range 21-30) compared to a mean postcourse test score of 40 (range 37-45, p < 0.005). All participants significantly improved their scores, with a mean improvement of 16 points (range 10-23). DISCUSSION Otolaryngologists are uniquely equipped to learn head and neck ultrasound given their familiarity with the anatomy and pathology in this region. Training physicians without prior experience can be done even over short timeframes. Early training should focus on ultrasound, with later stages of training focusing on pathology.
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Affiliation(s)
- Carey Burton Wood
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Kristen H Yancey
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Samuel N Okerosi
- Department of Otolaryngology, University of Nairobi, Nairobi, Kenya
| | - Jaime Wiggleton
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nolan B Seim
- Department of Otolaryngology - Head and Neck Surgery, Ohio State University Medical Center, Columbus, Ohio
| | - Kyle Mannion
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James L Netterville
- Department of Otolaryngology - Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Deptula P, Chang K, Chang J. Teaching Hand Surgery in the Developing World: Utilizing Educational Resources in Global Health. Hand Clin 2019; 35:411-419. [PMID: 31585601 DOI: 10.1016/j.hcl.2019.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The development of surgical capacity in the developing world is essential to address the global burden of surgical disease. Training local surgeons in low-income and middle-income countries is critical in this endeavor. The challenges to teaching hand surgery in the developing world include a shortage of local faculty, absence of a defined curriculum, no competency-based evaluation systems, few subspecialty training opportunities, and lack of financial support. To teach hand surgery in the developing world effectively, the authors suggest principles and components of a global training curriculum.
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Affiliation(s)
- Peter Deptula
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, CA 94304, USA.
| | | | - James Chang
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, CA 94304, USA
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Seim NB, Wood CB, Yancey KL, Mannion K, Netterville JL. Head and Neck Ultrasound in Otolaryngology Surgical Missions. EAR, NOSE & THROAT JOURNAL 2019; 98:535-536. [PMID: 31554430 DOI: 10.1177/0145561319864553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Nolan B Seim
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C Burton Wood
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kristen L Yancey
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kyle Mannion
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - James L Netterville
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Wood CB, Seim NB, Yancey KL, Netterville JL, Mannion K. Color Doppler Ultrasonography for Monitoring a Free Flap Anastomosis During a Head and Neck Surgical Camp. EAR, NOSE & THROAT JOURNAL 2019; 100:160-161. [PMID: 31547707 DOI: 10.1177/0145561319864556] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- C Burton Wood
- Department of Otolaryngology-Head and Neck Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nolan B Seim
- Department of Otolaryngology-Head and Neck Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kristen L Yancey
- Department of Otolaryngology-Head and Neck Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - James L Netterville
- Department of Otolaryngology-Head and Neck Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kyle Mannion
- Department of Otolaryngology-Head and Neck Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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Reconstructive considerations in low and middle-income countries. Curr Opin Otolaryngol Head Neck Surg 2018; 26:340-346. [PMID: 30124522 DOI: 10.1097/moo.0000000000000484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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