Microsurgery: A 10-Year Experience with Loupe Magnification

Microsurgery in low- and middle-income countries: Results of 20 years of experience in Cambodia

BACKGROUND

Microsurgical free tissue transfer is the gold standard for reconstructing major bone or soft tissue defects but requires complex training, and specific resources. Therefore, some authors have stated that microsurgery is impossible in low- and middle-income countries.

METHODS

Patients from Khmer underwent free flap surgery at the Children's Surgical Centre in Phnom Penh between 2004 and 2023. Two non-governmental organizations facilitated the program: Rose Charities Cambodia provided the facilities, patients and local staff, and Doctors of the World provided the surgeons, and anesthetists. At least one Khmer surgeon was trained during these operations. Digital data were collected retrospectively, and analyzed in June 2023.

RESULTS

Fifty-six free flaps in 54 patients have been performed since 2004. The most frequent sites requiring reconstruction were the head and neck (35.7%), lower limbs (30.4%), and upper limbs (21.4%). The most frequent free flaps were free fibula (44.6%), gracilis (19.6%), and anterolateral thigh (16.1%). Among the 56 flaps, 41 (= 73.2%) were viable long-term and 15 (26.7%) were microsurgical failures. Sixteen flaps underwent revision in the operating room. Twenty-three flap-related complications were reported in 21 patients with mostly vascular thrombosis (n = 12), hematoma (n = 3) and infections (3). However, 83.3% had improved or were cured of their initial pathology after final surgical management.

CONCLUSIONS

Free flaps performed in our series as part of international surgical collaborations in a low-income country are feasible, but we experienced higher failure rates, and later revisions compared to the results in high-income countries. We identified several solutions to improve the microsurgery outcomes in low-income settings.

Can Loupe magnification be a viable alternative to Operative Microscope magnification for vascular anastomosis in reconstructive surgery? A systematic review and meta-analysis

PURPOSE

The aim of this study is to compare the outcomes of vascular anastomosis using loupes magnification versus operative microscope magnification in reconstructive surgery.

METHODS

We performed a systematic review of MEDLINE (via PubMed), Scopus and Cochrane Library database according to the PRISMA guidelines. Comparative studies between the two techniques and single arm studies reporting on loupes reconstruction were included. Random-effects model meta-analyses were performed.

RESULTS

Twelve studies, reporting a total of 3908 of flaps, 3409 of which were performed under loupes magnification and 499 under the operative microscope magnification were selected for analysis. No statistically significant differences were observed regarding total flap loss and vascular complication between the two arms. In the Loupes group the rate of total flap loss was 2.65% (95% CI: 1.15-4.63) and the rate of vascular complications 4.49% (95% CI: 2.58-6.84).

CONCLUSION

Loupes magnification under circumstances can provide a safe and effective alternative to microvascular reconstruction in reconstructive surgery. With respect to flap failure and vascular complication rates, there appear to be no statistically significant differences between the anastomoses conducted under Loupes magnification and the standard operative microscope.

Realities and challenges of head and neck free flap reconstruction in sub-Saharan Africa

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.

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.