Beyond short-term surgical missions:On the role of surgeons from high-income settings to help improve surgical care in resource-limited settings

This dissertation provides data collected during the development and implementation of an alternative approach to short-term surgical missions. These missions have been the traditional strategy for surgeons from high-income settings to help to improve surgical care in resource-limited settings. This dissertation presents an alternative approach. During the Amsterdam-based international symposium, ‘Surgery in Low Resource Settings,’ held in November 2014, the urgency for collaborative solutions became more evident. On behalf of 65 international organizations and all participants of the symposium, the “Amsterdam Declaration on Essential Surgical Care” was published in April 2015. Chapter 2 describes that the number of people dying from surgical conditions outnumbers the death toll of HIV, malaria, and tuberculosis combined. Surgery should be a part of the United Nations’ post-2015 sustainable development goals. The aim of Chapter 3 is to present baseline information on surgical burn care in sub-Saharan Africa, and establish methods of process and care improvement. A systematic review provides a critical analysis of the available literature on basic surgical care of burn injuries in sub-Saharan Africa, including timing of excision, grafting, and wound dressing techniques. The results show that essential information—such as depth of burns, TBSA, timing of grafting and wound treatment—are unreported in many of the studies. Future studies should include uniform definitions and parameters such as depth of burns, TBSA, timing of grafting, and wound treatment. The aim of Chapter 4 is to present research insights into ‘access to surgical burn care’ in LMICs. Theoretically, the study is guided by investigating timeliness, surgical capacity, and affordability. In conclusion, the study shows that patients face critical barriers to receiving timely and affordable surgical care in the catchment area of Haydom Lutheran Hospital, Tanzania. To assure timely, safe, and affordable burn care for patients in LMICs, support is also needed beyond hospital management on regional and national levels. Short-term reconstructive plastic surgical missions are a well-established routine method of addressing surgical conditions. Chapter 5 provides a systematic review that assessed the effectiveness of short- term reconstructive surgical missions in LMICs. Original studies of short- term reconstructive surgical missions were included, which reported data on patient safety measurements, health gains of individual patients, and sustainability. Studies with a low follow-up quality could potentially be under-reporting complication rates and overestimating the positive impact of missions. It was concluded that evidence on the patient outcomes of reconstructive plastic surgical missions is scarce and of limited quality. The recommendations were supported by experienced health workers in the field of surgical missions, as recorded in a survey study on surgical missions (Chapter 6). The results showed that training activities were considered most impactful, and reporting on outcome/s, along with long-term follow-up was strongly recommended. According to 94 percent of the participants, the future focus should be on establishing collaborative practices with local actors, and encouraging strategic, long-term changes, under their leadership. Chapter 7 presents insights into the effects of basic reconstructive plastic surgical training activities on participants. The study demonstrates that surgical skills of the participants can improve, and it strengthens the recommendation that training is a key strategy for the much-needed goal of sustainable solutions to meeting the global burden of surgical disease. The larger goal of training activities for health care providers is to obtain a higher standard of care for the patients in need. In the last study, the focus lies on the outcome of post-burn contracture release surgery during the trainings. Based on the results, it can be concluded that contracture release surgery performed during surgical trainings in LMICs can be safe and effective in the long-term

Strategies Following Free Flap Failure in Lower Extremity Trauma: A Systematic Review

ABSTRACT: Background: Free flap reconstructions are an important reconstructive option for soft tissue defects in mangled lower extremities. Microsurgery facilitates soft tissue coverage of defects that otherwise would result in amputation. However, the success rates of traumatic lower extremity free flap reconstructions remain lower than those in other locations. Nevertheless, post-free flap failure salvage strategies have rarely been addressed. Therefore, the current review aims to provide an overview of post-free flap failure strategies in lower extremity trauma and their subsequent outcomes. Methods: A search of Pubmed, Cochrane, and Embase databases was performed on June 9, June 2021 using the following medical subject headings (MeSH) search terms: ‘lower extremity’, ‘leg injuries’, ‘reconstructive surgical procedures’, ‘reoperation’, ‘microsurgery’ and ‘treatment failure’. This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Partial and total free flap failures after traumatic reconstruction were included. Results: Twenty-eight studies with a total of 102 free flap failures fulfilled the eligibility criteria. Following the total failure, a second free flap is the predominant reconstructive strategy (69%). In comparison to the failure rate of a first free flap (10%), the fate of a second free flap is less favorable with a failure rate of 17%. The amputation rate following flap failure is 12%. The risk of amputation increases between primary and secondary free flap failures. After partial flap loss, the preferred strategy is a split skin graft (50%). Conclusion: To our knowledge, this is the first systematic review on the outcome of salvage strategies after free flap failure in traumatic lower extremity reconstruction. This review provides valuable evidence to take into consideration in the decision-making regarding post-free flap failure strategies

Impact of short-term reconstructive surgical missions: a systematic review

IntroductionShort-term missions providing patients in low-income countries with reconstructive surgery are often criticised because evidence of their value is lacking. This study aims to assess the effectiveness of short-term reconstructive surgical missions in low-income and middle-income countries.MethodsA systematic review was conducted according to PRISMA guidelines. We searched five medical databases from inception up to 2 July 2018. Original studies of short-term reconstructive surgical missions were included, which reported data on patient safety measurements, health gains of individual patients and sustainability. Data were combined to generate overall outcomes, including overall complication rates.ResultsOf 1662 identified studies, 41 met full inclusion criteria, which included 48 546 patients. The overall study quality according to Oxford CEBM and GRADE was low. Ten studies reported a minimum of 6 months’ follow-up, showing a follow-up rate of 56.0% and a complication rate of 22.3%. Twelve studies that did not report on duration or follow-up rate reported a complication rate of 1.2%. Fifteen out of 20 studies (75%) that reported on follow-up also reported on sustainable characteristics.ConclusionsEvidence on the patient outcomes of reconstructive surgical missions is scarce and of limited quality. Higher complication rates were reported in studies which explicitly mentioned the duration and rate of follow-up. Studies with a low follow-up quality might be under-reporting complication rates and overestimating the positive impact of missions. This review indicates that missions should develop towards sustainable partnerships. These partnerships should provide quality aftercare, perform outcome research and build the surgical capacity of local healthcare systems.PROSPERO registration numberCRD42018099285.</jats:sec

Impact of short-term reconstructive surgical missions: A systematic review

Introduction Short-term missions providing patients in low-income countries with reconstructive surgery are often criticised because evidence of their value is lacking. This study aims to assess the effectiveness of short-term reconstructive surgical missions in low-income and middle-income countries. Methods A systematic review was conducted according to PRISMA guidelines. We searched five medical databases from inception up to 2 July 2018. Original studies of short-term reconstructive surgical missions were included, which reported data on patient safety measurements, health gains of individual patients and sustainability. Data were combined to generate overall outcomes, including overall complication rates. Results Of 1662 identified studies, 41 met full inclusion criteria, which included 48 546 patients. The overall study quality according to Oxford CEBM and GRADE was low. Ten studies reported a minimum of 6 months' follow-up, showing a follow-up rate of 56.0% and a complication rate of 22.3%. Twelve studies that did not report on duration or follow-up rate reported a complication rate of 1.2%. Fifteen out of 20 studies (75%) that reported on follow-up also reported on sustainable characteristics. Conclusions Evidence on the patient outcomes of reconstructive surgical missions is scarce and of limited quality. Higher complication rates were reported in studies which explicitly mentioned the duration and rate of follow-up. Studies with a low follow-up quality might be under-reporting complication rates and overestimating the positive impact of missions. This review indicates that missions should develop towards sustainable partnerships. These partnerships should provide quality aftercare, perform outcome research and build the surgical capacity of local healthcare systems. PROSPERO registration number CRD42018099285

Gender-affirming mastectomy in transmasculine individuals in The Netherlands: a large cohort study on outcomes and trends

Introduction: Gender-affirming mastectomy is frequently performed in transmasculine individuals. The aim of this study is to describe surgical and demographic trends and outcomes in a large group of individuals undergoing this procedure. Materials and methods: All individuals who underwent gender-affirming mastectomy from 01-1990 to 01-2023 in our center were identified. A retrospective chart study was conducted, recording medical history, use of medication including hormones, puberty suppression, surgical history, preoperative chest characteristics, BMI at surgery, surgical technique, concurrent surgical procedures, resection weight, complications and re-operations. Procedural, demographic and surgical trends were analyzed. Results: A total of 2030 individuals were included of whom 1350 (67%) underwent double incision, 551 (27%) donut, 67 (3%) peri-areolar, 55 (3%) batwing and 7 (<1%) another mastectomy technique. A steep increase of performed mastectomies was observed in recent years. The mean age of people undergoing this procedure is increasingly lower. Surgical trend analysis showed: an increase in the use of the double incision technique, a smaller chest was deemed eligible for donut mastectomy and a less frequent use of a pedicled nipple-areolar complex. Postoperative bleeding that required a reoperation under general anesthesia occurred in 142 (7.0%) individuals (6.3% after double incision, 7.1% after donut, 14.9% after peri-areolar and 12.8% following batwing mastectomy). One or multiple surgical corrections were performed in 19.9% after double incision, 31.2% after donut, 14.9% after peri-areolar and 32.7% following batwing mastectomy. The median clinical follow-up time was 3.2 years (IQR 0.6-6.4). Discussion: The frequency of performed mastectomy procedures has increased drastically over recent years. Specific surgical and demographic trends were identified

Superficial circumflex iliac artery (SCIA) perforator flap for shaft-only phalloplasty: Surgical technique and outcomes

BackgroundPhalloplasty is the surgical (re)construction of a phallus using pedicled and/or free tissue flaps. The pedicled superficial circumflex iliac artery (SCIA) perforator flap is a novel, up-and-coming technique for phalloplasty. Here, we present our surgical technique and surgical outcomes for pedicled SCIA-based phalloplasty without urethral lengthening (i.e. shaft-only) in transgender men.MethodsAll transgender men who underwent shaft-only phalloplasty using SCIA-based perforator flaps between January 2017 and December 2023 were included in the analysis. Participant demographics, surgical characteristics, and postoperative outcomes were assessed, including (partial) flap failure and postoperative complications.ResultsForty-seven transgender men were included. Median age at surgery was 30 years (range 19-61 years), and mean BMI 23 +/- 2kg/m2. Average flap dimensions were 13 cm in length (range 12-15cm) and 11 cm in width (range 9-13cm). Successful penile reconstruction with a unilateral pedicled SCIA-based flap, without additional flaps or requirements, was achieved in 45 (96%) participants. One participant had total flap necrosis and one had partial flap necrosis. Primary closure was obtained in all participants (100%). Wound dehiscence was frequent at phallus/scrotum junction (n = 17), and infrequent at the donor-site (n = 3), and could be managed conservatively in all cases.ConclusionThe SCIA-based perforator flap is a safe and promising pedicled option for shaft-only phalloplasty, with a concealable donor site and without the need for microvascular anastomosis. Therefore, in our center, the SCIA-based perforator flap has become our primary choice for phalloplasty without urethral lengthening in slim patients

Access to burn care in low-and middle-income countries:an assessment of timeliness, surgical capacity, and affordability in a regional referral hospital in Tanzania

This study investigates patients’ access to surgical care for burns in a low- and middle-income setting by studying timeliness, surgical capacity, and affordability. A survey was conducted in a regional referral hospital in Manyara, Tanzania. In total, 67 patients were included. To obtain information on burn victims in need of surgical care, irrespective of time lapsed from the burn injury, both patients with burn wounds and patients with contractures were included. Information provided by patients and/or caregivers was supplemented with data from patient files and interviews with hospital administration and physicians. In the burn wound group, 50% reached a facility within 24 hours after the injury. Referrals from other health facilities to the regional referral hospital were made within 3 weeks for 74% in this group. Of contracture patients, 74% had sought healthcare after the acute burn injury. Of the same group, only 4% had been treated with skin grafts beforehand, and 70% never received surgical care or a referral. Together, both groups indicated that lack of trust, surgical capacity, and referral timeliness were important factors negatively affecting patient access to surgical care. Accounting for hospital fees indicated patients routinely exceeded the catastrophic expenditure threshold. It was determined that healthcare for burn victims is without financial risk protection. We recommend strengthening burn care and reconstructive surgical programs in similar settings, using a more comprehensive health systems approach to identify and address both medical and socioeconomic factors that determine patient mortality and disability