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

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.

Short-term general, gynecologic, orthopedic, and pediatric surgical mission trips in Nicaragua: A cost-effectiveness analysis

Background Short-term surgical missions facilitated by non-governmental organizations (NGOs) may be a possible platform for cost-effective international global surgical efforts. The objective of this study is to determine if short-term surgical mission trips provided by the non-governmental organization (NGO) Esperança to Nicaragua from 2016 to 2020 are cost-effective.
Methods Using a provider perspective, the costs of implementing the surgical trips were collected via Esperança’s previous trip reports. The reports and patient data were analyzed to determine disability-adjusted life years averted from each surgical procedure provided in Nicaragua from 2016-2020. Average cost-effectiveness ratios for each surgical trip specialty were calculated to determine the average cost of averting one disability adjusted life year.
Results Esperança’s surgical missions’ program in Nicaragua from 2016 to 2020 was found to be cost-effective, with pediatric and gynecology surgical specialties being highly cost-effective and general and orthopedic surgical specialties being moderately cost-effective. These results were echoed in both scenarios of the sensitivity analysis, except for the orthopedic specialty which was found to not be cost-effective when testing an increased discount rate.
Conclusions The cost-effectiveness of short-term surgical missions provided by NGOs can be cost-effective, but limitations include inconsistent data from a societal perspective and lack of an appropriate counterfactual. Future studies should examine the capacity for NGOs to collect adequate data and conduct rigorous economic evaluations

Cardiac Surgical Missions: What Works, What Does Not, Where We Need to Go From Here

Purpose of review: Although overall neonatal and infant mortality continues to decrease around the world, years of life lost to congenital heart disease (CHD) rank among the top 10 leading causes for that age group in Latin America, Central Asia, Africa and the Middle East. Short-term surgical missions (STSMs) continue to be the only resource available in some areas of the world.

Recent findings: There is a need for better communications between charity organizations and the supported institutions. We observe a raising concern with the limited published information on the results of the STSMs and a call for patient safety, the use of international databases and accountability.Funding and human resources in low-income and middle-income countries (LMIC) are a persistent problem and a shift toward long-term collaboration rather than short-term visits opens the path to sustainability.The cost-effectiveness of STSMs treating congenital heart disease in LMIC seems to be very high whereas the management of adults with CHD and rheumatic valvulopathies appear as a growing concern.

Summary: Pediatric cardiac surgery STSMs continue to deserve full support and funding, long-term commitments, accountability and coordinated international funding are needed to achieve global sustainable coverage.