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

Henry T De Berker,Gary Walton,Calum Honeyman,Daniel Bradley,Dominique Martin,Urška Čebron,Mark Mcgurk,Mekonen Eshete,Fernando Almas,Meklit Berhane,Vinod Patel

doi:10.1186/s13643-021-01797-0

Abstract

BackgroundIn 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.MethodsA 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.DiscussionTo-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 registrationPROSPERO 225613

Highlights

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
To-date the outcomes of microsurgical procedures performed on Short-term collaborative surgical trip (STCST) to low-income and middle-income countries (LMICs) are largely unknown
STCSTs provide a vehicle for sustainable collaboration and training

Summary

Introduction

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. Some STCSTs have been criticised for an unsustainable ‘fly-in-fly-out’ model of surgical care delivery in LMICs, with limited patient follow-up after discharge. One consequence of this is that surgeons working in resource-limited settings have a poor context-specific evidence base to work from [2]. Many STCSTs return annually to the same centre, building lasting relationships, offering sustainable education and training and treating patients who would otherwise have no access to healthcare. This model offers greater opportunity for thorough follow-up. There is a growing consensus that the model described above is better captured by the term ‘collaboration’ [5]

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