Short-term Surgical Missions Research Articles

Barriers to Obtaining Informed Consent on Shortterm Surgical Missions.

Background:Short-term surgical missions (STSMs) enable visiting surgeons to help address inequalities in the provision of surgical care in resource-limited settings. One criticism of STSMs is a failure to obtain informed consent from patients before major surgical interventions. We aim to use collective evidence to establish the barriers to obtaining informed consent on STSMs and in resource-limited settings and suggest practical solutions to overcome them.Methods:A systematic review was performed using PubMed and Web of Science databases and following Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. In addition to the data synthesized from the systematic review, we also include pertinent data from a recent long-term follow-up study in Ethiopia.Results:Of the 72 records screened, 11 studies were included in our review. The most common barrier to obtaining informed consent was a paternalistic approach to medicine and patient education. Other common barriers were a lack of ethics education among surgeons in low-income and middle-income countries, cultural beliefs toward healthcare, and language barriers between the surgeons and patients. Our experience of a decade of reconstructive surgery missions in Ethiopia corroborates this. In a long-term follow-up study of our head-and-neck patients, informed consent was obtained for 85% (n = 68) of patients over a 14-year period.Conclusions:This study highlights the main barriers to obtaining informed consent on STSMs and in the resource-limited setting. We propose a checklist that incorporates practical solutions to the most common barriers surgeons will experience, aimed to improve the process of informed consent on STSMs.

Short-term surgical trips: local collaboration and its effects on complications and patient satisfaction.

Short-term surgical missions can provide communities in need with desired expertise; however, it is uncertain who will manage the complications after visiting experts leave. Poor outcomes, decreased patient satisfaction, and tension on the healthcare system develop when local providers, often excluded from the initial patient care, are unable to cope with subsequent morbidity. Two-year retrospective review of pediatric general, plastic, and reconstructive surgery, and urology cases performed by a relief organization in the developing world. Case complexity and postoperative complications were analyzed. Phone interviews conducted with patients/families to quantify postoperative outcomes and satisfaction. 474 surgeries were performed on pediatric patients with 60% response rate. Respondents stratified into three levels of complexity: 159 simple, 72 intermediate, and 54 advanced surgeries. Six (2.1%) high-level complications occurred. No association between the complexity of the surgery and the occurrence of a complications. 83.5% were satisfied with outcomes and > 92% were happy with the provided support. Facilitating visiting and local surgeons performing cases together increases the expertise of local providers, strengthens infrastructure, and establishes clear follow-up. Despite complications, patients and families continued to recommend care to family and friends by the relief organization and were happy with support from local providers. Engaging local providers is the gold-standard for short-term trips.

Ethical considerations in global surgery: a scoping review

IntroductionAn unmet burden of surgical disease exists worldwide and is disproportionately shouldered by low-income and middle-income countries (LMICs). As the field of global surgery grows to meet this need, ethical...

The dark side of doing good: a qualitative study to explore perceptions of local healthcare providers regarding short-term surgical missions in Port-au-Prince, Haiti

Background In response to the increasing global burden of surgical diseases, medical providers from high-income countries are increasingly volunteering in underserved regions. Short-term surgical missions are growing in number but lack appropriate oversight. Many studies on volunteers’ perspectives have been published, but few have examined the perspectives of local healthcare providers. Aim To explore perceptions of Haitian healthcare providers regarding short-term volunteer missions in order to identify positive and negative perceptions. Methods A qualitative approach utilizing interpretivist epistemology and a social constructivist perspective captured perceptions of participants in their social setting. Interpretivism recognizes that perceptions are subjective and socially constructed. After purposive sampling, 17 participants were recruited. In-depth recorded interviews with assistance from local interpreters explored participants’ perceptions. Using thematic content analysis, unexpected themes emerged. Results Four themes emerged: general perceptions, perceived effect on healthcare system, perceived effect on healthcare workers, and future recommendations. In general, local healthcare workers appreciate the skills and knowledge that teams impart and the improved access to surgical services for the poor. However, volunteers working independent of local teams create negative perceptions, stress local healthcare providers, and strain hospital resources. Future teams should utilize local perceptions to measure impact and effectiveness of their efforts. Conclusions Perceived impact of short-term surgical missions is dependent on participant perspective. This study addresses negative perceptions and offers recommendations for before, during, and after a mission. Surgical missions that emphasize training local staff and forming long-term relationships have a greater impact on surgical capacity than do missions that focus primarily on surgical volume. Further research on local perceptions is essential to ensure that local voices continue to be heard and that altruistic efforts of volunteers do not inadvertently cause negative effects.

Long-term outcomes associated with short-term surgical missions treating complex head and neck disfigurement in Ethiopia: A retrospective cohort study

Long-term follow-up after short-term reconstructive missions is challenging, often due to financial constraints, remote geography and lack of post-operative communication with patients. The aim of this study was to conduct long-term follow-up of patients who have undergone surgery for complex facial disfigurement in Ethiopia. A retrospective cohort study was conducted in Ethiopia over a 2-week period between February and March 2017. All patients who were previously operated on by the charity Project Harar were eligible. Data were collected from semi-structured interviews and clinical examinations. Seventy patients (41 males: 29 females) were included in this study. This equates to a follow-up rate of 20% (70/350) of all patients operated on by the charity since 2008. Mean patient age was 26.8 years (range, 3-61 years). The most common pathologies were noma (24%), ameloblastoma (16%) and trauma (11%). The mean follow-up time after final surgery was 47 months (range, 12-180) with an average of 1.3 (range, 1-6) operations per patient. Long-term complications were reported by 30% of patients, with chronic fistula (n = 6) and chronic infection (n = 3) the most common. Following surgery, stigma experienced by patients decreased from 92% to 3%. This study demonstrates that complex head and neck reconstruction can be safely undertaken in resource-limited settings with improvements in stigma experienced and quality of life for patients. However, despite a decade of experience and refinements, early and late complications do occur, and this should be factored into pre-mission planning and careful follow-up. New, cost-neutral follow-up protocols are being developed.

Cardiac surgical missions: what works, what does not, where we need to go from here.

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. 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. 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.

Patient Experience and Outcomes of the Locally Organized ApriDec Medical Outreach Group.

Access to safe and effective surgery is limited in low and middle-income countries. Short-term surgical missions are a common platform to provide care, but the few published outcomes suggest unacceptable morbidity and mortality. We sought to study the safety and effectiveness of the ApriDec Medical Outreach Group (AMOG). Data from the December 2017 and April 2018 outreaches were prospectively collected. Patient demographics, characteristics of surgery, complications of surgery, and patient quality of life were collected preoperatively and on postoperative days 15 and 30. Data were analyzed to determine complication rates and trends in quality of life. 260/278 (93.5%) of patients completed a 30-day follow-up. Of these, surgical site infection was the most common complication (8.0%), followed by hematoma (4.1%). Rates of urinary tract infection were 1.2% while all other complications occurred in less than 1% of patients. There were no mortalities. With increasing time after surgery (0 to 15days to 30days), there was a significant improvement across each of the dimensions of quality of life (p < 0.001). All patients reported satisfaction with their procedure. This study demonstrated that the care provided by AMOG group to the underserved populations of northern Ghana, yielded complication rates similar to others in low-resourced communities, leading to improved quality of life.

Reducing Surgical Site Infections During Otolaryngology Surgical Missions.

To determine what measures an otolaryngology-head and neck surgery team might adopt to decrease the incidence of surgical site infection (SSI) on a short-term surgical mission. Despite concerns about safety and efficacy, short-term surgical missions remain the predominant structure for humanitarian surgical care in low- and middle-income countries (LMIC). Hospitals in high-income countries strive to improve surgical outcomes through implementation of World Health Organization (WHO) safe surgery guidelines. Reduction of SSI risk is a key part of this effort. Literature review and practical experience. WHO recommendations for reducing SSI are based largely on research done in the North America and Europe. LMIC populations are younger; comorbidities are fewer; infectious disease and trauma are prevalent; and delays in access to care are common. SSI are much more frequent in resource-limited settings. Recommendations regarding preoperative assessment, operating room environment, instrument sterilization, surgical antibiotic prophylaxis, surgical site preparation, gloving, draping, and postsurgical care are reviewed in the context of a surgical mission at a typical LMIC government hospital. Many of the WHO guidelines on reduction of SSI are logical and applicable to the short-term surgical missions; others may need to be modified. Careful prospective data collection and clinical trials are needed to learn which interventions are valid and which should be changed. 5 Laryngoscope, 130:1388-1395, 2020.

Long-Term Follow-Up of Humanitarian Surgeries: Outcomes and Patient Satisfaction in Rural Ghana

BackgroundNongovernmental organizations conduct short-term surgical outreach to lessen the substantial global burden of surgical disease. Long-term outcomes of short-term surgical missions (STSMs) are underreported, raising concern for clinical sequelae and patient satisfaction with essential general surgeries. This study aims to describe long-term follow-up results of one general surgical nongovernmental organization's provision of care in rural Ghana with focus on patient-related outcomes and satisfaction. MethodsFrom 2013 to 2018, Tetteh Quarshie Memorial Hospital in Mampong, Ghana, was the host site of annual 1-wk International Surgical Health Initiative (ISHI) STSMs. Beginning in 2016, an ISHI provider-hosted follow-up clinics augmented by mobile telephone support. Surgical patients from 2013 to 2016 were contacted by the local nursing staff and evaluated for long-term outcomes and self-reported satisfaction. ResultsSixty-nine of 256 patients (27%) responded; 39 patients (57%) were interviewed and examined by an ISHI physician, whereas 30 patients (43%) received mobile telephone follow-up. Mean age was 47 (±18) y, with 44% female patients, and mean duration of follow-up was 1.5 (±1) y. Eleven patients (16%) had surgical and anesthesia complications. All patients reported improvement in symptoms and activity level. Eighty-six patients reported complete satisfaction (5/5). Factors associated with reduced patient satisfaction (<5/5) included increased age and complications. ConclusionsTo our knowledge, this is one of the first studies focusing on patient-reported outcomes for the evaluation of long-term follow-up of general surgery STSMs. With mobile technology, long-term follow-up is achievable toward obtaining meaningful outcomes. Complications in this series are within an acceptable range, whereas symptom improvement and overall satisfaction are high.

Gender Equity in Humanitarian Surgical Outreach: A Decade of Volunteer Surgeons

BackgroundWorkforce trends in surgery demonstrate persistent gender inequity. Humanitarian surgical outreach opportunities exist for surgeons; however, it is unclear as to whether gender disparities exist in this arena. This pilot study examines gender equity among volunteer surgeons using a decade of compiled data from a surgical nongovernmental organization (NGO) that hosts multinational surgical outreach. We aim to evaluate gender proportions among surgical volunteers, compare the gender profiles of NGO surgeons with local and nationwide cohorts, and examine the productive output of surgical volunteers by gender. Materials and methodsA retrospective review was conducted of the records of the International Surgical Health Initiative, an NGO that hosts short-term surgical missions, to generate a demographic roster of volunteers between 2009 and 2018. Comparisons were made of gender profiles within volunteer cohorts against local institutional data and nationwide surgical workforce data. Productivity outputs of surgical volunteers were compared. Chi-square tests and Wilcoxon two-sample statistical t-tests were used. ResultsA total of 23 short-term surgical trips were inclusive of 227 volunteers, and 61% (139) were female. Physicians were less likely to be female than other volunteers. In addition, nonsurgical volunteers were more likely to be female compared with surgical volunteers (67% versus 44%, P < 0.01). No gender differences were observed by average number of trips or propensity for repeat trips among surgical volunteers. No differences were found in proportions of female surgical attendings and residents in the NGO cohort compared with the local and national cohorts. ConclusionsFemales contribute substantially to surgical outreach, representing more than half the volunteers in this organization. Gender profiles of female surgeons in this NGO are in parity with those of surgical attendings and residents in the national census. Male and female volunteer surgeons are equally productive. There is an equitable gender representation among volunteer surgeons in this NGO. Further studies of other surgical organizations participating in surgical outreach are required toward a more complete understanding of female participation in international humanitarian efforts.

Challenges and reflections from an international, humanitarian, short-term surgical mission on collecting ethnographic data in a remote environment.

The experiences of nurses participating in ethnographic fieldwork have been well documented, but often feature short-term, intermittent periods in the field of less than a day. To provide an overview of methodological issues related to collecting data while undertaking a focused ethnography of nurses volunteering with a humanitarian organisation providing surgical care in a remote setting. Particular challenges during the fieldwork included limited space and privacy influencing data collection and secure storage; sporadic and unreliable communications limiting contact with other members of the research team; the challenges of withdrawing from the intensity of the setting; and navigating blurred boundaries between the roles of clinician and researcher. Social research in practice, despite the best of intentions and significant planning, may not always travel the expected path of rational enquiry. Awareness of the challenges involved before embarking on longer term entry into remote environments may help prepare future nurse ethnographers.

Local and Visiting Physician Perspectives on Short Term Surgical Missions in Guatemala: A Qualitative Study.

To explore the impact of short-term surgical missions (STMs) on medical practice in Guatemala as perceived by Guatemalan and foreign physicians. STMs send physicians from high-income countries to low and middle-income countries to address unmet surgical needs. Although participation among foreign surgeons has grown, little is known of the impact on the practice of foreign or local physicians. Using snowball sampling, we interviewed 22 local Guatemalan and 13 visiting foreign physicians regarding their perceptions of the impact of Guatemalan STMs. Interviews were transcribed verbatim, iteratively coded, and analyzed to identify emergent themes. Findings were validated through triangulation and searching for disconfirming evidence. We identified 2 overarching domains. First, the delivery of surgical care by both Guatemalan and foreign physicians was affected by practice in the STM setting. Differences from usual practice manifested as occasionally inappropriate utilization of skills, management of postoperative complications, the practice of perioperative care versus "pure surgery," and the effect on patient-physician communication and trust. Second, both groups noted professional and financial implications of participation in the STM. While Guatemalan physicians reported a net benefit of STMs on their careers, they perceived STMs as an imperfect solution to unmet surgical needs. They described missed opportunities for developing local capacity, for example through education and optimal resource planning. Foreign physicians described costs that were manageable and high personal satisfaction with STM work. STMs could enhance their impact by strengthening working relationships with local physicians and prioritizing sustainable educational efforts.

Integrating Bleeding Control Training Into Surgical Missions in Low- and Middle-Income Countries

BackgroundBasic bleeding control (BCon) techniques can save lives globally but the knowledge is not widespread in low-income countries where trauma is a common cause of death. Short-term surgical missions (STSMs) are an effective route to share this public health initiative around the world. Materials and methodsOver 2017-2018, the International Surgical Health Initiative organized STSMs to locations in Sierra Leone, Bangladesh, Peru, and Ghana. The hour-long official American College of Surgeons Basic Bleeding Control course was offered to host participants several times over the course of the mission. Data including number and size of classes, type of trainee, instructors trained, and success rate in demonstrating acquisition of core BCon principles and techniques were collected. ResultsOver the course of four, week-long STSMs, 748 people were successfully trained in BCon over 27 sessions, with an average of 28 trainees and up to four instructors per class. One-hundred percent of trainees demonstrated acquisition of required skills proficiency. Trainees included health care workers and those in public security roles. ConclusionsConcurrent with a short-term surgical mission, a substantial number of health care providers and would-be bystanders can be trained in BCon in countries most impacted by trauma. Local instructors can be trained to teach BCon independently to sustain the initiative. STSMs are a feasible modality to teach bleeding control techniques to an international audience that does not have rapid access to effective prehospital care.

How Do We Know? Comparisons of Existing Datasets for Overseas Surgical Missions

Over five billion people lack access to safe surgery when they need it. Short-term surgical missions from high-resource countries are a popular strategy to try and address this deficit. Each year, thousands of providers spend billions of dollars participating in short-term surgical missions. These missions are poorly characterized in aggregate. In this exercise, we performed reviews of two databases in an attempt to identify and characterize short-term surgical missions to Uganda. The first, a traditional search of the medical literature. The second, an unorthodox search of the internet. We compare the results of each in terms of motive, trip length, operations performed, surgery type, country of origin, evidence of teaching, recurring missions, and year of mission. We found only one article in the academic literature that fits our criteria. We found 43 individual organizations responsible for 129 individual trips in our internet search. These are characterized in this paper. The medical literature contains few traces of short-term surgical trips in Uganda. The internet contains many traces. These traces are rich in both qualitative and quantitative data. It is possible to mine, organize, and evaluate this data to better understand what is happening on the ground in Uganda and potentially the rest of the world.

Effectiveness, cost-effectiveness, and economic impact of a multi-specialty charitable surgical center in Honduras

IntroductionDespite significant demand and evidence indicating cost-effectiveness, surgical care is neglected in low- and middle-income countries (LMIC). Research indicates complex charitable surgical interventions are more effective in specialty hospitals than in short-term mission trips. This study aims to determine the effectiveness, cost-effectiveness, and economic impact of a multi-specialty charitable ambulatory surgical center in a LMIC. Materials and methodsSurgeries performed at an ambulatory surgery center (ASC) in rural Honduras in six specialties were evaluated for a one-year period for complications, infections, and patient satisfaction. Each patient's decrease in disability was determined by the World Health Organization Disability Assessment Schedule (WHODAS 2.0), and these data were used to estimate the cost per Disability Adjusted Life Year (DALY) averted. Economic benefit was calculated by the human capital approach and the value of a statistical life (VSL) approach. ResultsOf the 963 surgeries performed, four patients (0.4%) experienced surgical site infections and 16 (1.6%) experienced complications, comparable to rates at ASCs in high-income countries. Cost per DALY averted was $638.08. The economic benefit was $17.9 million using the human capital approach and $328.4 million using the VSL approach. ConclusionsOur findings suggest a multi-specialty charitable surgical center in a low-middle income country can achieve similar outcomes to surgery centers in high-income countries. The operations were slightly less cost-effective than many short-term surgical missions, likely due to the investment in equipment and local labor which leads to the more favorable outcomes. This model of charitable surgical care provides a substantial benefit to the population.

Teaching Basic Bleeding Control in Sierra Leone during a Short-Term Surgical Mission: A Unique Opportunity to “Stop the Bleed”

Johnston, Peter F. MD; Jalloh, Samba MD; Padmanaban, Vennila MD; Valenzuela, Rolando G. MD, DTMH; Tran, Ashley BS; Fox, Adam D. DO, FACS; Sifri, Ziad C. MD, FACS Author Information

Cooperation in Surgery of the 21st Century

The need for healthcare cooperation in low- and middle-income countries is known and is implemented day by day. However, the surgical sanitary assistance in these countries in the 21st century is very controversial, as it is still below desirable levels and entails complex solutions. On the other hand, the number of surgeons seeking to get involved is increasing progressively. We analyze the causes of the low levels of medical assistance, such as the lack of qualified personnel, the brain drain of surgeons, healthcare costs or the lack of quantified needs. Opportunities for improvement, such as institutional twinning, short-term surgical missions or activities aimed at education, evaluation, evidence and training, are some of the possibilities proposed.

Cooperación en cirugía en el siglo XXI

The need for healthcare cooperation in low- and middle-income countries is known and is implemented day by day. However, the surgical sanitary assistance in these countries in the 21st century is very controversial, as it is still below desirable levels and entails complex solutions. On the other hand, the number of surgeons seeking to get involved is increasing progressively. We analyze the causes of the low levels of medical assistance, such as the lack of qualified personnel, the brain drain of surgeons, healthcare costs or the lack of quantified needs. Opportunities for improvement, such as institutional twinning, short-term surgical missions or activities aimed at education, evaluation, evidence and training, are some of the possibilities proposed.

Short-term surgical missions in resource-limited environments: Five years of early surgical outcomes

Outcomes of short-term surgical missions (STSMs) hosted in developing countries are underreported, raising quality concerns. This study aims to analyze early outcomes of one humanitarian surgical organization to show that safe essential general surgery can be provided in the context of STSMs.Records from 6 STSMs to Sierra Leone and Ghana were reviewed for early complications and analysis performed to identify associated factors. Missions performed elective, general surgery on low risk patients, with adherence to patient safety protocols.No perioperative mortality occurred from 372 procedures, most frequently inguinal hernia repair (54%). Seventeen surgical (5%), 3 infectious (1.2%), and 6 anesthesia (2%) complications were reported. Only younger age was significantly associated with complications.Essential general surgery can be performed safely on STSM assuming careful patient selection, avoidance of high-risk cases, and adherence to patient safety protocols. Data collection is feasible and should be undertaken to improve the quality of care.

Freedom of choice, expressions of gratitude: Patient experiences of short-term surgical missions in Guatemala

Lack of surgical care has been highlighted as a critical global health problem, and short-term medical missions (STMMs) have become a de facto measure to address this shortfall. Participation in STMMs is an increasingly popular activity for foreign medical professionals to undertake in low- and middle-income countries (LMICs) where their clinical skills may be in short supply. While there is emerging literature on the STMM phenomenon, patient experiences of surgical missions are underrepresented. This research addresses this gap through thirty-seven in-depth interviews with patients or caregivers who received care from a short-term surgical mission within the three years prior to the four-week data collection period in July and August 2013. Interviews were conducted in Antigua, Guatemala and nearby communities, and participants came from 9 different departments of the country. These first-hand accounts of health-seeking through a surgical mission provide important insights into the benefits and challenges of STMMs that patients encounter, including waiting time, ancillary costs, and access to care. Patient agency in care-seeking is considered within the pluralistic, privatized health care context in Guatemala in which foreign participants deliver STMM care.