Review of the First 108 Free Flaps at Public Health Concern Trust–NEPAL Hospitals

Nakarmi, Kiran; Rochlin, Danielle H; Basnet, Sijan; Shakya, Pramila; Karki, Bishal; Magar, Mangal Gharti; Nagarkoti, Krishna Kumar; Rajbhandari, Pradeep; Maharjan, Devendra; Prajapati, Sujan S.; Shankar, Murali

doi:10.1097/sap.0000000000001583

Cited by 11 publications

(11 citation statements)

References 20 publications

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“…There was no evidence of graft failure in any of the patients followed up in this study. This compares favourably with most studies reporting the survival rate of vascularised tissue used in microsurgical mandibular reconstruction in LMICs, which is 50%–100% survival 28–32,34,35 . It should be noted that the study reported 100% survival was a series of 22 patients in India treated by an experienced team over a period of 6 months, with flap observations performed frequently overnight by an anaesthetist.…”

Section: Discussionsupporting

confidence: 62%

“…This compares favourably with most studies reporting the survival rate of vascularised tissue used in microsurgical mandibular reconstruction in LMICs, which is 50%-100% survival. [28][29][30][31][32]34,35 It should be noted that the study reported 100% survival was a series of 22 patients in India treated by an experienced team over a period of 6 months, with flap observations performed frequently overnight by an anaesthetist. In addition, they do not disclose the duration that patients were followed postoperatively.…”

Section: Discussionmentioning

confidence: 99%

“…32 These studies report a substantially lower rate of infection (4.5%-25%) when compared with our results (57%). 29,32,34,35 We are not aware of any data on fistula rates following free flap reconstruction of mandibular defects in LMICs. However, in a series of over 1000 patients undergoing vascularised bone flaps for mandibular reconstruction in Shanghai, only 0.96% of patients experienced fistula formation post-operatively.…”

Section: Discussionmentioning

confidence: 99%

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Long‐term outcomes of mandibular reconstruction using non‐vascularised rib grafts following large ameloblastoma resection in Ethiopia

et al. 2021

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Aim Ameloblastomas are odontogenic tumours that often require radical excision and mandibular reconstruction. This is challenging in resource‐limited settings where access to microsurgery is often scarce or absent. Currently, some patients are left without reconstruction, and others with bulky metal plates prone to complications. This leads to disfigurement and poor functional outcomes. We aim to establish robust long‐term outcomes for non‐vascularised autologous rib grafts for patients in this setting. Materials and Methods Twelve adult patients with large ameloblastomas underwent hemimandibulectomy and rib graft reconstruction during international surgical collaborations in Ethiopia between 2012 and 2015. A long‐term follow‐up was conducted in rural Ethiopia in February 2017. Results Follow‐up was possible for seven patients (58% of those treated). Mean post‐operative follow‐up time was 42.9 months (SD 11.7; range 24–60 months). Early complications were four superficial surgical site infections. Late complications were two cases of wire extrusion and one of keloid scarring. There were no graft failures. Patients reported reduced social stigma (p = 0.001) and pain (p = 0.03), excellent function and 100% satisfaction. Conclusion When situational factors preclude the use of microsurgery, bundle rib grafts offer a reliable alternative for total mandibular reconstruction for patients after ameloblastoma resection. Mild complications were experienced by most patients, but these were straightforward to manage and the rib grafts still took well, being surprisingly resistant to infection. Importantly, this technique is associated with long‐term improvements in social stigma and quality of life for patients.

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Section: Discussionsupporting

confidence: 62%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Long‐term outcomes of mandibular reconstruction using non‐vascularised rib grafts following large ameloblastoma resection in Ethiopia

et al. 2021

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“…However, a select few centres in LMICs are undertaking these procedures as part of standard practice (15)(16)(17). Local and regional alternatives do exist, however many of these are also technically demanding, and even with extensive training, microsurgical equipment and techniques, they are vulnerable to complications requiring further surgery (18)(19)(20)(21).…”

Section: Introductionmentioning

confidence: 99%

Protocol for a Systematic Review of Outcomes From Microsurgical Free Tissue Transfer Performed on Short-term Surgical Missions in Low-income and Middle-income Countries

Berker

Čebron

Bradley

et al. 2021

Preprint

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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 December 2020. All clinical studies presenting sufficient data on free tissue transfer performed on short-term surgical missions (STSMs) 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 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), or the ‘Risk of bias in non-randomized studies of interventions’ (ROBINS-I) tools. 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 STSMs to LMICs are largely unknown. Improved education, funding and allocation of resources are needed to support surgeons in LMICs to perform free tissue transfer. STSMs 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 registration: Submitted to PROSPERO (15/12/20 ID: 225613)

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“…Performing microsurgery in LMICs is challenging, even for experienced teams. However, a select few centres in LMICs are undertaking these procedures as part of standard practice [16][17][18]. Local and regional reconstructive alternatives do exist (e.g.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2021

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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. Systematic review registration PROSPERO 225613

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Review of the First 108 Free Flaps at Public Health Concern Trust–NEPAL Hospitals

Abstract: Reconstructive microsurgery is challenging in Nepal and more generally in developing settings. However, persistent technical support such as training and workshops can make it feasible.

Cited by 11 publications

References 20 publications

Long‐term outcomes of mandibular reconstruction using non‐vascularised rib grafts following large ameloblastoma resection in Ethiopia

Long‐term outcomes of mandibular reconstruction using non‐vascularised rib grafts following large ameloblastoma resection in Ethiopia

Protocol for a Systematic Review of Outcomes From Microsurgical Free Tissue Transfer Performed on Short-term Surgical Missions in Low-income and Middle-income Countries

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

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