Challenges in global reconstructive microsurgery: The sub-Saharan african surgeons’ perspective

JPRAS Open 20 (2019) 19–26
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Original ArticleChallenges in global reconstructive microsurgery:The sub-Saharan african surgeons’ perspectiveChihena H. Banda a,b,∗, Pafitanis Georgios c,Mitsunaga Narushima a, Ryohei Ishiura a, Minami Fujita a,Jovic Goran da Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University, Tsu, Japanb Department of Surgery, Arthur Davison Children’s Hospital, Ndola, Zambiac Group for Academic Plastic Surgery, The Royal London Hospital, Barts Health NHS Trust, Queen MaryUniversity of London, London, UKd Department of Surgery, The University Teaching Hospital, Lusaka, Zambiaa r t i c l e i n f oArticle history:Received 20 November 2018Accepted 20 January 2019Available online 4 February 2019Keywords:MicrosurgeryFree tissue transferAfricaChallengesTrainingGlobal surgerya b s t r a c tBackground: Microsurgery is an essential element of plastic surgerypractice. However, it remains unavailable or rudimentary in severaldeveloping countries, especially in sub-Saharan Africa. This studypresents the local plastic surgeons experience, while focusing onspecific challenges encountered and methods to improve the sub-Saharan global microsurgery practice.Methodology: An online survey was sent to all plastic surgeonsregistered with the College of Surgeons East Central and SouthernAfrica and respective national plastic surgical societies in the eastcentral and southern Africa regional community. A total of 57questionnaires were sent. Surgeons’ country of practice, years ofexperience and rate of performing microsurgical procedures wereconsidered.
∗ Corresponding author: Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, Mie University,
2-174 Edobashi, Tsu, Mie Prefecture, 514-8507, JAPAN.
E-mail addresses: [e-mail], [e-mail] (C.H. Banda).
https://doi.org/10.1016/j.jpra.2019.01.009
2352-5878/© 2019 The Author(s). Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and
Aesthetic Surgeons. This is an open access article under the CC BY license. (http://creativecommons.org/licenses/by/4.0/)

20 C.H. Banda, P. Georgios and M. Narushima et al. / JPRAS Open 20 (2019) 19–26Results: The survey response rate was 56% (n = 32). Most partici-pants believed microsurgery was essential in the region. The lead-ing challenge was inadequate perioperative care, mainly attributedto shortage of support staff (n = 29, 91%). Others were lack of sur-gical expertise and resources. Interestingly, public unawareness ofthe benefits of microsurgery was also noted as a critical hindrance.The foremost suggestion on improvement (n = 19, 59%) was to en-hance training with a multidisciplinary team-building approach.Others included increased advocacy, publications and funding.Conclusion: The Plastic surgeons’ perspective recognizes the needsof Global Reconstructive Microsurgery in sub-Saharan Africa. How-ever, inadequate perioperative care, insufficient expertise, lack ofequipment and lack of public awareness were major hindrances.Finally, there is a need to improve microsurgery in the regionthrough advocacy, training and multidisciplinary team building.© 2019 The Author(s). Published by Elsevier Ltd on behalf ofBritish Association of Plastic, Reconstructive and AestheticSurgeons.This is an open access article under the CC BY license.(http://creativecommons.org/licenses/by/4.0/)IntroductionMicrosurgery is an essential component of modern plastic reconstructive surgery. The techniquefacilitates free tissue transfer providing optimal functional and aesthetic recovery for a wide range ofcomplex tissue defects. Although traditionally pioneered by plastic surgeons, microsurgery has sinceprogressed and is increasingly being utilized by other specialities such as otolaryngology, orthopaedicsand neurosurgery. With the current refinements in technique and materials, the success rates of freeflaps in developed countries are as high as 97%–99%.1,2 However, there is a growing gap between de-veloped and developing countries, with microsurgery completely unavailable or rudimentary in manydeveloping countries, particularly in the east, central and southern Africa (ECSA) region.3Excluding South Africa, there are scarcely any reports on microsurgical free tissue transfer per-formed in sub-Saharan Africa. A few procedures are occasionally performed by surgeons visiting fromdeveloped countries with variable results.4–7 Nevertheless, local teams most notably in Kenya andUganda have overcome the numerous challenges and have published their experiences in a resource-limited setting not indifferent from those found in other developing countries.3,6 Operations in theregion have largely been elective reconstructive procedures most commonly for head and neck pathol-ogy, such as cancer, noma and post-burn contracture, with the most frequently utilized flaps being theradial forearm, free fibular and anterolateral thigh flaps.3–6 , 8 Nangole et al. reported using relativelyinexpensive methods in Kenya including a basic microsurgery set along with surgical loupes to per-form free tissue transfers.3 However, such methods have attracted a mixed response of both praiseand criticism from the global community.9Several challenges to performing microsurgery in the region have been noted from the publicationsof individual units and visiting surgeons. These include poor postoperative monitoring, lack of high-quality equipment and a lack of surgical skill together resulting in relatively low free flap survivalrates of 76%–89%.3,6 , 7 However, there is a paucity of literature objectively assessing these challengesparticularly in countries that do not often practice microsurgery. Additionally, the perceived challengesnoted from individual unit experiences differ widely. For instance, Citron et al.6 found equivocal flapsurvival rates in cases performed in Uganda between local surgeons and experienced visiting surgeonsfrom developed countries suggesting lack of surgical skill3 may not be the prime cause of stagnation.This highlights the crucial need to further explore the causes of suboptimal results in the region.

C.H. Banda, P. Georgios and M. Narushima et al. / JPRAS Open 20 (2019) 19–26 21On the positive side, the number of plastic surgeons in the ECSA region is rapidly growing, largelydue to efforts in regional cooperation of surgical training fostered by the College of Surgeons EastCentral and Southern Africa (COSECSA) and its partners.10,11 Considering this, coupled with the posi-tive economic growth seen over the last decade,12,13 microsurgery is poised to play a greater part inreconstructive surgery in this region in the years to come.The aim of this study was to assess the opinions of local plastic surgeons on the challenges facedpractising microsurgery in the ECSA region and how to improve the service.MethodologyAn anonymous survey (5-point Likert-style) was sent to all plastic surgeons registered withCOSECSA. Additional invitations were sent to all plastic surgeons registered with respective nationalplastic surgery associations/societies to ensure surgeons not part of the regional college were also con-tacted. The countries forming the ECSA region included in this survey were; Burundi, Ethiopia, Kenya,Malawi, Mozambique, Namibia, Rwanda, South Sudan, Tanzania, Uganda, Zambia and Zimbabwe. Sur-geons from Namibia were contacted individually, as the country only recently joined the regionalbody. A total of 57 surgeons were invited. Plastic surgeons resident and practising in the region (in-cluding academic and administrative positions) as of July 1, 2018, were included in this study. Allsurgeons without permanent residency in the region, such as visiting surgeons, charity missions andCOSECSA overseas fellows, were excluded. Email reminders were sent after 2 weeks and 4 weeks toencourage participation.Data were collected for country of clinical practice, years of experience, number of microsurgeryprocedures performed over the last 5 years, opinions on the challenges of microsurgery and sug-gestions for improvement. The survey was delivered through an online platform, Google Forms(https://goo.gl/forms/nKnhD1MzFNN1Gxgh1). Respondents were grouped into two groups by countryof practice: countries with surgeons reporting > 10 microsurgical procedures annually were assignedto study Group A and the rest to Group B.All survey questions were digitalised and analysed using IBM SPSS Statistics 25 (IBM Corp. Released2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp). Data were analyseddepending on country group and surgeons’ years of experience using two-tailed Mann–Whitney Uand Kruskal–Wallis tests, respectively. Statistical significance was defined as P < 0.05.ResultsThe survey response rate was 56%, with 32 of the regions 57 surgeons completing the survey. Allcountries in the region were represented except for Burundi and South Sudan, which did not haveany known plastic surgeons (Figure 1). Most respondents were young surgeons with 0–5 years ofexperience (Figure 2). The overwhelming majority (n = 31, 97%) felt that microsurgery was essential inthe region, Median score (Mdn) 5, Interquartile range (IQR) 0, with a correspondingly high number(n = 28, 88%) interested in microsurgery (Mdn = 4.5, IQR = 1). Overall, 13 (41%) had not performedany microsurgical procedures in the past 5 years with the bulk of surgeons (n = 14, 44%) reporting1–10 cases annually (Mdn = 2, IQR = 1) (Figure 3). There was no significant difference in the rate ofprocedures performed when compared by surgeons’ years of experience (Kruskal–Wallis H = 2.544,df = 2,P = 0.28).Two countries, Kenya and Uganda, were identified with surgeons performing > 10 cases annually.Accordingly, respondents from these countries were allocated to Group A (n = 12) and all others toGroup B (n = 20) for subgroup analysis. Participants from the two groups were similar with regard tosurgeons’ years of experience (Mann–Whitney U = 112.5, P = 0.76).Most surgeons uniformly agreed with the challenges listed, with shortage of trained support staffreceiving the highest score (Mdn = 5, IQR = 1) with 29 (91%) in agreement (Table 1). Lack of micro-surgery materials was an exception with highly polarized views (Mdn = 4, IQR = 3), 21 (66%) agreeingand 8 (25%) disagreeing. However, no significant difference was found when compared by surgeonexperience or country group.