Plastic and Reconstructive Surgery – Global Open

Author Information

From the *Department of Plastic Surgery, Services Institute of Medical Sciences, University of Health Sciences, Lahore, Pakistan; †Department of Plastic Surgery, Dow Medical College and Civil Hospital, Dow University of Health Sciences, Karachi, Pakistan; ‡Department of Plastic Surgery, Chang Gung Memorial Hospital, Chang Gung Medical University, Taoyuan, Taiwan; §Professor Emaritus, Department of Plastic Surgery, University of Stanford, Stanford, California.

Received for publication October 21, 2014; accepted January 7, 2015.

Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by PRS GO at the discretion of the Editor-in-Chief.

Ghulam Qadir Fayyaz, MBBS, DSS, MS, Services Institute of Medical Sciences and CLAPP Hospital, 932-C, Faisal Town, Lahore, Pakistan, E-mail: gqfayyaz@hotmail.com

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Abstract

Background: There are many countries in the world where patients with cleft lip and palate cannot get access to specialized cleft care units. Cleft missions play an important role in providing surgical care to the areas of the world with limited resources. This article presents a model of cleft missions that can be adopted in many countries where expertise is available but resources are limited. Through proper utilization of local human resource, this type of mission can be a cost-effective and robust way of treating patients with cleft in countries with approximately 52% of the world’s population.

Methods: We present a case series of patients of one of our cleft missions carried out in Khairpur, Pakistan, in March 2014 over a period of 7 days. Specific details concerning the organization of mission, gathering of patients, preparation for surgery, and carrying out surgical procedures in a safe and swift manner are presented.

Results: A total of 312 patients were operated on in 7 days. There were 145 patients with cleft lip and 167 patients with cleft palate. There were 187 male and 125 female patients with mean age of 7 years. Contemporary operative techniques were utilized to repair different types of cleft lip and palate. Of 167 patients, only 16 developed fistula.

Conclusion: A locoregional cleft team can be more effective to care for the patients with cleft in countries where surgical and other expertise can be utilized by proper organization of cleft missions on a national level.

With advancements in the field of medical science, many untreatable congenital anomalies have become amenable to surgical reconstruction. A major difference between the developed, developing, and underdeveloped countries is the provision of advanced healthcare facilities. In the modern world, specific set protocols are in place for management of patients with cleft lip and palate, whereas there are many regions in the world which are still deprived of basic facilities for cleft care.1 In such areas, the need for integrated cleft care teams becomes paramount for poor patients with cleft lip and palate. Every year more than 160,000 new patients with cleft lip and palate are born in the whole world.2 Pakistan ranks fourth in the world (after China, India, and Indonesia) having the highest number of cleft children born every year.3 A cleft mission is a program/project that provides proper optimal care and delivers safe surgeries at remote sites in the developing and underdeveloped regions of the world.4 It helps to immediately fix the cleft lip and palate problems of a high number of patients in a short period of time, transforming them from the disabled to enabled members of the society.5 Various organizations all over the world are carrying out cleft missions in such countries, but channelizing their efforts to get maximum benefit of the endeavors is the need of the hour.

Since 2004, our team has conducted 130 cleft missions, including 4 international missions. The first mission comprised 5 team members, which included 2 surgeons, 2 operating room (OR) assistants, and 1 coordinator, and a total of 63 cleft surgeries were performed in a short span of 7 days. Ever since, the team has been regularly operating upon patients with cleft at different hospitals in remote areas of Pakistan and Afghanistan. Over the years, the team evolved and grew in size through training and induction of new team members in surgery, anesthesia, OR, recovery, nursing care, and follow-up departments. Procedures and protocols have also been developed resulting in improved surgical outcomes and more cost-effectiveness.

This article presents a model of a cleft mission for performing quality surgical procedures within limited period of time. This model can be easily adopted in countries where surgical expertise and ancillary services are available, but the burden of cleft lip and palate is quite significant. Such countries represent 52.2% of the world’s population6and locoregional teams and, when properly developed, can adopt the presented model to effectively address the stigma of cleft deformity in a more cost-effective way as compared with routine international missions.

MATERIALS AND METHODS

Table 1. Cleft Lip and Palate Association of Pakistan’s Fitness Criteria for Patients with Cleft

Under the auspices of Cleft Lip and Palate Association of Pakistan, a cleft mission was arranged at the Civil Hospital, Khairpur, from March 25 to April 2, 2014. Khairpur is capital of the Khairpur District in Sindh province of Pakistan. A Public Awareness Campaign was started 4 weeks in advance. Banners and posters with pictures of cleft lip and palate were affixed in adjoining districts; handbills were distributed while radio and cable TV were also used to disseminate information among the general public. Advertisements were also published in the local newspapers. A total of 467 patients with cleft reported at the outpatients’ clinic who were examined by the plastic surgeon and the anesthetist. Patients found suitable were scheduled for surgery. This examination and screening process was carried out from March 25 to 28, 2014.

All the equipment required to set up fully functional operation theaters was brought in from cleft center in Lahore, about 300 miles away. It included operating tables, anesthesia and diathermy machines, cardiac monitors, pulse oximeters, operating instrument sets, emergency equipment, and all other necessary medicines and surgical items. The equipment and medicines were packed in wooden containers to be wheeled down into the van. Six operating tables were set up, 3 each in 2 ORs. Large-sized oxygen cylinders were connected to the anesthesia machines. Pulse oximeters and cardiac monitors were also set up for each operating table. Emergency medicine trays were always kept ready in the OR and wards as well.

The total number of personnel involved and their responsibilities are detailed. There were 4 anesthesiologists, 2 in each room, to look after 6 operating tables. There were 5 surgeons to operate on patients with cleft. The sixth table was used to get the next patient with cleft ready. Each OR had 2 anesthesiologists, 3 surgery assistants, 1 anesthesia paramedic, and 1 circulating person to facilitate the team members. One paramedic was responsible for swift provision of sterilized instruments for surgery.

After the surgery was completed, the patients were immediately shifted, with the endotracheal tube attached, to the recovery area where extubation and smooth recovery was allowed. The recovery area was taken care of by a paramedic with extensive experience of over 25 years in pediatric and adult anesthesia. He was assisted by another paramedic and supervised by anesthesiologists. Meanwhile, the next patient with cleft was brought to the operating table and intubated. No time was wasted during this changeover saving at least 30 valuable minutes between 2 surgeries. To reduce fatigue and physical stress, all surgeons used adjustable chairs while operating.

Extubation in the recovery room on average takes 35 minutes. When fully in senses, the patients were shifted to the wards, where our trained nursing staff looked after them. The patients remained in the ward overnight under the supervision of a doctor from the team and discharged the next morning if the doctor deemed appropriate. Training on postoperative wound care and food restriction was administered by the specialist nurses. Patients were given 1-page instructions in the local language for postoperative care and follow-up.

Anesthesiologists and surgeons resided in a nearby hotel with travelling time less than 20 minutes while the rest of the team stayed in the hospital. Surgeries commenced at around 9:30 AM and continued till 11:00 PM

every day. Every day at the end of all surgeries, 1 surgeon and 1 anesthesiologist carried out the round of all patients operated on during the day to find and rectify any problems.