Top

Published in:

Open Access 01-12-2021 | Protocol

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

Authors: Henry T. de Berker, Urška Čebron, Daniel Bradley, Vinod Patel, Meklit Berhane, Fernando Almas, Gary Walton, Mekonen Eshete, Mark McGurk, Dominique Martin, Calum Honeyman

Published in: Systematic Reviews | Issue 1/2021

Abstract

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

Available only for authorised users

Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569–624. https://doi.org/10.1016/S0140-6736(15)60160-X.CrossRefPubMed

Shrime MG, Sleemi A, Ravilla TD. Charitable platforms in global surgery: a systematic review of their effectiveness, cost-effectiveness, sustainability, and role training. World J Surg. 2015;39(1):10–20. https://doi.org/10.1007/s00268-014-2516-0.CrossRefPubMed

Bradley D, Honeyman C, Patel V, Zeolla J, Lester L, Eshete M, Demissie Y, Martin D, McGurk M. Smartphones can be used for patient follow-up after a surgical mission treating complex head and neck disfigurement in Ethiopia: Results from a prospective pilot study. J Plast Reconstr Aesthet Surg. 2021;74(4):890–930. https://doi.org/10.1016/j.bjps.2020.10.025.

Honeyman C, Patel V, Yonis E, Fell M, Demissie Y, Eshete M, et al. Long-term outcomes associated with short-term surgical missions treating complex head and neck disfigurement in Ethiopia: a retrospective cohort study. J Plast Reconstr Aesthet Surg. 2020;73(5):951–8. https://doi.org/10.1016/j.bjps.2019.12.009.CrossRefPubMed

Jemec B, Lam W, Hodgson SP, Jones JWM, Eckersley R, Nyamulani N, et al. The governance of overseas surgical collaborations – BFIRST/BSSH. J Plast Reconstr Aesthet Surg. 2021;74(2):396–400. https://doi.org/10.1016/j.bjps.2020.08.022.CrossRefPubMed

Shah SC, Kayamba V, Peek RM, Heimburger D. Cancer control in low- and middle-income countries: is it time to consider screening? J Glob Oncol. 2019;5:1–8. https://doi.org/10.1200/JGO.18.00200.CrossRefPubMed

Semer NB, Sullivan SR, Meara JG. Plastic surgery and global health: how plastic surgery impacts the global burden of surgical disease. J Plast Reconstr Aesthet Surg. 2010;63(8):1244–8. https://doi.org/10.1016/j.bjps.2009.07.028.CrossRefPubMed

The World Health Organisation. The World Health Organisation. Injuries and violence: the facts [Internet]. 2010. Available from: http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:Injuries+and+Violence:+The+Facts#0. Accessed 12 Dec 2020.

Hazari A, Cole R, Fowler C, Schache A, Nugent M, Ho M, et al. The British Association of Plastic Reconstructive and Aesthetic Surgeons First UK National Flap Registry Report. 2019.

10.

Carney MJ, Weissler JM, Tecce MG, Mirzabeigi MN, Wes AM, Koltz PF, et al. 5000 free flaps and counting. Plast Reconstr Surg. 2018;141(4):855–63. https://doi.org/10.1097/PRS.0000000000004200.CrossRefPubMed

11.

Lewin J, Puri A, Quek R, Ngan R, Alcasabas AP, Wood D, et al. Management of sarcoma in the Asia-Pacific region: resource-stratified guidelines. Lancet Oncol. 2013;14(12):e562–70. https://doi.org/10.1016/S1470-2045(13)70475-3.CrossRefPubMed

12.

Ducic I, Rao S, Attinger C. Outcomes of microvascular reconstruction of single-vessel lower extremities: limb salvage versus amputation. J Reconstr Microsurg. 2009;25(08):475–8. https://doi.org/10.1055/s-0029-1225536.CrossRefPubMed

13.

Millard DR, Dembrow V, Shocket E, Zavertnik J, Clinton-Thomas C. Immediate reconstruction of the resected mandibular arch. Am J Surg. 1967;114(4):605–13. https://doi.org/10.1016/0002-9610(67)90026-8.CrossRefPubMed

14.

Habib AMA, Hassan SA. The feasibility of rib grafts in long span mandibular defects reconstruction: a long term follow up. J Cranio-Maxillofacial Surg. 2019;47(1):15–22. https://doi.org/10.1016/j.jcms.2018.11.002.CrossRef

15.

Lou C, Yang X, Hu L, Hu Y, SP, Loh J, et al. Oromandibular reconstruction using microvascularized bone flap: report of 1038 cases from a single institution. Int J Oral Maxillofac Surg. 2019;48(8):1001–8. https://doi.org/10.1016/j.ijom.2019.02.017.CrossRefPubMed

16.

Nangole WF, Khainga S, Aswani J, Kahoro L, Vilembwa A. Free flaps in a resource constrained environment: a five-year experience—outcomes and lessons learned. Plast Surg Int. 2015;2015(September):1–6. https://doi.org/10.1155/2015/194174.CrossRef

17.

Nakarmi KK, Rochlin DH, Basnet SJ, Shakya P, Karki B, Magar MG, et al. Review of the first 108 free flaps at Public Health Concern Trust-Nepal Hospitals: challenges and opportunities in developing countries. Ann Plast Surg. 2018;81(5):565–70. https://doi.org/10.1097/SAP.0000000000001583.CrossRefPubMed

18.

Trivedi NP, Trivedi P, Trivedi H, Trivedi S, Trivedi N. Microvascular free flap reconstruction for head and neck cancer in a resource-constrained environment in rural India. Indian J Plast Surg. 2013;46(1):82–6. https://doi.org/10.4103/0970-0358.113715.

19.

Schaverien MV, Hamilton SA, Fairburn N, Rao P, Quaba AA. Lower limb reconstruction using the islanded posterior tibial artery perforator flap. Plast Reconstr Surg. 2010;125(6):1735–43. https://doi.org/10.1097/PRS.0b013e3181ccdc08.CrossRefPubMed

20.

Wong JKF, Deek N, Hsu C-C, Chen H-Y, Lin C-H, Lin C-H. Versatility and “flap efficiency” of pedicled perforator flaps in lower extremity reconstruction. J Plast Reconstr Aesthet Surg. 2017;70(1):67–77. https://doi.org/10.1016/j.bjps.2016.09.028.CrossRefPubMed

21.

Olawoye OA, Ademola SA, Iyun K, Michael A, Oluwatosin O. The reverse sural artery flap for the reconstruction of distal third of the leg and foot. Int Wound J. 2014;11(2):210–4. https://doi.org/10.1111/j.1742-481X.2012.01075.x.CrossRefPubMed

22.

Bertrand B, Honeyman CS, Emparanza A, McGurk M, Ousmane Hamady IE, Schmidt A, et al. Twenty-five years of experience with the submental flap in facial reconstruction. Plast Reconstr Surg. 2019;143(6):1747–58. https://doi.org/10.1097/PRS.0000000000005678.CrossRefPubMed

23.

Caldron PH, Impens A, Pavlova M, Groot W. A systematic review of social, economic and diplomatic aspects of short-term medical missions. BMC Health Serv Res. 2015;15(1):1–12. https://doi.org/10.1186/s12913-015-0980-3.CrossRef

24.

Martiniuk AL, Manouchehrian M, Negin JA, Zwi AB. Brain Gains: a literature review of medical missions to low and middle-income countries. BMC Health Serv Res. 2012;12:134. https://doi.org/10.1186/1472-6963-12-134.

25.

Sykes KJ. Short-term medical service trips: a systematic review of the evidence. Am J Public Health. 2014;104(7):e38–48 Available from: http://ajph.aphapublications.org/doi/10.2105/AJPH.2014.301983.CrossRefPubMedPubMedCentral

26.

Hendriks TCC, Botman M, Rahmee CNS, Ket JCF, Mullender MG, Gerretsen B, et al. Impact of short-term reconstructive surgical missions: a systematic review. BMJ Glob Health. 2019;4(2):e001176. https://doi.org/10.1136/bmjgh-2018-001176.CrossRefPubMedPubMedCentral

27.

Banda CH, Georgios P, Narushima M, Ishiura R, Fujita M, Goran J. Challenges in global reconstructive microsurgery: the sub-Saharan african surgeons’ perspective. JPRAS Open. 2019;20:19–26. https://doi.org/10.1016/j.jpra.2019.01.009.CrossRefPubMedPubMedCentral

28.

Huijing MA, Marck KW, Combes J, Mizen KD, Fourie L, Demisse Y, et al. Facial reconstruction in the developing world: a complicated matter. Br J Oral Maxillofac Surg. 2011;49(4):292–6. https://doi.org/10.1016/j.bjoms.2009.08.044.CrossRefPubMed

29.

Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;349(jan02 1):g7647.CrossRef

30.

Sideri S, Papageorgiou SN, Eliades T. Registration in the international prospective register of systematic reviews (PROSPERO) of systematic review protocols was associated with increased review quality. J Clin Epidemiol. 2018;100:103–10. https://doi.org/10.1016/j.jclinepi.2018.01.003.CrossRefPubMed

31.

Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 6.1 (updated September 2020). Cochrane. 2020. Available from training.cochrane.org/handbook. Accessed 12 Dec 2020.

32.

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339(jul21 1):b2535.CrossRefPubMedPubMedCentral

33.

The World Bank. World Bank Country and Lending Groups [Internet]. [cited 2021 Jan 6]. Available from: https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups

34.

Richardson WS, Wilson MC, Nishikawa J, Hayward RS. The well-built clinical question: a key to evidence-based decisions. ACP J Club. 1995;123:A12–3.CrossRefPubMed

35.

Shanker MK, Rajan A, Hemant B, et al. Outcome of 1000 free flap head and neck reconstructions at a tertiary cancer care institute in India. Eur J Plast Surg. 2021;44:25–32. https://doi.org/10.1007/s00238-020-01693-1.

36.

Fischer JP, Nelson JA, Sieber B, Cleveland E, Kovach SJ, Wu LC, et al. Free tissue transfer in the obese patient. Plast Reconstr Surg. 2013;131(5):681e–92e.CrossRefPubMed

37.

Perisanidis C, Herberger B, Papadogeorgakis N, Seemann R, Eder-Czembirek C, Tamandl D, et al. Complications after free flap surgery: do we need a standardized classification of surgical complications? Br J Oral Maxillofac Surg. 2012;50(2):113–8. https://doi.org/10.1016/j.bjoms.2011.01.013.CrossRefPubMed

38.

Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;28:l4898.CrossRef

39.

Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;12:i4919.CrossRef

40.

National Heart Lung & Blood Institute. Managing blood cholesterol in adults systematic evidence review from the cholesterol expert panel, 2013. US Dept Heal Hum Serv [Internet]. 2013. Available from: https://www.nhlbi.nih.gov/sites/default/files/media/docs/cholesterol-in-adults.pdf. Accessed 15 June 2021.

41.

Howick J, Chalmers I, Glasziou P, Greenhalgh T, Heneghan C, Liberati A, Moschetti I, Phillips B, Thornton H. “Explanation of the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence (Background Document)”. Oxford Centre for Evidence-Based Medicine. Available from: https://www.cebm.ox.ac.uk/resources/levels-of-evidence/ocebm-levels-of-evidence. Accessed 12 Dec 2020.

42.

DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88. https://doi.org/10.1016/0197-2456(86)90046-2.CrossRefPubMed

43.

Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–6. https://doi.org/10.1136/bmj.39489.470347.AD.CrossRefPubMedPubMedCentral

44.

Matošević M, Pegan A, Sambunjak D, Solter D, Vagić D, Rašić I, et al. Significance of anthropometric and nutritive factors in oral and oropharyngeal cancer patients undergoing free flap reconstruction. J Oral Maxillofac Surg. 2020;78(4):644–50. https://doi.org/10.1016/j.joms.2019.11.012.CrossRefPubMed

Title: 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
Authors: Henry T. de Berker
Urška Čebron
Daniel Bradley
Vinod Patel
Meklit Berhane
Fernando Almas
Gary Walton
Mekonen Eshete
Mark McGurk
Dominique Martin
Calum Honeyman
Publication date: 01-12-2021
Publisher: BioMed Central
Published in: Systematic Reviews / Issue 1/2021
Electronic ISSN: 2046-4053
DOI: https://doi.org/10.1186/s13643-021-01797-0

At a glance: The STEP trials

Springer Medicine

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

Abstract

Background

Methods

Discussion

Systematic review registration

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Discussion

Systematic review registration

Please log in to get access to this content

Other articles of this Issue 1/2021

Interventions to prevent obesity in Latinx children globally: protocol for a systematic review and meta-analysis

Effects of home visits on quality of life among older adults: a systematic review protocol

Mapping evidence of depression in HIV-seropositive MSM in sub-Saharan Africa: a scoping review protocol

Patient-reported outcome measures in pediatric palliative care—a protocol for a scoping review

Evaluating measures of quality of life in adult scoliosis: a protocol for a systematic review and narrative synthesis

Effectiveness of matching human leukocyte antigens (HLA) in corneal transplantation: a systematic review protocol