Outcomes of 1,327 patients operated on through twelve multispecialty surgical volunteerism missions: A retrospective cohort study

Accepted Manuscript Outcomes of 1,327 patients operated on through twelve multispecialty surgical volunteerism missions: A retrospective cohort study Rifat Latifi, Renato Rivera, Mahir Gachabayov, Maria Melinda Borja Chiong, R. Dirk Noyes, Michael Kleinmann, Fancy S. Baluyot, Elizabeth Tilley, David Samson, Ayman El-Menyar PII:

S1743-9191(18)31679-0

DOI:

https://doi.org/10.1016/j.ijsu.2018.10.033

Reference:

IJSU 4770

To appear in:

International Journal of Surgery

Received Date: 19 August 2018 Revised Date:

18 October 2018

Accepted Date: 18 October 2018

Please cite this article as: Latifi R, Rivera R, Gachabayov M, Borja Chiong MM, Noyes RD, Kleinmann M, Baluyot FS, Tilley E, Samson D, El-Menyar A, Outcomes of 1,327 patients operated on through twelve multispecialty surgical volunteerism missions: A retrospective cohort study, International Journal of Surgery (2018), doi: https://doi.org/10.1016/j.ijsu.2018.10.033. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT

Outcomes of 1,327 patients operated on through twelve multispecialty surgical volunteerism missions: A retrospective cohort study.

RI PT

Rifat Latifi, MD, FACS1,2,3; Renato Rivera, MD, FACS2,4; Mahir Gachabayov, MD1, PhD; Maria Melinda Borja Chiong, MD, FPOGS,2,5; R. Dirk Noyes, MD, FACS6; Michael Kleinmann, MD, FACS2; Fancy S. Baluyot, RN7, Elizabeth Tilley, PhD1, David Samson, MS1, Ayman El-Menyar,

SC

MD1.

1. Director, Department of Surgery, Westchester Medical Center and Professor of Surgery,

2. Operation Giving Back Bohol;

M AN U

New York Medical College, Valhalla, NY, USA;

3. International Virtual e-Hospital Foundation, Hope, Idaho, USA; 4. St. Joseph Hospital, Breese, IL;

TE D

5. Borja Family Hospital, Tagbilaran, Bohol, Philippines;

6. Huntsman Cancer Institute at University of Utah, Intermountain Healthcare, Salt Lake City, Utah;

EP

7. Gift of Life, Bohol, Philippines.

Corresponding author: Rifat Latifi, MD, FACS, FICS

AC C

Director, Department of Surgery; Chief, Trauma and General Surgery Divisions, Department of Surgery, Westchester Medical Center Health Network; Professor of Surgery, New York Medical College. Taylor Pavilion, Suite D334, 100 Woods Road, Valhalla, NY 10595, USA Phone: 914 493-8279 e-mail: [email protected]

ACCEPTED MANUSCRIPT

Outcomes of 1,327 patients operated on through twelve multispecialty surgical volunteerism

RI PT

missions: A retrospective cohort study.

Abstract

Background: Surgical volunteer missions (SVMs) have become a popular approach for

SC

reducing the burden of surgical disease worldwide. The aim of this study was to evaluate the outcomes of 12 surgical missions between 2006 and 2018 from the mission entitled “Operation

M AN U

Giving Back Bohol” Tagbilaran, Philippines and discuss the lessons learned during these missions in particular seven challenges that every volunteer surgeon should be familiar with. Methods: This was a retrospective descriptive study of prospectively collected data on all patients treated during one SVM. The data collected included gender, age, diagnosis, types of

TE D

surgeries performed, and perioperative adverse events.

Results: During the study period 1,327 operations were performed (842 females (63.4%) and 485 males (36.6%); (male-to-female ratio 0.59); mean age 37±18 years. The majority of

EP

operations were for thyroid disease (31.6%), followed by hernia (17.3%), hysterectomies/salpingo-oophorectomies (12.2%), soft tissue tumors (9.9%), cleft lip/palate

AC C

repairs (7.2%), breast (6.4%), gallbladder disease (4.7%), cataract (2.9%), parotid masses (1.4%) and others (6.4%). For each mission, there were an average 5.5 days of operating, performing a median of 105.5 (80-148) cases per mission. There were 27 complications (2%), of which, 22 were postoperative bleeding and two temporary tracheostomies. The mortality rate was 0.15% (2/1327). In one patient, the family withdrew care following compassionate last ditch effort thyroidectomy for advanced cancer and one patient died as a result of intracranial bleeding from

1

ACCEPTED MANUSCRIPT

a brain tumor, which was unrecognized before mastectomy. Conclusions: Surgical volunteerism missions are safe and valuable in lessening the burden of

RI PT

surgical disease globally when performed in an organized fashion and with continuity of care. However, there is need for standardization of surgical care provided during SVMs and creation of a world-wide database of all SVMs, and each surgeon and others who participate in these

SC

mission should be familiar with critical elements and challenges for the successful mission.

Keywords: Surgical Volunteerism Missions, Operation Giving Back, Developing Countries,

Challenges, Third World Countries ABBREVIATIONS

M AN U

Global Health, Medical Geography, General Surgery, Gynecology, Telemedicine, Organizational

TE D

ASA, American Society of Anesthesiologists IRB, Institutional Review Board

EP

LIMIC, low- and middle-income countries OGBB, Operation Giving Back Bohol

AC C

SAFT, store and forward telemedicine SVM, surgical volunteer mission

1. INTRODUCTION The Lancet Commission on Global Surgery reported that nearly 45% of the total estimated surgical cases worldwide are left unoperated upon each year, leaving more than 143 2

ACCEPTED MANUSCRIPT

million people in low- and middle-income countries (LIMICs) without adequate surgical care [1]. Moreover, nearly two-thirds of the world’s population do not have access to safe, affordable, and timely surgical care, with the majority being from low-income countries, versus only fifteen

RI PT

percent from high-income countries [1,2]. While two billion people are currently unable to

undergo a necessary surgical procedure due to an insufficient surgical infrastructure including lack of surgeons, tens of millions each year face ruinous financial hardship when they are forced

SC

to pay for their own surgery and anesthesia [1,3]. Surgical volunteer missions (SVMs) offer a flexible and often rapid response to the gaps in surgical care worldwide [4]. However, long-term

M AN U

results have not been studied, and although SVMs are nearly universally welcomed, their overall benefits have not been studied. There are a number of SMVs taking place worldwide, mostly from developed countries to low- and middle-income countries.

The exact number of missions taking place world-wide, and number of patients that are

TE D

being served are not known. Some of these volunteer missions are organized by different hospitals, supported by governments, or are supported and organized by faith-based organizations. Other SVMs are based on emergency situations (i.e., disaster-response missions),

EP

created in an ad hoc fashion from a single institution, or are formed from an existing roster of

AC C

emergency volunteers. Irrespective, the goal of some missions is to lessen the burden of surgical conditions such as cataract, cardiovascular, plastic surgery, fistulae care and other surgical services with clearly defined, well-planned and executed mission goals [5-8]. However, the majority of SVMs address a variety of surgical problems, based on the expertise and composition of the surgical and anesthesia team, as well as the infrastructure of the hospital where the mission is taking place. What is not clear, however, is the long-term impact of SVMs. This is mainly due

3

ACCEPTED MANUSCRIPT

to the lack of data collection infrastructure on these long-term impacts as well as the lack of surgical practice guidelines.

RI PT

The aim of this study was to evaluate the outcomes of 12 surgical missions from a wellstructured SVM and their impact on lessening the burden of surgical disease. Furthermore, we will discuss the lessons learned during these missions in particular seven critical elements or

SC

challenges that every volunteer surgeon should be familiar with before and during these

2. MATERIALS AND METHODS

M AN U

missions.

2.1. Study Design, Eligibility Criteria, and Collected Data

The work has been reported in line with the STROCSS criteria [9]. The protocol of the study was registered in a prospective public research registry ResearchRegistry.com. This was a

TE D

retrospective analysis of prospectively collected data during the twelve missions performed between the years of 2006 and 2018. All patients who underwent surgery within the surgical missions were included. Collected data included demographics, comorbidities, diagnosis, types

EP

of surgery performed, perioperative complications (bleeding, re-operation, and other

AC C

complications including mortality), length of hospital stay, number and specialty of volunteer personnel participating in the mission. Data were kept within the headquarters of the mission, *** Hospital, Tagbilaran, Philippines. The IRB of the University of *** approved the study. Each year since 2006 (except for 2008), the surgical mission “Operation Giving Back

Bohol” (OGBB), with volunteers from various institutions from the U.S. has been organized to the province of Bohol, located in the Central Visayas region of Philippines. During these missions, surgeons of various disciplines (general, plastics, otorhinolaryngologic, and 4

ACCEPTED MANUSCRIPT

gynecologic), anesthesiologists, nurse anesthetists, surgical and anesthesia residents, surgical nurses, surgical technologists, and other volunteers have joined for a week-long mission in the city of Tagbilaran, Philippines. The OGBB is supported by a number of organizations, the local

RI PT

government, and individuals from the community and a non-governmental organization Gift of Life TM Foundation for the Philippines. The latter screens and identifies patients in need of surgery. On the day of surgical team’s arrival as many as 200 patients in a single day are

SC

screened. After evaluating patients, each surgeon will schedule four to seven operations a day for six operative days (Sunday- Friday). In recent years, in order to facilitate the process, we have

M AN U

used store and forward telemedicine to evaluate patients in advance, in order to better prepare for the mission [10]. During the telemedicine session, the surgeon can identify patients and plan for surgery.

TE D

2.2. Study Interventions

Preoperative assessment of all patients including biochemical, radiologic, morphologic (biopsy), or endoscopic tests were performed in local primary care facilities when possible. All

EP

patients were seen and scheduled for surgery on the first day of the mission. Thyroid surgery included partial, subtotal, and total thyroidectomies depending on the type and extent of the

AC C

disease. In case of thyroid malignancies involving regional lymph nodes, neck dissection was performed in addition to thyroidectomy, at the surgeon’s discretion. Hernias were repaired with synthetic meshes in the vast majority of patients, except for the pediatric population. Biologic mesh was used in only one patient with complex abdominal defect. Gynecologic surgery included total hysterectomies, salpingo-oophorectomies, and ovarian cystectomies. Breast surgery included both local excisions and mastectomies. Discharge criteria included no evidence

5

ACCEPTED MANUSCRIPT

of complications, ambulation and ability for self-care or good family support, tolerance of oral intake, adequate pain control with oral analgesia, and recovery of lower gastrointestinal and urinary functions. Postoperative wounds were checked daily by operating surgeons and on the

RI PT

day of discharge in all patients. 2.3. Definitions

Body mass index was expressed in kg/m2. Physical status of the patients was classified

SC

according to the American Society of Anesthesiologists (ASA) score. Postoperative

according to Clavien-Dindo system [11]. 2.4. Statistical Analysis

M AN U

complications were defined as any deviation from the normal postoperative course and classified

Statistical analysis was performed using SPSS software (version 18; SPSS Inc., Chicago, IL, United States). The data were tested for normality using Kolmogorov-Smirnov and Shapiro-

TE D

Wilk tests and histograms. Mean with standard deviation and median with interquartile range were used as descriptive statistics for continuous variables. Categorical variables were expressed in numbers, percentages, or ratios. Trend of impact of surgical missions was evaluated using a

EP

linear regression model. Multivariate logistic regression was utilized to determine independent predictors of postoperative morbidity within the surgical mission. Statistical significance was

AC C

defined as p<0.05.

3. RESULTS

Demographics and preoperative variables are shown in Table 1. During the study period 1,327 operations were performed (842 females (63.4%) and 485 males (36.6%) (male-to-female

6

ACCEPTED MANUSCRIPT

ratio 0.59); mean age 37±18 years. For each mission, a median 105.5 (80-148) operation were performed with an average 5.5 days per mission. Types of surgeries performed by years are illustrated in Figure 1. The majority of

RI PT

operations (419 (31.6%)) were for thyroid disease, followed by hernia (230 (17.3%)),

hysterectomies/salpingo-oophorectomies (162(12.2%)), soft tissue tumors (131 (9.9%)), cleft lip/palate repairs (95 (7.2%)), breast (85 (6.4%)), gallbladder disease (62 (4.7%)), cataract (39

SC

(2.9%)), parotid masses (19 (1.4%)) and other indications (85 (6.4%)). Overall, there was

increasing trend in impact of surgical missions (goodness of fit: R2 = 0.526; p = 0.007) (Figure

M AN U

2).

Intra- and postoperative variables are shown in Table 2. There were 27 complications (2%), of which, 22 were postoperative bleeding. Two temporary tracheostomies were performed for peri-operative stridor. The mortality rate was 0.15% (2/1327). In one patient, family

TE D

withdrew care following thyroidectomy for advanced cancer and one patient died as a result of intracranial bleed from brain tumor, unrecognized before mastectomy. There was one patient with large, recurrent papillary carcinoma that we were unable to re-operate due to involvement

EP

of major neck structures (Figures 1, 2). One year after total thyroidectomy with neck dissection, during which time she had carotid, tracheal and esophageal involvement, she had no ability to

AC C

undergo medical or radiation therapy. Independent predictors of postoperative morbidity are shown in Table 3. Female gender

(p=0.042) and type of surgery (p=0.05) appeared to be independent risk factors.

7

ACCEPTED MANUSCRIPT

4. DISCUSSION

RI PT

Surgical volunteer missions comprise a valuable approach for reducing the burden of surgical disease in countries with limited resources worldwide, but the data on efficacy and

overall benefits of surgical mission has not been studied adequately, despite many claiming that

SC

these missions are cost effective. This study represents a large report from a continuous single multispecialty surgical volunteer mission (SVM). In this retrospective review we report the

M AN U

results of 1,327 patients operated over 12 surgical missions (2006 – 2018), in one of the islands of Bohol in the Philippines (with a population of 1.3 million people). The surgical mission has been organized over the years by the same group of surgeons and local support system in the same hospital for 11 out of 12 missions (one mission was organized in a governmental hospital).

TE D

4.1 Challenges of Surgical Volunteerism

Surgical missions are complex by any stretch of imagination and have been shown to reduce the burden of surgical disease worldwide, but their organizational complexity has not

EP

been addressed adequately, and it is unclear if those who wish to undertake SVMs truly understand associated challenges. We have divided these challenging issues into seven groups:

AC C

1) Creation of the team; 2) Patient selection; 3) Case complexity; 4) Cost of the mission; 5) quality of care and safety of both patients and the team; 6) Changing the mindset and situational awareness; and 7) Overall efficiency of the SVM. 4.1.1. Decision to volunteer and creation of the team How does one decides on the country or region of the country to volunteer is complex, but mostly depends on the personal relationships, knowing the country’s need, knowing people

8

ACCEPTED MANUSCRIPT

involved in these mission and joining them or responding to calls for volunteers from a number of organization that offer surgical mission posted in websites such as Operation Giving Back https://www.facs.org/ogb) where one can find a number of other resources and toolkits that will

RI PT

be helpful. This mission and its site were chosen by the team leader (RR) originally from the same town and with great connection in the region, who knew about the needs and setting up the

SC

support system.

The core and soul of a surgical mission is the team itself, which consists of volunteer

M AN U

surgeons, anesthesiologists, nurses, and others. Depending on the nature of the mission, there may be additional individuals who support the surgical team, including pharmacist, pathologist, local nurses and other personnel [12-16]. Like in any institution, department or team, there is a need for the leader who will coordinate the entire mission. Diligent screening of potential personnel, however, is most important part of preparation of the mission. Many surgeons,

TE D

especially after they retire, believe that there is still something of value that they would like to give back. We believe that every surgeon who participates in a surgical mission should be able to demonstrate skills and surgical stamina and missions should be a continuation of active practice

EP

for the most part, and not “refreshing” of surgical skills. Every one who participate in SVM

AC C

should be actively practicing in their own countries the field of surgery and the cases that one does at home. As we improve participation of surgeons in global surgery, it is important that we bring residents and medical students along to expose to and improve their knowledge about global surgery and recruit them for future mission once they become independent surgeons. Their participation should be done under the supervision of the attending surgeon exactly the same way as it is done at their home institutions.

9

ACCEPTED MANUSCRIPT

Some have postulated that the main beneficiaries of surgical mission are the participants of the mission and not the patients and the country where the mission is taking place. While this may be partially true for some missions, we believe that missions should be structured, built and

RI PT

led in such a way, that it is surgically and medically sound, cost-beneficial, efficient, and offer real help to people who cannot afford otherwise such care. There is nothing wrong, however, if the team members, after the mission is complete, spend few extra days getting to know the

SC

country, their people and the culture. This in fact may be a good way to attract such volunteers to continue with missions and create long-term relationships. However, one has to make sure that

M AN U

“social” portion of the mission is not elaborate and does not impede or decrease and shorten the clinical aspect of the mission. This is up to the leadership of the mission. 4.1.2 Patient selection

TE D

While every surgeon wishes to help every patient, proper patient selection is of utmost importance for the successful impact of every mission. A well-defined screening process for patients is recommended [4,17,18]. For our missions, patients were identified from a large pool

EP

of potential patients by local agency staff (Gift of Life TM, Philippines). Then, at the beginning of the mission, surgeons of the SVM perform the final selection and put together the full schedule

AC C

for the week. Without such a process, the mission volunteers will likely be seeing many more patients who have conditions that either do not require surgery or are too complicated, and often futile, to be adequately handled in the short timespan when the mission will be present [10,12]. The main criteria, however, should be the expertise of the surgical and anesthesia team and ability to provide safe anesthesia and surgery. The team leader should know about all cases being scheduled by different surgeons and make sure that those cases are within credentialing and expertise frame of individual surgeons. 10

ACCEPTED MANUSCRIPT

Defining clear selection criteria prior to the mission is another important aspect of SVM, but this often depends entirely on the team composition and the expertise that they have. In our experience, for example, among thyroidectomies, we gave priority to those patients with the

RI PT

largest and most deforming masses, or biopsy-proven cancer. However, just because the surgeon can and wishes to perform the surgery, one has to ensure that anesthesiologists and the rest of the

SC

team can actually support such an undertaking.

4.1.3. Case Complexity

M AN U

Preoperative evaluation of surgical mission patients is a complex, time-consuming, and often chaotic process, because these evaluations typically require intense work by the operating team on the day of arrival at the mission site. Our group has experimented with low-cost store and forward telemedicine (SAFT) and found it to be a viable and secure alternative for

TE D

preoperative evaluation of surgical mission patients [10]. It increases efficiency and optimizes the use of existing resources. Specifically, SAFT helps to ensure an accurate assessment of patients before the surgical team arrives, reduces on-site pre-screening time, and decreases the

EP

number of surgical candidates on the waiting list. Previous results from our work described a high correlation rate between SAFT and in-person preoperative evaluations [10].

AC C

Patient selection and determining whether a surgical procedure is too complex for the

capabilities of the surgical volunteer team, or if the mission lacks the equipment and resources (such as blood products) to effectively handle the patient, are also critical issues [19] and should be carefully analyzed. Often surgeons in SVMs take on more than can be handled for many different reasons. Yet, on occasion, the team has to be able to get creative and use every possible “trick of the trade” to ensure safety of the operation, such as difficult or impossible airways [20].

11

ACCEPTED MANUSCRIPT

One of our patients, whose family withdrew care was an example of a case that was too complex and should have not have been done. She had widely-spread thyroid cancer and the surgery was basically a last ditch effort to improve the patient’s quality of life. While on SVM one has to be

RI PT

ready to see neglected disease at it worse (Figure 3), on occasion there is not much that one can do mostly due to lack of infrastructure and availability of other services. Recognizing the

limitations of the resources of the mission and accepting that in these situation simply you cannot

SC

help everyone, while very difficult, is of paramount importance. We learned that although

M AN U

heartbreaking one should avoid futile and heroic interventions during SVMs. Another major element of SVM is prioritizing surgeries and they should be performed. Some will argue that simple cases should make up the majority or even the entirety of the cases, with the premise that this ensures that the most patients are cared for during the mission. We, on the other hand, believe that we should work with even the sickest patients, as this may be their

TE D

only opportunity to get well. Yet, complex cases, such as abdominal wall reconstruction may take great time, and one has to balance between caring for more patients, or actually helping one patient and spending 3-4 hours operating.

EP

4.1.4. Cost of the Mission

AC C

The cost of the mission is very complex and difficult to measure. While we have not done so, the cost of a mission should be measured prospectively. We are currently conducting a retrospective analysis on the financial scope of the missions. In addition to the savings from the surgery that the patient would have to pay if done by private local surgeons (for example one thyroidectomy, including hospitalization cost around $2,000 US in the hospital we operate), great expenses are incurred by each member in travel, loss of income during the week of mission, and equipment that is offered by donors. 12

ACCEPTED MANUSCRIPT

4.1.5. Quality of care and safety of both patients and the team Surgery-related outcomes during volunteer missions should be subjected to the same quality assessment and regulation as other core medical treatments, including consent, universal

RI PT

protocols and checklists [22-26].

A clinical performance management team can then evaluate the events during the mission with the focus on increasing efficiency of care delivery and maintaining high standards [27].

SC

However, today there is no mechanism to ensure such quality, there is no morbidity and

mortality conference and there is no centrally deposited data base that researchers can view and

M AN U

analyze all surgeries performed and SVMs, such as the Nation Trauma Data Bank, and there is no overseeing body. During our missions we had 27 or (2%) complication rate, of which the majority (22) were postoperative bleeding. There were three reoperations only, all were for complications of thyroidectomy. Even though it was recently reported that in almost 85% of

TE D

cases of acute post-thyroidectomy respiratory failure tracheotomy can be avoided, in our cohort two tracheotomies were performed [28]. The volunteer community should strive to create their own quality metrics and ensure that quality and patient’s safety is above all.

EP

Given the dynamics of “strangers” working and living closely together under stressful conditions, efforts to improve team cohesion should begin as early as possible [29]. Most of our

AC C

team has worked together, so this issue is not as pronounced, although this is an important factor to consider when one leads the team of volunteers. There are several other factors that would negatively impact the team cohesion of any group but are unfortunately abundant during surgical volunteer missions: ineffective communication, scarcity of resources, and lack of trust [30]. An even more important issue is the safety of volunteers in hot zones such as during wars and conflicts where the safety of both patients and the volunteers of staff of different organizations

13

ACCEPTED MANUSCRIPT

are at significant risk [31]. Understanding such risk and taking all the precautions to ensure the safety of both the patient and the mission staff is particularly difficult in war zones and major

4.1.6. Changing the mindset and situational awareness

RI PT

conflicts.

In contrast with the western countries or any developed country, hospitals in low-income countries experience massive shortfalls in the infrastructure and physical resources required for

SC

basic surgical care [32]. In addition, often, there is gross deficiency in equipment necessary for surgery and anesthesia which leads to work under the pressure of need to save available

M AN U

resources. In other words, one has to work with what is available, but without grossly compromising the safety and outcomes of the patient. Moreover, one has to be sensitive to people who work in these settings and assure to understand entirely the conditions being fully aware of the situation. One can learn a great deal from local surgeons, on how to manage even

TE D

complex cases, how to diagnose in a simple clinical way. Based on how your mission is organized, often there are lots of surgical supplies that are simply “buried” in the pile of supplies and are not “found” till the end of the mission. Take your time at the beginning of the mission

EP

and help identify and become familiar with all you have at the disposal for your mission. This will help greatly with the efficiency and safety of the mission. Often, although laparoscopic

AC C

cholecystectomy is a “gold standard” procedure for symptomatic gallstones, open cholecystectomy is the reality of SVM settings requiring certain skills, and one must have the skills before undertaking such cases. 4.1.7. Overall efficiency of SVM Finally, the overall efficiency of the SVM depends on systematic preparation, team creation and team synergy, and the goals of each individual member. This is truly team work and

14

ACCEPTED MANUSCRIPT

as such each member should assist others with patient care, as well as other issues that may arise during the mission. Assisting with difficult cases and working together may help build that synergy and overall team spirit. Working with your unit of scrub nurses/techs before and each

RI PT

day increases the efficiency of the cases of the operating room. Offering constructive advice, and planning for surgery in advance may be of great benefit to the efficiency of the SVM. As we have demonstrated by our findings over the course of the missions, as team experience working

SC

together was acquired and built, the efficiency of the mission increased.

M AN U

5. SUMMARY

In this report, we have described a surgical mission that has been occurring since 2006, during which we have operated on 1,327 patients. While this mission is very successful, one soon realizes from the perspective of a volunteer surgeon, that role is perhaps the easiest role to play during these assignments. Identifying the patients, completing the preoperative work-up,

TE D

gathering, transporting, and successfully delivering the surgical equipment, medications, gowns, gloves, sutures, and all other needed materials on time are monumental tasks that are completed throughout the year by the mission leadership and volunteers. Selecting team members for the

EP

mission, ensuring their expertise and clinical privileges, and obtaining their licensing by local

AC C

authorities are addressed before the start of the mission. The study has several strengths. The majority of this SVM team consists of the same

people that started and continue to be vested in the mission. The mission has been organized in the same hospital for the last 11 out of 12 years, led by the same local team and there is a followup of patients who developed complications or recurrence.

15

ACCEPTED MANUSCRIPT

In the future, data on team creation and credentialing, patient selection, pre-operative diagnosis, procedures performed, perioperative complications, and other outcomes, including the cost of a mission should be reported to data base at a central location, such as OGB of the

provision of the highest quality possible care.

RI PT

American College of Surgeons (ACS). This will serve as a great research resource and ensure the

SC

In addition, there are a number of other considerations that arise during the SVM, such as the ability of the team to work together, and how to ensure the safety of both the team as well as

M AN U

the patients. Overall, it is a wonderful way to help those who otherwise cannot afford surgical care.

Declarations

TE D

Ethics approval and consent to participate: IRB approval was granted by the University of ***. Written informed consent was obtained from the patients included. Consent for publication: Written informed consent was obtained from the patients included.

EP

Availability of data and material: The data can be available on the Editor’s request. Competing interests: None.

AC C

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Authors' contributions: All authors contributed to the intellectual content, design of the study, collection and analysis of the data, drafting the manuscript, and approved the final version of the paper. Acknowledgements: The authors would like to thank and acknowledge all the members of ***

16

ACCEPTED MANUSCRIPT

Hospital in Tagbilaran, as well as all the dedicated individuals who contributed to Operation

RI PT

Giving Back Bohol over the years.

Provenance and peer review

REFERENCES

M AN U

SC

Not commissioned, externally peer-reviewed

1. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet 2015;386(9993):569-624.

TE D

2. Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. The Lancet Global Health 2015;3(6):e316-e23.

EP

3. Funk LM, Weiser TG, Berry WR, et al. Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet 2010;376:1055-61.

AC C

4. Casey KM. The global impact of surgical volunteerism. Surg Clin North Am 2007;87(4):949-60.

5. Wallen TJ, Arnaoutakis GJ, Blenden R, Soto R. Programmatic Changes to Reduce Mortality and Morbidity in Humanitarian Congenital Cardiac Surgery. World J Pediatr Congenit Heart Surg. 2018;9(1):47-53.

17

ACCEPTED MANUSCRIPT

6. Rapp DE, Colhoun A, Morin J, Bradford TJ. Assessment of communication technology and post-operative telephone surveillance during global urology mission. BMC Res Notes. 2018;11(1):149.

RI PT

7. Walker ME, Chuang C, Moores CR, et al. The Hand Surgeon Consultation Improves Patient Knowledge in a Hand Surgery Mission to Honduras. J Hand Surg Asian Pac Vol. 2018;23(1):11-17.

missions. Acta Cytol. 2009;53(5):524-6.

SC

8. Reyes CV, Reyes EA. The role of fine needle aspiration cytology in medical-surgical

M AN U

9. Agha RA, Borrelli MR, Vella-Baldacchino M, Thavayogan R, Orgill DP; STROCSS Group. The STROCSS statement: Strengthening the Reporting of Cohort Studies in Surgery. Int J Surg. 2017;46:198-202.

10. Latifi R, Mora F, Bekteshi F, Rivera R. Preoperative telemedicine evaluation of surgical

TE D

mission patients: should we use it routinely? Bull Am Coll Surg. 2014;99(1):17-23. 11. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg.

EP

2004;240(2):205-13.

12. Adams C, Kiefer P, Ryan K, et al. Humanitarian cardiac care in Arequipa, Peru:

AC C

experiences of a multidisciplinary Canadian cardiovascular team. Can J Surg 2012;55(3):171-6.

13. Eberlin KR, Zaleski KL, Snyder HD, et al. Quality assurance guidelines for surgical outreach programs: a 20-year experience. Cleft Palate Craniofac J 2008;45(3):246-55.

14. Brown DA, Ferrill MJ. Planning a pharmacy-led medical mission trip, part 1: focus on medication acquisition. Ann Pharmacother 2012;46(5):751-9.

18

ACCEPTED MANUSCRIPT

15. Kobayashi MA. Evolution of a triage and flow process during a joint American-Chinese medical mission in Dali, Yunnan, China. J Emerg Nurs 2011;37(4):394-8. 16. Naujokas A. Raising the Quality of Care During Medical Missions: A Survey to Assess

RI PT

the Need for Clinical and Anatomic Pathology Services in International Medical Missions. Arch Pathol Lab Med 2013;137:637-41.

17. McQueen KC, Casey, KM. The Impact of Global Anesthesia and Surgery: Professional

SC

Partnerships and Humanitarian Outreach. International Anesthesiology Clinics 2010;48(2):79-90.

M AN U

18. Nguah S. Ethical Aspects of Arranging Local Medical Collaboration and Care. The Journal of Clinical Ethics 2014;25(4):314-6.

19. Hollier LH, Jr., Sharabi SE, Koshy JC, et al. Surgical mission (not) impossible--now what? J Craniofac Surg 2010;21(5):1488-92.

TE D

20. Latifi R, Harper J, Rivera R. Total thyroidectomy for giant goiter under local anesthesia and Ketamine in a surgical mission. Int J Surg Case Rep. 2015;8C:52-4. 21. Eyal N. Pediatric Heart Surgery in Ghana: Three Ethical Questions. The Journal of

EP

Clinical Ethics 2014;25(4):317-22.

22. Chu KM, Trelles M, Ford NP. Quality of care in humanitarian surgery. World J Surg

AC C

2011;35(6):1169-72; discussion 73-4.

23. Holt G. Ethical Conduct of Humanitarian Medical Missions: I. Informed Consent. Arch Facial Plast Surg 2012;14(3):215-7.

24. Campbell A, Sullivan M, Sherman R, et al. The medical mission and modern cultural competency training. J Am Coll Surg 2011;212(1):124-9.

19

ACCEPTED MANUSCRIPT

25. Dempsey KE, Ghazinouri R, Diez D, et al. Enhancing the quality of international orthopedic medical mission trips using the blue distinction criteria for knee and hip replacement centers. BMC Musculoskeletal Disorders 2013;14(275):1-16.

RI PT

26. Maki J, Qualls M, White B, et al. Health impact assessment and short-term medical missions: a methods study to evaluate quality of care. BMC Health Serv Res 2008;8(121):1-8.

SC

27. Friedman DB, Berger DL. Improving Team Structure and Communication: A Key to Hospital Efficiency. Arch Surg 2004;139:1194-998.

M AN U

28. Ferraro F, Gambardella C, Testa D, et al. Nasotracheal prolonged safe extubation in acute respiratory failure post-thyroidectomy: An efficacious technique to avoid tracheotomy? A retrospective analysis of a large case series. Int J Surg. 2017 May;41 Suppl 1:S48-S54. 29. Sundstrom E, De Meuse KP, Futrell D. Work Teams: Applications and Effectiveness.

TE D

American Psychologist 1990;45(2):120-33.

30. Scarnati JT. On becoming a team player. Team Performance Management: An International Journal 2001;7(1/2):5-10.

EP

31. Serle J, Fleck F. Keeping health workers and facilities safe in war. Bull World Health Organ. 2012;90(1):8-9.

AC C

32. Kushner A. Addressing the millennium development goals from a surgical perspective. Essential surgery and anesthesia in 8 low- and middle-income countries. Arch Surg. 2010;145(2):154-159.

FIGURE LEGENDS 20

ACCEPTED MANUSCRIPT

Figure 1. A histogram depicting number and type of surgeries by years of mission. Figure 2. A scatter plot depicting increasing trends in impact of surgical missions.

RI PT

Figure 3. Examples of neglected surgical disease. a. Large thyroid goiter. b. Intraoperative view after thyroidectomy on the same patient. c. Soft tissue sarcoma of the right upper extremity

existing for 15 years. The patient underwent limb sparing radical surgery. d. Inoperable thyroid

AC C

EP

TE D

M AN U

SC

cancer in a 70 year old female.

21

ACCEPTED MANUSCRIPT

Table 1. Demographics and preoperative variables.

RI PT

485 (36.6%) 842 (63.4%) 23.4 ± 4.7

1,178 (88.8%) 133 (10%) 16 (1.2%) 192 (14.5%)

SC

Age (years) * Gender (n (%)) Male Female BMI (kg/m2) * ASA (n (%)) I II III Comorbidities (n (%)) Diagnosis (n (%)) Thyroid disease Hernia Gynecologic disease Soft tissue tumors Cleft lip/palate Breast tumors Gallbladder disease Cataract Parotid masses Others (including simultaneous surgical disease) Length of current disease (years) # Breakdown to years (n (%)) 2006 2007 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 * expressed in mean ± standard deviation # expressed in median (range) BMI, body mass index; ASA, American College of Surgeons

All patients (n = 1,327) 37 ± 18

AC C

EP

TE D

M AN U

419 (31.6%) 230 (17.3%) 162 (12.2%) 131 (9.9%) 95 (7.1%) 85 (6.4%) 62 (4.7%) 39 (2.9%) 19 (1.4%) 85 (6.4%) 4 (0.1-21) 78 (5.9%) 111 (8.4%) 95 (7.2%) 81 (6.1%) 101 (7.6%) 136 (10.2%) 105 (7.9%) 106 (7.9%) 101 (7.6%) 134 (10.1%) 131 (9.9%) 148 (11.2%)

ACCEPTED MANUSCRIPT

Table 2. Intra- and postoperative variables. All patients (n = 1,327)

RI PT

817 (61.6%) 198 (15%) 173 (13%) 95 (7.1%) 44 (3.3%) 45.9 ± 30.6 6 (0.5%) 27 (2%) 17 (1.3%) 5 (0.4%) 3 (0.2%) 2 (0.15%) 3 (0.2%) 2 (0.15%) 2.4 ± 0.9

EP

TE D

M AN U

SC

Number of procedures by specialty of the operating surgeon General surgery ENT, head and neck surgery Gynecology Plastic surgery Ophthalmology Operating time (min) * Intraoperative complications (n (%)) Overall postoperative morbidity (n (%)) Clavien-Dindo 2 Clavien-Dindo 3 Clavien-Dindo 4 Clavien-Dindo 5 Reoperation (n (%)) Overall postoperative mortality (n (%)) Length of hospital stay (days) * * expressed in mean ± standard deviation

Table 3. Independent predictors of postoperative morbidity at multivariate analysis.

AC C

Predictive factors OR (95% CI) Gender (female) 1.55 (1.12-1.95) Type of surgery (thyroid) 2.21 (1.01-3.76) OR (95% CI), odds ratio (95% confidence interval).

p-value 0.042 0.05

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

ACCEPTED MANUSCRIPT

ACCEPTED MANUSCRIPT

HIGHLIGHTS

RI PT SC M AN U TE D EP

• •

Surgical volunteerism missions are safe and valuable in lessening the burden of surgical disease globally when performed in an organized fashion and with continuity of care. Postoperative mortality rate in surgical mission was 0.15%. There is need for standardization of surgical care provided during surgical missions.

AC C

•

ACCEPTED MANUSCRIPT

AC C

EP

TE D

M AN U

SC

RI PT

The authors do not have permission to share the data.