A. Muzira1, N. Kakembo1, P. Kisa1, J. Sekabira1, E. Christison-Lagay2, M. Langer4, T. Fitzgerald3, M. Ajiko5, A. Kintu1, R. Kabuye1, D. Namuguzi1, R. Nassanga1, D. Ozgediz2 1Mulago Hospital,Surgery Department,Kampala, , Uganda 2Yale University School Of Medicine,New Haven, CT, USA 3Texas Tech University At El Paso,El Paso, TEXAS, USA 4Maine Medical Center,Portland, MAINE, USA 5Soroti Hospital,Soroti, , Uganda
Introduction:
Pediatric surgery access is limited in rural low-income sub-Saharan Africa. Uganda has two full-time clinical pediatric surgeons, and no physician anesthetists work outside the capital. A high burden of untreated pediatric surgical conditions exists in rural areas. Rural outreach with a primarily Ugandan team working with international collaborators was planned to improve surgical access.
Methods:
Needs assessments were conducted in public regional hospitals in rural Soroti (east) and in Masaka (west). Collaborative objectives included 1) skills transfer to local clinicians; 2) reducing operative backlog; and 3) community sensitization to pediatric surgical conditions. Patient recruitment was done through local providers who screened cases before outreaches, in addition to public radio announcements. Visiting teams were composed of primarily Ugandan providers. All operations were done with mixed teams of surgical and anesthesia providers to facilitate skills transfer. Patient follow-up occurred both by host clinicians and through regular communication (phone and email), referral to the capital as needed, and return visits as needed.
Results:
One-week outreach trips were made to Soroti (5/2012, 1/2013) and Masaka (8/2013, 2/2015). 103 patients (median) were screened/outreach and 83 cases completed/outreach (median). All operations were done under general anesthesia with frequent use of regional blocks. All anesthesia and surgery was done by a combination of visiting team and host providers. The most common operations were hernia/hydrocele repair, orchiopexy, colostomy, PSARP/pull through, and hypospadias repair. There was one post-operative death from dehydration due to enteritis. There were three major complications: wound dehiscence requiring re-operation and two patients with prolonged extubation. All made a full recovery and were discharged uneventfully. Follow up for major cases such as PSARP and pull through were more commonly performed by the host team in Soroti, and through follow up in the capital, for the patients in Masaka (located closer to the capital).
Conclusion:
Rural pediatric general surgery outreach can be performed safely in a very austere environment with primarily local providers. Preparatory planning with host clinicians, interdisciplinary teams, and careful case selection are essential for success. If skills transfer is a primary objective, joint participation in operations is important for hands-on experience of local clinicians. Longer-term follow-up, particularly for major cases, should be determined based on local personnel and practical barriers for follow up in the capital. Ongoing work will examine longer-term outcomes, impact, and cost-effectiveness of these programs.
