R. Patterson1,2, M. Wilson2, A. Bowder2,3, C. Dodgion3, L. Ward2, M. Padovany2 1Tufts University School of Medicine,Boston, MA, USA 2St. Boniface Hospital,General Surgery,Fond-des-Blancs, SUD, Haiti 3Medical College of Wisconsin,General Surgery,Milwaukee, WI, USA
Introduction:
Surgery is a neglected component of global health, and surgical subspecialty care is particularly absent in low- and middle-income countries (LMICs). Worldwide, head and neck (H&N) conditions contribute to 375,000 deaths per year. Typically managed by otolaryngologists in high-income countries, access to specialists is severely limited in LMICs.
Currently, Haiti has 16 practicing otolaryngologists for a population of 11 million. Thus, many general surgeons manage H&N conditions. In southern Haiti, surgical care at St. Boniface Hospital (SBH) is provided by two Haitian general surgeons and one rotating resident who manage a breadth of surgical disease including H&N conditions. Since 2015, SBH surgical capacity has grown in three distinct phases. Here, we examine the ability of SBH general surgeons to care for H&N conditions by analyzing the volume, complexity, and mortality of cases traditionally treated by otolaryngologists.
Methods:
A retrospective review was performed of all H&N surgical cases at SBH between February 2015 and August 2017. These procedures were divided into three phases correlating to increasing level of general surgery capacity: phase 1 (P1) with visiting surgical teams, phase 2 (P2) with one full-time general surgeon, and phase 3 (P3) with a surgical center, two general surgeons, and residents. Diagnosis, procedure details, and patient demographics were recorded in the surgical logbook.
Results:
SBH surgeons performed 2,068 surgical procedures, including 165 (8%) H&N procedures. No H&N procedures were performed in P1, but there were 73 in P2 and 92 in P3, with a monthly average of 4.6 and 10.6 in P2 and P3, respectively. Most cases were thyroidectomies (30.3%), excisions of unspecified head and neck masses (26.7%), and facial plastics procedures (9.7%). The transition from P2 to P3 allowed for increased rates of more complex surgery like H&N mass resections (mean of 1.1 to 2.3 per month, [range of 0-8]), Sistrunk procedures (0.1 to 0.8, [0-2]), and Ludwig’s Angina procedures (0.1 to 0.6, [0-2]). Few specialized procedures of the ear, nose, or throat were performed. There were no recorded mortalities of H&N patients.
Conclusion:
Building general surgery capacity contributed to SBH’s ability to care for H&N disease. SBH’s experience suggests that general surgeons can safely fill gaps in settings with limited subspecialty care. National surgical plans and otolaryngology training should prioritize general surgery cross-training to build on existing H&N surgical skills. This approach should be combined with strengthening referral networks and subspecialty H&N capacity at tertiary centers in order to maximize the availability of specialized care.
