Forum. Impact of Mobile Endoscopy on Neurosurgical Development in East Africa

Size: px

Start display at page:

Download "Forum. Impact of Mobile Endoscopy on Neurosurgical Development in East Africa"

Bryce Osborne
6 years ago
Views:

1 Forum Impact of Mobile Endoscopy on Neurosurgical Development in East Africa Jose Piquer 1, Mubashi Mahmood Qureshi 2,3, Paul Henry Young 4, East African Neurosurgical Research Collaboration Hydrocephalus, a disease frequently associated with poverty, becomes even more challenging to treat in developing regions because of lack of neurosurgical manpower, inadequately equipped public health care facilities, meager resource allocations, high rates of neonatal infection, difficulty of accessibility to hospitals able to treat hydrocephalus, and high complication rates in patients who are able to access and receive shunting procedures. Definitive treatment of hydrocephalus that avoids shunting procedures and long-term shunt dependence is a safer option. In environments such as Sub-Saharan Africa (and, indeed, in other similar resource-challenged regions), neuroendoscopic ventriculostomy (NEV), in appropriately selected patients can overcome the problems associated with shunting, including long-term shunt dependence. A novel approach promoted by volunteer neurosurgical teams from the Neurosurgery Education Development (NED) Foundation is described, and its important role in successfully providing NEV at hospitals in regional sites away from main tertiary referral hospitals is outlined. Using a single portable neuroendoscopy equipment system and a versatile free-hand, single operator neuroendoscope, an easily mobile outreach model has been successfully used to perform 187 procedures in 19 hospital sites around six countries and on two continents. Neuroendoscopy is not just a priority surgical tool for East Africa; it represents a best practices philosophy of what is possible within a highly sophisticated surgical speciality like neurosurgery in developing countries. It offers an opportunity to highlight the importance of tertiary care specialties like neurosurgery in this region, to develop closer relationships between African neurosurgeons and to convince medical students, general residents, and nurses that world-class neurosurgery can be possible in a developing region. INTRODUCTION Hydrocephalus is a potentially life-threatening condition affecting between one and three infants per thousand. It creates an enormous burden on developing countries worldwide. In East, Central, and Southern Africa (ECSA), with a population of more than 250,000 million, conservative estimates suggest an annual incidence of more than 14,000 infants developing hydrocephalus within the first year of life. Children born in Europe and USA with hydrocephalus are likely to be operated on as soon as possible to prevent consequent intracranial pressure. In the ECSA region less than 10% will be operated ( cases) annually using shunting procedures, with the attendant risks of shunt infection and blockage (as high as 25%-50%). The remaining infants are the more unfortunate ones who do not have any chance of receiving treatment. In this situation, many parents try to hide their children s condition from friends, neighbors, and extended family. The birth of the child is taken as a personal failure that must be concealed. Pressure is exerted on mothers by their families to get rid of the hydrocephalic child by abandonment in the bush. In the face of such pressures, it is not surprising that many of the mothers of hydrocephalic children who died expressed relief rather than sorrow (8). Today, 20 years later, African parents may be in a little more supportive situation, but they still often face impossible difficulties in access to adequate treatment. The primary aim of treatment for hydrocephalus is normalization of impaired cerebrospinal fluid (CSF) flow, aimed at achieving a state of arrested hydrocephalus (1, 6). The final goal after treatment is defined as shunt-dependent arrested hydrocephalus in Key words Hydrocephalus Neuroendoscopic ventriculostomy (NEV) Portable outreach neuroendoscopy East African neurosurgery Abbreviations and Acronyms ECSA: East, Central, and Southern Africa CSF: Cerebrospinal fluid NEV: Neuroendoscopic ventriculostomy NED: Neurosurgery Education and Development Foundation APDK: Association of Physically Disabled of Kenya From the 1 Neurosurgical Unit, Hospital Universitario de la Ribera, Alzira (Valencia), Spain; 2 Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Nairobi, Kenya; 3 Division of Neurosurgery, Kenyatta National Hospital, Nairobi, Kenya; and 4 Section of Neurosurgery, Department of Surgery, St. Louis University, St. Louis, USA To whom correspondence should be addressed: Jose Piquer, Ph.D. [ jpiquer@hospital-ribera.com] Citation: World Neurosurg. (2010) 73, 4: DOI: /j.wneu Journal homepage: Available online: /$ - see front matter 2010 Elsevier Inc. All rights reserved WORLD NEUROSURGERY, DOI: /j.wneu

Figure 1. Standard equipment used for neuroendoscopic ventriculostomy (NEV). cases of shunt placement or as postventriculostomy arrested hydrocephalus after neuroendoscopic ventriculostomy procedures.

An even lower number are able to do so in other countries in the Sub- Saharan region, with the majority being treated by a handful of neurosurgeons, by a few general surgeons, and occasionally by

2 Figure 1. Standard equipment used for neuroendoscopic ventriculostomy (NEV). cases of shunt placement or as postventriculostomy arrested hydrocephalus after neuroendoscopic ventriculostomy procedures. Of the large number of patients developing hydrocephalus within the first year of life, only about a fifth of the overall number are able to access shunting procedures in established centers in Kenya. An even lower number are able to do so in other countries in the Sub- Saharan region, with the majority being treated by a handful of neurosurgeons, by a few general surgeons, and occasionally by pediatric surgeons. Shunts are expensive to purchase for the family and not infrequently unavailable altogether. Even when affordable shunts are used, shunt failure through infection, shunt blockage, distal migration, scalp erosion, and/or shunt extrusion through the anal passage are a significant cause of morbidity and mortality in up to 25% of the treated patients (5). As a result, in developing regions shunt placement procedures and shunt dependency pose an additional burden on the health care systems as well as on the care receivers and specialist care providers, whose time and resources are further expended in managing the disproportionately high complication rates in these environments. For these reasons, it would seem advantageous to pursue a definitive approach to treating hydrocephalus and at the same time avoiding shunt dependency. NEV has the advantage of achieving normalization of CSF flow dynamics and avoiding shunt-related morbidities and dependency in a majority of children (2, 3). The equipment used for neuroendoscopic ventriculostomy (NEV) in centers able to provide this service include a camera control unit, a cold light source unit, a high-frequency electrosurgical cautery unit, and a flat-screen monitor display unit, all placed on a mobile cart riding on casters, which incorporates shelves and drawers (Figure 1). The use of this set of equipment, albeit mobile within an individual operating suite, is restricted to the provision of NEV procedures to only those patients who are able to reach the hospital facility. It cannot provide a readily accessible service to patients in rural and/or low socioeconomic regions, where the cost of such equipment makes it unaffordable. In essence, the large majority of patients who reside in rural communities cannot be offered the preferred mode of treatment using NEV procedures. The neurosurgical section of the Neurological Society of Kenya and the Neurosurgery Education and Development Foundation (NED), since November 2006, commenced a program of teaching and promoting neuroendoscopic management (ETV) using a fully mobile and portable system as the best solution to resolve this health and humanitarian problem. NED s neurosurgeons (JP, MQ, PY) developed a project with the aim of teaching neuroendoscopy for the treatment of hydrocephalus in children in the 11 countries of Central and East Africa: Ethiopia, Kenya, Uganda, Tanzania, Rwanda, Zambia, Zimbabwe, Malawi, Mozambique, Mauritius, and the Seychelles. The Association of Physically Disabled of Kenya (APDK), a charitable nongovernmental organization with a network of more than 280 outreach screening and treatment clinics countrywide, joined the effort as a partner specifically for the Hydrocephalus/Spina Bifida program, helping to select and refer infants for screening. The goal was to train local neurosurgeons and nurses in the treatment of hydrocephalus by neuroendoscopy. It is a hugely attractive alternative that cures more than 70% of the cases without the need of a shunt. Thousands of hydrocephalic patients can be operated on at no cost, on the donation of an endoscope (around the price of 15 shunts), with better results and fewer complications. In addition, if the intervention is effective, the infant does not need medical monitoring. The child is cured for life! It has become clear that any child in this part of Africa should have as a first option the opportunity to be treated by neuroendoscopy. MATERIAL AND METHOD In August 2006 the first Neuroendoscopy Workshop was conducted at the Kenyatta National Hospital (Nairobi, Kenya). After this course, a neurosurgical team that had established an outreach mission program to provide specialized neurosurgical services in regional hospitals outside the capital Nairobi (Figure 2) purchasedacompactneuroendoscopic Karl Storz Telepack system (Figure 3). This system incorporates a processing unit, combined with a camera unit and light source, all conveniently and safely transportable in a portable suitcase. An equally versatile and easy-touse rigid rod neuroendoscope, the Oi Handy-Pro (7), with a 0-degree autoclavable Hopkins II telescope was also purchased. The system offers a single surgeon the free-hand ability to perform neuroendoscopy safely (Figure 4). Figure 2. First mobile neuroendoscopy workshop celebrated in Kenyatta Hospital in August 2006 (Nairobi, Kenya). WORLD NEUROSURGERY 73 [4]: , APRIL

Figure 3. A mobile compact neuroendoscopic system (compare Figure 1). This incorporates a processing unit, combined with a camera unit and light source, and excellent-quality image.

This program utilizing a mobile neuroendoscopic system revolutionized the management of children with hydrocephalus in this region and during the next 3 years expanded to an additional six countries,

RESULTS In tandem with providing an opportunity of treatment through NEV for 187 patients (Figure 5), the program has been a source of training of local teams, both neurosurgical and nursing, in

The same single equipment system has been used to train 28 medical doctors (Figure 6), including 19 neurosurgeons and 9 neurosurgery residents, and 16 operating room nurses in the care, assembly, and

3 Figure 3. A mobile compact neuroendoscopic system (compare Figure 1). This incorporates a processing unit, combined with a camera unit and light source, and excellent-quality image. *Anatomical anomaly of the floor of the 3rd ventricle on a baby with spina bifida hydrocephalus. Figure 5. Hydrocephalus patient desperate for an opportunity of treatment through NEV. This program utilizing a mobile neuroendoscopic system revolutionized the management of children with hydrocephalus in this region and during the next 3 years expanded to an additional six countries, and more recently to another continent (South America Peru, Lima). RESULTS In tandem with providing an opportunity of treatment through NEV for 187 patients (Figure 5), the program has been a source of training of local teams, both neurosurgical and nursing, in performing the NEV procedure, sterilization, and care of the equipment. The same single equipment system has been used to train 28 medical doctors (Figure 6), including 19 neurosurgeons and 9 neurosurgery residents, and 16 operating room nurses in the care, assembly, and sterilization of the equipment. The sites served by one single unit include 19 hospitals (Table 1). The majority of the hydrocephalus in infants occurred as a sequelae of infection, followed by non infection-related hydrocephalus and myelomeningocele. These cases were often associated with ventricular anatomical anomalies, and postinfectious adhesions were the most challenging to treat. DISCUSSION Some decades ago, Jarvis (4) described current surgical options for hydrocephalus and the problems in developing countries in the use of third ventriculostomy. Some decades later in Nairobi, Kenya, developments in imaging and neuroendoscopy, a portable and mobile neuroendoscopy system, and a novel teaching Figure 4. The system offers a single surgeon the free-hand ability to perform neuroendoscopy safely as shown during the first historical provincial neuroendoscopy surgery in Kenya at the Nyeri Hospital. Figure 6. The same single equipment system has been used to train doctors, nurses, and neurosurgeons to perform the procedure in 19 hospitals around six developing countries and on two continents WORLD NEUROSURGERY, DOI: /j.wneu

4 Table 1. Hospitals and Sites Served by One Neuroendoscope Single Mobile Unit Between August 2006-November 2009 Include the Following: KENYATTA NATIONAL HOSPITAL NAIROBI KENYA 80 AGA KHAN UNIV HOSPITAL NAIROBI KENYA 6 GERTRUDE CHILDREN s HOSPITAL NAIROBI KENYA 6 MOI TEACHING HOSPITAL ELDORE KENYA 5 COAST PROV GENERAL HOSPITAL MOMBASA KENYA 6 MEWA MISSION HOSPITAL MOMBASA KENYA 5 AGA KHAN HOSPITAL MOMBASA KENYA 4 AGA KHAN HOSPITAL KISUMU KENYA 2 KIJABE MISSION HOSPITAL RIFT VALLE KENYA 6 MULAGO MEDICAL COMPLEX KAMPALA UGANDA 5 MUHIMBILI INSTITUTE DAR-ES-SALAAM TANZANIA 30 MNAZI MOJA HOSPITAL ZANZIBAR TANZANIA 4 BLACK LION HOSPITAL ADDIS-ABABA ETHIOPIA 3 BETHEL TEACHING HOSPITAL ADDIS-ABABA ETHIOPIA 3 MYUNSUNG CHRISTIAN MISSION ADDIS- ABABA ETHIOPIA 4 KIGALI UNIVERSITY TEACHING HOSPITAL KIGALI RWANDA 8 MNAZI MOJA HOSPITAL ZANZIBAR TANZANIA 4 HOSPITAL DEL NIÑO LIMA PERU 1 HOSPITAL DANIEL CARRION LIMA PERU 5 TOTAL 187 cases program designed by the NED Foundation, enabled East African surgeons to understand more clearly the critical anatomy associated with hydrocephalus. This resulted in more substantial surgical success and subsequently provided a new step in the neurosurgical development of this region. The NED philosophy is that the acquisition of equipment and supplies should go hand in hand with on-site training, as this ensures that good results are attainable at each location. The concept that mobile equipment and well-trained and versatile neurosurgeons brought together by practical and theoretical training is a pragmatic way to demonstrate that even without sophisticated materials, neurosurgery can be performed successfully. In addition, neuroendoscopy workshops and mobile endoscopy can change, step by step, the impression that neurosurgery is too narrow a specialty and, therefore, irrelevant in developing countries. General surgeons and others who have had to cope with neurosurgical problems with little training and no equipment have become convinced that neurosurgery can be practiced everywhere using whatever means available and that its introduction in any hospital boosts the overall level of care. The addition of neurosurgery often marks a new step in health care in developing countries and leads to improvements in other specialities: surgery, radiology, intensive care, pediatric, nurse training, etc. After just 3 years, visiting 19 hospitals, six countries, and two continents and organizing eight neuroendoscopy workshops, NED has convincingly shown that neurosurgery can act as the lead speciality with a dramatic multiplier effect in the development of many other specialties in developing countries. It is astonishing and also encouraging how much international interest the efforts of the NED foundation has gained in the last years. Now two regions, East Africa and South America, with huge neurosurgical needs are involved. From our point of view, neuroendoscopy is not only a priority surgical tool for East Africa, but it also represents a medical philosophy that promotes the importance of surgical art and science in developing areas and helps in the development of a surgical speciality: neurosurgery. It focuses attention on the neurosurgical conditions in this region and leads to improved relationship between neurosurgeons in Africa. It helps convince medical students, general residents, and nurses that neurosurgery can be possible in this region. During our project, we have noted that, in East Africa, infection is the most common cause of hydrocephalus, followed by non postinfections, and myelomeningocele. The same is likely to be the case in other developing countries (9, 10). Definitive treatment of hydrocephalus, while avoiding shunting, is a desirable mode of treatment, provided it could be achieved without increasing the management morbidity and mortality. NEV has shown to have the potential for avoiding shunt dependency in the majority of children, with lower morbidity and mortality (3, 9). With the high burden of disease in developing regions, such as Sub-Saharan Africa, as well as the recognized dangers posed by WORLD NEUROSURGERY 73 [4]: , APRIL

shunt dependency, the cost of purchasing the shunt (as well as subsequent shunts, external drains, reservoirs, sterile collection bags, repeated CSF microbiology studies, etc.

5 shunt dependency, the cost of purchasing the shunt (as well as subsequent shunts, external drains, reservoirs, sterile collection bags, repeated CSF microbiology studies, etc., in the event of shunt infection and failure) and the lifelong potential for shunt dysfunction, the wider use of NEV as the primary option for treatment has significant merit. On the other hand, the inadequate numbers of neurosurgical practitioners and their total absence in the rural areas of developing countries pose challenges that require a novel approach. It is not feasible to offer expensive neuroendoscopy equipment at rural sites, as this does not justify such large investment vis-à-vis the overall clinical workload at rural hospitals. However, the population of hydrocephalus patients presenting at these rural sites cannot, equally, be denied appropriate care that is currently possible through NEV endoscope mobile procedures. The merits of performing this current best-practice procedure in a convenient, cost-effective, and safe way as an outreach, mobile service for a condition that mainly affects children in rural populations is highlighted during this project. CONCLUSION The portable, neuroendoscopy outreach model developed in Kenya (and now being promoted across the broader East African region) is one that can achieve the objectives of NEV treatment with safety, convenience, and in a cost-effective manner. Its main requisites are the recognition that NEV is a preferred option for management of obstructive hydrocephalus, the availability of equipment that is readily portable, and a dedicated team willing to volunteer time and skill to not only provide care but also organize a structured approach to train neurosurgical specialists. REFERENCES 1. Boulton M, Flessner M, Armstrong D, Hay J, Johnston M: Determination of volumetric cerebrospinal fluid absorption into extracranial lymphatics in sheep. Am J Physiol 274 (1 Pt 2):R88-96, Cinalli G: Endoscopic Third Ventriculostomy in Pediatric Hydrocephalus. Italia, Milano: Springer-Verlag, Hopf NJ, Grunert P, Fries G, Resch KD, Perneczky A: Endoscopic third ventriculostomy: outcome analysis of 100 consecutive procedures. Neurosurgery 44(4): ; discussion , Jarvis JF: The treatment of hydrocephalus by third ventriculostomy. East Afr Med J 26:204, Noorani S: Complications of VP shunting seen at the Kenyatta National Hospital, Kenya. M.Med. (Surgery) Dissertation, University of Nairobi, Oi S: Classification and definition of hydrocephalus origin, controversy and assignment of the terminology. In: Cinalli G, Sainte-Rose C, Maixner W, eds. Pediatric Hydrocephalus. Chapter , Oi S, Samii A, Samii M: Frameless free-hand maneuver of a handy small diameter rigid-rod neuroendoscope with working channel under high resolution imaging technical note. J Neurosurg 102(1 Suppl.): , Oyewole A, Adeloye A, Adeyokunnu AA: Psychosocial and cultural factors associated with the management of spina bifida cystica in Nigeria. Dev Med Child Neural 27: , Warf BC: Neuroendoscopic management of hydrocephalus in African children. Results from 1000 ventriculoscopic procedures. Childs Nervous Syst 21:507, Warf BC: Hydrocephalus in Uganda: predominance of infectious origin and primary management with endoscopic third ventriculostomy. J Neurosurg (Pediatric 1) 102:1-15, received 27 December 2009; accepted 5 February 2010 Citation: World Neurosurg. (2010) 73, 4: DOI: /j.wneu Journal homepage: Available online: /$ - see front matter 2010 Elsevier Inc. All rights reserved WORLD NEUROSURGERY, DOI: /j.wneu

Annual Tanzania Neurosurgery Project Summary: 2013

Annual Tanzania Neurosurgery Project Summary: 2013 Neurosurgical training is almost non-existent in developing countries, particularly those in East Africa. In Tanzania, there is an estimated 1 neurosurgeon