Ten-Year Cleft Surgery in Nepal: Achievements and Lessons Learned for Better Cleft Care Abroad
Creators: name: Roldan, J. Camilo
name: Pape, Hans-Dieter
name: Koch, Heribert
name: Koller, Michael
Publisher: name: Universität Regensburg
Year: 2016
Subjects: subject: 610 Medizin

description: Background: 
Cleft lip and palate surgery abroad is devoid of global consensus regarding standards of therapy, follow-up, and outcome. Cleft surgery in Nepal during a 10-year sustained program provided the opportunity to inform on the need for such standards.

Methods: 
Medical records were evaluated from the cleft clinic at Sushma Koirala Memorial Hospital, Sankhu, Kathmandu, Nepal, from 1997 to 2007. Four groups were identified for analysis: total cohort, total surgical cohort (TSC), primary program patients (PPP; patients had not been operated on before), and nonprimary program patients (non-PPP; patients operated on elsewhere before). Patient demographics, diagnostic, primary and secondary surgery (corrective surgery), and follow-up were evaluated.

Results: 
One thousand forty-five patients were eligible for surgery. Three hundred twenty-three of 1,045 patients (30.9%) did not seek treatment, although scheduled for surgery. One thousand two hundred one procedures were performed in 722 patients [TSC; 845 PPP (70.4%); 356 non-PPP (29.64%)]. Corrective procedures were performed in 257 of 1,201 [3.5% (30 of 845 procedures in 509 patients) PPP vs 63.7% (227 of 356 procedures in 213 patients) non-PPP]. One hundred six lips were completely reoperated on (1 PPP vs 105 non-PPP), and 42 palates underwent a total revision (5 PPP vs 37 non-PPP). The surgical outcome of the TSC group in terms of complication rate was similar to the one in developed countries.

Conclusions: 
The high rate of corrective surgery reveals the need for global regulatory mechanisms and the need for nongovernmental organizations to introduce strategies for delivering sustained cleft care until achieving full rehabilitation. The World Health Organization should establish standards for cleft care delivered in less developed countries.

The reported prevalence of orofacial clefts in large municipalities of India 1 and Nepal 2 corresponds to the average in the world, which is 1.2 of 1,000.3 Epidemiologically, the number of children born with a cleft condition is a major challenge in less developed countries because of the high population and high birth rate in these countries. It is estimated that almost 250,000 children are born with a cleft lip and/or palate in less developed countries every year; in developed countries, 17,000 children are born with a cleft every year.4

Cleft surgery abroad was ranked as the most important missionary activity in low- and middle-income countries in a review from 1987 to 2009.5 Since the late 60s, nongovernmental organizations (NGOs) started cleft surgery programs in developing countries 6–8; detailed information on the number of patients treated every year is available.9–11 But almost no data are published on follow-up and corrective surgery from overseas activities, independently of the organizational model. The Global Burden of Disease introduced by the World Health Organization (WHO) in 1990 aims to quantify global and regional effects of diseases, injuries, and risk factors on the health of the population. Cleft lip and cleft palate are considered as a noncommunicable disease.12 The caused disability ends with the primary surgery; consequently, the corrective surgery is not considered.10 This conceptual approach limits the evaluation of cleft programs in developing countries, which are mostly driven by NGOs. In fact, the major criticisms against NGOs delivering cleft care abroad is the poor or inexistent follow-up.13,14 The aim of this study was to analyze the evolution of a full-range cleft program at an institution lead by foreign cleft surgeons in Nepal over 10 years.