PEDIATRICS
clinical article J Neurosurg Pediatr 15:552–559, 2015
Neurosurgery Education and Development program to treat hydrocephalus and to develop neurosurgery in Africa using mobile neuroendoscopic training José Piquer, MD, PhD,1,2 Mubashir Mahmood Qureshi, MD, FRCSEd(SN),3,4 Paul H. Young, MD,5 and Robert J. Dempsey, MD6 1 Neurosurgery Education and Development Foundation, Valencia, Spain; 2Neurosurgical Unit, Hospital Universitario de la Ribera, Alzira (Valencia), Spain; 3Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Nairobi, Kenya; 4Division of Neurosurgery, Kenyatta National Hospital, Nairobi, Kenya; 5Section of Neurosurgery, Department of Surgery, St. Louis University, St. Louis, Missouri; and 6The Foundation for International Education in Neurological Surgery, Madison, Wisconsin
Object A shortage of neurosurgeons and a lack of knowledge of neuroendoscopic management of hydrocephalus limits modern care in sub-Saharan Africa. Hence, a mobile teaching project for endoscopic third ventriculostomy (ETV) procedures and a subsequent program to develop neurosurgery as a permanent specialty in Kenya and Zanzibar were created and sponsored by the Neurosurgery Education and Development (NED) Foundation and the Foundation for International Education in Neurological Surgery. The objective of this work was to evaluate the results of surgical training and medical care in both projects from 2006 to 2013. Methods Two portable neuroendoscopy systems were purchased and a total of 38 ETV workshops were organized in 21 hospitals in 7 different countries. Additionally, 49 medical expeditions were dispatched to the Coast General Hospital in Mombasa, Kenya, and to the Mnazi Moja Hospital in Zanzibar. Results From the first project, a total of 376 infants with hydrocephalus received surgery. Six-month follow-up was achieved in 22%. In those who received follow-up, ETV efficacy was 51%. The best success rates were achieved with patients 1 year of age or older with aqueductal stenosis (73%). The main causes of hydrocephalus were infection (56%) and spina bifida (23%). The mobile education program interacted with 72 local surgeons and 122 nurses who were trained in ETV procedures. The second project involved 49 volunteer neurosurgeons who performed a total of 360 nonhydrocephalus neurosurgical operations since 2009. Furthermore, an agreement with the local government was signed to create the Mnazi Mmoja NED Institute in Zanzibar. Conclusions Mobile endoscopic treatment of hydrocephalus in East Africa results in reasonable success rates and has also led to major developments in medicine, particularly in the development of neurosurgery specialty care sites. http://thejns.org/doi/abs/10.3171/2014.10.PEDS14318
Key Words Africa; Foundation for International Education in Neurological Surgery; hydrocephalus; Neurosurgery Education and Development Foundation; mobile neuroendoscopy; endoscopic third ventriculostomy
H
ydrocephalus in sub-Saharan Africa occurs mainly in infants and is vastly undertreated. Hydrocephalus is frequently associated with infection, and estimates suggest that 100,000 newborns26 will develop the illness during their first year.17–19 The result is a regional
health crisis with a devastating rate of death and permanent disability. The management of hydrocephalus in developing countries is challenging due to lack of resources and trained staff. Europe has roughly 1 neurosurgeon per 100,000 inhabitants, while in this region of Africa 1 spe-
Abbreviations ETV = endoscopic third ventriculostomy; FIENS = Foundation for International Education in Neurological Surgery; NED = Neurosurgery Education and Development. submitted June 25, 2014. accepted October 17, 2014. include when citing Published online March 6, 2015; DOI: 10.3171/2014.10.PEDS14318. Disclosure Dr. Piquer belongs to the governing board of the NED Foundation. 552
J Neurosurg Pediatr Volume 15 • June 2015
©AANS, 2015
Mobile neuroendoscopic training in East Africa
cialist cares for more than 7 million people on average. Estimates indicate that less than 5% of children with hydrocephalus in Africa receive standard shunt surgery each year; however, due to multiple factors, including infection of permanent implants, the failure rate of shunt surgery performed on the children who actually receive it ranges from 25% to 50%.14,18,19 Placement of a ventriculoperitoneal shunt creates lifetime dependency. In addition to the need for periodic monitoring, this surgery presents numerous complications such as infections or mechanical malfunctions, and local doctors are often not qualified to find a solution.1,13,20 More importantly, widespread shunt surgery is presently impractical in Africa due to financial, social, and sanitary conditions, adding to the economic burden for families, and follow-up and re-evaluation of patients is often impossible if problems arise. An alternative, and minimally invasive, treatment is endoscopic third ventriculostomy (ETV).5,8,11 In ETV, the floor of the third ventricle is perforated, creating a natural bypass through which CSF drains toward the subarachnoid spaces. In selected patients, ETV is the safer option in a limited context such as sub-Saharan Africa.17–19,25 Innovative studies by Warf and others have shown that ETV can improve hydrocephalus in more than 70% of cases,28 with a low rate of complications (approximately 5%) and a normalizing of CSF dynamics.2 A mobile neuroendoscopy training program was developed in 2006 by the Neurosurgery Education and Development (NED) Foundation and the Foundation for International Education in Neurological Surgery (FIENS). The NED Foundation is dedicated to providing neurosurgical education in East Africa, and FIENS to the development of neurosurgical training and service in developing countries.6 This program was aimed at training local neurosurgeons and nurses in different hospitals and countries in sub-Saharan Africa to perform ETV with the aid of a mobile system. This system partly compensates for the shortage of qualified personnel as it can be used by a single local surgeon who can cover a large region including several hospitals, and also reach provincial hospitals in distant rural areas. The objective of this report is to describe the results of this program between 2006 and 2013, together with the unexpected outcome of multinational contact between neurosurgeons, and the launch of a subsequent project to develop specialized neurosurgery centers in this region of Africa.
regional contacts needed for ongoing educational programs. The neuroendoscopic device consists of a display unit with a camera and a light source manufactured to be conveniently transported in a single suitcase (Telepack, Karl Storz). It includes a rigid-rod neuroendoscope that is equally versatile and easy to use, the Oi Handy-Pro, with a 0° autoclavable Hopkins II telescope.16 The system can be used with 1 hand, thus allowing the surgeon to safely perform the endoscopic fenestration without assistance (Fig. 1). Educational Resources Since August 2006, 87 NED medical missions have been organized. These missions included 38 ETV training experiences in the form of conferences, seminars, handson courses, and supervised surgeries in hospitals from East, Central, and South Africa. Hydrocephalus Patient Characteristics Patients treated with this mobile equipment were under the age of 18, with clinical symptoms of hypertensive hydrocephalus confirmed through ultrasonography, and CT when available. ETV was performed through a bur hole or frontal fontanel. Fenestration of the floor of the third ventricle was achieved using a conventional technique and without choroid plexus cauterization, because a suitable bipolar or monopolar coagulator is not available in most hospitals. Patient follow-up was very complex due to the peculiarities of this interhospital international project within the context of extreme poverty. The intervention was considered effective when no subsequent hydrocephalus procedure was necessary within 6 months after ETV.
Methods
Between 2006 and 2013, a medical team composed of 3 neurosurgeons (M.M.Q., P.H.Y., and J.P.) developed an educational and health care project aimed at establishing neuroendoscopy as an initial treatment for infant hydrocephalus in various sub-Saharan countries. This project involved the acquisition of portable neuroendoscopic equipment and the implementation of an educational program to train local staff. By teaching in 21 hospitals and in 7 countries, this team hoped to rapidly achieve familiarity with this methodology, and also establish the
Fig. 1. A mobile compact neuroendoscopy system. The equipment incorporates a processing unit combined with a camera and light source. The Oi Handy-Pro, Hopkins II endoscope enables neuroendoscopy to be performed by a single neurosurgeon. Figure is available in color online only. J Neurosurg Pediatr Volume 15 • June 2015
553
J. Piquer et al.
Results
Surgical Outcomes Over a period of 7 years, 38 ETV mobile endoscopic workshops were held in 21 different hospitals, during which 376 children with hydrocephalus received surgery using only 2 mobile devices. Most of the interventions were performed in regional hospitals in rural areas with poor health infrastructures and lack of neurosurgical care services (Table 1). Six-month follow-up was completed in only 84 cases (22%) due to both the mobile nature of the
training and the difficulty of travel for patients and families. Patients with complete follow-up were classified according to age and status of the aqueduct of Sylvius (Table 2). Most of these cases presented with a history of infection (56%), followed by hydrocephalus related to spina bifida (23%). Approximately one-fifth of the patients (21%) had noninfectious hydrocephalus of other origin. The efficacy of ETV in patients with complete followup was 51%, which correlated with age, status of the fourth ventricle, and clinical history (Table 3). The group with
TABLE 1. Endoscopic third ventriculostomy workshops held in East Africa by NED Foundation teams from 2006 to 2013 Hospital Kenyatta Hospital Nyeri Provincial Hospital Aga Khan Hospital Aga Khan Hospital Aga Khan University Hospital Coast Provincial General Hospital Kenyatta Hospital Kijabe Mission Hospital Muhimbili Orthopaedic Institute Bethel Teaching General Hospital Black Lion Hospital Kenyatta Hospital Kigali National Hospital Mnazi Mmoja Hospital Moi Teaching and Referral Hospital Muhimbili Orthopaedic Institute Mulago Hospital Complex Myunsung Christian Mission Kenyatta Hospital Kigali National Hospital Mnazi Mmoja Hospital Gertrude’s Garden Children’s Hospital Kenyatta Hospital Mewa Hospital Mnazi Mmoja Hospital Neurospine Center Police Hospital Coast Provincial General Hospital Kenyatta Hospital Mnazi Mmoja Hospital Muhimbili Orthopaedic Institute Bugando Teaching Hospital Coast Provincial General Hospital Mnazi Mmoja Hospital Bugando Teaching Hospital Harare Central Hospital Mnazi Mmoja Hospital Nyeri Provincial Hospital Total 554
J Neurosurg Pediatr Volume 15 • June 2015
Year
City
Country
No. of ETVs Performed
2006 2006 2007 2007 2007 2007 2007 2007 2007 2008 2008 2008 2008 2008 2008 2008 2008 2008 2009 2009 2009 2010 2010 2010 2010 2010 2010 2011 2011 2011 2011 2012 2012 2012 2013 2013 2013 2013
Nairobi Nyeri Kisumu Mombasa Nairobi Mombasa Nairobi Rift Valley Dar es Salaam Addis Ababa Addis Ababa Nairobi Kigali Zanzibar Eldoret Dar es Salaam Kampala Addis Ababa Nairobi Kigali Zanzibar Nairobi Nairobi Mombasa Zanzibar Jartum Mandani Mombasa Nairobi Zanzibar Dar es Salaam Mwanza Mombasa Zanzibar Mwanza Harare Zanzibar Nyeri
Kenya Kenya Kenya Kenya Kenya Kenya Kenya Kenya Tanzania Ethiopia Ethiopia Kenya Rwanda Tanzania Kenya Tanzania Uganda Ethiopia Kenya Rwanda Tanzania Kenya Kenya Kenya Tanzania Sudan Sudan Kenya Kenya Tanzania Tanzania Tanzania Kenya Tanzania Tanzania Zimbabwe Tanzania Kenya
8 1 2 4 6 6 16 6 6 3 3 24 2 4 5 30 5 4 36 8 6 6 14 5 24 5 4 16 1 13 2 6 14 26 7 11 33 4 376
Mobile neuroendoscopic training in East Africa
TABLE 2. Patient classification according to age and state of the aqueduct of Sylvius for those who completed the 6-month follow-up evaluation Type
Age (yrs)
Aqueduct of Sylvius
No. of Cases
A B C D
clinical article J Neurosurg Pediatr 15:552–559, 2015
Neurosurgery Education and Development program to treat hydrocephalus and to develop neurosurgery in Africa using mobile neuroendoscopic training José Piquer, MD, PhD,1,2 Mubashir Mahmood Qureshi, MD, FRCSEd(SN),3,4 Paul H. Young, MD,5 and Robert J. Dempsey, MD6 1 Neurosurgery Education and Development Foundation, Valencia, Spain; 2Neurosurgical Unit, Hospital Universitario de la Ribera, Alzira (Valencia), Spain; 3Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Nairobi, Kenya; 4Division of Neurosurgery, Kenyatta National Hospital, Nairobi, Kenya; 5Section of Neurosurgery, Department of Surgery, St. Louis University, St. Louis, Missouri; and 6The Foundation for International Education in Neurological Surgery, Madison, Wisconsin
Object A shortage of neurosurgeons and a lack of knowledge of neuroendoscopic management of hydrocephalus limits modern care in sub-Saharan Africa. Hence, a mobile teaching project for endoscopic third ventriculostomy (ETV) procedures and a subsequent program to develop neurosurgery as a permanent specialty in Kenya and Zanzibar were created and sponsored by the Neurosurgery Education and Development (NED) Foundation and the Foundation for International Education in Neurological Surgery. The objective of this work was to evaluate the results of surgical training and medical care in both projects from 2006 to 2013. Methods Two portable neuroendoscopy systems were purchased and a total of 38 ETV workshops were organized in 21 hospitals in 7 different countries. Additionally, 49 medical expeditions were dispatched to the Coast General Hospital in Mombasa, Kenya, and to the Mnazi Moja Hospital in Zanzibar. Results From the first project, a total of 376 infants with hydrocephalus received surgery. Six-month follow-up was achieved in 22%. In those who received follow-up, ETV efficacy was 51%. The best success rates were achieved with patients 1 year of age or older with aqueductal stenosis (73%). The main causes of hydrocephalus were infection (56%) and spina bifida (23%). The mobile education program interacted with 72 local surgeons and 122 nurses who were trained in ETV procedures. The second project involved 49 volunteer neurosurgeons who performed a total of 360 nonhydrocephalus neurosurgical operations since 2009. Furthermore, an agreement with the local government was signed to create the Mnazi Mmoja NED Institute in Zanzibar. Conclusions Mobile endoscopic treatment of hydrocephalus in East Africa results in reasonable success rates and has also led to major developments in medicine, particularly in the development of neurosurgery specialty care sites. http://thejns.org/doi/abs/10.3171/2014.10.PEDS14318
Key Words Africa; Foundation for International Education in Neurological Surgery; hydrocephalus; Neurosurgery Education and Development Foundation; mobile neuroendoscopy; endoscopic third ventriculostomy
H
ydrocephalus in sub-Saharan Africa occurs mainly in infants and is vastly undertreated. Hydrocephalus is frequently associated with infection, and estimates suggest that 100,000 newborns26 will develop the illness during their first year.17–19 The result is a regional
health crisis with a devastating rate of death and permanent disability. The management of hydrocephalus in developing countries is challenging due to lack of resources and trained staff. Europe has roughly 1 neurosurgeon per 100,000 inhabitants, while in this region of Africa 1 spe-
Abbreviations ETV = endoscopic third ventriculostomy; FIENS = Foundation for International Education in Neurological Surgery; NED = Neurosurgery Education and Development. submitted June 25, 2014. accepted October 17, 2014. include when citing Published online March 6, 2015; DOI: 10.3171/2014.10.PEDS14318. Disclosure Dr. Piquer belongs to the governing board of the NED Foundation. 552
J Neurosurg Pediatr Volume 15 • June 2015
©AANS, 2015
Mobile neuroendoscopic training in East Africa
cialist cares for more than 7 million people on average. Estimates indicate that less than 5% of children with hydrocephalus in Africa receive standard shunt surgery each year; however, due to multiple factors, including infection of permanent implants, the failure rate of shunt surgery performed on the children who actually receive it ranges from 25% to 50%.14,18,19 Placement of a ventriculoperitoneal shunt creates lifetime dependency. In addition to the need for periodic monitoring, this surgery presents numerous complications such as infections or mechanical malfunctions, and local doctors are often not qualified to find a solution.1,13,20 More importantly, widespread shunt surgery is presently impractical in Africa due to financial, social, and sanitary conditions, adding to the economic burden for families, and follow-up and re-evaluation of patients is often impossible if problems arise. An alternative, and minimally invasive, treatment is endoscopic third ventriculostomy (ETV).5,8,11 In ETV, the floor of the third ventricle is perforated, creating a natural bypass through which CSF drains toward the subarachnoid spaces. In selected patients, ETV is the safer option in a limited context such as sub-Saharan Africa.17–19,25 Innovative studies by Warf and others have shown that ETV can improve hydrocephalus in more than 70% of cases,28 with a low rate of complications (approximately 5%) and a normalizing of CSF dynamics.2 A mobile neuroendoscopy training program was developed in 2006 by the Neurosurgery Education and Development (NED) Foundation and the Foundation for International Education in Neurological Surgery (FIENS). The NED Foundation is dedicated to providing neurosurgical education in East Africa, and FIENS to the development of neurosurgical training and service in developing countries.6 This program was aimed at training local neurosurgeons and nurses in different hospitals and countries in sub-Saharan Africa to perform ETV with the aid of a mobile system. This system partly compensates for the shortage of qualified personnel as it can be used by a single local surgeon who can cover a large region including several hospitals, and also reach provincial hospitals in distant rural areas. The objective of this report is to describe the results of this program between 2006 and 2013, together with the unexpected outcome of multinational contact between neurosurgeons, and the launch of a subsequent project to develop specialized neurosurgery centers in this region of Africa.
regional contacts needed for ongoing educational programs. The neuroendoscopic device consists of a display unit with a camera and a light source manufactured to be conveniently transported in a single suitcase (Telepack, Karl Storz). It includes a rigid-rod neuroendoscope that is equally versatile and easy to use, the Oi Handy-Pro, with a 0° autoclavable Hopkins II telescope.16 The system can be used with 1 hand, thus allowing the surgeon to safely perform the endoscopic fenestration without assistance (Fig. 1). Educational Resources Since August 2006, 87 NED medical missions have been organized. These missions included 38 ETV training experiences in the form of conferences, seminars, handson courses, and supervised surgeries in hospitals from East, Central, and South Africa. Hydrocephalus Patient Characteristics Patients treated with this mobile equipment were under the age of 18, with clinical symptoms of hypertensive hydrocephalus confirmed through ultrasonography, and CT when available. ETV was performed through a bur hole or frontal fontanel. Fenestration of the floor of the third ventricle was achieved using a conventional technique and without choroid plexus cauterization, because a suitable bipolar or monopolar coagulator is not available in most hospitals. Patient follow-up was very complex due to the peculiarities of this interhospital international project within the context of extreme poverty. The intervention was considered effective when no subsequent hydrocephalus procedure was necessary within 6 months after ETV.
Methods
Between 2006 and 2013, a medical team composed of 3 neurosurgeons (M.M.Q., P.H.Y., and J.P.) developed an educational and health care project aimed at establishing neuroendoscopy as an initial treatment for infant hydrocephalus in various sub-Saharan countries. This project involved the acquisition of portable neuroendoscopic equipment and the implementation of an educational program to train local staff. By teaching in 21 hospitals and in 7 countries, this team hoped to rapidly achieve familiarity with this methodology, and also establish the
Fig. 1. A mobile compact neuroendoscopy system. The equipment incorporates a processing unit combined with a camera and light source. The Oi Handy-Pro, Hopkins II endoscope enables neuroendoscopy to be performed by a single neurosurgeon. Figure is available in color online only. J Neurosurg Pediatr Volume 15 • June 2015
553
J. Piquer et al.
Results
Surgical Outcomes Over a period of 7 years, 38 ETV mobile endoscopic workshops were held in 21 different hospitals, during which 376 children with hydrocephalus received surgery using only 2 mobile devices. Most of the interventions were performed in regional hospitals in rural areas with poor health infrastructures and lack of neurosurgical care services (Table 1). Six-month follow-up was completed in only 84 cases (22%) due to both the mobile nature of the
training and the difficulty of travel for patients and families. Patients with complete follow-up were classified according to age and status of the aqueduct of Sylvius (Table 2). Most of these cases presented with a history of infection (56%), followed by hydrocephalus related to spina bifida (23%). Approximately one-fifth of the patients (21%) had noninfectious hydrocephalus of other origin. The efficacy of ETV in patients with complete followup was 51%, which correlated with age, status of the fourth ventricle, and clinical history (Table 3). The group with
TABLE 1. Endoscopic third ventriculostomy workshops held in East Africa by NED Foundation teams from 2006 to 2013 Hospital Kenyatta Hospital Nyeri Provincial Hospital Aga Khan Hospital Aga Khan Hospital Aga Khan University Hospital Coast Provincial General Hospital Kenyatta Hospital Kijabe Mission Hospital Muhimbili Orthopaedic Institute Bethel Teaching General Hospital Black Lion Hospital Kenyatta Hospital Kigali National Hospital Mnazi Mmoja Hospital Moi Teaching and Referral Hospital Muhimbili Orthopaedic Institute Mulago Hospital Complex Myunsung Christian Mission Kenyatta Hospital Kigali National Hospital Mnazi Mmoja Hospital Gertrude’s Garden Children’s Hospital Kenyatta Hospital Mewa Hospital Mnazi Mmoja Hospital Neurospine Center Police Hospital Coast Provincial General Hospital Kenyatta Hospital Mnazi Mmoja Hospital Muhimbili Orthopaedic Institute Bugando Teaching Hospital Coast Provincial General Hospital Mnazi Mmoja Hospital Bugando Teaching Hospital Harare Central Hospital Mnazi Mmoja Hospital Nyeri Provincial Hospital Total 554
J Neurosurg Pediatr Volume 15 • June 2015
Year
City
Country
No. of ETVs Performed
2006 2006 2007 2007 2007 2007 2007 2007 2007 2008 2008 2008 2008 2008 2008 2008 2008 2008 2009 2009 2009 2010 2010 2010 2010 2010 2010 2011 2011 2011 2011 2012 2012 2012 2013 2013 2013 2013
Nairobi Nyeri Kisumu Mombasa Nairobi Mombasa Nairobi Rift Valley Dar es Salaam Addis Ababa Addis Ababa Nairobi Kigali Zanzibar Eldoret Dar es Salaam Kampala Addis Ababa Nairobi Kigali Zanzibar Nairobi Nairobi Mombasa Zanzibar Jartum Mandani Mombasa Nairobi Zanzibar Dar es Salaam Mwanza Mombasa Zanzibar Mwanza Harare Zanzibar Nyeri
Kenya Kenya Kenya Kenya Kenya Kenya Kenya Kenya Tanzania Ethiopia Ethiopia Kenya Rwanda Tanzania Kenya Tanzania Uganda Ethiopia Kenya Rwanda Tanzania Kenya Kenya Kenya Tanzania Sudan Sudan Kenya Kenya Tanzania Tanzania Tanzania Kenya Tanzania Tanzania Zimbabwe Tanzania Kenya
8 1 2 4 6 6 16 6 6 3 3 24 2 4 5 30 5 4 36 8 6 6 14 5 24 5 4 16 1 13 2 6 14 26 7 11 33 4 376
Mobile neuroendoscopic training in East Africa
TABLE 2. Patient classification according to age and state of the aqueduct of Sylvius for those who completed the 6-month follow-up evaluation Type
Age (yrs)
Aqueduct of Sylvius
No. of Cases
A B C D
