A Decade of Australian Reconstructive Burn Surgery in Nepal 2004-2014

Nepal is a nation with an emerging economy that traditionally has faced challenges related to terrain, weather, political instability, natural disasters and poverty. It has a very high rate of burn injury. Due to the above factors, adequate primary treatment of burns is frequently rudimentary, resulting in a significant burden of human misery in the form of chronic debilitating burn-scar contractures. For several decades, international health teams have played a significant role in relieving the burden of disease and deformity, such as cleft lip and palate and burn-scar reconstruction. The current article summarises the experience of an Australian surgical team assembled to manage problems of burn-scar contracture in Nepal over the ten year period 2004-2014. The article covers Introduction, Patient Assessment Protocol, Patient statistics, Conditions treated, Procedures utilised with results, Complications, Discussion and Conclusion.


Introduction
Australasian plastic surgery has a history of involvement with international pro bono surgical programs to assist developing nations in the management of congenital and acquired conditions. Cleft lip and palate surgery has been the focus of many of these. Cooking is usually done with kerosene or gas bottle stoves, often on the floor of the communal living area. Children run freely in these areas. Accidents related to cooking are common, with toppled over boiling water pots, hot oil and house fires being the cause of a very high rate of burn injury. Immediate medical treatment is rare and both mortality and long-term morbidity from burns is much higher than in developed countries. Many communities only have access to basic medical facilities by walking several days, even before they reach a road. Peripheral hospitals able to treat burns are few. The clinic was set up as a day surgery/short stay  This was not to last, but the next few years were extremely unstable, with frequent riots that finally

Patient assessment
Assessment of suitability for surgery gradually evolved over the ten years of the program. Initially we relied on field assessments undertaken through the year by a lay field worker from ADRA Nepal. Because the field assessment process was somewhat unreliable, after a few years the field worker was encouraged to take digital photographs of each potential patient's deformity as well as their name and contact details. Photos were then emailed to the principal surgeon (the author) back in Australia, who would then assess the likelihood of success from surgery. This greatly refined the selection process so that non-starters would not travel large distances, only to be rejected as unsuitable. It also allowed more efficient planning of theatre time and length of patient stay in advance of the team's arrival.
It was not unusual to have more than 100 potential patients arrive at SMH for assessment and many had

Conditions treated
Although the focus of the program was the surgical relief of burn-scar contractures, a small number of patients were treated for syndactyly or polydactyly and rarely for other congenital deformities such as epispadias. Several patients were referred to other centres with conditions not treatable by our team.
As of 2014, the total number of patients treated was 378, with an (estimated) 100 or more further separate procedures under anaesthesia undertaken as Table 1 shows.
A complete breakdown of all procedures for all years is not available from records kept. However, Table 2 shows a breakdown of patient diagnosis and procedure type for the years 2007-2011.
A snapshot of the types of problems treated over a three-day period from the 2012 program is shown in Table 3.

Procedures utilised with results
As can be seen in Table 2 4, 5, 6). The first was a muscle-reduced flap, and the last two were true island perforator flaps. The first LD flap appears in Table 2. The other two were performed after 2011, so do not appear in Table 2.
Microsurgery was not available due to equipment limitations, so some out-dated procedures had to be resurrected for certain situations. Several cross-   Of 'major' complications, there was one loss of a digit due to circulatory inadequacy after extensive scar release. There was one complete loss of a major flap, a reverse radial forearm flap where venous anastomosis was not performed. No data is available for wound infections, but anecdotal experience revealed a remarkably low rate of serious wound infection. Single-dose prophylactic antibiotics (usually IV cephalosporin) were used extensively. Total graft loss was rare, but partial graft loss more common. This was partly due to the almost exclusive use of full thickness grafts.
Minor flap loss, such as the tips of z-plasties, was relatively common, as expected in patients where the skin had been substantially damaged by scarring. Tip loss occurred in several two-stage flaps, but in only one did that cause failure of the intended procedure, due to separation of the flap from its inset.   Note has been made of the female predominance among our patients. One explanation of this could be the working role of women in Nepali society.
Apart from the fact that they are invariably the cook of the household, and exposed to the risk of hot oil and boiling water, females are often the hardest workers. Gupta et al 5 found in a population-based study that the highest incidence was in the third decade and the commonest causes were scalds.
Our peak numbers were in the second decade, but we confirm Gupta's findings that scalding is the most common causative agent. Young girls are encouraged to learn cooking skills while brothers are outside kicking a ball or playing cricket. Women in this agrarian society dig fields, harvest crops and carry huge loads (hence the high incidence of uterine prolapse). Open fires to burn refuse are common. Spousal abuse is at least as common as in Australia, largely due to alcohol abuse, and can take severe forms, such as acid throwing. Criminal activity also contributes to burn injuries. 6 A number of our patients returned for further surgery a year or more after their first procedure.

Acknowledgements
The author wishes to acknowledge Dr Charles Sharpe OAM FRACS and John Sanburg RN who assisted in the preparation of this article.

Disclosure
The author has no conflicts of interest to disclose.

Funding
The author received no financial support for the research, authorship, and/or publication of this article.