Background The 7th Airborne Forward Surgical Team (FST) has deployed to Chad in 2015 and 2016, in support of French military forces. Humanitarian surgical care is known to represent a significant part of the surgical activity in such missions, but to date limited data have been published on the subject.
Methods All surgical patients from a civilian host population treated by the FST during these missions have been prospectively included. Indications, operative outcomes and postoperative outcomes were evaluated.
Results During this period, the FST operated on 358 patients. Humanitarian surgical care represented 95% of the activity. Most patients (92.7%) were operated for elective surgery. Emergencies and infectious diseases represented, respectively, 7.3% and 9.1% of cases. The mean length of stay (LOS) was three days (2–4), and the median follow-up was 30 days (22–34). Mortality rate was 0.6% and morbidity was 5.6%. Parietal surgery had no significant complication and had shorter LOS (p<0.001). Emergent surgeries were more complicated (p<0.01) and required more reoperations (p<0.05). Surgical infectious cases had longer LOS (p<0.01).
Conclusions Humanitarian surgical care can be provided without compromising the primary mission of the medical forces. Close surveillance and follow-up allowed favourable outcomes with low morbidity and mortality rates. Humanitarian care is responsible for a considerable portion of the workload in such deployed surgical teams. Accounting for humanitarian care is essential in the planning and training for such future medical operations.
- humanitarian surgical care
- medical support to population
- forward surgical team
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Humanitarian surgical care can be provided without compromising the primary mission of the medical forces.
Close surveillance and follow-up allowed favourable outcomes with low morbidity and mortality rates.
Humanitarian care is responsible for a considerable portion of the workload in such deployed surgical teams.
Accounting for humanitarian care is essential in the planning and training for such future medical operations.
Humanitarian medical care improved the acceptance of French military forces by the local population.
Since 2014, French forces have deployed to Chad in support of the Barkhane operation to combat terrorism development in the Sahelo-Saharan strip, in collaboration with G5 countries. The French Military Health Service (FMHS) has deployed several medical structures to support this initiative. Since 1983, a medical facility has been present in the military base of Hadji Koseï, N’Djamena, Chad, and has been progressively developed and improved over the years. This is currently one of the main medical centres of French medical military facilities deployed in Sahel.1 Since the 1980s, medical support to the population (MSP) is one of the civil-militarian actions conducted by French forces to support in the development of the civilian infrastructure.2 The French military surgical support to population experience has previously been described in Ivory Coast and Afghanistan.3–5 However data on postoperative complications and short-term clinical outcomes are rarely reported. ‘La 7è Antenne Chirurgicale Parachutiste’, translated as the 7th Airborne Forward Surgical Team (FST), was deployed in 2015 and 2016 in N’Djamena. The first objective of this unit was to undertake surgery on French combatants and the second was to provide medical support to the local civilian population.
We have previously described the composition of the most commonly deployed type of FST.6 The Role 2 Medical Treatment Facility (MTF) deployed in N’Djamena constitutes the main support base of the medical network deployed on Barkhane theatre. It is jointly located with the Role 1 MTF. There are two operating rooms and two intensive care beds dedicated to the host population. The remaining in-hospital facilities for MSP were located in a separate building. There is one large consultation room for surgical evaluation and dressing, two 12-bed wards (one for male patients and the other for female patients) and one eight-bed ward for children in this facility dedicated to host population care. The 12-member basic FST is reinforced with an emergency doctor, two other critical care nurses, a laboratory technician, a radiographer and three more emergency medical technicians. The medical staff included Chadian personnel working as three operating room nurses, six ward nurses and one laboratory technician. These Chadian personnel were homogeneously integrated and effectively participated in the night watch of the French medical military deployment.
Humanitarian surgical care provided by the FST in N’Djamena involves the whole surgical management including postoperative dressing and follow-up. Surgeons performed external surgical evaluations twice a week each. French and Chadian nurses provided postoperative care every day and the frequency of dressing was adapted for each case. Dressings were provided both in the immediate postoperative course during the hospital period and after discharge until healing completed. Surgical follow-up was systematically programmed on postoperative week 3 or 4. The aim of this study was to quantify the MSP provided by the 7th Airborne FST and describe its outcomes, particularly the postoperative morbidity and length of in-hospital stay.
Patients and methods
All civilian surgical patients treated by the 7th Airborne FST on Barkhane theatre from 1 February to 30 May 2015 and from 1 June to 30 September 2016 were included.
The primary endpoints were reason for admission, indications and type of surgery. The secondary endpoints comprised postoperative morbidity, short-term follow-up, reoperation rate and length of stay (LOS). Data were prospectively collected and included patient demographics, management type (elective surgery, emergency and infectious disease), indications, surgical specialty, postoperative interventions and length of hospital stay. Postoperative mortality included all deaths occurring before hospital discharge or during follow-up. Complications were classified according to the Clavien-Dindo classification.7 ‘In-hospital morbidity’ included all complications graded ≥2 occurring after surgery until discharge. ‘Overall morbidity’ included all complications graded ≥2 occurring after surgery until the end of follow-up. Follow-up was based on dressing and surgical wound examination and was prospectively achieved on outpatient routine postoperative visit with nurses and surgeons. The last date of follow-up was systematically recorded to calculate follow-up.
Statistical analysis was performed using Prism V.4.00 for Mac (GraphPad Software, San Diego, California, USA). Categorical variables are described in terms of frequency (percentages), and continuous data as median and 25–75 percentiles (IQR 25–75) or mean (±SD). Univariate analyses were conducted using a Student’s t-test for continuous variables, and a χ2 or Fisher’s exact test for categorical variables. All tests were two-sided. For all tests, statistical significance was defined as a p value ≤0.05.
Patients’ characteristics and circumstances of management
The characteristics of the patients are detailed in Table 1.
During these two periods, 703 civilian patients were surgically evaluated, leading to 385 procedures for MSP on 341 patients. Procedures performed on MSP represented 95% of the total surgical activity. Of the patients 80% were adults (n=270) and the majority were male (n=244, 71.5%). Twenty-five cases were emergencies, with five cases of penetrating injuries managed during FST deployment in remote areas.
Orthopaedic surgeons operated on 140 patients (41% of all patients) and performed 172 procedures (44.6%). Visceral surgeons (analogous to general surgeons) treated 201 patients (59%) and performed 213 procedures (55.4%). Soft tissue surgery (n=64) was divided between the two surgeons and represented 27% of orthopaedic surgeon activity (n=46) and 10% of visceral surgeon activity (n=21). Visceral and orthopaedic surgeons performed two vascular surgeries, both as joint operations.
Indications and management
The most common indications for orthopaedic surgery were closed fracture management (n=36, 30.5%), non-union (n=33, 28%) and osteosynthesis material ablation (n=18, 15.3%). Closed fractures were managed by internal fixation in 86% of cases (n=31), with a median delay of 30 days (15–60). Sixteen patients were operated for septic conditions, comprising five cases of septic non-union (4.2% of orthopaedic cases) and 11 cases of osteitis or arthritis (9.3%). Half of these cases were treated by amputation (n=8). Other indications for orthopaedic surgery were open fractures (n=3, 2.5%) and malunion (n=8, 6.8%). The remaining four cases (3.4%) were performed for neurological deficit treated by tendinous transfer, recurrent dislocation of the shoulder, acromioclavicular disjunction and clubfoot. Parietal cases included 102 patients (30.4%) who were operated for incisional or non-incisional hernias by raphy. Non-parietal general surgery cases (n=29, 55.2%) were divided between digestive diseases (four hepatobiliary, three gastrointestinal and two proctological diseases) and endocrine surgery with goitre treatment (n=28, 8.3%). Twenty gynaecological surgical operations were performed (5.9% of all operations), and included surgery to remove fibroids (n=13) and ovarian tumours (n=7). Soft tissue surgery (n=37, 11%) included soft tissue tumour resection (n=20), soft tissue infections (n=12) and burn surgery (n=5). For these latter cases, amputation was required in four cases (1.2%) and skin graft in 11 cases (3.2%). Six cases were performed to remove foreign bodies fibroscopically from the oesophagus or trachea. Urological surgery comprised treatment for hydrocoeles (n=9), testicular tumours (n=2), bladder stones (n=3), renal trauma grade IV treated by nephrectomy (n=1) and ureteral stent extraction (n=1).
Emergencies (n=25, 7.3%) were divided into non-traumatic cases (n=16, 4.7%) and traumatic cases (n=9, 2.5%), of which four injuries were caused by blunt trauma and five injuries were caused by penetrating trauma. These five patients were managed during the FST short-period deployment to a remote area. One patient had pelviperineal gunshot wound (GSW) with urethral and anal lesions. One patient had a GSW to the thigh, requiring soft tissue debridement, one in the knee with popliteal artery haemorrhage and one in the arm with ischaemic humeral artery injury. Arterial bypass with venous graft and fasciotomy was performed for these two last patients. The remaining patient was previously operated on in another institution and developed compartment syndrome requiring decompressive laparotomy.
Postoperative outcomes and follow-up
Postoperative morbidity is summarised in Table 2. Postoperative wound follow-up required 2694 nurse dressing visits. Three hundred and twenty-five patients (96.7%) were followed until wound healing. Two hundred and thirty-three patients (69.3%) were seen at surgeons’ postoperative control consultation on postoperative week 4. The median time of follow-up was 30 days (range 22–35).
The mortality rate until postoperative day 30 did not increase after discharge. Complications (grade ≥2) are described and reported in Table 2. Eight patients (2.3%) required reoperation during initial hospitalisation. Patients with complications had a significantly longer LOS (3.7±3.8 vs 13.1±17.2; p=0.03).
When compared with in-hospital morbidity, overall morbidity on postoperative day 30 increased from 3.8% (n=13) to 5.6% (n=19). Three patients required readmission (0.9%), with two requiring reoperation (0.6%). One patient had a grade 1 complication during hospital stay and 25 patients (7.3%) experienced grade 1 complication after hospital discharge. Twenty of these patients had superficial wound infection or disunion after hernia repair. All these patients were followed and treated by iterative dressing until healing.
Postoperative outcomes for emergencies, infectious diseases and for each type of surgery are reported in Tables 3 and 4. The rate of morbidity was significantly higher (p=0.008) and reoperation was more frequent (p=0.03) for emergent surgeries (cf Table 3). There was a trend towards an increased need for reoperation for patients operated for infectious diseases, but it did not reach statistical significance. The mean LOS was four days (±5.9). The mean LOS was significantly shorter for parietal surgery (p<0.001) and longer for soft tissue surgery (p<0.001) and infectious diseases (p=0.007).
This is the first detailed report of the scope and outcomes of humanitarian surgical care provided to a host population by a French military FST. The FMHS has a long history of MSP.1 3 8 This series, with 95% of MSP on global activity performed, illustrates the importance attached to this practice. However, there is always a potential conflict between the care provided during MSP and the requirement to treat military patients by the medical teams.9 To avoid this, MSP has to be integrated into global force actions and respect the priority given to the first mission.10 Our experience during these two missions illustrates the adaptation of MSP activity required by military action: only five civilian patients with penetrating injury were treated during deployment in a remote conflict area, and no civilian patients were treated for war injuries in N’Djamena. This adaptation of MSP is well known10 11 and has been previously described.3–5 In Afghanistan, most MSP patients were treated for war-related injuries4 and MSP aimed to respond to health situations related to crisis. In Ivory Coast, patients were essentially operated on for elective surgery3 and MSP aimed to contribute support to host nation. Surgeons deployed on these different theatres have to deal with the context and conflict course, and must continuously adapt their MSP activity.
MSP was a great part of surgical activity in Role 2 in N’Djamena and there was a specific provision of medications to the host population. However, supplies were more difficult to obtain and less regularly supplied when the team was deployed under canvas in remote areas. In these areas, airplane supplies were only available every two weeks and sometimes sandstorms made it impossible for the flights to be carried on. The surgical teams deployed in remote areas had to deal with inventory management and limited MSP, keeping in mind the possibility of having French wounded military soldiers.
Few studies on humanitarian care report short-term outcomes.5 12–16 Recently a large study including 25 African countries reported that patients operated in Africa were twice as likely to die after surgery (2.1%) when compared with the global average for postoperative deaths.17 Operative mortality in resource-limited settings reported by ‘Médecins Sans Frontières’ ranged from 0.2% to 1.9%,13 16 but postoperative mortality was not detailed. In paediatric humanitarian elective surgery, postoperative mortality reached 1.7%.12 Reports of surgical care provided in Afghanistan or in other combat zones mentioned higher mortality rates related to traumatic characteristics of cases.14 18 In civilian European practice, overall crude postoperative mortality rates reported for non-cardiac surgery were 4%, with wide variations between countries from 1.2% to 21.5%.19 The seven-day cohort study of outcomes following elective adult inpatient surgery in 27 countries reported a mortality rate of 0.5%.20 Our lower mortality rates (0.6% following global surgery and 0.3% following elective surgery) can be explained by the choice of simple surgeries with a predictable course, close in-hospital follow-up, and our younger and stronger population.
Expected surgical morbidity and LOS were critical endpoints. MSP treatment must not compromise the availability of the operating room, but in turn treatment of French military patients must not endanger a patient treated for MSP.9 To avoid this situation our team favoured simple and short surgeries with predictable short and simple postoperative course. Our policy was to evaluate patients with a clear-cut benefit to risk ratio. Most indications were reconstructive, short and effective surgeries for the ‘largest number’ of patients (eg, non-incisional hernias or closed fracture treatment). Parietal surgical procedures seemed to be the most appropriate type of surgery with no in-hospital or total major morbidity (Clavien-Dindo ≥2) and shorter LOS. This confirms previous reports of this type of surgery being performed in the humanitarian military context.3 9 21
Our series highlights the difficulties related to the management of emergent surgical cases and infectious diseases in the military context. Emergencies required significantly more postoperative care and resulted in higher reoperation rates. In 2017, Weeks et al,18 through a large retrospective series with more than 10 000 patients, reported significantly longer LOS, more procedures and more blood transfusions for patients operated for war-related procedures. The mortality rate was higher for these cases but was not significant. Assouto et al 22 described tropical practice of digestive surgery and reported higher mortality and morbidity rates (13% and 27%, respectively) after emergent abdominal surgery than after elective. Patients operated for infectious diseases required frequently longer LOS with repeated dressing and long antibiotherapies. Many reports have underlined the difficulties related to infectious diseases and surgical infections in such countries, requiring more numerous operations and more perioperative resources.23 In our opinion, infectious diseases have to be reasonably managed and in adequacy with therapeutic resources. Radical curative treatments (amputation, large debridement…) have to be more frequently considered in this context.
No significant difference was found in morbidity and mortality for younger compared with older patients. In a large retrospective study of ‘Médecins Sans Frontières’ with more than 19 000 procedures, Chu et al 13 reported a higher operative mortality rate for patients with American Society of Anesthesiologists (ASA) classifications 3–5. In our series, patients with ASA classification ≥3 were very rare for many reasons: (1) life expectancy is shorter in African population, (2) little information on medical history was available and (3) highly medical patients were not selected for elective non-critical surgery. Creamer et al 14 reported a higher mortality rate in MSP surgery for civilian Afghanistan children with 6.9% overall mortality. In this series, traumatic injuries represented 75% of all paediatric admissions. In ours, elective surgery was the main indication in paediatric cases.
Of the civilian patients 30% were female, which is very different from other similar reports in the literature. For example Woll and Brisson9 stated that in their patient population only 5% were female. In N’Djamena, our predilection towards male patients may have reflected selection bias related to disease categories we cared of. However, it is not clear if access to our facility was as easy for female as for male patients due to cultural behaviours.
The excellent compliance of Chadian patients to dressing follow-up and the exceptional assiduity to the one-month consultation were an interesting result of our studies. Despite the language barrier, long distance, and personal security and transport difficulties that patients can encounter in these countries, we found that patients made it to follow-up appointments, similar to that reported in similar studies.9 12 This high follow-up rate identified secondary complications for parietal surgery cases in particular. It convinced our team that the surgical MSP should plan follow-up as soon as patients leave the MTF. In a recent study on seven-day follow-up after elective surgery in 25 African countries, in-hospital postoperative surveillance was highlighted as a critical point in surgical patient management.17 Having nurses in the MTF from the host population facilitated, in particular, enhanced close postoperative surveillance. Moreover, it simplified communication with patients and helped the surgical team to understand local cultural idiosyncrasies and overcome the language barrier.9 Integration of the host population into the team for a duration of several years has led to the acceptance of the French medical military facility to the local Chadian population and is an excellent way to mentor and educate the host population on methods of medical care.24 Our team felt that treatment of the local population improved our clinical readiness and had a positive social and political impact on the local population. This improved acceptance of French military forces and enhanced their overall mission.6 9 25
We recognise that our review possesses several potential limitations. Our team managed few MSP emergencies during these missions, but it was an initial team choice to preserve operational capacities. Indications for elective surgery were also oriented towards surgeons’ expertise so that simple and effective surgeries were prioritised. For this reason, few patients were managed for infectious diseases. Finally, follow-up was shorter than ideal to enable evaluation of long-term outcomes. However this was balanced by the high follow-up rate, meaning that our conclusion on shorter term complications was likely more accurate than other comparable analyses.
To the best of our knowledge, our series is one of the first to comprehensively report short outcomes on MSP for a wide range of surgical activity. Adaptation of the surgical team for MSP practice appears fundamental to preserving the primary mission in supporting French military forces. The ability to identify expected complications and LOS according to each type of surgery enabled surgeons to identify the best surgery to perform on the local population.
Contributors YG contributed to designing the study, collecting and analysing the data, and writing the final manuscript. CB and CC contributed to collecting and analysing the data, and helped in the manuscript review. GP, ESdL, DC and GG helped in collecting the data. JB contributed to designing the study, analysing the data and did the critical revision. PB did the critical revision.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Ethics approval Permission from the Institutional Review Board (College of French Military Surgeons) was obtained prior to data review and analysis. In accordance with the Geneva Conventions and international humanitarian law, every patient referred to our facility who needed emergency care received treatment regardless of his origin or status.
Provenance and peer review Not commissioned; externally peer reviewed.
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