An Outreach Experience With Cleft Lip/Palate Surgery in selected Hospitals in Kenya
Authors: Wanjala N1, MMed and Khainga S 1,2, MMed,
1.Kenyatta National Hospital, Nairobi, Kenya
2. University of Nairobi
Correspondence: Dr. Nangole Wanjala, Kenyatta National Hospital.
To describe the presentation and surgical care of patients managed for cleft lips and palates during a surgical outreach program..
A five year retrospective chart study of the patients operated on between January 2005 to the 31st December 2009 in selected hospitals in Kenya.
Smile train-facilitated surgical outreach programs at the following hospi-tals: St Elizabeth Mission Hospital Mukumu, St Francis Mission Hospital, Mwiki, Embu Provincial General hospital , Isiolo District Hospital.and Alupe Subdistrict Hospital.
One hundred and sixty three patients with cleft lips and palates.
The male female ratio was 1.3 to 1. Left unilateral cleft lip was the most common malformation (34.6% of the patients) with modified Millards repair the most frequent surgical procedure. More than 30% of the patients operated on had attained their fifth birthday. There were eight complications for every 100 procedures. Palatal fistulae were the most common complications.
The overall pattern of deformity encountered and the morbidity profile correlate with other studies. There is need to intensify more outreach programs to capture younger patients and address the backlog of cleft cases in the community.
Cleft lips and palates are common congenital malfor-mations with variable prevalences. High prevalence rates have been quoted for native Americans, Orientals, Cau-casians and the blacks in that order (1,2). Both heredi-tary and environmental factors are thought to be impor-tant in the pathogenesis.
The ideal treatment of cleft lip and palate involves a multidisciplinary team approach, comprising plastic surgeons, maxillofacial surgeons, speech pathologists, otolaryngologists, among others (3,4) This treatment would also involve multiple stages of surgeries and revis-its commencing from neonatal life to early adulthood.
In the developing countries, this management approach is difficult if not impossible to craft. Compounding the problem of large disease burden are the twin challenges of few health personnel and poverty. Surgical outreaches remain a practical option to confront this problem.
The outreach programs mobilize skilled staff out of their usual work stations to go to ill-equipped and staffed ru-ral facilities. A good outreach program requires an effec-tive working relation between the visiting surgeons and the local hospital staffs. The hospital staff mobilize the patients as well as oversee the postoperative care once the outreach team leaves the site.The local team also en-sures proper documentation and follow up for the pa-tients
The authors have been involved in the “Smile Train” outreach program for the last five years. This paper de-scribes that experience in various facilities in Kenya.
Patients and Method
This study was a retrospective chart review of the records of patients operated on by the authors at the participat-ing hospitals. The outreach program was facilitated by Smile Train International, a non-governmental organi-zation with regional offices in Nairobi Kenya. The fol-lowing centers were included: St Elizabeth Mission Hos-pital Mukumu, St FrancisMission Hospital Mwiki,Embu Povincial Gen Hospital, Isiolo district Hospital and Al-upe Subdistrict Hospital.
All files for patients operated on for cleft lips/palates between January 2005 and 31st December 2009 were reviewed for demographics, types of defects, timing of surgery, procedures performed and complications encountered. Supplementary data was abstracted from the operating theatre registers and the Smile Train data base in Nairobi.
Cases with inadequate data were excluded from the study. Data were analyzed by the SPSS computer soft-ware for descriptive statistics.
Data on 163 patients out of a total of 186 patients oper-ated on during the study period were analyzed. Adequate information could not be retrieved for 23 patients and therefore were excluded. The male to female ratio for the patients was 1.3 to 1.The age range was 2.5 months to 28 years with a mean age of 4.8 years. The modal age range was 6-9 months. Fifty six patients (34.4 %) were older than 5 years at the time of surgery (table 1).
A total of 187 defects in 163 patients were recorded. Left unilateral cleft lip comprised 36.4 percent of the defects while bilateral cleft lips were 18.7 percent of the defects (table 2).
Modified Millard’s repair was used for all the unilateral cleft lips while the Manchester repair was the technique for the majority of bilateral cleft lips. Unipedicle mu-coperiosteal flaps were most commonly used surgical procedures for the cleft palate (table 3).
There were 14 complications following 177 procedures (Table 4). Half of the complications were palatal fistulae encountered in seven of 28 patients who underwent re-pairs for complete cleft palates.
The pattern of cleft deformities in this study is consistent with previous accounts.
Left unilateral cleft lip accounted for 36.4 percent, bilat-eral cleft lips 18.7% and right unilateral cleft lips 17.6% percent. Many studies have demonstrated left unilateral clefts to be more common than the right unilateral clefts (5-8). An inconsistent result is the lower prevalence (14%) of solitary cleft palates in our series compared to 30% in published series (6-7). Although a relatively lower turnout for patients with palatal defects as op-posed to patients with cleft lips could explain this dis-crepancy, more studies need to be done in this region to determine whether this is an isolated case or is a true reflection of the palatal defects in our community.
Cleft deformities in this study were found to be more common in males than females with a male female ratio
of 1.3 to 1. Wanjeri et al in Kenya(5), Masaki et al. in Japan(6), and Mossey et al. in Sweden(7) all demonstrated cleft deformities to be more common in the males with a ratio ranging from 1.2- 1.5 to 1. The reason for this remain unclear.
The median age group at the time of surgery was 6-9 months of age, accounting for 22% of the patients operated on. Only a small per-centage of the patients had their surgeries (8.3%) before 6 months of age, with only about 3 percent less than 3 month of age.
The optimal time to carry out cleft lip and palate surgery varies from centre to centre. In centres with good paediatric anaesthesia, surgery can be performed in early neonatal period. The rule of “ten” i.e, 10 weeks, 10 pounds, haemoglobin of ten and 10 months ,10 kilogram and a haemoglobin of 10 is a general guiding principle for the tim-ing of lip and palate surgery respectively. Early repair of cleft lip is advantageous to the parents and the child due to the psychoso-cial trauma attributed to this condition. Early repair of cleft palate allows for normal speech development (7). There seems to be no evidence that early palate surgery retards mid-face growth resulting into mid-face retrusion, as previously thought (9).
A significant proportion (34 %) of the defects were after the oper-ated patients’ fifth birthdays. One tenth of the patients were adults. This delayed treatment reflects limited access to the specialist ser-vice, a fact that reinforces the need and relevance of specialist out-reach services. The modified Millard’s technique commonly used in this study is the commonest technique for cleft lip repair especially in the United States of America and Europe (10,11). For bilateral clefts, the Manchester and Mullikens techniques are options to con-sider. The advantages of the Mullikens procedure is the collumella lengthening with a superior nose repair.(12,13). Its drawback is the extensive dissection over the nose as well as the long incisions as compared to the Manchester technique. Many techniques
have been described for the palatal surgery ,including two stage procedure(14,15). In our practice, a single stage unipedicle mucoperiosteal flap with a nasal mucosal back cut at the hard palate is usual. The overall complication rate in the current study also compares favourably with other studies reported in
literature. We did not determine the rea-sons for the complications which could include the weight at the time of surgery or cross infections in the post-opera-tive period (17).
In conclusion, the overall pattern of defor-mity in this study resembled other studies. Although surgical intervention for major-ity of the cases was ‘delayed’, the morbidity profile remains acceptable. More surgical outreach programs can address the huge burden of cleft cases outside central health facilities.
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