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Table 9.1 Sequence of care for the cleft lip and palate patient
Age Procedure Comment
3–6months Lip repair
7–12months Palate repair, myringotomies
4–5years old Speech evaluation May require additional palatal/
pharyngeal surgery
6–9years old Alveolar bone graft Phase 1 orthodontic therapy
Adolescence Mid-face advancement Phase 2 orthodontic therapy
Adolescence Nose/lip revision
S. B. Eisig et al.
traumatic hand injuries and a variety of other
facial deformities.
We have also developed an electronic medical
program with a ngerprint identication system.
In 2020 we introduced a nutrition program taught
by a well-known Colombian chef for our postoperative patients.
This chapter will discuss the requirements to
developing sustainable care in low and middleincome countries (LMICs) based on our experiences in Neiva, Colombia.
Mission Statement andGuiding
Principles ofCare
It is important that the team develops a mission
statement with a set of guiding principles in coordination with the host hospital. This will dene
expectations, allow the team to be focused, and
will set boundaries to patient care. Treatment
should be dened by assessing the local needs of
the community, the resources of the hospital, and
understand what restrictions and role you play in
the local healthcare system. Guidelines should be
established for teaching local doctors and
residents.
Site Selection andDeveloping
Partnerships
It is imperative that a clinician become part of an
existing team and make several trips before leading a new team. A thorough understanding of
planning, logistics, transportation, fundraising,
leadership, and how to execute the mission is
essential. It is critical to abide by all rules and
regulations related to entrance to, and exit from,
the host country.
A pre-trip site visit, approximately one year
in advance, is critical. A local champion is crucial to the continuing success of the partnership.
The goals of this visit are to develop relationships, to meet the local leadership of the city,
the hospital and chamber of commerce, to perform a needs assessment for the population, and
to evaluate the standards of care and equipment
in the host hospital. The expectations of the hospital must match what the team can provide. The
development of a close working relationship
with local healthcare providers is critical.
During this visit a medical liaison is identied
and local surgeons are invited to participate.
Agreement is reached as to who will care for the
patients when the team leaves. Emergency planning is also discussed and agreed upon during
this site visit.
The anticipated patient volume, the number of
operating rooms, the size of the recovery room,
presence of an intensive care unit, hospital bed
availability, and where the patients are being
housed prior to surgery and after discharge from
the hospital are ascertained.
The team administrator will assist your host in
credentialling the members of the team who will
be treating patients.
Security, housing, and transportation for the
team must be arranged in advance. Housing for
the team should be visited at the site visit.
Funding
The team needs a source of funding for travel,
lodging, local transportation, meals, and medical
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supplies. This can be done with grants, fundraisers, or donations. One can also establish a 501C
foundation and solicit donations. The local
Chamber of Commerce may have the resources
to assist with fundraising or provide gifts in kind
such as housing, meals, and transportation.
Although medical care is provided free of
charge, the hospital may need additional nancial
support to pay salaries of hospital employees caring for the patients and for meals for both patients,
their families, and the visiting team.
Team Development
The team administrator plays an important role in
planning the trip, arranging all the legal documents to practice, and logistics. The administrator must be uent in the host country’s language
to ensure a smooth logistical operation of the
team. The administrator serves as the direct liaison with the hospital administration and language
uency will help avoid misunderstandings and
miscommunications. The administrator, along
with the medical director of the Team, ensures
that all supplies, equipment, and luggage arrive.
The administrator also arranges the hotel and
meals, transportation to and from the airport, and
to and from the hospital each day. Well-structured
programs are productive and may be intense. The
administrator and other team leaders should
remember the importance of team camaraderie.
These leaders should plan team activities to alleviate the stress of work days and promote engagement among team members and the host
community.
The number of OR tables, hospital capacity,
and the anticipated scope of services determines
the size and skill set of the team. The host hospital may provide operating room nurses and technicians. In Neiva, our host hospital provides the
scrub nurse and circulator. However, we also
bring one circulator per room as well.
Team members are often dropped because of
their inability to work under sometimes adverse
circumstances, to get along well with others, or
their level of care does not meet the standards
that are expected.
Anesthesia
The delivery of safe anesthesia continues to be a
challenge in LMICs [2]. An anesthesia team
experienced in the care of infants and children
needs to be developed. This can be a combination
of anesthesiologists, certied registered nurse
anesthetists (CRNA), and anesthesia technicians.
All applicable laws in the host country as to who
can deliver anesthesia must be followed. Resident
anesthesiologists need to be supervised at the
same level as in their residency program.
Additional anesthesiologists not assigned to an
operating room are needed to provide relief, to
assist in case starts, and to provide emergency
care.
The visiting anesthesia team must develop a
good relationship with the hospital anesthesiologists and to include them in the day-to-day operations of the mission. The local anesthesiologists
are critical to help in difcult airways, emergencies, anesthesia machine maintenance, and overall care of the patient.
Anesthetic agents and supplies need to be
obtained in advance and the type of anesthesia
machines and monitoring equipment should be
evaluated at a pre-mission site visit. The anesthesia team must investigate in advance all host
country’s Customs regulations regarding travel
into the country with anesthetic agents and other
medications.
One rule that we have followed is it only takes
one healthcare provider, at any level, to cancel a
patient. This is not open for debate other than for
academic discussion. This avoids placing our
patients at undue risk. These patients are given
preference when we return the following year if
they are not treated by the local surgeon.
Surgical Team
The surgical team should include a combination
of skilled surgeons and residents; the resident
serves as rst assistant and not as the surgeon. It
is important to avoid having a surgeon operating
in a situation where they are not competent. In
addition, there should be a designated surgical
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S. B. Eisig et al.
team leader that can oversee the program, scheduling, and assignments. In high-volume surgical
missions, it is imperative that the surgical scheduler (typically the administrator or one on his/her
team) work closely with the medical director and
all attendings, discussing the creation of the
schedule often. The pace of the work is intense,
cases are often either included in case load for
that year or are postponed a year, so this close
communication helps create a smoother process
that benets the patients, surgeon, and success of
the campaign.
Nursing
Nursing care is key to many medical teams.
Nurses provide a variety of services on these trips
from assisting in the operating room to administering pre- and postoperative care. The number of
nurses is dependent on the number of patients
and the availability and skill of local nurses.
Pediatricians
All patients are evaluated by our pediatricians
prior to and after surgery. We prefer pediatricians
with critical care training. Our pediatricians
interact daily with the hospital’s pediatricians
and nursing staff and one of our pediatricians
takes call in the hospital each night.
Comprehensive Care
Surgical teams that provide cleft lip and palate
surgery are often criticized for not providing the
comprehensive care these children require as
they grow into adulthood. Providing comprehensive care for the cleft lip and palate patient in an
under-resourced region is a challenge.
Partnerships with local specialists take time to
develop. These clinicians may need to be trained.
All our patients are offered orthodontic care by
local orthodontists so we may provide bone grafting to the alveolar cleft and maxillary advancement (if needed) when age appropriate. We
incentivize the orthodontist by providing supplies through our fundraising. The children are
also provided with speech therapy by local
clinicians.
When you consider other specialties such as
orthopedics or other types of facial reconstructive
surgery, the same also holds true; postoperative
therapy and long-term care (follow-ups and
interim care between mission trips) have to be
considered and a method to provide that should
be ascertained before surgery is performed.
Emergency Planning
andPostoperative Care
It is important to have a plan for medical and surgical emergencies for both patients and team
members established prior to the visit. This is formulated at the time of the initial site visit and
reviewed once the team has arrived. Team members must have health insurance that provides
coverage for care and medical evacuation when
outside the United States.
Postoperative care at nighttime needs to be
decided in advance. Remember that a visiting
doctor or nurse may not be uent in the local language or familiar with how to write orders and
who is available in case there was a problem
developing. Including a local pediatrician, uent
in the team’s primary language, can help to
bridge this gap between the visiting surgical team
and the hospital-based staff that will provide
postoperative care. This person can then help
plan who is available at night to care for patients.
It is important to provide the contact information
of the other team members to those on call at the
hospital. Surgeons must round on their patients
while the patient is in the hospital.
Medical Records
In addition to entering into the hospital’s medical
record, the team should maintain its own records
to allow for continuity of care. Data can also
drive fundraising by demonstrating good surgical
outcomes and helping to develop patient stories.
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Designated personnel are assigned to do this. It is
helpful to have a medical student or resident from
the host hospital serve in this role.
For security reasons, the mission team may
not have direct access to the hospital’s electronic
medical record system. The mission team will be
responsible for creating paper records and sharing them with the hospital. The details of these
processes should be discussed before the mission
to avoid logistical problems during or after the
mission.
Care After theTeam Leaves
Visiting teams are often given the disparaging
term “weekend warriors.” The team operates and
leaves the problems to be taken care of by the
local doctors. It is prudent to have local doctors
who are willing to assume the postoperative care
of the patients that you are treating included in
your care of the patients. Obviously, for specic
surgeries, postoperative care has its own requirements. These discussions begin at the initial site
visit and are revisited when the team arrives.
Unusual procedures that may require a planned
or unplanned return to the operating room are
discussed with the local surgeons prior to surgery. Remember, the clinicians that will provide
the extended care after the team leaves do so in
addition to their regular patient load. Take the
time to establish close bonds with these local
team members and consider ways to incentivize
their participation.
Your hosts should be able to assist with this.
Check the internet for schedules of other medical
volunteer groups that might be providing care to
your proposed site. An excellent working relationship with the host hospital can frequently prevent this issue from occurring.
Local Diplomacy
The visiting medical group must never upstage
the local doctors. Do not create a situation where
the patients and their families are made to believe
that their local doctors are incompetent. It is
important that every attempt be made to engage
local doctors, nurses, and hospital administrators
and make sure that they are given the credit for
making this care possible. Mutual respect and
friendships that are developed will be sustaining
and rewarding.
One complication can overwhelm all the good
intentions and services provided by your team. It
is important to think very carefully about what
could go wrong and try to avoid those situations
and minimize the surgical risks. Having local
doctors as part of your team will minimize the
effects of the complication and avoid casting a
shadow on your team. Beware and avoid any selfaggrandizing or criticisms on the social media at
the expense of the local staff, administrators, or
local authorities. Such irresponsible action by
any member of the team may quickly lead to rupture of all relations and irrevocable termination
of the program. This must be avoided at all cost.
Availability ofPatients
We use the local media, churches, and surgeons
to inform the local population of our impending
visit. Our expansion into comprehensive care to
include orthodontists and speech pathologists has
greatly increased the number of patients we evaluate. We are now examining approximately 700
patients (from all over Colombia) on our screening day and operate on approximately 150–170
patients per trip. It is important to ensure you are
not competing with a well-established program.
Conclusion
Participation in a volunteer medical mission is
extremely rewarding. This discussion is meant as
a guideline to provide medical and surgical care
in LMICs. Additional information can be gleaned
from Butler et al. [3]. When people are often
asked why they do this, there is no specic
answer other than it is “a calling.” Having spent a
professional lifetime volunteering several times a
year, these trips have a unique meaning that can
only be understood by the individual. Whatever
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S. B. Eisig et al.
reasons motivate you to participate, understand
that you are part of a team and that the goal is to
provide medical care for people in need of your
services. Two favorite quotes that epitomize volunteer work are: “You make a living by what you
get; you make a life by what you give” and to
“save a life is to save the world.”
References
1. Meara JG, Leather AJ, Hagander L, Alkire BC,
Alonso N, Ameh EA, Bickler SW, Conteh L, Dare
AJ, Davies J, Mérisier ED, El-Halabi S, Farmer PE,
Gawande A, Gillies R, Greenberg SL, Grimes CE,
Gruen RL, Ismail EA, Kamara TB, Lavy C, Lundeg
G, Mkandawire NC, Raykar NP, Riesel JN, Rodas
E, Rose J, Roy N, Shrime MG, Sullivan R, Verguet
S, Watters D, Weiser TG, Wilson IH, Yamey G, Yip
W. Global Surgery 2030: evidence and solutions for
achieving health, welfare, and economic development. Lancet. 2015;386(9993):569–624. https://doi.
org/10.1016/S0140- 6736(15)60160- X.
2. Hodges SC. Anaesthesia and global health initiatives for children in a low-resource environment. Curr
Opin Anaesthesiol. 2016;29(3):367–71. https://doi.
org/10.1097/ACO.0000000000000319.
3. Butler M, Drum E, Evans FM, Fitzgerald T, Fraser J,
Holterman AX, Jen H, Kynes JM, Kreiss J, McClain
CD, Newton M, Nwomeh B, O’Neill J, Ozgediz D,
Politis G, Rice H, Rothstein D, Sanchez J, Singleton
M, Yudkowitz FS. Guidelines and checklists for
short-term missions in global pediatric surgery:
Recommendations from the American Academy
of Pediatrics Delivery of Surgical Care Global
Health Subcommittee, American Pediatric Surgical
Association Global Pediatric Surgery Committee,
Society for Pediatric Anesthesia Committee on
International Education and Service, and American
Pediatric Surgical Nurses Association, Inc. Global
Health Special Interest Group. J Pediatr Surg.
2018;53(4):828–36. https://doi.org/10.1016/j.
jpedsurg.2017.11.037.
How toOrganize aColon Cancer
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Screening Program inaLowandMiddle-Income Country
SpencerE.Amory
Kindness is the language which the deaf can hear and the blind can see.
– Mark Twain
10
Abbreviations
ACLS Advanced Cardiovascular Life Support
HICs high-income countries
LMICs low- and middle-income countries
Introduction
Colon cancer screening with colonoscopy is well
established as a technique for prevention and
early detection of colon cancer in the population
of developed countries. However, there are many
communities worldwide, such as low- and
middle- income countries (LMICs), that do not
have access and would benet from this evaluation. Before offering your services, it is important
to establish whether the target community perceives such a need or is receptive to considering
screening. This can be achieved by contacting
residents, providers, or health ofcials in the tar-
S. E. Amory (*)
Columbia University Vagelos College of Physicians
and Surgeons, New York, NY, USA
e-mail: sea99@cumc.columbia.edu
get community. These people can be a source of
information about the burden of colon cancer in
the community, the current screening options
available, and the likelihood that the community
will accept screening. They can also provide
information about support services needed such
as anesthesia, pathology, and surgery.
Establish Connection withProvider
I have found it essential when working temporarily in a distant community to establish a strong
relationship with a local provider. In addition to
providing valuable information about a variety of
local issues, this provider can assist with evaluation and preparation of patients, follow-up of
pathology reports, and referrals for surgery. This
individual is often motivated to assist since they
are connected to the community and would like
to improve their care. Also being part of such an
effort improves their continuing education and
prominence on the local scene. Ideally, they
would be inspired to acquire the skills to provide
the service locally on an ongoing basis.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_10
103
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S. E. Amory
Site Visit
A preparatory visit to a proposed screening site
serves many functions. One can meet with key
local personnel and initiate the process of publicizing the effort. Another important task is to
evaluate the local health facility for a suitable
space for conducting patient interviews, performing procedures, processing of endoscopes, and
storing supplies. I have found that space in or
close to the operating room will usually have
adequate security, and the utilities like electrical
power, water, and oxygen. Also, there may be
monitoring equipment necessary for endoscopic
procedures. One can also assess the potential for
power failures and the availability of portable
generators.
Assemble aTeam
Colonoscopy is a team effort. A technician skilled
in cleaning and maintaining the equipment is
essential especially when functioning away from
the usual services of your home hospital and
equipment company representative. An experienced endoscopy nurse who can administer sedation, monitor patients, and assist with procedures
is also vital. An anesthesiology member on the
team is ideal but often local practitioners can be
utilized instead since in LMICs there is frequently a shortage of trained anesthesiologists.
The members of the team should also be comfortable sharing their knowledge and skill with local
counterparts in keeping with the ultimate goal of
a sustainable screening program.
Acquire Equipment
Colonoscopy equipment is expensive, and this hurdle can be challenging in LMICs. Fortunately,
many home facilities in high-income countries
(HICs) routinely update and trade in old equipment
for a nominal discount. Your home institution may
be willing to donate or highly discount older but
highly functional equipment to your effort.
Alternatively, previously owned equipment can be
obtained from the supplier at a deep discount.
Equipment List
Instrument tower (processor, light source, moni-
tor, printer).
Colonoscopes.
Electrocautery generator, pedal activated
Pump irrigator, pedal-activated.
Disinfecting tubs for endoscopes.
Pump irrigator for endoscope cleaning.
Funding
The expenses associated with conducting screening at a distant location in LMICs include equipment mentioned previously, disposable supplies,
travel, and local accommodations and transportation. There may also be expenses for medications
acquired locally or for the services of anesthesia
personnel. There are many variables here since
donated supplies are sometimes available and
some team members may choose to pay for their
own travel. In any event one needs to carefully
budget the expected and unanticipated expenses.
I found it useful to establish a non-prot organization as a vehicle for fundraising and nancing
of this effort. Grateful patients are often aware of
your charitable activities and willing to support
these efforts, as may be charitable institutions
and foundations.
Supplies
A large volume of unused supplies from the “supply packs” opened for each patient in our endoscopy suites are often discarded. Unopened
packages of lubricant and gauze can be collected
and stored for later use. There are organizations
that routinely collect unexpired supplies from
hospitals and provide them free of cost to legitimate charitable efforts. Lastly, some supplies
may need to be purchased from suppliers. If these
supplies can be sourced at the destination, they
are often less expensive. The colon cleansing
regimens to which one is accustomed may not be
available. Advanced knowledge will guide the
decision to obtain and ship or transport these
supplies.
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Endoscope disinfectant solution.
Masks 10.
Needles, sharp.
Needles, blunt.
Oxygen cannulas.
Protective eyewear.
Simethicone.
Snares, endoscopic.
Specimen containers.
Specimen bags.
Specimen traps.
Suction tubing 10.
Syringes 6, 12, 60mL.
Underpads.
Wash brushes.
IV dressings.
Supply List
Adhesive strips.
Alcohol pads.
Angiocaths.
Baskets, endoscopic.
Biopsy forceps.
Cautery cable, snare.
Disinfecting wipes.
Enzyme cleaner.
Formalin.
Gauze.
Gloves, non-sterile.
Gloves, tted.
Gowns, procedure.
Grounding pads.
Hand sanitizing solution.
IV tubing 16.
overcome these barriers. Interviews on local
radio and television shows is one option, preferably conducted with one or more local health
care providers or ofcials. Another approach is to
target community groups and religious organizations. Ideally, a partnership with the local public
health system can facilitate the dissemination of
information about the value and availability of
colon cancer screening. After the initial experience, word-of-mouth dissemination about the
experience and benets is a potent method of
raising awareness and recruiting additional
patients.
Navigating Local Authorities
andSystems
Not all authorities and medical communities in
LMICs welcome activities by groups perceived
as outsiders. Leaders may be concerned that the
care of conditions discovered by screening will
place additional stress on the resources of the
health care system. Physicians may feel threatened nancially or be made to feel irrelevant. A
local physician champion can help to persuade
ofcials that the care of patients with advanced
colon cancer is more resource intensive than the
care of early disease. They can also be persuaded
that efforts to improve the health of the population benet them as leaders. The local champion
can also point out to his/her colleagues that offering a new service to patients enhances their practice. Encouraging the participation and training
of local physicians and nurses mitigates resistance in addition to promoting sustainability
which ought to be a critical goal of the effort.
Raising Awareness
Wide dissemination of the advantages of colon
cancer screening has not penetrated every community around the world, especially in LMICs.
Some communities are focused on the challenges
of daily life and others are resistant to screening
for asymptomatic conditions. Some persons,
especially males, may be reluctant to undergo
examination via the anus. A method to communicate with the target population is essential to
Pathology Services
The availability and quality of pathology services
varies considerably in LMICs. Even the terminology used to label specimens and describe
ndings may be different. Advanced knowledge
of this helps guide planning as well as data
recording. Specimens may need to be transported
to a regional laboratory. Most regional options
are preferable over home-based options because
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S. E. Amory
of cost and the benet of developing local and
regional capabilities.
Licensing
Virtually all destinations, whether LMICs or
HICs, have requirements to practice medicine.
This can be as simple as submitting home documentation of training and certication. In other
situations, a longer bureaucratic process is
required including endorsements by local health
personnel and fees. Begin early, like 6 months
prior to the visit, to assess and complete the
process.
Shipping/Transporting Supplies
The equipment tower with video processor, light
source, and monitor will need to be partially dissembled for transport and reassembled on site.
Label the connections, take pictures, and rehearse
the process before traveling. The company representative can be helpful in packing the equipment
safely for transport. The valuable colonoscopes
should be carried onto the airplane in their protective briefcases. Airport security will often
inspect but are quite accommodating of medical
equipment. When practicing away from home a
detailed knowledge of the equipment and how to
troubleshoot is critical. Having a spare and the
ability to change a blown bulb or fuse have saved
the day more than once.
start the procedures fresh and focused on the care
of the patient.
Pre-Procedural Assessment
The well-established practice of preprocedural
assessment of patient’s suitability to undergo
screening is even more important in populations
that do not receive routine preventative care.
While much of this can be accomplished by a
local health care provider, I recommend reviewing that assessment and the patient’s understanding of the procedure in a brief encounter prior to
the procedure.
Sedation/Drugs
It is now commonplace to perform colonoscopy
under deep sedation with an anesthetist using
propofol. These resources may not be available in
many settings in LMICs, and it is useful to be
comfortable performing the procedure under
moderate sedation with analgesia and a shortacting benzodiazepine. I have found that most
patients are comfortable with this level of sedation. I would rather err on the side of under sedation during colonoscopy. Despite careful
technique over-sedation remains a risk. In addition to Advanced Cardiovascular Life Support
(ACLS) certication, the team should be wellpracticed and equipped to monitor and manage
airway and cardiovascular emergencies, rare as
they should be.
Setting UpSpace
On arrival at your destination, budget time to set
up the endoscopy space. By this time you will
have already evaluated the procedure and endoscope processing space, determined how it should
be arranged, and acquired all the necessary extension cords, cables, hoses, and voltage transformers. Plan to this no later the day before starting
procedures. After setting up and testing the
equipment in advance you will be prepared to
Technique
CO2 insufation has become commonplace to
minimize post-procedure discomfort and expedite recovery. Supplies of medical grade CO2 are
often limited or a costly option in limited resource
settings. Insufation with room air remains a satisfactory and readily available option in LMICs.
Similarly, a foot-activated electrical irrigation
pump may not be available. A 60cc Luer lock
syringe and blunt needle is a workable solution.
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Endoscope washing machines routinely used in
endoscopic suites at one’s home endoscopy suite
are not available in many LMICs. An endoscopy
technician well versed in the manual cleaning
and disinfection of endoscopes is therefore essential and can teach local nurse or technician to do
this reliably. Specic information on recommended practice is available from the endoscope
manufacturer or from their institutional
representative.
Local Accommodations
The advent of online services to rent homes for a
limited period has greatly facilitated local accommodations. One has access not only to the size
and services of the housing but also to the reviews
of previous users. With the vagaries of transportation, it is preferable to be housed close to the
service location but the team’s needs for safety,
rest, and recreation should also be considered.
Entertainment
What is frequently forgotten is that volunteer
health professionals who are employed at home
often use paid time off to participate in voluntary
health care activities. Incorporating some time
for relaxation and recreation serves to keep the
team refreshed and motivated. This time can also
be used to explore interesting sites near the locale
and learn more about the community and its
needs. Interaction in a social setting enhances
bonding and teamwork, especially when volunteers are drawn from different institutions,
regions, or countries.
Data Recording
The demand for procedures can be overwhelming and can consume the full energy of the team.
An efcient database to record important demographic information and outcome of procedures
is essential if only to facilitate assessment and
continuous improvement. It also serves as an
important source of information for scholarly
activity. It is important to gain IRB approval
from the home institution and also from local
authorities if research is planned. This aspect of
screening is an ideal activity for medical students who wish to be involved in volunteer
activities and scholarship and when there are
medical school resources to fund their
participation.
Follow-Up Care
Colonoscopy has a low rate of complications, and
most patients feel normal by the following day.
Whenever possible, schedule most procedures at
the beginning of the screening interval to allow
time for follow-up care and concerns. Pathology
reports are often not complete by the time the
team departs. Plan to have those reports forwarded preferably via the internet. An addressed
prepaid envelope in the hands of a local contact
serves the same purpose if regular mail is the
only option. As mentioned earlier, the local team
members can facilitate follow-up for those
patients whose pathology dictates a need for further care. Usually, these patients are identied
based on gross ndings and can be counseled and
referred at the end of the procedure. I have found
it useful to print a copy of colonoscopy ndings
and recommended follow-up and provide it to the
patient with post-procedure instructions. I also
send a copy to the physician or clinic where the
patient receives care.
Surgical Care
Some patients with pathology discovered at
screening require surgical care. In most settings,
local surgeons are willing to accept referred
patients. Having a prearranged referral surgeon
in LMICs is mandatory for rare complications
such as perforation. I recommend referring
patients for elective surgery who might otherwise
require advanced endoscopic techniques. This
approach minimizes the risk of emergency surgery in limited resource settings.
Соседние файлы в папке Библиотека им академика М.И. Перельмана