Infantile and adult mortality in precarious conditions

Maxillofacial surgery plays an important role in humanitarian surgery because this specialty includes common procedures such as facial reconstruction after burns, facial clefts or Noma's sequelae, which do not require complex infrastructures and thus can be carried out in sub-optimal conditions. Nevertheless, there is a mortality rate during those missions and few studies evaluating their rate and circumstances have been published. The aim of our study was threefold: to study the deaths reported during humanitarian missions, to analyze the circumstances of those deaths, and to determine the risk factors in order to propose possible adaptations in operative indications and therapeutic attitudes so that those mortalities may be avoided in the future.

We evaluated the early deaths (between day 0 and day 8) observed among 3,494 patients operated on during humanitarian missions conducted between 2007 and 2018 in Africa and Asia by the charity organization "Les Enfants du Noma" (EDN). Information (patient, type of surgery, circumstances of death) was collected from the medical files and by questioning the medical teams who took part in the missions.

Five deaths were recorded from 2007 to 2018, representing a mortality rate of 0.14%. The deceased were between 1 and 20 years of age and the deaths occurred between the day of the surgical procedure and the third post-operative day. The causes of death were as follows: two cases of respiratory failure due to mucous plugs (one in the endotracheal tube and one in the tracheotomy canule), one cardio-respiratory failure, one bilateral tension pneumothorax and one peritonitis from several duodenal perforations.

In order to minimize the risks of lethal complications, it is important to identify as early as possible certain high-risk situations, to ensure the adequacy of the means available, and to establish an indication for surgery by a concerted discussion among the surgeons and anesthetists involved. One of the general limitations of humanitarian missions is the lack of resuscitation facilities and the lack of availability of further exams. Rites, beliefs, superstitions, gri-gri and ancestral practices often hold a prominent place in these cultures. The absence of well-kept medical records (including personal and family histories), language barriers, large volumes of patients to manage, the inexperience of first-time teams, the lack of knowledge of the terrain and local health conditions, and an inability to empathize with patients, limit the quality of preoperative assessment and sometimes lead to poor decisions.