Mobile Gastrointestinal and Endoscopic Surgery in Rural Ecuador – 20 Years Experience of Cinterandes

Haadi T Shalabi, BMedSci, BMBS1, Saggah T Shalabi, BMedSci, BMBS2, Matthew D Price3, Edgar B Rodas, MD4, Anita B Vicuna, MD5, Blasco Guzhnay, MD5, Raymond R Price, MD6, Edgar Rodas, MD5. 1King’s Mill Hospital, UK, 2Queen’s Medical Centre, UK, 3Brigham Young University, USA, 4Fort Lauderdale, USA, 5Cinterandes, Ecuador, 6Intermountain Healthcare, USA

Gastrointestinal and mobile surgery
In the poorest third of the world, only 3.5% of global surgery is delivered. High quality gastrointestinal and endoscopic care is rarely received by those in remote areas and the poor, commonly due to geographical limitations, and difficulty leaving family and occupation. One solution brings surgical care to the patient through mobile surgery. Cinterandes, a humanitarian Ecuadorian Mobile Surgical Unit, has travelled more than 300,000km over the last 20 years, to many remote areas in Ecuador. It has conducted 7,431 operations, 60% of which were gastrointestinal and laparoscopic. Cinterandes is one of the only mobile surgical units in LMICs.

How mobile surgery developed in Ecuador
A local surgeon initiated the mobile surgery project, and formed the Cinterandes foundation over 15 year’s duration. Funding was raised from donations by businesses and private-hospitals. This helped in developing a low-cost purpose-built operating truck, obtaining simple equipment, and basic running costs.

How mobile surgery is delivered
a. Mission structure
Patient identification; patients identified by a network of local medical contacts in remote regions. Brief examinations are conducted locally, and surgery scheduled.
Pre-operative assessments; conducted one week pre-operatively by core team via video-consultations.
Surgical mission; four day duration (truck travels one day prior-Figure 1). Secondary pre-operative assessments are conducted on arrival, followed by three days of surgery.
Primary post-operative care; in tent facilities or local clinic (Figure 2).
Secondary post-operative care; patients visit local clinic one week post-operatively. Tele-consultations are conducted from central office.

b. Team structure (Figure 3)
Cinterandes consists of seven permanent core members; president/lead surgeon, executive director/lead anaesthetist, medical co-ordinator, operating-room technician/general assistant, driver/general assistant, general co-ordinator, and receptionist. Additional members participate in surgical missions; seven regular surgeons, residents, medical students, and volunteers.

c. Types of surgical operations
Gastrointestinal operations are one of the most appropriate types of procedures for mobile surgical unit circumstances. This is mainly due to appropriate post-operative care in simple community-based settings, suitability of the required surgical equipment, and recovery times. Complication rates were<1%, similar to tertiary hospitals in developed countries.

d. Mobile surgical unit specifications
The mobile surgical unit is a 24-foot modified Isuzu van. There are two main rooms:
– The preparation room: general equipment storage and running water.
– The operating room: operating table, anaesthetic and surgical equipment (Figure 4).

Lessons Learned
Surgery is a very effective way to gain the trust of the community, due to immediate results. Trust opens doors to other programs (e.g.family medicine) more challenging to embrace as many of their benefits may be invisible or slow (e.g.nutrition).

Sincerity and compassion from patients in rural communities should not be underestimated. Communities care when their local people receive good treatment, and reciprocate this through taking care of the team out of genuine compassion and love.

Surgery can be incorporated with all other aspects of health-care, which can in-turn be incorporated with all other aspects of human development; education, food-production and nutrition, housing, work and productivity, communication, and recreation.

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