ACS HOPE and the Surgical Training Collaborative in Lusaka, Zambia—Part 2

Dr. Tom Pham, assistant professor in the Division of Transplantation at Stanford Surgery recently completed a 2-week visit to the University Teaching Hospital (UTH) in Lusaka, Zambia as part of the American College of Surgeons(ACS) Health Outreach Program for Equity (HOPE). Following his visit, he provided a review of opportunities and observations that would assist UTH in strengthening and maintaining a renal transplant program. The review led to a letter from the Zambian Ministry of Health to ACS requesting ongoing support and engagement to realize this effort.

Dr. Pham shared his experiences during his two-week visit:

I signed up for this mission because when I read about UTH, I learned that they had performed renal transplantations in the past. To me it meant that there is infrastructure to resume the program. I wanted to go there and learn more about the hospital and see what I could do to help.

To prepare, I relied a lot on the information I received from my colleagues here at Stanford who have made similar trips in the past. Drs. [Tom] Weiser, [Sherry] Wren and [Cara] Liebert were generous in sharing with me what to expect, and Dr. Wren introduced me to some individuals at UTH whom I exchanged emails with prior to the trip and ended up working with them closely when I was at Lusaka. Dr. Wren was also instrumental in helping me think through my approach to patients and to critically evaluate the entirety of the environment when making clinical decisions.

It is very well known that kidney transplant needs much more than a surgeon to perform the surgery; in fact, it’s crucial to have a certain level of patient care before and after surgery to ensure that the patients will benefit from the transplant for many years. I was keen to assess the available resources and care at UTH. I found that they could perform living donor kidney transplant locally; they had the infrastructure, resources, and capabilities. This eliminates the additional burden patients and their families face if they must travel to another country. The vast majority cannot financially afford such costs and end up with lifetime dialysis. I was also assured by the UTH colleagues that post-surgery medications are available to kidney transplant patients through their national health insurance and that there is an appropriate system in place to manage and follow up on these patients. All these factors helped me in making the decision to perform a transplant surgery in Zambia and encouraged the team at UTH to consider doing it, as well.

They had only performed 10-12 kidney transplants since 2018 when the program was launched. In those few transplants, they hired surgeons from outside the country. Guest transplant teams travelled to Lusaka and performed those transplants with their own surgeons, staff and equipment. Patients had to pay fees and certain amounts of money to undergo these transplants, while UTH provided care for the patients after surgery. I performed one kidney transplant with the local team, which I hope is the start of a more locally sustainable effort. I believe Stanford can help UTH improve the infrastructure that they already have and work with their surgeons to fine-tune the required skills that could make them an independent kidney transplant center that has the capacity to serve their own patients.

Another skills-transfer opportunity was in teaching arteriovenous (AV) fistula. One of the things I focused on was teaching them how to choose the appropriate patient, and I did a lot of teaching that involved the multidisciplinary care team including surgeons, nephrologists, and radiologists. AV fistula is the preferable means for dialysis, and it will significantly reduce infections and other possible complications. We created four AV fistulas during my time; I performed the first but assisted or observed on the others.

The hospital wasn’t comfortable creating AV fistulas in the past, so the greatest benefit from my visit was to help them identify the resources that they already have to do it, and—for the resources that they do not have—to request them from the government which is willing to support them.

After I evaluated their capacity and ability to do AV fistulas, we chose patients and worked with radiology to teach them how to do vein mapping and ultrasound themselves. We guided them on how to assess the patients and showed them everything that they can do when using the equipment as well as the personnel that they already have. We also identified where there were deficiencies that require more attention and improvement, such as training.

ACS HOPE will need to support further training of the UTH surgeons in performing brachial basilic fistulas and surgical management of postoperative fistulas. This training can be done by vascular, transplant, or general surgeons with AV fistula experience. Future ACS visiting surgeons should know that UTH has all the necessary equipment to perform basic autologous AV fistulas in the operating room. The focus on future visits should be skills transfer in the operating room and postoperative management.

I can comfortably say that the UTH surgeons are now able to identify appropriate patients for AV fistula creation. They are competent in their ability to perform a radial cephalic and brachial cephalic AV fistula, but they will benefit from further supervision of these fistulas and will require further training to perform a brachial basilic fistula and eventually AV graft placement. I believe that is possible if ACS HOPE offers the opportunity to surgeon from various US institutions to travel to Zambia and work on transferring skills to the surgeons at UTH.

It’s an ongoing process, and they could build on each other’s work to assess and improve the program. This is not a one-time thing and to really complete the process I am committed to going back. I would also like to recruit a team to either go back with me or take turns going, which I think would be more sustainable. We need to have volunteers to travel to Lusaka three or four times a year until the program is up and running.

I appreciate having this chance to meet with all the individuals there and work with them on building this service, I think there is a really good opportunity to move forward with the ACS HOPE effort and build on it. The team in UTH were incredibly engaged and enthusiastic about working with us, we couldn’t ask for more. I’m very excited and look forward to the next chapter of this collaboration.