SURGERY DAY 3-THE BIG HOLE

This lady arrived at the hospital several days before I came. She was told that I was coming and might be able to help her. She was reported to have a recurrent Spindle cell tumor that has been operated on four times in the past-the last surgery being about 1.5 years ago.  She has no evidence of metastatic disease so we decided to resect the tumor.

The surgery was quite dramatic. We had to remove all the skin that was involved, perform a radical neck, as well as remove the clavicle, the upper pectoralis major muscle, the deltoid muscle and part of the trapezius muscle. The capsule of the shoulder joint was completely exposed. We had a big hole! Using a somewhat radical solution to fill the hole, we mobilized the breast, removed most of the breast tissue and used the resulting skin as a cutaneous flap. In a few days we will cover the rest of the wound with a contralateral pectoralis flap. I hope this will be her last surgery.

Specimen including deltoid and pectoralis

Addendum (10/21/11) : After her big surgery, this patient was not nutritionally well enough to tolerate more operations so we dressed her wound and fed her well. She slowly improved. and her wound started granulating. At the time of my departure she is almost ready for discharge. Dr. Mike has agreed to do a skin graft in the near future.

THYROTOXICOSIS

"I'm a fuel injected suicide machine." Nightrider in Mad Max

Thyrotoxicosis is a deadly disease. It is like running your car at the redlne 24/7. It causes "spontaneous combustion"! Of course, few die from this disease in the USA, but not so in Nigeria. In Nigeria, this disease is often diagnosed late and patients present with severe wasting from their hypermetabolic state.  This poor lady is 23 years old and she is completely wasted. I can encircle her bicep with my ring and index finger and I have a small hand!

In the USA there are good drugs for comtrolling this disease. It can be cured with radioactive iodine. In Nigeria there are some drugs available but radioactive iodine is not an option.

In Nigeria, we treat these patients by first controlling their disease with drugs,  then surgically removing their entire thyroid gland. Usually this works out well. When these patients return 3 months after surgery, they often have gained 20 lbs and feel reborn. 

Occasionally, the story is not so happy. These patients can develop thyroid storm during or after surgery and they literally burn themselves up. Fortunately, we have developed a medical regimen that rapidly controls thryotoxicosis before surgery and thyroid storm rarely occurs.

SURGERY DAY 2-OLD FRIENDS

Today we had some pleasant surprises. Three old patients came to visit me-Innocent, Esther and Monday. Innocent was discussed in an earlier blog. He looks great! He is about to start radiation.

Esther is a woman who came July, 2011 with a maxillary tumor. We did a maxillectomy and the pathology showed fibrous dysplasia. This is a benign growth but it can become quite large and distort the face. You can hardly tell that she had major facial surgery. She is very happy.

Monday is an old man who came July, 2011 with an obvious thyroid cancer. We did a major resection with a radical neck. After surgery, he required a tracheostomy. Each day when we visited him, he appeared to be wasting away. When I finally left for the USA, I thought he would die soon but apparently he rallied. Today he appeared looking quite well.

Today was busy. We did 11 surgeries including 3 goiters,  a recurrent parotidectomy, a submandibular mass, a giant incisional hernia, a penile cyst, and 4 biopsies. There are now 27 patients waiting for surgery and they are starting to get anxious and pushy! 

SURGERY DAY 1-LET IT ALL HANG OUT

Today was the first day of surgery for the September mission trip to the Nigerian Christian Hospital. The hospital is exploding with patients. There are now 24 patients waiting for surgery. Today we took it "easy" so everyone could get in the swing of things and we only did five surgeries including a rectal prolapse, 2 goiters, a giant incisional hernia and an epididymal cyst. We saw dozens of patients between cases.

Rectal prolapse

One interesting (but sisgusting) case was this poor man has had rectal prolapse for years. This is not painful but it is impossible to stay clean. He has had to wear a diaper and has constant soiling. We were surprised to see him this trip as we already had operated on him for a completely different problem about one year ago. At that tme he came in with a strangulated femoral hernia. I noted then that he had rectal prolapse but we did not repair it as he was critically ill from the strangulated bowel. The plan was to attack the prolapse problem if he survived the hernia problem. Today. we performed a transabdominal rectopexy.

Addendum (10/4/11)-the patient went home with the prolapse corrected.

ARRIVAL

Nigeria or bust

Left home at 1030am 9/24- drove to Dallas/Ft. Worth Airport- flew to Atlanta then Atlanta to Lagos, Nigeria -11 hours and 7 minutes. Overnight in Lagos then Lagos to Uyo. Ground transportation  from Uyo to the Nigerian Christian Hospital-arrivied at 3pm. Total miles about 7000. Total travel time 36 hours. 

There are 25 patients in the hospital waiting for surgery, including 13 goiters, a submandibular mass, 2 abdominal masses, an incisional hernia, a rectal proloapse, a parotid tumor, a thyroglossal duct cyst, a varicoele, 2 elective C sections,  a jaw tumor and a sarcoma of the neck.


Tomorrow is going to be a big day!

PLANKING

Planking is not dead.  Here I am planking on top of 150 lbs of medical supplies. I think this is a first! Stay tuned for other daring 'firsts' this trip.

EXCESS BAGGAGE

When you are going to Africa, you don't just run down and jump on the shuttle. It takes some planning. I usually start this process before I leave from my last trip. I make a list of all the supplies we've used up and all the supplies we didn't have that we needed. Then, I spend the next several months gathering the supplies. This often requires talking with sales reps and organizations that donate supplies. Usually, through asking or begging, I get what I need. On this trip, I am taking Floseal, suture, books, computers, drains, clogs, drapes, camera, hats, Staplers, Rocephin, Precedex, scale, BP cuff, beef jerky, gum CDs, Plug adapter, IPod, Tape, cable ties, specimen bottles, gloves, central lines, gigli saws, biopsy gun, biopsy needles, spinal needles, LMAs, loops, light, batteries, toilet supplies, markers, pens, surgical instruments, towels, laps, calcium, inhalers, colostomy supplies, data sheets, cautery pencils, skin mesher, grafting knife, earphones, scrubs,  fetal dopplers, pulse oximeter, cameras and a bunch of other stuff.

Of course, I'll be charged for excess baggage. Its all worth it when you have that bloody thyroidectomy,  and ask for Floseal, and it's there.

I leave today. The patients are ready and the team is ready. I just have to travel for about 36 hours and I'll be ready.

Many thanks to my wife for letting me organize all the supplies in the foyer of our house!

MORE LIPS

"The two most powerful warriors are patience and time“ - Leo Tolstoy

SEPURUCHI

Sepuruchi was a wild banshee from the moment I saw her February, 2011. She didn’t want to have anything to do with examinations, surgery or me.  She had a benign hemangioma of the lip (a collection of blood vessels) that was growing.

At first, I considered doing some fancy surgery such as an Abbe-Estlander Lip switch in which a portion of the upper lip is transferred to the lower lip. But then I remembered KISS (Keep It Simple Stupid). I decided to just excise the lesion, and, if the results were unsatisfactory,  return for a more complicated surgery.

I did the operation and, in the week following surgery, it looked worse every day!  I fretted about it day and night. Finally, I told the Mom we would see how it looked on the next trip. When she returned July, 2011, my dreams were fulfilled. The result wasn’t perfect but it was pretty good and Mom was happy. Sepuruchi still wasn’t, however.

HEADING BACK

One more day till I return to Nigeria. There are dozens of patients lined up for surgery. I am anxious to go but one thing is holding me back!

Ready for the zip line in the Dominican Republic

SCHWANNOMAS

Schwannoma specimen

Schwannomas are peripheral nerve tumours of nerve sheath origin which are usually benign. These lesions are uncommon but we operated on two during my last trip. Both patients presented with a large neck mass which was unsightly but asymptomatic. 

Schwannoma beneath the carotid 

In the neck, these tumors can be intimately involved with the carotid artery and/or the jugular vein. In the case of our male patient, the tumor was growing under the carotid and pushing it outward. The tumor came out easily once we dissected it free from the carotid. 

Schwannoma excised

Scwannoma specimen

These tumors are fun to remove and have a nice name.

BLACK BOX

In Nigeria and many places in the third world, the patients are "black boxes". We really don't know whats going on inside them. Most diagnoses are made clinically or with the scalpel scan since most patients cannot affort costly diagnostic tests. This contrasts with the USA, where, for example, almost every patient that comes to the ER with abdominal pain gets an "abdomnal panel" and abdominal CT. 

This 3D reconstruction of a CT shows a pulmonary arteriogram which also catches the upper abdominal vessels. The detail is incredible. The celiac axis, hepatic artery, splenic artery and SMA are beautifully visible. Pathology cannot hide from this test.

While these tests are great and the detail exquisite, in most cases we don't need these tools. Good clinical exam and judgement can usually produce good clinical results.

Nonetheless, the scalpel scan will always be a powerful tool in the third world.

LOSS OF DOMAIN

We see some incredible hernias in Nigeria-inguinal as well as ventral. Many of these have been present for decades! Sometimes the intestines bulge out of these patients so long that they do not want to go back into the abdomen. The term loss of domain refers to the clinical situation where the viscera live in the hernia rather than in the abdominal cavity. This lady is a typical example. We were able to repair her hernia using mesh.

Loss of domain

Repair of these hernias can be difficult, sometimes almost impossible, without mesh. Unfortunately, mesh is expensive-way beyond the means of our typical patient. Fortunately, companies such as Ethicon, Atrium, and Covidien have been very generous in donating their product. 

Repair with mesh

Many of the Nigerian surgical residents and surgeons who come to work with me in Nigeria have never used mesh. It is very exciting for them to learn mesh repair and bring this knowledge back to their medical centers.

Dr. Ifeanyi with donated mesh

WOULD YOU KISS THIS MAN?

This patient arrived during my last trip. He had a lip lesion that had been growing for about a year. The lesion occupied at least 50% of the lower lip. We performed a simple wedge resection and the results were very good. The lips are very forgiving. They are elastic so they tolerate a large resection yet still look and function normally.

The pathology was invasive squamous cell carcimona. We will keep a close on on the lip to make sure there is no recurrence.

BLOOD

"In the midst of his finger-fiddling, Bailey tore the wall of the aorta. Blood poured from the patient's chest. Death was inevitable. Kantrowitz exclaimed in despair, at which point Bailey turned around and said, his stare cool and unblinking above his mask, "Adrian, if you are going to be a heart surgeon, you've got to remember one thing. The blood on the floor is not your own" - Charles Bailey, cardiac surgeon to Adrian Kantrowitz, cardiac surgeon in training".

Author giving blood

Blood is a problem in Nigeria. Nigerians don't like to donate blood. I am not sure exactly why.  Many are anemic to start. Many feel that it will drain their strength and reduce their ability to work-which is often hard labor. I'm sure there are other reasons but the bottom line is that blood is often scarce when you need it. As a result, the missionary team is often the walking blood bank. We all know our bood type and when the need comes, we give blood. I have given blood every week for three weeks, without any side-effects. Of course, when we give blood, the blood on the floor may well be ours. 

Nigerians are very thankful when you donate blood to them. I gave blood to a nurse at the hospital 20 years ago and she still thanks me for it every time I see her.

We save blood whenever we can. In cases such as a ruptured ectopic, we use our special "cell-saver". This consists of a funnel with guaze in it. We scoop up the blood from the abdomen with a decanter and pour it into the funnel. It comes through into an attached rubber tubing which is clamped. Then we collect the blood from the tubing with a blood bag. Near instant autotransfusion!

ADENOID CYSTIC CARCINOMA

Adenoid cystic carcinoma (ACC) is a bad cancer. During my last trip, we enountered 4 cases-all of the parotid gland. The surgery is difficult. It requires dissecting the facial nerve from the tumor. A simple mistake can injure the facial nerve and result in paralysis of all or part of half the face. This patient's tumor was relatively small (by NCH standards) and the dissection went well. There is very few things more pleasing to a head and neck surgeon then seeing a symetric smile on a postoperative parotid patient. I hope she is cured. 

The next patient was not so fortunate. She presented with recurrent ACC (My ego forces me to state that I did not do the first surgery). The surgery was actually relatively easy since her nerve was already non-functioning. We resected the tumor and did a radical neck dissection. We will send her for radiation but, unfortunately, the tumor is radio-resistant. In addition, radiation improves local control but probably does not improve survival.

This last patient arrived at NCH in 2010. She had a large fungating ACC. 

We did a radical resection which left a large defect of skin. After the patient recovered for a few days, we took her back to surgery and performed a pectoralis major myocutaneous flap to close the wound.

Pectoralis major myocutaneous flap

After the second surgery, she asked me to call her brother in the USA. Amazingly, he lives only four hours from my house. When I returned to the USA, he came to visit me and we have become great friends! Unfortunately, this nice lady died from metastatic disease about one year after surgery. 

Skin defect closed with flap 

PATHOLOGY

Pathology Specimens

On my mission trips, I see a large number of patients with tumors. Most of these patients ultimately require surgery. Surgically removing a tumor is not the end of the work, however. Just like in the USA, it is necessary to determine the type of tumor removed and what additional treatment is necessary. So what do we do with all the terrible tumors we remove in Nigeria?

Squamous cell carcinoma of the face in an albino patient

At the end of each case, we cut off a small specimen of the tumor to bring back to the USA. We don't take a specimen from every tumor we remove, just the ones that might be cancer, in order to cut down on costs. At the end of a typical trip, we have about 40 specimens (about one third of the cases). Before I leave, I tell each patient to contact the doctors in the hospital in about 6 weeks in order to get the pathology results. We also have their phone numbers and they have my email.

Next, we have to get the specimens though Nigerian customs. This can be tricky, occassionally. Customs officers have been known, on occasion,  to look for problems so that they can get a "gift" to solve it. One time the customs officer opened my box of specimens and demanded to know what they were. I told him they were body parts! He quickly closed the box and waved me through. 

Danny Milner, MD

Finally, I send the specimens to the pathologist. I am very fortunate to know Dr. Danny Milner, a pathologist at the Brigham and Women's Hospital in Boston.  Dr. Milner  has been traveling to Africa since 1997 and spent the last 11 years visiting Malawi to work in the Histopathology Department of the University of Malawi College of Medicine.  Dr. Milner actively collaborates with clinicians and scientists in Senegal, Mali, The Gambia, Nigeria, Rwanda, and Haiti for both medical pathology support and research efforts.  His humanitarian efforts focus largely on creating, expanding, and supporting pathology services in underserved areas through initiatives with the Dana-Farber Cancer Center, Partners in Health, the Harvard School of Public Health, and the Brigham and Women's Hospital.

Dr. Milner is the answer man. He and the Brigham team examine the specimens and determine what we have removed. Then I send the results on to Nigeria and all the patients are contacted. Despite the complexity of the followup, we are usually able to contact almost every patient.

LESS IS MORE

OR at the Nigerian Christian Hospital

On mission trips, we average ten major surgeries per day. Some days we do twelve cases.  We have two operating tables in a large room and usually do spinal anesthetics on one table  and general anesthetics on the other.

People often ask me how we get so many cases done. Simple-we don't fart around. Everyone is always working and we keep things simple. If we need a right angle clamp and we only have a tonsil clamp, we use the tonsil. I always say "If you can't do it with a can opener, then you probably can't do it.

Anesthetic machine

Of course, it takes a team to get the work done. Someone has to get the patient, start the IVs, set up the OR table, clean the room, set up the packs, etc. I work with a motivated group of people in Nigeria and without them, not much would get done.

OR team during excision of large ovarian tumor

THE REST OF THE STORY

It is not unusual to come upon a surgical mystery on the mission field.  The expression "I don't know what it is but its the worst case I've every seen" is funny,  but true. 

One time a elderly female patient came to see us with a complaint of pelvic pain and vaginal bleeding. She had a scar on her lower abdomen but did not know what surgery had been done. We feared the worst and assumed she had cervical cancer. We performed a pelvic exam and felt something like a wire ring in her upper vagina, but we could not remove it.

We put the patient asleep and  repeated the exam. We could see some wire rings partially eroding through the vagina. We grabbed them with a clamp and, with some difficulty, pulled the object  out. She recovered without difficulty.

Pessaries

Homemade pessary

After the surgery, we got the rest of the story. Someone had made her a  homemade pessary for uterine prolapse. She had it is place for years! Here are some  modern pessaries.

DEATH BY STRANGULATION

Strangulated hernia

This poor man came to the hospital with groin pain. His hernia, which he had for more than 10 years, was incarcerated for 1 week. We immediately took him to surgery and found strangulated bowel. He was septic and died after several days. 

He died from a simple problem that could have easily been corrected-a hernia. Unfortunately, he did not have enough money to get a repair.  This occurs often in the third world but also in the USA. The WHO estimates that one billion people lack access to healthcare-one seventh of the world's population. 

The dark reddish, black areas are dead intestine

There is no health insurance in the third world. In some countries, and even in a few parts of Nigeria, the government will pay for healthcare. But there are often long delays. In most of Nigeria, health care is paid for out-of-pocket. If there is nothing in the pocket, then there is no health care.