DELTA BAGGAGE WAIVER!!!

Delta Airlines granted Don Thompson and I a waiver for a third bag. Now we can each bring in 150 lb of supplies. WOW!!!

CYSTIC HYGROMA

This poor woman has a recurrent cystic hygroma. She has had 2 surgeries as a child and 2 as an adult. The tumor is back againm. She is coming to see us in January. 

I would describe this disease as the bane of the head and neck surgeon's existence. These tumors are difficult to remove-the surgery can be long and tedious and it can be difficult to preserve important structures in the neck. If it is not completely removed, recurrence is common.

A cystic hygroma (also known as cystic lymphangioma and macrocystic lymphatic malformation) is a congenital multiloculated lymphatic lesion that can arise anywhere, but is classically found in the left posterior triangle of the neck. This is the most common form of lymphangioma. It contains large cyst like cavities containing watery fluid. Microscopically cystic hygroma consists of multiple locules filled with lymph. In the depth the locules are quite big but they decrease in size towards the surface.

We will do our best to make this her last surgery!

KIDNAPPING

Kidnappers took a short break in Abia State but are back in action. Dr. Donatus Eze, one of the longest serving physicians at Nigerian Christian Hospital,  was kidnapped last night on the way to Aba. Kidnapping is a plague on Abia State and will be its undoing. Everyone is praying for his early and safe release.

Rising Cases of Kidnapping
From THE SUN-August 13, 2102

A recent report released by Campaign for Democracy (CD), a human rights body, indicates that the scourge of kidnapping in Nigeria, particularly in the South East, is rising steadily. According to the study carried out by CD, the South East has, in the past five years, recorded about 938 cases with about N1.2bn paid out as ransom.

We hardly can rely so much on these figures released by CD since it is not all cases of kidnapping that are usually reported or made public by affected families.

Besides, it is a well known fact that some families that have fallen victim to kidnapping do not like to disclose the amounts they paid out as ransom. Be that as it may, the fact that cannot be controverted is that cases of kidnapping are on the rise in the country.

This phenomenon is not only disturbing, it is a blot on the image of the country. Kidnapping as we know it in Nigeria today is a modern phenomenon. It is an offshoot of the decadence that is pervading every facet of our national life.

In recent years, the value system of the people of Nigeria has changed so drastically to the extent that values we used to cherish are no longer of any consequence to us.

The cohesiveness of family units and their consequent positive effect on the larger society have left us. Crass individualism and primitive pursuits have taken over. The result is that people now behave as if we are in a jungle where the strong must trample upon the weak to survive.

We hardly can discriminate now between acceptable and loathsome ways of life. This collapse in our values and mores has been exacerbated by the precarious social and economic conditions that pervade the land. Youth unemployment has become a monster.

Today, graduates of our tertiary institutions roam freely in the streets without gainful unemployment. There is no social security system that cushions the harsh effects of joblessness. The result is that a good number of these jobless youths indulge in anti-social pastimes. Kidnapping, armed robbery and prostitution, among others, are some of the fallouts of this set-up.

It is regrettable that our governments at all levels have not done much to tame the monster of youth dislocation occasioned by unemployment. Our governments have not taken deliberate and concrete steps to engage the teeming youth population meaningfully.

What obtains instead is that everyone is left to his own devices. Many have taken to unwholesome acts in this state of abandonment. But we cannot continue to live with this blight.

The defect in our social order must be addressed. The concerned governments across the country must see the scourge of kidnapping as a challenge. They must rise to the occasion and deal with it decisively. Paying lip-service to the problem as some of our governments do is unhelpful and will not help the effort to stamp out the scourge. The situation has also not been helped by law enforcement agencies, particularly the police.

One of the greatest inducements which kidnappers have received in the land is the prospect of not being punished when caught. Almost on daily basis, the police make arrests. Unfortunately, nothing is heard any more. We do not get to hear about the trial and conviction of arrested kidnappers. The result is that there is nothing to deter prospective offenders.

The police and its sister security agencies must wake up from their slumber. They have to change their approaches as well. Kidnapping relies on sophisticated technology and know-how. Our security agencies must recognize this and equally employ uncommon technology to arrest the situation.

It is embarrassing that the anti-social elements in the land have continued to have an upper hand. We must not allow this dangerous phenomenon to become a part of our national life.

NEXT TRIP

The next humanitarian surgical trip to Nigeria is january. patients are already lining up and jockying for position. It is a country where many never get the basics of what they need, so when an opportunity arises, they fight hard to get it. This is especially true with health care. When I tell a patients they will get surgery, many don't believe me until they are actually on the operating table. So you can be sure I make no promises until I am sure i can fulfill them-just to avoid a riot! We are ready and hopefully, no one will be disappointed.

APPLE

Steve Jobs died about 1 year ago. I didn't know him but he clearly loved perfection and precision. On our mission trips, we strive for the same. For me, surgery is an art and I like each creation to be perfect. This takes constant diligence. It is not enough to just do the surgery. For each patient, we do an evaluation before surgery, plan the surgery (sometimes this requires studying surgical texts and articles), coordinate with anesthesia and then get the surgery done. Often, this is just the beginning of the work. Postoperative care can be much more taxing and demanding than the surgery.  The pathology specimen must be taken back to the USA and processed. The diagnosis may determine that  further treatment is needed so the patient needs to be contacted and chemotherapy and/or radiation therapy arranged. Of course, the patient must have followup care, either by the local physicians or myself during the next visit. The surgery is the glamorous part but the postoperative care is critical. Skipping any of these steps can be disastrous and is unacceptable.

148

Of course, we ended up doing 3 more cases-patients that arrived at the last minute. The last case was a 69 year-old woman with a large tumor of the cheek. The tumor was located under the superior aspect of masseter muscle and had eroded into the lateral wall of the  maxillary sinus, partially eroding the lateral and inferior walls of the orbit and destroying the zygomatic arch. The tumor filled the maxillary sinus but appeared encapulated, suggesting it grew into the sinus rather than from the sinus. This was a very interesting and technically challenging surgery. We approached the mass from a parotid type incision. We were able to completely resect the tumor.  It was not clear where this tumor originated.

From this diagram, it is apparent how this tumor could cause the damage described. The aponeurotic portion of the muscle arises from the area of the zygomatic arch, and is near the orbit and the lateral maxillary wall.

145

This lady is our last case of the trip-case number 145 in 3 weeks. Everyone has worked very hard and it is amazing that we could do so much. We are already making plans for the next trip.

BIGFOOT

This lady presented with a 9 year history of foot swelling. This is possibly elephantiasis. She may also have TB so we are treating that first.

A Big Foot

Another Bigfoot

MORE STONES

A 20 year old man came in with a complaint of a bladder stone. We opened his bladder and he was right! The stone is quite beautiful.

SNACKS

When we get hungry in the OR, we send out for a snack-fried plantains. A small pack of 5-10 strips costs about 33 cents. Better than potato chips!

BREAST CANCER

As I have discussed previously, breast cancer is a bad problem in Nigeria. in the past several days, I have seen 2 patients aged 25 years with breast cancer. Many patients present in the late stages with necrotic tumors.

Young female with breast cancer

This poor woman has an enormous cancer. Immediately after I took this picture, the tumor started hemorrhaging. The patient lost several units of blood before I got her to the operating room and performed an emergency radical mastectomy! She is doing well now. 

Hemorrhagic breast cancer

This poor lady has recurrent breast cancer in the axilla. She had a previous modified radical mastectomy but I suspect the axilla was inadequately treated. 

Necrotic axillary tumor

GOITERS

Every trip we have a lot of patients with goiters. This trip is no different. Many are large, bilateral, and substernal. We have done 25 total thyroidectomies in the last 12 days. 

Goiter

Large goiter with intrathoracic component

Large goiter that was cancerous

Opened specimen

MORE ODDITIES

This baby has a large cystic hygroma-a congenital multiloculated lesion of lymphatic tissue. It can be difficult to excise completely. We operated and the surgery went well.

Cystic hygroma

 This 7 year old has bladder exstrophy-a congenital condition where the bladder is outside the abdominal wall. He also has abnormalities of the penis. Surgery for this condition is highly specialized so I referred the patient to an expert in this area.

Bladder Exstrophy

RETROPERITONEAL SARCOMA

We have completed 50 cases in the past 6 days. Today we started surgery with a lady who had a giant abdominal mass. At surgery we found a retroperitoneal sarcoma. It was attached to the transverse colon, spleen and stomach. We resected the tumor along with a splenectomy, colectomy and wedge resection of the stomach.

Retroperitoneal Sarcoma

Next we operated on a man with a giant inguinal hernia. He had the hernia for several decades!

Giant groin hernia

UNUSUAL THINGS

We have been seeing some unusual surgical problems-even considering that most of what we see is unusual.

Dr. Bock taking a break

This lady has had this parotid tumor growing for many years. We will resect it this trip.  It will be hard to preserve the facial nerve.

This man has an ameloblastoma. It has been growing for at least 5 years. Today we will do a hemimandibulectomy.

This lady developed a cystic forehead mass after head trauma. She probably fractired her frontal sinus and has a traumatic meningocoele.

Frontal sinus trauma

This man has a 4 year history of a mass of the upper lip. Biopsy showed basal cell carcinoma but he

never came for treatment. The lip has been constantly bleeding so he has been applying a salve. He will need resection of the entire upper lip.

Basal cell carcinoma

This is an intraoperative photo of a lady with a large abdominal mass. It is hard to discern from the photo but there was a very large mass approximately 12 inches in diameter coming off the stomach. The mass had the consistence of a brain! It was hollowed out and connected to a large hole in the stomach yet the mucosa of the stomach was normal. There were liver metastases. I am not sure what the pathology will show.

Gastric mass

NO TIME TO RELAX

The first 3 days of surgery have been a blur. We have done twenty-six cases so far. Dr. Dabs, Ifeanyi, Gbaanador and Drs. Bock are here assisting with the work. 

Dr. Gbaanador

Today we had a special visitor-the woman I did a Whipple Procedure on this past May came for a followup. Hre jaundice has resolved and she is doing well. She will start chemotherapy. 

Patient with ampullary cancer s/p Whipple Procedure

Despite working hard, there are still 21 patients waiting for surgery. More arrive every day.

TRADITIONAL HEALER OR ALIEN SIGNS?

This lady showed up with massive splenomegally. She had been treated by the local native healer.

Traditional healer signs

Alien signs

ARRIVAL

I arrived at NCH after 46 hours of total travel. Twenty-one patients were waiting for me! Here they are-pointing to their problems. Dozens more are pouring into the hospital. Surgery starts today.

YOU DON"T NEED SURGERY!

On my last trip, an elderly woman came with a goiter. It was moderate in size-noticeable but not so large that her chin rested on it. It was soft and almost certainly benign. She could breath and swallow without difficulty. I told her to leave it be. "Save your money" "You don't need surgery"!

She wasn't happy with that answer but I encouraged (or forced) her to leave. There was no need for her to risk the potential complications of surgery.

Realistically, this would not happen in the USA. This lady would have been signed up for surgery and booked for a date (assuming she had insurance) before she left the surgeon's office. In the USA, medicine is a business. When someone comes to your business, you don't sell them the cheapest thing you have, you sell them the most expensive. Have you ever gone to a car dealership and had the salesman try to sell you the bottom of the line model? No way. They start at the top. 

In Nigeria, it is possible to do what is right for the patient. That is one reason why its my passion.

WHERE IS THE NIGERIAN CHRISTIAN HOSPITAL?

The Nigerian Christian Hospital is located at Mile 11, Ikot Ekpene Road, Aba, Abia State, Nigeria, West Africa.

NEXT TRIP

I am ready for the next trip-beginning of September. Patients are lined up and waiting.

PUBLICATIONS

HAPPY BABY

This baby never stopped smiling!

YOU'RE GOING TO DO WHAT?

Not all our patients were enthusiastic about surgery.

Little girl for hernia repair

DEAR READERS-HELP

Mission trips are expensive and we are currently spending 3-4 months in Nigeria. In addition to paying our transportation, we also pay for room and board. Many of us pay for surgery, chemotherapy or radiation therapy for indigent patients. 

If you are able, please consider a donation. Earthwide Surgical Foundation has NO OVERHEAD, thus every penny donated is used for the humanitarian work. 

Earthwide Surgical Foundation is a 501(c)(3) non-profit organization thus donations are deductible. You will receive a letter acknowledging your donation.

If you want to donate, please donate via Paypal using the email address earthwidesurgicalfoundation@gmail.com

Thanks

STONES

I have a small stone collection from my patients in Nigeria. Stones can form in many parts of the body such as the gallbladder, kidney, bladder, appendix, tonsils, salivary glands etc. These stones can cause obstruction, pain, and infection,  so many stones need to be removed. 

The two stones in the lower left came from the distal urethra in a man. They were originally kidney stones that passed into the bladder and then into the urethra. They were too big to pass out and caused obstruction at the end of the penis,  like a ball valve. In order to urinate, the patient had to push the stones proximally! They were easily removed with a small incision.

TRIP SUMMARY

Author at work

This was a great trip! Of the eight team members, 4 were returning and 4 were there for the first time.  Drs. Uche Nkeonye, Mike Enyinnah, Dabs Ngwu and Mishack Akunekwe and nurse anesthetist, Wilson Anyanwu, returned to help, as well.

We operated for 5.5 days and did 54 surgeries. Hundreds of other surgical patients were seen that will have surgery in September. Overall, it was a very successful trip.

In the following days I will show some other pictures from the trip.

INTERNET

The internet was terrible the last few days so the blog has been difficult. On 7/20/12, we did 9 cases. We had several big cases including a boy with a large ameloblastoma. 

Ameloblastoma

Right hemimandible removed

Specimen

A mother brought her 1 month old baby in with abdominal distention. There baby had a large left sided mass. We did an exploratory laparotomy and found a large cystic kidney on the left and a much smaller cystic kidney on the right. There were megaureters and a massively distended bladder. We suspected some type of outlet obstruction. The left kidney was so large that we performed a nephrectomy.  The specimen showed that there was almost no functioning kidney remaining. We also placed a suprapubic catheter to drain the massively distended bladder.

Massively distended abdomen in a 1 month old

We also did two hernia repairs, a modified radical mastectomy, a laparotomy for SBO, a toxic goiter, a BKA and drainage of a deep neck abscess.