LEAVING

I will fly into Lagos next week for the May Humanitarian trip. Many patients are waiting and we are going to be busy! Follow the Blog to see our surgical adventures.

TOO OLD

I hope my patients in Nigeria don't realize I am over the hill!!

GENERAL SURGERY NEWS

In the News

Study hints at 'Prime Time' for surgeons: 35 to 50 Years Old

By Victoria Stern

Surgeons between the ages of 35 and 50 may provide the safest care to patients undergoing thyroid surgery, according to a new study published online Jan. 11 in the British Medical Journal(2012;344:d8041).

Overall, investigators found that surgeons within this 15-year age range had a lower risk for postoperative complications during thyroidectomies when compared with both their less and more experienced counterparts.

“The take-home message of the study is that surgeons can’t necessarily expect to maintain their top performance without trying to improve every day,” said lead study investigator Antoine Duclos, MD, assistant professor of public health in the Department of Medical Information, Health Evaluation and Clinical Research at Lyon Academic Hospital in France. “Surgeons should want to assist in tracking their own outcomes over time to see whether they are performing well and how they can get better.”

Previous studies have shown that surgeons generally reach their peak performance between the ages of 30 and 50 years and that physicians in practice for more years tend to possess less factual knowledge and are less likely to adhere to guidelines. In 2006, researchers looked respectively at mortality in approximately 461,000 patients undergoing one of eight surgical procedures between 1998 and 1999 and found that for pancreatectomy (adjusted odds ratio [OR], 1.67), coronary artery bypass grafting (OR, 1.17) and carotid endarterectomy, surgeons older than age 60 years, particularly those with low procedure volumes, had higher operative mortality rates than their younger counterparts (Ann Surg 2006;244:353-362). For the other five procedures, however, surgeon age was not an important predictor of patient mortality.

Although the results showed a tenuous relationship between age and postoperative risk, the study helped spawn a discussion about the possible drop in surgical performance over time. “Is there a decline in fine motor skills, worse judgment with advancing age, less of a grip on how to use new technology?” asked Amir A. Ghaferi, MD, MS, research fellow with the Michigan Surgical Collaborative for Outcomes Research and Evaluation group, in the Department of Surgery, University of Michigan Health Systems, Ann Arbor, who was not involved in the study. “I don’t think anyone really knows why a surgeon’s performance may decline after a certain age. You can speculate until you’re blue in the face, but it’s hard to say anything definitively.”

To help clarify whether years of surgical experience are associated with postoperative outcomes, Dr. Duclos and his colleagues prospectively collected outcomes data on 3,574 thyroid procedures completed by 28 surgeons between April 1, 2008 and Dec. 31, 2009, at high-volume referral centers in five academic hospitals in France. The team used thyroid surgery as a benchmark because it is a highly reproducible and well-defined procedure that has not changed substantially in many years. The two major complications of thyroid surgery measured—recurrent laryngeal nerve palsy or hypoparathyroidism—were evaluated once 48 hours after surgery and again six months postsurgery. The researchers also recorded all patient demographics as well as surgeons’ background and professional experience, adjusting surgical performance by the type and complexity of cases treated.

The investigators discovered that surgeons with five to 20 years of experience, those between the ages of 35 and 50 years, had the lowest risk for permanent complications after thyroid surgery. And it was surgeons in practice for 20 years or longer, not inexperienced surgeons, who had the greater increased risk for permanent complications after thyroid surgery. According to a multivariate analysis, 20 years or more of practice was associated with increased probability of both recurrent laryngeal nerve palsy (OR, 3.06; P=0.04) and hypoparathyroidism (OR, 7.56;P=0.01). The researchers, however, did not identify a volume threshold or a particular time of day associated with an increased risk for complication.

Dr. Duclos and his co-authors pointed to several possible explanations for why surgeon performance can decline over time, including mental fatigue from repeating detailed procedures over many hours, reduced stress with age or habits that might lead to poor compliance and increased complication rates as new techniques are introduced. Additionally, many veteran surgeons spend more time on academic and administrative duties than their younger colleagues, which could affect their attention in the operating room.

“Despite these findings, surgeon age is still a pretty weak predictor of outcomes, and the study is not predictive on the individual level,” said Dr. Ghaferi.

Dr. Duclos added that the results certainly cannot be generalized. “We don’t know if this trend holds for other surgeries, in other countries at other hospitals,” said Dr. Duclos.

To make sure surgeons continue to execute their surgical duties at a high level, Dr. Duclos suggested that the individual performance of surgeons should be tracked over time, not by benchmarking, but by receiving feedback on their outcomes every month or every quarter and by continuing to train in new techniques in order to keep sharp. “This way, if at some point a surgeon starts to perform poorly, he or she can work on figuring out the problem, sharpening techniques or changing tactics,” Dr. Duclos said.

Dr. Ghaferi agreed that surgeons may need coaching throughout their careers. “We need tactics that we can implement throughout a surgeon's career, even when we reach our pinnacle, to make sure we are up-to-date with the latest techniques.”

NEXT TRIP

I am returning to Nigeria in about one week and taking a truckload of supplies-I hope I can take it as carryon! Seriously, I do have a lot of supplies that will make a critical difference in our surgeries-mesh, suture, drapes, laps, towels, floseal, antibiotics, books, etc- and chocolate.

Patients are signed up and I expect about twenty to be in the hospital waiting for thyroidectomies, cancer surgery or herniorrhaphies. 

If you have any supplies for future trips, please contact me.

GIANT GOITERS

Removing a giant goiter like this one, which is common in Nigeria, is a formidable task. They have large blood vessels that are very friable. Often the bleeding doesnt stop completely until the goiter is completely out. In addition to removing the goiter safely, we need to do it expeditiously-on mission trips, there are a lot of patients waiting. We have developed some tricks to do it.

First, we get the goiter out of the neck and mediastinum-rather than working on the goiter in the neck. The relatively small skin incision, compared to the size of the goiter,  tends to constrict the base where the vessels are coming from. Second, we work fast. We only ligate the "staying side of blood vessels" while the assistant applies pressure to the "specimen side of blood vessels". We also use a clip applier when available. These clip appliers, made by AutoSuture or Ethicon, really help things move along. Third, if bleeding becomes heavy in one place, we apply pressure and work somewhere else. Fourth, we identify parathyroid glands and the recurrent laryngeal nerves early and protect them. 

The above are basic principles-nothing really new. We usually complete a total thyroidectomy in about one hour. A bunch of these goiters are waiting for us  for our May trip.

SURGICAL MESH

 

Various surgical meshes

Surgical mesh has revolutionized the repair of hernias. Mesh dramatically reduces the rate of recurrence and allows the repair of some hernias that simply cannot be repaired otherwise. This is especially true in undeveloped countries where patients often come with giant hernias that have been growing for years. The hernias are so large, they can't work.  Often, these patients present with strangulated hernias and die. Many of these hernias have been repaired, but recur since no mesh was available.

Giant groin hernia

Mesh is fantastic stuff! Common meshes are a weave of polypropylene, which is inert in the body and is great for patching holes. Unfortunately, mesh is expensive. Common brands can cost hundreds or even thousands of dollars per repair. This is unaffordable in undeveloped countries, such as Nigeria, where our patients may only be making $100/month. 

We have a solution. We have found that mesh can be used after soaking in our antiseptic solution, without any risk of infection. Yes-I know this is radical, but in clean hernia  repairs, we have found infections to be exceedingly rare, even in our environment that is only semi-sterile. You  work with what you have! We purchased bulk mesh that we cut to size,  reducing the cost of a piece of mesh for a groin hernia to about $10. 

Giant groin hernia

Hopefully, one day, patients won't die from something as easily repaired as a hernia.

MORE ON "WHAT IT TAKES"

“We cannot be sure of having something to live for unless we are willing to die for it.” ― Che Guevara Thursday September 3, 2009 MISSIONARY DOCTOR UNAFFECTED BY KIDNAPPING

 By GEORGE ROBERTSON, M.D.

Dr. Brian Camazine, a general surgeon from Texas, was at the Nigerian Christian Hospital during the time of the recent hijacking and kidnapping of the resident missionary doctor Robert Whitaker. In a telephone interview with him on Aug. 26, Dr. Camazine seemed unaffected by the barbaric treatment of his partner. Dr. Camazine said that he was watching a movie with the headphones on and thought the gunshots in the neighboring compound were part of the video. When he took his headphones off, he realized that they were shots next door. In an adjacent bedroom were two college girls who also heard the gunshots and called their parents in the United States. Dr. Camazine’s next contact was a call from the U.S. from the parents of the two girls who had called home. Rather than going to the next room to be advised as to what to do by the doctor chaperone, they had called the U.S. About an hour later, the word came that Dr. Whitaker had been abducted. The girls were completely freaked out by the situation and next morning they made plans to leave to go back to the U.S. while Dr. Camazine went to the hospital to take care of the guard who’d been shot in the hand. He said that following this surgery a daily schedule of surgical patients were operated on and he continued right on with his work as if nothing had happened. He did hire four guards with AK-47 guns to stand guard at night after the incident. The guards would shoot their guns every couple hours just to let any would-be robbers know that considerable firepower would be at the doctor’s disposal. Brian still plans to return to the Nigerian Christian Hospital in December. He did say that other doctors who had planned a trip later in the year were canceling their visits. Among those doctors are Dr. Netterville from Nashville and Dr. Robertson from Lebanon. Editor’s Note: Robertson is a physician with Family Medical Associates, PC, in Lebanon.

WHAT DOES IT TAKE TO BE A HUMANITARIAN SURGEON?

MANUAL OF ONCOLOGY

WHERE THERE IS NO ONCOLOGIST

A MANUAL OF PRACTICAL ONCOLOGY IN RESOURCE-LIMITED SETTINGS

Kelechi Eguzo, MD ¹

Chisara Umezurike, MD ¹

Charlotte Jacobs, MD ³

Brian Camazine, MD ^1,2

¹ Nigerian Christian Hospital

² Earthwide Surgical Foundation

³ Stanford University School of Medicine

For several decades, I have been making pilgrimages to the Nigerian Christian Hospital (NCH) on humanitarian surgical trips. As a result of my interest and training in surgical oncology, an increasing number of cancer cases have come under my care. Initially, these were approached largely from the surgical aspects because few patients could afford chemotherapy, and no physician had any specific interest in oncology. I could perform surgery in a few weeks time but was unable to manage chemotherapy from the USA.

Several years ago, a confluence of opportunities arose. I began to take 3-4 trips per year to NCH rather than just one; I formed a collaboration with Dr. Danny Milner, pathologist at Harvard’s Brigham and Women’s Hospital; and, most importantly, I met a young, ambitious physician, Dr. Kelechi Eguzo.  At the time, many of our cancer patients were being referred to teaching hospitals for chemotherapy. I suggested to Dr. Kelechi that we stop this practice and deliver comprehensive oncology care at NCH. Dr. Kelechi took the idea and ran with it. He contacted many international oncologists, studied oncology on the internet and became a self-made oncologist. Thus, the Nigerian Christian Hospital’s Oncology Service was born!

Soon, we realized that the knowledge we were acquiring would be helpful for practitioners in resource-limited environments where residency trained oncologists are rare or non-existent. We decided to write a hands-on manual so that a greater spectrum of practitioners could deliver the basics of cancer care. Thus, Where There is No Oncologist was born.

We hope this manual will continue to evolve with time and be available to many practitioners. If you want   a copy of the manual, email me and I will send it.

Brian Camazine, MD

General,  Thoracic, and Head and Neck Surgeon

Chief of Surgery, Nigerian Christian Hospital

briancamazine@gmail.com

SKIN GRAFTING KNIFE

This is a Cobbett Skin Grafting Knife- donated to Earthwide Surgical Foundation by  Integra Lifesciences for our plastic surgery work in Nigeria. Grafts can be done without such a knife but they rarely come out as well. This knife is a real beauty!

The history of skin grafts has its beginnings in ancient India, where Sanskrit texts document skin transplants performed by Hindus in 3000-2500 BC (1-3). Potters and tilemakers of the Koomas caste were reconstructing noses which had been mutilated as punishment for crimes such as theft and adultery. Grafts were obtained from buttock skin, which was reportedly slapped with a wooden paddle until red and congested, and then cut with a leaf to the appropriate size (3-5).

Despite early attempts at plastic and reconstructive surgery, hundreds of years passed until further work advanced the practice of skin transplantation. In Italy in 1442 AD, Brancas developed a novel technique of binding the patient's arm to the site of the skin graft (3). Brancas used skin from the arm to transplant a slave's nose to his master's nose. He unfortunately did not receive recognition for his technique of nasal reconstruction, which was instead credited to his fellow countryman, Tagliacozzi, over a hundred years later. Tagliacozzi, who is considered to be the pioneer of modern plastic surgery, publicized Brancas' method of skin grafting. Although he repaired soldiers' facial battle wounds, the most common reason for nose deformities at that time was tissue infection due to syphilis. In 1597, Tagliacozzi published his work in "De curtorum chirurgia per insitionem," and in so doing, transformed plastic surgery from a trade service to a scientific procedure (3).

In 1804 Baronio demonstrated the first successful autograft using the backs of sheep (4). By 1823, Bunger achieved the same success with autografts in human subjects. Attempting to revive the ancient Indian method of rhinoplasty, Bunger repaired nasal defects using full-thickness skin grafts from the patient's thigh (3,4). In 1869, the Swiss surgeon Reverdin performed the first allograft by pinch grafting very thin pieces of epidermis ('epidermic grafts') (3,9). Using this first split-thickness skin graft, Reverdin demonstrated a more rapid healing of granulating wounds. Two years later, Oilier furthered Reverdin's work and demonstrated a better outcome by using skin grafts that were not only composed of epidermis, but also contained a portion of the dermis (3,4,10). These 'dermoepidermic' grafts effected faster wound healing with less scarring. In 1871 Pollock introduced the idea of using skin grafts to treat burn wounds (11,12). He donated small pieces of his own skin which he used in conjunction with a burn victim's skin to cover a large denuded area. The idea was brilliant and paved the way for one of the most important modern functions of skin grafts, the treatment of burn victims. By the end of the century, Wolfe (13) had introduced full-thickness skin grafts into clinical practice to treat ectropion, and Girdner (14) had published the first report of skin grafting with human cadaveric skin.

The use of skin grafts revolutionized the care and ultimately the mortality of burn patients. However, problems arose because donor grafts uniformly died. Research in the twentieth century thus began with attempts to understand the physiology of graft survival (15). It was not until 1943 that Medawar and Gibson discovered that the rejection of transplanted skin was mediated by the body's immune system (16). The 1940s also witnessed the use of refrigerated skin as a temporary dressing (17), the development of the electric dermatome (18), the establishment of the first U.S. Skin Bank (19), and the discovery of a cryopreservative agent which allowed the freezing of tissue in a viable state (20).

In the latter half of the twentieth century, cadaver skin was employed as a biological dressing in burn patients and research revealed additional merits of skin grafting (21). In addition to providing wound coverage, Eade (22) proved that the bacterial count decreased after graft skin was placed over a wound, and O'Donaghue and Zarem (23) discovered that skin allografts stimulated neovascularization of the wound bed. By the early 1970s, cryopreserved skin (24) had been successfully grafted and a method of in vitro cultivation of epithelial sheets (25) had been developed. With the advent of cultured epithelial autografts, the problem of allograft rejections was eliminated, as was the problem of skin donor availability (26,27). However, cultured epithelial autografts could spontaneously blister and also took time to produce, typically a couple of weeks. And so the search for an optimal wound dressing continued.

In 1987, the term 'tissue engineering' was coined at a National Science Foundation meeting (28). The goal for scientists now was to create a readily available tissue replacement with the biologic and pharmacologic properties of human skin (29,30). In 1998, Apligraf, a bilayered construct of neonatal foreskin fibroblasts, keratinocytes, and bovine collagen, was the first tissue engineered skin to gain FDA approval (28).