WOULD YOU LIKE A MAMOSA?

A free upgrade to first class on a 12 hour Transatlantic flight is a great way to end a long trip!

HUMPTY DUMPTY

Mary came to NCH in August 2010. She had a tumor of the maxilla that had been growing for years. At surgery, we found that the maxilla was completely destroyed by the tumor-medial, lateral, inferior walls were gone. The orbital floor was also gone and the eye was sitting on tumor. The zygomatic arch was partially destroyed. The pathology showed fibrous dysplasia/ossifying fibroma. 

After resection of the tumor

As a result of the destruction of the maxilla, the face "caved in" after surgery since there was no bony structures to support it. In addition, there was a large defect between the sinus and the oral cavity. Mary also had difficulty closing her right eye. We performed a tarsorrhaphy which helped somewhat. Mary kept coming back for checkups and this trip we decided to do some corrective surgery.

We raised a temporalis muscle flap and placed it into the sinus cavity. This filled the facial defect as well as the defect between the sinus and the oral cavity.

The initial results are good but we will see how things look after the swelling decreases. We may need to place a support under the eye to rebuild the orbital floor.

Incision for temporalis flap

Flap raised off skull

Flap placed in sinus cavity

Results after 1 week

I THINK WE CAN AGREE

I think we can agree that this man looks better after surgery. It will be interesting to see what the pathology shows. We will do some reconstruction on his palate in the future or, perhaps, obtain an obdurate prosthesis which can isolate the nasal cavity from the oral cavity.

Maxillary Tumor

After central maxillectomy. The dark area below the lip is
the nasal cavity.

Postoperative day 1-Rapid Rhino nasal packs in place to
control bleeding, tracheostomy tube removed

AMELOBLASTOMA REDUX

This man came in with a slow growing tumor. He is from River State-quite far from NCH. He has an ameloblastoma.  The mandible was paper thin and completely replaced with tumor and fluid from the midline up to the temporomandibular joint. We performed a hemimandibulectomy with disarticulation of the joint.

Ameloblastoma

After hemimandibulectomy

Mandible cut longitudinally- completely replaced with tumor

WORK IS OVER

We performed 159 cases in 21 days. I am going home. The work is over but the job isn't done. We still need to get the pathology results and decide on treatment plans for the patients with cancer. The next trip is in July and patients are already waiting.

IF IT BLEEDS, WE CAN KILL IT

I don't know what this is but it is the worst case I have ever seen. The patient walks around with a rag over his mouth and looks like a robber. We will operate tomorrow!

SCRUB TECHNICIAN/RN

Prince Ezenwa is our new surgical technician. He has been in OR for 3 months. He is quite good.

NEUROFIBROMATOSIS

Some may remember this little girl with neurofibromatosis. She came for a 3 month followup after excision. She is doing well. The result is not perfect but it is better. We may do some more surgery when she is older.

 Neurofibromatosis

After resection

TIRED BUT HAPPY

Author-he needs to shave

MIRACLE

Here is our baby with jejunal atresia!!!

WHAT OF MINE?

Last night, after completing the Whipple Procedure and several other surgeries, I hobbled out of the OR. I met a pleasant lady sitting on a bench. She has been waiting patiently for her exploratory laparotomy. She said to me, "What of mine?" I said, "ndo (sorry), I am too tired". "Echi bu ubochi ozo (tomorrow is another day)"

She was happy with my attempts to speak Igbo. She was grateful that she would be taken care of eventually. Nigeria is a society where it is hard to get what you need. Most Nigerians are used to waiting and also to being disappointed. We won't disappoint this patient. Her surgery will be today.

ADDENDUM: Our sweet lady has some type of uterine cancer with malignant ascites. We will commence chemotherapy once she recovers.

WHIPPLE

We just completed the first Whipple Procedure at NCH for a patient with an ampullary carcinoma. Drs. Mike, Uche and Ifeanyi came to assist and Smart Uruakpa was the scrub nurse. Wilson and Eric did the anesthesia. The surgery took 3 hours and everything went smoothly. 

Pancreaticoduodenectomy specimen

CIRCLE OF LIFE

I taught Dr. Mike, who taught Dr. Uche, who is teaching Dr. Madu. As surgeons, it is our responsibility to pass on our knowledge to the next generation.

Dr. Uche and Dr. Madu

IT IS GOOD TO LOVE YOUR WORK BUT...

Taylor displaying an orchiectomy specimen. You can love your work too much!

SARCOMA OF THE THIGH

This elderly male came with a slow growing thigh tumor for 5 years. It appeared to be a sarcoma of the medial compartment of the thigh. We did a compartment excision. The specimen appears to be a liposarcoma on sectioning. He has an incidental right groin hernia that we will fix in the future.

Medial compartment excision

Specimen-it appears to be a liposarcoma

ADDENDUM (5/23/12)-The patient is doing well-the wound is still draining but slowing down.

HOLY GRAIL

Patient with deep jaundice secondary to biliary obstruction

This lady is not possessed! She has a problem that is the surgeon's holy grail of operations-operable cancer of the head of the pancreas. While we don't like our patients to half terrible diseases, most surgeons do like interesting cases. This patient will require a Whipple procedure which we plan in 3 days time. Drs. Mike and Uche will come to NCH and we will do the procedure together.

DRAPES

These are our new cloth drapes from the USA. They are a heavy cloth and great for our work. They replace the drapes that are disintegrating. Note Taylor estes (left), Dr. Mike (middle) and Smart Uruakpa (right)

SPLENOMEGALLY

Today we operated on a patient with a large spleen. She was symptomatic with  pain and satiety. Splenomegally is common in the tropics. The causes can be many including parasitic infections (especially malaria), viral infections, blood disorders, infiltrative conditions, congestive splenomegally and tropical splenomegally syndrome. We suspect our lady has a lymphoproliferative disorder since she has a high white count.

Splenomegally

SUBSTERNAL

Not all thyroids are in the neck. Today we operated on a lady who had a previous left thyroid lobectomy. She came in with a large goiter on the right and some difficulty breathing at night. This is an unusual complaint since most Nigerians I have encountered do not have breathing difficulty, even when they have giant goiters. We removed the left thyroid remnant and then the right goiter but there was a large mass extending into the mediastinum. I could feel the mass between the left carotid, left subclavian and innominate arteries and extending around the aortic arch. With some struggling, I was able to deliver the substernal goiter into the neck and remove it. 

Unfortunately, she bled after the surgery and required a left anterior thoracotomy. There was no blood available, so I scrubbed out of the case and donated, since she was my blood type. I feel like I am in an episode of the Vampire Diaries. We finally controlled the bleeding. We are both anemic now!

Goiter-the substernal component is next to the scalpel

Another episode of the Vampire Diaries

UNNA BOOT

Leg ulcer of unknown etiology

Leg ulcers are the bane of the surgeons existence. These ulcers are common in Nigeria from various causes. Occasionally, I use an old fashioned method of treatment-the Unna Boot. Unna Boots are named after a German dermatologist, Paul Gerson Unna. Dr. Unna specialized in diagnosing and treating diseases of the skin. The Unna Boot itself is a compression dressing, usually made of cotton, that has a zinc oxide paste applied uniformly to the entire bandage. The zinc oxide paste in the Unna Boot helps ease skin irritation and keeps the area moist. The zinc promotes healing within wound sites, making it useful for burns and ulcers.

Unna Boot with Coban wrap

KNOWLEDGE IS POWER

A significant problem in the third work is access to knowledge. Textbooks are prohibitively expensive. GLOBAL HELP is working to solve this problem by disseminating free online textbooks. This group is making a difference in the world. I have used their Paediatric Surgery: A Comprehensive Text for Africa and is is great.

PROGRESS

We have been working for 13 days and have completed 117 operations. Today two volunteers from the USA arrive-Taylor Estes, a pre-veterinary student who has been to NCH twice and Erna Winkler, an RN.  Patients continue to pour arrive. We hope the next week will be our most productive.

FAKE GUCCI

We have all heard of fake Gucci Bags. But have you heard of fake surgery? Unfortunately, this happens in Nigeria sometimes. Patients will come in with right lower quadrant pain, for example-having had an appendectomy. We explore the patient and find an appendix with no scarring and no evidence of past surgery except a scar on the skin. 

Today I saw a woman who apparently had a incomplete abortion. She went to a local doctor and had an ultrasound that showed retained products of conception. A D&C was performed but she kept bleeding and came to us. I performed a repeat D&C and found a uterus full of retained products. Clearly, no D&C had been performed. She got a sham operation but not a sham bill!

DISCHARGE

Our lady with the malignant parotid tumor is ready for discharge. Her wounds have healed well. As expected, she has a 7th nerve deficit. She will need radiation therapy.

Parotid tumor

Post excision

ANOTHER HELL

When she took off her shirt,  I thought I was in Zombieland-Brian Camazine

To die with the stench of rotting flesh is a special hell. We can't do much for this lady. I always wonder why they come so late. 

AN OLD FRIEND RETURNS

Diseases desperate grown
By desperate appliance are relieved.
Or not at all.


Hamlet


Some may remember the following post from 9/29/11. There is some followup at the end.

Ngozi arrived at the hospital several days before I came. She was told that I was coming and might be able to help her. She reportedly has 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.

Ngozi came back to visit today. The final pathology showed dermatofibrosarcoma protuberans-a non-malignant tumor,  but one that can be very locally invasive. The surgery was radical but she is doing well.

SUBMANDIBULAR GLAND

This lady came with a large submandibular mass. It was freely mobile and is certainly a pleomorphic adenoma-a benign tumor of the salivary gland. Occasionally these masses turn out to be a mucoepidermoid carcinoma-a malignant tumor. This mass was removed without difficulty. We await the pathology results.

Cut section of tumor

JEJUNAL ATRESIA

This 2 day-old baby came in today with a distended abdomen and inability to pass meconium since birth. We operated and found complete situs inverts, malrotation and jejunal atresia. We resected the non-functioning segment, and did a Ladd's Procedure. 

Jejunal atresia Type 1. Notice the sharp transition zone on
 the left between distended bowel and collapsed distal bowel.