July 2013 - Week Three - Benjamin Howard

Dear Colleagues and Professors:

This marks three weeks here in Tanzania, and it's been another seven days of incredible experiences, fascinating cases, and sometimes difficult lessons in the realities of "global surgery."

Last Monday was "Morning Meeting," the equivalent of department-wide grand rounds, and since the residents had been busy preparing for exams, our hosts were gracious enough to offer me the opportunity to give the weekly "Case Presentation." I followed the format of our Red/Blue service case conferences, using the literature to answer a patient-specific question, which was an interesting exercise - especially since it came off as a bit different from their usual style, which emphasizes the subtle details of the history and exam.

The case was a 31 year old man with recent history of right upper quadrant pain followed a few weeks later by the development of obstructive jaundice. Based on the history, labs, and imaging, the etiology seemed to be related to benign calculi. I reviewed the pertinent data, our general approach to such a patient, the sensitivity of the studies involved, the historical shift in treatment that occurred with the widespread availability of ERCP and its mortality/morbidity compared with open CBD exploration, the more advanced laparoscopic techniques - even got to show Dr. Carter's video of lap CBD exploration (as seen on youtube!). In the end, given our resource limitations in this setting (no ERCP or advanced laparoscopy, and T-tubes and cholangiography hard to come by), and after consulting with Dr. Schecter, I advocated for an open cholecystectomy with (open) common bile duct exploration, and possible biliary-enteric anastomosis. After some good (and a few tough!) questions, and after some consideration, the senior attending surgeons agreed, and we booked the case the following day... What a difference the lack of interventional endoscopy makes! All went well, and the patient is recovering (with decreasingly yellow sclerae) on the ward.


As for the wards, well, they look almost like those iconic images of crowded early-twentieth century American hospitals, the patients lined up in cots within arm's reach of each other - at times, on cots on the floor. The white mosquito nets are draped overhead during the day, and tucked tightly over each patient from sunset to sunrise. The windows are open to the outdoor breeze, which is nice on the upper floors, but not so nice when it gets hot - right now it's the coolest time of year, which means pushing 90, with 90% humidity. Last Wednesday the wards were being "fumigated," which meant that all patients spent the day outdoors under tents and trees. Once I got over the sight of the "outdoor hospital," I must admit that I was impressed with the nurses'

strategic skill in orchestrating the movement and care of so many displaced patients.

Though vital signs are recorded regularly on the wards, labs can take days to be resulted, and non-urgent radiology studies usually take several days to be completed. With the paucity of available data, morning rounds become rather empiric - instead of focusing on a magnesium level or a chest x-ray, one must take a more global view based on the information at hand - general appearance, heart rate, chest auscultation, a careful abdominal exam, post-op progression or regression, overnight symptoms and their sequence - I'd like to think that Sir Zachary Cope would approve. The ability to intervene is also limited - medications may be unavailable, there's no such thing as parenteral nutrition, and patients usually get their food from home.

Needless to say, from the wards to the operating "theatre," practicing in such an environment requires extraordinary patience, flexibility, and a willingness to adapt one's clinical judgment to often less-than-ideal information and resources.

Here's a selection of some of the cases we've been involved with this week:

- Exploratory laparotomy, sigmoid colectomy in a 53 year old man with sigmoid volvulus, with classic x-ray findings and clinical exam (the sigmoid colon was clearly outlined on his abdominal wall, 15 cm in


- Modified radical mastectomy in a 36 year old woman with left breast ductal carcinoma.

- Open cholecystectomy with common bile duct exploration and choledochoduodenostomy in a 31 year old man with recent cholecystitis and persistent obstructive jaundice.

- Feeding gastrostomy in a 60 year old woman with esophageal cancer invading the trachea, T-E fistula who had resection with tracheotomy three weeks prior.

- Exam under anesthesia for a 56 year old woman with an exophytic rectal tumor who had reported prior APR; in actuality had just had diverting colostomy. (We are planning possible APR this week.)

- Another modified radical mastectomy in a 68 year old woman with locally advanced breast cancer, with peau d'orange.

- Exploratory laparotomy in a 46 year old man with gastric cancer, with equivocal CT findings; determined to be unresectable intraoperatively, with gross invasion of the transverse mesocolon, satellite lesions through the duodenum.

- Abdominal perineal resection in a 41 year old woman with distal rectal cancer, who had attempted treatment with herbal remedies for the past two years.

- Omental resection, McVay repair in a 70 year old woman with incarcerated left femoral hernia.

- Open tracheotomy in a 77 year old woman who had traumatic intubation and upper airway obstruction in the OR.

 Hope all's well back home; if you'd like to get in touch, please use my gmail account, benjaminhoward@gmail.com.



Benjamin Howard, MD, MPH
UCSF Department of Surgery