March 2014 - Week Four - Rebecca Maine

Well, my four weeks at Muhimbili are, incredibly, already over.   I must again express my appreciation to the surgical service there that extended this opportunity to learn with and from them, and to the folks in the US who worked to put it together.  It was an incredible growth and learning experience.

 We hit a little bit of a quiet period in our call cycle, which Dr. Schecter jokingly attributed to having already operated on all the peritonitis in Dar.  So there were fewer late night cases with the residents, but still plenty of interesting opportunities to learn with the team during the elective cases.   We did a sigmoidectomy this week.  It’s interesting that the epidemiology of sigmoid volvulus in Africa are quite different than those in the US. It is fairly common here, and happens in much younger, healthier patients.  This was actually a topic of discussion at the COSECSA (College of Surgeons of East, Central and Southern Africa) in Zimbabwe in December.  There was a presentation on a anatomic study in fetuses looking at colonic development in the African population and noting longer colons further out of the pelvis.  However, these difference in volvulus incidence don’t seem to persist after emigration to the west, so diet and lifestyle are likely factors.  The patient we treated was in his early twenties with a history of intermittent constipation and an impressive CT scan.  The differences in epidemiology of different surgical conditions between different places are very interesting, and deserve more study to ensure adequate capacity to detect and treat them.  To me this is just one of the cases that highlights the need to support the growing field of academic global surgery.

The last case that I participated in was a common bile duct exploration for a woman with choledocholithiasis.  We started with an open chole and then proceeded to the duct exploration.  Passing the instruments through the common duct we were not able to clear it, but instead felt a somewhat mobile mass at the ampulla through the duodenal wall.  We were concerned it was a tumor, but were relieved to find that after the duodenotomy it was just a large, impacted stone that we removed with a sphincterotomy.   We then did an open sphincteroplasty, a procedure I had not yet seen in the US.  As I plan to continue to work in places where ERCP will not be available, it’s great to have had the opportunity to learn how to do this procedure.

 I finished my month with a mix of emotions.  I will in many ways be happy to return to the well-equipped hospitals of the US, where clinicians do not lose patients for lack of antibiotics or oxygen delivery.  But, I will miss working with clinicians who show strength in fighting against these types of limitations, many of whom are also eager to expand the care they can offer their patients.  I don’t know when it will be, but I look forward to returning to Muhibili to see my new see how things have changed.

Looking forward to seeing everyone when I get back to San Francisco in June.



Rebecca Maine, MD, MPH
Paul Farmer Global Surgery Research Fellow
Program in Global Surgery and Social Change, Harvard Medical School
Boston Children's Hospital
PGY5 UCSF General Surgery Residency