Report on the Alliance for Global Clinical Training Rotation at the Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
William Schecter, MD
December 1, 2016
I arrived in Dar Es Salaam on Saturday morning October 28, 2016 on a flight from London. I had attended the ACS meeting in Washington D.C., visited my daughter in NYC and spent 2 days in London prior to flying to Tanzania. The transition to the new time zone was relatively easy and I highly recommend staying a few days in Europe, Turkey or Dubai and arriving on a Friday or Saturday so you can sleep off the jet lag prior to starting work on Monday. Of course, I am retired and not everyone has the time to do this.
My Israeli resident, Dr. Ron Pery, arrived on Sunday. On Monday October 31 we attended the Dept. meeting and heard about a preventable death in a young man with a ruptured spleen who had a competent splenectomy but was sent to the ward under resuscitated and died in shock. This unfortunately is a common occurrence and as you shall see, we are taking steps to correct this problem.
Later in the morning we went with Dr. Akoko, the Dept Chair,to a ‘hydrocele camp”. This took place in a rural clinic about an hour’s drive from the hospital. There was a big room with 5 examining tables. Patients would walk into the room wrapped in a sheet and lie down on a table. The groin and scrotum were prepped and draped and a hydrocelectomy performed under local anesthesia with a spermatic cord block. 5 patients in one room with little or no privacy, 4-5 instruments and an electrocautery. By the end of the day, Ron could independently do the case with skill. We did 28 cases that day-reportedly a “light’ day. There are apparently about 3000 untreated cases of hydroceles due to filariasis in Dar Es Salaam alone. You can imagine how many there are in the entire country of 57 million people.
On Wed Nov 2 we did a Nissen fundoplication for free reflux. There is very good endoscopy here (done by both surgeons and gastroenterologists) but no esophageal manometry. When I first showed them how do a Nissen several years ago, I emphasized that they have to select the cases very carefully and they have adhered to that caution as far as I can tell. I was very impressed by their operative technique and the patient was discharged several days after surgery swallowing well with no symptoms of reflux.
On Saturday Nov 5 I helped one of the younger surgeons treat a patient with gastric outlet obstruction due to peptic ulcer disease. The stomach was gigantic and the patient had been vomiting for months. We did a truncal vagotomy and Jaboulay gastroduodenostomy. These cases are rare now in the US but I have helped them do several like this in the past couple of years. The patient was discharged and has had no further problems with gastric outlet obstruction.
Anorectal surgery has improved dramatically since Doug brought an anorectal set (courtesy of MEDSHARE) last year and I showed them how to use it. We did a few cases of very complex fistulas in ano including one supralevator fistula who is now improving significantly.
On Nov 7 we took off a giant sarcoma of the back. I keep re-emphasizing the need to remove tumors in a fascial envelope and I believe they have now adopted this principle. However, they were very reluctant to skin graft a perfectly clean wound bed, preferring to allow it to granulate (and waste several weeks of hospitalization). However you have to pick your battles and I decided not to go to the mat. They have since decided to follow my advice in the future and graft clean beds as we have had several subsequent successes.
On Nov 7 we had an interesting case, a lady with a mega esophagus and a large epiphrenic pulsion diverticulum due to either untreated achalasia or esophageal spasm for more than 20 years. She has been regurgitating her food constantly. They did a great job mobilizing the esophagus but asked for help with the diverticulum which went high up in the mediastinum and stuck to adjacent structures. It was a battle to get it out through the abdomen. I almost opened the chest but with a little more persistence was successful. After resecting the huge diverticulum, we did a Heller myotomy and Dor fundoplication. She is now home swallowing normally.
I supervised the Morbidity and Mortality Conference the following Monday and spent about 2 hours with the presenting Tanzanian resident on Sunday night. There were two terrible cases, another ruptured spleen in an 18 year old and a septic abdomen due to a 2 day old stab wound to the small intestine treated conservatively at a peripheral hospital. Both patients were sent to the ward in shock from the recovery room. Although operative technique has improved dramatically, there is very little understanding of pre and post-operative care. So three weeks ago we ran the first “MUHAS TRAUMA COURSE” which is a modification I designed of the ATLS Course. This was a suggestion of Dr. Ben Paz who was an Alliance volunteer in July. This was a “train the trainers” course. Two weeks ago, the instructors I trained the previous week ran their own course for the residents while I observed and critiqued the performance of the instructors. They did a fantastic job and the course got rave reviews from the residents. The plan is for the faculty to give the course several times a year and we have already received requests from the other surgery departments, nursing and the surgery department at the Kilimanjaro Christian Medical Center in Moshi (an hour’s flight from Dar) to attend the course.
I plan to make a new one day MUHAS PERIOPERATIVE CARE COURSE and hope to have it completed by the time I return in March so that I can again “train the trainers”. I think it is much better for our Tanzanian colleagues to take ownership of the course and give it multiple times a year to various constituencies rather than for the visitors to give the course (which happens often) but then nothing changes.
On Nov 14 we did a huge squamous cell carcinoma of the hand. Their plan was to amputate the hand but instead we were able to resect the tumor and preserve four fingers. I was trying to save the thumb as well but unfortunately near the end of the resection discovered that the tumor was invading the base of the first metacarpal bone so the thumb had to go with the specimen. We covered the defect with a large distally based radial artery forearm flap. The patient got a 100% take of the graft covering the donor defect and the flap is fine and he has full range of motion of his fingers.
Last weekend we did an Ivor Lewis esophagogastrectomy with a Roux en Y esophagojejunostomy in the chest. Unfortunately he developed a chest wall hematoma so we had to take him back 2 days later to evacuate it. However he otherwise has done well and has been discharged home. The next day Sunday Nov 20 we did an obstructive jaundice case which was billed as a cholangiocarcinoma. We opened the gall bladder-no stones. There was extensive portal lymphadenopathy. There was a palpable mass at the ampulla region. It certainly looked like a cancer but I smelled a rat. We did a common duct exploration and out popped two stones. We opened the duodenum and did a sphincteroplasty to totally exclude a tumor and then did a choledochoduodenostomy (rightly or wrongly) because the common duct was so dilated. He has done well and has been discharged. The following day we did an abdominoperineal resection for a large rectal cancer. He has done well but has been discharged home. That night I got sick and over the next two days passed what seemed like an 80 pound kidney stone!! After suffering all night, my Tanzanian friends insisted that I go to the ER for hydration and analgesia (they were of course correct—doctors are the worst patients, especially when treating themselves). It was a tough two days but I was then able to resume exercising and saw a couple of very complex patients in consultation.
Ron returned to Israel after his one month rotation. I stayed another week as I have to teach a course in Israel in mid December. We are planning a big operative week next week. We’ll if it actually happens
On November 26 we did a Whipple for a patient with a mass in the head of the pancreas. Unfortunately he did not survive and in retrospect it was an error in judgment to do such a big operation on an elderly patient. We all felt terrible and did our best to rescue him without success.
On November 28 we did an en bloc right nephrectomy, resection of a giant adrenal tumor and resection of a lateral segment of the right lobe of the liver through a right thoracoabdominal incision. The incision gave us spectacular exposure. As the tumor was up underneath the liver, I asked Dr. Henry Lau to assist. Henry is a Hopkins pediatric liver transplant surgeon who is here for a year with the Peace Corps working in Pediatric Surgery. He is a great surgeon and an expert liver surgeon and was very helpful with the dissection of the tumor off the retrohepatic cava. Today is POD # 3 and he is extubated and eating without any complications so far. The next day we did a palliative wide local excision of a giant sarcoma of the thigh that was about to ulcerate. The tumor invaded the right femoral vein. It was a battle to dissect the femoral artery off of the tumor and we had to repair a little hole in the right superficial femoral artery. We had to sacrifice the gracilis muscle so I had to swing a tensor fascia lata myocutaneous flap over to cover the exposed femoral vessels. The flap is doing fine and the right foot is warm and well perfused. He’ll need radiation therapy for local control but unfortunately will undoubtedly soon develop metastases.
I leave for Israel tomorrow evening. This letter is obviously written primarily for our surgical friends and volunteers and is filled with surgical jargon and operative details. However, I hope it may be of some interest to our non-clinical friends who read it. It is difficult to convey the sense of privilege, challenge, the elation, frustration and occasional profound disappointment that are part and parcel of surgical practice in Tanzania. I take particular pride in the dedication and skill of our Tanzanian colleagues who assure me that the efforts of the Alliance volunteers over the past 5 years have not only changed the skill set but also the attitude and dedication of the MUHAS surgeons.
Table1: Case list for William Schecter, November 2016
GERD, Hiatal hernia open Nissen funduplication
Polytrauma, splenic rupture exploratory laparotomy, splenectomy
Peritonitis exploratory laparotomy, lysis of adhesions, multiple biopsies of peritoneal lesions
Cholelithiasis Laparoscopic cholecystectomy
Gastric outlet obs. Due to chronic peptic ulcer trunchal vagotomy+gastrodouadenostomy
Complex perianal fistulas fistulectomy+Drainage of left supralevator abscess
Fistula in ano fistulotomy
Giant back mass (sarcoma?) Wide local excision
Peritonitis exploratory lspsrotomy, left oophorectomy
Epiphrenic diverticulum, achalasia diverticulectomy+Heller myotomy+Dor funduplication
Anal fissure Lateral sphincterotomy
Hydrocele Bilateral hydrocelectomy
Thumb SCC WLE+distal radial flap+skin graft
Peritonitis due to perforated rectal cancer laparotomy, double barrel colostomy, washing and drainage
Right IDC simple mastectomy+ level 2 axillary dissection
Intra abdominal tumor Mini laparotomy+biopsy
Acute colon pseudobstruction Transverse loop colostomy
Multinudular goiter Hemithyroidectomy
Distal esophgeal cancer Ivor lewis esophagectomy+gastrectomy
Obstructive jaundice Open cholecystectomy, bile duct exploration, sphincterotomy+ sphincteroplasty+choledochoduoadenostomy
Rectal carcinoma APR
Distal esophgeal cancer Wound exploration
Obstructive jaundice Whipple
Giant adrenal tumor Right thoracoabdominal incision, en bloc excision of right kidney and adrenal and lateral segment of right lobe of liver
Right supralevator fistula in ano Excision of fistula tract
Sarcoma Right thigh Excision wide local of mass, repair of RSFA, Right TFL Flap