William Schecter - November 2018 Rotation

Report on the Alliance for Global Clinical Training Rotation

October 29 – November 16, 2018

Participants: William Schecter MD, President Alliance for Global Clinical Training, Ronit Bar Haim MD, Attending Surgeon, Western Galilee Medical Center, Nahariya, Israel, Jahanara Graf, MD, newly appointed Medical Director, Alliance for Global Clinical Training

Clinical Experience:  We were gratified by the excellent technical performance of several of our MUHAS/MNH colleagues who have been working with the Alliance for several years. The Tanzanian surgeons have performed 8 esophagogastrectomies independently this year without a death. This is a remarkable achievement considering that prior to 5 years ago no esophagectomy has been performed in anyone’s memory. There are now two appointed chief residents and ICU rounds are performed twice a day. There is a surgical resident assigned to the ICU who is a constant presence. The quality of the rounds is excellent and characterized by disciplined reporting of data and very thoughtful discussion of therapeutic goals and options. We scrubbed on a number of interesting cases at the request of our Tanzanian colleagues. A list of our cases appears below.

 Case List for Alliance Volunteers, November 2018

 Diagnosis                                                         Procedure

Adenocarcinoma of GE junction Ivor Lewis Esophagectomy

Fistula in ano EUA, placement of Seton

Rectal Cancer Low Anterior Resection

Rectal Cancer Low Anterior Resection

Choleilithiasis Cholecystecomy

Mesenteric  Tumor Small bowel resection

Cecal Tumor Right hemicolectomy

Ruptured Spleen Splenectomy

Recurrent Ventral Hernia Rives-Stoppa Ventral Herniorrhaphy

Left leg soft tissue mass Incisional biopsy

Intrabdominal  cystic mass Roux en Y cyst jejunostomy

Anorectal Cancer EUA, and biopsy

Right diabetcic foot Right below knee amputation

Carcinoma of the esophagus Left thoraco-abdominal esophagogastrectomy

Metastatic ovarian sarcoma Small bowel resection, excision of multiple tumors fromperitoneal cavity

Fistula in ano Anal fistulotomy

Rectal Cancer Low anterior resection

Giant Ventral Hernia Rives-Stoppa Ventral Herniorrhaphy

Anal Warts Excision of Anal Warts

Head and  Neck Tumor Gastrostomy and Tracheotomy

Sigmoid Vovulus Hartmann Procedure

Penetrating Abdominal Trauma Small  bowel resection

Incarerated Rectal Prolapse Altemeier Procedure

Small bowel obstruction Laparotomy lysis of adhesions

Goiter Hemithyroidectomy

Abdominal Trauma Laparotomy

Perforated Duodenal Ulcer Graham Patch

Right inguinal hernia Right inguinal herniorrhaphy

Paracolostomy hernia Relocation of colostomy 

Formal Teaching Activities

1.     We ran a two-day Abdominal Wall Reconstruction Course on November 1 and 2. The first day consisted of didactic lectures.  The morning of the second day was a cadaver lab in which the students had an opportunity to perform the procedures they had studied the day before. In the afternoon, there were breakout sessions in which students reviewed the material from the previous day and a half guided by instructors. Several days after the course, Dr. Schecter assisted our Tanzanian colleagues in a Rives-Stoppa submuscular ventral herniorrhaphy in a woman who had 3 previous failed ventral hernia repairs. We believe this is the first submuscular mesh ventral herniorrhaphy done at MUHAS/MNH.  Two weeks later, the Tanzanian team together with Drs. Schecter and Bar Haim performed a Rives-Stoppa repair of a giant ventra hernia. A calendar of the course appears below.

 MUHAS Abdominal Wall Reconstruction Course

 Day 1

1.       09:00-09:30 Anatomy of the Abdominal Wall

2.       09:30-10:00 History of Abdominal Wall Reconstruction

3.       10;00-10:30 Routine Laparotomy Closure: the Sundsvall Technique

10:30-10:45 Break

4.       10:45-11:15 Delayed Primary Closure of the Difficult Open Abdomen

5.       11:15-11:45 Separation of Parts Technique for Abdominal Closure

6.       11:45–12:15 On-lay Mesh Ventral Herniorrhaphy

12:15-13:15 Lunch

7.       13:15-13:45 Rationale for Posterior Component Separation

8.       13:45-14:30 Technique of Posterior Component Separation

9.       15:00-15:30 Laparoscopic Ventral Herniorrhaphy

10.    14:30-15:00 Unplanned Challenges during Abdominal Wall Reconstruction

 Day 2

1.      09:00-12:00  Anatomy Lab

2.     12:00-13:00 Lunch

3.     13:00-15:00 Breakout Sessions

a.     Review of Abdominal Wall Anatomy (30 minutes)

b.    Review History of Abdominal Wall Reconstruction (30 minutes)

c.     Review Techniques of Separation of Parts Technique, Bridge, On-lay Mesh and Rives-Stoppa Procedure

d.    Review Technical Details of Transversus Abdominis  Release (TAR)

2.     Dr. Ronit Bar Haim made daily ICU teaching rounds with the resident and attending staff

3.     Dr. Schecter was approached by the Gynecology Residents to give a course on ICU care. They had heard about the course from their resident colleagues in surgery.  Unfortunately, the request came close to the end of the rotation so Dr. Schecter held evening teaching sessions for the Gynecology residents on November 14 and 15 and will investigate whether the gynecologists would like courses given by Dr. Jahanara Graf and our Tanzanian surgical colleagues later this year and next year.

 Administrative Issues

1.     The newly constructed hospital (about 1 1/2 to 3 hours drive from MUHAS/MNH depending on traffic) had been administered by MUHAS.  3 weeks prior to our arrival, control of the hospital was transferred to MNH. So, the overwhelming concern about the new hospital on the part of MUHAS surgeons and Nursing Educators has now disappeared as they are no longer responsible for this hospital. MNH surgeons now staff the surgical service there for 1 week at a time. This change has major implications for the Alliance Nursing Initiative as the MUHAS Nursing Administration (Lillian and Dickson) no longer are interested in our nurse educators making the trek to the new hospital and have agreed to run all teaching activities at the MUHAS/MNH campus.

2.     Dr. Ali Mwanga has unfortunately left for a 4 year period to study liver transplantation in China. This is a big loss for the MNH teaching program and for the Alliance as Dr. Mwanga was our Alliance Tanzania Coordinator.

3.     Dr. Larry Akoko has stepped down as Chair of MUHAS Surgery and plans to do a year Fellowship in Thoracic Surgery in India. He has been replaced by Dr. Obadiah, a Urologist

4.     Dr. Jahanara Graf has assumed the position of Medical Director of the Alliance for Global Clinical Training. She is based at MUHAS/MNH. She began work on Friday November 9, 2018 and jumped right in with a full day in the OR. Her major project will be to implement a data base for the MUHAS Dept. of Surgery. She is consulting with Drs. Clifford Ko and Girma Tefera of the American College of Surgeons. We hope to do a Pilot Project on Firm I. If successful, the Data Base could serve as a model for many hospitals in Africa. This data base will be surgeon led and collect only clinically relevant data.

 Oncology Consortium

A group from a multi-institutional consortium focused on esophageal carcinoma arrived to train MUHAS surgeons in insertion of esophageal stents for palliation. Dr. Katherine Van Loon, the Director of the UCSF Global Oncology Program accompanied the group. There will be an internist, who is applying for an Oncology Fellowship, Geofrey Buckle, who will be intermittently present and coordinating research in esophageal cancer. Dr. Van Loon offered to make Dr. Graf a co-investigator on the study and she is considering this opportunity. The title of the project is “Management of Esophageal Cancer in East Africa: A Prospective Cohort Study of Treatment Strategies and Supportive Care”. Dr. Van Loon has met with Dr. Sosa, the Chair of Surgery at UCSF. There is a potential opportunity for the Alliance to collaborate with the Consortium, the UCSF Global Oncology and the UCSF Global Surgery programs. We will see how this plays out.

Nursing Initiative

Dr. Schecter met with Lillian and Dickson re: the Nursing Course. As previously reported, the course was enthusiastically received and will be given by the Tanzanians to their colleagues later this year. Dr. Schecter emphasized that our Nurse Educators do not wish to travel to the new hospital but as mentioned earlier, this is no longer an issue because MUHAS is no longer responsible for the hospital. Options for additional courses were discussed.

On October 15, Dr. Schecter met with Zuhara Mlupio, the Acting Director of MNH Nursing, together with Salome Buluba and Masunga Iseselo representing MUHAS nursing and Dr. Akoko. Zuhara was enthusiastic about the Alliance Nursing Education Initiative, perhaps because she took the course in September. She agreed to have the course taught at the MUHAS/MNH campus, have our nurse educators mentor their students on the wards and in the ICU and provide free housing for the nurse educators during their stay. We agreed that the subject of the next course should be ICU nursing.

Farrah and Shannon will communicate with Lillian, Dickson and Zuhara re: the plan for next year’s course.

Data Base and M&M Conference Pilot Project

Drs. Schecter and Graf met with Dr. Obadiah, the new Chair of the MUHAS Dept of Surgery and Dr. Akoko. Unfortunately, we missed a meeting with Dr. Ibrahim Mkona, the Chief of the MNH Dept of Surgery but we have spoken informally with both him and Dr. Shamshama, the Head of Firm I. The plan is to institute a data base of all Firm I surgical cases prospectively and institute a weekly M&M Conference as a pilot project. If successful, the concept will be extended to the entire Department. Drs. Akoko and Obadiah agreed to supply one person to manage the data base. The Kitembo will be assigned to coordinate with Jahanara and run the M&M conference.

Drs. Schecter and Graf had a conference call with the American College of Surgeons staff. They agree to allow the MUHAS/MNH Department of Surgery to have access to the American College of Surgeons’ Surgeon Specific Registry as a platform for our data base. We will strongly consider this option and make the decision within the week.