Surgery in Angola (part 1 of 2)

WARNING:

Some of the following photos of surgical pathology may be

too graphic for certain audiences.

Greetings from Lubango!

It has been a while since we have updated our blog with news from our corner of the world. Our time in Angola seems to be flying by. CEML remains tremendously busy. In the next few updates, we hope to give you a flavor of this.

It seems every great talk or book on international health needs a section on surgical pathology. It is important to note that the difference in our surgical cases from those in North America comes not so much from different pathogens as it does from the lack of access to proper health care. To quote one of my mentors at Vanderbilt:

In low and middle income areas extending 23.5 degrees on either side of the equator, most situations encountered by the volunteer surgeon are better described as “surgery in the tropics” rather than “tropical surgery”; the majority of operations will be for conditions encountered in a Western surgical practice with the primary difference being late presentation at an advanced stage. Infrastructural challenges of deficient and intermittent water, electricity, and supplies cause more concern than exotic pathogens.

John Tarpley, Margaret Tarpley, and Donald E. Meier. “An Alternative Vacation: Surgical Volunteerism.” Article in submission.

As if to demonstrate this reality, we had four young women who presented with advanced rectal cancer. Ranging in age from 23 to 45 years, all of them had blood in their stool for over two years. All were slowly getting weaker and more anemic. All had seen many practitioners looking for help. Not one got any better. No one had ever done a simple digital rectal exam which would have diagnosed the problem. By the time they were seen at CEML and diagnosed, their tumors had grown extensively. All four of them required abdominal perineal resections (APRs), which involves removing the whole rectum down to the anus and creating a permanent colostomy. Two had to have their uterus and ovaries removed because the tumors had grown into these. In North America, all would have received chemotherapy and radiation pre-operatively to shrink their tumors, and may have avoided such drastic operations. Gratefully, all are recovering well, gaining weight and feeling stronger.

Angolan OR
While the majority of our time has been spent in Lubango at CEML, a few weeks ago we had the opportunity to travel. A team from Lubango flew about 45 minutes to an older mission hospital in the town of Kalukembe about 300km from here. We spent 2½ days there, did 45 operations, saw about as many new consults. Here is a picture of our operating room. Fairly typical of a busy African OR in the bush.

Osteosarcoma
Back in October, about a week after the hospital opened, Segundo presented with his father for evaluation. He was 13 years old and his left knee had been “swelling” over several months. Multiple attempts with traditional therapy in the village and antibiotics at the health posts failed to provide any improvement. His knee swelling was firm and bony. This was concerning for a malignancy. The x-ray confirmed the classic appearance of osteogenic sarcoma of the distal femur. A bad cancer, put a potentially curable one. We recommended amputation at the level of his thigh, and arranged a date for his operation. Sadly, he did not show up, and we have never seen him since. I doubt he is still alive. I’ve often wondered what deterred them – fear of amputation, cost, other reasons.

Uterine Myosarcoma
Ana is a 24 year old woman, and when we first saw her in clinic, both Beth and I thought she was pregnant. And so did she, until things didn’t check out in her pre-natal visit. A large uterine mass was found on her ultrasound (performed by the head nurse at Kalukembe). On exploration we found a huge tumor of her uterus, likely a uterine leiomyosarcoma. It weighed 3.3 kg (7 pounds, 4 ounces). This required removal of uterus and ovaries – tough at 24 years old, but she recovered well and is home now. Of note, that is my sister Gaby assisting me (we had the privilege of hosting her and my parents during the month of March), and Beth administering anesthesia.

Gangrene
Antonio is a 34 year old who has had several bouts of pyomyositis (pus in the muscles) of his calf and thigh. This time it got out of control, and gangrene set in. Living a couple days journey from any hospital, he has significant barriers to seeking the medical help he needs. Though it took 4 days after being admitted, he finally consented to the above-knee amputation that would save his life, after receiving several blood transfusions he needed to overcome his severe anemia. He has required several operations for drainage and debridement. But he is now getting along nicely on crutches, his wounds slowly cleaning up and healing. His story exemplifies the consequences of inadequate access to care and generalized poverty.

Squamous Cell Cancer
Helder is 35 years old and has grown up under the African sun as an albino, with no melanin to protect him from ultraviolet radiation. A few years ago, he developed a large squamous cell skin cancer of the face. Steve Foster resected it and covered the area over with a flap of tissue from his chest. On opening day of the hospital in October he presented with an awful recurrence that had grown into his maxilla and orbit, pushing his eye out of its socket. One of our first operations, he received a radical resection, including removal of his eye. The other thing to know about Helder is that he has a beautiful, gracious spirit. Upon waking from surgery, with a huge hole in his face, he thanked me for all we had done, his pain was now gone. Helder’s wound is now almost all covered with tissue and skin; but it has taken 5 months. At home, such tumors would be treated with pre-op radiation for shrinkage. Intra-op pathology reports would confirm clearance of all cancerous tissue, and allow immediate closure of the wound. Helder doesn’t have those options, but he thanks me every day he sees me.

Mesenteric Mass
Kachanjo is 16 years old, and lives a three-day journey by foot and public transport from CEML. His presenting problem last November was a large mass that had been slowly growing in his abdomen. Fortunately it wasn’t obstructing his intestines. Ultrasound in my hands was not very revealing. The nearest CT scanner is 700 miles away in another country. On surgical exploration I found this 15 x 15x 20 cm mass growing off the small bowel mesentery (connective tissue that carries blood supply to the intestines). With some difficulty it came out without requiring removal of any of his bowel. He recovered great, was out of the hospital in 4 days, and after two weeks I discharged him to home in the bush. I was relieved last week when I received his pathology report (5 months later) – mesenteric fibromatosis, a benign tumor.

Continued in the next entry...