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Experience report 2014
First brigade to treat anorectal malformations in Honduras
A report from Dr. Wilfried Krois and Dr. Carlos Albert Reck
Juan focuses primarily on anorectal malformations. It remains unclear why these occur more frequently in the poorest countries in the world. Malnutrition certainly plays the biggest role. During the drive from the airport to the hotel, Juan raves about his vision of founding the "Fundación MAR." With the support of the "Fundación Ruth Paz". "'MAR - malformaciones anorectales' sounds soft and reminds of" mar "- the sea; much better than ARM, ”he says. (Note: anorectal malformations). Most of the people here are “armed” - while we are still driving we are informed about the rules of conduct in San Pedro Sula. We already read about the high crime rate in advance; according to Wikipedia, Honduras is one of the most unsafe countries in the world and has by far the highest number of homicides per inhabitant in the world (91.6 per 100,000; compared to Germany: 0.8 per 100,000) . Juan tells us about the high level of poverty in the country and the dramatic increase in crime in the last 10 to 15 years. Honduras developed into one of the largest drug hubs in the world. Most of the desperate unemployed young people join the youth gangs that have developed, such as “Barrio 18” or “Mara salvatrucha” and terrorize entire regions. The government and the army are trying to take action against these gangs in which membership is already subject to long imprisonment. Nevertheless, reports of violent crimes on the street are in the newspapers. The tension, especially in the cities, is very high, Juan tells us. Most of the people are armed and arguments, including for trivial reasons, often end in the use of firearms. Juan advises us not to walk alone on the street, not to show any valuables openly, to stay in the hotel when it gets dark or only to go to safe places, to avoid any discussion and in the event of robberies to hand over everything without hesitation what we carry with us. With a bit of a queasy feeling we move into our hotel, which is considered to be one of the safest in the city of San Pedro Sula and are soon happy with our jetlag (8 hours time difference to Vienna) after a good meal and getting to know two other colleagues, who are from Boston and San Francisco also traveled to this mission to fall into bed.
On Sunday we start to look at patients in the "Hospital Ruth Paz" who are Dr. Juan Craniotis, the head of this first brigade for the treatment of anorectal malformations, and which he would like to discuss together in advance. The "Hospital Ruth Paz" is a private clinic for children founded by donations and was
formerly also intended as a children's burn clinic, which, however, was unable to start operations due to failure of the government to provide funding. Now there are mainly so-called brigades, which are organized by the "Fundacion Ruth Paz". Children with cleft lip and palate, club feet or heart defects are treated. In the background, Peggy is fully committed to organizing these brigades. We see more than 20 registered children between the ages of 1 month and 14 years - all of them have diseases such as Hirschsprung's disease or various forms of anal atresia and cloacas. There are only sparse examination results, almost all children have a colostomy. Contrast agent displays, ultrasound and pathology findings are not available in all children; these examinations are too expensive for most families. Colostomy is a good option for children with these malformations to survive these diseases, but you pay with a significantly reduced quality of life. For example, only richer families can afford ostomy bags, most are provided with diapers and wipes around their stomachs and the biggest problem is that these children are not allowed to go to school because they are refused entry with an artificial anus.
Afterwards Juan shows us the public hospital. We enter the children's emergency room, the doors of which are guarded by armed security. Countless children together with relatives in a dilapidated building, a first aid bed next to it
others, a noise level that one would not expect sick people to expect, the standing damp heat and an acrid smell in the nose paints a picture which does not seem in any way comparable with the European standards. Newborns and premature babies are located in a NICU directly afterwards - there is no separate sister for each child, sometimes several children lie in a small car without monitoring. Mortality, especially in pediatric surgical diseases, is extremely high. Patients with gastroschisis, for example, are treated surgically, but there is no money for parenteral nutrition. Children inevitably have to be fed orally at an early age despite paralysis, but more than 90% of children do not survive this procedure. We also see a newborn with esophageal atresia which will be operated on here in the public hospital in the next few days. However, nine out of ten of these patients die here from postoperative infections. The waiting list for elective pediatric surgical interventions currently includes around 900 patients, the prospect of receiving a hernial sac ligature of an inguinal hernia in the next six months, for example, is extremely low for most patients who are not privately insured.
We start early on Monday, and we arrive at the hospital at 7 o'clock. For this day we have a total of 5 children with Hirschsprung's disease on the surgical program. However, we can only manage 4 Soave pull-through operations by 7 p.m. We have to postpone a patient to Friday. We have a total of two operating theaters, each with two operating tables. On this first day we only operate in one room, but at two tables at the same time. The procedure usually used in Honduras is to anastomose the oral stoma anastomosis in the sense of a Soave pull-through. Intraoperative quick sections to determine the healthy intestine or a transition zone do not exist. "If the stoma is working, we pull it down." Juan explains his approach to us. Dr. Wolfgang Stehr, Head of Pediatric Surgery at Oakland's Children's Hospital, San Francisco, is probably the most experienced pediatric surgeon and takes on the role of coordinator and is always available to the surgical teams with tips and a helping hand. Wolfgang completed his training in pediatric anorectal surgery with Professor Alberto Pena in Cincinnati and has a wealth of experience. Explaining his way of explaining his calm and security and his fascination with passing on his knowledge to colleagues, encouraging them and being at their side in the event of problems was probably one of the most valuable gifts of this mission for us.
During the next few days we are sometimes in the operating room for more than 12 hours a day. We operate on many forms of anal atresia, sometimes 6 to 8 PSARP operations (note: PSARP = “posterior-sagittal anorectoplasty”) per day. Most impressive was probably the case of a 6 month old boy
with a supposedly high form of anal atresia. There was no visualization of the aboral stoma of the stoma, the aboral stoma was stenosed and could no longer be probed. No rectum or fistula can be visualized during PSARP, so we start exploring the situation via laparotomy. Surprisingly, neither a draining stoma muscle nor a distal colon or rectum can be visualized. It is not possible to understand what the site looked like when the colostomy was made, because operation reports (if they exist at all) are relatively little informative. In a second 2-year-old patient with anal atresia with a vestibular fistula, a septate vagina and an apparently blind-ended fistula can be seen intraoperatively. Behind the blind end, a rectum behind it only appears after the layers have been prepared more precisely. It is currently unclear whether this could have been a form of rectal duplication. In this case, however, we sent the samples for histopathological processing out of interest.
The case of a patient operated on in advance which urine empties via a rectal opening and a lying anterior vaginal fistula rectum probe leaves are still puzzled about the nature of that took place surgical intervention. As Juan tells us, there are still some pediatric surgeons in Honduras who do not believe in published and successful techniques for correcting anal atresia and practice their own surgical methods, rarely for the benefit of small patients.
With the first brigade to correct anorectal diseases, Dr. Juan Craniotis took the first step towards a "Fundacion MAR". This week we operated on a total of 35 patients, knowing full well that these patients will continue to receive a follow-up and will be supported by Dr. Craniotis are cared for. Both when dealing with patients and with colleagues, you can tell that Dr. Craniotis shows true empathy and tries with all his might for his patients and tries to provide the best care for children with this malformation in his country.
For us, this mission, both in human terms and in the experience of assisting in these operations, was the tips and techniques of Dr. Stehr and Dr. Collecting craniotis is extremely important.
Even though at the end of the mission we realized that even if all operations go well, it is not in our power to influence the postoperative course. On the last evening together, when we come together as a well-established and well-functioning team and review what we have experienced in a good mood, we get the call that the last patient, a 7-year-old boy, died a few hours after his Soave operation. The circumstances are unclear, there was no postoperative monitoring, and all efforts to resuscitate the boy failed. Unfortunately we leave Honduras with mixed feelings, because in our imagination nobody should die of this disease after living with Hirschsprung's disease for seven years, not even in a country like Honduras.
But we believe in the help that can be provided when experts donate their time for such campaigns and especially when they are supported by the resources of helpful people. It is important to us that the affected patients and their families are cared for on site by competent doctors, such as Juan with his tireless energy, and thus receive the best pre- and post-operative care as far as possible. Anorectal malformations are a little known, but for those affected a very limiting clinical picture, especially in developing countries, where much of the urgently needed support can still be provided.
Participants & information
First Brigade "Correction of anorectal Malformations" - Fundacion Ruth Paz
October 3, 2014 - October 10, 2014
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