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.