82. OP#9: Riobamba II

Day 4

Two major cases in the OR today:

Both were potential cancer, which raises a critical issue. The intraoperative diagnosis of cancer requires first a preliminary pathology report and then a decision whether to proceed with a "staging" procedure, basically the removal of lymph nodes, where cancer often spreads first. The absence of cancer in any of these analyses may mean no need for chemotheray. If the staging procedure is not done, the patient and her oncologsit is faced with the difficult decision whether to proceed with potentially life-threatening postop treatments.

Since I do not do these staging procedures, shoud I not do overseas surgery with no pathology on surgical oncologist back-up? But if I don´t do the surgery for these patients, they may not have it done until syptoms increase, whicy usually means that the cancer has spread and chemotherapy less likely to be successful.

Postmenopausal bleeding is often an early sign of uterine cancer. Martha presented with a single episode of such bleeding. Our ultrasound showed a markedly abnormal uterus, increasing the suspicion of cancer. The excised uterus showed a thumb-sized polyp, which is unlikely to be malignant, so she should do okay. I did request that the polyp be sent to a pathologist, but don´t know if that will happen.

Edelma presented with pain and a right ovarian cyst that had doubled in size over two years. This increase and the nature ("septated") of the cyst again suggested a risk for cancer. But operative findings were unequivocal for a benign growth. At the near-menopause age of 48 we had discussed the removal of the other ovary and she so requested. But it was adherent to the bowel, a consequence of her hysterectomy 15 years previously. Thw risks of injury to the bowel during attepted removal of the ovary was judged more of a risk than future ovarian cancer.

Just ten patients seen in clinic but three scheduled for surgery, an efficiency the reflects the the assistance of a nurse midwife who was part of the team and performed invaluable screening as well as excellent care of non-surgical patients. Nurse midwives are trained manage gynecologic conditions.

81: OP#9: Riobamba II

Day 3

Two surgeries, abdominal hystectomy for chronic pelvic pain for 49 year old Mario with chronic pelvic pain since her tubal ligation 20 years before. Hysterectomy for pelvic pain is always an iffy measure. Many women continue to have pain postop, suggesting other sources of pain (gastrointestinal, or muscular for example) or an esceptionally low threshold for pain. But studies have shown that most women who undergo hysterectomy for his reason (assuming that other sources have been investigated and exluded) end up having a better quality of life postop. 

Maria's hematocrit (the percentage of blood that is red blood cells) was 51, reflecting her high altitude adaption.  Normal range for U.S. is 36-45; for Riobamba 45-55.

The second case was bilateral removal of ovaries for a postmenopausal woman with a “complex” ovarian cyst. Simple cysts are like water balloons—thin walls and clear fluid contents. Complex cysts are everything else—thick walls, solid components. Simple cysts are benign; complex can be malignant. Martha's cyst appeared complex on ultrasound but intraoperatively was clearly benign.

A busy clinic showed just about the same grouping of presenting problems that I might find at home, with one exception: parasites. The other 19 included:

urinary tract problems: 2

reproductive counseling: 2

annual exams: 2

menopausal issues: 3

abnormal bleeding: 2

pelvic mass: 1

chronic pelvic pain: 7

80: OP #9/Riobamba II

Day 2:

Clinic: 14 patients

Surgery: With time and the effects of increased abdominal pressure (e.g., heavy lifting or chronic cough), vaginal supporting structures stretch and relax allowing the rectum and/or bladder to bulge into the vagina. Harmful, no; uncomfortable, even painful, yes. Anterior vaginal repairs (anterior colpopexy) begin with an incision in the vaginal roof that runs from the back to within about a half-inch of the urethra, and as it progresses, the underlying connective tissue is dissected away from the vaginal skin, extending one-half to one inch from the center. The freed vaginal skin is excised and the new edges are sewn together, thus eliminating the stretched, redundant vaginal skin that has allowed the bladder to drop. Two anterior repairs went well today, with one predictable complication.

At 46 and in good health Atienia should have recovered easily from this relatively simple procedure. But several hours postop, nurses found her weak, nauseated, syncopal. Her oxygen saturation level measured at 70%. Oxygen saturation is the percentage of hemoglobin binding sites filled with oxygen. Levels below 90% define hypoxia, the point at which organs don't function normally.

At Riobamba's 9035 feet, the atmosphere is still about 20% oxygen, but less gravity at higher altitudes means decreased air pressure, which makes it more difficult for oxygen to enter blood vessels. A number of physiologic changes help Riobambians maintain O2 sats above 95. But Atienia is from Guayaquil, a coastal city and arrived only yesterday to be seen by our team. By giving 100% O2 with a face mask, she did well.

At this level, 4 days is usually cited time required for altitude adjusment. On my first night in Quito (also 9000 feet), I ran 5km in the hotel gym and felt fine (tho at an admittedly wimpy 7km/hr).

79. Overseas Project 9: Riobamba II

Day 1

Arrived in Riobamba (aka friobamba) around 2pm, after a 5hr bus ride from Quito. Lunch, then to hospital to unpack (most of the 46 participants had two 30-50lb bags of equipment) and to hold clinic. Had time for 8 patients, with a thirty-something American expat translator living in Bogota with no medical background but a Spanish for health providers book, and eyes wide open as we delved into gynecologic issues.  Every one presented with incontinence.  I haven't done vaginal incontinence surgery in too many years, so turned most away (and felt bad about it since some had travelled from Guayaquil, a 5-6 hr bus ride away.  However, two also had symptomatic bladder prolapse and I scheduled them for surgery tomorrow. I'll have to think about resuming incontinence surgery for future overseas projects.

Chimborazoso from downtown Riobamba.  This is earth's tallest mountain as measured from the center of the earth, given the earth's equatorial bulge. In other words, the closest you can get to the sun, while still standing on earth.  20,565 feet above sea level (compare Everest's 29,029 and Mt Rainier's 14,411).

78. Hair, part two

Mildred's surgery showed an aggressive form of uterine cancer with biopsies showing the presence of this cancer in the omentum (intra-abdominal fat storage) and the abdominal surface of the diaphragm (the muscle that moves the lungs up and down).  In other words, metastatic disease.


She did well postpartum, and consulted with the oncologist who "explained risks and benefits of treatment, what would the advantages of treatment.  I also reiterated that treatment will not be curative and that she probably has to go on and off treatment in the years to come"