Morning Rounds 4

I hope you all didn't think I'd forgotten about Morning Rounds (posting about cool cases) because I haven't! Just been (obviously) busy with other stuff and wanna make sure to keep you interested. Sooooo...with that said.....let me tell you about the patients I saw today!

A team from Cincinatti Children's Hospital came to Korle-Bu this week for a whirlwind surgical mission of pediatric colorectal cases. The patients were already prescreened and prepped by the Ghanaian team so that the Americans could maximize their time here and complete as many cases as possible. I got wind of this mission and requested to tag along for a day. Thankfully, they were very gracious and welcomed me with open arms.

The first case I saw was a colonic resection for Hirschprungs Disease. Hirschprungs Disease occurs when neural crest cells don't migrate properly to the colon during the embryonic period. In layman's terms, this means that the developed child doesn't have the proper nerves in the rectum, and they can't poop! This can become seriously problematic as the stool remains in the colon over time, causing bacterial infection and distension. Eventually, the child will die. So correction (removing the part of the colon without nerves) is essential. The patient was only 18 months old, but Hirschprungs is something you ideally correct as soon as possible (even right after birth). The surgeons were able to do the entire procedure transanally, as opposed to doing it through the abdomen. This means an easier recovery period and less pain for the patient. I haven't seen this procedure before, and it was absolutely amazing to see the surgeons pull (just pull!) the colon out of the anus. Just trust me on this one.

The Hirschprungs-affected colon looks totally different from normal healthy intestine. It had a 'stretched-out,' leathery appearance, whereas the normal parts looked smooth, pink, and glossy. Now, usually during this procedure, the surgeons will pull out all the Hirschprungs colon, and then do frozen pathology sections to make sure that they've reached the margin of diseased v. normal tissue. But here in Ghana they can't do frozen sections intraoperatively, so the surgeons had to just send tissue to the pathologist and rely on a gross visual analysis to make sure they'd resected enough colon. For all the medical students out there, the pediatric surgical fellow asked me what the pathologist would be looking for at the margin of diseased v. nondiseased tissue. I'll put the answer at the bottom of this post.

The other procedures I was able to see and learn about were fistula corrections. Female babies can be born with a variety of congenital fistulas that connect the urethra, vagina, anus, or any combination therein. This can mean, in some cases, that they only have one opening for all three organs! Incredibly, some of these disorders remain undiagnosed in Ghana, and the surgeon had even done a congenital fistula repair on an 18-year old woman. I was particularly impressed at how quickly he could work: He repaired a rectovestibular fistula in just 1 hour, right before my eyes!

I had never really considered Colorectal Surgery as a career before, but seeing this team at work really intrigued me. The quality of life of these patients (and in cases like the Hirschprung's patient, the life expectancy) will be dramatically improved after just one surgery. That's pretty amazing.

For those interested, the pathologist analyzing the Hirschprung's patient's tissue will be looking for 3 signs that indicate diseased tissue:
1) aganglionosis
2) hypertrophied nerve fibers
3) abstainment of Acetylcholinesterase

If all 3 of these signs are absent, the tissue can be considered healthy.