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Bristol Neurosurgery 75th Anniversary | Dr Blessing Taremwa

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Summary

This session will be relevant to medical professionals and is geared towards teaching medical professionals about neurosurgical services available in Uganda. In this session, Blessing from Kampala, Uganda will share his experience in andaround Uganda and discuss his work in Bristol. The talk will include his journey, the three centers in Uganda where neurosurgery is practiced, the medical teams, the increasing demand for neurosurgery services, the four cases discussed, the profession's capacity to do general surgery, the skill gained from Bristol and the plans to scale up services. Participants will be able to engage in a Q&A session at the end of the session.
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Description

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Bristol Neurosurgery was founded in 1948, at Frenchay Hospital by the first female neurosurgeon in the world. This year marks the 75th anniversary for Bristol Neurosurgery.

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Dr Blessing Taremwa

Consultant Neurosurgeon, Uganda

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Learning objectives

Learning Objectives: 1. Understand the context of Uganda's medical environment. 2. Evaluate the need for and feasibility of performing neurosurgical operations in Uganda. 3. Appraise the benefits of pre-operative patient screening and selection for neurosurgical cases. 4. Analyze photos and videos of neurosurgical operations conducted in Uganda. 5. Critique the use of Teflon for interposition in performing nerve and vessel dissection.
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Computer generated transcript

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And blessing to um watch has come from Kampala in Uganda and uh he's going to give us a talk on his experience in Uganda. Thank you, blessing. Good evening. Um I'm very, very honored uh equally greatful for the invitation to be here to share with you uh most of the work which is going to be most of the extension of the work that actually and experience that I had in Bristol. Thank you very much Mr Mario to you and the entire organizing committee for having me over next laid as a Lord, I've carried with me a small gift to the division uh that I will hand over to Mr Malcolm at the end of uh my presentation. Uh This gift is coming from uh my division in Uganda and uh it is to appreciate much of the impact that uh gained from Bristol and it's actually making a lot of change. Yeah, back home in my country, Uganda. So this is uh the last day. Um uh my stay in Bristol. I spent two years training. Uh very good time, very great people. Uh There is, I cannot really mention names but uh I have to mention to just particular names uh Mister Malcolm, who, who really played a very big role, his kindness. There's no one's which can describe uh Mr uh who actually was the reason that I, I eventually came to Bristol. Uh This does not mean that all the other consultants, all my friends in theater uh are not any more important, but I really appreciate all of you so much next late. So Uganda is basically located in East Africa and uh which is uh on the X, on the, on the almost uh bordering uh Congo, Kenya, Uganda, Tanzania and Rwanda. And in Uganda, we have basically three centers that uh neurosurgery uh as highlighted by the three stars. Uh One is the extreme end uh the Kenyan border. Uh the other is in the center which is Kampala and I practice in the South West which is Mbarara close to the Congolese Randa border. So my catchment area of uh population is around 9 million, 9 to 15 million, which is basically encompassing that area. We are current around €15 sergeants in Uganda and uh 18 residents in training both locally and outside the country. And we have uh two training programs. Uh One is uh original program that encompasses around 15 countries in the East Center and Southern Africa known as Co CeleXA. And the other is basically a local uh med program next lay. So this is uh my uh hospital, it is attached to the university, which is the upper right corner picture that's a university gate. Uh Then the this is a new building where uh I see you and the theaters housed uh and the I see you in the left bottom hand corner. Next slide, that's the view from the back of the building which basically also highlights uh pathology department that you work closer with next slide. So basically, my, our unit is quite new uh only being founded around 2012 by Professor Qi to who is basically in his last year of uh service is going to be retiring next year. Uh We are currently three neuro sergeants. Uh That means when professor retires are going to remain too, but we're hoping that we're beginning another one soon to join us. We uh we also have a number of nurses and a medical officer that work with us next day. It's a 600 bed capacity hospital with 63 neurosurgical dedicated beds uh with that big breakdown nine beds in the emergency ward. Uh We have 30 beds uh in the in the surgical ward and we have a pediatric unit that is housed in the geno pediatric ward, however, separated uh NICU and uh and also have 14 bed. I see you that has the capacity to ex extend to 18 beds next lied. So that's our operating theater. Uh with the operating team, we have a number of equipments um uh old technology but a bit uh still viable. That's an NC uh 32 microscope. And we have also one that came in from a W finesse uh small dissect microscope. Uh And the team in the right upper corner is basically the neurosurgical team uh without professor addressed in the white uh clinical coat. Uh The lower image is basically our, I see you next slide. So over the years, uh since the inception of our division, we've seen increasing demand of neurosurgical services uh and also increase in the number of surgeries. Uh This data basically captured uh the three consecutive years from 2019 that has showed basically an increase in a number of admission's uh and both directive surgeries uh corresponding next laid uh back home. We still do general surgery. You as a as a neurosurgeon, you would literally do everything. Uh So, right from trauma pediatrics, uh and now to oncology cases. So we've been slowly uh scaling up the complexity of cases that we do back home. Uh And up to the time now that we are getting more uh subdiv, you know, sub specializing into uh oncology and mostly scar based oncology and silver vascular surgery. This is uh basically uh an extension or a skill that I got from Bristol. And I'm trying to set up back home next night. I just present four cases uh of the uh operations that we have been able to do back home. Uh The first one is basically this, uh, 70 16 year old boy who had the sudden collapse on the 29th of December 2021. Uh He was previously well with no any underlying conditions. Uh We image him and, uh, he had this, uh, right basal ganglia bleed, uh, that was quite suspicious for a young man. So we carried on and did further investigations next slide. Uh So we did an angiogram together with an MRI uh that basically confirmed the presence of uh a trio venous malformation. Um Next slide. Okay, next slide. So this A VM was basically located in the basal ganglia thalamus. Uh and it was having feeders from the third segment of the posse a cerebral artery. Uh It was draining deep basically in the uh clinic vein and also the transverse sinus. Uh basically great editors uh spectrum at in grade three with SM uh sub score of four. At that moment, we had no option but basically to offer the child surgery. Um I did consultation and I'm very grateful for, for the team of consultancy in Bristol because even though I left, I still disturbed them, I still consulted. Uh I did talk to doctor uh Mr Theo and we discussed and basically, I had to go in. So next late uh so I did a transcortical approach for this child having bled and basically, I had a good surgical corridor with the hematoma uh managed to resent uh tumor almost. I mean, the AVM almost uh entirely uh apart from uh some of the deep veins that I had to apply some uh surgical clips. Uh uh Next slide, yes, this is clip on the right hand corner. Next lied, that's the POSTOP ct scan after the resection. Uh That's the patient screen court condition. So the patient proceeded to do clinically very well. Uh Initially, they were having a hemi paris's with almost a power of uh to the lower limb band one in the upper limb globally. Uh But after the surgery, they continue to improve. Uh this is a video perhaps, maybe you can play it. It's a short video. He still has a bit of residue eo fine motor movements uh in the upper limb, but his lower limb is doing quite, very well. He's a young boy. He's actually back to school now. Okay. Maybe next slide. Okay too theory. Mhm. I'm sorry, 67, eight still had a little bit of weakness but much better we could do. Okay. Uh Next slide. Yeah. So basically this uh surgery added voice to the uh you know, growing body of evidence that some of these uh previously known a VM not to be surgically resected, that they can actually be resected was to select the patient's quite carefully as per this paper that was published um in the New Surgery General. Uh by basically a paper by Michael Oaten that showed um uh you know, surgical micro section of 48 patient's uh with these kinds of deep seated AVMs, basal ganglia, thalamus, uh and the insulin uh with very good outcomes, especially when you have very good pre operative patient selection. We also uh publishing our work. We have already written a manuscript that is being peer reviewed for this particular case X rayed. This is a case number two. Yeah, basically 78 year old lady who had suffered with right sided um trigeminal pain, pressure, pain that was not responding to medical treatment. Uh We did some imaging studies that showed um his uh cisternal uh segment of the trigeminal nerve having contact with Speeders better artery. I had offer her a microvascular decompression um uh with, with very good resolution with complete resolution and immediate resolution of pain. Next slide that is how with a very small knit scar. I think it's an I copped from Mr uh Nik Patel and surgeries. Uh So the airplanes are videos of uh the dissection basically uh can play them, but maybe in the interest of time um we could, we could skip them. I'd show you it was an interposition surgery whereby we use that Teflon uh to interpose between the vessel and um the nerve. So that's the 78 complex and we did a further dissection Matula down to expose the fifth. Uh now that uh shows uh it's contact with the spirits, a better artery branch uh in the next video, actually, maybe in the interest of time we can uh skip the next slide. Yeah. So the case three is, uh, a patient who had had surgery before a 52 year old patient who came in with a worsening visions and headaches. Uh, he had previously had a craniotomy, uh, five years ago, he had, uh, he was on hormonal therapy, but the Scottish. So and the levothyroxine, uh, we did further imaging studies which showed uh recurring uh recurring uh pituitary microadenoma. I offered him surgery. Uh next slide. The next, late next time, please. Yeah. So we, we did uh basically a right sided frontotemporal craniotomy massive with the extra duro um uh craniotomy and uh resection of the tumor. Uh total resection of the tumor. The patient is doing quite well. Uh He has managed to regain some bit of his vision uh and, and, and, and his resolution of complete complete resolution of his headaches. Next slide should be uh those are videos basically showing a sharp uh sylvian dissection uh up to the tumor and identifying the anatomy, internal corroded. Actually the optic nerves on both the right side and contralateral side. Again, this is a technique that I learned um with uh as a registrar for Mr to, you know, a unilateral approaches for even up to the contralateral side. So, yeah. Okay. Next slide. Yeah. So this, this kind of can identify uh the anatomy, the internal carotid artery um the optic nerve and the ipsilateral side, uh the tumor itself. Um and on the left side, also the similar anatomy, okay, next slide. So this is basically the POSTOP scan and the patient himself and the histology results had confirmed again, a pituitary microadenoma patient is doing quite well. The last one. So this is case for basically a 72 year old lady who came in with a left sided Cronin of three pulse. Uh with the background that had occurred for around three days on a background of five years of headache sbcs was 15 with normal pituitary hormones. Uh We did an MRI uh that showed uh pituitary microadenoma very highly like that had suffered an apoplectic event. I offered him an endoscopic transfer notice surgery next slide. So at home, because there's still a bit of challenge with human resource. So I still have to hold my scope as, as as I operate. Uh So I do a monastery approach which is quite cumbersome for the surgeon. However, very good results possibility because there's very many more destruction. I opened my dura usually with the U fashion and begin my dissection at the best towards the clivus and come all the way up around it. So this is short, basically Totori I I removed all the tumor, uh the death from came down quite well and uh not CSF leak with very good reconstruction. And I usually use the uh you're a flap again to uh repair the floor. Next slide. Yeah, that's uh the POSTOP image for the patient and she recovered quite well. She was discharged around after three days uh next slide. So all these, all these uh all these good work has not been without some challenges, were still having a lot of challenges. Uh majorly uh delayed presentation of a patient's, as you can see from there, most of the patient's present already even prop palliatively with complications of CSF leak like uh that uh factory government in Yuma. And maybe this uh young boy who was a bilateral vestibule, sonoma's, you can barely see the brainstem but they are still alive and they're still able to walk though uh very toxic. So we don't have an MDT uh which is a very big challenge. Uh So II I try to conduct my MDT remotely with the consultants here sometimes when I get very difficult cases. Uh but we're still trying to put that again together uh with radiology, pathology and uh and the other disciplines associated with neurosurgery. Uh we also don't have uh new intervention services. So in case of uh you know, um uh complications uh in the vascular, usually it's a very big challenge for us. So we are kind of limited when you see some bit of cases, you try to uh maybe refer them. Then of course, we don't have so much of the technology. Basically, it's also a very big limitation in terms of our complication reduction. So again, something we're still working around, we are working within the region um together with our colleagues being Tanzania, so to try and improve some of these challenges. Okay. Next slide. So I think, yeah, so basically, thank you. This is the, the last slide. This was one of my best moments in Bristol. So Christmas as Father Christmas on uh six B and uh some of my teams, I think Natalia is there and uh the uh the nursing team. Okay, next late. So that's the end of my talk. And uh you're most welcome to Uganda and most welcome to visit my division. It's very young, but we're still putting a lot of things together. Thank you. Thank you, blessing. Um It's impressive what you're doing with so little. Uh