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PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY January 2015 | Archived Issues

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Cedars-Sinai Doctors Help Chinese Surgeons Go Solo

After learning from the Cedars-Sinai team led by Philip Frykman, MD, (in yellow cap) Chinese surgeons are now performing anorectal surgeries on their own.

On their first medical mission to central China in 2011 to help orphans with anorectal malformations, Cedars-Sinai physicians and nurses performed life-saving surgeries that local doctors had never seen before. Last fall, thanks to a series of innovations the team has implemented since then, Chinese surgeons and nurses were handling similar cases on their own.

"It was a huge learning curve," said Philip Frykman, MD, associate director of Pediatric Surgery at Cedars-Sinai and the leader of the China mission team. "We're now very close to reaching the goal of sustainable missions, which means that the Chinese doctors and nurses will be able to work alone and teach these procedures to others."

Although the surgery they perform, known as PSARP (posterior sagittal anorectoplasty), is considered routine throughout the U.S., it is rarely performed in China. As a result, children who lack a functional rectum or anus at birth routinely die of complications such as sepsis or malnutrition.

Frykman and some of his colleagues during a recent mission to China. From left are volunteer Mickie Wang, Shiwei Zhai, MD, of the New Hope Foundation, Claire Esguerra, LVN, of Cedars-Sinai, Frykman and Drs. Yang and Liu, pediatric surgeons from the Luoyang Children's Hospital.

From the start, Frykman and his colleagues — including pediatric anesthesiologist Keith Kimble, MD, and Janet Kimble, RN, CPN — knew the most effective way to help the orphans was to teach the necessary techniques and procedures to the local doctors and nurses. Frykman and Shiwei Zhai, MD, quickly developed a strong working relationship, which allowed the American surgeon to teach and guide his Chinese colleague. Janet Kimble forged bonds with nursing leaders from Chinese hospitals where the Cedars-Sinai team worked over the years.

In the second year of the missions, as the Cedars-Sinai team began holding seminars, word quickly spread. Chinese doctors, nurses and medical personnel from throughout the region filled the lecture halls and operating rooms. Soon, knowledge of the techniques for dealing with anorectal malformations began to be shared widely.

Then, with an ingenious invention, Frykman and Keith Kimble supplied the final piece of the puzzle. They created and manufactured a low-cost version of the Peña muscle stimulator, a costly medical device crucial to performing anorectal surgeries that is beyond the budgets of hospitals in developing nations. Chinese surgical teams finally had both the knowledge and the tools to work on their own.

During the 2013 mission, two Chinese surgeons successfully performed the PSARP with Cedars-Sinai physicians in the operating room. That prepared the local doctors and nurses to perform the procedure on their own, which they did during the Americans' 2014 visit.

Because of the high number of cases and because the team had only four days to operate, Frykman said, "we decided to run two operating rooms."

Cedars-Sinai team members staffed one O.R. in which they tackled more advanced cases. The Chinese doctors and nurses worked in a neighboring O.R., doing PSARP procedures.

"When we first showed them the surgeries we wanted them to do, there was hesitation," Frykman said. "I would get them started and would be there to help if they needed it, but after a few cases, it was clear that wasn't necessary."

Working solo with Frykman close by gave the Chinese surgeons confidence. By the end of the four days, the local medical teams were handling the PSARP procedures by themselves.

As a result, the Cedars-Sinai team was now free to work on more complex cases, such as children with Hirschsprung's disease, a disorder in which nerve cells are missing from part or all of an infant's colon. To pinpoint the portion of the colon to be removed, a biopsy must be performed during the operation.

In the U.S., this would be a simple matter of sending a tissue sample to the hospital's own lab, Frykman said. But because the Chinese hospital didn't offer that service, the tissue sample had to be rushed through the city of 6.5 million people to a hospital across town, all while the patient remained under anesthesia.

"While this type of attention to detail and effort to be precise is virtually unheard of in the Chinese medical system, it did provide an example to our Chinese colleagues of how much better Hirschsprung surgery could be performed for patients if pathology is obtained during surgery, as is routinely performed in the U.S. and Europe," Frykman said.

Another boost to the teaching component of the mission came thanks to the loan of laparoscopic and exoscopic equipment by a local company. As a result, the surgeries were displayed on high-definition monitors for real-time teaching, and they were recorded for training videos.

"Over the past four years, the focus has definitely changed with a greater emphasis on consulting and teaching," Janet Kimble said. "We started out physically doing all of the care for the children, and now we've been one of the first groups to create sustainable care."

In addition to Frykman, Keith Kimble and Janet Kimble, members of the 2014 Cedars-Sinai team were:

  • Pediatric Intensive Care Unit nurses Jennifer Ross, RN, CN III, Mona Abney, RN, CN III, and Rebecca Ehling, RN
  • The operating room team of Claire Esguerra, LVN, surgical tech III, and Naty Portugal, RN, CN IV
  • Surgical resident Doug Liou, MD

Pediatric anesthesiologist Keith Kimble, MD, (right) has been a member of the Cedars-Sinai team since the first mission to Luoyang, China, in 2011.

Previously in Sutures:

Cedars-Sinai Innovation Helps Patients in China (February 2014)

Cedars-Sinai Surgical Team Expands Mission in China (January 2013)