Mexico – Thoracic Surgery

Conference coverage: Bolivian Society of Cardiac, Thoracic and Vascular Surgery

Notes from the day’s lectures at the XVI Congreso Boliviana de Cirugia Cardiaca, Toracica u Vascular in Santa Cruz de la Sierra, Bolivia

This afternoon’s thoracic surgery offerings were provided in a more relaxed, round-table style discussion.

Dr. Edwin Crespo Mendoza, thoracic surgeon, of Santa Cruz, Bolivia led the discussion on diaphragmatic hernia repair and reminded the audience that over 50% of traumatic diaphragmatic hernias go undiagnosed at the time of initial presentation after trauma. To illustrate this, Dr. Crespo presented several cases including a case of post-traumatic hernia diagnosed 13 years after initial auto accident.

Dr. Fernando E. Jemio Ojara, MD (cardiothoracic surgeon) here in Santa Cruz at the Clinica Folanini presented a fascinating case of bilateral lung injury after blunt trauma. In this case, the patient was preparing to undergo urgent repair of a right-sided bronchial tear but during attempted intubation saturations dropped dramatically to 60%. At that time, the patient was placed on ECMO by venous cannulation to maintain oxygenation during the case. The surgeons proceeded with a right posteriolateral thoracotomy. Patient had a short successful ECMO run of 85 minutes, with extubated within 36 hours of surgery, and had no further problems post-operatively,

Dr. Ojara also discussed the mechanism of these type of acceleration – deceleration injuries that most commonly affect the right middle lobe, and how stabilization with ECMO is an effective strategy to repair what is essentially a functional pneumonectomy (in this particularly patient).

Dr. Fidel Silva Julio, Thoracic Surgeon also talked on a similar theme in his overview of closed chest trauma. He reminded the audience that 75-85% of all closed chest trauma patients need some sort of surgical management from chest tube placement to urgent surgery. He reviewed the classic presentations and radiographic findings in some of the most common conditions after chest trauma such as tension pnuemothorax/ sucking chest wounds, flail chest, pneumomediastinum, cardiac tamponade and pulmonary contusions. There were several medical students in the audience, taking notes – so I have included links to the radiology signs mentioned in his lecture, as well as a basic radiology primer.

He also highlighted the need to prevent the typical trauma pitfall of massive volume resuscitation which can prove extremely detrimental in these patients.

More Radiology References

Pericardial effusion

Hamman sign – pneumomediastinum

Scan2 — with surgeons from La Paz, Bolivia

Surgery at altitude, part I

Calling all thoracic surgeons – particularly those in La Paz, Quito, Bogota and Mexico City.. We have an opportunity for collaborative research.

One of our newest endeavors is a research project on thoracic surgery at moderate altitude. We’ve completed our review of existing literature, and developed our patient parameters and data collection points.

The main base of our operations is Flagstaff, Arizona, which is located at 7000 ft. (2,000 meters) making it the highest altitude cardiothoracic program in the United States. The Flagstaff site has several strengths in that much of our patient population comes from the surrounding areas; which are located at both higher and lower elevations. However, one of the weaknesses in Flagstaff is our small patient population – as a single surgeon site devoted to both cardiac and thoracic surgery – our lung surgery volumes are fairly small.

Right now, I am doing some of the preliminary work with the hospital – meeting with staff to apply for IRB approval, and formalizing the data collection process. I am also interested in recruiting surgeons from other sites to participate in data collection. Dedicated thoracic surgeons with large thoracic surgery practices would be ideal – and all results will be published and presented by surgeon/ and site.

We are particularly interested in recruiting surgeons from the following areas:

1. La Paz, Bolivia

2. Quito, Ecuador

3. Bogotá, Colombia

4. Mexico City, DF – Mexico

These four cities combined house many millions of people living at moderate altitudes, and would help provide for a wider and more expansive collection of data on patients undergoing thoracic surgery. Demographic differences (such as pre-existing thoracic diseases, incidence of heavy cigarette smoking, etc.) of geographic locales will also allow for further points of comparison.

Please contact Cirugia de Torax if you are interested in participating. All participating surgeons and institutions will receive credit (in accordance to level of participation) in any and all subsequent professional and scientific publications.

You can also contact me, K. Eckland, directly at : k.eckland@gmail.com. Please place ‘cirugia de torax’ or ‘altitude project’ in the sibject line.

Talking with Dr. Carlos Cesar Ochoa Gaxiola

Cirugia de Torax in Mexicali, Baja California to interview Dr. Carlos Cesar Ochoa Gaxiola.

I spent a very pleasant and interesting morning talking to the enthusiastic and charming young surgeon, Dr. Carlos Cesar Ochoa Gaxiola in Mexicali, Mexico. Dr. Ochoa is my favorite type of surgeon to interview. He loves what he does despite the challenges it sometimes presents (due to limited local resources such as PET/CT modalities*). His enjoyment of surgery and caring for his patients is obvious – and he readily invites me to round with him, and see his daily practice. Unfortunately, on this occasion, I am unable to do so.

Just a year and a half since completing his thoracic surgery residency, and Dr. Ochoa has made Mexicali, (the capital of Baja California) his home. As the only full-time thoracic surgeon* in this city of almost one million residents – Dr. Ochoa stays busy operating and seeing patients at both the general hospital and the ISSSTecali hospital system.

Since much of his practice is working in public facilities, Dr. Ochoa spends much of his time caring for the poor, and the underserved patients of Mexicali – who have little access to preventative health and wellness therapies. He reports that he performs a large volume of decortications and other procedures to treat empyemas and similar endemic diseases of poverty. This includes surgical treatments for tuberculosis, which remains a serious health problem in Mexico.

During our interview, we discussed his work with tuberculosis patients many of whom have multi-drug resistant tuberculosis. (The emergence of MDR and XDR strains of tuberculosis has become a rapidly spreading health threat not just in the middle east and Asia but in the United States and Mexico, particularly in border towns.) In adjoining Calexico, the University of San Diego has a tuberculosis project to help identify and aggressively treat these resistant strains. While this program has been successful in encouraging compliance and adherence to complicated (and expensive) long-term drug regimens, it also highlights the importance of thoracic surgery in the treatment of this disease. Dr. Ochoa reports that he frequently treats pulmonary complications of this [TB], and other chronic lung infections. He performs many of these operatives to prevent constrictive complications and to restore patients functional status/ prevent disability.

He also performs the entire spectrum of other thoracic surgery procedures including other types of pulmonary resections for the treatment of cancer(s), traumatic injuries to the chest, thymectomies and other mediastinal procedures, esophagectomies and tracheal surgeries. He embraces the use of minimally invasive procedures including dual port thoracoscopic procedures, and performs the majority of his cases by VATS.

He prefers the transhiatal approach for the majority of esophageal cases since it limits the development of catastrophic complications such as mediastinitis from anastomosis leak. He reports that he does not get do as many esophageal cases as he would like since the majority of the cases performed locally are done by general surgeons.

This afternoon, Dr.Ochoa is giving a presentation at the Mexican Society of Pulmonologists and Thoracic Surgeons on the topic of surgery for the treatment of COPD.

Dr. Carlos Cesar Ochoa Gaxiola, MD

Thoracic Surgeon

Av. Madero 1059

Mexicali, Baja California

Tele: 686 – 552 – 5436

email: carlos_og@yahoo.com

Brief Biography of Dr. Carlos Cesar Ochoa Gaxiola

Dr. Ochoa is certified nationally as a cardiothoracic surgeon, though he explains that similar to the United States – the majority of programs are combined – and he subspecialized in Thoracic Surgery. He states that current board certifications in Mexico make no distinction between subspecialties. He has also received additional certification by the National Counsel of Thoracic Surgery, and is a member of multiple specialty organizations including: the LatinAmerican Association of Thoracics (ALAT), Sociedad Mexicana de Neumologico y Cirugia de Torax.

Dr. Ochoa attended medical school at the Universidad Autonoma de Baja California. He completed his general surgery residency (four years) at the Hospital General del Estado; in Hermosillo, Sonora. He then performed his thoracic surgery fellowship at the Instituto Nacional de Enfermedades Respiratorias (INER). This four-year program is one of the only Thoracic Surgery specialty training programs in Mexico. He had received additional training in bronchoscopy, and video assisted thoracoscopy (VATS).

He has presented multiple case reports at national conferences.

Publications: (note: I was unable to find live links for all of his publications).

Mucormicosis Pulmonar: Presentación de un caso. Neumología y Cirugía de Tórax 2009; 68: 78-81. Download pdf.

Additional references and information:

University of San Diego Tuberculosis program – podcast of this story.

The Border Health Initiative

Notes:

* The nearest PET/ CT scanner in Baja California is located in Tijuana.

** There are two cardiothoracic surgeons who divide their time between Tijuana and Mexicali, who primarily perform cardiac surgery. Dr. Ochoa sometimes partners with these surgeons on more complex, and complicated cardiac and thoracic cases.