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Posts Tagged ‘colombia’

I’m back in Cartagena, where it all started.. I’ll be here for a while, taking in more of the local culture and reacquainting myself with the city.

cartagena 008

Unlike my previous visits – I am going to spend a little time outside of the operating room.

If you haven’t been to the site in a while – you’ll notice, neither have I.  Having a separate Cartagena page was becoming overwhelming, so I have been transitioning it all to a sister site, latinamericansurgery.com.

However, the sites aren’t completely similar.  I admit, we don’t have as many lively debates and outside contributions as before.   I also miss the opportunity to write about a wider range of topics outside of medical tourism but I am still trying to build my audience and I was worried that my site was actually a little too diverse to offer helpful information.  Much of it was scattered over multiple sections.  So you’ll notice that Latin American Surgery is a little more organized – though the volume of pages makes precise organization difficult.

I miss the dialogues we often had here at Cartagena Surgery.  We would often get great feedback from other health care providers, researchers and experts in the field.  It was a lot of fun, and I hope that more experts will start to write in on cardiovascular and other health topics.  In the meantime, I will just keep traveling, learning, working and writing.

I also continue to write about various health care topics over at Examiner.com so if you can’t find it here –  try searching the archives over at the Examiner.

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Spent the weekend in Buga (Valle de Cauca) – just outside of Cali.  I didn’t get any photos but it’s a beautiful little touristy town (and one of the oldest in Colombia so it has that ‘Cartagena feel’).  Buga is mainly known for a famous Basilica – blessed by a former pope that attracts three million people a year.

I spent most of Saturday in the office with one of Colombia’s hard working vascular surgeons, Dr. Jhon Jairo Berrio.  That Saturday he saw about 40 patients between his office in Tulua and his second office in Buga.

Dr. Jhon Berrio with his wife, Maria Victoria on a Sunday morning in Buga

The majority of patients were referred for venous problems (varicose veins, venous stasis disease) but there were a few patients with peripheral arterial disease as well.

I got a chance to meet his lovely family which includes his wife, Maria Victoria.  She is a dentist and they share a spacious office (with several exam rooms, X-ray, etc.) at the Buga location.

Sunday, he had multiple surgeries scheduled – but alas! I was scheduled to come here, to Medellin for a few days before returning to Bogotá.  However, it was still a good opportunity to see the doctor in action.

Toured the hospital in Tulua as well, which was formerly the Hospital Occidental.  As an interesting side note – this hospital was previously supported with funds from narco-trafficking.  When the government attempted to close the hospital – the outcry from local residents who rely on its services was deafening – and prevented it’s closure.   It was then converted to a state facility, but derives much of its technology and equipment from its previous financial backers generosity.

Cali (and surrounding areas) themselves were different from what I had anticipated; Cali is less sophisticated than Medellin or Bogotá – by still has its distinct charms.  The weather is definitely better than what I expected.  While hot, it was not oppressive and the promised afternoon breezes arrived from the mountains just as reported.  The visits to Tulua and Buga were a great way to experience life outside the big city.  (Sometimes when you are living in Bogotá – it feels more like London or other global cities.)

It is however, very much a tropical clime – the appearance of large numbers of motorcycles and scooters gives weight to this.  The bikes serve as affordable, convenient and economical transportation for large numbers of citizens in these communities.  It isn’t entirely uncommon to see an entire family; husband, wife and child on the back of one of these bikes.  While certainly dangerous – for many of the lower class – it is the most reasonable option.  It’s not uncommon to see riders with their pets or large packages in arms as they criss-cross the city.

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XXIX Congreso Latinoamericano de cirugia vascular y angiologia

Santa Cruz de la Sierra, Bolivia

Dr. Berrio, Vascular Surgeon, Tulua, Colombia

Dr. Jhon Jairo Berrio is  the Chief of Vascular Surgery at the Clinica San Francisco, Tulua, Colombia, which is a small community outside of Cali.  He attended medical school in Colombia, completing his general surgery residency at Hospital clinics for Carlos.  He completed additional training at New York University and he completed his vascular surgery residency in Bogota at the Hospital de Kennedy  and trained under the instruction of Dr. Albert Munoz, the current president of the Association of Latin American Vascular Surgery and Angiography (ALCVA) .  He does a range of vascular procedures such as aortic aneurysm repair, fistula creation as well as endovascular surgery but his favorite procedures are limb salvage procedures such as aorto-femoral bypass, femoral-popliteal bypass and other treatments designed to prevent amputation.

He is here in Bolivia giving a presentation on the use of Prostaglandin E1 for critical ischemia / and last chance limb salvage.

Today we are talking to Dr. Berrio about the use of prostaglandin E1 (Iloprost/ iprostadil) for peripheral vascular disease (PAD).  In the past, we have used a myriad of treatments including statins, pentoxifylline, clopidogrel and even quinine for the prevention and relief of claudication symptoms.  However, all of these previous agents are designed for early PAD and are only minimally effective at treating later stages of disease.  Treatment of severe disease (rest pain or ulceration/ ischemia wounds) has been limited to stenting (angioplasty) and surgical revascularization – but this strategy often fails for patients with microvascular disease (or disease that affects vessels that can not be operated on.)

Last effort at Limb Salvage in critical ischemia

No – Prostaglandin E is not some magic ‘panacea’ for peripheral vascular disease.  There is no such thing – but it is a medication in the treatment arsenal for vascular surgeons – and it has shown some promising results particularly in treating limb-threatening ischemia.  In fact, the data goes back over 20 years – even though most people in the United States have never heard of it.  That’s because prostaglandin E1 is more commonly used for other reasons in the USA.  It is a potent vasodilator, and in the US, this medication is often used in a different (aerosolized form) for primary pulmonary hypertension.  It is also used for erectile dysfunction.  Despite a wealth of literature supporting its use for critical ischemia it is not currently marketed for such use in the United States – and thus – must be individually compounded in a hospital pharmacy for IV use.  Supplies of this medication in this form are often limited and costly.

Intravenous Prostaglandin E1

This medication offers a desparately needed strategy for patients with critical ischemia who (for multiple reasons) may not be surgical candidates for revascularization and is a last-ditch attempt to treat ‘dry’ gangrene and prevent amputation and limb loss.  Since more than 25% of all diabetes will undergo amputation due to this condition – this is a critical development that potentially affects millions of people.  (Amputations also lead to high mortality for a variety of reasons not discussed here.)

What is Prostaglandin E1?

As mentioned above, prostaglandin E1 is a potent vasodilator – meaning it opens up blood vessels by forced the vessels to dilate.  This brings much-needed blood to ischemia tissue (areas of tissue dying due to lack of blood.)

Treatment details:

A full course of treatment is 28 days.  Patients receive 60 micrograms per day by IV.

Patients must be admitted to the hospital for observation for the first intravenous administration of prostaglandin E1.  While side effects such as allergic reactions, rash or tachycardia are rare – since this medication is given as an IV infusion, doctors will want to observe you for the first few treatments. The most common side effect is IV irritation.  If this occurs the doctors will stop the infusion and dilute it further to prevent discomfort.  Once your treatment has been established, doctors may arrange for you to have either out-patient therapy at an infusion center, or home health – where a nurse comes to your house to give you the medication.

The surgeons will evaluate your legs before, during and after treatment.  If the ischemia or rest pain are not improving, or worsen during treatment – doctors may discontinue therapy.

Prostaglandin E1 therapy is compatible with other medications for PAD such as clopidogrel, aspirin, pentoxifylline and statins, so you can continue your other medications for PAD while receiving this treatment.  However, if you are taking nitrates such as nitroglycerin, (Nitro-dur, Nitropaste) or medications for pulmonary hypertension or erectile dysfunction – please tell your surgeon.

In Colombia, the average cost of the entire course of treatment (4 weeks of daily therapy) is 12 million Colombian pesos.  At today’s exchange rate – that is  a little under $ 7000.00  (seven thousand dollars, USD).

While this is a hefty price tag – it beats amputation.  In some cases, arrangements can be made with insurance companies to cover some of the costs.  (Insurance companies know that amputation-related costs are higher over the long run, since amputation often leads to a lot of other problems due to decreased mobility).

Additional Information about Dr. Berrio:

Dr. Jhon Jairo Berrio, MD

Vascular surgeon

Calle 414 – 30

Buga, Colombia

Tele: 236 9449

Email: vascular@colombia.com

Speaks fluent English, Espanol.

References/ Additional information about peripheral arterial disease (PAD) and prostaglandin e1

Pharmacotherapy for critical limb ischemia  Journal of Vascular Surgery, Volume 31, Issue 1, Supplement 1, January 2000, Pages S197-S203

de Donato G, Gussoni G, de Donato G, Andreozzi GM, Bonizzoni E, Mazzone A, Odero A, Paroni G, Setacci C, Settembrini P, Veglia F, Martini R, Setacci F, Palombo D. (2006).  The ILAILL study: iloprost as adjuvant to surgery for acute ischemia of lower limbs: a randomized, placebo-controlled, double-blind study by the italian society for vascular and endovascular surgery.  Ann Surg. 2006 Aug;244(2):185-93.  An excellent read – even for novices.

S Duthois, N Cailleux, B Benosman, H Lévesque (2003).   Tolerance of Iloprost and results of treatment of chronic severe lower limb ischaemia in diabetic patients. A retrospective study of 64 consecutive cases .  Diabetes & MetabolismVolume 29, Issue 1February 2003Pages 36-43

Katziioannou A, Dalakidis A, Katsenis K, Koutoulidis V, Mourikis D. (2012).  Intra-arterial prostaglandin e(1) infusion in patients with rest pain: short-term results.  Scientific World Journal. 2012;2012:803678. Epub 2012 Mar 12.e Note extremely small study size (ten patients).

Strecker EP, Ostheim-Dzerowycz W, Boos IB. (1998).  Intraarterial infusion therapy via a subcutaneous port for limb-threatening ischemia: a pilot study.  Cardiovasc Intervent Radiol. 1998 Mar-Apr;21(2):109-15.

Ruffolo AJ, Romano M, Ciapponi A. (2010).  Prostanoids for critical limb ischaemia.  Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006544.

Volteas N, Leon M, Labropoulos N, Christopoulos D, Boxer D, Nicolaides A. (1993).  The effect of iloprost in patients with rest pain.  Eur J Vasc Surg. 1993 Nov;7(6):654-8.

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Five hundred years of history are featured in this full length article in the Miami Herald on Cartagena, Colombia.  The article also mentions several of the must-see sites and destinations in the city.

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Hundreds of thousands of french made breast implants have been recalled – sending women all over the globe into a panic.  These implants which are no longer in use in France, have been linked to an increased rate of rupture, and possible increased incidence of cancer.

But good news for readers – as you may recall from my interviews with several of the surgeons (as written in the book) – none of the surgeons I interviewed used french implants.  The majority used FDA approved implants (only one brand currently FDA approved.)  Several others use german made implants*.. But this is an example of the details I’ve ferreted out for my readers..

* Brand information and other details are available in the book, “Bogota: a hidden gem guide to surgical tourism.”

More stories about fake docs including this one about a phony performing liposuction while smoking a cigar on AWAKE patients..

This guy was actually a doctor, but that didn’t stop ten of his patients from dying after bariatric procedures..

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As promised, my dear readers – more about the delightfully charming and sinfully attractive Frankie Jazz.. Since our fateful (but chance encounter) this summer, Frankie Jazz has released a new single, the acoustic version of one of my personal favorites, “Fight to Stay.”   This song, as well as his album, “Let me take my way” are available over at iTunes (and are now part of my newest playlist..  so move over, Wisin & Yandel – Frankie’s come to town!)

and I just couldn’t help myself – I lifted some of his album art from his website, Frankie Jazz.  (Let me tell you – the photos of Mr. Vergara don’t do him justice..)

 

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During my most recent visit to Cartagena, I stopped in to re-visit Dr. Barbosa, cardiac surgeon at Hospital Nuevo Bocagrande. We talked about some of the changes that had taken place since my last visit – as well as Dr. Barbosa’s future plans. (I wrote about it a little during a previous post but I wanted to talk a bit more about the procedure itself, now that I have the video to accompany the post).

Recent global downturns in the economy have begun affecting Cartagena as well, which has led to some slow downs at the hospital. Dr. Pulido, during his short tenure there had initiated several upgrades and expansion plans, including a new, larger emergency department. While the new ER was completed last year – during my visit to Cartagena, some of the other plans have been deferred due to the weakening peso.

Of course, that doesn’t stop Dr. Barbosa from providing his patients with excellent care. During my visit, I joined Dr. Barbosa and his team in the operating room as an observer. (Unfortunately much of the video footage was damaged), but I was able to make a short film showing Dr. Barbosa performing the Bentall procedure.

Dr. Barbosa on YouTube.com

The Bentall procedure is replacement of the aortic root with aortic valve replacement. Essentially a long prosthetic graft (which resembles a stiff tube sock with a prosthetic valve attached at one end) is used to replace the damaged segment of the aorta. In this case, the patient has a very large aneurysm of the ascending aorta (which is marked on one segment of the clip above – visible on full screen settings). Due to the size and location of the aneurysm, the aortic valve was no longer able to function – and it was this dysfunction (not the aneurysm itself*) that caused the patient’s symptoms (from severe aortic valve regurgitation). However, had this aneurysm remained untreated/ corrected this patient certainly would have died when the aneurysm eventually being leaking/ ruptured.

Instead – the patient was in the operating room with Dr. Barbosa where everything went quickly and smoothly. The aneurysmal section and aortic valve were replaced – the patient was transferred to the ICU and discharged a few days later.

As you can imagine, this is a fairly complex operation – requiring CPB (cardiopulmonary bypass or the heart-lung machine) which carries some risk of death, and serious complications such as organ failure.

Luckily for patients needing this surgery – for most cardiac surgery programs, it’s also a fairly routine procedure (which means we’ve gotten good at it.)
*intact aortic aneurysms rarely cause symptoms.

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