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25 How toManage Thoracic Surgical Problems inLow- andMiddle-Income Countries
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297
Fig. 25.10 The stay sutures shown are used to close the
skin incision and have an initial “air knot” against which
the tube is tightly tied
tube once the lung is expanded, whether with the
patient at full inspiration or full expiration. The
author’s preference is full inspiration with cutting
of the stay sutures just proximal to the air knot
with rapid removal and tying of the purse string
suture followed by placing an occlusive dressing
over the site.
Open Chest Wound/Sucking Chest
Wound
While rib fractures may cause a simple pneumothorax or a tension pneumothorax, collapse of a
lung with or without tension physiology may
result from an external penetrating wound with
Fig. 25.11 Additionally, a “U” stitch is placed. It is not
fully tied close to the skin. A single throw is placed against
the chest tube and its ends will be tied around the chest
tube well away from the stay sutures. The purse string “U”
suture is left long. When the chest tube is no longer
needed, the stay sutures are cut freeing the tube and the
“U” stitch is tied promptly as the chest tube is rapidly
withdrawn preventing air from being sucked into the chest
when the chest tube is removed
atmospheric air gaining entry into the chest cavity. With each inspiration, air is “sucked” into the
chest and it may or may not exit during expiration. If it does not exit, tension may develop with
resultant obstructive shock.
Diagnosis ofanOpen Chest Wound/
Sucking Chest Wound
The history of trauma and the physical examination make this diagnosis. If the lung has been
injured, bloody froth may bubble in and out of
the wound with inspiration and expiration.
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W. D. Widmann
Fig. 25.12 An improvised Heimlich valve can be made
easily by cutting a slit in a condom or a glove nger and
fastening it to the end of the chest tube
Management ofanOpen Chest Wound/
Sucking Chest Wound
The management of this type of injury is quite
simple. An occlusive dressing is applied and
taped only on three sides as shown in Fig.25.13.
Most penetrating chest wounds do not require
surgery for control of bleeding. Thoracotomy
may be a very difcult, if not dangerous, option
in LMIC.Fortunately, it is rarely needed for penetrating chest trauma. The best course of treatment is to get the patient to a major LMIC facility
that can safely perform open chest surgery if
there is continued bleeding.
Flail Chest
Road trafc accidents (RTAs) and falls may produce multiple rib fractures, and especially when
serial ribs are broken at two sites, the chest wall
becomes unstable with a resultant inward collapse of the chest wall on inspiration and then
outward bulging on expiration. There is lessened air entry into the lungs, and respiratory
insufciency with hypoxia and hypercarbia
develops.
Fig. 25.13 The three-sided application of tape over cellophane or any other clean impermeable exible material
allows for escape of air from the chest without air getting
sucked back in. Ongoing internal bleeding may require
uid or blood administration if available
The diagnosis is readily made by the history
of trauma, and examination shows the paradoxical caving in of the chest wall with inspiration
and bulging out with expiration. Bony crepitus
may be felt. The patient will be anxious and
tachypneic. Pain is severe. While the ideal treatment would be intubation and ventilator support, along with pain relief by a high epidural
catheter, these modalities are rarely available in
LMIC.
Management ofaFlail Chest
In LMIC the practical approach is to stabilize the
chest wall with a tight dressing being careful to
avoid restricting motion of the opposite side of
the chest. Pain relief by intercostal nerve block
with local anesthetics is preferable to narcotic
medication which may suppress the ventilatory
drive. Figure25.14 shows such a dressing using
expandable elastic wrapping. If possible, the
dressing should be taped only to the midline to
avoid restricting the opposite chest wall motion.
If available, plastic IV uid bags can be taped on
instead of bulky gauze material to compress and
stabilize the chest wall.
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While combined medical management with
appropriate antibiotics and chest drainage is
needed, the appropriate means for determining
the exact organisms involved (bacteriologic identication) and then antibiotic sensitivity proling
for selecting the appropriate antibiotic treatment
program may be lacking in a station hospital in
LMIC. However, usually a microscope and an
incubator are available. A smear of the sputum
with acid-fast stain may conrm diagnosis of
TB.Cultures should be sent to the major hospital
in the area, preferably along with the patient for
more precise and effective care. Basic supplies of
antibiotics are frequently lacking for empiric therapy and may require sending the patient’s family
to obtain them. Additionally, chest tube drainage
is most effective when instituted while the empyema uid is “thin,” that is, not thick/viscous and
will drain out from the chest without suction.
Further, with patients presenting with advanced
disease, the underlying lung may have become
encased in a thick, broinammatory “peel” and
not re-expand. Such cases need operative decortication or combined enzymatic lysis, modalities
beyond local treatment in a station hospital in
LMIC.Almost all LMICs have regional facilities
Fig. 25.14 The ail segment of the chest should be
splinted by a bulky dressing with care to avoid restriction
of the opposite side of the chest. Pain medication is
needed, and coughing is encouraged
with such capabilities for treatment of tubercular
and non-tubercular empyema [3]. However, in
most station hospitals or rural clinics in LMICs,
the only treatment readily available is chest tube
drainage, with possible diagnosis and antibiotic
Thoracic Infections
The complications of pulmonary infection may
treatment only until the patient can be transferred
to an appropriate facility.
lead to empyema, a buildup of pus within the
pleural cavity. This can be the result of bacterial
pneumonia or tuberculosis. Undrained, sepsis
and septic shock may be fatal. In LMIC patients
Airway Obstruction by Infection/
Foreign Bodies
typically present with advanced stages of empyema with thick intrathoracic pus. Tuberculous
effusions are most common. Echinococcal effusions may also occur.
The diagnosis is made from the history of fever,
cough, and sputum production, and it is conrmed
by physical examination showing diminished
The airway can become obstructed by aspiration
of foreign bodies most typically aspirated food
and by infection both bacterial and viral.
Complete obstruction rapidly results in anoxic
death. If the airway is not completely obstructed,
the patient may be brought to medical attention.
breath sounds on the affected side, with dullness to
percussion, and loss of tactile fremitus. Weight
loss and dehydration are common ndings.
Chronicity suggests tuberculous empyema.
Diagnosis ofAirway Obstruction
The history of eating and talking with a mouth
full of food followed by gasping and coughing
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W. D. Widmann
sometimes associated with a loss of the ability to
speak and with concomitant pointing to the neck
by the patient is the classical presentation. On
examination with a stethoscope or simply by listening to the chest by placing the examiners’ ear
directly on the chest wall, there may be localized
wheezing or diminished sounds on just one side
if the material is blocking just one major bronchus, but most commonly the food or other foreign materials are lodged just at or above the
vocal cords, and breath sounds are diminished on
both sides. Stridor is common when the vocal
cords are inamed by bacterial or viral infection.
Management ofAirway Obstruction
Ancillary personnel should be trained in the simple potentially life-saving maneuvers that may
aid the patient’s ability to cough out the foreign
material. The simplest means of increasing intrathoracic pressure to expel foreign material is by
forceful slapping the patients back between the
scapulae. A more advanced and more effective
maneuver is the Heimlich maneuver, in which the
operator gets behind the victim, and with one
hand formed into a st and placed in the subxi-
phoid region, the other hand overlying that hand,
and then both are forcefully pulled into the vic-
tim’s upper abdomen. The sudden increase in
intraabdominal pressure is transmitted through
the diaphragm, and the resultant elevated intra-
thoracic pressure may be sufcient for the
impacted foreign material to be dislodged and
coughed out, as shown in Fig.25.15.
When the Heimlich maneuver is not successful with repeated thrusts, the traditional approach
in medical facilities when patients are stridulous
would be to perform endotracheal intubation
with laryngoscopy and bronchoscopy for removal
of any foreign material. Such an approach
requires trained personnel, available instruments,
and resources (electricity) to utilize endoscopic
removal. Lacking these in an LMIC facility, the
next step should be performance of a
cricothyroidotomy.
Cricothyroidotomy
When the airway cannot be cleared by backslapping or the Heimlich maneuver, the next
Fig. 25.15 As shown, the Heimlich maneuver requires just one trained person and no additional equipment
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step when bronchoscopy cannot be done for
various reasons, relief of obstruction must be
done by performing the simplest, fastest opening of the airway below the larynx. The equipment needed is minimal and the simplicity of
cricothyroidotomy makes it feasible for medical personnel other than trained general or thoracic surgeons to perform the procedure safely.
The anatomic features of the neck dictate that
tracheostomy is a more advanced procedure,
fraught with more bleeding and need for more
equipment. To perform a tracheostomy may
require more equipment and more surgical skill
as the isthmus of the thyroid is in the operative
eld, bleeding is more of a concern, and the
time required is more than for a cricothyroidotomy. Figure 25.16 shows that there are no
signicant structures in front of the cricothyroid membrane, while the thyroid can cover tracheal rings and make rapid bloodless approach
to the tracheal lumen difcult. The quickest and
least bloody access to the cricothyroid membrane is by a vertical midline incision. There is
no need for sophisticated specialized tubes to
be inserted. Any hollow tube sufces, as shown
in Fig.25.17.
Fig. 25.16 The larynx and just inferior to it the cricoid
cartilage can be felt easily. Note that the very vascular thyroid gland covers much of the proximal trachea below the
cricoid cartilage
301
Fig. 25.17 The vertical
skin incision should be
2–3cm long. A Kelly
clamp or hemostat can
be used to spread the
skin and subcutaneous
tissue laterally, and then
a horizontal incision is
made in the underlying
cricothyroid membrane.
The opening can be
dilated with a clamp,
and any type of hollow
tube can be used to
establish the airway
302
Angle Of Disection
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W. D. Widmann
Carotid Sheath
Stemomastoid
Fig. 25.18 Under local anesthesia after making an incision anterior to the right or left sternocleidomastoid muscle and extending it through the underlying platysma
muscle, dissection is bluntly continued anterior to the
Retropharyngeal Space
Esophageal Injuries: Mediastinitis
Penetrating neck wounds may injure the proximal esophagus and produce mediastinitis.
Similarly, neglected dental and tonsillar infection
may cause descending mediastinitis. In LMIC
non-major hospitals, the only treatment practical
and safe for the patient would be transcervical
drainage by a longitudinal incision anterior to the
sternocleidomastoid muscle (Fig. 25.18).
Transcervical drainage can be performed using
local anesthesia and requires minimal instruments beyond scalpel, Kelly clamps, and soft
drainage tubes [4].
carotid sheath and dorsal to the thyroid gland. This leads
to the posterior (retropharyngeal) visceral space involved
in descending cervical mediastinitis. Soft drains are then
inserted
Chest Wall Burns
While most trauma especially road trafc accidents (RTAs) affect men, in LMIC burns are
more common among women due to their predominant engagement in cooking [5]. Chest wall
full-thickness burns may result in formation of a
restrictive eschar which impairs ventilation.
Providing the patient has been able to take sufcient uids by mouth and not succumb to “burn
shock” given such a patient, escharotomy is the
appropriate treatment. Since full-thickness burns
result in an insensate eschar, anesthesia is not
needed. Incisions must be made to allow relief of
Fig. 25.19 The incisions allow the constricted chest wall
to regain motion. Insensate skin and subcutaneous tissue
can be incised down to the fascia with little bleeding
the chest constriction. The typical incisions
needed are shown in Fig.25.19.
Cardiac Injuries
Cardiac injuries can result in cardiac tamponade
or exsanguination into the pleural cavity. If
patients survive with cardiac tamponade and are
able to present to a basic clinic in LMICs, facili-
25 How toManage Thoracic Surgical Problems inLow- andMiddle-Income Countries
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Fig. 25.20 Damage
control techniques in
Cardiac Trauma. In
cardiac injuries
extending through the
endocardium a Foley
catheter can be inserted
into the wound, inated,
and gently retracted to
achieve hemorrhage
control. Skin staples
may be used to close the
cardiac wound
303
ties will not likely have staff sufcient to perform emergency left anterior lateral thoracotomy
and decompression of the tamponade. For such a
procedure, anesthesia staff, nursing personnel,
surgical equipment, and then postoperative care
are not available. Trained physicians may be able
to perform subxiphoid decompression of the
pericardium as an alternative approach. Along
with the inability to provide operative care for
traumatic cardiac injuries, treatment of congenital heart disease and acquired heart disease
remain beyond the scope of available care in
other than in major health centers in some
LMICs. These efforts are frequently strengthened by collaboration under mutual agreements
with visiting cardiac surgery NGOs from highincome countries (HICs) such as the USA or
Sweden.
The possibility of saving a patient with a
stab wound of the heart is highly unlikely in a
rural station hospital in LMICs. If the diagnosis appears clear by physical examination or
ultrasound, an attempt at repair of the hole in
the heart may be tried (Fig.25.20). An anterolateral left thoracotomy is needed in the fifth
interspace, and once the hole is found, bleeding may be controlled with a finger or Foley
catheter. The cardiac wound can be closed
using skin staples. Blood replacement must
follow, and the patient must be evacuated to
the nearest major facility if they are to
survive.
Summary
At the current time, the thoracic procedures most
likely to be performed and to meaningfully save
lives in LMIC are for trauma victims and for
those suffering from infectious pleural effusions.
Securing an airway, treating a pneumothorax,
and draining the chest are basic procedures that
can be performed with a minimum of supplies
and not needing readily available complete operating room infrastructure, including staff, supplies, equipment, and anesthesiologists. There
remain a vast number of conditions needing thoracic surgical care for congenital and acquired
diseases of the chest that remain untreated—most
notably pediatric cyanotic heart conditions and
adult malignancies. Because of the infrastructure
needed to support major thoracic and cardiac
operations, basic structural changes in LMICs
need to be either supported or initiated before
those conditions can be treated effectively and
successfully in many LMICs. Basic training for
the procedures discussed in this chapter can be
performed with the limited resources in rural sta-
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W. D. Widmann
tion hospitals in LMICs at the current time and
should be a part of global health initiatives.
The reader is advised to seek further information from standard textbooks of surgery and
from the websites, regarding the problems discussed briey in this chapter and any other problems that may be encountered during daily
practice in LMICs. This includes treatment of
unusual respiratory distress syndromes associated with parasitic or viral infections. Other
chapters in this book address problems related to
diseases of the thorax including chapters on
trauma (Chap. 14), recovery room (Chap. 12),
operating room (Chap. 13), and injuries of the
neck (Chap. 24).
References
1. Lebenthal A, von Holzen U.Adult chest surgery. 2nd
ed. McGraw-Hill Education; 2015. p.366–80.
2. Khan RM, Sharma PK, Kaul N.Airway management
in trauma. Indian J Anaesthesia. 2011;55:463–9.
3. Kumar A, Lingaraju CV, Pulle MV, Asaf BB, Puri
HV, Bishnoi S.Comparison of outcome of surgery for
tubercular and nontubercular empyema: an analysis
of 285 consecutive cases. Lung India. 2021;38:514–9.
4. Sakai T, Matsutani N, Iito K, Mochiki M, Mineda J,
Shirai S, Kanaoka R, Yamamuchi Y, Saito Y, Sakao Y,
Kawamura M.Deep cervical and paratracheal drainage for descending mediastinitis. Asian Cardiovasc
Thoracic Ann. 2020;28:29–3.
5. Smiley KE, DeBas HT, deVries CR, Price
RR. Schwartz’s principles of surgery. 11th ed.
NewYork; 2019. 2077-2112
How toManage Conditions
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oftheStomach inLowandMiddle-Income Countries
PhilipVareedAlexander andMylaJacob
Nothing can be done without hope and condence.
– Helen Keller
Abbreviations
EGD Upper endoscopy
GI Gastrointestinal
IV Intravenous
LMICs Low- and middle-income countries
NCCN National Comprehensive Cancer
Network
NDMA N-nitrosodimethylamine
NSAIDS Non-steroidal anti-inammatory drugs
Endoscopy
26
porated into the syllabus of the general surgeon,
and rightfully so, but this is not yet quite universal. Short courses in endoscopy being made
available to the general surgeon will be invaluable in widening his repertoire, and those planning to serve in LMICs should learn it.
Colonoscopy is one step further in the interventional skill required of the remote rural surgeon,
but is more demanding in terms of training, and
skill and experience. Chapter 10 addresses the
approach to organizing an effective endoscopy
program in LMICs.
Upper GI endoscopy is an essential part of the
armamentarium of the surgeons in LMICs.
Besides being confronted with the chameleon of
epigastric discomfort and pain, the sinister spectre of upper gastrointestinal haemorrhage requires
life-saving intervention, particularly when the
next port of referral is many hours away.
Endoscopic training is being increasingly incor-
P. V. Alexander (*)
Lady Willingdon Hospital, Manali, India
M. Jacob
Christian Medical College Vellore,
Vellore, Tamil Nadu, India
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_26
Heartburn
Heartburn, or upper abdominal discomfort and
pain, is reportedly more common in the Western
world (10–20% prevalence) than in Asia (5%
prevalence) [1], but is a very common presentation to both the outpatient clinic and the emergency room. What is more sinister is that it can
camouage life-threatening conditions, like acute
myocardial infarctions, pancreatitis, ruptured
aortic aneurysms, or duodenal ulcer perforations,
and even severe cholecystitis. Failure of subsidence of pain to routine measures should raise the
index of suspicion and the search for these lethal
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P. V. Alexander and M. Jacob
lurkers. While endoscopy is not really indicated
emergently in such situations, it is reassuring to
schedule a routine endoscopy as part of a weekly
list for patients whose pain does subside and
whose symptoms do not merit further emergent
treatment.
All upper GI bleeds for any reason merits an
endoscopy emergently or electively. Emergent
endoscopic skills in the face of active and violent
bleeding require teamwork inclusive of the
anaesthetist and theatre staff who need to be
trained in what is expected of them, and conversant with the steps to be followed with an operating room on standby. This presents a challenge in
any circumstance, particularly so in a resourcepoor environment. In any emergent trauma or crisis, the rst chance is often the best chance to
surmount the situation. If the surgeon is not condent of being ably equipped to undertake this
challenge, timely resuscitation and referral may
be the wiser alternative.
Endoscopy inGERD
Endoscopy is indicated in patients with symptomatic GERD to evaluate alarm features. The
alarm features are detailed in Table 26.1.
Endoscopy is also indicated if “Barrett’s”
oesophagus is suspected on the basis of suspicious four-quadrant oesophageal biopsy.
damage and regeneration without inammation),
the presence of inammation in the stomach lining presents a blurred criterion that has resulted
in a plethora of systems to grade gastritis. It is
also divided into acute or chronic by chronology
of symptoms and type of inammatory cells
present. Concerns regarding a progression to
malignancy imbue the interpretation of these
biopsies. Endoscopically the lack of rugae,
increase in vascularity, supercial erosions, and
ulcerations are well-described features that surprisingly do not always have a strict correlation
with the histopathologic extent of disease or the
severity of symptoms. Multiple biopsies from
four quadrants and the incisura help the pathologist’s interpretation. Chromoendoscopy can be
performed quite easily to help identify aberrant
mucosa. The dyes commonly used are methylene
blue for absorptive epithelium (such as Barrett’s
oesophagus), Lugol’s iodine for squamous epithelium, and toluidine blue for oesophageal
malignancies.
Endoscopic screening for detection of gastric
cancer on a community level is found to have
worth in communities with a high predilection
for gastric malignancy but is of doubtful value in
other communities [2]. Any suspicious area
encountered upon endoscopy should be mandatorily biopsied.
Gastric Ulcers
Gastritis
Gastritis is a common melting pot for a variety of
conditions. Inclusive of gastropathy (epithelial
Table 26.1 Alarm features in patients with symptoms of
GERD
•New onset of dyspepsia in patient ≥60years
• Evidence of gastrointestinal bleeding (haematemesis,
melena, haematochezia, occult blood in stool)
•Iron deciency anaemia
•Anorexia
•Unexplained weight loss
•Dysphagia
•Odynophagia
•Persistent vomiting
•Gastrointestinal cancer in a rst-degree relative
Gastric ulcers may be symptomatic or quiescent
till they present with complications; 70% may be
asymptomatic [3] and 43% to 87% with bleeding
ulcers may have no antecedent symptoms [4].
Older patients or those on non-steroidal antiinammatory drugs may rst present with complications [5]. Previous history of Helicobacter
pylori infection is a red ag. Of those who are
symptomatic with upper abdominal pain, 80%
would have an ulcer [5]. Prepyloric and duodenal
ulcer pain may be differentiated by the relationship to meals; prepyloric and antral ulceration
cause pain and duodenal ulcers occur typically
5–6h post prandially [6]. Acid reux symptoms
and feeling of bloating may accompany these
symptoms in up to 47% of the time [5].
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