Caras Felices, the cleft surgery organisation

To far countries to operate on children with a cleft lip

Starting in 2002, we have made two or three trips a year to countries all over the world to operate on children with cleft lips. Our trips so far have led us to Kenya (9 times), Nepal (once), Burma (once), and Vietnam (four times).

Below you will find reports on some of our projects with photographs showing the places we work, the conditions of the children and the results of the surgery.

Kenya February 28th – March 6st 2010

Participants:            

Dr Thomas Jansen, Marbella, Spain
Henk and Yvonne Geerlings (anesthesia), Amersfoort, Netherlands
Dr Bart van de Ven, Marbella, Spain.

Coming home

For me coming to Kenya is almost as coming home, as my first time was in September 2002. Henk and Yvonne are coming for the fourth time, Thomas has his premiere in Africa even.

Thomas and I have been to Erbil in Iraq once in November 2009 to perform cleft lip and palate surgery and also to Damascus twice last year.

As usual we are being picked up from the Nairobi international airport on Sunday morning by a driver of Nazareth Hospital.

 

After having arrived in the hospital we sleep a couple of hours and then go to Village Market. This is a shopping centre near Nairobi, mainly for expats. The banana split ice-cream is still nice and this year the singer of the band is particularly good. In Kenya nothing changes really. Sometimes it’s for the good, sometimes for the bad.

Nazareth Hospital

So the singer was better than last year, the number of patients at Nazareth Hospital is lower which is not good. It doesn’t mean that less children with a cleft have been born than last year, but it means the publicity that has been given to our mission was less. We see 8 patients. One boy has a fistula of the hard palate that hardly has any functional implications. Therefore we decide not to operate him now. He should come back after having reached the age of 15 (he’s 6 now) when growth of his jaws has completed. Then we can close it. To close it now would compromise the growth of the upper jaw.

There also is a boy that misses part of the vermillion of his upper lip. The reason could be a trauma or noma (an infectious disease that can occur in people with malnutrition). He says he has no idea what is the reason. He has always had it as far as he knows. The deformity is very mild however and we think that any type of surgery is more likely to make it worse instead of improve it. The other patients we’ll operate.

Chelimo has both a cleft lip and cleft palate and has never been operated before. He’s 1 year old. We start with him and close the palate. Normally surgeons close the lip first at the age of a couple of months and the palate about 1 year later. It’s a treatment protocol that has been like that for decades and nobody ever changed it.
When the lip is still open it’s much easier to close the palate, especially the anterior part. We let the patient recover 2 days and then we close the lip. So palate and lip are closed within 3 days. We are very satisfied with the result and decide to make a video of the procedure and show it in an international congress about cleft lip and palate repair somewhere this year. Maybe we can convince some surgeons to change their protocol according to ours.

In 2 and a half days we perform the surgeries and on Wednesday by noon we’re picked up by the hospital van of Mathari hospital in Nyeri.

 

How to say thank you with a smile!

 

Mathari hospital in Nyeri

After a 3 hour drive through the beautiful highlands of Central Kenya we arrive in Nyeri. On top of Mount Kenya, which is on the equator we see snow.

On the road to Nyeri you can buy the best mango in the world...

 

The next morning we see the patients that have come. It’s obvious that also here in Nyeri little effort has been done to inform the patients about our presence now. Most children are too small for surgery. The’ll have to come back next year.

Child Dr Bart operated three years ago on the lip, comes back for palatal surgery.

 

 

During the 2 days in Nyeri we perform 5 surgeries: 4 lip closures and 1 patient that has an enormous lymphangioma (very blood-rich but benign tumor) of the lower lip. To prevent the patient will bleed to death we place clamps over parts of the tumor, place a continuous suture under the clamp and tie the suture before removing the clamp. Like that we can remove at least a big part of the tumor, but not everything. In the Western world it would be treated by embolisation when small granulas are injected through a feeding vein of the tumor. This however is a high-tech treatment that requires an experienced radiologist and is not available in this hospital.

Dr Thomas Janssens and dr Bart van de Ven operating.

 

 

Medical equipment (monitors) were given as a present to the hospital.

 

Evaluation

To have been able to help 11 people the way we could of course is a beautiful thing,but we could have operated more.
We decide however that from now on before buying flight tickets we want to know exactly how many patients of what age have been booked for surgery, so we’ll know how many surgeons should go for how long. For such missions abroad we should expect at least 20 patients.

In the meantime we’ve been informed that in Cameroon 42 patients are waiting for us.
We’re looking forward to going there.

Dr Bart van de Ven
Maxillofacial Surgeon
President Fundación Caras Felices

 

 

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Kenya February 2009

Saturday 15th of February

I lost track of the number, but this could be my 11th visit to Kenya for cleft operations.
The participants are my colleague, maxillofacial surgeon Joel Defrancq (9th time), anesthesiology nurses Henk and Yvonne Geerlings (3rd Time), first-timer Jan Vanhove, an almost-maxillofacial surgeon, and me. In the second week Ellen Defrancq will join us (1st time). She’s the daughter of Joel and a last year medical student with a great interest in maxillofacial surgery.
Furthermore my children Anne and Pino and another daughter of Joel, Lore, are on the trip. They are enjoying the spring holidays and will be doing a scuba diving course on the south-coast of Mombasa.

The plan is to work three days of the first week in Nazareth Hospital near Nairobi. Afterwards, we’ll rest over a long weekend on the coast. During the second week we’ll work for another five days in the Consolata Hospital in Nyeri. This hospital covers a very large region. We have always had a rather large amount of work there.

We will catch the night flight. Apart from a defective video system to Anne and Pino´s dismay, the trip is uneventful.

Sunday 16th of February

On arrival we find out that since our last visit the airport of Nairobi has invested in cameras to enable the customs take pictures of all the visitors. Moreover, they have placed signs that indicate which line is for Kenyans, which is for visa holders and which is for the remaining travelers. Not every change means advancement. In consequence our waiting time is more than an hour. By the way, in the end it appears that you can use any line. In Kenya, rules are no more than guidelines. My idea…

Outside, the chauffeur that has been sent by the sisters of Nazareth Hospital is waiting patiently, holding a sign that reads, “Dr Bat”. In former years the nurses came themselves. But that’s the result if you start doing things regularly. It’s not special anymore.

As always we stay in a house in the hospital area. For Kenyan standards this is an enormous luxury. It reminds us a bit of our student times. First, we nap for an hour or two. Then the same chauffeur from this morning brings us to Village Market, a shopping centre for expats and the Kenyan upper class. Each year have an ice cream there from The Italian and fetch some Camembert and Tusker bear at the supermarket.

In the evening we meet the patients for the next three days, 20 in total. Unfortunately, one patient is too small; one clearly suffering malnutrition and one doesn’t really look healthy and moreover has a heart murmur. The mal-nurtured and the unhealthy child are sent to a pediatrician. To the mother of the too small child, it is explained that she needs to come back next year. We come here each year in February/ March and will operate on her child then. She has to cry. Next year is so far. Will her child still be alive? Honestly speaking, we also have our doubts about that. The mother says her child has difficulty in drinking and this you can see. But to operate now would most likely lead to death.

Monday 17th

Today we performed five surgeries on two tables. Joel works alone and Jan sits at my table. He’s very happy. In Leuven, where he’s in training, the professor changes the design on the lip so often that in the end Jan is completely lost. Joel and I have a very systematic way of working, partly because of the book about cleft lip surgeries that we made. I like to explain what I’m doing and why and once in a while let him do some small things. Our technique for closing palates has been changed bit by bit over the last two years. With our new method, it’s possible to close the lip and palate in one operation in the somewhat older children. We do it in such a way so that there isn’t so much scarring that the growth of the upper jaw is inhibited. Today, I have two of such big operations which last four hours each. The satisfaction is high, because basically these two children from a surgical point of view are ready in a single operation.

Tuesday 18th

How progress can mean decline:
In the past few years we’ve been very active to improve our technique for closing the palate. Consequently, we now use a method in which a flap from the inside of the cheeks is being transposed to the palate. By doing this you’re capable of closing the palate and even make it longer without causing too much scarring. This is very important for good, understandable speech in which the soft palate needs to close the nose from behind for some sounds. However, now the palates are so long that some children, in the first days after surgery, can hardly breathe because of swelling. In western countries these children are kept asleep and are ventilated. Here they don’t have the equipment for that. So today we had to reanimate a child that we operated on yesterday. We have now left a tube from the nose to the throat to ensure an airway. We now do this in all patients as a means of prevention. Here in Kenya, you need to improvise, which is not without risk.

Wednesday 19th

Today we operated on another six patients: a total of 16 so far. Sister Sarah comes in the evening with one of the other sisters to give all of us a safari shirt as a present. As usual, it’s accompanied by a request: If we can help her to get an EKG machine. I tell her that in the basement of Agave Clinic there probably will be a used machine. I’ll have it checked and sent to her.

Tomorrow morning we leave early for the airport to have a short holiday with my children on the coast.

Tuesday 24th

As we knew from telephone contact with Consolata Nyeri Hospital that this year there wouldn’t be so many patients, we only go there today instead of Sunday. The problem is that we didn’t come last year because of political riots. In fact, afterwards everybody considered the project as stopped definitively. In addition, our contact person, ENT Patrick Nduduri, has left to work in a hospital in Nairobi. According to the new ENT, Patrick told them that we would only be coming in November, leaving them little time to prepare. Upon arrival it appears there are 11 patients, of which only eight are healthy and strong enough to undergo surgery.

 

Wednesday and Thursday 25th and 26th

Without any notable problems the eight patients are operated on. We do notice however that the operation theatre hasn’t improved at all in the last 2 years. Doors are stuck, sockets are hanging out of the wall, and it’s a dirty mess. It’s been said that they’re going to build new theatres. It’s about time for that.

Friday 27th

In order to have a good number of patients again next year, I’ll have to invest time and energy in organization. In the morning I see Father John, the new director of the hospital in Nyeri. We agree now that next year we’ll come to Kenya for operations in the 1st and 2nd week of March. He’ll get in contact with the regional manager for healthcare to make sure that through his canals all the hospitals in the region will know we’re coming. Dan Mbuti, the ENT, will see the patients beforehand and will make an operation list.
My colleagues leave for Nakuru National Park, which is at a two hours driving distance from Nyeri. It’s situated around a lake with millions of water birds, mainly flamingoes and pelicans. I once heard that our own prince Bernard (of Orange) was the founder of that park.
I myself get a lift from a radiologist from Nairobi. He works temporarily in Nyeri to explain the new CT scan to the local personnel.
In Nairobi I have an appointment in the evening with Patrick Nduduri. He was the ENT in Nyeri and we’ve been able to cooperate with him perfectly for six years. He now leads the hearing centre of the Lions Hospital nearby Nairobi and would like us to come there yearly and operate cleft patients as well. I meet the director of that hospital, Mr. Samson, also director of the biggest transportation company of Kenya. In 2002, Mr. Samson, an influential man, was governor of the Lions Club for East-Africa. He says Patrick spoke highly of us and that we’re most welcome to the Lions Hospital for cleft operations.

Saturday 28th

Finally I can check e-mails again and I visit a museum. In the evening my friends arrive from Nakuru. Tomorrow morning we’ll fly back to Amsterdam.
Our visit hasn’t brought what we hoped for in terms of the amount of patients, but we’ve still been able to help 24 children and probably have created a foundation again for many more years of very useful work in Nairobi and Nyeri.

Bart van de Ven

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Hanoi Vietnam 2007 

On arrival we take a taxi to our hotel. After a flight of almost 15 hours I just need a bed. I get woken up by a phone call from Dorte Werner from the Hanoi International Women’s Club (HIWC). She asks if she can pass by at  4PM. I agree.
Dorte takes care of the work permits, has the contacts with the hospital and brings us a lunch in the operating theatre every day. Dorte is an angel.

First lunch and then to work

The next day at 8AM as agreed we’re in the Hanoi Pediatric Hospital. It’s as busy as the Amsterdam central station on a Friday afternoon. The corridors are completely stuffed with people making lines everywhere. It’s a hospital with 600 beds but has mostly around 1000 patients admitted.
First we have to meet the director. Even delivery of our instruments for sterilization is not possible before this ceremony has taken place. Finally at 1 PM, after the welcome lunch we can start to operate. We perform 4 surgeries that day.

The day starts with traffic jams.

Again at 8AM we’re in the hospital. To get there has become a lot more complicated than the year before. The traffic suffers from a kind of infarction. When we came here for the first time, 4 years ago, you hardly saw any cars, but there were a lot of  
‘motorbikes’, with 4 stroke engines of about 100cc. They have around 1 million of those in Hanoi. Like ants they drive behind and through one another hooting loudly. Sometimes with 3 people sitting on top of it or someone carrying a step-ladder. But there are more and more cars and the roads absolutely cannot handle them. The city absolutely needs a subway system, for which plans have been made. But before that will be finished in 5 to 10 years the traffic will be in absolute chaos. The last couple of meters to the hospital we have to go by foot. The traffic is completely stuck. Today we operate on 10 children.

             

A difficult dilemma

A total of 78 children have been collected, a number that we’ll never be able to operate in one week. Most of them already have an operated lip. Now they come for closure of the palate. That’s important for good speech and to prevent food and liquids entering the nose. For this, different operating techniques have been developed. The Vietnamese doctors use the simplest one in which mucosa and muscles are mobilized from front to back and sutured in the middle.  The disadvantage of this technique is that the soft palate becomes too short causing a too nasal sound during speech that is difficult to understand. Moreover the scar tissue on the hard palate will counteract growth of the upper jaw. Therefore in a young child we prefer to operate on the soft palate only. With a Z-plasty we lengthen the soft palate. The hard palate we leave open until the age of 9 – 10 years. But parents and hospital personnel in Vietnam are used to a complete closure of the palate in one operation. Short term that’s nice for the patient but long term it isn’t. We do what is best for the patient on the long term, the Z-plasty. When children are a bit older we close the whole palate in one operation but with mucosal flaps that we take from the inside of the cheeks. A long tiring operation of about 2.5 hours, but with a nice result.

After a third day of surgeries we go for a massage to treat our painful backs in a massage centre. They should have some more centers like that in the Netherlands.

On the fourth working day we operated on another 10 children. About 25% of the operations are lip corrections, primary or secondary. Primary means they haven’t been operated before. For us that’s nice because then, with a more or less standard operation, we can achieve optimal function and beauty for the lip. Some children however have been operated before and the parents are right not to be happy with the result. A lot of these surgeries are performed by doctors in the provinces that have very little knowledge of the techniques available. But also in Hanoi the results of lip surgeries performed by local doctors leave much to be desired. The reason is that local surgeons are trained with the idea that an operation most of all needs to be done fast. Anesthetics are expensive and the budget is limited, so this is understandable. Another not so easy to understand reason is the idea that a good surgeon is a fast surgeon. Aesthetics are considered not to be important, but machismo is.

We propose to Dr Hai, a surgeon with whom we’re in close contact, to publish our book about cleft lip surgery in Vietnamese as well. We intend to publish this book ‘Cleft lip surgery, a practical guide’ this year. Dr Hai says that he’s willing to make the translation. We can finance the printing with money from the foundation, so that the book can be given to Vietnamese surgeons for free.
The fact that some parents are willing to travel several days (sometimes walking) to have a second surgery of an ugly operated lip, means that for them aesthetics absolutely are important.

It’s coming to an end again

Our last surgical day, 8 operations. In total we’ve been able to help 42 children. The Vietnamese doctors (no idea who they are, we haven’t seen them) according to Dorte have also operated on 22 children. The remaining children couldn’t be operated on this time because of bad health. They will have to come back another time.
In the evening we offer a dinner at the Metropole Hotel to the director of the hospital and a couple of doctors that have been involved in the operations. It’s a Vietnamese restaurant, but the chef is French, absolutely fabulous! Such a dinner is important to keep the contacts you need to be able to return each year. We settle to come back next year in October.

My travel partners stay in Vietnam for another week and travel around. Joel will give a presentation to Vietnamese doctors about orthognatic surgery (jaw surgery) next week. I’ll fly back to the Netherlands tomorrow. Monday I’ll have outpatient care in Leerdam and in the evening I’ll fly to Marbella. There I’ll have two surgeries on Tuesday. What a life….!

 

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