ERCP* is the common name for a common medical procedure in the U.S. that identifies and eliminates blockages in the bile duct using a long thin tube called an endoscope. Doctors at the IU School of Medicine perform about 3,000 of these ERCP procedures and more than 50,000 endoscopy procedures overall each year, making it one of the busiest endoscopy centers in the entire country.
Until this year, an ERCP procedure had never been performed in western Kenya. The best existing option for patients facing a bile duct blockage was placement of an external drain which has to be emptied several times a day and is prone to infection. For many, even that procedure is inaccessible and the blockage can lead to death.
Through the AMPATH partnership, a team from IU School of Medicine spent a week in March at Moi Teaching and Referral Hospital (MTRH) holding a surgery “camp” to begin the process of training the Kenyan team in ERCP and other advanced and therapeutic endoscopy procedures.
“The physicians were side by side with us looking at the techniques. In fact, by the end of the week they were holding the scope and doing the work themselves for the majority of time, which is amazing,” said Mohammad Al-Haddad, MD, director of the division of gastroenterology and hepatology at the IU School of Medicine, who led the team of two doctors and two nurses from IU.
Dr. Aidah Kenseko is a general and laparoscopic surgeon at MTRH and leads the endoscopy department. She wrote the initial draft of the proposal to collaborate with IU to bring advanced endoscopy procedures like ERCP to MTRH and worked with Sophia Abdulhai, MD, AMPATH surgery team leader, and Dr. Ivan Seno, MTRH surgeon, to refine the collaboration.
Dr. Kenseko said that each week there are 3-4 patients on the wards at MTRH with symptoms of an obstruction. When a patient has a lot of stones or a mass in their bile duct, they present with jaundice (yellowing of the skin), weight loss, loss of appetite and itching. “They're miserable,” lamented Dr. Al-Haddad.
With ERCP, the blockage can be removed or a stent placed in the bile duct without surgery and the risk of infection is minimal. If cancer is suspected, a biopsy can also be taken during the same procedure. “ERCP will help many of these patients that are a fit for the procedure. I took care of the patient recruitment and mobilization,” said Dr. Kenseko.
These procedures require both specialized equipment and supplies such as stents and catheters as well as general surgery supplies. “I engaged with some local industry partners to get some consumable surgical supplies for the camp. I also mobilized colleagues and students that were interested in this skills transfer camp and the logistics involved in that,” Dr. Kenseko continued.
During the week the combined team performed 27 ERCP procedures on patients from throughout western Kenya and from as far away as Nairobi. More than 30 healthcare professionals from MTRH and Moi University received training in the procedure including:
- 7 endoscopists (both surgeons and gastroenterologists)
- 7 registrars (equivalent to medical residents)
- 6 nurses and nursing students
- 6 anesthetist and anesthesia students
- 1 radiographer
- 2 biomedical technicians
- Multiple nurses on the ward and outpatient department did admissions and ward management
“Our aim was to not only provide these services to critically ill patients from underserved areas but also provide preliminary training and exposure to the local healthcare providers,” said Nasir Saleem, MD, assistant professor of clinical medicine at IU School of Medicine who also participated in the camp. “We saw patients in the clinics and on wards while working alongside trainees and consulting physicians. We also held meetings with the gastroenterology faculty and trainees to explore avenues for collaboration in research.”
Dr. Kenseko said the team at MTRH will soon start to perform basic ERCP procedures while planning for the next visit from the IU team in the fall. The collaborative team created a list of lessons learned from the first visit to build on and is working together on a practical strategic vision for the next 2 to 3 years to address the most pressing care and training needs.
The team from IU has stayed connected to the team in Kenya including a Zoom lecture on advanced endoscopy that was attended by more than 120 practitioners from all over the country. They continue to discuss difficult cases through WhatsApp and email.
Dr. Al-Haddad said he has been amazed by how many requests he has received from his team at IU to be part of future trips. He said the enthusiasm from the doctors and nurses who were part of the first trip has been contagious and they have enough interest to rotate teams of doctors and nurses for 2-3 trips per year. Some have offered to take vacation time or pay their own expenses.
“We have great team members who care and who want to bring some good to the world. They are very committed to their colleagues and their patients and really want to spread the knowledge everywhere,” he said. It’s a sentiment that Dr. Al-Haddad shares.
“I still derive most of the gratification from being a doctor from specific things and the main thing for me is essentially turning someone's life around and giving them some quality of life. That’s no different in Eldoret or Indianapolis or any other place. This is what really keeps me going. That was the part that I came to really touch and live over the course of the week in Kenya.”
“When we went the next day to see some of the patients we had performed interventions on the day before, we could tell that they look different. They have turned the corner. They are eating. They no longer have any fever. Some of them may be actually getting ready to go home, and they've been in the hospital for weeks. So that was very gratifying. I think this was probably the moment we decided that we cannot pull back from this program. There is so much more work that needs to be done to sustain what we have started. That’s what is going to keep us all engaged with this mission,” he concluded.
*ERCP stands for endoscopic retrograde cholangiopancreatography
