Report by Professors Michael Powell and Ashley Grossman (2017)
In June 2005, I first went to Tashkent. It was the start of my Uzbek life, to which I have now become addicted. I teach trans-nasal pituitary tumour surgery. At that time I was the leading exponent of this field in the UK, and had already published a couple of medical textbooks on the subject as well as being the trainer of over half of British pituitary neurosurgeons.
Pituitary surgeons work closely with endocrinologists, so I went to Tashkent with Professor Ashley Grossman, then Professor for Endocrinology at St Bartholomew’s Hospital (‘Barts’) in London. Professor Grossman had visited Tashkent Endocrine Institute after independence and subsequently trained two of their medical professors – Zamira Halimova and Yuldoz Urmanova – in neuro-endocrinology, supported by British Council bursaries at Barts.
No one in Uzbekistan had done the operation that I had been teaching for twenty years: all pituitary surgery was done either in Russia or, in Uzbekistan, by craniotomy but without a microscope. This is how things were in the UK in the 1960s, with a high mortality rate of 10%. By contrast, my method has a mortality rate of less than 0.1%.
On arrival in Tashkent on this, my first visit, we were met by Said Ismailov (then Institute director), Zamira and Yuldoz, and also Professor Kozim Mahkamov, at whose hospital unit I was to do my operations (the Endocrine Centre had no neurosurgical facilities). It was with some relief that I learnt that Kozim Makhamov’s unit had a neurosurgical operating microscope (if rather primitive) and an image intensifier X-Ray machine ‒ the two things I could not bring out in my luggage. I did have a set of the special tools for the surgery, borrowed from my home unit, so I now knew that the operations were feasible.
At some stage we carried out clinics where we saw countless patients. Eventually, we chose three patients for me to operate on: an acromegalic woman, another woman with a tumour affecting vision and a teenaged girl with a calcified tumour just starting to compress her optic nerves but causing menstrual problems.
Operating in a foreign country is always an interesting experience. Every country has its own little rituals, and the Uzbeks were no different. First, they have a fondness for those tall Russian-style doctors’ hats, then the overshoes and – oh my word! –the scrubbing ritual! This is completely different from ours, although with some similarities to the German procedure. In the operating room we were met by a scrum of people, who all wanted to watch. Luckily, it is very large!!!
Equally fortunate, the operations (over two days) went well. As long as one forgets the surroundings, a surgical approach is just another operation. I am famous for my calm, laid back style and also enjoy teaching and demonstrating operations. Kozim (who has now become a firm friend) was most attentive; I took him through the third operation as lead surgeon, just as I would my trainee at home, with me taking over for the tricky bits. Of the three operations, the girl’s tumour was the most challenging. I saw her in the out-patients department a couple of years ago and she made a complete recovery with no recurrence and had become a mum. Most gratifying!
After the clinics and operations, we were taken to Samarkand and Bukhara. The early morning drive to Samarkand was unpleasantly challenging as I had developed terrible diarrhoea, probably from injudiciously accepting a Pomegranate drink in the market. Professor Said put me to bed on arrival after administering the local remedy, a large glass of vodka laced with a lot of salt. I was too weak to resist and it worked! I was feeling much better when I reappeared in the early evening. Then, with no warning, Ashley and I were told that we were to give a lecture – and that an audience of some 200 people was waiting for us across the road in a large hall!
Fortunately, Ashley and I are both experienced public speakers and had something ready to say. We had a similar experience in Bukhara the next morning: after a drive across the desert, we were suddenly told that we had to give lectures!!!
After a day of tourism in Bukhara, sitting in the calm of a beautiful evening, eating dinner by the side of the small lake in the centre, I asked casually “when we were going back?”, only to be told ‘in twenty minutes, so let’s go!” By now we had amassed a collection of presents that included swords, carpets, gowns and a box of crockery. We rushed to the airport with assorted gifts and were loaded onto a very elderly Illyushin aeroplane, with bald tyres and peeling paint. We had to load the swords etc. ourselves, but the ‘dangerous’ surgical instruments went into the cockpit with the pilots. As we clambered aboard, Kozim said reassuringly “Very old, very reliable” and so it proved to be.
In 2006, I was able to get Kozim over to London for a training course in pituitary surgery at the Royal College of Surgeons. He also watched surgery at my hospital. I put him up at my house, and as a ‘thank you’ he decided to cook plov. We scurried around our local farmers market for lamb, carrots and rice in vast quantities. There were only five of us, but he found it necessary to cook plov for thirty, which resulted in a number of frantic phone calls to friends to come by and eat it up.
The following year, Ashley and I returned to Tashkent for more lectures, clinics and operating sessions. I donated a set of operating instruments to Kozim. There were plans to start a pituitary surgery at the Endocrine Centre, but that was still some time off. It was on this visit that I operated my first Uzbek Cushing’s patient. This hormone over-secreting pituitary tumour causes obesity and bloating and often leaves the patient, usually a woman, miserable. As is the case, when successful, the patient is transformed into a lovely happy young woman for our next visit. I was delighted to see her still well on our last visit in June 2017.
On a subsequent visit I brought my wife, Jenny, a London GP, with me. In 2009, Alisher Abutaev came to Britain for a four month visit, to work at our hospital (supported by my research fund). With excellent English, he gained maximum experience in the operating room and clinics. He was also able to return with an excellent operating microscope that was being thrown out. (It is hard to believe what our National Health Service is prepared to chuck out when it is perceived to be outdated …). The arrival of this instrument gave our Uzbek colleagues the raison d’étre to get the Tashkent neurosurgical centre up and running.
By this time, Kozim ‘s department had benefitted from a great deal of new equipment, including a much better microscope, thanks to the interest our visits had raised. The newly established Endocrine Centre was able to employ a Moscow-trained Uzbek, Professor Rafshan Faezullaev, for pituitary surgery. Professor Faezullaev had learned his trade at the Burdenko Neurosurgical Institute, the leading Russian neurosurgical unit, but used the endoscope rather than the microscope. This required a whole array of new equipment, but it freed up the microscope for other forms of neurosurgery. It is now in use for spinal and other cranial neurosurgery.
We also brought a radiation oncologist, Professor Sue Short, to Tashkent to check out the pituitary radiation facilities. These proved satisfactory and on this memorable visit I took my oldest daughter- another intrepid traveller – with me. The high point was a visit to Khiva where we attended a Khorezem wedding. It was November and freezing cold, but my daughter particularly enjoyed the dancing, furs and vodka!!!
I have subsequently brought over three other neurosurgeons to Uzbekistan: Professor Nic de Tribolet from Geneva, and my former trainees, Katie Gilkes from Liverpool and Simon Cudlip from Oxford. Nic was to become the first surgeon to ‘clip’ an intracerebral aneurysm (a tricky operation) in Uzbekistan, at Kozim’s unit.
Simon and Katie have taken to these adventures in Uzbekistan as ducks to water and clearly love it. As it is nearing seven years since I retired, I am feeling a bit long in the tooth and getting out of touch, so I am pleased to be handing over to safe hands.
As a result of our stimulus, there have been well over a thousand operations carried out, now taking place in three centres. There is a much clearer understanding of management pathways and we have had our first paper on results of Uzbek pituitary surgery published in a major international journal. Sadly, Ravshan died suddenly at the start of the year, aged only 49, but Alisher has now taken over. His formal training in pituitary endoscopy is almost entirely through Ravshan, but both Simon and Katie use the endoscope, and are both keen teachers. I am sure he will thrive in this role.