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ISSN 20732073-9990 East Cent. Afr. J. surg
Table of Contents: East and Central African Journal of Surgery. 2016; Vol 21 No 3
Title and Authors
Strong Support for a Context-Specific Curriculum on Non-Technical Skills for Surgeons
(NOTSS)
Lin Y, Scott JW, Mutabazi Z, Smink D, Yule S, Riviello R, Ntakiyiruta G
Congenital Diaphragmatic Hernia Outcomes in East Africa: The Ethiopian Experience
Miliard Derbew
Biliary Atresia – A Easily Missed Cause of Jaundice amongst Children in Uganda.
N Kakembo, A Muzira, P Kisa, J Sekabira
Pages
3
6
13
PDA Ligation in Adults – A 2-years Experience in Tikur Anbassa Hospital, Addis
Ababa University College of Health Sciences, School of Medicine
Abebe Bezabih
17
A 3- Year Review of Patients with Chronic Empyema Treated Surgically at Tikur
Anbessa Specialized Referral Hospital, Addis Ababa, Ethiopia
A. Tizazu, B. Nega.
Patterns and Short-Term Outcomes of Chest Injuries at Mbarara Regional Referral
Hospital in Uganda
M M Mwesigwa, D Bitariho, D Twesigye
Patient Profile and Outcome of Traumatic Extradural Haematomas as Seen at The
Nakuru Level Five Hospital in Kenya
Nasio A. Nasio.
Factors Associated with Interpersonal Violence Injuries as Seen at Kigali and Butare
University Teaching Hospitals In Rwanda
Sekabuhoro Safari, Ahmed Kiswezi Kazigo
Aetiology and Imaging Findings in Traumatic Spine Injury Patients Attending
Muhimbili Orthopedics Institute in Dar es Salaam
M Jacob , P K Sohal, R Kazema
The Surgical Management of Primary Hyperparathyroidism: The Experience in Tikur
Anbessa Specialized Tertiary Referral and Teaching Hospital, Addis Ababa, Ethiopia
Sahilu Wondimu, Berhanu Nega
The Jejunal Serosal Patch Procedure: A Successful Technique for Managing Difficult
Peptic Ulcer Perforation
Abebe Bekele, Kassa, Mulat Taye
Incidence of sigmoid volvulus in Northern Uganda. An observational study
Richard Wismayer
Uncovering the Burden of Urologic Disease: Admissions Patterns at the Main Teaching
Hospital of Ethiopia
I Feldhaus, G W Temesgen, A Laytin, A Y Odisho, A D Beyene.
Factors influencing outcome of sigmoid volvulus in Northern Uganda. A prospective
observational study
Richard Wismayer
Separation of Conjoined Twins in Harare, Zimbabwe: Case Report.
F D Madzimbamuto, B Mbuwayesango, T Zimunhu.
Colorectal Polyposis in a 15 Year Old Boy in Uganda - Case Report
N Kakembo , P Kisa, J Sekabira, D Ogdzediz
Acalculous cholecystitis: Three Case Reports
S G Mungazi, H Mungani
Wandering Spleen With Splenic Vein Thrombosis: A Case Report
M S Ismael
Lateral Pharyngeal Diverticulum presenting with Dysphagia
N Berhanu, K Philipos, T Ayalew
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28
36
42
48
56
63
68
77
85
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104
109
113
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COSECSA/ASEA Publication -East and Central African Journal of Surgery. December 2016; Volume 21 No 3 .
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Factors Associated With Manual Reduction of Incarcerated Inguinal Hernia in Children
T.A. Lawal, D.I. Olulana, O.O. Ogundoyin, K.I. Egbuchulem
Manual Detorsion of Testicular Torsion - A Primary Care Intervention Procedure.
Case Reports.
E L Mugalo
Cerebellar Pilomyxoid Astrocytoma
Hagos Biluts, Kibruyisfaw Zewdie, Tufa Gemechu
Surgical Abdomen in School Aged Children: A Prospective Review From Two Centers In
South-Western Nigeria.
A C Etonyeaku, A O Talabi, A.A Akinkuolie, O Olasehinde, C A Omotola, A O Mosanya,
E A Agbakwuru.
Presentation and Management Outcome of Umbilical Hernia in Children at the
University Teaching Hospital of Brazzaville.
E Koutaba, J C Mieret, C D Nzaka Moukala, I Ondima, M Makanga
Hidden Facts and the Role of Truthfulness in Academic Dishonesty
Pius Musau
Coming Conferences
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COSECSA is the second largest surgical training institute in Sub-Saharan Africa.
COSECSA provides a comprehensive Membership and Fellowship Programme in: Orthopeadics;
ENT; Urology; Paediatric Surgery; Neurosurgery; Plastic Surgery; and General Surgery.
COSECSA offers unique inservice training and an innovative e-learning platform for surgical
trainees.
COSECSA has 94 accredited hospitals and 169 accredited trainers, offering a wide range of
training programmes in urban and rural locations.
COSECSA has an established record of success: since 2004, 158 specialist surgeons have
graduated from COSECSA.
COSECSA is an internationally recognised, post-graduate training institution. As of 2016, there
are over 350 trainees enrolled in COSECSA training programmes.
Essential Surgical Training for Non-Surgeons is provided in three COSECSA Member Countries:
Zimbabwe, Rwanda and Zambia.
The COSECSA Headquarters is locally based in Arusha, Tanzania.
Research shows that COSECSA graduates experience significant career advancement.
Why is Surgery Important?
•
•
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6.5% of the global burden of disease is amenable to surgery.
Africa has approximately 25% of the burden of the world’s diseases and only 1.3% of the world
health workforce.
Most surgeons are based in urban areas.
COSECSA/ASEA Publication -East and Central African Journal of Surgery. December 2016; Volume 21 No 3 .
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Strong Support for a Context-Specific Curriculum on Non-Technical Skills for Surgeons (NOTSS)
Y Lin1,2, JW Scott1,3,4, Z Mutabazi5, D Smink3,4,6, S Yule3,4,6, R Riviello1,3,4,6, G Ntakiyiruta 5
1Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA
2Department of Surgery, University of Colorado, Aurora, CO
3Center for Surgery and Public Health: Harvard Medical School, Harvard T.H. Chan School of Public Health,
and the Department of Surgery, Brigham and Women’s Hospital, Boston, MA 4Department of Surgery, Brigham and Women’s Hospital, Boston, MA
5Department of Surgery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
6STRATUS Center for Medical Simulation, Brigham & Women’s Hospital, Boston, MA
Correspondence to: Yihan Lin, Email: [email protected]
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.1
Introduction
In the operating room, almost one-half of all surgical errors happen as a result of a failure of nontechnical skills, rather than technical mistakes1. These non-technical skills, identified as situation
awareness, decision making, communication and teamwork, and leadership, are critical to the success
of a procedure2. However, in the current training model, the majority of our efforts have been placed on
developing the technical expertise of trainees, often with a missing emphasis on teaching these nontechnical skills.
Fortunately, there has been increasing acknowledgement of the critical nature of non-technical skills to
provide high-quality surgical performance. A curriculum has been specifically designed to teach surgical
residents these skills through observation and feedback, called Non-Technical Skills for Surgeons (NOTSS)2.
The NOTSS curriculum is composed of didactic lectures, teaching videos, discussion sessions, as well as a
rating tool to identify areas for personal performance improvement and monitor progress. This curriculum
was first developed in Scotland and has been tested in multiple different settings, including the United States,
where it has since been integrated into the core training for surgical residents. However, there has not been
an evaluation of non-technical skills in low- and middle-income settings. Specifically, little is known about the
non-technical skills used by providers in LMICs and how to adapt existing NOTSS educational tools to the
LMIC context.
Due to the importance of this topic, our goal was to obtain more information on how the NOTSS curriculum
could be integrated into a low- and middle-income setting. As the authors work in the setting of Rwanda in a
tertiary government hospital with surgical trainees, we hoped to characterize the attitudes of Rwandan
surgical care providers on existing and modified NOTSS curricula.
Methods
Initially, we conducted 35 interviews with Rwandan providers including surgeons, anesthesiologists, and
nurses. We also observed multiple operations, for over 50 hours, in operating rooms (ORs) at three tertiary
Rwanda public hospitals. We found that although the NOTSS taxonomy was created in Scotland, the
taxonomy was very relevant to the setting of Rwanda. Based on the data from our interviews, we adapted the
existing NOTSS curriculum for the Rwandan context.
Our modified curriculum was presented via a one-day NOTSS master class at the University Teaching Hospital
of Kigali, Rwanda. The master class utilized simulated OR videos from the US to reinforce learning of nontechnical skills. We then surveyed 30 Rwandan surgeons, anesthetists, nurses, and trainees regarding their
impressions of the components of the adapted NOTSS curriculum – situation awareness, decision making,
teamwork/communication, leadership, and newly identified contextual factors – and its applicability to the
Rwandan surgical context. Clinicians’ attitudes regarding the accuracy, contextual applicability, and
COSECSA/ASEA Publication -East and Central African Journal of Surgery. December 2016; Volume 21 No 3 .
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preferred use of a modified NOTSS curriculum in Rwanda were assessed using questionnaires with a 4-point
Likert scale.
Results
Twenty-five (83.3%)of the 30 participants completed the survey. Participants found the existing NOTSS
taxonomy overwhelmingly consistent with their experience. When surveyed on how similar the main
categories were to the Rwandan context, participants reported an 87% agreement for situation awareness, a
96% agreement for decision making, a 100% agreement for teamwork and communication, and a 92%
agreement for leadership (Figure 1). However, the existing NOTSS videos, which were filmed in the United
States under simulated conditions, were less representative with only 20% of respondents reporting strong
clinical similarity to their context and 32% reporting little or no similarity to their context (Figure 2). 92% of
respondents would prefer videos filmed in Rwanda with more applicable clinical scenarios. Participants also
identified elements related to NOTSS that were novel to the Rwandan context, which include resource
variability, multi-lingual theatre, variable capacity for rescue, and dynamic provider roles (where a shortage
of staff results in surgical team members having to play multiple roles throughout an operation). Nearly all
(96%) participants would like for a variant of NOTSS taught and implemented in Rwanda, and the vast
majority (76%) prefers a context-specific curriculum.
Table 1. Are the following NOTSS categories relevant to the Rwandan context?
Somewhat/
Not at all
Very muchMostly
Situation
Awareness
Decision Making
Communication
Teamwork
&
Leadership
Table 2. Are the following unique to the Rwandan context?
Very much
Mostly
Somewhat/
Not at all
Resource
Variability
Decreased Capacity
for Rescue
Multi-lingual
Theatre
Dynamic
Roles
Provider
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Next Steps
These results show that the NOTSS curriculum is applicable and desired in Rwanda. However, such a
curriculum should be context-specific, integrating unique aspects of the LMIC context and relevant clinical
scenarios. These findings should be used to adapt NOTSS to LMIC contexts and tested for usability, reliability,
and effectiveness in improving surgeons’ non-technical skills. Therefore, the group plans to create a
curriculum which is focused on providers practicing in LMICs, so as to improve outcomes in the operating
rooms.
References
1.
2.
Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three
teaching hospitals. Surgery 2003;133: 614-21.
Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D. Development of a rating system for surgeons'
non-technical skills. MedicalEducation2006;40:1098-1104.
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Congenital Diaphragmatic Hernia Outcomes in East Africa: The Ethiopian Experience
Miliard Derbew
Addis Ababa University, School of Medicine, Addis Ababa, Ethiopia.
Correspondence to: Dr. Miliard Derbew, Email: [email protected]
Background: Despite advances in care leading to improved survival rate in high-income countries,
congenital diaphragmatic hernia (CDH) continues to have a poor prognosis in sub-Saharan Africa. This
retrospective analysis documents the demographics, presenting symptoms, initial diagnosis and
outcomes of those CDH patients on whom operations are performed at TikurAnbessa Specialized
Hospital (TASH), Ethiopia’s largest tertiary referral center, from September 2012 to August 2016.
Methods: The pediatric surgery database was reviewed for those patients who underwent CDH repair,
and these cases were retrospectively analyzed. All work was performed in compliance with the Addis
Ababa University institutional review board.
Results: Out of 15 patients who underwent operations, twelve cases were included in our study. Average
age at presentation to TASH was 233 days. 83.3% of our study patients were initially misdiagnosed;
50% were initially diagnosed with pneumonia. The diaphragmatic defect was on the left in six (50%) of
our patients and on the right in six (50%). Two patients died after surgery. The remaining ten survived.
All patients underwent primary repair via lateral subcostal incision. Average length of stay was 24.5
days.
Conclusion: Misdiagnosis of CDH remains to be a major problem in sub-Saharan Africa, likely
contributing to delay in diagnosis and early appropriate care. First line physicians and neonatal care
units should consider the possible diagnosis of CDH when neonates and infants present with respiratory
symptoms.
Key words: Congenital, diaphragmatic, hernia
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.2
Introduction
Congenital diaphragmatic hernia (CDH) remains one of the major diagnostic and management challenges of
pediatric surgery. How, when and if to operate on these patients are all hotly debated topics across the
scientific and medical literature. It is presumed that one third of patients affected by CDH die in utero and one
third will die in the neonatal period. Indeed, up to 30% of infants who have symptoms within in the first 6
hours of life will die1. Those who present later in life (>24-36 hours after birth) have a presumed survival
approaching 100% with appropriate care at a well-equipped tertiary referral center2. In more severe cases,
surgical intervention can be postponed until the patient is stable from a cardiorespiratory standpoint;
survival is often more dependent on management of physiologic sequelae of CDH, including pulmonary
hypertension and respiratory distress, rather than on repair of the hernia itself. That is why CDH is more of a
physiologic than surgical emergency. Advances in neonatal care have improved survival of early presenters in
high income countries, but prognosis remains poor in Africa3.
Tikur Anbessa Specialized Hospital (TASH) is Ethiopia's largest tertiary referral center and the only pediatric
surgical referral hospital in the country. There are currently 5 full time pediatric surgeons and three pediatric
surgery fellows. TASH serves as the training base for over 150 general surgery and other residents as well as
medical students. Cases have been collected into a database of 6900 general pediatric surgical patients who
have undergone operations between September 2012 and August 2016. Patients who underwent surgery for
CDH (0.21%) were identified from this database. This retrospective analysis seeks to document the
demographics, presenting symptoms, initial diagnosis and outcomes of those cases.
COSECSA/ASEA Publication -East and Central African Journal of Surgery. December 2016; Volume 21 No 3 .
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Patients and Methods
The TASH pediatric surgery database of cases from September 2012-August 2016 was reviewed for those
patients who underwent congenital diaphragmatic hernia repair. Cases were included if charts could be
located for review. Fifteen patients underwent operations. 12 cases were ultimately included in the study. All
work was performed in compliance with the Institutional Review Board at TASH.
Results
Fifteen patients underwent surgical repair at TASH from September 2012-August 2016. Three of these
patients were excluded from this study because their hospital charts could not be located. The remaining 12
(80%) formed the basis of our analysis (Table 1). Their ages ranged from 10 hours to 4 years with an average
age of 233 days at diagnosis. Only a third (33.3%) of our patients were diagnosed during the neonatal period
(before age 7 days). Nine (75%) of our patients presented to our center after age 30 days. No patients were
diagnosed between 7-30 days of life (Table 1). Nine patients were males. There were two deaths (mortality =
16.6%).
Prior to admission, most of our patients had been presented to other medical centers with initial complaints
of respiratory symptoms, including shortness of breath and cough (Table 2). Six (50% of our patients were
diagnosed with pneumonia and as such were treated first with antibiotics before any imaging was performed.
Three (25%) of the 12 patients were diagnosed with neonatal sepsis on presentation. One child was
diagnosed with congenital pulmonary airway malformation (CPAM). In total, 10 (83.3%) of our patients were
initially misdiagnosed. Only one patient had an initial diagnosis of congenital diaphragmatic hernia within the
first 10 hours of life. Four (33.3%) patients were found to have associated congenital abnormalities, including
Down syndrome (DS) (n=2), inguinal hernia (n=1), Sensorineuralhearing loss (SNHL) (n=1). One patient had
hypospadias and bilateral undescended testes (Table 3). Eight patients presented with chest X-Rays done in
other health facilities.
Two children underwent subsequent chest CT before referral to our hospital. Average age at surgery was 245
days (range 6 days to 4 years). Right sided hernias of all types made up 50% of our cases (n= 6); 16% (n=2)
were right sided Morgagni hernias. The most common hernia type was left Bodchalek diagnosed in 5 (41.7%)
of cases. There was one left sided diaphragm eventration in the series.
Table 1. Patient Demographics
Case no
1
Sex
M
Age at Diagnosis
4d
Age at Surgery
9d
2
F
7.5 m
8m
3
4
5
6
7
8
9
10
M
M
M
M
F
M
M
M
10 h
18 d
18 m
50 d
8m
3d
4y
7m
21 d
18 m
18 m
3 m11 d
8m
6d
4y
8m
11
12
M
F
38 d
4d
65 d
10 d
Key: d = days. h = hours. m = months. y = years
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Table 2. Signs, Symptoms, Initial Diagnosis and Modality of diagnosis
Case no
Symptoms
Signs
Initial Dx
Modality
1
Respiratory
distress at birth
Diminished breath
sounds on L
Perinatal
asphyxia (PNA)
Physical exam
2
Cough, SOB, emesis
following feeds,
diaphoresis
Scaphoid abdomen, nasal
flaring, subcostal
retraction, decreased air
entry
congenital
pulmonary
airway
malformation(C
Chest CT
3
Respiratory
distress
Respiratory
distress, difficulty
feeding
Tachypnea, FTT
Scaphoid abdomen
PAM)
CDH
CXR
Dextrocardia
Sepsis
Physical exam
Diminished breath
sounds
PNA
, Pneumothorax
CXR
6
Cough, tachypnea,
difficulty feeding,
projectile vomiting
Decreased air entry
bilaterally
Sepsis
Physical exam
7
SOB, fever, cough
absent air entry on left
PNA
Physical exam
8
Respiratory
distress
Bowel sounds in left
chest
Preterm/Syndro
mic
Physical exam
9
Cough, weight loss
x 3 weeks
Scaphoid abdomen,
failure to insert chest
tube due to omentum in
chest
PNA
CXR
10
Snoring, difficulty
breast feeding
Depressed nasal bridge,
low set ears, pectus
cavatum
PNA
Physical exam
11
Cough, SOB
Bowel sounds in right
chest
PNA
Physical exam
12
SOB, fever
Decreased breath sounds
Sepsis
Physical exam
4
5
Three (25%) patients were noted to have a portion of the liver herniated into the chest. One patient had
associated segment IV liver hypoplasia (Table 4). All hernias were repaired primarily. Mesh patch was used
in none of the cases. All repairs were performed through a subcostal abdominal incision. In the immediate
post-operative period, two patients required cardiopulmonary resuscitation. Return of spontaneous
circulation was achieved in one patient. One patient suffered from a small bowel obstruction, which was
managed conservatively, two months post operatively.
One patient developed incisional hernia. One patient was returned to the operating room for a jejuno-jejunal
intussusception requiring exploration and manual reduction (Table 4). Average length of stay in the hospital
was 24.5 days (range 12-60 days).
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Table 3. Associated Congenital Abnormalities
Case no
1
Congenital abnormalities
Right undescended testicle
2
3
4
None
None
Segment IV liver hypoplasia
5
R inguinal hernia
6
7
None
Mosaic Downs Syndrome (DS), bilateral undescended testicles, dysmorphic feature, hypospadias
8
None
9
DS, Sensorineural hearing loss (SNHL)
10
11
None
None
12
None
Table 4. Intraoperative Findings, Type of Hernia, Outcome/Complications
Case no
Intraoperative findings
Type of hernia
Outcome/ Complications
1
Spleen, small bowel in left chest
L Bochdalek
Superficial Surgical Site infection
2
Right lobe of liver in right chest
R Bochdalek
No complications
3
Stomach, transverse colon, spleen in left
chest
L Diaphragm
eventration
No complications
4
Hernia sac containing spleen, stomach,
transverse colon in left chest, splenic capsule
bleeding on reduction
L Bochdalek
Jejuno-jejunal intussusception requiring
manual reduction
5
Parasternal diaphragmatic defect with ileum
and large bowel
Right lobe of liver, gallbladder, bowel in
right chest
R Morgagni
No complications
R Bochdalek
7
Large bowel, small instestine in left chest
L Bochdalek
Prolonged intubation, failed extubation,
VAP, cardiac arrest with ROSC after CPR,
Kwashkior, Death
Death
8
Small bowel, colon and spleen in left chest
L Bochdalek
Incisional hernia
9
Large hernia from ribcage to central chest,
small bowel, transverse colon, stomach,
spleen and left lobe of liver in left chest
L Bochdalek
No complications
10
Anterior diaphragmatic defect of 6x5cm with
transverse colon and omentum in chest
R morgagni
No complications
11
Aschending colon and right lobe of liver in
chest with hernia sac intact
R Bochdalek
No complications
12
Small bowel, large bowel, stomach and
spleen in right chest
R Bochdalek
Partial SBO at 3 months post-op,
managed conservatively
6
Two of our patients died, making a mortality rate of 16.6%. The first death was in a patient who was born to a
polyhydramniotic mother. He first presented at age 6 days with tachypnea, difficulty feeding and projectile
vomiting. On physical exam, he was noted to have decreased air entry bilaterally. He was initially diagnosed
COSECSA/ASEA Publication -East and Central African Journal of Surgery. December 2016; Volume 21 No 3 .
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with neonatal sepsis. He was diagnosed with CDH at age 50 days, after presenting to our center on the 45th
day of the life, at which point he was noted to be severely malnourished due to difficulty feeding. He
underwent surgery at age of 3 months and 11 days. He was noted to have a right inguinal hernia at birth.
Intraoperatively, he was found to have a right Bochdalek hernia, which was repaired primarily through a
subcostal abdominal incision. After surgery, he had a prolonged hospital course complicated by failed
extubation, ventilator associated pneumonia, cardiac arrest with return of spontaneous circulation after CPR
and Kwashiorkor, ultimately dying two months after surgery.
The second death was in a patient who presented at 8 months with shortness of breath, fever, and cough. She
presented to an outside facility with similar complaints at age 3 months and was diagnosed with pneumonia.
On physical exam, she was found to have absent air entry over the left chest, and was found to have a Left
Bochdalek hernia intraoperatively, which was repaired primarily via subcostal abdominal incision. She died
two days after surgery. She was never extubated.
Discussion
The literature on CDH out of sub-Saharan Africa is made up largely of single case reports and relatively small
case series. Many institutions in the region see an average of one CDH patients per year because of lack of
antenatal diagnosis and high mortality in the neonatal period and possible misdiagnosis3. The mortality rate
among late presenters in the region remains unknown due to low case numbers. This series of 13 patients
contributes the experience of one of the largest tertiary referral centers in sub-Saharan Africa and one of the
few with a several full time pediatric surgeons.
CDH tends to have a slight male predominance with a ratio of 1:0.69 4. Our series was consistent with this
trend as 9/12 of our patients were male. Reported rates of other major associated congenital abnormalities in
CDH patients vary greatly, but may be as high as 47% 5. Five (41.7%) of our patients were noted to have
associated congenital abnormalities. Two patients (16.7%) in our series were noted to have Down syndrome
(DS), which is consistent with reports of trisomy 21 in five to sixteen percent of patients with CDH 6. One of
the patients with DS was noted to have Sensorineural hearing loss (SNHL) at birth. Though SNHL has a known
association with CDH and is often diagnosed in the toddler years 7, audiograms are not routinely performed at
our institution
Survival rates among CDH patients vary widely from institution to institution, but 80% is the most often
quoted number for patients who are cared for at a tertiary referral center 8, which is consistent with our
overall survival rate of 83.3%, which is most likely slightly higher than the world average as most of our
patients are late presenters. The clear majority of the literature comes from institutions with access to Extra
Corporal Membrane Oxygenation (ECMO), which is not available in our setting. Patients who present after 30
days are considered late presenters, and are expected to have an excellent prognosis of close to 100%
survival once they are properly diagnosed 9. In our series, two late presenters died.
Historically, most CDH patients died before surgery, either in utero or in the immediate postpartum period.
These uncounted cases are considered the “hidden mortality rate” of CDH. Despite worldwide advances in
neonatal and antenatal care, the hidden mortality remains constant at approximately 45% 10. We can only
assume that the hidden mortality rate in Ethiopia to be much higher, as average age of diagnosis in our series
was 232.7 days. Those who present to our center have largely already declared themselves survivors. The
majority (66.7%) of patients in our series come from regains outside of Addis Ababa, including Oromiya
(n=3), Amhar (n=2), Arada (n=2), and Dessie (n=1) and are referred to TASH after evaluation and initial
treatment in their home regions. In our series, 83.3% of patients were initially misdiagnosed, which worsens
the problem of hidden mortality as appropriate care is delayed.
CDH diagnostic index in the antenatal period has markedly increased, so that in many high resource
countries, most cases are diagnosed during prenatal ultrasound screening (11). None of our patients were
diagnosed prenatally. Only 25% (n=3) of our patients presented in the neonatal period, defined as prior to 7
COSECSA/ASEA Publication -East and Central African Journal of Surgery. December 2016; Volume 21 No 3 .
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days of life. Both patients who died were well outside of the neonatal period on presentation (50 days and 8
months).
In our group, one patient was preterm at delivery. His mother was diagnosed with preeclampsia. The patient
was transferred to our neonatal center in the immediate postnatal period for respiratory distress and
congenital abnormalities suggestive of Down syndrome, which were recognized on physical exam. CDH was
diagnosed at third day of life, and the patient underwent surgery at day 6 of life. He survived with a
complication of incisional hernia.
We found no association between age at diagnosis and length of stay or outcome. There was no association
between type of hernia and complication rate or length of stay. Our one preterm patient survived, even
though patients born preterm have lower chance of survival than full term infants (12). We can only assume
that most preterm infants with CDH born outside of our hospital never make it to our center, thereby
increasing the hidden mortality rate further.
The practice in many neonatal centers is to intubate all patients with CDH on delivery13. Because our patients
are not diagnosed prenatally, we do not intubate on delivery. In addition, though neonatal care is available
throughout Ethiopia, few centers have access to mechanical ventilation. Even at TASH, there are a limited
number of neonatal mechanical ventilators, and it is not a routine practice to intubate children on diagnosis.
Inhaled nitrous oxide is used routinely along with noninvasive respiratory support as necessary. Though the
practice at many institutions is to perform patch repair for certain diaphragmatic defects, at our institution all
such hernias are repaired primarily, as evidenced in our series. Most of our patients would not have qualified
for patch repair, again suggesting that those patients who make it to our center may have less severe disease.
The major limitation of our series is the relatively small number of patients, which is to be expected given the
rare nature of this condition. In addition, our analysis is dependent on handwritten charts as TASH has not
established an electronic medical record yet. 20% (3/15) of the charts were unable to be located and were
therefore not included in our series. How those patients may have affected our analysis remains unknown.
Conclusion
CDH remains a challenging problem in resource poor countries. Without prenatal diagnosis, the early
diagnosis of most vulnerable patients remains dependent on general practitioners and other primary care
physicians. We must better equip our doctors and ultrasonagraphers to make diagnose CDH and other
congenital abnormalities prenatally. Health care providers should be better trained to diagnose CDH early
and refer patients for appropriate care. Ultimately, said care should be available in centers outside of Addis
Ababa, which means increasing pediatric surgical capabilities in other parts of the country. Screening for the
CDH should be a routine investigation in all pregnant mothers. In the absence of prenatal diagnosis, CDH
should be one of the differential diagnoses in neonates and young children presenting with respiratory
distress. Far too many of our patients (50%) were initially diagnosed with pneumonia. Once the diagnosis of
CDH has been made or is suspected, patients should immediately be transferred to a tertiary care center for
prompt medical management and surgical repair.
Though it has fallen in the past two decades, Ethiopia’s fertility rate remains high at 4.6. The infant mortality
rate has also remained high at 47 deaths per 1000 live births 14. We believe that if routine antenatal care and
ultrasound screening were performed, we would find that CDH would account for a good number of still
births and perinatal deaths. Though religious and social barriers are a hindrance to autopsy in Ethiopia, we
do recommend the practice be encouraged, as investigation into cause of death would contribute greatly to
our understanding of the epidemiology of CDH and other congenital anomalies.
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Acknowledgment
I would like to thank the Department of surgery, Pediatric Surgery unit for the cooperation andMy special
appreciation goes to Dr. Mesay Haile pediatric surgical resident and Dr Freda Ready General surgery resident
from University of Texas, Dallas , who is on her elective with us ,for helping me in gathering data and finding
references.
References
1. Baird R, McNab C, Skargard E, “Mortality prediction in congenital diaphragmatic hernia,” Journal of
Pediatric Surgery, 2008; 43(5): 783-787
2. Javid P, Jaksic T, Skarsgard E, Lee S, Canadian Neonatal Network, “Survival rate in congenitial
diaphragmatic hernia: the experience of the Canadian Neonatal Network,” Journal of Pediatric
Surgery, 2004; 39(5): 657-660
3. Abubakar A, Bello M, Chinda J, Danladi K, Umar I, "Challenges in the management of early versus late
presenting congenital diaphragmatic hernia in a poor resource setting,"African Journal of Paediatric
Surgery, 2011; 8(1): 29-33
4. McGivern M, Best K, Rankin J, et al, “Epidemiology of congenital diaphragmatic hernia in Europe: a
register-based study,”ADC Fetal and Neonatal Edition, Published Online November 19, 2014
5. Colvin J, Bower C, Dickinson JE, Sokol J, “Outcomes of Congenital Diaphragmatic Hernia: A PopulationBased Study in Western Australia,” Pediatrics, 2005 116 (3): 356-363
6. Elawad ME, "Diaphragmatic hernia in Down's syndrome,"Annals of Tropical Medicine, 1989; 9(1): 434
7. Amoils M, Janik M, Lustig L, "Patterns and Predictors of Sensorineural Hearing Loss in Children with
Congenital Diaphragmatic hernia,"JAMA Otolaryngology Head and Neck Surgery, 2015; 141(10): 923926.
8. Logan JW, Rice HE, Goldberg RN, Cotten CM "Congenital diaphragmatic hernia: a systemic review and
summary of best-evidence practice strategies,"Journal of Perinatology, 2007; 27(9): 535
9. Congenital Diaphragmatic Hernia Group, “Late-presenting congenital diaphragmatic hernia,”Journal
of Pediatric Surgery, 2005, 40: 1839-1843
10. Burgos C, Frenckner B, "Addressing the Hidden mortality in CDH: A population-based study,"Journal
of Pediatric Surgery, 2016, published online September 2016
11. Done E, Gucciardo L, Mieghan T, Jani J, Cannie M, Van Schoubroeck D, Devlieger R, Catte L, Klaritsch P,
Mayer S, Beck V, Debeer A, Gratacos E, Nicolaides K, Deprest J, “Prenatal Diagnosis, predication of
outcome and in utero therapy of isolated congenital diaphragmatic hernia,” Prenatal Diagnosis, 2008,
28: 581-591
12. Tsao K, Allison ND, Harting MT, Lally PA, Lally KP, "Congenital diaphragmatic hernia in the preterm
infant.", Surgery, 2010, 148(2): 404.
13. Hedrick, HL, Adzick NS, "Congenital diaphragmatic hernia in the neonate," uptodate.com, last updated
Aug 01, 2016
14. “Ethiopia Statistics,” Unicef.org, Updated 2012
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Biliary Atresia – An Easily Missed Cause of Jaundice amongst Children in Uganda
N Kakembo, A Muzira, P Kisa, J Sekabira
Department of Surgery College of Health Sciences Makerere University
Corresponding to: Nasser Kakembo , Email: [email protected]
Back ground: Biliary atresia is characterized by biliary obstruction, it has an incidence of 1:15000 and
presents with jaundice, acholic stools / dark urine and hepatomegaly. This disease rapidly leads to liver
cirrhosis and liver failure if untreated surgically. The main objective was to establish the epidemiology
of patients presenting with biliary atresia and immediate surgical outcome.
Methods: A review of a prospective data base for pediatric surgical admissions from January 2012 to
December 2015 was made and examined all the entries for children admitted with biliary atresia.
Results: In this study 46 patients were recruited with an age range at admission of 2 weeks to 3.5 years
and a peak age of 2 months. During the four years, 14 Patients had portoenterostomy done and of these
5 died within 7 days after surgery. Thirty two (32) patients were not operated, 18 of them died and 13
were still alive by the close of 2015.
Conclusion: A big number of children with biliary atresia presented late with decompensated liver
functions having lost time in peripheral health facilities being managed for medical jaundice.
Key words: Biliary atresia, Uganda, Jaundice.
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.3
Introduction
Biliary atresia is characterized by biliary obstruction of un known origin and is the commonest cause of
cholestatic jaundice in neonates due to inflammatory damage to the intra and extra hepatic bile ducts with
sclerosis , narrowing and obstruction(1). It has an incidence of 1:15000 live births, and has two clinical
phenotypes; the syndromic or embryonic form that accounts for 10-20%, associated with congenital
anomalies like polysplenia/asplenia, situs inversus, cardiac defects, absence of inferior vena cava and
preduodenal portal vein, the perinatal or acquired/isolated form that accounts for 80-90% (2, 3). Biliary
atresia commonly presents with jaundice, acholic stools / dark urine and hepatomegaly but may be
associated with complicationsdepending on the extent of the disease (3, 4, 5). This disease rapidly leads to liver
cirrhosis and liver failure if untreated therefore a timely Kasai- portoenterostomy restores bile flow
enhancing survival without liver transplant and thus age at diagnosis of biliary atresia is a potentially
modifiable risk factor (6). We present data from a referral center analyzing the epidemiology and outcome of
children admitted with biliary atresia in a period of four years. This study was aimed at establishing the
epidemiology of patients presenting with biliary atresia and immediate surgical outcome.
Methods
A review of a prospective data base maintained for pediatric surgical admissions for 4 years from January
2012 to December 2015 was made and examined all the entries for children admitted with a diagnosis of
biliary atresia. Included all the children who presented with jaundice and pale stools. The following
parameters were evaluated; age at diagnosis /admission, sex, duration of symptoms, distance to access care,
surgery, complications at admission and final outcome. Permission to study and publish the information was
obtained from the hospital ethics and research review board.
Results
In a period of 4 years, 46 patients with confirmed biliary atresia were admitted at Mulago National Referral
Hospital -Pediatric Surgery Unit. Amongst these 24(52%)babies were males and 22 (48%) were females.The
age range at admission was 2 weeks to 3.5 years of age and a peak age of presentations was 2 months (see
Table 1).
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During the four years, 14 patients were operated (Kasai‘s portoenterostomy) and of these 5 patients died
within 7 days after surgery. Thirty two (32) patients were not operated, 18 of them died and 13 were still
alive by the close of 2015. Average distance travelled by patients for care ranged from 5 km to 800 km from
neighboring ͓South Sudan. The longest duration was one patient who had jaundice and pale stools for 9
months. At presentation 21 patients had complications and 25 had no complications.
Table 1. Distribution of patients by age at presentation
Age at presentation
Number
2 weeks
3 weeks
3
3
1 months
2 months
2
10
3 months
4 months
5 months
4
5
4
5 months
6 months
4
8
7 months
8 months
3
2
9 months
2.5 years
2
1
1
3.5 years
Total
46
Table 2. Patient Distribution by Mode Of Admission
Mode of referral
Routine outpatient clinics
Through emergency unit
Came in as referrals from other hospitals
Total
Number
9
11
26
46
Percentages
20%
24%
56%
Table 3. Distribution of Patients by Duration of Symptoms
Duration of symptoms (jaundice )
<1 month
͓> 1mont h
Total
Number
17
29
46
Percentages
37%
63%
Table 4. Distribution by Type of Complications
Complications
Failure to thrive (FTT)
Septicemia
Ascites
Liver cirrhosis
Portal hypertension
Total
Number
7
2
8
3
1
21
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Discussion
In a span of 4 years 46 patients with biliary atresia were admitted averaging to 11.5 cases admitted per year
compared to a study conducted in Brazil that reported a range of 1-13 cases per year with an average of 4.5
cases per year 7. Another study conducted at the Children’s Hospital and Medical center, Seattle Washington
between 1989 to 1993 recorded 23 cases in 4 years 8. In our study 24(52%) babies were males and 22 (48%)
were females compared to other studies that have significantly reported more females than males.
The age range at admission was 2 weeks to 3.5 years of age and a peak age of presentations was 2 months
which signifies that most babies present late to the center and its reflected in the low numbers of patients
who had a portoenterostomy done (14/46) because the rest of the patients were considered to be of
advanced disease at admission yet there are no liver transplantfacilities. A study in Seattle Washington
reported a median age of referral for biliary atresia to be 61 days with a mean of 51 days which was rather
late attributed to delays in investigating neonatal jaundice and acholic stools and this declines the success of
portoenterostomy 8, 9. This sharply contrasts the situation in the industrial world where the median age at
diagnosis is 40 days and median age at Kasai operation is between 54 and 69 days of age 10.
Of notice 63% of patients presented with jaundice for more than 30 days this can be explained by the long
distances travelled by patients to access the only center with specialized pediatric surgical services in the
country but also compounded by the fact that patients get delayed in peripheral health facilities being treated
for medical causes of jaundice as shown by 56% of admissions coming in as referrals from other hospitals. As
results patients present with complicated disease i.e. 21/46 (45%) presented with one of the following
complications at admission; failure to thrive, sepsis, ascites, liver cirrhosis, and portal hypertension. This
reflects complete lack of screening strategy for biliary atresia as reported in some come countries by using
colored (chromatic) cards with a stool color scale distributed to parents 6, 7, 10.
The mortality amongst operated children (5/14) 36% and the unoperated (18/32) 56% are still very high
probably due to low expertise, lack of infrastructure and support services. Efforts must continue to be made
to eliminate delayed diagnosis in order to improve success of Kasai and reduce the necessity of liver
transplantation 10.
Conclusion
A big number of children with biliary atresia presented late and for the first time with decompensated liver
functions having lost time in peripheral health facilities being managed for medical jaundice.
Acknowledgement
We appreciate Dr Doruk Ozgediz from Yale University USA for facilitating the maintenance of a progressive
pediatric surgery data base.
References
1.
2.
3.
4.
5.
Christophe Chardot. Biliary atresia. Review. Orphanet Journal of Rare Diseases 2006, 1:28doi:
10.1186/1750-1172-1-28
Deidre A Kelly, Mark Davenport. Current management of biliary atresia .review .Arch Dis Child 2007;
92:1132-1135. Doi:10.1136/adc.2006.101451.
C.K. Sinha and Mark Davenport .Billiaryatresia. J Indian AssocPediatr Surg. 2008 Apr-Jun;13(2:49-56)
Garret S. Zallen, David W. Bliss, Thomas J. Curran, Marvin Harrison and Mark L. Silen. Biliary Atresia.
Pediatrics in Review vol.27 No.7 July 2006
Barbara E. Wildhaber. Billiary atresia: 50 years after the Kasai. Review Article .ISRN Surgery
volume2012, Article ID 132089, 15 pages. Doi:10.5402/2012/132089.
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6.
Sharad I. Wadhwan, Yumirle P. Turmelle, Rosemary Nagy, and Ross W. Shepherd. Prolonged Neonatal
Jaundice and the diagnosis of Biliary Atresia; A single –center analysis of trends in age at diagnosis
and outcomes. Doi ;10.1542/peds.2007-2709
7. Carlos O, Jorge L. dos santos and et al. Billiary atresia : we still operate late. Jornal de pediatria-vol84,
no5, 2008. Doi :10.2223/JPED.185
8. PhillipI. Tarr, Joel E Haas and Dennis L Christie. Biliary atresia, Cytomegalovirus, and Age at Refferal .
Pediatrics Vol.97 no.6.june 1996.
9. Thais Costa Nascentes, Alexandre Rodrigues, Eleonora Druve Tavares. Billiary atresia: evaluation on
two distinct periods at reference pediatric service. ArqGastroenerol v.51 no.1-jan/mar.2014
10. Justin Hollon, Matilda Eid, Gregory Gorman. Early Diagnosis of Extrahepatic Biliary Atresia in OpenAccess Medical System. Plos one November 2012/volume 7/issue11/e49643
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PDA Ligation in Adults – A 2-years Experience in Tikur Anbassa Hospital, Addis Ababa University
College of Health Sciences, School of Medicine
Abebe Bezabih
Cardiothoracic surgeon, Addis Ababa University, college of Health Sciences, School of medicine, Department
of surgery, Assistant professor of surgery. Email- [email protected],
Backdround: Persistent Ductus Arteriosus (PDA) is commonly diagnosed & treated in infancy.It is
unusual to see patients with PDA in adults in developed countries.
Methods: Retrospective analysis of charts of adult patients who were operated & PDA ligation done in
Tikur Anbasa specialized hospital starting from September 1, 2009 to August 31,2011 was made.
Results: Out of thirty one patients operated in two years time, twenty six(84%) charts could be
retrieved. Nineteen pts(73 %) were female & Seven pts(27 %) were male. The commonest age group was
16-20(46%). The commonest presenting symptom was exertional dyspnea(61%), three pts(12%) were
asymptomatic. Twelve pts(46%) were on medical treatment preoperatively. Fifty four percent of pts had
PDA size 5-8mm.One patient died during reoperation .
Conclusion: In developed countries , PDA is exclusively managed at infancy but in developing countries
like ours, PDA may present in adults with symptoms and if there is no evidence of significant pulmonary
hypertension ,PDA ligation is safe and effective.
Key words: Ductus, arteriosus, patent
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.4
Introduction
Patent ductus arteriosus (PDA) is a vascular structure that connects the proximal descending aorta to the
roof of the main pulmonary artery near the origin of the left branch pulmonary artery. This essential fetal
structure normally closes spontaneously after birth. After the first few weeks of life, ductal patency is
abnormal. The physiological impact and clinical significance of the PDA depend largely on its size and the
underlying cardiovascular status of the patient1. The PDA may be "silent"(not evident clinically but diagnosed
incidentally by echocardiography done for a different reason) , small, moderate, or large2. PDA accounts for
approximately 10% of all congenital heart diseases , with an incidence of at least 2-4 per 1000 term births.
The female to male ratio is 2:1 in most reports 3,4. The factors responsible for persistent patency of the ductus
arteriosus beyond the first 24 to 48 hours of neonatal life are not completely understood. Prematurity clearly
increases the incidence of PDA , and this is due to physiological factors related to prematurity rather than
inherent abnormality of the ductus5. In term infants, cases most often appear to occur sporadically, but there
is increasing evidence that genetic factors play a role in many patients with ductus .In a family having one
sibling with a PDA, there is a 3% chance of PDA in a subsequent offspring(6). In addition, other factors such as
prenatal infection appear to play a role in some cases7.
Closure of the large, hemodynamically significant PDA is established as the standard of care, and can be
performed safely and effectively using either surgical or transcatheter methods 8,9. In asymptomatic patients
with significant left to right shunting that results in left heart enlargement , closure is indicated to minimize
the risk of complications in the future. The appropriate management of the very small, hemodynamically
insignificant PDA is less clear 10,11. Routine closure of such defects has been advocated to eliminate or reduce
the risk of infective endocarditis. Because closure methods are effective and safe & are associated with
minimal morbidity, a strategy advocating routine closure of any PDA in children & young adults appears most
reasonable. Surgical ligation or division of the PDA remains the treatment of choice for the rare very large
PDA. Rarely a large window-type PDA may have insufficient length to permit ligation and the appropriate
surgical procedure is patch closure on cardiopulmonary bypass12,13.
Complete closure rates of surgical ligation range from 94% to 100%, with 0% to 2% mortality. Important
complications include bleeding, pneumothorax, infection, and rarely ligation of the left pulmonary artery or
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Aorta. Surgical morbidity, cost and hospital length of stay have been decreased with use of transaxillary
muscle-sparing thoracotomy & by the technique of video-assisted thoracoscopic ligation of PDA14, 15.
Patients and Methods
Retospective analysis of collected charts of adult patients operated for PDA in Tikur - Anbassa Hospital
starting from September 1 , 2009 up to august 31, 2011 done. out of the 31 patients operated in the
specified time period, 26 of the charts were available in the record office while 5 of the charts were missing &
are not included in the study. All 26 patients had echocardiography as the main diagnostic tool.All had left to
right shunt & had no significant pulmonary hypertension. All of them had the operation done under general
anesthesia with single lumen endotracheal intubation & intra operative transesophageal sthethoscope
monitoring of the murmur. All of them had double ligation of the PDA by silk ties. Routine chest wall closure
over a chest tube left for 48 hours used.
Results
Nineteen of the 26 patients (73%) were females & 7 (27%) were male patients. Ages ranged from 14 to 40
but the commonest age group was 16 - 20 (46%) (Figure 2). Exertional dyspnea was the commonest
presenting symptom occurring in 16 (61%) of patients. Palpitation (23%), chest pain(8%), and orthopnea
(4%) were the rest of the symptoms. 3 patients(12%) were asymptomatic abd therefore "silent" PDA (Fig. 3).
Fourteen (54%) of the patients were not taking any medication while the rest 12(46%) were taking
medications preoperatively. Postoperatively none needed medications. All 12 patients took oral furosemide
and 9 of them additionally took spironolactone. Two patients took digoxin ,one patient ASA & one patient
was on metoprolol (Figure 4). one patient (4%) had infective endarteritis before surgery & operated after the
endarteritis is treated successfully medically. PDA sizes as measured by echocardiography ranged from 3mm
to 11 mm(Fig 5). On postoperative echocardiography one patient(4%) was reported to have residual PDA but
is asymptomatic & is still on the same condition on follow up.
Fig 2 : Age
distribution
Fig 1 : sex distribution
36-40
31-35
26-30
21-25
15-Nov
Female
Fig 2 : Age
distribution
16 -20
Male
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
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Fig 3 : symptomatology
exertional dyspnea
palpitation
asymptomatic
chest pain
orthopnea
Fig 4 : preoperative medication
60%
40%
20%
0%
Fig 4 : preoperative
medication
Fig 5 : PDA size
30%
20%
10%
0%
had
Fourteen (54%) of the patients were not taking any medication while the rest 12(46%) were taking
medications preoperatively. Postoperatively none needed medications. All 12 patients took oral
furosemide and 9 of them additionally took spironolactone. Two patients took digoxin ,one patient ASA &
one patient was on metoprolol (Figure 4). one patient (4%) had infective endarteritis before surgery &
operated after the endarteritis is treated successfully medically. PDA sizes as measured by
echocardiography ranged from 3mm to 11 mm(Fig 5). On postoperative echocardiography one
patient(4%) was reported to have residual PDA but is asymptomatic & is still on the same condition on
follow up.
There was one death(4%) related to PDA surgery. This 15 years old girl was found to have left pulmonary
artery ligated in place of the PDA on postoperative echocardiography & patient was reoperated. On
reoperation the arterial side of the PDA was found aneurysmal & tore on dissection & patient bled to
death on the table.
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Discussion
The F: M sex ratio was 3 : 1 as compared with the global F: M ratio of 2:1 1. Population studies are needed
to confirm this difference. The success rate in our PDA ligation was 92% which was comparable with the
global figures of 94-100%.We had one death (4% mortality rate). Because of the small size of the
study(only 26 cases) it is difficult to compare the mortality of global figures which is 0-2%.From this
small study surgical ligation of PDA in adults seems a safe & effective surgery & it is to be encouraged
14,15. Our patient who died probably would have been saved if the reoperation was done with
cardiopulmonary bypass 12, 13. So we suggest difficult cases like reoperations and huge and short PDA
cases be operated with cardiopulmonary bypass. The fact that only 12% of our patients had "silent" PDA
shows that PDA needs closure even if patients are adults as it causes symptoms in addition to the possible
complications like endarteritis and others2. The fact that 46% of patients were taking medications implies
that PDA is an important cause of symptoms in adults although this is a hospital based study & therefore
could suffer selection bias. Clearly a population based study is needed to confirm the degree of symptoms
PDA causes.
The age distribution (Figure 2) shows a gap between 25 and 36. But it is only one case at 36 – 40 years so
it appears that the commonest age of PDA in adults to be 25 – 35 years. This also needs a population
based study to confirm these results.
The size of PDA is 5 – 8 mm in more than half of the cases (Figure 5). We also had huge PDA sizes (> 11
mm) in 8% of cases. There could be selection bias in the size of PDA again either because symptomatic
cases presenting to the hospital could be bigger sizes and small size PDA being handled by catheter
methods2.
Conclusion
Overall from this small scale hospital based retrospective study, it can be concluded that PDA is still a
health problem in this country & can be handled by surgical ligation safely in most of the cases even if
open heart surgery facilities are not available. But a population based large scale study is needed to
confirm the incidence, percentage of symptomatic cases and correlation between size of PDA and
seriousness of the symptoms. A comparative study comparing transcatheter device closure with surgical
ligation is also necessary as few patients are being managed by transcatheter means in this country8,9.
Acknowledgement
Tikur Anbassa hospital record office provided the patients documents without which it would have been
impossible to do this job. Cardiothoracic unit in surgery department of medical faculty, Addis Ababa
university and staff are involved both in the surgery of patients and follow up ,& also on reviewing the
paper with special guidance and tutoring by Prof Adem Ali, head department of surgery, Addis Ababa
university medical faculty.
References
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Patrick J. Mc Namara , Arvind Sehgel; Staging of PDA s Towards rational management of PDA :
The need for disease staging. Archives of Disease in Childhood fetal neonatal edition 2007; 92: F
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Carlgren LE. The incidence of congenital heart disease in children born in Gothenburg 1941 –
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Mitchell SC, Korones SB, Berendes HW. Congenital heart disease in 56,109 births; incidence &
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Kitterman JA, Edmunds LH Jr, Gregory GA, Heymen MA, Tooley WH, Rudolph AM. Patent Ductus
Arteriosus in premature infants , relation to pulmonary disease & management. N Engl J med.
1972;287:473-477
Nora JJ. Multifactorial inheritance hypothesis for the etiology of congenital heart diseases ,the
genetic – environmental interaction. Circulation ,1968;38:604-617
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Gibson S, Lewis K, congenital heart disease following maternal rubella during pregnancy. Am J
Dis Child, 1952;83:117-119
Omar Galal, MD , PhD, Rodrigo Nehgme , MD. Fadel A-Fadley , FRCP(c) Michael de Moor,MD,
Fuoad I . Abbag,MD, Saud H. Al-Oufi,MRCP , Ella Williams,BSN,
Mohammad Eid Fawzy, FRCP;
Zohair Al-Halees,FRCS(c)
The role of surgical ligation of PDA in the era of the Rushkind
Device,Ann Thorac Surg 1997: 63 : 434 - 437
Kentaro Yamabe , Hideyuki Shimizu , Atsushi Nemato & Ryohei Yozu Endovascular aortic repair
of PDA in an adult patient Interactive cardiovascular & Thoracic surgery (2011)10.1093
icvts.oxfordjournals.org
William E. Bentiz: PDA: to treat or not to treat? Archives of Disease in Childhood fetal neonatal
edition 2011; 300381 fn.bmj.com
Fortescue EB, Lock JE, Galvin T , Mc Ethinney DB. To close or not to close : the very small PDA
Congenital Heart Disease , 2010 ; Jul - Aug : 5 (4) : 354 - 365
Bassam O.Omari ,MD ; Shelly Shapiro , MD ; Leonard Ginzton , MD; Jeffrey C. Milliken,MD ; Fritz
J. Baumgartner,MD How to do it, closure of Short, wide PDA with cardiopulmonary bypass &
ballon occlusion, Ann Thorac Surg 1998: 66: 277-278
Terry G. O'Donovan, MD ; & Walter Beck, MD Closure of complicated PDA Ann Thorac Surg 1978 ;
25: 463 – 465
Osman Baspinar,MD ; Metin Kilinc,MD; Mehmet Kervancioglu, MD ; & Ahmet Irdem , MD :
Transcatheter closure of a residual PDA after surgical ligation in children , Korean Circulation
Journal 2011 november 41(11): 654-657
Jorge A. wernly , Invited commentary on closure of PDA in Adults Ann Thorac Surg 2000;70:
1937 – 1938
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A 3- Year Review of Patients with Chronic Empyema Treated Surgically at Tikur Anbessa
Specialized Referral Hospital, Addis Ababa, Ethiopia
A. Tizazu, B. Nega.
Addis Ababa University College of Health Sciences, School of Medicine, Department of Surgery,
Cardiothoracic unit, Addis Ababa, Ethiopia.
Correspondence to : Berhanu N. Alemu, E-mail: [email protected]
Background: Empyema thoracic is one of the main causes of morbidity and mortality in developing
countries. This study was aimed at determining the causes, clinical presentation, outcomes of
surgical intervention and variables associated with adverse outcomes in patients with chronic
empyema treated surgically.
Methods: This was a cross sectional hospital based longitudinal case series analysis done at Tikur
Anbessa Specialized referral hospital, Addis Ababa, Ethiopia. All patients admitted and operated for
chronic Empyema over a period of three year. (April 01, 2011 - March 30, 2014) were studied.
Results: A total of 62 patients were operated for empyema thoracis. The Male to female ratio was
5.9:1 and mean age at presentation was 29.96+/-10.6 years. Patients presented after an average of
8.02 +/- 4.37 months from the onset of symptoms (range from 1-16 months). Shortness of breath
43(69.4%), cough 43(69.4%), chest pain 47(75.8%), fever 30(48.4%), weight loss 21(33.9%) poor
appetite 9(14.5%) and haemoptysis 1(1.6%) were the leading causes of symptoms on admission.
Thirty seven (59.7%) patients were previously treated for tuberculosis, 11 (17.7%) had pneumonia
and 53(85.5%) of them gave history of trauma. The right {32(51.6%)} and left pleural space,
{29(46.8%)} were affected with similar incidence. Only one patient was admitted with bilateral
empyema. In the majority of patients, 46(74.2%), open thoracotomy with abscess drainage and
decortications were done. In addition to this, either lobectomy or pnemonectomy was done for 4
(6.5%) and 7 (11.3%) patients respectively. Three patients were treated by rib resection and open
drainage. The average post-operative hospital stay was 12 days (range 3 - 63days). Major
complications encounter were lung laceration 15(24.2%), BPF 8(12.9), recurrent empyema
10(16.1%), and persistent air space 14(22.6%). Two (3.2%) patients died in their hospital stay.
During follow up visits, 52(83.9%) patients had shown significant subjective improvement of
symptoms.
Conclusion: In general, our experience on the outcome of open thoracotomy and decortication done
for chronic empyema was excellent with low mortality and very good Functional results as majority
of patients either returned to normal activities or showed significant improvement of symptoms.
Key words: Chronic Empyema, Decortication, Bronchopleural fistula
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.5
Introduction
Chronic pleural empyema is usually seen as the last phase of the inflammatory process occurring in parapneumonic effusion. According to Light et al1 1980 and Ahmet and Harrison2 1963, purulent fluid
accumulates in the pleural space, and fibrin is deposited on both pleural surfaces, forming a thick peel
that restricts the underlying lung. A study done on effect of decortications by Nieminen3 indicated that
restriction of the lung and impairment of chest wall elasticity due to the thickened pleural layer cause
thoracic asymmetry in the late phase of empyema. Hence, decortication aims to increase the lung volume
by freeing the trapped lung with surgical removal of the thickened pleura. There are several reports in the
literature5-7 about the benefits of lung decortication; focussing mostly on the improvement of lung
volume, lung perfusion and diffusion capacities.
There are various surgical techniques used to treat chronic empyema. As technology and medical science
develops, in the last decades the video-assisted thoracic surgery (VATS)8-9 has been demonstrated as an
effective procedure in selected patients, allowing an optimal debridement of early organized pleural
effusions. In the late phase of the pleural infectious process, when a thick pleural peel encases the lung, a
pulmonary decortication is required and open approach is often needed10-11.
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Empyema thoracic is one of the main causes of morbidity and mortality in developing countries.4 Many
epidemiological studies have also shown the increase in the prevalence of empyema and its importance of
immediate diagnosis and treatment.12-16 In our context, although the role of surgery in solving chronic
empyema is well demonstrated, the causes and its outcome of treatment and the causes are not well
studied. Besides, most patients seek medical help in its late stage. This happens because of the delay in
recognizing the infected pleural fluid and the initiation of appropriate measures to drain the pleural
space. This study was there for done with main objective of assessing the outcome of surgically managed
patients with chronic empyema done at Tikur Anbessa Specialized Hospital during three years period.
Patients and Methods
The study was done in the surgical department of Addis Ababa University, Ethiopia, at Tikur Anbessa
Specialized Teaching Hospital. The study design is a Cross sectional hospital based longitudinal case
series analysis. Source and study population for the study was all patients with empyema of the lung, seen
at Tikur Anbessa Specialized Hospital during the study period. The hospital records of sixty two patients
who underwent surgery for chronic empyema between April 2011 and March 2014 were reviewed
retrospectively and all patients who fulfil the inclusion criteria in the study period were included in the
study. Data was collected by the principal investigator and data extraction sheet was used using a pre
tested questionnaire. Data was collected from the routine patient chart recording system. Based on the
pre-test result the data extraction sheet was revised and edited. Data completeness and its clarity were
ascertained by the investigator before data entered for analysis. Then, data entered and cleaned using
SPSS version 20.0 statistical software and presented in descriptive and tabular forms. Errors related to
inconsistency of data was checked and corrected during data cleaning. Different variables are cross
tabulated and compared for significant differences and statistical analysis made using chi- square test and
t- test. For ethical purpose, Maximum caution was taken to maintain the anonymity of the study
participant. No personal identifier such as name was used in the report or data collection of this study.
Results
The total number of adult patients admitted for surgical management of empyema during the study
period was sixty two, of which 53 (85.5%) was males and 9 (14.5%) females. (F: M → 1:5.9). Their mean
(SD) age was 29.9 +/-10.6 years (range from18-60 years). The most frequent age group affected was the
18-28 years age group accounting for 35 (56.5%) followed by 40-50years in 16 (25.8%)]. Admission for
Empyema treatment was found uncommon in those patients beyond 50 years [2(3.2%)]. Both people
from urban as well as rural area were affected with similar incidence (48.4% Vs 51.6%). Right, 32(51.6%)
and left side, 29(46.8%), of the chest were affected with similar incidence. Only one patient was admitted
with bilateral empyema. Forty six (74.1%) patients had never smoked and 3(4.8%) were ex-smokers.
Only 23(37%) patients admitted to drink alcohol regularly. The mean (SD) duration of symptoms on
arrival to the OPD was 8.02 +/- 4.37 months ( range from 1-16 months).The major presenting symptoms
recorded were shortness of breath 43(69.4%), cough 43 ( 69.4%), chest pain 47 (75.8%) , fever
30(48.4%), weight loss 21(33.9%), poor appetite 9(14.5%) and haemoptysis 1(1.6%). Thirty seven
(59.7%) of patients were previously treated for tuberculosis. Among them 23 (37.1%) had completed
their treatment while 14(22.6%) were still on treatment while they were admitted for surgery. Twelve
(19.4%) patients had reported previous history of chest trauma. In 53(85.5%) of them, trauma has
happened 4-7months before, while in the rest 7(11.3%) and 2(3.2%) it occurred < 3 and >7 months
respectively. In 49(79%) of patients, the cause of trauma was not properly documented. Previous history
of pneumonia was reported in 11 (17.7%) of patients.
Empyema was considered the most likely diagnosis by the admitting doctor in all patients, besides the
definitive diagnosis (which depends upon the demonstration of purulent fluid in the pleural space) was
similarly made in all patients during surgery. Diagnosis was primarily made in all patients using chest Xray finding. However in 29 (46.7%) of patients an additional investigation of CT-Scan or Ultrasound
examination of the chest was made. In all patients neither a preoperative nor a properly documented post
operative microbiological studies were done to identify the responsible pathogen. All patients took either
single or a combination of antibiotics prior to admission. However, the choice of antibiotic before surgery
or during the subsequent postoperative period did not follow the culture and sensitivity result.
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During surgery, Empyema fluid was described as malodorous in 34 (51.6%) of patients. In all patients,
both Pleural fluid as well as the pleural surface was described as 'thick'. In the majority of patients,
46(74.2%), open thoracotomy with abscess drainage and decortications were done. In addition to this,
either lobectomy or pnemonectomy was done for 4 (6.5%) and 7 (11.3%) patients respectively. No
patient was treated by either diagnostic aspiration and antibiotics or intercostal tube drainage alone. The
majority of them, 59(95.2%), had initially treatment with intercostals tube drainage which fails to
completely resolve the abscess demanding further intervention. Three patients were treated by rib
resection and open drainage. The overall mean total hospital stay was 23 days (range 7-70 days). The
average post operative hospital stay was 12 days (range 3 - 63days). Thirty six (58.1%) of patients has
developed one or more complications during or later in subsequent days (Table 2) . Person Chi-square
test was done to identify any character which will show statistical significance association with post
operative complication P< 0.05) and found out that all characters had no significant association with it
(Table 1).
Table 1. Analysis of demographics and clinical presentations and its relation to adverse outcome
Feature
Adverse Outcome
Yes
Demography
Age ( years)
Sex –Male
- Female
―
33
3
No
Total
P-Value
―
20
6
29.9 +/-10.6
53 (85.5)
9 (14.5)
0.377
0.104
Duration Of illness ( Month)
―
―
8.02 +/- 4.37
0.484
Total Hospital Stay(days)
―
―
23.9+/- 12.1
0.241
Post-operative stay(days)
―
―
11.8 +/- 9.7
0.401
25
18
43 (69.4)
0.986
Hemoptysis
0
1
1 (1.6)
0.236
Productive cough
Dry Cough
Chest Pain
16
12
27
8
11
20
24 (38.7)
23 (37.1)
47 (75.8)
0.275
0.470
0.861
Fever
21
9
30 (48.4)
0.065
Weight Loss
History of Tuberculosis
15
21
6
16
21 (33.9)
37 (59.7)
0.127
0.104
History of pneumonia
9
2
11 (17.7)
0.078
Trauma History
6
6
12(19.4)
0.528
13
13
0
32(51.6)
29(46.8)
1 (1.6)
0.656
Clinical Presentation
Shortness of breath
Affected side of the chest
Left
Right
Bilateral
19
16
1
Data are frequencies; Values in parenthesis are percentages, ‡ P <0.05
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Table 2. Descriptive statistics on the type and frequency of adverse outcome encountered
surgery
Adverse Outcome
Frequency
following
Percent
Bleeding
6
9.7
Lung Laceration
15
24.2
Lobectomy
4
6.3
Pnemonectomy
7
11.1
Diaphragm Injury
3
4.8
Phrenic nerve injury
1
1.6
BPF
8
12.9
Pneumonia
2
3.2
Wound infection
4
6.3
Recurrent Empyema
10
16.1
Persistent air space
14
22.6
Death
2
3.2
P.S. Patient could develop more than one complication which was also counted
The major complications encounter during surgery were, bleeding {6(9.7%)}, lung laceration
{15(24.2%)}, Diaphragm injury {3(4.8%)}, phrenic nerve injury {1(1.6%)}, thoracic duct injury {1(1.6%)}.
Other post-operative complications seen were BPF {8(12.9)}, pneumonia {2(3.2%)}, wound infection
{4(6.3%)}, recurrent empyema {10(16.1%)}, and persistent air space {14(22.6%)}.
Due to intra-operative complications encountered, the intended procedure of decortication was changed
to either lobectomy or pnemonectomy in 4(6.3%) and 7 (11.1%) of patients respectively. Two (3.2%)
patients died during their hospital stay. Age of patients who died was 46 and 54 years. They have died
after 37 and 26 days of stay following surgery. Decortication with abscess drainage was done for both
patients. For the 54 year old patient, additional lower lobectomy was done because of a mass was
identified in the lower lobe. The possible causes of death for both patients were persistent BPF with
respiratory insufficiency and sepsis. Later, biopsy taken from the lower lobe mass has identified
bronchogenic carcinoma. During the subsequent months of follow up, 52(83.9%) patients had shown
significant subjective improvement of symptoms, while the rest 10 (16.1%) complain of either no
improvement or worsening of symptoms.
Discussion
It is generally accepted that pleural empyema should be treated early to avoid complications, extensive
operations and lengthy hospital stays 6. Unfortunately, there are some patients for whom early treatment
is not possible and in whom chronic empyema will develop, mainly due to delayed diagnosis or delayed
referral. At this stage, the standard treatment is open thoracotomy and decortication. Historically, other
surgical procedures have been practiced, including open window thoracostomy, rib resection,
thoracoplasty, Claggett´s procedure and percutaneous drainage guided by ultrasound or CT.6, 7 With the
increasing popularity of minimally invasive techniques, videothoracoscopy has been proposed for the
treatment of chronic empyemas.2, 4 ,7
The local experience in the management of chronic empyema is not well studied. It is for these reasons
that we decided to analyze our experience with open thoracotomy and decortication in the management
of chronic empyema. The study is a retrospective audit of the diagnosis and treatment of chronic
empyema in a sample collected over a period of three years in a central referral hospital of Ethiopia
(Tikur Anbessa specialized referral hospital). The average duration of symptoms before arriving to our
hospital was 8months which reflects the significant delay in referring and in making the diagnosis by
other health institutions. This is not surprising, as the patients usually presents very late and the
diagnostic armaments used for diagnosis of empyema are not readily available in most part of the
country. Moreover, the presenting features, rather than suggesting respiratory disease, are often
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nonspecific, so that other diagnoses like Tuberculosis pleurisy are frequently entertained. Our findings
emphasize the need for an early X-ray examination in patients with a vague history of malaise, fever,
weight loss, etc., particularly after a respiratory infection and chest trauma with unresolved haemothorax.
Further delay in diagnosis and treatment could also occurred in hospital because of delay in diagnosis and
long waiting list for admission and intervention.
Unlike most of the studies done in western countries like A.D. Ferguson9 who found a mean age of
patients with 54.8 years, our patients are relatively younger with the mean age of 29.9 years. This can be
explained by a good proportion of our patients have developed following either tuberculosis or trauma,
while those with past history of pneumonia are only 11 (17.7%).
Currently, in our hospital, diagnosis of empyema was primarily made in all patients using chest X-ray
finding, although additional investigation like CT-scan and ultrasound is done in 29(46.7%) of patients.
However proper microbiological studies were not properly done and antimicrobial drugs are given with
empirical base. This could be one of the possible explanations for the higher incidence of complications
like recurrent empyema, BPF and wound infections seen.
Almost all of the patients (95.2%) had initially been treated with intercostal tube drainage which fails to
completely resolve the abscess demanding further intervention. This happens because imaging studies
like CT scan and Ultrasound is not routinely done. However, different studies showed that CT scan is
particularly helpful to demonstrate the chronicity of empyema by showing thick pleural cortex, locations,
and size of the empyema and evidence of constriction of the thoracic cage. In addition to showing the
characteristics of the empyema, chest CT allows the surgeon to locate and determine the best surgical
approach, either limited or postero-lateral thoracotomy.
In the present work, it is important to note that chest intubation time averaged two weeks, and
postoperative stay averaged twelve days. Fifty eight percent of patients have developed complications
and there were two deaths. As compared to other similar study done by Ferguson4, the chest intubation
time averaged four and five days, and postoperative stay averaged 10 days. Only three patients presented
complications and there was no mortality. These results show longer duration of chest intubation, more
postoperative days and more morbidity and mortality.
Conclusion
In conclusion, even though the study had several limitations like small number of cases reviewed, the type
of study which is retrospective in nature where some of the variables could be missing, lack of
comparative studies among different modality of treatment, general outcome of open thoracotomy and
decortication was found to be an excellent surgical procedure with low mortality. Functional results were
also good, as most patients returned to the normal activities that they performed before surgery and
83.9% of them showed significant improvement of their symptoms. Though the complications
encountered during or after surgery are managed properly with little after effect, its incidence is
relatively high which needs further investigation. Open thoracotomy and decortication will continue to be
the standard treatment for chronic empyema, but it needs further prospective, randomized studies to
compare with other modality of treatment like videothoracoscopy.
References
1.
Light RW, Girard WM, Jenkinson SG, George RB. Parapneumonic effusions. Am J Med
1980;69:507-512
2. Ahmet FA, Harrison CV. The effect of prolonged pulmonary collapse on the pulmonary arteries. J
Pathol Bacteriol 1963;85:357-360
3. Nieminen MM, Antila P, Markkula H, Karvonen J. Effect of decortication in fibrothorax on
pulmonary function. Respiration 1985;48:94-96
4. A.Amare, B.Ayele, D.Mekonen, Thoracic empyema: cause and treatment outcome at
Gondar university teaching hospital, north west Ethiopia, East and central Africa journal
Of surgery, 2010:15(1):119-123
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5.
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Goshal AG, Saha AK, Roy DJ, Ghosh S. Fibrothorax-problem, profile and prevention. J Indian Med
Assoc 1997;95:610-612.
Swoboda L, Laule K, Blatmann H, Hasse J. Decortication in chronic pleural empyema:
Investigation of lung function based on perfusion scintigraphy. Thorac Cardiovasc Surg
1990;38:359-361.
Ryzman W, Skokowski J, Romanowicz, Lass P, Dziadziuszko R. Decortication in chronic pleural
empyema—effect on lung function. Eur J Cardiothorac Surg 2002;21:502-507.
Thomas F. Molnar, Review Current surgical treatment of thoracic empyema in adults
European Journal of Cardio-thoracic Surgery 32 (2007) 422—430
A.D. Ferguson et.al, The clinical course and management of thoracic empyema, Q J Med 1996;
89:285-289
H. Hamm, R.W. Light, Parapneumonic effusion and empyema, Europian Respiratory Jornal 1997;
10: 1150–1156
Davies CW, Gleeson FV,Davies RJ (2003) BTS guidelines for the management of pleural infection.
Thorax 58(suppl):ii18–ii28
Colice GL, Curtis A, Deslauriers J, et al. (2000) Medical and surgical treatment of parapneumonic
effusions: an evidence-based guideline. Chest 118:1158–1171.
Andrews NC, Parker EF, Shaw RR, et al. (1962) Management of nontruberculous empyema. Am
Rev Respir Dis 85:935–936.
Light RW (2006) Parapneumonic effusions and empyema. Proc Am Thorac Soc 3:75–80.
Manuel Porcel J, Vives M, Esquerda A, et al. (2006) Usefulness of the British Thoracic Society and
the American College of Chest Physicians guidelines in predicting pleural drainage of nonpurulent parapneumonic effusions. Respir Med 100:933–937.
Thomas, F. T. (2007) Current surgical treatment of thoracic empyema in adults. European Journal
of Cardio-thoracic Surgery 32 422—430.
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Patterns and Short Term Outcomes of Chest Injuries at Mbarara Regional Referral Hospital in
Uganda
M M Mwesigwa, D Bitariho, D Twesigye
Department of Surgery, Mbarara Regional Referral Hospital, Mbarara Uganda.
Mbarara University of Science and Technology /Mbarara Regional Referral Hospital.
Correspondence to: M M Mwesigwa, Email: [email protected]
Background: This study was conducted to establish the causes, injury patterns and short-term
outcomes of chest injuries at Mbarara Regional Referral Hospital.
Methods: This was a prospective study involving chest injury patients admitted to Mbarara Regional
Referral Hospital (MRRH) for a period of one year from April 2014 to 31st March 2015.
Results: A total of 71 chest injury patients were studied. Males (91.6%) were the majority and the
ages ranged from 8 to 76 years (mean 32.9 years (+/- 14.0). Majority of the patients (57.7%)
sustained blunt injury. RTA was the most common cause of injury, affecting 49.3%.The commonest
injury patterns were chest wall injuries and lung and pleural injuries accounting for 69.0% and 64.8
respectively. Rib fractures were the commonest chest wall injury (71.4%) while hemopneumothorax
was the commonest (34.9%) finding among those with lung and pleural injury. Associated injuries
were found in 64.2% and out of these, abdominal injuries were the commonest extra thoracic injury
(39.1%) followed by head injury(37.0%),cuts and lacerations(37%) andfractures (28.3%).The
commonest abdominal organs injured were spleen(44.4%), liver (27.8%) and stomach (16.7%).
Majority of the patients had thoracostomy (47.9%) while 33.8% had non surgical treatment.
Laparotomy and thoracotomy were done in 11(15.5%) and 3 (4.2%) of the patients respectively.
Complications occurred in 20(28.2%) and the commonest complication was pneumonia 6 (30%).The
mean length of stay was 7.14 days, SD=±6.1) and the mortality was 16.9%.The significant
determinants of mortality were associated injuries (X2=4.57, F.E=0.046), complications (X2=36.82,
F.E=0.000) and severe head injury (X2=13.85, F.E=0.001).
Conclusion: The causes, patterns and short-term outcomes of this study are similar to those observed
in other developing countries. Chest injury in our setting causes high mortality and measures to
reduce road traffic accidents are urgently required.
Key words: Chest injury, pattern, outcomes
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.6
Introduction
Thoracic trauma comprises 10-15% of all traumas worldwide. It directly accounts for approximately 25%
of trauma related mortality and is a contributing factor in another 25 % 1. In a study by Galukande et al2
carried out at Mulago Hospital, Accident and Emergency wards, on patients involved in bodaboda
(motorcycle) related road traffic crushes, chest injuries were the fourth (following soft tissue injuries,
fractures and head injuries respectively) commonest injuries , contributing 34.7 % . Chalya et al3 in
Tanzania found chest injuries to account for 44% of RTA injuries.
In a study in Tanzania by Massaga et al4, chest injuries had a mortality rate of 24.2%. The same study
blamed this high mortality rate on associated injuries, complications and delayed patient care. Chest
injuries are also often associated with other extra thoracic injuries including head, abdomen and
orthopedic injuries5, 6. Several studies4, 5, 7 show that RTA is the commonest cause except in war areas and
communities with high crime rates. Fortunately, the majority of the chest injuries are successfully
managed with simple surgical procedures with a few requiring thoracotomy7. According to Stewart et al8
the commonest complications are pneumonia and pleural sepsis. Segers et al9 found that the ISS was the
most significant factor determining survival (P < 0.0001) followed by neuro trauma (P=0.05).
Patients and Methods
This was a prospective study involving chest injury patients admitted to Mbarara Regional Referral
Hospital (MRRH) for a period of one year from April 2014 to 31st March 2015. All patients admitted at
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MRRH with chest injury diagnosed clinically and/or imaging were recruited by consecutive sampling.
Excluded chest injury caused by isolated burns, spinal injury, lacerations limited to subcutaneous fat and
inhaled or swallowed foreign bodies.
Results
A total of 71 patients with thoracic injuries were studied. Table 1 shows the age distribution. The peak
incidence was in the 31 – 40 years age group. Only 14 (20%) were aged above 40 years. There was a
predominance of males with a M : F ratio of 11 : 1.
Table 1. Distribution of Patients by Social Demographic Characteristics (N =71)
Variable
Frequency(N=71)
Percentage (%)
Age
32.9(+/- 14.0)
≤10
2
2.8
11-20
11
15.5
21-30
18
25.3
31-40
26
36.6
≥41
14
19.7
Male
65
91.6
Female
6
8.4
Peasants
43
60.6
Students
11
15.5
Driver/rider
5
7.0
Security personnel
3
4.2
Others
9
12.7
Mbarara
21
29.6
Isingiro
19
26.8
Ntungamo
9
12.7
Sheema
5
7.0
Kiruhura
3
4.2
Others
14
19.7
Sex
Occupation
Residence
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Causes
Figure 1 shows the causes of chest trauma. Road traffic crashes accounted for 49% of the cases. Four
(6%) of patients were injured by animals with wild and domestic animals contributing 2 cases each. Falls
were the causes of chest injury in 5 patients, 4 of them being aged below 20 years.
Figure 1. Distribution of patients by the cause of Chest injury (n =71)
Patterns of injury
Blunt trauma accounted for 41 (57.7%) of the chest injuries, 23 (32.4%) were penetrating chest injuries
while 7 (9.9%) were neither blunt nor penetrating. Among the 35 patients with rib fractures, 28 (80%) of
them had 1-4 ribs fractured while 7 (20%) had 5-9 ribs fractured.
Associated injuries
Other associated injuries were present in 46 (64.8%) of the cases while 25 (35.2%) had isolated the chest
injury. Among the 46 patients found with associated injuries, 18 (39.1%) had abdominal injuries, 17
(37%) had cuts and lacerations, head injuries were present in 17(37%) and fractures in 13 (28.3%).
Table 2 shows the specific injured abdominal organs. Eight patients had associated splenic injury.
Treatment
As regards to the various treatment options for the chest injuries, 47(66.2%) were surgical while
24(33.8%) were non surgical. Only two out of five patients with tension pneumothorax had emergency
needle decompression before chest tube insertion. The various treatment procedures used to treat the
chest injuries are shown in Figure 4.
Figure 2. Distribution of Types of Chest Wall Injuries (n =49)
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Figure 3. Distribution of Types of Lung and Pleural Injuries (n=46)
Table 2. The Specific Injured Abdominal Organs.
Abdominal injury
Frequency(n=18)
Percentage (%)
Spleen
8
44.4
Liver
5
27.8
Stomach
3
16.7
Others
2
11.1
.
Figure 4. Distribution of Surgical Procedures among Patients who received surgical treatment (n =47)
Short Term Outcomes of Chest Injuries
Fifty one (71.8%) of the patients had no complications as result of chest injury while 20 (28.2%) had
complications. These complications included pneumonia 6 (30%), surgical emphysema 5 (25%), clot from
inadequately drained haemothorax 2 (10%), empyema 2 (10%), wound sepsis 3 (15%) and
hypovolaemic 2 (10%).
The mean length of hospital stay was 7.14 days, (SD=±6.1) and 12 (16.9%) of the patients died as a result
of the chest injuries while the majority 59 (83.1%) survived. Among those who survived, 56 (95%) were
discharged, 2(3.3%) had run away from the hospital facility and 1 (1.7%) was referred for further
management.
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Relationship Between Associated Injuries and Patient Outcomes
The presence of associated injuries was found to have statistically significant association with mortality
(X2=4.57, F.E=0.046), OR 95% CI = .047(.142-.017). This meant that the more one had an associated injury
the more they were likely to die. Furthermore, among those participants that had head injuries (n=17), 12
participants had mild head injuries while 6 had severe head injuries, 12 (70.6%) survived while 5
(29.4%) died. Among those who had severe head injuries 5 (83.3%) died while 1 (16.6%) run away.
Severe head injury was found to be a statistically significant predictor of outcome. There the participants
who had chest injury associated with severe head injury were more likely to die (X2=13.85, F.E=0.001).
Relationship between Complications and Patient Outcome
There was a statistically significant relationship between complications and mortality (X2=36.82,
F.E=0.000). This implies that the more a participant had complications as a result of chest injury, the
more they were likely to die.
Table 3. Multivariate Analysis of Vital Signs and Patients Survival
Variable
Odds Ratio
P-value
95% CI
Pulse rate
1.8
0.461
(0.36 - 9.46)
Systolic Bp
1.6
0.464
(0.44 - 5.84)
SpO2
1.6
0.612
(0.25 - 10.73)
Respiratory rate
0.1
0.104
(0.01 - 1.57)
Glasgow Coma Scale
21
0.033*
(1.28 - 370.12)
F.E value <0.05 is statistically significant in the table above *indicates statistically significant
Discussion
Lema et al5 and many other authors also observed that males in their productive ages were
predominantly affected by chest injuries. The males being more involved in the risky daily activities to
earn a living for their homes explains their predominance. Most of the patients were from Mbarara
(29.6%) and its immediate neighboring districts due to their proximity to the regional referral hospital.
Peasants (60.6%) and students or pupils (15.5%) were the most affected by chest injuries. Chalya et al6 in
Tanzania studied RTA and also found that the students (58.8%) and businessmen (35.9%) were the main
victims. These people opt for the cheapest means of transport (walking and motorcycle) which also
happen to be more dangerous.10
All the participants in this study did not receive any pre-hospital while majority arrived to hospital in
private/hired cars. Chalya et al11 also found that none of the patients received pre-hospital care and
majority (58.8%) was also brought to hospital by relatives and good Samaritans. Murad et al12found prehospital care to be a significant contributor to survival.
In this study, the commonest cause of chest injuries were Road Traffic Accidents with motorcycles used
for commercial transport accounting for the majority. In a study on patients involved in bodaboda
(motorcycle) related road traffic crushes, chest injuries contributing 34.7%2 while Nwadiaro et al13 found
motorcycles to contribute 30% of morbidity and mortality arising from RTA. World Health Organization
notes the escalating road traffic accidents in developing countries, and gives the increasing motorization,
poor road infrastructure, not complying to traffic laws and driving or riding under the influence of
recreational substances as some of the major reasons for this trend14, 15. The increased usage of
motorcycle for commercial transportation is favored by the cheapness, ability to beat heavy traffic jams,
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access to remote non-motorable areas and poverty. Adeghehingbe et al16 and Solagberu et al17 studied
motorcycle accidents and found that poor licensing, non adherence to traffic rules, at times reckless riding
by largely illiterate motorcycle users as the factors responsible for the increased motorcycle accident
injuries.
Blunt injury (57.7%) represented the majority of the trauma mechanism while chest wall (69.0%) and
lung and pleura (64.8%) injuries occurred the most. Rib fractures were the most chest wall injures while
hemopneumothorax were the major lung and pleura injuries. Massaga et al4 found in their study that
majority of the chest injuries were blunt with rib fractures in 42.9% as the main contributors. Atri et al18
also found rib fractures as the commonest chest injury contributing 60%. Otieno et al19 documented
hemopneumothorax as one of the main injuries sustained in the Kenyan rural population.
Our study found number of rib fractures not to be a significant determinant of outcome. Whitson et al20
also found that increasing number of rib fracture among chest injury patients was not an independent
prognostic factor. Similarly, Huber et al21 found no effect of rib fractures on survival although the same
study found bilateral flail chest to be a significant predictor of outcome.
In this research, there were only 5 (7.0%) diaphragmatic injuries and 4 (80%) of them were diagnosed
intraoperative. Okugbo et al22 showed diaphragmatic injuries to be in only 8% of the chest injury
participants. The diagnosis of blunt trauma diaphragmatic rupture begins with clinical suspicion.23 Tariq
et al24 also found that about 50% of the diaphragmatic injuries were diagnosed for the first time at
laparotomy or thoracotomy for other concomitant injuries.
None of the participants had esophagus, tracheobronchial, cardiac and great vessels injuries. Injuries
involving the heart and great vessels cause sudden death and are therefore rarely seen in the chest injury
patient.25
In this study 64.2% of the participants had associated injuries, with abdominal injury being the
commonest. Splenic and liver injuries were the most common abdominal injuries observed. These 3
abdominal organs are anatomically in close proximity which explains the above trends. Subedi et al26
found that rib fractures were a good indicator of underlying liver and spleen injuries. Ibenzi et al27
studied patterns of abdominal injury at Muhimbili Hospital and found chest injury as the second most
common associated extra-abdominal injury while Chalya et al28 in Tanzania also found chest injuries
(75%) to be the most common associated injury among patients with splenic injuries.
The commonest complication encountered was pneumonia. Stewart et al8 also found pneumonia and
pleural sepsis as the commonest complication blaming it on retained clots, contamination from open
wounds and insertion of the chest tubes. There was no statistically significant relationship between
hospital stay and associated injuries or hospital stay and complications. Lema et al5 also found
complications were a significant determinant of mortality but not hospital stay.
The mortality was 16.9% which is high and the statistically significant predictors of mortality included
associated injuries, severe head injury and complications. Mezue et al29found a high mortality rate of 43%
among head injury patients who had associated chest injuries. While Lema et al5 in Tanzania had a much
less mortality of 3.3 %, Massaga et al4 reported a much higher mortality of 24.2% and documented
severity of injury, associated injuries and delayed medical care as being responsible for this outcome.
Lema et al5 attributed non severe chest injuries (unless there were serious associated extra-thoracic
injuries) on the low mortality rate but also the hospital the research was carried out does not offer free
services like ours.
Conclusions
The causes, patterns and outcomes of chest injuries observed in this study are not very different from
those made in other series done in developing countries. Road traffic accidents are the commonest causes
and measures to reduce them are urgently needed. Chest injury causes high mortality rate and also
mainly affecting males in their most productive ages. Associated injuries and complications are significant
determinants of mortality.
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Limitations
There was inadequacy in diagnostic capacity and emergency and intensive care services.
Acknowledgement
This stundy was funded by Massachusetts General Hospital- Mbarara University of Science and
Technology collaboration. To both institutions we are very grateful.
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Solagberu BA, Ofoegbu CK,Nasir AA, Ogundipe OK, Adekanye AO,Abdur-Radiman LO, 2006.
Motorcycle injuries in a developing country and the vulnerability of riders, passengers and
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Otieno T,Woodsfield J, Bird P, Hill A, 2004.Trauma in rural Kenya. Injury ; 35:1228-1233
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21. Stephan Huber, Peter Biberthaler, Patrick Delhey, Heiko Trentzsch, Hanke Winter, Martijn Van
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25. Pretre R, Chilcott M., 1997. Blunt trauma to the heart and great vessels. N Engl J Me ; 336(9):626632.
26. Subedi N, Yadav BN, Jha S., 2014. Liver and spleen injuries and associated rib fractures: Autopsy
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Patient Profile and Outcomes of Traumatic Extradural Haematomas as Seen at The Nakuru Level
Five Hospital in Kenya
Nasio A. Nasio.
Lecturer, Department of surgery, Egerton University. Consultant General Surgeon, Nakuru county level
five Hospital. Formerly the rift valley provincial general hospital – Kenya. E mail: [email protected]
Background: An extradural haematoma (EDH) also referred to as epidural haematoma is a
collection of blood between the skull and the dura. Extradural haematomas are present in 1-2% of
all head injury patients. In those who present in coma, extradural haematomas are present in 10%
of them. Mortality rates have been reported to range from 5-43% in different regions of the world.
Mortality is reportedly nil in patients who present without coma and 20% for those who present
comatosed.
Methods: A prospective cross sectional descriptive study of patients diagnosed with extradural
haematoma by CT scan conducted at the Nakuru level five hospital between 1st January 2015 and
30th November 2015. Descriptive patient demographic data, clinical presentation data,
investigations, surgical treatments offered, length of hospital stay and outcomes were captured
using a questionnaire.
Results: A total of 32 patients with extradural haematoma were recruited into the study. There was a
male preponderance that accounted for 96.8% of patients. Their ages ranged from 5 to 64 years
with a mean age of 30.75 years (+ 13.6) and. The commonest cause of injury was assault at 31.3% of
all head injury patients followed by motorcycle related accidents at 28.1%. There were 34.4% mildly
injured patients, 43.8% moderate and 21.9% of patients severely head injured. There were 8 deaths
(25%) of the patients and 59.4% of the patients had good recovery. Low GCS, rhinorhoea, otorhoea,
presence of an intracerebral haematoma, admission to the ICU, convulsions and loss of
consciousness were associated with poor outcome.( p=0.00, 0.001, 0.022, 0.002, 0.009, 0.000, and
0.044 respectively).
Conclusion: The extradural haematoma patient is mostly a young male. The commonest cause of
extradural haematoma is assault/violence related followed by motorcycle accidents. There is an
important co relationship between Glasgow coma score and outcome. Likewise Convulsions, loss of
consciousness at any time after injury, otorhoea , rhinorhoea and presence of associated injuries
worsened outcomes in this subset of extradural haematoma patients.
Key words: Profile, outcomes, traumatic, extradural, haematomas
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.7
Introduction
Extradural haematoma (EDH) also referred to as epidural haematoma is a collection of blood between the
skull and the dura. Extra dural haematomas (EDH) have been known for more than 140 years 1. They are
present in 1-2% of all head injured patients and in 20% of those who present in coma 2. Majority of the
extra dural haematomas are known to occur in the young as fewer than 10% are reported in those of age
above 50 years due to a strong and adherent dura to the skull 3. More than 70% of the extradural
haematomas are associated with a skull fracture in adults but the figure is notably low in children 3.
Mortality ranges from 5-43% in various jurisdictions 4, 5. A high mortality rate is noted in the extremes of
age, fewer than five years and those over 55 years of age 5. Patients who present with a GCS of 3 with
dilated and fixed pupils have specifically been reported to have a very high mortality rate 6. Survival has
been reported to depend on: the age of the patient, the speed of haematoma formation, the size and
location of the clot, the pre operative GCS and the presence of intra cerebral lesions and finally the
interval between the onset of pupillary changes and surgery 5, 6, 7, 8, 9. This study aims to highlight the
presentation, incidence, the functional outcome as measured by the Glasgow outcome scale 10 at
discharge of patients with extradural haematomas as seen at the Nakuru level five hospital.
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Patients and Methods
A prospective cross sectional descriptive study of patients diagnosed with extradural haematoma by CT
scan conducted at the Nakuru level five hospital between 1st January 2015 and 30th November 2015. All
patients diagnosed to have extradural haematoma on CT scan were included .Descriptive patient
demographic data, clinical presentation data, imaging investigations done, surgical treatments offered,
intensive care admission and the length of stay in the unit, length of hospital stay and Glasgow outcome
scores10 at discharge were captured using a questionnaire. This data was entered into SPSS version 21
and analyzed. Discrete variables were compared using the chi square test while continuous data was
analyzed using the Students’ T test. A p value < 0.05 was considered significant. Ethical approval was
obtained from the institutions’ ethics review board.
Results
Four hundred and forty five (445) patients were admitted to the hospital with a diagnosis of head injury
during the study period. Of these, 32 (7.2%) of them had extradural haematomas.
Table 1. Characteristics of the Patients with Extradural Haematoma.
Feature
Gender
Was patient a transfer in
Cause of brain injury
Glasgow coma score
Presence of convulsions
Presence of otorrhoea
Presence of raccoon eye
History of loss of consciousness
Presence of rhinorrhoea
Associated subdural haematoma
Associated brain contusion
Associated linear skull fracture
Associated depressed skull fracture
Intra cerebral haematoma
Admitted to the ICU
Finding
Male
Female
Yes
No
Falls from heights
Motor vehicle accidents
pedestrians
Assault/violence
Motorcycle rider/passenger
unknown
13-15
9-12
3-8
yes
No
Yes
No
yes
No
yes
No
Yes
No
Yes
No
yes
No
yes
No
Yes
No
yes
No
yes
No
No
31
1
23
9
2
2
5
10
9
4
11
14
7
8
24
5
27
8
24
8
24
2
30
1
31
3
29
3
29
1
31
3
29
5
27
%
96.9
3.1
71.9
28.1
6.3
6.3
15.6
31.3
28.1
12.5
34.4
43.8
21.9
25
75
15.6
84.4
25
75
25
75
6.25
93.75
3.1
96.9
9.37
90.62
9.37
90.62
3.1
96.9
9.37
90.62
15.62
84.37
P value
0.872
0.554
0.719
0.003
0.000
0.022
0.289
0.044
0.001
0.872
0.550
0.363
0.377
0.002
0.009
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The 32 patients with extradural haematoma were recruited into the study during the period of eleven
months giving an average monthly hospital incidence of 3 cases of extradural haematoma. Men accounted
for 31 cases, The male to female sex ratio was 31:1. Most (71.9%) of the patients were transferred to the
Nakuru level 5 hospital from neighboring institutions. The rest (28.1%) presented to the institution as
their first health care provider (Table 1).
The patients’ ages ranged from 5 years to 64 years with a median of 30 years and a mean of 30.75 years
+13.59). Most (90.6%) of the patients were young being aged 48 years and below. Only 9.3% of cases
were 50 years and above (figure 1). Advanced age was associated with bad outcome (p<001).
The main cause of traumatic extradural haematoma in this subset of patients was assault/ violence in
31.3%. Motorcycle accidents were responsible for 28.1% of the extradural haematomas, injuries to
pedestrians at 15.6%, motor vehicle accidents and falls at 6.3% each while in 12.5% of the patients the
cause could not be established (Table 1). Regarding the severity of injury, 34.4% of the patients had mild
head injury, 43.8% had moderate while 21.9 % had severe head injury. A low GCS was associated with a
poor outcome (p= 0.003). Eight patients (25%) presented having convulsed or had a convulsion while
undergoing treatment in the hospital. Of these eight patients who had convulsed at some time after injury
six died, one recovered with severe disability (GOS 2) and one had a good recovery (GOS 5).
A convulsion at any time after injury was associated with a poor outcome (p value 0.000). An extradural
haematoma patient who had a low GCS was more likely to convulse (p value 0.000). Likewise a history of
loss of consciousness after injury was associated with a poor outcome (p= 0.044). All the extradural
haematomas in this series were found to be unilateral.
Twelve of the patients (37.5%) had other associated injuries such as fractures of the pelvis, chest injuries
in addition to their head injury while 11 of the patients had associated injuries on the head. There were
three patients with linear skull fractures and one patient with a depressed skull fracture comprising
12.5% of the patients as diagnosed on the preoperative x ray and CT radiographs. Five patients were
admitted to the ICU for a period of one to thirteen days with a mean of 6.5 days (+ 5 days). A patient
admitted to the ICU was more likely to have a bad outcome (P=0.009). The range of hospital stay was one
to thirty four days with a mean of 7.58 days (+ 7.852 days). The presence of rhinorhoea, otorhoea and
intracerebral haemorrhage carried a poor outcome (p=0.001, 0.022 and 0.002 respectively).
The imaging investigations done included skull X ray in 14 (43.8%) patients. All the patients had CT scan
of the head. None of the patients had an ultrasound of the head since none of the patients was in the age
range where this could be done. Similarly no patient had MRI done as an investigation to aid in the
diagnosis of their extradural haematoma.
There were eight deaths which was 25% of all patients treated with extradural haematoma. A further five
patients recovered with varying levels of disability on the Glasgow outcome scale10 at discharge as below.
All 8 deaths were males (Table 3). Two of the patients were assaulted, two were pedestrians, two were
motorcyclists, one was hit by a log of wood while the last one sustained the injury as a result of a fall.
Seven of the eight patients who succumbed had been referred to the Nakuru level five hospital from
another facility while six of them had other associated injuries apart from the extradural haematoma and
head injury.
Table 2. Showing the Severity of Head Injury versus the GOS at Discharge
Glasgow outcome scale at discharge
Death
Severe
Moderate disability
Good recovery
disability
Mild
1
0
0
10
Moderate
2
0
3
9
Severe
5
1
1
0
Total
8
1
4
19
Total
11
14
7
32
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Figure 1. The Age Distribution of the Patients
Table 3. The Characteristics of the Patients who died
Age
Gender
Cause
injury
41
36
M
M
36
of
GCS
at
admission
Other
injuries
hospital stay
Alcohol
use
Transfer
into the
hospital
motorcyclist
pedestrian
4
14
1 day in ICU
2 days
yes
yes
yes
yes
M
assault
6
1 day
no
no
26
46
37
M
M
M
motorcyclist
fall
assault
3
3
3
13 hours
1 day in ICU
30 mins
yes
unknown
unknown
yes
yes
yes
60
M
Hit by a log
5
2 days
unknown
yes
64
M
pedestrian
9
none
Pelvic
and
Depressed
skull fracture
Linear skull
fracture
ICH
none
ICH
and
multiple
injury
Skull
and
Radio
ulna
fractures
Cerebral
contusion
13 days ICU
34 days
unknown
yes
Discussion
This study has confirmed that the majority of patients with extra dural haematoma are youthful (> 48
years which represented 90.6% of the patients) males. The male: female ratio is 31:1 similar results were
reported in a study done at Kenyatta National Hospital 11 and notably very high compared to 4; 1 reported
in Nigeria 12. This is a reflection of how active the youthful male population in Kenya is in terms of
outdoor activities whether those activities are involving assault/violence to riding motorcycles to eke out
a living as opposed to their female counterparts. Fewer than ten percent (9.4%) of our patients were of
age above fifty years which is similar to what has been observed elsewhere 3. The involvement of this
mainly youthful male population has huge economic implications to the nation. This finding is similar to
what has been observed elsewhere where it is reported that patients younger than 20 years account for
sixty percent of the injured and that extradural haematomas are uncommon in the elderly 3, 11, 13.
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The study has further revealed that the incidence of extradural haematoma at our single hospital is at
average three patients per month. The leading cause of extradural haematoma in our set up is assault
(31.3%) followed by motorcycle accidents (28.1%). This seems to be in agreement with findings reported
at Kenyatta National Hospital by Kiboi 11. This study shows a direct strong relationship between Glasgow
coma score and Glasgow outcome score (p=0.003). This finding has been reported similarly by several
other researchers elsewhere 11, 14, 15.
Convulsions occurring at any time after injury were associated with a poor outcome (p<0.001).
Convulsions are an important cause of secondary brain injury and therefore they must be anticipated and
prevented before they occur. There exists low quality evidence supporting the use of phenytoin to
prevention of early post trauma seizures and no evidence to show that phenytoin use prevents late onset
seizures or that it prevents mortality 16 the results here seem to indicate that convulsions should be
prevented. Otorrhoea, loss of consciousness, rhinorrhoea, Intra cerebral haematoma and admission to the
ICU were all associated with poor outcomes. Admission to ICU however is indicative of the severity of the
brain injury and thus may more likely be an indirect way of assessing how low the GCS was at admission.
Coexistence of other injuries with extradural haematoma were noted in twelve patients a further eleven
patients had injuries specific to the head ranging from linear skull fractures, depressed skull fractures,
brain contusions and intra cerebral haemorhages. This study found that 12.5% of patients with EDH had a
radiologically identifiable associated skull fracture which is significantly lower compared to studies which
have reported that more than 75% of patients with extradural haematoma have an associated skull
fracture 17, 18. The difference may be due to the fact that not all patients in this series were operated on,
hence, it was difficult to ascertain whether for sure the patients who had no fractures on radiograph
really didn’t have one or it was just missed and could have been found had all the patients been operated.
The yield therefore would most likely have increased if the criteria was both radiographic and the
findings at surgery. Subdural haematoma was coexistent with an extradural haematoma in 3.1% of
patients which is a lower figure as compared to the reported rate of up to 20% in other studies 14. Similar
to other studies advanced age was associated with poor outcome p<0.00111.
This study recorded a mortality rate of 25% of the patients which falls within the reported mortality rate
that ranges between 5 to 43 %19. This figure is similar to that reported at KNH11. The mortality rate
increased with increasing severity of the head injury. This is expected as mortality rate has been reported
as nil in the non coma patients and increases to 20% in the comatose 19.Towards zero mortality in
extradural haematoma patients 20 is a dream we should all aspire to achieve and hopefully a study as this
goes a long way to help elucidate the determinants of poor outcomes and therefore ways and means of
eradicating or avoiding those determinants.
Conclusion
This study has shown the extradural haematoma patient is mostly a youthful male. The commonest cause
of extradural haematoma is assault / violence related followed by motorcycle accidents. There is an
important co relationship between Glasgow coma score and outcome. Likewise Convulsions, loss of
consciousness at any time after injury, otorhoea, rhinorhoea and presence of associated injuries
worsened outcomes in this subset of extradural haematoma patients.
Acknowledgement
May I acknowledge Florence A. Ngoya and Ruth E. Osoo for their invaluable assistance and dedication in
collection of the data analyzed in this paper. I would also like to thank the Nakuru level five hospital and
last but not least Egerton University division of research and extension for funding this project.
References
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Hutchinson J. Effusion of blood between bone and dura matter. Lond Hosp Rep 1867; 4:51.
2. Mishra A, Mohanty S. "Contre-coup extradural haematoma: A short report". Neurology India 2001;
49 (94): 94–5.
3. Irie F, Le Brocque R, Kenardy J et-al. Epidemiology of traumatic epidural hematoma in young age.
J Trauma. 2011; 71 (4): 847-53.
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4.
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Shahid A, Mumtaz A, Mohammad I. Acute extra dural haematoma: factors affecting the outcome.
JPMI.2005;19(2):208-211
Cohen JE, Montero A, Israel ZH. Prognosis and clinical relevance of anisocoria-craniotomy latency
for epidural haematoma in comatose patients. J Trauma 1996;41:120—2
Sakas DE, Bullock MR, Teasdale GM. One-year outcome following craniotomy for traumatic
hematoma in patients with fixed dilated pupils. J Neurosurg 1995;82:961—5
Heinzelmann M, Platz A, Imhof HG. Outcome after acute extradural haematoma, influence of
additional injuries and neurological complications in the ICU. Injury 1996;27:345—9
Leung GKK, Wong ATY, Kwan EYC, et al. Extradural haematoma–—a five year audit at a tertiary
trauma centre in Hong Kong. Asian J Surgery 2001;24(3):305—9
PaternitiS, FioreP, MacriE. Extradural haematoma. Report of 37 consecutive cases with survival.
Acta Neurochir (Wien) 1994;131:207—10
Jennett B, Bond M. Assessment of outcome after severe brain damage. A practical scale. Lancet
1975; 1:480—4.
Kiboi JG, Nganga HK, Kitunguu PK, Et al. Factors influencing the outcomes in extradural
haematoma patients. Annals of African surgery. Jan 2015:12(1)14-18.
Mezue WC, Ndubuisi CA, Chikani MC, et al; Traumatic extradural hematoma in enugu, Nigeria.
Niger J Surg. 2012 Jul;18(2):80-4. doi: 10.4103/1117-6806.103111
Mishra SS, Nanda N, Deo RCh; Extradural hematoma in an infant of 8 months. J Pediatr Neurosci.
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Tassky P, Widmer HR, Takala J et al. Outcome after acute traumatic subdural and epidural
haematoma in Switzerland: a single center experience. Swiss Med WKLY. 2008; 138 (19-20)2815.
Kiboi JG, Kitunguu PK, Angwenyi P et al. Predictors of functional recovery in African patients with
traumatic intracranial hematomas. World Neurosurg. 2011; 75(5):586-91.
Thompson K, Pohlmann-Eden B, Campbell LA, et al; Pharmacological treatments for preventing
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Galbraith S, Smith J. Acute Traumatic Intracranial Haematoma without Skull Fracture. Lancet
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Mushtaq, Lal Rehman, Samina Khaleeq. Association of Outcome of Traumatic Extradural
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Mwangombe NJM. Outcome of severe traumatic brain injury at a critical care unit: a review of 87
patients. Annals of African Surgery. Sep 2009: 1(1)
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Factors Associated with Interpersonal Violence Injuries as Seen at Kigali and Butare University
Teaching Hospitals In Rwanda
Sekabuhoro Safari1, Ahmed Kiswezi Kazigo2
1Departments of Surgery, Bushenge Hospital; (Formerly at Kigali University Teaching Hospital); 2.
2Butare University Teaching Hospital, University of Rwanda.
Correspondence to: Dr. Sekabuhoro Safari, Email: [email protected], [email protected],
Background: Interpersonal conflicts often result into physical injuries of different magnitudes. Every
year, a significant portion of patients admitted with injuries to the Accident and Emergency units of
the hospitals in Rwanda, like in other African countries, are victims of intentional interpersonal
violence. Globally, studies indicate that the problem of interpersonal violence related-injuries is a
significant contributor to surgical morbidity and mortality. The aim of this study was to analyze and
document the patterns and risk factors associated with interpersonal violence injuries in two
referral hospitals in Rwanda (University Teaching Hospitals – Butare (CHUB) and Kigali (CHUK).
Methods: This was a prospective observational study. All patients with interpersonal violence
injuries (physical injuries) willing to participate in the study were included. Each participant was
assessed using the abbreviated injury sore (AIS), by which we categorized their injuries as minor,
moderate, and serious or severe, according to the anatomical distribution and severity of the
injuries.
The variables studied included types of injuries, weapons used, relationship between assailant and
victim, and factors leading to the violence. The study population consisted of 138 patients seen from
August 2015 to January 2016.
Results: Among the 138 participants (victims) the risk factors identified were: Alcohol abuse (31%);
Land conflicts (17%); Robbery (14.3%); Business-related / money issues (12.3%); Domestic violence,
including child abuse (5.8%); others (2%). Outcome: 119 patients improved well, 17 died and 2 were
left with permanent injuries. The total number of trauma cases admitted in the two referral
hospitals in this period was 1004, and the trauma mortality for the two hospitals in the same period
was 156. This meant a morbidity of 14%, and a mortality of 10% due to interpersonal violence.
Conclusion: The predisposing factors for interpersonal violence in Rwanda, as indicated by this
study, included land conflicts, alcohol abuse, robbery, unemployment, domestic violence, and low
levels of education. Interpersonal violence injuries contributed significantly to trauma related
surgical morbidity and mortality.
Key words: Interpersonal violence, Physical injuries, predisposing factors
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.8
Introduction
The history of trauma parallels the history of the evolution of man, with his aggressive instincts, creative
ability and endless ambition to conquer the environment without regard to the price he must pay to
achieve his goals2. Globally, studies indicate that the problem of interpersonal violence related-injuries is
recognized, and is a significant contributor to surgical morbidity and mortality 2, 7, 8.
Rwanda is a beautiful and safe country with a rich cultural heritage, admired worldwide. It has, however,
also had turbulent times of severe interpersonal violence. Every year, a significant portion of patients
admitted at the Accident and Emergency units of the hospitals in Rwanda, like in other African countries,
are victims of intentional interpersonal violence-related injuries.
The true incidence of the injuries resulting from interpersonal violence in Rwanda is unknown.
Healthcare practitioners are aware of this burden, but studies have not yet described it. In the accident
and emergency departments of CHUK and CHUB, interpersonal violence injuries were among the common
causes for consultation and admission. In the surgical wards these injuries accounted for a significant
percentage of morbidity and occasional mortality.
While the predisposing factors (or risk factors) of Interpersonal violence injuries were mostly known to
be community-based and to some extent preventable, as suggested by several similar studies, there had
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been no study focused on this problem to verify the statistical importance of the various factors
associated with it in Rwanda 1, 6, 9.
Every week, the Emergency Departments of referral hospitals in Rwanda received many victims of
interpersonal violence. Many of these injuries were fatal, because they involved delicate parts of the body,
and often led to significant morbidity and mortality, as well as occasional litigation. Many of the risk
factors of these injuries were possibly preventable through community based interventions.
Patients and Methods
This was a Prospective observational study, carried out in two University teaching hospitals of Kigali
(CHUK) and Butare (CHUB), between August2015 and January 2016. The victims of interpersonal
violence were consecutively received at emergencies, and always went through the initial ATLS
assessment protocols as soon as possible. Many patients with minor injuries were discharged after full
assessment, with an appointment for outpatient follow up. Those with serious injuries were hospitalized
for treatment in accordance with the hospital management protocols.
Included among the study variables were the predisposing (or risk factors), the gender of victims,
anatomical distribution of the injuries, age distribution, marital status, the types of injuries, occupation,
education level of the victims, the weapons used, the relationships of the people involved in the assault,
and the treatment outcomes of these injuries.
The aim of this study was to investigate the patterns of interpersonal violence related to intentional
injuries in Rwanda. We recorded the injuries, and determined their anatomic distribution, the
mechanisms of injury, factors associated with the physical assault, as well as the treatment modalities,
and outcomes of these injuries. Each participant was assessed using the abbreviated injury sore (AIS), by
which we categorized their injuries as minor, moderate, and serious or severe, according to the
anatomical distribution and severity of the injuries.
Data were collected using a pre-test questionnaire. Each participant or the next of kin (for unconscious
patients) enrolled and was assigned one questionnaire. The interviews were confidential, in line with the
ethical requirements, in addition to the fact that some of the cases were legally sensitive. Data were
analysed using the Statistical Package for Social Sciences SPSS version 16.
Results
During the study period, 1004 cases of trauma were admitted in both hospitals which included 138 (14%)
cases of interpersonal violence. The latter contributed to 10% to the trauma mortality In this study, the
males were 122 (88.4%), whereas the females were 16 (11.6%). This shows that the males were more
affected by injuries related to interpersonal violence (P < 0.000). The dominant age brackets were 20-30
at 42%, and 31-40 at 34.8%. This means that the sum of these two age brackets was 76.8%.
Most of the victims had a primary school level of education (68%); 15% had secondary school education;
and13% of the victims had never been to school (P<0.000). Only 4% of the victims had university level of
education ( P< 0.158). Unemployment affected 43.5% of the participants and peasant farming (39.9%)
combined, formed a greater part of the study population. These two give a combined percentage of
83.4%, (p <0.000).
Anatomical location of injuries: An Abbreviated injury score (AIS) was allocated to the victim at
admission according to the anatomical part of the body injured.
50% of victims were injured on their head and neck while extremities were affected in 29.7%. Chest and
abdominal injuries represent 20.3% (P <0.000).
Cut wounds represented 37% of injuries; lacerations represented 34%; penetrating injuries 28%.; These
were the most common injuries sustained by victims.
The weapons used during the assault are shown in Table 2. Wooden sticks were used in 47.8% of all cases
followed by knives in 21.7% and machetes in 13.8%. Most incidences of violence occurred at home in
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37% of cases; along the roadside in 35, 5%; and 23.9% in the bar. This does not show any one location as
being strongly indicative of increased risk for violence. This indicates that there was no specific place
tagged to interpersonal violence injuries. Home violence suggests domestic violence and conflicts with
neighbours, whereas in the bar suggests alcohol influence.
Table 1. Age, Education and Gender of the study population
Age
%
Education level
%
Gender
Primary
Secondary
Tertiary
Illiterate
Total
68
15
4
13
100
Male
112
Female
16
42.0
34.8
13.0
8.0
2.2
100.0
20-30
31-40
41-50
51-60
61-70
Total
%
88.4
11.6
Table 2. Factors associated with Interpersonal violence injuries
Factors
%
Link to
Assailant
%
Place
%
Weapon
%
Occupation
%
Alcohol
Land
Revenge
32.6
17.4
15.2
41.3
37.0
14.5
Home
Road
Bar
37.0
35.5
23.9
Stick
Knife
Machete
47.8
21.7
13.8
Jobless
Farmer
Business
43.5
39.9
9.4
Robbery
Money
Domest
Violence
Others
14.5
12.3
5.8
Friend
Neighbor
Family
Member
husband
Other
Wife
5.1
1.4
.7
Others
Farm
2.2
1.4
bottle
Others
Gun
11.6
4.3
.7
Motor driver
Office Worker
Others
2.2
1.4
1.4
Total
100.0
Teacher
1.4
Student
.7
Total
100.0
Sexrelated
Total
1.4
7
100.0
100.0
100.0
With regard to the timing of violence, most (77.5%) of the victims were injured at night. Only 22.5% of
the victims were injured during the The darkness of the night is often used for propagation of violent and
criminal acts as it conceals identification, and community resistance is often minimal or not present at
night. The majority (63%) of the victims involved in interpersonal violence were either married or
cohabitating. Single and widowed accounted for 36.2% of the cases. The difference was statistically
significant
In 41.3% of victims of interpersonal violence, the assailants were regarded as ‘friends’; 37% were injured
by
their
neighbours
and
14.5%
were
injured
by
their
family
members.
Among the factors that were considered to have le accounted d to the interpersonal violence included
alcoholism in 32.6% and land conflicts in 17.4% of the cases. These two factors contributed 50% of all the
risks to interpersonal violence identified in this Rwanda study (P<000). The other predisposing factors
included revenge (15.2%), robbery (14.5%), monetary issues (12.3%), and domestic violence (5.8%).
The length of hospital stay ranged between 0-3 days for the majority 53.6%; 4-7 days represent 19.6%, 811days represent 12.3%, and above 16 days represents 12.3%. Table 3 summarizes the distribution and
outcome of trauma in general and interpersonal violence in particular in the two teaching hospitals in
Rwanda
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Table 3. Interpersonal Violence injuries versus all trauma patients admitted during the same period in
the two hospitals
Trauma cases admitted
Total No of Trauma cases
Interpersonal violence cases
Permanent disability
Mortality
CHUK
661
80
CHUB
343
58
Total
1004
138
1
11
1
6
2
17
.
Discussion
Interpersonal violence injuries contribute to surgical trauma worldwide, and the patterns of this violence
vary greatly in terms of root causes, weapons used, and populations involved. In this study, the
interpersonal injuries were more common among people who knew each other such as friend, neighbour,
spouse, family member, other than strangers (P< 0.000).
Regarding the risk factors, 43% of the injuries were among the jobless, followed by 39% among the
peasant farmers. This is partly explained by the fact that land is a principal factor, and land conflicts with
the neighbours and relatives were a great root cause in this group. In addition, poverty, alcoholism,
gambling and frustration were common among the jobless. These risk factors were similar to those
reported in similar studies in Tanzania and Ethiopia1, 9. Among the business class (9.4%), money issues
such as business transactions and loans, plus robbery were the common causative factors.
Anatomically, 49.4% of the injuries involved the head and neck, and tended to often be multiple. This
suggests the lethal intentions of the assailants. The injuries involving extremities would explain the
defensive tendencies of the victims. The injuries involving the chest and abdomen, often penetrating
injuries, accounted for serious morbidity compared to those of head and neck, because of the
complications they often caused such as pneumothorax, bleeding, and infection.
The injuries in this study involved mainly soft tissues, were anatomically different from those found in a
similar study conducted in Gondor, Ethiopia, in which fractures of the limb bones accounted for 66%. In
this study, while most patients improved and were discharged without permanent complications (76%),
17 patients (12.3%) died following severe injuries and two sustained permanent disability. This is similar
to the findings from another study in South Africa in which the death toll due to interpersonal violence
was 8.3%, of all the deaths in the country.
The predisposing factors (the risk factors) in this study included the following: alcohol influence (32.6%);
land conflicts (17.4%); robbery (14.3%); money (12.3%); domestic violence (5.8%); and others (2%). It is
clear that these figures suggest that alcohol plus land conflicts combined add up to 50% of the risk factors
in the population studied. These factors have some similarities with those found in other researches done
on this subject in Ethiopia, Tanzania, and South Africa. These findings on the risk factors were comparable
to those from similar studies conducted in Ethiopia, Dodoma (Tanzania) and India. However they were
different from those from South Africa in which homicide, femicide and child sex abuse were found 6, 9, 10.
In this review, the weapons used were related to the environments of the conflict. Most injuries occurred
at home, where knives, swords, and sticks were often easily accessible and therefore used. This was
followed by injuries on the road, where knives and sticks were again used. In the drinking places, bottles
were often used. These findings indicate some variation from those in a similar study conducted at Groote
schuur in South Africa in which 18.4 % of the injuries were caused by falls from heights, and 4.8% by firearms 13, 17. The most common age group was 21-30 years (42%); followed by 31-40 years (34%) and 4150 years (18%). Most victims of interpersonal violence were young, frustrated by unemployment,
involved in robbery, and presenting with excess alcohol consumption when they got opportunity from
relatives. The injuries related to interpersonal violence had enormous consequences to the family and the
country by contributing to poverty, reducing the hours of productivity due to morbidity, and spending
family resources for surgical interventions.
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Poverty was found to be a cause and consequence of interpersonal violence. It was a cause of
frustrations, in turn, directly causing violence. The resulting morbidity (sometimes amputations)
resulted in poverty and misery. Poverty has mostly been explored as a societal-level risk factor for
interpersonal violence, although some studies have also examined its effects at the individual and
relationship or household levels. The above findings are similar to those is similar studies elsewhere1, 9 17.
Most of the injuries occurred during the night (77.5%), which suggests that the goal for assailants was to
conceal their identity from the victims or witnesses. As for the cases from a bar, alcohol was often shared
in the night. The fact that we collected 138 victims of interpersonal violence who voluntarily participated
in this study within 4 months in 2 referral hospitals, without accounting for victims who did not need to
transfer to referral hospitals for higher level of care, demonstrates that this is a significant problem in
Rwanda.
Conclusion
1.
2.
The predisposing factors for interpersonal violence in Rwanda, as indicated by this study
included land conflicts, alcohol abuse, robbery, unemployment, domestic violence, and low
levels of education.
Interpersonal violence injuries contributed significantly to trauma related surgical
morbidity and mortality.
References
1. Mensur O, Yigzaw K, Sisay A. Magnitude and Pattern of injuries in North GondarAdministrative
Zone, Northwest Ethiopia. Ethiop Med J 2003; 41:213-220.
2.
Peden M, McGee K, Sharma G. The injury chart book: a graphical overview of the global burden of
injuries. Geneva, WHO, 2002.
3.
3 Rahman M, Nakamura K, Seino K, Kizuki M. Does gender inequity increase the risk of intimate
partner violence among women? Evidence from a National Bangladeshi Sample. PLoS ONE 2013.
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Mulat T, Tadios M. Trauma Registry in Tikur Anbesa Hospital. Ethiop Med J. 2003; 41: 221-226
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Seedat M, Van Niekerk A, Jewkes R, Suffla S & Ratele K. Violence and injuries in SouthAfrica:
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Babu BV, Kar SK. Domestic violence in Eastern India:factors associated with victimization and
perpetration, PublicHealth, vol. 124, no. 3, pp. 136–148, 2010.
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Corso PS, Mercy JA, Simon TR, Finkelstein EA, Miller TR. Medical Costs and Productivity Losses
Due to Interpersonal and Self-Directed Violence in the United States. American Journal of
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National Center for Injury Prevention and Control. Web-based injury statistics query and
reporting system (WISQARS). Atlanta GA: Centers forDisease Control and Prevention. Available
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Mwashambwa MY, Kapatalata SN. Intentional injury:The experience of Dodoma regional
hospital,Central Tanzania. East Cent. Afr. J. Surg. 2015.
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Norman R, Matzopoulos R, Groenewald P, Bradshaw D: The high Burden of Injuries in South
Africa. Bulletin of the World Health Organization 2007, 85:695-702.
Abrahams N, Jewkes R, Martin LJ, Mathews S, Vetten L, Lombard C:Mortality of women from
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intimate partner violence in South Africa: anational epidemiological study. Violence and Victims
2009, 24:546-556.
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Norman R, Schneider M, Bradshaw D, Jewkes R, Abrahams N, Matzopoulos R, Vos T. Interpersonal
violence: an important risk factor for disease and injury in South Africa. Population Health
Metrics 2010, 8: 32.
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Tingne CV, Shrigiriwa MB, Ghormade PS, Kumar MB. Quantitative analysis of injury
characteristics in victims of interpersonal violence: An emergency department perspective.
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Odujinrin O. Wife battering in Nigeria. Int J Gynaecol Obstret, 1993, 41: 159-164.
15.
Nicol A, Knowlton LM, Schuurman N, Matzopoulos R, BBusSci M, Zargaran E, Cinnamon J, et al.
Trauma Surveillance in Cape Town, South AfricaAn Analysis of 9236 Consecutive Trauma Center
Admissions. JAMA Surg. 2014.
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16.
17.
Mohamed Seedat, , Ashley Van Niekerk, Shahnaaz Suffla, Rachel Jewkes, Violence and injuries in
South Africa: prioritising an agenda for prevention,25 August 200918.
Bindu Kalesan, Matthew E Mobily, Olivia Keiser, Jeffrey A Fagan, Sandro Galea, Firearm
legislation and firearm mortality in the USA: a cross-sectional, state-level study, 10 March 2016
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Aetiology and Imaging Findings in Traumatic Spine Injury among Patients Attending Muhimbili
Orthopedics Institute in Dar es Salaam
J Mboka , P K Sohal, R Kazema
Muhimbili University of Health and Allied Sciences, Department of Radiology Dar Es Salaam, Tanzania
Correspondence to: Dr. Mboka Jacob, Email addresses: [email protected]
Background: The main objective of the study was to determine etiology and imaging features of
traumatic spine injury in spine injured patients attending Muhimbili orthopedics institute
Methods: The study was a hospital based cross-sectional and consecutively included 87 with
traumatic Spine Injury. Data was collected through a structured questionnaire. Statistical package
for social science (SPSS 20) was used for data analysis.
Results: Eight seven (87) patients with traumatic spine injury were studied. The age range was 4 to
81 years, with a mean age of 33 years. Males were more affected than females. Young individuals
aged 16-30 years were the most affected. The commonest cause of spine trauma was motor traffic
crashes. The commonest vertebral spine injury seen was compression wedge fracture (35.6%),
followed by dislocation (18.4%). The most frequent spine level involved was lumbar spine (37.9%).
Paraplegia (33.3%) and quadriplegia (10.3%) were the common clinical presentations. Fifty six
percent of patients had associated injuries
Conclusion: Traumatic spine injury is common at our settings. Young individuals below 30 years of
age are most affected and the most common cause is motor traffic accident (MTA). The use of
Computed Tomography (CT) in this study helped to identify several types of injuries especially injury
to vertebral bodies and their effect unto neuro structures. MRI helped to identify patients with spinal
cord injury which was not evident on CT.
Key words: Spine trauma, vertebral fracture, Computed Tomography
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.9
Introduction
Trauma to the spine is devastating but when associated with spinal cord injury is life threatening
especially in low income countries where there is limited availability of quality assistive devices such as
wheelchairs, medical and rehabilitation services and also opportunities to participate in all areas of
personal and social life are constrained1. Most people with spinal cord injury (SCI )in a country such as
Sierra Leone and Tanzania die within a few years of injury 1, 2. The situation in many developing countries
is comparable to what it was in Europe and North America in the 1940s 2. Approximately 40% to 50% of
spinal injuries produce a neurologic deficit, often severe and sometimes fatal 1, 4. The neurological deficits
included paraplegia, quadriplegia, or even may cause death 5, 6.
Most injuries are secondary to blunt trauma (motor vehicle accidents, falls, sports injuries), although
penetrating trauma accounts for approximately 10% to 20% of the cases 1, 7. Variations exist across
regions, road traffic accidents are the main contributor to spinal cord injury in the African Region, nearly
70% of cases and the Western Pacific Region, 55% of cases. Falls are the leading cause in the South-East
Asia and Eastern Mediterranean Regions accounting for 40% of cases 1.
There are approximately 1,380 new cases each year in Tanzania, but in total only 100 - 120 victims are
treated in all hospitals per year. Majority of the victims are young people, from both males and females
who are bread earners of their families 1, 3. Spinal fractures represent 3% to 6% of all skeletal injuries.
The average age of patients with traumatic spine lesions is 32 years at the time of injury with the majority
(55%) being aged 16–30 years6. Approximately, half of spinal injuries occur in the cervical spine, the
other half involves the thoracic, lumbar, and sacral areas. Motor traffic crashes (MTC) are the most
common cause of spine trauma and account for approximately 40% of reported cases 6. Other injuries are
typically the result of falls or sporting activities 8.
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Up to 47% of patients with severe spine trauma have been reported to be associated other injuries: 26%
with head injuries; 24% with chest injuries; and 23% longbone injuries. Approximately 10–14% of all
spinal fractures and dislocations are associated with spinal cord injury 5.
The risk of damage to the spinal cord is greater in cervical spine injuries than in the thoracic and the
lumbar regions 4 occurring in about 40% of cases. Up to 17% of patients have a missed or delayed
diagnosis of cervical spine injury, with a risk of permanent neurologic deficit after missed injury of 29%.
In many parts of the developing world, even today Spinal Cord Injury (SCI) is neglected and poorly
managed. Research is sparse and there is limited data on especially on imaging in traumatic spine injury
at our settings.
Rapid diagnosis and treatment of fracture fragments, hematomas, or other lesions which compress the
spinal cord is life saving to patients who present with an incomplete injury as may regain a large amount
of useful function, or be spared the progression to complete injury. Imaging studies are essential to
confirm the exact location of the injury, to assess the stability of the spine to assess spinal stenosis (canal
and neural foramina), as well as compression on the spinal cord and nerve roots hence guide potential
surgical decompression. Several imaging modalities can be used, but nowadays multi-detector computer
tomography (MDCT) and magnetic resonance (MR) imaging are the most important imaging modalities 7.
In the developing world where CT and MRI are not readily available plain radiography is considered the
first imaging modality.
The plain radiography is a ‘quick way to assess the spine. May be helpful in fracture screening, and are
mainly used to detect a spinal deformity. Plain radiography, even with the best possible technique,
underestimate the amount of traumatic spine injury, and abnormalities may be missed. It has been shown
that 23–57% of spinal fractures are missed by standard radiography compared to multi-detector (multislice) Computed tomography (CT) 9. It is recommended that in severe spinal trauma CT should be the first
imaging modality 10. In the cervical spine, plain radiography detect only 60–80% of fractures; a significant
number of fractures are not visible, even when three views of the spine are obtained 10, 11. Despite of the
limitation, Radiography remains appropriate in low-risk subjects, as well as in those situations where CT
is not available. This study aimed at determining the causes and imaging findings of traumatic spine
injury by using CT and MRI as plain radiography is limited when it comes to evaluation of the extent of
vertebral fractures, spinal cord and ligamentous injuries. .
Computed tomography (CT) plays a critical role in the rapid assessment of the poly-trauma and high risk
patients. It has a higher sensitivity and specificity for evaluating spine injury compared with plain film
radiographs. In the cervical spine, CT detects 97–100% of fractures, but it is relatively poor in detection of
purely ligamentous injuries12. CT screening has a higher sensitivity and specificity for evaluating cervical
spine injury compared with plain film radiographs 13. In the cervical spine, CT detects 97–100% of
fractures 12. CT has been reported recently to be the most efficient imaging tool with a sensitivity of
100%, whereas a single cross-table lateral view had a sensitivity of only 63% in detecting skeletal injuries
of the cervical spine 14.
MRI is a preferred technique for the detection of soft tissue injuries due to its superior contrast
resolution. It is mainly used to exclude occult injuries and to identify spinal cord abnormalities. MR
imaging is the modality of choice for assessing trauma involving the intervertebral disks spinal ligaments
and spinal cord injury 5, 6.
In the current study we determined the, causes, demographic and imaging findings of traumatic spine
injury in patients with spine trauma attending at Muhimbili Orthopedics Institute (MOI).
Material and Methods
Formal ethics approval was obtained from the Muhimbili University of Health and Allied Sciences ethical
Committee. The study was conducted at Muhimbili Orthopaedic Institute (MOI), Radiology Department.
Muhimbili Orthopaedic Institute (MOI) is the largest referral and teaching hospital for Orthopaedics and
Neurosurgeons in Tanzania. Its main objective is providing primary, secondary and tertiary care of
preventive and curative health services in the field of Orthopaedics, Traumatology and Neurosurgery, as
well as being the role model for efficient hospital management in Tanzania. The Institute is also involved
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in human resources development for the nation and also carries out research in these fields with a view of
developing cheaper ways of treatment of patients and reducing invalidity to members of the community.
This study was a hospital based prospective descriptive cross-sectional study. The study was conducted
for a period of 6 months, from July 2014 to December 2014. All patients with traumatic spine injury were
consecutively included into the study. We recruited 91 patients during the study period, all had history of
traumatic spine injury but 4 were excluded (3 died and 1 was referred abroad for further treatment).
The sample size was calculated from the following formulan = Z2 x P (1-P)Where;
E2
N = sample size
P = estimated prevalence (%) = 6%.
This was the prevalence of spine injury in trauma patients in a study done by Suraj Bajracharya et al17. E
= error margin which is 0.05, Z = 1.96. Substituting the above mentioned values in the Formula, the size
was: n = 87.
Inclusion Criteria: All patients with the diagnosis of traumatic spine injury in the during the study
period were included and those who had undergone X-ray or CT or MRI.
A structured designed questionnaire was used to record the information that included the aetiolology ,
demographic and clinical information and Imaging findings
Imaging
Conventional radiographs were obtained using a Siemens type conventional radiography, with printing
on standard film and exposure was carried out in at least two incidents - anterior-posterior and profile.
The variables assessed on conventional x ray included signs of fracture or dislocation, reduced vertebral
height, loss of lordosis or malalignment and others that included paravertebral line distortion. Patients
who had abnormal spine x-ray were referred for CT.
CT images were acquired using a sequentially device (single-slice) and a spiral machine (8 coils) using
standard protocols for evaluation of the cervical spine, thoracic or lumbar and multi-planar
reconstructions in sagittal and coronal, or 3D reconstructions. The variables assessed on CT images were
presence of fracture or a dislocation, signs of cord compression, fragment displacement and others which
included decreased disc height, malalignment or loss or exaggerated lordosis. Patients who had abnormal
spine CT and neurological deficits were referred for spine MRI.
MRI images were performed by a trained Radiographer. Spine MRI was done using 1.5 T scanner,
(Phillips, Achiever, Best, Eindhoven, Netherlands). The scans consisted of saggital and axial T1-weighted
(repetition time/echo time (TR/TE) of 400/8 ms) and T2-weighted (TR/TE of 3,000/120 ms) turbo spin
echo and STIR images. The slice thickness of 4 mm was used for both sagittal and axial images. The
interslice gap of 0.4 mm used with 332 × 240 matrix and a field of view of 300 mm were used for sagittal
images, and 224 × 168 matrix and a field of view of 200 mm for axial images.
The variables assessed on MR images were fracture or dislocation, cord compression, cord signal
intensity change and other findings of ligamental injury, disc prolapse or herniation. The images were
evaluated by the principle investigator and a senior radiologist and the final diagnosis was reached by
consensus.
The statistical package for social science (SPSS) version 20 was used to for analysis. Statistical tests used
for comparison of variables were Pearson chi-square and Fisher’s exact test. P-value of 0.05 was
considered to indicate statistically significant difference.
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Results
Within a 6-months period, 87 consecutive patients with traumatic spine injury were included in the
study. All patients had spine X-rays done. A total of 52 (59.8%) of them had CT spine done while 31
(35.6%) of them had MRI of the spine.
Generally motor traffic crash (MTC) was the most common cause of spine injury (44.8%), followed by fall
from height (40.2%). Other causes included assault, hit by of heavy weight/object, bullet injury, and
animal attack [Figure 1]. The patient ages ranged from 4 to 81 years with a mean of 33.1 years. The 16-30
years age group was most commonly affected and accounted for 38 (43.7 %) of cases. This was followed
by the 31-45 years group that contributed 28 (32%) of the study population [Figure 2]. Sixty four (73.6%)
patients were males.
The lumbar region was most commonly injured in 33 (37.9%) patients, followed by thoracic 31(35.6%)
and cervical spine in 29(33.3%) (Table 1). On CT scan, the pattern of spine injury seen were: burst,
compression and wedge fractures, fracture dislocation, dislocation, odontoid fracture, facet fracture and
cord compression [Table 2]. Generally Fracture and dislocation constituted 52.2% of all of the observed
spine injuries. Cord compression was seen in 29.9%. On MRI the cord signal intensity changes were seen
in 26.4%, cord compression in 25.3% and others in 32.2% which constituted findings of ligamentous
injury, disc prolapse or herniation, and haemangiomas [Figure 3].
Two (2%) patients presented with spine deformity, 29 (28.7%) had paraplegia, 9 (8.9%) presented with
quadriplegia, gibbus and paraplegia was seen in 3 (3%), 28 (27.7%) had tender back, tender neck was
recorded in 19 (n=18.8%) and urine/faecal incontinence presented in 11 (10.9%) [Figure 4]. Forty nine
(56%) of our patients had associated injuries amongst which head injury was the commonest in a third
(33.3%) of the cases [Table 3].Thirty two (36.8%) of the patients underwent spine surgery, while 49
(56.3%) received conservative treatment; three patients died before they could receive any kind of
imaging and treatment. There was one self referral to India.
Fig. 1. Percentage Distribution of causes of traumatic spine Injury
N.B: Others included causes like assault, fall of heavy weight, bullet injury. One patient was attacked by a
buffalo
Table 1. Frequency distribution of Traumatic spine injury by spine level
Radiological level
Frequency
Percent
Cervical
29
33.3
Thoracic
Lumbar
31
33
35.6
37.9
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Figure 2. Percentage Distribution of spine injury by age
Table 2. Frequency distribution of Fractures and dislocation in patients with traumatic spine injury
Fracture type/Dislocation
Frequency
Percent
Burst
15
17.2
Compression wedge
31
35.6
Fracture dislocation
13
14.9
Dislocation
16
18.4
Odontoid fracture
4
4.6
Facet fracture
5
5.7
Others*
27
31.0
35%
30%
25%
20%
15%
10%
5%
0%
fracture or
dislocation
cord compression
cord signal
intensity change
others
Figure 3. Frequency distribution of MRI findings in patients with traumatic spine injury
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Figure 4. Frequency distribution of clinical findings in patients with traumatic spine injury
Table 3. Frequency Distribution of Associated Injuries
Associated injury
Yes
No
Associated injury
Head injury
Pelvic injury
Extremity injury
Chest injury
Total
Frequency
49
38
Frequency
29
8
8
4
49
Percent
56.3
43.7
Percent
33.3
9.2
9.2
4.6
56.3
Discussion
Traumatic spine injury is one of the major contributors of disability in the population. It leads to a major
impact on people’s lives. The sudden onset of spine trauma is tragic and has a profound impact on the
individuals and their families. The role of radiological diagnostic examinations is to provide accurate
anatomic details that can help in patient management. Several imaging studies can be used radiologically
to diagnose and characterize spine injury where CT scans are very sensitive and can identify even subtle
fractures. MRI is best used to study the extent of damage to the spinal cord 6. As compared with
radiographic film, CT offers superior quality visualization of the fractures, of the evaluation of cervicothoracic and cranio-cervical junctions 10, 15. Hence we determined causes, demographic and imaging
findings of traumatic spine injury by using CT and MRI.
Motor traffic accidents (MTA) are the main contributor to spine and spinal cord injury in the African
Region, nearly 70% of cases and the Western Pacific Region, 55% of cases 1. This observation is similar to
what was observed in the current study as most of the traumatic spine injury was caused by MTA
(44.8%). Other major causes include diving into shallow water, football/athletic injuries, falling objects,
or fired projectiles 1, 7. MTA is the principal cause of injury not only to spine but to all other types of
injuries in African settings though in the developed world the gunshot injuries are on the rise. This can be
explained by the fact that, we use frequently the cars and motorcycles daily. African infrastructures are
not well-developed, heavy traffic jam and overpopulation in urban areas may be the cause of to increased
incidences of MTA. Individuals below 15 and those above 60 years of age were more affected by falling
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from heights while the cause of spine injury in individuals aged 16 to 45 years was MTA. Individuals in
the age group of 16 to 45 are the most active and reproductive age group hence they are more vulnerable.
It is devastating that younger individuals are highly affected, as this is the economically active group.
Injuries to the spinal column and the spinal cord are the major cause of disability, affecting predominantly
the young, healthy individuals. They are the main bread earners of the family and main work force of the
nation thus affecting the socio-economic growth of the country.
In the current study the most affected level of the spine was lumbar spine 33 (37.9%), followed by
thoracic spine 31 (35.6%) and cervical spinal vertebrae 29 (33.3%) These findings are similar to those by
Udosen et al16. This is contrary to what has been reported by other studies where cervical spine injuries
are reported to be the most common. The observed differences between the current study could be due to
different settings and study population.
In the study, the most frequent pattern seen was compression wedge fracture 31 (35.6%) This could have
been due to mechanism of injury as the most common cause was MTA. Sudden downward force shatters
and collapses the body of the vertebrae. The combination of flexion and compression forces typically
causes an anterior wedge compression fracture. The anterior column is compressed, with variable
involvement of the middle and posterior column. If the force is great enough, it may send bone fragments
into the spinal canal, called a burst fracture.
MRI is the best modality for evaluation of soft tissues and spinal cord lesions. Twenty six percent (25%)
of patients had spinal cord compression and 26% had hyperintense signal on spinal cord. The signal
change signifies oedema due to spinal cord injury. None of the patient had haemorhagic spinal cord
injury.
Approximately 40% to 50% of spinal injuries produce a neurologic deficit, often severe and sometimes
fatal 1, 4. In the current study 57 (65.5%) patients had neurological deficits Paraplegia and quadriplegia.
Neurological deficits do occur when there is compression or injury to the neural structures. The fracture
dislocations, free bone fragments, the traumatically displaced disks and burst fractures may have
contributed to the observed neurological deficits in these patients. Other clinical features were
tenderness in the back and neck, urine and fecal incontinence and gibbus deformity.
Up to 47% of patients with severe spine trauma have associated injuries: 26% with head injuries; 24%
with chest injuries; and 23% long bone injuries 5. In the current study the prevalence of associated
injuries was higher (56%). This difference could have been contributed by a number of factors like the
cause of injury and the study settings as MOI is the only public facility where there is a neurosurgery unit.
The observation that head injury is the most frequent associated injury is similar to what was observed in
the current study.
Conclusion
Traumatic spine injury is common at our settings. Young individuals below 30 years of age are most
affected and the most common cause is motor traffic accident (MTA). Since motor traffic accidents are the
commonest cause of traumatic spine injury, focus should be more on ways to reduce or prevent car
accidents by sensitizing people more on road safety rules and regulations.
More than 50% of patients presents with neurological deficits indicating that the neuro-structures are
frequently injured in traumatic spine injury. Almost more than a half of patients have associated injuries
and the most frequent is head injury. Lumbar spine was the most affected spine level. Traumatic spine
injury is frequently associated with vertebral body fractures and the most common types are
compression wedge fractures. The use of Computed Tomography (CT) in this study helped to identify
several types of injuries especial injury to vertebral bodies and their effect unto neuro structures. MRI is
very useful for assessing the spinal cord lesions as it shows changes of signal intensity which signifies
injury to spinal cord. The use of advanced MRI techniques can be very helpful in early detection of spinal
cord injury. CT and MRI should be considered to all high risk patients with traumatic spine injury.
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Shimokata, and N. Ishiguro, “Can you diagnose for vertebral fracture correctly by plain X-ray?,”
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The Surgical Management of Primary Hyperparathyroidism: The Experience in Tikur Anbessa
Specialized Tertiary Referral and Teaching Hospital, Addis Ababa, Ethiopia
Sahilu Wondimu1, Berhanu Nega2
1General and HPB surgeon, Assistant professor of Surgery, Addis Ababa University School of Medicine,
Addis Ababa Ethiopia, E-mail: [email protected]
2Associate Prof of surgery, Consultant General and cardiothoracic surgeon, E-mail: [email protected]
Primary hyperparathyroidism is an endocrine disorder characterized by excessive and
inappropriate release of Parathormone (PTH) from parathyroid glands resulting in diverse clinical
manifestations involving the skeletal system in the form of bone and joint pains and pathological
fractures, the gastrointestinal system in the form of dyspepsia from Peptic ulcer disease and
pancreatitis, nephrolithiasis and other neuropsychiatric and nonspecific symptoms. There is nothing
known about the epidemiology of this condition in our country and experience in Parathyroidectomy is very limited. In the biggest tertiary referral and teaching hospital in the country,
only seven cases have been seen and treated over a period of seven years from 2007-2014 and only
three had complete medical documents. We therefore present these three cases in detail and review
the available literature in the management of primary hyperparathyroidism.
Key words: Primary hyperparathyroidism, hungry bone disease, parathyroid adenoma
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.10
Introduction
Primary Hyperparathyroidism is an endocrine disorder of the parathyroid glands resulting in excessive
and sustained release of Parathormone (PTH) with an overall effect of elevated serum calcium level in the
majority of patients. The clinical manifestation is protean and involves a number of organs and systems
and includes bone and joint pains, pathological fractures, renal stones, Peptic ulcer disease, pancreatitis,
neuropsychiatric symptoms like depression, polyuria, polydipsia and other nonspecific manifestations.
The most common cause is solitary adenoma of the parathyroid gland but may also be occasionally
caused by double adenomas, hyperplasia or carcinoma. It is commonly seen in females and diagnosis is
confirmed by determination of serum PTH and calcium levels. The lesion is localized by Ultrasound
and/or Sestamibi scan and Para thyroidectomy is curative.
No literature is available describing the state of primary hyperparathyroidism in our country and the
surgical experience in Para thyroidectomy is very limited. In the country’s biggest tertiary referral and
teaching hospital only seven cases had been diagnosed and treated over a period of seven years from
2007-2014. According to the Operation theatre registration book, four were males and the rest three
were females and the age ranges from 16-59. Unfortunately the complete medical file could be retrieved
only for three of these cases and we therefore present each of them in detail and review the available
literature on the current surgical management of primary hyperparathyroidism.
Case 1:
A 30 year old female patient presented with generalized bone and joint pain of 4 years duration which
initially began around the knee and ankles of the lower extremities but later involved the upper
extremities as well. She also complained of back pain, generalized weakness, epigastric burning pain with
occasional vomiting and excessive thirst. She could walk only with the help of crutches until 4 months
prior to admission where she couldn’t move at all and confined to bed. She denied history of fever and
swelling of any of her joints. Physical examination revealed a chronically sick, cachectic patient with
normal vital signs and an enlarged right lobe of the thyroid gland. She had limitation of movement of the
right hip joint with fixed flexed deformity of the left knee joint. Laboratory investigations revealed,
normal Haemogram, elevated calcium, low phosphorus, significantly elevated alkaline phosphatase level
and normal albumin (Table.1). Serum PTH level has not been determined. Plane x-rays of the skull
(Figure 1), both hands and pelvis showed generalized osteoporosis and pathological fracture of the
inferior ramus of the pubic bone on the right side (Figure 2). Ultrasound of the neck revealed a welldefined 1.8 cm by 2.4cm hypo-echoic mass on the right side of the neck medial to carotid artery and
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poster inferior to the right lobe of the thyroid possible parathyroid mass (Figure 3). FNAC of the enlarged
right lobe of the thyroid gland was suggestive of follicular neoplasm.
Table 1. Summary of Pre- and post-operative Relevant Laboratory Results
Date
calcium
phosphorus
Preoperative- 25/5/2007
13.1(8.4-10.2
mg/dl)
12.1
15.2
6.6
6.3
7.1
8.6
2.4 (2.5-5mg/dl)
25/7/2007
14/12/2007
Post-operative- 10/1/2008
7/2/2008
1/8/2008
21/9/2008
Alkaline
phosphatase
2174(32-92IU/dl)
1494
Figure 1. Plane x-rays of the skull (AP and Lateral views)
With an impression of metabolic bone disease secondary to primary hyperparathyroidism, she was
prepared and operated. Intraoperative findings were enlarged right and left inferior parathyroid glands
with normal superior glands. The right lobe of the thyroid was also found to be enlarged and nodular. The
enlarged inferior parathyroid glands and the right lobe of the thyroid gland were resected out. Operation
time was 100 minutes.
The post-operative course was smooth and the patient was put on IV calcium gluconate which were later
changed to oral form and given for several weeks. Post-operative serum calcium level was low but
gradually increased to approach normal level. Bone pain significantly improved and patient was
instructed to exercise her joints and gradually did better. She was discharged after 96 days of stay in the
hospital.
Biopsy: Gross –two nodular specimen of size 3x1.5x1 cm and 1.5x0.8x0.7 cm respectively which
are yellowish brown, indistinctly nodular seemingly capsulated with smooth surface.
There was a distinct 0.5 cm sized whitish node in the larger gland.
Microsxopy: lobulated and nodular glandular and epithelial elements with clear cells
having granular eosinophilic cytoplasm, small round nuclei arranged in clusters and wide
thin walled blood vessels
Index: chief cell hyperplasia of the inferior parathyroid glands with oxyphilic adenoma on
the bigger hyperplastic right inferior parathyroid gland. No evidence of malignancy on the
right lobe of thyroid gland.
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Figure 2. X-rays both hands and pelvis with Generalized Osteoporosis and Pathological Fracture of
Inferior Ramus of the Right Pubic Bone
Figure 3. Ultrasound of the Neck
Case 2
A 28 yr old female patient presented with progressively worsening pain in the region of the right hip joint
of 3 months duration associated with generalized body weakness. A year prior to her present complaint,
she sustained fall down accident to her left hip for which partial hip replacement had been done abroad.
She denied any other symptoms and any known medical illness. Physical examination revealed
tenderness and limitation of movement of the right hip joint with no swelling and sign of acute
inflammation. Laboratory investigations indicated a normal Haemogram, renal, thyroid, and liver function
tests except a significantly elevated alkaline phosphatase, highly elevated serum PTH level with normal
serum calcium (Table 2).
Table 2. Summary of Pre- and post-operative Relevant Laboratory Results
Date
calcium
ALP
PTH
Preop 19/3/2009
10.4mg/dl( 8.4-10.2)
2000IU/L
(64-306)
16/2/2009
9.6mg/dl (8.9-11.0)
1107IU/L
(0-483)
25/3/09
1060pg/ml (14-72)
Post op
2/4/09
23/4/09
3.55mg/dl(4.5-5.6mg/dl
ionized
11mg/dl(8.9-1mg/dl)
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Plane x-ray of both hands showed generalized osteoporosis with sub periosteal erosion and CT scan of
the lower extremities indicated multiple lytic lesions on the femurs tibia (Figure 4) and pelvic bones with
no pathological fracture and a replaced prosthetic left hip (Figure 5). Ultrasound of neck was consistent
with normal thyroid gland and a 1.9x1.6cm sized hypo echoic lesion in the region of projection of the
right parathyroid gland.With an impression of metabolic bone disease secondary to primary
hyperparathyroidism she was prepared and operated on. Neck exploration revealed enlarged right
inferior and superior parathyroid glands with normal left parathyroid and thyroid gland. Resection of
both right parathyroids was done.
Biopsy Report: Gross: two yellow brown nodular masses of size 2.5x1.5x0.5 cm and2x1.5x1cm
Mic: proliferation of chief cells arranged in cords and solid sheets with no features
of malignancy
Index: parathyroid Adenoma
Her post-operative course was smooth except few episodes of hypocalcemic tetany during the first 5
post-operative days that was successfully treated with IV calcium gluconate which was later changed to
oral calcium that the patient took for some weeks. Her symptom significantly improved and she was
discharged well.
Case: 3
A 30 yr old male patient presented with bilateral hip and lower extremity pain of nine months
duration.The pain was constant and dull aching in type and severe enough to limit his movement and
confine him to bed. He also complained of bilateral flank pain and reddish discoloration of the urine,
generalized weakness, anorexia and significant weight loss. He didn’t have history of swelling in the joints
and denied history of polydipsia and polyuria. Physical examination revealed a chronically sick and
cachectic patient with normal vital signs and mild limitation of movement of both hip joints.
Laboratory investigation is consistent with mild anemia (Hct-27.2%), Elevated creatinin (2.5mg %),
Elevated Ionized calcium 2.07mmol/l (0.62-1.54 mmol/l), significantly elevated alkaline phosphatase
(2930IU/l),highly elevated PTH level of 2620pg/ml(14-20 Pg/ml)(Table 3), ultrasound of the abdomen
showed bilateral renal stones, ultrasound of the neck showed 2.3x2.0cm hypo echoic solid mass in the
projection of the right parathyroid gland with normal thyroid gland, plane x-ray of the hands showed
generalized osteoporosis, saucerisation of the cortices of phalangeal bones with areas of lytic changes
and tuft resorption ,CXR revealed multiple pathological fracture of the ribs with resorption of the distal
end of the clavicle and generalized osteoporosis (Figure 6), lumbosacral x-ray showed bilateral renal
stones (Figure 6) with generalized osteoporosis and multiple lytic expansile lesions in the iliac bones and
proximal femur (Figure 6) .
Figure 4. CT scan of Lower Extremities: Multiple Lytic Lesions on the Femurs and Tibia
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Figure 5. Pelvic Bones with no pathological Fracture and a Replaced Prosthetic Left Hip
With an impression of metabolic bone disease secondary to primary hyperparathyroidism, he was
prepared and operated. Neck exploration revealed enlarged right superior parathyroid gland with the
rest three being normal, no lymphadenopathy and normal thyroid. Excision of the enlarged right superior
parathyroid gland was done (Figure 7).
Biopsy Report: Gross - Grey brown nodular, encapsulated 4x3x2cm single tissue fragment
weighing12gm
Microscopy –Round to polygonal cells with eosinophilia cytoplasm that is water
clear peripherally, hyper chromatic granular nuclei and prominent nucleoli
arranged in cords and tubules and surrounded by thick fibrous capsule, with
areas of calcification hemorrhage and cystic spaces. The overall finding is
consistent with parathyroid adenoma.
The patient had uneventful post-operative course with calcium supplementation and discharged
improved with a hospital stay of 56days.
Table 3. Summary of pre- and post-operative relevant lab results
Date
Preop - 9/3/08
30/4/08
10/5/08
16/5/08
20/5/08
14/6/08
Postop-27/6/08
30/6/08
14/7/08
Calcium
ALP
Creatinin
2.5mg/dl(0.7-1.4)
PTH
2620pg/ml
(14-72)
1.7mg/dl(0.7-1.4)
8.5mg/dl(8.8-10.2)
10.4mg/dl(8.9-11)
2930IU/l(0-483)
2.07mmol/l(0.621.54)
8.6mg/dl (8.9-11)
554IU/l(0-483)
1.5mg/dl(0.7-1.4)
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Figure 6. CXR with multiple pathological fracture of the ribs with resorption of the distal end of the
clavicle and generalized osteoporosis Lumbosacral x-ray showed bilateral renal stones with generalized
osteoporosis and multiple lytic expansile lesions in the iliac bones and proximal femur
Figure 7.
Discussion
Primary hyperparathyroidism is an endocrine disorder characterized by excessive and inappropriate
release of Parathormone (PTH) from parathyroid glands resulting in diverse clinical manifestations
involving the skeletal system in the form of bone and joint pains and pathological fractures, the
gastrointestinal system in the form of dyspepsia from PUD and pancreatitis, nephrolithiasis and other
neuropsychiatric and nonspecific symptoms. Truly asymptomatic cases of primary hyperparathyroidism
have been described mainly in developed countries like Canada and it is usually detected during
screening by serum calcium measurement5. It is commonly seen in females with a F:M of 2-3:1 1, 8.
All our patients presented with advanced skeletal involvement as was also reported from Pakistan 2 and
India 8 and unlike what is described in the literature 1, 2, 8. Four (57%) out of 7 of our patients were males.
The most common cause is a solitary adenoma involving one of the four glands usually the right inferior
but may also be caused by double adenomas, hyperplasia and rarely carcinoma. Of the seven cases we
operated on, two had double adenomas and one had three adenomatous parathyroid gland. Diagnosis
requires a high index of suspicion based on clinical evaluation and demonstration of elevated serum
levels of PTH along with raised or occasionally normal serum calcium level. The most commonly used
localization studies are ultrasound of the neck with a sensitivity of 65%, Technetium- 99 Sestamibi scan
with a sensitivity of 80% alone or in combination increasing the sensitivity to 96% 4. None of our cases
had Sestamibi scan done but all had ultrasound examination of the neck which showed the parathyroid
lesion preoperatively in all cases.
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Traditionally the treatment of primary hyperparathyroidism has been bilateral neck exploration with
examination of all the four glands and excision of the affected one 1. Recently this approach has been
questioned given the fact that about 85% of the disease is caused by adenoma involving only one of the
four glands and preoperative localization of this affected gland is possible nearly accurately using
ultrasound and Sestamibi scan. Furthermore in centers with best set ups, intraoperative determination of
serum PTH level following excision of the affected gland has decreased the number of unnecessary
bilateral neck explorations in effect reducing the rate of complications like hypocalcaemia and recurrent
laryngeal nerve injury 3 .This has led to a practice of unilateral targeted neck exploration as the most
favored approach in the current management of primary hyperparathyroidism 6. The list of new
developments in the surgical management of primary hyperparathyroidism goes on to include
endoscopic neck and mediastinal exploration making parathyroidectomy much less invasive and a quite
safe procedure 7.
The commonest complications following parathyroidectomy are recurrent laryngeal nerve injury and
hypocalcaemia 7. The latter is usually due to the so called hungry bone disease where most of the free
serum calcium returns to the skeleton following rapid drop in PTH after the surgery and will get better as
the remaining parathyroid glands start to produce and secrete PTH which maintains calcium
homeostasis. From the seven cases operated in our hospital, only one developed this complication and
was successfully treated with IV calcium gluconate and later with oral calcium and Vitamin D. All the
others had a smooth post-operative course.
Post-operative follow up of patients is done by serial determination of serum calcium and PTH level and
cure is declared if the level of calcium normalizes and stays so at least for six months after surgery7.
Persistent and recurrent primary hyperparathyroidism is also described according to this definition of
cure. Only one of the three cases presented had a long term post-operative follow up and she became
normocalcemic and stayed so for over six months and so can be declared cure. Complete information
couldn’t be found in all the rest and so it is difficult to comment on their long term outcome.
Recommendation
The few cases we operated on had significant skeletal manifestations with bone pains and multiple
fractures causing severe disability. This usually results from advanced disease due to late diagnosis.
Therefore high index of suspicion and proper screening using serum calcium and PTH measurement is
required to detect this disorder at the earliest stage.
References
1.
2.
3.
4.
5.
6.
7.
8.
Dina Elaraj, Orlo H.Clark, Current status and treatment of primary hyperparathyroidism, Review
article, The Permanente Journal, V12, N 1, 2008.
Ameer Afzal, Tooba Mahmud Gauhar et al, Management of Primary hyperparathyroidism a
5years surgical experience,Journal of Pakistan Medical Association, V 61, N 12 ,Dec.2011.
Nussbaum SR, Thompson AR, Hutchison KA, Gaz RD, Wang CA, intraoperative measurement of
PTH in surgical management of primary hyperparathyroidism, Surgery ,104(6), 1121-7 ,Dec.
1988.
Aricic, Cheah wk et al, Can localization studies be used to direct focused parathyroid operations?
Surgery , June 2001, 129(6) : 720-9
Blair A, William et al , Primary hyperparathyroidism in Canada , Journal of Otolaryngology ,head
and neck surgery 43:44 , 2014
Greene AB, Butler Rs, et al. National trends in Parathyroid surgery ,
American College of Surgeons 2009, 209: 332-334
Sarah C oltmann and Rebecca S Sippel, Surgical management of primary hyperparathyroidism,
International Journal of Endocrine Oncology 2:21-29, 2015
P. V. Pradeep,1 B. Jayashree,1 AnjaliMishra,2 and S. K. Mishra2 , Systematic Review of Primary
Hyperparathyroidism in India: The Past, Present, and the Future Trends , Review article,
International journal of Endocrinology, March 2011
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The Jejunal Serosal Patch Procedure: A Successful Technique for Managing Difficult Peptic Ulcer
Perforation
Abebe Bekele, Seyoum Kassa, Mulat Taye
Addis Ababa University, School of Medicine, Ethiopia
Correspondence to:Dr. Abebe Bekele, Email: [email protected]
Background: The selection of the most appropriate technique for the repair of peptic ulcer
perforations, especially when the initial attempt of closure has failed have been the concern of many
surgeons. Since the experimental report regarding the jejunal serosal patch procedure by Koboldin
in 1963, authors have reported its use with encouraging outcome. The main objective of this paper is
to describe our experience with the Jejunal Serosal Patch procedure in patients with failed Omental
patch procedure following perforated peptic ulcer disease.
Methods: This is a retrospective report of cases with failed pedicled omental patch procedure
initially performed for perforated peptic ulcer disease and who subsequently underwent Jejunal
Patch Procedure at the Minilik II Hospital in Addis Ababa, Ethiopia. Details of their surgical
procedure, complications observed and outcome is presented.
Results: Five patients, who are all male with mean age of 32.2 years (Range= 31-40 years) were
included in the study. The duration of illness of all patients before their first surgery ranged from 48360 hours (mean= 153.6 hours). All patients had significant collection of gastric and purulent
material in the peritoneum during the first surgery and the mean size of the perforation was 1.3 cm
(Range 1-2cm). All five patients were re-operated for the first time after a mean of 76.8 hours and all
were managed with re-patching of the duodenal perforation. The second re-operation for jejunal
patch procedure was within 24 hours in one patient and > 24 hours in four patients (Mean=34.8
hours). The omental patch was found completely detached in 4 patients and partially separated in
one. All patients were treated in a similar fashion by using a standardized Jejunal omental patch
procedure. Post operatively, a total of 16 complications were seen in the five patients. One patient
died, yielding an overall mortality rate of 20%. The mean hospital stay was 25.5 days of (Range 1751 days) mean 25.4 days.
Conclusion: The management of the leaking omental patch is very difficult. Although some leaks
transform into fistulas and will eventually close after prolonged period of hyperalimentation and
continuous nursing care, this approach requires extended hospitalization and the associated
morbidity, mortality and financial/social depletion on the patient is enormous. On the other hand,
prompt closure of these defects by serosal patching can result in a rapid return of fluid and
electrolytes to normal and permits early oral feedings. Our limited experience with this procedure is
encouraging and our post operative complications and mortality are within the acceptable range.
We believe this procedure is learnable, and has the potential to be utilised in difficult perforations
involving the other parts of the GIT.
Key words: Jejunal, Serosal, Patch Procedure, perforation, peptic ulcer
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.11
Introduction
The selection of the most appropriate technique for repair of duodenal perforations, especially when
perforation are recurrent or when there is duodenal tissue loss have been the concern of many surgeons
over the past many years. Various surgical techniques such as omental patch repair, (Cellan-Jones or
Roscoe Graham), duodenal resection with end-to-end anastomosis, application of a synthetic mesh,
jejunal serosal patching and pedicled jejunal flap have been used to manage such defects 1 - 4. The difficult
nature of the operation site, the high intra luminal pressure in the duodenum, the tendency of the
duodenal mucosa to extrude through closure, its limited vascular supply and the alkaline content of the
duodenum (pancreatic and biliary fluids) which interferes with healing and suture integrity has
prevented surgeons from following a clear-cut algorithm to approach this problem 1 - 4.
Kobold 5 in 1963 and Wolf 6 man in 1964 reported a simple serosa-to-serosa closure of experimental
duodenal defects in dogs by suturing an intact loop of jejunum over the hole. In their experiments, the
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serosal surface of the jejunum was gradually covered by duodenal epithelium, the process being complete
in four to seven weeks. No anastomotic leaks occurred, and there was no apparent tendency for peptic
digestion of the loop. Since then, many authors have utilised and described jejunal serosal patching in
experimental animals and clinically on patients, with reported very good outcome 5 - 10 .
Perforation of the anterior wall of the duodenum is the commonest cause of duodenal perforation in
Ethiopia, and in most african settings 11 - 14. The most acceptable method of ulcer peroration repair has
been patching of the perforation with omentum: pedicled or free graft and the success rate of this
procedure is said to be a high as 80-90% 11 - 14. However, in some cases, omental patch repairs fail and reoperations are required. The rate of re-leak following omentoplasty reported to be between 2 – 7.6%
Such a situation is very difficult to manage and is associated with repeated omental patch failures,
morbidity and very high 10 - 14. Therefore, the main objective of this paper is to describe our experience
with the Jejunal Serosal Patch procedure in patients with failed Omental patch procedure following
perforated peptic ulcer disease.
Patients and Methods
This is a retrospective report of patients operated for failed omental patch procedure at the Minilik II
Memorial Referral Hospital in Addis Ababa Ethiopia. The hospital is the oldest hospital in the country
(more than 105 years old) and currently serves as an affiliate teaching hospital for the Addis Ababa
University, School of Medicine. It has 120 surgical beds, about 100 of which are dedicated to General
Surgery. It is staffed with 7 consultant surgeons and no less than 15 rotating surgical residents at a time.
The study period was between June 1, 2013 and June 30, 2016 (a three year period).
During the study period, 87 complete records of patients admitted for surgical treatment of perforated
peptic ulcer disease were retrieved. All were treated initially with pedicled omental patch technique
(Cellen-Jones Procedure). However, 6 (6.8%) of patients developed failure of the first omental patch
procedure and had to be re-operated. All the 6 patch failures underwent peritoneal lavage, pedicled
omental re-patching of the perforation site and an additional vagotomy and gastro-jejunostomy. The repatch failed in four patients and three subsequently underwent jejunal serosal patch. Two patients were
also referred from other hospitals with a diagnosis of twice failed omental patch procedure to the Minilik
Hospital. Hence these five patients made the basis of the study.
Using a standardised data collection format, the following information was obtained: Socio-demographic
data of the patients, operative details and findings during re-laparotomy, mode of management, post
operative course of the patients and final outcome. Patients were excluded if the perforation was due to
malignant disease or trauma. Data handling and analysis were performed with EP-INFO for Windows and
appropriate statistical tests were done.
The diagnosis of failed omental patch was made based on clinical grounds, (Worsening of the post
operative patient, occurrence of fever and tachycardia within a few days of surgery, disruption of the
abdominal wound and appearance of bilious and gastric content), routine laboratory tests (raised WBC
count) and ultra sound finding of an intra abdominal collection in some cases. Invariably, the definitive
diagnosis of perforated peptic ulcer and omental patch leakage was obtained at surgery.
Results
During the study period, 87 perforated peptic ulcer cases were operated. Six (6.8%), all with perforated
duodenal ulcer, developed generalized peritonitis following omental patch repair. All were re-operated
and re-patching of the perforation site with pedicled omentum was done in all. However, the re-patched
omentum failed in 4 (66%) of these patients and three were managed by jejunal serosal patch. One
underwent re-patching for the second time, but died three days after surgery. Two patients were also
referred from other hospitals in Addis Ababa with a diagnosis of twice failed omental patch and were
managed in our hospital.
The socio-demographic status of the five patients showed that all five were males with mean age of 32.2
years (Range= 31-40 years). Four came to the hospital form a considerable distance from the hospital.
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Three were active alcohol users, two were chat chewers. The duration of illness of all patients before their
first surgery ranged from 48-360 hours (mean = 153.6 hours) and three presented in hypotension. All
patients had significant collection of gastric and purulent material in the peritoneum during the first
surgery and the mean size of the perforation was 1.3 cm (Range 1-2cm) (Table 1).
Table 1: Patterns of patients treated with Jejunal Serosal Patch
Sex
Age
No.
Duration of
Shock
illness before 1st
Size of
Time
Time
perforation
between
between
stay
1st and 2nd
2nd and 3rd
days
surgery
surgery
surgery (Hours)
Outcome
Hosp
1
M
31
96
Yes
2 cm
72 hours
24 hours
Improved
21
2
M
34
360
Yes
1 cm
48 hours
18 hours
Died
17
3
M
27
144
Yes
1.5 cm
72 hours
36 hours
Improved
16
4
M
30
120
No
1 cm
96 hours
24 hours
Improved
22
5
M
39
48
No
1cm
96 hours
72 hours
Improved
51
All five patients were re-operated for the first time after a mean of 76.8 hours. The second re-operation
was within 24 h in one patient and > 24 h in four patients, while the mean lapse between second omental
patch and jejunal serosal patch was 34.8 hours. A similar intra operative finding was encountered in all
patients: The previous skin wound was grossly infected and pouring pus mixed bilious fluid and the
peritoneum was filled with a similar fluid. There was gross adhesion in the operation site and distal
stomach and first part of the duodenum were oedematous and fragile. The omental patch was completely
detached in 4 patients and partially separated in one. All patients were treated in a similar fashion.
Post operatively, a total of 16 complications were seen in the five patients. One patient died, yielding an
overall mortality rate of 20%. The mean hospital stay was 25.5 days of (Range 17-51 days) mean 25.4
days (Table 2).
Table 2: Post operative complications seen in patients who underwent jejunal patch procedure
Post operative complications seen
Frequency (N=16)
Surgical Site Infections
5
Wound Dehiscence/Burst Abdomen
2
Intractable Septic shock
1
Pneumonia/Respiratory failure
4
Severe hypoprotenemia
3
Duodeno-cutaneous fistula
1
Discussion
The management of the leaking omental patch is very difficult. Although some leaks transform into
fistulas and will eventually close after prolonged period of hyperalimentation and continuous nursing
care, this approach requires extended hospitalization and the associated morbidity, mortality and
financial/social depletion on the patient is enormous. On the other hand, prompt closure of these defects
by serosal patching can result in a rapid return of fluid and electrolytes to normal and permits early oral
feedings.
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Literature review has shown that the jejunal serosal patch used to seal grossly infected duodenal
perforations are reliable procedures 4 - 9. Kobbold and Thal 9, in an experimental setting described the use
of a jejunal serosal patch to close the duodenal defect in a canine model where the serosa-to-serosa
anastomosis between the edges of duodenal defect and jejunum was performed. They have observed that
the jejunal serosa exposed to the lumen was completely covered with duodenal mucosa within 8 weeks.
James and Santa 7 in 1965 reported the first clinical application of a Serosal Patch in repair of a Duodenal
Fistula in a 55 years male and they reported a perfect closure of the perforation with no evidence of
continued leak. In an experimental setting, Jones, created a duodenal defect analogous to a perforated
duodenal stump, allowing the leak to continue for 20 hours. Then at a second operation the duodenal
defect was closed by the “serosal patch" technique. Again, all the experimental dogs survived and no
anastomotic leaks occurred 8. Another experiment has documented that in the presence of a grossly
contaminated peritoneum, jejunal serosal patches were still in place and there was ingrowth of neomucosa beginning along the margins on the serosal surface of the jejunal patch. The complete coverage of
duodenal neomucosa on jejunal surfaces was observed at 6 weeks 17.
The procedure is described as follows
After opening the previous surgical wound, the intra abdominal collection was sucked out and the
operation site approached. The duodenal perforation site was identified after gently dissecting through
the adhesions. Once identified, all the debris and obvious necrotic tissues were debrided. If the adhesions
allow, the second part of the duodenum was mobilized, then a loop of jejunum, 40-60cm way from the
ligament of Treitz was brought over the colon and sutured over the duodenal defect serosa-to-serosa with
interrupted sutures of 2-0 silk about 2-3 cms away from the perforation site. A diverting jejunojejunostomy was also done 20 cm distal to the patch in all cases. After generous intra abdominal lavage, a
large drainage tube (sometime 2 tubes) were left behind. The abdominal cavity was washed with copious
amount of warm normal saline, jejunal serosal patch was applied to the perforation site and a drainage
tube was inserted to the right sub hepatic space. Catheters were removed when there was no drainage
from the abdominal cavity.
Figure 1.
Adopted from: James MC Kittrick, Santa
Barbara. Use of a Serosal Patch in Repair of a
Duodenal Fistula: Clinical Application of an
Experimental Method 1965, California
medicine, 433-435.
Kumar15 in his publication has outlined some very important predictors of leak: ie. age > 60 years, Pulse
rate >110/minute, Blood pressure <90mmHg, Haemoglobin < 10g/dl, Serum albumin <2.5 g/dl, Total
lymphocyte count < 1800 cells/mm and size of perforation > 5mm. Other publications Maghsoudi 16, have
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identified pre-disposing factors for leak include delay in surgery, shock on admission, post-op abdominal
complications and age.
Conclusion
Our limited experience with this procedure is encouraging and our post operative complications and
mortality are within the acceptable range. We believe this procedure is easily learnable, and has the
potential to be utilised in difficult perforations involving the other parts of the GIT.
References
1. Astarcioglu H, Kocdor MA, Sokmen S, Karademir S, Ozer E, Bora S. Comparison of different
surgical repairs in the treatment of experimental duodenal injuries. Am J Surg 2001; 181: 309-12.
2. Lal P, Vindal A, Hadke NS. Controlled tube duodenostomy in the management of giant duodenal
ulcer perforation: a new technique for a surgically challenging condition. Am J Surg 2009; 198:
319-23.
3. Jani K, Saxena AK, Vaghasia R. Omental plugging for large-sized duodenal peptic perforations: A
prospective randomized study of 100 patients. South Med J 2006; 99: 467-71.
4. Chen GQ, Yang H. Management of duodenal trauma. Chin J Traumatol 2011; 14: 61-4.
5. Kobold TH, Thal AP. A simple method for the management of experimental wounds of the
duodenum. Surg Gynecol Obstet 1963; 116:340 –3.
6. Wolfman, E. F., Jr., Trevino, G., Heaps, D. K., and Zuidema, G. D.: An operative technic for the
manage- ment of acute and chronic lateral duodenal fistulas, Ann. Surg.,159:563,1964.
7. James Mc Citric andSantaBarbara. Use of a Serial Patch in Repair of a Duodenal Fistula: Clinical
Application of an Experimental Method 1965, California medicine, 433-435.
8. Jones, S. A., Gregory, G., Smith, L. L., Saito, S., and Joergenson, E. J.: Surgical management of the
dificult and perforated duodenal Stump,Am. J.Surg.,108:257, 1964.
9. S. Austin Jones, Alan B. Gazzanlga, Thomas B. Keller. The serial patch: A Surgical Parachute. The
American journal of surgery. Vol 126, August 1973, p 186-196.
10. Sanjay Gupta, Robin Kaushik*, Rajeev Sharma and Ashok Attri. The management of large
perforations of duodenal ulcers BMC Surgery 2005, 5:15 doi:10.1186/1471-2482-5-15
11. Jennifer Rickard. Surgery for Peptic Ulcer Disease in sub-Saharan Africa: Systematic Review of
Published Data. J Gastrointest Surg (2016) 20:840–850 DOI 10.1007/s11605-015-3025-7
12. Ersumo T1, Ali A, Kotiso B. Complicated peptic ulcer disease in Tikur Anbessa Hospital, Addis
Ababa. .Ethiop Med J. 2004 Apr;42(2):87-95.
13. Asefa Z, G/eyesus A.Perforated peptic ulcer disease in Zewditu Hospital .Ethiop Med J. 2012
Apr;50(2):145-51.
14. Abebe Bekele, Seyoum Kassa, Daniel Zemenfes, Andualem Deneke and Mulat Taye. Patterns and
seasonal variation in the incidence of Perforated Peptic Ulcer Disease: A Three- Years Experience
from Addis Ababa, Ethiopia. Sent for publication
15. Kumar K, Pai D, Srinivasan K, Jagdish S, Ananthakrishnan N. Factors contributing to releak after
surgical
closure
of
perforated
duodenal
ulcer
by
Graham's
Patch.
Trop
Gastroenterol.2002;23(4):190-2
16. Maghsoudi H, Ghaffari A. Generalized peritonitis requiring re-operation after leakage of omental
patch repair of perforated peptic ulcer. Saudi Gastroenterol 2011;17(2):124-8
17. Hu ̈seyin Astarcıog ̆lu, M.D., Mehmet Ali Koc ̧dor, M.D., Selman Sö kmen, M.D., Sedat Karademir,
M.D., Erdener O ̈ zer, M.D., Seymen Bora, M.D. Comparison of different surgical repairs in the
treatment of experimental duodenal injuries. The American Journal of Surgery 181 (2001) 309–
312
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Incidence of Sigmoid Volvulus in Northern Uganda. An Observational Study
Richard Wismayer1, 2
of Surgery, Faculty of Medicine, University of Edinburgh, United Kingdom
2Faculty of Medicine, Gulu University, Gulu, Uganda
Correspondence to: Dr. Richard Wismayer, Email: [email protected]
1Department
Background: Sigmoid volvulus (SV) has a considerable geographical variation in its incidence. The
purpose of this study was to determine the incidence of SV in Northern Uganda.Methods:A two year
retrospective and one year prospective study in 19 hospitals in Northern Uganda from January 2010
to December 2012 was conducted to determine the incidence of sigmoid volvulus. All patients’
records with a diagnosis of sigmoid volvulus were included in the study. Ethical approval was
obtained from the IRB Gulu University and Uganda National Council for Science and Technology
(UNCS&T). Data analysis was conducted using STATA/IC version 12.1.Results:The incidence of SV in
Northern Uganda was 251.8 per 100,000 surgical population in 2 years. Cases were least observed
from May to November and most cases were seen in the dry season from December to April.
Conclusions:The incidence of SV in Northern Uganda was 251.8 per 100,000 surgical population in 2
years. The proportion of bowel obstructions due to sigmoid volvulus in Northern Uganda was 23.4%
and similarly comparable with the proportion found in other African countries and higher than
those indeveloped countries.
Keywords: Sigmoid volvulus, incidence
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.12
Introduction
Sigmoid volvulus has a considerable geographical variation in its incidence1 and is a comparatively rare
disease in the United Kingdom, Western Europe and North America 1. However it is one of the commonest
causes of acute intestinal obstruction in Eastern Europe, India, West Indies and the Negro population of
Africa1. In the developed world, sigmoid volvulus is uncommon accounting for about 5% of all cases of
large bowel obstructions 9. In the developing world, sigmoid volvulus constitutes 50% of large bowel
obstructions 4,5,6.
A multi-factorial aetiology has been implicated mainly food containing a high fibre diet and pre-existing
redundant sigmoid colon10,11.In Uganda the basic foods include cassava, rice, millet, porridge, peas, soya,
beans, oranges and mangoes which have all been implicated in the aetiology of sigmoid volvulus 8.It is
postulated that this high fibre diet leads to a shortened intestinal transit time leading to a redundant
sigmoid colon to undergo volvulus 12. Studies conducted in Central and Eastern Uganda found that
sigmoid volvulus affects mostly the Baganda, Basoga and Bagisu tribes however, Nilotics where this study
was conducted, it was believed that they least often suffered from sigmoid volvulus 13.
Very little is known about sigmoid volvulus in Northern Uganda where in the last 20 years civil war
ruined the economy with most of the populace displaced into internally displaced peoples’ camp 14. In this
post conflict Northern Uganda, there is speculation that the patients’ poor socio-economic status makes
them unable to meet the costs of an elective operation resulting in a low registered incidence of sigmoid
volvulus. This prolonged civil war, poverty, lack of specialist care and patients’unawareness may have
contributed to the delay in reporting to hospital with acute sigmoid volvulus with the result that more
advanced stagesof bowel obstruction are seen 14. The obstructed bowel may become gangrenous as a
result of strangulation, and this may lead to intestinal perforation, peritonitis and sepsis which were
observations made in the respective hospitals 14,15. The purpose of this one year prospective and two year
retrospective study design was to determine the incidence of sigmoid volvulus in Northern Uganda,
Patients and Methods
A two year retrospective study conducted between January 2010 to December 2011 and a one year
prospective study from January 2012 to December 2012 was done to determine the incidence of sigmoid
volvulus in Northern Uganda.Nineteen out of 20 Hospitals which serve 95% of the population of Northern
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Uganda recruited sigmoid volvulus patients consecutively. Of these hospitals three were Regional
Referral Hospitals. These were Arua, Gulu and Lira Regional Referral Hospitals.The remaining 16
Hospitals were Missionary and Government Hospitals including St. Mary’s Lacor Hospital which is the
largest Missionary Hospital with 482 beds. The other Hospitals were: St. Joseph’s HospitalMaracha,
Kuluva, Yumbe, Nebbi, Moyo, Adjumani, Kalongo, St. Joseph’s Kitgum, Kitgum General, Angal, Nyapea,
Apac, Matany, Aber, and Anaka Hospitals respectively. The location of all the hospitals was in the
Northwest (West Nile), Northern Region and North eastern region (Karamoja region) of Uganda in East
Africa. Included in the study were patients aged 13 years and above with a peri-operative diagnosis of
sigmoid volvulus who had consented to the study. Exclusion criteria included patients treated nonoperatively and those who were not followed up to the 30th postoperative day.
Data collection
In the retrospective study, data was collected from the Hospital records using research assistants. The
total number of new patients that had been operated with a diagnosis of sigmoid volvulus in the nineteen
Hospitals over the 2 year period and the total number of bowel obstructions seen in the same Hospitals
were counted and recorded. The proportion of bowel obstructions due to sigmoid volvulus out of the total
number of all bowel obstructions seen in each Hospital during the study period was determined. This was
done by manually checking and counting the number of sigmoid volvulus patients through the Hospital
admission records and further counterchecking with the list of operations conducted in the record books
of each of the operating theatres.
The same procedure was also observed to determine the surgical inpatient population as the defined
surgical population in each Hospital in order to determine the incidence of sigmoid volvulus over the
study period. The data collected was stored in a safe place to avoid unauthorized access to the research
information and backup copy was also kept safely. Regular meetings with the surgeons to cross-check for
completeness of the proforma were made and any problems that were encountered during data collection
were addressed to ensure quality assurance of the information. In the prospective study, those patients
with a proven diagnosis of sigmoid volvulus were recorded in a questionnaire designed for this study.
Ethical approval for this study was obtained from the Institutional Review Board of Gulu University,
Institutional Review Board St. Mary’s Lacor Hospital and Uganda National Council for Science and
Technology (UNCS&T). Informed consent/Assent was obtained from each individual patient taking into
consideration the principles of good clinical practice for those participating in the study.
Statistical analysis
Data analysis and interpretation was carried out using STATA/IC version 12.1.On the univariate data
analysis, thesummary statistics were displayed for categorical variables into bar graphs, tables, and pie
charts for general descriptions. Continuous variables were summarized into ranges, mean, median and
standard deviation.
Results
There were a total of 77,844 surgical admissions and 196 new cases of sigmoid volvulus over the 2 years.
This gave an incidence of 251.8 (217.8, 289.6) per 100,000 surgical population in 2 years in Northern
Uganda. Table 1 shows the incidence of sigmoid volvulus in Northern Uganda as a proportion of the total
surgical inpatient population in 19 hospitals. The hospitals in the North Western region of Uganda
included: Maracha, Moyo, Kuluva, Arua, Yumbe, Adjumani, Nyapea, Angal and Nebbi. The total number of
cases of sigmoid volvulus in these Hospitals over 2 years was 50 patients and the total number of surgical
inpatients in these Hospitals over 2 years was 25,803 patients. The incidence of sigmoid volvulus in the
North Western region (West Nile region) was found to be 193.7 per 100,000 surgical population
compared to the rest of Northern Uganda which is at 251.8 per 100,000 surgical population over the same
time period.
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Table 1. The Incidence of Sigmoid Volvulus in 19 Hospitals in Northern Uganda in 2 Years
Sigmoid
volvulus cases
Surgical Inpatient
population
2010 to 2011
2010 to 2011
Maracha
7
1,468
476.8
Moyo
5
683
732.1
Kuluva
8
2,580
310.0
Arua
17
4,803
353.9
Yumbe
6
684
877.2
Adjumani
1
1,380
72.5
Aber
13
1,577
824.4
Lira
36
11,849
303.8
Apac
9
1,233
729.9
Nyapea
2
11,367
17.6
Angal
1
2,197
45.5
Nebbi
3
641
468.0
Kalongo
4
2,952
135.5
Anaka
5
104
4807.7
Kitgum General
33
2,010
1641.8
Kitgum
Joseph’s
13
17,794
73.1
Matany
6
2,683
223.6
Gulu
2
2,029
98.6
Lacor
25
9,810
254.8
Total
196
77,844
251.8
Hospital
St.
Incidence per 100,000
population
In the North Eastern region of Uganda, Matany Hospital was the major Referral Hospital and there were 6
cases of sigmoid volvulus. The total number of surgical inpatients in this Hospital was 2,683 patients in
the same time period. The incidence in the North Eastern region of Uganda was found to be 223.6 per
100,000 surgical population.
As can be seen in table 1 the highest incidence recorded in the Northern region was from Anaka Hospital
which was found to be 4807.7 per 100,000 surgical population. The second highest incidence was
recorded in Kitgum which accounted for 1,641.8 per 100,000 surgical population. Whilst the third highest
was in Yumbe which accounted for 877.2 per 100,000 surgical population.
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Finally, the district with the lowest incidence recorded was in the West Nile district of Nebbi in Nyapea
Hospital at 17.6 per 100,000 surgical population in the same time period.
Figure 1. The Number of New Cases of Sigmoid Volvulus in The Different Hospitals in Northern Uganda
Mar = Maracha Hospital; Mo = Moyo Hospital; Kul = Kuluva Hospital; Ar = Arua Referral Hospital; Yum = Yumbe Hospital; Adj =
Adjumani Hospital; Ab = Aber Hospital; Li = Lira Hospital; Ap = Apac Hospital; Nya = Nyapea Hospital; Agn = Angal Hospital; Neb =
Nebbi Hospital; Kal = Kalongo Hospital; An = Anaka Hospital; Kit1 = Kitgum General Hospital; Kit2 = Kitgum St. Joseph’s Hospital;
Mat = Matany Hospital; Gu = Gulu Regional Referral Hospital; Lac = St. Mary’s Lacor Hospital
Figure 2. Monthly variation in the incidence of sigmoid volvulus
Jan = January; Feb = February; Mar = March; Jun = June; Jul = July; Aug = August; Sept = September; Oct = October;Nov
= November; Dec = December. Cases = number of new patients presenting with sigmoid volvulus
The total number of new cases of sigmoid volvulus was recorded for three consecutive years. Figure 1
shows that the largest number of cases of sigmoid volvulus in 3 years was seen in Kitgum District which
included 84 cases. Lira District recorded the second highest at 52 cases and Gulu was the third highest at
37 cases and the West Nile district of Adjumani recorded only 2 cases which is the lowest number of cases
recorded.
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Figure 2 shows the variation in the monthly incidence of sigmoid volvulus in Northern Uganda. The
months of December to April recorded the highest number of cases with one hundred and forty two (142)
cases over 3 years. However the months of May to September recorded a lower number at one hundred
and twelve (112) cases over 3 years.The month of April recorded the highest number of cases, thirty four
(34) cases, whilst the month of September registered the lowest number of cases, twenty four (24) cases
of sigmoid volvulus over 3 years.
Table 2. Proportion of cases of bowel obstruction that are due to sigmoid volvulus in 19 hospitals in
Northern Uganda
Hospital
Sigmoid volvulus cases
Bowel obstruction cases
% Sigmoid volvulus
Maracha
2010 to 2011
7
2010 to 2011
41
17.07
Moyo
5
10
50
Kuluva
8
55
14.54
Arua
17
90
18.88
Yumbe
6
7
85.71
Adjumani
1
81
1.23
Aber
13
22
59.09
Lira
36
72
50
Apac
9
15
60
Nyapea
2
9
22.22
Angal
1
23
4.34
Nebbi
3
11
27.27
Kalongo
4
44
9.09
Anaka
5
21
23.8
Kitgum
General
Kitgum St.
Joseph’s
Matany
33
77
42.85
13
69
18.84
6
53
18.18
Gulu
2
15
13.33
Lacor
25
119
21
Total
196
834
23.5
Table 2 shows the proportion of bowel obstructions that were due to sigmoid volvulus in the different
Hospitals in Northern Uganda. There were a total of 834 bowel obstructions in 2 years in all the Hospitals.
Therefore the proportion of bowel obstructions that were due to sigmoid volvulus in Northern Uganda
was 23.5%.
In the West Nile region the proportion of bowel obstructions that were due to sigmoid volvulus was found
to be lower at 17.2% compared to the rest of Northern Uganda. The North Eastern region registered an
even lower proportion at 8.6% compared to West Nile and the rest of Northern Uganda.The West Nile
district of Yumbe revealed the highest proportion at 85.71%. The second highest was from Kitgum
district at 61.69%. The third highest was from Apac district at 60%. Finally, the lowest proportion of
cases was seen from the West Nile district of Adjumani at 1.23%.
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Outcome of management
A total of 196 new patients with sigmoid volvulus were observed in the region over 2 years. 165(84.38%)
had a resection ad primary anastomosis; 15(7.8%) had a Hartman’s procedure, 8(3.9%) had a double
barrel colostomy, 8(4.08%) had nonoperative management with supportive treatment or enema.
8(4.08%) of patients died.
Discussion
Observation from previous studies has shown, that the incidence of sigmoid volvulus has distinct
geographical predilections and high frequencies have been reported from Africa, Asia, Latin America and
Eastern Europe16. This study determined the incidence of sigmoid volvulus in Northern Uganda which
was 251.8 per 100,000 surgical population in 2 years which is similar to that seen in other African
countries4,12.The proportion of bowel obstructions that were sigmoid volvulus in Northern Uganda was
found to be 23.5% of all bowel obstructions. This figure compares well with the proportion of cases due
to sigmoid volvulus in other East African countries in particular Kenya (22%)16. The incidence was higher
than that seen in developed countries where it only accounts for 3-5% of all bowel obstructions17.
Furthermore, the proportion of bowel obstructions that are caused by sigmoid volvulus in this study also
compares similarly with another study conducted by Shepherd et al in Central Uganda at Mulago
Hospital18.
Table 3.Proportion of Sigmoid Volvulus Relative to All Cases of Intestinal Obstruction in Different
Countries
Country
% Sigmoid Volvulus
Source
USA
1-3
Polivka, 1966
UK
2.5
Poritt, 1950
30-50
Bruusgaard, 1947
79
Asbun, 1992
India
29.7
Sinha, 1967
Nigeria
1.0
Solanke, 1968
Ethiopia
50
Johnson, 1966
Eritrea
37.6
Polivka, 2002
Uganda
20.0
Shepherd, 1967
Northern Uganda
23.5
Kenya
22.0
Eastern Europe
Bolivia
Wismayer, 2013*
Miller, 1964
*=This study
Using the number of bowel obstructions that were observed to have sigmoid volvulus actually assumes
that there are no geographical and racial differences in other types of bowel obstruction, for example
obstruction due to inguinal hernia. Certain studies have shown that there is a large difference in the
incidence of external hernia in Africa, especially of the direct inguinal hernia19.This fact together with the
retrospective nature of this study pose limitations in determining the proportion of bowel obstructions
that were due to sigmoid volvulus.Another limiting factor is that those cases of sigmoid volvulus that
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were admitted and treated non-operatively were excluded from the study as the diagnosis had to be
proven at operation and this could have underestimated the incidence in this study.
One should note that the population of Northern Uganda are mainly rural people and a large number of
them are peasant farmers20. These peasant farmers consume cereals and high fibre crops like maize,
cassava, millet, mangos and beans17. In a study carried out by Tumusiime et al in Central Uganda, this diet
was found to make them more susceptible to sigmoid volvulus8. The high consumption of these high fibre
crops may lead to increased gas formation in the bowel, predisposing them to sigmoid volvulus21.
An observation made in this study is that sigmoid volvulus occurs predominantly in Northern Uganda
during the dry season, between the months of December and April (Fig.2). Perhaps this period is related
to a diet richer in cellulose and deficient in water which may be the contributing factor to the occurrence
of sigmoid volvulus. This was an observation previously made by Polivka et al., 1966 in Eritrea.
Furthermore, there are more holidays, feasts and ceremonies in this particular season than the rest of the
year which were accompanied by heavy meals. This excess consumption of food probably explains the
high incidence of bowel obstruction due to sigmoid volvulus. The month of April saw the largest number
of cases which coincides with the dry season and festive season whist the month of September saw the
lowest number on record, with only twenty three cases recorded over 3 years however no convincing
explanation can yet be given for this observation (Fig.2).
There were differences seen among the districts in Northern Uganda with more cases being reported in
Kitgum, Lira and Gulu districts than in districts from West Nile. The incidence in the West Nile region was
found to be lower at 193.7 per 100,000 surgical population compared to 278.6 per 100,000 population
over 2 years in the rest of Northern Uganda. This study did not however examine the reasons for this
difference but possibly dietary changes and difference in altitude may possibly be playing a part.
Furthermore the districts of Kitgum, Lira and Gulu which are mainly occupied by the Acholi tribe have
better access to health facilities which may be another reason why a higher number of cases were seen in
this region of Northern Uganda.
An observation made by Shepherd et al in Central Uganda found that there were tribal differences in the
occurrence of sigmoid volvulus with the Baganda tribe in Central Uganda having the greatest incidence of
sigmoid volvulus at 50% compared with the Northern tribes (7%)18. In our study it was not possible to
include tribe as a variant for comparison, as it was not part of the objective of this study.
In South America a study has shown that the incidence of sigmoid volvulus also tends to vary with
altitude22. It has been observed that a decrease in atmospheric pressure with increasing altitude initiates
the production of methane and carbon dioxide in the bowel causing distention in a redundant sigmoid
colon to undergo volvulus22. Evidence comes from studies from South America in the Andes also
suggested that high altitude increases the incidence of sigmoid volvulus22. However, in Northern Uganda
one may not conclude that a high altitude is a contributory factor for sigmoid volvulus. The explanation is
that the altitude of the highlands in Northern Uganda are much lower at 1,200 metres above sea level
than that of the Andes Mountains which lie at 6,962 metres above sea level.The altitude recorded in
Anaka district where the highest incidence of 4,807.7 per 100,000 surgical population over 2 years was
recorded is 909m above sea level and is lower than Arua district in West Nile which lies at 1,200 metres
above sea level were a lower incidence of 193.7 per 100,000 surgical population over 2 years was
recorded. Therefore one may conclude that variation in altitude in Northern Uganda does not contribute
to the high incidence of sigmoid volvulus seen in this part of the world.
In this study the mean duration of symptoms was 2.8 days and the majority of patients presented
themselves to hospital more than 48 hours from the onset of their symptoms. The reasons partly are that
the transportation links from the countryside to the nearby hospital are very underdeveloped. The other
reason is that there is a tendency among rural communities of using local medicines by traditional healers
before seeking the help of the professional health worker. These patients often do not report to the
Hospital until they are very sick and die at home. It is therefore probable that the actual incidence of
sigmoid volvulus is higher than that determined from our study as this incidence was determined on
hospital based data and not community based data.
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Untwisting of the sigmoid volvulus from sigmoidoscopy and enema in the Hospitals in Northern Uganda
might have been carried out more commonly and a significant number of patients may have been
discharged before a confirmatory diagnosis of sigmoid volvulus was made leading to an underestimation
in the incidence of sigmoid volvulus in this study.
Conclusions
In conclusion the incidence of sigmoid volvulus in Northern Uganda was found to be 251.8 per 100,000
surgical population in 2 years. The proportion of cases of bowel obstructions that were sigmoid volvulus
in Northern Uganda was 23.4% and compares similarly with the proportion found in other African
countries and remains higher than the incidence found in developed countries.
Ethical approval
This Master of Surgery Research Project was approved by the Ethics Committees of the Institutional
Review Board of Gulu University, Institutional Review Board of St. Mary’s Lacor Hospital and Uganda
National Council for Science and Technology.
Consent
Written informed consent was obtained from all patients that participated in this Master of Surgery
Research project.
Acknowledgements
Iwish to express my sincere gratitude to Dr. David Lagoro Kitara MB ChB, MMedSurg, FCS(ECSA), Head,
Department of Surgery, Gulu University for his supervisory contribution to my study
I wish to thank Dr. David Cairns MB Chir, FRCSEd, FRCSEng for havingalways encouraged me to continue
to pursue my surgical career.Mr. Michael OkugaTabu and family from West Nile, Uganda for having
helped me to collect all the patients serum samples from all the Hospitals in Northern Uganda and
bringing them to Gulu RegionalReferral Hospital laboratory for analysis.Professor Makumbi from
Makerere University for having helped in statistical data analysis and staff in all the 19 hospitals who
were involved in data collection.Finally my parents for having supported me and helped me financially to
carry out this Master of Surgery Research project.
References
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Shepherd JJ. The epidemiology and clinical presentation of sigmoid volvulus. Br J Surg. 1969.
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Anderson JR, Lee D, Taylor TV, Ross AH. The management of acute sigmoid volvulus. Br. J. Surg.
1981; 68: 117-120.
White A. Sigmoid volvulus in Rhodesia. Ibid. 1961;38:525.
Polivka J. Volvulus of the sigmoid colon in Eritrea. Ethiop Med J. 1966; 4:201-211.
Sule A.Z., D. Iya, P.O. Obekba, B. Ogbanna, J.T. Momoh, B.T. Ugwe. One stage procedure in the
management of acute sigmoid volvulus. J. R. Coll. Surg. Edin. 1999; 44: 164-6.
Manzoor A, Zahid H, Adnan Z. Management of acute sigmoid volvulus, using one stage resection
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Gakwaya AM. The diagnosis and treatment of symptomatic redundant sigmoid colon. Proc. Assoc.
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Tumusiime G, Kakande I, N.M. Masira. Factors associated with redundant sigmoid colon at
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Munir A, Ikramulla K. Management of viable sigmoid volvulus by mesogsigmoidoplasty. Gomal J
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10. Shepherd JJ. Volvulus of the sigmoid colon. BMJ. 1968;265.
11. Waterhouse H.F. An address on Volvulus. Br. Med. J. 1909: 1277-1280.
12. Mehari H. Management of sigmoid volvulus in Eritrea using primary anastomosis. South Afr J
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13. Kakande I, Ekwaro L, Obote WW, Nassali G, Kyamonywa P. Intestinal volvulus at St. Francis
Hospital, Kampala. East. Centr. Afr. J. Surg., 2002; 6(1): 21-24.
14. Okello TR, Ogwang DM, Kisa P, Komagum P. Sigmoid volvulus and Ileosigmoid knotting at St.
Mary’s Hospital, Lacor in Gulu, Uganda. East. Centr. Afr. J. Surg. 2009; 14 : 58-64.
15. Sabiston. The biological basis of modern surgical practice, 14th edn.Philadelphia: WB. Saunders
1991: 1360-1361.
16. Mariette D, Sbai – Idrissi S, Bobocescu E, Vons C, Franco D, Smadja C. [Laparoscopic colectomy:
technique and results] [French]. J. de Chirurgie 1996; 133: 3-5.
17. Wertkin MG and Augses A.H: Management of volvulus of the colon. Dis. Colon Rectum 1978: 21:
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18. Shepherd JJ. Management of sigmoid volvulus. East Afr Med J. 1963;1(4): 174-6.
19. Boggs HW, Ratcliffe HH. Volvulus of the Sigmoid colon. South Med J. 1960; 53: 1039 – 1042.
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Uncovering the Burden of Urologic Disease: Admissions Patterns at the Main Teaching Hospital of
Ethiopia
I Feldhaus1, G W Temesgen2, A Laytin1, A Y Odisho3, A D Beyene2.
1Center for Global Surgical Studies, Department of Surgery, School of Medicine, University of California,
San Francisco, San Francisco, CA, USA
2Tikur Anbessa Specialized Hospital, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
3Department of Corresponding Urology, School of Medicine, University of California, San Francisco, San
Francisco, CA, USA
Correspondence to: Andualem Deneke Beyene, Email: [email protected]
Background: Limited data exists profiling the urologic needs of populations in sub-Saharan Africa.
As the region builds training programs for urology, such data can inform strategic program
planning and investment. The objective of this study was to describe admissions patterns for
urologic disease at an academic medical center in Ethiopia.
Methods: Retrospective review of admission, discharge, and operative logs of the urology service
from November 2011 to October 2014 was conducted at Tikur Anbessa Specialized Hospital. Data
were collected on patient demographics, length of hospital stay, specific diagnoses, condition
classifications, and procedures performed, generating descriptive statistics.
Results: A total of 1,149 urologic procedures were reviewed. Patients were predominantly male
(74%) with median age of 43 years. The most common condition was urolithiasis (31%), followed by
malignant tumors (25%) and benign tumors (14%). Almost half of patients underwent open
surgical procedures (47%). Median inpatient stay was 14 days.
Conclusions: The breadth and volume of patients treated hints at the large, unmet burden of urologic
disease in Ethiopia. A large percentage of patients underwent open procedures and had prolonged
inpatient lengths of stay. Continued research to understand urologic disease patterns and increase
access to specialty care in this setting is needed.
Keywords: Ethiopia; Sub-Saharan Africa; Urological Surgical Procedures; Health Care Utilization;
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.13
Introduction
Global burden of disease estimates indicate that kidney and urinary tract diseases are responsible for
830,000 deaths and 18,467,000 disability-adjusted life-years (DALYs) each year, accounting for 1.4% and
1.0% of global mortality and disability, respectively1. The limited existing evidence suggests a
considerable burden of urologic disease in sub-Saharan Africa. A study of urologic disease in West Africa
determined that urologic diseases comprised a significant proportion of surgical disease and surgical
interventions2. Another study in Malawi concluded that cancer, 25.5% of which was urologic in nature,
comprised a significant proportion of surgical caseload in low-income countries3. Adequate care delivery
for such diseases is an essential component of a functioning health systemand critical to achieving the
goal of universal health coverage4.
Despite this burden, low- and middle-income countries (LMICs) often lack resources crucial to addressing
surgical disease, including appropriate infrastructure, skilled human resources for health, and
equipment5. As in much of sub-Saharan Africa, Ethiopia faces critical resource constraints for appropriate
surgical care. Access to prompt surgical care is limited by numerous challenges, including the significant
distances patients must travel to receive treatment and insufficient infrastructure, such as electricity,
water, central oxygen supply, and blood banks6.
One of the most significant barriers to adequate surgical care is the lack of healthcare providers. The
national health worker ratio per 1,000 population is 0.84, considerably below the 2.3 per 1,000
population minimum threshold set by the World Health Organization7, 8. In a study of five medical schools
in Ethiopia, the most commonly sought specialty training was general surgery6. However, the country
continues to have an especially large deficit of surgeons. Studies in Ethiopia suggest that rates of surgery
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are very low, consistent with the severe shortage of health workers providing surgical services9. This is a
common problem across LMICs. While Ethiopia has few physicians serving large populations, there are
even fewer specialists, with only one specialist per 100,000 population in the country in 20097. Patients
seeking care for urologic disease may have better outcomes when receiving care from specialists as
opposed to general surgeons or practitioners10.
Understanding the true burden of urologic disease is the first step towards evaluating how to address
gaps in service provision and care delivery – for Ethiopia and the region. There is extremely limited data
available profiling the needs of the population with regards to urologic diagnoses in sub-Saharan Africa11.
As Ethiopia and other countries in the region build training programs for urology, this information can
inform strategic program planning and investment. While there are inherent difficulties in measuring the
true prevalence of urological disease in resource-poor settings due to widespread unmet surgical need,
review of hospital admissions records can reveal valuable preliminary information for strategic health
planning and development for improved surgical care systems12. The objective of this study was to
describe admissions patterns for urologic disease at a public academic medical center in Ethiopia to begin
characterization of the urologic disease burden in the country.
Patients and Methods
Located in the Horn of Africa, Ethiopia is the second most populous country in Africa spanning 1.1 million
km2with a population of over 99.6 million and an estimated 29.6% living below the national poverty
line13, 14. With less than three physicians per 100,000 inhabitants, Ethiopia struggles with a general
shortage of health workers alongside concerns regarding appropriate skill-mix and distribution of
workers7, 15. In 2011, 45% of the total number of physicians and 28% of nurses work in Addis Ababa, the
country’s capital15. Ethiopia has very few urologists, and until 2009, all urologists were trained abroad.
In 2009, the first urology residency program and fellowship in urology for general surgeons was
established at Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa. TASH is a tertiary academic
referral center and the main teaching hospital of the Addis Ababa University Faculty of Medicine. A
retrospective analysis reported that surgical admissions comprised 35% of all TASH admissions;
urological admissions accounted for 20% of all surgical admissions and 5% of surgical mortality16.
At the time of data collection, TASH was the only public hospital providing urology referral services in the
country. While local general surgeons manage most urologic conditions presenting in rural areas,
particularly complex cases and those who can afford to seek further care are referred to TASH or other
private facilities. The urology service housed at TASH maintained two wards totaling 40 to 50 inpatient
beds and two operating rooms.
Data collection
This was a retrospective review of records of urologic admissions at the Urology Unit of TikurAnbessa
Specialized Hospital (TASH) between November 2011 and October 2014. A trained researcher
retrospectively collected data on patient demographics, length of hospital stay, urologic diagnoses,
condition classifications, and procedures performed. Data sources included operating room, admission,
and discharge registers at TASH. Data was collected from available existing registers in which information
is recorded as routine administration of care at TASH. Collected data was also de-identified for analysis.
For these reasons as well as unreasonable difficulty in re-contacting patients recorded in registers,
informed patient consent was not sought for inclusion in this retrospective review.
In light of study aims to understand admission patterns for urologic conditions at TASH, only the primary
procedure requiring admission was recorded. These data include all admitted patients over the age of
13 years; those under 13 years of age are seen by pediatric surgeons and are not considered urologic
admissions in this setting. Patients who were admitted, then deemed unfit for surgery and subsequently
discharged, were excluded from review.
The term “benign tumors” used in data collection indicated a number of benign conditions, namely benign
prostatic hyperplasia (BPH), benign kidney cysts, renal oncocytoma, and angiomyolipomas. Urinary tract
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infections (UTIs) that were documented refer only to UTI diagnoses associated with underlying surgical
conditions as the majority of other UTI diagnoses are treated by internal medicine specialists. As these
patients are not admitted for surgical care, UTI classification in data sources do not include simple
pyelonephritis.
Statistical analysis
Statistical analyses were performed using SPSS 22 and Stata 13. Descriptive statistical analyses were
conducted to determine frequencies and reveal trends across variables.
Ethical review
This study was conducted through collaboration of TASH, an academic tertiary facility affiliated with
Addis Ababa University (AAU), in Ethiopia and the University of California, San Francisco (UCSF) in the
United States. This retrospective review received ethical approval from the AAU Institutional Review
Board and UCSF Committee on Human Research.
Results
Between November 2011 and October 2014, a total of 1,149 urologic procedures were performed. The
mean and median age of patients was 44 years (SD=17.14) and 42.5 years [IQR=30, 56], respectively.
Figure 1 illustrates the age distribution of the patient sample. A quarter of urologic admissions were
female, while the remaining 75% were male. The median duration of inpatient stay was 14 days
[IQR: 10, 22]. Diagnosis categories of patients admitted to the TASH urology service are summarized in
Table 1. Urolithiasis comprised the greatest number of total urologic admissions (n = 360, 31%). Of
urolithiasiscases, 73% of patients underwent unilateralupper tract procedures, 25% underwent
bilateralupper tract procedures, and 2% were treated for bladder and urethral stones.
Table 1. Frequency and Percentage of Diagnoses among Urologic Admissions (N=1,149)
Diagnosis
Number
Percentage
Urolithiasis
360
31.3
Malignant tumors
282
24.5
Benign
161
14.0
Congenital
117
10.2
Urethral stricture
61
5.3
Obstructive uropathy of unknown etiology
65
5.7
UTI
15
1.3
Trauma
9
0.8
Other
79
6.9
The second most common cause of urologic admissionswas for malignancy (n = 282, 25%), the majority
of which were urothelial and non-urothelial bladder cancer (67%) followed by kidney cancer (24%). The
remainder consisted of prostate cancer (5.0%), testis cancer (2%), penile cancer (1%), and upper tract
urothelial cancer (0.4%)(Figure 2).BPH and benign tumors accounted for 161 admissions
(14%).Congenital abnormalities accounted for 117 urologic admissions (10%), 59.4% of which were due
to ureteropelvic junction obstruction. Urethral stricture made up 5% of cases, obstructive uropathy of
unknown etiology comprised 6%, and UTIs were 1% of urologic diagnoses.
During the study period, 543 patients (47%) underwent open surgical procedures. Of these, 49% were
renal surgeries, 21% were bladder procedures, and 10.7% were urethral procedures (Table2). For
another 511 cases, endoscopic procedures were performed. Procedures performed for kidney stones
diagnoses were ureteroscopy (14% of total urologic cases recorded), percutaneous nephrolithotomy
(PCNL) (4%), and extracorporeal shock wave lithotripsy (ESWL) (0.2%)(Table 2).
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Table 2. Urologic procedures performed at TASH (N=1,149)
Procedure
Number
Percentage
543
47.3
264
23.0
Testis
29
2.5
Ureter
25
2.2
Urethral
58
5.0
Penile
21
1.8
Bladder
112
9.7
Combined
14
1.2
Other
20
1.7
Endoscopic
511
44.5
Ureteroscopy
157
13.7
PCNL
41
3.6
ESWL
2
0.2
56
4.9
30
2.6
Open surgery (site)
Renal
Kidney Stones
Prostate Tumor
TURP/TUIP
Ureter Obstruction
Stent
Bladder Tumor
Cystoscopy
13
1.1
TURBT
166
14.4
4
0.3
9
0.8
Urethral Stricture
Bladder neck incision
Combined
Other
No Intervention
33
2.9
95
8.2
Key: DALYs =Disability-adjusted life years. ESWL = Extracorporeal shock wave lithotripsy. LMICs = Low- and middleincome countries. PCNL= Percutaneous nephrolithotomy. . TUIP = Transurethral incision of the prostate. TURBT
=Transurethral resection of bladder tumor
Figure 1. Age distribution of urologic admissions
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Figure 2. Types of Malignant Tumors Diagnosed (n=282)
The relatively low proportionof ESWL procedures may be attributable to the fact that the extracorporeal
shock wave lithotripter at TASH was not properly functioning for the majority of the study period.Less
than 5% of urologicpatients underwent transurethral resection or transurethral incision of the prostate
(TURP/TUIP). Stents for ureteral obstruction were places in 3% of cases. 166 patients underwent
transurethral resection of bladder tumor (TURBT) (15% of total urologic cases). Bladder neck incision
was performed for bladder neck contracture or stenosis for 0.4% of urologic cases.
Discussion
Retrospective review of hospital records demonstrates the considerable patient volume, burden of
urologic disease, and scope of urology services at TASH. During the study period, the majority of case
volume consisted of managing urolithiasis and urologic malignancy. Benign tumor diagnoses also made
up a considerable proportion of urologic cases at 14%, notable because of the significant morbidity
associated with BPH when left untreated.
The majority of urologic admissions were male. This may be because female urogynecologic conditions
are more commonly managed in departments and centers specifically for obstetrics, gynecology, and
fistula care. On the other hand, it would be worth investigating the possibility that unidentified barriers to
care or different care seeking behaviors among women exist in Ethiopia.
Open surgery was the management strategy most often used to treat urologic patients and these
surgeries were most often renal procedures. These high rates of open surgical procedures significantly
diverge from trends in high-income settings, where less than 5% of patients are treated by open
methods17. A lack, shortage, and/or malfunctioning of endourologic instruments as well as the shortage of
experts for particular endourologic procedures at any given time contribute to the high rates of open
surgical procedures in this setting. For example, only 0.2% of procedures performed were ESWL as a
result of non-functioning equipment for the majority of the study period. Increasing capacity for
endoscopic procedures could result in improved outcomes and reduced length of stay among these
patients. Delayed care-seeking among this patient population may also contribute to patients with more
advanced pathologies requiring open surgical intervention presenting to TASH. Previous urological
studies at TASH indicate that urolithiasis is a major reason for urologic admissions, and is commonly
complicated by renal failure17. This may also suggest late patient admission or insufficient medical
facilities for appropriate care and treatment of urologic disease.
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Study findings parallel those across sub-Saharan Africa. A recent study by the British Association of
Urological Surgeons surveying urologists and general surgeons working sub-Saharan Africa reported
most common urological conditions to be BPH, urethral stricture, prostate cancer, bladder cancer, and
urethral or ureteric trauma12, 17, 18. A study in Nigeria from 2002 determined that there is a significant and
increasing burden of urologic disease in the country with the majority of treatment being invasive
reconstructive surgery2. Open prostatectomy remains the most common approach for prostatomegaly in
this setting2. In this study, bladder and prostate cancer accounted for a majority of tumors, while 95% of
patients presented with advanced cancer2. A similar situation may exist in Ethiopia, giving context to the
high rates of open surgery as treatment for urologic disease.
Review of the logbooks at a tertiary referral center in Malawi found that cancer surgery makes up a
significant proportion of surgical caseload3. Worldwide estimates identify cancer as the second leading
cause of death in developing countries, while global trends suggest that many seek or are admitted to care
late, do not seek medical care at all, or do not receive referrals for cancer treatment19. As TASH remains
Ethiopia’s only cancer referral center, and only public hospital providing urology referral services, it is
likely that a significant burden of cancer remains unmet in the country.
Limitations of this study include those associated with the collection of data through the retrospective
review of records. Data sources were limited in detail, and only reflect complex cases that received
specialist urology care. Patients under 13 years of age were treated by pediatric surgeons and are not
included in this analysis. Similarly, UTIs were commonly treated by internists are not addressed here.
Data on complications including infection may also be underreported as only primary diagnoses are
recorded; additional infections or complications, such as BPH with cystitis, for example, is not regularly
recorded in hospital records. Finally, because this is a hospital-based study, we cannot comment on the
full extent of urologic needs of the larger population in Ethiopia, or on patients who received urologic
care through the private sector.
This review highlights the significant burden of urologic disease in this population. While this study
provides only an overview of urologic disease in Addis Ababa and surrounding areas, there is a clear need
for increased awareness of urologic need alongside appropriate investment in measures to build
infrastructure and human resources to effectively address this need. The establishment of the urology
residency and fellowship programs at TASH is an important first step toward addressing the increasing
demands on the health system. Still, awareness and advocacy for these programs are necessary to
effectively build capacity.
Continued research is critical for a comprehensive understanding of population needs andstrategic
development of appropriate infrastructure and services. For example, a study addressing whether
treatment choices were dictated by disease severity or resource availability would help to prioritize
systems development strategies. Investigating the underlying reasons for under-diagnosis, late
presentation, and delayed care may reveal critical opportunities to improve access to care in this setting.
Focused research into the effectiveness of care being provided for urologic diseaseis key to strengthening
surgical care systems. Population-level research aimed atassessing needs for urologic services, and how
institutions such as TASH can address these needs, can build on the foundation laid by this study to
inform evidence-based resource allocation and improve the quality of urologic care and services.
Conclusion
Urologic surgery is most often performed to treat urolithiasis and malignant tumors at TASH.Open,
invasive surgery has consistently been the primary management strategy in addressing patients’ urologic
needs. This may indicate a high proportion of patients presenting to TASH with urologic diagnoses arrive
to the hospital in late stages of disease, prompting the necessity of invasive treatments.Admissions
patterns suggest various potential barriers to accessing care for urologic disease.
Based on hospital admissions patterns, this study describes a large caseload for urologic disease that
results in significant morbidity, mortality and healthcare expenditure. Yet, this is only the first step
toward uncovering the burden of urologic disease in the region.
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Findings allude to the potentially high burden across sub-Saharan Africa. However, urologic disease
israrelyaddressed in the global conversation about the burden of surgical disease in LMICs. There is a
clear need to better understand the true burden of urologic disease in these settings. Trends in disease
prevalence call for greater strategic planning and investment in health system development and capacity
building for urology. Continued research aimed at characterizing broader urologic disease patterns and
increasing access to quality medical care for urologic disease is necessary to inform strategies for its
effective management in Ethiopia and similar settings.
Acknowledgements
We would like to acknowledge the efforts and support of the providers and staff at TikurAnbessa
Specialized Hospital for this research. We would also like to thank the UCSF Center for Global Surgical
Studies for its support in this research endeavor.
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Factors Influencing Outcome of Sigmoid Volvulus in Northern Uganda. A Prospective
Observational Study
Richard Wismayer1, 2
of Surgery, Faculty of Medicine, University of Edinburgh, United Kingdom
2Faculty of Medicine, Gulu University, Gulu, Uganda
Correspondence to: Dr. Richard Wismayer, Email: [email protected]
1Department
Introduction: Sigmoid volvulus (SV) is one of the commonest causes of intestinal obstruction in
Uganda. The purpose of this study was to determine the factors influencing the outcome of SV in
Northern Uganda.
Methodology: A prospective observational study was conducted on 103 sigmoid volvulus patients
admitted between January 2012 to December 2012 and surgically managed in 19 hospitals in
Northern Uganda and followed up postoperatively for 30 days. Surgical management was by
resection and primary anastomosis or Hartmann’s procedure or double barrel colostomy. Patients
13 years and above with sigmoid volvulus and who had consented/Assented were included in the
study and followed up to the 30th postoperative day. Ethical approval for the study was obtained
from the Institutional Review Committee of Gulu University and Uganda National Council for Science
and Technology. Data analysis was carried out using STATA/IC version 12.1. The outcome events
were uneventful recovery, morbidity and mortality.
Results: Eighteen(17.48%) patients developed complications including wound sepsis 10 (9.7%);
wound dehiscence 8(7.7%) and anastomotic leak 8(7.7%). There were 8 deaths, giving a mortality
rate of 7.7%. The factors associated with a high risk of adverse outcome were hypernatraemia
(RR=14.9; 95% CI: 1.46-152.9) and ileo-sigmoid knotting (RR = 4.94; 95% CI: 1.30-18.78). Resection
and primary anastomosis had a better outcome compared to Hartmann’s procedure (RR=0.15; 95%
CI: 0.02-0.099).
Conclusion: The risk factors associated with morbidity and mortality were preoperative
hypernatraemia and ileo-sigmoid knotting. Colostomy was associated with a higher risk of
morbidity and mortality than resection and primary anastomosis.
Keywords: Sigmoid volvulus, factors, influence, outcome
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.14
Background
Sigmoid volvulus is a common cause of intestinal obstruction in developing countries and one of the
commonest causes of intestinal obstruction in Uganda1,2. However, in the developed world, sigmoid
volvulus is uncommon accounting for about 5% of all cases of large bowel obstructions3. In the
developing world, sigmoid volvulus constitutes 50% of large bowel obstructions4,5,6 and a multi-factorial
aetiology has been implicated mainly food containing a high fibre diet and pre-existing redundant
sigmoid colon7,8. In Uganda the basic foods include cassava, rice, millet, porridge, peas, soya, beans,
oranges and mangoes which are high in fibre and have all been implicated in the aetiology of sigmoid
volvulus2. It is postulated that this high fibre diet leads to a shortened intestinal transit time leading to a
redundant sigmoid colon to undergo volvulus9. Studies conducted in Central and Eastern Uganda found
that sigmoid volvulus affects mostly the Baganda, Basoga and Bagisu tribes however, Nilotics where this
study was conducted, it was believed that they least often suffered from sigmoid volvulus10.
Prolonged civil war, poverty, lack of specialist care and patients’ unawareness in Northern Uganda may
have contributed to the delay in reporting to hospital with acute sigmoid volvulus with the result that
more advanced stages of bowel obstruction were often seen11. The obstructed bowel may become
gangrenous as a result of strangulation, and this may lead to intestinal perforation, peritonitis and
sepsis12. It was safer when the bowel was gangrenous to resect and leave a temporary stoma however,
colostomy management is a problem in many rural areas because of unacceptability, unavailability and
unaffordability of colostomy bags13. Resection and primary anastomosis was therefore carried out even
when there is a gangrenous portion of sigmoid colon that has been resected with the result that they may
experience increased morbidity from anastomotic leaks14. A study conducted in Africa has shown that coCOSECSA/ASEA Publication - East and Central African Journal of Surgery. December 2016; Vol. 21 No. 3
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morbidity is one of the most important determinants of outcome of sigmoid volvulus14. Many other
studies have shown that most deaths are due to co-morbidities example cardiovascular disease, chronic
respiratory disease and cancer15,16. Pre-operative shock on admission has been found to be associated
with a poorer outcome of morbidity and mortality14.
In a recent study conducted at St. Mary’s Lacor Hospital in Northern Uganda it was found that age and comorbidities were the main factors influencing outcome similarly to findings in Western countries11
however, many factors including the haemoglobin concentration, white blood cell count, electrolyte
pattern, vital signs, length of gangrenous sigmoid colon, presence of major peritoneal contamination,
grade of surgeon and importantly the delay in hospital admission were not examined in that study.
Hence the purpose of this one year prospective study was to determine the factors that influence outcome
of management of sigmoid volvulus in Northern Uganda.
Ptients and Methods
This was a prospective observational study which was conducted from January to December 2012 on a
30-day cohort of postoperative sigmoid volvulus patients.
Nineteen out of twenty Hospitals which serve 95% of the population of Northern Uganda recruited
sigmoid volvulus patients consecutively. Of these Hospitals three were Regional Referral Hospitals. These
were Arua, Gulu and Lira Regional Referral Hospitals. The remaining 16 Hospitals were Missionary and
Government Hospitals including St. Mary’s Lacor Hospital which is the largest Missionary Hospital with
482 beds. The other Hospitals were: St. Joseph’s Maracha, Kuluva, Yumbe, Nebbi, Moyo, Adjumani,
Kalongo, St. Joseph’s Kitgum, Kitgum General, Angal, Nyapea, Apac, Matany, Aber, and Anaka Hospitals.
The location of all the hospitals was in the Northwest (West Nile), Northern Region and North eastern
region (Karamoja region) of Uganda, in East Africa.
The study population consisted of patients aged 13 years and above and with a peri-operative diagnosis
of sigmoid volvulus and had given an informed consent by themselves or by gurdianco. The patients were
recruited consecutively in each of these hospitals in Northern Uganda. Exclusion criteria included
patients treated non-operatively and those who were not followed up to the 30th postoperative day.
Patients’ data was collected using a questionnaire on the following variables: patients’ socio-demographic
characteristics, period of symptoms prior to admission, co-morbidities, haemoglobin concentration, white
blood cell count, electrolyte pattern, vital signs (preoperative heart rate and blood pressure), type of
operation, presence of peritoneal contamination, length of gangrenous sigmoid colon, the presence of
ileo-sigmoid knotting and grade of the surgeon.
The sample size for the prospective cohort study was calculated to be 98 patients. The sample size was
increased by 5% to account for possible loss to follow up or non-response to the questionnaire and thus a
total of 103 patients were recruited.The morbidity was determined by recording the postoperative
complications over a 30-day period. This was done by conducting ward rounds twice a day while
monitoring and investigating the presence of any particular morbidity being suspected during the whole
study period. Mortality during this period was promptly investigated by conducting a postmortem
examination and obtaining samples to determine the possible causes of death.Surgeons and staff involved
in the study were trained to use a standard operative protocol. Trained research assistants transported
serum samples for electrolyte analysis within 48 hours from all the Hospitals while maintaining a cold
chain system to the central Laboratory of Gulu Regional Referral Hospital. A standard calibrated machine
was used for analyzing the serum electrolytes and the results recorded in the questionnaire.
At laparotomy a suture was used to measure the length of gangrenous sigmoid colon which was then
transferred to tape measure to determine the length of gangrenous sigmoid colon in centimeters. Being a
multi-institutional study the operative procedure was standardized as much as possible by training the
surgeons to use vicryl 2/0 and anastomose the bowel in double layers. Colostomy was also constructed
using vicryl 2/0.
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The outcome of the surgical management of sigmoid volvulus included uneventful recovery, morbidity
and mortality. The primary outcome for the study was a composite measure of morbidity and mortality.
Ethical approval was obtained from the Institutional Review Board of Gulu University, Institutional
Review Board of St. Mary’s Lacor Hospital and Uganda National Council of Science and Technology
(UNCS&T). Informed consent/Assent was obtained from each individual patient taking into consideration
the principles of good clinical practice.
Data analysis and interpretation was carried out using STATA/IC version 12.1. At univariate data analysis,
the summary statistics were displayed for each key variable assessed against the outcome in order to
obtain the relative risk (RR) at bivariate analysis. The associations between various independent and
outcome variables was determined. Factors associated with postoperative outcome were calculated using
chi-squared tests at 95% confidence intervals.
Multivariate logistic regression analysis was conducted to determine the factors independently
associated with outcome. This was done by adjusting for factors with potential or actual confounding, as
well as interaction. Variables in the bivariate model with p-value less than 0.2, or with a Relative Risk
(RR) less than 0.5 or more than 2.0 (0.5<RR>2.0), or potential confounders were included in the final
adjusted model. Any p-value less than 0.05 was taken as statistically significant.
Results
A total of 103 cases of sigmoid volvulus were recruited, managed and results eventually analyzed. The
patients’ ages ranged from 14-93 years, with a mean of (43.79 +/- 17.77) years. The mean age was 46.21
years for males and 37.54 years for females (p=0.036). There was a predominance of male 77 (74.8%)
patients over female 26(25.2%) patients. The male to female sex ratio was 3:1.
The distribution of the patients by age groups was the following: 14-24 years 19(18.5%); 25-34 years
13(12.6%); 35-44 years 10(9.7%); 45-54 years 24(23.3%); 55-64 years 18(17.5%); 63-93 years
19(18.5%).
Fig.1. Age and Sex Ditribution
Vertical axis = number of new male and female patients with sigmoid volvulus
Horizontal axis = age ranges of patients with sigmoid volvulus
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The proportion of male patients increased with age and in all age groups there was a male predominance.
In the 65-93 year age group 94.7% of patients were male and 5.26% were female. The proportion of
female patients were highest in the 45-54 year age group however this was still lower than the
proportion of male patients (Figure 1). The majority of patients, 61(59.2%), presented more than 3 days
from the onset of symptoms. Only 42 (40.7%) of the patients presented within less than 3 days from the
onset of their symptoms.
Pre-operative and post-operative antibiotics were given to all patients which included different
combinations of antibiotics all given intravenously. There were three types of major surgical operations
offered to patients with sigmoid volvulus. A total of 91(88.3%) of patients, had resection and primary
anastomosis; 7 (6.8%) had a Hartmann’s procedure and 5(4.9%) patients had resection and double barrel
colostomy.
Post-operative complications included wound sepsis 10 (9.7%), wound dehiscence 8(7.7%), anastomotic
leaks 8(7.7%), colostomy complications 7(6.8%), chest infections 6(5.8%), septic shock 6(5.8%), cardiac
arrest 1(0.97%), hypertension 2(1.94%), abdominal abscess 1(0.97%), enterocutaneous fistula 1(0.97%)
and urinary tract infection 1(0.97%) (Figure 2).
There were 8 deaths which gave a 7.7% mortality rate. The causes of death were: septic shock in 7 (6.8%)
patients and cardiac arrest in 1(0.97%) patient.
Factors that potentially influenced outcome of Management of Sigmoid volvulus
Table 1 shows the final model of the multivariate analysis showing the individual factors which
influenced the outcome.
Socio-demographic factors
Age: Increasing age was associated with an increased risk of developing an adverse outcome. In the
adjusted analysis, the risk of an adverse event was higher among 65-93 year old patients relative to 14-44
year patients (adj. RR=2.45; 95% CI: 0.44-13.16), however this was not statistically significant (p=0.308)
(Table 1).
Figure 2.
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Table 1
%
Morbidity/
Mortality
Unadjusted RR*
Adjusted RR*
P-value for
the
adjusted
Ratios
95%CI
Ratios
95%CI
12.5
17.4
1.0
1.39
0.33,5.91
1.0
2.48
0.47,13.11
0.285
7.9
18.0
31.3
1.0
2.27
3.96
0.58,8.88
0.81,19.39
1.0
0.78
2.42
0.27,2.26
0.44,13.16
0.644
0.308
54.6
11.0
1.0
0.20
0.07.0,0.58
1.0
0.24
0.02,2.35
0.219
10.3
20.0
22.2
1.0
1.95
2.17
0.49,7.72
0.78,6.02
1.0
1.31
1.56
0.35,4.94
0.37,6.52
0.693
0.542
10.0
16.9
1.0
1.69
0.22,12.69
1.012
2.86
0.67, 12.16
0.154
17.7
20.0
22.7
1.0
0.28
1.29
0.04,1.90
0.46,3.58
1.0
0.23
0.32
0.04,1.27
0.04,2.33
0.091
0.259
Overall
Variables
Sex
Female
Male
Age-group
14-44
45-64
65-93
Grade of Surgeon
Consultant
SMO/ MO/Registrar
Duration of symptoms
< 3 days
3 - 6 days
7 or more days
Pre-op BP and Pulse
Normal
Abnormal
Length of gangrene
0 cm
1 – 18 cm
>18 cm
Pre-operative
serum
sodium
Normal,135-145
16.1
8.7
1.0
Hyponatraemia,<135
Hypernatraemia, >145
Type of Operation
Hartmann
Resection
Double barrel
Presence
of
ileosigmoid knot
No
Yes
Faecal contamination
No
Yes
Post-operative serum
sodium
Normal
Abnormal
Post-operative serum
potassium
Normal, 3.5-5
Hypokalaemia >5
Hyperkalaemia <3.5
18.5
20.0
2.12
2.30
0.87, 5.17
0.20,26.30
3.33
14.9
0.44,25.47
1.46,152.9
0.246
0.023
66.7
9.8
60
1.0
0.15
0.67
0.078, 0.27
0.52, 0.85
1.0
0.15
3.59
0.02, 0.99
0.08,167.3
0.048
0.514
13.4
36.4
1.0
2.71
0.95, 7.76
1.0
4.94
1.30, 18.78
0.019
16.9
10.0
1.0
0.59
0.10, 3.68
1.0
0.20
0.03, 1.48
0.115
12.0
17.7
1.0
1.47
0.72, 2.99
1.0
3.16
0.38, 26.38
0.288
21.4
8.3
7.7
1.0
0.39
0.36
0.15, 1.02
0.06, 2.17
1.0
0.54
1.20
0.17, 1.66
0.54, 2.66
0.282
0.659
1.0
Where RR* = relative risk; BP = Blood Pressure
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Sex: In the adjusted analysis, the risk of an adverse event tended to be higher among male compared to
female patients (adj. RR=2.48; 95% CI: 0.47-13.11), however this association was not statistically
significant (p=0.285) (Table 1).
Period of symptoms prior to admission
The mean overall duration of symptoms prior to admission was (2.82 +/-1.56) days. In the adjusted
analysis patients that had symptoms for >3 days but <6 days had a risk of adverse outcome (adj. RR=1.31;
95% CI: 0.35-4.94), however this was not statistically significant (p=0.693). In the adjusted analysis,
when the duration of symptoms was more than 7 days the risk increased even further (adj. RR=1.56; 95%
CI: 0.37-6.52), however this was not statistically significant (p=0.542) (Table 1).
Vital signs
A normal pre-operative heart rate was taken as between 60-80 beats per minute. The mean pre-operative
heart rate was (86.5 +/- 13.8) beats per minute. A normal pre-operative blood pressure was in the range
of 110/70 mmHg to 130/85 mmHg. The mean systolic blood pressure was (117 +/- 22.8) mmHg whilst
the mean diastolic blood pressure was (71.2+/- 15.1) mmHg. In the adjusted analysis, abnormal preoperative vitals were associated with an increased risk of developing an adverse outcome (adj. RR=2.86;
95% CI: 0.67 – 12.16), however this was not statistically significant (p=0.154) (Table 1).
Haemoglobin Level
The normal range of haemoglobin in males was taken as 13.5 – 16.5 g/dl for males and 12.1 – 15.1 g/dl
for females. The mean preoperative haemoglobin concentration was found to be (13.7+/- 2.1) g/dl. In the
bivariate analysis, a low preoperative haemoglobin concentration tended to have a lower risk of adverse
event (unadj.RR=0.89; 95% CI: 0.19-4.21). The mean postoperative haemoglobin was found to be
13.2g/dl (SD +/-2.45). In the bivariate analysis a low postoperative haemoglobin was found to have a risk
of adverse event (unadj. RR=2.04; 95% CI: 0.57-7.30).
White blood cell count
The normal white blood cell count was taken as 4.3 – 10.8 x 109/ul. A white blood cell count of 11 x 109
/ul was considered a leukocytosis. The mean pre-operative white cell count was (9.9 x 109+/- 4.5 x
109)/ul. In the bivariate analysis a pre-operative leukocytosis was not found to influence outcome (unadj.
RR=0.97; 95% CI: 0.34-2.80). The mean postoperative white cell count was (10.3 x 109+/- 4.28 x 109)/ul.
In the bivariate analysis a postoperative leukocytosis tended to have a lower risk of adverse outcome
(unadj.RR=0.86; 95% CI: 0.31-2.34).
Serum sodium levels
The normal serum sodium levels were taken as between 135-145 mmol/L. A value above 145mmol/L
was taken as hypernatraemia and a value below 135 mmol/l was taken as hyponatraemia. The mean
preoperative serum sodium levels were found to be (132.3+/- 12.8) mmol/l. In the adjusted analysis,
hyponatraemia (<135 mmol/l) was found to have a risk of adverse outcome (adj.RR=3.33; 95% CI: 0.4425.47) but this was not statistically significant (p=0.246). Patients presenting with a preoperative
hypernatraemia (>145 mmol/L) were found to have a high risk of adverse outcome (adj. RR=14.9; 95%
CI: 1.46-152.9) and this was statistically significant (p=0.023). The mean postoperative serum sodium
level was (131.6 +/-7.55) mmol/l. There were only four (4) patients with a post-operative
hypernatraemia so that these were combined with the sixty four (64) patients with a post-operative
hyponatraemia and were analyzed as a combined abnormal serum sodium level. In the adjusted analysis,
an abnormal post-operative sodium level was found to have a high risk of adverse outcome (adj. RR=3.16;
95% CI: 0.38-26.38) however this was not statistically significant (p=0.288) (Table 1).
Serum potassium levels
The normal serum potassium levels were taken as between 3.5-5 mmol/L. A value above 5mmol/l was
taken as hyperkalaemia and a value below 3.5 mmol/L was taken as hypokalaemia. The mean
preoperative serum potassium level was found to be (4.2+/- 2.1) mmol/l. In the bivariate analysis,
preoperative hyperkalaemia was not found to have an adverse outcome (unadj. RR = 0.94; 95% CI: 0.34 –
2.57). The mean postoperative serum potassium level was (4.08+/-0.86) mmol/l. In the adjusted analysis,
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postoperative hyperkalaemia was associated with a higher risk of adverse outcome (adj. RR=1.20; 95%
CI: 0.54-2.66) however this was not statistically significant (p=0.659). Although postoperative
hypokalaemia tended to have a lower risk of adverse event (adj.RR=0.54; 95% CI: 0.17-1.66) this finding
was not statistically significant (p=0.282) (Table 1).
Serum chloride levels
The normal serum chloride levels were taken as between 98-108 mmol/L. A value above 108 mmol/L
was taken as hyperchloraemia and a value below 98 mmol/L was taken as hypochloraemia. The mean
preoperative serum chloride level was found to be (101.2+/- 10.4) mmol/l. In the bivariate analysis,
preoperative hyperchloraemia was found to have a risk of adverse outcome (unadj.RR = 1.64; 95%
CI:0.49-5.53). The mean postoperative serum chloride level was found to be (101.7+/-6.7) mmol/l. In the
bivariate analysis, post-operative hyperchloraemia was associated with a higher risk of adverse outcome
(unadj.RR=1.84; 95% CI: 0.43-7.85). Although a postoperative hypochloraemia tended to have a lower
risk of adverse outcome (unadj.RR=0.88; 95% CI:0.24-3.23).
Type of operation
There were 91(88.3%) patients that had a resection and primary anastomosis and only 5(5.5%) patients
died. 8(7.8%) patients had a Hartmann’s procedure and 2(25%) patients died. Four (3.9%) patients had a
double barrel colostomy and 1(25%) patient died.
In the adjusted analysis, resection and primary anastomosis had a lower risk of developing an adverse
outcome than a Hartmann’s procedure (adj. RR=0.15; 95% CI: 0.02-0.099) and this was statistically
significant (p=0.048). Similarly, a double barrel colostomy had a higher risk of adverse outcome than both
resection and primary anastomosis and Hartmann’s procedure (adj. RR=3.59; 95% CI: 0.08-167.3)
however this was not statistically significant (p=0.514) (Table 1).
Length of gangrene of sigmoid colon
A median length of 18cm was taken as a cut-off to establish whether the extent of gangrene of the sigmoid
colon had an influence on outcome. In the adjusted analysis, the presence of gangrene tended to have a
lower risk of an adverse event (adj. RR=0.23; 95% CI: 0.04-1.27) however this was not statistically
significant (p=0.091). Similarly increasing the length of gangrene of the sigmoid colon to greater than
18cm tended to have a lower risk (adj. RR=0.32; 95% CI: 0.04-2.33) however, this did not reach statistical
significance (p=0.259). The mortality among 46(44.6%) cases presenting with gangrenous sigmoid colon
was 10.87%. This contrasted with the mortality among 57(55.3%) non-gangrenous cases of 5.3%
(Table 1).
Presence of ileo-sigmoid knotting
The presence of ileo-sigmoid knotting was seen in 13(12.6%) patients. In the adjusted analysis, ileosigmoid knotting was associated with a higher risk of adverse outcome (adj. RR=4.94; 95% CI: 1.3018.78) and this was statistically significant (p=0.019)(Table 1).
Presence of faeculant contamination
In the adjusted analysis, faecal contamination was not found to increase the risk of adverse outcome (adj.
RR=0.20; 95% CI: 0.03-1.48) however, this was not statistically significant (p=0.219) (Table 1).
Grade of surgeon
The majority of laparotomy 91(84%), were carried out by the Medical Officer, Senior Medical Officer and
Registrars. Only 17(16%) laparotomies were carried out by Consultant surgeons. In the adjusted analysis,
Consultant surgeons were found to have a higher risk of adverse outcome than the Medical Officers,
Senior Medical Officers and Registrars (adj.RR=0.24; 95% CI: 0.02-2.35) however this was not statistically
significant (p=0.219)(Table 1).
Co-morbidity
There were only four co-morbidities in this study which was very low. Two patients had hypertension,
one patient had diabetes and the last patient had neuro-psychiatic illness. Out of these four patients
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presenting with co-morbidities only one patient, the diabetic died of a hypostatic pneumonia, otherwise
the rest had an uneventful recovery.
Discussion
The population of Northern Uganda is mainly rural people and a large number of them are peasant
farmers17. These peasant farmers consume cereals and high fibre crops like maize, cassava, millet,
mangos and beans17. In a study carried out by Tumusiime et al in Central Uganda, this diet was found to
make them more susceptible to sigmoid volvulus2. The high consumption of these high fibre crops may
lead to increased gas formation in the bowel, predisposing them to sigmoid volvulus14.
In this study the 45-54 year age group had the greatest number of cases. This study showed no
statistically significant association between age and outcome (p=0.308) and is in keeping with findings
from another study by Jumbi et al., 2008. Many studies from the West have shown that increasing age and
co-morbidity affects outcome18,19. In the Western population the mean age of presentation with acute
sigmoid volvulus is 62-78 years whilst in the African population it is 42-55 years14. The low mortality of
7.7% seen in our young study population compared with the high mortality rates seen in an older cohort
of patients in developed countries means that advanced age has a significant effect on outcome.
There was a male predominance (74.8%) of sigmoid volvulus in this study and these findings are
consistent with those of Atamanalp et al.,2005 and other studies but no statistically significant correlation
was observed20.
Co-morbidity tends to be higher in the Western population than in the African population. Studies by
Hiltumen et al and Ghosh et al in Western populations showed that co-morbidity is a major cause of
mortality15,21. The co-morbidities responsible for most cases are usually secondary to cardiorespiratory
disease and carcinoma. A very low mortality rate of 7.7% compared to the higher mortality rates seen in
Western populations is most likely due to a combination of a younger age and low co-morbidity seen in
this patients’ cohort.
Most patients presented more than 3 days after the onset of symptoms. This could explain the higher
percentage of patients presenting with gangrenous sigmoid colon (44.7%) in our study. Previous studies
have shown that the circulation to the bowel may be compromised if the volvulus is present for more than
6 hours resulting in gangrene of the bowel22. This study showed a higher risk of adverse outcome if the
duration of symptoms was more than 3 days and the risk increased even further above 6 days however
this was not statistically significant (p=0.542). Similarly another study by Jumbi et al, reported similar
findings13. The possible explanation is that the gangrenous sigmoid colon when present for more than 6
hours may lead to perforation and septicaemia resulting in a poorer outcome. The finding from this study
should encourage surgeons and other health workers in our community to raise public awareness on
reporting early to Hospital when a patient has features of intestinal obstruction. Heath education,
creating awareness and improvement in public health services should address the problem of a delay in
admission with acute sigmoid volvulus to Hospital.
This study found that preoperative shock was associated with adverse outcome however this was not
statistically significant (p=0.154). There was one death from eight patients that presented with
preoperative shock, which gave a mortality rate amongst patients presenting with pre-operative shock of
12.5%. These findings are consistent with studies carried out by Bhuivan et al and Kuzu et al, that have
shown that preoperative shock on admission is associated with a poorer outcome23,24.
Post-operative anaemia was found to have a high risk of adverse outcome in particular wound sepsis.
Stephen et al., found that in patients undergoing laparotomy for colonic resection, post-operative anaemia
was a risk factor for stroke, myocardial infarction and renal insufficiency25. However these complications
were not seen in this study. A longer hospital stay was seen in patients who developed post-operative
anaemia in this study. This finding is in keeping with findings from Stephen et al.,who found that patients
with a post-operative normal haemoglobin concentration have a reduced length of hospital stay
compared to those developing post-operative anaemia25.
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White blood cell count: In this study, leukocytosis did not have any significant effect on the outcome of
surgery. However this is contrary to the findings found in other studies, where leukocytosis was found to
be associated with an increased risk of anastomotic leakage of between 12-30% following large bowel
resection26.
Serum electrolyte levels: This study showed that pre-operative hypernatraemia was significantly
associated with adverse outcome (p=0.023). Pre-operative hyponatraemia was also associated with
adverse outcome but these were not statistically significant (p=0.246). Pre-operative serum
hyperkalaemia and hypokalaemia did not show any increased risk in adverse outcome whilst postoperative hyperkalaemia had a slightly increased risk however this was not statistically significant
(p=0.659). Studies carried out by Morris-Jones et al and Arieff et al, have shown that sodium imbalance
can cause confusion, seizures, cerebral bleeding and death28,29. Potassium imbalance may cause
arrhythmias and cardiac arrest which may lead to death29, however none were reported in this study.
In colonic obstruction fluid and electrolyte disturbances in particular of sodium, potassium and chloride
take place27. This study which showed that preoperative hypernatraemia was statistically and
significantly associated with adverse outcome (p=0.023). This contrasts with findings by Nurkal et al,
who found that hyponatraemia, hypernatraemia, hypokalaemia and hyperkalaemia were not found to
have a significant effect on morbidity and mortality (p>0.05) in patients presenting with colonic
obstruction27. These findings reinforce the importance of correcting electrolyte imbalance in particular
hypernatraemia prior to emergency laparotomy for acute sigmoid volvulus.
A limitation of this study is that fluid imbalance was not determined as several studies have shown that
adequate fluid resuscitation is important in the management of patients presenting with bowel
obstruction30. In a study carried out by Nisanevich et al, correct fluid management was found to reduce
post-operative morbidity and shortened the length of hospital stay30. Jumbi et al, also found a significant
association between intravenous fluid therapy and outcome in patients undergoing emergency resection
for acute sigmoid volvulus (p=0.0406)13. These findings on hypernatraemia coupled with the findings on
fluid imbalance from Jumbi et al and Nisanevich et al reinforce the importance of correcting electrolyte
and fluid imbalance prior to laparotomy in patients with acute bowel obstruction.
The majority of surgical procedures, carried out in this study were resection and primary anastomosis. A
large proportion of patients who survived had a resection and primary anastomosis of the sigmoid colon.
This study showed that the risk of a resection and primary anastomosis was lower than for a Hartmann’s
procedure and double barrel colostomy and this was statistically significant (p=0.048). The risk was
higher for stoma formation and in particular for Hartmann’s procedure possibly because all these
patients presented later than 48 hours, had gangrenous sigmoid colon and were septic on admission, so
that the outcome may not be related to the stoma itself.
For all cases the mortality was 4.8% for resection and primary anastomosis and 23% for colostomy.
Whilst in patients undergoing resection and primary anastomosis the mortality rates were low with
5.26% for viable gut and 10.8% for gangrenous gut. The findings in this study contrast to those of
Bagarani et al, who reported a 60% mortality rate for resection and primary anastomosis for gangrenous
sigmoid colon in a study carried out in West Africa31. There is a large variation in the literature when one
compares the outcome of resection and primary anastomosis versus colostomy. The findings of this study
contrast with those of Aekan et al and Okello et al, where there was no significant difference between
resection and primary anastomosis or colostomy in terms of morbidity and mortality11,32.
The length of Hospital stay in this study was 13.4 days for patients undergoing resection and primary
anastomosis. This is comparable to the length of hospital stay of 7-14 days in a study carried out by Sule
et al on 27 patients undergoing resection and primary anastomosis5 and there was no anastomotic
leakage and no mortality recorded in the same study. Similar to findings in this study, Sule et al found that
in patients undergoing resection and primary anastomosis the length of Hospital stay was shorter than
for those undergoing a staged procedure5. Therefore it may be stated that emergency resection and
primary anastomosis is cost effective, safe, reduces the recurrence rate, reduces hospital stay and avoids
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a stoma. In communities where a colostomy is unacceptable, unaffordable and where appropriate toilet
facilities are lacking such as in many parts of Northern Uganda, resection and primary anastomosis is
therefore a viable option even when gangrenous gut is present.
In our community there is a trend to perform more resection and primary anastomosis depending on the
general physiological condition of the patient. However, it is still remains unclear whether the choice of
operation really influences outcome. In this study, the two groups of patients were not similar enough in
order to make a conclusive comparison and therefore to compare the outcome of the different surgical
procedures a randomized clinical trial may need to be carried out emphasizing the limitation in this
study.
The length of gangrenous sigmoid colon did not have any significant influence on the outcome of surgery.
This is consistent with other studies in particular Jumbi et al, who also found no significant difference in
the outcome of patients having gangrenous sigmoid colon(p=0.5046)13. The reason was possibly because
more care was taken by the surgeons to resect the colon down to healthy viable colon and anastomose the
bowel ends with no tension. Furthermore, this study showed a very low mortality rate of 10.8% for
gangrenous sigmoid colon. This was lower than the average mortality of 38% found in South Africa14. This
mortality rate with gangrenous sigmoid colon is lower than the average global mortality of 35.3%. This
low mortality is the lowest found in all African series and possibly explains the reason behind gangrenous
sigmoid colon not influencing outcome of management of surgery.
Ilio-sigmoid knotting had a higher risk of developing an adverse outcome and was statistically significant
(p = 0.019). These findings are consistent with studies carried out by Gibney et al., and Mallick et al., that
have shown that ileo-sigmoid knotting is associated with a high risk of adverse outcome33,34. The possible
reason for ileo-sigmoid knotting adversely affecting outcome is that these patients presented with
gangrene of the sigmoid colon and small bowel and were septic on admission. The high mortality rate of
38.4% in this group of patients compares favorably with the high mortality rates seen in other studies.
Shepherd et al., found a mortality rate as high as 50% in patients with ileo-sigmoid knotting7. However,
our findings contrast with another study, where it was found that ilio-sigmoid knotting was not
associated with an increased risk of morbidity and mortality13. From my observations, in these patients
laparotomy should not be delayed as the surgeon is confronted with the prospect of resecting both the
small bowel and sigmoid colon in a very sick patient.
Peritoneal contamination did not have any significant influence on the outcome of surgery (p=0.115).
The possible reason was that only a small number, 15(14.5%) patients were seen. Furthermore in these
patients the surgeons took extra care in washing the peritoneal cavity with copious amounts of normal
saline. There were no anastomotic leaks reported from these patients. These findings contrast with those
of Bagarani et al and Kocak et al who found a high rate of anastomotic leakage in the presence of faecal
peritonitis as a result of perforated sigmoid colon and as a result of this finding recommend a
colostomy31,35.
The majority of laparotomies (84%) were operated by Medical Officers, Senior Medical Officers and
Registrars. The Consultant surgeons only operated on 16% of patients and were found to have a higher
risk of adverse outcome compared to the Medical officers however this was not statistically significant
(p=0.219). These findings were comparable with those from Kitara et al., 2010 and Jumbi et al., 2008
where the grade of the surgeon was not found to be related to outcome. However, these findings contrast
with those of Bennett-Guerrero et al, who found that there is a correlation between high risk surgery
performed by surgeons in training and poor postoperative outcome37. One must appreciate that the
patients operated by the Consultant surgeons tended to have higher physiological risk scores and had
abnormal preoperative vital signs on admission. In view of the small number of patients operated by
Consultant surgeons and the findings that lacked statistical significance, one cannot conclude that the
grade of the surgeon influences outcome.
The morbidity and mortality rates following laparotomy for sigmoid volvulus vary between developed
and developing countries. The overall mortality rate of sigmoid volvulus in our study was 7.7% which is
low compared to mortalities of up to 58% seen in developed countries38. Studies carried out in the West
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by Grossman et al, have also shown a higher mortality in developed countries than in Africa18. Earlier
studies had reported a mortality of 58% and 37% respectively38,39. Madiba et al, in South Africa also
reported a high mortality of 30%14 as have other studies in different parts of the world showed a higher
mortality rate following emergency resection compared to elective resection14,18.
Wound sepsis was the commonest complication 10(9.7%). This finding was similar to that found by
Kitara et al, at 9.9%36 .Wound sepsis mainly presented on the fourth to seventh postoperative day in
patients presenting with purulent or faeculant peritonitis. These findings contrasted with those of
Rousellot et al, in the US who found a higher incidence of wound infection at 15% and it was found to be
the commonest postoperative complication40. The second commonest complication was abdominal
wound dehiscence 8(7.7%). The patients who developed wound sepsis nearly all developed abdominal
wound dehiscence and this may explain the nearly similar incidence in both complications. The findings
however contrasted with those found by Mugisa et al, who found a higher rate of 15% which he
accounted this to poor surgical technique by junior residents41.
The incidence of anastomotic leakage 8(7.7%) in our study was similar to results from other African
studies21,23.In this study the bowel was unprepared in all cases prior to resection. There is evidence from
other studies that anastomosis on unprepared bowel is a safe option42. Mealy et alcarried out 126
emergency bowel resections with no preoperative bowel preparation. He found only 3(2.4%)
anastomotic leaks and no mortality42. The slightly higher anastomotic leakage of 7.7% in our study could
be due to a deficiency in surgical material and technique as many were performed by Medical Officers.
Colostomy complications were the fourth commonest complication 7(6.8%) and this morbidity rate is
comparable to that found in other Africa studies31. The majority, 6(85%) were due to surrounding
cellulitis and 1(14%) case was due to retraction of the stoma. Chest infection was the fifth common
complication 6(5.8%). This is in contrast to the findings by Kitara et al, where chest infections where
found to be the commonest postoperative complication following laparotomy36. This may be explained by
the fact that many of the abdominal incisions used for emergency sigmoid resection were lower midline
sub-umbilical incision and therefore patients had less postoperative pain.
The other morbidity rates for septic shock 6(5.8%), cardiovascular complications 3(2.9%), intraabdominal abscess 1(0.97%), enterocutaneous fistula 1(0.97%) and urinary tract infection 1(0.97%)
were comparable with results from other African and Asian studies5,23,43. There were no cases of wound
haemorrhage in this study. A study conducted in Uganda showed a 10% rate of wound haemorrhage in
patients operated by Senior House Officers41.
There were also no cases of thromboembolism reported in this study. The explanation was probably
because this study involved a younger population and sigmoid volvulus is a benign condition. This is in
contrast to the findings by Aagard who found a 15% prevalence of thromboembolism in patients above
50 years of age undergoing laparotomy44.
Conclusions
The risk factors significantly associated with morbidity and mortality in the surgical management of
sigmoid volvulus were preoperative hypernatraemia and ileosigmoid knotting. Colostomy was associated
with a higher risk of morbidity and mortality and a longer hospital stay than resection and primary
anastomosis.
Acknowledgements
I wish to express my sincere gratitude to Dr. David Lagoro Kitara MB BS, MMed Surg, FCS(ECSA), Head,
Department of Surgery, Gulu University,for his supervisory contribution to my Master of Surgery thesis
titled: ‘Incidence and factors influencing outcome of sigmoid volvulus in Northern Uganda. A prospective
observational study’ submitted to the University of Edinburgh.
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I wish to thank Dr. David Cairns MB Chir, FRCSEd, FRCSEng for having always encouraged me to continue
to pursue my surgical career. Mr. Michael Okuga Tabu and family from St. Joseph’s Maracha Hospital,
West Nile, Uganda for having helped me to collect all the patients’ serum samples from all the Hospitals in
Northern Uganda and bringing them to Gulu Regional Referral Hospital laboratory for analysis. Professor
Makumbi from Makerere University for having helped in statistical data analysis and staff in all the 19
hospitals who were involved in data collection. Finally my parents for having supported me and helped
me financially to carry out this Master of Surgery Research project.
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Sule A.Z., D. Iya, P.O. Obekba, B. Ogbanna, J.T. Momoh, B.T. Ugwe. One stage procedure in the
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Ali M, Zahid H, Adnan Z. Management of acute sigmoid volvulus, using one stage resection and
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Shepherd JJ. Management of sigmoid volvulus. 1963;1(4): 174-6.
Waterhouse H.F. An address on Volvulus. Br. Med. J. 1909: 1277-1280.
Mariette D, Sbai – Idrissi S, Bobocescu E, Vons C, Franco D, Smadja C. [Laparoscopic colectomy:
technique and results] [French]. J. de Chirurgie 1996; 133: 3-5.
Kakande I, Ekwaro L, Obote WW, Nassali G, Kyamonywa P. Intestinal volvulus at St. Francis
Hospital, Kampala. East. Centr. Afr. J. Surg., 2002; 6(1): 21-24.
Okello TR, Ogwang DM, Kisa P, Komagum P. Sigmoid volvulus and Ileosigmoid knotting at St.
Mary’s Hospital, Lacor in Gulu, Uganda. East. Centr. Afr. J. Surg. 2009; 14 : 58-64.
Sabiston. The biological basis of modern surgical practice, 14th edn.Philadelphia: WB. Saunders
1991: 1360-1361.
Jumbi G, Kuremu RT. Emergency resection of sigmoid volvulus. East Afr. Med J., 2008 85(8): 398405.
Madiba TE, Thomson SR. The management of sigmoid volvulus. J.R. Coll. Surg. Edinb, 2000; 45:
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Hiltunen, KM, Syria, H and Matikainen, M. Colonic volvulus. Diagnosis and results of treatment in
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Hamed, I.A. Recurret colonic volvulus in children. Paediatr. Surg. 1997; 32: 1739-1742.
Uganda Bureau of Statistics (UBOS): Population Census 2012 report, Kampala, Uganda; 2012
Gurel M, Alic B, Bac B, Keles C, Akgun Y, Boylu S. Intraoperative colonic irrigation in the treatment
of acute sigmoid volvulus. Br. J. Surg. 1989; 76: 957-8.
Shepherd JJ. The epidemiology and clinical presentation of sigmoid volvulus. Br J Surg. 1969.
5(5): 353-9.
Atamanalp SS, Yildirgan MI, Oren D, et al. Clinical presentation and diagnosis of sigmoid volvulus
Acta Chir Belg. 2005; 105(4): 365-368.
Gurel M, Alic B, Bac B, Keles C, Akgun Y, Boylu S. Intraoperative colonic irrigation in the treatment
of acute sigmoid volvulus. Br. J. Surg. 1989; 76: 957-8.
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Asbun HJ, Castellanas H, Balderrama B, Ochoa J, Arismendi R, Teran H, Asbun J. Sigmoid volvulus
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27. Nurkal Halis, Ozgur Sorgut, Cahfer Gwoglu, Abdullah Ozgonul, Mehmet Tahir Gokdemir. Factors
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Separation of Conjoined Twins in Harare, Zimbabwe: Case Report.
F D Madzimbamuto1, B Mbuwayesango2, T Zimunhu2.
1Department of Anaesthesia and Critical Care Medicine
Department of Health Professions Education.
2Department of Surgery, University of Zimbabwe College of Health Sciences
Correspondence to: FD Madzimbamuto, Email: [email protected]
Conjoined twins are rare, and those surviving beyond the first 24hrs occur about
1:200,000 pregnancies. There are often conflicting interests in their management. Medically, few are
separable. The families may not want separation for emotional, religious and ethical reasons.
Technically the surgery is often difficult and resource intensive. The occurrence of conjoined twins in
a resource poor setting presents all these challenges. We present a case of successful elective
separation of conjoined twins, in a resource poor setting.
Key words: Conjoined, twins, separation
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.15
Introduction
The following is a case review of our experience with separation of a pair of male conjoined twins
undertaken at Harare Children’s Hospital, Zimbabwe.
Case Presentation
Two male babies were delivered by caesarean section at a district hospital, and found to be conjoined
twins. They were transferred to the Harare Children’s Hospital where they were admitted and
investigated to establish an anatomical diagnosis, under the care of the paediatricians. Clinically they
were well looking and had a joint birth weight of 3.65kg. They were breastfeeding well and put on weight.
Twin A was smaller than twin B.
The anatomical diagnosis was thoraco-omphalo-pagus, made by radiological investigation. The twins
were joined from sternum to umbilicus and had separate gastrointestinal tracts. The livers were
conjoined but did not appear to share circulation. The pericardia were conjoined but appeared to have a
plane between them. The hearts were separate with no cardiac abnormalities. There was continuity of
abdominal muscle and skin from one twin to the other. [Fig 1]
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Figure 1. Conjoined twins preoperatively
The initial anaesthetic assessment of the twins for separation was at six weeks when their joint weight
was 6.4kgs. Laboratory results were almost the same for each twin for full blood count and electrolytes.
The larger twin [Twin B] appeared easier to intubate, and could adequately laterally rotate his head for a
laryngoscopy to be performed with ease. The area of abdominal wall attachment was large, which raised
concerns about potential blood loss and respiratory embarrassment post-operatively. The twins had good
veins, leaving the option of inhalation or intravenous induction open. The extent of cross-circulation was
unquantified, also raising concerns about anaesthetic drugs crossing from one twin to the other especially
at induction since this was going to be done sequentially. This could be a potential problem at separation.
If one twin was dependant on the anaesthetic crossing from the other twin to achieve a suitable depth of
anaesthesia, separation would then expose that twin to risk of lightening anaesthesia and waking up.
Figure 2. Use of manikins for practice drill-runs. The team responsible for each baby was identified by
the colour of the baby’s hat, and wore a similar colour hat
The Procedure
In preparation, two anaesthetic, surgical and nursing teams were established to prepare, practice drillruns and perform the separation. The practice drills were crucial for the appreciation of the spatial
positioning of the babies, sequencing of the operation and associated intraoperative events [Fig 2]. The
separation was done at 10 weeks and 5 days, when the twins’ joint weight was 8.2kgs. Anaesthetic and
surgical equipment was available in duplicate in theatre. The babies were placed on the theatre table in a
pre-determined orientation so that each baby and his team were on one side of the theatre. A sevoflurane
inhalation induction was done sequentially starting with twin B, and intubations with size 4.0
endotracheal tubes were performed after establishing intravenous access for each baby [Fig 3]. The
BiSpectral Index (BIS) was used to monitor the induction of anaesthesia in both twins. Twin A seemed to
sleep when twin B (the first one) was induced although his BIS remained at 97%. Fentanyl and
atracurium were given intravenously for analgesia as needed. Drugs and fluids were calculated for the
combined body weight and given in a ratio of 60:40 between twins B:A, based on a visual estimate of
relative sizes. Attempts to site central venous lines in both babies were unsuccessful despite ultrasound
guidance.
After induction and skin preparation, the babies were turned over for surgery to begin on the ‘down’ side,
in order to free the skin. The approximate centre between the two babies was marked for the skin
incision. The muscles were divided also until the peritoneum was exposed but left intact. Haemostasis
was achieved and the wound packed with gauze. Monitoring cables, intravenous fluid lines and
ventilation tubes were crossed during this period. After release of the skin the babies were turned again
so the planned operative side was now the ‘up’ side for the rest of the operation. Lines were then
uncrossed. Another incision in the approximate centre was made and extended to the peritoneum.
Unipolar diathermy was used for both cutting and coagulation. The peritoneal sac was opened. All viscera
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were separate and intact except for the livers which were joined. Each baby had a separate
gastrointestinal tract down to the anus, separate genitourinary system and spleens. The liver was fused in
the midline, but the biliary systems and pancreas were separate. The liver was divided down the midline.
The xiphisternum and lateral costal margins were fused anteriorly; division was easily accomplished. The
pericardial sacs were fused in the midline with a small window connecting them. These were separated
and the window closed. The diaphragms were separate with no hernias. The babies were then detached
from each other and placed on separate tables in the same operating theatre. The estimated combined
blood loss was 70mls, about 10% of their total blood volume. Twin B was transfused 40mls while twin A
was given 30mls.
The abdominal wall defect was too large in each baby to effect primary closure. This was achieved with
mesh but the skin was left open to allow shrinkage and granulation over time [Fig 4].
Intravenous fluids, blood loss and urine were calculated hourly to keep up with fluid balance. Monitoring
consisted of pulse oximetry, non-invasive blood pressure, electrocardiogram, core temperature,
BiSpectral Index, end-tidal carbon dioxide. Sevoflurane was monitored for both inspired and expired gas
fraction and minimum alveolar concentration (MAC).
Figure 3. Both babies intubated and monitors positioned.
Figure 4. Mesh closure of abdominal wall at end of surgery
.
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Figure 5. At Follow up, defect almost closed.
Figure 6. Sculpture by Zimbabwean artist Zephania
Tshuma ‘Separation’ [courtesy of Dr David
Katzenstein]
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Post operative management:
Both babies were admitted ventilated to ICU, sedated with fentanyl and ketamine infusions. Baby B had a
stormy recovery in ICU for the first 48 hours with periods of low urine output. Both babies were
extubated within 18hrs and started on naso-gastric breast milk feeds at 36hrs. By 48hrs they had both
recovered very well and were able to breast feed orally. They were discharged home at two weeks when
most of the mesh had been removed [Fig 5]. Regular outpatient reviews followed and their last surgical
review was done at 18 months with good progress and the twins growing well.
Discussion
The incidence of conjoined twins is quoted to be between 1:50 000 to 1:100 000 pregnancies 1. About
60% die in-utero or are stillborn, making the incidence of those born alive nearer 1:200 000. A significant
proportion of these die in the first 24 hrs.1 Based on this incidence, it would be expected that one set of
live conjoined twins would be born every five years in the Greater Harare Maternity Unit with
approximately 40 000 deliveries a year. In 1985, a set of conjoined twins were successfully separated at
Harare Central Hospital but not reported 2. In 2005 a set of conjoined twins from Chiweshe district, in
north east Zimbabwe, were transferred for separation to Canada, and are now healthy 10 year-old boys 3.
Shortly after the currently reported conjoined twin separation was performed, another case was reported
in the press 4. In 1983 Viljoen 5 reported on conjoined deliveries in Namibia, South Africa and Zimbabwe,
reporting that Zimbabwe showed the highest incidence.
Fully separate twins achieve complete separation in-utero by day 15-17 post-fertilization. The ‘fission’
theory suggests that failure to achieve separation results in conjoined twins, based on the conjoined twins
always being identical 6. The ‘fusion’ theory suggests that in twins that are fully separate but physically
close, ‘like’ embryonic cells migrate between them, so potential liver cells in one can migrate to be liver
cells in the other. An intrauterine diagnosis can be made by ultrasound from 12 weeks, and organ
conjunction can be diagnosed from 20 weeks by ultrasound. The presence of fluid in the foetal lungs
makes cardiac echocardiography easier and cardiac abnormalities can be diagnosed and followed from 20
weeks7. Heart and lung abnormalities are the main cause of non-viable foetuses.
The type of conjoinedness is classified according to Spenser et al as symmetric or asymmetric 8. ‘Pagus’
refers to the place of joining or ‘fixing / frozen’ (Greek). There are three categories of symmetric
conjoined twins: anterior (ventral) pagus, posterior (dorsal) pagus and lateral pagus.
The medical literature on conjoined twins consists mainly of case reports of single cases of conjoined
twins or rarely a series of a few cases going back 20 or more years6,9-12. Developments have mostly been
in early intrauterine diagnosis, especially using ultrasound in diagnosis of twin pregnancies and
preoperative anatomical diagnosis. This enables medical management and counselling to be well planned
for a suitable outcome for both family and medical team 7,12. The surgery of separation of conjoined twins
is generally complex and resource intensive. Only a small proportion of conjoined twins are amenable to
surgical separation. In a Brazilian series over 20 years, out of 21 pairs of conjoined twins, 12 pairs were
amenable to surgery and 16 infants out of the 24 (66%) survived.7 In a South African series only one set
out of three sets of conjoined twins having emergency surgery survived compared to 11 out of 14 sets
who had elective surgery 12.
Separation of conjoined twins where one of the twins is certainly or most likely not going to survive has
resulted in religious, legal and moral uncertainty. There are also questions about whether conjoined
twins are one or two persons and what constitutes beneficence and non-maleficence in this context 13,14.
The decision to operate or not to operate is usually taken by people other than the children: parents,
surgeons, courts etc and what is in the best interests of the children can be conflicted. Many conjoined
twins who have survived childhood to adulthood have not wanted separation, depending on the risk to
themselves. Families are often reluctant to have separation if there is a risk of sacrifice of one of the twins.
Conjoined twins have fascinated society for millennia, from being shrouded in superstition and religion,
to being exhibited as circus freaks and the wonder of successful surgery 15. There are historical records of
conjoined twins from as early as six millennia BC, such as the ‘double goddess’ 6. Many young African
medical students today state as their inspiration to study medicine the story of Ben Carson, the AfricanAmerican paediatric neurosurgeon who was the first to successfully separate craniopagus twin 16.
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The key lesson from this case is that surgical separations are possible for some cases in resource-limited
settings if conducted with thorough and adequate preparation and planning. This preparation is not
isolated to the surgical process but involves the entire journey from diagnosis to successful child
development. The groundwork for the case presented in this report involved use of counselling services
to establish the parents’ wishes and anxieties and to ensure full commitment to the surgery. For the
medical team, there were concerns based on previous experience that if the children went home before
surgery, they may not return and may face possible harm or neglect. According to Pathisa Nyathi,
‘Multiple births have traditionally caused alarm and apprehension among African societies’ 17. Historically
in Zimbabwe twins were regarded as bad omens and were left to die. Although this no longer happens,
children who are “different” are regarded with superstitious concern in many African communities. There
are also religious sects that counsel against medical intervention of any kind. In the case presented here,
the parents were very keen to have the babies separated and to look after them well. To give the
maximum chance of a surgical outcome, the children were kept in the hospital for the whole preoperative
period. The medical and nursing teams worked together closely for four weeks discussing and planning
the operation so that a common understanding developed about how the babies and parents would be
looked after. As with other ‘separation’ operations, there was a lot of media and public interest both local
and international in these twins, and pride on the part of the health system when the outcome was
successful.
Acknowkedgements:
Prof Ray for reviewing manuscript.
Surgical team
Anaesthetic team
Nursing team
Mbuwayesango B,
[Consultant: team blue: leader]
Zimunhu T
[Consultant: team red: leader]
Chitsika E [Consultant]
Dube I[Consultant]
Muteweye W
[Consultant:Cardiothoracics]
Munanzvi K [House Officer]
Moyo M[House Officer]
Mutambanengwe P[House Officer]
Muparadzi C[House Officer]
Mushonga M[House Officer]
Gwatirisa [House Officer]
Chifamba HN
[Consultant: team leader]
Shumbairerwa S
[Consultant: team red-lead]
Madzimbamuto FD
[Consultant: team blue-lead]
Mutetwa E
[Senior Reg]
Chimhundu-Sithole T[Registrar]
Mugadza F [Registrar]
Mazonde S[Consultant]
Chikumba E [Consultant]
Nyamayaro RT(Consultant)
Mutukwa T(Registrar)
Shaka I [Matron]
Charumbira C[Matron]
Bikisoni P [Theatre Sister-inCharge]
Simbini B[Operating Theatre NurseOTN]
Rutsito M
[Lead blue teamOperating Thetare Nurse]
Maarira
[Lead red teameOperating
Theatre Nurse]
Paediatric team
Chimhini G [Consultant]
Chimhuya S[Consultant]
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Colorectal Polyposis in a 15 Year Old Boy in Uganda - Case Report
N Kakembo 1, P Kisa 1, J Sekabira1, D Ogdzediz2
1Department of Surgery College of Health Sciences Makerere University
2Yale university, Department of Surgery, New Haven, CT, USA
Correspondence to: Nasser Kakembo Email: [email protected]
Colorectal polyps usually present as rectal bleeding and are associated with increased risk of
colorectal carcinoma. This is a 15 year old boy who presented with painless rectal bleeding for 9
years and mass protruding from the anus for 2 years after passing stool. He had history of 3
nephews with similar symptoms. On clinical assessment an impression of Adematous familial
colorectal polyposis was made and biopsy was taken from the mass that revealed inflammatory
polyps. He subsequently had a total colectomy and ileall pouch anal anastomosis with good outcome.
In absence of endoscopic surveillance and diagnostic services diagnosis of colorectal polyposis
syndromes is a challenge because clinicians rely on digital rectal assessment and examination under
anesthesia.
Key words: polyposis, polyps, Uganda
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.16
Introduction
Colorectal polyps commonly present with rectal bleeding in children, adolescents and adults. Multiple
juvenile polyps account for significant risk of intestinal cancer if there are more than 5 in number 1.
Commonly children have juvenile polyps that are solitary usually 1-5, but some children inherit genes
that lead them to develop polpoosis syndromes namely adenomatous polyposis and harmatomatous
polyps. The presence of multiple adenomatous polyps in the large bowel confers a high lifetime risk of
colorectal cancer and should undergo surveillance for colorectal neoplasia 8, 9. Although the presence of
multiple adenomatous polyposis (>100 polyps) can be accounted for by mutations in the adenomatous
ployposis coli (APC) gene, a large group of patients remain with multiple (5-100) adenomas and in whom
there is no detectable APC mutation3, 8.
The hereditary polyposis syndromes include adenomatous poyposis syndromes (FAP, Gardner
syndrome) and the harmatomatous polyposis syndromes (Putze-Jeghers syndrome, Juvenile polyposis,
and Cowden’s disease)2. The adenomatous polyposis syndromes are characterized by numerous
adenomatous polyps throughout the entire colon and a spectrum of extra colonic manifestations. They
invariably progress to colorectal cancer without appropriate intervention2, 8. Diagnosis of symptomatic
polyposis is by colonoscopy, and here we present a teenager with colorectal polyposis from a resource
limited setting where there were no pediatric colonoscopy services pausing a diagnostic challenge.
Case Report
Case 1.
A 15 year old boy presented with 9 years of rectal bleeding and 2 years of a red mass protruding from the
anus after passing stool. It was noted by the mother that this boy was staining the family pit latrine with
fresh blood whenever he would pass stool and he had been treated with herbs with no improvement.
Two years prior to admission he noticed a grape like red mass protruding through the anus associated
with pain and fresh bleeding on defecation. Initially the mass would spontaneously get reduced but later
on it would remain out. He would sometimes become so pale with generalized body weakness until when
the boy was brought to pediatric surgical outreach camp where multiple rectal polyps were diagnosed. He
had been treated with herbs, no medication, and no history of surgery or blood transfusion prior to this.
He was from a peasant family with no first degree relatives with a similar problem but he reported to
have three nephews who had occasional rectal bleeding .The boy was reported to be stunted compared to
other
siblings
and
children
in
the
same
community.
Clinical examination revealed a boy who was moderately pale with no jaundice and no edema. He was
generally
of
short
stature
weighing
35kg
with
general
body
weakness.
Digital rectal examination revealed: a normal peri anal area and sphincter tone. There were boggy
fungating masses in the rectum about 8 cm proximal to anal verge, they were red friable and
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circumferential easily prolapsed out of the anal canal with significant bleeding (Figure 1). The clinical
impression of Adematous familial colorectal poplyposis was made and biopsy was taken from the mass
that revealed inflammatory polyps.
The Patient was transferred to a tertiary hospital and counseled for an exploratory laparotomy due to
lack of pediatric colonoscopy services in the country. At laparotomy the peritoneal cavity was clean and
liver appeared normal with no tumor seeding. He had multiple enlarged lymph nodes at the ileocaecal
junction. The entire colon was inspected and palpated for polyps from caecum to rectum and multiple
boggy masses were felt in the caecum and sigmoid colon. Total colectomy was done excluding
proctectomy. The specimen was cleaned and opened up lengthwise and found multiple polyps (over 8
polyps) in the caecal area and descending colon (Figures 2 and 3). It was subjected to histology that
showed inflammatory polyps with no evidence of malignancy.
Patient had a relaparotomy 2 months later with proctectomy and illeal J-pouch anastomosed to the anus
with a proximal ileostomy in situ. He recovered from this surgery un eventfully and the ileostomy was
closed a month later. He is currently fine with no rectal bleeding and has good bowl control
Figure 1.
Figure 2
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Figure 3
Figure 4
Discussion
Colonic polyps usually present with, rectal bleeding, a mass per rectum, abdominal pain, mucopurulent
discharge, diarrhea, vomiting and sometimes it can be asymptomatic 4. Other forms of presentation
include intussusceptions and auto amputation of the polyps7. This particular boy presented with
excessive bleeding after stooling with a mass protruding through the rectum.
The World Health Organization criteria for diagnosis of juvenile polyposis syndrome are one of either;
more than five polyps in the colon or rectum, juvenile polyps throughout the gastrointestinal tract, any
number of juvenile polyps in a person with a family history of juvenile polyposis 8,10. The patient under
discussion fulfilled all the criteria. Patients at risk or with high suspicion of juvenile polyposis should have
endoscopic screening of the colon and upper gastrointestinal tract at 15 years or time of first symptoms 8.
The surgical choices for symptomatic juvenile popyposis syndrome patients are subtotal colectomy with
ileorectal anastomosis, or total proctocolectomy with a pouch 5, 8. In view of risk of rectal cancer or
intractable proctitis ileal pouch anal anastomosis is more acceptable to patients inspite of poorer bowel
function otherwise patients who undergo subtotal colectomy require routine endoscopic surveillance of
the remaining rectum every 6 months for recurrent polyps or carcinoma 6,11.
The role of chemoprevention in the treatment of colorectal and duodenal adenomas is still under study. It
involves use of sulindac which has shown reduction of established colorectal adenomas in adults by 50%
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and celecoxib a selective cycloxygenase -2 inhibitor that has shown some promise in reducing the number
colorectal adenomas as well as duodenal adenomas 11.
Conclusion
Routine digital recatal examination and examination under anesthesia are key methods of diagnosing
colonic pathology in children in absence of colonoscopy.
References
1.
Carol A Durno, Colonic polyps in children and adolescents. Can J Gastroenterol.Apr 2007;
21(4):233-239
2. Luk GD .Diagnosis and therapy of hereditary polyposis syndromes. Gastroenterologist .1995 Jun;
3(2):153-67
3. Lipton L, Tomlinson I. The genetics of FAP and FAP –like syndromes. Fam Cancer.2006; 5(3):2216
4. Pillai RB, ToliaV. Colonic polyps in children; frequently multiple and recurrent. Clin Pediatr
(Phila). 1998 Apr; 37(4):253-7
5. Oncel M, Church JM, Remzi FH, Fazio VW. Colonic surgery in patients with juvenile polyposis
syndrome: a case series. Dis Colon Rectum. 2005 Jan; 48(1):49-55; discussion 55-6
6. Soravia C, O’Connor Bl, BerkT, Mcloed RS, &Cohen Z. Functional outcome of conversion of
ileorectal anastomosis to ilieal pouch anal anastomosis in patients with familial adenomatous
polyposis and ulcerative colitis . Dis Colon Rectum. 1999 Jul; 42(7):903-8
7. Nagasaki A, Yamanaka K, Toyohara T, Ohgami H, &Sueishi K. Management of colorectal polyps in
children . Acta Paediatr Jpn. 1993 Feb; 35(1):32-5
8. Lodewijk AABrosens, Danielle Langeveld, & et al .Juvenile polyposis syndrome . World J
Gastroenterol 2011 November 28;17(44):4839-4844
9. Giardiello FM,Hamilton SR,& et al. Colorectal neoplasia in juvenile polyposis or juvenile polyps.
Arch Dis Child. 1991 Aug;66(8):971-5
10. Jass JR, Williams CB, Bussey HJ, Morson BC . Juvenile polyposis – a precancerous condition
.Histopathology 1988Dec;13(6):619-30
11. Aikhouri, Naim, & et al .Familial adenomatous Polyposis in Childrenand Adolescents. J ournal of
Paediatric Gastroenterology &nutrition.December 2010-Volume 51-issue 6-p727-732
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Acalculous cholecystitis: Three Case Reports
S G Mungazi1, H Mungani2
1General Surgery Registrar, University of Zimbabwe, Parirenyatwa Hospital, Harare
2Consultant General Surgeon, Harare Central Hospital, Harare
Correspondence to: Simbarashe Gift Mungazi, Email:[email protected]
Acute acalculous cholecystitis is an acute necroinflammatory disease of the gallbladder. Whilst
acalculous cholecystitis accounts for approximately 10 percent of acute cholecystitis cases it is
associated with a high morbidity and mortality.The condition rapidly progresses to complications
such as gangrene, perforation and empyema of the gallbladder. Gangrenous cholecystitis is the most
severe form and complication of acute cholecystitis. Acute acalculous cholecystitis warrants urgent
surgical intervention to prevent catastrophic outcomes. We report a series of three patients that we
managed for acute acalculous cholecystitis. The first patient was a 65-year-old, male who was
positive of Human Immunodeficiency Virus (HIV) with a CD4 count of 165 cells/mm3 and was on
antiretroviral treatment. The second patient was a 73-year-old male with no comorbidities. The last
patient was a 72-year-old female with congestive cardiac failure due to hypertension. One patient
had a successful laparoscopic cholecystectomy and the other two had open cholecystectomies. Two of
the patients did well and were discharged whilst the third patient died in intensive care unit day 2
postoperatively. All the three patients had no evidence of gallbladder stones. Two of the histology
reports confirmed acalculous gangrenous cholecystitis and the third histology showed acalculous
haemorrhagic cholecystitis. Acalculous cholecystitis is a surgical emergency. Once suspected,
principles of management include resuscitation, hospital admission, broad spectrum antibiotics,
adequate analgesia and emergency surgery.
Key words: Acalculous cholecystitis, Gangrenous cholecystitis, Cholecystectomy
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.17
Introduction
Acute acalculous cholecystitis (AAC) is an acute necroinflammatory disease of the gallbladder in the
absence of cholelithiasis and has a multifactorial pathogenesis1. It accounts for approximately 10% of all
cases of acute cholecystitis2.AAC can progress to gangrene, perforation, and empyema of the gallbladder
in 6% to 82% of cases3.The incidence of gangrenous cholecystitis ranges from 2–38% of all patients with
acute cholecystitis4. Gangrenous cholecystitis has a mortality rate of up to 22% and a complication rate of
16–25%4. The preoperative diagnosis of gangrenous cholecystitis is difficult and may often only be
entertained after deterioration of a patient suspected of having simple or uncomplicated acute
cholecystitis.
We report a series of three patients whom we managed for acute acalculous cholecystitis. Two of these
patients had confirmed gangrenous cholecystitis at histology.
Case Reports
Case 1
The first case was of a Human Immunodeficiency Virus (HIV) positive 65-year-old male patient, who was
on antiretroviral treatment for seven years. He presented at Harare Hospital surgical unit with one-week
history of right upper quadrant pain that worsened two days prior to presentation. There was no history
of jaundice. He did not have a history of diabetes mellitus or other chronic illnesses. Current CD4 count
was 165 cells/mm3. He was of sober habits.On examination the patient was ill, normotensive, afebrile and
not jaundiced. The gallbladder was palpable and tender with the rest of the abdomen being soft and nontender.The rest of the physical examination was unremarkable.
Full blood count showed a white cell count (WCC) 12.4/mm3 (4-11), hemoglobin (Hb) of 14 g/dl (15+/1.7), platelets (PLT) 185 x 103 (150-400). Liver function tests (LFTS) and urea and electrolytes (U &Es)
were normal.The abdominal ultrasound showed a distended gallbladder with thickened mucosa, absence
of stones or sludge and normal intra and extrahepatic ducts. After fluid resuscitation, antibiotics and
analgesia commencement he underwent a laparoscopic cholecystectomy. During the surgery there were
extensive adhesions on and around the gallbladder that was grossly dilated and friable. Laparoscopic
cholecystectomy was successfully done (see picture below) with an operative time of 2hours.
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Case 2.
He was a 73-year-old male, previously healthy, with no comorbidities who presented with a 3-day history
of an acute abdomen and no history of prior intermittent jaundice. On examination he was ill looking,
with a temperature 37.8 degrees Celsius but was not jaundiced. He had marked generalized abdominal
tenderness with associated rebound tenderness that signified peritonitis. Full blood count results showed
a WCC 11.5/mm3, Hb 13.0g/dl, MCV 80.0 fem to litres (80-96) and PLT 200x 103. The other investigations
were normal. The patient was resuscitated with intravenous fluids and broad spectrum antibiotics as well
as analgesia instituted. The patient underwent an emergency laparotomy. A gangrenous gallbladder with
no stones was found as shown in Figure 2. The common bile duct was of a normal caliber. A
cholecystectomy was done.
Both patients had an uneventful postoperative recovery period and were subsequently discharged. The
histology of the first patient reported “sections from the gallbladder show suppurative inflammation with
necrosis consistent with a gangrenous cholecystitis”. The histology of the second patient reported “the
gallbladder wall shows complete hemorrhagic necrosis consistent with torsion. Conclusion is gallbladder
gangrene”. Repeat LFTs of both patients after 2weeks were normal.
Figure 1: Gallbladder Specimen from Case 1.
Figure 2. Gangrenous Gallbladder of Case 2.
Case 3.
The third patient was a 72year old female with congestive cardiac failure due to hypertension who
presented with a 3-day history of generalized abdominal pain associated with vomiting. On examination
she was ill looking, dehydrated and not jaundiced. She had a temperature of 36.1 degrees Celsius, BP
166/72 mmHg, Pulse of 120 bpm and a respiratory rate of 16bpm. She had a positive Murphy’s sign.
Blood results showed WCC 12.31/mm3, Hb 13.4 g/dl, PLT 233x 103, urea 34.7mmol/l (2-6.7), creatinine
127umol/l (98-131), sodium 133mmol/l (133-146), and potassium 3.7mmol/l (3.5-5.2). LFTs: Total
Bilirubin 12umol/L (3-29) ALP 176 U/L (34-140) GGT 153U/L (13-63) AST 65U/L (10-30) ALT 70 U/L
(5-44).Transabdominal ultrasound showed a distended gallbladder with thickened mucosa, absence of
stones or sludge and normal intra and extrahepatic ducts. An electrocardiogram was normal. After
resuscitation the patient underwent an emergency open cholecystectomy. Unfortunately, the patient died
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in the intensive care unit on day 2 post operation. The histology showed acalculous hemorrhagic
cholecystitis.
Discussion
AAC most often occurs in old age, is associated with conditions such as immunosuppression, critically ill
patients in the intensive care unit, major surgery, severe trauma, sepsis and patients on long term total
parenteral nutrition2. Risk factors for AAC in our patients were notably of: age in all the patients,
immunosuppression in one patient and congestive cardiac failure on the third patient.The age of onset of
patients with AAC is known to be older than those patients with calculous cholecystitis5. Furthermore,
although calculous cholecystitis is much more common in women than in men, many studies on AAC have
revealed a male predominance5. The youngest of our patients was 65 years of age and the oldest being 73
years, 2 were males and one was female. However, no conclusion can be drawn from this case series as
our sample size is too small. AAC occurring in patients with acquired immunodeficiency syndrome (AIDS)
and other immunosuppressed patients maybe due to opportunistic infections such as microsporidia,
Cryptosporidium or cytomegalovirus6. The low CD4 count on our patient who had been on antiretroviral
treatment for seven years could indicate treatment failure. Unfortunately, a viral load was not done to
confirm treatment failure. However, the patient was referred to the physicians for consideration of
second line treatment.
The pathogenesis of AAC is ill defined and appears to be multifactorial2,5. The commonly postulated
theories regarding the pathogenesis of AAC are bile stasis, sepsis and ischemia5. There is histologic data
that explain some of the pathology of AAC as a response to systemic inflammation2. AAC showed the
following:
1. increased leukocyte margination (consistent with ischemia and reperfusion injury);
2. increased focal lymphatic dilation with interstitial edema associated with local microvascular
occlusion (ischemia related); and
3. increased and deeper bile infiltration in the GB wall suggesting that bile stasis and increased
epithelial permeability exist, leading to epithelial damage2.
These findings substantiate the hypotheses that bile stasis and ischemia are likely involved in the
pathogenesis of AAC2. Typhoid fever is a known cause of spontaneous gallbladder perforation in the
absence of stone disease in the young2. AAC may also occur in patients with disseminated fungal infection
(Candida species), systemic leptospirosis, Vibrio cholera and clonorchis sinensis5. AAC has also been
reported in patients with connective tissue disease5.
The clinical presentation of AAC is variable and more so when it complicates. In one large single center
report, 36 of 47 patients (77%) identified over a seven-year period developed symptoms at home without
evidence of acute illness or trauma7. This is in keeping with our patients’ presentations. They came from
home as opposed to critically ill patients in intensive care. Our patients presented with a 3 to 7 days’
history which suggests that our patients seem different by presenting late.There are studies that have
attempted to predict the risk factors for gangrenous cholecystitis. Based on the univariate analysis from
one study, nine variables were found to be associated with gangrenous cholecystitis: age 51 years or
older, African-American race, history of diabetes mellitus, WBC_15,000, AST _43 U/L, ALT _50 U/L, ALP
_200 U/L, lipase _200 U/L, and pericholecystic fluid on ultrasonography8. Based on multivariate analysis
variables associated with a gangrenous gallbladder were: male sex, diabetes mellitus and a raised white
cell count8. However, Contini et al9 showed that there is no single clinical or laboratory finding, apart from
a high WBC, predictive of severe inflammation of the gallbladder. Interestingly all three patients
presented with not much elevated fever. Possible explanations are could it be due to an insidious course
or that the immune response is poor. This is even shown on the marginal elevation of the white cell count
compared with other authors.
The preoperative diagnosis of gangrenous cholecystitis is difficult and often only be entertained after
deterioration of a patient suspected of having simple or uncomplicated acute cholecystitis. Two of our
patients had a histological diagnosis of gangrenous cholecystitis, signifying the much feared sequela to the
most severe form of cholecystitis. Clinical evaluation, laboratory and imaging investigations as well as a
high index of suspicion are all in the armamentarium of the clinician to suspect acalculous gangrenous
cholecystitis. Once suspected, acalculous gangrenous cholecystitis is a surgical emergency. Principles of
management include resuscitation, hospital admission, broad spectrum antibiotics, adequate analgesia as
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well as surgery. Laparoscopic cholecystectomy can be performed for AAC2; however,there is some
controversy regarding the best surgical approach to gangrenous cholecystitis10.
Conclusion
Acute acalculous cholecystitis (AAC) is a surgical emergency. It is associated with a high morbidity and
mortality. The pathogenesis is multifactorial. AAC rapidly progresses to complications such as gangrene,
perforation and empyema of the gallbladder. The preoperative diagnosis of gangrenous cholecystitis is
difficult and often only be entertained after deterioration of a patient suspected of having simple or
uncomplicated acute cholecystitis. Once suspected, acute acalculous cholecystitis,principles of
management include resuscitation, hospital admission, broad spectrum antibiotics, adequate analgesia as
well as surgery.
Acknowledgement
To Professor G I Muguti for his guidance, wisdom and mentorship and also to Lancet laboratories for the
pathological reports.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Barie PS, Eachempati SR. Acute Acalculous Cholecystitis. Vol. 39, Gastroenterology Clinics of North
America. 2010. p. 343–57.
Dr Hemendra Kumar DAJDDSDMJA. Acute Gangrenous Acalculous Cholecystitis In An Adolescent:
\nA Case Report\n. IOSR J Dent Med Sci [Internet]. 2014;13(11):56–9. Available from:
http://www.iosrjournals.org/iosr-jdms/papers/Vol13-issue11/Version-3/N0131135659.pdf
Wang AJ, Wang TE, Lin CC, Lin SC, Shih SC. Clinical predictors of severe gallbladder complications
in acute acalculous cholecystitis. World J Gastroenterol. 2003;9(12):2821–3.
Grant RL, Tie MLH. False negative biliary scintigraphy in gangrenous cholecystitis. Australas
Radiol. 2002;46(1):73–5.
Ryu JK, Ryu KH, Kim KH. Clinical features of acute acalculous cholecystitis. J Clin Gastroenterol.
2003;36(2):166–9.
Wind P, Chevallier JM, Jones D, Frileux P, Cugnenc PH. Cholecystectomy for cholecystitis in
patients with acquired immune deficiency syndrome [Internet]. Vol. 168, American Journal of
Surgery. 1994. p. 244–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/8080061
Savoca PE, Longo WE, Zucker K a, McMillen MM, Modlin IM. The increasing prevalence of
acalculous cholecystitis in outpatients. Results of a 7-year study. Ann Surg [Internet].
1990;211(4):433–7.
Available
from:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1358029&tool=pmcentrez&rendert
ype=abstract
Fagan SP, Awad SS, Rahwan K, Hira K, Aoki N, Itani KMF, et al. Prognostic factors for the
development of gangrenous cholecystitis. Vol. 186, American Journal of Surgery. 2003. p. 481–5.
Contini S, Corradi D, Alessandri L, Pezzarossa A, Scarpignato C. Can Gangrenous Cholecystitis be
Prevented ? Vol. 38. 2004. p. 710–6.
Chaudhry S, Hussain R, Rajasundaram R, Corless D. Gangrenous cholecystitis in an asymptomatic
patient found during an elective laparoscopic cholecystectomy: a case report. J Med Case Rep
[Internet].
2011;5(1):199.
Available
from:
http://www.jmedicalcasereports.com/content/5/1/199
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Wandering Spleen with Splenic Vein Thrombosis: A Case Report
M S Ismael
Mubende regional referral Hospital, Uganda
Correspondence to: Dr. M S Ismail, Email: [email protected]
Introduction
A wandering spleen is a rare clinical occurrence with fewer than 500 cases reported and an
incidence of less than 0.2%1, 2. The spleen is an important component of the reticuloendothelial
system, which is involved in immunological defence and can serve as a storage site for red blood
cells3. The spleen is normally supported by the gastrosplenic, splenorenal and splenocolic ligaments,
whereby failure of attachment of these ligaments to the spleen’s overlying peritoneum results in a
hypermobile spleen3, 4. All cases of a wandering spleen have been found associated with a long
splenic pedicle which consists of the splenic vessels and the tail of the pancreas2-4. A wandering
spleen can be either congenital or acquired. In the congenital condition the ligaments fail to develop
properly, whereas in the acquired form the hormonal effects of pregnancy and abdominal wall laxity
are proposed as determining factors 5-7. In addition, failure of fusion of the dorsal mesogastrium
during foetal development resulting in the characteristic long vascular pedicle has been attributed8.
However, the precise aetiology of the wandering spleen is not known 2.
Key words: Spleen, wandering, splenic, vein, thrombosis
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.18
Case Report
A 15-year-old girl, presented to the emergency department with a longstanding history of central
abdominal pain which had worsened in the last 3 days, she described as a tight band spanning from her
right lumbar region to her left lumbar flank. The pain was associated with a swelling in the umbilical area
and exacerbated by movement and eating. There was associated vomiting; clear vomitus and no
haematemesis. Her bowels were opening regularly and there was no reported blood in her stools. Her
past medical history entailed oesophageal gastric reflux with no history of haematemesis.
On examination, she appeared in discomfort, was apyrexial but had a tachycardia of 100beats per minute,
with otherwise normal cardiorespiratory function. Her abdomen was soft, with a mass and localised
tenderness in the umbilical area. On admission her haemoglobin was 11.7g/dL, white cell count
16.6×109/L, neutrophils 14.8×109/L, her renal, liver function, amylase and lactate were within normal
limits. An abdominal ultra sound scan was ordered to describe the mass in the umbilical region and
according to the sonographer he pointed the echo texture and pattern of the mass was consistent with
those of a spleen and he concluded an ectopic spleen. A chest radiograph was normal.
She was resuscitated with intravenous fluids, given analgesia, antiemetics and started on prophylactic
antibiotics. She was prepared for urgent laparotomy. An infarcted wandering spleen was found in her
mid-abdomen. Her spleen was enlarged to 20cm at its maximum diameter due to venous congestion and
resultant infarction. There were no ligamentous attachments to her spleen and the tail of her pancreas
was attached to the hilar vessels of her spleen which were on a long mesentery. The infarct was probably
due to recurrent torsion and splenic vein thrombosis. Patient was managed on antibiotics, maintenance
intravenous fluids and analgesics on first postoperative day. Second postoperative day oral feeding was
started, there were no eventualities and the patient was discharged from hospital on the fifth
postoperative day.
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Figure 1. shows a haemostat applied on to the splenic hilum and a babcock applied on the splenic vein
with blood clots inside.
Discussion
A literature review by Buehner and Baker3 showed that patients most commonly presented with: an
asymptomatic mass, in the subacute setting with nonspecific gastrointestinal complaints and could also
present with an acute abdomen. The use of biochemical blood tests has been found to be nonspecific in
terms of helping with diagnosis3.
Symptoms may remain quiescent over long periods, but complications are related to torsion or
compression of abdominal organs 3. These can include pancreatitis, bowel obstruction, gastric volvulus,
gastric and duodenal compression and most commonly splenic infarction7. Splenomegaly is usually a
result of torsion of the pedicle and splenic sequestration.
A wandering spleen usually presents between the ages of 20 and 40 years, being more common in
women. Children make up one-third of cases, with an equal preponderance in boys and girls under
10 years 9,10. US imaging with duplex scanning can be used as an initial mode of imaging which can show
the position of the wandering spleen with concomitant replacement of bowel in the left upper quadrant 7.
CT contrast imaging is the preferred mode of investigation, with the contrast helping to elucidate the
viability of the spleen6, 7. The most characteristic finding is the absence of the spleen in its normal position
and an ectopic mass found somewhere else in the abdomen or pelvis 6. The whirl sign of the splenic
pedicle and surrounding fat is specific for splenic torsion as was the case with our patient 5, 6. Splenopexy
is the treatment of choice if the spleen is not infarcted but a splenectomy proceeding detorsion is
necessary if there is any sign of infarction3, 11-13. This should be appropriately followed up by the
prophylactic vaccines against postsplenectomy sepsis syndrome. Ideally they should be administered
before surgery; however, in emergencies this is not always possible.
Conclusions
The wandering spleen is a rare differential diagnosis of an acute abdomen but must be considered if a
patient presents with abdominal pain associated with a palpable mass and displacement of bowel loops to
the left upper quadrant. The best method of confirming the diagnosis seems to be a CT scan, however, US
imaging is an equally helpful modality.
References
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Raissaki M, Prassopoulos P, Daskalogiannaki M, Magkanas E, Gourtsoyiannis N: Acute abdomen
due to torsion of wandering spleen: CT diagnosis. Eur Radiol 1998, 8:1409-1412.
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Buehner M, Baker MS: The wandering spleen.
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Gomez D, Patel R, Rahman SH, Guthrie JA, Menon KV: Torsion of a wandering spleen associated
with congenital malrotation of the gastrointestinal tract.
Int J Radiol 2006, 5:1.
Ben Elya A, Zissinb R, Copela L, Vassermana M, Hertzc M, Gottlieba P, Gayera G: The wandering
spleen: CT findings and possible pitfalls in diagnosis.
Clin Radiol 2006, 61:954-958. PubMed Abstract | Publisher Full Text
Karmazyn B, Steinberg R, Gayer G, Grozovski S, Freud E, Kornreich L: Wandering spleen-the
challenge of ultrasound diagnosis: report of 7 cases.
J Clin Ultrasound 2005, 33:9.
Allen KB, Gay BB Jr, Skandalakis JE: Wandering spleen: anatomic and radiologic considerations.
South Med J 1992, 85:976-984. PubMed Abstract | Publisher Full Text
Dawson JH, Roberts NG: Management of the wandering spleen.
Aust N Z J Surg 1994, 64:441-444. PubMed Abstract | Publisher Full Text
Steinberg R, Karmazyn B, Dlugy E, Gelber E, Freud E, Horev G, Zer M: Clinical presentation of
wandering spleen. J Pediatr Surg 2002, 37:30.
Steele RD: A torted pelvic spleen.
Aust N Z J Surg 1988, 58:157-159. PubMed Abstract | Publisher Full Text
Rodkey ML, Macknin ML: Pediatric wandering spleen: case report and review of the literature.
Clin Pediatr (Phila) 1992, 31:289-294. PubMed Abstract | Publisher Full Text
Gunning KA, Rosenberg IL: Symptomatic wandering spleen. Br J Surg 1993, 80:93.
PubMed Abstract | Publisher Full Text
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Lateral Pharyngeal Diverticulum presenting with Dysphagia
N Berhanu, K Philipos, T Ayalew
Cardiothoracic Surgery Unit, Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia
Correspondence to: Dr. Philipos Kidane, Email: <[email protected]>
Lateral pharyngeal diverticulum (Pharyngocele) is the protrusion of pharyngeal mucosa through
the pharyngeal wall, usually through either of two weak areas in the pharyngeal wall as an acquired
or congenital case. Lateral diverticula are very rare and not to be mistaken for the rather more
frequent and abundantly reported cases of posterior pharyngo-esophageal diverticula (Zenker`s).
Here, we present a case of this very rare condition in a young boy who presented with severe
dysphagia since childhood.
Key words: Lateral, pharyngeal, diverticulum dysphagia
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.19
Case Summary
A 16 year old male patient presented to our hospital with difficulty of swallowing of solid and liquid diet
since childhood with worsening of these symptoms since the past three years. Patient swallows with
significant effort while noticing bulging of his neck on the right side. There was no history of cardiac,
respiratory or neurologic condition in the past, no history of trauma, surgery or neck infection
Physical findings at admission included stable vital signs, otherwise unremarkable. Pertinent finding was
noticed upon attempt at swallowing and with Valsalva maneuver with significant bulging of the right
lateral neck which is cystic and reducible (Figure 1). No neck swelling on the left side.
Hence with the diagnosis of dysphagia secondary to lateral pharyngeal diverticulum he was investigated.
Routine lab work was normal. Barium swallow revealed an out-pouching on the right lateral side of the
hypopharynx on the right pyriform recess (Figure 2). CT scan of the neck also revealed the diverticulum.
On Endoscopy, the right side recess looked distorted with bulging mucosal folds and it was not possible to
intubate the esophagus.
The patient was subsequently operated with an initial incision made along the right anterior border of the
sternocleidomastoid muscle and dissection was made to the level of the diverticulum which was arising
between the middle and inferior pharyngeal constrictor muscles and the thyro-hyoid membrane. The
diverticulum was subsequently opened and attempt was made to pass in a nasogastric tube and failed due
to a tightly constricted cricopharyngeus muscle (Figure 3). Skin incision was then extended along the
anterior border of the left sternocleidomastoid muscle and and dissection made to the level of the cervical
esophagus which was mobilized and the right lobe of the thyroid gland was removed to gain better
exposure of the cricopharyngeal junction.
A
B
Fig 1. A and B Bulging right lateral neck mass during Valsalva maneuver (Arrows)
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Myotomy was done on the cricopharyngeus muscle and the diverticulum excised and closed in two layers
after nasogastric tube was inserted. Cervical fascia and platysma was closed in layers after a glove drain
was placed deep in the wound. After the patient was extubated and taken to the post anesthesia recovery
room he developed respiratory arrest and was reintubated again with about 1.5 litres of hemorrhagic
fluid sucked out through the endotracheal tube. Hence with the diagnosis of aspiration with pulmonary
edema and possibly transient recurrent nerve palsy he was kept in the ICU where he was extubated on his
4th post-operative day and recovered well to be discharged. He was evaluated on subsequent visits and is
able to swallow both solids and liquids.
A
B
Figure 2. Barium swallow with (A) and without (B) Valsalva maneuver demonstrating the big
diverticulum opening into the right Pyriform recess (Arrows)
A
B
Figure 3. Diverticulum dissected (A) and opened (B)
Discussion
Many descriptions of pharyngeal wall protrusion or herniation existed since Ludlow in 1764, one would
find terms like pharyngeal pouch, diverticulum or pharyngocele.[1] Lateral pharyngeal diverticulum or
Pharyngocele was first reported well in 1886 by Wheeler [2] and since then only 55 cases were reported in
the literature.[3] These conditions are usually seen between the 6th and 8th decades of life due to
progressive weakening of the pharyngeal wall (usually through the area between the middle and inferior
constrictors and thyro-hyoid membrane) but can also be exist in younger patients. The condition occurs
more commonly in males (2-3 times more common than in women)3. Lateral pharyngeal diverticulum can
be either congenital or acquired and is usually suspected to occur due to the combined effects of
weakened pharyngeal wall and increased intrapharyngeal pressure 6. The congenital ones are thought to
arise from remnants of third and fourth branchial pouches whereas acquired diverticula have been
reported in individuals occupied with professions that are related with the development of increased
pressure for prolonged time in the pharynx such as in Glass blowers and in individuals playing wind
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musical instruments. [4][6] Some also suggest that prior neck surgery and trauma leading to weakened
pharyngeal wall may predispose to the development of the herniation.
Our patient had history of dysphagia throughout his life which may indicate a congenital diverticulum as
a result of increased pressure in the pharynx though the cause of the increased pressure that was noticed
may also be from the tightly narrow cricopharynx. But if such had been the case, we would have likely
seen the usual Zenker`s diverticulum in the posterior hypopharynx through the weak Killian-Jemeson
dehiscence. Such is the case that it is very likely the diverticulum existed since congenitally and combined
with the narrowing in the cricopharyngeal area led to its increased size which led to the lately severe
dysphagia and huge swelling in the neck. The orifice of the diverticulum was wide in our patient
contributing to the lack of bad odor and delayed food regurgitation commonly seen with patients having
diverticula with narrow orifice.
Patients` presentation can be varied like with neck mass, dysphagia or pain, occasionally with
regurgitation and dysphonia (albeit from big diverticula impinging on nerves). [5] Investigations for lateral
pharyngeal diverticula usually involve Endoscopy which would reveal the site of the diverticulum
through a slit like orifice visualized around the tonsils/valeculla or pyriform sinus and in our patient due
to the big diverticulum and wide orifice such visualization was not possible. Barium swallow studies also
can give us better images as to the exact site and nature of the diverticula entering the pyriform recess as
in our case or sometimes around the tonsils or valeculla especially when performed with Valsalva
maneuver.[7.
Management of such patients is usually conservative with good oral hygiene (mouth wash and gargling),
avoidance of coarse particulate matter in diet like raw vegetables and whole corn especially when the
diverticula are small and asymptomatic but in cases such ours when the size of the diverticulum is large
and patients are symptomatic, surgical diverticulectomy would be indicated.[4][5][8] Surgically identifying
the diverticulum may be challenging at times and some surgeons would start the procedure under local
anesthesia with voluntary Valsalva maneuver done by the patient to aid in localization of the
pharyngocele especially when small in size and convert to general anesthesia after identifying the
diverticulum 4. But such endeavor was not necessary in our patient as the diverticulum was big in size
and was fairly easy to identify once the dissection was carried to the level of the pharyngeal wall.
Fortunately the respiratory distress in our patient that occurred post operatively was most likely from
contused nerves and recovered well once the inflammation subsided over the next three days.
Conclusion
Lateral pharyngeal diverticula or pharyngocele are rare conditions and should not be mistaken for the
more common Zenker`s or posterior pharyngo-esophageal diverticulum and should be included in the
differential diagnosis of cystic swellings and diverticula in the pharynx when presented especially in
young individuals. And as has been described in our case, barium study may be a better aid to the
diagnosis in certain cases.
References
1. Norris CW. Pharyngocele of the hypopharynx. Laryngoscope 1979;89:1788-1807
2. Wheeler WI. Pharyngocele and dilatation of pharynx. Dublin J Med Sci 1886:82:349-57.
3. Gundappa D. Mahajan, James Thomas, Priya Shah, Rashmi Prashanth. Pharyngocele opening in
vallecula: An unusual presentation. Medical Journal of Dr. D.Y. Patil University 2013: 6(3):318-20.
4. William G. Fowler. Lateral Pharyngeal Diverticula. Annals of Surgery January 1962; 155(1):16165.
5. P.M. Van De Ven, H.K. Schutte. The pharyngocele: infrequently encountered and easily
misdiagnosed. The journal of Laryngology and Otology 1995; 109:247-49.
6. OishiKonari M, ZapaterLatorre E, MosqueraLloreda N, BasterraAlegria J. Faringocele.
ActaOtorrinolaringol Esp. 2013; 64:369-370.
7. Hashem Fakhouri, Nabil Arda. Pharyngocele: A case report of a rare cause bilateral neck swelling.
JRMS 2007; 14(1):53-56
8. Pinto J. A., Marquis V. B., Godoy L. B. M., Magri E. N., Brunoro M. V. F. Bilateral hypopharyngeal
diverticulum. Otolaryngology 2009;141:144-145
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Factors Associated With Manual Reduction of Incarcerated Inguinal Hernia in Children
T.A. Lawal, D.I. Olulana, O.O. Ogundoyin, K.I. Egbuchulem
Department of Surgery University of Ibadan and Division of Paediatric Surgery, University College
Hospital, Ibadan, Nigeria
Correspondence to: Dr. Taiwo A. Lawal, Email: [email protected]
Background: In patients with incarcerated inguinal hernia, initial manual reduction, which is not
always feasible, rather than immediate surgery, is associated with fewer complications. The aim of
the study was to evaluate factors associated with successful manual reduction of incarcerated
inguinal hernia in children.
Methods: A prospective cohort study between January 2010 and December 2014 of children admitted
with incarcerated inguinal hernia to a single surgical unit.
Results: A total of 34 patients with a median age of 4.2 months (range: 2 weeks to 14 years) were
recruited. Manual reduction was attempted in 23 (67.6%) patients and successful in 13 (56.5%). A
total of 9 (26.5%) patients had bowel strangulation. Shorter incarceration (median of 18.2 vs. 48.4
hours, p = 0.004) and longer duration of previous swelling (median of 20 vs. 3.5 weeks, p = 0.029)
were associated with successful manual reduction. Bowel strangulation rate was higher amongst
patients excluded from manual reduction, using the set criteria, compared to those who had failed
reduction (77.8% vs. 22.2%, p = 0.044).
Conclusions: Manual reduction is more likely to be successful in patients who present early after
incarceration as well as those with wider internal rings.
Keywords: children, incarceration, inguinal hernia, manual reduction, strangulation
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.20
Introduction
Inguinal hernias occur in 0.8% to 5% of all children and virtually all has to be repaired since spontaneous
resolution is rare1, 2, 3. The surgical repair is easy to perform, relatively safe and has minimal
postoperative morbidities4, 5, 6. Delay in repair or failure to recognize and diagnose the condition may
result in development of incarceration. Incarceration occurs due to irreducibility of hernia contents,
mostly bowel loops, omentum, vas deferens and other cord structures. This may progress to frank
intestinal obstruction and subsequent strangulation as entrapment of blood supply to the testis via the
testicular artery and or bowel segment through the mesentery causes ischaemia and later, testicular
infarction or bowel gangrene.
In the treatment of patients with incarcerated hernia, emergency surgery has been associated with a
higher complication rate compared to an initial manual reduction because oedema impairs the visibility
at surgery6, 7. Following a successful reduction, herniotomy is performed after some hours to a few days
when the oedema is expected to have resolved. In developing countries, such as Nigeria, there is often a
delay in presenting to the paediatric surgeon when incarceration occurs1, 7, 8 and some patients may thus
not be fit for manual reduction. It is therefore, necessary in such settings to have criteria developed for
manual reduction to be attempted. This approach, will likely, lower the risk of reducing a gangrenous
segment of bowel into the abdomen9 and its associated morbidity as the patient is made to wait for a few
days before herniotomy in a bid to encourage resolution of oedema of the hernia. It will also help in
reducing the postoperative complications after emergency groin surgery.
A protocol in this regard was developed in the division to guide the management of incarcerated
childhood inguinal hernia. The study thus aimed to describe the outcome of management of patients with
incarcerated inguinal hernia at a single paediatric surgery unit in Nigeria, evaluate the factors associated
with successful manual reduction following a protocol and compare the characteristics of patients who
were ineligible for or had unsuccessful attempts with manual reduction.
Patients and Methods
This was a prospective cohort study conducted between January 2010 and December 2014 at the Division
of Paediatric Surgery of the University College Hospital, Ibadan, Nigeria. All the patients who presented to
the Children’s Emergency Room on account of irreducibility of a groin swelling, confirmed to be an
incarcerated or strangulated inguinal hernia on examination, were entered into the study. Incarceration
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was defined as irreducibility of the hernia by a surgeon. The incarcerated hernia was classified as
strangulated if there were symptoms and signs suggesting bowel ischaemia from vascular compromise
such as fever, persistent vomiting and abdominal distension7. Information was obtained on the patients’
socio-demographic details, nature and duration of presenting symptoms, presence of groin swellings
prior to the incarceration, examination findings, resuscitation measures, attempts made at reduction of
the swellings, treatment offered, operation findings and the outcome of care – measured in terms of
morbidity both before discharge and during follow up in the surgical outpatients.
Management of incarcerated hernia
Nasogastric decompression was instituted and intravenous antibiotics administered to those with
intestinal obstruction. The patients with incarceration but without features of strangulation were offered
manual reduction of the hernia using analgesia (intravenous pentazocine) and sedation (intravenous
diazepam). Those that were not eligible for manual reduction were prepared for an immediate surgery.
Exclusion criteria for manual reduction included persistent vomiting, constipation, fever and abdominal
distension. Those who had successful reduction of the hernia were admitted to the ward, commenced on
oral intake within 24 hours and scheduled for herniotomy on the next operation list. The patients who
had failed manual reduction under analgesia and sedation had immediate surgery.
The information obtained was entered into a computer using SPSS version 21 software and data analysis
performed. Descriptive data was presented using range and medians for continuous variables and
percentages, ratios or proportions for categorical variables. The Mann-Whitney U test was used to
compare continuous variables and Chi-square statistics or Fishers Exact test used to explore associations
between categorical variables. The p value for statistical significance was set at 0.05.
Results
A total of 246 patients were managed for inguinal hernia during the period of the study of which 34
(13.8%) presented with incarceration. There were 31 (91.2%) males and the male to female ratio was
10.3:1. There were 24 (70.6%) hernias on the right and 10 (29.4%) on the left. The median age of the
patients was 4.2 months with a range from 2 weeks to 14 years. A total of 22 (64.7%) patients, including
six neonates, were aged 12 months or less; 3 (8.8%) were aged 1 to 2 years and 9 (26.5%) were older
than 2 years.
The presenting features, apart from the irreducible groin or scrotal swelling, included obstructive
symptoms of vomiting in 9 (26.5%), constipation in 4 (11.8%) and abdominal distension in 9 (26.5%)
patients. Fever was present at presentation in 6 (17.6%) patients. The majority (22, 64.7%) had a groin
swelling prior to presenting with irreducibility and the swelling had been present for 2 days to 2 years
with a median duration of 6 weeks. The duration of groin pain or inconsolable crying heralding the
incarceration ranged from 1 hour to 5 days (median of 2 days). Manual reduction was attempted in 23
(67.6%) patients and it was successful in 13 (56.5%) of those. Following the reduction, the patients were
on admission for 48 to 96 hours and there was no post reduction peritonitis.
Twenty-one patients, consisting of 11 who were not suitable for manual reduction and 10 who had failed
reduction, had emergency surgery; these included two exploratory laparotomies for generalized
peritonitis and 19 groin surgeries. Findings at emergency surgery included small bowel gangrene in 9
(26.5%) patients of which 3 (8.8%) also had testicular infarction, and oedematous and dusky loops of
small bowel that became pink after application of warm abdominal gauze packs in 8 (23.5%) patients.
The entrapped bowel was oedematous and pink in 4 (11.8%) patients. A total of 9 (26.5%) patients, thus,
had true strangulation.
All 34 patients had herniotomy, nine had bowel resection and anastomosis and three had orchidectomy.
The surgeries were all done under general anaesthesia. The length of stay in the hospital after surgery
ranged from 0 (discharged on the day of surgery in patients who had delayed herniotomy after successful
manual reduction) to 7 days with a median of 4 days. Post operative complications included wound
infection in 4 (11.8%) patients, wound dehiscence in 2 (5.9%) – both patients had laparotomies – and
scrotal haematoma in 3 (8.8%). There was no mortality and there was no postoperative testicular
atrophy at a median follow up period of 10 months (range of 2 months to 4 years).
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Factors associated with successful manual reduction
Patients who presented early (median of 18.2 hours) had more successful attempts at reduction
compared to those who presented later (median of 48.4 hours), p = 0.004 (Table 1). Reduction was
equally more likely to be successful in patients with a previous groin swelling of a longer duration than a
shorter duration (median of 20 weeks vs. 3.5 weeks, p = 0.029). There was no significant relationship
between the age at presentation and success with manual reduction (Table 1).
Table 1. Relationship of age at presentation, duration of symptoms and duration of previous groin
swelling to outcome of manual reduction
Variable
Categories
Age at
presentation
(months)
Successful
Duration of
symptoms
(hours)
Successful
Duration of
previous groin
swelling
(weeks)
Successful
Not successful
Not successful
Not successful
Successful manual reduction
Range
U**
Z
(Median)
0.6 – 177.5
131.0
-0.195
(4.8)
0.7 – 120.7
(3.6)
1.0 – 36.0
57.0
-2.998
(18.2)
12.0 – 120.0
(48.4)
3.0 – 104.0
24.5
-2.155
(20.0)
0.3 – 78.0
(3.5)
r
p value
-0.033
0.845
-0.514
0.004*
-0.370
0.029*
* - Statistically significant, ** - Mann Whitney U Test statistic
Table 2. Comparison of patients who were excluded from manual reduction (not qualified for reduction)
and those with failed reduction
Variables
Excluded from
Failed reduction
Total
χ2
p value
reduction
No (%)
No (%)
No (%)
Gender
Male
10 (52.6)
9 (47.4)
19 (100.0)
FET
1.000
Female
1 (50.0)
1 (50.0)
2 (100.0)
Age
≤ 12 months
7 (53.8)
6 (46.2)
13 (100.0)
0.029
0.864
> 12 months
4 (50.0)
4 (50.0)
8 (100.0)
Duration of
incarceration < 36
4 (44.4)
5 (55.6)
9 (100.0)
0.398
0.528
(hours)
≥ 36
7 (58.3)
5 (41.7)
12 (100.0)
Prior groin swelling
Yes
8 (57.1)
6 (42.9)
14 (100.0)
0.382
0.537
No
3 (42.9)
4 (57.1)
7 (100.0)
Bowel gangrene
Yes
7 (77.8)
2 (22.2)
9 (100.0)
4.073
0.044*
No
4 (33.3)
8 (66.7)
12 (100.0)
Testicular infarction
Yes
2 (66.7)
1 (33.3)
3 (100.0)
FET
1.000
No
9 (50.0)
9 (50.0)
18 (100.0)
Total
11 (52.4)
10 (47.6)
21 (100.0)
* - Statistically significant, FET – Fishers Exact Test
Comparison of patients who had failed reduction and those excluded from manual reduction
The proportion of patients excluded from manual reduction, using the set criteria, who had bowel
gangrene (77.8%) was higher than the proportion of those who had failed manual reduction under
sedation and had evidence of bowel gangrene at surgery (22.2%), p = 0.044. There were no significant
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differences between the two groups of patients in terms of their gender, age, duration of incarceration,
presence of prior groin swelling and testicular infarction (Table 2).
Discussion
Incarceration is a feared and largely avoidable complication of inguinal hernia in children. In settings
where access to care is poor and delay in recognition and treatment is common, this complication can
progress to strangulation and its sequelae of testicular atrophy and or bowel gangrene. In this study,
13.8% of the patients treated on account of childhood inguinal hernia presented with incarceration. This
proportion, similar to the 14% incarceration rate reported in Ilorin – a city with similar socioeconomic
and health indices as Ibadan, is much higher than 1.6% to 9% reported from centres in more developed
countries with comparable hernia case loads10, 11, 12. The proportion is on the other hand, similar to the
12% rate reported amongst 6361 children with inguinal hernias treated by a single surgeon over a period
of 35 years in Toronto, Canada. These variations may be due to differences in practice of referral of
children with hernias by family physicians and paediatricians, waiting time to surgery and coding of
diseases10. Furthermore, it may, be due to delay in seeking care by parents when bulges are observed in
the groin as well as the economic implications of caring for children using out of pocket financing in
resource challenged settings. This is corroborated by the fact that 65% of the parents knew that their
child had a groin swelling for as long as two years without presenting to a hospital.
Nearly two thirds of the patients with incarcerated hernia in this study were infants and 74% had
incarceration before the age of two years. Aboagye et al.13 similarly reported that 56% of patients with
inguinal hernia would have developed incarceration before their first birthday. Incarceration is noted to
be more common in neonates than older children. In this study, 18% of the patients had incarceration
during the first month of life. Incarceration is common in this age group because of the narrow size of the
internal inguinal ring relative to the contents of the hernia sac. Thus, early repair of inguinal hernia has
been advocated when discovered immediately after birth14, 15. Unfortunately, quite a number of children
are delivered outside hospital settings in developing countries7. Public health education and
enlightenment may therefore be necessary for traditional birth attendants, midwives and others that are
involved in their deliveries in developing countries towards early recognition and prompt referral.
Manual reduction of the incarcerated hernia was attempted in 23 patients and successful in 57%. This is
also a reflection of delay in presenting to the hospital of up to five days from onset of symptoms. In the
study of 41 patients with incarcerated hernia in Ilorin, Nigeria, Bamigbola et al.1 noted that patients
presented between two hours and four days of onset of symptoms and manual reduction was successful
in 46% of the patients. The present study found that manual reduction is more likely to be successful in
patients who present early and in those who had a prior groin swelling that had been there for a longer
period. Time is of essence in the progression from incarceration to obstruction and finally strangulation
with the ability to successfully reduce the bowel mirroring this sequence16. A groin swelling that had been
there for a longer time was found easier to reduce than one that had been there for a shorter time,
perhaps because the older children in the study may have had their hernia for a longer time than the
younger ones. A wider internal inguinal ring may also allow the content to be easing in and out of the
inguinal canal much more readily, and thus stay for longer before becoming irreducible compared to a
narrower inguinal ring16.
In this study, manual reduction could not be attempted in 32% of patients. This group of patients had a
significantly higher strangulation rate than patients who were offered reduction but the attempt failed.
The criteria that were used to exclude patients from manual reduction thus appeared to be
discriminatory as far as bowel gangrene was concerned. This has helped in the cohort of patients to avoid
the risk of reducing a gangrenous bowel into the abdomen. It has been accepted in principle by paediatric
surgeons that since this event could occur, a child who has had manual reduction of an incarcerated
hernia should be observed closely over a period of 24 to 48 hours for features of peritonitis7, 11, 17.
The patients who had successful manual reduction in this study were all admitted to the ward to allow
oedema to subside and operated within 48 to 96 hours on the next available operating day. Although the
practice varies from one hospital to the other and many may not recommend admission, this practice was
adopted in our setting because the parents may not return for surgery on time if allowed to take the
children home after successful manual reduction. This is particularly of importance because there may be
repeat episodes of incarceration if there is further delay in performing the herniotomy. In a comparison of
75 paediatric patients who had herniotomy within 72 hours of reduction of incarceration and 108 who
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had delayed herniotomy one to four months after the reduction, 17 (15.7%) patients in the latter group
had 34 episodes of repeated incarcerations between five days and four months after reduction18. It was
therefore recommended that herniotomy be done at most five days after a successful manual reduction18.
No major complication such as recurrence of the hernia, testicular atrophy or iatrogenic ascent of the
testes was noted. A total of nine minor complications mostly related to surgical site infection or scrotal
haematoma that were all managed conservatively were seen. The outcome of management of the patients
in this study is comparable to what had been reported from similar settings where patients present late
after onset of incarceration. A limitation of the study, however, was the short period of follow up of some
of the patients. A longer period of observation may be required to monitor the development of testicular
atrophy, which can occur as long as one year after surgery.
Conclusions
Incarcerated inguinal hernia can be safely managed in children. Manual reduction is more likely to be
successful in patients who present early after incarceration as well as those with wider internal rings. The
bowel strangulation rate is higher in patients who have fever or obstructive symptoms at presentation.
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Baird R, Gholoum S, Laberge JM, Puligandla P. Prematurity, not age at operation or incarceration,
impacts complication rates of inguinal hernia repair. J Paed Surg 2011; 46: 908-911.
Kaya M, Huckstedt T, Schier F. Laparoscopic approach to incarcerated inguinal hernia in children.
J Paed Surg 2006; 41: 567-569.
Nah SA, Giacomello L, Eaton S, de Coppi P, Curry JI, Drake DP, et al. Surgical repair of incarcerated
inguinal hernia in children: laparoscopic or open? Eur J Ped Surg 2011; 21: 8-11.
Ameh EA. Incarcerted and strangulated inguinal hernias in children in Zaria, Nigeria. East Afr
Med J 1999; 76: 499-501.
Ezomike UO, Ekenze SO, Amah CC. Irreducible inguinal hernias in the paediatric age group. Niger
J Med 2013; 22: 230-233.
Strauch ED, Voigt RW, Hill JL. Gangrenous intestine in a hernia can be reduced. J Paed Surg 2002;
37: 919-920.
Gholoum S, Baird R, Laberge JM, Puligandla PS. Incarceration rates in pediatric inguinal hernia:
do not trust the coding. J Paed Surg 2010; 45: 1007-1011.
Houben CH, Chan KW, Mou JW, Tam YH, Lee KH. Irreducible inguinal hernia in children: how
serious is it? J Paed Surg 2015; 50: 1174-1176.
Stylianos S, Jacir NN, Harris BH. Incarceration of inguinal hernia in infants prior to elective repair.
J Paed Surg 1993; 28: 582-583.
Aboagye J, Goldstein SD, Salazar JH, Papandria D, Okoye MT, Al-Omar K, et al. Age at presentation
of common pediatric surgical conditions: Reexamining dogma. J Paed Surg 2014; 49: 995-999.
Antonoff MB, Kreykes NS, Saltzman DA, Acton RD. American Academy of Pediatrics Section on
Surgery hernia survey revisited. J Paed Surg 2005; 40: 1009-1014.
Wiener ES, Touloukian RJ, Rodgers BM, Grosfeld JL, Smith EI, Ziegler MM, et al. Hernia survey of
the Section on Surgery of the American Academy of Pediatrics. J Paed Surg 1996; 31: 1166-1169.
Glick PL, Boulanger SC. Inguinal hernias and hydroceles. In: Grosfeld JL, O’Neill (Jr) JA,
Fonkalsrud EW, Coran AG (eds). Pediatric Surgery Vol 2, 6th edn. Philadelphia: Mosby Elsevier,
2006; 1172-1192.
Al-Ansari K, Sulowski C, Ratnapalan S. Analgesia and sedation practices for incarcerated inguinal
hernias in children. Clin Pediatr 2008; 47: 766-769.
Gahukamble DB, Khamage AS. Early versus delayed repair of reduced incarcerated inguinal
hernias in the pediatric population. J Paed Surg 1996; 31: 1218-1220.
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Manual Detorsion of Testicular Torsion - A Primary Care Intervention Procedure.
Case Reports.
E L Mugalo
Moi University, department of medical Physiology and Moi Teaching and Referal Hospital, Department of
Urology, Eldoret, Kenya.
Email: [email protected].
Testicular torsion is one of the known acute urological emergencies that require prompt
intervention. Salvage of the testis is only possible if derotation is performed within 6 hours of onset
of symptoms. The objective of this paper is to report successful manual detorsion of the testes of
patients with testicular torsion. Three cases with testicular torsion requiring emergency scrotal
exploration underwent manual detorsion after sedation while waiting to be taken to theatre. Case 1,
a 15 year old male diagnosed with right sided testicular torsion. Case 2, a 28 year old male with
right testicular torsion. Case 3, a 15 year old male who presented with a 6 hour history of left
testicular torsion. Attempting manual detortion in patients with acute testicular torsion can salvage
the testis against loss.
Key Words: testicular torsion, manual detorsion, testicular survival, orchidopexy.
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.21
Introduction
Testicular torsion is a known urological emergency that is characterized by twisting of the spermatic cord
leading to acute pain and ischemia of the affected testes. It has a short window period within which
salvage can be achieved. Common signs include swelling and redness of the scrotum (in light skinned
people), nausea and vomiting, high riding testes, tender, swollen and firm with absent cremasteric reflex.
A clear clinical diagnosis and early intervention is essential to avoid testicular loss. Approximately 1 :
4000 males younger than 25 years and 1 : 160 males by the age of 25 years are affected 1, 2.. The “bell
clapper” deformity is the underlying anatomical anomaly and it accounts for 90% of all cases (a). Acute
scrotal pain in all prepubertal and young adult males could indicate testicular torsion until proven
otherwise. It had been demonstrated both clinically3, 4 and experimentally5 that testicular survival
depends on the duration of ischemia. Testicular salvage rate is over 98% when diagnosis and detorsion
occurs within 6 hours 6. The affected testes can only be preserved by detorsion of the spermatic cord to
restore perfusion. This can be achieved pre-operatively by manual detorsion or intra-operatively under
direct vision.
Case Reports
We report three cases of successful reduction following detorsion, one with oral analgesia and the other
with sedation and the third patient with Intramuscular analgesic injection. Scrotal exploration followed
soon after and it confirmed successful manual detorsion. Bilateral orchidopexy was thereafter performed.
Case 1
A 15 year old male who developed scrotal pain and swelling at 2a.m. He was brought to casualty at 6 am,
three (3) hours after the onset of pain, when the pain and swelling got worse. Physical examination
revealed an enlarged right hemi scrotum. It was raised, tender and the testes assumed a transverse
longitudinal axis. The tenderness was worsened by elevation of the scrotum, and cremasteric reflex was .
Ultrasound performed in casualty revealed testicular torsion.
He was received in theatre 71/2 hours after the onset of pain. Manual detorsion was attempted and
successfully achieved after sedation for induction of general anesthesia.
When the scrotal sac was opened, the testes was found to be pink, area of torsion on the spermatic cord
noted, bilateral orchidopexy was performed with non-absorbable silk2/0 suture.
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Case 2
A 28 year old man reported to our clinic with 4 hour history of sudden onset right scrotal pain, nausea
and vomiting with no dysuria or urethral discharge. On examination he had an enlarged right scrotum,
which was elevated with the testes lying transversely testes. The testicle was tender to touch, elevated
with absent cremasteric reflex. The Patient initially declined surgery, insisting on U/S which confirmed
absent Doppler flow in the right testes.
Manual detorsion was attempted by rotating the testes in anticlockwise direction, after giving oral
analgesic, as we waited for the patient to consent for surgery. At surgery blood flow had already been reestablished in the right testes with the testes viable.
Case 3
A 15 year old male patient reported to accident and emergency with a 6 hour history of sudden onset left
scrotal pain radiating to the lower abdomen. It was associated with nausea and vomiting, but no dysuria,
fever or body chills. . A Doppler ultrasound done in another hospital before referral, confirmed absent
color flow. On examination the left hemiscrotum was raised, tender to palpation. The testes had assumed
a transverse orientation and the cremasteric reflex was absent. There was a palpable knot in the
spermatic cord above the testes. An intramuscular injection of Tramadol 50mg stat was given in casualty
and the patient got completely relived of pain. Manual detorsion was successfully performed in casualty
and a repeat Doppler ultrasound revealed a swollen left testes with a normal Doppler color flow .The
patient taken to the operating theater for scrotal exploration where the left testes was found to be viable.
Bilateral orchidopexy using a 3/0 silk suture was performed.
Figure 1. Salvaged Left Testes after Manual Distortion of Case 3.
Discussion
Testicular torsion is one of the known acute urological emergencies that require prompt intervention.
Salvage is only possible if detorsion is performed within 6 hours of onset 6, 7.
Prolonged period of ischemia leads to loss of the affected testes. Most torsion of the spermatic cord is
from lateral to medial. The preponderance to medial rotation ranges from 67% to 71% 8. Manual
distortion has been reported since 1893 but is not widely practiced9. It provides an immediate noninvasive treatment for the problem. The affected tested is rotated away from the midline. Intravenous
sedation with or without local analgesia (5mls of 2% lidocaine/xylocaine) infiltration around the
spermatic cord near the external ring.
Manual detorsion aims at reversing the twisting through two planes. Due to the higher preponderance to
medial rotation, the initial step at reduction involves rotation of the testes in a caudal cranial direction to
release the locking mechanism. This is followed by a medial distortion of the spermatic cord. Sequential
rotation by 180° in one direction, initially lateral, due to higher predilection to medial rotation, then
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maintaining the twist after which it is followed by an attempt to a further 180° or more. Increase in pain
or increased resistance may indicate attempting distortion in the wrong direction.
Dramatic reduction in pain indicates success. Elective orchidpexy can be arranged if resumption of blood
flow has been documented by Doppler ultrasound. Success rate has been reported at 26.5 % in a metaanalysis 10 while another put it at 80% 11. Lengthening of spermatic cord ,resolution of epididymal and
spermatic cord edema, return to anatomical position and near or complete relief of testicular pain
confirms successful detorsion 12. In a primary health facility where surgical intervention is not possible or
is not quickly available, manual detorsion will greatly improve the salvage rate. Consequences of either
delay in intervention or due to referral usually lead to testicular loss, and may attract litigation.
Conclusion
Testicular torsion is a urological emergency that requires prompt intervention to salvage the affected
testes. Salvage rate is 98% when diagnosis and definitive treatment is performed within 6 hours. In view
of the delays that are commonly experienced in our healthcare care system, knowledge of this condition
and the procedure of manual detorsion will greatly improve the salvage rate in our set up. The health
professional will also refer the patients early for definitive management where there is limitation of
facilities for prompt surgical intervention.
Acknowledgements
To the Moi and Referral Hospital Management for giving permission to publish my experience in
managing the three patients reported in this publication.
References
1.
Erica Ringdal. MD and Lynn Teague MD.Testicular torsion. Am Fam Physician. 2006 Nov
15;
74(10):1739-1743.
2. Sinisi AA, Difinizio B, Lettieri F et al. Late gonadal function and autoimmunization in familial
testicular torsion. Arch Andriol 1993; 30:147.
3. E.V. Cattolica, J. Karol, K, Rankin, and R, Klein. “High testicular salvage rate in torsion of the
spermatic cord”. The Journal of urology, vol; 128, no.1, pp.66-68, 1982.
4. E. Makela, T. Lahdes-Vasama, H.Rajakorpi, and S. Wikstrom. "spermatic cord block and manual
reduction: Primary treatment for spermatic cord torsion”. The Journal of Urology, vol: 132, no.5,
pp, 921-923, 1984.
5. G. Smith. “Cellular changes from graded testicular ischemia”. The Journal of urology, vol, 72,
pp.355-362, 1955.
6. Paul Headway, John M Reynard. The six-hour rule for testis fixation in testicular torsion: Is it
History? Journal of clinical urology March 2013 vol.6 no.2 84-88.
7. Makela E, Lahdes –vasama T, Rajakorpi H, Vikstrom S. a 19 year review of pediatric patients with
acute scrotum. Scand J Surg. 2007; 96(1):62-6.
8. Session AE, Robinowitz R, Hulbert WG, Goldstein MM, Mevorah RA. Testicular torsion, direction,
degree, duration and destination. J Urol 2003 Feb 169(2):663-5
9. Nash W, acute spermatic cord: reduction: immediate relief. British Medical Journal 1893; 1:P742.
10. Hwatrey CE. Assessment of acute scrotal symptoms and findings. A clinician’s dilemma. Urol Clin
North Am. 1908; 25:715-23.
11. Cornel EB, Karthaus HF. Manual derotation of the twisted spermatic cord. BJU Int. 1999; 83:672-4
12. Kiesling VJ Jr, Schroeder DE, Pauljev P, Hull J. spermatic cord block and manual reduction:
Primary treatment for spermatic cord torsion. J urol 1984 Nov, 132(5):921-3.
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Cerebellar Pilomyxoid Astrocytoma
Hagos Biluts1, Kibruyisfaw Zewdie1, Tufa Gemechu2
1Department of surgery, Neurosurgery unit, COHS, AAU
2Department of Pathology, COHS, AAU
Correspondence to: Dr. Hagos Biluts, Email: [email protected].
Pilomyxoid astrocytomas (PMA) are new class of Pilocytic Astrocytoma (PA.), which typically have
their origin in hypothalamus and Chiasmatic region. There are very few case reports of PMAs
arising from cerebellum. Their imaging features are similar to PA but they behave more
aggressively than PA. To increase awareness of PMA within the neurosurgical community, the
authors reviewed a case of 11-year-old male child who presented with truncal and cerebellar
ataxia and vomiting and right cerebellar tumor diagnosed as PA radiologically but PMA on
histopathology examination. These findings indicate that PMA may be a unique entity that is
distinct from PA, or it may be an unusual variant.
Key words: -Pilocytic astrocytoma • pilomyxoid astrocytoma • diagnosis • cerebellar
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.22
Introduction
Pilocytic astrocytomas are generally benign, typically showing 20-year survival rates of 70 to 80%, even
when only a subtotal resection is achieved.1 These highly treatable and potentially curable pediatric
tumors are considered Grade I neoplasms according to the World Health Organization tumor
classification system.2, 3Prior to its recognition, PMA was grouped with PA, because the two display
similar histological features.
In 1999, Tihan and colleagues provided the sentinel description of PMAs.1 Because of their similar
histological and radiological features, 2 PMAs were classified as PAs prior to acceptance of this
publication. . Earlier reports pointed out unusual features of some pediatric astrocytomas, particularly
those within the hypothalamic/chiasmatic region, but did not specifically use a term to distinguish them.4,
5,9
In contrast to PAs, PMAs demonstrate a more aggressive clinical course8-9 and appear to be associated
with a higher incidence of leptomeningeal spread.9 Pilomyxoid astrocytomas are considered to be WHO
Grade II neoplasms, and most often arise from the hypothalamic/chiasmatic region. However, PMAs
sometimes originate from the posterior fossa.4whereas hypothalamic PMAs have been well described in
the literature, there is a relative paucity of information about PMAs that arise from the cerebellum.
Although limited clinical experience makes it difficult to generate conclusive prognostic data regarding
this recently described pediatric tumor, PMA has been shown to behave more aggressively than PA .11
Here we report a case of cerebellar PMA in a 11 year old male child and discuss literature review
Case report
This was an 11 year old male patient who was relatively in a good state of health prior to his presentation
to neurosurgical referral clinics at which time he presented with global headache,projectile vomiting of
ingested matter of one moth duration, these symptoms were associated with difficulty of maintaining
balance, and blurring of vision.Physical examination revealed papilledema with positive Romberg’s
test.Abnormal rapid alternating movements, and tandemwalk were indicative of cerebellar ataxia and
truncal ataxia. Brain CT scan with contrast was done,
Figure 1: First CT scan done on January 12, 2015 showed a cystic mass at cerebellar vermis measuring 5
by 4 cm which had compressed the 4th ventricle with obstructive hydrocephalus
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With diagnostic impression of cerebellar Pilocytic astrocytoma, he was operated on 07/05/2015 midline
sub-occipital craniectomy and gross total resection of the tumor was done, and patient was discharged
with improvement after 10days of hospital stay. Initial biopsy result was Pilocytic Astrocytoma. After
discharge patient resumed his daily normal activity and re started his education. On follow-up for 8
months he was perfectly healthy at which time he started to have similar previous symptom such as
global headache with difficulty of maintaining balance with frequent vomiting of ingested matter. Physical
examination revealed papilledema with positive cerebellar sign.
Figure 2: MRI with contrast of the brain, A-Axial View, B-Coronal View, C Sagittal view: all showing
predominantly cystic posterior fossa mass with markedmass effect, protrusion of the mass through the
surgical defect posteriorly tonsilar herniationand severe hydrocephalus
With diagnostic impression of recurrent posterior fossa mass with mass effect and severe Hydrocephalus re-do
surgery was decided and operative findings are described as follows.
Operation:
Patient under went reoperation on October 30,2015. The patient was placed on the operating table in
prone position and in a pin head holder. Midline sub-occipital craniotomy and frizer bur hole done and
temporary external ventricular drain was placed in the right lateral ventricle via posterior horn to lower
the intracranial pressure by draining CSF.The dura mater did not show any abnormality. Despite the
tumor had no capsule, it demarcated clearly with the normal tissues, so that it was not difficult to remove
the tumor from the cerebellum. Gross total resection of the tumor was done. Tumor was grayish,firm nonCOSECSA/ASEA Publication - East and Central African Journal of Surgery. December 2016; Vol. 21 (3)
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suckable mass.
Postoperative period:
The patient started to shoot low-grade fever at 3rdpostoperative day CSF analysis was taken and EVD was
removed at 4th day. Cell count was high but culture was negative .He was treated with IV antibiotic with
presumptive diagnosis of post operative meningitis and discharged improved after 18 days of hospital
stay. Figure 3: shows Postoperative control Brain CT scan image done on 2 Nov 2015. Showing Gross total
resection withsmall hematoma and questionable residual.
Figure 3. brain CT scan, Axial View, showing postoperative state with small hematoma and with
surgical bone defect
Pathology report
Figure 4. H and E (hematoxylin and eosin stain) 200X. Parallel bundles of bipolar spindle cells with
fibrillar cytoplasmic process set in myxoid stroma and aniocentric nature of he tumor cell close to the
meninges is also demonstrable.
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Histopathological examination of the specimen from reoperation wasdone on 8 November 2015: formalin
fixed paraffin embedded, hematoxylin and eosine stained section demonstrate parallel band of bipolar
spindle tumor cell with fibrillary cytoplasmic process set in myxoid stroma in places the tumor cell are
arranged near the blood vessels. The angiocentric nature of the tumor cell the myxoid stromal and the
proximity of the tumor to the meninges point to the diagnosis of pilomyxoid astrocytoma.
Patient stayed 3 weeks in the hospital and treated for meningitis, finally discharged with marked
improvement. Patient was sent to Radiotherapy center for Radiation therapy, but the oncologist decided
not to give him radiation treatment. Currently, 4 months postoperatively he become asymptomatic and in
a good state of health attending school.
Discussion
PMA have been reported in the English literature and the overwhelming majority of the patients were
children aged from 2 months to 4 years.10Under the current WHO grading scheme, PAs are designated
Grade I and PMAs are designated Grade II neoplasms8. Because of similar radiological and histological
features, PMAs were considered PAs prior to their sentinel description in 1999.6 In contrast to the
fibrillary background and biphasic cellular pattern observed with PAs, PMAs display a predominantly
myxoid background with a perivascular arrangement of tumor cells, reminiscent of ependymomatous
pseudorosettes. The myxoid background and angiocentric tumor cell arrangement are typically
discernible on a low-magnification examination of H & E–stained material. Examination at high power
then reveals a monomorphous population of small bipolar cells and an absence of Rosenthal fibers and
Eosinophilic granular bodies.11 PMAs were typically seen in the chiasmatic-hypothalamic region, but they
were also found in other locations, including the spinal cord, the temporal lobe, occipital lobe and sellarsuprasellar region.12, 13Histopathological differentiation within the pilomyxoid spectrum is based on
morphological analysis of H & E–stained material; the utility of other methods of differentiation—
including immunohistochemical staining and molecular analysis—remains speculative at this time. 14,15
In this case report, the diagnosis of PMA was made predominantly on the basis of histological features
after first surgery. Histopathological distinction between PA and PMA is useful because PMAs have been
associated with increased rates of local recurrence and leptomeningeal dissemination, as well as
decreased overall survival relative to PAs.9Although it is not uncommon for conventional PAs to spread
locally to involve the leptomeninges, the incidence of leptomeningeal dissemination in cerebellar PAs is
extremely rare, 17 and many neurosurgeons do not routinely obtain MR imaging of the neuraxis to rule out
leptomeningeal dissemination before or after resection.8 Thus, pathological designation in these patients
may influence the frequency and scope of surveillance imaging. Histological features influence the riskbenefit analysis of post resection adjuvant therapy as well. Complete surgical excision of a PA is believed
to obviate the need for adjuvant therapy18; however, adjuvant chemotherapy has been recommended as
initial therapy in the treatment of PMAs.16Whereas the literature is replete with clinical series of pediatric
patients with hypothalamic/chiasmatic PMAs, descriptions of cerebellar PMAs are rare. In 1 compilation
describing the radiological features of 21 patients with PMAs from 7 different institutions, 2 patients
(10%) had tumors that arose from the cerebellum.2 In another compilation of 84 patients with
pathological findings of pediatric astrocytomas with pilomyxoid features, 2 patients harbored cerebellar
tumors.15In our case, the tumor was located in the midline region of the cerebellum, that blocked
circulation pathway of cerebrospinal fluid and the initial symptoms were induced by increased
intracranial pressure .
On MRI, PMAs also have similar signal patterns to PA, and they both show isointensity on T1WI
sequences, hyperintensity on T2WIssequences and on FLAIR images. However, some features could be
used to distinguish PMA from PA on MRI. PAs are usually cystic with solid mural nodules and are
surrounded by edema. When contrast medium was administered, PA often showed intense enhancement
in the nodule or the cyst wall. On the contrary, PMAs are often demonstrates solid or cystic, tend to be
well circumscribed, and has little to no calcification rarely with peripheral edema. In PMAs, 40% cases
showed homogenous enhancement and 30%-60% cases displayed heterogeneous enhancement. (19,20)
Furthermore, PMAs may exhibit peritumotral edema, mass effect and necrosis.
our case, the tumor showed cyst with a mural nodule. Nodule displayed homogenous enhancement while
cyst wall was non-enhancing. However, neuroimaging features cannot yet distinguish between PMA and
PA, 19 and the diagnosis of PMA is made predominantly on the basis of distinctive histological features19, 21
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Similar to Tihan T and collegues our patients with PMA, regardless of total or partial resection, a majority
of the postoperative recurrences took place within one year and the local recurrence rate was 76%. 3 The
average survival time was 6 months when MRI demonstrated a recurred tumor. 6, 13
Conclusion
PMA generally exhibits more aggressive biological behavior. Currently, there is no standard of care in
treating patients with PMA. Surgical intervention remains the first step, with complete resection being the
goal. Given the uncertainties about the prognosis of PMA, it is not possible to provide strict management
guidelines at this stage. More definitive guidelines are certain to emerge as clinicians gain more
experience with PMA in the future.
Recommendation
Histopathologist should look for features of PMAs whenever they consider the diagnosis of PAs, as this
finding is important for the patient and surgeon for
Disclosure
The authors report no conflict of interest concerning the materials or methods used in this study or the
findings specified in this paper. Prognostication and further treatment especially in cases of recurrence
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Surgical Abdomen in School Age Children: A Prospective Review From Two Centers In SouthWestern Nigeria.
A C Etonyeaku 1, 2, A O Talabi1, 2, A.A Akinkuolie1, 2, O Olasehinde1, 2, C A Omotola3, A O Mosanya2,
E A Agbakwuru1, 2.
1Department of Surgery, Obafemi Awolowo University Ile-Ife, Osun state Nigeria
2Department of Surgery, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Osun state
Nigeria
3Department of Surgery, College of Medicine and Health Sciences, Afe Babalola University Ado-Ekiti., Ekiti
state, Nigeria.
Correspondence to: Dr. Etonyeaku Amarachukwu, .E-mail: [email protected]
Background: Surgical abdomen traverses all age groups. We sought to define the aetiology, patients’
characteristics, and outcome of management amongst children
Methods: Two years prospective review of patients aged 5-15 years managed for surgical abdomen
at the Wesley Guilds Hospital Ilesa and Mishmael Medical Centre Akure, Nigeria.
Results: Fifty two patients were treated. The male: female ratio was 1:1. The age range was 5years to
15years (mean=11.25 ±2.24years). Mean duration of illness was 29.5hours (range 2-72hours). Gut
perforation was the most common aetiology (n=39; 75%); with perforations due to infections most
prevalent (n= 34; 87.2%). Ten cases (19.2%) were trauma related and showed male predominance.
Obstructed gut accounted for 15.4% (n=8) of cases; and showed female predominance. Five out of
the eight small bowel obstructions (62.5%) were due to post operation adhesions. Pre-operative and
post-operative diagnoses were congruent in 90.4% (n=47) of cases. Major post-operative
complications were surgical site infection (20; 38.5%), and pneumonia (5; 9.6%). The average
hospital stay was 9days (range 4-21days). Mortality rate was 1.9% (n=1).
Conclusion: Acute abdomen requiring surgical intervention is mainly infective origin. The male child
is more at risk of abdominal trauma while gut obstruction was more common in females.
Keywords: Surgical, Abdomen, Children, Emergency.
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.23
Introduction
Acute abdomen is a clinical condition characterized by abdominal pain of short duration, with rapid
onset or progression, requiring prompt attention. Pain is the predominant symptom in patients with
acute abdomen. The aetiology of this acute abdominal emergency is numerous and includes traumatic,
infectious and inflammatory conditions1. Of importance is the need for a quick decision on whether it is a
surgical abdomen (i.e. requiring an operation) or whether it can be managed by non–surgical means.
Surgical abdomen has a worldwide distribution and transverses all age groups. They make up a
considerable number of emergency surgeries and account for a significant part of paediatric surgery
admission2, 3 and a surgeon’s practice. It is therefore very important for the surgeon to have an
understanding and be familiar with the presentations of common diseases that cause abdominal pain4, 5.
The morbidity and mortality associated with surgical abdominal conditions can be enormous6,7. This is
particularly true in children who may have atypical modes of presentation. Moreover, there may be a
delay in presentation causing most patients to present with complications. These often make surgical
intervention challenging with varying outcomes of management. Differing patterns of presentation and
outcome of management have been reported in parts of the country especially in children in the neonatal
and preschool ages, and these have highlighted some of the challenges in the management of these
patients2, 3, 7, 8. This study aims to evaluate the pattern of surgical abdomen and outcome of intervention
among children aged 5-15 years managed in our centers. We sought to determine if there is any variation
in disease pattern amongst the age groups and gender studied and to ascertain the most common cause of
surgical abdomen in our clients.
Patients and Methods
This was a descriptive prospective study conducted at the Wesley Guild Hospital Unit of the Obafemi
Awolowo University Teaching Hospitals Complex Ile Ife Osun State and Mishmael Medical Centre: a
private hospital in Akure, Ondo State; all in South-West Nigeria. Both hospitals are about 65 kilometers
apart. The period of study was between September 1, 2011 and August 31, 2013. The surgeries were
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carried out by the General Surgery service of the hospitals, and the surgeon was not below the rank of a
specialist senior registrar.
Consecutive patients whose ages were between 5years and 15years with acute abdomen that required
surgical intervention (surgical abdomen) were recruited into the study. All patients had clinical
evaluation with ancillary laboratory and radiological investigations to obtain a pre-operative diagnosis.
Patients with acute abdomen who have clinical features of intestinal obstruction, peritonitis, and those
who had trauma with abdominal distension associated with progressive tachycardia, hypotension and fall
in haematocrit were classified as having a surgical abdomen and were recruited. Patients below five years
and those who may require intensive care services were excluded from the study. Intra-operative findings
were used to determine the final diagnosis which was then compared with the pre-operative diagnosis for
congruency. During the study period, both centres did not have facilities for routine evaluation of Creactive protein, serum amylase values and/ or abdominal computerized tomography in patients with
surgical abdomen. Hence these investigations were not done.
All patients were adequately resuscitated with correction of fluid and electrolyte deficit where necessary.
All the patients, where necessary, had nasogastric tube to decompress the stomach, urethral
catheterization to monitor adequacy of fluid management, antibiotics (cefuroxime/ceftriaxone plus
metronidazole and gentamycin) and analgesics (paracetamol and/or pentazocine). Surgical wounds,
where indicated, were irrigated with copious saline, especially in those following surgical sepsis, before
primary wound closure was done. Superficial surgical site infections were managed with removal of
stitches, daily wound dressing with honey and antibiotics in those with systemic features of infection.
Data on age, gender, duration of illness at presentation, pre-operative and post-operative diagnosis, postoperative complications and survival were entered into a spreadsheet. Data analysis was done using SPSS
version 20 for averages, frequencies and simple percentages.
Results
A total of 52 patients had surgical intervention for acute abdomen during the study period. The age range
was 5-15 years with a mean age of 11.25 (± 2.24) years. There were 27 males and 25 females with a male
female ratio of 1:1 (Figure 1). Eighteen (34.6%) patients presented within 24 hours of onset of symptoms,
while 19 (36.5%) and 15 (28.8%) presented between 25-48 hours and beyond 48hours respectively.
When the cause of the surgical abdomen was matched with age group and gender, we observed that:
intra-abdominal sepsis was more common in children between 10 and 15years (Table 2). Furthermore,
trauma occurred more in males (males=8; females=2), while intestinal obstruction was more common in
females (females= 6; males=2).
Figure 1. Sex and Age distribution
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Table 1. Congruency of pre-operative and post-operative diagnoses
S/N
1
Pre-operative diagnosis
Appendicitis
Post-operative diagnosis
Perforated typhoid ileitis
*Congruency
Incongruent
2-6
Acute appendicitis (5)
Acute appendicitis (5)
Congruent
7
Perforated appendicitis
Perforated typhoid ileitis
Incongruent
8-15
Perforated appendicitis (8)
Perforated appendicitis (8)
Congruent
16-33
Perforated typhoid (18)
Perforated typhoid ileitis (19)
Congruent
34
Perforated typhoid
Perforated appendix
Incongruent
35-39
Adhesive intestinal obstruction (5)
Adhesive intestinal obstruction (5)
Congruent
40-44
Post-traumatic gut perforation (5)
Traumatic Ileal perforation (5)
Congruent
45
Post-traumatic mesenteric injury
Post-traumatic splenic laceration grade II
Incongruent
46-47
Post-traumatic splenic injury (2)
Ruptured spleen grade IV (2)
Congruent
48
Obstructed right inguinal hernia
Obstructed right inguinal hernia
Congruent
49
Obstructed left inguinal hernia
Strangulated left inguinal hernia
Congruent
50
Post-traumatic mesenteric injury
Liver laceration
Incongruent
51
Small bowel obstruction ?cause
Incomplete midgut voluvlus
Congruent
52
Post-traumatic viscera injury
Laceration of the spleen grade III
Congruent
*congruency rate = 90.4
Table 2. Distribution of Post-operative diagnosis amongst divers age group and gender
Patient’s
Post-operative diagnosis
characteristics
Sex
Age (yrs)
Male
(27)
Sepsis
Trauma
Total
Bowel obstruction
(%)
Ac Ap
Pf Ap
Ty Pf
Sp Lac
Gut pf
L Lac
Gr H
MGV
Ad Io
<6
0
1
0
0
0
0
0
0
0
1
6-10
0
1
4
1
1
0
0
0
1
8
10-15
2
2
7
2
3
1
0
1
18
Total
2
4
11
3
4
1
0
0
2
27
Female
<6
0
0
0
0
0
0
0
0
0
0
(25)
6-10
0
0
3
0
1
0
0
0
3
7
10-15
3
5
6
1
0
0
2
1
0
18
Total
3
5
9
1
1
0
2
1
3
25
Total
<6
0
1
0
0
0
0
0
0
0
1
for Age
6-10
0
1
7
1
2
0
0
0
4
15
10-15
5
7
13
3
3
1
2
1
1
36
5
9
20
4
5
1
2
1
5
52
Grand total
KEY: Ac Ap = Acute appendicitis.
Pf Ap = Perforated appendicitis.
Ty Pf = Typhoid ileal perforation
Sp lac = Splenic laceration.
L Lac = Liver laceration.
Gut pf = Gut perforation.
Gr H = Groin Hernia.
MGV = Mid-gut volvulus.
Ad Io = Adhesive intestinal obstruction
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Table 3. Post-operative Complications
Aetiology (Frequency )
Post-operative complication
Total
Atelectasis
Pneumonia
SSI
Abnormal /
hypertrophic
scar
Incisional
hernia
Perforated appendix (9)
0
0
3
2
0
5
Typhoid ileal perforation
(20)
2
4
13
2
2
22
Traumatic gut perforation
(5)
1
1
1
1
0
4
Traumatic viscera injury
(5)
1
0
0
0
0
1
Intestinal obstruction (8)
0
0
3
1
0
4
Total
4
5
20
6
2
Key: SSI = Surgical site infection
Patients with gut perforation had either simple closure of the perforation, or resection of involved bowel
segment and primary end-to-end anastomosis if the perforations were multiple and contiguous. Two of
the patients with splenic injury had splenorrhaphy while the remaining two had splenectomy. The patient
with hepatic laceration on the right lobe was observed to have stopped bleeding at laparotomy and only
drainage of the haemoperitoneum was necessary. The patients with adhesive bowel obstruction had
release of the adhesive bands if the bowels were viable, or resection with primary end-to end
anastomosis if the bowel segment involved were gangreneous.
The overall post-operative complications rate was 71.2% [n=37]. Surgical site infection (SSI) was the
most common complication: occurring in 20 patients (38.2 %) with 13 (65%) of these patients having
ileal perforation from typhoid fever. Five patients had pneumonia (9.6%). Other post-operative
complications encountered are as shown in Table 3. We recorded one death, giving a mortality rate of
1.9%; this occurred in a patient who presented in shock with blunt abdominal trauma following road
traffic accident; and whom intra-operatively was found to have had a shattered spleen and a huge
retroperitoneal haematoma. Patients with post-operative complications stayed longer on admission
(p≤0.05) compared to those that did not. Similarly patients with typhoid ileal perforation also had a
longer hospital stay. However, duration of illnesss at presentation, interval between admission and
surgery, and admission vital signs did not statistically influence the occurrence of complications (p>0.05).
Discussion
The seemingly low number of cases managed within the study period could be explained by the presence
of other health facilities in the region that could cater for patients with similar condition. In Akure, there
is a state-owned specialist hospital, several private hospitals (some manned by specialist surgeons).
Furthermore, about 50 km away is a federal medical centre (tertiary hospital) which could cater for
children with surgical abdomen. Similarly, Ilesa is about 40km from Ile-Ife where the main hospital unit of
out teaching hospital is domicile, and about same distance to Osogbo which also has a university teaching
hospital and numerous private hospitals. The lead author is an attending surgeon to the two facilities
involved in the study, hence choice of the two centres: howbeit tertiary and private.
Surgical abdomen transverses all paediatric age groups, and the aetiology usually maintain a close
relationship with the age group of the patients. Our findings showed that when the aetiology of surgical
abdomen was matched with age groups and gender of our patients,
the relative frequency of the
various causes was consistent with earlier reports was obtained1-3, 7-11. Patients below five years were
excluded from the study as most of them were referred directly to the specialist paediatrics surgery unit
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where better ancillary support [intensive care unit and paediatrics anaesthetists] services were available.
This explains the absence of such conditions as intussusceptions, and intestinal atresia and other
aetiologies found within this age group9, 12, 13. Similarly, patients who may require intensive care services
were also referred if they are stable enough to undertake the journey (40-50 km ride).
Majority of our patients were in the second decade of life, a period characterized by increased immune,
endocrine and psycho-social activities. In Nigeria, children in this age group are expected to be in
primary and secondary schools. Commuting to and from school in places where motorcycles are major
means of transport, with poor road infrastructure and impatient drivers/ riders put these children at risk
of road traffic injuries. Similarly, the absence of school feeding program encourages the pupils/ students
to patronize food vendors which may increase the risk of contracting food and water borne diseases like
enteric fever; which was a major cause of surgical abdomen in them14.
There was delayed presentation in more than a third of the patients studied. Similar late presentation by
patients had been noted by researchers across diverse specialties for different disease states8- 15. This
delay had been attributed to poverty16 and the poor health seeking behaviour of the populace9 which may
manifest as self-medication, patronage of unorthodox medical practitioners and quacks before coming to
the hospital. The poor drug control policies within the country also encourage procurement of
proprietary drugs (like antibiotics and antispasmodics) over the counter. This could alter the temporal
profile and mask clinical features of diseases; thus promoting delayed presentation and diagnosis with
attendant propensity towards disease complication at presentation. Moreover, patients with surgical
abdomen who present late do so in poor physiologic states: with fluid, electrolyte and acid-base
imbalance8- 14. Similarly, patients with surgical abdomen from trauma could have haemoperitoneum
sufficient enough to cause hypovolaemic shock requiring correction. Judicious and expeditious correction
of these deficits greatly improves surgical outcome10, 15-18.
Good clinical judgment in the preoperative diagnosis of acute abdomen is crucial in the management of
surgical abdomen. This helps to minimize the morbidity and mortality especially where the diagnostic
facilities are limited19. In our study, the pre-operative and post-operative diagnoses were congruent in
forty seven patients (90.4%) and we did not record any negative laparotomy. This further underscores
the importance of adequate and effective clinical evaluation of patients with acute (surgical) abdomen in
order to mitigate negative laparotomy rates20.
Typhoid ileal perforation was the singular most common cause of intra-abdominal sepsis among the
patients in this study: 51% of patients with intra-abdominal sepsis, and 38.5% of all patients managed for
surgical abdomen. It was also more common in the males and in patients within the second decade of life,
and still remains a leading cause of acute abdomen in children and young adults in Nigeria21, 22.
From this study, small bowel obstruction (SBO) was the least common cause of surgical abdomen.
Furthermore the SBO in this study had the girl child preponderance; and in them, adhesive intestinal
obstruction was the most common cause. This is in contrast to earlier works which reported obstructed
hernias as the most common cause of intestinal obstruction in patients within the age group studied3, 23.
This paucity of bowel obstruction from groin hernias could be an incidental finding, but most probably a
reflection of increasing elective repair of patent processus vaginalis and groin hernia as day case
procedures in both institutions. Our study suggests that there may be a changing pattern of intestinal
obstruction with increasing incidence of adhesive intestinal obstruction in teenagers and adolescents.
There may not be unconnected with sub-acute peritoneal inflammations causing adhesive intestinal
obstruction24. This is especially true in females who are prone to pelvic inflammatory conditions; and also
in individuals in the second decade of life who have higher prevalence of appendicitis11. However there is
need for further studies involving a larger population to affirm this assertion.
Surgical abdomen arising from trauma was more common in patients older than 10yrs. It also occurred
more in males which is in tandem with patterns documented in literature25, 26. Although the liver and
spleen were the most injured intra-abdominal organs in blunt abdominal trauma25-27, there was a slightly
higher incidence of traumatic gut perforation in our study. The reason(s) for this is not clear, further
studies, preferably multi-centre involving a larger population, may elucidate this. The current trend in
management of blunt abdominal injuries advocates non-operative care in those: with suspected intact
gastrointestinal tract (no clinical or radiological evidence of gut perforation), and those with stable, nondeteriorating cardiopulmonary status following initial resuscitation. Earlier reports from northern
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Nigeria by Ameh et al and Chirdan et al 18, 25, 26 had shown that a sizeable proportion of children with
blunt abdominal injuries can be managed non-operatively. There is also a growing trend towards splenic
conservation (splenorrhaphy) even in those with splenic laceration (grade I-III). Computerized
tomography scan of the abdomen is believed to be the gold standard imaging modatilty in classification of
visceral injuries following blunt abdominal trauma as pre-operative grading of splenic and hepatic can be
done. This facility was not available at the facilities during the period of study. We had to rely on
ultrasonography (which is operator dependent) and clinical judgment to determine those patients that
would require emergent surgical intervention28. Retrospectively we have found that sound clinical
judgment with at least an abdomino-pelvic ultrasonography (in suspected gut perforation or abdominal
trauma) and/or plain abdominal x-ray (in suspected intestinal obstruction) gave a diagnostic accuracy of
90.4% and negative laparotomy rate was zero percent. In resource poor settings we advocate thorough
clinical evaluation with abdominal ultrasonography with or without plain abdominal x-ray for all children
with suspected acute (surgical) abdomen.
The high overall post-operative complication rate in our study could be due to the fact that complicated
intra-abdominal infections (especially gut perforations due to appendicitis, typhoid enteritis) were the
major aetiology; and the surgical wounds in these conditions were considered dirty at surgery. Thus
surgical site infection occurring as the most common post-operative complication was not surprising in
patients with intra-abdominal sepsis when compared with other causes of surgical abdomen in this study.
The high rate of surgical site infection amongst patients with complicated intra-abdominal sepsis, like
typhoid ileal perforation, corroborates earlier reports8, 10, 11, 13, 15. Furthermore patients with typhoid ileal
perforation constituted the bulk of patients with post-operative complications; this may be due to the
pan-systemic nature of the disease with septicaemia. The latter could cause post-operative atelectasis and
pneumonia, defective wound healing with or without wound dehiscence, hypertrophic scars and
incisional hernias.
All patients in our study had primary wound closure even though some of the wounds (perforated
typhoid ileitis and perforated appendicitis) were considered dirty wounds at surgery. Given the high rate
SSI amongst patients with typhoid ileal perforation, we opine that delayed primary closure would have
been a better option compared to primary closure of the wounds even after diligent irrigation.
Furthermore over a quarter of patients with SSI also had hypertrophic scar which is not unexpected, and
also patients with pot traumatic visceral injury neither had SSI nor abnormal scars.
Though we recorded 100% morbidity amongst the patients managed for typhoid perforation, there was
no mortality. This is in contrast to reports by Ekenze et al16 and Uba et al29 who reported 19.1% and
22.8% mortality rates respectively for typhoid intestinal perforation. The small proportion of patients
with typhoid intestinal perforation in our study may account for this variation, and perhaps adequate
preoperative resuscitation and optimization of patients before surgery may have contributed to their
favorable outcome in our study.
Conclusion
Surgical infections still remains a major cause of surgical abdomen with perforated typhoid ileitis and
appendicitis (including perforated appendicitis) predominating. Bowel obstruction appeared to be more
common in girls while trauma related conditions were noted more in boys. Sound clinical acumen
supported by ultrasonography and plain abdominal X-ray were invaluable in diagnosis. Surgical site
infection remain a major cause of morbidity especially in patient with perforated typhoid ileitis.
Disclosure The work was presented at the Nigeria Surgical Research Society meeting that held in Enugu,
Nigeria in December 2013. All authors were involved in the conception, data acquisition and analysis, and
the preparation of this manuscript. The authors have no conflict of interest whatsoever regarding this
study. No funding was solicited and none was received.
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Presentation and Management Outcome of Umbilical Hernia in Children at the University
Teaching Hospital of Brazzaville.
E Koutaba1, J C Mieret1, C D Nzaka Moukala2, I Ondima1, M Makanga1
1Surgery and pediatric orthopedics,
2Digestive surgery department,
CHU Brazzaville BP 32Brazzaville Congo
Correspondence to: Dr. Koutaba Emmanuel, E-mail: [email protected]
Background: This study was aimed at determine the epidemiology, clinical and treatment outcome
of childhood umbilical hernia at the University Hospital of Brazzaville.
Methods: It was a retrospective study undertaken conducted over a 15 months period from 1st
January 2014 to 31st March 2015 in the pediatric surgery department of the University Teaching
Hospital of Brazzaville. The study population included both male and female children under the age
of 15 who underwent surgery for umbilical hernia. The study variables included the demographic
and clinical features and management outcome of patients with umbilical hernias. Xi2 test was used
to compare categorical variables. The significance threshold was set for a value of p <0.05.
Results: During the period under review, 1152 children were hospitalized, of whom 185 were
diagnosed with hernia including 98 (8.5%) who had umbilical hernias, a frequency of 8.5% of all
hospitalizations and 53% of hospitalizations for hernias. The sex ratio was 2.3. The average age was
3.8 years (range 1 month to 15 years). Abdominal pain was the most frequent reason for
consultation. The neck diameter was less than 1 cm in 51% and greater than 1 cm in 49% of cases.
Surgical treatment was done in all our patients. The average hospital stay was 1.5 days. The surgical
site infection was the main complication in 6.1% of cases.
Keywords: umbilical hernia-child-Brazzaville.
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.24
Introduction
Umbilical hernia (UH) is an anomaly related to a delayed closure of the umbilical ring. It is manifested by
an expansive swelling, reducible appearing in any effort creating a hyper intra-abdominal pressure1. Its
frequency in children varies between 5% and 20%2.
It is a benign disease but may develop life-threatening when it is complicated. The morbidity and
mortality related to the UH is low. Treatment is surgical and based on the closure of the umbilical ring
either by sutures either by umbilical plasty. The objective of this study was to determine the
demographic, clinical presentation and treatment outcome of umbilical hernia at the University Hospital
of Brazzaville.
Patients and Methods
It was about a retrospective study covering the period from 1 January 2014 to 31 March 2015, 15 months,
conducted in the pediatric surgery department of the University Hospital of Brazzaville. Had been
included, children of both sexes aged from 0 to 15 years, underwent emergency surgery or elective
surgery for an umbilical hernia complicated or not. We did not include children with non-operated
umbilical hernia.The tests were conducted sequentially at 1 month and 3 months postoperative.Data
were collected from hospital records of pediatric surgery and the operating room of the University
Teaching Hospital of Brazzaville.
The studied variables were epidemiological, clinical, therapeutic and outcome. The xhi2 test was used to
compare categorical variables. The significance threshold was set for a p-value of <0.05.
Results
During the study period, 1152 children were hospitalized in the pediatric surgery department; among
them 185 for hernia including 98 for umbilical hernia, corresponding to a frequency of 8.5% of all
hospitalizations and 53% of hospitalizations for hernias. They were 69 boys and 29 girls with a male to
female sex ratio of 2.3: 1. The Patients’ ages ranged from 1 month to 15 years with an average age of 3.8
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years. The children were seen in outpatient consultation clinic in 79 (81%) of the cases and in 19 (19%)
were seen as emergency cases (Table 1).
Table 1. Distribution of Children According to the Chief Complaint
Presentation
Umbilical pain
Reducible swelling
Irreducible swelling
Vomiting
Abdominal bloating
Number (N = 98)
Percentage (100%)
77
18
11
2
1
78.5
18.3
11.2
2.0
1.0
The diameter of the neck was less than 1 cm in 50 cases (51%) and greater than 1 cm in 48 cases (49%).
Umbilical hernia was uncomplicated in 79 (80.6%) and strangulated in 19 (19.4%) of the cases. The
diameter of the neck was less than 1 cm in 50 (51%) of children of which 11 (11.2%) had a strangulated.
In 39 (39.8%), the hernias were uncomplicated. The diameter of the neck was greater than 1 cm in 48
(49%), including in 8 (8.2%) of the children who had complicated hernia and in 40 (40.8%) which were
uncomplicated. However, there was no statistically significant difference (p = 0.7) between the diameter
of the neck of the ring and the occurrence of strangulation. The most frequent pathological associations
were inguinal hernia in 30 (31%), hydrocoele in 4 (4.1%) and cryptorchidism in six (6.1%) of the cases.
All children were treated with conventional surgery. A small median laparotomy was made in children
who had a strangulated umbilical hernias. A transversal skin incision below the umbilicus was performed
in other cases. The neck of the ring was closed by sutures in all children. For aesthetic reasons, plastic
reconstruction of the umbilicus with resection of the excessive umbilical skin was made in nine (9.2%) of
children, who had a very large hernia. Postoperatively, six children had surgical site infection (SSI). The
postoperative period was uneventful in 92 (93.9%) of children. After a follow-up of 3 months, there were
two (2%) of hernia recurrence considered to be secondary to subcutaneous infection. We registered no
cases of deaths. The average hospital stay was 1.5 days with extremes of 1 and 6 days.
Discussion
Umbilical hernia is a common condition in black Africa 3, 4. The 8.5%frequency found in our study is close
to that of several African, European, and US authors 2, 5, 6. The average age of our patients is similar to that
reported by other authors 3,7, 8. The male predominance can be explained in part by the anatomical
features of the umbilical region in boys 3. These results corroborate with those of some studies 4, 5, 8.The
diagnosis of hernia is mainly clinical 4. In general, the UH is not a painful condition 4. Abdominal pain was
the most frequent reason for consultation in our study; this could be explained by the fact that children
consult late and therefore often at the stage of complication in our country9.
The neck of the ring less than 1 cm was predominant in our study; this observation was made by Harouna
et al10 in Niger. In our series, the diameter of the neck did not influence significantly the occurred
complications (strangulation). Our results are contrary to some authors report that the diameter of the
ring’s neck is inversely proportional to the risk of complications in the UH 4, 6, 7.The repeated obstruction
is serious and can lead to a constriction with a risk of intestinal lesions 3, 5, 7, 10.Treatment of UH is strictly
surgical and should be systematic upon discovery of the disease 10, 11.
The average hospital stay was shorter (1.5 days) in our series. However, some authors report an average
of 2.5 days of hospitalization 3. The postoperative outcome of an uncomplicated umbilical hernia is
usually uneventful 3, 10, 12. Morbidity is usually dominated by the risk of infection that can lead to disunity
and recurrence 2. The absence of deaths could be explained partly by the good condition of the children at
the admission, on the other side by the early management in the treatment.
Conclusion
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Umbilical hernia is relatively common in children at the University Teaching Hospital of Brazzaville. For
any abdominal pain in children, the practitioner should search for an umbilical hernia. The surgical
treatment is well codified for reducing morbidity and mortality.
References
1.
Weick J, Moore D. An usual case of umbilical hernia rupture with evisceration. PediatrSurg 2005;
40: 33-5
2. Khen-Dunlop N, Audry G. Management of umbilical hernia in children. Journal de pédiatrie et de
puériculture 2007; 20:78-80
3. Fall I, Sanou A, Ngom G, Dieng M, Sankalé AA, Ndoye M. Strangulated umbilical hernias in
children. PediatrSurgInt 2006; 22: 233-5
4. Chirdan LB, Uba AF, Kidmas AT. Incarcered umbilical hernia in children. Eur J PediatrSurg 2006;
16: 45-8
5. Sankale AA, Ngom G, Fall I, Coulibaly Y, Ndoye M. Les plasties cutanées ombilicales chez l’enfant.
Annales de Chirurgie Plastique Esthétique 2004; 49: 17-23
6. Ameh EA, Chirdan LB, Nmadu PT, Yusufu LM. Complicated hernias in children. PediatrSurgInt
2003; 19: 280-2
7. Merie JM. Umbilical repair in children. PediatrSurgInt 2006; 22: 446-8
8. Feins NR, Dzakovic A, Papadakis K. Minimally invasive closure of pediatric umbilical hernias
2008; 43: 127-30
9. Massamba-Miabaou D, Passi LC, Elé N, et al. Problèmes de prise en charge des urgences
chirurgicales abdominales au CHU de Brazzaville. J AfrChir Digest 2013 ; 13: 1510-4
10. Harouna Y, Gamatie Y, Abarchi H. La hernie ombilicale de l’enfant noire Africain: Aspect clinique
et résultat du traitement à propos de 52 cas. Med Afr Noire 2001; 48: 6
11. Koura A, Ogouyemi A, Hounnou GM, Agoussou-Voyeme A, Goudote E. Les hernies ombilicales
étranglées chez l’enfant au CNHU de Cotonou : A propos de 111 cas. Med Afr Noire 1996; 43: 63841
12. Keshtgar AS, Griffiths M. Incarceration of umbilical hernia in children: Is the trend increasing?
Eur J PediatrSurg 2003; 13: 40-4.
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Hidden Facts and the Role of Truthfulness in Academic Dishonesty
Pius Musau
PhD candidate, Medical Education
Moi University, School of Medicine, Department of Surgery and Anaesthesiology
Email: [email protected]
Background: Academic dishonesty is widespread across the world and studies done have largely relied on
self-reporting to establish the extent and factors contributing to the practice. This demands of researchers to
take at face value what people who may not be entirely truthful are saying. It is not a surprise, therefore, that
varied interesting findings have been made in different studies. This paper delves into the complexity of
determining the key components of academic dishonesty and brings into focus the role of truthfulness in
understanding the elicited data. The objective of this study was to establish the role of truthfulness in
understanding various components of academic dishonesty.
Methods: This was a Cross sectional study using self-administered questionnaire. The Setting was the School
of Medicine, Moi University, Eldoret - Kenya. The study subjects were 156 students in the clinical (4th, 5th and
6th) years of study. They anonymously filled a 20-item self-administered questionnaire. The questionnaire
captured the demographic data and the views of the students on various aspects of academic dishonesty
ranked in a Likert scale of six levels starting with strongly agree to strongly disagree.
Results: The overall level of truthfulness among these medical students was 55.8%. While more males had
prior experience with academic dishonesty in secondary school and involvement at College, they were also
more truthful than the females. The untruthful were 2.2 times as often involved in academic dishonesty as
the truthful and were also less likely to report on their classmates.
Conclusion: There are hidden facts in academic dishonesty that can only be revealed by subjecting gathered
data to a scrutiny on how truthful the respondents are. Truthfulness is an inversely proportional surrogate
predictor of academic dishonesty.
Key words: Role. Thruthfulness, academic, dishonesty
DOI: http://dx.doi.org/10.4314/ecajs.v21i3.25
Introduction
Academic dishonesty is rampant across geographical regions 1, 2 and there is concern that it is rapidly rising due
to technological advancement 3. With prevalence between 13% and 95% (1), academic dishonesty is an elusive
practice with hidden facts not readily discernible. No one is immune from this vice and those in institutions rife
with it may be involved to either not be disadvantaged or to fit in the system 4. It sounds a contradiction in terms
to evaluate academic dishonesty by relying on data that may not be wholly truthful given the nature of the
source. This paper explores the hidden facts on academic dishonesty and establishes the role of truthfulness in
understanding various aspects of the malpractice.
Subjects and Methods
Medical students in the clinical (4th, 5th and 6th) years of study anonymously filled a 20-item self-administered
questionnaire. The questionnaire captured the demographic data and the views of the students on various aspects
of academic dishonesty ranked in a Likert scale of six levels starting with strongly agree to strongly disagree.
Collected data was transcribed into a sheet and entered for analysis using Statistical Package for Social Sciences
(SPSS) version 21. The truthfulness of the students’ information was adjudged on the basis of consistency in
answering questions derived from preceding answers. Subjective data was presented in frequencies while
measures of dispersion and central tendencies with statistical significance at p≤ 0.05 were applied on discrete
data. The results are presented in narratives, ratios and percentages.
Results
One hundred and fifty-six students responded to the self-administered questionnaire. The male to female ratio
was 1.3:1 and the age ranged from 21 to 34 years with a mean± standard deviation of 24.1±1.8 years. Academic
dishonesty was defined as any form of misconduct that gives undeserved advantage to the concerned student in
a formal academic exercise by 98.7% of the students. A total of 27 students (17.3%) had participated in
academic dishonesty while in secondary schools. Males were 3.2 times as likely to have been exposed to
academic dishonesty as the females (p=0.002). A total of 80% of the respondents were aware of academic
dishonesty, 75.6% had witnessed it in progress while 60.9% confessed to having participated at least once.
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Majority of those involved were males (55%). Of those who took part in academic dishonesty, 72.6% believed
that their classmates too were involved in the activity.
The overall level of truthfulness among these medical students was 55.8%. The males were more truthful than
the females (59.8% vs. 50.7%). Two thirds of the 6th year of study were truthful while the other two years barely
passed the 50% mark respectively. Bigger proportions of the untruthful claimed not to have participated in
academic dishonesty while in secondary school (85.5% vs. 80.5%) and to be aware of cheating in College
(81.2%vs. 79.3%) respectively. Three quarters of each group had witnessed academic dishonesty in progress but
the untruthful were 2.2 times as often involved in academic dishonesty as the truthful lot (p=<0.001). The
truthful were 1.4 times as often as the untruthful in believing that their classmates were involved in academic
dishonesty.
Discussion
Studies done on academic dishonesty have all along been counting on the honesty and truthfulness of the
respondents while at the same time exploring on a vice acknowledged to be complex and widespread 1-4. We
now have a situation where students consider dishonesty as a way of life “because everybody does it” 5, 6. With
academic dishonesty morphing into sophisticated forms due to advancement in technology 7 it is plausible that
we have not been having the complete picture of the monster. This informed the objective of this paper that set
out to unearth the hidden facts and establish the role of truth in understanding academic dishonesty.
The socialization has been to acknowledge academic dishonesty as more common in some and not other
courses 8. The presumption would be that some noble courses like Medicine and Engineering that deal with
matters of life and death would be free of the finding that only 55.8% of medical students are truthful; just
slightly better than tossing a coin on whom to believe! One would be tempted to augment this finding with the
fact that the participation level of 60.9% is perfectly within study findings of a range 13-95% for the others 1
and made more colourful by an awareness of 80% and witnessing of the vice in progress at 75.6%. It is possible
that the trends on academic dishonesty are no respecters of any given profession and this might explain why we
are increasingly getting litigations aimed at respected professions like Medicine and Architecture 9, 10.
The demography of academic dishonesty has been noted to change from study to study probably because of the
failure to factor in consistency and hence truthfulness of the respondents. While MacCabe and colleagues 1 as
well as Buckley et al 11 found males to be involved more, Leming 12 found that under a low-risk condition,
females cheated more than males and that a higher risk of punishment deterred females but not males. This
study established that women are less truthful than men and it is possible the higher numbers for men could be
due to a greater level of honesty in their reporting. It is also thought that in a paternalistic masculine society,
females would find it more difficult to disclose on their part the bad trait of dishonesty that may be considered a
necessity for the very survival of the competitive macho male and less so for the female 12.
Older students (6th years) were found to be not only more truthful but also less involved in academic dishonesty
when compared to the younger ones. This is in keeping with findings by other studies that females, older
students and higher academic endowment were associated with lesser likelihood of involvement 1, 2, 11, 13.
Truthfulness can, based on this study’s findings, be a surrogate predictor of involvement in an inverse
proportion manner and fits well with the finding that the untruthful were 2.2 times as likely to be involved in
academic dishonesty as the truthful students.
Of interest is the finding that both groups will have equal chances of witnessing an event like cheating in
progress but the truthful will have higher scores on disclosing the involvement of classmates in academic
dishonesty. It might suggest that the bigger number of the untruthful who say they were not involved in
academic dishonesty in secondary school and that they are aware of cheating in the College are rationalizing and
engaging in self-cleansing by creating a scenario where they not only absolve themselves but also drag in the
rest in the collective guilt of dishonesty. This can be affirmed by similar finding by Williams and Hosek who
asserted that even dishonest students are rational and disclose things based on their evaluation of best responses
pertaining to internal and external influences 14.
Conclusion
There are hidden facts in academic dishonesty that can only be revealed by subjecting gathered data to a
scrutiny on how truthful the respondents are. Truthfulness is an inversely proportional surrogate predictor of
academic dishonesty.
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Recommendation
A paradigm shift is advised in further studies on academic dishonesty with greater focus on reliability of
information gathered on the malpractice.
Acknowledgement
I wish to acknowledge the great input by the respondents without which this paper would not have been
realized.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
McCabe, D. L., Butterfield K. D., Trevino L. K. Academic Dishonesty in Graduate Business Programs:
Prevalence, Causes, and Proposed Action. Academy of Management Learning & Education 2006; 5(3):
294-305
Park, C. In Other (People's) Words: Plagiarism by University Students—Literature and Lessons.
Assessment & Evaluation in Higher Education 2003; 28: 471-488.
Born, A. D. How to Reduce Plagiarism Journal of Information Systems Education 2003; 14: 223.
Sattler, S., Graeff, P., Willen, S. Explaining the Decision to Plagiarize: An Empirical Test of the
Interplay between Rationality, Norms, and Opportunity. Deviant Behavior 2013; 34: 444-463
Davis, S.F., Grover, C.A., Becker, A.H., McGregor, L.N. Academic dishonesty: prevalence,
determinants, techniques, and punishments. Teaching of Psychology 1992; 19(1): 16-20.
DiBartolo, M. C., Walsh, C. M. Desperate times call for desperate measures: Where are we in
addressing academic dishonesty? Journal of Nursing Education, 2010 49(10), 543–544.
McCabe, D.L, Trevino, L.K, Butterfield D.L. Honor Code and Other Contextual Influences on
Academic Integrity: A Replication and Extension to Modified Honor Code Settings. Research in
Higher Education 2002; 43(3):368.
Bachore, M. M. Academic Dishonesty/ Corruption in the Period of Technology: Its implication for
Quality of Education.American Journal of Educational Research 2014; 2(11):1060-1064.
Akaranga, S.I .,Ongong , J.J. The phenomenon of Examination Malpractice: An Example of Nairobi
and Kenyatta Universities. Journal of Education and Practice 2013; 4(18): 87-96.
Gudo, C.O, Olel, M.A, Oanda, I.O. Students’ Admission Policies for Quality Assurance: Towards
Quality Education in Kenyan Universities. International Journal of Business and Social Science 2011;
2(8):177 – 183
Buckley, M. R., Wiese D. S., Harvey M. G. An Investigation Into the Dimensions of Unethical
Behavior . Journal of Education for Business, 1998; 73(5): 284-290.
Leming, J. S. Cheating Behavior, Subject Variables, and Components of the Internal-External Scale
Under High and Low Risk Conditions. Journal of Educational Research, 1980;74(2): 83-87.
Bushway,A. , Nash W.R . School Cheating Behavior. Review of Educational Research 1997;47(4):
623
Williams, M. S., Hosek W. R. Strategies for Reducing Academic Dishonesty. Journal of Legal Studies
Education 2003; 21: 87.
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teaser for scientific conference and agm
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