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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
Contents
Title / authors
Orthopaedic Outreach Program in Uganda: A Strategy to Improve Inequality in
Service Delivery between Rural and Urban Communities
J.J. Phillips, T. Beyeza, J. Okello, R.R. Coughlin
Pattern of Fatal Injuries in Addis Ababa, Ethiopia: A One-year Audit.
F. Tsegaye, K. Abdella, E. Ahmed, T. Tadesse, K. Bartolomeos
Surgical Mortality at a Mission Hospital in Western Uganda.
G . Tumusiime
Motorcycle Road Traffic Injuries in Southern Nigeria: The Small Motorcycle as
a Prevention Strategy.
T.E. Nottidge, U.S. Ekanem, S.O. Ogunlade, N.E. Ngim, E.S. Mkpouto-Obong
Traumatic Brain Injury in Accident and Emergency Department of a Tertiary
Hospital in Nigeria.
J.K.C. Emejulu, C.M. Isiguzo, C.E. Agbasoga, C.N. Ogbuagu
Missed Injuries in Multiple Trauma Patients: a Tertiary Care Experience in
Tanzania
P.L. Chalya , M.Mchembe , J.M. Gilyoma, J.B. Mabula, I.H.
Ngayomela, A.B. Chandika, B.Mawala.
Referral of Surgical Patients Abroad: A 5-years Review from a Tertiary
Teaching Hospital in Addis Ababa Ethiopia.
E. Teffera, B. Lemma, B.L. Wamisho
Challenges of Pancreatic Cancer Management in a Resource Scarce Setting
O.I. Alatise, O.O. Lawal, O.T. Ojo
The Pattern of Benign Breast Diseases in Rural Hospital in India
M. Kumar, K. Ray, S. Harode, D.D. Wagh
Comparision of Hook Phlebectomy and Endovenous Laser Therapy for Below
Knee Varicose Veins.
S.P. Deshpande, G.C. Gupta, P.D. Banodea, K.B. Golhar.
Levels of Bifurcation of the Sciatic Nerve as Seen at Mulago Hospital
J. Kukiriza, C. Ibingira, H. Kiryowa, J. Turyabahika, J. Ochieng
Thyroid Dysfunction among Young Adults in Uganda
M. Galukande, J. Jombwe, J. Fualal, A. Gakwaya
Effect of Spinal Anaesthesia on Hearing Threshold
A.O. Lasisi, H.O. Lawal, A.A. Sanusi
Prevalence of Otolaryngological diseases in Nigerians.
J.A.E. Eziyi, Y.B. Amusa, O.V. Akinpelu
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
The Postoperative Complications Prediction in Mulago Hospital using POSSUM
Scoring System.
D.L Kitara, I. Kakande, B.D. Mugisa, J.H. Obol
89
96
The Predictors, Prevalence and Outcome of Burst Abdomen in Emergency
Paediatric Surgical Centre.
O.D. Osifo, M.E. Ovueni.
Enterocutaneous Fistula: a Tanzanian Experience in a Tertiary Care Hospital
P.L. Chalya, M. Mchembe, J.M. Gilyoma, J.B. Mabula, B.Mawala, Mona L
Association between Intraoperative Bactibilia and Postoperative Septic Complications in Biliary
Tract Surgery.
Arshad B. Khan, Athar B. Khan, S. A. Salati , N.A Bhat, B.K. Parihar
103
112
Learning Radiology in an Integrated Problem-Based Learning (PBL)
Curriculum.
E. Kiguli-Malwadde, Z. Muyinda, M.G. Kawooya, S. Bugeza, R Okello Omara
Marjolin’s Ulcer in a Spina Bifida Patient: A Case Report
P.M. Nthumba, G. Bird
Female Urethral Leiomyoma: A Case Presentation
A.T. Tefera
Massive Assymetrical Virginal Breast Hypertrophy: A Case Report
S.B. Patil, S.M, Kale, N. Khare, S. Jaiswal, M. Math
Tongue Entrapment in Aluminium Milk Can: An Unusual Cause of Tongue
Injury.
J.A. Eziyi, J.B. Elusiya, O.O. Olateju, Y.B. Amusa, O.V. Akinpelu, A.K. Eziyi
Carpal Tunnel Syndrome in Patient on long Term Hemodialysis - a Case Report
S. A. Salati, N.F. Aldajani, B. Al Aithan, S.M. Rabah.
Extra-adrenal Pheochromocytoma: Experience in Mulago Hospital.
O.N Alema, J.O Fualal
Thymoma Presenting with Myasthenia Gravis: A Case Report.
P. Makobore, O.Omagino, T. Mwambu, S. Apio, G. Ibilata
121
Missed Intra Uterine Device: A Rare Indication for Appendicectomy- Case
Report with Review of Literature
S.R. Singhal, D.S. Marwah, A. Paul, S.K. Singhal
155
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East and Central African Journal of Surgery Volume 15 Number 2.
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Orthopaedic Outreach Program in Uganda: A Strategy to Improve Inequality in
Service Delivery between Rural and Urban Communities
J.J. Phillips1,2,4, T. Beyeza3, J. Okello3, R.R. Coughlin1,2
1
Department of Orthopaedic Surgery, Institute for Global Orthopaedics and Traumatology (IGOT), San
Francisco General Hospital, San Francisco, CA, USA
2
Department of Orthopaedic Surgery, University of California at San Francisco, San Francisco, CA, USA
3
Department of Orthopaedics, Makerere University Medical School, PO Box 7051, Kampala, Uganda
4
School of Medicine, University of California at Irvine, Irvine, CA, USA
Background: Musculoskeletal diseases are on the increase worldwide. Greater than 80% of
Ugandans live in rural areas, facing formidable barriers to specialized care. In 1991 the
Orthopedics Outreach Program (OOP) was initiated as a plausible solution to the inequity of
orthopedic care between the urban and rural disadvantaged populations. This investigation
was conducted to evaluate the output, effectiveness, and barriers to access, of the OOP over 13
years.
Methods: This was a retrospective analysis to quantify surgical output and effectiveness of the
OOP using the outreach record and a cross-sectional analysis to assess access and efficacy of the
program. Semi-structured and key informant interviews targeted to key actors involved in the
OOP were conducted to provide a qualitative assessment of the program.
Results: Sixty seven outreach visits were completed, 6,653 patients seen, and 1,071 surgeries
performed, at a total cost of US$12,701.00. The cost per patient seen was US$1.91 and US$11.86
per surgery performed. Poverty was uniformly cited as barrier to access, others were,
transportation, and lack of awareness. There was unanimous opinion on the worthiness and
effectiveness of the OOP, but many operational issues and constraints were cited.
Conclusion: The OOP may provide a short and medium term solution to equity and access for
orthopedic care in Uganda. There is need to quantify the burden of specific orthopedics
conditions. A follow-up analysis assessing operational efficacy and output from 2004 to date,
under the African Medical and Research Foundation (AMREF) and Ministry of Health funding
is recommended.
Introduction
There is an increasing awareness within the global health community as to the impact of traumatic
and non-traumatic musculoskeletal conditions. The burden of non-traumatic musculoskeletal
conditions along with an increase in road traffic injuries has shifted the disease burden to
musculoskeletal and other non-communicable disease conditions1.
With an increase in life
expectancy and dramatic increase in road traffic accidents, developing countries face serious
challenges to cope within systems already devastated by infectious disease, poor nutrition, and
inadequate water and sanitation2.
Uganda has prioritized decentralization and primary health care to tackle the enormous demand within
the setting of scarce resources and inadequate funding in the health sector3. Despite optimal primary
prevention and health promotion, surgical conditions will remain and surgical services will be
necessary. Surgery may be seen as an essential element of a good basic clinical package with its
capacity for secondary and tertiary preventive impact4.
Most developing countries suffer from inadequate human resource provision in the specialties of
healthcare5 leading to overall less health care both in terms of access and availability, with resultant
less “health”. The estimated population of Uganda is approximately 28 million people, 87.7% being
rural and 12.3% urban6,7. Twenty-three orthopedic surgeons (one for every 1,300,000 people) provide
specialist services that are available only at three regional hospitals and the National Referral Hospital
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
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in Kampala8. These limited resources are further aggravated by issues of poverty, long distances to
health facilities, poor means of transport, and cultural/language barriers. Specialist outreach has been
an established method to improve access to specialized care, enhance primary-specialist care
relationship, reduce pressure on national and regional referral hospitals, shift the balance of care to
community-based services, reduce costs and improve overall health9.
In recognition of the significant inequality of service delivery to much of the rural and disadvantaged
population in the country, the Department of Orthopedics at Mulago National Referral Hospital
instituted the Orthopedic Outreach Program (OOP) in 1991 as a possible solution. The mission of this
intervention was to provide quality orthopedic service to upcountry patients in their community.
Though the OOP was established to with this mission in mind, it’s effectiveness has never been
evaluated. There is a scarcity of published literature on specialist outreach clinics in the developing
world. A recent published Cochrane review, “Specialist Outreach Clinics in Primary and Rural
Hospital Settings”, has concluded the need for further studies in rural and disadvantaged setting where
outreach interventions may offer the most benefit to access, better health outcomes and greater
impact10. The aim of this study is to establish the effectiveness of the OOP through measures of
output, barriers to access, and harms/benefits of the program in Uganda.
Methods
Evaluation of the initial 13 year period of the OOP’s operation was made. The analysis was divided
into 3 component parts.
1) A retrospective quantitative analysis of the output of the OOP. Data spanned the 13 year
period from the initiation of the OOP in 1991 to the year 2004. Data from available records were
obtained from the Department of Orthopedics at Mulago National Referral Hospital (MNRH).
Location and number of trips, patients seen, number of surgeries performed and funding
information were compiled for analysis.
2.) A cross sectional descriptive analysis of 2 representative OOP sites. A descriptive analysis
was conducted to characterize the outreach patient population served. The visits were an outreach
in June 2004 from Mbale, a regional hospital, to the district/sub-district facilities compared with
an outreach conducted in July 2004 to the regional hospital of Fort Portal. Age and diagnosis, in
regards to degenerative conditions, back pain, and need for surgical referral were quantified.
3) A cross sectional qualitative analysis pertaining to issues of access and effectiveness was
conducted using semi-structured and key informant interviews. Key informant interviews were
conducted in Kampala at the Ministry of Health (MOH), various NGOs, mulago national referral
hospital, and the Institute of Public Health (IPH). Semi-structured interviews were conducted at 4
regionalreferal hospital sites of previous outreach,i.e. Arua, Masaka, Mbale, and Fort Portal,
representing each of the northern, southern, eastern, and western regions respectively. A
template question list was used to guide interviews. Key persons with varying levels of
involvement in the OOP were targeted as interviewees (Table 1). All interviews were conducted
by a single orthopedic surgeon; detailed notes were taken and later coded.
Qualitative data was analyzed and is presented in regards to the issues of access to care (availability,
accessibility, accommodation, affordability and acceptability), effectiveness, and operational
constraints. Results for effectiveness of the OOP are listed in 2 separate categories, harms/benefits
and operational issues/constraints. Major and minor themes were gleaned using thematic analysis of
the written interview records according to previously validated qualitative data analysis
methodology11. Major themes were defined as those cited by more than half of respondents. Minor
themes were cited by less than half of respondents.
Results
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
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Over the 13 year period from 1991-2004, the OOP accomplished 67 outreach visits. In total, 18
hospitals were visited over this period, primarily regional referral centers. The overall output of
performance demonstrates 6,653 patients seen, and 1,071 patients having surgery. Yearly output
totals in terms of number of patients screened and number of patients receiving operative care are
displayed in Figure 1. Associated costs to send an orthopedic team (orthopedic surgeon, clinical
officer and theatre nurse) for each of the 67 outreach visits, over the period of 13 years, totaled
US$12,701.
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
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Analysis of the patient populations seen at the district/sub-district facilities compared to that at the
regional referral hospital are outlined in Table 2. 110 patients were screened at the district/sub-district
level with an average age of 20.5 years compared to 39.8 years at the regional outreach. The ratio of
patients requiring surgery was 16% compared to 9% at the regional hospital. Back pain was observed
in 2%, compared to 10%. While 14% of patients presented with osteoarthritis (OA) and degenerative
spine conditions at the regional hospital, there was a 7% prevalence rate seen in patients presenting to
the district/sub-district site.
Barriers to Access
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East and Central African Journal of Surgery Volume 15 Number 2.
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With regards to the barriers to access, interview data revealed apart from unavailability of services,
the overwhelming reason for poor access was poverty and/or no money. A complete list of barriers to
access from greatest prevalence within interview responses to least prevalent is provided in Table 2.
Distances from available services, along with poor road conditions/transportation were uniformly
cited. Lack of awareness and sensitization of the community to service offerred were also frequently
repoted problems.
Issues of Effectiveness
Major and minor themes revealed on qualitative analysis in regards to benefits of the OOP to the
system are reported in Table 3.
Major and minor themes revealed on qualitative analysis in regards to benefits of the OOP system to
the patient/family are reported in Table 4.
A summary of the harms of the OOP to the outreach site and to the department/surgeon are tabulated
in Table 5.
Discussion
The challenge of prioritization to successfully allocate scarce resources in the face of overwhelming
need is formidable. With the push towards decentralization of Uganda’s healthcare system, the OOP
was initiated by Mulago Hospital Department of Orthopedics in 1991. This paper has attempted to
assess the output and effectiveness of the OOP over its initial 13 years in operation and hence draw
conclusions about its perceived “success”. The findings seem to highlight the essential nature of the
outreach strategy to penetrate the great need that exists in the rural and disadvantaged population.
In order to move towards evidence-based interventions and appropriate prioritization, there is an
essential need for an appreciation of the baseline. As in most of the developing world, Uganda has
scant information and data regarding musculoskeletal conditions and therefore, a pressing need for
surveys and quantification. There was overwhelming consensus amongst study participants of the
importance for baseline surveys of need. With the connections established in rural outlying
communities, the OOP can facilitate more comprehensive data gathering to begin to assess the needs
of the communities served.
Prior to discussing the results of this study, specific limitations in design must be recognized. All
interviews were conducted, coded, and analyzed by one individual, an orthopedic surgeon. While this
permits familiarity and insight to the intervention, it presents the possibility of researcher bias for
favorable analysis and conclusions. Beneficiary interviews, which may have permitted more valuable
insight into barriers of access, were not conducted. Lastly, whilst the overwhelming need and obvious
ability to benefit from surgery is apparent, the assumption of clinical and functional improvement is
fallacious without adequate and reliable outcome measures.
Comparing the demographics and diagnoses of patients from the district/sub-district level to regional
outreach, significant differences were demonstrated in neglected, treatable conditions as seen in the
former, with the degenerative and chronic age-related conditions seen in the latter. This likely
suggests that the regional level is not peripheral enough as an outreach to achieve more impact
through improved access. Further, the implication is that not until specialist services are available at
all regional “referral” levels will more peripheral outreach achieve the coverage, impact and equity
that have been articulated by the mission statement. Total costs to provide an outreach team (1
orthopedic surgeon, 1 clinical officer, and one theater nurse) for each of 67 outreach visits totaled
US$12,701 at time of calculation in 2004. This included transportation, accommodation and all
surgical service provided by the team. With 6,653 patients seen and 1,071 surgeries performed over
this same period, the total costs amounted to US$1.91 per patient seen and US$11.86 per surgery
performed. If the same number of patients had to travel to the capital city of Kampala (where 2/3 of
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
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the orthopedic surgeons practice), where they would likely have to receive treatment from private
hospitals, the cost of treatment would be exceedingly high.
When looking at barriers to access, uniform mention was made of the distance from available
services, along with poor roads and transportation costs, were also uniformly mentioned. Gender
issues were mentioned often; as women are the caregivers and frequently the breadwinners, time away
from family, farms, or home care becomes a major burden. Language and cultural priorities were felt
to limit many of the poorly educated rural villagers. Because of cultural beliefs and deficient services,
traditional healers were seen as important in changing health-seeking behavior. War and security
issues were seen as one of the major barriers in the north at time of interviews. Fear of Kampala, with
its lack of support services, housing and food, was frequently cited as a barrier to national referral.
The stigma of treatment was less frequently discussed by the respondents.
In terms of benefit to patients, the major themes included higher standard orthopedic care, both
conservative and surgical, to the underserved along with substantial lessening of the economic burden
to the patient and family. Further noted were improved patient satisfaction, increased awareness of
service availability, and decreased time commitment to care. The benefits to the system were seen as
support and supervision to the regional medical officers, increase in communication, and support to
the primary care service to musculoskeletal issues. Medical education and skills improvement were
especially valued.
In discussing the harms to the site of delivery it was felt that scheduling was intense and demanding,
with the added issue of the questionable ethics of relying on others for follow-up duties. Although it
was agreed that the quality and standard of care and surgery were high, the potential for worse
outcomes from poor follow-up or non-adherence was noted. Also frequently noted were the adverse
affects of increased local workload, and depletion of local supplies. An interesting theme that
emerged several times was the professional jealousy of the Outreach team that was being subsidized
by the government and seen as “from another planet.” This perception of outreach as “outsiders” may
suggest the need for more transparency and communication. In summarizing the harms, many
respondents cited the opportunity costs away from primary care.
Recognizing an overwhelming need, the Mulago Hospital Orthopedic Department has responded
through not only service delivery by the OOP, but through training of residents and establishing a
culture of outreach. With the recent landslides in the Bududa region, the department sent a third year
resident to offer orthopedic care to those in need in the aftermath of the devastation. The importance
and significance of academics and the educational system should be mentioned as an essential partner.
Outreach as an opportunity to teach and train should be emphasized and not considered as an
afterthought. Medical students and residents should be incorporated in the visiting teams, being given
both clinical and educational responsibilities. This early involvement and experience should reinforce
the culture of community involvement, altruism and academic mission.
Conclusion
A follow up study to assess operational effectiveness, output, and challenges from 2004 to present is
strongly recommended. Especially since during this time period, increased number of road traffic
injuries has changed the pattern of disease burden in this country. Not only will a follow up report
contribute greatly to the paucity of published literature on the outreach strategy in Uganda but may
help guide national policy decisions on healthcare funding.
References
1. The Burden of Musculoskeletal Conditions at the Start of the New Millenium.
Technical Report Series. Geneva, World Health Organization. (2003)
East and Central African Journal of Surgery
WHO
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
2. Mock, C., R. Quansah, et al. Strengthening the prevention and care of injuries worldwide.
Lancet 363 (9427): 2172-2179. (2004)
3. Ssengooba, F. Uganda's minimum health care package: rationing within the minimum? Health
Policy and Development 2(1): 14-23. (2004)
4. Debas HT, G. R., McCord C, Thind A. Surgery. Disease Control Priorities in Developing
Countries. E. D. Jamison D, Alleyne G, Jha P, Breman J, Measham A, et al. New York,
Oxford University Press: 1245-1260. (2006)
5. Farmer, P. E., J. J. Furin, et al. "Global health equity." Lancet 363(9423): 1832. (2004)
6. Uganda Bureau of Statistics: Statistical Abstract June 2006. From http://www.ubos.org.
(2006)
7. World Health Statistics 2006. Health system fact sheet, Uganda. From
http://www.who.int/whosis/en. (2006)
8. Naddumba, E. K. "Musculoskeletal trauma services in Uganda." Clin Orthop Relat Res
466(10): 2317-2322. (2008)
9. Powell, J. "Systematic review of outreach clinics in primary care in the UK." J Health Serv
Res Policy 7(3): 177-183. (2002)
10. Gruen, R. L., T. S. Weeramanthri, et al. "Specialist outreach clinics in primary care and rural
hospital settings." Cochrane Database Syst Rev(1): CD003798. (2004)
11. Ritchie J, S. L. Qualitative data analysis for applied policy research Analyzing Qualitative
Data. B. R. Bryman A, Routledge. (1994)
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East and Central African Journal of Surgery Volume 15 Number 2.
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Pattern of Fatal Injuries in Addis Ababa, Ethiopia: A One-year Audit.
F. Tsegaye1, K. Abdella2, E. Ahmed3, T. Tadesse4, K. Bartolomeos5
1
Addis Ababa City Administration Health Bureau, Addis Ababa, Ethiopia
World Health Organization, Addis Ababa, Ethiopia
3
Addis Ababa University, Medical Faculty,
4
Menelik II hospital, Addis Ababa, Ethiopia
5
World Health Organization, Geneva-Switzerland
Correspondence to: Elias Ahmed, E-mail: [email protected]
2
Background: Injury continues to account for a large number of clients attending emergency
department in Addis Ababa. Reliable information on causes of death is essential to the development
of health policies for prevention and control. The aim of this atudy was to identify the pattern and
common causes of fatal injuries
Methods: This is prospective study analyses autopsy data related to fatal injuries handled by Menilik
II Hospital between July1, 2006 –June 30, 2007. (Sene 24, 1998 - Sene 23, 1999)
Results: A total of 2107 cases were analyzed. The victims were mostly male and the most vulnerable
age group was found to be 15-44 years. Accidents versus homicide and accident versus suicide ratio
was 1.8:1 and 5:1 respectively. Road traffic accidents were the most frequent causes of accident
related death. Main means of homicide was hit by blunt or sharp object or firearm. More than 90% of
victims who committed suicide use hanging or poisoning.Ninety percent of deaths occur with in 24
hours of the injury and only 105 (5%) died from the second day on wards. Eighty one percents of this
patients had never received any medical care (either pre-hospital or hospital level).
Conclusion: Road traffic accidents accounted for most causes of injury related deaths. Significant
proportion of patients had no access to emergency medical care. The findings strongly suggest that
more aggressive, regulatory, educational, and rapid emergency treatment is necessary to address the
large number of injury related death.
Introduction
According to the 1996 World Health Organization report injury ranks fifth among all causes of death
accounting for 5.2% of all mortality worldwide1. It is a leading cause of death and disability for
people under 45 years in the industrialized world1,2. These rates are declining in developed countries 3
but injuries are important and a largely neglected health problem in developing countries3-8.
One million and two hundred people died as a result of road traffic collisions. This means that on
average 3242 people were killed daily on the world's roads. Twenty to fifty million people were
injured or disabled in road collisions9. Ninety percents of road traffic deaths occurred in low income
and middle-income countries, where 5098 million people or 81% of the world's
population live10 and own about 20% of the world's vehicles.
The WHO African Region had the highest mortality rate, with 28.3 deaths per 100 000 population.
This was followed closely by the low-income and middle-income countries of the WHO Eastern
Mediterranean Region, at 26.4 per 100 000 population. Countries in the WHO Western Pacific Region
and the WHO South-East Asia Region accounted for more than half of all road traffic deaths in the
world. In Ethiopia, like other developing countries, injuries are common but little attention is being
given to this problem11. Injuries constitute around a half of all surgical emergencies12, and were the
primary reason for an emergency hospital visit in Addis Ababa during 1999 13, 27% of emergency
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East and Central African Journal of Surgery Volume 15 Number 2.
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visit and 5% of all hospitalization during 2005/0614. It is also the main causes of emergency visit and
admission in orthopedics department of black lion hospital15,16. Road traffic accidents are the
commonest cause of injury in urban areas in Ethiopia with 199 fatalities per 10,000 licensed vehicles
per year17,18.
To our knowledge reliable cause of death statistics were not available in the country which shows the
pattern of injury related deaths. Our audit was devised mainly to assess the burden of fatal injuries
together with identifying common causes of fatal injuries in Ethiopia. It was specifically designed to
determine the profile or pattern of commonly occurring fatal injuries, and medical attention received
before their death.
Patients and Methods
All subsequent dead body presented to Menilik II hospital and confirmed that injury was the cause of
the death in one-year period, between July 1, 2006 –June 30, 2007. Menilik II memorial hospital is the
only hospital all over the country that providing the autopsy service to confirming the cause of death.
Unlike other departments the forensic pathology department records detailed information about the
dead body on their registration books by the pathologist for the medico legal reasons. According to
the National Road Safety Coordination Office of Ethiopia19, during the year 2006/7, there were a total
of 17,147 car accidents, 9,553 non fatal injuries and 2,517 fatalities. The total number of motor
vehicle was 244,252. The population of Ethiopia is 73,918,505 20.
Design: A prospective descriptive study were the data on injury was extracted from the registration
book of the department by using structured question of Fatal Injury Surveillance Data Collection
Form prepared by Addis Ababa City Administration Health Bureau. Significant number of variable
have been reviewed such as age, gender of the victims and date of death, date of autopsy, place of
injury and death, circumstance and manner of death and method of confirming the diagnosis. Causes
of death is classified according to International Classification of Diseases 10th Revision (ICD-10)21
these are unintentional, intentional (violence) and undetermined. Unintentional injuries comprise most
of the traffic injuries, fires, falls, poisonings and drowning. On the other hand intentional injuries or
violence are classified as homicide and suicide. Cases are classified as undetermined whenever
specific causes are unclear. The theoretical index of traffic accidents were calculated which will be
used as a base line for future progression and comparison, these are Motorization index (Vehicle
/population), Accidentability index (accidents /vehicle), Harmfulness index (Victims /accidents) and
Fatality index (Death / victims). Fatality per 10,000vehicle was also used.
Statistical Analysis: The data analysis was performed with the aid of Epi info and SPSS. software.
Results were expressed in absolute numbers, percentage and ratio.
Results
A total of 2985 dead body was seen at the pathology department of Menilik II hospital, during one
year period, between July 1, 2006 and June 30, 2007, of which 2,107 (70.4%) were related with
injuries. The diagnosis was confirmed by autopsy in 1877 (89.1%) and 230 (10.9%) by
reconnaissance. An average of 176 injury related death took place each month (ranging 147-220).
Among the victims 1,662 (78.9%) were male and 445 (21.1%) were female giving a male to female
ratio of 4:1. The mean age was 31 years (SD ± 16.1). The majority of the patients, 1,439 (68.3%),
were within the age groups of 15-44 years (Figure 1). The place of origin of the patients were Addis
Ababa in 862 (40.9%), Oromia 614 (29.1%), all other regions represents 315 (15.0%) but the address
of 316 (15.0%) were not known (Table 1).
Eight hundred sixty eight (41.2%) of the injuries occurred on the road, followed by home 253 (12.0%)
and only 68 (3.2%) occurred at work place but in 374 (17.8%) it was not possible to know the place.
Majority 1715 (81.4%) of the victims did not receive post crash care at any level either pre-hospital or
hospital/health facility. Eight hundred and sixty seven (41.2%) died either on the road or at home and
364 (17.3%) died in hospital (289 received care and 75 before receiving any care) (Table 2).
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
700
sex
600
Male
Female
500
Count
400
300
200
100
0
0-4
5-14
15-29
30-44
45-59
60 and
above
Age group of patients
Figure 1. Age and Sex distribution of cases
Table 1. Address of Origin of the Victims
Region
Addis Ababa
Oromia
SNNP
Amhara
Afar
Tigray
Benishangule
Harari
Somale
Gambela
Diredewa
Unknown
Total
Frequency
862
614
167
100
16
10
6
5
4
4
3
316
2107
Percentage
40.9
29.1
7.9
4.7
0.8
0.5
0.3
0.2
0.2
0.2
0.1
15.0
100.0
One thousand and eight hundred and eighty seven (90.2%) victims died on the same day of the injury,
157 (7.4%) died between 2-7th day and 49 (2.3%) after seventh day of injury. The majority 1679
(79.7%) of the autopsy was done on the second days of death (Table 3). A total of 1139 (54.1%) of
victims died because of accident, 641 (30.4%) homicide, 234 (11.1%) suicide, and in 93 (4.4%) it was
not possible to determine the circumstance of death. Of 1139 victims of death due to accident, road
traffic accident’s accounted for 782 (68.7%), followed by drowning 100 (8.8%). Among 782 road
traffic accidents, 402 (51.4%) occurred on pedestrian, 334 (42.7%) passengers, and 46 (5.9%) drivers.
Homicide victims were most likely to die after being hit by blunt object 300 (46.8%), firearm (21.4%)
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or sharp instrument 103 (16.1%). Hanging was the sole method of suicide in 80.6% (141/175) of male
and 76.3% (45/59) of female. Poisoning suicide was more common in female than male (23.7%,
15/59 versus 9.1%, 16/175). In 93 (4.4%) cases the manner of death couldn’t be determined (Table 4).
All causes and manner of death were higher in male age group of 15-44 with exception of substance
intoxication where 70.4 % (19/27) occurred in female age group of 15 to 29 years.
Table 2. Circumstance of Injury and Death
Character
Place of injury
Road
Home
Work Place
Recreational place
Others
Unknown
Level of care provided
None
Pre-Hospital Care
Hospital/Health Facility care
Unknown
Place of Death
Road
Hospital/ Health facility
Home
Work Place
Recreational place
Others
Unknown
Number
Percent
868
253
68
6
538
374
41.2
12.0
3.2
0.3
25.5
17.8
1715
93
289
10
81.4
4.4
13.7
0.5
621
364
246
53
7
520
296
29.5
17.3
11.7
2.5
0.3
24.7
14.0
Table 3. Time interval between injury, death and autopsy
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Time interval between (days)
Injury and death
<1
1-2
3-7
>7
Missed
Death and autopsy
First day
Second day
Third day
Fourth day and above
Number
Percent
1887
91
66
49
14
89.6
4.3
3.1
2.3
0.7
122
1679
252
54
5.8
79.7
12.0
2.5
Table 4. Manner and Cause of Death
Manner
Cause
Accident
Motor vehicle crash
782
Blunt Object
21
Sharp Object
1
Hanging
0
Firearm
1
Drowning
100
Strangulation
0
Fall
37
Electric accident
36
Suffocation
23
Poisoning
0
Intoxication
23
Explosive
blasts
1
(landmines, bombs)
Other specific causes
34
Missed
80
Total
1139
(%)
(54.1)
Homicide
0
300
103
1
136
2
50
1
0
7
0
3
0
Suicide
0
0
0
186
15
0
0
2
0
0
30
0
0
40
0
641
(30.4)
1
0
234
(11.1)
Undetermined
0
47
2
0
3
3
0
5
0
1
1
3
21
Total
782
368
106
187
155
105
50
45
36
31
31
27
22
Percentage
37.2
17.5
5.0
8,9
7.4
5.0
2.4
2.1
1.7
1.5
1.5
1.3
1.0
5
2
93
80
82
2107
3.8
3.9
(4.4)
100
The Motorization index was 3 per 1000 population, accidentability index for the same year was 70 per
1000 licensed vehicle, harmfulness index 70% and fatality index 21%.. The fatality was 103 per
10,000 licensed vehicles.
Discussion
Even though trauma related deaths are only the “tips of the iceberg” of trauma, there are several
reasons why it made sense to track them as a way to address the problem, mainly because of their
seriousness than about non-fatal injuries. Reliable information on causes of death is essential to
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development of health policies for prevention and control of injury. Menilik II hospital is the only
hospital where autopsy service is provided, therefore the autopsy data from this hospital can represent
a community and a substantial insight can be made into the commonly occurring fatal injuries,
circumstance and also provide useful information on mortality in the community, and help to establish
priorities in the provision of services and preventive measures.
We found that 70.4% of all deaths were due to injury. Most of injury related deaths either intentional
or unintentional occurred in most economically productive age group, so one can imagine the
economic impacts of such death. Seventy percents of the patients were either from Addis Ababa or
Oromia region. This is probably related to the distance, as the hospital is in Addis Ababa and near to
the Oromia region (the biggest region in the country).
The Autopsy is done mainly on physical examination of the deceased body and remnants which
makes the diagnosis of poisoning suicide, as a sole and concomitant cause of death, to depend solely
on circumstance of death and physical witnessing (seeing and smelling) of potentially dangerous
chemicals and/or materials. Such examination may lead to apparently low detecting rate of poisoning.
There are no written protocols on the type and extent of autopsy examination to be done according to
the body / remnant presented, body sample and body fluid preservation and examination and content
and style of autopsy result reporting. Majority of the injuries occurred on the road and only very few
occur at work place. Road traffic accident was the leading (37%) causes of fatal injury, similar with
the study in US 22 but different from the study in India where intentional self harm was the leading
cause 23-25. Road traffic fatalities affect pedestrian and vehicle occupants almost equally unlike other
low energy injuries were majority were pedestrian 14-17. This finding is in conformity with the pattern
of road users involved in road traffic crashes. Pedestrians account for 53% of all road users crashed by
vehicles in Ethiopia in 200719. A large number of deaths (41%) were intentional (homicide 30% and
suicide 11%). It needs a different study design and approach to understand the underlying causes of
interpersonal conflicts and motives for suicides.
Ninety percent of the victims died within 24 hours of the injury and 7 % within 2nd-7th day of post
injury. It is very sad that 81% of the victims died without receiving any post crash care either pre
hospital or hospital level and the patients died on the sites of accident or while they are on the process
of transfer to hospitals or on arrival and while awaiting services at emergency department. As it was
shown on other studies26 there are other factors, other than severity of trauma, that determine survival
such as effective emergency medical system and triage, prompt and correct diagnosis, adequate
medical treatment and care. If there were proper pre-hospital care, ambulance service and rapidly
acting hospital emergency service, most of these patients could have been saved.
The fatality per 10,000 licensed vehicles for the year was 103, previously it was 199 which seems the
fatality decrease but this may not be the case, probably due to increasing the number of vehicles.
According to the traffic police report there were 2515 road traffic fatal injuries but only 782 (31%)
were brought to Menilik II hospital, this shows that there is a need of coordinated national injury
surveillance which coordinates and combines data from different sources.
Recommendations
We recommend:
1. Details about injury related deaths from multiple sources and moving our understanding
beyond an appreciation of only the gross contour of the problem.
2. Study the apparent motives behind suicide and reasons for homicide
3. Specific and multi-disciplinary intervention methods are necessary to tackle multiple causes
of injuries and deaths.
4. In the mean time establishing proper emergency service (pre-hospital and hospital) are
urgently required to reduce the number of death from injury.
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5. The autopsy service and interpretation of the evidences should be supported with toxicology
laboratory and histo-pathology examination and decrease its dependence on the circumstances
of death solely.
6. Protocols on Type and extent of autopsy examination, Content and style of reporting and
Record keeping should be put into practice and strongly followed.
Acknowledgement
The cooperation of the health bureau of Addis Ababa city administration is greatly appreciated.
Special thanks go to all staffs of Menillik II hospital in pathology department and those involved in
data collection.
References
1. Maciaux M, Romer CJ. Accidents in children adolecent and young adults. Major public
heaith problem. Wld Hlth Stat Quart 1986;39:227-31
2. Zwi A. The public burden of injury in developing countries: a critical review of literature.
Trop. Dis. Bull. 1993; 90:5-45.
3. Nordberg E. Injuries in Africa: a review. East Afr. Med. J. 1994; 71(6):339-45.
4. Hunpono-Wusu, O.O. Disorders which shorten life among Nigerians. Trop. Geogr. Med.
1976; 28:343.
5. Omondi- Odhiamho, van Ginneken, J.K. and Voorhoeve, Am. Mortality by cuase of death in
a rural area of Machakos District. Kenya. In 1975-78. J. Biosoc. Sci. 1990;22:63
6. World Health Organization. Investing in health research and development: Report of Ad-Hoc
committee on health research relating to future intervention options. Geneva, 1996.
7. Smith G.S, Barrs P. Unintentional injuries in developing country. The epidemiology of
neglected problem. Epidemiol. Rev. 1991;13:228-66
8. Forjouh S.N Gyebi-Ofosu E. Injury surveillance: should it be concern to developing
countries? J. pub. Hlth. pol, Autumn 1993; 355-9.
9. Peden M et al. World report on road traffic injury prevention. Geneva, World Health
Organization, 2004
10. World population prospects: the 2002 revision. Volume 1: Comprehensive tables New York,
United Nations, 2003
11. Larson PC and Dessie T. Unintentional and intentional injuries, In Helmut Klos and Zein
Ahmed: Ecology of health and disease in Ethiopia. Westview press, 1993;473-82
12. Mensur O. Yizaw K. Sisay A. Magnitude and pattern of injuries in North Gonder
administrative zone, northeast Ethiopia, Ethiop. Med. J. 2003; 41:213 – 220.
13. Health and health related indicators, By Ministry of Health, Addis Ababa, Ethiopia 2000.
14. A. Wolde, K. Abdella, E. Ahmed, F. Tsegaye1, O. A. Babaniyi, O. Kobusingye, K.
Bartolomeos. Pattern of Injuries in Addis Ababa, Ethiopia: A One-year Descriptive Study.
East and Central Afr. J. Surg. 2008; 13(2); 14-22.
15. Elias Ahmed, Tezera Chaka. Orthopedic emergencies and major limb trauma in Tikur
Anbessa Hospital, Addis Ababa. East and Central Afr. J. Surg. 2005;10(2): 43-50
16. Elias Ahmed, Tezera Chaka. The Pattern of orthopedic admissions in Tikur Anbessa Hospital,
Addis Ababa. Ethiop. Med. J. 2005;43:85 – 91
17. Mulate Taye, Tadios Muni. Trauma registry in Tikur Anbessa Hospital, Addis Ababa,
Ethiopia. Ethiop Med J, 2003; 41: 221-226.
18. G. Jacobs and A. Aeron-Thomas (TRL Limited). African road safety review, final report. US
Department of Transportation/ Federal Highway Administration. PR/INT/659/2000.
19. National Road Safety Coordination Office of Ethiopia, reports of 1999 EC with regard to
RTI.
20. Central Statistics Agency of Ethiopia, 2008
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21. World Health Organization. International Statistical Classification of Diseases and Related
Health Problems, 10th Revision, Version for 2003. http://www3.who.int/icd/
vol1htm2003/fricd.htm.
22. Vyrostek SB, Annest JL, Ryan GW, Surveillance for ftal and non fatal injuries- United states,
2001. MMWR Surveill Summ. 2004. 3; 53(7):1-57.
23. M Cardona et.al.The burden of fatal and non-fatal injury in rural India. Injury Prevention
2008;14:232–237
24. Bose A, Konradsen F, John J, et al. Mortality rate and years of life lost from unintentional
injury and suicide in South India. Trop Med Int Health 2006; 11:1553–6.
25. Gajalakshmi V, Peto R. Suicide rates in rural Tamil Nadu, South India: verbal autopsy of
39,000 deaths in 1997–98. Int J Epidemiol 2007; 36:203–7.
26. Nicolic S. Micic J, Mihailovic Z. Correlation between survival time and severity of injuries in
fatal injuries in traffic accident. Srp Arh Celok Lek. 2001; 129(11-12).
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Surgical Mortality at a Mission Hospital in Western Uganda.
G . Tumusiime
Department of Surgery, Mubende Regional Referral Hospital, P.O Box 4, Mubende, Uganda.
E-mail: [email protected], [email protected].
Background: Audit of Surgical mortality seeks to focus on improvement in the process of
surgical care and not on individual surgical ability. Audit of surgical mortality was conducted to
establish the factors associated with the surgical deaths in Virika Hospital to propose ways of
improvement.
Methods: The study was conducted in Virika Mission Hospital in Western Uganda, a 155 bed
capacity hospital with a surgical bed capacity of 32 located in rural Uganda.Individual case file
review of the fourty three surgical deaths from 1st July 2008 to 31st June 2009 was conducted.
Additional data was retrieved from hospital admission register, operation registers, and death
certificate
books.
Results: The operation death rate was 1.3%, all were emergencies, and 82.6% were done under
general anaesthesia and17.4% died on table. The laparotomy death rate was 12.5%,
Herniorrhaphy 0.9%, drainage of pus 1.4% and wound suture 0.4%. Surgery was delayed due
to lack of blood in only one case but there was no record of lack of any resource for delaying
surgery. Surgical conditions were: Injuries 39.5%, Intestinal perforations 30.2%, Intestinal
obstruction 20.9% and others 9.3%. The hospital had no high dependency unit and no intensive
care unit. No postmortem was conducted in all cases.
Conclusion: Overall the Audit identified client, provider, administrative and community-related
factors that need to be addressed collectively to reduce surgical mortality in Virika
hospital.Audit of surgical mortality should be part of the health workers’ general approach to
making more information available in a meaningful way for continuous improvement of
surgical services.
Introduction
In recent years, audit has become an acquired concept in health care in both industrialized and
developing countries. Audit can measure the resources and personnel available, processes that happen
in practice and outcome that indicate the results of care. This is well appreciated that audit not fault
finding, but it encourages thoughtful planning which leads to valid information collection and
subsequently to informed decision making1,2. Mortality audit is important because it gives an
understanding of what happened and why. This helps to go beyond rates and ratios to determine the
inciting factors and to take measure of how they could be avoided3. Audit of Surgical mortality seeks
to focus on improvement in the process of surgical care and not on individual surgical ability.
In countries like the United Kingdom where audit of surgical mortality has been institutionalized,
there has been significant reduction in preventable death. The underlying principle of the audit is the
recognition that surgical care is system based. Ultimately the findings of audit of surgical mortality
may demonstrate deficiencies in surgical procedures, staffing in the hospitals, access to high
dependence beds and other resource matters that will then need to be addressed by all stakeholders.
The core purpose of audit of surgical mortality is the feedback of information to inform, educate and
facilitate change and improvement in service.
Audit of surgical mortality should be part of the health workers’ general approach to making more
information available in a meaningful way for continuous improvement of surgical services. The
emphasis on problem-solving, not punishment, helps address issues and build staff capacity. This
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study was aimed at reviewing the cases of surgical deaths with a view of determining the factors
associated with surgical mortality and consequently to propose ways of improvement surgical care.
Material and Methods
The study was conducted in Virika hospital, a 155 bed capacity hospital with a surgical bed capacity
of 32 located in rural Uganda. The hospital has neither an intensive care nor high dependency unit and
no intensive care unit.Individual case file review of the fourty three surgical deaths from 1st July 2008
to 31st June 2009 was conducted. Additional data was retrieved from hospital admission register,
operation registers, and death certificate books. The American Society of Anaesthesiologists (ASA)
classification was not documented on any anaesthesia sheet.
Results
During the period 1st July 2008 to 31st June 2009, there were 1,678 admissions of which 1,818
underwnt surgery. There were 43 deaths, giving a mortality rate of 2.6%. Thirty three (6.7%) of the
death occurred in males. The patients’ ages ranged from 3 days to 84 years with a mean age of
25years and median of 22yeays. 74.4% (32) were below the age of fourty years.
Of the 43 deaths, 23 (53%) had undergone surgery. The overall death rate of the operated cases was
1.3%. All the 23 had emergency operations. Nineteen (82.6%) of the 23 operations complicated by
death were done under general anaesthesia while four were performed under local anaesthesia.
Twenty (87%) of the 23 operations were laparotomy; there were 160 laparotomies performed during
the review period, giving a laparotomy death rate of 12.5%.The other three procedures performed
among the deceased with their respective death rates were: Herniorrhaphy (MR = 0.9%), incision and
drainage of pus (MR = 1.4%) and surgical toilet and suture of wounds (MR = 0.4%).
Five (21.7%) of those operated on had comorbid conditions that included diabetes mellitus in two and
AIDS WHO stage four in three cases. The interval between admission and surgery ranged from 30
minutes to nine days. Twelve (52.2%) were operated on within 24 hours of admission while 6 (26.1%)
had surgery three days after admission. Nineteen (82.6%) of the 23 were operated on once while four
were operated on twice before death. The reasons for reoperation were burst abdomen in all the four
cases. The interval between the first and second operations was 5 days, 10 days, 11 days and 12 days
respectively.
Of the twenty patients who were not operated on, the reasons for not doing surgery were: condition
not requiring surgery in 12 (60%), rapid death in 5 (25%) and in 3 (15%) an active decision was taken
by the attending doctor and anaesthetist not to operate because patients were not fit for anaesthesia.
None of the patients refused an operation. Twenty four (55%) of the 43 patients died within three days
of admission while 10 (23%) died after one week of admission.
Four (17.4%) of the 23 patients died intraoperativel on the table, 10 (43.5%) died within three days
after surgery and six (26.1%) died after seven days. The longest staying patient died on the 18th post
operative day. Two of the patients who died on the table underwent laparotomy, one had
herniorrhaphy, and one died before surgery was started. All the four were under general anaesthesia.
Twenty five (58%) of the 43 came direct from their homes and the rest came from various heath
institutions. Upon arrival in the hospital, only 7 (16.3%) were attended to first before admission. The
majority was first reviwed and admitted by either nurses or by clinical officers. All the 43 patients
who died were reviewed by a doctor at least once before death. Indications for admission among the
fourty three deaths were included traumatic injuries (39.5%), intestinal perforations (30.2%),
intestinal obstruction (20.9%) and others (9.3%). Fifteen (88%) of the 17 traumtic injuries were
unintentional while two were due to assault among tea plantation workers.
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Causes of the 15 unintentional injuries included 7 (47%) road traffic crashes, 7 (47%) due to burns
and one due to a collapsing wall. Eight of these cases were diagnosed as head injuries, seven of them
being open head injuries. Five of the seven cases of burns were due to scalds among children at home
while two were due to acid assault. Perforations were located in the ileum in 11 (84.6%) of the 13
cases of intestinal perforation and of the appendix in two cases. 76.9% (10) of these patients were first
admitted on the medical ward for more than three days and the remaining three were first treated for
malaria and gastroenteritis for more than three days by the referring hospitals.
Plain abdominal X-ray radiography was not done in any case of intestinal perforation. Of the eleven
patients with perforations on the ileum, 54.5% (6) were done abdominal ultrasound scan before
surgery and all suggested peritonitis. Full blood count was not done in any of the cases. Widal test
was done in four (36.4%) of the cases and of these only one was positive. HIV serology was done in
three (27.3%) of the cases and were all positive.
Seven (77.8%) of the nine patients with intestinal obstruction had large bowel obstruction five of
which were due to sigmoid volvulus and two had anorectal malformation.The two small gut
obstructions were due to strangulated hernia and intussusception.
No postmortem was conducted in all cases.
Discussion
Surgical complications are a considerable cause of death and disability around the world4.They are
devastating to patients, costly to healthcare systems, and often preventable, though their prevention
typically requires a change in systems and individual behaviour.
The death rates and complications observed in this study are in agreement with the findings by
Haynes et al5 in a settings like Virika hospital where the World Health Organisation Surgical Safety
checklist is not used.The risk of complications is poorly characterized in many parts of the world, but
studies in industrialized countries have shown a perioperative rate of death from inpatient surgery of
0.4 to 0.8% and a rate of major complications of 3 to 17% 6,7. These rates are likely to be much higher
in developing countries8-11. Thus, every facility should design a system of establishing individual rates
and contributing factors and institute appropriate measures to address them.
Introduction of the WHO Surgical safety checklist12 into operating rooms in eight diverse hospitals
was associated with marked improvements in surgical outcomes. Death rates and postoperative
complication rates fell by 36% and the results suggested that the checklist program can improve the
safety of surgical patients in diverse clinical and economic environments5. Its use would help the
surgical team to prevent omission of important processes noted in this study like ASA classification of
all surgical patients, adequate fluid resuscitation and recording on the daily fluid balance chart, timely
administration of prophylactic antibiotics and availability of all essential laboratory and imaging
results before surgery. This in turn would reduce on outcomes like intra-operative death and burst
abdomen noted in this study.
Previous efforts to implement practices designed to reduce surgical site infections or anaesthesiarelated mishaps have been shown to reduce complications significantly13-15. A growing body of
evidence also links teamwork in surgery to improved outcomes, with high-functioning teams
achieving significantly reduced rates of adverse events 16, 17.
There is a high likelihood that surgical intervention in our series was delayed given the fact that
majority of the deaths were among patients who came from to hospital direct from their homes. Those
referred from health facilities and even those within the hospital were first treated as medical cases.
Delays have been shown to cause adverse events and in a hospital setting delay in transferring to
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East and Central African Journal of Surgery Volume 15 Number 2.
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theatre is one of the most frequently reported causes for an area of concern or adverse event18. Delays
may be resource related or clinical decision-making process. In a setting like Virika hospital where
majority of the patients are first seen and admitted by nurses and clinical officers, delays in decisionmaking process can be reduced by regular refresher training of these cadres in timely recognition of
emergencies and resuscitation so that the few doctors available can concentrate on more complex
tasks in the care process.
Although physical access to health facilities in Uganda has improved with 82.5% of the population
reporting to be living within 5 km of a health facility19, considerable disparities exist regarding the
level and expertise of service delivery. This partly explains the observation that about 80% of the
deceased came from districts which do not have hospitals. In addition, actual access and utilisation
differs significantly between the poorer and richer segments of the population. Therefore, there is
need for health workers in lower level health units to be trained in recognising cases that require
surgical intervention and be able to make timely referrals to hospitals.
There is also need to educate communities especially those in remote areas on the danger signs of
common surgical diseases so that they can make a decision to go to health facilities before
complications set in. Timely surgical intervention is important especially in resource-limited facilities
like high dependence units, intensive care units and expertise to handle complicated cases.
Although the main concern raised in surgical mortality audits in developed countries is mortality
among the elderly 20-25, the main concern of this audit was that the majority were young people below
fourty years of age. This age group contributes to scholars, income for many families and the
country’s workforce. However, this is not surprising since over seventy percent of the Uganda’s
population and the life expectancy is below sixty years19,26.
Injuries were associated with the majority of the surgical mortality. Globally, injuries have been
recognised as one of the most life threatening public health problems. They represent 12% of global
burden of diseases and the third most important cause of overall mortality27. According to WHO, an
estimated 5.06 million people die each year as a result of some form of injuries, comprising almost
9% of all deaths. This equates to almost 14,000 injury deaths every single day 28. Majority of the
injuries (88%) were unintentional with a big proportion due to road traffic accidents in agreement
with injury experience in Addis Ababa, Ethiopia 29 and in Kampala, Uganda 30. However, the results
were contrary to findings in North Gonder, Ethiopia 31 and the Jamaican injury profile 32 where more
than half is violence related.
It is of great concern that none of the patients with head injury had their Glasgow coma scale recorded
since it is an objective way of determining the severity of head injury in a resource limited setting,
helps in monitoring the progress of a head injury patient and may be of importance in case of
litigation to justify the likelihood of death.
Similarly, failure to assess and record the burn surface area points to inappropriate fluid resuscitation
among the burns patients since the percentage burn surface area is used to estimate the fluid
requirements especially in resource-limited situations. Although no postmortems were not done,
autopsy has been shown to provide additional information while in some cases it has been rejected25.
Conclusion
Overall the audit identified client, provider, administrative and community-related factors that need to
be addressed collectively to reduce surgical mortality in Virika hospital. Audit of surgical mortality
should be part of the health workers’ general approach to making more information available in a
meaningful way for continuous improvement of surgical services.
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
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It is hoped that all health workers will accept audit of surgical mortality as a peer review audit
undertaken voluntarily by all participants, thereby ensuring that every surgical death is scrutinized
independently and the collective results of that scrutiny are widely and freely disseminated resulting
in improved care.
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Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J
Surg 2008 September 11 (Epub ahead of print).
Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing
among surgeons, nurses and anaesthesiologists to reduce failures in communication. Arch
Surg 2008; 143:12-8.
www.surgeons.org
Uganda Bureau of Statistics. The Uganda Demographic and Health Survey 2006.
McColl I. Medical audit in British hospital practice. Br J Hosp Med 1979; 22:485-90.
Shaw CD. Aspects of audit. Audit in British hospitals. Br Med J 1980; 280:1314-6.
Gilmore OJA, Griffiths NJ, Connolly JC, et al. Surgical audit: comparison of the workload
and results of two hospitals in the same district. Br Med J 1980; 281:1050-2.
Ward A. Surgical audit. Br Med J1981; 282:68.
Gallimore SC, Hoile RW, Ingram GS, Sherry KM. The report of the national confidential
enquiry into perioperative deaths 1994/1995. NCEPOD 1997.
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25.
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SASM steering group. Scottish audit of surgical mortality: annual reports 1996-2007.
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Uganda Public Expenditure
Review, May 2009.
The World health report 2001. Mental health: new understanding, new hope. Geneva, World
Health Organisation, 2001
Peden M, McGee K, Sharma G. The injury chart book: a graphical overview of the global
burden of injuries. Geneva, World Health organisation, 2002.
Mulate Taye, Todios Muni. Trauma registry in Tikur Anbessa Hospital, Addis Ababa,
Ethiopia. Ethiop Med J, 2003; 41:221-226.
Kobusingye OC, Guwatudde D, Owor G, Lett RR. Citywide trauma experience in Kampala,
Uganda: a call for intervention. Inj Prev. 2002; 8(2): 133-6. Kobusingye OC, Lett RR.
Hospital based trauma registries in Uganda. J trauma. 2000; 48(3):498-502.
Mensur O. Yizaw K. Sisay A. Magnitude and pattern of injuries in North Gonder
administrative zone, northeast Ethiopia, Ethiop. Med. J. 2003; 41:213-220.
Arscot-Mills S, Gordon G, McDonald A, Holder Y, Ward E. Profiles of injuries in Jamaica.
Inj control saf promot, 2000: 9(4):227-34),
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Motorcycle Road Traffic Injuries in Southern Nigeria: The Small Motorcycle as
a Prevention Strategy.
T.E. Nottidge1, U.S. Ekanem2, S.O. Ogunlade3, N.E. Ngim4, E.S. Mkpouto-Obong1
1
Department of Surgery, University of Uyo Teaching Hospital.
Department of Public Health, University of Uyo Teaching Hospital.
3
Department of Orthopaedics and Trauma, University College Hospital, Ibadan.
4
Department of Surgery, University of Calabar Teaching Hospital, Calabar.
Correspondence to: T.E. Nottidge, Email: < [email protected]>
2
Background: The commonest mode of public transportation in Uyo is by motorcycle. There are
two sizes of motorcycle in common use – the big one (Qlink or Skygo model, made in China) and
the small one (C90, made in China). The study was carried out to determine if there is a lower
risk of RTI severe enough to be brought to the hospital, attributable to using a small
motorcycle.
Methods: Motorcycle RTI victims admitted at the Accident and Emergency department of the
University of Uyo Teaching Hospital (UUTH), were reviewed prospectively over a 15 month
period. Three community visual surveys of the proportion of small to large motorcycles were
also conducted.
Results: A total of 131 RTI victims were reviewed over 15 months. The visual surveys of
motorcycles in Uyo revealed that the mean proportion of small to large is 38 to 62, a ratio of
1:1.6. Eighty-three (63.3%) of the 131 RTI’s involved motorcycles. 74 of these occurred in large
motorcycles. There was a statistically significant relationship between motorcycle size and
occurrence of an RTI severe enough to be brought to hospital.
Conclusion: There is a lower risk of RTI severe enough to be brought to hospital, from using a
small motorcycle.
Introduction
Motorcycle riders have the highest risk of fatal and nonfatal injuries among all types of road users1,
yet they are the predominant means of public transportation in Uyo, the capital city of Akwa-Ibom, a
southern Nigerian state. They have the advantage of easy manoeuvrability in traffic; take the rider to
his/her specified destination (unlike buses which ply defined routes); are cheaper than taxi’s and with
increasing unemployment, provide a ready means of quick self- employment. Thus these ‘Akaoke’, as
they are locally called, are here to stay.
The traffic situation is chaotic and poorly regulated, as in other low and medium income countries
(LMIC). Several attempts by other states in Nigeria to reduce the high rates of RTI’s by enforcing
traffic regulations, have failed. Two years ago, Abuja, the capital city of Nigeria, banned motorcycle
public transportation completely. The two sizes of motorcycle in use for public transportation are the
‘large’ and ‘small’. The large one has an engine capacity of 125cc or 150cc, while the small one has a
capacity of 90cc. Maximum speed for the small is 100km/hr, weight is 87kg; for the large type, the
maximum speed is 140 – 150km/hr and weight 107 – 125kg.
There is also the problem of overloading. It is common to find 4 passengers on the large motorcycle
or a huge bag of rice with the pillion passenger. These far exceed the maximum safe load and
predispose to RTI. The small motorcycle does not have space for such an overload. In addition, the
small size cycle has shin guards that may reduce the incidence of leg injury. This is important because
the tibia is the commonest long bone fractured in motorcycle RTI2. It was observed that the vast
majority of RTI victims presenting to the UUTH, had been on a large motorcycle. Thus this study was
carried out to determine if there was indeed a lower risk of RTI severe enough to be brought to
hospital, from using a small motorcycle.
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East and Central African Journal of Surgery Volume 15 Number 2.
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Studies in the developed world have been undertaken to identify and define the relationship between
motorcycle engine capacity and occurrence of motorcycle RTI3. Other authors have identified a link
between motorcycle engine capacity and increased fatality risk of a motorcycle crash4,5.There have
been varying results, probably because of general adherence to traffic regulations, which may
somewhat neutralise the difference between the various motorcycles studied. In an unregulated
environment, with added factors of regular overloading, many other variables apart from engine
capacity and speed alone, come into effect that affect the relationship between the type of motorcycle
and occurrence of an RTI severe enough to be brought to hospital . It was convenient to use size of
motorcycle rather than engine capacity, because most RTI victims did not know the engine capacity
of the cycles they had used.
The objective of this study was to determine if there is a lower risk of an RTI severe enough to be
brought to hospital, with the use of the smaller motorcycle. Thus the null hypothesis (Ho) was that
there is no relationship between motorcycle size and the occurrence of an RTI severe enough to be
brought to hospital.
Patients and Methods
Information on RTI victims, who presented to the Accident and Emergency Department of the
UUTH, from June 2005 to August 2006, was obtained from the patients, eye-witnesses to the event
and case records. Data for two months was missed. Three community visual surveys of the proportion
of large to small motorcycles in Uyo were carried out at different locations and time of the day. None
was done at night because of visibility problems, since there were no street lights. This was done by
standing by the roadside and noting the number of small motorcycles in the first 100 motorcycles that
pass the observer, going in one direction. The first author carried out two of these surveys and another
person carried out the third. Ethical approval was obtained from the hospital Ethical Review Board.
No separate approval was obtained from the patients included in this study.
In four of the motorcycle injury cases, data on motorcycle size was not obtained and these were
excluded from the study Data analysis was done with STATCALC, an internet software, in the
domain of Chi-Squared test for goodness of fit. P value of ≥ 0.05 was accepted as statistically
significant.
Results
There were 127 RTI victims reviewed from June 2005 to August 2006 including 92 males and 39
females, a male to female ratio of 2.4:1. The age range was from 4 to 65 years, with a median of 28
years. There were 79 patients on motorcycles i.e. 62.2%. 74 involved large motorcycles and 5
involved small motorcycles i.e. 93.6% and 6.4% respectively. The visual survey of motorcycle sizes
in Uyo revealed 39 small motorcycles twice and 37 once, in the 3 sets of 100 motorcycles surveyed.
The mean proportion of small to large is 38.3 small to 61.7 large in each 100, approximately 38 to 62,
a ratio of 1:1.6. Thus in 79 motorcycle crash cases it is expected that 30 of them should have involved
small and 79 involve large motorcycles, assuming that the same factors impact on both types of
motorcycle.
Df = 1
X2 = 22.94, p < 0.001
Thus Ho is rejected. and there is a significant relationship between motorcycle size and the occurrence
of an RTI severe enough to be brought to hospital, with increased risk of such an RTI attributable to
the large motorcycle.
Discussion
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The occurrence of an RTI severe enough to be brought to hospital can be somewhat assumed by the
fact of the patient presenting at the hospital. This study did not take injury severity scores into
account, so the severity of the injury on its own cannot be considered. The study did not obtain
information on the absolute numbers of small to large motorcycles involved in accidents during the
study period and so cannot determine the risk for occurrence of an RTI.
The two sites of observation for this study were chosen because the required data are not reliably kept
by public institutions, as obtains in the developed world. Thus using the information from patients
presenting to the hospital, on what size of motorcycle they were riding, is a surrogate for absolute data
on the number of large and small motorcycles involved in road traffic accidents (RTA), over the
period of the study. It should be noted that in 1975 Kraus et al6 found only 39% of the data used for
their study in California, from official police records. The majority of his data was from hospital
records, as in this study. A visual survey in the community, to determine the proportion of small to
large motorcycles, is in lieu of finding out how many small and large motorcycles plied the roads. The
results of the visual survey were taken as representative, because the figures obtained were similar,
despite varying sites and time of the day, in the same town.
The use of Chi-squared test for goodness of fit requires that all things be equal. For this study, it was
assumed that the same factors affected both the occurrence of RTI on either small or large
motorcycles and the presentation of more severe injuries at the only hospital in the state capable of
handling severe injuries.
The reason why only these two sizes are available for public transportation in the state may be related
to the current trend to use the larger, faster, roomier bike and the lower cost of purchase from eastern
countries - South Korea and China. The increased speed and more space for excess load may explain
why the less durable but more expensive large cycle, is much more common. Kraus et al6 found that
the risk of motorcycle injury was not related to motorcycle make, but to engine size. However, the
size of the motorcycle was not taken into account. Larsen7 noted that there was a statistically
significant relationship between the occurrence of a fatal motorcycle crash and use of a larger engine
capacity motorcycle. 50% of the motorcycles involved in Larsen’s study had a capacity above 560cc.
The threshold engine capacity for risk of a fatal crash was not specified, but both Yannis4 and
Bradbury8 place this threshold at about 750cc. Langley et al9 specified that the threshold engine
capacity above which the risk of motorcycle RTI increased by 50%, was 250cc. However, they note
that there was no linear relationship between RTI and engine capacity, above 250cc. Thus the
threshold engine capacity varies with the prevailing circumstances and other factors like the weight of
the motorcycle. Langley9 noted that engine power and weight considerations together, may have
greater import than engine capacity alone. This study amplifies this concept by using the motorcycle
size in this environment, as the main discriminator and thus considering specifics about the
motorcycle (engine capacity, speed, weight etc) together with the way it is used (overloading) in an
unregulated environment. In this environment, it is likely that all these factors combine to make the
smaller cycle the safer one.
It has already been noted that in developing countries, pedestrians, car passengers and motorcyclists
combined account for about 90% of deaths due to RTI10. Innovative measures are needed to help
tackle this ‘neglected epidemic’11, as reliance on regulations has been found to fail in a yet to be
regulated environment10. Adopting a policy of using the small motorcycle for public transportation is
likely to help critically reduce the occurrence of more severe types of motorcycle RTI.
Conclusion
Use of the small motorcycle in Uyo, has a lower risk of RTI severe enough to be brought to hospital.
Further studies are required to determine the factors responsible for this finding.
Acknowledgements
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The authors acknowledge Professor E. E. Ekanem of Lagos University Teaching Hospital for
statistical guidance and Mr Gboyega Jobi for help with data collection.
References
1. Lin M, Kraus JF. Methodological issues in motorcycle injury epidemiology. Accid Anal Prev.
2008; 40 (5):1653-1660.
2. Lateef F. Riding motorcycles: is it a lower limb hazard? Singapore Med J. 2002;43(11):566-9.
3. Yannis G, Golias J, Papadimitrou E. Driver age and vehicle engine size effects on fault and
severity in young motorcyclists accidents. Accid Anal Prev. 2005; 37(2):327-33.
4. Quddus MA, Noland RB, Chin HC. An analysis of motorcycle injury and vehicle damage
severity using ordered probit models. J Safety Research 2002; 33(4):445-62.
5. Pang TY, Umar RS, Azhar AA et al. Accident characteristics of injured motorcyclists in
Malaysia. Med J Malaysia. 2000; 55(1):45-50.
6. Kraus JF, Riggins RS, Franti CE. Some epidemiologic features of motorcycle collision
injuries. II. Factors associated with severity of injuries. Am J Epidemiol. 1975;102(1):99-109.
7. Larsen CF, Hardt-Madsen M. Fatal motorcycle accidents in the county of Funen (Denmark).
Forensic Sci Int. 1988; 38(1-2):93-9.
8. Bradbury A, Robertson C. Pattern and severity of injury sustained by motorcyclists in road
traffic accidents in Edinburgh, Scotland. Health Bull (Edinb). 1993; 51(2):86-91.
9. Langley J, Mullin B, Jackson R, Norton R. Motorcycle engine size and risk of moderate to
fatal injury from a motorcycle crash. Accid Anal Prev. 2000; 32(5):659-63.
10. Nantulya VM, Muli-Musiime F. Kenya. Uncovering the social determinants of road traffic
accidents. In: Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M, eds. Challenging
inequities: from ethics to action. Oxford: Oxford University Press, 2001.
11. Nantulya VM, Reich MR The neglected epidemic: road traffic injuries in developing
countries. BMJ 2002; 324:1139-1141.
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Traumatic Brain Injury in Accident and Emergency Department of a Tertiary Hospital
in Nigeria.
J.K.C. Emejulu, C.M. Isiguzo, C.E. Agbasoga, C.N. Ogbuagu
Department of Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, South East
NIGERIA,
Correspondence to: Dr J.K.C. Emejulu, E-mail: [email protected]
Background: Traumatic brain injury is a major public health problem in Nigeria, as it could be
associated with long term and life long deficits. Unlike other parts of the world, in our country,
motorcycles are possibly the main cause of this injury. Unfortunately, we do not have a national
epidemiological data base yet. This study was aimed at defining the peculiar demographic and
associated risk factors in traumatic brain injury among our patients, as part of a multiinstitutional data pool for a future meta-analysis to generate the national data base.
Methods: This was a 24-month retrospective study of all head injury patients who met the
criteria for traumatic brain injury in the Accident and Emergency Department of a tertiary
health institution. Data were collected from the emergency cards and case notes, then collated
and analyzed using the descriptive statistics on SPSS 13, with the p value taken as <0.05.
Results: A total of 9,444 patients were attended to during the 24 months; 510 (5.4%) of them
met the inclusion criteria for the study. This translated to a presentation rate of 5.3 cases per
week and an incidence rate of 2,710 per 100,000 per year. Males accounted for 404 (79.2%) of
the cases. The peak age incidence (31.2%) was in the >20 – 30 year age group. Traders
constituted the highest occupational group 125 (24.5%). Most (58.8%) of the cases resulted from
motorcycle accident. There were 28 deaths giving a mortality rate of 5.5% or 148 deaths per
100,000 per year.
Conclusion: The risk factors were the male gender, motorcycle riding, illiteracy, trading,
extremes of age and active daytime period of 12:01 – 18:00hours. The incidence rate was much
higher than in the developed countries, but could reduce with the use of crash helmets, seat
belts, speed limits and safety/protective vehicular devices, with better road rehabilitation.
Introduction
Head Injury is a general term used to describe any trauma to the head but most especially with
involvement of the brain1. It could be strictly defined as trauma to the brain and/or its coverings due to
an externally applied mechanical force. In essence, its functional significance becomes manifest when
there is an accompanying cranial neural injury, and this becomes known as traumatic brain injury
(TBI), a term used specifically to describe affectation of intracranial contents with its potential
likelihood of significant functional deficits. The enormity of the problem of head injury goes beyond
the hospital treatment because there could arise long term or lifelong complications affecting thought
processes, language, emotions, sensation and communication, that may necessitate different forms of
support services for the injured2. Locomotion, memory and post-traumatic seizures could also become
a problem
In United States (US), the incidence of head injury at the Emergency Department was recently
reported to be 394 per 100,000 people, male: female ratio was 1.8:1 and mortality rate 19.3 per
100,000 people3. The leading causes of TBI were reported as fall (28%), motor vehicular traffic crash
(20%), assault (11%) and others (41%). The highest incidence of motor vehicular traffic crash was
found in the 15 – 19 year group, while fall was the leading aetiology in the 0 – 4 and >75 year
groups4.
Another study done in a United Kingdom (UK) population on the attendance rate of head injury at an
Emergency Department showed that head injury constituted 3.4% of the total attendance and the
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East and Central African Journal of Surgery Volume 15 Number 2.
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incidence was 453 per 100,000. Nearly 11% were moderate to severe head injury, implying that mild
head injury (89.1%) was the most common type. Males were found to be at a higher risk for moderate
to severe head injury than females5. Thus, even in the regulated systems of the developed countries,
head injury is still of special public health concern.
The work done by Adeolu, et al, on aetiology of head injury in South West Nigeria involving 1541
patients that presented at the Accident and Emergency Department, showed that motor vehicular
accident (MVA) - both passenger and pedestrian, and fall were the leading aetiological factors,
accounting for 73.4% and 16.4%, respectively6. The aetiological dominance of MVA is consistent
with other regional studies, and the study also showed a higher incidence of head injury in the 21 – 30
(23.3%) and 1 – 10 (20.8%) year groups, respectively7,8,9. Fall was the dominant aetiological factor in
the first decade of life, raising concerns about surveillance and supervision of the paediatric age
group; while road traffic accident (RTA), was the most common in the third decade.
Solagberu, et al10 reported that the greater proportion of MVA involved motorcyclists (riders and
passengers). This contributed greatly to their cohort because of the reported increase in motorcycle
units on Nigerian roads. Some other studies have implicated motorcycle use as a major contributor to
head injury incidence in developing countries11,12. With the financial incapacity to buy the more
modern vehicles with protective devices and safety gadgets, the lack of strict traffic regulations and
the poor network of roads in various stages of dilapidation, the reasons for this situation in developing
countries would not be far fetched.
Nigeria lacks a national epidemiological data base on head injury6. This indeed makes it very difficult
to appreciate the scale, determinants and distribution of the problem, and as such, makes an effective
intervention, even more difficult. The lack of data also impedes the development of evidence-based
strategies for prevention of this injury and the objective assessment of the success of any injury
reduction intervention put in place. In the US and Italy, the implementation of helmet–use laws for
motorcyclists reduced the incidence of head injury associated with motorcycle crash to significantly
lower rates by 1975 – 198613,14. This assessment was only possible because of the availability of
epidemiological data pre- and post-intervention.
Against this backdrop, therefore, it would be pertinent in Nigeria to generate epidemiological data on
head injury and its sub-types which would logically contribute towards the objective evaluation of the
enormity of this problem. Such data on the distribution, pattern and determinants of injury would
inform the options to be used in the effective control of this preventable epidemic. Our focus in this
study was on the incidence, age, gender, aetiologic factors, injury patterns, time of injury and
occupational distribution of head trauma cases diagnosed with brain injury that presented in the
Accident and Emergency Department of Nnamdi Azikiwe University Teaching Hospital [NAUTH]
Nnewi, Anambra State, Nigeria from January 2007 to December 2008. Since most previous local
studies in the country were geographically restricted, we hope that, somehow, these segmented studies
could be meta-analyzed as a multi-institutional study pool to generate representative national figures
and over time, provide the country with her national epidemiological data base on the various facets
of head injury.
The aim of this study is to define the peculiar demographic and associated risk factors in traumatic
brain injury among head injury patients presenting at our Accident and Emergency Department in
Nnewi over 24 months, as part of the multi-institutional data pool for a future meta-analysis for the
generation of a national data base on head injury presenting under emergency situations in Nigeria.
Patients and Methods
This was a retrospective study of some demographic variables in all the patients that presented at the
Accident and Emergency Department of Nnamdi Azikiwe University Teaching Hospital, Nnewi,
Nigeria with traumatic brain injury from January 1, 2007 to December 31, 2008. Nnewi is a small
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scale industrial and commercial but rural town with different forms of transportation, mainly
motorcycles and motor vehicles.
Ours is a tertiary health institution that serves as a referral centre for neurosurgical diseases for most
States in the South East and South South Zones of Nigeria. Demographic data on age, sex,
occupation, Glasgow Consciousness Score (GCS) at presentation, aetiology of injury, type of head
injury, time of injury, mode of presentation, and clinical status of the patient at the time of referral to
another centre, transfer to the ward, or home discharge from the Accident and Emergency
Department, were collected, collated and analyzed.
Inclusion criteria were essentially all age groups, all genders, history of trauma with clinical evidence
of brain involvement exhibiting features of TBI – seizures, affectation of the level of consciousness,
amnesia, vomiting, brain evisceration and clinical findings of cranial neurological deficits including
hemispheric cerebral deficits. All patients that presented with extracranial head injury without features
of neural involvement were excluded.
The ages were grouped into nine, each spanning a decade. The aetiological factors were broadly
classified into motorcycle accident, motor vehicular accident, falls and assault. The data were then
analyzed using descriptive statistics on SPSS version 13. The p value was <0.05.
Results
A total of 9,444 patients attended the Accident and Emergency Department during the 24 months
study period. Of these, 510 (5.4%) met the inclusion criteria for traumatic brain injury and were
recruited in the study. This translated into a presentation rate of 21.3 cases per month or 5.3 cases per
week with an incidence rate of 2,710 per 100,000 per year. Most of them were graded using the
Glasgow Consciousness Scale, as mild (GCS 13-15); Moderate (GCS 9-12); Severe (GCS 3-8).
(Figure 1).
Table 1. Age group distribution of the patients
Age (years)
Frequency
%
0 -10
10-20
20-30
30-40
40-50
50-60
60-70
70-80
80-90
62
65
159
97
50
32
29
9
7
12.2
12.7
31.2
19.0
9.8
6.3
5.7
1.8
1.4
Frequency
(Total no = 510)
120
22
%
(100)
23.5
4.3
Table 2. Occupational Distribution.
Occupation
Commercial motorcyclists
Civil Servants
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Traders
125
24.5
Students
71
13.9
Others
168
32.9
No Record
4
0.8
Males constituted 404 (79.2%) and females were 106 (20.8%) of patients. The age distribution is
summarized in Table 1. The highest incidence of 159 (31.2%) in the >20 – 30 year age group,
followed by the >30 – 40 year age group with 97 (19%). The ≤40 year age groups constituted a
cumulative proportion of 383 (75.1%), of all the cases.
Tabulated for individual occupations, traders had the highest number with 125 (24.5%) cases,
followed by commercial motorcyclists 120 (23.5%), and civil servants 22 (4.3%) were the least
affected (Table 2). Data on the occupation of 4 of the cases were missing, whereas 168 (32.9%) cases
were in the extremes of age e.g. pre-school and those already retired from service/jobs, and did not
belong to any of the listed occupations.
It was also noted that the most common cause of traumatic brain injury was motorcycle accident 300
(58.8%), followed by motor vehicular accident 112 (22%), fall 61 (12%) and assault 37 (7.3%), see
Figures 2 and 7. Motorcycle accident was found to be the leading aetiologic factor of injury in males
and at all periods in the day (Figures 3 and 7), females 39 (7.6%) were more affected by fall than
males 22(4.3%), but there was an equal gender distribution for assaults, while children, the elderly
and traders appear to be more susceptible to assault (Figures 4 and 5).
Table 3. Outcome of injury at the Accident and Emergency Department
Outcome
Discharged from A/E
Transferred to ward
Dead
Referred
Total
Frequency
%
58
418
28
6
510
11.4
82.0
5.5
1.2
100
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Figure 1. Severity of Injury by GCS
KEY: GCS 13-15 = Mild; 9-12 = Moderate; 3-8 = Severe
Figure 2. Causes of Head injury
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Figure 3. Distribution of Causes by Sex
More than half of the cases presented to the department direct from the accident scene 294 (57.6%),
while the rest were referrals from other (primary, secondary and tertiary) health institutions in the
South South and South East Zones of the country. The hours of 12:01 – 18:00 recorded the highest
incidents of injury 265 (52%), and cumulatively more than 85.1% of all injuries occurred during the
busy hours of daytime (6.01 – 18.00 hours). The least incidence was recorded between 0.01 – 6.00
hours, (Figures 6 and 7).
The number of cases discharged home was 58 (11.4%) and those transferred to the wards for
definitive care were 418 (82%) (Table 3). Thus, about four traumatic brain injury patients were
admitted into the wards weekly from the department, and the reasons for the admission were primarily
the brain injury and/or other associated systemic injuries. Referrals to other centres for logistic and
technical reasons in the hospital accounted for 1.2%. Mortality rate was 28 (5.5%), representing 148
per 100,000 per year (Table 4).
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Figure 4. Distribution of Causes by Occupation
Figure 5: Histogram showing distribution of aetiology of injury according to age groups
KEY: A (0 -10yrs), B (>10-20yrs),C (>20-30yrs), D(>30-40yrs), E(>40-50yrs), F(>50-60yrs), G(>60-70yrs),H(>70-80yrs), I(>80-90yrs)
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East and Central African Journal of Surgery Volume 15 Number 2.
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Figure 3. Distribution of causes by Age
Figure 7. Distribution of Injury by Time of Occurrence.
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a]
b]
c]
Figure 8. Traumatic Brain Injury Illustrations
a]. Computerized Tomogram of one of our patients showing a massive right fronto-parietal acute
extradural haematoma with significant midline shift
b]. Right frontal comminuted compound depressed skull fracture with evisceration of contused brain
tissue in another patient
c]. Penetrating matchet injury lacerating the superior sagittal sinus, with eviscerating lacerated brain
tissue in a 12-year old boy.
Discussion
Traumatic brain injury (TBI) constituted an important cause of mortality and morbidity in our
environment. In this study, we found an Accident and Emergency Department (A&E) incidence of
2710 per 100,000 per year in our environment, far higher than the A&E figures of 453 and 394 per
100,000 per year for UK and US, respectively3,5,. This finding, thereby, stressed the urgency and
significance of this preventable killer in our environment, and further highlighted the need for a better
intervention protocol if improved outcome would be attained in our part of the world.
The greatest contributor to TBI in our study was road traffic accident (RTA) with the motorcycle
being the major contributor to the cohort, a finding that correlated with most local and regional studies
in our country6,10,11,12. This finding, however, was at variance with the situation in the US where fall
was reported as the leading aetiological factor3,4. Indeed, the dominance of RTA, precisely from the
motorcycle, was a serious indictment on the safety of our roads and conscientiousness of the
motorcyclists.
As had been previously reported, even by other local studies, the very active >20 – 30 year male age
group was the most commonly affected by TBI, and in our case, mainly from motorcycle accident (x2
– 112.866, df – 24, p<0.000) [6]. Interestingly, the peak age incidence was lower in the US (15 – 19
years) where majority resulted from vehicular crashes. This difference might suggest that the US
youths drive automobiles at an earlier age than our youths, and the high crash rate may thus, be due to
the lack of sound judgment on the part of these very young drivers.
Motorcycle accident rate in our series was followed by those of motor vehicular accident, assault and
fall. Fall was largely the aetiologic agent in the first decade of life while RTA was essentially the
main factor in the rest of the age groups. This finding was at variance with reports in literature which
generally record fall (mostly on level ground) as the predominant aetiologic factor in the very young
and elderly. It could imply that even in the 9th decade of life, our people are still prone to road mishap.
The explanation for this was not very certain but the indiscriminate and improper use of motorcycles
as a major mode of transportation in our locality, variously reported, could be a contributing factor,
more so since we recorded an outrageously higher incidence rate of RTA compared to domestic
accident like fall (80.8% vs. 12%) 6,10,11,12.
While discussing trauma resulting from traffic accidents, the high level of illiteracy and ignorance of
traffic laws and road signs found amongst the motorcycle operators were alarming, according to
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Adogu and Ilika15; in fact, most of the operators had no formal training and licensing before starting to
ply the roads. This probably explained the reason for the least affected occupational group being the
civil servants who were more likely to have some level of education and awareness of traffic laws and
road signs.
Recently, the Federal Government initiated a strict implementation of the helmet-use laws, borrowing
from the discovery that this interventional measure helped in reducing the incidence in other countries
like US and Italy. It is yet to be seen how this would reduce our local incidence of motorcycle-related
road accidents, and it would be well advised to study the impact of this intervention as an
epidemiological reference, after a few years of implementation, to assess its effectiveness in our
environment13,14.
The most common type of head injury based on severity was the mild type (57.1%), figure 5. Mild
head injuries, though predominant as reported from the UK, were still much less than the rate from
there (89.1% vs. 57.1%), implying that we had a higher rate of moderate and severe injuries than they
did (10.9% vs. 42.9%). The consequence of this was that our TBI would more likely lead to deaths or
significant neurological deficits than those in the developed world. Closed and open head injuries
accounted for 42.5% and 57.3% respectively, and males had a significantly increased risk (50%) of
open head injury than females (20%) (x2 – 17.942, p<0.000,df=1), see figure 7. This might just be as a
result of the higher rate of male incidence of TBI generally, rather than a male gender predilection,
ordinarily.
Increased risk of TBI amongst males had been unequivocally demonstrated in all local and
international studies3,4,5. The only issue was that the male risk in our environment was nearly four
times that for females unlike in UK and US where studies reported it as barely twofold. From
anecdotal reports, males were the predominant motorcycle/motor vehicular drivers; therefore and in
contrast, the females were expectedly less commonly affected by RTA than males. But then, more
females (7.6%) were affected by fall than males (4.3%). The reason for this could not be easily
adduced, but again might just be a fall out from the larger number of males involved in traffic
activities and transportation which far outstripped the incidence from relatively less active duties that
culminate in fall. Could it translate that if more females were involved in traffic activities, this trend
might be reversed?
Another remarkable observation was that fall occurred most frequently by 12.01 – 18.00 hours, but
declined by 18.01 – 24.00 hours, with the lowest incidence by 0.01 – 6.00 hours. This period of
lowest incidence, of course, coincided with the period of sleep or least activity, buttressing the fact
that all injuries, inclusive of those to the head or brain, were usually activity-driven. The peak time of
the injury was 12.01 – 18.00 hours and this reckoned with the level of societal outdoor activities in
that period. Most previous studies tended to be silent on this time rhythm.
Also, fall was found to be the most common aetiologic factor in the first decade of life, as in the
reports from US for the 0-4year age group. The incidence in this our report was noted to begin rising
from the 2nd quarter of the day (6:01 – 12:00), then peaked in the 3rd (12:01 – 18:00), and declined in
the fourth quarter (18:01 – 24:00) when most parents would be at home and children would be retiring
to bed. Children are known to be inexperienced, curious, adventurous, and sometimes, daring and as
such need close supervision both at home and school. By the 3rd quarter of the day, parents and caregivers would themselves be engaged in other activities on their own, thereby depreciating the
surveillance over the children. The consequence of this is the peak incidence of fall among the
children occurring while playing at home and school, or pedestrian road traffic accident as they walk
or hawk on the streets in the most active daytime period in our environment, 12.01 - 18.00 hours.
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
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Expectedly, both the transfers to the ward and incidence of mortality were inversely proportional to
the GCS, while discharges from the department and good outcome were directly proportional to GCS;
in other words as the GCS increased survival and discharges home also increased in number (Fig 6).
Of interest was the high mortality rate in the A&E in our study compared to other reports. It should be
noted however that, besides the quality of intervention available in our institution, the mortality in
TBI could also be related to the interplay between the brain injury, other associated injuries and level
of initial care received. A careful audit might be necessary to evaluate the adequacy of the initial
management given by the first care-givers vis-à-vis the outcome from TBI. Our study, equally, did not
extend to other associated injuries that could have contributed to the mortality rate, and this should
also be further explored, subsequently.
Conclusion and Recommendations
In summary, the risk factors for TBI in our environment were the male gender, motorcycle riding,
illiteracy, trading, extremes of age, and the active daytime period of 12:01 – 18:00 hours. Mortality
and morbidity from TBI in our environment was much higher than those from the developed countries
and this was a direct reflection of the much higher severity of our injuries. The corollary to this is that
if we made our accidents less tragic and less fatal, we would record more mild injuries and better
outcome.
To achieve this corollary, there is need to adopt public health safety measures like the use of crash
helmets, seat belts, speed limits, modern safety/protective vehicular devices and better road
rehabilitation. These are a completely different prescription from the need for better trauma centres
and optimally equipped health facilities; and the two should not be confused, because while the
former deals with the risk and prevention of accident and injury, the latter deals with the care of the
victims after the injury has occurred. Both measures, nonetheless, would definitely save and preserve
the lives of more Nigerians.
References
1. E-Medicine Health (2008 March), Head Injury; http://www.nlm.nih.gov/medlineplus /ency
/article /000028.htm
2. TBI Resource Centre, TBI Epidemiology; http://www.neuroskills.com/ epidemiology. shtml,
2009 August.
3. Thurman D, Janet G (1999); Trends in Hospitalization Associated with Traumatic Brain
Injury, Journal of American Medical Association; 282:954 – 957.
4. CDC–NCPIC (2008 March), Traumatic Brain Injury; http://www.cdc.gov/ncipc/ factsheets
/tbi.htm
5. Yates P J, Williams W H, Harris A, Round A, Jenkins R: An Epidemiological study of Head
Injuries in a UK Population Attending an Emergency Department, Journal of Neurology,
Neurosurgery and Psychiatry 2006; 77; 669 – 701.
6. Adeolu A.A, Malomo A.O, Shokunbi M.T, Komalafe E.O, Abiona T.C. Etiology of Head
Injury in South-western Nigeria, Internet Journal of Epidemiology 1998, ISSN 1540-2614;
http://www.ispub.com/journal/the_internet_journal_of_epidemiology/vol2_number_2_13/arti
cle/etiology_of_head_injuries_in_southwestern_nigeria_a_public_health_perspective.html
(2009 August).
7. Ohaegbulam SC. Analysis of 1089 cases of head injury, African Journal of Medical Science
1978; 7:23-7.
8. Muyembe VM, Suleman N. Head injuries at a Provincial General Hospital in Kenya, East
African Medical Journal 1998, 75:364-9.
9. Adeloye A, Ssembatya-Lule GC. Aetiological and epidemiological aspects of acute head
injury in Malawi, East African Medical Journal 1997, 74:822-8.
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10. Solagberu B.A, Ofoegbu C.P.K, Nasir A.A, Ogundipe O.A et al. Motorcycle Injury in a
Developing Country and Vulnerability of Riders, Passengers and Pedestrians, Injury
Prevention 2006, Vol 12 p266 – 268.
11. Adegbehingbe BO, Oluwadiya KS, Adegbehingbe OO. Motorcycle associated ocular injuries
in Ile-Ife, Nigeria; African Journal of Trauma 2004; 2:35–9.
12. Peden M. World report on road traffic injury prevention-summary. Geneva: World Health
Organization, 2004:12.
13. Sosin D.M, Sacks J.J. Motorcycle Helmet Use Law and Head Injury Prevention, Journal of
American Medical Association Vol 267 1992; No 12; 1649.
14. Servadei F, Begliomini C, Gardini E, Guistini M,Taggi F, Kraus J. Effect of Italy’s
Motorcycle Helmet Law on Traumatic Brain Injury, Injury Prevention 2003, Vol 9 pp 257 –
260.
15. Adogu OU, Ilika AL. Knowledge of and attitude towards road traffic codes among
commercial motorcycle riders in Anambra State. Niger Postgrad Med J 2006; 13: 297-300.
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Missed Injuries in Multiple Trauma Patients: a Tertiary Care Experience in Tanzania
P.L. Chalya 1, M.Mchembe 2, J.M. Gilyoma 1 J.B. Mabula 1, I.H. Ngayomela 1, A.B. Chandika 1
B.Mawala 1.
1
Department of Surgery, Weill- Bugando University Collage of Health Sciences, Mwanza, Tanzania
Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar Es Salaam,
Tanzania
Correspondence to: Dr. P.L. Chalya, Email: [email protected]
2
Background: Missed injuries remain a worldwide problem in all trauma centers and contribute
significantly to high morbidity and mortality among trauma patients. There is paucity of
information regarding missed injuries in Tanzania. The aim of this study was to establish the
incidence, contributing factors, and short-term outcome of missed injuries among
polytraumatized patients in our setting.
Methods: This was a one-year duration (from January to December 2009) prospective cohort
study involving all multiple trauma patients (ISS > 16) admitted to Bugando Medical Centre.
After informed consent to participate in the study, all patients were consecutively enrolled in the
study. Data was collected using a pre-tested, coded questionnaire and analyzed using SPSS
computer software version 11.5.
Results: Ninety six of 462 patients (incidence, 20.1%) had 112 missed injuries. Head and the
neck (46.4%) was the most common body region affected. Clinical error (57.1%) was the most
common factor contributed to the occurrence of missed injuries. Of the factors contributing to
missed injuries, 57.4% were potentially avoidable and 42.6% were unavoidable. There was
statistically significant difference in the mean ISS, mean GCS, orotracheal intubation, patient’s
arrival time and seniority of the attending doctor between patients with missed injuries and
those without missed injuries (p-value <0.001). Mortality in patients with missed injuries was
19.8% compared with 8.7% in patients without missed injuries (p-value <0.001). Among the
deaths in patients with missed injuries, 57.9% were directly attributable to missed injuries
(O.R. = 14.8, p-value =0.001, 95% CI = 6.1- 32.46). Patients with missed injuries had longer
stays in the hospital compared with patients without missed injuries (p-value <0.001).
Conclusion: The incidence of missed injuries at BMC is high in patients with high ISS, low
GCS, orotracheal intubation and those who reported during night hours. A high index of
suspicious is needed when dealing with such a group of patients. The majority of missed injuries
are potentially avoidable by repeated assessments both clinically and radiologically and by staff
redistribution to address the increase of missed injuries during night hours. Implementation of
a tertiary trauma survey should be routine in the Accident & Emergency department to
minimize the occurrence of missed injuries.
Introduction
The management of multiple trauma patients presents a worldwide diagnostic and therapeutic
challenge to trauma, orthopedic and general surgeons 1. Significant injuries can be missed during
primary and secondary surveys in multiply injured patients, for whom resuscitation, diagnosis and
therapy have to proceed simultaneously2. Many factors involved in the initial resuscitation of the
multiple trauma patients, such as altered level of consciousness, hemodynamic instability, or
inexperience and inadequate diagnostic evaluation, may lead to missed injuries. Injuries can be missed
at any stage of the management of the trauma patient, including intraoperatively, and may involve all
regions of the body1,3,4.
Missed injuries are a potential source of morbidity and mortality and may also represent varying
degrees of clinical inexperience and are common reasons for litigation5,6. Missed injuries are often
associated with prolonged length of hospital stay resulting in increased costs of care as well as
consumption of hospital resources3-6. The incidence of missed injuries has been reported in trauma
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literature to range between 0.6% and 65%, and less missed injuries have been found in retrospective
studies 5-9. In a prospective study which was done in Uganda, the rate of missed injuries was reported
to be 19.4% and the commonest contributing factor for missed injuries was found to be inadequate
assessment10.
At Bugando Medical Centre, missed injuries, though not studied, are a common surgical problem
among multiple trauma patients; however, its incidence, contributing factors and the impact of these
injuries on the outcome of trauma patients are not known, as no local studies have been done despite
large number of trauma admissions. The majority of missed injuries are potentially preventable,
therefore understanding the incidence, contributing factors and clinical outcome of these injuries is
essential in minimizing their occurrence and in planning preventive measures and management
strategies.The aim of this study was to establish in our setting, the incidence and factors contributing
to missed injuries in polytrauma patients, and to determine the influence of these concealed injuries
on the outcome of our polytraumatized patients.
Patients and Methods
A prospective cohort study was undertaken at the Accident and Emergency Department of Bugando
Medical Centre over a one year period from Jan 2009 to December 2009. Bugando Medical Centre is
one of the four consultant tertiary referral hospitals in the country and has a bed capacity of 1000.
Trauma patients are first seen at the A&E department where primary and secondary surveys are done
by the admitting surgical team. Resuscitation is initiated at this point (including operative
resuscitation if needed). Resuscitation is carried out according to Advanced Trauma Life Support
(ATLS) principles. From the A&E department these patients are admitted in their respective surgical
wards or ICU. Tertiary survey is later carried out by consultants during morning clinical meeting or
by the firm consultant or specialist surgeon during next ward round.
All multiple trauma or major trauma patients (defined as an injury severity score (ISS) of >16) of all
age groups and gender seen in the A&E department during the study period were, following informed
consent, consecutively recruited into the study. Patients who died before initial assessment and those
without next of kin to consent were excluded from the study.
All recruited patients were, after primary and secondary surveys by the admitting team, screened for
the presence or absence of missed injuries and were then stratified into two groups. Group I included
all patients with missed injuries and group II were patients without missed injuries. For the purpose of
this study, missed injury was defined as injury not detected during primary and secondary surveys of
the ATLS. Only clinically significant missed injury (defined as an injury with worse outcome as a
result of delayed diagnosis) was included. Minor injuries were taken into account when they
accompanied the former. The diagnosis of missed injury was established through clinical
examination, radiologically and surgically. In case of death, post-mortem examination was performed
to establish the missed cause of death. Missed injuries were classified into three types; type I (injuries
occurred outside the body area of clinical focus), type II (injuries occurred within the body area of
clinical focus) and type III (injuries occurred as a result of the surgeon’s decision to abbreviate
surgery).
The study variables included: demographic characteristics; times of injury; patient’s arrival and
receipt of care; mechanism of injury and type of injuries missed; injury scores (Injury Severity Score
and Glasgow Coma Score); reasons for missed injuries; type of physician involved in the primary and
secondary surveys; radiological findings; operative and post-mortem findings; length of hospital stay
and mortality. Delayed presentation of injury was defined as an injury that was not clinically or
radiologically evident on admission but became apparent upon repeat examination or imaging study.
Factors contributing to missed injuries were classified into 4 types: clinical error (injury missed
during physical examination), radiological error (injury missed as a result of error in the choice of
investigation, view taken, limitation of the technique chosen and interpretation of radiographs),
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communication error (injury missed as a result of poor communication between the radiologist and
clinician) and surgical error (injury missed during the surgical survey)
All identified missed injuries were managed accordingly. The study patients were followed up either
until discharge or for up to 30 days. During this period any unaddressed complaints were thorough
investigated. The approval to carry out this study was sought from relevant authorities. Data was
collected using a pre-tested and coded questionnaire and analyzed using SPSS computer software
version 11.5. Data were compared and statistically analyzed in two patient groups to identify factors
associated with missed injuries. A p-value of less than 0.05 was taken as statistically significant.
Results
A total of 462 multiple trauma patients were studied. Ninety six out of 462 patients (20.8%) had 112
missed injuries with an average of 1.2 injuries per patient. There were 62 males (64.6%) and 34
females (35.4%) whose ages ranged from 6 to 72 years (median age 23 years). The mechanism of
injury was road traffic accidents (RTAs) in 60 patients (62.5%), fall in 15 patients (15.6%), assault in
11 patients (11.5%), missile injuries in 9 patients (9.4%) and sport-related injuries in 1 patient (1.0%).
52 (54.2%) of RTAs were related to motorcycle injuries affecting passengers, cyclists and pedestrian.
The most frequent missed injuries were head and the neck which made up 46.4% of all missed
injuries. (Table1).
Of all the missed injuries, 56.5% occurred outside the body area of clinical focus (type I), 40.2%
occurred within the body area of clinical focus (type II) and 3.3% occurred as a result of the surgeon
to abbreviate surgery (type III). We found that 18%, 30% and 52% of missed injuries were discovered
during primary, secondary and tertiary surveys respectively. Clinical error due to incomplete clinical
assessment was the most common factor contributed to the occurrence of missed injuries and
accounted for 57.1% of all missed injuries (Table 2). Of the factors contributing to missed injuries,
57.4% were potentially avoidable and 42.6% were unavoidable in patients with increased ISS, a low
level of consciousness due severe head injuries and in intubated polytraumatized patients.
Table 1. Location, Type and Number of Missed Injury
Location
Type of Missed Injuries
Head/neck
Skull fractures
Subdural/epidural haematoma
Intracerebral haematoma
Cervical spine fracture/dislocation
Maxillofacial
Mandibular fracture
La forte I injuries
La forte II injuries
La forte III injuries
Loss of teeth
Thoracic
Rib fractures
Hemothorax/pneumothorax
Clavicle fracture/dislocation
Abdominal /pelvis
Bowel perforation
Gastric perforation
Pelvic fractures
Liver laceration
Renal injury
Urethral injury
Extremities
Fractures
Dislocations
East and Central African Journal of Surgery
Number of Missed Injuries (%)
(52 injuries, 46.4 %)
32
11
7
2
(8 injuries, 7.2%)
4
1
1
1
1
(18 injuries, 16.1%)
8
7
3
(22 injuries, 19.6%)
10
5
4
1
1
1
(12 injuries, 10.7%)
6
4
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
Compartment syndrome
2
Total
112 missed injuries
Missed injuries were detected by consultants/specialists in 61 cases (54.8%), by investigating team in
25 cases (22.3%), by radiologist in 3 cases (2.7%) and by pathologist (during post-mortem
examinations) in 13 cases (11.6%). Missed injuries were diagnosed by detailed clinical assessment in
42.8%, by surgery in 20.1%, by review of radiological error in 16.2% and by post-mortem
examination in 11.6%. 9.3% of the missed injuries were detected on the basis of no improvement.
Twelve patients ((12.5%) who had missed injuries had been reviewed by consultants and specialist
surgeon by the time the missed injuries was diagnosed and definitive treatment instituted. Eighty- six
(76.8%) of the injuries were detected within the first 24 hours. The remaining twenty-one (18.8%)
injuries were detected during the course of treatment and five (4.5%) injuries were detected on
discharge. Mean delay in diagnosis of missed was 4 days (range 1–16 days). Forty two (37.5%) of
missed injuries required some form of additional therapeutic interventions. Comparison of patient
characteristics between the population of patients with and without missed injuries is shown in Table
3. There was statistically significant difference in the median ISS, median GCS, patient’s arrival time,
patient’s orotracheal intubation and seniority of the attending doctor between patients with missed
injuries and those without missed injuries (p-value <0.001).
The mean patient’s waiting time between arrival and assessment was 58 minutes and 24 minutes
among night and day arrivals respectively. The overall mortality was 11.0%. Mortality in patients
with missed injuries was 19.8% compared with 8.7% in patients without missed injuries (p-value
<0.001). Among the deaths in patients with missed injuries, 57.9% were directly attributable to
missed injuries (O.R. = 14.8, p-value =0.001, 95% CI = 6.1- 32.46). Patients with missed injuries had
longer stays in the hospital compared with patients without missed injuries (p-value <0.001).
Table 2. Contributing Factors to Missed injuries.
Contributing factor
Number of missed injury (N=112)/%
Clinical error
Radiological error
Communication error
Surgical error
64 (57.1%)
24 (21.4%)
18 (16.1%)
6 (5.4%)
Table 3. Comparison of Patient Characteristics in the Two Groups
Study variable
No missed injuries (N=366) Missed injuries (N= 96) p-value
Mean age (in years)
26
32
Not significant
Gender
Males
262 (71.6%)
62(64.6%)
Not significant
Female
104 (28.4%)
34(35%)
Not significant
Median ISS
18.4
24.8
< 0.001
Median GCS
11.8
9.2
< 0.001
Designation of attending doctor
Consultant / Specialist surgeon 220 (60.1%)
12 (12.5%)
< 0.001
Resident in surgery
102 (27.9%)
30 (31.3%)
< 0.001
M.O.
38 (10.4%)
52 (54.2%)
< 0.001
Intern doctor
6 (1.6%)
2 (2.0%)
< 0.001
Patient’s arrival time
Day time (%)
192 (52.5%)
32 (33.3%)
< 0.001
Night time (%)
174 (47.5%)
64 (66.7%)
< 0.001
Orotracheal intubation
78 (21.3%)
54 (56.3%)
< 0.001
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Mortality (%)
Median LOS (days)
32 (8.7%)
16.5
19 (19.8%)
20.3
< 0.001
< 0.001
Discussion
Advanced Trauma Life Support (ATLS) of the American College of Surgeons11 has introduced
primary and secondary surveys in the management of multiple traumatized patients, to prioritize the
most life-threatening injuries and to address all other injuries respectively. Despite such detailed and
standardized treatment principles, some injuries still escape detection during these two phases. This
study was conducted to establish in our setting, the incidence, contributing factors and the clinical
outcome of these concealed injuries on multiple trauma patients; the problem not previously studied at
our centre or any other hospital in the country. The management of multiple trauma patients at our
centre follows ATLS principles.
Most studies of missed injuries report an incidence of 0.6% to 65%, depending on how a missed
injury was defined and the type of injury considered6-9. The incidence of missed injuries has been
reported to be higher in prospective studies compared with that of retrospective studies 5, 7, 12. This is
because retrospective studies may have a selective memory component or incomplete information,
and long-term follow-up may be difficult. The lack of extensive studies on this subject attributable to
a general reluctance of clinicians to admit and account for their errors in management may also
contribute to low incidence of missed injuries in some areas. Enderson et al1,7, in a prospective study,
reported an incidence of missed injury of 9% which, interestingly, was higher compared with that of
their retrospective study, which was 2%. This difference means that the incidence tends to increase
with the precise description of diagnostic or surgical errors in multiple injuries.
The incidence of missed injuries of 20.8% in our study was found to be higher than that reported in
Uganda10. Previous studies have suggested that patients with more severe injuries or associated head
injuries tend to have injuries missed during the resuscitation2,6. This is reflected in the high rate of
missed injuries in our patients, majority of whom had severe injuries and associated head injuries. The
increase in the incidence of missed injuries in patients with severe head injuries suggests that
diagnosing injuries improves with better patient communication. Our study confirmed this
observation. High incidence of missed injuries in our study can also be explained by the prospective
nature of the study.
Early detection of injuries
In the management of polytraumatized patients, any delay in the diagnosis and treatment of missed
injuries may lead to increased morbidity and mortality, prolonged length of hospital stay, and
increased cost 3-5. Early recognition and treatment of missed injuries appear to reduce mortality and
morbidity associated with the disease. In this study, we found that the majority of missed injuries
were detected within the first 24 hours. Other authors reported similar observation5,10.
Road traffic accident
Road traffic accidents (RTAs) remain a leading cause of trauma and admissions to the accidents and
emergency units of most hospitals in Tanzania and continue to contribute to an increased incidence of
missed injuries 13, 14. In this study, RTAs were the most common mechanism of injury accounting for
62.5% of patients with missed injuries. The majority of RTAs were due to motorcycle accidents, an
emerging popular mode of commercial transportation in Mwanza city, and the victims were
passengers, cyclist and pedestrian. Similar observation was also noted in other studies 3, 10. Factors
that contribute to high occurrences of RTAs are largely preventable and are due to a combination of
factors, including rapid motorization, poor road and traffic infrastructure as well as the behaviour of
road users. Findings from this study calls for urgent interventions targeting at reducing the occurrence
of RTAs and subsequently reduce the incidence of missed injuries in this region.
Contributing factors
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Analysis of the contributing factors for the missed injuries in our study revealed that 57.4% were
attributable to potentially avoidable factors while 42.6% were due to unavoidable factors such as lifethreatening injuries and severe head injuries. This finding is agreement with other studies reported
previously4,6,10. The majority of missed injuries are potentially avoidable with repeat clinical
assessments and a high index of suspicion.
The most frequent contributing factor for missed injuries in this study was clinical error due to
inadequate clinical assessment in 57.1%. This was followed by radiological error due to
misinterpretation or delayed radiological investigations in 21.4%. Similar trend was also reported by
other studies3,10. The high rate of clinical error in this study could be attributable to the fact that the
A&E department being a high risk specialty in which the majority of trauma patients are initially
managed by junior doctors with limited clinical experience; significant injuries may be missed during
primary and secondary surveys in severely injured patients. The reason for the radiological errors in
the present study might be that in most cases interpretation of radiological investigations is performed
by non-radiological staff (attending doctors) and not by consultant radiologist; another reason might
be the urgency of the situation and therefore lack of time to find less obvious injuries. Whilst
interpretation of the trauma films during the resuscitation by a consultant radiologist or reporting
within a few hours is the ideal, neither of these currently occur in our institution due to increasing
pressure on the radiologist workload. To overcome this problem, all radiology films and CT scans
must be seen by a senior radiologist as soon as possible.
In our study, injuries in the head and neck were frequently missed in 46.4%. Abdominal missed
injuries ranked second in 19.6%. Similar body region distribution was also noted in Uganda 10.
Patients with head injuries have high risk of suffering missed injuries due to altered levels of
consciousness. Abdominal missed injuries pose a diagnostic challenge especially in patients with
associated head injuries. Diagnostic peritoneal lavage (DPL) and Focused Adnominal Sonography in
Trauma (FAST) have been reported to be useful investigations in the diagnosis of abdominal missed
injuries 10, 16. However, none of these studies were used in our patients despite their usefulness. In our
resource-limited setting, clinicians need to develop, retain and rely on clinical acumen.
Seniority of attending physician
The majority of missed injuries in our study were detected by consultants and specialist surgeons (in
54.8% of cases) through detailed clinical assessment, review of radiological investigations, surgery
and postmortem examinations in case of death. In this study, only 12.5% of patients who had missed
injuries had been reviewed by consultants and specialist surgeon by the time the missed injuries was
diagnosed and definitive treatment instituted. This finding is in agreement with a Ugandan study in
which only 23.1% of patients who had missed injuries had been reviewed by consultants during
primary and secondary surveys10. The seniority of the attending physicians plays a pivotal in
diagnosis of missed injuries due to their good clinical experience. In our study, the occurrence of
missed injuries was found to be significantly influenced by the seniority of the attending physician.
We noted that the majority of our trauma patients arrive during the night probably due to increased
crime rates at night hours. We also noted high rates of missed injuries (66.7%) in patients arriving
during the night compared with 33.3% of day arrivals. Okello et al 10 in Uganda also reported similar
observation. High rates of missed injuries among night arrivals can be explained by the fact that
during night hours, the senior surgical and axillary staffs, which we found to be vital in the diagnosis
of missed injuries, were unlikely to be present unless called for difficult cases. In our resource-limited
setting, where staff shortage is a challenging problem, re-distribution of the few staff available needs
to be designed to address the problem.
Tertiary survey
The primary and secondary surveys of the ATLS are designed to identify all of a patient's injuries and
prioritize their management11. Implementation of a routine standardized tertiary trauma survey is
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
vitally important in the detection of clinically significant missed injuries and should be included in
trauma care3,5,7,10,15. This is reflected in our study in which high detection rate of missed injuries was
observed during tertiary survey phase (52%) compared to primary and secondary survey phases (18%
and 30% respectively). Enderson et al7, in their prospective study of missed injuries found a reduction
of 35% in missed injuries by applying the tertiary survey protocol; by using this protocol, early
detection and treatment can be achieved leading to an improvement in these patients’ morbidity and
mortality. Previous studies have demonstrated an association between the appearance of missed
injuries and an increased ISS, a low level of consciousness (due to brain injury), orotracheal
intubation, hemodynamic instability, and closed trauma1-10,15. Our study observed a statistically
significant association between missed injuries and high ISS, low GCS, patient’s arrival time,
patient’s orotracheal intubation and seniority of the attending physician.
Hospital stay
In our study it was found that patients with missed injuries stayed longer in hospital (mean hospital
stay of 20.3 days versus 16.5 days for those without missed injuries). Similar finding was also
reported in other studies3-6,10. This was because the injuries were not only presented late, but also
because more time was required to adequately treat them and their resultant complications, such as
shock, peritonitis and vascular injury. The prolonged stay could also have been due to the severity of
the injuries in this group as evidenced by the higher mean ISS.
The mortality rate in patients with or without missed injuries (19.8 %versus 8.7% respectively) in the
present study is comparable with other studies 4, 6, 10. The high mortality rate in patients with missed
injuries can be explained by the fact that the majority of patients with missed injuries had high ISS
with initial neurologic compromise.
Conclusion
The incidence of clinically significant missed injuries among multiple trauma patients in our
institution is unacceptably high and they are significantly associated with prolonged in-hospital stay
and mortality. This observations call for urgent interventions. In order to minimize the occurrence of
missed injuries and their effect on the outcome of polytraumatized patients, we recommend the
following:• A high index of suspicion is required when dealing with unconscious and intubated patients
with severe trauma (ISS↑) and brain injuries (GCS↓) during primary and secondary surveys.
• A tertiary survey to detect missed injuries should be performed as part of routine evaluation
of all severely injured patients within 24 hours of admission.
• An experienced consultant/specialist surgeon should be involved in the tertiary survey and
should be made available on 24-hour basis.
• Improvement in the radiological investigations such CT scan should also be made available
on 24-hour basis.
• Redistribution of the few staff available to cover the night hours.
• A24-hour Focused Abdominal Sonography in Trauma (FAST) should be introduced at the A
& E department and this should go simultaneously with training of staff.
• Urgent interventions targeting at reducing the occurrence of RTAs is necessary to reduce the
incidence of missed injuries in this region.
• Further study should be done to proper assess the effect of missed injuries on the cost of care.
References
1. Enderson BL, Maull KI. Missed injuries: The trauma surgeon's nemesis. Surg Clin North Am
(1991), 71:399-417
2. Brooks A, Holroyd B, Riley B. Missed injuries in major trauma patients. Int J Care Injured.
2004; 35:407-10
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
3. Shirzard H, Morlen SL, Carsten H. Missed injuries in a Level 1 Trauma Centre. J. Trauma
(2002), 52(4): 715-719
4. Kalemoglu M, Demirbas S, Akin ML, Yildirim I, Kurt Y, Uluutku H, Yildiz M. Missed injuries
in military patients with major trauma. Mil Med. J. 2006;171(7):598-602
5. Sandra M, Salvador N, Pere R, Judit MH, Gabriel C. A prospective study on the incidence of
missed injuries in trauma patients. Cir Esp. 2008;84(1):32-6
6. Buduhan GM, Donna I. Missed injuries in patients with multiple trauma. J Trauma 2000;
49(4):600—5.
7. . Enderson BL, Reath DB, Meadors J, Dallas W, DeBoo JM, Maull KI. The tertiary trauma
survey: a prospective study of missed injury. J Trauma-Injury Infect Crit Care
1990;30(6):666—9;
8. Janjua KJ, Sugrue M, Deane SA. Prospective evaluation of early missed injuries and the role of
tertiary trauma survey. J Trauma-Injury Infect Crit Care 1998;44(6):1000—6
9. Frawley PA. Missed injuries in the multiply traumatized. Aust NZ J Surg. 1993; 63:935-9.
10. Okello CR, Ezati IA, Gakwaya AM. Missed injuries. A Ugandan experience. J. Injury 2007;
38(1): 112-117
11. American College of Surgeons Committee on Trauma. Initial assessment and management.
ATLS reference manual. Chicago: American College of Surgeons; 1994. p. 17–37.
12. Robertson R, Mattox R, Collins T, Parks-Miller C, Eidt J, Cone J. Missed injuries in a rural area
trauma center. Am. J. Surg. 1996; 172:564-8.
13. Museru LM, Leshabari MT. Road traffic Accidents in Tanzania: A 10-year epidemiological
Appraisal. East Central Afr. J. Surg. 2002; 7 (1): 23-26
14. Museru LM, Leshabari MT, Grobu U, Lisokotala LNM. The pattern of injuries seen in the
orthopedic/trauma wards of Muhimbili Medical Centre. East Central Afr. J. Surg. 1998; 4 (1) :
15-22
15. Biffl WL, Harrington DT, Cioffi WG. Implementation of a tertiary trauma survey decreases
missed injuries. J Trauma. 2003; 54:38-44.
16. Wangoda R, Upoki AL, Owori FN, Kawooya GM. Use of urethral catheters for diagnostic
peritoneal lavage in blunt abdominal trauma. East Central Afr. J. Surg. 2002; 7 (1): 63-66.
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
Referral of Surgical Patients Abroad: A 5-years Review from a Tertiary Teaching
Hospital in Addis Ababa Ethiopia.
E. Teffera1, B. Lemma2, B.L. Wamisho3
1
Final Year Surgical Resident Dept. of surgery AAU MF
Consultant Urologist Dept. of Surgery AAU MF
3
Consultant Orthopedic Surgeon Dept. of Orthopedics AAU MF
Correspondences to: Dr. Ephraim Teffera, Email: [email protected],
2
Background: The general objective of this review was to determine the reasons for referral
abroad of surgical patients at Addis Ababa University Medical Faculty, Tikur Anbassa Hospital
Methods: The referral slips of patients who were referred abroad from September 2005 –
August 2009 by surgical Department were collected and reviewed.
Results: The study reviewed a total of 331 patents in the 5 year period mentioned. An average of
66 patients was referred per year. There was an over all male preponderance 183(55.3 %),
majority of patients were in the age group 26 - 50 years (173).Most were residents from the
Capital, 232 (70 %). Neoplastic diseases both benign and malignant account for 155 cases.
Primary brain tumors either malignant or benign account for 74 cases. 97 of the cases had at
least one surgical intervention done prior to referral. The overall trend is showing some
decrement. The main reason for referral was for better surgical intervention (249). Referral for
MRI which accounted for 16 of the referrals in the first 2 years was virtually non existent in the
next 3 years.
Conclusion: Most cases were form the capital, Neurosurgical cases have been referred more
than any other subspecialties, neoplastic changes constitute the main reason for referral, and
the overall trend seems decreasing along the course.
Introduction
Referring patients to a place where a better management can be given is a long standing element of
medical practice. Patients have been referred from one facility to another in search of better handling
of cases by well trained practitioners in that specific field. This has both advantages and
disadvantages1. Referral abroad incurs considerable amount of expense, stress, flights, and
interactions with embassies. It also necessitates hard currency, finding good hospitals, lodging…etc;
which are significant challenges for both the patients and their families and the country as well2.
This is apparently evident when it comes to the developing countries that send patients to developed
ones .The same applies to Ethiopia who falls short of such facilities. Developing countries spend a lot
or investigations and surgical procedures abroad. Patients have to deal with being alienated and
language barriers. They may also succumb before destinations as well. In Ethiopia AAU MF being
the highest Medical training, research and service center in the country is subjected to handling
difficult cases time and again and for the same exact reason has been referring patients for lack of
adequate subspecialty fields, experts, equipment, investigative modalities…etc.
Recently different subspecialty fields have been started in the Department of Surgery such as
Neurosurgery, Urology and Cardiothoracic Surgery and in the faculty as a whole. As a consequence it
is natural for one to wonder if the trend of referral has changed since they were established. In this
study we wanted to evaluate:
1. What are the leading disease entities that are being referred?
2. What are the main reasons for the referral?
3. Which subspecialty disciplines in surgery are referring? And which are referring most?
4. What is the trend of referral?
5. How many of the referral cases were intervened before referral?
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
Subjects and Materials
We reviewed the referral slip records in the Department of Surgery AAU MF for the period of 5 years
from September. 2004 to August 2009. Each referral was issued by the Surgeon managing the case
with endorsement from two other consultant Surgeons, the head of the department and the Medical
Director. The data recorded and analyzed included the following parameters:
Socio demography (Age, sex, residence…)
Referring Subspecialty
Diagnosis
Pathology
Whether any intervention made or not prior to referral
Reason for referral
The Age distribution was stratified on the epidemiological significance (natural disease entity
distribution at different age groups) and Socioeconomic factors (adolescents and early adults being
brought by parents or guardians) basis into Infants (<1year), Under 5 children (1-5years), Children (6
- 12 years), Adolescents and early Adult hood (13 - 25 years), Younger age group(26 - 50 years) ,
Older age group (51 - 75 years) and Extreme age group (>75 years). Residence was categorized based
on whether the patient lived in Addis or out of Addis Ababa. Referring subspecialty was categorized
by the treating sub specialist and the disease entity. The Diagnosis was classified both specific
diagnosis and according to the organ involved for instance Thyroid Ca, Breast Ca, Adrenal tumors or
the System subspecialties deal with (ex. Genitourinary system, Respiratory System…). Pathologic
Classification has taken ground on neoplastic process, infectious process, Inflammatory changes,
Degenerative changes, Trauma, Congenital….etc). An endoscopic or open surgical procedure carried
out for either diagnostic or treatment purpose was considered as an intervention
Results
A total of 331 patients were referred during the 5-years in the study period. The majority of the
patients (173) were in the age group 26 – 50 years (Figure 1). There was a slight male preponderance
183 (55.3 %).
Age Distribution
No
200
180
160
140
120
100
80
60
40
20
0
173
67
55
23
Year
5
6
<1
1_5
2
6_13
14_25
26_50
51_75
>75
Figure1. Age Distribution
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
Table 1. Distribution of Referral Cases Based on Pathological Basis.
Diagnosis
Neoplastic changes
Degenerative changes
Unspecified causes
Congenital
Inflammatory conditions
Iatrogenic
Trauma
Functional disorders
Unknown cause
Infectious
Stone formation
Thromboembolic phenomenon
Number of Patients
155
44
37
33
15
8
7
6
5
4
3
3
Table 2. The Top 8 Referral Conditions.
Diagnosis
Brain Tumors
Spinal Cord Lesions
Vascular Lesions
Intra Cerebral lesions
Intra Thoracic Tumors (Lung Ca, Mediastinal Mass …etc)
Thyroid Ca (recurrent, involvement of adjacent structures…etc)
Intra Thoracic Lesions (Lung destruction……etc)
Hepatobilliary Tumors (Cholangio carcinoma…etc)
Surgical referra Abroad; 5 Years Trend
Number of Patients
74
47
35
19
10
10
9
9
y = -3.9x + 77.9
R2 = 0.0902
90
80
No
70
60
50
40
30
20
10
0
1
2
3
4
5
Year
Figure.2.Overall Surgical Referral 5 years Trend
232 (70 %) of the cases were residents of the capital while 81(25 %) were out of the capital and 18
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
(5 %) of the referral slips did not have specified address.
Neoplastic diseases both benign and malignant accounted for 155 cases being the main pathological
class for referral. Neurosurgical cases were the highest number of patients which are referred (155),
followed by General surgery (45) and Urology (42).The least number of cases were sent for Plastic
and Reconstructive surgery (1), Maxillofacial (2) and Cardiac surgery (2)
The leading disease groups were primary brain tumors either malignant or benign, followed by
Vascular lesions such as stenosis, AV fistulas and aneurysms and Intra cerebral lesions for example
aneurysms and seizure disorders. In all, 97 of the cases had at least one surgical intervention done
prior to referral. The overall trend is showing some decrement (Fig.2) Urology and Neurosurgery
confirm to this trend while General surgery and Pediatric surgery have shown increment rather.
Reason for referral ranged form for renal transplant (1) to better surgical intervention (249) and
Investigation (49). Referral for MRI which accounted for 16 of the referrals in the first 2 years was
virtually nonexistent in the last 3 years.
Discussion
The three main departments in Addis Ababa University, referring patients abroad are: Internal
Medicine, Orthopedics and General Surgery3 and it was well observed that most of these referrals
would have been avoided provided that we the Hospital had wide range of sub-specialty consultants.
In Similar African countries, consultants who came back from advanced training in developed
countries have helped stop un-necessary referrals abroad and saved a lot of hard currency4. In face of
under staffed units, patients are forced to go abroad or higher mortality rate will be a dismal
prognosis5. The average number of surgical patients being referred per year (66) is relatively lower
than the number of cases referred by the Orthopedics department in 2008 (115). This could be
attributed to more number of, relatively, available subspecialty disciplines and expertise in the
surgical department. Easy access to health facilities ,investigations centers, better level of awareness
and better socioeconomic status may explain the significant number of patients coming out of the
capital , Addis. Neoplastic diseases mainly malignant ones continue to be of significant challenge by
requiring better diagnostic evaluation, combined modality management approaches (surgery , Chemo
radiotherapy, hormonal therapy) and recurrence. This is evidenced by the ongoing study of pattern of
Surgical admissions in our department6.
Neurosurgery as it is marked by inaccessibility due to the rigid cranium, need for delicate handling,
good equipment and most being Neoplastic changes with possibilities of incasing major vessels or so
will explain why the high number of referral cases abroad. The fact that Departments like Plastic and
Reconstructive surgery, Maxillofacial and ENT surgeries are located in other hospitals may have
contributed well to the point that they have fewer referrals as these cases are being referred directly
from the hospital they are located in.
The number of Cardiac patients’ referral could also be explained by the fact that most cardiac patients
are referred via the Cardiac foundation or via the Internal Medicine department. The overall trend is
decreasing (R2 = 0.09), not statistically significant, which may be partly attributed to the newly
introduced subspecialties as evidenced by same pattern in Neurosurgery and Urology. Additional
recruitment of both national and foreign surgeons to the department may have greatly contributed to
this decrement.
Availability of MRI and relative abundance of CT may have contributed in part as settling diagnosis
could have become easier than ever, there by interventions can be carried out here with out a need for
referral. Still few subspecialties and even fewer super subspecialties, long waiting list and probable
lack of confidence form the public in the general medical practice may be the driving forces for the
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
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slight decrement of referrals abroad despite the introduction of subspecialties. Medical tourism has
made referrals very simple and it is nowadays combined with a “safari” trip, weather African
Hospitals would be sites for referrals is a question of time7.
Conclusion
There is statistically insignificant trend on the referral to make any firm conclusion the over all
trend of referral, however, seems decreasing for the last 5 years. Most cases were form the capital,
Neurosurgical cases have been referred more than any other subspecialties, Neoplastic changes
constitute the main reason .Availability of better and newer investigative modalities seem to
decrease referral of patients for investigation purposes, while there seems to be no contribution
for apparent increase for referral.
Recommendation
1. Expansion of Subspecialty training in surgery can keep or may hasten the slightly declining
trend of sending patients abroad. Expansion may include training young surgeons or
recruiting expatriates and giving additional training to the existing professors.
2. Equipping the Medical School with better operative and investigative modalities may at the
end decrease the number of referrals as well.
3. It may be prudent to communicate with the public to gain the confidence in the general
medical practice and make the institution competent as well.
4. The overall data management in the hospital may better be upgraded.
References
1. http://www.privatehealthadvice.co.uk/disadvantages-having-treatment-overseas.html
2. Basel Al-Sumait,et al. Overseas Referral of Kuwaiti Surgical Patients. The Kuwait Medical
Journal 2001; 33 (1): 71-74.
3. B. Bezabih, B.L.Wamisho Referral of Ethiopian Orthopedic patients for treatment abroad,
KOA, JEAOS, 2010; 2: .
4. JAO. Mulimba. Is Hip Arthroplasty Viable in A Developing African Country? East and
Central African Journal of Surgery 2007; 12(1) -.
5. Hagos Biltus Inpatient Surgical Mortality in Tikur Anbassa Hospital . A 5 years review EMJ
2009; 47:135- 142
6. Ephraim T, Abebe B. Patterns Of surgical Admission at AAU MF Tikur Anbassa Hospital
(Unpublished data )
7. http://www.treatmentabroad.net/medical-tourism/medical-tourist-research/
.
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
Challenges of Pancreatic Cancer Management in a Resource Scarce Setting
O.I. Alati se, O.O. La wal, O.T. Ojo
Department of Surgery, College of Health Sciences, Obafemi Awolowo University/ Obafemi Awolowo
University Teaching Hospital Complex, Ile-Ife, Nigeria.
Correspondence to: Dr OI Alatise, E-mail: [email protected]
Backgrounds: Of all forms of gastrointestinal malignancy, adenocarcinoma of the pancreas is
associated with the worst survival. Management of pancreatic cancer is associated with some
challenges. This study is aimed at determining the hospital incidence, sociodemographic
characteristics, managements and management's outcome of carcinoma of pancreas at our
hospital. We also discuss the management challenges encountered with these patients.
Material and methods: We reviewed 96 pancreatic cancer patients seen at Awolowo University
Teaching Hospital Complex, Ile –Ife, Nigeria, from July 1989 to July 2007.
Results: There were ninety six patients diagnosed with cancer of the pancreas but only 80
patients had histological proof of pancreatic cancer. This account for 2.1% of all malignancies
seen and 238/100000 total admissions during the study period. The median age is 55.0. There
were 62 (64.6%) male and 34 (35.4%) female with male to female ratio been 2:1. Duration of
symptoms in the patients ranges from 4 weeks to 109 weeks. Only three (3.1%) patients has
tumor located in a particular anatomical sub site: two head of pancreas and one tail of the
pancreas. Other patients had extensive tumor involving the head and body of the pancreas.
Two patients had pancreaticoduodenectomy, one had resection of the tumor at the tail of
pancreas and 45 patients had triple bypass. Patients with low serum albumin and serum
sodium and elevated transaminases at presentation, had poorer prognosis than other patients.
Conclusion: Pancreatic cancer is not uncommon in our center with male preponderance. Most
patients present with advanced condition only amenable to palliative measures. There are
significant challenges in the area of diagnosis, screening, treatment and research.
Introduction
Pancreatic cancer is one of the most lethal human cancers and continues to be a major unsolved health
problem at the start of the 21st century. Similarly, of all forms of gastrointestinal malignancy,
adenocarcinoma of the pancreas is associated with the worst survival1. Most patients die within a year
after establishment of the diagnosis2. It is the fourth leading cause of death in both men and women in
United State of America and it has been estimated that in 2007 about 37,170 people in the United
States will be diagnosed with pancreatic cancer and about 33,370 will die of the disease3-4.
The peak incidence of pancreatic carcinoma occurs in the seventh decade with a slight male to female
predominance 5. There are variations in incidence in different populations ranging from 2.2 new cases
per 100,000 population in India, Kuwait, and Singapore to 12.5/100,000 in Sweden 5, 6. The incidence
in most developed countries is similar to that of the United States6.
Most research on pancreatic cancer has come from developed countries. Some of these researches
have indicted some environmental factors in the occurrence of this disease7-8. The environmental
factors include cigarette smoking, alcohol consumption, high meat intake and occupational exposure
to carcinogen like DDT and other organochlorine pesticides. Most of these environmental factors are
very prevalent in Africa especially Nigeria- the world largest black nation. Study from Egypt showed
that the incidence of pancreatic cancer is higher in the area of the country where this environmental
factor abound 9-10. However, few works have been done on this area of interest in Nigeria. The need to
look at local data also becomes very imperative because of the finding of some study that African
American and economic disadvantage population have higher incidence of pancreatic cancer 3-7.
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
This retrospective study was aimed at highlighting the hospital incidence, sociodemographic
characteristics, managements and management's outcome of carcinoma of pancreas at Obafemi
Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria. We also discuss the challenges
associated with management of the disease in resource-scarce settings that are typical of the health
sector in the sub-Saharan African region.
Patients and Methods
The study was conducted at Obafemi Awolowo University Teaching Hospital Complex, Ile –Ife,
Nigeria, from July 1989 to June 2007. The hospital services the rural and semi-urban agrarian
communities in the southwestern Nigeria. The hospital serves as the referral tertiary hospital for an
estimated population of approximately 7.7 million persons in the southwestern states of Nigeria.
Data Collection.
This was a retrospective cohort study. Admission and discharge diagnosis and procedure codes as
well as the cancer registry database were obtained from the Corporate Data Store of the hospital.
Current procedural terminology (CPT) and International Classification of Diseases Ten Revision
(ICD-10) codes for “Triple bypass”, “pancreaticoduodenectomy” and “pancreatic cancer” were used
to identify patients with proven or suspected pancreas neoplasm undergoing surgery. Manual review
of patient records was performed to obtain relevant data points. The Institutional Ethical Committee
approved the study. The data collected include the sociodemographic, laboratory parameters and the
treatment modalities, as well as, the outcome of management.
The diagnosis of pancreatic cancer was made using the combination of clinical parameters, upper
gastrointestinal endoscopy and radiological findings. Clinical parameters used included jaundice,
upper abdominal mass, upper abdominal pain that radiate to the back, weight loss and palpable gall
bladder. Radiological parameters included ultrasound and/or Computerized tomography scan showing
pancreatic mass. Upper gastrointestinal endoscopy was done for most of the patients to rule out the
possibility of gastric cancer. Endoscopic retrograde cholangiopancreatography was not done for any
of the patients because the facility was not available. All the patients with conflicting findings which
could not be substantiated at surgery were excluded from the study. Histolopathological finding
further corroborated the diagnoses for patients that had surgery or on postmortem examination.
Sixteen (16.7%) patients do not have histopathology result.
All the data obtained were coded, edited appropriately and entered into personal computer. Analysis
of the data was done using Statistical Packaging for Social Sciences (SPSS) version 11.0. Simple
descriptive statistics were used. Median and frequencies were calculated based on the numerous data
points. The P values were provided to indicate statistical significance. P value less than 0.05 were
regarded as significant. Chi-square tests were used to compare categorical variables such as sex.
Fisher exact test was used where applicable. Student t test was used to compare mean age between the
groups.
Results
There were ninety six patients diagnosed with cancer of the pancreas but only 80 patients had
histological proof of pancreatic cancer. This account for 2.1% of all malignancies seen and
238/100000 total admissions during the study period. The age of the patients ranges from 32 to 90
years. The median of the age is 55.0. As shown in figure 1, the most common age group affected with
pancreatic cancer is age group 51-60. There were 62 (64.6%) male and 34 (35.4%) female with male
to female ratio been 2:1. Majority of the patients were farmers (39.8%) and traders (26.4%). Other
patients were either artisan or work in Government establishment.
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
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Duration of symptoms ranged from 4 weeks to 109 weeks with a median of 8 weeks. None of our
patients have family history of pancreatic cancer. Only eleven (11.5%) have previous history of
diabetic mellitus (DM) before the onset of the symptoms. The diagnosis of DM was made within one
year prior to the commencement of the symptoms in 8 of the 11 patients. Seven and ten patients had
significant history of cigarette smoking and alcohol intake respectively. On investigation, 98% of the
patients had elevation of alkaline phosphatase, 20% had elevated Aspatate transaminate, 98% had
elevated bilirubin and 62.5% had packed cell volume of less than 25 at presentation.
Only 3 (3.1%) patients has tumor located in a specified anatomical sub site: 2 in head of pancreas and
one in tail of the pancreas. Other patients had extensive tumor involving the head and body of the
pancreas. There were liver metastases in 20(20.8%) patients at presentation.
Table 1. Factors Affecting the Outcome of Managements of Patients with Pancreatic Cancer.
Factors
Degree of Freedom
P-value
95% Confident Interval
Age
Sex
Duration of symptoms before
presentation
Serum bilirubin
SGOT
SGPT
Alkaline phosphatase
Total serum protein
Serum Potassium
Serum Sodium
Serum cretinine
Serum bicarbonate
PT
INR
94
1
94
0.354
0.036
0.427
2.535 – 7.012
-11.439 – 4.886
94
94
93
94
94
94
94
94
94
94
28
0.292
0.001
0.00001
0.798
0.031
0.782
0.024
0.402
0.014
0.078
0.193
-28.488 – 93.678
13.285 – 51.161
9.370 – 29.352
- 354.731- 272.684
- 10.231 - -493
- 2834 – 2140
5.4893 - -3977
-18.6939 – 46.1860
- 3.4820 - -4085
- 2.981 – 52.8287
- 3566 – 1.852
Frequency
Figure 1: Distribution of age of
patients with pancreatic cancer
45
40
35
30
25
20
15
10
5
0
39
19
17
10
9
2
<40
41-50
51-60
61-70
71-80
>80
Age in years
Table 2. Complication Associated with Methods of Triple Bypass
Complications
Braun Method
Roux-en-Y method
3
1
Bile leak
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
Recurrent vomiting
2
0
Prolonged ileus
2
1
Wound infection
2
0
Total
9
2
Fifty five (57.3%) patients had surgery. Two patients with localized tumor of the head had
pancreaticoduodenectomy. A patient with tumor at the pancreatic tail had resection of the tumor and
splenectomy. Forty-five (81.8%) of the operated patients had locally advanced pancreatic mass. These
patients had triple bypass to relieve the obstructive jaundice. Eleven of the 45 triple bypasses were
done with isolated bowel segment (Roux-en-Y) while in the others bowel loops were used (Braun).
Seven patients had biopsy alone of the pancreatic mass or the lymph node because of the widespread
metastasis to the bowel, liver and other organ in the peritoneal cavity. Fourteen patients had adjuvant
chemotherapy. Agents used include 5-fluorouracil and Adramycin.
One of the patients that had pancreaticoduodenectomy presented three month later with metastasis to
the spine. He died five month after surgery. The other patient who had pancreaticoduodenectomy was
lost to follow-up after a year. No recurrence was recorded for the patient with tumor at the tail of
pancreas after 5 years of follow up. Median survival for patients that had triple bypass using a bowel
loop was 3 months, while the median survival for patients that had triple bypass using an isolated
bowel segment was 5 months. This was statistically significant (p=0.02). One of the patients that had
pancreaticoduodenectomy had bile leak which was managed conservatively. Within one month of
presentation, 46 (47.9%) patients with pancreatic cancer died. As shown in table 1, the factors that
were found to be significant in patients that died within one month of presentation include elevated
transaminases, low sodium, serum protein and bicarbonate. Table 2 shows the various complications
from bypass surgery. The most common complication of triple bypass is bile leak which was seen in 4
patients.
Discussion
Despite past efforts, conventional treatment approaches, such as surgery, radiation, chemotherapy, or
combinations of these, have had little impact on the course of pancreatic cancer. The tumor is rarely
curable2,3. In this study, we found that the hospital incidence of pancreatic cancer is 238 per 100, 000
hospital admission. It also accounts for 2.1% of cancer cases seen in our centre. For several decades,
the incidence of pancreatic cancer has been consistently higher in blacks than in whites in the United
States8.11-12. From 1995 to 1999, the average annual age-adjusted incidence rates were 16.6/100,000
for blacks and 10.7/100,000 for whites12. The incidence of pancreatic cancer is higher in black
patients owing to several factors attributable to genetic mutations, socioeconomic status, smoking,
long-term diabetes, and alcohol use 11-12. However in our series, aside from the fact that most of our
patients belong to low socioeconomic class, few of our patients have history suggestive of these
identified risk factors. Majority of our patients are farmers. Occupational exposure to carcinogen may
play a major role in the occurrence of pancreatic cancer in our environment as stated in previous work
from Africa 9-10. Further studies will be necessary to identify the particular carcinogen that our patients
are exposed to. One interesting finding of this study is that the peak age of occurrence of pancreatic
cancer is 6th decade. Generally, cancers tend to occur in earlier age in the country; and pancreatic
cancer is not an exception13. Our study concurred with finding in other studies that showed male
preponderance in pancreatic cancer6,13-14.
Pancreatic cancer can mimic other benign conditions like chronic pancreatitis and biliary tree stone.
Several modalities are used in developed centres before primary therapy is initiated. These modalities
include endoscopic retrograde cholangiopancreatography, laparoscopy, endoscopic ultrasound, helical
computerized tomography (CT), Magnetic resonance imaging and the use of tumor markers 7,15-16.
Most of these facilities are not readily available in most centers in the developing countries. Though
CT scan is available, the cost of the procedure is prohibitive to most of our patients who are poor.
This suggests an urgent need for formal social support structure in our environment. Most developing
centers like ours depend on clinical presentations and few radiological investigations while
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East and Central African Journal of Surgery Volume 15 Number 2.
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confirmation of the diagnosis is done at laparotomy or at autopsy. Previous study has shown that
pancreatic cancer is the most common cause of obstructive jaundice in our environment13. Hence, all
patients with features of obstructive jaundice are painstakingly screened for pancreatic cancer and
subsequently, offered surgery after stabilization. The need to undertake definitive treatment without
prior tissue diagnosis had been substantiated by previous study16-17.
At presentation, most of our patients had advanced disease. Resection rate is about 3% which was
very low compared with data from developed country where resection rate of as high as 15-20% has
been quoted7. Stage of the tumor has been found to be an important predictor of resectability and
death in patients with pancreatic tumor18. Because of the location of pancreas, early symptoms of
pancreatic cancer are so vague and are usually ignored by most patient. Presentation with advanced
stage of the disease may also be due to poor health seeking behaviour of our patients 19-20. Obviously,
a high index of suspicion on the part of health workers is essential to early detection of pancreatic
cancer. Another reason for late presentation in our patients may be due to aggressive growth
behaviour of the pancreatic cancer which lead to early dissemination of the tumor7,21. Various efforts
had been made on how to diagnose pancreatic cancer early with little success16,22. Presently, no
population screening modality is available for pancreatic cancer. Moreover, targeted screening is also
very difficult for pancreatic cancer because primary causal factors for this tumor are poorly
understood. While effort is been made along this line, it is worthy to note that endoscopic
ultrasonography has been shown to be a reliable way to detect tumor invasion of visceral vessels and
thus predict unresectability and it also has the potential to be used to diagnose pancreatic cancer
early22-23.
Most of our patients had diversion of bile and the gastric contents to ameliorate the jaundice and the
possible gastric outlet obstruction. We found that patients that had triple bypass using Roux –en- Y
live longer than when a loop of bowel was used for the bypass. A randomized control trial will be
needed to substantiate this finding. However, a diversion using Roux en Y is said to be associated
with less complication21. There are debates about the rational for triple bypass since the procedure is
essentially palliative21-22. The rate of gastric outlet obstruction is said to be about 20% and the rate
may be on the increase the longer the patient live3,23. Most of our patients are poor and may not be
able to afford a repeat surgery hence the need to do a more encompassing surgery like triple bypass
when indicated. Endoscopy bypass was not done for any of our patient because the facility was not
available. These may not be a disadvantage because it has been found that surgical bypass are more
durable than endoscopic stents which is prone to recurrent obstruction and cholangitis24 .It worth
noting however, that the minimally invasive approach is associated with considerable less initial
morbidity and mortality than surgical bypass24-26.
The need for adjuvant therapy in pancreatic cancer cannot be over emphasized. Even with complete
surgical resection, most patients will die of recurrent disease because of the multifocality of the
disease and micrometastasis27-29. Several studies had shown that outcome of patients are improved
when placed on adjuvant chemotherapy, radiotherapy or combination of both7,28-29. Pancreatic cancer
is moderately sensitive to few agents like gemcitabine, capecitabine, cisplatin, bevacizumab and
cetuximab8,30. Most of these agents are more toxic, rarely available in our environment or very
expensive. One important question that is yet to find an answer is the reason why pancreatic cancer is
resistance to most commonly available chemotherapy. Radiotherapy facilities are extremely
congested; hence, the facilities are made available to those that will benefit most from the facilities
and the privileged few. These made management of patients with pancreatic cancer very difficult.
We found that patients with elevated transaminases, low serum sodium and reduced total protein
indicate that patients had very advanced disease with a much reduced life expectancy. These may be
due to involvement of the liver in this condition. These simple parameters can help predict a poorer
outcome at presentation. Further study will be needed to substantiate this finding.
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East and Central African Journal of Surgery Volume 15 Number 2.
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For long time, pancreatic cancer has been regarded as terminal disease; hence little attention is given
to the research on the disease. Report on pancreatic cancer is extremely scarce in Nigeria or Africa. If
it is true that blacks have higher risk to develop pancreatic cancer, concerted effort must be put to
characterize pancreatic cancer in Nigeria, the largest black nation in the world.
Conclusion
Pancreatic cancer is not uncommon in our center with a male preponderance.
Most patients present with advanced condition only amenable to palliative measures.
There are significant challenges in the area of diagnosis, screening, treatment and research.
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14. Beger HG, Rau B, Gansauge F, Poch B, Link K. Treatment of Pancreatic Cancer:
Challenge of the Facts. World Journal of Surgery. 2003; 27: 1075–1084.
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15. Silverman DT, Hoover RN, Brown LM, Swanson GM, Schiffman M, Greenberg RS,
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Fraumeni JF Jr. Why do black Americans have a higher risk of pancreatic cancer than
white Americans? Epidemiology. 2003; 14: 45–54.
16. Tessler DA, Andrew Catanzaro A, Velanovich V, Havstad S, Goel S. Predictors of
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17. Abraham SC, Wilentz RE, Yeo CJ, Sohn TA, Cameron JL, Boitnott JK, Hruban RH.
Pancreaticoduodenectomy (Whipple resections) in patients without malignancy: Are
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Eltoum I, Vickers SM. Prognostic factors for survival in pancreatic cancer: a
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their receptors in pancreatic cancer. Teratogenesis, Carcinogenesis, and Mutagenesis.
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2003; 186: 579–582.
23. Rosch T, Braig C, Gain T, Feuerbach S, Siewert JR, Schusdziarra V, Classen M.
Staging of pancreatic and ampullary carcinoma by endoscopic ultrasonography.
Comparison with conventional sonography, computed tomography, and angiography.
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24. Sarr MG. Cameron JL. Surgical management of unresectable carcinoma of the
pancreas. Surgery. 1982: 91: 123- I33.
25. Van Heerden JA, Heath PM, Alden CR. Biliary bypass for ductal adenocarcinoma of
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26. Singh SM, Reber HA. Surgical palliation for pancreatic cancer. Surgical Clinics of
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27. Fisher WE, Andersen DK, Bell RH, Saluja AK, Brunicardi FC. Pancreas. In
Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Pollock RE eds,
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28. Sohn TA, Yeo CJ, Cameron JL, Koniaris L, Abrams RA, Sauter PK, Colemam J,
Hruban RH, Lillemoe KD. Resected adenocarcinoma of the pancreas-616 patients:
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29. Richter A, Niedergethmann M, Sturm JW, Lorenz D, Post S, Trede M. Long-term
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The Pattern of Benign Breast Diseases in Rural Hospital in India
M. Kumar, K. Ray, S. Harode, D.D. Wagh
Department of Surgery, Jawaharlal Nehru Medical College & Acharya Vinoba Bhave Rural Hospital, Sawangi
(Meghe), Wardha. Maharashtra, India - 442004
Correspondence to: M. Kumar, Email: [email protected]
Background: Benign breast diseases are most common cause of breast problems. Up to 30% of
women suffer from benign breast diseases and requiring treatment at some time in their lives.
Benign breast diseases are 5 to 10 times more common than breast cancer. Until recently benign
disorders of the breast has been given less importance than breast cancer. Consequently, many
patients with benign breast diseases receive little attention from clinicians.
Methods: The present cross-sectional study was carried out in Acharya Vinoba Bhave Rural
Medical College and Hospital during the period April 2007 to September 2009. A total of 481
patients had breast disease, among these 380 patients had benign breast disease and which are
included in the study.
Results: Among all the benign breast diseases, right sided breast involvement was more
common constituting 181 (47.63%) cases while left breast involvement was less common
constituting 151 (39.73%) of the patients. Bilateral involvement was seen in only 48 (12.63%) of
patients. The pattern of benign breast disease, fibroadenoma was the most common lesion
constituting 160 (42.1%) cases.
Introduction
During the past decade there has been increasing interest in benign breast diseases for number of
reasons:1. Patients started demanding investigation and treatment for the benign breast diseases. These
have participated in scientific studies, classification and treatment of their conditions.
2. There is a question of pre-malignant disorders and histological features, which imply an
increased risk of breast cancer. Increasing understanding of these conditions may prove
important in understanding the pathogenesis of breast cancer and defining the high risk
groups in whom regular surveillance may be beneficial.
3. Finally, recently introduced breast screening programs are likely to present pathologists and
clinicians with as yet ill defined histological entities, which may be of importance in
understanding the development of invasive cancer and its eventual treatment
Thus, most of the previous epidemiological studies were based on histopathological evaluation, thus
concentrated on fibroadenoma and fibrocystic disease neglecting fibroadenosis and breast pain which
has significant contribution in benign breast disease. On this background the present study was
undertaken to analyze pattern and estimate the epidemiological burden of benign breast diseases in a
rural hospital.
Patients and Methods
The present cross-sectional study was carried out in Acharya Vinoba Bhave rural Medical College
and hospital during the period April 2007 to September 2009. A total of 481 patients had breast
disease, among these 380 patients had benign breast disease and which are included in the study. A
detailed clinical history of symptoms related to the breast such as mastalgia, lump in breast, nipple
discharge, retraction and their relation with menstruation was noted. Details of family history,
menstrual history and history of malignancy of the organ were inquired. Breast was examined with
respect to nipple, areola, details of the lump including size, site, surface, margins, mobility,
consistency, fixity to underlying structures, skin and chest wall. Axilla of same side is examined for
lymph nodes. The local examination was completed only after the examination of opposite breast and
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East and Central African Journal of Surgery Volume 15 Number
Num
2.
July/August 2010.
axilla. The systemic examination included respiratory system, cardiovascular system, central nervous
system, per abdomen, per vaginal and per rectal examination. Clinical record was maintained in each
case on the proforma. Informedd and written consent was taken in each case before interventional
procedures. The ultrasonographic examination of breast was done with machine, sonoline model no.
G-60,
60, with hand held microtransducer
microtransdu
of center frequency 7.5MHZ. The ultrasonographic
examination was carried out with special reference to site, size, echogenecity, heterogenecity,
margins, parenchymal interface of breast lesion & presence or absence of microcalcification.
microcalcification. The final
impression was noted.
Fine needle aspiration cytology was done in patients with palpable
palpable lump in breast and suspicious
lesions on sonomammography. FNAC was done by using 22 gauze needle attached to 10cc.
disposable syringe. Thee smears are prepared on a clean slide and sent for cytological examination
Results
A total of 18659 new patients attended the surgical outdoor patient department, out of which 481
patients had breast disease. 380 had benign breast disease and 101 had malignant
malignant breast disease. Thus,
hospital incidence of benign breast disease was calculated as 2.03 % and that of malignant breast
disease was calculated as 0.54 %. The benign to malignant ratio was calculated as 4: 1. The total
magnitude of problem of breast disease in the hospital setup was calculated as 2.03 %.
In the present study of 380 female patients with benign breast diseases, 181 (47.63%) had right sided
breast involvement while 151 (39.73 %) patients had left breast involvement whereas bilateral
involvement was seen in 48(12.63%) patients.
Table 1. Incidence of Benign Breast Disease in AVBRH
Incidence in hospital setup
Number(18659)
Percentage (%)
Breast disease
481
3.1
Benign breast disease
380
2.03
Malignant disease
101
0.54
No. of Patients
200
Fibroadenoma
151
Giant Fibroadenoma
150
101
100
50
50
6 3
Multiple fibroadenoma
Fibroadenosis
35
16 4 4
3 3 2 2
0
Mastalgia
Breast abscess
The Diagnosis of the breast diseases are as shown in the graph.
Figure 1.The
In my study Fibroadenoma was more commonly seen in age group of 11-30
11 30 years constituting 119
(74.3%) of all cases followed by 29 (18.1%) cases in age group of 31-40
31 40 years. Giant fibroadenoma
(6) and multiple fibroadenoma (3) were more commonly seen in age group 21-30
21 30 years. Only one
case of fibroadenoma was seen in a paunder
pa
60 years.
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East and Central African Journal of Surgery Volume 15 Number 2.
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Considering the size of lumps in fibroadenomas, it was seen that majority of the solitary
fibroadenomas 84 (55.6%) cases had size < 2 cm followed by 67 (44.3%) cases having size between
2-5 cm. All the cases of giant fibroadenomas had size more than 5 cm as per definition while
majority of multiple fibroadenomas 2 (66.66%) cases had size between 2-5 cm.
Fibroadenosis was more commonly seen in age group of 21-30 years constituting 51 (50.4%) cases
followed by 31-40 years constituting 28 (27.7%) cases and 41-50 years constituting 16 (16.8%) cases.
No case of fibroadenosis was seen below 10 years and above 60 years.
Breast abscess was more commonly seen in age group of 21-30 years constituting 22 (62.8%) cases
followed by 31-40 years constituting 11 (31.4%) cases. 1 cases were seen in age group of 11-20 years
and only one cases were seen in age group of 41-50 years which constituted the group of non
lactational breast abscess. No case of breast abscess was seen below 10 years and above 50 years.
Mastalgia was more commonly seen in age group of 21-30 years constituting 33(66%) cases followed
by 31-40 years constituting 9 (18.0%) cases and 41-50 years constituting 8(16%) cases. No case of
mastalgia was seen below 20 years and above 50 years.
Mastitis was more commonly seen in age group of 21-30 years constituting 11 (68.75%) cases
followed by 31-40 years constituting 5(31.25%) cases. No case of mastitis was seen below 20 years
and above 40 years. In the present study of 380 cases of benign breast disease, pain was seen in 246
(64.7%) patients. The other lesions which had breast pain included 3 cases of duct ectasia, 2 cases of
tuberculosis and 4 cases of galactocele. The breast lump was seen in 280 (57.3%) cases. The other
lesions which had breast lump included 2 cases of papilloma, 3 cases of galactocele, 3 cases of duct
ectasia, 3 cases of phyllodes tumour, 2 cases of tuberculosis and 2 cases of lipomas. Breast nodularity
was seen in all cases of fibroadenosis i.e 101 (26.5%) cases. Nipple discharge was seen in 21 (5.5%)
cases. The other lesions which had nipple discharge included 2 cases of papilloma, 3 cases of duct
ectasia and 2 cases of galactocele. Fever was seen in 37 (9.7%) cases. The other lesions which had
fever included 2 cases of tuberculosis and 2 cases of duct ectasia.
In the present study, among a total of 380 patients, only clinical diagnosis was done in 147 cases.
These were not confirmed by fine needle aspiration cytology or histopathology because either they
were confirmed with surety clinically or the patient was not willing for investigation or surgery or the
patient did not follow up or the lesion was so small that patient was managed conservatively with
regular followup. Only fine needle aspiration cytology was done in 95 cases, only nipple discharge
cytology was done in 26 cases while histopathology confirmation was done in 98 cases. A total of 156
cases were operated which included 98 cases of which histopathology was available and 35 breast
abscess for which histopathology confirmation was not done.
Discussion
For correct diagnosis of breast disease background knowledge of general features of individual breast
disease like incidence, age distribution, symptoms and palpatory findings are very important. Benign
conditions of breast are significantly more common than the malignant condition in developing
countries. . The limited literature available suggests that benign breast disease is a common problem
in the developing countries as well1. The incidence of these presentations varies in different
geographical areas according to the spectrum of the benign breast diseases encountered2.
The problem in treatment of breast disease in the developing countries is late because of illiteracy,
social taboo, unawareness resulting in delay in diagnosis, especially in malignancy as well as in
benign lumps in breast. Triple assessment that is combination of clinical examination, breast imaging
and aspiration cytology has been shown to be accurate for the preoperative diagnosis of breast lumps.
In the present study, 47.6% of patients had right sided breast involvement, 39.7% had left sided and
12.63% had bilateral involvement.
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East and Central African Journal of Surgery Volume 15 Number 2.
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Raju et al3 studied 1051consecutive breast biopsies over a period of 6 years and found that the right
side was involved in 47% of cases, the left in 48% cases whereas 5% had bilateral involvement. In the
current study, among benign breast disease, fibroadenoma was the most common and constituting
42.1% of cases among which solitary fibroadenoma accounted for 39.7%, 1.5% were giant
fibroadenomas and 0.7% were multiple fibroadenoma.
Similar results were obtained by Khanna et al in 1988 (38.4%), Iyer et al5 in 2000 (35.0%), and
Mayun et al6 in 2008 (39.8%). In all the above mentioned series, fibroadenoma was found to be the
most common benign breast disease. Thus, the present study is in concordance with the studies
available in the literature. The total incidence of fibroadenomas reported by Krishnaswamy et al1
(6.9%) is less because it was a cross sectional analysis of women undergoing routine health checkup
over a period of 10 years,he found that many females not presenting with any complaints while the
present study included women who presented to hospital with some complaints related to breast.
Siddiqui et al7 also showed decreased incidence of fibroadenomas (17%) because his studies was
based on histopathological analysis and he studied 3279 cases at tertiary care hospital while present
study was based on clinical history and examination and all cases were not subjected to
histopathology. Arihiro et al8 reported higher incidence of fibroadenomas 84.6% in their study as the
study was based on data retrieved from tumour tissue registry file between 1973 to 1995. The data did
not included cases of mastalgia which were diagnosed purely on clinical basis in present study.
Similarly, Akhator et al9 reported higher incidence of fibroadenomas 68.0% in their study as the data
was a 5 year retrospective review of all histologically proven benign breast lesions and did not include
clinical lesions like mastalgia. Also, Irabor et al10 reported higher incidence of fibroadenomas 64.3%
in their study as the data was a retrospective data of all breast biopsies over a period of 8 years and 3
months.
The next common diagnosis was fibroadenosis constituting 101 (26.5%) lesions. Iyer SP et al in 20005
reported similar incidence (28.3%) of fibroadenosis and Irabor et al in 200810 (22.7%). The present
study is in concordance with the study of Iyer et al5 and Irabor et al10. Siddiqui et al7 and Akhator et
al9 had lower incidence of fibroadenosis of 13% and 14.2% respectively. Kamal et al6 reported a
higher incidence of fibroadenosis (65.5%) as was reported by Memon et al11 (66.3%) as the study
was based on 500 young females in age group of 15-25 years.
Breast abscess accounted for 9.2% of lesions as compared to the 8.0% reported by Ochicha O et al12
in 2002 and 6.8% found by Siddiqui et al7. Mastitis accounted for 4.2% of the lesions which was
comparable with the 5% reported by Iyer et al5 but was lower than the 8.0% recorded by Mayun13 et al
in 2008.
Phylloides tumour represented 3 (0.7%) of all lesions which is similar to that reported by Akhator et
al9 in 2007 (0.65%). Other series have reported a higher incidence of phylloides tumour. In the present
study, fibroadenoma was more commonly seen in age group of 11-30 years. Similar results were
shown by Khanna et al4 in 1988 (11-30 years), Iyer SP et al in 20005(<30 years), Mcfarlane et al14 in
2001 (mean 20 years), Ochicha et al12 in 2002 (mean 21 years), Siddiqui et al7 in 2003 (mean 27
years), Akhator et al9 in 2007 (mean 23.9 years) and Irabor et al10 in 2008 (mean 24.4 years). In most
of the above mentioned series, fibroadenoma had the most common age of presentation 11- 30 years.
Thus, the present study is in concordance with the studies available in the literature.
Fibroadenosis was more commonly seen in age group of 21-30 years. Similar results were shown by
Khanna et al4 in 1988 (21-30 years), Iyer et al5 in 2000 (<30 years) and Akhator et al9 in 2007 (mean
26.6 years). Thus, the present study is in concordance with the above study. Breast abscess was more
commonly seen in age group of 21-30 years. A slightly higher age group was shown by Akhator et al9
in 2007 (mean 39.0 years). Mastitis was more commonly seen in age group of 21-30 years. Similar
results were shown by Khanna et al4 in 1988 and Ochicha et al12 in 2002. Thus, the present study is in
concordance with the above study available in the literature.
In the present study of 380 patients, the most common symptom was breast lump seen in 84.1% of
patients followed by breast pain in 64.7% of cases while nipple discharge was seen reported in 5.5%
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East and Central African Journal of Surgery Volume 15 Number 2.
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of patients. Dixon et al 15 conducted a study and found that breast lump in 69%, breast pain in 50%
cases and nipple discharge in 5% of cases. Iyer et al5 studied 60 patients and found breast lump in all
the (100%) whereas breast pain and nipple discharge were present in 50% and 15% respectively.
Krishnaswamy et al1 examined a total of 216 patients with benign breast disease and found that breast
pain was present in 56.9% of patients while breast lump was present in 13%. Nipple discharge was
present in only 3(1.4%) patients.
Memon et al (2007)11 in their study of 500 young females (15 – 25 years) found that breast lumps
were present in all 500 (100%) patients while breast pain was complained by 210 (71.42%) patients.
Most of the authors’ studies mentioned above showed that breast lump was the most common
presenting symptom followed by breast pain and nipple discharge except for Krishnaswamy U et al in
20031which mentioned breast pain as the most common presenting symptom followed by breast lump.
The findings in the present study are in accordance with majority of the studies reported in the
literature except that, in our study, 3 patients had all the three symptoms of a lump, pain and nipple
discharge.
Akhator et al9 in 2007 conducted a study and concluded that fibroadenoma was more commonly seen
in left side constituting 53 (49.9%) cases as compared to right side 46 (43.4%) cases while bilateral
involvement was seen in 7 (6.6%) cases. Fibroadenosis was more commonly seen in right side
constituting 10 (52.6%) cases as compared to left side constituting 9(47.4%) cases while no bilateral
involvement was seen. Breast abscess was more commonly seen in left side constituting 5 (71.4%)
cases as compared to right side constituting 2(28.6%) cases while no bilateral involvement was seen.
In the current study, solitary fibroadenoma and multiple fibroadenoma were on the right side in
72(47%), on the left in 54 (38.6%) of cases and were bilateral in 25(16.5%) of the cases.
Fibroadenosis was also more commonly found in right breast and constituted 52(51.4%), left sided in
39(38.1%) and bilateral in only 10 (10.5 %) of cases.
In cases of breast abscesses, the right side involvement was in 13(37.1%), left side was involved in19
(54.2%) and were bilateral in 3(8.5%) of the patients.Thus in breast abscess left side was commonly
involved than right side. Thus it is seen that present study is in concordance with the study of Akhator
et al9.
In present study, breast lumps commonly involved the upper outer quadrant which was in agreement
with findings by Haque et al16, Gupta et al17, Alam et al18, Hussain et al19 and Iyer et al5.
It was seen that accuracy of clinical examination for detection of benign breast diseases was 99% as
compared to histopathology and 96% as compared to cytology. The clinical diagnosis for
fibroadenomas and phylloides tumour was correlated with histopathology and sensitivity of clinical
diagnosis was found to be 99.4% for fibroadenoma and 100% for phylloides tumour. The clinical
diagnosis for fibroadenosis, breast abscess, mastitis, galactocele and tuberculosis was correlated with
fine needle aspiration cytology and the sensitivity was found to be 97% for fibroadenosis and 100%
for breast abscess, 90.5% for mastitis, 85.8% for galactocele and 33.3% for tuberculosis.
Iyer et al5 in 2000 conducted a study and concluded that the sensitivity of clinical diagnosis in
correlation to histopathological diagnosis for fibroadenomas was 95.45%, 100% for fibroadenosis,
mastitis, galactocele and phylloides tumour, 81.82% for breast abscess and 75% for tuberculosis. The
present study is in agreement with clinical sensitivity for diagnosis of fibroadenomas, fibroadenosis
and phylloides tumour.
Summaryand Conclusions
The benign to malignant breast diseases ratio was calculated as 4: 1. The hospital incidence of benign
breast disease was calculated as 2.03 % and that of malignant breast disease was calculated as 0.54 %.
The total magnitude of problem of breast disease in the hospital setup was calculated as 2.03%.
Considering the pattern of benign breast disease, fibroadenoma was the most common lesion
constituting 160 (42.1%) cases and which included 151 (39.73%) cases of fibroadenomas, 6 (1.5%)
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East and Central African Journal of Surgery Volume 15 Number 2.
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cases of giant fibroadenomas and 3 (0.7%) cases of multiple fibroadenomas. Fibroadenosis (presently
termed fibrocystic disease) was the second most common lesion constituting 101 (26.1%) of all cases
followed by mastalgia and which constituted 50 (13.1%) of all cases.
Breast abscess was seen in 35 (9.2%) of all cases while mastitis constituted 16 (4.2%) cases. Other
benign breast diseases included papilloma 4 (1.1%) cases, galactocele 4 (1.1%) cases, duct ectasia 3
(0.7%) cases, cystosarcoma phyllodes tumour constituted 3 (0.7%), tuberculosis 2(0.5%) cases and
lipomas 2 (0.5%) cases.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Krishnaswamy U. Profile of benign breast disease in the urban India. Ind J Surg 2003; 65:17881.
Shukla HS. An outline of benign breast diseases. In: Recent advances of surgey R L Gupta;
1992.
Raju GC, Jankey N, Naraynsingh V. Breast disease in young West Indian women: an analysis
of 1051 consecutive cases. Postgrad Med J 1985; 61:977-8.
Khanna S. Spectrum of breast disease in young females: A retrospective review of 22 years.
Indian Journal of Surgery 1988; May - June: 169 - 75.
Iyer SP. Epidemiology of Benign Breast Diseases in Females of Childbearing Age Group.
Bombay Hosp Jr 2000; 42:10.
Kamal F. Fibrocystic disease of breast - age frequency and morphological pattern. Pak J Patho
2000; 11 (4):11 - 4.
Siddiqui MS. Breast diseases - a histopathological analysis of 3279 cases at a tertiary care
centre in Pakistan. Jr Pak Med Asso 2003;53 (3):5.
Arihiro K. Trends in benign breast tumors in Japanese women, 1973-1995: experience of
Hiroshima Tumor Tissue Registry. Jpn J Cancer Res 2002;93:610-5.
Akhator A. Benign Breast Masses in Nigeria. Nieg Jr of Surg Sciences 2007; 17:105 - 8.
Irabor DO. An audit of 149 consecutive breast biopsies in Ibadan, Nigeria. Pak J Med Sci
2008;24 (2):257 - 62.
Memon A, Parveen S. Changing pattern of benign breast lumps in young females. World J
Med Sc 2007; 2 (1).
Ochicha O. Benign Breast Lesions in Kano. The Niegerian Jr of Surg Research 2002;4:1-5.
Mayun AA, Pindiga UH. Pattern of histopathological diagnosis of breast lesion in Gombe,
Nigeria. Nigerian J Med 2008; 17 (2):159 – 62.
McFarlane ME. Benign breast diseases in an Afro-Caribbean population. East Afr Med J
2001; 78:358-9.
Dixon JM, Mansel RE. ABC of breast diseases. Symptoms assessment and guidelines for
referral. BMJ 1994; 309:722-6.
Haque A. Breast lesions a clinicohistopathological study of 200 cases of breast lump. Indian
Journal of Surgery 1980; August: 419 - 25.
Gupta JC. Breast lumps in Jabalpur area. Ind J Surg 1983; May: 268 - 73.
Alam AM. Breast carcinoma and its clinicopathological aspects - A study of 117 cases.
Bangladesh Med Jr 1991; 24:1-13.
Hussain MA. Incidence of cancer breast at Aligarh. J Ind Med Asso 1994:290 - 7.
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East and Central African Journal of Surgery Volume 15 Number 2.
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Comparision of Hook Phlebectomy and Endovenous Laser Therapy for Below Knee
Varicose Veins.
S.P. Deshpande, G.C. Gupta, P.D. Banodea, K.B. Golhar.
Department of Surgery
Acharya Vinoba Bhave Rural Hospital, Sawangi (meghe) Wardha.
Correspondence to: Dr. SP Deshpande, Fax- +91 07152 246431.
Background: Varicose vein is a common surgical problem having multiple modalities available
for their treatment. We studied the treatment modalities available for the below knee varicose
veins comparing Endovenous Laser Therapy (EVLT) and Hook Phlebectomy at Acharya
Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha.
Methods: All patients with varicose veins presenting to our hospital were included in the study.
All the patients in our study were assessed by clinico-etiological anatomical and pathological
(CEAP) classification. Diagnosis was further confirmed by Duplex ultrasonography.
Results and Conclusions: of the 76 patients studied in this study, 15 patients underwent EVLT
whereas 55 patients underwent Hook Phlebectomy for below knee varicose veins. 6 patients
underwent EVLT for above knee varicose veins in combination with Hook Phlebectomy for
below knee varicose veins.
Conclusions: We find Hook Phlebectomy to be much better option than EVLT for below knee
varicose veins.
Introduction
Varicose Veins are present in 20 to 25% of adult females and 10 to 15 % of men in western
countries1. This disease has attained national and industrial importance in western world because of its
high prevalence. The disease is neglected by Indians. Moreover, dark complexion, costume habits of
covering legs and disregard for aesthetic appearance and delay in seeing medical help add to low
incidence of reporting and protracted morbidity.
Patients and Methods
All patients with varicose veins presented to our hospital were included in the study. All patients in
our study were assessed by clinico-etiological anatomical and pathological (CEAP) classification2.
Diagnosis was further confirmed by Duplex ultrasonography. Pre-operatively, the varicose veins were
marked by Duplex Doppler. The above knee varicose veins were treated by any one of Trendelenburg
procedure, Stripping, Endovenous Laser Therapy (EVLT). The below knee varicose veins were
treated by either Hook Phlebectomy or EVLT. The patients could not be randomized into the two
groups of hook phlebectomy or EVLT as economic factor played an important obstacle.
Results
Of the 55 patients that underwent Hook Phlebectomy for below knee varicosities, 3 (5.45%) had
recurrence which had to be treated by the end of one year. Of the 15 procedures in which EVLT was
performed, 2 (13.33%) were complicated by recurrence which was eventually treated by Hook
Phlebectomy (Figure 1). Of the 6 patients who underwent EVLT for Above Knee varicose veins and
Hook Phlebectomy for below knee varicose veins, no patient had any recurrence.
Duplex ultrasound examination was invariably used in all the 76 patients having below knee varicose
veins and perforators incompetence was seen in all the patients involving the Great Saphenous System
and 5 patients had additional short saphenous system involvement. Hand held Doppler is a simple
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East and Central African Journal of Surgery Volume 15 Number 2.
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inexpensive and can be used in outpatient department but, the review of literature shows that taking
help of the hand held Doppler may be inaccurate as compared to the standard Doppler3,4
Figure 1. Hook Phlebectomy
Figure 2. Varicose Ulcer
In our study, 12 patients had varicose ulcer (Figure 2).Of these, 8 were treated by Hook Phlebectomy
and 4 were treated by EVLT. Of the 8 patients with varicose ulcer treated by hook phlebectomy, 7
showed decrease in the size of ulcer; where as the 1 remaining ulcer underwent Sub-fascial
Endoscopic Perforator Surgery (SEPS). Of the 4 patients with varicose ulcer treated by EVLT, all
patients showed signs of healing and reduction in size.
Commonest complications for Hook Phlebectomy in our series were stitch abscess seen in 2 patients.
The commonest complaint of the patients undergoing EVLT was Cord Like feeling in the lower limb
after the procedure seen in 3 patients, but that was seen only upto 1 month. Immediate success was
noted in 100% of patients treated with both the procedures. We have not used stripping of the veins in
the below knee area in view of high chances of damage to the cutaneous nerves and lymphatics5.
Discussion
Varicose vein is a common surgical problem. The incidence of varicose veins varies among different
populations. This condition is considered a national health problem in western countries. According to
Callam1, prevalence of varicose veins is 10-15% in men and 20-25% in women. We do not have
statistical data of varicose veins in India but incidence in India is on the rise. This could be because of
environmental factors and increasing awareness.
Patients with large varicose veins or patients with skin changes should be offered treatment
specifically designed to avoid future ulceration. Peripheral arterial disease should be ruled out as a
cause of patient’s symptoms. Successful treatment of varicose veins requires a balance between their
complete removal with treatment of underlying etiology and an optimal cosmetic outcome. So
complete treatment of clinically symptomatic varicose veins must involve treatment of saphenous
vein reflux as well as the varicosities6. Superficial veins acts as collaterals in DVT. So, DVT is
absolute contraindication to varicose vein surgery.
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The presence of symptoms such as heaviness, aching or swelling and clinical or ultrasound evidence
of saphenous vein reflux is generally accepted as indications for surgery. Obvious indications for
surgery are skin changes ascribed to varicose veins, superficial thrombophlebitis and bleeding.
According to British Vascular Surgical Society, the commonest indications are symptomatic and
complicated varicose veins, 55% surgeons also perform surgery for cosmetic reasons5.
Trendelenburg’ procedure is an essential component of all varicose vein surgery and is done by flush
ligation and division of tributaries. Stripping doesn’t treat varicosities of tributaries and also causes
increased chances of injury to the cutaneous nerves and lymphatics in the below knee varicose veins5.
Recurrence of reflux in a previously operated great saphenous vein is due to revascularization of the
strip track leading to further venous disease8. Hence Hook Phlebectomy was developed as a quick,
easy, economical and cosmetic procedure which can be used as a ‘Day Care’ procedure as an
alternative to stripping in the below knee area and also for the varicosities of the tributaries, a
common problem in the below knee area9. EVLT can be used for varicose veins of whole of the lower
limb10. The long term results EVLT are not available.
In our study, out of 55 patients that had undergone hook phlebectomy for below knee varicose veins,
52 reported back for follow up for up to 12 months. 3(5.45%) patients had recurrence. Of the 15 cases
who underwent EVLT for below knee varicose veins, 2(13.33%) had recurrence whereas, the patients
who had undergone EVLT for varicose veins in the above knee area and Hook Phlebectomy for
varicose veins in the below knee area had no recurrence.
All the cases on follow up were evaluated with color Doppler ultrasound studies. In recurrent cases,
perforator incompetence was documented.In cases with varicose ulcers, 8 patients were treated with
Hook ph lebectomy while 4 were treated by EVLT. Of the 8 patients with varicose ulcer treated by
hook phlebectomy, 7(87.5%) patients had signs of healing of ulcer, 1(12.5%) had to undergo SEPS.
Of the 4 patients having varicose ulcer treated by EVLT, 100% showed signs of healing of the ulcer.
The 3 cases with recurrence after hook phlebectomy, the incompetent perforators were marked by
color Doppler and underwent sub-fascial ligation of perforators. Of the 2 cases with recurrence after
EVLT was treated with Hook Phlebectomy. EVLT in the below knee varicose veins was difficult at
times due to difficulty in cannulation of the tributaries. It also required experienced personnel which
are few in the rural hospital setup in our area and has a definite learning curve. The cost of therapy is
also a factor. EVLT in the above knee varicose veins with hook phlebectomy for below knee varicose
veins is a relatively simple and effective procedure which can be used with good results comparable
to the standard surgical procedures. It is a relatively easy procedure as, cannulation of above knee
varicose vein is simple and phlebectomy takes care of the varicosities of the below knee area
including the tributaries.
Conclusion
Varicose vein is a chronic morbid condition. Most people present to us only after complications like
pigmentation, eczema, lipodermatosclerosis and ulcer development. Preoperative evaluation by colour
Doppler ultrasound is essential and should be routinely done as it helps in planning surgery and
reducing incidence of recurrence.
Meticulous clinical examination and surgical treatment followed by closely monitoring post operative
management is required to reduce morbidity of varicose veins. Hook phlebectomy has a definite
advantage over EVLT for below knee varicose veins having less recurrence rates. Hook phlebectomy
is relatively simple, operator independent and cost effective and can be done with ease even for
varicosities of the tributaries as compared to EVLT. Both EVLT and Hook Phlebectomy can be used
as ‘Day Care’ procedure. EVLT in the above knee varicose veins with Hook Phlebectomy for the
below knee varicose veins has results comparable to the standard procedures and devoid of the other
complications of surgery like complications of the wound, limb elevation, post operative pain and bed
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rest. In cases of varicose ulcer, EVLT has a similar result to the Hook Phlebectomy. Patient should
always be followed up for detection of any recurrent or residual varicose veins.
References
1. Callam MJ. Epidemiology of varicose veins. Br J. Surg 1994; 81 (2): 167-173
2. Niren Angle, Julie A., Freischlag. Venous Disease. Sabiston Text Book of Surgery. 17th
edition. Elsevier publishers, India, 2004; pp. 2053-2070
3. Kim J., Richards S., Kent P.J. Clinical examination of varicose veins- a validation study. Ann
R Coll Surg Engl 2000; 82 (3): 171-175
4. Singh S., Lee TA, Donlon M. et al. Improving the preoperative assessment of varicose veins.
Br J Surg 1997; 84 (6): 801-802
5. Sami Asfar et al. Stripping or No Stripping of Varicose Veins. International journal of
Angiology 2003; 12:75-77
6. Teruya TH, Ballard JL. New approach for the treatment of varicose veins. Surg Clin N Am
2004; 84: 1397-1417
7. Lees TA, Beard JD, Ridler BM et al. A survey of the current management of varicose veins
by member of the vascular society. Ann R Coll Surg Engl 1999; 81 (6): 407-417
8. Munashinghe A, smith C, Kianfard B et al. Strip track revascularization after stripping of the
great saphenous vein. Br J Surg 2007; 94: 840-843.
9. Ramelett A.A. Ambulatory Phlebectomy by the Muller Method: technique, advantages and
disadvantages. J. Mal Vasc.1991; 16(2): 119-122[Medline].
10. Samaraee A.L. et al. Endovenous Therapy of Varicsoe Veins: A Better Outcome than
Standard Surgery? The Surgeon. 2009; June: 181-186.
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
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Levels of Bifurcation of the Sciatic Nerve as Seen at Mulago Hospital
J. Kukiriza, C. Ibingira, H. Kiryowa, J. Turyabahika, J. Ochieng
Faculty of Medicine Department of Anatomy, Makerere University, Kampala-Uganda.
Correspondence to: J. Kukiriza [email protected]
Background: The sciatic nerve is comprised of the tibial, and the common peroneal
nerves, and supplies the posterior thigh, the leg and foot. Its injury commonly results in
a condition referred to as foot drop. The level of bifurcation of the sciatic nerve above
the transverse popliteal crease is useful during sciatic nerve block, hence the need for
healthcare workers to have adequate appreciation of the anatomy of the nerve. The
objective of this study was to determine the level of bifurcation of the sciatic nerve
above the transverse popliteal crease among Ugandans at Mulago Hospital Complex.
Methods: This was a cross-sectional descriptive study conducted at the department of
anatomy dissection laboratory faculty of Medicine, Makerere University and Mulago
Hospital mortuary. Eighty cadavers were dissected in the gluteal region and posterior
thigh to establish the level of bifurcation of the nerve above the transverse popliteal
crease, and this distance was measured.
Results: A total of 80 left lower limbs were dissected including 56 males and 24 females.
Specimen height ranged between 145 and 182 cm with a mean of 162.8cm.The nerve
bifurcated in the gluteal region and posterior thigh in 77.5% cases and in the pelvis in
22.5% cases. For the 77.5% nerves that bifurcated beyond the pelvis, the level of
bifurcation ranged between 3.8 and 32.5 cm, most of the bifurcations occurred between
3.8-12cm above transverse popliteal crease. In four of the nerves that entered the gluteal
region after bifurcation, the nerve reunited before final bifurcation occurred in the
thigh.
Conclusions: The sciatic nerve bifurcation is very variable and adequate appreciation of
these variations is essential. It should be noted that more than 22% of all the nerves
leave the pelvis as two separate nerve which means the sciatic nerve trunk can not be
traced or used for anesthetic block in the gluteal region or thigh. Only 77.5% of
individuals have a sciatic nerve in the gluteal region and thigh, and even within this
group of people, the vertical distance of bifurcation ranges between 3.8-32.5cm.
Introduction
The sciatic nerve is the largest nerve in the body and is a continuation of the main part of a
nerve plexus which is formed by the L4, 5 and S1, 2 and 3 nerve roots known as the
Lumbosacral plexus. It consists of two nerves, the tibial, derived from anterior divisions of,
L4, 5, S1, 2, 3, and the common peroneal nerve derived from the posterior divisions of L4, 5,
S1, 2. The nerve normally leaves the pelvis by passing through the greater sciatic foramen
below the piriformis and anterior to the inferior and superior gemelli and the obturator
internus muscles. It is the nerve which supplies the posterior compartment of the thigh, and
the region of the lower limb below the knee joint except the skin on the anteromedial aspect
of the leg. The nerve usually separates into two and sometimes three components at
approximately half way or lowers down the thigh1-3.
Clinically, it is commonly injured during intramuscular injections, and, its level of bifurcation
above the popliteal fossa crease is considered by clinicians during sciatic nerve block for
surgery of the calf, Achilles tendon, the ankle and foot, thus locating its major trunk before it
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East and Central African Journal of Surgery Volume 15 Number
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bifurcates, and, applying the anesthesia at that level, which is usually 5 or 7cm according to
the classical teaching4-6. The level of bifurcation of the nerve among Ugandans had never
been studied; hence there was a \need
need for reference values in that population. The main
objective of this study was too determine the level of bifurcation of the sciatic nerve among
Ugandans at Mulago Hospital Complex.
Methods
This was a cross-sectional
sectional descriptive study conducted at the department of anatomy
dissection laboratory faculty of Medicine, Makerere University and Mulago hospital
mortuary. The study population included 80 specimens from adults which were dissected
from the gluteal region to the transverse popliteal crease. The level of bifurcation of the nerve
above the transverse popliteal crease was determined.
determined. Ethical review and approval was
sought from the faculty research and ethics committee. Informed consent was obtained from
the next of keens of the deceased in case of the postmortem specimens.
Results
A total of 80 adult left lower limbs were dissected among which 56 (70%) were males and 24
(30%) were females. The height range of the specimens was 145 cm to 182 cm with a mean
height of 162.8+1.9cm.
1.9cm. The nerve bifurcated in the gluteal region and posterior thigh in 62
cases (77.5%) and in the pelvis
vis in 18 cases (22.5%). Among the cases which bifurcated in the
pelvis, males contributed 13 cases (72.2%) and females 5 cases (27.8%).
Among the 62 cases where the nerve bifurcated in the gluteal region and posterior thigh, the
level of bifurcation above
ve the transverse popliteal crease ranged from 3.8 to 32.5 cm with a
mean vertical distance of bifurcation of 8.5cm (8.5+1.4cm)
(8.5 1.4cm) and a standard deviation of 5.8
cm. However, 57 cases (91.9%)
%) bifurcated between 3.8-12cm. The height of the specimen
was not related
lated with the level of bifurcation of the sciatic nerve from which Pearson chi
chisquare values of 0.810 with a P-value
P value of 0.937 were obtained. Among the 18 cases whose
nerves bifurcated in the pelvis, four fused again in the gluteal region and posterior thi
thigh
before final bifurcation.
Figure 1. Sciatic nerve components (short arrows) exit the pelvis below piriformis (long
arrow) in a bifurcated state
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East and Central African Journal of Surgery Volume 15 Number 2.
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Only 62 cadavers had the nerve bifurcated in the gluteal region and posterior thigh. The
remaining 18 cases had their nerves enter the gluteal region when already bifurcated .The
average height of the samples was 162.8 cm, most of the bifurcations 57(91.9%) occurred
within 12cm above the popliteal fossa crease, and, as indicated, there was no relationship
between height and level of bifurcation of the nerve in the gluteal region as indicated by the
Pearson Product Moment Correlation Coefficient. It should also be noted that all the
specimens used were for adults.
Table 1. Height of Cadavers
Height (cm)
Number of cases
145.0
146.0
148.0
149.0
150.0
151.0
152.0
153.0
154.0
155.0
157.0
158.0
158.5
159.0
160.0
161.0
162.0
163.0
164.0
165.0
166.0
167.0
168.0
169.0
170.0
171.0
172.0
174.0
175.0
176.0
177.0
179.0
182.0
1
1
2
1
3
1
1
1
2
2
3
2
1
8
5
7
5
1
1
3
4
1
2
1
4
2
3
3
3
2
2
1
1
Percentage
(%)
1.3
1.3
2.5
1.5
3.8
1.3
1.3
1.3
2.5
2.5
3.8
2.5
1.3
10
6.3
8.8
6.3
1.3
1.3
3.8
5.0
1.3
2.5
1.3
5.0
2.5
3.8
3.8
3.8
2.5
2.5
1.3
1.3
East and Central African Journal of Surgery
Cumulative percentage (%)
1.3
2.5
5.0
6.3
10.0
11.3
12.5
13.8
16.3
18.8
22.5
25.0
26.3
36.3
42.6
51.3
57.5
58.8
60.0
63.8
68.8
70.0
72.5
73.8
78.8
81.3
85.0
88.8
92.5
95.0
97.5
98.8
100.0
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East and Central African Journal of Surgery Volume 15 Number 2.
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Total
80
100.0
Table 2. Height of cadavers and its relationship with the level of bifurcation of the sciatic nerve above
the popliteal crease in cases where the nerve bifurcated in the gluteal region and posterior thigh.
Cadaver
Height (cm)
145-160
161-176
177-192
Total
•
•
Bifurcation Ranges (cm)
Total Number of
Cases
0-12
13-23
24-34
27
26
4
57(91.9%)
2
0
0
2(3.2%)
1
2
0
3 (4.8%)
30
28
4
62(100%)
Pearson Chi-square value = 0.810
P- 0.937
Table 3. Vertical level of bifurcation of the intact sciatic nerve above the transverse popliteal crease
in gluteal region and posterior thigh.
Level of bifurcation in cm
3.8
4.0
4.5
5.0
5.5
6.0
6.5
7.0
7.5
8.0
8.5
9.0
11.5
14.0
20.0
23.0
27.0
32.0
32.5
Total
Number of cases
1
2
1
8
2
8
7
11
4
3
3
5
1
1
1
1
1
1
1
62
Percentage (%)
1.6
3.2
1.6
12.9
3.2
12.9
11.3
17.7
6.5
4.8
4.8
8.1
1.6
1.6
1.6
1.6
1.6
1.6
1.6
100
Cumulative percentage
(%)
1.6
4.8
6.4
19.3
22.5
35.4
46.7
64.4
70.9
75.7
80.5
88.6
90.2
91.8
93.4
95.0
96.6
98.2
100
100
The mean height of the samples was 162.8 cm (162.8 + 1.9 cm) with a standard deviation of
8.5.
The mean vertical perpendicular distance of bifurcation of the intact sciatic nerve above the popliteal
fossa crease was 8.5cm. More than 90% of bifurcations occurred below 12 cm. However, there were
some extra ordinary cases where the nerve bifurcated at; 11.5, 14, 20, 23, 27, 32, and 32.5cm
respectively.
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Figure 2.
A bifurcation of the sciatic nerve (indicated by arrow) 32.5 cm above the popliteal fossa crease
Figure 3. Common peroneal and Tibial nerves entering the gluteal region when bifurcated
ifurcated and then
fusing again as indicated by the arrow.
Discussion
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The level of bifurcation of the sciatic nerve in the popliteal fossa is a characteristic which is
considered by clinicians in sciatic nerve regional block for surgery of the calf, Achilles tendon, the
ankle and foot. The logic behind this is to avoid frequent failures in popliteal block by locating the
major trunk of the sciatic nerve before it bifurcates and applying the anesthesia at that level. Previous
studies have indicated a failure rate of popliteal blocks as high as 21% with many requiring
supplementation7.
In this study, after excluding the 18 cases where the nerves entered the gluteal region bifurcated, the
remaining 62 cases had the average distance of bifurcation as 8.5 cm with a range of 3.8- 32.5cm.
Most of the bifurcation 57 cases (91.9%) occurred within a distance of 12cm above the transverse
popliteal crease. This is different from the classical teaching in which the level of bifurcation is taken
to be at an average of 5 or 7 cm above the transverse popliteal crease which has led to the placement
of the needle at 7cm5. Similar studies have indicated a mean level of bifurcation of 6.05 + 2.7cm with
a range of 0-11.5cm indicating that some nerves can bifurcate at a higher level than 7cm, and therefore
have implicated that when performing popliteal block, insertion of the needle at 10cm above the
transverse popliteal crease is more likely to result in placement of the needle proximal to the division
of the nerve than placement at 5 0r 7cm according to the classical teaching3. In this study, it should be
noted that 18 cases bifurcated before leaving the pelvis which is much higher, while among the
remaining 62 cases, 57 or 91.9 % bifurcated between 3.8-12cm above the transverse crease. This
should be put in consideration while locating the nerve for application of a regional block in the
posterior thigh, and the needle should be placed at the 12cm mark above the transverse popliteal
crease or higher.
Given the fact that the findings of this study indicate that on average the sciatic nerve among
Ugandans bifurcates much higher above the popliteal crease as compared to other studies done
elsewhere and because some of the nerves actually bifurcate even above the gluteal region, attempts
to block the two components of the nerve at different points and employment of modern technology
like ultrasound guided nerve block which have been proven to be more effective should not be
overlooked8-11.
Conclusion and Recommendations
The sciatic nerve bifurcates in the posterior thigh and gluteal region in 77.5% and in the pelvis in
22.5% of cases, and the level of bifurcation is independent of the height of the individual.
Most of the main trunks of the sciatic nerve which exit the pelvis when intact (91.9%), bifurcate
between 3.8 and 12 cm above the transverse popliteal crease in the gluteal region and posterior thigh
hence, when performing popliteal block in the posterior approach, the level of insertion of the needle
should be atleast at the 12cm mark above the transverse popliteal fossa crease if we are to increase our
chances of locating the main trunk of the sciatic nerve.
However, for the 22.5% nerves that leave the pelvis after separation, a sciatic nerve block is
impossible, rather individual tibial and perineal blocks.
Hence the need for ultrasound guided nerve block in this area cannot be over emphasized because
only about 50% of individuals studied had a sciatic nerve trunk within 5-7cm range of the transverse
crease which is the recommended distance for infiltration of the local anesthetic according to classical
teaching.
Acknowledgement
We appreciate the financial assistance by Sida/SAREC which enabled this study to be conducted. Our
thanks go to the staff in Departments of Anatomy and Pathology Makerere University.
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References
1. Moore KL, Dalley FA.Clinically oriented anatomy, Fifth edition. Baltimore, Lippincott
Williams and Wilkins. c2006. p. 379
2. Anatomy
of
the
sciatic
nerve.
Medical
illustration.
Available
at;
http://catalog.nucleusinc.com/generateexhibit.php?ID=1354
3. Nayak S. Case report; An unusual case of trifurcation of the sciatic nerve. 15th February,
2006. Available at; (http://www.neuroanatomy.org
4. Jery DV, Admir H, Ernest A. The division of the sciatic nerve in the popliteal fossa.
Anatomical implications for popliteal nerve block. Journal of Anesthesia Analgesia, 2001,
vol.92.pp. 215-217.
5. Admir H, Jerry DV. Popliteal block: Lateral approach, COPYRIGHT 1996, 2006.
NYSORA.COM. Available at; (http://www.nysora.com/whatsnew/
6. Admir H, Jerry DV. Popliteal Block: Intertendinosus Approach. 1996, 2006 NYSORA.COM.
http://www.nysora.com/techniques/popliteal_nerve_block_intertendinosus/
7. Avinash. S, Vincent. W.S.C, Ultrasound imaging for popliteal sciatic nerve block. Regional
Anesthesia and pain medicine, vol. 29, no. 2 (March –April), 2004: pp130-134.
8. Jaijesh P, Satheesha N. A case report of bilateral high division of sciatic nerve with a variant
inferior gluteal nerve. Journal of neuroanatomy. August (2006) 5: 33-34, Available at; (
http://www.neuroanatomy.org)
9. Nuket M, et al. A case of bilateral high division of the sciatic nerves, together with a
unilateral unusual course of the tibial nerve. Journal of neuroanatomy, 2003, volume 2, page
13-15. (http://www.neuroanatomy.org/2003/013_015.pdf
10. Simon. M, Nerve blocks for anesthesia and analgesia of the lower limb- A practical guide:
Femoral, Lumbar plexus, Sciatic nerve. Issue 11 (2000), article 12. Available at;
http:www.nda.ox.ac.uk/wfsa/htm/u11/u1112_04.htm
11. Vicente. D.T, Salvador. S, Francisco. M, et al, ultrasound guidance for lateral mid femoral
sciatic nerve block; A prospective, comparative, randomized study. Anesth. Analg. 2007;
104:1270-1274.
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Thyroid Dysfunction among Young Adults in Uganda
M. Galukande, J. Jombwe, J. Fualal, A. Gakwaya
Department of Surgery, Mulago Hospital, Kampala
Correspondence to: Dr. Moses Galukande, Email: [email protected]
Background: Most studies on thyroid dysfunction have been on patients refereed for treatment, little
is known about the prevalence in the general populations. The importance of knowing such
prevalence data lies in that fact that subclinical thyroid dysfunction is an important risk on
development of heart disease, osteoporosis, hypercholesterolemia and mental illness. This study set
out to determine thyroid dysfunction prevalence in a health young adult population.
Methods: A cross sectional study carried out at the College of Health Sciences, Makerere University
enrolled 100 Undergraduate medical students by invitations through notices and announcements.
Informed consent was sought after approval from research ethics committee.
Results: Of the 100 students enrolled and the samples drawn; 83 tests for TSH and 82 tests for FT4
were successfully run. Three results were abnormal making a prevalence of 3.6% for thyroid
dysfunction; a high TSH (5.71) with a normal fT4 (19.2), a normal TSH (1.67) with a high fT4
(22.31) and one with a low TSH (0.03). The mean age of participants was 23 years, there were
slightly more males 1.3:1.
Conclusion: The prevalence of thyroid dysfunction in this cohort was low but falls in the range found
elsewhere. These findings could inform the criteria of screening asymptomatic otherwise young health
adults.
Introduction
Most studies on thyroid dysfunction have been on patients refereed for treatment, little is known about
the prevalence in the general population1, 2. However some studies state the thyroid dysfunction is
common in adults 3, 4. The prevalence in the Ugandan population is not known. It is now known that
sub clinical thyroid dysfunction has an important impact on the risk of developing heart disease,
osteoporosis, hypercholesterolaemia and mental illness2.
Hypothyroidism and hyperthyroidism can be accurately diagnosed with laboratory tests5, they
frequently have significant clinical consequences yet readily treatable. The serum TSH assay is an
accurate, widely available safe and relatively inexpensive diagnostic test for all common forms of
hypothyroidism and hyperthyroidism6. Serum TSH measurement is the single most reliable test to
diagnose all common forms of hypothyroidism and hyperthyroidism particularly in the ambulatory
setting. An elevated serum TSH concentration is present in both overt and mild hypothyroidism. In
the later serum free T4 concentration is by definition normal.
Virtually all types of hyperthyroidism encountered in clinical practice are accompanied by suppressed
serum TSH concentrations, typically less than 0.1mIU/L. To diagnose hyperthyroidism accurately,
TSH assay sensitivity, the lowest reliably measured TSH concentration, must be 0.2mIU/L or less7.
The purpose of this study was to determine the prevalence of thyroid dysfunction evaluated by
biochemical variables with sensitive assays in an area of presumed minimal iodine deficiency.
Subjects and Methods
A cross sectional study was carried out at the College of Health Sciences, Makerere University
enrolled 100 Undergraduate medical students by invitations through notices and announcements.
Informed consent was sought after approval from research ethics committee. Data was collected by
using a pre tested questionnaire. Blood samples were drawn for the various thyroid variables: TSH
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and free T4. TSH were measured by chemiluminescence Immuno assay with mouse monoclonal
antibody (Roche Elecys 2010). The cut off values were as shown in Table 1. These criteria were
chosen from the reference interval given by the laboratory for daily use.
Data analysis was done using SPSS 11.5 software for windows.
Table 1.The cut off values of Thyroid Functions
Hyperthyroidism
Sub clinical hyperthyroidism
Euthyroidism
Sub clinical hypothyroidism
Hypothyroidism
Corresponds to the 2.5th and
97.5th percentile of results
TSH µIU/ml
< 0.27
< 0.27
0.15-5
> 4.2
> 4.2
0.27 – 4.2µIU/ml
Free T4 pmol/l
< 22
< 22
< 10
> 10
12-22pMol/L
Results
Of the 100 students enrolled and the samples drawn, 83 tests for TSH and 82 tests for FT4 were
successfully run. Three results were abnormal; a high TSH (5.71) with a normal fT4 (19.2), a normal
TSH (1.67) with a high fT4 (22.31) and one with a clearly low TSH (0.03).
Table 2. Summary of the Results
Variable
Result
Age (n) 89
Mean 23.1
Medium 22
Range 19-36
Sex (n) 89
Male 50
Female 39
Ratio M:F (1.3:1)
BMI (n) 89
Mean 23
Median 22
Range 18-33.3
TSH (n) 83
Mean 1.6
Median 1.46
Range 0.3-5.71
FT4 (n) 82
Mean 16.0
Median 15.6
Range 12-22.3
Discussion
This study reveals a thyroid dysfunction prevalence of 3.6%. The prevalence of thyroid dysfunction in
an adult population in literature ranges 0.1 – 17% 3. The interpretation of the three abnormal results
follows; the participant who had a high fT4 and a normal TSH with no overt symptoms falls under
two possibilities of dysfunction either euthyroid hyperthyroxinemia or thyroid hormone resistance that
would potentially lead to overt thyrotoxicosis later. The second participant with a normal TSH and a
normal fT4 has subclinical hypothyroidism
The third with a clearly low TSH and a normal fT4 falls under the category of early grave’s disease,
iodine deficiency or a solitary nodule.
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This study population is presumed to be taking iodized salt, its young and considered healthy. Those
on drugs that might have interfered with tests where excluded drugs, including multivitamin
supplements for any reason. So the results represent a presumed healthy young adult population.
Iodized salt intake achieves a 150-250µg/d intake, which is adequate. Foods of marine origin have
high iodine content. Major other sources are milk, bread and eggs 9. Iodine (as iodine) is widely but
unevenly distributed in the earth’s environment. In many regions, leaching from flooding, erosions
and glaciations have depleted surface soils of iodine and most iodine is found in the oceans (approx
50mg/liter). Iodine ions in sea water evaporate into the atmosphere and return to the soil by rain to
complete the cycle. However iodine cycling in many regions is slow and incomplete, leaving soils and
drinking water iodine depleted. Crops grown in these soils will be low in iodine and humans and
animals consuming food grown in these soils become iodine deficient. The study setting area is
considered to iodine sufficient, though there could be pockets of deficiency in highland mountainous
areas.
The thyroid adapts to low intakes of dietary iodine by marked modification of its activity, triggered by
increased secretion of TSH by the pituitary. In most individuals, if iodine intake falls below
approximately 100µg/day, TSH secretion is augmented which increases plasma in organic iodine
clearance by the thyroid 10. As long as daily iodine intake remains above a threshold of approximately
50µg/day, despite a decrease in circulating plasma in organic iodine, absolute uptake of iodine by the
thyroid remains adequate and the iodine content of the thyroid remains within normal limits (1010mg). Below this threshold, despite high fractional clearance of plasma inorganic iodine by the
thyroid absolute intake falls, the iodine content of the thyroid is depleted and many individuals
develop goiter 11
The participants in this study that had dysfunction had no over symptomatology, it is well
documented that the effects of iodine deficiency and hypofunction are extremely variable among
populations and individuals even in endemic areas. Dietary substances that interfere with thyroid
metabolism can aggravate the effect of iodine deficiency; these goitrogens include cabbage, cassava,
sorghum and sweet potatoes which foods are commonly eaten in this region. Linamarin is a
thyroglycoside in cassava, if cassava is not adequately soaked or cooked, to remove it; it hydrolyses in
the gut to release cyanide which is metabolized to thiocyanate 12. Thiocyanates compete with iodine
for thyroid uptake.
Cigarette smoking is associated with higher serum levels of thiocyanate. No participant admitted to
smoking in this study. Deficiencies of selenium, iron and vitamin A, influence iodine deficiency and
therefore thyroid function 13. Coverage of iodized salt use in Uganda is more than 90% 14, 15
Conclusion
The prevalence of thyroid dysfunction in this cohort was low but falls in the range found elsewhere.
These findings could inform the criteria of screening asymptomatic young otherwise health adults.
References
1. Nils K, Torben J, Rasmussen S, Christiansen E and Perrild H. The prevalence of thyroid
dysfunction in a population with borderline iodine deficiency. Clinical endocrinology. 1999;
51: 361-367
2. Wiersinga WM. Sub-clinical hypothyroidism and hyperthyroidism. Prevalence and Clinical
relevance Netherlands journal of Medicine. 1995; 46: 197-204
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3. Vanderpump MP, Tunbridge WM, French JM et al. The incidence of thyroid disorders in the
community: a twenty-year follow up of the Whickham survey. Clin Endocrinol (oxf). 1995;
43: 55-68
4. Bagchi N, Brown TR, Parish RF. Thyroid dysfunction in adults over age 55 years: a study in
an urban US community. Arch Intern Med. 1990; 150: 785-787
5. Singer PA, Cooper DS, Levy EG et al. Treatment guidelines for patients with hypothyroidism
and hyperthyroidism. JAMA. 1995; 273: 808-812
6. Spencer CA, Takenchi M, Kazarosyan M. Current status and performance goals for serum
thyrotropin (TSH) assays. Clin Chem. 1996; 42:140-145
7. Paul W Landerson, Singer PA, Kenneth B, Nandalal B, Bigos ST, Elliot GL, Steven AS and
Gilbert H Daniels. American Thyroid Association Guidelines for detection of Thyroid
Dysfunction. Arch Intern Med. Vol 160, June 12; 2000:1573-75
8. Supit EJ, et al. Interpretation of Laboratory Thyroid Function Tests. South Med .2002
95(5):481-485.
9. Haldimann M, Alt A, Blanc A, Blondeau K. Iodine content of food groups. J Food Comp Anal
2005; 18:461-471
10. Taki K, Kogai T, Kanamoto Y, Hershman JM, Brent GA. A thyroid-specific far-upstream
enhancer in the human sodium/iodine symporter gene requires Pax-8 binding and cyclic
adenosine 3’,5’-monophosphate response element-like sequence biniding proteins for full
activity and is differentially regulated in normal and thyroid cancer cells. Mol Endocrinol
2002; 16: 2266-2282
11. Delange F. Iodine deficiency. In: Braverman LE, Utiger RD, eds. Werner and Ingbar’s the
thyroid: a fundamental and clinical text. 8th ed. Philadelphia: JD Lippincott 2000; 295-316
12. Ermans AM, Delange F, Van der Velden M, Kinthaert J. Possible role of cyanide and
thiocyanate in the etiology of endemic cretinism. Adv Exp Med Biol. 1972; 30: 455-486.
13. Zimmermann MB, Kohrle J. The impact of iron and selenium deficiencies on Iodine and
thyroid metabolism: biochemistry and relevance to public. Thyroid. 2002; 12: 867-878
14. Zimmermann MB. Iodine deficiency .Endocrine reviews. Doi:10.1210/er.2009.0011
15. Baingana RK. The need for food composition data in Uganda. Journal of Food Composition
and Analysis. 2004; 17(3-4): 501-507
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Effect of Spinal Anaesthesia on Hearing Threshold
A.O. Lasisi1, H.O. Lawal2, A.A. Sanusi3,
1
Department of Otorhinolaryngolgy, University of Ibadan.
Department of Otorhinolaryngology, University College Hospital, Ibadan.
3
Department of Anaesthesia, University Of Ibadan
Correspondence to: Dr. OA Lasisi, Email: [email protected]
2
Background: Hearing loss following spinal anaesthesia is a known yet uncommonly reported
complication. This study was aimed at determining the incidence and type of hearing loss (HL)
following spinal anaesthesia (SA) and the relationship with the size of spinal needle.
Methods: A prospective study of patients scheduled for spinal anaesthesia for surgery at the
Operating room and Otorhinolaryngology department in a tertiary centre was undertaken. The
audiometry was done and the pre- and post – anaesthesia results were compared.
Results: Ninety – four ears of 47 patients, 16 males and 31 females, age range between 21 and 63
years (mean + SD= 41+5) were included. The duration of anaesthesia was between 90 and 150
minutes (mean + SD= 116+9). HL was seen in 9 ears of 7 patients (15%) and tinnitus in 14 ears.
The preoperative and postoperative BC PTA were 10 – 45dB (mean + SD= 26+ 5) and 25 – 65dB
(mean + SD=38+5) respectively, (P= 0.02) while the preoperative and postoperative AC PTA in
the early frequency range (0-100Hz) were between 5 – 45dB (mean + SD= 20+ 5) and 25 – 50dB
(mean + SD=25+7) respectively, (P= 0.08). There was significant difference in the mean BC
PTA between those who had procedure less than 1 hour, 37.2dB and those greater than 1 hour
38.4dB, (P=0.004). According to the Quincke needle sizes, the mean BC PTA among those who
had 26G and 27G were 37.4dB and 38.1dB respectively (P=0.2).
Conclusion: HL complicating SA is significant and associated with duration of procedure thus
should be included in informed consent for medico-legal and ethical reasons and measures must
be taken to avoid the leak of cerebrospinal fluid.
Introduction
Spinal anaesthesia is one of the most frequent regional anaesthesia techniques in surgical
interventions, being used in all procedures below the umbilicus1-4. The advantages over general
anaesthesia includes, cost reduction and elimination of the need for endotracheal intubation thus
reducing the risk of aspiration of gastric content, and respiratory infection.4-7 However, technique is
not suitable for procedures longer than two hours and difficult access/failed cerebrospinal fluid (CSF)
tap may occur.7 - 9
Hearing loss following spinal anaesthesia is a known yet uncommonly reported complication with
incidence between 0.4% and 40%, affecting the low frequency range. 4, 5 Other complications that
have been reported included postural headache, nausea, vomiting, vertigo and urinary retention with
incidence ranging between 0.4% and 17%. 10, 11 The disruption of the endolymph /perilymph balance
caused by the decrease CSF pressure has been proposed as the mechanism of hearing loss after spinal
anaesthesia. Our hypothesis was that the resultant CSF leak in spinal anaesthesia procedure would be
significant enough to lead to changes in the volume of the endolymph and clinical depression of the
hearing acuity. The aim of this study was to determine the incidence of hearing loss after spinal
anaesthesia, identify the frequencies of hearing involved and find the relationship between the size of
spinal needle and hearing loss.
Patients and Methods
This was a prospective study evaluating hearing loss among adult patients undergoing spinal
anaesthetic technique for surgery at the operating theatres of the University College Hospital, Ibadan.
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The inclusion criteria were all adult patients scheduled for elective surgical procedure using spinal
anaesthetic technique. While patients requiring emergency surgery and those with previous history of
hearing impairment/ear disease were excluded.
The sample size was determined using Fischer’s formula and recruitment into the study was
commenced.
All the participants who gave consent to the study were recruited. A structured questionnaire was
administered on interviewer basis to record the participant’s biographic data, relevant clinical
information on hearing impairment/ear disease and otological examination was done to rule out any
underlying pathology. Following this, pure tone audiometry was done using Amplivox Model 2150 in
a quiet side - room on the ward. Frequency range between 125 to 8000Hz was tested on both ears.
This was followed by induction of spinal anaesthesia. This was performed by the anaesthetist via a
subarachnoid injection at the L3-4 interspace by using a 26G or 27G - gauge Quincke needle with the
patient in the sitting position, and 3 ml of 0.5% isobaric bupivacaine. Patient selection into the 26G or
27G spinal needle group was done randomly. The audiometry was repeated between the 2nd post operative day. All auditory evaluation was conducted in a quiet side - room on the ward.s The main
outcome variable was the pure tone average before and after spinal anaesthesia while the dependent
variables were the sizes of the spinal needle and the duration of the anaesthesia. The data was initially
explored using the Stata software. The variables were analyzed by unpaired t-test both for equal and
unequal variance using the variance ratio function of the Stata software to determine the appropriate
use of the Satterthwaite’s correction for the degrees of freedom. A logistic regression analysis was
used to control for confounding factors. The Stata software® was used and the level of statistical
significance was set at p< 0.05 for all the analyses.
Results
The study included 94 ears in 47 patients, 16 males and 31 females age range between 21 and 63
years (mean + SD= 41+5). The duration of anaesthesia was between 90 and 150 minutes (mean + SD
= 116+9) and indications were urethroplasty, transurethral endoscopic prostatectomy, lower limb
amputation, transvaginal hysterectomy and elective caesarean section.
Hearing loss was seen in 9 ears of 7 patients (15%) and tinnitus in 14 ears. The preoperative and
postoperative BC PTA were 10 – 45dB (mean + SD= 26+ 5) and 25 – 65dB (mean + SD=38+5)
respectively, (P= 0.02) while the preoperative and postoperative AC PTA in the early frequency range
(0-100Hz) were between 5 – 45dB (mean + SD= 20+ 5) and 25 – 50dB (mean + SD=25+7)
respectively, (P= 0.08). Comparing the duration of procedure, the mean BC PTA among those who
had procedure less than 1 hour and greater than 1 hour were 37.2dB and 38.4dB(P=0.004).
Comparing the sizes of the spinal needle, the mean BC PTA among those who had 26G and 27G were
37.4dB and 38.1dB respectively (P=0.2).
The preoperative and postoperative AC PTA in the middle (speech) frequencies (1000-3000Hz)
(20dBvs 25dB, P=0.2), and BC PTA was (28dB vs 34dB, P= 0.9). Similarly, no statistically
significant difference was seen in high frequencies, the preoperative and postoperative AC PTA were
(40dB vs 42dB, P=0.3) and BC PTA were (42dB vs 45dB, P=0.2).
Discussion
This study found the incidence of bone conduction hearing loss complicating spinal anesthesia to be
15%. This is comparable with the report of 7.5% by Yildiz et al.12 In addition our finding revealed
significant difference between the pre-anaesthesia and post-anaesthesia involving bone conduction in
the early frequencies. This early frequency involvement is similar to the report of previous workers7-11
Hussain et al8 prospectively studied 35 women who were undergoing spinal anesthesia during
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cesarean section. A comparison of pre- and postoperative pure-tone audiometry showed that 5 of these
women developed a low-frequency hearing loss on the first postoperative day. Similarly, Kilickan et
al13 reported permanent, fluctuating sensorineural hearing loss (SNHL), disabling vertigo, and tinnitus
following spinal anesthesia for cesarean section in a 25-year-old female. The recruitment score (SISI)
was 95% at 2000 Hz on the right side and directional preponderance towards the right and the right
canal paresis were evidenced by bithermal caloric testing. They inferred from their findings a cochlear
pathology causing endolymphatic hydrops possibly induced by lumbar puncture for spinal anesthesia.
In an animal experiment, Walsted et al14 drained CSF from 18 guinea pigs and compared their preand post-drainage electrocochleography results with those of 18 untreated control animals. They noted
a slightly higher compound action potential threshold and latency in the CSF-drained group.
Schaffartzik et al11 suggested cerebrospinal fluid leakage via the spinal puncture hole as the factor
involved; however low-frequency hearing loss was also found after general anesthesia which
correlated with intraoperative volume replacement implying that cerebrospinal fluid leakage via the
spinal puncture hole is not the only factor involved.
The proposed pathogenesis of hearing loss was that the cochlear aqueduct, which connects the
perilymphatic space to the CSF-filled subarachnoid space, influences the relationship between low
CSF pressure and hearing impairment. Patency is poor in the adult cochlear aqueduct, and it decreases
throughout life15. In correlating changes in CSF pressure with perilymph pressure, Carlborg et al16
performed experiments in cats with open and artificially disrupted cochlear aqueducts. They noted
that CSF pressure and perilymphatic pressure equalized almost immediately when the aqueduct was
open. When the aqueduct was closed, the shift toward equalization occurred more slowly and was
usually incomplete. They hypothesized that equalization occurred as CSF flowed through small
tributaries and possibly the fundus of the internal auditory canal when the cochlear aqueduct was
disrupted16. They suggested that an obstructed aqueduct does not prevent equalization from occurring.
If the aqueduct is patent, loss of perilymph via decreased CSF pressure may lead to an endolymphatic
hydrops16. This condition resolves with either the release of endolymph through the endolymphatic
sac, or the re-accumulation of perilymph through the aqueduct, or perhaps another mechanism.
Endolymphatic hydrops is a pathologic correlate of Meniere's disease. Its early course shares a
common characteristic with hearing loss after a clinically significant CSF leak caused by dural
puncture. Both disorders are associated with a predominantly low-frequency hearing loss, as was seen
in patients in this study.
The mechanism of hearing loss after spinal anaesthesia has also been attributed to the disruption of
the endolymph /perilymph balance caused by the decrease CSF pressure17. The perilymph is the
substrate of the inner hair cells and is present in the cochlea, it’s a filtrate of the blood and CSF, and
communicate with the subarachnoid space through the cochlear aqueduct17, 18. The CSF dynamics are
important for auditory function of the inner ear. The puncture of the dura membrane results in CSF
leak and a drop in CSF volume and pressure. The reduced subarachnoid pressure is transmitted into
the inner ear via the cochlear aqueduct resulting in a transient reduction of perilymphatic pressure
causing endolymphatic hydrops. This endolymphatic hydrops is associated with hearing loss8.
In addition it is known that there is passive diffusion as well as active transport of ions between the
endolymph and the perilymph. The significant association found between the depressions of the BC
PTA with duration of anaesthesia in this study further suggests that the hearing loss may be evidence
of prolonged CSF leakage. In this study, the involvement of low frequencies may account for the
paucity of self report of hearing loss after operation. The speech frequencies are mainly between
1000Hz and 4000Hz, a range in which there was no significant depression of hearing threshold.
However, there is need for ethical consideration of enlightening the patients. Although such hearing
loss has been found to be transient with duration from 1-5 weeks5-11. Further follow up may be needed
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on this; in addition, we did not consider the number of punctures into dural space before spinal
anaesthesia was established. This could also affect the volume of CSF leakage and possibly changes
in the hearing threshold.
It may also be important for medico legal reasons to obtain informed consent for spinal anaesthesia
considering the high incidence of the hearing loss.
This study did not found significant difference in the post - anaesthesia hearing threshold between
sizes 26G and 27G Quincke needle. This finding suggested that CSF leakage following the use of the
two sizes of needles were comparable. In contrast, other workers have reported that hearing loss was
related to the needle size.19, 20 Öncela et al19 reported significant difference in the hearing loss between
size 25G and size 22G needle in the post-operative period. The hearing loss observed in the 25 Gspinal anaesthesia group was significantly (P<0.01) less than that seen in the 22 G group, although
none of the patients had headache after spinal anaesthesia. It was concluded that pure tone audiometry
is a more sensitive indicator of cerebrospinal fluid leakage than post-operative headache.
We conclude that bone conduction hearing loss is prevalent complication of spinal anaesthesia and
duration of anaesthesia was a significant factor. The implications of this study are as follows: Spinal
anesthesia must be performed carefully with measures taken to avoid leakage of CSF. Patients should
be informed about the possibility of hearing loss after spinal anesthesia for medicolegal and ethical
reasons.
References
1.
2.
3.
4.
5.
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9.
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Walsted A. Effects of cerebrospinal fluid loss on hearing. Acta Otolaryngol. 2000;543:9598.
Lee C. Hearing loss after spinal anaesthesia. Anesth Analg. 1990; 71:561-569.
Michel O, Brusis T. Hearing loss as a sequel of lumbar puncture. Ann Otol Rhinol
Laryngol. 1992; 101:390-394.
Day CJE, Shutt LE. Auditory, ocular and facial complications of central neural block: a
review of possible mechanisms. Reg Anesth. 1996; 21:197–201.
Wang LP, Fog J, Bove M. Transient hearing loss following spinal anesthesia.
Anaesthesia. 1987; 42:1258 - 1263.
Finegold H, Mandell G, Vallejo M, Ramanathan S. Does Spinal Anesthesia Cause
Hearing Loss in the Obstetric Population? Anesth Analg. 2002; 95:198-203.
Erkan K, Sitki G, Cengiz D, Yasemin I, Muzaffer K. Evaluation of Hearing Loss after
Spinal Anaesthesia with Otoacoustic Emissions. Eur Arch Oto-Rhino-Laryngol. 2006;
263:705-710.
Hussain SS, Heard CM, Bembridge JL. Hearing loss following spinal anaesthesia with
bupivacaine. Clin Otolaryngol Allied Sci. 1996; 21:449-54.
Hafer J, Rupp D, Wollbrück M, Engel J, Hempelmann G. The effect of needle type and
immobilization on postspinal headache. Anaesthesist. 1997; 46:860-866.
Hyderally H. Complications of spinal anesthesia. Mount Sinai J Med. 2002; 69:55-56.
Schaffartzik W, Hirsch J, Frickmann F, Kuhly P, Ernst A. Hearing loss after spinal and
general anesthesia: A comparative study. Anesth Analg. 2000; 91:1466-1472.
Yildiz TS, Solak M, Iseri M, Karaca B, Toker K. Hearing loss after spinal anesthesia: the
effect of different infusion solutions. Otolaryngol Head Neck Surg. 2007; 137:79-82.
Walsted A, Salomon G, Olsen KS. Low-frequency hearing loss after spinal anesthesia.
Perilymphatic hypotonia? Scand Audiol. 1991; 20:211-215.
Wlodyka J. Studies on cochlear aqueduct patency. Ann Otol Rhinol Laryngol. 1978;
87:22-28.
Carlborg BI, Konrádsson KS, Carlborg AH, Farmer JC Jr, Densert O. Pressure transfer
between the perilymph and the cerebrospinal fluid compartments in cats. Am J Otol.
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16.
17.
18.
19.
20.
1992; 13:41-48.
Becker WB, Naumann HH, Pfaltz CR. Ear nose and throat disease: a pocket reference.
New York: Thieme Medical Publishers 1989.
Johkura K, Matsushita Y, Kuroiwa Y. Transient hearing loss after accidental dural
puncture in epidural block. Eur J Neurol. 2000; 7:125-126.
Kiliçkan L, Gürkan Y, Ozkarakas H. Permanent sensorineural hearing loss following
spinal anesthesia. Acta Anaesthesiol Scand. 2002; 46:1155–1157.
Oncel S, Hasegeli L, Zafer UM, Savaci S, Onal K, Oyman S. The effect of epidural
anaesthesia and size of spinal needle on post-operative hearing loss. J Laryngol Otol.
1992; 106:783-787.
Fog J, Wang LP, Sundberg A, Mucchiano C. Hearing loss after spinal anesthesia is
related to needle size. Anesth Analg. 1990; 70:517-522.
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Prevalence of Otolaryngological diseases in Nigerians.
J.A.E. Eziyi, Y.B. Amusa, O.V. Akinpelu
ORL Unit, Department of Surgery, Obafemi Awolowo University,
Ile-Ife, Osun State, Nigeria.
Correspondence to: Dr. JAE Eziyi, Email: [email protected]
Background: To study the prevalence of Otolaryngological (ORL) diseases in a tertiary hospital.
Methods: Five hundred patients that were first attendee at the ORL clinic of the Obafemi Awolowo
University teaching hospital Ile-Ife were randomly selected from the clinic lists. The age, sex,
presenting complaints, and the diagnosis were noted. Analysis of the data were done using SPSS
version 10.0
Results: The age ranges of ENT clinic attendee were 10 days – 95years with a mean age of 30.5 ±
22.7years. There were 315 males and l85 females with a male to female ratio of 1.7:1. Diseases of the
ear was the most common 51.8% (n=259), nasal and paranasal sinuses diseases accounted for 26%
(n=130), pharyngeal diseases was found in 10.6% (n=53), laryngeal disease accounted for 3% (n=15).
Oral cavity lesions were seen in 1.4%. (n=7) and Head and Neck tumors were found in 7.2% (n=36)
these were made up of malignant (n=30) and benign (n=6) tumors.
Conclusion: Ear diseases were the most in this work and oral cavity lesions being the least common.
The peak age incidence was in the 0-9years. There is a need for manpower development in otological
and paediatric otolaryngological surgery.
Introduction
Otorhinolaryngology in Nigeria is not as advanced as in the developed countries. Many of the
tropical countries including Nigeria have few experts and very poor facilities to support the effort of
the experts; this creates a very heavy workload on the Otolaryngologists working in these areas. There
are therefore a few studies on the prevalence of the diseases of the Ear, Nose, and Throat-Head and
Neck region. Martin1 reported a personal survey on ENT diseases over a 5 – year period at Uganda,
and Bhatia and Varughese2.reported on the pattern of otolaryngological diseases in Jos community1,2..
Other works reported on particular disease entities like Secretory Otitis Media with Effusion (SOME),
Acute Otitis Media, and pattern of Otological diseases respectively3, 4,5. The remarks by Manson-Bahr
over five decades ago in his paper on Otorhinolaryngology in the tropics, still holds today: ‘Affections
of the ear, Nose Throat as they occur in the tropics certainly deserves a more generous measure of
scientific study than has so far been accorded them6.
A study on the prevalence of the Ear Nose throat and Head and Neck diseases in Nigeria in particular
will provide basic data that would help in identifying specific research and clinical priorities. The
direction of manpower development as regards Otolaryngological health in Nigeria can also be easily
identified.This paper aims at determining the prevalence of Otolaryngology – Head and Neck diseases
among Nigerians living in the southwestern part of Nigeria that are first attendee at the ENT clinic of
the Obafemi Awolowo University Teaching Hospital Complex (OAUTHC), Ile-Ife.
Patients and Methods
Records of 500 patients who are first attendee at the ENT clinic of OAUTHC, Ile-Ife were randomly
selected from the general Outpatients clinic appointments lists over a five year period from January
2003 to December 2007. Ile-Ife is in the southwestern part of Nigeria. It provides tertiary health care
to an aggregate population of 9 million people7. Official government regulations allow only patients
referred by medical institutions or private practitioners to receive appointments at the outpatient
department7. Every fourth patient who is a first attendee on the clinic list over a period of 5 years
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(2003-2007) was selected. Six thousand ORL patients were seen during the review period out of
which there were 2000 new attendees. The hospital records of the patients who met the inclusion
criteria were reviewed, and the information extracted from the records was the demographic data, the
presenting symptoms, the physical examination findings, and the diagnosis. The data collected were
analyzed using descriptive analysis with the help of SPSS version 10.0 statistical software.
Results
The age distribution of the patients showed that there were more children attending the ENT
clinic than adults. Mean Age: 30.5 ±22.7years (Table 1). Males were 315 and 185 caes were
females. The male to female sex ratio was 1.7: 1. Regarding the place of residence, 485 (97%)
came from the Southwestern part of Nigeria. Only 15(3%) resided in other part of Nigeria
Symptomatology of ENT diseases
Table 2 gives the descriptive statistics of the presenting symptoms. Ear symptoms was the chief
complaints in 53.6% of cases, nasal symptoms were found in 24.2%, pharyngeal and laryngeal
symptoms were found in 13.6%, head and neck tumors symptoms were seen in 7.2% of cases while
oral diseases symptoms were seen in 1.4%.
Table 1. Age Distribution
Age in years
0-9
10-19
20-29
30-39
40-49
50-59
60-69
70-79
80
Total
Mean Age: 30.5 ±22.7years
Frequency \Percentage of total (%)
113 (22.6)
76 (15.3)
80 (16.0)
69 (13.8)
41 (8.3)
46 (9.2)
38 (7.6)
27 (5.4)
9 (1.8)
500 (100)
Table 2. The Common Symptoms of ENT iseases
Symptoms
Otorrhea
Hard of hearing
Tinnitus
Otalgia
Vertigo
Inability to talk
Nasal blockade
Rhinorrhea
Epistaxis
Sneezing
Hoarseness
Sore throat
Stridor
East and Central African Journal of Surgery
Frequency (% of total)
109(21.8)
64(12.8)
49(9.8)
31(6.2)
10(2.0)
15(3.0)
41(8.2)
20(4.0)
16(3.2)
12(2.4)
28(5.6)
20(4.0)
14(2.8)
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East and Central African Journal of Surgery Volume 15 Number 2.
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10(2.0)
Table 3. The Four Most common ORL Diseases per Anatomic sites
A
B
C
D
E
F
Anatomical region
Ear:
CSOM
SNHL
AOM
Deaf Mutism
Nose and Paranasal sinuses
Chronic Sinusitis
Nasal polyp
Epistaxis
Frontal Mucocele
Pharynx
Adenoids
CNSP
Tonsillitis
Esophageal Foreign Body
Larynx
Chronic laryngitis
Foreign Body in the Airway
Laryngeal edema
Laryngomalacial
Oral Lesion
Cleft Lip
Benign Lip Tumour (fungal)
Ranular
Head and Neck tumours
Carcinoma of the Larynx
Paranasal and Nasal Carcinoma
Nasopharyngeal Carcinoma
Laryngeal Pappilloma
Parotid Carcinoma
Frequency (%)
259(51.8)
63
50
38
18
130(26)
78
14
10
5
53(10.6)
14
14
13
10
15(3.0)
4
5
4
2
7(1.4)
3
2
1
36(7.2)
10
6
4
3
2
Summary of diagnosis
Table 3 describes the four most common ENT diseases according to anatomical region. Ear diseases
were the most common in 51.8% followed by nasal diseases 26%, pharyngeal diseases 10.6%, and
Head and Neck cancers 6.0%, Laryngeal diseases 3.0%, Oral lesion 1.4% while benign head and neck
tumors were found in 1.2% of cases.
Discussion
This study shows that there are more males attending the ear, nose and throat (ENT) clinic and the
highest age incidence was found to be in the first decade of life (Table I). The highest incidence of
ORL diseases in the first decade of life is probably related to the fact that Otorrhea was the most
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common complaints and that Otitis media was the most common childhood ENT disease. This agrees
with existing literature; Ogisi and Brobby found Otitis Media to be the most common ear disease in
the tropics8,9.
Sensorineural hearing loss (SNHL) due to varying causes was the second most common ear disease,
while the incidence of deaf mutism was found to be 3% in this study. Likhachev found an association
between deaf mutism and poverty10. He noted that there was a significant reduction in the incidence of
deaf mutism with improvement in the material condition and improved socio-economic facilities of
the people in the then Soviet Union10. Establishment of a national neonatal hearing-screening
programme for high-risk infants in Nigeria will lead to an early diagnosis and rehabilitation of
affected patients.
Otosclerosis was found not to be common, accounting for 0.4% of the study population. An incidence
of 1% of clinical otosclerosis and 10% histological otosclerosis had been established in the white11.
The low incidence recorded in this work agrees with the low incidence of Otosclerosis in blacks that
had been established in the literature11. Brobby also reported low incidence of otosclerosis in Kumasis
Ghana12. The low incidence of Otosclerosis in black race has been attributed to the flat occipital
protuberance of the skull among Africans. However, Okafor found a higher incidence of otosclerosis
in the southeastern part of Nigeria13. Further study to confirm this regional variation in the incidence
of otosclerosis in Nigeria is necessary.
Cholesteatoma was found to be rare, while sequel of CSOM such as meningitis, brain abscess, and
mastoid abscess and lateral sinus thrombosis were found in 2% of the cases. In these patients with
intracranial suppurations, ENT referrals are usually very late and are associated with poor prognosis.
Nasal and Paranasal Sinus Diseases.
These constituted the second most common anatomical site for ENT diseases see (Table 3) and
chronic sinusitis was found to be the most common.
The maxillary sinuses were affected in 40 (8.0%) while, Pan Sinusitis, was found in 16(3.2%).
Complications of chronic sinusitis such as nasal polyp and frontal mucocele were seen commonly in
this study. Chronic sinusitis was found to also account for a large percentage of outpatients’
attendance at ORL clinics in the Western World until recently. Low socio-economic factors and
overcrowding which are prevalent in our society might be responsible for the high prevalence of
chronic sinusitis in this work. Improvement in the housing condition in western world has led to a
significant reduction in the incidence of this disease. Therefore an improvement in the housing,
feeding and better social facilities in our society is likely to be associated with a lower incidence of
many of the infective diseases of the ORL region.
Pharyngeal diseases
They are the third most common ORL diseases found in this study. Of these, chronic nonspecific
pharyngitis, acute tonsillitis, adenoids, and esophageal foreign bodies (FB) are the most common.
(Table 3). The FB in these cases were the N1 coin, some other metallic objects –kerosene stove
chamber cover, pin, coca cola bottle cover, kola nuts and fish bone. The FB in close to 90% of cases
was impacted at the level of cricopharyngeus and was promptly removed at emergency
oesophagoscopy, and this occurs in children of age 3 months - 5 years.
Hoarseness was associated with chronic laryngitis, laryngeal papilloma and cancer of the larynx while
stridor was found in patients with FB in the Airway, and Laryngomalacia (Table II). Airway
obstruction in 4(0.8%) was due to retropharyngeal abscess in infants of between 3 months – 2 years.
Retropharyngeal abscess constitutes an emergency and they usually present very late having being
treated as a case of bronchopneumonia before referral. A high index of suspicion is needed in order to
save this group of patients.
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Head and Neck tumors
They were seen in 7.2% of ORL patients in this study. Over 90% of the malignancies reviewed in this
work are Squamous cell carcinoma. Burkitts lymphoma was found in 0.6% of cases while
adenocarcinoma was also found to be rare. The head and neck malignancies were noted in the older
patients above the age of 50 years while the benign tumors were found in younger age group. This
figure is high when compared with the work of Bhatia and Varunghese in Jos community, in the
plateaus state of Nigeria2. A regional variation in the incidence of Head and Neck cancer in Nigeria
may be plausible.
There is a need for the Nigerian otolaryngologist to embark on a national survey of ORL diseases, so
as to find the probable aetiological factors, establish regional variation in the incidence of ORL
diseases and to stimulate research into the development of preventive measures.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13
Martin JAM. Diseases of the ear, nose and throat in tropical Africa. A Uganda survey.
Journal of Laryngology and otology 1967; 81: 1079-1098.
Bhatia PL, Varughese R. Pattern of Otolaryngological Diseases in Jos community NMJ
1987; 67-73.
Okeowo PA. Observation of non-suppurative middle ear problems in Nigerian children.
Journal of tropical Pediatrics 1978; 24: 4-6.
Elton P, Cornell J. Study of Otitis media and malaria among pyrexic attendees of an
under fives clinic. Journal of Tropical Medical Hygiene1978; 111-112.
Okafor BC. The chronic discharging ear in Nigeria. Journal of Laryngology and Otology,
1984; 98: 113-119.
Manson-Bahr. Tropical diseases affecting the throat, nose and ear. Journal of laryngology
and otology 1961; 75: 175-195.
Lawal O, Agbakwuru A, Olayinka OS, Adelusola K. Troid malignancy in endemic
nodular goiters: Prevalence, pattern and treatment. EJSO 2001; 27:157-161.
Ogisi FO, Osammor JY. Bacteriology of Chronic Otitis Media in Benin. NMJ 1987;
12(2): 187-190.
Brobby GW. The discharging ear in the tropics: a guide to the diagnosis and management
in the district hospital. Tropical Doctor, 1992; 22:10-13
Likhachev AG. Deaf Mutism: In Diseases of the Ear, Nose and Throat 1978; 102-105,
Mir Publishers 1978.
Belal AA. Otosclerosis. In: Belal AA, ed. Belals Otolaryngology- head and Neck
Surgery, Alexandria.1992; 32-33.
Okafor BC. Otolaryngology in South Eastern Nigeria. I. Pattern of Diseases
of the ear. NMJ, 1983:11-19.
Brobby GW. Two cases of Otosclerosis in Kumasi Ghana- a case report:
Tropical and Geological medicine 1985; 38: 292-295.
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
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The Postoperative Complications Prediction in Mulago Hospital using POSSUM
Scoring System.
D.L Kitara, I. Kakande, B.D. Mugisa, J.H. Obol
Kampala Uganda.
Correspondence to: Dr. David L Kitala Email: [email protected] ;Fax : 256-471 32913
Introduction: Prediction of complications is an essential part of risk management in surgery.
Knowing which patient to operate and those at high risk of developing complications
contributes significantly to the quality of surgical care and cost reduction. The postoperative
complications of patients who underwent Laparotomy in Mulago Hospital were studied using
POSSUM scoring system. The main objective of this study was to determine the postoperative
complications of Laparotomy in Mulago Hospital, between September 2003 and February 2004.
Methods: Consecutive patients, who underwent Laparotomy in Mulago, were studied using
POSSUM system for development of complications. For each patient operated, they were
followed up in wards until discharge. When the postoperative complications were reported, they
were reexamined by the surgeons, treated and followed up for 30 days postoperatively. Phone
contacts were used for the follow up. Surgical reviews were conducted once a week in Mulago
Hospital and the data obtained recorded in the data sheet for the patients.
Results: Seventy-six patients were studied. The observed post operative complications were as
follows: Respiratory tract infection (28.2%), wound haemmorrhage (18.2%), anaemia (15.5%),
hypotension (14.1%), UTI (2.2%), Anastomotic leak (1.4%), Wound sepsis (9.9%), wound
dehiscence (4.2%), Thromboembolism (1.4%). The postoperative nursing care significantly
determined the outcomes.
Conclusion: Postoperative complications can be predicted in the modern management of
surgery especially while using a scoring system.
Introduction
Risk management is an important health care issue. Prediction of complications is an essential part
of risk management in surgery. Knowing which patient is at risk of developing complications
contributes to the quality of surgical care and cost reduction in surgery.1 It is therefore essential to
identify and make appropriate decision on those patients who are at high risk of developing serious
complications1,2. Postoperative complications are sometimes determined by the surgical procedures
conducted.1,2 Postoperative complications delay patients discharge, mobilization and markedly
reduce the patients’ income, increase hospital costs, increase absenteeism at work and reduced
patients’ productivity. They create an unnecessary discomfort to the surgical team, stress, anger, and
sometimes depression especially when the complications can not be easily corrected or takes long to
be corrected e.g. enterocutaneous fistula.
Various studies have been conducted in Uganda to assess the postoperative complications. None has
been by use of a scoring system such as (POSSUM). This study showed that the development of the
postoperative complications is not affected by the socio-economic status of the patient but rather the
preoperative, operative and postoperative management of the patient.
Patients and Methods
This was a prospective descriptive study conducted over a period of 6-months in Mulago Hospital,
Kampala, Uganda. The study population consisted of 76 patients aged 13 years and above admitted
for elective and emergency surgery. Day-care surgery and those who died immediately before surgery
were excluded.The patients were assessed preoperatively, operatively and postoperatively for any
complications. 76 patients underwent Emergency or Elective Laparotomy in the Hospital Theatres.
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East and Central African Journal of Surgery Volume 15 Number 2.
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The patients were scored with the physiological component of POSSUM just before the induction of
general anesthesia. All the individual scores were computed and summed up to produce the POSSUM
physiological score for each patient.
The operative procedures were conducted in the same manner and using midline incision. Intraoperative blood loss, type of surgery, the presence or absence of peritoneal soiling and intraabdominal tumors were recorded and summed up to constitute the operative score for each patient.
The closure of the abdomen was done using the same suture material and equal size. The Follow-up
of the patients was done up to 30th postoperative day. Patients were reviewed weekly in Surgical
Outpatient Department. Telephone contacts were used, where possible. When a patient died, postmortem examinations were conducted by a pathologist and findings recorded and summarized for the
purpose of this study. Morbidity was investigated and appropriate treatment administered to the
patient as required.
Statistical data analysis was conducted using the SPSS version 10.0 software. A student t-test was
used to compare significant differences and chi-square/Fisher’s exact test was used in testing
association of categorical variables. The quality control was ensured by making the principal
investigator carryout all the pre-operative and postoperative assessment, clinical examinations and
measurements of parameters using standard International units (SI) to avoid inter-observer error.
Laboratory investigations were done by the same method and in standard unit.
Results
The patients’ ages ranged from 14 to 81 with a mean of 40.4 years. M:F ratio of 2:1. Peasant farmers
accounted for (52.6%), Business (self employed) (27.6%), Civil servant (13.2%) and Students (6.6%).
Intestinal obstruction comprised 19.4%, abdominal trauma (18.4%), peritonitis (18.4%) and
abdominal malignancy (18.4%), appendicitis (13.2%) and surgical jaundice (11.8%). The majority
(78.9%) of the patients investigated had no comorbid conditions. Hypertension accounted for 11.8%
and the others accounted for less than 10%, sickle cell disease, peptic ulcer disease and Diabetes
Mellitus each.
A total of 55 (72.4%) of the operations were performed by the Senior Residents compared to 13
(17.1%) and 8 (10.5%) by Consultants and Senior Registrars respectively. The Senior Residents
performed 86.3% of the emergency operations as compared with 9.8% by Senior Registrars and 3.9%
by Consultants. For elective surgery, (44%) by Senior Residents, (12%) by Senior Registrars and 44%
by consultants.
The mean duration of postoperative Hospital stay was 8.46 days. Thirty two patients were discharged
in the 1st post-operative week while thirty (30) were discharged in the 2nd week. The remaining
fourteen (14) spent more than 2 weeks in the Hospital.
The conditions associated with mortality included intestinal obstruction (45.5%), peritonitis (27.3%),
intra-abdominal tumor (18.2%), and surgical jaundice (9.1%). The mean postoperative day of death
was 12.4. All the patients died due to septic shock. Thirty-five patients had a mortality risk greater
than 50%; twenty patients had risk (21-49%), nine patients had (11-20%) and fifteen patients had (110%) of death. This result shows a positive correlation and a significant relationship between death
and physiological score (p=0.003).There was a positive correlation between death and the operative
severity score p-value 0.012).
Table 1. The Rank of Operating Surgeon.
Surgeon
Frequency
Consultant
13
Registrar
8
Senior House Officers
55
East and Central African Journal of Surgery
Percentage (%)
17.1
10.5
72.4
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Total
76
100.0
Table 1 shows the ranks of the operating surgeons. The surgical residents (Senior House Officers)
performed the majority of the procedures (72.4%), Senior Registrars (10.5%) and Consultants
(17.1%). Most (67.1%) of the operations were done as emergencies. Electives operation were 25
(32.9%).The Senior House Officers performed the majority of the emergency operations of 44
(86.3%), Registrar 5 (9.8%) and Consultant 2 (3.9%). Elective Procedures: Senior House Officer
(SHO) 11 (44%), Consultant 11 (44%), Registrar 3 (12%)
The commonest cause of morbidity was Respiratory tract infection in 20 (28.2%) and commonly
occurred on the 2nd postoperative day, followed by wound haemorrhage in 13 (18.2%), anaemia 11
(15.5%), hypotension in 10 (14.1%), wound sepsis in 7 (9.9%), urinary tract infection in 2 (2.2%),
anastomotic leak in 1 (1.4%), wound dehiscence developed in 3 (4.2%) and congestive cardiac failure.
Discussion
Assessing the postoperative complications following a Laparotomy is very important especially when
using a scoring system (POSSUM). This was an effective method of assessing the risk of morbidity
following Laparotomy in Mulago Hospital. The age, sex, tribe and religion of the patients did not
significantly affect the development of complications following Laparotomy. A study in the USA
indicated that increasing age was strongly associated with risk of complications but surprisingly, the
risk declined for patients older than 79 years of age. The most likely explanation for the phenomenon
was that there was a strong selection bias before hospitalization with older high-risk patients not being
considered suitable for admission for surgery.18 This observation was not made in this study probably
because over 80% of the patients were below 40 years and so their age did not significantly affect the
outcome.
Nature of Surgery
The nature of surgery had a significant effect on the operative scores for the patients. On average, the
emergency operations had higher operative scores (23.39). There was a positive correlation (t=4.375)
and a significant relationship (p=0.000) between emergency operation and the operative scores.
Similarly emergency surgery had a higher average physiological score (25.63). The risk of morbidity
was significantly increased by the nature of the operation. A study involving 232,440 surgical patients
at 168 hospitals in the state of Pennsylvania, USA indicated that a higher patient to nursing staff ratios
is associated with higher risk-adjusted postoperative mortality rate.20 This means that nursing care
alone can be shown to be a robust independent predictor of postoperative deaths.19,20These results
indicate that factors such as hospital resources, the availability and training of medical staffs have a
significant impact on the postoperative outcome (mortality and morbidity).5,19,20.
The Surgeons
There were three categories of surgeons who carried out the surgical procedures: Consultants,
Registrars, and Senior Residents (SHO). The consultants conducted 13 operations. All the patients
had very good physiological status. There was a negative correlation and an insignificant relationship
between the 2 variables (t=-1.643 and p=0.105). Similarly their mean operative score was low
(17.62). For the Registrars, they conducted 8 operations. There was a negative correlation (t=-0.344)
between the Registrar and the operative score. The majority of the operations were conducted by the
senior Residents (55/76). In general, the Senior Residents conducted operations on patients with
higher physiological scores (poorer physical condition). There was a positive correlation (t=2.765)
and a significant (p=0.007) relationships between the physiological score and the Senior Residents.
Higher- risk surgery performed independently by physician in training was shown to be related to
poor postoperative outcome.5The UK government report, have drawn attention to the dangers of
leaving high-risk procedures to trainee surgeons without supervision.5 In general, there was a negative
correlation between the surgeons and the risks of morbidity.
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The Physiological Score (PS)
The average physiological score observed in the study population was 25.22. This value is
comparable with other studies done in the USA and UK5 The most frequently observed group were
those between the ranges of 20-29. This score however, was found to have a positive correlation and a
significant p-value with mortality (t=2.228 and p=0.029). This is consistent with the findings observed
in the USA and UK5. The physiological score had a negative correlation (t= –0.019) and an
insignificant value (p=0.436) with morbidity. The physiological score alone could not be used to
predict the risk of development of omplications because there was other confounding factors
observed.3
The Operative Score (OS)
The average score was 21.2. Again this average is comparable with other studies done in the UK and
USA and other developing country such as Malaysia.5,10 Tribe, occupation, and diagnosis or co
morbid conditions did not significantly affect the operative score. There was a positive correlation and
a significant p-value for the relationship with mortality and morbidity and operative scores (t=3.280
and a p=0.00) and (t=0.197and p=0.044). This observation is consistent with the findings in USA,
UK5 and Malaysia.10
Postoperative Hospital Stays (Days)
The mean postoperative hospital stay was 8.46. This value was comparable with the findings in UK,
USA5 and Malaysia10. Olaro (1999) observed the postoperative hospital stay at Mulago Hospital was
at10 days11. The postoperative hospital stay had a negative correlation (t= –2.894) to mortality
(p=0.005). Furthermore, the postoperative hospital stay had a positive correlation (t=3.571) and
(p=0.001) with morbidity.
The Observed Mortality
Eleven out of the seventy-six patients studied died. This gave a mortality rate of 14.5%.This mortality
rate was comparable with other previous studies done in Mulago Hospital. Birabwa-male
1989(21.7%) and Fiedler et al 1986 in USA (17%), Mugisa (1988) and Kazibwe (1987) (10-20%)4,13.
The Laparotomy related to intestinal obstruction was the commonest cause of death (45.4%). similar
findings observed by Olaro (1999) with large gut surgery being commonest cause of mortality 28%.11
Peritonitis came second (27.3%). Surgical jaundice came third (9.1%) and carcinoma of the pancreas
fourth (9.1%). All the emergency patients who died had very high physiological scores (>25). All the
elective patients who died had high operative scores (>22). Diabetes Mellitus increased the risk of
mortality.
The observed Morbidity
Fifty two point three percent (34/65) of the patients who lived postoperatively developed
complications. The factors responsible were: operative scores (t= 0.193 and p= 0.044), surgical
jaundice (t= 0.202 and p= 0.040), and Peptic Ulcer Disease (t= 0.308 and p= 0.003). The operative
score directly affected both the risks of mortality and morbidity.5 Surgical jaundice contributed to the
development of complications (t= 2.654and p= 0.010). Those patients with the peptic ulcer diseases
had higher physiological and operative scores.
The Postoperative Complications
Respiratory tract infection was the commonest complication (28.2%) observed. This occurred mainly
in 2nd and 5th postoperative days. Those in second day were either due to aspiration pneumonia or
hypostatic pneumonia due to poor ventilation. All those who developed respiratory tract infection
experienced postoperative pain for most times. The pain therefore explains the cause of the poor
ventilation and subsequent postoperative retention of secretions and development of respiratory tract
infection.
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
Andrew14 in his study found that respiratory complications were common among those who had
higher abdominal incision and this was due to atalectasis. He observed that, the main pathological
changes observed was alveolar collapse of the lungs and this was observed in association with
restriction of ventilation especially in those patients who had a very poor pain control14. indeed the
evaluation of the treatment chart in Surgical department at Mulago Hospital confirmed that either the
drug given was inadequate or irregular and that the pain reliever were not titrated against the pain
experienced by the patient. In some instances, the quality of analgesics was not strong enough to
relieve pain following the Laparotomy e.g. use of paracetamol (1000mg) three times a day in the 2nd
post operative day.
Wound hemorrhage was the secund commonest (18.2%) cause of morbidity and this mainly occurred
on the 1st and 3rd postoperative day. Mugisa4 observed a rate of (10%) and mainly among patients
operated by the Senior Residents (SHO). He attributed this finding to emergency patients being
operated in a state of shock. They were usually inadequately resuscitated and therefore the failure to
localize the abdominal wall bleeders4.
Anemia was 3rd commonest postoperative complications accounting for (15.5%). The most reported
cases were in the 4th postoperative day. This mainly occurred in patients who had blunt abdominal
trauma with ruptured intra-abdominal viscera. They were in most cases, found to have lost more than
1 liter of blood in the peritoneal cavity in the operative period. Mugisa (1988) observed a rate of
anaemia in 11.3% of all the Laparotomy patients in Mulago Hospital.
Wound dehiscence accounted for (4.2%) and Wound sepsis accounted for (9.9%). Wound sepsis was
commonly seen in patients with pussy peritonitis between 4th - 7th postoperative days. Mugisa4 in
1988 observed a higher rate of 15% for wound dehiscence. He attributed this to poor surgical
technique among the surgeons. Rousellot15 found that in USA, the incidence of wound infection was
15% and was the commonest complications experienced. This occurred between 4th –7th postoperative
day clinically shown with a spiking fever.
Thromboembolism was observed in 1.4% of the cases and this was in a sickler. This sicker
experienced a painful crises in the postoperative period. Aagard16 observed 15% prevalence of
Thromboembolism in those above 50-years. This prevalence was higher compared to what was
observed in this study population probably because the majority of the patients were younger and
there were few cancer surgeries (a Thromboembolism promotion factor).
Conclusion
a. Respiratory tract infection is the commonest complication experienced in Mulago Hospital
following a Laparotomy.
b. Postoperative nursing care significantly contributed to the development of complications.
c. The choice of the patients for surgery markedly contributed to the development of
postoperative complications. Elective patients developed fewer complications than the
emergency ones and also the patients operated by the consultants developed less
complications.
Recommendations
a. Postoperative complications can be minimized in the surgical unit by improving
patients’ nursing care and pain management of postoperative patients.
b. The operative score and operative condition of the patient markedly influence the
postoperative complications.
c. Experience in surgery (hands on) is a useful in prevention of the development of
complications
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
Appendix 1. Physiological Score
1
2
AGE (years)
<60
61-70
Cardiac signs
No
Diuretic,
Chest
failure Digoxin, antiradiography
angina or
hypertensive
therapy
Respiratory
No
Dyspnoea
on
history
dyspno exertion
Chest
ea
radiography
Mild CAOD
Blood Pressure
110131-170
(systolic)
130
100-109
(mmHg)
Pulse
50-80
81-100
(beats/min)
40-49
Glasgow coma
15
12-14
scale
Hemoglobin
13-16
11.5-12.9
(g/dl-l)
16.1-17.0
4
>71
Peripheral edema, warfarin
therapy, borderline
cardiomegally
8
Limiting dyspnoea (one on
flight)
Moderate CAOD
Dyspnoea at rest
(rate>30/min)
Fibrosis or
consolidation
<89
>171
90-99
101-120
Raised JVP,
cardiomegally
9-11
>121
<39
<8
10.0-11.4
17.1-18.0
<9.9
>18.1
White cell
count (x1012/l)
4-10
10.1-20.0
3.1-4.0
>20.1
<3.0
Urea (mmol/l)
<7.5
7.6-10.0
10.1-15.0
>15.1
Sodium
(mmol/l)
Potassium
(mmol/l)
Electrocardiogr
am
>136
131-135
126-130
<125
3.5-5.0
3.2-3.4
5.1-5.3
2.9-3.1
5.4-5.9
Atrial fibrillation (rate 60-90)
<2.8
>6.0
Any other abnormal
rhythm
or
>5
ectopics/min
Q Waves or ST/ T
wave changes
Norma
l
Operative severity
Multiple Procedures
Total blood loss (ml)
Peritoneal soiling
1
Minor
1
<100
None
2
Moderate
101-500
Minor (serous fluid)
East and Central African Journal of Surgery
4
Major
2
501-999
Local pus
8
Major+
>2
>1000
Free bowel
content, pus or
blood
Page 96
East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
Presence of
Malignancy
Mode of surgery
None
Primary only
Elective
Nodal metastasis
Distant Metastases
Emergency
resuscitation of >2h
possible <24h after
admission
Emergency
(immediate
surgery <2h
needed
Appe
ndix
2.
Oper
ative Severity Score
References
1. Neary W.D: The Physiological and operative Severity score for the enumeration of mortality
and morbidity (POSSSUM). Br J Surg 2003; 90:157-165.
2. Copeland GP, Jones D, and Walter M - POSSUM: A Scoring system for surgical Audit. Br J
Surg 1991: 78 March 356-360.
3. Copeland GP. The POSSUM scoring system. Medical audit news.1992; 2:123-125.
4. Mugisa B.D. Complications Following Laparotomy In Mulago Hospital, Kampala. A
Dissertation Submitted For the Award of M.Med. Surgery of Makerere University.
5. Bennett-Guerrero E, Hyam J. A, Prytherch D. R, Shaefi S. Comparison of P-POSSUM riskadjusted mortality rates after surgery between patients in the USA and the UK. British Journal
of surgery.2003, 90. 1593-1598.
6. Birabwa-male D. Abdominal injuries in Mulago Hospital, Department of surgery Mulago
Hospital, Kampala. A Dissertation submitted for the award of M.Med. (Surgery) of Makerere
University (1989).
7. Kakande I, Ekwaro I, Obote w w, Nassali G, Kyamanywa P. The intestinal Volvulus at St.
Francis Hospital, Kampala. East and Central African journal of surgery vol. 6, 1: 21-24.
8. McAdam I W J. A three-year review of intestinal obstruction at Mulago hospital. East Afr.
Med J 1961:38:536.
9. Odonga AM. Variety of volvulus of the intestines seen at Mulago hospital. East
Afr.Med.1992: 11:711.
10. Yii MK, Ng KJ. Risk-adjusted surgical audit with POSSUM scoring system in a developing
country. British Journal of surgery 2002, 89,110-113.
11. Olaro Charles. Study to assess the risk factors for postoperative complications following
abdominal surgery in Mulago Hospital. A Dissertation submitted in for the award of M.MED
Surgery of Makerere University.
12. Yiga J.B. Abdominal trauma in Mulago Hospital 1979. A Dissertation submitted for M.MED
Surgery of Makerere University.
13. Kazibwe R.N.K.S Dynamic intestinal obstruction in Mulago hospital. A dissertation for
M.Med Surgery (MUK), 1987.
14. Andrew D, Blainey Roberts. Postoperative lung complication. Surgery Vol. 39, 921-924.
15. Rousellot L.M and Slattery. T. R. Immediate complications of surgery of large intestines. S.
clin. North. America, 44: 397, 1964.
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
16. STORMO.AAGARD: Administration of DICOURMOROL and MARCOUMER during
operations to prevent postoperative thrombosis complications in patients over 50 years.
Act.chir. Scandinav. Suppl. 283: 307, 1961.
17. Pilot study performed by the author during the months of March 2003 to September 2003.
18. Veltkamp S.C, Kemmeren J.K ,Edlinger M. Prediction of serious complications in patients
admitted to surgical ward. British Journal of surgery 2002, 89,94- 102.
19. Silber J H, Kennedy S K, Evan-shoshan O et al. Anesthesiologist direction and patients’
outcomes. Anesthesiology 2000, 93, 152-163.
20. Aiken L H, Clarke S P, Sloan DM. Hospital nurse staffing and patients’ mortality, nurses
burnout and job dissatisfaction. JAMMA 2002, 288:987-1993.
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
The Predictors, Prevalence and Outcome of Burst Abdomen in Emergency Paediatric
Surgical Centre.
O.D. Osifo, M.E. Ovueni.
Pediatric Surgery Unit, Department of Surgery, University of Benin Teaching Hospital, Benin City, Nigeria
Correspondence to: E-mail: [email protected]
Background: Combination of certain risk factors in children may predict burst abdomen, a
preventable postoperative complication. We sought to determine the prevalence, outcome, and
predictors of burst abdomen in emerging pediatric surgical centers.
Methods: Cases of laparotomy on children at two referral pediatric surgical centers in Nigeria
between January 2002 and June 2009 were analyzed in a retrospective study that determined
the prevalence, outcome, and predictors of burst abdomen.
Results: A prevalence rate of 31 (2.1%) was recorded among 1465 children who had open
laparotomy. They were mainly neonates [19 (61.3%)] during index laparotomy with a mean age
14.8 ± 6.7 months (range 2 days to 12 years), and a male: female ratio 1.5: 1 (18 males/12
females). Burst abdomen occurred between 4-10days in 5 (3%) children after
resection/anastomosis due to gangrenous/perforated bowels, 4 (5.5%) following colostomy
creation, 3 (7.7%) after open reduction of intussusception, 2 (1.7%) of exploratory laparotomy,
3 (33.3%) after enterocutaneous fistula closure, 9 (39.1%) following primary closure of bowels
perforation, 1 (20.0%) after drainage of intra-abdominal abscess, and 4 (1.9%) following
resection of intra-abdominal malignant tumour. Only 54.8% children survived, 19.4% having
incisional hernia and 12.9% ugly abdominal scars. Surgery on neonates, late referral,
emergency laparotomy, infective indication, intraperitoneal soiling, inanition, and postoperative
abdominal distension owing to protracted ileus that occurred in different combinations were
predictive of burst abdomen in these cases.
Conclusion: The prevalence of burst abdomen is high with attendant poor outcome, but
identifying the predictors may influence early institution of preventive measures.
Introduction
Postoperative complications arising from a breach of the peritoneal cavity especially following open
contaminated or dirty procedures are numerous1,2. Burst abdomen is one of the most dreaded life
threatening complications owing to the associated rapid onset of often irreversible pathological
sequelae. Early surgical consultation, the advent of minimally invasive abdominal surgery, and
availability of facilities and manpower resulted in a reduction in the incidence of post laparotomy
burst abdomen in many centers1-4. However, post laparotomy burst abdomen or wound dehiscence has
continued as a major cause of post operative morbidity and mortality in emerging pediatric surgical
centers, particularly in sub-Saharan Africa. Unlike the encouraging outcome recorded in more
developed centers, associated mortality is very high in many developing countries due to infective
complication and a lack of adequate facilities5,6.
Pre- and post-operative clinical conditions of a patient were reported, which to a large extent
influenced the development of postoperative burst abdomen5,7,8. Foreign literatures drew attention to
the possible risk factors that could precipitate post operative burst abdomen, and enumerated recent
advances in treatment and outcome especially in adults1-3,9-12. There are, however, scant studies5,6
outlining likely predictors of postoperative burst abdomen in children in developing countries where
open laparotomy is still commonly done with associated high incidence of this complication. Early
identification of predictors of imminent burst abdomen and institution of measures aimed at
prevention could be very crucial in resource-poor regions.
Consequently, a retrospective study based on children who underwent open abdominal operation was
undertaken at two emerging referral pediatric surgical centers in Nigeria. We aimed to determine the
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
current prevalence, outcome, and predictors of post operative burst abdomen in children in this
African subregion which may be useful for early institution of preventive measures in similar settings.
Patients and Methods
The study centers, University of Benin Teaching Hospital and Leadeks Medical Center, are emerging
referral pediatric surgical centers in Nigeria. Owing to lack of facilities and manpower for
laparoscopic operations, open abdominal surgeries were performed on children with abdominal
surgical pathology during the period. This retrospective study on burst abdomen spanning January
2002 to June 2009 was commenced after due approval by the University of Benin Teaching Hospital
Local Ethics Committee.
Analysis of records of all children who had abdominal operations during the period was done.
Findings, especially that of predictors of burst abdomen, were compared between children who had
postoperative burst abdomen and those who did not. Data collated were age, sex, indication for index
operation (including abdominal access/closure/suture materials), pattern of presentation, clinical state
on arrival, preoperative morbidity, intra-operative findings, surgical procedure, post operative
morbidity, time lag between index operation and occurrence of burst abdomen, closure, outcome and
follow-up. Twelve of the children who had abdominal operation during the period but on whom
sufficient data were not available because their case files could not be retrieved for analysis were
excluded from the study.
Statistical analysis: The data obtained were analyzed using SPSS version 11 software package
(SPSS, Chicago, IL, USA). Categorical data were analyzed using the Chi-square test with a p-value
<0.05 regarded as being statistically significant.
Results
A total 1465 abdominal operations were performed at the centers on children who were aged between
2 days and 16 years. The prevalence of burst abdomen recorded during the period was 2.1 %,
occurring in 31 of the children. These 31 children of whom 19 were neonates during index abdominal
operation had a mean age of 14.8 ± 6.7 months (range 2 days to 12 years), with a male: female ratio
1.5: 1 (18 males/12 females). Burst abdomen was only recorded in 31 among 644 children who had
some specific procedures and none in 821 who had other types of abdominal procedures. Therefore,
of 165 children who had gangrenous/perforated bowels necessitating resection and anastomosis, 5
(3%) were complicated with postoperative burst abdomen. Burst abdomen was also a complication in
4 (5.5%) of 73 children who had colostomy created, 3 (7.7%) of 39 who had open reduction of
intussusception, 2 (1.7%) following exploratory laparotomy in 121, and 3 (33.3%) among 9 cases who
had closure of enterocutaneous fistula. Other cases in which burst abdomen occurred were 9 (39.1%)
of 23 patients who had primary closure of bowels perforation, 1 (20.0%) of 5 who had drainage of
intra-abdominal abscess, and 4 (1.9%) of 209 children who had laparotomy for resection of intraabdominal malignant tumor (Table 1).
All the children had transverse abdominal access at index operation. The commonest suture used for
fascia closure was polyglactin in 18 (58.1%) children, followed by nylon in 10 (32.2%). Three (9.7%)
children with clean reduction of intussusception had fascia closure with rapidly absorbed polyglactin
suture (vicryl rapide). This resulted in burst abdomen between the fourth and sixth postoperative day.
The surgeon only discovered the difference between this product and conventional polyglactin suture
following quick succession of burst abdomen in these cases in one center. The mean time lag from
index abdominal operations to occurrence of burst abdomen in the 31 children ranged from 4 days
after colostomy creation to 10 days following resection of intra- abdominal malignant tumor as shown
in Table 1. Graphical representation as shown in Figure 1 revealed predictors of burst abdomen in the
644 children among whom 31 developed the complication. Occurrence of burst abdomen following
the abdominal operations detailed in Table 1, were directly proportional to the number of predictors
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
present in the patients pre- or postoperatively. Consequently, all the 31 children who were in very
poor clinical state before and/or after surgery developed postoperative burst abdomen compared to the
other children who had similar abdominal operations in stable clinical state (P<0.0001). Poor clinical
state was due to very late presentation by 28 children necessitating emergency operation in 27, of
whom 19 were neonates. Moreover, infective complication before laparotomy was recorded in 20
children, with 18 already having preoperative peritoneal soilage either from bowel
gangrene/perforation or intra-abdominal abscess
Table 1. Prevalence, index procedures, and outcomes of burst abdomen during the period
Surgical
procedure
No of
No (%)
patients with
burst
abdomen
Bowel resection
and
anastomosis
165
5 (3.0)
Colostomy
creation
73
4 (5.5)
Intussuception
reduction
39
Exploratory
laparotomy
Closure of
enterocutaneous
fistula
Closure of
bowel
perforation
Average
[
Outcomes of
]
time lag
of burst closure
from
in 31 abdomen
operation
children
to burst
abdomen
Excellent Incisional Scarred
Deaths
hernia
abdomen
5
1
1
0
3
days
4
2
0
0
2
6
1
1
1
0
5
0
2
0
0
7
0
0
2
1
8
2
2
1
4
7
1
0
0
0
10
0
0
0
4
―
―
―
―
days
3 (7.7)
days
121
2 (1.7)
days
9
3 (33.3)
days
23
9 (39.1)
days
Drainage of
intrabdominal
abscess
5
Resection of
malignant
tumour
209
Other
abdominal
operations
without
dehiscence
821
1 (20.0)
days
4 (1.9)
days
Nil
―
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
Total
1465
31 /1465
(2.1)
―
7/31
(22.6%)
6/31
(19.4%)
4/31
(12.9%)
14/31
(45.2%)
Fig.1: Relative frequency of predictors
35
30
25
20
Frequency
15
10
5
0
formation. This resulted in 11 children having protracted post operative ileus that culminated in
increased intra-abdominal pressure and eventual burst abdomen compared to other children in whom
ileus was infrequent, minimal and responded to nasogastric bowel decompression (P<0.0001).
Similarly, inanition due to delayed return of normal bowel functions was compounded by unavailable
total parenteral nutrition which resulted in poor and delayed wound healing in 22 children with
predictable and/or inevitable burst abdomen. This was found to be significant statistically compared to
the other children who were able to commence and tolerate adequate oral feeds within a week of
index abdominal surgeries (P<0.0002). Other rare risk factors such as unavailable adequate
antibiotics, presence of co-morbid illness, anaemia, poor postoperative wound care with resultant
contamination, anastomotic leakage and postoperative wound haematoma in combinations with the
more common ones predicted imminent burst abdomen.
Emergency mass abdominal closure was undertaken in all the children within 1-4 hours of occurrence
of burst abdomen. Outcomes of closure as shown in Table 1 were, however, very poor. This was
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
because 14 (45.2%) children, comprising 8 neonates and 6 older children died of multiple organs
failure within 6-72 hours after closure despite active resuscitation. Of the 17 (54.8%) children who
survived, 6 (19.4%) had incisional hernia that were successfully repaired 1-2 years later while 4
(12.9%) had ugly abdominal scars with only 7 (22.6%) recording excellent outcome.
Discussion
Post laparotomy burst abdomen is a known complication globally with variation in incidence reported
between centers5,7,11. Although technological advancement led to a significant reduction in developed
countries where recent works3,4,7,10,11 revealed incidence rate that varies between 0.8-1.4%, it remains
high in many developing countries. In the absence of readily available figures on children for
comparison, the prevalent rate of 2.1% recorded in this study corresponds with 2.5% reported two
decades earlier in adults in this African subregion, suggesting a persistently higher incidence than in
foreign reports. However, there was no appreciable difference in outcome reported7,10,11 on children
with post laparotomy burst abdomen in developed countries and findings in present study where only
54.8% children survived, with 19.4% having incisional hernia and 12.9% ugly abdominal scars. This
shows a worldwide poor outcome owing to the rapid onset of often irreversible pathological sequelae
in children which emphasize the importance of measures aimed at prevention. Similarly, the mean
time lag of occurrence of burst abdomen that ranged between 4-10 postoperative days of index
laparotomy in present review tallied with literatures3,7-13.
Many pre- and postoperative risk factors, especially the indication for the index operation, have been
identified that could predispose a patient to developing post laparotomy burst abdomen3,4,7,10-12. The
majority of 1465 children had some of these risk factors in this review but burst abdomen occurred
only in 2.1%. Therefore, neither the indication for index operation nor presence of other risk factor
alone was enough to precipitate burst abdomen. A combination of many preventable risk factors as
seen in this and other studies3,7-13 were predictable of imminent burst abdomen. In this study, clean
abdominal procedures on 821 (56%) children were not complicated with postoperative burst abdomen
during the period. This postoperative complication occurred only in 31 among the 644 (44%) children
who had gangrenous/perforated bowels necessitating resection and anastomosis, children who had
colostomy created, open reduction of intussusception, exploratory laparotomy following trauma and
acute abdomen, closure of enterocutaneous fistula, primary closure of bowels perforation, and
laparotomy for resection of intra-abdominal malignancy. Therefore, infective and malignant
indications for index laparotomy were the major predictors requiring just a combination with two or
more of the other identified risk factors to precipitate burst abdomen.
Consequently, in these 31 index operations, burst abdomen was predictable and could possibly have
been prevented were the common combinations of the risk factors taken into consideration. Notably,
neonates undergoing open laparotomy were particularly at risk 3,4,10. Their inadequate response to
abdominal surgical pathology was compounded by late presentation, a frequent denominator and a
major determinant of poor outcome in many developing countries. This allowed enough time for
compromised clinical conditions and infective complications to set. As a result, laparotomy on
clinically compromised neonates who constituted 61.3% of cases in this series was a major predictor
of burst abdomen 7,8. Emergency operation on clinically unstable patients is associated with many
avoidable complications, even more so on neonates. Previous reports3,7,8,12 indicated that neonates
who underwent emergency laparotomy were more likely to develop postoperative burst abdomen
which corresponded with finding in index study.
The importance of parenteral nutrition support for surgical patients, particularly neonates, who are
unable to commence adequate early oral intake owing to surgical bowel disease has been emphasized
by many authors14,15. Delayed wound healing is one of the many serious complications of inanition as
recorded in index cases that were complicated with burst abdomen. Identification of inanition as a
predictor of burst abdomen, provision and commencement of affordable nutritional supplement would
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
July/August 2010.
have prevented this complication. Pre- or postoperative intra-peritoneal and wound soilages which
were common in this series are known to cause postoperative peritonitis and wound infection.
Infection delayed wound healing, peritonitis caused paralytic ileus that negatively influenced
postoperative bowel functions, and the ensuing abdominal distension culminated in avoidable burst
abdomen. Early surgical treatment, provision of total parenteral nutrition support, prolonged
nasogastric bowel decompression, and use of broad spectrum antibiotics in at risk children, especially
neonates, are preventable measures emphasized in literatures2,3,13,16,17.
Many authors reported that vertical abdominal access are more commonly associated with
postoperative abdominal evisceration while others did not record any significant predisposition in
children who had single layer or mass closure of abdominal wounds10,12,18,19. These were not
contributory factors in this review as all the children had transverse abdominal access at index
operations and the types of closure were found to be adequate. However, although the choice of
sutures were to a large extent adequate, the inadvertent use of a wrong polyglactin material called for
caution as noted in other reports 7,8,20. Despite the associated abdominal scars and incisional hernia
recorded, mass closure of burst abdomen as done in this study agreed with reports in other centers 6,19.
The limitation of this study is that it addressed complication that occurs following open laparotomy at
a time when laparoscopic laparotomy has been popularized; thereby limiting its relevance to
developing countries.
Conclusion
The prevalence of burst abdomen is still high in this setting with associated poor outcome.
Emergency laparotomy on neonates consequent on late referral that allowed infective
complications to set in, extensive preoperative intraperitoneal soiling, the presence of
inanition, and prolonged postoperative abdominal distension owing to protracted ileus were
sure predictors of burst abdomen in this series.
Early referral, prompt surgical intervention, and use of the right sutures to close fascia in
clinically stable children are advised.
In children with a combination of the predictors of burst abdomen as recorded in this review,
provision of total parenteral nutrition, prolonged nasogastric bowels decompression, and
adequate selection of antibiotics are important additional preventive measures.
References
1. Fleischer GM, Rennert A, Ruhmer M. Infected abdominal wall and burst abdomen. Chirurg
2000; 71: 754-762.
2. Tillou A, Weng J, Alkousakis T, Velmahos G. Fascial dehiscence after trauma laparotomy: a
sign of intra-abdominal sepsis. Am Surg 2003; 69: 927-929.
3. Begum B, Zaman R, Ahmed M, Ali S. Burst abdomen – a preventable morbidity.
Mymensingh Med J 2008; 17: 63-66.
4. Khan MN, Nagvi AH, Irshad K, Chaudhary AR. Frequency and risk factor of abdominal
wound dehiscence. J Coll Physician Surg Pak 2004; 14: 355-357.
5. Senbanjo RO, Ajayi OO. Abdominal wound dehiscence: a review of 60 cases in Ibadan. Afr J
Med Sci 1988; 17: 133-140.
6. Shittu OS, Ifenne DI, Ekwenpu CC. A simple mass-closure technique compared with layered
technique in the closure of high-risk abdominal wounds. West Afr J Med 1995; 14: 11-14.
7. Cigdem M, Onen A, Otcu S, Duran H. Post operative abdominal evisceration in children:
possible risk factors. Pediatr Surh Int 2006; 22: 677-680.
8. van Ramshorst GH, Salu NE, Bax NMA, Hop WCJ, van Heurn E, Aronson DC et al. Risk
factors for abdominal dehiscence in children: a case-control study. World J Surg 2009; 33:
1509-1513.
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9. Webster C, Neumayer L, Smout R, Horn S, DAlly J, Hendersen W. Prognostic models of
abdominal wound dehiscence after laparotomy. J Surg Res 2003; 109: 130-137.
10. Wagar SH, Malik ZI, Razzaq A, Abdullah MT, Shaima A, Zahid MA. Frequency and risk
factors for wound dehiscence/burst abdomen in midline laparotomies. J Ayub Med Coll
Abbottabad 2005; 17: 70-73.
11. Graham DJ, Stevenson JT, McHenry CR. The association of intra-abdominal infection and
abdominal wound dehiscence. Am Surg 1998; 660-665.
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versus vertical incisions. J Am Coll Surg 2000; 190: 688-691.
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strategy for dirty abdominal incisions: primary or delayed primary closure? Surg Infect 2009;
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Benin City, Nigeria. Eur J Pediatr Surg 2008; 18: 107-110.
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Coran AG Ed. Pediatric Surgery. 5th ed. Philadelphia: Mosby year book Inc, 1998: 171-196.
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factors associated with tissue reactivity, infection, and wound dehiscence among plastic
surgery outpatients. Plast Reconstr Surg 2001; 107: 38-45.
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Enterocutaneous fistula: a Tanzanian experience in a tertiary care hospital
P.L. Chalya 1, M. Mchembe 2, J.M. Gilyoma 1, J.B. Mabula 1, B.Mawala 1, Mona L.1
1
Department of Surgery, Weill- Bugando University Collage of Health Sciences, Mwanza, Tanzania
Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
Correspondence to: [email protected]
2
Background: Enterocutaneous fistulae pose a therapeutic challenge to general surgeons all over the
world and contribute significantly to high morbidity and mortality. The aim of this study was to
describe our experience in the management of enterocutaneous fistulas, outlining the causes, fistula
characteristics, treatment outcome and prognostic factors for fistula closure and mortality in our local
setting.
Methods: A prospective study of patients with enterocutaneous fistulae was conducted at Bugando
Medical Centre between December 2007 and November 2009. After informed written consent for the
study and HIV testing, all patients who met the inclusion criteria were consecutively enrolled into the
study. Data were collected using a pre-tested, coded questionnaire and analyzed using SPSS software
version 11.5.
Results: Ninety two patients were seen during the study. There were 54 males (58.7%) and 38
(41.3%) females (M: F ratio = 1.4:1). Post-operative complication was the commonest cause of
enterocutaneous fistulae in 91.3% of cases. The majority of patients (63.0%) had high output fistulae
and the jejuno-ileum was commonly affected (60.9%). The complication rate was 34.8% and sepsis
was the most common complication. Sixteen patients (17.4%) had HIV infection. Fistula closure was
successfully achieved in 64 patients (69.6%). Of these, 42 patients (65.6%) had spontaneous closure
and 22 patients (34.4%) underwent surgical closure. Mortality rate was 30.4%. Using multivariate
logistic regression, the cause of fistula, fistula output, presence of complications and institutional
origin of the patient were found to be significant predictors of spontaneous closure (p-value < 0.001),
where as surgical closure was significantly associated with presence of complications and pre-morbid
illness (p-value < 0.001). Fistula output, institutional origin of the patient, presence of complications
and premorbid illness, HIV positivity and CD4 count were significant predictors of mortality.
Conclusion: Enterocutaneous fistulae pose a therapeutic challenge at BMC and contribute
significantly to high morbidity and mortality. A multidisciplinary approach focusing on fluid
resuscitation, nutritional supplementation, electrolyte replenishment, control of sepsis, containment of
effluent, skin integrity and surgery at appropriate time is necessary to lessen morbidity and mortality
with a higher fistula closure rate. The high rate of postoperative enterocutaneous fistulae resulting
from anastomotic breakdown in patients referred from peripheral hospitals calls for urgent surgical
skill training course in this region. The high rate of HIV infection in these patients needs further
studies.
Introduction
Enterocutaneous fistulas, defined as abnormal communications between epithelial lining of the bowel
and skin, are among the most challenging conditions managed by general surgeons 1, 2. Morbidity and
mortality associated with enterocutaneous fistulae are still considerable, primarily due to inadequate
nutrition, sepsis, fluid and electrolyte disturbance and skin digestion and the current treatment even if
successful, may require prolonged hospitalization or repeated operations1-3. The challenge is even
more conspicuous in a developing country like Tanzania where parenteral nutrition for nutritional
support in these patients is inaccessible.
At Bugando Medical Centre, enterocutaneous fistula is not uncommon in the surgical wards 4. Being
a referral hospital, the majority of fistulas seen at Bugando Medical Centre are an end- result of post
operative complication referred from peripheral hospitals in the North-western and Lake Zones of
Tanzania.
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The etiological pattern of enterocutaneous fistula in the developed countries is reported to be different
from that in the developing countries. While the most common causes of enterocutaneous fistula in
the developed countries are inflammatory bowel diseases and diverticular diseases, the main cause in
the developing countries is due to iatrogenic postoperative complications of abdominal surgery 1, 3, 5.
Understanding the etiological factors involved in fistula formation and determination of fistula
characteristics is essential in planning for prevention strategies to minimize its occurrence and also
allows prediction of the course of the patient and likelihood of spontaneous closure. Identification of
factors that influence the likelihood of fistula closure and death is of greater value for the surgeon
when making decision6.
This study was conducted to describe our experience in the management of enterocutaneous fistula
and to compare this with what is happening in other parts of the world. The study outlined the
etiological spectrum, fistula characteristics, treatment outcome and prognostic factors for fistula
closure and mortality in our setting.
Patients and Methods
This was a prospective study of patients with enterocutaneous fistula admitted to the general and
pediatric surgical wards of Bugando Medical Centre (BMC) over a 2-year period between December
2007 and November 2009. BMC is a 1000-bed, consultant and tertiary care hospital for the Northwestern and Lake Zones of Tanzania. It is also a teaching hospital for the Weill- Bugando University
College of Health Sciences and other paramedics. During this study, patients with enterocutaneous
fistula either occurred at BMC or admitted to BMC after being referred from peripheral hospitals were
(depending on the age of the patient) admitted to the general or pediatric surgical wards.
On admission, these patients were aggressively resuscitated with fluid and electrolytes in the first 48
hours. Concurrent with fluid resuscitation, appropriate antibiotics (commonly parenteral ceftriaxone,
metranidazole and gentamicin) were often prescribed. A colostomy bag was applied to the fistula
opening to protect the skin from effluent and to give accurate measurement of the daily fistula output.
Enteral feeding was commonly given for nutritional support. Facilities for total parenteral nutrition
(TPN) are not usually available at our centre and therefore no patient in our study used TPN. Fluid
and electrolyte imbalances were assessed by measurement of serum electrolytes and creatinine and
this was done to all patients. Fistulogram and barium studies were occasionally performed to define
the anatomical location of the fistula. The anatomical location of the fistula was also confirmed at
surgery. Abdominal ultrasound was performed to localize abdominal collections. Patients were first
treated conservatively for a minimum of four weeks to allow spontaneous closure. Surgical closure
was only considered when spontaneous closure failed or when the patient developed complications.
In this study, all patients with enterocutaneous fistula were screened for inclusion criteria. Those who
met the inclusion criteria were, after informed consent for the study and for HIV testing,
consecutively enrolled in the study. The approval to carry out the study was sought from relevant
authorities.
A pre-tested, coded questionnaire was used to collect data. Data entered in the questionnaire were:
demographic data, premorbid illness, institutional origin of the patient, cause of the fistula, the timeinterval between the causative event and appearance of the fistula, fistula output, anatomical location
of the fistula, type of nutritional support, HIV status and presence of complications; outcome
variables included: spontaneous closure, surgical closure and mortality. Fistula output was recorded as
high output when the fistula effluent was 500mL/24 hours or more and low output when the fistula
output was less than 500mL/24 hours; Spontaneous closure was recorded when the fistula closed after
conservative treatment alone. Surgical closure was recorded either as an ancillary surgical procedure
(abscess drainage, enterostomy etc) or as definitive fistula closure (resection and anastomosis).
Mortality was recorded if it occurred during the same hospitalization in which the fistula was treated.
Data was analyzed using SPSS computer software version 11.5. In the univariate analysis, Chi-square
test was used for categorical variables and t-test for continuous variables, to identify which of the
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independent (predictor) variables were the significant predictors of the outcome (spontaneous closure,
surgical closure and mortality). Multivariate logistic regression analysis was used to determine
predictor variables that are associated with outcome. A p-value of less than 0.05 was considered
statistically significant.
Results
A total of 92 patients were studied. Fifty four (58.7%) patients were males and thirty eight (41.3%)
females (M: F ratio = 1.4:1). Their ages ranged from 6 to 76 years (median 26 years) with the highest
age incidence in the 21-30 years age group (Figure 1).
Fourteen patients (15.2%) had pre-morbid illness such as diabetes mellitus in 6 patients, heart disease
in 2 patients, tuberculosis in 2 patients, and renal disease , a huge goiter, obstructive jaundice and
chronic chest infections in one patient each respectively.
Surgical complication was the most common cause of enterocutaneous fistula accounting for 84
patients (91.3%). Of these, 71 patients (84.5%) were referred from peripheral hospitals as a result of
postoperative complications of abdominal surgery. Only in 13 patients (15.5%), enterocutaneous
fistulae occurred at Bugando Medical Centre. Of these, enterocutaneous fistulae resulted from
complications of abdominal surgery performed by junior doctors (resident in surgery, medical officers
and interns) in 9 patients (69.2%). Consultants /specialists contributed to enterocutaneous fistulae in
the remaining 4 patients (30.8%). Anastomotic breakdown was the most common reason for fistulae
resulting from postoperative complications in 65 patients (70.7%). Non–surgical causes of
enterocutaneous fistulae occurred in eight patients (8.7%) mainly due to penetrating abdominal
trauma in 3 patients, blunt abdominal trauma in 2 patients and inflammatory, neoplastic and
strangulated Richter’s inguinal hernia in one patient each respectively . One patient who had
penetrating abdominal trauma had also multiple injuries. The time-interval between the causative
event and appearance of the fistula varied from 1 to 82 days (median of 6 days).
Fifty eight patients (63.0%) had high output fistulae and the remaining 34 patients (37.0%) had low
output fistulae. The mean fistula output for the high output and low output fistulae were 634 mL/ 24
hours and 358 mL/ 24 hours respectively. In this study, the jejuno-ileum was the most common part of
the bowel affected and occurred in 45 patients (48.9%). This was followed by the colon in 33 patients
(35.9%). The duodenum was involved in 2 patients (2.2%), one patient due to gunshot penetrating
abdominal trauma and the other patient was due to missed injury at first laparotomy. Cholecystoenterocutaneous fistula occurred in one patient (1.0%) as a result of neglected cholelithiasis. The
anatomical location of the fistula could not be established by any studies in 11 patients (11.9%) who
had spontaneous fistula closure and those who died respectively (i.e. 28 patients died giving a
mortality rate of 30.4%).
Significant intra abdominal collection was detected by abdominal ultrasound in 19 patients (20.7%)
and all, except one patient who had burst abdomen, were treated successfully with laparotomy and
drainage of pus.
All patients in this study received enteral feeding. No patient had total parenteral nutritional support.
Complications mainly sepsis occurred in 32 patients (34.8%). In this study, 16 patients (17.4%) were
HIV positive with CD4 count ranging from 50 to 675 cells/µl (median 245 cells/µl). The mortality
rates was 75% and 21.1% for HIV positive and HIV negative patients respectively and it was
significant. The mortality rates among patients with CD 4 count < 200 cells/µL and CD 4 count ≥200
cells/µL was 81.8% and 60.0% respectively. This was also significant. There was no significant
association between HIV infected patients with CD 4 count < 200 cells/µL and either spontaneous or
surgical fistula closure (p-value > 0.05).
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East and Central African Journal of Surgery Volume 15 Number 2.
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50
42
Percent
40
30
20
22
13
10
8
7
5
0
0-10
11-20
21-30
31-40
41-50
51-60
61-70
>70
Fi gure 1: Age group di stri buti on
Table 1. Univariate analysis for spontaneous closure, surgical closure and mortality
NB. “ns” stand for statistically non-significant
Independent variable
Spontaneous closure
%
p-value
Age (in years)
< 50
46.3
≥50
40.0
Gender
Male
53.7
Female
34.2
Premorbid illness
Present
14.3
Absent
51.3
Institutional origin
BMC
66.7
Not-BMC
41.6
Cause
Surgical
47.6
Non-surgical
25.0
Fistula output
High output
32.8
Low output
67.6
Anatomical location
Duodenum
50.0
Jejuno-ileum
33.3
Colon
51.5
Biliary
0.0
Not established
81.8
Complications
Present
13.6
Absent
55.7
HIV status
Positive
12.5
Negative
65.8
CD4 count (cells/µ
µL)
Surgical closure
%
p-value
%
Mortality
p-value
0.213
23.2
30.0
“ns”
30.5
30.0
0.065
22.2
26.3
“ns”
24.1
39.5
“ns”
0.321
35.7
21.8
“ns”
50.0
26.9
“ns”
0.032
26.8
23.4
“ns”
6.8
35.0
“ns”
0.021
22.6
37.5
“ns”
29.8
37.5
“ns”
0.024
29.3
14.8
“ns”
37.9
17.6
“ns”
0.0
26.7
33.3
100.0
0.0
“ns”
50.0
40.0
18.2
0.0
27.2
“ns”
0.011
9.1
28.6
“ns”
77.3
15.7
0.001
0.043
12.5
13.1
“ns”
75.0
21.1
“ns”
< 0.05
East and Central African Journal of Surgery
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East and Central African Journal of Surgery Volume 15 Number 2.
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< 200
9.1
9.1
≥ 200
20.0
0.023
20.0
“ns”
Table 2. Multivariate logistics regression analysis for spontaneous closure
Independent (predictor) variable
Odds ratio
95% C.I.
Cause of fistula
3.6
1.3-97.1
Fistula output
12.1
4.3-24.6
Institutional origin of the patient
2.82
0.9-8.3
Presence of complications
14.3
5.6-38.7
81.8
60.0
“ns”
p-value
“ns”
“ns”
“ns”
0.001
Table 3. Multivariate logistics regression analysis for surgical closure
Independent (predictor) variable
Odds ratio
95% C.I.
Presence of complications
15.4
5.9-37.2
Presence of pre-morbid illness
2.45
1.9- 10.7
p-value
0.001
“ns”
Table 4. Multivariate logistics regression analysis for mortality
Independent (predictor) variable
Odds ratio
95% C.I.
Institutional origin of the patient
2.13
1.0-4.6
Fistula output
11.5
4.2-25.2
Presence of pre-morbid conditions
10.2
5.3 -25.4
Presence of complications
8.5
1.2-176.4
HIV positivity
4.1
1.9-9.3
CD4 count
11.0
4.7-26.6
p-value
“ns”
“ns”
“ns”
0.001
0.001
0.000
Fistula closure was successfully achieved in 64 patients (69.6%). Of these, 42 patients (65.6%) had
spontaneous closure and the remaining 22 patients (34.4%) underwent surgical closure. The time
interval between the occurrence of the fistula and spontaneous closure ranged from 30-90 days (mean
52 days). Of the patients who underwent surgical closure, 10 patients (45.5%) required a second
procedure for the final closure. These included; laparotomy and drainage of pus in 2 patients (20%),
laparotomy and exteriorization of the fistula in 4 patients (40%) and laparotomy and enterostomy
(ileostomy/ colostomy) in 4 patients (40%). The mean time interval between the second procedure and
the final fistula closure was 34 days (range 30-50 days).
In this study, 28 patients (30.4%) died of complications related to sepsis, poor nutritional support,
premorbid conditions and HIV infections. The prognostic factors for spontaneous closure, surgical
closure and mortality in the univariate analysis are shown in Table 1. Multivariate regression analysis
is presented in Tables 2, 3 and 4.
Discussion
Since its first description, enterocutaneous fistulae still contribute significantly to high
morbidity and mortality worldwide and pose therapeutic challenges to general surgeons
despite improvement in its management 7. This study was conducted to describe our own
experience in the management of this devastating disease in our environment. The majority of
our patients was youth in their most productive years and showed a male preponderance.
However, the age and gender in this study were not significantly related to the chance of
fistula closure or mortality. Similar findings have been reported from other studies 6, 8. We
could not establish the reason for the young age and male predominance.
In this study, postoperative enterocutaneous fistulae secondary to anastomotic breakdown
were the most common preventable cause of enterocutaneous fistulae and the majority of
patients were referred from peripheral hospitals in the North-western and Lake zones of
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Tanzania. Similar admission trend was also noted in other studies 7, 9. This observation
reflects poor surgical technique in bowel anastomosis and lack of surgical skill training
among doctors in the peripheral hospitals. This finding calls for urgent surgical skill training
course among doctors in this region.
In our study, the institutional origin of the patient was a significant predictor of spontaneous
fistula closure and mortality (p-value <0.001). Spontaneous closure was achieved in 66.7% of
the patients operated upon primarily in our hospital and in only 41.6% of referred patients.
Mortality rate was 35.0% and 6.8% for referred patients and patients operated upon primarily
at BMC respectively (p-value <0.001). This is in agreement with other studies which reported
similar findings 8, 10. The reason for this observation may be due to the fact that BMC been a
tertiary and referral hospital, the majority of patients referred to this hospital are in poor
general condition, and on admission, most patients are malnourished and septic and have
severe skin lesions with fluid and electrolyte imbalances, and organ dysfunction, so the
chance of spontaneous closure and survival among referred patients is unlikely compared
with patients operated upon primarily at BMC. These findings stress the importance of
prompt general and nutritional care when enterocutaneous fistula is diagnosed to avoid
deterioration of the patient’s condition.
Our study demonstrated high rates of high output fistulae compared with low output
enterocutaneous fistulae. This is in contrast with one study which reported high rate of low
output fistula 11. High rates of high output fistulae in our study may be attributable to the fact
that the jejuno-ileum which is the more proximal part of the digestive tract was commonly
affected. As a general rule, the more proximal in the digestive tract, the greater the fistula
output will be.
Accurate measurements of fistula output, although often difficult to obtain secondary to poor
fitting ostomy appliances or nursing issues, can be helpful in predicting outcome. In our
study, fistula output was found to be a significantly independent predictor of spontaneous
closure and mortality (p-value <0.001). Spontaneous fistula closure was greater in low-output
fistulas than in high-output fistulas. This was in agreement with findings of studies done
elsewhere 12-14. High output enterocutaneous fistulas are more likely to be associated with
malnutrition, sepsis, fluid and electrolyte disturbances, lower incidence of spontaneous
closure and mortality.
Although the anatomical location of the fistula was associated with both fistula closure and
mortality in univariate analysis, the association was not statistically significant in multivariate
logistic regression analysis.
The provision of nutritional support with either enteral or parenteral feeding is a key
component of management in patients with enterocutaneous fistula and can also be used to
predict outcome. These patients are often malnourished due to the lack of food intake, the
hypercatabolism of sepsis, and the loss of protein-rich enteral content. Parenteral nutrition has
long been recognized to be an integral part of the management of enterocutaneous fistulas
7,11,13
. However, in limited-resource countries like ours, parenteral nutrition may not be
accessible. Parenteral feeding was not used in our patients due to its inaccessibility. Although
the type of nutritional support was associated with both fistula closure and mortality in some
studies 6, 8, this variable was not assessed in our study due to logistic problem.
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The proportion of patients with complications in the present study is comparable with other
studies 5, 6, 8. The presence of complications was found to be significantly associated with
both fistula closure (spontaneous and surgical) and mortality (p-value < 0.001). Mortality rate
was 77.3% and 15.3% in patients with complications and those without complications
respectively. Similar finding was also observed in other studies 5, 15, 16. The reason for the
high mortality rate associated with complications in our study is due to the fact that sepsis
which contributes significantly to high mortality in these patients was the most cause of
complications accounting for 72.7% of all cases with complications.
The prevalence of HIV infection in our patients (17.4%) was found to be higher than in
general population (5.7%). Further studies are needed to explain this observation. Our study
also demonstrated high mortality rates among HIV positive patients with low CD 4 count
(< 200 cells/µL). We could not find any study in the literature outlining the impact of HIV
positivity and CD 4 count on the outcome of patients with enterocutaneous fistula. The
reason for the high mortality rate in HIV infected patients with low CD 4 count (< 200
cells/µL) is due to the fact that HIV infection causes low immunity predisposing these
patients to sepsis which is the commonest cause of death in these patients.
The rate of spontaneous closure has been reported in literature to vary from 23% to 80% 12, 17,
18
. The rate of spontaneous closure in our study was higher than in other studies 1, 3, 8, 11. In
our study, the majority of patients had a spontaneous fistula closure after an average of 50
days. Reber et al 15 reported higher rates of spontaneous closure in fistula resulted from
surgical causes than in fistulae resulted from non-surgical causes. They concluded that the
likelihood of spontaneous closure is higher in fistula resulting from surgical causes and with
no complications. The high rate of fistula from surgical causes reflected the high rate of
spontaneous closure in our study.
The timing of definitive surgical closure of the fistula is a controversial subject. Most studies
advocate delayed surgical closure for at least 3 months after the fistula has arisen to allow for
fistula maturation, resolution of inflammation within the peritoneal cavity, optimization of
the patient’s nutritional state and for residual sepsis to resolve 5, 7, 11. Premature attempts at
operative closure with inflamed, erythematous or necrotic tissue increases the risk of
peritoneal contamination, the formation of dense adhesions and recurrent fistula formation.
This teaching has been challenged by a recent study which advocated an aggressive early
surgical closure in which surgical intervention was done after a maximum period of 14 days
of conservative treatment with judicious use of octreotide, nutritional support, stoma care and
control of sepsis 1. Our own experience generally tries to wait at least 8-12 weeks from the
time of occurrence of the fistula. This is because most of our patients come from peripheral
hospitals and require some weeks of preparation for nutritional parameters to improve so that
operation can be carried out.
The overall mortality rate of enterocutaneous fistulae has been reported in literature to vary
from 6.45% to 48% 1, 3, 6-17. The overall mortality rate (30.4%) in our study was found to be
higher than that reported in Nigeria (18%) 11. The high mortality rate in our study can be
explained as follows; first, the majority of patients referred to BMC are in poor general
condition, and on admission, most of them are malnourished and septic and have severe skin
lesions with fluid and electrolyte imbalances, and organ dysfunction, so the chance of
survival is unlikely. Second, the majority of our patients had high output fistulae predisposing
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them to fluid and electrolyte imbalances, sepsis, malnutrition, lower incidence of spontaneous
closure and mortality. Third, the presence of pre-morbid illness and high rate of septic
complications contributed significantly to high mortality rate in these patients. Fourth, the
high rate of HIV infection in these patients was also a predictor of mortality.
Lack of parenteral nutrition, failure to assess nutritional status of the study population and
small sample size were the major limitations in this study. However, despite the above
limitations, this study has clearly demonstrated that enterocutaneous fistulae are a major
problem in our setting and are associated with considerable morbidity and mortality primarily
due to inadequate nutrition, sepsis, fluid and electrolyte disturbance and skin digestion, and
present a considerable challenge in their management. The study has also demonstrated HIV
seroprevalence and its effect on the outcome of these patients.
Conclusion
Enterocutaneous fistulae present a therapeutic challenge at BMC and contribute significantly
to high morbidity and mortality. The majority of fistulae are due to postoperative
complication of abdominal surgeries performed in the peripheral hospitals. The likelihood of
spontaneous fistula closure is higher for fistulas with surgical causes, low output, and with no
complications. Surgical closure is more likely to be indicated in patients with premorbid
illness and complications. Mortality is higher in HIV infected patients with low CD4 count,
high-output
fistulas
and
patients
with
premorbid
ill
ness and complications. HIV seroprevalence is higher in patients with enterocutaneous
fistulae than in general population.
Recommendations
A multidisciplinary approach focusing on fluid resuscitation, nutritional supplementation,
electrolyte replenishment, control of sepsis, containment of effluent, skin integrity and
surgery at appropriate time is necessary to avoid morbidity and mortality associated with this
complication. The high rate of preventable postoperative enterocutaneous fistulae resulting
from anastomotic breakdown in patients referred from peripheral hospitals is unacceptable
and calls for urgent surgical skill training course in this region. Further studies are needed to
explain the higher rate of HIV infection in these patients.
Early referral to well equipped hospitals or Tertiary hospitals is highly recommended.
Acknowledgement
The authors would like to acknowledge the efforts of all doctors, nurses and the operation
theatre staff who were involved in the care of these patients.
References
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2. Martineau P, Shwed JA, Denis R. Is Octerotide a new hope for enterocutaneous and
external pancreatic fistula closure? Am J Surg 1996;172:386-95
3. McIntyre PB, Ritchie JK, Hawley PR. Management of enterocutaneous fistulas: a
review of 132 cases. Br J Surg 1984; 71:292-6.
4. Bugando Medical Centre (BMC)-medical record database 2007-2009
5. Metcalf C. Enterocutaneous fistulae. Journal of Wound Care.1999;8(3):141-142.
6. Campos ACL, Meguid MM, Coelho JCU. Factors influencing outcome in patients
with gastrointestinal fistula. Surg Clin Nort Am 1996; 76:1191–1198
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7. Amy RE, Josef EF. Current management of enterocutaneous fistulas. J Gastrointest
Surg 2006; 10: 455-464
8. Antonio CL, Dalton F A, Guilherme MR, Jorge EF, Julio CU. A Multivariate Model to
Determine Prognostic Factors in Gastrointestinal Fistulas. J Am Coll Surg 1999;
188:483–490.
9. Berry SM, Fischer JE. Enterocutaneous fistulas. In: Wells SA Jr, ed. Current
Problems in Surgery, Vol. 31. St.Louis: Mosby, 1994, pp 469–576.
10. Schein M, Decker GA. Postoperative external alimentary tract fistulas. Am J Surg
1991; 161:435–438.
11. Nwabunike TO. Enterocutaneous fistulas in Enugu, Nigeria. Dis Colon Rectum.
1984;27(8):542-4
12. Sitges-Serra A, Haurieta E, Sitges-Creus A. Management of postoperative
enterocutaneous fistulas: the roles of parenteral nutrition and surgery. Br J Surg 1982;
69:147–150.
13. Levy E, Frileux P, Cugnenc PH, et al. High-output external fistulae of the small
bowel: management with continuous enteral nutrition.Br J Surg 1989; 76:676–679.
14. Edmunds LH, Williams GM, Welch CE. External fistulas arising from the
gastrointestinal tract. Ann Surg 1960;152:445–471
15. Reber HA, Roberts C, Way LW, Dunphy JE. Management of external gastrointestinal
fistulas. Ann Surg 1978;188:460–467
16. Soeters PB, Ebeid AM, Fischer JE. Review of 404 patients with gastrointestinal
fistulas. Impact of parenteral nutrition. Ann Surg 1979; 190:189–202.
17. RinsemaW, Gouma DJ, Meyenfeldt MF, et al. Primary conservative management of
external small-bowel fistulas. Acta Chir Scand 1990; 156:457–462.
18. Rose D, Yarborough MF, Canizaro PC, Lowry SF. One hundred and fourteen fistulas
of the gastrointestinal tract treated with total parenteral nutrition. Surg Gynecol Obstet
1986;163:345–350
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Association between Intraoperative Bactibilia and Postoperative Septic Complications
in Biliary Tract Surgery.
Arshad B. Khan1, Athar B. Khan2 , S. A. Salati1 , N.A Bhat1, B.K. Parihar3
1
Assistant consultant General surgery, King Fahad Medical city, Riyadh, Po Box 59046, KSA-11525
2
Senior resident General surgery, Sheri Kashmir institute of medical Sciences, soura Srinagar,
Jammu & Kashmir, India-180001
3
Professor & former Head of Department, Government MedicalCollege and associated hospitals, Jammu,
Bakshi Nagar India-180001
Correspondence to: Dr.Arshad Bashir Khan, Email: [email protected], [email protected]
Infected Ductal Bile and Postoperative Septic Complications
Background: The present study intended to clarify the role of biliary bacteria in the
development of postoperative septic complications in patients undergoing biliary operations
and need for antibiotic prophylaxis.
Patient and methods: A total of 121 patients with various biliary tract disease underwent
various surgical interventions. The relation between contaminated ductal bile and
postoperative septic complications was analyzed prospectively.
Results: 42/121 patients were bile culture positive (B+) while 79/121 patients were bile
culture negative (B-).14 patients in B (+) group developed septic complications compared to
only 3 patients in B (-) group (P = 0.0001). In B (+) group,bacteria found in ductal bile were
also detected in infected sites of 85% of patients with septic complications. In B (+) group
postoperative antibiotic modification significantly (p=0.001)reduced infectious
complications.
Conclusion: Infected bile plays a critical role in development of post operative septic
complications. Hence patients with risk factors for bactibilia should receive prophylactic
antibiotics covering endogenous gram negative organisms which should be modified in
postoperative phase according to the results of sensitivity. However this issue requires to
investigated further by the studies conducted on similar lines.
Introduction
Benign disease of the biliary tract is one of the most common indications for major
abdominal surgery in India, particularly in the northern part of the country. Bactibilia has
long been known to be associated with biliary tract diseases and culturable bacteria in bile
can represent a state of asymptomatic bactibilia which can disseminate after any intervention
causing infective complications [1]. Various risk factors for the presence of bactibilia like
age>65 years, recent acute cholecystitis, recent acute pancreatitis, cholangitis, jaundice, and
choledocholithiasis have been well established [2,3].Septic complications have been
established to play an increasingly important role in the morbidity and mortality of biliary
tract diseases and biliary surgery, and despite advances in the antibiotic therapy such
complications still continue to be a problem in biliary surgery [2,4,5]. There has been a
considerable debate on the use of antibiotics in biliary surgery with some favoring antibiotic
prophylaxis in open biliary surgery while others disapproving the need for routine antibiotic
prophylaxis in elective cholecystectomy [6,7,8]. But all of these studies included patients
undergoing cholecystectomy alone and there is dearth of data regarding the need for
antibiotics in open and complex biliary operations . In order to associate high incidence of
septic complications in biliary surgery to culturable bacteria in bile, it needs to be proven that
same organisms are cultured from the infected source, in case a postoperative septic
complication occurs. So the aim of our study was to find a relation between postoperative
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septic complications and culturable bacteria in bile and to assess the need for antibiotic
prophylaxis. The present study further explored, is it worthwhile to prolong and tailor
antibiotic prophylaxis in the postoperative period as per the results of culture sensitivity
patterns of organisms present in ductal bile.
Patients and Methods
This prospective study included 121 consecutive patients who underwent various biliary
operations in the department of surgery of a tertiary hospital over a period of one year.
Following groups of patients were included in the study: Recent acute cholecystitis (21),
recent acute pancreatitis (3), obstructive biliopathy due to carcinoma or stones (12),
cholelithiasis (71), CBD stones without jaundice (10) and cholangitis (4). Details of age,
history, radiology, operation and postoperative course were noted in SPSS version 14
database . Patients were included in the study after obtaining an informed consent. All
patients received a single preoperative shot of cefazolin at induction of anesthesia as per the
previously established protocols.
Surgical procedures
The surgical procedures performed are shown in Figure 1.
Distribution of operative procedures (n=121)
140
120
100
80
60
40
20
0
100%
78.50%
95
121
17.30%
21
0.82%
1
2.40% 0.82%
3
1
Percentage
Number of patients
Figure 4. Operative Procedures Performed
Bile cultures
At operation about 3-5ml of bile was harvested and transported immediately to lab for
testing. Patients were were stratified in to bile culture positive (B+) and bile culture negative
(B -) groups according to the presence and absence of culturable bacteria in bile. Both groups
were analyzed for the absence or presence of risk factors for bactibilia including age>65
years, recent acute cholecystitis, recent acute pancreatitis, jaundice, CBD stones without
jaundice and cholangitis. B (+) patients were randomly selected to receive or not to receive
postoperative therapeutic antibiotics as dictated by the results of culture sensitivity.
Postoperative complications
Infectious complications were demonstrated by positive site specific cultures and need for
antibiotic therapy. Samples were taken for culture in each complication and compared to
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intraoperative culture sensitivity of bile. Postoperative complications in B+ group were
compared with B- group and inferences were drawn.
Statistical analysis:
Statistical analysis of qualitative variables was performed using the χ2 test and analysis of
quantitative variables was performed using unpaired t test and statistical significance was
taken at 5% level.
Results
There were121 biliary operations performed. 42 patients were B(+) while 79 patients were
(B-). The characteristics of these two groups are shown in the following table (Table I).
Greater number of patients in B+ group had acute presentations.
Table 1. Patient Characteristics (n=121).
Patient
characteristic
Bile
Bile
culture(+) culture
(-)
P
value
Age(Mean±SD)
Sex(M/F)
Diagnosis
Chronic cholecystitis
Recent
acute
Cholecystitis
Recent
acute
pancreatitis
Jaundice
CBD stones, no jaundice
Cholangitis
Operative procedures
Cholecystectomy
Choledochotomy
Cholecystojejunostomy
ERCP+Cholecystectomy
Cholecystostomy
65±3.6
28/14
55.5±10.2
30/49
0.0001‫٭‬
0.003‫٭‬
14
10
57
11
0.0001‫٭‬
0.20
1
2
1.00
8
6
3
4
4
1
0.02‫٭‬
0.09
0.11
24
14
1
3
0
71
7
0
0
1
0.0001‫٭‬
0.27
0.34
0.03‫٭‬
1.00
*p<0.05 by unpaired t test
The analysis of prevalence of the risk factors for bactibilia is shown in Table 2.
B+ group had 14(33.3%) infective complications with wound infection being the most
common complication while B- group had 3(3.7%) wound infections only (p<0.0001) as
summarized in the following table (Table III):
As per the study protocol patients in B+ group were randomly selected to receive or not to
receive postoperative antibiotics. Hence antibiotics in 17 patients in B (+) group were
modified as dictated by culture sensitivity, where as in 25 patients they were not modified. In
the antibiotic modification arm only one wound infection was seen, where as in no antibiotic
modification arm, 13 septic complications (p=0.001) occurred as shown in Table 4.
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Table 2. Prevalence of risk factors for bactibilia
Parameter
Bile
culture+(
n=42)
Bile
culture(n=79)
P
value
Age>65 years
Recent
acute
cholecystitis
Recent
acute
pancreatitis
Jaundice
CBD
stones,
no
jaundice
Cholangitis
Total proportion with
risk
factors
for
bactibilia
7(16.6%)
10(23.8%)
4(5.0%)
11(13.9%)
0.04*
0.20
1(2.3%)
2(2.5%)
1.00
8(19.0%)
6(14.2%)
4(5.0%)
4(5.0%)
0.02*
0.09
3(7.1%)
35(83.3%)
1(1.2%)
26(32.9%)
0.11
0.0001*
*p≤0.05 statistically significant by χ2 test
Table 3. Septic complications as per bile cultures
Parameter
Wound infection
Intra-abdominal
abscess
Bacteremia
Septicemia
UTI
Total
Bile culture
+(n=42)
9
1
Bile
culture
(n=79)
3
0
1
2
1
14(33.3%)
0
0
0
3(3.7%)
P value
–
0.001*
0.34
0.34
0.11
0.34
0.0001*
P=0.0001 by χ2 test
Table 4. Antibiotic versus no antibiotic modification arms in B (+) group
Parameter
No. of patients
Wound infection
Intra-abdominal
abscess
Septicemia
Bacteremia
UTI
Total
Antibiotic
modification
17(40.4%)
1
0
No antibiotic
modification
25(59.6%)
8
1
0
0
0
1(2.3%)
2
1
1
13(30.9%)*
*p=0.001 by χ2 test
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In order to find the influence of severity of operative trauma on septic complication in wake
of positive bile culture, a note was taken of different septic complications in different
operative procedures in presence of bactibilia. In laparoscopic cholecystectomy group (n=60),
12 patients were bile culture positive and only 1 patient developed urinary tract infection.
While patients who underwent open cholecystectomy (n=35), 8 were bile culture positive and
4 developed infective complications. Similarly in all other operative groups the severity of
operative trauma correlated with occurrence of postoperative infective complications. These
observations are tabulated in Table 5.
Table 5. Septic Complication Related to Type of Operation
Operation
Cholecystectomy(open)
Cholecystectomy(Laparos)
Choledochotomy
Cholecystojejunostomy
Cholecystostomy
ERCP+Open
cholecystectomy
Number of
patients/Bile
culture(+)
35 / (8)
60/ (12)
21/ (18)
1/ (1)
Septic complication/no. of pts.
Wound infection 4
UTI 1,
Wound infection 4, Intra-abdominal abscess 1, septicemia 1
Septicemia 1
1/ (1)
3/(2)
Bacteremia 1
Wound infection 1
Table 6. Correlation between intraoperative bile culture and organism recovered in case of
infective complication
Complications
No.
of
patients
Wound infection
9
Bile culture + (n=42)
Intraoperative
Postoperative
bile cultures/no. culture source
of patients
E coli/7
Wound swab
Proteus/2
Complicating
patients
organism/no.
of
Ecoli/6
Staphylococcus/1
Proteus/1
Staphylococcus/1
Intra-abdominal
abscess
Septicemia
1
E coli/1
Pus
Ecoli/1
2
Ecoli/1
Klebsiella/1
Blood
Ecoli/1
Klebsiella/1
Bacteremia
1
Ecoli/1
Blood
Ecoli/1
UTI
1
Wound infection
3
Ecoli/1
Urine
Bile culture – (n=79)
Negative
Wound swab
Ecoli/1
Staphylococcus/3
The organism obtained on culture in case of a postoperative septic complication was
compared with the organism obtained during intraoperative bile culture. Overall in B (+)
group 9 wound infections occurred. 6/9 were caused Ecoli, 1 by Proteus and remaining 2 by
staphylococcus. In 7/9wound infections the complicating organism from wound swab culture
and organism grown on bile culture displayed same colony, sensitivity and resistance
patterns. In all other infective complications specimen culture grew the organisms similar to
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that grown on intraoperative bile culture. Thus the organism grown from septic source
correlated with the organisms grown on intraoperative bile culture in 85% of cases. These
results are shown in Table 6.
Discussion
In the present study the bile of 121 consecutive patients undergoing various biliary
procedures was examined for the presence of bactibilia and the patients were followed for the
development of septic complications in the postoperative course. Certain preoperative risk
factors were identified to be associated with the possibility of having positive bile cultures
viz: age>65 years, recent acute cholecystitis, recent acute pancreatitis, jaundice,
choledocholithiasis and cholangitis. Similar risk factors have been confirmed by previous
studies [3,9,15] .In the present study the preoperative risk factors predictive of bactibilia were
present in 35/42(83.3%) (B+ )patients , whereas only 26/79 (32.9%) B- patients had presence
of such risk factors. This difference could be explained by the greater proportion of patients
with complicated gall bladder disease in B (+) group compared to B (-) group. Moreover the
absence of culturable bacteria in bile in many patients in B (-) group who otherwise had risk
factors predictive of bactibilia could be explained by frequent antibiotic courses which these
patients had received during the course of their illness. As the presence of these risk factors
correlates with the incidence of positive bile cultures, it would be worthwhile to categorize
the patients with such risk factors as high risk, and subject such patients to routine bile
cultures. This finding is in accordance with published study by Morris et al, where the
authors found one of the risk factor to be present in 19 out of 20 patients with bactibilia [9].
Though it has been established through various studies that bile is colonized in biliary
diseases and high incidence of septic morbidity has been identified in such patients [2,10] . On
the other hand patients with out biliary disease have been found to have sterile bile. A study
by Csendes et al[11] compared the prevalence of bactibilia in normal controls (gastric ulcer
surgery) to patients undergoing cholecystectomy for acute and chronic cholecystitis. They
found that all controls had sterile bile while those with acute and chronic cholecystitis had
positive cultures in 47% and 30% of cases, respectively.
In the present study antibiotics were administered following induction of anaesthesia in all
cases, in accordance with published recommendations [12]. It may be argued that
administration of antibiotics may have adversely biased the positive culture rates of the bile.
A study by the Pitt et al showed that antibiotic therapy does not sterilize bile, but merely
altered biliary bacteriology [13]. So it seems highly unlikely that a single dose of an antibiotic
would have rendered bile sterile. Another consideration is that the antibiotics may have
influenced the incidence of postoperative infections. As Cephazolin was used which has good
activity against gram positive organisms and extremely poor gram negative spectrum, it is
conceivable that the effect would have been comparable for the two groups. So in present
study effect of Cephazolin on endogenous biliary organisms was considered to be minimal
based on predominant gram positive spectrum of this antibiotic. A further support for
inability of preoperative antibiotics to completely prevent septic complications of biliary
surgery comes from the study of Harling et al, where the authors found that septic sequelae of
uncomplicated laparoscopic cholecystectomy were not entirely prevented by antibiotic or
mechanical prophylaxis [14].
In the present study septic morbidity occurred in 14/42 (33.3%) B +ve patients with wound
infection dominating (9/14) the group. Whereas only 3/79 (3.7%) B -ve patients got wound
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infections. These findings are in close agreement to the host of previous studies. Nomura T et
al in their series found septic complications in 42% patients, with higher number of
complications in patients with contaminated bile[4]. Cainzos et al had septic complications in
42% of patients in their series [5] . Dellikaris et al in their study during 174 operations on
extrabiliary tree found 26% patients to be bile culture positive and septic complications
occurred in 33.3% patients. Wells GR in their series had septic complications in 22% patients
with positive bile culture while the incidence was only 2% in culture negative patients.
In order to find the need for therapeutic antibiotics in bile culture positive patients, as per the
study protocol, antibiotic modification as dictated by the result of culture sensitivity was done
in 17 B+ patients, while no antibiotics were given in rest of the B+ patients (n=25). Only 1
infection was observed in the former group whereas 13 infections occurred in the latter
group. In B (-) group 3 wound infection occurred, 1in cholecystectomy and 2 in
choledochotomy patients. Furthermore in B+ve group, the organisms causing the
postoperative septic complications were the similar to the organisms grown from the bile
culture in 85% of patients. The similarity was known from their colony characteristic and
sensitivity patterns. Only 2 wound infections in this group were caused by staphylococcus
which was presumably an exogenous organism, as E coli and Proteus were grown on bile
culture. In B -ve patients all the three infections were caused by Staphylococcus. Based on
this observation it could be argued that septic morbidity in biliary surgery is due to
endogenous organisms. Our observation is supported by several previous studies [16,17,18].
Wound infections in culture negative group could be explained on the basis of expected range
of operating room contamination or colonization by skin commensals. A further proof in
support of this observation comes from a study by Hambraeus et al where patients with and
without bactibilia developed wound infections at the rate of at 12.8% versus 3.2%,
respectively. In bile culture negative patients S. aureus was the predominant bacteria
responsible for causing wound infections [19]. On the contrary occurrence of large number of
septic complications in culture positive group could be explained by the spillage occurring
during the procedures or dissemination of bacteria occurring through the blood stream
secondary to manipulation of biliary tract which is already harboring bacteria [4,16] . In
choledochotomy bile invariably spills in peritoneal cavity. Thus it seems likely that direct
spread is an important factor in septic complications.
Despite prophylactic antibiotics, bile colonization remains the major factor associated with
postoperative sepsis. Scottish Intercollegiate Guidelines Network (SIGN) recommended that
antibiotics should not be prescribed, still most patients undergoing laparoscopic
cholecystectomy receive a single dose of prophylactic antibiotics on induction of anesthesia
[20]
.This advice is contrary to that given by Meijer and colleagues in a meta-analysis of trials
of antibiotic prophylaxis in open biliary tract surgery. From the results of 42 trials looking at
the effects of antibiotic prophylaxis in the prevention of wound infection, they suggested that
there was an overall 9% benefit in favor of antibiotic prophylaxis. When high-risk patients
were analyzed as a subgroup, the benefit of prophylaxis was greater. This paper concluded
that antibiotic prophylaxis should be administered [8]. As all of these studies concentrated on
cholecystectomy, the present study further explored the role of antibiotics in patients
undergoing complex biliary operations. The findings of the present study support the use of
postoperative antibiotics in B+ve patients till the results of culture become available, as it
helped to remarkably reduce the incidence of septic complications, as only 1 septic
complication occurred B+ve patients who received postoperative antibiotics. The present
study had some limitations which could have had an impact on the results. The number of
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patients included in the study was small. Secondly it involved a biliary case mix. Thirdly both
laparoscopic and open biliary operations were included while computing results. Fourthly it
did not look at the optimal duration for which antibiotics should be continued in
postoperative period. And lastly preoperative antibiotics were routinely given in all the
patients. So a study which takes in to account all these limiting factors needs to be designed
to explore this topic further.
Taken all evidence together it could be argued that infected ductal bile plays a critical role in
postoperative septic complications in biliary surgery. Routine intraoperative bile cultures
should be done only in patients with high risk for bactibilia and preoperative antibiotics
covering endogenous organisms should be given in such patients which should be modified
postoperatively according to the results of culture sensitivity. While patients in absence of
these risk factors justify a single preoperative dose of antibiotic covering exogenous gram
positive organisms only.
References
1. Flema RJ, Lwis M, William W et al. Bacteriologic studies of biliary tract
infection. Annals of surgrey 1967; 563-570.
2. Raphael Reiss,
Avinoam Eliashiv
and
Alexander A. Deutsch.
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3. Khan A B, Salati S A, Khan A B, Parihar BK. Are clinicopathological factors
predictive of bactibilia in biliary tract diseases? East and central African journal
of surgery 2009; 14(1): 24-31
4. Nomura T, Shirai Y, Hatakeyama K. Impact of bactibilia on the development of
postoperative abdominal septic complications in patients with malignant biliary
obstruction. Int Surg. 1999 Jul-Sep;84(3):204-8.
5. Cainzos M, Sayek I, Wacha H, Pulay I, Dominion L, Aeberhard PF, Hau T, Aasen
AO. Septic complications after biliary tract stone surgery: a review and report of
the European prospective study. Hepatogastroenterology. 1997 JulAug;44(16):959-67.
6. Illig KA, Schmidt E, Cavanaugh J, Krusch D, Sax HC. Are prophylactic antibiotic
required for elective laparoscopic cholecystectomy? J Am Coll Surg.
1997;184:353–6
7. Dobay KJ, Freier DT, Albear P. The absent role of prophylactic antibiotics in lowrisk patients undergoing laparoscopic cholecystectomy. Am Surg. 1999;65:226–8
8. Meijer WS, Schmitz PI, Jeekel J. Meta-analysis of randomized, controlled trials of
antibiotic prophylaxis in biliary tract surgery. Br J Surg. 1990;77:283–90
9. Morris-Stiff G J, O'Donohue P, Ogunbiyi S and Sheridan WG. Microbiological
assessment of bile during cholecystectomy: is all bile infected? HPB (Oxford).
2007; 9(3): 225–228
10. Wells GR, Taylor EW, Lindsay G, Morton L. Relationship between bile
colonisation, high-risk factors and postoperative sepsis in patients undergoing
biliary tract operations whilst receiving prophylactic antibiotic. Br J Surg.
1989;76:374–7
11. Csendes A, Fernandez M, Uribe P. Bacteriology of the gallbladder bile in normal
subjects. Am J Surg. 1975;129:629–31
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12. Classen DC, Evans RS, Pestonik SL, Horn SD, Menlove RL, Burke JP. The
timing of prophylactic administration of antibiotics and the risk of surgical-wound
infection. N Engl J Med. 1992;326:281
13. Pitt HA, Postier RG, Cameron JL. Biliary bacteria: significance and alterations
after antibiotic therapy. Arch Surg. 1982; 117:445–9.
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bacteriologic and epidemiologic study. Acta Chir Scand. 1990; 156:155–62.
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15. Keighly MRB, Flinn R, Williams JA. Multivariate analysis of clinical and
operative findings associated with biliary sepsis. Br J Surg 1976; 63: 528-531.
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Learning Radiology in an Integrated Problem-Based Learning (PBL) Curriculum.
E. Kiguli-Malwadde, Z. Muyinda, M.G. Kawooya, S. Bugeza, R Okello Omara
Department of Radiology, Mulago Hospital, Kampala, Uganda
Corresponding to: E. Kiguli-Malwadde, Email: [email protected]
Background: The Faculty of Medicine (FoM) has been training health professions in Uganda
since 1924. Five years ago, it decided to change the undergraduate curriculum from traditional
to Problem Based Learning (PBL) and adopted the SPICES model. Radiology was integrated
into the different courses throughout the 5 year program. The objective was to improve the
implementation of the integration of Radiology in the integrated PBL curriculum.
Methods: This was a cross sectional descriptive study of radiologists and medical students using
interviews and semi-structured questionnaires respectively.
Results: Radiologists’ and students’ perceptions and opinions on Radiology training were
gathered. A Radiology training rationale was developed. Learning outcomes for Radiology were
defined and learning formats were chosen. Learning materials were identified and strategies to
improve the implementation were formulated.
Conclusions: This work has culminated into changes in Radiology integration in the curriculum
and training at the FOM.
Introduction
Integration is the organization of teaching matter to interrelate or unify subjects frequently taught in
separate academic courses or departments 1. Integration in the medical curriculum dates back to1952
when the Case Western School of Medicine initiated what was said to be the most advanced medical
curriculum by integrating the basic and clinical sciences focusing on organ system and featuring early
patient encounters right from the first year. Now it is universally accepted 2. However integration is
not easily achieved and requires a lot of time and work in respect of planning, organization and
execution3.
The Faculty of Medicine (FoM), Makerere University is the oldest health professions training
institution in East Africa. Five years ago as a result of a curriculum review, it decided to change the
undergraduate training from traditional to Problem Based. It adopted the SPICES model (Student
centered, problem based, integrated, community based, electives, Systematic)4.
As a result of the review, radiology was integrated into the different courses in the medical curriculum
which is five years. In the old curriculum radiology was taught as 2 courses in the 2nd and 4th years.
Radiology is considered an important part of the curriculum. There is a need to address Uganda’s
radiology needs by training medical doctors that have good radiology skills considering that there is a
shortage of Radiologists in the country. There are 30 radiologists for a population of 30 million
people. Following the review the Radiologists realized that they could not rely on the old methods of
training and so had to become innovative so as not to remain behind. This was also noted by
Subramaniam in Australia5. In addition there is a need for the radiologists to be actively involved in
training medical students if they are to influence their learning and be good role models so as to
attract them to the profession later on.
This work set out to redesign the learning of Radiology in PBL curriculum and to improve the
implementation of the integration of Radiology in the PBL curriculum. There is a need to ensure
quality training by stimulating active learning in radiology and understanding of concepts. This
involved formulating a rationale for the integrated Radiology training, defining the learning outcomes
for Radiology by focusing on Ugandan needs, choosing active learning activities for these outcomes
with focus on horizontal integration, sequencing the learning activities focusing on vertical
integration.
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Subjects and Methods
The Department of Radiology is one of the 23 departments at the FoM. There are 12 radiologists
involved in the training of undergraduates. It also runs a Radiology post graduate program.The
objective was to improve the implementation of the integration of Radiology in the integrated PBL
curriculum.The study was a cross sectional descriptive study. The radiologists were interviewed to
find out how they thought Radiology training should be conducted in the new curriculum. The
radiologist ideas were collated in a short summary and conclusions were formulated and sent to them
for validation. Semi-structured questions were administered to fourth and fifth year students.
Results
The radiologists agreed that the new curriculum was good (7/8) as students are responsible for their
learning(5/8), are more involved in the process of learning(5/8), work collaboratively (4/8) and are
stimulated to find information by using problems (5/8). They also thought it makes Radiology more
relevant to patient management for the students (7/8). However they felt that the integration could not
be easily achieved (5/8)and expressed the need to be more involved in the integration process (8/8).
They felt that Radiology may loose identity in the curriculum and that some important concepts like
physics, equipment, radiation safety and Radiotherapy were missing (5/8). Many (6/8) also felt that
the student numbers were big and this strains the human resource when conducting small group
learning. Despite this many thought that the PBL tutorials were an appropriate teaching tool and that
students were motivated (5/8). Implementation was noted to be a challenge because there was a long
chain of implementers through course coordinators and block coordinators before things got to the
department.
The Radiologists(5/8) think that students aren’t choosing radiology as a career because they don’t get
exposed to radiology enough for them to be interested in it. This was confirmed by the students who
said there was limited exposure to radiology as a discipline `(N=82). A student wrote that “ Radiology
was treated as a good to know field as compared to other disciplines”. Another wrote that “My
interest in the discipline is not stimulated because there is little exposure to radiology”. Only 15
students said they would take up radiology as a career. One Reported that he found it interesting, that
it has a future because at the moment there are very few radiologists and that it is multi-disciplinary as
well as a fast growing field.
All the 82 students and the 8 radiologists agreed that Radiology in the country was not getting
adequate attention. They observed that the upcountry hospitals were not well equipped so students
don’t see its future. A student said “Radiology is an expensive discipline so I think it would be an
expensive venture for me to go into private practice”. one said Radiology is an unsafe environment
to work in. The students (N=68) said that during their community placement exposure to Radiology
was limited and the Radiology practice seemed to be limited to the big hospitals(N=60). They
commented that Radiology did not seem to offer opportunities for career growth and advancement in
Uganda(N=59). The students (N=27) said that there is little contact between the radiologist and the
real patient and this would discourage them from taking Radiology as a future career.
The radiologists suggested that radiology should be made more visible in the curriculum and that
there should be more interaction between the radiologists and the students for example by attending
and participating in tutorials, seminars and grand rounds. This will help them to role model and
impress the students that radiology is an interesting discipline. The students (N=54) and radiologists
(6/8) suggested that more radiology and specifically images should be included in the tutorial
problems.
Both groups recommended that an elective in radiology could attract students.
The radiologists proposed clinical radiology rounds, once a week on the wards in each of the 4 major
4th and 5th year rotations that is Surgery, Internal Medicine, Paediatrics, Obstetrics and Gynaecology.
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This would be worked out so that a radiologist would be allocated each semester to a discipline and
for example every Friday afternoon, he/she would go through images on the wards. This would help
the students to see many images during their time as students and would improve their pattern
recognition as well as make the experience contextual.
A Radiologist would be nominated to be in charge of radiology undergraduate training and he/she
would be the person responsible for making sure that the curriculum is followed so that things are not
only on paper but actually happen. He /she would follow up on timetables and would work closely
with the faculty education coordinator so that radiologists are involved in the planning.
The students proposed that lectures and seminars should supplement the other learning activities for
the different courses in order to allow them meet the experts so as to fill up the gaps. The radiologists
proposed that topics like radiation safety and Physics of Radiology could be given as lectures as they
did not fit into other learning activities. Radiologists proposed that the skills lab could have a viewer
where students could look at images from the archive.
A rationale for Radiology Training was developed as follows” A medical doctor should be able to
apply the knowledge of radiology in the management of his patients. Radiology is intended to help the
doctor investigate his patients so as to come to a diagnosis. This doctor in Uganda is likely to end up
working in a place where there is no radiologist. The knowledge he/she would have acquired in
radiology as an undergraduate would be a hallmark for patient management and improving the health
of the community”.
Learning outcomes for Radiology were developed. The students were expected to be able to:
1. identify normal radiological anatomy so as to recognize the abnormal
2. request for appropriate investigations
3. know the indications for investigations and their limitations
4. appreciate the radiology terminologies so as to interpret the radiology reports and use them for
evidence based patient management
5. identify the different radiological and imaging investigations
6. know how to prepare patients for the basic examinations like Intravenous pyelogram and barium
studies
7. know the basic Physics of Radiation, image formation, common artifacts and radiation safety
8. interpret basic radiological investigations like the Chest X-ray, Abdominal radiographs and
Skeletal radiographs especially pertaining to the Ugandan context.
9. identify emergencies at basic radiological images
10. use a cost effective approach to imaging
11. relate clinical features, laboratory and radiological findings
12. recognize when referral to a radiologist is necessary.
It was agreed on that the following learning formats would be employed PBL tutorials,
demonstrations, Seminars and conferences, Lectures, Skills lab, Radiological clinical (ward) rounds,
Small group hands on interpretation sessions, Grand rounds and a Radiology Elective. Learning
Materials are to be selected by a committee of radiologists at the beginning of every semester. The
Radiologists recommended that all the radiology activities should be assessed and the results
communicated to the course coordinators. During the session’s feedback should be given to the
students. Sequencing was agreed on and using the curriculum map, courses which had objectives
pertinent to Radiology were identified.
Discussion
The Radiologists agreed that integration of Radiology in the curriculum was a good approach to
training. There is evidence from Cognitive Psychology to show that the integration of knowledge
facilitates the storage and later retrieval of knowledge. It has also been noted to prepare students better
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for actual practice6. Integration also puts radiology in context and more problem based rather than
discipline based.
The learning outcomes for Radiology training for medical students do not vary from region to region;
this is evidenced by the similarities between the objectives for Uganda, Australia and New Zealand7.
However when it comes to the specific topics these may vary depending on the location, for example
in Uganda HIV and Tuberculosis would feature more prominently. Both areas identified the value of
students observing certain radiological procedures. The radiologists in Uganda think this is important
for the students to understand what their patients are in for so as to prepare them and explain to them
the procedures. Subramaniam argues that the ability to select the most appropriate and cost effective
radiological investigation is important because most are expensive and so care must be taken to use
the most cost effective approach for achieving the desired goal in patient management 5. This is
particularly important in a developing country like Uganda and the radiologists in Uganda agreed with
him.
It has been noted that an effective radiology education program has the advantage of giving the
radiologist an opportunity to teach future medical professionals and influence their future practice and
it also enables the department to attract the top performers to take up a career in Radiology. It has also
been said that if Radiology is learnt in context as happens in a PBL approach, it will be effectively
approached and practiced 5. For example a patient with a pneumothorax or cardiac failure will be used
as the focus of learning and this would show the relevance of Radiology in patient management. This
is the approach that is used during radiology exposure sessions and rounds and is carried out on the
wards. These enable the students to see many imaging results as to improve the pattern recognition
abilities8.
Clarity of purpose has been noted to be important in learning that is why learning outcomes for the
students have been formulated so that they can learn to perceive and accept the relevance of the
learning activities in relation to the large task of learning Radiology. It is also hoped that having
formulated overall learning outcomes for the students will help support the students in developing
ownership of the overall problem or task. Survey et al emphasise the role of a stimulus for learning, in
which case the objectives given out to the students to help them study and later come up with their
own learning objectives in the small group radiology sessions will act as stimulus and organisers for
learning8.
Encoding specificity has been defined as learning in a situation that resembles the situation in which
the knowledge will be applied. In this case, by incorporating Radiology into the problems and also for
radiologists to conduct rounds where images are seen alongside the patient will favour encoding
specificity. It will also encourage elaboration 9. So by using problems that have Radiology in them in
the tutorials and using the small group discussions the students will work collaboratively, practice
activation of prior knowledge, exchange and critically discuss acquired new information. All this
enhances acquisition, retention and use of new knowledge. At the same time it will vary the situation
in which learning occurs 10.
Conclusion
Improvement of the implementation of the integration of radiology into the PBL curriculum is an
ongoing process that depends on the commitment of the radiologists and other faculty members to
implement the proposals and suggestions in this article. Strengthening the Radiology component of
the curriculum is hoped to help improve the delivery of health services in Uganda.
Acknowlegement
We are grateful to all the radiologists and students who accepted to be interviewed and to take the
questionnaires and to Bas Leng and Herma Roebertsen who helped us with the completion of this
work.
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References
1. Harden RM, Sowden S, Dunn WR: Educational strategies in curriculum development: The
SPICES model. Medical Education 1984, 18, 284-297.
2. Grant, J. Asme Principles of Curriculum Design 2006 (No. 0 904473).
www.library.auckland.ac.nz/subjects/med/course-pages/clined712.htm
3. Dahle LO, Brynhildsen J, Behrbohm Fallsberg M, Rundquist I., Hammar M: Pros and cons of
vertical integration between clinical medicine and basic science within a problem-based
undergraduate medical curriculum: examples and experiences from Linköping, Sweden.
Medical Teacher 2002, 24(3), 280-285.
4. Dent JA, Harden, RM: Section 1 Curriculum development (2 ed.). Eddinbrough: Elsevier
Churchill Livingstone 2006.
5. Subramaniam, RM: Problem - based learning: concept theories, effectiveness and application
to radiology teaching. Australasian Radiology 2006, 50, 339-336.
6. Regehr AJ, Norman GR: Adult Learning, Objectivity and other Self - evident Un truths.
Advances in Health Sciences Education 2002, 7(2), 81-160.
7. Subramaniam R, Scally P, Tress B: Medical Student Radiology Training: What are the
Objectives for Contemporary Medical Practice? Academic Radiology 2003, 10(3), 295-300.
8. Savery JR, Duffy Thomas M: Problem Based learning: An instructional model and its
constructivist framework. Bloomington: Indiana University 2001.
9. Schmidt H: Problem -based learning: Rationale and description. Medical Education 1983, 17,
11-16.
10. Dent, JA, Hesketh, EA: Developing the teaching instinct. 13: how to teach in the clinical
skills centre. Medical Teacher 2004, 26(3), 96-105.
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Marjolin’s Ulcer in a Spina Bifida Patient: A Case Report
P.M. Nthumba, G. Bird
AIC Kijabe Hospital, Kijabe, Kenya, Africa
Correspondence to: Dr. Peter M. Nthumba, Email: [email protected]
‘They dress the wound of my people as though it were not serious’1 Jeremiah 6:14.
Pressure ulcers are a frequent complication among neurologically-impaired patients, including
those with spina bifida. Malignant degeneration of these pressure ulcers, known as Marjolin’s
ulcers, although a rare complication, results in a virulent cancer and often death. The history of
a twenty year-old spina bifida patient who presented with a longstanding sacral pressure ulcer
that was found to be malignant is reported. Pressure ulcers should be thoroughly investigated
at presentation, to avoid labeling malignancies ‘chronic ulcers’, leading to delay in appropriate
treatment.
Introduction
Pressure ulcers are common after spinal cord injuries (SCI). Increased motor vehicle accidents
alongside improved healthcare, has led to an increase in the number of SCI survivors, and
concomitantly, pressure ulcers2. Although SCI and spina bifida patients are different entities, they
have in common the absence of sensation and immobility, factors that place them at similar
heightened risks for the development of pressure ulcers2,3. As improved healthcare creeps into SubSaharan Africa, the number of children with spina bifida surviving and attaining adulthood is
increasing. As a consequence, pressure ulcers are seen more frequently. Because pressure ulcers and
ulcer recurrences in this population are such a common and difficult problems to manage2, there has
been a general tendency towards a degree of ‘benign neglect’, both by the patient and healthcare
givers. This attitude is dangerous, as noted by Ratliff, who reported malignancies in the chronic
pressure ulcers of two spina bifida patients referred for treatment4. The term ‘Marjolin’s ulcer’ is used
to describe malignant degeneration of chronic ulcers, burn scars and other chronic processes4,5.
Case report
A 20 year-old African female presented with a huge foul-smelling sacral ulcer. Born with a spina
bifida, she had had a bilateral below-knee amputation as a child, but was able to ambulate using
bilateral prosthesis and crutches (Figure 1). Her past medical history was sketchy, and with no
medical records available, was reconstructed from memory. Except for occasional visits to
dispensaries and hospitals, home wound care consisted only of pieces of clothing used to cover the
ulcer and absorb its exudate. She had urinary bladder and bowel incontinence. She developed a sacral
pressure ulcer at the age of four. The ulcer smoldered over the subsequent 16 years, gradually
growing bigger, unable to access appropriate care. Because she had no perineal sensation, she had no
pain from the ulcer, but was aware of the foul smell emanating from the ulcer.
She was referred to our institution by a ‘Good Samaritan’, who also paid for her treatment. On
examination, the ulcer edges were indurated, elevated, but inverted. The ulcer base and walls had
multiple elevated lesions, extending over a large undermined area, with multiple sinuses (Figure 2).
The perineum was macerated and patched with areas of vitiligo by urine. She had no palpable nodes.
An initial biopsy of the pressure ulcer revealed a squamous cell carcinoma (Marjolin’s ulcer). A
pelvic/abdominal ultrasound and a chest radiograph did not show any evidence of metastases. A wide
excision and wound closure using local flaps were performed. The histopathology reported a
squamous cell carcinoma deeply invasive, extending into bone, but with clear margins. Wound
infection and dehiscence in the first week post-operatively was debrided and closed primarily.
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Figure 1. Bilateral amputatim.
Figure 2. Sacral pressure ulcer. Note multiple fistuli with purulent discharge – all communicated with
the ulcer. Note also chronic skin changes, including perineal vitiligo from repeated exposure to urine.
The wound healed completely over the ensuing four weeks, with no evidence of local tumor
recurrence at 5 months. She received no further treatment, but went back to normal life, rid of the foul
smell, and with enhanced social relations. Prior to her surgery, the patient had been secluded from
social interaction, preferring to stay indoors because of the odour emanating from her ulcer.
Post-operatively, for most of the ten months that she lived post-operatively, she ran a small business:
this period that may have been the best time of her short life. No additional tests were done after her
surgery, because of cost constraints. She died at home, and though no autopsy was performed, death
due to metastatic disease was presumed, based on the history given by relatives on her last few weeks
of her life.
Discussion
Malignant degeneration of chronic ulcers, usually into squamous cell carcinomas was first described
by Jean Nicolas Marjolin in 1828. Marjolin’s ulcers have since been reported in burn scars, chronic
osteomyelitis, post-traumatic wounds and chronic fistuli5,6.
The causes of malignant degeneration are not known, but a few theories have been proposed. The
initiation and promotion theory proposes a process of transformation of normal cells into dormant
malignant cells, with subsequent cellular promotion and tumor growth, with infection acting as a cocarcinogen. The chronic irritation theory suggests malignant transformation results from cycles of
repeated irritation, trauma and attempted repair. Toxins released by chronic ulcer cells may act as
carcinogens, leading to development of tumors. Traumatic implantation of epidermal cells into the
dermis resulting in foreign body reaction and ultimately malignant transformation is another
hypothesis. The relatively avascular area of scars may interfere with immune surveillance, leading to
uncontrolled proliferation of immunologically undetected tumor cells5-8. Spina bifida, with the
associated lack of sensation and immobility are congenital in origin, while SCIs are acquired, many in
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young adulthood. Although the proposed theories are applicable to ulcers in both SCI and spina bifida
patients, it is feasible that different mechanisms may be at play in pressure ulcers of these two
populations, resulting in the differences in rates of malignant degeneration.
While squamous cell carcinoma is the most commonly observed Marjolin’s ulcer type, basal cell
carcinoma, adenocarcinoma, sarcomas, melanoma and verrucous carcinoma have also been reported.
Malignant degeneration of pressure ulcers though rare, is well described4-10. Mustoe found a 0.5%
incidence of Marjolin’s ulcer amongst patients with pressure ulcers5. Most Marjolin’s ulcers occur in
the sacral and ischial areas. Although malignant degeneration in a pressure ulcer has been reported to
have occurred after 6 months, the average latency period of about 20 years is much shorter than that in
burn scars (31 years)5,6.
Malignant transformation of pressure ulcers frequently leads to the death of the patients. These sadly,
are preventable deaths – either by the prevention of pressure ulcers, or early and effective
management, should they occur2,4,5. Some workers have suggested that these are immunologically
privileged tumors that overwhelm the patient’s immune system upon surgical manipulation, leading to
systemic metastasis and death5, as may have been the case with our patient. Marjolin’s ulcers in burn
scars or chronic osteomyelitis, with no evidence of metastases have a much better prognosis than
those in pressure ulcers7. Although tumor-negative margins are generally reassuring in surgical
oncology, this may not be true for the virulent pressure ulcer carcinomas8. Wide excision with elective
nodal dissection, or even hemicorporectomy as indicated, have been proposed for pressure ulcer
carcinomas, when cure is intended8,9. Radiotherapy and chemotherapy, although frequently used postoperatively, have not been shown to be effective5,8.
This is the first report of Marjolin’s ulcer in a spina bifida patient from Africa. Although pressure
ulcers are common amongst spina bifida patients, the incidence of Marjolin’s ulcers in this population
is extremely rare. A search of English literature revealed a total of six reported cases of Marjolin’s
ulcers, in four articles4,8-10. This rarity is difficult to explain. While Marjolin’s ulcers generally affect
patients with poor access to healthcare, all previous reports were from developed countries, indicating
that vigilance is required, irrespective of the economic environment. All pressure ulcers should be
thoroughly investigated at presentation, to avoid labeling malignancies ‘chronic ulcers’, leading to
delay in appropriate treatment.
References
1. Jeremiah 6:14. Scripture taken from the Holy Bible, New International Version. Copyright
1973, 1978, 1984 by International Bible Society. Zondervan.
2. Nthumba PM. Bilateral thigh flaps: A case report and review of literature. East and Central
African Journal of Surgery 2007; 12: 82 - 7.
3. Plaum PE, Riemer G, Frøslie KF. Risk factors for pressure sores in adult patients with
myelomeningocele – a questionnaire-based study. Cerebrospinal Fluid Res 2006; 3: 14.
4. Ratliff CR. Two case studies of Marjolin’s ulcers in patients referred for management of
chronic pressure ulcers. J Wound Ostomy Continence Nurs. 2002; 29: 266 – 8.
5. Mustoe T, Upton J, Marcellino V, Tun CJ, Rossier AB, Hachend HJ. Carcinoma in chronic
pressure sores: a fulminant disease process. Plast Reconstr Surg 1986; 77: 116 – 21.
6. Tan O, Atik B, Bekerecioglu M, Tercan M, Bayram I. Squamous carcinoma in a pressure sore
with a very short latency period. Eur J Plast Surg 2003; 26: 360 – 2.
7. Fitzgerald RH Jr., Brewer NS, Dahlin DC. Squamous cell carcinoma complicating chronic
osteomyelitis. J Bone Joint Surg 1976; 58: 1146.
8. Stankard CE, Cruse CW, Wells, EW, Karl R. Chronic pressure ulcer carcinomas. Ann Plast
Surg 1993; 30: 274 - 7.
9. Peterson R, Sardi A. Hemicorporectomy for chronic pressure ulcer carcinoma: 7 Years of
Follow-Up. Am Surg 2004; 70: 507 - 11.
10. Burke J, Cunningham M, Li B. Squamous cell carcinoma arising from a chronic ulcer
secondary to spina bifida. Surg Rounds 1999; 22: 368 - 74.
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Female Urethral Leiomyoma: A Case Presentation
A.T. Tefera
Urologic Surgeon St. Paul’s General Specialized Hospital, Addis Ababa, Ethiopia
Correspondence to: Dr. Alemayehu T. Tefera, Email: [email protected]
We present a case of female urethral Leiomyoma. The mass which protruding from the urethral
meatus causing dysuria and urethrorragia. Our physical examination revealed the presence of
the mass on the anterior wall of the vagina protruding from the urethral meatus.
Histopathological examination showed leiomyoma of the female urethra. The patient was
treated surgically and the symptoms disappeared completely.
Introduction
Leiomyomas are benign tumors of smooth muscle origin and rarely found in the urinary tract, with
only 40 cases of urethral leiomyoma reported in the literature1,2,3,4,9.It is more common in women
between 30 and 50 years old1,3,5. The first case was reported in 1984 by Buttner6. There is a
controversy about its dependency on estrogen hormones. Its diagnosis is made only by
histopathologic examination. The topographic site of the lesion is very useful for the prognosis.
Grabstald and Cols7 classified the tumors as distal or anterior when it’s located at the distal 1/3 of the
urethra, and proximal or posterior when it’s located at anterior 1/3. We report a case of leiomyoma of
the female urethra with its clinicopathological characteristics.
Case Report
A 27 years old female patient with no history of past illness, came to our clinic presenting a mass
protruding from the urethral meatus for 18 months, accompanied with dysuria and urethrorragia. On
physical examination there was a polyploid and rounded mass with the size of 3.5 cm in
diameter,smooth surfaced, firm with pink colour, located at the distal posterior urethra.on straining it
protrudes through the urethral meatus (Figures 1. All investigations were normals.
FNA Biopsy done revealed Epidermid cyst of the urethra. She was operated, tomour excised and
specimen sent for histopahologic examination (Figures 2).
Figure 1. Leiomyoma of Female Ureathra Before Surgery
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Figure 2. Macroscopic View of the Tumour
The histopathologic examination showed a leiomyoma of the urethra. On follow after surgery the
patient was found to be asymptomatic with out any abnormal finding on urologic examination.
Discussion
Leiomyoma is a benign tumor of mesenchimal origin, composed of smooth muscle cells found rarely
in the urinary tract. Our patient histopathologic result is also same. It is known to involve in
decreasing order of frequency, the kidney bladder and urethra3,13,14. Leiomyomas are 3 times more
common in women between 30 and 50 years1,3,5. According to the mentioned criteria, the case
presented was atypical because it appeared in a 27 years old lady.The diameter of the tumors ranged
from 1 – 40 cm2,3,14,15. The pathogenesis of leiomyoma is unknown but its growth is probably
endocrine dependent, with the growth patterns and size influenced by estrogen2,3,8,15. But our case did
not have hormone dependency because as we mentioned above that she is young with no such
abnormality on investigations and there is no history of oestrogen based contrceptives usage. The
clinical presentations depends on the location and size of the tumor.Patient can be asymptomatic
being the leiomyoma an incidental finding during gynecological examination. Common presenting
symptoms are periurethral masses, urinary tract infection, hematuria,urethrrragia,dysuria and
dyspareunia and even acute urine retention and acute renal failure2,3,4,10,12 patient also had two of the
mentioned clinical presentation.
The clinical diagnosis is made by history, physical examination, uretherocystoscopic examination and
imaging studies like transvaginal sonography, retrograde urethrography,voiding cystourethrogram and
MRI2,3,4,10,12,13,14. The histopatholgic study will give the definitive diagnosis. We also reached on
definitive diagnosis by histopathologic examination. The differential diagnosis of female urethral
leiomyoma should be done with urethral caruncle,papilloma, urethral diverticulum, ectopic
ureterocele, fibrous polyp, Gratner’s duct cyst, periurethral abscess, urethral carcinoma and other
mesenchymal tumors3,14.
The urethral leiomyoma is treated surgically without recurrence1,3. Even we treated the patient
surgically and she is asymptomatic with no recurrence.The operation techniques depends on the site
of the tumor.So we removed the masas through incision of the anterior vaginal wall. The prognosis of
this tumor is excellent as malignant transformation has not been reported1,2,3,8. Our patient is also
doing good with no complication or recurrence after surgical therapy.
Conclusion
1. Leiomyoma of the female urethra is a benign mesenchymal tumor and rarely found in the
urinary tract.
2. The diagnosis is always confirmed by histopathological study.
3. The treatement is always surgical.
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4. The prognosis is excellent since it has no risk of malignant transformation.
References
1. Bozo Kruelin, Misng Lechpammer, Josip Katusie et. All calcitied Leiomyons of the female
urethra: A case Report.
2. Cheng C, Mac-Moune Lai F, Chan PSF: Leiomyoma of the female urethra: a case report and
review. J Urol 1992; 148: 1.526-1.527.
3. A: Rodriguez Alonso, D. Perez Garscia, A. Nunez Lopez, et. All Leiomioma de uretra
femeniana. Presentacio de caso. Actas Urol Esp. 24(9): 753-756, 2000
4. Leung YL, Lee F, Tam PC: Leiomioma of the female urethra causing acute urinary retention
and acute renal failure. J Urol 1997; 158: 1.911-1.912.
5. Nogueira March JL: Tumores de la uretra masculina y femenina. Tratado de Urología, J.F.
Jiménez Cruz y L.A. Rioja Sanz. J.R. Prous Editores 1993; 1.237-1.257.
6. Buttner Ein Fall von Myom der Weibliehen Urethra. Z Geburshc Gynäk 1894; 28: 135-136.
7. Grabstald H, Hilaris B, Henschke UR, Whitmore WF Jr: Cancer of the female urethra. JAMA
1966; 197: 835-841.
8. Caballero J, Carrero V, Vazquez S, Calahorra L: Tumores de uretra femenina: presentación
de nuestros casos y revisión de la literatura. Actas Urol Esp 1993; 17 (1): 8-21.
9. A Strang, S. W. Lisson S. P. Petron. Urethral Endometriosis and Coexistent Urethral
Leiomyoma in Post meno pausal woman.
10. Panigua P, Extramiana J, Mora M, Pamplona M: Leiomioma de uretra femenina. Actas Urol
Esp 1990; 14 (1): 53-55.
11. Cornella JL, Larson TR, Lee RA, Magrina JF: Leiomyoma of the female urethra and bladder:
report of twenty-three patients and review of the literature. Am J Obstet Gynecol 1997; 176
(6): 1.278-1.285.
12. Lee M, Lee S, Kuo H, Huang TW: Obstructive leiomyoma of the female urethra: report of a
case. J Urol 1995; 153: 420-421.
13. Sheild DE and Weiss RM. Leiomyoma of the female urethra. J Urol 1973; 109: 430-431.
14. Jain R, Sawhney S, Bandhu S, Seth A. Leiomyoma of the female urethra. Indian J Radiol
Imaging [serial online] 2000 [cited 2008 Dec 17];10:159-60.
15. Leidinger RJ, Das S. Leiomyoma of the female urethra. A report of two cases. J Reprod Med
1995; 40:
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Massive Assymetrical Virginal Breast Hypertrophy: A Case Report
S.B. Patil, S.M, Kale, N. Khare, S. Jaiswal, M. Math
Department of Plastic Surgery
Government Medical College , Nagpur (Maharashtra) – India.
Correspondence to: Dr. Sumeet jaiswal, Email: [email protected]
Virginal breast hypertrophy (VHB) is a rare , distinct disorder of unknown etiology with the
rapid onset of macromastia at the onset of puberty.We reported a 12 year old, peripubertal girl
presented to us with abnormal assymetrical growth of her breasts in 10 months. Due to the
enormous breast volume, which caused her physical and psychological problems, she curtailed
her social life. On examination, left breast was enlarged more in comparision to right ,with
associated skin changes. Endocrinological investigations were normal. A bilateral reduction
mammaplasty with free nipple graft was performed. Histological analysis of the breast tissue
revealed the diagnosis of virginal hypertrophy. During the follow-up period of 13 months, no
recurrence was noted and patient is physically and psychologically satisfied.
Introduction
Virginal hypertrophy of the breast (VHB) is an uncommon, benign disorder and typically occurs in
peri-pubertal females1-5. This entity was first described by Durston in 1669. The etiology of VHB is
uncertain1-5. VHB usually develops sporadically, but familial cases have also been reported1,6. It
occurs more commonly in girls between 8 and 16 years of age, and is clinically characterized by rapid
enlargement of the breast1-3. The overgrowth of the breasts is usually bilateral, although unilateral
VHB has been described4,5. It can cause several clinical problems such as breast pain, back and neck
pain, dilatation of superficial veins, and skin ulcerations. It may also cause some serious
psychological and cosmetic disturbances. We present a case of 12 year old female having assymetrical
bilateral VHB with left breast larger than lright and reaching upto left groin crease. Associated
psychological and social morbidity is also discussed in brief.
Case Present\
A healthy, postmenarchal 12-year-old girl was seen in our
Plastic surgery OPD with chief complaint of enlargement of
both the breasts since last ten months. This massive breast
enlargement created multiple socio-cultural problems for her
along with the medical complains. Constant nagging by peers
and response of general public to her appearance made her
home bound. The patient dropped out of school and curtailed
her social appearance to bare minimum. She also had
difficulty fitting clothes of any size and at presentation to the
OPD said that she even contemplated suicide but could not
muster enough courage. In addition to the breast enlargement,
she had bilateral mastalgia and pain in shoulders.
The growth was more enormous and rapid in left breast. Her
past medical history was unremarkable and she was not on any
medications or oral contraceptive pills. General survey
revealed, a girl with thin built and average state of nutrition
having slumped shoulders and sagging posture On local
examination, the left breast was markedly enlarged, reaching
upto left groin crease. Nipples and areola were flattened and
stretched. She developed a pressure ulcer of size 4 X 3 cm
over inframammary crease on left side. The right breast was
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moderately enlarged (Fig. 1 and Fig 2). The skin over the left breast was hyperemic, tender and warm.
Palpation of the left breast revealed firm, poorely defined masses (4-7cmin diameter), whereas right
breast had a uniformly firm texture without any discrete mass. No axillary nodes were noted . Other
secondary sexual characters were normal. FNAC from the both the breasts were suggestive of virginal
hypertrophy. Hormonal studies revealed no elevated estrogens or hypothyroidism. Preoperative
ultrasonography suggested multiple hyperehoic mass lesions on right side and no parenchymal
abnormality on right side.
Surgical reduction with free-nipple graft was performed. The weight of the removed mammary tissue
was 2510gms and 1010 gms, respectively, for the left and the right breast. The breast was reduced by
combining technique of superior pedicle reduction with partial breast amputation. Nipple –areola
complex was applies as free graft. The patient had an uneventful recovery and was discharged on 10th
post operative day. Pathological findings were characterized by hypertrophy of cellular connective
tissue and ductal epithelium, with absence of circumscribing capsule. The ducts were distorted,
swollen and lined with perplastic epithelium. At six months after surgery, the patient wass satisfied
psychologically and physically with good. Cosmetic appearance of breast. Clinical and
ultrasonographic examinations have not indicated any persistent tumors.
The patient rejoined her school education after three months of surgery. She leads a normal social life
now and intermingles enthusiastically with her peers. Postoperative psychiatric evaluation at 6
months, have found no signs of depressive behavior or suicidal tendency in her.
Discussion
In most girls, thelarche is usually the first sign of puberty and the usual breast development occurs
during the period of 3-5 years of onset of puberty. Complex hormonal influences affect breast
development. Ductal and lobular-alveolar development is mainly influenced by estrogen and
progesterone respectively3-5. Juvenile hypertrophy of the breast is an uncommon disorder that occurs
near the time of menarche and results in pathologic overgrowth of the breasts1. In VHB, the
overgrowth of the breasts is usually bilateral. Initially, rapid enlargement of the breast occurs for
about three to six months followed by continuous but slow growth of the breast1,3. In our case there
was rapid growth for initial 6 months followed by slow growth in next 2 months. The breast can grow
to weight as much as 13.5 kg to 22.5 kg4,12. In VHB, the breasts are usually pendulous and diffusely
firm, with or without any discrete mass lesions. It can cause breast pain, and back and neck pain.
Dilatation of superficial veins or skin ulcerations may be present. Physical and psychological
problems may develop.
The etiology of VHB is uncertain. In these individuals hormonal level and number of estrogen
receptors are normal1,5.End organ hypersensitivity is assume to be reason for massive enlagement of
breasts1,3-5,7. The differential diagnosis of abnormal breast enlargement during childhood includes
pseudo-gigantomastia associated with obesity, juvenile phyllodes tumor, fibroadenomas, lymphomas8
and sarcomas.Ultrasonographic (US) examination of the breasts is rarely useful for differential
diagnosis. USG breast examination of our patient showed irregular, hyperechoic, mass lesions in the
right breast, which suggested multiple giant fibroadenomas.
In our patient, the final diagnosis of VHB was made by histopathological examination. Histologically,
this condition is an exaggeration of the normally developing breast. Characteristically the breast tissue
shows varying degrees of stromal and ductal hyperplasia, often with dilatation and cystic degeneration
of the ducts with interstitial and periductal edema. Many modalities of treatment have been
recommended in VHB, including reduction mammoplasty, mastectomy with implantation of
prosthesis, hormonal manipulation, and combination of surgery and medications1-5,9.
Appropriate surgical intervention should be performed in late adolescence or early adulthood when
breast growth rate stabilizes and ideally when no change in size is detected over the last 12 months 1-5.
As in our patient, early surgical interventions are required in cases with severe mastalgia ,shoulder
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and back pain,pressure ulceration,and social and psychological stress.associated with
gigantomastia,Breast reduction surgery is usually the treatment choice. The most commonly applied
procedure is reduction mammoplasty with free grafting of nipple areola complex3,10. Hormonal
manipulation remains controversial because of unknown long-term effects. Antiestrogen drugs such
as medroxyprogesterone, dydrogesterone, and tamoxifen citrate have been shown to be useful. Several
cases with VHB who were treated successfully with tamoxifen citrate have been reported in the
literature and it was found to be the most effective agent for preventing recurrence3,10,11. However,
potential side effects of tamoxifen citrate limit its use in children.
There is huge amount of psychological distress associated with massive breast enlargement. There is
not only limitation of physical activities but also embarrassment due to easily observable huge breast,
which ultimately leading to social isolation, loss of love life and low self confidence. As in our case,
due to social problems, girl refused to go to school and was unable to mingle with her friends.
Postoperatively patient was not only physically satisfied, but there was drastic improvement in social
behavior and personal attitude. We believe that VHB has profound psychological impact on the
patient. Our interaction with the patient leads us to believe that psychological factors should be
considered importantly in deciding the time of surgery.
Conclusion
VHB is a rare benign disorder that should be kept in mind during the differential diagnosis of
abnormal breast enlargement in pubertal girls. Fibroadenomas should be considered in the differential
diagnosis of VHB. Especially juvenile and giant forms of fibroadenomas are more likely to mimic
VHB2,3. Definitive diagnosis can be made by histopathologic examination. Surgery is only treatment
for severe symptomatic cases. Role of hormonal therapy in young girl is controversial. Problem of
associated psychological stress should not be under estimated. Optimal treatment strategy should be
based on the patient's clinical and psychological status.
References
1. Kupfer D, Dingman D, Broadbent R. Juvenile breast hypertrophy: report of a familial pattern
and review of the literature. Plast Reconstr Surg 1992; 90: 303-9.
2. Bauer BS, Jones KM, Talbot CW. Mammary masses in the adolescent female. Surg Gynecol
Obstet 1987; 165: 63-5.
3. Baker SB, Burkey BA, Thornton P, et al. Juvenile gigantomastia: presentation of four cases
and review of the literature. Ann Plast Surg 2001; 5: 517-26.
4. Neinstein LS. Breast disease in adolescents and young women. Pediatr Clin North Am 1999;
46: 607-29.
5. Templeman C, Hertweck SP. Breast disorders in the pediatric and adolescent patient. Obstet
Gynecol Clin North Am 2000; 27: 19-34.
6. Govrin-Yehudain J, Kogan L, Cohen HI, et al. Familial juvenile hypertrophy of the breast. J
Adolesc Health 2004; 35: 151-5
7. Jabs AD, Frantz AG, Smith-Vaniz A, et al. Mammary hypertrophy is not associated with
increased estrogen receptors. Plast Reconstr Surg 1990; 86: 64-66.
8. Di Noto A, Pacheco BP, Vicala RE. Two cases of breast lymphoma mimicking juvenile
hypertrophy. J Pediatr Adolesc Gynecol 1999; 12: 33-35.
9. Cardoso de Castro C, Aboudib JH, Salema R, Valladares B. Massive breast hypertrophy in a
young girl. Ann Plast Surg. 1990 Dec;25(6):497-501.
10. Govrin-Yehudain J, Kogan L, Cohen HI, et al. Familial juvenile hypertrophy of the breast. J
Adolesc Health 2004; 35: 151-155.
11. Kucukaydin M, Kurtoglu S, Okur H, et al. Virginal hypertrophy. Case report. Turk J Pediatr
1994; 36: 243-248
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East and Central African Journal of Surgery Volume 15 Number 2 - July/August 2010.
Tongue Entrapment in an Aluminium Milk Can: An Unusual Cause of Tongue Injury.
J.A. Eziyi1, J.B. Elusiya2, O.O. Olateju1, Y.B. Amusa1, O.V. Akinpelu1, A.K. Eziyi1
1
Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex (O.A.U.T.H.C), Ile-Ife,
Osun State, Nigeria.
2
Paediatric Emergency Unit, Department of Paediatrics, Obafemi Awolowo University Teaching Hospitals
Complex (O.A.U.T.H.C), Ile-Ife, Osun State, Nigeria.
Correspondence to: J.A. Eziyi, E- mail: [email protected].
Peri-oral injuries are common findings in paediatric patients; however, tongue injury following
entrapment in bottles and cans is rare and has not been reported in our locality. A case of a 9year old previously healthy female child who got her tongue tightly entrapped in an half opened
aluminium milk can while in school is hereby presented. This case highlights the result of
careless and often dangerous play and misadventures of children and the challenge of
management. It calls for vigilance and close supervision of children by caregivers at home and
at school. Early presentation, immediate intervention and treatment can prevent grave
consequences.
Introduction
Peri oral injuries are common findings in paediatric patients, and they may have significant medical,
dental and psychological consequences in the affected children1. In the USA, the tongue is the second
most common site of oral mucosal lesion in children and youths after the lip and this is commonly due
to bites, followed by stomatitis, herpes labialis and geographic tongue2. In Nigeria however, the
tongue is the most common reported site of oral mucosal lesion and this is most commonly due to fall
followed by road traffic accident3.
Tongue injury may also result during convulsions in children with epilepsy, intense oro - facial
spasms in Leigh diseases4, forceful insertion of spoon into the mouth of children with febrile
convulsion5 and from baby walker injury6. A complete tongue amputation during a fight had been
reported7. It is seen more commonly in boys than girls2,3 within the age range of 3 months to 17years
with the highest occurrence in the 0-5 years old2,3. These may be due to the fact that children are more
restless, exploitative and adventurous8, and are constantly exploring9. Most tongue injuries are minor
injuries that can be managed conservatively3. There are few report of tongue injury from tongue
entrapment in bottles10,11 and can12 from the western world but we are not aware of any such report
from the tropics.
We are reporting the case of a 9-year old Nigerian girl who had tongue entrapment in an old half
opened condensed milk can while trying to lick ’garri’ and sugar contained in the can.
Case Report:
O. J, a 9-year old Nigerian girl presented to the paediatric emergency unit of our hospital with
history of tongue entrapment in an old aluminium milk can 20 minutes before presentation while
licking garri (A staple Nigerian food) and sugar contained in it while at school. There was associated
pain, drooling of saliva and minimal blood loss. There was no difficulty in breathing. There was
neither a previous history of similar incidence nor history suggestive of mental derangements. She had
no history of previous hospital admission, surgery or blood transfusion. She was the only child of
deceased parents, and lives with her maternal grandmother. Review of systems revealed no
abnormality.
Examination showed a healthy school girl in obvious painful distress, sweating profusely and drooling
saliva. Vital signs were within normal limits. The anterior 1/3 of the tongue was trapped in a half
opened milk can (Figure 1). It was massively edematous and cyanotic. There was minimal bleeding.
The ear, nose, oro-pharynx and other systems were essentially normal.
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The tongue release was done under sedation with intravenous diazepam in the emergency paediatric
department, using a strong Mayo’s scissors to cut open the can. Fragments of the can were removed
and the oral cavity copiously irrigated with normal saline (Figure 2).
Post procedure findings were minimal abrasions on the dorsum tongue at the junction of the anterior
and middle one-third. The anterior one-third of the tongue was massively edematous. This however
returned to normal size within one and a half hour (Figure 3) which began to resolve quickly. She was
given 750 i.u of anti-tetanus serum after a test dose, 0.5ml of tetanus toxoid, amoxicillin- clavulanic
acid antibiotics, analgesic and regular warm salt water gargle.
She was subsequently discharged the same day to the ear, nose and throat clinic for follow up in the
outpatient clinic after several hours of observation but was lost to follow up.
Figure 1. Tongue was trapped in a half opened milk can
Figure 2. Post procedure findings showing minimal abrasions on the dorsum tongue at the junction of
the anterior and middle one-third. The anterior one-third of the tongue was massively edematous.
Figure 3. Normal sized Tongue within one and a half hours after release.
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East and Central African Journal of Surgery Volume 15 Number 2 - July/August 2010.
Discussion
Injury commonly occur in children due to the fact that they are more restless, exploitative and
adventurous and are constantly exploring8,9. These injuries commonly follows falls from heights,
febrile convulsions, burns and electrical injuries, drowning and near drowning and usually affect
major body parts3,5,13 and occasionally the tongue. Tongue injury due to entrapment had been reported
as isolated cases mainly in the United State of America10,11,12. This 9 year old girl presented with
tongue entrapment in an-old half opened milk can while trying to lick garri (a powdered Nigerian
staple cassava food) contained in it while at school.
In injury to the tongue, the most common location is the dorsum of the anterior 1/32,14 . This is also the
site in this index case. The age of our patient is also within the commonly affected age group involved
in oro- facial tissue injury 2,3. The tongue on presentation was massively edematous because of
impaired venous return due to constriction by the edge of the half opened can. After removal of the
can and copious irrigation, the edema resolved within one and a half hour (fig. 3). The challenge in
the management of this case is that metal cutting facilities are not part of the regular surgical
armamentarium and repeated attempts were made with different instruments to cut open the can. This
type of problem is well illustrated in a tongue entrapped in a bottle in which a professional glazier was
involved in the management11. This may lead to delay in the intervention unless an alternative is
readily available. Early presentation and immediate intervention are important. This was the case of
this patient who presented within 30 minutes of the incidence and this prevented the complications
that could follow prolonged entrapment which include ecchymosis, lingual edema, ischaemia,
gangrene and auto amputation7,10,15.
Conclusion
Tongue entrapment though rare, is a cause of peri-oral injury which is preventable1 but not without
grave consequences. However, early presentation, immediate intervention and treatment can prevent
these. This case highlights the result of careless and often dangerous play and misadventures of
children and the challenge of management. It calls for vigilance and close supervision of children by
caregivers at home and at school.
References
1. Rothman DL. Pediatric orofacial injuries. J Calif Dent Assoc. 1996; 24(3): 37-42.
2. Shulman JD. Prevalence of oral mucosal lesions in children and youths in the USA.
Int J Paediatr Dent. 2005; 15(2): 89-97.
3. Bankole OO, Fasola AO, Denloye OO. Oro-facial soft tissue injuries in Nigerian children: a
five-year review. Afr J Med Med Sci. 2004; 33(2): 93-7.
4. Diab M. Self-inflicted orodental injury in a child with Leigh disease. Int J Paediatr Dent.
2004; 14(1): 73-7.
5. Ndukwe KC, Folayan MO, Ugboko VI, Elusiyan JB, Laja OO Orofacial injuries associated
with prehospital management of febrile convulsion in Nigerian children. Dent Traumatol.
2007; 23(2): 72-5.
6. Al-Nouri L, Al-Isami S. Baby walker injuries. Ann Trop Paediatr. 2006; 26(1): 67-71.
7. Toure S, Fall I, Diallo BK, Diouf R, Sane JC, Diouf M, Neissem B, Diop R, Diop EH
[Emergency reimplantation of the tongue after complete traumatic amputation]. Rev Stomatol
Chir Maxillofac. 2003; 104(1): 52-4.
8. Lather M, Borchard S, St-vil D, et al. Falls from heights among children: A retrospective
review. J. Paediatric Surg 1999; 34: 1060-3.
9. Broz L, Kripner J, Brucek S. Emergency care of severe burn children ( an experience of
Pragua burn center). Acta Chir Plas 1995; 37: 89-93.
10. Green DC. Bottleneck entrapment of the tongue. Otolaryngol Head Neck Surg. 1995; 113(4):
508-9.
11. Guha SJ, Catz ND Lingual ischemia following tongue entrapment in a glass bottle. J Emerg
Med. 1997; 15(5): 637-8.
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12. Bank DE, Diaz L, Behrman DA, Delaney J, Bizzocco S. Tongue entrapment in an aluminum
juice can. Pediatr Emerg Care. 2004; 20(4): 242-3.
13. ShimoyamaT, Kaneko T, Nasu D, Suzuki T, Horie N. A case of an electrical burn in the oral
cavity of an adult. J Oral Sci. 1999; 41(3): 127-8.
14. Lamell CW, Fraone G, Casamassimo PS, Wilson S. Presenting characteristics and treatment
outcomes for tongue lacerations in children. Pediatr Dent. 1999; 21(1): 34-8.
15. Singh K. Partial glossectomy for lingual edema following injury. Indian Pediatr. 2004; 41(5): 520.
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East and Central African Journal of Surgery Volume 15 Number 2 - July/August 2010.
Carpal Tunnel Syndrome in Patient on long Term Hemodialysis - a Case Report
S. A. Salati1, N.F. Aldajani1, B. Al Aithan2, S.M. Rabah1.
1
King Fahad Medical City, Riyadh, Saudi Arabia
Military Hospital, Riyadh, Saudi Arabia
Correspondenceto: Dr Sajad Ahmad Salati, Email: [email protected], [email protected]
2
Pain in hands is a common complaint in patients of end-stage renal disease on long term
hemodialysis. This pain can arise from various different etiological factors. We present one such
case of 56 years old lady who suffered from pain in the hand due to carpal tunnel syndrome on
the side with angioaccess. Carpal tunnel was released by open surgical technique resulting in
symptomatic relief of the patient.
Introduction
Complaints related to hand are not uncommon in patients of end stage renal disease on long term
hemodialysis 1 and need proper work and evaluation so that relief can be provided to these otherwise
chronically ailing patients. These symptoms may represent complications of angioaccess 2 or may be
related to other common diseases. Carpal tunnel syndrome is the commonest compression neuropathy
leading to painful hands 3 and need early detection and management to bring about symptomatic relief
and prevent disabilities.
Case presentation
A 56 years old female reported with pain and abnormal sensations (numbness/tingling) in her left
hand of three years duration. The patient was a known case of diabetes, hypertension and end-stage
renal disease on regular hemodialysis and had functioning Cimino-Brescia fistula (for angioaccess) on
the affected side since 17 years. The patient used to experience increase in pain and paresthesias after
dialysis or routine work and after sleeping for a few hours. The patient had been receiving analgesics
and was using a volar splint to immobilize the wrist but without satisfactory relief. One examination,
the patient had features suggestive of carpal tunnel syndrome with positive Tinel's, Dercum's and
Phalen's tests. Two-point discrimination was 16-17mm but there was no motor deficit. There was no
atrophy of hand muscles and color and capillary return was within normal limits and comparable to
opposite hand. There was no other neurodeficits on general physical examination.
Electrophysiological studies were conducted in both upper extremities (Figure 1). The left median
sensory potentials were not obtained on stimulation proximal to the wrist. The left median motor
distal latency was significantly prolonged (6.75 ms at left wrist as compared to 4.5ms over right
wrist). In addition, the left median motor compound muscle action potential (CMAP), left median
motor and sensory conduction velocities were decreased (sensory peak amplitude of 1.7uV over left
palm as compared to 58.5 uV on right side and motor peak amplitude of 2.1mV over left wrist as
compared to 4.3 mV on right side). These electrophysiological studies were interpreted as evidence
for a severe degree of left Median Neuropathy at the wrist.
The patient was operated upon under local anesthesia and open release of carpal tunnel was done. One
day prior to operation, the patient was had session of hemodialysis. Per-operatively the transverse
carpal ligament was found to be compressing the median nerve along the whole extent of carpal
tunnel. No other pathological lesion was found. The patient had an uneventful postoperative phase.
At six months follow-up, the patient was pain free but still had paresthesias although of lesser
intensity.
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Figure 1. Nerve Conduction Studies - (A) Motor NCS of right median nerve over right abductor
pollicis brevis (B) Motor NCS of left median nerve over left abductor pollicis brevis (C) Sensory NCS
of right median nerve over right index finger (D) Sensory NCS of
of left median nerve over left index
finger
Discussion
Symptoms related to hand are common in cases of end-stage
end stage renal disease on maintenance
hemodialysis1. These symptoms can arise from complications of angioaccess2 which include steal
syndrome and ischemic
mic monomelic neuropathy or else the patient may be suffering from other usual
diseases prevalent in general population, the carpal tunnel syndrome (CTS) being one such condition
when either one or both of the hands could be symptomatic. Our case suffered from carpal tunnel
syndrome on the side with Cimino-Brescia
Brescia fistula.
Warren and Oriento3 in 1975 were the first to report the development of carpal tunnel syndrome in
patients on chronic dialysis and since then, multiple studies have been published on this subject. The
incidence of carpal tunnel syndrome in patients having dialysis is difficult
difficult to assess, and depends on
the criteria for diagnosis, be it by EMG or by clinical assessment4. Scardapane et al reported in 1979
that the incidence of EMG evidence of nerve entrapment rises with an increase of time on dialysis and
50% of their patients who had been on dialysis for over five years had EMG evidence of carpal tunnel
syndrome 4. Al-Homrany
Homrany et al also found statistically significant positive correlation ((P = 0.039)
between the finding of abnormal EMG suggesting CTS and the duration on dialysis,
dialysis, with increasing
prevalence observed in patients treated for more than 5 years5 .
Carpal tunnel syndrome (CTS) is the most common peripheral entrapment disorder, and results from
compression of the median nerve at the wrist where it courses deep to transverse
transverse carpal ligament. This
condition was initially described by James Jackson Putnam in 1880 and later on medical luminaries
like Paget, Marie, Ramsay Hunt, Phalen and Osler contributed to our understanding of the syndrome6.
The usual symptoms includee numbness, paresthesias, and pain in the median nerve distribution, with
nocturnal exacerbation. These symptoms may or may not be accompanied by objective changes in
sensation and strength of median--innervated
innervated muscles in the hand. Some patients can report with
features secondary to autonomic nerve fiber involvement (the median nerve carries most autonomic
fibers to the whole hand) including sensitivity to changes in temperature (particularly cold), a
difference in skin color or changes in sweating pattern of affected hand. Our patient had pain and
paresthesias as presenting features.
As far as pathophysiology is concerned, it is now known that the median nerve is damaged within
the rigid confines of the carpal tunnel, initially undergoing demyelization followed
followed by axonal
degeneration. Sensory fibers often are affected first, followed by motor and/or autonomic fibers.
Though the precise cause of the damage to nerve is still uncertain; however, it seems likely that
abnormally high carpal tunnel pressures in patients with CTS causes obstruction to venous outflow,
back pressure, edema formation, and ultimately, ischemia in the nerve and subsequent manifestations.
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Most cases are idiopathic, although the risk of development of CTS appears partly to be associated
with a number of different epidemiologic factors, including genetic, medical, social, vocational and
demographic7. In the patients on chronic hemodialysis (like the one we are presenting), the etiology is
multifactorial, though multiple reports are found in literature which tend to establish the relation
between CTS and long-term hemodialysis due to chronic renal failure 8, 9. Amyloidosis due to beta 2microglobulin deposition is recognized with increasing frequency in patients undergoing long-term
hemodialysis and deposition of amyloid in carpal tunnel leading to median nerve compression is
being projected as a possible cause of CTS in this subset of population. This amyloid deposition has
been confirmed in studies by biopsy of transverse carpal ligament and median nerve9,10. However
since no material was retrieved by us during operation for histopathological analysis, we could not
study this aspect in our case. Uremia leads to extracellular fluid retention which may cause raised
pressure in the carpal tunnel. Besides peripheral neuropathy is common in chronic renal failure with
its associated uremia which can present as painful hands. Both these effects of uremia can get
worsened by the arteriovenous fistula used for dialysis. During dialysis both the venous pressure and
the volume of the hand are increased distal to the fistula because of the venous engorgement and the
patient can become symptomatic as was true of our patient who would feel significant increase in pain
and paresthesias in her affected hand during her dialysis sessions4. Lesser common related factors for
carpal tunnel syndrome in chronic renal failure include extensive uremic tumoral calcinosis
that affecting the wrist11 and acute thrombosis occurring in a persistent median artery12.
Diagnosis of CTS is based on meticulous history, physical examination and electrophysiological
studies. A constellation of bedside tests are mentioned in literature as aids to diagnosis13; the
prominent ones include (a) Hoffmann-Tinel sign-gentle tapping over the median nerve in the carpal
tunnel region elicits tingling in the nerve's distribution , (b) Phalen sign- tingling in the median nerve
distribution is induced by full flexion (or full extension for reverse Phalen) of the wrists for up to 60
seconds, (c) Carpal compression test - this test involves applying firm pressure directly over the carpal
tunnel, usually with the thumbs, for up to 30 seconds to reproduce symptoms (d) A positive flick sign
- having to shake the hand for relief. Electro physiologic studies include electromyography (EMG)
and nerve conductions studies (NCS) and are the first-line investigations in diagnosis of carpal tunnel
syndrome (CTS). In addition, other neurologic diagnoses (like neuropathies due to uraemia, diabetes
etc) can be excluded besides providing an accurate assessment of severity of damage to the nerve,
thereby directing management and providing objective criteria for the determination of prognosis14.
Carpal Tunnel Syndrome is usually divided into mild, moderate, and severe; patients with mild CTS
have sensory abnormalities alone on electrophysiologic testing, and patients with sensory plus motor
abnormalities have moderate CTS. Patients with any evidence of axonal loss (e.g., decreased or absent
sensory or motor responses distal to the carpal tunnel or neuropathic abnormalities on needle EMG)
are classified as severe CTS. Radiologic imaging methods are infrequently used, particularly in cases
with features of predominantly unilateral median nerve compression to rule out any space occupying
lesion in the carpal tunnel. MRI has consistently shown the greatest sensitivity and specificity in the
regard though in the hands of experienced operators, high frequency ultrasound may be equally
useful.
Management in mild to moderate cases is conservative and comprises of use of nocturnal wrist-hand
orthosis (splints) maintaining the wrist joint in neutral position. Non steroidal anti inflammatory drugs
(NSAIDS) and steroids may be of benefit. Patients of severe carpal tunnel syndrome or the ones not
responding to conservative therapy over 3-4 weeks are treated by surgical release of carpal tunnel
.However before undertaking surgery, the patient needs to be fully informed about complications
which include failure of recovery of neurodeficits, scar tenderness, pillar pain, and neuroma
formation15.Our patient had persistent paresthesias even at six months follow-up but did not develop
any other complication and was satisfied with the outcome of carpal tunnel release.
Conclusion
It is stressed that carpal tunnel syndrome be ruled out early in every case of end stage renal disease
presenting with complaints related to hand to prevent serious neurodeficits and disabilities.
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Furthermore it is emphasized that neurophysiological studies are utilized for detection of early cases
of carpal tunnel syndrome.
References
1. Carroll LL, Tzamaloukas AH, Seremin AE, Ecsenberg B. Hand symptoms in patients on
chronic dialysis. Int J Artif Organs 1993; 16:694-9
2. Haimov M, Schanzer H, Skladani M. Pathogenesis and management of upper-extremity
ischemia following angioaccess surgery. Blood Purif 1996; 14(5):350-4
3. Warren DJ, Otieno IS. Carpal tunnel syndrome in patients on intermittent haemodialysis.
Postgrad Med J 1975; 51:450-2.
4. Bradish C F. Carpal tunnel syndrome in patients on haemodialysis. J Bone Joint Surg 1985;
67B (1):130-132
5. 5. Al-Homrany MA, Khan MH, Adzaku F, Harding MG. Carpal tunnel syndrome in
haemodialysis patients: early detection by
electroneurophysiological studies. Nephrology
2001; 6 (6): 259-262
6. Sternbach G. The carpal tunnel syndrome. J Emerg Med 1999; 17(3):519-23
7. de Krom MC, Kester AD, Knipschild PG, et al. Risk factors for carpal tunnel syndrome. Am J
Epidemiol 1990; 132(6):1102-10
8. Jose L. Zamora, James E. Rose, Vidal Rosario et al. Hemodialysis associated carpal tunnel
syndrome -A clinical review. Nephron 1985; 41:70-74
9. Kimura I, Sekino H, Ayyar D. Carpal tunnel syndrome in patients on long-term
hemodialysis. Tohoku J Exp Med 1986; 148(3):257-66
10. Chung YJ, Choi KC, Ha JH, et al. A case of carpal tunnel syndrome due to dialysis-related
amyloidosis in a patient undergoing long-term hemodialysis. Korean J Intern Med 1997;
12(1):75-9
11. Cofan F, Garcia S, Combalia A, Segur JM, Oppenheimer F. Carpal tunnel syndrome
secondary to uraemic tumoral calcinosis. Rheumatology 2002; 41:701-703
12. Rose RE .Acute carpal tunnel syndrome secondary to thrombosis of a persistent median
artery. West Indian Med J 1995; 44(1):32-3
13. D'Arcy CA, McGee S. The rational clinical examination. Does this patient have carpal tunnel
syndrome? JAMA 2000; 283(23):3110-7
14. Robinson LR. Electro diagnosis of carpal tunnel syndrome. Phys Med Rehabil Clin N Am
2007; 18(4):733-46
15. Boya H, Ozcan O, Oztekin HH. Long-term complications of open carpal tunnel release.
Muscle Nerve 2008; 38(5):1443-6
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Extra-adrenal Pheochromocytoma: Experience in Mulago Hospital.
O.N Alema, J.O Fualal
Breast and Endocrine Unit, Mulago Hospital, Kampala – Uganda.
Correspondence to: Dr. Nelson Alema, Email: [email protected]
Exta-adrenal pheochromocytomas are rare tumors that arise from extra-adrenal chromaffin
cells of the sympathetic ganglia. Experience with two cases is reported here and a review of
literature was conducted. Like pheochromocytomas, extra-adrenal pheochromocytomas present
with episodic hypertension, tachycardia, headache, and diaphoresis, and can be either benign or
malignant. Diagnosis is made by serum and urine analysis for catecholamines and
metanephrines, and confirmed with imaging studies including computed tomography scanning,
magnetic resonance imaging, or 123-I metaiodobenzylguanidine imaging. Ultrasound scanning
in the developing world is beneficial. Genetic testing should be offered were available,
particularly patients who are young, have multiple tumors, or have a family history of
malignancy. Management of extra-adrenal pheochromocytoma is enblock en-mass surgical
resection. Chemotherapy, and radiation therapy may be necessary in malignant disease. Longterm follow-up is essential, as extra-adrenal pheochromocytomas can recur many years after
initial diagnosis.
Introduction
Exta-adrenal pheochromocytomas are rare tumors that arise from extra-adrenal chromaffin cells. They
represent 10–18% of all chromaffin tissue-related tumors1-3. These tumors may be divided into tumors
derived from the parasympathetic or sympathetic ganglia. Most parasympathetic ganglia derived are
found in the neck constituting of about 69% 4. The common sympathetic ganglia derived tumors are
found within the adrenal medulla consisting of 85-90% and are called pheochromocytoma and those
that arise outside the adrenal gland are known as paragangliomas or Extra-adrenal pheochromocytoma
of which the majority are found in the para-Aorta sympathetic chain, commonly located in the organ
of Zuckerkandl (centered around the root of the inferior mesenteric artery)5,6,7.
The presentation of extra-adrenal pheochromocytoma varies widely, but early recognition and
appropriate treatment is necessary to avoid morbidity and potential mortality associated with the
disease. Only 10% of the extra-adrenal pheochromocytomas are malignant, however, this often cannot
be determined on a biochemical or histologic basis. Malignancy in these tumors is defined by the
presence of local invasion on gross or microscopic examination at the time of resection, or much more
commonly by the presence of metastases, which may only be recognized years later when the tumor
recurs8. Further, in certain familial syndromes, the rate of malignancy in extra-adrenal
pheochrocytomas can be as high as 50%9.
In this article, we report our experience with two cases of extra-adrenal pheochromocytomas and
review similar cases published in the literature, focusing on the clinical presentation, diagnosis,
management and prognosis. For purposes of clarity we will use the term extra-adrenal tumors
referring to paragangliomas.
Case reports
Case 1.
A 53-year old woman presented with 3-years history of on and off palpitations, sweating and severe
headache at the heart institute. She was thought to have post-menopausal syndrome with Labile
Hypertension. She developed a Hypertensive Crisis, received multiple antihypertensives (verapamil,
carvedilol, enalapril, digoxin and primaan) with little improvement of the symptoms. The throbbing
headache, dizziness, blurring of vision, palpitation with chest pain worsened. An abdominal
ultrasound and CT revealed a retroperitoneal mass in the vicinity of the left side of abdominal aorta
below the lower. The mass measured 7 X 4 cm, diagnosed as extra-adrenal pheochromocytoma from
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organ of Zuckerkandl was noted. The Vanillymandellic acid (VMA) assay was normal. The patient
had a recurrent thyroid nodule with normal thyroid. The patient was put on prasozin only and liberal
salt intake. Propranolol was introduced after the patient remained tachycardic. The blood pressure
dropped to normal ranges after 2-weeks of prasozin.
Laparatomy was performed and a mass on the left side of the abdominal aorta extending caudally
from below the lower pole of the left kidney excised. Both kidneys were normal. Intraoperatively
patient was stable. A yellowish brown tumor nodule measuring 7x4x4 cm, with histologically large
tumor cells with granular cytoplasm and fibrovascular stroma was diagnosed.
Patient’s postoperative blood pressure was normal and stable. Prasozin was stopped she was
discharged, followed for 3-years with recurrence of symptoms.
Case 2.
A 12-year old boy was referred with a 2-month history of headache, abdominal pain, nausea &
occasional vomiting and constipation, Palpation, Excessive sweating and generalized body weakness.
He had labile blood pressure. He did not respond to conventional treatment (Atenolol, Nifedipine),
and pain killers (Cetamol). Abdominal US revealed a well defined predominantly solid mass with
central cystic area, anterior to the left Psoas muscle and inferior to and separated from the lower pole
of left kidney. It measured 5.4 x4.6 cm. Adrenal areas were free. Laboratory evaluations at the time
revealed normal 24-hour Vanillymandellic acid (MVA).
Patient received α-adrenergic blockade ( parasozin) , the rest of the drugs were stopped. Patient was
allowed liberal salt intake to replete the intravascular volume. Bed rest was encouraged while
abdominal examination was restricted. Propranolol was re-instituted as pulse remained > 90b/min.
At laparotomy a yellowish brown tumor measuring 5 X 4 cm was excised, patient was stable.
Histoloy confirmed pheochromocytoma. Postoperative urine VMA levels were normal and the
symptoms resolved.
Two years after surgery the patient remains disease-free.
Discussion
Clinical presentation
Extra-adrenal pheochromocytomas cause clinical symptoms as a result of the catecholamines
(epinephrine, nor epinephrine, and dopamine) that are released by the tumors. The classic triad of
symptoms associated with these tumors are episodic headache, diaphoresis, and tachycardia10,11,12.The
presentation depends primarily on whether it is of parasympathetic or sympathetic origin, although
there may be an overlap between the two types. The mode of presentation may be in form of mass
effect, incidental discovery or excess catecholamine production4,13,4.
Excessive Catecholamine production is however the commonest presentation and is one of the most
worrisome manifestations and can be life threatening. The classic constellation of signs and symptoms
associated with catecholamine excess include headache (26%), palpitations (21%), sweating (25%),
and episodic hypertension (64%)13,4,6,14. Only a third of the patients will present with these striking
features. Other less common features associate with catecholamine excess are; hyperglycemia, fever,
weight loss, panic attacks, myocardial infarction and Rynaud’s phenomenon. A triad of hypertension,
intermittent hematuria and symptoms upon micturation or sexual intercourse may indicate bladder
extra-adrenal pheochromocytoma in almost 50% of the cases15. Majority of patients have paroxysmal
(48%) or sustained (29-50%) hypertension. Only 2-13% may are normotensive16,17.
Our patients we presented had both cardinal symptoms and signs of excessive catecholamine release;
severe headache, palpitation, diaphoresis and labile hypertension. However the diagnosis of case 1
was delayed and inappropriate management was instituted. It is much easy to suspect a child with
excessive catecholamine release than an adult or an elderly patient since they are prone to
cardiovascular problems with age.
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Diagnosis
The diagnosis of extra-adrenal pheochromoctomas is made both biochemically and by imaging.
Biochemical diagnosis is confirmed by measurement of 24-hour urine metanephrines with sensitivity
of 87-90% and specificity of 99% or greater1819. Plasma metanephrine levels can also be measured but
has low specificity of 85% and a high sensitivity of 96%18,20,21. Therefore the relatively low sensitivity
and high specificity of urine metanephrines leads to fewer false positives making it a screening
modality of choice. Urine norepinephrine and epinephrine levels may be measured where possible.
Remember that medications including; tricyclic antidepressants, decongestants, amphetamines,
antipsychotic medications, reserpine, levodopa, ethanol and acetaminophen, can increase both urine
and plasma catecholamine measurements and cause false positive tests22.
We only measured the urine VMA levels which were not elevated in our patients due to lack of
facilities for urine metanephrines, norepinephrines and epinephrines. It is not unusual to find normal
levels of VMA in catecholamine secreting extra- adrenal pheochromocytoma or pheochromocytoma
and may be misleading and this was the case in our patients23. Once the diagnosis of catecholamine
secretion tumor is made, it must be localized.
Computer tomography (CT) has sensitivity of 98% and specificity of 92% [24, 25]. Its major
limitation is that it only provides anatomic but not functional information23.
Magnetic resonance imaging (MRI) can detect catecholamine secreting tumor in 95% of the cases
and has a sensitivity of 93-100% [26]. Good in patients with iodine- based contrast allergy, children
and in pregnancy. Despite this, CTS is still preferred over MRI because of lack of anatomical
information.
Metaiodobenzylguanidine scan (MIBG) is a good functional test and surveys the whole body but has
high false negative rate (29%) for extra-adrenal pheochromocytomas than pheochromocytomas4.
Positron emission tomography (PET) may be used in cases of negative MIBG sca27.
Combined PET/CT scans increases precise detection and localization, which could eventually reduce
cumulative cost for additional and multiple imaging modalities28,29.
There is no consensus on which patients diagnosed with extra-adrenal pheochromocytoma should be
genetically tested for familial chromaffin-cell tumor syndromes. However, even in the absence of a
suggestive family history, more than 10% of patients presenting with extra-adrenal
pheochromocytoma will ultimately be found to be part of a familial syndrome30,31,32. Therefore,
according to the guidelines of the American Society of Clinical Oncology33 when available, patient
with extra-adrenal pheochromocytoma should undergo screening for germ line mutations in
Neurofibromatosis type 1(NF1), Retproto-oncogene (ret), von Hippel- Lindau (VHL), Succinyl
dehydrogenase Subuinit complexes (B,C,D) or SDHB,SDHC, and SDHD.
A recently published article34 suggests that patients in whom a tumor occurs before the age of 40 or
with multiple tumors may be prioritized for genetic testing. However, in our case series none of the
modern localizing modalities was used except CTS. Abdominal Ultrasound Scan which is hardly
described in literature for localizing catecholamine secreting tumor was used in localizing the tumors
in both cases and it is still the primary localizing modality in our setting in suspected para-aortic
extra-adrenal pheochromocytomas.
Management
Except in the case of widely metastatic disease, the definitive treatment of any extra-adrenal
pheochromocytoma is complete surgical resection. Patients with surgically resected benign tumors
have a life expectancy similar to age-matched controls35. The pre and intra-operative management of
this tumor is unique because of the risk for hypertensive crisis and hypotensive episodes. Fortunately,
most of the extra-adrenal phechromocytomas are benign and of manageable size4,36,37.
Patients would suffer hypertensive crises due to catecholamine release during positioning of patients
and surgical manipulation of the tumor. In anticipation of surgical resection, it is imperative to avoid
catastrophic consequences. Therefore preoperative use of alpha adrenergic blockade for at least
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2-weeks is essential in reducing surgical mortality rates and this is most often achieved with
phenoxybenzamine, prazosin, or doxazosin, titrated to a systolic blood pressure of 120 mm Hg when
seated and of 90 mm Hg when supine for an adult. Once alpha blockade is achieved, beta-adrenergic
blockade may be initiated if the pulse rate remains > 90b/min; low doses are used initially, and
gradually up titrated to a goal heart rate of 60 to 8038.
During this time it is crucial to replete the patient’s intravascular volume (which was chronically low
due to inappropriate vasoconstriction) by keeping the patient on liberal salt diet13. In our case series,
surgery was undertaken after giving alpha-adrenergic blockade for at least 2-weeks until their blood
pressures returned to normal and use of moderate to high salt diet was mandatory. Both patients
received beta-blockade after they became tachycardic with alpha-adrenergic blockade. This is
important because starting beta-blockade prior to alpha-adrenergic blockade leads to unopposed
alpha-mediated vasoconstriction and may cause “paradoxical hypertension”13. Some authors have
advocated use of calcium channel blockers to alpha-blockade because of their role in arterial
vasodilatation.
Intraoperatively, acute hypertensive crises and tachyarrhythmias may occur which may be managed
with intravenous sodium nitroprusside, phentolamine and short-acting beta-blockers such as
esmolol36. However in the patients we presented we did not encounter intraoperative acute
hypertensive crises. The use of intravenous magnesium sulphate in these two patients to stabilize the
heart and the good communication between the aneasthesia and the surgical team may have helped.
Therefore with adequate preoperative preparation, the patient should not experience wide fluctuations
in the heart rate and blood pressure.
Postoperatively, we continued hemodynamic monitoring of our patients, as the changes in vascular
tone, inotropy, and glycemic control can continue to fluctuate quite rapidly in the early postoperative
period. Biochemical evaluations for residual disease were performed until the acute recovery phase
was successful.
Prognosis
Excision of extra-adrenal pheochromocytomas, is less well studied and likely associated with much
higher morbidity and mortality. The vascularity of these tumors and their lack of encapsulation,
makes these surgeries extremely challenging [37].
The largest series to date examined 25 patients with cardiac extra-adrenal pheochromocytomas
undergoing surgical excision, and reported a 20% intraprocedural mortality rate, with an additional
20% of patients suffering significant complications (sepsis, myocardial infarction, and mitral valve
injury) [39]. We did not have any mortality in the case series presented, probably due to the small
number.
Conclusion
Extra-adrenal pheochromocytomas do exist though rare. High index of suspicion is mandatory for
early diagnosis. Management for the majority of extra-adrenal pheochromocytoma is surgical.
Aggressive perioperative management with alpha- and beta-adrenergic blockade and close
postoperative follow-up are essential to ensure optimal outcomes. Prognosis is good though evidence
of polyglandular disease should be looked for.
References
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Edis AJ, Grant CS, Egdahl RH 1984 Manual of endocrine surgery, 2nd Ed. New York:
Springer Verlag
2. Whalen RK, Althausen AF, Daniels GH Extra-adrenal pheochromocytoma. J Urol 1992;
147:1–10[Medline]
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3. Beard CM, Sheps SG, Kurland, Carney JA, Lie JT. Occurrence of pheochromocytoma in
Rochester, Minnesota, 1950 through 1979. Mayo Clin Proc 1983; 58:802–804[Medline]
4. Erickson D, Kudva YC, Ebersold MJ. Benign paranglioma: clinical presentation and
treatment outcome in 236 patients.J Clin Endocrinol Metab 2001; 86(11); 5210-5216
5. Whalen RK, Althausen AF, Daniels GH. Extra-adrenal phaeochromocytoma. J Urol 1992;
147(1): 1-10
6. Plouin PF, Gimenez-Roqueplo AP (2006). Phaeochromocytomas and secreting
paragangliomas, Orphanet J Rare Dis 1(1):49.
7. Hartley L, Perry-Keene D. Pheochromocytoma in Queensland–1970–83.Aust N Z J Surg.
1985;55:471– 475.
8. Goldstein RE, O’Neill JA Jr, Holcomb GW III, et al. Clinical experience over 48 years with
pheochromocytoma. Ann Surg. 1999;229:755–764;discussion 764 –756.
9. Brouwers FM, Eisenhofer G, Tao JJ, et al. High frequency of SDHB germline mutations in
patients with malignant catecholamine-producing paragangliomas:implications for genetic
testing. J Clin Endocrinol Metab. 2006;91:4505–4509
10. Bravo EL. Pheochromocytoma. Cardiol Rev. 2002;10:44 –50.
11. Manger WM, Gifford RW. Pheochromocytoma. J Clin Hypertens (Greenwich).2002;4:62–72.
12. Manger WM. The vagaries of pheochromocytomas. Am J Hypertens. 2005;18:1266 –1270.
13. Lee, James; Duh, Quan-Yang. Sporadic paraganglioma.World Journal of Surgery, Volume
32, Number 5, May 2008 , pp. 683-687(5)
14. Plouin PF, Duclos JM, Menard J. (1981) Biochemical tests for diagnosis of phaeochrocytoma:
urinary vs plasm determinations. Br Med J (Clin Res Ed) 282(6267):853-854
15. Leestma JE, Prince EB Jr (1971) Paraganglioma of the urinary bladder, cancer 28(4): 10631073
16. Grifford RW Jr, Manger WM, Bravo EL (1994) Phaeochromocytoma. Endocrinol Metab Clin
North Am 23(2):387-404
17. Bravo EL, Tagle R (2003) Phaeochromocytoma: state-of-the-art and future prosfects. Endocr
Rev 24(4)539-553
18. Kudva YC, Sawka AM, Young wf Jr (2003) Clinical review 164: the laboratory diagnosis of
adrenal phaeochromocytoma: the mayo clinic experience. J Clin Endocrinol Metab 88(10):
4533-4539
19. Sawka AM, Jaeschke R, Singh RJ et al (2003). A comparison of biochemical tests for
phaeochromocytoma: measurement of fractionated plasma metanephrines compared with the
combination of 24-hour urinary metanephrines and catecholamines. J Clin Endocrinol Metab
88(2): 553-558
20. Lender JW, Eisenhofer G, Armando I, et al (1993). Determination of metanephrines in plasma
by liquid chromatography with electrochemical detection. Clin Chem 39(1): 97-103
21. Lender JW, Keiser HR, Goldstein DS, et al (1995). Plasma metanephrines in the diagnosis of
phaeochromocytoma. Ann Intern Med 123(2):101-109
22. Adler JT, Meyer-Rochow GY, Chen H, et al. Pheochromocytoma: current approaches and
future directions. Oncologist. 2008; 13:779 –793.
23. Luc A, Dubois MD, Daryl K, Gray MD (2005). Dopamine – secreting phaeochromocytoma:
In search of a syndrome
24. Manger WM, Eisenhofer G (2004) phaeochromocytoma: diagnosis and management update.
Curr Hypertens Rep 6(6): 477-484
25. Pacak K, Eisenhofer G (2004) Diagnostic imaging of phaeochromocytoma. Front Horm Res
31: 107-120
26. Francis IR, Korobkin M (1996) Phaeochromocytoma. Radiol Clin North Am 4(6): 1101-1112
27. Pacak K, Einenhofer G, Ahlham H, et al. Phaeochromocytoma: recommendations for clinical
practice from the firs international symposium, October 2005. Nat Clin Prac Endocrinol
Metab 2007; 3 (2): 92-102
28. Hicks, R.J., Ware, R.E., & Lau, E.W. (2006) PET/CT: will it change the way that we use CT
in cancer imaging? Cancer Imaging, 6, S52-S62.
29. Strobel, K., Schaefer, N.G., Renner, C., Veit-Haibach, P., Husarik, D., Koma, A.Y., &Hany,
T.F. (2007) Cost-effective therapy remission assessment in lymphoma patientsusing 2-
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Baysal BE, Willett-Brozick JE, Lawrence EC, et al. Prevalence of SDHB, SDHC, and SDHD
germline mutations in clinic patients with head and neck paragangliomas. J Med Genet. 2002;
39:178 –183.
Amar L, Bertherat J, Baudin E, et al. Genetic testing in pheochromocytoma or functional
paraganglioma. J Clin Oncol. 2005; 23:8812– 8818.
Neumann HP, Bausch B, McWhinney SR, et al. Germ-line mutations in nonsyndromic
pheochromocytoma. N Engl J Med. 2002; 346:1459 –1466.
American Society of Clinical Oncology policy statement update: genetic testing for cancer
susceptibility. J Clin Oncol. 2003;21:2397–2406
Erlic Z, Neumann HP. Clinical question: When should genetic testing be obtained in a patient
with pheochromocytoma or paraganglioma? Clin Endocrinol (Oxf). 2009; 70:354 –357.
Huang H, Abraham J, Hung E, et al. Treatment of malignant pheochromocytoma/
paraganglioma with cyclophosphamide, vincristine, and dacarbazine: recommendation from a
22-year follow-up of 18 patients. Cancer. 2008; 113:2020–2028.
Pacak K, Ishuzu KI, T orizuka T et al. Recent advances in genetics, diagnosis, localization
and treatment of phaeochromocytoma.Ann. Intern.Med. 2001; 134:315-329
Karen E. Joynt, MD, Javid J. Moslehi, MD, and Kenneth L. Baughman, MD paraganglioma
Etiology, Presentation, and Management (Cardiology in Review 2009;17: 159–164)
Eigelberger MS, Duh QY. Pheochromocytoma. Curr Treat Options Oncol.2001; 2:321–329.
Jeevanandam V, Oz MC, Shapiro B, et al. Surgical management of cardiac
pheochromocytoma. Resection versus transplantation. Ann Surg. 1995; 221:415–419.
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Thymoma Presenting with Myasthenia Gravis: A Case Report.
P. Makobore, O.Omagino, T. Mwambu, S. Apio, G. Ibilata
Mulago Hospital, Kampala – Uganda.
Correspondence to: Dr. Makobore Patson, Email: [email protected]
A 20 year old man was referred to Mulago hospital with a diagnosis of Myasthenia Gravis (MG)
which was suspected to be due to a thymoma. The patient came with complaints of blurring of
vision for one year and body weakness for six months. He was investigated using conventional
X-rays and C.T. The chest CT scan showed an anterior mediastinal mass. The diagnosis was
confirmed on histology report which was consistent with thymoma. The patient was managed
surgically, did well post operatively, and was discharged when his vision and muscle power had
dramatically improved. On follow up for two years, patient was symptom free.
Introduction
Myasthenia Gravis (MG) is the most common disorder of the neuromuscular transmission1. The hall
mark of the disorder is a fluctuating degree and variable combination of weaknesses in the ocular,
bulbar, limbs and respiratory muscles. Weakness is the result of an antibody-mediated T-cell
dependant immunological attack directed at proteins in the post synaptic membranes of the
neuromuscular junction. The diagnosis of MG can be established by clinical and serological testing.
An important consideration is that about.15%-40% of Thymoma is malignant, 35%-40% of patients
with thymoma have MG and about 10%-15% of those with MG have underlying thymoma.1,2
Case Report
A 20- years old man was referred to Mulago hospital from a private clinic with a diagnosis of MG due
to thymoma. His presenting complaints were; blurring of vision for two years, diplopia for two years
and body weakness for six months. He was well until two years prior to admission when he
developed these symptoms. The blurring of vision was initially mild but eventually worsened. He
sought the help of an ophthalmologist who made a diagnosis of Ocular M.G. He was started on
pyridostigmine and improved initially but the symptoms worsened later.
He soon developed an unusual fatigue in the evening. He had difficulty in holding small objects like
pens and cups although, he felt strong. A chest CT scan which was done revealed an anterior
mediastinial mass most likely a thymoma (Figure 10.1 A and B).
There was no history of difficulty in speech, nasal regurgitation, or chewing. He had no difficulty in
breathing or chest pain. There was no history suggestive of superior venacava syndrome or Horner’s
syndrome. There was no hoarseness of voiced or retrosternal pain. He gave no history of weight loss,
fever, diarrhea or vomiting. There was no history of palpitation, backache or muscle wasting. This
was his index admission. There was no history suggestive of metabolic diseases, Diabetes mellitus,
hypertension or thyrotoxicosis. He had never had any operation however, had mild allergy to dust but
was not allergic to any drug. There was no history of MG in the family. He was a banker who lived
alone, did not smoke cigarette or drink alcohol.
On examination he was in good general condition with no anemia, jaundice, edema and or enlarged
lymph nodes. His blood pressure was 120/70 mm Hg, pulse 66/minute, temperature 36.8. All systems
were essentially normal. His hemoglobin, WBC, ESR, Renal and liver function test were within
normal limits. Chest X-ray did not reveal any mediastinial mass or mediastinial widening. A diagnosis
of a thymoma complicated by myasthenia gravis was made.
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The patient underwent surgery. Using a midline incision, a Sternotomy was done. A thymus tumor
was identified in both lobes. The gland was still encapsulated .The thoracic viscera were normal.
Excision of both right and left lob was done successfully. Postoperatively, the patient was admitted in
intensive care unit for close monitoring. The specimen removed was sent for histology.
A post operative chest X-ray showed the tubes in situ and widening of the mediastinium possibly due
to hemorrhage (Figure 10.2A). A repeat post operative chest X-ray showed right basal infiltrates
with lingula opacity possibly collapse, elevated left hemi diaphragm and mild pleural effusion.
(Figure 10.-2B)
Histology report was consistent with thymoma (Figure 10-3 A&B) and (Figure 4). The patient did
well in the intensive care unit and was later transferred back to the parent ward where he was
managed on analgesics, antibiotics, pyridostigmine and physiotherapy. The rest of the post operative
days were uneventful. The patient was discharged on treatment and referred to the Surgical Out
patient for follow up.
Discussion
Myasthenia gravis (MG) is a relatively uncommon disorder. However, it is the most common disorder
of neuromuscular transmission1. This is the first case seen in Mulago Hospital in twenty years. Age of
onset is characterized by an early peak in the second and third decades (female predominance) and
late peak in the sixth to eighth decade (male predominance).The patient presented here was in his
twenties4.
About (10 to 15) % percent of those with MG have underlying thymoma. The case presented here had
Ocular MG. A chest CT scan revealed an anterior mediastinal mass which was removed at Surgery
and confirmed a thymoma by histology1,5.
The cardinal feature of MG is fluctuating skeletal weakness, often with true muscle fatigue. The
fatigue is manifested by worsening contractile force of the muscle5, 6,10. The patient presented here
had unusual fatigue in the evenings and muscle weakness exhibited by difficulty in holding small
objects like pens and cups
There are two clinical forms of MG: ocular and generalized. In ocular MG, the weakness is limited to
the eyelids and extra-ocular muscles. In generalized disease, the weakness may also commonly affect
ocular muscles, but it also involves a variable combination of bulbar, limb, and respiratory
muscles7,8,9. Ocular MG was more marked in the patient presented here than the generalized MG.
More than 50 % of patients present with ocular symptoms of ptosis and diplopia. Of those who
present with ocular manifestations, about half will remain purely ocular, about 15% of the patients
will present with bulbar symptoms. These include fatigable chewing, dysphagia and dysarthria8. Less
than 5% present with proximal limb weakness alone. There were no bulbar symptoms in the patient
presented here although he had proximal limb weakness8,9 . Eyelid muscle weakness can lead to ptosis
that can vary through out the day. Extra ocular muscle weakness produces binocular diplopia that
disappears when the patient closes or occludes one eye7. The patient above had complaints of blurring
of vision and diplopia.
Muscles of jaw closure are often involved and produce weakness with prolonged chewing;
oropharyngeal muscle weakness produces dysarthria and dysphagia. Facial muscles are frequently
involved and make the patient appear expressionless 6. These symptoms were not exhibited in this
patient.
Neck extensor and flexor muscles are commonly affected. The weight of the head may over come the
extensors producing a “dropped head syndrome”. Involvement of the limbs produces predominantly
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proximal weakness similar to other muscle diseases 10 Predominantly distal presentations of otherwise
typical myasthenia can occur. As already mentioned above the case presented here had weakness of
the upper limb
imb but not of the lower limbs. Involvement of the muscles of respiration produces the
most serious symptoms in MG, such as respiratory insufficiency and pending respiratory failure,
5,
called
“myasthenic
crisis.”5,6
.
This
was
not
seen
in
this
patient
A
B
Figure 10-1 Thymoma A,, A scan at the level of T3; a soft tissue mass of 43HU and
Brachocephalic artery of 53.6 HU are seen. B,, A chest CT scan at a level below T3; a retrosternal
mass (M) is seen.
A
B
Figure 10.2 Chest X-rays. A, A supine post operative X-ray
X ray showing the chest tube in situ, and
widening of the mediastinum. B,, An erect postoperative X-ray
X ray a right basal infiltrates and
opacification of the lingual lobe (arrow).
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East and Central African Journal of Surgery Volume 15 Number 2 - July/August 2010.
A
B
Figure 10-3 Thymoma Histology report. A, A section of the tumor consisting of matured lymphoid
cells with hassalls corpuscles and fat. B, Abortive Hassalls corpuscle lined by epitheloid cells and
lymphocytes.
Figure 10-4 Thymoma Histology report. Outer cortex with mature lymphocytes, medulla
composed of plump ovoid epitheloid cells with vesicular nuclei and Hassalls corpuscles at
varying stages of maturity.
Early in the disorder, the symptoms of MG are often transient in many patients, with hours, days, or
even weeks free of symptoms. New symptoms often develop weeks or months later. The maximal
extent of the disease is seen in 77% of patients by three years of onset.
The diagnostic approach to myasthenia is focused on confirming the clinical diagnosis established by
the history and typical examination findings described above. Bedside tests (the tensilon test and the
ice pack test) are easy to perform and are sensitive, but they have major limitations due to concerns
about excess false-positive results with these techniques. Confirmation by these tests alone is unwise.
More reliable laboratory methods that aid in the confirmation are serologic test for autoantibodies and
electrophysiological studies (repetitive nerve stimulation studies and single-fiber EMG). It should be
kept in mind that the diagnostic sensitivity of these studies also vary considerably depending on
whether
the
patient
has
ocular
or
generalized
disease.
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Differential diagnosis
Many of the disorders that are likely to be confused with myasthenia gravis (MG) involve weakness
of the extra ocular muscles. The diagnosis of ocular myasthenia is often difficult to establish with
certainty, since the confirmatory tests are often negative.
The differential diagnosis of ocular myasthenia gravis includes Grave’s disease, chronic progressive
external ophthalmoplegia (CPEO), as well as multiple cranial neuropathies from structural or
inflammatory disease of the brainstem and basilar meninges.
Generalized fatigue and number of neuromuscular disorder can also be confused with myasthenia.
Electrodiagnostic studies are particularly crucial in the differential diagnosis of these other
neuromuscular disorders. Fatigable weakness, an important aspect of MG, must be distinguished from
complaints of generalized fatigue or tiredness.
Amyotrophic lateral sclerosis (ALS) is a progressive disease that, like myasthenia, can involve the
bulbar muscles and can produce a false-positive tensilon test even rarely a false-positive test for
AChR-Ab. The Lambert- Eaton myasthenic syndrome (LEMS) shares the same pathologic site with
MG and has a similar pathophysiology. However, the clinical presentation in LEMS is markedly
different than in MG. Proximal leg weakness is typically the earliest and most prominent symptom.
Involvement of the bulbar muscles or diplopia is rare, but ptosis is frequently seen. Symptoms in
LEMS are more likely to be present in the morning and to improve with exercise. Autonomic
dysfunction is frequent in LEMS.
Botulism can be confused with myasthenia because it also prominently affects the bulbar and eye
muscles. An autoimmune form of MG occurs in approximately 1% of the patients treated with
penicillamine. There are several rare forms of congenital myasthenic syndrome. They should be
considered when there is positive family history, a lack of response to anticholinesterase drugs, and
the absence of AChR-Ab.
Conclusion
Patients with MG should be investigated for Thymoma. Thymectomy can be curative as seen in this
patient.
References:
1. Spencer B .Gay and Richard J.Woodcock.Radiology Recall pg 92
2. Drachman, DB. Myasthenia gravis. N Engl J Med 1994; 330:1797
3. Keesey, JC. Clinical evaluation and management of myasthenia gravis. Muscle and Nerve
2004; 29:484.
4. Phillips, LH. The epidemiology of myasthenia gavis. Semin Neural 2004; 24:17
5. Glob, D, Arsura, EL, Brunner, NG, Namba, T. The course of myasthenia gravies and
therapies affecting outcome. Ann N Y Acad sci 1987; 505:472.
6. Oosterhuis, HJ. The natural course of Myasthenia gravis and: a long term follow up study. J
Neurol Neurolsurg Psychiatry 1989; 52:1121.
7. Bever, C, Aquino, AV, Penn, AS, et al. Prognosis of ocular myasthenia gravis. Ann Neurol
1983; 14:516.
8. Sommer, N, Melms, A, Weller, M, Dichgans, J. Ocular myasthenia gravis: a critical review of
clinical and pathophysiological aspects. Doc Ophthalmol 1993; 84:309.
9. Weinberg, DH, Rizzo JF, 3rd, Hayes, MT, et al. Ocular myasthenia gravis: predictive value of
single- fiber electromyography. Muscle Nerve 1999; 22:1222.
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10. Werner, P, Kiechl, S, Loscher, W, et al. Distal myasthenia gravis frequently and clinical
course in a large prospective series. Acta neural Scand 2003; 108:209.
11. Werner, P, Kiechl, S, Loscher, W, et al. Distal myasthenia gravis frequently and clinical
course in a large prospective series. Acta neural Scand 2003; 108:209.
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East and Central African Journal of Surgery Volume 15 Number 2 - July/August 2010.
Missed Intra Uterine Device: A Rare Indication for AppendicectomyAppendicectomy Case Report with
Review of Literature
S.R. Singhal1, D.S. Marwah2, A. Paul1, S.K. Singhal3
Department of Obstetrics and Gynecology, 2Department of Surgery, 3Department
epartment of Anesthesia.Pt.
B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
Corresponding to: Dr. Savita Rani Singhal,
Singhal Email- [email protected], Fax- 0091 126
1262 211308
1
Appendicitis is a common indication for appendicectomy. Other indications are mucocele,
faecoliths, calculi and tumors. Intra Uterine Device (IUD) perforation is a rare complication of
IUD and it may perforate and lodge in the appendix leading to IUD appendicitis which is a rare
indication for appendicectomy. We review the literature and report a case in which
appendicectomy was done for IUD appendicitis due to missed IUD.
Introduction
Common indications for appendicectomy are acute appendicitis, mucocele, faecolith, calculi and
tumours1. Misplaced intrauterine device (IUD) is a rare complication. Incidence of IUD perforation
ranges from 1-33 per 1000 insertions2. Common sites where it mayy be found after perforation include
broad ligament, pouch of Douglas, sigmoid colon and urinary bladder.
bladder. Very rarely misplaced IUD
may perforate and lodge in the appendix leading to IUD appendicitis which may be an indication for
appendicectomy. There are solitary reports of misplaced IUD found in appendix
appendix and till now only 17
cases have been reported. Standard clinical protocols are available for localization and recovery of the
extra uterine translocated device, and current recommendations require that all extra uterine devices
should be removed from the peritoneal cavity to prevent intestinal obstruction, viscus perforation and
peritonitis either by laparoscopy or laprotomy3.
Case Report
A 22 years old lady with previous two normal deliveries and one abortion was referred to tertiary care
centre with diagnosis of misplaced intrauterine device. The woman had got CuT380A inserted 3 year
back at general hospital by a medical officer at six month postpartum when she was in lactational
amenorrhea. One month back, she underwent suction and evacuation for termination
termination of six weeks of
pregnancy which she conceived with CuT in-situ.
in situ. As CuT was not found after suction and evacuation,
plain X-ray
ray abdomen revealed IUD near right sacroiliac joint and then the patient was referred to
present hospital where she was planned
nned for laparoscopy and proceed.
On laparoscopy CuT could not be visualized due to jumbled up mass of intestine, caecum and
appendix. Laprotomy was performed and after separating the adhesions, CuT was seen coming out of
appendix (Figure-1).
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East and Central African Journal of Surgery Volume 15 Number 2 - July/August 2010.
Figure1- Showing Copper T perforating appendix
Appendicectomy was performed, followed by bilateral tubal ligation. The uterus and the adnexa were
found to be normal with no old site of perforation. Postoperative period was uneventful and patient
was discharged after one week in healthy condition.
Discussion
Intrauterine device has been used throughout the world for almost three decades. The incidence of
perforation ranges from 1-3 per 1000 insertions2, which is affected by the IUD type, timing of
insertion related to pregnancy termination, position of uterus, insertion technique, experience of
operator and follow-up period. The mechanism and etiology of IUCD perforation and translocation to
sites far from uterine cavity remains controversial. In addition to a primary perforation at the time of
IUCD insertion, complete extrusion of IUCD through the myometrium may be aided by spontaneous
uterine contraction and hydrostatic negative pressure differences between the low intraperitoneal
pressure and relatively higher intrauterine pressure4. The migration and movement of the device in the
peritoneal cavity may also be aided by the contraction of other abdominal viscera i.e. urinary bladder
and small and large intestines. The myometrium has long been established as capable of spontaneous
contractions in the non-pregnant and puerperal states5. Another possible mechanism for migration of
the extra uterine IUCD is movement of the peritoneal fluid4. In the present case, it seems that IUD had
perforated the uterus at the time of its initial insertion as at that time, the patient was in lactational
amenorrhea which is a high risk for IUD perforation due to small uterus.
Copper containing devices have been shown to cause considerable tissue response when present in
peritoneal cavity as was seen in present case. There was lot of granulation tissue and adhesions to the
extent that laprotomy had to be performed for appendicectomy. In the present case, patient was
apparently asymptomatic following insertion till she conceived. However the patient can present with
symptoms of epigastric pain radiating to right iliac fossa and right lumbar region, nausea, vomiting
and fever. Thus the possibility of Copper T should be kept in mind while ruling out the cause of
appendicitis in a patient presenting with such symptoms.
On searching various websites like Pubmed, Medline, Scopee, bioline, till date, many cases have been
reported where IUD has perforated the bowel and bladder but there are only 17 reported cases of
appendicectomy performed for IUD appendicitis due to perforated IUD. The first case was reported in
1975 by Rubinoff et al5 where the strings of Copper T intrauterine device protruded from the
midportion of the appendix and the main segment of intrauterine device was palpated within caecal
lumen. Appendicectomy along with closure of caecal perforation was done.
There are two case reports of IUD appendicitis in pregnancy6,7. In first case reported by Carson et al6,
it was interesting to find that strings of IUD (Copper T) was lying in the myometrium about one cm
below the right uterotubal junction indicating the site of perforation as well. Body of the IUD,
however was embedded in the lumen of appendix. Postpartum appendicectomy was done in this case.
In the second case the woman had Copper T inserted 8 years back and she conceived after one year of
placement. Patient had acute right lower quadrant pain in the fifth month of this pregnancy, but
missed IUD could not be diagnosed. Patient continued to have right lower quadrant pain for seven
years, until 20 weeks in the second pregnancy, when the symptoms got exaggerated and patient was
taken up for emergency laparotomy and followed by dissection of inflamed mass and
appendicectomy7.
Out of 17 cases of IUD appendicitis reported till date, one was with Lippe’s loop8 and four cases had
perforation due to Copper 7 5,6,9,10.These cases are reported in ‘70’s and early‘80’s when Cu7 and
Lippe’s loop were the only available IUD’s. However cases reported later than that were with
CuT200, MLCu375 etc. In all the cases reported, there was lot of inflammation and adhesion
surrounding the appendix, thought to be due to copper present in IUD. However inflammation was
also seen in a case where perforation was due to non-medicated IUD, Lippe’s loop, and lot of
dissection had to be carried out for performing the appendicectomy8.
All the cases 4-20mentioned in literature, including our present one were managed either by laparotomy
or laparoscopy followed by laparotomy due to extensive inflammation and adhesions except one,
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where Coelho et al12 (2003) was able to manage it by laparoscopy alone; in spite of the presence of
inflammation and adhesion. This may be due to more expertise of the surgeons in laparoscopy.
The treatment of migrated intrauterine device is surgical either laparoscopy or laparotomy and it
should not be left inside abdominal cavity3. In any instance of missing IUD, an abdominal X-Ray,
USG and hysteroscopy is indicated to exclude perforation and migration2. Thus, missed IUD can lead
to lot of morbidity, as seen in the present case and other reported cases. So, to prevent the delayed
diagnosis and morbidity, the patients with intrauterine device should be alerted about the possibility of
its migration and importance of regular self examination for missing threads which is useful for early
detection of migration of intrauterine device.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Nitecki S, Karmeli R, Sarr MG. Appendiceal calculi and faecoliths as indications for
appendicectomy. Surg Gynecol Obstet 1990; 171(3): 185-8.
Grimes DA. Whither the intrauterine device? Clin Obstet Gynecol1989; 32: 369-76.
World Health Organization (WHO) Special Programme of Research Development and
Research Training in human reproduction: the TCU380A IUD and the frameless IUD “The
Flexigard” Interim three year data from an international multicentre trial. Contraception 1995;
52(2):77-83
Eke N, Okpani AO. Extra uterine translocated contraceptive device: A presentation of five
cases and revisit of enigmatic issues of iatrogenic perforation and migration. Afr J Repro
Health. 2003; 7(3): 117
Rubinoff ML. IUD appendicitis. J Am Med Asso.1975;231(1):6
Carson SA, Gatlin A, Mazur M. Appendiceal perforation by copper-T intrauterine
contraceptive device. Am J Obstet Gynecol 1981;141(5): 586-7.
McLaughlin DI, Bevins W, Karas BK, Sonnenberg L. IUD appendicitis during pregnancy.
West J Med 1988; 149(5): 601-2
Goldman JA, Peleg D, Feldberg D, Dicker D, Samuel N. IUD appendicitis: A case report. Eur
J Obstet Gynecol Reprod Biol 1983;15(3):181-310.
Chang HM, Chen TW, Hsieh CB, Chen CJ, Yu JC, Liu YC, Shen KL, Chan DC. Intrauterine
contraceptive device appendicitis: A case report. World J Gastroenterol 2005; 11(34): 5414-5.
Gorsline JC, Osborne NG. Management of missing intrauterine contraceptive device. A case
report. Am J Obstet Gynaecol 1985; 153(2): 228-99.
Moodley TR. Unusual displacement of intrauterine contraceptive device: A case report. South
Afr Med J 1984; 66: 110
Coelho JC, Goncalves CG, Graf CM. Laparoscopic treatment of periappendicitis caused by
intrauterine contraceptive device. Arq Gastroenterol 2003; 40(1): 45-6.
Gruchy M V. Perforated appendix caused by an IUD. Med J Aust 1982;2:116-7.
McWhinney NA, Jarrett R. Uterine perforation by a Copper7 intrauterine
contraceptive device with subsequent penetration of the appendix.Br J Obstet Gynecol
1983; 90:774-6.
Serra I. Appendicitis caused by an intrauterine contraceptive device.Br J Surg 1986; 73:927-8.
Abbey R K, Gupta R, Sharma R K, Sood P C. Acute appendicitis-an unusual case. Indian J
Med Sci 1999;53: 108-9.
Chang T C, Eden JA. Intrauterine device appendicitis. J Obstet Gynaecol 1989; 9:257-8.
Khanna AK, Khanna A. Perforation of the appendix caused by an IUD. Med J Aust 1986;
144: 109.
Cuillier F, Ben Ghalem S, Haffaf Y. Intrauterine device appendicitis: an exceptional
complication. J Gynecol Obstet Biol Rprod 2003; 32: 55-7.
Katara AN, Chandramani VA, Pandya SM, Nair NS. Migration of intrauterine contraceptive
device into appendix. Indian J Surg 2004; 66: 179-80.
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