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TITLES AND AUTHORS
Contents
Epidemiology of road traffic accidents: - A Prospective study At a Tertiary
University Hospital in Addis Ababa Ethiopia
H. Seife, E. Teffera
Intentional injuries: the experience from Dodoma Regional Hospital, central
Tanzania.
M.Y. Mwashambwa, S.N. Kapalata,, L.O. Akoko
Diagonal Thoraco-abdominal Arrow and Gunshot Injuries as Seen at Juba
Teaching Hospital, South Sudan.
M.M. Achiek, F.K. Tawad, B. M. Alier2, C.T. Yur
Childhood Limb Fracture at Tikur Anbessa Specialized Hospital, Addis Ababa,
Ethiopia
D. Admassie, B. Ayana, S. Girma
PAGES
1
3
Tertiary Trauma Survey: Evaluation of Missed Injuries at a Teaching
Hospital in the Developing World.
O.J. Ogundele, A.O. Ifesanya. O.A. Oyewole,.T.O. Alonge
32
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20
27
Outcome of Ventriculoperitoneal Shunt insertion at Myungsung Christian 39
Medical Centre in Ethiopia
H. Biluts, A.K. Admasu
Laparoscopic Surgery in a Governmental Teaching Hospital: An Initial
Experience from Ayder Referral Hospital in Northern Ethiopia
R. Esayas, A. Shumey, K. G Selassie
Early Outcome of Mitral Valve Replacement: Results from Chordal Preservation
at Muhimbili National Hospital, Tanzania
E.V. Ussiri, B.CW. Wandwi, E.T.M. Nyawawa, B.J. Nyangassa BJ, B.A. Kamala BA,
N. Satyaki, W. Mahalu
Ambulatory Cleft Lip Surgery in a Developing Country
O.A. Olawoye, A.A. Olusanya, S.A. Ademola, A.O. Iyun, A.I. Michael, V.I. Akinmoladun
One Stop Management of Sigmoid Volvulus in an African Setting with Limited
Resources
M.M. Achiek, F.K. Tawad, B.M. Alier, C.T.Yur
49
55
63
68
Acute Mechanical Bowel Obstruction among Adults Seen at the Ladoke Akintola 73
University of Technology Teaching Hospital in Nigeria.
O.L. Idris, M.O. Adejumobi, O.A. Kolawole, A.S. Oguntola, O.O. Akanbi,
K.B. Beyioku.
O.A. Adedeji.
Peritonitis Outcome Prediction using Mannheim Peritonitis Index at St. Francis 79
Hospital Nsambya, Kampala - Uganda
A. Ojuka, L Ekwaro, I. Kakande
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Course of the Sciatic nerve: a Review of Cases Seen at Mulago Hospital, Kampala 90
- Uganda
J. Kukiriza, C. Ibingira, J. Ochieng
A Rare Case of Rosacea Rhinophyma in an African Patient.
95
F.C. Muchemwa, O.B. Chihaka, R. Mutasa, G.I. Muguti
Gossybipoma, an Overlooked Cause of Bowel Obstruction: A Case Report and
Literature Review.
Y. Mohammed, A. Ali
Fourth Consecutive Ectopic Pregnancy- Beating the previous number
S.R. Singhal, V. Sangwan
Retrocaval Ureter: a Case Report
T. BerheGebretsadik, Y. Suga
Deep palmar space lipoma: Case report and review of the literature
O. A. Olawoye, O.N. Enemo, A.0. Iyun, E.E. Akang.
`Prevalence of Low Back Pain amongst Workers at a Paediatric Hospital in
Nairobi.
V.M. Mutiso, A.S. Muoki, M.M. Kimeu
Lumbar Disk Degenerative Disease: Magnetic Resonance Imaging Findings in
Patients with Low Back Pain in Dar Es Salaam.
M. Jacob, L.O. Akoko , R.R. Kazema
Effects of Computerized tomography scan features on outcome of traumatic
brain injuries
M.O.N. Nnadi, O.B. Bankole, B.G. Fente, A.A. Ikpeme .
Major limb amputations at a teaching hospital in the sub-Saharan Africa: Any
change in trend?
O.J. Ogundele, A.I. Ifesanya, O.A. Oyewole, O.O. Adegbehingbe
Cast Bracing for Accelerated Treatment of Femur Fracture in the District
Hospital
O.K. Johnson
Pseudomyxoma Peritonei: An Unusual Complication of Ovarian Tumor
S.R. Singhal, R. Sharma, R. Sen, A. Gupta
Challenges in Management of Pheochromocytoma at a Tertiary Hospital in
Northern Tanzania: A 21 years Descriptive Retrospective Study (1992- 2012)
R.A. Rugakingila, A.K. Mteta
Doctor’s Prayer
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Epidemiology of road traffic accidents: - A Prospective study At a Tertiary University
Hospital in Addis Ababa Ethiopia
H. Seife1, E. Teffera2
Professor of Surgery, General Surgeon, Addis Ababa University School of Medicine
TAH department of Surgery
2Assistant Professor of Surgery, Consultant Cardiothoracic Surgeon Addis Ababa University
School of Medicine TAH, department of surgery.
Correspondence to: Henok Seife MD, Email: henokyees@gmail.com or henokyees@yahoo.com
1Assistant
Background: Road traffic injuries (RTIs) are major but neglected public health problems.
Without appropriate action, by 2020, road traffic injuries are predicted to be the third
leading contributor to the global burden of disease and injury. Most of the projected
increase in road traffic crashes will occur in low- and middle-income regions of the world,
Ethiopia is one of countries with the highest fatality rates worldwide. The road fatality
rates have grown by a quarter in the some African countries like Ethiopia. The main
objective of this study was to determine the epidemiological characteristics and outcomes
of RTIs presenting at Tikur Anbassa Hospital (TAH) in Addis Ababa Ethiopia.
Methods: All 210 patients involved in Road traffic crashes (RTCs) and seen at the
Emergency surgical department at TAH over a one month period were included in the
study. Patients aged under 13 years were excluded from the study. Data were collected by
preformed questioners and was analyzed using statistical tool EPI info 2000.
Results: The peak incidence was in the 21 – 30 years age group and accounted for 40% of
cases. There was a preponderance of males who accounted for 67.6% of victims. There were
6 deaths giving 2.9% case fatality rate. Two of the deaths occurred on arrival while the
other four died while receiving treatment. Eight (3.8%) of the cases were admitted and 37
(17.6%) were referred for admission at other hospitals. One hundred six (50.5%) of the
victims had major injury while 104(49.5%) had minor injury. There were 5 cases of
moderate head injuries and 14 cases of severe head injuries with 4 cases of vertebral
fracture. Closed extremity fractures were 37 (24.2%), compound single fractures were
10(4.3%) and multiple fracture (either closed or compound) occurred in 15 (7.6%).
Majority, 147(70.4%), of victims were from Addis Ababa. About 1 in 20 (5.2%) of the
accidents happened on the highway. Vast majority of injuries were sustained by
pedestrians 140(66.7%). Majority of patients presented to the OPD within 4 hours 120
(57.4%). Most of the injuries occurred during day time 151(71.9%). Hundred and thirtyone patients (62.4%) presented primarily to TAH. Majority of the drivers who caused the
accidents were in the age group of 25 – 35 accounting for 39.5% of injuries. Commercial
vehicles have caused the majority 72(34.3%) the injuries.
Conclusion and Recommendation: Road traffic crashes are major public health problems
in Ethiopia. There are lots of injuries requiring subspecialty treatment due to RTCs
requiring the need of specialized treatment centres and specialists. There is a need of
trauma centres in the country including the capital city with beds and equipment and
personnel to handle the increasing RTC victims. There is need a lot to be done to improve
awareness of the public both to the drivers and pedestrians about the safe use of roads and
vehicles.
Introduction
Road traffic injuries are a major but neglected public health challenge that requires concerted
efforts for effective and sustainable prevention. Of all the systems with which people have to
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deal every day, road traffic systems are the most complex and the most dangerous. Worldwide,
an estimated 1.2 million people are killed in road crashes each year and as many as 50 million
are injured. Projections indicate that these figures will increase by about 65% over the next 20
years unless there is new commitment to prevention.
Every day around the world, more than 3000 people die from road traffic injury. Low-income
and middle-income countries account for about 85% of the deaths and for 90% of the annual
disability adjusted life years (DALYs) lost because of road traffic injury. Projections show that,
between 2000 and 2020, road traffic deaths will decline by about 30% in high-income countries
but increase substantially in low-income and middle-income countries. Without appropriate
action, by 2020, road traffic injuries are predicted to be the third leading contributor to the
global burden of disease and injury1.
Most of the projected increase in RTAs will occur in low- and middle-income regions of the
world, due to the rapid growth in motor vehicle numbers increasing exposure to risk factors
such as speed and alcohol, and exacerbated by inadequate enforcement of traffic safety
regulations and public health infrastructure2. The sub-Saharan African counties represent 11%
of world population and only 4% of motor vehicles but contribute to 11% of the read traffic
accidents. The annual road fatality has actually in the decrement in the developed counties but it
is still ascending in the developing ones3.
The highest fatality rates (deaths /100000 vehicles) worldwide occur in Africa – Ethiopia,
Uganda, and Malawi whilst fatality risk (deaths /100000population) is highest in disparate
group of countries Thailand, Malaysia, South Africa and Saudi Arabia3.
The road fatality rates have grown by a quarter in African countries with large population size
like Ethiopia, Nigeria, Kenya and Tanzania. Drivers accounted for a much larger share of road
fatalities in South Africa and Zimbabwe than in Ethiopia and Zambia. Pedestrian accounted to
the most frequently reported road fatality type in all the countries except for Botswana and
Malawi where passenger deaths dominated2.
The nationwide figure in Ethiopia indicates that 40% of victims of RTAs are pedestrian and 50%
passengers but the figure for pedestrians increases to 79% in Addis. In Ethiopia one out of four
RTAs victims are females with similar severity of injury and 5% of the drivers killed in RTAs in
Ethiopia were women. Out of all accidents registered in Ethiopia Addis Ababa accounts about
60% or around partly because the city has great contact with other regions of the country
through its different gates on a daily basis.
Out of the registered motor vehicles of Ethiopia the large majority is found in the capital city
Addis Ababa which is about 77% and this is the other reason why the city takes higher shares of
the accidents. Addis Ababa experience about 700 RTAs per month, 1800 people died while 7000
were disabled in Ethiopia in the year 2003 due to RTAs and death rate is 136/100000 vehicle
and hence Ethiopia is losing 20 million USD annually as a result of RTAs2. Most of the figures
found here are collections of data from the Ethiopian traffic reports. Only few studies are done
to evaluate the actual causes of deaths, major injury types and some other epidemiological data
which may assist in the programming and implementation of the preventive strategies.
The main objective of this study was to assess the epidemiological characteristics of injuries and
outcomes of patients presenting from road traffic accidents at emergency surgical OPD of a
tertiary university Hospital [Tikur Anbassa Hospital (TAH)] in Addis Ababa Ethiopia. The
specific objectives were to assess the incidence of mortality secondary to Road traffic crashes
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(RTC), to evaluate the incidence of major injuries requiring hospitalization secondary to RTC
and to appraise the incidence of musculo-skeletal injuries with bone fractures secondary to RTC
presenting to TAH.
Other specific objectives were to determine the types of Vehicles involved in the Road traffic
crashes time laps between the occurrence of Road traffic accidents and presentation to TAH
primarily or after referral and the associated epidemiological factors which might contribute to
the worsening of the effect of road traffic accidents or increase the frequency of accidents
Patients and Methods
This was a prospective study conducted at TAH from March 1st 2008 – March 31st 2008. All
patients presenting to the emergency adult surgical OPD with Road traffic accident injuries for
the specified one month period were included in this study after getting consent from every
patient who was conscious and stable attendants when otherwise a preformed questionnaire
was filled by physicians which includes demographic data place of injury, mechanism of injury,
time of presentation, type of injury and severity and the final outcome at the surgical OPD . The
study was conducted at TAH which is the center where most of the RTAs are brought primarily
and also a lot of patients are referred after first line treatment has been given at the other
hospitals because of lack of specialist care for the treatment of most injuries but especially head
and orthopedic injuries. Hence most cases of read traffic accident victims usually end up
referred to TAH surgical emergency OPD. The data were run and analyzed in to EPI info 2000
In this study, Road Traffic crash injuries [RTI]refers to all injuries involving motorized or un
motorized vehicles, major injuries were any injury that includes fracture of one or more bones
or any injury that requires admission and/ or surgery; severe head injury were head injury
with Glasgow coma scale of 8 or below, moderate head injury were head injury with Glasgow
coma scale of between 9 and 12 while mild head injury were head injury with Glasgow coma
scale of 13 or above.
Results
There were a total of 210 victims brought to the emergency surgical OPD of TAH in the study
period. The most commonly involved age groups were the 21 – 30 and the 31 -40 years of age
which accounted for 40% and 19% respectively (Table 1). One hundred forty two (67.6%) of
victims were males. Most of the drivers who caused the crashes were in the age group of 25 – 35
accounting for 39.5% of injuries (Table 2). The next common being age less than 25yrs. There
were three cases of hit and run. Taxi’s as a whole take the major share of the injuries with
commercial public transport minibuses 56(26.7%) and other small public taxi’s 16(7.6%).
Automobiles have caused 38 of the accidents, while Medium sized trucks and buses account for
26 and 15 of the accidents respectively.
There were 6 deaths (2.9%) out of the 210 registered RTCs making it 2.9% case fatality rate.
Two of them were death on arrival and the other four died while on treatment. Eight cases were
admitted (3.8%) and 37 (17.6%) cases deserving admission were referred making the number
of cases requiring admission 45(21.4%). One hundred six (50.5%) of the victims had major
injury and the rest 104(49.5%) had minor injury (Tables 3 and 4). There were 30 cases of mild
head injury, 5 cases of moderate head injuries and 14 cases of severe head injuries with 4 cases
of vertebral fractures. The extremity injuries recorded were 113 (53.8%) of which soft tissue
injuries were 51(35.8%), closed fractures were 37 (24.2%), compound single fractures
accounted for 10(4.3%) and multiple fractures occurred in 15 (7.6%). Majority of the victims
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(70.4%) were from the capital Addis Ababa out of which 11 (5.2%) accidents happened on the
highway road in Addis Ababa where pedestrians are not allowed to cross. Hundred and forty
five of the injured patients were pedestrians (69%), 46 were passengers (21.9%) and the rest
19 (9%) were drivers. Tables 5 and 6 show the type of vehicle and the mechanism of injuries.
Table 1 . Age of the Patient Involved in the Road Traffic Crashes
Age Pt
11-20
21-30
31-40
41-50
51-60
61-70
71-80
81-90
91-100
Total
Frequency
36
84
40
20
13
10
2
3
2
210
Percent
17.1%
40.0%
19.0%
9.5%
6.2%
4.8%
1.0%
1.4%
1.0%
100.0%
Cum Percent
17.1%
57.1%
76.2%
85.7%
91.9%
96.7%
97.6%
99.0%
100.0%
100.0%
Table 2. Age Distribution of the Driver Causing the Crashes
Age of Driver
<25
>56
25-35
36-45
46-55
Hit and Run
Unkown
Total
Frequency
36
7
83
30
12
3
39
210
Percent
17.1%
3.3%
39.5%
14.3%
5.7%
1.4%
18.6%
100.0%
Cum Percent
17.1%
20.5%
60.0%
74.3%
80.0%
81.4%
100.0%
100.0%
Table 3. Musculoskeletal Injuries sustained in RTC
Extremity Injury
Frequency
Percent
Cum Percent
Closed fracture
37
32.7%
32.7%
Compound fracture
10
8.8%
41.6%
Multiple fractures
15
13.3%
54.9%
STI
51
45.1%
100.0%
Total
113
100.0%
100.0%
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Table 4 – Incidence of Head and Spinal Injuries
HEAD INJURY
Frequency
Percent
Cum Percent
Mild
30
32.6%
32.6%
Moderate
5
5.4%
38.0%
NO
1
1.1%
39.1%
Sever
14
15.2%
54.3%
STI
38
41.3%
95.7%
Vertebral fracture
4
4.3%
100.0%
Total
92
100.0%
100.0%
Table 5. Mechanism of the Injury in the Road Traffic Crashes.
Mechanism Of
Frequency
Percent
Cum Percent
140
66.7%
66.7%
Collusion with stationary object
7
3.3%
70.0%
Decelerating injury for motorbikes
6
2.9%
72.9%
Rolling over
43
20.5%
93.3%
Two cars collusion
14
6.7%
100.0%
Total
210
100.0%
100.0%
Car on pedestrian
Table 6. Type of Vehicle Involved in the Road Traffic Crash.
Type Of Vehicle
4wd
Automobile
Bus
Hit and Run
Light weight trucks
Minibus
Motor cycle
Other Taxi
Others
UK
Total
Frequency
13
38
15
1
26
56
6
16
22
17
210
Percent
6.2%
18.1%
7.1%
0.5%
12.4%
26.7%
2.9%
7.6%
10.5%
8.1%
100.0%
Cum Percent
6.2%
24.3%
31.4%
31.9%
44.3%
71.0%
73.8%
81.4%
91.9%
100.0%
100.0%
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Discussion
Road traffic crashes are a major public health challenge. We have noted Mortality form RTA
constituted about 40% of the overall deaths of same period at our department including all
elective and emergency operations (unpublished data from the department of surgery registry).
The fact that most of the injured are males and are pedestrians goes with most international
data for developing countries and also results of previous studies in Addis 6. Out of the 210
cases presented to the emergency surgical OPD due to road traffic accidents 113 cases of
orthopedic injuries in the form of single or multiple fractures and 48 cases of different levels of
head injuries were entertained of which most required admission. This is a huge case burden
which gravely affects and contracts the health service delivery for other diseases.
The numbers of injuries requiring hospitalization and the major cases according to the
definition of this paper are by far very significant as a burden of disease in a country like
Ethiopia where communicable diseases have been the major health problems and continue to
be. Referred patients to other less specialized hospitals which may also have the bed shortages
of their own beckons to the need to increase the bed capacity of the TAH and other hospitals to
decrease the mortality and morbidity due to lack of early treatment and specialized care.
Our study showed most of the victims were brought within 4 hours which is acceptable for a
country with nonexistent triage and accident response system but demands a stronger effort to
make these durations as short as 15 to 20 minute to save more lives and reduce lots of
disabilities.
Age group distribution of drivers involved indicates maturity may have a significant role in road
safety and prevention of accidents. It makes a strong argument that it may be prudent that
public transport vehicles to be driven preferably by a higher and mature age group than only
the cut- off age of 18 and above for the driving license in the country. The other fact that most of
the injured patients are in the same age group as the driver’s show that there needs a lot to be
done to increase awareness in the most important work force of the country about road
accidents so that they comply with safe road use as pedestrians. Loosing these important
productive population group will have significant effect in the overall productivity of the
country and as they support lots of family who may be completely dependent on the income
generated by these people. There must be something done to reduce its serious effect on the
growing economy of the country.
The fact that most of the injuries were caused by commercial vehicles is in conformity with
other middle and low income countries. Probably the way these vehicles are driven with some
degree of competition and hence disregard for the traffic laws in the city are contributing
factors why they cause most of the injuries.
Conclusion
RTA’s are major public health problems in Ethiopia as it is everywhere in the world especially in
developing countries. There are lots of injuries requiring subspecialty treatment due to RTAs
requiring the need of specialized treatment centers and specialists. There is a need of trauma
center in the country including the capital with beds and equipment and personnel to handle
the increasing RTA victims. There is need a lot to be done to improve awareness of the public
both as driver and pedestrian about the safe use of roads and vehicles
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References
1. D.K. Srinivasa, Gautam Roy, S. Jagdish Epidemiological study of road traffic accident
cases: a study from south india Nilambar Jha,
2. Ameratunga et al., 2006; Nantulya and Reich, 2002; WHO, 2004
3. G D Jacobs and Amy Aeron-Thomas :- A review of global road accident fatalities Medical
care the official website http://pt.wkhealth.com/pt/re/medcare/userLogin.htm
4. Mensur et al magnitude and pattern of injuries in north Gondar administrative zone,
northern Ethiopia EMJ July 2003 volume 41 number 3 page 213
5. Mulat et al Trauma registry in Tikur Anbessa Hospital Addis Ababa Ethiopia EMJ July
2003 volume 41 number 3 page 221
6. Yasushi Nishida :- Road Traffic Accident Involvement Rate by Accident and Violation
Records: New Methodology for Driver Education Based on Integrated Road Traffic
Accident Database -National Research Institute of Police science, Japan
7. Dan Chisholm, PhD 1 and Huseyin Naci, MSc 2 :- Road traffic injury prevention - an
assessment of risk exposure and intervention cost-effectiveness in different world
regions 8. Paul M. Salmon* & Michael G. Lenné :- Systems-based Human Factors analysis of road
traffic accidents: Barriers and solutions 9. Shanthi Ameratunga, Martha Hijar, Robyn Norton :- Road-traffic injuries: confronting
disparities to address a global-health problem - Paul Gutoskie Transport Canada
August 2003 :- SPECIAL REPORT- The Availability of Hospitalised Road User Data in
OECD Member Countries (2001
10. Estimating
global
road
fatalities
http://www.factbook.net/EGRF_Regional_analyses_Africa.htm
11. Reporting on Serious Road Traffic Casualties Combining and using different data
sourcesto
improve
understanding
of
non-fatal
road
traffic
crashes
http://www.internationaltransportforum.org/irtadpublic/pdf/Road-CasualtiesWeb.pdf
12. World report on road traffic injury prevention: summary World Health Organization
Geneva
2004
http://www.searo.who.int/LinkFiles/whd04_Documents_summary_en_rev.pdf
13. Mobile use a growing problem
of driver distraction WHO REPORT
http://www.who.int/violence_injury_prevention/publications/road_traffic/distracted_
driving_summary.pdf
14. Determinants of within-country variation in traffic accident mortality in Italy: a
geographical analysis http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174448/
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Intentional injuries: The Experience from Dodoma Regional Hospital, Central Tanzania.
M.Y. Mwashambwa1, S.N. Kapalata2, L.O. Akoko 3
of Surgery and Maternal Health, College of Health Sciences, University of Dodoma,
2Department of Public Health, College of Health Sciences, University of Dodoma,
3Department of Surgery, Muhimbili University of Health and Allied Sciences.
Correspondence to: M.Y. Mwashambwa, Email: masuytm2011@gmail.com
1Dept
Background: Worldwide intentional injuries cause about 9 deaths for every 100,000
persons; in Africa the contribution is estimated to be twice as much (25 out of 100000
persons).The true incidence of intentional injuries in Tanzania is unknown. There are very
few hospital based studies which have characterized patients with intentional injuries. This
study shares the experience obtained in management of patients with intentional injuries
at Dodoma Regional Hospital for a period of about 9 months.
Methods: A hospital based prospective descriptive study was carried out, in which all
patients admitted with history of intentional injury were conveniently recruited into the
study. Demographic data, injury causes and pattern were recorded; treatment was given
according to hospital standard protocol. Consent was obtained from all patients.
Results: Two hundred and fifty two patients were studied, the age ranged from 10 to 60
years with a mean age of 30.54 (standard deviation = 9.6). Males outnumbered females by
1.6. The commonest assailants were persons not related to victims (80%). The majority of
injuries occurred outside home environment (70%), with marital status having a
significant contribution. Most injuries took place at night. Sexual violence was a leading
overall cause (27%), in men robbery or theft was the commonest cause (82%).
Knives/machetes in 42% were among the commonest weapons used, followed by wooden
sticks 26%. Head and neck were the most common body parts injured (79%), followed by
chest and abdomen (19%), with significant difference between men and women (p value =
0.0001). Non-penetrating stabs or cuts wounds were the commonest injuries (70%),
followed by penetrating chest and abdominal injuries (12%). Surgical debridement and
primary suture was performed in 77% of cases, followed by thoracotomy and or
laporatomy. Men needed more radical forms of surgical intervention than women (p value
< 0.0001). The wound complication rate was 37%. The mean hospital stay was 4.7 days,
with standard deviation of 7.7 and a range of 1 to 64 days.
Conclusion: Intentional injuries in Dodoma are probably very high, and there is possibility
that domestic violence may be higher in this area, if findings from this study are to be
extrapolated into the community. There is no doubt that this may significantly contribute to
family poverty through morbidity, hospital expenses and lost hours of productivity. Further
community based studies and community advocacy through health education are
recommended.
Key words: Intentional injuries, Pattern, Causes, Treatment, Complication and Hospital stay
Introduction
Injuries in general have become a global public health concern in terms of mortality and
morbidity1. It is also estimated that injuries in general cause 10-30% of all hospital admissions
across the globe and contribute about 9% of all deaths and 16% of all disabilities with heaviest
impact in developing countries.2
Intentional injuries which has been defined by Krug et al, 2004 as a spectrum of injuries
resulting from interpersonal violence, self inflicted injuries, and group act of violence 3 are also
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very common and contribute significantly to mortality and morbidity. Globally, intentional
injuries cause about 9 deaths for every 100,000 persons, most of whom are individuals of good
economic productivity in the society at the age of 15-45 years, in Africa, and probably other
developing countries, the contribution of intentional injuries is even higher, it was estimated in
2004 that about 25 out of 100000 persons (twice as much as global incidence) died due this
type of injuries2. The true incidence of intentional injuries in Tanzania is unknown, although
Moshiro et, al 2001 found the overall mortality related to injuries in general to be 5-8% in some
districts 4.
Most studies which have reported intentional injuries are community based 5-10, there are very
few hospital based studies which have characterized patients with intentional injuries as seen in
hospitals11-13, none has been done in central part of Tanzania. This study shares the experience
obtained in management of patients with intentional injuries at Dodoma Regional Hospital for a
period of about 9 months, it is envisaged that the study will also increase awareness of the
problem to different stakeholders, including residents of this area.
Patients and Methods
This was a nine months hospital based prospective descriptive study, conducted in Dodoma
regional referral hospital in Tanzania from February to October, 2011. Ethical clearance to
conduct this study was obtained from the University of Dodoma Ethical Review Committee. All
252 patients who were admitted with history of intentional injury were conveniently recruited
into the study after providing a written informed consent. Data collected from patients included:
demographic characteristics, setting of injury, type of injury, assailant/perpetrator of injury and
their social history, type of weapon used, history of past violence, treatment modality and
outcomes.
Patients were treated according to standard procedure set by the Hospital; such treatments
included; resuscitation, debridement, wound irrigation and suturing. In some patients specific
treatments included insertion of chest tube, thoracotomy and or laparotomy. All patients were
monitored for local wound complications such as discharge, gaping, delayed healing and nonhealing and systemic complications which included observation for presence of septicemia and
distant infection. All parameters were recorded on the pre-formed pretested questionnaire and
coded accordingly.
Collected data was cleaned, coded and entered into an SPSS version 12.0 for analysis where
cross tabulations and association between dependent and independent variables were
calculated before analysis. Where necessary, chi-square and p-value was determined where a
value of 0.05 with a confidence interval of 95% was considered to have significant difference.
Results
A total of 252 patients with various intentional injuries were recruited into the study. The age
ranged from 10 to 60 years with a mean age of 30.5 years with standard deviation of 9.6. The
most common age group was 18 to 36 years (72%), followed by 36-54 age groups (21%), the
two age groups making 93% of all patients admitted, males outnumbered females by 1.6.
Majority (70%) of respondents had formal education status. The commonest assailants were
persons not related to victims (80%), while spouses (which included partners and close
relatives) contributed 20% of all injuries in this study.
The majority of injuries occurred outside home environment (71%), but there was no
significant difference of setting of violence across the age groups (p value = 0.17), but when
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comparison between males and females was done, males tended to be injured outside home
environment more often (81%) as compared to females (56%) (p value <0.0001) (Figure 1).
Marital status was significantly associated with setting of violence (p value = 0.001),
married/cohabiting patients were likely (72%) to be injured outside while 50% of those who
are single or widowed were injured at home (Table 1).
Timing of violence
Majority (69%) of injuries which took place at night was among those married or cohabiting
and 59% of day injuries also came from the same group. Single or widowed individuals tend to
injured during the day than night.
Figure 1. Violence Settings by Sex
Table 1. Percentage distribution of setting of violence by marital status
Setting
of
Violence
Home
Outside
home
Total
Number
Marital status
Single/widowed
Marriage/cohabiting
Divorced/separated
72 (29%)
180 (71%)
50%
27%
46%
72%
4%
2%
252
33%
64%
3%
p value = 0.001
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Figure 2. Marital status and timing of violence
Table 2: Percentage Distribution of Reasons for violence or Injury as Related to Sex
Reasons
Number (%)
Alcohol related
Robbery or Theft
Sexual related
(Jealous, adultery)
Others**
Total
Sex
Male
Female
65%
35%
60 (24%)
61 (24%)
82%
18%
69 (27%)
36%
64%
62 (25%)
68%
32%
252
62%
38%
** Includes a range of other reasons such us farm conflicts, assault by unknown or mentally ill
people, peer conflicts, etc.
Table 3. Percentage Distribution of Weapons Used for Violence or Injury as Related to Gender
Type of weapon
used
Broken glasses/
bottles
Number
Sex
31 (12%)
Male
58%
Female
42%
105 (42%)
64%
36%
Iron Bars
21 (8%)
86%
14%
Wooden sticks
66 (26%)
68%
32%
56%
15%
44%
85%
62%
38%
Knives/ Machetes
Multiple weapons
9 (4%)
Bodily (no weapons
20 (8%)
used)
Total
252
p value < 0.0001, note cells with values <5
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Table 4. Distribution of Body Parts Injured and Type of Injury Inflicted by Sex
Part of body injured
Number
Gender
Females
42%
36%
100%
38%
Males
Head and Neck
198 (79%)
58%
Chest and or Abdomen
48 (19%)
64%
other parts**
6 (2%)
0%
Total
252
62%
p value = <0.0001, note a cell with value less than 5
Type of injury inflicted
Number
Gender
Males
Females
Non penetrating stabs/cuts
177 (70%)
71%
29%
Blunt trauma
27 (11%)
22%
78%
Penetrating chest/abdominal injury
31 (12%)
52%
48%
Others
17 (7%)
47%
53%
Total
252
62%
38%
p value = <0.0001
** Other parts included upper and lower limbs or pelvis.
p value <0.0001
Figure 3. Surgical intervention by Sex
Reasons for violence
The commonest reason for injury was sexual violence (27%), with women being the commonest
group in 64% of cases as compared to men (36%). On the other hand men were mostly injured
in or during robbery or theft (82%). The table 2 above summarizes the various reasons cited by
patients by gender.
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Weapons used in injuries
The commonest category of weapons used in violence was knives/machetes in 42% cases,
followed by wooden sticks in 26% of cases. Significantly, more men tended to be injured by
weapons than women (.p value <0.0001). Most of those injured bodily (85%) were women.
Injury distribution
Most injuries occurred around the head and neck region in 79% (n = 198), followed by chest
and or abdomen in 19% (n = 48%). There was significant difference (p value = 0.0001), when
body parts injured was compared by sex. The commonest injuries were none penetrating stabs
or cuts wounds, penetrating chest and abdominal injuries were noted in 12% of patients
Treatment and interventions
Surgical debridement and primary suture was the commonest procedure done (77%, N 171),
followed by thoracotomy and or laporatomy. Significantly, more men tended to be treated with
radical forms of surgical intervention (p value < 0.0001). [Graph 3]
Treatment complications
A total of 70 patients (30%), had superficial wound infection, deep wound infection occurred in
7%. (Table 5).
Table 5: Distribution of Wound Complication by Gender
Type surgical intervention
Number
Gender
Males
Females
Superficial wound infection
70 (30%)
60%
40%
Deep wound infection
16 (7%)
74%
26%
234
65%
35%
Total
p value = <0.003, 18 cases were lost to follow
Discussion
Similar to other studies 5, 11, 14, the commonest age group involved in intentional injuries was
found to be 18-54 years, contributing to about 93% of all patients, with men being 1.6 times
more likely to be admitted in the hospital due intentional injuries than their female counter
parts. Although this is not a community based study, seeing a total of 252 patients being
admitted in just eight months in one hospital may indicate that the incidence at community level
is probably very high, it may even be higher than the estimated incidence in Africa as reported
by WHO 2. It is important to also note that almost all the patients in our series needed a surgical
intervention, thus making an assumption that it is only those with serious injuries who
managed to come to the hospital and those with minor injuries remained at home or are treated
at a lower health facility and discharged home. Men dominance may also keep women faced
with Gender Based Violence from reporting to health facility for attention in fear of retaliation
and breakage of marriages. It is known that, central parts of Tanzania, Dodoma inclusive are dry
areas, with poor rainfall and poor annual harvests; all these factors are related to poverty, one
can therefore be tempted to associate the later with risk behaviors which may lead to
intentional injuries, as cited by Challya and Gillyoma 2012, that poverty, lack of education,
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unemployment and lower socioeconomic class as the major sources of injuries 13. It should be
noted however that, most of our patients had some form of formal education contrary the
Challya and Gillyoma, 2012, findings.
This study has also established that the commonest assailants (persons who committed an act
of violent injury) were persons not directly related to victims (80%), this finding is similar to
other studies 6, 10. The high prevalence of non relative assailant, probably reflects the facts that
confrontations are more likely to involve non related members of society than the other way
round; although some studies have shown that relatives or close friends are commoner
assailants in intentional injuries [13, 15]. The differences possibly reflect study setting and the
socio-cultural characteristics of the populations, the topic which was beyond the scope of our
study.
The commonest setting of violence in this study was found to be outside home environment
accounting for about 71% of all cases, with men being significantly more likely to be injured
outside home environment with a prevalence of 80%, versus 56% of women (p value <0.0001).
This observation contradicts with other workers such as Aggarwa;l et at, 2010 5, Challya &
Gillyoma, 2012 13 and Faduazar et al, 2011, 15: The study by Aggarwal was a community based
study, which is definitely different from the index study, and that of Faduazar et al, 2011 mainly
involved women of reproductive age a population not similar to ours, the only study similar to
this study is that of Challya and Gillyoma 2012. The differences may be explained by; study
setting, and population differences in terms of practices, and social-cultural-economic dynamics.
Furthermore, and surprisingly, it has been found that marital status was significantly associated
(p value = 0.001) with setting of violence, with married or cohabiting being more likely to
injured outside home environment (72%), than those who are either single or widowed (50%).
The difference observed may be due to the fact that men and women who are married are more
likely to involved in sexual affairs than those who are not married, more importantly, most of
those who are single or widowed may have been children, who are unlikely to be involved in the
major reasons for violence as found in this study. A large proportion of injuries occurred during
the night (56%), but there was no significant difference when males were compared to females,
similar to Challya and Gillyoma 2012 findings13, however this study has demonstrated a
significant relationship between the marriage status and timing of violence, a pattern which was
not reported in the former study, in which once again married and or cohabiting individuals
were taking a lead.
With regard to reasons for injuries, a sexual related assault was the commonest in 27% of cases,
majority being females (64%). This category included all injuries related to sexual affairs in
form of jealousy, adultery and other forms of promiscuities which lead to fights, involving either
men to men or men to women. The observation is contrary to Challya and Gillyoma 2012, who
found criminal assault to be the leading overall cause of intentional injuries, however, the
observation that sexual violence was among the commonest causes of injuries in women, is
similar to this study. Robbery or theft ranked the second most common reason (the commonest
in men) for injuries in this study at (24%), in which majority were men 82% (p value = 0.0001),
similar to another study 13. There are may be three main reasons to explain the difference: one,
men are usually the bread winners in most homes and therefore responsible for daily economy
of their formal or informal families, two men are more commonly involved in drinking and other
forms of luxuries which entail them to look for extra income and therefore robbery and theft,
three some scholars have suggested that men are more likely to engage in more risky behaviors
than females and therefore high preponderance of men in robbery and theft. On the other hand,
one possible explanation for high involvement of women in sexual violence is that women are
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usually at the epicenter of sexual affairs in all its forms, and therefore high likelihood of being
injured.
This study has also evaluated the prevalence of weaponization of injuries; it has been revealed
that, 92% of confrontation resulted in injuries. The commonest weapons used were
knives/machetes (42%) and wooden sticks (26%), broken glasses or bottles were used in 12%
of patients. There was a significant difference (p value < 0.0001) when type of weapons used to
injure were compared by sex, note that men tended to be injured by weapons than women, and
most (85%) of those injured by bodily physical assault were women. This pattern of weapons
differs from other studies, for example, Farduazar, et al, 2011 in Iran found hot liquids to be the
commonest weapon injury inflictor 15, while in South Africa, guns were the most common9.
Challya and Gillyoma 2012, found almost similar pattern of weapons13. Of importance in this
study is the common use of wooden sticks which results in significant trauma, to explain this
one has to understand the culture and traditions of Gogo ethnic group which reside in this
region (Dodoma, central Tanzania), this ethnic group is semi pastoralist, men have tendency to
carry hard wooden sticks, with a club like projection at the end. It is the strength and the club
like projection which inflict very severe injury. Authors have witnessed some patients with
severe head injury as a result of this weapon. Moreover, the high prevalence of use of bottles
and broken glass reflect the possible alcohol related violence, typical in urban settings. An
important note is the total absence of guns contrary to other studies 9, 13, in Tanzania guns are
rarely used in violence, ownership of weapons is tightly regulated in this country and therefore
use of these weapons are normally heard of in regions bordering unstable countries in Western
and North-western parts of the country.
Similar to Challya and Gillyoma, 2012, the commonest part of the body injured in this study was
found to be head and neck in 79% of all patients, the second commonest region was chest and
abdomen which contributed to about 19% of all cases. It has been established in this study that
body parts injury distribution was statistically significant by sex (p value = 0.0001), but not by
age groups (p value = 0.105), The common occurrence of injuries in areas around head and neck
probably reflects that this area is easily accessible during fight involving non ballistic hand held
short weapons typical in this study. Some investigators have suggested, the preponderance of
injuries of this areas to be due to the underlying intention to kill13, although this explanation
may be true for ballistic weapon. This observation, however, is dissimilar to that documented by
Majori et al, 2011 and Farduazar et al, 2012 who found that the most common sites involved
were upper and lower limbs11, 15. The possible explanation for the dissimilarities observed
essentially may be due to the difference in study setting and the difference in study populations,
in the later study participants were predominantly women of reproductive age, as it is
understood in most Islamic states, women are obliged to be home care takers and therefore
high likelihood of injuries in respective parts of the body.
The difference in types of wound inflicted may be explained by the difference in classification
systems used, in this study 70% of injuries were classified as non penetrating type, which
included all kinds of stabs or cuts involving both sharp and blunt objects as classified by Challya
and Gillyoma 2012, penetrating abdominal or chest injuries were the second commonest
representing about 12% of all injuries, in this category large proportion of patients were males
58% , the significance of this classification is that most of these patients needed opening of the
chest and abdomen for further exploration. The current observation differs from that of Majori
et al, 2009 in which penetrating chest or abdominal injuries were not reported at all 11. As it can
be obviously noted, this study has not reported any fracture as opposed to Majori et al, 2009,
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Challya and Gillyoma, 2012 possibly due to the nature of weapons commonly used; most of
them are unlikely to cause major fractures.
With regard to management of patients involved in intentional injuries, most of the patients
(88%) were treated with some form of surgical intervention. The commonest surgical
procedure performed was surgical debridement with primary suturing of wound, accounting for
about 77% of cases. About 18% of them needed exploratory thoractotomy or laparotomy, these
were the patients who presented with penetrating stab or cut wounds. It should not go without
saying that, exploration was needed to exclude thoracic or abdominal visceral injuries and to
avert a more likely morbidity such as infection in case of intestinal perforation or
exsanguination in case of vascular or solid organ injury. In this regard, men are significantly
more likely to require radical surgical intervention than women, (p value < 0.0001). As
explained above, men were more likely to engage in more risk behavior than women, just like
women are possibly faced with more humane eyes of offenders than men. The intraoperative
findings during thoracotomy or laparotomy, has shown high prevalence of intestinal perforation
in 19 of cases, followed by diaphragmatic tears and pneumothorax 6 cases each, only stresses
the need to do exploratory opening of the respective cavities when a penetrating injury is seen.
It should be noted however, that, authors have not been able to find any similar study, from
which these findings can be compared. But it is our belief that all cases of penetrating injury
should proceed to theatre after thorough pre operative evaluation especially in resource poor
countries.
Lastly, this study has demonstrated that 37% of patients did indeed get some form of wound
infection as a complication, majority of them (82%) getting superficial wound infection with no
significant differences in terms of complications across the age groups, however when
compared by sex, a significant difference was noted, with men being more likely to get wound
complications (p value = 0.003). The high rate of wound infection in this study can be explained
by the fact that, wounds which follow trauma are generally at higher risk of infection as
compared to wounds which follow elective surgery, partially due to wound inflicting
instruments being dirty as it has been witnessed by the variety weapons used in this study, but
more importantly delayed hospital reporting may allow bacterial overgrowth on the wounds.
This complication is commonly translated to long hospital stay as it has been found in this study,
in which the longest duration of stay at the hospital was 64 days, and this was a case of deep
wound infection with subsequent abdominal dehiscence. There was no single death witnessed
in this report, and nothing can be reported on the 18 patients lost to follow.
Conclusion and Recommendation
This study has demonstrated that, intentional injuries in Dodoma is probably very high, and
there is possibility that domestic violence particularly gender based violence may be a bigger
problem in this area if findings from this study are to be extrapolated in the community. It has
been found that the most common reason for intentional injuries in Dodoma is sexual related
assault, although robbery/theft and alcohol consumption also contribute significantly.
Furthermore, it has been determined that weaponization of injuries is very common, with use of
unusual weapons such as bottles/broken glasses and wooden sticks, all of which results in
significant trauma to victims with subsequent hospitalization, and intervention. There is no
doubt that this may significantly contribute to family poverty through morbidity, hospital
expenses and lost hours of economic productivity. It is therefore recommended that, more
thorough community studies be done to establish the extent of the problem in this region, but
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more importantly community advocacy through health education should be carried out to
reduce this problem.
References
1. WHA, Prevention of Violence: a public health priority. 49th World Health Assembly., 1996.
Available on www.who.int, Accessed on September 2012.
2. WHO, World Health Organization. Ten facts on injuries and violence. www.who.int, accessed
on September, 2012, 2008.
3. Krug EG, et al., The world report on violence and health. Lancet, 2002. 360(9339): p. 10831088.
4. Moshiro C, et al., The importance of injury as a cause of death in sub-saharan Africa: results
of a community based study in Tanzania. Public Health, 2001. 115(2): p. 96-102.
5. Aggarwal R, Singh G, and Aditya K, Pattern of domestic injuries in a rural area in India. The
Internet Journal of Health, 2010. 11(2).
6. Le LC and Blum RW, Intentional injury in young people in vietnam: Prevalence and Social
correlates. MEDICC review, 2011. 13(3): p. 23-28.
7. Moshiro C, et al., Injury morbidity in an urban and a rural area in Tanzania: an
epidemiological survey. BMC Public Health, 2005. 5(11).
8. Omoniyi O, Incidence and pattern of injuries among residents of a rural area in SouthWestern Nigeria: a community based study. BMC Public Health, 2007. 7(246).
9. Mendes JF, et al., The prevalence of intentional and unintentional injuries in selected
Johannesburg housing settlements. SAMJ, 2011. 101(11): p. 835-838.
10. Smith BJ, et al., Intentional injury reported by young people in the Federated States of
Micronesia, Kingdom of Tonga and Vanuatu. BMC Public Health, 2008. 8(145).
11. Majori S, et al., Epidemiology of domestic injuries. A survey in an emergency department in
Noth-East Italy. J Prev Med Hyg, 2009. 50(3): p. 164-169.
12. Museru LM, et al., The pattern of injuries seen in patients in the orthopedics/truama wards
of Muhimbili Medical Centre. East and Central African Journal of Surgery 1998. 4: p. 15-21.
13. Challya P and Gilyoma JM, The burden of intentional injuries in Mwanza City, north-western
Tanzani: a tertiary hospital survey. Tanzania Journal of Health Research, 2012. 14(3).
14. Farduazar Z, Sadeghi-Bazargani H, and Mohammadi R, Domestic injuries and suicide among
women of reproductive health in Iran. International Journal of General Medicine 2012. 5: p.
547-552.
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Diagonal Thoraco-abdominal Arrow and Gunshot Injuries as Seen at Juba Teaching
Hospital, South Sudan.
M.M. Achiek1, F.K. Tawad1, B.M. Alier2, C.T. Yur1
of Surgery, College of Medicine, University of Juba, South Sudan
2Juba Teaching Hospital, Ministry of Health.
Correspondence to: Mayen Achiek, email: mayen.achiek@gmail.com
1Department
Background: Civil wars and inner city violence in Africa and worldwide are associated with
multiple severe injuries to various anatomical sites or combined. The thoraco-abdominal
variety tends to cause high mortality or significant morbidity and they warrant an auditing
study to guide practice and reduce mortality.
Methods: At Juba Teaching Hospital, South Sudan we receive numerous victims of gunshot
or arrow shot injuries to most parts, head, neck, chest abdomen, pelvis, and limbs or
combined. Between Dec.2012-Jan.2014, we managed a significant number of casualties,
and out of this number we selected to study prospectively the outcome of management of
patients with thoraco-abdominal arrow and gunshot injuries.
Results: We managed 23 patients. 22 adult males and one female child aged 7years, mean
age (29) and range 7-59years. 11 patients (47.8%) survived and discharged and 12/23
died (52.2%).
*Two patients died on table before operative intervention.
Conclusion: Diagonal thoraco-abdominal gunshot and arrowshot injuries are associated
with high mortality in African setting with limited resources that do not include specialist
and intensive therapies units.
Introduction:
Civil wars and inner city violence in Africa are associated with severe multiple injuries. Gunshot
injuries are the most dominant, and cause most anatomical damage. They are anatomically
classified according to sites, eg. Head, neck, chest, pelvis, limbs or combined as in open combats.
The combined injuries tend to cause multi-organ damage leading to high morbidity and
mortality1. We tend to receive and manage a significantly high number of victims of violence
with multiple gunshot and arrowshot injuries to various anatomical regions and specific organs.
The thoraco-abdominal injuries are associated with most damage and severer impact on the
victims and this is shown by high rates of morbidity and mortality 2. Violence using firearms and
injurious weapons is a socio-economic significant issue that is on the rise world-wide and costly
needs a holistic approach to prevent 3,4.
Patients and Methods:
Our study was carried out at Juba Teaching Hospital in Juba City, the capital of South Sudan,
which is a post-war new country. Between December 2012 and Jan.2014 we selected to follow
prospectively patients with a particular pattern of combined injuries, the diagonal thoracoabdominal injuries. During this period we recorded 23 patients. These patients were identified
on admission and put on the study if they had sustained combined chest and abdominal gunshot
or arrowshot injuries. The pattern and extent of damage caused by the shots were finally
described after Laparotomy and chest drain. The presentation was noted on a designed
Performa for every patient, recording demographic data, mode of transport to hospital
(ambulance or public/private vehicle). Evidence of an effective clinical assessment by an
appropriately trained surgeon was shown. The duration from the scene of accident to the
hospital, the mode of injury; gunshot or arrow shot, the anatomical site; left chest to abdomen
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or diagonally right chest to abdomen were documented. Clinical signs of severity of injury were
recorded as; external signs of bleeding at both entry and exit wounds. Vital signs were
documented on the Performa sheet as respiratory rate (RR), pulse (P), blood pressure BP,
Oxygen saturation and urine output on catheterisation. Essential trauma investigations done
and resuscitation therapies given were recorded. Emergency surgical interventions performed
were documented in each case. The findings on chest drain or laparotomy were finally
described and noted (Tables 1 and 2). Outcomes of surgical intervention were documented as
mortality or survival on discharge.
Results
During the study period we recorded 23 patients who sustained thoraco-abdominal injuries; 19
were males and one was a female child. With the mean age of 29 and range 7-59 years. All the
patients were brought to the hospital by public or private transport and no accredited
ambulance delivery to the hospital. The causes of injury were thoraco-abdominal gunshot in 19
and arrow shot in 4 of the 23 cases. All the patients were triaged urgently at the Accident &
Emergency Department (A&E) and main operating theatres by a senior surgeon within 15
minutes of arrival. All the 23 patients were haemodynamically unstable, with abnormal vital
signs; 5 patients had signs of active external bleeding while 18/20 showed trace signs of
bleeding at the entry and exit wounds with abdominal tenderness.
The patients were unstable and because our setting lacks diagnostic scans, no scans (CT or US)
were done. The clinical decisions to intervene were taken in all cases by the attending
consultants. The intravenous (IV) fluids resuscitation (Crystalloids and blood transfusion of 4
units or more), analgesia, IV antibiotics and monitoring were administered actively with
surgical intervention. The duration spent from the scene of the injury to the hospital was
recorded as given by the accompanying individuals to be; between 2 hours to 48 hours
(Table 3).
Table 1. Chest intervention
Intervention
*No chest drain
Chest drain < 500ml of blood
Chest drain > 500ml of blood
Yes
16/20
5/20
No
2/23
-
Table 2. Intra-abdominal Injuries at laparotomy and outcomes
No
Survival
Mortality
Bowel(SB/LB +Liver +spleen)
Extensive bowel Injury(SB/LB)
Bowel SM/LB Moderate +Liver Laceration
1
4
6
0
0
4
1
4
2
Bowel SB/LB +Splenic injury
Viscera other( Stomach, Bladder, Mesentery
Kidneys, blood vessels and spleen alone)
1
0
1
9
7
2
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Table 3. Vital Signs records
Normal
0
Vital signs
Resp. rate
Tachypneoa
Tachycardia
Normal pulse
Normal BP
Hypotension
Normal Temperature
Pyrexial
Normal urine out put
Low urine output
PO2 Concentration
High
22/23
22/23
23/23
Low
1/20
0
21/23
21/23
23/23
2/23
0
0
0
23/23
23/23
Table 4. Glasgow Coma Scale (GCS)
Score
No.
Group Survival
Mortality
15
10
9
1
11-14
8
2
6
<10
5
0
5
Table 5. Duration from Accident Scene to Arrival at the Facility (Hospital) and Mortality
Duration
No.
Mortality
Survival
1 hr
0
0
0
2 hrs
6
4
2
4 hrs
7
6
1
>6 -24 hrs
6
2
4
>24- 48 hrs
4
0
1
> 48 hrs
0
0
0
Total
23
12
8
No patient was reported to have reached within one hour, the golden hour, 13/20 reached the
hospital between 2-4 hours and most of mortality cases were among this group, 10/20. Those
reaching the hospital over 6 hours, but less than 24 hours were 6/20, two of these patients died.
Only a single victim was reported to have reached the hospital in about 48 hours and underwent
surgical intervention and survived.
The anatomy of the injury was a combined chest and abdominal injury by a gunshot or an
arrowshot. Four patients sustained arrowshot and 19 sustained gunshots. We noted the portal
of entry to be either left chest to abdomen 10/23 or right chest to abdomen 13/23 diagonally as
demonstrated by entry wounds and exits or embedded and no exit in the case of an arrow. The
mortality according to the anatomical passage of the bullet or the arrow is 7/13 of the rightsided and 5/10 of the left-sided traversing shots.
The operative intervention was apparently dictated by the haemodynamic conditions of the
patients. 21/23 had operations, 2/23 died on table in operating theatres (OT) just before
surgery. The two procedures performed were chest drainage (thoracotomy) and a laparotomy.
The multiplicity and the degree of severity of the injuries were finally described intraoperative
during the surgical interventions by chest drains and laparotomies (Tables 1 and 2)
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Thoracic Injuries
The chest injuries were measured intra-operatively by how much blood is drained from the
pleural cavity.
The intra-abdominal Injuries
The passage of the shots (bullets or arrows) through the abdominal cavity caused significant
organ damage from upper quadrant to lower abdomen, right to left or left to right diagonally.
Injuries of solid organs (spleen and liver) associated with bowel damage did result in most cases
of mortality (Table 4 and 5), the arrows passage was less damaging and all 4 patients with
arrow shots survived.
Table 6. Intra-abdominal Injuries identified and outcomes
Bowel(SB/LB)
Liver +Spleen
Bowel Extensive Injury
SB/LB
Bowel SM/LB Moderate
+Liver Laceration
Bowel SB/LB
+Splenic injury
Viscera other( Stomach,Bladder, Mesentry
Kidneys,blood vessels and spleen alone)
No
1
Survival
0
Mortality
1
4
0
4
6
4
2
1
0
1
9
4
2
Figure 1. Evisceration at the exit wounds (Courtesy of M Achiek, FRCS
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Discussion
In our series despite the rather small number and only one year’s experience chosen from a
large pool of patients with gunshot injuries to various parts, we are showing effectively the
extent of damage caused by bullets or arrows that traverse the thoracic and abdominal
cavities at the same time. The victims of these injuries reach health facilities unstable
clinically with a double impact of haemorrhagic and septic shock and attempts are made to
conduct resuscitative operations (Thoracotomy and laparotomy)as shown in our study,
even some larger series over 5 years do have comparable numbers5. Patients who do not
reach hospitals within the golden hour and no pre-hospital rescue attempts by trained
professionals have less survival opportunity5,6,7, as in our series all the patients were
brought to the hospital by untrained good Samaritans or private public transport. The
teaching hospital our patients were brought to is modest and developing with very limited
resources, both material and human.
Management by a multidisciplinary team of specialists in trauma centres supported by
intensive therapy units(ITU) may improve survival significantly8.The outcome of combined
thoracic and abdominal injuries may take long to improve in relation to the poor African
inner city terrorist violence or the civil wars battlefields9.The mortality of (52.2%) in our
series is relatively higher than what is quoted by others 2,10 because non of our patients was
treated on an ITU as we lack critical care facilities that could have supported these severely
injured younger patients we managed. The pattern of injuries also has a role, as most
patients had visceral injuries, affecting the bowel 11/23, With associated bowel perforating
injuries, these patients on presentation had already developed septicaemia from peritonitis
and this added to the effect of blood loss from the chest and the abdomen, this is a doubly hit shocked patient who easily slips into multi-organ dysfunction 1,8,11. There could be at
times assessment and diagnostic scans (US/CT) prioritization difficulties in managing
critically ill multiple trauma patients9. However, in our series the patients had never have
imaging investigations (x-Rays, US &CT scans, as they were all unstable barely reaching the
operating theatres moribund, and we have to adhere to the ATLS principles and tried
desperately life- saving 12.
We have chosen a subset of patients from a larger pool of victims of multiple trauma. In
clinical practice in the areas of high violence prevalence whether military or civilian, the
morbidity and mortality associated with these injuries is high10,13,14,15, specially gunshots
and blasts. Traditional weapons like arrows could equally cause significant damage when
traversing cavities as in our series and may compare implement like knives and spears, but
there is an element of velocity with an arrowshot.
Mortality and morbidity associated with thoraco-abdominal injuries will continue to be
high as long as patients in developing nations are not benefiting from well developed
prehospital systems and managed on tertiary centres with specialist multidisciplinary
teams6. This auditing study is a painful lesson in our national healthcare planning strategy.
Although the circumstances were far from ideal and very much similar to situation on the
battle fields of the African civil wars, we are making a point of reflection on what could have
been done differently at different points of patients contact, from trauma scene retrieval to
the A&E triage and emergency surgical intervention.
Conclusion
A trauma patient who is doubly-hit by the impact of haemorrahage from injury and septic
from a viscus penetration has minimal chances of survival. These patients are in a doubled
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shock, both haemorrhagic and septic and therefore, slip quickly into multi-organ
dysfunction, critically ill and this sequence of events is associated with high mortality .They
should be ideally managed on an ITU in a designated trauma centre.
Patients with thoraco-abdominal shot injuries will remain challenging to manage even to
the best facilitated. In Africa if the healthcare authorities at least establish cardiothoracic
surgical units HDUs/ITUs, the high mortality may be improved to some point.
References
1. Om P Sharma , Michael F Oswanski, Patrick W White. Injuries to the colon from blast
effect of penetrating extra-peritoneal thoraco-abdominal trauma. Injury,Volume 35,
Issue 3, March 2004, Pages 320–324
2. Asensio JA, Arroyo H Jr, Veloz W, et al.: Penetrating thoracoabdominal injuries: ongoing
dilemma-which cavity and when? World J Surg 2002, 26:539-543
3. Krug EG, Powell KE, Dahlberg LL: Firearm-related deaths in the United States and 35
other high- and upper-middle-income countries. Int J Epidemiol 1998, 27:214-221.
PubMed Abstract | Publisher Full Text
4. The Violence Prevention Task Force of the Eastern Association for the Surgery of
Trauma: Violence in America: a public health crisis--The role of firearms. The Violence
Prevention Task Force of the Eastern Association for the Surgery of Trauma. J Trauma
1995, 38:163-168. PubMed Abstract | Publisher Full Text
5. Band RA, Gaieski DF, Hylton JH, Shofer FS, Goyal M, Meisel ZF , Arriving by emergency
medical services improves time to treatment endpoints for patients with severe sepsis
or septic shock. Acad Emerg Med. 2011 Sep;18(9):934-40
6. Husum, Hans MD; Gilbert, Mads MD, PhD; Wisborg, Torben MD, DEAA; Van Heng, Yang
paramedic; Murad, Mudhafar MD. Rural Prehospital Trauma Systems Improve Trauma
Outcome in Low-Income Countries: A Prospective Study from North Iraq and Cambodia
Journal of Trauma-Injury Infection & Critical Care: June 2003 - Volume 54 - Issue 6 - p
1188–1196
7. Frezza EE1, Mezghebe H. Is 30 minutes the golden period to perform emergency room
thoratomy (ERT) in penetrating chest injuries? J Cardiovasc Surg (Torino). 1999 Feb;
40(1):147-51.
8. Carlos A. Ordoñez, MD and Juan Carlos Puyana, Management of Peritonitis in the
Critically Ill Patients Surg Clin North Am. Dec 2006; 86(6): 1323–1349. Surg Clin North
Am. Author manuscript; available in PMC Aug 7, 2012
9. The persistent diagnostic challenge of thoraco-abdominal stab wounds (, 16 yrs
experience,30 RT,high mortality) ,Berg et al. Regan J. Berg, MD, Efstathios Karamanos,
MD, Kenji Inaba, MD, Obi Okoye, MD, Pedro G. Teixeira, MD, and Demetrios Demetriades,
MD, PhD, Los Angeles, California. J Trauma Acute Care Surg Volume 76, Number 2
(2013), 418-423
10. Philipp Lichte, Reiner Oberbeck, Marcel Binnebösel, Rene Wildenauer, Hans- Christoph
Pape and Philipp Kobbe A civilian perspective on ballistic trauma and gunshot injuries.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2010,
18:35. Combined thoracic and abdominal injuries ranges between 6%-42%, and even
could be higher in the battle fields.
11. D V Feliciano, J M Burch, V Spjut-Patrinely, K L Mattox, and G L Jordan, Jr Abdominal
gunshot wounds. An urban trauma center's experience with 300 consecutive patients.
Ann Surg. Sep 1988; 208(3): 362–370. Hypovolaemic &septic forms of Shock are the
main cause of death.
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12. American College of Surgeons Committee on Trauma: Advanced Trauma Life Support for
Doctors, ATLS Student Course Manual. Chicago: American College of Surgeons; 2008
13. O Genc, M Dakak, S Gürkök, AGözübüyük, K Balkanli. Thoracic Trauma And Management.
The Internet Journal of Thoracic and Cardiovascular Surgery.2000 Volume 4 Number 1.
14. Zakharia AT. Cardiovascular and thoracic battle injuries in the Lebanon War.Analysis of
3,000 personal cases. J ThoracCardiovasc Surg. 1985 May; 89(5):723-33.
15. Mandal AK1, Sanusi M Penetrating chest wounds: 24 years experience. (About mortality)
World J Surg. 2001 Sep; 25(9):1145-9.
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Childhood Limb Fracture at Tikur Anbessa Specialized Hospital (TASH), Addis Ababa,
Ethiopia
D. Admassie1, B. Ayana2, S. Girma3
1Associate Professor of Radiology, Addis Ababa University Medical Faculty, 2Assistant
Professor of Orthopedic Surgery, Addis Ababa University Medical Faculty, 3Consultant
Radiologist.
Correspondence to: Dr Birhanu Ayana, E-mail. ayanabirhanu@gmail.com
Background: Childhood injury is a major public health problem worldwide. The burden is
greatest in low- middle income countries. There is limited data on patterns of childhood
fractures in Ethiopia. The aim of this study is to evaluate the pattern of childhood fractures
and dislocations presented at Tikur Anbessa Specialized Hospital.
Methods: The data was retrieved retrospectively from the hospital record books and
charts of all children aged 0-13 years, presented at Tikur Anbessa Specialized Hospital
emergency department with limb fractures or dislocations between September 2011 to
September 2012.
Results: A total of 325 cases with limb fractures and /or dislocations were analyzed. The
majority were males 254(78.2%). Most common age group involved were 6 -13 years of
age. Fall down accident accounts the largest proportion, 236(72.6%) followed by road
traffic injury, 57(17.5%). Upper limb fractures were more common than lower limb
fractures. The most common fractured bone was humerus followed by radius and ulna.
More than ninety percent of cases were closed fracture.
Conclusion: Pediatric limb fractures resulting from fall and road traffic injuries are a major
public health problem in our setting. Urgent preventive measures targeting at reducing the
occurrence of accidental fall and traffic injury is necessary to reduce the incidence of
pediatric limb fractures. Further large scale studies are necessary to know the final
outcome of treatment given.
Keywords: Childhood, Pattern, Limb fractures.
Introduction
Trauma is a major cause for childhood morbidity, mortality and disability worldwide. Injury and
violence is a major killer of children throughout the world, where unintentional injuries account
for almost 90% of these cases. Many of these are left with some form of disability, often with
lifelong consequences. The leading causes of disability being road traffic crashes and falls in
children aged 0–14 years. Within all countries, the burden is greatest in low and middle income
countries where more than 95% of all injury deaths in children occur in these countries 1,2,3.
In developing countries, children comprise a higher proportion of the total population.
Fractures of childhood constitute a major part of public health problem. The incidence and
patterns of fractures depend on different factors and understanding mechanism of injuries and
their corresponding patterns of fracture can help in assessment of the extent of a patient’s
injury1,4. In Ethiopia, fractures are a common and significant injury in childhood, but the
information about the pattern of fractures among children is scarce. The aim of the study is to
determine the patterns limb fractures presented to the emergency department of Tikur Anbessa
Specialized Hospital and identify contributing factors in order to determine preventive
measures.
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Patients and Methods
This was a retrospective study conducted at Tikur Anbessa specialized teaching hospital
between September 2011 – September 2012. During the study period a total of 325 patients
with limb fracture were presented to emergency department age ranging from zero to 13 years.
The hospital is the largest tertiary referral and teaching hospital in the country providing
elective and emergency Orthopedics services. The investigation was approved by joint ethical
Committee of the department of orthopedics and radiology.
The data was retrieved from log book and charts of children aged 13 and below who had
attended the emergency department of Hospital during the study period. Log book is a prepared
format in which orthopedic residents on duty recorded prospectively the characteristics of all
patients and their fracture patterns. Incomplete data of log book and pathological fracture were
excluded. Data were collected with regard to the patient’s demographic characteristics, pattern,
mechanism of injury and anatomical location. Data was analyzed using SPSS version soft ware.
Results
A total of 325 children presenting with limb fractures during the study period were included.
There were 254 boys (78.2%) and 71 girls (21.8%), making male to female ratio 3.5:1 (Table
1). The most affected age group was 6-13yrs of age (Figure 1). In all age groups the proportion
of males was higher than females. The majority (86.2%) of the patients were from Addis Ababa;
only 45(13.8%) came from outside Addis Ababa.
The most common mechanism of injury was a fall, which accounted for 236 (72.6%) followed by
road traffic crashes (RTC) in 57(17.5%) of all cases, (Table 2). Table 3 showed that the upper
limb fracture was more common comprising (66.2%), whereas lower limb fractures were
(33.2%). The commonest single anatomical site of fracture occurred in the humerus which
contributed 97(29.8%), followed by Radial bone fracture in 93(28.6%) and ulnar fracture in
67(20.6%) (Table 3). Of the 325 patients with fracture, 313 (96.3%) sustained fractures only
while 10 (3.1%) had only dislocations and 2 (0.6%) had both fractures and dislocations. The
specific site of fracture incidence showed that supracondylar fracture of humerus being
commonest followed by distal radial fracture.
Table 1. Age and Sex Distribution of Patients with Limb Fractures.
Age Groups
<2 years
2-5 years
6-13 years
Total
Sex
Female
7
16
48
71
Male
16
48
190
254
Total
Percent
23
64
238
325
7.1
19.7
73.2
100
Table 2. Most Common Causes of Fracture and Dislocations
Mechanism of injury
RTC
Fall
Others
Total
Frequency
Percent
57
236
32
325
17.5
72.6
9.8
100
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200
150
Female
100
Male
50
0
< 2 years
2-5 years
6-13 years
Figure 1. Pattern of Fracture According to Age-group and Gender
Table 3. Distribution of Fractures Sites.
Site of fracture
Humerus
Radius
Ulna
Radioulnar
Femur
Tibia
Fibula
Tibiofibular
Short bones
Only Joint(dislocation)
Bone and Joint
Patella
Frequency
97
93
67
55
54
46
27
27
14
10
4
2
Percentage
29.8
28.6
20.6
16.9
16.6
14.2
8.3
8.3
4.3
3.1
1.2
0.6
The majority (90.2%) of fractures were closed 293; open fracture accounted for only 32(9.8%)
of cases. Physeal fracture of the distal end of the radius was the single most common physeal
injury. In the lower limb femoral fracture were the commonest followed by tibial fracture.
Discussion
In the this study, it was found that falls accident accounted for a majority of fractures followed
by road traffic accidents, which is in agreement with many studies 5-8. However, other studies
have accounted road traffic accidents to be the major cause of pediatric fractures9-11. Deakin et
al 12 reported that falls accounted for the majority of upper limb fractures, while, sports related
injuries to be responsible for the majority of lower limbs fractures. The differences in the
etiology can be attributed to socio-cultural differences in different countries, where the studies
were conducted.
Male children accounted for the majority of patients with fracture in our study in all age groups
which is similar to other studies 6-8,10,13-18. This could possibly be explained by the fact that male
children are more active and adventurous. Upper limb was more frequently involved. This is in
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line with other studies 8,15,18. More than ninety percent of cases were closed fracture. There were
32 (9.8%) patients with open fractures which were caused mainly by road traffic injury.
The most affected age groups were 6-13 years which indicates the increasing risk of fracture
with age. Comparable findings were observed in many other studies 7,13,17,19. In our series, the
most common site of fracture was observed in the humerus predominantly supracondylar.
Similar finding was observed in others previous studies 7,18. This is contrasted with other
studies in the literature, where forearm fracture specifically distal radius were the most
common fractures 6,14-17,20. Physeal fracture of the distal end of the radius was the single most
common physeal injury in our cases which is in accordance with other studies 4,8,13,15.
This study contributes to the understanding of childhood limb fracture pattern at Tikur Anbessa
Specialized Hospital which is, the only government tertiary hospital in Addis, which provides
pediatric most of orthopedic care. The drawback of this study is that it is not including, other
private hospitals and government hospitals where emergency services is given.
Conclusion
The burden of fractures among children in Ethiopia is a significant source of morbidity. The
injuries are preventable and paediatric trauma prevention strategies directed at parents,
schools and children with changes in lifestyle are an imperative in order to reduce the burden of
limb fracture in childhood. A further large scale study is now recommended.
Acknowledgement
We would like to thank the Radiology and Orthopedic Departments of Addis Ababa University,
School of Medicine for their full support and to Dr Geletaw Tessema for his cooperation at a
time of data collection. Our special thanks goes to Dr Metasebia Mesfin for his support on data
analysis.
References
1. WHO. The global burden of disease: 2004 update. Geneva (Switzerland): World Health
Organization, 2008.
2. Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health 2000;
90: 523-6
3. Mónica Ruiz-Casares, Unintentional childhood injuries in sub-Saharan Africa, Journal of
Health Care for the Poor and Underserved, 2009; 20: 51–67.
4. Beaty,JH.; Kasser, JR. Rockwood and Wilkins’ Fractures in Children. 6th Ed. Philadelphia:
Lippincott, 2006.
5. Hedström EM., Svensson O., Bergström U, Michno P. Epidemiology of fractures in
children and adolescents. Acta Orthop, 2010; 81: 148–153.
6. Kopjar, B., Wickizer, TM. Fractures among children: Incidence and impact on daily
activities. Injury Prevention, 1998; 4: 194 –197.
7. Rennie, L., Court-Brown CM, Mok JYQ., Beattie, TF. The epidemiology of fractures in
children. Injury, 2007; 38: 913–922.
8. Simon et al. Paediatric injuries at Bugando Medical Centre in North western Tanzania: a
prospective review of 150 cases, Journal of Trauma Management and outcomes 2013;
7:10
9. Renee Y. Hsia et al. Epidemiology of child injuries in Uganda: challenges for health
policy, Journal of Public Health in Africa 2011; 2(e15): 63-67
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10. Nwadinigwe CU, Ihezie CO, Iyidiobi IC. Fractures in Children.Nigerian Journal of
Medicine, 2006; 15(1), 81-84.
11. Landin, LA. Fracture patterns in children. Analysis of 8682 fractures with special
reference to incidence, etiology and secular changes in a Swedish urban population
1950-1979. Acta Orthop Scand Suppl, 1983; 54(202): 1–109.
12. Deakin et.al. Childhood fractures requiring inpatient management, Injury , 2007;
8(11): 1241–1246.
13. Cooper C, Dennison EM., Leufkens HGM, Bishop N, Van Staa TP. Epidemiology of
childhood fractures in Britain: a study using the general practice research database. J.
Bone Miner. Res, 2004; 19: 1976–1981.
14. Valerio et al. Pattern of fractures across pediatric age groups: analysis of individual and
lifestyle factors BMC Public Health 2010; 10: 656.
15. Thandrayen K., Norris SA, Pettifor JM. Fracture rates in urban South African children of
different ethnic origins: the Birth to Twenty cohort. Osteoporosis Int, 2009; 20: 47–52.
16. Lyons, R. A. et al. Children’s fractures: a population based study. Inj. Prev,1999; 5: 129–
132.
17. Paudel KP, .Thapa SK. Children’s fracture: an experience from a zonal hospital in Nepal,
Journal of college of Medical Sciences-Nepal, 2010; 6(2): 14-17.
18. Tandon T et al. Paediatric trauma epidemiology in an urban scenario in India, Journal of
Orthopaedic Surgery 2007; 15(1): 41-5.
19. A Saw, et. Al. Pattern of Childhood Fractures in a Developing Country, Malasian
Orthopedic Journal 2011; 5(1):13-16
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Tertiary Trauma Survey: Evaluation of Missed Injuries at a Teaching Hospital in the
Developing World.
O.J. Ogundele, A.O. Ifesanya. O.A. Oyewole,.T.O. Alonge
Department of orthopaedics and Trauma, University College Hospital, PMB 5116, Ibadan,
Oyo state, Nigeria.
Correspodence to: OJ Ogundele, Email:ogunjosh@yahoo.com & ogunjosh128@gmail.com.
Background: The gold standard in the care of the multiply injured is the prompt
identification of all life-threatening and associated injuries by using the Advanced Trauma
Life Support protocol (ATLS). The main objective of this study was to determine the
incidence of missed injuries in patients presenting to our hospital and to identify the
primary contributing factors for each missed injury.
Methods: An initial evaluation of our trauma registry data for missed injuries in a 90%
population of trauma victims yielded an incidence of 12%. However, to determine the true
incidence of missed injuries, a prospective tertiary trauma survey was performed on all
injured patients admitted during a six month period. After the primary and secondary
surveys, all injuries and treatments were documented in the patients’ trauma medical
records. They were then re-examined immediately by the senior orthopaedic registrars and
subsequently by the investigator.
Results: Fifty-two missed injuries were found in 46 patients (10.5%) out of 438 cases.
Reasons for missed injuries include haemodynamic instability 3 (0.7%), head injury 17
(3.9%), low index of suspicion 5 (1.1%), lack of symptoms 6 (1.4%) and technical problems
12 (2.7%).
Conclusion: There is a need to re-appraise our trauma care practice to reduce the
incidence of missed injuries.
Introduction
The management of multiple trauma patients presents a worldwide diagnostic and therapeutic
challenge to trauma, orthopedic and general surgeons1. Trauma care in a busy hospital setting
brings about medical errors as a result of unstable patients, incomplete histories, time-critical
decisions, synchronous tasks, involvement of many disciplines, and inexperienced personnel
working after-hours2. Significant injuries can be missed during primary and secondary
surveys in multiply injured patients, who require simultaneous resuscitation, diagnosis and
therapy. Unfortunately, 34% of missed injuries during trauma treatment occur in the
Emergency Department.1, 3. A common quality indicator in trauma care is missed injury 4.
A missed injury may draw attention as the most exciting event in a patient’s clinical course,
clouding the brave efforts of the trauma team5. Missed injuries occur in the time-critical and
complex assessment of severely injured trauma patients in the Emergency Department.
Altered level of consciousness, distracting injury, or early surgical intervention may prevent
adequate and detailed assessment of the trauma patients. These difficulties with initial
examinations may therefore lead to injuries going undetected and their subsequent
management may increase morbidity6or even mortality6, 7. Injuries can be missed at any stage
of the management of the trauma patient, including intra-operatively, and may involve all
regions of the body8.
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Missed injuries are a potential source of morbidity and mortality and may also represent
varying degrees of clinical inexperience and are common reasons for litigation9. Missed
injuries are often associated with prolonged length of hospital stay resulting in increased
costs of care as well as consumption of hospital resources 9, 10. The incidence of missed
injuries has been reported in trauma literature to range between 0.6% and 65%, and less
missed injuries have been found in retrospective studies 11. In a prospective study in Uganda,
the rate of missed injuries was reported to be 19.4% and the commonest contributing factor
for missed injuries was inadequate assessment 12.
To reduce undiagnosed injuries, hospitals need effective means of identifying errors and error
associated deaths, which have been found to be 2.7–6.5%. 13 There is a general disinclination
of physicians to admit and account for their errors which is further complicated by paucity of
literature and difficulties in researching this area. 12, 13 Missed injuries are defined variously
as injuries identified after the initial period of resuscitation (primary and secondary survey of
Advanced Trauma Life Support®), although they may also be injuries identified after a
defined time period after injury, such as 12 or 24 hours 14. However, there is no absolute
definition, since some missed injuries may be asymptomatic and may present long after the
initial event. Missed injury has been a source of concern to clinicians for many years;
however, what is surprising is that injuries are missed even in developed countries with
experienced units and facilities15.
The main objective of this study was to determine the incidence of missed injuries in patients
presenting to our tertiary hospital and to identify the primary contributing factors leading to
each missed injury and the attendant morbidity and mortality.
Patients and Methods
A questionnaire was completed for all trauma patients presenting in the emergency
department of our hospital after the initial evaluation and resuscitation. The medical officers
in conjunction with the postgraduate surgical registrars initially evaluate the patients before
subsequent review by the consultants in the emergency medicine department. Patients were
eventually referred to various departments according to the parts of the body and pattern of
injuries sustained for definitive management. Those referred to the orthopaedic and trauma
department were then re-examined immediately by the senior registrars in the unit. They were
then reviewed by the investigator who is an orthopaedic and trauma surgeon before
ambulation, discharge from the intensive care unit, hospital, and in head- injured patients,
upon regaining consciousness. All missed injuries were identified and documented, including
type, site and number of injuries, reasons why they were missed, how they were identified
and any attendant morbidity and mortality. Patients were also re-examined at the initial
follow up visit to the surgical outpatient department by the investigator.
At the emergency department of our hospital, about 600 new cases of traumatic injuries
present for management every month. Our emergency department is composed of 4
consultants (one surgeon, one anaesthetist and two physicians) 4 postgraduate year 2 surgical
registrars on emergency medicine rotation and eighteen medical officers who are at least two
years post qualification from medical schools awaiting placement into the residency training
programmes of our hospital. There is also a dedicated trauma team which can be summoned
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at any time. Neurosurgical, cardiac and other surgical subspecialty care is available for 24
hours of the day. A dedicated operating theatre for trauma is available on request. Portable
ultrasonography, echocardiography, radiological facilities and computerized tomography
scan were available 24 hours of the day in the hospital. We also have facilities for performing
laboratory analyses and consultations from any department are available on request.
Results
The ages ranged between 2 and 100 with a mean of 37.0±20.0 years. Figure 1 shows the age
distribution and the number of patients who had missed injuries. There were 273 males and
165 females with a male to female sex ratio of 1.7: 1. A total of 52 (10.5%) missed injuries
were found in 46 patients out of 438 patients seen. They included 27 males had missed
injuries while 19 females also had missed injuries. These included fractures of the clavicle,
scapular, ulna, radius, pelvis, acetabulum and femoral condyles. Others are shoulder
dislocation, brachial plexus and transverse colonic injuries. Tibia plateau fractures (1.4%)
were the most commonly missed injuries. 4 Patients (0.9%) had multiple missed injuries
(Table 1). The injury severity score in patients who presented for trauma care is shown in
Table 2.
Factors contributing to missed injuries included haemodynamic instability necessitating early
surgery in 3 (0.7%), head injury in 18 (4.1%), low index of suspicion in 5 (1.1%), lack of
symptoms in 7 (1.6%) and technical problems in 13 (3.0%) of the patients with missed
injuries..
Table 1. Missed Injuries in Trauma Patients after Completion of Primary and Secondary
Surveys
Missed injuries
Clavicular fractures
Scapular fractures
Brachial plexus injury
Shoulder dislocation
Ulnar fractures
Distal radial fractures
Pelvic fractures
Acetabular fractures
Femoral condylar fractures
Tibia plateau fractures
Tibia fractures
Metatarsal fractures
Malleolar fractures
Transverse colonic injury
Multiple missed injuries
Total
Frequency (%)
2
3
1
2
2
4
4
4
2
6
2
2
3
1
4
52
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Table 2. Injury Severity Scores in Patients Who Presented for Trauma Care .
No of pts with missed injuries
Injury severity score
Number
26
16-18
10
19-21
2
22-24
5
25-27
3
>28
Total
46
χ2- value = 4.966, P-value=0.291
No of pts without missed
injuries
%
Number
9.0
14.1
6.3
16.7
20.0
10.5
264
61
30
25
12
392
% %%)
91.0
85.9
93.8
83.3
80.0
89.5
Figure 1. Age Distribution of Patients with and without Missed Injuries
Discussion
All emergencies resemble each other at first sight, but each emergency has its own reasons
for a
missed diagnosis16. The primary and secondary surveys outlined by the Advanced Trauma
Life Support (ATLS) protocol and the tertiary survey have helped to minimize the incidence
of missed injuries. However, many injuries can still entirely escape detection at the hospital17.
Missed injuries are defined variously as injuries identified after the initial period of
resuscitation (primary and secondary survey of Advanced Trauma Life Support®), although
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they may also be injuries identified after a defined time period after injury, such as 12 or 24
hours. The definition of missed injuries also varies between studies. Some studies describe it
as ‘any injury missed by the primary and secondary surveys, and detected as a result of the
tertiary trauma survey’
(i.e. Type I)14, 18.
Another study defined it as any injury that escaped detection at the time of the tertiary trauma
survey and then subsequently discovered either while the patient is still in the hospital or after
discharge from the hospital (i.e. Type II) 19. In this study, missed injuries are classified as
injuries detected during or after the tertiary trauma survey. Our rate of missed injuries of
10.5% is comparable to that reported by Enderson et al 6 and better than that reported by
some other studies. 5, 10, 20 In this study most missed injuries were in the 4th and 6th decades
of life.
Patients with injury severity score of between16 and 18 recorded the highest number of
missed injuries in this study which finding differed with earlier reports 17, 21, 22 which reported
higher rate of missed injuries with higher injury severity scores. The reason for this disparity
may be because of higher early mortality associated with high injury severity scores at our
centre and the rudimentary state of our pre-hospital emergency medical care where patients
with such high injury severity scores may not have survived the initial trauma. Patients who
appear to be most at risk for missed injuries include those who cannot cooperate with the
examinations due to head injury or the effects of drugs or alcohol and patients whose initial
assessment is rushed because of haemodynamic instability. Therefore, in patients presenting
in such fashion, a careful tertiary trauma survey to seek missed injuries is recommended.
Head injury is responsible for most of the missed injuries in this study due to lack of
cooperation on the part of the patients because of their injuries.
Technical problems as a factor responsible for missed injuries also featured prominently in
this study. Such technical challenges include inadequate radiographic facilities especially
during the off-peak hours, incessant power outrages leading to non functioning elevators
needed for transporting patients from the emergency department to other parts of the hospital,
inadequate supporting facilities such as para-medical staffs, trolleys, for example. There is
need for construction of useful alternatives to elevators like stair-cases to facilitate moving
patients from the emergency department to other parts of the hospital during power outages.
The fact that trauma care in this environment is also on “cash and carry” basis also
contributes to this problem as most trauma victims in the initial post traumatic period have
financial constraints which delays or precludes complete ancillary investigations.
It is a fact that for many missed injuries, it is impossible to discover which determinant was
the main cause of delay in detection of the injury, and multiple contributing factors can be
ascribed to a single missed injury. 16, 23 In our study, radiological challenges included
inappropriate views of radiographs, no availability of x-ray cartridges, delay in reporting
radiographs, misinterpretation by the clinicians, among others. In studies investigating the
characteristics of patients with missed diagnosis in addition to the reasons mentioned above,
several other features included communication problems (language barrier, infant), admission
into the intensive care unit, the patient being directly dispatched to the operation room from
the emergency department, emergency department admissions during the night time,
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misleading medical history, haemodynamic instability, and multiple injuries in the same
extremity 6, 24.
Some patients who presented for follow-up in the surgical out- patient department also had
missed injuries. However, their injuries were not life-threatening and subsequently managed.
It is expedient that we improve our pre-hospital emergency medical care services to enhance
the survival of patients with severe injuries and to increase the number and cadres of surgical
residents on emergency medicine rotation with respect to the number of medical officers who
are less experienced in trauma care to minimize the risk of missed injuries.
Conclusion
Our rate of missed injuries is comparable to that in other parts of the world. However, there is
a need to re-appraise our trauma care practice in order to reduce the incidence of missed
injuries. Tertiary trauma survey should be included in the evaluation of our patients and this
should be taught to trauma care providers.
References
1. Enderson B, Maull K. Missed injuries: The trauma surgeon's nemesis. Surg Clin
North Am 1991; 71: 399-17.
2. Gruen R, Jurkovich G, McIntyre L, et al., Patterns of errors contributing to trauma
mortality. Lessons learned from 2594 deaths. Ann Surg 2006; 244: 371-80.
3. Brooks A, Holroyd B, Riley B. Missed injuries in major trauma patients. Int J Care
Injured 2004; 35: 407-10.
4. Stelfox H, Straus S, Nathens A, et al., Evidence for quality indicators to evaluate adult
trauma care: a systematic review. Crit Care Med 2011; 39: 846-59.
5. Kalemoglu M, Demirbas S, Akin M, et al., Missed injuries in military patients with
major trauma. Mil Med 2006; 171: 598–02.
6. Enderson B, Reath D, Meadors J, et al,. The tertiary trauma survey: a prospective
study of missed injury. J Trauma 1990; 30:666-70.
7. Buduhan G, Donna I. Missed injuries in patients with multiple trauma. J Trauma
2000; 49:600–05.
8. Shirzard H, Morlen S, Carsten H. Missed injuries in a Level 1 Trauma Centre. J
Trauma 2002; 52 (4): 715-9.
9. Sandra M, Salvador N, Pere R, et al., A prospective study on the incidence of missed
injuries in trauma patients. Cir Esp 2008; 84(1):32-6.
10. Buduhan G, Donna I. Missed injuries in patients with multiple trauma. J Trauma
2000; 49(4):600-05.
11. Frawley P. Missed injuries in the multiply traumatized. Aust N Z J Surg 1993;
63:935-39.
12. Okello C, Ezati I, Gakwaya A. Missed injuries: A Ugandan experience. J Injury 2007;
38(1): 112-7.
13. Gedeborg R, Thiblin I, Byberg L, et al., The impact of clinically undiagnosed injuries
on survival estimates. Crit Care Med 2009; 37: 449–55.
14. Vles W, Veen E, Roukema J, et al., Consequences of delayed diagnoses in trauma
patients: a prospective study. J Am Coll Surg 2003; 197:596-02.
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15. Janjua K, Sugrue M, Deane S. Prospective evaluation of early missed injuries and the
role of tertiary trauma survey. J Trauma 1998; 44:1000-6.
16. American College of Surgeons Committee on Trauma. Initial assessment and
management. In: Advanced trauma life support reference manual. Chicago: American
College of Surgeons; 1994. p. 17–37.
17. Biffl W, Harrington D, Cioffi W. Implementation of a tertiary trauma survey
decreases missed injuries. J Trauma 2003; 54:38-44.
18. Ursic C, Curtis K, Zou Y, et al., Improved trauma patient outcomes after
implementation of a dedicated trauma admitting service. Injury 2007; 38:112-7.
19. Soundappan S, Holland A, Cass D. Role of an extended tertiary survey in detecting
missed injuries in children. J Trauma 2004; 57:114-8.
20. Houshian S, Larsen M, Holm C. Missed injuries in a level 1 trauma center. J Trauma
2002; 52:715-9.
21. Emet M, Saritas A, Acemoglu H, et al., Predictors of missed injuries in hospitalized
trauma patients in the emergency department. Eur J Trauma Emerg Surg 2010;
36:559-66.
22. Rizoli S, Boulanger B, McLellan B, et al., Injuries missed during initial assessment
of blunt trauma patients. Accid Anal Prev 1994; 26: 681-6.
23. Furnival R, Woodward G, Schunk J. Delayed diagnosis in paediatric trauma.
Pediatrics 1996; 98:56-62.
24. Stothert J, Gbaanador G, Herndon D. The role of autopsy in death resulting from
trauma. J Trauma 1990; 30:1021-6
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Outcome of Ventriculoperitoneal Shunt insertion at Myungsung Christian Medical Centre
in Ethiopia
H. Biluts1, A.K. Admasu2
1Associate Professor of Neurosurgery, 2Chief Neurosurgery Resident,
Neurosurgery unit, College of Health sciences, School of Medicine, Addis Ababa University
Correspondence to: Dr Hagos Biluts, E-mail: hagosbiluts@gmail.com
Background: We investigated the feasibility of shunt insertion procedures with acceptable
short-term outcomes in Ethiopia, and to identify factors associated with good and bad
outcomes.
Methods: This is a hospital based prospective cohort study of outcome of
ventriculoperitoneal shunt insertion at Myungsung Christian Medical center (MCM), Addis
Ababa, Ethiopia in the period between January 2011 and December 2012. Medical records
were reviewed in a structured questionnaire prepared for this purpose. Epidemiological
data, head circumference, clinical investigations, etiology of the hydrocephalus, details of
the ventriculoperitoneal(VP) shunt insertion, outcome by the end of 6 months, morbidity
and mortality data were collected. Outcomes were graded as good, fair, or poor, according
to head circumference, anterior fontanels status, visual, motor, and seizure criteria.
Difference in proportions was examined using Chi-square test.
Results: The Authors review141 VP shunt insertions in 114 patients≤ 12 years of ageatMCM,
61(53.5%) were male and 46(46.5%) female. The median age was 3 months (range 0.3144); the mean head circumference at presentation was 50.4 ± 10.1cm (range, 34-106). The
commonest causes of hydrocephalus were spina bifida (42.3%) and post infectious
(20.2%). Early complications following surgery were seen in 65(58.0%) patients. The
commonest complication was mechanical failure in 54(48.2%) patients, under shunting
constituted 83.3% of the mechanical shunt failure, shunt infection being 7%. Follow-up was
available in 75.4% of children, with a mean follow-up period of 6.8 ± 7.2 months (range 136). In-hospital mortality was 1.8%. The overall shunt function rate at last visit was 88.3%,
head circumference ≥ 50 cm had significant early complication compared to those with ≤ 50
cm. Age and Sex were not significantly correlated to the occurrence of complications and
outcomes.
Conclusion: Spina bifida was main etiological cause of hydrocephalus. Our study has
documented good outcomes at 12 months follow-up period for VP shunt insertion with
acceptable early complication rates. However, children with a head circumference greater
than 50 cm had significant early complication (p=0.028). Given the availability of fully
subsidized VP shunts in a country with enormous number of hydrocephalic children, shunts
will continue to play a pivotal role in the management of hydrocephalus in Ethiopia.
Key words: Ethiopia, hydrocephalus, outcome, Ventriculoperitoneal shunt
Introduction
The prevalence and incidence of hydrocephalus in developed nations is estimated as 0.91.2/1000 and 0.2-0.6/1000 respectively.1No reliable estimate is available in the African
literature, but its incidence is likely higher because of untreated / poorly treated neonatal
meningitis, congenital malformation and nutritional deficiencies. Some of several hypothesized
causes of pediatric hydrocephalus include, congenital malformations, meningitis/ventricuitis,
tumors, traumatic head injury or subarachnoid hemorrhage2,3. Two forms of hydrocephalus
exist, communicating and non-communicating. The clinical exam is the most readily available
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investigation for the diagnosis of hydrocephalus. Hydrocephalus and its complications such as
shunt malfunction or infection are also regularly diagnosed by cranial imaging including
ultrasonography, computed tomography (CT) or magnetic resonance imaging (MRI). The
surgical treatments for hydrocephalus are inserting a shunt system to redirect the flow of
cerebrospinal fluid (CSF) to other parts of the body or endoscopically diverting CSF from
ventricular system to subarachnoid space. Despite the increasing use of endoscopic procedures
in our centers, Ventriculoperitoneal (VP) shunt placement remains the principal method of
treating hydrocephalus in Ethiopia. It is the gold standard against which newer procedures are
judged. VP shunts are associated with substantial complication rates. Worldwide failure rates
currently still range between 25% and 40% within the 1st year following insertion3-6.
This was a prospective cohort study of patients who had undergone VP shunt surgeries with
respect to etiology, complications and outcome.
Materials and Methods
This is a prospective study of 114 patients≤ 12 years with hydrocephalus who received VP
shunt as primary treatment (93%) or VP shunt insertion following endoscopic third
ventriculostomy (ETV) failure between January 2011 and December 2012 at Myungsung
Christian Medical Center (MCM). Medical records were reviewed meticulously in a structured
questionnaire prepared for this purpose. Epidemiological data, duration of symptoms, clinical
investigations, etiology of the hydrocephalus, details of the VP shunt insertion, complications
and outcome by the end of 6 months, and morbidity and mortality data were collected.
All the shunts used were medium pressure shunts. Shunt complications were looked for during
the follow up period, even though it was not always feasibledue to high dropout rate.
Complications were generally put as Infectious, mechanical failure and seizure. Mechanical
shunt failure can occur through proximal obstruction, distal obstruction, component
separation/fracture/migration or excessive CSF drainage A ventricular tap was routinely
carried out for majority of patients with infected/ ruptured spinal bifida andif infection is
strongly suspected, CSF analysis was done, Gram stain test and cultures/ sensitivity were also
obtained for those patients who presented with a elevated CSFwhite blood cell(WBC)count and
protein values.
The category post-infectious hydrocephalus(PIH)was used in cases in which one of the
following criteria were met: 1) There was a clear history of meningitis, which was followed by
onset of the hydrocephalus. 2) There was a history of a febrile illness, followed in closely by the
onset of hydrocephalus. 3) Ultrasonography and CT scans demonstrated loculation/septations/
bands in the ventricles. Some of them were labeled as PIH after ETV. Non post-infectious (NPIH)
included cases of congenital hydrocephalus due to aqueductal stenosis, Dandy-Walker
malformation and other congenital malformations, and hydrocephalus associated with tumors.
The Chhabra medium pressure “slit-valve” shunt donated by International Federation of Spina
Bifida was used in the majority and Hakim-Codman and Integra in few cases prophylactic
intravenous ceftriaxone was given preoperatively.
Complications were classified as early: complications occurring between immediate
postoperative period and discharge, Late: Complications in the follow-up period. Outcomes
were graded as good, fair, or poor, according to visual, head circumference, and anterior
fontanelle status, motor, and seizure criteria. Mortality was defined as death from any cause
before discharge or within 30 days of the operation. Data was analyzed using computer-based
software IBM SPSS statistical data editor version 20.0. Independent-samples T test for
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dichotomized variables and one-way ANOVA for multiple comparisons were used. A p- value of
< 0.05 was considered significant and ethical clearance was obtained from MCM.
Results
One hundred thirty-five patients were treated with VP shunt insertion our center. One hundredfourteen patients ≤ 12 years of age treated with VP shunt insertion were included in the current
study, of which 61(53.5%)were male and 46(46.5%) female. A slight male predominance was
observed, in a male: female ratio, 1.2:1, and statistically insignificant (p=0.38). The median age
of patients was 3.0 months and ranged from 1 day to 12 years, majority of the patients were
below 1 year (71.1%) and 83% were below 4 years of age, mean age at shunt insertion being
10.1±18.3 months with range, 0.3-144 months (Table 1). The mean head circumference at
presentation was 50.4 ± 10.1cm (90th percentile) with a range, 34-106 cm. All patients had a
radiologic investigation available before treatment, computed tomography scan results were
available for 59(51.8.%) patients, brain MRI was used in 9(7.9%) patients and brain ultrasound
was method of investigative modality in 36(31.6%)patients (infants with open fontanelle). The
mean time delay from admission to the first VP shunt insertion was 4 ± 5.06 days (range 1-20).
Table 1. Socio-demographic Characteristics of Patients with Hydrocephalus in MCM,
Addis Ababa: 2011 – 2012.
Age (months)
Male (%)
<3.0
28(20.7)
>3-6
8(5.9)
>6-12
15(11.1)
>12-24
3(2.2)
>24-48
3(2.2)
>48-96
2(1.5)
96+
1(0.7)
Total
61(54.1)
Mean=10.12±18.3(range, 0.3-144 months
Median=3.0 months
Female (%)
30(22.2)
6(4.4)
9(6.6)
1(0.7)
5(3.7)
2(1.5)
0(0.0)
53(45.9)
Total (%)
58(43.0)
14(10.4)
24(17.8)
4(2.9)
8(5.9)
4(2.9)
1(0.7)
114(100.0)
Table 2. Percentage of the Various Causes of Patients with Hydrocephalus in MCM,
Addis Ababa: 2011 – 2012.
Age (mos)
≤3.0
3.1-6.0
6.1-9.0
9.1-12.0
12+
Total
SB
31(27.2)
8(7.0)
5(4.4)
2(1.8)
3(2.6)
49(42.9)
CMII
12(10.5)
0(0.0)
0(0.0)
0(0.0)
1(0.7)
14(12.3)
DWM
3(2.6)
0(0.0)
0(0.0)
0(0.0)
5(4.4)
8(7.0)
PIH
8(7.0)
3(2.6)
3(2.6)
5(4.4)
4
23(20.2)
CAS
2(1.8)
2(1.8)
2(1.8)
2(1.8)
2(1.8)
10(8.8
Masses
1(0.7)
1(0.7)
5(4.4)
0(0.0)
3(2.6)
10(8.8)
Total
58(50.9)
14(12.3)
15(13.1)
9(7.9)
18(15.8)
114(100.0)
SB - Spina Bifida, CMII - Chiari Malformation type 2, DWM- Dandy Walker Malformation, PIH post-infectious hydrocephalus, CAS - Congenital aqueductal stenosis.
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Table 3. Distribution of early and late complications among the various age groups of
Hydrocephalicpatients treated with VP shunt insertion in MCM, Addis Ababa: 2011 – 2012
Complications
Early=114
Cardiorespiratory arrests
Aspiration pneumonia
Death
Total
Late, n=112
None
Undershunting
Infection
Overhunting
Seizure
Distal catheter problem
Skin break down
Extrusion via anus
Lost vent catheter
Total
0-6 mos
2(1.8.)
1(0.9)
2(1.8)
5(4.4)
Age Group (%)
6-12 mos
12+ mos
1(0.9)
0(0.0)
1(0.9)
0(0.0)
0(0.0)
0(0.0)
2(0.7)
0(0.0)
Total (%)
3(2.6)
2(1.8)
2(1.8)
7(6.1)
30(26.8)
30(26.8)
3(2.8)
4(3.8)
1(0.7)
1(0.9)
1(0.9)
1(0.9)
1(0.9)
72(54.0)
12(10.5)
6(5.4)
4(3.8)
0(0.0)
1(0.9)
1(0.9)
0(0.0)
0(0.0)
0(0.0)
24(20)
49(43.8)
45(40.2)
8(5.2)
4(3.8)
3(2.8)
2(1.8)
1(0.9)
1(0.9)
1(0.9)
114(100.0)
7(6.2)
9(8.0)
1(0.9)
0(0.0)
1(0.9)
0(0.0)
0(0.0)
0(0.0)
0(0.0)
18(25.9)
Figure 1. Typical patient in this series with severe
Macrocephaly (HC, 63cm) and sunsetting of the eyes.
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Table 4. Condition on discharge and outcome at 6 months of Hydrocephalus
Patients treated with VP shunt insertion, Addis Ababa: 2011 – 2012
Condition
Improved
Same
Deteriorated
Death
Total
Outcome
Good
Fair
Poor
Total
Frequency
101
9
2
2
114
Percentage
88.6
7.9
1.8
1.8
100.0
53
6
1
60
46.5
5.3
0.9
52.6
Figure 2. Pie chart showing the Various Aetiologies in 114 Patients with Hydrocephalus.
SB=spina bifida, DWM= dandy walker malformation.
The causes of hydrocephalus identified in 114 patients include spina bifida, Chiari and Dandy
walker malformation, and post infectious, congenital aqueductal stenosis, brain tumors. Spina
bifida was significant cause of hydrocephalus in 42.3% patients (p=0.001) followed by post
infection and Chiari malformation II in 20.2% and 12.3 %respectively (figure 1 and Table 2).
Communicating type of hydrocephalus was seen in 34 patients (29.8%) and 80patients (70.2%)
had non-communicating type of hydrocephalus
The ventricular insertion site was frontal in 70 patients (61.4%), parietal in 9 patients (7.9%)
and occipital in 35 patients (30.7%). Three types of shunts were used Chhabra, Codman and
Integra. Most patient 107(93.9%) received Chhabra shunts. In 114 patients with hydrocephalus,
141 VP shunt insertion procedures were done, 93(81.6%) were primary VP shunt insertions, 17
(14.9%) were revised once, 3 (3.5%) twice; and one patient had four revisions.
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The surgery for VP shunt insertion went smoothly for 105 patients (92.1%). Four intraoperative
complications were noted, such as bleeding and cardiorespiratory arrest and early
postoperative complications including death were recorded in 5(4.4%) patients
(Table 3).
Early complications following surgery were seen in 65(57.0%) patients. The commonest
complication was mechanical failure in 54(48.2%) patients, under shunting constituted 83.3%
(45/54) of the mechanical shunt failure and 40% of the overall complications, 38/65 (58.5%)
and 30/65(46.2%) of the under shunting occurred in the age group 0-6 months. Rare
complications like extrusion via anus and lost ventricular catheter were seen in one patient each
(figure 2). Shunt infection was demonstrated in only 7 patients (6.1%). The in-hospital mortality
was recorded in 2(1.8%) patients. On discharge, 97/112 patients (86.6%) improved clinically
and 9 patients (8.9%) were in the same condition, 2(1.8%) deteriorated.
All patients had 100% follow-up on their first visit within the first one-month after discharge,
89/112 patients (79.5%) had follow-up for the first 3 months, 87/112(53.4%) for 6 months,
mean duration of follow-up was 6.8 ± 7.2(range 1-36 months). The follow-up rate at one year
was 17.5%.
The shunt function rate at 6 months was good in 53/60 (88.3%) patients, because these patients
had normal vision, motor activity, and decrement in head circumference, soft fontanelle and no
seizures. Patients with a head circumference greater than 50 cm had significant early
complication compared to those with ≤ 50 cm after VP shunt insertion (p=0.028).No significant
age difference was noted between patients with complication and without complication
(p=0.7);age was not also significantly correlated to the early outcome (p=0.76).Sex was
insignificantly correlated to the occurrence of complications (p=0.32) and so was outcome
(P=0.22).
Figure 3. Extrusion of Peritoneal Catheter through Anus in 1-year-old Female Patient
Discussion
The mean and median age of patients at shunt insertion was 10.1±18.3 (range 0.3-144 months)
and 3.0 months respectively,71.1% of the patients were below 1 year and 83% were below 4
years of age, this agrees well with Warf (2005), and Gathura et. al (2010) who reported mean
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age of 13.3 months, 88% 1 year or younger and median age 3.3 months,84.6% of the children
were younger than 1 year old repectively2,3,7.
Fifty-four percent of the patients were male in our study, which is consistent with a previously
reported male preponderance in hydrocephalus3,8,9. Gathura et. al, reported that female patients
are more likely to develop infectious complications, but our results showed no significant
relationship between sex and complications. This relationship has not been previously
documented as well9-11.
Imaging modalities such as CT and MRI are done in 65.1%, which makes accurate diagnosis
possible and better compared to studies conducted in East Africa2,3. This might have contributed
to a lesser mortality rate as compared to these studies. But cranial ultrasonography (US) is also
an essential diagnostic tool in developing countries; it can readily assess ventricular size and it
is relatively inexpensive2.
The causes of hydrocephalus in the developed countries are intraventricular hemorrhage and
congenital hydrocephalus. Most studies in developing countries report infection as a cause of
hydrocephalus2, 12. In this study most cases are associated with spina bifida (49.7%) similar to a
study done in Kenya 3. This finding is strongly associated with rampant malnutrition in women
of childbearing age. These women are also prone in developing folate deficiency, which is highly
associated with increased occurrence of neural tube defects.
The most common surgical intervention to treat hydrocephalus is the insertion of a VP shunt
and yet, VP shunts are associated with a high rate of complications all over the world, with
failure rates reaching up to 40% within the 1st year of insertion. In this study, the over all early
complication rate was 57.0% and is higher than the rate reported in studies done from Africa,
Malaysia, Canada and Europe3-7, 13,17-22. High complication rate compared to not only Western
literature but also Sub-Saharan Africa could be explained as follows, our patients present with
severe malnutrition, advanced disease, poor skin integrity. Delay in surgical intervention, and
generally physical debilitation is also routinely seen in our patients2, 3,7. The infection rate was
7% and is comparable to the rate in the developed nations, which is reported to be 2 - 9%.
3,11,14Young age has previously been identified as a major risk factor for shunt infection, and our
infection rate of 7% is in line with published results for infants.15, 16,24 An overall infection rate of
5 to 10% without regard to risk factors is considered acceptable, and commonly reported in the
literature15.
At MCM, common techniques to avoid shunt infection include the use of generous skin
preparation, meticulous and consistent surgical technique, improving intraoperative factors like
double gloving, Ioban dressing of the operative site, flushing the shunt with gentamycin and the
avoidance of shunt-to-skin contact and preoperative prophylactic antibiotics2, 3,16,23,25
The other important complication is mechanical failure seen in 47.4%, higher than a multicenter
study from Canada which reported 40% mechanical failure17 and most reports2,3. In general high
rate of mechanical failure could be due to the limited experience of the surgeon doing the
procedure and the number of shunt procedures done at the center.16 Hence, considering these
complications endoscopic third ventriculostomy presents a plausible option in the management
of hydrocephalus2.
The overall surgical mortality rate in this study is 1.8%, it is lower than reported in Sub-Saharan
studies such as Kenya (6%)3 and Uganda (5.3%). 2,7 Although the true figure was probably
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higher considering the likelihood of death in patients lost to follow-up.3Eventhough, survival
and long-term mortality rates are not included in this review because extremely low one-year
follow-up rate (17.5%), our results would have been not far from reports documented in most
African counties. A recent study from Zimbabwe revealed a medium-term survival (over 2
years) of only 33%–47% of patients18, and one-year mortality rate of 16% by Warf 7. Unlike to
the report by Gathura et al3. Age and sex were not significantly correlated to the occurrence of
early complication, less complications rates were observed in patients with head circumference
≤ 50 cm compared to > 50 cm., this is in agreement with study conducted in East Africa 2,3.
Shunt function rate of 88.3% at mean follow-up period of 6.8 months is higher than reported by
Gathura et al3 and others who reported shunt function rate of 65% at 2 years. It is too early to
compare ours to most studies with relatively longer period of follow-up duration2. This study
only dealt with short-term outcomes, which makes it difficult to reach to shunt failure rates in
our set up. Long-term follow up requires a few years of data collection and acceptable follow-up
rates. There was a high dropout rate from follow up in this study, which introduces bias on the
overall outcome and mortality rates.
Our definition of “good outcome” as the absence of seizures, motor difficulties, or visual
problems, decrement in head circumference, soft fontanelle is at best an assumption, since
intellectual development and QOL include multiple other unmeasured factors. Our follow-up
was short and middle term.
Conclusion
In a developing country such s Ethiopia, clinical symptoms and signs and cranial ultrasound are
sufficient for the diagnosis and management of children with hydrocephalus. Spina bifida was
main etiological cause of hydrocephalus in our setting.
Our study done in a resource-limited African setting has documented good outcomes at 6
months follow-up period for VP shunt insertion with acceptable early complication rates.
However, children with a head circumference greater than 50 cm had significant early
complication.
Recommendation
The association of neural tube defects with hydrocephalus also mandates their prevention.
Advocacy of all stakeholders for food fortification with folate is highly recommended.
Alternative methods of treatment like ETV need to be strengthened in the training of residents
who are major players in the treatment of children with hydrocephalus.
Given the significant complication rates of VP shunts, ETV presents an attractive option in the
management of hydrocephalus. Shunts, on the other hand are widely available and effective in
the management of hydrocephalus. Considering the availability of reasonably priced or even
fully subsidized VP shunts, and use of ETV is limited by expensive equipment and a paucity of
available expertise, shunts will continue to play a pivotal role in the management of
hydrocephalus in Ethiopia.
Acknowledgments
The authors thank the International Federation of Spina Bifida for their generous Chhabra
shunts donation and MCM for allowing us to conduct this study.
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References
1. Garton, H and Piatt, J. “Hydrocephalus” J Pediatric Clinics N.A. 51:305-325, 2004
2. Warf BC: Hydrocephalus in Uganda: the predominance of infectious origin and primary
management with endoscopic third ventriculostomy. J Neurosurg102 (1 Suppl): 1–15,
2005.
3. Gathura E, Poenaru D, Bransford R: Outcomes of ventriculoperitoneal shunt insertion in
Sub-Saharan Africa. J Neurosurg Ped 6: 329-335, 2010
4. Sainte-Rose C, Piatt JH, Renier D, Pierre-Kahn A, Hirsch JF, Hoffman HJ, et al. Mechanical
complications in shunts. Pediatr Neurosurg 1991-92; 17:2-9.
5. Kaufman BA. Management of complications of shunting. Paediatr Neurosurg 2001;
44:529-47.
6. Ahmed A, Sandlas G, Kothari P, Sarda D, Gupta A, Karkera P, Joshi P. Outcome analysis of
shunt surgery in hydrocephalus. J Indian Assoc Pediatr Surg 2009; 14,3: 98-101
7. Warf BC, Comparison of 1-year outcomes for the Chhabra and Codman-Hakim Micro
Precision shunt systems in Uganda: a prospective study in 195 children. J Neurosurg
(Pediatrics 4) 102:358-362,2005.
8. Adeloye A: Management of infantile hydrocephalus in Central Africa. Trop Doct 31:67–
70, 2001
9. Dallacasa P, Dappozzo A, Galassi E, Sandri F, Cocchi G, Masi M: Cerebrospinal fluid shunt
infections in infants. Childs Nerv Syst 11:643–649, 1995
10. Davis SE, Levy ML, McComb JG, Masri-Lavine L: Does age or other factors influence the
incidence of ventriculoperitoneal shunt infections? Pediatr Neurosurg 30:253–257,
1999
11. Piatt JH Jr, Carlson CV: A search for determinants of cerebrospinal fluid shunt survival:
retrospective analysis of a 14-year institutional experience. Pediatr Neurosurg 19:233–
242, 1993
12. Abdullah J, Naing NN: Hydrocephalic children presenting to a Malaysian communitybased university hospital over an 8-year period. Padiatr Neurosurg34: 13–19, 2001.
13. Heij HA: The fate of ventriculoperitoneal shunts and outcome of revision surgery. East
Central Afr J Surg 5:17–19, 2000
14. Crnich CJ, Safdar N, Maki DG: Infections associated wiimplanted medical devices, in
Finch RG, Greenwood D, Norby SR, et al (eds): Antibiotic and Chemotherapy: Ant
Infective Agents and Their Use in Therapy, ed 8. London Churchill Livingstone, 2003, pp.
575–618
15. Haines SJ: Shunt infections, in Albright AL, Pollack IF, Adel- son PD (eds): Principles and
Practice of Pediatric Neurosurgery. New York: Thieme, 1999, pp. 91–106
16. Cochrane DD, Kestle JRW: The influence of surgical operative experience on the duration
of first ventriculoperitoneal shunt function and infection. Pediatr Neurosurg38: 295–
301, 2003
17. Drake JM, Kestle JRW, Tuli S: CSF shunts 50 years on—past, present and future. Childs
Nerv Syst 16:800–804, 2000
18. Laurence FL: Treatment of hydrocephalus. East Central Afr J Surg 11:78–80, 2006.
(Abstract).
19. Kinasha ADA, Kahamba JF, Semali IT: Complications of ventriculoperitoneal shunts in
children in Dar es Salaam. East Central Afr J Surg 10:55–59, 2005
20. Komolafe EO, Adeolu AA, Komolafe MA: Treatment of cerebrospinal fluid shunting
complications in a Nigerian neurosurgery programme. Case illustrations and review.
Pediatr Neurosurg 44:36–42,2008
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21. Lima MM, Pereira CU, Silva AM: [Ventriculoperitoneal shun infections in children and
adolescents with hydrocephalus. Arq Neuropsiquiatr 65:118–123, 2007 (Portuguese)
22. Mwang’ombe NJM, Omulo T: Ventriculoperitoneal shunt surgery and shunt infections in
children with non-tumour hydrocephalus at the Kenyatta National Hospital, Nairobi.
East Afr Med J 77:386–390,2000.
23. Faillace WJ. “A No-Touch Technique protocol to diminish cerebrospinal fluid shunt
infection.” Surg Neurol 43:344-50, 1995.
24. Pople IK, Bayston R, Hayward RD: Infection of cerebrospinal fluid shunts in infants: a
study of etiological factors. J Neurosurg 77:29–36, 1992.
25. Haines SJ, Walters BC. “Antibiotic prophylaxis for cerebrospinal fluid shunts: a
metanalysis.” Neurosurgery. 34(1): 89-92, 1994
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Laparoscopic Surgery in a Governmental Teaching Hospital: An Initial Experience from
Ayder Referral Hospital in Northern Ethiopia
R. Esayas1, A. Shumey2, K. G Selassie1
1Mekelle University, College of Health Sciences, School of Medicine, Ayder Referral Hospital
2Mekelle University, College of Health Sciences, School of Public Health, Ayder Referal Hospital
Correspondence to: Dr. Reiye Esayas, Email: reiyeesayas@gmail.com
Background: Laparoscopic surgery has long been practiced in western countries, but the
practice is relatively new in Ethiopia. Documented practices of laparoscopic surgery in
public hospitals are, to the best of our knowledge, nonexistent in Ethiopia. The objective of
our study is to give an account on the practice of laparoscopic surgery in a resource limited
setting in Ethiopia.
Methods: A retrospective cross-sectional study was done. Records of 100 patients who
underwent laparoscopic abdominal surgery from January 2013 to February 2014 were
included in the study. Parameters like the type and duration of surgery, the operating and
assisting surgeon, postoperative hospital stay and early postoperative complications were
evaluated. A pretested designed questionnaire was used to obtain data.
Results: Of the 100 procedures 73 were cholecystectomy, 12 were appendectomies, five
were diagnostic laparoscopies, and four were hernia repairs. There were also two
drainages, two orchidectomies, one perforated PUD repair and one salphigoopherectomy.
Male: Female ratio was 1:1.6. There was no conversion, but 20% of them were difficult.
There were two trocar site infections. Ninety two percent of the surgeries were done by
local surgeons.
Conclusion and Recommendation: Laparoscopic surgery is feasible in resource-limited
areas like Ethiopia. We suggest that it should be expanded to the other hospitals with shortterm surgeon trainings.
Key words: laparoscopic surgery, resource-limited areas, government hospitals
Introduction
The laparoscopic approach is a technique used in abdominal surgery by gaining minimal access
into the abdomen to achieve the same surgical result as an open laparotomy. This type of
surgery is also referred to as minimal access surgery and is a procedure evolving in the surgical
field1-2. Advanced and radical surgeries which once were believed to be hard to be done with
open surgery are now being operated laparoscopically in many centers with better outcome 3.
Studies revealed that laparoscopic surgery has advantages over conventional open surgeries. To
mention some of the advantages; there is less pain after laparoscopic surgery, resuming early
normal day to day activity after surgery, and reducing tissue damage 4-6 . But it has also its own
shortcomings like high running cost due to expensive consumables and the need for additional
training required to perform successful laparoscopic procedures because the traditional
surgical dictum 'see one, do one, teach one' doesn't apply for laparoscopy7-9.
One of the most exciting aspect of laparoscopic surgery is the day-to-day discovery and
introduction of materials which are supposed to "make life easy" but their exorbitant cost and
the need for high investment to establish the service and for the disposable materials used
during the surgery makes it less practical in developing countries10 . In Sub Saharan Africa, for
example, there are only few places where laparoscopic surgery is well established, though many
newer centers are also emerging despite all the challenges11-12. In Ethiopia, there are only few
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private hospitals, in the Capital city Addis Ababa, which are practicing laparascopic Surgery
regularly13.
In fact, these challenges like the sky-high costs, may be decreased by using reusable instruments
and improvised equipment while maintaining good results11. Most of the complications can be
prevented by proper training of surgeons on their skill and by identifying high risk patients
preoperatively14.
The aim of this study is to describe the outcomes of laparoscopic surgery done in a
governmental hospital, with limited resource, in Ethiopia 780 Km away from Addis Ababa.
Patients and Methods
The study was conducted in Ayder Referral Hospital which is located 780 km North of Addis
Ababa, the capital city of Ethiopia. Ayder Hospital commenced rendering its referral and
specialized medical services in 2008 to a nearly 8 million population in its catchment areas. It
stands as the second largest hospital in the nation with total capacity of about 500 inpatient
beds in four major departments and other specialty units. It is also used as a teaching hospital
for the College of Health Sciences, Mekelle University. Currently, there are three surgeons doing
the laparoscopic surgery. It started giving laparoscopic service in January 2013.
A retrospective cross-sectional study design was done. The records of all 100 consecutive
patients who underwent laparoscopic abdominal surgery from January 2013 to February 2014
were evaluated. The data were collected using a checklist. Completeness and accuracy of data
were checked every day by the principal investigator. Data were cleared, entered and processed
using Epi Info Version 3.5.1 and analyzed through SPSS version 20. Frequency distribution and
proportions were used to describe the data. Tables were used to present the result. The study
was conducted after getting a full approval from Mekelle University, College of Health Sciences
Ethical Review Committee. Patient confidentiality was respected.
Results
The medical records of 100 consecutive patients who had undergone a range of laparoscopic
surgical procedures within a fourteen month period was reviewed. Sixty-two of the patients
(62%) were females with male to female ratio of 1:1.6.. The median age of the patients was 38.0
years with Inter-Quartile Range (IQR) being 18.75 (28, 46.75).
We used locally made reusable drapes, gowns, ports, and camera cases. The working
instruments were re-used after sterilization. The tower we had was an ordinary Storz with
single chip camera unit and a non HD screen. We had to bring CO2 from the main city (780kms
away). One surgeon took a short-term training initially started the procedure. The other
surgeons got local training with the help of visiting surgeons from abroad.
Seventy-three (73%), patients had a laparoscopic cholecystectomy; twelve (12%) patients had a
laparoscopic appendectomy for acute appendicitis. In three of the five diagnostic laparoscopies,
biopsies were taken. Four hernia repairs were done: two were the Trans-Abdominal PrePeritoneal (TAPP) and the remaining two were Totally Extraperitonial (TEP) repairs. Drainage
of liver abscess was done in two patients while there were two unilateral orchidectomies for
undescended testis. One patch repair of perforated PUD repair and one salphingoopherectomy
for torsion of the ovary was performed. The complication rate was five percent. Ninety two
(92%) of the surgeries were done by local staff surgeons, while 8 of them were done by guest
surgeons. Seventy four (74%), of the procedures was performed by a surgeon who had a formal
short term training in laparoscopic surgery. (Table 2).
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Table 1. Types of the laparoscopic procedures performed among the 100 patients.
Types of procedure
Cholecystectomy
Appendectomy
Diagnostic laparoscopy
Hernia repair
Liver abscess drainage
Orchidectomy
Perforated PUD repair
Salphingoopherectomy
Number
73
12
5
4
2
2
1
1
Table 2: Number of laparoscopic procedures done by different surgeons among 100 patients in
Ayder referral Hospital from January 2013 to February 2014
Operation Done by
Guest Surgeon
Formally Trained staff surgeon
Staff surgeon with informal training
Total
Number of Operations done
8
74
18
100
Table 3: Materials used to secure ligation in the laparoscopic procedures done among 100
patients in Ayder referral Hospital from January 2013 to February 2014
Materials used to secure
Type of operation
ligation
Cholecystectomy Appendictomy
Hernia
repair
Staples
68
2
0
Extracorporal suture
5
9
0
Intracorporal suture
0
1
2
None
0
0
2
Total
73
12
4
Others
0
1
4
6
11
Residents, local surgeons, scrub nurses, and surgeons from abroad assisted 38%, 32%, 18% and
12% of the procedures, respectively. In 94 % of cases, there was a need for ligation and we used
staples in 70% of the cases, and extracorporal and intracorporal ligation in 15% and seven
percent of the cases respectively, and electrocoagulation in two percent of them.(Table 3). In 20
of the cases the procedure was difficult. The causes of the difficulties were adhesion, stone
impacted at the neck, acutely inflamed gallbladder with edematous surrounding, bleeding from
an aberrant cystic artery, and/or lack of proper instruments. The complications were tackled
laparoscopically and there was no conversion to open laparotomy.
Operation time ranged from 20 minutes to 120 minutes, depending on the type of procedure
with the median time of 45.0 minutes. While post-operation hospital stay ranged from one to
twelve days with a median of 2 days.(Table 4)
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Table 4: Average Time Spent for the Operation and Post operative Stay.
Variables
Average
time spent
for
the
operation
Post
operation
stays
<=30
minutes
31-60min
>60 minutes
<=3 days
4-6 days
>6 days
Operation type
Cholecystectomy Appendictomy
Hernia
repair
6
2
0
53
14
61
6
6
9
1
7
3
2
0
4
4
0
0
Others
3
7
1
9
2
0
After discharge, patients were seen for at least three visits: on the 5th- 7th day, one week after,
and then one month later. During the early post-operative period, there were only five
complications; two trocar site infection, two prolonged epigastric trocar site pain and postoperative fluid collection. The first trocar site infections were on the right most lateral port and
the umbilical port. They were empirically treated and responded to broad-spectrum antibiotics.
The prolonged epigatric trocar site pain, i.e. for a month post-operative, was managed by oral
analgesics. The fifth patient had an abdominal pain on the 2nd post op day with tenderness on
examination; ultrasound showed moderate amount of fluid collection more on the right
subdiaphragmatic and subhepatic space. With the impression of bile leak diagnostic
laparoscopy was done, there was only bile stained saline but no biliary leak from the cystic duct
stump or the liver bed. Fluid was sucked, and patient was followed in the ward, discharged
improved.
Discussion
Currently laparoscopic surgery is not widely introduced in Ethiopia except in private hospitals,
mainly in the capital city Addis Ababa. Prior to this study, there was only one report on
laparoscopic cholecystectomy in a private hospital, but none from a public hospital13.
The service was not widely practiced in public hospitals mainly due to the huge initial
investment needed for its implementation. In addition, most developing countries focus more
on funding the preventive medicine than spending on such technologies in tertiary hospitals.
Despite this, some developing countries manage to expand minimal access surgery through
‘local adaptation and improvisation.15
The fact that we used re-usable instruments instead of disposable has reduced the cost
significantly. Studies also show that re-usables are better because they are cost effective and
environmental friendly16,17. The cost of surgery for open and laparoscopy was the same , which
was 50 Ethipian Birr (2.5 USD ) as the service was new and we wanted to create awareness
about the advantages of laparoscopic surgery. Although it was difficult and beyond the scope of
this paper to deduct the total cost breakdown of the procedure, the average expense of a patient
for uncomplicated laparoscopic cholecystectomy or appendectomy ranged from 800 to 1100
Ethiopian birr (40 -55 USD). This is including all the consumables and hospital stay fee.
The other factor why minimal access surgery is not widely practiced in developing countries is
the lack of skill and negative attitude of general surgeons towards laparoscopic surgery. It was,
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however, possible to manage it with only short-term training of general surgeons and the
outcome was comparable.
Like many other studies, the most common procedure done was laparoscopic cholecystectomy.
It could be due to the lesser learning curve needed to do it compared to other advanced
procedures18. The second common procedure done was an appendectomy (12% of all the
cases). We need to do the procedure in particular cases when there is a diagnosis uncertainty or
when the patient is overweight19. Though the number of our cases is limited, the variety of the
procedures is a witness that even in places like ours laparoscopy can be utilized in diversified
surgical conditions.
As our hospital is a teaching center, most of the surgeries (38%) were assisted by surgical
residents and 18% of them by scrub nurses. This creates the advantage of exposing the resident
to laparoscopic surgery. It also adds to the fact that there is a need for an intensive and frequent
training of scrub nurses. Though we used staples for most of the laparoscopic
cholecystectomies, we had to use extracorporal and intracorporal suturing in some (22%) of the
cases when we ran out of staples. These techniques are mandatory for set ups like ours where
we don’t get consumables timely.
Adhesion was the commonest cause of difficulty (20%) which is similar to some studies from
Africa. The outcome of our procedures is promising. There was no conversion unlike the other
reports from Africa13,20,21. Operation time ranged from 20 minutes to 120 minutes with the
median time being 45.0 minutes. While post operation hospital stay ranges from one to twelve
days with a median of two days. This is comparable with a previous study done in Ethiopia
though it was done only for laparoscopic cholecystectomy13. During the early postoperative
period, there were two trocar site infections and one post operative collection which was
reoperated and the finding was reactive fluid. There was no mortality. It is difficult to compare
our results with the previous Ethiopian study as the duration and number of our cases is
relatively small. But compared to other African studies, still the complication rate is much
smaller20.
Conclusion and recommendation
Though it doesn’t significantly advance knowledge to the field of minimal access surgery, our
results show that abdominal laparoscopic surgery is feasible in resource-limited areas like ours
once the basic infrastructure is established. The continuity of the service can be realized by
“adaptation and improvisation” without compromising the proved advantage of laparoscopic
surgery to our patients. We suggest that it should be expanded to the other hospitals with
short-term hands- on trainings for surgeons and the operation theatre staff. Though the number
of cases in this review does not allow us to draw a conclusion based on statistical significance,
our findings can serve as a witness and encouragement for most surgeons working in setup like
ours to strive for realization of abdominal laparoscopic surgery. Besides it can serve as a
baseline data for future studies.
References
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2. Cuschieri A. Laparoscopic surgery: current status, issues and further developments.
Surgeon, 2005:3(3):125-133.
3. Abdelshafy, M. Hand-Assisted Laparoscopic Live-Donor Nephrectomy (HALDN)
improves outcomes and Results in Increased Kidney Donation. African Journal of
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4. Bhattacharya KK.. Ethical considerations in laparoscopic surgery. Indian Journal of
Medical Ethics, 2004; 1(1):22-23.
5. Kikuchi I et al. Questionnaire analysis of recovery of activities of daily living after
laparoscopic surgery. Journal of Minimally invasive Gynaecology, 2008; 15(1):16-19.
6. Baraza, R. Laparoscopic cholecystectomy at the Nairobi hospital. Medical Journal, 2005;
82(9):473-476.
7. Apostolou, C & Panieri, E. National surveys of surgeons attitudes to laparoscopic training
in South Africa. South African Journal of Surgery, 2007; 45(3):86-90
8. Satava, RM. Emerging technologies for surgery in the 21st century. Archives of Surgery
134(11):1197-1202.
9. Zendejas B et al. State of the Evidence on Simulation-Based Training for Laparoscopic
Surgery:A Systematic Review. Ann Surg 2013; 257: 586–593.
10. Bittner, R. Laparoscopic surgery today. The British Journal of Surgery, 2006;
93(11):1433
11. Ray-Offor E et al. Pilot study on laparoscopic surgery in Port-Harcourt, Nigeria. Niger J
Surg 2014; 20:23-5.
12. Parkar RB et al. Experience with laparoscopic surgery at the Aga Khan Hospital, Nairobi.
East Afr Med J. 2003 Jan;80(1):44-50.
13. Bekele S, Biluts H. Laparascopic cholecstectomy at Myungsung Christian Medical
Center, Ethiopia: a five-years experience. Ethiop Med J. 2012 Jul; 50(3):251-7.
14. Wolf AS et al. Surgical outcomes of open cholecystectomy in the laparoscopic era. Am J
Surg. 2009 Jun; 197(6):781-4.
15. Adisa AO, Arowolo OA, Salako AA, Lawal OO. Preliminary experience with laparoscopic
surgery in Ile-Ife, Nigeria. African Journal of Medicine and Medical Sciences. 2009; 38:
351–356.
16. Schaer GN, Koechli OR, Haller U. Single-use versus reusable laparoscopic surgical
instruments: a cost analysis. Am J Obstet Gynecol 1995; 173: 1812– 1815.
17. Adler S, Scherrer M, Ru¨ ckauer K. D, Daschner F. D. Comparison of economic and
environmental impacts between disposable and reusable instruments used for
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18. Adisa AO et al. An audit of laparoscopic surgeries in Ile-Ife, Nigeria. West Afr J Med. 2011
Jul-Aug; 30(4):273-6.
19. Cothren CC et al. Can we afford to do laparoscopic appendectomy in an academic
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Early Outcome of Mitral Valve Replacement: Results from Chordal Preservation at
Muhimbili National Hospital, Tanzania
1
1
1
1
2
3
E.V. Ussiri , W.B.C. Wandwi , E.T.M. Nyawawa , B.J. Nyangassa , B.A. Kamala , N. Satyaki ,
4
W. Mahalu
1Muhimbili National Hospital, Dar es Salaam, Tanzania. 2Hubert Kairuki Memorial University,
Dar es Salaam – Tanzania. 3Apollo Hospital, Bangalore – India. 4Bugando College of Health
Sciences, Mwanza - Tanzania
Correspondence to: Dr Ussiri, E-mail: eussiri@yahoo.com
Background: Mitral Valve Replacement (MVR) is a common procedure for chronic
Rheumatic Heart Disease (RHD) in developing countries. MVR may involve excision of
chordae tendinae with leaflet(s) depending on the extent of pathology. Follow up of these
patients reveals a progressive Left Ventricle (LV) dilatation, LV dysfunction and low cardiac
output syndrome which has been attributed to the loss of annulo-ventricular continuity.
Many studies revealed that, preservation of chordae tendinae has a significant role in
maintaining post –operative normal LV size and function. The main objective of this study
was to determine early outcome of mitral valve replacement among patients operated for
Mitral Valve Replacement (MVR) with regards to chordal preservation at Muhimbili
National Hospital
Patients and Methods: All patients admitted in the Cardiothoracic Unit, Muhimbili National
Hospital for Mitral Valve Replacement from November 2011 to November 2013. Detailed
echo was done pre-and post- operatively and New York Heart Association class (NYHA)
assessment were recorded. Intra-operative valve assessment was done and categorized
into; Total Chordal Excision (TCE), Posterior Mitral Leaflet (PML) preservation or Total
Chordal Preservation (TCP). Patients were followed up at one month for control echo and
NYHA assessment
Results: A total of 59 patients were recruited, male accounting for 31.7% and female 68.3%
with age ranging from 10 years to 58 years. Indications for surgery were; severe mitral
valve stenosis (MS)-33.2%, severe mitral valve regurgitation (MR)-35.6% and severe mixed
mitral valve disease (MMVD)-32.2%. Among all patients, 45.8% had calcified leaflet(s) and
30.55% had atrial fibrillation. TCE was done in 22 patients (37.3%), PML in 21 patients
(35.6%) and TCP in 16 patients (27.1%). There was a significant increase in End Diastolic
Volume (EDV) and End Systolic Volume (ESV) with decrease in Ejection Fraction (EF) postoperatively in the TCE group (p=0.024, 0.001 and 0.000 respectively), a significant decrease
in EDV and ESV in PML preservation (p=0.001 and 0.002 respectively), increase in EF
(p=0.004) and a significant decrease in EDV in TCP group (p=0.008), increase in EF
(p=0.016).
Conclusion and Recommendation
Chordal Preservation in chronic rheumatic Mitral Valve Replacement is encouraged
Chordal Preservation plays a significant role in the reduction of Left Ventricular
volumes and improvement in ventricular function
A larger scale study with longer follow up is required
Key Words: Mitral Valve Replacement, Chordal Preservation, Early Outcome
Introduction
Mitral Valve Replacement is a common procedure for chronic Rheumatic Heart Disease (RHD)
in developing countries. The commonest indications includes; severe Mitral Valve Stenosis,
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severe Mitral Valve Regurgitation and severe mixed Mitral Valve Disease. 1,2,3 Mitral Valve
Replacement may involve excision or sparing of chordae tendinae with the accompanying
leaflet(s) depending on the extent and severity of the pathology Follow up of these patients
reveals a progressive Left Ventricle (LV) dilatation, LV dysfunction and low cardiac output
syndrome which has been attributed to the loss of annulo-ventricular continuity 4,5,6,7.
Many studies revealed that, preservation of chordae tendinae has a significant role in
maintaining post-operative normal LV function despite whether partial or complete
preservation 4,5,6,7. There are many techniques used in chordal preservation but, no one is
superior to the other ones in terms of their outcome and therefore, Surgeon’s choice5,8. The
prospective study was done to evaluate early Left Ventricular functions and NYHA class
following Mitral Valve Replacement at Muhimbili National Hospital, MNH.
Patients and Methods
A prospective study was done for two years from November 2011 to November 2013 to analyze
59 patients, 19 males and 40 females admitted for MVR in the Cardiothoracic Unit at MNH
following Cardiac Panel. Both sexes and all age groups were included. Informed consent was
obtained from all patients. Detailed pre-operative echo findings were recorded including Left
Atrial (LA) diameter, left ventricular diastolic diameter (LVDD), left ventricular systolic
diameter (LVSD), end diastolic volume (EDV), end systolic volume (ESV), pulmonary
hypertension (PHT) and ejection fraction (EF). Pre-operative NYHA class was recorded and
cardiac profile work-up was completed.
Surgical Technique
Standard Cardio-Pulmonary By-Pass (CPB) with cold blood cardioplegia and moderate
hypothermia was used.
Mitral Valve was approached through the left atrium and assessment was done to determine
type of chordal preservation as follows;
•
•
•
•
Total Chordal Excision (TCE) – whole valve was fibrotic, stenotic and fixed with
calcifications extending to the chorda tendinae and papillary muscles
Posterior Mitral Leaflet (PML) preservation – posterior mitral leaflet is thickened,
fibrotic and fixed but, not calcified
Total Chordal Preservation (TCP) – both leaflets are mobile but, thickened edges,
retracted and nodular, not possible for repair
Finally, standard Mitral Valve Replacement and weaning from CPB was completed. Left
atrial appendage was ligated for 18 patients who had atrial fibrillation, All 100 patients
were followed up after one from discharge. Postoperative echo and YHA class were
recorged. Data was analyzed using SPSS 22 program. Exclusion criteria included all
patients who underwent double valve replacement, all patients with incomplete echo
reports and those who died one month before surgery.
Results
A total of 59 patients (100%) were recruited in this study. Male patients accounted for 31.7%
and female 68.3% with age ranging from 10 years to 58 years. Majority of patients (81.7%)
were below 40 years of age (Table 1). Ten patients were excluded; 3 had double valve
replacement, two died within 24 hours of operation due to low cardiac output syndrome despite
high dose inotropic support and 5 had incomplete echo report.
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All patients (100%) operated for mitral valve replacement had echocardiographic features of
severe chronic rheumatic heart disease presenting with severe mitral valve stenosis (33.2%),
severe mitral valve regurgitation (35.6%) and mixed mitral valve disease (32.2%) with NYHA
IV. Among all patients, 45.8% had calcified valve and 30.5% had atrial fibrillation. Considering
type of procedure done, Total Chordal Excision accounted for 37.3% due to severe fibrosis and
calcification, Posterior Mitral Leaflet preservation were 35.6% and Total Chordal Preservation
were 27.1% (Table 2, Fig 1). All these patients present with severe symptoms, NYHA class IV .
There was no significant difference between the indication of operation and type of operation
done, p = 0.605 (Table 3)
Table 1 Background characteristic of patient
Age group(yrs)
10 -19
20 -29
30 -39
40+
Total
Sex
Male
Female
Total
Number
19
13
16
11
59
(%)
33.3
21.7
26.7
18.3
100
19
40
59
31.7
68.3
100
Table 2. Proportion for Indication, Calcification, Atrial Fibrillation and Type of operation
Number
(%)
Indication
Severe MS
Severe MR
Severe MMVD
Total
19
21
19
59
32.2
35.6
32.2
100
Calcification
Yes
No
27
32
45.8
54.2
Atrial Fibrillation
Yes
No
18
41
30.5
69.5
Type of Operation
TCE
PML
TCP
Total
22
21
16
59
37.3
35.6
27.1
100
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Table 3. Indication versus Type of Operation
Indication/Type Total Chordal
Excision (%)
Severe MS
11 (55.0)
Severe MR
6 (30.0)
Severe MMVD
5 (26.3)
Total
22 (37.3)
p = 0.605
PML
Preservation (%)
3 (15.0)
8 (40.0)
10 (52.6)
21 (35.6)
Total Chordal
Preservation (%)
6 (30.0)
6 (30.0)
4 (21.1)
16 (27.1)
Total
20 (100)
20 (100)
19 (100)
59 (100)
70
70
54
60
46
Percentage
50
40
32
36
37
32
36
31
27
30
20
10
Indication
Calcification
Atrial
Fibrillation
Total Chordal Preservation
PML Preserved
Total Chordal Excision
Abscent
Present
Abscent
Present
Mixed Mitral Valve Disease
Severe MR
Severe MS
0
Type of
Operation
Figure1. Proportion of Indication, Calcification, Atrial Fibrillation and Type of Operation
Current study showed a significant decrease in the mean overall diameter of left atrium from
6.2cm, std=1.4 to 4.7cm, std=1.0 (p=0.000), left ventricle diastolic diameter from 5.2cm, std=1.1
to 4.4cm, std 0.9 (p=0.000), left ventricle systolic diameter from 3.5cm std=0.9 to 3.0cm, std=0.9
(p=0.000), end-diastolic volume from 109ml, std=51.4 to 95.7ml, std= 40.8 (p=0.000), no
significant change in the end-systolic volume, from 55.7ml std=29.1 to 56.6ml std=26.8
(p=0.502), pulmonary hypertension decreased significantly from 75.4 mm Hg, std=23.1 to
57.7mmhg, std= 18.9 (p= 0.000) and NYHA improved from class IV std=0.652 to class II
std=0.642 (p=0.000) following mitral valve replacement(Table 4) . All patients had severe
pulmonary hypertension and therefore, long term follow up is required to determine its
outcome as well as the end-systolic volume which had no significant change.
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There was a significant increase in end-diastolic volume (p=0.024) and end-systolic volume
(p=0.000) which was accompanied by decrease in the Ejection Fraction (p=0.000) in the Total
Chordal Excision group compared to the preserved groups both Posterior Mitral Leaflet and
total chordal preservation which showed remarkable improvement in the Ejection Fraction
(p=0.004 and 0.016 respectively). No significant difference was found in the end systolic volume
among patients who underwent total chordal preservation. All patients had improved NYHA
post-operatively in all groups but, a long follow -up is required to evaluate the effect on TCE.
There was no significant improvement in ESV from the TCP (p=0.717) and this will need a long
follow up (Table 5). Four patients of out of 69 operated patients died making an overall
mortality rate for mitral valve replacement of 5.8%.
Table 4. Overall Mean Echo and NYHA Comparison before and after Operation
LV diameter/ Function
LA (cm)
LVDD (cm)
LVSD (cm)
EDV (cm)
ESV (cm)
PHT (mmhg)
EF (%)
NYHA (class)
Mean Before
Operation (Std
Deviation)
6.2 (1.4)
5.2 (1.1)
3.5 (0.9)
109 (51.4)
55.7 (29.1)
75.4 (23.7)
62.3 (13.5)
4 (0.652)
Mean after Operation
(Std Deviation)
p-value
4.7 (1.0)
4.4 (0.9)
3.0 (0.9)
95.7 (40.8)
56.6 (26.8)
57.7 (18.9)
62.3 (13.5)
2 (0.642)
0.000
0.000
0.000
0.004
0.502
0.000
0.779
0.000
Table 5. Mean Echo Findings versus Type of Operation
MeanEcho/
Type of
Operation
LA
LVDD
LVSD
EDV
ESV
PHT
EF
NYHA
Mortality
Total Chordal Excision
PML Preservation
Total Chordal Preservation
Pre-Op
mean
(SD)
Post-Op
mean
(SD)
p-value
Pre-Op
mean
(SD)
Post-Op
mean
(SD)
pvalue
Pre-Op
mean
(SD)
Post-Op
mean
(SD)
p-value
6.3
(1.3)
4.9
(0.9)
3.3
(0.7)
90.8
(26.2)
47.5
(22.8)
77.8
(21.2)
65.6
(15.3)
4
(0.7)
4.9
(0.9)
4.5
(0.8)
2.9
(0.7)
103.3
(47.5)
59.5
(26.8)
68.7
(17.7)
55.1
(9.6)
2
(0.6)
2
0.001
6.3
(1.8)
5.7
(1.3)
3.7
(1.0)
118.8
(70.6)
64.9
(30.7)
72.3
(22.9)
61.4
(9.1)
4
(0.6)
4.7
(1.2)
4.3
(0.8)
2.9
(0.8)
93.9
(44.4)
54.5
(26.2)
52.2
(16.1)
66.2
(8.1)
2
(0.6)
0.001
4.4 (1.0)
0.001
0.001
6.10
(1.16 )
5.2 (0.9)
4.3 (1.1)
0.008
0.001
3.4 (0.9)
3.2 (1.2)
0.244
0.001
113.8
(44.4)
54.9
(33.2)
76.0
(28.0)
58.9
(15.9)
4 (0.5)
87.7
(22.3)
55.3
(28.9)
49.8
(17.6)
65.9 (6.5)
0.008
2
0.000
0.001
0.016
0.024
0.001
0.000
0.000
0.000
0.002
0.000
0.004
0.000
(0.7)
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0.000
0.016
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Discussion
Chronic rheumatic heart disease still is a major problem in developing countries and surgical
intervention is the definitive treatment of choice 1,2,3,9.
Chordal transection during mitral valve replacement is accompanied by a progressive dilatation
of the left ventricle and subsequently, left ventricular dysfunction and low cardiac output
syndrome which has been attributed to the loss of annulo – ventricular continuity. Therefore,
maintaining the geometrical anatomy of the left ventricle during mitral valve replacement plays
a key role in determining post-operative normal left ventricular dimensions and function.
Several studies found that preservation of at least Posterior Mitral Leaflet or both have a
significant impact on the improvement of the left ventricular functions following mitral valve
replacement 4,5,6,7,8.
Rozich et al 10 evaluated 15 patients who underwent mitral valve replacement for pure mitral
valve regurgitation and found a significant decrease in ejection fraction, significant increase in
the left ventricle end systolic volume and no change in the left ventricle end diastolic volume in
the chordal transected group when compared to the preserved group which revealed a
significant decrease in the left ventricle end diastolic and systolic volumes with unchanged
ejection fraction
Zakai et al 7 did an echo at discharge and six month following mitral valve replacement and
found that the preserved groups (posterior mitral leaflet and total chordal preservation) had
remarkable improvements in terms of EDV and ESV. EF remained the unchanged in all groups at
discharge but improved progressively at six month of follow up. Similar improvement in the size
of LA, PHT and NYHA
Garcia-Fuster et al 11 found that complete excision of the Chordae was associated with low
cardiac output syndrome (p< 0.01) and more patients in NYHA III and IV (p=0.001) compared to
the preserved groups, posterior mitral leaflets and total chordal preservation who had
significant reduction in ventricular volumes, EF and PHT. Rao et al 12 evaluated the impact of
subvalvular apparatus preservation on long term outcomes for 10 years and found that
preserved group survived longer than unpreserved group (65.7% vs 58.1% respectively)
Shah et al 13 studied on LV dimension changes after chordal preservation in mitral valve
replacement and no significant change was found in median size of LA in both groups but, LV
EDV and LV ESV remained the same or increased where no chorda was preserved and
decreased where the chorda was preserved
Morimoto et al 14 did a study on mid-term echo comparison of chordal preservation following
mitral valve replacement at 4 years and found a significant improvement in the EF in the total
chordal preservation (p=0.017) and posterior mitral leaflet preservation (0.025) and significant
decrease in EF in the total chordal excision group (0.036) which was accompanied by a
significant increase in EDV(P=0.005) and ESV (p=0.001)
Current study has findings which are comparable to the other studies although a long-term
follow up with bigger sample size will be required
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Conclusion and Recommendation
Chordal Preservation in chronic rheumatic Mitral Valve Replacement is encouraged
Chordal Preservation plays a significant role in the reduction of Left Ventricular
volumes and improvement in ventricular function
A larger scale study with longer follow up is required
References
1. Marcus RH, Sareli P, Pocock WA, Berlow JB. The Spectrum of Severe Rheumatic Mitral
Valve Disease in Developing Countries. Correlation among Clinical Presentation, Surgical
Pathologic findings and Haemodynamic Sequelae. Annals of Int. Medicine 1994;120(3):
177 – 183
2. Marijon E, Celermaer DS, Tafflet M, El-Haron S, Jani DN, Ferreira B, Mocumbi A, Paquet C,
Sidi D, Jouven X. Rheumatic Heart Disease Screening by Echo. Circulation 2009;120:
663-668
3. Nyawawa ETM, Ussiri EV, Wandwi WBC, Mpoki U, Lugazia E, Waane T, Mlay G, Bgoya J
and Mahalu W. Cardiac Surgery: One- Year experience at Muhimbili National Hospital.
East & Central African J Surgery 2010; 15: 111-118
4. Athanasion T, Chow A, Rao C, Aziz O, Siannis F, Ali A, Darzi A, Wells F. Preservation of
the Mitral Valve Apparatus: Evidence synthesis and critical re-appraisal of surgical
techniques . Eur J Cardiothorac Surg 2008; 33 (3): 391 - 401
5. Talwar S, Venkataiya H, Kumar J, Kumar AS. Review Article: Chordal Preservation during
Mitral Valve Replacement: basis, techniques and results. Indian J Thoracic Cardiovasc
Surg 2005; 21: 45 -52
6. Thomas W, Sven L, Volkmar F, Claudia W, Nico D, Ardawan R, Sebastian M, Johannes S,
Jan G, Friedrich W. Mid-Term Results after Stentless Mitral Valve Replacement.
Circulation 2003;108: 85 - 89
7. Zakai SB, Khan SU, Rabbi F, Tasneem H. Effects of Mitral Valve Replacement with or
without chordal preservation on Cardiac Function: Early and Mid-Term Results . J Ayub
Med Coll Abbottabad 2010; 22(1): 91-96
8. Chouwdhary UK, Kumar AS, Airan B, Mittal D, Subramaniam KG, Prakash R, Seth S, Singh
R, Venugopal P. Mitral Valve Replacement with or without chordal preservation in a
rheumatic population: Serial Echocardiographic assessment of Left Ventricle size and
function. Ann Thorac Surg 2005; 79 (6): 1926 -33
9. Bonow RO, Carabello BA, Kanu C, Antonio C, Faxon DP, Gaasch WH, Lyte BW, Nishihura
RA, Patrick TO, Robert AO, Otto CM, Shah PM, Shanewise JS. ACC/AHA 2006 Guidelines
for the management of patients with valvular heart disease: a report on the American
College of Cardiology/American Heart Association Task Force on Practice guidelines.
Circulation 2006; 114: 84 – 231
10. Rozich JD, Carabello BA, Usher BW, Kratz JM, Bell AE, Zile MR. Mitral Valve Replacement
with and without chordal preservation in patients with chronic Mitral Regurgitation.
Mechanisms for differences in post-operative ejection performance. Circulation 1992;
86: 1718 – 26
11. Garcia-Fuster R, Estevez V, Gil O, Canovas S, Martinez-Leon J. Mitral Valve Replacement
in Rheumatic patients: Effect of Chordal Preservation. Ann Thorac Surg 2008; 86: 472 81
12. Rao C, Hart J, Chow A, Siannis F, Tsalafouta P, Murtuza B, Darzi A, Wells FC, Athanasion
T. Does Preservation of the subvalvular apparatus during mitral valve replacement
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affect long-term survival and quality of life? A Microsimulation Study. J Card Thorac Surg
2008; 3: 3-17
13. Shah S, Ghosh PK, Das A, Chandra M, Agarwal SK, Mittal PK, Krishn SR. Left Ventricle
dimension changes after chordal preservation in Mitral Valve Replacement. Indian J T
Cardiovasc Surg 1991; 7(1): 27 – 32
14. Morimoto N, Aoki M, Murakami H, Nakagiri K, Yoshida M, Mukohara N. Mid-Term
Echocardiographic comparison of Chordal Preservation Method of Mitral Valve
Replacement in patients with Mitral Stenosis. Heart Valve Disease 2013; 22 (3): 326 332
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Ambulatory Cleft Lip Surgery in a Developing Country
O.A. Olawoye1,3, A.A. Olusanya2,3, S.A. Ademola1,3, A.O. Iyun1, A.I.
V.I. Akinmoladun 2,3
1Departments of Plastic Surgery and 2Oral& Maxillofacial Surgery
University College Hospital, Ibadan. Nigeria
3College of Medicine, University of Ibadan.
Correspondence to: Dr O A Olawoye, Email address: yinkaolawoye@yahoo.co.uk
Michael1,
Background: Ambulatory cleft lip surgery has been practiced extensively in many
developed countries, however cleft lip repair in most developing countries involve patient
hospitalization of varying duration. Driven bythe recent acute shortage of pediatric bed
space in our hospital, an increasing number of cleft lip surgeries are being performed on
out-patient basis. The aim of this study was to report our experience with ambulatory cleft
lip surgery at the University College Hospital, Ibadan.
Methods: A retrospective review of Cleft lip Surgeries performed between February 2007
and January 2010 was done. Data of patients who had cleft lip surgery was retrieved from
our Smile Train data base, the operating room surgery records and the Nurses’
admission/discharge records on all the wards on which the patients were either received or
admitted. Information obtained included the demographic characteristics of the patients,
complications reported, length of stay (LOS) for in-patients and the need for re-admission
before the first follow-up clinic appointment among the two groups.
Results: Eighty three patients were identified but complete data was obtained for forty
patients. (Retrieval rate of 48%) The ambulatory group comprised of 15 patients while- the
in-patient group had 25 patients. The mean patient age was 5.7 years in the ambulatory
and 9.7 years in the in-patient group. Both groups were homogenous for other parameters.
None of the patients in the ambulatory group was re-admitted for any post-operative
complication while only one patient in the in-patient group had a post-operative
complication necessitating prolonged hospitalization.
Conclusion: Ambulatory cleft lip surgery was found to be safe in our practice with
comparable patient outcome to the in-patient group. It is anticipated that this may assume
increasing prominence in the scope of cleft lip management in many more centers in the
developing world.
Key words: Cleft lip repair, Out-patient cleft lip surgery, Ambulatory cleft lip surgery
Introduction
The care of patients with clefts of the primary palate in our hospital as well as in many other
centers around the world involve pre-operative evaluation of the patients in the out-patient
clinic, admission for surgery, operative correction, postoperative in- patient care for varying
duration of days and outpatient follow up care. However, many more centers in the developed
economies are adopting ambulatory cleft lip repair in order to bring down the treatment cost.
Several reports from the developed countries1,2 have documented the safety and effectiveness of
ambulatory cleft lip repair however there are limited reports on the practice and safety of
ambulatory cleft service from the developing low and middle income countries3.
The practice of ambulatory cleft lip repair in many western countries wasdriven by enhanced
patient safety, increased efficiency and cost reduction. Whereas these same values are as
important in the developing countries, many centers have continued to practice the traditional
in-patient management of the patients with length of stay ranging between two to four days or
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more. It is unlikely that this practice can be sustained any further because of the changing
dynamics of health care funding in many developing countries. Whilst there has been a relative
minimal improvement in the health care infrastructure, there has been a progressive increase in
the uptake of patients for cleft lip and palate surgeries in many centers over the past couple of
years because of the recently introduced free surgical treatment provided by SMILE TRAIN, an
American based nongovernmental organization. Alongside this increase came the challenge of
securing pediatric bed spaces for the in-patient care of cleft lip and palate patients in many
centers including ours. This need necessitated the option of increasing out-patient management
of some of the patients. The aim of this study was to report our experience with ambulatory cleft
lip repair in our hospital and to add to the sparse literature from the low and middle income
countries on ambulatory cleft lip surgery.
Patients and Methods
A retrospective review of cleft lip surgeries performed at the University College Hospital, Ibadan
by the authors over a three year period between February 2007 and January 2010 was carried
out. Data of patients who had cleft lip surgery was retrieved from our operating room records,
the admission and discharge record books on the wards and the Smile Train data subset form
Ibadan. The patients were divided into two groups: The ambulatory group comprised of cleft lip
patients who were admitted for surgery on the morning of the operation and were discharged
later the same day while the in-patient group were those who were admitted a day before their
operation and kept on admission till the first day post-surgery or beyond before discharge.
Information obtained included the demographic characteristics of the patients, complications
reported (if any) among the patients that were hospitalized and those treated as day cases,
number of days on admission for hospitalized patients and the need for re-admission before the
first follow-up clinic appointment among the two groups. The patients with cleft lip anomaly
were reviewed by one of the authors in the outpatient clinic where the initial evaluation was
done and necessary investigations ordered. The patients were adjudged to be fit before they
were scheduled for surgery. The patients were usually admitted a day before the scheduled
surgery but when there was no available bed space for admission, the patient was requested to
come to the ward on the morning of surgery. Both the in-patient and out-patient groups were
routinely evaluated by the anesthesiologist before anaesthesia was administered.
All the patients had Mallards’ repair, the children had general anesthesia via endotracheal
intubation for their procedures while the adult patients had their surgery under local anesthesia
using 1% xylocaine with 1 in 200,000 dilution of adrenalin solution. The in-patient group were
admitted to the ward post operation and discharged home the following day while the
ambulatory group were discharged from the post anaesthesia recovery room when their postoperative condition have been adjudged to be satisfactory.The outcome measures were the
post-operative complications necessitating hospitalization beyond the usual 2 days or the need
for re-hospitalization before the scheduled follow-up date. Descriptive statistics of the data was
done.
Results
Eighty three (83) patients were identified but complete data was obtained for forty (40) of them
(Retrieval rate of 48%) The patients were divided into two groups, the ambulatory group
(n=15) and the in-patient group (n=25)
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The median age was 7 months (range 3 months to 25 years) and the mean age was 5.7 years in
the ambulatory group while the median age was 10 months (range 3 months to 33 years) with a
mean of 9.7 years in the in-patient group. (Table 1)
Both groups were homogenous for other parameters. One patient in the in-patient group had
post operative complication necessitating extended hospitalization for five days. None of the
patients in the ambulatory group was re-admitted for any post-operative complication. All the
patients in both groups had satisfactory wound healing and had their sutures removed in the
clinic on the 5th post-operative day.
Table 1. Summary of Patients’ Characteristics Between the Two Groups
Number (n)
Mean age
Median age
Age range
Re-admission rate
Average number of days on
admission
Ambulatory group
15
5.7 years
7 months
3 months – 25 years
0
Nil
In-patient group
25
9.7 years
10 months
3 months – 33 years
0
1.24 (1 – 5)
Discussion
The traditional standard of care for cleft lip repair in many centers across the world include
preoperative clinic evaluation, admission of patient for surgery and post-operative in-patient
management for between 2 to 5 days for patient monitoring, establishment of satisfactory
resumption of feeding by the babies and adequate post-operative analgesia among other things.
In some centers the patients are routinely kept on admission till the 5th post-operative day for
suture removal before they are discharged.
Without doubt, the additional period of hospitalization puts a burden of increased utilization of
hospital resources and pediatric bed space and a concomitant increase in the cost of careon the
system. Improved quality of care and better patient outcome in many advanced countries
birthed the possibility of shorter patient hospitalization and the introduction of ambulatory
surgical service in many of these countries. In addition, the dynamics of health care economics
has been a major impetus that has driven the evolution of ambulatory cleft lip surgery in many
developed countries.
The emphasis on cost reduction, increased efficiency and improved safety standards in health
care delivery has prompted significantly shortened patient hospitalization in many countries.
The advantages of ambulatory surgical service include reduced economic burden on the
hospital, reduced risk of nosocomial infections and the provision of a familiar environment for
the child during the recovery period4.
Ambulatory cleft lip repair has been in practice in the developed countries since the 1980s5 and
several studies1,2,3,5 have reported on its’ high safety standard. In one of the largest studies that
compared the perioperative complication rates between ambulatory and in-patient cleft lip
patients in two hospitals across two countries, the United States and Austaralia Rosen et
al1found a 3.3% (n= 91) and 7.1% (n=14) readmission rates in the out-patient and in-patient of
the Children’s Hospital, Los Angeles respectively compared to a readmission rate of 2% (n=50)
among the inpatient group of the Royal Children’s Hospital, Australia. These differences were
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not however statistically significant. Similarly, Kim and Rothkopf 2 in their ten year review of 24
patients with unilateral cleft lip comprising 11 outpatients and 13 inpatients found no
complications in the outpatient group but minor complication of wound separation in 2 patients
(15.4%) in the inpatient group. They concluded that outpatient cleft lip repair is a safe
alternative.
In a similar study conducted in Saudi Arabia, Al-Thunyan et al3affirmed the safety of ambulatory
cleft lip repair and suggested that patients with pre-existing cardiac problems should be
managed as in-patients while patients that develop post-operative respiratory complications in
the ambulatory group should be hospitalized for further care.
The patients in both arms of our study demonstrated satisfactory surgical outcome with high
safety record. None of the patients in the ambulatory or in-patient group was readmitted for any
complication following their discharge from the hospital although one patient (4%) in the inpatient group had extended hospitalization for 5 days for a respiratory complication. The high
safety record is attributable to the presence of a multi-disciplinary cleft team in our hospital and
the comprehensive pre-operative evaluation in the outpatient clinic and maintenance of a strict
guideline of indications before the patients are booked for surgery. The booking criteria include
1. Satisfactory weight gain over the course of out-patient clinic appointments, 2. A packed cell
volume of not less than 30%, 3. Absence of respiratory tract infection and 4. Absence of fever
amongst other things. In addition, patients who present with any other congenital anomalies are
referred to the appropriate specialists and managed until safety for general anaesthesia and
surgery are guaranteed. The three predominant causes of delay in booking of our cleft patients
for surgery include poor weight gain, suboptimal packed cell volume (less than 30%) and upper
respiratory tract infection.
Early postoperative complications in primary cleft lip and palate surgery have been related to
preexisting cardiorespiratory problems4. It is therefore important that preexisting
cardiopulmonary conditions are diagnosed early and treated appropriately in addition to other
possible causes of morbidity before the patients are booked for ambulatory cleft lip repair.
Patient uptake for cleft lip repair is bound to increase in many developing countries currently
battling with limited Paediatric bed spaces with the introduction of ambulatory surgical service.
The improvement in institutional infrastructure along with the introduction of competent and
experienced multidisciplinary cleft team will ensure high standard of care and safety records
commensurate with the records in the developed countries.
Conclusion
Ambulatory cleft lip repair is a safe alternative to inpatient cleft lip repair. Extending its practice
to many more centers in the developing countries will ensure greater uptake of cleft lip patients
for repair and significantly reduce the waiting list of patients in accessing surgical care. An
added advantage of ambulatory cleft lip repair is the potential significant reduction of
transmission of nosocomial infection in the vulnerable infant age group.
Acknowledgement
The authors express appreciation to Prof O. M. Oluwatosin for his leadership of, and direction
for the cleft team at the University College Hospital, Ibadan. Nigeria.
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Conference presentation
This paper was presented in part at the Nigerian Association for Cleft Lip and Palate Conference
(NACLP) at Ibadan, 23rd -24th April 2010 and at the Pan African Association for Cleft Lip and
Palate Conference (PACLP) at Kumasi, Ghana 10th – 14th July, 2011.
References
1. Rosen H, Barrios LM, Reinisch JF, Macgill K, Meara JG. Outpatient cleft lip repair. Plast
Reconstr Surg. 2003;112:381–387;
2.
3.
4.
5.
Kim TH, Rothkopf DM. Ambulatory surgery for cleft lip repair. Ann Plast Surg. 1999; 42:442–444.
Al-Thunyan A, Aldehayel S, Al-Meshal O, Al-Qattan M; Ambulatory Cleft Lip Repair. PRS 124 No 6
pp 2048-2053
Lees VC, Pigott RW. Early postoperative complications in primary cleft lip and palate surgery:
How soon may wedischarge patients from hospital? Br J Plast Surg. 1992; 45:232–234.
Eaton AC, Marsh JL, Pilgram TK. Does reduced hospital stay affect morbidity and mortality rates
following cleft lip andpalate repair in infancy? Plast Reconstr Surg. 1994; 94:911–915; discussion
916–918.
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One Stop Management of Sigmoid Volvulus in an African Setting with Limited Resources
M.M. Achiek1, F.K. Tawad1, B.M. Alier2, C.T.Yur1
1College of Medicine& University of Juba
2Juba Teaching Hospital
Correspondence to: Dr. M.M. Achiek, Email: mayen.achiek@gmail.com
Objective: To show the feasibility and safety of emergency resection of an unprepared
redundant sigmoid colon and primary anastomosis.
Methods: A prospective study conducted at two Sudanese Hospitals, Nyala (Darfur) and
Juba (South Sudan). Between January, 1st 2011 and December, 31st 2013, patients
presenting with acute abdominal pain caused by large bowel obstruction were included on
the study by two university firms.
Results: Thirty eight patients were included in the study; 33 were males and 5 were
females. Of these, 9 patients were excluded at Laparotomy when the cause of their bowel
obstruction was found to be due to small bowel obstruction and colonic tumour. Therefore,
29 patients were legible for the study. Of these 29 patients, 3 were females and 26 males
with mean age (48), and range (22-75) years. All 29 patients at Laparotomy had redundant
sigmoid colon resected. 4 (4/29) ended up with a Hartmann’s procedure and 25/29
underwent redundant sigmoid colectomy and primary anastomosis. Post-operatively 6/29
had wound infections and none had a documented anastomotic dehiscence.
Conclusion: This series shows the feasibility and safety of management of large bowel
obstruction caused by sigmoid volvulus by an emergency one stop resection and primary
anastomosis
Introduction
Sigmoid volvulus is a significant cause of acute large intestinal obstruction and in rural Africa it
is a leading cause1,2,3 over the years the operative management of the emergency presentation
has developed from staged-surgery to a non-operative relief of the acute volvulus followed by a
later elective open or laparoscopic procedure3,4,5. In the African setting with limited resources it
is very challenging and unsafe with inadequate patient’s pathways from presentation to
discharge and follow up. Most patients come from far away rural areas. When managed by open
Hartmann’s procedure, the patients do not accept colostomies as this is a cultural taboo6, 7. In
our setting there are no trained stoma therapies either in the healthcare facilities or in the
communities where the patients go back to, making wound care a significant costly problem.
With problematic staged-operative management the length of stay on the wards may go beyond
8 weeks on average.
Adequate resuscitation of patients with large bowel obstruction caused by sigmoid volvulus and
a careful resection and double-layered primary anastomosis, is safe, feasible and cost-effective.
The series of patients we are presenting does show the feasibility and safety of this
procedure 8, 9, 10.
Patients and Methods:
This is a prospective study conducted by two surgical firms from two Sudanese Hospitals, Juba
Teaching Hospital (JTH), South Sudan and Nyala Teaching Hospital (Darfur), Western Sudan.
Between January 2011 and December 2013, patients admitted under the university firms with
clinical and radiological diagnosis of large bowel obstruction were consecutively identified and
included.
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As the patients presented, careful documentations were made of demographic data, clinical
presentation, and comorbidites, diagnostic and assessing investigations. The patients after the
diagnosis were prepared for surgery including an informed consent for surgery. At laparotomy
the cause of obstruction was specified and those with sigmoid volvulus were definitively
diagnosed and managed with sigmoid resection and anastomosis with no defunctioning stoma
or Hartmann’s procedure 11.
Results
During the specified period of the study, 38 patients were identified, 5 females and 33 males.
The mean age of 49 s.d and range 22 to 75 years were recorded. They all underwent an
emergency laparotomy after pre-operative resuscitation with IV fluids and broad spectrum IV
antibiotics. All were taken to the operating theatres with stable vital signs of Pulse, BP, RR, and
urine output. All our patients were managed as emergency cases and therefore did not have any
form of bowel preparation.
At laparotomy, 7 patients were found to have small bowel obstruction with a degree of
chronicity and one patient who had hepatic flexure colonic tumour and another with an
advanced recto-sigmoid tumour were excluded leaving 29 patients for the analysis. There were
3 females and 26 males. All the 29 patients were diagnosed with large bowel obstruction caused
by an obvious sigmoid volvulus with an evident redundancy of sigmoid colon with a lax mesocolon. Of the 29 patients, 4 had perforations at the point of the colonic twisting and 25/29 had a
twist with only oedematous viable sigmoid colon. We performed resection and primary
anastomosis on an unprepared large bowel if there was no perforation and faecal peritonitis, no
visible ischaemic segment at the point of twist, and the patient’s vital signs on monitoring were
stable (Normal BP, normal urine output, normal PO2 on the pulse oxymeter).
Based on the intra-operative criteria (Table 1) 25/29 volvulus patients underwent sigmoid
resection and a doubled-layered interrupted anastomosis was fashioned using vicryl 2/o
(Ethicon).
The 4 of the 29 patients who were observed to have colonic perforation at a visibly ischaemic
segment with an apparent faecal peritonitis or those patients with perforations and were not
stable, had a Hartmann’s procedure performed on them.
Table 1. Intra-operative Observations
Criteria/Sign
Perforation&faecal contamination
Visible ischaemic segment
Abnormal vital Signs
Yes
4
4
4
No
25
25
25
The post-operative period:
The patients with colonic perforations were continued on IV antibiotics (Metronidazole 500mg
and Ceftriaxone 1g) 8-hourly for a week. One of the 29 patients who had a Hartmann’s
procedure did not show any signs of improvement from the time of the surgery and
deteriorated developing, multiple organ failure and died within 72 hours. The two patients who
were diagnosed with advanced colonic cancer died within a month, making mortality among the
38 patients was 3 giving a mortality rate of 7.9%. The surgical site infection was recorded in 6
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(20.7%) of the 29 volvulus patients. All the 4 of the 29 patients who had Hartmann’s procedure
had wound infection and all also stayed on the ward for over two months and were discharged
after the closure of their stomas.
Figure 1. Intra-operative diagnosis of sigmoid volvulus (Courtesy of MM.Achiek, FRCS)
Discussion
In our series sigmoid volvulus is the commonest cause of large bowel obstruction in relatively
young African males and adds significantly to the emergency surgical disease burden 11. The
management approaches have evolved over the years with the development of surgical
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techniques and technology 13,16. In limited-resourced African settings open surgery has been and
is still the gold standard despite the advent of the endoscopic surgery (Colonoscopic
decompression and a later laparoscopic resection. Our patients presented with acute large
bowel obstruction that has gone on for 48 hours or more, young with least comorbidites and
largely rural.
The tough realities of resources limitation and traditional taboos, patient’s misconceptions and
rejection of stomas do dictate a desperate attempt to put these patients through one stop
management pathway, which has been tried by others8. We used the intra-operative
observational assessment method and carried out sigmoid colonic resection and anastomosis on
an acute unprepared bowel in 25/38. We did not have a post-operative anastomotic dehiscence
and a re-operation with a stoma. The mortality of 8% in our series was not related to the onestage surgical management1,2,3,19. No patients ended up with a permanent stoma. The number of
patients in our series is rather small, but despite the numbers we could draw a conclusion that
emergency colonic resection and end to end anastomosis on an unprepared bowel is feasible
and safe.
References
1. JO Larkin, TB Thekiso, R Waldron, K Barry, and PW Eustace. Recurrent Sigmoid
Volvulus – Early Resection may Obviate Later Emergency Surgery and Reduce Morbidity
and Mortality. Ann R Coll Surg Engl. Apr 2009; 91(3): 205–209.
2. Mangiante EC, Croce MA, Fabian TC, Moore OF 3rd, Britt LG Department of Surgery,
University of Tennessee, Memphis 38163. Sigmoid volvulus. A four-decade experience,
Historical Article. The American Surgeon [1989, 55(1):41-44]
3. G H Ballantyne, M D Brandner, R W Beart, Jr, and D M Ilstrup. Volvulus of the colon.
Incidence and mortality. Ann Surg. Jul 1985; 202(1): 83–92.
4. James B. Peoples M.D., John C. McCafferty M.D., Kenneth S. Scher M.D. Operative therapy
for sigmoid volvulus, Diseases of the Colon & Rectum August 1990, Volume 33, Issue 8,
pp 643-646
5. Y. F. A. ChungK.-W. Eu, D. C. N. K. Nyam, A. F. P. K. Leong, Y. H. HoF. Seow-Choen.
Minimizing recurrence after sigmoid volvulus. British Journal of Surgery 1999; 86 (2):
231–233.
6. Hiltunen KM, Syrjä H, Matikainen M Department of Clinical Sciences, University of
Tampere, Finland. Colonic volvulus. Diagnosis and results of treatment in 82 patients.
The European Journal of Surgery = Acta Chirurgica [1992, 158(11-12):607-611]
7. G J Arnold and Nance, Volvulus of the sigmoid colon. Ann Surg. May 1973; 177(5): 527–
537.
8. A.Z. Sule, D. Iva, P.O. Obekpa, B. Ogbonna, J.T. Momoh, B.T. Ugwu.
One-stage procedure in the management of acute sigmoid volvulus J.R.Coll.Surg.Edinb.,
1999; 44: 164-6
9. T.E. Madiba, S.R. Thomson. The management of sigmoid volvulus J.R.Coll.Surg.Edinb., 45,
April 2000, 74-80
10. Laurence F. Yee, MD, FACS, FASCRS Vice Chairman, Department of Surgery
California
Pacific
Medical
Center
Assistant
Clinical
Professor
of
Surgery
University of California, San Francisco. Colonic Volvulus
11. Norman Williams, CJ.Bulstrode, PR.O’Connell (edit), Aetiological factors of sigmoid
colon volvulus, it is also common in young African. Short text of Practice of Surgery,
intestinal obstruction, Ch70, 26thEd. 2013.
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12. Ali Nuhu, Abubacar Jah1, Acute sigmoid volvulus in a West African population. Annals of
African Medicine, Vol. 9, No. 2, April-June, 2010, pp. 86-90
13. Turan M, Sen M, Karaday¦ K, Koyuncu A, Topcu O, Y¦ld¦r¦r C, Duman M. Our sigmoid
colon volvulus experience and benefits of colonoscope in detortion process. Rev
EspEnferm Dig 2004; 96: 32-35.
14. S. Sozen, K. Das, H. Erdem, E. Menekse, S. Cetinkunar, F. Karateke. Resection and Primary
Anastomosis with Modified Blow-Hole Colostomy or Hartmann's Procedure. Which
Method should be Performed for Gangrenous Sigmoid Volvulus? Chirurgia 2012; 107:
751-755 No. 6, November – December
15. Mealy K, Salman A, Arthur G. Definitive one-stage emergency large bowel surgery Br J
Surg. 1988 Dec;75(12):1216-9.
16. Roberto Cirocchi1, Eriberto Farinella, Francesco La Mura, Umberto Morelli, Stefano
Trastulli, Diego Milani, Micol S Di Patrizi, Barbara Rossetti, Alessandro Spizzirri, Ioanna
Galanou, Konstandinos Kopanakis, Valerio Mecarelli and Francesco Sciannameo. The
sigmoid volvulus: surgical timing and mortality for different clinical types World Journal
of Emergency Surgery 2010, 5:1
17. Taha SE, Suleiman SI Volvulus of the sigmoid colon in the Gezira. Br J Surg. 1980 Jun;
67(6):433-5.
18. Mehmet Ayhan Kuzu M.D., Ahmet Keşşaf Aşlar M.D., Atilla Soran M.D. Arife Polat M.D.,
Ömer Topcu M.D., Süleyman Hengirmen M.D. Emergent Resection for Acute Sigmoid
Volvulus, Diseases of the Colon & Rectum, August 2002, Volume 45, Issue 8, pp 10851090
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Acute Mechanical Bowel Obstruction among Adults Seen at the Ladoke Akintola
University of Technology Teaching Hospital in Nigeria.
O.L. Idris1, M.O. Adejumobi1, O.A. Kolawole1, A.S. Oguntola, O.O. Akanbi1, K.B. Beyioku2.
O.A. Adedeji3.
1Consultant General Surgeon, 2Surgical Resident, 3Surgical Intern
Department and institution: Department of Surgery, Ladoke Akintola University of Technology
Teaching Hospital, PMB 5000, Osogbo. Osun State.
Correspondence to: Adejumobi Musibau Olaniyi, E-mail address: adejumobi43@gmail.com
Background: Acute mechanical bowel obstruction (AMBO) is one of the common life
threatening emergencies globally. This study was aimed at determining the pattern of
causes of acute mechanical bowel obstruction in adult seen at the Ladoke Akintola
University of Technology Teaching Hospital, Osogbo.
Methods: This was a prospective study of all adult patients with clinical, radiological and
intra-operative features of acute mechanical bowel obstruction between June 2007 and
June 2014, in the Ladoke Akintola University of Technology Teaching Hospital, Osogbo.
Results: A total of 126 adult patients with the diagnosis of acute mechanical bowel
obstruction were enrolled in the study. The patients’ ages ranged between 15 and 87 with a
mean of 44.5 + 2.1 (SD) years. The male to female sex ratio was 1: 1. Adhesions and bands
accounted for 81 (64.3%) of the cases. Obstructed /strangulated hernia were responsible
for 20 (15.9%) of the patients. Other causes included volvulus in 25 (19.8%), bowel tumors
(6.3%), anastomotic strictures (5.6%), anastomotic strictures (3.2%), intussusceptions
(3.2%) and faecal impaction (1.6%). The overall mortality was 10.3%.
Conclusion: Post-operative adhesion is the most common cause of acute mechanical
intestinal obstruction with majority of these resolving on conservative management. The
reduced incidence of obstructed/ strangulated external hernia in our environment is
perhaps due to increased patients’ awareness with many patients now presenting in the
outpatient clinic with uncomplicated hernia.
Key words: Current pattern, Aetiology, Mechanical bowel obstruction.
Introduction
In many resource poor countries of the world, acute abdominal emergencies cause significant
mortality1,2 Acute intestinal obstruction, which accounts for about 15 percent of all emergency
department visits for acute abdominal pain, is one of the wide varieties of abdominal
pathologies responsible for these deaths.1 The causes of acute small bowel obstruction have
changed dramatically during the past century.3 At the turn of the 20th century, hernias
accounted for more than half of the cases of mechanical intestinal obstructions. With a notable
increase in routine elective repair of hernias, this aetiology has dropped to the third most
common cause of small bowel obstruction in industrialized countries.3,4
The diagnosis of intestinal obstruction is not always easy and the indications for surgery needs
high index of suspicion. Detailed history and thorough clinical examination are helpful in
making a diagnosis and planning treatment. Classically there are four cardinal features, i.e.
colicky abdominal pain, abdominal distension, projectile vomiting and constipation, but the
prominence of each of these is affected by the site and type of obstruction.3,5,6 The exact cause of
obstruction and the facilities available for treatment are known to influence the outcome.1 This
study was carried out to determine the current pattern of aetiology of acute mechanical
intestinal obstruction in adults.
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Patients and Methods
This is a prospective study of all adult patients who were admitted and managed for acute
mechanical bowel obstruction (AMBO) from June 2007 to June 2014, at the Ladoke Akintola
University of Technology Teaching Hospital (LTH), Osogbo, Osun State, South-Western Nigeria.
Patients with paralytic ileus and those below the age of 15 years were excluded from the study.7
The hospital number, age and sex of each patient were recorded on a specially prepared chart.
The onset, duration, and main symptoms of obstruction, as well as the past medical/ surgical
history were recorded. Findings on abdominal radiographs and later at operation (for those
operated) confirmed the diagnosis1.
Patients with AMBO from postoperative adhesion were managed conservatively and those who
failed to resolve within 72 hours were offered operative management. However patients with
associated features of peritonitis or patients who developed features suggestive of gangrenous
bowel within this period had operative management after initial resuscitation.7 The interval
between presentation and operation was also recorded. Surgery was defined as emergency if
carried out within 48 hours of admission.1 Intraoperative findings were recorded which
included the site and primary cause of obstruction with the operative procedure performed to
relieve the obstruction. All deaths were recorded and mortality in this study was taken as
deaths occurring during the same hospital admission.1,5 This study was approved by Research
Ethics Committee of LTH, Osogbo and written informed consent was also obtained from each
patient before being enrolled into the study. The data were recorded on a proforma sheet of
individual patient and analysis was done using Statistical Package for Social Sciences (SPSS)
version-16.
Results
During the seven years of this study, a total of 126 patients with AMBO were admitted and
managed. The mean age was 44.5 + 2.1 (SD) with a range of 15 to 87 years. The modal age group
was 15 – 30years accounting for 31.0% of cases and seventy-four (58.8%) of all cases were aged
45 years and below. Males constituted 50.8% (n = 64) of the study population. Table
1summarizes the characteristics and presentation of the study population. Adhesion was the
most common cause of AMBO, constituting 64.3% (n = 81) with a majority of them being postoperative 97.5% (n = 78). Out of the patients with postoperative adhesive MBO 71.8 percent (n
= 56) patients had previously undergone only one abdominal surgery. In most of the patients,
70.5 percent (n = 55), with adhesive AMBO, the obstruction resolved with conservative
management, while others had surgery ranging from adhesiolysis to resection of the bowel
followed by end-to-end anastomosis.
The site of obstruction was found to be in the small intestine in all the cases of adhesive AMBO
that were operated. Out of the three patients with primary adhesive AMBO found at laparotomy,
one was due to recurrent pelvic inflammatory disease (PID) and the second was congenital
band. The third case was due to abdominal tuberculosis in a man who was diagnosed with the
human immunodeficiency virus (HIV) infection during the same admission. Table 2 summarizes
the aetiology of AMBO. There were twenty patients with obstructed / strangulated hernias with
inguinal hernia constituting 75% (n = 15) of them. Inguinal hernia was more common on the
right, 60% (n = 9) and majority of them 73.3% (n = 11) were funicular type while the others
were complete (inguino-scrotal). Ten percent (n = 2) of AMBO from obstructed hernia were due
to strangulated peri-umbilical hernia, 10% were due to femoral hernias and 5% (n = 1) due to
giant spigelian hernia. The average duration before strangulation was about 14 months. Apart
from the eight cases of obstructed inguinal hernia that reduced spontaneously within 24 hours
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of admission and were electively operated on the next available operation day, all other cases of
obstructed hernia had emergency surgery.
Table 1. Characteristics and Presentation of the Study Population
Gender
Number of patients
Percentage
64
62
50.8
49.2
39
35
22
16
14
31.0
27.8
17.5
12.7
11.1
113
97
87
82
25
17
12
4
2
1
89.7
77.0
69.0
65.1
19.8
13.5
9.5
3.2
1.6
0.8
94
24
5
2
1
74.6
19.0
4.0
1.6
0.8
Male
Female
Age distribution (years)
15 – 30
31 – 45
46 – 60
61 – 75
>75
Clinical features
Colicky abdominal pain
Vomiting
Abdominal distension
Constipation
Fever
Groin swelling
Weight loss
Shock
Peri-umbilical swelling
Swelling in the Left Spigelian
Zone
Comorbid Illnesses⃰
No illness
Systemic hypertension
Diabetes mellitus
HIV
Obstructive uropathy
⃰
Some patients had multiple comorbid illnesses
Table 2. Aetiology of Mechanical Bowel 0bstruction
Aetiology
Adhesions and Bands
Obstructed / Strangulated
external hernia
Sigmoid volvulus
Intra-abdominal Tumor
Intussusception
Anastomotic Stricture
Fecal Impaction
Total
Frequency
81
20
Percentage
64.3
15.9
8
7
4
4
2
126
6.3
5.5
3.2
3.2
1.6
100.0
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All 8 cases of the volvulus were of the sigmoid colon, but one of them has associated ileal
knotting (ileo-sigmoid knotting) and seven of them were operated as one died before surgery.
There were seven cases of AMBO due to intra-abdominal malignancies. These malignancies
included four cases carcinoma of the left colon, one case each of the transverse colon, the
rectum. There was one case of gastrointestinal stroma tumor (GIST) of the ileum in a known HIV
infected patient.
Three of the cases of intussusception were due to lymphoma with enlarged mesenteric nodes
being the lead points (two were ileo-colic and one ileo-ileal) while in the third case, no lead
point pathology could be identified and this was ileo-colic type. The two cases of intestinal
obstruction due to faecal impaction were found in elderly men. One resolved with conservative
management while the other was an intraoperative diagnosis where multiple pellets of
impacted calcified faeces were found at the rectosigmoid junction and the patient had sigmoid
colostomy done. Table 3 shows the indications for the prior abdominal surgery leading to
adhesive AMBO.
Table 3. Indications for the prior abdominal surgery leading to adhesive AMBO
⃰ Indications
Generalized Peritonitis
Acute appendicitis
Obstetric
/Gynecologic
operations
Previous adhesive AMBO
Gastric outlet obstruction 20
PUD
Strangulated
umbilical
hernia
Sigmoid Volvulus
Open cholecystectomy
Splenic rupture 20 RTA
Unknown
Total
⃰
Frequency
28
17
14
Percentage
35.9
21.7
17.9
9
2
11.5
2.6
2
2.6
2
2
1
1
78
2.6
2.6
1.3
1.3
100.0
Some patients had multiple previous abdominal surgeries.
Postoperative complications occured in seventeen patients (some of them had multiple
complications) with surgical site infection (SSI) constituting the majority 64.7% (n = 11), eight
of these were incisional SSI, which resolved with regular dressing while the remaining three
were organ space (residual abscess) which required drainage. The other complications were
four cases of post-operative enterocutaneous fistula, three of which resolved with conservative
management, the fourth requiring operative management. Two patients had burst abdomen and
both had emergency laparotomy with reclosure. Three patients had deep venous thrombosis
(DVT) and there was a case of pulmonary thromboembolism (PTE).
The overall mortality was 10.3% (n = 13). The operative mortality of 7.1% (n = 9) included
three adhesive AMBO with strangulated bowel, two patients with advanced left sided colonic
carcinoma, one patient with advanced rectal carcinoma and one each of GIST , Sigmoid volvulus
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with ileo-sigmoid knotting and strangulated inguinal hernia with obstructive uropathy. The
remaining deaths occurred before surgery from complications related to late presentation in
some and in others due to associated poorly managed co morbid illnesses.
Discussion
Acute mechanical bowel obstruction (AMBO) is one of the common life threatening emergencies
all over the world.8 -10 There is a global change in the spectrum of the aetiology of AMBO over
past years. Recent studies have shown that adhesive intestinal obstruction has replaced
obstructed hernias as the most common cause of AMBO. 4,8 -10 although, there is wide
geographical variation in the pattern of AMBO. This study was done to determine the current
pattern of aetiology of AMBO in our part of the developing world. The pattern of presentation in
our study is consistent with that in the reports of many similar studies but the male to female
ratio is 1:1 (64/62), though similar to what was reported recently by Abdulrahman 11 but it is
quite different from other studies which showed significant male preponderance. These gross
discrepancies may be due to a large proportion of adhesive MBO occurring after gynecological
procedures. In this study, the mean age was 44.5 years which is consistent with the age
incidence in many similar reports.4,8,9
The most regular presenting symptoms were colicky abdominal pain, vomiting, abdominal
distension and constipation which is in agreement with what is documented in
literature.5,7,11,12 -14 In addition, abdominal distension, tenderness and increased bowel sounds
were the most common signs. This study showed that adhesion was the most common cause of
AMBO and in majority of cases occurred after laparotomy which is similar to what was reported
by Lawal et al. The most common indications for previous abdominal surgery were generalized
peritonitis from ruptured viscous (mainly rupture appendix, perforated typhoid, perforated
gastric/ duodenal ulcers etc). In other studies, the most common indication for previous
abdominal surgery was appendectomy.1,15 Obstetrics and Gynecological conditions were the
indications for previous abdominal in 17.9% of patients which may be responsible for the
almost equal sex distribution seen in this study. It is of interest that cases of AMBO from hernias
were not as common as previous reports from this region4. This may due to the increasing
knowledge of hernia and rising fear of likely complications with majority of patients now
presenting early with uncomplicated hernia thus increasing the number of the elective hernia
surgery.
The complication rate in our study is 29.3% (n = 17) (some patients had multiple
complications). This is falls within the range of 14.7 -53.6% reported by Kagizman et al and
Uludag et al. The most common complication is surgical site infection (SSI) which constitute
64.7% (n = 11). This is similar to the report of Kaya et al and Adesunkanmi et al, who stated that
the wound infection is the most common complication. Eight of the cases of SSI resolved with
regular dressing while the remaining three were organ space (residual abscess), one of which
was aspirated percutaneously under ultrasound guidance and the remaining two were drained
with repeat laparotomy. The other complications were four cases of post-operative
enterocutaneous fistula, three of which resolved on conservative management, the fourth
requiring operative management. Two patients had burst abdomen and both had emergency
laparotomy with reclosure. Two patients had deep venous thrombosis (DVT) and there was a
case of massive pulmonary thromboembolism (PTE) who eventually died.
The overall mortality was 10.3% (n = 13) which is found to be related to the delay between
onset of symptoms and presentation in the hospital. This is comparable to 14% reported by
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Lawal et al and 12% reported by Ohene-Yeboah et al both in the developing countries. However,
the mortality rate recorded in this study was higher than the rate of 3.5% reported by Arshad et
al and 2.4% reported by Naseer et al, both in other developing communities.5,8 This may be
partly due to a difference in case mix, but complications related to late presentation in some and
in others due to associated poorly managed co-morbid illnesses, could be responsible.
Conclusion
The pattern of aetiology of mechanical bowel obstruction in our environment is changing with
postoperative adhesion taking the lead, while obstructed / strangulated hernia as a cause is
rather on a downward trend. We believe that the unacceptably high mortality can be reduced by
increasing the awareness of the public about AMBO with the need to present early coupled with
early diagnosis and prompt surgical intervention. In addition, research aimed at finding ways to
reduce adhesion formation may reduce the incidence of adhesive obstruction. Furthermore, a
general improvement in health care infrastructure especially in the rural communities could
further reduce mortality as patients may then present early and have prompt diagnosis and
treatment.
Reference
1. Ohene-Yeboah M, Adippah E, Gyasi-Sarpong. Acute Intestinal Obstruction in Adults in
Kumasi, Ghana. Ghana Medical Journal 2006; 40 (2): 50 -54
2. McConkey SJ. Case series of acute abdominal surgery in rural Sierra Leone. World J Surg
2002; 26: 509-513
3. Mark- Ever B. Small Intestine in Sabiston Textbook of Surgery, 18th Edition, Courtney
MT, Daniel RB, Mark ME, and Kenneth LM (editors): Elsevier Saunders; 2007; 1334-42.
4. Oladejo OL, Olayinka SO, John OB. Spectrum of causes of Intestinal Obstruction in Adult
Nigerian Patients.SAJS 2005; 43 (2): 34-36
5. Naseer AB, Din M, Shoaib AQ. Current Pattern of Mechanical Intestinal Obstruction In
Adults. Journal of Surgery Pakistan (International) 2011;16 (1): 38-40
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Naaeder SB, Tandoh JFK. Acute Intestinal Obstruction in Principle and practice of surgery
including pathology in the tropics. 4th edition, Badoe EA, Archampong EQ and da Rocha-Afodu JT
(editors): Ghana Publishing Cooporation. 2004: 572 - 599.
Haridimos M, Evangelos M, Dimitrios D, Nikolaos P, Dimitrios T, Panagiotis G et al. Acute
mechanical bowel obstruction: Clinical presentation,etiology, management and outcome. World
Journal of Gastroenterology 2007; 13 (3): 432-437
Arshad MM, Madiha S, Rafique P, Krishan S. Pattern of Intestinal Obstruction: Is There a Change
in the Underlying Etiology? Saudi J Gestroenterol. 2010; 16 (4): 272-274
Agarwal T, Sharma SC, Mamta S, Jain SK. Changing Pattern of Acute Intestinal Obstruction in
Western Up Region: An Observational Study. International Journal of Scientific Study 2014; 2 (5):
39 -41
Oladele AO, Akinkuolie AA, Agbakwuru EA. Pattern of Intestinal Obstruction in a Semi-urban
Nigerian Hospital. Niger J Clin Pract. 2008; 347-50 [PubMed: 19320408]
Abdulrahman SM. Intestinal Obstruction in Adult Saudi Arabian Population: A Review of 754
Patients. Scl. J. App. Med. Sci., 2014; 2 (5A): 1532-1536
Shawana A, Hafizullah K, Ishtiaq A K, Sher A, Salma G, Ziaur R. Aetiological Factors in Mechanical
Intestinal Obstruction. J Ayub Med Coll Abbottabad 2011; 23 (3): 26-28
Adesunkanmi ARK, Agbakwuru EA. Changing Pattern of Acute Intestinal Obstruction in Tropical
African Population. East Afr Med J 1996; 11: 726 - 730
Osuigwe AN, Anyanwu S. Acute Intestinal Obstruction in Nnewi Nigeria: A five year review.
Nigerian J Surg Res. 2002; 4: 107-11
Murat K, Akin O, Serkan P, Ibrahim A, Zulfu A, Fatih T et al. Mechanical Bowel Obstruction and
Related Risk Factors on Morbidity and Mortality. Journal of Current Surgery 2012; 2 (2): 55-61
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Peritonitis Outcome Prediction using Mannheim Peritonitis Index at St. Francis Hospital
Nsambya, Kampala - Uganda
A. Ojuka1,2, L. Ekwaro1, I. Kakande 1
of Surgery, Mother Kevin Post graduate medical School , Uganda Martyrs
University. 2Kanye SDA Hospital, Kanye, Botswana
Correspondence to: Dr. Andrew Ojuka, Email: andrewojuka@gmail.com
1Department
Background: A wide variety of disease states give rise to intra-abdominal infection 1. While
varying according to age, gender and geography, the three most common causes of
generalized peritonitis in low-income countries are probably appendicitis, perforated
duodenal ulcer and typhoid perforations, in no particular order 2.The management of
peritonitis for a long time has presented a challenge to surgeons despite different
advancements in the field of medicine. This led to the development of disease severity
grading systems that would aid in classifying patients by individual risk factors and hence
appropriately predict possible outcome. Mannheim Peritonitis Index (MPI) which was
developed by Wacha and Linder in 1983 is one of the scoring tools being used to predict
outcome. MPI was used to assess outcome in patients with peritonitis at Nsambya hospital.
The objective was to predict outcome using the MPI in patients with peritonitis at Nsambya
Hospital.
Methods: Retrospective and Prospective evaluation of the MPI score was performed for
patients with peritonitis who underwent surgical treatment at Nsambya Hospital for 15
months (Jan 2012- march 2013).
Results: Of the 62 patients included, 29 patients were retrospective and 33 patients
prospective, 46 (74.2%) were males while 16 (25.8%) were females, giving a male to
female ratio of 3:1. The mean age of presentation was 30.79 (Sd15.55) years, the youngest
being 11 years and the oldest 77 years.
The mean MPI was 21.92±6.02 points with 10 points as the lowest score and 37 points as
the highest score. 58.1% of our patients had an MPI score < 21and 29% MPI 21-29 and
12.9% MPI>29. No death was noted at MPI<21, 2 deaths at MPI 21-29 and 1 death at MPI
>29.
The most significant predictive factors for morbidity/mortality in this study were the
presence of organ failure and female gender. The ROC curve for morbidity showed a
predictive power of 0.875 with a sensitivity of 84.2% and a specificity of 90.7% at MPI of
≥26 points. The predictive power of the MPI for mortality was 0.579 with a sensitivity of
15.8% and a specificity of 100% at MPI score of ≥26 points. The positive predictive value
and negative predictive value for morbidity and mortality at MPI≥26 points were 75.9%,
94.4% and 100%, 95.9% respectively.
Conclusion: The MPI score is a good tool in predicting morbidity than mortality at Nsambya
hospital and can be used to evaluate outcome in patients with peritonitis.
Key words: Peritonitis, Prediction, Outcome, Mannheim Peritonitis Index
Introduction
Peritonitis, the inflammation of the serosal membrane lining the abdominal cavity and
contained viscera, is associated with a high mortality rate 3. Despite surgical treatment,
sophisticated intensive care units, latest generation antibiotics and a better understanding of
peritonitis’s pathophysiology, the mortality rates are still high, ranging from 10-30% even in
good centers 4, 5.
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The outcome of an abdominal infection depends on the complex interaction of many different
factors and the success obtained with the early onset of specific therapeutic procedures 3. Early
prognostic evaluation of abdominal sepsis is desirable to identify high-risk patients for more
aggressive therapeutic procedures such as radical debridement, lavage systems, open
management, and planned reoperations in cases where source control has not been achieved 5,6.
Many scoring systems have been invented for assessing risks of death in patients with
peritonitis. Nevertheless similar results have been achieved with the Mannheim Peritonitis
Index (MPI) which was developed by Wacha and Linder7 in 1983. It was developed based on the
retrospective analysis of data from 1253 patients with peritonitis, in which 20 possible risk
factors were considered. Of these only 8 proved to be of prognostic relevance and were entered
into the MPI, classified according to their predictive power. Patients with a score exceeding 26
were defined as having a high mortality rate. The index takes into account the patients age and
gender, organ failure, malignancy as the source of contamination, preoperative duration of
symptoms greater than 24 hours, origin of sepsis other than colonic, extent of spread and
character of peritoneal fluid. The effectiveness of the MPI as a reliable predictor of the
peritonitis outcome was also confirmed after investigation exceeding two thousand patients
from several European surgical units 8, 9. Prognosis in peritonitis is strongly influenced by the
health status of the patient at the start of treatment, and hence prediction of outcome can be
made on the basis of risk scores determined then.
Patients and Methods
It was both a retrospective and prospective observational study done over a period of 15
months. The Retrospective arm from January 2012 to August 2012 and Prospective arm from
September 2012 to March 2013. Patients in the retrospective arm were recruited when their
medical files had satisfactory information required for the study. In the Prospective arm,
patients were consecutively enrolled until the sample size was achieved. The study was
conducted in the department of Surgery of Nsambya Hospital which is a tertiary referral faith
based private not for profit hospital founded by Franciscan Sisters in 1903. All surgically
managed patients with peritonitis were included meanwhile all patients with peritonitis who
were medically managed or transferred in after laparotomy for peritonitis, or transferred out to
continue treatment elsewhere were excluded. The sample size was calculated using Fisher’s
formula and was 60 patients. Patients who met the inclusion criteria were enrolled in the study.
Prospective candidates for inclusion in the study were recruited by investigator at the initial
visit at the emergency department. Following a complete history taking and physical exam and a
diagnosis of peritonitis, full blood count, urea and electrolytes, liver function tests were done
and imaging studies ultra sound scan, plain abdominal X-ray were done to confirm or exclude
the diagnosis. The patients were resuscitated and targeting systolic BP > 100mmHg, pulse <100
beats. They were prepared for emergency surgery, unless they were unfit for surgery where
further resuscitation and monitoring were continued from the ward until they were fit for
surgery. Following anesthetic evaluation, the patients were transferred to theatre. At operation
the diagnosis was made or confirmed and the underlying cause of peritonitis determined.
According to the findings the following were done; appendisectomy, abscess drainage, repair of
perforation was done. Medical peritonitis was not further explored. The colon, small bowel were
explored and quantity and distribution of peritoneal fluid or abscess were recorded. Copious
lavage with 6 litres or more of normal saline was undertaken until the last effluent was free of
pus, inflammatory exudates or fibrinous sediments. Where abscess was found, a peritoneal
closed drain directed to the sub diaphragmatic spaces was left in situ.
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Postoperatively patients were monitored for resolution abdominal signs and return of bowel
sounds. The complications that occurred were also recorded. The end point of the treatment
was complete resolution of abdominal signs and return of bowel function. The study was
terminated when the patient was discharged from the hospital or died. There was no follow up
study. All specimens recovered from operation were subjected to histopathology for
malignancy. The Total MPI score was obtained by appropriately scoring as shown in the table 1
below. Total patient MPI score was the sum total of all the positive risk factor scores. Morbidity
was considered if patient’s hospital stay exceeded 14 days or if any of the following
complications arose: chest infection, surgical site infection, wound dehiscence, fistulation or
ileus lasting more than 5 days, DVT and pulmonary embolism.
Table 1. Mannheim Peritonitis Index (MPI) Score.
Risk factor
Yes
No
Age >50 years
Female gender
Organ failure
Malignancy
Preoperative duration >24 hours
Origin of sepsis not colonic
Diffuse peritonitis
Exudates: Clear
Cloudy/purulent
Faecal
5
5
7
4
4
4
6
0
6
12
0
0
0
0
0
0
0
0
0
0
In the Retrospective arm, Theatre operation records and ward admission records were used to
generate a list of patients who had been managed for peritonitis within the study period. Using
the list, admission files for patients who had peritonitis from January 2012 to August 2012 were
retrieved. The data in the files were analyzed and used to complete the questionnaires and only
files with required information were included in the study.
From the data collection sheets, data were progressively entered in Microsoft Excel Sheet. At the
end of collection, data was transferred to Medcalc Biomedical statistical software version
12.5.0for analysis. Descriptive statistics used included mean, mode, median, standard deviation,
measure of central tendencies and 2 x 2 tables were used for comparison of outcomes.
Confidence intervals of 97% were applied as necessary. Chi-square was used as a statistical test.
Individual patient MPI score and respective outcome were determined followed by stratification
of the scores into 3 main groups of <21 points, 21-29 points and >29 points. Morbidity and
mortality rates for the stratified MPI scores were calculated and the predictive power of the
MPI, sensitivity and specificity derived from receiver-operator characteristic (ROC) curve
analysis. Negative and positive predictive values were also calculated.
Results
A total of 62 patients were recruited in the study, 29 retrospectively and 33 prospectively. Forty
six (74.2%) of the patients were males and 16 (25.8%) were females with a male to female sex
ratio of 2.9:1. Their ages ranged between 11 and 77 with a mean of 30.8 years (Table 2). Table 3
shows the risk factors included in the MPI. Table 4 shows the source of infection. Perforated
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duodena ulcer and perorated appendix were the commonest source of sepsis. The two
accounted for two thirds (66.1%) of the cases. Perforated ileum was the third and accounted for
8 (12.9%) of the causes. There was one case of primary peritonitis. Only 12 of the 62 patients
in this study were operated within 24 hours of onset of symptoms. Seventy seven
percent were operated within 5 days after onset of symptoms and 8% of patients were
operated after 14 days of onset of symptoms. The longest preoperative duration of
symptom was 30 days and this was due to the fact that the patient had atypical
presentation of peritonitis.
Table 2. Sex and age distribution
Variable
Sex
Age
Frequency/Value
Percentage
46
16
55
7
30.8 years
11 years
77 years
74.2
25.8
88.7
11.3
-
Male
Female
<50
>50
Mean
Youngest
Oldest
Table 3. Risk factors included in MPI
Variable
Organ
dysfunction
Preoperative
Duration of
symptoms
Organ
dysfunction
Malignancy
Extend of
exudate
Character of
exudates
Yes
No
<24 hours
1 - 5 days
6 - 10 days
>10 days
Mean
Range
Ileus
Renal
Shock
None
Gastric adenocarcinoma
4 quadrants
2-3 quadrants
Localized
Cloudy
Fecal
Frequency/Value
Percentage
13
49
12
36
9
5
4.5 days
1-30 days
5
2
6
49
1
27
23
12
56
6
21.0
79.0
19.4
58.1
14.5
8.0
8.0
3.2
9.8
79
1.6
43.6
37.1
19.1
90.0
10.0
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Table 4. Source of sepsis
Source
Frequency/Value
Appendicitis
Ovarian Abscess
Para Nephric Abscess
Pelvic Abscess
Perforated Appendix
Perforated Duodenal Ulcer
Perforated Gastric Ulcer
Perforated Ileum
Perforated Sigmoid Colon
Primary Peritonitis
3
1
1
1
14
27
4
8
2
1
Percentage
4.8%
1.6%
1.6%
1.6%
22.6%
43.5%
6.5%
12.9%
3.2%
1.6%
Table 5. Morbidity and Mortality
Variable
Causes of
morbidity
Morbidity
Mortality
Hospital stay
Reoperations
Enterocutaneous
Fistula
Pneumonia
Septic shock
Wound sepsis
Male
Female
Female
Male
Mean
Range
In morbidity (mean)
No morbidity(mean)
Survivors (mean)
Non survivors(mean)
Frequency/Val
ue
Percentage (%)
Overall
%
2
3.2
-
1
3
14
8
12
2
1
8.7 days
1-54 days
13.6 days
6.4 days
9.1 days
2.0 days
3
1.6
4.8
22.6
17.4%
75.0
12.5
2.2
4.8 %
32.0
4.8
-
Those who were operated within 24 hours after onset of symptoms had a morbidity of 8.3% and
mortality of 16.7% meanwhile those who were operated after 24 hours of onset of symptoms
had a morbidity of 38.8% and mortality of 2%. Table 5 shows the morbidity and mortality
associated with peritonitis. The commonest cause of morbidity was surgical site infection
recorded in 14 (22.6%) of the cases. Three patients had re-operation. Two patients developed
entero-cutaneous fistulas. There were three deaths (mortality rate = 4.8%).
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Table 6. Analysis of MPI Scores
Variable
MPI
MPI
groups
MPI ≥
26
points
Mean
Range
Female (mean)
Male (mean)
<21 points
21-29 points
>29 points
Relative risk
Value/
Frequency
Percentage
Morbidity
Mortality
21.92(Sd
6.05) points
10- 37 points
28 points
19.8 points
36
18
8
19
-
-
27.8 points
28.3 points
58.1%
29%
12.9%
30.6%
-
12
3
1
1
1
-
63.2%
15.8%
5.2%
5.2%
5.2%
-
2 (5.6%)
11 (61%)
7 (87.5%)
16 (84.2%)
9.05 times
(P<0.0001)
84.2%
90.7%
75.9%
0 (0%)
2(11.1%)
1(14.3%)
3 (15.8%)
15.4 times
(p= 0.066)
15.8%
100%
100%
-
-
94.2%
95.9%
Wound sepsis
Septic shock
Fistula
Pneumonia
Reoperation
Sensitivity
Specificity
Positive predictive
value
Negative
predictive value
Morbidity_
100
Sensitivity
80
Sensitivity: 84.2
Specificity: 90.7
Criterion : >0
60
40
20
0
0
20
40
60
80
100-Specificity
100
Figure 1. Morbidity ROC Curve for MPI≥26, AUC = 0.875
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Mortality_
100
Sensitivity
80
60
40
20
Sensitivity: 15.8
Specificity: 100.0
Criterion : >0
0
0
20
40
60
80
100-Specificity
100
Figure 2. Mortality ROC Curve at MPI ≥26, AUC=0.579
The average hospital for the survivors and non-survivors was 9.1 and 2.0 days respectively. The
mean MPI for morbidity in this study was 27.8 points (19.2points for no morbidity) with group
morbidity rates rising progressively from 5.6% at MPI< 21 points to 87.5% at MPI >29 points.
Mortality also rose from 0% at MPI <21 points to 14.3% at MPI>29 (Table 7).
Table 7. Significant Risk Factors Included in the MPI
Risk factor
Female gender
MPI
Statistical test
<26
≥ 26
Yes
5
11
No
38
8
χ2=12.415:
(0.0004)
1df:
P<0.05
1df:
P<0.05
significant
Organ
dysfunction
Yes
1
11
No
42
8
No
40
13
χ2=22.631:
(0.0001)
significant
Discussion
The majority of the patients were young with a mean age of 30.79 ± 15.5 years and 75.8% of the
study group falling in the 10-40 years age category. Rodolfo et al10 in Mexico reported a similar
distribution with a mean of 34.6 years and median of 27 years 11 but studies from Europe show
a much older age group with a range of 44-58 years. The explanation could also be due to the
major etiological cause of peritonitis being perforated diverticulum and malignant perforations
in Europe which occurs in older age group 3, 5, 12, 13. In contrast to our setting where the major
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etiological cause of peritonitis was perforated peptic ulcers which is known to occur in younger
age group and has a strong association with H. pylori that is prevalent in developing countries
with low socioeconomic status like ours 14, 15.
Early operation within 24 hours carried a lower morbidity compared to operation after 24
hours of onset of symptoms. Though statistically there was no significant difference in
morbidity (p = 0.103) and hospital stay (p = 0.257) between those who were operated within 24
hours of onset of symptoms and those operated after 24 hours of onset of symptoms. Wabwire
16 found similar findings however Ntirenganya, Ntakiyiruta and Kakande 17 and Seiler et al 3
found that operation after 24 hours of onset of symptoms was associated with morbidity and
mortality. The explanation could be that in the later studies the major causes of peritonitis was
ileal17 and colonic perforation(1) respectively and therefore
more virulent bacterial
contamination from the sources accounted for the poorer outcome after 24 hours of onset of
symptoms compared to our study where there was less virulent bacterial contamination from
the perforated peptic ulcers.
Shock was the most frequent organ dysfunction encountered; 2 out of 13 of the patients who
had organ dysfunction died. They presented with irreversible septic shock despite resuscitation
and source control the outcome could not be changed. Eight out of the thirteen patients who
had the organ dysfunction had morbidity. The influence of organ failure on outcome has been
highlighted in previous studies, with some noting increasing mortality with more organs failing
and as high as 100% mortality were reported where 4 organs were failing 3,4,18,19. This study
found organ failure was associated with morbidity and mortality though only two patients had
more than one organ dysfunction (Septic Shock and renal dysfunction).
The mean MPI of 21.92 ± 6.05 points in this study compares well with previous studies. Sailer
et al 3 analyzed 258 patients with an exclusive diagnosis of generalized peritonitis and reported
so far the highest mean of 27.1 points. Bielecki , Karminski and Klukowski 20 found a mean of
24.2 points amongst patients with large bowel perforation. In this study, the mean male MPI
score of 19.8 points was lower than the overall study mean compared to female’s mean of 28
points. Females compared poorly to their male counterparts recording higher gender morbidity
(73.3%) and mortality (12.5%) rates compared to males with 19.1% morbidity and 2.1%
mortality. Like in other previous studies female gender was one of the risk factors for morbidity
in this study 3, 20.
The MPI for morbidity and mortality trend in this study is similar to what other studies have
found3, 17, 20. The overall mortality rate of 4.8% is quite lower than rates from European studies
of 6% to 42% 3, 8, 10, 13, 20, 21. Regionally, a rate of 12.9% was found in Kenya and 17% in Rwanda 16,
17. The mean MPI for non survivors was 28.3 points (21.7 points in survivors) and compared
favorably with other studies that gave a range of 26.3 -32.7 points 3, 8, 13, 21. In a meta-analysis of
results from 7 centers involving 2003 patients, Billing et al(8) reported an average group
mortality rate of 2.3% for MPI <21 points, 22.5% at MPI of 21-29 points and 59% with MPI of
>29 points. In this study, the group mortality rate were generally lower but appear to follow
this pattern as no mortality occurred at MPI <21 points, was 11.1% with MPI 21-29 points and
was14.3% with MPI >29points. Differences in patient’s sex, age, sepsis source and co
morbidities between our study populations may have been responsible for the lower mortality
rates observed in this study. Also Nsambya hospital surgery department had an overall low
annual mortality of 3.14% in 2012(22) which could have reflect good management of patients or
the patients that were presenting were not very sick and not having co morbidities.
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Multi-organ failure is the most common cause of death in peritonitis. It is often a sequel of
severe sepsis, the progenitor of systemic inflammatory response syndrome (SIRS) in this
setting, which culminates in multi-organ dysfunction syndrome (MODS) and eventually multiorgan failure (MOF)3, 8, 10, 13,21. Two out of the 3 patients who died had developed irreversible
septic shock, followed by renal failure and cardio-respiratory arrest despite aggressive
resuscitation and source control. Morbidity increased hospital stay significantly to a mean of
13.6 days (6.4 days without morbidity) eventually pushing the overall mean hospital stay to 8.7
days, a finding that was in keeping with other studies 8, 21, 23. The patients who had morbidity
(wound sepsis, fistulae, and pneumonia) had longer hospital stay in order to have the
complications managed. Prolonged hospital stay correlated with MPI ≥26 points in this study.
The most significant predictive factors for morbidity/mortality in this study were female gender
and organ dysfunction. Sailer et al3 whose study focused on generalized peritonitis reported
similar findings except that they found preoperative duration of symptoms also to significantly
influence eventual mean MPI from 23.2 to 29 points.
This study attained a morbidity predictive power of 0.875 by ROC curve analysis. This has
shown an excellent discrimination, with a good sensitivity of 84.2% and good specificity of
90.7% at a score of ≥26 points. This means MPI of ≥ 26 points can predict morbidity with good
precision and it is similar to other studies 3, 8, 11, 19, 21. In the ROC curve for mortality, Biondo et al
21 reported a predictive power of 0.725 at a MPI score of ≥26 points. Billing et al (8) in a Meta
analysis of 2003 patients reported a mean sensitivity of 86% (54%-98%) and specificity of 74%
(58%-97%) at a score of ≥ 26 points. This study attained a mortality predictive power of 0.579
with a sensitivity of 15.8% and specificity of 100% at an MPI ≥26 points. This result shows no
discrimination for mortality and is not statistically significant for predicting mortality though it
is very specific for those who will not die. The low mortality recorded in the study could explain
these findings.
Studies evaluating the usefulness of the MPI in outcome prediction in comparison with other
scoring systems have shown that it compares well with most of them, if not superior. Validation
studies comparing its strength in outcome prediction with established scoring systems like
acute physiology and chronic health evaluation (APACHE) II have shown that the two are
accurate predictors of early outcome in peritonitis 8, 19,21. Overall, our results validate MPI
usefulness in risk evaluation for morbidity. This study showed a statistically significant positive
predictive value of 75.9% and negative predictive value of 94.2% for morbidity and positive
predictive value of 100% and negative predictive value of 94.9% for mortality at MPI≥26
Conclusion
Increasing Mannheim Peritonitis Index score predicts poor outcome especially the morbidity.
The MPI score of ≥26 had a good sensitivity of 84.2% and specificity of 90.7% in predicting
morbidity. Paying close attention in these patients to maximally support vital systems and to
prevent complications is crucial for their eventual prognosis. Therefore MPI can be a useful tool
that can be used in our setting for predicting outcome in peritonitis and stratification of
management.
Recommendations
From the findings of this study, it is recommended that:-
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1) The MPI score be adopted as a risk evaluation tool in management of patients
with secondary peritonitis at Nsambya hospital with the aim of identifying and
aggressively managing high risk patients so as to improve outcome
2) Longer duration similar study could be done to further investigate the MPI and
mortality with more cases of mortality included.
3) Findings of this study can be used to develop a protocol for management of
patients with peritonitis and guidelines for admission of patients with peritonitis
into HDU/ICU.
References
1. Levinson M&BL. Peritonitis and Intra-abd Abscesses. In: Mandell B&D, editor. Principles
and Practice of Infectious Diseases. Churchill Livingstone, 2005.
2. Gupta S, Kaushik R. Peritonitis - the Eastern experience. World J EmergSurg 2006; 1:13.
PM:16759427
3. Seiler CA, Brügger L, Forssmann U, Baer HU, Büchler MW. Conservative surgical
treatment of diffuse peritonitis. Surgery 2000; 127: 178-84.
4. Malangoni MA. Contributions to the management of intraabdominal infections. [Review]
[30 refs]. American Journal of Surgery 2005; 190(2):255-259. http://hinarigw.who.int/whalecomwww.sciencedirect.com/whalecom0/science/journal/00029610
5. Correira MM et al, Prediction of death using the Mannheim peritonitis Index in oncologic
patients, RevistaBrasileira de Cancerologia, 2001, 47(1): 63-68
6. Wittman DH. Intra-abdominal infections: pathophysiology and treatment. New York:
Marcel Dekker, 1991: 48-51.
7. Wacha H, Linder MM, Feldman U, WeschG, Gundlach E, Steifensand RA. Mannheim
peritonitis index - prediction of risk of death from peritonitis: construction of a statistical
and validation of an empirically based index. Theoretical Surg 1987; 1: 169-77.
8. Billing A, Frölich D, Schildberg FW. Prediction of outcome using the Mannheim peritonitis
index in 2003 patients. Br J Surg 1994; 81:209-13.
9. Demmel
M,
Maag
K,
Osterholzer
G.Wertigkeitklinischer
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zurprognosebeurteilung der peritonitis - Validierung des Mannheimer peritonitis index.
Langenbecks Arch Chir 1994;379: 152-8.
10. Rodolfo L. Bracho-Riquelme MC, M en C, Armando Melero-Vela MC, Aidee TorresRamírez MC.Mannheim Peritonitis Index Validation Study at the Hospital General de
Durango (Mexico). Cir Ciruj 2002; 70: 217-225
11. Basnet RB, Sharma VK, Evaluation of predictive power of MannheimPeritonitis Index,
Postgraduate Medical Journal of NAMS, Jul-Dec 2010 , Volume 10/ No 2
12. Koperna T, Schulz F. Prognosis and treatment of peritonitis. Do weneed new scoring
system? Arch Surg 1996;131:180-186.
13. Ali Yaghoobi et al. Evaluation of Mannheim Peritonitis Index and Multiple organ failure in
patients with peritonitis. Indian Journal of Gastroenterology, vol 24, sept- oct 2005
14. Epidemiology of helicobacter pylori. The helicobacter foundation, 2013
http://www.helico.com/?q=Epidemiology
15. Vikram Kate, N. Ananthakrishnan, Frank I. Tovey, Is Helicobacter pylori Infection the
Primary Cause of Duodenal Ulceration or a Secondary Factor? A Review of the Evidence,
Gastroenterology
Research
and
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2013
(2013),http://www.hindawi.com/journals/grp/2013/425840.
16. Benjamin Wabwire et al, Stratified outcome evaluation in peritonitis, M Med (Surgery)
UoN dissertation 2009
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17. F. Ntirenganya, G. Ntakiyiruta, I. Kakande. Prediction of Outcome Using the Mannheim
peritonitis Index in Patients with Peritonitis at Kigali University Teaching Hospital, East
Cent. Afr. J. Surg, 2012; 17 (2): 52-64.
18. Schein M, Gecelter G, Freinkel W, Gerding H, Becker PJ. Peritoneal lavage in abdominal
sepsis. A controlled clinical study. Archives of Surgery 125(9):1132-5, 1990.
19. A.A. Malik, K.A. Wani, L.A. Dar, M.A. Wani, R.A. Wani, F.Q. Parray, Mannheim Peritonitis
Index and APACHE II - Prediction of outcome in patients with peritonitis, Turkish Journal
of Trauma & Emergency Surgery 2010;16 (1):27-32
20. Bielecki K, Karminski P, Klukowski M. Large bowel perforation: morbidity and
mortality. Tech Coloproctol 2002; 6: 177-182
21. Biondo S, Ramos E, Fraccalvieri D, et al. Comparative study of left colonic peritonitis
severity score and Mannheim peritonitis index. Br J Surg 2006; 93: 616-622
22. Surgical Audit, Department of surgery, Nsambya Hospital Kampala, Jan 2012- Dec 2012
23. Bosscha K, van Vroonhoven TJ, van der WC. Surgical management of severe secondary
peritonitis.[see comment]. [Review] [85 refs]. British Journal of Surgery 86(11):1371-7,
1999.
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Course of the Sciatic nerve: a Review of Cases Seen at Mulago Hospital, Kampala - Uganda
J. Kukiriza, C. Ibingira, J. Ochieng
Department of Anatomy, School of Biomedical Sciences, Makerere University, Uganda
Correspondence to: J Ochieng, Email: ochiengjoe@yahoo.com
Background: The sciatic nerve is the largest in the body with nerve roots L4, 5 S1, 2, 3. It is
commonly injured in the body particularly following administration of gluteal
intramuscular injections to children. The nerve usually leaves the pelvis by passing
through the greater sciatic foramen below the piriformis and anterior to the superior and
inferior gamelli and the obturator internus muscles. However, it should be noted that this
usual course varies on many occasions and these variations have been cited as
predisposing factors to certain clinical conditions including piriformis syndrome,
coccydynia, muscle atrophy, traumatic administration of intramuscular injections leading
to foot drop and bilateral gluteal fibrosis. This study describes the course of the sciatic
nerve among adult subjects at Mulago hospital complex.
Methods: This was a cross-sectional descriptive study conducted at the department of
anatomy dissection laboratory Makerere University and the associated Mulago teaching
hospital mortuary. Dissections of the lower limbs from the gluteal region through the thigh
to the leg were done to expose the nerves and surrounding structures.
Results: A total of 80 adult thighs and gluteal regions were dissected in 56 males and 24
females to trace and expose sciatic nerves. . All sciatic nerves were located in the lower
medial quadrant between the ischial tuberosity and the greater trochanter. In the gluteal
region, the whole sciatic nerve measured 4.2 cm, and among subjects with bifurcated
nerves, the tibial and common peroneal nerves were 4.67cm and 3.3cm, respectively, along
a perpendicular line drawn medially from the midpoint between the posterior superior
iliac spine and the greater trochanter.
Conclusion: The course of the sciatic nerve in the gluteal region is variable and hence,
appreciation of these variations can be useful during clinical and surgical procedures in
the gluteal and thigh regions.
Key word: sciatic nerve, course, cases
Introduction
The sciatic nerve (L4, 5 S1, 2, 3) is largest and most commonly injured nerve in the body
particularly following administration of gluteal intramuscular injections to children. It usually
has two branches as the tibial and common peroneal nerves and innervates the muscles and
skin of the gluteal region, posterior thigh, leg and foot.
The nerve leaves the pelvis by passing through the greater sciatic foramen below the piriformis
and anterior to the superior and inferior gamelli and the obturator internus muscles 1, 2.
However, this usual course may at times vary and these variations have been cited as
predisposing factors to certain clinical conditions like Piriformis syndrome, Coccydynia, muscle
atrophy and trauma when administering intramuscular injections leading to foot drop and
bilateral gluteal fibrosis 3-7. Proper location of the nerve is also important for sciatic nerve block
that is employed to facilitate surgery on the leg and foot. Despite the importance of the nerve, its
vulnerability to iatrogenic injury and plenty of literature on its course, no such documentation
had been made among the Ugandan population. We are reporting findings of a study conducted
among cases seen at the department of Anatomy Makerere University and its associated Mulago
National Referral and Teaching Hospital.
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This study set out to describe the course of the sciatic nerve among cases seen at Mulago
hospital complex.
Subjects and Methods:
This was a cross-sectional descriptive study conducted at the department of anatomy dissection
laboratory Makerere University and Mulago teaching hospital mortuary. Using a dissection
manual, the lower limbs were dissected from the gluteal region to the upper leg in order to
expose the nerve. The relationships and branches of the nerve along its course were then
identified, recorded and photographed. Measurements were taken using a tape to estimate the
distances. Ethical review and approval was sought from the Makerere University Faculty of
Medicine 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 thighs from 56 males and 24 females were dissected. 60 were postmortem
(41 male/19 female) and 20 were from the anatomy dissection laboratory (15 male/5 female).
All the sciatic nerves were located in the lower medial quadrant between the ischial tuberosity
and the greater trochanter. In 18 (22.5%) of the cases, the nerve bifurcated in the gluteal region
but all others occurred in the posterior thigh. In 4 (5%) of the cases, the tibial nerve passed
below superior gamellus and the common peroneal nerve passed above the same muscle. Yet in
another 2 (2.5%), the common peroneal nerve passed above and the tibial nerve below the
piriformis. (Figure 1 and 2)
In one case (1.2%) the common peroneal nerve pierced the piriformis and the tibial nerve
passed below it. In the gluteal region, the whole sciatic nerve was 4.2 cm, and among subjects
with bifurcated nerves, the tibial and common peroneal nerves were 4.67cm and 3.3cm
respectively along a perpendicular line drawn medially from the midpoint between the
posterior superior iliac spine and the greater trochanter.
Figure 1. Common peroneal nerve (A) passing above superior gamellus (B) and Tibial nerve (C)
passing below.
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Figure 2. Common peroneal nerve (A) passing above piriformis (B) and the Tibial nerve
passing below piriformis.
Discussion
All the sciatic nerves were located in the lower medial quadrant between the ischial tuberosity
and the greater trochanter. This is in agreement with other studies which have indicated that
the traditional outer upper quadrant is still safe for administration of intramuscular injections
and hence calling the lateral side of the gluteal region a side of safety. The superolateral
quadrant of the gluteal region has also been preferred for intramuscular injections because it
has been found to be relatively free of nerves and blood vessels (8). Hence the need to stress that
gluteal injections should be given in the lateral upper quadrant in order to minimize the injuries
to the nerve which are still common in Uganda.
The common peroneal nerve passed through the piriformis muscle in 1.2% of all cases in this
study. Similar studies have found, however, the whole sciatic nerve passing through the
piriformis in 0.8% in Americans(9) 2.2%,(10),, and 15% in another study among Amaricans (11) of
individuals, respectively. The implication of this in individuals with this variation is that when
the piriformis muscle contracts, it compresses the nerve which may lead to sciatic nerve pain
known as piriformis syndrome. (9-11). The findings of 2.2% and 0.8% are close to what is being
reported in the current study of Ugandan population which is 1.2%. However, this is very far
from the 15% reported in another study.
The tibial nerve passed below the superior gamellus while the common peroneal nerve passes
above the superior gamellus in 5% of the cases. (Figure 1) A similar variation was observed in
some of the cases dissected in previous studies (12-14). This makes the Uganda population exhibit
similarities to other populations. In 2.5% of the cases the common peroneal nerve passed above
the piriformis muscle whereas the tibial component passed below (Figure 2). Similar variations
have been reported in other related studies (15, 16).
As a result of these variations, the tibial nerve may be either found between the piriformis and
the external rotators of the thigh or between the superior gamellus and the obturator internus
muscle, resulting in the compression of this nerve when these muscles contract leading to
piriformis or superior gamellus syndromes (17). Much as the occurrence of these variations is not
so high, their existence should be taken into consideration by clinicians in the etiology and
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pathogenesis of sciatica. It should be noted that the above variations occurred in cases where
the sciatic nerve entered the gluteal region in a bifurcated state indicating a high risk of
compression of the nerve in these people than in cases where the nerve enters the gluteal
region in an intact state.
The sciatic, tibial and common peroneal nerves were found at mean variable distances along a
perpendicular line drawn medially from the midpoint between the posterior superior iliac spine
and the greater trochanter of the femur of; 4.2cm, 4.67cm and 3.3cm respectively. Previous
studies have reported this distance to be 3-5cm and 2-5cm (18, 19). Hence the findings in this
study are in agreement with previous studies elsewhere. This technique is applied to locate the
nerve during the posterior approach of sciatic nerve block in the gluteal region. It is usually
done in surgery of the knee, tibia, ankle, foot, calf and Achilles tendon. The major trunk of the
nerve before it gives off the hamstring branches is found at variable distances on this medial
perpendicular line. As a result, the needle is placed at the 5cm point if the anesthesia is to be
placed proximal to the nerve. Additionally, modern technology like ultrasound-guided nerve
blocks has proved to be more successful and effective and should be applied in our population.
(13, 14 20-22)
Conclusions
The sciatic nerve and its components in this study were found in the lower medial quadrant of
the gluteal region and therefore the outer upper quadrant is still safe for administration of intra
muscular gluteal injections.
The tibial nerve passed between the superior and the inferior gamelli while the common
peroneal nerve passed between the piriformis and the superior gamellus in 5% of cases. The
common peroneal nerve pierced the piriformis and the tibial nerve passed below it in 1.2% of
cases. The point of 5cm along a perpendicular line drawn medially from the midpoint between
the posterior superior iliac spine and the greater trochanter of the femur is still safe for needle
placement during sciatic nerve block in the gluteal region among the Ugandan population
studied.
Acknowledgement
We appreciate the financial assistance from SIDA/SAREC which enabled this study to be
conducted. Our thanks go to the s Departmental staff of Anatomy and Pathology, School of
Biomedical Sciences, Makerere University.
.References:
1. Moore KL, Daley FA. Clinically oriented anatomy, Fifth edition. Baltimore, Lippincott
Williams and Wilkins. c2006. p. 379
2. Snell RS. Clinical Anatomy. Seventh edition. Lippincott Williams and Wilkins. 2006.
Chapter 10, Sciatic nerve; pg 610- 611.
3. Small SP. Preventing Sciatic nerve injury from intramuscular injections. Journal of
Advanced Nursing. 47(3): 2004 August; pp. 287- 296
4. Papadopoulos SM., McGill cuddy JE, Alberts LW. Unusual case of piriformis muscle
syndrome. Arch. Neurologia. 47(10): 1990; pp.1144-1146.
5. Okello J, Franceschi F, Kintu D, Otim L. Report on foot drop in CORU Mengo Hospital. East
and Central journal of surgery. 12 (1): 2006 April; pp. 139-143.
6. Ekure J. A case report of bilateral gluteal fibrosis. East and Central African journal of
surgery. 11(2): 2006 December; pp.78-104
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7. Naddumba EK, Ndoboli P. Sciatic nerve palsy associated with intramuscular quinine
injections in children. East and Central African Journal of surgery vol.4, no.2, 1999, pp.
17-20.
8. O’rahilly, Muller, Carpenter and Swenson, Basic anatomy, 2008, Partmouth Medical
School, (http://www.partmouth.edu/~.humananatomy/part_3/chapter_14.html)
9. Beaton LE, Anson AJ. The relationship of the sciatic nerve and of its subdivisions to the
piriformis muscle. Anat. Rec. 70; 1-5. 1937.
10. http://www.en.wikipedia.org/wiki/piriformis_syndrome
11. http://www.rice.edu/˜jenky/sports/piri.html
12. Babinski M A, Machado FA., Costa WS. A rare variation in the high division of the Sciatic
nerve surrounding the Superior gamellus muscle. European journal of morphology.
Volume 41; 1st February 2003. pg 41-42.
13. Jaijesh P, Satheesha N. A case report of bilateral high division of sciatic nerve with a
variant inferior gluteal nerve. Journal of neuroanatomy. Vol 5: 33-34, August (2006)
Available at; (http://www.neuroanatomy.org)
14. 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, volume 2; 2003,
page 13-15. (http://www.neuroanatomy.org/2003/013_015.pdf
15. Machado FA, Babinski MA, Brasil FB, Favorito LA, Abidu FA, Costa MG: Anatomical
variations between sciatic nerve and piriformis muscle during fetal period in human. Int.
Journal of Morphology. 21(1); 2003. Pp29-35.
16. Prasad AM, et al. Clinically important variations in the lower limb- a case report.
European journal of anatomy, 9(3): (2005). Pp.167-169.
17. Arifoglu Y, Sürü .C. H. S, Sargon. M.F, et al. Double superior gamellus together with double
piriformis and high division of the sciatic nerve. Volume 19, number 6 / March, 1998.
18. Shruti S, et al. Neurological complication after anterior sciatic nerve block. Journal of
Anesth Analg. vol.100: 2005. Pp.1515-1517.
19. Labat G. Regional anesthesia: Its technique and clinical application. Philadelphia, PA: WB.
Saunders, 1992. (http://www.cookcountryregional.com/chapter_frame7.htm)
20. 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
21. 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.
22. J. Kukiriza; H. Kiryowa, J. Turyabahika; J. Ochieng; CBR Ibingira. Levels of Bifurcation of
the Sciatic Nerve among Ugandans at School of Biomedical Sciences Makerere and
Mulago Hospital Uganda. East and Central African Journal of Surgery. Vol 15 No 2
July/Aug 2010
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A Rare Case of Rosacea Rhinophyma in an African Patient.
F.C. Muchemwa1, 2, O.B. Chihaka1, R. Mutasa3, G.I. Muguti1
1Department of Plastic and Reconstructive Surgery
2Department of Immunology ,
3Department of Histopathology
University of Zimbabwe College of Health Sciences
Corresponding to: Dr. Faith C Muchemwa, E mail: fcmuchemwa@yahoo.co.uk
Rosacea rhinophyma is an extremely rare entity in the African population; only 4 cases
have been reported to date. We report the case of a 72-year-old African man, with a 4 year
history of an enlarging nodular mass on the nose. Examination led to the diagnosis of
rosacea rhinophyma. A shave procedure using a scalpel was used to excise the phymatous
tissue and histological analysis confirmed the diagnosis of rosacea rhinophyma. The
patient healed well by epithelialization and was discharged on the 5th day. He was very
satisfied with the immediate cosmetic result, however, he defaulted long-term follow-up.
We report the first case of rosacea rhinophyma in an African patient in sub-Saharan Africa,
and the fifth in the published literature
Key words: Rosacea, Rhinophyma, African
Case report
A 72 year old man, a peasant farmer presented with a 4 year history of progressively enlarging
nodules on his nose. The symptoms started insidiously, when the patient noticed some acne-like
lesions which produced a foul smelling discharge. Scratching and frequent squeezing resulted in
hypertrophic scarring and progressive enlargement of the nose. There was gross disfigurement
but the enlarged nose did not affect or compress the nares. Pressure on the acneoid lesions
forced out whitish, pasty, and fetid sebum. He had no significant surgical or medical history and
was not on any medication. He occasionally took opaque beer and had a 4 pack-year history of
cigarette smoking. He was widowed 30 years ago and had remarried; he had a total of 14
children.
On examination he was a healthy elderly man with a non-contributory systemic examination.
Local examination showed nodular lesions affecting all aesthetic units of the nose. The largest
nodule was on the right alar-nostril and the nasal tip significantly protruded anteriorly. The
clinical picture of this patient is shown in Figure 1.
The patient then proceeded to have a shave procedure of the phymatous lesion under general
anaesthetic. Meticulous haemostasis was achieved by electrocautery and the patient was
dressed with tulle gras for 5 days. The first exposure showed partial epithelialization as shown
in Figure 1. The patient was then discharged on day 5 post operatively. Histological
examination of the specimen revealed a lesion comprised of hyperplastic sebaceous glands, and
distended hair follicles, some of which were distended by keratin. The pilo-sebaceous units
were surrounded by an inflammatory infiltrate, comprised of lymphocytes, plasma cells &
histiocytes.The dermal matrix showed solarelastosis and only mildly telengiectatic vessels. No
granulomata or micro-abscesses were evident.
The appearances were consistent with the phymatous subtype of rosacea (Fig 2). The patient
did not report for long-term follow up and attempts to contact him were fruitless.
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Figure 1.Pre-operativeand day 5 post-operative pictures of the
phymatous nose.
Figure 2. Low and high power fields of ahaematoxylin &eosin
(H&E) section of the phymatous tissue showing dermal solar
elastosis with distended hair follicles & sebaceous glands
surrounded by an inflammatory infiltrate of lymphocytes,
plasma cells & histiocytes.
Discussion
Rosacea rhinophyma is part of a complex dermatological condition known as rosacea,
comprising three main subtypes:
the erythemato-telengiectatic, papulopustular, and
phymatous type. This is a condition which is common in the Caucasian population and is very
rare in the black population. Rosacea is four times more common in Caucasians than in Asians
and Africans.
Rhinophyma is generally accepted as being an end stage of acne rosacea, a connection first
suggested by Virchow in 1864. Acne rosacea is three times commoner in women than men,
whereas the incidence of rhinophyma is nearly twenty times greater in men. This discrepancy
may possibly be explained by an androgenic hormonal influence.
There is a very remote risk of malignant transformation in rosacea rhinophyma; Ross and
Davies presented a case of squamous cell carcinoma arising from a rhinophyma of 10 years1,
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however, our case was confirmed to be completely benign.There are, however, significant
psychological, functional, aesthetic consequences of this condition.
Conventional surgical methods utilize a scalpel, skin graft knife, carbon dioxide laser
vaporization 2, 3 electrocautery or cryotherapy. However, disposable shavers were described to
be cheap, easy to use and in inexperienced hands, allow for better depth gauging therefore
preventing inadvertent cutting of deep tissues 4. In this case, we used a scalpel and managed to
get an excellent result.
Although rosacea rhinophyma is fairly common in fair skinned people of celtic origin, it is
uncommon in black people5, only 4 cases have been reported in the literature 6,7,8. The reason
for the racial disparity is not known, but may be related to the way the different races
respond to sun damage, as sun damage appears to play an important role. Our patient had
significant dermal solar elastosis as illustrated in Fig 2.We report here the 5th case of rosacea
rhinophyma in an African patient, and the first to be reported from sub-Saharan Africa.
References
1. DA Ross, MP Davies. Squamous cell carcinoma arising in rhinophyma. Journal of the
Royal Society of Medicine 1992: 85; 236-37.
2. Roenigk RK. Carbon dioxide laser vaporization for the treatment of rhinophyma. Mayo
Clin Proc 1987; 62: 676–80.
3. el-Azhary RA, Roenigk RK, Wang TD. Spectrum of results after treatment of rhinophyma
with the carbon dioxide laser. Mayo Clin Proc 1991; 66: 899–905.
4. Jonathan M Fishman, Sujata Kundu, Mark Draper. ‘A close shave’ use of a disposable
razor blade in the management of rhinophyma. Ann R Coll Surg Engl 2009; 91: 161-70.
5. Rosen T, Stone MS. Acne rosacea in blacks. J Am Acad Dermatol 1987;17:70-3
6. Allah KC, Kossoko H, Yéo S et al, Rhinophyma in a black African male patient. Rev
Stomatol Chir Maxillofac. 2009;110:347-9.
7. Koffi-Aka V, Kouassi AA, D'Horpock FA et al,.Rhinophyma in a black African Rev
Laryngol Otol Rhinol (Bord). 2002;123:109-10. (Article in French)
8. Redett RJ, Manson PN, Goldberg et al. Articles Methods and Results of Rhinophyma
Treatment. Plastic & Reconstructive Surgery 2001; 107:1115-23.
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Gossybipoma, an Overlooked Cause of Bowel Obstruction: A Case Report and Literature
Review.
Y. Mohammed1, A. Ali2
Hospital, Department of Surgery
2 Addis Ababa University School of Medicine TAH, Department of Surgery
Correspondence to: Yusuf Mohammed, Email: dr.yusufmohammed@yahoo.com
1 Ethio-Tebib
Gossypiboma or Retained Surgical Sponge (RSS) is not an ordinarily encountered
occurrence. It is most often reported less for fear of its medico-legal implications
and possible unfavorable exposure. Here we report the first ever published case in
Ethiopia of a transmural migration of a RSS causing small intestinal obstruction.
The 38 year old patient presented with signs and symptoms of intestinal
obstruction nine months following a Caesarian Section. Confirmation of a RSS as the
cause of the obstruction was made only at surgery. Right hemi- colectomy with
ileotransverse anastomosis was done as the distal ileum containing the RSS was
gangrenous. The patient had an uneventful stay in the hospital and was discharged
in a stable condition.
Keywords: Gossypiboma, retained surgical sponge, transmural migration, intestinal
obstruction.
Introduction
Gossypiboma, Textiloma, Gauzoma and Muslinoma are among the terms used to
describe RSS post-operatively1. This iatrogenic but avoidable misfortune is often
underreported and is seen to have damaging effect to the health of the patient, and
entails an embarrassment as well as medico-legal consequences to the surgeon1,2 .
Diagnosis is usually difficult since clinical symptoms are vague and imaging
characteristics are diverse3.
Gossypibomas can be discovered in the early post-operative period or may remain
silent for years2,4 . Various types of foreign bodies can be retained following a surgical
procedure. Among the list are included; surgical sponges, towels, haemostatic forceps,
retractors, pieces of drainage tubes etc2,5. The most commonly found among these is a
surgical sponge. This can be due to its small size, common usage and ill-defined shape.5
Transmural migration of a RSS is a rare event. It occurs as a result of the RSS abutting
against the wall of the intestine and causing an inflammation that eventually evolves
into necrosis1,6.
In a systematic review covering the period 1960-2007, Zantvoord et al. found 64 cases
of transmural migration of RSS6. Migration of RSS has been reported to occur into any
organ like the stomach, duodenum, ileum, colon, urinary bladder and the diaphragm.2,3,6.
However the most commonly involved is the ileum3,6. We report a case of RSS that
underwent a complete transmural migration and subsequently causing small intestinal
obstruction.
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Case Report
A 38 year old lady presented to our hospital with complaints of severe crampy
abdominal pain and vomiting of two weeks duration. The vomiting was feculent and she
also had failure to pass faeces and flatus for one week. She had caesarian section done 9
months back at a private hospital. Soon after the 2nd post-operative day, she began to
experience abdominal pain and occasional vomiting. She was discharged on the 3rd postoperative day despite the presence of the symptoms. On the 7th post-operative day she
went back to her doctor for a checkup, but was told that all is going well. Two months
passed without improvement in the symptoms. She spent most of her time in bed as the
abdominal pain would force her to bend forward when trying to walk. But one day she
felt sudden onset of shortness of breathing and chest pain associated with left leg
swelling. She was hospitalized in a medical intensive care unit for twenty one days for
the treatment of pulmonary thromboboembolism and deep venous thrombosis. Then
she went abroad to South-East Asia to seek better medical care. Even though
sophisticated investigative modalities like CT angiography of the chest were used, the
focus was solely on pulmonary thromboboembolism and deep venous thrombosis
management, thus was no solution to the abdominal complaints.
Upon her presentation to us, the pertinent physical examination findings were; BP110/90 mmHg, P.R. - 100/min, R.R. – 24/min, sunken eyeballs, dry tongue, distended
abdomen, which was tender on left lower quadrant and hyperactive bowel sounds.
Routine laboratory investigation results were WBC- 10,300/mm3, Hgb- 14.5 g/dl, liver
and renal function tests and serum electrolytes (Na+, k+, Cl-) were all in the normal
ranges. Plain abdominal film showed centrally located distended bowel loops with
multiple air-fluid levels. Ultrasound examination was normal.
Figure 1. Retrieved RSS after laparotomy
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With the impression of mechanical small bowel obstruction, she was admitted,
resuscitated and explored. Intra-operative finding was distended loops of the whole
length of ileum and jejunum. The most distal end of ileum was found to be purplish in
colour and a firm but compressible ill-defined mass was felt inside it. Ileotomy was done
to reveal the content and to our astonishment a surgical sponge sized 25 cm x 25 cm
was surely recovered. The ileum was given adequate time for the ischemia to improve
but it showed no sign of recovery. Right hemicolectomy with ileo-transverse
anastomosis was performed. Inadvertent perforations that resulted while trying to
release adhesions between proximal loops of ileum were closed. Patient was discharged
well on the 11th post-operative day.
Discussion
Gossypiboma denotes a mass of cotton matrix that is retained inside the body following
surgery.4 ‘Gossypium’ means cotton in Latin and ‘boma’means a place of concealment in
Swahili.4 Although it is a preventable gross error, it continues to be reported worldwide
since the first case was described by Wilson in 1884 4,7. The incidence is estimated to be
1 in 100-3000 surgeries and 1 in 1000-1500 laparotomies 7,8. Abdomen takes the
biggest share (56%), followed by the pelvis (18%) and the thorax (11%)1.
The manifestations of RSS can be acute or chronic depending on the type of reaction it
induces in the surrounding tissues; the first type is an aseptic fibrinous response
characterized by granuloma and scar tissue formation that encapsulates the retained
foreign body1,4,5,7,8. The second type is an exudative reaction which may result in wound
infection, abscess, fistula formation or sepsis1,4,5,7,8. Although it is rare, transmural
migration of RSS can occur as a result of necrosis of bowel wall due to inflammation1,7,8.
The sponge is then driven by peristaltic waves to be expelled per rectum5,9. But in most
cases the sponge is stuck at the terminal ileum causing intestinal obstruction1,9. In
majority of the previously reported cases, no sign of intestinal wall opening or fistula
were observed at the time of surgical exploration5,7. This could be contrary to our
finding since the site of adhesion between proximal loops of ileum was most likely the
point of entry.
Although the diagnosis of RSS can be made by taking a detailed history, a
comprehensive physical examination and using different radiographic modalities, still
some are diagnosed at the time of explorative laparotomy5. It should be stressed that
the physician should always have a high index of suspicion in a patient giving a previous
history of surgery and presenting with persistent abdominal pain, signs of infection or a
palpable mass1,10.
Our patient had been to three different hospitals in search of a solution but got none as
a critical fact of her history was unmistakably overlooked. And the fact that she
developed deep venous thrombosis and pulmonary thrombo-embolism eventually
shifted the attention of the responsible physicians away from the abdominal complaints.
Sticking to the golden rule, i.e., a comprehensive physical examination of all systems be
done regardless of the complaints the patient may present with, saves one from missing
such rare incidents.
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The diagnostic modalities that can be used to show RSS are; plain radiographs (35%),
ultrasound (34%), CT (6%)1,4. Since almost all centers in Ethiopia are using surgical
sponges without radio-opaque markers, plain x-rays will have limitations in aiding to
make the diagnosis. The radio-opaque markers even if present undergo disintegration
with the passage of time adding to the diagnostic difficulty 4,5,11.
Gossypibomas can have calcifications and ‘whorl-like pattern’ on plain x-ray7,12.
Ultrasonography allows the identification of gossypibomas including the radiolucent
ones, the common finding being a poorly echogenic or cystic mass with hyperechoic
center of wavy structures and a strong posterior acoustic shadow4,5,7,12. A combination
of clinical and ultrasonographic evidences assists the diagnosis of RSS to be made
successfully in more than 65% of cases13.
Both plain abdominal x-ray and ultrasound examination failed to give a hint as to the
presence of RSS in our patient. This could be due to lack of radio-opaque marker on the
surgical sponge and since the RSS was present completely within the lumen of small
bowel5. Moreover, no one had in mind the suspicion of a case of RSS when performing
the investigations.
CT excels plain radiographs in detecting RSS14. The most characteristic appearance is a
low density heterogeneous mass with a spongiform pattern that contains gas
bubbles1,14. Even though the abdominal complaint was persistent, abdominal CT was not
done for our patient as the presence of RSS was not suspected. The most usual mode of
intervention in patients diagnosed to have RSS is re-operation, which may also help to
solve the resulted complications such as bowel obstruction and fistulae4. Laparoscopic
removal is also a possibility for those who are diagnosed early4,7.
The most common factors associated with RSS are emergency operations, unplanned
changes in the surgical procedures and high body mass index 3. Other reasons include;
lengthy procedures, change in nursing staff during procedures and failure to count
surgical instruments and sponges3. Since the overall burden incurred by the patient is
too heavy, all health workers should give emphasis to the preventive measures that
should be taken to tackle this dreadful experience. Crucial to the implementation of this
step is strict adherence to the operating room guidelines under all circumstances. The
most important being meticulous count of all surgical materials. This should be done at
the setting of instruments, just before incision, at the start of closure of body cavities
and at skin closure 1,10. The surgeon should also do thorough exploration of the surgical
site at the conclusion of the procedure 1,10. And routine use of surgical textile materials
impregnated with a radio-opaque marker should be encouraged 1,10.
References
1. S.P. Stawicki, D.C. Evans, J. Cipolla, M.J. Seamon, J.J. Lukaszczyk, M.P. Prosciak et al.
Retained surgical foreign bodies: a comprehensive review of risks and preventive
strategies. Scand J Surg. 2009; 98(1):8-17.
2. Malhotra MK. Migratory Surgical Gossypiboma- Cause of iatrogenic perforation: Case
report with review of literature. Niger J Surg. 2012; 18:27-9.
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3. Yun-Xiao Lv, Cheng-Chan Yu, Chun-Fang Tung, Cheng-Chung Wu. Intractable
duodenal ulcer caused by transmural migration of gossypiboma into the duodenuma case report and literature review. BMC Surgery 2014; 14:36.
4. Kohli S, Singhal A, Tiwari B, Singhal S. Gossypiboma, varied presentations: A report
of two cases. J Clin Imaging Sci 2013; 3:11.
5. Md. Moniruzzaman Sarker, A.K.M. Golam Kibari, Md. Manzurul Haque, Kali Prosad
Sarker, Md. Khalilur Rahman. Spontaneous transmural migration of a retained
surgical mop into the small intestinal lumen causing sub-acute intestinal
obstruction: a case report TAJ 2006;19(1):34-37.
6. Zantvoord Y, Weiden RM, van Hoof MH. Transmural migration of retained surgical
sponges: a systematic review. Obstet Gynecol Surv. 2008; 63(7):465-71.
7. Singhal BM, Kumar V, Kaval S, Singh CP. Spontaneous intramural migration of
gossypiboma with intestinal obstruction. OA case reports 2013 Nov 15; 2(5):145.
8. Sarda AK, Pandey D, Neogi S, Dhir U. Postoperative complications due to a retained
surgical sponge. Singapore Med J 2007; 48(6):160-164.
9. Luigi Camera, Marco Sagnelli, Paolo Guadagno, Pier Paolo Mainenti, Teresa Marra,
Maria Scotto di Santolo et al. Colonic perforation by a transmural and transvalvular
migrated retained sponge: Multi-detector computed tomography findings. World J
Gastroenterol 2014; 20(15): 4457-4461.
10. A.Y Ukwenya, P.M Dogo, A. Ahmed, and P.T Nmadu. The retained surgical sponge
following laparotomy; forgotten at surgery, often forgotten at diagnosis. Our
Experience. Nigerian Journal of Surgical Research Vol. 8 No. 34 2006; 164-168.
11. Gencosmanoglu R, Inceoglu R. An unusual cause of small bowel obstruction:
gossypiboma- case report. BMC Surg 2003; 3:6.
12. Coche G, Pardonnet MH, Chanois AM, Rohmer P, Weill FS, Etienne G et al.
Ultrasonography, x-ray, computed tomography in the diagnosis of intraabdominal
textiloma: Apropos of 12 cases. J Radiol 1988; 69: 243-51.
13. Tacyildiz I, Aldemir M. The mistakes of surgeons: ‘Gossypiboma’. Actachir Belg.
2004; 104(1):71-5.
14. Manzella A, Filho PB, Albuquerque E, Farias F, KaercherJ. Imaging of gossypibomas:
pictoral review. AJR AmJ Roentgenol 2009; 193:594.
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Fourth Consecutive Ectopic Pregnancy- Beating the previous number
S.R. Singhal1, V. Sangwan2
Institutional Affiliation- 1Professor, 2Assistant Professor, Department Of obstetrics and
Gynecology, Pt B D Sharma Post Graduate Institute Of medical Sciences, Rohtak, Haryana,India.
Correspondence to: Savita Rani Singhal, Email- savita06@gmail.com
Recurrent ectopic pregnancy is not very uncommon. There are few case reports of
consecutive three ectopic pregnancies. We present an interesting case of 26 years
old patient who presented with consecutive fourth ectopic pregnancy which is not
reported in literature. In this patient, for the first ectopic pregnancy left
salpingectomy and for the second ectopic pregnancy, laparotomy followed by
conservative surgical treatment (milking of right fallopian tube) was done three
and two and half years ago respectively. Third ectopic pregnancy was managed
medically by giving one intramuscular injection of 50 mg of methotrexate. Present
one was fourth ectopic in right fallopian tube for which, patient was given medical
treatment (intra muscular methotrexate) and she was advised to undergo in vitro
fertilization.
Key Words : Ectopic pregnancy, Consecutive, Fourth.
Introduction
Recurrent ectopic pregnancy is not uncommon. Various factors like pelvic inflammatory
disease, tubal surgery, infertility and previous history of ectopic pregnancy can lead to
consecutive ectopic pregnancies. The incidence of recurrence reported after first and
second ectopic is 15% and 27.5% respectively 1. A case of consecutive fourth ectopic
pregnancy is being reported for the first time.
Case ReportA 26-years old, gravida four with history of previous three consecutive ectopic
pregnancies was admitted with history of seven weeks of amenorrhea and pain
abdomen for one day. Her general condition and vitals were stable. Ultrasound reported
a heteroechoic mass of 2.5 X 3.0 cm size in right adnexa with minimal free fluid and
her serum β hCG levels were 4000 miu/ml. Diagnosis of unruptured ectopic pregnancy
and was made and conservative treatment with single dose of 50 mg methotrexate was
started. She responded well and her βhCG levels on day 4 and day 7 were 2710 and 900
miu/ml respectively. Detailed past history and records revealed that she was married
for seven years and could not conceive for first four years for which she took off and on
treatment. However, three years back her first pregnancy was left tubal pregnancy
which ruptured and for which left salpingectomy was done.
Two and half years back she had right tubal pregnancy which was managed by
exploratory laparotomy followed by milking of the tube as the pregnancy was already in
the process of tubal abortion. After two months of that episode, two years back, she
again developed ectopic pregnancy in the right tube which was managed conservatively
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with single dose of 50 mg of methotrexate. Present was the fourth consecutive ectopic
pregnancy after a gap of one and half years which was managed conservatively and she
was advised to go for in vitro fertilization.
Discussion
There are case reports of three consecutive recurrent ectopic pregnancies2,3,4. Milingos3
reported a patient who had three consecutive ectopic pregnancies on the ipsilateral side
after natural conception and was treated surgically in each case with partial
salpingectomy, removal of tubal stump, and resection of the uterine cornua,
respectively. In the present case also three ectopics were ipsilateral after left sided
salpingectomy in the first ectopic pregnancy. Adelusi et al2 reported a case of three
consecutive ectopic pregnancies in a 36-year-old woman who was under treatment for
infertility. There is a report of seven ectopic pregnancies but those were not consecutive
and patient had term deliveries before and in between the ectopic pregnancies5. There
is no significant difference in the outcome in terms of recurrence and further fertility
after medical and conservative surgical management. In the present patient infertility
and ectopic pregnancy caused recurrent ectopic pregnancies.
Early diagnosis and management of ectopic pregnancy is crucial as delay can be
disastrous for the patient’s fertility as well as for her life, as previous ectopic pregnancy
is a high risk for recurrence. One important issue is whether a woman with previous
three ectopic pregnancies, who is at very high risk for recurrent ectopic pregnancy,
should go for spontaneous conception or be offered other options for fertility treatment.
In the present case this was fourth consecutive ectopic pregnancy unreported so far in a
span of three years and she was counselled for in vitro fertilization.
Conclusion
Every woman with a previous ectopic pregnancy is at high risk for recurrence and
woman should be counselled to report at the earliest in next pregnancy to rule out
ectopic gestation as delay can be disastrous for fertility and her life.
References
1. Tulandi T. Reproductive performance of women after two tubal ectopic
pregnancies. Fertil steril 1988; 50:164.
2. Adelusi B, AL- Meshari A, Akande EO, Chowdhury N. Three consecutive
recurrent ectopic pregnancies. East Afr Med J 1993 Sep; 70(9):592-4.
3. Milingos DS, Black M, Bain C. Three surgically managed ipsilateral spontaneous
ectopic pregnancies. Obstet Gynecol 2008 Aug; 112:458-9.
4. Eryılmaz ÖG et al. Recurrent Ectopic Pregnancies: Analysis of Risk Factors of
Thirteen Patients. J Clin Analytical Med 2012; 3(2): 131-3.
5. Faiz SA, Sporrong BG, Al-Meshari A.A case of seven recurrent ectopic
Pregnancies. Saudi Med J 2003; 24 (5): 52.
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Retrocaval Ureter: a Case Report
T. BerheGebretsadik1, Y. Suga2
Assistant professor of urology, Department of surgery, St. PaulHospital Millennium medical
college, Addis Ababa, Ethiopia
2Lecturer and surgery resident, Department of surgery, St. Paul Hospital Millennium medical
college, Addis Ababa, Ethiopia
Corresponding author: Tekleberhan Berhe, E-mail: tekberr@yahoo.com
1
Retrocaval ureter or preureteral vena cava is a rare congenital abnormality which leads to
external ureteral compression by the inferior vena cava (IVC) resulting in lumbar pain and
Hydronephrosis. Intravenous urography, retrograde pyelography, CT, and MRIare main
diagnostic investigations. Surgical intervention is required in most of cases.
We present a case of 22 years old male who presented with right flank pain and
Hydronephrosis. Diagnosis was confirmed by IVU and retrograde pyelography. Exploration
of ureter, its transaction and end toend anastomosis was done anterior to the inferior vena
cava.
Introduction
A variety of vascular lesions can cause ureteral obstruction. With these lesions, the vascular
system rather than the urinary system is anomalous. Retrocaval ureter also referred to as
circumcaval ureter or preureteral vena cava is a rare congenital anomaly with the ureters
passing posterior to the inferior vena cava.It was initially considered as aberration in ureteric
development; however current studies in embryology have led to it being considered as an
aberration in the development of the inferior vena cava 1, 2, 3. Hence it is being suggested that the
anomaly be referred to as a pre-ureteral vena cava4,5. This disorder involves the right ureter,
which typically deviates medially behind (dorsal to) the inferior vena cava, winding about and
crossing in front of it from a medial to a lateral direction, to resume a normal course, distally, to
the bladder. The renal pelvis and upper ureter are typically elongated and dilated in a J or
fishhook shape before passing behind the vena cava. Cardinal veins are considered to be the
basic abnormality in which right subcardinal vein forms the main portion of IVC ventral to the
ureter instead of right supra cardinal vein. Consequently the ureter winds behind the IVC from
medial to lateral instead of lying lateral to it.
Intravenous Urography (IVU) and retrograde ureteropyelograpy are very helpful for the
diagnosis. On IVU there may be hydronephrosis of the right kidney, dilatation of the upper
1/3rd of ureter an S-shaped curve of the ureter and on oblique view ureter hugging the lumbar
spine. Abdominal ultrasound demonstrates hydronephrosis. IVU usually does not demonstrate
the middle and distal ureter requiring a retrograde ureteropyelogram to demonstrate the ureter
and hence confirm the diagnosis .Retrograde pyelography reveals medial displacement of nondilated lower ureter beyond the midline. Ultrasound and CT or MRI also have been useful in
defining the vascular malformation. When necessary, CT may be the procedure of choice to
confirm the diagnosis and avoid retrograde ureteropyelograpy 6.
MRI can nicely demonstrate the course of a preureteral vena cava and may be a more detailed
and less invasive imaging modality when compared with CT and retrograde pyelography.
Clinically, patients may present with symptoms of flank pain, recurrent infections and
haematuria. It is of interest, as this case report happens to be the second symptomatic case to be
reported in Ethiopia and one of the few cases in Africa 7, 8.
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Case Report
A 22 year old male patient presented to us with history of right flank pain of 2 years duration
and recent onset of hematuria. He had no other urinary complaints. Physical examination was
unremarkable. Urinary microscopy showed 4-5 RBC casts. Complete blood count, urea and
creatinine were all normal. Through right flank subcostal incision the right ureter was explored.
Right ureter was dilated and passing behind the IVC and then normal looking ureter coursing
downward. The Right ureter was transected and spatulated end to end anastomosis over double
J stent done. Post-operative recovery was uneventful. Double J sent removed after 4 weeks and
follow up sonography showed remarkable improvement in hydronephrosis.
Figure 1. Intravenous Pyelography
Figure 2a
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Figure 2b
Figure 2a & 2b.. Retrograde pyelography.
Figure 3. Diagrammatic representation illustrating the radiological features of Type I (left side)
and Type II (right side) circumcaval ureter (modified from Bateson and Atkinson. Circumcaval
ureter: a new classification. ClinRadiol 1969;20:173–7).
Discussion
Retrocaval ureter is a rare condition that results from an anomaly in the development of the
inferior vena cava 9. The incidence was reported to be approximately 1 in 1000 people, with
male predominance 10. It was first reported by Hochstetter in 1893 11. Although the lesion is
congenital, most patients do not present until the third or fourth decade of life. Common
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presentation includes right flank pain, recurrent urinary tract infections and varying degree of
haematuria
Retrocaval ureter can be classified into two verities according to radiological appearances (12).
1. The more common type I has hydronephrosis and a typically obstructed pattern
demonstrating some degree of fishhook-shaped deformity of the ureter to the level of
the obstruction, and
2. Type II has a lesser degree of hydronephrosis or none at all. Here, the upper ureter is not
kinked but passes behind the vena cava at a higher level, with the renal pelvis and upper
ureter lying almost horizontal before encircling the vena cava in a smooth curve
(Figure 3).
In type I, the obstruction appears to occur at the edge of the iliopsoas muscle, at which point the
ureter deviates cephalad before passing behind the vena cava. In type II, the obstruction, when
present, appears to be at the lateral wall of the vena cava as the ureter is compressed against the
perivertebral tissues. Both CT scan and magnetic resonance imaging are efficient methods of
confirming the diagnosis.
Surgical intervention is often required toalleviate the symptoms. Open surgical exploration is
commonly used technique. Surgical correction involves ureteral division, with relocation and
ureteroureteral or ureteropelvic reanastomosis, usually with excision or bypass of the
retrocaval segment, which can be aperistaltic. Open surgical exploration is commonly used
technique although it is being replaced by minimally invasive laparoscopic technique with
advantages of minimal postoperative pain and early recovery 13,14,15,16,17.
References
1. Chuang VP, Mena CE, and Hoskins PA. Congenital anomalies of the inferior vena cava.
Review of embryogenesis and presentation of a simplified classification. Br J
Radiol.1974; 47: 206–213.
2. Schlussel, RN, Retik AB. Preureteral Vena Cava. In: Kavoussi LR, Novick AC, Partin AW,
Peters CA editors. Campbell-Walsh Urology. 9th ed. El-sevier Saunders; 2007.p 34183420.
3. Lesma A, Bocciardi A, Rigatti P. Circumcaval Ureter: Embryology. European Urology
2006; (supplements 5):444 – 448
4. Dreyfuss W. Anomaly simulating a retrocaval ureter. J Urol. 1959; 82:630.
5. Lerman I, Lerman S, Lerman F. Retrocaval ureter: Report of a case. J Med Soc N J. 1956;
53:74.
6. Bass FE, Redwine MD, Kramer LA, Huynh PT, Harris JH. Spectrum of congenital
anomalies of the inferior vena cava: cross-sectional imaging findings.
RadioGraphics2000; 20:639–52.
7. A.Tegegne, C. Cobas , East and Central African Journal of Surgery, Vol. 14, No. 1, MarchApril 2009, pp. 119-121
8. M.Y. Kyei, E. D. Yeboah , G. O. Klufio, J. E. Mensah, S. Gepi-Atee, L. Zakpaa, B. Morton, and
B. Adusei. Two case reports on retrocaval ureter, Number 4 Ghana Medical Journal
2011; 4: 45.
9. Lautin EM, Haramati N, Frager D, Friedman AC, Gold K, Kurtz A, et al. CT diagnosis of
circumcaval ureter. AJR Am J Roentgenol. 1988; 150(3):591–594.
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10. Uthappa MC, Anthony D, Allen C. Case report: Retrocaval ureter: MR appearances. Br J
Radiol. 2002; 75(890):177–179.
11. Ouyang CC, Chueh SC, Hsu TC, Chen J, Tsai TC,Chiu TY. Retrocaval ureter- three case
reports andreview of the literature J Urol ROC 1994; 5:49-53.
12. Bateson EM, Atkinson D. Circumcavalureter: A new classification. Clinical Radiol.1969;
20: 173-7.
13. Bhandarkar DS, Lalmalani JG, Shivde S. Laparoscopic ureterolysis and reconstruction of
a retrocaval ureter. SurgEndosc2003; 17:1851-1852.
14. Tobias-Machado M, Lasmar MT, Wroclawski ER. Retroperitoneoscopic surgery with
extracorporeal uretero-ureteral anastomosis for treating retro-caval ureter.IntBraz J
Urol2005; 31:147-150.
15. Nagraj HK, Kishore TA, Nagalakshmi S.Transperitoneal laparoscopic approach
forretrocaval ureter. J Minim Access Surg.2006; 2(2): 81-2.
16. Singh O, Gupta SS, Hastir A, Arvind NK.Laparoscopic
transperitonealpyelopyelostomyand reteroureterostomy of retrocaval ureter:Report of
two cases and review of theliterature. J Minim Access Surg. 2010;6(2): 53-5.
17. Hemal AK, Rao R, Sharma S, Clement RG.Pure robotic retrocaval ureter repair.IntBraz J
Urol. 2008; 34(6): 734-8.
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Deep palmar space lipoma: Case report and review of the literature
O. A. Olawoye1,2, O.N. Enemo3,A.0. Iyun2, E.E. Akang4.
1Department of Surgery, College of Medicine University of Ibadan;
2Department of Plastic Surgery, University College Hospital, Ibadan;
3Department of Surgery, University College Hospital, Ibadan;
4Department of Pathology, University of Ibadan and University College Hospital, Ibadan.
Correspondence to: Dr O. A. Olawoye -Email: yinkaolawoye@yahoo.co.uk
Background: Although lipoma is the commonest benign tumour in the body, it is rarely
found in the hand. Subcutaneous lipomas have characteristic distinguishing features which
place them among the most easily diagnosed cutaneous lesions. However, the diagnosis of
deep lipomas of the hand are often missed because of the rarity of the condition and the
inelastic aponeurosis of the hand which obscures the usually commonly distinguishing
features of lipoma.
Case presentation: We present the case of a 55 year old right hand dominant woman who
had an 18 month history of painless swelling on the right hand. The physical examination
and plain radiograph were uncharacteristic and it was difficult making a definitive
diagnosis. With a presumptive assessment of right palmar soft tissue swelling, an excision
biopsy was planned which revealed a lipomatous mass diagnosed as right palmar lipoma
on histology.
Conclusion: The rarity of lipoma of the hand makes the clinical preoperative diagnosis
challenging. A high index of suspicion along with the use of appropriate imaging
techniques such as magnetic resonance imaging becomes critical in the pre-operative
diagnosis and management of deep lipoma of the hand.
Keywords: Palmar lipoma, lipoma of the hand, lipoma
Introduction
Lipomas are the commonest benign tumours found in humans. They have been reported to be
the single most common soft tissue tumour.1 Though they have been reported in virtually every
part of the body, the deep palmar space of the hand remains a less likely location, posing
significant diagnostic challenge on physical examination. Lipomas of the hand are usually
asymptomatic and patients usually present only when there are cosmetic concerns or rarely
when there are pressure effects and they become symptomatic with paraesthesia, muscle
atrophy and paralysis. A high index of suspicion is helpful to make a diagnosis of deep palmar
lipoma.
Case Report
The patient was a 55 year old right hand dominant trader who presented with18 month history
of progressive swelling on the ulnar aspect of the palmer surface of her right hand. She had no
antecedent history of trauma. She is of the Yoruba decent and there was no family history. She
noticed some limitation of extension of the ring and little finger about 6 months after the onset
of the lesion, she however did not have pain, itching or loss of sensation over the lesion. She
denied any history of diabetes mellitus or any other medical co morbidity.
On examination, a prominent fluctuant swelling was found on the hypothenar eminence of the
right palm (Figure 1). The lesion had no features of inflammation and there was no sensory
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deficit over the lesion. There was spontaneous capillary refill of all the fingers of the right hand.
There was some flexion deformity of the proximal interphalangeal joints of the ring and little
fingers. The contralateral hand was essentially normal.
Figure 1
Radiographic findings
The mass was apparent on plain radiograph as a hypo dense circumscribed lesion at the base of
the little finger (Figure 2). A diagnosis of right palmar soft tissue tumour was made.
Figure 2 . Plain radiograph of the right hand
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Surgical management
Her surgery was performed under wrist block with 0.5% lignocaine solution. A longitudinal
incision was made and the intraoperative finding was that of a circumscribed yellowish mass
located deep to the hypothenar muscles with attachment to the metacarpophalangeal joint of
the little finger by a fibrous band. Marginal excision of the tumour was done. The tumour
measured 4 cm by 3 cm and weighed 9 grams (Figure 3). Haemostasis was secured and the
wound cavity was irrigated with saline and closed in layers. She was managed on outpatient
basis.
Figure 3. Photograph of gross specimen showing a circumscribed lobulated yellow mass
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Figure 4- Photomicrograph of specimen showing benign neoplasm composed of mature
adipocytes
The histopathological analysis of the resected tumourrevealed a benign mesenchymal neoplasm
composed of sheets of mature adipocytes (Figure 4).
Discussion
Unlike subcutaneous lipomas that have characteristic pathognomonic clinical features, deep
lipomas of the hand are rarely diagnosed clinically before surgery. Some of the reasons for this
include the presence of the unyielding aponeurosis in the hand and the rarity of the condition.In
one of the early reports by Straus2 in which thirty four cases of deep palmar lipomas were
reviewed, it was found that the diagnosis of deep lipoma of the hand was made correctly in only
one patient. Our patient similarly presented with an eighteen month history of a progressive
mass in the ulnar aspect of her right hand with no other characteristic feature of a lipoma. This
was the only record of palmar lipoma managed in our unit over a ten year period.
The deep lipomas of the hand have been categorized into two groups based on their relationship
to the tendon sheath. Those whose origin and expansion occur within the tendon sheaths have
been referred to as endovaginal3. They constitute the largest group and they have been further
divided into lipoma simplex symetricum and lipoma arborescens. The occurrence of lipoma
arborescens within a tendon sheath was first reported by Billroth2. The second group is the
epivaginal or subaponeurotic lipoma. Epivaginal lipomas are attached to the tendon sheath
rather than the subaponeurotic tissue.2 Both endovaginal and epivaginal lipomas have been
found in the fingers, palm and the wrist while the endovaginal lipomas have been described in
the hand, the dorsum of the wrist and the foot.4,5The palmar lipoma in our patient was
epivaginal as it was attached to the tendon sheath.
Another classification of palmar lipomas into superficial and deep palmar lipomas was
proposed by Mason6 in 1937. Superficial palmar lipomas have been found to be more common7.
The rarity of deep palmar lipoma is buttressed with the scarcity of reported cases. In a case
series of four hundred and seventy six lipomas of the upper limb by Barrile8, only one palmar
lipoma was found. Similarly some other authors have highlighted the rarity of the condition in
their reports9 – 13. Most lipomas of the hand begin as painless swellings and remain quiescent for
a variable period of time before the onset of a progressive growth phase. Many patients seek
medical attention when the size of the lesion attains such a proportion as to give them cosmetic
concerns. Others present as a result of compressive neuropathy, grasping difficulties, decrease
in digital flexion or deviation of the fingers7, 12 – 15.
Deep palmar lipoma are usuallyin close approximation to vital structures such as the
neurovascular bundle and tendons in the hand thus extreme caution is required in their
dissection to avoid iatrogenic injury to these structures. The pressure effect of relatively bigger
lesions may also lead to distortion of the anatomical landmark of some of these vital structures.
Many of the palmar lipomas have been reported to be peripherally located as was found in our
patient. (Figure 1) The peripheral location of most of these tumours is said to be due to the
centrally located thick deep palmar fascia13. Deep palmar lipomas can be deceptively large and
extensive16 and magnetic resonance imaging has been found useful for its preoperative
diagnosis and surgical care16,17,18.
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Conclusion
Though lipomas are the commonest soft tissue tumour in the body, they are rarely found in the
hand, thus presenting a diagnostic dilemma and high rate of misdiagnosis. A high clinical index
of suspicion coupled with the use of appropriate imaging modalities should assist with prompt
diagnosis and surgical care.
Acknowledgement
The authors thank Dr Maina for his involvement in the management of the patient.
References
1. Pagonis T., Givissis P., Christodoulou A. Complications arising from a misdiagnosed giant
lipoma of the hand and palm; a case report. J MedCaseRep 2011; 5(1):552.
http//jmedicalcasereports.com/content/5/1/552 accessed on the 13th October, 2013
2. Straus F.H. Deep lipomas of the hand. Ann Surg. 1931; 94(2):269-73.
3. Gross F.C., Rohmer J., Vautrin A., André P. Nouveaux éléments de pathologie chirugicale
générale. Paris, Baillière, 1898: pp. 392.
4. Muller P. Palmar lipoma of finger. Bull Men. Soc. Chir. Paris 1928; 20:390-2.
5. Martin A., Grenier J. A case of lipoma of a finger. Paris Med. 1922;12:303-4.
6. Mason M.C. Tumours of the hand. Surg. Gynecol. Obstet. 1937; 64:129-35.
7. Leffert R.D. Lipomas of the upper extremity. J. Bone Joint Surg. 1972; 54A:1262-6.
8. Barrile N.M. Gran lipoma subaponeurotico. Presna Med. Argent. 1958; 45:318-20.
9. Schmitz R.L., Kelly J.L. Lipoma of the hand. Surgery 1957; 42:696-700.
10. McEnery E.T., Schmitz R.L., Nelson P.A. Palmar lipoma; report of a case AMA Arch. Surg.
1959; 699-700.
11. Hueston J.T. Massive lipoma of the hand. Aust. NZJ. Surg. 1965;34:19-21.
12. Paarlberg D., Linscheid R.L., Soule E.H. Lipoma of the hand. Mayo Clin. Proc. 1972;
47:121-4.
13. Oster L.H., William F.B., Curtis M.S. Large lipomas in the deep palmar space. J. Hand Surg.
1989; 700-4.
14. Booher R.J. Lipoblastic tumours of the hands and feet: Review of literature and report of
thirty-three cases. J Bone Joint Surg. 1965; 47A:727-40.
15. Brand M.G., Gelberman R.H. Lipoma of the flexor digitorum superficialis causing
triggering at the carpal canal and median nerve compression. J. Hand Surg. 1988;
13A:342-4.
16. Jagannath KK, Ramachandra KB, Praveen B, Shridhar Chetna S. A giant lipoma in the
hand – Report of a rare case. Online J. Health Allied Sci. 2006; 5.
http://www.ojhas.org/issue17/2006-1-6.htm. Accessed on 19 November 2013.
17. Capelastegui A., Astigarraga E., Fernandez-Canton G., Saralegui I., Larena J.A., Merino A.
Masses and pseudomasses of the hand and wrist: MR findings in 134 cases. Skeletal
Radiol. 1999; 28:498-507.
18. Phalen G.S., Kendrick J.I., Rodriguez J.M. Lipomas of the upper extremity. A series of
fifteen tumours in the hand and wrist and six tumours causing nerve compression. Am. J
Surg. 1971; 121:298-306.
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`Prevalence
of Low Back Pain amongst Workers at a Paediatric Hospital in Nairobi.
V. M. Mutiso1, E. Amayo2, A.S. Muoki3, M.M. Kimeu4
1 Department of Orthopaedic Surgery, University of Nairobi Medical School, Kenya
2 Department of Medicine, University of Nairobi Medical School, Kenya
3 Department of Surgery (Plastic), University of Nairobi Medical School
4 Forces Memorial Hospital, Nairobi
Correspondence to: Vincent Muoki Mutiso. Email: mutisovm@yahoo.com
Background: Back pain is a common complaint among working individuals worldwide. It is
a significant cause of reduced work productivity and sick days.
Methods: This was a prospective hospital based study done to determine the pattern of back
pain amongst workers at a paediatric hospital in Nairobi.
Results: Validated structured questionnaires were administered to 347 employees with a
response rate of 19.3% The age range was 25 to 57 years with a mean of 34 years Females
comprised 72.6% of the total with a Male to Female ratio of 2.6:1.Nurses comprised 42.2%
of the total. 63.6% had suffered back pain in that year. 90.5% of back pain was located in
the lower back.
Conclusion: Back pain is a common affliction amongst staff especially the nursing staff. This
is in keeping with other health Institutions around the world.
Keywords: back pain, pattern, paediatric, hospital
Introduction
Back pain is the most common cause of disability among young adults. There are many factors
that contribute to this condition ranging from physical, psychological and occupational amongst
others. There are many work environments including those that do not present with obvious
strenuous conditions that have workers suffering back pain 1. About 80–85% of back pain
episodes have no known cause. Low back pain, the most common spinal disorder, affects over
80% of persons at some point in their life, and from 4–33% of a population at any one time1.
Back pain is widespread in both developed and developing Nations in the work environment.
Ergonomic stressors play a role in this. Data from developing countries is scarce but that
collected from developed countries indicate that back pain significantly affects global economic
productivity2. In the United States studies have shown that at least 26 million working
Americans suffer lower back pain annually.2 with an estimated annual productivity loss of U$28
billion annually3. It is linked to lifting heavy objects, twisting and bending, rapid work pace,
repetitive motion patterns, insufficient recovery time and non neutral body positions 4, 5. In the
developed countries, it is also one of the most common reasons for filing a workers’
compensation claim, hence, one of the most costly health disorders to society6.
Studies show that occupational risk factors account for 37% of back pain worldwide7. Many
workers in the hospital setting are prone to these forces especially nurses and porters and thus
risk suffering occupational back pain. Despite the prevalence of this disease and the toll that it
exacts on workers and their families there are some cost effective interventions.
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Patients and Methods
This was a prospective hospital based survey conducted by questionnaire at Gertrude’s Garden
Children’s Hospital (GGCH) in Nairobi, Kenya. GGCH is a private institution located about 7
kilometres from the central business district dedicated to children’s health care. Following
Hospital ethics committee approval and informed consent by participant’s data was collected. A
structured questionnaire was used to collect data which included demographic data and other
variables. Data was analysed using SPSS computer software.
Results
Responses from 67 employees were analyzed. Their ages ranged from 25 to 61 with a mean of
35, a median of 34 and a mode of 25 years (Figure 1). The majority (72.6%)were females. The
Male to Female sex ratio was 1:3. Nursing officers constituted 42.2% of the study population
(Table 1). Subordinate staff and Secretaries accounted for 9.4% and 7.8% respectively. A total of
16.7% worked in general paediatrics, 13.6% in theatre and 7% in administration (Table 2).
number
Age Distibution (Years)
18
16
14
12
10
8
6
4
2
0
Age Distibution (Years)
25-29 30-34 35-39 40-44 45-49 50-54 55-59
Age
Figure I. Age Distribution in Years
Table 1. Distribution by Occupation
Occupation
Nursing Officer
Subordinate staff
Secretary
Administrator
Porter
Catering
Clerical Officer
Others
Total
Frequency
Percent
27
6
5
3
3
3
1
16
64
42.2
9.4
7.8
4.7
4.7
4.7
1.6
25.0
100.0
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Table 2. Work Station
Work station
General Paediatrics
Theatre
Administration
Casualty
Outpatient clinic
Maintenance
Medical wards
Private wing
Surgical wards
Others
Total
Frequency
Percent
11
9
7
5
5
5
3
1
1
19
66
16.7
13.6
10.6
7.6
7.6
7.6
4.5
1.5
1.5
28.8
100.0
Most (76.2%) of the respondents had previously suffered back pain at one time of which the
majority was within the last twelve months (63.6%) and 55.2% within the last six months. Of
the 37 individuals who reported back pain within the previous 6 months, the majority (40.5%)
complained of 1-2 episodes. 21.6% reported 3-4 episodes, 18.9% more than 6 episodes, 8.1%
5-6 episodes and 10.8% reported continuous pain. The majority of patients (90.5%) reported
lower back pain compared to the 4.8% each who reported pain in the upper back and pain in
the whole back. The severity of the back pain was rated as moderate in 64.3%, as mild in 19%
and severe in 16.7%.
A total of 92.9% of patients reported presence of a precipitating factor for the backache. The
most common precipitating factor was lifting and carrying a load (51.3%), bending (41%),
physical activity (38.5%) and menstrual periods (34.1%) (Table 4). The commonest aggravating
factors were bending (61.5%) followed by carrying a load (43.6%) (Table 5).
History of previous back injury: The majority (81%) had no prior history of injury to the back.
Of the 19% who had history of back injury. Road traffic crash (RTC) was the commonest trauma
accounting for 44.4% followed by falls (33.3%). The range of duration of occurrence of back
injury was 20 years.
Table 3. Number of Episodes of Backache Suffered During the Previous 6 Months
Number of episodes
1-2
3-4
5-6
More than 6
Continuous
Total
Frequency
Percent
15
8
3
7
4
37
40.5
21.6
8.1
18.9
10.8
100.0
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Table 8. Site of Pain
Area
Frequency
Percent
38
2
2
42
90.4
4.8
4.8
100.0
Lower back
Upper back
The whole back
Total
Table 4. Factors precipitating back pain
Factor
Frequency
Percent
20
16
15
14
4
3
6
51.3
41.0
38.5
34.1
10.3
7.7
15.4
Carrying weights
Bending
Physical activity
Menstrual periods
Sleeping
Emotional change
Other factors (e.g. sitting)
Table 5. Aggravating Factors
Factor
Frequency
Percent
24
17
12
11
4
4
2
1
2
61.5
43.6
29.3
28.2
10.0
10.3
5.1
2.6
5.1
Bending
Carrying weights
Menstrual periods
Physical activity
Sleeping
Emotional change
Sneezing
Coughing
Other factors (e.g. sitting)
Table 6. History of Previous Back Injury
Kind of Injury
RTA
Fall
Lifting
Others
Total
Frequency
Percent
4
3
1
1
9
44.4
33.3
11.1
11.1
100.0
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Table 7. Effect of Backache on Working Ability
Able to work normally
Working ability moderately impaired
Working ability mildly impaired
Working ability severely impaired
Bed rest required
Frequency
(n = 41)
16
15
8
1
1
Percent
(100)
39.0
36.6
19.5
2.4
2.4
Effect of back pain on work performance
A total of 39% were able to work normally, 36.6% had moderately impaired working ability and
19.5% had mildly impaired working ability. 7.1% reported missing work due to back ache in the
last 12 months.
Effect of work on backache: Four (10.8%) of attributed their back pain to work as the cause,
21 (56.8%) considered their work as an exacerbating factor and while the rest (32.4%) felt that
there was no relationship between the two. Only 4.9% reported that they have previously had
to change their work station due to back pain.
Subjective Opinion of Health status: 17.1% felt that they were in excellent health whilst the
majority (61%) were of the opinion that their state of physical health was good. 22% thought it
was fair. Over half of the subjects (57.5%) reported participation in exercise programs whilst
26.8% considered themselves overweight.
Instruction on back pain control and prevention: Almost one fifth (19.5%) of the subjects had
received some form of instruction on control and prevention of back pain.
Discussion
Back pain is a common complaint among working individuals worldwide. It is a significant cause
of reduced work productivity and sick days. Its aetiology is largely non-traumatic with
occupational causes dominating and is largely preventable. Mechanical hazards within the
hospital put staff at risk of back pain. In this study the prevalence of back pain was 63.6% which
is similar to studies done in Nigeria and Ethiopia.8
The age range of 25-61 years with the majority of the patients falling between 25 and 34 years
indicates younger and more productive members of society suffering from back pain and is a
pointer to a potentially big economic burden. There are more females affected than males at
72.6%. This is similar to many studies.8, 10 The cause could be the anatomic, physiologic and
structural differences between males and females that result in mechanical disadvantages to
females.11,12 However in our case we note the fact that there were numerically more female
nurses would skew the ratios towards the females.
The majority of the subjects were nurses at 42.2%. This could be due to the fact that they are
prone to mechanical strains such as heavy lifting of loads, twisting and bending, rapid work
pace, repetitive motion patterns, insufficient recovery time and non neutral body positions
which are proven causes of back pain4, 5. The same factors may play a role as the cause of back
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pain in the other occupations as well as working stations. The majority of the workers suffered
lower back pain at 90.5% which is in line with global statistics1.
Most of the workers attributed their back ache to work related activities such as carrying
weights, bending and other physical activity. Many also thought that their work contributed or
exacerbated their back pain (56.8%). This is indicative of the need for improved working
conditions in institutions. Some physiological factors also play a big role such as monthly
menses. The physiological factors may indicate the need for better back care during pregnancy.
This is in keeping with the above reasons for females being more prone to back pain 11, 12.
Interestingly workers reported minimal work impairment when afflicted with back pain with
only 2.4% being severely impaired or requiring bed rest. Only 7.1% of workers had had days off
due to back pain with only 4.8% taking more than 9 days off duty. This is in contrast with
international studies that name back pain as one of the biggest causes of reduced worker
productivity 3.
Low Back Pain has been identified as one of the main causes of loss of work days among the
working class citizens in developed countries. A report in England in 1989 13 showed an
increase of 40% in comparison to 5.6% for other complaints. The survey by Triolo14 indicated
that nurses lost 750,000 days a year as a result of back pain. One could speculate that the reason
for the relatively small loss of work days in this study could be a result of perceived potential
job loss that could result from reduced productivity.
Study limitations: In this study recall bias was a potential confounder
Conclusion
Back pain is a significant and common complaint amongst health workers. The occupational
stresses appear to be a cause and exarcebator of back pain. There is need for Institutional work
place policies to reduce the risk and incidence of back pain amongst health workers and thereby
improve productivity. A study done in Nigeria9 has shown a lack of knowledge of lower back
pain among sectional heads and a lack of knowledge of understanding of their roles in managing
lower back pain.
Studies have been conducted 15, 16 that outline the role of managers in health institutions in
controlling back pain. The results of these studies could be applied locally pending our own
studies to establish management protocols. Courses on back care ergonomics and installation of
lifting equipment in health institutions could impact on back pain and reduce the incidence.
Studies show that improvements in ergonomics often result in improvements in productivity
(and vice versa). In fact, greater output per worker is often a consequence of ergonomic
interventions17
In this study the most of the workers denied receiving any education on back pain control and
prevention (80.5%). Didactic instruction and physiotherapy based activity for staff to manage
prevent and control back pain could improve the situation.
Acknowledgement
We would like to thank the Gertrude’s Garden Children’s hospital for their co-operation in this
Study. We also wish to thank Anita Muoki for the computer entries and data analysis.
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9. Odole A.C., Adegoke B.O.A., Akinpelu A.O., Okafor A.C. AJPARS vol. 3, no. 1, june 2010, pp.
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of Medicine: Department of Surgery, Kampala, Uganda. African Health Sciences 2005;
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11. Gilette JV. and Haycock CE. What kinds of injuries occur in women’s athletics?
Proceedings of the 18th Conference of the Medical Aspects of Sports. (Pp18-25).
Chicago: American Medical Association.1977.
12. Darden E. Are women really the weaker sex? Young Athlete.1979; 2, (10): 60-61.
13. Frost H. and Moffett JK. Physiotherapy management of chronic low back pain.
Physiotherapy. 1992; 78(10): 751-754.
14. Triolo PK. Occupational health hazard of hospital staff nurses. Part II Physical, chemical
and biological stressors. AAOHN – J. 1988; 37(7): 274-279.
15. Cunningham C., Doody C. and Blake C. 2008. Managing low back pain: knowledge and
attitude of hospital manager. Journal of Occupational Medicine 258:282-288.
16. McLellan, R.K., G. Pransky and W.S. Shaw. 2001. Disability management training for
supervisors: A pilot intervention program. Journal of Occupational Rehabilitation 11:33–
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17. Hendrick HW. (2003). Determining the cost-benefit of ergonomics projects and factors
that lead to their success. Applied Ergonomics 34: 419-27.
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Lumbar Disc Degenerative disease: Magnetic Resonance Imaging Findings in Patients
with Low Back Pain in Dar Es Salaam.
M. Jacob1, L.O. Akoko2 , R.R. Kazema1
of Radiology, Muhimbili University of Health and Allied Health Sciences
2Department of surgery Muhimbili University of Health and Allied Sciences,
Corresponding to: Dr M. Jacob, E-mail: mbokajacob@gmail.com
1Department
Financial support: Government of Tanzania through Ministry of Health and Social
Welfare(MOHSW).
Background: Lower back pain (LBP) is a public health problem and lumbar disk
degenerative disease (LDDD) is a main cause. Studies elsewhere show that the prevalence
of LDDD ranges from 85% - 95%. MRI being the best modality for spine disorders, we
studied pattern of LDDD in patients with LBP.
Methods: This was a seven months, hospital based descriptive, prospective study which
involved all patients presenting with LBP referred for MRI. Patient characteristics were
analyzed using SPSS version 13.
Results: One hundred and sixty five patients were recruited into the study. Their ages
ranged from 20 to 80 years with a mean of 50±12.5 years. Female accounted for 87 (53%)
of the cases.
Most of the patients had LDDD. The disease mostly affected individuals in the age group
above 60 years (P<0.05) with no sex difference. Disk herniation, central canal stenosis and
nerve root compression were significantly seen in patients with radiculopathy (P=0.00).
L4/L5 & L5/S1 were the most affected.
Conclusions: LDDD occurs in all age groups but individual aged 60 years and above are
most affected. There is a relationship between radiculopathy and disk herniation, central
canal stenosis and nerve root compression. The lower lumbar spine levels remain the most
affected area for disk degenerative disease.
Introduction
Lumbar disc degenerative Disease (LDDD) is the most common cause of low back pain
worldwide and refers to a syndrome in which an intervertebral disk with adjacent spine
structures are compromised. The prevalence of LDDD increases with age affecting 85% to
95% of adults aged 50 to 55 years, with no sex difference1,2. Lumbar spine is the common area
affected by degenerative changes, as it is a part of spine, which is subjected to heavy mechanical
stress3. Lumbar degeneration can occur at any level but mainly it occurs on L3-L4, L4-L5 and
L4-S1 vertebrae3,4,5.
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Lumbar degenerative disk disease may present as disk degeneration, Modic changes, disk
displacement, lumbar spinal stenosis, facet joint arthropathy or their combination. Disk
degeneration is a loss of disk signal on T2W images with/without disk height reduction1. The
dark signal of the disk on T2W images is due to loss of water content. Initially there are
biochemical changes within a disk, resulting in dehydration of disk1. In later stages of the
disease there is morphological changes such as loss of disk height, annular tears, rim lesions and
osteophyte6. The occurance of annular tears leads weakening of the annulus fibrosus hence disk
displacement beyond the vertebral margins. Disk degeneration is common in individuals who
are more than 40 years of age though its prevalence increases progressively to over 90% by 50
to 55 years of age7,8,9.
Modic changes are endplate degenerative changes due to disk degenerative disease10. These
Modic changes can be painful – especially type I changes1. They are common observation on MR
images and are of three main forms1. Type I is the acute stage of disk disease, there is invasion
of the cancellous spaces by fibrovascular reactive tissue1.11. With time, fatty replacement of red
marrow occurs leading to type II Modic changes; eventually bony sclerosis of the marrow occurs
and leads to type III Modic changes1,11. Spinal stenosis is defined as loss of signal in epidural fat
with compression of neural tissues within the canal10,12. Spinal stenosis is evident when there is
reduction of spinal canal diameter to less than 18mm7.
Disk displacement is also one of the findings in spine degenerative disease. The displaced disk
can be a simple bulge, herniation, extruded or sequestration13. Disk bulge is a circumferential
enlargement of the disk contour in a symmetric fashion in a weakened disk, the annulus is intact
with disk extension outward involving >50% of disk circumference 14. Herniation occurs when
nuclear materials protrude or extrude into the perineural space through radial tears of the
annulus7,12,13. Disc degeneration and loss of disc space height, leads to increased stresses on the
facet joints with craniocaudal subluxation resulting in facet joint arthropathy15.
LBP is the main presenting symptom followed by sciatica. Features suggestive of sciatica are
unilateral or bilateral leg pain radiating to the feet and toes, numbness in dermatomes
distribution and positive straight leg raising test. Sciatic pain aggravates on standing, walking,
bending, straining and coughing16. Eighty percent (80%) of the adult population suffers from
LBP at some time in their lives and around 10% of sufferers become chronically disabled17,18.
The possible sources of pain are mechanical compression of neural elements by disk herniation,
as well as direct biochemical and inflammatory13,19.
Ageing is main factor implicated in spine degenerative disease13. Apart from age other factors
include genetic inheritance, physical loading history, trauma and impaired nutrition, smoking,
obesity, immobilization, psychosocial factors, gender, height, occupations like machine drivers,
carpenters and office workers 1,20,21,22.
Main diagnostic tool and imaging technique for the evaluation of disc degeneration is magnetic
resonance imaging (MRI)23. The role of diagnostic imaging in spine degenerative disease is to
evaluate the status of the neural tissues and to affect the therapeutic decision making24.
The main objective of this study was to determine the pattern of lumbar degenerative disk
disease by using MRI and we also evaluated the relation between lumbar degenerative diseases
with symptomatology
Patients and Methods
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This was a cross sectional study conducted in the MRI unit department of Radiology in
Muhimbili National Hospital Dar Es Salaam. The duration of the study was 7 months from March
to September 2010. A total of 165 patients with LBP were included in this study after obtaining
written consent. Once the subject was entered in the study, multiplanar MRI was done from the
first lumbar to the first sacral vertebra with a 1.5-tesla imaging system (Phillips, Achiever, Best,
Eindhoven, Netherlands).
Two observers analyzed all scans independently. Intra- and inter-observer reliabilities were
assessed by calculating kappa statistics. All images were screened for evidence of neoplastic,
inflammatory or infectious disorders, and if any were observed, the patient was excluded from
the study. Each spinal level was evaluated separately. Each level from L1-S1 was assessed for
disk degenerative disease, using the latest international nomenclature for describing disk
pathology. The variables evaluated on MRI were disk degeneration, Modic changes, Disk bulge,
herniation, central canal stenosis and nerve root compression. Disk degeneration was classified
by using a nomenclature used by Dominic et al25. Grade 1-2 disc degeneration was considered
normal while grade 3-5 were accepted as a presence of degeneration. Modic changes were
evaluated in accordance with the system described by Modic13. Disk bulge was defined as
presence of circumferential enlargement of the disk contour in a symmetric fashion in a
weakened disk, the annulus is intact with disk extension outward involving >50% of disk
circumference. Disk herniation presence of (localized/focal displacement of disk beyond the
intervertebral disc space. Central canal stenosis was defined as narrowing of the spinal canal
anterior-posterior diameter anywhere along its axis. Severity of canal stenosis was graded as
per Borenstein et al14. Mild canal stenosis was evaluated by the presence flattening of the
ventral thecal sac. Moderate canal stenosis is the triangularization of spinal canal with loss of
posterior epidural fat pad and severe canal stenosis: compression of the canal with loss of
epidural fat in all planes. Only those with moderate and severe canal stenosis were diagnosed as
patient with canal stenosis. Nerve root compression was defined as presence of mass effect on
nerve root.
A structured questionnaire was used to collect patient findings, which included questions
regarding biodata (age, sex, gender, and date), symptomatology, and MRI findings. The study
was approved by Institutional Review Board of Muhimbili university of Health and Allied
sciences.
Each spine level and all aspects of degeneration were considered individually as 100%. Most of
the patients had more than one spine level affected and more than one finding. Institutional
Review Board of Muhimbili University of Health and Allied Sciences (MUHAS) ethically
approved the study. Descriptive indices, like frequency, percentage, mean and standard
deviation, were used to summarise patient demographic and MR imaging findings. Chi-square
and Fisher’s exact test were used for comparison between demographic, presenting symptoms
and MRI findings. All analyses was performed using the Statistical Package for Social Sciences
(SPSS) version 13. A p-value of 0.05 was considered to indicate a statistically significant
difference.
Results
The study included 165 patients, with age ranges from 20-80 years, and a mean of 50±12. A
slight female preponderance was observed at 53% (87) fig 2 with 132 (80%) of the patients
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presenting with radiculopathy. One hundred and fifty nine (94%) of the patients had at least
one degenerative finding.
The commonest degenerative finding was disk degeneration in 137 (83%) followed by nerve
root compression in 127 (77%) and disc herniation in 104 (63%). Of all the degenerative
findings, only disc bulge and herniation did not significantly increase with age [Table 1]. With
the exception of disk bulge, all disk degenerative changes were proportionally higher among
men, but these observations were not statistically significant [Table 2]. Figure 2 shows the
distribution of patients by age and sex. Table 4 shows the distribution of disk degenerative
changes by disk level. The commonest two site were L4/L4 and L5/S1 level
Table1. Distribution of patients with degenerative imaging findings by age.
Pathological Findings
Age in years
Disk degenerative
20-39
40-59
60-80
Total
changes
(n=30)
(n=98)
(n=37)
(n=165)
Disk degeneration
13 (43)
87(89)
37(100.0)
137(83.0)
0.000
Modic changes
2(6.7)
31(31.6)
14(37.8)
47(28.5)
0.011
Disk bulge
12(40.0)
40(40.8)
12(32.4)
64(38.8)
0.664
Disk Herniation
14(46.7)
63(64.3)
27(73.0)
104(63.0)
0.079
2(6.7)
30(30.6)
18(48.6)
50(30.3)
0.001
17(56.7)
77(78.6)
33(89.2)
127(77.0)
Canal Stenosis
Nerve root
P value
0.002
compression
Table 2. Percentage Distribution of Degenerative Imaging Findings by Sex.
Disk degenerative
changes
Sex
Male (n=78)
Female(n=87)
Total(N=165)
P- value
Disk degeneration
67(85.9)
70(80.5)
137(83.0)
0.353
Modic changes
26(33.3)
21(24.1)
47(28.5)
0.191
Disk bulge
27(34.6)
37(42.5)
64(38.8)
0.298
Disk herniation
54(69.2)
50(57.5)
104(63.0)
0.118
Canal stenosis
24(30.8)
26(29.9)
50(30.3)
0.902
Nerve root compression
63(80.8)
64(73.6)
127(77.0)
0.272
p-value was calculated by from chi-square
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(b)
(a)
Figure 1. (a) Sagittal and axial (b) T2-W MR image showing disk herniation at L4/L5 and L5/S1
and severe central canal stenosis at L5/S1.
Table 3. Distribution of degenerative imaging findings by patient presenting symptoms.
Symptoms
Disk degenerative changes
LBP with
LBP only
Radiculopathy
(n=33)
P. value
(n=132)
Disk degeneration
111(84)
26(79)
0.468
Modic changes
43(33)
4(12)
0.020
Disk bulge
50(38)
14(42)
0.632
Disk herniation
100(76)
4(12)
0.000
Canal stenosis
50(38)
0(0)
0.000
Nerve root compression
118(89)
9(27)
0.000
P
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value was calculated from Fishers’ Exact test.
Figure 2. Distribution of Patients by Age and Sex
Table 4. Frequency Distribution of Disk Degenerative Changes by Disk Level.
Degenerative changes
Spine level
L1/L2
Disk degeneration
L2/L3
L3/L4
L4/L5
24(14.5) 43(26.11) 57(34.5) 109(66.1)
L5/S1
87(52.7)
Modic changes
3(1.8)
7 (4.2)
9(5.5)
22(13.3)
14(8.5)
Disk bulge
1(0.6)
4(2.4)
15(9.1)
38(23)
26(15.8)
Disk herniation
3(1.8)
13(7.9)
29(17.6)
78(47.3)
51(30.9)
Canal stenosis
1(0.6)
2(1.2)
14(8.5)
41(24.8)
15(9.1)
5(3)
16(9.7)
38(23)
107(64.8)
71(43)
Nerve root compression
Discussion
We studied disk degenerative disease in patients with LBP by using MRI. MR imaging is a
modality of choice for diagnosing spine disorders as it provide accurate anatomic information
and hence affect the management decision making. All recruited patients underwent MRI of the
lumbar spine and both sagittal and axial views of all images were interpreted. Degenerative
changes were observed in majority 155 (94%) and most of them had multiple degenerative
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changes and more than one spine levels were affected and this findings were also consistent
with other studies8,26(26)(8). Since lumbar spine is subjected to heavy mechanical stress, it is a
common area affected by degenerative changes this could partly explain such observation in
this study27. The mean age of this study group is 50±12.5 years could be another explanation, as
degenerative changes is common in individuals above 50 years of age and its prevalence
increases progressively to over 90% by 50 to 55 years of age8,9 .
The main presenting symptom was LBP followed by radiculopathy consistent with a studies
done in Pakistan and Ethiopia26,28. Disk degeneration was the most frequent finding observed
(83%), in contrary to some other studies where disk herniation is the most common finding26.
Disk degeneration increased with age, the difference observed was statistically significant (pvalue = 0.000) and compares well to the findings of other studies8,9.26. The difference in
prevalence among young and aged individual could be contributed by aging process. Disk
degeneration was slightly more frequent among males 67 (85.9%) as compared to females
70(80.5%), though the variation observed was not statistically significant and compares well
with other studies5,13. Proportion of degenerated disks progressively increases the lower the
spine level , and the most common affected spine levels are L4/L5 and L5/S19,25, this is similar
to what was observed in this study.
The prevalence of Modic changes (28%), was higher compared to other studies1. In young
individuals aged <30 years prevalence of Modic changes is low, ranging from 1.4% to 3.7%29; in
this study it was 6.7%. The young individuals in this study were in the age group of 20 – 39
years , could explain this difference. Modic changes progressively increased the lower the spine
level, and the most common location were L4/L5 and L5/S1. This observation is consistent with
previous studies1,30.
In this study disk herniation were more common than bulges (63% and 39% respectively); and
this is different to the findings reported by other studies(3). This difference could be due to
young study population (individuals below 30 years) included in other studies. The prevalence
of disk herniation is similar to the findings reported by Modic 24, but lower than what was
reported in other studies28,31,32.
Disk bulges were more common among young individuals aged 20 to 39 years as compared to
individuals aged 60 to 80 years, unlike disk herniation, which was higher among older
individuals. However, these findings were not statistically significant (p-value >0.05). In this
study, no significant difference in sex was found in the prevalence of disk bulges and herniation.
Various studies have reported that disk herniation is common at L4/L5 and L5/S1 and the
frequency at these levels is ranging from 30% to over 90%26,28. This was also reflected in this
study as 74% of the herniated disks were at L4/L5 and L5/S1, this can be due to the large
workload causing stress at these lower lumbar levels of the spine.
The main presentation of disk herniation is sciatica. In this study 76% of patients with LBP with
radiculopathy had disk herniation as compared to 12% in those with LBP only (p value 0.000),
this is different from report published by Modic24. This difference could be due to the short
duration of patient’s presenting symptoms (less than 3weeks) in Modic’s study, while in this
study most of patients (88%) had symptoms for more than twelve weeks.
Fifty (30%) patients in this study had central canal stenosis, which is higher compared to that
reported by other previous studies24,31. The difference observed could be due to much older
study population in this study. Older individuals had higher prevalence of canal stenosis in this
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study. Both sexes were equally affected. Canal stenosis was frequent at L4/L5 and L5/S1, while
none was found at L1/L2 level, these findings are similar to other previous studies24,31.
Degenerative spinal stenosis is more common in patients with sciatica than in patients with low
back pain31. In this study the prevalence of canal stenosis among patients with radiculopathy
was 38% and none was found among patients with LBP only (p-value 0.000). These findings are
similar to findings of previous studies31. The small canal in patients with stenosis causes thecal
sac or nerve roots to impinge against the spine bone elements hence causing radiculopathy and
activity dependent pain.
Nerve root compression is most common among sciatic patients and lower among patients with
LBP31. In this study prevalence of nerve root compression was 77%, and it increased with age.
Males more affected than females, prevalence being 80.8% and 73.6% respectively, though
these findings were not statistically significant. Nerve root compression was more frequently
seen at L4/L5 contrary to what was reported by Shobeiri et al 31.
A limitation encountered was a skip technique used that can reduce the sensitivity of MR
imaging in the detection of smaller disc protrusions, migrated free disk fragments, and their
effect on the thecal sac. In conclusion lumbar spine degenerative disease is prevalent (94%)
among patients with LBP and cuts across all age groups. There is a relationship between
radiculopathy and disk herniation, central canal stenosis and nerve root compression. The
lower lumbar spine levels remain the most affected area for disk degenerative disease. As less is
known on MRI pattern of disk degenerative disease in Tanzania, we have established the base
line data to be used for future research planning in the field of spine.
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Effects of Computerized tomography scan features on outcome of traumatic brain
injuries
M.O.N. Nnadi1, O.B. Bankole2, B.G. Fente3, A.A. Ikpeme 4.
1Division of Neurosurgery, Department of Surgery, University of Calabar Teaching Hospital,
Calabar, Cross River State, Nigeria.
2Neurosurgical Unit, Department of Surgery, Lagos University Teaching Hospital, Lagos, Nigeria.
3 Department of Surgery, Niger Delta University Teaching Hospital, Okolobri, Bayelsa State,
Nigeria.
4Department of Radiology, University of Calabar Teaching Hospital, Calabar, Cross River State,
Nigeria.
Correspondence to: MON Nnadi, E-mail: nnadimon@yahoo.com
Background: Computerized tomography (CT) scan is the image modality of choice in acute
traumatic brain injuries. It helps in identifying urgent surgical emergency lesions. We
assessed the effect of computerized Tomography scan features on the functional outcome of
traumatic brain injury patients managed in our center. The objective was to determine CT
scan features that could predict outcome in traumatic brain injury patients.
Methods: It was a prospective observational study carried out on our patients with
traumatic brain injuries who did CT scan of the brain. Data were collected using structured
proforma which was component of our prospective data bank that was approved by our
ethics and research committee. The data were analyzed with Environmental Performance
Index (EPI) info 7 software.
Results: There were 173 patients whose CT scans were studied. One hundred and thirty five
were males. The mean age was 30.61years. One hundred and thirty patients were involved
in road traffic accident. Status of mesencephalic cistern, intra-ventricular hemorrhage,
midline shift, and diffuse axonal injuries were significant predictors of functional outcome.
Conclusion: Some CT scan features such as the status of mesencephalic cistern, midline
shift, diffuse axonal injury, predicted outcome in our patients.
Keywords: CT scan, traumatic brain injury, outcome.
Introduction
Traumatic brain injury is responsible for up to 45% of in-hospital trauma mortality.[1]Quick
decision taking is essential in treating these patients. CT scan is the imaging modality of choice.
It is cheap, fast to perform and readily available[2] It reveals urgent surgical emergency lesions[3]
and helps in admission decision making.[4]Many CT scan characteristics such as basal cistern
status,[5]midline shift,[6,7] traumatic subarachnoid hemorrhage[8,9,10] and intraventricular
hemorrhage[11] predicted outcome. We prospectively studied the brain CT scan features of our
patients and their relationships to outcome.
Methods
It was a prospective, observational study of traumatic brain injury patients managed in our
center from August 2010 to July 2014. It was carried out on those who did CT scan of the
brain.The patients were managed using our protocol for head injury: advance trauma life
support protocol in accident and emergency, investigations, definitive treatment (conservative
or surgery) and follow up of the patients in the out-patient clinic. Data were collected using
structured proforma which was part of our prospective data bank that was approved by our
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hospital’s ethics and research committee. Data collected included biodata, clinical findings
(history and physical signs, including Glasgow Coma Score after resuscitation), CT scan of brain
features (extradural hematoma, subdural haematoma, intracerebral hematoma/contusions,
fractures, cerebral edema, intraventricular hemorrhage, subarachnoid hemorrhage, number of
lesions, midline shift, mesencephalic cistern status, diffuse axonal injury features),treatment
modalities (surgery or conservative), and Glasgow Outcome Scores (GOS) 12 three months postinjury. It had been found that GOS at three months post-injury predicted long term outcome.[13]
In getting our CT scan findings, we did not apply time limit bearing in mind that up to 50% of CT
lesions were observed to progress 14,15. In patients with multiple CT scan, different findings
were added to the first CT findings. Studies found that the worst CT scan obtained during the
clinical course had greater predictive values 16, 17.
We did not pay much emphasis on subdural hematoma because of its age bias (common at both
extremes) and its correlation to midline shift. We used midline shift as continuous variable
parameter18. Subarachnoid haemorrhage and edema were scored if they were the only lesion
seen or dominant lesion in multiple lesions. The data collected were analyzed using
Environmental Performance Index (EPI) info 7 (Center for Disease Control and Prevention,
Atlanta, Georgia, USA, EPI info 7 version 7.0.8.0 of 2011). At 95% confidence interval, P≤ 0.05
was considered significant.
Results
One hundred and seventy three patients were studied. There were 135 males and 48 females.
Their mean age was 30.61years and their age ranged from one year to 76 years. Age group 20-<
30 had highest frequency (55), (Table 1). The commonest cause was road traffic crash (RTC),
75.14% (Table 2). Status of mesencephalic cistern was a strong predictor of outcome, P = 0.004,
(Table 3). Midline shift also predicted outcome, P = 0.0306, (Table 4). Twenty eight had diffuse
axonal injuries. Twenty of them had severe head injury, six moderate and two mild head
injuries. All of them were involved in road traffic accident. Eight (28.57%) had skull fracture.
Four patients (100%) who died from diffuse axonal injuries had severe head injury. Diffuse
axonal injury was strong predictor of outcome, P = 0.0015 (Table 6).
Table 1. Age Distribution
Age
0 - < 10
10 - < 20
20 - < 30
30 - < 40
40 - < 50
50 - < 60
60 - < 70
70 - < 80
Total
Frequency
Percentage
18
16
55
40
24
9
6
5
173
10.40
9.25
31.79
23.12
13.87
5.20
3.47
2.89
100
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Table 2. Distribution of Causes.
Aetiology
assault
fall
Gun shot
others
RTA
sports
Total
Frequency
16
20
4
2
130
1
173
Percentage
9.25
11.56
2.31
1.16
75.14
0.58
100
Table 3. Mesencephalic Cistern vs GOS
Mesencephalic
cistern
Normal
Partially effaced
Totally effaced
Total
P ꞊ 0.004
1 (%)
6 (4.96)
6 (12.77)
2 (40.00)
14 (8.09)
Glasgow Outcome Score
3 (%)
4 (%)
5 (%)
0 (0.0)
13 (10.74)
102 (84.30)
2 (4.26)
9 (19.15)
30 (63.83)
0 (0.0)
1 (20.00)
2 (40.00)
2 (1.16)
23 (13.29)
134 (77.46)
Total (%)
121 (100)
47 (100)
5 (100)
173 (100)
Table 4. Midline shift vs GOS
Midline
Glasgow Outcome Score
shift
1 (%)
3 (%)
4 (%)
5 (%)
Total (%)
Yes
8 (14.29)
2 (3.57)
6 (10.71)
40 (71.43)
56 (100)
No
6 (5.13)
0 (0.0)
17 (14.53)
94 (80.34)
117 (100)
Total
14 (8.09)
2 (1.16)
23 (13.29)
134(77.46)
173 (100)
P ꞊ 0.0306
Intraventricular hemorrhage was also a predictor of outcome, P = 0.0128, (Table 5).
Table 5. Intraventricular hemorrhage vs GOS
Intraventricular Glasgow Outcome Score
hemorrhage
1 (%)
3 (%)
Yes
2 (50.00)
0 (0.0)
No
12 (7.10)
2 (1.18)
Total
14 (8.09)
2 (1.16)
P = 0.0128
Table 6. Diffuse axonal injury vs GOS
Diffuse axonal Glasgow Outcome Score
injury
1 (%)
3 (%)
Yes
4 (14.29)
1 (3.57)
No
10 (6.90)
1 (0.69)
Total
14 (8.09)
2 (1.16)
P = 0.0015
4 (%)
1 (25.00)
22 (13.02)
23 (13.29)
4 (%)
9 (32.14)
14 (9.66)
23 (13.29)
5 (%)
1 (25.00)
133 (78.70)
134 (77.46)
5 (%)
14 (50.00)
120 (82.76)
134 (77.46)
Total (%)
4 (100)
169 (100)
173 (100)
Total (%)
28 (100)
145 (100)
173 (100)
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Table 7. Number of lesions vs GOS
Number of
Glasgow Outcome Score
lesions
1(%)
3(%)
0
1(5.88)
0(0.00)
1
1(2.04)
0(0.00)
2
7(13.73)
0(0.00)
3
1(7.69)
0(0.00)
4
0(0.00)
1(7.69)
>4
4(13.33)
1(3.33)
Total
14(8.09)
2(1.16)
P = 0.0167
4(%)
0(0.00)
4(8.16)
6(11.76)
1(7.69)
3(23.08)
9(30.00)
23(13.29)
5(%)
16(94.12)
44(89.80)
38(74.51)
11(84.64)
9(69.23)
16(53.33)
134(77.46)
Total(%)
17(100)
49(100)
51(100)
13(100)
13(100)
30(100)
173(100)
Subarachnoid hemorrhage did not predict the outcome, P = 0.1862. The higher the number of
lesions seen, the worse the outcome, P = 0.0167 (Table 7}.
All 20 patients with extradural hematoma (conservatively and surgically treated), had favorable
outcome of GOS ≥ 4. Of interest were two patients with hemiparesis who did CT scan some days
after the accident. Their CT scans showed subacute extradural hematoma of about 1.5cm in
diameter. Because of their improving neurological status they were managed non-operatively.
Three weeks after the accident, they had favorable recovery and repeat CT scan showed the
haematomas had resorbed. Another interesting finding was a 21 year old girl that was involved
in road traffic accident who presented with headache. Her Glasgow Coma Score was 14/15. Her
CT scan showed bilateral acute subdural hematomas of about 1.2cm each. There was no midline
shift. She was managed non-operatively with close monitoring. The headache gradually resolved
over two weeks. She became fully conscious third week. Repeat CT scan showed the hematomas
had resorbed. All patients with edema (14) had favorable outcome. Eighteen patients (10.40%)
did not have any CT finding. Fourteen of them had mild head injury while four had moderate
head injury. One patient (5.56%) among those without CT finding died from complications of
musculoskeletal injuries while 17 patients had GOS score of five.
Discussion
In our study, majority of the patients were males. Road traffic crash was the commonest
etiology of traumatic brain injury. The highest frequency was in the 20-40 years old age group.
They were part of active work force of our nation trying to make ends meet for them and their
families. In high unemployment developing countries like ours this group resorts to commercial
motorcycle, tricycle and vehicle driving with majority not adequately trained and had poor
knowledge of road safety rules. These have been documented by many authors 19, 20, 21.
In our study, we found midline shift, intraventricular hemorrhage, effacement of mesencephalic
cistern, number of lesions, and diffuse axonal injuries as CT features predicting unfavorable
outcome. Traumatic subarachnoid hemorrhage did not predict outcome. In their study of 2269
patients with moderate and severe head injuries, Maas et al 11 found midline shift, basal cistern,
intraventricular hemorrhage and traumatic subarachnoid hemorrhage as significant predictors
of mortality. Jacobs et al 22 in their study of 605 patients with moderate and severe head injuries
found midline shift as significant predictor of outcome. They did not find any cut-off mark in
midline shift; rather it was a continuous variable. We did not sign any cut-off number in our
study; rather midline shift was a continuous variable. Nelson et al 18 also recommended the use
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of midline shift as a continuous variable. Many authors have documented the prognostic nature
of midline shift 6, 7.
Many authors had shown diffuse axonal injuries to be related to outcome[23, 24] and noted that CT
scan showed 20-50% of diffuse axonal injuries. All our patients with diffuse axonal injuries were
involved in road traffic accident. Adams et al[25] in their study of 45 patients with diffuse axonal
injuries also noted that all were from road traffic crash. Subarachnoid hemorrhage and
intraventricular haemorrhage were documented as predictors of outcome by many authors.[8,
26]Jacobs et al 27 in their outcome prediction in mild head injury found number of contusions as
significant predictor of outcome. In their study of 605 patients with moderate and severe head
injuries, Jacobs et al 22 also found number of lesions as predictor of outcome. Other authors
documented similar findings 28, 29. The prognostic value of basal cistern had been documented by
many authors 5,30. Our findings were similar to the findings of above authors except
subarachnoid hemorrhage. This might have been due to our assigning method to only or
dominant lesion being subarachnoid hemorrhage. We believed that in lesions in which other
lesions dominate, subarachnoid would play secondary role to the dominant lesions.
In our study, all patients with extradural haematoma had favorable outcome. Nelson et al 18 in
their study of 890 CT scans, found that extradural hematoma was a positive predictor of
outcome. This was also found by other authors 31, 32. Our zero mortality in extradural
haematoma care was in keeping with zero mortality in extradural haematoma as predicted by
Bricolo et al 33.
The use of initial or admission CT scan to predict outcome by many authors has some problems.
Many authors noted that severe and moderate head injuries were dynamic processes that
progress with time 34, 35. Narayan et al 14 noted that up to 50% of CT lesions were observed to
progress after traumatic brain injury (TBI). Lobato et al 36 after their study, recommended that
since one third of patients with normal admission CT scan developed new pathology within first
few days of injury, a strategy for controlled scanning should be adopted. All these showed that
most studies done with admission CT scan might not have been correct.
Many authors found that CT scan is unreliable method for detecting non-hemorrhagic brain
injuries especially small contusions in diffuse axonal injuries 2, 37, 38. Since diffuse axonal injury is
an unfavorable outcome predictor and visible only in 20-50% 39, the strength of its prediction
cannot be sure of and the effect on other predictors cannot be ascertained.
Future direction
The future of determining the outcome of traumatic brain injuries will lie on combination of CT
scan and emerging imaging modalities of Magnetic Resonance Imaging (MRI) such as
Susceptibility Weighted Imaging (SWI) and Diffusion Tensor Tractography (DTT) of Diffusion
Tensor Imaging (DTI) which can circumvent the problems seen in CT scan.
Conclusion
Our study found that intraventricular hemorrhage, midline shift, diffuse axonal injuries, number
of lesions, and status of mesencephalic cistern were negative predictors of outcome. Extradural
hematoma was positive predictor of outcome.
Due to inability of CT scan to detect diffuse axonal injuries in large percentage of patients, we
feel that CT scan, susceptibility weighted imaging and diffusion tensor tractography
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combination study will be a better synergistic study in determining outcome of traumatic brain
injury patients.
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Major limb amputations at a teaching hospital in the sub-Saharan Africa: Any change in
trend?
O.J. Ogundele, A.I. Ifesanya, O.A. Oyewole, O.O. Adegbehingbe
University College Hospital, PMB 5116, Ibadan,Oyo state,Nigeria
Correspondence to: Joshua Ogundele, Email: <ogunjosh@yahoo.com>
Background: Major limb amputation is a serious but usually preventable public health
problem that is often associated with profound social, psychological and economic impacts
on the patient and family. The objective of this study was to evaluate the trend, indications
and short term complications of major limb amputations and to compare our experience
with that of other published data.
Methods: A retrospective study of medical records of all patients who underwent major
limb amputations at a Nigeria teaching hospital between 2006 and 2013. Information
about age, sex, indications, level of amputation, facilities where patients had initial care
before presenting in our centre, complications and outcomes of care were studied.
Results: One hundred and sixty-five major limb amputations were done in 158 patients
with bilateral lower limb amputations in seven of them. 60.8% of these were due to severe
extremity trauma with irreversible vascular damage while diabetic foot gangrene
accounted for 30.4%. Complications included wound infections (24.2%), flap necrosis
(3.6%), phantom limb pain (2.4%) and knee flexion deformity (0.6%). Mortality was 0.2%.
Conclusion: Trauma with irreversible vascular damage is still the leading indication for
major limb amputation in our hospital.
Key words: Major, Limb, amputation, sub=Saharan , Africa, trend
Introduction
Major limb amputation is a serious but usually preventable public health problem that is often
associated with profound social, psychological and economic impacts on the patient and family
especially in developing countries where prosthetic services are poor. Major limb amputation is
described as amputation proximal to the wrist or ankle 1. The indications for limb amputations
are generally considered as the three “D”s: dead limb, deadly limb and a damn nuisance of a
limb. The most common indications for limb amputation vary from study to study and includes
trauma with irreversible ischemia to a limb, complications of diabetes mellitus and peripheral
vascular disease.
There is a growing aggressive policy of limb revascularization in the developed world with
various procedures being advocated to attempt to revascularize an ischemic limb even in poor
candidates. Medicolegal issues also sometimes influence decision making as to whether to
salvage or amputate a limb. Hence the decision for limb salvage or primary amputation is a
crucial one for the surgeon to make, and it is imperative that the surgeon makes a good initial
decision2. In some instances amputation of the limb may be the only viable option to save the
patient’s life. The objectives of this study were to evaluate the trends, indications and short term
complications of major limb amputations and to compare our experience with that of other
published data.
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Patients and Methods
A retrospective study of all patients who underwent major limb amputations at a Nigeria
teaching hospital during the seven year period between 2006 and 2013 was carried out. The
patients were identified from the operating theatre records and their case notes were retrieved
from the Medical Records department. A questionnaire was designed to capture the relevant
data from the patients’ hospital records. Information about age, sex, indications for amputation,
level of amputation, facilities where patients had initial care before presenting in our center,
complications and outcomes of care were studied. The data was fed into a computer
spreadsheet and analyzed using the Statistical Software for the Social Sciences (SPSS) version
17. Quantitative variables are described by mean and standard deviation while qualitative
variables are described with percentages and proportions. The results are presented with the
aid of tables and figures.
Results
A total of 165 major limb amputations were done in 158 patients. Bilateral lower limb
amputations were carried out in seven of them. The patients were aged between 1 and 91 years
with a mean age = 41.0±21.4 years (Table 1). There were 107 males and 51 females with a M: F
sex ratio of 2.1: 1.0. One hundred and twenty five (75.8%) lower extremity amputations were
done while 40 (24.2%) amputations done in the upper limb (Figure 1). Forty eight (30.4%)
patients who had lower extremity amputations were due to diabetic foot gangrene, 76 (48.1%)
were due to severe extremity trauma with irreversible vascular damage, 6 (3.8%) were due to
peripheral vascular disease while 4 (2.5%) were due to neoplasm.
Twenty (12.7%) patients had upper extremity amputations due to trauma such as gangrene
from improperly managed fractures, gunshot injuries with irreversible vascular damage and
electric burns. Two (1.3%) were due to neoplasm and 2 (1.3%) badly managed chronic
osteomyelitis (Figure 2).
Table 1. Age Distribution of Patients Who Had Major Limb Amputations.
Age (years)
0-9
10-19
20-29
30-39
40-49
50-59
60-69
≥70
Total
Frequency
(%)
11
15
25
31
19
18
25
14
158
7.0
9.5
15.8
19.6
12.0
11.3
15.8
9.0
100.0
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Figure 1 Types of major limb amputations
Figure 2. Indications for Major Limb Amputations
Twelve (7.6%) patients had re-amputation. Eighty-five (53.8%) of the patients who had lower
limb amputations were able to procure and ambulate with prosthesis while 40 (25.3%) were
not able to procure prosthesis due to financial constraints. Only two (1.3%) patients who had
upper extremity amputations procured prosthesis. Sixty-three (40.0%) of the patients
presented directly to our hospital while the rest presented initially to other health care facilities
(Figure 3). Complications included wound infections (24.2%), flap necrosis (3.6%), phantom
limb pain (2.4%) and knee flexion deformity (0.6%). 163 (99.8%) patients were discharged
home while 2 (0.2%) died.
Mean age is 41.0±21.4years.
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Figure 3. Health Facilities Where Amputation was Done
Discussion
Amputation is the removal of whole or parts of the body and can be as a result of unprecedented
havoc or natural disasters; like accidents, earthquakes of major intensity, terrorism and war, or
medical reasons with the aim of improving health outcomes and quality of life of patients.
Despite advances in medicine and surgery, amputation continues to be a major problem in the
world, predominantly for older adults. It has been estimated that there were 664,000 persons
living with major limb loss in the United States in 2005 and more than 900,000 with minor limb
loss. Lower limb amputations are much more frequent than upper limb and are most commonly
the result of diseases such as diabetic foot gangrene, neoplasm, peripheral vascular diseases
followed by trauma 3. Although amputation is still often erroneously viewed as a failure of
treatment, it can actually be the treatment of choice in severe trauma, vascular disease and
tumours 4. The decision to perform an amputation often comes after all other options have been
exhausted and once it is initiated, it cannot be reversed. Unfortunately, most often, patients’
present late when extensive gangrene had occurred such that revascularization and limb
salvage is no longer a feasible option.
As amputation indications and patterns vary between hospitals and between countries, this
study was undertaken to describe our experiences on major limb amputations in a large tertiary
care teaching hospital and compare the findings with an earlier study conducted in our center
and those in other parts of the world with a view to highlighting the variations in the pattern
and indications for amputations. There was a male predominance in this study, which is
consistent with findings in other reports in our country as well as in the western world 5, 6, 7, 8.
The mean age for amputations is consistent with findings in other studies8, 9 though a higher
mean age was reported from Ghana10. This age differences can be explained by differences in
the indications and patterns of amputation. The male to female ratio is comparable with
findings in studies in Nigeria and Sub Saharan Africa 4, 10.
The indications for amputation are similar to an earlier study in this center a decade ago11 and
in other studies in sub-Saharan Africa 4, 6, 11. In the advanced countries, 80-90% of limb
amputations are due to vascular problems 7, 8, 12. Trauma was the commonest indication for
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amputation in young adults in the productive and reproductive age groups. Limb amputation in
this group almost always results in a serious economic crisis for the family, especially due to the
fact that prosthesis is either unavailable or unaffordable 13. Amputations due to infections and
malignancies appear to be declining. Other indications for amputations in this study included
peripheral vascular diseases, post burns contractures, severe electric burns, neoplasm, and
severe infections like gas gangrene.
As in other reports, most of our amputations were performed in the lower limbs and below knee
amputation was the most common procedure performed 4, 6. This is similar to findings in earlier
studies where lower extremities were found to be injured more often than the upper
extremities and diabetic gangrene is common on the lower extremities than elsewhere on the
body11, 13. However, other reports have indicated above knee amputation as the commoner
procedure performed than below knee amputation 6, 14. Late presentation with spreading
gangrene or advanced diabetic foot gangrene or malignant lesions that have involved the
underlying bones may make the surgeon to opt for a higher level of amputation.
Wound infection, our commonest complication is in keeping with earlier reports4, 6, 14. The
overall surgical site infection rates in these studies reflect the severity of complications leading
to amputation in the first instance coupled with the fact that majority of the patients presented
late when severe sepsis had already set in. The rate of re-amputation is lower in this series
compared to that reported by other studies 2, 4 but similar to that reported by Kidmas et al 6 in
Nigeria (7.4%). These differences may be due to the fact that traumatic limb injuries are the
commonest indications for amputation in our study. Poor management of the amputation stump
coupled with the fact that majority of the amputations were done by junior doctors may have
been responsible for the re-amputation rate in this study.
The mean duration of hospital stay in this series is shorter than that obtained by Essoh et al.4
The length of hospital stay is an important measure of morbidity and an important determinant
of cost associated with amputation15.
Eighty-five (53.8%) of the patients who had lower extremity amputations were able to procure
and ambulate with prosthesis while only 2 (1.3%) patients who had upper extremity
amputations procured prosthesis. The cost of health care in this environment is entirely out of
pocket by the patients and the relations. Few non- governmental organizations are involved in
providing prostheses for amputees but this is largely inadequate compared to the teeming
number of individuals who need these services.
The mortality rate in our study is lower compared with other reports4, 6, 15. This may be due to
the relatively younger patients who presented with severe extremity injuries. These are
otherwise healthy individuals prior to their injuries and once life threatening events have been
treated they usually make satisfactory recovery.
Conclusion
Road traffic limb injuries and diabetic foot gangrene are still the commonest indications for
major limb amputation in our environment. These are potentially preventable through
provision of health education, early presentation and adequate treatment of these conditions.
Measures on prevention of road traffic crashes, community health education to encourage early
presentation to hospital, good diabetic control and early recognition and management of risk
factors for foot complications will reduce the number of patients undergoing major limb
amputations in this environment and subsequently reduce the number of amputees.
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References
1. Ziegler-Graham K, Mackenzie E, Ephraim P, Travision T, Brookmeyer R. Estimating the
prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil. 2008;
89(3): 422-429. [http://dx.doi.org/10.1016/j.apmr.2007.11.05] [PMID:18295618]
2. Tomaino M, Bowen V. Reconstructive surgery for lower limb salvage. Can J Surg. 1995;
38:221-228. [PMID:7788601]
3. Tseng C, Helmer D, Rajan M, Tiwari A, Miller D, Crystal S, Safford M, Greenberg J, Pogach
L. Evaluation of regional variation in total, major, and minor amputation rates in a
national health-care system. Int J Qual Health Care. 2007; 19(6):368-376.
[http://dx.doi.org/10.1093/intqhc/mzm044] [PMID:17947387]
4. Essoh J, Bamba I, Dje Bi Dje V, Traore A, Lambin Y. Limb amputations in adults in an
Ivorian Teaching Hospital. Niger J Ortho & Trauma. 2007; 7(2):61–63.
[http://dx.doi.org/10.4314/njotra.v6i2.29299]
5. Solagberu B. The scope of amputations in a Nigerian teaching hospital. Afr J Med Med
Sci. 2001; 7: 225-227. [PMID:14510134]
6. Kidmas A, Nwadiaro C, Igun G. Lower limb amputation in Jos, Nigeria. East Afr Med J.
2004; 7:427–429. [http://dx.doi.org/10.4314/eamj.v81i8.9205] [PMID:15622938]
7. Rommers G, Vos L, Groothoff J, Schuiling C, Eisma W. Epidemiology of lower limb
amputees in the north of The Netherlands: aetiology, discharge destination and
prosthetic use. Prosthet Orthot Int. 1997;7(2):92–99. [PMID:9285952]
8. Greive A, Lankhorst G. Functional outcome of lower-limb amputees: a prospective
descriptive study in a general hospital. Prosthet Orthot Int. 1996; 7:79–87.
[PMID:8876000]
9. Abbas A, Musa A. Changing pattern for extremity amputations in University of Maiduguri
Teaching Hospital, Nigeria. J.R. Coll Surg Edinb. 1996; 7(2):102–104.
10. Naaeder S. Amputation of the lower limb in Korle-Bu Teaching hospital, Accra. West Afr J
Med. 1993; 7:21–26. [PMID:8512877]
11. Ogunlade S, Alonge T, Omololu A, Gana J, Salawu S. Major limb amputations in Ibadan.
Afr.J.Med.med.Sci. 2002; 31:333-336. [PMID:15027774]
12. Pernot H, Winnubst G, Cluitmans J, De witte L. Amputees in Limburg: Incidence,
morbidity and mortality, prosthetic supply, care utilization and functional level after one
year.
Prosthet
Orthot
Int.
2000;7:90–96.
[http://dx.doi.org/10.1080/03093640008726531] [PMID:11061195]
13. Holcombe C, Hassan S. Major limb amputation in northern Nigeria. Brit J. Surg. 1991;
7:885–886. [http://dx.doi.org/10.1002/bjs.1800780735] [PMID:1873725]
14. Umaru R, Gali B, Ali N. Role of inappropriate traditional splintage in limb amputation in
Maiduguri, Nigeria. Ann Afr Med. 2004;7(3):138–140.
15. Solomon C, van Rij A, Barnett R, Parker S, Lewis-Barned N. Amputations in the surgical
budget. N Z Med J. 1994; 7:78–80. [PMID:8202289]
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Cast Bracing for Accelerated Treatment of Femur Fracture in the District Hospital
O. Kenneth Johnson
Choma General Hospital, Choma, Zambia
Current Institution -- College of Medicine, University of Malawi
Correspondence to: O. Kenneth Johnson, Email: okjohnsonsj@jesuits.net
The average time for healing after mid and lower femoral shaft fracture in adult men
requires about 8 weeks in traction. We have successfully adapted a technique of cast
bracing within the resources of many district hospitals which substantially shortens the inhospital admission time to about 4 weeks.
Key words: Cast, bracing, femur, fracture, treatment
Introduction
The general treatment of femur fracture in our district hospitals has been skeletal traction using
Steinman pin through proximal tibia. The ordinary bed is adjusted to allow for Perkins exercise.
There are generally good results but the average length of hospitalization remains about 8
weeks. A recent review from Addis Ababa documents the success of this method citing an
average length of traction 30-40 days followed by continued physiotherapy1i. This has been the
general treatment for all femur fractures in our district hospitals (upper, mid, lower shaft
femur; transverse, oblique, or comminuted).
The clinical problem of delayed union and the logistical problem of many patients with femur
fracture in a ward of limited space led us to re-evaluate the treatment program. The cast brace
method has been described to be effective and to shorten hospitalization2,3,4. It has been studied
biomechanically5. The theoretic advantage of a cast brace is early mobilization of the joint with
mechanical support to prevent angulation. Care must be taken so that the brace is applied when
there is adequate callus formation to prevent shortening when traction is removed. If weight
bearing is delayed while the cast brace is in place, this potential complication can be avoided.
The total time for healing and weight bearing is similar to patients treated by traction alone but
the cast brace method can shorten the time of hospitalization.
We developed a system of functional cast bracing which we could apply after the initial period
of Perkin’s traction for 4 weeks. After initial development, the cast brace method was
subsequently applied to all patients with mid and lower femur shaft fractures where the
fracture site would be contained within the thigh cylinder. Fractures were oblique or
transverse. A few fractures had minimal comminution. We did not apply this method to
fractures of the upper third because of expected problems in angulation when the fracture site
would not be included securely in the usual thigh cylinder (although some authors have found a
solution applying cast brace even in proximal femur fractures)6. At this time there was clinical
evidence of callous formation and early healing, ability to flex the femur slightly but not yet
ability to raise the femur off the bed with knee extended. Without cast bracing, such patients
would generally require an additional 2 weeks traction with Perkins exercise.
Methods
A retrospective audit was made of the experience treating femur fracture with an interest to
review length of hospitalization and return to normal activity and the complications associated
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with the treatment programs at Choma General Hospital for the ten-year period 2000 - 2009.
Adult male patients were included of ages from 18-65 (median age 30). Records of theatre log
and surgical clinic were reviewed by the author. Most patients were followed as outpatients for
9 months. All of these patients were treated by the one consultant surgeon during this period.
Table 1. Comparison of Effectiveness
Treatment
Group
Number
Patients
Traction
only
38
Traction;
15
Cast Brace
Length
Hospitalization
(days)
Complications
of infection
Mean Average 45
6 (pin site)
2 shortening over
2cm
1 pressure sore
2 angulation
(No of Patients)
(range 40-50)
Mean Average 35
(range 30-42)
Complications of
union
3 shortening over
2 cm
Discussion
The general treatment of femur fracture in the adult in our district hospitals has been skeletal
traction using Steinman pin through proximal tibia. It takes just a few demonstrations for
many family bedside attendants to become proficient in helping their relatives begin a good
daily exercise program. The patient is helped to sit up, the springs are removed from the distal
third of the bed and the mattress folded. With slight adjustment of traction, the patient can
begin flexing and extending the knee joint. We had been generally pleased with the results –
good union being achieved, good range of motion preserved at the knee, fairly good
preservation of muscle mass in the quadriceps as described in the comprehensive study of the
technique by Bezabeh et al2. There are few easily managed complications.
Although the skeletal traction with Perkins exercise gave generally good results, we had a few
patients who required prolonged traction. None had non- union. Reports of functional cast
bracing were reviewed2 and adaptations were made for our environment. All patients had
begun Perkins exercise with tibial Steinman pins in place. We found that we could apply cast
brace after 4 (or sometimes 5) weeks, markedly decreasing the length of hospitalization for
most patients. The cast brace method went through several modifications beginning with an
unlocked but extension-limited hinge fixed to a plate which was embedded in plaster cylinders
around thigh and leg. The final method simply used aluminium struts with bolt hinges
(materials easily available in ordinary hardware shops) embedded in plaster cylinders. The
patients were able to go home with crutches delaying weight bearing for another two- three
weeks. The cast brace facilitates correct flexion/ extension exercise without the complication of
valgus / varus angulation in this early period if weight bearing were to begin too early. The
patients return for follow-up after 6 weeks for plaster removal. The patients were then
followed up at 3 months and 6 months.
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Two complications of the fracture deserve special attention in applying this technique. The
incidence of shortening when cast bracing is applied after good callous formation is similar to
patients treated with the more usual prolonged period of traction. The incidence of angulation
may be higher if the fracture site is not well contained within the thigh plaster cylinder or if
weight bearing begins too early. What the cast bracing method achieves is facilitating earlier
discharge, with correctly aligned knee joint motion without continued traction in place; but
patients must be warned against too early weight bearing.
Conclusion
Closed femur fractures of the mid and lower femur, can be successfully treated by skeletal
traction with Perkins exercise followed by cast bracing at 4- 6 weeks. This method is achievable
in district hospitals with locally sourced materials from hardware outlets. The final outcome in
terms of joint mobility, muscle strength is probably similar but the benefit is shortened
hospitalization – a genuine benefit for most small district hospitals and for many families in
rural areas who must make repeated journeys to the hospital for care of their patient.
Figure 1. Simple Cast bracing materials available in rural district hospital
Acknowledgement
I gratefully acknowledge the dedication of the Choma General Hospital staff for their dedicated
care of patients involved in this audit. The management of these patients was under the
direction and direct care of one consultant surgeon.
Conflict of Interest
There was no agency funding, no conflict of interest.
References
1.
2.
3.
Bezabeh B, Wamisho BL, Coles MJM. Treatment of adult femoral shaft fracture using Perkins
Traction at Addis Ababa Tikur Anbessa University Hospital: The Ethiopian Experience. Int Surg
2012; 97:78-85
Pyper PC, Taylor TC. The Treatment of femoral shaft fracture using a cast brace. Ulster Med J
1981; 50:113-119.
Wardlaw D. The cast brace treatment of femoral shaft fracture. J Bone and Joint Surgery 1977;
59-B (4): 411- 416.
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4.
5.
6.
7.
Hardy AE, White P, Williams J. The Treatment of Femoral Farcture by Cast brace and early
walking. J Bone and Joint Surgery 1979; 61-B (2) 151-154.
Wardlaw D, McLauchlan J, Pratt DJ, Bowker P. Biomechanical of Cast Brace Treatment for
Femoral Shaft Fracture.. J Bone and Joint Surgery 1981; 63-B (1) 7-11.
Meggit BF, Juett DA, Smith JD. Cast Bracing for Fractures of the Femoral Shaft. J Bone and Joint
Surgery 1981; 63-B (1) 12-23
Bezabeh B, Wamisho BL, Coles MJM. Op. Cit.Thomas TL, Meggit BF. A Comparative Study of
Methods for treating fracture of distal half of the femur. J Bone Joint Surg 1981; 63 B (1):3-6.
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Pseudomyxoma Peritonei: An Unusual Complication of Ovarian Tumor
S.R. Singhal1, R. Sharma1, R. Sen2, A. Gupta1
1Department Of obstetrics and Gynecology, 2Department of pathology, Pt B D Sharma Post
Graduate Institute Of medical Sciences, Rohtak, Haryana, 124001, India
Correspondence to: Dr Savita Rani Singhal, Email- savita06@gmail.com
Pseudomyxoma peritonei, also known as adenomucinosis or jelly-belly, is enlisted
as very rare and recurrent clinical condition accidently diagnosed by surgeons
during laparotomy and laparoscopy. It is characterized by excessive extracellular
mucin accumulation in peritoneal cavity due to leakage of mucin secreting cells
from a mucinous tumor of appendix. There is an exception where this condition
arises from mucinous tumor of ovary. We present an interesting case where a 40
years old woman presented with an ovarian mass and intraoperatively abdominal
cavity was found to be filled with huge mucinous ascites and big ovarian tumor.
Surgical debulking was done and the histopathology report demonstrated a well
differentiated adenocarcinoma of ovary with mucin deposits in the omentum and a
malignant variant of pseudomyxoma peritonei (Peritoneal mucinous
carcinomatosis).
Key Words- Ovarian tumor, Pseudomyxoma peritonei, chemotherapy
Introduction
Pseudomyxoma peritonei (PMP) is a very rare clinical condition also known as
adenomucinosis or gelatinous ascites with an estimated incidence of one to two cases
per million per year1. It is usually encountered accidently during the surgery, and this
pathology is seen in two of 10,000 laparotomies2. This condition usually has its origin
from ruptured appendiceal mucinous adenoma, though there are some case reports
where PMP is seen in presence of normal appendix or prior appendectomy3. It also
shows association with mucinous malignancies of ovary, colon, urachus, biliary tree,
stomach and uterus. There occurs progressive accumulation of large amount of
extracellular mucin in the peritoneal cavity and metastatic implants on peritoneum and
omentum.. WERTH coined the term Pseudomyxoma peritonei and he found its
association with an mucinous tumour of ovary in 18842. It is pathologically and
prognostically classified in three distinct categories such as DPAM (Disseminated
peritoneal adenomucinosis), PMCA (Peritoneal mucinous carcinomatosis) and an
intermediate group4. A case of pseudomyxoma peritonei with origin from mucinous
tumour of ovary is reported due to its rarity.
Case Report
A 40-years old woman with four live children was referred by a private practitioner
with complaints of abdominal distension, dull aching abdominal pain and decreased
appetite for three months. Her general and systemic examination was normal.
Abdominal examination revealed ascites with cystic to firm mass of about 24 week
gravid uterus size, well defined, arising from pelvis, reaching up to umbilicus and with
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restricted mobility. Same mass was felt through anterior and lateral fornices on vaginal
examination. Ultrasonography of whole abdomen showed ascites with a large 18х 15
cm hypoechoeic right adnexal mass with multiple internal septations and uterus, liver,
gall bladder, spleen, kidney, urinary bladder and appendix appeared normal. CECT
pelvis also showed a large well defined rounded hypodense mass lesion in pelvic region
arising from right adnexa with CT attenuation value of 5-10 HU with fluid content and
mild enhancing walls and normal left adnexa and uterus.
Figure 1. Gross Appearance of Mucin Filled Right Ovarian Cyst
Figure 2. Omentum Showing Pools of Mucin along with Metastatic Deposits from
Adenocarcinoma of Ovary at 40x
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Tumor marker CA-125 level was 96.7 U. patient was taken for staging laparotomy which
revealed, around 1000cc mucinous ascites, dense adhesion of intestines with uterus,
ovaries and omentum, tumor seedlings on gut, bladder, omentum, under surface of
diaphragm, left ovary and uterus. There was a right sided multiloculated ovarian cyst
filled with mucin of 18х15 cm size with smooth surface (Figure 1). Surgical debulking
was done which included right sided salpingo-opherectomy and omentectomy with
multiple biopsies. Removal of uterus, left side tube and ovary was not possible due to
dense adhesions.
Histopathological report showed a well differentiated adenocarcinoma ovary and
metastatic deposits from mucin secreting adenocarcinoma in omentum (Figure 2).
Pseudomyxma peritonei was designated as peritoneal mucinous carcinomatosis
(PMCA). She was given cisplatin based chemotherapy after radiotherapy department
consultation. Patient was discharged in good condition and was alright after six courses
of chemotherapy. She did not consent for complete surgery after chemotherapy and
continued to come for follow up till one year and there was no recurrence.
Discussion
Pseudomyxoma peritonei has an indolent course and presents with non specific
symptoms. There occurs leakage of tumor cells in to peritoneal cavity from rupture of
mucinous tumors of appendix or ovary. Peritoneal cavity is filled with septate jelly like
fluid. Mucinous implants are found on all peritoneal surfaces and the omentum. This
mucin causes compression of vessel, gastrointestinal tract and other abdominal
structures and results in distortion and impaired function of these organs5. These cases
present unexpectedly during laparotomy and laparoscopy. Some cases may present
with intestinal obstruction associated with fibrosis caused by mucin. Its preoperative
diagnosis is very difficult and tumor markers like CEA, CA125 CA19-9 have prognostic
value. CECT is currently the optimal imaging modality for the diagnosis and staging of
PMP and it predicts likelihood of complete cytoreduction6.
Ultrasonography of abdomen may detect immobile ascites. Histology of the tumor
shows clinical behavior of the tumor. PMP designated as DMPA is slow progressive and
have prolonged survival whereas PMCA depicts metastatic adenocarcinoma with
aggressive clinical course7. Standard treatment for pseudomyxoma peritonei is surgical
debulking, in which the tumor is removed as much as possible. Intraperitoneal cisplatin
chemotherapy is also a good modality of treatment for pseudomyxoma peritonei.
Intraperitoneal hyperthermic chemotherapy is a newer modality of treatment for PMP
and it is given for 30 minutes at 41-42celsius temperature using cisplatin (100 mg/m2)
and mitomycin-c (25mg/m2) or 5-flurouracil and mitomycin5. Hyperthermia causes
destruction of malignant cells and improves absorption of chemotherapy. Even with a
better understanding and recent advances in the management of these cases, low
incidence of PMP makes it difficult to study the disease and to evaluate the real
efficiency of the various modalities of treatment.
Conclusion
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This condition can be encountered by any surgeon during the surgery and the best
treatment is to perform complete cytoreduction after taking multiple biopsies and to do
appendicectomy if possible.
References
1. Amini A, Moghaddam SM, Ehteda A, Morris DL. Secreted mucins in
pseudomyxoma peritonei: pathophysiological significance and potential
therapeutic prospects. Orphanet Journal of Rare Diseases. 2014;71:1-12.
2. JacqueminG, Laloux P. Pseudomyxoma Peritonei : Review on a Cluster of
Peritoneal Mucinous Diseases. Acta chir belg. 2005;105:127-33.
3. Sueblinvong T, Hanprasertpong J. Pseudomyxoma Peritonei Associated with
Ovarian Tumor. Thai J Obstet Gynecol.2003;15(3):123-28.
4. Pranesh N, Menasce LP, Wilson MS, O’Dwyer ST. Pseudomyxoma peritonei:
unusual origin from an ovarian mature cystic teratoma. J Clin
Pathol.2005;58:1115–7.
5. Kamal SM , Bakar MA, Ali MY, Ahad MA. Pseudomyxoma peritonei: A Review.
Faridpur Med. Coll. J. 2012;7(2):88-92.
6. Bevan KE, Mohamed F, Moran BJ. Pseudomyxoma peritonei. World J Gastrointest
Oncol.2010; 2(1): 44-50.
7. Djordjevic B, Stojanovic S, Ljubenovic N and Djordjevic I. Pseudomyxoma
peritonei and mucinous ovarian tumors. Acta Medica Medianae. 2009; 48(1):
46-9.
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Challenges in Management of Pheochromocytoma at a Tertiary hospital in Northern
Tanzania. A 21 Years Descriptive Retrospective Study.
R.A. Rugakingila1 A.K. Mteta2
1Urology institute, Faculty of Medicine, Kilimanjaro Christian Medical University College.
Moshi Tanzania.
2Bugando Medical Centre, Director General. Mwanza, Tanzania.
Corresponding to: Dr. A.R Remigius, Email: andyremmy@hotmail.com
Background: Pheochromocytomas are rare catecholamine-secreting tumors that arise
from chromaffin tissue within the adrenal medulla and extra adrenal sites
(paraganglioma). Due to excess secretion of catecholamines, these tumors often cause
debilitating symptoms ending to death if actions are not taken. Management requires
competent physician, surgeons and anesthesiologists.
The main objective the study focused on pattern of presentation and treatment challenges
of pheochromocytoma patients over a period of 21 years (1992- 2012)
Methods:This was a retrospective study on patients underwent adrenelectomy at KCMC
Urology Institute during the course of 21 years and histologically confirmed cases of
pheochromocytoma were enrolled. A structured data collection sheet was designed with
parameters of demographic data, disease presentation, investigations done, tumor
localization, surgical technique and follow up, in a course of overseeing the challenges in
each step of management.
Results: A total of 13 patients were included in this study, median age of participants was
25 years. M:F 6:7. Majority of patients presented with clinical features related to episodic
elevation of catecholamines. Localization of the tumor was done with ultrasonography,
Computer Tomography scan and upon surgical exploration.12 cases were found to have
right side tumor and 1 case was on the left. All cases were operated using the Chevron
incision as the main surgical approach.12 patients got symptoms cured at the first 3 month
visit. One died in the ward.
Conclusion: Upon a study Pheochromocytoma showed to be a rare condition. Despite the
challenges occurred in managing all the cases, surgery has cured in 99% of all patients
operated. Radiological investigation was able to localize the tumor in 100% of the patients.
Key words: Pheochromocytoma, challenges, management
Introduction
Pheochromocytoma is a rare tumor arising from catecholamine-producing cells in the adrenal
medulla– an intra-adrenal paraganglioma (PGL), according to the World Health Organization
(2004) classification, Adrenal and extra-adrenal PGLs produce significant amounts of
catecholamine and give rise to the well-known clinical picture of pheochromocytoma. The
parasympathetic paraganglioma (mainly in head and neck) rarely produce significant amounts
of catecholamine. It is an important, often clinically occult neoplasm with devastating
consequences if overlooked.[1]The first clinical description of pheochromocytoma was by F.
Frankel in 1886 through a young female patient with a history of episodic attacks of headaches,
palpitations and anxiety, died suddenly and postmortem examination revealed bilateral adrenal
medulla tumors. In 1912 Pick coined the term pheochromocytoma when he was describing the
dusky (pheo) color (Chromo) of the cut surface of the tumor when exposed to dichromate. The
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first surgical excision of the pheochromocytoma was reported in 1927 by Roux who described
removal of suprarenal tumor in patient with two years of episodic vertigo and nausea.[2]
Prevalence of pheochromocytoma isn’t precisely known and large number of patients with
PHEOs do not present with classic symptoms suggesting that majority of PHEO are not
diagnosed during life[3] Several studies have revealed familial predisposition in autosomal
dominant manner. In a large series of patients screened biochemically for suspicion of PHEO,
the incidence has been reported to be as high as 1.9%, occurring equally in men and women[5]
The adrenal medulla and ganglia of the sympathetic nervous system (SNS) are derived from the
embryonic neural crest. The endocrine cells of this sympathoadrenal system synthesize and
secrete catecholamines and exhibit a characteristic histochemical (chromaffin) reaction when
treated with oxidizing agents. During the last few years, a considerable amount of new data,
concerning the genetics of PHEO/PGL, have accumulated and changed the whole approach to
such patients. It has been shown that in about 25% of cases, PHEO/PGLs develop secondary to
germ line mutations in any of five susceptibility genes 2,3.
A classic PHEO, a solitary tumor of the adrenal medulla, reminds us of a ‘tip of an iceberg’ the
expression suggesting beyond a single tumor there is potentially a broader clinical picture
awaiting exploration. KCMC being a referral center has been receiving complicated cases
including those of pheochromocytoma. Pheochromocytoma is a life threatening tumor and if left
untreated it is fatal and mortality approaches 100% due to hypertension with secondary stroke
and other multi-organs failure. Since there was no collective documented study at the setting,
this 21-years retrospective study overviewed the pattern of presentation and experience in
managing the disease.
Patients and Methods
This study was a Descriptive Retrospective hospital based study conducted at KCMC referral
hospital in institute of urology over the past 21 years. All patients who histological confirmed
having pheochromocytoma were included. Data collected through registry books and medical
files (1992-2012) were entered into data collection forms designed based on the specific
objectives. Ethical clearance was obtained at first place.
Results
The study involved 13 patients whowere diagnosed histologically with pheochromocytoma
after adrenalectomy at KCMC for a period of twenty one years. Of these, 7 were female, and they
were coming from rural area. The Median age of patients was 25 years.
Clinical features
Patients with pheochromocytoma presented with different symptoms (Table 1). Eleven patients
presented with persistent hypertension, two had paroxysmal hypertension.
Biochemical Evaluation and pharmacological tests
Neither biochemical tests nor pharmacological tests documented including Urine and plasma
catecholamine, Vinillymandelic acid (VMA) and clonidine tests.
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Table 1. Associated Symptoms in Pheochromocytoma Patients
Symptoms
Patients presented with
Postural hypotension
Yes
No
Number (%)
2 (15.38%)
11 (84.62%)
Headache
Yes
No
12 (92.31%)
1 (7.69%)
Anxiety
Yes
No
12 (92.31%)
1 (7.69%)
Weight loss
Yes
No
6 (46.15%)
7 (53.85%)
Pallor
Yes
No
7 (53.85%)
6 (46.15%)
Flushing
Yes
No
7 (53.85%)
6 (46.15%)
Generalized Body Malaise
Yes
No
1 (7.70%)
12 (92.30%)
Palpitation
13 (100%)
Sweating
13 (100%)
Localization of the tumor
Localization of the tumor was done with Ultrasound, computer Tomography scan and during
exploration. All were found unilateral, predominantly on the right side 11 candidates.
Preoperative preparation
All hypertensive patients were preoperatively treated with phenoxybenzamine and propranolol
to control hypertension. Phenoxybenzamine was prescribed 10mg three times a day for the
duration of two weeks. Experienced anaestheologist was consulted before starting stabilizing
patients, during pre-operative and intraoperative care with adequate monitoring equipment.
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A minimum of two units of blood was prepared pre-operative in each patient. All patients were
adequately given intravenous fluids, Ringer’s lactate and normal saline for volume expansion.
Phentolamine was made available to reverse hypertensive crisis.
Intraoperative events.
All 13 patients underwent open laparotomy, transperitoneal approach by Chevron abdominal
incision was used in all cases. The Adrenal vein was identified and ligated first as shown in
Figure 1. The tumour was gently handled in all cases. Eleven cases were found with right
adrenal tumours, while 2 cases were on the left. Malignancy was reported in one patient.
Neither tumour dimension nor weight measure were recorded. There were intraoperative
anaesthetic challenges despite the fact that all the patients records showed stabilized blood
pressure pre-operative. There were episode of hypertension and hypotension crisis which was
managed with intravenous fluids like plasma expanders and blood.
Follow up
Patients were closely monitored by checking vitals sign were done in all patients including
blood pressure and pulse. Twelve (12) out of 13 cases were found to be normotensive in a
course of three month. Moreover all patients had their blood glucose level checked to detect
hypoglycemia. One patient who intraoperative was found to have unresectable tumor died one
week after operation. No patient was followed up by checking level of adrenaline and
noradrenaline before and after operation. No patient had a check Ultrasound and CT scan as a
control postoperatively.
Figure 1. Adrenal vein identified first
Figure 2. Adrenal vein ligated and resection
continue
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Figure 3. Sample biopsy after resection
Figure 4. Histology(Zellballen)
Consent Obtained: ©Prof. A.K Mteta (2009)
Discussion
This study is similar to previous studies done by Berd[4]showing Pheochromocytoma is a rare
condition as in 21 years duration only 13 patients were recruited. Most of the patients in this
study belonged to younger age group with median age being 25 years. Pheochromocytoma was
equally found in both males and females in this study similar to other studies done by Young et
al [6] and a nationwide survey in 2009 by Nurse[7]. All patients were initially diagnosed clinically
with signs and symptoms of hypertension, headache, palpitation and sweatiness. Data from
previous studies confirm that pheochromocytoma have to be taken into account in differential
diagnosis of adrenal incidentilomas and the absence of hypertension doesn’t rule out the
presence of Pheochromocytoma 30.
The time interval from initial clinical diagnosis to operation time was averaged to 246 days. The
current study showed all patients manifested with hypertension, palpitation and sweating with
other clinical features which correlate with other previous studies showing diverse
manifestation reflecting the variations of hormone secretion, the pattern of release, and the
individual to individual differences in catecholamine sensitivity.[6,10,17] Tumor localization relied
on abdominal Ultrasound and CT scan, correlates with other studies which showed 100%
sensitivity [25]
There were challenges in obtaining biochemical study in all patients; this can be a reason of
delay in a diagnosis of the tumor as in similar studies has shown to establish diagnosis in more
than 95% of cases [19]. There was a significant time lag from diagnosis to the introduction of preoperative medications like phenoxybenzmine and phentolamine as per required in our
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management protocol. These challenges of time lag from diagnosis to operation can be partly
explained by difficulties in getting the premedication for stabilizing the blood pressure before
the operation in our local set up. Also diagnosis of the tumor itself needs high clinical suspicious
index, biochemical evaluation and radiological tumor localization before intervention which
impose challenge in time lag before resection
Tumour localization relied on abdominal Ultrasound and CT scan, correlates with other studies
which showed 100% sensitivity [25]. In this study right adrenal gland was more affected
compared to the left adrenal gland, in contrast with a study done by Krishnappa et al [12]. which
showed 5 left adrenal gland out of total 7 cases were affected
Pre-operatively all cases received phenoxybenzamine in a minimum of four weeks in a dose
range 20-40mg and propranolol to stabilize hypertension and arrhythmias respectively as in
previous studies showed. Arterial line placement and preoperative correction of intravascular
volume was done 17. In our study all patients were evaluated adequately with anaesthesiologist
and hypertension stabilized with α blocker medications before given β blockers and
intravenous fluids.
Intra-operatively anesthesiologists took special consideration to control blood pressure by
giving phentolamine and propranolol and proper monitoring of all vitals.
The operative management of patients with pheochromocytoma may be complicated by large
and potentially lethal swings in blood pressure with high peaks during tumor handling and
severe hypotension immediately following removal of the tumor [32]. Hypotensive episodes
occurred intraoperative were managed by volume replacement with crystalloids and blood.
There was no intra-operative mortality in all patients. 12 patients out of thirteen stabilized
blood pressure 1 month post-operative during the follow up. This is similar to other literatures
which concluded that there is little mortality if the patient is prepared well and blood pressure
stabilized before operation.
Conclusion
Pheochromocytoma is a rare condition, challenging in management but surgically cured as
shown this study. The clinical features of pheochromocytoma vary between hypertension,
headache and sweating manifest in all cases in current study. Despite the challenges in
diagnosis, ultrasound and CT scan play a big role in tumor localization. Biochemical studies
should be initiated in diagnosis of pheochromocytoma which will help to in early diagnosis of a
condition.
Our patients presented late in our department as they have to pass in different department like
internal medicine department before they came in urology department which can be one factor
to explain delay of operation from date of diagnosis. Moreover preoperative medications like
phenoxybenzamine intraoperative medications e.g. phentolamine had to be purchased by
patients as they were not locally available and this delayed the operation.
There were challenges in histopathological description of the tumour as in all histology results
none showed if it is malignant or benign.
Surgery is the main stay of treating pheochromocytoma despite the intraoperative challenges.
Recommendations
• We need multicenter studies to evaluate magnitude of the problem and long follow up of
the patients.
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•
•
•
•
Phenoxybenzamine is effective in the preoperative management of Pheochromocytoma.
Drugs like phenoxybenzamine and phenntolamine should make readily available to
reduce the duration from diagnosis to operative time.
In this study we have seen the importance of CT scan and how have it contributed in
localization of the tumor. This diagnostic instrument should be available all the time.
There is a need to do adrenal autopsy for all the cases that dies with essential
hypertension and its complications to rule out pheochromocytoma enabling us to have a
clear picture of disease.
There is a need to do a study on follow up of all patients diagnosed with
pheochromocytoma and operated on their progress including recurrence and quality of
life afterwards.
Acknowledgement
To all members of KCMC Urology Institute and pathology department who involved in care of all
patients who involved in care for those patient enrolled this study.
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i
Doctor’s Prayer
Bezabeh B, Wamisho BL, Coles MJM. Treatment of adult femoral shaft fracture using Perkins Traction at
Addis Ababa Tikur Anbessa University Hospital: The Ethiopian Experience. Int Surg 2012; 97:78-85
Lord, as I treat my Patients
Help me to be wise;
Let me see their problems
Through your discerning eyes
Guide me Lord, and use me
In everything I do
For you are the Great Physician
And I long to be like You.
-
Robin Foyle
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