ECAJS VOL 15 No 1 2010

Transcription

East and Central African Journal of Surgery Volume 15 Number 1.
March/April 2010.
Contents ECAJS Volume 15 Number 1. March/April 2010
Titles and Authors
Pages
The Impact of HIV Infection on the Surgical Disease Burden in Africa
B.F.K. Odimba
3
Exposure to Human Immunodeficiency Disease. What Precautions for the Healthcare
Professional?
T.E. Madiba, N.P. Magula
9
Breast Cancer Awareness among Females in a Developing world- A Study from
Kashmir, India.
S.A. Salat, A. Rather, S. Ahmad, A.B. Khan
16
Pr
Practice of Breast Self Examination among female students in a Sub Saharan African Uni
University
Obaikol R, Galukande M, Fualal J
22
Bilateral Breast Cancer: Experience in a Poor Resource Black African Setting.
A.S. Oguntola, S.O. Agodirin, M.L. Adeoti, A.O.A. Aderonmu.
28
Changing pattern of incidence, aetiology and mortality from acute pancreatitis at
Kalafong Hospital, Pretoria, South Africa, 1988-2007: A retrospective evaluation.
I. Chamisa, T. Mokoena, T.E. Luvhengo
35
40
Truncal Vagotomy for Peptic Pyloric Stenosis and Assessment of its Completeness by
Acid Tests.
B. Nega
The Management Outcome of Acute Hand Injury in Tikur Anbessa University
Hospital, Addis Ababa, Ethiopia.
E. Ahmed
48
The Impact of Bodaboda Motor Crashes on the Budget for Clinical Services at Mulago
Hospital, Kampala.
J. Kigera, L. Nguku, E.K.Naddumba
57
A Comparison of Kampala Trauma Score II with the New Injury Severity Score in
Mbarara University Teaching Hospital in Uganda.
Mutooro S.M, Mutakooha E, Kyamanywa P.
62
A Comparision of Clinical Diagnosis and Knee Arthroscopy Findings at Mulago
Hospital.
I. Kajja, L. Nguku, T.Beyeza
72
HIV Infection Among Orthopedic In-patients at Dil Chora Referral Hospital, Ethiopia.
M. Dessie
78
Tracheostomy Decannulation: Suprastomal Granulation Tissue in Perspective
J.A. Fasunla, A. Aliyu, O.G.B. Nwaorgu, G.T.A. Ijaduola
81
Challenges of Otolaryngologic Referral in a Nigerian Tertiary Hospital.
A.D. Dunmade, O.A. Afolabi , A.P. Eletta
87
Choanal Atresia in Siblings. Case report
B.M. Kaitesi
93
96
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March/April 2010.
Hearing Disorders in HIV Positive Adult Patients
B.A Ongulo , H.O Oburra.
Pattern of Surgical Diseases Based on Histopathological Findings: A 13-year Personal
Experience in a Rural Hospital in Kenya.
P.M. Nthumba
102
Cardiac Surgery: One year experience of cardiac surgery at Muhimbili National
Hospital, Dar es Salaam- TANZANIA.
E.T.M. Nyawawa, E.V. Ussiri, P. Chillo, T. Waane, E. Lugazia, U. Mpoki, R. Luchemba, B.
Wandwi , B. Nyangasa, J. Bgoya, W. Mahalu.
111
Thoracic empyema: Cause and Treatment Outcome at Gondar University Teaching 119
Hospital, Northwest Ethiopia
A. Amare, B. Ayele, D. Mekonnen
Neurocritical Care Audit in A Tertiary Institution
O.E. Idowu, S.O. Oyeleke, A.A. Olaoya
124
129
Primary Splenic Hydatid: A Case Report
S.I. Gul, M. Sheikh, T.S. Khan, M. Mushtaq, F. Reshi.
Hydatid Cyst of the Left Thigh: A case report
A. A. Abebe
133
Recurrent Hypoglycaemia and Seizures in HIV-positive Patient
135
N.S. Motsitsi, S. Craig
Missed Foreign Body Presenting as a Chronically Painful Hand. A Case Report
138
S.A. Salati, T. Rizvi, S.M. Rabah,
Crocheting Pin in The Falciform Ligament: A Rare Cause of Recurrent Right
Hypochondriac Pain.
G.F. Ngock, S.R. Sparks, D. Poenaru
2
141
March/April 2010.
The Impact of HIV Infection on the Surgical Disease Burden inAfrica
BFK Odimba
University Teaching Hospital, Lusaka – Zambia. Email: [email protected]
The Human immunodeficiency virus (HIV) infection stands among the greatest health
challenges facing Africa today. However, the impact of the pandemic on the surgical diseases
burden in the continent has received scant attention in the world literature. This study had as
general objective to determine through literature the impact of the HIV infection on surgical
diseases in Africa and in our regions in particular. To achieve this task searched Google website
in the first half of July 2008 to reference lists of literature on HIV and surgical diseases burden
to add to our own humble experience. We also contacted and discussed with local experts in the
field.
Data retrieved point out that HIV infection, throughout last two decades, has highly increased
the number of African common surgical burdening diseases, mainly in Sub-African countries.
The burden is on all categories of surgical diseases: injuries, congenital abnormalities, tumours,
surgical inflammations and infections. However, while the management of the HIV and its
opportunistic infections has met the attention of the international community and has continued
attracting health care donors and partnerships, surgical practice has not been given any rank
among disease control priorities of the United Nations Millennium Goals. It is suggested that
that African surgeons, especially in sub-Saharan countries, should together join in efforts so
that surgical diseases be considered as “Other Neglected Tropical Diseases (NTD)” listed among
the UN health care problems and deserve the attention of the international committee
Introduction
Twenty five years only since its first recognition in early 1983, the Human immunodeficiency virus
(HIV) infection has become the world number one pandemic, currently affecting more than 40 million
peoples1. It is estimated that 60-70% of the victims reside in Sub-Saharan Africa1. The infection is
then among the greatest health challenges facing Africa today. However, the impact of the pandemic
on surgical diseases burden in the continent has received scant attention in the world literature2. The
main objective of this study was to determine through literature review the current situation of this
impact in the continent and to propose the way forward in alleviating the burden. As specific
objectives, the study is intending:
1. To establish through literature review, the impact of HIV infection on each of the well known
groups of surgical diseases burden in Africa mainly in sub-Saharan Africa. congenital
malformations, injuries, surgical inflammations and infections and tumours
2. to analyse the burden of that viral infection on the practice of surgery itself
Methods
To accomplish the task, we searched Google website in the first half of July 2008 to reference lists of
literature on HIV and surgical diseases burden. We also read basic and textbooks3 on “infection
prevention” as well as the professional guidelines on HIV infection from the Association of Surgeons
of East, Central and Southern Africa, Central Board of Health4 and the Medical Council of Zambia5.
At last we contacted and discussed with local experts in the field. We yielded from this exercise more
than 25 references that allowed us making following comments, conclusions and recommendations.
Results and Discussion
The impact of HIV infection on the surgical diseases burden in Africa
The first evidence was that, despite recent improvement, very few clinical trials have been done on the
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burden of HIV infection in Africa. A study was conducted by Siegfried, Clarke and Volmink6. They
constructed and analysed a database of randomised trials on HIV infection, carried out wholly or
partly in Africa, using as sources Central, Medline, Embase and LILACS. They only took in account
articles reported and published between 1987 and 2004. They found only 77 randomised trials. The
trials were conducted only in 18 countries of 48 sub-Saharan Africa (no one from North Africa). Only
19 had a principal investigator located in an African country!
The second evidence was that the burden was particularly enormous in sub-Saharan Africa and caused
mainly by high rates of injuries, obstetric complications, cancers, birth defects, and perinatal
conditions8.
HIV and Congenital malformations
Congenital defects are known as surgical diseases burden in Africa not only because of their
frequency, but also because of the skills and logistics needed for their management in very limited
facilities. Ozgediz and Riviello8 have estimated the disability adjusted life year (DALY) for
congenital defects for Africa at two million DALYs. Up to 2002, while congenital rubella and syphilis
were considered birth defects, congenital HIV was not yet. Bourne and Borman9, during an
International Conference on AIDS. in July 2002, demonstrated that not only the congenital HIV was
the most common birth defect globally and is particularly in Sub-Saharan Africa, butthat it was the
most amenable to cost effective prevention with current mother to child treatment regimes.
HIV and injuries
Injuries represent the largest portion of surgical disease burden in Africa followed by obstetric
complications, malignancies, congenital anomalies and peri-natal conditions. Ozgediz and Riviello8
have estimated the DALYs ( disability adjusted life year) of injuries at 63 million DAILYs
worldwide and at 10 million DALYs for Africa. In men aged 15 to 44 years, the predominant
economically active segment of the population, only HIV takes more lives than road traffic crashes.
For every death from a road crash, dozens are left with temporary or permanent disabilities8,10,11,12;.
Most of these deaths result from road traffic injuries, wars, and interpersonal violence11. According to
the WHO13), road traffic injuries, war, and homicide, respectively, were the 10th, 11th, and 14th
leading causes of mortality in Africa during the year 2000.
Moreover for many authors there are many relationships between injuries and HIV infection. The role
of stress, stigma, depression, anxiety in leading directly to physical trauma has been emphasised14,15,16.
But HIV infection may indirectly put people in vulnerable groups predisposed to trauma as pointed
out by Kelly at a seminar of SADC-EU17. For example increase of street kids exposed to road traffic
accident and to violence
HIV and surgical inflammatory/infectious diseases
Bailey at the UTH, Lusaka, wrote that “the human immunodeficiency virus has resulted in a major
change in the presentation and behaviour of certain common diseases in Africa”. This review
describes some of the important changes and discusses the implications for management. Among
these syndromes are clinical spectrum and management of peritonitis and other intra-abdominal
sepsis.
HIV infection overloads surgical staff in sub-Saharan Africa as mentioned by many reports
on surgical infections/ inflammations: appendicitis in HIV –positive patients19; HIV and
surgical anal conditions and sepsis20,21; cardiovascular diseases: pericardial disease, arterial
aneurism2, surgical tuberculosis: pleural effusion, extra-pulmonary tuberculosis. Even in rural
area, the burden of paediatric HIV disease in poses a substantial challenge for health resources22.
HIV, obstetric emergency and peri-natal conditions
Ozgediz and Riviello8 have estimated in Africa the DALY at 4 million DALYs for obstetric
complications and at 2 million DALYs for perinatal conditions Emergency obstetric complications as
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referrals from rural districs cause more than 50% of maternal mortality23, 24 Newell25 and Sinyinza26
have reported high rates of child peri-natal mortality and morbity in HIVpositive mothhers. The
reports from WHO Geneva 2002 and 2005 give all dimension of the problem27,28,29. Fortunately
obstetric complications and perinatal conditions have been taken in account in the Millennium
Development Goals by the international Community. Since 2000, when the United Nations
Millennium Declaration was signed, efforts to reduce mortality among children younger than five
years of age have been accelerating.
HIV and cancer diseases
Ozgediz and Riviello8 have estimated the DALY for malignancies at 2 million DALYs in Africa. As
for the HIV opportunistic viral, bacterial, parasitic and mycolitic infections, publications worldwide
have shown high increase of cancer diseases related to HIV infection. In sub-Saharan Africa, reports
from Uganda and Zimbambwe are quite explicite32,33.
The impact of HIV infection on the burden of the practice of surgery itself
Not only, HIV infection has increased the burden of the surgical practice by increasing the related
surgical diseases but the pandemic has overloaded the practice of surgery by introducing more and
more surgical interventions of HIV infected patients bringing other challenges on how to prevent
occupational transmission and how to improve the outcomes of HIV infected patients with surgical
conditions.
In a very large retrospective study to audit the impact of HIV/AIDS in general surgical practice in the
UK, Dua et al34 concluded that surgery for HIV patients can be safely conducted for anorectal
procedures, vast majority of surgery in HIV/AIDS patients. Medical treatment for patients with
HIV/AIDS has developed dramatically over the last two decades. In parallel, this has resulted in a
heavy, new and varied workload for general surgeons. In our own practice a study was taken on
outcomes of HIV positive laparotomised patients of two big neighbouring departments in Austrian
Africa35. We noted a high rate of of re-interventions, long periods of hospital stay and high occurrence
of surgical site infection in HIV-positive patients in comparison with those HIV negative
.In summary, HIV /AIDS presents unusual and challenging acute surgical problems across all
specialties. Surgeons play a vital synergistic role, working in conjunction with HIV physicians in the
management of HIV positive patients34. However this overload of surgical disease has not been taken
in account by the international community and has not met the concern of the Millennium
Development Goals priorities.
The way forward in promoting the practice of Surgery and alleviating the HIV surgical diseases
burden in Africa
The first need is to quantify this burden by establishing the disease control priorities in our settings.
Such initiative has been launched by the Fogarty International Center of the US national Institutes of
Health, the WHO and the World bank in 2001 in a project called the Disease Control priorities project
or DCPP. It allows to identifying policy changes and interventions strategies for health problems of
our Low-income and middle-income countries (LIMICs). After establishing these priorities the
project focuses on the assessment of the cost-effectiveness of health-improving strategies (or
interventions) for the conditions responsible for the greatest burden of disease, examining also
crosscutting issues crucial to the delivery of quality health services, including the organisation,
financial support, and capacity of health systems.
After such studies in Africa, (mainly in sub-Saharan Africa) two surgeons, Doruk Ozgediz (University
of California San Francisco, USA) and Robert Riviello (Harvard University, Boston, are calling on
the international health community to recognize that surgical conditions account for a huge burden of
disease in the developing world, and that the human right to health must include access to essential
surgical care8. The authors furher remark that “while there has been an explosion of donor aid to
support infectious disease control, there has been little donor support to improve basic, essential
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surgical services, even though providing such services is an extremely cost-effective way to improve
public health.”
What should be done in the Region?
Working under the Ptolemy Research Project, Massey Beveridge et al36,37 have identified and
summarised the priorities as follow in order to reduce the burden of surgical disease in East Africa by
2010:: improve opportunities for continuing medical education (CME) for practicing surgeons;
introduce more surgical skills workshops for medical students and clinical officers; involve
COSECSA in surgical training as well as curriculum development and certification of surgeons;
provide a feedback system by which medical students and surgical trainees may evaluate their
teachers; recruit and train more nurses and anesthetists. provide free HIV counselling and postexposure prophylaxis for health care workers with occupational exposure; improve surgical resources
in local hospitals so they can perform basic surgery; provide or increase service and maintenance for
current hospital equipment.; attract funding for surgical research into common diseases; develop
protocols and treatment logarithms for common conditions.
Four types of activities may be undertaken by surgeons themselves/: efforts of getting funds by
available means, research on the burden on the surgery, organisations of training programmes,
outreach and continuous education to rural areas. Funds are needed to practice training programmes,
outreach programmes and continuous educations as well as research. The research of funds shall be a
permanent concern. International donors’ community, partnerships, private and public funds. We shall
join our colleagues Ozgediz and Riviello8 in considering the successful approaches of neglected
tropical disease initiatives for surgical conditions , and proposing a variety of mechanisms that could
stimulate efforts to improve delivery of surgical care in Africa, including donation programs and
public-private partnerships
The training programmes based on surgical disease burden are available and their running must be
more frequent. It has been shown that they may reduce the burden by 50% if sufficiently done8.
1. Injuries: Trauma management Course; Non-operative treatment of fractures, management of
burns8.
2. Workshop on prevention of occupational transmission of HIV and other serious infection in
operating theatre38.
3. Formal services of diagnostic counselling testing and care in all surgical settings.
Outreach programmes and organisation of continuous education and recycling in rural area must
be combined. The outreach programmes alleviate rural areas people’s suffering. The education
programme for rural staff will allow the effects last. All this shall contribute in saying like Ozgediz
and Rivello that “Patients with untreated surgical conditions as well as the local clinicians
struggling to care for them, must gain greater recognition by the global public health
community.African surgeons shall join the adage “ Surgery is cheap and effective but donors
neglect it”
References
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19. Meagher B.R. Appendicitis in HIV-positive patients. Aust NZ J Surg. 1998;68:337–9.
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26. Sinyinza F, Mulenga V, Lishimpi K, et al.- Prognostic markers of survival in HIVinfected children in the CHAP trial, Zambia. Program and abstracts of the 11th
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DM.- Aids and cancer in Africa: the evolving epidemic in Zimbabwe. Zimbabwe Cancer
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Exposure to Human Immunodeficiency Disease. What Precautions for the Healthcare
Professional?
T E Madiba1, N P Magula2
1
Department of Surgery, University of KwaZulu-Natal, Durban, South Africa.
2
Department of Medicine, University of KwaZulu-Natal, Durban, South Africa
Correspondence to: Professor T E Madiba, Fax: 27 31 260 4389, Email: [email protected]
Background: The Human Immunodeficiency Virus (HIV) epidemic is more pronounced in subSaharan Africa. The ever-increasing prevalence of HIV infection and the continued improvement in
clinical management has increased the likelihood of these patients being managed by healthcare
workers. The aim of the review was to assess current literature on the risks of transmission of HIV
infection and protection of the healthcare worker.
Methods: A literature review was performed using MEDLINE articles addressing ‘human
immunodeficiency virus’, ‘HIV’, ‘Acquired immunodeficiency syndrome’, ‘AIDS’, ‘HIV and
Surgery’. We also manually searched relevant surgical journals and completed the bibliographic
compilation by collecting cross references from published papers.
Results: Transmission is by contamination with body fluids for example needle-stick injury and blood
splashes. The risk of HIV transmission from patient to healthcare worker always exists. The risk of
transmission is very small and depends on the type of discipline and type of procedure. Hollow
needles are more dangerous than suture needles. Sero-conversion is, however, very minimal.
Universal precautions are emphasised. In case of needle-stick injury or splash it is important that
affected healthcare workers take post-exposure prophylaxis.
Conclusion: Occupational HIV transmission is lower than that for other infections. However,
protection of all health care personnel should be the prime objective. Universal infection control
guidelines must be accepted and strictly enforced. A prompt response to blood contact is crucial and
post-exposure
prophylaxis
is
essential.
Introduction
Infection with blood-borne pathogens such as human immunodeficiency virus (HIV), Hepatitis B
virus (HBV) and Hepatitis C virus (HCV) and Coxsackie B has long been recognised as an
occupational risk for healthcare workers, particularly surgeons 1-4. Because of the ever-increasing
prevalence of HIV infection, healthcare workers are becoming more involved in the care and
management of a variety of disorders in this population 5,6 and the number of HIV-infected patients,
both known and unknown, presenting for treatment is increasing 7.
This review addresses the prevalence of HIV infection, risk of transmission of HIV infection and
ways of protecting healthcare workers from infection with HIV. As the operating room is the area
most highly exposed to body fluids, more attention is paid to it in this review.
Prevalence of HIV Infection in the Population
In 2008 the World Health Organisation (WHO) estimated that there were approximately 33 million
people in the world infected with HIV. It was estimated that 4.9 million new infections occurred and
that there were 3 million deaths due to AIDS 8. In South Africa the HIV prevalence rate in the
population was 11% in 2004, with a slightly higher rate among women 9 and the infection rate among
pregnant women attending antenatal services in 2006 was 29.1% 8. The hospital prevalence for HIV in
general surgical populations varies from 0.3% to 24% 6,10. According to the 1993 report by the
Centres for Disease Control and Prevention (CDC) 11 the proportion of “AIDS” among healthcare
workers was similar to the proportion among the general population. The criticism of the CDC data is
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March/April 2010.
that they did not differentiate between HIV infection and AIDS and both are categorised under the
term “AIDS”.
Risk of transmission
HIV transmission can be due to exposure to body fluids, the most important of which is blood 2,3. The
causes of exposure are puncture by sharp objects (such as needles, scalpels, and bone fragments),
blood splash and body fluid contamination 2,3.
The risk of HIV transmission from patient to healthcare worker is far greater than the risk from
healthcare worker to patient 12,13, with only two cases of transmission from healthcare worker to
patient having been reported 11,13. The risk for surgeons remains extremely small but greater than that
of non-operating clinicians and other healthcare workers 4,11,14-20. Patient-to-patient transmission of
HIV has been described but it remains uncommon and is probably related to breaches in infection
control 21-25.
The most common exposure to patient’s blood is from blood contamination and needle-stick injuries
. Blood contamination may be due to blood splash or glove perforation, which may itself be
caused by needle-stick injury or factory defects. As glove punctures are often minute, the surgeon is
not always aware of the occurrence 16. The risk of blood contamination by splashes is directly
associated with various factors including type of surgical specialty, type of procedure, procedure
duration, blood loss and emergent case status as well as the use of fingers rather than an instrument to
hold the tissues 4,9,16,18,21,27-35. Surgeons are particularly prone to blood splashes during certain
procedures such as drilling 36 and in procedures associated with a lot of blood splashes 36.
2,4,26
Irrespective of specialty or procedure performed, suture needles are the leading cause of sharps
injuries in operating rooms and delivery rooms and the second leading cause in hospitals overall
10,32,37,38
. Hollow needles transfer more blood compared to solid (suture) needles and, in both types of
needles, increasing the needle size and the depth of injury leads to an increase in the inoculum 2.
There are various predisposing factors for s needle-stick injuries namely: inadequate assistance
and excessive adipose tissue 30, major operations involving use of the mass closure technique 30,39,40,
holding tissues while suturing or cutting 37, suturing deep in the pelvic areas where the surgeon cannot
see what he is doing 36 and manipulation of instruments deep within the wound or during wound
closure 30,41. Most of the needle-stick injuries to the hand and leading to glove perforations are selfinflicted 30,41; they occur mainly on the digits (84%) followed by digital inter-phalangeal crease
(80%)16,42 and most occur on the palmer surface of the index finger of the surgeon’s non-dominant
hand 15,16,33,40-45.
The average risk of sero-conversion after a needle-stick injury with infected blood is 0.3% 0.5%3,6,16,24,26,46. While some authors have estimated the risk of sero-conversion following mucous
membrane contact at 0.09% 47, more recent estimates suggest that the sero-conversion rate for
mucous membrane is similar to that of percutaneous injury 48,49. A surgeon's cumulative lifetime risk
of sero-conversion is estimated to be as high as 1-10% 16,24.
Protection of the health-care professional
The only way to reduce the cumulative risk of occupational HIV infection is to reduce the number of
injuries as the sero-prevalence of HIV in the surrounding population cannot be influenced by the
healthcare professionals 7. The principles of exposure prevention consists of (i) the use of personal
protective equipment, and (ii) work practice and engineering controls 37. The adoption of universal
precautions by all healthcare workers is one way of achieving this 50,51.
10
March/April 2010.
These Universal Precautions can be achieved by (i) routine use of appropriate barrier precautions and
techniques to reduce the likelihood of exposure to blood and other body fluids, (ii) washing hands and
skin surfaces immediately after contamination, (iii) avoidance of recapping, bending or removal of
needles, and (v) refraining of healthcare workers with exudative lesions or weeping dermatitis from
direct patient care 51.
Protective equipment includes impervious garments, double gloving and eye protection. Impervious
garments are preferable to pervious garments; disposable gowns and drapes are more secure barriers
than woven cloth 7,18,52. Whereas surgical gloves are impermeable to viruses, they do not prevent
needle-stick injury 2,16,20,41,53,54, although they can significantly decrease the amount of blood conveyed
by suture needles 2. Double gloving has a proven record of reducing the incidence of glove perforation
2,6,10,16,34,44,54-57
. As there is a potential risk of virus transmission via conjunctiva, mucous membranes
and minor facial lesions (e.g. after shaving), these must be covered as much as possible, using masks
and eye protection by goggles or visors to prevent contact of blood stained body fluids with
conjunctiva 1,7,33,58; ordinary eye glasses are not protective 1,52.
Changes in surgical practice to reduce blood contamination or needle-stick injury can be achieved by
adapting the operative technique. Surgeons should operate carefully and methodically and surgery
should not be rushed 50. The needle should be grasped with instruments, rather than by the finger;
when resetting the needle in the needle-holder, the operator should avoid passing the suture needle
toward the non-dominant hand or toward an assistant’s hand; retracting tissues manually should be
avoided and, when sewing in a bloody field, surgeons should not grope for a sharp needle to identify
its location 37. Dissection using the blunt end of sharp instruments such as scalpels is discouraged 7.
Blunt-tip needles have been shown to be effective in reducing the likelihood of suture-related injuries
4,16,37,38,40,59
; they are sharp enough to pierce internal tissues such as muscle and fascia, but generally
not sharp enough to pierce skin. Scissors, diathermy and blunt retractors should be encouraged 33. The
adoption of the so-called neutral zone between surgeon and scrub nurse in which surgeon and nurse
do not touch the same sharp instrument at the same time is recommended 16,50. Other methods of
replacing sharp instruments is the use of adherent drapes to avoid towel clips, blunt forceps instead of
classic sharp surgical forceps vascular clips for vessel ligation, staplers for bowel surgery as well as
electro-cautery and Argon beam coagulator 7,37,40,60. Involvement of a second surgical team to relieve
fatigued surgeons during long procedures is advised 4,59. Glass ampoules should be avoided or
replaced by removable covers that do not require breaking glass 61; alternatively all glass items should
be substituted by plastic 62. Other more recently developed alternatives include use of safety
engineered devices such as needle-less devices and shielded or retractable needles or blades 38.
Barriers to compliance
Barriers to compliance with universal precautions include familiarity with needle-stick and cutting
injuries during operations to such an extent that they have more or less accepted them as unavoidable
7,50,63
, the forgetting of safety protocols during crucial times such as resuscitation 7,63, variable
acceptance of double gloving and eye protection by surgeons 9,64,65, discomfort and loss of sensitivity
in the fingers 44 and the under-estimation of sero-conversion rates 64. Furthermore healthcare workers
rarely report needle-stick injuries even when they know that the patient is HIV-infected 64,66.
Resources for the protection of healthcare workers especially at government hospitals are severely
lacking as demonstrated in many African countries 67.
Screening of patients
Screening of patients, although previously proposed, 7,20, is no longer regarded as an option, the
reasons being that compulsory HIV testing (i) does not work in emergencies, (ii) it does not cater for
false negative window period prior to antibody positivity and (iii) it may be regarded as social
discrimination and may lead to breaches of confidentiality 7,28,36,50,68. The decision to operate or not
11
March/April 2010.
should not take into account the HIV status of the patient 36,69,70. Furthermore the adoption of universal
precautions for all healthcare workers would resolve all these problems.
In the event of exposure
In the event of exposure the exposure site should be vigorously washed with soap and water 69,71.
Exposed mucous membranes (nose, mouth, and conjunctiva) should be flushed with copious
quantities of clean water, 0.9% sodium chloride or sterile irrigants appropriate for these membranes 71.
Secondly the exposure should be reported to an infection control person as soon as possible, followed
by screening for HIV status on both the healthcare werkers and the patient within 24 hours in order to
document the infection for both medical and legal reasons 69. Consideration should then be made to
taking post-exposure prophylaxis (PEP).
The first dose should always be offered as soon as possible after exposure. Once commenced, the full
PEP should be taken unless there are specific reasons to stop and the recommended duration is 28
days72 . Post-exposure follow-up of the healthcare workers regarding possible HIV sero-conversion is
paramount; the CDC recommends follow-up testing at 6 weeks, 12 weeks, and 6 months 71. healthcare
workers should be counselled about expected adverse events and the strategies for managing these;
they should also be advised that PEP is not 100% effective in preventing HIV sero-conversion 73. It
should be recognised that patients who test negative for HIV may be in the window period and the
healthcare worker needs to continue taking prophylaxis.
Conclusion
The HIV pandemic is likely to continue for sometime. Healthcare professionals will continue to treat
HIV infected patients. Prevention of HIV transmission requires education of all H healthcare workers
and health managers about adherence to Universal precautions.
The universal infection control guidelines must be accepted and strictly enforced from top leadership
down. Better protection of all health care personnel should be the prime objective through
modification of operational practices. A prompt response to blood contact when it does occur is
crucial and post-exposure prophylaxis is essential.
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15
March/April 2010.
Breast Cancer Awareness among Females in a Developing world- A Study from Kashmir.
S.A. Salat1, A. Rather2, S. Ahmad3, A.B. Khan4
1
Department of Surgical Specialties, King Fahad Medical City, Riyadh, Saudi Arabia2Sheri Kashmir
Institute of Medical Sciences, Srinagar, Kashmir, India,
3
College of Medical Sciences in Al-Kharj, King Saud University, Riyadh, KSA
4
Department of Surgical Specialties, King Fahad Medical City, Riyadh, Saudi Arabia
Correspondence to: Dr S. A. Salati, Email: [email protected]
Background: Breast cancer is a major health issue and in developing regions, where the early cancer
detection facilities are unavailable awareness about this disease can lead to early detection and
thereby potentially decrease the morbidity and mortality.
Methods: A self designed questionnaire was used to study the level of awareness regarding breast
cancer among 864 Kashmiri females. The questionnaire had 18 questions and on the basis on score
attained, the subjects were classified as having poor, average or good breast cancer awareness.
Results: Out of 864 participants, 703(81.37%) had poor breast cancer awareness and 103(11.92%)
had average awareness. Only 58(6.71%) had good awareness about breast cancer.
Conclusion: The level of awareness regarding breast cancer in Kashmiri females is very low and
there is a need to spread awareness about this disease among the general population.
Introduction
Breast Cancer is globally one of the leading causes of morbidity and mortality in women1. In
underdeveloped and developing regions of the world, lack of awareness about breast cancer and facilities
for early detection and treatment, results in delay in seeking medical care and hence in poorer prognosis 2.
Presently, about 75,000 new cases are reported in Indian women every year. 3 This figure looks even more
alarming if viewed against the backdrop that the National Cancer Registry and that the Hospital-based
Tumor Registries hardly sample 3% of the total population. Advanced breast cancer (LABC) constitutes
more than 50 to 70% of the patients presenting with breast cancer. 3
In Kashmir valley, dedicated breast cancer screening clinics are nonexistent and hence increased breast
cancer awareness among general population can be a hope to fight this disease. A study was undertaken to
study the level of awareness regarding breast cancer among Kashmiri females.
Subjects and Methods
The study was conducted in the Department of General Surgery, Sheri-Kashmir Institute of Medical
Sciences,(Medical College), Bemina, Srinagar,Kashmir,India over a period of one year from August 2008
to July 2009 , to assess the level of awareness of breast cancer in Kashmiri women. Kashmir is a subHimalayan valley with a total population of about 6 million. The female visitors of patients were selected
randomly and explained the purpose of the study as per the ethical guidelines of Helsinki. The ladies who
agreed to participate in the study were requested to answer a self designed questionnaire after assuring them
of confidentiality. The female medical interns in the department assisted in administering the questionnaire
to subjects who did not understand the English language. The exclusion criteria included self or family
history of breast disorders, on the presumption that their level of awareness will be higher. The
questionnaire included basic signs and symptoms of breast cancer and breast self examination as shown in
Table 1.
The questionnaire was designed after taking text books of general surgery 4 and Toronto breast self
examination inventory 5 into consideration. Attempt was made to simplify the questionnaire with the aim of
getting insight into level of knowledge of subject with minimum possible consumption of time of the
participants. There were 18 features related to breast cancer; for awareness of each feature a single point
was awarded and no point was awarded if the lady was unaware. Accordingly three categories of breast
cancer awareness were defined as per the total scores as depicted in Table 2.
16
March/April 2010.
Table 1. Questionnaire to assess breast cancer awareness
(Score 1 if aware, 0 if unaware)
Features/ Risk factors of Breast Cancer
1.A breast lump that feels different from the surrounding tissue
2.Bloody discharge from the nipple
3.Change in the size or shape of a breast
4.Changes to the skin over the breast, such as dimpling
5.Inverted nipple (A nipple turned inward into the breast )
6.Peeling or flaking /swelling of the nipple or areola skin
7.Redness or pitting of the skin over your breast, like the skin of an orange
8.A lump or thickening in the underarm area
9.Being female (females has more risk as compared to males)
10.Increasing age
11.Family history of breast cancer
12.Beginning menstrual period at a younger age(less than 12 yrs)
13.Having the first child at an older age(above 35 yrs)/not having children
14.Beginning menopause at an older age (above 50 yrs)
15.Breast Self Examination awareness
16.Awareness regarding screening mammogram
17.Basic awareness about treatment options for breast cancer
18.Awareness about possibility of breast reconstruction
Table 2. Categories as per the Attained Scores
Categories of awareness level
Score
Poor awareness
0-6
Average awareness
7-12
Good awareness
13-18
Data was processed and analyzed after one year of study period with the aid of SPSS software (statistical
package for social sciences version- 10) for Windows. Statistical significances were determined by testing
null hypothesis (computing p-values).
17
March/April 2010.
Results
During the study period 2132 females were approached for participation in the study and 864(40.49%)
participated in the study. The results
ults derived after analysis of data are given in the Figures 11-2 and
Table 3.
Table 3. Awareness as per the Economic Status
S
Awareness level
Income group (in Indian Rupees)
5000-10000
>10000
327 (80.94%)
164 (80%)
Poor awareness
<5000
212 (83.14%)
Average awareness
32 (12.55%)
43 (10.64%)
28 (13.66%)
Good awareness
11 (4.31%)
34 (8.42%)
13 (6.34%)
Table 4. Awareness as per Educational Background
B
Awareness level
Poor awareness
None
Primary level Secondary level
Graduate and above
102(82.93%)
251(86.25%)
188(80.34%)
162(75%)
Average awareness
10(8.13%)
23(7.90%)
34(14.53%)
36(16.67%)
Good awareness
11(8.94%)
17(5.84%)
12(5.13%)
18(8.33%)
Good awareness -58(6.71%)
Average awareness - 103
(11.92%)
Poor awareness -703
(81.37%)
Figure 1. Breast cancer awareness among Kashmiri women
March/April 2010.
Table 5. Awareness as per Occupation
ccupation
Awareness level
Professional Background
Housewives Craftswomen
Teachers
Students
Office/bank
employees
Poor awareness
219(82.33%)
165(88.96%)
66(71.74%)
140(72.54%)
113(85.61%)
Average awareness
23(8.65%)
13(7.18%)
17(18.48%)
38(19.67%)
12(9.09%)
Good awareness
24(9.02%)
3(1.66%)
9(9.78%)
15(7.77%)
07(5.30%)
Table 6. Awareness as per the Age Group
roup
Awareness Level
Age Groups (in years)
20-30
30- 40
40 -50
50-60
Above 60
Poor awareness
39(58.21%)
467(86.32%)
94(77.05%)
86(77.48%)
17(73.91%)
Average awareness
17(25.37%)
48(8.87%)
15(12.29%)
19(17.12%)
4(17.39%)
Good awareness
11(16.42%)
26(4.81%)
13(10.66%)
6(5.40%)
2(8.70%)
Radio/TV-72(44.72%)
Newspapers-43 (26.71%)
Textbooks -21(13.04%)
Friends/relations 21(13.04%)
Internet -4 (2.48%)
Figure 2. Sources of Information Regarding Breast Cancer
March/April 2010.
None of the subjects in our study was aware about the correct concept or technique of breast self
examination (BSE). In the 161 patients who were found to have average (score 6-12) and good (13 and
higher score) awareness, the sources of information regarding breast cancer are as given in Fig.2.
Discussion
Breast cancer is the commonest cause of cancer in females in most of the states of India 6 . The facilities of
breast clinics for early detection of breast cancer are not available to a major percentage of the population
both in India and Kashmir valley. The only feasible way to decrease the morbidity and mortality associated
with cancer is when the females seek medical advice in early stages of the disease7 and in the absence of
breast screening facilities; this can only be possible if the females are breast aware2 8. Being ‘breast aware’
means that women should be aware of what is normal for them and what the features in the breast are, they
should look and feel for. It was against this background, this study was undertaken to assess the breast
awareness among our female population. A similar study regarding breast cancer awareness among
Kashmiri males has been published by the authors separately 9.
From our study, we found that out of 864 participants, 703(81.37%) had poor breast cancer awareness and
103(11.92%) had average awareness. Only 58(6.71%) had good awareness about breast cancer. This
scenario is similar to many other parts of developing world 10, 11. However we could not detect any
statistically significant difference (p>0.05) among the subjects when classified on the basis of economic
status depicting thereby that improvement in economic status does not reflect in improved health related
awareness. When studied on the basis of level of formal education, graduates and above were better aware
than less or uneducated group (p<0.05). Similarly teachers and students were better aware though the
difference was not significant. But the fact that about 72% of teachers had poor awareness about breast
cancer needs a serious attention and improvement as it has been proved in many studies that by improving
the health-related awareness among the teachers, the level of awareness in children improves significantly
12, 13
who in turn have been found to disseminate health awareness in homes and general population.
However even in developed regions of the world, health education has not been found as a constant part of
certification programmes of teachers 14. When classified on the basis of age-groups, the subjects belonging
to 20-30 years age group had better awareness than other groups but most of these aware subjects were
either graduates, students or teachers, so age alone per se cannot be considered as significant factor.
Keeping in view this dismal state of awareness regarding breast cancer in Kashmiri women and the near
absence of dedicated breast screening clinics, there is a need to improve the level of awareness as only that
can lead to early reporting of breast cancer patients to healthcare facilities and thereby leading to ultimate
reduction in morbidity and mortality of this disease. In many studies from India 15 and elsewhere, it has
been clearly proved that, it is the lack of awareness and late reporting, that results in poorer prognosis of
breast cancer.
Breast self examination is still being advocated in developing countries as a method of early detection of
breast cancer 11 though in developed countries its importance has faded due to availability of well equipped
breast clinics 16 and the evidences that breast examination do not reduce mortality associated with cancer.
None of our subjects had awareness about the correct technique of breast self examination. In other studies
also 17, only a small percentage of females have been found to be aware of the correct technique.
The sources of information included health related programmes on local radio, television and articles in
local newspapers were sources of information of 71.4% of subjects having average and good awareness
regarding breast cancer. Since these sources are widely available, impetus needs to be laid on further and
focused utilization of these means of education to improve breast cancer awareness among masses. Special
teachers training sessions need to be organized particularly during winter vacations when schools remain
closed for three months as these in-service training sessions have been found effective in other health
related issues 12. Change to positive result can be achieved by establishing a definite role for schools and
teachers in promotion of health 18. Even the social and religious leaders can also be educated and made part
of a programme aimed at health education as they have direct access to the population and can influence
their knowhow19.
20
March/April 2010.
Conclusion
Breast cancer awareness is very low among Kashmiri women .In the absence of breast cancer screening
clinics, there is a dire need to take measures to improve breast cancer awareness so that the patients might
present earlier in the course of this killer disease.
References
1. Parkin DM, Bray FI, Devesa SS. Cancer burden in the year 2000: the global picture. Eur J Cancer
2001; 37(suppl. 8):54-66
2. Rao RS, Nair S, Nair NS, Kamath VG. Acceptability and effectiveness of a breast health awareness
programme for rural women in India. Indian J Med Sci 2005; 59:398-402
3. Sandhu DS, Sandhu S, Karwasra RK, Marwah S. Profile of breast cancer patients at a tertiary care
hospital in north India. Indian J Cancer 2010; 47:16-22
4. Tjandra JJ, Collins JP. Breast Surgery. In: Text book of Surgery .Blackwell Publishing Ltd, USA
Ed 3rd 2006, p.273-93
5. Ferris L, Shamian J and Tudiver F. The Toronto Breast Self examination instrument Its
Development, Reliability and Validity. Journal of Clin Epid 1991; 44 :1309-17
6. Murthy NS, Chaudhry K, Nadayil D, Agarwal UK, Saxena S Changing trends in incidence of
breast cancer: Indian scenario. Indian J Cancer 2009 ; 46 (1):73-4
7. Richards M, Westcombe A, Love S, et al. Influence of delay on survival in patients with breast
cancer: a systematic review. Lancet 1999; 353: 1119-1126.
8. Austoker J. Screening and self-examination for breast cancer. BMJ 1994; 309:168–74.
9. Salati SA, Rather A. Awareness regarding female breast cancer in Kashmiri males - A study.
Online J Health Allied Scs 2009; 8(4):11
10. Han Y, Williams RD, Harrison RA. Breast cancer screening knowledge, attitudes, and practices
among Korean American women. Oncol Nurs Forum 2000; 27(10):1585-91
11. S. Puri, C. Mangat, V. Bhatia, M. Kalia, A. Sehgal & A. P. Kaur . Awareness Of Risk Factors And
Aspects of Breast Cancer Among North Indian Women. The Internet J Health 2009; 8: 2
12. Susan K, Everret A, James PH . Effects of an inservice workshop on the health teaching self
efficacy of elementary school teachers. J Sch Health 1996:66; 261-265.
13. Alnasir Fasal A . Health attitudes of school teachers. Saudi Med J 2004; 25(3):326-30
14. Young EM, Auty D, Lee SY. Development of students attitudes towards school safety
measures(SATSSM). J Sch Health 2002;72: 107-114
15. Sadler G, Dhanjal S Bhatia N et al Asian Indian Women :Knowledge attitude and behavior towards
early breast cancer detection .Journal Pub Health Nursing 2001 15:214-6
16. Larkin M. Breast self examination does more harm than good says task force. Lancet 2001;
357:210
17. Thomas DB, Gao Dl, Ray RM et al. Randomized trial of breast self-examination in Shanghai:
Final results. J Natl Cancer Inst 2002; 94:1445-1457.
18. Iverson DC, Kolbe LJ . Evaluation of a national disease prevention & health promotion strategy –
establishing a role for the schools. J Sch Health 1983; 53:294-302
19. Leane W, Shute R ; Youth suicide: The knowledge and attitudes of Australian teachers and clergy.
Suicide Life Threat Behav 1998; 28:165-173
21
March/April 2010.
Knowledge and Practice of Breast Self Examination among Female Students in a Sub
Saharan African University
Obaikol R, Galukande M, Fualal J
Department of Surgery, Mulago Hospital – Kampala, Uganda
Correspondence to: Dr. Galukande Moses, Email: [email protected]
Background: Breast cancer is the most common cancer among women in many parts of
Africa. Facilities for screening and early detection are extremely limited yet early
diagnosis improves survival. This study explored the practice of Breast Self Examination
among female university students as a means of screening and early detection in a low
resources environment.
Subjects andMethods: A cross sectional descriptive study at a Sub Saharan university. A
call for volunteers to the study was made; a pretested standardised questionnaire was
used for data collection. The process was limited to an interview and a physical
examination. IRB approval was granted before the study began.
Results: A total of 320 participants volunteered, 314 were recruited. The majority were
aged between 21 and 25. The range was between 19 to 31 years. There was a high
awareness of Breast self Examination (BSE) of 81.5%, 30% had ever performed a BSE, 14
% performed it regularly, 8% knew the correct monthly timing, the technique was
accurately demonstrated by 1% of participants. 4.8 were found to have breast lumps.
Conclusion: There is a likelihood of most young women in the country practicing BSE
inadequately. There is a need for widespread BSE campaigns emphasizing the correct
technique and a need to evaluate BSE efficacy. The prevalence of breast lumps among
young women attending this university was comparable to other community prevalence
studies in this age group.
Introduction
Breast cancer is the most common cancer among women is many parts of Africa and a lead
cause of cancer mortality in African women1. The incidence in Uganda is rapidly raising2, though
mass screening with use of mammography has been effective in the more affluent countries, it is
not readily available to most of the women in Sub Saharan Africa3,4 .
The peak of Breast Cancer in a recent Ugandan study5 is in the 3rd decade of life, therefore
necessitating mass screening and awareness campaigns among younger women than the model in
western countries. Mammogram guidelines indicate that a mammogram is appropriate only in
women above 35 years old6 due to breast density in the younger women making visualization of
present lesions and interpretation difficult and therefore unreliable. The available options left are
ultrasound scan and Breast Self Examinations (BSE). Breast Self Examination is appealing as a
routine screening method because the examination has no financial cost (apart from the initial
instruction sessions) and can be conducted in private7. Most studies on the effectiveness of BSE
have been observational. They suggest that these women are more likely to find their breast
tumour themselves, that the tumours tend to be smaller and that these women have an increased
survival8,9 . This study investigated the knowledge, frequency and quality of practice of Breast
Self Examination among university female students.
22
March/April 2010.
Methods
A cross sectional study carried out at Makerere University an 80-year-old institution over a 10day period. A call was made for students to participate. Participants were enrolled consecutively
until the minimum required sample size was reached. Participants were residents in designated
halls of residence. A total of 1400 students were on the residents register on the camps. 320
volunteer participants were interviewed using a pretested standardized questionnaire and were
physically examined, for possible breast pathology including lumps, nipple discharge and any
other related pathologies. In the interview sessions the participants were asked to demonstrate
how they normally examine their breasts (if they did) before the investigator.
Variables in the questionnaires included demographics, frequency on Breast Self Examination,
timing, consistency, action taken when an abnormality was thought to be found and the interval
between noticing and taking action especially in consulting a health professional and what type
of professional. The reasons for delay were solicited. For data entry and analysis STATA 8.2
package was used. Proportions were compared using Fischer’s exact test. Consent was sought
from all the participants; Institutional Review Board approval was sought prior to carrying out
the study.
Results
The data was collected over a period of 10 days in the month of April 2009. A total of 320
participants were recruited and due to recording errors, analysis was carried out on the results of
314 of them. Table 1 sumarizes the demographic character of the study population. Their mean
age was 21.9 years with 83.4% being in the 21-25 years age group.
Table 1. Demographics of the Study Population, Awareness and BSE performance
Characteristic
Frequency
Age in Years
21.9 (mean)
1.53 (sd)
45
262
6
1
14.33
83.44
1.91
0.31
115
34
26
14
125
36.62
10.83
8.28
4.46
39.8
141
38
135
44.9
12.1
43.0
284
30
90.45
9.95
≤ 20
21-25
26-30
≥ 30
%
Tribe
Ganda
Ankole
Teso
Nyoro
Others
District of Residence
• Kampala
• Wakiso
• Others
Parity
• Nulliparous
• Parous
23
March/April 2010.
Table 2. BSE Awareness and Performance
Characteristic
Frequency
%
Heard about BSE (n=314)
Yes
No
255
59
81.21
18.79
110
107
37
43.31
42.13
14.57
20
59
195
7.87
15.36
76.77
Rationale for doing a BSE (n = 254)
To screen
To diagnose
Do not know
When BSE should be performed n=254
Know when
Know wrong timing
Don’t know
Breast self technique examination described correctly n= 254
Could not describe at all
220
86.67
Described a few steps accurately
31
12.07
Described entire technique accurately
3
1.18
96
159
37.65
62.35
At least monthly
Occasionally
45
46.88
51
53.13
Twice a month
5
22.73
Ever performed a BSE
Yes
No
Regularity of performance of a BSE(n=96)
Table 3.
Frequency
Percent (%)
Average size of the
lumps(cm)
5
33
2.4
10
67
3.4
Coincidental
2
20
2
By breast self examination
8
80
4
Awareness of the breast lump(n=15)
Not aware
Aware
Detection (n=10)
History of Seeking Help(n=10)
•
From a health professional
7
70
-
•
From a non-health professional
2
20
-
•
Did not seek help
1
10
-
Timing between detection and seeking help (n=9)
•
Immediately
7
78
-
•
After sometime
2*
22
-
24
March/April 2010.
*The two participants who took time between finding the breast lump and seeking help spent 1month and 2years. The
reasons where that one was scared and the other thought it was a ‘normal’ finding.
Discussion
This study involved university students, the demographics are what was anticipated. The mean
age was in the early twenties. Most were nulliparous and most of them being ‘direct’ university
entrants, they were not expected to have started families. The district of residence and ethnicity
is a general reflection of who may have access to tertiary education in the country and reflection
of the dominant ethnic groupings in terms of numbers. The Ganda and Nkole contribute close
to 45% of the general population12.
Practice of BSE
In this study, the level of awareness was high; but the knowledge of the technique and practice
ratios was poor.
The knowledge awareness of BSE was over 80% similar to figures cited in other studies such as
by Demirkiran in 2007 performed among Turkey nurses. It is important that the awareness of
BSE translates into adequate or appropriate practice early detection of breast lumps. Most
cancerous breast lumps are self discovered, but it is important that these lumps are discovered in
the early stages when they are still small. Tumors detected at 2cm in diameter allow women more
treatment choices and a greater chance of long-term survival13 . In this study, lump sizes ranged
from 2.4cm to 3.4 cm on average. They were smaller (2.4cm) for those who has lumps but were
not aware of them and had not practiced BSE, and they averaged 3.4cm for those that were
aware, they had the lumps. Is it possible that correctly performed BSE (correct technique and
regular and timing could pick lumps less than 3.4 cm in our context?.
Breast Self Examination should be practiced correctly and this involves a number of aspects;
frequency, timing, a correct technique consistent application of it as well as acting on any
positive findings without much delay. In published work, women who practice BSE tend to be
younger, pre menopausal and of a higher socio economic status14,15 . Possibly this has to do with
access and exposure to health talk information through the media, peers and health workers.
This description agrees with the demographics of this study even though, selection of this study
population was self fulfilling.
Role of university graduates in society
University students are thought to be the more enlightened and empowered lot living in an area
with good geographical access to health care facilities. The less empowered and less exposed
rural women face a lot more barriers to not only seeking professional attention but also access to
knowledge of Breast Self Examination. The lack of empowerment and the subsequent missed
opportunities for early detection is owed to lack of information, knowledge and opportunities
for screening. Yet BSE is considered a reliable self screening tool for early detection of Breast
cancer in less privileged communities11.
Utility and efficacy
Whereas, in the Sub Saharan Africa there is limited resource for health care including Human
Resources for Health, most resources are dedicated to infectious diseases such as HIV/AIDS,
malaria and tuberculosis, this creates a scenario of neglect of surgical conditions in which Breast
Cancer would fall for that matter. It is imperative therefore that we heighten awareness of breast
cancer and better still advocate for use of low cost interventions, but also investigate the efficacy
of these low cost interventions.
25
March/April 2010.
Delay
In this study, only two women had self discovered lumps; one took a month before seeking
professional help. In some of the literature reviewed, it is not a significant delay. The second
sought help after 2 years. This is considered a significant delay16 . The reasons cited for delay; the
first was scared and the second thought it was normal to have a lump in the breast. Factors that
influence seeking help for women that self discover lumps range from sociodemographics (age)
to women’s knowledge and beliefs, social and psychological factors, health service issues, health
seeking habits, among others17,18 .
Owing to the small numbers in this study, we may not make strong inferences as to what reasons
would prevent Ugandan young females from seeking help for self discovered lumps but these
findings give us an idea and are similar reasons to those found elsewhere17,1718,19,20.
Conclusion
The level of awareness of BSE was high but the knowledge and practice ratios were poor, we
therefore advocate for and encourage use of BSE though we need studies to prove that it has an
impact on survival in our context, given that it is the only method that is affordable for wide
spread use in resource limited settings.
An optional module on female health education that includes Breast health should be introduced
at the universities possibly in the first year of study, in resource limited environments.
References
1. Parkin DM, Bray F, Ferlay J, Pisani P. Estimating the world cancer burden: Globocan 2000.
Int J Cancer 2001; 94: 153–156.
2. Wabinga HR, Parkin DM, Wabwire-Mangeni F, Nambooze S. Trends in cancer incidence in
Kyadondo county, Uganda, 1960 – 1997. British Journal of Cancer 2000; 82:1585-92
3. Anderson BO, Braun S, Carlson RW, Gralow JR, Lagios MD et al. Overview of breast health
care guidelines for countries with limited resources. Breast J 2003; 9 (suppl 1): S42-50
4. Duffy SW, Tabar L, Vitak B, Warwick J. Tumor size and breat cancer detection: what might
be the effect of less sensitive screening tool than mammography? Breast J 2006; 12(suppl 1):
S91-95
5. Gakwaya A, Kigula-Mugambe JB, Kavuma A, Luwaga A, Fualal J, Jombwe J, Galukande M
and Kanyike D. Cancer of the breast: 5-year survival in a tertiary hospital in Uganda. British
Journal of Cancer 2008; 99: 63 – 67.
6. Gakwaya A, Galukande M, Luwaga A, Jombwe J, Fualal J, Kiguli-Malwadde E, Baguma P,
Kanyike A, Kigula-Mugambe JB. Breast Cancer guidelines for Uganda (2nd Edition 2008).
African Health Sciences June 2008; Vol 8 N0 2: 126 -133
7. Hackshaw AK, Paul EA. Breast Self Examination and death from breast cancer: a meta
analysis. BJC. 2003; 88: 1047 – 1053.
8. Hackshaw AK. Screening for breast cancer in young women using Breast Self Examination.
In evidence guided prescribing of the pill, Hanna ford PC Webb AMC (eds). 1996. Royal
College of general Practitioners. Parthenon Publishing Group, Lancs, UK.
9. International Agency for Research on Cancer (IARC). Efficacy of screening by selfexamination in Hand book of Cancer Prevention. 2002. Vol 7. Breast cancer Screening,
Vainio H, Bianchini Freds. Lyon France. IARC
10. Uganda Bureau of Statistics (UBOS). The 2002 Uganda Population and housing Census –
main report: March, Kampala: UBOS.
http://www.ubos.org/2002%20census%20Fianl%20Reportdoc.pdf
26
March/April 2010.
11. Demirkiran F, Akdolun BN, Memis S, Turk G, Ozvurmas S, Tuncyurek P. How do nurses
and teachers perform breast self Examination: are they reliable sources of information? BMC
Public Health 2007; 7: 96 http://www.biomedcentral.com/1471-2458-7-96
12. UBOS Report 2006. http://www.austria-uganda.at/_ubos_2006 report.htm
13. Chong PN, Krishnan M, HongCY, Swash TS: Knowledge and practice of breast screening
amongst public health nurses in Singapore. Singapore Med J 2002; 43: 509-516
14. Le Geyte M, Mant D, Vessey MP, Jones L, Yudkin P. Breast self-examination and survival
from breast cancer. Br J Cancer. 1992;66:917–918
15. Auvinen A, Elovainio L, Hakama M. Breast self-examination and survival from breast
cancer; a prospective follow-up study. Breast Cancer Res Treat. 1996; 38:161–168.
16. O'Mahony M, Hegarty J. Factors influencing women in seeking help from a health care
professional on self discovery of a breast symptom, in an Irish context. Journal of Clinical
Nursing 2009; 18(14): 2020-29
17. Facione NC, Miaskowski C, Dodd MJ & Paul SM. The self-reported likelihood of patient
delay in breast cancer: new thoughts for early detection. Preventive Medicine 2002; 34: 3978-407.
18. Arndt V, Sturmer T, Stegmaier C, Ziegler H, Dhom G and Brenner H. Patient delay and
stage of diagnosis among breast cancer patients in Germany – a population based study.
British Journal of Cancer 2002; 86: 1034 -1040
19. Abdel-Fattah M, Zaki A.B, EL-Sady, Tongoni G. Breast Self Examination Practice and its
impact on Breast Cancer diagnosis in Alexandria, Egypt. East Mediterranean Health J. 2000;
6(1): 34 – 40.
20. Boulos S, Godallah M, Negnib S, Breast Screening in the emerging world. High prevalence
of Breast Cancer in Cairo, Egypt. Breast 2005; 14(5): 340 – 6.
21. Onwere S, Okoro O, Chigbu B, Aluka C, Kamanu C, Onwere A. Breast Self-Examination as
a method of early detection of breast cancer: knowledge and practice among antenatal clinic
attendees in South Eastern Nigeria. Pak J Med Sci 2009; 25(1): 122 – 125.
27
March/April 2010.
Bilateral Breast Cancer: Experience in a Poor Resource Black African Setting.
A.S. Oguntola, S.O. Agodirin, M.L. Adeoti, A.O.A. Aderonmu.
Department of Surgery, Lautech Teaching Hospital Osogbo, Nigeria.
Correspondence to: Dr. A.S. Oguntola, Email: [email protected], [email protected]
Background: Breast cancer is the most common malignancy in women in Nigeria. Women
previously treated for ipsilateral breast cancer have increased risk of developing contalateral
breast cancer (CBC), the chance of which increases with longer period of survival and is
associated with worse prognosis. Reports from Nigeria are few on this.The aim of this study was
to assess the prevalence, predisposition, presentation, and outcome of management of bilateral
breast cancer (BBC) in a population, South-western Nigeria.
Methods: A review of bio-data of all patients with BBC seen in LTH, Osogbo, Nigeria between
2001 and 2008 was done. Age, parity, age at menarche and first child birth, family history,
duration of symptoms, tumour characteristics and exposure to cigarette, oral contraceptive pills
(O.C Pills) and outcome of treatment were also assessed.
Results: BBC constituted 4.6% of the 256 breast cancer patients. Eight (73%) were
metachronous and 91% were infiltrating ductal carcinoma. Patients’ mean age, mean age at
menarche and first child birth were 39, 14.5+3 and 22.5yrs respectively. Mean parity was 3.5
child birth, 91% were premenopausal and all have menstruated for 12-31yrs. None had positive
family history while only 1 and 3 had insignificant exposure to cigarette and O.C pills
respectively. The mean interval between the 2 onsets was 18mths (0-68mths). 91% of all
tumours were advance, while 81% of the first tumours were on the right. Mean duration before
presentation for the first and second tumours were 261 and 111days respectively. One patient
has survived for 2 years thus far.
Conclusion: The incidence of BBC was 4.26%. Most patients were young and premenopausal
with mostly infiltrating ductal carcinoma (NOS) and presenting with late stage disease, hence
poor prognosis. Aggressive follow-up of patients with ipsilateral cancer will aid early detection
of CBC.
Introduction
Breast cancer is the most common female malignancy in Nigeria1. A woman with unilateral breast
cancer is known to have increased risk of developing contralateral breast cancer (CBC) 2. This
increases the agony brought about by the disease, more side effects from the ablative surgical
treatment, adjuvant chemotherapy, radiotherapy all leading to poor prognosis3.
Breast cancer incidence though known to be less in the black Africans appears to be on the increase
from clinical and also laboratory experiences 4,5,6,7. The incidence of bilateral breast cancer (BBC) has
been reported to be 2.4% (Ilorin), 2% (Benin), 2.2% (Ife), 4 % ( Lagos) all in Nigeria4,8,9,10, while
higher incidences of between 3.3% and 9.6% has been reported among the Caucasians 3,11-14.Breast
cancer is known to occur more in younger and premenopausal women among the blacks, and usually
with more aggressive lesion. A long post survival period may give a high propensity for developing
metachronous CBC. This retrospective study is therefore aimed at highlighting the incidence, biodata,
clinical features, histology, possible predisposing factors and outcome of treatment of patients with
BBC in a Nigerian population.
Patients and Methods
The case files of all patients who have had cancer involving the two breasts during an 8 year period
(2001-2008) in LAUTECH Teaching Hospital, a 300 bed hospital in Osogbo, South western Nigeria
were retrieved. Bio-data, age, sex, age at menarche and first child birth, parity in addition to family
history of breast or any other cancers, use of O.C pills or menopausal hormone and social habits like
smoking, alcohol ingestion were extracted. The tumour locations, disease stage, histology, treatment
given with outcome were also retrieved. Patients who developed primary contralateral breast cancer
28
March/April 2010.
(CBC) within 6 months of onset of the initial cancer were termed synchronous. The period between
the onsets of the two lesions is referred to as interval. Simple analysis of results was done.
Results
Eleven (4.26%) out of 256 breast cancer patients seen during the study period had bilateral breast
cancers. All were females with age ranging from 27- to 50 yrs with a mean of 39.1 years. The mean
age at menarche and first child birth were 14.5 and 22.5 years respectively (Table 1). The mean parity
was 3.5 child births; one was nultiparous at the age of 45yrs while 3 were grand multips having
between 6-8 children. All were premenopausal except one in the peri-menopausal period. They have
all menstruated for between 12-31years. None has family history of breast or any other cancer, only
one patient smoked and three patients took oral contraceptive pills for period varying from 2-4 years
(Table 1).
The duration before presentation of the initial tumour was between 2 months and 1 year with a mean
of 261days; 45%presented within 6months as against 81% for the contalateral lesion. The mean
duration of symptom for CBC was 111days. The interval between the first and second tumour onset
ranged between 0 and 68 months with a mean of 18months. In only 3 patients was the interval less
than 6months (synchronous) (Table 2). Tumour locations were symmetrical in 5 of the 11 cases (50%
of metachronous and 33% of synchronous). Nine of the first lesions were on the right, one each of the
patient with first left lesion had synchronous and metachronous contalateral lesion.
Initials
Age at 1st
Presentatio
n (Yrs)
Age (Yrs)
at
Menarche
Age at
1st
Child
birth
(Yrs)
Parity
Duration
Before
Presentatio
n (Months)
1ST
2ND
Interval
Between
Presentatio
n (Months)
Smoking
O .C. Pills
Usage
Outcome
Table 1. Patients’ Data and Outcome.
1
2
3
OB
OS
FF
35
36
50
13
14
18
35
20
21
2
8
6
2
6
11
1
6
3.7
16
18
24
-
+
-
4
AJ*
45
18
/
0
6
2
2
-
-
5
6
BO
SA
44
34
13
13
22
28
6
2
12
12
8
1
20
20
+
-
7
OA
45
14
22
4
10
1
68
-
+
8
AO
40
15
24
4
18
6
12
-
+
9
OO
30
15
28
2
15
9
6
-
-
10
AK
44
12
25
3
2
1
13
-
-
11
UK
27
15
23
2
2
2
0
-
-
LTFP
LTFP
DEA
D
DEA
D
LTFP
DEA
D
DEA
D
DEA
D
DEA
D
ALIV
E
DEA
D
Mean
39.09
14.55
22.55
3.5
8.72
(261
days
KEY: O.C =oral contraceptive, LTFP= Lost to follow-up.
29
3.7
18.09
(111
days)
-=No, += Yes, * = Nuliparous
March/April 2010.
Serial
No.
Initials
Table 2. Tumour Site, Stage and Histology.
1
2
3
4
5
6
7
8
9
10
11
OB
OS
FF
AJ
BO
SA
OA
AO
O
AK
UK
Tumour
Laterality
1ST
Tumou
r
R
R
R
L
L
R
R
R
R
R
R
Tumour Location
(Quadrants)
Disease Stage
(Manchester
Class. )
Histology
2ND
Tumour
1ST
Tumour
2ND
Tumour
1ST
Tumour
2ND
Tumour
1ST
Tumour
2ND
Tumour
L
L
L
R
R
L
L
L
L
L
L
UOQ
CENT
UIQ
UOQ
UOQ
UOQ
CENT
CENT
UIQ
UOQ
CENT
UOQ
CENT
CENT
CENT
CENT
UIQ
UOQ
CENT
UOQ
UOQ
CENT
3B
3B
4
4
3B
3B
3A
4
3B
2
3A
4
3B
3A
3B
4
4
3A
4
3A
2
3A
IDC
IDC
IDC
IDC
IDC
IDC
IDC
IDC
IDC
IDC
LYMPH
IDC
IDC
IDC
IDC
IDC
IDC
IDC
IDC
IDC
IDC
LYMP
H
KEY: R=Right, L=Left, IDC=Infiltrating Ductal Carcinoma(NOS), LYNPH = lymphoma
Five and 2 of the first tumours were located in the outer and inner quadrants respectively while 4 were
central. Six (55%) of the contalateral tumours were central while 4 were in the outer quadrant.
Seventy-five percent of the central first lesion had centrally located contalateral lesion. (Table 2).
All except one had either Manchester stage III or IV in both breasts. All were diagnosed to be
infiltrating ductal carcinoma (IDC, NOS) except the youngest (27 yr old) with generalized Burkitt
lymphoma involving both breasts. (Table 2)
All patients with IDC had neo-adjuvant cytotoxic chemotherapy using cyclophosphamide and
Adriamycin based regime (CAMF). The two patients with synchronous lesions were offered
simultaneous bilateral mastectomy. The others had simple or modified radical or radical mastectomy
at each presentation. Tamoxifen at the dose of 20mg daily was given to all while the care lasts. Three
of them had radiotherapy for additional loco-regional control, two of these developed complications
including pleuritis, severe pleural effusion and pulmonary fibrosis. The patient with Burkitt
lymphoma was managed medically using cycles of cytotoxic drugs (CMVP) along with the clinical
haematologists. Seven of the patients died and three were lost to follow-up within the first year of
treatment of the contalateral breast lesion. Only one patient is still living 2 years after diagnosis of
synchronous primary BBC.
Discussion
Incidences of breast cancer in women are on the increase worldwide in the recent years 4,7. More cases
of BBC should be expected, especially in areas where large percentage of breast cancer patients are
found in the pre- and perimenopausal period.The younger age at presentation provide for higher risk
of developing contalateral primary breast cancer (CPBC) after surviving the initial lesion. The poor
survival pattern in the developing world has been attributed to various social, environmental15, in
addition to some biological factors8.
The incidence of 4.26% found in this study is a bit higher than reported values from other centers in
Nigeria but lower than reported cases among Caucasians. Poor survival rate and high rate of loss to
30
March/April 2010.
follow-up in addition to some social beliefs may partly explain this. Only 27% of cases were
synchronous, this is in keeping with findings from other centers11-13,16. However the mean age of
39.1years in BBC patients is significantly lower than 474 and 4816 years reported for all breast cancer
patients in nearby teaching hospitals, thus supporting the fact that the former are usually younger.
The mean age at menarche and the age at first child birth of these patients are all similar to that of
other females with unilateral breast cancer in this environment and comparable with that of women
population in the locality. Age at menarche, age at first child birth and duration of breast feeding has
been implicated by some authors as possible predisposing factors to breast cancer17. It has also been
postulated that carrying a full term pregnancy on or before 18 years is protective against breast
cancer18. However many studies in Nigeria including that by Ihekwaba FN19 who assessed the risk
factors in 1946 breast cancer patients could not demonstrate these to be significant predisposing
factors.
Parity does not appear to offer significant protection against developing first or second primary breast
cancer in Nigeria, as only one of the patients in this series was nuliparous and three were
grandmultips. This is in keeping with other reports from within and outside Nigeria 20-23 and in
contrast to report by George GF from Baltimore (USA) 24. I n the same vein, none of our patients with
BBC had positive history as against earlier studies in Caucasians in which family history was found to
be a significant predisposing factor 12,24. Transfer genetically through the Breast cancer related antigen
(BRCA) I and II as autosomal dominant trait has been proved and this may account for between 50
and 70% of highly penetrant hereditary breast cancer2. The strength of family history (genetic
transfer) as a risk factor for unilateral and BBC still need further evaluation among indigenous black
African women in view of heterogeneity of breast cancer aetiology across regions. However it will be
difficult to estimate the significance of unknown family history.
The short mean duration of symptoms before the second presentation could be due to awareness from
their previous experience though this appears to have no effect 0n disease stage of CBC. Mertins
et.al25 among others reported that subsequent tumours are usually of smaller size and stage, though
initial tumour size and stage is strongly associated with CPBC size and stage. Aggressive follow-up
care of the initial tumour including screening of contalateral breast will lead to early detection thus
smaller size and stage of the subsequent cancers.
The mean interval between cancers of 18months (0-68months) is rather short compared with
117months reported by Golgas14 or 144months by George GFet.al24, though most are also young and
premenopausal but with positive family history. Short interval, age, large second tumour size, higher
number of positive lymph nodes of first and second cancers are factors that decrease the disease
specific survival in patients with BBC3,26. Skowronek J et.al 27 reported 0 and 73.9% 5-year survival
in patients with interval period < 2years and > 5years in Poland. In addition, lympho-vascular
invasion, nuclear grade, histology and hormone receptor status are also related with overall survival28.
Primary breast cancers are more common on the right4 and 81% of first primary lesions here are found
on the right. CBC lesions are noted to be commonly located centrally while upper outer quadrant
lesions are commoner overall; the significance of the former is unknown.
Late presentation with breast cancer is common in the developing world 15,19,23,29, low level of
awareness30, poverty and fair of mastectomy31 among others could account for this. Presentations of
CBC at a late stage, in spite of previous experience, leave much to desire. Inadequate follow up care
in addition to rapidity of growth as good number of studies have suggested a biologically aggressive
form of breast cancer in Nigerians and other black women32,33. They are usually of poorly
differentiated invasive ductal carcinoma “Not Otherwise Specified” with high proliferation ratio and
poor host cellular immune reaction22,34-all translating to poor prognosis. Infiltrating lobular carcinoma
has been described to have propensity to occur in both breasts24 but none was found in this series, as it
is uncommon in this environment4. The rarity of carcinoma-in-situ as histology finding in the
developing world can only be accounted for by non availability of screening facility, in fact greater
than 90% of most patients after self-detection23.
31
March/April 2010.
Distinguishing features of primary cancer in contalateral breast has been described to include
demonstration of in-situ-carcinoma in the breast tissue with invasive carcinoma, histologically
dissimilar infiltration and location deep within the breast parenchyma35.
The only case of synchronous bilateral Burkitt’s lymphoma seen died within one year, this is in
keeping with the experience reported by Aghadiuno et.al36 in which 12 out of 18 patients with
simultaneous bilateral breast malignancy had Burkitt lymphoma and none survived 2 years. They tend
to have multi-organ involvement as depicted in a case report by Fadiora et.al.37
Young age, strong family history, histology confirming infiltrating lobular carcinoma, or gross
multicentricity in the first primary tumour are considered as factors predisposing to developing
PCBC14,24. Any of these should alert the surgical oncologists on the need for detail follow-up so as to
be able to diagnose a CBC early enough with the hope of better prognosis. Outcome of treatment for
patients with breast cancer in the developing world is generally poor.
Follow-up of patients with unilateral disease should include frequent self breast examination, 3monthly clinical breast examination by physician, half yearly or yearly mammography or breast
magnetic resonance imaging (MRI). MRI is known to detect occult malignancy missed by
mammography38.
Use of tamoxifen has been found to reduce the incidence of CPBC in women who received the drug
as adjuvant therapy for the first primary breast cancer by 47% 39 and has been proved to be of value in
chemoprophylaxis of breast cancer40. Oophorectomy brought about surgically or by irradiation and
prophylactic contalateral mastectomy may be considered in those with high risk of developing
CPBC32. In fact the concept of possible bilateralism of breast cancer should be introduced to our
patients during the first visit after confirmation of a unilateral lesion and adequate education given on
treatment and follow-up care plan.
Conclusion
The incidence of BBC was 4.26%, most were young with no positive family history, 90% were
premenopausal and histology was IDC (NOS) in 90%of cases. The burden of BBC is enormous on
both the patients and the involved treatment team. Effort should be put in to determining the risk
factors to breast cancer and BBC in the black African women. Improve level of awareness of breast
cancer, provision of screening facilities, coordinated multi-centered research in breast oncology and
establishment of specialized oncology center will go a long way in improving the outcome of
treatment of breast cancer in the poor resource African setting.
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Edition p. 555-590 (W B Saunders 2001).
3. Abdalla I, Thisted R A, Heimann R. The impact of contalateral breast cancer on the outcome
of breast cancer patients treated by mastectomy. Cancer J 2000 jug-Aug; 6(4):266-72.
4. KA Adeniji. Pathological appraisal of carcinoma of the female breast in Ilorin Nigeria. Niger
Postgrad Med J. 1999; 6(2):56-59.
5. Adelusola K A, Fadiran OA, Adesunkanmi ARK, Odesanmi WO. Breast cancer in Nigerian
women in Ile-Ife. Nig Med. Pract. 1996; 31:17-20.
6. Otu A, Ekanem IA, Khalil MM, Ekpo MM, Attah EB. Characterrisation of breast cancer
subgroups in an African population. Br. J. Surg. 1989; 76(2):182-184.
7. Adebamowo CA, Ajayi OO. Breast cancer in Nigeria. W. Afr. Med. J.2000; 19:179-191.
8. Chiedozi LC. Breast cancer in Nigeria. Cancer 1989; 55(3):653-657.
9. Oluwole SF, Fadiran OA, Odesanmi WO. Diseases of breast in Nigeria. Br. J. Surg.1987;
74(7):582-585.
32
March/April 2010.
10. Atoyebi OA, Atimomo CE, Adesanya AA, Beredugo BK, da Rocha-Afodu JT. An appraisal
of 100 patients with breast cancer seen at Lagos University Teaching Hospital. Nig. Qt.
J.Hosp. Med 1997; 7:104-108.
11. Kollias J, Ellis IO, Elston CW, Blamey RW. Prognostic significance of synchronous and
metachronous bilateral breast cancer. World J. Surg. 2001Sep; 25(9):1117-24.
12. Carmichael AR, Bendall S, Lockerbie L, Prescot R, Bates T. The long time outcome of
synchronous bilateral breast cancer is worse than metachronous or unilateral tumours. Eur .J
surg. Oncol. 2002 jun; 28(4):388-91.
13. Mose S, Adamietz IA, Thilmann C, Saran F, Pahnke R, Bottcher HD. The prognosis of
bilateral breast carcinoma compared to unilateral breast tumour. 5- and 10-year follow-up.
Stachlenther Oncol. 1995 Apr; 171(4):207-13.
14. Gogas J, Markopoulos C, Skandalakis P, Gogas H. Bilateral breast cancer. Am Surg.
1993Nov; 59(11):733-5.
15. ML Adeoti, AS Oguntola, AOA Aderonmu, OS Agodirin: (2008) Influence of socio-cultural,
political, Economic status and environment on the outcome of surgical practice in a
developing tropical Country-Using Breast Cancer as case study. Surgery Journal Vol.3
(2):21-23. Med well journals publishers.
16. Bailey MJ, Royce C, Sloane JP, Ford HT, Powles TJ Gazet JC. Bilateral carcinoma of the
breast. Br. J. Surg. 1980 Jul; 67(7):514-6.
17. Okobia M, Bunker C, Zmuda J, Kammerer C, Vogel V, Uche E, Anyanwu S, Ezeome E,
Ferrell R, Kuller L. Case-control study of risk factors for breast cancer in Nigerian women.
Int J Cancer. 2006 Nov 1; 119(9):2179-85.
18. Okobia MN, Bunker CH. Epidemiological risk factors for breast cancer;-A review.
Niger
J. Clin. Pract. 2005 Jun; 8(9):35-42.
19. Ihekwaba FN. Breast cancer in Nigeria women. Br. J. Surg. 1992 Aug; 79(8)771-5.
20. Goksel HA, Yagmurdur MC, Karakayali H, Moray G, Demirhan B, Isiklar I, Bilgin N,
Haberal M. Management of bilateral breast carcinoma: long-term results. Int. Surg.2004 jul;
89(3):166-71.
21. Jobsen JJ, Van der Parlen J, Ong F, Meerwaldt JH. Synchronous, bilateral breast cancer:
prognostic value and incidence. Breast. 2003 Apr; 12(2):83-8.
22. Hassan J, Onukak EE, Mabogunje OA. Breast cancer in Zaria, Nigeria. J. R coll. Surg. Edinb.
1992; 37(3):159-61.
23. Adesunkanmi AR, Lawal OO, Adelusola KA, Durosimi MA. The severity, outcome and
challenges of breast cancer in Nigeria. Breast. 2006 Jun; 15(3):399-409
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Brown. Bilateral breast cancer, clinical and pathological review. Ann. Surg. May1972;
175(5):635-42.
25. Mertens WC, Hilbert V, Makari-Judson G. Contralateral breast cancer: factors associated
with stage and size at presentation. Breast J. 2004 Jul.; 10(4):304-12.
26. Engin K. Prognostic factors in bilateral breast cancer. Neoplasma. 1994; 41(6):353-7.
27. Skowronek J, Piotrowsky T. Bilateral breast cancer. Neoplasma 2002; 49(1):49-54.
28. Beinart G, Gonzalez-Angulo AM, Broglio K, Mejia J, Ruggeri A, Mininberg E,
Hortobagyi GN, Valero V. Clinical course of 771 patients with bilateral breast cancer:
characteristics associated with overall and recurrence free survival. Clin.Breast Cancer. 2007
Dec; 7(11):867-74.
29. Stanley N Anyanwu. Temporal trends in breast cancer presentation in the third world. J. Exp.
Clin. Cancer Res.2008; 27(1):17.
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and non-educated women to cancer of the breast in semi-urban and rural areas of Southwest,
Nigeria. Niger Postgrad Med J. 2006 Sep; 13(3):182-8
31. Ajekigbe AT. Fear of mastectomy: the most common factor responsible for late presentation
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32. ES Garba. Contralateral breast cancer. Nig. J. Surg. Res.2003; 5:1-6.
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33. Gukas ID, Jennings BA, Mandong BM, Igun GO, Girling AC, Manasseh AN, Ugwu BI,
Leinster SJ. Clinico-pathological features and molecular markers of breast cancers in Jos,
Nigeria. W, Afr. J. Med. 2005; 24(3):209-13.
34. Gogo-Abite M, Nwosu SO. Histopathological characteristics of breast carcinomas seen at
UPTH, Port Hacourt, Nigeria. Nig. J. Med. 2005 Jan; 14(1):72-6.
35. Robbins GF, Berg SW. Bilateral primary breast cancers- A prospective clinicopathological
study. Cancer 1964; 17:1501.
36. Aghadiuno PU, Akang EE, Ladipo JK. Simultaneous bilateral malignant breast neoplasm in
Nigerian women. J. Natl. Med. Assoc. 1994 May; 86(5):365-8.
37. SO Fadiora, VO Mabayoje, AOA Aderonmu, ML Adeoti, SA Olatoke, AS Oguntola.
Generalised Burkitt’s lymphoma involving both breasts- A case report. W.Afr.J.Med. 2005
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38. Constance DL Lehman, Constantin Gatsonis, Christiane KK, R. Edward Hendrick, Atta D
Pissano, Lucy Hanna et.al . MRI evaluation of the contalateral breast in women with recently
diagnosed breast cancer. N. Eng. J. Med.2007; 356(13):1295-1303.
39. Early Breast Cancer Trialists’Collaborative Group. Tamoxifen for early breast cancer: An
overview of randomized trials. Lancet 1998; 351:1451.
40. Fisher B, Cconstantino, JP, Wichersh DL, et.al: Tamoxifen for prevention of breast cancer:
Report of NSABP P-1 study. J Natl. Cancer Inst. 1998; 90(18):1371.
34
March/April 2010.
Changing pattern of incidence, aetiology and mortality from acute pancreatitis at
Kalafong Hospital, Pretoria, South Africa, 1988-2007: A retrospective evaluation.
I. Chamisa, T. Mokoena, T.E. Luvhengo
Kalafong Hospital, Department of General Surgery, University of Pretoria, Pretoria, South Africa
Correspondence to: Dr. I. Chamisa, Email: [email protected]
Background: Literature reports from Western countries suggest an increasing incidence of acute
pancreatitis (AP) and changing pattern over the past two decades. The aim of this
study was to document the incidence, aetiology and mortality from AP over two decades and to
examine any emerging trends.
Methods: A retrospective study of all confirmed cases of AP admitted over a 20-year period to the
surgical department was performed. Patients’ demographics, year of admission,
number of attacks, aetiology, management and outcome were entered on a special
study proforma.
Results: Altogether 707 attacks of AP (M: F, 5.7: 1) were recorded. The proportion of gallstone AP
increased (3.1% to 12.7%) and that of alcohol-related AP decreased (84% to 67.6%). Alcohol was the
main aetiological factor for AP. Drugs, hyperlipidaemia, human immunodeficiency virus (HIV) and
endoscopic pancreatography-related AP increased in the second decade. The in-hospital mortality rate
during the respective periods was 6.5% and 3.1%.
Conclusion: Gallstone AP increased during second decade from more Caucasian admissions and
increased gallstones among Blacks. The reduced mortality was attributed to changing trends in the
nature and aetiology of AP recorded, heightened awareness of the condition and improved
management.
Introduction
The incidence, aetiology, demographics and mortality of AP appears to be changing worldwide1 but
few studies in South Africa 2,3 have examined this. The annual incidence of AP in different Western
reports ranges from 5 to 50 per 100 000. 4,5 The differences in consumption and incidence of GD in
different parts of the world partly explains this difference. The increased incidence of AP in Western
countries 6,7 has been attributed to improved diagnostic tests and imaging procedures, and heightened
interest. GD has been reported to be the most common cause of AP in reports from England 8 and
Scotland 9 while alcohol has been suggested as an aetiological factor of rising importance. South
Africa has undergone significant socio-political changes following the first democratic elections in
1994. Previous racially segregated hospitals are now integrated resulting in a change in the admission
patterns and the nature of diseases seen. The aim of this study was to document the incidence,
demographics, aetiology and mortality from AP over two decades in a single institution. Patients were
classified into decades one (1988-1997) and two (1998-2007) and the results analysed.
A retrospective study of all confirmed cases of AP admitted over a 20-year period to the surgery
department at Kalafong Hospital was performed. Discharge letters and summaries of all patients with
AP were retrieved from a computer database. Patients’ demographics, year of admission, number of
attacks, aetiology, management and outcome were entered on a special study proforma. The diagnosis
of AP was only accepted in those with a consistent clinical history and physical examination,
supported by increased serum amylase or lipase levels or from laparotomy, laparoscopy or necropsy
findings. Alcohol was considered the aetiology when the patient reported a regular high intake of
alcohol or an alcoholic binge directly before the onset of the disease, and no signs of other aetiologies
were present.
35
March/April 2010.
Ultrasonography for GD disease was routinely performed in most patients. GD was considered the
aetiology when there were positive findings of gallstones and no signs of alcohol abuse or other
aetiology. The aetiology was considered idiopathic when no aetilogical factor could be found and
unspecified if not documented.
Results
Altogether 707 attacks of AP were identified over a 20-year period. Of these 588 (83.2%) were first
attacks and 16.8% recurrent. The absolute number of AP admissions between the two decades
decreased proportionately to the total number of surgical admissions (34128 and 26723) with a ratio
of 1.2% and 1.1 % respectively. Over a period of 20 years, more Caucasian (0.01% to 0.21%) and
Asian (0.03% to 0.13%) patients were admitted in the second decade due to the desegregation of
health institutions in 1994.
Table 1. Acute Gallstone Pancreatitis by Racial Distribution (Number and %).
Decades
Africans
Asians
Caucasian
Total
First (1988-1997)
6 (1.4)
4 (1.0)
3 (0.7)
13 (3.1)
Second (1998-2007)
14 (4.8)
3 (1.0)
20 (6.9)
37 (12.7)
Total
20 (6.2)
7 (2.0)
23 (7.6)
50 (15.8)
Table 2. Aetiology of Acute Pancreatitis by Decades (Number and %).
Aetiology
Alcohol
First (1988-1997)
Second (1998-2007)
350 (84.0)
196 (67.6)
Idiopathic
32 (7.6)
22 (7.6)
Gallstones
13 (3.1)
37 (12.7)
Unspecified
20 (4.8)
10 (3.4)
Trauma
2 (0.5)
7 (2.4)
Post ERCP
0 (0)
6 (2.1)
Drugs
0 (0)
6 (2.1)
Hyperlipidaemia
Pancreatic carcinoma
Total
0 (0)
5 (1.7)
0 (0)
1 (0.3)
417 (100)
36
290 (100)
March/April 2010.
There was a significant male preponderance (M:F, 5.7:1). The number of females with AP increased
by 12.8% between the decades. AP in both decades was most common in 31-40 years age group and
the proportion of Black patients with gallstone AP increased by 16% during the study period (Table
1).
In both decades for both genders, alcohol was the main aetiological factor for AP (84.0% and 67.6%)
respectively (Table 2). There was an overall increase in gallstone AP between the two decades by
9.7%, which was attributed to changing demographics with admission of Caucasians and absolute
increase among the Black population. The incidence of gallstone disease (GD) in general increased by
1.2% (Table 3).The second decade saw a rise in anti-retroviral drugs, endoscopic retrograde
cholangiopanctreatography (ERCP) and hyperlipidaemia-related AP. One 73 year old patient had AP
related to pancreatic carcinoma. During the study period, the rate of ERCP increased by 23% and six
episodes of ERCP-induced AP (2.1%) were identified.
The in-hospital mortality rate during the respective decades was 6.5% and 3.1%. Mortality from
alcohol-induced AP decreased by 4.9% but that for gallstone AP decreased less, by 2.3% (Table 3).
Two deaths from the first decade were one each blunt trauma-related and ‘idiopathic’ AP. Three
deaths in the second decade were: one ‘idiopathic’ and two related to HIV and HIV drugs. There was
a downward trend in mortality from AP probably attributed to changing pattern in the aetiology of AP
and alsoimproved management.
Table 3. Incidence and Demographics of Symptomatic Gallstone Disease in General.
Decades
Total cases
Average age (Y)
First (1988-1997)
240 (0.7%*)
Second (1998-2007)
500 (1.9%*)
32.2
47.3
Gender ratio (F:M)
3.9:1
* Per cent of total surgical admissions.
4.3:1
Table 4. Percentage mortality per decade according to aetiology
Aetiol Aetiology
Gallstones
Alcohol
Others
Decades
First (1988-1997)
Second (1998-2007)
7.7
5.4
6.9
2.0
0.6
1.5
Discussion
AP has been known for more than a century, but its epidemiology remains poorly documented
especially in African countries. Western studies have indicated an increasing incidence rate during the
past two decades.1,10 Beyers, 11 in a review of surgical diseases at Johannesburg during the 5-year
period 1921-1926, stated that no cases of AP were observed in Blacks. Thereafter, in the 3-year period
1981-1983 there were 55 new cases, 12 the increased admission rate occurring some 20 years after
Blacks had access to Western-type alcohol. African literature is scanty on this subject and comparing
the incidence of AP between different reports is difficult.
37
March/April 2010.
There was no significant change in the overall incidence rate of AP during the study period. This
finding differs from Western reports, which documented a rise in the incidence of AP during the last
20 years13 . The change in the admission pattern during the study period could explain the apparent
decrease in AP admissions in the second decade when the Black middle class patients gained wider
access to private health care after. Although more men than women were admitted throughout the
study period, the incidence of AP in women began to increase considerably in the second decade. AP
was almost six times more in males than in females, which we linked to the higher consumption of
alcohol by this gender group. Differences in lifestyle amongst the young may explain the young age
peak incidence.
A significant number of our patients were labelled as ‘idiopathic’ AP, which serves to highlight the
importance of excluding all possible underlying causes to reduce the risk of recurrence attacks. The
acquired immunodeficiency syndrome (AIDS) epidemic and the widespread use of HIV drugs saw a
rise in HIV and HIV drugs-related AP mostly in the second decade. We partly associated the increase
in hyperlipidaemia-related AP and gallstone AP with the change in the admission pattern in the
second decade (more Caucasians and Asians admitted in formally Africans-only hospitals). Our rate
of ERCP-induced AP (2.1%) was lower than that from a recent review of prospective series which
found the mean frequency to be 5.2% after diagnostic and 4.1% after therapeutic ERCP.14
In a 12-month audit of patients with a first attack of AP undertaken at Baragwanath Hospital in 1994
, alcohol was the predominant aetiological factor in 83.1%, gallstone disease in 7.4% and idiopathic
causes in 6.6%. Their overall mortality was 8%. In a study from London (1988-1992), alcohol
represented 29% and gallstones 30% of episodes of AP.16 These Western results contrast sharply with
our findings and those from Baragwanath Hospital in which alcohol predominates as the cause of AP
although gallstones are on the increase. It is difficult to ascertain whether this trend can be attributed
to improvements in patients care or to an increasing incidence of mild attacks. An increase in the
diagnostic rate is likely to have resulted in the diagnosis being established in greater numbers of
patients with mild disease and thus a fall in the case mortality rate. Previous South African studies
have shown that in Soweto, alcohol-related AP is common, 17 and the first attack pursues an
aggressive course with significant long-term morbidity. The association between increasing age and
death from AP is well-described 18 and was confirmed in this study.
15
Conclusion
The absolute number of AP admissions between the two decades decreased proportionately to the
total number of surgical admissions. Alcohol is the main aetiological factor for AP in our setting,
however GD and gallstone AP has increased in the Black population. There has been a steady rise in
the incidence of HIV and HIV-drugs related AP over the past two decades. The increase in females
has been attributed more to increased alcohol consumption than to GD. There was a general
downward trend in mortality from AP but that among the elderly remains high. While improved
treatment of AP may have contributed to the falling case fatality rate, another explanation may be the
increased diagnosis of mild AP through the wide use of diagnostic pancreatic enzymes elevation,
which has lower mortality.
References
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23 (2): 63-66
4. Trapnell JE, Duncan EHL. Patterns of incidence in acute pancreatitis. BMJ 1975;ii: 179-183.
5. Thomson HJ. Acute pancreatitis in north and north-east Scotland. J R Coll Surg
Edinb
1985; 30: 104-111.
38
March/April 2010.
6. Wilson C, Imrie CW. Changing patterns of incidence and mortality from acute pancreatitis
in Scotland, 1961-1985. Br J Surg 1990; 77:731-734.
7. Corfield AP, Cooper MJ, Williamson RC. Acute pancreatitis: a lethal disease of increasing
incidence. Gut 1985; 26:724-729.
8. Bourke JB. Variation in annual incidence of primary acute pancreatitis in
Nottingham,
1969-1974. Lancet 1975; ii: 967-969.
9. Imrie CW. Observations on acute pancreatitis. Br J Surg 1974; 61:539-544.
10. Mckay CJ, Evans S, Sinclair M et al. High early mortality rate from acute
pancreatitis in
Scotland, 1984-1995. Br J Surg 1999; 86:1302-1305.
11. Beyers CF: Incidence of surgical diseases among the Bantu races of South Africa.
J Med
Assoc S Afr 1927; 1:606-612.
12. Segal I, Leios M, Grieve T. The emergence of chronic calcifying pancreatitis in a
developing country; in Gyr K, Singer MV, Sarles H (eds): Pancreatitis: Concepts
and
Classification. Amsterdam, Excepta Medica, 1984, pp417-420.
13. Thomson SR, Hendry WS, McFarlane GA et al. Epidemiology and outcome of acute
pancreatitis. Br J Surg 1987; 74: 398-401.
14. Gottlieb K, Sherman S. ERCP and endoscopic biliary sphincterotomy-induced
pancreatitis. Gastrointest Clin N Am 1998; 8: 87- 114.
15. MacPhail AP, Simon MO, Torrance JD et al: Changing patterns of dietary iron
overload
in black South Africans. Am J Clin Nutr 1979; 32:1272-1278.
16. Mann DV, Hershmann MJ, Hittinger R et al. Multicentre audit of death from acute
pancreatitis. Br J Surg 1994; 81: 890-893.
17. Segal I. Pancreatitis in Soweto, South Africa: Focus on alcohol-related disease.
Digestion
1998; 59 (suppl): 25-35.
pancreatitis in
18. Svensson JO, Norback B, Bokey EL et al. Changing pattern in aetiology of
an urban Swedish area. Br J Surg 1979; 66: 159-161.
39
March/April 2010.
Truncal Vagotomy for Peptic Pyloric Stenosis and Assessment of Completeness by Acid
Tests.
B. Nega
Department of Surgery, Addis Ababa University Medical Faculty - Ethiopia
E-mail: [email protected]
Background: Several types of operations are used for Peptic pyloric stenosis (PPS) which
includes Vagotomy with antrectomy or drainage procedures. This study was done primarily to
analyze the completeness of Truncal vagotomy (TV) by gastric acid secretion tests. The
secondary analyses included demographic, clinical profile and out come of the operation.
Methods: From December 27/2004 to June 26/2006, 32 consecutive patients, aged 10 to 65 years
underwent trans-abdominal (TV) and Posterior Gastrojejunostomy for PPS at Glen C. Olsen
memorial hospital. TV without mobilizing and encircling the esophagus. Prospective
longitudinal case serial analysis was done to assess the completeness of TV. Outcome measures
used for assessment were the pre-operative basal acid output (BAO), Post-operative BAO, Postoperative sham feeding acid out put (SAO) and other relevant clinical characteristics.
Results: After surgery, the average pre-operative BAO had decreased from 6.07+/2.7mmol/hour to 0.42+/-0.29mmol/hour. The BAO was decreased by 91.3%. Mean peak acid
response after TV to SAO was 0.83+/- 0.45mmol/hour. The difference between the peak
15minutes out put of SAO and lowest 15 minutes out put of post-operative BAO did not exceed
0.6mmol in 30/32 patients. This shows that TV was complete in 93.7%. There was no operative
mortality and clinically significant post-operative complication developed in only three patients.
Conclusion: Trans-abdominal TV done without mobilizing and encircling the esophagus was
found safe and effective means of reducing acid secretion for patients with long standing peptic
pyloric stenosis.
Introduction
Peptic pyloric stenosis is a world wide event seen in all age and sex1. It is a frequent reason for
surgical admission to our hospital accounting for 7.3% of major surgeries. Similar trend was also seen
in other developing countries.2-7 It is one of the major complication of duodenal ulcer reported to
occur in 6- 8%.8 PPS requires dual operation which includes relieving obstruction and controlling
peptic ulcer disease9. These are best achieved by Vagotomy with antrectomy, TV with
Gastrojejunostomy, or Billroth II Gastrectomy. Vagotomy combined with antrectomy is regarded as
the most effective curative operation, because the subsequent recurrent ulcers are < 1%10. Although
this operation is effective, the difficulty in dissection of the obstruction segment of the pyloric
channel, the difficulty in the closure of the duodenal stump, the longer operation time, and the larger
extent of operation usually lead to a higher postoperative complications.11
Laparoscopic assisted posterior vagotomy with seromyotomy can be done with good results, thou it is
technically demanding and requires more expertise and resources.12 Selective or highly selective
vagotomy alone is not appropriate in the setting of pyloric stenosis as it dose not relieve the
obstruction13. Pyloroplasty is not advisable in case of severe inflammation of the pyloroduodenal
area13.Endoscopic balloon dilatation has been proposed as an alternative to surgical treatment.
However, 50% of patients treated with balloon dilatation remained with recurrent ulceration or outlet
obstruction at 3 years.14-15Even though ulcer recurrence after TV-Gastrojejunostomy is about 10%, 16
it still has a role in the treatment of PPS. It is technically simple and easy to perform with few side
effects. The main objective of TV is the completeness of vagal denervation which is the determining
factor for its long term out come. For achieving complete denervation of the vagi, proper knowledge
of its anatomy is essential. In a study of vagal structures using 100 cadavers, in 88% anterior and
posterior vagus were found without split, in 7% there were four divisions, and in 5% more than four
divisions of both trunks seen at the level of the hiatus.17 Therefore, during trans abdominal TV, it is
required to properly identify both Trunks and divide them properly. Because of this routine anatomic
40
March/April 2010.
land marks, a complete division of both vagus can be achieved without encircling and mobilizing the
esophagus.
To the author’s best knowledge, for cases of PPS, there has been no previous study published on the
acid secretion test after TV done without encircling and mobilizing the esophagus. This study is
therefore aimed to highlight the role of TV done without encircling and mobilizing the esophagus for
treatment of PPS which can be used as an alternative technique to the standard method.
A prospective hospital based longitudinal case series analysis of all patients admitted and operated for
PPS from Dec 27/2004 – June 26/2006 at Glenn C. Olsen memorial primary general hospital was
done. All patients were initially evaluated by history, physical examination with relevant laboratory
and imaging studies. Diagnosis of pyloric stenosis was made based on clinical finding of non bilious
projectile vomiting, audible suction splash 3-4 hours after meal and barium study demonstrating
dilated stomach with narrowed gastric outlet with retention of 50% or more of ingested barium after 4
hours. All patients with possible diagnosis of pyloric stenosis were admitted and treated with fluid &
electrolyte replacement and decompression of the stomach with Naso-gastric tube for variable number
of days. Parentral nutrition was not available for use. Lavage of the stomach with normal saline was
done until the effluent was clear an hour before surgery and prophylactic antibiotics was given 30
minutes before surgery. Informed consent was obtained from all patients or their guardian before
surgery and acid secretary test.
Operative approach
All procedures were carried out by a single surgeon who only had two years of independent
experience as a general surgeon. In all patients the approach was similar where patients were placed in
reverse Trendelenberg position and abdomen was opened through long upper midline incision
extending from the base of xiphoid process to the umbilicus. A large self retaining retractor was used
in separating the abdominal wound at its center. Kelly retractor with pack protecting the liver used to
expose the esophago-gastric junction. Abdominal viscera were inspected systematically. The presence
of ulceration, fibrosis and /or cicatrisation was confirmed by careful inspection of the first part of
duodenum and pylorus. Then the peritoneum overlying the distal esophagus, as close to the level of
the esophageal hiatus as possible was incised transversely and ext ended medially to the lesser sac.
Using a Mickulicz pad the assistant places a gentle down ward traction on the greater curvature of the
stomach, there by placing traction on the gastro-esophageal junction and lower esophagus. In the
course of this maneuver the nerve trunks usually was palpated as a taut cord.
The anterior vagus was first identified usually adherent to the anterior wall of the esophagus and
separated from it using long dissector artery forceps and divided high in the hiatus. The rest of the
anterior esophagus will then be palpated for possible additional nerve fibers and if identified it will be
divided. Once division of the anterior vagi is completed, index finger will then gently passed to the
medial side of the esophagus in to the areolar tissue, in the mean time the assistance will continue on
gentle down ward traction of the greater curvature which will enable the posterior vagus to ‘bow
string’ and makes it easier to be identified and divided. Following this, retro-colic gastro-jejunostomy
was done for drainage purpose. Finally mid-line incisions were closed in layers. Patients were allowed
to fluid diet a day after removal of naso-gastric tube and were encouraged to ambulate on the next
post operative day. They were discharged when acceptable condition achieved and oral intake was
well tolerated.
Acid secretion test
Before Truncal vagotomy
Basal acid output (BAO) was measured after an overnight fast on the day of surgery. Patients were
sited on semi-recumbent position and 18 Fr nasogastric tube was positioned under fluoroscopic
41
March/April 2010.
guidance with its tip in the antrum. All residual gastric contents was aspirated and discarded. Then
gastric contents were collected in 15 min period four times in 1 hour using intermittent suction.
After Truncal Vagotomy
Post–operative tests were performed between 7th-21st postoperative days and BAO was measured
first followed by sham feeding stimulated acid out put (SAO). During sham feeding procedure
patients were given a meal which was chewed and spat out in to basin every 15 minutes period, and
collected four times in 1 hour. Food was cooked in separate area so that they could not see or smell it
before the test began. In both BAO and SAO, gastric juice was collected in 15 minutes period and the
volume was measured. The PH was measured using a glass electrode PH meter called PH-315 I set.
(WTN 82362 WEILHEIM conforms to UL STD 3101, certified CSA standard C-22.2 No. 1010).
Given the PH, the hydrogen ion concentration was calculated using electronic calculator with
antilogarithmic functions ([H+] = 10-PH) 18-19.Finally, acid secretion in millmoles per 15 min is
calculated by multiplying the acidity (mmol/l) times the volume (liter/15 min). The BAO and SAO
per hour were also determined by adding the four consecutive 15 minutes acid out put and comparison
of pre and post operative BAO was made.
Test interpretation
An acid secretary response of SAO not exceeding BAO by more than 0.6 mmol per 15 minutes
collection period was used as a criterion for establishing the completeness of vagotomy.20-21
Statistical analysis
Structured formats were used to collect all relevant information and statistical analysis was done
using Statistical Package for Social Science (SPSS) version 15.0 for Windows (SPSS Inc., Chicago,
IL, USA). Data are presented as mean or median (range) evaluated using analysis of variance for
repeated measures.
Results
For all patients, TV with posterior gastro-jejunostomy was done with the method described above and
both vagus were identified and transected. Analysis of the acid secretion showed an average preoperative BAO of 6.07+/-2.71mmol/hour (range 2.9 to 12.55). After TV, it decreased to 0.42+/0.29mmol/hour (range 0.003 to 1.394). Comparison of the pre and post vagotomy BAO showed a
mean reduction of 91.3% (range 66.3%-99.9%). (Fig 1)
The mean peak acid response after vagotomy to sham feeding was 0.83+/- 0.45mmol/hour (range 0.19
to 2.43), compared with BAO after vagotomy which was 0.42+/-0.29 mmol/hour (range 0.003 – 1.39).
Figure two shows the difference between the highest post vagotomy BAO and the lowest SAO
recorded in 15 minutes for each patient. The average increase after SAO, the peak 15 minutes out put
minus the lowest basal 15 minutes out put value , did not exceed 0.6 mmol per 15minutes in 30/32
patients. Since only two patients had an acid response to SAO which exceeds the lowest basal level by
more than 0.6mmol/15 minutes, it can be considered that vagotomy was complete in 93.7% of
patients. Patient number 9 and 24 were found to have a difference of 0.815mmol and 1.054mmol Per
15 minute records. There for considering that there is a possibility of incompleteness, they were given
H.pylori eradication treatment during the subsequent follow up period.
The clinical presentation and out come measure showed that there was 21/32 male and 11/32 female
patients (M: F→1.9:1). Mean age at presentation was 36+/-15.2 years (range 10 to 65 years). The
highest age specific prevalence was between 25 to 35 years accounted for 8/32. The mean duration of
vomiting was 20.4+/- 17.4 months (range 2 to 60 months). It was only 10/32 patient’s look for
medical advice with in 6 months of onset of vomiting. No patient used NSAIDs on regular base, 11/32
is social alcohol drinkers, and 7/32 was smokers and 20/32 chew Khat daily. Khat is leaves which
contain cathinone, an amphetamine like stimulant used for excitement.
42
March/April 2010.
BAO preoperative
BAO post operative
Sham feeding
postoperative
12.5
Value (mmol/hr)
10.0
7.5
5.0
2.5
0.0
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Patients Case Number
Figure 1. The preoperative BAO, post operative BAO and SAO of 32 patients with PPS.
maximum measured
BAO/15 minutes post
operative
minimum measured
SAO/15 minutes post
operative
1.250
Value ( mmol/hr)
1.000
0.750
0.500
0.250
0.000
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Patients Case Number
Figure 2. The difference between the highest and the lowest BAO and SAO Recorded in 15 minutes
of 32 patients who under go TV for PPS
During admission, due to prolonged episodes of vomiting, 10/32 patients present with signs of
dehydration and hypovolemic shock. Pyloric stenosis was the initial manifestation of peptic ulcer
disease in 21/32patinets. The rest, 11/32, were previously treated for PUD with different anti-ulcer
medications but not H.pylori eradication treatment. In 31/32 patients cicatrisation and fibrosis of the
duodeno-pyloric area with or with out adhesion and proximal big dilated stomach was found. One
patient had pyloric stenosis assisted with anterior perforation of the duodenum with minimal localized
peritonitis. One patient had pyloric obstruction from tuberculosis lymphadenitis and inflammatory
edema which was treated with drugs alone and responded well. He was excluded from the final
43
March/April 2010.
analysis. The duration of surgery was 51+/- 13.8min (range 40 to 90 minutes) and the estimated blood
loss was 156.8+/- 56.4ml (range 100 to 500ml). The average hospital stay was 10.3+/- 3.4 days (range
7 to 24 days). (Table 1)
There was no operative mortality and early post operative complication was seen in three patients.
One patient had transient symptoms of delayed gastric emptying who responded well with
metclopromide, continuous stomach suction and adequate fluid electrolyte replacement. He was
allowed to take fluid diet after 10th post-operative day. The other two had wound infection and
pneumonia.
Table 1. Descriptive Statistics of age, hospital stay, duration of vomiting, resuscitation, stomach
decompression, blood loss, surgery time and different acid secretary tests.
Minimum
Age
Hospital Stay
Duration of vomiting(month)
NGT decompression (days)
Resuscitation ( Days)
Blood loss (ml)
Duration of Surgery(min)
Preoperative BAO(mmol/hour)
Postoperative BAO(mmol/hour)
Postoperative SAO(mmol/hour)
Mean reduction of BAO after
surgery (%)
10
7
2
1
0
100
40
2.9
0.003
0.19
66.3
Maximum
65
24
60
3
10
500
90
12.55
1.394
2.43
99.9
Mean
36
10.3
20.4
1.28
2.84
156.8
51
6.07
0.42
0.83
91.3
Std.
Deviation
15.2
3.4
17.4
0.52
2.03
56.4
13.8
2.71
0.29
0.45
7.1
Discussion
The results show that TV done without encircling and mobilizing the esophagus has safely and
effectively reduces the acid secretion similar to other standard methods1-10.It also had shorter
operative time and similar or less complication in the immediate postoperative period. Dragstedt L22
had found that basal vagal activity had an important driving force for the spontaneous gastric acid
secretion and Johnston21 found that basal acid secretion had markedly reduced after proximal gastric
vagotomy, a finding which was similarly observed in this study in which BAO reduced by an average
of 93.3%. Richard C.23 had studied the effect on basal, sham feeding and pentagastrin-stimulated acid
secretion (PAO) after transthoracic vagotomy done for 16 patients with postoperative recurrent ulcer.
He found that the BAO has decreased by 91.2% and the SAO and PAO decreased by 98+/-1% and
73+/-8 % respectively. Gastric acid secretion test done on thirty-one patients, aged 40 to 76 years
(mean 53 years), who were treated by conventional and 10 by a laparoscopic stapling-modified
Taylor procedure for chronic duodenal ulcer showed that the basal and peak acid output were 1.5+/0.6 mmol /hour and 12.2+/-6.4 mmol /hour, respectively.24 Another review conducted after highly
selective vagotomy and truncal vagotomy and pyloroplasty performed for peptic ulcer disease found
a reduction of basal acid output by 80% and maximal acid output by 50% to 60% in both
conditions25.
Mean operative time of this procedure was shorter than the other procedures22-26.This could be due to
the fact that TV was done without mobilizing and encircling the esophagus. Furthermore, with
increasing time, expertise will develop and operating time reduces. In this study, patients were
discharged on the tenth postoperative day (average). This is relatively longer than other studies .2425
This happened because a significant number of patients stayed long before surgery for they need to
be resuscitated before operation. Due to long duration of vomiting, 10/32 of our patients presented
with signs of dehydration and hypovolemic shock. Other studies done by Berhanu K2 and Duglas etal
44
March/April 2010.
32
reported 4/63 (6.3%) and 22% respectively. The incidence of post-operative complication we
encountered is relatively low. We have seen only 1/32 (3.1%) patient who had developed gastricatony. Similarly low incidence of atony after vagotomy was also reported from both developing4-7 and
developed countries.9-13
Identification of H. Pylri infection as a cause of peptic ulcer has influenced not only treatment
strategy for peptic ulcer disease but also types of surgeries for peptic ulcer complications. In
unpublished data found in the editorial by Chung and Li33, 50% of patients with pyloric stenosis in the
Department of Surgery of the Chinese University of Hong Kong were infected with H.Pylori. One
author report reversal of PPS after eradication of H.Pylori infection .34 With this observation he
suggests that oral eradication of H.Pylori might be indicated as a first-line treatment in patients with
PPS followed by endoscopic dilatation before surgery15,34. In our institute all patients with PPS are not
initially treated with medications to eradicate H Pylori. Besides, endoscopic balloon dilatation is not
available. Surgery is considered right away because most of our patients seek medical advice late in
the course of the illness. In the future, the association between PPS and H. Pylori eradication
treatment requires further investigation.
Conclusion
Although the number of patients studied was small, the short duration of follow up and the
lack of comparable similar studies are some of the limitations. The result showed that truncal
vagotomy done without encircling and mobilizing the esophagus safely and effectively
reduces the acid secretion similar to other standard methods.
The procedure is technically simple and has short learning curve. It may be beneficial for less
qualified general surgeon or even general practitioners with some experience in bowel
surgery. It also helps to minimize complications associated with mobilizing the esophagus
like bleeding, esophageal perforation, disruption of the gastro-esophageal junction and spleen
injury.35
It could be used as alternative method specially when technical consideration make dissection
of the esophagus dangerous or associated with systemic illness precludes longer duration of
surgery. In resource limited hospital like ours, patients with peptic pyloric stenosis can benefit
from this type of procedure.
Acknowledgment
I am very much grateful to Dr Tessema Ersomo, who diligently taught me this procedure during my
residency training at Addis Ababa University Medical Faculty. I also want to express my appreciation
to the nursing and laboratory staff members of Glen C. Olsen Memorial Hospital for their assistance
during sample collection and analysis.
References
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Philip E (eds), Surgery of the Esophagus, Stomach and Small intestine, 5th Ed, Boston, Little,
Brown and company (inc.), 1995; 370
2. Kotisso B, Gastric outlet obstruction in North west Ethiopia, East and central African Journal
of surgery, 2000; 5(2):25-29
3. Woldetsadik B, the role of surgery for peptic ulcer in Eastern Ethiopia, East and Central
African Journal of surgery, 2000; 5(2):21-24
4. Ersomo T, Ali A, Kotisso B, Complicated peptic ulcer disease in Tikur Anbessa Hospital,
Addis Ababa, Ethiopia, Ethiop Med J, 2004; 42(2):87-95
5. Sabo S, Ameh E, Obstructing duodenal ulcer in a tropical population, East Afr Med J, 1999;
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6. Kakande I, Peptic ulcer surgery at a rural Hospital in Kenya, East Afr Med J, 1991; 68:15-20
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7. Ameh E, Nmadu P, Pattern of peptic ulcer disease in Zaria, Nigeria, East Afr Med J, 1998;
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8. Ellis, H.: Pyloric stenosis complicating duodenal ulceration. World J. Surg. 11:198, 1987
9. Bertrand Millat, Abe Fingerhut, Frederic Borie, Surgical treatment of complicated duodenal
ulcers: Controlled Trials, World J.Surg, 2000; 24:299-306
10. Sachdeva AK, Zaren HA, Sigel B, Surgical treatment of peptic ulcer disease; Med Clin North
Am; 1991 Jul; 75(4):999-1012
11. JF Jr, Antrectomy with Billroth II anastomosis. In: Ballantyne GH, Leahy PF, Modlin IM
(eds) Laparoscopic surgery. Saunders, Philadelphia, 1994: 444–448
12. Petrakis I, Vassilakis SJ, Chalkiadakis G, Anterior lesser curve seromyotomy using a
stapling device and posterior truncal vagotomy for the treatment of chronic duodenal ulcer:
long term results, J Am Coll Surg;1999 Jun;188(6):623-8
13. Fraser AG, Brunt PW, Matheson NA., A comparison of highly selective vagotomy with
truncal vagotomy and pyloroplasty--one surgeon's results after 5 years, Br J Surg. 1983
Aug;70(8):485-8
14. DiSario, J.A., Fennerty, B., Tietze, C.C., Huston, W.R., Burt, and R.W.: Endoscopic balloon
dilatation for ulcer induced gastric outlet obstruction. Am. J. Gastroenterol. 89:868, 1994
15. Krevsky, B.: Endoscopic management of gastric outlet obstruction, Gastroenterology
101:553, 1991
16. Michael J. Zinner, Duodenal ulcer and Peptic ulceration, In : J. Zinner, I. Schwartz, Harold
Ellis, W. Ashley, W. McFadden(eds) Maingot’s Abdominal Operation, 10th ed, London;
Prentice Hall International(Inc), 1997: 945
17. Josef E. Fischer, Mastery of General surgery In: E. Fisher, I.Bland(eds) 5th ed, Philadelphia,
Lippincott(Inc), 2007: 824-827.
18. Kenneth W, Chemistry, 4th eds, Mc Graw-Hill(inc), Newyork,1991;278
19. Drew H, Introduction to college Chemistry, Mc Graw-Hill(inc), Newyork,1988;486-487
20. Stenquist B, Forssell H, Olbe L, and Lundell L, Role of acid secretor response To sham
feeding in predicting recurrent ulceration after proximal gastric vagotomy, Br Journal of Surg,
1994; 81: 1002-1006.
21. Forssell H, Stenquist B, Lundell L, Olbe L, A criterion for completeness of Vagotomy based
on basal and vagally stimulated gastric acid secretion after esophagectomy or proximal gastric
vagotomy, Scand J Gastroenterol, 1988; 23: 534-538
22. Dragstedt LR, Peptic ulcer, An abnormality in gastric secretion, Am J Surg, 1969: 117(2)
143-156
23. Richard C, Mark F, Transthoracic vagotomy for postoperative peptic ulcer, Ann Surg, May
1985; 01(5):648-653
24. Petrakis I, Vassilakis SJ, Chalkiadakis G, Anterior lesser curve seromyotomy using a stapling
device and posterior truncal vagotomy for the treatment of chronic duodenal ulcer: long term
results, Am Coll Surg; 1999 Jun; 188(6):623-8.
25. McLeod RS, Cohen Z., Highly selective vagotomy and truncal vagotomy and pyloroplasty for
duodenal ulcer: a clinical review, Can J Surg. 1979 Mar;22(2):113-20
26. Kim SM, Song J, Oh SJ, Hyung WJ, Choi SH, Noh SH., Comparison of laparoscopic truncal
vagotomy with gastrojejunostomy and open surgery in peptic pyloric Stenosis. Surg endosc.
2009 Jun; 23(6):1326-30. Epub 2008 Sep 24
27. Irabor DO, An audit of peptic ulcer surgery in Ibadan, Nigeria. West Afr J Med. 2005 JulSep; 24(3):242-5.
28. Steger AC, Galland RB, Spencer J., Remaining indications for vagotomy with drainage or
antrectomy in duodenal ulcer, Ann Coll Surg Engl 1987 Jan;69(1):24-6
29. Sachdeva AK, Zaren HA, Sigel B, Surgical treatment of peptic ulcer disease,Med Clin North
Am 1991 Jul;75(4):999-1012
30. Millat B, Fingerhut A, Borie F, Surgical treatment of complicated duodenal ulcers: controlled
trials, World J Surg 2000 Mar;24(3):299-306
31. Siu WT, Tang CN, Law BK, Chau CH, Yau KK, Yang GP, Li MK., Vagotomy and
gastrojejunostomy for benign gastric outlet obstruction.,J Laparoendosc Adv Surg Tech. 2004
Oct;14(5):266-9.
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32. Douglas W, Daniel H, Edward W, Michael L, Gastric outlet obstruction in peptic Ulcer
disease; an indication for surgery, The American Journal of Surgery, 1982; 143:90-93
33. Chung, S.C.S., Li, A.K.C.: Helicobacter pylori and peptic ulcer surgery. Br. J. Surg. 84:1489,
1997
34. Boer, W.A., Driessen, W.M.: Resolution of gastric out let obstruction/ after eradication of
Helicobacter pylori. J. Clin. Gastroenterol, 21:329, 1995.
35. Michael J. Zinner, Complication following gastric operations, In : J. Zinner, I. Schwartz,
Harold Ellis, W. Ashley, W. McFadden, eds: Maingot’s Abdominal Operation, 10th ed,
London; Prentice Hall International Inc, 1997: 1029-1030
47
March/April 2010.
The Management Outcome of Acute Hand Injury in Tikur Anbessa University Hospital,
Addis Ababa, Ethiopia.
E. Ahmed,
Addis Ababa University, Medical faculty, Addis Ababa, Ethiopia
Background: Hand is the most commonly injured part of our body. The aim of treatment is
always to restore its movement, strength and dexterity. The quality of primary treatment often
determines the maximal potential for recovery. The objective of this study was to evaluate the
management
outcome
and
consequences
of
the
injured
hand.
Methods: Between 1st January 2005 and 31st December 2005, a total of 253 patients were treated
in Tikur Anbessa University Hospital for acute hand injury that presented within the first 24
hours of the occurrence. We evaluate the mechanism of injury, types and duration of treatments
and complications.
Results: The mean age was 32 years and the male to female ratio was 7:1. The majority of
patients were wood worker (32%) followed by laborers (25%) and machine operators (15%).
Three quarter of the injuries occurred at work, of which 74% were caused by machines. The
commonest injuries included fracture in 39% of which the majority (85%)mwere compound,
amputation in 31% and soft tissue injury in 26%. The injury severity was moderate and above
in 54%. Most were managed at emergency out-patient department and the average total
treatment time was 93 days. The average impairment of hand function before and after
treatment was 6% and 19% respectively. The main reason for more loss of function after
treatment were more proximal corrective amputation (31%), prolonged immobilization (28%)
in nonfunctional position (17%), healed in unacceptable position (19%) and infection (13%).
Final results were poor in 62%, this was not significantly associated with severity of the injury.
Conclusion: Improving treatment of injured hand and establishing specialized center for hand
injury may shorten duration of treatment and improve result.
Introduction
Our hand is a truly complex, active and intricate part of our body, allowing for variety of functions. It
allows us to feel, grasp, perform fine movements and discriminate while displaying exquisite
dexterity. Hand is the most frequently injured parts of our body1-4 and accounts for 5-10% of all
accidents seen in the emergency department and 28% of injuries to musculoskeletal systems5-10.
Injury of the fingertip and/or nail bed is by far the most common hand injury11. Fractures of the
metacarpals and phalanges account for 10% of all fractures and are responsible annually for 16 trillion
lost days of work12. Phalangial fractures are unique in that an isolated fracture can affect the
functional unit of the hand and the digit. Digital function can be impaired not only by fracture stability
or deformity but equally by concomitant injury to the soft tissues that provide motion, stability, blood
flow, and sensation to that digit.
Hand injury can be functionally disabling, psychologically crippling and economically disastrous
for the workers thus placing great responsibility on the part of the attending clinician. The aim of
treatment is always to restore function that is movement, strength and dexterity followed by pain
relief and cosmetic appearance. Hand and fingers tolerate injury and immobilization poorly and it
should be managed very carefully.
The hand being the most important productive organ of the worker, prevention of hand injuries, care
of the injuries and restoration of function of the injured hand are of great human, social and economic
importance. It is extremely important to treat even minor injuries of the hand with care, to minimize
morbidity and to restore a person to his job as early as possible. In our hospital acute hand injury
accounted for 12% of all patients with major limb trauma13 and there is no specialized hands unite.
48
March/April 2010.
The main objective of this study was to evaluate the management and its outcome and consequences
of the injured hand. The specific objectives were to identify the types and duration of treatments,
complication and extent of hand impairment.
This was a Prospective, descriptive study of all 253 patients with acute hand injury that resulted in
amputation, fracture, dislocation, or extensive soft tissue injury and presented within the 24 hours of
the occurrence to Tikur Anbessa University hospital (TAUH) and treated over a one year period from
January 1 until December 31, 2005. The patients had been informed and had given consent to be
included in the study. A structured questionnaire was used to collect the data that include patient
profile, circumstance, time and nature of the injury, they were also asked about treatment and
presence of pain. The hand function was evaluated based on loss of part, range of motion and
presence or absence of sensation. These patients were evaluated at least at two visits. The Orthopedic
Department had approved the study protocol. International standard classification was used to classify
occupation14. Place of occurrence and type of injury classified based on ICD-10 15.
The severity of the injury was graded according to Campbell and Kay scale, Hand Injury Severity
Scoring system16. Results were determined for all patients after last follow-up examination by the
author based on amputation as loss of digits and loss of range of motion expressed as percentage of
impairment related to entire hand17, and a system formulated by Belsky et al18.
Excellent: No symptom or sign, pain free union, no angulation or rotatory deformity, PIP
motion at least 100°, total active motion (TAM) greater than 250°. (Total active movement is
the sum of flexion at MP, PIP, and DIP joints minus the extension deficit at the same joints.)
Good: Minimal angular or rotatory deformity, PIP motion at least 80, TAM greater than 180°.
Poor: All the remaining results.
The data analysis was performed with the aid of SPSS software. Results were expressed interns of
percentage, mean and ratio. Chi square test were used for significance test.
Results
Of the 253 patients assessed 221 (87.4%) were males and 32 (12.6%) females (M:F of 7:1). The age
ranged 21-53 years (mean 32) and 231 (91.3%) were right handed. Twenty (7.9%) patients could not
read or write. The leading job category includes: crafts & related trade workers 82 (32.4%), laborer 62
(24.5%) and machine operators 37 (14.6%) (Table1). One hundred and ninety one (75.5%) of the
injuries occurred at work either in industries 127 (50.2%), construction areas 30 (11.9%) or trade and
service areas 26 (10.3%). The commonest cause of the injury were machines in 141 (55.7%) followed
by road traffic crash in 30 (11.9%), crash by heavy object 21 (8.3%) and blow by stick in
interpersonal conflict 21(8.3%) (Table2). Of 141 patients who sustained machine injury, 21 (14.9%)
experienced previous hand injury by machines.
Ninety Nine (39.1%) patients had at least one fracture that involved 95 digits in 83 patients, 14
metacarpal and 4 Scaphoids. The majority (85%) of fractures were compound. The commonest digits
to be fractured were the index in 30 (31.6%), usually at the level of distal phalanges (43.2%) or
middle phalanges (33.7%).
A total of 151 digits were amputated in 79 Patients and involved the ring finger in 34.4% followed by
middle in 31.8% and index digits in 17.9%. In 109 (72.2%) of the amputations it was at the level of
the distal phalanx (Table3). The other hand injuries included extensive soft tissue injury in 66
(26.1%), dislocation in 22 (8.7%) and tendon injury in 16 (6.3%) of the cases. Some patients had a
combination of the above injuries.The severity of the injury were minor in 116 (45.8%), moderate 92
49
March/April 2010.
(36.4%), severe 29 (11.5%) and major 16 (6.3%) (Table 4). Thirty four (75.5%) of the 45 severe
injuries were caused by machines
One hundred and ninety-eight (78.3%) of patients were managed non-operatively at out-patient level
were there is no operative facility, by immobilization of the hand or some of the digits in 121 hands
(Fracture 79, STI 28 and Dislocation 22), method of immobilization was cotton ball (43, 35.5%),
splint with adjacent digits or spatula (24, 19.8%) and POP (54, 44.6%). Even though the majority
(81%) presented within 8 hours of the injury (Golden period), Fifty five (21.7%) patients had
corrective amputation very late in Minor Operation Theater (16 within the 1st week, and 39 after 10
days of the injury). Usually corrective amputations were done more proximal in 47 patients and 12
patients with initial diagnosis of extensive soft tissue injury were amputated later.
Problems observed in immobilization were immobilizing in non functional position 44 (36.4%),
involving unnecessary joints 40 (33.1%) and prolonged immobilization 48 (39.7%). Only 42 (17%)
patients had physiotherapy. Mean duration of follow up was 93 days (SD ± 34.3 days) and ranged
from 45- 180. The commonest complications were joint stiffness 210 (83.0%), complain different
degree of persistent pain 100 (40.0%), fracture healed in unacceptable position in 47 (18.6%),
infection in 33 (13.0%), and late amputation in 12 (4.7%) of the cases (Table 5).
Overall mean loss of hand function before treatment was 5.6% and after treatment 19.2 % due to joint
stiffness and ankylosis, proximal corrective amputation and late amputation.
Table 1. Socio-Demographic Characteristics of the Studied Patients
Character
Gender
Male
Female
Age (years )
Number
Percent
221
32
87.4
12.6
21-30
113
44.7
31-40
128
50.5
41 or more
12
4.8
20
71
137
25
7.9
28.1
54.1
9.9
82
32.4
62
37
22
24.5
14.6
8.7
Mobile plant operator
12
4.7
Others
38
15.0
Educational level
Illiterates
Grade 1-6
Grade 7-12
Grade 12+
Occupational category
Crafts & related trade
workers
Laborer
Machine Operators
Drivers and conductors
50
March/April 2010.
Table 2. Place and Causes of the Injury
njury
Cha ra ct er
Nu mb er
Percent
Per
cent
Industrial Production
127
50.2
Street
54
21.2
Construction Area
30
11.9
Trade & service area
26
10.3
Home
8
3.2
Other
8
3.2
Machine
141
55.7
RTA
30
11.9
Crush
21
8.3
Blow
21
8.3
Fall
15
5.9
Others
25
9.9
Place of occurrence
Causes of the injury
Table 3.. Frequency of Digital Amputation and Fracture in Respect to the Level
L
Digits
DP
MP
PP
Total
Amputation
Thumb
8
-
0
8
Index
19
8
0
27
Middle
38
10
0
48
Ring
36
16
0
52
Little
8
8
0
16
Total
109
42
0
151
Thumb
4
_
7
11
Index
14
8
8
30
Middle
9
8
7
24
Ring
8
16
0
24
Little
6
0
0
6
41
32
22
95
Fracture
Total
March/April 2010.
Table 4. Types of injury and severity
Character
Number
Percent
Fracture
99
39.1
Amputation
79
31.2
Laceration /Digloving
66
26.1
Dislocation
22
8.7
Tendon
16
6.3
I – Minor
116
45.8
II – Moderate
92
36.4
The injuries
Injury Severity score
III – Severe
IV – Major
29
11.5
16
6.3
Few patients had more than one types of injury
Table 5. Types and Final Result After Management
Character
Number
Percent
Joint stiffness or ankylosis
210
83.0
Persistent pain
100
39.5
Deformity
47
18.6
Infection
33
13.0
Late amputation
12
4.7
Excellent
3
1.1
Good
93
36.8
Poor
157
62.1
Very satisfied
20
7.9
Satisfied
62
24.5
Unsatisfied
143
56.5
Very unsatisfied
28
11.1
Complication
Final results
Patient satisfaction
Few patients had more than one types of complication
The management results were excellent in 3 (1.1%) patients, good in 93 (36.8%), and poor in 157
(62.1%). Severity of the injury is not significantly associated with the treatment outcome (P>0.05).
Because of this injury 14,112 working days were lost with the mean of 55.8 days ± SD 14.5 (range
15 -90 days ) and 63 (17.0%) patients could not able to resume the previous work.
52
March/April 2010.
Table 5. Types and Final Result After Management
Character
Number
Percent
Joint stiffness or ankylosis
210
83.0
Persistent pain
100
39.5
Deformity
47
18.6
Infection
33
13.0
Late amputation
12
4.7
Excellent
3
1.1
Good
93
36.8
Poor
157
62.1
Very satisfied
20
7.9
Satisfied
62
24.5
Unsatisfied
143
56.5
Very unsatisfied
28
11.1
Complication
Final results
Patient satisfaction
Few patients had more than one types of complication
Finally the patients satisfaction on this management was considered satisfactory in 82 (32.4%) and
unsatisfactory in 171 (67.6%) (Table5).
Discussion
Hand injury predominantly affects young male (M:F ratio of 7:1), most (76%) occurred at work.
Different studies have shown that the rate of occupational injuries is higher for men than women19-25.
The commonest cause was machine (56%), particularly wood working machine is by far the most
dangerous machine. Of all reported machine injuries 58% (82/141) were caused by wood and
products of wood working machine. Which is supported by other study in Ethiopia20 and study of
Heycock in 1964 revealed that of all hand injuries treated in the Derbyshire Royal Infirmary, 15% was
caused by wood working machine26. But this is different in findings of the some other countries where
it was highest in food product manufacturing in Swedish, steel manufacturing in Singapore, petroleum
manufacturing in USA, and in the textile industry in India27-30.
The injury severity was moderate and above in 54%, with an amputation rate of 31%, fracture of 39%,
as compared with less severe injuries with an amputation rate of 1% and fracture of 5-9% in the
developed world31-34 and this is comparable with the study in India35. This severity was probably due
to patients with minor injuries being treated in peripheral health centers, small clinics in a factory and
also with little importance given to minor injuries in our patients. Moreover most of these injuries
were caused by machine which contributes for the severity because the most severe hand injuries are
caused by machine36,37.
It is very sad that all our hand fracture, extensive soft tissue and tendon injury patients had to be
treated in the emergency out patient department with no tourniquet, inadequate anesthesia, inadequate
sterility, poor light and no proper type and size of suture. Those who need corrective amputation was
appointed to minor orthopedic operation day which is one day a week (every Thursday), because there
is no operative facility for emergency out patient and never enough beds available38. All cases were
initially attended by resident doctors, this shortcoming was recognized earlier by Entin and Broback
53
March/April 2010.
et.al. Who recommend that post graduate training in hand surgery be made obligatory for all general
and orthopedic surgeons who deal with hand surgery39,40.
Hand and fingers tolerate injury and immobilization poorly and thus accepted protocol for treatment
for hand injuries is immediate reconstruction of all injured tissue structures because the quality of
primary treatment often determines the maximal potential for recovery (as delay of treatment can have
direct long term consequences)41-44. Mean duration of treatment of our patients was 93 days. Most
have at least one of the following complication; joint stiffness or ankylosis 83%, persistent pain 40%,
deformity 19%, infection 13% and late amputation 5%. The over all results of our treatment was poor
in 62% of the patients and the range of persistent post traumatic disability was between 3% and 90%
and the average permanent disability was 19%. The severity of the injury was not significantly
associated with the treatment out come. This high incidence of complication and poor outcome reflect
our poor and delayed management and practically no proper rehabilitation. Sixty seven percents of
our patients were unsatisfied in our treatment. The indirect cost of these injuries was high because the
mean duration off work was 56 days and 17 % had to change the occupation.
Recommendation
1. There is a great need of improving and increasing physical facility and manpower preferably by
establishing specialized hand center to improve treatment of injured hand that may shorten
duration of treatment, improve result and decrease indirect cost.
2. Hand surgery attachment should be mandatory for general and orthopedic surgery residents.
3. There should be a means to decrease machine injury particularly wood working machine.
Acknowledgement
The cooperation of the Orthopaedic department is greatly appreciated. Special thanks go to Professor
Geoffrey Walker FRCS for assistance with the preparation of the manuscript and to Dr. Tezera Chaka
for administrative support.
References
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Med. 2002; 44(4): 345-51.
2. Joseph E. Sheppard MD. Hand injury among the most common. The University of Arizona,
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3. Gaul JS. Identifiable costs and tangential benefits resulting from the treatment of acute injuries of
the hand. J hand surg (Am) 1987;12A:966-70.
4. Burket FD et al. Providing care for hand disorders; trauma and elective. J hand surg
(Br)1991;16B:13-18.
5. Hill C et al. Regional audits of hand and wrist injuries. J hand surg (Br)1998;23B:196-200.
6. Angermann P Lohmann M. injuries to the hand and wrist. Study of 50,272 injuries. J hand surg
(Br)1993;18B:642-4.
7. Packer GJ, Shaheen MA. Patterns of hand fractures and dislocations in district general hospital. J
hand surg (Br)1998;18B:511-4.
8. Glen Vaughn, MD. Fingertip injuries. In: Jeffery G, Francisco T, Eric L, John H, Steven D, eds.
Trauma and orthopedics, instant access to the minds of medicine, eMedicine.com, Inc. 2001; 2:1.
http://www.emedicine.com/emerg/topic179.htm, 6/1/2004
9. Antosia RE, Lyn L: The hand. In: Emergency Medicine: Concepts and Clinical practice 1998;
4:625-68.
10. Markovick VJ, Pons PT, Wolfe RE. Emergency medicine Secrets, Philadelphia: Hanley and
Belfus, Inc; 1993.
11. Elvin G. Zook. Nail Bed and Fingertip Injuries, Skin and Soft Tissue. Hand Surgery Update.
American Society for Surgery of the Hand; 1996; 28 (&): 289-293.
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12. Holbrook, T. L., Grazier, K., Kelsey, J., and Stauffer, R. The Frequency of Occurrence, Impact
and Cost of Selected Musculoskeletal Conditions in the United States. Chicago: AAOS, 1984. 1–
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13. Elias, MD. and Tezera, MD. Orthopedics emergencies and Major limb trauma in Tikur Anbessa
University Hospital. Addis Ababa. East and central African journal of surgery 2005; 10 (2): 4350.
14. Statistics of occupational injuries, International Labor Organization. Sixth international
conference of labor statisticians report III. Geneva. 1998.
15. WHO International Statistical Classification of Disease and Related Health Problems, ICD-10.
Geneva, 1992.
16. Campbell DA, Kay SPJ. The Hand Injury Severity Scoring System. J Hand Surg (Br)
1996;21B:295-8.
17. Swanson, Göran-hagert, and Swanson. Evaluation of impairment in the upper extremity. J Hand
Surgery 1987; 12A(5): 896- 925.
18. Belsky MR, Eaton RG, Lane LB. Closed reduction and internal fixation of proximal phalangeal
fracture. J Hand SURG. 1984; 9A725-9.
19. Elias A, and Tezera C. Prospective audit of all patients with a Hand Injury, Tikur Anbessa
University Teaching hospital, Addis Ababa. Eth. Med. J. 2006;44 (4):175-182
20. Elias A, C. The Risk Factors for Machine Injury of the Upper Limb, Case cross-over study. Tikur
Anbessa University Teaching hospital, Addis Ababa, Ethiopia. Eth. Med. J. 2008;46 (2):163-7.
21. Skov O. The incidence of hospital treated occupational hand injuries. J hand surgery.
1994;19B:118-119.
22. Pizatella TJ, Moll MB. Simulation of the after reach hazard on power presses using dual palm
button actuations. Human factor. 1987;29:8-9.
23. Sorock GS, Lombardi DA, Hauser R, et al. Hospitalized finger amputation, New Jersey. 19851986. Am J Ind Med.1993;23:439-447.
24. Oslon, DK., Gerberich SG. Traumatic amputation in work place. J. Occ. Med. 1986;28(7):480485.
25. Laflamme L, Blank VL. Age related accident risk, longitudinal study of iron ore miners. Am. J.
Ind. Med.1996;30:479-487.
26. Heycock MH. On the managements of hand injuries caused by wood working tools. J plat Surg
(Br) 1966;19:58-67
27. Carlsson A. Hand injuries in Sweden in 1980. J. Oc. Acc. 1984;6:155-65.
28. Ong CN, et al. Shiftwork and mill injuries in an iron and steel mill. Appl Ergon 1987;18:51-6.
29. Jensen DG. Scenario analysis of finger injuries in industrial accidents. Proceeding of human
factor society, 31st annual meeting, 1987:916-19
30. Nag PK, Patel VG. Work accident among shift workers in industry. Int J Ind Ergon
1998;21:275-81.
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study of transient risk factors for occupational acute hand injury: USA. J Occup Environ Med.
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32. Sorock GS, Lombardi DA, Hauser R, et al. A case-crossover study of occupational traumatic
hand injury: Methods and initial findings. Am J Ind Med.2001; 39:171-179.
33. Dubert T. et al. Eight days of hand emergencies. Report of the audit carried at FESUM Center
from June 3 to June 9, 2002. Pub Med, France. Chir Main. 2003; 22(5): 225-32
34. Hertz RP, Emmett EA. Risk factor for occupational hand injury. USA. J Occup Environ Med.
1986; 28(1): 36-41.
35. M.K.Mam, A.G.Thomas, Bobby John, Koshy George. Hand Injuries: A clinical study of four
hundred twenty eight patients. Orthopedic update, India. 1998; 8(3): 1-4.
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36. Marek T, Jacek L, Leszek B, Waldemar H. Causes and consequences of hand injuries. Am J
surgery. 2006;192:52-57.
37. Sorock GS, Lombardi DA, Courtney TK, Cotnam JP, and. Mittleman MA. Epidemiology of
occupational acute traumatic hand injuries: a literature review. ScienceDirect – Safety Science,
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38. Elias A. Tezera C. The Pattern of Orthopedic Admissions In Tikur Anbessa University Hospital,
Addis Ababa (A prospective one-year descriptive study, April 1st, 2003 – March 31st, 2004)
Ethiop. Med. J. 2005; 43:No. 2.
39. Entin MA self fulfilling prophesies, reflection on the future of A.S.S.H. j Bone and joint surg .
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40. Broback LG, Ekdahl PH, Ashan GW, Grenobo JK: Clinical and socieconomical aspect of hand
injuries. Acta Chir Scand 1978; 144:455-61.
41. Burke FD, Dias JJ, Lunn PG, et al. providing care for hand disorder: trauma and Elective. J hand
surgery. 1991;16B:13-8.
42. Aneger manP, Lohmann M. Injury to the hand and wrist. A study of 50,272 injuries. J hand
surgery. 1993;18B:642-4.
43. Hung LK, choi KY, Yip K, et al. Recent changes in pattern of hand injuries in Hong Kong: a
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56
March/April 2010.
The Impact of Bodaboda Motor Crashes on the Budget for Clinical Services at Mulago
Hospital, Kampala.
J. Kigera, L. Nguku, E.K.Naddumba
Department of Orthopedics, Mulago Hospital, Kampala Uganda
Correspondence to: Kigera JWM, Email [email protected]
Background: Bodabodas are a common form of transport and are becoming a major cause of
road traffic accidents in Uganda. We evaluated the magnitude of injuries related to bodabodas
and their impact on clinical services at Mulago hospital.
Methods: This was a retrospective review of all trauma patients who presented at Mulago
hospital emergency ward between June and August 2008 following bodaboda crash. The
hospital costs involved in their management were obtained from the office of the hospital
statistician.
Results: Road Traffic Crashes (RTCs) were the leading cause of trauma and bodabodas were
involved in 41% of all trauma patients. The average duration of stay was 8.3 days. The average
cost to maintain a bodaboda patient was determined at Uganda shillings 700,359/ or the
equivalent of US $369. Bodaboda injuries consumed 62.5% of the budget allocation for the
directorate of surgery, Mulago Hospital.
Conclusions: Bodabodas are a major cause of traumatic injuries among cases seen in the
surgical emergency department at Mulago and the costs incurred by the hospital in managing
these injuries are enormous. Efforts should be made to reduce the menace that is brought about
by bodaboda motorcycle crashes. Resources currently being spent on treating injuries resulting
from accidents involving bodabodas would then be used to improve the care of other patients.
Introduction
Bodaboda motorcycles are a common and popular form of transportation in Kampala city and in
many other towns in Uganda. Since their introduction in Kampala in 2001, there has been an increase
in the number of road traffic crashes many attributable to them. The percentage of accidents
attributable to bodabodas between RTCs has been increasing annually. Bodabodas are also the leading
cause of accident scene fatalities in Kampala1. Road traffic crashes and in particular bodaboda ones
commonly affect the young adults in the 20 – 29 years age group2.This is because the bodabodas
business is dominate by youths as a means to a livelihood. Naddumba3 in his study found that the
peak age incidence of both the riders and passengers was in the 20-30-age group. Otieno4 reported
that 14.5% of all patients with long bone fractures were due to injuries sustained while riding while
Lule5 found that bodabodas trauma accounted for 25.6% of all tibial fractures. This study was aimed
at determining the magnitude and cost implication of injuries caused by bodabodas at Mulago
hospital. The study also undertook to quantify the impact of these injuries to the provision of quality
services at Mulago. Direct costs resulting from the injury and its management were derived.
This retrospective study included all patients admitted for trauma at the emergency surgical ward in
the three-month period ending 30th August 2008. Patients’ files were analyzed for the demographic
data, the cause of trauma, diagnosis on admission, duration of stay and operative procedures
performed. An accident was deemed to have involved a bodaboda if the patient was a passenger, a
rider or was hit by a bodaboda. The data was collected using a research tool designed for that purpose
and later keyed in to a computer using MS Excel. The data was then analyzed. Details on costs
associated with hospital stay were derived from the hospital statistician’s office. Costs were calculated
based on the average cost of maintaining a patient in the ward per day, the costs of surgical
procedures done and the cost of any implants used in surgery.
57
March/April 2010.
Results
Records of 921 (61.4%) of the 1500 trauma cases admitted during the study period were retrieved and
analyzed. Road traffic crashes contributed 51% of all trauma patients seen. Of the 428 patients
admitted after RTCs, 75 % were due to bodaboda accidents. The majority (80.6%) of the cases were
males with a male to female sex ratio 4.2:1. The peak incidence was in the third decade of life. About
two thirds of the patients were aged between 20 and 40 years and 85% of all patients were below 40
years of age (Figure 1). Table 1 shows the number of patients that required surgical intervention
during the study period. Nearly half (49.7%) of them had sustained bodaboda injuries.
Lower extremity injuries especially open fractures were predominant. Figure 3 shows injury sustained
by a bodaboda passenger who was thrown off the motorcycle when it collided with a truck which then
ran over her thigh. She suffered a traumatic amputation above the knee. A rare form of an obturator
anterior hip dislocation (Figure 4) was among the victims. The patient was thrown off a bodaboda that
had knocked down a pedestrian. He presented to hospital two weeks after the injury and underwent
open reduction for the anterior Hip dislocation. Majority of the closed fractures of the femur were
managed by open reduction and IM nailing using implants from the Surgical Implant Generation
Network (SIGN) and some by skeletal traction.
Age in Years
45.00%
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Age
<11
11 to 20
21-30
31-40
41-50
51-60
61-70
71-80
>80
Figure 1. Age Distribution in Years.
Duartion of Stay
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Days in
Hospi tal
0
1
2 to 5
6 t o 10
11 t o 20
21 - 30
>30
Figure 2. Duration of Hospital Stay in Days
Table 1. Patients requiring surgical intervention
Cause of Injury
Boda Boda
RTC other than Boda Boda
Non RTC
Number
101
20
82
58
Percentage
49.75%
9.85%
40.40%
Table 2. Operations requiring implants
Operations Done
External Fixation Tibia
IM Nails femur
Other ORIF Femur
Hemiathroplasty
ORIF Humerus
ORIF Forearm
ORIF Ankle
TBW Patella
Total Hip Athroplasty
March/April 2010.
Number
Percentage
21
19
4
3
2
2
1
1
1
38.9%
35.2%
7.4%
5.6%
3.7%
3.7%
1.8%
1.8%
1.8%
Figure 3. Typical Injuries - Open Femoral Fracture Sustained in a Bodaboda Crash.
Figure 4. Anterior obturator dislocation
Of the 203 Patients requiring theatre about half were due to bodaboda injuries and of these 75%
required the services of an orthopedic surgeon (Table 1). Table 2 shows the operation that required
implants. The Duration of hospital stay of the patients ranged from 1 to 105 days with a mean of 8.3
59
March/April 2010.
days (Figure 2). The average cost of maintaining a patient in the wards was UGX 56,740. With an
average length of stay of 8.3 days, the average cost per patient translates to Uganda Shs 470,942. The
total costs for maintaining the patients in the wards were UGX 151,172,382. The total theatre costs
attributable to patients with injuries caused by bodaboda were UGX 73,642,813. This was for the 101
patients who required operative management. The total costs added up to UGX 224,815,195 for the
three-month period studied. This cost excludes rehabilitation costs, which we were unable to
determine and quantify. The average cost of managing a bodaboda patient is hence calculated at UGX
700,359 (USD 369)
Discussion
Bodabodas were responsible for about 75% of all trauma caused in road traffic collisions. This is a
very high figure when compared to other countries in the region. A study in Rwanda estimated that
motorcycles were responsible for about 30% of all RTCs6. This difference may to a great extent be
explained by the facts that in Rwanda there are strict laws governing bodaboda ridders and users that
are strictly abided by. For instance, in Rwanda both the motorcycle rider and his passenger must
strictly wear helmets which law, in Uganda, has not been enforced by the police. Most of the patients
admitted due to injuries related to bodabodas were in the economically viable age group and at the
prime of their lives. These injuries hence result in disruption of economic activities and a further drain
in the incomes of these patients. Naddumba3 in 2001, found that majority of bodaboda accident
victims were self employed and hence will not generate any income while they are in hospital and at
home recuperating from their injuries. Most of the patients who were involved in bodaboda accidents
tended to have more severe injuries and this may be due to the fact that most accidents tend to involve
collisions with motor vehicles and the unprotected bodaboda riders and passengers bear the brunt of
the impact3.
The total cost of managing all inpatients due to bodaboda injuries is UGX 224,815,195 in the threemonth period of the study. This translates to UGX 899,260,780 a year. Given the fact that that we
were only able to collect data from about 60% of the files we anticipated, it can be postulated that the
total cost is in the region of 1.5 billion shillings each year. When weighed against the budget
allocation for the Directorate of Surgery of about 2.4 billion shillings annually, this translates to
62.5%. This is a colossal sum of money could have been used up by one aspect of the greater field of
surgery. The costs attributable to bodaboda injuries comprise a significant 15% of the 10 billion
shillings allocated to Mulago for health services and 4.2% of the total budget for Mulago for the year
2008/2009 (35 billion shillings). This is a colossal sum given that Uganda is a developing economy
and these funds could be utilized in other areas. It should be noted that part of these costs were borne
out by various donors most notably the SIGN organization that provides intramedullary implants and
the Health Volunteers Overseas that provided most of the external fixator implants.
A reduction in the number of trauma cases seen at Mulago hospital most of which are from bodabodas
will free up space for the hospital to attend to other pressing matters. Trauma has overwhelmed the
orthopedics department and hence skewed teaching of residents who require exposure in areas of
adult and pediatric orthopedics.
Conclusion
Bodabodas and the injuries attributable to them are a pressing problem and efforts should be
made to seek solutions aimed at mitigating this.
Reduction of these injuries will free up resources to attend to other pressing areas in
orthopedics.
Recommendations
Efforts should be geared towards prevention of injuries attributable to bodabodas. Regulation of
training and operations of bodabodas will go a long way in ensuring that this mode of transport is safe
60
March/April 2010.
to its users. The traffic regulations and the Highway Code should be strictly enforced by the police so
as to reduce carnage on our roads. Health authorities should empower hospitals managing these
injuries with the necessary resources to properly manage these patients. These will range from
personnel, equipment and implants.
References
1. Central Police Station Road Traffic Accidents (2000-2002) Kampala, Uganda Police
2. Injury Control Injury Surveillance Reports (2000 – 2003) Kampala
3. Naddumba E.K, A Cross-Sectional Retrospective Study of Boda Boda InjuriesAt Mulago
Hospital IN Kampala-Uganda, East Centr Afr J 2004; 9: 44-48.
4. Otieno E.S. Prevalence, etiology and types of long bone fractures in children 18yrs and below
Dissertation 2001.
5. Lule J. Pattern of Tibial Shaft fractures and early complications as seen at Mulago Hospital
Complex – Dissertation
61
March/April 2010.
A Comparison of Kampala Trauma Score II with the New Injury Severity Score in
Mbarara University Teaching Hospital in Uganda.
Mutooro S.M, Mutakooha E, Kyamanywa P.
Department of Surgery Mbarara University of Science and Technology, Uganda;
Corresponding to: Patrick Kyamanywa, E-mail: [email protected]
Background: Road traffic injury is of growing public health importance because of its
significant contribution to the global disease burden. The need to predict outcome of injuries
has led to the development of injury scores. The Kampala Trauma Score II (KTSII) now
recommended for use in resource-poor settings, has not been compared with, the New Injury
Severity Score (NISS) preferred by many authors. We compared the performance, predictive
power, sensitivity, and specificity in predicting mortality at two weeks of the KTSII and NISS in
patients involved in road traffic accidents seen on the surgical ward at Mbarara Regional
Referral Hospital (MRRH).
Methods: This prospective study conducted between June 2005 and August 2006, examined
clinical and radiological data of 173 consecutive patients admitted to the emergency surgical
ward at Mbarara Regional Referral Hospital with road traffic injuries. Only patients presenting
within 24 hours of injury and with 3 or more injuries were recruited in the study. The KTS II
and NISS scores were computed for each patient on admission. The primary outcome measure
was survival. Receiver Operating Characteristics (ROC) analysis, and logistic regression
analysis were used for comparison.
Results: The KTSII predicted mortality and discharge with AUC of 0.87 (NISS, AUC 0.89). The
KTSII was less accurate (AUC 0.65) than the NISS (AUC 0.83) in predicting long stay in the
hospital. At cut off point of 9 and below, the KTSII had sensitivity of 87% and specificity of
81% while the NISS had 96% and 78.4% respectively in predicting mortality. The KTS II
predicted long hospital stay at cut off score of 9 and below, with sensitivity of 87.5% and
specificity of 81%.
Conclusions: The KTSII is as reliable a predictive score as is the NISS. This study demonstrated
that the KTS II provides reliable objective criterion upon which injured patients can be triaged
in emergency care conditions. The KTS II may enhance the use of ambulance services and
timely transfer of the injured and its use in trauma management should be further encouraged
in resource-poor settings. In addition, the KTS II will make the documentation of the
epidemiology of trauma more feasible in resource-poor settings.
Introduction
The high rates of road traffic injuries and the complexity of management, focusing on the treatment
and outcome of injuries, brought about the development of injury scores1. Injury scores quantitatively
summarize injury severity and have played a major role in the management of road traffic injuries in
the developed countries due to an improved triage. The improvement in triage has been shown to
contribute to 28% reduction in fatality rates in some centres2.
Injury-scoring systems are either anatomical, physiological or combined anatomical/ physiological
scores. The New Injury Severity Score (NISS) introduced in 1997 is considered by some authors as
the “gold standard” injury severity score3. However, the severity scores used in industrialized
countries are complex and require extensive retrospective review of completed patient records. This
has made such scores difficult to apply in resource poor settings. In 1996, the Injury Control Center –
Uganda (ICCU) developed a new simplified trauma outcome prediction model; the Kampala Trauma
Score I (KTS1). KTS I is a simplified modification of the RTS and ISS scores.4,5 The KTS I has been
promoted for use in resource-poor settings for easy scoring of injury and prediction of outcome in
trauma patients.6 The KTS I was revised in 2002, giving rise to the KTS II. Although KTSII is said to
62
March/April 2010.
be a more simplified injury severity instrument for use by most health cadres it has not been validated
for predicting mortality and need for admission. We set out to compare the KTS II against the NISS as
a measure of injury severity and its ability to predict mortality and need for admission in road traffic
injured patients.
Data was collected at the Emergency unit of the Surgical Department at Mbarara Regional Referral
Hospital that also serves as the main teaching hospital for Mbarara University of Science and
Technology. All patients aged 18 years and older admitted to the Emergency ward between June 2005
and August 2006 with road traffic injury in the preceding 24 hours, were eligible for the study.
Additional inclusion criteria were: Patients who had sustained three major injuries involving any of
the four body organ systems (integument, bone, nerve, and vessel); and patients with three minor
injuries and one major injury involving the above organ systems. Patients referred to the hospital after
initial surgical management, were excluded from the study.
On admission, patients were resuscitated following trauma care protocol until they were
hemodynamically stable. Patients’ demographics, details of the injury, initial clinical assessment and
calculation of KTSII, NISS, were compiled by the same team of staff. The unconscious patients with
no informants were identified as unknown until identified. All patients received the necessary medical
care as per the injury(s) sustained in order to assess the predicted outcome by the two scores in the
second phase. Surgical management was carried out wherever indicated. The second phase involved
active follow-up of the patients for two weeks both on ward and as outpatients. Indications of severity
of injury and complication were a hospital-stay longer than two weeks, requirement for redebridement and death.
All data was entered into the Epi-Info version 3.3.2 statistical packages and exported to Statistical
Package for Social Scientists (SPSS) version 12.0 for analysis. Receiver Operating Characteristics
(ROC) curve for NISS and KTSII as predictors of mortality at two weeks were constructed and the
areas under the curve (AUC) based on non-parametric assumptions were generated for each KTSII
and NISS, and compared (Appendix 1 for KTS II and NISS description). Similarly ROC curves for
prediction of hospitalization at two weeks were constructed. The KTSII was compared to the NISS on
the cohort database using logistic regression. Odds ratio and 95% confidence interval were computed
for each model. The two scores were again compared at 90% sensitivity and 90% specificity for the
performance of the corresponding sensitivity, specificity and a likelihood ratio for a positive test
(LR+). McNemar chi-squared, (X2) test for paired data were used to test for the statistical significance
of the differences.
Results
One hundred seventy three patients were recruited. There were 145 (83%) males, giving a male-tofemale ratio of 5:1. Peasants and students were the most vulnerable of the of road users (22% and 15.6
% respectively) as per occupation. Passengers were the most commonly injured category of road user.
On further analysis, passengers on motor-cycles accounted for 69% of the passengers injured. The
productive age bracket between 18 and 45 years formed the majority of patients seen (80.3%), while
those above 45years of age stayed longer in hospital.
The majority of patients had penetrating injuries (58%) while 41.6% had blunt injuries. Seventy six
percent of the study population sustained fractures. Patients who sustained cuts and bruises were
40.2%. Out of these, 60.4% had cuts and bruises more than 5cm wide, 42.9% underwent debridement
of the wounds, only 8.7% had wound sepsis. Open fractures accounted for 36.3% of the
musculoskeletal injuries seen. Closed fractures and dislocations accounted for 15.9% and 7.6%
respectively. The head and extremities were the most inured body regions (Table 1). Using the NISS
classification, most (84%) of the injured patients were classified as serious, severe or critical (Figure
1) while the KTS II classified most (71.7%) of the injured as moderate (Figure 2). At the end of two
weeks, the outcomes were recorded as died, discharged and still in the hospital. 100 patients (58%)
63
March/April 2010.
were discharged; 24 (14%) run away and an equal number were still admitted at two weeks. 25
patients (14%) had died over the two weeks (Table 2).
Table 1. The Frequency Distribution for Body Region with Serious Injuries
Body
Frequency of injuries (n=270)
region
92
Head
17
Spine
19
Thorax
11
Abdomen
Extremities
131
Percentage
34.1
6.3
7.0
4.1
48.5
Class ification of Injuries using NISS
60
49
50
49
47
NISS
40
28
30
20
10
0
0
1-3(Minor)
4-8(Moderate)
9-15(Serious)
16-24(Severe)
25-75(Critical)
Class
Figure 1. Classification of injuries using NISS
140
124
120
100
No
80
of
60
Pts
40
20
35
14
0
Minor
Moderate
Class
Figure 2. Classification of Injuries Using Kampala Trauma Score II
Severe
March/April 2010.
Prediction of mortality and hospitalization using NISS and KTSII
The majority of the patients who died had NISS of 24 while those who were still hospitalized had
NISS of 16. The KTS II scored such patients as having KTS II of 16 and 14 respectively.
The performance of the two scores were assessed and compared in terms of mortality prediction and
still hospitalized using the ROC. Figure 3 shows a comparison of KTSII and NISS in predicting shortterm mortality. At 95% confidence interval of NISS as 0.852- 0.948, the KTSII has 0.791-0.951, both
with P=000.
Table-2 Frequency of deaths/hospitalization as classified by NISS/KTSII
Death
Hospitalization
Death
Hospitalization
Classification
New Injury Severity Score (NISS)
Minor Moderate Serious Severe
0
0
0
1
0
1
2
5
Kampala Trauma Score II (KTS II)
Mild
Moderate
1
8
14
7
Critical
24
16
Severe
16
3
At the end of two weeks, the outcomes were recorded as died, discharged and still in the hospital. 100
patients (58%) were discharged; 24 (14%) run away and an equal number were still admitted at two
weeks. 25 patients (14%) had died over the two weeks (Table 2).
0.50
0.00
0.25
Sensitivity
0.75
1.00
Prediction of mortality and hospitalization using NISS and KTSII
The majority of the patients who died had NISS of 24 while those who were still hospitalized had
NISS of 16. The KTS II scored such patients as having KTS II of 16 and 14 respectively. nThe
performance of the two scores were assessed and compared in terms of mortality prediction and still
hospitalized using the ROC. Figure 3 shows a comparison of KTSII and NISS in predicting short-term
mortality. At 95% confidence interval of NISS as 0.852- 0.948, the KTSII has 0.791-0.951, both with
P=000.
0.00
0.25
0.50
1-Specificity
NISS ROC area: 0.8997
Ref erence
0.75
KTS11 ROC area: 0.8711
Figure 3. ROC curves comparing the NISS and KTSII in predicting mortality at 2 weeks
65
1.00
March/April 2010.
0
.5
0
0
.0
0
0
.2
5
S
e
n
sitivity
0
.7
5
1
.0
0
0.00
0.25
0.50
1-Specif icity
NISS ROC area: 0.8311
Ref erence
0.75
1.00
KTS11 ROC area: 0.6556
Figure 4. Comparison of NISS and KTSII in predicting hospitalization at 2 Weeks
Table-3. The prediction of NISS and KTSII for short-term mortality
New Injury Severity Score
Mortality
Coefficient
-5.211
Constant
NISS
0.164
P- value
Kampala Trauma Score II
Constantt
4.455
KTS
P-value
-1.063
95% Confidence I
Odds
ratio
Pseudo R2
-6.760- 3.663
.102-.226
1.178
0.304
0.345
0.383.
.000
2.430 - 6.480
-1.428 - 0.700
.000
Prediction of status of hospitalization at two weeks
Figure 4 shows the ROC for the predictive ability of the two scores for the status of hospitalization
(still in the hospital). The ROC area under the curve for NISS (0.831) was compared at 95%
confidence interval of 0.728-0.935, and KTSII (AUC-0.6556), at 95% confidence interval of 0.5110.800, both with P=. 005.
Comparison of predictive power of KTSII and NISS
A two-predictor logistic model was fitted to the data to test the research hypothesis regarding the
relationship between the likelihood that the two scores predict mortality equally. The variable
(mortality) was then fitted in the logistic regression equation and the results are shown in table 3.
The proportion of the variation in the mortality rate that can be explained by NISS was 0.304 while
the KTSII showed a proportion of 0.383 (chi-square 49.7, p-value 0.00). NISS is statistically better
than KTSII in prediction of mortality.
Comparisons of sensitivity and specificity at cut off points for the NISS and KTSII in prediction
of mortality at two weeks.
The sensitivity of NISS and KTSII as predictors of mortality at two-weeks at cut-off points was
compared. At a cut off of NISS 20, the NISS had a sensitivity of 96% and specificity of 78.3%
66
March/April 2010.
(90%CI 4.44-0.05; OR 1.18; p-value 0.000). This is in comparison to 64% sensitivity and 60%
specificity (90%CI 0.064-26.6; OR 0.35, p-value 0.00) for the KTS II at a cutoff score of 9.
Comparison of sensitivity and specificity of NISS and KTSII in predicting stay in hospital at two
weeks at a 90% CI was not statistically significant. The NISS had a sensitivity of 70.8% and
specificity of 87.9% (90%CI 0.204-20.101), compared to a sensitivity of 87.5% and specificity of
69.0% (90% CI 0.950-2.196) for the KTS II.
Discussion
The demographic characteristics of the patients seen in this study and the proportion (37%) of injuries
due to road traffic reflects the huge burden of road traffic injuries in our society. A similar pattern has
been cited in other studies.5,7,8,9. The KTSII classified majority of injuries registered as moderate
injuries while NISS classified them as serious and critical injuries. The difference between these
distributions is due to the fact that KTSII is a combined score while NISS is anatomical score. The
KTSII therefore classified the injuries less accurately than NISS since KTSII has less anatomical
parameters. However NISS classified injuries in MRRH similar to other reported studies while there
was a significant difference in the classification of injuries between MRRH and the hospitals in
Kampala city reported by Kobusingye and Guwatudde8 using KTSI. Among the city Hospitals, Kibuli
had a relatively higher proportion of injuries classified as moderate and severe (11% and 5%
respectively using KTSI). In comparison with MRRH using KTSII, the proportion of moderate and
severely injured patients was 71.7% and 20.2% respectively. The difference is as a result of using
KTSII, a more accurate and specific score than KTSI.
The bony pelvis and/or extremities were the most commonly isolated body region injured 48.5%,
followed by head, 34.1%. In addition, the majority of patients sustained penetrating injuries.
Mugabi10 and Odero7 reported similar findings and attributed it to failure to observe road safety
precautions. Similarly most passengers, drivers and cyclist in this study, did not observe road safety
precautions.
In a study by MacLeod et al4, the highest number of deaths occurred with KTSI <14 while in the
present study, the highest number of deaths occurred with KTSII <6. The difference in the scoring
most likely arose from the upgrading of KTSI where the score for each phrase is reduced from 1-4 to
0-3 as in KTSII.
The outcome at two weeks
The highest percentage of patients who died (44%) as classified by NISS was almost double those
assigned by KTSII (28%). The difference in classifying was statistically significant (p = 0.000) for
NISS at 95% Confidence interval of 0.102-0.226 and -1.428 to -0.700 for KTSII. This difference is
due to the fact that NISS assigns a score depending on the severity of injury(s). Whereas KTSII
assigns a score whether the injury is present as one or not present which does not describe the severity
of injury. The highest percentage of NISS & KTSII for survivors but still in hospital at the end of two
weeks was compared, and KTSII was higher than NISS by 2%. This indicted that KTSII predicts
survivors better than NISS. Neurological compromise continues to be a major underlying factor in
the outcome of injuries and KTSII assesses central nervous system better than NISS. This supports
studies by Mohammed et al11 that physiological scores predict survival better than anatomical scores.
At 95% confidence interval, NISS had 96% sensitivity and 78.4% specificity, in discriminating those
that died, from the survivors while KTSII had 87% sensitivity and 81% specificity to discriminate the
two categories. This indicates that NISS correlates well in prediction of mortality than KTSII. The
observed cut off point in this study was similar to the results obtained by Brennaman et al.12
Considering the 60.5% sensitivity reported previously during the development process of KTSII and
the present study (87.0%), the upgrading of KTSI to KTSII improved the sensitivity of the score.
This improvement in sensitivity followed the assigning of a lower score value to a more severe injury.
67
March/April 2010.
Performance assessment of KTSII and NISS
The ROC shows the ability of the two scores to predict mortality in the study population based on
Area Under the Curves (AUC). The NISS (AUC 0.899) provided the better prediction of hospital
mortality than the KTSII (AUC 0.871). Osler et al13 and Balogh et al14 reported similar findings of
NISS in predicting mortality as the current study. The difference in KTSII performance as compared
to NISS in this study was not statistically significant. The magnitude of the difference in AUC was
marginal; hence KTSII would be used with confidence. The KTSII had limitations in scoring patients
who were intubated and those under the influence of alcohol. KTSII also failed to score multiple
injuries in the same body region. These limitations are identical to findings by Balogh et al14 who had
reported such limitations associated with RTS and ISS, in predicting mortality. While the NISS was
difficult to use at the bedside since it requires AIS dictionary.
The KTSI performed better in predicting mortality than the KTSII in present study. The disagreement
between the two scores as observed by Mugabi10 and may have been due to the fact that such
limitations were not excluded in the present study. The patients were thus underscored by KTS II
accounting to less prediction in mortality. Recent studies have shown that the component of ‘best
motor response’ in physiological/combined scores adds more weight in predicting trauma mortality.
KTSII lacks such components. The study population of 173 respondents included 85 (49%) patients
with head injuries and 35.8% patients who had taken alcohol. The KTSII therefore underestimated
the severity of these two major categories of patients in the study population, leading to a low
predictability of mortality.
Prediction of two weeks Hospitalization
The NISS (AUC_0.831) predicted ‘still in the hospital’ better than KTSII (AUC 0.656) in this study,
the KTSII predicted ‘still in the hospital’ similar to the reported findings in earlier studies.4,5,10 This
indicted that the upgrading of KTSI to KTSII did not add predictive value to “still in the hospital”
patients. The NISS predicted those who were hospitalized as having wound or fracture complications
better than KTS II. This is due to the fact that the KTSII does not take into account the severity of a
particular injury than only mentioning its presence. The KTS II behaves more less a physiological
score similar to its parental score the TRISS, much as it is a combined score.
Predictive power of KTSII and NISS
The separation of the severity score value(s) for survivors versus non-survivors is a rough indication
of the predictive power of the test.15 According to Wilcoxon non-parametric methodology, ROC
judges the discrimination ability of different statistical models. Higher separation of score values for
one test against the other indicates a higher accuracy and its discrimination ability. In this study,
NISS predicted short-term mortality better than KTSII with a small difference, 0.899 and 0.871
respectively. Furthermore, the two scores accurately discriminated between patients to be discharged,
and those still in hospital. The KTSII was observed to have an accurate discriminative ability to
perform both tasks comparable to the gold standard score.
Husum and Strada15 disagreed with findings by Osler et al13 and Brenneman et al12 that NISS
performs slightly less in penetrating injuries while considering missile injuries. The present study
population consisted of both penetrating injuries (58%) and blunt injuries (41.6%), with penetrating
injuries being the majority, where the NISS performed with preference. Commenting on such
disagreement however, needs a pure study population of road traffic penetrating injuries other than
injuries caused by missiles. However, NISS and KTSII performed differently as prediction models
different cut-off values. Where as the NISS almost approached sensitivity of one the KTSII was
closing to a sensitivity of 0.8. This justified the fact that NISS has better performance in predicting
mortality/still in the hospital, as compared to KTSII. However the KTSII was greater than 0.5, hence
its predictive ability is not by chance. The NISS performance was slightly higher than that reported
in an earlier study13. Comparing the predictive power of KTSI and KTSII (present study), the results
indicated that KTSI nearly approached 0.7, where as KTSII approached 0.84. This stresses the
improvement from KTSI to KTSII in prediction ability.
68
March/April 2010.
Comparison of NISS and the KTSII at 90% sensitivity and specificity
The NISS, at cut off point 16 and below was 88% sensitive in identifying those who died and 60% for
those still in the hospital at two weeks, in comparison to 73% and 80% respectively for KTS II.
In general, the two scores were sensitive at detection of mortality among the study population though
KTS II was slightly less than the NISS. This was attributed to the improvement of KTSII, by
assigning a small value to an injury, which corresponds with the severity of injury. This was opposed
to the KTSI that would have assigned a higher value, which would indicate survival in a related
injury. The McNemar value of 0.727 shows a statistically significant difference between the two
scores. The difference is attributed to the fact that the two scores have different in-built anatomical/
physiological properties. Therefore, the two scores cannot be good at predicting mortality, survival
and hospital status at two weeks with the same accuracy. Most scoring systems studied, have such
characteristics of high sensitivity (prediction of mortality) and low specificity (prediction of survival).
Conclusions
The two scores quantitatively summarized injury severity and predicted the outcome though
differently, as survival, death or long stay in the hospital. Furthermore, the KTS II was easier to
compute given the fewer parameters and the simple addition of scores. This therefore will help to
enhance quality medical service delivery to the injured in Mbarara Regional Referral Hospital through
easier triage.
The intensive care unit team will find the KTSII application helpful in providing objective
information for prognostication. The scores especially the KTSII, may enhance appropriate use of
ambulance services and timely transfer of severely injured patients to trauma wards.
The classification and stratification of patients into comparable groups using scoring systems, is
useful in clinical studies of the epidemiology of trauma. The ‘ease’ of the KTSII to predict the
outcome can be used retrospectively to identify and control for differences in baseline injury severity
between patient populations during epidemiological studies. Although developed in an urban hospital
better equipped than MRRH, KTSII performs well as a triage tool on admission in rural set-ups.
Furthermore KTSII performance was comparable to the NISS in this study.
Appendix 1.
NISS Description
AIS
1
Severity level
Minor
Example
Fracture of a finger
2
Moderate
Undisplaced tibial fracture
Perforation of colon
3
Serious
Incomplete transection of the thoracic aorta
4
Severe
Intracerebral bleeding
5
Critical
Penetrating brain stem injury
6
Unsurvivable
NISS = Square of (AIS)
Source: Eur J Trauma (2002; 28:52–63)
69
March/April 2010.
Kampala Trauma Score (KTS II) Description
A
B
C
D
E
Age: Adults-
Yrs. Children < 5 yrs--
Age: 5-55 (1)
Age: <5 or 55 (0)
Systolic Blood Pressure on admission:
More than 89 mm Hg
Between 89-50mm Hg
Equal or below 49mm Hg
Respiratory rate on admission
0-29/minute
30+
< or =9/minutes
Neurological status:
Alert
Responds to verbal stimuli
Responds to painful stimuli
Unresponsive
Score for serious injuries
None
One injury
More than one
(2)
(1)
(0)
(2)
(1)
(0)
(3)
(2)
(1)
(0)
(2)
(1)
(0)
KTS II Total = A+B+C+E
References
1. Baker SP, O’Neill B, Haddon Jr W, Long WB. (1974) The injury severity score: A method
for describing patients with multiple injuries and evaluating emergency care. Journal of
Trauma; 14 (3).187–96.
2. Champion H, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME (1989): A
revision of the Trauma Score. Journal of Trauma 29 (5) 623–9.
3. Balogh ZJ, Varga E, Tomka J, Suveges G, Toth L, Simonka JA(2003) The New Injury
Severity Score Is a Better Predictor of Extended Hospitalization and Intensive Care Unit
Admission Than the Injury Severity Score in Patients With Multiple Orthopaedic Injuries.
Journal of Orthopedic Trauma; 17(7);508-12.
4. MacLeod J.B.A, Kobusingye O, Frost C, Lett R, Kirya F, Schulman C (2003) A Comparison
of the Kampala Trauma Score (KTS) with the Revised Trauma Score (RTS), Injury Severity
Score (ISS) and the TRISS Method in a Ugandan Trauma Registry Is Equal Performance
Achieved with Fewer Resources? European Journal of Trauma 29:392–8
5. Kobusingye O, Lett R (2000): Hospital trauma registries in Uganda. Journal of Trauma; 48.
498–502.
6. Dinesh S, Krug E (2000) WHO-Guidance on surveillance of injuries due to landmines and
unexploded ordnance Report 2000.
7. Odero W (2004) Africa’s epidemic of road traffic injuries: trends, risk factors and strategies
for improvement. Presentation on World Heath day April 2004 Harvard Centre for
Population and Development Studies
8. Kobusingye O, Guwatudde D: Injury patterns in rural and urban Uganda. Injury Prevention
journal 2001; (7) 46-50
9. Kobusingye, O.C., Guwatudde, D. Owor, G., Lett, R. (2002). Citywide trauma experience in
Kampala – Uganda: A call for intervention Injury Prevention 8; 133-136
10. Mugabi Pl (2003) To compare the KTS with PTS in predicting hospital stay and mortality at
two weeks in children. Dissertation handed to the postgraduate school Makerere 2003
11. Mohammed HFS, Vicken YT, Stephanie AT. (1999) Trauma scoring systems explained.
Emergency Medicine;11 (3): 155-166
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March/April 2010.
12. Brenneman FD, Boulonger BR, McLellan BA, Redelmeier DA (1998). Measuring injury
severity: time for a change? Journal of Trauma; Injury, Infection and Critical Care, 44, No.
4, 580-584.
13. Osler T, Baker SP, Long W.(1997) A modification of the injury severity score that both
improves accuracy and simplifies scoring. The Journal of Trauma: Injury, Infection, and
Critical Care. Dec;43(6):922–926.
14. Balogh Z, Offner PJ, Moore EE, Biffl WL. (2000) NISS predicts post injury multiple organ
failure better than the ISS. J Trauma. 48(4):624-7; discussion 627-8.
15. Husum H, Strada G (2002): Injury severity score vs. new injury severity score for
penetrating injuries. Prehosp Disast Med 17(1):27–32.
71
March/April 2010.
A Comparision of Clinical Diagnosis and Knee Arthroscopy Findings at Mulago
Hospital.
I. Kajja, L. Nguku, T.Beyeza
Department of Orthopedics Makerere University College of Health Sciences.
Correspondence to: I. Kajja, Email: [email protected]
Background: Many patients present to the orthopaedic surgeon with complaints of knee pain. In
many such cases making a diagnosis based on clinical examination is often difficulty and frequently
inaccurate. This study sought to document the common findings at knee arthroscopy and how they
compare with clinical impressions.
Methods: A cross-sectional study of 34 patients undergoing diagnostic knee arthroscopy with
undetermined diagnosis was conducted at Mulago Hospital. The preoperative clinical provisional
diagnosis and the findings at arthroscopy were documented, compared and analysed.
Results: The commonest clinical diagnosis was medial meniscal tear (21%), while the most frequent
finding at arthroscopy was osteochondral lesions (27%). The highest correlations between clinical
impressions and arthroscopic findings were in ACL tears and osteoarthritis. The overall accuracy of
clinical examination was 87.2%.
Conclusion: Clinical examination is a useful tool in diagnosing knee pathologies. In Mulago, the
accuracy of the clinical impressions as proved at arthroscopy is high.
Introduction
Up to 28% of patients presenting to orthopaedic surgeon in an outpatient setting complain of
knee pain(1, 2). The causes range from trauma, degenerative joint conditions, infections,
inflammatory conditions to congenital lesions (3). In the diagnosis of the lesion in the knee, the
surgeon has to obtain a thorough clinical history, examine the patient and do investigations as may be
required. Arthroscopy is regarded as the gold standard among the investigative modalities (4-7).
The commonly missed diagnoses in the knee are osteochondral fractures, partial anterior cruciate
ligament (ACL) tears and loose bodies (8). Failure to recognise these has both medical and
socioeconomic complications. The common medical complications include an unstable knee, chronic
knee pain and post traumatic arthritis (9, 10). The socioeconomic complications include loss of
income during the duration of treatment, high cost of medical care for procedures such as total knee
arthroplasties and a perception of general poor health (11).
At Mulago hospital, up to 2% of the patients presenting to the orthopaedic out-patients clinic have
knee pain without a definite clinical diagnosis and require diagnostic arthroscopy to define the
pathology. This study therefore intended to compare the correlation of clinical impressions and
arthroscopic findings and therefore asses the sensitivity of clinical assessment.
Methods
A cross sectional study was conducted at the Mulago Hospital orthopaedic ward between September
2008 and Jan 2009. Thirty four patients were recruited in the study. All the patients were referred by
an orthopaedic surgeon for a diagnostic knee arthroscopy procedure and thereafter the relevant
management. We excluded any patient whose diagnosis was based on another investigative modality
and patients who were suspected to have septic arthritis of the knee(s).
The arthroscopy was performed by one surgeon in all cases. The procedures done under asceptic
condition was performed either under general or spinal anaesthesia and used a A high thigh esmarch
tourniquet.A 30o Aeusculap arthroscope with a 250w Aesculap light source was used. The portals
used were the anterolateral for the arthroscope, anteromedial for the probe and if necessary the
superolateral or superomedial for the probe. The diagnostic procedure was then performed. . The data
collected was analysed using SPSS Ver. 12. The independent t test was used to compare the means of
the male and female populations. The categorical variables were cross tabulated and subjected to the
Fisher’s exact test to ascertain the statistical significance. Results were termed significant if the p
72
March/April 2010.
value was < 0.05. Calculations for sensitivity, specificity, positive predictive value, negative
predictive value, accuracy missed diagnoses and relevant p values were done
done using the following
formulae:
Sensitivity = True Positives x 100 / (True Positives + False Negatives), Specificity = True Negatives x
100 / (True Negatives + False Positives), Positive Predictive Value = True Positives x 100 / (True
Positives + False Positives),
sitives), Negative Predictive Value = True Negatives x 100 / (True Negatives +
False Negatives), Accuracy = (True Positives + False Negatives) x 100 / (True Positives + True
Negatives + False Positives + False Negatives) and Missed diagnoses = False Negat
Negatives x 100 /
(False Negatives + True Positives).
Results
Of the 34 patients recruited, 23 (68%) were male and 11 (32%) were female. The mean (SD) age for
the patients was 38.35 +/-9.43
9.43 years with a range of 8 – 81 years. There was a significant differenc
difference in
the mean ages of the male and the female patients. The mean age for the male patients was 31.52+/
31.52+/2.65 compared to 52.64 +/- 7.23 years for the females (p = 0.016). Most of the patients seen were
professional sportsmen, 12 (35%) having sustained the injuries in the course of playing (Table 1).
The commonest preoperative diagnosis was a medial meniscal tear, while the least common was a
clinical impression of knee pain. However at arthroscopy the
the commonest findings were osteochondral
lesions in 12 (27%)) and osteoarthritis in 6 (13%)
(
(Figure 1). Nine patients had multiple knee
pathologies (Table 2).
Clinical mpressions and Arthroscopy Findings
12
12
10
7
8
6
6
5
4
4
4
5
5
4
3
4
2
6
5
5
2
2
0
Clinical
0
0
Figure 1. Clinical and Arthroscopic Findings
Table 1. Patients' Occupations
Occupation
Businessman
Housewife
Motorcyclist
Office worker
Peasant farmer
Professional sportsman
Student
Frequency
3
6
1
8
1
12
3
Arthroscopic
March/April 2010.
Table 2. Multiple Findings at Arthroscopy
Case No.
1
2
3
4
5
6
7
8
9
Clinical
impression
Medial meniscal
tear
Osteochondral
lesion
Medial meniscal
tear
Lateral meniscal
tear
Medial meniscal
tear
Knee pain
Osteochondral
lesion
ACL tear
ACL tear
Arthroscopic
diagnosis 1
Synovial plica
Arthroscopic diagnosis
2
Chondromalacia
Arthroscopi
c diagnosis 3
-
Osteochondral lesion
Osteoarthritis
-
Synovial plica
-
Advanced synovitis
Medial meniscal tear
Synovial plica
Synovial
plica
-
Advanced synovitis
Synovial plica
Advanced synovitis
-
ACL tear
ACL tear
Medial
meniscal tear
Table 3. True positives, true negatives, false positives and false negatives with reference to
arthroscopic findings.
Test
True Positive
(TP)
True Negative
(TN)
False Positive
(FP)
False Negative
(FN)
1
1
4
4
3
5
0
0
26
29
21
28
28
28
29
29
6
3
1
2
2
0
0
0
1
1
8
0
1
1
5
5
Medial meniscal tear
Lateral meniscal tear
Loose body
ACL Tear
Osteoarthritis
Advanced synovitis
Synovial plicae.
Table 4. Accuracy of Clinical Findings
Diagnosis
Sensitivity
Specificity
Medial
Meniscal
50%
81.3%
Tear
Lateral
Meniscal
50%
90.6%
Tear
Osteochondral
33%
95.5%
Lesion
Loose Bodies
100%
93.3%
ACL Tear
75%
93.3%
Osteoarthritis
83%
100%
Overall
60%
91.95%
P value obtained by the Fisher’s exact test
74
1
PPV
NPV
P
Accuracy
Missed
Diagnoses
0.14
0.037
0.374
79.4%
50%
0.25
0.033
0.225
88.2%
50%
0.8
0.276
0.042
73.5%
67%
0.67
0.6
1
0.56
0.000
0.034
0.034
0.07
0.000
0.006
0.000
94.1%
91.2%
97.1%
87.2%
0%
25%
17%
40%
March/April 2010.
The highest true positive clinical impression based on diagnostic arthroscopy as a gold standard was
osteoarthritis (5 out of 34) while all clinical impressions had high true negatives.(Table 3). The
clinicians’ impressions were most sensitive for looses bodies (100%) and most specific for
osteoarthritis (100%) - (Table 4).
Discussion
The male population is usually at a higher risk of suffering traumatic knee pathologies. This has been
proved by this study and others, both within and outside Africa (12-16). This could be due to the fact
that males are more involved in active sports than females hence the higher risk of injury. The female
patients on the other hand, having lived more sedentary lives tend to gain weight and later present
with degenerative knee conditions. Brooks in 2002 (14) also noted that the were more elderly female
patients than male patients, implying a higher incidence of degenerative knee conditions among
females.
Traumatic lesions comprise the commonest indications for knee arthroscopy. In their series, Terry had
197 of 216 patients, and Brooks 140 of 238 patients with traumatic lesions of the knee (14, 17). In this
study about two thirds of the patients had such lesions. However, up to a third had degenerative knee
lesions. Worldwide, meniscal tears constitute the largest group in the preoperative clinical
impressions (17). The anatomical position of the menisci is between two hard structures, the femoral
and the tibial condyles. This predisposes them to degenerative and traumatic injuries. The medial
meniscus is less mobile as compared to the lateral meniscus due to its attachment to the medial
collateral ligament, predisposing it more to injury.
Three study patients did not have defined clinical impressions other than knee pain. Making a definite
clinical impression is not easy especially in the presence of rare or multiple pathologies in the knee
(8). At arthroscopy one was found to have a normal knee. In the remaining two patients, one had
relatively rare multiple pathologies (advanced synovitis and a pathological synovial plica). Accuracy
of clinical diagnosis has been suggested to be lower in multiple pathologies (8). The third was a
lateral meniscal tear in a 30 year old housewife with no clear history of trauma, a factor that may have
contributed to the physician’s inability to diagnose the lesion.
While in other studies the commonest finding at knee arthroscopy is a meniscal tear (12, 14-17), in
this study it was an osteochondral lesion. Mulla in Zambia found meniscal injuries to be the
commonest arthroscopic finding (34%). He had no report of any osteochondral injuries (15). In his
study of 1000 patients, Hjelle in Norway had a 57% prevalence of meniscal injuries and only 15% of
his patients had osteochondral injuries (16). Terry in the US, in a study of 216 patients, had a 71%
prevalence of meniscal injuries at arthroscopy. Osteochondral injuries were only seen in 1% of his
patients (17). The discrepancy in the findings could be due to a larger sporting population in the cited
countries. In this study’s sample, only about a third of our patients were involved in sports. The rest of
the patients could have contributed in skewing the results in favour of non-sporting pathologies.
In the criteria of this study, any patient who was suspected to have sepsis or a septic arthritis was
excluded. At arthroscopy, one patient was found to have a resolving septic arthritis. This had not been
suspected by the referring physician and the patient had been referred with a diagnosis of a medial
meniscal tear. In the resolution stage of septic arthritis, the acute features of fever, knee pain, swelling
and warmth are usually missing. Within the knee, there may also be arthrofibrotic changes. These
factors could have made it more difficult for the physician to make the correct clinical impression.
Correlation of clinical impressions and arthroscopic diagnosis
Many studies have been done with the aim of assessing the accuracy or reliability of clinical
examination in diagnosis of knee derangements. Some have been for general knee conditions (8, 14,
17-22) and some for specific lesions (12, 13, 23, 24). The accuracy of clinical diagnosis in these
studies ranges from 21-83%. The overall accuracy of 87.2% rates higher than O’Shea’s figure of 83%,
the highest noted accuracy (22). O’Shea’s study was conducted at a US army hospital and a total of
75
March/April 2010.
156 patients were seen. The high clinical accuracy obtained may have been primarily due to the
inclusion of radiological findings in arriving at a primary clinical impression. The high accuracy in
this study, however, may be due to the large number of easily diagnosed conditions of the knee that
were seen. Up to a third of the conditions seen were relatively easy to diagnose by clinical assessment,
namely: osteoarthritis, loose bodies and ACL tears.
Most of the missed diagnoses were due to osteochondral lesions. This is similar to the findings of
Yoon (8). Loose bodies and osteoarthritis, being rather easy to diagnose were less frequently missed.
Of the eight misdiagnosed osteochondral lesions, four were diagnosed as medial meniscal tears, two
as lateral meniscal tears and two as ACL tears, a pattern similar to that seen by Terry (17). In his
study, all the six osteochondral lesions were missed: four patients were misdiagnosed as medial
meniscal tears and two as lateral meniscal tears.
The one misdiagnosed medial meniscal tear had been thought to be an ACL tear while the
misdiagnosed lateral meniscal tear had been diagnosed just as knee pain. The one case of
osteoarthritis that was missed on clinical examination had been diagnosed as a loose body in a 59 year
old ex footballer. All the patients with loose bodies were correctly diagnosed by clinical examination.
There were nine knees with multiple pathologies. In one of the nine, the referring physician made a
correct diagnosis of two co-existing pathologies that were confirmed at arthroscopy. In four of the
nine, the physicians made a correct diagnosis of one of the pathologies affecting the knee. In the
remaining four of the nine knees the physicians missed the diagnoses. This proves what both Esmaili
and Yoon have reported in their papers, that clinical accuracy decreases with an increased number of
knee pathologies(8, 12). Patients with multiple knee pathologies will have an atypical clinical
presentation making it difficult for the physician to arrive at a diagnosis. Furthermore the presence of
multiple lesions in the knee makes eliciting signs specific to any one condition more difficult resulting
in missed diagnoses.
Conclusions
Clinical examination is a useful tool in diagnosing knee pathologies. In Mulago, the accuracy of
clinical examination for knee pathologies among the referring physicians is high. There are however a
significant proportion of knee pathologies that are missed by clinical examination hence the need to
strengthen training of medical personnel in diagnosis of knee derangements so as to reduce the missed
diagnoses.
References
1. McAlindon TE. The Knee. Best Practice & Research Clinical Rheumatology 1999;
13(2):329-44.
2. Peat G, McCarney R, Croft P. Knee pain and osteoarthritis in older adults: a review of
community burden and current use of primary health care. Ann Rheum Dis 2001; 60:91-7.
3. Calmbach WL, Hutchens M. Evaluation of Patients Presenting with Knee Pain: Part II.
Differential Diagnosis. American Family Physician2003;68(5):917-22.
4. Crawford R, Walley G, Bridgman S, Maffulli N. Magnetic resonance imaging versus
arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL
tears: A Systematic review. London: British Medical Bulletin 2007.
5. Kim S-J, Shin S-J, Koo T-Y. Arch type pathologic suprapatellar plica Arthroscopy: The
Journal of Arthroscopic and Related Surgery 2001;17(5):536-8.
6. Coumas JM, Palmer WE. Knee arthrography. Evolution and current status. Radiologic Clinics
of North America 1998;36(4):703-28.
7. Khan Z, Faruqui Z, Oguynbiyi O, Rosset G, Iqbal J. Ultrasound assessment of internal
derangement of the knee. Acta Orthopaedics Belgium 2006;72:72-6.
8. Yoon YS, Rah JH, Park HJ. A prospective study of the accuracy of clinical examination
evaluated by arthroscopy of the knee. International Orthopaedics 2004;21:223-7.
9. McDaniel W, Dameron T. Untreated ruptures of the anterior cruciate ligament. A follow-up
study. J Bone Joint Surg Am 1980;62(5):696-705.
76
March/April 2010.
10. Jomha NM, Borton DC, Clingeleffer AJ, Pinczewski LA. Long-term osteoarthritic changes in
anterior cruciate ligament reconstructed knees. Clin Orthop 1999;358:188-93.
11. Oreilly S C, Muir K R, Doherty M. Knee pain and Disability in the Nottingham Community:
Association with poor health status andPsychological Distress. British Journal of
Rheumatology 1998;37:870-3.
12. Esmaili AA, Keihani S, Zarei R, Moghaddam AK. Accuracy of MRI in comparison with
clinical and arthroscopic findings in ligamentous and meniscal injuries of the knee. Acta
Orthop Belg 2005;71:189-96.
13. Mohan BR, Gosal HS. Reliability of clinical diagnosis in meniscal tears. International
Orthopaedics (SICOT) 2007;31:57-60.
14. Brooks S, Morgan M. Accuracy of clinical diagnosis in knee arthroscopy. Annals of the
Royal College of Surgeons England 2002;84:265-8.
15. Yakub M. Arthroscopy in Lusaka. Lusaka, Zambia: Surgical Society of Zambia2005
[accessed 2008 30th June]; Available from: www.surgicalsocietyzambia.org.zm
16. Hjelle K, Solheim E, Strand T, Muri R, Brittberg M. Articular Cartilage Defects in 1,000
Knee Arthroscopies. Arthroscopy: The Journal of Arthroscopic and Related Surgery
2002;18(7):730-4.
17. Terry GC, Tagert BE, Young MJ. Reliability of the clinical assessment in predicting the cause
of internal derangements of the knee. Arthroscopy 1995;11:568-76.
18. Stanitski CL. Correlation of Arthroscopic and Clinical Examinations With Magnetic
Resonance Imaging Findings of Injured Knees in Children and Adolescents. Am J Sports
Med 1998;26(1).
19. DeHaven KE, Collins HR. Diagnosis of internal derangements of the knee. J Bone Joint Surg
[Br] 1975;57A:802-10.
20. Johnson LL. Impact of Diagnostic Arthroscopy On the clinical judgement of an experienced
arthroscopist. Journal of Clinical orthopaedics 1982;167:75-83.
21. Oberlander MA, Shalvoy RM, Hughston JC. The accuracy of the clinical examination
documented by arthroscopy. Am J Sports Med 1993;21:773-8.
22. O'Shea KJ, Murphy KP, Heekin RD, Herzwurm PJ. The diagnostic accuracy of history,
physical examination, and radiographs in the evaluation of traumatic knee disorders. Am J
Sports Med 1996;24:164-7.
23. M Schurz, Erdoes JT, Platzer P, Petras N, Hausmann JT, Vecsei V. Value of Clinical
Examinatin and MRI Vs Intraoperative Findings in the Diagnosis of Meniscal Tears. Scripta
Medica (BRNO) 2008; 81(1):3-12.
24. Chang SCF, Fang D. Arthroscopic correlation of clinical diagnosis of meniscal injuries using
the McMurray Test. J Hong Kong Med Assoc 1994;46(3):187-9.
77
March/April 2010.
HIV Infection among Orthopedic In-patients at Dil Chora Referral Hospital, Ethiopia.
M. Dessie
Dil Chora Referral Hospital, Dire Dawa, Eastern Ethiopia. E-Mail: [email protected]
Back ground: In Health care centers receiving HIV positive patients the risk of occupational
exposure is of special concern to Health Care Workers (HCW’s). Exposure to infected blood
and body fluids due to needle stick injuries present greatest over all risk to medical personnel
although in surgery ‘Cuts’ during operations are additional hazard. The objective of the study
was to determine the Incidence of HIV infection among patients admitted to orthopedic ward in
Dil chora referral Hospital.
Methods: Between may 2007 and May 2009, and After pre test counseling the incidence of HIV
infection was determined For all patients admitted to our orthopedic ward using ‘Rapid tests’
as out-lined by Ethiopian Nutrition and Health Research Institute(ENHRI) guide lines. The
patients were again counseled before being given their test results. All the data was recorded by
the sole Author.
Results: A total of 731,525 male (72%), 206 Females (28%) were admitted during the two year
study period. Out of these 28 patients (3.8%) were found to be infected by HIV; 17 (2.3%) were
males, and 11 (1.5%) were females and the majority(96%) were between the age of 15-54 Years.
The reason for admission among the HIV positive patients were Trauma in 20(71%), infections
in 6 (21%) and other diagnosis of musculoskeletal disorders in 2(7%).Non-operative treatment
was given for 16 (57%) and operative treatment for 12 (43%) of the HIV infected patients.
Conclusion: Implementation of universal Safety precautions (USP) for prevention of nosocomial
infection is recommended.
Introduction
The overall incidence of HIV in Ethiopia was estimated in 2006 to be 3.5%; 3% in males and 4% in
females1. In health care centers receiving HIV positive patients the risk of occupational exposure is of
special concern to Health Care Workers( HCW’s). Exposure to infected blood and body fluids due to
needle stick injuries present the single greatest risk to medical personnel 2,3 although in Surgery ’Cuts’
during operations are even an additional hazard 2. The risk of HIV infection after a single
percutaneous exposure was recorded as 0.42% by CDC study and by Ippolito et al. and in the CDC
study 2,4,7 .The injuries in this study occurred in the patient’s ward(46.8%), the ICU and dialysis
unit(17.7%), the theaters(15.6%) and the Accident and emergency department(13.8%) 5.
Between may 2007 and May 2009, and After pre test counseling the incidence of HIV infection was
determined For all patients admitted to our orthopedic ward using ‘Rapid tests’ as out-lined by
Ethiopian Nutrition and Health Research Institute(ENHRI) guide lines. The patients were again
counseled before being given their test results. All the data was recorded by the sole Author.
Results
A total of 731,525 male (72%), 206 Females (28%) were admitted during the two year period. Out of
these 28 patients (3.8%) were found to be infected by HIV (17 males 2.3%,11 Females 1.5%)(Table
1) and the majority(96%) were between the age of 15-54 Years(Table2). The reason for admission
among the HIV positive patients were Trauma in 20(71%), Infections in 6(21%) and other diagnosis
of musculoskeletal disorders in 2(7%)(Table 3).Non Operative treatment was given for 16(57%) and
Operative treatment for 12(43%) of the HIV infected patients(Table 4).
78
March/April 2010.
Table 1. Total Number of Admissions to Orthopedic Ward by Gender and HIV Test Results.
Gender
Male
Female
HIV Test results
Positive
Negative
17(2.3%)
508(69.5%)
11(1.5%)
Total
525(71.8%)
206(28.2%)
Total
28(3.8%)
195(26.7%)
703(96.2%)
731(100%)
Table 2. Total Number of Admission to Orthopedic Ward by Age and HIV Test Results
Age in years
Age
0-4
5-14
15-24
25-34
35-44
45-54
55-64
65-74
75-84
> 84
Total
HIV test Result
Negative
13(1.8%)
91(12.5%)
2(0.3%)
149(20.4%)
6(0.7%)
206(28.2%)
15(2.0%)
123(16.8%)
4(0.6%)
61(8.3%)
1(0.2%)
32(4.4%)
12(1.6%)
11(1.5%)
5(0.7%)
28(3.8%)
703(96.2%)
Positive
Total
Total
13(1.8%)
91(12.5%)
151(20.7%)
212(28.9%)
138(18.8%)
65(8.9%)
33(4.6%)
12(1.6%)
11(1.5%)
5(0.7%)
731(100%)
Table 3. Total Number of Admissions to Orthopedic Ward by Diagnosis and HIV Test Results
Diagnosis
All traumas
All infections
All other diagnoses
Total
HIV test Results
Positive
Negative
20(71.4%)
548(78.0%)
6(21.4%)
54(7.7%)
2(7.2%)
101(14.3%)
28(100%)
703(100%)
Total
568(77.7%)
60(8.2%)
103(14.1%)
731(100%)
Table 4. Total Number of Orthopedic Admission by Types of Treatment and HIV Test Results
Types of treatment
Non Operative
Operative
Total
HIV test Results
Positive
Negative
16(57.1%)
536(76.2%)
12(42.9%)
167(23.8%)
28(100%)
703(100)
Total
552(75.5%)
179(24.5%)
731(100%)
Discussion
This audit has shown that the incidence of HIV infection in our orthopedic ward was 3.8% and this
finding is not significantly higher than the 2006 estimate of 3.5% for the whole of Ethiopia1. It is also
evident that with 43% of our HIV patients requiring surgical intervention there must be a significant
risk of occupational exposure in our day to day orthopedic surgical practice be it in patient’s ward,
ICU, theaters or the accident and emergency department. However Proper use of the recommended
universal precautions(USP) for prevention of nosocomial Hospital acquired infections namely hand
79
March/April 2010.
washing, use of protective barriers ( Gloves, gowns, mask etc.), proper disinfection and sterilization,
proper disposal of sharps and other infectious materials and post exposure drug prophylaxis will
reduce the risk of occupational exposure to HIV for all Health Care Workers( HCW’s )2,6.
Conclusion
Appreciation of the magnitude of HIV infection in orthopedic and other surgical practice alerts Heath
care workers more about risk of occupational exposure and encourages the use universal
precautions(USP) for prevention of nosocomial Hospital acquired infections including HIV.
Acknowledgment
I
would like to express my thanks to Professor Geoffrey Walker FRCS for his help in the preparation of
this manuscript.
Reference
1. Aids in Ethiopa Sixth Sixth Report Federal Ministry of Health, national HIV/AIDS
prevention and control office, 2006,pp13-26.
2. Role M,Mathur M,Turbakar D. Risk of needle stick injuries in health care workers – A
report. Indian J med microbial 2002;20:206-207.
3. Kelen GD,Fritz SF,Qaqish B,et al.Un recognized HIV infection in emergency department
patients.N Engl J Med 1998;38:1645-1650.
4. Philippa E, Giuseppe I. Prophylaxis after occupational exposure to HIV.BMJ
1997;315(9):557-558
5. Hassan Ahmed Abu-Gad, Khalid Abdurahman Al-Turks. Some epidemiological aspects of
Needle stick injuries among Health care workers, European Journal of Epidemiology,
Vol.17,No.5(2001),pp401-407.
6. Infection prevention guidelines for health facilities in Ethiopia, Ministry of health, February
2005,pp1-32.
7. Harrison’s
principles
of
internal
medicine,16th
Edition,2005,pp1081-1082
80
March/April 2010.
Tracheostomy Decannulation: Suprastomal Granulation Tissue in Perspective
Fasunla JA, Aliyu A, Nwaorgu OGB, Ijaduola GTA
Department of Otorhinolaryngology, University College Hospital, Ibadan. Nigeria
Correspondence to: Dr. J.A. Fasunla, E-mail:[email protected], [email protected]
Background: Suprastomal granulation tissue is a complication of tracheostomy which may
make decannulation difficult and presents a therapeutic challenge to the
Otorhinolaryngologists. The aims of this study therefore were to evaluate tracheostomy in black
African population, determine the prevalence of suprastomal granulation tissue and provide
updated information on it that will enable the otorhinolaryngologists to better understand and
manage the lesion.
Methods: We reviewed case files of patients who had tracheostomy between 1993 and 2007 at
University College Hospital, Ibadan, Nigeria for essential clinical data.
Results: Of the 256 patients who had tracheostomy, 133(51.95%) had prior orotracheal
intubation for 10 – 21days. Suprastomal granulation tissue complicated 16 (6.25%) cases, this
accounted for 88.89% of cases of failed decannulation. Indications for tracheostomy in these
patients included severe head injury in 12 (75%), tetanus in 3 (18.75%)] and intubation
granuloma in 1(6.25%) of these cases. Sixteen (4.3%) cases had stomal infection.
Conclusion: This study showed that the prevalence of suprastomal granulation is high among
our patients. There is a need for good surgical tracheostomy technique to prevent this
complication and stomal infection should be promptly treated while cuffed orotracheal
intubation for more than two weeks in unconscious and tetanus patients should be avoided.
Introduction
Tracheostomy is a life-saving surgical procedure which is indicated, more often, in relieving upper
airway obstruction1. Other indications include mechanical ventilatory support especially in critically
ill patients, tracheobronchial toileting and protection of lower respiratory tract from secretions during
some head and neck surgical procedures or in a patient with risk of aspiration1,2. Although the
increased use of tracheostomy has prevented many deaths from diseases which formally were
inevitably fatal, it is not without challenges of complications. Suprastomal granulation tissue is a
significant complication of tracheostomy1. It is an exophytic growth of granulation tissue at the
tracheostome. It narrows the tracheal airway lumen, leading to recurrent pulmonary morbidity and
difficulties with decannulation2. In the long term, an excessive or circumferential suprastomal
granulation tissue may result in tracheal stenosis3. Although patients wearing tracheostomy tube
desire decannulation at the earliest possible time, obstructive suprastomal granulation tissue will make
this unsuccessful. This usually presents a therapeutic challenge, not only to the managing surgeons
but also, to the patients wearing the tracheostomy. There is however paucity of literature on
suprastomal granulation tissue as a late complication of tracheostomy among the black Africans,
despite their innate tendency to develop exuberant granulation tissue4. This study therefore aimed to
evaluate tracheostomy in black Africans, observe the pattern of indications and associated
complications, determine the prevalence of suprastomal granulation tissue and provide updated
information that will enable otorhinolaryngologists to manage tracheostomy better and prevent
complications.
This was a 15-year retrospective review of cases of tracheostomy managed in University College
Hospital, Ibadan, Nigeria between 1993 and 2007. The data collected from the medical records
included demographic data, indications for tracheostomy, duration of tracheostomy, history of prior
intubation, duration of orotracheal or nasotracheal intubation, frequency of tracheostomy tube
changes, complications of tracheostomy, and antimicrobial usage. The results were presented in tables
and simple descriptive forms. The statistical analysis was performed using statistical package for
social sciences version 11.
81
March/April 2010.
Results
Two hundred and fifty six cases of tracheostomy were reviewed. There were 192(75%) males and
64(25%) females with a sex ratio (M: F) of 3: 1. The ages ranged from 2 to 68 years with a median
and mean age of 36 and 43.2years respectively. The indications for tracheostomy are shown in Table
1. Of the 256 patients, 141(55.08%) had elective tracheostomy while 115(44.92%) had emergency
tracheostomy (within 24 hours of presentation to the hospital). Of the 74 patients with laryngeal
tumours, 65 (87.84%) were malignant tumours while the remaining 9 (12.16%) were benign tumours.
Only the malignant cases had permanent tracheostomy as part of the treatment for their oncologic
lesions.
Of the 191 patients who had temporary traditional surgical open tracheostomy, 133 (69.63%) patients
had prior orotracheal intubation for a period of 10 – 21 days before tracheostomy was performed. The
remaining 58 (30.37%) had orotracheal intubation for less than 10 days or no prior oro- or nasotracheal intubation. The duration of temporary tracheostomy ranged from 2 weeks to 4years in all the
cases. Cuffed portex (polyvinyl chloride) tracheostomy tube was used initially for all the patients and
214 (83.60%) patients had their tube changed from cuffed to plain portex tracheostomy tube (with
inner tube) within 48hours post surgery.
Table 1. Indications for tracheostomy
Indications for tracheostomy
Pathology
Relieve
upper
airway Laryngeal tumours
Retropharyngeal abscess
obstruction
Bilateral vocal fold paralysis
Blunt neck trauma
Intubation granuloma
Corrosive laryngitis
Frequency
74
3
3
4
1
1
Percentage
28.91
1.17
1.17
1.56
0.39
1.17
Mechanical ventilator support/
Tracheobronchial toileting
Severe head injury
Tetanus
Guillain Barrẽ syndrome
Difficult intubation
99
28
3
11
38.67
10.94
1.17
4.30
Protection of lower airway
Foreign body aspiration
Cut throat
24
5
9.38
1.95
256
100.00
Total
Table 2. Complications of tracheostomy
Complications
Frequency
Percentage (%)
Suprastomal granulation tissue
Tracheal stenosis
Dependence
Stomal infection
Impacted tracheostomy tube
14
2
2
11
1
5.47
0.78
0.78
4.30
0.39
Total
30/256
11.72/100
82
Number of patients with suprastomal granulation tissue
March/April 2010.
6
5
4
3
2
1
0
12
13
14
15
17
18
20
Duration of orotracheal intubation in days before tracheostomy
Figure 1: Duration of Orotracheal intubation before tracheostomy in the patients with
suprastomal granulation tissue.
Figure 2. Lateral soft tissue neck x-ray showing the shadow of tracheostomy tube in-situ and
suprastomalsoft tissue [Granulation tissue (arrowed)] with narrowing of the tracheal air column.
One hundred and sixty-two (63.28%) patients had their plain tube replaced or changed to a new one
within two weeks of insertion. Three (1.17%) patients had premorbid history suggestive of gastritis.
All the patients had prophylactic antibiotics post-operatively. Eighteen (7.03%) patients had difficult
decannulation and this accounted for 60% of the complications. The complications observed are as
shown in Table 2.
Suprastomal granulation tissue was found in 14 (5.47%) patients and this accounted for 77.78% of
cases of failed decannulation. All these patients had prior orotracheal intubations for 12 – 20days
(Figure 1). The indication for tracheostomy in these patients with suprastomal granulation tissue were
Severe head injury [12(85.72%)] and Tetanus [2(14.28%)]. Surgical decannulation was performed
successfully in these patients. Difficult decannulation was also experienced in two patients with
tracheal stenosis. Eleven (4.30%) patients had stomal infection and microbiological cultures from
their tracheal swabs grew Staphylococcus aureus in 2(18.18%), Pseudomonas aeruginosa in
3(27.27%), Klebsiella spp in 1(9.09%), mixed organisms in 5 (45.45%) cases [Klebsilla spp and
83
March/April 2010.
Staphylococcus aureus in 2(18.18%) and Staphylococcus aureus and Pseudomonas aeruginosa in 3
(27.27%)].
Discussion
Tracheostomy is not psychosocially acceptable to patients because of the difficulty with phonation
and the stigma associated with it by some uninformed people. Therefore, most patients with
tracheostomy desire decannulation before being discharge into the community from the hospital. This
decannulation process may sometimes be difficult especially in patients who had developed
complication like suprastomal granulation tissue. Suprastomal granulation tissue is a late
complication of tracheostomy that requires both preventive measures and surgical therapeutic
methods for its successful management. Before a patient is considered for decannulation, it must be
clinically and radiologically established that the concomitant airway lesion or the indication for which
the tracheostomy was performed is no longer present. This should be followed by tracheostomy tube
downsizing and then capping after 24hours if downsizing is tolerated. If the patient can maintain
adequate ventilation over a 12 to 24 hours period with the tube capped, complete removal of the
tracheostomy tube from the trachea is carried out and the stoma dressed with sterile gauze or stomal
edges sutured together to achieve immediate closure5,6. This procedure may not be tolerated in a
patient with obstructive suprastomal granulation tissue.
The degree of granulation tissue formed during the process of wound healing varies from one
individual to another. Formation of exuberant granulation tissue is due to an aberrant prolongation of
the phase of granulation tissue formation in wound healing7. Factors such as foreign bodies, casts,
chronic inflammation, wound location and motion, tissue involved, breed and repeated iatrogenic
trauma have been implicated7. Polednak mentioned in his work that the blacks are more susceptible to
form exuberant granulation tissue during wound healing4. Unfortunately, this study has no data to
support and substantiate racial predisposition to formation of suprastomal granulation tissue. A
comparative, prospective study of the black Africans and non-African subjects on suprastomal
granulation tissue is however desirable.
Fourteen (7.33%) of the 191 patients who had temporary tracheostomy developed suprastomal
granulation tissue and this caused difficult decannulation. The indications for the tracheostomy in
these patients were severe head injury [12(85.72%)] and tetanus [2(14.28%)]. The male
preponderance with severe head injury may be due to the fact that males are more involved in risky,
outdoor jobs and activities which make them usually more susceptible to injuries. All these patients
with complication of obstructive suprastomal granulation tissue had prior intubation with polyvinyl
chloride cuffed orotracheal tube for 12 – 20 days in the intensive care unit of our hospital before
tracheostomy. There is a significant correlation between the duration of prior orotrachael intubation
and suprastomal granulation tissue formation (p < 0.05%, p=0.000). Having orotracheal tube insitu for
more than 2 weeks has been identified and implicated as a predisposing factor to tracheal stenosis,
suprastomal and infrastomal granulation tissue formation8,9. The use of an appropriate size
endotracheal tube will reduce the risk of developing any of these complications. Also, rough
intubation by an inexperience anaesthetist or use of an inappropriately large size cuffed tube could
cause a tear of the laryngotracheal mucosa. This may heal with polyp or exuberant granulation tissue
if the mucosa overlying the cricoid cartilage was involved3,8-10. Tube granuloma is developed. The
granulation tissue may then project into the laryngotracheal lumen and narrow the airway. When
tracheostomy is in-situ, this will be unnoticed until during decanulation process which becomes
difficult.
An unconscious, critically ill orally-intubated patient may bite on or chew the tube during recovery
thereby rubbing it on the mucosa. This may cause a tear of the mucosa, with resultant polyp or
granulation tissue formation. A patient with severe tetanus may also have similar presentation during
uncontrolled spasm. None of the patients who had prior nasotracheal intubation developed
suprastomal granulation tissue or tracheal stenosis. When pre-tracheostomy intubation is desirable, we
recommend naso-tracheal intubation with appropriate size tube especially in patients with severe head
injury or severe tetanus not on muscle relaxants. The incidence of tetanus in the community however
84
March/April 2010.
could be reduced by having a working policy of antitetanus immunization according to World Health
Organization. Mechanical irritation and laryngopharyngeal reflux have been documented as critical
factors in formation of suprastomal granulation tissue, subglottic and tracheal stenosis11,12.
Polymicrobial colonization of laryngotracheal stents and tracheostomy tube by microorganisms such
as Streptococci viridians, Streptococcus pneumonia, Klebsiella pneumonia, Neisseria species,
Haemophilus influenza, Pseudomonas aeruginosa, Staphylococcus aureus etc have been reported.
These organisms have been implicated in causing infection and inflammation around the tube, thereby
promoting excess granulation tissue formation2,13-16. The organisms and /or their toxins continually
irritate the wound leading to delayed wound healing. Three (18.75%) of the patients with severe head
injuries who developed obstructive suprastomal granulation tissue had associated stomal infection.
The organisms cultured from the tracheal swabs of these patients were similar to what had been
previously reported. Although tracheostomy supposes to be a clean wound, we recommend that the
stoma of the patients should still be routinely examined for evidence of infection. If this is present,
early treatment with the appropriate antibiotic will reduce the risk of granulation tissue formation. The
patient’s tracheostomy tube and tracheostomy dressings should be changed as frequently as required.
Yaremchuk reported that if the tracheostomy tube is changed every two weeks, suprastomal
granulation tissue formation may be prevented17. Tracheostomy tubes are expensive and also, not
readily available in our community hence our patients cannot afford to have their tubes changed or
replaced as frequently as he has recommended. This may be the reason while some of our patients
developed suprastomal granulation tissue readily.
Although only 3 (1.17%) of these patients had history suggestive of gastritis, none of them developed
suprastomal granulation tissue. Gastroesophageal reflux has been reported has an important factor in
the development of subglottic stenosis and hence, suprastomal granulation tissue10. The use of
prophylactic proton pump inhibitor in all patients that had endotracheal intubation or tracheostomy for
severe head injury and/ or tetanus for more than ten days will be an important part of their
management protocol. Good surgical techniques which avoid the cricoid cartilage will minimize the
risk of suprastomal granulation tissue formation18.
The management modality of an obstructive suprastomal granulation tissue begins with investigation
to confirm the presence of the lesion. In our centre, lateral soft tissue neck X-ray is usually done and
the presence of a suprastomal soft tissue shadow which narrows the laryngotracheal air column is
suggestive (Figure 2). Thereafter, Flexible, optical direct laryngoscopy is performed to assess the
suprastomal airway and confirm the presence of granulation tissue, its location and extent. Obstructive
suprastomal granulation tissue requires operative intervention for its removal in order to re-establish a
patent tracheal airway and successful decannulation. Various methods or techniques have been used.
These include microlaryngoscopy and translaryngeal laser excision19, translaryngeal forceps excision
or mechanical debulking, electrocautery, cryotherapy and trans-stomal endoscopically - guided
excision with rongeurs4. The microdebrider, which is a powered rotary dissection device with suction
assistance, is also effective in the removal of suprastomal granulation tissue20,21. In our centre,
debulking of the obstructive suprastomal granulation tissue is performed during microlaryngoscopy
by using trans-laryngeal forceps and electrocautery. The excision of the tracheostomy tract with any
granuloma is also performed. There is no facility for laser excision or microdebrider in our centre. In
cases of recurrence after excision, the patient would have the trachea splinted with an indwelling
nasotracheal stent for 3 - 7 days after a repeated excision. This surgical decannulation protocol is
similar to the practice reported by Al-Saati et al in children22. The stoma edges can be freshened and
sutured together after the removal of tracheostomy tube in order to achieve secondary closure.
Adjunct steroid therapy is also given. There were 3 patients that developed subglottic stenosis and
could not be decannulated using this treatment method.
Conclusion
85
March/April 2010.
Suprastomal granulation tissue is a notable complication of tracheostomy but can be prevented with
good surgical technique, sparing the cricoid cartilage during dissection. Stomal infection should be
promptly treated and cuffed orotracheal intubation for more than a week in unconscious and tetanus
patients should be avoided.
References
1. McClelland RM. Complications of Tracheostomy. Brit Med J. 1965; 2: 567 – 569.
2. Merritt RM, Bent JP, Smith RJ. Suprastomal Granulation Tissue and Pediatric Tracheostomy
Decannulation. Laryngoscope. 1997; 107: 868 – 871.
3. Benjamin B, Kertesz T. Obstructive suprastomal granulation tissue following percutaneous
tracheostomy. Anaesth Intensive Care. 1999; 27: 596 – 600.
4. Polednak AP. Connective tissue responses in blacks in relation to disease: Further
observations. Am J Phys Anthropol. 2005; 74: 357 – 371.
5. Gray RF, Todd NW, Jacobs IN. Tracheostomy decannulation in children: approaches and
techniques. Laryngoscope 1998; 108: 8 – 12.
6. Christopher KL. Tracheostomy decannulation. Respir Care 2005; 50: 538 – 541.
7. Wilmink JM, Van Weeren PR. Treatment of exuberant granulation tissue. Clinical
Techniques in Equine Practice, 2004; 3: 141 – 147.
8. Arola MK, Inberg MV, Puhakka H. Tracheal stenosis after tracheostomy and after orotracheal
cuffed intubation. Acta Chir Scand. 1981; 147: 183 – 192.
9. Terashima H, Sakurai T, Takahashi S, et al. Postintubation tracheal stenosis; problems
associated with choice of management. Kyobu Geka. 2002; 55: 837 – 842.
10. Prescott CA. Peristomal complications of pediatric tracheostomy. Int J Pediatr
Otorhinolaryngol. 1992; 23: 141 – 149.
11. Halstead LA. Gastroesophageal reflux: A critical factor in pediatric subglottic stenosis.
Otolaryngol Head Neck Surg. 1999; 120: 683 – 688.
12. Schmal F, Fegeler W, Terpe HJ, et al. Bacteria and granulation tissue associated with
Montgomery T – tubes. Laryngoscope. 2003; 113: 1394 – 1400.
13. Simoni P, Wiatrak BJ. Microbiology of stents in laryngotracheal reconstruction.
Laryngoscope. 2004; 114: 364 – 367.
14. Reza Nouraei SA, Petrou MA, Randhawa PS, et al. Bacterial Colonization of Airway Stents.
Arch Otolaryngol Head Neck Surg. 2006; 132: 1086 – 1090.
15. Noppen M, Pierard D, Meysman M, et al. Bacterial colonization of central airways after
stenting. Am J Respir Crit Care Med. 1999; 160: 672 – 677.
16. Schmal F, Fegeler W, Terpe HJ, et al. Bacteria and granulation tissue associated with
Montgomery T – tubes. Laryngoscope. 2003; 113: 1394 – 1400.
17. Yaremchuk K. Regular tracheostomy tube changes to prevent formation of granulation tissue.
Laryngoscope. 2003; 113: 1 – 10.
18. Koitschev A, Simon C, Blumenstock G, et al. Surgical technique affects the risk for
tracheostoma-related complications in post-ICU patients. Acta Oto-Laryngologica 2006; 126:
1303 – 1308.
19. Mandell DL, Yellon RF. Endoscopic KTP laser excision of severe tracheostomy-associated
suprastomal collapse. Int J Pediatr Otorhinolaryngol 2004; 68: 1423 – 1428.
20. Rees C, Tridico T, Kirse D. Expanding applications for the microdebrider in pediatric
endoscopic airway surgery. Otolaryngol Head Neck Surg 2005; 133: 509 – 513.
21. Fang T, Lee H, Li H. Powered instrumentation in the treatment of tracheal granulation tissue
for decannulation. Otolaryngol Head Neck Surg. 2005; 133: 520 – 524.
22. Al-Saati A, Morrison GAJ, Clary RA, et al. Surgical decannulation of children with
tracheostomy. J Laryngol Otol. 1993; 107: 217 – 221.
86
March/April 2010.
Challenges of Otolaryngologic Referral in a Nigerian Tertiary Hospital.
A.D. Dunmade1, O.A. Afolabi1, A.P. Eletta2
1
University of Ilorin/University of Ilorin Teaching Hospital, Ilorin
2
Federal medical Center, Bida,
Correspondence to: Dr O.A. Afolabi, Department of ENT, UITH, Ilorin. Nigeria.
Email: [email protected]
Background: The referral system offers one strategy for making the best use of hospitals and
tertiary healthcare services. The aim of this study was to analyze the referral system of patients
to the otorhinolaryngologist and to examine the use of in-house referral system in the teaching
hospital set up.
Methods: This was a retrospective review of all patients referred to the ENT Department
between January 2000 and December 2007. Data retrieved from all referral notes included the
review of referral letter, demographic, referral status, clinical presentations and examination
findings. These data were entered into the SPSS computer software version 11.0 and analysed
Results: A total of 1402 cases were analyzed. The patients’ ages ranged from 3weeks to 90yrs,
with 70.4% of cases being below 40yrs of age while 25.9% were between 40-64yrs and 3.7%
were above 65yrs. The Male to female sex ratio was 1:1. The majority (70.4%) of the patients
had at least primary school education. The rest (29.6%) had no formal education. Slight over
half (51.5%) of the patients were unemployed. The rest were either civil servants or self
employed. Out of the 1402 patients that were referred to the hospital, in-house referral
accounted for 74.1%, 7.2% of came from private health facility and 4.3% were self referrals.
Out of the 1038 in-house referrals, 42.8% were from GOPD, 5.0% from Staff clinic, 13.3% from
surgery, 4.7% from medicine, 3.5% from Obstetrics and Gynaecology, 10% from paediatrics
and 10.4% from ophthalmology and 10.3% from ENT staffs such as residents, ENT Nurse
Practitioner and ENT supporting staffs such as speech therapist and audiologist.
Conclusion: The challenges of referral to the otolaryngologists are enormous thus the need to
organize continuous medical education for the family physician, to make patients have
confidence in the primary care physician, early referral of patients and to allow the
otorhinolaryngologist to focus on the cutting edge issues of the specialty
Introduction
In any health care delivery system an appropriate structure is essential to promote comprehensive
scope, continuity, integration of components and operational efficiency. Patient must be able to easily
access healthcare workers and or health center in their own community. In the first contact with a
health care practitioner particularly if that contact is with the GP’s 90% of patient’s need can be met.
If the initial problem cannot be managed the decision will be made to refer the patient to a specialist
or hospital outpatient department (OPD)1. Referral is a process by which a health worker transfers the
responsibility of care temporarily or permanently to another health professional or social worker or to
the community2. The referral system offers one strategy for making the best use of hospitals and
tertiary healthcare services, but all patients should be seen first by a primary healthcare physician who
decides whether a referral is necessary or not. In other words, access to hospital care should be
through primary healthcare centers, except for emergency cases where patients may access the
3
hospital directly via the hospital’s emergency department . Thus whoever can be treated adequately at
primary health centre level will be treated there, and the referral system will ensure that all others are
referred to the district hospital in a timely fashion 4-8. Some patients present directly to the hospital,
through emergencies and self-referrals, while a physician, nurse or other health care workers refer
9-11
other patients .
The national health system provides for three tiers of health care; primary, secondary and tertiary. The
three should enjoy patronage from clients and a good referral system is the main link between them12.
87
March/April 2010.
In Nigeria many secondary and tertiary health facilities are crowded with people with simple ailments
that can be managed at primary health centers, while health workers in many of later are idle13.
Otolaryngology is a specialized medical practice that cares for ear, nose and throat, head and neck
diseases.
A moderate percentage of Nigerians with ear, nose and throat diseases are not likely to enjoy the
services of an otolaryngologist. This is because there are few of such specialists in Nigeria and they
are located in cities and mainly in tertiary health facilities. The aim of the study is to audit the referral
of patient to ear, nose and throat practice and to examine the use of in-house referral system in the
teaching hospital set up.
It was a retrospective review of all patient referred to the ear, nose and throat department between
January 2000 and December 2007. Patients who have incomplete records were excluded from the
study. The instruments used for the study were patients case notes and semi-structured questionnaire
where information was documented, case notes without referral forms were excluded. Data retrieved
from all referrals included the review of referral letter, demographic data (the age, sex), referral status
(time of referral, name of referring facility, if within or outside the teaching hospital, does the patient
have a referral note or not), (clinical presentations, examination findings, diagnoses) in ENT
compared to outside diagnoses and outcome in terms of referral from the institutional case note..
These data were entered into the SPSS computer software version 11.0 and analysed descriptively.
Results
A total of 1456 patients were referred from to the ear, nose and throat specialty during the study
period out of which 1402 case notes were analyzable. The 54 case notes not analyzed have either
incomplete record with critical items missing, some containing only referral and no other
documentation and some with referral and no demographic data but just diagnosis or not found. Age
ranges from 3weeks to 90yrs, about 70.4% are below 40yrs of age while almost 40% were in between
15-40yrs while 25.9% were between 40-64yrs and 3.7% among the elderly (Table 1). The Male to
female ratio was 1:1
The patients were predominantly Yoruba (74.2%). Only 12.8% were Ibos, 2% Hausa/Fulani while the
rest (11%) were from other ethnic groups. Among these patients 49.8% were married and 50.2% not
married.About two-thirds (70.4%) of the new patients had at least primary school education. The rest
29.6% had no formal education. However those with no formal education included children below
school age and some adults. Among the 973 patients above 15 years age, 194 (20%) had no formal
education, 323 (33.2%) had primary education, 275 (28.2%) had secondary education and 181
(18.6%) had post-secondary education. As much as 51.5% of the patients were unemployed (children,
students, housewives and some young adults). The rest 48.5% were either civil servants or self
employed.
Table 1. Age of Patients
Age
1day-28days
>28days-1year
>1year-15years
>15years-40years
>40years-65years
>65years
Total
Frequency (%)
0 (0.00)
52 (3.7)
377 (26.9)
558 (39.8)
363 (25.9)
52 (3.7)
1402 (100)
88
March/April 2010.
Table 2. Health Facility
Health facility type
Private clinic/hospital
PHC
General hospital
Teaching hospital
Home
Non
Total
Frequency (%)
158 (11.2)
66 (4.7)
80 (5.7)
1308 (74.1)
38 (2.7)
22 (1.6)
1402 (100)
Table 3. In-house Referrals
Dept within UITH
GOPD
Staff clinic
Surgery
Adult medicine
Obstetric/Gynecology
ENT
Paediatrics
Ophthalmology
Total
Frequency (%)
444 (42.8)
53 (5.0)
139 (13.3)
49 (4.7)
36 (3.5)
105 (10.1)
104 (10.0)
108 (10.4)
1038 (100)
Table 4. Duration Before Referral
Duration Before Referral
<24hrs
1-5days
>5days-2weeks
>2weeks
Not stated
Total
Frequency (%)
222 (15.8)
189 (13.5)
210 (15.0)
429 (30.6)
352 (25.1)
1402 (100)
Out of all the new cases 87.3% of them were resident in Ilorin and the rest 12.9% came from outside
Ilorin. Among those that reside outside Ilorin town, 74.8% of them came from within Kwara State and
the rest 13.4% were from other states in Nigeria in the range of 200-300Km West-East and 150200Km north-south of Kwara state. Only 1038 (74.1%) of the patients with referrals, excluding those
that were referred from UITH, only 21.6% of these were referred to the UITH, Ilorin from other
health facilities and about 4.3% from health workers at home (Table 2.). The remaining 364 (25.9%)
patients reported directly to the hospital without any referral. Among the 1038 patients referred,
47.8% (497) of them had referral note from GOPD/Staff clinic, 52.2% (541) from other
departments/units in the hospital and about 10.1% (105) are referred by ENT staffs (table 2.0).
Out of the 1402 patients that were referred to the hospital, in-house referral accounted for 74.1%
(1038), 7.2% (158) from private health facility and 4.3% (60) are self referred (Table 3.). Most of the
patients were referred after an average of 2 weeks of consultation in both outside and in-referrals with
about 15.8% of the patient being referred within 24hrs (Table 4.)
Discussion
A two-way referral system is advocated from the lowest level of health care to the highest (Village
health worker to health post, to primary health care, to comprehensive health centre and to state
General Hospital), except in emergency when patients can be referred to any of the facilities for
89
March/April 2010.
5
immediate treatment . This is hardly the case in many of the developing countries, especially with the
specialized areas like the otolaryngology where these specialists are sparsely distributed. Previous
study done to assess the referral system in Nigeria revealed 7.1% going through the proper referral
system14. However this study has shown a high proportion (88.3%) of these patients referred to
otorhinolaryngology makes the outpatient departments of the Teaching Hospital their first contact
with the National Health System. This is irrespective of the types of otolaryngologic problems. This
supports the observation that awareness about the otolaryngologic practice is still coming up among
both the health practitioner and the populace as those with simple ailment such as wax, foreign body
in the orifices which should be treated at the primary or secondary health center still come to the
9-12
tertiary
.
Many ( approximately 40%) of the patient seen were young adults aged between 15 and 40 years
while the least was among the extreme of ages these may be associated with their inability to present
self. Although we expected the children and elderly to be more likely to be referred by colleagues, it
was not the case in this study.
In this study the patients’ educational status had no influence on whether they were referred or not.
Both the educated and uneducated bypass the lower levels of health care to obtain health care at the
otolaryngology department irrespective of their ailments this is supported by the number of patients
referred by staffs in ENT department in table 4.0 below. Some reasons for this include; the fact that
people have little confidence in the care they would receive at the level of primary and secondary
care- due to the obvious lack of an ENT specialist at this level, also the lack of well-designed referral
6, 10
system with defined procedures, management support and appropriate forms may be contributory.
The practices of bypassing the lower levels of health care and provision of primary care distorts a
hospital function. It is believed many of the apparent shortcomings of hospitals are linked to
9
congested outpatient departments as about a third of the patient (30.6%) spend minimum of 2weeks
before referral with about 15.8% referred within 24hrs of presentation. Majority of the patient referred
were in-house referral which constituted about three-quarter (74.1%) of the referrals most of these are
due to lack of basic medical equipments required in the quick evaluation of patients and making the
right diagnosis also there is need to improve the training of the family physician who first had contact
with the patients, this is because some of the basis for referral are for simple ailments like wax
impaction which a family physician by virtue of rotation through otolaryngology posting should be
able to handle. What is desirable of a primary care physician is to be proficient in the management of
simple cases of aural foreign bodies removal, wax impaction15, 16, 17, 18. If a paediatrician – not many
either at primary centers could be so innovative to adapt a paper clip to function like a jobson Horne’s
probe with some degree of success16, 19 thus he will do a lot with appropriate instrument, this will save
the care giver the problems, cost and stress of seeking the services of a not always available
otolaryngologists15-17, 19 and this will also allow the otolaryngologists to focus on cutting edge issues
of the specialty18. Some countries train ENT clinical officers who are competent at performing simple
ENT procedures and diagnosing ENT diseases for referral to Specialists – this would solve some of
the problems and reduce the numbers jumping the referral chain. Some also work in separate clinics at
referral hospitals to decongest the Specialists’ queues. However when indicated there should be no
hesitation to seek the services of the otolaryngologists who are very limited in number16
Some of the referral are influenced by nurses, attendants, relatives or other hospital staffs so in this
situation a short note with no clinical information were given to patients or patients just come without
a referral note was observed in 25.9% of the patients. This can make it difficult to accurately
determine what had been done for the patient before the referral and it is surprising to see that about
52.9%of the referral given to patient does not state what treatment has been offered to the patient.
This was also observed in table 3.0 where about 10.1% of the in-house referral is from ENT clinic.
90
March/April 2010.
This practice is likely to be found mostly among patients that were not referred by doctors14.
Late referral is also found to be common among the patients referred however this influences the
outcome of treatment of their disease management such as in case of a patient with cervical
lymphadenopathy who was repeatedly placed on antibiotics with no improvement had his tumor
progressed from a early stage to a late stage. It is important to address this situation, believed to be
similar in most Nigerian teaching hospitals. It may affect the running of the National Health Insurance
Scheme (NHIS). It is good to ensure that hospitals concentrate on their roles as referral centers and
not made to perform functions of health centres. To realise this, people must be made to have
confidence in these health centres by providing the necessary trained manpower, drugs and facilities
to carry out some of this baseline treatment.
Conclusion
The challenges of referral to the otolaryngologists are enormous thus the need to make the
populace have confidence in the family physician who are the first point of call on getting to a
tertiary center in the treatment of simple ailments.
The need to organize continue medical education for the family physician in the treatment of
simple ORL disease condition, the need for early referral of a patient the family physician
have doubting diagnosis
Reference
1. Starfield B. Primary care: concept, evaluation and policy. New York: Oxford University
Press, 1998; 213-241.
2. Ransome-Kuti O, Sorungbe AOO, Oyegbite KS et al. Strengthening primary health care at
the local Government level. The Nigerian experience. Academy Press, Lagos, 1998; 44-47.
3. Holmes C. Toward the measurement of primary care. Health and society 1978; 56: 231-252.
4. Committee, WHOE. Hospitals and health for all, Committee WHOE. Editor.. Geneva, World
Health Organisation; 1987; 1 : 1–81. (Technical Report Series 744).
5. Bank, W. World development report 1993 Investing in health. Bank W. editor. New York,
Oxford University Press; 1993: 1–329.
6. Görgen, H. Le Système de Santé de District Expériences et Perspectives pour l'Afrique. 1.
Eschborn, GTZ Division Santé, Population, Nutrition; 1994: 1–132.
7. Shaw, RP.; Elmendorf, AE. Better Health in Africa: Experience and Lessons Learned. 1
Washington, World Bank; 1994; 1(4)
8. Vitalizing National systems of Health Care; pp. 45–66. (Development in Practice). Bank W.
9. World Health Organization (WHO). Hospital and health for all. Report of a WHO expert
committee on the role of hospitals as the first referral level. Technical report series 744,
WHO, Geneva, 1987; 20-34.
10. Beebe SA, Casey R, Magnusson MR, Pasquariello PS Jr. Comparison of self-referred and
physician-referred patients to a pediatric diagnostic center. Clin Pediatr (Phila) 1993; 32: 412416.
11. Dunne MO, Martin A.J. The appropriateness of A and E attendances: a prospective study.
Ireland Med J 1997; 90: 268-269.
12. 12.Irvine DH. The advertising of doctors' services. J Med Ethics 1991; 17: 35-40.
13. 13.Osibogun A. The role of health center in the rational use of health resources. Paper
presented at the 17th Annual Scientific Conference of Association of Community Physicians
of Nigeria. March 1996; 4-9.
14. 14.Ak an de T. M. Ref err al syst em in Ni geria: study of a t ertiar y h ealth
facility, Ann al s of African Medi cin e, 2004; 3(3): 130-133
15. Di Muzio J Jr,Descheler DG. Emergency department management of foreign bodies of the
external ear canal in children. Otol Neurotol 2002;23 :473-475.
91
March/April 2010.
16. Ologe FE, Dunmade AD, Afolabi OA Aural foreign bodies Indian J Paediatr 2007; 74(8)
:755-758
17. 17.Ngo A, Ngo KC, Sim TP. Otorhinolaryngeal foreign bodies in children presentngto the
emergency departmentsingapore Med J 2005; 46(4): 172-178.
18. Olajide TG, Ologe FE, Alabi BS, Management of impacted cerumen: Observational report
Aust Fam Physician 2005; 34(5):395-396
19. Ezechukwu CC, Removal of ear and nasal foreign bodies where there is no
otorhinolaryngologist. Trop Doct 2005;35 :12-13
92
March/April 2010.
Choanal atresia in siblings; Case report
Kaitesi B.M.
Otolaryngology Department, University Teaching Hospital, Kigali – Rwanda.
Choanal atresia is an uncommon and often poorly recognized cause of unilateral or bilateral
nasal obstruction. This report describes the case of bilateral choanal atresia in two consecutive
siblings and describes the methods of treatment offered.
Case Report
A female infant born at term by spontaneous vaginal delivery was brought to the Otolaryngology
Department two hours after birth with difficulty in breathing. The infant was born by a 24- years old
woman, gravida 2 para 1. On arrival in the Otolaryngology Department, the infant was noted to have
generalised cyanosis. Detailed physical examination revealed an infant at term, normal for gestational
age but with severe respiratory distress. The vital signs were normal except for oxygen saturation
which was below 85%. Tachypnoea was also noted. Marked intercostal and subcostal retractions were
noted but vesicular breath sounds were perceived and were symmetrical. A 3.5mm suction tube could
not be passed through either nostril. On placement of an oral-pharyngeal airway breathing improved
significantly and the cyanosis decreased till it disappeared. Urgent choanoplasty and placement of
stents was done and the patient had an uneventful recovery (Figure 1). The infant was followed up
weekly then fortnightly then monthly. At 3 months, the stents were removed and the patient has fared
on very well.
During history taking, it was established that the same woman had been admitted eleven months
before with her first born. We reviewed our records and found out that a term infant was brought to
our department at the similar timing and presented with similar symptoms like the second child
immediately after birth. This was a female infant on whom choanoplasty was done for bilateral
choanal atresia. Stents had been removed six weeks after placement and the child was doing well.
During her last visit, both children were examined. No gross congenital anomalies were found except
a single pre-auricular pit found on the right side in both children.
Figure 1.The infant one week after choanoplasty and stenting.
March/April 2010.
Discussion
Choanal atresia was first described by Roederer in 1775, and was first reported in Britain in 1881 by
Ronaldson. Carl Emmert, in Bern, operated successfully on a patient with choanal atresia in 1851.1
Choanal atresia is a rare condition with an incidence of 1 in 7000 live births. It is believed to be as a
result of persistence of the buccopharyngeal membrane during the embryological period. The genetics
remain unclear.2 In one review, the family histories of patients with choanal atresia revealed no
obvious hereditary trend, and a chromosome analysis showed no abnormalities.3 This results in
complete obstruction of the posterior nasal openings in one or both sides. This condition usually
occurs sporadically, but has been described in siblings and successive generations.2 The blockage may
be either bony or membranous. A mixed picture is usually seen in up to 70% of cases. It affects
women more frequently than men in the ratio 2: 1; there are 3 unilateral cases of choanal atresia for
every two bilateral. Bony atresia is far more common than membranous atresia, accounting for 90%
of reported cases 4. Bilateral choanal atresia will present as an acute emergency since neonates are
obligate nasal breathers. The classical picture of cyclical cyanosis which is relieved by crying is
usually seen.1 Placement of a metallic spatula just below the child’s external nasal aperture helps to
exclude choanal atresia if misting occurs unilaterally or bilaterally. Failure to pass a nasal catheter
suggests atresia which can be confirmed on nasal endoscopy or CT Scanning.
Choanal atresia may be isolated or a feature of associated congenital anomalies. However 60% of
cases of choanal atresia have an associated congenital defect. It has been found to be associated with
syndromes such as Downs and Treacher-Collins. It may however, be found with other isolated defects
such as palatal cleft, high arched palate, micrognathia, tracheoesophageal fistula, missing teeth or
facial cleft. Choanal atresia has been linked with a collection of defects - CHARGE association.5, 6
These anomalies should be excluded in subjects with choanal atresia. One should search for other
congenital defects of the heart, eyes, and gastrointestinal and urinary tract whenever a diagnosis of
choanal atresia is documented. An ophthalmologic and audiology review is also necessary.
Unilateral choanal atresia may present late in life with symptoms of persistent unilateral nasal
discharge. A foreign body should be excluded. Management is purely surgical by a transpalatal or
transnasal by endoscopy approach.7 The outcome and superiority of the surgical approaches is still
under scrutiny since no comparative studies have been conducted yet. Differential diagnoses include
deviated nasal septum, dislocated nasal septum, septal hematoma, mucosal swelling, encephalocele,
nasal dermoid, hamartoma, chordoma, hypertrophied turbinate and teratoma.
Conclusion
In acute respiratory distress in a neonate, bilateral choanal atresia should be considered. It is a medical
emergency. The diagnosis is easily made with a small catheter; a tongue blade and feeding tube
should be used for diagnosis. Anatomical confirmation by radiographs should be made. Whenever one
congenital anomaly is found, others should be sought. Surgical correction is required. Heredity of
choanal atresia has been disapproved in most studies conducted on animals and this has been
projected in humans. In our case report, consecutive siblings had bilateral choanal atresia. Is this
hereditary or an incidental finding?
References
1. A P Booth, A B Drake-Lee. Unilateral choanal atresia, Case report; Journal of the Royal
Society of Medicine 1991; 84:622.
2. Chia SH, Carvalho DS et al. Unilateral choanal atresia in identical twins: case report and
literature review. Int J Pediatr Otorhinolaryngol. 2002; 62(3):249-52
3. Freng A. Congenital choanal atresia. Etiology, morphology and diagnosis in 82 cases. Scand J
Plast Reconstr Surg. 1978; 12(3):261-5.
94
March/April 2010.
4. Kaplan LC. Choanal atresia and its associated anomalies. Further support for the CHARGE
association. Int J Pediatr Otorhinolaryngol 1854; 8:237-42
5. Freng A. Congenital choanal atresia. Etiology, morphology and diagnosis in 82 cases. Scand J
Plast Reconstr Surg. 1978; 12(3):261-5.
6. Pagan RA, Graham JM Jnr, Zanava J, Young SL. Coloboma, congenital heart disease and
choanal atresia with multiple anomalies in CHARGE association. J Pediatr 1981;99:223-7
7. Pasquini E, Sciarretta V, et al Endoscopic treatment of congenital choanal atresia. Int J
Pediatr Otorrhinolaryngol. 2003; 67(3): 271-6
95
March/April 2010.
Hearing Disorders in HIV Positive Adult Patients
B.A Ongulo, H.O Oburra.
Department of Surgery, Kenyatta National Hospital Nairobi, Kenya.
Correspondence to: Prof. H. O. Oburra Email: [email protected], [email protected],
Background: This study was aimed at determining the prevalence and type of hearing disorders
in HIV positive patients and any correlationship with the CD4 counts/stage of HIV/AIDS in
patients
attending
the
comprehensive
care
clinic
(CCC).
Methods: Case control study of 194 HIV positive patients attending CCC recruited into the
study after informed consent. A thorough clinical examination and otoscopy done followed by
tuning fork tests, Pure Tone Audiometry and tympanometric tests. This was compared with 124
HIV negative subjects matched for age and sex who were recruited from the voluntary
counseling and testing centre. The world health organization staging of the HIV/AIDS disease
and the CD4 positive lymphocyte cell count were carried out and correlated with any hearing
disorder. Results were analyzed using statistical package for social sciences version 10.0.
Results: Hearing loss (HL) was present in 33.5% of HIV positive compared to 8.1% in negative
subjects. No gender bias in HL but HL worsened with advancement of age. SNHL was the most
common and the higher frequencies were the most affected. Low CD4 cell count and advanced
HIV disease were associated with increased chance of having a hearing loss.
Conclusion: Hearing loss is more prevalent in HIV positive individuals than negative normal
subjects and tends to worsen with the advancement of the HIV disease. This may negatively
impact on the overall care and standard of living of HIV positive patients, hence otological care
should be part of the comprehensive care.
Introduction
Over 50% of HIV infected patients present first to the otorhinolaryngologist1. Of all the
otorhinolaryngological manifestations, otological symptoms comprise at least 62%, yet many caregivers are unaware of these otological symptoms hence they are more likely to concentrate on other
manifestations2, 3. Somefun et al3 looked at 98 patients at Lagos University teaching hospital and
found that while only 17% of the patients were referred because of otorhinolaryngological (ORL)
diseases, 80% of them actually had ORL/head and neck conditions.
Numerous international studies have demonstrated a relationship between HIV/AIDS and auditory
function. Kohan et al2 conducted a 5-year retrospective study to evaluate otologic disease in patients
with AIDS at New York university medical center- Bellevue hospital. They found that 62% had
hearing loss 2. Marra et al4 did a case control study of 99 HIV positive patients at the university of
Washington HIV based clinic and found that 29% of the patients had hearing loss4.
Hearing disability compromises the overall economic productivity of an individual and may render
one an outcast. In HIV positive patients who are still stigmatized, it can lead to marked reduction of
quality of life. In this study, the nature and degree of hearing disability in HIV infected patients
presenting at CCC were determined. This will raise the awareness of care-givers and eventually
improve the quality of life and productivity of HIV/AIDS patients.
This was a hospital based case control study done between January and April 2007, at the
comprehensive care clinic and voluntary counseling and testing centre. A minimum sample size of
115 was required in each arm. The study subjects were adult HIV positive patients not on
antiretroviral drugs aged between 18 and 50years recruited into the study from the CCC clinic
whereas the controls were HIV negative subjects who were age and sex matched recruited from VCT
centre. Patients who suffered diabetes, meningitis, head injury or cerebrovascular accident and those
96
March/April 2010.
who had exposure to ototoxic medications were excluded from the study. Written informed consent
was obtained from the subjects. Approval to carry out this study was obtained from the Ethics and
Research committee of Kenyatta national hospital.
A clinical history was taken followed by thorough physical examination, otoscopy and tuning folk
tests, PTA and tympanometry. The WHO staging of the HIV disease and CD4 cell count were carried
out in the study subjects. CD4 count was determined by the automated flow cytometry analyzer,
FASCOUNT (benedict dick, USA). Data analysis was done using SPSS version 10.0 software and
descriptive statistics were done.
Results
The study group comprised of 194 subjects who were HIV positive but not on ARVs and the control
group were 124 subjects who were HIV negative. In the study group, males were 75 (38.7%) while
females were 119 (61.3%). In the control group, males were 47 (37.9%) and females were 77
(62.1%). The age and sex in both the study group and the control were similar because they were
matched for age and sex. The age ranged from 18 yrs to 50 yrs in both the study and control groups
with a mean age of 36.09 and 36.4 yrs respectively and the median age as 35 yrs and 36 yrs
respectively. The mode was 37 in both groups. Most of the patients were between 32 yrs to 38 yrs old.
As seen below (table 1), the hearing loss was 33.5% in the study group and 8.1% in the control group.
This is statistically significant. There was no gender bias in hearing loss.
The hearing level when computed according to age groups showed that hearing loss worsens with
increasing age as shown in figure 1. This was statistically significant (P=0.022).
Table 1. Hearing Loss in the Study and Control Groups.
HL
Total
Present
Absent
Study Group
65
129
194
Percent
33.5
66.5
100
Control Group
10
114
124
Percentage
8.1
91.9
100
Distri of HL along age groups.
87%
76.00%
63.10%
74%
54.50%
45.50%
36.90%
13%
18-24
24.00%
25-31
26%
32-38
39-45
46-50
Age in yrs.
HL present
No HL
Figure 1. Correlationship between hearing level and age in the study group.
97
March/April 2010.
Relatioship btw WHO stage & HL.
15
who stage IV
25
who stage III
who stage II
who stage I
11
36
12
33
13
0%
49
20%
40%
HL present
60%
80%
100%
No HL
Figure 2.. Relationship between WHO stage and hearing level.
Relationship between CDC stage & HL.
HL present
40
lab stage C
61
lab stage B
19
50
lab stage A
6
18
0%
20%
No HL
40%
60%
80%
100%
Figure 3. Relationship between CDC stage and hearing level.
The subjects were classified according to the WHO clinical
clinical staging for retroviral disease and the
hearing level determined. Results indicate that hearing loss worsens as the WHO clinical stage of the
disease advances as shown in figure 2. This was statistically significant correlation (P=0.004). The
worsening off hearing level with advancement of the HIV disease was likewise confirmed when the
CDC stage was correlated with the hearing level as shown in Figure 3.
When the nature of hearing loss was assessed, it was found that 74% had SNHL, 22% CHL and 4%
had mixed HL. As the age advances, the proportion of subjects with CHL decreases but those with
SNHL increases as shown in figure 4 below.
March/April 2010.
HL type distr along Age groups
CHL
SNHL
MIXED HL
83%
80%
50% 50%
75%
47%
38%
25%
15%
17%
14%
6%
0%
18-24 yrs
25-31 yrs
32-38 yrs
0%
39-45 yrs
0%
46-50 yrs
Figure 4. Relationship Between Age and Type of Hearing Loss.
Dscussion
Hearing loss is a cardinal feature and disability in HIV/AIDS patients. In this study, 33.5% of HIV
positive patients not on ARVs had hearing level above 25 dB in at least one of the hearing frequencies
compared to only 8.1% in HIV negative normal subjects. Soucek and Michaels5 got 39% in a sample
size of 65 subjects and Wang et al6 got 45.5% in a sample size of 350. There is a wide variation found
in different studies and this could be due to the sample size and the cut off decibel for hearing loss.
It has been shown that HIV positive subjects are at a higher risk of developing a hearing loss.
Mandela in her study of the effect of streptomycin on the cochlear found that HIV positive patients on
streptomycin are at a higher risk of sustaining sensorineural hearing loss than HIV negative patients
on the same treatment7. Many other drugs commonly prescribed to treat various opportunistic
infections as well as ARVs have been implicated in causing hearing loss4,8. This study found no
difference in the HL according to gender. In both sexes, 33.45 % had a HL. This suggests that the sex
of the subject does not play any role in the causation of hearing loss but males are the ones who
mostly work in noisy environments and are therefore predisposed to noise induced hearing loss,
however, such patients were excluded from the study.
The HL gets worse with advancement of age and this was found to be statistically significant P<0.05
(0.022). Marra et al4 also got a similar finding. In this study, patients over 50 yrs of age were excluded
to avoid the effects of presbyacusis since it is a known fact that as one ages, HL gradually develops
especially after the age of 60 yrs. The elderly subjects in this study comprised the majority with HL
compared to the younger population, this may indicate that HIV has more adverse effects on the
hearing apparatus in the elderly population9, but this needs to be proved beyond question in a suitably
designed study with hearing loss corrected for presbyacusis.
The number of subjects with a HL increases with advancement in the WHO stage of the disease. This
was statistically significant and it could be due to the effect of the HIV virus on the cochlear10, middle
ear infections11 or CNS complications5. Patients with advanced HIV disease are more predisposed to
infections including those that interfere with hearing. Michaels et al found that 60% had features of
otitis media in temporal bones of patients who succumbed to HIV11. This may account for the increase
in HL with advancement of HIV disease stage.
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March/April 2010.
Subjects who had HL mostly experienced SNHL (74%) followed by CHL (21.5%) and mixed HL
(4.5%) was the least. Mild HL (26-40 dB) was the most common at 70% followed by moderate HL
(24.5%), moderate severe HL (4.5%) and severe HL was 1%. There was no profound HL in the study
population. This is the same trend found by Soucek5. The possible causes of HL in HIV disease could
be divided into three, those due ototoxic drugs administered to these patients, CNS effects of the virus
including CNS infections and tumours e.g. toxoplasmosis, meningitis, CMV, tuberculosis and
lymphoma, and lastly the effects of the virus on the cochlear. Michaels et al found reduced
otoacoustic emissions due to hair cell loss in temporal bones of HIV infected patients11.
The higher frequencies i.e. 4 KHz and 8 KHz are the most affected while the middle frequencies are
largely spared. Similar findings were gotten by Soucek5 where 6 KHz and 8 KHz were the most
affected. This is thought to be due to changes in the cochlear mechanics5.
Subjects with CD4 cell counts below 200/µl had the highest proportion of those with HL at 38%,
followed by those with CD4 cell counts between 200 and 500/µl at 28% and those whose CD4 cell
counts were above 500/µl at 22%. This means that as the CD4 cell count falls, the chance of
developing a hearing loss increases. The absolute CD4 cell count was found to be statistically related
to the development of a HL. Kohan and Giacchi12 found that the more immunocompromised AIDS
patients had more advanced otologic disease. The markedly lower incidence of otitis media of 8%
overall found clinically5 compared to that found at autopsy of 20% 11 might suggest that severe otitis
media is a late terminal manifestation of AIDS, this supports the finding of HL being more common
in advanced disease.
Conclusion
Hearing loss is more prevalent in HIV positive individuals. This indicates that the HIV
positive patient may not be able to follow the instructions and counseling usually given as
part of the comprehensive care and this may negatively impact on the overall care and quality
of life.
HIV-positive patients frequently do not complain of deafness until significant hearing loss has
occurred. They usually have many symptoms and initially may perceive hearing loss as a
relatively minor problem in comparison or may actually think it is part of the disease problem
(13). Therefore, clinicians should deliberately seek to find out the hearing level of these
patients in order for early and timely remedial measures especially in elderly since there is a
strong association of HL with advancement of age.
There is strong association of HL and the CD4 cell count. Patients with a low CD4 cell count
are likely to develop a hearing loss. There is also a general trend of increased prevalence of
those with a HL with advancement in WHO stage of HIV disease.
SNHL is the most common type of hearing disorder in HIV positive individuals and the
intensity of the hearing loss is mostly mild. The higher frequencies are the most affected
followed by the lower frequencies while the middle ones are largely spared.
References
1. Moazzez AH, Alvi A. Head and neck manifestations of AIDS in adults, Am Fam Physician
1998; 57; 1813-1822.
2. Kohan D, Rotherstein SG, Cohen NL. Otologic disease in patients with acquired
immunodeficiency syndrome. Ann Otol Rhinol Laryngol 1988; 97:636-640.
3. Somefun A. Otorrhinolaryngological manifestations of HIV/AIDS in Lagos, Niger Postgrad
Med J 2001; 8: 170-174.
4. Marra CM, Wechkin HA, Longstreth WT Jr et al. Hearing loss and antiretroviral therapy in
patients infected with HIV-1. Arch Neurol. 1997; 54:407-410.
5. Soucek S, Michaels L. The ear in AIDS: II. Clinical and audiologic investigation. Am J
Otol.1996; 17:35-39.
100
March/April 2010.
6. Simdon J, Watters D, Barlett S. et al. Ototoxicity associated with use of Nucleoside Analog
Reverse Transcriptase inhibitors: A Report of 3 possible cases and Review of Literature.;
Clinical Infectious Dis 2001; 32:1623-1627.
7. Idenya PM. Cochleotoxic effects of streptomycin amongst patients on anti-TB treatment at
KNH. Dissertation for M. Med 2000.
8. Jason S, Dan W, Stephen B et al. Ototoxicity associated with use of nucleoside analog reverse
transcriptase inhibitors: a report of 3 possible cases and review of literature, CLIN INFECT
DIS 2001; 32:1623-1627.
9. Wang Y, Yang H, Dong M. The hearing manifestations of 350 patients of AIDS. LIN Chua
ER BI Yan Hou KE ZA Zhi. 2006 Nov; 20(22):1020-1.
10. Pappas DG Jnr, Chandra HK, Lim J et al. Ultrastructural findings in the cochlear of AIDS
cases. Am J Otol. 1994; 15: 456-465.
11. Michaels L, Soucek S, Liang J. The ear in AIDS: Temporal bone histopathologic study. Am J
Otol. 1994; 15:515-522.
12. Kohan D, Giacchi RJ. Otologic surgery in patients with HIV-1 and AIDS. Orl/Hn Surg. 1999;
121:355-360.
13. Lubbe DE. Hearing Help Needed. Hearing Health 2004; 20:2-3.
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March/April 2010.
Pattern of Surgical Diseases Based on Histopathological Findings: A 13-years Personal
Experience in a Rural Hospital in Kenya.
P.M. Nthumba
Department of Surgery, AIC Kijabe Hospital – Kenya.
Email: [email protected]
Background: Church/mission hospitals and other non-government health institutions in
Kenya provide 30% of the healthcare needs, providing affordable care to the rural
poor. This review presents the surgical pathology to which a general surgeon working in
a rural Kenyan hospital is exposed through training and beyond. Additionally, some of
the rarer surgical pathology, ‘rare birds’, encountered during this period is reported.
Methods: In this retrospective study, all the surgical specimens submitted by the author
for histopathological examination over a period of thirteen years were reviewed and
analyzed.
The
findings
are
reported.
Results: The results of 1826 surgical specimens were divided into the major surgical
specialties that a surgeon working in this environment is exposed to. General surgical
specimens constituted 48.4% of the total specimens, while urology, gynecology,
maxillofacial/otolaryngology and ‘other’ specialties made up 34.6%, 7.8%, 6.7%, and
2.5% respectively. There were a total of 389 malignancies, of which 55% were in
general surgery and 31.1% in urology. Rare surgical pathologies encountered over this
period included acne conglobata, an intramuscular lipoma of the forearm, intraosseous
lipoma of the fibula, primary tuberculosis of the prostate gland and of the thyroid
gland,
amongst
others.
Conclusion: Church/mission hospitals currently present excellent opportunities both for
training and career development in general surgery and related disciplines.
Introduction
Church/mission hospitals constitute most of the non-governmental health institutions that
provide 30% of healthcare in Kenya. Many struggle to provide affordable care to the rural
poor that they serve, and are largely dependent on foreign donor support. Church hospitals
are administered by a local indigenous church, while mission hospitals are wholly
administered by foreign organizations. Until 1995, these health institutions were not involved
in medical education beyond elective terms for medicals students. The Ministry of Health,
Government of Kenya (MOH), was the only institution at the time that provided employment
with an assured sponsorship for post-graduate training, discouraging most Kenyan doctors
from working in church/mission hospitals. These institutions were therefore forced to
continue depending on missionary doctors, with a number collapsing upon the departure of
these missionaries1.
In 1995, the Kenya Medical Practitioners and Dentists Board (MPBD) approved medical
internship training in 3 church hospitals. The same year, the MOH sent medical interns to
these hospitals; the current author was one these. Subsequently, along with the internship
program, some of these institutions became training sites for the Family Practice postgraduate program offered by Moi University, Eldoret. Training in general, orthopedic and
pediatric surgery, under the auspices of the College of Surgeons of East, Central and
Southern Africa (COSECSA); Pediatric surgery training under the Pan African Academy of
Christian Surgeons and a general surgery rotation for University of Nairobi registrars are
additional programs that evolved between 2004 and 2008.
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March/April 2010.
Thus training programs and surgical career development opportunities in some of these
institutions have opened opportunities for training of more surgeons, as well as provided an
impetus for improved surgical care in rural hospitals. The AIC Kijabe hospital has a welldeveloped surgical service, with a supporting Pathology department that also provides
pathology services to 70 other hospitals in Kenya and the surrounding region. It processes
more than 4500 specimens annually, and has maintained computerized pathology records
since 1992.
The main objective of this review was to present the range of surgical pathology handled by a
single doctor from internship, and through training and practice in general surgery, while
working in a rural Kenyan hospital. This review also reports on some of the rarer surgical
pathology encountered over this period.
A retrospective review of pathology records of all the specimens submitted by the author
between 1995 and 2008 was done. Data extracted from the Pathology department database
included patient name, age, sex, clinical history, macroscopic description, microscopic
description, diagnosis and comments. Although all the patients whose records were retrieved
had been managed by the author, for the purposes of reporting, the records were then divided
into the different specialties under which they would fall in large teaching centers: urology,
general surgery, gynaecology, maxillofacial/otolaryngology and ‘others’. Some of the rarer
pathologies encountered in each specialty are reported as ‘rare birds’, and briefly discussed.
A search of the internet, including Pubmed and Medline databases did not yield comparable
studies: a single author experience, detailing the surgical experience from internship through
training in general surgery and beyond.
Results
A total of 1826 specimens were taken and submitted for histological examination during this
period (Table 1). In 747 (44.8%) of the cases the specimens were from from females and 919
(55.2%) were from males. The constituted only about 25% of the surgical specimens but
included all the prostate and appendix specimens. About 3.6% of the specimens analyzed
had no abnormality, and it could be argued that this was unnecessary expenditure on the part
of the patients. The converse however, is also true: some specimens not submitted may have
had significant pathology and thus these patients failed to benefit fully the surgical
intervention. Submission of specimen for analysis was for many years dictated by the clinical
impression and the ability of the patient to pay for the examination, leading to a relatively
low submission; transformation into a training institution has led to a reduction of
dependence on clinical judgment and intuition.
Specimens submitted in the first 6 years (Table 1) represented 18.5% of the total: these
initially consisted of minor procedures, such as bone marrow aspirates and lymph node
biopsies, with a gradual increase in variety and complexity of cases, drawn from different
specialties (Table 1, 2 and 3). General surgical specimens constituted 48.4% of the total,
while urology, gynaecology, maxillofacial/otolaryngology and ‘other’ specialties made up
34.6%, 7.8%, 6.7%, and 2.5% respectively (Table 3). Primarily cardiothoracic, neurosurgery
and orthopedic specimen were grouped together under ‘others’ (Table 2).
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March/April 2010.
Table 1. Number of Specimens Submitted Between 1995 and 2008.
Year
Specimen
1995
5
1996
29
1997
136
1998
136
1999
7
2000
26
2001
0
2002
273
2003
403
2004
316
2005
335
2006
156
2007
0
2008
5
Total number of specimens submitted for histopathology between 1995 to 2008. Few or none were submitted
during periods of training
ning (1995, end of1998 to beginning of 2002, and mid
mid-2006 to mid-2009).
Figure 1. Distribution of Malignancies by Surgical Speciality
March/April 2010.
Table 2. Specialties grouped under ‘others’
Specialty
Cardiothoracic
surgery
Neurosurgery
Orthopedic surgery
Benign
7
Total
Intermediate Malignant
0
1
Total
8
1
32
0
0
0
5
1
37
40
0
6
46
Table 3. Specimen totals by specialty
Speciality
Urology
Gynaecology
General
surgery
Maxillofacial
/ENT
Others
Total
No
Benign Intermediate Malignant(%)
abnormality
in each
specialty
23
489
0
121(19.1)
5
108
6
23(16.2)
39
628
4
214(24.2)
Total
633
142
883
1
97
0
25(20.5)
122
1
66
39
1361
0
10
6(13)
389(21.3)
46
1826
Table and pie chart of specimen totals by specialty. Specimens labeled ‘intermediate’ had dysplastic features,
but no frank malignant features.
Table 4. ‘Rare birds’. The Rare Conditions
Organ
Thyroid
Appendix
Truncal skin
Duodenum
Skin
Systemic
Prostate
Urethra
(female)
Face
Maxilla
Parotid gland
Fibula
Forearm
Pathology
Primary thyroid Tb
Taenia spp acute appendicitis
Endemic KS
Adenocarcinoma
Lymphoma
Acne conglobata
Systemic lymphangiomatosis
Tb prostatitis
Spindle cell sarcoma
Adenocarcinoma
Pts
1
1
1
2
1
1
1
2
1
2
Reported incidence
0.003% to 0.1%8
very rare10
incidence uncertain11,12.
0.5% of all GI cancers13
very rare14
rare15,16, Figure 2
very rare17, Figure 3
rare18
<0.1% of prostatic malignancies19.
0.02% of all female cancers20
Lupus vulgaris
Solitary plasmacytoma
Adenoid cystic carcinoma
1
1
1
Intra-osseous lipoma
Intramuscular lipoma
1
1
0.14% of all Tb21
rare22.
10% of salivary gland cancers23,
Figure 6
<0.1% of all bony lesions24
extremely rare26-28.
105
March/April 2010.
Figure 2. Frequency of tissue sources submitted for pathological examination
Top 6 organ histopathologies, repre
representing
senting of 63.2% of the total 1826 specimens.
There were a total of 389 (21.3%) malignancies. Of these, 55% were in general surgery and
31.1% in urology. General surgery had the highest incidence (24.2%) of malignancy;
maxillofacial/otolaryngology, urology,
urology, gynaecology, and ‘others’ had rates of 20.5%, 19.1%,
16.2%, and 13%, respectively (Table 3 and Figure 1). The prostate constituted the 30.3% of
all organ pathologies (Figure 2).
Rare Conditions in different specialties
General surgery
General surgery is an expansive specialty in rural Africa, and crosses into areas otherwise
managed by different specialties in other environments. For the purposes of this review,
gastrointestinal, pancreaticohepatobiliary, skin/scalp, thyroid and breast pathologies were
wer
classified under general surgery, totaling 838 specimens. Thyroid malignancy, hyperplastic
and multinodular goiters made up 8.9%, 20.2% and 29.8% of thyroid lesions, respectively.
One thyroid tumor was reported as tuberculosis; the patient had no evidence
evidence of tuberculosis
elsewhere in his body.
There were 60 appendectomies performed by the current author over the 13 years covered in
this review, an average of five cases per year. Twelve (20%) had no histological
abnormalities; 44 had appendicitis, while four
four had other pathologies, including carcinoid
tumor, mucocele, adenocarcinoma and a periappendicitis. One case of acute appendicitis was
associated with Taenia species (Table 4). Of 18 duodenal biopsies, three were malignant –
two with high grade adenocarcinomas,
cinomas, and one a large cell malignant lymphoma.
Amongst rare skin pathologies encountered was a large posterior trunk ulcer in an HIV
negative patient that was reported as Kaposi’s sarcoma (Figure 1). A 55-year
55 year old female
presenting with extensive keloids
ds covering most of her body, simulating post
post-severe burn
sequelae, was found to have acne conglobata on histopathology (Figure 2). A biopsy from
another patient with a facial ulcer was reported as skin tuberculosis, acne vulgaris. Biopsies
from a two year-old
old child with bilateral lower extremity lymphedema and abdominal masses
were reported as lymphangiomatosis; an accompanying CT scan confirmed a diagnosis of
systemic lymphangiomatosis.
March/April 2010.
Urology
Urology takes up a significant portion of the general surgeon’s practice in our environment,
mostly as prostate pathology, which made up 87.4% of the urology specimens – 30.3% of the
total specimens, in this review. ‘Rare birds’ included two cases of tuberculous prostatitis and
one of spindle cell sarcoma of the prostate (Figure 4). Two females presented in acute urinary
retention; both were found to have adenocarcinoma of the urethra on histopathology.
Maxillofacial surgery
A 61 year-old patient underwent a maxillectomy for a maxillary tumor; microscopic
examination revealed a plasmacytoma, hence a clinical diagnosis of solitary plasmacytoma.
A fine needle aspirate of a parotid nodule in a patient with a history of a previous
parotidectomy that had been reported elsewhere as pleomorphic adenoma was found to be an
adenocystic carcinoma, with a chest radiograph revealing canon-ball lesions.
Orthopedics
A patient presented with a large proximal leg mass with common peroneal nerve palsy; the
excised tumor turned out to be a lipoma of the fibula. Another patient with progressive
median nerve weakness and a forearm mass was found to have an intramuscular lipoma.
Discussion
Poverty and illiteracy, two vicious ills that bedevil rural communities, prevent healthcareseeking behavior amongst the populace. Additionally, infectious diseases like malaria,
pulmonary tuberculosis and HIV have permanently taken center-stage of both government
and donor-support health policy and priority, relegating surgical diseases to the periphery1.
Sustaining the provision of affordable health care to the rural patients such as the one the AIC
KH serves continues to be demanding, and a cost-benefit consideration must be made before
any given test, procedure or service is offered.
Submitted specimens reflect a bias peculiar to our institution. Like many other
church/mission hospitals in Kenya, general surgeons initially had to manage patients of
different surgical specialties; however, in the last six years, AIC KH has developed wellstaffed pediatric surgical, orthopedic, gynaecology and obstetrics departments to optimize
care in these different specialties. While the current author’s preference was reconstructive
surgery2,3 and the high-volume urology service was equally shared amongst three general
surgery units4, one of the surgeons handled most of the breast pathology, reported elsewhere5.
Many of the unusual pathologies encountered in this review form excellent bases for case
reports6,7, but were reported in this review in order to give a complete account of the rich
surgical pathology encountered in clinical practice in our environment.
General surgery
Thyroid cancer, hyperplastic and multinodular goiters made up 8.9%, 20.2% and 29.8% of
thyroid lesions, respectively a previous study from the same institution found these to be:
11.7%, 13% and 47% respectively8. While the current study concentrated on the work of a
single surgeon, previous studies reflect the work of the entire institution, and may be the
reason for the discrepancy of results.
107
March/April 2010.
Primary tuberculosis of the thyroid is a very rare disease, even in endemic regions9.
Postmortem studies suggest rates of between 0.003% and 0.1%; with higher rates in military
TB. This review found one patient with primary thyroid tuberculosis.
Appendicitis in our setting is lower than that reported from urban settings, with an average of
five appendectomies per year; consistent with an earlier report from our institution of 112
patients over a 5-year period10. Taenia species (adults and eggs), the cause of one case of
acute appendicitis, is a very rare presentation11.
The incidence of African/endemic Kaposis’ sarcoma (KS) is uncertain in the current era of
epidemic HIV, however it is relatively rare. One of the patients was HIV-negative patient and
had a huge ulcer reported to be KS (Figure 1). The most common type of KS is the epidemic
(AIDS-related) type. Endemic or African KS generally affects patents younger than 40 years,
and in children may present with an aggressive form. Other types of KS include the classic
(Mediterranean) KS and the Iatrogenic (transplant-related or immunosuppressive therapy)
KS12,13. The patient reported here had a giant aggressive variant of the endemic KS.
Duodenal malignancy is rare – two adenocarcinomas and a lymphoma were found in three
patients. Adenocarcinoma of the duodenum is quite rare, representing 0.5% of all
gastrointestinal (GI) malignancies14. The two cases reported here represented 0.75% of all the
GI malignancies in this review. Malignant lymphomas of the duodenum are similarly rare. In
a review of 117 GI lymphomas, there was none from the duodenum15.
Acne conglobata, found in one patient in this review, is the most severe form of acne, a rare
chronic nodulocystic dermatological disorder that presents with comedones, pustules,
abscesses and draining sinuses, most commonly in the face, arms, back and thighs16.
Progressive scarring is due to repeated infections, and may cause severe disfigurement from
the resultant keloids, leading to social isolation and functional impairment. It usually affects
males17. This is the first report of acne conglobata from Africa, and likely the most severe
case reported to date. Cutaneous tuberculosis is rare, representing about 0.2% of all
dermatologic cases, and about 0.14% of all tuberculosis disease18. The clinical diagnosis in
the patient reported here was lupus vulgaris.
Systemic lymphangiomatosis, as reported in a child in this study, is a rare condition
characterized primarily by skeletal system angiomatous lesions; concomitant skin, soft tissue
and visceral involvement occurs in 50% of the cases is associated with poor prognosis19.
Although benign, progressive growth of the lesions may cause pathological fractures of bones
or cause compression of vital structures.
Urology
Of the 553 prostates examined, 19.7% were malignant; of these, adenocarcinomas constituted
97.2%. A previous study on suprapubic prostatectomies in the same institution found a 6.7%
incidence of prostate malignancy4. While the current study included all prostatic specimen
(including biopsies), the earlier study looked only at prostatectomy specimens, hence the
apparent discrepancy in malignancy rates. Rare prostatic histopathologies included two
patients with primary tuberculous prostatitis, a rare condition usually diagnosed
histologically, after prostatectomy20. The high grade spindle cell sarcoma of the prostate
represented 0.09% of all prostatic cancers in this review; adult prostatic sarcomas constitute
less than 0.1% of all prostatic malignancies, in most studies21. Adenocarcinoma of the female
urethra was found in two patients. Female urethral adenocarcinoma represents 0.02% of all
female malignancies; most are at an advanced stage when first diagnosed22. Radical cystourethrectomy with uretero-sigmoidostomies was performed for both.
108
March/April 2010.
Maxillofacial surgery
Solitary bone plasmacytoma of the maxilla is a rare neoplasm. It most commonly affects
males aged 50 to 60 years, with the male to female ratio of 3:1 23. Our patient, a female, had
no evidence of systemic involvement. Adenoid cystic carcinoma of salivary glands constitute
10% of all the neoplasms of salivary glands. They are associated with poor prognosis due to
local recurrences and distant metastases, usually pulmonary24. An initial misdiagnosis and an
incomplete excision of the lesion most likely led to the ‘recurrence’ and metastases.
Intra-osseous lipomas are rare lesions, accounting for less than 0.1% of all bony lesions. They
affect both the axial and appendicular skeleton, and are found most frequently in the
metaphysis of long bones, especially the proximal femur25. Pathological fractures and
malignant degeneration have been reported26. In the patient reported here, cosmesis and
common peroneal nerve compression were the main problems. Only unusually located
lipomas or those of doubtful pathology were submitted for histological evaluation.
Intramuscular lipomata are rare tumors, accounting for 1.8% of fatty tumors. These lesions
are even rarer in the forearm; only three previous cases have been reported in English
literature27-29. The patient reported here had median nerve paraesthesia that improved after
surgery.
Conclusion
Church/mission hospitals provide a significant contribution to healthcare provision in Kenya.
Training programs and surgical career development opportunities in some of these
institutions have opened opportunities for training of more surgeons, as well as provided an
impetus for improved surgical care in rural hospitals. A surgical career in these institutions,
though demanding because of the breadth of pathology, is a rewarding educational
experience, as reflected in this review.
Acknowledgements
The author is grateful to AIC Kijabe Hospital Pathology Department for the pathology
specimen results.
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Chicarilli ZN. Follicular occlusion triad: hidradenitis suppurativa, acne conglobata, and
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Sarifakioglu N, Aslan G, Terzioglu A, Atas L. A new surgical treatment of acne
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110
March/April 2010.
Cardiac Surgery: One year experience of cardiac surgery at Muhimbili National
Hospital, Dar es Salaam- TANZANIA.
Nyawawa ETM1, Ussiri EV1, Chillo P1, Waane T1, Lugazia E1, Mpoki U1, Luchemba R1,
Wandwi B1, Nyangasa B1, Bgoya J2 Mahalu W3.
1
Muhimbili National Hospital, Tanzania, 2 visiting Cardiac Anaesthesiologist, Zimbabwe, 3Visiting
Cardiac surgeon Bugando University College of Health Sciences-Tanzania
Correspondence to: Dr. Evarist T.M Nyawawa, E-mail: [email protected]
Background: Establishing a cardiac unit in developing countries is usually difficult as it is
associated with many obstacles of both expertise and financial constraints and more alarming
is the mortality rate that may be high. Even after success in the initial stage sustainability of
such program is a dilemma. The aim of this study was to determine pattern of disease profile,
type of cardiac surgery done and the overall outcome.
Methods: All patients who underwent cardiac operation at the centre were prospectively
recruited. Patients’ demography and disease characteristics as demonstrated at
echocardiography and its confirmation at operation were recorded. Peri-operative factors
were the measurable statistics that determined the overall patients’ outcome. All data were
entered and analyzed using a spss11.5 window program.
Results: A total of 105 cases of cardiac surgery were done 21% were male and 79% were
females. Mean age was 19.4±12.3. The majority of cases were due to Rheumatic heart
diseases (47.6%), congenital heart disease (35.2%), myxomatous valvular degeneration
(16.2%) and pericardial disease 1%. Mitral valve disease was the commonest cause of cardiac
disease (58.1%). Prolonged duration of aortic cross-clamp and total operation time were
associated with prolonged intensive care stay and poor patients’ outcome respectively
(p<0.05). While, ventricular dysfunction and total cardiopulmonary bypass time were not.
The overall mortality rate was 13.3%. Majority of all death (64.3%) followed mitral valve
repair.
Conclusion: The majority of patients (86.7%) who underwent cardiac surgery had full
recovery. The mortality of (13.3%) is probably comparable to other settings. The diversity of
spectrum of cardiac disease found elsewhere is also found in our community and therefore
need to increase community awareness. Mitral valve repair deserve a special entity that
requires skills and expertise. The mere presence of suboptimal ventricular dysfunction is
probably not a contraindication to cardiac operation. The duration of aortic cross-clamp and
total operation time were determinant of postoperative outcome.
Introduction
In view of the outstanding global heart disease that is expected the world population of 6.5
billion people is at risk of heart diseases1. While the developed countries estimate a
population of one billion, the majority of people (5.5 billion) are found in developing
countries. With emerging economy the backlog of patients with rheumatic heart disease,
congenital heart diseases are immense. There is an epidemic rise of atherosclerotic coronary
heart disease due primarily notable risk factors such as hypertension, hyperlipidemia,
westernized diet, smoking, inactivity and change in life style2. Fifty-seven million people die
each year on the planet with over 17 million from cardiovascular disease3. Non
communicable diseases are clearly a greater cause of death than communicable disease and
will continue to rise4. To the emerging countries the situation is even worse as there are few
cardiac centers when comparing number of inhabitants per centre (Africa 1/33,000,000 as
compared to Asia 1/16,000,000 Europe 1/1,000,000 USA 1/120,000)5. To worsen the
111
March/April 2010.
situation in the developing countries there is lack of expertise and the frequent political
conflicts.
Establishing a cardiac centre especially in a developing country is usually difficult and
associated with many obstacles6. Pezzela7 classified cardiac projects in developing countries
as ; nonexistent but wanting to start, previously existed but failed, small or even larger
existing programs now limited by financial and political consideration, ready to start but need
financial and political support, already functional but needing academic support and various
combinations of these. Even after starting the reputation mighty be lowered with an
exceedingly high mortality rate that can be anticipated that may again retards the smooth
running of the unit. Sustainability of such program in emerging countries is a problem again.
If not well planned even the cadres of staff mighty be inadequate. If there good success
particularly with regards to number of operation and having the staff acquired good skills and
experience, moving of staff to green pastures is all what is anticipated due to low payment6,
8
.With exception of south Africa and Egypt a few other African countries have far made
progress in open heart Surgery if not fully established yet some are doing operations in
collaboration with visiting cardiac team from else where9, 10. In Tanzania earliest plan to
establish cardiac unit started in early 1970s but could not mature till 2005 when strong
commitment by the government was taken including sending the team of staffs to train in
various institutions that had composed all various cadres of staff required to make a complete
cardiac team. Further more commitment was the necessity to acquire the tools that it
managed successful. Since then the team was back by 2007 and appropriate measures was
taken to officially start open heart surgery that by 21st may 2008 open heart surgery started
and by June 2009 a total of 105 cases had been operated. And we here present our first one
year outcome of open heart surgery at Muhimbili National Hospital in Dar es Salaam.
This was a prospective study that recruited all patients who underwent cardiac operation
between May 2008 and June 2009. Patients’ details including age, sex and duration of
symptoms were taken. The diagnosis as found from echocardiography and confirmed during
operation and whether there was an associated cardiac lesion was recorded; the type of
operation whether done on pump or off pump was coded and recorded. The pulmonary
pressure was also determined during echocardiography and quantified to whether there was
pulmonary hypertension or not. The ejection fraction combined with fraction of shortening
were used to assess ventricular function simultaneously the diastolic function was assessed
and whether cardiac dysfunction was present or not were recorded. During operation the time
of aortic cross-clamp that was categorized into short if it was less or equal to 60 minutes and
prolonged when more than 60minutes, total duration of conduct of bypass that was
categorized into short if less or equal to 60 minutes, moderate when 61-100minutes and
prolonged when >100minutes. Operation time that was counted from skin incision to its
closure was recorded and categorized into short to average time if the procedure lasted to less
or equal to 4 hours and prolonged when it was more than that. Patient was followed into the
ICU while closely monitored for any complication that develops. Further noted was the total
duration of intensive care stay. The duration of ICU stay was categorized as early stay if it
was five days or less and prolonged when it was more. The duration of hospital stay known
as post intensive care hospital stay was noted at the time of discharge of the patient from the
hospital. This duration was categorized into short to normal when the patient stayed for less
than or equal to two weeks and prolonged when it was more. Further noted were any
complication the patient develops while in the ward. The final disposition of the patient as to
112
March/April 2010.
whether recovered fully, partially or died was also noted. Data were entered into a master
data sheet and then into SPSS 11.5 window program and analyzed accordingly.
Results
There were 105 cardiac cases of which 22(21%) were males and 83(79%) were females
making1:4 male to female ratio. The mean age was 19.4±12.3 years, range 2-52 years. The
mean duration of operation was 3.1±1.0 hours ;( range 1-5.5 hours). The mean duration of
aortic cross-clamp was 64.4±25.4 minutes; (range 12-176 minutes) for 72 cases. The mean
duration of cardio bypass was 94.0±33.6 minutes; (range 40-240 minutes) for 72 cases. The
mean duration of intensive care stay was 4.5±2.1 days; (range 2-20 days). And mean duration
of post ICU hospital stay 13.7±6.6 days ;( range5-50 days) for 94 cases.
Females (79%) had more cardiac disease as compared to males (21%). Majority of patients
occurred in the ages between 7-16 years. (Table 1)
Table1. Age-sex Distribution
Age Group(years)
2-6
7-11
12-16
17-21
22-26
27-31
32-36
37-41
42-46
47-51
52-56
Total
Male
3(30)
4(19)
8(30.8)
3(23)
2(22)
2(25)
0(0)
0(0)
0(0)
0(0)
0(0)
22(21)
Female
7(70)
17(81)
18(69.2)
10(77)
7(78)
6(75)
6(100)
4(100)
3(100)
3(100)
2(100)
83(79)
Total (%)
10( 9.5)
21(20.0)
26(24.8)
13(12.4)
9( 8.5)
8( 7.7)
6( 5.7)
4( 3.8)
3( 2.8)
3( 2.9)
2( 1.9)
105(100)
Number of cases
20
10
Year
2008
0
2009
r
be
r
be
113
em
ov
er
ob
ct
Figure 1. Number of Operations per month and Year
m
ce
De
N
O
r
be
em
pt
Se
st
gu
Au
ly
Ju
ne
Ju
ay
M
ril
Ap
ry
ua
br
Fe
y
ar
nu
Ja
Month of operation
March/April 2010.
Table 2. Pattern of group of cardiac disease
Cardiac disease
frequency
percentage
35.2
47.6
16.2
1.0
100.0
Valid
percentage
35.2
47.6
16.2
1.0
100.0
Cumulative
percentage
35.5
82.9
99.0
100.0
CHD
RHD
Myxomatous
Pericardial
Total
37
50
17
1
105
Cumulative
Percentage
17.1
22.9
27.6
29.5
33.3
35.2
67.6
68.6
94.3
99.0
100.0
Table 3. Distribution of Cardiac Diseases
Diagnosis
Frequency
Percentage
Valid percentage
PDA
ASD
VSD
Single atrium
Pulmonary stenosis
AV_Canal
MR
TR
MS
AR
Pericardial effusion
Total
18
6
5
2
4
2
34
1
27
5
1
105
17.1
5.7
4.8
1.9
3.8
1.9
32.4
1.0
25.7
4.8
1.0
100.0
17.1
5.7
4.8
1.9
3.8
1.9
32.4**
1.0
25.7**
4.8
1.0
100.0
PDA
Associated lesion
ASD
Ms
VSD
AR
Diagnosis
Single atrium
Clot
Pulmonary stenosis
PFO
AV-canal
Pericarditis
MR
Aortic membrane
TR
Pulmonary stenosis
MS
TR
AR
MR
Pericardial effusion
0
10
20
30
Figure 2. Cardiac Diseases Occurring in Combination
114
40
March/April 2010.
Table 4. Presence of Ventricular Dysfunction and Patients’ Outcome
Perioperative factors
Total
Postoperative outcome
Full
recovered
Partial
recovered
Died
pvalue
Ventricular
dysfunction(105cases)
Yes
No
23(21.9)
82(78.1)
19(82.6)
65(79.3)
0(0.0)
7(8.5)
4(17.4)
10(12.2)
0.3
χ2=2.4
df=2,
Ischaemia
time(72cases)
Short
41(56.9)
Prolonged 31(43.1)
34(82.9)
19(61.3)
4(9.8)
2(6.5)
3(7.3)
10(32.3)
0.0
χ2=7.4;
df 2,
Table 5. Total operation time, ventricular dysfunction and postoperative complications
*= Total operation time, §= ventricular dysfunction, CCF= congestive cardiac failure, Techn.diff= technically
Perioperative
factors
Total
Postoperative complications
TOT*
89(84.8) 65(73.0) 8(9.0) 2(2.2)
None
Short
Prolonged 16(15.2)
Ventr.dysf§
CCF
Techn.diff
9(56.3) 0(0.0) 0(0.0)
PVS
LOS
Wound
inf.
ARDS
4(4.5)
2(2.0) 0(0.0)
1(6.3) 3(18.8) 1(6.3)
1(6.0) 1(1.0)
5(5.6) 3(3.4)
Par’lysis
Yes
23(21.9) 18(78.3) 1(4.3) 0(0.0)
2(8.7) 2(8.7)
0(0.0)
0(0.0) 0(0.0)
No
82(78.1) 56(68.3) 7(8.5) 2(2.4)
4(4.9) 4(4.9)
5(6.1)
3(3.7) 1(0.0)
difficult, PVS= paroxysmal ventricular systoles, Wound inf= wound infection, ARDS= Acute respiratory
distress syndrome, Para’lysis= paralysis
20
Final outcome
10
Count
Full recovered
Partial recovered
0
Died
as
eg
ev n
ce
D
la
o
i
p
at
re
pt
e
t
lv
Se
en
va
c
m
rti
ce
Ao pla
e
-R r
y
V
ai
M
om
ep
ct
y
-R y/e
om
V
ot
M tom
y
lv
s
Va tom
rio
y
ro
Pe
ar
su om
on
s
i
t
lm
m
ro
m
Pu
su
co
is
n
m
pe om
O
c
d
se
lo
C
re
su
lo
C
n
tio
ga
Li
Type of operation
Majority of patients had recovered fully and w ere discharged(86.7%)
Mitral valve repair accounted for more death 9(64.3%) of all deaths
Figure 3. Morbidity/Mortality with Type of Operation
115
pValue
0.04
χ2=14.4;
df 7
0.7
χ2=4.7;
df=7,
March/April 2010.
Table 6. Total operation time and duration of ICU Stay
Total operation Duration of ICU stay
Died in theatre
time
Short
0(0)
78(87.6)
Short
2(12.5)
10(62.5)
Prolonged
Total
2(1.9)
88(83.8)
χ2=13.7; df 2, p=0.001
Total (%)
Prolonged
11(12.4)
4(25.0)
15(14.3)
89(84.8)
16(15.2)
105(100)
Table 7. Outcome of Management
Outcome
Discharged home
Died in theatre
Died in ICU
Died in ward
Total
Number(Percentage)
91 (86.7)
2 ( 1.9)
9 (8.6)
3 (2.9)
105 (100)
Number of Deaths (%)
2(14.3)
9(64.3)
3(21.4)
14 13.3)
Operations started in may 2008 and we progressed to December (red bars) (Figure 1).
Rheumatic heart diseases accounted for the large number of cases that were operated at the unit
(47.6%) (Table 2)
Mitral valve disease accounted for the majority of cardiac diseases (58.1%) (Table 3). Majority
of cardiac diseases occurred with other associated cardiac lesions (Figure 2). There was
statistical significant between duration of aortic-cross clamp and postoperative outcome
(p<0.05). There was no statistical significant difference between patients with ventricular
dysfunction and patient outcome (p>0.05). (Table 4). There was significant statistical difference
between total duration of operation and emergency of complications (p<0.05)
There was no statistical significant between ventricular dysfunction and postoperative complications
(p>0.05) (Table 5). There was significant statistical difference between total operation time and
duration of intensive care stay (p<0.01) (Table 6)
When comparing morbidity/mortality, majority of patients had full recovery and the mortality
was probably within acceptable limits in a newly established cardiac centre (Figure 3). The
overall mortality rate was 13.3% with 64.3% of all deaths occurring in the ICU. Nine (64.3%)
of the deaths followed mitral valve repair, 3 patients died following mitral valve replacement,
1 patient died following VSD closure and one patient died following PDA ligation.(Table 7).
Discussion
The study showed that with initial setting of a cardiac unit in our centre majority of patients
(86.7%) had fully recovery and were discharged. However the mortality of 13.3% is probably
comparable to other settings11. The spectrum of cardiac disease found elsewhere is also found
in our community8. Majority of our patients had Rheumatic valvular heart disease (47.6%
Table 2) this high incidence noted in this study as compared to other cardiac lesions goes in
parallel with the high incidence of the disease to any African country that is the result of the
burden of rheumatic fever attributed to combination of lack of resources, infrastructure,
political and economic instability, poverty, overcrowding and malnutrition12. Further the
116
March/April 2010.
highest incidence of rheumatic heart disease is found in sub-Saharan Africa with a prevalence
of 5.7 per 1000 as compared to 1.8 per 1000 in North Africa and 0.3 per 1000 in economically
developed countries with established market economy 13, 14. Since the majority of cases were
mitral valvular disease and in particular mitral regurgitation and patients who succumbed to
death followed mitral valve repair it implies that mitral valve repair requires more skills and
expertise. Nkomo VT, portrays that problem to valve repair or replacement for rheumatic heart
disease with or without infective endocarditic in young economically disadvantaged patients
are numerous12. The fulminant course of rheumatic fever, rheumatic heart disease and infective
endocarditis coupled with delayed patient presentation results in a high incidence of heart
failure at presentation15, associated with high in-hospital and late mortality even with surgical
intervention16,17,18. Our patient had long duration of symptoms of mean 32±14 months (range
18.2-46.3) in rheumatic heart diseases and at presentation 80% were in NYHA class III and IV.
Despite staying in the ward for 3 weeks to 3 months in some, for optimization of medication
before surgery was undertaken, it was possible that some portions myocardial tissue could have
undergone remodeling. The mere presence of suboptimal ventricular dysfunction is probably
not a contraindication to cardiac operation.
The duration of aortic cross-clamp and total operation time were determinant of postoperative
outcome. This finding was similar to other series where ischemia time and total operation time
was found to be determinant of early extubation and postoperative complications for prolonged
operations 19, 20. However this study could not demonstrate any association with the total pump
time. Garcia-Montes et al also could not find any similarity with total pump time while
determining factors associated with prolonged mechanical ventilation in paediatric patients21.
Conclusion
Majority of patients who underwent cardiac surgery had full recovery. The diversity of
spectrum of cardiac disease found elsewhere is also found in our community and therefore
need to increase community awareness. Mitral valve repair deserve a special entity that
requires skills and expertise. The mere presence of suboptimal ventricular dysfunction is
probably not a contraindication to cardiac operation. The duration of aortic cross-clamp and
total operation time were determinant of postoperative outcome.
Acknowledgement
We thank the government through Ministry of Health and Social welfare for having realized the need
of its people and training the cardiac team. We also thank the administration of Muhimbili National
Hospital for having supported the unit throughout the period since its establishment. We thank
members of the task force who have played a big role since its early plans and for close monitoring of
the project.
References
1. World health report 2000, http:// www. who.int/whr
2. Pezzela AT. Open heart Surgery in a developing country. Asian Cardiovascular and
Thoracic Ann. 2006; 14: 355-356
3. Pezzela AT, International Cardiac Surgery: A global perspective seminars in Thoracic
and Cardiovascular Surgery. Asian Journal of cardiovascular and thoracic Ann 2002;
14: 298-320
4. Fuster V, Voute J. Comment: MDGS: Chronic diseases are not on the Agenda.Lancet
2005; 366: 1512-1514
117
March/April 2010.
5. Vladmir V, Michel M, Marek B, Gregory K, Xaverier M, Peter N. The development
of cardiac surgery in an emerging country. Texas Heart Inst J. 2008;35(3): 301-306
6. Ghosh p. Setting up an open heart surgical program in a developing country. Asian
Cardiovascular Thorac Ann. 2005;13(3): 299-301
7. Pezzella A T. Global Expansion of Cardiac Surgery in the New Millennium. Asian
Cardiovasc Thoracic Ann 2001; 9: 253-256
8. John CE and Ndubueze E. Open heart surgery in Nigeria indications and challenges.
Texas Heart Inst J. 2007;34: 8-10
9. National department of health annual report 2008/2009. www.doh.gov.za
10. Akomea-Agyin C, Galukande M, Mwambu T, TtendoS, and Clarke I. pioneer human
open Heart Surgery using cardiopulmonary by pass in Uganda. African Health
Sciences, 2008; 8(4): 259-260
11. Luis AL, Kathy JJ, Kimberlel G. Improvement in Congenital Heart Surgery in a
Developing Country: The Guatemalan Experience, Circulation 2007; 116: 18821887.
12. Nkomo VT. Global burden of cardiovascular disease: epidemiology and prevention of
valvular heart diseases and infective endocarditis in Africa. Heart 2007; 93: 15101519
13. World Health organization. The current evidence for the burden of group A
streptococcal diseases. http:// www.who.int/child-adolescent
14. Carapetis JR, Steer AC, Mulholland EK et al. The global burden of group A
streptococcal diseases. Lancet Inf Dis 2005; 5: 685-694
15. Amoah AG, Kallen C. Aetiology of heart failure as seen from a National Cardiac
Referral Centre in Africa. Cardiology 2000; 93: 11-18
16. Touze JE, Ouattra K, Coulibaly AO et al. Infectious endocarditis surgically
treatedbduring the acute phase.26 cases. Presse med 1986;15: 787-790
17. Louw JW, Kinsley RH, Dion RA et al . Emergency heart valve replacement: an
analysis of 170 patients. Ann Thorac Surg 1980; 29: 415-422
18. Fradi I, Drissa MA Cheour M, et al Retrospective study on 100 cases of infective
endocarditis, Rabta University Hospital, Tunis. Arch Mal Coeur Vaiss 2005; 98: 966971
19. Steve D, Sarah W, Roger BB, Mee MB, Harrison. Factors associated with early
extubation after cardiac surgery in young children. PCCM 2004; 5(5): 63-68.
20. Varro M, Gombocz K, Wrana G. Factors influencing early extubation after open heart
surgery. Orv Hetil 2001; 142(23): 1217-1220.
21. Garcia-Montes JA, Calderon-Colmenero J, Casanova M, Zarco E, Fernandez de la
Requera G, Buendia A. Risk factors for prolonged mechanical ventilation after
surgical repair of congenital heart disease. Arch. cardiol. Mex 2005; 75(40): 402-407
118
March/April 2010.
Thoracic empyema: Cause and Treatment Outcome at Gondar University Teaching
Hospital, Northwest Ethiopia
A. Amare, B. Ayele, D. Mekonnen
College of Medicine and Health Sciences, Department of Internal Medicine, Gondar University,
Ethiopia.
Correspondence to: Dr Amanuel Amare, Email: [email protected]
Background: Despite improved antimicrobial therapy and multiple options for drainage of
infected pleural space, thoracic empyema (TE) continues to cause significant morbidity and
mortality. The objectives of this study were to assess the causes and treatment outcome of
patients with thoracic empyema.
Methods: Patients aged ≥ 13year with TE who were admitted to Gondar University Teaching
Hospital, Northwest Ethiopia, from Nov 1999 to Dec 2007 were included. Retrospectively,
medical records were reviewed and demographic and clinical data were collected.
Results: Records of 81 patients were analyzed; majority (82%) were below the age 50 year. The
mean duration of symptoms prior to presentation and hospital stay was 97.4 and 38days,
respectively. HIV/AIDS was detected in 60%. Causes of empyema were pulmonary tuberculosis
(56%), pneumonia (36%) and lung abscess (7%). Closed chest tube was inserted in 86% of cases
and was successful in 93% of them. Case-fatality was 12% and poor outcome occurred in 26%.
Conclusions: Early identification of TE and aggressive management with antibiotics or
antituberculosis, drainage with chest tube, and surgical treatment when closed tube drainage
fails is recommended to improve the high mortality and morbidity.
Introduction
Thoracic empyema (TE) is characterized by bacterial organisms seen on gram stain or aspiration of
pus on thoracentesis. Despite improved antimicrobial therapy and multiple options for drainage of the
infected pleural space, TE continues to cause significant morbidity and mortality. TE is commonly
caused by pneumonia, lung abscess, tuberculosis, and chest trauma and predisposing factors include
alcoholism, malignancy, Diabetes mellitus and HIV infection1-11 . The mortality rate of TE in different
studies ranges from 4.7% to 24 %2-5,8-11. Antibiotic therapy and drainage of the pleural space remain
the first line of therapy for TE11. Early adequate operative drainage in patients with TE results in low
morbidity, shorter stays in hospital, and good long term outcome8. In our set up the available methods
for drainage are therapeutic aspiration and intercostal drainage tube connected to water seal. There
was one study done in Ethiopia which studied retrospectively patients with TE who were treated in
Tikur Anbessa Hospital where chest surgery service is available3. To the best of our knowledge there
is no study done in Gondar University Teaching Hospital (GUTH) in patients with TE. This study was
designed to assess the clinical presentation, cause, predisposing factors, treatment and out come of
patients with TE who presented to GUTH, Northwest Ethiopia.
In this hospital-based retrospective study patient aged 13 years and above who were admitted to
Gondar University Teaching Hospital with the diagnosis of thoracic empyema from Novenber 1999 to
December 2007 were included. The diagnosis of thoracic empyema was based on the finding of gross
purulent exudate or pleural fluid culture or Gram stain showing organisms. The study was started after
getting ethical clearance from the Research and Publication Office of the University of Gondar.
Confidentiality was assured by assigning each patient record a unique number.
Medical records of eligible patients were manually searched and datasheet was prepared to collect the
following data: age, gender, address, presenting symptoms and signs, duration of illness, predisposing
factors, investigations, chest x-ray, treatment, complications, duration of hospital stay and outcome at
hospital discharge and cause of death. Successful chest tube drainage was defined as clinical and
119
March/April 2010.
radiological improvement. Poor outcome included both deteriorated and dead patients. Tuberculose
empyema was diagnosed based on clinical presentation, suggestive investigations, chest x-ray and
favorable response to antituberculosis drugs. The data were analyzed using SPSS version 13.0 for
Windows (SPSS, Chicago IL, U.SA.).
Results
Data from 81 patients with empyema thoracis were analyzed. There were 47 males and 34 females.
The ages ranged from 16 to 90 with a mean of 36.6 years and a peak was in the 21-30 age group. The
presenting symptoms are shown in Table 1. Right-side chest findings slightly outnumbered left-side
chest findings (Table 3).
More than one type of chest x-ray findings were detected in some patients. Pleural fluid was frank pus
in 74 (91.4%) of patients and the mean pleural fluid cell count was 16,038 cells/mm3 (range 340 110,650). Gram staining of the fluid was revealing in 29(36%) of cases: Gram positive (n=21), Gram
negative (n=2), and both types of organisms (n=6). Acid-fast staining of the empyema showed
mycobacterial species in 2 patients. Culture of the empyema grew bacteria in 12(15%) of cases: S.
aureus (n=5), streptococcus species (n=3), proteus species (n=2), pseudomonas species (n=1) and
Klebsella Ozenae (n=1).
Pathological examination was done in 9 patients and revealed inflammatory empyema. Sputum acidfast staining and fine-needle aspiration of lymph node showed evidence of tuberculosis in one patient
each.
Table 1. Presenting Symptoms.
Symptoms
Cough
Fever
Sputum production
Weight loss
Chest pain
Shortness of breath
Night sweating
Chills
Haemoptysis
spontaneous drainage of empyema
Number of Patients
79
76
67
64
63
61
58
27
22
5
%
97.5
93.8
82.7
79.0
77.8
75.3
71.6
33.3
27.2
6.2
Table 2. Physical Signs Identified.
Physical sign
Signs of pleural effusion
Signs of hydropneumothorax
Crepitations
Signs of consolidation
Tracheal/mediastinal deviation
Lymphadenopathy
Change in mentation
Cyanosis
Pleural friction rub
Wheezes
Number of Patients
59
22
22
21
19
12
4
4
2
2
120
%
72.8
27.2
27.2
25.9
23.5
14.8
4.9
4.9
2.5
2.5
March/April 2010.
Table 3. Chest X-ray Findings in 78 Patients.
Chest x-ray Findings Suggestive of:
Fluid
Hydropneumothorax
Consolidation
Parenchymal infiltrates
Collapsed lung
Fibrotic changes
Hilar mass
Cavity
Milliary pattern
Pleural thickening
Number of Patients
44
35
10
7
6
3
2
2
1
1
%
56.4
44.9
12.8
9.0
7.7
3.8
2.6
2.6
1.3
1.3
Peripheral blood examination showed leukocytosis in 7.4%, in leucopenia 26.5%, anaemia in 65.6%
and high erythrocyte sedimentation rate (ESR) in 96.9% of cases with mean value of 94 mm in the
first hour. Serology test for HIV was done in 53(65.4%) and it was positive in 32(60.4%) cases. Chest
ultrasound showed loculated empyema in 7 patints and subphrenic abscess in 1 case.
Causes of empyema were pulmonary tuberculosis in 45 (55.6%), pneumonia in=29 (35.8%), lung
abscess in 6 (7.4%) and subphrenic abscess in 1 (1.2%) of the cases. Of the 32 patients with HIV
infection, 20 (62.5%) had empyema due to tuberculosis.
Treatment
Anti-tuberculosis and antibiotics were respectively given to 45 (55.6%) and 77 (95.1%) of the
patients. Seventy (90.9%) cases required 2 or more types of antibiotics and the duration of treatment
ranged from 1 to 49 days with a mean of 25days. Chest tube was inserted in 70 (86.4%) and it was
successful in 65 (92.9%) of the cases. The mean interval in days between admission to hospital and
chest tube insertion was 2.1 days with a range of 0 to 13 days. The mean duration of stay of chest tube
before removal was 14 days (range3 to 66). Chest tube reinsertion was required in 9(13%) patients
and the indications for reinsertion were recollection of empyema in 7 and pneumothorax in 2 patients.
Chest physiotherapy was given to 46(56.8%) cases.
Outcome
Outcome at hospital discharge was cure or improved in 60 (74.1%), deterioration without death in 11
(13.6%) and death in 10 (12.3%). The cause of death was septic shock in 7 and respiratory failure in
3 of the cases. Among the deceased 7 (70%) were males. HIV test was done in 6 of the patients who
died; 3 had tested positive. Poor outcome tht is the sum of those who died and those who deteriorated
was 21(26%). In patients with poor outcome HIV test was done in 13 patients and it was positive in 7
of them.
The following sequelae were observed at discharge: collapsed lung (n=9), empyema necessitance
(n=8), pneumothorax (n=5), fibrothorax (n=4), and bronchopleural fistula (n=4). After hospital
discharge, 33 (46.5%) patients had one or more follow up visit(s).
Discussion
The objectives of our study were to analyze the clinical presentation, causes, treatment and outcome
of patients with thoracic empyema admitted to Gondar University Teaching Hospital. The types of
treatment that were given to these patients were antibiotics, antituberculosis, aspiration(s), and
intercostal drainage tube connected to water seal. Surgical treatment (decortication etc) was not
available. Most other thoracic empyema studies showed male preponderance.1-4 Similarly in our series
121
March/April 2010.
58% were males. Majority of our patients (81.5%) were below the age 50 which is consistent with
other studies done in Africa .2-4 This mainly reflects the Ethiopian demographics that projected that
95.6% of the population would be ≤ 59 year old in 2005.12
In this study there was marked delay at presentation of patients to our hospital. The mean duration of
symptoms prior to presentation was 3.2 months which is long compared to other studies done in
Zambia4 and Pakistan5 which was 1.4 and 1.5 months , respectively. The mean hospital stay was 38
days which is consistent with other studies 3,11which was 43.2 and 37days, respectively. A shorter
mean hospital stay (19.8days) was observed in another study .1 Previous study has suggested that
delay to drainage of an infected pleural space is associated with increased morbidity and hospital
stay.8
The commonest cause of thoracic empyema in our series was pulmonary tuberculosis (55.6%) which
is similar to other studies done in Africa which ranges from 48.7% to 63.2%.2-4 In a study done in
India, pulmonary tuberculosis caused thoracic empyema in 21% of cases.6 The second commonest
cause identified in our study was pneumonia(35.8%) which is the commonest etiology of thoracic
empyema in other studies ranging from 46.7 % to 94.9% .1,5,8,10,11 The commonest serous associated
disease identified in our study was HIV/AIDS (60.4%) which is similar to a study done in Zambia
(66.7%).4 Associated malignancy which occurred in 23% of patients in one study 11 was not identified
in our cases which is similar to a study done in Tanzania.2 Late referral for surgical management of
empyema thoracis had a significantly greater incidence of anemia .8 The high incidence of anemia in
our patients (65.6%) might be explained by the marked delay at presentation and the high incidence of
associated HIV/AIDS.
Thoracostomy tube drainage success rate from previous studies ranged from 46.6% to 86%.3,5,10,11 In
our series the success rate was 86.4%. Previous studies showed that the mortality of thoracic
empyema ranges from 4.7% to 24% .2-5,8-11 Mortality rate may be as high as 10% in healthy patients
and 50% in elderly and debilitated patients .5 The hospital mortality rate in our study was 12.3%; it
may have been lower due to younger age group. In a prospective study of patients with pleural
infection, early and aggressive treatment with chest tube drainage and antibiotics was associated with
good outcome (mortality 4.7%) and emphasizes the need for rapid and effective intervention in this
disease.9The high percentage of patients with poor outcome (26%) probably indicates the marked
delay at presentation, the unavailability of surgical treatment when closed tube drainage fails and the
high prevalence of HIV/AIDS.
Conclusion
Most of our patients were young males and presented with cough, fever, expectoration and weight
loss. There was marked delay at presentation and the commonest cause was pulmonary tuberculosis
followed by pneumonia. Underlying HIV/AIDS was found in 60% of cases.
High mortality and poor outcome was noted in our series 12.3% and 26%, respectively. Early
identification of thoracic empyema and aggressive management with antibiotics or antituberculosis,
drainage with chest tube, surgical treatment when tube drainage fails is recommended to improve
mortality and morbidity.
Acknowledgment
The academic staff of the College of Medicine and Health Sciences, Department of Internal Medicine,
University of Gondar, is acknowledged for their multidimensional support.
References
1. LeMense GP, Strange C, Sahn SA . Empyema thoracic: therapeutic management and
outcome. Chest 1995;107: 1532-1537
122
March/April 2010.
2. Mteta KA. Thoracic empyema in Dar Es Salaam, Tanzania. East Afr Med J 1994;71(10):
684-6
3. Ali A, Biluts H, Gulilat , D. Management of empyema thoracis in Tikur Anbessa Hospital: A
three-year experience. East and central African journal of surgery 2003; 8 (1):47-50
4. Desai GA, Mugala DD. Management of empyema thoracis at Lusaka,Zambia. Br. J. Surg
1992; 79 : 537-538
5. Nadeem A, Bilal A, Shahkar S, Shah, A. Presentation and management of empyema thoracis
at Lady Reading Hospital Peshawar. J Ayub Med Coll ABottabab 2004; 16(1): 14-7
6. Gupta SK, Kishan J, Singh SP. Review of one hundred cases of empyema thoracis. Indian J
Chest Dis Allied Sci 1989;31(1): 15-20
7. Chu MA, Dewar LS, Burgess JJ, Busse EF. Empyema thoracis: lack of awareness results in a
prolonged clinical course. Can J Surg 2001; 44 (4): 284-288
8. Cham CW, Haq SM, Rahamim J. Empyema thoracis: A problem with late referral? Thorax
1993;48:925-7.
9. Davies CH, Kearney SE, Gleeson FV, Davies RO. Predictors of Outcome and Long-term
Survival in patients with Pleural Infection. Am. J. Respir. Crit. Care Med. 1999; 160(5):16821687.
10. Huang HC,Chang HY, Chen CW, Lee CH, Hsiue TR.(1999) Predicting Factors for Outcome
of Tube Thoracostomy in Complicated Parapneumonic Effusion or Empyema. Chest
1999;115 :751-756
11. Alfagame I,Munoz F, Pena N, Umbria S. Empyema of the thorax in adults:
etiology,microbiologic findings and management. Chest 1993;103:839-843
12. Federal Democratic Republic of Ethiopia (FDRE). Office of Population and Housing Census
Commission, Central Statistics Authority. The 1994 Population and Housing Census of
Ethiopia, results at country level. Vol. I Addis Ababa, 1998.
123
March/April 2010.
Neurocritical Care Audit in A Tertiary Institution
O.E. Idowu1, S.O. Oyeleke2, A.A. Olaoya1
1
Neurosurgery Unit, Department of Surgery and 2Department of Anaesthesia, Lagos State University
College of Medicine, and Lagos State University Teaching Hospital Ikeja, Lagos.
Correspondence to: O.E. Idowu, E mail: [email protected]
Background: The ‘open’ intensive care unit (ICU) predominates in most low and middle
economy societies. This is associated with paucity of personnel and cost challenges involved for
its maintenance and smooth running despite the great public demand for this service. Data on
neurocritical care in scare in Nigeria and the subregion as a whole. Our objective is to audit our
neurocritical care facility, human resources, patient admission and outcome.
Patients and Method: We conducted a retrospective audit of all patients admitted to our ‘open’
ICU following a neurological indication. This study was carried out over a one year period
(January 2008-December 2008). In addition to patients’ boidata, we recorded date of admission,
indication for admission, treatment (operative/non-operative), ventilatory support if any, and
outcome (Alive or dead).
Results: One hundred and twenty-nine patients were admitted during the study period, 85
(65.9%) of which was due primarily to a Neurosurgical indication. The overall mortality was
25.9% while mortality of ventilated patients was 64.5%. Mortality rate was significantly by
ventilation.
Conclusion: Neurological patients account for most of our ICU admission. Hospitals with ICUs
should ensure that they have a proper high dependency unit. We also recommend that
appropriate equipments and staff training in the area of neurocritical care be incorporated into
existing ‘open’ ICUs in our environment. The use of protocol for ventilated patients and
managing common ICU cases and common procedures should enhance treatment outcomes.
Introduction
The critically ill patient pose a lot of management challenges to the managing physician especially in
low income societies. This is truer in poverty stricken third world countries where limited facilities in
terms of beds, drugs and equipment are a common scenario. The quality of care is directly related to
manpower and equipment. Intensive Care has emerged as a distinct specialty in the world over the last
3-4 decades1. The original concept of the nursing legend, Florence Nightingale of rounding up all
seriously ill patients in hospital matured to become recovery units for postoperative care in the early
1950’s. The importance of mechanical ventilation was mostly realized in the polio epidemic in
Copenhagen in 1952 where the mortality rates reduced from 90% to 40% following its introduction2.
This gradually led to the recognition of the importance of close monitoring and vital function support
in the treatment of life threatening diseases.
It is recommended that 15% of total bed strength of hospitals should be equipped for critical care;
most countries have provision for only 1-2% of their total bed strength for critical care3. In Nigeria as
a whole, ICU bed availability is substantially low, perhaps below 1% and there is no governing body
or a planning institute that scrutinizes the standards of such units (personal communication).
Alarmingly, in Nigeria’s most densely populated state there are just five functional ICUs- two
government-owned ICU and four privately operated ICUs. All these are grossly inadequate for an
estimated 14million population of the state. To make matters worse, some states in the country do not
even have an ICU. Intensive Care Unit (ICU) is not only a medically important part of the Hospital,
but is also a politically sensitive issue because of the costs involved for its establishment, maintenance
and running despite the obvious public demand for this service.
Data on intensive care services in the country and the subregion is rare. Our objective is to audit our
neurocritical care facility, human resources, patient admission and outcome so as to find out areas that
need adjustment to better improve the quality of our patient care practice.
124
March/April 2010.
We carried out a retrospective study of the patients admitted into one of our ICUs at the Lagos State
University Teaching Hospital (LASUTH), Ikeja, Lagos, Nigeria, over a 12month period (January
2008- December 2008). All surgical and non-surgical
surgical patients were included in the study. Data were
extracted from the Medical Records and reviewed. Data retrieved from each patient’s record included
demographic data, date of admission, indication for admission, treatment (operative/non
(operative/non-operative),
ventilatory support if any, and outcome (Alive or dead).
Our institution has two ICU facilities, one of which is restricted to patients due to its high cost. The
study was restricted to the relatively affordable ICU facility. The daily running cost
cost is two thousand
naira; this is due to major subsidization be the government. This ICU is a four bedded facility. It is a
multidisciplinary station managing medical, surgical including obstetrics and gynecology, and
pediatric patients. The resources and
and facilities available at our four bed ICU includes a nurse: bed
ratio of 1:1, a centrifuge, one blood gas analyzer, a defibrillator, multiparameter monitor and
ventilator for each bed, with facility and expertise for central lines. Data was analysed by ssimple
frequency, percentages, Chi-square
square and Fischer’s Exact test as appropriate. P<0.05 was considered
significant. Data collected was analyzed using SPSS version 13 computer software.
Results
During the study period a total of 129 admissions were made.
made. The indication for admission was due
primarily to a neurosurgical indication in 85 patients (65.9%). The main indication for admission was
following significant head trauma (Figure 1). Majority of the patients were males (69 patients) with a
male female ratio of 4.3:1. The age distribution is depicted in figure 2 (range: 1.5 – 84 years; mean:
36.1 years; median:30 years).
Table 1. Outcome of Ventilated compared with Unventilated Patients
Management
Alive
Died
Total
Not ventilated
57
11
68
Ventilated
Total
6
63
11
22
17
85
80
70
60
50
40
30
20
10
0
Brain trauma
Brain tumour
Spine trauma
Figure 1.The
The indication for ICU in Neurosurgical patients.
(Brain trauma- 70 patients, brain tumourtumour 7 patients, Spinal cord injury- 8 patients).
March/April 2010.
40
35
30
25
20
15
10
5
0
Male
Female
Total
Figure 2. Age and gender of all neurocritically ill patients admitted into the ICU
The overall mortality was 22/85 (25.9%) while mortality of ventilated patients was 11/17 (64.5%).
Mortality rate was not significantly affected by gender (p=0.170) but those that were ventilated were
more likely to die (p=0.000).
The ICU was fully occupied by patients most of the time. Only 11patients were admitted to the ICU
following surgery, 3 of these were admitted following elective brain surgery while the remaining eight
were already in the ICU prior to surgery. Most patients that needed ICU admission after surgery were
not admitted due to lack of space. Facilities for mobile X-ray, intracranial pressure, trancranial
Doppler and electroencephalography were absent during the study period. Likewise 24hour in house
intensivist was epileptic. The proposed high dependency unit was yet to take off during the study
period, putting more strain on the ICU.
Discussion
Current evidence support ‘closed’ ICU systems when compared with ‘open’ ICUs; this is in the
context of better outcomes for patients4,5. Despite this, the ‘open’ type of ICU still predominates in
most low and middle income societies due to paucity of intensivists, ICU teams and a relatively high
cost to establish and maintain them compared with the ‘closed’ ICU. An open ICU has unlimited
access to multiple doctors who are free to admit and manage their patients. A closed ICU has
admission, discharge and referral policies under the control of intensivists. Improved cost benefits are
likely with a closed ICU, and patient outcome may be better, especially if the intensivists have full
clinical responsibilities6.
Most ICUs are located in teaching hospitals, with the “luxury” of several specialized ICUs in each
hospital. At present we do not have a specialized ICU. But our unit often has inputs from multiple
specialties. Historically, the two most important milestones in critical care that made a significant
impact on morbidity and mortality i.e. 24 hours resident medical officer and a nurse:bed ratio of 1:1.
This is to be coupled with minimum monitoring standards which includes multiparameter monitor
with ECG monitor at the bedside of each patient3. In this study we noted that the the medical officer
coverage was not in-house. This is increases the response time to patient’s problems.
126
March/April 2010.
In some centres, over 40% of intensive care unit admissions are for post – operative patients7,8. An
unplanned admission to an intensive care unit within 24 hours of surgery is an event that most patients
and physicians would consider to be an important adverse outcome. Such an unfavourable outcome
results from an amalgamation of inherent risk factors surrounding a combination of coincidences and
even misjudgements in the perioperative period. The multifactorial interaction of patient, anaesthesia
and surgical variables determines the overall patient risk. Early recognition and intervention remains
the key to avoidance of unfavourable outcome. In our centre this is the contrary as most patients had
admitted were not pot-operative patients. Due to its small size, our ICU was usually full. This may
explain the relatively low percentage of post-operative patient’s admission.
Persistent occupancy of more than 70% suggests a unit is too small9. Occupancy of 80% or more is
likely to result in non-clinical transfers, with associated risks. Too few beds may increase mortality or
non-clinical transfers, while extra capacity may not decrease occupancy if patients of a lower
dependency level are admitted, or there are problems discharging patients to other locations10.
The problems identified in our ICU included non-availability neurocritical care equipments for
intracranial pressure (ICP) measurements, etc. The absence of appropriate protocols for managing
common ICU cases and common procedures was also the norm. There are times where
communication breakdown results due to the diversity of the various specialties making use of the
ICU.
The high intake of Neurosurgical patients makes case for more facilities to serve these groups of
patients. Current neuromonitoring techniques involve a range of tools that have evolved from the
study of cerebral physiology and advances in the understanding of the pathophysiology of acute brain
injury. These techniques have focused on the measurement of cerebral physiologic and metabolic
parameters with the goal of improving the detection and management of primary and secondary brain
injury in patients who have suffered head injury, stroke, subarachnoid haemorrhage, or have had
neurosurgical procedures11-13.
The development of new neuromonitoring techniques has been particularly important because
standard monitoring techniques, such as ICP and cerebral perfusion pressure measurements, are
sometimes insufficient in detecting subtle manifestations of brain injury or are poor surrogates for
physiologic parameters of interest. For example, cerebral perfusion pressure may be an unreliable
method to measure cerebral blood flow14,15.
The more recently developed neuromonitoring techniques like cerebral blood flow monitoring
techniques, brain tissue oxygen tension (P bt O 2 ) and jugular bulb venous oxygen saturation (SjVO 2 )
monitoring, and cerebral microdialysis, provide more detailed information regarding cerebral
metabolic function. These measurements provide information that is of prognostic utility as well as
help direct management of the neurocritically ill patient in order to improve clinical outcome. Even as
many of these tools are now becoming integrated into regular neurocritical care, research is ongoing
to determine the validity, reliability, and utility of these techniques in the clinical management of
patients and in predicting and potentially improving clinical outcome12.
Conclusion
Neurological patients account for most of our ICU admission. Hospitals with ICUs should ensure that
they have a proper high dependency unit. This will significantly reduce the strain on their ICUs. We
also recommend that appropriate equipments and staff training in the area of neurocritical care be
incorporated into existing ‘open’ ICUs in our environment. The use of protocol for ventilated patients
and managing common ICU cases and common procedures should enhance treatment outcomes. A
regulator for the maintenance of standards in the country will also help in achieving appropriate
standards in the country.
References
127
March/April 2010.
1. Dudley HAF. Intensive care: a specialty or a branch of anaesthetics? British Medical Journal
1987; 294: 459-460.
2. Bennett D, Bion J. ABC of intensive care. British Medical Journal 1999; 318: 1468-1470.
3. Minimum standards for intensive care units. Policy document IC-1, 1997, Faculty of Intensive
Care: Australian and New Zealand College of Anaesthetists, Melbourne.
4. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcome from
intensive care in major medical centres. Annals of Internal Medicine 1986; 104(3): 410-418.
5. Brown JJ, Sullivan G. Effect on ICU mortality of a full-time critical care specialist. Chest
1989; 96(1): 127-129.
6. Oh TE. Design and organization of intensive care units. In: Bersten AD, Soni N, Oh TE, eds.
Oh's Intensive care manual, 5th ed. Edinburgh: Butterworth Heinemann, 2003: 3-10.
7. Rose K, Byrick RJ, Cohen MM. Planned and unplanned postoperative admissions to critical
care for mechanical ventilation. Can J Anesth 1996; 43: 333-40.
8. Swann D, Houstin O, Goldberg J. Audit of intensive care unit admissions from the operating
room. Can J Anesth 1993; 40:137-41.
9. Intensive Care Society. Standards for intensive care units. ICS, London 1997
(www.ics.ac.uk/).
10. Parker A,Wyatt R, Ridley S. Intensive care services; a crisis of increasing expressed demand.
Anaesthesia 1998; 53:113–120
11. Dunn IF, Ellegala DB, Kim DH, Litvack ZN, Neuromonitoring in neurological critical care:
Neuromonitoring in neurological critical care. Neurocrit Care 2006;4:83-92
12. Suarez JI. Outcome in neurocritical care: Advances in monitoring and treatment and effect of
a specialized neurocritical care team. Crit Care Med 2006;34:S232-8
13. De Georgia MA, Deogaonkar A. Multimodal monitoring in the neurological intensive care
unit. Neurologist 2005;11:45-54
14. Vespa PM. Multimodality monitoring and telemonitoring in neurocritical care: From
microdialysis to robotic telepresence. Curr Opin Crit Care 2005;11:133-8
15. Wintermark M, Sesay M, Barbier E, Borbely K, Dillon WP, Eastwood JD, et al .
Comparative overview of brain perfusion imaging techniques. Stroke 2005;36:e83-99
128
March/April 2010.
Primary Splenic Hydatid: A Case Report
S.I. Gul, M. Sheikh, T.S. Khan, M. Mushtaq, F. Reshi.
Address????????/
Hydatid disease is a parasitic infection caused mainly by Echinococcus granulosus and is a
common entity in this part of the world . However, primary hydatid disease of spleen is a rare
entity. We are reporting a case of a massive primary splenic hydatid cyst in a 27 yr old female,
who presented with left upper quadrant swelling and pain. USG disclosed a large hydatid cyst
and the CT scan confirmed the diagnosis. IgM Elisa for hydatid serology was strongly positive .
An elective open splenectomy was performed, with an uneventful post operative recovery.
Introduction
A hydatid cyst is a zoonotic illness and a significant problem in endemic areas. Hydatid cyst is caused
by echinococcus infestation. Humans are the accidental intermediate hosts. After ingestion, the eggs
hatch and oncospheres penetrate the intestinal mucosa and enter the circulation. The embryos are
carried to the liver to be arrested in the sinusoidal capillaries (liver acts as first filter). Some of the
embryos may pass through the hepatic capillaries and enter the pulmonary circulation and filter out in
the lungs (lungs act as second filter). Rarely a few embryos may pass through the pulmonary
capillaries, enter the general blood stream, and lodge in various organs. Wherever the embryo settles,
it forms a hydatid cyst. The life span of larval worm is considerable and it may continue to develop
for many years1. Liver and lungs are the organs most commonly affected by this disease as evident by
the life cycle of the parasite. Primary infestation of the spleen by the parasite is a rare phenomenon.
Case Report
A 27 yr old tribal married female (G2 P2 A0) from a remote hamlet from south Kashmir , with no
significant past medical history presented with a history of progressively increasing upper abdominal
swelling for the last 6 months. There was also a 4-weeks duration of pain in the right upper abdomen.
General physical examination of patient was normal. Abdominal examination revealed moderate
splenomegaly. The haemogram and routine serum chemistry were normal. Abdominal
Ultrasonography disclosed a large hydatid cyst measuring 152mm x 135mm x 141mm wit a volume
of 1514c.c); with intra cystic rupture seen towards upper pole of spleen (Figure 1). The CT scan
confirmed the presence of a large isolated splenic hydatid cyst with no cyst in the liver, lungs or
kidney (Figure 2). IgM Elisa for hydatid was strongly positive.
Figure 1.
129
March/April 2010.
Figure 2.
Figure 3.
Preoperative albendazole therapy (15mg/kg bwt) was started. Splenectomy was done by left upper
transverse incision. There were dense omental adhesions over spleen with perisplenic adhesions with
surrounding viscera. After careful adhesiolysis, splenectomy was performed and a large sized spleen
(20cm x 15cm) was delivered (Figure 3). Postoperative stay in the hospital was uneventful and the
patient was discharged of 8th postoperative day.
Discussion
Hydatidosis or Echinococcosis, which is caused by E.granulosus has diverse presentations and has
been reported since ancient times. Berlott (1790) was the first to describe splenic hydatidosis as an
autopsy finding2.
It is endemic in sheep rearing areas of Mediterranean, Eastern Europe, Australia, South America and
Middle East. Most common organs involved are liver and lungs. Involvement of the spleen is a rarity
even in endemic areas with an incidence of 0.5-4% of all cases of hydatidosis3,4,5. The incidence
varies widely in sheep rearing countries with maximum reported from Iran(4%)6. In India maximum
incidence of splenic hydatidosis has been reported from Nagpur in Central India5. In various series on
splenic hydatidosis from our state an incidence of 3.5 % and 4.1% has been reported7,8.
Parasitic cysts of the spleen are almost exclusively hydatid cysts. In endemic areas, 50%-80% of
splenic cysts are echinoccoca9.
130
March/April 2010.
Splenic hydatid cysts are generally asymptomatic and they are diagnosed incidentally while
evaluating such patients for other reasons. When the cyst attains a considerable size the patient
becomes symptomatic and mostly presents with painful left upper abdominal mass9,10, as was the
presentation with our patient. If the cyst gets infected patient may present with fever and
leukocytosis11. Sometimes the patient may also present with fatal anaphylactic reaction due to the free
intra peritoneal rupture of the cyst10. Due to the constant risk of this latter dreadful complication, there
is an absolute indication of splenic hydatid cysts, especially large ones, to be treated surgically10,12,13.
The standard treatment option is Total or Partial splenectomy6. In our case we preferred open total
splenectomy. The literature also favours such treatment modality because of the following reasons :
1) In large cysts splenic parenchyma is significantly reduced due to pressure atrophy.
2) The thickened fibrous membrane as seen in hepatic hydatid cysts is quite thin and fragile in
splenic hydatid cysts ,so the risk of intra op rupture is high in splenic cysts if a conservative
approach is adopted during surgery15.
Complications of splenectomy such as hemmorhage, pancreatic or gastric injuries,
thromboembolic phenomena and overwhelming postsplenectomy infections (OPSI) are reviewed
in literature10,16,17. None of such complications occurred in our patient.
Due to the risk of OPSI(approx 10%) some authors advocate conservative approach to be adopted
in splenic surgery. However it is suggested that spleen sparing surgery can be done, if there is
adequate amount of splenic parenchyma remaining and if the cyst is small and located
peripherally15. Both these factors were absent in our case. With the advance in laparoscopic
surgery, laparoscopic splenectomy is being increasingly performed at advanced laparoscopic
centers. Though some authors find it safe and effective alternative to open splenectomy18, while
as others believe that it is unsafe, to approach splenic hydatid laparoscopically, due to the risk of
anaphylactic shock and intraperitoneal dissemination, which can occur subsequent to uncontrolled
puncturing of the cyst10,16,18,19.
To conclude, in endemic regions, in cystic lesions of spleen, a primary diagnosis of splenic
hydatidosis must be made, unless proved otherwise. Moreover, because of the above risks, we
advocate open splenectomy as the ideal procedure for massive splenic hydatidosis.
References
1. Chatterjee K.D, Parasitology, protozoology, and helminthology, 12th Edition 1980,
pg-122
2. Muro J, Ortiz-Vazquez J, Mino G, Sanmartin P. Demonstration angiografica del
quiste hidatidico de bazo. Rev Clin Esp 1969; 115 : 433-38.
3. Golematis B, Delikaris P. Treatment of echinicoccal cyst. In Mastery of Surgery.
Boston, Massachusetts: little brown, 1984; 633-41.
4. Humphreys WG, Jhonston GW. Splenic cysts : a review of six cases. Br J Surg 1979;
66 : 407-8.
5. Manouras AJ, Nikolaou CC, Katergiannakis VA, Apotolidis NS, Golematis BC.
Spleen-sparing surgical treatment for echinococcosis of the spleen. Br J Surg 1997;
84 : 1162.
6. Torbati M. Hydatid diseases of the spleen, Report of an unusual case. Brit J Surg
1972; 59 : 489-91
7. Manzoor Ahmad Dar, Omar Javed Shah, Nazir Ahmad Wani, Fayaz Ahmad Khan
Surgical Management of Splenic Hydatidosis Surgery Today, Volume 32, Number 3
/ March, 2002 Pages 224-229
8. Wani NA. Hydatid Disease of the spleen. Ind J Surg 1993; 55 (3) : 155-60.
9. Uriarte C: Splenic hydatidosis. Am J Trop Med Hyg 1991;44:420–4239.
10. Ratych RE: Tumors, cysts and abscesses of the spleen; in Cameron JL (ed): Current
Surgical Therapy, ed 4. St. Louis, Mosby, 1992, pp 518–521.
131
March/April 2010.
11. Franquet T, Cozcolluela R, Montes M, Sanchez J: Abscessed splenic hydatid cyst:
Sonographic and CT findings. Clin Imaging 1991;15:118–120.
12. Muro J, Ortiz-Vazquez J, Mino G, Sanmartin P. Demonstration angiografica del
quiste hidatidico de bazo. Rev Clin Esp 1969; 115 : 433-38.
13. Wolf O, Lenner V: Cystische Echinokokkose der Milz. Chirurg 1998;69:208–211.
14. Gharaibeh KI: Laparoscopic excision of splenic hydatid cyst. Postgrad Med J
2001;77:195–196.
15. Vedat Durgun, Selin Kapan, Metin Kapan, Ilhan Karabiçak Fatih Primary Splenic
Hydatidosis , Dig Surg 2003;20:38–41
16. Beauchamp RD, Holzman MD, Fabian TC:Spleen; in Townsend CM Jr (ed):
SabistonTextbook of Surgery, ed 16. Philadelphia,Saunders, 2001, pp 1144–1165.
17. Ellison EC, Fabri PJ: Complications of splenectomy:Etiology, prevention and
management.Surg Clin North Am 1983;63:1313.
18. Khoury G, Abiad F, Geagea T, Nabout G, Jabbour S: Laparoscopic treatment of
hydatid cysts of the liver and spleen. Surg Endosc 2000; 14:243–245.
19. Ammann RW, Eckert J: Cestodes. Echinococcus.Gastroenterol Clin North Am 1996;
25:655–689.
132
March/April 2010.
Hydatid Cyst of the Left Thigh: A case report.
A.A. Abebe ,
Department of Orthopaedic Surgery Menilik II Hospital AA Ethiopia
E-mail [email protected]
A 25-year old female patient from Gurage zone rural area, a shepherd by occupation
presented with a with a cystic swelling of the left thigh which had been gradually
increasing in size and became painful. She reported having been taking unboiled pond
water from the pond the sheep and other domestic animals used to drink from. She was
apparently in a good state of health until 2 years previously when she started to notice
swelling of the left upper thigh which gradually increased in size and became painful.
For which presented to our center.
Introduction
Echinococcosis is prevalent in areas where live stokes are raised in association with dogs. In many
part of Africa where man, sheep, and dogs live in close contact, the diases can be found. This tape
worm species is found in Australia, Argentina, Chile, Africa, Eastern Europe, Middle east ,
Newzealand, and Mediterranean region. Echinococcus cysts have both intermediate and definitive
host. The definitive hosts are dogs that pass eggs in their feces. cysts develop in intermediate host
(sheep, Cattle, Humans, Goats, Camel, and horses). Many organs are affected but the most frequently
affected sites are the liver, lung, liver, brain, and bone. Skeletal muscle involvement is rare.
Case report
This is a case report of a twenty five years old female patient from rural area of Ethiopia, a shepherd
At farm yard presented with a cystic swelling of lt thigh which increase in size gradually and become
painful. On physical examination the pertinent findings were as fallows. Diffuse cystic swelling of
the left thigh 18 x10 cm size located at the upper thigh anteriorly with smooth surface non tender and
non adherent to overlying skin (Figure 1). .Laboratory findings were as fallows, Hematocrite=35%,
WBC=8900 Xmm3, eosinophilia. X-ray of the left thigh revealed diffuse soft tissue swelling no bony
involvement. Fine needle aspiration done prior to arrival to our center (although it is not
recommended) described as fallows: Clear fluidly back ground with no cellular element amorphous
pale laminated material seen Suggestive of hydatid cyst.
Figure 1.
133
March/April 2010.
Figure 2.
Excision of the mass done where the cysts and daughter cysts were removed in toto. where we could
see the eggs of the parasite (Figure 2).
Discussion
Echinococcosis infection is acquired by ingestion of infective eggs .The usual source of infection is
stool of dogs or other carnivores. The transmission is fecal oral route. The parasites causes human
morbidity and mortality and also contribute indirectly to human disease by its effect on domestic
animals .the usual site of human infestation are Liver, Lung, spleen, bone and brain. Other sites are
possible but rare. In endemic areas echinococcosis can be prevented by regular deworming of dogs
using praziquantel, by denying dogs access to infected animals, by vaccinating sheep, by safe disposal
or boiling of offal are important control measures. Ultrasound evaluation of any cystic lesion in
endemic areas is safer than doing fine needle aspiration to prevent rapture and anaphylactic shock.
Further Reading
1.
2.
3.
4.
5.
6.
7.
8.
9.
Current medical diagnosis & treatment by Steven A.schroeder Markus ,A.Krupp,Laurence
M.TierneyJr &Stephen ,J.Mephe1900.
Orthopaedic Surgical pathology M.forest, B.Tomeno,D.varel
Pathology for surgeons a-z revision textthrd edition,DC.Gardner&D.E.FTweedle p.p357
Kocharsconcise text book of Medicen KesavanKutty.JANSl.Sebastianthird edition.p609
Text book of Medicen RLSultami,JMOXHAMP.P32
Mechanismof MicrobialDisease sclaechtermedoff,Schlessinger p.p575
Principles of Medicen in Africa Eldria Parry,RichardGodfrey.
HarissonPrinciples of internal medicen sixteenth edition vol.1p.p 1275
134
March/April 2010.
Recurrent Hypoglycaemia and Seizures in an HIV-patient .
S.N. Motsitsi, S. Craig
University of Pretoria, Kalafong Hospital
Department of Orthopaedic Surgery, Pretoria - South Africa.
Correspondence to: Dr. Silas N Motsitsi, Email: [email protected]
A young male patient recently diagnosed with HIV presented to us with a septic
tibia. He developed recurrent seizures and hypoglycaemia. Terminally he developed
a clinical picture of Addison’s crisis and disseminated intravascular coagulation.
Addison’s crisis must always be borne in mind in patients with HIV who are
subjected to stressful conditions like surgery.
Intrduction
It is estimated that the number of people with HIV worldwide is 33.2 million1. HIV
is a serious health issue, particularly in developing countries. There is great controversy
whether HIV per se predisposes to higher incidence of post - operative infection2,3,4,5.
Serious musculo-skeletal infection occurs in advanced or WHO stage 3 disease.
Seizures can be the presenting symptoms in 2- 20% of HIV-positive patients.1 The
cause can be infective or non-infective. Hypoglycaemia can be due to drugs, metabolic or
hormonal disturbances. We report on a HIV - positive patient who developed recurrent
hypoglycaemia, seizures and Addison’s crisis during treatment for a septic united tibia.
Case Report
A 43 year-old male presented to the orthopaedic trauma unit with a clinical problem
of septic united tibia. He had intramedullary nail three years ago. He was recently
diagnosed with HIV. The CD4 count was 78x106/litre and he was not on anti-retroviral
treatment. Clinically he looked well. He was apyrexial. The only clinically relevant findings
were cervical lymphadenopathy.
The nail was removed and reaming sent for microscopy, culture and sensitivity.
Culture results isolated Proteus Mirabilis and Streptococcus pyogenes sensitive to
cloxacillin, ampicillin and bactrim (trimethoprim plus sulphamethoxazole). Intravenous
treatment was started with the first two drugs and continued for 35 days. Oral
therapy with bactrim (160mg trimethoprim + 800mg sulphamethoxazole) two tablets
twice daily for four days was commenced.
A day after stopping oral therapy with bactrim, he developed hypoglycaemia with a
blood glucose of 1.6 mmol/l (normal = 4.1- 59 mmol/l) and coma. He was resuscitated
with 50% dextrose intravenously and the infusion continued with 10% dextrose normal saline. Eight hours later he developed generalizedtonic clonic seizures. Blood
glucose level was 2.4 mmol/l. Resuscitation was done using the same regime as before. The
following morning, approximately five hours later, he had a second generalized tonic
clonic seizures which lasted a minute. The glucose level was normal. His clinical
condition stabilized. The last episode of hypoglycaemia ( blood glucose = 1,1 mmol/l )
with no convulsions occurred four hours later, was accompanied by low blood
pressure (90/60 mmHg) and hypoventilation. The third seizure occurred six hours later.
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March/April 2010.
Table 1. Laboratory Data
Test
RCC
HB
HCT
MCV
MCH
MCHC
RCDW
PLT
WCC
NEUT
LYMP
MONO
EOSIN
BASO
NA
K
CL
UREA
CREAT
AG
CRP
CD4
PT
INR
PTT
Normal values
4.89-6.11 x 10 12/l
14.3-18.3 g/dl
0.43-0.55 l/l
79.1-98.9 fl
27.0-32.0 pg
32.0-36.0 g/dl
11.6-14.0 %
137-373 x 109/l
4.0-11.0 x 109/l
135-147 mmol/l
3.3-5.3 mmol/l
99-113 mmol/l
2.6-7.0 mmol/l
60-120 ųmol/l
7-17 mmol/l
0-10 mg/l
500-2010 x 106/l
10-14 seconds
0.9 -1,2
26-36 seconds
22/8/8
3,56
9,0
0,287
80,6
25,3
31,4
15,4%
222
3,11
57 %
19 %
22,5%
0,6 %
0,3 %
131
3,8
4,1
79
83,3
5/9/8
17/9/8
2/10/8
2,71
6,4
0,186
68
23
34
18 %
80
2,12
2/10/8
133
3,1
94
3,9
66
16
131
3,2
93
5,2
117
128
5,1
88
40
734
30
279
2
21
1,74
60
120
5,4
83
39
677
Abbreviation:
RCC = Red cell count, HB = Haemoglobin, HCT = Haematocrit, MCV = Mean corpuscular volume, MCH
= Mean corpuscular haemoglobin, MCHC = Mean corpuscular haemoglobin concentration, RCDW = Red
cell distribution width; PLT = Platelets, WCC = White cell count, NEUT = Neutrophil, LYMP =
Lymphocytes, MONO = Monocytes, EOSIN = Eosinophils, BASO = Basophils, NA = Sodium, K =
Potassium, CL = Chloride, CREAT = Creatinine, AG = Anion gap, CRP = C-reactive protein, PT =
Prothrombin time, INR = International normalized ratio, PTT = partial thromboplastin time
Three hours after the hypoglycaemia and shock he developed generalized seizures and severe
hypoglycaemia ( blood glucose = 0.6 mmol/l). The final hypoglycaemic episode ( blood glucose
= 0,9 mmol/l)occurred an hour later. Resuscitation was unsuccessful. The blood results show a
picture of Addisonian crisis plus disseminated intravascular coagulation. Laboratory data and
normal ranges are shown in Table 1.
Discussion
Recurrent hypoglycaemia in this patient could be due to either cotrimoxazole therapy or
Addisonian crisis. Seizures could be due to metabolic ( hypoglycaemia) or infective causes.
Cerebral infection was unlikely because the patient recovered well between episodes of
seizures. He had no evidence of neurological deficit. Addisonian crisis showed a full-blown
picture in the terminal stage: hypotension, hyperkalaemia, hyponatraemia and hypoglycaemia.
Cotrimoxazole is known to cause hypoglycaemia. Hypoglycaemia may be prolonged: lasting
for more than 12 hours.6 The drug can induce demand-related or over-use hypoglycaemia.6
Patients at risk are those with renal failure.
Subclinical adrenal dysfunction is common in HIV-positive patients.7 Patients have marginal
adrenal reserves.8,9 Clinically significant adrenal insufficiency is not common.9 Adrenal failure
is the most serious complication in these patients. It is not clear from the literature whether
136
March/April 2010.
adrenal insufficiency should always be excluded in patients with HIV, especially if they are
subjected to stress; like surgery. Mohsin Saley Eledrisi et al.8 state that identification of
adrenal insufficiency in HIV-positive patients is imperative.
References
1. Satishchandra P, Sinha S. Seizures in HIV-seropositive individuals: NIMHANS
experience and review. Epilepsia 2008; 49 (suppl. 6): 33-41
2. Bahebeck J, Bedimo R, Eyenga V, et al. The management of musculoskeletal
infection in HIV carriers. Acta Orthop. Belg 2004; 70: 355-360
3. Harrison WJ, Lavy CBD, Lewis CP. One-year follow-up of orthopaedic implants in
HIV-positive patients. Int Orthop 2004; 28: 329-332
4. Rowley DI, Clift BA, Sripada S. Surgery in infectious diseases. Current Orthop 2004;
18: 371-378
5. O’Brien ED, Denton JR. Open tibial fracture infections in asymptomatic HIV antibody
positive patients. Orthop Review 1994; 662-664
6. Strevel EL, Kuper A, Gold WL. Severe and protracted hypoglycaemia associated with
co-trimoxazole use. Lancet Infect Dis 2006; 6: 178-182
7. Mayo J, Collazos J, Martinez E, Ibarra S. Adrenal function in the human
immunodeficiency virus-infected patient. Arch Intern Med 2002; 162: 1095-1098
8. Eledrisi MS, Verghese AC. Adrenal insufficiency in HIV infection: A review and
recommendations. Am J Med Sci 2001; 321: 137-144
9. Findling JW, Buggy BP, Gilson IH, Brummit CF, Bernstein BM, Raff H. Longitudinal
evaluation of adrenocortical function in patients with the human immunodeficiency
virus. J Clin Endocrinol Metab 1994; 79: 1091-1096
137
March/April 2010.
Missed Foreign Body Presenting as a Chronically Painful Hand. A Case Report
S.A. Salati1, T. Rizvi 2, S.M. Rabah1,
1
Department of Plastic &Reconstructive Surgery,
2
Department of Radiology,
King Fahad Medical City, Riyadh, Saudi Arabi
Arabia
Correspondence to: Dr Sajad Ahmad Salati, Email: [email protected]
Missed foreign bodies are common. They may remain asymptomatic or else lead to wide range
of complications.
mplications. We present an 88 years boy who suffered from chronic pain in his right hand
case due to a missed foreign body..
Introduction
Foreign bodies might accidently penetrate the hand and might get missed when patient initially
reports. Missed foreign bodies may become symptomatic after varied
varied periods and lead to
complications of bones and joints, soft tissue, nerves and blood vessels. The management comprises
of accurate preoperative localization and surgical exploration and removal.
Case report
An 8-years
years old boy reported with about nine months history of getting pain in right hand on
attempting to grip objects like handle of bicycle. There was no other significant past history. On
examination, there was a 5 mm scar over the thenar eminence. The parents attributed this scar to
injury, which
hich was sustained while playing and managed by self-dressings.
self
X-Rays
Rays of the right hand
AP (Figures 1 and 2) view showed a radiopaque foreign body on the volar aspect of proximal right
hand in relation to carpal bones and carpometacarpal joint. No bony injury was seen.
Figure 1. X-Ray
Ray right hand AP view shows a radiopaque foreign body in relation to carpal bones and
carpometacarpal joint
March/April 2010.
Figure 2. Lateral view (Figure 2) shows the foreign body seen on AP view to lie on the volar aspect.
Figure 3. Glass piece removed from the hand of the patient
The patient was operated upon under general anesthesia with proximal tourniquet haemostatic control
and fluoroscopic guidance. Magnification was achieved with the help of m
magnifying
agnifying loupes. A glass
piece measuring 11mmx9mmx2mm was recovered. There were no perioperative complications and
the patient was asymptomatic and pain free when reviewed three months follow-up.
follow
Discussion
Accidental penetration of the hand by foreign
foreig body is common, especially in children1, 2. The patient
may report at the time
me of injury when foreign body wa
wass detected on the basis of history, clinical
examination3 and imaging4.. The foreign bodies may however be missed initially, particularly if
these are not radio opaque such as thorns and wooden pieces5. A missed foreign body in fact forms a
major cause of litigation against emergency physicians6. The patient may remain asymptomatic or
with passage of time, develop wide range of complications incl
including
uding pain, abscess, chronic
discharging wound, necrotizing fasciitis7, bone and joint destructive lesions1,8,migration9,10,
granulomas11, delayed tendon ruptures10,12, neurodeficits9,13,14, and vascular events2 .
March/April 2010.
Accurate preoperative localization is the key to successful surgical removal of foreign body as error at
this stage can result in long intraoperative searches and extensive damage to soft tissues15. A foreign
body may remain undetected even after thorough exploration5.
Conclusion
The possibility of presence of a foreign body should always be considered seriously at the
time of initial management of wounds to prevent complications and future litigations.
Presence of a foreign body should always be kept in mind as a differential diagnosis while
evaluating cases of unexplained pain in hands and elsewhere.
References
1. N. Dastgir & P. O'Rourke : Pseudotumor Of Metatarsal: A Thorny Problem . The Internet
Journal of Orthopedic Surgery. 2003 Volume 1 Number 2.
2. James W, Robert A, Suzanne M. Vascular Complications of a Foreign Body in the Hand of an
Asymptomatic Patient Ann Plast Surg1995; 34(1):92-94.
3. Lammers, R. L. Soft tissue foreign bodies. Ann. Emerg. Med.1988; 17: 1336-1347.
4. Ginsburg M.J, Ellis G., Horn L. L.: Detection of soft-tissue foreign bodies by plain
radiography, xerography, computed tomography and ultrasonography. Ann. Emerg. Med.
1990; 19: 701-703.
5. Anderson M. A., Newmeyer W. L., Kilgore E. S., Jr.: Diagnosis and treatment of retained
foreign bodies in the hand. Am. J. Surg. 1982; 144:63-67.
6. Dunn, J. D.: Risk management in emergency medicine. Emerg. Med. Clin. North
America.1987; 5: 51-69
7. Yanay O, Vaughan DJ, Brownstein D, et al. Retained wooden foreign body in a child’s thigh
complicated by severe necrotizing fasciitis: a case report and discussion of imaging
modalities for early diagnosis. Pediar. Emerg. Care 2001; 17 (5): 354-5.
8. Fakoor M Prolonged retention of an intra medullary wooden foreign body Pak J Med Sci
2006; 22 ( 1 ):78-79.
9. Choudhari K. A. , Muthu T., Tan M. H. Progressive ulnar neuropathy caused by delayed
migration of a foreign body Br J Neurosurg. 2001; 15( 3): 263 – 265.
10. Yang SS, Bear BJ, Weiland AJ. Rupture of the flexor pollicis longus tendon after 30 years
due to migration of a retained foreign body. J Hand Surg [Br]. 1995; 20 (6): 803-5.
11. Freund EI, Weigl K. Foreign body granuloma. A cause of trigger thumb. J Hand Surg [Br].
1984; 9 (2): 210.
12. Jablon M, Rabin SI. Late flexor pollicis longus tendon rupture due to retained glass
fragments. J Hand Surg [Am]. 1988; 13 (5): 713-6.
13. Rainer C , Schoeller T, Wechselberger G,et al Median nerve injury caused by missed foreign
body Scand J Plast Reconstr Surg 2000; 34(4):401-03
14. González-García R, Rodríguez-Campo FJ, Román-Romero L et al. An interesting case: late
sequelae of a primary asymptomatic glass fragment injury of the wrist. Handchir Mikrochir
Plast Chir. 1996; 28(6):306-8.
15. Coombs, C. J., Mutimer, K. L, Slattery, P. et, al. Hide and seek: pre-operative ultrasonic
localization of non radio-opaque foreign bodies. Austr & New Zealand J. Surg. 1990; 60:
989-991,
140
March/April 2010.
Crocheting Pin in the Falciform Ligament: A rare cause of Recurrent Right
Hypochondriac Pain.
G.F. Ngock1, S.R. Sparks 1, D . Poenaru2
Pan-African Academy of Christian Surgeons (PAACS)
1
Mbingo Baptist Hospital, Mbingo, NW Region, Cameroon
2
AIC Kijabe Hospital, Kijabe, Kenya
Correspondence to: Prof. Dan Poenaru, Email: [email protected]
A 24-year-old woman presented with a 3-year history of recurrent right upper quadrant pain.
Following inconclusive investigations an exploratory laparotomy was performed, revealing a
crocheting pin impacted in the falciform ligament. This case report highlights the importance of
a thorough work-up in chronic conditions, even in resource-poor settings. To our knowledge
this is the first case report of a crocheting pin impacted in the liver.
Introduction
Recurrent right upper quadrant and epigastric pain are among the commonest symptoms presenting in
an outpatient setting. Particularly in the resource-poor African setting often lacking proper
investigations, these complaints are typically first treated empirically with anti-ulcer drugs, reserving
investigations for persistent symptoms. This naturally results in significant delays in diagnosis, and
often advanced disease at diagnosis.
There are very few reports in the literature of foreign bodies as the cause of recurrent right upper
quadrant pain. We report below the case of a crocheting pin causing recurrent right upper quadrant
pain, which was detected only at exploratory laparotomy.
Case Report
A 24-year woman presented with a 3-year history of recurrent right upper quadrant pain, described as
piercing and radiating to the epigastric region. The pain was apparently relieved by traditional
medications, and also several times by anti-ulcer medications. The pain was exacerbated 2 weeks
prior to presentation and associated with vomiting, resulting in presentation to hospital and
subsequent admission. There was no history of fever.
On physical examination the only significant finding was a positive Murphy’s sign. Abdominal
ultrasound twice revealed a right hepatic mass with features suggestive of an abscess. Stool
examination was positive for occult blood and white blood cells. Based on the above findings medical
treatment for a presumptive amoebic liver abscess was initiated, but the condition did not improve.
Nine days later, physical examination showed a tender right upper quadrant mass 6cm below the
costal margin. A decision was made to proceed with an exploratory laparotomy. Intraoperatively, a
15cm long crocheting pin was found in the falciform ligament of the liver, which was grossly
inflamed. There were also multiple adhesions between the gallbladder, stomach and the porta hepatis.
The pin was removed, the falciform ligament excised and adhesiolysis performed. The patient was
discharged on post-operative day 9, due to a wound infection managed with dressing changes.
Follow-up visits showed no recurrence of the symptoms.
Discussion
Foreign bodies outside the gastrointestinal tract are uncommon in the literature. Most reported cases
to date have been intrahepatic in locationi. They are typically diagnosed through their complications
(commonly intestinal obstruction), or remain asymptomatic and are found incidentally during
investigations for unrelated conditionsii.
Other cases of needles related to the liver have also been reported in the literature. Chintamaniiii et al
in 2003 described a sewing needle which migrated from the GIT and caused an intrahepatic abscess.
Li Voti Giv et al reported two cases of intestinal perforation secondary to accidental ingestion of
141
March/April 2010.
needles in children. Harjaivet al also reported two cases of silent needle perforation from the GIT into
the mesentery of the small bowel & anterior abdominal wall in one case & the liver and the anterior
abdominal wall in the second case.
The clinical history may be positive for (incidental or deliberate) swallowing of an object or surgical
instrumentation e.g. dilation and curettage for an incomplete abortion or to terminate pregnancy, or
previous surgery with an instrument left behind. Interestingly, no such history was obtained in the
present case. Another issue of significance, common in other reported cases, is the age of the patients
- usually in the extremes of age ii,vi. Another associated factor, sometimes related to old age, is mental
disability or a known psychiatric condition. Thus it may be difficult for these individuals to remember
if any objects were swallowed or insertedi. However this report is of a young woman with normal
mental capacity. Even in young individuals with psychiatric illness ingesting foreign objects, the
presentations are typically acute, unlike our case.
An abdominal radiograph was unfortunately not obtained in this case, which would have probably
aided in the diagnosis. The radiograph was omitted because there was no clinical suspicion of
intestinal obstruction or acute abdomen, and the cost of this investigation was significant in our
setting. This case also highlights the potential unlimited ability of foreign bodies to migrate within the
abdominal cavityvii,viii. Unfortunately in our case the route of migration is difficult to ascertain –
although the oral route (with penetration via stomach or duodenum) is more likely than a vaginal /
uterine / fallopian route.
There have also been reports in the literature of unusual migration of foreign bodies into areas in the
abdomen & or other regions of the torso or even outside the torso following a GIT perforation or
migration from a vaginal / uterine / fallopian route.
In 2002 Pang and Pangix reported migration of a fish bone from the upper GIT to the soft tissues of
the neck, just below the skin. Dhillion and Parkx reported the migration of a laparotomy sponge from
the abdominal wall into the lumen of the small bowel. Leveyxi reported perforation inside a
parastomal hernia by a plastic biliary stent. Bulbulogluxii et al reported the migration of a sewing
needle presumably from the transverse colon or the ligament of Treitz to the greater omentum.
Moralesxiii reported the migration of a foreign body from the rectum into the epidural space at S1-L5.
Frangxiv & colleagues reported the migration of a swallowed needle into the renal pelvis after
perforation of the duodenum. Patelxv et al reported the migration of a fish bone into the common
hepatic duct, without perforation. Finally, Stuckeyxvi & colleagues reported perforation of the caecum
by an IUCD which was retrieved via an appendectomy.
In conclusion, this unusual case
patients with chronic abdominal
body even in the absence of
investigations are expensive to
affordable.
emphasizes the importance of a thorough pre-operative work-up of
symptoms, and always keeping in mind the possibility of a foreign
pertinent history. Precisely in the resource-poor settings where
the patient, the cost of a rushed laparotomy may be even less
References
i.
ii
Roca B. A sewing needle in the liver. South Med J 96(6): 616-617,2003i Roca B. A sewing needle
in the liver. South Med J 96(6): 616-617,2003
Azili MN, Karaman A, Karaman I, Erdoğan D, Cavuşoğlu YH, Aslan MK, Cakmak O.A sewing
needle migrating into the liver in a child: case report & review of literature. Pediatr Surg Int.2007
Nov;23(11):1135-7. Epub 2007 Mar 27
iii
Chintamani, Singhal V, Lubhana P, Durkhere R, Bhandari S. Liver abscess secondary to a broken
needle migration-a case report. BMC Surg. 2003 Oct 7;3:8.
iv
Li Voti G, Di Pace MR, Castagnetti M, De Grazia E, Cataliotti F. Neddle perforation of the bowel
in childhood. J Pediatr Surg. 2004 Feb;39(2):231-2.
142
March/April 2010.
v
Harjai MM, Gill M, Singh Y, Sharma A. Intra-abdominal needles: an enigma (a report of two cases).
Int Surg. 2000 Apr-June;85(2);130-2.
vi
Nishimoto Y, Suita S, Taguchi T, Noguchi S, Ieiri S. Hepatic foreign body – a sewing needle – in a
child. Asian J Surg. 2003 Oct;26(4): 231-3
vii
De la Vega, Rivero JC, Ruiz L, Suarez S. A fish bone in the liver. Lancet 2001; 358: 982
viii
Santos SA, Alberto SC, Cruz E, Pires E, Fiqueira T, Coimbra E, Estevez J, Oliveira M, Novais L,
Deus JR. Hepatic Abscess induced by foreign body: Case report and literature review. World J
Gastroenterology. 2007 Mar 7; 13(9): 1466-70
ix
Pang KP, Pang YT. A rare case of a foreign body migration from the upper digestive tract to the
subcutaneous neck. Ear Nose Throat J.2002Oct,18(10):730-2.
x
Dhillion JS, Park A.Transmural migration of a retained laparatomy sponge. Am Surg. 2002 Jul
;68(7):603-5.
xi
Levey JM.Intestinal perforation in a parastomal hernia by a migrating plastic biliary stent. Surg
Endosc. 2002 Nov;16(11):1636-7. Epub 2002 Jun 27
xii
Bulbuloglu E, Yuksel M, Kantarceken B, Kale IT. Laparascopic removal of a swallowed sewing
needle that migrated into the greater omentum without clinical evidence. J. Invest Surg.2004 NovDec;17(6):323-6
xiii
Morales L, Rovira J, Mongard M, Sancho MA, Bach A.Intraspinal migration of a rectal foreign
body.J Pediatr Surg. 1983 Oct;18(5):634-5.
xiv
Frang D, RÓzsahegyi G, Czvalinga I. A swallowed needle found in the renal pelvis. Z. Urol
Nephrol. 1978 Sep;71(9):647-51. German.
xv
Patel VM, Prajapati BG, Patel JK, Patel MM. A wandering fish bone. Postgrad Med J.2006 May
82(967):e9.
xvi
Stuckey A, Dutreil P, Aspuru E, Nolan TE. Symtomatic caecal perforation by an intrauterine
device with appendectomy removal. Obstet Gynecol. 2005 May;105(5 pt 2): 1239-41.
143
144
March/April 2010.

ECAJS VOL 15 No 1 2010

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