Pediatric intestinal obstruction in Malawi: characteristics and outcomes

Abstract Background Intestinal obstruction (IO) is a common pediatric surgical emergency in sub-Saharan Africa with high morbidity and mortality, but little is known about its etiopathogenesis in Malawi. Methods Retrospective analysis of patients seen from February 2012 to June 2014 at Kamuzu Central Hospital in Lilongwe, Malawi (n = 3,407). Pediatric patients with IO were analyzed (n = 130). Results Overall, 57% of patients were male with a mean age of 3.5 ± 4.1 years. A total of 52% of patients underwent operative intervention. The overall mortality rate was 3%. Leading causes of IO were Hirschprung's 29%, anorectal malformation 18%, and intussusception 4%. Neonates and patients with congenital causes of IO underwent surgery less frequently than infants and/or children and patients with acquired causes, respectively. These groups also demonstrated increased number of days from admission to surgery. Conclusions Increasing pediatric-specific surgical education and/or training and expanding access to resources may improve mortality after IO in poor medical communities within sub-Saharan Africa

Effect of direct and indirect transfer status on trauma mortality in sub Saharan Africa

Traumatic injuries account for the greatest portion of global surgical burden particularly in low-and middle-income countries (LMICs). To assess effectiveness of a developing trauma system, we hypothesize that there are survival differences between direct and indirect transfer of trauma patients to a tertiary hospital in sub Saharan Africa

The role of the anatomy of the sigmoid colon in developing sigmoid volvulus: A case-control study

Sigmoid volvulus is a common condition throughout much of the world. To this date, there are no adequately controlled clinical trials examining the role of anatomy in sigmoid volvulus. Therefore, the objective of this study was to determine if the anatomic dimensions of the sigmoid colon differ in sigmoid volvulus compared to controls. This prospective case–control study was conducted at Kamuzu Central Hospital, Lilongwe, Malawi. Cases included individuals 18 years or older with surgically confirmed sigmoid volvulus, while controls included individuals undergoing surgery for reasons unrelated to the descending or sigmoid colon, or rectum. Intraoperative measurements of the sigmoid colon were taken, including mesosigmoid root width and mesosigmoid length. A total of 26 cases and 12 controls were enrolled. When compared to controls, the mesosigmoid of cases had a greater length and maximal width; however, mesosigmoid root width was similar between groups. These findings support the assertion that sigmoid volvulus is due to a long and wide mesosigmoid that rotates on a constant mesosigmoid root width. This is the first adequately controlled trial examining anatomy in sigmoid volvulus and provides strong evidence that refines prior hypotheses regarding the anatomic basis of sigmoid volvulus

An observational study addressing the anatomic basis of mesosigmoidopexy as a rational treatment of non-gangrenous sigmoid volvulus

Sigmoid volvulus is a common cause of bowel obstruction.We describe mesosigmoidopexy, an accepted surgical technique for the management of non-gangrenous sigmoid volvulus, and provide anatomic correlations supporting the therapy. Mesosigmoidopexy should be considered as a rational alternative to resection and anastomosis when operating on non-gangrenous sigmoid volvulus

Human papillomavirus in head and neck squamous cell carcinoma: A descriptive study of histologically confirmed cases at Kamuzu Central Hospital in Lilongwe, Malawi

Background: Head and neck squamous cell carcinoma (HNSCC) is common in sub-Saharan Africa, but the aetiologic contribution of human papillomavirus (HPV) is not well established.Methods: We assessed HNSCC cases for HPV using p16 immunohistochemistry (IHC) in Malawi. Associations between p16 IHC and tumour site, behavioural risk factors, demographic characteristics, and HIV status were examined.Results: From 2010 to 2014, 77 HNSCC cases were identified. Mean age was 52 years, 50 cases (65%) were male, and 48 (62%) were in the oropharynx (OP) or oral cavity (OC). HIV status was known for 35 patients (45%), with 5 (14%) HIV-infected. Substance use was known for 40 patients (52%), with 38% reporting any tobacco and 31% any alcohol. Forty-two cases (55%) had adequate tissue for p16 IHC, of which seven (17%) were positive, including 22% of OP/OC tumours.Conclusions: Despite high cervical cancer burden, HPV-associated HNSCC is not very common in Malaw

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

An observational study addressing the anatomic basis of mesosigmoidopexy as a rational treatment of non-gangrenous sigmoid volvulus

Sigmoid volvulus is a common cause of bowel obstruction.We describe mesosigmoidopexy, an accepted surgical technique for the management of non-gangrenous sigmoid volvulus, and provide anatomic correlations supporting the therapy. Mesosigmoidopexy should be considered as a rational alternative to resection and anastomosis when operating on non-gangrenous sigmoid volvulus

Complications and 3-month outcomes of children with hydrocephalus treated with ventriculoperitoneal shunts in Malawi

OBJECTIVEHydrocephalus is the most common pediatric neurosurgical condition, with a high prevalence in low- and middle-income countries. Untreated, hydrocephalus leads to neurological disability or death. The epidemiology and outcomes of hydrocephalus treated by ventriculoperitoneal (VP) shunts in Sub-Saharan Africa are not well defined and vary by region. The aim of the present study was to examine the mortality and morbidity rates and predictors of mortality in children treated by VP shunt placement for hydrocephalus at Kamuzu Central Hospital in Lilongwe, Malawi.METHODSThis is a prospective study of 100 consecutive children presenting with hydrocephalus who were treated with VP shunt placement from January 2015 to August 2017. Demographics, nutritional status, maternal characteristics, developmental delay, shunt complications, readmissions, and in-hospital and 3-month mortality data were collected. Multivariate logistic regression was used to identify predictors of death within 3 months of surgery.RESULTSOverall, 46% of participants were female, with an average age of 5.4 ± 3.7 months at the time of surgery. The majority of patients were term deliveries (87.8%) and were not malnourished (72.9%). Only 10.8% of children were diagnosed with meningitis before admission. In-hospital and 3-month mortality rates were 5.5% and 32.1%, respectively. The only significant association with mortality was maternal age, with older maternal age demonstrating decreased odds of 3-month mortality (OR 0.9, 95% CI 0.8–1.0, p = 0.045).CONCLUSIONSSurgical management of hydrocephalus with VP shunts portends a high mortality rate in Malawi. The association of younger maternal age with mortality is likely a proxy for social determinants, which appear to contribute as much to mortality as patient factors. VP shunting is inadequate as a sole surgical management of hydrocephalus in resource-limited settings.</jats:sec

Human papillomavirus in head and neck squamous cell carcinoma: A descriptive study of histologically confirmed cases at Kamuzu Central Hospital in Lilongwe, Malawi

Head and neck squamous cell carcinoma (HNSCC) is common in sub-Saharan Africa, but the aetiologic contribution of human papillomavirus (HPV) is not well established