Enterocutaneous fistula: a Tanzanian experience in a tertiary care hospital

Background: Enterocutaneous fistulae pose a therapeutic challenge to general surgeons all over the world and contribute significantly to high morbidity and mortality. The aim of this study was to describe our experience in the management of enterocutaneous fistulas, outlining the causes, fistula characteristics, treatment outcome and prognostic factors for fistula closure and mortality in our local setting.Methods: A prospective study of patients with enterocutaneous fistulae was conducted at Bugando Medical Centre between December 2007 and November 2009. After informed written consent for the study and HIV testing, all patients who met the inclusion criteria were consecutively enrolled into the study. Data were collected using a pre-tested, coded questionnaire and analyzed using SPSS software version 11.5.Results: Ninety two patients were seen during the study. There were 54 males (58.7%) and 38 (41.3%) females (M: F ratio = 1.4:1). Post-operative complication was the commonest cause of enterocutaneous fistulae in 91.3% of cases. The majority of patients (63.0%) had high output fistulae and the jejuno-ileum was commonly affected (60.9%). The complication rate was 34.8% and sepsis was the most common complication. Sixteen patients (17.4%) had HIV infection. Fistula closure was successfully achieved in 64 patients (69.6%). Of these, 42 patients (65.6%) had spontaneous closure and 22 patients (34.4%) underwent surgical closure. Mortality rate was 30.4%. Using multivariate logistic regression, the cause of fistula, fistula output, presence of complications and institutional origin of the patient were found to be significant predictors of spontaneous closure (p-value < 0.001), where as surgical closure was significantly associated with presence of complications and pre-morbid illness (p-value < 0.001). Fistula output, institutional origin of the patient, presence of complications and premorbid illness, HIV positivity and CD4 count were significant predictors of mortality.Conclusion: Enterocutaneous fistulae pose a therapeutic challenge at BMC and contribute significantly to high morbidity and mortality. A multidisciplinary approach focusing on fluid resuscitation, nutritional supplementation, electrolyte replenishment, control of sepsis, containment of effluent, skin integrity and surgery at appropriate time is necessary to lessen morbidity and mortality with a higher fistula closure rate. The high rate of postoperative enterocutaneous fistulae resulting from anastomotic breakdown in patients referred from peripheral hospitals calls for urgent surgical skill training course in this region. The high rate of HIV infection in these patients needs further studies

Missed Injuries in Multiple Trauma Patients: a Tertiary Care Experience in Tanzania

Background: Missed injuries remain a worldwide problem in all trauma centers and contribute significantly to high morbidity and mortality among trauma patients. There is paucity of information regarding missed injuries in Tanzania. The aim of this study was to establish the incidence, contributing factors, and short-term outcome of missed injuries among polytraumatized patients in our setting.Methods: This was a one-year duration (from January to December 2009) prospective cohort study involving all multiple trauma patients (ISS > 16) admitted to Bugando Medical Centre. After informed consent to participate in the study, all patients were consecutively enrolled in the study. Data was collected using a pre-tested, coded questionnaire and analyzed using SPSS computer software version 11.5.Results: Ninety six of 462 patients (incidence, 20.1%) had 112 missed injuries. Head and the neck (46.4%) was the most common body region affected. Clinical error (57.1%) was the most common factor contributed to the occurrence of missed injuries. Of the factors contributing to missed injuries, 57.4% were potentially avoidable and 42.6% were unavoidable. There was statistically significant difference in the mean ISS, mean GCS, orotracheal intubation, patient’s arrival time and seniority of the attending doctor between patients with missed injuries and those without missed injuries (p-value <0.001). Mortality in patients with missed injuries was 19.8% compared with 8.7% in patients without missed injuries (p-value <0.001). Among the deaths in patients with missed injuries, 57.9% were directly attributable to missed injuries (O.R. = 14.8, p-value =0.001, 95% CI = 6.1- 32.46). Patients with missed injuries had longer stays in the hospital compared with patients without missed injuries (p-value <0.001).Conclusion: The incidence of missed injuries at BMC is high in patients with high ISS, low GCS, orotracheal intubation and those who reported during night hours. A high index of suspicious is needed when dealing with such a group of patients. The majority of missed injuries are potentially avoidable by repeated assessments both clinically and radiologically and by staff redistribution to address the increase of missed injuries during night hours. Implementation of a tertiary trauma survey should be routine in the Accident & Emergency department to minimize the occurrence of missed injuries

Histological Review of Skin cancers in African Albinos: A 10-year Retrospective Review.

Skin cancer is rare among Africans and albinism is an established risk for skin cancer in this population. Ultraviolet radiation is highest at the equator and African albinos living close to the equator have the highest risk of developing skin cancers. This was a retrospective study that involved histological review of all specimens with skin cancers from African albinos submitted to The Regional Dermatology Training Center in Moshi, Tanzania from 2002 to 2011. A total of 134 biopsies from 86 patients with a male to female ratio of 1:1 were reviewed. Head and neck was the commonest (n = 75, 56.0%) site affected by skin cancers. Squamous cell carcinoma (SCC) was more common than basal cell carcinoma (BCC) with a ratio of 1.2:1. Only one Acral lentiginous melanoma was reported. Majority (55.6%) of SCC were well differentiated while nodular BCC (75%) was the most common type of BCC. Squamous cell carcinoma is more common than basal cell carcinoma in African albinos

Diathermy versus Scalpel incision in elective midline laparotomy: A prospective randomized controlled clinical study

Background: Skin incisions have traditionally been made using a scalpel. Diathermy, a more recent alternative, is thought to increase the risk of infection, impair healing and decrease cosmesis. Recent studies suggest that diathermy may offer potential advantages with respect to blood loss, incision time and postoperative pain. The aim of this study was to compare the efficacy and safety of surgical diathermy incisions versus conventional scalpel incisions for midline laparotomy in our local setting with an aim to evaluate diathermy as an effective alternative to scalpel incision.Methods: This was a prospective randomized clinical study which was conducted in the surgical wards of Bugando Medical Centre between January 2010 and December 2011. Patients were randomly assigned to two groups i.e. Group A (Scalpel group) and Group B (Diathermy group).Results: A total of 214 patients were enrolled in the study. Of these, 108 patients were randomized to Group A (Scalpel group) and 106 patients to Group B (Diathermy group). The two groups did not differ significantly in relation to age and sex (p > 0.001). Laparotomy skin incisions using diathermy were significantly quicker than scalpel incisions (p = 0.001). There was significantly less blood loss in the diathermy group compared with the scalpel group (P =0.012). The mean visual analogue scale was significantly reduced more in the diathermy group than in Group Scalpel group patients on postoperative day 1 (p =0.001), day 2 (p =0.011) and 3 (p =0.021) respectively. The mean amount of intramuscular analgesicrequirement was significantly less in the Diathermy group than in the Scalpel group (p=0.021). Postoperative complication rates did not differ significantly between the Scalpel and Diathermy groups (p = 0.243). There was no significant difference between two groups with respect to the mean length of hospital stay (p = 0.834).Conclusion: We conclude that diathermy incision in elective midline laparotomy has significant advantages compared with the scalpel because of reduced incision time, less blood loss, reduced early postoperative pain and analgesic requirements

Bite injuries at Bugando Medical Centre, Mwanza, Tanzania: A five year experience

Background: Bite injuries constitute a continuing challenge to trauma or general surgeons practicing in developing countries. Little work has been done on bite injuries in our setting. This study describes our experience in the management of bite injuries, outlining the etiological spectrum, injury patterns and results of management of bite injuries in our setting. Methods: A 5-year retrospective study of patients who were attended after sustained bite injury was conducted at Bugando medical Centre between October 2005 and September 2009. Data were collected from patients’ records and operation theatre registers and analyzed using SPSS software version 11.5. Research Ethics committee approval was sought before the study was commenced. Results: A total of 98 bite injury patients were recruited in the study. Males were 55 (56.1%) and females were 43 (43.9%). Majority of patients were in the age group of 21-30 years old. Human bites (58.2%) were the most common type of injury. Most injuries occurred in the upper limbs (29.6%). Bruises (41.8%) and punctured wounds (33.9%) were the most type of wounds sustained. Majority of patients (59.2%) were treated conservatively and the remaining patients (40.8%) underwent operative procedures. Wound infection was the most common complication and majority of patients had polymicrobial bacterial profile. Staphylococcus aureus was the most common organism isolated. Majority of patients had no permanent disability. The mean length of hospital stay was 7 days. Mortality rate was 0.8%. Conclusion: Bite injuries, though rare in our setting, are a unique form of trauma that is associated with high complication rates such as wound infections, tetanus, rabies, HIV transmission and limb amputations. Measures towards prevention and proper treatment are important in order to reduce morbidity and mortality resulting from this form of trauma. Similar study is recommended in a prospective setting to proper assess the magnitude of the problem