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

Ear, nose and throat injuries at Bugando Medical Centre in northwestern Tanzania: a five-year prospective review of 456 cases.

Injuries to the ear, nose and throat (ENT) regions are not uncommon in clinical practice and constitute a significant cause of morbidity and mortality in our setting. There is dearth of literature on this subject in our environment. This study was conducted to describe the causes, injury pattern and outcome of these injuries in our setting and proffer possible preventive measures. This was a descriptive prospective study of patients with ear, nose and throat injuries managed at Bugando Medical Centre between May 2007 and April 2012. Ethical approval to conduct the study was sought from relevant authorities. Statistical data analysis was performed using SPSS computer software version 17.0. A total of 456 patients were studied. The median age of patients at presentation was 18 years (range 1 to 72 years). The male to female ratio was 2:1. The commonest cause of injury was foreign bodies (61.8%) followed by road traffic accidents (22.4%). The ear was the most common body region injured accounting for 59.0% of cases. The majority of patients (324, 71.1%) were treated as an outpatient and only 132(28.9%) patients required admission to the ENT wards after definitive treatment. Foreign body removal and surgical wound debridement were the most common treatment modalities performed in 61.9% and 16.2% of cases respectively. Complication rate was 14.9%. Suppurative otitis media (30.9%) was the commonest complication in the ear while traumatic epistaxis (26.5%) and hoarseness of voice (11.8%) in the aero-digestive tract were commonest in the nose and throat. The overall median length of hospital stay for in-patients was 8 days (range 1 to 22 days). Patients who developed complications and those who had associated injuries stayed longer in the hospital (P < 0.001).Mortality rate related to isolated ENT injuries was 1.3% (6 deaths). The majority of patients (96.9%) were treated successfully and only 3.1% of cases were discharged with permanent disabilities. Injuries to the ENT regions are not uncommon in our environment and foreign bodies constitute a significant cause of injury. Majority of these injuries can be prevented through public enlightenment campaigns

Cut Throat Injuries at a University Teaching Hospital in Northwestern Tanzania: A Review of 98 cases.

Cut throat injuries though rarely reported in literature pose a great therapeutic challenge because multiple vital structures are vulnerable to injuries in the small, confined unprotected area. A sudden increase in the number of cut throat patients in our centre in recent years prompted the authors to analyze this problem. This study was conducted in our local setting to describe the etiology, patterns and treatment outcome of these injuries. This was a combined retrospective and prospective study of cut throat injury patients who were managed at Bugando Medical Centre between February 2009 and January 2013. Statistical data analysis was done using SPSS software version 17.0. A total of 98 patients with cut throat injuries were studied. Males outnumbered females by a ratio of 2.4: 1. The median age of patients was 26 years (range 8 to 78 years). Majority of patients (79.6%) had no employment and most of them (65.3%) came from rural community. Homicide was the commonest (55.1%) cause, followed by suicidal attempts (34.7%) and accidental (10.2%) injuries. Interpersonal conflict (24.4%) was the most common motivating factor for homicidal injury whereas psychiatric illness (16.2%) and road traffic accidents (9.2%) were the most frequent motivating factors of suicidal attempt and accidental injuries respectively. The majority of injuries were in Zone II accounting for 65.3% of cases and most of them had laryngeal (57.1%) injury. Surgical debridement, laryngeal/hypopharynx repair and tracheostomy were the most common surgical procedures performed in 93.9%, 73.5% and 70.4% of patients respectively. Postoperative complication rate was 57.1%, the commonest being surgical site infections in 28.1% of patients and it was significantly associated with late presentation and anatomical zones (P < 0.001). The overall median duration of hospitalization was 12 days. Patients who had postoperative complications stayed longer in the hospital and this was statistically significant (p = 0.011). Mortality rate was 11.2% and was significantly associated with co-morbidities, delayed presentation and presence of complications (p < 0.001). The follow up of patients was poor. Cut throat injuries are a major cause of morbidity and mortality among young adult males in our setting. Addressing the root causes of violence such as poverty, unemployment, and substance abuse will reduce the incidence of these injuries in our environment

Endoscopic procedures for removal of foreign bodies of the aerodigestive tract: The Bugando Medical Centre experience

<p>Abstract</p> <p>Background</p> <p>Foreign bodies in the aerodigestive tract continue to be a common problem that contributes significantly to high morbidity and mortality worldwide. This study was conducted to describe our own experience with endoscopic procedures for removal of foreign bodies in the aerodigestive tract, in our local setting and compare with what is described in literature.</p> <p>Methods</p> <p>This was a prospective descriptive study which was conducted at Bugando Medical Centre between January 2008 and December 2009. Data were collected using a structured questionnaire and analyzed using SPSS computer software version 15.</p> <p>Results</p> <p>A total of 98 patients were studied. Males outnumbered females by a ratio of 1.1:1. Patients aged 2 years and below were the majority (75.9%). The commonest type of foreign bodies in airways was groundnuts (72.7%) and in esophagus was coins (72.7%). The trachea (52.2%) was the most common site of foreign body's lodgment in the airways, whereas cricopharyngeal sphincter (68.5%) was the commonest site in the esophagus. Rigid endoscopy with forceps removal under general anesthesia was the main treatment modality performed in 87.8% of patients. The foreign bodies were successfully removed without complications in 90.8% of cases. Complication rate was 7.1% and bronchopneumonia was the most common complication accounting for 42.8% of cases. The mean duration of hospital stay was 3.4 days and mortality rate was 4.1%.</p> <p>Conclusion</p> <p>Aerodigestive tract foreign bodies continue to be a significant cause of childhood morbidity and mortality in our setting. Rigid endoscopic procedures under general anesthesia are the main treatment modalities performed. Prevention is highly recommended whereby parents should be educated to keep a close eye on their children and keep objects which can be foreign bodies away from children's reach.</p

Pattern of childhood burn injuries and their management outcome at Bugando Medical Centre in Northwestern Tanzania

Burn injuries constitute a major public health problem and are the leading cause of childhood morbidity and mortality worldwide. There is paucity of published data on childhood burn injuries in Tanzania, particularly the study area. This study was conducted to describe the pattern of childhood burn injuries in our local setting and to evaluate their management outcome. A cross sectional study was conducted at Bugando Medical Centre (in Northwestern Tanzania) over a 3-year period from January 2008 to December 2010. Data was collected using a pre-tested coded questionnaire and statistical analyses performed using SPSS software version 15.0. A total of 342 burned children were studied. Males were mainly affected. Children aged = 2 were the majority accounting for 45.9% of cases. Intentional burn injuries due to child abuse were reported in 2.9% of cases. Scald was the most common type of burns (56.1%). The trunk was the most commonly involved body region (57.3%). Majority of patients (48.0%) sustained superficial burns. Eight (2.3%) patients were HIV positive. Most patients (89.8%) presented to the hospital later than 24 h. The rate of burn wound infection on admission and on 10th day were 32.4% and 39.8% respectively.Staphylococcus aureus were more common on admission wound swabs, with Pseudomonas aeruginosa becoming more evident after 10th day. MRSA was detected in 19.2% of Staphylococcus aureus. Conservative treatment was performed in 87.1% of cases. Surgical treatment mainly skin grafting (65.9%) was performed in 44 (12.9%) of patients. The overall average of the length of hospital stay (LOS) was 22.12 ± 16.62 days. Mortality rate was 11.7%. Using multivariate logistic regression analysis; age of the patient, type of burn, delayed presentation, clothing ignition, %TBSA and severity of burn were found to be significantly associated with LOS (P < 0.001), whereas mortality rate was found to be independently and significantly related to the age of the patient, type of burn, HIV positive with stigmata of AIDS, CD4 count, inhalation injury, %TBSA and severity of burn (P < 0.001). Childhood burn injuries still remain a menace in our environment with virtually unacceptable high morbidity and mortality. There is need for critical appraisal of the preventive measures and management principles currently being practiced

Drain versus No Drain after Thyroidectomy: A prospective Randomized Clinical Study

Background: Drains have been traditionally used routinely after thyroidectomy despite limited evidence to suggest any benefit. We conducted a prospective randomized clinical study to evaluate the necessity of drainage after thyroid surgery. Methods: This was a prospective randomized clinical study which was conducted at Bugando Medical Centre between March 2009 and February 2010. Patients were randomized into two groups i.e. Group A (drain) and Group B (no drain). Results: A total of 62 patients were enrolled in this study and randomly assigned to use drains (n=32) or not (n=30). There was no statistically significant difference in the age, gender, mean operating time, volume of fluid collection in thyroid bed, complication rates and the necessity for re-operation between the two groups (P &gt; 0.001). The mean VAS score was significantly reduced more in Group B (non-drained group) than in Group A (drained group) patients on postoperative day 0 and 1 respectively (P &lt; 0.001). The mean amount of intramuscular analgesic requirement was significantly less in the nondrained group than in the drained group (p-value = 0.021). The mean hospital stay was significantly shorter in the non-drained group when compared to the drained group (P = 0.002). The satisfaction of patients was found to be superior in the non-drained group. Conclusion: We conclude that thyroidectomy without drains is safe and effective and appears to confer several advantages over the routine drainage method and achieves significant reduction of hospital stay, which led to a reduction in costs for the patient

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 &gt; 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

Gunshot injuries: A Tanzanian experience in a Teaching hospital in the Lake Zone

Background: Gunshot injuries (GSIs) are a unique form of trauma that are on increase all over the world and contribute significantly to high morbidity and mortality. The aim of this study was to evaluate the incidence, injury characteristics and treatment outcome of GSI in our local setting and to suggest preventive strategies as well as treatment protocols. Methods: This was a combined retrospective and prospective study of GSI patients who were managed at Bugando Medical Centre from April 2006 to March 2010. Data were collected from patients’ records and operation theatre registers and analyzed using SPSS software version 11.5. Results: A total of 84 GSI patients were studied. Males outnumbered females by a ratio of 15.8:1. Their mean age was 29.82 ± 16.26 years. The modal age group was 21-30 years. The majority of GSIs (84.6%) were caused by armed robbery attacks and low-velocity injuries were the majority (61.9%). Most injuries were in the limbs (64.1%) and the majority of gunshot wounds were punctured wounds (56.5%) and lacerations (23.9%). Soft tissue injuries (100%) and fractures (45.7%) were the most common type of injuries sustained. The majority of patients (85.7%) were treated surgically. Wound exploration and debridement were the mode of treatment in the majority of cases. Wound infection (49.1%) and complications of fractures (21.1%) were the most common complications. The mean duration of hospital stay was 34.2 days (1 – 186 days). Mortality rate was 8.3%. Conclusion: Gunshot injuries are a major cause of morbidity and mortality among young adult males in our setting. Addressing the root causes of violence such as poverty, unemployment, and substance abuse will reduce the incidence of gunshot injuries in our environment

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&rsquo; 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