Major Intraoperative Complications of Cholecystectomy in a Teaching Hospital, Addis Ababa, Ethiopia

Background: Gall stone disease is one of the commonly handled surgical pathologies by a General Surgeon. Major intra operative complications are less commonly encountered in experienced hands. The rate may increase in a teaching hospital where Residents are allowed to operate. Therefore it was with this assumption that a study was carried to assess the incidence and contributing factors for the complications in a tertiary teaching hospital.Methods: A retrospective chart and operation log book review was done in a two -year period between January 2009 and December 2010 in St Paul’s teaching hospital, AA, Ethiopia.Results: A total of 645 cholecystectomy, 588(91.2%) open and 57(8.8%) laparoscopic, were done in the study period. Females comprised 80.9% of the patients. The average age of the patients was 42.8 years with a range of 18 to 80. Major surgical complications were seen in 19(2.9%) patients but adequate information was found for 16 patients only with a retrievalrate of 84.2 %. Of the 16 patients 14(87.5%) were female. Thirteen  patients had open cholecystectomy and the rest 3 patients had  laparoscopic cholecystectomy. Accordingly the rate for open  cholecystectomy was 13/588(2.21%), and that of laparoscopic surgery3/57(5.26%). Twelve (92.3%) of the complicated cases in open   cholecystectomy were done by residents alone. The rate of complications for the consultants in open surgery was 0.2% and that of the residents 6.0%. The odd that patients operated by residents will develop IBDI was 6.25 times higher than that of the seniors. There is statistically significantassociation between seniority and major surgical complications(X2= 11.91, P=0.001).Conclusions: The incidence of major complications of cholecystectomy is unacceptably high in this study. Almost all complications occurred in the hands of residents which show that experience matters. Therefore it is our recommendation that residents should not be left alone until they get reasonable experience in the field

Outcomes of colostomy reversal procedures in two teaching hospitals in Addis Ababa, Ethiopia

Background: Colostomy creation and reversal procedures are common procedures, frequently performed by surgeons working in Ethiopia. Collected information is lacking concerning the outcome of colostomy reversal procedures in the country.Methods: A hospital based retrospective analysis was undertaken to describe the patterns of patients who underwent colostomy reversal, the timing of colostomy reversal, the frequently witnessed complications and the postoperative outcomes of patients admitted to the Tikur Anbessa and Saint Paul hospitals in Ethiopia for colostomy reversal procedure. Data was collected from 87 patients.Results: The majority of patients were males 70(82.8%). Seventy-six (87.4%) of the colostomies were situated in sigmoid colon and Hartmann’s colostomy was the most common type in 64 (60.6%). Most colostomies, 69 (79.3%), were created for non-trauma related disease conditions. The interval from the colostomy creation to colostomy closure varied from 8 weeks (2 months) to 72 weeks (18 months) with a mean interval of 28.2 weeks (6.6 months). Most, 71(81.6%) of the procedures were performed by consultant surgeons and the frequently used method was the two layered hand-sewn method in 72 (82.8%) patients. The overall incidence of complication was 17 (19.5 %). The rate of anastomotic leakage is 4(4.6 %). One patient who underwent sigmoid colostomy reversal done initially for gangrenous sigmoid volvulus died after anastomotic leak, making the overall mortality rate 1.1%. More complications occurred during Hartmann’s colostomy reversals. The morbidity rate for reversal performed within 16 weeks (4 months) of its creation was 3/28 (10.7%) for those within 16 to 24 weeks, 0/28 (0%); and for those after 24 weeks, 1/29 (3.4%).Conclusions and recommendations: Colostomy reversal is a commonly performed procedure in our setting and should be well mastered by consultant surgeons and residents under training. The associated morbidity and mortality are found to be low. It appears that delayed reversal is more advantageous and safer than early reversal procedures

HIV related isolated tuberculosis of the spleen: A case report

A patient with left upper quadrant pain, intermittent fever, and weight loss but no radiographic evidence suggestive of pulmonary tuberculosis is presented. Abdominal sonography showed multiple hypo echoic nodular splenic lesions reported as foci of infection/abscess. Histopathology study of splenectomy specimen revealed caseous tuberculous lesions of near normal size organ

The Gap between Surgical Resident and Faculty Surgeons Concerning Operating Theatre Teaching: Report from Addis Ababa, Ethiopia

Background: In a continent like Africa where the number of surgeons is alarmingly few, training of a large number of residents is the way forward. However, sudden expansion in the number of trainees in an existing teaching environment may bring the quality of the most fundamentaleducation i.e. operation room teaching into question.Method: We wanted to investigate the different perceptions of our surgeons-under-training and faculty concerning preoperative preparation, intra operative teaching and postoperative feedback. A validated questionnaire was administered to our surgical residents and faculty at the Addis Ababa University, School of Medicine, Department of Surgery. Results were analyzed with 2-sample t tests, comparing Likert scores. Findings were significant if the p value was < 0.05.Results: Forty residents (15 second year, 15 third years and 10 final years) and 30 faculty members completed the survey. With respect to preoperative preparation, faculty were significantly more likely to claim that residents’ preparation in terms of reading is low (3.77 vs 2.45; p=0.001) and anatomy review (3.73 vs 2.34; p=0.001) before the procedure. There was a very significant difference with regards to intra-operative teaching activities, i.e teaching of the operative steps (2.60 vs 3.79; p=0.048), instrument handling (2.30 vs 3.72; p=0.002), and surgical technique (2.23vs 3.83; p= 0.001). Residents’ perception of the effort of the faculty to act as a teacher in the operating room was significantly lower compared to the faculty (2.13 vs 3.94; p=0.002). Postoperatively, significant differences were found in perceptions of positive feedback (2.48 vs 3.86; p=0.01) and feedback on areas to improve (1.85 vs 3.34; p=0.001).Conclusion: There is a universal agreement on the need to improve the current residency training. However, the difference between resident and faculty in the teaching-learning process is alarmingly significant. As there is no substitute for the intra-operative training of residents, every effort must be made to not to trade off number of graduates with quality and  competence of surgeons-under-training.  Keywords: Resident, Surgeons, Operating, Theatre, Teachin

A causal relationship between right paraduodenal hernia and superior mesenteric artery syndrome: a case report

<p>Abstract</p> <p>Introduction</p> <p>Cases of right paraduodenal hernia and superior mesenteric artery syndrome have been reported separately, but their occurrence in combination has not been reported.</p> <p>Case presentation</p> <p>A 46-year-old Japanese man who had never undergone laparotomy was admitted to our hospital due to an acute abdomen. An enhanced multidetector-row computed tomography scan of our patient showed a cluster of small intestines with ischemic change in his right lateral abdominal cavity. Emergency surgery was subsequently performed, and strangulation of the distal jejunum along with incidental right paraduodenal hernia was found. His necrotic ileum was resected, and the jejunum encapsulated by the sac was repaired manually without reduction.</p> <p>Three days after the operation, however, our patient developed vomiting. An upper gastrointestinal series revealed a straight line cut-off sign on the third portion of his duodenum. A second enhanced multidetector-row computed tomography scan showed that he had a lower aortomesenteric angle and a shorter aortomesenteric distance compared to his condition before his right paraduodenal hernia was surgically repaired. We strongly suspected that the right paraduodenal hernia repair may have induced superior mesenteric artery syndrome. On the 21st post-operative day, duodenojejunostomy was performed because conservative management had failed.</p> <p>Conclusions</p> <p>In this case, enhanced multidetector-row computed tomography, which permits reconstructed multiplanar imaging, helped us to visually identify these diseases easily. It is important to recognize that surgical repair of a right paraduodenal hernia may cause superior mesenteric artery syndrome.</p

Outcomes of Colostomy Reversal Procedures in Two Teaching Hospitals in Addis Ababa, Ethiopia

Background: Colostomy creation and reversal procedures are common procedures, frequently performed by surgeons working in Ethiopia. Collected information is lacking concerning the outcome of colostomy reversal procedures in the country. Methods: A hospital based retrospective analysis was undertaken to describe the patterns of patients who underwent colostomy reversal, the timing of colostomy reversal, the frequently witnessed complications and the postoperative outcomes of patients admitted to the Tikur Anbessa and Saint Paul hospitals in Ethiopia for colostomy reversal procedure. Data was collected from 87 patients. Results: The majority of patients were males 70(82.8%). Seventy-six (87.4%) of the colostomies were situated in sigmoid colon and Hartmann&apos;s colostomy was the most common type in 64 (60.6%). Most colostomies, 69 (79.3%), were created for non-trauma related disease conditions. The interval from the colostomy creation to colostomy closure varied from 8 weeks (2 months) to 72 weeks (18 months) with a mean interval of 28.2 weeks (6.6 months). Most, 71(81.6%) of the procedures were performed by consultant surgeons and the frequently used method was the two layered hand-sewn method in 72 (82.8%) patients. The overall incidence of complication was 17 (19.5 %). The rate of anastomotic leakage is 4(4.6 %). One patient who underwent sigmoid colostomy reversal done initially for gangrenous sigmoid volvulus died after anastomotic leak, making the overall mortality rate 1.1%. More complications occurred during Hartmann&apos;s colostomy reversals. The morbidity rate for reversal performed within 16 weeks (4 months) of its creation was 3/28 (10.7%) for those within 16 to 24 weeks, 0/28 (0%); and for those after 24 weeks, 1/29 (3.4%). Conclusions and recommendations: Colostomy reversal is a commonly performed procedure in our setting and should be well mastered by consultant surgeons and residents under training. The associated morbidity and mortality are found to be low. It appears that delayed reversal is more advantageous and safer than early reversal procedures

HIV Related Isolated Tuberculosis of the Spleen: A Case Report

A patient with left upper quadrant pain, intermittent fever, and weight loss but no radiographic evidence suggestive of pulmonary tuberculosis is presented. Abdominal sonography showed multiple hypo echoic nodular splenic lesions reported as foci of infection/abscess. Histopathology study of splenectomy specimen revealed caseous tuberculous lesions of near normal size organ

Surgical Management of Common Bile Duct Stones at Saint Paul’s Hospital, Addis Ababa, Ethiopia

Background: This study was aimed at evaluating the trend and outcome of surgical management of choledocholithiasis in St. Paul Teaching Hospital Addis Ababa, Ethiopia. Methods: This was a clinical based retrospective analysis. The operation register was used to identify the cases that were operated for biliary lithiasis. Their clinical records were obtained from the record office of the hospital and data collected and recorded on a predesigned format. Data was analyzed by SPSS statistical software. Pearson’s chi-square test was used for statistical analysis. P-value < 0.05 was considered significant. Results: A total of 1230 underwent open cholecystectomy over 5 year period of which 98 patients where found to have choledocholithiasis constituting 7%. Of the 98 patients who underwent common bile duct (CBD) exploration, the records of 78 patients were found and made the basis of this analysis. Fifty-nine (75.6%) patients were females and 19(24.4%) were males, with a male to female ratio 1: 3. The mean age was 49.15 years. The most common symptoms were right upper quadrant pain and jaundice. The most frequent physical findings was right upper quadrant tenderness. Choledocholithotomy with T-tube insertion was done in 39 patients, side to side choledochoduodenostomy in 34 patients, and hepaticojejunostomy in 5 patients. Twenty-four (71.6%) choledochoduodenostomy patients were discharged in less than ten days after operation while 36(87.1%) of those with T-tube were discharged after 10 days (p<0.019). The re-operation rate was 12.8% for the T-tube insertion group and 2.9% for choledochoduodenostomy patients. There were 3(8.8%) deaths in the former and 1(2.9%) in the group of choledochoduodenostomy. The overall complication rate was 11 (30.6%) for the T-tube insertion and 3 (8.8%) for the choledochoduodenostomies. Conclusion: Choledochoduodenostomy is a better option than Choledocholithotomy with T-tube insertion in the treatment of choledocholithiasis in African setting. We recommend choledochoduodenostomy (CD) for multiple CBD calculi, big calculi in the CBD, much dilated CBD (>2cm), primary CBD stones, hepatic stones, recurrent stones, and elderly patients where the size of the CBD is 15mm and above