The changing epidemiology of esophageal cancer in sub-Saharan Africa – the case of Ghana

Introduction: Esophageal cancer portends a grim prognosis. Most patients present with incurable disease. Scanty epidemiologic data on the disease has contributed to its low priority on the national. We sought to evaluate the current national trend in the presentation and outcome of esophageal cancer using our institutional experience from 1992 – 2010. Methods: This is a retrospective study based on 152 patients who were seen in our institution during the study period. The perioperative data of these patients were retrieved and the relevant details recorded. Histopathological reports were available for 75 patients managed over the period. The study setting was The National Cardiothoracic Centre, which serves as the only tertiary referral centre in the country for cardiothoracic problems. Results: There were 122 males and 30 females with a mean age of 57.8±11.7 years. The yearly trend from 1992 to 2010 showed a steady increase in the incidence of esophageal cancer. High alcohol consumption and smoking dominated the history of 82.2% of the patients. Squamous cell carcinoma accounted for 78.7% and adenocarcinoma 21.3%. Distribution of esophageal carcinoma by anatomical location was 84.9% for distal third, 11.8% for middle third and 3.3% for upper third. All patients presented with incurable disease. Conclusion: The study shows an increasing incidence of esophageal carcinoma in this country. Alcohol abuse and smoking are major risk factors; squamous cell carcinoma is the dominant histological type in this study.Pan African Medical Journal 2012; 13:

The development of cardiac surgery in West Africa-the case of Ghana

West Africa is one of the poorest regions of the world. The sixteen nations listed by the United Nations in this sub-region have some of the lowest gross domestic products in the world. Health care infrastructure is deficient in most of these countries. Cardiac surgery, with its heavy financial outlay is unavailable in many West African countries. These facts notwithstanding, some West African countries have a proud history of open heart surgery not very well known even in African health care circles. Many African health care givers are under the erroneous impression that the cardiovascular surgical landscape of West Africa is blank. However, documented reports of open-heart surgery in Ghana dates as far back as 1964 when surface cooling was used by Ghanaian surgeons to close atrial septal defects. Ghana's National Cardiothoracic Center is still very active and is accredited by the West African College of Surgeons for the training of cardiothoracic surgeons. Reports from Nigeria indicate open-heart surgery taking place from 1974. Cote D'Ivoire had reported on its first 300 open-heart cases by 1983. Senegal reported open-heart surgery from 1995 and still runs an active center. Cameroon started out in 2009 with work done by an Italian group that ultimately aims to train indigenous surgeons to run the program. This review traces the development and current state of cardiothoracic surgery in West Africa with Ghana's National Cardiothoracic Center as the reference. It aims to dispel the notion that there are no major active cardiothoracic centers in the West African sub-region

Junctional ectopic tachycardia following repair of congenital heart defects - experience in multimodal management from a West African Centre

Background: Postoperative junctional ectopic tachycardia (JET) is a rare and transient phenomenon occurring after repair of congenital heart defects. Report on this arrhythmia in the subregion is rare. We set out to determine the incidence of this arrhythmia and review the treatment and outcomes of treatment in our centre. Methods: Retrospective search of the records of all patients aged 18 years and below admitted into the intensive care unit (ICU) following repair or palliation of a congenital heart defect over 5 years, from January 1, 2006 to December 31, 2010. A review of clinical notes, operative records, anaesthetic charts, cardiopulmonary bypass (CPB) records, nursing observation charts, electrocardiograms (ECGs) and out-patient follow-up records was undertaken. Results: 510 children under 18 years were enlisted. 7 cases of postoperative JET were recorded, (1.37%). 184 (36.1%) of these were performed under CPB. All JET cases were from cases done under CPB, 3.8%. Median age was 3 years and median weight 11.3kg. No patient was febrile at diagnosis. 4 patients had amiodarone administration, 5 had magnesium sulphate infusion, 2 patients had direct current shock (DCS) whilst 3 patients had all three therapeutic modalities. All patients had control of the arrhythmia with conversion to sinus rhythm and no recurrence. Conclusion: We report a JET incidence of 1.37% among children undergoing CPB for repair of congenital heart defects. We demonstrate the therapeutic effectiveness of amiodarone, magnesium sulphate infusions and DCS alone or in combination in the management of JET on various substrates with good outcome. Pan African Medical Journal 2012; 12:1

Separation of Conjoined Hearts in Thoracopagus Twins

<p><b>Introduction</b></p> <p>Eight hours after delivery of thoracopagus twins, the right twin developed circulatory failure forcing an emergency separation to save the left twin. The twins had conjoined livers and conjoined hearts in a common pericardial cavity, and they appeared to have no ventricular-level fusion. </p> <p><b>Procedure</b></p> <p>Surgery was performed on the second day of life using general anesthesia and full invasive monitoring. The twins were placed with the ventral side uppermost; the ventral side being the side with the greater inter-areolar distance. After skin preparation and draping, an incision was made along the line of somatic fusion and the abdomen was entered to separate the conjoined livers and intestines.</p> <p>Moving to the chest, the two diaphragms were conjoined and the two hearts were in a common pericardial cavity. The heart of the right twin was clearly hypoplastic but had good contractility. The preoperative echocardiogram had shown this twin’s heart to have functionally single ventricle morphology. The left twin had a normal-sized four-chambered heart on echocardiogram, and this appeared to be the case at surgery. The caval and pulmonary venous connections were separate and normal for each heart. At the atrial level, a short tubular bridge of myocardium connected the two atrial masses. There was no connection at the ventricular level and so the hearts could be separated by simple division of the atrial bridge. The hearts were thus separated completely. Subsequently, the surgical incision was carried round dorsally through the layers of the chest and abdominal walls to effect complete separation of the twins. Care was taken to commit as much of the conjoined chest and abdomen to the healthy twin to limit the potential for flail chest and abdominal compartment syndrome.</p> <p>The chest wall of the healthy twin was reconstructed with a mesh as shown in the video. The abdomen was closed primarily without tension.</p> <p><b>Outcome </b></p> <p>As expected, the heart of the right twin could not support an adequate cardiac output, and death ensued shortly after separation. The apparently healthy twin remained hemodynamically stable postoperatively, maintaining adequate tissue perfusion without inotropic support. However, her respiratory function remained suboptimal and deteriorated gradually into refractory respiratory failure until her death on the eighth postoperative day.</p> <p><b>Comment</b></p> <p>Three reports from the UK [1], USA [2], and South Africa [3] represent the largest surgical experience of separation of conjoined hearts in thoracopagus twins gathered over three to four decades. Our limited experience fits fairly well with these reports: in the current era, successful surgical separation of conjoined hearts in thoracopagus twins remains largely elusive. Pulmonary hypoplasia ostensibly results from the lungs having to develop within the thoracic volume of half a conjoined body cavity. In addition, impaired ventilatory mechanics resulting from postoperative flail chest, pneumothoraces, a restrictive chest wall, and respiratory infection all contribute to make respiratory insufficiency an important confounder of survival after an apparently successful surgical separation.</p> <p><b>References</b></p> <p>1. Andrews RE, McMahon CJ, Yates RW, et al. Echocardiographic assessment of conjoined twins. <i><a href="https://doi.org/10.1136/hrt.2005.069682">Heart. 2006;92(3):382-387</a></i>.</p> <p>2. Thomas Collins R 2nd, Weinberg PM, Gruber PJ, St John Sutton MG. Conjoined hearts in thoracopagus twins. <i><a href="https://doi.org/10.1007/s00246-011-0125-3">Pediatr Cardiol. 2012;33(2):252–257</a></i>.</p> <p>3. Rode H, Fieggen AG, Brown RA, et al. Four decades of conjoined twins at Red Cross Children's Hospital--lessons learned. <a href="https://www.ncbi.nlm.nih.gov/pubmed/17077920"><i>S Afr Med J</i>. 2006;96(9 Pt 2):931-940</a>.</p

Freedom from thromboembolism despite prolonged inadequate anticoagulation

Life-long and meticulous control of anticoagulation is mandatory following mechanical valve replacement to prevent thromboembolism. Two patients who underwent mechanical mitral valve replacement with third generation bi-leaflet valves and in whom therapeutic anticoagulation could not be achieved for many months postoperatively form the basis for this report. In the first patient, the target international normalised ratio (INR) of 2.5–3.5 could not be achieved until 53.5 months postoperatively despite good compliance with oral anticoagulation and INR monitoring. In the second patient, the target INR was achieved after 16.9 months of oral anticoagulation treatment and regular INR monitoring. No thromboembolism occurred in either patient; nor did any valve-related event occur. The two patients are in excellent physical health 8 and 5 years, respectively, after the procedure. This unusual phenomenon is reviewed in light of the few reported cases of patients with mechanical heart valves surviving for prolonged periods without anticoagulation