Bowel Perforation Secondary to Illegally Induced Abortion: a Tertiary Hospital Experience in Tanzania.

Bowel perforation though rarely reported is a serious complication of induced abortion, which is often performed illegally by persons without any medical training in developing countries. A sudden increase in the number of patients in our centre in recent years prompted the authors to analyze this problem. The study was conducted to describe our own experiences in the surgical management of these patients. This was a retrospective study involving patients who were jointly managed by the surgical and gynecological teams at Bugando Medical Centre (BMC) for bowel perforation secondary to illegally induced abortion from January 2002 to December 2011. The statistical analysis was performed using SPSS version 17.0. A total of 68 patients (representing 4.2% of cases) were enrolled in the study. Their ages ranged from 14 to 45 years with a median age of 21 years. Majority of patients were, secondary school students/leavers (70.6%), unmarried (88.2%), nulliparous (80.9%), unemployed (82.4%) and most of them were dependent member of the family. Previous history of contraceptive use was reported in only 14.7% of cases. The majority of patients (79.4%) had procured the abortion in the 2nd trimester. Dilatation and curettage (82.4%) was the most common reported method used in procuring abortion. The interval from termination of pregnancy to presentation in hospital ranged from 1 to 14 days (median 6 days ). The ileum (51.5%) and sigmoid colon (22.1%) was the most common portions of the bowel affected. Resection and anastomosis with uterine repair was the most common (86.8%) surgical procedure performed. Complication and mortality rates were 47.1% and 10.3% respectively. According to multivariate logistic regression analysis, gestational age at termination of pregnancy, delayed presentation, delayed surgical treatment and presence of complications were significantly associated with mortality (P<0.001). The overall median length of hospital stay (LOS) was 18 days (1day to 128 days ). Patients who developed complications stayed longer in the hospital, and this was statistically significant (P=0.012). Bowel perforation following illegally induced abortion is still rampant in our environment and constitutes significantly to high maternal morbidity and mortality. Early recognition of the diagnosis, aggressive resuscitation and early institution of surgical management is of paramount importance if morbidity and mortality associated with bowel perforation are to be avoided

Gastric Cancer at a University Teaching Hospital in Northwestern Tanzania: A Retrospective Review of 232 Cases.

Despite marked decreases in its incidence, particularly in developed countries, gastric cancer is still the second most common tumor worldwide. There is a paucity of information regarding gastric cancer in northwestern Tanzania. This study was undertaken to describe our experience, in our local setting, on the management of gastric cancer, outlining the clinicopathological and treatment outcome of these patients and suggesting ways to improve the treatment outcome. This was a retrospective study of histologically confirmed cases of gastric cancer seen at Bugando Medical Centre between January 2007 and December 2011. Data were retrieved from patients' files and analyzed using SPSS computer software version 17.0. A total of 232 gastric cancer patients were enrolled in the study, representing 4.5% of all malignancies. The male to female ratio was 2.9:1. The median age of patients was 52 years. The majority of the patients (92.1%) presented late with advanced gastric cancer (Stages III and IV). Lymph node and distant metastasis at the time of diagnosis was recorded in 31.9% and 29.3% of cases, respectively. The antrum was the most frequent anatomical site (56.5%) involved and gastric adenocarcinoma (95.1%) was the most common histopathological type. Out of 232 patients, 223 (96.1%) patients underwent surgical procedures for gastric cancer of which gastro-jejunostomy was the most frequent performed surgical procedure, accounting for 53.8% of cases. The use of chemotherapy and radiotherapy was documented in 56 (24.1%) and 12 (5.1%) patients, respectively. Postoperative complication and mortality rates were 37.1% and 18.1%, respectively. According to multivariate logistic regression analysis, preoperative co-morbidity, histological grade and stage of the tumor, presence of metastases at the time of diagnosis was the main predictors of death (P <0.001). At the end of five years, only 76 (32.8%) patients were available for follow-up and the overall five-year survival rate was 6.9%. Evidence of cancer recurrence was reported in 45 (19.4%) patients. Positive resection margins, stage of the tumor and presence of metastasis at the time of diagnosis were the main predictors of local recurrence (P <0.001). Gastric cancer in this region shows a trend towards relative young age at diagnosis and the majority of patients present late with an advanced stage. Lack of awareness of the disease, poor accessibility to health care facilities and lack of screening programs in this region may contribute to advanced disease at the time of diagnosis. There is a need for early detection, adequate treatment and proper follow-up to improve treatment outcome

Etiological spectrum, injury characteristics and treatment outcome of maxillofacial injuries in a Tanzanian teaching hospital

Background: Maxillofacial injuries pose a therapeutic challenges to trauma, maxillofacial and plastic surgeons practicing in developing countries. This study was carried out to determine the etiology, injury characteristics and management outcome of maxillofacial injuries at our teaching hospital. Patients and Methods: A prospective hospital based study of maxillofacial injury patients was carried out at Bugando Medical Centre from November 2008 to October 2009. Data was collected using a structured questionnaire and analyzed using SPPS computer software version 11.5. Results: A total of 154 patients were studied. Males outnumbered females by a ratio of 2.7:1. Their mean age was 28.32 ± 16.48 years and the modal age group was 21-30 years. Most injuries were caused by road traffic crushes (57.1%), followed by assault and falls in 16.2% and 14.3% respectively. Soft tissue injuries and mandibular fractures were the most common type of injuries. Head/neck (53.1%) and limb injuries (28.1%) were the most prevalent associated injuries. Surgical debridement (95.1%) was the most common surgical procedures. Closed reduction of maxillofacial fractures was employed in 81.5% of patients. Open reduction and internal fixation was performed in 6.8% of cases. Complications occurred in 24% of patients, mainly due to infection and malocclusion. The mean duration of hospital stay was 18.12 ± 12.24 days. Mortality rate was 11.7%. Conclusion: Road traffic crashes remain the major etiological factor of maxillofacial injuries in our setting. Measures on prevention of road traffic crashes should be strongly emphasized in order to reduce the occurrence of these injuries

Geriatric Injuries among Patients Attending a Regional Hospital in Shinyanga Tanzania

Geriatric injuries pose a major challenge to surgeons and general practitioners in developing countries. The objective of this study was to determine the prevalence, injury characteristics and outcomes of geriatric injury among patients at Shinyanga Regional Hospital in Tanzania. Data was collected using a pre-tested, coded questionnaire and analyzed using SPSS computer system. A total of 94 geriatric trauma patients constituting 22.7% of all trauma admissions were studied. The male to female ratio was 1.4:1. Their mean age was 68.5 years (ranged 60-98 years). Premorbid illness was reported in 38.3% of patients. Most injuries were intentional in fifty-three (56.4%) patients. Assaults, falls and road traffic crashes were the mechanism of injuries in 52.1%, 19.1% and 11.7% of cases, respectively. The majority of cases of assault were females accounting for 64.6%. The majority of injuries (81.9%) occurred at home. Pre-hospital care was recorded in 5.3% of cases. The musculoskeletal (72.3%) and head (66.0%) regions were commonly affected. Soft tissue injuries (wounds) (89.4%) and fractures (52.2%) were the most common type of injuries. The majority of patients (90.4%) underwent surgical treatment of which wound debridement was the most common procedure performed in 91.8% of cases. Complication rate was 39.4%. The mean length of hospital stay was 28.6 days (ranged 1 – 124 days). The length of hospital stay was significantly longer in patients with co-morbidities, long bone fractures and those with complications (P<0.05). Mortality rate was 14.9% and it was significantly related to advanced age, presence of pre-morbid illness, high injury severity score, severe head injuries and the need for ventilatory support (P< 0.05). In conclusion, traumatic injuries in elderly constitute a major but preventable public health problem in Shinyanga region and contribute significantly to high morbidity and mortality. Urgent preventive measures focusing at the root causes of the injuries and early appropriate treatment is highly needed to reduce the occurrence, morbidity and mortality associated with these injurie

Antibiotic use in urological surgeries: a six years review at Muhimbili National Hospital, Dar es salaam-Tanzania

Introduction: Antimicrobial prophylaxis for urologic procedures is a major issue, as potential   advantages of antibiotic administration should be carefully weighed against potential side effects,   microbial resistance, and health care costs. This study aimed to review a six years trend of antibiotic  use  in urological surgeries at Muhimbili National Hospital (MNH) being an experience in a typical third  world environment.Methods: This was a six years hospital based descriptive, retrospective study conducted of which all case notes of urological patients operated on in between January 2007 to December, 2012 were reviewed by using a structured data collecting tool. The data were analyzed using SPSS software.Results: Male patients were the majority at 62% (450). The age range was 0 - 90 years, with a mean of 30 ± 22.09. Among the urological surgeries done at MNH 86.5% (628) received prophylactic antibiotics  regardless of the type surgery done. Majority 63.7% (463) received antibiotics during induction.  Ceftriaxone was the commonly given antibiotic regardless of the type of urological surgery done. Most of patients (86.4%) were given antibiotics for five days regardless whether it was for prophylactic or  treatment intention.Conclusion: Antibiotic use is still a challenge at our hospital with over use of prophylactic antibiotics  without obvious indications. Prolonged use of prophylactic antibiotics beyond five days was the main finding. Ceftriaxone was the most given antibiotic regardless of the urological surgery done and its level of contamination. Antibiotic stewardship needs to be addressed urgently to avoid serious drug resistances leaving alone the cost implication.Key words: Antibiotics, urological surgeries, Tanzania

Clinicopathological patterns and challenges of management of colorectal cancer in a resource-limited setting: a Tanzanian experience

BACKGROUND: Colorectal cancer is one of the most common cancers worldwide and its incidence is reported to be increasing in resource-limited countries, probably due to the acquisition of a western lifestyle. However, information regarding colorectal cancer in Tanzania and the study area in particular is limited. This study was conducted in our local setting to describe the clinicopathological pattern of colorectal cancer and highlight the challenging problem in the management of this disease. METHODS: This was a retrospective study of histologically confirmed cases of colorectal cancer seen at Bugando Medical Center between July 2006 and June 2011. Data were retrieved from patients’ files and analyzed using SPSS computer software version 17.0. RESULTS: A total of 332 colorectal cancer patients were enrolled in the study, representing 4.7% of all malignancies. Males outnumbered females by a ratio of 1.6:1. The median age of patients at presentation was 46 years. The majority of patients (96.7%) presented late with advanced stages. Lymph node and distant metastasis at the time of diagnosis was recorded in 30.4% and 24.7% of cases, respectively. The rectosigmoid region was the most frequent anatomical site (54.8%) involved and adenocarcinoma (98.8%) was the most common histopathological type. The majority of adenocarcinomas (56.4%) were moderately differentiated. Mucinous and signet ring carcinomas accounted for 38 (11.6%)and 15 (4.6%) patients, respectively. Three hundred and twenty-six (98.2%) patients underwent surgical procedures for colorectal cancer. Only 54 out of 321 (16.8%) patients received adjuvant treatment. Postoperative complication and mortality rates were 26.2% and 10.5%, respectively. The overall median duration of hospital stay was 12 days. Only nine out of 297 survivors (3.0%) were available for follow-up at the end of 5 years. Cancer recurrence was reported in 56 of 297 survivors (18.9%). Data on long-term survival were not available as the majority of patients were lost to follow-up. CONCLUSIONS: Colorectal cancer is not uncommon in our environment and shows a trend towards a relative young age at diagnosis and the majority of patients present late with advanced stage. There is a need for screening of high-risk populations, early diagnosis and effective cost-effective treatment and follow-up to improve outcome of these patients

Antibiotic use in urological surgeries: a six years review at Muhimbili National Hospital, Dar es salaam-Tanzania

Introduction: Antimicrobial prophylaxis for urologic procedures is a major issue, as potential   advantages of antibiotic administration should be carefully weighed against potential side effects,   microbial resistance, and health care costs. This study aimed to review a six years trend of antibiotic  use  in urological surgeries at Muhimbili National Hospital (MNH) being an experience in a typical third  world environment.Methods: This was a six years hospital based descriptive, retrospective study conducted of which all case notes of urological patients operated on in between January 2007 to December, 2012 were reviewed by using a structured data collecting tool. The data were analyzed using SPSS software.Results: Male patients were the majority at 62% (450). The age range was 0 - 90 years, with a mean of 30 ± 22.09. Among the urological surgeries done at MNH 86.5% (628) received prophylactic antibiotics  regardless of the type surgery done. Majority 63.7% (463) received antibiotics during induction.  Ceftriaxone was the commonly given antibiotic regardless of the type of urological surgery done. Most of patients (86.4%) were given antibiotics for five days regardless whether it was for prophylactic or  treatment intention.Conclusion: Antibiotic use is still a challenge at our hospital with over use of prophylactic antibiotics  without obvious indications. Prolonged use of prophylactic antibiotics beyond five days was the main finding. Ceftriaxone was the most given antibiotic regardless of the urological surgery done and its level of contamination. Antibiotic stewardship needs to be addressed urgently to avoid serious drug resistances leaving alone the cost implication.Key words: Antibiotics, urological surgeries, Tanzania

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 &lt; 0.001), where as surgical closure was significantly associated with presence of complications and pre-morbid illness (p-value &lt; 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

Splenic injuries at Bugando Medical Centre in northwestern Tanzania: a tertiary hospital experience

Splenic injuries constitute a continuing diagnostic and therapeutic challenge to the trauma or general surgeons practicing in developing countries where sophisticated imaging facilities are either not available or exorbitantly expensive. The purpose of this review was to describe our own experience in the management of the splenic injuries outlining the aetiological spectrum, injury characteristics and treatment outcome of splenic injuries in our local environment and to identify predictors of outcome among these patients. A prospective descriptive study of splenic injury patients was carried out at Bugando Medical Centre in Northwestern Tanzania between March 2009 and February 2011. Statistical data analysis was done using SPSS software version 17.0. A total of 118 patients were studied. The male to female ratio was 6.4:1. Their ages ranged from 8 to 74 years with a median age of 22 years. The modal age group was 21-30 years. The majority of patients (89.8%) had blunt trauma and road traffic accidents (63.6%) were the most frequent cause of injuries. Most patients sustained grade III (39.0%) and IV (38.1%) splenic injuries. Majority of patients (86.4%) were treated operatively with splenectomy (97.1%) being the most frequently performed procedure. Postoperative complications were recorded in 30.5% of cases. The overall length of hospital stay (LOS) ranged from 1 day to 120 days with a median of 18 days. Mortality rate was 19.5%. Patients who had severe trauma (Kampala Trauma Score II ≤ 6) and those with associated injuries stayed longer in the hospital (P < 0.001), whereas age of the patient, associated injuries, trauma scores (KTS II), grade of splenic injuries, admission systolic blood pressure ≤ 90 mmHg, estimated blood loss > 2000 mls, HIV infection with CD4 ≤ 200 cells/μl and presence of postoperative complications were significantly associated with mortality (P < 0.001). Trauma resulting from road traffic accidents (RTAs) remains the most common cause of splenic injuries in our setting. Most of the splenic injuries were Grade III & IV and splenectomy was performed in majority of the cases. Non-operative management can be adopted in patients with blunt isolated and low grade splenic injuries but operative management is still indispensable in this part of Tanzania. Urgent preventive measures targeting at reducing the occurrence of RTAs is necessary to reduce the incidence of splenic injuries in our centre

Experiences With Surgical Treatment of Chronic Lower Limb Ulcers at a Tertiary Hospital in Northwestern Tanzania: A Prospective Review of 300 Cases.

Chronic lower limb ulcers constitute a major public health problem of great important all over the world and contribute significantly to high morbidity and long-term disabilities. There is paucity of information regarding chronic lower limb ulcers in our setting; therefore it was necessary to conduct this study to establish the patterns and outcome of chronic lower limb ulcers and to identify predictors of outcome in our local setting. This was a descriptive prospective study of patients with chronic lower limb ulcers conducted at Bugando Medical Centre between November 2010 and April 2012. Ethical approval to conduct the study was sought from relevant authorities. Statistical data analysis was done using SPSS version 17.0 and STATA version 11.0. A total of 300 patients were studied. Their ages ranged from 3 months to 85 years (median 32 years). The male to female ratio was 2:1. The median duration of illness was 44 days. Traumatic ulcer was the most frequent type of ulcer accounting for 60.3% of patients. The median duration of illness was 44 days. The leg was commonly affected in 33.7% of cases and the right side (48.7%) was frequently involved. Out of 300 patients, 212 (70.7%) had positive aerobic bacterial growth within 48 hours of incubation. Pseudomonas aeruginosa (25.5%) was the most frequent gram negative bacteria isolated, whereas gram positive bacteria commonly isolated was Staphylococcus aureus (13.7%). Twenty (6.7%) patients were HIV positive with a median CD4+ count of 350 cells/μl. Mycological investigation was not performed. Bony involvement was radiologically reported in 83.0% of cases. Histopathological examination performed in 56 patients revealed malignancy in 20 (35.7%) patients, of which malignant melanoma (45.0%) was the most common histopathological type. The vast majority of patients, 270 (90.0%) were treated surgically, and surgical debridement was the most common surgical procedure performed in 24.1% of cases. Limb amputation rate was 8.7%. Postoperative complication rate was 58.3% of which surgical site infection (77.5%) was the most common post-operative complications. The median length of hospital stay was 23 days. Mortality rate was 4.3%. Out of the two hundred and eighty-seven (95.7%) survivors, 253 (91.6%) were treated successfully and discharged well (healed). After discharge, only 35.5% of cases were available for follow up at the end of study period. Chronic lower limb ulcers remain a major public health problem in this part of Tanzania. The majority of patients in our environment present late when the disease is already in advanced stages. Early recognition and aggressive treatment of the acute phase of chronic lower limb ulcers at the peripheral hospitals and close follow-up are urgently needed to improve outcomes of these patients in our environment