Bilateral thigh flaps: A case report and review of literature

Background: Pressure ulcer management is difficult for the patient, relatives, doctor, and nursing staff and requires enormous resources. Management of multiple pressure ulcers in the spinal cord injured patient is a near-impossible task, especially in resource-deprived environments. The paraplegic, with multiple pressure ulcers, will frequently be managed under palliative care in these settings. A case report of a young motivated paraplegic with multiple infected pressure ulcers managed using total thigh flaps, in a rural hospital in Kenya is made. The surgical procedure is detailed, and a review of literature made.Case Report: A 16-years old school boy presented to AIC Kijabe Hospital in extremis because of severe sepsis from multiple infected pressure ulcers. He had sustained a spinal cord injury 4 years previously, after a fall from a tree. After initial resuscitation, including nutritional support, blood transfusion, urinary drainage and stool diversion; bilateral hip disarticulation, pressure ulcer excision and defect closure using bilateral total thigh flaps was performed. All the pressure ulcers were successfully covered. Rehabilitation enabled him to find a new level of independence and self care. He returned to school.Conclusion: Bilateral hip disarticulation with bilateral thigh flap utilization for the coverage of multiple pressure ulcers is a useful, life-saving tool. This procedure enhanced the patients’ independence and self-esteem. It is however, a tool to be used only as a last option

Pattern of Surgical Diseases Based on Histopathological Findings: A 13-years Personal Experience in a Rural Hospital in Kenya

Background: Church/mission hospitals and other non-government health institutions inKenya provide 30% of the healthcare needs, providing affordable care to the rural poor. This review presents the surgical pathology to which a general surgeon working in a rural Kenyan hospital is exposed through training and beyond. Additionally, some of the rarer surgical pathology, ‘rare birds’, encountered during this period is reported.Methods: In this retrospective study, all the surgical specimens submitted by the author for histopathological examination over a period of thirteen years were reviewed and analyzed. The findings are reported.Results: The results of 1826 surgical specimens were divided into the major surgical specialties that a surgeon working in this environment is exposed to. General surgical specimens constituted 48.4% of the total specimens, while urology, gynecology, maxillofacial/otolaryngology and ‘other’ specialties made up 34.6%, 7.8%, 6.7%, and 2.5% respectively. There were a total of 389 malignancies, of which 55% were in general surgery and 31.1% in urology. Rare surgical pathologies encountered over this period included acne conglobata, an intramuscular lipoma of the forearm, intraosseous lipoma of the fibula, primary tuberculosis of the prostate gland and of the thyroid gland, amongst others.Conclusion: Church/mission hospitals currently present excellent opportunities both for training and career development in general surgery and related disciplines

Versatility of the Pedicled ALT Flap in Defect Reconstruction: Experience of a Unit in Rural Sub-Saharan African

Background: The free anterolateral thigh flap with its large caliber vessels, a reliable skin territory and minimal donor site morbidity is the reconstructive surgeons’ workhorse. The pedicled flap though not as popular, has been used extensively for the reconstruction of defects from the mid-leg to the epigastrium. The favorable profile of the anterolateral thigh flap, with minimal variability of its vascular anatomy and donor site complications is well described in most races; literature of its use in sub-Saharan Africa is scanty. Methods: The author describes the use of the anterolateral thigh flap in a series of 17 patients in a rural African hospital, illustrating its versatility as well as the complications associated with its use in this patient population. Results: Seventeen patients withtwenty antero-lateral thigh flaps were followed for an average of 24 months. Conclusions: The pedicled antero-lateral thigh flap is an excellent reconstructive tool with very good results in the black African population. This versatile flap has low donor site morbidity. The risk of developing hypertrophic scars and keloids remains a real concern in Black patients and longer term follow-up and a larger number of patients are needed to establish this potential complication.Key words: Anterolateral thigh flap, Afric

Case report: Accidental insertion of a tampon into the bladder

No Abstract

Neurofibromatosis type 1: Surgical Perspectives

Introduction: Neurofi bromatosis type 1 (NF1) affects about 1 in 3000 people. The indications for surgical intervention in patients with NF1 are not always clear-cut. In low-income economies, where scarcity of resources and skilled manpower often dictate levels of healthcare, a broad knowledge base of NF1 is required in order to adequately manage NF1 complications.Materials and Methods: The authors performed PubMed/internet searches for articles on surgical aspects of NF1, as well as a review of the pathology department database for reports on all specimens submitted from patients with NF1 over a 16 year period. A retrospective chart review was performed on all patients with NF1 referred to the authors’ institution for surgical intervention between January 2004 and January 2011.Results: Forty fi ve articles describing aspects of surgical care of patients with NF1 qualifi ed for inclusion in the review. Pathological specimens were submitted from a total of 333 patients with NF1 between 1992 and 2008. These represented 0.4% of all submitted specimens during this period. The male to female ratio was 1.05:1; 9.3% of these specimens were reported as malignant peripheral nerve sheath tumors. Fifteen of sixteen NF1 patients referred to the institution for surgical intervention over a seven year period underwent an average 1.7 interventions. Most presented late, some with malignancies (27%), making it difficult to obtain good cosmetic and functional results. Three representative case presentations are reported from these patients to show that (i) NF1 complications affects any system, cannot be predicted, making prognosis uncertain, (ii) cervical spine instability, excessive intra-operative bleeding and post-operative edema are important peri-operative considerations, (iii) essential role of access to safe blood for transfusion and an intensive care service.Conclusions: Surgical symptom control (cosmesis, function, and pain) rather than surgical cure is the primary, achievable goal of most interventions in patients with NF1. Lifelong surveillance is necessary for all NF1 patients to avert or minimize complications, and thus improve surgicaloutcomes

Marjolin’s Ulcer in a Spina Bifida Patient: A Case Report

‘They dress the wound of my people as though it were not serious’ Jeremiah 6:14.Pressure ulcers are a frequent complication among neurologically-impaired patients, including those with spina bifida. Malignant degeneration of these pressure ulcers, known as Marjolin’s ulcers, although a rare complication, results in a virulent cancer and often death. The history of a twenty year-old spina bifida patient who presented with a longstanding sacral pressure ulcer that was found to be malignant is reported. Pressure ulcers should be thoroughly investigated at presentation, to avoid labeling malignancies ‘chronic ulcers’, leading to delay in appropriate treatment

Visor flap for total upper and lower lip reconstruction: a case report

<p>Abstract</p> <p>Introduction</p> <p>Noma, aptly named the 'face of poverty', is a scourge with a mortality rate of up to 90% that affects some 140,000 people each year, predominantly children in the sub-Saharan 'noma belt'. Survivors of the acute attack suffer severe facial disfigurement from loss of facial tissue and scarring. Surgical reconstruction of noma defects is a major challenge, especially in Africa, where the majority of cases occur.</p> <p>Case presentation</p> <p>We report the case of a 40-year-old Somali man who presented with severe facial disfigurement, including total absence of both upper and lower lips. After a failed initial reconstruction, a combination of platysma flaps and a left deltopectoral flap provided mucosal lining, while a scalp visor flap served to recreate upper and lower lips, the beard and moustache.</p> <p>Conclusion</p> <p>The scalp visor flap offers a simple but extremely versatile tool for use in midfacial reconstruction, especially in the male, providing neo-lip tissue, a moustache and a beard. This is the first report of a simultaneous total upper and lower lip reconstruction using a scalp visor flap, in the English literature. We also emphasize on a process of transfer of skills to enable local surgeons to effectively manage the challenge that noma presents.</p

Outcome of moderate and severe thermal injuries at Kenyatta National Hospital

Background: Thermal injuries are a major cause of morbidity and mortality in Kenya. Though a lot is known about burns, the morbidity patterns and mortality rates of burns in this country have not been established. This study was designed with the general objective of investigating the outcome of moderate and severe burns managed at the Kenyatta National Hospital (KNH). It was also the aim of the authors to try to validate an existing simple clinical burn injury score, based on the Abbreviated Burn Severity Index (ABSI) score.Methods: This was a retrospective study of burn patients treated at KNH between January 1999 and December 2000. The main parameters studied included the age, sex, and depth of burn injury, inhalation injury and percentage total burn surface area (%TBSA). Other parameters recorded were the type of burn, pre-morbid or co-morbid illnesses, specimen culture and sensitivity and the length of hospital stay. Single variable analyses (χ2-test) were used to determine the value and influence of single variables on burn mortality. Multiple stepwise logistic regression analysis was performed on all the variables used in the ABSI score, as well as on hospital stay and type of burn (scald or flame), to determine their influence on burn mortality.Results: Out of the 1205 patient records retrieved, 1157 satisfied the inclusion criteria for the study. The findings confirmed the role of percentage total burn surface area, associated inhalation injury and depth of burn as the strongest prognostic variables (multivariate analysis); while age and sex have prognostic significance on single variable analysis. This data was then used to validate the ABSI score, which performed very accurately as a prognostic score.Conclusion: It is recommended that the ABSI score be adopted into clinical practice in this country, as an objective and accurate predictive clinical score

Ambiguous genitalia in rural Africa and the complexities of management: Which way forward?

Intersex disorders are amongst the most controversial conditions managed by doctors today. Although the diversity of their presentations demands broad classifications to help standardize management guidelines, each patient remains unique, requiring individualized care. The authors review the prevailing schools of thought on gender determination, assignment and re-assignment of intersex patients. The “liberal” views on sexuality, as espoused in current Western literature, vis-a-vis the “traditional” views of the average rural African community on sexuality are noted. The case histories of four patients highlight the diversity of presentations as well as the challenges in their management in a rural Kenyan hospital

Malignant Peripheral Nerve Sheath Tumors in Africa: A Clinicopathological Study

Introduction. Malignant peripheral nerve sheath tumors (MPNSTs) are rare, aggressive soft tissue sarcomas associated with poor prognosis, that most commonly affect patients aged 20 to 50 years, but have also been reported in children. There is little reported in literature on these tumors in Africa. Materials and Methods. A search of the hospital pathology database between 1992 and 2008 revealed 333 nerve sheath tumors, of which 31 were MPNSTs. Four representative case reports are presented. Discussion. MNPSTs have rarely been reported from sub-Saharan Africa; in this study, they constituted 9.3% of all nerve sheath tumors. The trunk (42%) and limbs (45%) were the most frequently affected anatomical sites. Late presentation of malignant lesions in this environment is exemplified by the four case presentations patients. Conclusions. This report confirms observations from studies on MPNSTs from other environments. Anatomically centrally located MPNSTs may have a higher incidence in sub-Saharan Africa than in the West. Because NF1-associated MPNSTs are difficult to diagnose clinically, and because surgery is the only mode of therapy that offers a complete cure, a lifetime follow-up is important, as this would enable diagnosis of early lesions amenable to surgical extirpation