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

Case report: Accidental insertion of a tampon into the bladder

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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

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

Squamous cell carcinoma (Marjolin's ulcer) in an orocutaneous fistula of a large mandibular ameloblastoma: a case report

<p>Abstract</p> <p>Introduction</p> <p>Ameloblastomas are rare lesions constituting 1% of all jaw tumors. Oral squamous cell carcinomas are common lesions; these constitute about 90% of all oral cancers. Concurrent tumors consisting of ameloblastoma and squamous cell carcinoma are extremely rare.</p> <p>Case presentation</p> <p>This case report describes a 35-year-old African man who presented with a large mandibular tumor with an orocutaneous fistula that was found to be an ameloblastoma on histopathological examination, with concurrent squamous cell carcinoma histology within the fistula. This presentation was consistent with a Marjolin's ulcer within an ameloblastoma.</p> <p>Conclusion</p> <p>Ameloblastomas and Marjolin's ulcers require different management strategies. Careful histopathological examination of surgical specimens is key to patient outcome, as treatment of these patients depends on an accurate diagnosis.</p

Giant condyloma acuminatum of the scrotum in a man with AIDS: a case report

Abstract Introduction Giant condyloma acuminatum, also called a Buschke-Löwenstein tumor, first described in 1925, is a slow-growing, locally aggressive, destructive tumor of the ano-genital region. Scrotal tumors are rare. Reports on giant condyloma acuminatum lesions in patients with HIV and AIDS are surprisingly even rarer. Case presentation In this report, we present the case of a 42-year-old African man with AIDS who was undergoing anti-retroviral therapy. He was found to have a giant condyloma acuminatum of the scrotum. Wide surgical excision and scrotal reconstruction with a pedicled anterolateral thigh flap was performed, significantly improving his quality of life. Conclusion Decision making regarding the goals of surgical intervention in the terminally ill is a complex process. The options include conservative medical palliation or palliative excision versus a curative excision that has the potential for significant morbidity. Wide surgical excision with local flap reconstruction significantly improved the quality of life of the patient described herein. The challenges presented by emerging or unusual presentations of surgical pathology secondary to HIV and AIDS in patients who are on anti-retroviral therapy provide an opportunity for research and the establishment of guidelines for the use of adjuvant chemotherapy in these patients.</p

Marjolin's ulcers: theories, prognostic factors and their peculiarities in spina bifida patients

<p>Abstract</p> <p>Background</p> <p>Due to improved care, more and more children born with spina bifida in rural Kenya are surviving into adulthood. This improved survival has led to significant challenges in their lifestyles, especially the need to ensure pressure ulcer prevention and treatment. Malignant degeneration of pressure ulcers in spina bifida patients is very rare. The author describes the clinical presentation of two pressure ulcer carcinomas that are at variance from classical descriptions.</p> <p>Materials and methods</p> <p>An internet/Medline/PubMed search of English literature for theories on Marjolin's ulcer evolution and prognostic features of Marjolin's ulcers was performed.</p> <p>A chart review of two young adults with spina bifida who had presented to the author's hospital between 2004 and August 2010 with chronic pressure ulcers found to be Marjolin's ulcers on histo-pathological examination was performed, and the clinical features are reported.</p> <p>Results</p> <p>The two ulcers appeared clinically benign: one was a deep ulcer, while the other was shallow; both had normal, benign-appearing edges, and a foul smelling discharge. The two ulcers were surrounded by induration and multiple communicating sinuses, with no evidence of chronic osteomyelitis. The internet search revealed a total of nine theories on Marjolin's ulcer development, as well as seven clinical and four histological prognostic features.</p> <p>Discussion</p> <p>The multifactorial theory, a coalescence of a number of proposed theories, best explains the evolution of Marjolin's ulcers. Poor prognostic features include pressure ulcer carcinomas, lesions and location in the lower limbs/trunks, all present in the two patients making their prognosis dim: this is despite the surgical margins being clear of tumor. Benign appearance, induration and presence of multiple communicating sinuses are features that have not been previously described as presenting features of pressure ulcers carcinomas.</p> <p>Conclusion</p> <p>There is need for spina bifida patients and their guardians/caretakers to receive a close follow-up throughout life; health education focused on pressure ulcer prevention as well as early treatment of pressure ulcers when they occur, will avert the development of Marjolin's ulcers, and save lives.</p