Post oesophagectomy leakage at Kenyatta National Hospital – Nairobi - Kenya

Background: Post oesophagectomy leakage is a common postoperative complication. This present review was aimed at documenting the problem of post-oesophagectomy leakage and associated variables at Kenyatta National Hospital (KNH) between January 1998 and December 2004.Methods: All patients presenting with carcinoma of the oesophagus and who underwent an oesophagectomy were included into the study. Analysis of data was carried out to determine the leakage rate as well as determining the association of leaks with other preoperative and postoperative variables. Statistical analysis performed on Microsoft Excel (10.2614.2625), and Epinfo 2002. The Chi2 test was used to determine statistical significance. Level of significance was achieved if the p value was < 0.05.Results: A total of 201 oesophagectomies were carried out in the period under review. The male to female sex ratio was 1.6:1. The average age was 57 years with a range of 24 years to 88 years. Two thirds (67.1%) of the anastomoses were fashioned within the thoracic cavity while the rest were fashioned within the cervical area. A total 16.4% of anastomoses leaked. The in-hospital mortality rate for all oesophagectomies was 28.9%. The in-hospital mortality for the post anastomotic leakage patients was 48.4% as compared to 27.2% among those patients who did not develop anastomotic leakage.Conclusion: Post oesophagectomy leakage remains common complication at Kenyatta National Hospital (KNH)

Pattern of anticoagulation control after heart value surgery at the Kenyatta National Hospital, Nairobi

Objective: To determine the pattern of anticoagulation control for post heart-valve surgery for patients on follow up at Kenyatta National Hospital(KNH).Design: A combined prospective and restrospective hospital-based study. Retrospective period from January 1991 to 31st August 1997, while the prospective period was from 1st September 1997 to 31st November 1999.Setting: Cardiothoracic surgery clinic, Kenyatta National Hospital, Nairobi.Patients: Post heart valve surgery patients on warfarin and attending the cardiothoracic surgery clinic at Kenyatta National Hospital.Main outcome measures: Clinic attendance intervals, average warfarin dosages, interval of dosage change, INR values and variations from accepted normal.Results: A total of 103 patients fulfilled the criteria for inclusion into the study consisting of 77 mitral valve replacements, 18 aortic valve replacements, seven double valve replacements and one mitral valve repair. The total follow up time for the study period is 316.9 patientsyears. On average, patients attended their anticoagulation clinic once every 59 days. The average dose of warfarin prescribed was 6.81mg daily(±2.67mg), with double valve replacement patients receiving a statistically significant lower dosage of 6.04 mg (±1.36mg),(95% confidence limits). On average, a warfarin dose change was made 1.48 times a year per patient. For all the patients, the mean INR was 2.50 (±1.18). The respective values for mitral, aortic, double valve replacement and the mitral repairs were 2.53(±1.21), 2.32 (±1.04), 2.5(±1.05) and 2.02 (±0.53), respectively. Mitral valve repair patients maintained a significantly lower level of INR (95% confidence limits). Only during 18% of the follow up time was adequate anticoagulation maintained. During the study period only 6.9% of patients were able to maintain adequate anticoagulation for 50% or more of their follow up time.Conclusion: Anticoagulation control at the KNH still needs some improvements in clinic attendance and better dosage adjustments to achieve more appropriate INR values

Thromboembolic and bleeding complications in patients with prosthetic heart valves at the Kenyatta National Hospital

Background: Despite constant monitoring of anticoagulation in prosthetic valve patients, haematologic complications occur. This study documented the occurrence of such complications and associated risk factors at the Kenyatta National Hospital (KNH).Study design: Observational study reviewing 142 patients, 39 prospective and 103 retrospective.Outcome measures: International Normalised Ratio (INR); presence of signs and symptoms of haematological complications.Results: Forty four (31%) patients presented with bleeding tendencies, 28 grade I and 4 grade III. The most common thromboembolic complication was headache in 33 (23.2%) patients. Mean duration of anticoagulation for patients with complications was 82.9 months (± 64), compared to 60.8 months (± 43.8) in those without. Nine patients were non-compliant in taking medications, haematologic complications presenting in 8 of them.Conclusion: A positive association was established between hematologic complications and INR levels, duration of anticoagulation therapy, non-compliance in taking of medications, and increased period between clinic visits. Of these only the duration of anticoagulation was an independent predictor for haematological complications

Surgical Apgar Score Predicts Post- Laparatomy Complications

Introduction: The Surgical Apgar score (SAS) presents a simple, immediate and an objective means of determining surgical outcomes. The score has not been widely validated in low resource settings where it would be most valuable. This study aimed to evaluate its accuracy and applicability for patients undergoing laparatomy at Kenyatta National Hospital (KNH), Nairobi.Methodology: Using intra-operative records, we calculated Surgical Apgar Scores for 152 patients during a 6-month study between March 2011 and August 2011. Our main outcome measures were the incidence of major postoperative complications and/or death within 30 days of surgery.Results: The mean age of the patients evaluated was 35.18 years, range of 14 to 80 years. Most laparatomies were emergency procedures (86.8%) with mean duration for surgery of 131 minutes. The overall rate for major complications and mortality was 40.8% and 7.9% respectively. Common morbidities were superficial and deep wound infection, anastomotic leakage and wound dehiscence. The mean SAS for patients with complications was lower (4.0) compared to those without (5.73) (p<0.001). Patients categorised as high risk had a 58.3% complication rate compared to low risk patients with 16.6 % (p=0.04). These outcomes compare favourably with other studies. The SAS demonstrated good predictive accuracy for postoperative morbidity (ROC area under the curve of 0.796, CI 0.727-0.865).Conclusion: This study confirms the SAS as adequate in stratification of post-operative risk of major complications following laparatomy in our setting with good predictive accuracy

Risk Of Conjunctival Contamination From Blood Splashes During Surgery At The Kenyatta National Hospital, Nairobi

Objectives: To determine the utilisation rate of design specific eye protection by surgeons and to assess the risk of conjunctival contamination with blood splashes during surgery. Design: Cross sectional, observational study. Setting: The theatre suite of Kenyatta National Hospital, Nairobi Subjects: Surgeons from all specialties operating in the theatre suite. Results: The minority of surgeons, 5.2% utilised protective eye goggles compared to 3.5% of assistants. Prescription eye spectacles were the most common form of eye protection at 41.9 and 20.9% respectively for surgeons and their assistants. The contamination rate for provided protective eye wear was 53.1% with the average number of droplets being 2.48 per procedure for the principal surgeon. The duration of surgery and the use of power tools influenced the contamination rate. Conclusions: The utilisation rate of design specific protective eye wear is low and with a significant risk of conjunctival contamination, changes in attitudes and practices are needed to increase utilisation

Post-infaction ventricular septal defect in Nairobi: case report

No Abstract. East African Medical Journal Vol 82(12) 2005: 660-66

Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.

BACKGROUND: Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. METHODS: A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. FINDINGS: Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 per 100 000 population (IQR 0·2-2·0). Maternal mortality was 20 (0·5%) of 3684 patients (95% CI 0·3-0·8). Complications occurred in 633 (17·4%) of 3636 mothers (16·2-18·6), which were predominantly severe intraoperative and postoperative bleeding (136 [3·8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4·47 [95% CI 1·46-13·65]), and perioperative severe obstetric haemorrhage (5·87 [1·99-17·34]) or anaesthesia complications (11·47 (1·20-109·20]). Neonatal mortality was 153 (4·4%) of 3506 infants (95% CI 3·7-5·0). INTERPRETATION: Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa. FUNDING: Medical Research Council of South Africa.Medical Research Council of South Africa