Sutured and open clean-contaminated and contaminated laparotomy wounds at Muhimbili National Hospital: A comparison of complications

Background: Whether to close or leave open an abdominal incision wound depends on the degree of wound contamination at the end of operation. The aim of this study was to compare the complication rates between delayed primary closure and primarily closed laparotomy wounds for clean-contaminated and contaminated abdominal operations.Methods: Eighty-six patients undergoing laparotomy were included in a randomized clinical trial. Patients were randomized to have their wounds left open or closed primarily. In this study, all patients received Ceftriaxone Sodium (Powercef ®) as a prophylactic antibiotic at the time of induction of anaesthesia.Results: There was a statistically significant difference (p=0.002) in wound infection rate between those wounds left open (30.2%) and those closed primarily (2.1%). It required a longer duration of time for dressing those wounds left open compared to those closed primarily, The average duration for wound dressing was 16 days for open wounds compared to 11 days for primarily closed ones (p=0.0002). There was no significant difference in the development of wound dehiscence between the two groups (p>0.05). No death was related to wound complication.Conclusion: Clean-contaminated and contaminated laparotomy wounds should be closed primarily if no gross spillage of visceral contents occurs during operation and a patient receives prophylactic antibiotics

Primary gastrointestinal lymphoma in immunocompromised patient. Case report and literature review

Primary gastrointestinal lymphoma is a rare disease with no specific clinical presentation. Early diagnosis is usually based on suspicious index, otherwise majority of patients present at late with very advanced disease with complications. The incidence of primary gastrointestinal lymphoma is increasing with HIV disease. There are several classification and staging systems with different treatment options varying from one center to another. Prognosis depends on the stage at presentation, degree of differentiation and age. It was concluded that early diagnosis depends on degree of suspicious index with good treatment response. Late presentation is accompanied by marked immunosuppresion. Future research needs to determine whether single or combined modalities of treatment have good treatment outcomes. A case of primary gastrointestinal lymphoma in immunocompromised patient is reported with literature review

Perioperative factors affecting fast tracking in paediatrics cardiac surgical patients

Background: Preoperative and intraoperative factors that influence the postoperative period including weaning time from mechanical ventilation and extubation: in a paediatric cardiac patients have been widely studied with contradicting reports and variation from centre to centre. The aim of this study was to determine factors that influence the duration of weaning in paediatric cardiac surgical patients and their associated complications at our centre.Methods: This was a prospective study that recruited all eligible paediatric patients from infancy to childhood whom underwent cardiac surgical repair at Care Hospital Hyderabad, India between January and June 2007.Excluded were old age more than 18 years or patient with cardiac lesion undergoing palliative operation other than those involving cardiopulmonary bypass. Patients` demographic data including age, sex, height, weight and consequently body surface area were retrieved from patients` record file. The duration of symptoms was also determined and reported in months. Patients’ diagnoses details of the nature of the cardiac lesion as reported from echocardiography and or cardiac catheterization was recorded. Intraoperative parameters including the type of cardiac operation were taken care and recorded accordingly. Patient was followed up postoperatively both in the intensive care unit and in the general ward while closely monitored noting for any complications till the patient was discharged from either of these units. Patients’ data were entered into a master sheet data and later into a SPSS.11.5 window program for analyses using χ2-test for categorical data.Results: There were 103 patients of which 60.2% and 39.8% were male and female respectively. The mean age was 74.45 months: mean duration of symptoms was 54.52 months. Majority of patients had congenital heart disease that accounted for 93.6% of all cases while chronic rheumatic heart disease was found in 6.8% of cases. Tetrallogy of fallot and ventricular septal defect were the commonest among congenital heart disease representing 27.2% and 25.2% respectively. Young age was found to be a factor associated with prolonged mechanical ventilation and extubation. Further, the presence of pulmonary hypertension, lower cardiac grade and ventricular dysfunction were found to be factors significantly associated with prolonged weaning. While, cardiac disease occurring in combination, ischemia time, duration of cardiopulmonary bypass, total operation time, left ventricular ejection fraction, pH at the end of cardiopulmonary bypass and preoperative hemoglobin were factors found not to be associated with prolonged weaning.Conclusion: Our study has shown that presence of pulmonary hypertension, cardiac grade and ventricular dysfunction were factors associated with prolonged time to weaning. While aortic cross-clamp, total duration of cardiopulmonary bypass, , cardiac disease occurring in combination, total operation time and level of hemoglobin were not associated with prolonged time to weaning

Early outcome of Mitral Valve replacement: Results from Chordal Preservation at Muhimbiba National Hospital, Tanzania

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Modified blalock-taussig shunt in palliative cardiac surgery

Background: Cyanotic congenital heart diseases present early in life with poor general condition of the patient. Majority of deaths occurs within one year of life before surgical intervention due to severe cyanosis and metabolic acidosis. Modified Blalock-Taussig Shunt (MBTS) is one of the palliative cardiac surgeries done for cyanotic congenital heart diseases. It improves the general condition of the patient before definitive surgery is done. The aim of this study was to determine the commonest indications, post-operative anticoagulation and early complications following MBTS at CARE Hospital, India.Methods: This was a retrospective study from January 2004 to December 2006 including all patients who underwent Posterolateral Thoracotomy for MBTS. All patients had deep cyanosis, oxygen saturation of 65% or less and small pulmonary vasculature due to congenital heart defects. Acyanotic patients and those with oxygen saturation more than 65% were excluded from the study. All patients received a single dose of heparin intra-operatively and oral aspirin as anticoagulant regimen post-operatively. No heparin given postoperatively.Results: A total of 20 children with a mean age of 27.4 months were studied. Two patients had pre-operative ICU admission due to severe cyanosis (both had oxygen saturation of 35%), hypotension and severe body weakness. The commonest indications for MBTS included Tetralogy of Fallot (70%), pulmonary atresia (10%) with or without Ventricular Septal Defect (VSD), tricuspid atresia (10%) with pulmonary atresia or stenosis and Double Outlet Right Ventricle (DOVR) with pulmonary atresia or stenosis (10%). Mean duration of ICU stay was 2 days, mean duration of mechanical ventilation was four and half hours, mean duration of hospital stay was 7 days and mean systemic oxygen saturation improved significantly from 46% to 84% ( x2 = 7.03, p = 0.0080). No post-operative bleeding, seroma, shunt thrombosis or death occurred in this study.Conclusion: The commonest indication for MBTS is TOF. Intra-operative single dose of heparin followed by post-operative oral aspirin as anticoagulant regimen was not associated with a major complication in terms of bleeding, seroma, shunt thrombosis, or death

Cardiac Surgery: One year experience of cardiac surgery at Muhimbili National Hospital, Dar es Salaam- TANZANIA

Background: Establishing a cardiac unit in developing countries is usually difficult as it is associated with many obstacles of both expertise and financial constraints and more alarming is the mortality rate that may be high. Even after success in the initial stage sustainability of such program is a dilemma. The aim of this study was to determine pattern of disease profile, type of cardiac surgery done and the overall outcome.Methods: All patients who underwent cardiac operation at the centre were prospectively recruited. Patients’ demography and disease characteristics as demonstrated at echocardiography and its confirmation at operation were recorded. Peri-operative factors were the measurable statistics that determined the overall patients’ outcome. All data were entered and analyzed using a spss11.5 window program.Results: A total of 105 cases of cardiac surgery were done 21% were male and 79% were females. Mean age was 19.4±12.3. The majority of cases were due to Rheumatic heart diseases (47.6%), congenital heart disease (35.2%), myxomatous valvular degeneration (16.2%) and pericardial disease 1%. Mitral valve disease was the commonest cause of cardiac disease (58.1%). Prolonged duration of aortic cross-clamp and total operation time were associated with prolonged intensive care stay and poor patients’ outcome respectively (p<0.05). While, ventricular dysfunction and total cardiopulmonary bypass time were not. The overall mortality rate was 13.3%. Majority of all death (64.3%) followed mitral valve repair.Conclusion: The majority of patients (86.7%) who underwent cardiac surgery had full recovery. The mortality of (13.3%) is probably comparable to other settings. The diversity of spectrum of cardiac disease found elsewhere is also found in our community and therefore need to increase community awareness. Mitral valve repair deserve a special entity that requires skills and expertise. The mere presence of suboptimal ventricular dysfunction is probably not a contraindication to cardiac operation. The duration of aortic cross-clamp and total operation time were determinant of postoperative outcome

Palliative cancer surgery

Palliative care or End-of-life care in terminally-ill patients requires multi-displinary approach and therefore, different modalities of treatment. The aim of palliative care is to improve the quality of life and make the subject as comfortable as possible. Palliative cancer surgery is a branch of surgical oncology which relieves the symptoms of the patient with advanced cancer at the endstage. Majority of the patients in our environment present at late with advanced cancer. Majority of the cancer patients are managed by general surgeons in many centers due to lack of oncology surgeons and therefore, literature review in palliative Cancer Surgery. It was concluded that palliative cancer surgery play an important role in patients with advanced cancer to improve quality life as well as a need to improve surgical training in palliative cancer surgery

Kaposi’s sarcoma of the lung: A case report

Pulmonary Kaposi’s sarcoma is a rare condition. Its diagnosis may be tricky due to its similarities in clinical and radiological features with pulmonary opportunistic infections as well as other lung lesions. Treatment for Kaposi’s sarcoma include radiotherapy, chemotherapy and/or immunotherapy whereby lung Kaposi’s sarcoma respond well to chemotherapy. An immunocompetent 68-year-old man was admitted with clinical, radiological and bronchoscopic features of bronchogenic carcinoma. However, the histological result revealed Kaposi’s sarcoma of the lung. The patient was treated with radiotherapy and recovered well from his symptoms. Six months later the patient remain asymptomatic with essentially a normal chest x-ray

Closed Mitral Valvotomy-a Life Saving Procedure in Facility Deprived Countries: Experience at Muhimbili National Hospital, Tanzania.

Background: Rheumatic heart disease remains a major health cardiac problem in developing countries as the culprit of rheumatic fever. Mitral valve stenosis is the most common complication of valvular heart disease and its consequences of increase in pulmonary hypertension, heart failure, pulmonary vascular disease and if untreated death ensues. The management of this condition varies depending on availability of expertise and resource; however in a facility deprived country with low economic status closed mitral valvotomy remain the standard palliative treatment! The aim of this study was to evaluate the clinical status of patients with mitral stenosis following closed mitral valvotomy treated at Muhimbili National Hospital, Cardiothoracic Unit. Methods: All patients presenting with severe mitral stenosis in absence of calcification in its leaflets and regurgitation were enrolled for the study from May 2008 to November 2009. Excluded were those who failure consents. Results:A total of fourteen patients were included in the study of which 10 (71.4%) were females and 4 (28.6%) were males. They had a mean age of 21.5±8.8 and range from 11 to 41 years. The diagnosis was based on clinical evaluation using NYHA class and 2D-Echocardiography findings. All patients’ demographic data, preoperative and post operative findings were taken and data analysis was done using an SPSS 11.5 program. Categorical data were compared and analyzed using two Tailed- χ2 and values were taken 5% significance level. Conclusion: There was an overall highly significant improvement in clinical stage of the disease, reduction in mean pressure gradient across the mitral valve, reduction in pulmonary hypertension and mean left atrial size. Similarly there was improvement in ventricular function in terms of ejection fraction and increase in mean mitral valve area