Patterns and Seasonal Variations of Perforated Peptic Ulcer Disease: Experience from Ethiopia

Background: Perforated Peptic Ulcer Disease occurs in 2-10% of patients with ulcer disease and its principal treatment is surgical. Objective: To describe the socio-demographics of the patients, seasonal variation in its incidence, modes of surgical management and outcome of patients. Methods: This was a retrospective study on patients operated for acute perforated peptic ulcer at the Minilik II Memorial Referral Hospital, Ethiopia over a three-year period. Results: Eighty-seven patients were studied, 75 (86.2%) males were predominant. Current use of Chat and Cigarettes were reported by 44 (50.5%) and 41 (47.1%) of patients. Significant number of patients 39 (44.8 %) were operated during the Ethiopian rainy Season of July-September. The commonest presenting symptoms were sudden onset epigastric pain that become very severe in 83 (95.5%). Perforation of the anterior aspect of first part of the duodenum is the most common intra-operative findings in 88.7% (77) of cases and Pedicled omental patch repair after Cellan- Jones was performed in 83 (95.4%) of the patients. Atotal of 42 complications occurred in 20 (22.9%) of the patients, the commonest being wound infection. Ten (11.4%) underwent re-laparotomy. Nine patients (10.3%) died. Conclusion: This study has shown that perforated PUD affects young males who are smokers, alcohol users and khat chewers. It is also very common during the rainy Ethiopian months. We recommend further studies to study the interplay of these risk factors in the pathogenesis of perforations, especially their interaction with H.Pyloriinfection.Key words: Perforated PUD, Omental Patch, Seasonal variation, risk factors

Pattern and Outcome of Colorectal and Perianal Surgery in a Referral Hospital, Addis Ababa, Ethiopia

BACKGROUND: Colorectal and perianal surgery encompasses a broad range of procedures to address various pathologies arising from the colon and anorectum. Data regarding the pattern and outcome of colorectal and perianal disorders requiring surgery remains largely unknown in Ethiopia.METHODS: A descriptive cross sectional one-year review was made and all patients who were admitted and operated for colorectal and perianal disorders were included in the study. Data was collected by chart review and analyzed by SPSS version 23.RESULT: Colorectal and perianal surgeries accounted for 14.6% of the procedures in the study period. Males constituted the major share of the study population. The mean age for perianal and colorectal pathologies were 39.6±13.7 and 44.8± 16.2 years respectively. Among the colorectal disorders redundant sigmoid was the most common indication for admission 41(34.4%) followed by colorectal neoplasms 38(31.9%) while among the perianal conditions, fistula in ano was the most common pathology accounting for 69(43.4%) of admissions followed by hemorrhoids 35(22%). The overall incidence of post-operative complications in the colorectal and perianal procedure groups was found to be 29(24.4%) and 4(2.5%) respectively. There was no mortality in the perianal group whereas there were 11(9.2%) deaths in the colorectal procedure group.CONCLUSION: Colorectal surgeries accounted for a fair share of procedures among the other specialty units. The morbidity and mortality associated with colorectal procedures is fairly high and warrants attention

Multidisciplinary Cancer Management of Colorectal Cancer in Tikur Anbessa Specialized Hospital, Ethiopia.

PURPOSE Multidisciplinary cancer care is currently considered worldwide as standard for the management of patients with cancer. It improves patient diagnostic and staging accuracy and provides patients the benefit of having physicians of various specialties participating in their treatment plan. The purpose of this study was to describe the profile of patients discussed in the Tikur Anbessa Multidisciplinary Tumor Board (MTB) and the potential benefits brought by multidisciplinary care. METHODS The study involved the retrospective assessment of all patient cases presented to the Tikur Anbessa Hospital colorectal cancers MTB between March 2016 and November 2017. The data were collected from the MTB medical summary documents and were analyzed using SPSS version 20 (SPSS, Chicago, IL). RESULTS Of 147 patients with colorectal cancer, 96 (65%) were men. The median age at presentation was 46 years (range, 17-78 years). The predominant cancer was rectal (n = 101; 69%), followed by colon (n = 24; 16%). Of these, 68 (45%) and 22 (15%) had stage III and IV disease, respectively, on presentation to the MTB. The oncology department presented the majority of the patients for discussion. Most patients had undergone surgery before the MTB discussion but had no proper preoperative clinical staging information. The majority of patients with rectal cancer treated before the MTB discussion had undergone surgery upfront; however, most of the patients who were treatment naive before MTB received neoadjuvant chemoradiotherapy before surgery. CONCLUSION Decisions made by tumor boards are more likely to conform to evidence-based guidelines than are those made by individual clinicians. Therefore, early referral of patients to MTB before any treatment should be encouraged. Finally, other hospitals in Ethiopia should take a lesson from the Tikur Anbessa Hospital colorectal cancers MTB and adopt multidisciplinary cancer management

Feasibility of Gastrografin Use for Adhesive Small Bowel Obstruction in Low-Income Countries

IntroductionSmall bowel obstruction (SBO) is one of the most common causes for hospital admission in Ethiopia. The use of water-soluble contrast agents (WSCAs) such as Gastrografin to manage adhesive SBO can predict nonoperative resolution of SBO and reduce decision time to surgery and length of hospital stay. However, nothing is known about practice patterns and Gastrografin use in low-income settings. We sought to characterize current management practices, including use of WSCAs, as well as outcomes for patients with SBO in Addis Ababa, Ethiopia.MethodsWe conducted a mixed-methods study consisting of a survey of surgeons throughout Ethiopia and a retrospective record review at five public, tertiary care-level teaching hospitals in Addis Ababa.ResultsOf the 76 surgeons who completed the survey, 63% had heard of the use of WSCAs for SBO and only 11% used oral agents for its management. Chart review of 149 patients admitted with SBO showed the most common etiology was adhesion (39.6% of admissions), followed by small bowel volvulus (20.8%). Most patients (83.2%) underwent surgery during their admission. The most common diagnosis in patients who did not require surgery was also adhesion (68.0%), as well as for those who had surgery (33.9%), followed by small bowel volvulus (24.2%).ConclusionsThe etiology of SBO in Ethiopia may be changing, with postoperative adhesions becoming more common than other historically more prevalent causes. Although a Gastrografin protocol as a diagnostic and potentially therapeutic aid for SBO is feasible in this population and setting, challenges can be anticipated, and future studies of protocol implementation and effectiveness are needed to further inform its utility in Ethiopia and other low-income and middle-income countries

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. Methods: ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. Results: The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. Conclusions: This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. © 2018 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.Medical Research Council of South Africa gran

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