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East and Central African Journal of Surgery
Association of Surgeons of East Africa and College of Surgeons of East Central and Southern Africa
ISSN: 1024-297X EISSN: 2073-9990
Vol. 7, Num. 1, 2002, pp. 7-22
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East and Central African Journal
of Surgery, Vol. 7, No. 1, August, 2002 pp. 7-22
Abstracts of
papers presented at the annual scientific conference of the Association of
Surgeons of East Africa held in Lusaka, Zambia on 5th to 7th
December 2001.
Code Number: js02002
GENERAL SURGERY
Should all hernias undergo
elective surgery?
Stefan Post,Professor
and Chairman of Surgery, University Hospital Mannheim, University of Heidelberg,
Germany.
It is generally accepted in the
international surgical community that all inguinal hernias should be operated
electively unless the patient is extremely old or frail. However, the main
argument rests on the risk of strangulation despite the fact that little is
known about the actual risk in a particular patient.
This study presents a risk calculation
based on a few historical reports dealing with the risk of incarceration and
on contemporary epidemiological data from Germany. Three strategies are presented:
prophylactic indication on principle (A), elective operation in every second
case (B) and operation in case of strangulation only (C). It is calculated
that for the male German population aged 65 years and above 69954 (A), 36292
(B) and 2630 (C) inguinal hernia repairs would be necessary annually; 167
(A), 145 (B) and 123 (C) perioperative death would occur associated with 1702
(A), 1373 (B) and 1048 (C) years of life lost respectively. Thus operation
of every inguinal hernia would even result in a (small and negligible) reduction
of life expectancy. These data provide evidence that that in elderly patients,
the indication to operate inguinal hernias should depend upon symptoms and
suffering. In Europe there is no reason to operate asymptomatic cases because
of a presumed risk of strangulation. These figures change dramatically in
an environment like rural Africa where the mortality of a strangulated hernia
is much higher thus increasing the need for prophylactic surgery.
Conclusion: Contrary to current
practice health policy should encourage less hernia repair in industrialized
countries and probably more hernia repairs in rural Africa.
Short-stay thyroidectomy: Trends
in length of post-operative hospitalisation over a period often years in a
developing country central Hospital.
K L Erzingatsian,
Professor of Surgery, UTH. P0 Box 50110, Lusaka, Zambia.
Short-stay surgery is an established
form of patient management in the developed countries. There is little published
on the subject from the developing world. This paper describes the personal
experience of short-stay thyroidectomy over a period of 10 years. It is a retrospective
study on the work carried out in the Department of Surgery, University Teaching
Hospital, Lusaka. Seventy-nine consecutive thyroidectomy patients were included
in the study. There were 65 female and 14 male patients with an average of 38n
years. General anaesthesia was used in 60 patients and 19 had local anaesthesia.
Type of operation included subtotal (32), lobectomy (28), total (5), near total
(3) and various other operations (11). Malignancy was diagnosed in nine patients.
Minor post-operative complications occurred inl 6 patients and airway related
difficulties were noted in eleven, seven of who ha, temporary voice change.
There were four tracheostomies performed, two permanent ones before thyroidectomy
and two temporary ones post-operatively. There was no record of iatrogenic permanent
recurrent nerve palsy. Four patients had thyrotoxicosis one of which developed
a thyroid crisis. Another patient developed hypocalcaemic crisis. There was
no post-operative mortality. Seventy-seven patients were followed-up and there
were three readmissions, two with terminal cancer and one with hypocalcaemic
crisis. The length of stay varied between 4.1 days early in the series to 1.3
days in 1999. Short-stay throidectomy offers advantages and is safe where expertise
is available. Early review following hospital discharge is recommended.
FNAC of breast lumps in the University
Teaching Hospital, Lusaka, Zambia.
Kasonde Bowa,
Department of Surgery, University Teaching Hospital, Lusaka.
This was a prospective study done
to assess fine needle aspiration cytology (FNAC). As a diagnostic tool in
the investigation of breast lumps in the University Teaching Hospital. Though
this method is inexpensive and has been shown to be highly accurate, it is
not in common use.
Seventy-three female patients
from surgical outpatients clinic were included in the study. Their average
age was 25 years. Most of the lumps were clinically benign (71%). All the
patients consented to FNAC but only 49% went on to have histopathological
diagnosis. Of all these, 31% were malignant while 69% were benign. The average
age of patients with malignant lumps was 30 years while that of benign was
24 years. Patients above 25 years had a higher likelihood of malignancy than
those below 25. In this study, it was found that FNAC had a sensitivity of
73% and a specificity of 96%. This level of accuracy compares favourably with
that reported in centres in the United Kingdom and meets the quality assurance
requirements recommended for the United Kingdom. FNAC was found to be a safe
and accurate method of screening and investigating breast lumps in the University
Teaching Hospital. Guidelines for its use in the Hospital are given
ONCOLOGY
Mandibulectomy: Technical consideration
in 50 mandibulectomies. A personal series.
K L Erzingatsian,
Professor of Surgery, University Teaching Hospital, Lusaka, Zambia.
This paper describes the technique
of mandibulectomy as used by the author in a series of fifty patients with
large mandibular tumours. The operations were performed
in the Department of Surgery of the University Teaching Hospital between 1987
and 2000.
The operative management is given
in detail including anaesthetic considerations, oropharyngeal packing, positioning,
the type of incision used, resection of the mandible, vascular control, the
technique of reconstruction used by the author and the type of wound closure.
General anaesthesia was administered for mandibulectomy and local anaesthesia
for tracheostomies. Elective tracheostomy was performed in 22 patients as
first step, followed by the mandibulectomy. The oropharynx was packed with
iodinated cotton gauze as a routine. Patients were restrained on the operating
table with a belt to maintain a reverse Trendelenburg position. The operative
approach was lip splitting in 34 and submandibular alone in 16. mandibular
resection for lateral body tumours started with division of bone at the ipsilateral
parasymphysis. Resection required control of the inferior dental vessels either
within the mandibular canal or above the foramen. Troublesome bleeding from
pterygoid plexus of veins sometimes created difficulties. Carotid vessels
control and/or ligation of the external carotid were rarely required and were
done in 10% of patients during the first few years of the series. Twenty-three
patients underwent hemimandibulectomy, 14 segmental and 13 had various other
operations. Half the patients were reconstructed with wire implant. The implant
was buried deep to the pharyngeal dilators by using 4/0 nylon in three layers.
The mucosa and the muscle layers were closed separately. The mucosa was closed
with catgut 2/0 or 3/0 everting stitches and the muscle layer with a running
suture. Skin was closed with vertical mattress continuous suture preferably
using absorbable monofilament. Drains were not routinely used. The commonest
tumour excised was amelablastoma in 22 patients. The most common complication
was sepsis in 21 patients. Three implants removed for exposure, fracture and
migration.
Genetic epidemiological aspects
of gastric cancer in Iceland.
A Klmsiand, BJ Eldon, S Aribjamarson
et al, Iceland
Purpose
To describe genetic epidemiological
aspects of gastric cancer in Iceland.
Background: associations between
gastric cancer and environmental factors e.g. diet and infections have been
established and somatic
genetic changes are well described in adenocarcinomas of the stomach. Less
is known regarding clinical features of hereditary gastric cancer and whether
other malignancies are associated with family clustering.
Methods
Family trees of all patients diagnosed
with gastric cancer in Iceland between 1955 and 1999 were identified in the
Genealogical Database of the University of Iceland. Probands with age of onset
<60 years were used in the study. Families of all probands (N = 455 males
and 161 females) all reported cancers were identified. The expected number
of cases was calculated using the age specific population rates in Iceland.
Results
A relative risk (RR) of 2.2 (95%
Cl =1.6-3.0) and 1.3 (95% Cl = 1.0 - 1.7) for the gastric cancer risk was
observed was observed among 2846 first and 8658 second degree relatives of
male probands respectively. For female probands the corresponding RR was 1.6
(95% Cl = 1.1 -2.6) and 1.4 (95% Cl = 0.9-2.0) and statistical significant
for the first-degree relatives (N = 2764). The excess risk was even more pronounced
for relatives of males and females diagnosed with gastric cancer before the
age of 50 years. No difference in RR was found between relatives of probands
that were diagnosed as Lauren I (intestinal) or Jervi-Lauren 2 (diffuse).
Special attention was also given to other common cancers such as prostate,
breast, kidney and brain cancers among the relatives although no significant
risk elevations were found. Fifty-eighth families with at least two or more
relatives with cancer were identified. In 32 families two relatives with gastric
cancer were identified and in and in 26 families three or more relatives had
gastric cancer.
Conclusions
Relatives of gastric cancer patients
have 2 - 3 fold increased risk of developing cancer. The risk is elevated
for both sexes although more for males.
Limb Saving Surgery in Osteosarcoma
J A Mulimba. Consultant
Orthopaedic and Trauma Surgeon, Nairobi, Kenya.
Osteosarcoma is common in Kenya.
The age groups affected are mostly children and adolescents. Since 1972 the
age has been noticed to rise to include 3rd
and 4th decades. The time of presentation
has continued to be late. Investigations available will determine the ability
of early diagnosis or otherwise. We are now able to do, in addition to plain
X-rays, C.T. scans, NM scans and radio isotopic scans. Immunological studies
such as HEGFR2 are still not available. Treatment has continued to be biopsy,
amputation and adjuvant chemotherapy of various combinations having high dose
methotraxate as a major component. In Kenya patients and parents are becoming
increasingly reluctant to accept amputation. In developed countries 90% of
all cases are treated with limb sparing surgery.
Is this practical in developing
countries?
Presented here are a number of
osteosarcoma cases I treated and one case in which limb sparing operation
was done and the problems that were encountered.
INFECTIONS
"Damage Control and 'Second
Look' in Emergency Abdominal Surgery"
I.J.P. Loefler, Nairobi
Hospital, Kenya.
The major causes of mortality
after emergency abdominal surgery - whether this is necessitated by
trauma or by some other instance of "Acute abdomen" - are
hypothermia, acidosis, coagulapathy and abdominal compartment syndrome. In
order to avoid these complications, emergency operations in physiologically
compromised patients should consist of "damage control" only: haemostasis,
reestablishment of blood flow in large vessels, peritoneal lavage and avoidance
of further soiling. Anastomoses should be eschewed at this stage and temporary
stomata should be fashioned. The abdomen is best left open, this saves time,
prevents wound infection, and forestalls abdominal compartment syndrome. (intraabdominal
pressures can be measured by using the indwelling bladder catheter as a measuring
device).
There are various ways in which
the temporary closure of the abdomen can be achieved, one is the use of the
"Bogota Bag". The correction of organ dysfunction, under optimal
circumstances in the ICU, includes rewarming, ventilation, normalization of
the acid/base balance etc. Improvement is usually rapid and the "Second
look" operation can be undertaken after 48 to 72 hours. At this stage
reconstruction of the abdominal contents as well as the abdominal wall may
be possible.
The preoccupation of surgeons
with anatomy has caused much morbidity and mortality. By shifting the focus
to physiology, many complications can be avoided, others are easier to treat.
The principles of damage control are simple.
There is no reason to fear an
open abdomen (or, indeed, the reopening of an abdomen in the ICU, if the intraabdominal
pressure rises). A "Bogota Bag" is a cheap, ubiquitously available
device, easily applied. Evidence for its usefulness is overwhelming and the
reluctance to use it is merely emotional.
Primary Squamous Cell
carcinoma Presenting As Psoas abscess
K.L. Erzingatsian, R. Zulu, R.
Chavuma, M. Labib. Department of Surgery, UTH, P.O. Box 50110, Lusaka,
ZAMBIA.
Squamous cell carcinoma is a common
malignancy affecting all tissues, which arise from ectoderm. Untreated, metastases
occur to regional lymphatics. Occasionally metaplasua occurs in non-ectodermal
tissues such as the urinary bladder, lung and elsewhere, resulting in transformation
to squamous cell carcinoma. However, primary squamous carcinoma arising de
novo in psoas muscle and presenting as an abscess must be an extremely rare
occurrence that merits reporting.
This is a case report of a 42-year
old female patient who presented to University Teaching Hospital in May 2000
with a complaint of right loin pain and "appendicitis". The chronology
of the disease progress, investigations carried out on the patient and the
operative management is detailed in this report. The patient survived six
months.
Ipsi lateral vascularised fibular
transfer for reconstruction of osteomyelitic and traumatic tibial gap defects
S. Mannion, S. Chimangeni, C.
Lavy, MAP Orthopaedic, Malawi Against Physical Disability, P.O. Box
30333, Lilongwe 3, Malawi
Gap defects in the tibia shaft
can arise as a result of trauma or as a consequence of chronic osteomyeitis.
A severe compound fracture may result in segmental diaphyseal loss with subsequent
non-union and gap defect. In chronic osteomyelitis, although doctrine would
advocate delaying sequestrectomy until sufficient mature involucrum capable
of weight bearing has formed, occasionally auto-sequestrectomy will occur
in advance of this; again leading to a tibial defect. Whilst bone transport
techniques can be utilised to treat such defects, the skills and equipment
necessary for such procedures are seldom available in the developing world.
An alternative, and more freely available method of reconstruction is to use
ipsilateral vascularised fibular transfer. Approach to the fibula is postero-lateral.
Muscle attachments to the lateral and antero-medial surfaces of the bone are
released but care is taken to maintain the posterior proximal vascular pedide,
arising from the peroneal artery to keep the periosteum intact The fibula
is then osteotomised proximally and distally and then transported, by translation
and rotation into a pre-prepared graft bed spanning the tibial defect. Some
form of fixation and stabilisation may then be required and cancellous bone
graft applied. Over the past 12 months 6 cases of ipsilateral vascularised
fibular transfer have been performed in Malawi. In 5 cases the defect was
of osteomyelitic origin and the remaining case was traumatic. Mean age of
the patients was 9 (range 3 - 22), 4 males and 2 females. In three cases stabilisation
was effected by a trans-calcaneal, intramedullary K-wire. In the other three
cases interfragmentary screws were used at the proximal and distal ends of
the graft, supplemented by external fixation. Cancellous bone grafting was
only performed in those cases also undergoing external fixation. In all cases
the graft united satisfactorily at both the proximal and distal ends. No further
procedures were necessary to effect this union. Particularly in the younger
age group compensatory hypertrophy of the fibula, in response to the increased
weight bearing demand, was both marked and rapid. 4 of the five cases that
completed treatment needed no mobility aids when walking. The fifth case can
weight bear but still requires crutches. A further procedure is contemplated
on this patient; not to the graft site, but to correct a fixed ipsilateral
equines deformity which developed secondary to the longstanding traumatic
tibial defect. In conclusion we feel that the ipsilateral vascularised fibula
graft is a useful method for treating tibial gaps defects both of osteomyelitic
and traumatic origin. Few specialised resources are required and thus it is
a suitable technique for the developing world.
False Aneurysms In Association
with Aids
G. Desai, FRCS Ed. Consultant
surgeon, WE Amadi, M.MED (Surg),Consultant surgeon Akhtaev,
M.D., Consultant Surgeon, UTH
Two patients with three false aneurysms
(one carotid and two femoral) associated with HIV infection are presented. Both
patients made good recovery post-operatively. A few African reports suggested
the affection of young population without arteriosclerosis, rapid development
of focal vasculitis, leading to rupture or slow progression to granulomatous
vasculitis. Aetiologically, these aneurysms may result from inflammation of
the vasa vasorum or periadventitial vessels. These aneurysms should not necessarily
prelude the patients from surgery. These patients are young, without arteriosclerosis,
collateral and cross-circulation is adequate to sustain perfusion after division
and ligation of major vessels.
TRAUMA
Audit of the conservative treatment
of an adult diaphyseal femoral fractures in Lilongwe Central Hospital.
C. Kafodya, S. Mannion, Lilongwe
Central Hospital, Lilongwe, MALAWI.
Adult femoral fractures are a common
presentation to Malawian hospitals and are often associated with severe trauma.
Several alternatives exist for the definitive treatment of these injuries: traction,
plating, external fixation and intramedullary nailing. Due to severe shortage
of both orthopaedic operating theatre time and skilled staff, combined with
a massive demand on these services, acute femoral fractures in Lilongwe have
traditionally been treated conservatively on skeletal traction. In order to
assess the success of this protocol from October 2000 all patients presenting
with such injuries were prospectively followed up.
On admission all patients were given
opiate analgesia and placed in a temporary traction splint device. Conversion
to skeletal traction, by insertion of a Steinman's pin, usually under local
anaesthesia or ketarnine, was done at the first opportunity. Perkin's traction
was utilised, with up to lO% of body weight being applied until the fractured
limb was out to length. From 4 weeks onwards, the fracture site was assessed
weekly for evidence of clinical
union. When the fracture was thought to be clinically united, check X-rays were
done to assess the extent of callus formation. If satisfactory on X-rays, traction
was removed but S-pin left in situ for a further week whilst the patient exercised
in bed. At the end of one week, the pin was removed and the patient mobilised
partial weight bearing on crutches. After discharge, outpatient follow-up was
continued. A total of 39 femoral fractures presented during the study period;
35 males and 4 females. The mean age was 37 (range 14-85). Road traffic accidents
accounted for 53% of cases and 25% resulted from falls. Four fractures were
compound. By AO classification, 49% were A ("simple"), 38% B ("wedge")
and 13% C ("complex"). Thus far 23 (58%) have completed treatment,
with a mean time to union of 11 weeks. An average of 1.7 X-rays were taken per
patient during treatment. At follow-up, 3 cases were noted to have shortening.
There were no cases of non-union.
We feel that treatment of femoral
fractures by conservative methods has a high union rate with minimum complications.
Theatre time is spared and the use of expensive implants and materials is avoided.
Potential metalwork infection is also avoided. Although in-patient stay
was on average 11-weeks, this has minimal cost implications in Malawi.
Clinical officers in district hospitals can readily assimilate the technique,
thus obviating the need to refer closed femoral fractures to Central Hospitals
for specialist care.
BODA BODA INJURIES AT MULAGO
HOSPITAL IN KAMPALA, UGANDA.
A 3-Month Cross Sectional Retrospective
Study For The Period July to September 2001.
E.K.Naddumba, Senior Consultant
Orthopaedic Surgeon Mulago Hospital, P.O.Box 7051, Kampala, Uganda.
During the last 5 years, Ugandans
have taken up seriously the practice of riding small motorcycles (SUZUKI and
HONDAS) imported from Japan, which are popularly known as Boda Boda by the Ugandans.
This name originated from the bicycle means of transport operating at the "Border"
between Uganda and Kenya, which was introduced in the late 1970s and early 1980s
by the Ugandans to ease the INTERBORDER Trade. These Boda Bodas, which are
mainly operated by the youth, have been responsible for musculo-skeletal injuries
with serious consequences. In some cases, the injuries have been fatal.
The purpose of this paper is to
highlight the Musculo-Skeletal injuries that are directly or indirectly a result
of Boda Boda traffic accidents, with a view of assisting the Policy Makers in
their effort of controlling Road Traffic Accidents in Uganda. A Cross Sectional
Retrospective Study was hence conducted at Mulago Hospital on the Surgical and
orthopaedic Wards.
During the period under study, total
of 182 Road Traffic injuries were admitted. 46 [25%] of these were as a result
of Boda Bodas. The commonest injury was open tibial fracture [21%]. The majority
of the victims [20%] had polytrauma.
The motorcyclists were mainly youth
with an average of 24 years.
It is strongly recommended that
strict legislation be put in place to curb the reckless Motor Cyclists as an
effort top control these emerging traffic injuries.
Diagnostic criteria for AC-joint
pathology
Nicolaas GJ Maritz, Hannes (PJ)
Oosthuizen Dept. Of Orthopaedic Surgery, Pretoria Academic Hospital,
Pretoria SOUTH AFRICA
The literature and standard textbooks
is scanty on specific presentation and examination methods for acromio-clavicular
joint pathology.
Purpose of study:To
define and identify the most reliable tests.
Materials and Methods:Thirty
patients with probable AC-joint pathology were identified and examined. Eight
patients who did not have pain relief after local lignocaine infiltration were
excluded. Twenty-two patients with 24 shoulders were examined.
Results: Pain localization:
AC-joint (15), anterior (13), posterior (5), lateral (5). Pain radiation:
Anterior (14), posterior (2), lateral (3), cervical (3). Pain increased:
With weight bearing (18), elevation (5), ADL (6), night pain or lying
on shoulder (11), reaching across body (3).On examination:
Swelling (7), AC-joint prominence (7), local tenderness (21), crepitations (4),
forced cross-body test (22), elevation further than 60o(22),
Jobe test (20), speed test (19), O'Brien's test (15), compression test (12),
distraction test (13), pain arc less than 160o
(13), neck tenderness (13). Concomitant diagnoses: Shoulder arthritis (2), impingement
(6), cuff tears (2), biceps tendonitis (2), cervical pathology (2). Radiological
changes: AC-joints (19), shoulder joints (13), cervical views (11). Ultrasound
pathology: present in 10 of 15 cases.
Conclusion: Most
common symptoms: Pain with weight bearing, elevation and lying on shoulder.
Pain localization: Anterior and
posterior.
Most common clinical findings: Forced
cross-body test, elevation more than 160o,
local tenderness, Jobe's and Speed's tests. No test is 100% accurate. The whole
clinical presentation must be taken into account.
Local infiltration of the Ac-joint
is extremely helpful.
ORTHOPAEDICS
Perioperative Normovolaemic
Haemodilution in Major Elective Orthopaedic Surgery In Lusaka
Lishman L Kosipre, John E.Jellis,
School of Medicine, University of Zambia, Lusaka, Zambia
Operative Normovolaemic haemodilution
technique was used on twenty-three patients who had major elective Orthopaedic
Surgery both at the University Teaching Hospital, Lusaka and the Zambian-Italian
Orthopaedic Hospital, Lusaka between July 1997, and June 1999.
There were twelve males and eleven
females with ages ranging from 13 to 78 years (mean 42.1 years). The Preoperative
haemoglobin of these patients ranged from 9.2g/dl to 16.8g/dl (mean 12.9g/dl).
The postoperative haemoglobin measured at 72 hours ranged from 7.0g/dl to 13.lg/dl
(mean 10.6g/dl). The drop in haemoglobin at 72 hours postoperatively ranged
from 0.3g/dl to 5.8g/dl (mean 3.7g/dl).
Hip surgery was the commonest operation
performed. There was one death (4.4% mortality); all the other patients had
uneventful recovery. None of the patients had homologous blood transfusion and
no operation was cancelled due to failure of the technique.
(This paper was presented at The
Surgical Society of Zambia Scientific Conference in October 1999, Lusaka.)
Additional cases have been performed
which were added to the new
Presentation for ASEA Meeting in December 2001.
NEUROSURGERY
New Approach To The Classification
Of Head Injury
S. Zohrabian, A. Zohrabian, R. Gaboyan
Medical centre For Emergencies, Armen Tigranian Str. 54, Yerevan 375037,
Armenia.
Due to the latest achievements in
the field of neurology and neurosurgery and particularly in pathophysiology
of the Nervous system, the development of a new classification of the Head Injuries
(HI) has become somewhat a necessity. Based on our Clinical observation and
also on the data from a large number of neurosurgeons we are suggesting the
following classification of HI. We distinguish two major types of HI: closed
and open, depending on the presence or absence of the wounds on the head (see
fig.) In the group of closed HI we have included the three main forms: concussion
of the brain contusion and compression, recognising three degrees of contusion
- light, moderate and severe. In the group of HI there are four sub-groups:
- Damage to the soft tissues of
the head without neurological
symptoms.
- Damage to the soft tissues of
the head withneurological symptoms.
- Damage to the skull and brain
(cranio-cerebral injury):
(a) Non-penetrating dura
mater
(b) Penetrating dura mater
- Gun shot wounds of the peacetime.
- Separate group - Fractures of
the base of the skull.
In addition to the above forms,
the latest data on the pathogenesis of HI has convinced us in the necessity
of outlining the four major pathophysiological syndromes, which may accompany
the above clinical forms:
- Syndrome of cerebral hypertension
- Syndrome of cerebral hypotension
- Syndrome of cerebral haemorrhage
- Syndrome of diffuse axonal brain
damage
The article provides a detailed
analysis of the principle behind this division and the characteristics of these
syndromes.
The Separation Of Zambian Craniopagus
Twins
Prof M.S. Mokgokong,BSc, MBChB,
MMed (Neurosurgery), FCS (SA) Head: Department of Neurosurgery, Medical
University of Southern Africa
INCIDENCE:
It is well known that Siamese twins
can be joined at various parts of the body, for instance, the thorax, the back,
the abdomen, as well as the hips. When they are joined at the head, it is called
craniopagus twins. This is least common of all the sites of union. In fact,
the quoted incidence in literature is one out of every 2.5 million births
worldwide. It is a rare occurrence and hence experience to deal with the problem
surgically is also rare.
CASE REPORT OF RECENT CRANIO
PAGUS SEPARATION IN SOUTHH AFRICA
In 1998, the author was part of
a team headed by the late Professor R Lipschitz of the Baragwanath hospital,
University of Witwatersrand. This team separated a set of craniopagus twins
that were presented to them. A complete separation was achieved. Both twins
survived, although one died several months later. However, the surviving twin
has significant higher mental function impairments. In 1994, the author was
Acting Head of Neurosurgery at the Medical University of Southern University
Ga-Rankuwa Hospital. We were also presented with another set of craniopagus
twins to separate. It made sense to bring together the team that was involved
not only in the South African experience, but also to incorporate Professor
Benjamin Carson. This was done and the entire team came together. A complete
separation was achieved. However, one twin died on the operating table, it was
discovered that there was a phenomenon of interdependence between the two twins.
This phenomenon had not been previously described and in fact changed the course
of future preparations for such operations. In 1996, a set of craniopagus twins
was brought in from Zambia to our institution, the Medical University of Southern
Africa, for the purpose of separation. Once more, the entire neurosurgical team
was brought together, viz. the Medunsa neurosurgeons, the Baragwanath neurosurgeons,
as well as professor Benjamin Carson from Baltimore, USA. In addition, the surgical
team was complimented by Zambian specialists who were part of the project. This
time round, with the lessons learnt before, thorough operations were done. The
anaesthetic was the same as the one that did the previous separation, as was
the theatre set-up and staff. It came as no surprise therefore that this
was the most successful separation of craniopagus twins in comparison with the
previous separations that were done in South Africa and in America by the members
of the same team.
Conclusions: The
past 15 years has seen a team of medical experts in South Africa and Zambia
gain valuable experience in the separation of craniopagus twins. This team was
headed by the author and included Professor Benjamin Carson from John Hopkins
hospital in Baltimore, USA. It is the intention of this paper to share the experience
of this team with the rest of the world, and it makes very good sense that this
presentation will take place in Zambia, the home of the most successful craniopagus
twins separated to this date. The author aims to highlight the following recommendations
from the valuable experience learnt:
a) Pre-operative evaluations and
investigations.
b) The timing of the operation.
c) The execution of the separation
itself
d) Subsequent management, inclusive
of operations done on the separated twins
themselves.
CT DIAGNOSIS OF CEREBRAL STROKES
COMPLICATED BY HEAD INJURY
Dr Arshak Zohrabian, Head
of Radiology Department, "Erebuny" Medical Centre, Yerevan 375037,
Sayat Nova 37, App.38, Armenia. Email: zogsur@arminco.com
The combination of disorders of
cerebral circulation (DCC) complicated by head injury (HI) following a fall
due to loss of consciousness is quiet common. We had 415 patients with DCC under
observation. In 75 patients (17%) DCC were in the form of Cerebral Stroke (CS)
and were combined with HI. Out of 71 cases with CS, 58 patients (82%) suffered
from haemorrhagic stroke (HS) and 13 patients (18%) had ischaemic stroke (IS).
Our investigations have revealed a certain CT criteria enabling us to differentiate
the lesions produced by stroke from the ones produced by trauma. Haemorrhagic
lesions due to CS were mainly round or oval in shape, had a high-density homogenous
structure and were usually found in areas of cerebral hemispheres supplied by
the major cerebral vessles. Haemorrhagic lesions resulting from a HI were mainly
localised in the cortico-subcortical zones, irregular in shape and heterogeneous
in structure in structure (i.e. partially hypo- or hyperdence). Intracranial,
epidural or subdural haematomas resulting from HI have a homogenous structure
and they can easily be distinguished from DCC based on their shape and localisation.
Analysis of the results has allowed us to make the following conclusion. Cerebral
strokes complicated by HI cause more severe deterioration of the general condition
of the patient often with disturbances of the vital functions. CT investigation
enables us to make an early detection of the traumatic area in the brain and
evaluate properly the disorders caused by the HI with due consideration of the
main focus of acute DCC.
RESOURCES
ORTHOPAEDICS WITH LIMITED RESOURCES:
A Mozambican Experience
Jose Langa, Maputo, Mozambique.
E-mail: jlanga@zebra.uem.mz
The Orthopaedic National Programme
aim is to co-ordinate the provision of efficient orthopaedic and trauma services
from central and provincial to rural hospitals. The country is divided into
southern, central and northern regions, each with a Central Hospital with orthopaedic
surgeons.
The 1500-bed Central Hospital
in Maputo is the national referral centre and the teaching hospital for Eduardo
Mondlane University. The Orthopaedic department has 200 beds and 12 orthopaedic
surgeons. In each provincial hospital an orthopaedic surgeon provides specialist
care and supports and supervises the surgical paramedical staff (surgical technicians)
at district and rural hospitals.
The referring hospitals have been
equipped to provide conservative treatment. The types of fractures that should
be treated surgically have been clearly defined. In some rural hospitals with
surgical facilities, there are well-trained surgical paramedics, but where
possible patients are treated conservatively. We guarantee the supply of equipment
and material and provide regular refresher training.
In Mozambique fractures constitute
more than 70% of the orthopaedic pathology. In adults the most common are fractures
of the femur, tibia and fibula, radius and ulna, pelvis, humerus and ankle.
In children under 16 years, 60%
of hospital admissions are for trauma, usually sustained in falls from trees
or motor vehicles accidents. Infections account for 30% of admissions. In contrast
with developed countries, we have few patients with fractures due to osteoporosis.
Lignocaine 0.1% with adrenaline
1:1000000 in general surgery. Further experience in 328 patients.
K.L. Yerzingatsian, Department
of Surgery University Teaching Hospital, P.O. BOX 50110, LUSAKA, ZAMBIA
There is little published in the
English language surgical literature on the use of very dilute solutions of
lignocaine and adrenaline in general surgery. The author has used 0.1 per cent
lignocaine with 1:1000 000 adrenaline in 328 patients following premedication
with pethidine, chlorpromazine
and diazepam.
The responseto
surgery was evaluated using six categories. Ninety three percent of patients
were categorised in the top three categories of perfect, excellent and very
good. Good and fair categories were seen in seven patients. The poor category,
which meant conversion to endotracheal general anaesthesia, was not recorded.
The discussion section deals with
the method of preparing the solution, technical considerations, relative contraindications,
complications in 2 common operations, drawbacks of the technique and its advantages.
The solution is effective, inexpensive
and safe.
POSSIBLE ROLE OF SPECIALIST IN
RURAL ZAMBIA:
Two Years of RlySpec Visits and
Telemedicine
We reviewed 2 years of FlySpec visits
to Zambian Rural Hospitals by orthopaedic and Plastic Surgeons together with
our experience of telemedicine and Specialist support to District Hospitals
through E-mail and computer network. District and Mission hospitals do not have
specialists. They have medical officers that very
often need specialist opinions. Provincial hospitals (Secondary Referral centres)
have specialists in very few disciplines. They depend on referral of patients
to a Tertiary Referral Centre (U.T.H. in Lusaka) for consultation and treatment.
In the past three years, we have
tried to answer consultations of the doctors working at district levels over
the Internet by conducting requests for consultations to respective specialists
and then sending answers back to them. Over 421 requests so far.
The FlySpec project has flown Orthopaedic
Surgeon to the districts for 20years, and, for the past 8 years has involved
a plastic surgeon.
We present our experience of the
past 2 years. In that time we have seen almost 2000 patients and performed over
500 operations. In addition we have taught the resident District Medical Officers
and helped in referring difficult patients to Lusaka. We also present the shortcomings
of these visits and the obstacles and problems related to Specialist visits
to the District levels.
ORAL KETAMINE: A Four-Year Experience
in a Developing World Tumour Clinic
Doreen Ngonga, Ennie Tembo, Mutale
Nsakashalo, Glenda Kalunga, Nkandu Simom Mfula, Kazadi Kabongo, K.L. Erzingatsian,
Tumour Clinic, Department of Surgery, University Teaching Hospital,
LUSAKA, ZAMBIA
Pain management is an important
component in cancer patients. The administration of painful injections to the
children in an oncology clinic can create difficulties. The study was under
taken to determine the role of oral ketamine to modify the response to pain.
Between 1996 and 1999, 6324 patients
attended a Tumour Clinic in a developing country teaching hospital. Fourty-eight
children required cytotoxic injections on 103 occasions. These children were
subdisided into 3 groups according to the year of attendance: 1996, 1997 and
1998/9. Each group was premedicated differently. The first group received ketamine
4.5mg/kg, the second group received ketamine 6mg/kg and the last group in 1998/1999
received ketamine 6mg/kg with diazepam 0.1mg/kg.
The response to pain in each group
was evaluated by using an observer based scoring system. The visual analogue
scale was not used.
The study has shown that oral ketamine
is an effective and safe drug for use in a clinic setting. However, its action
was not always predictable due to a number of confounding factors. A phenothiazine
should be routinely used in these children to enhance the effectiveness of ketamine
and to diminish the likelihood of its well-known side effects. Further
studies using less costly lower doses of ketamine is recommended.
EDUCATION! PLASTIC:
Results of a standardised approach
for correction of hypospadias in young boys.
H.A. Heij, Professor of
Paediatric Surgery, Paediatric Surgical Centre, University of Amsterdam and
VU University Medical Centre, Amsterdam, The Netherlands
Introduction: The
overall incidence of hypospadias is about 1: 125 males, most of which are distal
(granular or coronary) types. More severe forms are hypothesized to be associated
with decreased androgen sensitivity or exogenous oestrogen administration to
the mothers. Operative correction is indicated in the distal types for psychological
reasons. In more severe forms the proximal location of the meatus and the ventral
curve interfere with normal micturition and sexual activities.
In Amsterdam, the Meatal Advancement
and Glanuloplasty (MAGPY) procedure is applied for distal forms and the Island
onlay procedure for proximal forms. The results of these operations were reviewed.
Patients and Methods:
Between 1995 and 2000, 131 boys with hypospadias were operated. The mean age
at operation was 23.6months. Half of them had distal hypospadias (glandular
or coronary), the other half more severe forms: subcoronary, midshaft or penoscrotal.
Significant curvature was present in these proximal types.
Operations done were:
MAGPY in 42%, island onlay or tube in 41% and other various procedures in the
rest. Technical details of the procedures will be presented. All procedures
were performed by general paediatric surgeons or by trainees under their supervision.
Results: All operations
were done under general anaesthesia. The MAGPY operations were usually performed
as day cases.
Complications occurred in 30% of
the patients: fistula formulation in 17%; infection in 3%, structure of the
neo-meatus in 2%, urinary retention in 3% and redundant skin in 7%. Secondary
operations were performed for these complications in most patients. The overall
cosmetic and functional results were good in 69%, acceptable in 18%, poor in
2% and not known in 11%. There was a strong correlation between the type of
hypospadias and the risk of complications and the final result
Conclusion: Correction
of hypospadias with modern surgical techniques can be done at a young age with
satisfactory results by general paediatric surgeons. In the majority, a good
result is achieved in one procedure. The more proximal type of hypospadias carries
a higher risk of complications.
Long-term follow-up
is needed to assess the functional and cosmetic results in adolescence and adulthood.
EDUCATION
Defining Core Anatomy for a Surgical
Clerkship
Sekelani S. Banda, Department
of Surgery and Department of Medical Education Development, UTH, Lusaka, Zambia
Introduction: The
General Physicians Education Programme (GPEP) report in the USA and General
Medical Council (GMC-UK) in its tomorrow's doctors have all recommended radical
undoing of undergraduate curricula. Defining the core provides the challenge
in the "core and options" strategy. In particular defining core anatomy
for undergraduate medical education presents a unique challenge because of the
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