Global surgery volunteerism with operation hernia: a trainee surgeon’s experience

Access to adequate health services is a universal right for individuals and lack of it can have adverse consequences. The elective hernia repair rate in Ghana remains low and a considerable number of inguinal hernias still present as emergencies. Operation hernia is a charitable, UK-based organization that supports the healthcare infrastructure in Ghana through the provision of elective hernia repairs to prevent complications. Mesh repairs are carried out using sterilized, affordable mesh which is made of polyester and is a cheaper alternative to the expensive, commercial mesh. In November 2017 Operation hernia sent two teams of Surgeons and scrub nurses to work in two hospitals in Ghana. This was a successful mission that resulted in more than 150 successful hernia repairs. This article is written by a full-time general surgical ST6 Registrar detailing her first experience as a volunteer surgeon in Volta Regional Hospital in the town of Ho and the rewards reaped from this global surgical volunteerism experience.

Incidence of pyramidal thyroid lobe in the university college hospital Ibadan

The pyramidal lobe of the thyroid gland is derived from remnant of the thyroglossal duct. Its presence may be missed clinically; however radiologic and intra-operative findings reveal its presence in up to 50% of cases. The incidence of pyramidal lobe is however not clearly known in Sub-Saharan Africa, particularly in Nigeria. Our aim is to determine the incidence and histological variation of pyramidal lobe of the thyroid gland among surgical patients who underwent thyroid surgery in the University College Hospital, Ibadan.
Consecutive surgical patients that underwent total thyroidectomy in the Endocrine Surgery Division, Department of Surgery, University College Hospital, Ibadan between April 2013 and April 2017 were recruited irrespective of age, sex and clinical diagnosis. The presence, anatomy and subsequent histological diagnosis of the pyramidal lobe were noted.
One hundred sixty thyroid surgeries were done. Pyramidal lobe was found in 70 patients (44.0%). The presence of the pyramidal lobe was most often associated with multinodular goitres 42 (61.8%) and least found in thyroids with malignant tumours 3 (4.4%). The pyramidal lobe originated commonly from the midline (50.0%) and least from the right (10.3%). The length of the pyramidal lobes ranged from 8 to 80 mm (average 50 mm) in males and 5 to 54 mm (average 42 mm) in females.
The presence of a pyramidal lobe is not uncommon in people of southwestern Nigeria with its morphologic and histologic profile akin to what obtains in other geographical locations of the world.

Bariatric Surgery Did Not Increase the Risk of Gallstone Disease in Obese Patients: a Comprehensive Cohort Study

The aim of this study was to evaluate the influence of bariatric surgery on gallstone disease in obese patients.
This large cohort retrospective study was conducted based on the Taiwan National Health Insurance Research Database. All patients 18-55 years of age with a diagnosis code for obesity (ICD-9-CM codes 278.00-278.02 or 278.1) between 2003 and 2010 were included. Patients with a history of gallstone disease and hepatic malignancies were excluded. The patients were divided into non-surgical and bariatric surgery groups. Obesity surgery was defined by ICD-9-OP codes. We also enrolled healthy civilians as the general population. The primary end point was defined as re-hospitalization with a diagnosis of gallstone disease after the index hospitalization. All patients were followed until the end of 2013, a biliary complication occurred, or death.
Two thousand three hundred seventeen patients in the bariatric surgery group, 2331 patients in the non-surgical group, and 8162 patients in the general population were included. Compared to the non-surgery group (2.79%), bariatric surgery (2.89%) did not elevate the risk of subsequent biliary events (HR = 1.075, p = 0.679). Compared to the general population (1.15%), bariatric surgery group had a significantly higher risk (HR = 4.996, p < 0.001). In the bariatric surgery group, female gender (HR = 1.774, p = 0.032) and a restrictive procedure (HR = 1.624, p = 0.048) were risk factors for gallstone disease.
The risk for gallstone disease did not increase after bariatric surgery, although the risk was still higher than the general population. The benefit of concomitant cholecystectomy during bariatric surgery should be carefully evaluated.

The fluctuating incidence, improved survival of patients with breast cancer, and disparities by age, race, and socioeconomic status by decade, 1981-2010.

Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer-related deaths among women worldwide. However, the data on breast cancer incidence and survival over a long period, especially the dynamic changes in the role of race and socioeconomic status (SES), are scant.

To evaluate treatment outcomes of patients with breast cancer over the past 3 decades, the data from the Surveillance, Epidemiology, and End Results (SEER) registries were used to assess the survival of patients with breast cancer. Period analysis was used to analyze the incidence and survival trend; survival was evaluated by the relative survival rates (RSRs) and Kaplan-Meier analyses. The HRs for age, race, stage, and SES were assessed by Cox regression.

A total of 433,366 patients diagnosed with breast cancer between 1981 and 2010 were identified from the original nine SEER registries. The incidences of breast cancer in each decade were 107.1 per 100,000, 117.5 per 100,000, and 109.8 per 100,000. The 10-year RSRs improved each decade, from 70.8% to 81.5% to 85.6% (P<0.0001). The lower survival in black race and high-poverty group is confirmed by Kaplan-Meier analyses and RSRs. Furthermore, Cox regression analyses demonstrated that age, race, SES, and stage are independent risk factors for patients with breast cancer in each decade.

The current data demonstrated a fluctuating incidence trend with improving survival rates of patients with breast cancer over the past 3 decades. In addition, the survival disparity exists among different races, ages, SESs, and stages.

Adult liver transplantation in Johannesburg, South Africa (2004 – 2016): Balancing good outcomes, constrained resources and limited donors

Background. Liver transplantation is the standard of care for the treatment of liver failure worldwide, yet millions of people living in sub-Saharan Africa remain without access to these services. South Africa (SA) has two liver transplant centres, one in Cape Town and the other in Johannesburg, where Wits Donald Gordon Medical Centre (WDGMC) started an adult liver transplant programme in 2004.

Objectives. To describe the outcomes of the adult liver transplant programme at WDGMC.

Methods. This was a retrospective review of all adult orthotopic liver transplants performed at WDGMC from 16 August 2004 to 30 June 2016 with a minimum follow-up of 6 months. The primary outcome was recipient and graft survival and the effect of covariates on survival. Kaplan-Meier survival analysis included all adults who underwent their first transplant for end-stage liver disease (ESLD) (N=275). Proportional hazards regression analysis using hazard ratios (HRs) was conducted to determine which covariates were associated with a significantly increased risk of mortality.

Results. A total of 297 deceased-donor liver transplants were performed during the study period; 19/297 (6.4%) were for acute liver failure (ALF) and the remainder were for ESLD. The median age of recipients was 51 years (interquartile range 41 – 59), and two-thirds were male. The most common cause of ESLD was primary sclerosing cholangitis. The median follow-up was 3.2 years, and recipient survival was characterised in the following intervals: 90 days = 87.6% (95% confidence interval (CI) 83.1 – 91.0), 1 year = 81.7% (95% CI 76.6 – 85.8), and 5 years = 71.0% (95% CI 64.5 – 76.5). Allograft survival was similar: 90 days = 85.8% (95% CI 81.1 – 89.4), 1 year = 81.0% (95% CI 75.8 – 85.2), and 5 years = 69.1% (95% CI 62.6 – 74.7). The most significant covariates that impacted on mortality were postoperative biliary leaks (HR 2.0 (95% CI 1.05 – 3.80)), recipient age >60 years at time of transplant (HR 2.06 (95% CI 1.06 – 3.99)), theatre time >8 hours (HR 3.13 (95% CI 1.79 – 5.48)), and hepatic artery thrombosis (HR 5.58 (95% CI 3.09 – 10.08)). The most common infectious cause of death was invasive fungal infection.

Conclusions. This study demonstrates that outcomes of the adult orthotopic liver transplant programme at WDGMC are comparable with international transplant centres. Management of biliary complications, early hepatic artery thrombosis and post-transplant infections needs to be improved. Access to liver transplantation services is still extremely limited, but can be improved by addressing the national shortage of deceased donors and establishing a national regulatory body for solid-organ transplantation in SA.

Rosai‐Dorfman disease in Malawi

Rosai‐Dorfman Disease (RDD) is a rare lymphoproliferative disease with limited cases reported in sub‐Saharan Africa, potentially due to a lack of pathological services throughout the region. RDD diagnosis can be difficult, especially in resource‐limited setting, as symptoms can be nearly identical to more common causes of lymphadenopathy.

Pioneering endoscopic retrograde cholangiopancreatography in a Sub Saharan African hospital: A case series

Background and study aims
Although endoscopic retrograde cholangiopancreatography (ERCP) was introduced in Europe, Asia and America over four decades ago, East Africa and Africa as a whole has been slow in taking up this very important minimally invasive procedure for the management of various hepatopancreaticobiliary conditions. This has led to reliance on open surgery for even simple benign biliary strictures, stones and malignant causes of biliary and pancreatic duct obstruction that can be treated endoscopically without a need for a morbid open surgical intervention. In Uganda, ERCP was introduced in January 2017 after obtaining training and equipment support from Senior Experten Service (SES), German. We therefore report the first six cases of ERCP performed at our endoscopy unit.

Patients and methods
This is a case series report of six patients referred with yellowing of eyes and body itching as the main complaints. They predominantly had raised gamma glutamyl transferase (GGT), alkaline phosphatase (ALP), total bilirubin and direct bilirubin. They also had different imaging investigations demonstrating hepatic ducts dilatation.

Four out of the six patients had complete post ERCP symptom resolution. One patient had partial symptom resolution and the other patient recovered after conversion to open surgery.

Collaborative skills transfer made ERCP feasible in our institute and this marked the start of this specialised service in Uganda.

Exploring the role of obesity and overweight in predicting postoperative outcome of abdominal surgery in a sub-Saharan African setting: a prospective cohort study

Current literature on the role of excess weight in predicting surgical outcome is controversial. In sub-Saharan Africa, there is extreme paucity of data regarding this issue in spite of the increasing rates of obesity and overweight in the region. This prospective cohort study, carried out over a period of 4 months at Limbe Regional Hospital in the Southwest region of Cameroon, assessed 30-day postoperative outcome of abdominal surgery among consecutive adults with body mass index (BMI) ≥ 25 kg/m2. Adverse postoperative events were reported as per Clavien–Dindo classification.

A total of 103 patients were enrolled. Of these, 68.9% were female. The mean age was 38.2 ± 13.7 years. Sixty-four (62.1%) of the patients were overweight and the mean BMI was 29.2 ±4.3 kg/m2. The physical status scores of the patients were either I or II. Appendectomy, myomectomy and hernia repair were the most performed procedures. The overall complication rate was 13/103 (12.6%), with 61.5% being Clavien–Dindo grades II or higher. From the lowest to the highest BMI category, there was a significant increase in the proportion of patients with complications; 25–29.9 kg/m2: 6.25%, 30–34.9 kg/m2: 18.75%, 35–39.9 kg/m2: 25.0%, and ≥ 40 kg/m2: 66.70%; p = 0.0086.

Risk factors associated with perforated acute appendicitis in geriatric emergency patients.

The aim of this study was to identify factors associated with perforated acute appendicitis in geriatric patients at the emergency department (ED).
The medical records of 223 consecutive patients aged >60 years with acute appendicitis between 2006 and 2017 were retrospectively reviewed. Patients were grouped into those with perforated and non-perforated appendicitis. A comparison was made between the two groups in regard to baseline characteristics, clinical presentation, physical examination, time from onset of symptoms to ED arrival, time from ED arrival to operation, postoperative complications, hospital length of stay, and mortality. Significant factors associated with perforated appendicitis were examined using univariate and multivariate analyses by logistic regression.
A total of 78 (35%) patients had perforated appendicitis. Four significant factors associated with perforated appendicitis were as follows: 1) time duration from onset of symptoms to ED arrival >24 hours (OR 2.49, CI 1.33-4.68); 2) heart rate ≥90 beats/minute (OR 1.93, CI 1.04-3.59); 3) respiratory rate ≥20 breaths/minute (OR 2.54, CI 1.33-4.84); and 4) generalized guarding (OR 12.58, CI 1.43-110.85).
Time duration from onset of symptoms to ED arrival >24 hours, heart rate ≥90 beats/minute, respiratory rate ≥20 breaths/minute, and generalized guarding were the significant factors associated with perforated acute appendicitis in geriatric patients.

Management and Outcomes Following Surgery for Gastrointestinal Typhoid: An International, Prospective, Multicentre Cohort Study.

Gastrointestinal perforation is the most serious complication of typhoid fever, with a high disease burden in low-income countries. Reliable, prospective, contemporary surgical outcome data are scarce in these settings. This study aimed to investigate surgical outcomes following surgery for intestinal typhoid.

Two multicentre, international prospective cohort studies of consecutive patients undergoing surgery for gastrointestinal typhoid perforation were conducted. Outcomes were measured at 30 days and included mortality, surgical site infection, organ space infection and reintervention rate. Multilevel logistic regression models were used to adjust for clinically plausible explanatory variables. Effect estimates are expressed as odds ratios (ORs) alongside their corresponding 95% confidence intervals.

A total of 88 patients across the GlobalSurg 1 and GlobalSurg 2 studies were included, from 11 countries. Children comprised 38.6% (34/88) of included patients. Most patients (87/88) had intestinal perforation. The 30-day mortality rate was 9.1% (8/88), which was higher in children (14.7 vs. 5.6%). Surgical site infection was common, at 67.0% (59/88). Organ site infection was common, with 10.2% of patients affected. An ASA grade of III and above was a strong predictor of 30-day post-operative mortality, at the univariable level and following adjustment for explanatory variables (OR 15.82, 95% CI 1.53-163.57, p = 0.021).

With high mortality and complication rates, outcomes from surgery for intestinal typhoid remain poor. Future studies in this area should focus on sustainable interventions which can reduce perioperative morbidity. At a policy level, improving these outcomes will require both surgical and public health system advances.