Assessment of the Surgical Oncology Case Volume Within the Public Sector in Tanzania.

PURPOSE: Surgery provides vital services to diagnose, treat, and palliate patients suffering from malignancies. However, despite its importance, there is little information on the delivery of surgical oncology services in Tanzania. METHODS: Operative logbooks were reviewed at all national referral hospitals that offer surgery, all zonal referral hospitals in Mainland Tanganyika and Zanzibar, and a convenience sampling of regional referral hospitals in 2022. Cancer cases were identified by postoperative diagnosis and deidentified data were abstracted for each cancer surgery. The proportion of the procedures conducted for patients with cancer and the total number of cancer surgeries done within the public sector were calculated and compared with a previously published estimate of the surgical oncology need for the country. RESULTS: In total, 69,195 operations were reviewed at 10 hospitals, including two national referral hospitals, five zonal referral hospitals, and three regional referral hospitals. Of the cases reviewed, 4,248 (6.1%) were for the treatment of cancer. We estimate that 4,938 cancer surgeries occurred in the public sector in Tanzania accounting for operations conducted at hospitals not included in our study. Prostate, breast, head and neck, esophageal, and bladder cancers were the five most common diagnoses. Although 387 (83%) of all breast cancer procedures were done with curative intent, 506 (87%) of patients with prostate and 273 (81%) of patients with esophageal cancer underwent palliative surgery. CONCLUSION: In this comprehensive assessment of surgical oncology service delivery in Tanzania, we identified 4,248 cancer surgeries and estimate that 4,938 likely occurred in 2022. This represents only 25% of the estimated 19,726 cancer surgeries that are annually needed in Tanzania. These results highlight the need to identify strategies for increasing surgical oncology capacity in the country.

Surgical Antibiotic Prophylaxis: A Proposal for a Global Evidence-Based Bundle.

In the multimodal strategy context, to implement healthcare-associated infection prevention, bundles are one of the most commonly used methods to adapt guidelines in the local context and transfer best practices into routine clinical care. One of the most important measures to prevent surgical site infections is surgical antibiotic prophylaxis (SAP). This narrative review aims to present a bundle for the correct SAP administration and evaluate the evidence supporting it. Surgical site infection (SSI) prevention guidelines published by the WHO, CDC, NICE, and SHEA/IDSA/APIC/AHA, and the clinical practice guidelines for SAP by ASHP/IDSA/SIS/SHEA, were reviewed. Subsequently, comprehensive searches were also conducted using the PubMed®/MEDLINE and Google Scholar databases, in order to identify further supporting evidence-based documentation. The bundle includes five different measures that may affect proper SAP administration. The measures included may be easily implemented in all hospitals worldwide and are based on minimal drug pharmacokinetics and pharmacodynamics knowledge, which all surgeons should know. Antibiotics for SAP should be prescribed for surgical procedures at high risk for SSIs, such as clean-contaminated and contaminated surgical procedures or for clean surgical procedures where SSIs, even if unlikely, may have devastating consequences, such as in procedures with prosthetic implants. SAP should generally be administered within 60 min before the surgical incision for most antibiotics (including cefazolin). SAP redosing is indicated for surgical procedures exceeding two antibiotic half-lives or for procedures significantly associated with blood loss. In principle, SAP should be discontinued after the surgical procedure. Hospital-based antimicrobial stewardship programmes can optimise the treatment of infections and reduce adverse events associated with antibiotics. In the context of a collaborative and interdisciplinary approach, it is essential to encourage an institutional safety culture in which surgeons are persuaded, rather than compelled, to respect antibiotic prescribing practices. In that context, the proposed bundle contains a set of evidence-based interventions for SAP administration. It is easy to apply, promotes collaboration, and includes measures that can be adequately followed and evaluated in all hospitals worldwide.

Colorectal cancer in Tanzania: the current status and future directions.

Introduction: Globally, colorectal cancer (CRC) is the third most common malignancy and the second most common cause of cancer death. By 2030, the incidence is expected to increase to reach 2.2 million cases and 1.1 million deaths. In Sub-Saharan Africa, accurate cancer incidence data is limited, but anecdotally, clinicians note a significant rise in the incidence of CRC in the past decade. To educate clinicians on the growing burden of CRC, the Tanzanian Surgical Association hosted a 4-day CRC symposium from 3rd to 6th October 2022. Following the meeting, a group of multidisciplinary stakeholders created a working group whose first task was to assess the epidemiology, presentation and available resources for CRC care in Tanzania. The findings of that assessment are described in this article. Findings: The true incidence of CRC in Tanzania is currently unknown. However, individual high-volume centres have noted a dramatic rise in cases of colon and rectal cancer on their wards. A review of the published data on CRC in Tanzania showed that most patients present with CRC late and the limited availability of endoscopic and diagnostic services poses a challenge for accurately staging these patients prior to treatment. Multidisciplinary care, including surgery, chemotherapy and radiation, is available for the treatment of CRC in Tanzania, although the capacity and quality of these services vary throughout the country. Conclusion: There is a substantial burden of CRC in Tanzania that appears to be increasing. While there is capacity in the country to provide all aspects of multidisciplinary care, late presentation, limited access to diagnostic and treatment services and poor coordination continue to be significant barriers to providing optimal treatment to these patients.

Hirschsprung's disease in low- and middle-income countries.

Hirschsprung's disease (HD) is one of the most common causes of pediatric bowel obstruction in low- and middle-income countries (LMICs). This paper describes the unique aspects of presentation, diagnosis, management and post-operative care and outcomes of HD in LMICs. In LMICs, patients with HD are much more likely to present in a delayed fashion with subsequent increased morbidity and mortality including higher rates of chronic obstruction, malnutrition with failure to thrive, complete obstruction and perforation. There are multifactorial causes for delay, with opportunities to improve initial timely diagnosis and referral, support families to address socioeconomic and cultural barriers, and improve workforce and infrastructure resources to provide definitive care. In LMICs, the diagnosis is often made based on clinical presentation and radiographic findings as pathological services may be limited. Initial diversion with multi-stage procedure, instead of a single-stage pull-through, predominates. This is also a result of multifactorial causes, including initial presentation to general surgeons at first-level hospitals instead of pediatric surgeons, delayed presentation with sick, malnourished children with significantly distended bowel, and a lack of fresh-frozen pathological services to guide the extent of resection. Post-operatively, HD patients in LMICs experience higher complication and mortality rates - likely stemming from sicker baseline presentations and more limited resources. Significant recent advances in care have occurred for patients with HD in LMICs, while opportunities to continue to improve care remain.

A caecal pseoudotumour with an incidental adenomatoid testicular tumour in a man with right undescended testis: a case report.

BACKGROUND: Inflammatory pseudotumour refers to a non-malignant tumour-like mass resulting from an inflammatory reaction that is composed of granulation tissue with leukocyte infiltration that commonly occurs in the paediatric or young adult population. These tumours occur more commonly in the lungs and the orbit but rarely does it affect the gastrointestinal tract. It poses a clinical diagnostic challenge since it is a benign condition than can mimic the malignant counterpart. Our case is a rare presentation of the caecal pseudotumour in the presence of a right undescended abdominal testis evaluated as a caecal tumour with a differential diagnosis of a testicular malignancy. CASE PRESENTATION: We report a 53-year-old male who presented with clinical signs suggestive of right colon tumour and undescended right testis. Intra-operatively, a caecal mass was found with no clearly discernable appendix and extensive adhesion of the right colon to the retroperitoneum, to the liver and gall bladder. A testis was found adherent to the posterior aspect of the caecum and terminal ileum. A right hemicolectomy was performed. Histopathology findings revealed an inflammatory mass with abundant fibroblast proliferation and chronic inflammatory cells infiltrate, involving bowel wall and periceacal adipose tissue; no malignant cells were identified. The testis had within it an adenomatoid tumour nodule. He had uneventful recovery and was discharged home 7 days post-operatively. At the moment, he is symptoms free. CONCLUSIONS: The occurrence of right colonic inflammatory pseudotumour and co-existent adenomatoid testicular tumour arising from a cryptorchid testis is very unusual. This would make one incline towards a malignant testicular lesion in the presence of cryptorchidism. Testicular adenomatoid tumour is a rare benign neoplasm, mostly affecting fully descended testis and usually does not warrant orchidectomy for purposes of preserving testicular function. On the other hand, surgical resection remains the only safe and curative treatment option available for inflammatory pseudotumours.

Branchial cysts: an unusual cause of a mediastinal mass: a case report.

INTRODUCTION: Complex embryological processes form the head and neck of humans. It is not flawless; remnants lead to sinuses or cysts, commonly in the head and neck region. CASE PRESENTATION: We present the a case of an 8-year-old boy, a primary school pupil, from rural Kenya with chronic cough, wheezing, difficulty in breathing and dyspnea on exertion. He was treated with antibiotics and antitubercular drugs without improvement prior to referral to our hospital. A computed tomography scan of his chest revealed a superior mediastinal mass extending into his neck. A diagnosis of a brachial cleft cyst was made and our patient underwent a successful excision of the mass through a median strenotomy and neck dissection. CONCLUSIONS: Branchial cysts of the neck are common, accounting for 20% of pediatric neck masses. Usually they present as a neck mass but in our case it presented as a mediastinal mass, which is a very rare clinical presentation. Surgical excision is the mainstay of treatment. To the surgeon, the embryology and anatomy should be absolutely clear as dissection may be challenging due to the close proximity and variable course of the cystic stalk to major neck vessels and nerves.

High-grade spindle cell sarcoma of the heart: a case report and review of literature.

Primary cardiac spindle cell sarcomas are extremely rare and have poor prognosis. Complete surgical resection represents the only treatment option proven to work. We report a case of a 28-year-old man who was referred to our cardiothoracic unit with a right ventricular mass extending to the main pulmonary artery with a provisional diagnosis of a thrombus or a right ventricular myxoma. He sought medical attention after experiencing shortness of breath, cough, chest pain, abdominal pain and bilateral leg swelling for about 6 weeks. Two dimensional transthoracic echocardiogram showed a mass arising from the right ventricle and extending into the main pulmonary artery; findings that were confirmed with contrast chest CT scan.He underwent extensive resection of the mass and had uneventful postoperative period with immediate symptomatic relieve. He is on adjuvant chemotherapy using vincristine, adriamycin and cyclophosphamide (VAC). Right ventricular sarcoma is a very rare cause of right sided heart failure, a very aggressive tumour whose only chance of successful treatment is complete surgical excision.

Surgical education at Weill Bugando Medical Centre: supplementing surgical training and investing in local health care providers.

Global surgery initiatives increasingly are focused on strengthening education and local health care systems to build surgical capacity. The goal of this education project was to support local health care providers in augmenting the surgical curriculum at a new medical school, thus promoting long-term local goals and involvement. Working with local surgeons, residents, and medical and assistant medical officer students, we identified the most common surgical conditions presenting to Weill Bugando Medical Centre in Mwanza, Tanzania, and the areas of greatest need in surgical education. We developed an 8-week teaching schedule for undergraduate students and an electronic database of clinical surgery topics. In addition, we started teaching basic surgical skills in the operating theatre, bridging to an official and recurring workshop through a supporting international surgery organization. The medical and assistant medical officer students reported increased satisfaction with their clinical surgery rotations and mastery of key educational subjects. The initiation of an Essential Surgical Skills workshop through the Canadian Network for International Surgery showed students had improved comfort with basic surgical techniques. Short-term surgical missions may appear to fill a void in the shortage of health care in the developing world. However, we conclude that global health resources are more appropriately used through projects giving ownership to local providers and promoting education as a foundation of development. This results in better coordination among local and visiting providers and greater impact on education and long-term growth of health care capacity.

Les initiatives internationales en ce qui concerne la chirurgie sont de plus en plus axées sur le renforcement des programmes de formation et des systèmes de soins de santé locaux pour consolider les capacités dans ce domaine. L'objectif de ce projet éducatif était d'aider les professionnels de la santé locaux à enrichir le programme de chirurgie d'une nouvelle faculté de médecine et de favoriser ainsi l'atteinte des objectifs et une meilleure participation à long terme à l'échelle locale. En travaillant avec des chirurgiens, des résidents, des étudiants en médecine et de futurs aides-médecins locaux, nous avons recensé les chirurgies les plus fréquentes au Centre médical Weill Bugando à Mwanza à la Tanzanie, et les domaines de la chirurgie où les besoins de formation sont les plus grands. Nous avons mis sur pied un calendrier d'enseignement échelonné sur 8 semaines pour les étudiants et une base de données électronique sur les différents types de chirurgie clinique. Nous avons également commencé à enseigner les techniques chirurgicales de base au bloc opératoire, en parallèle avec un atelier officiel récurrent, grâce au soutien d'une association internationale de chirurgie. Les étudiants en médecine et les futurs aides-médecins se sont dits plus satisfaits de leur stage de chirurgie clinique et de leur maîtrise des principaux enjeux didactiques. Le lancement d'un atelier sur les compétences chirurgicales de base, rendu possible grâce au Réseau canadien pour la chirurgie internationale, a montré que les étudiants se sentent plus à l'aise avec les techniques chirurgicales de base. Les missions chirurgicales de courte durée peuvent sembler combler une lacune dans les pays en développement où les soins de santé sont insuffisants. Toutefois, nous concluons que les ressources en santé internationale sont utilisées de manière plus appropriée dans le cadre de projets qui responsabilisent les fournisseurs de soins locaux et favorisent leur formation comme base du développement. Cela donne lieu à une meilleure coordination entre les professionnels locaux et les coopérants et exerce un impact plus grand sur la formation et la croissance des capacités en matière de soins de santé à long terme.

Bush animal attacks: management of complex injuries in a resource-limited setting.

INTRODUCTION: Though animal-related injuries and fatalities have been documented throughout the world, the variety of attacks by wild animals native to rural East Africa are less commonly described. Given the proximity of our northwestern Tanzania hospital to Lake Victoria, Lake Tanganyika, and the Serengeti National Park, and presentation of several patients attacked by bush animals and suffering a variety of complex injuries, we sought to report the pattern of attacks and surgical management in a resource-limited setting. MATERIALS AND METHODS: Four patients who were admitted to the northwestern Tanzania tertiary referral hospital, Bugando Medical Centre (BMC), in 2010-2011 suffered attacks by different bush animals: hyena, elephant, crocodile, and vervet monkey. These patients were triaged as trauma patients in the Casualty Ward, then admitted for inpatient monitoring and treatment. Their outcomes were followed to discharge. RESULTS: The age and gender of the patients attacked was variable, though all but the pediatric patient were participating in food gathering or guarding activities in rural locations at the time of the attacks. All patients required surgical management of their injuries, which included debridement and closure of wounds, chest tube insertion, amputation, and external fixation of an extremity fracture. All patients survived and were discharged home. DISCUSSION: Though human injuries secondary to encounters with undomesticated animals such as cows, moose, and camel are reported, they often are indirect traumas resulting from road traffic collisions. Snake attacks are well documented and common. However, this series of unique bush animal attacks describes the initial and surgical management of human injuries in the resource-limited setting of the developing world. CONCLUSION: Animal attacks are common throughout the world, but their pattern may vary in Africa throughout jungle and bush environmental settings. It is important to understand the management of these attacks in resource-limited health care environment. Further, the growing population and human encroachment on previously wild habitats such as the northwestern Tanzania bush argues for increased community awareness to assist in prevention of human injuries by animals.

Prolapsed sigmoid intussusception per anus in an elderly man: a case report.

BACKGROUND: Intussusception in pediatrics is widely documented and well described. On the basis of the literature, however, adult intussusception is a rare entity with a prevalence of from 1% to 5%. The majority of adult patients with intussusception have an underlying pathology that needs to be identified by performing a proper physical examination and a wide array of investigations. CASE PRESENTATION: We present a case of a 66-year-old African man who presented to our emergency department with a mass protruding per anus with obstipation. During laparotomy, we found that the sigmoid colon had intussuscepted into the rectum and out from the anus. Other abdominal viscera were normal and without any obvious mesenteric lymphadenopathy. Sigmoid colectomy and spectacle colostomy were performed. Grossly, the excised bowel looked normal, but the histologic results showed features of necrosis and chronic inflammation. CONCLUSION: While 70% to 90% of cases of adult intussusception have an identifiable cause or lesion, most pediatric intussusceptions are idiopathic. The presentation in an adult described herein was of an uncommon idiopathic type with no identifiable cause found on the basis of the history, physical examination, or histological findings.