Global disease burden of conditions requiring emergency surgery.

BACKGROUND: Surgical disease is inadequately addressed globally, and emergency conditions requiring surgery contribute substantially to the global disease burden. METHODS: This was a review of studies that contributed to define the population-based health burden of emergency surgical conditions (excluding trauma and obstetrics) and the status of available capacity to address this burden. Further data were retrieved from the Global Burden of Disease Study 2010 and the University of Washington's Institute for Health Metrics and Evaluation online data. RESULTS: In the index year of 2010, there were 896,000 deaths, 20 million years of life lost and 25 million disability-adjusted life-years from 11 emergency general surgical conditions reported individually in the Global Burden of Disease Study. The most common cause of death was complicated peptic ulcer disease, followed by aortic aneurysm, bowel obstruction, biliary disease, mesenteric ischaemia, peripheral vascular disease, abscess and soft tissue infections, and appendicitis. The mortality rate was higher in high-income countries (HICs) than in low- and middle-income countries (LMICs) (24.3 versus 10.6 deaths per 100,000 inhabitants respectively), primarily owing to a higher rate of vascular disease in HICs. However, because of the much larger population, 70 per cent of deaths occurred in LMICs. Deaths from vascular disease rose from 15 to 25 per cent of surgical emergency-related deaths in LMICs (from 1990 to 2010). Surgical capacity to address this burden is suboptimal in LMICs, with fewer than one operating theatre per 100,000 inhabitants in many LMICs, whereas some HICs have more than 14 per 100,000 inhabitants. CONCLUSION: The global burden of surgical emergencies is described insufficiently. The bare estimates indicate a tremendous health burden. LMICs carry the majority of emergency conditions; in these countries the pattern of surgical disease is changing and capacity to deal with the problem is inadequate. The data presented in this study will be useful for both the surgical and public health communities to plan a more adequate response.

Strangulated inguinal hernia in adult males in Kumasi.

BACKGROUND: The complications of untreated inguinal hernias are common surgical emergencies in adult Ghanaian men. OBJECTIVE: To describe the epidemiology of strangulated inguinal hernia in adult males in Kumasi. METHOD: From the hospital records the age and sex of all male adult patients treated for strangulated inguinal hernia were recorded at the Komfo Anokye Teaching Hospital(KATH), the University Hospital (UH), the Seventh Day Adventist Hospital (SDAH) and the Kumasi South Hospital (KSH) for the period January 2007 to December 2011 inclusive. The total number of inguinal hernia repairs from all four facilities was also recorded. The annual incidence of strangulated inguinal hernia and the hernia repair rates were estimated using the 2010 population data. RESULTS: Five-hundred and ninety-two cases of strangulated inguinal hernia were treated over the five years. The incidence of strangulated inguinal hernia was 0.26%. A total of 2243 inguinal hernia repairs were performed and 26.4 % of these repairs were for strangulation. The total number of inguinal hernia repairs averaged 77.3 repairs per 100 000 adult males per year and the elective repair rate was low at 0.9%. CONCLUSION: There is the need to increase the levels of elective repair of inguinal hernia in Kumasi.

Breast cancer in Kumasi, Ghana.

BACKGROUND: Breast cancer is the leading cause of cancer deaths in Ghanaian women. OBJECTIVE: To describes the characteristics of breast cancer patients attending the Komfo Anokye Teaching Hospital in Kumasi, Ghana. METHOD: The study was conducted at the Komfo Anokye Teaching Hospital. Between July 1st 2004 and June 30(th) 2009 patients presenting with breast lumps were assessed by clinical examination, imaging studies and pathological examination. Relevant clinical and pathological were recorded prospectively data on all patients with microscopically proven breast cancer. The cancers were graded according to the modified Bloom-Richardson system. Tissue immunoperoxidase stains for oestrogen, progesterone receptors and c-erb2 oncogene were performed with commercially prepared antigens and reagents. RESULTS: Nineteen thousand four hundred and twenty-three (19,423) patients were seen during the study period. There were 330 (1.7%) patients with histologically proven breast cancer. The mean age was 49.1 years. A palpable breast lump was detected in 248 patients (75.2%). Two hundred and eighty-one patients (85.2%) presented with Stages III and IV, 271 (82.1%) invasive and 230 (85.2%) high grade carcinomas. Oestrogen and progesterone receptors were positive in 32 and 9 cases respectively. Her2 protein was positive in 11 cases. CONCLUSION: In Kumasi, as in other parts of Ghana, breast cancer affects mostly young pre-menopausal who present with advanced disease. The cancers have unfavourable prognostic features and are unlikely to respond to hormonal therapy.

Inguinal hernia disease in Africa: a common but neglected surgical condition.

BACKGROUND: Hernia surgery is one of the most frequent procedures done by surgeons - paediatric and general surgeons -in the African continent. OBJECTIVE: To review the surgical literature, on the epidemiology, clinical features, treatment and outcome of inguinal hernia surgery in Africa. DATA SOURCE: The search terms used were groin hernias in Africa, hernia surgery in Africa, inguinal hernias in Africa, hernias in adults and hernias in children in Africa using Medline, Cochrane Central Register of Controlled Trials and EMBASE. SELECTION CRITERIA: All journal articles on inguinal hernias performed in Africa and published in the world journals from 1990-2010 were retrieved. DATA EXTRACTION AND ANALYSIS: All articles containing information on inguinal hernias in children and adults were carefully studied for epidemiology, clinical presentation, method of hernia repair, complications (including morbidity and mortality rates) and the future of hernia surgery in Africa. RESULTS: There was an absolute dearth of knowledge of the burden of inguinal hernias in the various communities in Africa, especially, in sub-Saharan Africa. There were non-existent population-based studies in the sub-Saharan context that could inform us about the epidemiology of inguinal hernias and hence estimate the necessity for surgery in Africa. The studies were all clinical in nature and did not reflect the true burden of the disease among Africans. In many of these hospital-based studies, the method of inguinal hernia repair used most was the Bassini repair. Not much was found in the literature about the use of the Lichtenstein tension-free mesh repair of inguinal hernias, the reason being that the mesh was too expensive for the patients to afford. Scarcely, was laparoscopic hernia repair mentioned. CONCLUSION: Based on the clinical studies reviewed, there is a large disease burden of inguinal hernias in Africa. There is, understandably, also a limited surgical capacity to reduce this burden. The authors advocate the formation of an African Hernia Society to partner with corporate and international organisations to make hernias a public health problem and to attempt to determine, using population-based studies, the actual burden of the disease in Africa and then to take modern hernia surgery to most parts of the continent to help reduce the hernia burden, especially its complications.

Penetrating abdominal injuries in adults seen at two teaching hospitals in ghana.

BACKGROUND: The incidence of penetrating abdominal injuries (PAI) has increased in the West African sub-region. OBJECTIVE: To determine the pattern and management outcome of penetrating abdominal injuries (PAI) in the two main teaching hospitals in Ghana. STUDY DESIGN: A prospective and retrospective descriptive study. SETTING: Komfo Anokye Teaching Hospital (KATH), Kumasi and Korle-Bu Teaching Hospital (KBTH), Accra. METHODS: Relevant details of all adult patients admitted with penetrating abdominal injuries over a 11-year period were recorded at KATH and KBTH in Accra. The study in KATH was prospective pro forma based and that in the KBTH was a retrospective case review of all penetrating abdominal injuries. RESULTS: There were 411 patients, mostly men (M: F-8:1). The peak age of patients was 20-29 years, 164 patients (39.9%). Abdominal stab wound injuries accounted for 251 (61.1%). Three hundred and thirty - one patients (80.5%) had an emergency laparotomy. Twelve patients required 16 emergency thoracotomies. The small bowel (23.2%), stomach (12.9%), colon (10.2%), the liver (10.0%), were the most commonly injured organs. In 92 patients (29.0%) no significant intra-abdominal injury was detected at laparotomy CONCLUSION: Stab wounds are the main penetrating abdominal injuries seen mostly among young male adults in Ghana. Management was by a mandatory laparotomy after clinical assessment. The overall mortality was 4.4%. Selective non-operative management of abdominal stab wounds is possible.

Incidence of acute appendicitis in Kumasi, Ghana.

BACKGROUND: Acute appendicitis is a leading cause of surgical admissions for abdominal pain in many hospitals. OBJECTIVE: To report the incidence of acute appendicitis in Kumasi and highlight the increasing admissions rates of the disease in the metropolis. METHODS: A combined prospective and retrospective analysis of hospital records was performed to obtain data on the age and sex of each patient, and the total number of patients who had appendectomies performed for acute appendicitis. Data were obtained from the major hospitals in Kumasi including Komfo Anokye Teaching Hospital (KATH), the Kwame Nkrumah University of Science and Technology Hospital simply known as University Hospital (UH), the Seventh Day Adventist Hospital (SDAH), the Animwa Medical Centre, the Kumasi South Hospital and the South Suntresu Health Centre for the period January 2000 to December 2005. RESULTS: There were a total of 1266 patients 869 (68.6%) males and 397 (31.4%) females with an overall male to female ratio of 2.2:1.The yearly incidence of acute appendicitis in Kumasi was 1.8 per 10,000 of the population. The peak incidence was in the 25-29 year age groups in both sexes. Appendicitis was twice as common in the male and in all age groups. The admission rates at the start of the study were 1.7/10,000 and 0.8/10,000 for male and females respectively and 3.4/10,000 and 1.4/10.000 for male and females at the conclusion of the study. CONCLUSION: In Kumasi acute appendicitis occurs in all age groups of both sexes. Males are more affected than females. Admission rates from the disease are rising in both sexes most likely due to increasing hospital attendance.

Some aspects of the epidemiology of external hernias in Kumasi, Ghana.

BACKGROUND: In our communities there are large numbers of longstanding external hernias that remain untreated. This paper describes the epidemiological characteristics of these hernias. The data is expected to provide guidelines for sustained national and international efforts to reduce the burden of hernia by performing large-scale elective hernia repairs. METHOD: Between January 1998 and December 2007, a simple pro-forma was designed and used to record, in a prospective manner, the age, sex of patient and anatomical site of all external hernias seen and operated on both as emergencies and non-emergencies. These were patients who presented to a single general and paediatric surgeon at the Komfo Anokye Teaching Hospital in Kumasi, Ghana. RESULTS: A total of 2,506 patients were studied, of which 1,930 were male and 576 female, giving a male:female ratio of 3.4:1. Inguinal hernia was seen in 1,766 patients: 1,613 males and 153 females, a male:female ratio of 10.5:1. Children 4 years old or younger accounted for 20.9% of inguinal hernias. Femoral hernia was seen in 79 patients: 70 females and 9 males. These groin hernias were diagnosed in 1,845 patients, accounting for 73.6% of all patients. Incisional hernia was diagnosed in 380 patients (15.2%): 179 males and 201 females-a male:female ratio of 1:1.1. These two hernia types (groin and incisional) were seen in 2,225 patients, representing 88.8% of all the patients studied. All other hernias studied, including para-umbilical, umbilical and epigastric, were seen in 281 patients, representing 11.2% of the hernias studied. CONCLUSION: The epidemiology of external hernias seen and treated in our hospital is no different from that of hernias in other communities. Sustained efforts at elective repair will reduce the vast numbers of untreated accumulated hernias in our communities and thus prevent unnecessary morbidity and mortality.

A giant guteal schwannoma with extension into the pelvis: a case report.

BACKGROUND: Schwannomas are uncommon slow growing tumours arising from the nerve sheath or Schwann cell. OBJECTIVE: To report a case and the surgical removal of a giant complex schwannoma and to highlight the value of extensive investigations including a preoperative histologic diagnosis in the successful surgical management of uncommon large benign tumours. METHODS: A 39-year-old man presented with a 15-year history of a large mass in the right gluteal region. He was clinically evaluated, subjected to imaging studies and surgery. RESULTS: Clinical examination revealed a 40 cm by 60 cm mass in the right gluteal region and continuous with a 25 cm by 15 cm pelvic mass. The ultrasound scan revealed a very complex (mixed solid and fluid containing) gluteal mass with extension to the pelvis. The CT scan showed a very large, well defined lobulated tumour with cystic spaces and enhancing nodules. The tumour extended through the ischiadic foramen into the pelvis and posteriorly into the thigh muscles. A Doppler scan of the pelvic vessels revealed that the right common and internal iliac arteries were both compressed but not occluded. An incisional biopsy was reported as a Schwannoma with xanthomatous changes and an immuno histochemistry profile of S-100+, Ki-67+ (less than 1% of the cells). A right foot drop following the surgery responded to physiotherapy. The duration of total hospital stay was 12 weeks. CONCLUSION: The staged excision of large and complex schwannomas is safe. It is essential that a preoperative histological diagnosis is made to establish that the tumor is truly benign.

Breast pain in Ghanaian women: clinical, ultrasonographic, mammographic and histological findings in 1612 consecutive patients.

BACKGROUND: Increasing awareness of breast cancer in Ghana has led to many women in our communities often anxious to know if the pains they feel in their breasts may be due to cancer. OBJECTIVE: To determine the causes of breast pain in a large number of Ghanaian women reporting at a specialist breast clinic. METHODS: From July 1st 2004 to June 30th 2006, all women presenting at the Komfo Anokye Teaching Hospital-Breast Care Centre with a complaint of breast pain were assessed by a combination of clinical history, clinical breast examination, ultrasonography, mammography, excisional biopsy and daily breast pain charts. Relevant data were retrieved from the clinical notes after each consultation and transferred to a proforma. RESULTS: One thousand six hundred and twelve women were studied. Their ages ranged from 15 years to 90 years. In 762 (47.3%), the clinical breast examination was normal. Fibrocystic breast changes, lactational mastitis, nonlactational mastitis, and chronic breast abscess were the most common diagnosis made and accounted for 307 (19%), 189 (11.8%), 87 (5.4%) and 77 (4.8%) respectively of all the cases respectively. Carcinoma was diagnosed in nine (0.6%) of all the cases. CONCLUSION: In most Ghanaian women with breast pain there are no palpable abnormalities on clinical examination. In many in whom palpable abnormalities are found the pain is due to benign breast disease. The prevalence of carcinoma is low in patients presenting with breast pain.

Spectrum of complaints presented at a specialist breast clinic in kumasi, ghana.

BACKGROUND: In Ghana data on breast disease is lacking. OBJECTIVE: To describe the type of complaints presented at a specialist clinic. STUDY DESIGN: A prospective descriptive study. SETTING: The Komfo Anokye Teaching Hospital Breast Care Centre (KATH-BCC) METHOD: Data including the age, type of complaints, the clinical, radiological and histological diagnosis was obtained and recorded from all consecutive adult patients seen and treated at the KATH-BCC between July 2004 and March 2005. RESULTS: A total of 1678 patients were studied. There were 10 males. The ages of the patients varied between one month and 95 years. The three most common complaints were breast pain 1210 (72.1%), breast lump 312 (18.6%), nipple discharge 96 (5.7%) and other miscellaneous condition 60 (3.6%). The three most common finding in the 1210 patients with breast pain were normal breast 736 (60.8%), fibrocystic breast changes 200 (16.5%) and breast abscess or mastitis 161(13.3%). The main histological types of the 312 breast lumps were fibroadenomata 159(51.0%), fibrocystic changes 97 (31.1%) and carcinoma 56 (17.9%). CONCLUSION: Breast pain is the most common breast related problem presented at our specialist breast clinic. One in five women with a breast lump had cancer.

Acute intestinal obstruction in adults in kumasi, ghana.

SUMMARY OBJECTIVES: To describe the causes of acute intestinal obstruction in Kumasi and highlight the associated morbidity and mortality. DESIGN: A proforma based prospective study. SETTING: The study was conducted at the Department of Surgery, Komfo Anokye Teaching Hospital Kumasi, Ghana, from January 1998 to December 2003 inclusive. PARTICIPANTS: All consecutive adult patients admitted to the surgical emergency ward with a clinical diagnosis of acute intestinal obstruction, strangulated hernia, volvulus and intussusceptions were included in the study. Patients diagnosed as incarcerated or irreducible hernia were excluded. RESULTS: Strangulated external hernias 412 (63.2%), and post- operative adhesions 176 (27.2%) accounted for nearly (90.4%) of the 652 cases. All other causes of obstruction including volvolus, neoplasia, strictures and intussusceptions accounted for less than 10% of the patients. Five hundred and eighty - one patients were operated upon and nearly half (242) required bowel resections with an overall mortality of 12 %. Compared with previous reports, adhesive obstructions are increasing whiles strangulated hernias are decreasing. CONCLUSION: Strangulated external hernias and adhesions remain the leading causes of acute intestinal obstruction in our environment. Sustained efforts at elective repair of hernias and research aimed at reducing adhesions are likely ways to reduce the high mortality from acute intestinal obstruction.

Strangulated external hernias in Kumasi.

BACKGROUND: In our hospital, Komfo Anokye, Kumasi theatre records show that more than 65 per cent of hernia repairs are performed for strangulation. The low level of elective repair may be linked to poverty, ignorance and fear, factors commonly found in a rapidly expanding young city like Kumasi with ever increasing population. This paper highlights the morbidity and mortality associated with surgery for strangulated external hernias. METHOD: The details of consecutive adult patients admitted to our emergency ward with a diagnosis of strangulated hernia were recorded. In addition the mode of presentation, hernia type, treatment and the outcome were recorded for each case. RESULTS: Out of 120 strangulated external hernias 76 were indirect, 6 recurrent and 4 direct a total of 86 (71.7%) inguinal hernias. Strangulated femoral hernias were diagnosed in 12 (10 percent)) of the cases. These were all females. Other hernias included 13 (10.8%) para-umbilical and 9 (7.5%) of incisional hernias. Strangulation occurred in more men (80) than women (40) and 75% of these patients were aged 50 years or below. The most common physical sign for the diagnosis of strangulation was a tender lump at a previous hernia site. One hundred and seventeen patients were operated upon with an over all bowel resection rate of 24.1%. The over-all mortality was 11.8%. For the inguinal hernias, mortality was lower at 6.2% but higher for the incisional hernia at 33%. Apart from hernia type delayed operation after 72 hours increased the need for bowel resection. CONCLUSION: The significant and unacceptable morbidity and mortality associated with surgery for strangulated hernias may be avoided by advocating for mass elective repair of these hernias before strangulation occurred.