Intraoperative hypotension is not associated with adverse short-term postoperative outcomes after esophagectomy in esophageal cancer patients.

BACKGROUND: The effect of low systolic blood pressure and its subsequent postoperative outcome during esophagectomy for esophageal cancer is not well studied. METHODS: A prospective study was conducted and data were collected on patients who underwent esophagectomy and esophagogastric anastomosis for esophageal cancer. Intraoperative hypotension (IOH), defined as systolic blood pressure (SBP) < 90 mm Hg lasting more than 5 min, was recorded. Patients' 30 days post-operative composite outcome of mortality, anastomotic leak, and prolonged hospital stay were analyzed as outcome variables. RESULT: A total of 54 patients underwent esophagectomy for esophageal cancer during the study period. The mean age was 54 years. The mean duration of the surgery was 208 min. Intraoperative mean low SBP was 80 mmHg while the lowest record was 55 mmHg. IOH occurred in 51% (n = 29) of patients. Anastomotic leak occurred in 7% (n = 4) (OR 1.2, 95% CI 0.26-6.3; p = 0.76). In-hospital mortality was 5% (n = 3) (OR 1.44, 95% CI 0.22-9.3; p = 0.7) and 33% (n = 18) had prolonged hospital stay (OR 0.53, 95% CI 0.14-1.9; p = 0.34). The overall anastomotic leak rate was 13% (n = 7). Multivariate analysis (logistic regression model) showed SBP < 90 mmHg for more than 5 min was not significantly associated either with individual or composite outcomes of mortality, anastomotic leak, and prolonged hospital stay (AOR 1.06, 95% CI 0.98-1.14; p = 0.16) CONCLUSION: In patients undergoing esophagectomy for esophageal cancer, a systolic blood pressure < 90 mm Hg for greater than 5 min during surgery has no significant statistical association with composite adverse outcomes of mortality, anastomotic leak, and prolonged hospital stay.

Nonmalignant tracheal stenosis: presentation, management and outcome in limited resources setting.

BACKGROUND: Nonmalignant tracheal stenosis is a potentially life threatening conditions that develops as fibrotic healing from intubation, tracheostomy, caustic injury or chronic infection processes like tuberculosis. This is a report of our experience of its management with tracheostomy, rigid bronchoscopic dilation and surgery. METHODS: Retrospective study design was used. 60 patients treated over five years period were included. RESULTS: Mean age was 26.9 ± 10.0 with a range of 10-55 years. Majority (56 patients (93.3%)) had previous intubation as a cause for tracheal stenosis. Mean duration of intubation was 13.8 days (range from 2 to 27 days). All patients were evaluated with neck and chest CT (Computed Tomography) scan. Majority of the stenosis was in the upper third trachea - 81.7%. Mean internal diameter of narrowest part was 5.5 ± 2.5 mm, and mean length of stenosed segment was 16.9 ± 8 mm. Tracheal resection and end to end anastomosis (REEA) was the most common initial modality of treatment followed by bronchoscopic dilation (BD) and primary tracheostomy (PT). The narrowest internal diameter of the tracheal stenosis (TS) for each initial treatment category group was 4.4 ± 4.3 mm, 5.1 ± 1.9 mm and 6.7 ± 1.6 mm for PT, tracheal REEA and BD respectively, and the mean difference achieved statistical significance, F (10,49) = 2.25, p = 0.03. Surgery resulted in better outcome than bronchoscopic dilation (89.1% vs. 75.0%). DISCUSSION AND CONCLUSION: Nonmalignant tracheal stenosis mostly develops after previous prolonged intubation. Surgical resection and anastomosis offers the best outcome.

Patterns of mediastinal tumors operated at the Tikur Anbessa Hospital, Addis Ababa, Ethiopia over a six years period.

BACKGROUND: The mediastinum is the space that lies between the two pleural cavities containing many vital structures in it. When tumors or cysts arise in the mediastinum they can be either asymptomatic or present as space occupying lesions causing symptoms and signs by their effect on the neighboring organs. Though mediastinal tumors are routinely treated at the study center, there are no studies in Ethiopia concerning the patterns, and modes of treatments of Mediastinal space occupying lesions. OBJECTIVE: To review all the primary mediastinal tumors and cysts operated upon at the Tikur Anbessa Teaching Hospital, Addis Ababa University over a six year period, from August 2005-2011. METHODOLOGY: Clinical retrospective review. RESULTS: In the six years, 73 patients were operated, 49 (67.1%) were males, the and male to female ratio being 2.04:1. The mean age of patients was 35.9 +/- 10.5 years (range 14 to 74). Forty-five (61.6%) had lesions of the anterior mediastinum, 23 (31.5%) in the posterior mediastinum and 5 (6.8%) in the middle. The commonest anterior mediastinal tumors were thymic origin (24/45), and thymic lesions were found more common in females (17:7 ratio). From the 23 patients with posterior mediastinal tumors, 18 had benign neurogenic tumors (4 of which were dumbbell tumors). Chest pain and shortness of breath (dyspnea) were the two most common symptoms in 31 (42.4%) of the patients. Twenty three patients (31.5%) were asymptomatic, and all had benign lesions. None of the malignant lesions were asymptomatic. Eleven (15%) patients; eight with anterior and three with posterior mediastinal masses, had undergone pre-operative tissue diagnosis procedure by image guided FNAC. Fifty-nine (80.8%) patients were operated with intent of therapeutic surgical procedures. There were 28 (38.5%) midline sternotomies, 40 (54.7%) thoracotomies, four underwent a left sided mediastinotomies and one mediastinoscopy performed. The rate of malignancy in this study was 24 (32.8%), of which 19 (79.1%) were in the anterior compartment. A total of 13 (17.8%) patients had complications in the hospital and four (5.4%) of the patients died CONCLUSION: Primary mediastinal tumors are not so rare in the setting. We would also like to recommend further large scale prospective studies which also included long-term outcome so that we can further understand the situation in the country.

Tension chylothorax following blunt neck injury: case report.

INTRODUCTION AND IMPORTANCE: Chyle is tryglyceride reach fluid absorbed from the intestines. A total of 1500 ml-2400 ml of chyle flows through thoracic duct per day. CASE PRESENTATION: A 15 years old boy accidentally hit himself with a stick while he was playing with a rope attached to the stick. He was hit on the left side of anterior neck in zone one territory. He came seven days after the trauma when he experienced a progressively worsening shortness of breath and a bulge at the trauma site that appears with each breath. On exams, he had features of respiratory distress. The trachea was significantly shifted to the right side. There was dull percussion note on the entire left hemichest with decreased air entry. Chest x-ray showed massive left pleural collection with mediastinal shift to the right side. Chest tube was inserted and approximately 3,000 ml of milky fluid was evacuated. These continued for the following three days for which repeated thoracotomies were done for an attempt to obliterate the chyle fistula. The final successful surgery done was embolization of the thoracic duct with blood coupled with total parietal pleurectomy. After staying for approximately one month in the hospital, the patient was safely discharged improved. DISCUSSION: Chylothorax following blunt neck injury is very rare. Chylothorax with significant output leads to malnutrion, immunocompromization and high rate of mortality without timely intervention. CONCLUSION: Early therapeutic intervention is the core for good patient outcome. Decreasing thoracic duct output, adequate drainage, nutritional support, lung expansion and surgical intervention are the pillars of chylothorax management. The surgical options of thoracic duct injury are mass ligation, thoracic duct ligation, pleurodesis and pleuroperitoneal shunt. Intraoperative thoracic duct embolization with blood, as we have used in our patient, needs further study.

Transhiatal esophagectomy on a patient with aberrant right subclavian artery: A case report.

INTRODUCTION: Esophageal dissection is generally safe and easy during transhiatal esophagectomy (THE). The right subclavian artery crosses between the esophagus and spine in about 1 % to 2 % of cases. This condition is called aberrant right subclavian artery and is the most common congenital aortic arch anomaly. Pre-operative recognition of this anomaly is important in esophageal surgeries. In unprepared situations injury to this vessel may result in life threatening bleeding. CASE PRESENTATION: A 45 year old female patient presented with progressive dysphagia and weight loss. Esophageal mass was found during upper gastrointestinal endoscopy. Additionally, a CT scan of the thorax and abdomen revealed an aberrant right subclavian artery and a distal esophageal mass. Biopsy revealed squamous cell carcinoma. A transhiatal esophagectomy was performed successfully with no complications. DISCUSSION: The vast majority of patients with an aberrant right subclavian artery do not experience any symptoms. In rare cases, patients may present with dysphagia (dysphagia lusoria) and obstructive respiratory symptoms in their fourth or fifth decade. When patients present with dysphagia from esophageal cancer, careful review of imaging is needed to identify the aberrant artery. CONCLUSION: The presence of aberrant right subclavian artery causes difficulty in performing esophagectomy. If it is diagnosed preoperatively, cautious retroesophageal dissection prevents injury to this vessel and complications following it.

Pulmonary arteriovenous malformation: Challenging diagnosis: A case report.

Pulmonary arteriovenous malformation is characterized by an anatomic right-to-left shunt between the pulmonary arteries and veins, is characterized by an anatomic right-to-left shunt which reduces the arterial oxygen saturation and then results in clinical manifestations such as dyspnea and cyanosis. Most cases are congenital, and although uncommon, they are a significant part of the differential diagnosis of pulmonary problems like hypoxemia and lung nodules. We present a case of a 60 years old female patient who presented with the complaint of exacerbation of dry cough of 1-month duration and was diagnosed with right pulmonary arteriovenous malformation and successfully treated with surgery.

Penetrating cardiac injury presentation and management in resource-limited settings: A case series from Ethiopia.

INTRODUCTION AND IMPORTANCE: Penetrating cardiac injury is rare (0.1 % of trauma admissions) but fatal. Presentation is with features of cardiac tamponade or hemorrhagic shock. Urgent clinical evaluation, ultrasound, temporizing pericardiocentesis or surgical repair with cardiopulmonary bypass as back up consist of standard management. In this paper, experience of management of penetrating cardiac injury from a resource limited country is presented. CASE PRESENTATIONS: There were seven patients, five had a stab injury and two had gunshot wound. All were men with mean age of 31.1 years. Patients arrived within 30 min (3), 2 h (2), 4 h (1) and 18 h (1) after injury. Mean initial blood pressure and pulse rates were 83/51 mm Hg and 121, respectively. One patient had pericardiocentesis before referral. Exploration was via left anterolateral thoracotomy. Four (57.1 %) had right ventricle perforation, one had both right and left ventricle, and two (28.5 %) had left ventricle perforation. Suture repair (6) and pericardial patch (1) were done without bypass machine as back up. Mean duration of stay in the intensive care unit and in the surgical wards were 4.4 days (range: 2-15) and 10.8 days (range: 1-48), respectively. All were discharged improved. CLINICAL DISCUSSION: Penetrating cardiac injury presents with low blood pressure and tachycardia after stab or gunshot wounds. Right ventricle is mostly affected. Pericardiocentesis can be done as temporary measure. While having bypass machine as back up is recommended, the absence of it should not preclude intervention. Suture repair can be done with left anterolateral thoracotomy. CONCLUSION: Penetrating cardiac injury can be managed in resource limited settings without back up of cardiopulmonary bypass. Early identification and surgical intervention results in favorable outcome.

A two years prospective follow up and outcome of patients operated for carotid body tumors: experience from Ethiopia.

OBJECTIVE: We aimed to describe the patterns of patient presentation, management and prospective two-year follow up at the Tikur Anbessa Hospital. INTRODUCTION: Carotid body tumors (CBTs) constitute about 80% of paragangliomas and they occur frequently in Ethiopia. METHODOLOGY: This is a two years prospective study, involving all patients operated from September 2007-August 2009 (over a two year period) at the Tikur Anbessa Hospital, Addis Ababa, Ethiopia for CBTs. Routine patient characteristics along with details of presentation, diagnostic tools employed, preoperative and post operative management, intra-operative staging and postoperative complications were recorded. All patients were followed post operatively for an average of 13 months. Data was prospectively collected and analysis done. RESULTS: A total of 19 patients were admitted and operated. All patients presented with a painless slowly growing neck mass. The tumor was situated in the left side in 12 (63.2%) and was bilateral in only 1 (5.2%). The preoperative diagnosis was suspected by clinical examination in all patients and confirmation done with fine needle aspiration cytology (FNAC) in 18 (94.7%) and doppler ultrasound in 12 (57.9). No patient required vascular bypass or deliberate resection and reconstruction of the carotid artery during surgery. Staging of the tumor showed 5 (26.3%) were Shamblin I, 10 (52.6%) were Shamblin II and 4 (21.1%) were Shamblin III. Five (26.3%) of the patients had evidence of temporary nerve injury. Malignancy was not diagnosed in any of the patient. Nine (47.4%) of the procedures were complicated by bleeding in excess of 500 ml and mortality was 0%. CONCLUSION: The experience in carotid body tumor excision at our center is encouraging and our surgical management of carotid body tumors had good long term outcome and low complication rates.

An unusual manifestation of hydatid disease: A case in a 20-year old male patient.

Echinococcosis is a re-emerging public health issue in developing countries as most communities are homes to dogs and other domesticated animals while cattle raising is a major habit of most sub-Saharan countries. The usual presentations include liver and lung cysts. While few documentations and publications have been made on extra-pulmonary intrathoracic hydatid cysts in other parts of the world, there has been no published document on extra-pulmonary intrathoracic hydatid cysts consisting of eighty or more cystic masses in a single patient in Ethiopia. We present a case of right sided extra-pulmonary intrathoracic hydatid cysts in a 20-year old Ethiopian male patient with compressive respiratory symptoms and significant social history of cohabiting with dogs throughout childhood. The patient was treated by surgery via a posterolateral thoracotomy and had a smooth Post-operative course and discharged home on postoperative day 15 on albendazole and analgesics. Intraoperative findings included approximately 1500 ml of cystic fluid, eighty cystic masses and collapsed lung.

Patterns of injury at an Ethiopian referral hospital: Using an institutional trauma registry to inform injury prevention and systems strengthening.

BACKGROUND: Data about injury patterns and clinical outcomes are essential to address the burden of injury in low- and middle-income countries. Institutional trauma registries (ITRs) are a key tool for collecting epidemiologic data about injury. This study uses ITR data to describe the demographics and patterns of injury of trauma patients in Addis Ababa, Ethiopia in order to identify opportunities for injury prevention, systems strengthening and further research. METHODS: This is an analysis of prospectively collected data from a sustainable ITR at Menelik II Specialized Hospital, a public teaching hospital with trauma expertise. All patients presenting to the hospital with serious injuries requiring intervention or admission over a 13 month period were included. Univariable and bivariable analyses were performed for patient demographics and injury characteristics. RESULTS: A total of 854 patients with serious injuries were treated during the study period. Median age was 33 years and 74% were male. The most common mechanisms of injury were road traffic injuries (RTI) (37%), falls (30%) and blunt assault (17%). Over half of RTI victims were pedestrians. Median delay in presentation was 2 h; 17% of patients presented over 6 h after injury. 58% of patients were referred from another hospital or a clinic, and referrals accounted for 84% of patients arriving by ambulance. Median emergency center length of stay was 2 h and 62% of patients were discharged from the emergency center. CONCLUSION: This study highlights the utility of institutional trauma registries in collecting crucial injury surveillance data. In Addis Ababa, road safety is an important target for injury prevention. Our findings suggest that the most severely injured patients may not be making it to the referral centers with the capacity to treat their injuries, thus efforts to improve prehospital care and triage are needed. AFRICAN RELEVANCE: Injury is a public health priority in Africa. Institutional trauma registries play a crucial role in efforts to improve trauma care by describing injury epidemiology to identify targets for injury prevention and systems strengthening efforts. In our context, pedestrian safety is a key target for injury prevention. Improving prehospital care and developing referral networks are goals for systems strengthening.