Factors associated with peptic ulcer perforations in Uganda: a multi-hospital cross-sectional study.

INTRODUCTION: Perforated peptic ulcer is the worst complication of peptic ulcer disease whose burden is disproportionately higher in low-income settings. However, there is paucity of published data on the patterns of perforated peptic ulcer in the region. The aim of this study was to determine the factors associated with anatomical patterns of peptic ulcer perforation, as well as the clinical, socio-demographic, and anatomical patterns among patients in Uganda. METHODS: This was a cross sectional study that enrolled 81 consecutive patients with perforated peptic ulcers. Using a structured pretested questionnaire the social demographic and clinical characteristics were obtained. At surgery, the patterns of the perforations were determined. Logistic regression was done in SPSS version 22 to determine the factors associated with the anatomical patterns. RESULTS: Perforated peptic ulcer disease was more prevalent among males (79.5%), peasants (56.8%) and those from rural areas (65.4%). Majority of study participants were of blood group O (43.2%). Gastric perforations were more common (74.1%). Majority of the perforations were found anteriorly (81.5%). Being a casual laborer was independently associated with lower odds of having a gastric perforation compared to being a peasant farmer (P < 0.05). CONCLUSION: Public health campaigns aimed at prevention of peptic ulcer perforations should prioritize the males, peasants and those living in rural areas. When a patient in our setting is suspected to have a peptic ulcer perforation, the anterior part of the stomach should be considered as the most likely site involved more so in peasant farmers.

New Trauma Score versus Kampala Trauma Score II in predicting mortality following road traffic crash: a prospective multi-center cohort study.

INTRODUCTION: Mortality due to injuries disproportionately impact low income countries. Knowledge of who is at risk of poor outcomes is critical to guide resource allocation and prioritization of severely injured. Kampala Trauma Score (KTS), developed in 1996 and last modified in 2002 as KTS II, is still widely being used to predict injury outcomes in resource-limited settings with no further revisions in the past two decades, despite ongoing criticism of some of its parameters. The New Trauma Score (NTS), a recent development in 2017, has shown potential in mortality prediction, but a dearth of evidence exist regarding its performance in the African population. OBJECTIVES: To compare NTS to the modified Kampala Trauma Score (KTS II) in the prediction of 30-day mortality, and injury severity amongst patients sustaining road traffic crashes in Ugandan low-resource settings. METHODS: Multi-center prospective cohort study of patients aged 15 years and above. Of the 194 participants, 85.1% were males with a mean age of 31.7 years. NTS and KTS II were determined for each participant within 30-minutes of admission and followed-up for 30 days to determine their injury outcomes. The sensitivity, specificity, and area under receiver operating characteristics curve (AUC) for predicting mortality were compared between the two trauma scores using SPSS version 22. Ethical clearance: Research and Ethics Committee of Kampala International University Western Campus (Ref No: KIU-2022-125). RESULTS: The injury severity classifications based on NTS vs. KTS II were mild (55.7% vs. 25.8%), moderate (29.9% vs. 30.4%), and severe (14.4% vs. 43.8%). The mortality rates for each injury severity category based on NTS vs. KTS II were mild (0.9% v 0%), moderate (20.7% vs. 5.1%), and severe (50% vs. 28.2%). The AUC was 0.87 for NTS (95% CI 0.808-0.931) vs. 0.86 (95% CI 0.794-0.919) for KTS II respectively. The sensitivity of NTS vs. KTS II in predicting mortality was 92.6% (95% CI: 88.9-96.3) vs. 70.4% (95% CI: 63.0-77.8) while the specificity was 70.7% (95% CI: 64.2-77.2) vs. 78.4% (95% CI: 72.1-84.7) at cut off points of 17 for NTS and 6 for KTS II respectively. CONCLUSIONS: NTS was more sensitive but its specificity for purposes of 30-day mortality prediction was lower compared to KTS II. Thus, in low-resourced trauma environment where time constraints and pulse oximeters are of concern, KTS II remains superior to NTS.

Local anesthesia versus saddle block for open hemorrhoidectomy: cost-analysis from a randomized, double blind controlled trial.

BACKGROUND: Despite the benefits attributed to the use of local anesthesia (LA) for open hemorrhoidectomy (OH) in developed countries, this technique is still not considered as the first line technique in low-income countries such as Uganda; therefore, we aimed at comparing the cost of OH under LA versus Saddle block among patients with 3rd or 4th degree hemorrhoids. METHODS: This trial was conducted from December 2021 to May 2022 among patients with primary uncomplicated 3rd or 4th degree hemorrhoids. The operating time, and direct costs in (US$) including medical and non-medical were recorded. We analysed the cost in the two groups (local anesthesia versus saddle block) using SPSS version 23.0. RESULTS: Findings of fifty-eight patients were analysed including 29 participants per group. There was a significant difference in operating time and cost among the two groups (p < 0.05). The mean operating time was 15.52 ± 5.34(SD) minutes versus 33.72 ± 11.54 min for OH under LA and SB respectively. The mean cost of OH under LA was 57.42 ± 8.90 US$ compared to 63.38 ± 12.77US$ in SB group. CONCLUSION: The use of local anesthesia for OH was found to have less operating time with high-cost effectiveness. Being affordable, local anesthesia can help to increase the turnover of patients who would otherwise wait for the availability of anesthesia provider. Policy makers should emphasize its applicability in low-income settings to help in the achievement of 2030 global surgery goals. TRIAL REGISTRATION: Pan African Clinical Trials Registry, PACTR202110667430356. Registered on 08/10/2021.

Determinants of adverse management outcomes of blunt abdominal trauma patients operated at a referral hospital in southern Ethiopia: a retrospective record review.

BACKGROUND: Abdominal trauma is one of the common reasons for emergency visits yet there is paucity of data about the subject in the horn of Africa. This study was aimed at determining the determinants of adverse management outcomes of blunt abdominal trauma among operated patients at Wolaita Sodo University Teaching and Referral Hospital, Ethiopia. METHODS: This was a three-year retrospective review conducted among 128 patient records selected using purposive sampling in which all records for the patients operated for a diagnosis of blunt abdominal trauma during the study period were included. A pretested checklist was used to extract the data relating to adverse outcomes and characteristics of the patients. A descriptive analysis followed by logistic regression was done. RESULTS: Of the 128 patients, adverse management outcomes related to blunt abdominal trauma occurred in 52%. Patients residing in rural areas (adjusted odds ratio 3.23, 95% confidence interval: 1.13-9.24) and those with tachycardia, (adjusted odds ratio = 3.25, 95% confidence interval: 1.19-8.83) or tachypnea (adjusted odds ratio 3.25, 95% confidence interval: 1.19-8.83) were more likely to have adverse management outcomes. CONCLUSION: Adverse management outcomes are relatively high and associated with rural residence and deranged vital signs (tachycardia and tachypnea). Close monitoring targeting patients from rural residence and those presenting with tachycardia and tachypnea is recommended.

Testicular salvageability and its predictors among patients with testicular torsion in a resource limited setting: a multicentre longitudinal study.

INTRODUCTION: Testicular torsion refers to ischemia of the testicle due to twisting or rotation of the vessels supplying the testes. It is a urologic emergency requiring a high index of clinical suspicion and prompt surgical intervention with management aimed at avoiding testicular loss and resulting infertility. This paper gives an update on the current situation regarding this topic in low-income settings. The aim of this study was to determine testicular salvageability and its predictors amongst patients with testicular torsion at two tertiary African hospitals. METHODS: This was a hospital-based multicentre longitudinal study at two tertiary hospitals in western Uganda. Patients with acute scrotum were enrolled and evaluated for testicular torsion. Those with confirmed testicular torsion underwent surgery and salvageability was reported as the primary outcome. Predictors for testicular salvageability were determined using backward binary logistic regression in SPSS version 22. RESULTS: During the study period, 232 patients with acute scrotum were enrolled. The mean age was 35.3 (SD = 20.4) years. Forty-one (17.7%) patients had testicular torsion. Only 16 (39.0%) of patients with torsion had viable testes that were salvageable. Orchiectomy was performed on 25 patients (61.0%). At multivariate analysis, a patient who presented after 48 h from the onset of symptoms was 34.833 times more likely to have orchiectomy compared to one who presented within 12 h [AOR = 34.833, (95% CI = 5.020-60.711), P < 0.001]. CONCLUSION: In this study, the testicular salvage rate was low. The only predictor of salvageability was the time from the onset of symptoms to presentation. All males should be sensitized about the clinical features of testicular torsion to ensure early presentation to increase salvage rates.

24 h mortality and its predictors among road traffic accident victims in a resource limited setting; a multicenter cohort study.

INTRODUCTION: The incidence of road traffic accidents (RTAs) is on the rise contributing to the global burden of mortality as a major global health threat. It has been estimated that 93% of RTAs and more than 90% of the resulting deaths occur in low and middle income countries. Though death due to RTAs has been occurring at an alarming rate, there is paucity of data relating to incidence and predictors of early mortality. This study was aimed at determining the 24 h mortality and its predictors among RTA patients attending selected hospitals in western Uganda. METHODS: This was a prospective cohort that consecutively enrolled 211 RTA victims admitted and managed in emergency units of 6 hospitals in western Uganda. All patients who presented with a history of trauma were managed according to the advanced trauma life support protocol (ATLS). The outcome regarding death was documented at 24 h from injury. Data was analyzed using SPSS version 22 for windows. RESULTS: Majority of the participants were male (85.8%) aged 15-45 years (76.3%). The most common road user category was motorcyclists (48.8%). The 24 h mortality was 14.69%. At multivariate analysis, it was observed that a motorcyclist was 5.917 times more likely to die compared to a pedestrian (P = 0.016). It was also observed that a patient with severe injury was 15.625 times more likely to die compared to one with a moderate injury (P < 0.001). CONCLUSION: The incidence of 24 h mortality among road traffic accident victims was high. Being motorcycle rider and severity of injury according to Kampala trauma score II predicted mortality. Motorcyclists should be reminded to be more careful while using the road. Trauma patients should be assessed for severity, and the findings used to guide management since severity predicted mortality.

Early outcome measurement of the effectiveness of conventional physical therapy versus continuous passive motion in knee function following retrograde femoral nailing-a prospective randomized controlled trial.

PURPOSE: This study evaluated the efficacy of continuous passive motion (CPM) versus conventional physical therapy (CPT) in the early postoperative period following retrograde femoral nailing (RFILN). Based on the principles of operation of CPM, we hypothesized that it would improve knee function and decrease pain after open reduction and internal fixation with a retrograde femoral interlocking nail. PATIENTS AND METHODS: Eighty-eight patients over the age of 18 years who met the inclusion criteria got randomized into one of two groups. The experimental group had CPM, while the control group had CPT. Postoperative knee functions assessed were the degree of knee stiffness, the total arc of motion, and knee pain. Knee stiffness, defined as the range of motion ≤ 90° assessed one week, two weeks, and six weeks postoperatively, while knee pain was measured using the visual analog scale (VAS) on days one, two, three, four, five, six and seven postoperatively. RESULTS: The CPM group had a significantly lower incidence of knee stiffness at one week, two weeks, and six weeks postoperatively than the CPT group (all p < 0.0001). The VAS scores of the CPM group on days one, two, three, four, five, six and seven were significantly lower than those of the CPT group (p < 0.006 for day one and p < 0.001 for the remaining days). Similarly, the total arc of motion gained postoperatively was significantly greater in the CPM group than in the CPT (all p < 0.001). CONCLUSION: The continuous passive motion effectively reduced the number of patients with knee stiffness and knee pain. It increased the total arc of motion in the early postoperative period compared to CPT. Therefore, we recommend CPM for patients undergoing retrograde femoral nailing use in the early postoperative period.

Efficacy of extended focused assessment with sonography for trauma using a portable handheld device for detecting hemothorax in a low resource setting; a multicenter longitudinal study.

INTRODUCTION: Chest trauma is one of the most important and commonest injuries that require timely diagnosis, accounting for 25-50% of trauma related deaths globally. Although CT scan is the gold standard for detection of haemothorax, it is only useful in stable patients, and remains unavailable in most hospitals in low income countries. Where available, it is very expensive. Sonography has been reported to have high accuracy and sensitivity in trauma diagnosis but is rarely used in trauma patients in low income settings in part due to lack of the sonography machines and lack of expertise among trauma care providers. Chest X-ray is the most available investigation for chest injuries in low income countries. However it is not often safe to wheel seriously injured, unstable trauma patients to X-ray rooms. This study aimed at determining the efficacy of extended focused assessment with sonography for trauma (eFAST) in detection of haemothorax using thoracostomy findings as surrogate gold standard in a low resource setting. METHODS: This was an observational longitudinal study that enrolled 104 study participants with chest trauma. Informed consent was obtained from all participants. A questionnaire was administered and eFAST, chest X-ray and tube thoracotomy were done as indicated. Data were analysed using SPSS version 22. The sensitivity, specificity, predictive values, accuracy and area under the curve were determined using thoracostomy findings as the gold standard. Ethical approval for the study was obtained from the Research and Ethics Committee of Kampala International University Western Campus REC number KIU-2021-53. RESULTS: eFAST was found to be superior to chest X-ray with sensitivity of 96.1% versus 45.1% respectively. The accuracy was also higher for eFAST (96.4% versus 49.1%) but the specificity was the same at 100.0%. The area under the curve was higher for eFAST (0.980, P = 0.001 versus 0.725, P = 0.136). Combining eFAST and X-ray increased both sensitivity and accuracy. CONCLUSION: This study revealed that eFAST was more sensitive at detecting haemothorax among chest trauma patients compared to chest X-ray. All patients presenting with chest trauma should have bedside eFAST for diagnosis of haemothorax.

Iatrogenic enterocutaneous fistula following an incarcerated Richter's femoral hernia misdiagnosed for an inguinal abscess: A case report.

INTRODUCTION AND IMPORTANCE: As the Richter's hernia contains anti-mesenteric intestinal wall, patients usually do not present with obstructive symptoms. Consequently, this leads to delays in diagnosis and increased morbidity and mortality. Early detection and surgical treatment are therefore paramount to improving outcomes. CASE PRESENTATION: A 51-year-old female presented with an incarcerated Richter's femoral hernia misdiagnosed as inguinal abscess that underwent incision and drainage. This developed into an enterocutaneous fistula (EC Fistula) and was eventually complicated by peritonitis, requiring laparotomy and herniorrhaphy. Post-operative recovery was uneventful. CLINICAL DISCUSSION: In advanced stages, Richter's femoral hernia may present with obstructive symptoms as in other incarcerated hernias. Richter's hernias may eventually present with obstructive symptoms in their advanced stages. Their relatively asymptomatic nature increases the risk of complications, such as enterocutaneous fistula. CONCLUSION: This case highlights how an incarcerated Richter's femoral hernia in a female misdiagnosed as an abscess delayed treatment, increased patient morbidity with development of an enterocutaneous fistula and peritonitis, and mandated surgical exploration to control sepsis and repair the hernia.

Factors associated with early inhospital adverse outcome following surgery for acute appendicitis in Uganda: a multicenter cohort.

INTRODUCTION: Surgery for acute appendicitis has been associated with significant morbidity. This study aimed to determine the factors associated with early inhospital adverse outcomes following surgery for acute appendicitis in Uganda. METHODS: This was a multicentre, prospective cohort in which early inhospital outcome following surgery for acute appendicitis was assessed at 4 regional referral hospitals in Uganda. The occurrence of complications during the admission period was documented as well as the length of hospital stay. Factors associated with adverse outcomes were determined using Poisson regression. RESULTS: Of the 102 patients who underwent surgery for acute appendicitis, the majority were males 79(77.5%) with a mean age of 23.8(SD = 12.5) years. The perforated appendix was seen in 26 (25.5%) patients. Post-operative complications occurred in 21(20.6%) with the commonest being surgical site infection in 19(18.6%) patients. The median length of hospital stay was 3(IQR = 3-4) days with 43(42.2%) staying in hospital for more than 3 days. The presence of anemia (Hb < 8) (aRR = 1.376, CI = 1.159-1.634, P = < 0.001) and having a perforated appendix (aRR = 1.263, CI = 1.026-1.555, P = 0.027) were independently associated with occurrence of complications while being HIV positive (aRR = 1.379, CI = 1.105-1.721, P = 0.005) and having a perforated appendix (aRR = 1.258, CI = 1.019-1.554, P = 0.033) were independently associated with prolonged hospital stay. CONCLUSION: Community education about early presentation is still required in order to reduce the number of patients that present late which should, in turn, reduce the risk of complications and length of hospital stay.

Bacterial profile and antibiotic susceptibility patterns in patients with secondary peritonitis: a cross-sectional study in Uganda.

INTRODUCTION: Secondary peritonitis is the second leading cause of sepsis worldwide. Drug resistance to peritoneal cavity bacterial infection remains a public health threat, especially in resource-limited settings in Africa, including Uganda. This study aimed to determine the antibacterial susceptibility patterns and factors associated with secondary peritonitis among patients with acute abdomen who underwent surgery at a Regional Referral Hospital in Uganda. METHODS: This was a cross-sectional study conducted at Hoima Regional Referral Hospital (HRRH) that enrolled 126 patients with acute abdomen. Clinical samples were aseptically collected at laparotomy from patients with secondary peritonitis for culture and sensitivity using standard Microbiological methods. Binary logistic regression was used to identify factors associated with secondary peritonitis among patients with acute abdomen. RESULTS: The majority of the patients were males (61.9%) with a mean age of 37.9(SD ± 21.8). Secondary peritonitis was found in 57(45.2%) of the patients. Gram-negative bacteria were the most commonly isolated organisms with Escherichia coli (35.8%) and Klebsiella spp (17.0%) predominating. Imipenem 88.8%(8/9), Amikacin 88.8%(8/9), Ciprofloxacin 44.4%(4/9) and Gentamicin 44.4%(4/9) demonstrated sensitivity to the different isolated organisms at varying degrees. Being a male (AOR = 3.658; 95% CI = 1.570-8.519, p = 0.003) and presenting 3 days after onset of symptoms (AOR = 2.957; 95% CI = 1.232-7.099, p = 0.015) were independently associated with secondary peritonitis. CONCLUSION: Imipenem, Amikacin, Ciprofloxacin, and Gentamicin should be considered for empirical therapy in cases of secondary peritonitis. Patients, more especially males with abdominal pain should be encouraged to present early to the hospital to minimize progression to secondary peritonitis.

Psychosocial impact of surgical complications and the coping mechanisms among surgeons in Uganda and Eastern Democratic Republic of the Congo.

We aimed to assess the psychosocial impact from postoperative complications on the surgical workforce and the coping mechanisms they use following these complications in Uganda and Eastern Democratic Republic of the Congo (DRC). This was a cross-sectional multi-center study conducted from first February 2022 to 31st March 2022 in the preselected main teaching hospitals of Uganda and Eastern DRC. We surveyed the surgical workforce (practicing surgeons, Obstetrician-Gynecologists, and residents in surgery/ Obstetrics-Gynecology) who had experienced postoperative complications in their career. Data was analysed using SPSS version 23. One hundred ninety-eight participants responded to the questionnaire. Worry about patient and reputation were the commonest psychological impacts in 54.0% and 45.5% of the participants respectively. Majority of the participants (55.1%) used positive coping mechanisms with a positive impact on their practice (94.4%). Being a female doctor (AOR = 2.637, CI 1.065-6.533, P = 0.036), worrying about reputation (AOR = 3.057, CI = 1.573-5.939, P = 0.001) and guilt after a complication (AOR = 4.417, CI = 2.253-8.659, P = <0.001) were predictors of a negative coping mechanism. Postoperative surgical complications continue to cause a huge psychological impact on the operating doctors in Uganda and the Eastern DRC. Female doctors, those that worry about the reputation and those that feel guilty following a complication should be given more support and guidance by peers when surgical complications occur to their patients.

A rare presentation of a giant malignant melanoma in a 67 year old female Ugandan: A case report.

INTRODUCTION AND IMPORTANCE: Malignant melanoma (MM) is a skin cancer whose incidence is alarmingly increasing globally. However, the public, especially among the black population, still has very little knowledge about this condition, yet its early diagnosis is associated with a good prognosis. CASE PRESENTATION: We report a 67-year-old female Ugandan who presented with a big ulcerated, fungating mass on her right foot for 3 years which was later confirmed to be a giant MM in advanced stage, and managed palliatively. DISCUSSION AND CONCLUSION: To the best of our knowledge, this has been one of the very few acral lentiginous MMs to be reported in Uganda and Africa at large. MM is still a cancer of public health concern. Increased public and health care workers' sensitization about its early diagnostic features is recommended for better management outcomes among those affected by this cancer.

Traumatic bilateral testicular amputation in a 31 year old male: A case report.

INTRODUCTION AND IMPORTANCE: Testicular loss following assault is a very rare occurrence and uncommon in the low income countries. Testicular amputation is usually associated with blast injuries, sexual violence and self-mutilation in psychiatric cases. Management involves a multidisciplinary approach and is focused on resuscitation, aggressive debridement, testosterone supplementation, and reconstructive surgery. CASE PRESENTATION: We present a 31 year old male referred to the emergency department of a Regional Referral Hospital in western Uganda with a history of trauma to his scrotum. The patient had been well till 16 h prior to presentation when he was attacked by unknown assailants who broke into his house in the night. The patient was reportedly beaten before his scrotum was pulled and amputated with eventual profuse bleeding. Evacuation of approximately 150 cc hematoma was done plus debridement of necrotic testes and achieving hemostasis. DISCUSSION AND CONCLUSION: To the best of our knowledge, this was the first reported case of bilateral traumatic testicular amputation as a result of assault. Revascularization with micro-vascular techniques can be done if the patient presents early, but due to late presentation, the patient was only managed with aggressive debridement, reconstruction and testosterone supplementation.

Complex pelvic fracture with massive hemorrhage in low resource settings: Case report.

Pelvic fractures can range from simple, requiring almost no therapy, to complex, mandating the attention of the orthopedic surgeon, trauma surgeon, interventional radiologist, or other specialists because they are associated with multisystem injury and life-threatening hypotension. We present a 16-year-old male who presented with a complex pelvic fracture following a motor vehicle accidents that did not survive despite the efforts in resuscitation. In complex pelvic fracture with hemodynamic instability (hypotension persevered) and high index suspicion of bladder injury, there is an immediate need for operative intervention, regardless of negative/positive FAST (Focused Assessment with Sonography in Trauma).

A rare presentation of urolithiasis in a child with urine retention from a nonendemic area: a case report and literature review.

Even though urolithiasis in general is not uncommon, urethral stones have an incidence of less than 0.3% and are 20 times less common in children. Though cases of urethral stones have been reported in children from endemic areas, they are even rarer in countries like Uganda that are not endemic for urolithiasis. Case Presentation: The authors present a 7-year-old male who presented with acute urine retention. Though the diagnosis of retention was made in a lower-level health facility, the cause of the retention was not determined till the patient arrived at a general hospital. Diagnosis of an obstructing stone in the penile urethra was made clinically. Meatotomy and stone extraction were done, and a urethral catheter was passed. Clinical Discussion and Conclusion: When attending to children with acute urine retention, urolithiasis should be kept among the differential diagnoses, even in areas that are not endemic for urinary tract stones. A thorough clinical evaluation may be all that is needed to make a diagnosis.

Retrocaval ureter in a child presenting at a regional referral hospital in South-Western Uganda: A case report.

INTRODUCTION AND IMPORTANCE: Retrocaval ureter is a rare developmental abnormality of the inferior vane cava. Commonly presents in the 3rd and 4th decades of life hence a rare presentation in the pediatric population. This condition presents a surgical challenge both in terms of diagnosis and management due to costly investigations and few urology specialists in resource limited settings. We present a case of retrocaval ureter surgically managed in a resource limited setting with excellent outcome. CASE PRESENTATION: A 13-year-old female presented with 3 months history of progressive right sided abdominal pain and history of treatment for recurrent lower urinary tract infections. Intravenous pyelogram showed a ureter with a fish hook shape. At laparotomy, the ureter was identified, divided, relocated and ureteroureterostomy done anterior to the inferior vena cava. The patient recovered with no complications. DISCUSSION AND CONCLUSION: To the best of our knowledge, this is the first reported case of retrocaval ureter in a child surgically managed in Africa. It's a congenital anomaly of the inferior vena cava not ureter hence a misnomer. Amidst of being in a less resourced setting, an intravenous pyelogram may be all that is required to make a diagnosis.

A giant choledochal cyst in a 17 year old female managed in a resource limited setting: A case report.

INTRODUCTION AND IMPORTANCE: Choledochal cysts are rare congenital bile duct anomalies that lead to cystic dilatations of the biliary tree. This condition is very rare in Africa. When these cysts exceed 10 cm in diameter, they are referred to as giant choledochal cysts, which are much rarer. Giant choledochal cysts present both a diagnostic and surgical challenge. We present a case of a giant Choledochal cyst surgically managed in a resource limited setting with excellent outcome. CASE PRESENTATION: A 17-year-old female presented with 4 months history of progressive abdominal distension associated with abdominal pain, yellow discoloration of eyes, and occasional constipation. Abdominal CT-scan revealed a huge cystic mass in the right upper quadrant extending inferiorly to the right lumbar region. Complete excision of a type IA choledochal cyst was done plus cholecystectomy in addition to bilioenteric reconstruction. The patient recovered uneventfully. DISCUSSION AND CONCLUSION: To the best of our knowledge, this is the largest giant Choledochal cyst reported in literature. Even in a resource limited settings, sonography and a CT scan may be all that is required to make a diagnosis. During surgical excision, the surgeon should take extra caution to carefully dissect the adhesions off the giant cyst for a successful complete excision.

Incidence and outcomes of surgical site infection following emergency laparotomy during the COVID-19 pandemic in a low resource setting: A retrospective cohort.

Introduction: Surgical site infection (SSI) is the commonest form of hospital acquired infection in sub-Saharan Africa, associated with increased morbidity and mortality. This study was aimed at determining the incidence and outcomes of surgical site infection following emergency laparotomy during the COVID -19 pandemic in a low resource setting. Methods: This was a retrospective single Centre cohort of patients that had emergency laparotomy between July 2021-June 2022 (COVID period) and July 2018-June 2019 (pre-COVID period). Analysis was done using SPSS version 22 in which SSI rates were compared between the two periods using the chi squared test. Mortality, re-operation rates and length of hospital stay were also compared. Results: Of the 453 patient files included in analysis, 244 (53.9%) were for the COVID period, while 209 (46.1%) were for the pre COVID period. The incidence of SSI was insignificantly higher in the COVID period (17.6% versus 16.7%; P = 0.901). Mortality was also insignificantly higher in the SSI group (3.8% versus 3.5%; P = 0.745). Presence of surgical site infection increased the risk for re-operation (P < 0.001) and prolonged hospital stay (P < 0.001). Conclusion: Since the incidence and outcomes of surgical site infection appear not to have changed following the pandemic, the same measures that were previously used to prevent SSI could still be effective even during the pandemic if followed appropriately and combined with the COVID specific peri-operative care recommendations.

Congenital infantile hypertrophic pyloric stenosis in preterm dizygotic twins infants diagnosed early: A case report.

INTRODUCTION AND IMPORTANCE: The association in the occurrence of hypertrophic pyloric stenosis (HPS) is 0.25 % to 0.44 % between monozygotic twins and 0.05 % to 0.10 % in dizygotic twins. A combination of genetic and environmental factors may have contributed to the occurrence of HPS. In view of the few related cases reported recently, we present two dizygotic twins who were diagnosed with HPS. CASE PRESENTATION: This report describes a rare case of congenital infantile hypertrophic pyloric stenosis in preterm dizygotic twins diagnosed early, in which the first case presented with severe clinical features and managed surgically while the second presented with moderate features and hence managed non-operatively with atropine for 14 days. At 6 months of age, both twins continued to tolerate feeds, demonstrated satisfactory weight gain and had achieved appropriate developmental milestones. The postoperative course was uneventful in the twin A. CLINICAL DISCUSSION: Congenital HPS in premature twins remains an underdiagnosed pathology due to its clinical picture mimicking digestive intolerance to feeds. The mean age at diagnosis is about 38 days, and only 0.4 % of all children suffering from HPS show symptoms in the first 3 days of life. Symptom relief is achieved after a classic pyloromyotomy is performed by a more preferable laparoscopic technique or using the open surgical technique. CONCLUSION: If one of the dizygotic twins has HPS, the other baby should be evaluated for the same diagnosis as early as possible, to ensure timely management. HPS with moderate clinical features can be treated with atropine for 14 days while severe HPS should be treated by pyloromyotomy.