Nutritional status and outcome of surgery: A prospective observational cohort study of children at a tertiary surgical hospital in Harare, Zimbabwe.

BACKGROUND: Undernutrition contributes to nearly 50% of all child deaths in the world, yet there is conflicting evidence regarding the association between nutritional status and postoperative complications. The aim was to describe the preoperative nutritional status among pediatric surgery patients in Zimbabwe, and to assess if nutritional status was a risk factor for adverse postoperative outcome of mortality, surgical site infection, reoperation, readmission, and longer length of stay. METHODS: This prospective observational cohort study included 136 children undergoing surgery at a tertiary pediatric hospital in Zimbabwe. Nutritional status was standardized using Z-scores for BMI, length, weight, and middle upper arm circumference. Primary outcomes after 30 days included mortality, surgical site infection, reoperation, and readmission. Secondary outcome was length of stay. Univariate and multivariable analyses with logistic regression were performed. RESULTS: Of the 136 patients, 31% were undernourished. Postoperative adverse outcome occurred in 20%; the mortality rate was 6%, the surgical site infection rate was 17%, the reoperation rate was 3.5%, and readmission rate was 2.5%. Nutritional status, higher ASA classification, major surgical procedures, and lower preoperative hemoglobin levels were associated with adverse outcome. Univariate logistic regression identified a seven-fold increased risk of postoperative complications among undernourished children (OR 7.3 [2.3-22.8], p = 0.001), and there was a four- to six-fold increased adjusted risk after adjustment for ASA, major surgery, and preoperative hemoglobin. CONCLUSION: A third of all pediatric surgery patients were undernourished, and undernourished children had a considerably higher risk of adverse outcome. With a positive correlation identified between undernourishment and increased postoperative complications, future aims would include assessing if preoperative nutritional treatment could be especially beneficial for undernourished children. LEVELS OF EVIDENCE: Level II treatment study.

Negative appendicectomy: evaluation of ultrasonography and Alvarado score.

Background: High negative appendicectomy rates are no longer acceptable with improvements in imaging techniques and clinical prediction rules. The use of ultrasound and CT scan in addition to clinical assessment and blood investigations has greatly reduced the negative appendicectomy rate to less than 10%. Objectives: The aim of the study was to determine the negative appendicectomy rate at the two major teaching hospitals in Harare and to evaluate the accuracy of the Alvarado score and ultrasound scan in diagnosing acute appendicitis. Design: Prospective observational, cross sectional study. Setting: Parirenyatwa Group of Hospitals and Harare Central Hospital, in Zimbabwe. Materials and Methods: A total of 206 patients undergoing appendicectomy at the two major teaching hospitals in Harare were included in this study between June 2012 and May 2013. Information recorded included: age, sex, clinical features, investigations and treatment. Alvarado score was calculated from the data in the case notes and ultrasound scan results were also captured. All appendices removed at operation were sent for histopathological examination. Appendicitis was confirmed at histology. The positive predictive value of Alvarado score and sensitivity and specificity of ultrasound scan were calculated. Results: The overall negative appendicectomy rate was 16.5%. The negative appendicectomy rate for men was 13.3% and that for females was 24.4%. The negative appendicectomy rate for Parirenyatwa Group of Hospitals was 19.0% and that for Harare Central Hospital was 12.1%. The mean age was 28 years (SD 12.8). Appendicitis was diagnosed commonly in the second and third decades of life. Sensitivity of ultrasound scan in diagnosing acute appendicitis was 89.5% with a positive predictive value of 77.2%. Females were 2.6 times more likely to have an ultrasound scan done to diagnose appendicitis than males. Alvarado score had a sensitivity of 95.3% with a positive predictive value of 90.3%. Conclusion: The negative appendicectomy rate (16.5%) at the two University Teaching Hospitals in Harare is relatively high when compared with modern trends. Alvarado score had a high sensitivity (95.3%) and predictive value (90.3%). Ultrasound scan had a high sensitivity (89.5%) and a relatively low predictive value (77.2%) in diagnosing acute appendicitis. Regular use of these assessment modalities should contribute substantially to reduction in the negative appendicectomy rate in our practice.

Giant appendiceal mucocele: a case report and review of the literature.

Appendiceal mucocele is a rare condition characterised by cystic dilatation of the lumen of the appendix. Whenever possible it is essential to identify the disease pre-operatively by full clinical assessment and thorough investigations including abdominal CT scan and colonoscopy or barium enema. Accurate diagnosis helps to plan for a careful resection to remove the mass without spillage of the cyst contents, which can lead to the most dreaded complication of pseudomyxoma peritonei. In this paper we report on a rare case of giant mucocele of the appendix and review the relevant literature.

An analysis of the factors contributing to mortality rates in burns patients treated at Mpilo Central Hospital, Zimbabwe.

We present a retrospective analysis of 49 patients (61% males and 39% females) with burns who died at Mpilo Central Hospital between January 1990 and December 1993. Of the patients, 61% (30/49) were in the paediatric age group, with 55% (27/49) under 2 years of age. Most burns occurred at home (79%) and 17% of the burns occurred at the workplace. The commonest burning agents were hot water (39.5%) and open fires (39.5%). The surface area of burns ranged from 10 to 88% with a mean of 35%. Deep partial thickness and full thickness burns accounted for 52% of cases. All the patients required active resuscitation with intravenous fluids. A total of 35 organisms were isolated on 18 pus swabs. The most commonly isolated organisms were Staphylococcus aureus (43%) and Pseudomonas (23%). The main factors contributing to death were septicaemia (n = 15), pneumonia (n = 10) and acute renal failure (n = 7). The majority of patients (65%) died within 10 days, 61% of whom were children. The average time to death was 14 days (range 1-64 days). It is clear that some patients with severe burns will die regardless of how well they are managed. The key to successful management of those patients who should survive lies in early presentation and active resuscitation, prevention and control of infective complications and adequate nutritional support.

Major vascular injury in civilian practice in Bulawayo, Zimbabwe.

OBJECTIVE: To assess the extent of the problem of major vascular injuries in our practice and also to analyse the causes and the results of our management of these injuries at Mpilo Central Hospital. DESIGN: A study of eight patients who were treated for major vascular injuries at Mpilo Central Hospital between 1989 and 1994. SETTING: Mpilo Central Hospital, Bulawayo, Zimbabwe. SUBJECTS: Eight patient who were treated for major vascular injuries. MAIN OUTCOME MEASURES: Causes of vascular injury, other injuries, haemodynamic state on admission, surgical procedures carried out, complications and outcome. RESULTS: All three major vascular injuries due to stab wounds were successfully repaired. Of the four patients with major vascular injuries due to complicated orthopaedic injuries, two had successful repair of the vascular injury but the other two underwent amputation. The eighth patient who sustained an arterial injury during the course of a difficult operation for a tumour on the left forearm had a successful repair of the vascular injury. CONCLUSION: This study has shown that stab wounds and complicated orthopaedic injuries are the main cause of major vascular injury in civilian practice in our community. The importance of adequate resuscitation, early diagnosis and early appropriate surgical intervention is emphasized.

The outcome of surgical treatment of pressure sores at Mpilo Central Hospital, Zimbabwe.

OBJECTIVE: To analyze the results of surgical management of pressure sores at Mpilo Central Hospital and also to identify the characteristics of patients who develop pressure sores in our community. DESIGN: A retrospective study of 25 patients who were treated surgically for pressure sores at Mpilo Central Hospital between January 1991 and December 1994. SETTING: Mpilo Central Hospital, Bulawayo, Zimbabwe. SUBJECTS: Twenty five patients who under-went surgical treatment for pressure sores. MAIN OUTCOME MEASURES: Site of pressure sore, underlying cause of pressure sore, investigations, surgical procedures, complications, recurrence of pressure sores and length of hospital stay. RESULTS: The mean age of the patients was 35 years (standard deviation, SD 17). There were more patients with pressure sores from rural areas (n = 15) than from urban areas (n = 10). Most pressure sores occurred in the trochanteric region, 36pc (12/33), ischial region, 33pc (11/33) and in the sacral region, 21pc (7/33). The commonest condition predisposing to pressure sores was spinal cord trauma, 48pc (12/25). Most of the patients underwent excision and flap repair (58pc) and excision and direct closure of the pressure sore (35pc). The main post operative complication was wound infection which occurred in about half the cases (n = 12). The only death in this series occurred in one patient who developed a gram negative septicaemia. The mean hospital stay was 66 days (SD37). CONCLUSION: This study indicates that spinal cord trauma, 48pc (912/25), is the commonest condition predisposing to pressure sores in our community. The incidence of such injuries can be reduced by strict enforcement of Road Traffic Regulations and improving safety precautions at the work place. As shown in this study the use of suitable flaps reduces the recurrence rate of pressure sores.

Stab wounds in Bulawayo, Zimbabwe: a four year audit.

Between January 1989 and December 1992 a total of 102 patients (88 pc male and 12 pc female) were treated for stab wounds at Mpilo Central Hospital, Bulawayo, Zimbabwe. The case records of these patients have been studied retrospectively. The mean age of the patients was 30 years (Standard Deviation 9). Most of the patients, 82 pc (82/102) were residents of the city of Bulawayo with only 18 pc (18/102) coming from rural areas. The mean delay in presentation was 12 hours (SD 11). A knife was the stabbing instrument in most cases (82 pc). Fights, 38 pc (26/68), domestic disputes, 26 pc (18/68) and robbery 21 pc (14/68) were the commonest motives for stabbing. In most cases stabbing occurred in a beer hall, 47 pc (26/55) and at home, 31 pc (17/55). The majority of stab wounds occurred in the chest, 51 pc followed by the abdomen, 31 pc. Of the patients with stab wounds of the chest 22 pc (14/65) required intercostal chest drains. Of the 39 patients with stab wounds of the abdomen 20 patients were subjected to laparotomy. No abnormality was found at operation in 50 pc (10/20) of cases. No major complications or mortality were recorded in this series. Based on the findings in this study, there is need for us to adopt a more conservative approach to the management of stab wounds, especially those involving the abdomen. This policy of "selective conservatism" should be based on a thorough physical examination and appropriate special investigations. Active surgical intervention should be reserved for specific indications.

The sensate deep inferior epigastric musculocutaneous flap and the twelfth thoracic nerve.

A detailed anatomical study of the terminal branches of the twelfth thoracic nerve (subcostal nerve) based on observations made during dissections of 23 embalmed cadavers is presented. In all 23 cadavers, the twelfth thoracic nerve had an ascending branch which joined the deep inferior epigastric vascular pedicle about half way between the lower border of the umbilicus and the symphysis pubis. This observation, we believe, explains how it is possible to preserve sensation in the deep inferior epigastric musculocutaneous flap.

Splenic and hepatic trauma: a three year review.

We present a three year study of 22 consecutive patients treated for splenic and liver injuries at Mpilo Central Hospital between 1988 and 1990. A total of eight patients died giving an overall mortality rate of 36 pc. There was no mortality recorded in nine patients (41 pc) treated for splenic injuries. However, of the nine patients (41 pc) treated for liver injuries four patients died giving a mortality rate of 44 pc in this group. The highest mortality rate was recorded in the group of patients with both splenic and liver injuries because these injuries were invariably associated with other severe multiple injuries. We admitted four patients (18 pc) in this group and they all died.

Umbilical hernia in Bulawayo: some observations from a hospital based study.

We present a retrospective study of 40 consecutive patients admitted with umbilical herniae to Mpilo Central Hospital between January 1990 and December 1993. The majority of the patients 95 pc (38/40) were children and only 5 pc (2/40) were adults. The study included 18 males and 22 females giving a M:F ratio of 1:1,2. In children the age range was from 1 month to 13 years with 63 pc (24/38) occurring in the zero to five year age group. The commonest indication for admission was obstruction of the umbilical hernia in 37.5 pc (15/40) of cases. Other indications included: large umbilical hernia 30 pc (12/40), recurrent discomfort and peri-umbilical pain 20 pc (8/40), incidental finding in patients admitted for some other problem 7.5 pc (3/40), one case of recurrent hernia and one case of accidental injury. Spontaneous reduction of obstructed umbilical herniae occurred in 86 pc (13/15) of cases and operative reduction was carried out in 14 pc (2/15) of cases. There was no mortality recorded in this series. It is clear from our findings in this study that obstruction of the umbilical hernia in children in our practice although relatively uncommon, is a well recognised surgical emergency. On the basis of our findings we would recommend that prophylactic umbilical hernia repair should be performed in all girls over two years of age and in all children over four years of age.

A review of burns treated over a one-year period at Mpilo Central Hospital, Zimbabwe.

A retrospective study is presented of 297 patients (57% male and 43% female) treated for burns at Mpilo Central Hospital, Bulawayo, Zimbabwe in 1991. Of the patients, 73% were in the paediatric age group, 60% of whom were under 5 years of age. Most burns occurred at home (90%), with the majority occurring in the kitchen (61%). The commonest burning agent was hot water (55%). Open-fire burns accounted for 18% of cases. The surface area of burns ranged from 1% to 80% with a mean of 7%. The majority of patients (84%) had superficial thickness burns. Only 6% of the patients required active resuscitation with intravenous fluids. A total of 159 organisms were isolated on 111 pus swabs. The most commonly isolated organism was Staphylococcus aureus (66%). Seven patients (five children and two adults) died, giving a mortality rate of 2%. Although it is desirable to have a purpose-built burns unit this study shows that satisfactory results can be achieved with limited facilities. In our practice, where 90% of burns occur in the home situation, an active public-education campaign would help to reduce the incidence of burns.

Some pitfalls in burns management: illustrative case reports with a discussion on ways to improve the outcome of treatment.

We present two females with severe, mainly full thickness burns, who have developed gross deformities due to inadequate treatment of their burns. Early referral to major centres with the technical expertise and material resources to manage such complicated injuries will help to minimise the degree of deformity and disability suffered by these patients. Adequate resuscitation, relatively early split skin grafting, intensive physiotherapy and appropriate splintage are the hallmark of treatment of such severe burns.

Torsion of the testis: review of clinical experience in Zimbabwe.

A detailed retrospective analysis of 90 patients with torsion of the testis managed at Mpilo Central Hospital between January 1987 and December 1991 is presented. The mean age of all patients was 17 years (range two months to 32 years). Sudden and severe scrotal pain was the commonest mode of presentation seen in 98 pc (88/90) of cases. Vomiting occurred in 30 pc (27/90) of cases and urinary symptoms were present in 5.5 pc (5/90) of cases. A history suggestive of previous episodes of torsion was obtained in 12 pc (11/90) of cases. Seventy one pc (64/90) of patients presented within 72 hours (mean delay 32 hours). Twenty nine pc presented late (i.e. after 72 hours) with a mean delay of seven days. The overall testicular salvage rate was 36 pc in this series. The only complications encountered were two minor wound infections which settled down on dressings and antibiotics. The successful management of a patient with torsion of the testis depends on; early consultation on the part of the patient, correct diagnosis by the doctor at first consultation and urgent surgical exploration of the affected testis.