Epidemiology and Perioperative Mortality of Exploratory Laparotomy in Rural Ghana.

Background: Perioperative mortality rate (POMR) has been identified as an important measure of access to safe surgical and anesthesia care in global surgery. There has been limited study on this measure in rural Ghana. In order to identify areas for future quality improvement efforts, we aimed to assess the epidemiology of exploratory laparotomy and to investigate POMR as a benchmark quality measure. Methods: Surgical records were reviewed at a regional referral hospital in Eastern Region, Ghana to identify cases of exploratory laparotomy from July 2017 through June 2018. Patient demographics, health information, and outcomes data were collected. Logistic regression was used to identify predictors of perioperative mortality. Findings: The study included operations for 286 adult and 60 pediatric patients. Only 60% of patients were covered by National Health Insurance (NHI). The overall POMR was 11.5% (12.6% adults; 6.7% pediatric). Sixty percent of mortalities were referrals from outside hospitals and the mortality rate for referrals was 13.5%. Odds of mortality was 13 times greater with perforated peptic ulcer disease (OR = 13.1, p = 0.025) and 12 times greater with trauma (OR = 11.7, p = 0.042) when compared to the most common operation. Female sex (OR = 0.3, p = 0.016) and NHI (OR = 0.4, p = 0.031) were protective variables. Individuals 60 years and older (OR = 3.3, p = 0.016) had higher mortality. Conclusion: POMR can be an important outcome and quality indicator for rural populations. Interventions aimed at decreasing emergent hernia repair, preventing perforation of peptic ulcer disease, improving rural infrastructure for response to major trauma, and increasing NHI coverage may improve POMR in rural Ghana.

Cysteine fluxes across the portal-drained viscera of enterally fed minipigs: effect of an acute intestinal inflammation.

Cysteine is considered as a conditionally indispensable amino acid. Its dietary supply should thus be increased when endogenous synthesis cannot meet metabolic need, such as during inflammatory diseases. However, studies in animal models suggest a high first-pass extraction of dietary cysteine by the intestine, limiting the interest for an oral supplementation. We investigated here unidirectional fluxes of cysteine across the portal-drained viscera (PDV) of multi-catheterized minipigs, using simultaneous intragastric L-[(15)N] cysteine and intravenous L-[3,3D2] cysteine continuous infusions. We showed that in minipigs fed with an elemental enteral solution, cysteine first-pass extraction by the intestine is about 60% of the dietary supply, and that the PDV does not capture arterial cysteine. Beside dietary cysteine, the PDV release non-dietary cysteine (20% of the total cysteine release), which originates either from tissue metabolism or from reabsorption of endogenous secretion, such as glutathione (GSH) biliary excretion. Experimental ileitis induced by local administration of trinitrobenzene sulfonic acid, increased liver and ileal GSH fractional synthesis rate during the acute phase of inflammation, and increased whole body flux of cysteine. However, cysteine uptake and release by the PDV were not affected by ileitis, suggesting an adaptation of the intestinal sulfur amino acid metabolism in order to cover the additional requirement of cysteine linked to the increased GSH synthesis. We conclude that the small intestine sequesters large amounts of dietary cysteine during absorption, limiting its release into the bloodstream, and that the other tissues of the PDV (colon, stomach, pancreas, spleen) preferentially use circulating methionine or cysteine-containing peptides to cover their cysteine requirement.

[A case of esophageal carcinoma complicated by Crohn's disease].

A case of an esophageal cancer complicated by Crohn's disease is reported. A 76-year-old female was admitted to the Nara National Hospital with symptoms of melena and dysphagia. An esophageal X-ray study revealed a circular, stenotic lesion at the lower intra-thoracic esophagus. Histological examination of a specimen confirmed a moderately differentiated squamous cell carcinoma. A barium enema was then given which showed an irregular stenotic lesion, 28 cm in length, at the terminus of the ileum. Thus, an esophageal blind resection and a resection of the terminal portion of the ileum was jointly performed. A histological examination of the resected ileum confirmed Crohn's disease.

[Ileocecal Crohn disease with sigmoid involvement]. / Ileocöcaler Crohn mit Sigmabeteiligung.

This report concerns 14 patients with Morbus Crohn and inflammatory conglomerat tumors between ileo-coecum and sigma. In the case of primary affliction of the ileo-coecum and secondary involvement of the sigma (group A), it is generally sufficient to perform an ileo-coecal resection and suture over the sigma, if a fistula is present. In case of Morbus Crohn afflicting primarily the sigma (group B) or simultaneous involvement of ileo-coecum and sigma (group C), a double resection is necessary. It was always possible to demonstrate the presence of an ileo-sigmoidal fistula by means of barium enema and mostly possible with barium meal or enteroclysis. We consider preoperative colonoscopy with graduated biopsies to be absolutely necessary to determine the exact stage of the illness. Fistulas can be more accurately demonstrated by radiogram than endoscopically.

[The extent of Crohn's disease. Radiological measurements. Correlation with surgical findings]. / La estensione dell'enterite di Crohn. Misurazione radiologica. Correlazione con i reperti chirurgici.

Twenty-three patients with small intestinal Crohn's disease were studied by barium-methylcellulose infusion. All patients underwent surgery within 1-24 months (average 7 months). The extent of the lesions and the small bowel length were radiologically evaluated by means of a map measurer. The same measurements were performed at surgery. Radiological and surgical data concerning the extent of enteritis were statistically correlated (r = 0.7). The correlation between radiological and surgical measurements of total small bowel length was not significant.