Improving care and survival of newborns with surgical conditions in Tanzania (TINY Tanzania): a focus on gastroschisis.

PURPOSE: Gastroschisis is associated with over 90% mortality in many sub-Saharan African countries. The introduction of the Gastroschisis Care Bundle at Muhimbili National Hospital (MNH) increased survival up to 60%. We aim to explain the impact of using implementation science methods to decentralize the care of babies with gastroschisis to other parts of Tanzania. METHODS: We used a Step-Wedge Implementation Science design to scale up gastroschisis care through training of providers, dissemination and current revision of evidence-based care protocols, advocacy, and engagement with stakeholders. We used mixed methods for data collection. Anonymous patient and provider evaluation data were collected using a nationwide Gastroschisis Database via REDCap. We evaluated the implementation and effectiveness of the care bundle in different hospitals in Tanzania. RESULTS: Decentralizing care nationally was feasible, acceptable, and adaptable. A total of nine trainings have been conducted training 420 providers (14 Master Trainers) reaching seven regions of Tanzania. The three advocacy national campaigns have ensured community reach and patient engagement. A countrywide gastroschisis database was developed to collect data on patients with gastroschisis, hosted locally at MNH with 332 patients' data entered in 1 year. The majority (90.2%) were treated using preformed silo bags with an overall survival of 28.5% in all centers. Late presentation and infection remain to be the main challenge. CONCLUSION: To achieve quality and sustainable surgical care, there is a need to design, implement, evaluate, and continuously improve context-relevant strategies to achieve and sustain the survival of neonates with congenital anomalies. Decentralization enables clear connectedness of hospitals, bringing care closer to patients.

An unusual presentation of penetrating bladder injury with vesicocutaneous fistula: a case report.

BACKGROUND: Blunt trauma to the urinary bladder is common with penetrating injury being a rare occasion. Most common entry pint for penetrating injuries includes buttock, abdomen and perineum with thigh being rare. There are a number of complications that may develop as a result of penetrating injury with vesicocutanous fistula being a rare occurrence that usually presents with typical sign and symptoms. CASE PRESENTATION: We present a rare case of penetrating bladder injury through medial upper thigh as an entry point that had complicated into vesicocutaneous fistula with atypical presentation of long-standing pus discharge that had been managed by incision and drainage several times with no success. MRI demonstrated a presence of fistula tract and a foreign body (piece of wood) in-situ confirmed the diagnosis. CONCLUSION: Fistulas are a rare complication of bladder injuries and can cause negative impact on the quality of life of patients. Delayed urinary tract fistulations and secondary thigh abscesses are uncommon therefore a high index of suspicion is needed for early diagnosis. This case emphasizes the importance of radiological tests in aiding the diagnosis and ultimately proper management.

Carpenter syndrome in a patient from Tanzania.

Carpenter syndrome (acrocephalopolysyndactyly type II) is a rare autosomal recessive disorder. It was clinically diagnosed in a female baby with polysyndactyly and craniosynostosis in a referral clinic in Northern Tanzania. In the RAB23 gene, a previously described homozygous variant c.82C>T p.(Arg28*) was detected that results in a premature stop codon. Both parents were demonstrated to be heterozygous carriers of this variant. Herewith, its pathogenicity is proved. A literature search suggests this is the first molecularly confirmed case of Carpenter syndrome in continental Africa.

Colorectal cancer in a patient with intestinal schistosomiasis: a case report from Kilimanjaro Christian Medical Center Northern Zone Tanzania.

BACKGROUND: Colorectal cancer associated with chronic intestinal schistosomiasis has been linked with the chronic inflammation as a result of schistosomal ova deposition in the submucosal layer of the intestine. Among all species Schistosoma japonicum has been more linked to development of colorectal cancer as compared to Schistosoma mansoni due to absence of population-based studies to support the association. Despite the weak evidence, some cases have been reported associating S. mansoni with development of colorectal cancer. CASE PRESENTATION: We report a patient who presented to us as a case of intestinal obstruction and found to have a constrictive lesion at the sigmoid colon at laparotomy, then later found to have colorectal cancer with deposited S. mansoni ova at histology. CONCLUSION: Given the known late complications of schistosomiasis, and as S. mansoni is endemic in some parts of Tanzania, epidemiological studies are recommended to shed more light on its association with colorectal cancer.

Colocolic intussusception as a rare cause of intestinal obstruction in a preschool child: A case report.

INTRODUCTION AND IMPORTANCE: Colocolic intussusception occur in less than 5 % of all cases of intussusception. Median age at presentation is 4.4 years. Usually presents with features of intestinal obstruction. Common causes include pathological lead points like juvenile polyps, Meckel's diverticulum and lymphoma. However, rarely occurs without an organic cause as presented in the index case. CASE PRESENTATION: We present a case of colocolic intussusception in a 5-year-old boy with clinical evidence of blood-stained mucoid stools, abdominal distention and post prandial vomiting. CT-scan confirmed the clinical diagnosis. Surgical exploration revealed left-sided colocolic intussusception without a pathological lead point. CLINICAL DISCUSSION: Most cases of colonic intussusception have a pathological lead point. Clinical features are unspecific but mostly present with intestinal obstruction, hence, a CT-scan aids in establishing the diagnosis. CONCLUSION: Colocolic intussusception is a rare subtype of intussusception in the paediatric age group especially in the absence of a pathological lead point. This case report presents a rare case of colocolic intussusception without pathological lead point, highlighting the importance of advanced imaging modalities like CT-scan in establishing the diagnosis and guiding management.

Diagnosis and management of a sacrococcygeal teratoma at a tertiary hospital in northern Tanzania: A case report.

INTRODUCTION AND IMPORTANCE: Sacrococcygeal teratoma is a rare extragonadal germ cell tumor occurring at the lower end of the back. It is congenital, and can be diagnosed in utero or just after birth. These tumors are sporadic in nature, more common in females than in males. They can be solid, cystic or a mixture of the two in consistency. Authors present this case to share their experience because these congenital tumors are rare and a lapse in appropriate management can be devastating because of chances of recurrence and the possibility of a malignant nature of the disease. CASE PRESENTATION: Authors in this case present a baby that was referred to their center 5 days post vaginal delivery with a huge mass on the sacrococcygeal region. MRI revealed sacrococcygeal teratoma type II. Wide local excision was done. Tumor margins were microscopically negative. The patient recovered well and was discharged. The patient did not require adjuvant treatment. CLINICAL DISCUSSION: Routine obstetric ultrasound can diagnose sacrococcygeal teratoma with 100 % sensitivity. Fetuses with tumors <5 cm in size can be delivered vaginally. Tumors larger than that should be delivered at term through cesarean section. High risk sacrococcygeal teratomas can be delivered at 28 weeks of gestation by cesarean section followed by ex-utero intrapartum therapy. MRI is useful to assess the intrapelvic extent of the tumor and to plan management. Surgical intervention should be done after delivery. CONCLUSION: Intrauterine diagnosis is not an indication for termination of pregnancy. Surgical resection with negative margins provides a cure. Histological examination of the tumor is mandatory. For malignant sacrococcygeal teratomas, adjuvant chemotherapy is necessary for positive tumor margin after surgical resection. Positive margins may require chemotherapy. Neoadjuvant chemotherapy may be used for tumor debulking prior to surgery if the tumor infiltrates neighboring structures or is metastatic.

Giant liposarcoma of the thigh: A case report.

Liposarcoma is a tumor derived from primitive cells that undergo adipose differentiation. They comprise 10%-35% of all soft tissue sarcomas. We present a 46-year-old female patient with a 4-year history of a giant swelling on the lateral aspect of the left thigh. Wide local excision of the mass was performed and histopathological analysis revealed a well-differentiated liposarcoma. Liposarcomas commonly appear in the extremities and have distinct features on imaging studies. Surgical treatment and histology are the most important prognostic factors for patients with lipomatous tumors, as complete surgical excision reduces local recurrence rate.

From penetrating abdominal injury to enterocutaneous fistula, a deadly outcome: A case report.

Enterocutaneous fistula is a dreaded complication by most surgeons especially after emergency abdominal surgery. It can also occur spontaneously from an underlying disease. The pathology is demanding both mentally and physically and causes medical and nursing problems for the affected individual. In this case report we present a timeline of a young 4-year-old boy who sustained penetrating abdominal-perineal injury from a fall and later presented with peritonitis. His condition progressed to complicate into enterocutaneous fistula and succumbed unfortunately due to multifactorial reasons. This shows the impact and burden of the disease pathology not only on patients but also on the medical system as a whole.

Type 3B jejunoileal atresia management at a tertiary hospital in northern Tanzania: A report of three cases.

Key Clinical Message: Jejunalileal atresia is a cause of intestinal obstruction in the newborn, hence a surgical emergency. Prenatal diagnosis can be made by simple obstetric ultrasound and postnatal by plain abdominal x-ray to plan a multidisciplinary approach to reduce morbidity and neonatal mortality. Abstract: Atresia can occur anywhere along the intestines and is a common cause of intestinal obstruction in neonates. Jejunoileal atresia (JIA) is a rare disease occurring in 2.1 per 10,000 live births. Type 3b jejunoileal atresia occurs in 11% of all small bowel atresia. We present three cases of type 3b jejunoileal atresia. They were all missed by prenatal ultrasonography, and presented with features of intestinal obstruction. The diagnosis was confirmed by plain abdominal x-rays and ultrasound, followed by laparotomy. Postoperative care was given in the neonatal unit according to local protocols. One recovered, however, two succumbed from neonatal infection. Jejunoileal atresia requires surgery and long postoperative care, with outcomes associated with numerous prognostic factors including multidisciplinary care and neonatal intensive care. Jejunoileal atresia is less commonly associated with other congenital anomalies, unlike duodenal atresia. Efforts are needed to scale up prenatal diagnosis of jejunoileal atresia, and therefore to plan for appropriate care after delivery. Also, further studies are needed to understand neonatal sepsis in the postoperative period and ways to improve outcomes.

Primary Breast Lymphoma: A Case Report of a Common Tumor in an Uncommon Location.

Primary breast lymphoma (PBL) is a rare malignant lymphoid neoplasm limited to the breast, accounting for about 0.15% of all malignant breast tumors and 1.7% to 2.2% of extra-nodal lymphomas. PBL must be distinguished from conventional breast carcinomas due to different therapeutic approaches. A 25-year-old female presented with a left breast mass. Histopathology and immunohistochemical tests confirmed the diagnosis of diffuse large B-cell lymphoma (DLBCL). She had no similar lesions elsewhere in the body. She received 1 cycle of R-CHOP chemotherapy but absconded from the treatment and succumbed afterward while at home. Recent developments in DLBCL treatment have greatly improved patient outcomes by incorporating targeted medicines like rituximab, increased chemotherapy regimens, new drugs, and individualized treatment techniques. PBL appears to have a worse prognosis; thus, delay or abscondment from treatment is of serious concern when it comes to improving the prognosis of patients with PBL.

Calcified chronic subdural hematoma: A rare cause of epilepsy - Case report.

INTRODUCTION AND IMPORTANCE: Chronic subdural hematoma (CSDH) is a common neurosurgical condition, particularly in the elderly. A rare variant, calcified chronic subdural hematoma, occurs more frequently in children and young adults. The calcification mechanism involves poor circulation, absorption issues, intravascular thrombosis, and prolonged hematoma existence. Clinical symptoms resemble non calcified CSDH. Surgery is generally recommended, especially for infants, young patients, or those with progressive neurological deficit. Calcified subdural hematoma is a rare cause of epilepsy. CASE PRESENTATION: Rare case of a 49-year-old male with chronic calcified subdural hematoma (CCSDH) and increased seizures. Despite a history of epilepsy, his symptoms were poorly controlled with medication. Surgical intervention, involving craniotomy and careful removal of the calcified hematoma, led to significant improvement in symptoms and restored neurological function. CLINICAL DISCUSSION: Subdural hematoma (SDH) is a blood collection between the arachnoid and dura membranes, often following minor head trauma. Chronic subdural hematoma (CSDH) can occur without recalled injury, especially in individuals with conditions like epilepsy. Our patient, with a 23-year history of poorly controlled seizures, likely had undiagnosed CSDH that calcified over time. Calcified chronic subdural hematoma (CCSDH) is typically due to regressive changes and often requires surgical intervention in young or symptomatic patients to prevent further brain damage. Our patient's postoperative recovery highlights the effectiveness of surgery for symptomatic CCSDH. CONCLUSION: The case highlights the importance of considering surgical treatment for symptomatic CCSDH, especially in cases with clinical deterioration. The successful outcome aligns with existing literature, emphasizing the efficacy of surgical intervention for this uncommon condition.

Delayed presentation of congenital diaphragmatic hernia: A report of 2 cases.

Late presentation of congenital diaphragmatic hernia (CDH) presents usually after the neonatal period and often misdiagnosed for other respiratory pathologies. It is crucial to differentiate late presentation of CDH from other potential causes of respiratory distress and gastrointestinal symptoms. Herein, we present 2 cases of delayed presentation of congenital diaphragmatic hernia in infants. Initially, both cases were managed as respiratory conditions in outpatient settings, with no significant improvement. The correct diagnosis was eventually made through radiological evaluation at our tertiary centre, leading to successful surgical management. Delayed presentation of CDH beyond the neonatal period is rare, owing to the wide spectrum of clinical manifestations. Early diagnosis and surgical management are crucial to reduce morbidity and mortality, making a high index of suspicion essential for timely intervention.

Pulmonary hydatidosis with hepatopleural fistula: A case report.

INTRODUCTION AND IMPORTANCE: Cystic echinococcosis (CE) is a chronic illness caused by the tapeworm Echinococcus granulosus. It is classified as a neglected disease and is a priority according to the World Health Organization. CE is prevalent in populations engaged in specific livestock practices and is associated with poor living conditions. CASE PRESENTATION: 41-year-old female Maasai patient who presented with symptoms of cough, dyspnea, fever, and weight loss. Physical examination and CT scans confirmed the presence of cystic masses in the lungs and liver. The patient underwent a thoracotomy procedure to address complications from a hepato-pleural fistula. CLINICAL DISCUSSION: Echinococcus is a tropical disease that affects over a million people worldwide annually. It primarily affects communities engaged in animal husbandry and causes the development of hydatid cysts. Diagnosis can be challenging due to prolonged asymptomatic periods. In rare cases, cysts can rupture into the pleura and bronchial tree, causing respiratory symptoms. Surgical treatment involves the systematic evacuation of cysts and visceral cyst excision, with concurrent laparotomy and thoracotomy being the optimum approach. CONCLUSION: Hydatid cysts remain a significant health problem, particularly when large pleural cysts occur with subphrenic liver cysts. Surgical intervention, specifically a single-stage thoracotomy, is the preferred first-line treatment. This approach allows for both cysts to be addressed in a single procedure, providing effective and efficient treatment to patients.

Colon Lipoma Causing Colo-Colic Intussusception in an Adult: A Case Report from Tanzania.

Intussusception is rarely seen in adulthood but is commonly seen in the pediatric age group. Causes of intussusception in adults are commonly due to tumors and inflammatory diseases. Intussusception in adults accounts for less than 5% of intestinal obstruction. Colonic lipomas are usually asymptomatic and are mostly managed surgically with promising outcomes as seen in our case.

Invasive breast cancer with Paget's disease: A rare case report from a tertiary facility in Northern Tanzania.

Paget's disease of the breast is a rare pathology resulting from abnormal proliferation of glandular epithelial cells in the nipple-areolar epidermis. The disease is named after James Paget, a pathologist and surgeon, who reported a relationship between a nipple rash and mammary gland tumors in 1874. Early diagnosis may be quite difficult. Histopathology can give the definitive diagnosis and the treatment depends upon the presence or absence of an associated breast lump. The treatment options include simple lumpectomy, mastectomy or radical mastectomy depending upon the lump (cancer) in the diseased breast. Herein, we present a case of Paget's disease of the breast presented with a long history of nipple eczema.

Burr hole as a management for extra axial hematomas in a low-resource setting.

INTRODUCTION AND IMPORTANCE: In a low-resource setting, the availability of neurosurgeons and neurosurgical equipment for neurosurgery has proved to be a challenge for the management of extra-axial hematomas hence general surgeons perform burr hole surgeries for emergencies. CASE PRESENTATION: We share our experience with three patients who presented with extra-axial hematomas and managed successfully in our institute with craniostomy as the surgical approach. CLINICAL DISCUSSION: Traumatic brain injury is a major global health burden as it is a leading cause of death among the middle-aged population. Mortality associated with brain injury is highest in low- and middle-income countries. From our experience, we had good outcome in terms of improved Glasgow Coma Scale and overall clinical status in those who underwent burr hole surgery for extra axial hematoma. CONCLUSION: The need for neurosurgeons in sub-Saharan Africa is high but training comes at a cost hence general surgeons can perform life-saving emergency procedures with good outcomes.

A unique presentation of metaplastic breast carcinoma, NOS: A case report.

Key Clinical Message: A rare form of invasive breast carcinoma, NOS, also known as matrix-producing carcinoma made up of epithelial and mesenchymal components. Usually, they are triple negative and clinically aggressive and respond poorly to neoadjuvant systemic therapy. Abstract: Metaplastic breast carcinomas (MBCs) are ductal carcinomas that undergo metaplasia to form nonglandular growth patterns. They are extremely rare, constituting less than 1% of all invasive breast carcinomas. Matrix-producing carcinoma is an exceedingly rare form of MBC distinguished by a ductal carcinomatous component with direct transition to areas of cartilaginous or osseous differentiation without the presence of an intervening spindle cell element. MBCs are clinically aggressive, but matrix-producing subtypes have a relatively better prognosis. The tumors are usually triple negative. Therefore, surgery and chemotherapy are the main therapeutic approaches. Our report describes this unique form of MBC with prominent osseous differentiation in a 33-year-old female patient. Its distinct histological features and peculiar clinical behavior necessitate a thorough understanding of this one-of-a-kind disease entity.

Chondromyxoid fibroma: A rare benign tumor with potential for local recurrence.

Chondromyxoid fibroma is one of the rarest benign cartilaginous tumors accounting for less than 0.5% of bone tumors and mostly found in the metaphysis of long bones. Diagnosis is by histology showing lobular pattern with stellate-shaped cells in a myxoid or chondroid background. Often they can be misdiagnosed as chondrosarcomas. Recommended treatment approach is surgically excision due to the high risk of malignancy. Although benign, local recurrence is common as presented from this case report.

Sclerosing epithelioid fibrosarcoma of the foot: A case report.

Sclerosing epithelioid fibrosarcoma (SEF) is a rare and distinctive variant of fibrosarcoma. To date, about 100 cases only have been documented. Histopathologically, it resembles a variety of benign, pseudosarcomatous and other malignancies. Early diagnosis and treatment are vital for improving the treatment outcomes.

Traumatic left common carotid artery thrombosis with ischemic brain injury: A case report.

INTRODUCTION AND IMPORTANCE: Penetrating neck injuries (PNIs) are common and are associated with arterial injuries in 10-25 % of the cases, with carotid artery twice as frequent as to vertebral arteries. Carotid artery injury constitutes about 22 % of all cervical vascular injuries. CASE PRESENTATION: We present a case of a 44-year-old male who sustained penetrating neck injury in a motor traffic crash. He presented with monoplegia of his right upper limb and an open wound on the left side of his neck which was not actively bleeding hence surgical debridement was done and sutured. CT angiography and CT-scan brain concluded of left common carotid thrombosis secondary to penetrating neck trauma with ischemic brain injury. Patient was successfully managed conservatively. CLINICAL DISCUSSION: The general mortality rate in PNI with associated cervical vascular injury is approximately 66 %. Artery dissection occurs when the intima tears causing intramural hematoma leading to narrowing or occlusion. CT angiography is the best and fastest modality to assess these injuries and management depends on the clinical bases of the patient. CONCLUSION: Neck is vulnerable to external trauma because it is not protected by the skeleton. The neck contains vital structures such as the trachea, esophagus, blood vessels and nervous system organs. Vascular injuries can be life-threatening owing to its prompt clinical assessment and investigation.