PATTERN OF ANORECTAL MALFORMATIONS AND EARLY OUTCOMES OF MANAGEMENT AT MOI TEACHING AND REFERRAL HOSPITAL ELDORET-KENYA.

UNLABELLED: Objectives: To describe the anatomical sub-types of Anorectal malformations, their management and the early outcome at Moi Teaching and Referral Hospital (MTRH) over a 16 month period. Design: A prospective study. SETTING: MTRH, in the neonatal Unit and paediatric surgical wards for theinitial capture of patients and initial follow up. The Paediatric Surgical out-patient clinic was used for the subsequent follow ups. SUBJECTS: All infants diagnosed with ARM (Anorectal malformations) at MTRH from November 2011 to April 2013. MAIN OUTCOME MEASURES: Sub-types of the Anorectal malformations, coexisting abnormalities morbidity and mortality rates. RESULTS: There were 42 participants including 24 (57%) males and 18 (43%) females. Neonates presented at an average age of 4 ± 3, three days and older children presented on average age of 152 ± 118, three days. There were 30 (71%) neonates and 12 (29%) older infants. In males, the predominant sub-type was imperforate anus without a fistula found in ten participants (42% of males). In females, the predominant sub-type was recto-vestibular fistula found in 14 participants (78% of females). Mortality occurred in 13 (31%) participants among them ten (24%) had coexisting abnormalities. The main causes of morbidity were: colostomy complications in four (9.5%); wound,infections in one (5%); and wound dehiscence in one (5%). CONCLUSIONS: Patients with Anorectal malformations presented late at MTRH. The diagnosis at birth was missed in babies born at home as well as those delivered in health institutions.

MANAGEMENT AND OUTCOME OF PATIENTS WITH WILMS' TUMOUR (NEPHROBLASTOMA) AT THE MOI TEACHING AND REFERRAL HOSPITAL, ELDORET, KENYA.

BACKGROUND: Wilms' tumour is a common malignant neoplasm of the kidney and is ranked among the top six solid tumours in children in Kenya. Despite its rapid growth and therefore debilitating effects on its victims, it is one tumour that has shown good response to combined modality approach to its treatmentwith encouraging possibilities of survival even in resource poor settings. OBJECTIVE: To evaluate the management and outcome of patients with Wilms'tumour attended to at Moi Teaching and Referral Hospital (MTRH) during the period between January 2000 and December 2007. DESIGN: Retrospective Study. SETTING: The Paediatric Oncology Service (Oncology unit in the Paediatric Ward, the Paediatric Surgical Ward and the Outpatient Oncology Clinic) at the Moi Teaching and Referral Hospital, Eldoret, Kenya. RESULTS: Information of 45 patients diagnosed with Wilms' tumour was analysed. Forty two (93%) of the patients were referrals from various health facilities in the region. Twenty three (51%) were male and 34 (76%) were aged less than 48 months. Twenty five (56%) had the left kidney affected, 19 (42%) the right kidney and one (2%) bilateral. All the 45 (100%) had an abdominal ultrasound done but none had exhaustive investigations done to stage the disease. Only eight (18%) of the patients had a medical insurance cover. Fourty one (91%) of the patients received specific cancer treatment with 28 (62%) getting combined modality treatment. Nineteen (42%) were lost to follow up. Thirty (67%), 21 (47%), 15 (33%) and 13 (29%) patients were alive six months, one year, two years and three years respectively from the time of diagnosis. 29% survived beyond three years of diagnosis. CONCLUSION: Staging of Wilms tumour fell short of the expected. Neo-adjuvant chemotherapy reduced morbidity and mortality of patients managed for Wilms' tumour. Loss to follow up and cost of treatment had a negative impact on the outcome, a situation that requires to be improved.

Burden and pattern of cancer in Western Kenya.

BACKGROUND: Cancer regisries worldwide have evolved to provide useful information on the burden and diversity of the patterns of cancer, information that is vital for establishing appropriate programmes for disease management. Population based data on cancer in western Kenya as captured in the Eldoret cancer registry established in 1999 is analysed and reported in this paper. OBJECTIVE: To determine the burden and pattern of cancer in Western Kenya by use of data from the Eldoret cancer registry. DESIGN: Retrospective study. SETTING: The cancer registry located in the Department of Haematology at the Moi University, School of Medicine situated at the Moi Teaching and Referral Hospital, Eldoret, Kenya. The hospital has a catchment population of 13 to 15 million people forming about 40% of the Kenyan population. RESULTS: A total of 5,366 patients were diagnosed to have cancer and attended to at the MTRH and other hospitals in Eldoret during the period between January 1999 and December 2006 giving an average of 671 cases per year. Among those treated 2,699 were males and 2,667 were females giving a M: F ratio of 1:1. About 21% of the patients had haematological malignancies with non-Hodgkins lymphoma being the most common. Another 79% of the patients had solid tumours with cancer of the oesophagus being the commonest. Cancer of the cervix and prostrate were the commonest among the females and males respectively. A general increase in the number of patients with Kaposis sarcoma associated with HIV/AIDS pandemic was observed. CONCLUSION: The burden of cancer is a significant health problem in western Kenya and there is need for the development of a comprehensive cancer care programme in the region to address the growing problem.

Emergency resection of sigmoid volvulus.

OBJECTIVES: To determine the outcome of emergency resection of sigmoid volvulus and to determine the factors associated with adverse outcome. DESIGN: Retrospective case series review. SETTING: Moi Teaching and Referral Hospital (MTRH), Eldoret, Kenya. SUBJECTS: All cases of sigmoid volvulus operated at MTRH during the six years period between year 2000-2005. MAIN OUTCOME MEASURES: Mortality rate; morbidity rate; and duration of hospital stay. RESULTS: Ninety two case files were analysed. Sigmoid volvulus accounted for 14.1% of all cases of intestinal obstruction and 80% of large gut obstruction. The mean age was 47.3 years and the median was 50 years. The range was 16 to 86 years. The male to female ratio was 29.3:1. Mortality was three (3.3%) cases and the morbidity was 20 (21.7%) cases. The mean duration of hospital stay was 11.8 days. Inadequate intravenous fluid therapy had a statistically significant adverse effect on outcome in this study. The yearly outcome remained unchanged during the six years of the study. CONCLUSIONS: Emergency resection in cases with a viable colon had a similar outcome to the traditional standard treatment by emergency endoscopic derotation followed by semi-elective or elective resection. The overall outcome was comparable to global standards. Inadequate postoperative intravenous fluid therapy significantly affected the outcome.

Patient transfer practices by hospitals in Western Kenya.

BACKGROUND: Patients who are critically ill and those requiring emergency care are transported within and between hospitals on a regular basis seeking diagnostic or therapeutic services not available at the bed side or within the referring institution. The emergency of specialty systems often determines the ultimate destination of patients rather than proximity of facility and this has heightened the need for patient transfer. To achieve a favorable outcome, it is necessary to ensure that any transfer is carried out safely and effectively with minimum disruption of the continuum of care. OBJECTIVES: To determine the gap between existing knowledge of patient transfer principles and the practice by hospitals in Western Kenya referring patients to Moi Teaching and Referral Hospital (MTRH). DESIGN: Cross-sectional descriptive study. SETTING: Accident and emergency department at MTRH. SUBJECTS: Patients transferred in over a period of six months for critical/emergency care. RESULTS: Evaluation was done for 97 transfers during the six months period. Age ranged from four days old to 70 years with a median of 28 years. A wide spectrum of diseases were seen. However in order of frequency the leading five were; trauma and accidents, vascular disorders, infections; anaemia and malignancies. Of the infections, respiratory infections topped the list with pulmonary tuberculosis as the leading disease entity. Majority of patients 43 (44%) were referred within 24 hours of being seen at the primary hospital. Only 56% were transported by ambulance; appropriate escort(nurse) was provided in 60%; documentation was provided in 85%; monitoring enroute was done in 24%; warmth was provided in 62%, 27% were dehydrated requiring resuscitation; respiratory support was inadequate as only 14% (of those who required) had airway and 32% had oxygen provided; intravenous fluids were provided in 34% of those who required; nasogastric intubation was provided in 30% of those who required; urethral catheterisation was provided in 23% of those who required; 50% of those with long bone fractures were splinted and only 3% of those who required cervical spine stabilisation had cervical collar. CONCLUSION: There was significant failure by hospitals in Western Kenya in the application of principles of patient transfer while referring patients to MTRH.

Gastrointestinal tract perforation in neonates.

Gastrointestinal tract perforation in neonates is a serious problem associated with high morbidity and mortality. Co-morbid factors, particularly prematurity and low birth weight, impact negatively on the outcome. This article highlights issues related to diagnosis and treatment with a view to improving the poor prognosis found in this condition.

Adhesive intestinal obstruction.

BACKGROUND: Adhesions after abdominal and pelvic surgery are a major cause of intestinal obstruction in the western world and the pathology is steadily gaining prominence in our practice. OBJECTIVE: To determine the magnitude of adhesive intestinal obstruction; to determine the types of previous operations in patients who presented with adhesive intestinal obstruction; to determine the outcome of treatment; and to determine the factors affecting the overall management of adhesion-related intestinal obstruction. DESIGN: Retrospective descriptive study. SETTING: The Moi Teaching and Referral Hospital (MTRH) - Eldoret, Kenya. RESULTS: Ninety three patients were managed for adhesive intestinal obstruction. Of these, 57 were male and 36 were female. Abdominal distension, bilious vomiting, absolute constipation and abdominal pain were the main symptoms. Forty two (45%) patients were operated on, twenty five (59%) of them being operated on more than 72 hours after the start of the symptoms. Eight (9%) patients had ischaemic gut injury by the time of operation. Fluid therapy was inadequately administered in 86 (92%) patients, and their charts were not completely filled. CONCLUSION: Adhesion-related intestinal obstruction is a common problem encountered in the surgical service at the Moi Teaching and Referral Hospital-Eldoret. It is the major cause of intestinal obstruction. Fluid therapy and delayed surgical intervention were the major challenges in the management of these patients.

Gastroschisis: immediate reduction by bianchi procedure at Moi Teaching and Referral Hospital, Eldoret: case report.

This is a report of the only case of gastroschisis that has survived at the Moi Teaching and Referral Hospital in the past five years. Others, who have been referred to this hospital arriving occasionally without the necessary care for this problem in place, have not even managed to survive through the period of resuscitation. The objective of this report is to show that these children can survive. Immediate post-natal care for protruded abdominal organs, fluid resuscitation and adherence to the principles of neonatal transport are essential.

Surgical management of peptic ulcer disease.

OBJECTIVE: To determine the pattern of surgically managed peptic ulcer disease. DESIGN: A retrospective study. SETTING: Department of Surgery, Moi Teaching and Referral Hospital, Eldoret, Kenya. SUBJECTS: Fifty three patients operated on for peptic ulcer disease. RESULTS: The mean age was 47 years with a male/female ratio of 1.7:1. Duodenal ulcer associated complications were the commonest with duodenal ulcer/gastric ulcer ratio of 11.5:1. Most patients had chronic peptic ulcer symptoms with inadequate or no medical treatment. Perforations were the commonest complications (56.6%) followed by gastric outlet obstruction (34.0%). Closure with omental patch was done in 83.3% of perforations while truncal vagotomy and drainage was done in gastric outlet obstruction. Hypostatic pneumonia was the commonest post-operative complication. Seventy one point seven per cent of the patients were free of dyspeptic symptoms during the brief follow-up period. CONCLUSION: Most patients with chronic peptic ulcers had had inadequate treatment and perforation was the most common complication. Repair of perforations with omental patch, and truncal vagotomy and drainage procedure for gastric outlet obstruction, were satisfactory surgical methods offered to patients at the Moi Teaching and Referral Hospital.

Testicular torsion: case report.

This is a report of bilateral testicular torsion. The objective of the report is to highlight the serious implications of misdiagnosis of testicular torsion. Other than loss of the testis due to necrosis in unilateral torsion, immunological damage of the opposite testis occurs. Early, accurate diagnosis, and institution of the appropriate treatment are desirable to prevent total loss of reproductive potential in the affected male.

Childhood intussusception at the Moi teaching and Referral Hospital Eldoret: management challenges in a rural setting.

OBJECTIVE: To review the management of childhood intussusception at the Moi Teaching and Referral Hospital, Eldoret and identify factors that require attention for improved outcome. DESIGN: A retrospective descriptive study covering the period January 2000 to December 2003. SETTING: Moi Teaching and Referral Hospital, Eldoret. PATIENTS: Thirty six children. RESULTS: Of the 36 children, 28 (78%) were males and eight (22%) females giving a ratio of 3.5:1. Median age was six months with a range of 2-72 months. The duration of symptoms was a mean of 5 days with a range of 1-14 days. Sixty one percent were referrals. Initial diagnosis of intussusception based on signs and symptoms was made in 6 out of 36 (17%) patients. The rest were initially treated for other problems. Decision to refer to surgeons, was based on abdominal distension. Plain x-ray was done in four patients and barium enema in one patient. Seventy five percent of the patients required fluid resuscitation before operation. All patients (100%) were managed operatively. Seventy two percent had ileo-colic intussusception, 8% ile-oileal and 22% colo-colic. Perforation was found in 22% and gangrene in 31%. Sixty seven percent were successfully reduced by "milking" while 33% required resection and anastomosis/or stoma creation. Complications included: anastomatic breakdown, bronchopneumonial renal failure, sepsis, recurrent intussusception and death. Mortality was 14% overall. CONCLUSION: Early diagnosis and presentation coupled with improved peri-operative management are essential in improving outcome.

Neonatal gastric perforation.

BACKGROUND: Gastric perforation in neonates is a catastrophe associated with high morbidity. Most are due to underlying primary pathology. OBJECTIVES: To review the management of gastric perforation in neonates in Kwa Zulu-Natal, South Africa. DESIGN: Retrospective study of consecutive complete data sets of neonates presenting with gastric perforation. SETTING: Department of Paediatric Surgery, Nelson R. Mandela School of Medicine, University of Natal, Durban, South Africa. SUBJECTS: Eight neonates treated for gastric perforation between January 1998 and April 2003. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: There was an equal number of males and females. Median birth weight was 2.0 kg with a range of 1.4 to 3.2 kg. Five of the eight neonates were premature. Primary pathologies were associated with perforation in seven of the eight neonates. Prematurity, low birth weight and pneumonia were contributing factors to the poor outcome. Sepsis was a complication in seven of the eight neonates leading to their death (88% mortality). CONCLUSION: Active perinatal management, early treatment of primary pathologies, and protection of the stomach against distension in neonates at risk are essential in the management of neonatal gastric perforation.

Gastro-intestinal tract perforation in neonates.

BACKGROUND: Gastro-intestinal tract (GIT) perforation in neonates is a serious problem associated with high mortality due to resulting sepsis. Co-morbid factors, eg. prematurity, respiratory problems, low birth weight, and nutritional factors, negatively affect the outcome. OBJECTIVES: To review the management outcome of gastro-intestinal tract perforation in neonates in KwaZulu-Natal and identify factors that require attention for better survival of neonates with GIT perforation. DESIGN: Retrospective study of consecutive complete data sets of patients presenting with a diagnosis of GIT perforation. SETTING: Department of Paediatric Surgery, Nelson R. Mandela School of Medicine, University of Natal, Durban, South Africa. SUBJECTS: Fifty four neonates treated for gastro-intestinal tract perforation between January 1998 and January 2003. MAIN OUTCOME MEASURES: Morbidity as determined by complications and mortality. RESULTS: More males (69%) were affected than females (31%). The median birth weight was 2.3 kg and median age at presentation was four days. Eighty nine percent were referred from peripheral hospitals. Abdominal distension was the leading symptom and sign (74%). Co-morbid factors were present in 89%, with prematurity as the leading factor (52%). Necrotising enterocolitis (NEC) was the main cause of perforation (33%) and the terminal ileum was the most common site. Most (56%) were treated by excision and primary repair of perforations. Sepsis was the leading complication (44%) and major cause of death (72%). Mortality was highest (56%) in perforations due to other primary pathology followed by NEC (53%). Overall mortality was 46%. CONCLUSION: It is essential to prevent secondary perforations by early recognition and management of primary pathology. Management of pneumoperitoneum in neonates with respiratory difficulties should be included in resuscitation before transfer. Rectal temperature monitoring and herbal enemas should be strongly discouraged.

Hydatid disease of the spine: case report.

A rare case of spinal hydatid disease presenting with paraparesis and sensory loss is reported. The patient was treated with albendazole resulting in significant improvement within eight weeks. Investigations and treatment modalities are discussed.