Medieval (arrow) weapon injuries in contemporary surgical practice: Impaled posterior thoracic wall arrowhead leading to haemo-thorax: Management protocols. Case report.

INTRODUCTION AND IMPORTANCE: Arrow injuries are rare in modern surgical practice. However, there are still case reports in tribal and guerrilla conflicts in rural settings were arrows are still used as weapons. Since the discovery of gun powder, guns and explosives have been the preferred effective assault weapons. Most surgeons in metropolitan trauma centers face scarce arrow injuries cases, mostly due to accidents or suicide attempts using the crossbow mechanism. CASE PRESENTATION: We present a case of an 18-year-old boy who sustained penetrating posterior thoracic wall arrow injury leading to haemothorax and review of the management protocols. CLINICAL DISCUSSION: Arrow injuries to the chest can span the entire spectrum of organs in the chest cavity ranging from superficial muscle to vital organs and vessels injury. Immediate death can result from injury to vital organs or vessels with late fatalities due to infection or toxins from dipped arrow heads with "poisons". Pre-operative radiological investigations such as CT scanning with angiography have proved its predictive value of intra-thoracic injuries when compared to post-operative diagnoses. CONCLUSION: Management protocols range from open thoracotomy of unstable patients to simple retrieval under thoracoscopy guide. Several management protocols set date back as early as the 16th Century still hold water to date.

Management of a road traffic accident poly-trauma patient in a limited regional resource hospital setting in Tanzania: Review of literature and case report.

INTRODUCTION AND IMPORTANCE: Poly-trauma is among the top ten leading causes of mortality and morbidity in developing countries. Road traffic injuries are the major cause of mortality in the overall burden of deaths related to injuries. The aim of this publication is to show how important are the principles of management in saving life even in austere limited resource settings. CASE PRESENTATION: We herein present a case of a 17-year-old male who presented to our emergency department about an hour after being involved in motor traffic accident in a semiconscious state, in hypovolemic shock and sustained multiple injuries. He had multiple limb and ribs fractures and blunt abdominal injury. He was rushed to the hospital where he was resuscitated at the emergency department and admitted in the Intensive Care Unit (ICU). He was scheduled for surgery the following day. His post-operative recovery was uneventful and was discharged after one month. CLINICAL DISCUSSION: The scarce resources and efforts spent on these patients prove to be futile in many situations because of delayed admission, lack of proper pre-hospital care and associated complications which cause irreversible damage. Management of a Poly-trauma patient should start from the scene of accident, during transportation and finally in the hospital by following all the principles of poly-trauma management using a multi-disciplinary approach. CONCLUSION: Timely diagnosis and proper management of a Poly-trauma patient can save life even in limited resource Centers.

Potential Spectrum of Accompanied Penetrating Abdominal Intraperitoneal Injuries with Bowel Evisceration: Surprises Awaiting the Trauma Surgeon in Resource Limited Settings.

Penetrating abdominal injuries involves violation of the peritoneal cavity and injuries to solid organs and other intraperitoneal viscera such as major blood vessels and hollow organs. Typically such injuries arise from gunshot wounds or stab wounds. With increase in crime rates and motor traffic accidents in urban areas, the trauma surgeon in civilian urban centers faces spectrum of injuries similar to his colleague in war torn areas. Potential spectrum of penetrating abdominal injuries is wide and accurate diagnosis in resource limited centers is challenging. Majority of injuries are concealed and diagnosed intraoperatively and dealt with relatively junior trauma surgeons in emergency settings in remote limited settings. Computed tomography (CT) scans and Magnetic Resonance Imaging (MRI) facilities are scarce in resource limited settings. Haemodynamic states of penetrating abdominal injuries patients presenting in emergency departments necessitate urgent surgical exploration and management with minimal room for full radiological work-up. Evisceration of bowels with unstable haemodynamic states mandate laparotomy due to wide spectrum of accompanied intraperitoneal injuries. Four cases of penetrating abdominal injuries are presented with modes of assault ranging from gunshot injuries to stab wounds with broken bottles to highlight the intra-abdominal spectrum of injuries, challenges in diagnosis and emergency managements done in a resource limited setting.

Standard Urine Collection Bag as an Improvised Bogotá Bag as a Temporary Abdominal Closure Method in an Open Abdomen in Preventing Abdominal Compartment Syndrome.

Primary abdominal wall closure post laparotomy is not always possible. Certain surgical pathologies such as degloving anterior abdominal wall trauma injuries and peritoneal visceral volume and cavity disproportion render it nearly impossible for the attending surgeon to close the abdomen in the first initial laparotomy. In such surgical clinical scenarios leaving the abdomen open might be lifesaving. Forceful closure might lead to abdominal compartment syndrome and impair respiratory status of the patient. Open abdomen closure techniques have evolved over time from protection of abdominal viscera to complex fascia retraction prevention techniques. Silo bags, i.e., (Bogotá Bags), are relatively cheap, available materials used as a temporary abdominal closure method in limited resources settings. Despite its limitations of not preventing fascia retraction and draining of peritoneal fluid, it protects the abdominal viscera. We report a case of a 29-year-old male who developed incisional anterior abdominal wall wound dehiscence. He was scheduled for emergency explorative laparotomy. Intraoperatively, multiple attempts to reduce grossly dilated edematous bowels into the peritoneal cavity and fascia approximation into the midline were not possible. A urinary collection bag was sutured on the skin edges as a temporary abdominal closure method in prevention of abdominal compartment syndrome. He fared well postoperatively and eventually underwent abdominal incisional wound closure. In emergency abdominal surgeries done in limited surgical material resource settings were primary abdominal closure is not possible at initial laparotomy, sterile urine collection bags as alternatives to the standard Bogota bags as temporary abdominal closure materials can be safely used. These are relatively easily available and can be safely used until definite surgical intervention is achieved with relatively fewer complications.

Clinical profiles of diabetic foot ulcer patients undergoing major limb amputation at a tertiary care center in North-eastern Tanzania.

BACKGROUND: Diabetic foot ulcers complications are the major cause of non-traumatic major limb amputation. We aimed at assessing the clinical profiles of diabetic foot ulcer patients undergoing major limb amputation in the Surgical Department at Kilimanjaro Christian Medical Centre (KCMC), a tertiary care hospital in North-eastern Tanzania. METHODS: A cross-sectional hospital-based study was conducted from September 2018 through March 2019. Demographic data were obtained from structured questionnaires. Diabetic foot ulcers were graded according to the Meggitt-Wagner classification system. Hemoglobin and random blood glucose levels data were retrieved from patients' files. RESULTS: A total of 60 patients were recruited in the study. More than half (31/60; 51.67%) were amputated. Thirty-five (58.33%) were males. Fifty-nine (98.33%) had type II diabetes. Nearly two-thirds (34/60; 56.67%) had duration of diabetes for more than 5 years. The mean age was 60.06 ± 11.33 years (range 30-87). The mean haemoglobin level was 10.20 ± 2.73 g/dl and 9.84 ± 2.69 g/dl among amputees. Nearly two thirds (42/60; 70.00%) had a haemoglobin level below 12 g/dl, with more than a half (23/42; 54.76%) undergoing major limb amputation. Two thirds (23/31; 74.19%) of all patients who underwent major limb amputation had mean hemoglobin level below 12 g/dl. The mean Random Blood Glucose (MRBG) was 13.18 ± 6.17 mmol/L and 14.16 ± 6.10 mmol/L for amputees. Almost two thirds of the study population i.e., 42/60(70.00%) had poor glycemic control with random blood glucose level above 10.0 mmol/L. More than half 23/42 (54.76%) of the patients with poor glycemic control underwent some form of major limb amputation; which is nearly two thirds (23/31; 74.19%) of the total amputees. Twenty-eight (46.67%) had Meggitt-Wagner classification grade 3, of which nearly two thirds (17:60.71%) underwent major limb amputation. CONCLUSION: In this study, the cohort of patients suffering from diabetic foot ulcers treated in a tertiary care center in north-eastern Tanzania, the likelihood of amputation significantly correlated with the initial grade of the Meggit-Wagner ulcer classification. High blood glucose levels and anaemia seem to be also important risk factors but correlation did not reveal statistical significance.

Surgical Approach in Management of Posttraumatic Diaphragmatic Hernia: Thoracotomy versus Laparotomy.

Breach in diaphragmatic musculature permits abdominal viscera to herniate into the thoracic cavity. Time of presentation and associated injuries determines the surgical approach in management. This case report sets to highlight the challenges in clinical diagnosis, radiological interpretation, and surgical management approaches of posttraumatic diaphragmatic hernia. We report a case of a 43 years old male who was diagnosed with traumatic diaphragmatic hernia 6 months post blunt thoracoabdominal trauma due to motor traffic accident. He was initially diagnosed with haemothorax, drained with an underwater thoracostomy tube, and discharged. He continued to experience on and off chest pain worsening postfeeding, difficulty in breathing and abdominal pain for the next six months until his eventual diaphragmatic hernia diagnosis. He was scheduled for an elective thoracotomy. A left posterolateral thoracic over the 7th intercostal space incision was used. Intraoperatively, the stomach, left lobe of liver, part of transverse colon, small bowel, and omentum had herniated into the thoracic cavity adhering into thoracic viscera and wall. Adhesiolysis was done, and abdominal organs reduced into abdominal cavity. Rent was closed by interrupted Prolene sutures reinforced with a mesh. In patients with delayed presentation of diaphragmatic hernia post blunt thoracoabdominal injury without associated intra-abdominal visceral injury, we recommend the thoracic diaphragmatic repair approach as long-standing herniated bowels might adhere with thoracic cavity walls or viscera. In such cases, adhesiolysis and rent repair is easier through thoracotomy.