Surgical aspects and outcomes after nephrectomy for Wilms tumour in sub-Saharan Africa: A report from Wilms Africa Phase II-CANCaRe Africa.

BACKGROUND: Wilms tumour (WT) is one of the common and curable cancer types targeted by the Global Initiative for Childhood Cancer. Tumour excision is essential for cure. This analysis focuses on surgical outcomes of patients with WT in sub-Saharan Africa. METHODS: We implemented a risk-stratified WT treatment guideline as a multicentre, prospective study across eight hospitals and six countries. Eligibility criteria were age 6 months to 16 years, unilateral WT, surgery performed after preoperative chemotherapy and diagnosed between 1 January 2021 and 31 December 2022. Data collection included a specific surgical case report form (CRF). RESULTS: The study registered 230 patients, among whom 164 (71.3%) had a nephrectomy. Ninety-eight percent of patients had a completed surgical CRF. Out 164 patients, 50 (30.5%) had distant metastases. Median tumour diameter at surgery was 11.0 cm. Lymph node sampling was done in 122 (74.3%) patients, 34 (20.7%) had intraoperative tumour rupture, and for 18 (10.9%), tumour resection involved en bloc resection of another organ. Tumour size at surgery was significantly correlated with tumour rupture (p < .01). With a median follow-up of 17 months (range: 2-33), 23 (14.0%) patients have relapsed. Twenty-two (13.4%) patients abandoned treatment post nephrectomy. Two-year event-free survival was 60.4% ± 4.7% with treatment abandonment as an event. CONCLUSION: Survival post nephrectomy is challenged by treatment abandonment, treatment-related mortality and relapse. Large tumours after preoperative chemotherapy were associated with a higher risk of tumour rupture. Earlier diagnosis and access to radiotherapy are expected to improve survival.

Spontaneous rectosigmoid perforation at the watershed area of the Sudeck point in an apparently healthy toddler boy: a case report.

BACKGROUND: Spontaneous colon perforation can be classified into stercoral and idiopathic. Stercoral type is associated with chronic constipation, thus it is rare in infants and children. The idiopathic type is sporadic and could occur at any age. Delay in diagnosing or treating idiopathic colon perforation is associated with high mortality and morbidity rates. There are few studies on rectal perforation related to other etiologies or past the neonatal period, and their effect on disease onset and prognosis are unknown. CASE PRESENTATION: We report on a case of 2-year-and-5-month-old Oromo boy who presented with fever, diarrhea, vomiting, and progressive abdominal pain of 5-day duration. The boy underwent an exploratory laparotomy for suspected peritonitis and there was a single perforation of approximately 2.0 cm size in the anterior part of the upper one-third of rectum. The perforated rectum was repaired primarily and sigmoid divided diversion colostomy was carried out. CONCLUSION: It is important to be aware of idiopathic colon perforation in children, a rare but dangerous condition with high mortality and morbidity in cases of delayed diagnosis or management. Pediatricians and surgeons should consider colon perforation as a cause in children who present with abdominal distention and a history of diarrhea for more than 5 days.

Omental Cyst Presenting as an Acute Abdomen in a Pediatric Patient: A Case Report.

BACKGROUND: Omental cysts are the rarest forms of intra-abdominal cystic lesions. They are usually asymptomatic but can also present as acute abdomen. The presentation is confusing in some cases, which may result in mismanagement, added costs, and trouble for the patient. A pre-operative diagnosis is challenging, especially in resource-limited settings, and requires a high level of suspicion and a cautious approach during emergency exploratory laparotomy to avoid complications. CASE DETAILS: This is a 4 year old male child who presented with high grade fever, vomiting, and abdominal pain of 2 days duration. He was tachypneic, tachycardic, and had diffuse abdominal tenderness. Emergency laparotomy revealed a large cyst with hemorrhagic content. Complete removal of the cyst was done, and the patient was discharged after improvement on the third post-operative day. CONCLUSION: Omental cysts are rare in children and have varieties of presentations. Even though preoperative diagnosis is challenging, esspecially in resource-limited settings, clinicians should consider omental cysts in a child presenting with an acute abdomen. It is important for surgeons to consider omental cysts when carrying out emergency laparotomy for an unidentified abdominal condition.

Swallowed Metallic Spoon Causing Doudeno-Jejunal Junction Perforation in a 13-Year-Old Child: Case Report.

BACKGROUND: A child swallowing a long metallic spoon is an extremely rare phenomenon. Foreign bodies longer than 6 cm are unlikely to pass through the gastrointestinal tract spontaneously and require endoscopic or surgical removal in order to avoid associated complications, such as visceral perforations. CASE DETAILS: A 13-year-old child presented with accidental swallowing of a metallic spoon 10 days prior to hospital admission. He had history of loss of appetite, epigastric and left upper quadrant abdominal pain and started to have high grade intermittent fever 11 days after swallowing the spoon. A plain abdominal radiograph revealed a metallic spoon in the mid-abdomen. An exploratory laparotomy revealed an 11 cm long metallic spoon impacted at the duodeno-jejunal junction with walled off perforation and erosion of the mesentery of the colon. The metallic spoon was removed and the perforated site was repaired. The surgery was smooth and the patient recovered fully and was discharged seven days post-operation. CONCLUSION: A swallowed long metallic spoon is unlikely to pass spontaneously and should be removed as soon as possible in order to avoid associated complications like impaction, perforation and subsequent peritonitis.

Pattern of trauma admission and outcome among patients presented to Jimma University Specialized Hospital, south-western Ethiopia.

BACKGROUND: Trauma is an ever evolving world problem that needs close attention and devising means to prevent and treat. The aim of the study is to identify the main reason for trauma admissions and assess the patient outcome after intervention. Therefore, knowing its actual nature might aid in postulating possible intervention as well as prevention measures. METHOD: A cross-sectional study was conducted from August to December 2015 in Jimma University Specialized Hospital, which is located in south-western Ethiopia. Two hundred and eleven consecutive trauma admissions to surgery department were included in the study. Data were collected and analyzed using computer software SPSS V.23. RESULT: A total of 211 admitted trauma patients were studied with male to female ratio of 3.14. The leading cause of trauma admission was road traffic collision at 84 (39.8%) and the least being bullet injury which was 6 (2.8%). Hospital mortality was 31 (14.7%). Factors associated with outcome of patients before discharge from hospital were male sex, adjusted OR (AOR)=2.3, 95% CI 1.08 to 4.75; Glasgow Coma Scale score 15/15, AOR=0.04, 95% CI 0.00 to 0.46; and hemoglobin >10 g/L, AOR=0.225, 95% CI 0.074 to 0.464, p<0.05. CONCLUSION: Road traffic collision takes the top position from all causes of trauma and unlike other developed countries and low and middle-income countries, pedestrians and motorcyclists were the major victims of the collision in this study.Level of evidence VI (This level of effectiveness rating scheme is based on the following: Ackley, B. J., Swan, B. A., Ladwig, G., & Tucker, S. (2008). Evidence-based nursing care guidelines: Medical-surgical interventions. (p. 7). St. Louis, MO: Mosby Elsevier.

Aphalia: An Extremely Rare Congenital Genitourinary Malformation-A Case Report.

BACKGROUND: Congenital aphalia is an extremely rare, urogenital malformation of the external genitalia characterized by congenitally absent penis in a karotypically XY child. It occurs 1 in 30 million live births. So far, only less than 100 cases have been reported. CASE DETAILS: A 3-hour old newborn was diagnosed with aphalia after being referred from health center for respiratory distress and congenital malformation of the external genitalia. He had deranged renal function tests, hypoplastic kidneys, small patent foramen ovale and ventricular septal defect. Management of the acute conditions and parental counseling were done, but he passed away on the 8th day of life, due to the underlying diseases. CONCLUSION: A patient with aphalia needs thorough evaluation for possible associated malformations. Management is multistaged and multidisciplinary. Parental counselling should be started as early as possible, and their decision should be respected.

Developing Process Maps as a Tool for a Surgical Infection Prevention Quality Improvement Initiative in Resource-Constrained Settings.

BACKGROUND: Surgical infections cause substantial morbidity and mortality in low-and middle-income countries (LMICs). To improve adherence to critical perioperative infection prevention standards, we developed Clean Cut, a checklist-based quality improvement program to improve compliance with best practices. We hypothesized that process mapping infection prevention activities can help clinicians identify strategies for improving surgical safety. STUDY DESIGN: We introduced Clean Cut at a tertiary hospital in Ethiopia. Infection prevention standards included skin antisepsis, ensuring a sterile field, instrument decontamination/sterilization, prophylactic antibiotic administration, routine swab/gauze counting, and use of a surgical safety checklist. Processes were mapped by a visiting surgical fellow and local operating theater staff to facilitate the development of contextually relevant solutions; processes were reassessed for improvements. RESULTS: Process mapping helped identify barriers to using alcohol-based hand solution due to skin irritation, inconsistent administration of prophylactic antibiotics due to variable delivery outside of the operating theater, inefficiencies in assuring sterility of surgical instruments through lack of confirmatory measures, and occurrences of retained surgical items through inappropriate guidelines, staffing, and training in proper routine gauze counting. Compliance with most processes improved significantly following organizational changes to align tasks with specific process goals. CONCLUSIONS: Enumerating the steps involved in surgical infection prevention using a process mapping technique helped identify opportunities for improving adherence and plotting contextually relevant solutions, resulting in superior compliance with antiseptic standards. Simplifying these process maps into an adaptable tool could be a powerful strategy for improving safe surgery delivery in LMICs.

Development of a Surgical Infection Surveillance Program at a Tertiary Hospital in Ethiopia: Lessons Learned from Two Surveillance Strategies.

BACKGROUND: Surgical site infections (SSIs) are a leading cause of post-operative morbidity and mortality. We developed Clean Cut, a surgical infection prevention program, with two goals: (1) Increase adherence to evidence-based peri-operative infection prevention standards and (2) establish sustainable surgical infection surveillance. Here we describe our infection surveillance strategy. PATIENTS AND METHODS: Clean Cut was piloted and evaluated at a 523 bed tertiary hospital in Ethiopia. Infection prevention standards included: (1) Hand and surgical site decontamination; (2) integrity of gowns, drapes, and gloves; (3) instrument sterility; (4) prophylactic antibiotic administration; (5) surgical gauze tracking; and (6) checklist compliance. Primary outcome measure was SSI, with secondary outcomes including other infection, re-operation, and length of stay. We prospectively observed all post-surgical wounds in obstetrics over a 12 day period and separately recorded post-operative complications using chart review. Simultaneously, we reviewed the written hospital charts after patient discharge for all patients whose peri-operative adherence to infection prevention standards was captured. RESULTS: Fifty obstetric patients were followed prospectively with recorded rates of SSI 14%, re-operation 6%, and death 2%. Compared with direct observation, chart review alone had a high loss to follow-up (28%) and decreased capture of infectious complications (SSI [n = 2], endometritis [n = 3], re-operations [n = 2], death [n = 1]); further, documentation inconsistencies failed to capture two complications (SSI [n = 1], mastitis [n = 1]). Concurrently, 137 patients were observed for peri-operative infection prevention standard adherence. Of these, we were able to successfully review 95 (69%) patient charts with recorded rates of SSI 5%, re-operation 1%, and death 1%. CONCLUSION: Patient loss to follow-up and poor documentation of infections underestimated overall infectious complications. Direct, prospective follow-up is possible but requires increased time, clinical skill, and training. For accurate surgical infection surveillance, direct follow-up of patients during hospitalization is essential, because chart review does not accurately reflect post-operative complications.