Nutritional status and outcome of surgery: A prospective observational cohort study of children at a tertiary surgical hospital in Harare, Zimbabwe.

BACKGROUND: Undernutrition contributes to nearly 50% of all child deaths in the world, yet there is conflicting evidence regarding the association between nutritional status and postoperative complications. The aim was to describe the preoperative nutritional status among pediatric surgery patients in Zimbabwe, and to assess if nutritional status was a risk factor for adverse postoperative outcome of mortality, surgical site infection, reoperation, readmission, and longer length of stay. METHODS: This prospective observational cohort study included 136 children undergoing surgery at a tertiary pediatric hospital in Zimbabwe. Nutritional status was standardized using Z-scores for BMI, length, weight, and middle upper arm circumference. Primary outcomes after 30 days included mortality, surgical site infection, reoperation, and readmission. Secondary outcome was length of stay. Univariate and multivariable analyses with logistic regression were performed. RESULTS: Of the 136 patients, 31% were undernourished. Postoperative adverse outcome occurred in 20%; the mortality rate was 6%, the surgical site infection rate was 17%, the reoperation rate was 3.5%, and readmission rate was 2.5%. Nutritional status, higher ASA classification, major surgical procedures, and lower preoperative hemoglobin levels were associated with adverse outcome. Univariate logistic regression identified a seven-fold increased risk of postoperative complications among undernourished children (OR 7.3 [2.3-22.8], p = 0.001), and there was a four- to six-fold increased adjusted risk after adjustment for ASA, major surgery, and preoperative hemoglobin. CONCLUSION: A third of all pediatric surgery patients were undernourished, and undernourished children had a considerably higher risk of adverse outcome. With a positive correlation identified between undernourishment and increased postoperative complications, future aims would include assessing if preoperative nutritional treatment could be especially beneficial for undernourished children. LEVELS OF EVIDENCE: Level II treatment study.

Exploring the Impact of COVID-19 on Progress Towards Achieving Global Surgery Goals.

INTRODUCTION: In the 5 months since it began, the COVID-19 pandemic has placed extraordinary demands on health systems around the world including surgery. Competing health objectives and resource redeployment threaten to retard the scale-up of surgical services in low- and middle-income countries where access to safe, affordable and timely care is low. The key aspiration of the Lancet Commission on global surgery was promotion of resilience in surgical systems. The current pandemic provides an opportunity to stress-test those systems and identify fault-lines that may not be easily apparent outside of times of crisis. METHODS: We endeavoured to explore vulnerable points in surgical systems learning from the experience of past outbreaks, using examples from the current pandemic, and make recommendations for future health emergencies. The 6-component framework for surgical systems planning was used to categorise the effects of COVID-19 on surgical systems, with a particular focus on low- and middle-income countries. Key vulnerabilities were identified and recommendations were made for the current pandemic and for the future. RESULTS: Multiple stress points were identified throughout all of the 6 components of surgical systems. The impact is expected to be highest in the workforce, service delivery and infrastructure domains. Innovative new technologies should be employed to allow consistent, high-quality surgical care to continue even in times of crisis. CONCLUSIONS: If robust progress towards global surgery goals for 2030 is to continue, the stress points identified should be reinforced. An ongoing process of reappraisal and fortification will keep surgical systems in low- and middle-income countries responsive to "old threats and new challenges". Multiple opportunities exist to help realise the dream of surgical systems resilient to external shocks.

Maffucci's syndrome in association with giant tubular adenoma of the breast: Case report and literature review.

INTRODUCTION: Maffucci's syndrome is a rare congenital, non-hereditary mesodermal dysplasia characterised by multiple enchondromas and vascular lesions. To our knowledge this is the first report of tubular adenoma of the breast in association with Maffucci's syndrome. PRESENTATION OF CASE: We report a 31-year-old female who presented with a large, ulcerated slow-growing painless breast mass. She had also sustained two pathological fractures during childhood as well as progressive deformity and limb shortening on the right side of the body. Skeletal survey revealed enchondromas exclusively on the right side in association with phleboliths. Excision of the breast mass was performed. Histological examination of the breast lesion revealed a diagnosis of tubular adenoma, core biopsy of the bony lesions confirmed enchondromas and a cutaneous haemangioma was excised from the abdominal wall. DISCUSSION: Tubular adenoma of the breast is a rare benign tumour. When large they may cause ulceration leading to diagnostic and management dilemmas. Patients with Maffucci's Syndrome require lifelong surveillance for the development of malignancy. CONCLUSION: Tubular adenomas of the breast carry no risk of malignancy. However, malignancy remains high on the differential list when the skin is ulcerated. Ulceration can also be caused by pressure necrosis in benign tumours. This diagnostic dilemma can lead to unnecessarily radical surgery.

A Case Report of a Bite From the Nile Crocodile (Crocodylus niloticus) Managed with Regional Anesthesia.

Crocodile attack injuries plague communities near bodies of water and continue to be an infrequent but significant form of trauma encountered in our medical facility. Regional anesthesia techniques are a novel adjunct to treatment and may facilitate simplified definitive management and better utilization of constrained operating room resources. We report a case of an adult male who presented with a large lower extremity wound after a crocodile bite. The patient was managed with initial debridement and irrigation and serial wound care entirely under regional anesthesia at the bedside. The patient did not develop wound infection, eventually receiving a skin graft with good functional outcomes. Regional anesthesia techniques are increasingly being used in the trauma setting, and their versatility allows for their use in multiple settings, by practitioners with limited experience and in resource-limited environments. No specific guidelines exist for performance of neuraxial techniques in the setting of animal bite injuries, but concerns about infectious complications have been raised. Regional anesthesia techniques may be useful in the management of extremity trauma due to crocodile attacks without infectious complications. They may reduce utilization of theatre resources and reduce opioid requirements.

Volvulus of the ascending colon due to failure of zygosis: A case report and review of the literature.

INTRODUCTION: Volvulus of the mobile ascending colon is a serious complication of a subtle embryological abnormality that frequently goes unrecognised. There has been renewed interest in the development of the mesentery because of its relevance to the contemporary management of surgical diseases. This case is presented to illustrate the dire consequences of missing this diagnosis and to review the fascinating embryology of the condition as well as its clinical implications. PRESENTATION OF CASE: We report on a 23-year-old male who presented with signs and symptoms of distal small bowel obstruction after a long prior history of intermittent right lower quadrant pain. At laparotomy, a 360-degree counter-clockwise volvulus of the entire right colon was noted as the result of an excessively long ascending mesocolon and unattached hepatic flexure. All gangrenous bowel was resected with primary ileocolic anastomosis performed thereafter. The patient did well post-operatively and was subsequently discharged. DISCUSSION: Interruption of the in-utero events of fixation known as peritoneal zygosis lead to a persistence of the mesocolon in parts of the bowel that ordinarily are retroperitoneal. The events that lead to this anomaly are poorly understood and have been subject to controversy for centuries. New insights have challenged surgical dogma and informed new surgical techniques. Its true incidence is probably underestimated because of its indolent clinical prodrome, and it requires a high index of suspicion. CONCLUSION: Failure of peritoneal zygosis is implicated in a myriad of clinical conditions. Expeditious recognition and intervention in the prodromal period can avert potentially disastrous complications.

Combined pancreatic and duodenal transection injury: A case report.

INTRODUCTION: Combined pancreatic-duodenal injuries in blunt abdominal trauma are rare. These injuries are associated with high morbidity and mortality, and their emergent management is a challenge. CASE PRESENTATION: We report a case of combined complete pancreatic (through the neck) and duodenal (first part) transections in a 24-year-old male secondary to blunt abdominal trauma following a motor vehicle crash. The duodenal stumps were closed separately and a gastrojejunostomy performed for intestinal continuity. The transacted head of pancreas main duct was suture ligated and parenchyma was over sewn and buttressed with omentum. The edge of the body and tail pancreatic segment was freshened and an end to side pancreatico-jejunostomy was fashioned. A drain was left in situ. Post operatively the patient developed a pancreatic fistula which resolved with conservative management. After ten months of follow up the patient was well and showed no signs and symptoms of pancreatic insufficiency. DISCUSSION: Lengthy, complex procedures in pancreatic injuries have been associated with poor outcomes. Distal pancreatectomy or Whipple's procedure for trauma are viable options for complete pancreatic transections. But when there is concern that the residual proximal pancreatic tissue is inadequate to provide endocrine or exocrine function, preservation of the pancreatic tissue distal to the injury becomes an option. CONCLUSION: Combined pancreatic and duodenal injuries are rare and often fatal. Early identification, resuscitation and surgical intervention is warranted. Because of the large number of possible combinations of injuries to the pancreas and duodenum, no one form of therapy is appropriate for all patients.

Clostridium difficile infection in low- and middle-human development index countries: a systematic review.

OBJECTIVE: To describe the impact and epidemiology of Clostridium difficile infection (CDI) in low- and middle-human development index (LMHDI) countries. METHOD: Prospectively registered, systematic literature review of existing literature in the PubMed, Ovid and Web of Science databases describing the epidemiology and management of C. difficile in LMHDI countries. Risk factors were compared between studies when available. RESULTS: Of the 218 abstracts identified after applying search criteria, 25 studies were reviewed in detail. The weighted pooled infection rate among symptomatic non-immunosuppressed inpatients was 15.8% (95% CI 12.1-19.5%) and was 10.1% (95% CI 3.0-17.2%) among symptomatic outpatients. Subgroup analysis of immunosuppressed patient populations revealed pooled infection rates similar to non-immunosuppressed patient populations. Risk factor analysis was infrequently performed. CONCLUSIONS: While the percentages of patients with CDI in LMHDI countries among the reviewed studies are lower than expected, there remains a paucity of epidemiologic data evaluating burden of C. difficile infection in these settings.

Peritoneal encapsulation syndrome: A case report and literature review.

INTRODUCTION: Peritoneal encapsulation is an infrequently described congenital anomaly that results in formation of an accessory peritoneal membrane. The case presented below is unique in that it illustrates one of the rare complications of this condition. It is important for clinicians to be aware of this condition and its complications in order to limit potential morbidity and mortality. PRESENTATION OF CASE: We report on an eleven-year-old boy without prior abdominal symptoms who presented with an acute abdomen after an episode of intense physical exertion. At laparotomy, gangrenous small bowel loops were identified extruding from an opening in a peritoneal sac consistent with peritoneal encapsulation syndrome. All gangrenous bowel (mostly ileum) was resected. The sac was excised and a primary jejunum to ascending colon anastomosis was created. The patient did well post operatively and was subsequently discharged. DISCUSSION: Peritoneal encapsulation is an aberration of peritoneal development that is frequently confused with other visceral encapsulation syndromes of inflammatory origin. Due to its mostly asymptomatic course, its true incidence remains unknown. An appreciation of the condition and its potential complications allows surgeons to take appropriate action in the event of incidental discovery at laparoscopy or laparotomy. CONCLUSION: Peritoneal encapsulation is a rare, mostly asymptomatic, surgical finding which may predispose patients to an acute abdominal crisis.