Treatment outcomes of esophageal cancer in Eastern Africa: protocol of a multi-center, prospective, observational, open cohort study.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) is a major cause of cancer morbidity and mortality in Eastern Africa. The majority of patients with ESCC in Eastern Africa present with advanced disease at the time of diagnosis. Several palliative interventions for ESCC are currently in use within the region, including chemotherapy, radiation therapy with and without chemotherapy, and esophageal stenting with self-expandable metallic stents; however, the comparative effectiveness of these interventions in a low resource setting has yet to be examined. METHODS: This prospective, observational, multi-center, open cohort study aims to describe the therapeutic landscape of ESCC in Eastern Africa and investigate the outcomes of different treatment strategies within the region. The 4.5-year study will recruit at a total of six sites in Kenya, Malawi and Tanzania (Ocean Road Cancer Institute and Muhimbili National Hospital in Dar es Salaam, Tanzania; Kilimanjaro Christian Medical Center in Moshi, Tanzania; Tenwek Hospital in Bomet, Kenya; Moi Teaching and Referral Hospital in Eldoret, Kenya; and Kamuzu Central Hospital in Lilongwe, Malawi). Treatment outcomes that will be evaluated include overall survival, quality of life (QOL) and safety. All patients (≥18 years old) who present to participating sites with a histopathologically-confirmed or presumptive clinical diagnosis of ESCC based on endoscopy or barium swallow will be recruited to participate. Key clinical and treatment-related data including standardized QOL metrics will be collected at study enrollment, 1 month following treatment, 3 months following treatment, and thereafter at 3-month intervals until death. Vital status and QOL data will be collected through mobile phone outreach. DISCUSSION: This study will be the first study to prospectively compare ESCC treatment strategies in Eastern Africa, and the first to investigate QOL benefits associated with different treatments in sub-Saharan Africa. Findings from this study will help define optimal management strategies for ESCC in Eastern Africa and other resource-limited settings and will serve as a benchmark for future research. TRIAL REGISTRATION: This study was retrospectively registered with the ClinicalTrials.gov database on December 15, 2021,  NCT05177393 .

Operative Self-Confidence, Hesitation, and Ability Assessment of Surgical Trainees in Rural Kenya.

BACKGROUND: The education of surgical trainees is ideally designed to produce surgeons with both confidence and competence. This involves the development of autonomy in the operating room. Factors associated with autonomy and entrustment have been studied in high-resource settings. In a resource-limited context, where autonomy is solely at the discretion of faculty, and there are fewer external constraints to restrict it, we hypothesized that assessment of a trainee's performance would be dependent upon reported confidence levels of both faculty and trainees in those trainees' abilities. MATERIALS AND METHODS: At a teaching hospital in rural Kenya, operative experience surveys were administered to eleven general surgery trainees (PGY1-5) and six faculty paired dyads immediately following operative procedures in May 2016 to elicit self-reported assessments of confidence, hesitation, and ability as measured by the Zwisch Scale. We examined factors related to learning and used dyadic structural equation models to understand factors related to the assessment of ability. RESULTS: There were 107 paired surveys among 136 trainees and 130 faculty evaluations. Faculty scrubbed into 76 (72%) cases. In comparison to trainees, faculty were more likely to give a higher average score for confidence (4.08 versus 3.90; P value: 0.005), a lower score for hesitation (2.67 versus 2.84; P value: 0.001), and a lower score for the ability to perform the operation independently (2.73 versus 3.02; P value: 0.01). Faculty and trainee perceptions of hesitation influenced their ability scores. Trainee hesitation (OR 12.1; 1.2-127.6, P = 0.04) predicted whether trainees reported experiencing learning. CONCLUSIONS: Between trainees and faculty at a teaching program in rural Kenya, assessment scores of confidence, hesitation, and ability differ in value but remain fairly correlated. Hesitation is predictive of ability assessment, as well as self-reported learning opportunities. Focus upon identifying when trainees hesitate to proceed with a case may yield important educational opportunities.

Necrotizing Fasciitis: A Predictable Burden in Rural Kenya.

BACKGROUND: Necrotizing fasciitis (NF) is a devastating disease with substantial morbidity and mortality. Poor outcomes are attributed to delayed diagnosis and management. Tenwek Hospital, a teaching and referral center in rural Kenya, manages many cases despite variable resources. We aimed to understand the burden of NF. METHODS: All patients with admission NF diagnosis who presented in 2017 were reviewed for demographics, investigations, treatment, and outcomes. The primary outcome was unfavorable outcome defined as in-hospital mortality or amputation. Secondary outcomes were discharge diagnosis of NF and cost. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was calculated. Logistic regression models were utilized to assess the impact of risk factors. RESULTS: Sixty-seven patients were identified with an average age of 49.2 (±21) years. Medical comorbidities were present in 48% and history of trauma in 58%. Discharge diagnosis of NF occurred in 61% (N = 41). Overall, mortality occurred in 10% (N = 7) of patients with an initial NF diagnosis. At discharge, patients without NF had favorable outcomes in 96% (N = 25) compared to 78% (N = 32) with NF (p = 0.043). Final NF diagnosis costs 122,098 Kenyan Shillings more (95% confidence interval 36,142-208,054) than non-NF diagnosis (p value = 0.006). Factors associated with unfavorable outcome include diabetes mellitus, any comorbidity, increased heart rate, fever, hyperglycemia, anemia, and discharge NF diagnosis. Increased LRINEC score was associated with discharge NF diagnosis (p = 0.0006) and unfavorable outcome (p = 0.0157). CONCLUSIONS: Patients with NF in rural Kenya experience delays to presentation, unfavorable outcomes, and substantial costs. Certain factors, including LRINEC score, help predict diagnosis and outcome.

Burr-Hole Craniostomy for Chronic Subdural Hematomas by General Surgeons in Rural Kenya.

INTRODUCTION: Chronic subdural hematoma (cSDH) is a common condition that causes significant morbidity and mortality. In rural sub-Saharan Africa, there are very few neurosurgeons. Yet, cSDH is treatable by relatively simple surgical intervention with potential for rapid clinical improvement. METHODS: We conducted a retrospective chart review of all patients with cSDH who underwent burr-hole trephination at Tenwek Hospital, Kenya, between July 2014 and July 2016. We extracted and compared the clinical presentation, risk factors, operative details, and outcomes. RESULTS: A total of 119 patients were identified with a mean age of 61.3 years. The majority were men (80%). The main predisposing factors were trauma (54.6%) and alcohol intake (34.4%). Patients were generally managed with two burr-holes, irrigation, and a subdural drain, remaining for a median of 2 days. Operations were assisted by general surgery residents under direct supervision of senior residents (46), general surgeons (65), and neurosurgeons (8). Complications included recurrence (5.2%), subdural empyema (2.5%), postoperative seizures (3.4%), and mortality (6.7%). Improvement of symptoms was noted in 91% of all patients. CONCLUSION: Operative management of cSDH can be safely performed in rural facilities by general surgeons familiar with the procedure and with the institutional resources. The majority of patients had satisfactory outcomes.

The Spectrum of Paediatric Intestinal Obstruction in Kenya.

INTRODUCTION: Intestinal obstruction (IO) occurs when there is impedance to the flow of intestinal contents due to a congenital or acquired pathology, and is a common paediatric surgical emergency. This study aimed to assess the pattern and outcome of paediatric IO in western Kenya. METHODS: A retrospective review of all recorded cases of mechanical IO in patients aged 15 years or below admitted at Tenwek Hospital between January 2009 and December 2013. RESULTS: The cohort included a total of 217 children (130 boys and 87 girls). The mean age was 6.7 years (range: newborn-15 years), with most (65, 30%) cases aged 1-3 years. Vomiting (161, 74.2%), abdominal pain (152, 70%), abdominal tenderness (113, 52.1%), constipation (111, 51.2%), and abdominal distension (104, 47.9%) were the predominant signs and symptoms. The most common causes of IO were ascariasis (96, 44.2%), adhesions (34, 15.7%), and intussusception (30, 13.8%). Intussusception was the leading cause of IO in children aged ≤ 1 year, ascariasis in children aged 1-5 and 6-10 years, and adhesions in children aged 11-15 years. Operative management was undertaken in 120 (55.3%) cases with 39 (32.5%) of these having gangrenous bowel. The overall mortality rate was 5%. CONCLUSION: The most common causes of mechanical bowel obstruction in this series were ascariasis, adhesions, and intussusception. Ascariasis remains a significant cause of paediatric IO in this region, thus public education, improved sanitation and deworming campaigns may be helpful in reducing the worm burden.

Ileo-sigmoid knotting: a review of 61 cases in Kenya.

INTRODUCTION: Ileo-sigmoid knotting (ISK) is a rare cause of bowel obstruction in which the ileum twists around the sigmoid colon. It is associated with rapid bowel gangrene and a high mortality rate. Little has been published about this condition in Kenya. The objective was to determine the presentation, management, and outcome of patients with ISK. METHODS: A seven year (January 2008-December 2014) retrospective chart review of patients managed for ISK at Tenwek Hospital in Bomet, Kenya. RESULTS: A total of 61 cases were identified, with a mean age of 35.8 years (range 2-68), and mean symptom duration of 1.6 days (range 3 hours-7 days). Gangrene was noted to involve both the ileum and colon in 45 patients, the ileum only in 9 patients, and the sigmoid colon only in one. Resection and primary anastomosis was carried out in most cases of gangrenous ileum (48/54, 89%) and gangrenous sigmoid colon (34/46, 74%), while resection and stoma was performed in 8 patients with gangrenous colon. Death occurred in 7 (11.5%) patients due to severe sepsis and multisystem organ failure. Morbidities were noted in 15 (24.6%) patients, including surgical site infection (8, 13.1%), respiratory insufficiency (4, 6.6%), fascial dehiscence (3, 4.9%) and anastomotic leak (2, 3.2%). The mean duration of hospitalization was 8.3 days (range 1-26). CONCLUSION: In this review, though retrospective in nature, ISK was noted to have high rates of bowel gangrene. In the appropriate setting, resection and primary anastomosis can be safely carried out in most cases of gangrenous colon.