Care of Injured Children Compared to Adults at District and Regional Hospitals in Ghana and the Impact of a Trauma Intake Form: A Stepped-Wedge Cluster Randomized Trial.

BACKGROUND: This study aimed to determine the effectiveness of a standardized trauma intake form (TIF) to improve achievement of key performance indicators (KPIs) of initial trauma care among injured children, compared to adults, at non-tertiary hospitals in Ghana. METHODS: A stepped-wedge cluster randomized trial was performed with research assistants directly observing the management of injured patients before and after introducing the TIF at emergency units of 8 non-tertiary hospitals for 17.5 months. Differences in outcomes between children and adults in periods before and after TIF introduction were determined with multivariable logistic regression. Differences in outcomes among children after TIF introduction were determined using generalized linear mixed regression. RESULTS: Management of 3889 injured patients was observed; 757 (19%) were children <18 years. Trauma care KPIs at baseline were lower for children compared to adults. Improvements in primary survey KPIs were observed among children after TIF introduction. Examples include airway assessment [279 (71%) to 359 (98%); adjusted odds ratio (AOR): 74.42, p = 0.005)] and chest examination [225 (58%) to 349 (95%); AOR 53.80, p = 0.002)]. However, despite these improvements, achievement of KPIs was still lower compared to adults. Examples are pelvic fracture evaluation [children: 295 (80%) vs adults: 1416 (88%), AOR: 0.56, p = 0.001] and respiratory rate assessment (children: 310 (84%) vs adults: 1458 (91%), AOR: 058, p = 0.030). CONCLUSIONS: While the TIF was effective in improving most KPIs of pediatric trauma care, more targeted education is needed to bridge the gap in quality between pediatric and adult trauma care at non-tertiary hospitals in Ghana and other low- and middle-income countries. TYPE OF STUDY: Stepped-wedged cluster randomized controlled trial. LEVEL OF EVIDENCE: I.

Late migration of an aspirated foreign body from the lung to the bowel: A plausible explanation or a medical mystery. A case report.

INTRODUCTION AND IMPORTANCE: Foreign body (FB) aspiration is a common preventable cause of death among children between ages 1-3 years. A rare case of an aspirated sharp metallic object in a 4-year-old boy that migrated from the left lung to the GIT after a year is presented after bronchoscopy and thoracotomy failed to retrieve it. PRESENTATION OF CASE: A 4-year-old boy presented with cough a year after aspirating a sewing machine needle. He was stable with normal chest findings. Previous bronchoscopy attempts failed to retrieve the needle. A thoracotomy was done after a chest CT revealed the foreign body in the left lower lobe. FB could not be palpated nor visualized intraoperatively. Flexible bronchoscopy could also not visualize the needle in the airway. A postoperative x-ray done revealed the needle was no longer in the chest but in the bowel. CLINICAL DISCUSSION: Bronchoscopy is the standard treatment for FB aspiration but in our case, it failed on two occasions to retrieve the sharp object. Our literature search revealed only reported cases of migrating FB from one bronchus to the other, and from the bronchus to the gastrointestinal tract (GIT) but not from the lung into the GIT. CONCLUSION: FB migration from the lung to the GIT after a year without signs of perforation is possible. While we brainstorm the plausible explanations for this migration, one may wonder if this is just a medical mystery.

Review of rigid esophagoscopy in a Tertiary Hospital in Ghana.

Rigid esophagoscopy is a common endoscopic procedure worldwide for both diagnostic and therapeutic purposes. Even though this procedure is performed commonly in our center no published reports exist. We reviewed our experience with rigid esophagoscopy. This was a 9-year review of rigid esophagoscopy, done under general anaesthesia, at ENT and Cardiothoracic Units of Tamale Teaching Hospital. Parameters evaluated were patients´ demographics, indication for rigid esophagoscopy and outcome of the procedure. One hundred and fifteen cases of rigid esophagoscopies were evaluated. The ages ranged from 10 months to 87 years with a peak incidence 69.6% (n = 80) occurring within the first decade of life and a male preponderance of 54.8% (n = 63). Majority of the cases were emergencies 87.8% (n =101) and for therapeutic reasons 87% (n =100). The most common findings during esophagoscopy were: coins 60.9% (n = 70), fish bone 11.3% (n = 13), esophageal tumours 7.8% (n = 9) and dentures 5.2% (n = 6). All the cases were successfully treated with no mortality recorded. Rigid esophagoscopy was more commonly performed in males with peak age incidence occurring during the first decade of life. Emergency patients and esophagoscopy with therapeutic intent constituted the largest two groups in this study. Coins, fish bone, esophageal tumours and dentures were the most common findings. There was no mortality recorded.

Flexible bronchoscopy in Ghana: initial experience in a tertiary hospital.

INTRODUCTION: the use of flexible bronchoscopy in developing countries is limited. We report our initial experience and outcome with the use of flexible bronchoscopy at the Tamale Teaching Hospital in Ghana. This is the first reported case series of flexible bronchoscopy in Ghana. METHODS: a retrospective review of patients who had flexible bronchoscopy from 2017-2019 was analyzed. Patient demographics and outcomes were summarized using frequency distribution and percentages. RESULTS: we performed flexible bronchoscopies in 33 patients with mean age of 43 years. All patients were symptomatic at the time of presentation with the most common symptoms being chest pain (63.6%), dyspnea (57.6%) and cough (48.5%). The indication for bronchoscopy in most of the cases were suspected malignancy in 16 (48.5%) followed by infection 9 (27.3%), trauma 4 (12.1%) and others 4 (12.1%). We observed abnormal bronchoscopic findings in 25 (75.8%) of the cases with most of the pathologies in the right main bronchus. Twelve patients had toilet bronchoscopy, 6 had biopsy, 5 had no intervention and 4 patients had bronchoalveolar lavage (BAL). Culture and sensitivity results were available for 11 patients, of which 7 patients had negative results. Thirteen (13) malignancies and 11 inflammatory/infectious diseases were diagnosed in this case series. The mean procedure time was 32 minutes with mean hospital stay of 7 days. There was no complication or mortality in our series. Conclusion: flexible bronchoscopy is a safe procedure and indispensable in Ghana where there is an increasing incidence of lung diseases.

Oki stent application in different indications: Six cases.

INTRODUCTION: We have used Oki stents for a number of different indications. After discovering that there are limited reports in the literature on these stents, we were motivated to share our experiences in Oki stenting. OBJECTIVES: While there is vast knowledge on double Y-stents, the Oki stent is a relatively recent development in pulmonology. Here, we demonstrate that stenting of the right secondary carina using an Oki stent should be considered for obstructions in this region. METHODS: We placed 13 mm × 10 mm × 9 mm Oki stents in six patients under general anesthesia via rigid bronchoscopy. RESULTS: Three cases were post-transplant patients with malacia, stenosis, and bronchopleural fistula. One case had an airway obstruction due to malignant disease, another case had a right aortic arc and aberrant left subclavian artery anomaly, and the final case had bronchopleural fistula. No serious complications were observed during stent placement. CONCLUSIONS: Oki stents can safely be used for many clinical conditions. Patients benefit greatly from stenting; however, two of our cases died due to infection, and one case died due to malignancy.

Preoperative chemoradiation therapy decreases the number of lymph nodes resected during esophagectomy.

BACKGROUND: This study aimed to analyze the effect of preoperative chemoradiation on the adequacy of lymph node dissection. METHODS: Patients with esophageal cancer treated with esophagectomy by the same surgeon between 2004 and 2011 were reviewed. Specimens were examined by the same pathologist. Patients were grouped into two depending on the type of treatment received. RESULTS: Forty-seven patients with curative esophagectomy were included in the study. Twenty patients had preoperative chemoradiation followed by surgery and 27 had surgery alone. Open and hybrid esophagectomy approaches were used. The average number of lymph nodes dissected was 16 ± 10 (1-39). There was a significant decrease in the number of lymph nodes examined in patients with preoperative chemoradiotherapy in comparison to surgery alone (p = 0.001). Median length of stay was 12 days. R0 resection rate was 96%. The median survival was 36.3 months, with a 42% 5-year survival. Seven patients (25%) had complete pathologic response following chemoradiation. No significant difference was recorded in terms of disease recurrence (p = 0.3). While morbidity was higher in the preoperative therapy group with 30 day mortality of 10%, type of surgical approach does not seem to influence the number of lymph nodes dissected (p = 0.7). CONCLUSIONS: Preoperative chemoradiation decreases the number of harvested lymph nodes following esophagectomy regardless of the surgical technique used. The optimum number of lymph nodes currently recommended to be dissected for accurate nodal staging and survival needs revision in this group of patients.

Two unusual cases of adult onset congenital bronchoesophageal fistulas treated with fistula division.

Adult onset congenital bronchoesophageal fistula is a very rare entity. We report 2 cases of adult onset type II congenital bronchoesophageal fistula between the distal thoracic esophagus and the lower lobe superior segmental bronchi surgically treated through a right and left thoracotomy, respectively. In both cases the fistula was transected and sutured with no parenchyma resection. Both patients had an uneventful recovery. Resection of the underlying parenchyma during surgery for bronchoesophageal fistula is not always necessary as the lung can heal in time after performing just fistulectomy.

Accidental superior vena cava access to central venous system lately disclosed by thoracotomy.

We report the case of a 51-year-old woman who underwent hemicolectomy for colon cancer and subsequent hepatic metastasectomy for liver metastases. Right percutaneous infraclavicular subclavian venous port catheterization was performed during the initial operation for chemotherapy. She received chemotherapy after each operation with no reported complications. During a right thoracotomy for lung metastases 2 years after the catheter placement, we noticed the catheter perforating the right subclavian vein and directly entering the superior vena cava. To prevent hemorrhaging during catheter removal, we initially performed the lung metastasectomy, after which we decided to intrathoracically remove the catheter. No complication was observed. To the best of our knowledge, this case is the first of its kind to be reported in the published literature.

Left-sided thoracoscopy in the prone position for surgery of distal esophageal benign pathologies.

Exposure of the distal esophagus can be achieved by a wide variety of surgical approaches. The standard procedure is mostly by laparoscopy. In cases where laparoscopy is relatively contraindicated, thoracoscopy is preferred. In this case, exposure of the distal esophagus from the aorta, heart and lung is technically challenging using thoracoscopy in the right lateral decubitus position. Surgery in the prone position for esophageal cancer has been successfully described in previous literature. We present our experience with left-sided thoracoscopy in the prone position in three patients with benign distal esophageal pathologies. This approach provided a much better exposure of the distal esophagus and enabled a successful surgery to be done in all patients with less manipulation of the lung.

Quality of life of patients who have undergone the minimally invasive repair of pectus carinatum.

OBJECTIVES: Several studies previously demonstrated an improvement in the quality of life (QoL) of the patients undergoing a minimally invasive repair of pectus excavatum, but there are no data about such improvement following the minimally invasive repair of pectus carinatum (PC) deformity. The purpose of this study was to investigate the effects of the minimally invasive repair of PC deformity on the psychosocial and physical functioning of the patients. METHODS: Among 40 patients who underwent minimally invasive repair for PC deformity from July 2008 to March 2011, 35 patients accepted to answer the QoL questionnaires, and 30 of them who had completed the postoperative 6th month were evaluated in this study. The modified two-step Nuss questionnaire was used for the QoL assessment. All patients and their parents completed the appropriate questionnaires regarding the patients' preoperative psychosocial and physical functioning, and they were asked to answer the same questions on the postoperative 6th month. The results from these questionnaires were analysed using Wilcoxon signed rank test to investigate the effects of the minimally invasive repair of PC deformity on psychosocial and physical functioning of the patients. RESULTS: The questionnaires used in the study confirmed the positive impact of the surgical correction on psychosocial and physical well-being in the patients and their parents. Spearman's ρ correlation coefficient determined how well the answers to the same question at two different times correlated with each other, and Cronbach's alpha demonstrated the internal consistency of these answers. These two parameters showed that the statistical results of the study were reliable enough. Statistical analysis of the scoring of the individual questions and the total scoring of individual patients revealed a statistically significant improvement (P < 0.05) following surgery. Similar significant improvements were observed in the total scoring of individual parents and in most scoring of the individual questions (10 of 13, 77%) in the parental questionnaire (P < 0.05). CONCLUSIONS: The results of this study confirm for the first time that minimally invasive repair of PC deformity has a positive impact on both psychosocial and physical functioning of the patient, which is supported by parental assessment.