Outcomes of Proximal Spleno-Renal Shunt Operations for Idiopathic Portal Hypertension in Tertiary Hospital in the Sub-Sahara.

Purpose: Idiopathic portal hypertension (IPH) also known as non-cirrhotic portal hypertension is an entity of hepatic conditions including disorders of blood vessels that leads to portal hypertension (PHT). Current management of PHT includes medical or endoscopic therapy. A proximal spleno-renal shunt (PSRS) operation has been shown to improve the outcomes of patients with IPH with upper gastrointestinal bleeding refractory to medical and endoscopic therapy in high income countries but the same has not been well described in our resource limited setting. Patients and methods: This study consecutively included patients who were diagnosed with IPH on pre-operative imaging and underwent PSRS surgery. Data on four patients across the time period of 3 years was obtained with a male to female ratio of 1:1 and age range of 7 to 34 years. Results: All patients in this study had features of upper gastrointestinal bleeding and, after an endoscopy they were all diagnosed with grade IV esophageal varices. Symptom duration prior to admission varied between 3 months to 8 years. All these patients had multiple episodes of rebleeding varices with recurrent admissions and were managed conservatively by multiple blood transfusions and propranolol tablets, pre-operatively. Only one patient had previous variceal band ligation done though he developed rebleeding. All four patients underwent both PSRS surgery and splenectomy and were intra-operatively verified to have a normal smooth liver and thus IPH was the cause of the esophageal varices. After an average follow-up period of 26.5 months, we found that all patients were alive with early symptomatic relief, no recurrent bleeding and no long-term complications. Conclusion: Good outcomes were achieved in terms of symptom resolution, endoscopic variceal resolution at follow-up endoscopy, length of stay ranging from 8 to 15 days and all four patients were alive at the time of follow-up, that ranged from 14 to 46 months.

Endoscopic esophageal foreign body removal among children at Lubaga Hospital, Kampala, Uganda.

Background: Diagnostic upper gastrointestinal endoscopy involves examination of the lining of the esophagus, stomach and part of the duodenum. Interventional endoscopy in addition to evaluating the upper gastrointestinal tract to make a diagnosis, also offers a treatment benefit. Traditionally, esophageal foreign bodies (FBs) in Uganda were removed using rigid endoscopy. We therefore report an emerging trend of using flexible endoscopy to remove these FBs. Objective: To describe participant characteristics and endoscopic findings among children who underwent esophageal FB removal in Lubaga Hospital in Kampala. Methods: This was a retrospective review of endoscopy reports for children who underwent endoscopic esophageal FB removal at Lubaga Hospital from December 2014 to March 2022. Results: Overall, 61 symptomatic children underwent this procedure. The majority of the FBs were removed by flexible endoscopy (n=55, 90.16%). The mean age of the participants was 7.88 (SD=2.12) years old. The majority of the children were females (72.13%) and coins were the most ingested FBs (84%), others included steel crucifix, nails etc. The upper esophageal sphincter was the commonest site for FB impaction (74%). Conclusion: We report high success rates of 90.16% for endoscopic removal of impacted esophageal foreign bodies among Ugandan children using the now widely available flexible endoscopy.

Endoscopic esophageal stenting for advanced esophageal cancer in Lubaga Hospital, Kampala, Uganda.

OBJECTIVE: Esophageal cancer is a common malignancy globally. Most patients in sub-Saharan Africa present at advanced stage not amenable to curative therapy. Stenting provides palliation for these patients. In Uganda, many endoscopy units can perform diagnostic endoscopy but only a handful routinely perform endoscopic interventions like stenting. We describe esophageal cancer patients who underwent esophageal stenting intending to highlight its importance in a resource-limited setting. Endoscopy reports were reviewed for patients who underwent evaluation for esophageal cancer at Lubaga Hospital from December 2014 to March 2022. RESULTS: 315 records of patients with esophageal cancer were reviewed. Male to female ratio was 2:1. 188(60%) patients were 60 years and above. 268 (85%) esophageal lesions were described as fungating, friable or polypoid. 249 (79%) tumors were in mid or distal esophagus. 66% esophageal lesions caused severe luminal obstruction not traversable by the scope. 164 (52%) patients did not opt for stenting due to personal and other reasons. Stenting wasn't successful in 7 out of the 148 patients who underwent either primary or tandem stenting. Despite 207 (66%) of patients with advanced esophageal cancer presenting with endoscopically non-traversable tumors, endoscopic stenting was still possible with a technical success rate of 95.3%.

Treatment of hepatocellular carcinoma in sub-Saharan Africa: challenges and solutions.

Most patients who develop hepatocellular carcinoma reside in resource-poor countries, a category that includes most countries in sub-Saharan Africa. Age-standardised incidence rates of hepatocellular carcinoma in western, central, eastern, and southern Africa is 6·53 per 100 000 inhabitants to 11·1 per 100 000 inhabitants. In high-income countries, around 40% of patients are diagnosed at an early stage, in which interventions with curative intent or palliative interventions are possible. By contrast, 95% of patients with hepatocellular carcinoma in sub-Saharan Africa present with advanced or terminal disease. In high-income countries, targets of 30-40% that have been set for intervention with curative intent are regularly met, with expected 5-year overall survival rates in the region of 70%. These outcomes are in sharp contrast with the very small proportion of patients in sub-Saharan Africa who are treated with curative intent. Primary prevention through the eradication and reduction of risk factors is still suboptimal because of logistical challenges. The challenges facing primary prevention, in combination with difficult-to-manage historic and emerging risk factors, such as ethanol overconsumption and metabolic dysfunction-associated liver disease, mandates secondary prevention for populations at risk through screening and surveillance. Although the increased treatment needs yielded by screening and surveillance in high-income countries are manageable by the incremental expansion of existing interventional resources, the lack of resources in sub-Saharan Africa will undermine the possible benefits of secondary prevention. An estimate of the projected effect of the introduction and expansion of screening and surveillance, resulting in stage migration and possibilities for active interventions for hepatocellular carcinoma, would facilitate optimal planning and development of resources.

Cytoreductive surgery for giant locally advanced intra-abdominal tumors in Uganda.

Cytoreductive surgery is removal of tumor as much as possible when complete resection is impossible because of advanced disease. It is a management option for giant intra-abdominal tumors with pressure symptoms. We present three patients who underwent cytoreductive surgery for giant intra-abdominal tumors between May 2019 and November 2021. Patient 1 had a gastrointestinal stromal tumor (GIST) involving stomach, spleen and transverse colon. En bloc resection of the GIST with the involved viscera was done. Patient 2 had a liposarcoma measuring 25.8 × 19.6 × 15.3 cm infiltrating the stomach, spleen and the left hemidiaphragm. Involved viscera and liposarcoma were resected en bloc. Patient 3 had a liposarcoma measuring 40 × 35 × 12 cm and encasing the left ureter. Mass was excised together with part of the left ureter and left ureter reconstructed. Giant intra-abdominal tumors are rare. Involvement of adjacent structures may necessitate multivisceral resections with or without organ reconstruction.

Jejunal transection following trivial trauma: Case report and review of literature.

INTRODUCTION: Severe hollow organ injury following trivial blunt abdominal trauma is uncommon. If it occurs it can easily be missed during routine clinical evaluation. Though less than ten cases of jejunal transection following trivial trauma have been reported in literature, this is the first case of jejunal transection occurring in a patient who fell while walking. CASE PRESENTATION: We report a 32year old female Ugandan, who walked into the emergency room due to abdominal pain following a fall while walking. She was found to be hemodynamically stable and was initially hesitant to do further investigations but finally accepted to go for abdominal ultrasound scan and a chest x-ray. Abdominal ultrasound scan noted free peritoneal fluid and erect chest radiograph revealed a pneumoperitoneum. She was admitted for an exploratory laparotomy. At laparotomy we found a complete jejunal transection with mesenteric laceration. Primary anastomosis was done; the patient had an uneventful recovery and was discharged on the tenth postoperative day. DISCUSSION: Any trauma to the abdomen can potentially cause devastating injury to hollow viscera and should therefore be evaluated thoroughly. CONCLUSION: This case demonstrates that even in a resource limited setting, basic investigations like an abdominal ultrasound scan and erect chest radiographs are important when managing a patient with blunt abdominal trauma even though the injury seems trivial.

Serum lactate as a predictor of early outcomes among trauma patients in Uganda.

BACKGROUND: Trauma is the leading cause of death in the developed world. Accurate assessment of severity of injuries is critical in informing treatment choices. Current models of assessing severity of injury are not without limitations. The objective of this study therefore was to determine the diagnostic accuracy of serum lactate assays in assessing injury severity and prediction of early outcomes among trauma patients. METHODS: This was a cross-sectional analytical study. Consecutive series of all eligible patients had a single venous blood sample drawn for lactate assay analysis (index test) and a concurrent Kampala Trauma Score (KTS) II value determination (reference test). Admitted patients were followed up to assess early outcomes (length of hospital stay and mortality). RESULTS: Out of the 502 trauma patients recruited, 108 (22%) were severely injured, 394 (78%) had non-severe injuries, and 183 were admitted. There was a significant difference between median (interquartile range (IQR)) lactate levels among the severely injured (4.3 (2.6, 6.6)) and the non-severely injured (2.4 (1.6, 3.5), p < 0.001). After a 72-h follow-up of the admitted patients, 102 (56%) were discharged, 61 (33%) remained in the hospital, 3 (2%) remained in the ICU, and 17 (3%) had died. The area under the receiver operator characteristic (ROC) curve was 0.75 for injury severity. Serum lactate ≥2.0 mmol/l had a hazard ratio of 1.10 (p < 0.001) for emergency department disposition, 4.33 (p = 0.06) for the 72-h non-discharge disposition, and 1.19 (p < 0.001) for 72-h mortality. Serum lactate ≥2.0 mmol/l at admission was useful in discriminating severe from non-severe injuries with a sensitivity of 88%, specificity of 38%, PPV of 30%, and NPV of 92%. CONCLUSION: Hyperlactatemia in an emergency trauma patient suggests a high probability of severe injury.