Treatment of thyroid cancer.

The management of differentiated thyroid cancer remains controversial. A consecutive series of 234 thyroidectomies done by one surgeon in various Nairobi Hospitals from July 1990 to June 1993 were studied. 18 patients were operated on for thyroid cancer. The procedures ranged from lobectomy to total thyroidectomy. Young adults from 20-40 years of age were mainly affected, with a male/female sex ratio of 8:1. The immediate and subsequent morbidity of the operation of total thyroidectomy, in our opinion, overweighs its advantages of improved disease control. This is particularly so when low socio-economic standards lead to lack of compliance with replacement therapy.

Munchausen's syndrome: case report.

A case report of a 31-year old butcher with haemorrhagica histrionica is presented. The patient went to great lengths to induce haematemesis and fake its symptoms to gain admission to hospital. The alarming frequency of admissions and dramatic behaviour of the patient prompted this report.

Evaluation and surgical treatment of solitary thyroid nodules.

This is a prospective study based on 146 consecutive thyroidectomies over a two year period (July 1990 to June 1992). All patients with solitary thyroid nodules which were suspicious or equivocal on fine needle aspiration cytology (FNAC) were subjected to a hemithyroidectomy plus isthmal resection. 60% of all the thyroidectomies were for solitary thyroid nodules of which 15% were malignant. This mode of surgery is suggested for these patients as it is an acceptable although controversial method of treatment for early localized differentiated thyroid cancer. This is justified by the high incidence of malignancy and the difficulty encountered in most of our hospitals regarding adequate assessment of such patients to decide whether surgery is indicated or not. There is also the problem of all those "enucleated" nodules especially in remote areas which are not subjected to histopathological diagnosis. What about the patient who never returns for follow-up?

Acute appendicitis: an overview.

OBJECTIVE: To provide an overview of the changing epidemiology of acute appendicitis in the developed and developing countries and the presumptive reasons. DATA SOURCE: Major published series of the last two decades were reviewed using Medline Search and Index Medicus. The myriad of diagnostic approaches currently employed to reduce the hitherto high rates of negative appendicectomy were examined and current trends of management analysed. CONCLUSION: The treatment modalities of acute appendicitis have undergone tremendous changes in the last decade.

Post-operative management of pain following major abdominal and thoracic operations.

OBJECTIVE: To study the common methods of analgesia and their effectiveness in post-operative patients and to assess the occurrence of common post-operative complications related to pain. DESIGN: A prospective descriptive study. SETTINGS: Three general surgical wards and one cardiothoracic ward at the Kenyatta National Hospital, Nairobi, between 1st September 1996 and 30th November 1996. PATIENTS: One hundred and six adult patients admitted in the hospital for thoracotomy and/or laparotomy over a period of three months. RESULTS: Overall, 60% of the patients did not achieve adequate pain relief during the first 72 hours after surgery. Age, sex, weight, drug and type of operation did not influence pain score significantly. All but two patients were not prepared psychologically about expectations after surgery. Over ninety seven per cent received pethidine while 2.8% had morphine. The drugs were prescribed and administered with too little attention to the patient' s response and too much concern about adverse effects and narcotic addiction. CONCLUSION: The results suggest that the standard of post-operative pain relief is poor. Patients need to be told more about what to expect (and demand). The medical and nursing staff need further education in how to prescribe and administer analgesia with reference to individual drug response. Other more effective methods of pain control should be introduced.

Diagnostic peritoneal lavage in the evaluation of abdominal trauma using the dipstick.

OBJECTIVE: To determine the accuracy and sensitivity of diagnostic peritoneal lavage in the assessment of intra-abdominal injury using the dipstick method. DESIGN: Prospective study, involving the performance of diagnostic peritoneal lavage in the out patient department and surgical wards prior to surgical intervention. SETTING: Kenyatta National Hospital-General Surgical and Orthopaedic wards and outpatient department. The study was conducted over a duration of six months, starting from January 1995 to July 1995. RESULTS: Ninety six patients with penetrating (68) and blunt (28) abdominal trauma underwent diagnostic peritoneal lavage as evaluation of the severity of abdominal trauma. Dipstick (combur 9 strips) was used to evaluate lavage effluent for red blood cells, white blood cells, protein and bilirubin. Forty three patients had positive diagnostic peritoneal lavage (DPL) results, of which 40 (93%) had positive findings at laparatomy and three (7%) had negative findings at laparatomy. The remaining 53 patients had negative DPL results and were managed conservatively. One patient with a negative DPL result became symptomatic and had a positive laparatomy. Conservatively managed patients were discharged after 24 hours observations without any complications. DPL had an accuracy and sensitivity of 93% and specificity of 98%. CONCLUSION: Diagnostic peritoneal lavage is a cheap, safe and reliable method for assessment of abdominal trauma. The method is easy to perform by trained junior doctors in the OPD, or as a bedside procedure. Use of this method reduced negative laparotomy rate from 50% to 6.9% and average duration of stay from 6.5 days to 1.9 days. This method is recommended as a basic tool in the assessment of abdominal trauma patients.

Wandering spleen presenting as a right hypochondrial mass and intestinal obstruction.

This is a case report of a 23 year old multiparous woman who presented with intestinal obstruction and a right hypochondrial mass. Laparatomy revealed an infarcted 1.4 Kg spleen in the right lumbar region compressing the ascending colon. There was also ileal volvulus around the splenic pedicle. This is probably the first documented case of wandering spleen in the right hypochondrium, presenting as right large bowel obstruction, to be reported in our region. Wandering spleen is a rare condition, often asymptomatic, but may present as an acute abdomen. Pre-operative diagnosis is difficult and rarely made. Laboratory tests are seldom useful, but imaging studies do assist. Up to 1971 only 350 cases had been reported in the western literature. Review of English literature from 1900 to 1991 reported only 51 cases in children. In our region 11 cases were reported in Uganda between 1968 and 1971. No other literature is available from our region. Clinical presentation, aetiology, investigation, and management of wandering spleen is discussed.

Role of fine-needle aspiration biopsy in the diagnosis of breast lumps at the Kenyatta National Hospital.

During 1990-1991, all patients seen at the surgical out-patient clinic at the Kenyatta National Hospital (KNH) with breast lumps had a fine-needle aspiration biopsy for diagnosis prior to open biopsy. Out of 105 that had corresponding surgical biopsies, 82 aspirates were considered satisfactory. Of these, the correct diagnosis was made in 59 (71%), another 12 (21%) were called benign but the correct histologic diagnosis was not made, 7 (8.5%) were correctly called negatives. The diagnostic accuracy of this method in differentiating benign from malignant was 95% in this study.