sub-Saharan Tertiary Hospital Research Articles

Incidental venous thrombosis in oncology in a sub-Saharan tertiary hospital

Incidental venous thrombosis in oncology in a sub-Saharan tertiary hospital

Review of: "Audit of Dialysis Vascular Access in a Sub-Saharan Tertiary Hospital"

Review of: "Audit of Dialysis Vascular Access in a Sub-Saharan Tertiary Hospital"

Timing of Surgery and Preoperative Predictors of Surgical Site Infections for Patients with Depressed Skull Fractures in a Sub-Saharan Tertiary Hospital: A Prospective Cohort Study.

Surgical site infections (SSIs) remain a major cause of life-threatening morbidity following surgery for depressed skull fractures (DSFs) among patients with traumatic brain injury (TBI). The timing of the surgery for DSF has been questioned as a risk of SSI without a clear cutoff. We aimed to compare the risk of SSI within 3 months between surgery done before versus after 48 h of injury and with its preoperative predictors. We conducted a prospective cohort study at Mulago Hospital, Uganda. Patients with mild-to-moderate TBI with DSF were followed up perioperatively from the operating time up to 3 months. The outcome variables were the incidence risk of SSI, types of SSI, microbial culture patterns of wound isolates, and hospital length of stay. We enrolled 127 patients with DSF, median age = 24 (interquartile range [IQR] = 17-31 years), 88.2% (112/127) male, and assault victims = 53.5%. The frontal bone involved 59%, while 50.4% had a dural tear. The incidence of SSI was 18.9%, mainly superficial incisional infection; Gram-negative microorganisms were the most common isolates (64.7%). The group of surgical intervention >48 h had an increased incidence of SSI (57.3% vs. 42.7%, p = 0.006), a longer median of postoperative hospital stay (8[IQR = 6-12] days versus 5 [IQR = 4-9], [p < 0.001]), and a higher rate of reoperation (71.4% vs. 28.6%, p = 0.05) in comparison with the group of ≤48 h. In multivariate analysis between the group of SSI and no SSI, surgical timing >48 h (95% confidence interval [CI], 1.25-6.22), pneumocranium on computed tomography [CT] scan (95% CI: 1.50-5.36), and involvement of air sinus (95% CI: 1.55-5.47) were associated with a >2.5-fold increase in the rate of SSI. The SSI group had a longer median hospital stay (p value <0.001). The SSI risk in DSF is high following a surgical intervention >48 h of injury, with predictors such as the frontal location of DSF, pneumocranium on a CT scan, and involvement of the air sinus. We recommend early surgical intervention within 48 h of injury.

Incidence and Predictive Factors of Lower Extremity Deep-vein Thrombosis in Patients with Neurological Diseases in a Sub-Saharan Tertiary Hospital

Background: Deep-vein thrombosis (DVT) is a major cause of morbidity among patients with neurological disease and is implicated in 50%–90% of pulmonary embolisms (PE). Aim: This study aims to identify the incidence and predictive factors of lower extremity (LE) DVT in high-risk neurological patients. Materials and Methods: All patients with neurological diseases who were confined to bed for three days or more, or had elevated D-dimer over a 22 months were included in the study. They all had routine mechanical and chemical prophylaxis. Serial color duplex ultrasonography of the LE was performed for all the patients, and the results were used to stratify them into two groups: DVT positive and DVT negative, and their clinical parameters were recorded and utilised for statistical analysis. Multivariate logistic regression analysis was used to determine the predictive risk factors. Results: A total of 611 patients were admitted, and 107 met the inclusion criteria. The mean age was 57 ± 17 years, with a male-to-female ratio of 1.7:1. Forty-four (41.4%) patients had DVT (overall incidence was 7.2%). Primary intracranial tumours and craniocerebral trauma accounted for 27.2% and 20.5% of aetiology, respectively. The comparative DVT-positive versus DVT-negative group D-dimer levels were 7.9 versus 4.9 mg/L (P = 0.0065), duration of immobility 65.0 versus 35.3 days (P = 0.0001), and length of hospital (LOH) stay 32.5 versus 18.2 days (P = 0.0001). The proximal LE vessels were involved in 64.2%. The PE risk was 0.98%, with three mortalities. The predictive factors on multivariate logistic regression were elevated D-dimers (odds ratio [OR] 2.02, 95% confidence interval [CI] 1.1–4.45 P = 0.030) and preoperative immobility &gt;seven days ([OR] 2.38, 95% [CL] 1.28–4.39 P = 0.042). Gender, C-reactive protein, Glasgow Coma Scale, comorbidities, LOH, and chronic steroid use were not predictive. Conclusion: The overall incidence of DVT and mortality from PE were low among patients with neurological diseases. Most thrombi involved proximal LE veins. Elevated D-dimers and preoperative immobility &gt;seven days were predictive factors for LE DVT.

Some Rare Neurosurgical Pathologies in a Sub-Saharan Tertiary Hospital

In sub-Saharan Africa, several neurosurgical diseases are rare in neurosurgical practice, in contrast to other climes. Poor diagnostic and health facilities are always blamed. More than six decades after the birth of neurosurgery in the region, those deficiencies and workforce have markedly improved in neurosciences.

Impact of corona virus disease 2019 pandemic on paediatric surgery in a sub-saharan tertiary hospital: An observational study.

The impact of the corona virus disease 2019 (COVID-19) pandemic on global health, has reached far beyond that caused by the disease itself. With ongoing mutations and the emergence of new strains of the virus alongside repeated waves of the pandemic, the full impact of the pandemic is still evolving and remains difficult to predict or evaluate. In paediatric surgery, it has led to significant disruptions in patient care, the extent and consequence of which are not fully documented in Nigeria. This study aims to evaluate the impact of COVID-19 on services, training and research in a busy paediatric surgery unit during the initial 3-month period of the COVID-19 pandemic lockdown. This study was an ambispective evaluation of the preceding 3 months before lockdown and the initial 3 months of lockdown. Clinic cancellations, elective and emergency surgeries, delays in access, extra cost of care to patients, impact on training and research, and the psychologic impact of the pandemic on staff and guardians were evaluated. During the 3-month lockdown period, an estimated 78 new cases and 637 follow-up cases could not access care. Ninety-seven elective surgeries in 91 patients were postponed. Two (2.2%) patients' symptoms progressed. All emergency patients received care. Out-of-pocket expenditure increased averagely by $124. The pandemic contributed to delays in seeking (13%), reaching (20%) and receiving care (6%). Trainee participation in surgeries was reduced and academic programmes were suspended. Five staff were exposed to the virus and 3 infected. Paediatric surgery has been negatively impacted by COVID-19. Efforts must focus on planning and implementing interventions to mitigate the long-term impact.

Time to return to school in child and adolescent burn patients from a sub-Saharan tertiary hospital.

Africa, with the largest number of paediatric burns needs to focus more attention on paediatric burn survivors. Burn injury truncates schooling in child and adolescent burn patients. The aim of this study was to determine the time to return to school and factors influencing this in child and adolescent burn patients. A cross-sectional study of child and adolescent patients aged one to nineteen years that had been managed for bun injuries. Demographic variables were obtained from archived computerized data. Phone interviews were conducted to obtain time to return to school variables using a questionnaire. Descriptive statistics, students t test, fishers exact test and Chi square test were uses as appropriate for analysis on data on SPSS version 23. A p value <0.05 was considered statistically significant. Thirty-one patients were recruited for the study. There was a female preponderance, 19 (61.3%). The mean age of the patients was 7.2 (±5.3) years. Scald injuries were the commonest [N = 14 (45.2%)] cause of burn. The mean Total Burn Surface Area (TBSA) was 14.1 (±12.0)%. The mean length of hospital stay was 30 (±59) days. The mean time to return to school after discharge from the hospital was 8.4 (±8.7) weeks. The occurrence of burns on the trunk was significantly (p = 0.048) associated with an earlier time to return to school. Time to return to school from burn injury and from discharge in child and adolescent burn survivors in this study are at least three times longer than previous studies. The burn care team needs to consider school re-entry programs for these children.

Charcot arthropathy of the diabetic foot in a sub-Saharan tertiary hospital: a cross-sectional study

BackgroundCharcot foot arthropathy is a potentially limb-threatening condition that leads to progressive destruction of the bones and joints in the neuropathic foot. One of its main causes is diabetes mellitus whose prevalence is steadily increasing. The acute phase is often misdiagnosed thus leading to foot deformity, ulceration and increased risk of amputation. There is a paucity of literature on this condition from sub-Saharan Africa. This study aimed at determining the extent of Charcot foot arthropathy, the radiological patterns of Charcot foot arthropathy and patient’s factors associated with Charcot foot arthropathy among adult patients with longstanding diabetes in an African setting.MethodsThis was a cross-sectional study that was carried at a national referral and university teaching hospital in Kampala, Uganda. One hundred patients with longstanding diabetes mellitus were consecutively recruited. Patients with a history of having diabetes mellitus for at least seven years since diagnosis were considered to have a longstanding disease. Clinical assessment of both feet was done. Weight-bearing radiographs of the selected foot were taken and evaluated using the Sanders and Frykberg and modified Eichenholtz classifications. A blood sample was taken for glycosylated haemoglobin (HbA1c). Data were summarized using descriptive statistics and student t-test.ResultsThe proportion of Charcot foot arthropathy among patients with longstanding diabetes was 12% of which one-third (4 out of 12) were acute cases. Fifty percent of the lesions were in the forefoot and 50% in the midfoot. Seventeen percent of lesions were at the inflammatory stage of the modified Eichenholtz classification, 50% at the developmental stage, 25% at the healing stage, and 8% at the remodelling stage. An abnormal foot radiograph was significantly associated with Charcot foot arthropathy among patients with longstanding diabetes.ConclusionCharcot foot arthropathy is fairly common in patients with longstanding diabetes mellitus in these settings with one third of patients presenting in the early acute phase. An abnormal weight-bearing radiograph was an associated factor of Charcot foot arthropathy among this specific group of patients. To reduce on the morbidity and limb threatening sequelae of this condition, clinicians are therefore advised to routinely examine the feet of patients with diabetes and send those with suspicious signs and symptoms for radiographic assessment.

Medication-related problems among adult chronic kidney disease patients in a sub-Saharan tertiary hospital.

Chronic kidney disease (CKD) patients are prone to medication-related problems (MRPs). Few studies address the clinical relevance of MRPs among CKD patients in sub-Saharan Africa. To investigate the frequency and predictors of MRPs among adult CKD patients treated at a tertiary care facility in an urban sub-Saharan setting. Kenyatta National Hospital in Nairobi, Kenya. A cross-sectional study involving 60 adult patients with CKD was carried out. Data were collected through structured interviews and patient chart reviews between April 2016 and June 2016. MRPs identified from the collected data were classified according to Hepler and Strand classification. The frequencies of the identified MRPs were computed and logistic regression used to investigate the associations between the MRPs and covariates in the data. frequencies and predictors of MRPs. 271 MRPs were identified. The commonest MRPs were drug interactions (21.8%), indication without drug (18.1%) and medication non-adherence (15.5%). Compared to patients with CKD stage 3, patients with CKD stage 4 were 5.9 times more likely to have an improper drug selection and 4.7 times more likely to experience overdosage. Other significant predictors of MRPs were the number of medications per prescription and the number of comorbidities per patient. This study found a high frequency of MRPs among patients with chronic kidney diseasereceiving care in urban sub-Saharan tertiary hospital settings. The predictors of MRPs among CKD patients in this setting are likely to be multifactorial and include the CKD stage, polypharmacy, and comorbidities.

Review of adult head injury admissions into the intensive care unit of a tertiary hospital in Nigeria

Background: Head injury is frequently associated with death and disability and imposes considerable demands on health services. Outcome after head injury is closely related to prompt management, including prevention of secondary brain injury and intensive care unit (ICU) management. This study aimed at determining the aetiological spectrum, injury characteristics, ICU admission patterns, and treatment outcomes of adult head-injured patients at a sub-Saharan tertiary hospital. Methods: A retrospective study on adult head-injured patients admitted to the ICU of a sub-Saharan tertiary hospital between July 2000 and June 2010. Results: A total of 198 head-injured adult patients were managed in the ICU during the study period. This included 128 males and 70 females with a male-to-female ratio of 1.8:1. The most common mode of injury was road traffic accident. All the patients admitted to ICU had either moderate or severe head injury, with 73.7% having severe head injury. About 26.3% of the patients had associated cervical spine injuries and 50% had various musculoskeletal and soft tissue injuries. Cranial computed tomography findings included brain contusions and intracranial haematomas. Mean duration of ICU stay was 18 days (range 24 hours-42 days), with 89.9% discharged out of ICU care. The overall mortality was 10.1%, although only 36.9% had satisfactory outcomes, as determined by the Glasgow Outcome Scale. Outcome had statistically significant (P < 0.05) relationship with severity of head injury and surgical intervention. Conclusions: Head injury management in the ICU requires an approach to ensure prevention of secondary brain injury; appropriate and early neuroimaging to diagnose lesions that would benefit from timely surgical intervention; as well as management of fluid, electrolyte and haematological derangements. Keywords: head injury; admissions; ICU

Palliative Radiotherapy and Hormonal Deprivation for Prostate Cancer Induced Urinary Obstruction at a Sub-Saharan Tertiary Hospital

The occurrence of bladder outlet obstruction (BOO) in men with prostate cancer is common. Although relieving the obstruction may not change prognosis, it is highly valued by patients and is generally associated with improvement in general functioning and wellbeing in the short-term. The aim of this study was to assess the efficacy of high-dose external beam radiation therapy (EBRT) combined with bilateral subcapsular orchidectomy (BSO) to relieve BOO due to prostate cancer. A retrospective study design was employed and conducted at the Mulago National Referral Hospital. Records of all patients with high-risk prostate cancer who presented with urinary obstructive symptoms and treated with the BSO and EBRT were retrieved. The study variables were age, clinical stage, and pathological Gleason score. The endpoint of the study was for patients to be able to pass urine after removing the urethral catheter, analysed as follows: complete failure to pass urine; partial emptying with a post-void volume &gt;100 mL, and passing urine with complete emptying and a post-void volume &lt;100 mL. In total, 46 patients were analysed in the period of January 2011–December 2012. Mean age was 71 years (range: 63–93). Eight patients failed to pass urine, while six passed urine incompletely (partial emptying). Thirty-two passed urine with a good stream and emptied the bladder completely. The success rate was 32/46 (70%). All patients had T3 and T4 stage disease with Gleason scores &gt;8. In conclusion, orchidectomy combined with EBRT was found to be an effective and feasible option for relieving BOO due to prostate cancer.

Pattern and outcome of elderly admissions into the Intensive Care Unit (ICU) of a low resource tertiary hospital

Background: Globally, the population of the elderly is increasing and the greatest increase is occurring in the developing and middle income countries because of falling death rate and high birth rate. The ageing of the population in developing countries may result in increasing requirement for health care facilities including ICU care for the elderly. This study was aimed at assessing the pattern and outcome of elderly patients’ admissions into the ICU of our hospital and identifies the determinants of outcome. Method: This was a retrospective study covering a 5 year period (January1 st 2010 to 31 st December 2014) in the ICU of a sub-Saharan tertiary hospital. Data was obtained from the review of ICU admission records over this period. We included as elderly patients aged 65years and above. Results: During the period under review, 90 cases were identified but only 62 cases were available for review (68.9%). There were 40 males and 22 females with ages ranging between 65 and 92years. Surgical admissions accounted for 75.8% of admissions while medical admissions were 24.2%. The overall ICU mortality in the elderly was 58.1%.The major predictors of mortality were: need for endotracheal intubation (p=0.001), mechanical ventilation (p=0.001), vasopressor (p=0.001), electrolyte derangement (p=0.001), sepsis on admission (p=0.001), shock on admission (p=0.001). Conclusion: Elderly patients admitted into the ICU are a population with an increased risk of mortality. The predictors of high risk of death are sepsis on admission, septic shock, need for vasopressor, endotracheal intubation and or mechanical ventilation and the presence of electrolyte derangement. The outcome of this study calls for a need to pay more attention to this rapidly expanding group of the population. Keywords: Elderly, Admission, ICU, low resource hospital

Prevalence, associated factors and treatment of post spinal shivering in a Sub-Saharan tertiary hospital: a prospective observational study.

BackgroundSurgery and anaesthesia cause shivering due to thermal dysregulation as a compensatory mechanism and is worsened by vasodilatation from spinal anaesthesia that redistributes core body heat. Due to paucity of data Mulago Hospital’s post spinal shivering burden is unknown yet it causes discomfort and morbidity.MethodsEthical approval was obtained to perform the study among consenting mothers due for elective caesarean section from March to May 2011. We recruited ASA class I & II parturients and excluded non-consenting or spinal contra-indication patients. A standard spinal anaesthetic of 2mls of 0.5 % bupivacaine was given, intraoperative vitals were recorded every 5 min and we monitored for perioperative shivering till PACU discharge.ResultsWe recruited 270 patients with majority being emergency caesarean deliveries (90.74 %), mainly due to failed progress from cephalopelvic disproportion. We noted 8.15 % shivering occuring mostly at 20 min, with hypotension plus hypothermia as associated factors. Intravenous pethidine (Meperidine) 25 mg effectively treated shivering and we had drowsiness, nausea and vomiting as PACU side effects that resolved on discharge to the ward.ConclusionPost spinal shivering had a prevalence of 8.15 %, commonly occurred at 20 min postoperatively with hypotension plus hypothermia as main associated factors and intravenous Pethidine controlled it.

The outcome of anaesthesia related cardiac arrest in a Sub-Saharan tertiary hospital

BackgroundAnaesthesia related cardiac arrest is undesirable, and different attempts have been made to reduce the mortality associated with it through continuous specialist training, and provision of state of art equipment, combined with rigorous research.Patients and methodsWe determined the outcome of all cardiac arrests that occurred within 24 h of a surgical procedure and anaesthesia from January 2013 to May 2014.ResultsThere were nine anaesthesia related cardiac arrest in 4229 cases, (incidence of 21.28 per 10,000), with a mortality of 7/4229; (16.55 per 10,000). There were 60 perioperative cardiac arrests (incidence of 141.88 per 10,000), with a mortality of 55/4229 (130.05 per 10,000). There was return of spontaneous circulation in 34 (56.67%) cases, among them only 7 (20.59%) survived to hospital discharge. The independent determinant of perioperative mortality was the duration of cardiac arrest ⩾ 5 min (RR 10.50, 95% CI 2.721–40.519, p < 0.001), cardiac arrest in the absence of a witness (RR 9.56, 95% CI 2.486–36.752, p < 0.001), nonstandard time of cardiac arrest (RR 3.2, 95% CI 1.792–5.714, p < 0.001), ASA physical status ⩾ III (RR 2.017, 95% CI 1.190–3.417, p = 0.017), and emergency surger (RR 2.17, 95% CI 1.151–4.049, p = 0.011).ConclusionAnaesthesia related cardiac arrest and mortality were linked to cardiovascular depression from halothane overdose in our institution. The burden can be reduced by improving on establishing standard monitoring in the perioperative period, and a team approach to patients care.

Abnormal Admission Chest X-Ray and MEWS as ICU Outcome Predictors in a Sub-Saharan Tertiary Hospital: A Prospective Observational Study.

Background. Critical care in Uganda is a neglected speciality and deemed costly with limited funding/prioritization. We studied admission X-ray and MEWS as mortality predictors of ICU patients requiring mechanical ventilation. Materials and Methods. We did a cross-sectional study in Mulago Hospital ICU and 87 patients for mechanical ventilation were recruited with mortality as the outcome of interest. Chest X-ray results were the main independent variable and MEWS was also gotten for all patients. Results. We recruited 87 patients; most were males (60.92%), aged between 16 and 45 years (59.77%), and most admissions for mechanical ventilation were from the Trauma Unit (30.77%). Forty-one (47.13%) of the 87 patients died and of these 34 (53.13%) had an abnormal CXR with an insignificant IRR = 1.75 (0.90–3.38) (p = 0.062). Patients with MEWS ≥ 5 (p values = 0.018) and/or having an abnormal superior mediastinum (p values = 0.013) showed a positive association with mortality while having a MEWS ≥ 5 had an incidence risk ratio = 3.29 (1.00–12.02) (p = 0.018). MEWS was a good predictor of mortality (predictive value = 0.6739). Conclusion. Trauma (31%) caused most ICU admissions, having an abnormal admission chest X-rays positively associated with mortality and a high MEWS was also a good predictor of mortality.

An audit of airway management in critically ill patients in a sub-Saharan tertiary hospital

Critically ill patients have poor physiological reserves, and are at increased risk of cardiopulmonary complications such as hypoxia, hypotension, arrhythmias and cardiac arrest when undergoing airway management. This study audited airway management in critically ill patients. Patients Method: A Prospective observational study in 120 critically ill adult patients who required endotracheal intubation over a one year period. Induction was with IV midazolam (0.15mg/kg), and suxamethonium (1.5mg/kg). Data collected included immediate complications (complications during intubation), and early complications (complications on days one to seven of tube insertion). Results: The median age was 32 years, males constituted 68 (56.6%) and female 52 (43.4%). One hundred and fifty-eight intubation attempts were recorded, one attempt to success in 93 (77.5%), and 2 attempts in 22 (18.33%). Difficult intubation occurred in 17 (10.49%), of whom 5 subjects had more than 3 intubation attempts, and 2 had surgical tracheostomy performed. The intubation aids used included stylet in 86.67%, bougie (3.33%), and laryngeal mask airway (1.67%). There was a significant association between the number of attempts at intubation, and trauma, bleeding, oesophageal intubation, aspiration or cardiac arrest, P<0.05. Tubal blockade occurred in 65 (36.31%) subjects after a median duration of 38.5 hours. Conclusion: This study elicited the need to review the airway management of critically ill patients in our institution, provide different airway and intubating devices during difficult intubation, and ensure appropriate training in airway skills.

Complications and outcomes following central neuraxial anesthesia in a sub-Saharan Tertiary Hospital: The legal implication

BackgroundComplications following central neuraxial anesthesia have led to litigations and claims in developed nations, however, the incidence of litigation is low in our environment. Anesthetist practicing in Nigeria need to be aware that such complications are not uncommon.Aim and objectiveTo determine central neuraxial anesthesia related complications and the legal implications.MethodThis was a prospective observational study conducted in 821 patients scheduled for surgery under central neuraxial anesthesia from February 2012 to January 2013. The choice of anesthesia depended on the indication and the duration of surgery.ResultsThe observed complications of central neuraxial anesthesia, which may result in litigation included inadvertent high block (22.4%), paresthesia during needle placement (6.2%), inadequate block (3%), failed block (1.2%), and postdural puncture headache (1.15%). Others were seizure (0.1%), meningism (0.1%), persistent pain in the lower limb for 48 hours (0.1%), back pain (0.7%) and cardiac arrest (0.49%); three of the four cardiac arrest died. There was, however, no report of litigation or claim in this study.ConclusionWe have demonstrated that complications, which may result in litigation and claim following central neuraxial anesthesia is not a rare occurrence in our institution. However, there was no record of litigation or claim in our review. Anesthetist in Nigeria need to be aware of the legal implication of such complications. When performing blocks, well recognized complications should be discussed before obtaining consent. If any untoward effect occurs, a detailed note of the findings and treatment should be documented for future reference.

Clinical Parameters and Challenges of Managing Cervicofacial Necrotizing Fasciitis in a Sub-Saharan Tertiary Hospital.

Introduction:Necrotizing fasciitis is a severe soft tissue infection. In our environment, patients presenting with this infection are usually financially incapacitated and, therefore, their management can be challenging. This paper aimed to document the pattern and challenges encountered in the management of cervicofacial necrotizing fasciitis (CNF) in the University College Hospital, Ibadan.Materials and Methods:Information such as biodata, site of infection, systemic conditions, widest span of defect, management provided, hospital stay, and outcome of management was prospectively collected on all patients with CNF who presented at the Department of Oral and Maxillofacial Surgery between January 2007 and December 2013. The patients were managed according to a devised protocol of antibiotic therapy, serial debridement and honey dressings.Results:Twenty-four cases of CNF were seen. There were 9 males and 15 females while 70.9% of the patients belonged to the low socioeconomic class. The mean span of wound defect was 12.2 (±8.844) cm. The mean hospital stay was 27.8 (±23.1) days, and scar formation was the most common complication encountered.Conclusion:Our study represents the largest series of CNF from a Nigerian health facility presently. The management of necrotizing fascitis in the maxillofacial region poses a significant challenge to both the surgeon and the patient. However, the mortality rate of CNF in our center appears comparatively low.

The Effect of a New Surgery Residency Program on Case Volume and Case Complexity in a Sub-Saharan African Hospital

Improved access to surgical care could prevent a significant burden of disease and disability-adjusted life years, and workforce shortages are the biggest obstacle to surgical care. To address this shortage, a 5-year surgical residency program was established at Kamuzu Central Hospital (KCH) in July 2009. As the residency enters its fourth year, we hypothesized that the initiation of a general surgical residency program would result in an increase in the overall case volume and complexity at KCH. We conducted a retrospective analysis of operated cases at KCH during the 3 years before and the third year after the implementation of the KCH surgical residency program, from July 2006 to July 2009 and the calendar year 2012, respectively. During the 3 years before the initiation of the surgical residency, an average of 2317 operations were performed per year, whereas in 2012, 2773 operations were performed, representing a 20% increase. Before residency, an average of 1191 major operations per year were performed, and in 2012, 1501 major operations were performed, representing a 26% increase. Our study demonstrates that operative case volume and complexity increase following the initiation of a surgical residency program in a sub-Saharan tertiary hospital. We believe that by building on established partnerships and emphasizing education, research, and clinical care, we can start to tackle the issues of surgical access and care.

Outcomes of Dorsal and Ventral Buccal Graft Urethroplasty at a Tertiary Hospital in Uganda

Purpose. Although the use of buccal mucosa in substitution urethroplasty has been practiced for some years, it has not been free of controversy over which surgical technique is the most appropriate to use. There is paucity of data in Sub-Saharan Africa about its success; this study presents the outcomes of dorsal and ventral buccal graft urethroplasty at a sub-Saharan tertiary hospital. Methods. This is a prospective study in which buccal mucosa was used for ventral and dorsal grafts; followup was up to two years. All patients provided informed written consent for the procedures. Results. Seventy-two patients with bulbar urethral strictures underwent buccal graft one-stage urethroplasty. Mean age was 55 years; etiology of the strictures was postinflammatory due to urethritis from sexually transmitted infections 97% (70/72) and trauma 3% (2/72). Buccal mucosa grafts were harvested from the cheek using a two-team approach. Grafts were placed on the ventral and dorsal urethral surfaces in 32 and 40 cases, respectively; the success rate was 84 and 80%, respectively. Repeated urethroplasty was successfully done among 10% (7/72) and patients reported resolution of symptoms in the follow-up period. Conclusion. There was no difference between dorsal and ventral onlay buccal graft outcomes for bulbar urethral strictures. The success rate was 80 to 84%.