Local anesthesia versus saddle block for open hemorrhoidectomy: cost-analysis from a randomized, double blind controlled trial

BACKGROUND

Despite the benefits attributed to the use of local anesthesia (LA) for open hemorrhoidectomy (OH) in developed countries, this technique is still not considered as the first line technique in low-income countries such as Uganda; therefore, we aimed at comparing the cost of OH under LA versus Saddle block among patients with 3rd or 4th degree hemorrhoids.

METHODS

This trial was conducted from December 2021 to May 2022 among patients with primary uncomplicated 3rd or 4th degree hemorrhoids. The operating time, and direct costs in (US$) including medical and non-medical were recorded. We analysed the cost in the two groups (local anesthesia versus saddle block) using SPSS version 23.0.

RESULTS

Findings of fifty-eight patients were analysed including 29 participants per group. There was a significant difference in operating time and cost among the two groups (p < 0.05). The mean operating time was 15.52 ± 5.34(SD) minutes versus 33.72 ± 11.54 min for OH under LA and SB respectively. The mean cost of OH under LA was 57.42 ± 8.90 US$ compared to 63.38 ± 12.77US$ in SB group.

CONCLUSION

The use of local anesthesia for OH was found to have less operating time with high-cost effectiveness. Being affordable, local anesthesia can help to increase the turnover of patients who would otherwise wait for the availability of anesthesia provider. Policy makers should emphasize its applicability in low-income settings to help in the achievement of 2030 global surgery goals.

TRIAL REGISTRATION

Pan African Clinical Trials Registry, PACTR202110667430356. Registered on 08/10/2021.

Urethral calculus with a recurrent acute urinary retention in a male child aged 11 years: A case report

Urolithiasis is the presence of a stone anywhere in the urinary tract, it is commonly seen in adult patients and rare in children, especially when it is associated with acute urinary retention. In children, history is not suggestive and not specific; diagnosis is made by exclusion, and imaging studies often get the findings as incidental. In this case, the clinical presentation made early diagnosis quite difficult. The management of urethral calculi varies according to the site, size, associated urethral pathology, and available resources. It becomes an emergency when it causes acute urinary obstruction, urethral bleeding, or pain. We present a case report of an 11-year-old male with a history of 3 episodes of acute urinary retention secondary to urethral obstruction by calculi. The period between 1 episode and the next was observed to be approximately 1 year, with no logical explanation. Urethral calculus in children is less frequent than in adults worldwide. Urethral calculi are either formed in the native urethra or migrate from the upper urinary tract. Urgent urinary diversion and removal of the calculus with minimal urethral trauma is the recommended treatment.

Testicular salvageability and its predictors among patients with testicular torsion in a resource limited setting: a multicentre longitudinal study

INTRODUCTION

Testicular torsion refers to ischemia of the testicle due to twisting or rotation of the vessels supplying the testes. It is a urologic emergency requiring a high index of clinical suspicion and prompt surgical intervention with management aimed at avoiding testicular loss and resulting infertility. This paper gives an update on the current situation regarding this topic in low-income settings. The aim of this study was to determine testicular salvageability and its predictors amongst patients with testicular torsion at two tertiary African hospitals.

METHODS

This was a hospital-based multicentre longitudinal study at two tertiary hospitals in western Uganda. Patients with acute scrotum were enrolled and evaluated for testicular torsion. Those with confirmed testicular torsion underwent surgery and salvageability was reported as the primary outcome. Predictors for testicular salvageability were determined using backward binary logistic regression in SPSS version 22.

RESULTS

During the study period, 232 patients with acute scrotum were enrolled. The mean age was 35.3 (SD = 20.4) years. Forty-one (17.7%) patients had testicular torsion. Only 16 (39.0%) of patients with torsion had viable testes that were salvageable. Orchiectomy was performed on 25 patients (61.0%). At multivariate analysis, a patient who presented after 48 h from the onset of symptoms was 34.833 times more likely to have orchiectomy compared to one who presented within 12 h [AOR = 34.833, (95% CI = 5.020-60.711), P < 0.001].

CONCLUSION

In this study, the testicular salvage rate was low. The only predictor of salvageability was the time from the onset of symptoms to presentation. All males should be sensitized about the clinical features of testicular torsion to ensure early presentation to increase salvage rates.

Hirayama disease with proximal upper limb involvement in an adolescent female: A case report

Introduction and importance

Hirayama disease is a rare benign motor neuron disorder that involves a single upper limb. It affects the lower cervical myotomes and presents clinically by muscle wasting and weakness.

Case presentation

We report the case of a 17-year-old female who presented with a four weeks history of progressive weakness of the left upper limb. The blood investigations and image reported unremarkable findings. Patient improved on physiotherapy.

Clinical discussion

Hirayama disease is rarely encountered in clinical settings and should be suspected in female patients presenting with unilateral or asymmetrical bilateral lower motor weakness of hands and forearms.

Conclusion

We present a rare condition in a 17-year-old female with a left upper extremity monomelic amyotrophy, a Hirayama disease.

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We report a case of Hirayama disease in a 17-year-old female who was managed conservatively by physiotherapy.

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Patient presented with left shoulder amyotrophy with a normal cervical CT scan and normal blood investigations.

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Conservative management still the management of choice in our setting in case of Hirayama disease.

Bilateral concomitant inguinal and femoral hernias in an adult male: A case report

Introduction and importance

Bilateral concomitant inguinal and femoral hernias are an uncommon presentation clinically. If not managed in time, femoral hernias may be associated with incarceration or even strangulation.

Case presentation

We report the case of a 75-year-old male who presented with bilateral inguinal and femoral swellings which were diagnosed clinically and by ultrasound scan as uncomplicated inguinal and femoral hernias. Surgical management was done using the inguinal approach. His postoperative period was uneventful and was discharged without any complaint on the 4th post-operative day.

Clinical discussion

Bilateral concomitant inguinal and femoral hernias are a rare presentation. Surgery was done as the best option to prevent complications. The literature suggests that it remains the gold standard of management in groin hernias in adults.

Conclusion

We present a rare condition in a 75-year-old male with uncomplicated bilateral concomitant inguinal and femoral hernias.

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We reported a first African case of bilateral inguinal and femoral hernias in a 75-year-old male who underwent Lotheissen and McVay operation.

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Patient presented with 2 left and right groin swellings confirmed clinically and by ultrasound scan as uncomplicated inguinal and femoral hernias.

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Surgery remains the management of choice for groin hernias.

Kigali Surgical Sepsis (KiSS) Score: A New Tool to Predict Outcomes in Surgical Patients with Sepsis in Low- and Middle-Income Settings

BACKGROUND

Sepsis is common in surgical patients, and its presence influences the outcomes in those to undergo surgery. Factors such as advanced age, presence of comorbidities and many other conditions increase mortality in surgical patients with sepsis. The sequential organ failure assessment (SOFA) score simplified into qSOFA helps to define sepsis and to identify patients who are likely to die from it. Sepsis in surgery is under investigated in low- and middle-income countries and so are the factors for mortality in that specific surgical population. Our aim was to develop a prognostic tool accurate in predicting outcomes in surgical patients with sepsis who present at University Teaching Hospitals of Kigali (CHUK) and Butare (CHUB) and in other centers with limited resources METHODS: This was a prospective cohort study conducted over a period of 1 year from February 2018 to January 2019. The surgical patients with sepsis recruited in the first 6 months at CHUK served as the derivation cohort and those recruited in the next 6 months from both CHUK and CHUB served as the validation cohort. The Kigali surgical sepsis (KiSS) score was derived, and to determine its accuracy in predicting mortality, we measured sensitivity, specificity and area under receiver operator characteristic (AUROC) curve. We then compared this with qSOFA score.

RESULTS

A total of 288 patients were recruited with 144 in each cohort. The mean age was 36.5, and median age was 32.6. The mean length of hospital stay (LoHS) was 22.9 days. The overall intensive care unit (ICU) admission rate was 51.4%, and the surgical sepsis-related hospital mortality rate was 21.7%. Factors associated with surgical sepsis-related hospital mortality were age above 55 years (p = 0.034), presence of comorbidities (p = 0.069), hypotension (p = 0.014), tachycardia (p = 0.061), tachypnea (p = 0.028), decreased level of consciousness (p = 0.021), presence of GIT perforation (p = 0.026) and number of impaired organ function (p = 0.035). A predictive score (KiSS score) consisting of six parameters was derived from these factors and compared to qSOFA score. The sensitivity of KiSS score in predicting mortality was 73% (vs 52% for qSOFA), and the specificity was 97% (vs 87% for qSOFA). The predictive validity for hospital mortality was assessed by AUROC curve, and it was 0.939 (95% CI, p < 0.001) for KiSS and 0.684 (95% CI, p < 0.001) for qSOFA.

CONCLUSION

The KiSS score was effective in predicting surgical sepsis-related hospital mortality in low-resource setting. The KiSS score showed an added advantage of stratifying septic surgical patients to be operated on into those with good, variable and poor prognosis.