Outcomes after surgery for children in Africa (ASOS-Paeds): a 14-day prospective observational cohort study

BACKGROUND

Safe anaesthesia and surgery are a public health imperative. There are few data describing outcomes for children undergoing anaesthesia and surgery in Africa. We aimed to get robust epidemiological data to describe patient care and outcomes for children undergoing anaesthesia and surgery in hospitals in Africa.

METHODS

This study was a 14-day, international, prospective, observational cohort study of children (aged <18 years) undergoing surgery in Africa. We recruited as many hospitals as possible across all levels of care (first, second, and third) providing surgical treatment. Each hospital recruited all eligible children for a 14-day period commencing on the date chosen by each participating hospital within the study recruitment period from Jan 15 to Dec 23, 2022. Data were collected prospectively for consecutive patients on paper case record forms. The primary outcome was in-hospital postoperative complications within 30 days of surgery and the secondary outcome was in-hospital mortality within 30 days after surgery. We also collected hospital-level data describing equipment, facilities, and protocols available. This study is registered with ClinicalTrials.gov, NCT05061407.

FINDINGS

We recruited 8625 children from 249 hospitals in 31 African countries. The mean age was 6·1 (SD 4·9) years, with 5675 (66·0%) of 8600 children being male. Most children (6110 [71·2%] of 8579 patients) were from category 1 of the American Society of Anesthesiologists Physical Status score undergoing elective surgery (5325 [61·9%] of 8604 patients). Postoperative complications occurred in 1532 (18·0%) of 8515 children, predominated by infections (971 [11·4%] of 8538 children). Deaths occurred in 199 (2·3%) of 8596 patients, 169 (84·9%) of 199 patients following emergency surgeries. Deaths following postoperative complications occurred in 166 (10·8%) of 1530 complications. Operating rooms were reported as safe for anaesthesia and surgery for neonates (121 [54·3%] of 223 hospitals), infants (147 [65·9%] of 223 hospitals), and children younger than 6 years (188 [84·3%] of 223 hospitals).

INTERPRETATION

Outcomes following anaesthesia and surgery for children in Africa are poor, with complication rates up to four-fold higher (18% vs 4·4-14%) and mortality rates 11-fold higher than high-income countries in a crude, unadjusted comparison (23·15 deaths vs 2·18 deaths per 1000 children). To improve surgical outcomes for children in Africa, we need health system strengthening, provision of safe environments for anaesthesia and surgery, and strategies to address the high rate of failure to rescue.

FUNDING

Jan Pretorius Research Fund of the South African Society of Anaesthesiologists and Association of Anesthesiologists of Uganda.

Management of caustic pharyngoesophageal injuries in Korle Bu Teaching Hospital, Accra, Ghana: a 12-year retrospective review of 29 cases

Introduction

caustic pharyngoesophageal strictures are life-threatening injuries with important management difficulties, lacking clear therapeutic guidelines. The aim of this study is to evaluate the surgical procedures and outcomes of severe caustic pharyngoesophageal strictures in our institution.

Methods

a total of 29 patients who underwent surgery for severe caustic pharyngoesophageal injury at the National Cardiothoracic Center from June 2006 to December 2018 were retrospectively reviewed. The age distribution, sex, management procedures, complications after surgery, and the outcome were analyzed.

Results

there were 17 males. The mean age was 11.7 years (range 2- 56 years). All patients accidentally swallowed caustic soda, except the oldest patient who ingested an unidentified substance. The treatment procedures included colopharyngoplasty in 15 (51.7%) patients, colon-flap augmentation pharyngoesophagoplasty (CFAP) in 10 (34.5%), and colopharyngoplasty with tracheostomy in 4 (13.8%). There was one case of graft obstruction from a retrosternal adhesive band and one case of postoperative reflux with nocturnal regurgitation. No cervical anastomotic leak occurred. Rehabilitative training for oral feeding was required for less than a month in most patients. Follow-up period ranged from one to twelve years. Four patients died within this period; two were immediate post-operative deaths and two occurred late. One patient was lost to follow-up.

Conclusion

outcome of surgery for caustic pharyngoesophageal stricture is satisfactory. Colon-flap augmentation pharyngoesophagoplasty reduces the need for tracheostomy before surgery, and our patients start eating early without aspiration.

Changes in origin of acute chest pain in a sub-Saharan African setting

Our aim was to demonstrate a shifting epidemiology of acute chest pain in Ghana. Efforts to increase physician awareness and best practices are urgently required. Patients presenting with acute chest pain to the two leading tertiary care centres in Accra were investigated.

Pattern of esophageal injuries and surgical management: A retrospective review

Background

The consequence of significant injury to the esophagus is devastating. The initial management when timely and appropriate is rewarding and often prevents lethal complications. The objective of this study is to describe the etiology of esophageal injury in our institution, the management procedures and the mid-term results.

Method

Consecutive patients diagnosed and managed for esophageal injury from January 2005 to March 2015 were retrospectively reviewed.

Results

One hundred and eleven patients were seen and treated during this period; 85 (76.6%) predominantly children were corrosive esophageal injuries who accidentally ingested caustic soda and 26 (24.4%) were traumatic esophageal injuries. Patients with corrosive esophageal injuries were predominantly male (2:1), mean age 12.8 ± 14.2 years (2-58 years) and predominantly children (53% ≤5 years; 18.8% ≥ 18 years). Patients with non-corrosive esophageal injury were also predominantly male (4:1) with a mean age of 34.4 ± 20.1 years (1-73 years). The treatment procedures for corrosive esophageal injuries included esophagocoloplasty 64 (75.3%), colopharyngoplasty 10 (11.8%), colon-flap augmentation pharyngo-esophagoplasty 4 (4.7%), colopharyngoplasty with tracheostomy 4 (4.7%) and esophagoscopy and dilatation 3 (3.5%). Mortality was 5.9% and 5 patients were lost to follow-up. In patients with noncorrosive esophageal injury, esophageal perforation from instrumentation accounted for 14 (53.9%), foreign body impaction 11 (42.3%) and spontaneous perforation 1 (3.8%) making up the rest. Management of these patients included esophagotomy and removal of foreign body 7 (26.9%), esophagectomy, cervical esophagostomy and feeding gastrostomy 10 (38.6%), primary repair 7 (26.9%), Ivor Lewis procedure 1 (3.8%) and emergency esophagectomy with colon replacement 1 (3.8%). Mortality in this group of patients was 7.7% and 4 patients were lost to follow-up.

Conclusion

Corrosive esophageal injuries were the most frequent form of esophageal injury at our center due to unrestricted access to corrosive substances. Generally, appropriate surgical intervention in patients with esophageal injury based on individualization of care yields excellent early and mid-term results.

Challenges of Caring for Functionally Single Ventricle Patients in Africa

Surgical palliation has remarkably improved survival of functionally single ventricle (FSV) patients born in developed nations but such outcomes have not occurred in Africa. The poor care coverage for FSV patients in Africa exists within the larger sphere of deficient health care for children born with congenital heart defects (CHDs) in Africa generally. This review takes the position that to improve health-care coverage for CHD patients on the continent, political priority is paramount. This can be attained with cohesive leadership for the CHD agenda, a guiding institution, and the mobilization of civil society to drive advocacy at national and international levels.

Conotruncal Heart Defect Repair in Sub-Saharan Africa: Remarkable Outcomes Despite Poor Access to Treatment

BACKGROUND

The outcome of children born with conotruncal heart defects may serve as an indication of the status of pediatric cardiac care in sub-Saharan Africa (SSA). This study was undertaken to determine the outcome of children born with conotruncal anomalies in SSA, regarding access to treatment and outcomes of surgical intervention.

METHODS

From our institution in Ghana, we retrospectively analyzed the outcomes of surgery, in the two-year period from June 2013 to May 2015. The birth prevalence of congenital heart defects (CHDs) in SSA countries was derived by extrapolation using an incidence of 8 per 1,000 live births for CHDs.

RESULTS

The birth prevalence of CHDs for the 48 countries in SSA using 2013 country data was 258,875; 10% of these are presumed to be conotruncal anomalies. Six countries (Nigeria, Democratic Republic of the Congo, Ethiopia, Tanzania, Uganda, and Kenya) accounted for 53.5% of the birth prevalence. In Ghana, 20 patients (tetralogy of Fallot [TOF], 17; pulmonary atresia, 3) underwent palliation and 50 (TOF, 36; double-outlet right ventricle, 14) underwent repair. Hospital mortality was 0% for palliation and 4% for repair. Only 6 (0.5%) of the expected 1,234 cases of conotruncal defects underwent palliation or repair within two years of birth.

CONCLUSION

Six countries in SSA account for more than 50% of the CHD burden. Access to treatment within two years of birth is probably <1%. The experience from Ghana demonstrates that remarkable surgical outcomes are achievable in low- to middle-income countries of SSA.

Colon bypass with a colon-flap augmentation pharyngoesophagoplasty

Extensive caustic stricture of the upper aero-digestive system (oro- and hypo-pharynx) is a severe injury with limited surgical options. We adopted augmentation of the cicatrized upper aero-digestive tract with colon as our preferred management option. The aim of this report is to describe our initial experience with the technique of colon-flap augmentation pharyngo-esophagoplasty (CFAP) for selected patients with severe pharyngo-esophageal stricture. Between October 2011 and June 2013, three male patients (aged 16, 4 and 18 years respectively) underwent CFAP following extensive pharyngo-esophageal stricture. Postoperative recovery was uneventful in all three cases and all started swallowing within 7 - 10 days after surgery without significant dysphagia. Colon-flap augmentation pharyngo-esophagoplasty is an effective procedure for reconstruction of the pharynx and the hypopharynx after extensive caustic pharyngoesophageal structure in selected cases.

Strictly-posterior thoracotomy: a minimal-access approach for construction of the modified Blalock-Taussig shunt in West African children

Introduction

In resource-poor settings, the modified Blalock-Taussig shunt (MBTS) is often performed for symptomatic relief of Fallot's tetralogy. From September 2011, we adopted the strictly posterior thoracotomy (SPOT), a minimal-access technique for the MBTS and report the cosmetic advantages in this communication.

Methods

We retrospectively analyzed the records of consecutive patients in whom the SPOT approach was used to construct the MBTS. Study end-points were early mortality, improvement in peripheral oxygenation, morbidity, and the cosmetic appeal.

Results

Between September 2011 and January 2013, 15 males and 8 females, median age 4 years (1.3 - 17 years) and weight 13 kg (11 - 54 kg) underwent the MBTS through the SPOT approach. The polytetrafluoroethylene grafts used ranged from sizes 4 - 6mm (median 5mm). The median preoperative SpO2 was 74% (55% - 78%), increasing to a postoperative median value of 84% (80% - 92%). Shunts were right-sided in 22 patients and left-sided in one. There were no shunt failures. Hospital stay ranged from 7 - 10 days. There was one early death (4.3%), and two postoperative complications (re-exploration for bleeding and readmission for drainage of pleural effusion). The surgical scars had excellent cosmetic appeal: they ranged from 5-10 cm in length; all were entirely posterior and imperceptible to the patient.

Conclusion

The SPOT approach represents a safe and cosmetically superior alternative to the standard posterolateral thoracotomy, the scar being imperceptible to the patient. The excellent cosmetic appeal and preservation of body image makes this approach particularly attractive in children and young adults.

Thoracic endometriosis syndrome

BACKGROUND

Thoracic endometriosis syndrome is a rare constellation of different pathological entities arising from intrathoracic endometriosis. Reports from centers in Africa are scanty. Varying theories have been proposed but none satisfactorily explains the varying clinical manifestations.

OBJECTIVE

To describe the demographics, pathological spectrum, and outcome of treatment of patients seen at a single centre in West Africa with intrathoracic endometriosis.

METHODS

Twelve women who were seen at Ghana's National Cardiotharacic Centre with intrathoracic endometriosis from 2004-2012 were retrospectively reviewed.

RESULTS

The age range was from 24 - 39 years with a mean of 32 ± 5 years. Pelvic endometriosis was confirmed in 8 (66.7%) of the patients, 2 (16.7%) had ectopic endometrial tissue at the umbilicus and one (16.7%) had ectopic endometrial tissue at the mons pubis. Seven (58.3%) of the patients had undergone prior uterine surgery before the clinical onset of thoracic endometriosis. The right hemithorax was involved in all 12 (100%) patients studied. Pneumothorax was present in six (50%) women, hemothorax in five (41.7%) and hemopneumothorax in one (8.3%). Three of the four patients who benefited from video assisted thoracoscopy had abrasive pleurodesis followed by hormonal therapy. The rest of the patients had chemical pleurodesis with or without hormonal therapy.

CONCLUSION

Thoracic endometriosis may be more prevalent in West Africa than previously believed. Outcome of treatment is satisfactory using a multidisciplinary approach.

The changing epidemiology of esophageal cancer in sub-Saharan Africa - the case of Ghana

INTRODUCTION

Esophageal cancer portends a grim prognosis. Most patients present with incurable disease. Scanty epidemiologic data on the disease has contributed to its low priority on the national. We sought to evaluate the current national trend in the presentation and outcome of esophageal cancer using our institutional experience from 1992 - 2010.

METHODS

This is a retrospective study based on 152 patients who were seen in our institution during the study period. The perioperative data of these patients were retrieved and the relevant details recorded. Histopathological reports were available for 75 patients managed over the period. The study setting was The National Cardiothoracic Centre, which serves as the only tertiary referral centre in the country for cardiothoracic problems.

RESULTS

There were 122 males and 30 females with a mean age of 57.8 ± 11.7 years. The yearly trend from 1992 to 2010 showed a steady increase in the incidence of esophageal cancer. High alcohol consumption and smoking dominated the history of 82.2% of the patients. Squamous cell carcinoma accounted for 78.7% and adenocarcinoma 21.3%. Distribution of esophageal carcinoma by anatomical location was 84.9% for distal third, 11.8% for middle third and 3.3% for upper third. All patients presented with incurable disease.

CONCLUSION

The study shows an increasing incidence of esophageal carcinoma in this country. Alcohol abuse and smoking are major risk factors; squamous cell carcinoma is the dominant histological type in this study.

The National Cardiothoracic Centre, Accra Ghana: proceedings of the second International Update Course in Cardiology - improving the coverage of cardiology services

Many developing countries now face the growing phenomenon of the double burden of disease. Most are still grappling with infectious diseases resulting from poor environmental sanitation and lack of access to good drinking water like malaria, cholera, and enteric fever. At the same time changes in diet and lifestyle in general in these countries is resulting in increasing numbers of people with obesity, sedentary life styles, increased salt intake from fast foods, increased smoking and consumption of alcohol and fizzy drinks, hypertension and diabetes. To increase the scope and depth of cardiovascular care in Ghana, the National Cardiothoracic Centre, (NCTC), organised the 2nd International Update Course in Cardiology for cardiologists and general practitioners, with emphasis on a practical approach to cardiology. Post conference evaluation indicated that the course was very useful especially for practitioners in district and regional hospitals. Close to 98% of the participants revealed that the update course will greatly impact positively on their management of cardiovascular diseases.