The Pattern and Management of Chest Trauma at Muhimbili National Hospital; Dar es Salaam

Background: Chest trauma is common and its pattern varies in different places. Majority of patients are managed mainly conservatively. Tube thoracostomy is a simple procedure but it is associated with significant number of complications. The aim of this study was to evaluate the clinical pattern and its management at Muhimbili National Hospital. Methods: A hospital based prospective study of all consecutive patients admitted with chest trauma at Muhimbili National Hospital between November 2007 and September 2008. Clinical assessment and chest x-ray findings were used to diagnose and to evaluate any complications associated with chest tubes using a structured questionnaire. Results: The majority (95/119) of patients were males. Their age ranged from 12 to 72 years with the mode of 32 years. Motor traffic injury (MTI) was the commonest cause of chest trauma accounting for 72.3of the cases. Rib fractures were the most clinical type of chest injury and accounted for about 42.9of cases. Blunt chest injuries were more common (75.6) than penetrating injuries. Seventy three (61.3) patients had other associated injuries; in which fracture of extremities (25.2) and head injury (21.8) were the commonest. Sixty seven (56.3) patients were treated with closed tube thoracostomy only. The overall complication rate of the chest tubes was 32.9of which infection (24.7) and nonfunctional tubes (17.4) were the commonest. High mortality rate of 24.2was recorded. Conclusion: The clinical pattern and the management of chest injuries in this study was similar with many other series of study; however; the rate of closed tube thoracostomy remained high with many and avoidable complications

Missed Injuries in Multiple Trauma Patients: a Tertiary Care Experience in Tanzania

Background: Missed injuries remain a worldwide problem in all trauma centers and contribute significantly to high morbidity and mortality among trauma patients. There is paucity of information regarding missed injuries in Tanzania. The aim of this study was to establish the incidence; contributing factors; and short-term outcome of missed injuries among polytraumatized patients in our setting. Methods: This was a one-year duration (from January to December 2009) prospective cohort study involving all multiple trauma patients (ISS 16) admitted to Bugando Medical Centre. After informed consent to participate in the study; all patients were consecutively enrolled in the study. Data was collected using a pre-tested; coded questionnaire and analyzed using SPSS computer software version 11.5. Results: Ninety six of 462 patients (incidence; 20.1) had 112 missed injuries. Head and the neck (46.4) was the most common body region affected. Clinical error (57.1) was the most common factor contributed to the occurrence of missed injuries. Of the factors contributing to missed injuries; 57.4were potentially avoidable and 42.6were unavoidable. There was statistically significant difference in the mean ISS; mean GCS; orotracheal intubation; patient's arrival time and seniority of the attending doctor between patients with missed injuries and those without missed injuries (p-value 0.001). Mortality in patients with missed injuries was 19.8compared with 8.7in patients without missed injuries (p-value 0.001). Among the deaths in patients with missed injuries; 57.9were directly attributable to missed injuries (O.R. = 14.8; p-value =0.001; 95CI = 6.1- 32.46). Patients with missed injuries had longer stays in the hospital compared with patients without missed injuries (p-value 0.001). Conclusion: The incidence of missed injuries at BMC is high in patients with high ISS; low GCS; orotracheal intubation and those who reported during night hours. A high index of suspicious is needed when dealing with such a group of patients. The majority of missed injuries are potentially avoidable by repeated assessments both clinically and radiologically and by staff redistribution to address the increase of missed injuries during night hours. Implementation of a tertiary trauma survey should be routine in the Accident et Emergency department to minimize the occurrence of missed injuries.) had 112 missed injuries. Head and the neck (46.4) was the most common body region affected. Clinical error (57.1) was the most common factor contributed to the occurrence of missed injuries. Of the factors contributing to missed injuries; 57.4were potentially avoidable and 42.6were unavoidable. There was statistically significant difference in the mean ISS; mean GCS; orotracheal intubation; patient's arrival time and seniority of the attending doctor between patients with missed injuries and those without missed injuries (p-value 0.001). Mortality in patients with missed injuries was 19.8compared with 8.7in patients without missed injuries (p-value 0.001). Among the deaths in patients with missed injuries; 57.9were directly attributable to missed injuries (O.R. = 14.8; p-value =0.001; 95CI = 6.1- 32.46). Patients with missed injuries had longer stays in the hospital compared with patients without missed injuries (p-value 0.001). Conclusion: The incidence of missed injuries at BMC is high in patients with high ISS; low GCS; orotracheal intubation and those who reported during night hours. A high index of suspicious is needed when dealing with such a group of patients. The majority of missed injuries are potentially avoidable by repeated assessments both clinically and radiologically and by staff redistribution to address the increase of missed injuries during night hours. Implementation of a tertiary trauma survey should be routine in the Accident et Emergency department to minimize the occurrence of missed injuries

Enterocutaneous Fistula: a Tanzanian Experience in a Tertiary Care Hospital

Background: Enterocutaneous fistulae pose a therapeutic challenge to general surgeons all over the world and contribute significantly to high morbidity and mortality. The aim of this study was to describe our experience in the management of enterocutaneous fistulas; outlining the causes; fistula characteristics; treatment outcome and prognostic factors for fistula closure and mortality in our local setting. Methods: A prospective study of patients with enterocutaneous fistulae was conducted at Bugando Medical Centre between December 2007 and November 2009. After informed written consent for the study and HIV testing; all patients who met the inclusion criteria were consecutively enrolled into the study. Data were collected using a pre-tested; coded questionnaire and analyzed using SPSS software version 11.5. Results: Ninety two patients were seen during the study. There were 54 males (58.7) and 38 (41.3) females (M: F ratio = 1.4:1). Post-operative complication was the commonest cause of enterocutaneous fistulae in 91.3of cases. The majority of patients (63.0) had high output fistulae and the jejuno-ileum was commonly affected (60.9). The complication rate was 34.8and sepsis was the most common complication. Sixteen patients (17.4) had HIV infection. Fistula closure was successfully achieved in 64 patients (69.6). Of these; 42 patients (65.6) had spontaneous closure and 22 patients (34.4) underwent surgical closure. Mortality rate was 30.4. Using multivariate logistic regression; the cause of fistula; fistula output; presence of complications and institutional origin of the patient were found to be significant predictors of spontaneous closure (p-value 0.001); where as surgical closure was significantly associated with presence of complications and pre-morbid illness (p-value 0.001). Fistula output; institutional origin of the patient; presence of complications and premorbid illness; HIV positivity and CD4 count were significant predictors of mortality. Conclusion: Enterocutaneous fistulae pose a therapeutic challenge at BMC and contribute significantly to high morbidity and mortality. A multidisciplinary approach focusing on fluid resuscitation; nutritional supplementation; electrolyte replenishment; control of sepsis; containment of effluent; skin integrity and surgery at appropriate time is necessary to lessen morbidity and mortality with a higher fistula closure rate. The high rate of postoperative enterocutaneous fistulae resulting from anastomotic breakdown in patients referred from peripheral hospitals calls for urgent surgical skill training course in this region. The high rate of HIV infection in these patients needs further studies

Tunical vaginalis excision: the hydrocelectomy technique not to be forgotten

Background: The technique of excising the hydrocele sac (tunica vaginalis) rather extensively; leaving only 1- 2 cm rim of tissue adjacent to the testis and epididymis in the treatment of hydrocele in adults is to be advocated; as it gives the same result as Jaboulay's technique. The advantage with this technique is that; it reduces the size of the remaining tissue to near normal postoperatively and no risk of strangulating the spermatic cord as it may happen in Jaboulay;s technique.Methods: Adult male patients with different sizes of hydroceles were seen; investigated and operated with this technique in three hospitals- Muhimbili National hospital; Tumaini and MHS- Massana hospitals between January 2004 and June 2006.Results: A total of 25 patients were operated using this technique. The age ranged between 20 - 60years. Most of them had right-sided idiopathic hydrocele; the technique provided excellent results in the treatment of such conditions.Conclusion: The technique of excising the hydrocele sac (tunica vaginalis) needs to be advocated and should not be forgotten hydrocelectomy techniques