Pull-Through for Hirschsprung's Disease: Insights for Limited-Resource Settings From Mbarara.

INTRODUCTION: In many resource-limited settings, patients with Hirschsprung's Disease (HD) undergo initial diverting colostomy, followed by pull-through, and finally, colostomy closure. This approach allows for decompression of dilated and thickened bowel and improved patient nutritional status. However, this three-stage approach prolongs treatment duration, with significant stoma morbidity, costs, and impact on quality of life. Our aim was to determine whether pull-through for HD can safely be performed with simultaneous stoma closure, reducing treatment approach from three to two stages. METHODS: Children with HD and diverting colostomy were prospectively followed as they underwent pull-through with simultaneous stoma closure. Their in-hospital course and 3-mo outpatient course were assessed for postoperative complications. Patients with total colonic HD, redo pull-through, and residual dilated colon were excluded from the study. RESULTS: Of the 20 children, 17 were male (n = 17, 85%). All patients had rectosigmoid HD. The median weight, age at colostomy formation, and age at pull-through were 11.05 kg (interquartile range [IQR] 10-12.75), 0.9 y (IQR 0.25-2.8), and 2.08 y (IQR 1.28-2.75), respectively. Mean duration with colostomy before pull-through was 1.1 y (standard deviation 1.51). Median hospital length of stay was 6 d (IQR 5-7). Early complications included anastomotic leak (n = 1), perianal skin excoriation (n = 2), surgical site skin infection (n = 3), and fascial dehiscence (n = 1). Longer-term complications included stricture (n = 1, 5%) and enterocolitis (n = 2, 10%). CONCLUSIONS: In this small case series, we have demonstrated that pull-through with simultaneous stoma closure can be safely performed in resource-constrained settings. Further studies are needed to understand the quality of life and economic impact of this change in management for HD patients.

Pediatric abdominal trauma in a National Referral Hospital.

Background: Trauma is a major contributor to pediatric morbidity and mortality. Injury and violence are a major killer of children throughout the world. Unintentional injuries account for almost 90% of these cases. They are the leading cause of death for children aged 10-19 years. More than 95% of all injury deaths in children occur in low income and middle-income countries. Abdominal trauma is present in approximately 25% of pediatric patients with major trauma and is the most common cause of unrecognized fatal injury in children. Objectives: To describe the patterns, the management and outcomes of pediatric abdominal trauma.This was a descriptive retrospective study. Data was extracted from the Pediatric surgery Unit database from January 2012 to July 2019 on all abdominal trauma admissions to the unit. Results: Falls were the commonest (51.3%) mechanism for trauma on the unit. Most (84%) of the admissions had blunt abdominal trauma, with the majority (77%) managed non operatively. Only 16% had penetrating trauma, with the majority (84%) of these managed operatively. The average length of hospital stay for most (71.9%) of the patients was less than 7 days, with 96.1% of all admitted patients being discharged upon recovery. Conclusion: Blunt abdominal trauma is the most common pattern of pediatric abdominal trauma, with majority of these patients being managed non-operatively with good outcomes. Selective non-operative management for penetrating pediatric abdominal trauma has good patient outcomes as well.

High incidence of acute kidney injury among patients with major trauma at Mulago National Referral Hospital, Uganda: risk factors and overall survival.

Introduction: Acute kidney injury (AKI) is a common and life-threatening complication of major trauma. Recognition is often delayed and management is frequently sub-optimal. We determined the incidence, risk factors and immediate outcomes of AKI in patients with major trauma at Mulago National Referral Hospital. Methods: This was a prospective study. We recruited adult patients with ISS of > 16. The KDIGO criteria was used to stage AKI. Serum creatinine was measured at baseline, 24, 48, 72 hours and on discharge from the study. Participants were followed up for seven days if not yet discharged. Bivariate and multivariate analysis was done using modified Poisson regression with robust standard errors. Results: 224 patients were recruited. The incidence was 67/1000 persons per day. The risk factors were male sex, delayed presentation, hypoglycemia at admission, RR=1.62 (95%CI 1.24-2.12) and non-operative management RR=1.39 (95%CI 1.02-1.89). Out of the 62 patients that died, 34 (54.8%) had AKI. The overall mortality rate was 39.5 patients per thousand per day. Conclusion: There was a high incidence of AKI among patients with major trauma. Efforts to reduce morbidity and mortality should be prioritized.