Advancing complex hepato-pancreato-biliary surgery in Uganda: Challenges and outcomes.

INTRODUCTION: Uganda has until recently mostly referred patients for complex hepato-pancreato-biliary (HPB) surgery abroad due to lack of local expertize. We report indications and a spectrum of surgeries performed in the first 4 years following the establishment of a routine HPB service at Lubaga Hospital (LH), Kampala, Uganda. We also detailed the challenges encountered in setting up this service. METHODS: Demographic, clinical parameters, surgery indications, procedures performed, and outcomes of consecutive patients that underwent HPB surgeries at LH from December 2018 to October 2022 were analyzed. RESULTS: Majority were females 72 (57.6%) with a median age of 50 (6-88) years. Forty-one (32.8%) underwent surgery on the pancreas (PS), 34 (27.2%) on the liver (LS), and 50 (40.0%) on the bile ducts (CBS). The most common symptom was abdominal pain. Benign disease was present in 37 patients (29.6%) while 88 (70.4%) had malignancy. A total of 34 patients (27.2%) had unresectable pancreatic head cancer and distal cholangiocarcinoma missed at preoperative imaging and discovered intraoperatively thus underwent palliative hepaticojejunostomy. Only 34 (27.2%) patients received postoperative ICU care. In-hospital mortality for this heterogenous group of patients was 6 (4.8%) for PS, 3 (2.4%) for LS, and 8 (6.4%) for CBS. CONCLUSION: Despite many challenges like limited access to ERCP accessories, lack of endoscopic ultrasound scans and PET-CT scans in the whole country, late presentation, and low quality imaging especially in preoperative determination of resectability of hepato-pancreato-biliary cancers, we managed to establish a functional HPB service. Patient results achieved were good in spite of these limitations.

Gastroduodenal intussusception as a rare cause of pancreatitis in a young female Ugandan: A case report.

INTRODUCTION AND IMPORTANCE: Gastroduodenal intussusceptions are rare and usually secondary to gastric lesions acting as the lead point. Gastrointestinal stromal tumors (GISTs) commonly occur in the stomach (40-60%). Other gastric tumors include; adenocarcinomas, leiomyomas, lymphomas among others. When gastric tumors act as lead points in gastroduodenal intussusception, pancreatitis may arise due to compression of the ampulla of Vater or pancreatic head. Gastroduodenal intussusception may mimic other inflammatory upper gastrointestinal conditions leading to delays in early diagnosis and timely intervention. CASE PRESENTATION: A twenty three year old female with gastroduodenal intussusception secondary to a gastric body GIST with associated pancreatitis. This gastroduodenal mass was initially diagnosed as a pancreatic head echo-complex mass by ultrasound. Confirmatory preoperative diagnosis was made after doing contrasted abdominal computed tomography (CT) scan and upper gastrointestinal endoscopy. Open gastric wedge resection was done. Patient had uneventful recovery and was discharged on the fifth postoperative day. CLINICAL DISCUSSION: Gastroduodenal intussusceptions have non-specific clinical features that may lead to delays in making the correct diagnosis. CT scan is a good imaging modality for diagnosing this condition but access is limited in low resource settings. Resection of the organic cause after reducing the intussusception leads to resolution of the symptoms caused by the intussusception, the GIST and the resultant pancreatitis. CONCLUSION: Gastroduodenal intussusception is rare and may present with nonspecific clinical features. Pancreatitis may arise due to the compression effects on the ampulla of Vater or pancreatic head. A high index of suspicion is key in making a timely diagnosis.

Internal medicine clerkship amidst COVID-19 pandemic: clinical learning experience of undergraduate medical students at Makerere University, Uganda: a cross-sectional study

BackgroundThe coronavirus-2019 (COVID-19) pandemic continues to impose a significant impact on medical education. We aimed to describe the clinical learning experience of undergraduate medical students undertaking internal medicine clerkship during the COVID-19 pandemic at Makerere University, Uganda. MethodsA descriptive, cross-sectional study among medical students in clinical years of study pursuing the Bachelor of Medicine and Bachelor of Surgery undergraduate degree program was conducted in November 2020. Only 3rd (junior clerks) and 5th (senior clerks) year medical students whose internal medicine clerkships were interrupted by the COVID-19 pandemic were studied. ResultsData of 188 (95%) eligible clinical year students; junior (101, 54.0%) and senior (86, 46.0%) were analysed. Median age was 24 (range: 22-42) years. Majority (70.1%) were male and Ugandan nationals (94.1%). Sixty-four (30.3%) students reported inadequate personal protective equipment, 152 (81.7%) felt at risk of contracting COVID-19, and 127 (67.9%) said it was difficult to observe COVID-19 standard operating procedures. Twenty-two students (11.9%) were discouraged from pursuing a career in internal medicine. Overall, most students reported good or excellent clinical experience pre-COVID-19 era compared to during the COVID-19 era (4.0 vs. 3.5, p<0.0001). Senior clerks significantly believed that the time allocated for the rotation was adequate (p<0.0001) and they were able to complete their study objectives (p<0.001), compared to the junior clerks. Senior clerks believed that learning was difficult when combined with junior clerks (p=0.013). About half of the students (51.4%, n=95) reported clinical teaching should remain as it was in the pre-COVID-19 era. ConclusionsThe COVID-19 pandemic has had a significantly negative effect on the clinical learning experience of the students. There is need to review the current teaching and learning methods to suit teaching and learning during pandemics of highly infectious diseases to ensure safe and effective learning experience. HighlightsO_LINearly half of the medical students reported a negative clinical learning experience during their internal medicine clerkship in the COVID-19 pandemic. C_LIO_LIOver two-thirds of the participants expressed that it was difficult to observe COVID-19 prevention standard operating procedures during their clinical rotations. C_LIO_LIOver 80% of the medical students felt at risk of contracting COVID-19 during their clinical rotation. C_LIO_LIAbout one-third of the medical students reported inadequacy in personal protective equipment like masks during their rotation. C_LI