Locating the arcuate line of Douglas: is it of surgical relevance?

Ventral hernia formation is a common complication of rectus abdominis musculocutaneous flap harvest. The site and extent of harvest of the flap are known contributing factors. Therefore, an accurate location of the arcuate line of Douglas, which marks the lower extent of the posterior wall of the rectus sheath, may be relevant before harvesting the flap. This study is aimed at determining the position of the arcuate line in relation to anatomical landmarks of the anterior abdominal wall. Arcuate lines were examined in 80 (44 male, 36 female) subjects, aged between 18 and 70 years, during autopsies and dissection. The position of the arcuate line was determined in relation to the umbilicus, pubic symphysis, and intersections of rectus abdominis muscle. Sixty four (80.4%) cases had the arcuate line. In most cases (52), this line was located in the upper half of a line between the umbilicus and the pubic symphysis. Most males (93%) had the arcuate line, while more than a third of females did not have it. In all these cases, the line occurred bilaterally as a single arcade, constantly at the most distal intersection of the rectus abdominis muscle. Consequently, the arcuate line is most reliably marked superficially by the distal tendinous intersection of the rectus abdominis muscle. Harvesting of the muscle cranial to this point will minimize defects in the anterior abdominal wall that may lead to hernia formation.

Correlation of clinical data, anatomical site and disease stage in colorectal cancer.

OBJECTIVE: To evaluate the colorectal cancer clinical data with respect to the anatomical location and stage of disease. DESIGN: Retrospective observational study. SETTING: Kenyatta National Hospital (KNH), Nairobi, Kenya. SUBJECTS: Two hundred and fifty three tumours were categorised as right colonic (RCC), left colonic (LCC) and rectal (RC) lesions. The distribution of symptoms (rectal bleeding, tenesmus, change in bowel habits, abdominal pain, intestinal obstruction, rectal mass), anaemia, transfusion requirement, and the Dukes' stages were compared for right colon, left colon and rectal tumours. RESULTS: There were 54 RCC, 59 LCC, 140 RC lesions. Patient delay from onset of symptom(s) to presentation was a mean of 26.6 +/- 43, 20 +/- 25 and 33.7 +/- 42 weeks for right, left and rectal lesions respectively (p = 0.092). The proportion of patients presenting with rectal bleeding was 21%, 44% and 79% for RCC, LCC and RC lesions, respectively. The prevalence of intestinal obstruction was 14.8%, 27.1% and 43.6% in right, left and rectal lesions, respectively. The haemoglobin levels were significantly lower for right sided lesions (p = 0.05 for right colon/rectum pair; p = 0.059 for right colon/left colon pair). The sites of the lesions had no relationship to the stage of disease at presentation. CONCLUSION: In patients with colorectal cancer, the duration of symptoms was prolonged irrespective of the anatomical sub-sites. Symptoms were evenly distributed across the anatomical regions except for bleeding and obstruction which predominated in rectal and left colon cancers respectively. This underlines the need for early investigations in patients with rectal bleeding, change of bowel habit, intestinal obstruction and anaemia.

Prevalence and Distribution of the Third Coronary Artery in Kenyans / Prevalencia y Distribución de la Tercera Arteria Coronaria en Kenianos

A third coronary artery (TCA) has been defined as a direct branch from the right aortic sinus (RAS) that contributes to the vascularization of the infundibulum of the right ventricle (RV). The distribution of this artery may be important in surgical procedures and in understanding the extent and progression of acute myocardial infarction. Its reported prevalence however shows ethnic disparity. The aim of the study was describe the prevalence and distribution of the third coronary artery in a Kenyan population. 148 cadaveric and postmortem human adult hearts obtained from the Department of Human Anatomy, University of Nairobi, and the Chiromo and Nairobi city mortuaries were used after an ethical approval. The hearts were studied by gross dissection for the prevalence and topographical anatomy of the TCA. Data was coded and analyzed using SPSS. The TCA is present in 35.1% of the heart specimens. It was variably distributed to the conducting system (23%), anterior wall of the RV (100%), interventricular septum (IVS) (51.9%) and the apex of the heart (5.8%). The TCA, with substantial contribution to cardiac vascularization, may be present in about a third of the Kenyans. It may constitute a significant collateral circulation to apical and septal perfusión. Interpretation of signs and symptoms of coronary occlusion should therefore consider possible contribution of this vascular channel.

La tercera arteria coronaria (TCA) ha sido definida como una rama directa del seno aórtico derecho (RAS) y contribuye a la vascularización del cono arterioso del ventrículo derecho (RV). La distribución de esta arteria puede ser importante en los procedimientos quirúrgicos y para comprender la magnitud y progresión del infarto agudo del miocardio. El reporte de su prevalencia, sin embargo, muestra disparidad étnica. Se describen la prevalencia y distribución de la tercera arteria coronaria en la población keniana, en un estudio transversal. Se utilizaron 148 corazones de cadáveres adultos, obtenidos del Departamento de Anatomía de la Universidad de Nairobi y de las morgues, de las ciudades de Chiromo y Nairobi, luego de su aprobación ética. Se estudiaron en los corazones por medio de la disección macroscópica, la anatomía topográfica de la TCA y su prevalencia. Los datos fueron codificados y analizados utilizando el software SPSS. La TCA estuvo presente en el 35,1% de los corazones. Su distribución variable fue del 23% en el sistema de conducción cardíaco, un 100% en la pared anterior del ventrículo derecho, 51,9% en el septo interventricular (IVS) y en el ápex del corazón un 5,8%. La tercera arteria coronaria contribuye sustancialmente a la vascularización cardiaca y puede estar presente en cerca de un tercio de los kenianos. Esto puede constituir una significativa circulación colateral para la perfusiones apical y septal. En la interpretación de signos y síntomas de oclusión coronaria se puede considerar la posible contribución de este vaso.

Initial injury care in Nairobi, Kenya: a call for trauma care regionalisation.

OBJECTIVE: To describe the emergency care of injuries at a main city hospital. DESIGN: A prospective study. SETTING: Data were collected between February 1st, 1999 and 30th April, 1999 from the records of the 2000 bed Kenyatta National Hospital (KNH) in Nairobi, Kenya. SUBJECTS: Two hundred and forty injury patients admitted at KNH were analysed. METHODS: All patients were analysed for demographics, environment of injury hospital arrival and Emergency Department times. The effects of injury severity, place of injury and time of day on these time intervals were analysed statistically. RESULTS: Road injury admissions formed 31% of all injury admissions. The mean age was 30 years. Males comprised 84.6% of all patients. The proportions of patients under 20 years of age was 20% with a peak age of 20-29 years. Majority (43.3%) of the injured resided in deprived neighbourhood of East Nairobi. The mean pre-hospital time was 2.56 hours. The Emergency Department disposition time was 3.36 hours. Injuries of all severities, as determined by the Injury Severity Score (ISS), were treated. The pace of care did not match severity of the injuries. Only 17.5% reached their areas of definitive care within sixty minutes. CONCLUSION: Injuries following road traffic accidents (RTAs) are common in Nairobi. The response to injury is slow and haphazard. The insitution of a care incorporating the city's health centers and pre-hospital triage may optimise care.

Use of a modified Alvorado score in the diagnosis of acute appendicitis.

BACKGROUND: The negative appendicectomy rates have remained high. The integration of clinical scores into the diagnostic process in acute appendicitis has had the purposes of improving decision making and reducing the negative rates in this common condition. The performance of these score systems have however, not been uniform. OBJECTIVE: To assess the usefulness of a modified Alvorado score (1986) to predict groups of patients with suspected appendicitis for definite surgery, observation or discharge from hospital. DESIGN: Prospective study. SETTING: Kenyatta National Hospital (KNH), a central referral and teaching hospital in Nairobi, Kenya. PATIENTS: One hundred and eighty nine patients with suspected acute appendicitis were studied over a period of twelve months. METHODS: Five symptoms and four signs were assigned numerical values and the patients scored out of a total of 10 points. A score of >7 predicted mandatory operation, 5-6 observation and score 1-4 predicted those not considered for surgery. The decision to operate was the prerogative of the surgeon or surgical resident based on overall clinical suspicion and not the diagnostic score. RESULTS: The proportion of patients with scores >7 was 40.7%. The mean score was 6.02. The mean ages and the gender ratios were similar across score groups. The negative appendicectomy rate was 17.6% for group 1-4, 16.5% for 5-6 and 19.7% for >7. These were similar to the overall negative rate of 18% based on clinical suspicion. The overall sensitivity and sensitivity for the scoring system was 80.3% and 16.8% respectively. CONCLUSION: High scores were found to perform poorly in predicting diagnosis of acute appendicitis preoperatively and in the reduction of negative appendicectomies. The integration of a scoring system does not offer advantage over degree of clinical suspicion.

Gunshot injuries as seen at the Aga Khan Hospital, Nairobi, Kenya.

OBJECTIVE: To determine the prevalence, injury patterns, offender-victim characteristics, treatment and outcome of firearm-related injuries at the Aga Khan Hospital, Nairobi. DESIGN: Retrospective descriptive study. SETTING: The Aga Khan Hospital, a major private hospital in Nairobi. SUBJECTS: One hundred and seven patients who presented at the Aga Khan Hospital Accident and Emergency Department (January 1993-December 1998) with firearm injuries and were subsequently hospitalised. There were 97 males and 10 females aged four to 94 years. The mean age was 39 years. RESULTS: The peak incidence was in the 40-49 year age group. The male to female ratio was 10:1. The victim offender was a thug, thief or robber in 74.7% of cases. Law enforcement officers were responsible for 9.4% of the injuries. The Injury Severity Scores (ISS) ranged from one to 32 with mean score of 8.25. Injuries involving the extremities were the most prevalent. There were 31 major operations performed. The complication rate was 35.5%. Six (6.5%) of these patients died. CONCLUSION: Gunshot injuries cause profound morbidity and significant mortality. A wider and larger study needs to be undertaken to elucidate the true nature of firearm injuries.

Anatomy and pathology of coronary artery in adult black Kenyans.

OBJECTIVE: To determine the pattern of coronary arterial anatomy and prevalence of postmortem coronary pathology in adult Kenyan Africans. DESIGN: Cross-sectional study. SETTING: The Nairobi City Mortuary and the Department of Human Anatomy, University of Nairobi. METHOD: One hundred hearts were retrieved during consecutive autopsies over a three month duration and systematically dissected. Details on coronary ramification, dominance, atherosclerosis, tunnelling and hypoplastic segments were obtained and statistically analysed. RESULTS: Seven patterns of left coronary ramifications were identified. The right coronary artery anomalously exited from the left coronary sinus in one situation. There were separate ostia for the coronary artery branches in 2% and 31 % of cases on the left and right coronary systems respectively. The right coronary artery was dominant in 82% of the hearts. Coronary ostial sizes and luminal dimensions showed wide variations. Only two of the hearts had atheromatous luminal narrowing greater than 75% of the cross-sectional area. Muscle bridges of average depths of 1.1-2 mm were demonstrable in 29% of the autopsies. Diminutive left anterior descending artery was present in four cases. The right coronary artery was diminutive in one case. CONCLUSION: Coronary atherosclerosis is still a rarity in the setting within which the study was undertaken. The diverse patterns of ramifications of the coronary tree begs for caution during coronary investigations and interventional procedures. Coronary arterial anomalies, myocardial bridges, atheroma and diminutive arteries should be considered in cases of sudden cardiac death in the absence of other pathologies.

Experience with road traffic accident victims at The Nairobi Hospital.

OBJECTIVE: To evaluate the clinical and epidemiological data on automobile injuries and to assess the adequacy of road trauma documentation at the Nairobi Hospital. DESIGN: A retrospective descriptive study. SETTING: The Accident and Emergency Centre of the Nairobi Hospital. SUBJECTS AND METHOD: Medical records of randomly selected road trauma patients who presented at The Accident Centre between 1st July 1997 and 31st August 1998 were analysed. RESULTS: The mean age was 32 years with a peak incidence in the 21-30 year age group. Males comprised 63.1% of the injured. The predominant category of the road user injured was the vehicle occupant (70%). Pedestrians only constituted 21.3%. Major city roads or highways were the commonest scenes of injury (38.3%). Most of the responsible vehicles were small personal cars (65.8%). The public service minibuses (popularly known as matatu) caused 20% of the injuries. Most of the injuries were mild and transport of the injured to hospital was uniformly haphazard. A quarter of the injuries were severe enough to warrant admission. Trauma documentation was poor with less than 30% accuracy in most parameters. CONCLUSION: The pre-hospital and initial care of the injured is not systematized. The study calls for re-orientation of trauma care departments to the care of the injured.

Coronary arterial vessels in relation to sudden cardiac death: a review.

OBJECTIVE: To review literature on the coronary vascular factors related to the syndrome of sudden cardiac death. DATA SOURCE/SYNTHESIS: Major published articles and case reports on the nature of sudden cardiac death were searched electronically (Medline, Internet) and through hand scanning. Comparison of the different studies with regard to common themes was undertaken and consensus opinions highlighted. RESULTS: The aetiology of sudden cardiac death is diverse. Many conditions, hitherto considered benign, including coronary arterial anomalies and muscle bridges have been shown to cause sudden cardiac death. Coronary atherosclerosis, hypoplastic coronary vessels, coronary artery dissections are the commoner causes. The role of coronary arterial thrombi is controversial. The protective role of exercise is seriously questioned by the many reports of sudden cardiac death in long distance runners. CONCLUSION: Cases of sudden cardiac death are increasingly being reported. As a minimum, autopsy worksheets for cases of sudden death should include atherosclerosis, congenital coronary anomalies, tunneling of coronary vessels and hyposplastic vessels in addition to valvular and myocardial disorders.

Acute appendicitis: an overview.

OBJECTIVE: To provide an overview of the changing epidemiology of acute appendicitis in the developed and developing countries and the presumptive reasons. DATA SOURCE: Major published series of the last two decades were reviewed using Medline Search and Index Medicus. The myriad of diagnostic approaches currently employed to reduce the hitherto high rates of negative appendicectomy were examined and current trends of management analysed. CONCLUSION: The treatment modalities of acute appendicitis have undergone tremendous changes in the last decade.