Positive tumor margins in wide local excision of breast cancer: a 10-year retrospective study

Background. The safety of wide local excision as a standard surgical option for early stage breast cancer management in Ghana has not been evaluated. The aim of this study was to use retrospective histopathological descriptive study to evaluate the prevalence of positive tumor margins in wide local excision specimens and offer recommendations. Study design. We reviewed 147 breast lumps; following wide local excision; which were received in the Department of Pathology; for positive tumor margins. The data was analyzed using SPSS software (version 16). Results. A total of 2;751 female breast cancers were diagnosed during the study period; of which 147 (5.3%) were from wide local excisions (lumpectomies). Thirty-one (21.0%) had positive tumor margins. The mean age of women with positive margins was 53.4 (SD = 17.1) years. The mean size of primary tumor was 4.0 (SD = 2.1) cm; the majority (53.0%) of which were greater than 2.0?cm; but less than or equal to 5.0?cm (T2). A total of 26 (83.4%) of these tumors were invasive ductal carcinomas (NOS); 24 (92.3%) of the cases had combined Bloom-Richardson grading; and many; 10 (41.7%); were grade 1. Conclusion. Our study shows that 21.0% of all wide local excision biopsies had positive tumor margins; a figure that is comparable to those of other studies. Tumors with positive margins in this study were large; 4.0?cm (T2); and common in relatively young women. Treatment failure is therefore likely to occur in these patients

Pathology and the surgical management of goitre in an endemic area initiating supplementary iodine nutrition.

UNLABELLED: Goitre in the West African sub-region is caused by iodine deficiency and goitrogens in the diet. Supplementary iodine nutrition on a mass scale was started in Ghana in 1996. In areas where iodine deficiency have been corrected the histological pattern of goitre changes and this influences surgical decision making. Data on the histological types of goitre in our institution is lacking. OBJECTIVE: To define the histopathological types of goitre in this initial period of iodine supplementation and relate this to the types of thyroid surgeries that were performed. METHODS: It was a prospective study of consecutive patients who underwent thyroidectomy from January 2003-December 2007. Descriptive statistics was employed in analyzing the data RESULTS: Five hundred and twenty eight cases were studied made up of 470 (89%) females and 58 (11%) males with mean age of 41.98 yrs, SD ± 12.90 yrs. The excised mean thyroid tissue weight was 161.4 g, SD ± 116.3 yrs. Hyperplastic goitres were 373 (70.7%), toxic goitre 70 (13.3%), adenoma 37 (7.0%), carcinoma 25 (4.7%) and thyroiditis 23 (4.4%). Papillary carcinoma accounted for 56% (14) cancers. Subtotal thyroidectomy was performed in 278 (52.7%) of patients, near total thyroidectomy 107 (20.3%), lobectomy 98 (18.6%),total thyroidectomy 24 (4.5%), excision or completion thyroidectomy 20 (3.8%) and de-bulking 1 patient. Overall, complications occurred in 32 patients (6.1%) and were made up mostly of haemorrhage in 10 (1.9%), Hypocalcaemia 10 (1.9%), unilateral Recurrent Laryngeal Nerve(RLN) injury 3 (0.57%), Tracheal collapse 3 (0.57%) and Bilateral RLN injury 2 (0.4%). CONCLUSION: The introduction of iodine supplementation on a mass scale in Ghana is yet to have its fullest impact on thyroid diseases. Goitres are still large and cause pressure effects. Toxic, inflammatory and malignant goitres are gaining prominence, and surgery for malignant goitre was oncologically inadequate.Near total thyroidectomy is recommended as the minimum surgery to avert the need for completion thyroidectomies in view of the lack of preoperative pathological diagnosis of thyroid lesions.

Colorectal carcinoma: an update of current trends in Accra.

BACKGROUND: Clinical experience and earlier studies indicate that the number of colorectal cancer cases seen annually in the Accra metropolis is increasing. OBJECTIVE: This study was aimed at providing a current update on colorectal cancer in Accra, Ghana. METHODS: A prospective study of confirmed cases of colorectal cancer diagnosed from January 1997- December 2007. RESULTS: Three hundred and fifty-nine colorectal cancer cases were studied. Males were 192(53.5%) and females 167(46.5%) with an annual incidence of 32.6 new cases. The crude incidence rates were 12.53, 9.87 and 11.18 per 100,000 population for males, females and overall respectively. Rectal bleeding 185(51.1%), abdominal mass 76(21.1%), intestinal obstruction 62(17.3%), intestinal perforation nine (2.5%) and iron deficiency anaemia nine (2.5%) cases were the main presentations. There were 168 (46.8%) rectal and 191(53.2%) colon tumours. Two hundred and thirty-one patients had laparotomy with 225 resections, and 128 patients for various reasons did not undergo surgery. The Astler Coller stages of the tumours at diagnosis were C2 84(36.7%), C1 53(22.1%), B2 49(21.4%), D 17(7.4%), B1 14(6.1%) and A 12(5.1%) cases. Adenocarcinoma was the commonest histological type 321(89.4%), with the majority either well-differentiated (62.5%) or moderately well-differentiated (25.6) carcinomas. Poorly differentiated carcinomas accounted for 28 cases (7.8%). Post-operative mortality was 6.1%. Long term survival could not be assessed as the majority of patients were lost to follow up. CONCLUSION: The incidence of colorectal cancer has increased over the last four decades in tandem with an aging population of Accra with adenocarcinoma as the predominant histological type.

Colorectal Carcinoma: an Update of Current Trends in Accra

BACKGROUND: Clinical experience and earlier studies indicate that the number of colorectal cancer cases seen annually in the Accra metropolis is increasing. OBJECTIVE: This study was aimed at providing a current update on colorectal cancer in Accra; Ghana. METHODS: A prospective study of confirmed cases of colorectal cancer diagnosed from January 1997 - December 2007. RESULTS: Three hundred and fifty-nine colorectal cancer cases were studied. Males were 192(53.5) and females 167(46.5) with an annual incidence of 32.6 new cases. The crude incidence rates were 12.53; 9.87 and 11.18 per 100;000 population for males; females and overall respectively. Rectal bleeding 185(51.1); abdominal mass 76(21.1); intestinal obstruction 62(17.3); intestinal perforation nine (2.5) and iron deficiency anaemia nine (2.5) cases were the main presentations. There were 168 (46.8) rectal and 191(53.2) colon tumours. Two hundred and thirty-one patients had laparotomy with 225 resections; and 128 patients for various reasons did not undergo surgery. The Astler Coller stages of the tumours at diagnosis were C2 84(36.7); C1 53(22.1); B2 49(21.4); D 17(7.4); B1 14(6.1) and A 12(5.1) cases. Adenocarcinoma was the commonest histological type 321(89.4); with the majority either well-differentiated (62.5) or moderately well-differentiated (25.6) carcinomas. Poorly differentiated carcinomas accounted for 28 cases (7.8). Post-operative mortality was 6.1. Long term survival could not be assessed as the majority of patients were lost to follow up. CONCLUSION: The incidence of colorectal cancer has increased over the last four decades in tandem with an aging population of Accra with adenocarcinoma as the predominant histological type

Gastro-duodenal peptic ulcer perforation.

OBJECTIVES: To determine the epidemiology of, and define the morbidity and mortality factors following emergency surgery for patients with perforated peptic ulcer disease in Accra, Ghana. DESIGN: A retrospective and prospective hospital-based study. SETTING: The general and paediatric surgical wards of the Korle-Bu Teaching Hospital. MAIN OUTCOME MEASURES: Demography, the systolic BP, pulse rate and haemoglobin on admission at ER, co-morbid conditions, site of perforation, surgical method and treatment outcome. SUBJECTS: A total of 326 cases treated for peptic ulcer perforation, 267 males and 59 females; ratio 4.5:1, with mean age of 40.9, SD 16.4 and range 4-87 years, were studied. RESULTS: The incidence of peptic ulcer perforation rose from 1.6% in 1998 to 5.3% in 2002 and stabilised at 5%, and overall accounted for 4.6% of acute abdomen. Co-morbid conditions were present in 48 (18.2%) of cases. Ulcerogenic substance intake was in 177 (67%) patients. One hundred and twenty two (46.2%) patients reported to hospital within 24 hours of perforation. There were 287 (88%) duodenal, 22 (7.1%) prepyloric, and 19(4.9%) type 1 gastric ulcer perforations. Simple closure with omental patch was performed in 299 (94.3%), truncal vagotomy and drainage in 10 (3.2%), and Billroth II partial gastrectomy in seven (2.2%). Post-operative complications occurred in 62 (19%); overall mortality was 36 (11%). Logistic regression analysis of the patients clinical variables showed that age less that 60 years (p-value, OR and 95% CI; 0.002, 3.964 and 1.668-9.420), duration of perforation of more than 24 hours before admission (p-value, OR and 95% CI; 0.011, 2.471 and 1.228-4.971), alcohol intake (p-value, OR and 95% CI; 0.009, 2.543 and 1.259-5.135) and resectional surgery (p-value, OR and 95% CI; 0.000, 8.25E and 74204908.138-9162648048.1) were statistically significant in determining postoperative complications. Age 60 years and above (p-value, OR and 95% CI; 0.018,4.359 and 1.284-14.802), alcohol intake (p-value, OR and 95% CI; 0.042, 3.238 and 1.046-10.021) and resectional surgery (p-value, OR and 95% CI; 0.000, 1.20E and 938112920.94-1.54E+ 11) were the factors that showed statistical significance in determining post-operative mortality. CONCLUSION: Perforated peptic ulcer disease is emerging as a frequent cause of acute abdomen in our centre and affects the youth commonly. Age 60 years and above, duration of perforation for more than 24 hours before admission, alcohol intake and resectional surgery were the variables that showed statistical significance in predicting post-operative morbidity and/or mortality.

Upper gastrointestinal endoscopy at the Korle Bu Teaching Hospital, Accra, Ghana

Objectives: To study the indications for endo-scopy, the endoscopic diagnosis and other lessons learnt.. Methods: A retrospective and prospective audit of all upper gastrointestinal endoscopies performed in the Endoscopy Unit of the Korle-Bu Teaching Hospital from January 1995 to December 2002 was performed. Results: A total of 6977 patients, 3777 males and 3200 females with age range 1 year 8 months to 93 years were endoscoped. The mean age of males was 43.5 + 0.5 and females 43.7 + 0.6 years. Epi-gastric pain (42.5%), dyspepsia (32.8%) and haematemesis and melaena (14.2%) were the commonest reasons for endoscopy. Chronic duo-denal ulcer (19.6%), acute gastritis (12.7%), duo-denitis (10.2%), oesophagitis (7.5%) were the commonest diagnoses. Normal endoscopy was reported in 41.1% patients, and was higher in the younger age group compared to the older (R = 0.973, P<0.001). Nine hundred and ninety (14.2%) patients were endoscoped for haematemesis and melaena of which chronic duodenal ulcer (32.1%), gastritis/gastric erosions (12.8%), oesophageal varices (9.8%), carcinoma of the stomach (6.4%), and duodenitis (4.2%), were the commonest causes. No lesion was found in 20.6% of these patients. Urease test was positive in 75% of all biopsy specimen and 85% in chronic duodenal ulcer, gastritis and duodenitis. Conclusion: The normal endoscopy rate is high and needs to be reduced in order to help prolong the lives of the endoscopes. Chronic duodenal ul-cer is usually associated with H. pylori infection and is the commonest cause of upper gastrointesti-nal bleeding

Human pentastomiasis: a case report.

We report a case of human pentastomiasis in a 55-year-old farmer whose diagnosis was made incidentally during laparotomy on account of a mechanical small intestinal obstruction caused by adhesions. Encysted parasites and degenerative granulomas were found in the omentum and in the subserosal layer of the small intestine. These parasites were diagnosed as Armillifer armillatus larvae. The patient made an uneventful recovery after the operation and was discharged. He is being followed up.

Position and susceptibility to inflammation of vermiform appendix in Accra, Ghana.

OBJECTIVES: To determine the normal (non-inflamed) position of the vermiform appendix in Ghana and carry out a pilot study to test the hypothesis "The retrocaecal appendix is less prone to inflammation". DESIGN: Retrospective autopsy study. SETTING: The pathology department and the department of surgery theatres of the Korle Bu Teaching hospital in Accra, Ghana SUBJECTS: Consecutive autopsies and inflamed appendices at appendicectomy. Deaths occurring from untreated appendicitis were excluded from the autopsy study. Conversely non-inflamed appendices and appendices from interval appendicectomy were excluded from the appendicitis study. RESULTS: There were 1358 autopsies and 323 inflamed appendices. In the autopsy study the retrocaecal position was the most common (914 [67.3%]). Other positions were pelvic (294 [21.6%]), preileal (66 [4.9%]), postileal (51 [3.8%]) and paracaecal (33 [2.4%]). These positions were similar in males and females. The positions of 323 inflamed appendices were: retrocaecal (183 [56.7%]), pelvic (66 [20.4%]), preileal (20 [6.2%]), postileal (15 [4.6%]) and paracaecal (39 [12.1%]). Comparing the nonretrocaecal to the retrocaecal position by chi square, the non-retrocaecal position was more prone to inflammation (p<0.001). CONCLUSION: The position of the normal appendix in Ghana differs from Western literature. The retrocaecal position appears less prone to inflammation in Ghanaians.

Changing pattern of intestinal obstruction in Accra, Ghana.

BACKGROUND/AIMS: Over the past 50 years acute intestinal obstruction has remained among the commonest causes of the acute abdomen, along with peritonitis, appendicitis and gastrointestinal perforations. However several observers have noticed over the past 2 decades a shift in the etiological spectrum. The study aims at ascertaining the precise nature of the change. METHODOLOGY: Published data on intestinal obstruction from the Korle Bu Teaching Hospital over the past 50 years were reviewed, as the consistent report format permitted ready comparison of the series. Emphasis was placed on clinical features, established cause and resulting complications. RESULTS: The case load of intestinal obstruction has dwindled over the past 3 decades, accounting for 0.7% of all hospital admissions compared with 1.4% 30 years earlier. External hernias together with adhesive bands still constitute the bulk of presenting cases, but the proportions have changed with strangulated hernias accounting for 59.8% instead of 77.6%. The change has paralleled a rise in elective hernia day case surgery. The incidence of intussusception has almost doubled (7.4% from 4.0%) and it still afflicts the very young. Colonic neoplasms have been commoner over the past 2 decades although the incidence (3.3%) falls short of Western figures. Overall mortality has remained unchanged at 9.4% and this has been associated with a rise in resection rates to 18.3%. CONCLUSIONS: The patterns of intestinal obstruction have been much influenced by changing attitudes regarding elective hernia surgery and evolving financial policies.

Clinical spectrum of acute abdominal pain in Accra, Ghana.

In a 12-month prospective study 370 patients with acute abdominal pain were admitted to a single surgical unit of a large teaching hospital. The most common diagnoses were appendicitis (23.5 percent), Non-specific abdominal pain (NSAP) (21.4 percent), acute intestinal obstruction (10.8 percent), gynaecological causes (9.5 percent, and peptic ulcer (9.2 percent). Emergency operations were performed in 146 patients (39.5 percent). Appendicectomy was the commonest operation (77 cases or 52.7 percent) and there was a high incidence of complicated appendicitis (41.6 percent). Eleven patients (3.0 percent) died within 30 days of admission (8 postoperative and 3 non-operative deaths). The clinical spectrum of the acute abdomen in this study shows that surgeons in developing countries are not facing surgical challenges similar to those of their counterparts in developed countries and the most important diagnostic distinction surgeons in both localities have to make is that between acute appendicitis and non-specific abdominal pain.

Effect of acute dietary fibre supplementation on colonic pH in healthy volunteers.

Dietary fibre and undigested starch are fermented to short chain fatty acids by colonic bacteria with acidification of the colon. It has been suggested that acidification of the colon by these fatty acids inhibits bacterial metabolism, but this concept has been disputed. The aim of this study was to investigate the short term effect of a dietary fibre load on colonic metabolism. Colonic pH and breath hydrogen was measured in healthy omnivorous British male volunteers following ingestion, in turn and at weekly intervals, of 15g lactulose, wheat bran biscuits, oat bran biscuits and ispaghula husk. All the test meals caused a reduction in caecal pH and an increase in breath hydrogen production. The changes were greatest with lactulose. Lactulose and wheat bran caused acidification of the right and left colon whereas oat bran and ispaghula husk caused acidification of mainly the right colon. An inverse correlation between right colonic pH and breath hydrogen was observed in only the oat bran study. This study has demonstrated the ability of dietary fibre to lower right colonic pH and to increase breath hydrogen excretion. The changes were greater with soluble fibre than with insoluble fibre but the change in luminal pH was persistent all round the colon with insoluble fibre.

Effect of chronic dietary fibre supplementation on colonic pH in healthy volunteers.

Dietary fibre supplementations studies to evaluate the effect of dietary fibre on colonic and faecal pH have relied on the use of the unabsorbed disaccharide and osmotic laxative lactulose. We studied the effect of chronic dietary fibre supplementation on colonic pH in healthy British volunteers who consumed a normal mixed diet but who consumed a normal mixed diet but who were asked to double their daily intake of dietary fibre from their usual fibre sources. The median dietary fibre intake of the 5 male volunteers was 17.5 g/day. This was doubled to 34.4 g/day. The pH in all the parts of the colon decreased progressively during the period of study, being lowest at the end of two weeks of fibre supplementation. The pH returned to the presupplementation values within two weeks of cessation of fibre supplementation. This study has shown that the effect of dietary fibre on colonic pH is short-lived and therefore its use for dietary intervention in large bowel diseases should be indefinite.

Acute appendicitis and dietary fibre intake.

It has been postulated that acute appendicitis is the first serious disease to emerge with the adoption of fibre-depleted diets. The incidence of acute appendicitis is rising in Africa and this has been attributed to socio-economic advancement and the adoption of low residue diets. The aim of this study was to determine whether income levels and the level of dietary fibre intake play any role in the rising incidence of acute appendicitis in Ghana. Between June and November 1997 patients aged 13 years and above with acute appendicitis were studied. Their monthly net income levels or those of their parents if they were minors were ascertained and a dietary fibre questionnaire completed on each patient in order to assess his or her dietary fibre intake. The clinical details of each patient were recorded on a proforma. One hundred and seventy-three patients, 128 males and 45 females, mean age 29.2 (range 13-75) years were studied. 14 percent presented within 6 h, 46.8 percent within 24 h and 41.6 percent after 2 or more days. 53.2 percent had acute appendicitis and 42.8 percent presented with complicated appendicitis. The appendix was normal in 4.0 percent. Two patients died (1.2 percent). 61.3 percent of patients were low income earners and 38.7 percent were high income earners. The overall dietary fibre intake was 39.4 g per day with no significant difference in fibre consumption between low income earners (39.0 g/day) and high income earners (43.5 g/day). We conclude that dietary fibre may not be the important factor in acute appendicitis and other luminal and/or morphological factors may be predisposing factors.

Multiple primary carcinomas of the gastrointestinal tract.

A case of multiple primary Carcinomas of the gastrointestinal tract is reported in a man presenting with Carcinomas of the rectum and oesophagus.

Cancer of the colon and rectum in Ghana: a 5-year prospective study.

A prospective study of 134 patients who presented to a teaching hospital in Ghana for the first time with colorectal cancer between January 1987 and December 1991 is reported. The mean number of new patients per year was nearly three times that of a decade ago. The disease afflicts both sexes equally and the age of highest incidence is in the seventh and eighth decades. Some 65 patients had colonic cancer and 69 rectal lesions. Most patients presented with advanced disease and only four of 109 in whom disease was staged (3.7 per cent) had Dukes A tumours. Right-sided cancer of the colon was more common than that of the left. The importance of rectal examination is emphasized by the finding that 78 per cent of rectal tumours were within reach of the examining finger. 'Curative' resection was possible in 60 per cent of patients with colonic cancer but in only 36 per cent of those with rectal tumours. The postoperative mortality rate of patients who underwent laparotomy was 13.6 per cent and in those who had resection 5.5 per cent. Long-term follow-up was poor. These results emphasize the need for accurate data collection on colorectal carcinoma, public education on the importance of early diagnosis and follow-up after treatment. These findings also call for a study of the epidemiology and aetiology of colorectal cancer in Ghana.

Changing pattern of acute intestinal obstruction in Accra.

Five hundred and fifty-two cases of intestinal obstruction were seen over a two year period, January 1987 to December 1988. Strangulated external hernias and adhesions still remain the most common causes of intestinal obstruction in Accra, but there has been a change in their relative incidence with external hernias falling to 59.8 per cent and adhesive obstruction increasing to 21.0 per cent. There has been no change in the overall mortality and mortality from inguinal hernia which are still 9.4 per cent and 4.9 per cent respectively. However, there has been a significant improvement in mortality rate from volvulus and a slight improvement in mortality from adhesive obstruction even though the overall resection rate has increased from 12.7 per cent to 17.6 per cent.

Amputation of the lower limb in Korle-Bu Teaching Hospital, Accra.

With the increasing life expectancy of our population, peripheral vascular disease will soon become a major problem in our society. The incidence of neoplasia affecting the lower limbs is reported to be on the increase in Africa. The increased activity of our herbal colleagues has brought in its wake large numbers of patients with disastrous complications of cellulitis. The lack of sophisticated methods of diagnosis and treatment coupled with the ignorance of our people and late presentation mean that many limbs that could be salvaged will continue to be lost. We, as health workers, can lessen the emotional and social burden of these unfortunate patients by ensuring their early and rapid integration back into their communities.

Pattern of abdominal injuries in Korle Bu Teaching Hospital; Accra

Two hundred and thirty-four cases of abdominal trauma over the past 6 years were reviewed. There were four times as many male as female patients. The peak age incidence was in the second and third decades. Road traffic accidents were the commonest causes of blunt injuries whereas stab wounds predominated penetrating injuries. The spleen and the small bowel were the most common viscera injured. Although accidental injury in our environment is a common cause of morbidity; fatalities are few in those with abdominal trauma

Small intestinal obstruction secondary to peritoneal encapsulation - a case report

Encapsulation of the small bowel is a rare congenital anomaly in which the entire small intestine lies within an accessory peritoneal sac. It has been suggested by some authors that this anomaly is usually symptomless and could be left alone when encountered at laparotomy for an unrelated condition. This view is supported by the fact that the majority of patients in whom this condition has been discovered are in their sixth or seventh decade. However; Huddy et al. recently reported a case of small bowel obstruction due to peritoneal encapsulation. They suggested that this anomalous peritoneal sac should be removed whenever it is encountered. A similar case was recently treated in our unit and is here reported