Surgery : Current Challenges with Their Evolving Solutions in Surgical Practice in West Africa
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Editors : E.Q. Archampong, V.A. Essuman, J.C.B. Dakubo, J.N Clegg-Lamptey
Publisher : Sub-Saharan Publishers
Date of Publication : 2013
Place of Publication : Accra
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Item Outcome of Treatment of Clubfoot at the Korle Bu Orthopaedic Unit Using the Ponseti Method(2013-12-09) Bandoh, A.K.; Addo, A.O.; Segbefia, M.Clubfoot deformity is common in Ghana and the understanding of the deformity is woefully inadequate among the general population. The current approach in the treatment of idiopathic clubfoot has focused on conservative techniques. The Ponseti technique has superior outcomes. This involves weekly manipulations and casting of the clubfoot to gradually correct the clubfoot. The functional result is good with the painfree and plantigrade foot after treatment very acceptable to the parents. This charpter addresses the predictiveness of the Pirani score in determining the number of casts in the treatment of Clubfoot at Korle-Bu Orthopaedic Unit using the Ponseti method. Each clubfoot was evaluated using the Pirani score at two weekly intervals with scores documented. Abduction brace was applied at full correction until age four years. There were 74 respondents made of 31 (42%) females and 43 (58%) males. The highest score at the beginning of treatment was 5 and at the end of treatment it dropped to zero in some cases. Overall mean score at 6 weeks was 2.5, at 10 weeks was 2.1 and at 16 weeks was 1.9. The highest drop in score occurred within the first 6 weeks. The Ponseti method is an effective method of treating idiopathic clubfeet. When started early, its outcome can be predicted with the Pirani score. Most of the correction took place in the first six weeks of casting. The Ponseti method is cost effective with excellent results and appeals to resource constrained nations including Ghana.Item Management of Oesophageal Atresia in a Developing Country like Ghana(2013-12-09) Appeadu-Mensah, W.The management of Oesophageal atresia has improved in most modern centres with survival figures rising from 50% in the 1950s to over 90% in the modern era. Factors that have contributed to this improvement include antenatal diagnosis, improvement in the anaesthetic management of neonates with improved intensive care and better management of associated anomalies. In developing countries, antenatal diagnosis of Oesophageal atresia remains rare and late presentation is the norm. With the absence of neonatal ventilators postoperative care is more challenging. The Waterston classification system which recognized the contribution of factors such as Pneumonia, low birth weight below 2.5 kilograms and Congenital anomalies to prognosis remains relevant in developing countries while the Spitz classification has become more relevant in prognostication in developed countries where survival in children weighing more than 1.5 kg and without a severe cardiac anomaly is high.Item The History, Development and Future of the Cardiothoracic Unit, Department Of Surgery, College of Health Sciences, University of Ghana(2013-12-09) Frimpong-Boateng, K.The cardiothoracic unit in the Department of Surgery at the College of Health Science, University of Ghana has evolved over the years from an obscure unit tucked at the fringes of “allied surgery” to become a foremost medical facility providing leading-edge care and research in adult cardiac surgery, paediatric cardiothoracic surgery, general thoracic surgery and cardiothoracic critical care, not only for clients in Ghana but also others from the entire West African sub-region. As a leading facility and pace setter in patients care and research the unit also continues its other mission of training the next generation of cardiothoracic surgeons, cardiologists, cardiac anaesthetists, critical care and operating room nurses as well as cardiac technicians and medical students. The cardiothoracic unit has had tremendous impact on the health delivery system not only through its traditional functions of care, research and teaching but also by been a model of excellence in hospital management and team building and interdisciplinary cooperation thus blazing the trail for other units and departments. The unit has had a palpable impact on the socio-economic development of Ghana and it is looking into the future with hope and determination so as to maintain the high standards achieved so as not fall behind world standards. The unit will endeavour to maintain its traditional ties to partner centres abroad as well as seeking sub-regional cooperation especially in areas such as research and organ transplantation.Item Lower Urinary Tract Obstruction(2013-12-09) Kyei, M.Y.The lower urinary tract, comprising the bladder and urethra, acts as a functional unit that allows low pressure storage of urine and subsequent emptying at intervals when appropriate. At voiding, there is contraction of the bladder muscles, relaxation of the bladder neck and the external urethral sphincter allowing urine to flow, with complete bladder emptying facilitated by the urethrovesical reflex. Lower urinary tract obstruction (LUTO) refers to conditions that block the flow of urine from the bladder leading to difficulty with voiding. For this review, publications and ongoing research work on LUTO in the Urology Unit of the Department of Surgery are primarily considered. Generally, the causes of LUTO show some variation according to age and sex. Urethral stricture and benign prostate enlargement is a common cause of LUTO in the adult male population, while urinary tract infections, uterine fibroids and pelvic prolapsed disease are observed in females. The patients present with lower urinary tract obstructive symptoms such as straining at micturition and poor urine stream. Management is based on the cause of the LUTO which may include catheterization as an emergency intervention followed by a definitive medical management and/or surgical intervention. For malignant lesions radiation therapy may be used. LUTO remains a major presentation by patients in the Urology Unit. While preventive measures are helpful in some conditions, others require not only well planned management strategies but further research into more optimal and lasting interventions.Item Obstruction of the Biliary Tract(2013-12-09) Darko, R.R. Darko The obstruction of the biliary tree may be intrahepatic or extrahepatic. It may also be partial or complete. When obstruction is significant the classical symptoms of jaundice, pruritus, pale stools and dark urine are prominent. Most cases of intra hepatic bile duct obstruction are not amenable for surgical repair and therefore emphasis will be placed on extrahepatic bile duct obstruction. Carcinoma of the head of pancreas is the commonest cause followed by a gall stone causing the biliary obstruction. There are four categories based on the behaviour of the jaundice.(a) Progressive jaundice (b) Fluctuating jaundice (c). Chronic continuous obstruction and (d), Segmental obstruction where the patient is usually not jaundiced. Even though the clinical diagnosis is usually satisfactory investigations are important. The most important investigations include observing a high level of blirubin and alkaline phosphatise. Delineation of the common bile duct by ultrasonography is the initial investigation but other investigations are necessary. Magnetic resonance imaging is reliable. Treatment may be palliative where the site of obstruction is bypassed or curative where the cause of the obstruction is removed. Complications abound if adequate preparation is not done in the jaundiced patient. The liver glycogen stores should be instituted by adequate intake of daily infusion of 10% dextrose for 3 to 4 days before operation. Coagulopathy that occurs in the jaundiced patient is corrected by administration of parenteral Vit K1. To prevent post-operative renal failure it is important to ensure adequate pre-operative, intra-operative and post-operative hydration.Item Lower Gastrointestinal Bleeding(2013-12-09) Archampong, E.Q.The management of gastrointestinal bleeding poses the principal challenge of location of source of the bleeding, since some upper gastrointestinal (UGIB) sources occasionally present with features indistinguishable from lower gastrointestinal bleeding (LGIB).1,2 Recent advances in endoscopic procedures, in particular, increasing use of capsule endoscopy, have prompted some rethinking of the dichotomous classification with a proposal for upper, mid and lower catagories.1,2 In most parts of the world mid and lower source of bleeding account for 25-30 percent of GI bleeding 3,4 and since 80 percent of these forms of GI bleeding settle spontaneously within 24 hours, it seemed essential to ascertain the features of LGIB in our practice and determine how these affect management. Six hundred and seventy-five patients who were referred from the surgical and medical out patients and general services for endoscopy for the two year period October 2010 to September 2012 were analysed retrospectively. The findings indicate that LGIB is not only less frequently encountered but also presents a less dramatic picture than UGIB. Haemorrhoids are the commonest cause (70.2 per cent), but increasingly significant are amoebic granulomas (7.0 percent) Diverticular disease (5.9 per cent) and Colo-rectal carcinoma (7.0 per cent).Item Cancer of the Colon and Rectum(2013-12-09) Naaeder, S.B; Dakubo, J.C.B.The global incidence of colorectal cancer currently exceeds 1.2 million new cases per year with a third of cases coming from developing countries where hitherto the disease was thought to be uncommon. In Africa there has been a steady increase in the annual incidence of new cases colorectal cancer over the past five decades. An aging African population may be accounting for this trend although environmental factors may also be contributing to the rising incidence of the disease. Whereas the mortality rate from colon cancer is declining in western nations it continues to have a devastating effect on half of its victims worldwide. Surgical excision remains the linchpin in the management of colorectal cancer and offers the only chance of cure in approximately half of the patients. Local and distant recurrences of the disease are not uncommon. Adjuvant chemoradiation has been and is still the standard of care for rectal cancers staged beyond Dukes Stage B1 as it has been shown to improve disease-free survival and overall survival. Newer chemotherapeutic agents have recently been introduced for the treatment of metastatic cancer with moderate outcomes. Novel molecular targeting therapies have been incorporated into a multimodality treatment of metastatic colorectal cancer and they have shown promising response rates and progression-free survival. With the introduction of thermal ablation techniques patients with inoperable and local recurrent colorectal cancer may have some hope as early results are encouraging.Item MANAGEMENT OF UPPER GASTROINTESTINAL BLEEDING(2013-12-09) Archampong, E.Q.While the recent emphasis on conservative measures in the management of peptic ulcer disease has facilitated control of the disease in the community, this has not reflected in commensurate decline in complications of the disease, such as bleeding or perforation. Indeed, recent reports from Ghana indicate that perforation and bleeding incidents are on the increase and do result in significant morbidity and mortality posing serious challenges in management. This chapter sets out to ascertain the magnitude of the problem posed by upper gastrointestinal bleeding at the Korle-Bu Teaching Hospital, exploring the dominant causes and the current protocol for management. This has been done through a retrospective analysis of some 552 cases of haematemesis and melaena referred to the endoscopy centre at the hospital over a two year period. The study has revealed that peptic ulcer disease is responsible for 27.5 percent (Duodenal Ulcer: 15.9 and Gastric Ulcer: 11.6) and that contrary to perception, oesophageal and grastric varices together account for 31.3 percent (oesophageal 30-6, and gastric 0.7). Negative findings were made in 14.1% of cases. Management has emphasized importance of initial management (resuscitation) and early diagnosis by endoscopy in a stable patient.Item MALIGNANT GASTRIC NEOPLASMS; HOPE FOR THE FUTURE(2013-12-09) Adu-Aryee, N.A.Gastric cancers are known to have poor prognosis worldwide except for Japan and Korea. There is a changing trend in the distribution of tumours with a relative increase in the proportion of proximal tumours in the western world. This has not been found to be true in Ghana. The addition of various forms of adjuvant treatment has improved the prognosis of treatment worldwide and these are being introduced into oncologic practice in Ghana with good prospects. Opportunities exist for researching into prognostic features of this devastating tumourItem GASTROINTESTINAL STROMAL TUMOURS ( GIST)(2013-12-09) Baako, B.GIST is the commonest mesenchymal neoplasm of the gastrointestinal tract. It was classified a leiomyoma, leiomyosarcoma until recently 1998 when it had been characterised by a specific histological and immunological pattern. GIST is proven only if the tyrosine kinase receptor kit- CD117 or the platelet derived growth factor receptor alpha (PDGFRA) can be demonstrated and spindle cell, epithelioid cells and cells of mixed differentiation are present histologically. It was unresponsive to chemo and radiotherapy until the Food and Drug Administration (FDA) of the USA’s approval of the tyrosine kinase inhibitor imatinib in the year 2000- the first effective systemic treatment to be discovered. Primary and secondary resistance can occur. Surgery in the early stages (<5cm), when it can be completely excised with healthy margins with no spillage or intraperitonea l bleeding has been curative.Item PEPTIC ULCER DISEASE(2013-12-09) Archampong, E.Q.Nothing short of a revolution has transpired in our understanding of the aetiology, pathogenesis and the management of peptic ulcer disease over the past century, and the burning issue is how far this has influenced the outcome of management. Dominance of treatment by surgical intervention based on the acid dogma “no-acid, no ulcer” has given way to conservative measures aimed at elimination of helicobactor pylori using short term antibiotic regimes. This chapter represents a descriptive study through review of the literature on the outcome of these interventions over the past half century. The study is supplemented with the outcome of interviews with colleagues on their practice as physicians and surgeons in the Korle-Bu Teaching Hospital. It is evident that in the local practice as elsewhere the management of peptic ulcer disease has become increasingly conservative; surgical interventions are virtually confined to complications – perforations, bleeding and cicatrisation. Control of the disease within the communities has been effective, but for problems of compliance on account of access to the necessary drugs in the community.Item ACUTE APPENDICITIS(2013-12-09) Naeder, S.B.; Clegg-Lamptey, J.N.; Dakubo, J.C.B.There is considerable variation in the incidence of acute appendicitis worldwide. The disease is common in western nations but much less so in developing countries. However recent reports suggest that the incidence of acute appendicitis is declining in the developed world and the reverse is occurring in developing countries. Acute appendicitis is now the leading cause of the acute abdomen in Africa including Ghana and West Africa. The aetiology of acute appendicitis has been attributed to the substitution of high residue diets with refined foods but this hypothesis has been disputed. Appendicular luminal obstruction by a faecolith is thought to initiate the inflammatory changes associated with acute appendicitis as the majority of cases are due to an obstructing faecolith. Diagnosis of acute appendicitis is largely clinical with the symptomatology essentially similar globally. In children, the elderly and pregnancy acute appendicitis may present a formidable diagnostic challenge and therefore a high index of suspicion is required. Sophisticated investigations are not necessary in the majority of cases. However ancillary investigations may be done to improve diagnostic accuracy and minimize the negative appendicectomy rate. The treatment of acute appendicitis is appendicectomy. Prophylactic antibiotics are required in all cases to reduce the incidence of surgical site infection. However in resource-limited settings conservative management with antibiotics may be the only option as the natural history of acute appendicitis includes spontaneous resolution. Recurrence rates following conservative treatment are, however, unacceptably high. Generally mortality and morbidity rates are low in acute appendicitis but are higher in those with complicated appendicitis.Item BENIGN AND PREMALIGNANT BREAST DISEASE(2013-12-09) Dedey, F.Benign Breast disease is one of the common diseases mainly affecting women. It includes a wide spectrum of disorders, some of which have malignant potential. It is therefore important to diagnose and manage these diseases appropriately. Breast Disease is assessed using the triple assessment. This includes clinical and radiological assessment, as well as biopsy for histological confirmation. Breast pain, lumps and nipple discharge are the most common features of benign breast disease. A thorough examination is useful in distinguishing benign from malignant breast disease. Radiological assessment involves the use of mammography and ultrasonography commonly. Core biopsies are usually preferable for obtaining tissue for histological diagnosis. Fine Needle Aspiration Cytology, incision and excision biopsies may however be indicated in specific situations. Treatment options depend on the specific disease and may be surgical or non surgical. Common benign breast diseases include fibrocystic changes and fibroadenoma in females and gynaecomastia in males. Premalignant breast disease, most commonly Ductal Carcinoma In Situ, has become more common with increase in screening procedures. It carries a higher risk of invasive disease as compared to the benign breast diseases. It should therefore be treated appropriately to prevent development of invasive carcinoma.Item Current Global Developments in Breast Cancer and Management in Ghana(2013-12-09) Clegg-Lamptey, J.N.; Vanderpuye, V.Breast cancer is the leading malignancy globally, and one of the leading cancers in Ghana. Global developments in the management of breast cancer have led to better patient management. These include the use of multidisciplinary teams (MDTs) in the formulation of management plans. These teams form the basis for best practice in the management of breast disease, and there are attempts to incorporate them in the management of Breast cancer in the two main treatment centres in Ghana. Others include the concept of patient-centred care, use of protocols and clinical trials. Developments in mammographic screening have not been reproduced in developing countries like Ghana for many reasons. These include the absence of mammographic facilities and the relatively young age of patients. A suggested programme that involves Clinical Breast examination, Breast self examination and opportunistic screening has been recommended. Triple assessment remains the basis for diagnosis. Of the various means of biopsy now possible, methods for taking biopsy of non-palpable lesions need to be developed in Ghana, since more patients now have mammograms with some of them reporting with non-palpable abnormalities There have been advances in treatment: surgery, radiotherapy and chemotherapy. Biological therapy in the treatment of patients with HER2 receptor overexpression is often hindered by the high cost of treatment. Generally, Breast cancer management in Ghana has kept pace with global developments. The young age breast cancer patients in Ghana, sociocultural differences and financial limitations require some modifications in the approach of the management of this condition in our country.Item THE WORLD THROUGH THE CHILD’S EYES-THE JOURNEY TOWARDS ELIMINATION OF CHILDHOOD BLINDNESS IN GHANA - THE KORLE-BU EXPERIENCE.(2013-12-09) Essuman, V.A.The World Health Organization (WHO) has identified the prevention, treatment and control of blindness and visual impairment in childhood as a priority area of work worldwide. This is targeted under the Vision 2020 Initiative for Elimination of Avoidable Blindness. The initiative requires specialised paediatric ophthalmology teams and units to achieve this goal, but these are non-existent in most developing and under-developed countries. WHO with its Partners and some Governments embarked on the establishment of such units in some deprived countries on pilot basis, and Ghana was one of the beneficiary countries. The Child Friendly Eye Care Centre (CFECC) was set up in Korle-Bu Teaching Hospital in Accra under the Phase I of the WHO/Lions Club International/ Goverment of Ghana Project for the Elimination of Childhood Blindness in Ghana. The experiences from the CFECC is presented here, looking at the achievements and the strengths, weaknesses, opportunities and threats (SWOT) analysis of the project.