Publications by authors named "Kondo Chilonga"

21 Publications

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Bilateral Subdural Hematoma following Ventriculoperitoneal Shunt Insertion in a Ten-month Old Tanzanian Female with Congenital Hydrocephalus: An Uncommon Presentation.

East Afr Health Res J 2021 11;5(1):17-19. Epub 2021 Jun 11.

Department of General Surgery, Kilimanjaro Christian Medical Center, Moshi-Tanzania.

There is an unmet need for the treatment of hydrocephalus in Tanzania. Thousands of newborns each year in the region are affected by this condition and access to care remains a challenge. While treatment options like cerebrospinal fluid diversion through ventriculo-peritoneal shunting are within the skill set of general surgeons, the potential complications represent an additional challenge. We present a 10-month-old Tanzanian female who developed bilateral-subdural hematomas after insertion of a ventriculoperitoneal shunt.
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http://dx.doi.org/10.24248/eahrj.v5i1.646DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8291209PMC
June 2021

Modified gastrostomy feeding tubes in patients with oesophageal cancer: our experience from Northern Tanzania.

J Surg Case Rep 2021 May 27;2021(5):rjab221. Epub 2021 May 27.

Department of General Surgery, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.

Surgeons in resource-limited settings have adapted to overcome the challenges of the limitations of resources using different available methods and inventions from the local environment. We report four cases of oesophageal cancer palliatively treated with improvised gastrostomy feeding tubes by using 24Fr urinary catheters, to optimize their nutritional status to withstand chemotherapy/radiotherapy. Two patients managed to begin chemo and radiotherapy, but only one out of the four survived. The aim of this report is to appraise the methods used by surgeons to overcome the challenges they face in clinical practice.
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http://dx.doi.org/10.1093/jscr/rjab221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8159268PMC
May 2021

Ectopia cordis: A case report of pre-surgical care in resource-limited setting.

Int J Surg Case Rep 2021 Jun 12;83:105965. Epub 2021 May 12.

Kilimanjaro Christian Medical University College, Faculty of Medicine, P O Box 2240, Moshi, Tanzania; Department of Pediatrics, Kilimanjaro Christian Medical Center, P O Box 3010, Moshi, Tanzania.

Introduction And Importance: Ectopia cordis is a rare congenital malformation of thoracic midline fusion that presents as location of the heart outside the open chest cavity. This presents as a surgical emergency and demands early and specialized intervention. Particularly in resource-limited settings, where prenatal ultrasonography screening is not done, these children are often born in facilities without the capability of managing such conditions definitively, necessitating them to be referred to a specialized centre. At lower health facilities, the challenge is in ensuring that the child is kept stable and protected from infection until they can reach a centre with the facilities required for care. This report describes the management give to such a child until they were successfully handed over to a cardiac institute.

Case Presentation: We present a newborn male baby delivered at term to a mother from a low socio-economic background with his heart and abdominal viscera outside the thoracic and abdominal cavity. Despite presenting at a centre without cardiac surgery facilities or cardiologists, they were sustained until referral.

Clinical Discussion: Ectopia cordis is a rare congenital anomaly characterized by defect in the fusion of the anterior chest wall resulting in the abnormal extra-thoracic location of the heart. Five types exist; cervical type with worst prognosis, attempts can be made to re-locate the heart and close the thoracic defect surgically.

Conclusion: Even with limited resources, it is possible to provide the basic care necessary to sustain a child with this complex anomaly until definitive management can be provided.
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http://dx.doi.org/10.1016/j.ijscr.2021.105965DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8141755PMC
June 2021

Surgical service monitoring and quality control systems at district hospitals in Malawi, Tanzania and Zambia: a mixed-methods study.

BMJ Qual Saf 2021 Mar 16. Epub 2021 Mar 16.

Department of Epidemiology & Public Health, Royal College of Surgeons in Ireland Division of Population Health Sciences, Dublin, Leinster, Ireland.

Background: In low-income and middle-income countries, an estimated one in three clinical adverse events happens in non-complex situations and 83% are preventable. Poor quality of care also leads to inefficient use of human, material and financial resources for health. Improving outcomes and mitigating the risk of adverse events require effective monitoring and quality control systems.

Aim: To assess the state of surgical monitoring and quality control systems at district hospitals (DHs) in Malawi, Tanzania and Zambia.

Methods: A mixed-methods cross-sectional study of 75 DHs: Malawi (22), Tanzania (30) and Zambia (23). This included a questionnaire, interviews and visual inspection of operating theatre (OT) registers. Data were collected on monitoring and quality systems for surgical activity, processes and outcomes, as well as perceived barriers.

Results: 53% (n=40/75) of DHs use more than one OT register to record surgical operations. With the exception of standardised printed OT registers in Zambia, the register format (often handwritten books) and type of data collected varied between DHs. Monthly reports were seldom analysed by surgical teams. Less than 30% of all surveyed DHs used surgical safety checklists (n=22/75), and <15% (n=11/75) performed surgical audits. 73% (n=22/30) of DHs in Tanzania and less than half of DHs in Malawi (n=11/22) and Zambia (n=10/23) conducted surgical case reviews. Reports of surgical morbidity and mortality were compiled in 65% (n=15/23) of Zambian DHs, and in less than one-third of DHs in Tanzania (n=9/30) and Malawi (n=4/22). Reported barriers to monitoring and quality systems included an absence of formalised guidelines, continuous training opportunities as well as inadequate accountability mechanisms.

Conclusions: Surgical monitoring and quality control systems were not standard among sampled DHs. Improvements are needed in standardisation of quality measures used; and in ensuring data completeness, analysis and utilisation for improving patient outcomes.
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http://dx.doi.org/10.1136/bmjqs-2020-012751DOI Listing
March 2021

Economic Costs of Providing District- and Regional-Level Surgeries in Tanzania.

Int J Health Policy Manag 2021 Feb 23. Epub 2021 Feb 23.

Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.

Background: Access to surgical care is poor in Tanzania. The country is at the implementation stage of its first National Surgical, Obstetric, and Anesthesia Plan (NSOAP; 2018-2025) aiming to scale up surgery. This study aimed to calculate the costs of providing surgical care at the district and regional hospitals.

Methods: Two district hospitals (DHs) and the regional referral hospital (RH) in Arusha region were selected. All the staff, buildings, equipment, and medical and non-medical supplies deployed in running the hospitals over a 12 month period were identified and quantified from interviews and hospital records. Using a combination of step-down costing (SDC) and activity-based costing (ABC), all costs attributed to surgeries were established and then distributed over the individual types of surgeries. These costs were delineated into pre-operative, intra-operative, and post-operative components.

Results: The total annual costs of running the clinical cost centres ranged from $567k at Oltrumet DH to $3453k at Mt Meru RH. The total costs of surgeries ranged from $79k to $813k; amounting to 12%-22% of the total costs of running the hospitals. At least 70% of the costs were salaries. Unit costs and relative shares of capital costs were generally higher at the DHs. Two-thirds of all the procedures incurred at least 60% of their costs in the theatre. Open reduction and internal fixation (ORIF) performed at the regional hospital was cheaper ($618) than surgical debridement (plus conservative treatment) due to prolonged post-operative inpatient care associated with the latter ($1177), but was performed infrequently due mostly to unavailability of implants.

Conclusion: Lower unit costs and shares of capital costs at the RH reflect an advantage of economies of scale and scope at the RH, and a possible underutilization of capacity at the DHs. Greater efficiencies make a case for concentration and scale-up of surgical services at the RHs, but there is a stronger case for scaling up district-level surgeries, not only for equitable access to services, but also to drive down unit costs there, and free up RH resources for more complex cases such as ORIF.
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http://dx.doi.org/10.34172/ijhpm.2021.09DOI Listing
February 2021

Using Group Model Building to Capture the Complex Dynamics of Scaling Up District-Level Surgery in Arusha Region, Tanzania.

Int J Health Policy Manag 2020 Dec 13. Epub 2020 Dec 13.

Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands.

Background: Scaling up surgery at district hospitals (DHs) is the critical challenge if the Tanzanian national Surgical, Obstetric, and Anesthesia Plan (NSOAP) objectives are to be achieved. Our study aims to address this challenge by taking a dynamic view of surgical scale-up at the district level using a participatory research approach.

Methods: A group model building (GMB) workshop was held with 18 professionals from three hospitals in the Arusha region. They built a graphical representation of the local system of surgical services delivery through a facilitated discussion that employed the nominal group technique. This resulted in a causal loop diagram (CLD) from which the participants identified the requirements for scaling-up surgery and the stakeholders who could satisfy these. After the GMB sessions, we identified clusters of related variables using inductive thematic analysis and the main feedback loops driving the model.

Results: The CLD consists of 57 variables. These include the 48 variables that were obtained through the nominal group technique and those that participants added later. We identified 6 themes: patient benefits, financing of surgery, cost sharing, staff motivation, communication, and effects on referral hospital. There are 5 self-reinforcing feedback loops: training, learning, meeting demand, revenues, and willingness to work in a good hospital. There are four self-correcting feedback loops or 'resistors to change:' recurrent costs, income lost, staff stress, and brain drain.

Conclusion: This study provides a systems view on the scaling up of surgery from a district level perspective. Its results enable a critical appraisal of the feasibility of implementing the NSOAP. Our results suggest that policy-makers should be wary of 'quick fixes' that have short term gains only. Long term policy that considers the complex dynamics of surgical systems and that allows for periodic evaluation and adaption is needed to scale up surgery in a sustainable manner.
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http://dx.doi.org/10.34172/ijhpm.2020.249DOI Listing
December 2020

Standard Urine Collection Bag as an Improvised Bogotá Bag as a Temporary Abdominal Closure Method in an Open Abdomen in Preventing Abdominal Compartment Syndrome.

Case Rep Surg 2021 29;2021:6689000. Epub 2021 Jan 29.

Department of General Surgery, Kilimanjaro Christian Medical University College (KCMUCo), P.O. Box 2240 Moshi, Tanzania.

Primary abdominal wall closure post laparotomy is not always possible. Certain surgical pathologies such as degloving anterior abdominal wall trauma injuries and peritoneal visceral volume and cavity disproportion render it nearly impossible for the attending surgeon to close the abdomen in the first initial laparotomy. In such surgical clinical scenarios leaving the abdomen open might be lifesaving. Forceful closure might lead to abdominal compartment syndrome and impair respiratory status of the patient. Open abdomen closure techniques have evolved over time from protection of abdominal viscera to complex fascia retraction prevention techniques. Silo bags, i.e., (Bogotá Bags), are relatively cheap, available materials used as a temporary abdominal closure method in limited resources settings. Despite its limitations of not preventing fascia retraction and draining of peritoneal fluid, it protects the abdominal viscera. We report a case of a 29-year-old male who developed incisional anterior abdominal wall wound dehiscence. He was scheduled for emergency explorative laparotomy. Intraoperatively, multiple attempts to reduce grossly dilated edematous bowels into the peritoneal cavity and fascia approximation into the midline were not possible. A urinary collection bag was sutured on the skin edges as a temporary abdominal closure method in prevention of abdominal compartment syndrome. He fared well postoperatively and eventually underwent abdominal incisional wound closure. In emergency abdominal surgeries done in limited surgical material resource settings were primary abdominal closure is not possible at initial laparotomy, sterile urine collection bags as alternatives to the standard Bogota bags as temporary abdominal closure materials can be safely used. These are relatively easily available and can be safely used until definite surgical intervention is achieved with relatively fewer complications.
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http://dx.doi.org/10.1155/2021/6689000DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864741PMC
January 2021

Immature teratoma of the ovary in a 1 year and 9-month-old child: a case report and review of the literature.

J Surg Case Rep 2021 Jan 30;2021(1):rjaa609. Epub 2021 Jan 30.

Department of General Surgery, Kilimanjaro Christian Medical Center, Moshi, Tanzania.

Immature teratoma of the ovary is a rare malignant germ cell tumor whose etiology is unknown. Preoperative diagnosis and treatment of this tumor can be challenging for clinicians. We present a 1-year and 9-month female child who presented with a 1- month history of progressive nontender abdominal distension. Computed tomography scan of the abdomen revealed a huge well-defined heterogenous mass arising from the peritoneal cavity. Surgical resection was performed. Histopathology coupled with immunohistochemical analysis of the specimen confirmed it to be an ovarian immature teratoma, grade one. The child recovered well postoperatively. Surgery alone is curative for most children and adolescents with resectable ovarian immature teratoma thus avoiding the long-term effects of chemotherapy in most children with this disease.
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http://dx.doi.org/10.1093/jscr/rjaa609DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7849942PMC
January 2021

Surgical Approach in Management of Posttraumatic Diaphragmatic Hernia: Thoracotomy versus Laparotomy.

Case Rep Surg 2020 5;2020:6694990. Epub 2020 Dec 5.

Department of General Surgery, Kilimanjaro Christian Medical University College (KCMUCo), P.O. Box 2240 Moshi, Tanzania.

Breach in diaphragmatic musculature permits abdominal viscera to herniate into the thoracic cavity. Time of presentation and associated injuries determines the surgical approach in management. This case report sets to highlight the challenges in clinical diagnosis, radiological interpretation, and surgical management approaches of posttraumatic diaphragmatic hernia. We report a case of a 43 years old male who was diagnosed with traumatic diaphragmatic hernia 6 months post blunt thoracoabdominal trauma due to motor traffic accident. He was initially diagnosed with haemothorax, drained with an underwater thoracostomy tube, and discharged. He continued to experience on and off chest pain worsening postfeeding, difficulty in breathing and abdominal pain for the next six months until his eventual diaphragmatic hernia diagnosis. He was scheduled for an elective thoracotomy. A left posterolateral thoracic over the 7 intercostal space incision was used. Intraoperatively, the stomach, left lobe of liver, part of transverse colon, small bowel, and omentum had herniated into the thoracic cavity adhering into thoracic viscera and wall. Adhesiolysis was done, and abdominal organs reduced into abdominal cavity. Rent was closed by interrupted Prolene sutures reinforced with a mesh. In patients with delayed presentation of diaphragmatic hernia post blunt thoracoabdominal injury without associated intra-abdominal visceral injury, we recommend the thoracic diaphragmatic repair approach as long-standing herniated bowels might adhere with thoracic cavity walls or viscera. In such cases, adhesiolysis and rent repair is easier through thoracotomy.
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http://dx.doi.org/10.1155/2020/6694990DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7787844PMC
December 2020

Clinical profiles of diabetic foot ulcer patients undergoing major limb amputation at a tertiary care center in North-eastern Tanzania.

BMC Surg 2021 Jan 12;21(1):34. Epub 2021 Jan 12.

Department of General Surgery, Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania.

Background: Diabetic foot ulcers complications are the major cause of non-traumatic major limb amputation. We aimed at assessing the clinical profiles of diabetic foot ulcer patients undergoing major limb amputation in the Surgical Department at Kilimanjaro Christian Medical Centre (KCMC), a tertiary care hospital in North-eastern Tanzania.

Methods: A cross-sectional hospital-based study was conducted from September 2018 through March 2019. Demographic data were obtained from structured questionnaires. Diabetic foot ulcers were graded according to the Meggitt-Wagner classification system. Hemoglobin and random blood glucose levels data were retrieved from patients' files.

Results: A total of 60 patients were recruited in the study. More than half (31/60; 51.67%) were amputated. Thirty-five (58.33%) were males. Fifty-nine (98.33%) had type II diabetes. Nearly two-thirds (34/60; 56.67%) had duration of diabetes for more than 5 years. The mean age was 60.06 ± 11.33 years (range 30-87). The mean haemoglobin level was 10.20 ± 2.73 g/dl and 9.84 ± 2.69 g/dl among amputees. Nearly two thirds (42/60; 70.00%) had a haemoglobin level below 12 g/dl, with more than a half (23/42; 54.76%) undergoing major limb amputation. Two thirds (23/31; 74.19%) of all patients who underwent major limb amputation had mean hemoglobin level below 12 g/dl. The mean Random Blood Glucose (MRBG) was 13.18 ± 6.17 mmol/L and 14.16 ± 6.10 mmol/L for amputees. Almost two thirds of the study population i.e., 42/60(70.00%) had poor glycemic control with random blood glucose level above 10.0 mmol/L. More than half 23/42 (54.76%) of the patients with poor glycemic control underwent some form of major limb amputation; which is nearly two thirds (23/31; 74.19%) of the total amputees. Twenty-eight (46.67%) had Meggitt-Wagner classification grade 3, of which nearly two thirds (17:60.71%) underwent major limb amputation.

Conclusion: In this study, the cohort of patients suffering from diabetic foot ulcers treated in a tertiary care center in north-eastern Tanzania, the likelihood of amputation significantly correlated with the initial grade of the Meggit-Wagner ulcer classification. High blood glucose levels and anaemia seem to be also important risk factors but correlation did not reveal statistical significance.
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http://dx.doi.org/10.1186/s12893-021-01051-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802243PMC
January 2021

A Report of a Large Axillary Cystic Hygroma (a.k.a Lymphangioma) in a Newborn from a Tertiary Hospital in Northern Tanzania.

Case Rep Surg 2020 17;2020:5624019. Epub 2020 Nov 17.

Department of General Surgery, Kilimanjaro Christian Medical Center, P O Box 3010, Moshi, Tanzania.

Introduction: Cystic hygroma is a rare condition of the lymphatic system that occurs mainly in children. They are found around the neck, axilla, inguinal, or thoracic regions. . A newborn female baby with a right-sided axillary mass since birth was admitted to our center. She was otherwise a healthy baby with noncontributory prenatal history. The mass was 12 cm in diameter and cystic. Wide excision of the mass was done, and histology confirmed cystic hygroma. Postoperatively, the baby did well clinically and was discharged.

Conclusion: Due to its rare incidence, reports and literature on management of cystic hygroma are few. A multidisciplinary approach is vital to yield the best prognosis for this rare condition.
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http://dx.doi.org/10.1155/2020/5624019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7685843PMC
November 2020

Day case laparoscopic cholecystectomy at Kilimanjaro Christian Medical Centre, Tanzania.

Surg Endosc 2021 08 1;35(8):4259-4265. Epub 2020 Sep 1.

Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, United Kingdom.

Introduction: The Lancet Commission on Global Surgery has promoted the case for safe, affordable surgical care in low- and middle-income countries (LMICs). In 2017, Kilimanjaro Christian Medical Centre (KCMC) in Tanzania introduced a day case laparoscopic cholecystectomy (DCLC) service, the first of its kind in Sub-Saharan Africa (SSA). We aimed to evaluate this novel service in terms of safety, feasibility and acceptability by patients and staff.

Methods: This study used mixed methods and was split into two stages. In stage 1, we reviewed records of all laparoscopic cholecystectomies (LCs) comparing day cases and admissions. These patients were followed up with a telephone questionnaire to investigate complication rates and receive service feedback. Stage 2 consisted of semi-structured interviews with staff exploring the challenges KCMC faced in implementing DCLC.

Results: 147 laparoscopic cholecystectomies were completed: 109 were planned for DCLC, 82 (75.2%) of which were successful, whilst 27 (24.8%) patients were admitted. No variables significantly predicted unplanned admission, the commonest causes for which were pain and nausea. In the DCLC group there was 1 readmission. 62 patients answered the follow up questionnaire, 60 (97%) of which were satisfied with the service. Stage 2 interviews suggested staff to be motivated for DCLC but revealed poor organisation of the day case pathway.

Conclusion: High rates of DCLC combined with low rates of complications and readmission suggests DCLC is feasible at KCMC. However, staff interviews alluded to administrative problems preventing KCMC from reaching its full DCLC potential. A dedicated day case surgery unit would address most of these problems.
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http://dx.doi.org/10.1007/s00464-020-07914-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263400PMC
August 2021

Perioperative serum albumin as a predictor of adverse outcomes in abdominal surgery: prospective cohort hospital based study in Northern Tanzania.

BMC Surg 2020 Jul 14;20(1):155. Epub 2020 Jul 14.

Kilimanjaro Christian Medical University College, P.O Box 2240, Moshi, Tanzania.

Background: Albumin is an important protein that transports hormones, fatty acids, and exogenous drugs; it also maintains plasma oncotic pressure. Albumin is considered a negative active phase protein because it decreases during injuries and sepsis. In spite of other factors predicting surgical outcomes, the effect of pre and postoperative serum albumin to surgical complications can be assessed by calculating the percentage decrease in albumin (delta albumin). This study aimed to explore perioperative serum albumin as a predictor of adverse outcomes in major abdominal surgeries.

Methods: All eligible adult participants from Kilimanjaro Christian Medical Centre Surgical Department were enrolled in a convenient manner. Data were collected using a study questionnaire. Full Blood Count (FBP), serum albumin levels preoperatively and on postoperative day 1 were measured in accordance with Laboratory Standard Operating Procedures (SOP). Data was entered and analyzed using STATA version 14. Association and extent of decrease in albumin levels as a predictor of surgical site infection (SSI), delayed wound healing and death within 30 days of surgery was determined using ordinal logistic regression models. In determining the diagnostic accuracy, a Non-parametric Receiver Operating Curve (ROC) model was used. We adjusted for ASA classification, which had a negative confounding effect on the predictive power of the percent drop in albumin to adverse outcomes.

Results: Sixty one participants were studied; the mean age was 51.6 (SD16.3), the majorities were males 40 (65.6%) and post-operative adverse outcomes were experienced by 28 (45.9%) participants. In preoperative serum albumin values, 40 (67.8%) had lower than 3.4 g/l while 51 (91%) had postoperative albumin values lower than 3.4 g/l. Only 15 (27.3%) had high delta albumin with the median percentage value of 14.77%. Delta albumin was an independent significant factor associated with adverse outcome (OR: 6.68; 95% CI: 1.59, 28.09); with a good predictive power and area under ROC curve (AUC) of 0.72 (95% CI 0.55 0.89). The best cutoff value was 11.61% with a sensitivity of 76.92% and specificity of 51.72%.

Conclusion: Early perioperative decreases in serum albumin levels may be a good, simple and cost effective tool to predict adverse outcomes in major abdominal surgeries.
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http://dx.doi.org/10.1186/s12893-020-00820-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362485PMC
July 2020

Juvenile Polyposis Syndrome in a Young Girl from Northern Tanzania.

Case Rep Surg 2020 3;2020:1536090. Epub 2020 Mar 3.

Department of General Surgery, Kilimanjaro Christian Medical Center, PO Box, 3010 Moshi, Tanzania.

. Juvenile polyposis syndrome is a rare autosomal dominant disorder in children characterized by multiple polyps in the gastrointestinal tract. A variety of clinical features manifest, including prolapse of a polyp or entire rectum, gastrointestinal bleeding, anaemia, and intussusception. This condition if left unmanaged promptly leads to fatal complications including the development of cancer of the bowel. . A 13-year-old girl with a history of mass protrusion per anus associated with bloody diarrhea. Colonoscopy showed multiple polyps in her large bowel. She underwent total colectomy with ileorectal anastomosis and did clinically well post surgery with no complications. . Juvenile polyposis syndrome is an inherited condition with significant morbidity and a high risk of colon malignancy. It is important for early screening and diagnosis and hence management in its early stages as there are no specific standard guidelines for children.
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http://dx.doi.org/10.1155/2020/1536090DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7073492PMC
March 2020

Isolated Pulmonary Hydatid Cyst: A Rare Presentation in a Young Maasai Boy from Northern Tanzania.

Case Rep Surg 2019 1;2019:5024724. Epub 2019 Oct 1.

Department of General Surgery, Kilimanjaro Christian Medical Center, PO Box 3010, Moshi, Tanzania.

Introduction: Hydatidosis is a parasitic manifestation caused by It is characterized by cystic lesions in the liver and lungs. Diagnosis is based on typical history and radiological measures.

Case Presentation: A four-year-old boy presented with a one-year history of dry cough and difficulty in breathing which was of gradual progression. Computed tomography of the chest revealed a large 11.7 cm × 8.6 cm × 11.0 cm cyst in the right hemithorax. The patient underwent thoracotomy and recovered well post procedure.

Conclusion: This case report highlights that large hydatid cysts can be surgically removed with good outcome and the importance of realizing that the disease is a burden to the public health and is much neglected.
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http://dx.doi.org/10.1155/2019/5024724DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6791237PMC
October 2019

Anesthesia Capacity of District-Level Hospitals in Malawi, Tanzania, and Zambia: A Mixed-Methods Study.

Anesth Analg 2020 04;130(4):845-853

Department of Epidemiology and Public Health Medicine, Royal College of Surgeons in Ireland, Beaux Lane House, Dublin 2, Ireland.

Background: District-level hospitals (DLHs) are the main providers of surgical services for rural populations in Sub-Saharan Africa (SSA). Skilled teams are essential for surgical care, and gaps in anesthesia impact negatively on surgical capacity and outcomes. This study, from a baseline of a project scaling-up access to safe surgical and anesthesia care in Malawi, Tanzania, and Zambia, illustrates the deficit of anesthesia care in DLHs.

Methods: We undertook an in-depth investigation of anesthesia capacity in 76 DLHs across the 3 countries, July to November 2017, using a mixed-methods approach. The quantitative component assessed district-level anesthesia capacity using a standardized scoring system based on an adapted and extended Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) Index. The qualitative component involved semistructured interviews with providers from 33 DLHs, exploring how weaknesses in anesthesia impacted district surgical team practices and quality, volume, and scope of service provision.

Results: Anesthesia care at the district level in these countries is provided only by nonphysician anesthetists, some of whom have no formal training. Ketamine anesthesia is widely used in all hospitals, compensating for shortages of other forms of anesthesia. Pediatric size supplies/equipment were frequently missing. Anesthesia PIPES index scores in Malawi (M = 8.0), Zambia (M = 8.3), and Tanzania (M = 8.4) were similar (P = .59), but an analysis of individual PIPES components revealed important cross-country differences. Irregular availability of reliable equipment and supply is a particular priority in Malawi, where only 29% of facilities have uninterrupted access to electricity and 23% have constant access to water, among other challenges. Zambia is mostly affected by staffing shortages, with 30% of surveyed hospitals lacking an anesthesia provider. The challenge that stood out in Tanzania was nonavailability of functioning anesthesia machines among frequent shortages of staff and other equipment.

Conclusions: Tanzania, Malawi, and Zambia are falling far short of ensuring universal access to safe and affordable surgical and anesthesia care for district and rural populations. Mixed-methods situation analyses, undertaken in collaboration with anesthesia specialists-measuring and understanding deficits in district hospital anesthetic staff, equipment, and supplies-are needed to address the critical neglect of anesthesia that is essential to providing surgical responses to the needs of rural populations in SSA.
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http://dx.doi.org/10.1213/ANE.0000000000004363DOI Listing
April 2020

Patterns and outcomes of patients with abdominal trauma on operative management from northern Tanzania: a prospective single centre observational study.

BMC Surg 2019 Jun 26;19(1):69. Epub 2019 Jun 26.

Department of General surgery, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania.

Background: The abdomen is one of the most commonly injured regions in trauma patients. Abdominal injury surgeries are common in Tanzania and in many parts of the world. This study aimed to determine the relationships among the causes, characteristics, patterns and outcomes of abdominal injury patients undergoing operations at Kilimanjaro Christian Medical Centre.

Methods: A prospective observational study was performed over a period of 1 year from August 2016 to August 2017. A case was defined as a trauma patient with abdominal injuries admitted to the general surgery department and undergoing an operation. We assessed injury types, patterns, aetiologies and outcomes within 30 days. The outcomes were post-operative complications and mortality. Multivariate logistic regression was used to explore the association between factors associated with morbidity and mortality.

Results: Out of 136 patients, 115 (84.6%) were male, with a male-to-female ratio of 5.5:1. The most affected patients were in the age range of 21-40 years old, which accounted for 67 patients (49.3%), with a median age (IQR) of 31.5 (21.3-44.8) years. A majority (99 patients; 72.8%) had blunt abdominal injury, with a blunt-to-penetrating ratio of 2.7:1. The most common cause of injury was road traffic accidents (RTAs; 73 patients; 53.7%). Commonly injured organs in blunt and penetrating injuries were, respectively, the spleen (33 patients; 91.7%) and small bowel (12 patients; 46.1%). Most patients (89; 65.4%) had associated extra-abdominal injuries. Post-operative complications were observed in 57 patients (41.9%), and the mortality rate was 18 patients (13.2%). In the univariate analysis, the following were significantly associated with mortality: associated extra-abdominal injury (odds ratio (OR): 4.9; P-value< 0.039); head injury (OR: 4.4; P-value < 0.005); pelvic injury (OR: 3.9; P-value< 0.043); length of hospital stay (LOS) ≥ 7 days (OR: 4.2; P-value < 0.022); severe injury on the New Injury Severity Score (NISS) (OR: 21.7; P-value < 0.003); time > 6 h from injury to admission (OR: 4.4; P-value < 0.025); systolic BP < 90 (OR: 3.5; P-value < 0.015); and anaemia (OR: 4.7; P-value< 0.006). After adjustment, the following significantly predicted mortality: severe injury on the NISS (17 patients; 25.8%; adjusted odds ratio (aOR): 15.5, 95% CI: 1.5-160, P-value < 0.02) and time > 6 h from injury to admission (15 patients; 19.2%; aOR: 4.3, 95% CI: 1.0-18.9, P-value < 0.05).

Conclusion: Blunt abdominal injury was common and mostly associated with RTAs. Associated extra-abdominal injury, injury to the head or pelvis, LOS ≥ 7 days, systolic BP < 90 and anaemia were associated with mortality. Severe injury on the NISS and time > 6 h from injury to admission significantly predicted mortality.
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http://dx.doi.org/10.1186/s12893-019-0530-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6595599PMC
June 2019

Evaluation of a surgical supervision model in three African countries-protocol for a prospective mixed-methods controlled pilot trial.

Pilot Feasibility Stud 2019 18;5:25. Epub 2019 Feb 18.

10Institute of Global Surgery, Royal College of Surgeons in Ireland, 123 St Stephen's Green, Dublin 2, Ireland.

Background: District-level hospitals (DLHs) can play an important role in the delivery of essential surgical services for rural populations in sub-Saharan Africa if adequately prepared and supported. This article describes the protocol for the evaluation of the Scaling up Safe Surgery for District and Rural Populations in Africa (SURG-Africa) project which aims to strengthen the capacity in district-level hospitals (DLHs) in Malawi, Tanzania and Zambia to deliver safe, quality surgery. The intervention comprises a programme of quarterly supervisory visits to surgically active district-level hospitals by specialists from referral hospitals and the establishment of a mobile phone-based consultation network. The overall objective is to test and refine the model with a view to scaling up to national level.

Methods: This mixed-methods controlled pilot trial will test the feasibility of the proposed supervision model in making quality-assured surgery available at DLHs. Firstly, the study will conduct a quantitative assessment of surgical service delivery at district facilities, looking at hospital preparedness, capacity and productivity, and how these are affected by the intervention. Secondly, the study will monitor changes in referral patterns from DLHs to a higher level of care as a result of the intervention. Data on utilisation of the mobile based-support network will also be collected. The analysis will compare changes over time and between intervention and control hospitals. The third element of the study will involve a qualitative assessment to obtain a better understanding of the functionality of DLH surgical systems and how these have been influenced by the intervention. It will also provide further information on feasibility, impact and sustainability of the supervision model.

Discussion: We seek to test a model of district-level capacity building through regular supervision by specialists and mobile phone technology-supported consultations to make safe surgical services more accessible, equitable and sustainable for rural populations in the target countries. The results of this study will provide robust evidence to inform and guide local actors in the national scale-up of the supervision model. Lessons learned will be transferred to the wider region.
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http://dx.doi.org/10.1186/s40814-019-0409-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6378729PMC
February 2019

Colorectal cancer in a patient with intestinal schistosomiasis: a case report from Kilimanjaro Christian Medical Center Northern Zone Tanzania.

World J Surg Oncol 2017 Aug 2;15(1):146. Epub 2017 Aug 2.

Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O Box 3010, Moshi, Tanzania.

Background: Colorectal cancer associated with chronic intestinal schistosomiasis has been linked with the chronic inflammation as a result of schistosomal ova deposition in the submucosal layer of the intestine. Among all species Schistosoma japonicum has been more linked to development of colorectal cancer as compared to Schistosoma mansoni due to absence of population-based studies to support the association. Despite the weak evidence, some cases have been reported associating S. mansoni with development of colorectal cancer.

Case Presentation: We report a patient who presented to us as a case of intestinal obstruction and found to have a constrictive lesion at the sigmoid colon at laparotomy, then later found to have colorectal cancer with deposited S. mansoni ova at histology.

Conclusion: Given the known late complications of schistosomiasis, and as S. mansoni is endemic in some parts of Tanzania, epidemiological studies are recommended to shed more light on its association with colorectal cancer.
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http://dx.doi.org/10.1186/s12957-017-1217-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5541651PMC
August 2017

Postoperative pain management outcomes among adults treated at a tertiary hospital in Moshi, Tanzania.

Tanzan J Health Res 2014 Jan;16(1):47-53

Inadequately controlled postoperative pain (POP) subjects individuals to complications which may be fatal or leading to prolonged hospital stay. Complications from inadequately controlled POP may alleviate the existing shortage of hospital human resource for health in health facilities in developing countries. The burden and challenges of POP management at health facilities in Tanzania is not known. This study was therefore carried out to evaluate postoperative pain management and patient satisfaction with care given at Kilimanjaro Christian Medical Centre (KCMC). This descriptive prospective hospital based study, was conducted at the Kilimanjaro Christian Medical Centre in Moshi, Tanzania from August 2011 to March 2012. POP and patients' satisfaction with pain relief scores were assessed using pain and satisfaction numerical rating scales. Pain assessment was done at 24 hours and 48 hours after operation. Satisfaction was assessed on 48 hours post surgery. All adult patient aged 18 years and above whom were operated in general surgery ward, KCMC and accepted by signing consent were involved in the study. Patients suffering from nervous system were excluded from the study. A total number of 124 patients were recruited and participated in the study. Sixty-five (52.4%) were males and 59 (47.6%) females. Mean age (SD) years 40.9 ± 15.4. The largest percentage of individuals had mild pain both at rest (45.2%) and during movement (44.4%). Patients whose analgesia was administered intravenously were more likely to be satisfied with POP management than those given intramuscular analgesics (P = 0.028). Analgesia used in combination increased significantly the proportion of pain free individuals 48 hours postoperative compared to 24 hours postoperative (P = 0.003). In conclusion, the postoperative pain management is still a challenge in our centre as nearly half of the patient had mild pain in.the first 48 hours post surgery.
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http://dx.doi.org/10.4314/thrb.v16i1.7DOI Listing
January 2014
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