ministry of health 21st college of surgeons of east

Ministry of Health

21st COLLEGE OF SURGEONS OF EAST CENTRAL AND SOUTHERN

AFRICA GRADUATION AND SCIENTIFIC CONFERENCE AND 28TH

SURGICAL SOCIETY OF ZAMBIA ANNUAL GENERAL MEETING

Theme:

Universal Health Coverage

Providing Safe Surgery in the Advent of Covid-19

Venue:

Mulungushi International Conference Centre

1st – 2nd December 2021

1

LOCAL ORGANISING COMMITTEE

Chairperson

• Prof. Laston Chikoya

Examinations Subcommittee

• Dr. Michael Mbambiko –

Chairperson

• Dr. Emmanuel J. Simwanza

• Dr. Mildred Nakazwe

• Dr. Webster Musonda

• Dr. Frank Changwe

• Dr Miriam Maimbo

• Dr Powell Kafwanka

Communications Subcommittee

• Dr. Jonathan Sitali - Chairperson

• Prof. Emmanuel Makasa

• Dr. Michael Mbelenga

• Dr. Martha Mukonka- Munga

• Dr. Bulaya Bulaya

• Dr. Munahimbala Hamweemba

• Dr. Joel Kandila

• Dr. Raymond Musowoya

• Dr Nyembezi Moyo

• Dr Mumba Chalwe-Kaja

Registration Subcommittee

• Dr. James Mulenga- Chairperson

• Dr. David Linyama

• Dr. Webster Musonda

Hospitality Subcommittee

• Dr. Mwamba CJ. Mulenga –

Chairperson

• Dr. Jabu Munalula

• Dr. Bernard M. Mpabalwani

• Dr Vanessa Savopoulos

• Dr. Taonga Mbewe

Transport Subcommittee

• Dr. Mwila Lupasha- Charperson

• Dr. Charles Mbewe

• Dr. Kizito Kabongo

• Dr. Brian Malao

Finance Subcommittee

• Dr. Patricia Shinondo- Chairperson

• Dr. Collin West

• Dr. Bright Moyo

Scientific Subcommittee

• Dr. James Munthali - Chairperson

• Prof. Kasonde Bowa

• Prof. Etienne Odimba

• Dr. Seke Kazuma

• Dr. Victor Mapulanga

Members

• Prof. Krikor Erzingatsian

• Dr. Elijah Mutoloki

Secretary- Mrs Roydah Hamalabbi,

COSECSA Country Coordinator

2

SPONSORS

Ministry of Health

3

Programme Overview

Sunday, 28th November 2021 ARRIVAL OF SECRETARIAT & COUNCIL

Date Activity Venue Persons

Responsible

Monday 29 November,

2021

Committee Meetings Taj Pamodzi Hotel Secretariat

Tuesday 30 November

2021

Council Meeting Taj Pamodzi Hotel CR/ Secretariat

Wednesday 1st

December 2021

Plenary

RDTF Oration

Graduation

Scientific Meeting

Mulungushi

International

Conference Centre

ECC/ Registrar/

Secretariat/

Chair/MC

Thursday 2nd

December, 2021

Scientific Meeting

Closing Ceremony

Mulungushi

International

Conference Centre

CR/Chair/MC

Pre-Conference Workshops

Date Workshop Venue Person Responsible

23rd to 25th November

2021

Primary Trauma

Course

University Teaching

Hospital, Tissue

Bank

Dr. Michael

Mbelenga/ Dr.

Simba Kaja

26th to 28th November

2021

Basic Surgical Skills

Course

University Teaching

Hospital, Tissue

Bank

Dr. Seke Kazuma/

Dr. Charles Mbewe

20th to 23rd November

2021

Orthopaedics

Workshop

Levy Mwanawasa

Teaching Hospital

Dr. Sitali Jonathan

27th November 2021 Publications in

Surgery

Levy Mwanawasa

Teaching Hospital

Dr. Mumba Chalwe-

Kaja

16th to 17th November

2021

Research Workshop Levy Mwanawasa

Teaching Hospital

Dr. James Mulenga

4

Wednesday 1st December 2021

Mulungushi International Conference Centre Time Activity Responsible

07:30-08:00 Registration Country Coordinator

Country representative

Zambia/Arusha Secretariat

08:00-08:10 Opening Remarks

• Welcome and conference overview

Host Chair

08:10-08:20 Welcome Remarks Dr. Michael Mbambiko

President Surgical Society of

Zambia

08:20-08:35 Welcome Remarks President COSECSA

08:35-09:20 Official Opening by Minister of Health Honourable Sylvia Masebo

MP

09:20-11:15 Graduation Ceremony Registrar/Chair, ECC

11:15-11:30 Motivational talk to Graduating Fellows Professor

Sean Tierney. RCSI

11:30-11:40 PRIZE GIVING AND CLOSING OF GRADUATION CEREMONY

• Lindsay Stewart Prize

Best Performing Students’ Awards

11:40-11:45 Housekeeping announcements Master of Ceremony

11:45-12:00 TEA BREAK, EXHIBITIONS, SPONSOR

POSTERS AND POSTER SESSION 1

PP1-Impact of the COVID-19

Pandemic on Pediatric Surgical Volume

in four Low- and Middle-Income

Country Hospitals: Insights from an

Interrupted Time Series Analysis.

Master of Ceremony

Dr. Paul Park, Bvulani B,

Ki B, Ameh E A, Ugazzi M,

Ozgediz D

12:00-12:30 “What diversity matters in Orthopaedics, hope

we are not late”

Dr. Mark Thiart-

International Orthopaedics

Diversity Alliance (IODA)

Executive Committee Africa

Regional Representative

12:30-12:50 Smile Train Presentation TBA

Mrs. Nkeiruka Obi, Vice

President & Regional

Director, Smile Train, Africa

12:50-13:00 Housekeeping announcements Master of Ceremony

13:00-14:00 LUNCH, EXHIBITIONS, SPONSOR

POSTERS AND CONTINUATION OF

POSTER SESSION.

PP2-Breast Cancer Management in sub-

Saharan Africa-

Master of Ceremony

James Wester, Chwa E,

Lockman S

14:00-14:45 Rahima Dawood Travelling Fellow Oration Prof. Emmanuel Makasa

14:45-15:00 Presentation by KidsOR Mr. Gareth Wood KidsOR

15:00-17:00 SCIENTIFIC SESSION 1-

CHAIR- TBA

5

15:00-15:15 OP30- Using Delta Mortality-to-Incidence

Ratios to Prioritize Cancer Care in Africa

Diehl T, Pourdashti S,

Schroeder D, Zafar N S,

University of Wisconsin

15:15-15:30 OP21- What is known about Burns in East

Africa? A scoping review

Dr. Francoise Mukagaju &

Pompermaier, L

Rwanda Military Hospital

Linkoping University

15:30-15:45 OP29- The RAIS device for global surgery:

navigating the translational pathway from

clinical-need to clinical-use

Dr. Peter Culmer, Bridges

P, Aruparayil N, Chugh C,

Bains L, Mishra A

University of Leeds, Mualana

Azad Medical College

15:45-16:00 OP1- Complications of Abdominal Surgery,

Study Carried Out in the Eastern Region of the

Democratic Republic of the Congo

Mr Aymar Akilimali

Official University of

Bukavu, DRC

16:00-16:15 OP3 - A Cross Section Study to Correlate Fine

Needle Aspiration Cytology and

Histopathology in the Diagnosis of Parotid

Tumours at Four Major Hospitals in Zambia

Dr. Seke Kazuma

Ndola Teaching Hospital,

Zambia

16:15-16:25 Q & A

16:25-16:35 Health Break

16:35-17:30 SCIENTIFIC SESSION 2-

CHAIR-TBA

16:35-16:50 OP13- Determining the prognostic value of

peripheral blood derived inflammatory markers

in predicting disease free survival in early

breast cancer

Dr. Ralph Obure, Wasike

R, Omuse G

Aga Khan University

Hospital, Nairobi, Kenya

16:50-17:05 OP14- The presence and availability of

essential diagnostics in Malawian District and

Central hospitals

Dr. Kiran Agarwal-

Harding, Chokotho L,

Young S, Kamalo P D,

Makasa E M, Mkandawire

N

Harvard Global Orthopaedics

Collaborative, Boston, MA,

USA

17:05-17:20 OP20- Patterns of facial fracture at tertiary care

hospital All Africa Leprosy, Tuberculosis and

Rehabilitation Training Center.

Dr. Fikru Sima,

ALERT Hospital, Ethiopia

17:20-17:35 Q & A

17:35 Adjournment

6

Thursday 2nd December 2021

Concurrent

Sessions

Auditorium Venue Room 2 Venue Room 3

SESSION CHAIR-TBA SESSION CHAR-TBA SESSION CHAIR-TBA 08:00-08:15 OP2- Jejunostomy, end

ileostomy, and transverse

colostomy management for a

patient who underwent laparotomy for faecal

peritonitis at a teaching

hospital in Ndola, Zambia-

Seke Kazuma

OP15- The experiences of

adult patients receiving

treatment for femoral shaft

fractures at Kamuzu Central Hospital, Malawi: a

qualitative analysis- Kiran

Agarwal-Harding, Atadja

L, Chokotho L, Banza L ,

Mkandawire N, Katz J N

OP36- Integration of

Uniformed Medical

Services into National

Surgical Obstetric and Anaesthesia Planning-

Michelle Joseph

08:15-08:30 OP32- The impact of

protocols on enhanced

Recovery after colorectal

surgery [ERAS] at Kamuzu

Central Hospital (KCH) in

Lilongwe, Malawi- Vanessa

Msosa

OP22- Burden of

Musculoskeletal disease

among a Refugee

population in South-

western Uganda- Peter

Muwanguzi, Ozgediz D,

Namugga M M, Klazura

G, Tang J

OP31- Feasibility of

telephone assessment for

surgical site infection: A

study embedded within a

global surgery trial-

Faustin Ntirenganya,

Glasbey J

08:30-08:45 OP5- Benign oesophageal

disease: Four cases managed

at a teaching hospital in

Ndola, Zambia- Seke

Kazuma

OP17- Clinical and

Functional Outcomes of

Nonoperatively Treated

Pediatric Supracondylar

Humerus Fractures at the

Nkhotakota District

Hospital, Malawi- Kiran

Agarwal-Harding, Mlinde

E, Amlani L, May J C,

Banza L, Chokotho L

OP33 Separation of

conjoined twins in resource

limited settings: A case

series exploring unique

challenges, solutions and

lessons learnt.- Kudzayi

Munanvi, Mutambanengwe G T,

Mbuwayesango B A,

Mazingi D

08:45-09:00 OP19- Early postoperative

complications associated

with perforation peritonitis at

a tertiary teaching hospital in Lusaka, Zambia- Kizito

Kabongo

OP23- Protocol for a

prospective cohort study of

open tibia fractures in

Malawi with a nested implementation of open

fracture guidelines-

Alexander Schade,

Nyamulani N, Banza L,

Metcalfe A, Harrison J W,

MacPherson P

OP35- Outcomes and

Lessons of Pediatric of a

Ten-year Pediatric Surgical

Data Initiative in Uganda- Nasser Kakembo

09:00-09:15 OP4- A retrospective case

series describing the

outcomes of 7 early reversals

of temporary ileostomies at a

teaching hospital in Ndola,

Zambia- Seke Kazuma

OP26- Epidemiology of

fractures and their

treatment in Malawi:

Results of a multicentre

prospective registry study

to guide orthopaedic care

planning- Linda Chokotho,

OP34- Leg amputation in

childhood, perspectives

from the amputee and the

community in an East

African setting- Tesmegen

Kebede, Timothy Nunn

7

Schade T A, Martin C,

Harrison J W,

MacPherson P, Graham M

S,

09:15-09:30 DISCUSSION

SESSION CHAIR-TBA SESSION CHAIR-TBA SESSION CHAIR-TBA

09:30-09:45 OP9- Fundoplication

Surgery for

Gastroesophageal Reflux

Disease – A Case Report-

Mulenga Chansa

OP24- The economic

burden of open tibia

fractures: a systematic

review- Alexander Schade,

Khatri C, Nwankwo H,

Carlos W, Harrison J W,

Metcalfe A

OP37- The accuracy of the

diagnosis of Prostate

Cancer using Fine Needle

aspiration cytology at

Ndola Teaching Hospital-

Donald Kasoma, Kasonde

Bowa,

09:45-10:00 OP11- A Successful Garlock

Procedure: The Left

Thoracoabdominal Approach for Adenocarcinoma of the

Esophagogastric Junction at

Ndola Teaching Hospital,

Zambia, Africa. – Case

Report with Literature

Review- Edgar Mumba,

Kazuma S M E, Musowoya

J, Chirengendure B,

Mackmadhov Z, Musas K

OP10- An evaluation of

the carrying angle of the

elbow joint in school children and adolescent in

Ndola, Zambia -Anadi

Bulaya, Bowa K

OP38- Variable

presentation of circumcaval

ureter, report of two cases and review of literature-

Bassem Yani, Kasoma

Zacharia

10:00-10:15 OP12- Management of a

Patient with a 9.6kg Gastric

Gastrointestinal Stromal

Tumour at Ndola Teaching

Hospital- Seke Kazuma

OP27- Quality of life and

functional outcome at 1

year in patients with

femoral shaft fractures

treated with intramedullary

nailing or skeletal traction

in a low-income country.

A prospective observational

study of 187 patients in

Malawi- Chokotho L,

Gjertsen J, Shearer D, Lau

B, Mkandawire N, Young

S

“We are fighting like a

team”: using supervision to

improve surgical services in

rural Malawi: a qualitative

study of Thyolo District

Hospital- Sophia A

Downey, Chiara Pittalis,

Jakub Gajewski

10:15-10:30 OP6- Management of a

Patient with Foreign Body

Ingestion at Ndola Teaching Hospital, Zambia- Boniface

Kaela

OP25- “Don’t rush into

thinking of walking again”:

Patient views of treatment and disability following an

open tibia fracture in

Malawi- Alexander

Schade, Siande W,

Karasouli E, Desmond N,

Harrison J W, Metcalfe A

10:30-10:45 OP7- Mucinous

Adenocarcinoma Associated

with Fistula in an 87-Year-

Old Managed with

Neoadjuvant Chemoradiation

and ELAPE at Tata

OP28- Cost utility analysis

of intramedullary nailing

and skeletal traction

treatment for patients with

femoral shaft fractures in

Malawi= Linda Chokotho, Donnelley C, Gjertsen J,

8

Memorial Hospital, in

Mumbai- Seke Kazuma

Hallan G, Agarwal-

Harding K J, Shearer D


11:00-11:30 REFRESHMENTS

SESSION CHAIR-TBA SESSION CHAIR-TBA SESSION CHAIR-TBA

11:30-11:45 OP8- Perineal Repair of a

Postoperative Perineal

Hernia: A Case Report- Seke

Kazuma

OP16- Improving

management of adult ankle

fractures in Malawi: an

assessment of providers’

knowledge and treatment

strategies- Kiran Agarwal-

Harding, Kapadia A,

Banza L, Chawinga M,

Mkandawire N, Kwon J Y

11:45-12:00 OP18- The prevalence and

incidence of adults with

femoral shaft fracture

receiving care in Malawian

district and central

hospitals- Kiran Agarwal-

Harding, Chokotho L,

Young S, Mkandawire N,

Losina E, Katz J N

12:00-12:15 OP39- Lindsay-Stewart

Prize Presentation- Prognostic factors for

surgical site infection

following intramedullary

nailing of diaphyseal

fractures of the femur and

tibia in adult patients at a

tertiary hospital in Lusaka,

Zambia.-Webster Musonda


12:30-13:30 LUNCH AND DEPARTURE

13:30-14:30 VENUE ROOM 2

INTERNATIONAL FEDERATION OF SURGICAL COLLEGES AGM

14:30-17:00 AUDITORIUM

SURGICAL SOCIETY OF ZAMBIA ANNUAL GENERAL MEETING

17:00 END OF PROGRAM

9

ORAL AND POSTER PRESENTATION ABSTRACTS

OP1-Complications of Abdominal Surgery, Study Carried Out in the Eastern Region of

the Democratic Republic of the Congo

Akilimali A, Official University of Bukavu

Email: [email protected]

Keywords: Abdominal surgery, Postoperative complication, Surgical complication

Background

In some regions like ours, the complications from abdominal surgery are important indicators

of the quality of surgical care, particularly in general surgery. The objective of our work is to

study the complications of abdominal surgery.

Methods

This is a retrospective and descriptive study carried out in the general surgery Department of

the Skyborn Hospital Center, over a period of 5 years, period from March 2016 to April 2021,

with a total of 286 patients.

Results

A total of 286 patients having participated in our study, we found that the male sex occupies

186 cases, the age group of the age group between 21 and 40 years occupies the first place, the

cesarean with 42% was the first the surgical history, the surgical site infection and wound

infection was the first postoperative complications with 64%. 91.6% of patients left the hospital

without any particularity and 75.4% of patients received surgical treatment for the management

of complications.

Conclusion

The delay in the management or non-prevention of complications is an important factor in the

occurrence of complications from abdominal surgery. Good postoperative management of the

operative site and the surgical wound can prevent and avoid complications of abdominal

surgery.

mailto:[email protected]

10

OP2- Jejunostomy, end ileostomy, and transverse colostomy management for a patient

who underwent laparotomy for faecal peritonitis at a teaching hospital in Ndola, Zambia

Kazuma SME, Ndola Teaching Hospital


Keywords: jejunostomy, ileostomy, colostomy, intestinal failure, HIV, Zambia

Abstract

The management of an HIV patient with high-output stomas is a big challenge in surgery. Such

patients present with physiological derangements that are life-threatening. The prognosis of

such patients in our setting is very poor, with a high mortality rate. The outcomes of surgery in

HIV/AIDS patients, however, do not depend on the clinical stages of HIV but rather on the

CD4 count. The CD4 count has been shown to be a predictor in determining the outcomes of

surgery in patients with HIV. In HIV patients, emergency surgery should be done as necessary,

but elective surgery is not advised until the CD4 count is above 500. The commonest and most

problematic complication of surgery in HIV patients is septic sequelae, which commonly result

in increased morbidity and mortality. After intestinal resections encountered in a septic

abdomen, a stoma is better than anastomosis, and an early reversal of such should be

encouraged in patients with HIV. Correction of dehydration, electrolyte balance, and

nutritional support are key to ensuring good outcomes after surgery. A multidisciplinary team

approach should be encouraged in managing such patients, as kidney disease, and not septic

sequelae, was the cause of death for our patient. We present a patient who was managed with

a high-output fistula at Ndola Teaching Hospital, Ndola, Zambia.

OP3- A Cross Section Study to Correlate Fine Needle Aspiration Cytology and

Histopathology in the Diagnosis of Parotid Tumours at Four Major Hospitals in Zambia

Kazuma SME., Ndola Teaching Hospital


Keywords: fine needle aspiration cytology, FNAC, Parotid gland

Background

Needle Aspiration Cytology (FNAC) is cheap, simple, quick, minimally invasive procedure

that is widely used for preoperative diagnosis of Parotid tumours.

Methods

Twenty-five patients were prospectively studied over a two-year period at four major hospitals

in Zambia. FNAC was done using a 10cc syringe and 20-22G needles for sample collection

and specimen staining was done with papanicolaou stain. Histopathology was assessed with

Haematoxylin and Eosin (H&E) stained sections.

Results

FNAC correlated with histopathology with a sensitivity of 100% and specificity of 66.7%;

positive and negative predictive values of 95.7% and 100% respectively and a likelihood ratio

of 3. All Parotid tumours were neoplastic with 76% benign and 24% malignant tumours on

histopathology. FNAC accurately diagnosed 68% benign and 20% malignant tumours.

Conclusion



11

This study found that FNAC correlates well with histopathology in the diagnosis

of parotid tumours. FNAC is useful in the preoperative assessment of Parotid tumours as it

provides a preoperative diagnosis that influences management by either avoiding surgery

(inflammatory lesion) and limiting the extent of surgery for benign and malignant Parotid

tumours.

OP4- A retrospective case series describing the outcomes of 7 early reversals of temporary

ileostomies at a teaching hospital in Ndola, Zambia



Keywords: ileostomy, early ileostomy closure, early ileostomy reversal, quality of life, surgical

wound infection, morbidity, intestinal perforation, typhoid, peritonitis

Abstract

Temporary ileostomy, though a simple surgical procedure, is associated with high morbidity

arising from a complicated clinical course that affects the quality of life and body image of the

patient. Ileostomies are offered to moribund patients with delayed presentation, fulminant

enteritis, and long-standing peritonitis due to ileal perforation with severe peritoneal

contamination. Ileostomies enhance intestinal decompression with improved healing, early

resolution of ileus, and early initiation of enteral feeding. However, ileostomy reversal to

restore intestinal continuity is a major surgical procedure associated with high morbidity and

mortality. The optimal timing of temporary ileostomy reversal is controversial following

emergency surgery. We report on 7 cases of delayed presentation of peritonitis due to ileal

perforation. The patients were initially treated with double-barrelled end ileostomies, and they

underwent ileostomy closure at Ndola Teaching Hospital, Zambia, within 14 days of the

respective index admissions, with good outcomes. For 6 of the patients, the indication for

ileostomy reversal was dehydration resulting in renal dysfunction, and psychosocial

disturbances were evident in all 7 patients. Five of the patients developed skin excoriation. Two

patients developed surgical site infections after ileostomy closure. The mean duration of

hospitalization was 22 days.

OP5- Benign oesophageal disease: Four cases managed at a teaching hospital in Ndola,

Zambia





12

Keywords: Benign oesophageal stricture, dysphagia, caustic stricture, oesophageal

reconstruction, gastric conduit, colon conduit, transhiatal and Ivor Lewis oesophagectomy

procedures.

Abstract

Benign oesophageal stricture disease presents with slow progressive dysphagia and minimal

weight loss. Progression of the disease results in total dysphagia, malnutrition and psychosocial

complications that compel patients suffering this condition to seek an oesophagectomy as their

last definitive treatment option. Upper gastrointestinal (GI) endoscopy with tissue biopsy and

barium swallow are important for evaluating the sequelae of oesophageal stricture disease, with

endoscopy being the golden standard evaluation procedure. Transhiatal oesophagectomy, as

opposed to the Ivor Lewis, is the preferred corrective procedure because it avoids a

thoracotomy and intra-thoracic anastomosis. The preferred conduit is gastric followed by the

colon. Jejunal conduit is technically challenging as it requires microvascular anastomosis

techniques. Colon conduit is preferred in those patients with lesions above the T1 vertebra or

more proximal strictures, and those with expected long-life survival because the colon

undergoes differential growth. Reconstructive procedures for patients with benign oesophageal

stricture are not common in poorly resourced settings. In Zambia, such patients have

historically been managed with feeding gastrostomies and/or referred abroad for reconstructive

surgery. In this article, we present our maiden experience of reconstructive surgical

management of benign oesophageal stricture by using both Ivor Lewis and transhiatal

oesophagectomy procedures, performed at Ndola Teaching Hospital, Zambia.

OP6- Management of a Patient with Foreign Body Ingestion at Ndola Teaching Hospital,

Zambia

Kaela B, Kazuma SME, Ndola Teaching Hospital


Keywords: foreign body ingestion

Abstract

Foreign body (FB) ingestion refers to intentional swallowing of indigestible, non-nutritious

solid substances. It is more common in children and psychiatry adult patients. Adult psychiatry

patients have the highest incidence of recurrent ingestion of multiple FB that results from poor

impulse control by caregivers and as a response to stress. Foreign bodies longer than 6cm,

wider than 2.5cm and sharp edged are unlikely to pass without getting imparted or causing

perforation. These warrant removal by endoscopy where available or laparotomy. We report

on the management of a case of intentional swallowing of multiple FBs by a known psychiatric

patient at Ndola Teaching Hospital, in Ndola, Zambia.

OP7- Mucinous Adenocarcinoma Associated with Fistula in an 87-Year-Old Managed

with Neoadjuvant Chemoradiation and ELAPE at Tata Memorial Hospital, in Mumbai


13



Keywords: Colorectal cancer colorectal mucinous adenocarcinoma anal cancer

adenocarcinoma associated with anal fistula anal fistula

Abstract

Colorectal cancer is the third most diagnosed cancer and the fourth leading cancer-related death

worldwide. Mucinous adenocarcinoma associated with anal fistula is a rare variant of

adenocarcinoma, presents with delayed diagnosis, locally advanced, low nodal, and no distant

metastasis. Adenocarcinoma associated with fistula (ACAF) is rare, has delayed diagnosis and

poor prognosis but can be managed with neoadjuvant chemoradiation (NACRT) and complete

curative resections with reconstruction by V-Y advancement cutaneous flap.

OP8- Perineal Repair of a Postoperative Perineal Hernia: A Case Report



Keywords: Perineal hernia, V-Y flap, biological mesh, Extra levator abdominoperineal

excision, ELAPE

Abstract

Postoperative perineal hernia (PerH) following abdominoperineal resection is a rare

complication of radical pelvic oncologic surgery performed with curative intent for rectal

cancer, with a reported prevalence of 0.6–7%. PerH is clinically diagnosed as an occurrence of

a swelling in the perineum caused by the herniation of abdominal or pelvic viscera through a

defect in the pelvic floor. The definitive repair method of pelvic floor defect of PerH is not

established but includes exclusion of tumor recurrence and repair of pelvic floor defect. We

herein report the treatment of a PerH using a combination of biological mesh and a V-Y gluteal

fascio-cutaneous advancement flap.

OP9- Fundoplication Surgery for Gastroesophageal Reflux Disease – A Case Report

Chansa M, Ndola Teaching Hospital


Keywords: Gastroesophageal reflux disease, heartburn, upper endoscopy, oesophageal

manometry, pH monitoring, Nissen fundoplication

Abstract




14

Gastroesophageal reflux disease (GERD) is a common condition that results from an

abnormally elevated reflux of gastric material through the lower esophageal sphincter (LES)

into the oesophagus, causing symptoms and/or injury to oesophageal tissue. GERD affects

about 20% of the population in the United States. Today, proton pump inhibitors (PPIs) are the

most frequently prescribed drugs, with an estimated cost of US $10 billion per year. Surgical

management is indicated in patients with failed medical management or in patients who

experience complications of PPI therapy. This case report concerns a 38-year-old female who

presented at our facility with persistent gastroesophageal reflux symptoms for 4 years that were

being managed with PPIs. After the patient underwent a Nissen fundoplication procedure, she

stopped using PPIs in the early postoperative period, and her reflux symptoms had reduced.

OP10- An evaluation of the carrying angle of the elbow joint in school children and

adolescent in Ndola, Zambia

*Bulaya A1, Bowa K2,

1. Ndola Teaching Hospital

2. University of Lusaka

*Corresponding author: [email protected]

Keywords: carrying angle, supracondylar fractures, goniometer

Background

Mango season in Zambia brings with it a lot of fractures, unique o this are supracondylar

fractures at Arthur Davison Children's Hospital. It has a classic history of falling from a mango

tree on an outstretched elbow. The peak age of such fractures has been reported around 7 years

of age.

Methods

A cross sectional study was conducted on school going children and young adults from Ndola.

Four hundred and seven with ages ranging from 8 to 20 years were chosen from two

government schools of the same locality by stratified random sampling resulting in 30 boys

and 30 girls in each of the age groups: 8-9, 11-12, 14-15, and 17-20 years. The carrying angle

was measured off the dial at the centre of the goniometer to the nearest degree

Results

The study showed that girls have a higher carrying angle than boys by a mean difference left

carrying angle LCA and Right carrying angle RCA being 2 and 4 respectively in Ndola Zambia

Conclusion

The carrying angle was seen to increase in the female population as compared to the male

population with puberty while in males showed a gradual decrease of the carrying angle.


15

OP11- A successful Garlock procedure: the left thoracoabdominal approach for

adenocarcinoma of the esophagogastric junction at Ndola Teaching Hospital, Zambia,

Africa. – Case report withlLiterature Review

*Mumba E, Kazuma S M E, Musowoya J, Chirengendure B, Mackmadhov Z, Musas K,

Ndola Teaching Hospital


Keywords: Garlock procedure, esophagectomy, oesophageal carcinoma

Abstract

The Garlock procedure refers to the left thoracoabdominal approach to lesions of the

cardioesophageal junction. This is a rare but optimal approach used to treat patients with

adenocarcinoma of the esophagogastric junction for palliation and for cure.

This left transthoracic incision simultaneously and safely exposes the entire lower and middle

oesophagus, mediastinum, and upper abdomen for an expeditious and conventional route for

resection of lower oesophageal cancer and for complete local and regional clearance. Thus, the

Garlock procedure, outperforms the right transthoracic esophagectomies, especially the Ivor-

Lewis procedure, in several ways, such as it being a simpler operation with a shorter operative

time, a greater tolerance by patients, and fewer postoperative complications.

We present the case of a 56-year-old female patient who presented with invasive

adenocarcinoma of the distal oesophagus at our institution and underwent a successful Garlock

procedure.

OP12- Management of a Patient with a 9.6kg gastric gastrointestinal Stromal Tumour at

Ndola Teaching Hospital

Kazuma S M. E., Ndola Teaching Hospital, Zambia


Keywords: GIST, Gastrointestinal stromal tumours, gastric GIST

Abstract

Gastrointestinal stromal tumours (GIST) account for 1% to 3% of tumours of the

gastrointestinal tract and 5% to 6% of sarcomas and are the most common subset of

mesenchymal tumours. GIST have an annual incidence of 10 to 20 million people per year

worldwide. Carcinogenesis of GIST arises in the interstitial cells of Cajal due to a mutation of

the KIT (also known as CD117) and the platelet-derived growth factor A (PDGFA) gene,

leading to activation of the tyrosine kinase receptor. GIST are usually asymptomatic and/or

incidentally diagnosed during surgery or on imaging. Diagnosis is based on a positive stain of

KIT (CD117) on immunohistochemical (IHC) staining. Surgical resection with clear margins

must be achieved for resectable GIST and for GIST with resectable oligometastasis (liver or



16

peritoneal metastasis). We present management of a patient at Ndola Teaching Hospital who

was known to have an abdominal tumour that was thought to be arising from the ovary but was

found to be a tumour arising from the stomach.

OP13- Determining the prognostic value of peripheral blood derived inflammatory

markers in predicting disease free survival in early breast cancer

*Obure R, Wasike R, Omuse G, Aga Khan University Hospital, Nairobi


Keywords: Early breast cancer, recurrence, neutrophil - lymphocyte ratio, platelet lymphocyte

ratio, systemic immune-inflammation index

Background

There is increasing evidence supporting the prognostic value of peripheral blood derived

inflammatory markers such as the neutrophil lymphocyte ratio (NLR), platelet lymphocyte

ratio (PLR) and systemic immune-inflammation index (SII) in breast cancer. The prognostic

value of peripheral blood derived inflammatory markers has however not been investigated in

a black African population despite evidence of racial differences in peripheral blood counts.

Methods

A retrospective cohort study of 100 non – obese black Kenyan women with early breast cancer

was conducted. The primary end point was disease free survival at 2 years following surgery.

Receiver operating characteristics analysis allowed categorisation of women into 2 groups for

each maker, a high and low group. Disease free survival was compared using Kaplan-Meier

survival curves and hazard ratios obtained from univariate and multivariate analyses using the

Cox proportional hazards model.

Results

Women with higher NLR, PLR and SII had an increased risk of recurrence H.R. = 1.33 (95%

C.I 0.374 – 4.738, P = 0.659), H.R. 2.308 (95% C.I 0.649 – 8.205, P = 0.196) and H.R. 1.542

(95% C.I 0.433 – 5.492, P = 0.504) respectively. This was however not statistically significant.

Conclusion

Preoperative NLR, PLR and SII did not prognosticate risk of disease recurrence in black non-

obese Kenyan women with early breast cancer.


17

OP14- The presence and availability of essential diagnostics in Malawian district and

central hospitals

*Agarwal-Harding K1, Chokotho L2, Young S3, Kamalo P D2, Makasa E M4, Mkandawire

N2

1. Harvard Global Orthopaedics Collaborative, Boston, MA, USA

2. Queen Elizabeth Central Hospital, Blantyre, Malawi

3. Kamuzu Central Hospital, Lilongwe, Malawi

4. Wits-SADC Regional Collaboration Centre for Surgical Healthcare, Faculty of Health

Sciences, University of Witwatersrand, Johannesburg, South Africa


Keywords: trauma, capacity, infrastructure, manpower, material resources, essential resources,

diagnostics, health system strengthening, pandemic preparedness, Malawi, Africa.

Background

Diagnostics are foundational to effective health systems, but remain unavailable to many

worldwide, especially in low-income countries like Malawi. To achieve health equity in

Malawi, it is necessary to assess availability of essential diagnostics.

Methods

We analyzed data collected during a nationwide survey of musculoskeletal trauma care

capacity. In all 25 district and 4 central hospitals in Malawi, we analyzed presence, availability,

and reasons for unavailability of laboratory testing, vital signs monitoring, electrocardiograms,

and diagnostic radiology. We used geospatial models to estimate the proportion of the

Malawian population with 1-hour and 2-hour access to these resources. Taking 1-hour access

to most accurately represent geospatial coverage in the Malawian context, a hypothetical

intervention was designed whereby diagnostic capacity improvement would be prioritized at

select hospitals to cover at least 75% of Malawians nationwide.

Results

Twelve of 29 hospitals had basic laboratory testing available when needed, covering an

estimated 58% of Malawians with 1-hour access; 95% with 2-hour access. Vital signs

monitoring was available when needed in 18 hospitals, covering an estimated 74% of

Malawians with 1-hour access; 97% with 2-hour access. Six hospitals reported an

electrocardiogram available when needed, covering an estimated 49% of Malawians with 1-

hour access; 91% with 2-hour access. Four hospitals had x-ray available when needed and of

adequate quality to make accurate diagnoses, covering an estimated 39% of Malawians with 1-

hour access; 86% with 2-hour access. Broken machinery, inadequate supplies, and inadequate

staff training were common reasons for resource unavailability.

Conclusion

Essential diagnostics were found to be unavailable for many Malawians. By prioritizing

capacity improvements in all four central hospitals and 11 district hospitals, over three-quarters

of Malawians could have 1-hour access to laboratory testing, vital signs monitoring,


18

electrocardiogram, and diagnostic x-ray. These capacity improvements are essential to meet

the needs of a growing population, especially in the context of the current COVID-19

pandemic.

OP15- The experiences of adult patients receiving treatment for femoral shaft fractures

at Kamuzu Central Hospital, Malawi: a qualitative analysis

Agarwal-Harding K1, Atadja L2, Chokotho L3, Banza L4 , Mkandawire N3, Katz J N5,


2. University of Texas Southwestern, Dallas, TX, USA

3. Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi

4. Department of Orthopedics, Kamuzu Central Hospital, Lilongwe, Malawi

5. The Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopedic

Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA


Keywords: trauma, patient experience, health system navigation, femoral shaft fracture, trauma

care system, Malawi, Africa

Background

Malawi has a rising burden of musculoskeletal trauma, and insufficient surgical capacity to

manage common, debilitating injuries like femoral shaft fractures (FSFs). Non-operative

treatment remains the standard of care, with surgery available only at central hospitals. We

sought to understand how patients navigate the Malawian health system and the barriers they

face while seeking care.

Methods

We performed in-depth, semi-structured interviews of 15 adults with closed FSFs during their

hospitalization at Kamuzu Central Hospital (KCH), a public referral hospital in Lilongwe,

Malawi. We additionally interviewed one patient who left KCH to seek care at a private

hospital. An English-speaking investigator performed all interviews with a Chichewa-speaking

medical interpreter. Interviews focused on patients’ pathways from injury to present treatment

(health system navigation); impressions of the hospital and care received; and the effects of

injury/treatment on patients and their families. Interviews were audio-recorded, translated, and

transcribed in English. We coded the transcripts and performed thematic analysis.

Results

We identified 6 themes: high variability in health system navigation; frustrations with the

biopsychosocial effects of hospitalization; lack of participation in decision-making and

uncertainty about treatment course; preference for surgery (vs. traction) based on patients’ own

experiences and observations; frustrations with the inequitable provision of surgery; and

patients’ resignation, acceptance, and resilience in the face of hardship. Many patients

receiving non-operative treatment described the devastating financial burden imposed upon

them and their families by their injury and prolonged hospitalization. They felt they were

receiving inferior treatment compared to surgery and suspected that richer patients were

receiving more timely care.


19

Conclusion

This qualitative study suggests a need to standardize care for FSF in Malawi, increase surgery

availability and timeliness, and increase transparency and communication between providers

and patients. These remedies should focus on improving quality of care and achieving equity

in access to care.

OP16- Improving management of adult ankle fractures in Malawi: an assessment of

providers’ knowledge and treatment strategies

*Agarwal-Harding K1, Kapadia A2, Banza L3, Chawinga M3, Mkandawire N4, Kwon J Y5,


2. University of Texas Southwestern School of Medicine, Dallas, TX, USA,

3. Department of Orthopaedics, Kamuzu Central Hospital, Lilongwe, Malawi


5. Division of Foot and Ankle Surgery, Department of Orthopaedics, Massachusetts

General Hospital, Boston, MA, USA


Keywords: orthopaedic trauma, foot and ankle, ankle fracture, treatment strategies, knowledge

assessment, Malawi, Africa

Background

The burden of musculoskeletal trauma is increasing worldwide especially in low-income

countries like Malawi. Ankle fractures are common in Malawi and may receive suboptimal

treatment due to inadequate surgical capacity and limited provider knowledge of evidence-

based treatment guidelines.

Methods

This study was conducted in three phases. First, we assessed Malawian orthopaedic providers’

understanding of anatomy, injury identification, and treatment methods. Second, we observed

Malawian providers’ treatment strategies for adults with ankle fractures presenting to a central

hospital. These patients’ x-rays underwent blinded, post-hoc review by three US-based

orthopaedic surgeons and a Malawian orthopaedic surgeon, whose treatment recommendations

were compared to actual treatments rendered by Malawian providers. Third, an educational

course addressing knowledge deficits was implemented. We assessed post-course knowledge

and introduced a standardized management protocol, specific to the Malawian context.

Results

In Phase 1, deficits in injury identification, ideal treatment practices, and treatment

standardization were identified. In Phase 2, 17/49 patients (35%) who met operative criteria

did not receive surgery, mainly due to resource limitations and provider failure to recognize

unstable injuries. In Phase 3, 51/61 participants (84%) improved their overall scores between

the pre- and post-course assessments from a mean of 32.4/49 (66%) to 37.7/49 (77%) with a

statistically significant improvement of 5.2 questions (95% CI 3.8-6.6, p<0.001). Providers

were able to identify one more injury correctly out of 8 (1.1 question, 95% CI 0.6-1.6, p<0.001),


20

and identify one more ideal treatment out of 7 that were tested (1.0 question, 95% CI 0.5-1.4,

p<0.001).

Conclusion

Adult ankle fractures in Malawi were predominantly treated non-operatively despite often

meeting evidence-based criteria for surgery. This was due to resource limitations, knowledge

deficits, and lack of treatment standardization. We demonstrated a comprehensive approach to

examining challenges of providing adequate orthopaedic care in a resource-limited setting and

the successful implementation of an educational intervention to improve care delivery. This

approach can be adapted for other conditions to improve orthopaedic care in low resource

settings.

OP17- Clinical and Functional Outcomes of Nonoperatively Treated Pediatric

Supracondylar Humerus Fractures at the Nkhotakota District Hospital, Malawi

*Agarwal-Harding K1, Mlinde E2, Amlani L3, May J C4, Banza L5, Chokotho L6


2. Department of Orthopedics, Nkhotakota District Hospital, Nkhotakota, Malawi

3. Johns Hopkins University School of Medicine, Baltimore, MD, USA

4. Department of Orthopaedics, Boston Children’s Hospital, Boston, MA, USA

5. Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi



Keywords: orthopaedic trauma, pediatric trauma, elbow fracture, supracondylar humerus

fracture, nonoperative treatment, treatment outcomes, Malawi

Background

Displaced supracondylar humerus fractures (SCHFs) benefit from closed reduction and

percutaneous pinning. In Malawi, many SCHFs are treated non-operatively due to limited

surgical capacity. We sought to assess clinical and functional outcomes of nonoperatively

treated SCHFs in a resource-limited setting.

Methods

We retrospectively reviewed all patients with SCHFs treated at Nkhotakota District Hospital

(NKKDH), Malawi between January 2014 and December 2016. Patients subsequently

underwent clinical and functional follow-up assessment.

Results

We identified 182 children (54% male, mean age 7.0 years) with SCHFs, 151 (83%) due to

falls, and 178 (98%) extension-type. Gartland class distribution: 63 (35%) type I, 53 (29%)

type II, and 63 (35%) type III. Four patients with type I injuries were treated with an arm sling

alone, 59 with straight-arm traction to reduce swelling, then splint immobilization until union.

All 119 patients with Gartland type II/III or flexion-type injuries were treated with straight-


21

arm traction, manipulation under anesthesia without fluoroscopy, then splint immobilization

until union. We followed up 137 (75%) patients at a mean 3.9 years after injury. Flynn’s

functional outcome was excellent in 39 (95%) type I, 30 (70%) type II, and 14 (29%) type III

fractures. Flynn’s cosmetic outcome was excellent in 40 (98%) type I, 42 (98%) type II, and

41 (84%) type III fractures. Children returned to school without limitation in 40 (98%) type I,

41 (95%) type II, and 32 (65%) type III fractures. Controlling for sex, delayed presentation,

medical comorbidities, injury mechanism, and skin blistering/superinfection during traction,

patients with type II fractures were 5.82 times (95% CI 1.71-19.85) and type III fractures were

9.81 times (95% CI 3.00-32.04) more likely to have a clinical complication or functional

limitation, compared to patients with type I fractures.

Conclusion

Non-operative treatment of type III SCHFs resulted in high rates of clinical complications and

functional impairment. These results illustrate the urgent need to increase surgical capacity in

low-income countries like Malawi to improve pediatric fracture care.

OP18- The prevalence and incidence of adults with femoral shaft fracture receiving care

in Malawian district and central hospitals

*Agarwal-Harding K1, Chokotho L2, Young S3, Mkandawire N2, Losina E4, Katz J N4,



3. Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi

4. The Orthopaedic and Arthritis Center for Outcomes Research, Department of

Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School,

Boston, MA, USA


Keywords: trauma, incidence, prevalence, femoral shaft fracture, trauma care, low- and middle-

income countries, Malawi, Africa

Background

Diaphyseal femoral fractures are a common musculoskeletal injury in Malawi, often due to

road traffic collisions. Most adults are treated non-operatively as inpatients, occupying limited

beds for up to 2 months. We sought to document current prevalence and incidence of adult

patients with femoral shaft fractures admitted to Malawian public hospitals.

Methods

Between May 29th and June 15th, 2018, we performed in-person surveys of all 25 district and 4

central hospitals in Malawi. At each hospital, we asked a single orthopaedic provider to report

the number of adults with femoral shaft fractures currently being treated on the inpatient wards,

and the number who were admitted in the last 7 days. To assess accuracy of reporting by

orthopaedic providers, we performed independent counts in a randomly selected 25% of

hospitals. We calculated prevalence (per 100,000 persons) and incidence (per 100,000 person-

weeks) by dividing the number of observed cases by the adult population. We compared our

observed incidence to estimates derived from a previously published model.


22

Results

We identified 120 adults currently being treated in Malawian public hospitals at the time of

survey completion, with a median of three cases at district hospitals and 10 at central hospitals.

Nationwide prevalence among adults was 1.38 per 100,000 persons. We identified 44 patients

nationwide who were admitted in the 7 days prior to survey completion, with a median of one

patient per week at district hospitals, and 4 patients per week at central hospitals. We estimated

a national incidence of 0.51 per 100,000 person-weeks.

Conclusion

Our estimation of femoral shaft fracture prevalence and incidence at public hospitals may be

useful for planning the resources required to treat femoral fractures in Malawi. The capacity of

Malawian hospitals to treat musculoskeletal injuries should be assessed nationwide to develop

strategies for effective trauma system development.

OP19- postoperative complications associated with perforation peritonitis at a tertiary

teaching hospital in Lusaka, Zambia

Kabongo K, University Teaching Hospitals-Adult, Lusaka


Keywords: Perforation peritonitis, emergency laparotomy, mortality

Background

Perforation peritonitis is a common surgical emergency seen by surgeons and remains a life-

threatening condition with high morbidity and mortality. The study aimed to determine the site

of perforation and the post-operative complications of perforation peritonitis.

Methods

A prospective observational study was conducted at the Department of Surgery of the

University Teaching Hospitals (UTH), Lusaka from July 2018 to March 2019. All

consecutively admitted patients aged 18 years and above undergoing emergency exploratory

laparotomy for non-traumatic perforation peritonitis were included in the study.

Results

One hundred patients participated in the study (77 males, 23 females), and the mean age was

37.24 (range 18 to 78 years). The main site of perforation was stomach in 49 (49%), small

bowel in 40 (40%), colon in 8 (8%), both small bowel and colon in 1 (1%), urinary bladder 1

(1%), and unidentified site in 1 (1%). The postoperative outcomes included leak 9%, wound

dehiscence 3%, and re-laparotomy 17%. The frequency of outcome (leak, relaparotomy and

mortality) were highest for stomach followed by ileum. The stomach was significantly related

to the outcome of leak (p=0.008). The mortality rate was 36%.

Conclusion

The stomach was the leading site of perforation. The commonest postoperative outcome was

relaparotomy. Perforation peritonitis has a high mortality rate.


23

OP20- Patterns of facial fracture at tertiary care hospital All Africa Leprosy,

Tuberculosis and Rehabilitation Training Center.

Fikru S, ALERT Hospital, Ethiopia


Keywords: Facial fracture ALERT hospital

Background

Facial fractures have various causes and occur with in every population in the world and the

presence of maxilofacial trauma have a substantial impact in the psychology and aesthetic of

the patient lays an everlasting effect on the behaviour and function of the patient.

Methods

This is hospital based retrospective study conducted at ALERT hospital Plastic and

reconstructive surgery department. Charts were reviewed for patient who were treated at

ALERT hospital for facial trauma from May 2018 to April 2021

Results

385 maxilofacial fractures were treated in 290 patients seen.The mean age was 29.62 with age

range of 2-75 years. Majority of patients (48.27%) were within the age group of 21- 30 years

and Male to female ratio was 7:1. interpersonal vviolence (7.93) and road traffic accident

21.72% were the leading cause of injury. Cause of injury and age groups were found

significantly associated.one third of patients reported use of alcohol.There was high incidence

of trauma in the month of January and during the night time. Nasal fractures followed by orbital

fractures were the most common fracture types.There was an associated injury in 68.27 % of

patients including soft tissue injury, traumatic brain injury, eye glob, trunk and extremities.

Various treatment modalities were given for facial fractures among them 40.9 % were managed

conservatively with observation while 46.34 % received closed reduction. ORIF with plate was

done for 12.69% of them.

Conclusion

Interpersonal violence was the major cause of maxilofacial trauma, while nasal and orbital

fractures were the commonest fracture types. Cause of injury and age group were found

significantly associated. Majority of patients were young Male in the third decade of age.

Conservative management was the most common modality of treatment given.

OP21- What is known about Burns in East Africa? A scoping review.

*Mukagaju F1, Pompermaier L2

1. Rwanda Military Hospital

2. Linkoping University




24

Keywords: Burns Epidemiology East Africa, Scoping review

Background

Burns are a global public health concern, with the majority of the disease burden affecting low-

and middle-income countries. Yet, as suggested by previous publications, there is a widespread

belief that literature about burns in low- and middle-income countries is lacking. Therefore, we

aimed to assess with a scoping review, the extent of the literature output on burns in East Africa,

and to investigate patient demographics, injury characteristics, treatment and outcomes, as

reported from the existing publications.

Methods

Studies discussing burns in East Africa were identified by searching PubMed / Medline

(National Library of Medicine), EMBASE (Elsevier), Global Health Database (EBSCO), and

Global Index Medicus on December 12, 2019. Controlled vocabulary terms (i.e., MeSH,

EMTREE, Global Health thesaurus terms) were included when available and appropriate. No

year restrictions were applied.

Results

A total of 1,044 records were retrieved from the database searches, from which 40 articles from

6 countries published between 1993 and 2019 were included in the final review. No studies

were found from five East African countries with the lowest GDP. Most papers focused on

pediatric trauma patients or tertiary hospital settings. The total number of burn patients

recorded was 44,369, of which the mean proportion of males was 56%. The most common

cause of injury was scalds (61%), followed by open flame (17%). Mortality rate ranged from

0-67%. The mean length of stay in hospital was between 9-60 days.

Conclusion

Burn data is limited in the East African region, with socio-economically weak countries being

particularly underrepresented. This scoping review has identified the largest set of literature on

burns in East Africa to date, indicating the importance of reviewing data at a regional or local

level, as “global” studies tend to be dominated by high-income country data. Data collection

in specific registries is needed to better characterize the exact burden of burn injuries in East

Africa.

OP22- Burden of Musculoskeletal disease among a Refugee population in South-western

Uganda.

*Muwanguzi P1, Ozgediz D2, Namugga M M1, Klazura G, Tang J3

1. Mulago Hospital

2. University of California San Francisco

3. Yale University


Keywords: Refugee. Musculoskeletal disease. Humanitarian research


25

Background

Uganda is the largest refugee-hosting nation in Africa and 3rd in the world. The vast influx of

refugees in the Great lakes geo-political region is due to armed conflict and related violence.

Refugees are faced with both communicable and non-communicable diseases. Physical trauma

exposure is an important but underestimated health problem among refugees. However, most

research and interventions are focused on communicable illnesses like HIV and TB. There is

limited published data on the musculoskeletal disease burden among refugees in Uganda.

We described which patients required operative and non-operative intervention, the types of

surgical interventions needed, and the proportion that required further diagnostic intervention.

Methods

A cross sectional survey of patients in Kyaka 2 and Rwamwanja refugee settlements in

Kamwenge district was carried out over a two-day period. Patients were reviewed by

orthopedic specialists at an out-patient clinic.

Results

159 patients were reviewed, 65% males and 21% children. Conditions were categorized as

traumatic injuries, infections, congenital, degenerative diseases. Traumatic injuries were

commonest among 13 to 50 years olds among both sexes. Of these, mal-unions, non-unions

and gun-shot injuries were the most common. Femur and tibia were most commonly affected

long bones.

Infections were the second most common condition (21.3%), with femur and tibia

osteomyelitis predominant. Two peaks of infection were noted among children (6 to 12) and

young adults (19 to 30).

Among adults (51 to 80), degenerative diseases (17%) were most common condition.

78% of patients required radiological assessment and 50.3% required surgical intervention.

Debridement for osteomyelitis and open reduction/internal fixation for neglected fractures

were the most common planned surgeries.

Conclusion

Musculoskeletal disease is a major Non-Communicable Disease observed among refugees in

developing countries. A limited proportion of the refugee population were screened, and this

highlighted the burden of disease for trauma and infections that require urgent radiological and

surgical intervention. We recommend further research as a population-based study in this

neglected area of a refugees' health to generate reliable scientific evidence on which policy and

action plans can be formulated.

OP23- Protocol for a prospective cohort study of open tibia fractures in Malawi with a

nested implementation of open fracture guidelines

Schade T A1, Nyamulani N2, Banza L3, Metcalfe A4, Harrison J W5, MacPherson P1 ,

1. Malawi-Liverpool-Wellcome Trust

2. Queen Elizabeth Central Hospital

3. Kamuzu Central Hospital

4. Warwick University

26

5. AO Alliance


Keywords: trauma, open fractures, implementation, guidelines

Background

Road traffic injury (RTI) is the largest cause of death amongst 15–39-year-old people

worldwide, and the burden of injuries such as open tibia fractures are rapidly increasing in

Malawi. This study aims to investigate disability and economic outcomes of people with open

tibia fractures in Malawi and improve these with locally delivered implementation of open

fracture guidelines.

Methods

This is a prospective cohort study describing function, quality of life and economic burden of

open tibia fractures in Malawi. 160 participants will be recruited across six centres and will be

followed-up with face-to-face interviews at six weeks, three months, six months and one year

following injury. The primary outcome will be function at one year measured by the short

musculoskeletal functional assessment (SMFA) score. Secondary outcomes will include

quality of life measured by EuroQol EQ-5D-3L, catastrophic loss of income and

implementation outcomes (acceptability, adoption, appropriateness, costs, feasibility, fidelity,

penetration, and sustainability) at one year. A nested pilot pre-post implementation study of an

interventional bundle for all open fractures will be developed based on other implementation

studies from LMICs. Regression analysis will be used to model and investigate associations

between SMFA score and fracture severity, infection and the pre- and post-training course

period.

Results

Preliminary results of 180 participants. Median age: 34 years old (IQR:25-44), 84% male

(n=152), 91% have no NCDs co-morbidities (heart, lung, diabetes, HTN, neurological,

mobility issues), 69% are isolated (no other injuries). 97% received antibiotics. 69% either had

same day or next day debridement. Median Eq-5D score at baseline was 1 vs 0.6 at 6 weeks.

Median SMFA at baseline was 0 (no problems) vs 42 at 6 weeks.

Conclusion

This prospective cohort study will report patient reported outcomes from open tibia fractures

in low-resource settings. Subsequent detailed evaluation of both the clinical and

implementation components of the study will promote sustainability of improved open

fractures management in the study sites and further scale-up of open fracture management

guidelines.

OP24- The economic burden of open tibia fractures: a systematic review

*Schade T A1, Khatri C2, Nwankwo H2, Carlos W3, Harrison J W4, Metcalfe A2,



3. University of Coventry and Warwickshire Hospitals


27

4. AO Alliance


Keywords: injury, open fractures, economics, systematic review, trauma

Background

Open tibia fractures are a common injury following road traffic collisions and place a large

economic burden on patients and healthcare systems. Summarising their economic burden is

key to inform policy and help prioritise treatment.

Method

All studies were identified from a systematic search of Medline, Embase and the Cochrane

Central Register of Controlled Trials. We included any human with a diagnosed open tibia

fracture, following any intervention. The primary outcome was any costs reported or patient

return to work status. Secondary outcomes included average length of stay, wage loss,

absenteeism and complications such as infection, amputation and nonunion. Data was extracted

and we performed a descriptive narrative summary.

Results

We reviewed 1,204 studies from our searches. A total of 34 studies were included from 14

different countries. The average age was 37.7 years old and 76% of the patients were male.

6.5% were Gustilo I, 12% Gustilo II and 82% Gustilo III. Initial direct hospitalisation costs

were reported to be between £356 to £126,479 with an average length of stay of 56 days (3.1-

244). 89% participants were working pre-injury, 60% fully returned to work, 17% returned to

work part time or changed profession and 22% did not return to work at one-year. The most

common complications reported were 22% infection, 11% nonunion and 16% amputation.

Mean follow-up duration for the studies was 25 months.

Conclusion

The economic burden of open tibia fractures varies greatly, but it is costly for both hospitals

and patients. The current evidence is predominantly from high-income countries (HICs),

especially the USA. Further research is required to investigate the costs of open tibia fractures

using validated costing tools, especially in LICs, to help inform and direct policy.

OP25- “Don’t rush into thinking of walking again”: Patient views of treatment and

disability following an open tibia fracture in Malawi

*Schade A1, Siande W1, Karasouli E2, Desmond N1, Harrison J W3, Metcalfe A2



3. AO Alliance


Keywords: qualitative, open fractures, disability, trauma, treatment



28

Background

Open tibia fractures are a common injury following road traffic accidents in Malawi and can

lead to long term disability. Very little is known about patients’ experiences of the healthcare

system and the disability in low-income countries following this injury

Methods

A qualitative study was conducted using semi-structured interviews with ten patients with open

tibia fractures at a central hospital in Blantyre, Malawi. A mixed deductive-inductive thematic

analysis was used to identify broad themes of treatment and disability. Written consent was

obtained from all participants (P.07/19/2739).

Results

Patient characteristics included an average age of 39.1 years old (22-63) and 80% were male.

Broad themes found were delays in receiving treatment, change in individuals’ societal role

and delayed recovery associated with pain and immobility.

Conclusion

The treatment of open fractures in Malawi has a devastating impact on patients and their

families. Further studies are required to explore the reasons for the delays in open fracture

emergency treatment.

OP26- Epidemiology of fractures and their treatment in Malawi: Results of a multicentre

prospective registry study to guide orthopaedic care planning

*Chokotho L1, Schade T A2, Martin C3, Harrison J W4, MacPherson P5, Graham M S6,

1. Department of Surgery, Kamuzu University of Health Sciences

2. Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Malawi

3. AO Alliance Foundation

4. Countess of Chester NHS Foundation Trust

5. Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Malawi

6. Department of Orthopaedic and Trauma Surgery, Liverpool University Teaching

Hospital Trust, Liverpool, UK


Keywords: Fractures Registry Epidemiology Prospective Treatment

Background

Injuries cause 30% more deaths than HIV, TB and malaria combined. Musculoskeletal (MSK)

injuries account for the majority of these. Effective improvement of fracture care requires

baseline knowledge of what is the need and what resources are available. A prospective fracture


29

care registry was established to investigate the fracture burden and treatment in Malawi to

inform evidence-based improvements.

Methods

Prospective fracture care registries were established in two large referral centres and two

district hospitals in Malawi over a 3.5-year period (September 2016 to March 2020). All

patients with a fracture (confirmed by radiographs)—including patients with multiple

fractures—were eligible to be included in the registry. Demographics, characteristics of

injuries, and treatment outcomes were collected on all participants.

Results

23,734 patients were enrolled with a median age of 15 years (interquartile range: 10–35 years);

68.7% were male. The most common injuries were radius/ulna fractures (n = 8,682, 36.8%),

tibia/fibula fractures (n = 4,036, 17.0%), humerus fractures (n = 3,527, 14.9%) and femoral

fractures (n = 2,355, 9.9%). The majority of fractures (n = 21,729, 91.6%) were treated by

orthopaedic clinical officers; 88% (20,885/2,849) of fractures were treated non-operatively,

and 62.7% were treated and sent home on the same day. Open fractures (OR:53.19, CI:39.68–

72.09), distal femoral fractures (OR:2.59, CI:1.78–3.78), patella (OR:10.31, CI:7.04–15.07),

supracondylar humeral fractures (OR:3.10, CI:2.38–4.05), ankle fractures (OR:2.97, CI:2.26–

3.92) and tibial plateau fractures (OR:2.08, CI:1.47–2.95) were more likely to be treated

operatively compared to distal radius fractures.

Conclusion

The current model of fracture care in Malawi is such that orthopaedic surgeons manage

fractures operatively in urban referral centres whereas orthopaedic clinical officers mainly

manage fractures non-operatively in both district and referral centres. We recommend that

orthopaedic surgeons should supervise orthopaedic clinical officers to manage non-operative

injuries in central and district hospitals. There is need for further studies to assess the clinical

and patient reported outcomes of these fracture cases, managed both operatively and non-

operatively

OP27- Quality of life and functional outcome at 1 year in patients with femoral shaft

fractures treated with intramedullary nailing or skeletal traction in a low-income

country. A prospective observational study of 187 patients in Malawi.

*Chokotho L1, Gjertsen J2, Shearer D2, Lau B3, Mkandawire N1, Young S4

1. Department of Surgery, Kamuzu University of Health Sciences

2. The Institute for Global Orthopedics and Traumatology, Orthopedic Trauma Institute,

University of California San Francisco, San Francisco, CA, USA

3. Department of Orthopedic Surgery, Duke University Medical Centre

4. Kamuzu Central Hospital, Lilongwe, Malawi


Keywords: Femoral shaft Fracture, Intramedullary nailing, Skeletal Traction, Quality of Life,

EQ-5D, SMFA


30

Background

Intramedullary nailing (IMN) is underutilized in low-income countries (LICs) where skeletal

traction (ST) remains the standard of care for femoral shaft fractures. This prospective study

compared patient-reported quality of life and functional status after femoral shaft fractures

treated with IMN or ST in Malawi.

Methods

Adult patients with femoral shaft fractures managed by IMN or ST were enrolled prospectively

from 6 hospitals. Quality of life and functional status were assessed using EQ-5D-3L, and the

Short Musculoskeletal Function Assessment (SMFA) respectively. Patients were followed up

at 6 weeks, 3-, 6-, and 12-months post-injury.

Results

Of 248 patients enrolled (85 IMN, 163 ST), 187 (75%) completed 1-year follow-up (55 IMN,

132 ST). 1 of 55 IMN cases had non-union compared with 40 of 132 ST cases that failed

treatment and converted to IMN (p < 0.001). Quality of life and SMFA Functional Index Scores

were better for IMN than ST at 6 weeks, 3 and 6 months, but not at 1 year. At 6 months, 24 of

51 patients in the ST group had returned to work, compared with 26 of 37 in the IMN group (p

= 0.02).

Conclusion

Treatment with IMN improved early quality of life and function and allowed patients to return

to work earlier compared with treatment with ST. Approximately one-third of patients treated

with ST failed treatment and were converted to IMN

OP28- Cost utility analysis of intramedullary nailing and skeletal traction treatment for

patients with femoral shaft fractures in Malawi

Chokotho L1, Donnelley C2, Gjertsen J3, Hallan G3, Agarwal-Harding K J4, Shearer D2

1. Department of Surgery, Kamuzu University of Health Sciences, Blantyre

2. Institute for Global Orthopedics and Traumatology, Orthopedic Trauma Institute,

University of California San Francisco, San Francisco, CA, USA

3. Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway

4. Harvard Global Orthopaedics Collaborative, Harvard Combined Orthopaedic

Residency Program, Massachusetts General Hospital, Boston, MA, USA


Keywords: Femoral shaft fracture, Intramedullary nailing, Skeletal Traction, Cost-utility,

QALY, EQ-5D

Background

In Malawi, both skeletal traction (ST) and intramedullary nailing (IMN) are used in the

treatment of femoral shaft fractures, ST being the mainstay treatment. Previous studies have

found that IMN has improved outcomes and is less expensive than ST. However, no cost-


31

effectiveness analyses have yet compared IMN and ST in Malawi. We report the results of a

cost-utility analysis (CUA) comparing treatment using either IMN or ST

Methods

This was an economic evaluation study, where a CUA was done using a decision-tree model

from the government healthcare payer and societal perspectives with an 1-year time horizon.

We obtained EQ5D-3L utility scores and probabilities from a prospective observational study

assessing quality of life and function in 187 adult patients with femoral shaft fractures treated

with either IMN or ST. The patients were followed up at 6 weeks, and 3-, 6-, and 12-months

post-injury. Quality adjusted life years (QALYs) were calculated from utility scores using the

area under the curve method. Direct treatment costs were obtained from a prospective micro

costing study. Indirect costs included patient lost productivity, patient transportation, meals,

and childcare costs associated with hospital stay and follow-up visits. Multiple sensitivity

analyses assessed model uncertainty

Results

Total treatment costs were higher for ST ($1,349) compared with IMN ($1,122). QALYs were

lower for ST than IMN, 0.71 (95% confidence interval [CI] 0.66– 0.76) and 0.77 (CI 0.71–

0.82) respectively. Based on lower cost and higher utility, IMN was the dominant strategy.

IMN remained dominant in 94% of simulations. IMN would be less cost-effective than ST at

a total procedure cost exceeding $880 from the payer’s perspective, or $1,035 from the societal

perspective.

Conclusion

IMN was cost saving and more effective than ST in the treatment of adult femoral shaft

fractures in Malawi and may be an efficient use of limited healthcare resources.

OP29-The RAIS device for global surgery: navigating the translational pathway from

clinical-need to clinical-use

Culmer P1, Bridges P1, Aruparayil N1, Chugh C2, Bains L2, Mishra A2

1. University of Leeds

2. Mualana Azad Medical College

* Corresponding author: [email protected]

Keywords: global health, medical device design, participatory design, frugal engineering,

surgical technology

Background

Over 5 billion people worldwide have no access to surgery worldwide, typically in low-

resource settings, despite it being a primary life-saving treatment. Gas Insufflation-Less

Laparoscopic Surgery (GILLS) is a method which can address this inequity, unfortunately

current GILLS instrumentation falls short of modern surgical standards.

Objective


32

Our aim was to develop and translate the Retractor for Abdominal Insufflation-less Surgery

(RAIS) into clinical use to provide a context-appropriate system to advance GILLS surgery.

Method

We assembled a multidisciplinary team from the UK and India alongside clinical stakeholders

and a commercial partner. System development used traditional medical device design

methodologies adapted to meet participatory and frugal design principles. A critical evaluation

of the development approach was undertaken.

Results

Close collaboration with stakeholders was used to define clinical and contextual requirements,

then to support iterative design development and evaluation of RAIS. An optimisation phase

refined functional prototypes through evaluation workshops with rural surgeons simulating

surgical procedures using cadaveric models. The final RAIS system was produced with Indian

regulatory approval and used by our surgical partners to run a series of GILLS workshops with

patients in India. Feedback showed RAIS provides a high-quality surgical experience and

enabled new surgical teams to perform GILLS independently.

Conclusion

Using a context-specific development approach with close engagement of stakeholders was

crucial to meet the needs of developing the RAIS device for resource-scarce regions. The

outcome is translation from global health need into a fully realized commercial instrument used

by surgeons in resource-scarce regions of India.

OP30- Using Delta Mortality-to-Incidence Ratios to Prioritize Cancer Care in Africa

*Diehl T, Pourdashti S, Schroeder D, Zafar N S, University of Wisconsin


Keywords: cancer, global surgery, mortality, disparities, MIR, LMIC, cancer control, quality,

Africa

Background

Cancer outcomes are disparate around the world. Low- and middle-income countries (LMICs)

face higher cancer mortality rates, and the burden will only intensify as cancer incidence is

projected to rise 81% by 2040. Mortality-to-incidence ratios (MIR), calculated by dividing

mortality rates by incidence rates, have been used to study disparities in cancer control. By

calculating delta mortality-to-incidence ratios (dMIR), the difference between MIRs in high-

income countries (HICs) and LMICs, we can develop country-specific cancer priority lists for

Africa.

Methods

We extracted country-specific incidence and mortality rates for 35 cancer types from 183

countries using GLOBACAN 2020. Countries were grouped into income categories as defined

by the World Bank. Health indicators and country metadata were extracted from the United

Nations Development Programme. MIRs were calculated for each cancer in each country.

Linear regression was used to test the relation between MIRs and country development


33

indicators. Delta MIR was calculated by subtracting the cancer specific average MIRs for HICs

from the average MIRs for African countries.

Results

For all cancers combined, MIRs varied across Africa, ranging from 0.50 in South Africa to

0.80 in Gambia. Worldwide, variation in MIR was low for certain cancers such as pancreas

(range=0.80-1.0), but high for screenable cancers such as colon (0-1.0) and breast (0.11-0.63).

Upon multivariate linear regression, MIRs were associated with life expectancy and income

index. In Africa, cancers of the nasopharynx (0.55), Kaposi sarcoma (0.44), anus (0.438),

salivary grands (0.31) and prostate (0.30) had the highest dMIRs, indicating that these cancers

can be targeted to have the highest impact on African cancer mortality rates.

Conclusion

Delta MIRs can be employed to systematically address disparities in cancer care survival.

These data can be used to create country-specific lists that inform cancer control initiatives and

resource allocation in Africa.

OP31- Feasibility of telephone assessment for surgical site infection: A study embedded

within a global surgery trial

*Ntirenganya F1, Glasbey J2,

1. NIHR Global Health Research Unit, Rwanda Hub, Kigali, Rwanda

2. NIHR Global Health Research Unit, University of Birmingham, UK


Keywords: Surgical site infection, Telephone follow-up, Trial methodology, Telemedicine,

Surgical complications

Background

Reducing surgical site infection (SSI) is a global health priority. In-person wound assessment

after discharge is costly, resource-intensive and challenging across international settings. This

study aimed to evaluate the feasibility of telephone wound assessment in a global surgical trial.

Methods

A Study Within a Trial (SWAT) embedded within FALCON, a pragmatic multi-centre factorial

randomised trial testing measures to reduce SSI after abdominal surgery across low- and

middle-income countries (ClinicalTrials.gov: NCT03700749). Consecutive adult patients

recruited to FALCON were contacted by telephone by a trained clinical assessor between 4th

April and 9th September 2020 (during the SARS-CoV-2 pandemic) to complete an adapted

Universal-Reporter Outcome Measure for SSI at 27-days after surgery. If possible, patients

were invited to travel back to hospital for in-person follow-up by a second assessor at 30-days

postoperatively. The primary outcome was the proportion of patients for whom the telephone

questionnaire was successfully administered (retention rate).

Results

Of 1049 patients recruited (Rwanda:122, 11.6%), 1019 were alive 30-days after surgery. Of

these, 908 completed a telephone questionnaire (retention rate:89.1%); follow-up was

performed in 23 different languages across seven countries. 587 patients were contacted on


34

their own phone (64.7%) and 35.3% via a friend/relative. All patients were satisfied with

undergoing telephone follow-up. Telephone assessment enabled 494 (50.1%) additional

patients to achieve follow-up that were unable to return in-person.

Conclusion

Telephone wound assessment is acceptable and feasible across diverse settings, and improved

retention within a global surgery trial. This has particular importance to delivering safe care

during the SARS-CoV-2 pandemic.

OP32- The impact of protocols on enhanced recovery after colorectal surgery [ERAS] at

Kamuzu Central Hospital (KCH) in Lilongwe, Malawi

Dr Vanessa J Msosa, Kamuzu Central Hospital

Correspondence: [email protected]

Keywords: ERAS, Enhanced Recovery After Surgery

Background

Enhanced Recovery After Surgery (ERAS) protocols refer to patient-centred evidence-based

pathways aimed at reducing the patient’s stress response, optimising the physiologic function

and facilitating the recovery of the patient. We are not aware of any studies on ERAS protocols

in Malawi.

Method

This was a mixed methods study involving a retrospective cohort study plus qualitative study

done at a tertiary heath facility in 2020.

Results

Out of all the colostomy reversals in this study, an account of completeness of peri-operative

orders showed that 12(66.7%) had most evaluation done, and these cases were those done

during a surgical camp. No deaths and no anastomotic leaks, 0(0%), were recorded. One case

(5.6 %) that developed a surgical site infection occurred in the post-camp period. The length

of hospital stay was ±2 days shorter in the cases done during plus after the camp, compared to

the pre-camp period [8; ±6]. T-test analysis for the outcome variables was not statistically

significant. Overall, the ERAS protocol for colorectal surgery was considered feasible and

acceptable. Facilitators for the protocol included availability of supplies and a culture in line

with the concept of ERAS, whereas barriers included resource limitations and lack of

knowledge about the goals of ERAS.

Conclusion

The development of the ERAS protocol for colorectal surgery at KCH may have had a role in

the apparent satisfactory completeness of patient evaluations and favourable post-operative


35

outcomes ever since then. However, these results could not be established with statistical

significance in this study. Insight into acceptance and feasibleness of ERAS protocol shall be

invaluable in advances towards implementation of the written ERAS protocol.

OP33- Separation of conjoined twins in resource limited settings: A case series exploring

unique challenges, solutions and lessons learnt.

Munanzvi K S1 Mutambanengwe G T1, Mbuwayesango B A2, Mazingi D3

1. Harare Children's Hospital

2. University of Zimbabwe

3. Oxford University


Keywords: Conjoined twins, resource limited settings, ethical dilemma, paediatric surgery

Background

Separation of conjoined twins in resource limited settings remains a formidable undertaking

due to their rare occurrence and resource intense nature. Often surgical teams have to contend

with religious and cultural apprehension from parents, inadequate equipment and technical

support and lack of robust multidisciplinary teams. Over the course of seven years, three sets

of conjoined twins were separated at the children's hospital in Harare, Zimbabwe. Each

presented a unique array of challenges that required a different approach to their cases. Herein

we present a summary of the cases and their management.

Methods

Case notes were retrieved and reviewed. Interviews of key personnel involved in the cases were

conducted

Results

The first set of twins separated were thoracomphalopagus boys. Formulating a coherent

management plan with the multidisciplinary team who had no previous experience was the

major challenge. A set of omphaloischiopagus girls with a bladder extrophy were separated at

the height of the Covid- 19 pandemic. Their anatomy also posed a huge surgical and anaesthetic

hurdle. The third set were asymmetric conjoined twins separated emergently and presented an

ethical dilemma.

Conclusion

Separation of conjoined twins in resource limited settings is difficult but possible. Each of the

sets presented a different challenge to the teams managing them that required a thoughtful,

concise and organised approach. The team was able to build on previous experience in the

management of each subsequent set.

OP34-Leg amputation in childhood, perspectives from the amputee and the community

in an East African setting

Dr Temesgen Kebede, Mr. Timothy Nunn, CURE Ethiopia Children's Hospital


36


Keywords: Childhood Amputation Leg Attitudes East Africa

Background

There are few reports about the attitudes towards childhood leg amputation in society in East

and Central Africa. It is important for the children’s orthopedic surgeon to understand the

ramifications of amputation in the decision-making process and consent for the procedure as

well as for patient counsellors and prosthetists. We wanted to find out about the society views

on amputation as well as the experiences of lower limb amputees in our patient population and

their families.

Methods

We surveyed 50 adult caregivers of children with upper limb conditions on their views toward

leg amputation. This group was selected to represent the ‘society’s view’ of amputation. This

group was selected as none of the participants, or their children were considering or

contemplating amputation of the leg. Open questions were posed on their views and knowledge

of amputation. In addition, we surveyed 19 children and their parents who had undergone leg

amputation and prosthetic fitting about their experiences of living with an amputation and a

fitted prosthesis. Open questions were asked, and responses compared between the groups. IRB

approval was obtained.

Results

The group who represented ‘society’ had good knowledge of amputation and many knew

someone with a leg amputation. Willingness to undergo a leg amputation for life-threatening

condition was high at 92%, and perceptions on the quality-of-life following amputation was

mostly positive although it was acknowledged that for an un-married female there would be

more challenges. Of the amputees surveyed, the majority had very significant psycho-social

challenges resulting from bullying and avoidance of the amputees and their families. This was

evidenced in school refusal, financial difficulties, and in some cases family breakdown and

displacement from communities.

Conclusion

Although the general perceptions of life with an amputation are often positive, the reality

experienced by amputees is contrastingly challenging with a host of psycho-social problems.

Surgeons should be aware that the decision to amputate a leg in a child has far-reaching

implications even if functionality is enhanced. This study reveals the need for multidisciplinary

input for all children and families contemplating leg amputation.

OP35-Outcomes and Lessons of Pediatric of a Ten-year Pediatric Surgical Data Initiative

in Uganda

Nasser Kakembo, Makerere College of Health Sciences


Keywords: audit, database, pediatric surgery, mortality, global child health



37

Background

In Uganda we manage a high burden of pediatric general surgical conditions with limited

resources and physical infrastructure. To better assess epidemiology, access, and outcomes, we

started pediatric surgical surveillance through a ward database in 2012. Here we report the

impact ten years later.

Methods

We designed an 11-variable database for our ward with the primary outcome condition at

discharge. In 2015, we expanded the database to 3 additional regional sites in Uganda. This

work was initiated with no funding. We analyzed access and outcomes for pediatric surgery

and used population-based data to assess unmet need and economic impact and disseminated

the work locally and internationally.

Results

From 2012-2016, 60% of our patients were < 1 year old and third had congenital conditions.

Overall mortality rate was 14%, with higher mortality rates for select neonatal conditions.

Expansion to three additional sites showed that approximately 1% of population childrens

surgical need is met but that 28,000 DALYs are averted each year across all four sites together.

The database also led to over ten masters’ theses by Ugandan post-graduate students in surgery

as well as the initiation of several Ugandan faculty PhD projects. Recent work has suggested

that a 3 variable model sampled at 10% would detect a 20% reduction in mortality. Data-driven

advocacy supported the installation of the initial operating rooms from KIDS OR, and impact

evaluation using our database also catalyzed expansion of this initiative.

Conclusion

Initiation of a basic ward database, even with no funding, strengthened our knowledge about

access, outcomes, and unmet need for our patients. Several regional hospitals joined this

program and further informed our substantial unmet need as well as the significant economic

impact of our services. Data driven advocacy has increased infrastructure development with

international partners and has also inspired local research and collaboration with our colleagues

in pediatrics and public health and our international partners.

OP36- Integration of Uniformed Medical Services into National Surgical Obstetric and

Anaesthesia Planning

Michelle Joseph, Harvard Medical School


Keywords: Trauma systems, National Surgical Obstetric and Anaesthesia Planning, NSOAP,

Military, Civilian, Civilian-Military

Background


38

Militaries and academic civilian organizations have an interest in building trauma capacity

and capability in multiple regions around the world both in conflict and in peacetime. In the

past, different militaries and academic institutions may work on trauma system development

in the same region but do not necessarily work together.

The National Surgical Obstetric and Anaesthesia Planning structure promotes collaboration

of stakeholders and guide effective engagement. This is the ideal entry point for an integrated

trauma system between military and civilian institutions to be devised. To date there are no

integrated frameworks that give guidance on how to systematically work together and pool

resources to improve trauma care.

Methods

Development of such a framework requires three key phases: stakeholder analysis, priority

setting analysis, framework construction and testing. We present our methods and outcome

for phase I: stakeholder analysis.

A multinational group of civilian and military surgeons (Sri Lanka, Jordan, South Africa,

Peru, UAE, US, and UK) were identified through convenience sample methods. Structured

meetings were conducted to identify key areas for trauma system integration. An iterative

analysis of metrics was performed, followed by classification into specific domains.

Results

The domains and metrics were converted into a survey for dissemination to each of the six

World Health Organisation regions.

An extensive list of identified subjects for survey analysis was constructed, informed by

literature and recommendations. Additionally, key conferences have also been identified for

survey dissemination.

Through the stakeholder analysis a strategic framework development plan was created: study

series and collateral research to strengthen and support the survey and qualitative interview

data to be collected.

Conclusion

We believe this systematic approach to assessing feasibility of integration of civilian and

military trauma systems into NSOAPs will enhance the interoperability between these

disparate entities, particularly in peacetime, but also in the event of conflict or disaster.

OP37- The accuracy of the diagnosis of Prostate Cancer using Fine Needle aspiration

cytology at Ndola Teaching Hospital.

*Bowa K, Kasoma D University of Lusaka School of Medicine and Health Sciences


Background

Prostate cancer is the leading Urological Cancer worldwide. In Zambia it’s the second leading

Cancer in men. This study explores the accuracy of the use of Fine Needle Aspiration Cytology

in the diagnosis of Prostate Cancer. This is a low-cost method that can be used in primary care

facilities in Africa.

Methods


39

The study was conducted at Ndola Teaching Hospital. The inclusion criteria were men aged

between 50 to 85 years, with a digital rectal examination suggestive of Cancer of the Prostate

and an elevated PSA. These patients had FNAC using the transrectal route as well as

Transrectal Biopsy, using finger guided technique. The slides were processed and unlinked.

This allowed them to be reported independently. The biopsy was taken as the gold standard for

the diagnosis of Prostate cancer. This allowed for the computation of sensitivity and specificity

of FNAC.

Results.

Twenty-four were recruited in the study and had both a complete cytology report and biopsy

report. Sixteen patients were reported with malignancy by cytology and 20 patients reported

with malignancy by biopsy. Cytology showed 3 patients as having benign lesions, while biopsy

reported 4 as benign. The study computed the sensitivity of FNAC as 80% and the specificity

at 75%.

Conclusions

The study found that FNAC has a high sensitivity and specificity for the detection of Prostate

Cancer. The Royal College of Pathologists recommends a minimum sensitivity and specificity

of 60% in FNAC. Though the study sample was small, the study suggests that FNAC can be

used in low resource setting for the early diagnosis of Prostate Cancer.

OP38-Variable presentation of circumcaval ureter, Report of Two Cases and Review of

Literature

*Bassem WY1, Kasoma Z2

1. Department of Surgery, Urology Division, University Teaching Hospital, Lusaka, Zambia

2. Department of Surgery, Urology Unit, Levy Mwanawasa Teaching Hospital, Lusaka,

Zambia.


Summary

An anomalous development of the infra-renal inferior vena cava leads to circumcaval ureter or

preureteral vena cava, a rare congenital anomaly with an autopsy incidence of 1 per 1500

people and three to four times more common in males compared to females.

Circumcaval ureter usually presents in the third and fourth decades of life. Very few cases are

reported in our region possibly due to the condition remaining undetected as most of the cases

are asymptomatic or could be due to limited access to imaging facilities.

We present the first two cases reported in Zambia diagnosed and managed as a circumcaval

ureter in the University Teaching Hospital, Lusaka, Zambia in 2013. The first patient presented


40

with recurrent right loin pain due to a Type 1 circumcaval ureter and the second patient

presented with recurrent UTI due to Type 2 circumcaval ureter. The first patient was diagnosed

preoperatively by IVU but in the second patient preoperative diagnosis was difficult as the

lesion mimicked uretro-pelvic junction obstruction. Both patients had an open surgical repair

with excellent outcome.

OP39- Prognostic factors for surgical site infection following intramedullary nailing of

diaphyseal fractures of the femur and tibia in adult patients at a tertiary hospital in

Lusaka, Zambia

Musonda W, University of Zambia, Dept. of Surgery, Orthopaedic Unit, Lusaka, Zambia


Keywords: Surgical site infection, femur, tibia, intramedullary nailing, risk factors.

Background

Surgical site infection (SSI) is common adverse outcome following orthopaedic surgery. It has

a difficult and often protracted course of management. Associated adverse effects include deep

bone and implant infection.

Despite the observed delay in fracture repair by open reduction and internal fixation (ORIF),

information regarding SSI rate and antibiograms following intramedullary nailing (IMN) of

femoral and tibia diaphyseal fractures was lacking at the study. Both delay and ORIF can

potentially increase SSI rate.

Methods

This was a prospective case series in patients that underwent elective IMN at a tertiary care

hospital in Lusaka, Zambia between September 2019, and August 2020. Skeletally mature

participants with closed diaphyseal fractures of the femur and tibia who signed informed

consent for both operation and participation in the study were included in the study while those

with pathological fractures, established spine injuries and those that missed any planned clinic

visit within the active surveillance period following surgery were excluded. The active

surveillance period for SSI was 90 days as defined by the Centres for Disease Control - National

Healthcare Safety network (CDC-NHSN) criteria. Data analysis was done using Stata version

15. For all statistical analyses, a p-value of <0.05 was considered statistically significant.

Results

There were 132 participants, median age 30 years (IQR, 25-42). An SSI rate of 15.9% was

found. Five (23.8%) participants with SSI subsequently developed deep bone infection which


41

led to explantation. After multivariate analysis, femoral diaphyseal fractures (AOR=0.08, 95%

CI [0.02-0.35]; p = 0.001) were associated with lower odds of developing SSI when compared

to tibial. Staphylococcus aureus, mostly MRSA, was commonly isolated.

Conclusion

Both SSI rate and MRSA were found to be higher than universally accepted. The information

is important for locally relevant SSI case management.

Poster Presentations

PP1-Impact of the COVID-19 Pandemic on Pediatric Surgical Volume in four Low- and

Middle-Income Country Hospitals: Insights from an Interrupted Time Series Analysis

*Parker P1, Bvulani B2, Ki B3, Ameh E A4, Ugazzi M5, Ozgediz D6

1. School of Medicine, University of California San Francisco

2. Paediatric Surgery Unit, Department of Surgery, University Teaching Hospital, Lusaka,

Zambia

3. Department of Paediatric Surgery, Centre Hospitalier Universitaire Pédiatrique Charles

De Gaulle

4. Division of Paediatric Surgery, National Hospital, Abuja

5. Division of Pediatric Surgery, Hospital de los Valles

6. Department of Surgery, University of California San Francisco


Keywords: Global surgery, Pediatric surgery, COVID-19, interrupted time-series analysis,

LMIC

Background

The impact of the COVID-19 pandemic on surgical care delivery in LMIC where there are

large unmet surgical needs, has been difficult to assess due to lack of data. This study examines

the impact of COVID-19 on pediatric surgical volumes at four LMIC hospitals.

Methods

Retrospective and prospective pediatric surgical data were collected at hospitals in Burkina

Faso, Ecuador, Nigeria, and Zambia that are partnered with the international non-governmental

organization Kids Operating Room (KidsOR). Data from January 2019 to April 2021 was

reviewed. Changes in surgical volume associated with the pandemic were assessed using

interrupted time series analysis.

Results


42

6,078 total operations were assessed. During pre-COVID, the surgical volume increased by 21

cases/month across the sites. However, there was a decrease of 82 cases in the immediate month

following March 2020 at the onset of the pandemic. During the pandemic, patients were

younger (2.7 vs 3.3 years, p<0.001) and more classified as ASA I (69% vs 66%, p=0.003).

There were improvements in clinical outcomes such as rates of post-operative sepsis (0.3% vs

1.5%, p<0.001), surgical site infections (1.3% vs 5.8%, p<0.001), and mortality (1.6% vs 3.1%,

p<0.001).

Conclusion

Generally, there were increases in surgical volume pre-COVID across the sites, followed by

sharp declines in the month following March 2020 and slow recovery post-COVID. Patients

were younger and healthier with better post-operative outcomes. Given the large unmet burden

of pediatric surgical diseases and lack of data in these regions, the pandemic has presented a

substantial additional challenge with a need for immediate mitigation strategies.

PP2- Current Practices in Breast Cancer Management in sub-Saharan Africa

Wester J1, Chwa E2, Lockman S1

1. Botswana Harvard Partnership

2. Northwestern University Feinberg School of Medicine


Keywords: breast cancer, mastectomy, breast-conserving therapy, axillary lymph node

dissection, outcomes, sub-Saharan Africa

Background

Breast cancer is the most-commonly diagnosed cancer and leading cause of cancer death in

women worldwide. Breast cancer management has improved over the past 50 years to reduce

morbidity and optimize outcomes. However, management practices are often dictated by

available resources and local practices, resulting in substantial global disparity. In this study,

we review current surgical and therapeutic practices for breast cancer in sub-Saharan Africa

(SSA).

Methods

Full text published studies in PubMed discussing breast cancer management in sub-Saharan

Africa from 1990 to present met inclusion criteria for this narrative, non-systematic review.

Results

The primary surgical treatment for breast cancer in SSA is modified radical mastectomy. Many

studies explore the global disparity in rates of breast-conserving therapy (lower in SSA) to

mastectomy (more frequent in SSA). However, nearly 80% of women with breast cancer in

SSA are diagnosed with stage III or IV disease at presentation compared to 15% in high-income

countries. More extensive breast and axillary surgeries are often required with advanced stage

at presentation. Nonetheless, axillary surgeries have not transitioned from axillary lymph node

dissection to sentinel lymph node biopsies in the case of a clinically node-negative axilla in

many regions of SSA due to limited surgical capacity. Chemotherapy for breast cancer is not

utilized by many individuals in SSA due to limited availability and prohibitive cost. Recent

data suggest that only 18% of the projected radiotherapy needs in SSA are met as over two


43

thirds of the countries in SSA do not have access to radiotherapy facilities in public health

systems. Lastly, estrogen-targeted hormonal therapy, though markedly more affordable than

HER2-targeted therapy, still faces challenges of limited availability and non-adherence.

Conclusion

Significant surgical and therapeutic challenges exist for breast cancer management in SSA. In

this study, we identify some of these challenges and note the impact on patient morbidity and

mortality.

Kindly send me the revised programme I send it along with the invitation letters

For the graduation and Scientific Conference only

ministry of health 21st college of surgeons of east

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