A review of the epidemiology, post-neurosurgical closure complications and outcomes of neonates with open spina bifida

Background. Spina bifida (SB) is a neural tube defect (NTD) that has an increased risk of fatal and disabling effects if not repaired early, i.e. within the first 24 to 48 hours of life. Its diagnosis holds an increased burden for the patient and the caregiver owing to secondary complications. The effects of the disease are detrimental even with early repair, because of the long-term disabling nature of the disease.

Objective. This retrospective study aimed to assess the effects of demographics, immediate post-surgical complications and impact of time to surgical intervention on the outcome of neonates with open SB (OSB) admitted to the neonatal intensive care unit (NICU) at Inkosi Albert Luthuli Central Hospital (IALCH) in KwaZulu-Natal, South Africa (SA), between January 2011 and December 2015.

Methods. A retrospective chart review was conducted at the NICU of IALCH. All neonates diagnosed with SB were identified. The study period was from 1 January 2011 to 31 December 2015. Data were collected from the IALCH electronic database. All neonates with SB admitted to the IALCH NICU were included; any patient who presented beyond the neonatal period (i.e. >28 days) was excluded from the study. Data collected included maternal demographics. Additionally, neonatal history was reviewed and post surgery complications evaluated. Outpatient management post discharge was reviewed.

Results. One hundred and fifty neonates were included (58% male). The mean (standard deviation) maternal age was 26.7 (6.6) years. Only 10% had an antenatal diagnosis of OSB. Seventy-eight percent were born at term and 22% prematurely. The lumbar/sacral region was the most commonly affected. More males (14%) had thoraco/lumbar lesions than females (7.8%). Forty-eight percent presented before 3 days of life (early presentation). In the late-presentation group, there was an association with wound sepsis (p=0.003). Twenty-five percent were repaired between days 0 and 3 of life and 75% after 3 days. Postoperative complications in patients whose open SBs were repaired beyond 3 days of life were not statistically significant compared with those with early repair; all were p>0.05. There was a borderline association of prolonged hospitalisation with wound sepsis (p=0.07). Long-term outcomes showed that 68% had lower limb dysfunction, 18% urological complications, 14% limb deformity, and 11% hydrocephalus. A minority had psychomotor (7%) and developmental (15%) disorders. Ten percent required readmission secondary to shunt complications, and 7% died.

Conclusion. SB remains a significant disease burden that affects outcome and survival of neonates in SA. Lack of good antenatal care, which includes early ultrasound and timely referral to centres, are barriers to good outcomes. Long-term follow-up is also necessary to prevent morbidity.

Percutaneous dilatational tracheostomy: A prospective analysis among ICU patients

Introduction: Percutaneous dilatational tracheostomy (PDT) is a simple bedside procedure, particularly useful in the intensive care units. Over the last few decades, the technique of PDT has gained popularity due to its comparable safety to the more surgical tracheostomy (ST).

Objective: To describe the outcome of PDT using modified Ciaglia’s technique in patients of Surgical ICU.

Methodology: This was a prospective cohort study that analysed the outcomes of PDTs carried out on critically ill patients admitted in the surgical ICU, Pakistan Institute of Medical Sciences, Islamabad from August 2015 to January 2017. All PDTs were performed by the presiding consultant and his team using modified Ciaglia’s (Blue Rhino) technique. The main outcome was the frequency of perioperative and early complications within the first six days. Demographic variables and complications were recorded. Data was analysed using SPSS version 18.

Results: Seventy-four patients underwent PDTs in the surgical ICU with mean age of the patients was 49.17 ± 12.82 years. The commonest indication of tracheostomy was prolonged mechanical ventilation followed by failure to wean. Complications rate was 12.16% of which perioperative bleeding occurred in 6.7% of patients. Early complications within the first six days were wound infection, tube displacement and blocked tube.

Conclusion: PDT is a valuable, efficacious and safe method that can be performed at the bedside with minimal complication rate and needs to be considered more frequently in the intensive care units in developing countries.

Perioperative Management of Gastrointestinal Surgery in a Resource-Limited Hospital in Niger: Cross-sectional Study

Background
Perioperative management in digestive surgery is a challenge in sub-Saharan Africa. Objective: To describe the process and outcomes of perioperative management in gastrointestinal surgery.
Materials and methods
This was a single center cross-sectional study over a 4-month period from June 1 to September 30, 2017, in a Nigerien hospital (West Africa). This study included caregivers and patients operated on gastrointestinal surgery.
Results
We collected data for 56 caregivers and 253 patients underwent gastrointestinal surgery. The average age of caregivers was 38.6 ± 8.7. The median length of professional practice was 9 years. Almost 52% of caregivers (n = 29) did not know the standards of perioperative care. The median age of patients was 24 years, and male gender constituted 70% of cases (n = 177) with a sex ratio of 2.32. Patients came from rural areas in 78.2% (n = 198). Emergency surgery accounted for 60% (n = 152). The most surgical procedure was digestive ostomies performed in 28.9% (n = 73), followed by hernia repair and appendectomy in 24.5% (n = 62) and 13.9% (n = 35) respectively. The postoperative course was complicated in 28.1% (n = 71) among which 13 deaths. In the group of caregivers, the poor practice of perioperative management was associated with poor professional qualification, insufficient equipment, insufficient motivation (p < 0.05). The ASA3&ASA4 score, undernutrition, emergency surgery, poor postoperative monitoring, and poor psychological preparation were associated with complicated postoperative outcomes (p < 0.05).
Conclusion
The inadequacy of the technical platform and the lack of continuous training for healthcare staff represented the main dysfunctions of our hospital. The risk factors for complications found in this study need appropriate perioperative management to improve prognosis in gastrointestinal surgery.

Chronic osteomyelitis: a continuing orthopaedic challenge in developing countries.

Nine patients with chronic osteomyelitis, three with problems due to diagnosis, three with dilemmas regarding treatment and three with other complications are presented. It is suggested that although the diagnosis of osteomyelitis in most cases is straightforward, presentation might sometimes be similar to other conditions, which can lead to a dilemma in the diagnosis. Because of the formidable complications, which may be difficult to manage and the difficulty in guaranteeing permanent cure, the best approach is prevention by judicious treatment of acute haematogenous osteomyelitis and of open fractures.

A Prospective Observational Study of Anesthesia-Related Adverse Events and Postoperative Complications Occurring During a Surgical Mission in Madagascar

BACKGROUND:
Two-thirds of the world’s population lack access to safe anesthesia and surgical care. Nongovernmental organizations (NGOs) play an important role in bridging the gap, but surgical outcomes vary. After complex surgeries, up to 20-fold higher postoperative complication rates are reported and the reasons for poor outcomes are undefined. Little is known concerning the incidence of anesthesia complications. Mercy Ships uses fully trained staff, and infrastructure and equipment resources similar to that of high-income countries, allowing the influence of these factors to be disentangled from patient factors when evaluating anesthesia and surgical outcomes after NGO sponsored surgery. We aimed to estimate the incidence of anesthesia-related and postoperative complications during a 2-year surgical mission in Madagascar.

METHODS:
As part of quality assurance and participation in a new American Society of Anesthesiologists Anesthesia Quality Institute sponsored NGO Outcomes registry, Mercy Ships prospectively recorded anesthesia-related adverse events. Adverse events were grouped into 6 categories: airway, cardiac, medication, regional, neurological, and equipment. Postoperative complications were predefined as 16 adverse events and graded for patient impact using the Dindo-Clavien classification.

RESULTS:
Data were evaluated for 2037 episodes of surgical care. The overall anesthesia adverse event rate was 2.0% (confidence interval [CI], 1.4-2.6). The majority (85% CI, 74-96) of adverse events occurred intraoperatively with 15% (CI, 3-26) occurring in postanesthesia care unit. The most common intraoperative adverse event, occurring 7 times, was failed regional (spinal) anesthesia that was due to unexpectedly long surgery in 6 cases; bronchospasm and arrhythmias were the second most common, occurring 5 times each. There were 217 postoperative complications in 191 patients giving an overall complication rate of 10.7% (CI, 9.3-12.0) per surgery and 9.4% (CI, 8.1-10.7) per patient. The most common postoperative complication was unexpected return to the operating room and the second most common was surgical site infection (39.2%; CI, 37.0-41.3 and 33.2%; CI, 31.1-35.3 of all complications, respectively). The most common (42.9%; CI, 40.7-45.1) grade of complication was grade II. There was 1 death.

CONCLUSIONS:
This study adds to the scarce literature on anesthesia outcomes after mission surgery in low- and middle-income countries. We join others in calling for an international NGO anesthesia and surgical outcome registry and for all surgical NGOs to adopt international standards for the safe practice of anesthesia.