A dissertation of ten surgical conditions

A study of ten common surgical conditions seen by the author over a 3 years period at the Muhimbili Medical Centre is presented. A critical review of the relevant literature follows each condition studied. In general surgery, the conditions studied were peptic uclcer perforation, rectal carcinoma, splenic rupture, appendicitis and endemic goitre. Peptic ulcer peroration was found to be the commonest complication of peptic ulcer disease demanding surgical intervention. It accounted for 70% of peptic ulcer patients requiring surgery. This greatly contrasts with a figure of about 5% in most Western series. The rarity of this complication in the female sex was very remarkable in this study; not a single case was seen in the female population. Utilizing simple closure as the intial surgical treatment in all patients resulted in 17% and 30% of acute ulcers and chronic ulcers respectively requiring subsquent definitive surgery. A mortality of 15% was experienced and this was related to delay in surgical intervention. Rectal cancer constituted 80% of all the colorectal cancers seen by the author at Muhimbili. Only 42% of these tumours were resectable. Compared to European patients, the author’s patients were relatively young with a median age of 46 years. Although the clinical presentation was classical from onset in over 80% of these patients, 64% of the patients were refered to hospital from the dispensaries only after one or more years have elapsed. However, a shorter symptom duration was found not to be associated with a favourable stage of tumour. Acute appendicitis, the commonest surgical emergency in developed countries and believed to be rare in Africans, was found to be not so uncommon at the Muhimbili Medical Centre. In one of the 3 surgical firms, the average rate of acte appendicitis (confirmed surgically or histopathologically) was one case per month while the rate of appendicectomy was 1.7 cases per month. Despite the high diagnostic error (32%) experienced, the rate of perforation was also high (60%). This was mainly due to delay in making diagnosis at the dispensaries. There was no mortality from acute appendicitis but the morbidity from perforated appendix was very high and this could only be significantly reduced by training the dispensary staff in early recognition of this condition. The classical clinical presentation was observed in only 60% of the author’s patients. Laparatomy for traumatic rupture of the spleen, ranked as the fourth major emergency procedure in one of the general surgical firms at Muhimbili. Road Traffic Accidents were the cause of 50% of the ruptured spleens while urban violence and falling from coconut trees were the second major causes. Inefficient facilities for evacuation of trauma victims from the scene of accident to hospital resulted in many patients with serious injuries dying before reaching hospital. The author extensively reviews the rationale and trend towards spleen conserving operations. Many regions of Tanzania are endemic of goitre but only few patients come to require surgical invervention at the Muhimbili Medical Centre. Follicular carcinoma of the thyroid was observed to be the commonest type of thyroid cancer at Muhimbili. This was a reflection of the prevalence of endemic goitre in the country. Mass prophylaxis by salt iodinization, rather than the surgeon's knife, is the only rational cheap solution to this nutritional disorder of the throid which the government should undertake. Three common paediatric surgical conditions were also studied. These included Burkitt’s lymphoma, infantile hydrocephalus and crytorchidism. Burkitt’s lymphoma was the commonest cancer which constituted 70% of all the cancers seen by the author in the paediatric surgical ward. The absominal form of Burkitt lymphoma was the commonest manifestation found in the ward. It accounted for 71% of the total cases of Burkitt’s Lymphoma. A hospital mortality of 43% was observed and this was attributed mainly to chemotheraupetic complications. Patients with Burkitt’s Lymphoma and hydrocephalus mostly came from far upcountry stations. These patients were usually lost to follow up after the initial treatment at Muhimbili. The Long term benefit of the therapy offered from Muhimbili was therefore not known. It is a known fact that devices for shunts in hydrocephalus are very expensive but are useless, if not dangerous, when close expert follow up is not possible. Even in the best medical centres in the world, the current available treatment procedures for hydrocephalus are often attended by a multitude of late complications and appear not to affect much the natural course of the disease in the long run. The author ends the paediatric section by looking at the presently rather controversial subject of cryptorchidism. At Muhimbili Medical Centre, these children were usually operated on as they came. The age for operation was mainly influenced by the parents or the referring doctors. This situation resulted in only 33% of the patients being operated before the age of 5 years. An extensive up to date review of this currently evolving problem is presented. Finally, the author ends the dissertation by studying two common orthopaedic conditions, namely distal femoral epiphyses plate injuries and traumatic meniscal tears. The special diagnostic and management reduction of displaced distal femoral epophyseal separation failed in all the author’s 7 patients. This occurred despite the fact that 28.6% of the patients reported for treatment within 5 days of the injury and 57.1% reported within 10 days. Traumatic meniscal tears mainly affected young adults; 75% of the patients were aged 30 years or below. Sports activities were the major causes which accounted for 64% of cases. Both sexes were equally affected. Associated tears of knee ligaments were present in 18% of the cases. Total menisectomy, with repair of knee lignments where indicated, rusulted in good results in all patients studied at a 3-month follow up. Partial menisectomy for traumatic meniscal tears is becoming popular, though it was not utilized in the author’s patients. The merits and demerits of partial menisectomy is extensively reviewed