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Esophageal squamous cell carcinoma (ESCC) is common in some parts of Kenya. Both the regional factors associated with ESCC in Kenya and geographic distribution has not been completely described. Methods: We analyzed the association of ESCC with smoking, khat chewing, alcohol, diet, socioeconomic status, caustic ingestion and first degree family history of ESCC in a multi-center based matched case-control study. We also determined the geographic origin, age, gender and ethnicity of patients visiting the participating centers between August 2008 and April 2009. Results: Eighty three cases and 166 controls matched for age and gender were studied. The male to female ratio of cases was 2.1:1, majority were from Central and Eastern provinces of Kenya, about one fifth (19%) were younger than 45 years of age. On multivariate analysis, caustic ingestion (OR 11.3 CI 3.0 – 42.5), first degree family history of ESCC (OR 3.5 CI 1.3 – 9.5) and poor housing (OR 2.0 CI 1.1 – 3.5) were independent predictors. Conclusions: Majority hailed from the Central and Eastern provinces probably due to proximity to the study centres. A large proportion of cases were young compared to studies in other high incidence regions in the world. Low socio-economic status, family history of ESCC and a history of caustic ingestion were significant risk factors.

BACKGROUND: The onset of colorectal cancer appears to be two to three decades earlier in developing countries. Data on whether colorectal cancer in the young has worse prognosis than in older patients is conflicting. METHOD: Clinical charts of 70 patients ≤40 years old were reviewed to determine clinical and pathological patterns and treatment outcomes. Their data were compared with a larger group of older patients treated between 1993-2005 at Kenyatta National Hospital in Nairobi, Kenya. RESULTS: The data retrieval was highest for sub-site distribution and lowest for pathology information. Patients ≤ 40 years of age comprised 27.3% of all colorectal cancer cases treated over the study period. There were 41 males (58.6%) and 29 (41.4%) females patients. The most common symptoms were abdominal pain (76.9%), change in bowel habit (71.4%) and rectal bleeding (54.3%). The mean duration of symptoms was 24.6 ± 30 months. The rate of advanced colorectal disease (Duke C and D) was 73.5%. Mean follow-up time was 5.8 months with median survival of only 6.9 months. The Duke staging, histology, symptom duration, locations of tumours, follow-up and the complication rates were similar for young and older patients. ​CONCLUSION: Younger patients form a significant proportion of colorectal cancer burden. Both the clinico-pathological characteristics and treatment outcome correspond to older individuals. It is suggested that the concluded colorectal symptoms in younger patients should also be aggressively evaluated including early endoscopy. A prospective follow-up study of patients with the disease will unravel the true survival picture.

Background: Trauma remains a significant cause of morbidity and mortality globally. Trauma registries are a key component of trauma systems in developed countries which have promoted improvement of patient care and outcomes. The experience with trauma registries in low income countries is limited. The current study shares preliminary data from the Kenyatta National Hospital Trauma Registry whilst documenting the process of design to implementation. Methods: A de novo registry dataset was designed based on previous studies and programmed as a custom application for deployment to the site. Scope of data collected was demographic, details of injury, pre-hospital events, hospital care and outcomes. Data were summarized as percentages and means for analysis. Results: The development of the registry from concept to operational software took 12 months. Preliminary data revealed an average completion rate of 88.6%. Majority of patients were young males who were referred to the hospital. Accidental injury at home or on the roads was the most common cause of admission with majority of patients not receiving any pre-hospital care. Sixteen percent of patients died while admitted. Conclusion: The data obtained from this de novo registry largely aligns to previous institutional reports while revealing data points for increased focus during training for registry abstraction. This experience may form the platform for trauma quality improvement initiatives at the institution as well as scaling to other institutions to allow for collation of regional trauma data.

The incidence of colorectal cancer in Africa is increasing. True data on clinical outcomes of the disease is hampered by follow up challenges.Method: Follow up data of 233 patients treated for colorectal cancer between 2005 and 2010 at various Nairobi hospitals were evaluated. The primary outcome was mortality while secondary outcomes included recurrence rates, time to recurrence and the patient, disease and treatment factors associated with mortality and recurrence. Kaplan Meir charts were charted for survival trends. Results: Half of the lesions were located in the rectum. There was no relation-ship between the sub-site location and recurrence and mortality. The mean follow-up period was 15.9 months. Overall recurrence and mortality rates were 37.5% and 29.4% respectively. Most recurrences occurred within one year of surgery. Recurrence was not influenced by age, gender, sub-site, chemotherapy receipt or presence of co-morbidity. Factors significantly associated with mortality included the male gender ( p 0.04), presence of co-morbidity (p 0.029), recurrence (p 0.001), curative intent (p 0.01), disease stage (p 0.036) and receipt of chemotherapy ( p< 0.01). Conclusion: Follow up of colorectal cancer patients is still challenging. The mortality and recurrence rates are high for the short follow up periods. Further studies are needed to explore the determinants of both survival and recurrences, especially with longer follow ups.

Background: Environmental conditions have been shown to influence incidence of rugby injuries. Harsh weather conditions and detrimental effect on poor Kenyan rugby pitches create a unique environment for injury exposure. We conducted a whole population prospective cohort study to determine the association of pitch conditions with injury incidence and severity. Methods: The study was conducted on 364 registered Kenya Rugby Union (KRU) players throughout the 2010 15-aside season. The injury incidence was calculated as injuries per 1000 match player hours (mph). Pitches were categorized into good and suboptimal based on quality indicators of ground characteristics. Injuries were defined and recorded according to the Rugby International Consensus Group (RICG) protocol and compared between the pitches. Results: One hundred and two injuries were recorded in 60 league games (2400 mph). Twenty nine of the 60 league games were played in the category B (suboptimal condition) pitches. The overall incidence of injuries was 42.50/1000mph. Good pitches had an injury of 29.0 injuries/1000mph (95% CI 0.81- 1.61) compared to 56.9 injuries/1000mph (95% CI 1.76- 2.90) for suboptimal pitches. Conclusion: Although the overall Kenyan injury rate is comparable to the amateur level incidence from other studies, the higher rate associated with suboptimal pitches suggests interventions that can target pitch optimization.

Background: The burden of traumatic brain injury (TBI) is rising in developing countries. Minor head injuries accounts for majority of non-fatal head injury and is associated with significant resource use. The utility of the CT scan in cases of mild head injury is undetermined although a big proportion of our patients are offered the investigation. We hypothesized that the introduction of the Canadian CT head rule (CCTHR) will reduce the utilization rate. Methods: Eighty four eligible patients diagnosed with minor head injury were recruited at the Accident and Emergency Department. The proportion of CT scan orders before (Group I-42 patients) and after (Group II- 42 patients) the introduction of the CCTHR was determined. Treatment in Group I patients followed the primary physician orders while group II patients were offered CT scans only if they presented with ‘high risk’ features of the CCTHR. Group II patients with ‘moderate’ risk factors were admitted for observation or discharged as appropriate to the rule. Results: The proportion of CT scans ordered in Group I was 95.2% while that in Group II was 21.4%. The proportion of patients with moderate risk factors Group I was 90.5%, representing the proportion of patients who did not require a CT scan. None of the patients required neurosurgical intervention and all had good recovery on follow up. Conclusion: The proportion of mild head injury patients requiring a CT scan at AKUH is 21.4%. Limiting CT scans to only this group was not associated with adverse outcomes. It is the recommended that CT scan rates for mild head injury be capped at 25% to save time and money currently being expended.

Background: Esophageal squamous cell carcinoma (ESCC) is common in some parts of Kenya. Both the regional factors associated with ESCC in Kenya and geographic distribution has not been completely described. Methods: We analyzed the association of ESCC with smoking, khat chewing, alcohol, diet, socioeconomic status, caustic ingestion and first degree family history of ESCC in a multi-center based matched case-control study. We also determined the geographic origin, age, gender and ethnicity of patients visiting the participating centers between August 2008 and April 2009. Results: Eighty three cases and 166 controls matched for age and gender were studied. The male to female ratio of cases was 2.1:1, majority were from Central and Eastern provinces of Kenya, about one fifth (19%) were younger than 45 years of age. On multivariate analysis, caustic ingestion (OR 11.3 CI 3.0 – 42.5), first degree family history of ESCC (OR 3.5 CI 1.3 – 9.5) and poor housing (OR 2.0 CI 1.1 – 3.5) were independent predictors. Conclusions: Majority hailed from the Central and Eastern provinces probably due to proximity to the study centres. A large proportion of cases were young compared to studies in other high incidence regions in the world. Low socio-economic status, family history of ESCC and a history of caustic ingestion were significant risk factors.

Background: The heterogeneity of disease severity in peritonitis makes outcome prediction challenging. Risk evaluation in secondary peritonitis can direct treatment planning, predict outcomes and aid in the conduct of surgical audits. Objective: To determine the outcome of peritonitis in patients stratified according to disease severity at the Kenyatta National Hospital (KNH). Design: Prospective descriptive cross sectional survey. Methods: Seventy patients were consecutively enrolled within 24 hours of operation for peritonitis between December 2007 and April 2008. To stratify patients according to severity, Mannheim Peritonitis Index (MPI) scores were calculated using the following risk variables: age, sex, preoperative duration, organ failure, sepsis source, malignancy, character and extent of exudate. The main outcome on follow up was complications. Secondary outcomes were length of hospital stay and mortality for different MPI scores. Results: Fifty six males and 14 females (M:F=4:1) were analysed. The mean age was 32.17 years (age range 13-59 years). Forty six (65.7%) had generalised peritonitis, 15(21.4%) had 2-3 quadrant peritonitis while 9(12.9%) had focal peritonitis. Common sources of peritonitis were perforations of appendicitis (31.4%), duodenal ulcer (22.9%) and ileum (18.6%). Patients who complicated had a mean MPI of 26.9 compared to those who did not (22.8) (p=0.018). Morbidity rates increased with rising MPI scores (31% for MPI 29). The risk of death was double for patients with an MPI ≥26. Hospital stay was 14 days for the whole group but 22 days for those who developed complications. ROC curve analysis showed a predictive power of 0.916 with a sensitivity of 88.9% and specificity of 85.2% at MPI of 29 points. Conclusion: MPI scores related with outcomes of peritonitis and can be used in prognosticating early outcome in patients with surgical peritonitis at KNH.

Background: The recurrence rate after soft tissue sarcoma (STS) treatment ranges between 20-25 % ,and usually occurs within 2-3 years after primary surgery. In Africa, many of the patients present late, access to adjuvant therapy is not guaranteed either. The basis of this study was to establish patterns and factors affecting recurrence and mortality after surgical treatment at a national referral medical facility. Methods: A five and a half years retrospective study between January 2003 and June 2007 and a six months prospective follow-up arm between July 2008 and March 2009. Data reviewed from all eligible surgically treated patients were demographic variables, duration of symptoms, anatomical distribution, investigations, adjuvant therapy, tumour type, size, grade and stage and surgical margins status. The outcome variables were tumour recurrence and death. Results: Mean age was 32.52+18.17 years. The male/ female sex ratio was 0.97:1. The mean duration of symptoms was 10.87+18.75 months. The extremities had the most number of cases (62%). Fibrosarcoma was the most common histological type (36.0%) and the mean tumour size was 13.0 +7.36 cm. Most (44.7%) patients presented with high grade tumours and 78.0 of the patients presented with a recurrence. Most of the recurrences (71.7%) occurred within the first year of treatment. Failure to get adjuvant therapy (p5cm (p=0.02), advanced stage (III and IV) (p

Background: General anaesthesia is the anaesthetic agent of choice during thyroidectomy, however, recent reports there is a role for local anaesthesia. This study reports on the experience of thyroidectomy performed under infiltrative local anaesthesia in a rural surgical setting. Methods: This was a review of patients who underwent thyroidectomy during a surgical camp. We included the bio data of the patients, anaesthesia used, duration of surgery, immediate complications and duration of stay. Patients underwent either general or infiltrative local anaesthesia. Results: Out of seven patients undergoing surgery, three were performed under infiltrative local anaesthesia. The average age for all the patients was 37.43 +/- 5.3 years and there was no statistical difference in the mean age between patients who underwent infiltrative anaesthesia and those who underwent general anaesthesia. We noted one immediate transient difficulty in breathing in a patient who underwent general anaesthesia. The average length of stay was 2 days for local anaesthesia group and 2.25 days for general anaesthesia. Conclusions: There was no difference between the two groups either on biodata or outcome measures. Local anaesthesia is a safe alternative to general anaesthesia for patients undergoing thyroid surgery.

Background: Accuracy of initial assessment of acute abdominal pain (AAP) is confounded by subjectivity and multiple etiologies for similar presentation. Standardized forms may harmonize the initial assessment, improve accuracy of diagnosis and enhance outcomes. Objectives: To determine the extent to which use of a structured data collection form (SDCF) affected the diagnostic accuracy of AAP. Methodology: A before and after study carried out from October 2011 to March 2012 of patients aged 13 years and older presenting with AAP in the emergency department (ED) of Aga Khan University Hospital, Nairobi (AKUH,N). Patients clerked by ED physicians using conventional history taking and examination between October and December 2011 were compared to a second group clerked after the introduction and use of a SDCF (January – March 2012) for proportion of correct diagnosis at initial encounter. This influence of age, gender and disease type on the impact of the form was evaluated as was the impact of the introduction of the structured forms on time to ED disposition, hospital stay, number and cost of investigations. Data were compiled in MS-Excel spreadsheets and analyzed using SPSS v16. P value of

Objective: To determine the incidence and characteristics of injury amongst Kenya rugby union players and associated factors. Design: A whole population prospective cohort study. Methods: 364 registered Kenya rugby union (KRU) players were stud-ied throughout the 2010 season. Data on their demographics, injury incidence, pattern and severity were gathered. The study tool used was the Rugby International Consensus Group (RICG) Statement. Results: There were 173 backs and 191 forwards. One hundred and two 1 injuries for 60 league games (2400match player hours) were recorded. The incidence of injuries was 42.5/1000 match player hours (mph), (44.2 for forwards and 40.8 for backs). Lower limb injuries were the most common (41.2%) . Players were most prone to injuries in the in tackle scenario (63.7%), at the beginning of the season (47.1%), and in the last quarter (50%) of a game. Conclusion: The injury incidence recorded contrast the earlier Kenyan data but is comparable to international amateur level incidence, uniqueness of the Kenyan environment notwithstanding. The higher rates associated with the tackle/tackled scenario, earlier part of the season and later part of the game, suggest interventions can target player conditioning, and use of protective gear.

Background: Perforations complicate up to 5-10% of peptic ulcer diseases. Mortality following peptic ulcer perforation can peak 29%. Of the factors that influence the outcome of peptic ulcer perforation, treatment delay is most important and modifiable. This study reviewed delay and how it affected outcome in patients treated for perforated peptic ulcers at the Kenyatta National Hospital. Methods: Patient’s files for the period January 2002 to December 2007 were reviewed and direct interviews carried out for patients seen from January to December 2008. Data sought included patient demographics, clinical presentation, time from symptom onset to presentation at casualty, time from presentation at casualty to surgical treatment and the treatment outcomes. Data was entered using a structured data sheet /questionnaire. The effect of delay as a determi-nant of outcome was evaluated using univariate analysis. ​ Results: One hundred and ninety three patients were evaluated. Twenty four patients (12.4%) died. Sixty one patients (31.6%) developed complications post-operatively. Thirty patients were re-operated for the complications. No patient treated within 24 hours died. Complications rate was 0 %, 1.5% and 29.5% for patients treated within 24 hours, 24-48 hours and after 48 hours respectively. Delay >48 hours was significantly associated with increased mortality (p value

Background Surgical mentorship crosses both skilled training and the gamut of career choices and surgical decision making. The challenge also lies in the ideal mentorship balance that transcends the mere transfer of surgical skills and addresses other key components such as career development and research. Objective To explore the views and perceptions of surgical residents in Kenyan Institutions on mentorship and its importance in training. Method Sixty four surgical residents were surveyed. Thirty four (56%) were involved in a mentorship program. Twenty three percent of residents within an actual mentorship program reported satisfaction with their mentorship program. Mentors were perceived to be most critical in research and competency. Expectations were lower for their role in career development, handling stress and character building. About half of respondents felt that an ideal mentorship program would entail a structured mentoring program with regular monitoring. ​ Conclusion Current uptake of mentorship roles is suboptimal. There is need to strengthen our mentorship links to enhance the support of new resi-dents to balance professional and private personal needs.

Background The incidence of colorectal cancer in Africa is increasing. True data on clinical outcomes of the disease is hampered by follow up challenges. Method Follow up data of 233 patients treated for colorectal cancer between 2005 and 2010 at various Nairobi hospitals were evaluated. The primary outcome was mortality while secondary outcomes included recurrence rates, time to recurrence and the patient, disease and treat-ment factors associated with mortality and recurrence. Kaplan Meir charts were charted for survival trends. Results Half of the lesions were located in the rectum. There was no relation-ship between the sub-site location and recurrence and mortality. The mean follow-up period was 15.9 months. Overall recurrence and mortality rates were 37.5% and 29.4% respectively. Most recurrences occurred within one year of surgery. Recurrence was not influenced by age, gender, sub-site, chemotherapy receipt or presence of co-morbidity. Factors significantly associated with mortality included the male gender ( p 0.04), presence of co-morbidity (p 0.029), recurrence (p 0.001), curative intent (p 0.01), disease stage (p 0.036) and receipt of chemotherapy ( p< 0.01). Conclusion Follow up of colorectal cancer patients is still challenging. The mortal-ity and recurrence rates are high for the short follow up periods. Fur-ther studies are needed to explore the determinants of both survival and recurrences, especially with longer follow ups.

Background: Configuration and branching pattern of the posterior communicating artery influence occurrence and approaches to management of aneurysms. Distribution of the various configurations and branching patterns shows population variations but reports from Africa are scanty. Objective: To determine the prevalence of various configurations and branching pattern of the posterior communicating artery in a Kenyan population. Materials and Methods: Eighty four posterior communicating arteries obtained from Department of Human Anatomy were studied. The configuration and number of branches in each third and length of the longest perforator free zone of the posterior communicating artery were evaluated Results: Adult configuration was observed in 56%, hypoplastic in 25%, fetal in 12% and transitional in 7%. Mean number of branches given off was 7.2 ± 1.9 (range: 3-12), highest in proximal and lowest in the distal third of the artery. Perforator free zone ranged between 1mm to 8mm with a mean of 4.01 ± 1.54mm and was longest in the hypoplastic configuration. Conclusion: Configurations observed in the Kenyan population are comparable to those reported in the Caucasian populations. From an anatomical standpoint, the two are equally predisposed to development of aneurysms. Posterior third of PComA had the least number of branches suggesting that the pterional approach to basilar tip aneurysm among Kenyans may be a safer procedure.

Background: In Sub Saharan Africa, surgical conditions account for a significant disease burden. Surgical workforce is however inadequate, and thus strategies such as attracting medical students to surgical specialties could avert the situation. This study determined the proportion of students interested in pursuing surgical career and factors that influence choice of this specialty. Methodology: Four hundred and fifty medical students, from first to fifth year of study at the University of Nairobi, were each issued a self administered questionnaire designed to assess their specialty preferences, and factors influencing these choices. Results: The response rate was 385/450(85.6%). Surgery was the most popular specialty with 105(27.3%) students. Majority, 60(57%), of those who preferred surgery were in the preclinical years. Male students had a two-fold likelihood of selecting a surgical career compared to females. Significant factors that attracted students to surgery instead of non surgical careers were prestige of the specialty (p

The evolution of systemic inflammatory response syndrome (SIRS) to septic shock is a continuum that can be stemmed using dedicated and early goal directed interventions. In the setting of necrotizing soft tissue infection, mortality approaches 100% when debridement is delayed or altogether omitted. Volume depletion, vasodilatation, myocardial depression, high metabolism and attendant global hypoxia that precede multi- organ dysfunction syndrome (MODS) and mortality need to be addressed early, avoiding delays in the emergency department, hospital ward, or the intensive care unit. Early goal -directed therapy denotes the use of interventions such as administration of crystalloid solutions, vaso-active agents, blood transfusion and inotropic agents to achieve specific targets, namely, a central venous pressure of 8 – 12 mmHg, a mean arterial pressure of 65 – 90 mmHg, a urine output of > 0.5mls/kg/hr, a hematocrit of >30% and a central venous oxygen saturation of > 70% in a patient who is intubated, sedated and paralysed.We present an illustrative case of the management of severe Fournier’s gangrene and how a series of misadventures at home, the A & E and the wards contributed to the inevitable demise.

Background: The Physiological and Operative Severity Score for enUmeration of Morbidity and Mortality (POSSUM) and its Portsmouth modification (P-POSSUM) were developed for comparative audit in surgical patients. This study evaluated applicability of these systems in estimating mortality and morbidity risks in a cohort of patients undergoing laparotomy at the national referral hospital in Nairobi, Kenya. Methods: Data of 166 patients undergoing laparotomy was subjected to POSSUM and P-POSSUM scoring systems and analyzed using linear and exponential methods. The discrimination power of POSSUM and P-POSSUM as predictors of surgical outcome was measured using the receiver–operating characteristic (ROC) curve. Results: The overall observed to expected (O:E) ratio using linear analysis was 0.29:1 (POSSUM) and 0.67:1 (P-POSSUM) while exponential analysis gave an O:E of 0.2:1 (POSSUM) and 0.4:1 (P-POSSUM). The predicted morbidity using POSSUM was 1.09:1 (linear analysis) and 1:1 (exponential analysis). Hosmer–Lemeshow analysis did not show a significant lack of fit with the observed mortality when applied to POSSUM and P-POSSUM. The area under ROC curve was 0.74 (POSSUM) and 0.78 (P-POSSUM). Conclusion: Our results support the suitability of P-POSSUM and POSSUM scoring systems to stratify morbidity and mortality risk in our study population.

Background: The burden of injury in low-income countries is greater than in high income countries, but injury documentation and prevention policies are inadequate. The who, where and how of firearm injuries in Kenya has received little attention. Objective: This study describes the epidemiology of small and light firearm injuries to highlight the problem and stimulate further methodologically and scientifically sound research in the area. Method: This retrospective study involved abstracting socio-demographic data, injury mechanism, intention, resources consumed and outcome information from case notes in the records departments of two major health facilities in Nairobi. Results: Eight hundred and fifty two hospital admissions due to gunshot injuries were recorded between 1997 – 2002 (average, 142 per year) representing 1.8% of all injury admissions, and 0.2% of total admissions at the two hospitals. There were 10 times more male admissions and 89.9% of those involved were in the 15-44 year age group. Six hundred and twenty nine (85.9%) of the admissions were as a result of intentional injuries (assaults) while 101 (13.8%) were as a result of unintentional injuries. Forty two (5%) patients died in hospital while 800 (94.5%) were discharged home. The burden on health care facilities included a total of 15,392 ward days for 841 patients whose records were available and a total of 144 ICU days for 19 patients. Seven hundred and eighty four (92.9%) patients underwent some form of surgery, mostly limb surgical toilet with wound excision/debridement. Hospital resources used included 3346 units of intravenous fluids and 518 units of blood. Conclusion: The study recommends that policy makers be sensitized on the magnitude of this problem and more studies on risk factors to be carried out so that the process of testing interventions can begin.