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Background Undernutrition contributes to nearly 50% of all child deaths in the world, yet there is conflicting evidence regarding the association between nutritional status and postoperative complications. The aim was to describe the preoperative nutritional status among pediatric surgery patients in Zimbabwe, and to assess if nutritional status was a risk factor for adverse postoperative outcome of mortality, surgical site infection, reoperation, readmission, and longer length of stay. Methods This prospective observational cohort study included 136 children undergoing surgery at a tertiary pediatric hospital in Zimbabwe. Nutritional status was standardized using Z-scores for BMI, length, weight, and middle upper arm circumference. Primary outcomes after 30 days included mortality, surgical site infection, reoperation, and readmission. Secondary outcome was length of stay. Univariate and multivariable analyses with logistic regression were performed. Results Of the 136 patients, 31% were undernourished. Postoperative adverse outcome occurred in 20%; the mortality rate was 6%, the surgical site infection rate was 17%, the reoperation rate was 3.5%, and readmission rate was 2.5%. Nutritional status, higher ASA classification, major surgical procedures, and lower preoperative hemoglobin levels were associated with adverse outcome. Univariate logistic regression identified a seven-fold increased risk of postoperative complications among undernourished children (OR 7.3 [2.3–22.8], p = 0.001), and there was a four- to six-fold increased adjusted risk after adjustment for ASA, major surgery, and preoperative hemoglobin. Conclusion A third of all pediatric surgery patients were undernourished, and undernourished children had a considerably higher risk of adverse outcome. With a positive correlation identified between undernourishment and increased postoperative complications, future aims would include assessing if preoperative nutritional treatment could be especially beneficial for undernourished children. Levels of Evidence Level II treatment study.

Highlights • Maffucci’s syndrome is a rare congenital musculoskeletal disorder. • Life-long surveillance is mandatory for early detection of malignancies. • Tubular adenoma of the breast is benign with an almost non-existent risk of malignant transformation. • Benign breast tumours may cause ulceration of the skin leading to diagnostic confusion with malignancy. • Giant tubular adenomas of the breast may be treated with lumpectomy even when the ratio of abnormal breast tissue to normal breast tissue is very high., Introduction Maffucci’s syndrome is a rare congenital, non-hereditary mesodermal dysplasia characterised by multiple enchondromas and vascular lesions. To our knowledge this is the first report of tubular adenoma of the breast in association with Maffucci’s syndrome. Presentation of case We report a 31-year-old female who presented with a large, ulcerated slow-growing painless breast mass. She had also sustained two pathological fractures during childhood as well as progressive deformity and limb shortening on the right side of the body. Skeletal survey revealed enchondromas exclusively on the right side in association with phleboliths. Excision of the breast mass was performed. Histological examination of the breast lesion revealed a diagnosis of tubular adenoma, core biopsy of the bony lesions confirmed enchondromas and a cutaneous haemangioma was excised from the abdominal wall. Discussion Tubular adenoma of the breast is a rare benign tumour. When large they may cause ulceration leading to diagnostic and management dilemmas. Patients with Maffucci’s Syndrome require lifelong surveillance for the development of malignancy. Conclusion Tubular adenomas of the breast carry no risk of malignancy. However, malignancy remains high on the differential list when the skin is ulcerated. Ulceration can also be caused by pressure necrosis in benign tumours. This diagnostic dilemma can lead to unnecessarily radical surgery.

Background Raw mortality and morbidity, though commonly studied in surgical audit can nonetheless be misleading because of differences in preoperative and intraoperative findings of patients. There are some common scoring systems specifically designed to cater for case mix but these have not been tried locally. This study sought to validate these scoring systems and hopefully adopt them for our teaching hospitals. Materials and methods A prospective observational cohort study was conducted at two central hospitals in Harare Two hundred and two patients undergoing a variety of major general surgical operations were recruited into the study. Results of physiological and intraoperative parameters collected from the patients’ records were scored according to POSSUM, P-POSSUM and SRS scores. Predicted mortality and morbidity rates of all these subjects were then compared to the observed rates. Results One hundred and eighty one patients participated (123 males, 58 females). Using the POSSUM morbidity score, the observed versus expected (O: E) ratio of 0.88 showed no difference (p = 0.970). Using POSSUM, P-POSSUM and SRS mortality scores, O: E ratios of 0.74, 1.06 and 1.0 respectively were obtained, the differences were not significant (p = 0.650, p = 0.987 and 0.730). All three scores were comparable on the Receiver Operating Characteristic curve. The Physiological score independently predicted mortality (p Conclusion POSSUM, P-POSSUM and SRS scores are comparable and suitable for estimating outcomes after major surgery in Harare. A larger study inclusive of low risk patients is needed to generalise these findings across Zimbabwean patients.

Surgical healthcare has been prioritised in the Southern African Development Community (SADC), a regional intergovernmental entity promoting equitable and sustainable economic growth and socioeconomic development. However, challenges remain in translating political prioritisation into effective and equitable surgical healthcare. The AfroSurg Collaborative (AfroSurg) includes clinicians, public health professionals and social scientists from six SADC countries; it was created to identify context-specific, critical areas where research is needed to inform evidence-grounded policy and implementation. In January 2020, 38 AfroSurg members participated in a theory of change (ToC) workshop to agree on a vision: ‘An African-led, regional network to enable evidence-based, context-specific, safe surgical care, which is accessible, timely, and affordable for all, capturing the spirit of Ubuntu[1]’ and to identify necessary policy and service-delivery knowledge needs to achieve this vision. A unified ToC map was created, and a Delphi survey was conducted to rank the top five priority knowledge needs. In total, 45 knowledge needs were identified; the top five priority areas included (1) mapping of available surgical services, resources and providers; (2) quantifying the burden of surgical disease; (3) identifying the appropriate number of trainees; (4) identifying the type of information that should be collected to inform service planning; and (5) identifying effective strategies that encourage geographical retention of practitioners. Of the top five knowledge needs, four were policy-related, suggesting a dearth of much-needed information to develop regional, evidenced-based surgical policies. The findings from this workshop provide a roadmap to drive locally led research and create a collaborative network for implementing research and interventions. This process could inform discussions in other low-resource settings and enable more evidenced-based surgical policy and service delivery across the SADC countries and beyond.

Background HIV-infected individuals are at increased risk of anal cancer; in the majority of cases this is linked to human papillomavirus (HPV) infection. Anal cancer screening is not routinely offered in Zimbabwe. Methods A cross-sectional study was performed on 152 patients (88 females; 64 males) attending Opportunistic Infection Clinics at 2 tertiary hospitals between November 2014 and June 2015. Demographic data, immunological parameters and behavioural characteristics were collected. An anal swab was collected from each patient for HPV genotype testing. HPV testing was performed using MY09/MY11 PCR, followed by typing using the dot blot method. Results The mean age was 39.6 years (range, 18–69 years). Median CD4 count was 375 cells/μL. 96% were on antiretroviral therapy. Only one patient identified as a man who has sex with men. Of 122 samples tested for HPV, 54 were positive (44%). HPV was three times more common in females (60%) than males (20%). Being HPV-positive was associated with history of perianal warts, history of cervical intraepithelial neoplasia and having more than ten lifetime sexual partners. The most commonly detected high-risk HPV genotypes were HPV-58 (13%), HPV-31 (11%) and HPV-16 (9%). Nine patients harboured multiple high-risk HPV types. The two most commonly detected low-risk genotypes were HPV-11 (17%) and HPV-53 (11%). Conclusion Overall anal HPV prevalence was 44% in this mostly heterosexual HIV-positive population. Oncogenic HPV types accounted for almost half of infections, supporting the need for surveillance of anal cancer in this population.

Background Helicobacter pylori infection is present in more than 50% of the world's population. The estimated life time risk of peptic ulcer disease is 20 percent and of gastric cancer is 1–2 percent. Materials and methods A cross sectional study was done at two Central hospitals in Harare, Zimbabwe, with the objective being to estimate the prevalence of Helicobacter pylori infection in asymptomatic individuals. Other objectives were to determine the association of the Helicobacter pylori infection with potential risk factors. Four hundred and fifty patients visiting the outpatient surgical clinics for other complaints other than upper gastrointestinal symptoms were recruited in the study. Drops of whole blood were obtained by fingertip puncture from each patient. The Onsite H. pylori Combo Rapid Test was used to confirm the presence or absence of antibodies against Helicobacter pylori. A questionnaire was used to record the sociodemographics of the participants. Results Three hundred patients, 186 males (62%) and 114 females (38%) participated. The prevalence of Helicobacter pylori infection was 67.7 percent (203/300). The prevalence of H pylori infection was significantly correlated with increasing age (p = 0.012), sharing of a bed with siblings during childhood (p = 0.013) and the mode of sanitation methods (p = 0.023). There was no association found between H pylori infection and other risk factors such as; gender, level of education, employment status or number of rooms in a house. Conclusion H. pylori infection prevalence was significantly associated with increasing age, sharing of a bed with siblings during childhood and the mode of sanitation used. Clinicians and the public have to be aware of the important role of H pylori in upper gastrointestinal disease. Use of better sanitation methods, appropriate hygiene, avoidance of over-crowding amongst other measures should be encouraged as a means to reduce the acquisition and transmission of H pylori., Highlights • Prevalence of H. pylori infection is 67.7%. • The results are from Zimbabwe. • It is associated with increasing age and the mode of sanitation. • It is associated with sharing of a bed with siblings during childhood.

Highlights • The ascending colon has been described as a retroperitoneal organ however it may occasionally have a long mesentery. • The process of peritoneal zygosis is incompletely understood and is subject to perturbation leading to many abnormalities. • The excessive mobility may predispose to volvulus of this intestinal segment. • There is often a long symptomatic prodrome before volvulus occurs during which the observant surgeon may intervene. • The mesentery has gained new relevance with respect to its role in the contemporary management of surgical diseases., Introduction Volvulus of the mobile ascending colon is a serious complication of a subtle embryological abnormality that frequently goes unrecognised. There has been renewed interest in the development of the mesentery because of its relevance to the contemporary management of surgical diseases. This case is presented to illustrate the dire consequences of missing this diagnosis and to review the fascinating embryology of the condition as well as its clinical implications. Presentation of case We report on a 23-year-old male who presented with signs and symptoms of distal small bowel obstruction after a long prior history of intermittent right lower quadrant pain. At laparotomy, a 360-degree counter-clockwise volvulus of the entire right colon was noted as the result of an excessively long ascending mesocolon and unattached hepatic flexure. All gangrenous bowel was resected with primary ileocolic anastomosis performed thereafter. The patient did well post-operatively and was subsequently discharged. Discussion Interruption of the in-utero events of fixation known as peritoneal zygosis lead to a persistence of the mesocolon in parts of the bowel that ordinarily are retroperitoneal. The events that lead to this anomaly are poorly understood and have been subject to controversy for centuries. New insights have challenged surgical dogma and informed new surgical techniques. Its true incidence is probably underestimated because of its indolent clinical prodrome, and it requires a high index of suspicion. Conclusion Failure of peritoneal zygosis is implicated in a myriad of clinical conditions. Expeditious recognition and intervention in the prodromal period can avert potentially disastrous complications.

Crocodile attack injuries plague communities near bodies of water and continue to be an infrequent but significant form of trauma encountered in our medical facility. Regional anesthesia techniques are a novel adjunct to treatment and may facilitate simplified definitive management and better utilization of constrained operating room resources. We report a case of an adult male who presented with a large lower extremity wound after a crocodile bite. The patient was managed with initial debridement and irrigation and serial wound care entirely under regional anesthesia at the bedside. The patient did not develop wound infection, eventually receiving a skin graft with good functional outcomes. Regional anesthesia techniques are increasingly being used in the trauma setting, and their versatility allows for their use in multiple settings, by practitioners with limited experience and in resource-limited environments. No specific guidelines exist for performance of neuraxial techniques in the setting of animal bite injuries, but concerns about infectious complications have been raised. Regional anesthesia techniques may be useful in the management of extremity trauma due to crocodile attacks without infectious complications. They may reduce utilization of theatre resources and reduce opioid requirements.

Background Prominent ear is the most common congenital ear deformity affecting 5% of children in the Western world and has profound psychosocial effects on the bearer. It is important to know the prevalence in the local population to have a better appreciation of the local burden of the abnormality as well as to know the parameters of ear morphology locally. These parameters can be useful in the diagnosis and evaluation of ear anomalies and may help reconstructive surgeons in reproducing an anatomically correct ear of an African/Zimbabwean child. Objectives To evaluate the frequency of prominent ears in black school going children in Zimbabwe and to establish morphometric properties of the ear. Design Prospective observational, cross sectional study. Setting Three Primary schools in Harare. Two in a high density area and one in a low density area. Materials and methods Three Primary schools in Harare were selected at random. The following measurements were taken: ear lengths, ear projection and face height using a sliding caliper. Three hundred and five healthy pupils of the age range 9–13 years of both sexes were included in the study, whilst children with congenital anomalies, ear tumours and history of ear trauma were excluded. Results The mean ear height across the cohort was 56.95 ± 5.00 (right ear) and 56.86 ± 4.92 (left ear). Ear projection was 19.52 ± 2.14 (right ear) and 19.59 ± 2.09 (left ear). Gender related differences were noted. Mean ear height was significantly higher in males (p-value = 0.000). Ear projection was higher in males compared to females. A total of 6.89% had prominent ears. Among males, 7.69% had prominent ears whilst 6.17% of females had prominent ears. Conclusion The prevalence of prominent ear among black African children in the studied population is comparable to that of Caucasians. The study provides a set of biometric data of auricular dimensions for normal black African children aged 9–13 years., Highlights • Study shows prominent ear occurs in African Child with a higher frequency (6.89%) compared to Caucasian children (5%). • Mean ear height was significantly higher in males than females (p-value = 0.000). • Ear projection was higher in males than females. • Among males, 7.69% had prominent ears whilst 6.17% of females had prominent ears.