Seif I. Mahadi

Retrosternal Goiter: The Need for Median Sternotomy

IntroductionThe aim of this study was to analyze the features of patients with goiter who underwent thyroidectomy via a cervical incision and a median sternotomy in Khartoum.MethodsA total of 267 thyroidectomies were performed in Khartoum Teaching Hospital during the period from January 2002 to December 2003. There were 40 patients with evidence of retrosternal goiter (15%). Of those 40 patients, 13 had clinical and radiologic evidence of deep retrosternal extension of the goiter possibly necessitating sternotomy. Only 9 of the 13 patients actually required sternotomy, which accounted for 3.4% of all thyroidectomies performed (n = 267). The clinical, radiologic, and pathologic findings of those 9 sternotomy patients were analyzed and compared to those of the 258 patients who underwent cervical thyroidecomy.ResultsTotal thyroidectomy was undertaken in all nine patients. Six of them had retrosternal extension on the right side of the mediastinum, and three had bilateral extension. Seven patients had symptoms of respiratory distress, and two were asymptomatic. The duration of the goiter ranged between 7 and 30 years. The chest radiograph and computed tomography scan revealed that the retrosternal part was below the level of the aortic knuckle at the tracheal bifurcation in all cases. The histopathology revealed a simple multinodular goiter in eight of the nine patients (89%) and in one patient with papillary carcinoma. Five of the nine patients underwent intraoperative prophylactic tracheostomy due to tracheomalacia.ConclusionsA long-standing goiter with deep (below the aortic knuckle) mediastinal extension and tracheal space compromise can be postulated to increase the likelihood of sternotomy.

Hallux Ulceration in Diabetic Patients

We undertook a prospective cohort study to assess risk factors associated with hallux ulceration, and to determine the incidence of healing or amputation, in consecutive patients with diabetes mellitus who were treated over the observation period extending from September 2004 to March 2005, at the Jabir Abu Eliz Diabetic Centre, Khartoum City, Sudan. There were 122 diabetic patients in the cohort (92 males and 30 females) with an overall mean age of 58 +/- 9 years. Fifty-three percent of patients had complete healing within 8 weeks and 43% healed within 20 weeks. The overall mean time to healing was 16 +/- 8 weeks. In 32 (26.2%) patients, osteomyelitic bone was removed, leaving a healed and boneless hallux. The hallux was amputated in 17 (13.9%) patients; in 2 (1.6%) patients it was followed by forefoot amputation and in 7 (5.7%) patients by below-the-knee amputation. In 90 (73.8%) patients the initial lesion was a blister. In conclusion, hallux ulceration is common in patients with diabetes mellitus and is usually preceded by a blister. Neuropathy, foot deformity, and wearing new shoes are common causative factors; and ischemia, osteomyelitis, any form of wound infection, and the size of the ulcer are main outcome determinants. Complete healing occurred in 103 (85%) of diabetic patients with a hallux ulcer. Vascular intervention is important relative to limb salvage when ischemia is the main cause of the ulcer.

Diabetic foot infections with osteomyelitis: efficacy of combined surgical and medical treatment

Diabetic foot infections are a high risk for lower extremity amputation in patients with dense peripheral neuropathy and/or peripheral vascular disease. When they present with concomitant osteomyelitis, it poses a great challenge to the surgical and medical teams with continuing debates regarding the treatment strategy. A cohort prospective study conducted between October 2005 and October 2010 included 330 diabetic patients with osteomyelitis mainly involving the forefoot (study group) and 1,808 patients without foot osteomyelitis (control group). Diagnosis of osteomyelitis was based on probing to bone test with bone cultures for microbiological studies and/or repeated plain radiographic findings. Surgical treatment included debridement, sequestrectomy, resections of metatarsal and digital bones, or toe amputation. Antibiotics were started as empirical and modified according to the final culture and sensitivities for all patients. Patients were followed for at least 1 year after wound healing. The mean age of the study group was 56.7 years (SD = 11.4) compared to the control group of 56.3 years (SD = 12.1), while the male to female ratio was 3:1. At initial presentation, 82.1% (n=271) of the study group had an ulcer penetrating the bone or joint level. The most common pathogens were Staphylococcus aureus (33.3%), Pseudomonas aeruginosa (32.2%), and Escherichia coli (22.2%) with an almost similar pattern in the control group. In the study group, wound healing occurred in less than 6 months in 73% of patients compared to 89.9% in the control group. In the study group, 52 patients (15.8%) had a major lower extremity amputation versus 61 in the control group (3.4%) (P=0.001). During the postoperative follow-up visits, 12.1% of patients in each group developed wound recurrence. In conclusion, combined surgical and medical treatment for diabetic foot osteomyelitis can achieve acceptable limb salvage rate and also reduce the duration of time to healing along with the duration of antibiotic treatment and wound recurrence rate.

Diabetic Foot Infections with Pseudomonas: Jabir Abueliz Diabetic Center Khartoum Experience

Background: The isolation of Pseudomonas organism in diabetic foot infection (DFI), is notorious of being multidrug resistant. The objective of this study is to report on the incidence, antibiotic sensitivity, treatment and outcome of pseudomonas infection. Patients and methods: This is a prospective observational analytic hospital based study in which all diabetic patients with Pseudomonas aeruginosa infected wounds seen in JADC during 18 months period were included. Results: Pseudomonas was grown in 302 out of 3620 cultures (8.3%) of whom 70 cultures were true pathogenic (1.9%). 41.4% of patients infected with pseudomonas were clinically septic when first seen in the clinic of whom 92.9% were febrile at presentation and 67.1% had chills. Ceftriaxone and ciprofloxacin were the most commonly used antibiotics. Amikacin was the most sensitive antibiotics in 77.1%. All patients took antibiotics >21 days after the isolation of pseudomonas to complete the eradication in combination of daily sharp excision of all coloured infected tissues. Forty six patients (66%) needed amputation, 30 had minor toes (43%) and 16 had transtibial amputation, (23%). Conclusion: Diabetic foot infected with pseudomonas carries a higher risk for toe or lower limb amputation. For complete medical eradication of P. aeruginosa; antibiotics should be used for at least 21 days combined with daily sharp excision of infected discoloured tissues.