Torsten J. Wilhelm

Commercial Mesh versus Nylon Mosquito Net for Hernia Repair. A Randomized Double-blind Study in Burkina Faso

PurposeThe goal of this study was to investigate whether locally available Nylon mosquito net might be a useful alternative to expensive commercial mesh implants for hernia repair, a clinical randomized double-blind study was performed.Materials and MethodsOver a period of 3 months 35 patients with a total of 40 inguinal hernias were randomized for hernia repair with either a commercial graft (Ultrapro®) or a piece of sterilized 100% Nylon mesh available as mosquito net in most African village markets. The surgeons’ comfort in handling the meshes, the incidence of complications, and the patients’ quality of life before and 30 days after hernia repair were evaluated. In addition, the costs of the two materials were compared.ResultsThere was no significant difference in the clinical short-term outcome of the hernia treatment or the surgeons’ comfort in handling the two different materials. The price of the locally bought Nylon mesh was 0.0043 US

Anaesthesia for elective inguinal hernia repair in rural Ghana - appeal for local anaesthesia in resource-poor countries

as compared to 108 US

Sterilized Mosquito Net versus Commercial Mesh for Hernia Repair

for the commercial mesh.ConclusionsIn situations where superior results of hernia repair depend on the use of a mesh prosthesis but where commercial material is not available or affordable, the use of Nylon mosquito net may be an alternative. Further studies with a larger number of patients and longer follow-up are justified and recommended.

Efficacy of major general surgery performed by non-physician clinicians at a central hospital in Malawi

Local anaesthesia has been identified as the most favourable anaesthesia for elective inguinal hernia repair with respect to complication rate, cost-effectiveness, and overall patient satisfaction. Operation theatre notes in all seven hospitals in the Northern Region in Ghana over the period of 1 year were reviewed. Only 22.4% out of 1038 repairs were performed under local anaesthesia while predominantly spinal and general anaesthesia were used (48.0 and 29.6%, respectively). African surgeons chose local anaesthesia far less frequently than visiting overseas surgeons (15.6 versus 27.7%, respectively). All surgeons in resource-poor countries should be encouraged to use local anaesthesia more frequently for elective inguinal hernia repair. Valuable resources in sub-Saharan African hospitals could be saved, especially if used in combination with outpatient surgery. The technique should be taught in teaching institutions. A simple step-by-step technique is described.

Partial pancreatoduodenectomy versus duodenum-preserving pancreatic head resection in chronic pancreatitis: the multicentre, randomised, controlled, double-blind ChroPac trial

Background: In industrialized countries alloplastic meshes are routinely used for hernia repair. However, in developing countries they are rarely available or affordable. This study compares textile properties and tissue response of commercial polypropylene mesh (PM) vs. sterilized nylon mosquito net (MN). Methods: Textile properties were examined in vitro. In 12 goats one MN and one PM (5.5 × 8 cm) were implanted onto the posterior layer of the rectus sheath. Wound healing was clinically assessed. Histology was assessed after 4 or 16 weeks. Results: MN was thinner and lighter, but weaker than PM. All wounds healed without complications. After 16 weeks foreign body granulomas in the MN group contained a higher proportion of inflammatory tissue (32.7 vs. 22.1%) and more giant cells (3.1 vs. 1.7/10 granulomas) with a significantly lower partial volume of foreign body (23.2 vs. 36.9%). Partial volume of fibrotic tissue was similar. MN was 1,000-fold cheaper than PM. Conclusions: PM was superior concerning strength and extent of inflammatory response. However, the findings indicate that MN might serve as a cheap substitute if an alloplastic mesh is needed but no commercial one is available or affordable. Further studies are justified which should include mosquito nets of different materials and long-term outcome.

Gastrointestinal endoscopy in a low budget context: delegating EGD to non-physician clinicians in Malawi can be feasible and safe

In some sub-Saharan African countries non-physician clinicians have to perform major general surgery without medical officers and surgeons. The safety of this practice has not been established. The aim of this study was to evaluate the contribution of clinical officers (COs) to major general surgery at Zomba Central Hospital. We performed a retrospective five-year period study during 2003–2007. The perioperative outcome for three procedures was analysed. During the study 2931 major general surgical procedures were performed: 1437 (49%) by surgeons; 366 (12.5%) by COs assisted by surgeons; and 1128 (38.5%) by COs alone. COs performed 50% of prostatectomies, ventriculo-peritoneal-shuntings and strangulated hernia repairs with bowel resection alone. Baseline parameters and perioperative outcomes of the patients who underwent operations with surgeons present (as operator or assistant, ‘surgeon group’) or patients operated by COs alone (‘CO group’) were similar. COs can safely perform major general surgery when adequate training and supervision are provided.

Self-expanding metal stents (SEMS) for patients with advanced Esophageal cancer in Malawi: An effective palliative treatment†

BACKGROUND There is substantial uncertainty regarding the optimal surgical treatment for chronic pancreatitis. Short-term outcomes have been found to be better after duodenum-preserving pancreatic head resection (DPPHR) than after partial pancreatoduodenectomy. Therefore, we designed the multicentre ChroPac trial to investigate the long-term outcomes of patients with chronic pancreatitis within 24 months after surgery. METHODS This randomised, controlled, double-blind, parallel-group, superiority trial was done in 18 hospitals across Europe. Patients with chronic pancreatitis who were planned for elective surgical treatment were randomly assigned to DPPHR or partial pancreatoduodenectomy with a central web-based randomisation tool. The primary endpoint was mean quality of life within 24 months after surgery, measured with the physical functioning scale of the European Organisation for Research and Treatment of Cancer QLQ-C30 questionnaire. Primary analysis included all patients who underwent one of the assigned procedures; safety analysis included all patients who underwent surgical intervention (categorised into groups as treated). Patients and outcome assessors were masked to group assignment. The trial was registered, ISRCTN38973832. Recruitment was completed on Sept 3, 2013. FINDINGS Between Sept 10, 2009, and Sept 3, 2013, 250 patients were randomly assigned to DPPHR (n=125) or partial pancreatoduodenectomy (n=125), of whom 226 patients (115 in the DPPHR group and 111 in the partial pancreatoduodenectomy group) were analysed. No difference in quality of life was seen between the groups within 24 months after surgery (75·3 [SD 16·4] for partial pancreatoduodenectomy vs 73·0 [16·4] for DPPHR; mean difference -2·3, 95% CI -6·6 to 2·0; p=0·284). The incidence and severity of serious adverse events did not differ between the groups. 70 (64%) of 109 patients in the DPPHR group and 61 (52%) of 117 patients in the partial pancreatoduodenectomy group had at least one serious adverse event, with the most common being reoperations (for reasons other than chronic pancreatitis), gastrointestinal problems, and other surgical morbidity. INTERPRETATION No differences in quality of life after surgery for chronic pancreatitis were seen between the interventions. Results from single-centre trials showing superiority for DPPHR were not confirmed in the multicentre setting. FUNDING German Research Foundation (DFG).

Pancreatitis, panniculitis and polyarthritis (PPP-) syndrome caused by post-pancreatitis pseudocyst with mesenteric fistula. Diagnosis and successful surgical treatment. Case report and review of literature.

Gastrointestinal endoscopy is rarely performed in low-income countries in sub-Saharan Africa. One reason is the lack of available medical doctors and specialists in these countries. At Zomba Central Hospital in Malawi, clinical officers (non-physician clinicians with 4 years of formal training) were trained in upper gastrointestinal endoscopy. Prospectively recorded details of 1732 consecutive esophagogastroduodenoscopies (EGDs) performed between September 2001 and August 2010 were analyzed to evaluate whether upper gastrointestinal endoscopy can be performed safely and accurately by clinical officers. A total of 1059 (61.1%) EGDs were performed by clinical officers alone and 673 (38.9%) were carried out with a medical doctor present who performed or assisted in the procedure. Failure and complication rates were similar in both groups (P=0.105). Endoscopic diagnoses for frequent indications were generally evenly distributed across the two groups. The main difference was a higher proportion of normal findings and a lower proportion of esophagitis in the group with a doctor present, although this was significant only in patients who had presented with epigastric/abdominal pain (P<0.001). In conclusion, delegating upper gastrointestinal endoscopy to clinical officers can be feasible and safe in a setting with a shortage of medical doctors when adequate training and supervision are provided.

Do patients in rural Malawi benefit from upper gastrointestinal endoscopy

Esophageal cancer is common in Malawi and most patients are inoperable at time of diagnosis. The aim of this study was to prospectively evaluate palliative treatment with self‐expanding metal stents (SEMS) in Malawi, a low‐income country with limited medical resources.

Fishing Line Suture: Cost-saving Alternative for Atraumatic Intracutaneous Skin Closure—Randomized Clinical Trial in Rwanda

Highlights • Pancreatitis, panniculitis and polyarthritis syndrome is a very rare manifestation of pancreatitis with panniculitis and polyarthritis with intraosseous fat necrosis.• A rare differential diagnosis of unclear polyarthritis, panniculitis or osteonecrosis.• Surgical treatment, if possible can lead to complete remission.