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Browsing Dissertations by Author "AGYEI FAREEDA"

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    TYPES, PRESENTATION AND CHALLENGES WITH THE MANAGEMENT OF ANORECTAL MALFORMATIONS AT KOMFO ANOKYE TEACHING HOSPITAL, KUMASI, GHANA.
    (AGYEI FAREEDA, 2022-06-08) AGYEI FAREEDA
    Introduction: Anorectal malformations remain a significant challenge to the child and the paediatric surgeon. Clinical outcomes depend on the surgeon's skill, the type of anorectal malformation, associated anomalies and the availability of perioperative and rehabilitation facilities. Anorectal malformation is rare, occurring in about 2-6 per 10000 live births. ⁠ However, its rarity becomes relative in Sub-Saharan Africa, where few surgeons are paediatric surgeons, and only a handful of these few surgeons handle these cases. The burden of treating these patients falls on the few paediatric surgeons available in the region. The paediatric surgeon is faced with challenging clinical scenarios; some children present with complications, either as a result of late presentation or from the initial surgery, done mainly by a local surgeon as a lifesaving procedure. Understanding the challenges the patient, the parents and caregivers, and the paediatric surgeon face in this resource-limited setting is essential. Aim: The aim of the study was to assess the types, modes of presentation, the challenges carers of patients with anorectal malformation encounter during management and the cost implication in a resource-challenged tertiary teaching hospital, Komfo Anokye Teaching (KATH), in Kumasi, Ghana. Methods: The study was a cross-sectional descriptive study carried out on Anorectal malformations at the Paediatric Surgery Unit of Komfo Anokye Teaching Hospital (KATH) over a period of eight months. It employed both qualitative and quantitative study design which was taken at the same time period; a concurrent mixed methodology. Data on all children with anorectal malformation being managed by the Paediatric Surgery Unit of the Department of Surgery, KATH, were obtained. The ARM types, presentation, associated anomalies, surgical interventions, peri operative challenges; challenges with managing and taking care of a child with anorectal condition, and the cost of managing the condition were captured using a structured questionnaire (quantitative study). In-depth interviews of guardians of the children with anorectal malformations who were being managed were also conducted (qualitative study). Results: A total of 61 patients (male: female ratio 1:0.96) were included in the study. A majority, 35 (57.38%), of the patients with anorectal malformations were observed between days 2 and 5. The average birth weight was 3.12kg (SD =0.51). Most of the patients, 88.52% reported late (> 24hrs). Majority of the patients 55.74% presented in a stable state at the emergency department. Acute intestinal obstruction accounted for 32.79% of presentations. All the 61 patients with anorectal malformation underwent a staged procedure. The majority, 60 (98.63%) out of the 61 patients, underwent a three-staged procedure; an initial colostomy, definitive repair, and colostomy closure. Only 1 patient underwent a two-stage procedure in which colostomy + PSARP was done on day 1 of presentation. Closure of colostomy was done 14 months later. The definitive repair for all the children who underwent the three-staged procedure was PSARP. For this study, 45 (75%) had had PSARP, and 29 (48.33%) had closure of colostomy done at the end of the study. Overall complication after all surgeries was 39.3%. There was no significant association between, birth weight (p-value = 0.596), the presence of a fistula (p-value = 0.061), when the malformation was detected (p-value = 0.349) and time of presentation to KATH, (p-value = 0.306). Overall Complications at the initial colostomy, PSARP and colostomy closure were 21.6%, 26.7%, and 27.59%, respectively. The mean duration between a colostomy and PSARP was 7.02 +/- 2.05 months, while between PSARP and colostomy closure was eight months. The mortality rate at the end of the study was 3.3%. The length of stay in the hospital was 11.89 +/- 8.93 days, 29.95 +/- 9.26 days, and 17.51+/- 7.0 days for the initial colostomy, PSARP and the closure of colostomy respectively. The mean cost for the complete three-staged procedure was GHC11604.93 ($2053.90) (1$ = GHC5.65), with out-of-pocket payments accounting for 61.91% of the total cost. 44.3% of the caregivers rated the cost as moderate. Findings from the qualitative study indicated that most caregivers lacked adequate knowledge regarding anorectal malformations. Most respondents highlighted the stigma associated with having a child with ARM and having a colostomy. Rescheduling surgeries, financial constraints, increased out-of-pocket payments, and lack of psychological support were some challenges caregivers had with managing anorectal malformations. Conclusion: Anorectal malformation is challenging to the paediatric surgeon, the patient and the carer. There is a general lack of awareness about the condition among health professionals and carers. The stigma attached to having a child with colostomy is rife and it is associated with a lot of psychological trauma to the carers and family members. The cost of managing anorectal malformation is high and steps must be taken to help carers pay for the cost. Improving public awareness of the condition and our referral system, providing psychological support, training more stoma therapists, increasing the partial amount the NHIS pays for this condition will all go a long way to improve the management and the lives of children born with this congenital abnormality.