Faculty of Surgery and Subspecialties

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    A STUDY OF PROSTATE CANCER DETECTION RATES IN MEN UNDERGOING TRANS-RECTAL ULTRASOUND-GUIDED PROSTATE BIOPSY AT KATH, KUMASI
    (MINTAH DOMINIC ANNOR, 2024-04-28) MINTAH, DOMINIC ANNOR
    Introduction: Prostate cancer is the second most common cancer among men worldwide. The risk of developing prostate cancer increases with advancing age, elevated serum PSA level, a family history of prostate cancer, and being black or of African ancestry. The diagnosis of prostate cancer is made by histopathological evaluation of the prostate gland. TRUS-guided biopsy of the prostate gland is the gold standard technique for obtaining prostate gland specimen for histopathological evaluation of the prostate gland and for the diagnosis of prostate cancer. This study sought to evaluate the prostate cancer detection rate of TRUS-guided prostate biopsy and analyze its characteristics among the men undergoing prostate biopsy at Komfo Anokye Teaching Hospital, Kumasi. Method: A total of 218 men were referred on various indications for TRUS-guided prostate biopsies at the Urology Unit of the Directorate of Surgery of the Komfo Anokye Teaching Hospital from September 2022 to October 2023 participated in this study. The study participants were prospectively evaluated, and the data analyzed to determine the prostate cancer detection rate and its characteristics. Results: The mean age of the study participants was 69.84 + 8.10 years with a range of 45 - 89 years. Of the 218 men who underwent-guided prostate biopsy, 121 (55.5%) were detected to have adenocarcinoma of the prostate whilst 97 (44.5%) had no cancer. The indications for prostate biopsy from this study were elevated serum PSA level (61.5%), suspicious DRE findings (32.1%) and a combination of both (6.4%). The cancer detection rates for men who underwent biopsy with indications of suspicious DRE findings alone, abnormal serum PSA levels alone, and a combination of both were 14.3, 50.4 and 67.9%. The cancer detection rate was found in the study to increase with increasing serum PSA level and advancing age, and decreases with increasing volume of the prostate gland in the study population. Conclusion: TRUS-guided biopsy of the prostate gland detects more prostate cancer cases than non-cancer cases. The indication with the highest positive predictive value for prostate cancer was the presence of both elevated serum PSA level and suspicious DRE findings. The risk of diagnosis increases with increasing levels of serum PSA and advancing age in the study population. Whilst the risk of being diagnosed with prostate cancer decreases with increasing prostate volume (size).
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    DETERMINANTS OF SIGNIFICANT VOIDING DYSFUNCTION AFTER IODINE-125 BRACHYTHERAPY FOR LOCALIZED PROSTATE CANCER AT THE KORLE BU TEACHING HOSPITAL.
    (LAMPTEY JONATHAN CHARLES, 2024-04-27) LAMPTEY, JONATHAN CHARLES
    Background: Prostate cancer is the second most commonly diagnosed cancer amongst men after lung cancer accounting for 14.1% of cancers in men. Both incidence and mortality vary tremendously across geographic regions and populations reflecting multifactorial impacts of genetic variation; diet, lifestyle, environmental factors, access to care and variations in use of prostate specific antigen (PSA)-based screening policies. With the increasing use of PSA as a screening tool in Sub Saharan Africa many more cases of localized cancer of the prostate are being diagnosed. Radical prostatectomy and radiation therapy remain the main options for active treatment of localized cancer of the prostate. Low dose rate brachytherapy has recently (2008) become available in Ghana. Patients are therefore able to participate in the decision making process on which form of treatment they should undergo. With largely similar oncologic outcomes from radical prostatectomy and brachytherapy, the complications associated with each procedure plays a major role in deciding on the treatment option. Studies in other jurisdictions have pointed at urinary morbidity as the main complication from brachytherapy. Furthermore, some studies point to different factors as predicting which patients are most at risk of significant urinary morbidity after low dose rate brachytherapy. Local data for this sub-region would be important to guide local practice. Objective: To determine the factors that are associated with significant voiding dysfunction at one month after I-125 prostate brachytherapy of men undergoing the procedure at the Korle Bu Teaching Hospital. Methodology: Patients presenting for prostate brachytherapy were recruited into this prospective study. Basic demographic and disease related data were taken including the pre –operative International Prostate Symptom Score(IPSS). Peri-operative data such as u30 and D90 were also documented. The post-operative IPSS were evaluated monthly for 4 months and documented together with any other complaints at one month. Post-operative follow up evaluation was done via phone interviews. Results: Significant voiding dysfunction at 1month post brachytherapy occurred in 67.7% of the study population. Two persons representing 2.8% had Acute Retention of Urine (AROU) with both occurring within 2 days of the procedure. The most common complaints at 1month were related to the urinary system. At one month, the median IPSS score had increased from 5 to 11. It gradually declined thereafter but did not reach pre-procedure levels during the four month follow up period. Digital Rectal Examination (p= 0.686), Gleason score (p= 0.799), prostate volume (p= 0.137), Pre-biopsy PSA (p= 0.949), number of needles used (p= 0.465), number of seeds implanted (p=0.724) and u30 (p= 0.9310) all showed no statistical correlation with the occurrence of significant voiding dysfunction at 1month. Pre-operative IPSS and the prior use of tamsulosin both showed statistical significance on bivariate regression analysis with p= 0.001 and p<0.011 respectively. However these two parameters failed to show statistical significance when subjected to multivariate regression analysis (p= 0.635 and p= 0.069 for pre-operative IPSS and prior use of tamsulosin respectively). D90 and pre-operative nocturia (as scored on IPSS) were predictive of occurrence of significant voiding dysfunction at one month both on bivariate and multivariate regression analysis. The D90 scores analysis yielded p=0.009 and p=0.037 on bivariate and multivariate analysis respectively. With regards the pre-operative nocturia score, p<0.001 and p=0.002 on bivariate and multivariate analysis respectively. Conclusion: The study confirmed that prostate brachytherapy significantly worsens voiding function at one month. D90 and preoperative nocturia value on IPSS scoring were predictors of significant voiding dysfunction at one month.
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    ELASTIC VERSUS INELASTIC COMPRESSION BANDAGING IN LYMPHOEDEMA MANAGEMENT; A COMPARATIVE ANALYTIC STUDY IN KORLE BU TEACHING HOSPITAL
    (Ghana College of Physicians and Surgeons, 2023-03-31) TETTEH, NATHANIEL
    Background Lymphoedema is a long-term chronic condition requiring a comprehensive multidisciplinary approach as there is no cure for it. Management is therefore aimed at reducing its symptoms and improving on the aesthetics and function of the body part involved. Currently the first line of lymphoedema management is the Complete Decongestive Therapy (CDT), which comprise of manual lymphatic drainage (MLD), compression bandaging, exercise and skin care. CDT is cumbersome, uncomfortable, inconvenient and time-consuming making compliance a big problem. Hence most institutions place emphasis on compression therapy. The prescription of the appropriate compression is a real challenge, since one must choose between inelastic and elastic bandages. It must be adapted to the patient and its pathology as well as provide comfort and ensure good compliance. The diversity of modalities of compression therapy is reflected by the different schools of compression within countries. In France, elastic compression is commonly prescribed whiles in Germany, Netherlands and Austria the standard treatment is inelastic compression. In UK the 4-layer system with an elastic bandage is the choice and in the USA a plaster type inelastic bandage (Unna’s boot) is favoured. The large discrepancies among treatment modalities underline the need of a research into what type of compression therapy is best suited for lymphoedema patients in our centre and to an extent in the Ghanaian population. Aim The study aims to compare the clinical outcomes of treating lymphoedema of the limbs with elastic compression bandaging and inelastic compression bandaging in Ghanaian patients. Methodology The study was a prospective randomized study involving 23 Ghanaian patients with lymphoedema of the upper or lower limbs. Using defined inclusion and exclusion criteria, patients with extremity lymphoedema seen at the Physiotherapy Unit of the National Reconstructive Plastic Surgery and Burns Centre, Korle Bu Teaching Hospital, were selected by simple random sampling into two groups. (Group A – Inelastic bandage, Group B – Elastic bandage). Informed consent was obtained from each patient after clinical assessment. Measurements for both the affected and unaffected limbs were taken using a tape at specific parts of the limb. Manual lymphatic Drainage was done by the physiotherapist and then the appropriate bandage applied based on patient’s group. Limb measurements (affected limb) and Physiotherapy sessions were repeated every two weeks for eight weeks to complete the intensive phase of Compression Bandaging. Quality of life assessment score was taken before and after the 8 weeks of compression bandaging. Data was collected and analyzed using ANOVA to compare the percentage change in the total circumference and volume of the limb with lymphoedema in each of the groups. The quality of life score was compared before and after treatment for each group. Results The mean age of the participants was 48.61 years. There was a statistical significant difference in the occupational status and level of education of the patients. 70% of patients had upper limb lymphoedema and the mean age at diagnosis was 46.26 years. 82.6% 0f patients had secondary lymphoedema with malignancy being the commonest cause. Both inelastic and elastic compression bandages were effective in reducing the circumference and volume of the affected limb. Compression bandaging in all resulted in a statistically significant difference in the quality of life before and after treatment (p< 0.0001). Conclusion Compression bandaging using either elastic or inelastic compression bandages are effective in the treatment of limb lymphoedema with a better quality of life outcome. There is no statistical significant difference in the efficacy of both inelastic and elastic bandages. However inelastic compression bandage gives a better reduction in limb volume.
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    EPIDEMIOLOGY AND TREATMENT OUTCOME IN PATIENTS PRESENTING WITH PLANTAR FASCIITIS AT THE KORLE BU TEACHING HOSPITAL
    (NGISSAH, REUBEN KWESI SAKYI, 2015-12-01) NGISSAH, REUBEN KWESI SAKYI
    Background Plantar fasciitis (PF) is a common cause of heel pad pain. The pain associated with this clinical condition can result in impairment of activities of daily living. Although the diagnosis of this condition is easy to clinch, the aetiology remains unclear with numerous treatment options, because no single treatment has strong scientific evidence to support its use to improve outcome. For most patients presenting with this condition at the Orthopaedic unit of Korle-Bu Teaching Hospital (KBTH), the main treatments offered are plantar fascia stretching exercises and corticosteroid injection if the former fails. The rationale of this study was to describe the epidemiology of this clinical condition, identify some of the risk factors common in patients presenting to the Orthopaedic unit of the Korle Bu Teaching Hospital and to determine baseline outcome of KBTH treatment protocol for PF and compare it to those reported in the literature. Methods This was a longitudinal study on patients presenting with plantar fasciitis to the unit between September, 2014 and August, 2015. Those who met the inclusion criteria were recruited in this study. All newly diagnosed patients were offered plantar fascia stretching exercises; those who failed to respond to treatment based on the Visual Analogue Scale for pain and a modification of foot function index after a month or two were offered corticosteroid injection in addition to plantar fascia stretching exercise. Results Forty four patients met the inclusion criteria for this study with an incidence of 2.75% of all new cases reporting at the Orthopaedic OPD of the KBTH over the study period. At the end of the 12th week, thirty seven patients were available for follow up. Majority of the patients seen were females (thirty eight), leading to a female to male preponderance of 6.3:1. Twenty three patients representing 52.5% belonged to the age group of 41-50%. The mean age was 47.9 years with a standard deviation of 9.7 years. All the patients seen responded ‘yes’ to morning pain marked after a few couple of steps and to pain after prolonged periods of inactivity. Twenty six patients (59.1%), admitted to be involved in occupations that involved prolonged weight bearing. No significant structural risk factors in terms of pes planus, pes cavus, and leg length discrepancy were detected. Ninety percent of the patients seen were either overweight, obese or morbidly obese. Thirty five patients (79.4%) had a heel spur on X-ray. At four weeks, out of the 42 patients available for follow up, only 5(11.9%) required steroid injection in addition to physiotherapy. At eight weeks, only one (2.56%) of the 39 patients available for follow up had steroid injection in addition to the physiotherapy. By the end of the 12 weeks, 37 patients were available for follow up. All the 37 patients had significant improvement in their VAS scores as well as their modified foot function index scores. The means and (standard deviations) for VAS scores at baseline, 4th week, 8th week and 12th week were, 7.05 (2.2); 5.05 (2.5); 3.15 (1.6); 1.9 (1.2) respectively. The means for the modified FFI at baseline, 4th week, 8th week and 12th week were, 16.0, 11.4, 6.8, 3.7 respectively, with corresponding standard deviations of 4.0, 5.6, 4.6, and 3.0 respectively. These results shows a trend in improvement of symptoms with time. Conclusions Plantar Fasciitis was found to be common in females. Majority of the patients were middle aged 41 to 50 years with a mean age of 47.9 years and a standard deviation of 9.7 years. Early morning pain at the heel which is marked with few couple of steps is characteristic of plantar fasciitis. Not all patients with plantar fasciitis have a heel spur on X-ray. Structural risk factors in terms of pes cavus, pes planus, and leg length discrepancy were uncommon in this study. Elevated BMI, happened to be a major risk factor in this study; ninety percent of the patient were either overweight, obese or morbidly obese. Stretching exercises should be employed as the first line of treatment for patients presenting with plantar fasciitis
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    FUNCTIONAL OUTCOME BETWEEN THE USE OF Z-PLASTY AND FULL THICKNESS SKIN GRAFTING IN THE RELEASE OF AXILLARY CONTRACTURES AT KOMFO ANOKYE TEACHING HOSPITAL (KATH) -KUMASI, GHANA.
    (Ghana College of Physicians and Surgeons, 2023-09-30) ADAE-ABOAGYE, KWADWO
    Axillary post-burn scar contracture is a challenging problem to the reconstructive surgeon owing to the wide range of movement with respect to the shoulder joint. Axillary post-burn contracture is disturbingly common and severe in developing countries and a significant problem in developed nations as well. Age related injuries abound as well as possible gender disparities. Most injuries have been found to be domestic related and when diagnosed, intervention need to be instituted at the earliest opportunity. The aim of this study was to compare the functional outcome between the use of z- plasty and the use of skin grafting in the release of axillary contractures in patients presenting to the Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana. Methods: The study was longitudinal, prospective and comparative to assess the functional outcome of axillary contractures release of patients presenting to Komfo Anokye Teaching Hospital, Kumasi. Study subjects included patients with axillary contractures presenting at KATH over a period of one (1) year. Data management and analysis: Data was collected from the patients, using a case reporting form, after informed consent was sort, coded and analysed with SPSS software. Outcome of the study was presented in tables and charts and Chi-square and these were used to establish the relationship between dependent and independent variables to test the hypothesis. Results: The median age for the sampled data was 13.5 years with 58% females and 42% males. The commonest aetiology was flame burns (50%), scald injury (31.6%), chemical burns (10.5%)and electrical burns (7.9%). The median angle changed from a mean of 92.9 degrees pre-operatively to 175 degrees immediate post-operatively, 170 degrees at two (2) weeks and 168 v degrees at four (4) weeks post-operatively. With a p-value of 0.72 at the end of the study, the difference in change in abduction when the two modalities were compared was found not to be statistically significant. Conclusion: The functional outcomes achieved in using z-plasty or full thickness skin grafting in the release of post-burns anterior and posterior axillary contractures are comparable and can be employed interchangeably.
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    POSTOPERATIVE PAIN MANAGEMENT IN EMERGENCY ABDOMINAL SURGERY: BIMODAL VERSUS UNIMODAL ANALGESIA
    (GYAMFI, FRANK ENOCH, 2022-03-01) GYAMFI, FRANK ENOCH
    Introduction Emergency abdominal surgery may be the right intervention for patients who have traumatic abdominal injuries or surgically correctible abdominal disease processes. The pain after surgery can be distressful to patients if not optimally managed. Postoperative pain management in developing countries like Ghana is considered to be suboptimal. In Ghana, there is a paucity of data comparing the efficacy of parenteral opioids as unimodal analgesia with a combination of paracetamol and opioids in postoperative pain management. Aim This study compared the efficacy of intramuscular (i.m.) morphine as unimodal analgesic with bimodal administration of i.v paracetamol and i.m. morphine in managing postoperative pain in emergency abdominal surgery. Methods/Design This study was conducted at the Surgery Directorate of Komfo Anokye Teaching Hospital, Kumasi, Ghana. It was a single-blinded randomised controlled trial (RCT). Participants were randomised into two arms: those receiving i.m. morphine only and those receiving a combination of i.v. paracetamol and i.m. morphine. Inclusion criteria were patients between 18 and 80 years undergoing emergency abdominal surgery. Elective surgery, contraindications to morphine or paracetamol were exclusion criteria. Pain intensity was measured at intervals of one, three, six, twelve and twenty-four hours after a patient received the first dose of analgesia at the recovery ward, using the Numeric Rating Scale for pain. Data were collected with a structured questionnaire, using an electronic data capturing system and extracted onto STATA 13 for analysis. Chi-Square test and multivariate logistic regression analysis were carried out, putting into consideration odd ratios where statistical significance was derived with p<0.05. Results A total of 110 participants were recruited and data from 108 were analysed of which 75% were males and 25% were females. Mean pain scores were lower at six hours, twelve hours and twenty-four hours after the administration of the first dose of analgesia with statistical significance (P-value 0.02, 0.002 and 0.001 respectively) for those who received only Morphine as opposed to morphine with paracetamol. There was no statistically significant difference between the length of stay and whether a participant received morphine or morphine with paracetamol (P-value 0.33). Those who received only morphine had their first bowel movement earlier than those who received a combination of morphine and paracetamol (P-value 0.03). Nausea and/or vomiting was likely to occur if a participant received only morphine as opposed to receiving morphine with paracetamol ( P-value 0.02). Conclusion Receiving morphine alone or morphine with paracetamol provided adequate pain relief after emergency abdominal surgery even though those who received morphine alone had a lower mean pain score. Whether a patient received morphine alone or morphine with paracetamol did not have any statistical difference in the length of stay. Nausea and vomiting were common in those who received morphine only.
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    THE ROLE OF SUBCUTANEOUS TISSUE IRRIGATION WITH NORMAL SALINE IN DECREASING SURGICAL SITE INFECTION FOLLOWING APPENDICECTOMIES AT THE KORLE-BU TEACHING HOSPITAL
    (GAWU VICTORIA SENA, 2024-03-27) GAWU, VICTORIA SENA
    BACKGROUND According to the World Health Organization Surgical Site Infection(SSI) is the most common type of hospital acquired infection in the developing world and it is common after appendicectomy with an incidence of SSI as high as 37.4% in low income countries. Wound irrigation may reduce the level of bacterial contamination in the surgical wound and may reduce SSI but there is lack of evidence for its usage, and the agent to use that is safe, effective and affordable.In Ghana no studies have been conducted on the use of normal saline as irrigation fluid in reducing surgical site infection following appendicectomy. AIM To evaluate the role of subcutaneous tissue irrigation at incision site using normal saline, in reducing post appendicectomy surgical site infection at the Korle-Bu Teaching Hospital (KBTH). METHODOLOGY This was a randomized prospective study involving patients diagnosed with appendicitis, who underwent appendicectomy at the Korle-Bu Teaching Hospital (KBTH). Recruited patients were randomized into 2 groups. One group had the subcutaneous tissue irrigated with normal saline after closure of the fascia during appendicectomy while the second group, the control group, did not. Patients were followed up with wound inspection on post-operative days 3, 7, 14 and 30 for signs of surgical site infection. All data collected were captured on Microsoft excel work sheet and imported into Statistical Package for the Social Sciences (SPSS version 23) for analysis. A Chi-square test/ Fisher’ exact test was used to compare the incidence of SSI between those with irrigation of the subcutaneous tissue and those with non-irrigation of the subcutaneous tissue following appendicectomy. Relative Risk (RR) and their confidence intervals between the two groups were also determined. P-values less than 0.05 was considered statistically significant. RESULTS In total one hundred and fourteen (114) patients were recruited for the study, 57 in each arm. The patients were followed up on post-operative days 3,7,14 and 30 for signs of surgical site infection. The overall surgical site infection rate was 8.8%. The surgical site infection rate in the irrigation arm was 3.5 % and non-irrigation arm was 14%. There was a significant statistical reduction in the rate of SSI when irrigation was done. Various factors associated with SSI include wound class, duration of hospital stay, male gender and age were identified as risk factors The commonest organisms isolated were Escherichia coli, Klebsiella pneumonia, Staphylococcus aureus and Pseudomonas aeruginosa. CONCLUSION: Irrigation of the subcutaneous tissue using saline solution during appendicectomy is effective in reducing SSI at the KBTH.
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    TREATMENT AND OUTCOMES OF PEDIATRIC SUPRACONDYLAR HUMERAL FRACTURES IN KORLE-BU TEACHING HOSPITAL.
    (BAIDOO PAA KWESI, 2015-12-01) BAIDOO, PAA KWESI
    BACKGROUND Supracondylar humeral fractures are the most common elbow fractures in the pediatric population. These normally result from either a fall on the outstretched hand or the flexed elbow resulting in either the extension or flexion types respectively. They are usually associated with complications such as neurovascular injuries, compartment syndrome, pin tract infections and malunion which in the end after the cosmetic and functional outcomes according to the Flynn’s criteria. The objective of this study was to determine the treatment and outcomes of pediatric supracondylar fractures of the distal humerus at Korle Bu Teaching hospital. METHODOLOGY This was a prospective study carried out at the trauma and orthopedic unit of Korle Bu Teaching Hospital, Accra. Patients for this study were recruited over a year period from January 2014 to January 2015. An evaluation form was filled by the principal investigator and attached to patient’s folders. One hundred and one patients were entered into the study. Treatment of supracondylar humeral fractures in children were guided by the department’s protocol. Patients were followed up over a six (6) month period . Data collected during this period were entered into the REDCap data base, which is a secured web based data collection tool hosted by the University of California, San Francisco (UCSF). The results were then analysed using SPSS version 23. RESULTS The mean age was 5.2 years with a peak of 4-5 years. There were seventy three (73) males and twenty eight (28) females with a ratio of 2.6:1. Most of the injuries occurred at home (64.3%) followed by at school (27.7%). The left arm (non-dominant) was the most injured (62%) compared to the right (38%), though most of the patients seen were right hand dominant (92%). Gartland type III (43.6%) was the commonest fracture followed by type I (31.7%) and type II (24.7%) respectively. Outcomes of management of these fractures were satisfactory based on Flynn’s criteria in over 95 % of the patients. The pediatric quality of life outcome was significantly affected at three weeks after the injury. However, they returned to the population normal at six month. Pin tract infections (5 patients), nerve injury (3 patient), vascular (1 patient), cubitus varus (1 patient), elbow stiffness (1 patient) and myositis ossificans (1 patient) were the complications observed in the study and were mostly associated with high energy injuries (type III fractures). CONCLUSIONS Pediatric supracondylar humeral fractures are very common injuries and their diagnosis and treatment presents a major difficulty to us as orthopedic surgeons. However, through this study, it is concluded that the outcomes of treatment of these fractures at our institution is satisfactory and comparable to other places where they manage such fractures.
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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.
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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.