IntroductionIleo-sigmoid knotting (ISK) is a rare cause of bowel obstruction in which the ileum twists around the sigmoid colon. It is associated with rapid bowel gangrene and a high mortality rate. Little has been published about this condition in Kenya. The objective was to determine the presentation, management, and outcome of patients with ISK.MethodsA seven year (January 2008-December 2014) retrospective chart review of patients managed for ISK at Tenwek Hospital in Bomet, Kenya.ResultsA total of 61 cases were identified, with a mean age of 35.8 years (range 2-68), and mean symptom duration of 1.6 days (range 3 hours-7 days). Gangrene was noted to involve both the ileum and colon in 45 patients, the ileum only in 9 patients, and the sigmoid colon only in one. Resection and primary anastomosis was carried out in most cases of gangrenous ileum (48/54, 89%) and gangrenous sigmoid colon (34/46, 74%), while resection and stoma was performed in 8 patients with gangrenous colon. Death occurred in 7 (11.5%) patients due to severe sepsis and multisystem organ failure. Morbidities were noted in 15 (24.6%) patients, including surgical site infection (8, 13.1%), respiratory insufficiency (4, 6.6%), fascial dehiscence (3, 4.9%) and anastomotic leak (2, 3.2%). The mean duration of hospitalization was 8.3 days (range 1-26).ConclusionIn this review, though retrospective in nature, ISK was noted to have high rates of bowel gangrene. In the appropriate setting, resection and primary anastomosis can be safely carried out in most cases of gangrenous colon.

IntroductionIntestinal obstruction (IO) occurs when there is impedance to the flow of intestinal contents due to a congenital or acquired pathology, and is a common paediatric surgical emergency. This study aimed to assess the pattern and outcome of paediatric IO in western Kenya.MethodsA retrospective review of all recorded cases of mechanical IO in patients aged 15 years or below admitted at Tenwek Hospital between January 2009 and December 2013.ResultsThe cohort included a total of 217 children (130 boys and 87 girls). The mean age was 6.7 years (range: newborn-15 years), with most (65, 30%) cases aged 1-3 years. Vomiting (161, 74.2%), abdominal pain (152, 70%), abdominal tenderness (113, 52.1%), constipation (111, 51.2%), and abdominal distension (104, 47.9%) were the predominant signs and symptoms. The most common causes of IO were ascariasis (96, 44.2%), adhesions (34, 15.7%), and intussusception (30, 13.8%). Intussusception was the leading cause of IO in children aged ≤ 1 year, ascariasis in children aged 1-5 and 6-10 years, and adhesions in children aged 11-15 years. Operative management was undertaken in 120 (55.3%) cases with 39 (32.5%) of these having gangrenous bowel. The overall mortality rate was 5%.ConclusionThe most common causes of mechanical bowel obstruction in this series were ascariasis, adhesions, and intussusception. Ascariasis remains a significant cause of paediatric IO in this region, thus public education, improved sanitation and deworming campaigns may be helpful in reducing the worm burden.

IntroductionAcute mechanical intestinal obstruction (IO) is one of the leading causes of surgical admissions in most emergency departments worldwide. The causes of IO vary significantly depending on geographical location. The aim of this study was to identify the etiology, management and outcomes of patients with acute mechanical IO presenting in south-western Kenya.MethodsA 4 year (November 2009–October 2013) retrospective review of all adult patients admitted with acute mechanical IO at Tenwek Hospital in Bomet, Kenya.ResultsA total of 303 male and 142 female patients, presented with acute mechanical IO during the study period. Mean patient age was 40.6 years (range 17-91), with peak incidence in those aged 31-40 years. The foremost signs and symptoms were abdominal pain (89.4%), abdominal tenderness (81.6%), vomiting (78%), abdominal distension (65.4%) and constipation (50.8%). Sigmoid volvulus (25.6%), adhesions (23.1%), small bowel volvulus (21.3%), and ileo-sigmoid knotting (8.5%) were the leading causes of IO. Laparotomy was undertaken in 361 (81.1%) cases, with bowel gangrene noted in 112 (30.4%). The overall morbidity and mortality rates were 15% and 4.5% respectively. Patients with gangrenous bowel at laparotomy had a higher morbidity rate (22.3% vs 9.6%, P=.001), a higher mortality rate (9.8% vs 3.2%, P=.02) and a longer duration of stay (9.9 days vs 7.6 days, P=.0001) compared to those with viable bowel.ConclusionThe most common causes of IO in this study were sigmoid volvulus, adhesions, small bowel volvulus and ileo-sigmoid knotting. Presence of bowel gangrene was associated with higher morbidity and mortality rates.

Background: Intussusception, a common cause of Intestinal obstruction in infants and young children, occurs when one segment of the bowel invaginates into a distal segment. While non-operative reduction has been well described, surgery remains the predominant mode of therapy in many developing countries due to delayed presentation. This study aimed to describe the presentation, management and outcome of children with intussusception at a single institution. Method: A retrospective review of patients aged 16 years and below with intussusception managed at Tenwek hospital from January 2009 through December 2014 was undertaken. Diagnosis was based on the presenting signs, symptoms, physical findings and plain upright or supine abdominal X-rays, and confirmed via ultrasonography, barium enema or at surgery. Results: A total of 45 cases (24 boys, 21 girls) of intussusception were noted, with a mean age of 2.6 years (range 1 month-15 years). The mean duration between symptom onset and presentation was 4.4 days (range 1-14), and the classic triad (vomiting, bloody mucoid stools and abdominal pain/distension) was noted in 27 (60%) cases. Abdominal ultrasound was diagnostic in 7 of the 11 cases ordered, with the rest diagnosed clinically. Nonoperative reduction was undertaken in 4 cases and successful in 3. Surgery was performed in 42 cases with bowel gangrene and perforation noted in 20 (47.6%) and 15 (35.7%) casesrespectively. The main types of intussusception were ileocolic (23, 51.1%), colocolonic (10, 22.2%) and ileoceacal (7, 15.6%). Five (11.1%) mortalities and 4 (8.8%) morbidities were noted at discharge, most commonly being surgical site infection in three cases. Conclusion: Intussusception, in this series, was primarily diagnosed clinically and managed surgically, with a majority of the patients having gangrenous or perforated bowel at laparotomy.

Objective: We describe a structured approach to developing a standardized curriculum for surgical trainees in East, Central, and Southern Africa (ECSA). Summary Background Data: Surgical education is essential to closing the surgical access gap in ECSA. Given its importance for surgical education, the development of a standardized curriculum was deemed necessary. Methods: We utilized Kern's 6-step approach to curriculum development to design an online, modular, flipped-classroom surgical curriculum. Steps included global and targeted needs assessments, determination of goals and objectives, the establishment of educational strategies, implementation, and evaluation. Results: Global needs assessment identified the development of a standardized curriculum as an essential next step in the growth of surgical education programs in ECSA. Targeted needs assessment of stakeholders found medical knowledge challenges, regulatory requirements, language variance, content gaps, expense and availability of resources, faculty numbers, and content delivery method to be factors to inform curriculum design. Goals emerged to increase uniformity and consistency in training, create contextually relevant material, incorporate best educational practices, reduce faculty burden, and ease content delivery and updates. Educational strategies centered on developing an online, flipped-classroom, modular curriculum emphasizing textual simplicity, multimedia components, and incorporation of active learning strategies. The implementation process involved establishing thematic topics and subtopics, the content of which was authored by regional surgeon educators and edited by content experts. Evaluation was performed by recording participation, soliciting user feedback, and evaluating scores on a certification examination. Conclusions: We present the systematic design of a large-scale, context-relevant, data-driven surgical curriculum for the ECSA region.