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Background: Cholecystectomy and common bile duct exploration for biliary stone disease are common hepatobiliary surgeries performed by general surgeons in Nigeria. These procedures can be complicated by injury to the biliary tree or retained stones, requiring repeat surgical intervention. This study presents the experience of using endoscopic retrograde cholangiopancreatography (ERCP) in the management of hepatobiliary surgery complications at the academic referral center of Obafemi Awolowo University Teaching Hospital (OAUTHC) Ile-Ife, Nigeria., Methods: All patients with postcholecystectomy complications referred to the endoscopy unit at OAUTHC from March 2018 to April 2023 were enrolled. Preoperative imaging included a combination of abdominal ultrasound, CT, MRI, magnetic resonance cholangiopancreatography (MRCP), and T-tube cholangiogram. All ERCP procedures were performed under general anesthesia., Results: Seventy-two ERCP procedures were performed on 45 patients referred for postcholecystectomy complications. The most common mode of presentation was ascending cholangitis [16 (35.6%)], followed by persistent biliary fistula [12 (26.7%)]. The overall median duration of symptoms after cholecystectomy was 20 weeks, with a range of 1-162 weeks. The most common postcholecystectomy complication observed was retained stone [16 (35.6%)]. Other postcholecystectomy complications included bile leakage, bile stricture, bile leakage with stricture, and persistent bile leakage from the T-tube in 12 (26.7%), 11 (24.4%), 4 (8.9%), and 2 (4.4%) patients, respectively. Ampullary cannulation during ERCP was successful in all patients (45, 100%). Patients with complete biliary stricture (10/12) required hepaticojejunostomy., Conclusion: Endoscopic management of postcholecystectomy complications was found to be safe and reduce the number of needless surgeries to which such patients are exposed. We recommended prompt referral of such patients for ERCP., (© 2024. The Author(s).)

Introduction: Colorectal cancer (CRC) is the second leading cause of cancer-related death worldwide. There is a significant burden of mortality from colorectal cancer in Africa. Due to the heterogeneity of dietary and lifestyle practices throughout Africa, our work sought to define risk factors for the development of CRC in the African continent., Methods: We systematically searched PubMed, Embase, Global Health, CINAHL, Cochrane CENTRAL, and African Index Medicus for studies written in English, examining the incidence and risk factors of CRC in Africa. A systematic analysis was done to compare different risk factors in constituent studies. A meta-analysis random effects model was fitted to estimate the pooled incidence of CRC., Results: Of 2471 studies screened, 26 were included for the quantitative analysis; 20 in the incidence analysis, and six in the risk factor analysis. The overall ASIR per 100,000 person-years of CRC for males and females was 7.51 and 6.22, respectively. The highest incidence rates were observed between 2012 and 2021. Risk factors for CRC in Africa include tobacco smoking, and consumption of red meat, butter, and alcohol. Protective factors included, regular consumption of fruits and regular physical activity., Conclusion: The incidence of CRC in Africa is higher than that suggested by previous studies. Our study shows that nonmodifiable and modifiable factors contribute to CRC in Africa. High-quality studies conducted on generalizable populations that examine risk factors in a comprehensive fashion are required to inform primary and secondary prevention initiatives for CRC in Africa., (© 2024. The Author(s).)

This cost analysis of a community-based viral hepatitis screening program in Cameroon found an investment of $3.52 per person screened, $50.63 per new diagnosis of hepatitis B, $159.45 per new diagnosis of hepatitis C, and $47.97 per new diagnosis of either hepatitis B or C., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts of interest., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Low- and middle-income countries have a high prevalence of Helicobacter pylori infection (HPI). In Cameroon, the majority of HPIs are diagnosed and treated by primary care physicians (PCPs). We sought to assess the knowledge and practices of PCPs in the diagnosis and management of HPI in Cameroon., Methods: A hospital-based cross-sectional study was carried out in four randomly selected regions of Cameroon from November 2021 to June 2022. In each of the selected regions, PCPs were recruited by non-probability convenience sampling and interviewed using a pre-structured questionnaire. Chi-squared, Fisher's exact and Student's t-tests were performed for descriptive analyses. Multivariable logistic regression was used to examine associations between knowledge and practice, with the model adjusted by age of the PCP, geographic region, number of patients and years in practice. Analysis was performed in SAS version 9.4 (SAS Institute, Cary, NC, USA)., Results: A total of 382 PCPs were included in the analysis. The majority (60.0%) were males between the ages of 20-29 y (64.1%). Most PCPs (80.9%) reported that HPI is the cause of gastroesophageal reflux disease and 41.8% reported that HPI is the main cause of dyspeptic symptoms. The dominant diagnostic tests used for HPI were serology (52.8%) and stool antigen (30.9%). The most frequently used first-line therapies were amoxicillin (AMX), clarithromycin (CLA), metronidazole (MNZ) and proton pump inhibitor (PPI) concomitant therapy (32.2%), AMX-CLA-PPI triple therapy (18.6%) and AMX-MNZ-PPI triple therapy (13.1%). Half of the practitioners (48.6%) treat HPI empirically, without positive H. pylori testing. About half of the PCPs (48%) do not request laboratory confirmation of H. pylori eradication following treatment., Conclusions: There is inadequate knowledge and significant differences in the clinical approach towards HPI among PCPs in Cameroon. We recommend more teaching programs and continuous medical education on HPI., (© The Author(s) 2024. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Competing Interests: We declare no competing interests. Editorial note: The Lancet Group takes a neutral position with respect to territorial claims in published maps.

Background: Antimicrobial resistance (AMR) poses a serious threat to global healthcare, and inadequate education has been identified as a major challenge by the WHO. The human , animal and agricultural sectors contribute to the emergence of AMR. Gamification has emerged as an innovative tool to improve knowledge and change behaviours. Our study provides an overview of the literature on existing games in prescribers' education across the One Health sectors, with a particular focus on the impact of gamification on learning., Methods: Using the PRISMA guidelines, we searched Cochrane, PubMed, Scopus and Google Scholar for articles related to gamification for future prescribers of antimicrobials from inception until 28 March 2023. Retrieval and screening of articles was done using a structured search protocol with strict inclusion/exclusion criteria., Results: A total of 120 articles were retrieved, of which 6 articles met the inclusion criteria for final analysis. High-income countries had the most studies, with one global study incorporating low- to middle-income countries. All games were evaluated in the human sector. Board and card games, featuring scoring and point systems, were the most prevalent game types. Most games focused on improving knowledge and prescribing behaviours of medical students, with bacteria or antibiotics as the only content. All studies highlighted the significant potential of gamification in mitigating AMR, promoting antimicrobial stewardship, and improving retention of information compared with conventional lectures., Conclusions: Our review found an absence of studies in the animal and environmental sectors, disproportionately focused on medical students with questionable sample size, inadequate assessment of game content and effectiveness, and opportunities for game developers., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

Introduction: Antimicrobial resistance (AMR) is a major global health threat, particularity in lower-middle-income countries (LMICs) where antibiotics are readily available, leading to antibiotic misuse. Educational interventions are lacking in Zambia. Our study assessed antimicrobial use and resistance knowledge, attitude and perceived quality of education relating to AMR in Zambian medical schools., Methods: A cross-sectional anonymous survey of students at six accredited medical schools in Zambia using a self-administered questionnaire was administered, using Qualtrics. Chi-squared, Fisher exact test, Pearson correlation test and Student's t -tests were performed for descriptive analyses. Multivariable logistic regression was used to examine associations between knowledge and antibiotic use, beliefs and behaviours. Analysis was performed in SAS version 9.4., Results: One hundred and eighty responses from six medical schools were included in the final analysis. Fifty-six percent of students rated their overall education on antibiotic use as useful or very useful. Ninety-one percent thought that antibiotics are overused, and 88% thought resistance was a problem in Zambia. Only 47% felt adequately trained on antibiotic prescribing, and 43% felt confident in choosing the correct antibiotic for specific infections. Only 2% felt prepared interpreting antibiograms, 3% were trained to de-escalate to narrow-spectrum antibiotics, 6% knew how to transition from IV antibiotics to oral antibiotics, 12% knew of dosing and duration, and 14% understood the spectrum of activity of antibiotics. Forty-seven percent of respondents think hand hygiene is unimportant., Conclusions: Medical students in Zambia expressed a good level of knowledge, but low levels of training and confidence regarding antimicrobial prescribing practices and resistance. Our study highlights training gaps and possible areas of intervention in the medical school curriculum., (© The Author(s) 2023. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

Background: The prevalence, management, and clinical outcomes of cholangiocarcinoma in Africa are unknown. The aim is to conduct a comprehensive systematic review on the epidemiology, management, and outcomes of cholangiocarcinoma in Africa., Methods: We searched PubMed, EMBASE, Web of Science and CINHAL from inception up to November 2019 for studies on cholangiocarcinoma in Africa. The results reported follow PRISMA guidelines. Quality of studies and risk of bias were adapted from a standard quality assessment tool. Descriptive data were expressed as numbers with proportions and Chi-squared test was used to compare proportions. P values < 0.05 were considered significant., Results: A total of 201 citations were identified from the four databases. After excluding duplicates, 133 full texts were reviewed for eligibility, and 11 studies were included. The 11 studies are reported from 4 countries only: 8 are from North Africa (Egypt 6 and Tunisia 2), and 3 in Sub-Saharan Africa (2 in South Africa, 1 in Nigeria). Ten studies reported management and outcomes, while one study reported epidemiology and risk factors. Median age for cholangiocarcinoma ranged between 52 and 61 years. Despite the proportion with cholangiocarcinoma being higher among males than females in Egypt, this gender disparity could not be demonstrated in other African countries. Chemotherapy is mainly used for palliative care. Surgical interventions are curative and prevent cancer progression. Statistical analyses were performed with Stata 15.1., Conclusion: The known global major risk factors such as primary sclerosing cholangitis, Clonorchis sinensis and Opisthorchis viverrini infestation are rare. Chemotherapy treatment was mainly used for palliative treatment and was reported in three studies. Surgical intervention was described in at least 6 studies as a curative modality of treatment. Diagnostic capabilities such as radiographic imaging and endoscopic are lacking across the continent which most likely plays a role in accurate diagnosis., (© 2023. The Author(s).)

Background: Antimicrobial resistance (AMR) is widely acknowledged as a global health problem, yet its extent is not well evaluated, especially in low-middle income countries. It is challenging to promote policies without focusing on healthcare systems at a local level, therefore a baseline assessment of the AMR occurrence is a priority. This study aimed to look at published papers relating to the availability of AMR data in Zambia as a means of establishing an overview of the situation, to help inform future decisions., Methods: PubMed, Cochrane Libraries, Medical Journal of Zambia and African Journals Online databases were searched from inception to April 2021 for articles published in English in accordance with the PRISMA guidelines. Retrieval and screening of article was done using a structured search protocol with strict inclusion/exclusion criteria., Results: A total of 716 articles were retrieved, of which 25 articles met inclusion criteria for final analysis. AMR data was not available for six of the ten provinces of Zambia. Twenty-one different isolates from the human health, animal health and environmental health sectors were tested against 36 antimicrobial agents, across 13 classes of antibiotics. All the studies showed a degree of resistance to more than one class of antimicrobials. Majority of the studies focused on antibiotics, with only three studies (12%) highlighting antiretroviral resistance. Antitubercular drugs were addressed in only five studies (20%). No studies focused on antifungals. The most common organisms tested, across all three sectors, were Staphylococcus aureus, with a diverse range of resistance patterns found; followed by Escherichia coli with a high resistance rate found to cephalosporins (24-100%) and fluoroquinolones (20-100%)., Conclusions: This review highlights three important findings. Firstly, AMR is understudied in Zambia. Secondly, the level of resistance to commonly prescribed antibiotics is significant across the human, animal, and environmental sectors. Thirdly, this review suggests that improved standardization of antimicrobial susceptibility testing in Zambia could help to better delineate AMR patterns, allow comparisons across different locations and tracking of AMR evolution over time., (© 2023. The Author(s).)

Introduction: Viral hepatitis is a major cause of death in Africa. A paucity of community-based studies on the determinants of viral hepatitis in Africa impedes efforts to appropriately target prevention, screening, and treatment interventions. We assessed factors associated with hepatitis B virus (HBV) and hepatitis C virus (HCV) in a semi-urban health district in Cameroon., Methods: We conducted a community-based, cross-sectional study from 28 February to 15 May 2021 in the Buea Health District in Buea, Cameroon. We recruited a sample of consenting individuals aged over 15 years old. Participants were surveyed for factors associated with HBV/HCV and were screened for HBV surface antigen (HBsAg) and HCV antibody using rapid point-of-care tests. We performed univariable and multivariable logistic regression analyses to identify factors associated with HBsAg and HCV seropositivity., Results: We screened 1144 participants (66% female) with a median age of 30 years (IQR: 23-44). HBsAg prevalence was 5.7% (95%CI: 4.5-7.2%) and HCV seropositivity was 1.9% (95%CI: 1.3-2.9%). Three people (0.3%) were seropositive for both HBsAg and HCV antibody. Male sex (adjusted OR [aOR] = 2.31; 95%CI: 1.28-4.18) and a history of traditional operation or scarification (aOR = 2.87; 95%CI: 1.67-4.92) were associated with HBsAg. None of the assessed factors was significantly associated with HCV antibody., Conclusion: Men and participants with a history of traditional operation and scarification had higher odds of HBsAg. We did not observe any associations with HCV seropositivity. Prevention and screening efforts among adults in this setting should prioritize men and those with a history of traditional operation and scarification., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Article Title: Spontaneous internal pancreatic fistulae complicating acute pancreatitis., (Copyright © 2021 by The American College of Gastroenterology.)

Nonvariceal upper gastrointestinal bleeding is common, morbid, and potentially fatal. Cornerstones of inpatient management include fluid resuscitation; blood transfusion; endoscopy; and initiation of proton-pump inhibitor therapy, which continues in an individualized manner based on risk factors for recurrent bleeding in the outpatient setting. The International Consensus Group released guidelines on the management of nonvariceal upper gastrointestinal bleeding in 2019. These guidelines provide a helpful, evidence-based roadmap for management of gastrointestinal bleeding but leave certain management details to the discretion of the treating physician. Here, 2 gastroenterologists consider the care of a patient with nonvariceal upper gastrointestinal bleeding from a peptic ulcer, specifically debating approaches to blood transfusion and endoscopy timing in the hospital, as well as the recommended duration of proton-pump inhibitor therapy after discharge.

Introduction: published data on oesophageal cancer (EC) in Zambia is limited and our study is the only study in Zambia evaluating the demographics and clinicopathologic features of patients presenting with EC at time of diagnosis., Methods: a retrospective analysis of data from Cancer Diseases Hospital (CDH) database was conducted on EC patients diagnosed between 2007 and December 2018. Medical records of EC patients were manually retrieved and reviewed using medical record numbers identified from the CDH database. Demographics, clinicopathologic features and modes of treatment were extracted. A coding sheet was created a priori, and data analysed in SAS version 9.3., Results: two hundred and seventy eight (278) complete EC medical records were included in the analysis, 183 (66%) were males, mean age was 55 years (range 21-89). One hundred and fifty six (156) (56%) resided in Lusaka, the location of CDH. The age-standardized incidence for EC was 5.5 per 100,000 people (95% CI, 4.3-6.6). The commonest symptom was dysphagia (83%), 97% were diagnosed endoscopically, squamous cell carcinoma and adenocarcinoma accounted for 90% and 8.3% respectively, 65% received treatment. One hundred and twenty four (124) medical records had missing cancer staging. Of 154 medical records with complete cancer staging, 98 (35%) were diagnosed at stage 4 of which 33% were between 40 and 49 years., Conclusion: the age-standardized incidence for EC is high at CDH. Patients with EC are predominantly male, reside in Lusaka and present with late stage EC at time of diagnosis; mostly between the ages of 40-49 years. Robust prospective research and improved data recording is needed., Competing Interests: The authors declare no competing interests., (Copyright: Akwi Wasi Asombang et al.)

Background: This study aimed at evaluating the endoscopic management and clinical outcomes in patients with obstructive jaundice undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP) within a newly established apprenticeship teaching model at an academic centre in a resource-limited setting., Materials and Methods: We employed an apprenticeship-style model of ERCP training with graded responsibility, multidisciplinary group feedback and short-interval repetition. We collected sociodemographic and clinicopathologic data on consecutive patients who underwent ERCP from March 2018 to February 2020., Results: A total of 177 patients were referred, of which 146 patients had an ERCP performed for obstructive jaundice and 31 excluded during the study period. The median age was 55 years, age range from 8 to 83 years. The most common referral diagnosis was pancreatic head cancer 56/146 (38.1%), followed by choledocholithiasis 29/146 (19.7%), cholangiocarcinoma 22/146 (15.0%) and gall bladder cancer 11/146 (7.5%). In all, 102 patients had a malignant indication for ERCP. The cannulation rate was 92%. The most common site for malignant biliary obstruction was proximal bile stricture in 31/102 (30.4%), followed by distal bile strictures in 30/102 (28.4%), periampullary cancer 20/102 (19.6%) and mid bile duct stricture in 9/102 (8.8%). The common benign obstructive etiology includes choledocholithiasis in 33/44 (75%) and mid duct obstruction from post-cholecystectomy bile duct injury in 3/44 (2.9%) while 2/44 (2.0%) patients had choledochal cyst. Overall complications were post-ERCP pancreatitis (8/146 patients), cholangitis (3/146 patients), stent migration and post-sphincterotomy bleeding (one patient each). Peri-procedural mortality was 5/146 (3.4%)., Conclusion: ERCP is an effective and safe method of treatment of patients with benign and malignant biliary obstruction. The low morbidity and mortality and its immediate therapeutic benefits, together with the short duration of hospitalization, indicate that this procedure is an important asset in the management of such patients., Competing Interests: None

Background: Esophageal cancer (EC) is associated with a poor prognosis, particularly so in Africa where an alarmingly high mortality to incidence ratio prevails for this disease., Aim: To provide further understanding of EC in the context of the unique cultural and genetic diversity, and socio-economic challenges faced on the African continent., Methods: We performed a systematic review of studies from Africa to obtain data on epidemiology, risk factors, management and outcomes of EC. A non-systematic review was used to obtain incidence data from the International Agency for Research on Cancer, and the Cancer in Sub-Saharan reports. We searched EMBASE, PubMed, Web of Science, and Cochrane Central from inception to March 2019 and reviewed the list of articles retrieved. Random effects meta-analyses were used to assess heterogeneity between studies and to obtain odds ratio (OR) of the associations between EC and risk factors; and incidence rate ratios for EC between sexes with their respective 95% confidence intervals (CI)., Results: The incidence of EC is higher in males than females, except in North Africa where it is similar for both sexes. The highest age-standardized rate is from Malawi (30.3 and 19.4 cases/year/100000 population for males and females, respectively) followed by Kenya (28.7 cases/year/100000 population for both sexes). The incidence of EC rises sharply after the age of 40 years and reaches a peak at 75 years old. Meta-analysis shows a strong association with tobacco (OR 3.15, 95%CI: 2.83-3.50). There was significant heterogeneity between studies on alcohol consumption (OR 2.28, 95%CI: 1.94-2.65) and on low socioeconomic status (OR 139, 95%CI: 1.25-1.54) as risk factors, but these could also contribute to increasing the incidence of EC. The best treatment outcomes were with esophagectomy with survival rates of 76.6% at 3 years, and chemo-radiotherapy with an overall combined survival time of 267.50 d., Conclusion: Africa has high incidence and mortality rates of EC, with preventable and non-modifiable risk factors. Men in this setting are at increased risk due to their higher prevalence of tobacco and alcohol consumption. Management requires a multidisciplinary approach, and survival is significantly improved in the setting of esophagectomy and chemoradiation therapy., Competing Interests: Conflict-of-interest statement: All the authors declare that they have no competing interests.

Introduction: Colon cancer is preventable. There is a plethora of data regarding epidemiology and screening guidelines, however this data is sparse from the African continent. Objective: we aim to evaluate the trends of colorectal cancer (CRC) in a native African population based on age at diagnosis, gender and stage at diagnosis., Methods: We conducted a retrospective analysis of the Cancer Disease Hospital (CDH) registry in Zambia, Southern Africa., Results: 377 charts were identified in the CDH registry between 2007 and 2015, of which 234 were included in the final analysis. The mean age at diagnosis was 48.6 years and 62% are males. Using descriptive analysis for patterns: mode of diagnosis was surgical in 195 subjects (84%), histology adenocarcinoma in 225 (96.5%), most common location is rectum 124 (53%) followed by sigmoid 31 (13.4%), and cecum 26 (11%). 122 subjects (54%) were stage 4 at diagnosis. Using the Spearman rank correlation, we see no association between year and stage at diagnosis (p = 0.30) or year and age at diagnosis (p = 0.92)., Conclusion: Colorectal cancer was diagnosed at a young age and late stage in the Zambian patients.

Fatty pancreas is a newly recognized condition which is poorly investigated until today as compared to nonalcoholic fatty liver disease. It is characterized by pancreatic fat accumulation and subsequent development of pancreatic and metabolic complications. Association of fatty pancreas have been described with type 2 diabetes mellitus, acute and chronic pancreatitis and even pancreatic carcinoma. In this review article, we provide an update on clinical implications, pathogenesis, diagnosis, treatment and outcomes.

For patients recovering from acute pancreatitis, the development of a pancreatic fluid collection (PFC) predicts a more complex course of recovery, and introduces difficult management decisions with regard to when, whether, and how the collection should be drained. Most PFCs resolve spontaneously and drainage is indicated only in pseudocysts and walled-off pancreatic necrosis when the collections are causing symptoms and/or local complications such as biliary obstruction. Historical approaches to PFC drainage have included surgical (open or laparoscopic cystgastrostomy or pancreatic debridement), and the placement of percutaneous drains. Endoscopic drainage techniques have emerged in the last several years as the preferred approach for most patients, when local expertise is available. Lumen-apposing metal stents (LAMS) have recently been developed as a tool to facilitate potentially safer and easier endoscopic drainage of pancreatic fluid collections, and less commonly, for other indications, such as gallbladder drainage. Physicians considering LAMS placement must be aware of the complications most commonly associated with LAMS including bleeding, migration, buried stent, stent occlusion, and perforation. Because of the patient complexity associated with severe pancreatitis, management of pancreatic fluid collections can be a complex and multidisciplinary endeavor. Successful and safe use of LAMS for patients with pancreatic fluid collections requires that the endoscopist have a full understanding of the potential complications of LAMS techniques, including how to recognize and manage expected complications., Competing Interests: Conflict-of-interest statement: Dr. Berzin is a consultant and speaker for Boston Scientific.

Objectives: Before an endoscopic procedure, an evaluation to assess the risk of sedation is performed by the gastroenterologist. To risk stratify based on medical problems, the American Society of Anesthesiologists (ASA) classification scores are used routinely in the preprocedure evaluation. The objective of our study was to evaluate among physicians the ASA score accuracy pre-endoscopic procedures., Methods: At a single tertiary-care center an institutional review board-approved retrospective study was performed. Upper endoscopies performed from May 2012 through August 2013 were reviewed; data were collected and recorded. Statistical analysis was performed using descriptive statistics and linear weighted kappa analysis for agreement (≤0.20 is poor agreement, 0.21-0.40 is fair, 0.41-0.60 is moderate, 0.61-0.80 is good, and 0.81-1.00 is very good)., Results: The mean ASA scores by the gastroenterologist compared with the anesthesiologist were 2.28 ± 0.56 and 2.78 ± 0.60, respectively, with only fair agreement (weighted kappa index 0.223, 95% confidence interval [CI] 0.113-0.333; 48% agreement). The mean ASA scores for gastroenterologists compared with other gastroenterologists were 2.26 ± 0.5 and 2.26 ± 0.44, respectively, with poor agreement (weighted kappa index 0.200, 95% CI 0.108-0.389; 68% agreement). Agreement on ASA scores was only moderate between the gastroenterologist and himself or herself (weighted kappa index 0.464, 95% CI 0.183-0.745; 75% agreement)., Conclusions: Gastroenterologists performing preprocedure assessments of ASA scores have fair agreement with anesthesiologists, poor agreement with other gastroenterologists, and only moderate agreement with themselves. Given this level of inaccuracy, it appears that the ASA score pre-endoscopy is of limited significance.

Objectives: To describe the survival outcomes of patients with histologically proven primary pancreatic cancer based on geographic location and sex., Methods: We conducted a retrospective review of medical records from 2009 through 2013 of patients with pancreatic cancer using International Classification of Diseases, Ninth Revision code 157.9 and International Statistical Classification of Diseases, 10th Revision code C 25.9. The variables extracted included demographics, date of diagnosis, mode of diagnosis, duration, treatment methods, family history, history of chronic pancreatitis, and diabetes mellitus. ZIP codes were used to identify the geographic location of each subject, and rural urban commuting area codes were used to further classify the areas as metropolitan, micropolitan, small town, and rural. Population sizes were classified as metropolitan >50,000, micropolitan 10,000 to 49,999, small town 2500 to 9999, and rural <2500. Descriptive analysis and Kaplan-Meier survival for survival outcomes were performed with statistical significance identified as P < 0.05., Results: A total of 400 medical charts were extracted for review, 301 of which belonged to patients with primary pancreatic cancer. Of the 301 cases, we identified 175 men (58%), 125 women (41%), and 1 missing sex data. There were 280 whites (95%), 8 African Americans (2%), 2 Asian Americans (0.64%), 1 Hispanic American (0.34%) and 1 Native American (0.34%), with a mean age of 63.2 ± 12.6 years. Based on geography, there were 34%, 27%, 20%, and 19% in rural areas, metropolitans, small towns, and micropolitans, respectively. No statistically significant difference was noted in sex on survival outcomes ( P = 0.85) or geography ( P = 0.62). Additional analysis revealed no statistical significant difference between sexes when stratifying by location ( P = 0.96)., Conclusions: There is no difference in survival outcomes of patients with primary pancreatic cancer based on sex or geographic location. Our survival outcomes differ from the national survival outcomes, which reveal that mortality in men is higher than it is in women.

Aim: To identify risk factors associated with esophageal cancer in Zambia and association between dietary intake and urinary 8-iso prostaglandin F2α (8-isoPGF2α)., Methods: We conducted a prospective, case control study at the University Teaching Hospital. Subjects included both individuals admitted to the hospital and those presenting for an outpatient upper endoscopy. Esophageal cancer cases were compared to age and sex-matched controls. Cases were defined as patients with biopsy proven esophageal cancer; controls were defined as subjects without endoscopic evidence of esophageal cancer. Clinical and dietary data were collected using a standard questionnaire, developed a priori. Blood was collected for human immunodeficiency virus (HIV) serology. Urine was collected, and 8-isoPGF2α was measured primarily by enzyme-linked immunosorbent assay and expressed as a ratio to creatinine., Results: Forty five controls (mean age 54.2 ± 15.3, 31 male) and 27 cases (mean age 54.6 ± 16.4, 17 males) were studied. Body mass index was lower in cases (median 16.8) than controls (median 23.2), P = 0.01. Histopathologically, 25/27 (93%) were squamous cell carcinoma and 2/27 (7%) adenocarcinoma. More cases smoked cigarettes (OR = 11.24, 95%CI: 1.37-92.4, P = 0.02) but alcohol consumption and HIV seropositivity did not differ significantly (P = 0.14 for both). Fruit, vegetables and fish consumption did not differ significantly between groups (P = 0.11, 0.12, and 0.10, respectively). Mean isoprostane level was significantly higher in cases (0.03 ng/mg creatinine) than controls (0.01 ng/mg creatinine) (OR = 2.35, 95%CI: 1.19-4.65, P = 0.014)., Conclusion: Smoking and isoprostane levels were significantly associated with esophageal cancer in Zambians, but diet, HIV status, and alcohol consumption were not.

Introduction: Gastric cancer is one of the major causes of cancer related deaths, but data from sub-Saharan Africa are very scanty. The cancer genome atlas (TCGA) initiative confirmed Epstein-Barr virus (EBV) related cancer as a distinct subtype, and we set out to look for serological evidence of its role in a sub-Saharan African patient group., Methods: We used stored serum samples obtained from a gastric cancer case-control study conducted between 2010 and 2012 in Lusaka, Zambia. A total of 147 patients were included with 51 gastric adenocarcinoma cases and 96 age and sex matched controls. The presence of antibodies to EBV nuclear antigen-1 (EBNA-1) and early antigen (EA) was determined using commercially available ELISA kits. Data were analysed in STATA Stata Corp, College Station TX., Results: Over 90% of all the samples analysed were positive for antibodies to EBNA-1. The presence of antibodies to EBV EA was significantly higher in gastric cancer cases than in controls, (OR 4.38; 95% CI 1.53-13.06, P = 0.0027), with an attributable risk of 23%. HIV infection was also associated with EBV EA seroprevalence (OR 10.97; 95% CI 2.26 -13.06, P = 0.001) but not EBNA-1 (OR 0.81; 95% CI 0.10 -38.75, P = 0.596). There was no association of EBV infection with age below 45 years, Helicobacter pylori infection, intestinal metaplasia, gastric atrophy or inflammation., Conclusion: We therefore conclude that EBV exposure is common among Zambian adults and that EBV EA seropositivity is associated with gastric cancer and HIV infection, but not premalignant lesions.

There is emerging evidence that esophageal cancer occurs in younger adults in sub-Saharan Africa than in Europe or North America. The burden of human immunodeficiency virus (HIV) is also high in this region. We postulated that HIV and human papillomavirus (HPV) infections might contribute to esophageal squamous cell carcinoma (OSCC) risk. This was a case-control study based at the University Teaching Hospital in Lusaka, Zambia. Cases were patients with confirmed OSCC and controls had completely normal upper endoscopic evaluations. A total of 222 patients were included to analyze the influence of HIV infection; of these, 100 patients were used to analyze the influence of HPV infection, alcohol, smoking, and exposure to wood smoke. The presence of HIV infection was determined using antibody kits, and HPV infection was detected by polymerase chain reaction. HIV infection on its own conferred increased risk of developing OSCC (odds ratio [OR] 2.3; 95% confidence interval [CI] 1.0-5.1; P = 0.03). The OR was stronger when only people under 60 years were included (OR 4.3; 95% CI 1.5-13.2; P = 0.003). Cooking with charcoal or firewood, and cigarette smoking, both increased the odds of developing OSCC ([OR 3.5; 95% CI 1.4-9.3; P = 0.004] and [OR 9.1; 95% CI 3.0-30.4; P < 0.001], respectively). There was no significant difference in HPV detection or alcohol intake between cases and controls. We conclude that HIV infection and exposure to domestic and cigarette smoke are risk factors for OSCC, and HPV immunization unlikely to reduce OSCC incidence in Zambia., (© 2015 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Aim: To evaluate usefulness of prophylactically intubating upper gastrointestinal bleeding (UGIB) patients., Methods: UGIB results in a significant number of hospital admissions annually with endoscopy being the key intervention. In these patients, risks are associated with the bleeding and the procedure, including pulmonary aspiration. However, very little literature is available assessing the use of prophylactic endotracheal intubation on aspiration in these patients. A comprehensive search was performed in May 2014 in Scopus, CINAHL, Cochrane databases, PubMed/Medline, Embase, and published abstracts from national gastroenterology meetings in the United States (2004-2014). Included studies examined UGIB patients and compared prophylactic intubation to no intubation before endoscopy. Meta-analysis was conducted using RevMan 5.2 by Mantel-Haenszel and DerSimonian and Laird models with results presented as odds ratio for aspiration, pneumonia (within 48 h), and mortality. Funnel plots were utilized for publication bias and I 2 measure of inconsistency for heterogeneity assessments., Results: Initial search identified 571 articles. Of these articles, 10 relevant peer-reviewed articles in English and two relevant abstracts were selected to review by two independent authors (Almashhrawi AA and Bechtold ML). Of these studies, eight were excluded: Five did not have a control arm, one was a letter the editor, one was a survey study, and one was focused on prevention of UGIB. Therefore, four studies ( N = 367) were included. Of the UGIB patients prophylactically intubated before endoscopy, pneumonia (within 48 h) was identified in 20 of 134 (14.9%) patients as compared to 5 of 95 (5.3%) patients that were not intubated prophylactically ( P = 0.02). Despite observed trends, no significant differences were found for mortality ( P = 0.18) or aspiration ( P = 0.11)., Conclusion: Pneumonia within 48 h is more likely in UGIB patients who received prophylactic endotracheal intubation prior to endoscopy.

Objectives: In advance of endoscopic procedures, an evaluation to assess the risk of sedation is performed by the gastroenterologist. Based on regulations, gastroenterologists are required to perform an airway assessment. At this time, data supporting this regulation are limited; therefore, we evaluated airway assessment accuracy by gastroenterologists before endoscopic procedures., Methods: A retrospective, single tertiary care center study was performed from May 2012 through August 2013. Patients who underwent an endoscopy or colonoscopy performed at the University of Missouri-Columbia with documented Mallampati scores were included in the analysis. Three primary cohorts of patients were included in our study: gastroenterologist versus anesthesiologist, gastroenterologist versus other gastroenterologists, and gastroenterologists versus themselves. Data were collected and recorded for patient age, body mass index, and Mallampati score. Statistical analysis was performed using descriptive statistics and linear weighted kappa analysis for agreement., Results: For gastroenterologists versus anesthesiologists and versus other gastroenterologists, the agreement on Mallampati scores was poor (weighted kappa index 0.103, 95% confidence interval [CI] -0.0126 to 0.219; percentage of agreement 42% and 0.120, 95% CI -0.0211 to 0.260; percentage of agreement 46%, respectively). For gastroenterologists versus themselves for the same patient, the agreement on Mallampati scores was only moderate (weighted kappa index 0.420, 95% CI 0.119-0.722; percentage of agreement 65%)., Conclusions: Gastroenterologists performing a preprocedure assessment using Mallampati scores have poor agreement with anesthesiologists and colleagues and only moderate agreement with themselves.

Gastric cancer (GC) is the fourth most common cancer in the world with more than 70% of cases occur in the developing world. More than 50% of cases occur in Eastern Asia. GC is the second leading cause of cancer death in both sexes worldwide. In Asia, GC is the third most common cancer after breast and lung and is the second most common cause of cancer death after lung cancer. Although the incidence and mortality rates are slowly declining in many countries of Asia, GC still remains a significant public health problem. The incidence and mortality varies according to the geographic area in Asia. These variations are closely related to the prevalence of GC risk factors; especially Helicobacter pylori (H. pylori) and its molecular virulent characteristics. The gradual and consistent improvements in socioeconomic conditions in Asia have lowered the H. pylori seroprevalence rates leading to a reduction in the GC incidence. However, GC remains a significant public health and an economic burden in Asia. There has been no recent systemic review of GC incidence, mortality, and H. pylori molecular epidemiology in Asia. The aim of this report is to review the GC incidence, mortality, and linkage to H. pylori in Asia.

Gastric cancer is the fourth most common cancer and second most common cause of cancer death worldwide. Globally, gastric cancer poses a significant public health burden - both economically and socially. In 2008, the economic burden from premature cancer deaths and disability was $895 billion and gastric cancer was the second highest cancer responsible for healthy life lost. With the expected increase in cancer deaths and non-communicable diseases, these costs are expected to rise and impact patient care. World Health Organization, estimates a 15% increase in non-communicable disease worldwide, with more than 20% increase occurring in Africa between 2010 and 2020. Mali, West Africa, is ranked 15(th) highest incidence of gastric cancer worldwide at a rate of 20.3/100000, yet very scarce published data evaluating etiology, prevention or management exist. It is understood that risk factors of gastric cancer are multifactorial and include infectious agents (Helicobacter pylori, Epstein-Barr virus), genetic, dietary, and environmental factors (alcohol, smoking). Interestingly, African patients with gastric cancer are younger, in their 3(rd)-4(th) decade, and present at a late stage of the disease. There is sparse data regarding gastric cancer in Africa due to lack of data collection and under-reporting, which impacts incidence and mortality rates. Currently, GLOBOCAN, an International Agency for Research on Cancer resource, is the most comprehensive available resource allowing comparison between nations. In resource limited settings, with already restricted healthcare funding, data is needed to establish programs in Africa that increase gastric cancer awareness, curtail the economic burden, and improve patient management and survival outcomes.

Background: Schistosomiasis is a major cause of morbidity and mortality, with over 200 million people infected worldwide. Eighty-five percent of cases are in Africa. The hepatosplenic form develops over time by an immune reaction to trapped Schistosoma mansoni eggs in the portal system leading to liver fibrosis, portal hypertension and oesophageal varices. Most patients presenting to the University Teaching Hospital in Lusaka with oesophageal varices, come from Western province, but no formal studies have been carried out in this area assessing the burden of hepatosplenic pathology. We aimed to define the extent of the problem in Kaoma district, western Zambia, and to correlate signs and symptoms with serology., Findings: A symptom questionnaire, demographic survey and physical examination was conducted amongst patients presenting to Kaoma district outpatient clinics. To assess the prevalence of Schistosoma mansoni infections, blood was collected and screened for the presence of Schistosoma antibodies using Enzyme linked immunosorbent assay (ELISA). Of the 110 patients screened, 97 (88%) were ELISA positive. Forty-six percent (51/110) reported haematochezia and 7% experienced haematemesis (8/110). On physical examination 27% (30/110) hepatomegaly and 17% (30/110) splenomegaly was observed amongst participants but there were few correlations between serology and signs/symptoms. On questioning 68% (75/110) of participants knew nothing about schistosomiasis transmission., Conclusions: Our serological and clinical data indicate a very heavy burden of schistosomiasis-related portal hypertension. Our evidence highlights a need for mass treatment in Kaoma to address and prevent extensive pathology of hepatosplenic schistosomiasis. Safe water and health education throughout Western Province are clearly also important.

Aim: To evaluate need for and efficacy of a structured gastroenterology didactic session in expanding awareness and understanding of digestive disorders., Methods: A four-day symposium was developed with didactic sessions (days 1, 2) and practical endoscopy (days 3, 4). Didactic sessions included case presentations highlighting pathophysiology and management. One nurse and four practicing gastroenterologists from the United Kingdom led lectures and supervised workshops with audience participation. Practical endoscopy focused on diagnostic and therapeutic procedures and their application to diagnosis and treatment of ailments of the gastrointestinal tract. Pre- and post-workshop questionnaires were distributed to participants during didactic sessions. A pre-workshop questionnaire gauged expectations and identified objectives to be met at the symposium. Post-workshop questionnaires were administered to assess efficacy of each session. Participants graded sessions from 1 (poor) to 5 (excellent) on quality of case presentations, knowledge, clarity and mode of presentation. We assessed if time allotted to each topic was sufficient, value of sessions, impact on practice and interest in future symposiums., Results: There were 46 attendees on day 1: 41% undergraduates, 41% residents, 11% consultants and 4% unspecified. Day 2 (a Saturday) had 24 participants: 17% undergraduates, 71% residents, 9% consultants, 4% unspecified. Primary pre-workshop symposium expectation was to gain knowledge in: general gastroenterology (55.5%), practical endoscopy (13.8%), pediatric gastroenterology (5%), epidemiology of gastrointestinal disorders specific to Zambia (6%), and interaction with international speakers (6%). The post-symposium questionnaire was answered by 19 participants, of whom 95% felt specific aims were met; all would attend future conferences and recommend to others., Conclusion: The beneficial effect of a structured symposium in developing countries warrants further attention as a mechanism to improve disease awareness in areas where resources are limited.

Background: Gastric cancer is increasingly recognized in Zambia. Although nutritional factors contribute to gastric cancer risk, their effect in Zambia is unknown., Objective: The objective was to investigate the association between intake of dietary antioxidants, urinary 8-iso prostaglandin F2α (8-iso PGF2α) as a marker of oxidative stress, and gastric cancer., Design: This was a case-control study at the University Teaching Hospital in Zambia. Gastric cancer cases were compared with age- and sex-matched controls. Urine 8-iso PGF2α was measured primarily by ELISA, and by gas chromatography-mass spectrometry in a subset, expressed as a ratio to creatinine. Blood was collected for Helicobacter pylori, HIV serology, gastrin-17, and pepsinogen 1 and 2 concentrations. Clinical and dietary data were collected by using questionnaires. Food items were broadly classified into 7 major categories (fruit, vegetables, fish, meat, insects, cereals, and starches)., Results: Fifty cases with gastric cancer (mean age: 61 y; n = 31 males) and 90 controls (mean age: 54 y; n = 41 males) were enrolled. Median urinary 8-iso PGF2α excretion was higher in cases (0.014; IQR: 0.008-0.021) than in controls (0.011; IQR: 0.006-0.018; P = 0.039). On univariate analysis, habitual fruit intake was lower in cases than in controls during the dry season (P = 0.02). On multivariate analysis, smoking (OR: 7.22; IQR: 1.38-37.9) and gastric atrophy (OR: 2.43; IQR: 1.12-5.13) were independently associated with cancer, and higher fruit intake was protective (OR: 0.44; IQR: 0.20-0.95). Isoprostane excretion was inversely correlated with total fruit intake (ρ = -0.23; n = 140; P = 0.006)., Conclusion: Urinary 8-iso PGF2α excretion was associated with the risk of gastric cancer, as were smoking and gastric atrophy, but increased fruit intake conferred protection. This trial was registered at www.pactr.org as ISRCTN52971746.

Background: Gastric cancer is a leading cause of cancer deaths worldwide but there are few data from Africa. We recently observed a trend towards diagnosis in younger patients., Objective: To test the hypothesis that HIV might have altered risk factors for acquisition of gastric cancer, in a case-control study in the University Teaching Hospital, Lusaka, Zambia., Methods: Patients (n=52) with confirmed gastric adenocarcinoma and controls (n=94) undergoing endoscopy but with no macroscopic gastric pathology. Established risk factors and HIV status were compared., Results: HIV status did not differ significantly between cases and controls (odds ratio 1.03; 95% CI 0.2 - 4.3; p=1.00) and seroprevalence in cases was similar to that of the Zambian population. Smoking, regular alcohol intake, and gastric atrophy were all associated with cancer in univariate and multivariate analysis. Helicobacter pylori serology was positive in 84% of patients studied and cagA serology in 66%; neither serological marker was associated with cancer. Atrophy was common in cases (57%) and controls (30%) and associated with both smoking and alcohol use. Intestinal metaplasia was present in 17% of the controls, but was not associated with atrophy., Conclusions: HIV was not associated with gastric cancer and does not explain the apparent younger age distribution. Atrophy was common and was not essential for the development of intestinal metaplasia, suggesting that gastric carcinogenesis in Africa does not always follow the pathway from atrophy to intestinal metaplasia to gastric carcinoma (the so-called Correa pathway).

Gastric cancer is a major contributor to mortality worldwide, yet its incidence varies widely around the world in a way which our current understanding of aetiology cannot fully explain. Incidence data from Africa are weak, reflecting poor diagnostic resources, but there are firm data on intestinal metaplasia and gastric atrophy which are important steps in the carcinogenesis pathway. The available registry data suggest that incidence is unlikely to be dramatically different from Europe or North America. Helicobacter pylori infection is an important permissive factor in the development of cancer, but H. pylori seroprevalence is high all over Africa and cannot clearly be correlated with cancer. However, there is evidence that specific bacterial virulence genes, particularly vacA and iceA allele1, do contribute to cancer risk. Intestinal metaplasia and gastric atrophy have been the focus of twelve studies and are common in Africa. Epstein-Barr virus, which causes 10% of cancer worldwide, is the focus of only one African study. Work in other continents demonstrates that other risk factors apply only to one or other of the two major histological types, intestinal and diffuse. Diet, smoking, alcohol and salt intake predispose to the intestinal type of cancer, but genetic factors predispose to the diffuse type. There is a pressing need for information on the histological types occurring in Africa, and their associated risk factors. Most urgently, information on dietary predisposition to cancer is required to inform public health policy with respect to the demographic transition (urbanisation and lifestyle changes) which is occurring all over the continent., (Copyright © 2011 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.)