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Introduction: Neurofibromatosis type 1 (NF1) affects about 1 in 3000 people. The indications for surgical intervention in patients with NF1 are not always clear-cut. In low-income economies, where scarcity of resources and skilled manpower often dictate levels of healthcare, a broad knowledge base of NF1 is required in order to adequately manage NF1 complications. Materials and Methods: The authors performed PubMed/internet searches for articles on surgical aspects of NF1, as well as a review of the pathology department database for reports on all specimens submit-ted from patients with NF1 over a 16 year period. A retrospective chart review was performed on all patients with NF1 referred to the authors’ institution for surgical intervention between January 2004 and January 2011. Results: Forty five articles describing aspects of surgical care of patients with NF1 qualified for inclusion in the review. Pathological specimens were submitted from a total of 333 patients with NF1 between 1992 and 2008. These represented 0.4% of all submitted specimens during this period. The male to female ratio was 1.05:1; 9.3% of these specimens were reported as malignant peripheral nerve sheath tumors. Fifteen of sixteen NF1 patients referred to the institution for surgical interven-tion over a seven year period underwent an average 1.7 interventions. Most presented late, some with malignancies (27%), making it difficult to obtain good cosmetic and functional results. Three representative case presentations are reported from these patients to show that (i) NF1 complications affects any system, cannot be predicted, making prognosis uncertain, (ii) cervical spine instability, excessive intra-operative bleeding and post-operative edema are important peri-operative considerations, essential role of access to safe blood for transfusion and an intensive care service. Conclusions: Surgical symptom control (cosmesis, function, and pain) rather than surgical cure is the primary, achievable goal of most interven-tions in patients with NF1. Lifelong surveillance is necessary for all NF1 patients to avert or minimize complications, and thus improve surgical outcomes.

The development of a safety culture is challenging, primarily because it often disrupts institutional attitudes, norms and values. In the healthcare industry, most of the data on the results of unsafe care come from High-Income Countries. The Hospital Survey on Patient Safety Culture (HSOPS) is a tool for assessing, building, sustaining and comparing institutional safety cultures within healthcare organizations. We used the HSOPS over a 7-year period, and herein report our experience. The authors report their experience using the HSOPS tool in Kijabe Hospital, an institution with 650 employees, over a 7-year period. The HSOPS tool, with no local modifications, was distributed to all employees during each survey. The institutional HSOPS percent positive dimension scores for 2015, 2017 and 2019 were compared with baseline data from the 2013 survey. The average response rate during the study period was 84.5% (range 65.1% to 93.6%). In general, the mean percentage positive dimension scores of most domains improved in the 2019 survey (p<0.05), including reduced staff turnover and, improved hospital support for patient safety (p<0.0001), amongst other domains. The overall patient safety grade (excellent/very good), was 50% (range 43-64%). Although the dynamics of high staff turnover and hospital leadership change presented challenges in developing and measuring institutional patient safety culture, this study demonstrates that patient safety ideals can be developed and embraced in sub-Saharan Africa. Patient safety champions, a generative institutional leadership that is supportive of patient safety, are important for the development of an institutional safety culture. Creating an institutional just culture creates a patient safety culture., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Nthumba et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Modern science has conquered seas, land, and space. Although great strides have been made in technology and infectious diseases, global surgery, which was reborn in 2015, has not made much progress. The burden of surgical disease in low- and middle-income countries remains seemingly unconquerable, and its growth unstoppable. The myriad challenges in meeting the surgical needs of 5 billion people has intrigued the author., Methods: The author collected the views of plastic surgeons on sources and impediments to the scale-up of plastic surgery in low- and middle-income countries, as well as potential strategies for overcoming these obstacles. The author then performed a literature search reviewing the topics that arose from those discussions. The author proposes a strategy using plastic surgery as a model surgical discipline., Results: A root-cause analysis suggests that the Alma Ata Declaration, with its focus on primary healthcare, is the probable genesis of global surgery (GS) woes. The absence of a clear GS community leader and the fragmented nature of GS advocates who operate in multiple silos, without a clear unified goal, are the primary reasons GS advocates have achieved so little on the ground., Conclusions: Global surgery requires a business model to sustainably meet the surgical needs of the 5 billion people globally. The proposed and implemented strategies must meet rigorous criteria to ensure sustainability, as quick-fix solutions are counterproductive. The development of centers of excellence offers a viable solution to problems that must be addressed successfully., Competing Interests: The author is actively developing CIEPS, as a proof-of-concept model for plastic surgery training and collaboration in Kenya and the larger sub-Saharan Africa region. The author received the American Society of Plastic Surgeons Noordhoff Humanitarian Award for 2023. This article is a product of the author’s presentation at the meeting. The author has no financial interest to declare in relation to the content of this article., (Copyright © 2024 The Author. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Surgery in low- and middle-income countries (LMICs) is poorly developed because of years of neglect. Sustained research on global surgery led to its recognition as an indivisible and indispensable part of primary healthcare in 2015. However, this has had little visible effect on surgical ecosystems within LMICs, especially in sub-Saharan Africa (SSA). SSA surgical research systems strengthening, which includes skills transfer, with local priority setting driving the research agenda, is needed to propel global surgery into the future., Methods: The authors performed a literature review of the state of surgical research within SSA and also report the initial efforts of two research training nonprofits to empower young African surgeons with research skills., Results: Surgical research in SSA is disadvantaged even before it is birthed, facing monumental challenges at every stage of development, from research agenda determination to funding, study execution, and publication. Compared with a global output of 17.49 publications per 100,000 population, SSA produces 0.9 ( P < 0.0001). The Surgeons in Humanitarian Alliance for Reconstructive, Research, and Education and Enabling Africa Clinical Health Research programs are involved in the longitudinal research mentorship of surgical residents within SSA; the improved quality of research and successful publications by participants suggest nascent steps in growing young surgical scientists., Conclusions: In the absence of an existing surgical research infrastructure within LMICs, global surgery research trainers should link up and collaborate to help develop a surgical research community that will provide the local data required to help transform the SSA surgical ecosystem., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Competing Interests: The authors have no financial interest to declare in relation to the content of this article.

Background: Glomus tumors are rare benign tumors that were first described in 1812 by Wood. They arise from normal glomus apparatus, usually located in the reticular dermis of the body. Although glomus tumors are universal in occurrence, the sub-Saharan Africa experience has not been well documented., Methods: The authors performed a systematic literature review of eligible studies between 1960 and August 2023, using the terms "glomus," "tumor," "glomangioma," "glomangiomyoma," and "Africa." We also performed a search of the AIC Kijabe Hospital pathology department database of about 140,000 records, covering 30 years, for the terms "glomus tumor," "glomangioma" and "glomangiomyoma.", Results: The systematic literature search and institutional database search produced a total of 74 patients who had glomus tumors. These patients had a lag of between 3 months and 20 years from symptom development to definitive treatment., Conclusions: There are very few reports of glomus tumors from sub-Saharan Africa in the current literature: the authors' histopathology database of 140,000 specimens had 46 glomus tumors (0.03%), and only 28 additional patients were found in literature from sub-Saharan Africa. The low numbers of African patients may indicate racial differences in the occurrence of glomus tumors, although this may also be due to failure of clinicians to recognize glomus tumors. The prolonged lag period between symptom development and definitive treatment for glomus tumors indicates the need for diligence in the diagnosis and treatment of a simple problem that is otherwise the cause of incapacitating pain and misery., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

The use of the wide-awake local anesthesia no tourniquet, a tumescent local anesthetic technique in recent years, emerged as a powerful tool primarily in hand surgery. It has been adopted in many low- and middle-income countries where it was applied to an increasingly broad group of procedures. We report the case of an older patient with an arm liposarcoma for which surgery under general or regional anesthesia was deemed unsafe, but was successfully managed with a curative right shoulder disarticulation using tumescent local anesthesia., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: The need to address inequities in global surgical care has garnered increased attention since 2015, after the Lancet Commission on Global Surgery underscored the importance of ensuring safe, accessible, affordable, and timely surgical and anesthetic care. The vast unmet global plastic surgery needs make plastic surgery care essential in reducing the global burden of disease. In the past, many nonprofit organizations undertook humanitarian activities within low- and middle-income countries that were primarily service-provision oriented. The Lancet Commission on Global Surgery report prompted a shift in focus from direct patient care models to sustainable global surgical models. The realization that 33% of deaths worldwide were due to unmet surgical needs led to a global shift of strategy toward the development of local systems, surgical capacity, and a focus on patient safety and quality of care within international global surgery partnerships., Methods: In this report, the authors explore some of the primary components of sustainable international global surgical partnerships discussed in a recent panel at the American Society of Plastic Surgeons Plastic Surgery The Meeting 2022, titled "Safety and Sustainability Overseas: Optimizing Outcomes and Changing Paradigms in Global Health Endeavors." A literature review elaborating the topics discussed was performed., Results: This report focuses on cultural competence and humility, international collaboration, and the use of technology and innovation, all of which are needed to promote sustainability and patient safety, within global surgery efforts., Conclusions: The adoption of these components into international surgical collaborations will lead to greatly enhancing the development and sustainability of mutually beneficial relationships., Competing Interests: The authors have no financial interest to declare in relation to the content of this article., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Academic global surgery is a rapidly growing field that aims to improve access to safe surgical care worldwide. However, no universally accepted competencies exist to inform this developing field. A consensus-based approach, with input from a diverse group of experts, is needed to identify essential competencies that will lead to standardization in this field. A task force was set up using snowball sampling to recruit a broad group of content and context experts in global surgical and perioperative care. A draft set of competencies was revised through the modified Delphi process with two rounds of anonymous input. A threshold of 80% consensus was used to determine whether a competency or sub-competency learning objective was relevant to the skillset needed within academic global surgery and perioperative care. A diverse task force recruited experts from 22 countries to participate in both rounds of the Delphi process. Of the n = 59 respondents completing both rounds of iterative polling, 63% were from low- or middle-income countries. After two rounds of anonymous feedback, participants reached consensus on nine core competencies and 31 sub-competency objectives. The greatest consensus pertained to competency in ethics and professionalism in global surgery (100%) with emphasis on justice, equity, and decolonization across multiple competencies. This Delphi process, with input from experts worldwide, identified nine competencies which can be used to develop standardized academic global surgery and perioperative care curricula worldwide. Further work needs to be done to validate these competencies and establish assessments to ensure that they are taught effectively., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Pawlak et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Intraoperative peritoneal lavage (IOPL) with saline has been widely used in surgical practice. However, the effectiveness of IOPL with saline in patients with intra-abdominal infections (IAIs) remains controversial. This study aims to systematically review randomized controlled trials (RCTs) evaluating the effectiveness of IOPL in patients with IAIs., Methods: The databases of PubMed, Embase, Web of Science, Cochrane library, CNKI, WanFang, and CBM databases were searched from inception to December 31, 2022. Random-effects models were used to calculate the risk ratio (RR), mean difference, and standardized mean difference. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to rate the quality of the evidence., Results: Ten RCTs with 1318 participants were included, of which eight studies on appendicitis and two studies on peritonitis. Moderate-quality evidence showed that the use of IOPL with saline was not associated with a reduced risk of mortality (0% vs. 1.1%; RR, 0.31 [95% CI, 0.02-6.39]), intra-abdominal abscess (12.3% vs. 11.8%; RR, 1.02 [95% CI, 0.70-1.48]; I 2  = 24%), incisional surgical site infections (3.3% vs. 3.8%; RR, 0.72 [95% CI, 0.18-2.86]; I 2  = 50%), postoperative complication (11.0% vs. 13.2%; RR, 0.74 [95% CI, 0.39-1.41]; I 2  = 64%), reoperation (2.9% vs. 1.7%; RR,1.71 [95% CI, 0.74-3.93]; I 2  = 0%) and readmission (5.2% vs. 6.6%; RR, 0.95 [95% CI, 0.48-1.87]; I 2  = 7%) in patients with appendicitis when compared to non-IOPL. Low-quality evidence showed that the use of IOPL with saline was not associated with a reduced risk of mortality (22.7% vs. 23.3%; RR, 0.97 [95% CI, 0.45-2.09], I 2  = 0%) and intra-abdominal abscess (5.1% vs. 5.0%; RR, 1.05 [95% CI, 0.16-6.98], I 2  = 0%) in patients with peritonitis when compared to non-IOPL., Conclusion: IOPL with saline use in patients with appendicitis was not associated with significantly decreased risk of mortality, intra-abdominal abscess, incisional surgical site infection, postoperative complication, reoperation, and readmission compared with non-IOPL. These findings do not support the routine use of IOPL with saline in patients with appendicitis. The benefits of IOPL for IAI caused by other types of abdominal infections need to be investigated., (© 2023. The Author(s).)

Background: To establish the role of surgical antibiotic prophylaxis (SAP) in the prevention of surgical site infection (SSI) in children undergoing surgery. Design: A systematic review and meta-analysis of six databases: MEDLINE (PubMed), EMBASE, CINAHL Plus, Cochrane Library, Web of Science, and Scopus. Study Selection: Included studies (irrespective of design) compared outcomes in children undergoing surgery, aged 0 to 21 years who received SAP with those who did not, with SSI as an outcome, using the U.S. Centers for Disease Control and Prevention (CDC) definitions for SSI. Data Extraction: Two independent reviewers applied eligibility criteria, assessed the risk of bias, and extracted data. Results: A total of six randomized control trials and 26 observational studies including 202,593 surgical procedures among 202,405 participants were included in the review. The pooled odds ratio of SSI was 1.20; (95% confidence interval [CI], 0.91-1.58) comparing those receiving SAP with those not receiving SAP, with moderate heterogeneity in effect size between studies (τ 2  = 0.246; χ 2  = 69.75; p < 0.001; I 2  = 57.0%). There was insufficient data on many factors known to be associated with SSI, such as cost, length of stay, re-admission, and re-operation; it was therefore not possible to perform subanalyses on these. Conclusions: This review and metanalysis did not find a preventive action of SAP against SSI, and our results suggest that SAP should not be used in surgical wound class (SWC) I procedures in children. However, considering the poor quality of included studies, the principal message of this study is in highlighting the absence of quality data to drive evidence-based decision-making in SSI prevention in children, and in advocating for more research in this field.

Competing Interests: The authors report no conflicts of interest.

Background: The burden of healthcare-associated infections (HAIs) is greatest in low- and middle-income countries (LMICs); surgical site infections (SSIs) are the most common HAI in LMICs. Hand hygiene is the single most effective strategy for reducing HAIs and the transmission of antimicrobial drug-resistant pathogens. Similarly, effective surgical hand preparation is a critical step in the prevention of SSIs in the surgical patient. Methods: Surgical hand preparation (SHP) is a seemingly simple activity that is easily overlooked. Performed properly, however, along with other measures, it has the potential to reduce SSIs in LMICs. The article reviews the current state of surgical hand preparation in LMICs. Results: Alcohol-based handrubs (ABHRs) have received wide acceptance by healthcare workers for both hand hygiene and SHP; when mixed with emollients, ABHRs retain efficacy against microorganisms and gain skin tolerability and user acceptability. Healthcare institutions in many LMICs face difficulties obtaining the products needed to ensure effective SHP using ABHRs. Conclusion: The ABHRs are the most efficacious surgical hand preparation products available today. They are cost-effective and can safely be prepared locally in hospitals, even in LMICs. The challenge of access to ABHRs should be addressed by national and local governments, through advocacy by healthcare workers coupled with continued lobbying and campaigns by the World Health Organization. Effective surgical hand preparation, like hand hygiene, saves lives.

Hemostasis, wound closure and prevention of infection are critical to wound healing after an injury. Skin adhesives have been used to seal incisions, thus aiding primary wound healing, as well as creating a barrier to microbes. We constructed a skin adhesive with antibacterial and hemostatic activities (AHAs) for wound management. The adhesive was made by using methacrylated hyaluronan-polyacrylamide (MHA-PAAm) hydrogels, integrated with silver nanoparticles (AgNPs) and bonded to gelatin. Because of the three-dimensional network structure of the hydrogels, nanoscale particles can be encapsulated into their voids; the AgNPs, through sustained delivery of silver ions, endow the adhesives with sustained broad-spectrum antibacterial activity. Furthermore, due to the introduction of MHA which can be crosslinked by visible light, the polyacrylamide hydrogel matrix can be formed through photo crosslinking. In addition, gelatin can be bonded to both the hydrogel matrix and host tissues because of the interaction between carboxyl and amino-moieties. Our animal studies demonstrated that the AHAs which possess tissue adhesive and antibacterial properties were easy to stretch, and were able to stop bleeding in rat tail amputation and liver injury models. AHAs enhance wound granulation tissue formation, vascular tissue formation, and collagen formation, as well as alleviate inflammation. These properties promoted wound closure in rat wound infection models, promising great potential for applying AHAs in clinical uses.

Introduction: Global surgery is increasingly recognized as a vital component of international public health. Access to basic surgical care is limited in much of the world, resulting in a global burden of treatable disease. To address the lack of surgical workforce in underserved environments and to foster ongoing interest in global health among US-trained surgeons, our institution established a residency rotation through partnership with an academic hospital in Kijabe, Kenya. This study evaluates the perceptions of residents involved in the rotation, as well as its impact on their future involvement in global health., Materials and Methods: A retrospective review of admission applications from residents matriculating at our institution was conducted to determine stated interest in global surgery. These were compared to post-rotation evaluations and follow-up surveys to assess interest in global surgery and the effects of the rotation on the practices of the participants., Results: A total of 78 residents matriculated from 2006 to 2016. Seventeen participated in the rotation with 76% of these reporting high satisfaction with the rotation. Sixty-five percent had no prior experience providing health care in an international setting. Post-rotation surveys revealed an increase in global surgery interest among participants. Long-term interest was demonstrated in 33% (n = 6) who reported ongoing activity in global health in their current practices. Participation in global rotations was also associated with increased interest in domestically underserved populations and affected economic and cost decisions within graduates' practices.

Objective: Burns are important preventable causes of morbidity and mortality, with a disproportionate incidence in sub-Saharan Africa. The management of these injuries in sub-Saharan Africa is a challenge because of multiple other competing problems such as infectious diseases (HIV/AIDS, tuberculosis and malaria), terrorist acts and political instability. There is little investment in preventive measures, pre-hospital, in-hospital and post-discharge care of burns, resulting in high numbers of burns, high morbidity and mortality. Lack of data that can be used in legislation and policy formulation is a major hindrance in highlighting the problem of burns in this sub-region., Methods: An online search of publications on burns from sub-Saharan countries was performed., Results: A total of 54 publications with 32,862 patients from 14 countries qualified for inclusion in the study. The average age was 15.3 years. Children aged 10 years and below represented over 80% of the burn patient population. Males constituted 55% of those who suffered burns. Scalds were the commonest cause of thermal injuries, accounting for 59% of all burns, while flame burns accounted for 33%. The burn mortality averaged 17%, or the death of one of every five burn victims., Conclusions: These statistics indicate the need for an urgent review of burn policies and related legislation across the sub-Saharan region to help reduce burns, and provide a safe environment for children., (Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.)

Background: Glomus tumors of the hand are rare, benign but debilitating neoplasms arising from the neuromyoarterial glomus body. They may present a diagnostic dilemma, and take years with multiple consultations and investigations before an appropriate diagnosis is made, but once a diagnosis is made, surgical excision is curative., Case Presentation: This is a case presentation of a 35-year-old African man who presented with complex regional pain syndrome of his left upper extremity, whose genesis was found to be a glomus tumor of the pulp of his left middle finger. Surgical excision resulted in resolution of the chronic regional pain syndrome and a return to a normal lifestyle. Chronic regional pain syndrome is a rare presentation of a glomus tumor, which has only been previously reported in patients with neurofibromatosis type 1, and one patient who did not have neurofibromatosis., Conclusions: Patients with glomus tumors may spend many years in pain and distress because of misdiagnosis. Sensitization and education of both the public and health care workers will help in early diagnosis and treatment of this otherwise potentially disabling pathology for which surgical excision is curative.

Introduction. Palliative care in Kenya and the larger Sub-Saharan Africa is considered a preserve of hospices, where these exist. Surgical training does not arm the surgeon with the skills needed to deal with the care of palliative patients. Resource constraints demand that the surgeon be multidiscipline trained so as to be able to adequately address the needs of a growing population of patients that could benefit from surgical palliation. Patients and Methods. The author describes his experience in the management of a series of 31 palliative care patients, aged 8 to 82 years. There were a total of nine known or presumed mortalities in the first year following surgery; 17 patients experienced an improved quality of life for at least 6 months after surgery. Fourteen of these were disease-free at 6 months. Conclusion. Palliative reconstructive surgery is indicated in a select number of patients. Although cure is not the primary intent of palliative surgery, the potential benefits of an improved quality of life and the possibility of cure should encourage a more proactive role for the surgeon. The need for palliative care can be expected to increase significantly in Africa, with the estimated fourfold increase of cancer patients over the next 50 years.

Penetrating tracheal injuries are rare. Even rarer is the finding of intrabronchial foreign bodies caused by penetrating objects. We report a patient who experienced a gunshot injury to the trachea and mandible. The tracheal wound was debrided and used as a tracheostomy; a spent bullet in the bronchial tree was missed on initial evaluation but later successfully retrieved bronchoscopically. Spent bullet aspiration is a very rare occurrence. A careful examination of radiographs is essential to aid with the diagnosis. Flexible bronchoscopy is the best means of bullet retrieval. Management of any associated injuries is made easier after the airway is secured.

Introduction: In order to implement effective burn prevention strategies, the WHO has called for improved data collection to better characterize burn injuries in low and middle income countries (LMIC). This study was designed to gather information on burn injury in Kenya and to test a model for such data collection., Methods: The study was designed as a retrospective case series study utilizing an electronic data collection tool to assess the scope of burn injuries requiring operation at Kijabe Hospital from January 2006 to May 2010. Data were entered into a web-based tool to test its utility as the potential Kenya Burn Repository (KBR)., Results: 174 patients were included. The median age was 10 years. There was a male predominance (59% vs. 41%). Findings included that timing of presentation was associated with burn etiology (p=0.009). Length of stay (LOS) was associated with burn etiology (p<0.001). Etiology differed depending on the age group, with scald being most prominent in children (p=0.002)., Conclusions: Burn injuries in Kenya show similarities with other LMIC in etiology and pediatric predominance. Late presentation for care and prolonged LOS are areas for further investigation. The web-based database is an effective tool for data collection and international collaboration., (Copyright © 2012 Elsevier Ltd and ISBI. All rights reserved.)

The gold standard for mandibular defect reconstruction is the fibular free flap. Nevertheless, the pedicled osteomuscular dorsal scapular flap as a reconstructive tool offers promise for mandibular defect reconstruction and could be the first choice in certain circumstances. Its use in resource-limited settings offers an excellent solution to otherwise difficult reconstructive problems of the mandible. In 8 patients, mandibular defects resulting from the excision of benign tumors (6), trauma (1), and chronic osteomyelitis (1) were reconstructed using the pedicled osteomuscular dorsal scapular flap; these defects included the central segment of the mandible. The pedicled osteomuscular dorsal scapular flap is an excellent choice for mandibular reconstruction; it may serve as the primary choice in patients with vascular pathology that precludes free tissue transfer, as well as in resource-limited environments, as a secondary choice after a failed free flap reconstruction.

Background: In the head and neck region, osteosarcoma is the most common primary malignant bone tumor, representing 23% of total head and neck malignancies. Osteosarcomas of the jaws are nevertheless rare lesions, representing only 2 to 10% of all osteosarcomas. This report reviews a single-center histopathology experience with craniofacial osteosarcomas, and reports the management of unusually large synchronous mandibular and maxillary osteosarcomas in a patient., Patients and Methods: A search of the hospital pathology database for specimens with a histological diagnosis of osteosarcomas submitted between July 1992 and May 2011 was made. A chart review of a patient with large synchronous maxillary and mandibular osteosarcomas was performed, and is reported., Case Presentation: A 21-year-old African man with large maxillary and mandibular tumors under palliative care presented with increasing difficulties with eating, speech, and breathing. Surgical debulking was performed, with histology confirming synchronous osteosarcomas of the mandible and maxilla. The patient is well after one year, with no evidence of recurrence, having undergone no further treatment., Conclusion: Osteosarcomas of the jaw remain enigmatic, and a number of difficulties related to their diagnosis and treatment are yet to be resolved. True synchronous multicentric osteosarcomas of the jaws are extremely rare but, like other osteosarcomas of the jaws, have a favorable outcome, and palliative resection of such lesions, though challenging, can therefore lead to an enormously improved quality of life and self-image, and may even offer the opportunity for cure.

Purpose: The supraclavicular skin is thin and pliable; it closely resembles that of the neck and facial skin, making it the perfect source of tissue for neck and orofacial reconstructions. The author sought to provide a concise compilation of the use of the supraclavicular artery flap, including surgical landmarks, modifications, uses, common complications, and anomalies, and experience with the use of the flap in a sub-Saharan African country., Materials and Methods: A literature search was performed on the Internet and PubMed for anatomic and clinical studies/reports in the English language on the supraclavicular artery flap with a minimum of 10 subjects and sufficient data on postoperative complications., Results: Five anatomic studies (2 of which included clinical cases) and 12 clinical series qualified for inclusion. These articles included 146 flaps from 73 cadaveric studies and 376 supraclavicular flaps in patients (including a series of 22 flaps by the present author). The supraclavicular artery was present in 99% of anatomic dissections and was a branch of the transverse cervical artery in 91% of anatomic dissections. Safe margins for elevation of the supraclavicular artery flap were delimited anteriorly by the clavicle, posteriorly by the superior border of the trapezius, and distally by the insertion of the deltoid muscle. Common flap complications included tip and partial flap necroses. The flap was used successfully in nononcologic and oncologic reconstructions, even with concurrent neck dissection., Conclusions: The pedicled supraclavicular fasciocutaneous flap is emerging as a versatile reconstructive tool for the neck and orofacial regions. It is an excellent option, especially in resource-poor environments and in patients in whom free flaps may be technically difficult. Anatomic and clinical studies have shown it to be consistently reliable, with excellent color matching for the face and neck regions, and have established reliable surgical landmarks, modifications, uses, common complications, and anomalies., (Copyright © 2012 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of the current study was to determine the incidence of pediatric surgical site infections(SSIs) at an academic children’s hospital in rural sub-Saharan Africa and to identify potentially modifiable risk factors., Methods: Prospectively collected data from 1,008 surgical admissions to Bethany Kids Kijabe Hospital (Kijabe, Kenya) were analyzed retrospectively. Follow-up data were available in 940 subjects., Results: SSIs occurred in 6.8% of included subjects(N = 64). Superficial (69%) and deep (29%) infections of the back (38%) and head (25%) were most common. When comparing children who developed SSI to those who did not, we found that wound contamination classification and duration of operation were the only variables with significant differences between groups., Conclusions: Our rate of SSI among pediatric patients insub-Saharan Africa is the lowest reported in the literature to date. More work is needed to identify modifiable risk factors for pediatric SSI in low- and middle-income countries.

Introduction: Ameloblastomas are rare lesions constituting 1% of all jaw tumors. Oral squamous cell carcinomas are common lesions; these constitute about 90% of all oral cancers. Concurrent tumors consisting of ameloblastoma and squamous cell carcinoma are extremely rare., Case Presentation: This case report describes a 35-year-old African man who presented with a large mandibular tumor with an orocutaneous fistula that was found to be an ameloblastoma on histopathological examination, with concurrent squamous cell carcinoma histology within the fistula. This presentation was consistent with a Marjolin's ulcer within an ameloblastoma., Conclusion: Ameloblastomas and Marjolin's ulcers require different management strategies. Careful histopathological examination of surgical specimens is key to patient outcome, as treatment of these patients depends on an accurate diagnosis.

Introduction: Giant condyloma acuminatum, also called a Buschke-Löwenstein tumor, first described in 1925, is a slow-growing, locally aggressive, destructive tumor of the ano-genital region. Scrotal tumors are rare. Reports on giant condyloma acuminatum lesions in patients with HIV and AIDS are surprisingly even rarer., Case Presentation: In this report, we present the case of a 42-year-old African man with AIDS who was undergoing anti-retroviral therapy. He was found to have a giant condyloma acuminatum of the scrotum. Wide surgical excision and scrotal reconstruction with a pedicled anterolateral thigh flap was performed, significantly improving his quality of life., Conclusion: Decision making regarding the goals of surgical intervention in the terminally ill is a complex process. The options include conservative medical palliation or palliative excision versus a curative excision that has the potential for significant morbidity. Wide surgical excision with local flap reconstruction significantly improved the quality of life of the patient described herein. The challenges presented by emerging or unusual presentations of surgical pathology secondary to HIV and AIDS in patients who are on anti-retroviral therapy provide an opportunity for research and the establishment of guidelines for the use of adjuvant chemotherapy in these patients.

Cutaneous malignancies are the most common malignancies in Whites; traditionally considered rare among Blacks, their occurrence in sub-Saharan Africa is yet to be fully characterized.Data on specimens submitted between 1992 and April 2008 on all histologically proven primary cutaneous malignancies were collected from the Pathology Department, including patient age, sex, anatomic site of malignancy, and histologic diagnosis. There were 1900 patients with primary cutaneous malignancies, aged between 8 months and 110 years, with a mean age of 49 years. There were 14 different types of malignancies found, with squamous cell carcinoma representing 45% of the total. A number of the rarer types have not been reported previously, from this region.Cutaneous malignancies in Africa present a number of management challenges including the following: difficulties in early diagnosis in the dark skin, late presentation, access to treatment, and the ability to pay for the appropriate treatment. The current human immunodeficiency virus/acquired immune deficiency syndrome scourge on the continent may lead a significant increase in cutaneous malignancies, posing even bigger challenges.

Introduction. Malignant peripheral nerve sheath tumors (MPNSTs) are rare, aggressive soft tissue sarcomas associated with poor prognosis, that most commonly affect patients aged 20 to 50 years, but have also been reported in children. There is little reported in literature on these tumors in Africa. Materials and Methods. A search of the hospital pathology database between 1992 and 2008 revealed 333 nerve sheath tumors, of which 31 were MPNSTs. Four representative case reports are presented. Discussion. MNPSTs have rarely been reported from sub-Saharan Africa; in this study, they constituted 9.3% of all nerve sheath tumors. The trunk (42%) and limbs (45%) were the most frequently affected anatomical sites. Late presentation of malignant lesions in this environment is exemplified by the four case presentations patients. Conclusions. This report confirms observations from studies on MPNSTs from other environments. Anatomically centrally located MPNSTs may have a higher incidence in sub-Saharan Africa than in the West. Because NF1-associated MPNSTs are difficult to diagnose clinically, and because surgery is the only mode of therapy that offers a complete cure, a lifetime follow-up is important, as this would enable diagnosis of early lesions amenable to surgical extirpation.

Background: Due to improved care, more and more children born with spina bifida in rural Kenya are surviving into adulthood. This improved survival has led to significant challenges in their lifestyles, especially the need to ensure pressure ulcer prevention and treatment. Malignant degeneration of pressure ulcers in spina bifida patients is very rare. The author describes the clinical presentation of two pressure ulcer carcinomas that are at variance from classical descriptions., Materials and Methods: An internet/Medline/PubMed search of English literature for theories on Marjolin's ulcer evolution and prognostic features of Marjolin's ulcers was performed.A chart review of two young adults with spina bifida who had presented to the author's hospital between 2004 and August 2010 with chronic pressure ulcers found to be Marjolin's ulcers on histo-pathological examination was performed, and the clinical features are reported., Results: The two ulcers appeared clinically benign: one was a deep ulcer, while the other was shallow; both had normal, benign-appearing edges, and a foul smelling discharge. The two ulcers were surrounded by induration and multiple communicating sinuses, with no evidence of chronic osteomyelitis. The internet search revealed a total of nine theories on Marjolin's ulcer development, as well as seven clinical and four histological prognostic features., Discussion: The multifactorial theory, a coalescence of a number of proposed theories, best explains the evolution of Marjolin's ulcers. Poor prognostic features include pressure ulcer carcinomas, lesions and location in the lower limbs/trunks, all present in the two patients making their prognosis dim: this is despite the surgical margins being clear of tumor. Benign appearance, induration and presence of multiple communicating sinuses are features that have not been previously described as presenting features of pressure ulcers carcinomas., Conclusion: There is need for spina bifida patients and their guardians/caretakers to receive a close follow-up throughout life; health education focused on pressure ulcer prevention as well as early treatment of pressure ulcers when they occur, will avert the development of Marjolin's ulcers, and save lives.

Background: The aim of this cluster-randomized, crossover trial was to compare the efficacy of plain soap and water with an alcohol-based handrub for surgical hand preparation and prevention of surgical-site infection (SSI) in a Kenyan rural hospital., Methods: A total of 3317 patients undergoing clean and clean-contaminated surgery were included. Follow-up data 30 days after discharge were available for 3133 patients (94.5 per cent)., Results: SSI occurred in 255 patients (8.1 per cent), with similar rates for both study arms: 8.3 per cent for alcohol-based handrub versus 8.0 per cent for plain soap and water (odds ratio 1.03, 95 per cent confidence interval 0.80 to 1.33). After adjustment for imbalances between study arms and clustering effects, the main outcome measure remained unchanged (adjusted odds ratio 1.06, 0.81 to 1.38). The duration of surgery and wound contamination class independently predicted SSI. The cost difference between the methods was small (€4.60 per week for alcohol-based handrub compared with €3.30 for soap and water)., Conclusion: There was no statistically or clinically significant difference in SSI rates, probably because more important factors contribute to SSI development. However, this study demonstrated the feasibility and affordability of alcohol-based handrubs for hand preparation before surgery in settings without continuous, clean water., Registration Number: NCT00987402 (http://www.clinicaltrials.gov)., (Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background: Cutaneous malignancies are considered rare among Africans. Trauma, its sequelae, and other chronic non-healing wounds are known to predispose to malignant degeneration. Not much is known of the demographics of Marjolin's ulcers in sub-Saharan Africa., Methods: Pathology records on patients suspected to have Marjolin's ulcers submitted to the Pathology Department were extracted from a database of 75,124 specimens. A review of the English literature on Marjolin's ulcers from Nigeria, a sub-Saharan country, was also performed., Results: Of 210 specimens from suspected Marjolin's ulcers, 167 records had a histological diagnosis of malignancy, with a male to female ratio of 1:1.4, and a mean age of 48 years (range: 4-97 years). There were 163 (97.6%) squamous cell carcinomas, 3 (1.8%) sarcomas, and 1 (0.6%) malignant melanoma. Burn scars, chronic ulcers, osteomyelitis, and "other" ulcers constituted 82 (49%), 70 (42%), 9 (5.4%), and 6 (3.6%), respectively. Subjects in six sub-Saharan Marjolin's ulcer studies had a mean age between 36 and 42 years, with a mean latent period 16 years., Conclusions: Marjolin's ulcers in sub-Saharan African have a shorter latent period, and they occur in younger patients. Provision of early stable wound cover is essential for prevention of malignant degeneration of scars, while early appropriate intervention is crucial in the treatment of chronic ulcers.

Background: Most reconstructive surgery in Sub-Saharan Africa is provided by numerous noncoordinated individuals and organizations, in multiple short trips, or "surgical blitzes." Because many such groups do not train local surgeons, these communities have become dependent on unsustainable systems. By providing much-needed care to otherwise neglected areas, the blitzes offer an easy solution to what would otherwise be the source of a significant headache to local governments., Methods: The collection of data and other material in this highly ambiguous and fluid field is nearly impossible, as scientific papers on the results of poor surgical treatment, especially in the realm of humanitarian medicine, do not exist: The author has had to rely on personal experience and community interaction to reach the views and conclusions articulated in this article., Results: Although not the rule, blitz surgeries have poorer outcomes than in-hospital procedures, primarily because of inadequate preoperative and postoperative care., Conclusions: Although the value of blitz surgery in meeting some of the surgical needs of otherwise neglected communities is undeniable, the author seeks to provoke a sober reexamination of these efforts vis-à-vis the long-term sustainability of such programs, with the objective of harnessing strengths that would see the evolution of a new reconstructive surgical service tailor-made for Africa--affordable and sustainable yet able to deliver quality surgical care to the remotest villages. Otherwise, these humanitarian efforts' will continue to be 'drops in the ocean, meeting the needs of a few in the community but resulting in no long-term gains.

Introduction: Pyogenic granuloma or lobular capillary hemangioma remains an etiopathological enigma, with trauma, inflammatory and infectious agents being the commonest suspected causative agents. These lesions affect mucous membranes of the upper aero-digestive tract, and skin. HIV patients diagnosed with pyogenic granuloma present with multiple lesions, caused by Bartonella spp., Case Presentation: A 28-year-old woman presented with a solitary large tumor on a skin graft donor site on her left thigh. On excision and histological examination the tumor was found to be a lobular capillary hemangioma (pyogenic granuloma). Further investigation in search of a possible explanation for this unusual presentation revealed HIV infection as the underlying cause., Conclusion: This report underscores the fact that the full spectrum of presentation of HIV infection is still unknown. Unusual or unexpected presentations should arouse suspicion of underlying immunosuppression, especially in HIV endemic areas.

Introduction: A cutaneous horn is a conical projection of hyperkeratotic epidermis. Though grossly resembling an animal horn, it lacks a bony core. These lesions have been well described in Caucasian patients, as well as in a number of Arabic and Asian patients., Case Presentation: A young female presented with a large 'horn' of five-year duration, arising from a burn scar. Excision and scalp reconstruction were performed. Histology was reported as verrucoid epidermal hyperplasia with cutaneous horn., Conclusion: This may be the first documentation of this lesion in a black African. Although likely rare, it should be considered in the differential diagnosis of dermatologic lesions. Up to 40% of cutaneous horns occur as part of a premalignant or malignant lesion, and surgical extirpation with histological examination is thus more important than the curiosity surrounding these lesions.