EUROPEAN TISSUE REPAIR SOCIETY
NEWS FROM ZIMBABWE |
EUROPEAN TISSUE REPAIR SOCIETY NEWS FROM ZIMBABWE |
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WOUND HEALING
IN ZIMBABWE – SURGICAL
ASPECTS The third world countries in Africa often share the same medical problems, some are old some are new. Burns related to cooking on open fires are one of the old health hazards especially to children. The HIV infection is a new health hazard with an enormous impact on society and healthcare facilities. Zimbabwe is at present one of the worst affected countries by the HIV pandemic. It is estimated that one quarter of the grown up, sexually active population is HIV infected. Burns and wounds in HIV patients account for a large part of the workload for a General Surgeon even in tertiary care institutions. Basically, only severe burns are admitted to surgical wards and to the burn units. Children under the age of six years account for almost half of all admissions. The mortality in this group is about 12%1. In the adult population young women with self-inflicted burns have the highest mortality (73%)1. The reasons for these self-inflicted burns are often problems in marriage or love relationships experienced by young women married according to customary law2. These self-inflicted burns seem to be a rather local phenomenon, confined to the catchment area of the burns unit in Harare. The optimum treatment for many of these deep dermal burn wounds would be primary excision and skin grafting, but only 3% of our surgically treated burns were handled in this way the rest (26%) had delayed split skin grafting and 71% had non surgical treatment. Delayed split skin grafting prolonged hospital stay from 17 to 42 days compared to primary excision and grafting of burns with equal size and severity. In wounds undergoing split skin grafting, early excision and grafting would have been preferred but lack of theatre time, trained surgeons and blood products are limiting factors for this procedure. The cost and workload incurred by the burns is demonstrated by the fact that one third of all operations performed by general surgeons, in government tertiary care units in Harare, were skin grafting due to burns. This was found in a survey both in 1993 and 1998. This high number of burns in need of surgical intervention is related to the fact that 85% of the population are cooking their meals on open fires. (Census 1994) The three major causes for burns are:
thus many of these are preventable. The other large group of wounds causing suffering, increased cost and prolonged hospital stay is related to HIV infection. The impact of the HIV epidemic is demonstrated by the fact that burns patients with comparable size burns who were HIV positive stayed thirty-seven days in hospital compared to twenty-one days in the HIV negative group (p<0.001). (Mzezewa et al) The impact of the HIV pandemic for the General Surgeon in a country with a very high prevalence of HIV infection is recognised by an increased number of septic wounds also after clean surgical procedures. Prophylactic antibiotics to HIV positive patients undergoing clean surgical procedures should be considered even if this is not recommended in patients who are HIV negative. Orthopaedic implants (e.g., internal fixation for fractures) should if possible be avoided in HIV positive patients if a possibility exists to heal the fracture in a non operative way. Many of our patients present to our clinics and hospitals with septic conditions like perianal abscesses, necrotizing faciitis, Fournier’s gangrene and pyomyositic abscess. Almost all of the patients with these conditions in our catchment area are nowadays immuno-compromised by HIV infection. Surgical excision in these patients should if possible be performed in a tissue saving manner because of the delayed wound healing. Extreme debridement may result in wounds which hardly can be treated in outpatient care clinics and hospital stay in some of these may amount to 4–6 months. Thyroid abscess is another infectious manifestation often related to HIV infection not very often seen in areas with low HIV prevalence. However, this is a rare manifestation compared to tuberculos lymphadenitis in the neck region. New cases of tuberculos adenitis are referred for biopsy and seen every week in our outpatients surgical clinics. Pleural effusion is other manifestation of tuberculosis. In more than 70% these patients are also HIV positive when tested in prospective studies (unpublished data). A herpes zoster scar in any person in this high prevalence area of HIV infection is related to HIV infection in more than 95% of cases. Very many of our patients seeking medical advise for difficult to heal wounds thus present with a history of tuberculosis or herpes zoster. The clinical signs of an ongoing HIV-infection may not be obvious until carefully looked for reliable signs are often noticed as then (silky) hair, grey nails, target scars, (i.e. scars with a lighter hyperkeratotic centre), temporal wasting, palpable epitrochlear lymphnodes and oral candidiasis. These clinical symptoms and signs are like to be correlated to a positive test for HIV in more than 80% in an area with our prevalence of HIV infection. There are no specific signs in the wound per se to observe in the HIV infected patients, but it is the complete history and the knowledge of physical signs which will be of value to establish the correct diagnosis. Gangrene of the toes and lower limbs is a more acute and severe manifestation of the HIV pandemic seen in young male patients (often with a history of smoking). The pathology underlying these manifestations is not very well understood, but some sort of vasculitis causing thrombosis is thought to be contributing to the often not very painful development of gangrene. In these patients high amputations are recommended in order to facilitate primary wound healing and short hospital stay. References
For further information contact: Kent Jönsson MD, PhD |
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