|Year : 2019 | Volume
| Issue : 2 | Page : 103-106
Synopsis of cardiovascular and thoracic surgical cases in the University of Port Harcourt Teaching Hospital
Kelechi E Okonta1, Praise K Briggs2, Christain E Amadi1, Sandra N Ofori3, Emmanuel O Ocheli4, Petronilla N Tabansi5, Barbara E Otaigbe5
1 Department of Surgery, Cardiothoracic Surgery Unit, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
2 Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
3 Department of Internal Medicine, Cardiology Unit, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
4 Department of Surgery, Cardiothoracic Surgery Unit, University of Port Harcourt, Port Harcourt, Rivers State, Nigeria
5 Department of Paediatric and Child Health, Paediatric Cardiology Unit, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
|Date of Submission||21-Jun-2018|
|Date of Decision||28-Nov-2018|
|Date of Acceptance||08-Feb-2019|
|Date of Web Publication||11-Nov-2019|
Dr. Kelechi E Okonta
Department of Surgery, University of Port Harcourt, Port Harcourt, Rivers State
Source of Support: None, Conflict of Interest: None
Background: The aim of the study was to identify the spectrum of cardiothoracic and vascular surgical cases in the University of Port Harcourt Teaching Hospital (UPTH) and identify the limitations to service delivery and recommend solutions to improve service delivery to patients.
Methods: A cross-sectional study of all the cases seen over a 5-year period at UPTH was analyzed. The data were retrieved from theatre records of both elective and emergency cases. All patients were included except those with closed tube thoracostomy drainage inserted in the accident and emergency theaters and patients who were referred out before they could have surgery. The results were tabulated and described using frequencies and percentages.
Results: A total of 93 patients had surgeries in the 5-year period with a mean age of 38.5 years and a range of 3–82 years. Fifty-seven (61.3%) were males, with a male-to-female ratio of 3:2. Fourteen (15.1%) patients were children aged 3–16 years, 67 (72.0%) were adults (17–64 years), and 12 (12.9%) were the elderly (65 years and above). Twenty (21.5%) had surgeries on cardiac structures, 46 (49.5%) had surgeries on thoracic structures, and 27 (29.0%) had different vascular surgeries. For the cardiac structures, 8 (40%) had pericardiectomy and tube pericardiostomy while 12 (60%) had pacemaker insertion. Thoracic surgical procedures included 3 (6.5%) diaphragmatic repairs, 7 (15.2%) esophageal surgeries, 22 (47.8%) pleuropulmonary surgeries, 6 (13.0%) chest wall reconstructions, 5 (10.9%) mediastinal tumor excisions, and 3 (6.5%) other surgeries. The vascular surgeries included 26 (96.3%) peripheral vascular repairs and 1 (3.7%) abdominal aortic aneurysm repairs.
Conclusion: There are shortcomings with the practice of cardiothoracic surgeries at the hospital as major procedures like open-heart surgeries are not done despite availability of human expertise. Thus, there is an urgent need for measures to ensure that open-heart surgery commences, in addition to the provision of some surgical equipment and improvement on some surgical techniques. Furthermore, more collaboration with the other team members in the hospital needs to be actively encouraged.
Keywords: Cardiovascular surgeries, needs assessment, thoracic surgeries
|How to cite this article:|
Okonta KE, Briggs PK, Amadi CE, Ofori SN, Ocheli EO, Tabansi PN, Otaigbe BE. Synopsis of cardiovascular and thoracic surgical cases in the University of Port Harcourt Teaching Hospital. Nig J Cardiol 2019;16:103-6
|How to cite this URL:|
Okonta KE, Briggs PK, Amadi CE, Ofori SN, Ocheli EO, Tabansi PN, Otaigbe BE. Synopsis of cardiovascular and thoracic surgical cases in the University of Port Harcourt Teaching Hospital. Nig J Cardiol [serial online] 2019 [cited 2020 Sep 22];16:103-6. Available from: http://www.nigjcardiol.org/text.asp?2019/16/2/103/270683
| Introduction|| |
The spectrum of successful surgical cases performed in a center is an indicator of clinical competency and skill, and the diversity and complexity of diseases needing surgical intervention will influence the provision of workforce, infrastructure, and modern equipment. Disparity between surgical cases in a cardiothoracic surgery unit and available human competency and equipment to tackle them have previously been reported from Nigeria., This is not unusual in resource-limited countries with low health indices and competing needs for available scarce resources., To convince the policy-makers on the need to equip our hospitals, a needs assessment to appraise the issues and challenges should be conducted. A needs assessment is a systematic procedure to determine and address needs or “gaps” between present conditions and expected conditions or “wants.” The difference between the prevailing and desired state must be determined to appropriately identify the needs.
To embark on a needs assessment in a cardiothoracic surgical unit, the spectrum of diseases must first be analyzed. The result will guide the procurement of surgical equipment or materials based on the pattern/distribution of diseases. It will also kick start the development of training needs and an improved curriculum and institutional framework.
The aim of the study was to identify the spectrum of cardiothoracic and vascular surgical cases in the University of Port Harcourt Teaching Hospital (UPTH). This will help to identify existing gaps and form the basis for the conduction of a needs assessment study with the ultimate aim of improving service delivery to patients.
| Methods|| |
To assess the spectrum of cardiovascular and thoracic surgical cases managed the UPTH, a retrospective survey of all the cases seen over a 5-year period from September 2012 to August 2017 was analyzed. The hospital is one of the federal tertiary hospitals in Nigeria which is located in Rivers State along East-West road with coordinates of 44°53′58′N 6°55′43′E. The hospital originally commenced its operations in 1980 with 60 beds and later was relocated to its permanent site in 2006. The hospital's current bed is 500 with a bed occupancy rate of 70%. It has about 26 clinical departments and units of which cardiothoracic surgery is in the department of surgery.
UPTH currently has three cardiothoracic surgeons, seven adult cardiologists, and two pediatric cardiologists.
The data were retrieved from theater records of both elective and emergency cases. All identified patients were included except those with closed tube thoracostomy drainage inserted in the accident and emergency theaters and patients who were referred out before they could have surgery. The data were described using frequencies and percentages and presented in a tabular form.
| Results|| |
A total of 93 patients had surgeries with a mean age of 38.5 years (range: 3–82 years). Fifty-seven (61.3%) were males, with a male-to-female ratio of 3:2. The distribution of the age shows that 14 (15.1%) were children aged 3–16 years, 67 (72.0%) were adults (17–64 years), and 12 (12.9%) were the elderly (65 years and above).
Twenty (21.5%) had surgeries on cardiac structures, 46 (49.5%) had surgeries on thoracic structures, and 27 (29.0%) had different vascular surgeries [Table 1].
For the surgeries on cardiac structures, 8 (40%) had pericardiectomy and tube pericardiostomy while 12 (60%) had pacemaker insertion.
Thoracic surgical procedures included 3 (6.5%) diaphragmatic repairs, 7 (15.2%) esophageal surgeries (modified Heller procedure, esophagectomy, esophageal bypass, and esophageoplasty), 22 (47.8%) lung and pleural surgeries (lobectomies, decortications, bronchopleural repair, excisional/incisional biopsies, and ligation of bleeding vessels), 6 (13.0%) chest wall repairs, 5 (10.9%) mediastinal tumor excisions, and 3 (6,5%) other surgeries (neck surgeries for masses).
Vascular surgeries included 26 (96.3%) peripheral vascular repairs and 1 (3.7%) abdominal aortic aneurysm repair.
| Discussion|| |
Understanding the spectrum of cardiovascular surgical cases in a cardiothoracic unit and reviewing the successes of the surgeries are preliminary ways of identifying the gaps in terms of competency, training requirement, educational needs, equipment needs, and the resources for wholesome patient care. With these results of the spectrum of cardiovascular and thoracic surgical cases now available, we can compare the success of the surgery with the competencies of the surgeons based on experience, training exposure, and qualification, vis-a-vis the availability of equipment and resource. The fallout will be the prioritization of the training needs of the staff in order fill in deficiencies and to boost skills and competencies. This we hope will spur the administrators to make available more equipment for the surgical procedures.
Cardiothoracic surgery should be more collaborative requiring good teamwork between the cardiothoracic surgeons and other members of the team including the pediatric cardiologist who manage and refer patients with congenital cardiac diseases and adult and geriatric physicians for acquired heart diseases. In this study, 15.1% of the patients were children highlighting the need for the input of the pediatricians for pre- and postoperative fluid and electrolyte management and provision of social support for the children, where necessary. The same applies to elderly patients who will need the attention of the geriatricians. Competencies by anesthetics in instituting central venous pressure lines, single-lung ventilation for bronchopleural fistula repair, regional anesthesia, and the use of cardiopulmonary support like intra-aortic balloon pump and cardioactive and vasoactive drugs are vital for practice. Nurses with trained skills in postoperative care for cardiothoracic surgical patients and chest tube care are very few, as well as intensivists with competency in management of postoperative cardiothoracic patients admitted to the intensive care unit.
The UPTH currently does not perform open-heart surgery. This is despite the significantly high burden of both modifiable and congenital cardiovascular diseases in Nigeria, and the prevalence of 14/1000 of congenital heart disease reported in Port Harcourt. This is alarming, yet no open-heart surgery is done due to lack of funds to set up and run the service. The other anecdoctal reasons are lack of heart–lung machines, lack of trained personnel such as perfusionists, cardiothoracic anesthetists and nurses, and no availability of cell saver machine, heater–cooler machine, sternal saw set, intensive care unit ventilator machines, multiparameter cardiac monitors, defibrillators, and others for open-heart surgery, activated clotting time measuring machine, among other essential laboratory support requirements are also not available.
The cost of open-heart surgery when available is an important factor as most of the patients pay out of pocket. This is besides the problem of the enormous capital investment which constitutes a significant hindrance in the initial takeoff of an open-heart surgical center. To add to the problem, the National Health Insurance Scheme does not cover for the care of these cardiac cases.
In a newly established cardiothoracic surgical unit in a part of this country, it was observed that thoracic surgical cases were done more than cardiac, so they advocated for the need to prioritize and ensure workforce development for treatment of all kinds of thoracic pathologies.
Based on the current data available from this study, there is the need to equip the theater suite with basic instruments such as sternotomy set, thoracotomy set, and vascular set. The blood transfusion department should be sufficiently equipped and stocked with blood and blood products that will be readily available and accessible to patients going for vascular and thoracic surgeries.
Concerning the pathology of the different surgical cases operated in our service, malignancy, trauma, and chronic infection were the three top pathologies identified from our study. This finding is similar to a previous review in the country. Similarly, the bulk of cardiothoracic practice in that center showed a low rate of minimal open-heart surgery activities. With malignant pathology being the most frequent, it is imperative to build up collaboration with the radio-oncologists and oncologic surgeons for palliative and curative patients care. There is also the need to advocate for the availability of radiotherapeutic services and cancer chemotherapy for the care of cancer patients.
In our centre, the use of current techniques like minimal access surgical techniques and prosthetics for chest wall reconstruction are still in the infancy stage. In one of our chest wall repairs, the diaphragm was superiorly advanced after the excision of a huge lower chest wall tumor as a way of improvising for prosthetic material.
The impediment to achieving the desire to care wholesomely for our cardiothoracic and vascular surgical patients includes lack of funds for staff training, aimed at optimum proficiency of required skills, and the procurement of equipment and materials required for the patient management. Another reason is the incessant industrial crises in the health sector that also interrupts services in the cardiothoracic unit and the hospital in general.
It should be a national target to get open-heart surgical services accessible, affordable, and dispensed with the greatest skills and competencies required for wholesome patient management.
In summary, this survey has demonstrated the existing scope of cardiothoracic surgeries in UPTH. This will form a basis for the conduction of an extensive needs' assessment on workforce, the right competencies, right people and the right methods of training, and place to seek for the training. The need to start open-heart surgery cannot be overemphasized as the burden of cardiovascular diseases is significantly high in Port Harcourt. Furthermore, institutional strengthening is essential in other departments such as the histopathology and hematology departments to enhance service delivery.
| Conclusion|| |
The present competencies and the availability of equipment in UPTH can only allow the surgeons do what was enumerated in this study. We highlight an urgent need to direct resources to ensure that open-heart surgery commences as well as to specifically identify the competencies and develop them, identify some training needs that should be developed, and vigorously sponsor such training of requisite personnel. Furthermore, the provision of some surgical equipment and improvement on some surgical techniques and collaboration with the other team members in the hospital should be actively encouraged.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Okonta KE, Tobin-West CI. Challenges with the establishment of congenital cardiac surgery centers in Nigeria: Survey of cardiothoracic surgeons and residents. J Surg Res 2016;202:177-81.
Uzochukwu BS, Ughasoro MD, Etiaba E, Okwuosa C, Envuladu E, Onwujekwe OE, et al.
Health care financing in Nigeria: Implications for achieving universal health coverage. Niger J Clin Pract 2015;18:437-44.
] [Full text]
Olakunde BO. Public health care financing in Nigeria: Which way forward? Ann Niger Med 2012;6:4-10.
Adebonojo SA, Adebo O, Osinowo O. Pattern of thoracic surgical diseases in Nigeria: Experience at the university college hospital, ibadan. J Natl Med Assoc 1978;70:651-7.
Baker CJ, Sinha R, Sullivan ME. Development of a cardiac surgery simulation curriculum: From needs assessment results to practical implementation. J Thorac Cardiovasc Surg 2012;144:7-16.
Falase B, Sanusi M, Animasahun A, Mgbajah O, Majekodunmi A, Nzewi O, et al.
The challenges of cardiothoracic surgery practice in Nigeria: A 12 years institutional experience. Cardiovasc Diagn Ther 2016;6:S27-43.
Okonta KE, Ocheli EO, Gbeneol TJ. Surgical management of recalcitrant peripheral bronchopleural fistula with empyema: A preliminary experience. Niger Med J 2015;56:12-6.
] [Full text]
Oguoma VM, Nwose EU, Skinner TC, Digban KA, Onyia IC, Richards RS, et al.
Prevalence of cardiovascular disease risk factors among a Nigerian adult population: Relationship with income level and accessibility to CVD risks screening. BMC Public Health 2015;15:397.
Abdulkadir M, Abdulkadir Z. A systematic review of trends and patterns of congenital heart disease in children in Nigeria from 1964-2015. Afr Health Sci 2016;16:367-77.
Otaigbe BE, Tabansi PN. Congenital heart disease in the Niger delta region of Nigeria: A four-year prospective echocardiographic analysis. Cardiovasc J Afr 2014;25:265-8.
Ekpe EE, Ette VF, Akpan A. Pattern of cardiothoracic surgical diseases in a new cardiothoracic surgery unit in Nigeria. Niger J Med 2014;23:77-82.
Okonta KE, Gbeneol TJ, Ocheli EO. Superior advancement of the diaphragm and rectus muscle flap as an alternative to prosthetic chest wall reconstruction following the excision of huge lower chest wall tumour. Niger J Surg Sci 2016;26:15-8. [Full text]
Okonta KE, Okonta OC. Industrial crises in a tertiary health institution (THI) in Nigeria: The perspective of resident doctors. Int J Healthc Manage 2018;11:269-75.