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ABSTRACTS Table of Contents   
Year : 2009  |  Volume : 6  |  Issue : 2  |  Page : 144-153
APSON 2008 Abstracts



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Date of Web Publication29-Jul-2009
 

How to cite this article:
. APSON 2008 Abstracts. Afr J Paediatr Surg 2009;6:144-53

How to cite this URL:
. APSON 2008 Abstracts. Afr J Paediatr Surg [serial online] 2009 [cited 2020 Apr 1];6:144-53. Available from: http://www.afrjpaedsurg.org/text.asp?2009/6/2/144/54789
Abstracts of scientific papers presented at the 7 th Scientific Conference and Annual General Meeting of the Association of Paediatric Surgeons of Nigeria

(APSON) which held in November 2008, in Jos. Nigeria


Neonatal gastrointestinal perforation: Is it a sequel to perinatal distress?

Osifo Osarumwese David, Ogbomo Reginald Osagie, Evbuomwan Iyekoretin

Department of Surgery, Pediatric Surgery Unit, University of Benin Teaching Hospital, Benin City, Nigeria

Objective: To determine the aetiology, presentation and outcome of neonatal gastrointestinal perforation in an underserved region. Methods: A prospective study based on neonates who presented with gastrointestinal perforation at the University of Benin Teaching Hospital, Benin City, and Leadeks Medical Center, both in Edo state, Nigeria, between July 2001 and June 2008. Results: A total of 68 neonates aged between 1 and 28 days (mean 12 2.1 days), weighing from 1.5 to 4.1kg (mean 2.8 1.3 kg) and comprising 41 males and 27 females (ratio 1.5:1) presented with gastrointestinal perforation. Fifty-one (75%) neonates had perinatal distress, following complicated delivery in 47 (69.1%) and drugs/infections in four (5.9%). These factors were the only cause of perforation (primary perforation) in 21 (37.5%) neonates, increased the risk of perforation of gut pathologies (secondary perforation) in 30 (62.5%), while only 17 (25%) neonates with perforation had no perinatal distress. Emergency caesarean delivery, prolonged rupture of membrane, prematurity, prepartum haemorrhage, drugs, infections and maternal diabetes mellitus were the causes of perinatal distress. Volvulus in 20 (29.4%) neonates, anorectal anomaly in 14 (20.6%), necrotizing enterocolitis in 11 (16.2%) and Hirschsprung's disease in two (2.9%) were contributory factors in secondary perforations. Late presentation of clinically compromised neonates was rampant, with attendant 27 (39.7%) deaths. Conclusion: Perinatal distress was a leading cause of neonatal gastrointestinal perforation with an associated high mortality. Antenatal care in hospitals with adequately supervised delivery is advocated.

Neonatal intestinal obstruction in Benin City, Nigeria

Osifo Osarumwes David, Evbuomwan Iyekoretin, Okolo C. Jonathan

Department of Surgery, Paediatric Surgery Unit, University of Benin Teaching Hospital, Benin City, Nigeria

Background: Intestinal obstruction is a life-threatening condition in the newborn, with an attendant high mortality rate, especially in the underserved subregion. This study reports the aetiology, presentation and outcome of management of intestinal obstruction in neonates. Materials and Methods: A prospective study of neonatal intestinal obstruction at the University of Benin Teaching Hospital, Benin City, Nigeria, between January 2006 and June 2008. Data were collated on a structured proforma and analysed for age, sex, weight, presentation, type/date of gestation/delivery, aetiology, clinical presentation, associated anomaly, treatment and outcome. Results: There were 71 neonates, of which 52 were males and 19 were females (2.7:1). Their ages ranged between 12 hours and 28 days (mean 7.9 2.7 days) and they weighed between 1.8 and 5.2 kg (average 3.2 kg). Anorectal anomaly 28 (39.4%), Hirschsprung's disease eight (11.3%), prematurity three (4.2%), meconeum plug two (2.8%), malrotation six (8.5%), intestinal atresia eight (11.3%), necrotizing enterocolitis four (5.6%), obstructed hernia four (5.6%) and spontaneous gut perforation three (4.2%) were the causes of intestinal obstruction. Twenty-seven (38%) children had colostomy, 24 (33.8%) had laparotomy, nine (12.8%) had anoplasty while 11 (15.4%) were managed nonoperatively. Forty-one (57.7%) neonates required an incubator, 26 (36.6%) needed total parenteral nutrition while 15 (21.1%) required a paediatric ventilator. Financial constraint, late presentation, presence of multiple anomalies (6), aspiration, sepsis, gut perforation and bowel gangrene were the main contributors to death. Neonates with lower obstructions had a better outcome compared with those that had upper intestinal obstruction ( P < 0.0001). Conclusion: Outcomes of intestinal obstruction are still poor in our setting. Late presentation, financial constraints, poor parental motivation and lack of basic facilities were the major determinants of mortality.

Pattern of congenital malformations in the Federal Medical Centre, Lokoja

J. O. Taiwo

Department of Surgery, Federal Medical Centre, Lokoja

Introduction: Babies born with congenital anomalies present a challenge to the parent, relatives and the medical staff. This is especially so if the malformation affects a conspicuous part of the body. Many such babies are either abandoned or outrightly murdered by the same mother who carried the pregnancy for 9 months. Methods: The admission register of all babies admitted into the special care baby unit of the Federal Medical Centre, Lokoja, over a 14-month period was reviewed and data were analysed. Results: A total of 332 neonates were admitted for both medical and surgical conditions: 29 neonates had gross congenital anomalies (8.7%); 16 males, 12 females; M:F 1.3:1; anterior abdominal wall defects six (20%); CNS six (20.1%); CVS one; GIT 11 (38%); limbs one; urogenital system two. Conclusion: Gross congenital malformations represent a sizeable proportion of neonatal admissions; thus, provision of adequate facilities and staffing is required to improve management outcome in these very sick babies.

Harmful traditional practices in neonates: Cause of severe morbidity

J. O. Taiwo

Department of Surgery, Federal Medical Centre, Lokoja

Introduction: Neonates are vulnerable beings subjected to a lot of harmful practices because of their lack of strength! This usually among survivors resulted in severe morbidities and strain on the lean resources of the care givers. Methods: Case notes of three patients managed recently for complications arising from harmful traditional practices are presented. Results: All three patients survived after spending various durations on admission with significant morbidity. Conclusion: Advocacy is necessary to protect these highly vulnerable beings from these unwarranted practices.

Surgical management of sublingual cysts in infants

E. A. Ameh, P. M. Mshelbwala, C. S. Lukong, A. Gomna, M. A. Anumah

Department of Surgery, Division of Paediatric Surgery, Ahmadu Bello University Teaching Hospital, Zaria

Background: Most sublingual cysts in infants and children are of salivary gland origin. Nonsalivary gland cysts are uncommon and the surgical approach to their management is not frequently reported or described in standard operative texts. Methods: A retrospective review of the surgical management of five infants with nonsalivary gland sublingual cysts treated in 10 years. Results: The infants were all girls, aged 3-6 months (median 5 months). The main presentation was that of slowly progressive swelling in the floor of the mouth from birth. Three patients had upper airway obstruction from the swelling. Ultrasonography confirmed the sublingual location of the cysts as well as their complete cystic nature. Surgery was undertaken as emergency in the three patients presenting with airway obstruction. Surgical access to the cysts was by transverse submental incision. Dissection and complete removal of the cysts was not difficult. The surgical approach will be described. There was no morbidity or mortality and no recurrence. Conclusion: The submental surgical approach is safe and effective for these uncommon sublingual cysts in infants.

Massive pneumoperitoneum following neonatal necrotising enterocolitis: Aspiration vs laparotomy

C. O. Bode, S. Ikhisemojie, A. O. Ademuyiwa

Department of Surgery, Pediatric Surgery Unit, LUTH, Lagos

Background: Surgery is only reserved for complications of neonatal necrotising enterocolitis (NNEC) and massive pneumoperitoneum is an indication of bowel perforation. Aim and Objectives: To compare aspiration with open laparotomy in massive pneumoperitoneum among 16 consecutive newborns with NNEC treated in Lagos. Setting: Lagos University Teaching Hospital . Parameters Measured: Morbidity and mortality . Results: Four out of five laparotomies were "open-and-close" cases, with little else beside massive air found in the abdominal cavity. The remaining 12 underwent careful aspiration with large bore needles. Nine of these babies made successful recovery while the three other babies subsequently had open exploration following failed aspiration. Conclusion: Initial needle aspiration should be considered in NNEC-induced massive pneumoperitoneum as it is less invasive and may spare some babies from needless abdominal exploration.

A review of anterior abdominal wall defects in Ibadan

D. I. Ogunlana 1,2 , O. O. Ogundoyin 1,2 , T. A. Lawal 1 , O. O. Ayandipo 1

Department of Surgery, Division of Paediatric Surgery, 1 University College Hospital, Ibadan, 2 College of Medicine, University of Ibadan, Ibadan, Nigeria

Introduction : Anterior abdominal wall defects represent major challenges to paediatric surgeons worldwide. The challenges are greater in resource-poor settings such as ours, where delayed presentation has been reported as contributing to a higher morbidity and mortality. We therefore reviewed the data from our centre with the goal of improving upon the present status of care. Methods : A retrospective review of all cases of anterior abdominal wall defect presenting within a 6-year period (2003-2008) to our centre was performed. Results : A total of 46 patients presented with anterior abdominal wall defects over the period, consisting of 27 males and 19 females. Four patients had gastroschisis and the rest had exomphalos. Majority (66%) of the exomphalos cases were major and 34% were exomphalos minor cases. Over 60% of the patients presented after 48 h of delivery, while six of the patients were diagnosed prenatally. Surgery was carried out in all of the gastroschisis and exomphalos minor cases and 44% of the exomphalos major cases. Eight of the 36 patients with available data died, six were discharged against medical advice and 22 were followed-up. Conclusion : Anterior abdominal wall defects are not uncommon in our environment. Mortality is high because of a delay in presenting to the paediatric surgeons, nonavailability of paediatric ventilators and conventional silos.

Neonatal cleft lip repair: Preliminary report

Abdur-Rahman Lo, Nasir Aa, Adigun Ia

Department of Surgery, Paediatric Surgery Unit, University of Ilorin Teaching Hospital, Ilorin. E-mail: bolarjide@yahoo.com

Introduction: The birth of a baby with grotesque facial appearance provokes a devastating emotional reaction when it occurs. Many children have been abandoned or neglected, resulting in morbidity and mortality. The general recommendation is to repair the lip at 10 weeks, 10 lbs weight and when haemoglobin is 10 g/dl. Objective: This is to review the pattern and feasibility of surgical repair of cleft lip in the neonatal period. Methodology: Neonates aged 3-27 days with cleft lip and palate was reviewed prospectively. Additional congenital life-threatening anomalies were used as exclusion criteria. Adequate counseling and informed consent was obtained. Results: There were eight children, six females and two males, aged 4-22 days. Four had primary palate cleft (three incomplete and one complete) while four had combined primary and secondary palate cleft. Two were on the right while the others were on the left. Their weight ranged between 2 and 3.8 kg (mean = 3.5 kg). Mean packed cell volume was 48.3%. Only three patients had ECG to rule out a cardiac anomaly. No echocardiograph was done.

All had Millard repair of the lip, although three patients also had primary nasal correction. Seven were done under general anaesthesia and endotracheal intubation and one had local anaesthesia and sedation. Age at operation was between 3 and 22 days, median 19 days.

There was a partial wound dehiscence managed by passage of a NG tube to keep the wound dry. This necessitated the subsequent use of a NG tube to protect the wound and for early feeding of the patients. There was no mortality recorded. Conclusion: Neonatal cleft lip repair is advocated to reduce psychological trauma to parents and reduce morbidity among the patients.

Factors affecting clinical outcome of neonates with intestinal atresias and stenosis

Lohfa B. Chirdan, Aba F. Uba, Mathias I. Igoche, Charles T. Soo, Olabisi O. Osagie

Department of Surgery, Paediatric Surgery Unit, Jos University Teaching Hospital, Jos, Nigeria

Background: Intestinal atresias are associated with prolonged hospitalization and high mortality, especially in developing countries. It is not clear which factors impact on the clinical course and poor outcome of intestinal atresias. This study seeks to identify predictors of untoward outcome of intestinal atresias in our setting. Methods: Neonates with intestinal atresia or stenosis treated in two tertiary institutions in Jos from January 1989 to October 2008 were reviewed. Data were analysed using simple statistical methods. Results: A total of 43 neonates were evaluated during the study period, which was divided into Group A (1989-2002) and Group B (January 2003-October, 2008). The clinical outcome of the first group has been reported in an earlier publication. There were nine duodenal atresia/stenosis, 31 jejunoileal atresias and three colonic atresia. The overall mortality was 35% (41% in Group A and 21% in Group B). Low birth weight (wt < 2.5 kg) and associated congenital anomaly were identified as definite risk factors ( P < 0.02, P < 0.05, respectively). Infants with associated congenital anomalies were more likely to have low birth weight. The type or site of atresia did not affect outcome. The mortality decreased from 41% in Group A to 21% in Group B, although this was not statistically important. Conclusion: Although mortality from intestinal atresia has decreased over the years, is still high in our setting. Mortality is dependent on the birth weight and associated congenital anomalies.

Intestinal atresia and stenosis: The Lasuth experience

R.I. Osuoji, O.M. William, L. Ajai, B. Olayiwola, M.A. Bankola

LASUTH, Lagos

Intestinal atresia is a well known cause of bilious vomiting and neonatal intestinal obstruction. The management in recent times has improved in the developed world with the use of total parenteral nutrition. Despite that, the problem of atony, dysmotility and the short gut syndrome still exist postoperatively. We evaluate the causes, clinical presentation, diagnosis, operative management, postoperative care and outcomes in patients with intestinal atresia in our institution during a period of 4 years.

Key words: Atresia, intestinal, stenosis

Do infants and children have definite inguinal canals?

R.I. Osuoji, O. Williams, L. Ajai, Olayiwola, M.A. Bankole

Department of Surgery, Paediatric Surgical Unit, LASUTH

This prospective study was aimed at refuting the widely held view that in infants and children, the deep and superficial inguinal rings of the inguinal canal are superimposed and therefore there will not be any point opening the inguinal canal routinely during herniotomies. From October 2007 to September 2008, infants and children up to 2 years of age diagnosed with inguinal hernias were operated on by the consultant paediatric surgeons in our unit. The inguinal canals were all opened using a simple sterilised metallic ruler, the distances between the positions of the ipsilateral inferior epigastric vessels and the ipsilateral pubic tubercles were measured in centimeters. Forty-two consecutive inguinal canals were opened in 35 male children and two female children. One male child was preterm but had his operation at 4 months. Four children had bilateral hernias and three had incarcerated hernias. The length of the inguinal canals ranged from 1 to 4 cm, with a mean of 2.72 cm. So far, our finding points to the fact that infants and children indeed have definite and measurable inguinal canals.

Key words: Herniotomies, inguinal canal in children

Ruptured omphalocoele and gastroschis: Management problems and outcome in a tertiary paediatric surgical centre

Lohfa B. Chirdan, Aba F. Uba, Charles T. Soo and Olabisi O. Osagie

Department of Surgery, Paediatric Surgery Unit, Jos University Teaching Hospital, Jos, Nigeria

Background: The survival of infants with omphalocoele and gastroschisis has improved over the years in developed countries. The outcome of children with ruptured omphalocoele and gastroschis remains dismal and a major challenge in developing countries. The aim of this study was to outline the outcome and management problems of infants presenting with ruptured omphalocoele and gastroshisis at a tertiary paediatric surgical centre . Methods: From October 2000 to December 2007, 21 infants with ruptured omphalocoele ( n = 14) and gastroschisis ( n = 7) were treated at the JUTH. Their clinical data have been retrospectively reviewed for presentation, management, morbidity and mortality. Results: There were 13 boys and eight girls. Their ages at presentation ranged from 1 to 6 days (median 2 days). Fourteen infants presented 24 h after birth and seven presented within 24 h of birth. Their weight at presentation ranged from 1.1 to 3.2 kg (median 2.2 kg). In 12 infants, the weight at presentation was < 2.5 kg, while nine had a weight of > 2.5 kg on presentation to the hospital. Fifteen were delivered at home while six were delivered in hospital facilities other than our own. Only four mothers admitted to having some antenatal care during the course of the pregnancy. Associated anomalies was present in five (23.8%) of the infants. Fascial closure was achieved in eight children, skin closure in six while in seven children, improvised silo was used for initial closure of defects. All patients were managed in the general intensive care unit and none had total parenteral nutrition. The main cause of morbidity was infection. The overall mortality was nine (43%). Conclusion: Ruptured omphalocoele and gastroschisis is associated with high mortality in our setup, the main causes of poor outcome being late presentation, low birth weight, infection, lack of NICU and total parenteral nutrition.

Doubly recurrent giant lymphangioma: What are the viable treatment options?

Okoro Philemon E, Anyaeze Chineme M

Department of Surgery, Federal Medical Centre, Owerri, Imo State

Summary: We report this case of two-times recurrence of extensive lymphangioma involving the neck, chest and both breasts of a female. Despite diagnosis at birth, and excision in a teaching hospital, there has been a twice recurrence within a duration of 14 years. The patient's grotesque appearance caused loss of self-esteem and futile search for treatment from religious and native sources. This paper is aimed at highlighting the difficulties and dilemma in managing extensive lymphangiomas. We wonder if surgery alone was sufficient in this case. Could adjunct of sclerotherapy have made a difference at the first surgery? Faced with the patient's current state, could we have done better than we did? If there is a third recurrence, what other options are left?

Key words: Extensive, lymphangioma, management options, recurrent

Developing a paediatric tumour database: Problems and challenges in Zaria

E. A. Ameh, P. M. Mshelbwala, G. O. Ogunrinde 1 , A. Musa, M. A. Anumah 1 , A. Gomna, B. A. Jabo, C. S. Lukong

Departments of Surgery, Division of Paediatric Surgery, 1 Paediatrics, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Background: Availability of adequate data and information has helped in providing quality care for children with solid tumours in developed countries as well as planning of prevention and control strategies. In most of sub-Saharan Africa, however, reliable data on paediatric tumours (including hospital-based data) are not available and not much attention is given to these tumours. Objectives: To develop a hospital-based database for paediatric solid tumours in a large teaching hospital in Nigeria. Methods: In January 2000, we started a paper-based paediatric tumour database in our institution using a 32-point, one-page proforma. The proforma was designed to capture information on demographics, evaluation, hospital care and follow-up. Data were entered by surgical staff. The database (2000- 2007) has been reviewed to identify shortcomings and institute modifications. Results: In the 8 years, a total of 51 children aged 8 days-12 years with solid tumours have been entered into the database. The tumours included nephroblastoma 15 (29%), teratoma 12 (24%), rhabdomyosarcoma eight (16%), neuroblastoma two (4%), lymphoma two (4%) and others two (4%). In 10 (20%) patients, definite histological diagnosis was not made before death and autopsies were not performed. Twenty-one (41%) patients presented late with advanced disease and this contributed to mortality in 18 (35%) patients. It has been observed that dataentry was incomplete in 29 (57%) patients due largely to unsupervised entry by surgical trainees. Because not all solid tumours come primarily to our paediatric surgery service (others are treated by paediatricians, radiotherapists and various specialties), it is projected that the database has captured only about 30% of childhood solid tumours. A multidisciplinary paediatric tumour board is now being established and dataentry will be closely supervised. It is planned to migrate to an electronic database once the multidisciplinary tumour board is fully established. Conclusions: It is feasible to establish reliable paediatric tumour database in our setting but close supervision, appropriate training at database management and multidisciplinary collaboration are necessary for adequate data capture. The database should help in planning care as well as resource allocation and cancer control.

Problems of managing retinoblastoma in Jos University Teaching Hospital: A 6-year review of cases

P. D. Wade, C. D. Mpyet, S. K. Alli, L. Langnap

Department of Ophthalmology, Jos University Teaching Hospital, Jos

Aim: To determine the problems of managing retinoblastoma in Jos University Teaching Hospital . Methods: A total of 27 cases of patients were reviewed. Results: Twenty-seven cases of patients were reviewed of which 20 (74.0%) presented with fungating mass and proptosis. Leukocoria was seen in 15 (18.52%) and only two (7.41%) patients presented with poor vision and redness. Late presentation was seen in 15 (55.55%) patients. This was attributed to visits to peripheral clinics by 18 (66.67%) patients and to alternative healers by 14 (51.58%) patients. Only eight (29.63%) patients benefited from surgery and cytotoxic drugs. The 2-year survival rate was 3.70%. Conclusion: Ignorance of the disease, inadequate health education, poor financial status of most patients and late presentation to the hospital contributed to the high mortality.

Epithelial neoplasm of the pancreas in a 5-year-old female child

M. Ibrahim, A.M. Mohammad 1 , S. Malami 1 , K. I. Getso

Murtala Mohammed Specialist Hospital, 1 Aminu Kano Teaching Hospital, Kano, Nigeria

Introduction: Epithelial neoplasm of the pancreas in children is a rare, low-grade, uncommon malignant tumour, mostly seen in young females. Frantz described the first two cases in 1959 and since then not more than 150 cases have been reported in the English literatures. Because these tumours of the pancreas are very rare in infants and children, this justifies our case report. Case Report: On 27 December 2007, patient P presented with a history of abdominal pains of 1-year duration. The patient received medical treatments in various health centres without relief. Abdominal USS concluded multiple splenic abscesses.

At laparotomy, a mass lesion that occupied the whole tail of the pancreas was seen. Distal pancreaticosplenectomy was performed. Histological examination showed lymphoepithelial cyst of the pancreas [Figure 1]. Postoperative serum amylase was 24 U/l. Discussion: Epithelial neoplasm of the pancreas is very rare, accounting for only 2-3% of pancreatic tumours of all ages. Frantz described the first two cases in 1959 and since then not more than 150 cases have been reported in the English literatures. A review of the literature has shown that this lesion is more common among Asians. We have not come across a report from our subregion. Conclusion: Epithelial pancreatic tumour has good prognosis and requires complete surgical resection. Our patient in this report remains stable and symptom-free throughout the follow-up period.

Primary malignant hepatic tumours in children: Problems of management in a resource-limited setting

Lohfa B. Chirdan, Aba F. Uba, Samuel Olori, Monday A. Ituen, Barnabas M. Mandong 1 , Agabus Manasseh 1 , Godwin O. Echejoh 1

Departments of Surgery, Paediatric Surgery Unit, 1 Pathology, Jos University Teaching Hospital, Jos, Nigeria

Background: Primary malignant hepatic tumours are relatively uncommon in children. The treatment has evolved over the years and involves a combination of surgery, chemotherapy (adjuvant and neoadjuvant) and possible liver transplantation. While the outcome of children with primary malignant liver tumours has improved over the years in developed countries, the outcome is still poor in resource-limited settings. Objective: The aim of this study was to evaluate the management problems and outcome of primary malignant liver tumours in children in a tertiary paediatric care facility in Nigeria. Methods: A retrospective analysis was performed on all patients aged 18 years or below with confirmed diagnosis of primary hepatic tumours over a 12-year period (January 1996-December 2007). Results: There were 15 children with primary liver tumours. Ten (66.7%) were males and five (33.3%) were females. Eight (53.3%) had hepatocellular carcinoma (HCC). Their median age at presentation was 13 years (range 8-18 years). They presented with hepatomegaly, abdominal discomfort and jaundice. Hepatitis B surface antigen was positive in five (62.5%) and alpha-fetoprotein was elevated in two of four patients that had the test. All the patients presented with advanced-stage disease; six had highly malignant pleomorphic HCC and two had differentiated tumour; five had chemotherapy after biopsy and only two (25%) were alive at 1 year; three were too sick for chemotherapy and died within 3 months of diagnosis. Seven (46.7%) patients had hepatoblastoma, with a median age at presentation of 7 years (range 4-12 years). Alpha-fetoprotein was elevated in three of four children that had the test; two (28.6%) had pulmonary metastasis at diagnosis, the parents of two others declined consent for further therapy after diagnosis while chemotherapy was administered to the remaining five children. Two had surgical resection after chemotherapy and were alive at 12 months of follow-up. One of them died 18 months after surgery while the other was lost to follow-up. The remaining three children could not afford chemotherapy after the 1st course. Conclusion: In our setting, HCC is the most common primary malignant liver tumour in children and has a poor outcome. Late presentation and poverty appear to be the major problems of management. A multicentre study is needed to characterise the presentation and optimal management of malignant primary liver tumours in children in our subregion.

Typhoid perforation in children: Our experience from two referral centres in Kano, Nigeria

Am Mohammad, I. Musa, Anyanwu Ljc

Department of Surgery, Bayero University/Aminu Kano Teaching Hospital and Murtala Mohammed Specialist Hospital, Kano, Nigeria

Typhoid intestinal perforation is the principal cause of morbidity and mortality, affecting both adults and children. This study aims to evaluate the pattern of typhoid intestinal perforation and outcome of its management in children in Kano, Nigeria. The data were collected and collated using a predesign proforma from consecutive children managed for typhoid intestinal perforation at Aminu Kano Teaching Hospital (AKTH) and Murtala Mohammed Specialist Hospital (MMSH), between September 2006 and August 2008. There were 372 children; 252 from AKTH and 120 from MMSH (206 males and 166 female) (M:F = 1.38:1), with a mean of 4.8 years (range 2.5-12 years). More than half (62.5%) of the patients were in the 6-9 years age group. Of note is the fact that 64 (17.20%) were between the ages of 2-4 years. The incidence peaked in April-June and October-December. All patients presented with the classic features of typhoid enteric perforation. Hypokalaemia and anaemia were common at presentation. Only 298 (80.1%) patients had an operation within 24 h of presentation. The types of surgery included simple excision of the edges of the peroration and closure (92.2%), wedge resection and closure in 6.5%, segmental resection with primary end-to-end anastomosis (1.3%) and right hemicolectomy with ileocolic or ileotransverse anastomosis.

Wound infection and dehiscence, anastomotic breakdown with faecal fistula, intraperitoneal abscesses and chest infections were the main postoperative complications. The overall mortality rate was 5.9 (22). Excision and simple closure was associated with the least incidence of anastomotic breakdown and operation time. The incidence of typhoid intestinal perforation is still high at our institutions. Aggressive resuscitation and limited surgery provides optimal results in our series.

Key words: Children, Kano, outcome, typhoid perforation

An overview of 15 years of experience with typhoid ileal perforation in children at a referral centre in Nigeria

Osifo Osarumwese David, Scott O. Ogiemwonyi, Ovueni E. Mike, Evbuomwan Iyekoretin

Department of Surgery, Pediatric Surgery Unit, University of Benin Teaching Hospital, Benin City, Nigeria

Background: Typhoid ileal perforation is a common complication of typhoid fever, a multisystemic infection, which is endemic in many developing countries. This study aimed to review and compare the incidence, morbidity and mortality in this centre with other referral centres located in areas with similar socioeconomic and population status. Methods: The incidence, morbidity and mortality of typhoid ileal perforation in children treated among Edo people at the University of Benin Teaching Hospital, Nigeria, between 1993 and 2007 were retrospectively studied and compared with centres in localities of similar socioeconomic and population status. Results: Twelve children, all of middle-class parents who resided in a suburban community with poor water supply and substandard sewage disposal, accounted for 70.6% of the patients with typhoid ileal perforation managed over 15 years while 29.4% occurred in adults. The children comprised seven males and five females (M/F ratio 1.4:1) who were aged between 5 and 13 (average 9) years. The few patients seen could be due to cultural beliefs, which influenced proper sewage disposal by about four million Edo people, especially those living in rural areas. Therefore, no child from the rural area with clean natural water supply or urban areas with pipe-born water supply, where sewages are disposed off properly, had typhoid perforation. Unacceptably high morbidity (100%) and mortality (75%) due to late referrals were recorded in comparison with centres in other localities. Conclusion: Proper sewage disposal may have influenced the low incidence but early referral is advocated so as to improve present outcome.

Infection control upon application of low-level laser therapy after thermal injuries in the paediatric age group

Ibrahim Musa, A. M. Mohammad 1 , K. I. Getso

Departments of Surgery, Murtala Mohammed Specialist Hospital and 1 Aminu Kano Teaching Hospital, Kano, Nigeria

Introduction: "LASER" (Light amplification by stimulated emission of radiation) is used with success in treating burns in neonates and children. Laser rays penetrate human tissues and the energy stimulates rapid regeneration of tissues. It also has local bacteriostatic effects. Thermal injuries are included among the many indications for laser therapy. Aim: To study the effects of low-level laser therapy on skin healing and infection control after thermal injuries in paediatric age groups. Patients and Methods: Within a period of 18 months, from September 2007 to November 2008, a total of 78 patients aged of thermal injuries to the skin at the Pediatric Surgical Unit of Murtala Mohammed Specialist Hospital, Kano, Nigeria. The patients were assigned into two groups. Group A (control n = 42) are those treated without low-level laser therapy while group B (study n = 36) comprises patients without application of laser energy. Results: The effects of laser rays on wound healing and infection control after thermal injuries to the skin, days of hospital stay, cost-effectiveness, pain management, postburn stress and itching were compared and analysed. We found that applying low-level laser therapy lasting 2-5 min for 7-14 days on children has significant advantages, with a P -value < 0.05 in all the categories when compared with group A. Conclusion: Low-level laser therapy in the management of thermal injuries is effective, has an excellent healing effect and reduces the rate of infection, low cost of treatment to the parents and the system.

What is the occupational risk of HIV exposure from paediatric surgical clients?

C. O. Bode, S. Ikhisemojie, A. O. Ademuyiwa

Pediatric Surgery Unit, LUTH, Lagos

Background: The emergence of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) has remained a worry to surgeons who are constantly exposed to body fluids from patients. Objective: To assess the seroprevalence of HIV/AIDS among children presenting for surgery at the Lagos University Teaching Hospital (LUTH). Patients, Materials and Methods: Venous blood from 1000 consecutive children who presented for surgery at the LUTH over a 3-year period were prospectively analysed for seroprevalence of HIV. Results: Seven (0.7%) children were confirmed as HIV positive by the Western Blot method. Conclusion: Although there is a low rate of HIV seroprevalence among children presenting for surgery in Lagos, this Figure is likely to rise unless concerted efforts are made to curtail the scourge of this dreadful disease in Nigeria. The use of universal precautions should be strictly taught to all operation theatre users.

HIV seropositivity in 1000 paediatric surgical patients in LUTH

C. O. Bode, S. Ikhisemojie, A. O. Ademuyiwa, O. A. Elebute

Department of Surgery, Pediatric Surgery Unit, LUTH, Lagos

Background : The human immunodeficiency virus (HIV) scourge is a constant source of worry to the surgical team. The scope of this threat remained unknown in LUTH. Objective: To document the seroprevalence of HIV among paediatric surgical patients in LUTH. Patients, Materials and Methods: Prospective study of the HIV seropositivity in 1000 consecutive children treated by the Pediatric Surgery Unit, LUTH, using the enzyme-linked immunosorbent assay technique and Western blot for confirmation. Results: Only four seropositive children were discovered, giving a rate of 0.04%. Conclusion: Although there is a low HIV seropositivity among paediatric surgical patients in Lagos, this incidence will most likely rise over time. In the interim, surgeons should therefore continue to observe universal precautions while performing surgeries.

Primary Swenson's pull through in children with chronic constipation: A preliminary result

T. I. B. Bakare, T A. Badmus 1 , I. A. Kaltung, A. O. Lawal 2

Department of Surgery, Federal Medical Centre, Owo, Ondo State, 1 Department of Surgery, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria, 2 General Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos State

Introduction:
Sequel to the success we experienced with primary Swenson's pull through in infants less than 4 months with Hirschsprung's disease, as trainees, we thought that such results could be reproduced in older children with chronic constipation. This prospective study was conducted in a centre that lacked facilities for intraoperative frozen section for determination of the level of aganglionosis. Materials and Methods: Four consecutive patients (aged 4 months-11 years) who presented with chronic constipation were given warm saline enema with 2.5-10 ml of Castor oil/g twice daily for 1 week before and 2 weeks after full-thickness biopsies that confirmed Hirschsprung's disease. All the patients had intravenous Ceftriaxone and Metronidazole at induction of anaesthesia. Intraoperatively, the levels of resections were 6-8 cm proximal to the most contractile part of the colon adjacent to the transition zone observed after complete division of the mesenteric vessels. Results: There was a case each of anastomotic stenoses, mild enterocolitis and severe perianal excoriation. The level of aganglionosis was in the rectosigmoid region, except in one, where it was in the distal transverse colon. The bowel motions were two to four times per day. Conclusion: From this preliminary study, it can be concluded that with preoperative saline enema and oral Castor oil for about 3 weeks in children with Hirschsprung's disease presenting with chronic constipation primary pull-through procedures can be performed successfully. However, further prospective work is required with this method.

Giant rectosigmoid lithobezoar in an 8-year-old boy

A. M. Mohammad

Department of Surgery, Bayero University/Aminu Kano Teaching Hospital

Generally, bezoars are rare foreign body concretions formed in the stomach and small bowel, composed mainly of hair (trichobezoars), vegetable matter (phytobezoars), milk curds (lactobezoars) and, very rarely, stones (lithobezoars). Colonic bezoars, especially lithobezoars, are very rare findings in children. We report an 8-year-old boy with a giant rectosigmoid lithobezoar, with history of recurrent constipation and pica for 5 years. Abdominal palpation revealed an intraluminal fecoliths and prickly hard pieces of stone were found on rectal examination, whereas plain abdominal X-ray showed radioopaque multiple calculi scattered in the colon and congregated in the rectosigmoid region. Psychiatric assessment did not reveal any abnormality. Four hundred and seventy-two (472) pieces of (same type of) asphalt stones ware manually evacuated under general anaesthesia with full recovery within 5 days.

Key words: Bezoars, child, colon, lithobezoar, rectosigmoid

Omphalomesenteric duct abnormalities in Kano: A report of six cases

A. M. Mohammad, I. Musa

Department of Surgery, Bayero University/Aminu Kano Teaching Hospital and Murtala Mohammed Specialist Hospital, Kano, Nigeria

Omphalomesenteric duct malformations comprise a wide spectrum of anatomic structures and associated symptoms (or no symptoms). They may range from a completely patent omphalomesenteric duct at the umbilicus to a variety of lesser remnants, including cysts, fibrous cords connecting the umbilicus to the distal ileum, granulation tissue at the umbilicus, umbilical hernias and the famous diverticulum of Meckel. Symptoms may involve faecal fistulas at the umbilicus, intussusception/prolapse of the ileum at the omphalomesenteric duct from a variety of causes, melena and anaemia, abdominal pain and inflammation, etc.

We present six neonates with omphalomesenteric duct abnormalities presenting as umbilical faecal fistulas (four cases) and intestinal obstruction in association with omphalocoele minor (umbilical cord hernias) (two cases). They were all successfully managed with surgical excision.

Awareness of the diversity of these malformations in type and symptomatology is essential for their proper and optimal management.

Key words: Faecal fistulas, omphalomesenteric duct, umbilicus

The causes, spectrum and effects of surgical child abuse and neglect in Benin City, Nigeria

Osifo Osarumwense David, Oku Onome Rosalyn

Department of Surgery, Paediatric Surgery Unit, University of Benin Teaching Hospital, Benin City, Nigeria

Background:
Children are dependent on parents/caregivers for the quality of health care services received and, in developing countries, where they are not protected against child abuse, many die as a result of denial of appropriate treatment. Objective: The objective of this study was to determine the causes, spectrum and effects of abuse/neglect on surgical children. Methods: Analysis of cases of surgical child abuse/neglect between January 1998 and December 2007 at the University of Benin Teaching Hospital, Benin City, Nigeria, was carried out. Results: A total of 281 children aged 2 days and 12 years comprising 113 males and 168 females with the male/female ratio 1:1.4, mainly with congenital malformation, suffered surgical child abuse/neglect, ranging from delayed presentation to child abandonment, which was perpetuated by ignorance, poverty, superstitious beliefs, customs as well as nonavailability of free medical services for children. Counseling and home visits in addition to surgeries were performed and 198 (70.5%) children were successfully treated with those abandoned happily reunited with their families, while a mortality of 56 (19.9%) was recorded due to complications of the primary surgical pathology, and this was statistically significant compared with other children with similar lesions but without abuse or neglect during the period ( P = 0.0102). Whereas 27 (9.6%) among those discharged against medical advice were lost to follow-up, of the 198 children that survived, 22 suffered psychological trauma and were comanaged with psychologists while seven were transferred to orphanage homes. Conclusion: Surgical child abuse/neglect was rampant and it is hoped that these findings will influence policymakers in this subregion to formulate policies that will protect children against this form of child abuse.

Role of international collaborations in improving the quality of paediatric surgical care and training in Zaria

Emmanuel A. Ameh

Department of Surgery, Division of Pediatric Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Background: Paediatric surgical training in most of sub-Saharan Africa is limited by lack of funding and limited attention from relevant agencies. Methods: A review of the impact of international collaborations (individuals and associations) on the quality of paediatric surgical care and training in Zaria. Results: From 1969 to the early nineties, only one surgeon was fully trained in paediatric surgery. From the mid nineties, two other paediatric surgeons completed training. Although efforts at training in paediatric surgery continued, progress was faced with much difficulty. Paediatric surgical care also faced several limitations and challenges, largely due to inadequate staffing and funding. In 2001, the International Society of Surgery gave a travel scholarship to one of the paediatric surgeons, affording him the opportunity to travel to Brussels to attend the ISC. This marked the beginning of a collaboration with international colleagues and surgical associations. Subsequently, support by the American College of Surgeons and British Association of Pediatric Surgeons led to training periods in the USA and the UK. The result has been two-fold. In training of our paediatric surgeons, the training programme has been modified and improved: The programme is now fully accredited and 11 trainees have been trained. The care of patients has also significantly improved due to the introduction of practice-changing practices learnt from abroad. Conclusions: The overall impact of the international collaboration has been that of enhanced and improved training as well as quality of care. Such collaborations should be strengthened and encouraged.

Primary PSARP in the adolescent girl: How safe?

J. O. Taiwo, L. O. Abdurrahman, A. A. Nasir, T. O. Odi

Department of Surgery, Federal Medical Centre, Lokoja, University Teaching Hospital, Ilorin

Introduction: Anorectal malformations usually present to the paediatric surgeon in the neonatal period. Presentation in the adolescent is, however, not uncommon in our resource-poor environment. Stage management is recommended for treatment but, in patients who have decompressed well, single-stage management may still be attempted and good outcome may be obtained. Methods: Two adolescent girls managed for ARM with rectovestibular fistula presenting at age 11 and 14, respectively, who were managed with very good outcome via a single-stage PSARP are presented. Conclusion: Single-stage PSARP in well-selected adolescent girls is a good option for patients with this anomaly. If performed well, the outcome should be very satisfactory.

Delayed diagnosis of malrotation despite several hospital visits: A cause for worry

J. O. Taiwo

Department of Surgery, Federal Medical Centre, Lokoja

Introduction: Making a diagnosis of intestinal malrotation to the uninitiated may be a Herculean task. The stress on the parent moving from one hospital to another in an attempt to get a solution is enormous. The basic investigative tool is available in most towns, yet most doctors rarely think or make use of it! Methods: Two cases of intestinal malrotation with recurrent volvolus aged 6 months and 6 years, respectively, whose symptoms started form the first week of life and 1 year, respectively, and who did not get treatment until 6 months and 6 years, respectively, is reviewed and the cause of the delayed diagnosis presented. Conclusion: There is a need for improved exposure of undergraduates to paediatric surgery to reduce this misdiagnosis, which will ultimately reduce the morbidity and mortality that may occur in this serious but very treatable anomaly!

Burst abdomen due to spontaneous rupture of a congenital probiscoid umbilical hernia in a background of cyanotic heart disease

S. Olori, A. S. Sani, Y. Dawang, J. Idama, P. Musa

Department of Surgery, Division of Paediatric Surgery, University of Abuja Teaching Hospital, Gwagwalada, Abuja

Umbilical hernia is a common pathology in children. It could either be congenital or acquired. In the negroid, the acquired type tends to predominate due to the increased cord infection rate among the newborn.

Burst abdomen is a major complication of abdominal operations. We report an unusual cause of burst abdomen; a probiscoid umbilical hernia with cyanotic heart disease in a 2-year-old child.

He had emergency laparotomy and umbilical herniorrhaphy through an infraumbilical smiling incision. The patient's wound healed well and he is presently awaiting corrective cardiac operation.

Congenital hypertrophic pyloric stenosis twinning with duplication of the cyst of the pylorus

S. Olori, A. S. Sani, Y. C. Dawang, S. OAnene-Nzelu Yakubu

Department of Surgery, Division of Paediatric Surgery, University of Abuaja Teaching Hospital Gwagwalada

Congenital hypertrophic pyloric stenosis is a common disorder affecting the gastric outlet in infants. Its incidence ranges from 2.1 to 5.1, with a male preponderance. It is a common cause of early infant morbidity and mortality if not treated properly. Objective: To highlight an unusual association of common pathologies. Material and Methods: It is a case report of a 7-week-old boy with congenital hypertrophic pyloric stenosis who had Ramstedt procedure and enucleation of duplication cyst at the same site. Results: The patient however died from severe malnutrition and persistent hypothermia . Conclusion: Persistent vomiting after Ramstedt operation may be due to a rare coexisting obstructive condition other than incomplete pyloromyotomy. Severe malnutrition may be responsible for poor postoperative recovery in the at-risk group.

Management outcome of circular myectomy for short-segment Hirschsprung's disease among children in Lagos

C. O. Bode

Department of Surgery, Pediatric Surgery Unit, LUTH, Lagos

This paper discusses the use of circular myectomy in the management of short-segment Hirschsprung's disease in 29 consecutive cases seen at the Lagos University Teaching Hospital and highlights the management outcome and complications of this approach.

Waugh's syndrome: A report of seven cases

T. I. B. Bakare, O. A. Sowande 1 , U. E. Usang 2 , O. A. Ademuyiwa 3

Department of Surgery, Federal Medical Centre, Owo, Ondo State, 1 Department of Surgery, Faculty of Clinical Sciences, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Osun State, 2 Department of Surgery, University of Calabar Teaching Hospital, Calabar, Cross River State, 3 Paediatric Surgery Unit, Department of Surgery, Lagos

Introduction: Since the first report of the association of malrotation with intussusception by Waugh in 1911, there has been scantly reports of this condition in the literature and, to our knowledge, none have been reported in our community. Methods: We present seven cases of Waugh's syndrome in children aged 2-6 months managed in our centre. Results: None of the patients had a history of respiratory tract infections but two were given local herbal concoction for treatment of depressed anterior fontanels resulting from dehydration due to febrile illness. Nonrotation of the gut was found in one (14.3%) patient, two (28.6%) had complete nonfixation while the remaining four (57.1%) had floating ascending colon. All the patients had ileocaecocolic intussusceptions, except one with ileocolic. One patient had associated ileal volvulus and two patients had obstruction of the ileal lumens by hyperplastic lymphoid tissues. Mortalities were recorded in three patients, two of who ingested a local herbal concoction. Conclusion: In addition to the premorbid gut malrotation, the possible lead-point for intussusception may be found in some patients with Waugh's syndrome, and there should be a high index of suspicion of intussusception in an infant presenting with features of intestinal obstruction following ingestion of a local herbal concoction.

An audit of the use of small intestinal enterostomies in Ahmadu Bello University Teaching Hospital, Zaria

M. A. Anumah, E. A. Ameh, P. M. Mshelbwala, C. S. Lukong, B. Jabo

Department of Surgery, Division of Paediatric Surgery, Ahmadu Bello University Teaching Hospital, Zaria

Introduction : Ileostomies are not frequently performed for gastrointestinal disorders as colostomies. They are, however, associated with postoperative complications. Despite the challenges of postoperative management of ileostomies, it is an indispensable procedure in paediatric surgical practice. Few studies have been reported in this part of the world. Aims and Objective : To identify indications for ileostomies and the postoperative complications associated with this procedure. Methodology: This is a 8-year retrospective study of paediatric patients who had ileostomies performed in the Ahmadu Bello University Teaching Hospital. The case folders and operation notes were the source of the data analysed. Results: Thirty-four patients who had complete data were analysed. There were 21 males and 13 females. Their ages ranged between 3 days and 12 years, with a median of 6 months.

The most frequent indications for ileostomies were anastomotic leak in 11 (32.4%), intestinal perforation in eight (23.5%), intestinal gangrene in five (14.7%) and intestinal atresia and stenosis in four (11.7%) of the patients who had ileostomy. Typhoid perforation was the most common primary disease in 12 (35.3%), followed by intussusception in seven (20.6%). Complications were common with this procedure and occurred in 31 (91.2%) of the patients. Sepsis was the most common complication, occurring in 18 (52.9%) of the patients. There were 20 (58.8%) mortalities. However, only four (11.8%) of the mortalities were directly due to ileostomy as a result of dyselectrolytemia. Sixteen (80%) of the mortalities were due to complications associated with the underlining diseases. Severe sepsis due to the primary disease accounted for 12 (60%) of the mortalities. Conclusions : Ileostomy is associated with significant morbidity and mortality. However, most of the mortalities were due to nonileostomy postoperative complications.

Pilot study on determinants of the outcome of paediatric surgical emergencies in a referral centre in Southeast Nigeria

S. O. Ekenze, P. A. Anyanwu, U. O. Ezomike

Department of Paediatric Surgery, University of Nigeria Teaching Hospital, Enugu, Southeast Nigeria

Background: In many developing countries, the management of children with surgical emergencies remains challenging. This study aims to evaluate the factors that may influence outcome in paediatric surgical emergencies in a tertiary referral hospital in Southeast Nigeria. Methods: Prospective evaluation of 81 children with surgical emergencies managed at the University of Nigeria Teaching Hospital, Enugu, Nigeria, from January to November 2006. Results: The mean age was 5.2 years (range 1 day-15 years). Emergencies encountered were typhoid intestinal perforation in 14 (17.3%), acute appendicitis in nine (11.1%), obstructed hernia in eight (9.9%), posterior urethral valve with retention in eight (9.9%), massive rectal prolapse in eight (9.9%), intussusception in six (7.4%), neonatal intestinal obstruction in six (7.4%), ruptured omphalocele/gastroschisis in six (7.4%), abdominal trauma in five (6.1%), adhesive small bowel obstruction in four (4.9%), malrotation with obstruction in three (3.7%), bleeding haemangioma in two (2.5%) and Hirschsprung's disease with acute obstruction in two (2.5%). The average duration of symptoms before presentation was 2.9 days (range 2 h-13 days). After resuscitation, 61 (75.3%) children were managed by operative intervention and 20 (24.7%) nonoperatively. Eighteen (29.5%) developed a total of 21 postoperative complications and 11 (13.6%) children died from overwhelming infection or acute renal failure. Mortality was higher in neonates compared with older children

( P = 0.029) and in children presenting after 48 h of symptoms ( P = 0.024). Conclusion: Neonatal age and presentation after 48 h of symptoms are significant adverse factors for outcome in paediatric surgical emergencies in our setting. Mortality may be reduced by earlier referral to the tertiary centres and improvement of our emergency neonatal surgical services.

Challenges of major surgery in children of Jehovah witness parents

C. O. Bode, A. O. Ademuyiwa, S. Ikhisemojie, O. A. Elebute

Department of Surgery, Pediatric Surgery Unit, LUTH, Lagos

Background: Major operations in Jehovah witnesses (JW) is often constrained by the patient's objection to blood transfusion. Objective: To document our experience on major surgeries in children of JW parents in terms of the spectrum of presentation, preoperative care and surgical outcome. Setting: Lagos University Teaching Hospital, Lagos, Nigeria . Results: There were 17 minor cases and 11 major cases. All the patients came with strongly expressed feelings objecting to blood transfusion. All the minor cases were operated on electively and without incident. Of the 11 major cases, four patients were discharged against medical advice and one died from prolonged delay in consenting to surgery by parents. Of the remaining six who were operated on, consent was given for transfusion by three parents and all survived. A patient with Wilm's tumour died on the operation Table from massive haemorrhage. Two others had prolonged hospital stay and wound dehiscence on account of refusal of blood transfusion. Conclusion: Children of JW are suffering significant morbidity and mortality on account of their parents' faith. This paper discusses the implication and possible options of tackling these unacceptable results.

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