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   2012| January-April  | Volume 9 | Issue 1  
    Online since February 28, 2012

 
 
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ORIGINAL ARTICLES
Ventriculoperitoneal shunt complications needing shunt revision in children: A review of 5 years of experience with 48 revisions
Rajendra K Ghritlaharey, Keshav S Budhwani, Dhirendra K Shrivastava, Jyoti Srivastava
January-April 2012, 9(1):32-39
DOI:10.4103/0189-6725.93300  PMID:22382102
Background: The aim of this study was to review the management of ventriculoperitoneal (VP) shunt complications in children. Patients and Methods: During the last 5 years (January 1, 2006 to December 31, 2010), 236 VP shunt operations were performed in children under 12 years of age; of these, 40 (16.94%) developed shunt complications and those who underwent VP shunt revisions were studied. Results: This prospective study included 40 (28 boys and 12 girls) children and required 48 shunt revisions. Complications following VP shunts that required shunt revisions were peritoneal catheter/peritoneal end malfunction (18), shunt/shunt tract infections (7), extrusion of peritoneal catheter through anus (5), ventricular catheter malfunction (4), cerebrospinal fluid (CSF) leak from abdominal wound (4), shunt system failure (2), ventricular end/shunt displacement (2), CSF pseudocysts peritoneal cavity (2), extrusion of peritoneal catheter from neck, chest, abdominal scar and through umbilicus, one each. Four-fifth of these shunt complications occurred within 6 months of previous surgery. Surgical procedures done during shunt revisions in order of frequency were revision of peritoneal part of shunt (27, 56.25%), revision of entire shunt system (6, 12.5%), extra ventricular drainage and delayed re-shunt (5, 10.41%), shunt removal and delayed re-shunt (5, 10.41%), opposite side shunting (2, 4.16%), cysts excision and revision of peritoneal catheter (2, 4.16%) and revision of ventricular catheter (1, 2.08%). The mortalities following VP shunt operations were 44 (18.64%) and following shunt revisions were 4 (10%). Conclusions: VP shunt done for hydrocephalus in children is not only prone for complications and need for revision surgery but also associated with considerable mortality.
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Gastroschisis: A multi-centre comparison of management and outcome
Joanna Manson, Emmanuel Ameh, Noel Canvassar, Tiffany Chen, A Van den Hoeve, F Lever, Afua Hesse, Alastair Millar, Sherif Emil, Niyi Ade-Ajayi
January-April 2012, 9(1):17-21
DOI:10.4103/0189-6725.93296  PMID:22382099
Background: Anecdotal evidence and a handful of literature reports suggest that the outcome for infants born with gastroschisis in many African countries is poor when compared to Western nations. We wished to evaluate current management strategies and outcomes in African and Western units that treat infants with gastroschisis. Patients and Methods: We conducted a retrospective review of case-notes for infants with gastroschisis who presented to a hospital between 1 January 2004 and 31 December 2007. There were five participating centres, divided for analysis into an African cohort (three centres) and a Western cohort (two centres). Results: Fewer infants presented to a hospital with gastroschisis in the African cohort when compared to the Western cohort, particularly when the size of catchment area of each hospital was taken into account. The physiological state of the infant on presentation and management strategy varied widely between centres. Primary closure, preformed silo and surgical silo with delayed closure were all utilised in the African cohort. Use of the preformed silo and delayed abdominal wall closure was the strategy of choice in the Western cohort. The 30-day mortality was 23% and 1% respectively. This primary outcome measure varied considerably in the African cohort but was the same in the two Western units. Conclusions: Gastroschisis in the African cohort was characterised by fewer infants presenting to a hospital and a more variable outcome when compared to the Western cohort. A detailed epidemiological study to determine the incidence of gastroschisis in African countries may provide valuable information. In addition, interventions such as prompt resuscitation, safe neonatal transfer, the use of the preformed silo and parenteral nutrition could improve outcomes in infants with gastroschisis.
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Tube thoracostomy: Primary management option for empyema thoracis in children
Rajendra K Ghritlaharey, Keshav S Budhwani, Dhirendra K Shrivastava, Jyoti Srivastava
January-April 2012, 9(1):22-26
DOI:10.4103/0189-6725.93297  PMID:22382100
Aim: The aim of this study was to review our experience with tube thoracostomy in the management of empyema thoracis in children. Patients and Methods: This retrospective study included 46 children (26 boys and 20 girls) who were admitted and managed for empyema thoracis, between January 1, 2010 and December 31, 2010 at the author's department of paediatric surgery. Results: During the last 12 months, 46 children aged below 12 years were treated for empyema thoracis: Five (10.86%) were infants, 22 (47.82%) were 1 to 5 years and 19 (41.30%) were 6 to 12 years of age. All the patients presented with complaints of cough, fever and breathlessness of variable durations. Twenty three (50%) children had history of pneumonia and treatment prior to development of empyema. Thirty five (76.08%) children had right-sided and 11 (23.91%) had left-sided empyema. Thirty nine (84.78%) children were successfully treated with tube thoracostomy, systemic antibiotics and other supportive measures. Seven (15.21%) children failed to respond with above and needed decortications. Most commonly isolated bacteria were Pseudomonas (n = 12) and Staphylococcus aureus (n = 7). The average length of hospital stay in patients with tube thoracostomy was 15.35 days, and in patients who needed decortications was 16.28 days following thoracotomy. There was no mortality amongst above treated children. Conclusions: Majority of children with empyema thoracis are manageable with tube thoracostomy, antibiotics, physiotherapy and other supportive treatment. Few of them who fail to above measures need more aggressive management.
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Foreign body in the ear, nose and throat in children: A five year review in Niger delta
Matilda U Ibekwe, Lucky O Onotai, Barbara Otaigbe
January-April 2012, 9(1):3-7
DOI:10.4103/0189-6725.93293  PMID:22382096
Background: Foreign body (FB) injury in children is becoming increasingly common in developing countries. Children tend to be curious and exploratory hence the easily accessible orifices tend to be at risk of this form of injury. This study is to determine the prevalence, treatment outcome and complication of foreign body injury to the ear, nose and throat in children. Materials and Methods: A retrospective study of all pediatric patients with FB in the ear, nose and throat (ENT) seen at the ENT surgery department and children emergency ward of our institution from January 2004 to December 2008. Demographic and clinical data were obtained from records of the patients and analyzed. Results: There were 202 children with ENT injuries within the period under study, 181 (89.60%) had FB injuries. There were 94 males (51.93%), 87 females (48.07%) male:female ratio of 1.1:1. Age ranged from 2 months -15 years with a mean of 3.71 ± 2.59 years, a mode of 3 years. Most of the patients were below age seven years, highest in the range 0-3 years (61.8%). The nose recorded the highest injury 88 (48.62%). Commonest FB was ornamental bead 51 (28.17%) found both in the ear and the nose. Fish bone constituted the highest FB in the laryngotracheobronchial (LTB) tree and the oesophagus. Twenty-three cases (12.7%) had emergency tracheostomy done. Conclusion: Foreign body injuries constitute a significant portion of pediatric ENT trauma in clinical practice. The under 3 years are most affected. There is need for more public education of parents and care givers so as to prevent this avoidable injury.
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Management of postoperative enterocutaneous fistulae in children: A decade experience in a single centre
Francis A Uba, Stella C Uba, Emmanuel O Ojo
January-April 2012, 9(1):40-46
DOI:10.4103/0189-6725.93302  PMID:22382103
Background: Enterocutaneous fistula (ECF) in children poses a lot of management challenges due to sepsis, malnutrition, fluid and electrolyte deficits, which are frequent complications. Knowledge of prognostic factors of postoperative ECF is essential for therapeutic decision-making processes. This study examined the variables that relate to the outcomes of management of ECF in children. Patients and Methods: Consecutive children who were managed for postoperative ECF in our unit between 2000 and 2009 were evaluated. Data were analysed for clinical features, management and its outcome. Results: A total of 54 patients were managed for ECF. Majority of the fistulas were due to operation for infective causes, with typhoid intestinal perforation ranking the highest. Overall, spontaneous closure without operative intervention occurred in 29 (53.7%) patients. Twenty-one (38.9%) patients required restorative operations to close their fistulas, which was successful only in 12 (22.2%) patients. There was a strong correlation between high-output fistulas (jejunal location) and surgical closure (P<0.001). Hypoalbuminaemia and jejunal location profoundly resulted in non-spontaneous closure of ECF (P<0.001) and were associated with high morbidity (P<0.001). Thirteen (24.1%) patients died due to hypokalaemia, sepsis and hypoproteinaemia/hypoalbuminaemia. Conclusions: Majority of the ECF in children closed spontaneously following high-protein and high-carbohydrate nutrition. Hypoalbuminaemia and jejunal location were important prognostic variables resulting in non-spontaneous closure, while hypokalaemia, sepsis and hypoproteinaemia/hypoalbuminaemia were associated with high mortality in children with ECF.
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CASE REPORTS
Ruptured liver abscess in a neonate
Prashant Jain, Ashwani Mishra, Vyom Agarawal
January-April 2012, 9(1):80-82
DOI:10.4103/0189-6725.93320  PMID:22382113
We report a rare case of 17-day-old neonate, diagnosed to have ruptured liver abscess secondary to Methicillin-resistant Staphylococcal aureus infection. The child presented with septicemia and abdominal distension. On exploration, there was pyoperitoneum with ruptured liver abscess.
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Giant bladder diverticulum: A rare cause of bladder outlet obstruction in children
William Appeadu-Mensah, A. A. J. Hesse, Mensah B Yaw
January-April 2012, 9(1):83-87
DOI:10.4103/0189-6725.93323  PMID:22382114
Giant bladder diverticula are rare causes of bladder outlet obstruction in children and have rarely been reported. [1] In this paper, we present three children with giant bladder diverticula who presented with bladder outlet obstruction within a year. Micturating cystourethrogram is important for investigating bladder outlet obstruction in children and was used to confirm the diagnosis in all the patients. The relationship between the diverticula and ureters varied, with the ureters running either through the wall of the diverticulum and opening directly into the bladder, or opening into the diverticulum. In one patient, there was a recurrence, which was excised successfully. Excision is important to reduce the risk of recurrence.
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An unusual foreign body in an inguinal hernia sac: Case report and literature review
Go Miyano, Toshiaki Takahashi, Tsubasa Takahashi, Geoffrey J Lane, Yoshifumi Kato, Tadaharu Okazaki, Atsuyuki Yamataka
January-April 2012, 9(1):66-67
DOI:10.4103/0189-6725.93312  PMID:22382108
A 13-month-old boy accidentally ingested a 5 cm dressmaker's pin. On presentation, the pin was in the duodenum and there was a right inguinal hernia. After 17 days, the pin failed to progress. At surgery, the sac contained appendix perforated by the pin. This is the first case in the literature.
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Chylous ascites caused by resection of a choledochal cyst
Tatsuzo Mizukami, Tadao Okada, Shohei Honda, Hisayuki Miyagi, Masashi Minato, Satoru Todo
January-April 2012, 9(1):68-70
DOI:10.4103/0189-6725.93313  PMID:22382109
Chylous ascites is a rare complication of abdominal surgery in children. Particularly, reports of postoperative chylous ascites are rare. This report describes the very rare case of a 10-month-old girl complicated by chylous ascites after resection of a choledochal cyst with a Roux-en-Y hepaticojejunostomy, who was successfully treated medically. To date, we have found a few cases of postoperative chylous ascites in the paediatric literature. To the best of our knowledge, this is the first report of chylous ascites after the resection of a choledochal cyst in a child who was successfully treated solely by no fasting. No fasting might be a therapeutic option of paediatric postoperative chylous ascites after the resection of a choledochal cyst if the outflow volume of chylous ascites is small.
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EDITORIAL COMMENTARY
Septic arthritis of the hip joint in children is an emergency
Erich Rutz
January-April 2012, 9(1):1-2
DOI:10.4103/0189-6725.93292  PMID:22382095
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ORIGINAL ARTICLES
Pre-operative haematological investigations in paediatric orofacial cleft repair: Any relevance to management outcome?
Anthony T Adenekan, Aramide F Faponle, Fadekemi O Oginni
January-April 2012, 9(1):52-56
DOI:10.4103/0189-6725.93306  PMID:22382105
Aim and Objectives: To determine the value of routine pre-operative haematologic investigations in children undergoing orofacial cleft repair. Background: Although routine pre-operative laboratory screening tests are carried out traditionally, some studies suggest that they are not absolutely necessary in the management of elective surgical patients. Materials and Methods: This is a prospective cohort study carried out at a tertiary health facility located in Nigeria. A review of the laboratory investigations in 116 paediatric orofacial cleft patients undergoing surgery during a 6-year period was undertaken. Pre-operative laboratory investigations and peri-operative transfusion records were analysed for the frequency and impact of abnormal results on treatment plan and outcome using the Statistical Packages for the Social Scientists 16.0. Results: All the children had pre-operative packed cell volume (PCV) check on admission for surgery. The PCV ranged from 23% to 43%, mean was 32.9 (±3.7%). Twenty-two children (18.6%) had sub-optimal PCV (<30%). Patients with the lowest PCV values (23% and 26%) were transfused pre-operatively. The lowest post-operative PCV was 23%, mean 30.8 (±3.3%). There was no occasion of post-operative blood transfusion. Eighty-six patients (72.9%) had full or partial serum electrolyte and urea analysis. Screening for sickle-cell disease was rarely done. Fourteen intra- and post-operative complications were recorded. None of these were predictable by the results of pre-operative screening tests carried out. All the children were discharged home in satisfactory condition. Conclusions: Routine laboratory testing has minimal impact on management and outcome of orofacial cleft surgeries. However, haematocrit screening may be appropriate, particularly in clinically pale patients.
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CASE REPORTS
Gastric teratoma in a 6-month-old boy
Peer Wildbrett, Hagen Graf Einsiedel, Björn Lange, Holger Lode, Winfried Barthlen
January-April 2012, 9(1):71-73
DOI:10.4103/0189-6725.93315  PMID:22382110
Gastric teratomas are very rare embryonal neoplasms, accounting for 2.6% of all perinatal diagnosed germ cell tumours. About 85% are well-differentiated mature lesions and about 15% are immature tumours with the potential of malignant transformation. The recommended therapy for gastric teratomas is surgical excision. We present the case of a 6-month-old boy with an incidentally detected epigastric mass. The histological examination revealed a mature gastric teratoma. The diagnostic imaging, therapy and postoperative follow-up are discussed.
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Idiopathic gastric perforation in an asplenic infant
Alex Olsen, Leigh McGill
January-April 2012, 9(1):74-76
DOI:10.4103/0189-6725.93317  PMID:22382111
Introduction: The cause of idiopathic gastric perforations in neonates remains unknown. Perforations of the abdominal oesophagus, stomach and duodenum in infants and children are the rarest type of intestinal perforations. There are 21 reported cases of an idiopathic gastric rupture in non-neonates. Case Report: A 6-week-old boy presented with nausea, vomiting and decreased oral intake. Physical examination revealed a firm, distended abdomen tender. Abdominal lateral decubitus radiograph revealed massive free air. Patient was found to have an idiopathic gastric perforation of the greater curvature with incidental findings of asplenia. Conclusion: Paediatric abdominal foregut perforations have diverse aetiologies. The foregut is the least likely portion of the gastrointestinal tract to perforate in children. The aetiology is unknown but there are many postulated theories. We present a case of an idiopathic gastric rupture involving the greater curvature of 6-week-old boy with incidental findings of being asplenic.
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Self-bougienage of oesophageal stricture by an 8-year-old child
Carsten Mueller, Winfried Barthlen, Peer Wildbrett
January-April 2012, 9(1):77-79
DOI:10.4103/0189-6725.93318  PMID:22382112
Oesophageal corrosive injuries have a high potential to result in stricture formation with the requirement for repeat oesophageal dilation. Especially in children, oesophageal bougienage is performed under general anaesthesia or strong sedation. In developing countries without comprehensive medical care, this service might not be available. We report the case of daily oesophageal self-bougienage performed by an 8-year-old Afghan child as highly effective treatment of recurrent oesophageal stricture formation after caustic substance ingestion.
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INNOVATION
The "diamond port configuration": A standardised laparoscopic technique for adolescent intestinal resection and anastomosis
Richard Hill, Niyi Ade-Ajayi, Ashish Desai, Joseph Nunoo-Mensah
January-April 2012, 9(1):57-61
DOI:10.4103/0189-6725.93309  PMID:22382106
Background: Familiarity with technique and repetition enhance efficiency during laparoscopic surgery. This is particularly important when undertaking complex bowel resections. We report a standardised protocol that includes theatre layout, patient position and port insertion, which we believe facilitates excellent abdominal access and ergonomics and has the potential to shorten the duration of the team-learning curve. Materials and Methods: A strategic unit development plan led to the commencement of a laparoscopic service for adolescents with bowel disorders. A standardised protocol for intestinal resections was agreed upon at a monthly Paediatric Minimal Access Group meeting. This covered patient position, port insertion, technical aspects of intestinal resection and perioperative management. In particular, a diamond configuration for ports was agreed upon. Data were prospectively collected, and included patient demographics, operative times, conversion rates and postoperative outcomes. Unless otherwise indicated, data are presented as medians with ranges. Results: Seven procedures were carried out in six patients (three female) aged 14 (11-14) years. Access to the entire abdominal cavity, vision and ergonomics were excellent in all. There were no conversions to open surgery. In all procedures, the technique was considered safe and effective. The length of hospital stay was 6.5 (5.8-14) days. Conclusion: A standardised protocol including the use of the diamond port configuration has several putative advantages for laparoscopic bowel resections and anastomoses. These include efficiency, reproducibility, predictability, good visibility and excellent ergonomics. We recommend this approach as a means to shorten the procedure-specific learning curve of the laparoscopic team.
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LETTER TO THE EDITOR
Amyand's like hernia
Ibrahima Sall, Balla Diop, Eric Wilson, Serigne Mamadou Sarré
January-April 2012, 9(1):88-89
DOI:10.4103/0189-6725.93324  PMID:22382115
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ORIGINAL ARTICLES
Feasibility of a tubularised incised-plate urethroplasty with double de-epithelised dartos flaps in a failed hypospadias repair: A preliminary report
Abdullah Yildiz, Mirko Bertozzi, Melih Akin, Antonino Appignani, Marco Prestipino, Ali Ihsan Dokucu
January-April 2012, 9(1):8-12
DOI:10.4103/0189-6725.93294  PMID:22382097
Background: Reoperation for failed hypospadias has been considered to be seriously problematic. The dense fibrotic tissue causes difficulties in wound healing and increases the rate of complications. The tubularised incised-plate urethroplasty (TIPU) method has become a preferred method for all varieties of hypospadias in the past decade. However, fistulas are still one of the most common complications of this technique. The aim of this paper was to present the preliminary results of TIPU procedure with double de-epithelised dartos flaps in failed hypospadias repair. Materials and Methods: All patients were treated between January 2009 and August 2010 by the same procedure, utilising TIPU with double de-epithelised dartos flaps. Vascularised ventral dartos flaps harvested from each side of the penis with their vascular supply were transposed to cover the suture line by wrapping them from either side of the penis. Results: There were 21 boys with failed hypospadias: 20 had previously undergone TIPU, and one Koyanagi repair. Patients presented with very large fistulas in four and dehiscence in 17. Repair of the failed hypospadias using TIPU with double de-epithelised dartos flaps was quite successful, with no fistula recurrence or dehiscence observed. Conclusion: The preliminary results showed that TIPU with double de-epithelised dartos flaps is a useful method of successfully repairing failed hypospadias.
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Intralesional bleomycin and sodium tetradecyl sulphate for haemangiomas and lymphangiomas
Man Mohan Harjai, Manvendu Jha
January-April 2012, 9(1):47-51
DOI:10.4103/0189-6725.93304  PMID:22382104
Background: To compare the efficacy of intralesional bleomycin and sodium tetradecyl sulphate in treatment of haemangiomas and lymphangiomas. Patients and Methods: Between July 2007 and May 2009, 120 patients, sixty each of peripheral haemangiomas and lymphangiomas, were administered intralesional injection of bleomycin in a dose of 0.5-1 U/kg in children less than one year of age and 1 to 15 units in children more than one year of age and 1 to 3 ml of 2% sodium tetradecyl sulphate, depending on the size of the lesion at intervals of 14 days. Patients more than 20 years of age and those with diffuse or visceral lesions were excluded from the study. Results: Complete resolution occurred in 16 patients (53%) of haemangiomas and 14 patients (47%) of lymphangiomas treated with bleomycin, while the results were 12 patients (40%) and 10 patients (33%), respectively, in sodium tetradecyl sulphate group. The satisfactory resolution (resolution more than 50%) occurred in eight patients (27%) of haemangiomas and lymphangiomas groups treated with bleomycin, while the results were six patients (20%) and eight patients (27%), respectively, in sodium tetradecyl sulphate group. Poor response rate was observed in six patients (20%) of haemangiomas and eight patients (27%) of lymphangiomas of bleomycin group and 12 patients (40%) of haemangiomas and lymphangiomas in sodium tetradecyl sulphate group. No pulmonary fibrosis or other serious side effects were found. Conclusions: Intralesional bleomycin and sodium tetradecyl sulphate are effective sclerosants in peripheral haemangiomas and lymphangiomas, but bleomycin was found to be more efficacious.
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Single-stage Modified Duhamel procedure for Hirschsprung's disease : Our experience
Paras R Kothari, Parag J Karkera, Abhaya R Gupta, Rahul Kumar Gupta, Gursev R Sandlas, Ritesh R Ranjan, Krushna K Kesan, Namrata Kothari
January-April 2012, 9(1):13-16
DOI:10.4103/0189-6725.93295  PMID:22382098
Introduction: Primary single-stage pull-through for Hirschsprung's disease (HD) has been reported to give comparable surgical outcomes to staged operations with less morbidity. Herein, we present our experience with single-stage Modified Duhamel procedure for management of HD. Patients and Methods: This was a review of 48 cases of HD who underwent single-stage Modified Duhamel procedure without a protective colostomy. Results: The age at surgery ranged from 6 months to 10 years (median - 9 months, mean - 2.3 years). The average weight of the child was 7.2 kg (range, 4.9-22 kg). 38 (79.2%) patients had classical rectosigmoid HD, the rest being long segment HD (the proximal most level being the splenic flexure). The average duration of surgery was 175 minutes (range, 130-245 minutes). The average blood loss was 45 ml. The average hospital stay was 7.2 days (range: 6-10 days). The major postoperative complications (n=3) included postoperative adhesive intestinal obstruction, anastomotic leak and persistent constipation due to residual aganglionosis. Each required a re-exploration. Minor complications included surgical site infection (n=3) and post-operative enterocolitis (n=3), which were managed conservatively. Six patients had constipation for a limited period post-operatively. All patients have a satisfactory functional outcome and normal development and growth. Conclusions: For HD, we recommend that single-stage Modified Duhamel procedure should be the preferred approach in view of its low morbidity, satisfactory functional outcome and avoidance of stoma, multiple surgeries and economic benefit in view of decreased hospital stay.
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Feasibility of a simple drainage system in Cameroonian children after thoracotomy and decortication for empyema thoracis
Bernadette Ngo Nonga, Bonaventure Jemea, Faustin Mouafo Tambo, Nelly Kamgaing, Jean Bahebeck, Maurice A Sosso
January-April 2012, 9(1):27-31
DOI:10.4103/0189-6725.93298  PMID:22382101
Background: To analyse the outcome of children with empyema thoracis treated by decortication followed by a simple drainage system. Patients and Methods: Retrospective chart review from July 2001 to June 2010 of all cases of children who had a thoracotomy for empyema. We used an endotracheal tube as chest drain and a urinary bag as a collector. Statistical analyses were done using EXCEL and SPSS 9.0. Results: Forty one children underwent thoracotomy and decortication for empyema, there were 23 boys and 18 girls with a sex ratio of 1, 21. The mean age was 2½ years with a minimum of 1 month and a maximum of 15 years of age; 27 children were below two years of age. All the patients have received antibiotic for a long period before surgery. The culture was negative, except in two cases where we found Klebsiella pneumonia and Staphylococcus aureus. In five cases, the empyema was due to Mycobacterium tuberculosis. Three children presented a complication: One child had a persistent purulent drainage for 2 weeks; another one was re-operated upon because of necrotic lung abscess and one child died of sepsis. In most cases, the chest tube was removed between day 4 and day 6 post-operatively. The average length of hospital stay after the surgery was 10 days. Conclusion: Thoracotomy and decortication in children with empyema can be safely done in Cameroon using a simple drainage system with good results compared to those in the literature.
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SYMPOSIUM
Generating evidence for surgical practice in Africa: The role of clinical research
Jonah Musa
January-April 2012, 9(1):62-65
DOI:10.4103/0189-6725.93310  PMID:22382107
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