Characteristics and Clinical Outcomes of Children With Wilms' Tumour: A 15-year Experience in a Single Centre in Nigeria

BACKGROUND

Wilms' tumor (WT) is the most common paediatric renal tumor and is one of the most treatment-responsive solid tumours. Survival from Wilms tumour (WT) in sub-Saharan Africa remains dismal as a result of late presentation, treatment abandonment and infrastructure deficit. The purpose of this study was to analyze the clinical outcome of children with Wilms tumour managed in a Nigerian referral centre over a 15-year period.

METHODS

This is a retrospective study of children with WT (nephroblastoma) who were treated at our institution between January 2006 and December 2020. Clinical characteristics, treatments, and outcomes were analyzed.

RESULTS

Thirty-five patients were identified. The median age at diagnosis was 36 months including 22 (62.9 %) females. Twenty-six (74.3 %) had advanced (stage III & IV) disease. Confirmatory histology was available for 16 patients ((45.7 %) among which 10 (62.5 %) were mixed type. The right kidney was affected in 18 patients (51.4 %), left in 15 (42.9 %) and 2 were not documented. Preoperative chemotherapy was given in 22 (62.9 %) patients and 13 (37.1) patients had primary nephrectomy. Eight (22.9 %) patients died during treatment (from disease or treatment related causes), and one abandoned treatment. A total of 26 patients completed treatment. Out of these, 8 (30.8 %) were lost to follow up, four patients died and 14 (53.8 %) patients survived at a median follow-up period of 18 months. The survival decreased with advancing stages of the disease, p = 0.002.

CONCLUSIONS

Majority of children with Wilms tumour in our practice presented with advanced disease. Death during treatment, treatment abandonment and lost to follow up were common.

LEVEL OF EVIDENCE

Level II.

TYPE OF STUDY

Retrospective Study.

Neonatal abdominal cocoon arising from atypical sequelae of intestinal malrotation: A case report

Background: Abdominal cocoon (AC) is the partial or complete encasement of the intestines and sometimes other abdominal organs by a fibro-collagenous sac causing varied presentations of intestinal obstruction. It has been found in all age groups from neonates to the elderly although neonatal AC is quite rare and only very few cases have been reported. In neonates, the presentation could mimic other causes of partial or complete intestinal obstruction and preoperative diagnosis is usually difficult. Case Presentation: We report an atypical sequela of intestinal malrotation causing neonatal intestinal obstruction due to omental encasement of the small and large bowel. The diagnosis was made intraoperatively though contrast gastrointestinal series suggested the partial obstruction at the duodenal-jejunal level. The patient made a good postoperative recovery after extraction of the bowel from the cocoon (omental sac), partial omentectomy, and Ladd’s procedure. Conclusion: A neonatal abdominal cocoon caused by an omental encasement in a malrotated intestine is a unique presentation and a rare cause of neonatal intestinal obstruction.

Awareness and Practice of Laparoscopic Surgery among Trainee Surgeons in Nigerian Tertiary Hospitals

BACKGROUND

The advent of laparoscopy has been a notable landmark in surgery; however, there is a slow progress to widespread utilization in West Africa.

AIMS

To study the awareness and practice of laparoscopic surgery among trainee surgeons in Nigerian tertiary hospitals while highlighting measures to mitigate challenges.

MATERIALS AND METHODS

A cross-sectional study conducted during a 2-week West African College of Surgeons update course in September 2018 at Ilorin, Kwara State, Nigeria. A structured questionnaire was distributed to registered trainee surgeons for completion. Data collated included demographics, cognitive knowledge, common procedures in centres, referrals, routine practice, performing laparoscopic surgeon, and routine practice. Statistical analysis was done using IBM SPSS Statistics for Windows version 20 Armonk NY USA.

RESULTS

There were 184 registered trainee surgeons with 80 respondents from 26 Nigerian tertiary health facilities. The age range was 29 -51 years (mean 35.0 ± 4.4) and a mean training duration of 3.3 years (R2= 0.12). Seven (63.6%) senior registrars and 54(76.3%) registrars were reported as first assistants in laparoscopic surgeries performed but no unassisted surgery. Four (15.4%) represented centres had no laparoscopy equipment or expertise. A non-referral rate of 52/80(65.0%) for laparoscopic surgery was recorded.

CONCLUSION

Laparoscopic surgery is practiced in some Nigerian tertiary hospitals with trainee surgeons actively involved in performing these surgeries. However, there is limited unassisted experience by trainee surgeons in the basic laparoscopic surgeries predominantly performed.

Short-Term Outcomes of Treatment of Boys with Posterior Urethral Valves

Background:

Posterior urethral valve (PUV) is a significant cause of morbidity and mortality among male children resulting in renal failure in 25%–30% before adolescence irrespective of initial treatment. This study aimed at evaluating the early outcomes of children managed for PUV.

Materials and Methods:

This was a prospective study of all children who were treated for PUV between 2012 and 2016 at a single referral institution. Information reviewed included demographic and clinical data, imaging findings, pre- and post-operative serum electrolytes, and postoperative renal outcomes.

Results:

Twenty-nine male children were managed for PUV at a median age of 6 months including 7 (24.1%) neonates. Two (6.9%) patients had antenatal diagnosis. Micturating cystourethrogram confirmed PUV in all patients. Fourteen (48.3%) patients had impaired renal function (IRF) at presentation and 8 (57%) had improved renal function (RF) after initial catheter drainage. The mean creatinine at presentation was 1.86 ± 1.69 mg/dl and the mean serum creatinine following initial catheter drainage was 0. 93 ± 0.49 mg/dl (P = 0.003). For those patients with normal RF, the mean creatinine at presentation was 0.81 ± 0.22 mg/dl versus 0.74 ± 0.21 mg/dl (P = 0.012), following initial catheter drainage. Children with IRF on admission had mean creatinine at presentation of 2.61 ± 2.00 mg/dl compared to 1.17 ± 0.53 mg/dl (P = 0.002) after initial catheter drainage. Valve ablation was achieved with Mohan's valvotome in 26 (96.3%) patients. All patients had good urine stream at a median follow-up of 5 months. Four (13.8%) patients developed IRF at follow-up. Renal outcomes of patients presenting before 1 year and those presenting after 1 year were similar. Two children died preoperative of urosepsis and one out of hospital death given an overall mortality of 10.3% (n = 3).

Conclusion:

There was significant improvement in RF after initial catheter drainage. The incidence of IRF at follow-up was 13.8%. Long-term follow-up is necessary to identify patients at risk of end-stage renal disease.

Genomic analyses in African populations identify novel risk loci for cleft palate

Orofacial clefts are common developmental disorders that pose significant clinical, economical and psychological problems. We conducted genome-wide association analyses for cleft palate only (CPO) and cleft lip with or without palate (CL/P) with ~17 million markers in sub-Saharan Africans. After replication and combined analyses, we identified novel loci for CPO at or near genome-wide significance on chromosomes 2 (near CTNNA2) and 19 (near SULT2A1). In situ hybridization of Sult2a1 in mice showed expression of SULT2A1 in mesenchymal cells in palate, palatal rugae and palatal epithelium in the fused palate. The previously reported 8q24 was the most significant locus for CL/P in our study, and we replicated several previously reported loci including PAX7 and VAX1.

Analysis of Presentations and Outcomes of Care of Children with Disorders of Sexual Development in a Nigerian Hospital

STUDY OBJECTIVE

To describe the presentation, diagnosis, management, and short-term outcome of children with disorders of sexual development (DSD) in the context of multidisciplinary team care.

DESIGN

Prospective descriptive study.

SETTING

University Teaching Hospital.

PARTICIPANTS

All children who presented with genital ambiguity.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Records of all patients diagnosed and managed for DSD between January 2011 and December 2016 were reviewed. The care pathway included clinical, laboratory, internal genitalia evaluation, and panel (including parents) meeting.

RESULTS

Fifteen children presented with DSD at a median age of 20 months. Only 5/15 (33.3%) presented in the neonatal period. Ten of fifteen patients (66.7%) presented with genital ambiguity. Ovotesticular DSD was the most common diagnosis (9/15; 60%). Seven of the patients were genetically female (46, XX), 1 was genetically male (46, XY) and 1 without genetic diagnosis. Six patients were assigned male gender and they underwent male genitoplasty. Five of them had excision of Müllerian structures with gonadectomy. Three of fifteen patients (20%) were diagnosed as 46, XX DSD, at a median age of 7 years. All of them were due to congenital adrenal hyperplasia and underwent female genitoplasty. Two patients were diagnosed as XY, DSD. They were both raised as female at presentation and were reassigned male sex. Both had urethroplasty done. Four patients had postoperative urethrocutaneous fistula and 1 had partial wound dehiscence. The median follow-up period was 21 months (interquartile range, 2-26 months).

CONCLUSION

The frequency of ovotesticular DSD is high in our setting. The decision of sex assignment was finally made at a median age of 7.5 months in most of our patients with satisfactory short-term surgical outcome.

Identification of paternal uniparental disomy on chromosome 22 and a de novo deletion on chromosome 18 in individuals with orofacial clefts

Background

Orofacial clefts are the most common malformations of the head and neck region. Genetic and environmental factors have been implicated in the etiology of these traits.

Methods

We recently conducted genotyping of individuals from the African population using the multiethnic genotyping array (MEGA) to identify common genetic variation associated with nonsyndromic orofacial clefts. The data cleaning of this dataset allowed for screening of annotated sex versus genetic sex, confirmation of identify by descent and identification of large chromosomal anomalies.

Results

We identified the first reported orofacial cleft case associated with paternal uniparental disomy (patUPD) on chromosome 22. We also identified a de novo deletion on chromosome 18. In addition to chromosomal anomalies, we identified cases with molecular karyotypes suggesting Klinefelter syndrome, Turner syndrome and Triple X syndrome.

Conclusion

Observations from our study support the need for genetic testing when clinically indicated in order to exclude chromosomal anomalies associated with clefting. The identification of these chromosomal anomalies and sex aneuploidies is important in genetic counseling for families that are at risk. Clinicians should share any identified genetic findings and place them in context for the families during routine clinical visits and evaluations.

Novel GREM1 Variations in Sub-Saharan African Patients With Cleft Lip and/or Cleft Palate

OBJECTIVE

Cleft lip and/or cleft palate (CL/P) are congenital anomalies of the face and have multifactorial etiology, with both environmental and genetic risk factors playing crucial roles. Though at least 40 loci have attained genomewide significant association with nonsyndromic CL/P, these loci largely reside in noncoding regions of the human genome, and subsequent resequencing studies of neighboring candidate genes have revealed only a limited number of etiologic coding variants. The present study was conducted to identify etiologic coding variants in GREM1, a locus that has been shown to be largely associated with cleft of both lip and soft palate.

PATIENTS AND METHOD

We resequenced DNA from 397 sub-Saharan Africans with CL/P and 192 controls using Sanger sequencing. Following analyses of the sequence data, we observed 2 novel coding variants in GREM1. These variants were not found in the 192 African controls and have never been previously reported in any public genetic variant database that includes more than 5000 combined African and African American controls or from the CL/P literature.

RESULTS

The novel variants include p.Pro164Ser in an individual with soft palate cleft only and p.Gly61Asp in an individual with bilateral cleft lip and palate. The proband with the p.Gly61Asp GREM1 variant is a van der Woude (VWS) case who also has an etiologic variant in IRF6 gene.

CONCLUSION

Our study demonstrated that there is low number of etiologic coding variants in GREM1, confirming earlier suggestions that variants in regulatory elements may largely account for the association between this locus and CL/P.

EFFICACY AND SAFETY OF ORAL KETAMINE PREMEDICATION IN CHILDREN UNDERGOING DAY CASE SURGERY

BACKGROUND

Oral premedication for paediatric age group is an uncommon practice amongst anaesthetists in Nigeria. Both parents and the child suffer some form of emotional or psychological distress.

AIM

To determine the efficacy and safety of oral formulated ketamine for premedication in children scheduled for ambulatory surgeries.

METHODS

Seventy three children aged 1 - 6 years with American Society of Anesthesiologists (ASA) physical status I-II were prospectively studied. They were assigned randomly to receive either 5 mg/kg (Group A), 10 mg/kg (Group B), or no ketamine (Group C).The children were observed for acceptance of premedication, sedation and anxiolysis at 10, 20 and 30 minutes after drug administration. Behavior/response of each child at the time of separation from parents, intravenous access, and acceptance of facemask for induction, postanaesthetic arousal state and complications were also recorded.

RESULTS

There were 73 children in this study with a mean age of 37.4±18.0 months. The groups were comparable in age. The studied agent was tolerated by both groups that received premedication with no significant difference (P 0.73). Adequate sedation and anxiolysis were observed in groups A and B, (52%, 84%) and (68%, 88%) respectively. However, more children in group B (82.6%) had satisfactory behaviour at separation from parents and a better acceptance of anaesthetic face mask (64%) at induction than those in groups A and C (33.3%, 21.7%, respectively). No side effect was recorded in either of the premedication groups or the control group.

CONCLUSION

Oral ketamine is acceptable and safe premedication for children. It provided good sedation, relieved anxiety and had no side effect in the children at the studied doses.

Medical students' perception of objective structured clinical examination: a feedback for process improvement

BACKGROUND

Medical educators have always been desirous of the best methods for formative and summative evaluation of trainees. The Objective Structured Clinical Examination (OSCE) is an approach for student assessment in which aspects of clinical competence are evaluated in a comprehensive, consistent, and structured manner with close attention to the objectivity of the process. Though popular in most medical schools globally, its use in Nigeria medical schools appears limited.

OBJECTIVES

This study was conceived to explore students' perception about the acceptability of OSCE process and to provide feedback to be used to improve the assessment technique.

DESIGN

A cross-sectional survey was conducted on final-year medical students, who participated in the final MBBS surgery examination in June 2011. A 19-item self-administered structured questionnaire was employed to obtain relevant data on demographics of respondents and questions evaluating the OSCE stations in terms of the quality of instructions and organization, learning opportunities, authenticity and transparency of the process, and usefulness of the OSCE as an assessment instrument compared with other formats. Students' responses were based on a 5-point Likert scales ranging from strongly disagree to strongly agree. The data were analyzed using SPSS, version 15 (SPSS, Inc, Chicago, IL).

SETTING

The study took place at the University of Ilorin, College of Health Science.

PARTICIPANTS

A total of 187 final-year medical students were enrolled in to the survey.

RESULTS

Of 187 eligible students, 151 completed the self-administered questionnaire representing 80.7% response rate. A total of 61 (40.4%) students felt that it was easy to understand written instructions at the OSCE stations. In total, 106 (70.2%) students felt that the time allocated to each station was adequate. A total of 89 (58.9%) students agreed that the OSCE accurately measured their knowledge and skill, and 85 (56.3%) reported that OSCE enhanced their communication skill. Of the respondents, 80 (53%) felt that OSCE caused them to be nervous, and 73 (48.3%) expressed their concern about the interevaluator variability at manned stations. OSCE was perceived to be the second most fair test format by 53 (35.1%) respondents, and 56 (37.1%) also suggested that OSCE needs to be used much more than the other assessment formats.

CONCLUSION

The findings in this survey appear reassuring regarding students' perception about the validity, objectivity, comprehensiveness, and overall organization of OSCE in the department of surgery. The need to introduce OSCE early in the surgical curriculum is also underscored. The overall feedback was very useful and will facilitate a critical review of the process.

Do geography and resources influence the need for colostomy in Hirschsprung's disease and anorectal malformations? A Canadian association of paediatric surgeons: association of paediatric surgeons of Nigeria survey

BACKGROUND

This survey compared surgical management of Hirschsprung's disease (HD) and anorectal malformations (ARM) in high and low resource settings.

MATERIALS AND METHODS

An online survey was sent to 208 members of the Canadian Association of Paediatric Surgeons (CAPS) and the Association of Paediatric Surgeons of Nigeria (APSON).

RESULTS

The response rate was 76.8% with 127 complete surveys (APSON 34, CAPS 97). Only 29.5% of APSON surgeons had frozen section available for diagnosis of HD. They were more likely to choose full thickness rectal biopsy (APSON 70.6% vs. CAPS 9.4%, P < 0.05) and do an initial colostomy for HD (APSON 23.5% vs. CAPS 0%, P < 0.05). Experience with trans-anal pull-through for HD was similar in both groups (APSON 76.5%, CAPS 66.7%). CAPS members practising in the United States were more likely to perform a one-stage pull-through for HD during the initial hospitalization (USA 65.4% vs. Canada 28.3%, P < 0.05). The frequency of colostomy in females with vestibular fistula varied widely independent of geography. APSON surgeons were less likely to have enterostomal therapists and patient education resources.

CONCLUSIONS

Local resources which vary by geographic location affect the management of HD and ARM including colostomy. Collaboration between CAPS and APSON members could address resource and educational needs to improve patient care.

Outcome of management of complicated extragonadal teratoma in a resource poor setting

BACKGROUND

Extragonadal teratomas (EXGTs) are ubiquitous in the human body; hence, they have varied presentation. In underdeveloped areas presentation and management are affected by socio-economic, cultural and health facilities factors. The aim of this study was to review the outcome of management of complicated EXGT in a tertiary health centre.

MATERIALS AND METHODS

A review data of paediatric patients with EXGT was done between January 1999 and December 2012. Variables reviewed were bio-data, mode of presentation and site of tumour, comorbidity, treatments and outcome. The data was analysed with Statistical Package for Social Sciences (SPSS (R)) version 16.0.

RESULTS

There were 21 complicated EXGT (77.8%) among 27 children, age ranges from 4 days to 16 years (median = 2 years). Male:Female ratio of 1:2. The complications per region of the body at presentation were cervical 4 (66.7%), mediastinal 2 (100%), abdominal 3 (75%) and sacrococcygeal 12 (75%). The complications were respiratory distress 6, intestinal obstruction 5, faecal incontinence 2, bladder outlet obstruction 3, malignant transformation 5, ruptured sacrococcygeal teratoma 2, ulcerated tumour 2, anaemia 3 and malnutrition 3. There were 5 (23.8%) progressive disease post-excision outside our facility. Excision biopsy was successful in 19 (85%) patients two of which had neoadjuvant cytotoxic therapy. Overall mortality was 5 (23.8%) (septicaemia, anaemia, respiratory distress, renal failure) and post-excision mortality was 11.8% (endotracheal tube blockage and progressive disease).

CONCLUSION

Delay presentation (due to local belief, ignorance and poverty) malnutrition, sepsis, malignant transformation characterised presentation of children in this study and the lack of paediatric intensive care unit facility and intensivists compromised survival of children with EXGT.

Is non-operative management still justified in the treatment of adhesive small bowel obstruction in children?

BACKGROUND

Adhesive small bowel obstruction (ASBO) is a feared complication after abdominal operations in both children and adults. The optimal management of ASBO in the pediatric population is debated. The aim of the present study was to examine the safety and effectiveness of non-operative management in ASBO.

PATIENTS AND METHODS

A retrospective review of 33 patients who were admitted for ASBO over a 5-year period was carried out. Follow-up data were available for 29 patients. Demographic, clinical, and operative details and outcomes were collected for these patients. Data analysis was done with SPSS version 15.0. P ≤ 0.05 was regarded as significant.

RESULTS

Out of 618 abdominal surgeries within the 5-year period, 34 admissions were recorded from 29 patients at the follow-up period of 1-28 months. There were 19 boys (65.5%). The median age of patients was 4.5 years. Typhoid intestinal perforation (n = 7), intussusception (n = 6), intestinal malrotation (n = 5), and appendicitis (n = 4) were the major indications for a prior abdominal surgery leading to ASBO. Twenty-five patients (73.5%) developed SBO due to adhesions within the first year of the primary procedure. Of the 34 patients admitted with ASBO, 18 (53%) underwent operative intervention and 16 (47%) were successfully managed non-operatively. There were no differences in sex (P = 0.24), initial procedure (P = 0.12), age, duration of symptoms, and time to re-admission between the patients who responded to non-operative management and those who underwent operative intervention. However, the length of hospital stay was significantly shorter in the non-operative group (P < 0.0001). Five (14.7%) patients had small bowel resection. A 43-day-old child who initially underwent Ladd's procedure died within 15 h of re-admission while being prepared for surgery, accounting for the only mortality (3.4%).

CONCLUSION

Non-operative management is still a safe and preferred approach in selected patients with ASBO. However, 53% eventually required surgery.

Circumcision: perspective in a Nigerian teaching hospital

BACKGROUND

The practice and pattern of male infants circumcised is influenced by culture, religion and socio-economic classification. The debate about the benefits and risks of circumcision has made a hospital-based practice the most acceptable.

OBJECTIVE

The objective of this study is to evaluate the ages, indications, co-morbidity, types and methods of circumcision, usage and mode of anaesthesia and outcome of male circumcision at a tertiary health centre in Nigeria.

MATERIALS AND METHODS

A retrospective review of male circumcision in a paediatric surgery unit was done from January 2002 to December 2007. The data was analysed using SPSS software version 15.

RESULTS

There were 438 boys with age ranged between 6 days and 10 years (median 28 days, mean 53.6 days standard deviation 74.2). Neonatal circumcision (<29 days) was 201 (46%) and 318 (72.6%) of the children were circumcised by the 3 rd month of live. Religion or tradition were the major indicators in 384 (87.7%) patients while phimosis 38 (8.7%), paraphimosis 4 (1%), redundant post circumcision skin 10 (2.3%) and defective prepuce in 2 (0.5%) were other indications. Plastibel™ (PD) was used in 214 (48.9%), classical circumcision 194 (44.2%), guillotine technique (GT) and Gomco™ 10 (2.3%) cases each while 10 (2.3%) had a refashioning/re-excision post previous circumcision. There was an increase in use of PD, drop in the use of GT; and increase in the number of circumcision done over the years. Only 39.7% had anaesthesia administered and complication rate was 6.7%.

CONCLUSION

Neonatal circumcision was highest in the hospital-based circumcision practice, which allowed the expected ideals in the use of devices in a tertiary health centre. However, the low rate of anaesthetic use is unacceptable.

Genitourinary plexiform neurofibroma mimicking sacrococcygeal teratoma

Neurofibromatosis is a common inherited autosomal dominant disease, but genitourinary neurofibroma is rare. The unpredictable nature of neurofibromas has a serious impact on the quality of life of patients, and their management is challenging for clinicians. We present a 9-year-old girl with plexiform neurofibroma of genitourinary system associated with pulmonary hypertension, masquerading as sacrococcygeal teratoma. Intraoperative finding and histological examination of the resected tumor confirmed the diagnosis.

Complicated childhood inguinal hernias in UITH, Ilorin

BACKGROUND

Complicated inguinal hernias pose a threat to the life of the child as well as increase the morbidity associated with management of an otherwise straightforward condition. The aim of this study was to determine the presentation, treatment and management outcome of complicated inguinal hernias in children.

MATERIALS AND METHODS

A retrospective study of all children 15 years and less managed for complicated inguinal hernia between 2002 and 2010. Data obtained included demographic characteristics, presentation, operative findings and outcome.

RESULTS

Complicated hernia rate was 13.9%.There were 41 children, 38 boys (92.7%) and 3 girls. Ages ranged between 4 days and 15 years (Median = 90days). Most were infants (48.8%, n = 20) and neonates accounted for 19.5% (n = 8). Median duration of symptoms prior to presentation was 18 h (range = 2-96 h). Seven patients had been scheduled for elective surgery. Hernia was right sided in 68.3% (n = 28). Symptoms included vomiting (68.3%), abdominal distension (34.1%) and constipation (4.9%); one patient presented with seizures. In 19 (46.3%) patients hernia was reducible while 22(53.7%) had emergency surgery. Associated anomalies included undescended testis (12.2%), umbilical hernia (14.6%). Intestinal resection rate was 7.3% and testicular gangrene occurred in 14.6%. Mean duration of surgery was 60.3 ± 26.7 min. Wound infection occurred in six patients (14.6%). Overall complication rate was 24.4%, 30% in infants. The mortality rate was 2.4% (n = 1).

CONCLUSIONS

Morbidity associated with complicated inguinal hernia is high in neonates and infants. Delayed presentation is common in our setting. Educating the parents as well as primary care physicians on the need for early presentation is necessary.

Laparoscopic inguinal hernia repair in children: a single-centre experience over 7 years

BACKGROUND

To evaluate 209 consecutive children who underwent laparoscopic hernia repair over a 7-year period. Technical details and clinical results are reported.

MATERIALS AND METHODS

A total of 284 open internal rings were closed laparoscopically in 209 children (142 boys and 67 girls, aged 30 days to 15 years, mean 44 months). One 5-mm and two 3-mm instruments were used to access the peritoneal cavity. A 270° anterolateral peritoneal incision was made. The internal inguinal ring was closed with a nonabsorbable suture.

RESULTS

There were no significant intraoperative complications. Length of procedure ranged between 15 and 65 minutes with a mean of 30 minutes. Postoperative hospital stay ranged from 1 to 9 days. Thirty children who presented with a right-sided hernia and 23 with a left hernia (total of 53) were found to have a patent contralateral internal ring on laparoscopy. Mean follow-up was 30 months. There were 2.4% hernia recurrences and cosmesis was excellent.

CONCLUSIONS

Laparoscopic hernia repair in children can be a routine procedure with increasing experience and better learning curve of surgeons. There is clear visualization of structures and vas remains untouched. The recurrence rate is comparable to that of the traditional open approach with a superior cosmetic result.

Prevalence of snoring and symptoms of sleep disordered breathing among primary school pupils in Ilorin, Nigeria

BACKGROUND/AIM

Snoring is the production of sound from the upper aero-digestive tract during sleep due to turbulent airflow This study is to determine the prevalence, pattern, night and daytime symptoms of snoring among nursery and primary school pupils in Ilorin, Nigeria due to its public health importance.

MATERIALS AND METHODS

This cross sectional survey was carried out among nursery /primary school pupils in Ilorin, Kwara state between April and September, 2010. Ten schools were selected randomly from 100 schools sited within the 3LGAs of Ilorin municipality. Also private and public schools with different parental social economic status were selected. The pupils were selected from nursery 2 to primary 6 in each school using the class registers with the aid of a table of random numbers with 1500 children assessed. The parents/guardians were made to fill the questionnaires and same returned with visitations to the schools twice weekly and reminders sent via phone calls. Data were analyzed using EPIINFO 2002 version 2 software.

RESULTS

1500 questionnaires were given out but 909 were completely filled and returned (response rate of 61%.). There were 598(65.8%) non snorers (NSn) and 311(34.2%) snorers (Sn) at different scales with 153 male snorers to 158 female snorers. The ages of the children ranges from 3 to 16 years (mean ± SD, 8.3 ± 4.8 years. The mean age for the Sn was 8.2 and 8.3 for NSn (range 3-6 years). No statistical difference in age, gender or socio-economic status between Sn and NSn. 598(65.8%) were non snorers (NSn) and 311(34.2%) were snorers (Sn) especially in the age groups 3-6 years, 121(38.9%) and above 6 years of age 101(32.7%) and below 3 years were 89(28%).

CONCLUSION

Snoring is an important health problem among the pupils as a significant percentage snores and most of them are between third and sixth year of life.

Pediatric trauma care in Africa: the evolution and challenges

Childhood trauma is one of the major health problems in the world. Although pediatric trauma is a global phenomenon in low- and middle-income countries, sub-Saharan countries are disproportionally affected. We reviewed the available literature relevant to pediatric trauma in Africa using the MEDLINE database, local libraries, and personal contacts. A critical review of all cited sources was performed with an emphasis on the progress made over the past decades as well as the ongoing challenges in the prevention and management of childhood trauma. After discussing the epidemiology and spectrum of pediatric trauma, we focus on the way forward to reduce the burden of childhood injuries and improve the management and outcome of injured children in Africa.

Is intraabdominal drainage necessary after laparotomy for typhoid intestinal perforation?

PURPOSE

This study was designed to compare the safety and effectiveness of routine drainage and nondrainage after emergency laparotomy for typhoid intestinal perforation (TIP).

METHODS

A retrospective review of children 15 years or younger who underwent surgery for TIP from 2002 to 2009 was performed. All children underwent resuscitation and laparotomy and were given antibiotics but were then divided into 2 groups: group I (n = 81), postoperative peritoneal drainage, and group II, (n = 66) no drainage.

RESULTS

There was no demographic difference between the groups (e.g., mean age 9.6 vs 9.0 years; P = .21). There was no significant difference in mean time for return of bowel function (3.8 vs 4.0 days; P = .6), rate of surgical site infection (63% vs 70%; P = .39), wound dehiscence (36% vs 27%; P = .27), anastomotic leak (2.5% vs 1.5%; P = .27), enterocutaneous fistula formation (10% vs 6.1%; P = .40), intraabdominal abscess formation (4% vs 9%; P = .18), or mean length of hospital stay (22 vs 19 days; P = .26).

CONCLUSION

The results of this study clearly show that routine peritoneal drain placement after laparotomy for TIP is unnecessary, and such drains are not effective in reducing the rate of postoperative complications.

Predictor of mortality in children with typhoid intestinal perforation in a Tertiary Hospital in Nigeria

PURPOSE

Typhoid intestinal perforation (TIP) exerts a great toll both on the patients and the surgeons in resource poor countries. Factors that predict mortality in patients with TIP remain controversial. The study aims to determine factors that predict mortality in a Nigerian tertiary facility and to offer strategies for improvement.

MATERIALS AND METHODS

We conducted a retrospective analysis of data of 153 children who underwent surgery for TIP at a Tertiary Hospital in Nigeria over a period of 8 years (January 2002 to December 2009). Data collected included patient demographics, presentation, haemoglobin level (Hgb), presentation-operation interval, type of surgical procedure, nature of peritoneal collection, the number of perforations and duration of surgery. Postoperative complications, duration of hospital stay and outcome were also examined.

RESULTS

There were 99 (64.7%) boys and 54 (35.3%) girls aged 3-15 years, mean (SD) = 9.4 (±3.6) years. There were 105 single perforations and 46 multiple perforations (range 1-32). The surgical procedure was simple 2-layer closure in 128 (83.7%) and segmental resection in 9 (5.9%) children. The mortality was 16 (10.4%). The mean (SD) age of children who survived and those who died was 9.3 (±3.6) years and 10.1 (±4.0) years, respectively; p = 0.446, the mean duration of symptom in children who survived and those who died was 10.3 (±4.9) days and 12.3 (±5.6) days; p = 0.164, and the mean interval between presentation and operation in those who died and those who survived was 29.3 (±25) h and 28.4 (±13.4) h; p = 0.896. Temperature ≥ 38.5°C (p = 0.040), anastomotic leak (p = 0.029) and faecal fistula (p = 0.000) were significantly associated with mortality. Age <5 years (p = 0.675), male gender (p = 0.845), presentation-operation interval ≥24 h (p = 0.940), Hgb less than 8 g/dL (p = 0.058), faeculent peritoneal collection (p = 0.757), number of perforations (p = 0.518) and the surgical technique (p = 0.375) were not related to mortality. Logistic regression analysis showed that only postoperative faecal fistula (p = 0.001; OR = 13.7) independently predicted mortality.

CONCLUSION

Development of postoperative fecal fistula significantly predicted mortality. Prioritizing the prevention of typhoid fever than its treatment and attention to surgical details may significantly reduce mortality of TIP in children in this setting.

Genetic studies in the Nigerian population implicate an MSX1 mutation in complex oral facial clefting disorders

BACKGROUND

Orofacial clefts are the most common malformations of the head and neck, with a worldwide prevalence of 1 in 700 births. They are commonly divided into CL(P) and CP based on anatomic, genetic, and embryologic findings. A Nigerian craniofacial anomalies study (NigeriaCRAN) was set up in 2006 to investigate the role of gene-environment interaction in the origin of orofacial clefts in Nigeria.

SUBJECTS AND METHODS

DNA isolated from saliva from Nigerian probands was used for genotype association studies and direct sequencing of cleft candidate genes: MSX1 , IRF6 , FOXE1, FGFR1 , FGFR2 , BMP4 , MAFB, ABCA4 , PAX7, and VAX1 , and the chromosome 8q region.

RESULTS

A missense mutation A34G in MSX1 was observed in nine cases and four HapMap controls. No other apparent causative variations were identified. Deviation from Hardy Weinberg equilibrium (HWE) was observed in these cases (p = .00002). A significant difference was noted between the affected side for unilateral CL (p = .03) and bilateral clefts and between clefts on either side (p = .02). A significant gender difference was also observed for CP (p = .008).

CONCLUSIONS

Replication of a mutation previously implicated in other populations suggests a role for the MSX1 A34G variant in the development of CL(P).

Challenges and outcomes of management of anterior abdominal wall defects in a Nigerian tertiary hospital

BACKGROUND

Abdominal wall defect presents a great challenge when it is large, ruptured, or associated with other anomalies.

OBJECTIVE

To review the challenges and outcome of management of anterior abdominal wall defects (AAWD).

MATERIALS AND METHODS

A retrospective review of omphalocele and gastroschisis managed over 8 years at our institution.

RESULTS

Omphalocele (n=49) and gastroschisis (n=7) constituted 2.4% of total admission. The median age was 23.5 hours, with male-female ratio of 1:1.1. Term infants were 91.7% and more than 75% weighed above 2.5 kg. The mean maternal age was 28.5±5.87 years and mean parity was 3.1±2.0, with P values of 0.318 and 0.768, respectively. More than 92.9% of infants were out-born, 46 pregnancies (82.1%) were booked, and 51 (91.1%) had at least one ultrasound scan, but only 1 (1.8%) was diagnosed with gastroschisis. Ruptured omphalocele were 11 (6 major, 5 minor) in number, 3 of which presented with enterocutaneous fistula, and 3 (6.1%) were syndromic omphalocele. Positive blood culture confirmed septicaemia in 21 cases (37.5%). Surgical repair was done in 35 cases (62.5%), 44.6% as emergency, and 17.9% as elective. Non-operative management was done in 21 patients (37.5%) and 5 (8.9%) were discharged against medical advice. Median length of hospital stay was 10 days (mean, 15.98±14.38). Postoperative complication rate was 32.1% and overall mortality was 30.4%, with the highest case fatality among gastroschisis (57.1%) and omphalocele major (32.1%).

CONCLUSIONS

There were large numbers of out-born infants due to poor prenatal diagnosis in spite of high instances of antenatal ultrasound scan. Many patients presented with complications that resulted in poor outcome.

Outcomes of surgical treatment of malrotation in children

BACKGROUND

Abnormalities of rotation and fixation of the intestines are of intense interest to the pediatric surgeon, as they are frequently associated with volvulus which has catastrophic consequences when diagnosis is delayed or not even considered. This study evaluates the outcomes of surgical management of intestinal malrotation (IM) in children.

MATERIALS AND METHODS

The medical records of all patients with symptomatic malrotation, who underwent surgery between January 2000 and September 2009, were reviewed. Patients' characteristics, management, complications, and survival were evaluated.

RESULTS

Nine patients (eight boys and a girl) underwent surgery for malrotation at a median age of 15 days. Eight presented with acute symptoms and one with chronic symptoms. All the patients had symptoms of intermittent or complete upper intestinal obstruction, and malrotation was documented by an upper gastrointestinal contrast study in two of them. Volvulus was found at the time of surgery in seven patients, five of whom were neonates. One patient also had associated mesentery cyst. Seven patients were treated by Ladd's operation. One patient with massive bowel gangrene due to volvulus had right hemicolectomy. There was one perioperative death from anastomostic leak. Median length of stay was 9 days. Postoperative bowel obstruction was seen in two patients (one died), resulting in an overall mortality of 22.2%.

CONCLUSIONS

Bowel gangrene from volvulus contributes to mortality, and small bowel adhesive intestinal obstruction is a cause of morbidity and mortality following surgery for IM. Neonates with bilious vomiting should raise the suspicion of malrotation until proven otherwise and given prompt intervention. There is a need for high index of suspicion in babies with bilious vomiting especially when recurrent to prevent devastating complications when present.

Persistent Mullerian duct syndrome: a case report and review of the literature

Persistent Mullerian duct syndrome is a rare form of internal male pseudohermaphroditism, in which Mullerian duct derivatives (uterus and fallopian tubes) are present in a genotypic (46XY) and phenotypic male. Over 150 cases have been reported, mainly from outside the African setting. This article presents an unexpected case encountered in an African setting. Handicaps in the management were unavailability of necessary diagnostic tools as well as lack of finance to assess those available. Although a diagnosis was eventually arrived at and the parents thoroughly counseled, the patient has not represented for definitive surgery.

Pediatric day case surgery: experience from a tertiary health institution in Nigeria

BACKGROUND

The general observation that children achieve better convalescence in the home environment supports the need for adoption of day case surgery, which is gaining considerable acceptance in developing countries. Pediatric surgical service is in great demand in developing countries, and in-patient beds and surgical supplies are insufficient.

METHOD

A prospective collection of data on all pediatric day surgeries (PDSs) by the pediatric surgical unit University of Ilorin Teaching Hospital (UITH, Ilorin, was done. Parents had pre-operative outpatient briefing and postoperative interviews on the second and ninth days for consultation regarding post-operative complications and events at home. Study period was between April 2005 and September 2007 (2(1/2) years).

RESULTS

Of the 660 elective cases, 449 (68.02%) children were recruited as day cases. The male-to-female ratio was 14.3:1. Age ranged between 20 days and 15 years with a mean of 37.6 months and standard deviation (SD) of 34.4 months. Congenital hernias/ hydroceles were the highest indications (71.2%), followed by lump/ masses (12.9%), undescended testes (8.7%), umbilical hernias (4.8%) and thyroglossal duct cyst (2.5%). In 98.9% of cases, the parents resided within 20 km radius of the hospital, and 91.5% of them could reach the hospital within 1 hour. Fathers and mothers of 80.1% and 77.1% of children, respectively, had above-primary education. More than half of the fathers (55%) were civil servants, while 30% were self-employed. The mothers were civil servants in 37.3% of cases, and 34% were self-employed. The average number of outpatient clinic visits before surgery was 2-3 visits (41.2%) with mean interval to surgery of 4-5 weeks (60.3%). Logistics (investigations and availability of operation list) and patient's fitness for surgery were statistically significant delay factors (P= 0.001).

CONCLUSION

Parents reported 14 children to be irritable at home due to pain, while the others reported satisfactory day case experience. No unplanned admission or mortality was recorded, and only 3 (0.8%) parents would not recommend day case surgery to other people.

CONCLUSION

Pediatric day case surgery is feasible for well-selected and monitored cases in our environment. Term neonates with informed parents are suitable for pediatric day case surgery. There is a need for a day case center to reduce waiting list at UITH.

Traumatic diaphragmatic hernia masquerading as left-sided hydropneumothorax: a case report

Traumatic diaphragmatic rupture (TDR) is rare in children and can be easily overlooked because of lack of awareness of late presentation and concomitant injuries. A 4-year-old girl presented with respiratory distress 2 months after a road traffic accident. The initial differential diagnosis was pneumonia or pulmonary tuberculosis with associated pleural effusion. On further assessment, a diaphragmatic hernia was suspected. The initial radiograph showed left hydropneumothorax. Fluoroscopy, follow-up chest radiographs and barium swallow confirmed the diagnosis of left TDR. Surgery was undertaken but unfortunately she did not survive. Awareness of delayed presentation of TDR is essential for prompt management.

Bowel resection in Nigerian children

BACKGROUND

Although bowel resections are commonly done for congenital malformations in children in developed countries, they usually follow neglected and preventable acquired diseases of the intestine in developing countries.

OBJECTIVES

To determine the indications and outcome of bowel resections in children of a developing country in a university teaching hospital.

MATERIALS AND METHODS

Data of the patients operated (from birth to 15 years) was retrospectively collected over eight years (January 1999 to December 2006). The biodata of children included the following: Indications for operation, type of operations, duration of admission, and outcome of treatment including complications. Patients with Hirschsprung's disease were excluded from the study because bowel resection forms part of their definitive surgical management.

RESULTS

There were 70 patients (38 boys and 32 girls). The age ranged between four hours to 15 years (median, five months). There were 16 (22.9%) neonates, 26 (37.1%) infants, and 28 (40%) grown children. The indications were congenital anomalies in the 16 neonates. Also, 23 (88.5%) infants had intussusception, 2 (7.7%) had midgut vovulusm and 1 (3.8%) had congenital small intestine band. Among the grown children, typhoid ileal perforation (TIP) was seen in 14 (50.0%), intussusception in 5 (17.9%), and other causes in nine patients. Overall, intussusception was the most common indication for bowel resection, followed by TIP. A total of 24 patients developed 33 complications. Complications included wound infection in 47.8% and anastomotic leak in 42.8%. The duration of admission ranged between 4-35 days (median, 15 days). The overall mortality was 17.1% -; which was highest among neonates (56.3%), followed by the infants (26.9% -).

CONCLUSION

Bowel resections are mainly done for intussusception and complications of TIP at our centre. Late presentation, preexisting malnutrition, and nonavailability of parenteral nutrition contributed to unacceptable morbidity and mortality.

Pyogenic liver abscess in children: is ruptured appendix still relevant as cause? Case report

Pyogenic liver abscess [PLA] is a rare and life-threatening disease in children. Appendicitis was the leading source of PLA in the pre-antibiotic era, but it essentially has been eliminated in recent times. Most patients with persistent fever after exploratory laparatomy for perforated appendicitis are often found to have residual abdominal collection. We report a 12-year old girl with PLA after laparotomy for perforated appendix. She developed persistent fever and respiratory distress post operatively. Physicians had an impression of pneumonia but abdominal ultrasound showed cystic mass with mobile internal echoes within the right lobe of the liver suggesting an abscess. Patient was successfully managed by percutaneous drainage under ultrasound guidance. Culture of the pus yielded no growth. She was discharged after 7 weeks of hospital stay. Aetiology, evaluation and treatment modalities were reviewed.

Penile shaft sinus: A sequalae of circumcision in urethral duplication

Urethral duplication (UD) is rare congenital anomalies with varied presentation. Careful clinical evaluation of children by specialist would enhance diagnosis, adequate management and reduce occurrence of complication. We present a 12-year-old boy with chronic post circumcision ventral penile sinus that was successfully managed for urethral duplication.

"Growing" meconium cyst in one of a discordant twin: a case report

Introduction

Giant meconium cyst resulting from antenatal bowel perforation is rare and hardly reported in multiple gestations. We found only four documented cases in the electronic literature.

Case presentation

We report a giant meconium cyst in an 11-hour-old Nigerian boy of a discordant twin having ultrasonographic and plain radiographic diagnosis and surgical confirmation. Increasing abdominal girth from 35 cm to 41 cm within four hours of admission without ascites, pneumoperitneum and significant bowel distension make us assumed the meconium cyst to be “growing” in size. We reviewed the literature and proposed that where the fibrinous wall of meconium cyst allows for distensibility and the communication between the perforated bowel and meconium cyst persists, the meconium cyst acting as reservoir may continue to “grow” in size without remarkable intestinal distension probably, until the elastic limit is lost.

Conclusion

Meconium cyst can occur in twin pregnancy, grow to occupy the abdomen almost completely and may cause neonatal apnoea. The outcome is good post surgery.

Pre-hospital care in Nigeria: a country without emergency medical services

OBJECTIVES

Efficient pre-hospital transport (emergency medical services, EMS) is associated with improved outcomes in road traffic injuries (RTI). This study aims to discover possible interventions in the existing mode of transport.

METHODS

Persons bringing all RTI victims to the Emergency room (ER) over a 4-year period and the injury arrival intervals were noted prospectively.

FINDINGS

There were 2,624 patients (1,886 males and 738 females); only 2,046 (78%) had clear documentations of three categories of persons bringing victims to ER: Relatives (REL, 1,081, 52.83%); Police/Federal Road Safety Corps (P/F, 827, 40.42%) and Bystanders (BS, 138, 6.74%). No intervention was provided during transport: Within 1 hour, 986 victims (48.2% of 2,046) arrived ERbrought by P/F (448, 21.9%), REL (439, 21.5% of 2,046), and BS (99, 4.8%). These figures, in each instance, represent 40.6 % of total victims brought by REL; 54.2% by P/F and 71.7% by BS. However, after 6 hours, REL were the main active group as they brought 94.5% (359 of 380) patients of this period. In 91 victims (4.4%) the injury arrival time was not captured.

CONCLUSION

This study has identified three groups of persons involved in pre-hospital transport with nearly 50% getting to ER within 1 hour without any intervention or prior notification of ER. Absence of EMS obscures pre-hospital death records. The P/F responsible for only 40% of transport should be trained and equipped to offer basic trauma life support (BTLS). The REL and BS (both responsible for 60% of transport) represent a pool of volunteers for BTLS to be trained.

Fetus-in-fetu in a 6-month-old

Fetus-in-fetu is a malformed parasitic monozygotic diamniotic twin found inside the body of the living child or adult. We report a case of lumbar mass having superficial rudimentary phallus, labioscrotal fold, testes, pedunculated thumb-like digit and rudimentary pelvis in addition to bowel loops in a 6-month-old Nigerian girl. The mass was excised and the baby did well. We propose based on these that dizygotic parasitic foetiform twin could exist.

Typhoid intestinal disease: 32 perforations in 1 patient

Typhoid intestinal perforation is a common complication of typhoid fever in our environment. The occurrence of multiple intestinal perforations that involves both small and large bowel is increasingly being seen in our practice. We report a case of 32 intestinal perforations in a child. This is the highest number of perforations seen in any 1 patient in our search of the English literature. This article details our approach to management of this type of patient.

New method of hand anastomosis to complete the Duhamel operation for Hirschsprung's disease

OBJECTIVE/PURPOSE

This paper describes a new method of hand anastomosis to complete the Duhamel operation for Hirschsprung's disease (HD).

METHODOLOGY

All patients had diagnosis of Hirschsprung's disease confirmed by rectal biopsy and had defunctioning colostomy. At the definitive operation, the ganglionic bowel was brought down in a retro-rectal position and anastomosed at the anal canal just above the dentate line. At this anastomosis, the sutures at 11 and 1 o'clock were left long as stay sutures. An incision was then made down the new bowel at the antimesenteric border from the pelvic brim. Another incision was made down the back of the native rectum. A long-curved artery forceps was then passed into the incision in the native rectum out of the anal canal. This forceps was now hooked round the anastomosis at 12 o'clock and further pushed in until the point appears through the colotomy in the ganglionic bowel. The two layers of bowel between the forceps were incised. The forceps was now inserted to grab the long sutures at 11 o'clock and 1 o'clock in turn, and delivered through the pelvis. Anastomosis between the edges of the native rectum and the neorectum was then done with interrupted PDS inside and silk outside.

RESULTS

Seven patients had the procedure done. Age ranged between 4 months and 4 years (mean 3.4 years). They were all males. One patient died early in the series from reaction to postoperative analgesia. Four older patients have bowel motions 2-3 times per day, do not soil at night, and are fully continent.

CONCLUSION

This preliminary study shows that hand anastomosis could be used to complete Duhamel operation for patients with HD with satisfactory early results.

Motorcycle injuries in a developing country and the vulnerability of riders, passengers, and pedestrians

At a Nigerian university hospital, none of the motorcyclists who presented over a 12 month period had been wearing a helmet, and of the eight patients who died, seven had head injuries. Of the five collision types described, the rate of motorcycle-other vehicle collisions was highest at 40.6%, while the motorcycle-pedestrian rate was 23.4%. Measures to prevent these collisions might reduce overall crashes by 64%; in addition, helmet law should be enforced.

Epidemiology of trauma deaths

OBJECTIVES

This study was done to highlight the pattern and distribution of trauma deaths in a Nigerian teaching hospital in order to enhance trauma research, improve treatment strategies and prevent trauma deaths.

PATIENTS AND METHODS

a prospective data collection was done for 24 months beginning September 1999 detailing the age, sex, occupation, diagnosis, mechanism of trauma, injury-arrival time, and circumstances of death and determining retrospectively the severity of trauma using Revised Trauma Score (RTS), Injury Severity Score (ISS) and Trauma and Injury Severity Score (TRISS).

RESULTS

There were 129 deaths but 84 (65.1%) had sufficient data for trauma scoring. Male:Female ratio was 60:24 = 2.5:1. The age range was 2.95 years, mean 36.8 +/- 15.2 years for males and 45.5 +/- 23.0 years for females. Two thirds (66.7%) of the deaths occurred among traders/business 27.4%, artisans 20.2%, drivers and students 9.5% each. Three quarters of the deaths (75.0%, 63) were in patients involved in road traffic accidents (RTA) followed by violent trauma (10.7%), falls 9.5% and burns 4.8%. The trauma deaths include head injury (26 deaths, 31.0%), multiple injuries (30.0%), fractures (13.1%), cervical spine injury (10.7), gunshot injuries (8.3%), burns (4.8%) and others (5.0%). Sixty-two patients (73.8%) reached the hospital within 6 hours of the injury. The patients were brought by the Police, Good Samaritans or relatives in nearly equal proportions. The mean RTS, ISS and TRISS probability of survival scores were 5.16, 25 and 67% for males but 6.0, 22 and 75% for females, respectively.

CONCLUSIONS

The pattern and distribution of trauma revealed a typical trauma death is a male aged below 40 years, who is a trader/businessman involved in RTA or violent trauma. Despite a probability of survival above 60% and majority of the patients getting to hospital within 6 hours, the inadequate A and E care has thrown up possibilities for prevention of trauma death, improving treatment strategies and enhancing trauma research.