OUTCOMES OF POSTERIOR SAGITTAL ANORECTOPLASTY FOR HIGH ANORECTAL MALFORMATION IN BENIN CITY, NIGERIA

BACKGROUND

Surgical treatment for high anorectal malformations has evolved over the years with introduction of posterior sagittal anorectoplasty in the early 80s. Posterior sagittal anorectoplasty is being perfomed in many centres which necessitates a review of its outcomes in Benin City, Nigeria.

AIM

To report a 10-year outcome and experience gained with posterior saggital anorectoplasty for children diagnosed with high anorectal malformation.

METHODS

A retrospective analyses of the records of all children with high anorectal malformation and managed with posterior sagittal anorectoplasty between April 2006 and March 2016 at the University of Benin Teaching Hospital.

RESULTS

A total of 96 children were managed for anorectal malformation during the period. High anorectal malformation accounted for 33 (34.4%) cases, the intermediate 15 (15.6%) and the low types were 48 (50%). The 33 radiologically confirmed high type were19 males and 14 females with a male/female ratio of 1.3: 1. They were aged between 2 days and 4 years with a mean of 6.8 ± 3 months. A child each had additional prune belly syndrome, multiple limbs anomalies and unilateral undescended testis. Recto-bladder neck/recto-prostatic and recto-vaginal fistulae were recorded in 31 (94%) children. Five (15%) clinically stable neonates had primary posterior sagittal anorectoplasty without colostomy which was well tolerated. The majority, 28 (85%), had conventional posterior sagittal anorectoplasty that involves initial colostomy. Minor postoperative morbidities recorded in 10 (30.3%) children included superficial wound infection in 3 (9%), anal stenosis in 3 (9%) and fecal incontinence in 2 (6%) children which resolved on conservative treatment while 2 (6%) with rectal mucosal prolapse required refashioning. The functional clinical anal outcomes of posterior sagittal anorectoplasty recorded showed that the majority 18 (54.5%) of children were continent while 4 (12.1%) had voluntary bowel controls corresponding with their ages. Anal stenosis in the 3 and incontinence in the 2 children were the common anal dysfunctions recorded. The child with prune belly syndrome had breakdown of colostomy closure which resulted in the one (3%) death recorded.

CONCLUSION

Anorectal malformation was common in this setting during this study with a large proportion of the children diagnosed with the high type and were managed with good outcome using posterior sagittal anorectoplasty.

Outcome of primary posterior sagittal anorectoplasty of high anorectal malformation in well selected neonates

BACKGROUND

Conventional posterior sagittal anorectoplasty (PSARP) for high anorectal malformation (ARM) involves initial colostomy creation with its attendant complications, but primary PSARP in neonates requires no initial colostomy.

OBJECTIVES

To report on locally adapted inclusion criteria and outcomes of primary PSARP in neonates in Benin City.

MATERIALS AND METHODS

Babies who presented during the first week of life in clinically stable conditions, without cardiac anomaly, and had hemogram and blood chemistry within normal ranges, were included in this prospective study undertaken at the University of Benin Teaching Hospital in 2008-2011.

RESULTS

Fifty children with ARM comprising 19 (38%) low/intermediate and 31 (62%) high anomalies were treated during the period. Five (10%) singletons delivered via spontaneous vaginal delivery at term. Aged at operation between two and seven (mean 4) days and comprised three males and two females (ratio 1.5:1), met the inclusion criteria for primary PSARP. The procedure was well tolerated by all the babies; oral intake was commenced on the second post-operative day with nine days median hospitalization duration. No mortality was recorded on six months to four years follow-up. Apart from minor superficial perianal surgical site infection in one baby which responded to antibiotics, no post-operative sepsis or breakdown of repair was recorded. Continence and other anal functions were found excellent using the modified Wingspread scoring during follow-up.

CONCLUSION

These outcomes showed that with meticulous selection, primary PSARP in neonates was feasible and safe in a developing country. Multicenter studies and long-term follow-up are advocated World-wide.

Postoperative wound infection and perioperative prophylactic versus therapeutic antibiotics in paediatric abdominal surgeries: a five-year review

BACKGROUND

Outcome of a most successful surgical procedure may be affected by infective complications. This is a report of postoperative wound infection and outcome of perioperative antibiotics used in children with surgical abdomen.

METHODS

Postoperative wound infection and perioperative antibiotics used in children who had abdominal surgeries at two referral paediatric surgical centres between June 2004 and May 2009 were analyzed in a retrospective study.

RESULTS

All 1298 childrenaged between one month and 16 years with a male: female ratio 1.5:1 managed with surgical abdomen who presented after an average of 48 hours of symptoms had antibiotics; 458 (35.3%) prophylactic versus 840 (64.7%) therapeutic.Antimicrobials in penicillin, aminogycoside, quinolone, cephalosporingroups, and metronidazole were used either as single or combined agents in 458 (35.3%) children with clean-contaminated, 459 (35.4%) contaminated and 381 (29.3%) dirty wounds. Emergency operations performed on 791 (60.9%) children resulted in 157 (19.8%) postoperative wound infection compared to 507 (39.1%) operated on elective bases with 30 (5.9%) (P<0.0001). The wounds were superficial 71 (38%), deep 47 (25.15%) and intraperitoneal 39 (20.9%) in emergency cases, and 21 (1.6%) deaths occurred overall. Postoperative wound infection recorded in 16.7% (140/840) was higher in children who had therapeutic than in 10.3% (47/458) who received prophylactic antibiotics (P=0.0022). It was lower, 25% (38/152), using single agents for prophylaxis than therapy 60.6% (134/221) (P=0.0091), and also lower, 9.1% (84/925), using combined agents that included cephalosporin for both prophylaxis and therapy than 46.1% (172/373) using single agents (P<0.0001).

CONCLUSION

Early referral to reduce emergency operations and timely commencement of combined antimicrobials which includes cephalosporins are advocated.

Outcomes of skin closure with suture materials in clean paediatric surgical procedures

Except through natural orifices, all surgical operations involve making skin incisions which are often closed with suture materials to which the skin may react. This is a five-year (2005-2009) retrospective study of postoperative outcomes of 998 clean skin incisions closed with continuous subcuticular suture materials in 796 children at two Nigerian centres. The children were aged between 1 day and 18 years (mean 6.5 +/- 3.4 years) with a male to female ratio of 2.5:1. The location of the incisions ranged from groin in 678 (67.9%) cases to lower limbs in 15 (1.5%), these were associated with 414 (61.1%) and 13 (86.7%) postoperative complications respectively. Sutures were not removed from the skin in 734 cases and were associated with 558 (76%) postoperative complications whereas sutures were removed between 5-7 postoperative days in 264 cases and were associated with 39(14.8%) postoperative complications (P < 0.0001). Whereas postoperative wound infection in 69 (6.9%) cases occurred before ten days, stitch abscess/sinus, 156 (15.6%), suture extrusion, 80 (8%), hyperpigmentation, 211 (21.1%), pruritus, 182 (18.2%), hypertrophied scars, 128 (12.8%), and keloid formation, 9 (0.9%), occurred after the tenth postoperative day among those whose sutures were not removed in direct proportion to patients' age/ suture size. These postoperative complications gave rise to 343 (34.3%) good, 245 (24.5%) fair, and 9 (0.9%) poor cosmetic outcomes, whereas 401 (40.2%) incisions without postoperative complication gave excellent cosmetic outcomes. It is suggested from this study that continuous subcuticular suture materials which should be removed not later than the tenth postoperative day be used for skin closure in children.

Circumcision mishaps in Nigerian children

BACKGROUND/OBJECTIVE

Circumcision may be associated with complications which are usually minor but could be life threatening on certain occasions. This study determined contributory factors, pattern of presentation, challenges of management and outcome of circumcision mishaps in Benin City, Nigeria.

METHODS

A retrospective analysis of all male children managed for circumcision mishaps between January 1998 and December 2007 at the University of Benin Teaching Hospital, Benin City, Nigeria.

RESULTS

There were 346 male children aged between 6 days and 12 years. Period of presentation to the unit ranged between 1 hour and 12 years. Redundant prepuce, 51 (14.7%); glandulopenile adhesions, 30 (8.7%); implantation cyst, 10 (2.9%); penile chordee, 11 (3.2%); local wound infection, 17 (4.9%); and proximal migration of plastibell ring, 11 (3.2%), were common mishaps treated with good outcome. On the other hand, urethrocutaneous fistula, 73 (21.1%); hemorrhage, 46 (13.3%); glandular amputation, 9 (2.6%); penile tissue avulsion, 24 (7.0%); and transmission of infections, 4 (1.2%), were challenging mishaps to manage. These resulted in 18 children with residual penile deformity and 4 deaths. Challenging mishaps and late referrals were common among children circumcised by traditional circumcisionists (P < 0.0001). Inadequate training of circumcisionists; circumcision in unhygienic environment; circumcision with unsterilized instruments; circumcision without the use of anesthesia, analgesia and antibiotics - which were compounded by late referrals - influenced the development and final outcome of circumcision mishaps.

CONCLUSION

Circumcision mishaps presenting very late with resultant poor outcome are still common in our setting. Hospital circumcision by experts, health awareness campaigns, adequate training of circumcisionists and early referrals of affected children should be encouraged.

Causes, spectrum and effects of surgical child abuse and neglect in a Nigerian city

BACKGROUND

Children are dependent on parents and care givers 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 and neglect on surgical children.

METHODS

Analysis of cases of surgical child abuse and neglect between January, 1998 and December, 2007 at the University of Benin Teaching Hospital, Benin City, Nigeria, was done.

RESULTS

A total of 281 children aged two days and 12 years comprising 113 males and 168 females with male to female ratio 1:1.4, mainly with congenital malformation, suffered surgical child abuse and neglect ranging from delayed presentation, to child abandonment which was perpetuated by ignorance, poverty, superstitious beliefs, customs as well as non availability of free medical services for children. Counselling and home visits in addition to surgeries were done and 198 (70.5%) children were successfully treated with those abandoned happily reunited with their families, while 56 (19.9%) mortality 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 co-managed with psychologists while seven were transferred to orphanage homes.

CONCLUSION

Surgical child abuse/neglect is rampant, hence, it is hoped that these findings will influence policy makers in this sub-region to formulate policies that will protect children against this form of child abuse.

Outcome of trans-anal posterior anorectal myectomy for the ultrashort segment Hirschsprung's disease--Benin City experience in five years

OBJECTIVE

The conventional treatment of Hirschsprung's disease involves colostomy creation, excision of aganglionic segment, pull through using normally ganglionated proximal bowel segment and colostomy closure. The ultrashort segment variety is treated with posterior anorectal myectomy which requires no prior colostomy creation. This study sought to evaluate the benefits and outcomes of the procedure in a tertiary hospital in Nigeria.

PATIENTS AND METHODS

All children diagnosed with ultrashort segment Hirschsprung's disease between January 2003 and December 2007 at the University of Benin Teaching Hospital, Benin City, were prospectively studied.

RESULTS

Of 64 children managed with Hirschsprung's disease in five years, 11 (17.2%) were diagnosed with ultrashort segment variety and had posterior anorectal myectomy without prior colostomy. They comprised 7 males and 4 females with male/female ratio 1.8:1 and were aged between 1 month and 9 years (mean 1.5 +/- 0.8 years). The procedure was well tolerated and gave satisfactory results in all the patients as no wound infection or any life threatening morbidity and mortality was recorded. Postoperative pain which responded to paracetamol in the majority of children was statistically significant in older compared to younger patients (P<0.0001). Oral feeds were commenced and tolerated earlier, length of hospitalisation was shorter and no incontinence was recorded unlike the conventional treatment. Also, postoperative nursing care was easier and the single procedure resulted in availability of theatre space for other paediatric operations. All the children did well on 9 months to 4 years follow-up.

CONCLUSION

The procedure was found to be beneficial and effective for ultrashort segment Hirschsprung's disease, and should be employed in this subregion.

Small intestinal tubulovillous adenoma--case report and literature review

Benign small intestinal tumour, though rare, have been reported. We report a case of sessile and extensive tubulovillous adenoma in a 13-year-old girl. She presented in a private hospital with three months history of abdominal pain, abdominal distension, vomiting, constipation, weight loss and anorexia. Significant findings on examination were weight loss, dehydration, and a huge smooth, not tender, mobile and indentable mass which extended from the left lumbar region to right iliac fossa. Visible peristalsis coursing from left to right was seen on the mass. Erect and supine plain abdominal x-rays revealed features of partial intestinal obstruction and abdominal ultrasound scan revealed dilated and hypertrophied bowel segment but could not say the bowel segment affected. The affected segment was found to be a 55cm portion of terminal ileum at operation which was resected due to hypertrophied proximal and collapsed distal segments, features in keeping with chronic intestinal obstruction, and ileo-ileal anastomosis done. Histology report was that of benign tubulovillous adenoma and the girl has enjoyed stable health for more than a year on close follow up in surgical outpatient clinic. This case highlights the unusual presentation and unusual gross nature of this small intestinal adenoma, which was found to be a benign adenoma on histological examination.

Hazards of pentazocine for neonatal analgesia: a single-centre experience over 10 years

BACKGROUND

In developing countries, neonatal analgesia for surgical procedures is a major challenge where postoperative care is inadequate.

AIM

To report experience of pentazocine for neonatal surgery in a Nigerian tertiary hospital.

METHODS

A retrospective study of surgical neonates who received pentazocine at the University of Benin Teaching Hospital in Benin City between January 1998 and December 2007.

RESULTS

During the period, 2590 paediatric operations were performed including 368 (14.2%) neonates, 49 (13.3%) of whom had pentazocine. The other neonates received a variety of analgesics. Of 56 neonates who developed respiratory depression, 40 (71.4%) had pentazocine (p<0.0001). Fifteen (30.6%) neonates aged between 9 hours and 28 days [mean (SD) 12 (1.2) days] died between 1 and 36 hours following 8-hourly administration of 0.5 mg/kg pentazocine. In older children who had pentazocine, over-sedation was also a problem but there were no deaths. Deaths in neonates were mainly owing to persistent respiratory depression which was compounded by the unavailability of a paediatric ventilator. However, many neonates responded to naloxone. All neonates who died had an autopsy and no lesion was found which could have compromised respiratory function.

CONCLUSION

The use of pentazocine in neonates was associated with high morbidity and mortality. Caution is required when using pentazocine for neonatal analgesia where post-operative respiratory support is insufficient.

Congenital hydrocele: prevalence and outcome among male children who underwent neonatal circumcision in Benin City, Nigeria

OBJECTIVE

To determine the prevalence and spontaneous resolution of congenital hydrocele diagnosed in male neonates who underwent circumcision at our centre.

PATIENTS AND METHODS

All male neonates presented for circumcision at the University of Benin Teaching Hospital, Benin City, Nigeria between January 2002 and December 2006 were examined for the presence of hydrocele. Those diagnosed with this condition were recruited and followed up in a surgical outpatient clinic for 2 years. The number of cases of spontaneous resolution and age at which this occurred were documented on a structured pro forma.

RESULTS

A total of 2715 neonates were circumcised and 128 (4.7%) were diagnosed with 163 cases of hydrocele, while 27 cases in 25 (0.9%) children failed to resolve at the age of 2 years. Neonatal hydrocele was bilateral in 112 (68.7%), and there were 20 (12.3%) right and 31 (19.0%) left. Among those with hydrocele, 28.1% were delivered preterm and resolution was spontaneous in many of them, with no observed significant statistical difference to those delivered full term (P=0.4740). Of the 163 hydrocele cases, 136 (83.4%) resolved spontaneously by age 18 months with peak resolution at 4-6 months. No spontaneous resolution occurred after 18 months and no hydrocele-related complication occurred during follow up.

CONCLUSION

Neonates with congenital hydrocele should be observed for spontaneous resolution for at least 18 months before being subjected to surgery.

Male infertility secondary to varicocele: a study of the management of 45 patients

Varicocele is a common condition worldwide. The aim of this five-year prospective study is to examine the effect of varicocelectomy on the fertility profile of affected men in a male infertility clinic in Benin City, Edo State. A total of 45 men aged 16-65 years were diagnosed with varicocele during the period. Forty one (91.1%) had infertility while 4 (8.9%) were unmarried boys with third degree varicocele. Thirty seven (82.2%) consented to varicocelectomy; thirty three had infertility. Varicocelectomy was done through an open subinguinal approach. Restored testicular volume and semen quality were achieved within the first 12 months in all but one. Among the 33 men who had infertility, the spouses of 23 (69.7%) achieved pregnancy during the period of follow-up after varicocelectomy while the spouses of 10 (30.3%) had not. No major complication was recorded after operation. It is recommended that in subtropical Africa where there are no facilities for microscopic varicocelectomy and embolization, open varicocelectomy should be used. It is safe, effective and has much to offer.