Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a model-based cost-effectiveness analysis of a pragmatic, cluster-randomised trial in seven low-income and middle-income countries

BACKGROUND

Surgical site infection (SSI) is a major burden on patients and health systems. This study assessed the cost-effectiveness of routine change of sterile gloves and instruments before abdominal wall closure to prevent SSI.

METHODS

A decision-analytic model was built to estimate average costs and outcomes of changing gloves and instruments before abdominal wall closure compared with current practice. Clinical data were obtained from the ChEETAh trial, a multicentre, cluster-randomised trial in seven low-income and middle-income countries (LMICs), and costs were obtained from a study (KIWI) that assessed costs associated with SSIs in LMICs. Outcomes were measured as the percentage of surgeries resulting in SSIs. Costs were measured from a health-care provider perspective and were reported in 2021 US$. The economic analysis used a partially split single-country costing approach, with pooled outcomes data from all seven countries in the ChEETAh trial, and data for resource use and unit costs from India (KIWI); secondary analyses used resource use and costs from Mexico and Ghana (KIWI).

FINDINGS

In the base case, the average cost of the intervention was $259∙92 compared with $261∙10 for current practice (cost difference -$1∙18, 95% CI -4∙08 to 1∙33). In the intervention group, an estimated 17∙6% of patients had an SSI compared with 19∙7% of patients in the current practice group (absolute risk reduction 2∙10%, 95% CI 2∙07-2∙84). At all cost-effectiveness thresholds assumed ($0 to $14 000), the intervention had a higher likelihood of being cost-effective compared with current practice, indicating that the intervention was cost-effective. Similar results were obtained when the analysis using data from India was repeated using resource use and unit cost data from Mexico and Ghana.

INTERPRETATION

Routine sterile glove and instrument change before abdominal wall closure is effective and the costs are similar to those for current practice. Routine change of gloves and instruments before abdominal wall closure should be rolled out in LMICs.

FUNDING

National Institute for Health and Care Research (NIHR) Clinician Scientist Award, NIHR Global Health Research Unit Grant, and Mölnlycke Healthcare.

Closure of Fistula-in-Ano Using a Radial-Emitting Laser Probe: Initial Experience in Lagos, Nigeria

Background

Fistula-in-ano treatment has remained quite challenging with high failure rates and a potential for damage to the anal sphincteric complex leading to flatal or faecal incontinence. The treatment of fistula-in-ano using the fistula laser closure (FiLaC) as a minimally invasive, sphincter-saving procedure for complex disease has recently been documented.

Objectives

This review aimed to report the outcome of using it at the Lagos University Teaching Hospital.

Patients and Methods

The procedures were performed with a radially emitting laser fibre from Biolitec AG-CeramOptec (Bonn, Germany). The duration of symptoms, type of fistula, duration of the procedures, and postoperative complications were evaluated.

Results

Eleven male patients had laser fistula-in-ano closure. The age range was 33-51 years, with a median age of 39 years and an interquartile range (IQR) of 37-47 years. Five patients were noted to have high fistula/e, whereas six had low fistula/e, seven had a single tract each, and three had three tracts each. The duration of surgery ranged, approximately from 3 to 60 min, with a median of 19 min and IQR of 9-33 min. Postoperative pain was mild in all patients and were all discharged as day case. There was no postoperative wound infection, anal incontinence, anal stenosis, and subcutaneous abscess. However, there was a recurrence in two patients.

Conclusions

FiLaC has been demonstrated to be a reliable and safe sphincter-saving procedure for treating fistula-in-ano even for complex and high fistulae that is feasible in our subregion.

Challenges and Prospects of Laser Haemorrhoidoplasty in a Low Resource Setting: The LUTH Experience

Background

Haemorrhoids are the most common condition of the anal canal causing significant disability. Traditional excisional haemorrhoidectomy and its various modifications, while effective, may be attended by severe postoperative pain and other complications. Laser haemorrhoidoplasty is reported to be effective with fewer complications and shorter hospital stay.

Objectives

The aim of this study was to report the outcome of intrahaemorrhoidal coagulation with 1470-nm diode laser at the Lagos University Teaching Hospital.

Patients and Methods

The procedures were performed with a radially emitting laser fibre from Biolitec AG-CeramOptec (Bonn, Germany). The duration of symptoms, grade of the haemorrhoids, duration of the procedures, and postoperative complications were evaluated.

Results

Eleven patients had laser haemorrhoidoplasty. There were seven males and four females. The age range was 23-71 years, with a median age of 47 years and an interquartile range (IQR) of 28-57 years. Duration of surgery ranged from 20 to 90 min, with a median of 33 min and IQR of 25-53 min. Postoperative pain was mild in eight patients and moderate in three. Ten patients were discharged as day cases and one 3 days later due to spinal anaesthesia-related headache and acute urinary retention. One patient later had an anal ulcer probably due to too much energy delivered during the procedure, this was managed conservatively. There was no postoperative wound infection, anal incontinence, anal stenosis, subcutaneous abscess, and fistula or recurrence.

Conclusion

The advantages of laser haemorrhoidoplasty make it a readily acceptable form of treatment for haemorrhoids in our setting.

Strategies to minimise and monitor biases and imbalances by arm in surgical cluster randomised trials: evidence from ChEETAh, a trial in seven low- and middle-income countries

BACKGROUND

Cluster randomised controlled trials (cRCT) present challenges regarding risks of bias and chance imbalances by arm. This paper reports strategies to minimise and monitor biases and imbalances in the ChEETAh cRCT.

METHODS

ChEETAh was an international cRCT (hospitals as clusters) evaluating whether changing sterile gloves and instruments prior to abdominal wound closure reduces surgical site infection at 30 days postoperative. ChEETAh planned to recruit 12,800 consecutive patients from 64 hospitals in seven low-middle income countries. Eight strategies to minimise and monitor bias were pre-specified: (1) minimum of 4 hospitals per country; (2) pre-randomisation identification of units of exposure (operating theatres, lists, teams or sessions) within clusters; (3) minimisation of randomisation by country and hospital type; (4) site training delivered after randomisation; (5) dedicated 'warm-up week' to train teams; (6) trial specific sticker and patient register to monitor consecutive patient identification; (7) monitoring characteristics of patients and units of exposure; and (8) low-burden outcome-assessment.

RESULTS

This analysis includes 10,686 patients from 70 clusters. The results aligned to the eight strategies were (1) 6 out of 7 countries included ≥ 4 hospitals; (2) 87.1% (61/70) of hospitals maintained their planned operating theatres (82% [27/33] and 92% [34/37] in the intervention and control arms); (3) minimisation maintained balance of key factors in both arms; (4) post-randomisation training was conducted for all hospitals; (5) the 'warm-up week' was conducted at all sites, and feedback used to refine processes; (6) the sticker and trial register were maintained, with an overall inclusion of 98.1% (10,686/10,894) of eligible patients; (7) monitoring allowed swift identification of problems in patient inclusion and key patient characteristics were reported: malignancy (20.3% intervention vs 12.6% control), midline incisions (68.4% vs 58.9%) and elective surgery (52.4% vs 42.6%); and (8) 0.4% (41/9187) of patients refused consent for outcome assessment.

CONCLUSION

cRCTs in surgery have several potential sources of bias that include varying units of exposure and the need for consecutive inclusion of all eligible patients across complex settings. We report a system that monitored and minimised the risks of bias and imbalances by arm, with important lessons for future cRCTs within hospitals.

Picture Cards Versus Physical Examination: A Proof-of-Concept Study to Improve the SOSAS Survey Tool

INTRODUCTION

The Surgeons OverSeas Assessment of Surgical Needs (SOSAS) survey tool is used to determine the unmet surgical needs in the community and has been validated in several countries. A major weakness is the absence of an objective assessment to verify patient-reported surgically treatable conditions. The goal of this study was to determine whether a picture portfolio, a tool previously shown to improve parental recognition of their child's congenital deformity, could improve the accuracy of the SOSAS tool by how it compares with physical examination. This study focused on children as many surgical conditions in them require prompt treatment but are often not promptly diagnosed.

METHODS

We conducted a descriptive cross-sectional community-based study to determine the prevalence of congenital and acquired surgical conditions among children and adults in a mixed rural-urban area of Lagos, Southwest Nigeria. The picture portfolio was administered only to children and the surgical conditions to be assessed were predetermined using an e-Delphi process among pediatric surgeons. The modified The Surgeons OverSeas Assessment of Surgical Needs-Nigeria Survey Tool (SOSAS-NST) was administered to household members to collect other relevant data. Data were analyzed using the REDCap analytic tool.

RESULTS

Eight hundred and fifty-six households were surveyed. There were 1984 adults (49.5%) and 2027 children (50.5%). Thirty-six children met the predetermined criteria for the picture portfolio-hydrocephalus (n = 1); lymphatic malformation (n = 1); umbilical hernia (n = 14); Hydrocele (n = 5); inguinal hernia (n = 10) and undescended testes (n = 5). The picture portfolio predicted all correctly except a case of undescended testis that was mistaken for a hernia. The sensitivity of the picture portfolio was therefore 35/36 or 97.2%.

CONCLUSIONS

The SOSAS-NST has improved on the original SOSAS tool and within the limits of the small numbers, the picture portfolio has a high accuracy in predicting diagnosis in children in lieu of physical examination.

Clinical predictors of Covid-19 mortality in a tertiary hospital in Lagos, Nigeria: A retrospective cohort study

Background

The predictors of mortality among patients presenting with severe to critical disease in Nigeria are presently unknown.

Aim

The aim of this study was to identify the predictors of mortality among patients with COVID-19 presenting for admission in a tertiary referral hospital in Lagos, Nigeria.

Patients and Methods

The study was a retrospective study. Patients' sociodemographics, clinical characteristics, comorbidities, complications, treatment outcomes, and hospital duration were documented. Pearson's Chi-square, Fischer's Exact test, or Student's t-test were used to assess the relationship between the variables and mortality. To compare the survival experience across medical comorbidities, Kaplan Meir plots and life tables were used. Univariable and multivariable Cox-proportional hazard analyses were conducted.

Results

A total of 734 patients were recruited. Participants' age ranged from five months to 92 years, with a mean ± SD of 47.4 ± 17.2 years, and a male preponderance (58.5% vs. 41.5%). The mortality rate was 9.07 per thousand person-days. About 73.9% (n = 51/69) of the deceased had one or more co-morbidities, compared to 41.6% (252/606) of those discharged. Patients who were older than 50 years, with diabetes mellitus, hypertension, chronic renal illness, and cancer had a statistically significant relationship with mortality.

Conclusion

These findings call for a more comprehensive approach to the control of non-communicable diseases, the allocation of sufficient resources for ICU care during outbreaks, an improvement in the quality of health care available to Nigerians, and further research into the relationship between obesity and COVID-19 in Nigerians.

Preputial cyst in the newborn: A case report from Africa

Cysts of the prepuce are rare, and documented reports from the English literature are mostly from Asia. Presentations in children are worrisome to the parents. We report a case of a preputial cyst occurring in a neonate who was brought to our facility due to parental anxiety. After a thorough clinical evaluation, a freehand circumcision technique was performed which allowed exposure of the full extent of the cyst, the external urethral meatus and the glans, thus ensuring complete excision and minimising the risk of injury to the adjoining structures. We postulate that preputial cysts are rare in Africa due to the universality of circumcision, which is one of the options of treatment. Preputial cysts are benign foreskin cystic lesions that can be effectively treated with circumcision. This is probably the first reported case of a benign epithelioid preputial cyst from Africa. The paucity of reported cases may be due to the universal practice of circumcision in most of Africa.

Biliary Atresia Splenic Malformation: A Case Report from A Tertiary Centre in West Africa and the Lessons Learnt

Biliary atresia (BA) is a rare disease characterised by biliary obstruction of unknown origin that presents in the neonatal period. It is classified into syndromic with various congenital anomalies and non-syndromic (isolated anomaly). We present a case of syndromic BA associated with polysplenia and intestinal malrotation, discovered incidentally during the Kasai procedure. The small intestine was found to be non-rotated with the duodenojejunal junction to the right of the vertebral column. The presence of accessory spleens was noted. Kasai portoenterostomy and Ladd's procedure were performed. The patient had an uneventful postoperative course with the passage of cholic stool from the third postoperative day. At the seventh-month follow-up, the stool remained cholic. A multidisciplinary approach in the care of babies with BA and long-term follow-up is crucial for a successful outcome.

Routine sterile glove and instrument change at the time of abdominal wound closure to prevent surgical site infection (ChEETAh): a pragmatic, cluster-randomised trial in seven low-income and middle-income countries

BACKGROUND

Surgical site infection (SSI) remains the most common complication of surgery around the world. WHO does not make recommendations for changing gloves and instruments before wound closure owing to a lack of evidence. This study aimed to test whether a routine change of gloves and instruments before wound closure reduced abdominal SSI.

METHODS

ChEETAh was a multicentre, cluster randomised trial in seven low-income and middle-income countries (Benin, Ghana, India, Mexico, Nigeria, Rwanda, South Africa). Any hospitals (clusters) doing abdominal surgery in participating countries were eligible. Clusters were randomly assigned to current practice (42) versus intervention (39; routine change of gloves and instruments before wound closure for the whole scrub team). Consecutive adults and children undergoing emergency or elective abdominal surgery (excluding caesarean section) for a clean-contaminated, contaminated, or dirty operation within each cluster were identified and included. It was not possible to mask the site investigators, nor the outcome assessors, but patients were masked to the treatment allocation. The primary outcome was SSI within 30 days after surgery (participant-level), assessed by US Centers for Disease Control and Prevention criteria and on the basis of the intention-to-treat principle. The trial has 90% power to detect a minimum reduction in the primary outcome from 16% to 12%, requiring 12 800 participants from at least 64 clusters. The trial was registered with ClinicalTrials.gov, NCT03700749.

FINDINGS

Between June 24, 2020 and March 31, 2022, 81 clusters were randomly assigned, which included a total of 13 301 consecutive patients (7157 to current practice and 6144 to intervention group). Overall, 11 825 (88·9%) of 13 301 patients were adults, 6125 (46·0%) of 13 301 underwent elective surgery, and 8086 (60·8%) of 13 301 underwent surgery that was clean-contaminated or 5215 (39·2%) of 13 301 underwent surgery that was contaminated-dirty. Glove and instrument change took place in 58 (0·8%) of 7157 patients in the current practice group and 6044 (98·3%) of 6144 patients in the intervention group. The SSI rate was 1280 (18·9%) of 6768 in the current practice group versus 931 (16·0%) of 5789 in the intervention group (adjusted risk ratio: 0·87, 95% CI 0·79-0·95; p=0·0032). There was no evidence to suggest heterogeneity of effect across any of the prespecified subgroup analyses. We did not anticipate or collect any specific data on serious adverse events.

INTERPRETATION

This trial showed a robust benefit to routinely changing gloves and instruments before abdominal wound closure. We suggest that it should be widely implemented into surgical practice around the world.

FUNDING

National Institute for Health Research (NIHR) Clinician Scientist Award, NIHR Global Health Research Unit Grant, Mölnlycke Healthcare.

Evaluation of the effect of nutritive versus non-nutritive pacifiers as adjuncts to local anaesthesia in male neonatal circumcision using the plastibell technique - A prospective randomised controlled study

BACKGROUND

Male circumcision is the most common surgical procedure worldwide and is often carried out for religious, cultural, medical and public health reasons. It is commonly performed during the neonatal period. Many studies have now shown that pain is a common intra- and post-operative complication. To ensure proper analgesia during the procedure, many surgeons opt for the use of pacifiers as an adjunct to anaesthesia during neonatal circumcision. The aim of this study is to compare nutritive pacifiers (NPs) versus non-NPs (NNPs) as adjuncts to local anaesthesia in male neonatal circumcision using the Plastibell technique.

METHODS

A prospective randomised controlled study was carried out between October 2019 and March 2020. A total of 100 neonates were circumcised using the Plastibell technique and randomised into NP (Group A, n = 33), NNP (Group B, n = 33) and controls (Group C, n = 34), respectively. The differences in pain scores using the Neonatal Infant Pain Scale, total crying time and heart rate during circumcision were recorded and assessed.

RESULTS

The age of participants ranged from 5 to 28 days and the weight ranged from 2.5 to 5.0 kg. The overall mean age, birth weight and current weight of the participants were 15.5 ± 6.1 days, 3.4 ± 0.4 kg and 3.5 ± 0.6 kg, respectively. The control group had the highest average pain score of 5.5 (4.5-5.8) compared to the intervention groups with median pain score (NP: 3.3 [1.3-4.3] and (NNP: 4.3 [3.1-5.1], respectively). NPs had significantly lower pain scores (P = 0.023) and reduced total crying time (P = 0.019) at all stages of the circumcision compared to those given NNPs and controls.

CONCLUSION

This study showed that NPs were superior to NNPs in providing additional pain control during male neonatal circumcision.

Assessment of the utility of a screening tool for COVID-19 diagnosis in an accident and emergency department in Lagos, Nigeria: A pilot study

The use of reverse transcription-polymerase chain reaction (RT-PCR) is the gold standard laboratory test for diagnosing SARS-CoV-2 infection. However, it has the disadvantage of a long turnaround time and cost. The Nigeria Centre for Disease Control (NCDC) formulated a case definition for COVID-19. We sought to determine the utility of a 14-item, point-weighted clinical screening questionnaire adapted from the NCDC case definition in identifying patients more likely to have the disease. This was to aid prompt clinical decision-making.

METHODS

We retrospectively reviewed the data of 113 non-surgical patients presenting to the Accident and Emergency Department (A and E) of Lagos University Teaching Hospital, Lagos, Nigeria. Patients were stratified based on screening scores into low (0-2), moderate (3-5) and high (6) pre-test categories. Patients with low and high scores ≥6 were admitted to the A and E and the COVID-19 holding ward, respectively, while the moderate group had chest computed tomography scans to aid further decision-making, pending the outcome of their RT-PCR results. The validity of the triage score as compared to the RT-PCR test result was calculated and the kappa score of agreement was utilised to evaluate the concordance between two triage scores. The optimum cut-off score was also obtained based on the maximal Younden's index.

RESULTS

The frequencies of low, moderate and high pre-test scores were 34 (30%), 43 (38.1%) and 36 (31.9%), respectively. Overall, 38.1% (43/113) were RT-PCR positive. RT-PCR was positive in 26.5% (9/34) with low screening scores, 55.8% (24/43) with moderate scores and 27.8% (10/36) with high scores. The sensitivity and specificity of a high score of 6 were 25% and 92.86%, while the lower score of 3 had sensitivity and specificity of 62.5% and 58.6%, respectively.

CONCLUSION

The screening tool showed a high specificity in its initial design, which suggests that anyone with a low score using this tool has a high probability of testing negative. We recommend a cut-off score of 4 (score A) or 6 (score B) of the current screening tool be used to increase the chances of identifying persons with COVID-19 for RT-PCR testing.

A 5-year multidisciplinary care outcomes in children with wilms' tumour managed at a tertiary centre: A retrospective observational study

BACKGROUND

Over the last two decades, there has been significant improvement in the outcomes of children with Wilms' tumour (WT) in high income countries (HICs) with approximately 85% survival rate globally. This is partly attributable to a multi-disciplinary team approach to care and the evolution of more robust treatment measures. A previous review in our centre prior to multi-disciplinary team shows a survival rate of 31.48%, However, the survival rates from low- and middle-income countries are still low when compared to HICs due to delays in access to care at all levels, poor to non-existent health insurance coverage, limited workforce resources, weak health-care systems and infrastructure. The aim of this study is to determine the impact of a multi-disciplinary team approach on the treatment outcomes of children with WT.

METHODOLOGY

This is a 5-year retrospective review of all patients managed with WT at the Lagos University Teaching Hospital, Lagos, Nigeria. Information was extracted from the patients' case notes, operation notes and ward admission records. The data were analysed with SPSS 25, and P < 0.05 was considered to be statistically significant.

RESULTS

Forty patients were included in the study; male to female ratio was 1.6:1. The disease occurred in the right kidney in 23 patients (57.5%) and on the left in 17 patients (42.5%). The average duration of symptoms before presentation was 3.6 months (range 1-7 months), majority of patients presented with abdominal masses and were assessed as per unit protocol with abdominal Computerized tomography scan, chest X-ray and abdominal ultrasound scan to assign the patient International Society of Paediatric oncology regimen. The predominant stage at surgery was Stage III 26 (65%), while Stage IV was 9 (22.5%). Morbidity after chemotherapy was 10 (25%). Twenty-five patients (63%) completed chemotherapy while 15 patients (37%) started chemotherapy but defaulted midway. The 5-year survival rate was 75%. Increasing age and male sex were associated with reduced odds of mortality; however, this was not statistically significant. Increased duration of treatment, being treated with chemotherapy alone, as well as advanced tumour stage and histology were associated with increased odds of mortality, however, this was not statistically significant.

CONCLUSION

The development of an institutional WT treatment pathway involving a multidisciplinary team has resulted in improved outcomes. There is need for increased community awareness to improve the time to presentation.

Impact of corona virus disease 2019 pandemic on paediatric surgery in a sub-saharan tertiary hospital: An observational study

Background

The impact of the corona virus disease 2019 (COVID-19) pandemic on global health, has reached far beyond that caused by the disease itself. With ongoing mutations and the emergence of new strains of the virus alongside repeated waves of the pandemic, the full impact of the pandemic is still evolving and remains difficult to predict or evaluate. In paediatric surgery, it has led to significant disruptions in patient care, the extent and consequence of which are not fully documented in Nigeria.

Aim

This study aims to evaluate the impact of COVID-19 on services, training and research in a busy paediatric surgery unit during the initial 3-month period of the COVID-19 pandemic lockdown.

Methods

This study was an ambispective evaluation of the preceding 3 months before lockdown and the initial 3 months of lockdown. Clinic cancellations, elective and emergency surgeries, delays in access, extra cost of care to patients, impact on training and research, and the psychologic impact of the pandemic on staff and guardians were evaluated.

Results

During the 3-month lockdown period, an estimated 78 new cases and 637 follow-up cases could not access care. Ninety-seven elective surgeries in 91 patients were postponed. Two (2.2%) patients' symptoms progressed. All emergency patients received care. Out-of-pocket expenditure increased averagely by $124. The pandemic contributed to delays in seeking (13%), reaching (20%) and receiving care (6%). Trainee participation in surgeries was reduced and academic programmes were suspended. Five staff were exposed to the virus and 3 infected.

Conclusion

Paediatric surgery has been negatively impacted by COVID-19. Efforts must focus on planning and implementing interventions to mitigate the long-term impact.

Ivermectin shows clinical benefits in mild to moderate COVID19: a randomized controlled double-blind, dose-response study in Lagos

INTRODUCTION

In vitro studies have shown the efficacy of Ivermectin (IV) to inhibit the SARS-CoV-2 viral replication, but questions remained as to in-vivo applications. We set out to explore the efficacy and safety of Ivermectin in persons infected with COVID19.

METHODS

We conducted a translational proof of concept randomized, double blind placebo controlled, dose response and parallel group study of IV efficacy in RT-polymerase chain reaction proven COVID 19 positive patients. Sixty-two patients were randomized to three treatment groups. (A) IV 6 mg regime, (B) IV 12 mg regime (given Q84 h for 2 weeks) (C, control) Lopinavir/Ritonavir. All groups plus standard of Care.

RESULTS

The Days to COVID negativity (DTN) was significantly and dose dependently reduced by IV (P = 0.0066). The DTN for Control were, = 9.1+/-5.2, for A 6.0 +/- 2.9 and for B 4.6 +/-3.2. Two way repeated measures ANOVA of ranked COVID 19 +/- scores at 0, 84, 168 and252h showed a significant IV treatment effect (P = 0.035) and time effect (P < 0.0001). IV also tended to increase SPO2% compared to controls, P = 0.073, 95% CI-0.39 to 2.59 and increased platelet count compared to C (P = 0.037) 95%CI 5.55-162.55 × 103/ml. The platelet count increase was inversely correlated to DTN (r = -0.52, P = 0.005). No SAE was reported.

CONCLUSIONS

12mg IV regime given twice a week may have superior efficacy over 6mg IV given twice a week, and certainly over the non IV arm of the study. IV should be considered for use in clinical management of SARS-COV2, and may find applications in prophylaxis in high risk areas.

Recommendations of the Laparoscopic Surgery Society of Nigeria on the Conduct of Minimal Access Surgeries during and after the COVID-19 Pandemic in Nigeria

BACKGROUND

COVID-19 pandemic has affected surgical practice worldwide. Laparoscopic procedures utilizing gas for pneumoperitoneum require specific consideration.

METHOD

A panel of experts of the Laparoscopic Surgery Society of Nigeria (LASSON) was constituted to draft recommendations on the conduct of minimal access surgical (MAS) procedures during and after the pandemic in Nigeria.

RESULTS

The Society strongly believes that laparoscopy and other (MAS) procedures can be safely performed during and after the current COVID-19 pandemic if appropriate safety measures are adhered to. The Society therefore makes the following recommendations for all units performing MAS in Nigeria: (1) Design clear cut measures to navigate the pandemic in each hospital. (2) Triage surgical services and procedures. (3) Encourage screening and testing of all patients (4) Provide adequate patient communication and consenting (5) Ensure compulsory use of Personal Protective Equipments (PPEs) (6) Minimize preoperative and intraoperative personnel (7) Envisage postoperative respiratory challenges and make adequate preparation for respiratory support: (8) Make specific considerations for the confirmed COVID 19 positive patients:(9) Private facilities offering MAS and endoscopic procedures should take special measures during the pandemic (10) Know your limits.

CONCLUSION

The Society encourages all MAS practitioners to adhere to these recommendations.

Development and practice of laparoscopic surgery in a Nigerian tertiary hospital

Background

For the benefits of less postoperative pain, early recovery and discharge, and better cosmesis, laparoscopic surgery is rapidly gaining acceptance amongst surgeons as a better alternative to traditional open procedures. In January 2015, bookings for laparoscopic surgery became a more regular feature on our operation list.

Aims

We reported the indications, management outcome, and challenges in patients who had laparoscopic surgery in our institution. This is to document the trends in our surgical practice.

Methodology

This is a descriptive study of 137 patients who had laparoscopic surgery for general surgical indications in our institution over a period of 5 years. Patients data as collected from the records department were evaluated for demographic characteristics, medical comorbidities, type of procedures done, and perioperative outcome. Data analysis was performed using Statistical Package for Social Sciences (SPSS).

Results

A total of 137 Patients had laparoscopic general surgery between January 2015 and December 2019. There were 48 males and 89 females with a male-to-female ratio of 1:1.9. The mean age of the patients was 38.8 ± 3.4 years (range 16-87 years). Laparoscopic cholecystectomy (35%) and laparoscopic appendicectomy (29.9%) were the most common procedures performed. Five (3.7%) cases were converted to open surgery. Superficial surgical site infection (5.8%) following laparoscopic appendicectomy was the most common postoperative complication. There was no 30-day postoperative mortality.

Conclusion

Laparoscopic surgery is safe and can be applied to wide variety of general surgical conditions in developing countries. Minimal postoperative morbidity of laparoscopy is a major benefit to the patients.

Laparoscopy-assisted Transanal Endorectal Pull-through for the Management of Hirschsprung's Disease in Nigeria: Report of Two Cases

Hirschsprung's disease is a relatively common disease in pediatric colorectal surgery. The treatment modalities have evolved from third-stage to single-stage in the past three decades. The single-stage procedure can be performed using the open, transanal or laparoscopy-assisted techniques. We use these cases to illustrate the first laparoscopically assisted procedures for Hirschsprung's disease in our center. The laparoscopic-assisted technique is described, and lessons in collaboration across institutions and within institutions are discussed.

Prevalence of surgically correctable conditions among children in a mixed urban-rural community in Nigeria using the SOSAS survey tool: Implications for paediatric surgical capacity-building

Background

In many low- and middle-income countries, data on the prevalence of surgical diseases have been derived primarily from hospital-based studies, which may lead to an underestimation of disease burden within the community. Community-based prevalence studies may provide better estimates of surgical need to enable proper resource allocation and prioritization of needs. This study aims to assess the prevalence of common surgical conditions among children in a diverse rural and urban population in Nigeria.

Methods

Descriptive cross-sectional, community-based study to determine the prevalence of congenital and acquired surgical conditions among children in a diverse rural-urban area of Nigeria was conducted. Households, defined as one or more persons ‘who eat from the same pot’ or slept under the same roof the night before the interview, were randomized for inclusion in the study. Data was collected using an adapted and modified version of the interviewer-administered questionnaire—Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool and analysed using the REDCap web-based analytic application.

Main results

Eight-hundred-and-fifty-six households were surveyed, comprising 1,883 children. Eighty-one conditions were identified, the most common being umbilical hernias (20), inguinal hernias (13), and wound injuries to the extremities (9). The prevalence per 10,000 children was 85 for umbilical hernias (95% CI: 47, 123), and 61 for inguinal hernias (95% CI: 34, 88). The prevalence of hydroceles and undescended testes was comparable at 22 and 26 per 10,000 children, respectively. Children with surgical conditions had similar sociodemographic characteristics to healthy children in the study population.

Conclusion

The most common congenital surgical conditions in our setting were umbilical hernias, while injuries were the most common acquired conditions. From our study, it is estimated that there will be about 2.9 million children with surgically correctable conditions in the nation. This suggests an acute need for training more paediatric surgeons.

Survey of Basic Laparoscopic Training Exposure of Nigerian Postgraduate Trainees

Background:

The practice of laparoscopy involves the use of training models that are different from conventional open surgery. These concepts are not captured in the traditional models of surgical residency training. Residency training in surgery has been seen as an ample opportunity for early introduction and training in laparoscopy.

Objectives:

This study aimed to assess the level of exposure and training experience of some surgical resident doctors in accredited training institutions in Nigeria on laparoscopy.

Methodology:

A cross-sectional survey was conducted among the resident doctors undergoing revision course in surgery at the National Orthopaedic Hospital, Igbobi, Lagos, and Lagos University Teaching Hospital, Lagos, in March 2018. Using the quantitative method of data collection, a pre-tested structured questionnaire was used to collect information on the demography and training exposure of the residents in laparoscopy.

Results:

A total of 54 of 96 residents surveyed returned the questionnaire, giving a response rate of 56%. There were 53 (98.1%) males and 1 (1.9%) female. The age range of the respondents was between 30 and 46 years, with a mean of 34.2 ± 3.96 years. Thirty-two (59.3%) respondents had spent at least 2 years training in surgery. Thirty-six (66.7%) respondents had not participated in more than four laparoscopic procedures during their rotation. Forty-six percent of respondents reported that their experience in laparoscopy was mainly by observation of the procedures. Forty-nine (90.7%) of respondents surveyed had not attended any training program in laparoscopy. Eighty-one (81.0%) of respondents had a strong motivation and desire for future practice of laparoscopy.

Conclusion:

This study revealed that few Nigerian postgraduate trainees sampled in the survey were exposed and had training experience in laparoscopy.

Formal saline versus honey as escharotic in the conservative management of major omphaloceles

Background

The use of honey as an escharotic agent in the conservative management of omphalocele major has not been widely explored in spite of its proven benefits in chronic wound management. We explored the use of local honey as an escharotic agent by comparing its use with 2.5% formal saline in the conservative management of major omphaloceles at the Lagos University Teaching Hospital, Lagos, Nigeria.

Methods

From January 2006 to December 2009, 43 consecutive newborns with intact omphalocele major were alternately assigned into either Honey (H) or formal saline (FS) group. The membrane cover of each omphalocele was painted with the allotted group agent once every 48 h. The occurrence of faecal fistulas, rupture of eschar, intestinal obstruction as well as the mean duration of full wound healing, infection rates and overall mortality rates were compiled for the two groups.

Results

Eighteen newborns were assigned to the FS group while 25 others were prospectively enrolled into the H group. The age, sex and weight of newborns in both groups at presentation were comparable. Three omphaloceles (16.7%) ruptured and eviscerated among the FS group during the study while 1 (4%) of these occurred in the H group. Four (22.2%) cases of faecal fistula occurred in the FS group while none was recorded in the H group. One (5.6%) patient in the FS group developed small bowel stricture. This was not recorded in the honey group. Overall, there were 8 (44.4%) complications in the FS group and 1 (4%) in the H group. There was no statistical difference between the two groups concerning the occurrence of fistulae, sac rupture or bowel stricture. However, overall number of complications was statistically more in the FS group when compared to the H group (P < 0.05). Wounds in the H group healed within a mean period of 34.4 ± 4.9 days while those in the FS group healed within a mean period of 45.7 ± 6.8 days P < 0.01).

Conclusion

Honey is a good escharotics agent in the conservative management of major omphaloceles. Honey promotes faster healing and unlike 2.5% formal saline, is not significantly associated with faecal fistulas, rupture or bowel stricture.

Routine hemoglobin electrophoresis for pediatric surgery day case in at-risk populations: Suggested algorithm for screening using clinical risk factors

BACKGROUND

Hemoglobin electrophoresis (HBE) is a part of the preoperative routine requested by anesthetists. However, the prevalence of hemoglobinopathy in the population is low. This study aims to determine the clinical risk factors for hemoglobinopathies and propose clinical guidelines for preoperative screening of patients for pediatric day care surgery.

PATIENTS AND METHODS

A prospective study carried out over 12 months. Consecutive patients aged 6 months and older who had day case surgery were recruited to the study. Biodata and relevant clinical data were collated and documented in a proforma and analyzed using a statistical package for social sciences version 17.

RESULTS

There were 124 patients106 boys and 18 girls. The median age was 3 years. Scrotal lesions were the most common conditions managed (71.7%). Seventy-eight percent of patients had HbAA, 15.3% had HbAS, and 4.8% had HbAC while 0.8% each had both HbSC and HbSS. At least one parent of 78.2% knew their Hb phenotype, of which, 79% were HbAA. A history of jaundice (P = 0.0001), hand and foot syndrome (P = 0.0001), frontal bossing (P = 0.0001), and low packed cell volume at surgery (P = 0.001) were found significant in predicting hemoglobinopathies. There was no mortality.

CONCLUSION

Risk factors for hemoglobinopathies from this study included a positive history of jaundice, hand and foot syndrome, frontal bossing, and anemia. Proposed guidelines for HBE screening include the presence of hemoglobinopathy in one parent if one parent has sickle cell trait, and the other parent's genotype is unknown or if any of the risk factors is present.

Factors influencing waiting time in hypospadias repair surgery

AIMS

Hypospadias is a common congenital anomaly of the urethra and phallus, which is not life threatening. It is thus less prioritised in a resource-limited setting. The aim of this study was to evaluate the management of hypospadias by our paediatric surgery unit and determine the factors affecting the delay between presentation and surgical repair while proffering possible solutions to such delay in hypospadias repair surgery.

PATIENTS AND METHODS

This was a retrospective review of all hypospadias repair surgeries carried out by our paediatric surgery unit over a 38-month period, evaluating the period between presentation and first surgery for each patient. Data were analysed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Released 2011, Armonk, NY, USA). Chi-square test was used to compare categorical variables and P ≤ 0.05 was considered significant.

RESULTS

In 38 months, 47 operations for hypospadias were carried out on 42 boys. Thirty-seven patients (88.1%) had >3 months delay to surgery. The most frequent contributory factor to delay was unavailable theatre space (13 patients, 31%). Surgical outcome was good in only 16 patients (44%). Of the 16 patients with good outcome, 10 (63%) were operated between the ages of 2-4 years (P > 0.05).

CONCLUSIONS

Multiple factors are responsible for delays in carrying out hypospadias surgery in resource-limited environments, notably securing a functional operating theatre suite in the light of more urgent conditions. To combat these delays, we recommend having dedicated hypospadias repair sessions and surgeons dedicated to hypospadias repair. Hypospadias outreach camps are also proposed.

Preoperative localization of undescended testes in children: comparison of clinical examination and ultrasonography

BACKGROUND

Preoperative localization of the testis aids effective management of undescended testes. Various diagnostic techniques have been applied in the localization of undescended testes with varying results. The aim of this study was to compare clinical assessment and ultrasound evaluation in the preoperative localization of undescended testes in children.

METHODS

A prospective evaluation of all boys undergoing operation for undescended testes at the Lagos University Teaching Hospital, Idi Araba, from July 2010 to June 2011 was carried out. The findings on preoperative clinical and ultrasound examinations were compared with intraoperative findings.

RESULTS

Forty boys with 52 undescended testes were studied. The median age of the boys at the time of surgery was 4 years (range 1-11 years). Forty-five testes (86.5%) were accurately localized preoperatively by ultrasound while 25 testes (48.1%) were accurately localized on clinical examination. Ultrasound evaluation had an accuracy of 86.5% in preoperative localization of undescended testes. Clinical examination had an accuracy of 48.1% in preoperative localization of undescended testes. Ultrasound was more accurate than physical examination (p < 0.001).

CONCLUSIONS

Ultrasonography is more accurate than clinical examination in the preoperative localization of undescended testes in children and could play a role in preoperative evaluation of patients with undescended testes.

Routine haemoglobin electrophoresis screening in day case herniotomy in Nigerian children: Is it evidence-based?

Background:

To determine the prevalence of haemoglobinopathies in children who require day case herniotomy in our centre and ascertain if routine screening is necessary in all patients who require herniotomy.

Materials and Methods:

A 12-month retrospective analysis of patients requiring herniotomy in our centre. Data including age, sex, diagnosis, haemoglobin electrophoresis status, surgical outcome and hospital stay were analysed.

Results:

Ninety-five patients had complete records. There were 84 boys and 11 girls. M:F ratio: 7.6:1. The mean age was 3.2 ± 0.6 years. Fifty-five point eight per cent of the patients had right inguinal hernias while 35.8% had left inguinal hernias. Eight patients (8.4%) had bilateral inguinal hernias. Twenty-six patients (27.4%) had haemoglobinopathies while 69 patients (72.6%) had homozygous Haemoglobin A. The Sickle Cell trait (HbAS) was found in 22 patients (23.2%) while the HbAC was found in three patients (3.2%). One patient (1.1%) had Sickle Cell disease (Haemoglobin SS). He had had blood transfusion and previous history of jaundice. All patients survived and all patients were discharged on the day of surgery (mean hospital stay: 4hrs (range: 2.5 hrs–12 hrs)) except the patient with Sickle Cell disease who was admitted a day before surgery and discharged a day after the operation.

Conclusion:

One in four children coming for day case herniotomy in our centre had the Sickle Cell trait while only 1% had the Sickle Cell disease. These findings are in keeping with the prevalence in the Nigerian population. Routine screening may not be necessary for all patients coming for herniotomy in our centre. Clear indication(s) should be outlined for screening.

H-type tracheo-oesophageal fistula: a diagnostic challenge in a resource-poor country. A case report

H-type fistula is a rare form of congenital tracheo-oesophageal fistula accounting for 4% of all cases of Tracheo-oesophageal fistula. The typical picture is that of recurrent chest infection due to both missed and delayed diagnosis as well as cyanosis and choking during feeds. In resource poor countries this problem is further exaggerated by ignorance, poverty and lack of access to basic investigative modalities. This is the case of [abstract incomplete].

Diagnostic value of high resolution ultrasound in localisation of the undescended testis in children

BACKGROUND

The use of ultrasonography in the pre-operative localisation of undescended testes has become controversial due to fears about its accuracy. This study was designed to ascertain the accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ultrasonography in the localisation of the undescended testes in children.

PATIENTS AND METHODS

A prospective evaluation of all boys undergoing operation for undescended testes at the Lagos University Teaching Hospital, Idi-Araba, Lagos, over a 12 month period was performed. The pre-operative clinical and ultrasound findings were compared with the findings on surgical exploration.

RESULTS

Forty boys with 52 undescended testes were studied. The mean age of the boys at the time of surgery was 4.0 ± 0 years (range 1-11 years). Forty-six (88.5%) testes were localised pre-operatively by ultrasound- 20 of 22 (90.9%) palpable testes and 26 of 30 (86.7%) non-palpable testes. Intra-operatively, 49 (94.2%) of the undescended testes were found while 3 (5.8%) were absent/vanishing testes. Ultrasound evaluation had an accuracy of 86.5%, sensitivity of 89.8%, and specificity of 33.3%, PPV of 95.7% and a NPV of 16.7%.

CONCLUSION

Ultrasound assessment is beneficial in pre-operative evaluation of children with undescended testes.

Duplication cyst of ascending colon presenting as an ileal volvulus in a child: a case report and review of literature

Alimentary tract duplications are uncommon congenital anomalies that may be found anywhere along the gastrointestinal tract. They have a diverse presentation and often times present with complications of intestinal obstruction and/or lower gastrointestinal haemorrhage. We report a very rare finding of a colonic duplication cyst which presented as an ileal volvulus in a young girl. While available investigations were non-specific, the child survived on account of an early decision to operate. She had resection of the duplication cyst and ileo-colic anastomosis. She made good recovery post-operatively. A high index of suspicion is necessary on the part of clinicians to recognise this condition. Early operative intervention is necessary in the developing world setting where state of the art investigations are not available for accurate pre-operative diagnosis.

Accreditation of Training Programmes by the West African College of Surgeons

The establishment of surgical training programmes of the West African College of Surgeons started in six teaching hospitals the early 1970s in Nigeria and Ghana; it was championed by College Fellows, surgeons who had returned to the sub-region after having trained in Europe and America. Surgical programmes accreditation, captured in the College's constitution and mission statement, uses objective guidelines in the identification and encouragement of suitable institutions for surgical training through periodic peer-review audits of installed manpower, facilities, clinical services and academic programmes. This pan-regional model adopted by the five Anglophone countries of West Africa has standardized and nurtured surgical training in the disciplines of surgery, obstetrics and gynaecology, ophthalmology, otorhinolaryngology, dental surgery, radiology and anaesthesia. It has also proven to be a useful template in the current drive for the ongoing harmonization of surgical training programmes with Francophone West African as a prelude to an integrated sub-regional accreditation body. This paper details the evolution of surgical programmes accreditation in West Africa, its progress, challenges, opportunities and future trends.

Penile injuries from proximal migration of the Plastibell circumcision ring

BACKGROUND

Although circumcision is the commonest surgical procedure performed on male neonates, complications still arise from all methods used by operators.

PATIENTS AND METHOD

This was a prospective study of penile injuries resulting from proximal migration of the Plastibell device in neonate boys referred to the Lagos University Teaching Hospital, Lagos, Nigeria. The parameters measured were patients' biodata, presentation, management and treatment outcome.

RESULTS

Twenty-three injuries resulting from circumcision with the Plastibell device all occurred from prolonged retention of the ring. In each case, the ring was retained and had migrated proximally. There was extensive skin loss in 17 (74%) babies. Urethrocutaneous fistulae were the result in nine (39%) of these cases, while partial necrosis of the glans penis occurred in four (17%). These complications resulted from the use of wrong-sized Plastibell kits, lack of follow-up by the medical staff, and inadequate maternal knowledge of ring fall-out time.

CONCLUSION

Proximal migration of the Plastibell ring can result from employment of an inappropriate size, causing grievous penile injury. Adequate information should be provided to mothers of circumcised babies about possible complications of the Plastibell kit when employed. There is a need to redesign the Plastibell kit to eliminate its migration up the penile shaft.

Appropriateness of intra-operative blood transfusion in children at the Lagos University Teaching Hospital--an initial survey

BACKGROUND

The decision to transfuse intra-operatively is based on preoperative haemoglobin (Hb), estimated blood loss and physiological variables. The visual estimate of blood loss is notoriously unreliable especially with small volumes of blood losses in children.

OBJECTIVES

We sought therefore to determine the appropriateness of intra-operative blood transfusion in a sample of children

METHODS

All children requiring intra-operative blood transfusion between May and June 2008 were prospectively studied. Neonates and children already on blood transfusion at induction were excluded. Transfusion was prescribed at the discretion of the attending anaesthetist. The Estimated blood volume (EBV) and estimated blood loss (EBL)were determined. Appropriate transfusion was defined as blood transfusion at EBL > 15% of EBV, maximum allowable blood loss to PCV of 27% and pre-transfusion Hb < 8g/dl.

RESULTS

Twenty-five patients were studied with a mean age of 4.16 +/- 3.59 years (Range 0.33-11 years). The mean preoperative PCV was 31.14 +/- 3.53% (range 25-34%). Twelve patients (48%) were appropriately transfused when MABL was calculated to PCV of 27%. Nine patients (36%) had appropriate blood transfusion at an EBL greater or equal to 15% of the EBV. Of the 12 patients that had pre-transfusion Hb measured, 2 (16.6%) were appropriately transfused at Hb < 8 g/dl.

CONCLUSION

The use of near patient monitoring devices should be encouraged as this will give an accurate assessment of Hb and appropriate indication for transfusion. Equipment should be made available to perform gravimetric estimation of blood loss as the visual method is notoriously unreliable.

Presentation and management outcome of childhood intussusception in Lagos: a prospective study

BACKGROUND

Intussusception is the commonest cause of bowel obstruction in infancy and childhood. Early diagnosis and effective management have reduced its morbidity and mortality in developed countries.

AIM

To document the presentation, management and treatment outcome of intussusceptions at the Lagos University Teaching Hospital (LUTH).

PATIENTS AND METHODS

One hundred seventy-four consecutive cases of this condition seen in children presenting at LUTH over a 5-year period were prospectively studied. Details of symptoms and signs, pre-hospital care, treatment, and outcome in LUTH were documented.

RESULTS

The triad of abdominal pain, bloody mucoid stools and palpable abdominal mass was seen in 106 (61%) of the cases. One hundred thirty-five (77.6%) had been admitted and treated with antibiotics and intravenous fluids in primary healthcare centers for an average of 3 days before referral to the LUTH. Prolonged mean duration of recognizable symptoms of 3 days accounted for a 70.4% bowel resection rate. Wound infection occurred in 61 (36.1%), whereas fecal fistulae developed in six (3.6%), and burst abdomen in five (3%) of cases. Seven (4.1%) patients developed incisional herniae. Overall, mortality rate was 12.1%.

CONCLUSION

The early symptoms of intussusception would seem to be missed by primary healthcare workers in Lagos, with consequently high morbidity and mortality. There is an urgent need to re-emphasize these symptoms to first-line healthcare providers and parents through public enlightenment campaigns.

A comparative study of the haemodynamic effects of atropine and glycopyrrolate at induction of anaesthesia in children

BACKGROUND

Bradycardia following administration of halothane and suxamethonium in children leads to reduced cardiac output, which can be prevented with prophylactic anticholinergics. Anticholinergics may result in tachycardia and arrhythmias. This study was designed to compare haemodynamic changes and incidence of cardiac arrhythmias following intravenous atropine and glycopyrrolate.

STUDY DESIGN

Ninety ASA I and II children between one month and twelve years were studied. Premedication was with oral promethazine 1mg/kg. Anaesthesia was achieved with 3 % halothane in 33 % oxygen and nitrous oxide. Patients were randomly allocated to receive atropine 0.01mg/kg (Group I) or glycopyrrolate 0.005mg/kg (Group II). Tracheal intubation was facilitated with suxamethonium 1.5mg/kg.

RESULTS

Patients in Group I had a 35.7% rise in heart rate from baseline, compared to 22.5 % in Group II two minutes after anticholinergic administration (p=0.001). Following intubation, heart rate rose by 9.7 % and 13.2 % (p<0.05) in Groups I and II respectively. MAP rose similarly in both groups. Arrhythmia occurred in 44.4 % of patients in Group I and 11.1% in Group II (p=0.001) and were mainly sinus tachycardia. 2.2% of patients in Group I exhibited bigemini. No patient experienced bradycardia. Hypoxia occurred in 2.2 %, hypotension in 13.3% and mild laryngeal spasm in 0% of Group I and 11.1%, 4.4% and 4.4% of Group II respectively.

CONCLUSION

The use of glycopyrrolate compared to atropine, offered better cardiovascular stability in Nigerian children. Arrhythmias occurred more in patients who had atropine and occurred most frequently after tracheal intubation.

Cardiothoracic anesthesia, respiration and airway modified mallampati test, thyromental distance and inter-incisor gap are the best predictors of difficult laryngoscopy in West Africans

PURPOSE

To determine the ability to predict difficult visualization of the larynx (DVL) from the following preoperative airway predictive indices, in isolation and combination: modified Mallampati test (MMT), thyromental distance (TMD), sternomental distance (SMD), horizontal length of the mandible (HLM) and inter-incisor gap (IIG).

METHODS

Three hundred and eighty consecutive patients undergoing general anesthesia were evaluated using the MMT, TMD, SMD, HLM and IIG and the cut-off points for the airway predictors were Mallampati III and IV; < or = 6.5 cm, < or = 13.5 cm, < or = 9.0 cm and < or = 4.0 cm respectively. During direct laryngoscopy, the laryngeal view was graded using the Cormack and Lehane (CL) classification. CL grades III and IV were considered difficult visualization. Sensitivity, specificity and positive predictive value for each airway predictor in isolation and in combination were determined. Logistic regression analysis was used to determine independent predictors of DVL.

RESULTS

Difficulty to visualize the larynx was found in 13 (3.4%) patients. The sensitivity, specificity and the positive predictive value for the five airway predictors were: MMT (61.5%; 98.4%; 57.1%), TMD (15.4%; 98.1%; 22.2%), SMD (0%; 100%; 0%), HLM (30.8%, 76.0%; 4.3%) and IIG (30.8%; 97.3%; 28.6%). The best combination of predictors was MMT/TMD/IIG with a sensitivity, specificity and positive predictive value of 84.6%; 94.6%; 35.5% respectively. Logistic regression analysis showed that weight, MMT, IIG and TMD were independent predictors of DVL.

CONCLUSION

MMT, TMD and IIG appear to provide the optimal combination in prediction of DVL in a West African population.

Endothelin-like action of Pausinystalia yohimbe aqueous extract on vascular and renal regional hemodynamics in Sprague Dawley rats

The bark of the African tree Pausinystalia yohimbe has been used as a food additive with aphrodisiac and penile erection enhancing properties. The effect of an aqueous extract of P. yohimbe (CCD-X) on renal circulation was assessed in order to test the hypothesis that it possesses additional effects on nitric oxide production and/or endothelin-1 (ET-1)-like actions. In vivo studies with CCD-X in Sprague Dawley rats demonstrated a dose-dependent (1-1000 ng/kg) increase in mean blood pressure (p < 0.001) and an increase in medullary blood flow (MBF) (p < 0.001). Both the pressor action and renal medullary vasodilation were blocked by endothelinA (ETA) receptor antagonist BMS182874 and endothelinB (ETB) receptor antagonist BQ788 in combination. L-Nomega-nitro-l-arginine methyl ester (L-NAME; 10 mg/kg) also inhibited the increase in MBF induced by CCD-X. In vitro studies in isolated perfused kidney and in pressurized renal microvessels confirmed the dose-dependent vasoconstrictor action of this extract. ETA receptor antagonist BQ610 and ETB receptor antagonist BQ788 separately and significantly attenuated the renal vasoconstrictor actions of the extract (p < 0.001 ANOVA). These preliminary observations indicate that, in addition to the alpha-adrenergic antagonist actions that characterize yohimbine, CCD-X possesses endothelin-like actions and affects nitric oxide (NO) production in renal circulation. These findings suggest a strong possibility of post-receptor cross-talk between alpha2-adrenoceptors and endothelin, as well as a direct effect of alpha2-adrenoceptors on renal NO production.

Surgical swab foreign bodies--observations on 7 cases in Lagos

Foreign bodies inadvertently left in body cavities are a rare complication of abdominal and other surgeries. The true incidence of this condition is not known. The author reports on 7 such cases occurring over a 16-year period and comments on preventive measures, early diagnosis, tactful handling and the need for damage control when dealing with this unwelcome issue in a surgical setting.

Viral isolates of intussusception in Nigerian infants

Idiopathic intussusception is associated with viral pathogens of gastrointestinal respiratory and febrile diseases of infancy and early childhood. These agents are known to vary from one region to another. No such specific viruses have, however, been reported from Nigeria. We therefore collected stools from 28 infants with intussusception as well as 20 age- and sex-matched healthy controls and subjected these specimens to viral isolation techniques. Of the 21 viral isolates obtained from the two groups, 17 (81%) were from the intussusception group while 4 (19%) were from the controls. Ten (58.8%) of the 17 isolates from these subjects were identified as adenoviruses using monoclonal antibody. All of them were from the intussusception group. None of the four isolates from the controls significantly reacted with this antibody. We concluded that adenoviruses are strongly associated with primary intussusception in Nigerian infants.

Factory floor injury in a Lagos sawmill

We retrospectively reviewed injuries sustained in 36 consecutive accidents in a wood-processing factory and managed at a private hospital over a 2-year period in Lagos. The commonest injuries were lacerations by revolving saws, followed by crush injuries from entrapment by machines and from falling logs and planks. The upper limbs were involved in 24 (66%) of these accidents cases. Of 137 workers on the factory floor, the highest injury rate (64%) occurred among machine operators. While 80.6% of these injuries were simple ones treated by suturing and dressing, 7 (19.4%) were life-threatening enough to warrant hospitalisation and major surgery, with 6 sustaining a mean permanent disability of 7.1 +/- 6%. Although factory-floor injuries constituted only 6.5% of 553 hospital attendance recorded within the period from the company, they were responsible for 44.2% of total medical expenditure by the company within the same period. Non-use of protective gears and disregard for safety procedures were noted in most of the accidents. The in-house first-aid program was adjudged as life-saving in the few major cases managed. We concluded that while many factory-floor injuries in wood-processing factories may be minor hand injuries, provision and strict observance of safety protocols as well as an active first-aid program are invaluable to minimise morbidity, cost and loss of productive man-hours in wood processing factories.

Abuse and neglect in the surgically ill child

Child abuse and neglect are a global phenomenon often symptomatic of underlying psychosocial family problems, which may represent a transferred aggression from one or both disturbed parents onto the child. Although the scope has been widely explored in Africa, little has been written on children presenting with surgical lesions. We report 31 children abused by their parents on accounts of frustrations engendered by the children's surgical conditions in Lagos. 26 (83.9%) of these children had major congenital defects while only 5 (16.1%) had acquired lesions. The commonest form of abuse was child abandonment, seen in 9 (29%) of cases. Neglect was recorded in 7 (23%) cases while 2 children were mutilated because of surgical lesions. Three patients were starved, 3 children with colostomy were evicted by landlords while 2 were locked up by parents out of shame. One child died of infanticide. Reasons for abuse included financial constraints, hopelessness and shame associated with grotesque lesions, broken homes and maternal pregnancy. Doctors and nurses engaged in the care of gross congenital anomalies and other major surgical lesions should anticipate this problem and evolve appropriate strategies to deal with it. The social worker should be involved early enough in the management. Provision of adequate social safety nets, affordable medical care and specific legal protection for children will curtail this ugly trend in our society.

Entero-cutaneous fistula of the vermiform appendix in childhood: case report

Entero-cutaneous fistula involving only the vermiform appendix is rare in childhood. We report a case recently managed in our practice, the first of such report from West Africa, along with a review of world literature on the subject.