Treatment of colorectal cancer in Sub-Saharan Africa: Results from a prospective Nigerian hospital registry.

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer worldwide. Mortality for CRC is improving in high income countries, but in low and middle income countries, rates of disease and death from disease are rising. In Sub-Saharan Africa, the ratio of CRC mortality to incidence is the highest in the world. This study investigated the nature of CRC treatment currently being offered and received in Nigeria. METHODS: Between April 2013 and October 2017, a prospective study of consecutively diagnosed cases of CRC was conducted. Patient demographics, clinical features, and treatment recommended and received was recorded for each case. Patients were followed during the study period every 3 months or until death. RESULTS: Three hundred patients were included in our analysis. Seventy-one percent of patients received a recommended surgical operation. Of those that didn't undergo surgery as recommended, 37% cited cost as the main reason, 30% declined due to personal reasons, and less than 5% absconded or were lost to follow up. Approximately half of patients (50.5%) received a chemotherapy regimen when it was recommended, and 4.1% received radiotherapy when this was advised as optimal treatment. With therapy, the median overall survival for patients diagnosed with stage III and stage IV CRC was 24 and 10.5 months respectively. Overall, we found significantly better median survival for patients that received the recommended treatment (25 vs 7 months; P < .01). CONCLUSIONS: A number of patients were unable to receive the recommended treatment, reflecting some of the burden of untreated CRC in the region. Receiving the recommended treatment was associated with a significant difference in outcome. Improved healthcare financing, literacy, training, access, and a better understanding of tumor biology will be necessary to address this discrepancy.

Circumareolar Incision-subdermal Tunneling Dissection for Excision of Multiple Breast Fibroadenomata.

Excision of multiple fibroadenomas (MF) in separate breast quadrants presents difficulties of number and location of incision(s) and extent of tissue dissection and may be associated with more complications and poorer cosmetic outcome. This is a report of excision of MF in multiple quadrants of the breast using a modification of subcutaneous dissection technique dubbed the circumareolar incision and subdermal tunneling (CAST) dissection. After exposure of the superficial fascia with circumareolar incision, subdermal cone-wise dissection was made to allow mobilization of the segment bearing the lump(s). The lump(s) were enucleated and removed. MF were removed from four breasts in three young unmarried females. The first patient had multiple adenomas removed from three quadrants of both breasts: 14 on the right and six on the left. The second patient had excision of three lumps in three separate quadrants, and the third patient had excision of two lumps in two separate quadrants. All patients had edema and bruising. One breast had wound infection and dehiscence. There were no skin necrosis, no nipple loss, and no breast distortion. All ensuing scars were camouflaged. CAST dissection was used for excision of MF in multiple quadrants of the breast with preservation of excellent cosmetic outcome of a single circumareolar incision.

ORAL CLINICAL LONG CASE PRESENTATION, THE NEED FOR STANDARDIZATION AND DOCUMENTATION.

BACKGROUND: The oral presentation of the clinical long case is commonly an implied knowledge. The challenge of the presentation is compounded by the examiners' preferences and sometimes inadequate understanding of what should be assessed. OBJECTIVES: To highlight the different opinions and misconceptions of trainers as the basis for improving our understanding and assessment of oral presentation of the clinical long case. METHODOLOGY: Questionnaire was administered during the West African College of Surgeons fellowship clinical examinations and at their workplaces. Eligibility criteria included being a surgeon, a trainer and responding to all questions. RESULTS: Of the 72 questionnaires that were returned, 36(50%) were eligible for the analysis. The 36 respondents were from 14 centers in Nigeria and Ghana. Fifty-two percent were examiners at the postgraduate medical colleges and 9(25%) were professors. Eight(22.2%) indicated they were unaware of the separate methods of oral presentation for different occasions while 21( 58.3%) respondents were aware that candidate used the "5Cs" method and the traditional compartmentalized method in long case oral presentation. Eleven(30.6%) wanted postgraduates to present differently on a much higher level than undergraduate despite not encountering same in literature and 21(58.3%) indicated it was an unwritten rule. Seventeen (47.2%) had not previously encountered the "5Cs" of history of presenting complaint in literature also 17(47.2%) teach it to medical students and their junior residents. CONCLUSION: This study has shown that examiners definitely have varying opinions on what form the oral presentation of the clinical long case at surgery fellowship/professional examination should be and it translates to their expectations of the residents or clinical students. This highlights the need for standardization and consensus of what is expected at a formal oral presentation during the clinical long case examination in order to avoid subjectivity and bias.

Jejunal choristoma: a very rare cause of abdominal pain in children.

Choristoma is development of a normal tissue in an aberrant location. This report describes jejunal salivary choristoma (JSC) causing recurring episodes of abdominal discomfort in a 5-year-old girl. Exploratory laporatomy revealed a pale yellow subserosal jejunal lesion. Wedge resection of the lesion and repair of the bowel were performed. The child did well postoperatively and has since that time been free of pain at follow-up. Histopathological examination of the resected lesion revealed salivary gland choriostoma. Literature review (PUBMED search engine) revealed no previous report of this rare clinicopathologic entity. We conclude that choriostoma should be considered a possible differential when evaluating abdominal complaint in children.

Bilateral Breast Cancer: Experience in a Poor Resource Black African Setting

Background: Breast cancer is the most common malignancy in women in Nigeria. Women previously treated for ipsilateral breast cancer have increased risk of developing contalateral breast cancer (CBC); the chance of which increases with longer period of survival and is associated with worse prognosis. Reports from Nigeria are few on this. The aim of this study was to assess the prevalence; predisposition; presentation; and outcome of management of bilateral breast cancer (BBC) in a population; South-western Nigeria.Methods: A review of bio-data of all patients with BBC seen in LTH; Osogbo; Nigeria between 2001 and 2008 was done. Age; parity; age at menarche and first child birth; family history; duration of symptoms; tumour characteristics and exposure to cigarette; oral contraceptive pills (O.C Pills) and outcome of treatment were also assessed.Results: BBC constituted 4.6of the 256 breast cancer patients. Eight (73) were metachronous and 91were infiltrating ductal carcinoma. Patients' mean age; mean age at menarche and first child birth were 39; 14.5+3 and 22.5yrs respectively. Mean parity was 3.5 child birth; 91were premenopausal and all have menstruated for 12-31yrs. None had positive family history while only 1 and 3 had insignificant exposure to cigarette and O.C pills respectively. The mean interval between the 2 onsets was 18mths (0-68mths). 91of all tumours were advance; while 81of the first tumours were on the right. Mean duration before presentation for the first and second tumours were 261 and 111 days respectively. One patient has survived for 2 years thus far.Conclusion: The incidence of BBC was 4.26. Most patients were young and premenopausal with mostly infiltrating ductal carcinoma (NOS) and presenting with late stage disease; hence poor prognosis. Aggressive follow-up of patients with ipsilateral cancer will aid early detection of CBC

Male breast cancer in LAUTECH Teaching Hospital Osogbo, South Western Nigeria.

AIM: To assess the prevalence, presentation, treatment and outcome of management of male breast cancer (MBC) in Osogbo, Nigeria. METHODS: A review of all cases of MBC seen at LAUTECH Teaching Hospital Osogbo between January 2004 and December 2006 was done. The age, presenting symptoms and signs, stage, histology, associated co-morbid illnesses, treatment and outcome of care were all retrieved and analysed. RESULTS: Seven (8.86%) out of seventy nine cases of breast cancers seen are males. Ages ranged between 38 and 80 years (mean 60.5 median 65 years). They all presented with advanced lesions after a 6 -36 months delay (mean-11.57 months). All were invasive ductal carcinoma. All the four with significant co-morbid illnesses died of them within one week to seven months. Only one patient had mastectomy. CONCLUSION: MBC constitutes 8.86% of all breast cancer, all presented late with advanced lesions and co-morbid illnesses contributed significantly to mortality.

Mirizzi syndrome caused by a bile pseudocyst.

BACKGROUND: Mirizzi syndrome caused by bile pseudo cyst presents diagnostic and management challenges to the surgeon. OBJECTIVE: To emphasize to clinicians the need to always recognize and correct associated liver derangements before surgery so as to prevent the usual accompanying high morbidity/mortality associated with Mirizzi syndrome. CASE REPORT: We report an unusual and previously unreported pathology of post-cholecystectomy Mirizzi syndrome in a 35 year old female who developed a bile pseudo-cyst and which may possibly qualify for Mirizzi syndrome type 5--highlighting the need for maximum pre, -intra, and post-operative challenges for improved prognosis. The patient was lost from reactionary haemorrhage due to limited facilities. CONCLUSION: There is a crying need in developing countries to have Critical Care centers and for Clinicians to recognize the necessity for adequate pre, intra and post-operative care of these high risk patients.

Intestinal obstruction from a forgotten artery forceps: a case report.

A 43-year-old multiparous patient p2+0 all alive who had abdominal hysterectomy secondary to ruptured uterus 2 1/2 years prior to presentation, was seen with acute (surgical) abdomen. An artery forceps was seen on plain abdominal X-ray and subsequent laparotomy revealed gangrenous ileum. The entire length of the ileum was involved, including the ileocecal valve and part of the cecum. The patient had limited right hemicolectomy and anastomosis of the distal part of the jejunum with the proximal section of the transverse colon. The post-operative period was uneventful and she was discharged to outpatient clinic 2 weeks post operatively.