The History and Evolution of the West African College of Surgeons/Jos University Teaching Hospital Trauma Management Course.

BACKGROUND: Inadequate trauma care training opportunities exist in Low- and Middle-Income Countries. Jos University Teaching Hospital and the West African College of Surgeons (WACS) have synergized, over the past 15 years, to introduce a yearly, certified, multidisciplinary Trauma Management Course. We explore the history and evolution of this course. METHODS: A desk review of course secretariat documents, registration records, schedules, pre- and post-course test records, post-course surveys, and account books complemented by organizer interviews was carried out to elaborate the evolution of the Trauma Management Course. RESULTS: The course was started as a local Continuing Medical Education program in 2005 in response to recurring cycles of violence and numerous mass casualty situations. Collaborations with WACS followed, with inclusion of the course in the College's yearly calendar from 2010. Multidisciplinary faculty teach participants the concepts of trauma care through didactic lectures, group sessions, and hands-on simulation within a one-week period. From inception, there has been a 100% growth in lecture content (from 15 to 30 lectures) and in multidisciplinary attendance (from 23 to 133 attendees). Trainees showed statistically significant knowledge gain yearly, with a mean difference ranging from 10.1 to 16.1% over the past 5 years. Future collaborations seek to expand the course and position it as a catalyst for regional emergency medical services and trauma registries. CONCLUSIONS: Multidisciplinary trauma management training is important for expanding holistic trauma capacity within the West African sub-region. The course serves as an example for Low- and Middle-Income contexts. Similar contextualized programs should be considered to strengthen trauma workforce development.

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.

Neonatal surgery in Africa.

The management of neonatal surgical problems continues to pose considerable challenges, particularly in low-resource settings. The burden of neonatal surgical diseases in Africa is not well documented. The characteristics of some neonatal surgical problems are highlighted. Late presentation coupled with poor understanding of the milieu interior of the neonates by incompetent health care providers and poorly equipped hospitals combine to give rise to the unacceptable high morbidity and mortality in most parts of Africa. Proper training of all staff involved in neonatal health care coupled with community awareness must be vigorously pursued by all stakeholders. Various governments throughout the continent of Africa, in conjunction with international donor agencies, must not only provide an adequate budget for health care services and improve infrastructures, but must also deliberately encourage and provide funding for neonatal surgical care and research across the continent. The well-established pediatric surgical training programs, particularly in North and South Africa, should hold the moral responsibility of training all possible numbers of young surgeons from other African countries that do not have any existing pediatric surgical training programs or those countries suffering from remarkable shortage of trained pediatric surgeons.

Challenges of training and delivery of pediatric surgical services in Africa.

BACKGROUND: The practice of pediatric surgery in Africa presents multiple challenges. This report presents an overview of problems encountered in the training of pediatric surgeons as well as the delivery of pediatric surgical services in Africa. METHODS: A returned structured self-administered questionnaire sent to pediatric surgeons practicing in Africa was reviewed and analyzed using SPSS version 11.5 (SPSS, Chicago, IL). RESULTS: Forty-nine (57%) of 86 questionnaires were returned from 8 countries. Great variability in the requirements and training of pediatric surgeons, even within the same country, was found. Many surgical colleges are responsible for standardization and board certification of pediatric surgeons across Africa. There were 6 (12%) centers that train middle level manpower. Twenty-six (53%) participants have 1 to 2 trainees, whereas 22 (45%) have irregular or no trainee. A pediatric surgical trainee needs 2 to 4 (median, 2) years of training in general surgery to be accepted for training in pediatric surgery, and it takes a trainee between 2 to 4 (median, 3) years to complete training as a pediatric surgeon in the countries surveyed. The number of pediatric surgeons per million populations is lowest in Malawi (0.06) and highest in Egypt (1.5). Problems facing adequate delivery of pediatric surgical services enumerated by participants included poor facilities, lack of support laboratory facilities, shortage of manpower, late presentation, and poverty. CONCLUSION: The training of pediatric surgical manpower in some African countries revealed great variability in training with multiple challenges. Delivery of pediatric surgical services in Africa presents problems like severe manpower shortage, high pediatric surgeon workload, and poor facilities. Standardization of pediatric surgery training across the continent is advocated, and the problems of delivery of pediatric surgical services need to be addressed urgently, not only by health care planners in Africa but by the international community and donor agencies, if the African child is to have access to essential pediatric surgical services like his or her counterpart in other developed parts of the world.

Sacrococcygeal teratoma: clinical characteristics and long-term outcome in Nigerian children.

BACKGROUND/PURPOSE: The excision of sacrococcygeal teratoma (SCT) may be associated with significant long-term morbidity for the child. We reviewed our experience with SCT in a tertiary health care facility in a developing country with particular interest on the long-term sequelae. METHODS: Between January 1990 and May 2008 inclusive, 38 consecutive children with the diagnosis of SCT were identified from the operation register and the Cancer Registry of the Jos University Teaching Hospital. Their clinical presentation, investigation, operative findings, histology report, and outcome were recorded and analyzed. The long-term follow-up of some of the patients were also recorded and analyzed. RESULTS: There were 31 females and 7 males. Twenty-three patients presented during the neonatal period with a median age at presentation of 7 days (range 1-18 days) and a median weight at presentation of 2.8 kg (range 2.0-3.6kg), 10 presented between 1 month and 12 months, while 5 were older than 1 year at presentation. Most of the patients had significantly external tumors. Excision of the tumor was mainly by the sacral route, four had abdominal-sacral excision. Histology was mainly benign; four were malignant at presentation. Four children with malignant disease had chemotherapy in addition to excision of the tumor. Eight had immediate post-operative wound-related complications while three children died, two of the deaths were related to anesthesia, while one died of colostomy complications. Twenty-one (60%) were followed up for a median duration of 6 years (range 1 month-8 years). Two (9.5%) had recurrent disease after primary excision; five (23.8%) had some degree of functional impairment at the follow-up. CONCLUSION: While SCT is usually benign, recurrence, malignant transformations in patients who present late and long-term functional sequelae are problems that must be tackled by the care givers. A multi-center study may be necessary to characterize this disease in developing countries and assess the long-term functional sequelae in survivors.

Childhood cancers: challenges and strategies for management in developing countries.

The developing countries bear the greatest burden of childhood cancers as over 90% of the world's children live in these countries. Childhood cancer in most instances is curable, but many children die from cancer because most children live in developing countries without access to adequate treatment due to high cost of treatment and poor organization in these countries. Initiatives to increase cancer care in developing countries would therefore include establishment of standard cancer care centres, manpower training, establishment of standardized management protocols, procurements of standard drugs and collaboration with international organizations.

Colostomy for high anorectal malformation: an evaluation of morbidity and mortality in a developing country.

Colostomy is a life-saving procedure in newborns with high anorectal malformations (ARM). However, the procedure may be attended by complications, particularly in resource limited settings. This is an evaluation of the morbidity and mortality following colostomy for ARM in newborns in two paediatric teaching centres in a developing country. A retrospective review of 61 neonates who had colostomy for high ARM in 4 years is conducted. The babies were categorised into Group A (weight at presentation < 2.5 kg) and Group B (weight at presentation > 2.5 kg). There were 47 boys and 14 girls aged 18 h to 28 days (median 6 days). There were 23 babies in Group A; 18 had colostomy under local anaesthetic (LA), 5 of whom died while 5 had the procedure done under general anaesthetic (GA), 3 of whom died (mortality 8/23, 34.78%). Group B consisted of 38 babies, 18 had colostomy under GA, 3 died, while in 20 the procedure was under LA, 1 of who died (mortality 4/38, 10.5%). The difference in mortality between groups A and B was statistically insignificant (p < 0.056). There were no significant differences in outcome between the two groups when the type of anaesthesia or types of colostomy were considered. Surgical site infection was the most common 12/61, 19.7%. Of the 12 babies that died, 7 were due to overwhelming infections, 4 respiratory insufficiencies and 1 cyanotic heart disease. The overall procedure related mortality was therefore 7 (11.5%). None of the centres had adequate neonatal intensive care services during the period of this report. Morbidity and mortality following colostomy for ARM in newborns is still high in this setting, due largely to infective complications, particularly in babies < 2.5 kg.

Clinical characteristics and outcome of surgical treatment of childhood rhabdomyosarcoma: a 7-year experience.

BACKGROUND: The aim of this study was to describe the outcome and determine the prognostic factors of outcome of childhood rhabdomyosarcoma in a tertiary hospital in a developing country. PATIENTS AND METHODS: This was a retrospective review of the clinical presentation, investigation, intervention, and treatment outcomes of children with rhabdomyosarcoma in our hospital over a 7-year period. Statistical analysis was performed using Chi-square test. RESULTS: A total of 18 patients were identified with two-thirds being males (n = 12) with median age of 7 years. Most of the children were below 10 years of age. Lower limbs tumour predominated (n = 6) followed by the upper limbs and head and neck (n = 4 each). Other sites included perianal/perineal (n = 3) and the orbit (n = 1). Two patients were Intergroup Rhabdomyosarcoma Study (IRS) group I, four group II, five group III, and seven group IV. Lymph node involvement was the commonest site of metastasis. Clinical group and stage was significantly more advanced in patients older than 10 years compared to younger than 10 years (P = 0.010, P = 0.008, respectively). There were 12 patients with alveolar disease while six had embryonal type of rhabdomyosarcoma. Treatment was by combination chemotherapy, and surgical excision which was done primarily in 11, after chemotherapy in four, and after radiotherapy in one. Two had biopsy only. Five patients are alive, two of them without evidence of disease at average follow-up period of 2 years. CONCLUSION: Mortality from rhabdomyosarcoma in our setting is still unacceptably high. Late presentation may be the major contributor to high mortality. A more aggressive multimodality treatment approach may improve the outcome.

Clinical characteristics and outcome of surgical treatment of childhood rhabdomyosarcoma: a 7-year experience

Background: The aim of this study was to describe the outcome and determine the prognostic factors of outcome of childhood rhabdomyosarcoma in a tertiary hospital in a developing country. Patients and Methods: This was a retrospective review of the clinical presentation; investigation; intervention; and treatment outcomes of children with rhabdomyosarcoma in our hospital over a 7-year period. Statistical analysis was performed using Chi-square test. Results: A total of 18 patients were identified with two-thirds being males (n = 12) with median age of 7 years. Most of the children were below 10 years of age. Lower limbs tumour predominated (n = 6) followed by the upper limbs and head and neck (n = 4 each). Other sites included perianal/perineal (n = 3) and the orbit (n = 1). Two patients were Intergroup Rabdomyosarcoma Study (IRS) group I; four group II; five group III; and seven group IV. Lymph node involvement was the commonest site of metastasis. Clinical group and stage was significantly more advanced in patients older than 10 years compared to younger than 10 years (P = 0.010; P = 0.008; respectively). There were 12 patients with alveolar disease while six had embryonal type of rhabdomyosarcoma. Treatment was by combination chemotherapy; and surgical excision which was done primarily in 11; after chemotherapy in four; and after radiotherapy in one. Two had biopsy only. Five patients are alive; two of them without evidence of disease at average follow-up period of 2 years. Conclusion: Mortality from rhadomyosarcoma in our setting is still unacceptably high. Late presentation may be the major contributor to high mortality. A more aggressive multimodality treatment approach may improve the outcome

Typhoid intestinal perforation in children: a continuing scourge in a developing country.

Typhoid intestinal perforation is a principal cause of morbidity and mortality affecting both adults and children. This study aims to evaluate the pattern of typhoid intestinal perforation and outcome of its management in Nigerian children. The records of consecutive children managed for typhoid intestinal perforation at Juth, between 1996 and 2005 have been reviewed. There were 184 children (M:F = 1.04:1), with a mean of 5.8 years (range 4 to 15 years). More than a half (62.5%) of the patients were in the 5-6 year age group. The incidence peaked in April-May, and November-December. Increased incidence of typhoid perforation was observed between 2002 and 2005. All patients presented with the classic features of typhoid enteric perforation. Hypokalaemia and anaemia were common at presentation. Only 75 (40.6%) patients had operation within 24 h of perforation. The types of surgery included simple excision of the edges of the peroration and closure (74.5%), wedge resection and closure in (14.5%), segmental resection with primary end-to-end anastomosis (3.6%) and right hemi-colectomy with ileo-colic or ileo-transverse anastomosis. Wound infection and dehiscence, anastomotic breakdown with faecal fistula, intra peritoneal abscesses and chest infections were the main post operative complications. The overall mortality rate was 22.8 (42). Excision and simple closure was associated with the least incidence of anastomotic breakdown and operation time. The incidence of typhoid intestinal perforation is on the increase at our institution. Early limited surgery provides optimal results.

Management of cystic lymphangioma in children: experience in Jos, Nigeria.

The management of cystic lymphangiomas (CL), especially in the head and neck region, presents challenges to the pediatric surgeon. This is a retrospective study of all children seen with lymphangioma at the Pediatric Surgical Unit of the Jos University Teaching Hospital from 1996 to 2004. There were 27 children, 14 (51.9%) were males and 13 (48.1%) were females (M:F = 1.2:1), with ages ranging from 2 days to 5 years (median 5 months). Majority (84.6%) of the patients were below 1 year. The head and neck region was the most frequent site of involvement. There were three cases of lymphangioma circumscriptum. Six (54.5%) of the 11 children with cervical CL presented with complications including infection in 4, respiratory obstruction in 3, ulcerated lesion in 1 and intracystic hemorrhage with rapid increase in cyst size in 1. Twenty-three children had either surgical excision or marsupialization. The main complications were wound infections and respiratory obstructions, which led to five deaths. Six children had recurrences, some of which occurred at sites which were normal at the initial or previous excision. The mortality rate was high (34.8%), mainly due to respiratory obstruction and asphyxia in the head and neck lesions. Head and neck region was the most commonly involved site by CL. The management of CL at this site is associated with significant morbidity and a high rate of mortality.

Colostomy in children--an evaluation of acceptance among mothers and caregivers in a developing country.

BACKGROUND: Colostomy is a common procedure performed in children, mostly for anorectal malformation and Hirschsprung's disease. However, acceptance by parents in developing countries is thought to be poor. METHODS: A prospective evaluation was done to determine the acceptability of colostomy among parents and caregivers, and their attitude towards colostomy in their children. RESULTS: During the period January 1999 - January 2004 a structured questionnaire was administered to 57 parents and caregivers of children with colostomies (41 boys and 16 girls). The indication for colostomy was anorectal malformation in 28 children and Hirschsprung's disease in 29. The length of time the children had the colostomy ranged from 3 weeks to 8 years. Forty-four respondents (77%) found the colostomy and its management acceptable. Thirteen (23%) found the colostomy unacceptable, mainly because of a feeling of social isolation. Problems the respondents complained of included disturbing smell (17, 30%), frequent change of the cloth napkin used as colostomy appliance (15, 26%) and intermittent bleeding from the stoma (4, 7%). CONCLUSIONS: Colostomy in children is acceptable to most parents in our environment. Although some parents found it unacceptable, adequate explanation and counselling may modify their view.

Complicated umbilical hernias in children.

Umbilical hernia is a common problem in children, particularly in Africans, but complications in these hernias are thought to be rare. In a retrospective study of 47 children presenting for umbilical hernia repair in 14 years, 30 had complications. The complications included acute incarceration 15, recurrent incarceration 10 and spontaneous evisceration 5. Of the 15 with acute incarceration, 2 required bowel resection for gangrene, and an abscess formed in the hernia sac in one. The age of patients with acute incarceration was 2 months-8 years (median 5 years). The 10 with recurrent incarceration were aged 1-3 years (median 3 years). Of the 5 with spontaneous evisceration, one had umbilical sepsis and another intestinal obstruction from intussusception. These patients were aged 3-12 weeks (median 7 weeks). All the complications occurred in hernias that were 1.5 cm or more in diameter. The hernias were repaired using standard methods. Postoperatively, 2 patients developed wound infection. There was no mortality. Though complications of umbilical hernias appear to be rare, there is a need for more active observation of these hernias to identify complications early and treat promptly to avoid morbidity.