Impact of hepatectomy margin on survival following resection of colorectal metastasis: the role of adjuvant therapy and its effects.

INTRODUCTION: The optimal width of microscopic margin and the use of adjuvant therapy after a positive margin for hepatic resection for colorectal liver metastasis (CRCLM) has not been conclusively determined. The aim of the current study is to evaluate the influence of width of surgical margin and adjunctive therapy upon disease free and overall survival. METHODS: All patients undergoing hepatectomy for CRCLM from 1997 to 2012 were identified from a prospectively maintained, IRB approved database. Patients were divided into four subgroups based on the parenchymal margin: positive, <0.1 cm, 0.1 cm-1 cm, and >1 cm. RESULTS: A total of 373 patients were included for analysis with a median follow up of 26 months (range 9-103 months) and a median overall survival of 53 months. The resection margin was positive (26 patients median OS 24 months), <0.1 cm (48 patients median OS 36 mon), 0.1 cm-1 cm (82 patients median OS 44 months), and >1 cm (217 patients median OS 64 months). The most common adjunctive therapy was chemotherapy, hepatic arterial therapy, or local. Patients with positive margins also had the shortest disease free survival (DFS), 16 months. The DFS was similar amongst the other margin groups (<0.1 cm: 21 months, 0.1-1 cm: 22 months, >1 cm 25 months). Hepatectomy margin independently influenced survival (p = 0.017) and disease free survival (p = 0.034). Patients with negative margins has similar overall recurrence rates (p = 0.36) and survival rates (p = 0.89). CONCLUSIONS: A positive surgical margin indicates a worse overall biology of disease for patients undergoing hepatectomy for CRCLM, and appropriate multi-disciplinary therapy should be considered in this high risk patient population. Marginal width if a complete resection has been achieved does not adversely effect overall surgical in patients with CRCLM.

Hospital frequency of large bowel cancer: factors thought to influence outcome.

BACKGROUND: One of the leading causes of death from malignancies is cancer of the large gut. Elsewhere in the developed world, the disease severity and operative mortality are falling due to increased use of screening, earlier diagnosis and improvement in surgical techniques. AIM: To report our experience with this disease at the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto. PATIENTS AND METHODS: This is an 8-year retrospective analysis (January 1998 December 2005) of all established cases of large bowel cancer managed at the surgical services of the Usmanu Danfodio University Teaching Hospital (UDUTH), Sokoto. RESULTS: A total of 40 cases of colorectal cancer were seen in this centre during the study period. There were 21 (52.5%) males and 19 (47.5%) females, representing a male: female ratio of approximately 1:1. The modal age was the 5th decade. The youngest patient was 15 years old. Forty-two percent of patients were below 40 years of age. All were symptomatic at time of detection. There was no patient in Dukes' stage A category. Nineteen (47.5%) were stage D at presentation. Potentially curative resection was performed in 5 (12.5%) patients. Another 22 (55.0%) cases had palliative surgical treatment. The remainder were either inoperable (n= 3; 7.5%), refused colostomy (9; 22.5%) or died before surgical treatment (1; 2.5%). Among those who were surgically treated, 6 (22.2%) died within 30 days of operation. The mean duration of post-operative follow up was 16 months (5 67 months). CONCLUSION: Cancers of the large intestine are not uncommon in this part of the world. A rising frequency of colorectal cancers in our locality is observed. Presentation to hospital is usually late. A significant number of patients are below 40 years of age.

Decreasing need for elective peptic ulcer disease surgery.

BACKGROUND: With the advent of potent gastric acid suppressing drugs and antibiotics effective against Helicobacter pylori, the rate of surgical operations for the treatment of peptic ulcer disease (PUD) and its complications have drastically fallen. OBJECTIVE: To audit our experience with this disease and its operative treatment at the surgical services of one tertiary health institution in Nigeria. METHODS: A-5-year retrospective audit (January 2000-December 2004) of all hospital admissions of PUD managed at the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto. The case folders of those who were surgically treated were subsequently isolated and further analyzed in detail. Data collected included patient's demographics, clinical details, indication for surgical treatment, operation report and outcome of care. RESULTS: Out of 624 patients admitted with a clinical diagnosis of peptic ulcer disease into the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto during the study period, 21 (3%) were surgically treated. Of this subpopulation, 18 were males and three females; giving a sex ratio of 6:1. Their ages ranged between 30 and 62 years with a mean of 40.8 years. Thirteen (62%) of the patients had emergency procedures for life threatening complications of the disease. The remainder were operated electively. All but one survived representing a mortality rate of 4.8%. CONCLUSION: Elective peptic ulcer surgery has decreased in comparison with the emergency procedures in our centre. The advent of effective antibiotics against Helicobacter pylori and the use of potent gastric acid suppressing drugs may relegated the surgical approach to the treatment of PUD to history someday in the 21st century.

AIDS-associated Kaposi's sarcoma in Sokoto, Nigeria.

BACKGROUND: Since the advent of the HIV/AIDS pandemic, Kaposi's sarcoma (KS) is now seen in places not previously considered endemic for this disease. In Nigeria, the African-endemic KS had been known to be prevalent in the southern parts of the country, particularly the southeast. Until now, reports on the disease from northern Nigeria are few. OBJECTIVE: To describe the prevalence ofKaposi's sarcoma in Sokoto, northwestern Nigeria. METHOD: A retrospective review of 27 cases of histologically confirmed KS seen over an 11-year period (Jan.1994-Dec.2004) at the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Northwestern Nigeria. RESULTS: The average hospital incidence of KS in this review was 2.5 cases per annum (27 cases in 11 years). The modal age was the 4th decade of life (range 18-70 years). Fifteen percent were females; M: F = 5.8: 1. There was no case of childhood involvement identified. More cases of the disease were HIV-positive (59.3%). The commonest symptom was cutaneous nodules in 96.3% of cases. The body region with the highest affectation of the lesions was the lower limb (70.4%). CONCLUSION: Kaposi's sarcoma is still uncommon in the northwestern region of Nigeria. The epidemic variant of the disease predominates among the few cases diagnosed. The finding of nodular lesions and/or indurated leg swelling in any adult male in our environment must be considered to be KS until histologically investigated.

Morbidity and mortality associated with inguinal hernia in Northwestern Nigeria.

BACKGROUND: Treatment of uncomplicated inguinal hernia is relatively simple and the outcome is often favourable. Complicated hernias are fraught with increased mortality with and without operative management. OBJECTIVE: To determine the scope of adverse events which attend the management of inguinal hernia in extreme northwestern region of Nigeria. METHODS: Subjects. From the hospital records department, the case folders of all patients with the clinical diagnosis of hernia seen between January 2000 and December 2002 were retieved. Of the cases identified, 227 patients diagnosed of inguinal hernia, either alone or in combination with other forms of hernia formed the basis of this report. Relevant data extracted and analyzed included the patient's demographics, clinical details, treatment offered and outcome. RESULTS: Two hundred and fifty three inguinal hernias in 227 individuals were seen.. This represented 76.9% of patients diagnosed of external abdominal hernias., 16 times more commonly in males than females. Fifty two (20.6%) hernias presented as acute abdominal emergencies while 225 hernias in 199 patients were repaired. Local anesthesia was used in 32 (16.1%) of the patients with 33 (14.7%) inguinal hernias. Four (1.8%) individuals were managed on day case basis. Twelve (5.3%) deaths occurred in this series, three of which were pre-operative. At a mean follow up of 7 months (range 1-23 months), 1 (0.4%) hernia recurrence was noted. CONCLUSION: Complicated inguinal hernias and their emergency surgical treatment are associated with increased mortality in our environment. Prophylactic elective herniorrhaphy is recommended as a safeguard for inguinal hernia as soon as identified irrespective of patient's age.

Terminal events in women dying of advanced breast cancer: improving the care for terminal breast cancer patients in Africa.

We studied the terminal events preceding death in all patients dying in hospital over a period of 10 years. Hepatomegaly, massive ascites, cachexia, jaundice, massive pleural effusion and haemoptysis were the most frequent terminal events. The predominance of visceral-related terminal events is unexplained but may be related to site-specific metastasis and premorbid organ pathology.

Testicular torsion on the Jos Plateau.

In order to determine the pattern and the factors that influenced outcome, we retrospectively studied fifty-seven patients with torsion of the testis admitted to the Jos University Teaching hospital between August 1993 and July 2001. The age ranged from 2 to 55 years with a mean of 22.7 years. Majority (79%) of the patients were in the second and third decades of life. The main suspected precipitating factors in this study were cold weather and scrotal trauma: in 28% of the cases no cause could be ascertained. Eight (14%) patients presented within 4 hours and 35 (61%) presented after 24 hours of the onset of symptoms. Both sides were equally affected. Testicular pain, retraction and scrotal swelling were the most common presenting complaints. The highest incidence 65%) occurred between November and February when the weather on the Jos plateau is coldest. At surgery, 34 (60%) patients were found to have associated congenital anomalies; in 22 (39%) patients, the testis was non-viable. There was no mortality in this series and the complications were superficial wound infection (14%), testicular atrophy (7%) and sub-fertility (16%). High index of suspicion in a patient with acute scrotum, prompt and effective surgery will improve testicular salvage.

Adult intussusception: the Jos experience.

Twenty two consecutive cases of adult intussusception managed between January 1990 and December 1998 at Jos University Teaching Hospital formed the basis of this study. Thirteen (59.1%) of the patients were males and 9(40.9%) females, with a male to female ratio of 1:4:1 and a mean age of 49.6 years. Most patients were referred late to our service as a result of poor index of suspicion and misdiagnosis. Laparotomy was done in all the cases and in 5(22.7%) patients no cause could be found, but in the remaining 17(77.3%) definite causes were identified which were mainly polyps in 7(31.8%) patients and colonic malignancies in 4(18%). The ileocolic intussusception was the commonest variety. Sixteen (72.7%) patients had bowel resection for colonic carcinoma, gangrenous bowel and irreducibility of the intussusception while manual reduction was successful in the other 6(27.3%) patients. The morbidity rate was 22.7% and the complications were wound infection and adhesive intestinal obstruction. Two deaths were recorded with a mortality rate of 9.1%. The pattern of adult intussusception as seen in the western world was observed in this tropical highland.

Childhood intussusception: a 9-year review.

Sixty-four consecutive cases of intussusception in 48 infants and 16 older children managed at Jos University Teaching Hospital between January 1990 and December 1998 are reviewed. The age range was between 3 months and 15 years (mean 2.2 years) and the male to female ratio was 3.6:1. The quartet of abdominal pain, bloody mucoid stools, abdominal mass and palpable rectal mass was present in 70% compared with the classical triad (abdominal pain, bloody mucoid stools and abdominal mass) which occurred in only 32%. All the children had surgery. In 26 (41%) of the children, no associated cause was found, in three polyps formed the lead point and in five children a buried appendicectomy stump formed the lead point. In 30 (47%) other children, mesenteric lymphadenopathy and inflamed Peyer's patches were noted. Ileo-colic intussusception occurred in 32 (50%) children. Manual reduction was successful in 67%. Bowel resection for gangrene, irreducibility and an iatrogenic colonic tear was done in 30% of patients. Two (3%) had spontaneous reductions. There were four deaths. The commonest complications were wound infection and adhesive intestinal obstruction.