One-stage treatment of left-sided large bowel emergencies.

OBJECTIVE: To evaluate the safety and benefits of left-sided colectomy and primary anastomosis without intraoperative colonic irrigation in the management of patients with colorectal emergencies. DESIGN: Prospective descriptive analysis of patients with emergency left-sided colonic and rectal lesions requiring resection and primary anastomosis. Setting A hospital based cohort over a five and a half year period at Jos University Teaching Hospital, Jos, Nigeria. SUBJECTS: A total of 42 patients with left sided and rectal emergency lesions. Their ages ranged from 9-65 years with a mean of 43.1 years. INTERVENTION: Twenty patients had sigmoid colectomy and primary colorectal anastomosis for sigmoid volvulus. Two patients with compound sigmoid volvulus had sigmoid colectomy as well as ileal resection and primary colorectal and ileoileal anastomosis. Transverse colectomy and primary colocolic anastomosis was carried out in six patients who had transverse colon tumour from gastric neoplasia. These six patients had in addition distal partial gastrectomy and gastrojejunal anastomosis to remove the primary gastric neoplasia. One patient had transverse colectomy and another four left hemicolectomy and primary colocolic anastomosis for trauma. Left colectomy and colocolic anastomosis was performed in three patients with left colon tumour while anterior resection and colorectal anastomosis for rectosigmoid cancer was carried out in six patients. MAIN OUTCOME MEASURES: Manual decompression of the colon is as good as antegrade colonic irrigation in the management of left-sided large bowel emergency conditions in selected patients when undertaken by dedicated experienced surgeons. RESULTS: There was one clinical anastomostic leak presenting as enteric fistula on the sixth postoperative day. The discharge was bilious and occurred in a patient with gastric mesenchymal stromal tumour who had distal partial gastrectomy and gastrojejunal anastomosis. He had no features of generalised peritonitis nor residual intra-abdominal abscesses. The fistula was managed non-operatively. A 12% wound infection rate was recorded. All infections were superficial and healed with conservative measures. We had no mortality in our series. The hospital stay ranged from 6 to 21 days with a mean of 7.5 days. CONCLUSION: Manual decompression of the colon alone is as good as colonic irrigation in the management of left-sided large bowel emergencies. However, on-table antegrade colonic irrigation should be reserved for the loaded colon that may interfere with the use of a stapling instrument, when the resection margins are limited as in low anterior resections and when left-side colonic emergencies are undertaken by non-dedicated, less experienced surgeons.

One stage procedure in the management of acute sigmoid volvulus without colonic lavage.

BACKGROUND: There is a growing acceptance of one-stage primary resection and anastomosis of left-sided colon obstruction with on-table antegrade colonic lavage to reduce the risk of post-operative infectious complications and anastomotic dehiscence. The purpose of this study was to evaluate the safety of single-stage resection and anastomosis for acute left-sided colonic obstruction due to acute sigmoid volvulus, without intraoperative colonic lavage, in a consecutive series of patients admitted to our department. METHODS: Emergency resection of acute sigmoid volvulus was performed by an experienced senior surgeon (consultant grade). This was followed by primary anastomosis without on-table colonic lavage after a manual decompression. RESULTS: A total of 21 patients underwent bowel decompression, resection and primary colorectal anastomosis. Two of the patients who had ileosigmoid knotting and gangrenous bowel had double resection with primary ileoileal and colorectal anastomosis. There were two superficial wound infections. No death or clinical anastomotic failure were recorded in this series. The mean hospital stay was 10.3 days. CONCLUSION: Our results suggest that resection of acute sigmoid volvulus and primary anastomosis after decompression alone can be carried out safely in reasonably fit patients.

Fat necrosis of the breast--a review.

Fat necrosis of the breast is a benign condition that most frequently affects peri-menopausal women. It can mimic breast cancer clinically or radiologically. In other cases it can obscure malignant lesions. The core of this review is derived from a MEDLINE database literature search from 1966-2004. Further references were from lateral search. In this paper, we review the pathogenesis and pathology clinical and radiological features of fat necrosis of the breast. The implication of fat necrosis in the management of patients with breast lump is also discussed. Fat necrosis of breast is a complex process. Therefore, a systematic review of this condition will enable surgeons, radiologists and oncologists working in the field of breast disease to understand it better and improve its management.

A 5-year audit of haemodialysis access.

This is a review of our experience with vascular access procedures over a 5-year period at Derriford Hospital, Plymouth, UK. The aims of the study were to examine the outcome of vascular access procedures and factors influencing access survival. Between April 1995 and March 2000, 151 patients who underwent 221 vascular access procedures were studied. Of these, 136 had autogenous arteriovenous fistulae, whereas 85 had prosthetic AV grafts (41% in the thigh). The overall primary failure rate was 21% whereas the 1- and 5-year cumulative access survival rates were 60 and 41%, respectively. Thigh grafts have a mean survival of 36 months compared with 32 months for prosthetic upper limb and 43 months for autogenous fistulae. Age, diabetes and predialysis status did not significantly influence access survival. Thrombosis was responsible for access failure in 62 cases (28%). Avoiding subclavian vein canulation and performing vessel mapping prior to access placement should reduce the risk of access failure due to outflow obstruction.

Typhoid intestinal perforation in north central Nigeria.

BACKGROUND: Typhoid intestinal perforation is a surgical problem with severe morbidity and high mortality in North Central Nigeria. PATIENTS AND METHODS: In order to determine the pattern and the prognostic indices, we studied 101 patients with typhoid intestinal perforation managed over a ten-year period RESULTS: Children constituted 49% of the cases and majority (78%) of the patients were in the low socio-economic strata. The incidence peaked to 67% between November and March - the dry season in Nigeria. The male/female ratio was 1.9:1 with a mean age of 19 years and a mean hospitalization period of 18 days. There were 167 perforations; four involved the large bowel and appendix, and in 72.2% cases, the perforation was single. The mortality rate was 13.9%, affected mostly children and significantly worsened by prolonged perforation-surgery interval > 72 hours, jaundice, convulsion, ASA V, faecal peritonitis and re-exploration for early intra-peritoneal complications. Morbidity rate was 65.3% and significantly affected more children than adults and associated with perforation-surgery interval of between 24 and 72 hours, haematochezia and multiple perforations. Moribund patients fared better when operated upon under local anaesthesia with adequate analgesia. The least traumatic but effective surgical procedure that could seal the perforations and keep the peritoneum clean gave the best results. Children who survived up to 5 days and adults who survived up to 10 days after surgery had better chances of survival. CONCLUSION: The most significant prognostic factor is late presentation which prolongs perforation-surgery interval and the other complication and mortality indices are directly influenced by it.

Male breast malignancy in Jos University Teaching Hospital.

BACKGROUND: Male breast malignancies are rare. Cancer of the male breast accounts for about 1% of all breast cancers. Poor level of awareness often results in late presentation and delayed diagnosis in our environment. PATIENTS AND METHODS: A retrospective study of all cases of male breast cancer (MBC) managed in Jos University Teaching Hospital over a 17-year period (January 1987-December 2003.) RESULTS: A total of 302 cases of breast malignancies were managed over the study period. Twenty-six (8.6%) of these were males giving a male:female ratio of 1:10.6. The ages of the 26 MBC cases ranged from 12 years to 85 years, with a mean of 57.9 years and median age of 67 years. The right breast was affected in 15 and the left in 11. Mean duration of symptoms before presentation was 6 months with a range of 3 months to 4 years. All the patients had history of breast lumps, 21 (80.8%) of which were painless. Skin ulceration and axillary node enlargement were present in 19(73.1%) and 24(92.3%) respectively. Five (19.2%) were stage II; 15(57.7%) stage III and 6(23.1%) stage IV. There were 23 (88.5%) carcinomas, 2 (7.7%) fibrosarcomas and a case of Hodgkin's lymphoma. Invasive ductal carcinoma was the most common histological type in 20 (76.9%) of all breast malignancy and 20 (87.0%) of all breast carcinomas. Modified radical mastectomy (mastectomy with axillary clearance with or without division of the pectoralis minor muscle) was done in 10(38.5%) patients. Two of these were fibrosarcomas. Simple mastectomy was done in 13 (50%) as toilet procedures for advanced disease. The only case of Hodgkin's lymphoma had chemotherapy. Bilateral orchidectomy (BO), Tamoxifen, chemotherapy and radiotherapy were offered in 7(26.9%), 13(50%), 17(65.4%) and 7(26.9%) patients respectively. Wound infection was the most common complication in 14(53.8%) patients. There was no case of hospital mortality. CONCLUSION: MBC accounts for 8.6% of all breast cancers in our centre. It affects elderly males. Late presentation with advanced disease and ulceration is a common feature in our environment.

Typhoid intestinal perforation in North Central Nigeria

Background: Typhoid intestinal perforation is a surgical problem with severe morbidity and high mortality in North Central Nigeria.Patients and Methods: In order to determine the pattern and the prognostic indices; we studied 101 patients with typhoid intestinal perforation managed over a ten-year periodResults: Children constituted 49 of the cases and majority(78) of the patients were in the low socio-economic strata. The incidence peaked to 67 between November and March - the dry season in Nigeria. The male/female ratio was 1.9:1 with a mean age of 19 years and a mean hospitalization period of 18 days. There were 167 perforations; four involved the large bowel and appendix; and in 72.2 cases; the perforation was single. The mortality rate was 13.9; affected mostly children and significantly worsened by prolonged perforation-surgery interval 72 hours; jaundice; convulsion; ASA V; faecal peritonitis and re-exploration for early intra-peritoneal complications. Morbidity rate was 65.3 and significantly affected more children than adults and associated with perforation-surgery interval of between 24 and 72 hours; haematochezia and multiple perforations. Moribund patients fared better when operated upon under local anaesthesia with adequate analgesia. The least traumatic but effective surgical procedure that could seal the perforations and keep the peritoneum clean gave the best results. Children who survived up to 5 days and adults who survived up to 10 days after surgery had better chances of survival.Conclusion: The most significant prognostic factor is late presentation which prolongs perforation-surgery interval and the other complication and mortality indices are directly influenced by it