Clinicopathological Features and Treatment Outcome of Patients with Gastric Cancer in Lagos: Is the Outlook Getting Better?

Background: Gastric cancer (GC) is an important cause of morbidity and mortality in Nigeria. Significant advances in the management of GC in South-West Nigeria occurred in the last three decades. Patients and Methods: This was a retrospective comparative study of patients with GC that presented at our tertiary hospital in the last three decades. Information on clinicopathological features and treatment outcome were analysed. Data of two consecutive periods; 1991-2004 (Group I) and 2005-2018 (Group II) were compared. Results: Ninety-one patients were studied; Group I (47 patients), Group II (44 patients). The mean age was 56.4 ± 12.7 years and male-to-female ratio was 1.8 to 1.0. The predominant symptoms were epigastric pain in 81(89.0%) (43 vs. 38) and weight loss in 63(69.2%) (32 vs. 31), whereas the signs were epigastric tenderness in 44(46.1%) (24 vs. 20) and epigastric mass in 42(46.1%) (26 vs. 16). The overall mean duration of symptom was 12.3 ± 16.9 months. Barium meal diagnosed GC in 29(61.7%) patients in Group I vs. 4(9.1%) patients in Group II. Conversely, endoscopy diagnosed GC in 23(48.9%) patients in Group I vs. 37(84.1%) patients in Group II. Operations undertaken included palliative subtotal gastrectomy 26(28.6%), potentially curative subtotal gastrectomy 15(16.5%) and non-resectional surgeries in 27(29.7%) patients. The overall incidence of major post-operative complications was 33%. Thirty-nine (42.8%) of the studied patients were lost to follow up. The median postoperative survival for Groups I and II patients was 22 weeks and 58 weeks, P = 0.012, respectively. Conclusion: The outcome of management of patients with GC at our tertiary hospital has improved modestly in the past three decades. Patients are still presenting late with very advanced disease.

Clinicopathological features, risk profile assessment, and the surgical outcome of gastrointestinal stromal tumors in Lagos, Nigeria.

Background: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. GISTs originate from the interstitial cells of Cajal and are most commonly found in the stomach. Most available reports on GISTs in the Sub-Sahara Africa were in case reports and case series. Aim: To report our local experience and challenges in the management of GISTs in 33 patients in Lagos, Nigeria. Methodology: This is a descriptive study of adult patients of 16 years and above managed for GISTs at the Lagos University Teaching Hospital and some Lagos private hospital facilities between January 2015 and March 2021. Information on the patients' demographic characteristics, clinicopathological features, surgery performed, and postoperative complications were retrieved from the hospital's medical records for analysis. Data analysis was carried out using IBM SPSS Statistics for Windows, Version 23.0., Armonk, NY, USA: IBM Corp. Results: Thirty-three patients comprising 19 males and 14 females with a male: female ratio of 1.4:1 were included in the study. The mean age at presentation was 52.5 years. Abdominal pain (69.7%) and anemic symptoms (45.4%) were the principal modes of presentation. Abdominal computed tomography (CT) scan revealed stomach as the primary source of GISTs in 75.8% of patients. Forty-five percent of the patients had CT features of local organ invasion and 27.2% had features of metastasis. Surgical resection was feasible in 28 (84.8%) patients. Postoperative mortality was recorded in two patients with recurrent GISTs. Histological cell types were spindle cell (57.6%), mixed spindle and epithelioid (24.2%), and epithelioid (18.2%). Joensuu high-risk tumors (64. 3%) were the most prevalent in our series. Conclusion: Advanced-stage disease and features of anemia were hallmarks of GISTs among patients in this series. Surgical resection of GIST may be possible in some cases of advanced disease. Spindle cell types and high-risk GISTs were the most common pathological varieties in our patients.

Résumé Contexte: Les tumeurs stromales gastro-intestinales (GIST) sont les tumeurs mésenchymateuses les plus courantes du tractus gastro-intestinal. Les GIST proviennent des cellules interstitielles de Cajal et se trouvent le plus souvent dans l'estomac. La plupart des rapports disponibles sur les GIST en Afrique subsaharienne étaient des rapports de cas et des séries de cas. Objectif: rendre compte de notre expérience locale et des défis dans la gestion des GIST chez 33 patients à Lagos, au Nigeria. Méthodologie: Il s'agit d'une étude descriptive de patients adultes de 16 ans et plus pris en charge pour des GIST à l'hôpital universitaire de Lagos et dans certains établissements hospitaliers privés de Lagos entre janvier 2015 et mars 2021. Informations sur les caractéristiques démographiques des patients, les caractéristiques clinicopathologiques, la chirurgie effectuée, et les complications postopératoires ont été extraites des dossiers médicaux de l'hôpital pour analyse. L'analyse des données a été effectuée à l'aide d'IBM SPSS Statistics pour Windows, version 23.0., Armonk, NY, États-Unis: IBM Corp. l'étude. L'âge moyen à la présentation était de 52,5 ans. Les douleurs abdominales (69,7 %) et les symptômes anémiques (45,4 %) étaient les principaux modes de présentation. La tomodensitométrie abdominale (TDM) a révélé que l'estomac était la principale source de GIST chez 75,8 % des patients. Quarante-cinq pour cent des patients présentaient des caractéristiques CT d'invasion d'organes locaux et 27,2 % présentaient des caractéristiques de métastases. La résection chirurgicale était réalisable chez 28 (84,8 %) patients. La mortalité postopératoire a été enregistrée chez deux patients avec des GIST récurrents. Les types de cellules histologiques étaient les cellules fusiformes (57,6 %), les cellules mixtes fusiformes et épithélioïdes (24,2 %) et les épithélioïdes (18,2 %). Les tumeurs à haut risque de Joensuu (64,3 %) étaient les plus répandues dans notre série. Conclusion: La maladie à un stade avancé et les caractéristiques de l'anémie étaient les caractéristiques des GIST chez les patients de cette série. La résection chirurgicale des GIST peut être possible dans certains cas de maladie avancée. Les types de cellules fusiformes et les GIST à haut risque étaient les variétés pathologiques les plus fréquentes chez nos patients. Mots clés: Bilan, tumeurs stromales gastro-intestinales, pathologie, risque, gestes chirurgicaux.

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.

Comparison of rubber band ligation with 3% polidocanol injection sclerotherapy for the treatment of internal haemorrhoids at a Nigerian tertiary hospital.

BACKGROUND: The surgical treatment of internal haemorrhoids is yet to be fully elucidated. Rubber band ligation (RBL) and injection sclerotherapy (IS) are less invasive alternative day-case treatment options with lower morbidity than excisional haemorrhoidectomy. AIMS: This was a prospective study that compared the efficacy of RBL with 3% polidocanol IS in the treatment of Grades I to III internal haemorrhoids. PATIENTS AND METHODS: Sodergren haemorrhoid symptom severity (SHSS) scores of consecutive adult patients with internal haemorrhoids were calculated before and after each of three therapy sessions with RBL and IS. Outcome measures included SHSS scores after treatment, post-procedure pain and complication rates. Data were collated and analysed using SPSS version 23. RESULTS: A total of 74 patients participated in the study with 37 patients in each treatment group. The RBL and IS groups were not statistically different in age (P = 0.506), weight (P = 0.117), height (P = 0.462), BMI (P = 0.153) and gender (P = 0.639). The mean SHSS scores for both groups before therapy (P = 0.876), at 4 weeks (P = 0.669), 8 weeks (P = 0.168) and 12 weeks (P = 0.391) after commencement of therapy were not statistically different. The SHSS scores at 12 weeks after treatment were statistically significantly lower than before treatment in both the groups (P < 0.01). The post-procedure pain score was significantly higher in the RBL than IS group after the first (P < 0.001) and second (P < 0.006) but not after the third therapy session (P = 0.501). The complication rates were low and not significantly different for the RBL and IS groups (5.7% versus 8.1%; P = 0.643). CONCLUSION: The study concluded that RBL and IS are both effective and safe in the treatment of Grades I, II and III internal haemorrhoids.

Determinants of Outcome of Abdominal Trauma in an Urban Tertiary Center.

BACKGROUND: Abdominal trauma constitutes a significant cause of potentially preventable mortality. Therefore, knowledge of the determinants of outcome facilitates the development of rational treatment protocols for improving outcome. OBJECTIVE: To identify the determinants of outcome in patients with abdominal trauma managed in a tertiary health center. PATIENTS AND METHODS: This is a prospective study of consecutive patients presenting with abdominal trauma to our tertiary health center over a 12-month period. Data regarding patient demographics, injury mechanisms, type of organ injuries, treatment modalities, injury-to-intervention time, and outcomes were documented. The Injury Severity Scores and Revised Trauma Scores were determined. The data were analyzed using the Statistical Package for the Social Sciences version 20. RESULTS: There were 76 patients, 66 males and 10 females, whose ages ranged from 15 to 66 years (mean of 32.9 ± 10 years). Thirty-one (40.2%) patients had blunt abdominal trauma whereas 45 (59.8%) patients had penetrating trauma. There was a mortality rate of 8% predominantly from blunt trauma as compared to penetrating abdominal trauma (12.9% vs. 4.4%). There was a statistically significant difference between survivors and nonsurvivors as regards the means of injury-to-intervention time (25.4 ± 36.4 vs. 67.5 ± 58.2, P = 0.007), the means of Injury Severity Scores (15.1 ± 27.9 vs. 23.7 ± 9.8, P = 0.008), and the presence of brain injury (50.0% vs. 5.6%, P = 0.029). CONCLUSION: This study has shown that delayed intervention, high Injury Severity Score, and associated significant brain injury were determinants of poor outcomes. Prompt intervention and postoperative management in intensive care definitely improve outcome.

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.

An appraisal of the presentation and management of adult intussusception at a Nigerian Tertiary Hospital.

BACKGROUND: Intussusception in adults is considered rare in surgical practice. It is the causative lesion in a small proportion of cases of intestinal obstruction and lower gastrointestinal bleeding. In the last decade, the incidence of adult intussusception appears to be increasing at our centre. AIMS: This study aims to document the pattern of presentation and management outcome of adult intussusception at our institution during the last decade. We also observed the occurring trends of this lesion. PATIENTS AND METHODS: This was a 10-year retrospective study of consecutive adult patients with intussusception seen at our institution from July 2008 to June 2018. Information on biodata, clinicopathological features and management outcome retrieved from case notes and pathology records were analysed on a personal computer using SPSS version 23. RESULTS: Twenty adult patients who had intussusception were seen during this period. There were 9 (45%) males and 11 (55%) females giving a male-to-female ratio of 1:1.2. The mean age of presentation was 45 (range 18-66) years. Clinical features were abdominal pain (85%), abdominal distension (80%), vomiting (70%), rectal bleeding (70%) and palpable abdominal mass (35%). Majority of patients (70%) presented with features of intestinal obstruction. Idiopathic intussusception (55%) accounted for more than half of the cases with the jejunoileal variety (30%) as the most common pathological type. One patient who had intussusception in the postoperative period was treated with manual reduction at laparotomy. Bowel resections were performed in the remaining 19 (95%) patients. CONCLUSION: Adult intussusception is still uncommon in our general surgical practice. Bowel resection is the mainstay of treatment.

Stump Appendicitis due to Retained Fecalith after Laparoscopic Surgery.

Stump appendicitis is a rare cause of right iliac fossa pain in patients with a previous history of appendectomy for acute appendicitis. The presentation is often delayed and may pose a clinical diagnostic challenge to the surgeon. More often, a high index of suspicion backed with relevant radiologic investigations is required for diagnosis. Open and laparoscopic appendectomy may be complicated by stump appendicitis. We report our experience in a 49-year-old Nigerian who presented to us with recurrent right iliac fossa pain and abdominal distension of 2 weeks' duration. The patient had laparoscopic appendectomy 1 year prior to presentation to us. A diagnosis of stump appendicitis with small-bowel obstruction was made with an abdominal computed tomography scan. He had an open stump appendectomy and small-bowel adhesiolysis with a good postoperative outcome.

Acute perforated appendicitis in adults: Management and complications in Lagos, Nigeria.

Background: Acute perforation of the appendix is one of the complications of appendicitis that is associated with increased morbidity and mortality and hence regarded as a surgical emergency. Risk factors for perforated appencidicits include extremes of age, male sex, pregnancy, immunosuppression, comorbid medical conditions and previous abdominal surgery. Objectives: This study focuses on the pattern of presentation, risk factors, morbidity and mortality of patients managed for perforated appendicitis in our centre. Subjects and Methods: We conducted a seven-year retrospective review of consecutive adult patients who had surgery for perforated appendicitis in our centre. Results: The perforation rate in the study was 28.5%. The peak age of presentation was between 21-30 years. Forty-two (71.1%) of the patients under study were males. Only 3 (5.1%) of the cohorts had history of recurrent abdominal pain. Majority of the patients were in the American Society of Anesthesiologists (ASA) II (44.1%) and III (42.4%) categories. Surgical site infections (SSI) (18.6%), wound dehiscence (15.2%) and pelvic abscess (13.5%) were the most common complications. The Incidence of SSI was found to correlate with male gender, (P = 0.041), co-morbidity (P = 0.037) and ASA score (0.03) at 95% confidence interval. Routine use of intraperitoneal drain after surgery for perforated appendicitis did not appear to reduce the incidence of pelvic abscess. No mortality in the studied population. Conclusion: Appendiceal perforation was more common in male patients with first episode of acute appendicitis. Previous abdominal surgery and comorbid medical conditions were of lesser risk factors for appendiceal perforation in our patients. Surgical site infection was the commonest complication after surgery.

RésuméContexte: La perforation aiguë de l'appendice est l'une des complications de l'appendicite associée à une augmentation de la morbidité et de la mortalité et donc considérée comme une urgence chirurgicale. Les facteurs de risque pour les applications perforées comprennent les extrêmes d'âge, le sexe masculin, la grossesse, l'immunosuppression, les conditions médicales concomitantes et la chirurgie abdominale antérieure. Objectifs: Cette étude se concentre sur le schéma de présentation, les facteurs de risque, la morbidité et la mortalité des patients pris en charge pour une appendicite perforée dans notre centre. Sujets et méthodes: Nous avons effectué une revue rétrospective sur sept ans de patients adultes consécutifs ayant subi une chirurgie pour une appendicite perforée dans notre centre. Résultats: Le taux de perforation dans l'étude était de 28,5%. L'âge maximal de présentation était entre 21-30 ans. Quarante-deux (71,1%) des patients étudiés étaient des hommes. Seulement 3 (5,1%) des cohortes avaient des antécédents de douleurs abdominales récurrentes. La majorité des patients étaient dans les catégories II (44,1%) et III (42,4%) de l'American Society of Anesthesiologist (ASA). Les infections du site opératoire (SSI) (18,6%), la déhiscence des plaies (15,2%) et les abcès pelviens (13,5%) étaient les complications les plus fréquentes. L'incidence de SSI a été trouvée corrélée avec le sexe masculin, (p = 0,041), la co-morbidité (p = 0,037) et le score ASA (0,03) à intervalle de confiance de 95%. L'utilisation systématique d'un drain intrapéritonéal après une chirurgie pour une appendicite perforée ne semble pas réduire l'incidence des abcès pelviens. Aucune mortalité dans la population étudiée. Conclusion: La perforation appendiculaire était plus fréquente chez les patients masculins présentant un premier épisode d'appendicite aiguë. La chirurgie abdominale antérieure et les conditions médicales comorbides étaient des facteurs de risque moins pour la perforation appendiculaire chez nos patients. L'infection du site opératoire était la plus courante après la chirurgie.

Histopathological report of colorectal carcinoma resections: A 5-year audit in Lagos.

BACKGROUND: Complete and accurate pathology reporting of colorectal carcinoma (CRC) resection specimen is critical to clinical management of individual patients. The study aims to audit colorectal cancer histopathology reporting in Lagos between 2011 and 2015 before the adoption of the Society for Gastroenterology and Hepatology in Nigeria pro forma in 2016. MATERIALS AND METHODS: All resected CRC cases were identified from the Histopathology record of our Department and that of a private Laboratory in Lagos over a 5-year from 2011 to 2015. The dataset as contained in the pro forma was extracted from the reports and analysed using SPSS version 16 software. RESULTS: A total of 92 colorectal resections were received during the 5-year period consisting of 90 colonic and 2 rectal tumours. Data inclusiveness on tumour differentiation, extent of primary tumour, total lymph node and lymph node involvement were 96.7%, 91.3%, 83.7% and 92.4%, respectively. Tumour perforation, level of venous involvement and distant metastasis were reported in 73.9%, 21.7% and 96.7% respectively. The circumferential resection margin (CRM) in the 2 rectal tumours had 100% inclusiveness. Tumour node metastasis staging was complete in 87% of cases while Dukes staging was documented in 8.7% of the reports. CONCLUSION: None of the data items was 100% complete except the CRM for rectal carcinoma. Free text reporting results in incomplete data resulting in improper staging, especially the lymph node status. This highlights the need for pro forma reporting to ensure and maintain consistent reporting of important parameters required for proper staging and management of patients with colorectal cancer.

Predictive factors of management outcome in adult patients with mechanical intestinal obstruction.

BACKGROUND: Mechanical intestinal obstruction (MIO) is a common and potentially fatal surgical emergency, which constitutes about 20% of all admissions to the surgical emergency departments. OBJECTIVE: To determine the predictive factors of morbidity and mortality in patients undergoing treatment for MIO at our tertiary hospital. PATIENTS AND METHODS: This was a prospective study of consecutive patients, 18 years and above, that presented with features of MIO during a 1-year period (May 2014 to April 2015). Each patient had resuscitation, comprehensive clinical evaluation, appropriate investigations and definitive treatment. The data were analysed using SPSS version 22. RESULTS: One hundred and five patients were studied. The age range was 18-86 years with a mean (standard deviation) of 45.6 (14.8) years. There were 54 males with a male to female ratio of 1.1-1. The common causes of MIO were post-operative adhesion (48.6%), tumour (25.7%), external hernia (15.2%) and volvulus (5.7%). Eighty-four patients (80%) had operative intervention while 21 patients (20%) had conservative management. Univariate analysis showed that dehydration, tachycardia (>90 bpm), pyrexia, abnormal levels of potassium, urea and creatinine, leucocytosis, American Society of Anesthesiologists (ASA) status >IIIE, bowel resection, intraoperative blood loss >500 ml and duration of surgery >2 h were significant predictors of mortality (P < 0.05). Multivariate analysis showed that elevated serum urea at hospital presentation and ASA status greater than IIIE were the independent predictors of mortality, but none of the factors could independently predict morbidity. The most common post-operative complication and cause of death were wound infection (29.6%) and sepsis (66.7%). The mortality rate was 14.3%. CONCLUSION: The most common cause of MIO was post-operative adhesion. Elevated serum urea and ASA status greater than IIIE were the independent predictors of mortality.

Abdominal stab wounds in Lagos: A review of fifty cases.

BACKGROUND: The optimum management of patients with abdominal stab wounds (ASWs) is yet to be fully elucidated. AIMS AND OBJECTIVES: To evaluate the pattern of injury, treatment offered and outcome in patients with ASWs seen at our tertiary hospital. PATIENTS AND METHODS: This was a retrospective descriptive study of patients who sustained ASWs seen from January 2011 to December 2015. Information obtained from case notes were analysed on a personal computer using SPSS version 22 (SPSS Inc., Chicago, IL, USA).P<0.05 was considered statistically significant. RESULTS: Fifty patients who sustained ASWs were included in the study. Forty-four (88%) were males, mean age was 27 years and 50% were between the ages of 21 and 30 years. The wounding weapon in patients was the knife in 26 (52%) and broken bottle in 14 (28%). Our patients presented at the hospital about 3 h after abdominal stabs and surgical intervention time was uniformly prolonged. Forty-eight (96%) patients had emergency laparotomy, whereas two (4%) patients with omental evisceration were treated using the policy of selective non-operative management. The commonly injured organs were stomach (22.9%), small bowel (20.8%), omentum (18.8%), colon (18.8%) and liver (14.6%). The negative laparotomy rate was 31.3%. The knife was a more lethal weapon than broken bottle in our patients (P<0.05). Seven (14%) patients suffered serious post-operative complications and two (4%) died. CONCLUSION: The high therapeutic laparotomy rates observed in our patients who had generalised peritonitis, evisceration and shock, support the fact that these findings should be indications for immediate laparotomy.

Differential diagnosis and management of giant fibroadenoma: comparing excision with reduction mammoplasty incision and excision with inframammary incision.

Giant fibroadenoma (GFA) may present with breast asymmetry and can be excised with an inframammary incision (IFI) or reduction mammoplasty incision (RMI). This study investigated the clinical presentation and compared excision with the IFI and RMI. All patients with benign breast tumours greater than 5 cm underwent core needle biopsy and a histopathological diagnosis. All confirmed GFA had their clinical details documented and randomised into two groups for excision with an IFI or RMI. Twenty-two patients were studied. The age range was 12-46 years, mean 21.18 ± 2.22 years. The patients were divided into two groups: a juvenile group (n = 16) (73%) aged 12-18 years, mean age 14.06 ± 0.42 years, and a perimenopausal group (n = 5) aged 28-46 years. The juvenile group showed cyclic increases in breast size monthly with menstruation while the perimenopausal showed an initial slow growth of 6-24 months followed by a rapid growth. Fifteen patients (68%) had excision biopsy with IMI and seven patients with RMI. Seven of the patients treated with IFI had minimal preoperative asymmetry and satisfactory aesthetic outcome. Among the patients with severe preoperative asymmetry treated with IFI (n = 8) and RMI (n = 7), those treated with IFI had persistent postoperative skin redundancy and asymmetry, which was not found in those treated with RMI. In conclusion, for patients with significant asymmetry, excision with the IFI was associated with persistent asymmetry while excision with RMI was associated with restoration of symmetry.