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.

Asymptomatic incisional endometrioma presenting as abdominal wall mass: a case report.

Asymptomatic incisional endometrioma of the anterior abdominal wall is rare. Clinical diagnosis may be difficult. We present a 26-year-old woman with incisional abdominal wall endometrioma discovered 5 years after caeserian section. It was painless and there was no change in size with menstruation. The patient's body size was average with a palpable lump at the edge of the caeserian section scar. Clinically desmoid tumour was suspected. The patient underwent surgical excision. Histopathology confirmed endometrioma. There was no recurrence on three months follow-up.

Management of patients with obstructive jaundice: experience in a developing country.

BACKGROUND: Surgical Obstructive Jaundice can be life-threatening. Management of these patients can be a major diagnostic and therapeutic challenge. OBJECTIVE: The aim of this study is to determine the sociodemographic data of patients with obstructive jaundice, clinical, laboratory and radiological findings as well as surgical procedures done and immediate postoperative outcome in a tertiary health institution. METHODS: Patients who presented in a Nigerian tertiary health institution with surgical obstructive jaundice between. January 1991 and December 2004 were retrospectively studied. Information was extracted from clinical records, operation notes and histopathology records. Data was entered into SPSS version 11.0 for windows to generate frequency table, percentages, proportion, histogram and pie chart. RESULTS: Sixty-four patients with obstructive jaundice were managed during the study period. Majority of the patients were in the 6th decade of life. More than 50% of the patients have had symptoms for more than 4 weeks before presentation. Carcinoma of the head of pancreas was the cause of obstructive jaundice in more than 60% of the patients. About 47% of the patients had cholecystojejunostomy and operative mortality was 15.6%. CONCLUSION: Carcinoma head of pancreas is the commonest cause of obstructive jaundice in Nigeria with many of the patients in the 6th decade. Diagnosis and management continue to be a challenge especially as a result of late presentation and limited radiological facilities. Patients benefited from palliative surgical intervention in form of bili-enteric diversion.

Anaesthesia management for thyroidectomy in a non-euthyroid patient following cardiac failure.

A 24-year-old male thyrotoxic student of a tertiary institution had thyroidectomy in the presence of a persistently elevated thyroxine (T4) and tri-iodothyronine (T3) levels. He was initially managed for hypertension at a private hospital before he was referred to our hospital for expert management. He had symptoms of thyrotoxicosis three years before presentation at our hospital. Physical examination revealed bilateral anterior neck masses and a diagnosis of toxic goitre was made. The serum T3 and T4 were elevated. Chest X-Ray, electrocardiogram and echocardiography showed abnormal findings. He was commenced on antithyroid drugs. Surgery was postponed several times due to persistently elevated thyroid hormones. However, he developed cardiac failure after six months on medical treatment and was treated with digoxin and frusemide. He had thyroidectomy under general anesthesia after his cardiovascular status was optimized in order to prevent further deterioration of his cardiac function. The anesthetic management is presented and discussed.

Rectal cancer: pattern and outcome of management in University of Ilorin Teaching Hospital, Ilorin, Nigeria.

BACKGROUND: Cancer of the colon and rectum was considered to be rare in Africa three to four decades ago. This is no longer true though it is not as common as in Western Europe and North America. The aim of this study is to determine the incidence of rectal cancer, its pattern of presentation, diagnosis, treatment and outcome of treatment at the University of Ilorin Teaching Hospital (UITH), Ilorin, Nigeria. METHODS: This is a prospective study of all the patients with rectal cancer seen at the UITH from January 1998 to December 2002. Clinical and radiologic findings as well as findings at surgery were recorded and evaluated. They were all histologically confirmed. The data were analyzed using SPSS 10.0. RESULTS: Thirty-six patients with rectal cancer were seen during the period. The male to female ratio was 1:1. Fourteen (38.9%) of the patients were younger than 40 years. Only three (8.3%) patients presented as emergency. Eighteen patients had resectable lesions at presentation. Ten had abdomino-perineal (A-P) resection and eight had anterior resection. Operative mortality was 5.9%. Ten (60%) of the patients who had A-P resection were alive at 5 years and 62.5% of those who had anterior resection were alive at 5 years. None of the patients who had unresectable tumors was alive at 5 years. CONCLUSION: Rectal cancer is not rare in Africans. Surgical therapy still remains as the main treatment. When patients present early, outcome is satisfactory. Since most cases in this environment are accessible to digital rectal examination (DRE), the need for this procedure in patients with lower gastrointestinal symptoms cannot be overemphasized.

Epidemiology, etiology, and treatment of chronic leg ulcer: experience with sixty patients.

BACKGROUND: Chronic leg ulcer (CLU) is reported to have an impact on virtually all aspects of life. Treatment is expensive and has large economic burden on many countries' health services. This presentation is to determine the impact, etiology, and presentation of CLU as well as the procedures for processing in a Nigeria tertiary care facility. METHODS: All patients with CLU seen that were prospectively managed in our hospital between 2004 and 2006 have been included in the study. The data were analyzed by SPSS version 11.0 of software. RESULTS: Sixty consecutive patients seen over a period of 3 years (2004-2006) were prospectively studied. There were two peak period of age presentation 30-39 and 50-69 years. The male female ratio was 1:1. Most of the patients (93.3%) had unilateral ulcers and it was as common on the right as on the left. Fifty percent of patients had medical disorders. The commonest cause of CLU was poorly managed traumatic wound. CONCLUSION: Most patients benefited from debridement with or without split thickness skin graft or flap.

Macromastia: a review of presentation and management.

BACKGROUND: Macromastia is a condition of abnormal enlargement of the breast tissue in excess of the normal proportion. The condition may be caused by glandular hypertrophy, excessive fatty tissue or combination of both. The usual physiologic enlargement of female breast occurs over 3 to 5 years and the female breast size is related to body habitus and hereditary characteristics. METHOD: A review of the literatures of Macromastia was undertaken with emphasis on presentation and management. RESULT: The aetiology of macromastia is usually undetermined, however, hormonal excesses and hypersensitivity of the target organ have been found in some cases. Cases of hyperprolactinaemia has been reported by some workers. Immunological risk factors for development of macromastia have also been seen in some groups of patients with Myasthenia gravis, Chronic arthritis, and Hashimoto thyroiditis. Ultrasonography may show no breast parenchyma abnormalities, while mammography may be indicated in some patients who are 40 years or older. Hormonal assay can be done but its value in treatment is doubtful. Drugs are only marginally effective in reversing gigantomastia, therefore surgery remains the mainstay of treatment. CONCLUSION: Management of macromastia can be physically, socially and psychologically satisfying to both the patients and the surgeons.

Unusual cutaneous metastatic follicular thyroid carcinoma.

Follicular thyroid carcinoma (FTC) is the second most common thyroid cancer (TCs) after papillary carcinoma, but it is ranked first in producing distant metastases among TCs. It accounts for 10 - 20% of all thyroid malignancies and is most often seen in patients over 40 years of age. Distant metastases at the time of diagnosis are reported in 11 - 20% of the patients and may be the reason for presentation. There have been less than 30 reported cases of cutaneous metastases from FTC in the English Literature, a majority affecting the scalp. We present an unusual aggressive, hypervascular FTC in a 58-year-old man with a previous diagnosis of multinodular goiter. The difficulty in gaining his acceptability of orthodox management resulted in the development of multiple giant scalp and right facial metastatic masses associated with lytic calvarial destruction and the involvement of frontal and right maxillary sinuses. These imposed serious challenges in managing him in a resource-poor community.

Thyroid cancers amongst goiter population in a Nigerian tertiary hospital: surgical and radiographic perspective.

BACKGROUND: Goiters are commonly benign, but cases of malignancy can develop. Thyroid cancer is known to be commoner in whites than in blacks and in females than in males. Bone metastasis is a common occurrence and may be the initial manifestation in a small subset. We hope to determine the incidence and the cervical radiographic patterns of thyroid cancer amongst goiter population in Nigeria. METHOD: Surgical, histological and radiographic findings in patients with goiter who had thyroidectomy in our hospital from 1999 to 2006 were reviewed. Those with proven cancer were analyzed for sex, age and radiographic changes using SPSS 11.0 for windows. RESULTS: Thirteen (8.2%) cases out of the 160 goiters were malignant and distant metastases were present in 1.3% at presentation. The histological sub-types of malignant goiters were follicular (5.0%), papillary (1.9%) and poorly differentiated or anaplastic thyroid carcinoma (1.3%). As much as 30% of thyroid cancers demonstrated calcification on plain neck radiograph, which were commonly scattered or diffused. CONCLUSIONS: Carcinomatous goiters occurred in 9.3% of the goiter population studied with predominance of follicular variant. Surgery remains the main stay but was inappropriate in about 1.2% of population with goitre. Aside evidence of bony destruction, TC should be suspected in goiters with mixed (diffused or scattered) calcifications.

Thyroid Cancers amongst Goiter Population in a Nigerian Tertiary Hospital:Surgical and Radiographic Perspective

Background: Goiters are commonly benign; but cases of malignancy can develop. Thyroid cancer is known to be commoner in whites than in blacks and in females than in males. Bone metastasis is a common occurrence and may be the initial manifestation in a small subset. We hope to determine the incidence and the cervical radiographic patterns of thyroid cancer amongst goiter population in Nigeria. Method: Surgical; histological and radiographic findings in patients with goiter who had thyroidectomy in our hospital from 1999 to 2006 were reviewed.Those with proven cancer were analyzed for sex; age and radiographic changes using SPSS 11.0 for windows. Results Thirteen (8.2) cases out of the 160 goiters were malignant and distant metastases were present in 1.3at presentation. The histological sub-types of malignant goiters were follicular (5.0); papillary (1.9) and poorly differentiated or anaplastic thyroid carcinoma (1.3). As much as 30of thyroid cancers demonstrated calcification on plain neck radiograph; which were commonly scattered or diffused. Conclusions: Carcinomatous goiters occurred in 9.3of the goiter population studied with predominance of follicular variant. Surgery remains the main stay but was inappropriate in about 1.2of population with goitre. Aside evidence of bony destruction; TC should be suspected in goiters with mixed (diffused or scattered) calcifications

Epidemiology, etiology, and treatment of chronic leg ulcer: experience with sixty patients

Background: Chronic leg ulcer (CLU) is reported to have an impact on virtually all aspects of life. Treatment is expensive and has large economic burden on many countries' health services. This presentation is to determine the impact; etiology; and presentation of CLU as well as the procedures for processing in a Nigeria tertiary care facility. Methods: All patients with CLU seen that were prospectively managed in our hospital between 2004 and 2006 have been included in the study. The data were analyzed by SPSS version 11.0 of software. Results: Sixty consecutive patients seen over a period of 3 years (2004-2006) were prospectively studied. There were two peak period of age presentation 30-39 and 50-69 years. The male female ratio was 1:1. Most of the patients (93.3) had unilateral ulcers and it was as common on the right as on the left. Fifty percent of patients had medical disorders. The commonest cause of CLU was poorly managed traumatic wound. Conclusion: Most patients benefited from debridement with or without split thickness skin graft or flap

Surgical trainees' understanding of Dukes' staging in rectal cancer.

BACKGROUND: This study was conducted to determine the understanding of Dukes' Staging of Rectal Cancer by surgical trainees. METHODS: At a West African College of Surgeons' revision course, questionnaires were distributed asking questions related to staging of Rectal Carcinoma with special emphasis on Dukes' staging, the results were analyzed using SPSS Version 10.0. RESULTS: We had sixty-one (61) respondents, one (1) questionnaire was incompletely filled and sixty were therefore analyzed. They were all males. Majority of respondents 53 (88.3%) were between 30 and 39 years of age. Fifty (83.3%) were junior residents, while 10 (16.7%) were senior residents. Exactly 71.1% of the residents have had more than 6 months of general surgery posting. Forty-nine (81.7%) had staged rectal cancer in practice. Fifty-four (90%) knew no other staging system apart from Dukes'. Only 11 (18.3%) were able to outline Dukes' staging correctly. Fourteen (23%), 12 (20%), and 25 (41%) were able to correctly get Stage A, B and C of Dukes' Classification. CONCLUSION: Adequate comparison of outcome of treatments will be difficult if there is confusion in staging. The 1932 Dukes' Staging should be uniformly adopted for its simplicity Alternatively, proformas of the TNM Staging can be introduced in clinical practice to decrease the reliance on memory.

Cervical plexus block for thyroidectomy: experience with a giant goitre: case report.

Local or regional anaesthesia has long been recognised as a useful anaesthetic option for thyroidectomy. A few authors have reported the successful use of local infiltration anaesthesia for thyroidectomy in our environment. The technique is said to be particularly suitable for simple giant goitres. Cervical plexus block has also been found useful for this operation in other parts of the world. However, we are unaware of any report on the use of cervical plexus block for thyroidectomy in our environment. We used bilateral superficial cervical plexus block for thyroidectomy in a 20-year old girl with a simple multinodular goitre. Surgery was performed with the patient in the classical thyroidectomy position. Though the patient was lightly sedated during the operation, the anaesthetist maintained communication with her throughout the procedure. Anaesthesia was generally effective, except for minor complaints of pressure symptoms during mobilization of the gland and postural aches. These, the patient described as tolerable. Surgery, which lasted 2 hours 45 minutes, was uneventful. The patient was allowed oral fluid intake within 2 hours postoperatively. Superficial cervical plexus block is simple, safe, effective and cheap for thyroidectomy for Simple Giant Goitre.

Conjunctival Kaposi's sarcoma in HIV-positive heterosexual Nigerian woman--a case report.

BACKGROUND: Neoplastic conditions are increasingly been encountered in HIV/AIDS patients. Till date only two cases of conjunctiva Kaposi sarcoma (KS) have been reported in the background of HIV and both in males. OBJECTIVE: To present a 27-year-old African woman with histologically proven conjunctival KS and marked CD4+ cell depletion and to reinforce the fact that KS is an important differential of conjunctival tumour especially in the background of immunosupression in Africa. METHODS: A 27-year-old housewife, presented to the hospital with a three-month history of a rapidly growing tumour attached to the right upper eyelid, cough and weight loss. Patient was given full workup including x-rays, HIV status determination and histological assessment. RESULTS: She was markedly wasted, with widespread pruritic papular skin lesion, and florid oropharyngeal candidiasis. Clinical and chest x-ray findings were suggestive of bilateral lower lobar pneumonia. Screening and confirmatory tests were positive for human immunodeficiency virus (HIV) with CD4+ lymphocyte cell count of 120 cells/ml. Histologic report of the biopsy revealed the mass to be a conjunctival KS. Patient was subsequently commenced on antibiotics and antiretroviral combination therapy. The mass had regressed in size considerably along with improvement in her clinical condition at six months review. She is still being followed up at the medical clinic. CONCLUSION: This is the first reported case of conjunctival KS in an HIV positive African woman. KS should be considered as a possible differential of conjunctiva mass, especially if the patient is HIV positive irrespective of patient's gender.

Bacteriological Pattern of Wound Swab Isolates in Patients with Chronic Leg Ulcer

Purpose: To determine the pattern of bacterial pathogens and their antibiotic sensitivity profile in patients with infected chronic leg ulceration. Methods: Sixty swab specimens obtained from chronic leg ulcer (CLU) patients were cultured aerobically and the antibiotic sensitivity pattern of the recovered organisms determined by the modified Kirby -Bauer disc-diffusion method. Results: 47 (78.3) of the ulcers were infected out of which 39 (83.0) were culture positive. Most of the culture positive ulcers were on the distal third of the leg. The isolated bacteria from the wounds were Pseudomonas aeruginosa (33); Staphylococcus aureus (24); Proteus spp (15); Klebsiella spp (13); Citrobacter spp (13) and Escherichia coli (2). None of the patient without clinical evidence of wound infection had bacterial positive wound swab culture. All isolates were sensitive to third generation cephalosporin and floroquinolones but majority were resistant to ampicillin. Conclusion: Pseudomonas aeruginosa; Staphyloco-ccus aureus. Proteus spp; Klebsiella spp; Citrobacter spp and Escherichia coli sensitive to third generation cephalosporin and floroquinolones have been recovered from 78of patients with chronic leg ulcers in a tertiary health facility in Nigeria

Preoperative staging of rectal carcinoma using transrectal ultrasonography (Trus): experience with 30 Nigerians.

BACKGROUND AND OBJECTIVE: Colorectal cancer is the second most common malignancy; accounting for approximately 155,000 new diagnosed cases each year in the United States. It is about the commonest Gastrointestinal Malignancy in Nigeria. For cancers specifically located in the rectum, various therapeutic options are available including local excision, total mesorectal excision, preoperative radiotherapy etc. These treatment modalities vary in morbidity and chance for cure. The choice of surgery as well as possible outcome largely depends on the depth of tumour infiltration of the rectal wall as well as extent of perirectal tissue involvement. The aim of this study was to assess local fixity clinically and also to assess the ability of transrectal ultrasound (TRUS) to fulfil staging requirements in patients with rectal cancer. The results of these findings were compared with findings at operation and subsequent findings at pathological examination. This is with the aim of evaluating the usefulness of transrectal ultrasound in selecting patients for surgical intervention especially with respect to resectability. MATERIALS AND METHODS: Thirty consecutive patients with histologically confirmed rectal carcinoma at UITH, Ilorin from January 1998 to December 2002 who underwent preoperative TRUS were prospectively studied. After clinical examination including digital rectal examination they all had TRUS, proctoscopy and sigmoidoscopy. Result of findings on clinical examination, TRUS, findings at surgery and histological findings were compared and analysed using SPSS 10.0. RESULTS: There were 30 patients reviewed. Twenty per cent of patients who were thought to have fixation of the tumour on clinical examination were not confirmed on TRUS and at surgery. All the patients that TRUS diagnosed as fixed and therefore not resectable were confirmed at surgery and histopathology. Digital Rectal Examination (DRE) identified four patients with peri-rectal lymph nodes but TRUS picked six; though only five were histologically positive. CONCLUSION: TRUS is a useful preoperative imaging technique especially where CT and MRI are not readily available. This can assist the surgeon in preoperative decision taking as to the resectability of the tumour and possible prognosis.