Management of the mass casualty from the 2001 Jos crisis.

BACKGROUND: We report our experience in the hospital management of mass casualty following the Jos civil crisis of 2001. MATERIALS AND METHODS: A retrospective analysis of the records of patients managed in the Jos civil crisis of September 2001, in Plateau State, Nigeria. Information extracted included demographic data of patients, mechanisms of injury, nature and site of injury, treatment modalities and outcome of care. RESULTS: A total of 463 crisis victims presented over a 5 day period. Out of these, the records of 389 (84.0%) were available and analyzed. There were 348 (89.5%) males and 41 females (10.5%) aged between 3 weeks and 70 years, with a median age of 26 years. Most common mechanisms of injury were gunshot in 176 patients (45.2%) and blunt injuries from clubs and sticks in 140 patients (36.0%). Debridement with or without suturing was the most common surgical procedure, performed in 128 patients (33%) followed by exploratory laparotomy in 27 (6.9%) patients. Complications were documented in 55 patients (14.1%) and there were 16 hospital deaths (4.1% mortality). Challenges included exhaustion of supplies, poor communication and security threats both within the hospital and outside. CONCLUSION: Most patients reaching the hospital alive had injuries that did not require lifesaving interventions. Institutional preparedness plan would enable the hospital to have an organized approach to care, with better chances of success. More effective means of containing crises should be employed to reduce the attendant casualty rate.

Laparoscopic paediatric surgery: a potential for paradigm shift in developing countries.

BACKGROUND: Until recently, surgical conditions in children requiring operation were managed by the traditional open method. The introduction of the laparoscopic surgical technique seems to be reversing this trend in many centres. We are pioneering some laparoscopic surgery procedures in our environment and the aim of this study was to document our experience with laparoscopic paediatric surgical procedures in a developing country. MATERIALS AND METHODS: This was a prospective analysis of all consecutive children that had laparoscopic surgery at 5 hospitals in Northern Nigeria from June 2008 to February 2011. RESULTS: Twenty-one patients had laparoscopic surgeries during the study period with a mean age of 12.5 ± 2.6 years and age range of 10-16 years. There were 14 females and 7 males with a M:F ratio of 1:2. Seven patients (33.3%) had cholecystectomies and 13 (61.9%) had appendicectomies and the remaining one patient (4.8%) had adhesiolysis for partial adhesive intestinal obstruction following previous open appendicectomy. The mean operating time was 89 min with a range of 45-110 min for appendicectomies, 55-150 min for cholecystectomies and the adhesiolysis took 50 min. The mean hospital stay was 2 days except for the conversions that stayed up to 7 days. There were 2 (9.5%) conversions with no mortality. CONCLUSION: We solicit a paradigm shift in our approach to surgical management and implore other centres to embrace laparoscopic surgery in the management of surgical conditions in children since it confers obvious advantages over open surgery.

Paediatric solid tumours in Nigerian children: a changing pattern?

BACKGROUND: Childhood cancer is fast becoming an important paediatric problem in Nigeria and several parts of Africa, with the progressive decline of infectious and nutritional diseases. The following study was a 5-year retrospective review of paediatric solid tumours as seen at the Jos University Teaching Hospital, Nigeria. OBJECTIVE: To determine the relative frequencies of childhood solid malignant tumours in Jos, Central Nigeria and compare with reports of previous studies both locally and abroad. MATERIALS AND METHODS: Cancer registers and medical records of patients were used to extract demographic data, specimen number and/or codes. Archival materials were retrieved from the histopathology laboratory and sections were made from paraffin embedded blocks of these specimens. Slides of these histological sections were reviewed and reclassified where necessary. The relative frequencies were then determined. RESULTS: One hundred and eighty one solid tumours of children were diagnosed within the study period. Ninety-four (51%) were benign and 87 (49%) malignant. Male: Female ratio was 1.3:1. The commonest malignant tumour diagnosed was rhabdomyosarcoma which accounted for 27 (31%), comprising of 15 (55.6%), 11 (40.7%) and 1 (3.7%) embryonal, alveolar and pleomorphic rhabdomyosarcomas, respectively. Non Hodgkin lymphoma and Burkitt lymphoma accounted for 17 (19.5%) and 12 (13.8%), respectively. CONCLUSION: Based on the result of our study, we conclude that the commonest solid malignancy of childhood in Jos, Nigeria is rhabdomyosarcoma. This has implications for diagnosis, management and prognosis of theses soft tissue sarcomas in our paediatric population.

Paediatric solid tumours in Nigerian children: a changing pattern?

Background: Childhood cancer is fast becoming an important paediatric problem in Nigeria and several parts of Africa; with the progressive decline of infectious and nutritional diseases. The following study was a 5-year retrospective review of paediatric solid tumours as seen at the Jos University Teaching Hospital; Nigeria. Objective: To determine the relative frequencies of childhood solid malignant tumours in Jos; Central Nigeria and compare with reports of previous studies both locally and abroad. Materials and Methods: Cancer registers and medical records of patients were used to extract demographic data; specimen number and/or codes. Archival materials were retrieved from the histopathology laboratory and sections were made from paraffin embedded blocks of these specimens. Slides of these histological sections were reviewed and reclassified where necessary. The relative frequencies were then determined. Results: One hundred and eighty one solid tumours of children were diagnosed within the study period. Ninety-four (51) were benign and 87 (49) malignant. Male: Female ratio was 1.3:1. The commonest malignant tumour diagnosed was rhabdomyosarcoma which accounted for 27 (31); comprising of 15 (55.6); 11 (40.7) and 1 (3.7) embryonal; alveolar and pleomorphic rhabdomyosarcomas; respectively. Non Hodgkin lymphoma and Burkitt lymphoma accounted for 17 (19.5) and 12 (13.8); respectively. Conclusion: Based on the result of our study; we conclude that the commonest solid malignancy of childhood in Jos; Nigeria is rhabdomyosarcoma. This has implications for diagnosis; management and prognosis of theses soft tissue sarcomas in our paediatric population

Gastrointestinal injuries following blunt abdominal trauma in children.

PURPOSE: Gastrointestinal (GI) injuries in children following blunt abdominal trauma is rare; early diagnosis and treatment is important for good outcome. The purpose of this report is to describe the management problems encountered in children with GI injuries following blunt abdominal trauma. PATIENTS AND METHODS: From January 1996 June 2006, 168 children were treated at our centre for abdominal trauma. Twenty three had GI injuries, 19 were due to blunt trauma while four were due to penetrating trauma. We retrospectively reviewed the clinical data of the 19 children that had GI injuries as a result of blunt abdominal trauma to document the presentation, clinical features, diagnosis and outcome. RESULTS: There were 19 patients, 14 were boys, and five were girls. The median age at presentation was nine years (range 1.5 15 years). Road traffic accident was responsible for injuries in 10, fall from heights in six and assault in two children. In one child the cause of injury was not recorded. Most children presented late and at presentation over 80% had abdominal signs. Diagnosis was mainly by physical examination supported by plain abdominal x-ray in 15 children. All 19 children had laparotomy. There were a total of 23 injuries. Gastric and duodenal injuries accounted for one each. Most of the injuries were in the jejunum and ileum (10 perforations, two contusions with one mesenteric haematoma and one mesenteric tear). There was one caecal perforation and six colonic injuries, one of which was associated with intraperitoneal rectal injury. Five children had other associated injuries (three splenic injuries, one renal injury, one bladder contusion associated with long bone fractures and one severe closed head injury). Treatment included segmental resection with end to end anastomosis, wedge resection with anastomosis, exteriorizations stomas, simple excision of the perforation and closure in two layers (gastric perforation). The total mortality was four (21.1%), two of them due to associated injuries. CONCLUSION: Gastrointestinal injuries due to blunt abdominal trauma pose a management challenge. Management based on decisions from serial clinical examinations and simple tests without recourse to advance imaging techniques may suffice.

Pilot study on one-stage colonic resection without lavage in obstructed left colon in children in an emergency setting.

Classically, left-sided colon obstruction is managed by a multi-staged resection and defunctioning colostomy. The purpose of this study was to examine the feasibility of single-stage resection and anastomosis without intraoperative colonic lavage for acute left-sided colonic obstruction in children. Between October 2000 and May 2006, nine consecutive patients who had a one-stage left-sided colon resection without preceding colonic lavage were evaluated. The main outcome measures were anastomotic leakage, wound infection and death. There were nine patients: six were males and three were females (M:F = 2:1). Their ages ranged from 2-10 years (mean age 6 years). The obstruction was due to irreducible colo-colic intussusceptions in two patients and colo-colic intussusceptions with colonic perforation in four patients, and colo-colic intussusceptions with gangrene in three. All the patients had resection and primary anastomosis without on-table colonic lavage. There were no anastomotic leakages or deaths. Postoperative complications included superficial wound infections in two patients and dry cough in four other patients. Three patients were lost to follow up after 3 years of follow up, but the remaining six are presently doing well. Primary anastomosis without colonic lavage is safe for resection of the left colon in children in an emergency setting.

Intensive care unit admissions in the Jos University Teaching Hospital.

OBJECTIVE: To determine the pattern of admissions to the intensive care unit (ICU) of the Jos University Teaching Hospital (JUTH), a tertiary level referral hospital. METHOD: This is a retrospective study of the record of patients admitted between January 1994 and December 2002 to the ICU of the Jos University Teaching Hospital. The information obtained from the admission/discharge record as well as the patients' case notes included demographic data, working diagnosis, type of treatment, length of stay (LOS) in the ICU and outcome. RESULT: A total of 738 patients were admitted over this period and comprised 403 males (54.6%) and 335 females (45.6%) giving a male: female ratio of 1.2:1. The age ranged from one day to 98 years with a mean of 28.3 +/- 19.8 years. Postoperative surgical patients accounted for 48.2% of all admissions, while 15.2% were medical cases. Other indications for admissions included polytrauma (9.5%), Obstetrics and Gynaecological complications (16.1%) and burns (11%). The length of stay (LOS) in the unit ranged from 1 to 56 days, with a mean of 4.5 +/- 5.1 days. A total of 241 patients died while on admission giving an overall mortality of 42.8%. Postoperative surgical admissions accounted for 38.6% of deaths followed by burn and polytraumatised patients with 23.2% and 11.6% respectively. The lowest mortality of 8.7% was in the obstetrics and gynaecology patients. CONCLUSION: The pattern of admission into the unit and the outcome of treatment has not significantly changed after 1-2 decade of an initial report. There is need to increase the number and quality of equipment to cope with the increasing need for ICU care, as well as draw up a policy on the type of cases to be managed in order to improve the out come of care.

Paediatric burns: management problems in a teaching hospital in north western Nigeria.

The records of 168 children managed for burns in a teaching hospital in northwestern Nigeria, between April 1998 and March 2003, were assessed to determine the factors that are responsible for high rates of morbidity and mortality in paediatric burns. The causes of burns were hot water in 86 cases (51.2%), flame in 45 (26.8%), hot soup in 32 (19%) and electricity in five (3%). The main complications were wound infections in 109 (64.9%) patients, anaemia in 68 (40.5%), malnutrition in 54 (32.1%), contracture in 50 (29.8%), persistent hypothermia in 27 (16.1%), tetanus in 14 (8.3%) and one case (0.6%) of massive upper gastrointestinal bleeding, possibly as a result of Curling's ulcer.

Paediatric blunt abdominal trauma: challenges of management in a developing country.

BACKGROUND: In developed countries, the availability of advanced imaging techniques has reduced the necessity for laparotomy following blunt abdominal trauma in children. Laparotomy rates still remain high in developing countries where these advanced imaging techniques are lacking. A simple management protocol to identify patients who require laparotomy could reduce the laparotomy rate in children with blunt abdominal trauma in these countries. PATIENTS/METHODS: This is a review of children aged 15 years or below managed in our institution over a 5 1/2-year period for blunt abdominal trauma. The children were divided into two groups. Group A consisted of children managed from January 1999 - December 2000. During this period, there was no protocol. Group B consisted of children managed from January 2001 - June 2004. During this period, a simple management protocol was introduced. The laparotomy rates in the two groups were analysed using a simple chi-square. RESULTS: A total of 48 children, representing 63 % of children with abdominal trauma during the study period, were examined (Group A 17; Group B 31). Their ages ranged from 1.5 years - 15 years (median 9 years). Thirty-four were boys, 14 were girls (M:F = 2.4:1). Road traffic accidents accounted for 38 (79.1 %) and falls from heights for 9 cases (18.75 %), and one boy with a hydronephrotic kidney fell off the staircase at home. The diagnosis was clinical, supported by abdominal ultrasound scan (USS) and plain abdominal film. Twenty-eight (58.3 %) children had laparotomy (15 in Group A; 13 in Group B). There was a statistically significant difference in the laparotomy rates between Group A and B (p < 0.01). Nineteen children were managed nonoperatively (2 in Group A; 17 in Group B); one child died before an operation could be performed. There were 59 abdominal organ injuries in 45 children. In 2 children, ultrasound could not diagnose any organ injury. There were 33 splenic injuries; 15 children had splenic conservation, 7 underwent a splenectomy, while 10 were managed nonoperatively. One child with splenic injury died before operation. Of 7 liver injuries, 4 required suturing of lacerations, 1 subcapsular haematoma was left undisturbed at laparotomy, while 2 were managed nonoperatively. There were 4 pancreatic injuries. Three were managed nonoperatively, while 1 associated with duodenal injury had a laparotomy. All 6 gastrointestinal injuries had laparotomy. There were 5 renal injuries: 3 had laparotomy with suturing, while 2 were managed nonoperatively. There were 4 bladder injuries: 2 had laparotomy with suprapubic catheter insertion, while 2 were managed nonoperatively. There were 7 retroperitoneal haematomas in association with other organ injuries. Associated injuries included head injury in 2, long bone fracture in 2, spinal injury and chest trauma in 1 each. There were 4 deaths, 1 before surgery could be performed. CONCLUSION: Blunt abdominal trauma in children resulted mainly from road traffic accidents. The use of a simple protocol supported by ultrasound scan could reduce the laparotomy rate in countries with limited facilities.

Childhood Wilms' tumour: prognostic factors in North Central Nigeria.

BACKGROUND: Childhood Wilms' tumour or nephroblastoma represents one of the challenges for paediatric oncologists in developing countries. OBJECTIVE: To review the clinical characteristics and outcome of management of childhood nephroblastoma in North- Central Nigeria. METHODS: The clinical, operative and histological records of children aged 15 years and below, that were managed for Wilms' tumour at the Jos University Teaching Hospital between 1998 and 2005 were retrospectively reviewed. RESULTS: There were 32 children (M:F=1.9:1) with histologically confirmed nephroblastoma seen over the 7-year period. Their median(range) age was 4 (3-15) years. The patients invariably presented with a palpable abdominal mass, but haematuria was exceptional. The neoplasm tended to be larger on average than those reported previously among Caucasian children. At presentation, 1 (3.1%) patient was in stage I, 8 (25%) stage II, 11 (34.4%) stage III and 12 (37.5%) stage IV. About 72% of the patients presented with stage III-IV disease. Poorly differentiated neoplasm was more common in male than in female patients. Nephrectomy and chemotherapy were the modality of treatment. Fifteen (46.9%) of the patients received little or no induction chemotherapy due to unavailability of drugs while only 12 (37.5%) received the prescribed maintenance treatment with the remainder getting erratic or no treatment. Overall, only 43.8% were alive between 1 and 9 months (median: 6 months) of follow-up period, but there was no survivor at two years after treatment. CONCLUSION: Childhood nephroblastoma has a high mortality rate in north central Nigeria because of late clinical presentation with advanced disease, poor availability of cytotoxic drugs and frequent interruptions in treatment and inadequate follow-up.

Posterior urethral valves in childhood : experience in a center with scarce facilities

Objective: Posterior urethral valves (PUV) are the most common congenital causes of lower urinary tract obstruction in male children; but few cases have been reported from Nigeria. In this study we describe our 7-year experience of management of PUV in children in order to increase the awareness of this condition in our environment. Patients and Methods : This is a report of 41 consecutive children with PUV who were managed at the Jos University Teaching Hospitals (JUTH); Jos; Nigeria; from June 2000 to April 2006. Their age at presentation ranged from 2 days to 15 years (mean: 2.5 years). The relevant clinical; laboratory and radiological data were entered into a database and analyzed.Results: Twenty-eight patients presented with a condition highly suspicious of PUV; while 7 patients presented with other urological conditions. Six patients presented with non-urological symptoms which caused a delay in diagnosis and institution of treatment. Voiding cystourethrography was diagnostic in all cases. In the majority of patients (n=31); management consisted of transurethral balloon avulsion of the valves yielding a satisfactory outcome in over 80. Conclusion : Although this study was restricted to one hospital; there appears to be a high incidence of PUV in children in North Central Nigeria. An increased awareness of varied clinical features; a high index of suspicion and simple conservative treatment by balloon avulsion of PUV would improve the outcome.of the patients. Urethral stricture was the main complication (which responded to serial dilatation) and occurred in 3 patients. The postoperative mortality rate was 2.6

Management of Conjoined Twins : a Report of Two Sets

Background: Conjoined twinning is a rare congenital anomaly. We present here; our experience in the management of two sets of conjoined twins at a Teaching Hospital in north central Nigeria. Method: Data of conjoined twins managed at the Jos University Teaching Hospital in 1987 and 2004 were retrospectively collated and analyzed. Result: Two sets of pyopagus tetrapus conjoined twins were managed within the period; one was a set of triplets. The conjoined pairs in both sets of twins were females. None of the twins was diagnosed prenatally. Both sets of conjoined twins were delivered spontaneously by vaginal route. Emergency surgical separation was undertaken in both sets be- cause of deteriorating anencephaly in one twin in the first set and anorectal malformation and intestinal obstruction in one twin in the second set. Both sets of twins died after separation. Conclusion: Our experience showed that separation of conjoined twins may be associated with high mortality. Sepsis and electrolyte imbalance appear to be the major causes of morbidity and mortality; particularly when the resultant skin defects are large

Anorectal anomaly: a review of 82 cases seen at JUTH, Nigeria.

BACKGROUND: The management of anorectal anomaly remains a challenge to Surgeons. This study was carried out to determine the pattern and outcome of management of anorectal malformations (ARM) in a Nigerian tertiary hospital. PATIENTS AND METHODS: The clinical and operative records of consecutive children with anorectal anomaly managed between October 1990 and September 2000 at the Jos University Teaching Hospital, Jos, were reviewed. RESULTS: There were 82 patients, (57.3%) males and 35 (42.3%) females (m:f=1.3:1). There were 20 (24.4%) cases each of the high and intermediate types, 40 (48.8%) low variety and 2 (2.4%) cases of persistent cloaca. The high type was proportionately commoner in the males. Less than one-third presented within 24 hours. Eighty three percent of patients (mainly males) presented in acute intestinal obstruction. Passage of stools from abnormal sites and "imperforate" anus were complaints in 60 (73.1%) patients each. A total of 63 patients had definitive corrective procedure. Four patients with stenotic anus were treated by serial anal dilatations while 29 with low anomaly had anoplasty during the neonatal period. Twenty eight patients with intermediate or high anomalies or persistent cloaca had definitive repair or pull-through operations carried out 6-12 months after an initial colostomy. The definitive pull-through operations included abdominoperineal pull-through in 11 patients, PSARP in 15, while 2 girls with persistent cloaca had posterior sagittal anorectovaginoure-throplasty (PSARVUP). Twenty nine children were fully continent of stools after surgery; three patients developed occasional faecal soiling; while six patients had faecal incontinence. CONCLUSION: Anorectal anomaly is common, but presentation is late in our environment. Although mortality rate was high (26%), early results of definitive operation among survivors were generally good after a mean follow-up period of 19 months.

Incarcerated umbilical hernia in children.

BACKGROUND: Umbilical hernia is common in children. Complications from umbilical hernias are thought to be rare and the natural history is spontaneous closure within 5 years. PATIENTS AND METHODS: A retrospective analysis was performed of the medical records of a series of 23 children who presented with incarcerated umbilical hernias at our institution over an 8-year period. RESULTS: Fifty-two children with umbilical hernias were seen in the hospital over the period. Twenty-three (44.2%) had incarceration. Seventeen (32.7%) had acute incarceration while 6 (11.5%) had recurrent incarceration. There were 16 girls and 7 boys. The ages of the children with acute incarceration ranged from 3 weeks to 12 years (median 4 years), while the ages of those with recurrent incarceration ranged from 3-15 years (median 8.5 years). Incarceration occurred in hernias of more than 1.5 cm in diameter (in those whose defect size was measured). Twenty-one children (15 with acute and all six with recurrent incarceration) underwent repair of the umbilical hernia using standard methods. The parents of two children with acute incarceration declined surgery after spontaneous reduction of the hernia in one and taxis in the other. One boy had gangrenous bowel containing Meckel's diverticulum inside the sac, for which bowel resection with end-to-end anastomosis was done. Operation led to disappearance of pain in all 6 children with recurrent incarceration. Superficial wound infection occurred in one child. There was no mortality. CONCLUSION: Incarcerated umbilical hernia is not as uncommon as thought. Active observation of children with umbilical hernia is necessary to prevent morbidity from incarceration.

Intestinal malrotation: presentation in the older child.

BACKGROUND: The clinical diagnosis of intestinal malrotation in the older child is not always easy because of its non-specific presentations. The aim of this study was to determine the pattern of presentation of malrotation in older Nigerian children. METHODS: The clinical, radiological and operative records of all the children aged 2 years or above, managed for malrotation at the Jos University Teaching Hospital between March 1992 and December 2002 were retrospectively reviewed. RESULTS: There were 9 patients, with a median age of 5 years (range: 3-14 years). The commonest complaint was intermittent colicky abdominal pain in 9 (100%), followed by recurrent vomiting in 8 (88.9%), haematemesis and constipation each in 5 (55.6%) and repeated episodes of bloody stools and diarrhoea. Other features included abdominal distension in 5 (55.6%) and failure to thrive in 4 (44.4%). Preoperative diagnosis was possible only in 3 patients, through the use of barium meal. Operative findings included obstructing bands of Ladd, partial volvulus and mesocolic hernias. Surgery promptly and satisfactorily relieved the symptoms. CONCLUSION: The diagnosis of intestinal malrotation should be considered in any child with prolonged history of recurrent colicky abdominal pain, vomiting or diarrhoea, especially if there is associated history of failure to thrive. Surgical intervention provides satisfactory relief of symptoms and should be implemented as soon as the diagnosis is made.

Experience with anorectal malformations in Ile-Ife, Nigeria.

The study was carried out to determine the characteristics and outcome of management of anorectal malformations (ARM) in Nigerian children at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) in Ile-Ife, Nigeria, between January 1986 and December 2002. Eighty-six children with ARM were studied, 48 males and 38 females. Only 12 (13.9%) presented to the hospital within 24 h of birth. Twenty-four (27.9%) patients had one or more associated congenital anomalies, with oesophageal atresia with tracheo-oesophageal fistula being the most common associated malformation. A low variety was identified in 26 (30.2%) cases, while 60 (69.8%) had intermediate or high lesions. Twenty-two patients with the low type of anomaly were offered primary anoplasty in the neonatal period, whereas 59 patients with intermediate or high malformations were offered a preliminary colostomy. A definitive pull-through procedure was ultimately performed in 27 of these 59 cases. Twenty-six patients (30.2%) died. Infection and severe associated malformations were responsible for most (65%) of the deaths. Early results of definitive surgery among survivors were generally good after a mean follow-up period of 13 months. Late presentation, inadequate facilities for neonatal intensive care, and paucity of specialist supportive personnel appear to have negatively influenced the outcome of treatment in our environment. Increasing awareness and availability of medical facilities and specialists are needed.

Typhoid enteric perforation in north western Nigeria.

BACKGROUND: Typhoid perforation is the most important surgical complication of typhoid enteritis and is associated with high morbidity and mortality. AIMS AND OBJECTIVES: To determine the pattern and outcome of management of typhoid perforation in Aminu Kano University Teaching Hospital, Kano. METHOD: A retrospective Analysis of patients treated for typhoid perforation over a 6-year period. RESULTS: There were 47 patients: 35 males and 12 females, ratio 2.9 to 1. The patients were aged 4 years to 58 years (mean 18.9 years). Typhoid perforation occurred all the year round with a peak prevalence in September; Six (12.8%) patients perforated in the first week, 29 (61.7%) second week, and 12 (25.5%) third week, of illness. Single perforation was found in 91.5% of cases, and two to three perforations in 8.5%. Surgical treatment was by simple closure in 72.3%, wedge resection in 8.5%, ileal resection in 17.1% and right hemi-colectomy in 2.1%. Of the 41 survivors (87.2%), wound infection was the most common postoperative complication in 44.7% of cases. The mortality rate was 12.8% mostly due to overwhelming sepsis. CONCLUSION: Typhoid perforation requiring surgical intervention is still endemic in our subregion, and emphasis should be on preventive measures such as safe drinking water and appropriate sewage disposal, and typhoid vaccination.

Acquired rectal fistula in human immunodeficiency virus-positive children: a causal or casual relationship?

Acquired rectal fistula in human immunodeficiency virus (HIV)-positive children is a new and worrisome entity. The aim of this paper is to highlight the relationship between HIV infection and acquired rectal fistula (RF) in children in order to create awareness among clinicians who attend to children. Over a 1-year period, 11 girls aged 4 weeks-11 months (median 5 months) with acquired RF were managed at our institution. Ten were HIV-positive by enzyme-linked immunosorbent assay and confirmed by Western blot test. One child defaulted before the test. All the mothers and three fathers of the 10 children were seropositive for HIV. Bronchopneumonia, otitis media, oral thrush, diarrhoea, and lymphadenopathy were common associations. Treatment was essentially conservative because the result of surgical intervention was disappointing. Two of the infants and one of the fathers are now dead from full-blown acquired immunodeficiency syndrome. Acquired RF seems to be a sign of HIV infection in children. It will be necessary to screen any child presenting with acquired RF for HIV infection.

Open versus closed haemorrhoidectomy.

OBJECTIVE: To compare post operative complications, rates of wound healing, and cost effectiveness between the closed and open methods of haemorrhoidectomy. DESIGN: Prospective. SETTING: Jos University Teaching Hospital (JUTH), Jos and Evangel Hospital, Jos. PATIENTS AND METHODS: Consecutive patients who presented with second and third degree haemorrhoids were randomised into an open group A and a closed group B. Time taken for wound to heal, the postoperative complications and cost of management in each group were assessed. Each patient was followed up for at least three months. RESULTS: There were 59 males and 20 females, distributed between group A (n=39) and B (n=40). The average postoperative hospital stay was 5 days in group A and 3 days in group A. There were no differences in the complication rate between the two groups. Post operative retention of urine was the commonest complication and occurred in 12 patients: 7 in group A and 5 group B. This was followed by reactionary haemorrhage in 6. All of which occurred in group A. There were 8 patients with skin tags: 5 in group A and 3 in group B. Other complications included secondary haemorrhage (2), wound dehiscence (4) and wound infection (2), all in group B. The average wound healing time was significantly shorter in group B (2.8 vs 5.0 weeks). The financial difference between the two treatment groups was not statistically significant (N4,593.00 and N4,598.00, or 34.02 dollars and 34.06 dollars in groups A and B, respectively). CONCLUSION: The cost per patient and morbidity did not show any statistically significant differences between the open and closed methods of haemorrhoidectomy. However, healing was significantly faster in group B.