Health Worker (HW) Factors in Delayed Access to Pediatric Surgery in Low- and Middle-Income Countries (LMICs).

Background: In the developing world, access to pediatric surgery has been associated with sociocultural factors and healthcare funding challenges. Aim: This study aims to evaluate health worker (HW) factors in delayed access to appropriate care for children with surgical problems in South East Nigeria. Subjects and Methods: A cross-sectional analysis of the awareness of children's surgery and ability for appropriate referral among 503 HWs of various cadres in South East Nigeria was carried out using a structured questionnaire. Data was analyzed using IBM SPSS 21. Results: Of 419 (83.3%) respondents, 211 (50.4%) were doctors, 217 (51.8%) were aged 26-35 years, 261 (62.3%) indicated awareness of pediatric surgical conditions, 114 (27.2%) knew of sites to examine on the newborn at birth, and 147 (35.1%) inclined to timely referral to experts. Predictors of early referral include age <35 years, (P = 0.001) and cadre: doctors (P = 0.006). Female HWs (P = 0.013) and doctors (P = 0.008) displayed better knowledge of pediatric surgical cases. Delayed referral was mostly HW-related and included inaccurate diagnosis and wrong assumption of competence. Conditions commonly misdiagnosed were intussusception and posterior urethral valve. Conclusion: Awareness of surgical needs of children is poor among HWs in our setting. To address this and improve access to care, there may be a need to incorporate basic training in common pediatric surgical conditions in the training curriculum for HWs at various levels.

Evaluation of postgraduate educational environment in a Nigerian teaching hospital.

BACKGROUND: Congenial educational environment (EE) is paramount to effective impartation of knowledge as required in residency training. In this study EE for residency training is evaluated using Postgraduate Hospital Educational Environment Measure (PHEEM). OBJECTIVES: To assess the postgraduate educational environment at the University of Nigeria Teaching Hospital (UNTH), South-East Nigeria, using PHEEM and to determine if there are significant differences in PHEEM scores amongst various sub-groups of resident doctors. METHODS: A cross-sectional study, employing a census survey, involving the administration of validated PHEEM questionnaires to residents in the Departments of Internal Medicine, Obstetrics/Gynaecology, Pediatrics and Surgery in the year 2018. Data entry and analysis were done using SPSS. ANOVA assessed significance of total scores and sub-scale scores. Cronbach's alpha was calculated. RESULTS: A total of 114 Males and 46 females; 93 registrars and 67 senior registrars responded giving 71% response rate. Overall PHEEM score was 85.82; Role autonomy (29.27), Perception of teaching (34.80), Perception of social support (21.55). Males scored more than females in total PHEEM score (p = 0.000, F = 148.235), perception of teaching (P = 0.000, F = 420), and perception of social support (p = 0.000, F = 162.95), but not in role autonomy (p = 0.748, F = 0.104). Registrars scored more than senior registrars in total PHEEM (p = 0.000, F = 67.159), role autonomy (p = 0.000, F = 25.123), Perception of teaching (p = 0.000, F = 18.042) but not in perception of social support (p = 0.31, F = 1.045). There were significant differences in total and subscale scores amongst the specialties. Cronbach's alpha was 0.915. CONCLUSIONS: Postgraduate educational environment in UNTH has more positives than negatives but with room for improvement. There are significant differences in PHEEM scores among various groups of resident doctors.

Practice patterns of preoperative hormonal stimulation in pediatric penile surgeries-A survey of Nigerian pediatric surgeons.

BACKGROUND: Variable practice patterns exist in the use of Preoperative Hormonal Stimulation (PHS) prior to penile surgeries and there seems to be no generally agreed standards. OBJECTIVE: To assess the current practice patterns of PHS before penile surgeries among Nigerian pediatric surgeons and compare with literature. MATERIALS AND METHODS: Self-administered questionnaires were distributed amongst consultants and senior registrars in Pediatric surgery during the 2019 Association of Pediatric Surgeons of Nigeria (APSON) national conference. SPSS version 20 was used for data entry and analysis and results presented as ranges, percentages, tables. Test for association was done using chi square test and a p-value of <0.05 was deemed significant. RESULTS: All fifty respondents comprising 43 males, 7 females; 31 consultants and 19 senior registrars have managed hypospadias, with eighty-six percent managing less than 50 per year. Seventy-six percent practice PHS and more proportion of males use PHS than females (p = 0.027).Only 15.8% and 7.9% respectively estimated serum testosterone before and after PHS. Majority (92.1%) gave PHS because of small-appearing penis and 86.8% have used it in proximal hypospadias. Most commonly used form of PHS was intramuscular testosterone (76.3%) while 2 mg/kg testosterone was commonest dose (65.7%). Ninety-one percent give intramuscular testosterone at 2-4 weeks intervals; ninety-four percent give 2-3 doses of intramuscular testosterone preoperatively with last dose given 2-4 weeks before surgery in 57.9%. Ninety-two percent thought PHS will not increase postoperative complications and pubic hair was most common complication of PHS (63%). DISCUSSION: There is diversity in PHS practices among Nigerian pediatric surgeons. Though mainly low-volume surgeons, majority use PHS before penile surgeries especially in proximal hypospadias and small-appearing penis. Males tend to practice PHS more than females and most commonly used form of PHS is 2-3 doses of 2 mg/kg intramuscular testosterone at 2-4 weekly intervals with last dose given 2-4 weeks before surgery. This study may be limited by bias inherent in self-reported practices and outcomes as seen in surveys, though surveys help to evaluate practices of professionals. CONCLUSIONS: Majority of Pediatric surgeons in Nigeria use PHS in form of intramuscular testosterone mainly for small appearing penis and proximal hypospadias. Most common dosing is 2 mg/kg at 2-4 weeks intervals and 2-3 doses preoperatively with the last dose 2-4 weeks preoperatively. Serum testosterone estimation is not common before PHS. Many believe that PHS does not increase complications following penile surgeries. Current diversity in practice suggests the need for further studies to encourage standardization or guidelines for practice in Nigeria.

Indications, Types and Outcomes of Resections for Acquired Intestinal Conditions in Children.

BACKGROUND: Variable intestinal segments of children may need resection due to congenital or acquired conditions. Resection is done when these intestinal segments are nonviable or dysfunctional. In HICs most resections are for congenital conditions while in LMICs acquired and largely preventable conditions predominate.The spectrum of acquired intestinal conditions leading to bowel resection may also vary between HICs and LMICs. OBJECTIVES: To determine the indications, types and outcomes of intestinal resection for acquired conditions in children. METHODS: A retrospective review of pediatric bowel resections from acquired anomalies over a 10-year period in a tertiary hospital. Data entry and analysis done using SPSS. Fisher's exact test was used to assess level of significance for categorical variables and p-value of <0.05 was adjudged significant. Results are presented as means±SD, ratios, percentages and tables. RESULTS: Fifty-nine males and thirty-three females with a median age of 8 months were recruited. Complicated intussusceptions and right hemicolectomy were the most common indication and procedure respectively. Proportion of right hemicolectomies was more in infants than older children (p=0.0103) while ileal resection was higher in older children (p<0.001). Post-operative complications were seen in 35.8% and mortality rate was 8.7%. CONCLUSION: Complicated intussusception is the main acquired indication for intestinal resection. Right hemicolectomies and ileal resections were done mainly during infancy and beyond infancy respectively.

Assessment of the effect of urethral plate width on outcome of hypospadias repair.

BACKGROUND: The paradigm for hypospadias repair is a straight penis with a vertical meatus at the tip of the glans that provides satisfactory urination and is cosmetically acceptable to the parents of the patient. OBJECTIVE: To determine the cosmetic and functional outcomes of hypospadias repair in relation to the width of the urethral plate. PATIENTS AND METHODS: This study was a prospective evaluation of patients operated for hypospadias. The urethral plate width (UPW) of the patients were measured preoperatively using vernier calipers. The patients were categorized into groups A and B. Group A patients have a UPW <8 mm, whereas group B patients have a UPW ≥8 mm. The width of the urethral plate was correlated to the cosmetic outcome (using hypospadias objective penile evaluation [HOPE]) and functional outcome (using the urinary stream) of hypospadias repair. RESULTS: Overall, 47 patients had their hypospadias repaired during the study period. But, only 42 patients who had their distal hypospadias repaired using tubularized incised plate urethroplasty were evaluated. There were 20 patients (47.6%) in group A and 22 patients (52.4%) in group B, with a mean urethral plate of 7.3 mm ± 0.50 SD. The mean UPW in group A was 5.6 mm ± 1.22 SD and the mean UPW in group B was 8.8 mm ± 0.88 SD. Overall, mean HOPE score was 40.0 ± 6.83 SD. Group A patients had a mean HOPE score of 38.7 ± 7.49 SD, whereas Group B patients had a mean HOPE score of 41.2 ± 6.08 SD. P-value was 0.725, which is not statistically significant. Relating good urinary stream (15 in group A and 20 in group B) with the width of the urethral plate statistically (using Spearman correlation technique) gave a P-value of 0.03 (P < 0.05), which is statistically significant. CONCLUSION: Our findings indicate that the cosmetic outcome of hypospadias repair may not be determined by UPW, but the functional outcome may be predicted by the width of the urethral plate.

Outcome of feminizing genital reconstruction in female sex assigned disorder of sex development in a low-income country.

BACKGROUND: In patients with disorders of sex development (DSD), surgical/medical treatments are undertaken after sex assignment to ensure congruent bodily appearance and function. Genital reconstruction in these patients can be daunting with varied outcome. Understanding these outcomes is imperative, more especially in a developing country where added challenges exist. OBJECTIVE: This study evaluates the outcome of genital surgery in patients with DSD assigned female sex. METHODS: A retrospective analysis of 25 cases of female sex assigned DSD managed in two tertiary centers in southeast Nigeria was performed. Data of these cases were collected from the case notes, discharge summaries, and theater records. IBM SPSS Statistics Data Editor, version 21, was used for data entry and analysis. RESULTS: The patients presented at median age of 12 months (range 2 days-30 years), with 15 (60%) cases reared as female and 10 (40%) reared as male before presentation. The predominant phenotype was phallus with empty fused/unfused labioscrotum and urethra opening in the labioscrotum or perineum in 21 (84%) patients. Evaluation revealed features suggestive of 46XX DSD in 21 (84%) patients, ovotesticular DSD in two (8%), and androgen insensitivity in two (8%). A total of 10 cases required sex reassignment after evaluation. Overall, 24 of the 25 cases had feminizing genital procedures. After a median follow-up period of 2 years (range 2 months-8 years), six (25%) cases developed procedure-related complications, three (12.5%) had social maladjustment, and two (8.3%) patients reported features of gender dysphoria. DISCUSSION: The procedures of feminizing genitoplasty in this study did not differ from the established procedure. However, as a result of challenges of delayed presentation, inadequate early management, sociocultural factors, and a lack of facilities for full evaluation, some cases may require sex reassignment and more daunting reconstructive procedures. This may give rise to less than optimal outcome. The study was limited by the retrospective nature, small number of cases, and the short duration of follow-up of the cases. CONCLUSION: Feminizing genital procedures for DSD in our setting may be associated with procedure-related complications and non-surgical complications. Improving surgical technique and addressing the challenges of delayed presentation and fixation on male gender may improve overall outcome.

The Value of Internet Tools in Undergraduate Surgical Education: Perspective of Medical Students in a Developing Country.

OBJECTIVE: Advances in information technology (IT) in the past decade present opportunities and challenges in undergraduate surgical education. There may be need to evaluate the knowledge base and the use of Internet tools among medical students in settings where traditional mode of education is preeminent. This may help to establish a conceptual framework for integrating e-learning into the traditional teaching to enhance learning experience. In this study, we evaluated the medical students' knowledge and use of Internet tools, and their opinion on the application of these tools in surgical education. METHODS: We undertook a cross-sectional survey of 2013 and 2014 graduating medical class of College of Medicine University of Nigeria, Enugu using structured self-administered questionnaire. The survey assessed the knowledge, utility, and application of Internet tools in surgical education using 5-point Likert scale. RESULTS: Overall response rate was 78% (227/291) comprising 151 (66.5%) males and 76 (33.5%) females. The median age was 24 years (range 20-33 years). Although 106 (46.7%) had formal training on information technology, 223 (98.2%) can access Internet, and 162 (71.4%) use one or more of the Internet tools, 90.6% (96/106) of those trained on ICT use Internet for education/learning compared to 88.4% (107/121) of those without ICT training (p = 0.76). Google™ search tool had the highest rating in terms of familiarity and utility for education/learning (mean rating 4.3 on a scale of 5.0), while Skype™ had the least rating (mean 2.0). Overall, 89% of respondents (mean rating 4.5 on a scale of 5.0) indicated that Internet tools could be effectively applied in surgical education specifically in areas of lectures, assignments, real-time procedure demonstration, case discussion, and interaction with surgical experts. The key benefits are utility as a regular self-assessment tool (mean rating = 4.6) and offer of flexible learning schedule (mean rating = 4.0). Fifty-two percent (118/227) strongly agree that combination of the use of Internet tools with the traditional teaching may give better learning outcome (mean rating 4.44). The major challenges were cost of accessing Internet (n = 126; 55.5%), lack of facility with the technology (n = 115; 50.7%), and network availability (n = 96; 42.3%). Availability of affordable Internet (n = 205; 90.3%), improvement of training on ICT (n = 135; 59.5%), and encouragement of the use of these tools by faculty (n = 107; 47.1%) were the major suggestions to address the challenges. CONCLUSION: In our setting, a substantial number of undergraduate medical students are familiar with and use Internet tools for learning and believe that the tools may have utility in surgical education. However, to further consolidate and enhance learning experience, it may be useful to integrate this learning modality with the traditional mode of teaching through a well thought out curriculum modification.

Evaluation of neonatal circumcision training for resident doctors in a developing country.

BACKGROUND: There is a high prevalence of neonatal circumcision (NC) in Sub-Saharan Africa. However, when providers do not have adequate training on the procedure, neonatal circumcision can result in complications. There are indications that the reported high complication rate of NC in the current setting might be a reflection of inadequate training of the providers. In order to establish a framework for better training of providers of NC, it may be necessary to evaluate the providers' opinions of their training and competence of the procedure. OBJECTIVE: The opinions of surgical, paediatric, and obstetrics-gynaecology resident doctors were evaluated for their exposure to, training on and perceived competence of neonatal circumcision. STUDY DESIGN: The resident doctors in surgery, paediatrics and obstetrics-gynaecology (OBGYN) at two teaching hospitals in southeastern Nigeria were surveyed using a self-developed questionnaire. The self-assessment survey evaluated the residents' exposure and training on NC, and their perceived competence of the procedure. The responses from the different specialties were compared. Data were analysed using Statistical package for Social Sciences (SPSS). RESULTS: The summary of findings is shown in Table below: The confidence in the ability to perform the NC did not significantly differ between the sexes (male 53/87 vs female 6/15; P = 0.22) and the level of training (SHO, Senior house officer 7/17, Registrar 24/42, senior registrar 28/43; P = 0.24). DISCUSSION: A substantial proportion of residents who encountered neonatal circumcision considered their training in NC to be sub-optimal, despite their perceived exposure to the procedure. Notwithstanding this deficiency of training, the majority of the residents planned to perform NC and this presaged an expectedly higher rate of complications. Well-thought-out and structured training, comprising lectures, workshops and hands-on training, for the resident doctors and the other providers of NC might address these shortcomings and minimise complications. This may further be strengthened with a government policy on circumcision. The limitations of the study included: (1) It was a self-assessment survey and this introduced bias in the assessment of competency; (2) There were no outcome measures in the survey for those who had practical exposure vs those who did not. CONCLUSION: The resident doctors perceived that their exposure, training and competence in NC might be sub-optimal. Curriculum modification that incorporates appropriate hands-on training in NC might address these deficiencies.

Disorders of sex development in a developing country: perspectives and outcome of surgical management of 39 cases.

OBJECTIVE: Improvements in diagnostic testing and genital repair have significantly advanced the management of disorders of sex development (DSD). Challenges however, still exist in the management of DSD. This study evaluated the types, challenges of surgical management, and outcome of DSD in south-east Nigeria. METHODS: Retrospective analysis of 39 children with DSD managed from January 2005 to December 2013 at the University of Nigeria Teaching Hospital, Enugu, Nigeria. RESULTS: Types of DSD were: 46, XX DSD in 17 (43.6 %) cases; 46, XY DSD 16 (41 %); Ovotesticular DSD 5 (12.8 %); and one (2.6 %) 46, XY Ovotesticular DSD. Median age at definitive gender assignment was 3 years (range 2 months-14 years). Gender assignment was female for 20 (51.3 %; all 46, XX DSD, one each of 46, XY DSD, Ovotesticular DSD and 46, XY Ovotesticular DSD), and male for 19 (48.7 %; 15 of 46, XY DSD, 4 of Ovotesticular DSD). Eight cases reared as male before presentation required gender reassignment after evaluation and counselling. Genital repair was undertaken at mean age of 4.1 years (range 6 months-14 years). After average follow-up of 22.5 months (range 1 month-7 years), a total of eleven (28.2 %) developed procedure-related complications. Challenges were delayed diagnosis, inadequate diagnostic facilities, and need for gender reassignment. CONCLUSION: There is a wide spectrum of DSD in our setting. Time to diagnosis, evaluation, and outcome may be improved by public enlightenment initiative, focused education of healthcare personnel and provision of relevant diagnostic facilities through enhanced funding and collaboration.

Outcomes of surgical management of intestinal atresias.

BACKGROUND: Outcome of managing intestinal atresias has improved in many developed countries, but most reports from low and middle income countries (LMICs) still show high morbidity and mortality. OBJECTIVE: The objective of the following study is to evaluate the outcome of surgically managed intestinal atresias in our health resource-limited setting. PATIENTS AND METHODS: All cases of intestinal atresias managed surgically from July 2007 to July 2012 were retrospectively analyzed. RESULTS: There were 23 patients comprised of 11 males and 12 females; 10 duodenal atresias (DA), 13 jejunoileal atresias (JIA) and no colonic atresias. The mean age at presentation to the surgeon was 10.3 days (range 2-43 days) for JIA and 10.6 days (range 1-35 days) for DA. Average weight at presentation was 2.2 kg for JIA and 2.4 kg for DA. Mean duration from presentation to surgery was 3.4 days for JIA and 4.8 days DA. All the JIA had primary repair; type 1 DA had duodenotomy and web excision while others had diamond duodenoduodenostomy. However one DA had duodenojejunostomy. 7 out of 10 DA patients (70%) had at least one associated anomaly, the most common being annular pancreas. There were 4 re-operations in JIA and none in DA (17.4% reoperation rate for 3 anastomotic leaks, 1 anastomotic stricture). Average hospital stay was 23 days for JIA and 12.3 days for DA. Overall, 5 (5) patients died (2 JIA and 3 DA) giving a mortality rate of 21.7%. Mortality rate for DA is 30% while for JIA is 15.4%. Causes of death were: Sepsis with disseminated intravascular coagulation (1), sepsis from anastomotic leakage (1), septic shock (1), anesthesia-related (1), undetermined (1). Two of the mortalities (40%) had re-operation for anastomotic leak. CONCLUSIONS: Short-term survival of neonates with intestinal atresias in our unit is still poor when compared with statistics from developed countries. Late presentation is common in this series, but does not appear to have negatively affected outcome. A high proportion of the mortalities had reoperation for anastomotic leak.

Virilized external genitalia in young girls: clinical characteristics and management challenges in a low-resource setting.

OBJECTIVE: Virilization of the external genitalia in young girls (VEG) manifests mostly as ambiguity of the genitalia and elicits concerns and uncertainties especially in settings with poor awareness. This study evaluates the profile and challenges of VEG in southeast Nigeria. METHODS: We analyzed 23 children with VEG managed in 2 referral centers in southeast Nigeria from June 2005 to January 2013. RESULTS: They presented at median age of 13.3 months (interquartile range [IQR] 3 months-3 years). The cases included 3 (13%) of Prader type 1, 6 (26%) of type 2, 11 (48%) of type 3, and 3 (13%) of type 4. Five of the Prader type 3 and all 3 cases of Prader type 4 were reared as male prior to presentation. Following evaluation, all the cases were assigned female gender at a mean age of 2.7 years (range 2 months-10.5 years). Appropriate feminizing genitoplasty was undertaken in all the cases and after a follow-up period of 3 months to 5 years (mean 2 years), 2 patients developed vaginal stenosis, and 3 cases had surgical wound infection. Poor awareness, delayed presentation, inadequate facilities, and lack of trained manpower were the challenges in the management of the cases. CONCLUSION: VEG in our setting is associated with delayed management. Focused health education and public awareness programs, and improved healthcare funding may improve outcome and minimize the need for gender reassignment.

Neonatal head injury unrelated to birth trauma in South-East Nigeria.

BACKGROUND: Neonatal head trauma resulting from causes other than birth trauma has rarely been the focus of many a research theme in the literature. AIM/OBJECTIVE: To highlight the occurrence of non-birth trauma related neonatal head injury, and evaluate the causes and outcome of treatment. METHODS: A 3 year retrospective review of neonatal patients with head injury from two tertiary hospitals in South-East Nigeria between July 2009 and June 2012 (n-37). Data was collected from patients' birth and medical records. Data was analyzed using the SPSS version 15. RESULT: Among the one hundred and seventy-six cases (11.78)% pediatric head injury cases seen, thirty seven (2.48)% occurred in neonatal patients. The most common cause of head injury was fall 22 cases [59.5%]. Children of mothers with low educational qualification were more likely to sustain falls 22 cases (59.5%). Road traffic accident (n = 15) was associated with more severe injuries and poorer outcome. Operative treatment was associated with increased mortality (two of three cases). The mortality rate in our series is 8.10%. CONCLUSION: Reduction of neonatal head trauma could be achieved through improved maternal education.

Irreducible inguinal hernias in the paediatric age group.

BACKGROUND: An inguinal hernia is said to be irreducible when the content fails to return into the peritoneal cavity without surgical intervention. Irreducibility is an ever present risk in untreated inguinal hernias and its management remains an important part of pediatric surgery practice. When a hernia is irreducible, morbidity and mortality increase This risk of irreducibility is more in some patient groups. METHODS: A retrospective analysis of all irreducible inguinal hernias in children of both sexes from neonatal age to 15 years who presented at the University of Nigeria Teaching Hospital from January 2000 to June 2010 and needed emergency groin exploration when reduction failed on conservative management. RESULTS: There were 25 irreducible inguinal hernias requiring emergency groin exploration. This represents 10.2% of all inguinal hernias managed within the period, with a male:female ratio of 11.5:1. Nineteen (76%) were on the right while six (24%) were on the left. Forty percent (40%) of the irreducible hernias were in older infants. Sixty-seven (67%) of the neonatal hernias presented as irreducible. There were 3 bowel resections (12% bowel resection rate), 2 testicular losses (8% testicular loss rate) and one death (4% mortality). CONCLUSION: There is a high rate of irreducibility of inguinal hernias in neonates, and in right-sided hernias Identification of risk factors in and risk stratification of patients with uncomplicated inguinal hernias will help reduce the rate of irreducible inguinal hernias and their attendant morbidities.

Undergraduate surgery clerkship and the choice of surgery as a career: perspective from a developing country.

BACKGROUND: There are concerns regarding a possible decline in the proportion of students choosing surgery as a career in some countries in sub-Saharan Africa. Published works indicate that most students choose their ultimate career during undergraduate training. The present study was undertaken to assess the medical student's perception of the surgery clerkship and determine its influence in the choice of surgery as a career. METHODS: The study involved a cross-sectional survey of 2009 and 2010 graduating medical classes of the University of Nigeria based on self-administered questionnaires. The clerkship evaluation was assessed on a 3-point Likert scale (1 = poor; 3 = excellent). RESULTS: The response rate was 70.3 % (275/391); 179 (65.1 %) of the students were males and 96 (34.9 %), females. Sixty-one (22.2 %) rated the overall quality of their surgery clerkship as excellent (mean rating = 2). Compared with the other three major clerkships, surgery has the lowest rating for overall quality (mean rating: surgery = 2; others = 2.2). Aspects of the clerkship experience that contributed to the overall lower rating of surgery include quality of opportunity to participate in direct patient care; clarity of posting goals and objectives; experience in learning history taking skills, basic physical examination skills, and interpretation of laboratory data; accessibility of faculty; and students' perception that they were treated in a respectful manner. The major suggestions to improve clerkship quality were these: (1) more involvement in direct patient care (n = 154; 56 %), and (2) improvement in student-faculty interaction (n = 9 1; 33.1 %). Overall, 96 (34.9 %) students selected surgery as a specialty, and 39.3 % (108/275) selected the other three major specialties. Surgery was selected by 17/48 (35.4 %), 59/166 (35.5 %), and 20/61 (32.8 %) students who rated the surgery clerkship as "poor," "just right," and "excellent," respectively (p = 0.876). Factors indicated as major influences in the choice of surgical specialty included personal satisfaction 41.7 % (40/96), clerkship experience 36.4 % (35/96), and diligence of faculty 13.5 % (13/96). CONCLUSIONS: Periodic assessment of the satisfaction of medical students regarding their surgical clerkship experience is important. In our setting, we have identified aspects of the surgical clerkship that could be improved to enhance the quality of the experience, ensure the attractiveness of the field to the most qualified candidates, and boost interest in surgery as a career.

The utility of ultrasonography in the management of undescended testis in a developing country.

BACKGROUND: The use of ultrasonography to localize the testis in children with undescended testis is still controversial. This study was designed to determine the value of ultrasound in the preoperative assessment of children with undescended testis in a resource-limited setting. METHODS: A retrospective evaluation of all boys undergoing operation for undescended testes at the University of Nigeria Teaching hospital Enugu from June 2005 to December 2009 was performed. The operative findings were compared with the preoperative findings on clinical and ultrasound examinations. RESULTS: Overall, 49 boys with 60 undescended testes (unilateral in 38, and bilateral in 11 cases) were operated on during the study period. The median age of the patients was 5 (range, 1-14) years. At operation, 39 (65%) testes were located at the inguinal region, 17 (28.3%) were intra-abdominal, and 4 (6.7%) were vanishing testes. Of the inguinal testes, 30 (77%) were clinically palpable, and 38 (97.4%) accurately localized by ultrasound (p = 0.006). The intra-abdominal testes, the vanishing testes, and one inguinal testis were not identified with ultrasound. However, two testes identified as inguinal by ultrasound were found intraabdominal at operation, and two of the vanishing testes were recognized as viable testes by ultrasound. CONCLUSIONS: Ultrasound may identify some otherwise nonpalpable inguinal testes and hence affect therapeutic approach. It may, however, be unhelpful in truly abdominal and vanishing testes.

Neurological disease burden in two semi-urban communities in South East Nigeria.

BACKGROUND: Neurological disorders are a significant cause of morbidity and mortality worldwide. Urban hospital-based studies give some perspectives on the burden of neurological disease but there are no community-based studies from South East Nigeria. AIM: This study sought to screen for the scope and pattern of neurological dysfunction affecting inhabitants of two semi-urban communities in Enugu, South East Nigeria. METHODS: A descriptive, cross-sectional, questionnaire-based study of inhabitants living in Alfred Camp and Udi Siding communities in Enugu was carried out in March 2008. Using a structured questionnaire, house-to-house interview of the residents was conducted by doctors trained for this purpose. Residents' knowledge and experience of clinical features that suggest neurological dysfunction were ascertained. Informed consent was obtained and ethical approval obtained from the Ethics Committee of the University of Nigeria Teaching Hospital Enugu. Data obtained was analyzed using SPSS version 13.5. RESULTS: Completed questionnaires were 239 in number. There were 138 males and 101 females with age range of 18-75 years. Most respondents, 127 (53.1%), were aged 21-30 years. Pain syndromes were most commnon with headache, low back pain and neuropathic pain accounting for the top 3 neurological disorders. CONCLUSION: This study has suggested that pain syndromes affect large numbers of people ordinarily resident in semi-urban communities in Enugu, South East Nigeria. These syndromes have an effect on quality of life. There is need for further large scale studies as well as increased public health strategies for addressing neurological diseases including pain disorders.

Spontaneous scrotal enterocutaneous fistula: a case report and review of literature.

BACKGROUND: Spontaneous scrotal enterocutaneous fistula (SSECF) is a rare entity both in our local and international literature. No report of such has emanated from south eastern Nigeria. METHOD: The case note of the patient was retrieved and relevant data extracted and summarized. An extensive pubmed search was done and results reviewed and compared with the present case. RESULT: The case report of the successful surgical management of a 7 week male who developed right hemiscrotal SSECF as a result of neglected, irreducible right inguinoscrotal hernia is outlined. A review current literature is also highlighted. CONCLUSION: Spontaneous scrotal enterocutaneous stula is a very rare complication of neglected, educible, strangulated inguinoscrotal hernia. Treatment is invariably inguinal exploration, excision of iseased bowel with end to end anastomosis. Early detection and early repair policy will prevent this.

Childhood intussusception: the implications of delayed presentation.

BACKGROUND: In some developing countries, many children with intussusception are reported to present late for definitive therapy. This study determines the effect of delayed presentation on clinical parameters, management, and outcome of childhood intussusception in southeast Nigeria. METHODS: Comparative analysis of 87 consecutive children with intussusception managed from January 1998 to December 2007 at the University of Nigeria Teaching Hospital, Enugu, was done. RESULTS: Overall, the mean time from onset to presentation was 3.0 days (range 4 hours to 7 days). Thirteen (14.9%) presented within 24 hours of symptoms (group 1) and 74 (85.1%) presented after 24 hours (group 2). Clinical presentations were similar in the children with the exception of bilious vomiting, rectal bleeding, and abdominal distension which were significantly commoner in group 2 children (P < 0.05). Type of intussusception found at operation did not differ in the groups, but cases in group 2 had higher incidence of bowel complications, and greater risk of failed operative reduction and bowel resection than group 1 patients (P < 0.05). Though the postoperative complications did not differ significantly between the two groups, mortality directly related to intussusception occurred only in patients who presented after 24 hours. CONCLUSION: Significant number of children with intussusception in our setting presented late for definitive treatment. These cases have a higher risk of bowel complications and intestinal resection. Outcome in these patients might be enhanced through improved perioperative care in the short term, or by improving access to, and reducing delays in seeking health care, in the long run.

Problems and outcome of Hirschsprung's disease presenting after 1 year of age in a developing country.

BACKGROUND: The purpose of the present study was to evaluate the problems, treatment outcome, and contributory factors to delayed presentation in Hirschsprung's disease (HD) after 1 year of age in a resource-limited setting. METHODS: This retrospective study included 41 children aged >1 year with HD managed at the University of Nigeria Teaching Hospital, Enugu, in south eastern Nigeria, between January 2000 and June 2009. RESULTS: Complications of HD were evident at presentation in 38 (92.7%) of the 41 children. Late presentation was due to delayed referral in 27 cases (65.9%), parental ignorance in 11 (26.8%), and poverty in 3 (7.3%). The HD was rectosigmoid in 33 patients (80.5%) and was of ultra-short length variety in 8 patients (19.5%). Thirty-five patients (85.4%) required colostomy for decompression, and colostomy-related complications occurred in 24 of them (68.6%). The definitive surgical procedure was a Swenson pullthrough in 34 cases (82.9%) and posterior myectomy in 7 others (17.1%). Twenty patients (48.8%) experienced at least one postoperative complication. After follow-up of 7-64 months (mean: 31 months), 31 (75.6%) patients had a good outcome, 6 (14.6%) had persistent constipation, 3 had (7.3%) incontinence, and one child (2.4%) died from overwhelming infection. CONCLUSIONS: Hirschsprung's disease presenting after 1 year of age may be associated with high colostomy rates and increased morbidity. Continued dissemination of updated information on HD to medical practitioners and a public awareness campaign may improve time to diagnosis.

Management of sexual assault-related large rectovaginal fistula in an eight-year-old.

Rectovaginal fistula may be a complication sexual assault in children. Management of these cases could be daunting with possibilities of significant psychological and physical morbidity. An eight-year-old girl presented with vulvar fecal leakage from a large rectovaginal fistula two weeks after sexual assault. The child was managed by initial diverting colostomy and the fistula repair was carried out via a posterior sagittal approach. This report highlights significance of initial thorough evaluation in cases with suspected traumatic rectovaginal fistula, and demonstrates benefits of posterior sagittal approach in the definitive treatment of large-sized fistula.