Circumcision: perspective in a Nigerian teaching hospital.

BACKGROUND: The practice and pattern of male infants circumcised is influenced by culture, religion and socio-economic classification. The debate about the benefits and risks of circumcision has made a hospital-based practice the most acceptable. OBJECTIVE: The objective of this study is to evaluate the ages, indications, co-morbidity, types and methods of circumcision, usage and mode of anaesthesia and outcome of male circumcision at a tertiary health centre in Nigeria. MATERIALS AND METHODS: A retrospective review of male circumcision in a paediatric surgery unit was done from January 2002 to December 2007. The data was analysed using SPSS software version 15. RESULTS: There were 438 boys with age ranged between 6 days and 10 years (median 28 days, mean 53.6 days standard deviation 74.2). Neonatal circumcision (<29 days) was 201 (46%) and 318 (72.6%) of the children were circumcised by the 3 rd month of live. Religion or tradition were the major indicators in 384 (87.7%) patients while phimosis 38 (8.7%), paraphimosis 4 (1%), redundant post circumcision skin 10 (2.3%) and defective prepuce in 2 (0.5%) were other indications. Plastibel™ (PD) was used in 214 (48.9%), classical circumcision 194 (44.2%), guillotine technique (GT) and Gomco™ 10 (2.3%) cases each while 10 (2.3%) had a refashioning/re-excision post previous circumcision. There was an increase in use of PD, drop in the use of GT; and increase in the number of circumcision done over the years. Only 39.7% had anaesthesia administered and complication rate was 6.7%. CONCLUSION: Neonatal circumcision was highest in the hospital-based circumcision practice, which allowed the expected ideals in the use of devices in a tertiary health centre. However, the low rate of anaesthetic use is unacceptable.

Outcome of management of complicated extragonadal teratoma in a resource poor setting.

BACKGROUND: Extragonadal teratomas (EXGTs) are ubiquitous in the human body; hence, they have varied presentation. In underdeveloped areas presentation and management are affected by socio-economic, cultural and health facilities factors. The aim of this study was to review the outcome of management of complicated EXGT in a tertiary health centre. MATERIALS AND METHODS: A review data of paediatric patients with EXGT was done between January 1999 and December 2012. Variables reviewed were bio-data, mode of presentation and site of tumour, comorbidity, treatments and outcome. The data was analysed with Statistical Package for Social Sciences (SPSS (R)) version 16.0. RESULTS: There were 21 complicated EXGT (77.8%) among 27 children, age ranges from 4 days to 16 years (median = 2 years). Male:Female ratio of 1:2. The complications per region of the body at presentation were cervical 4 (66.7%), mediastinal 2 (100%), abdominal 3 (75%) and sacrococcygeal 12 (75%). The complications were respiratory distress 6, intestinal obstruction 5, faecal incontinence 2, bladder outlet obstruction 3, malignant transformation 5, ruptured sacrococcygeal teratoma 2, ulcerated tumour 2, anaemia 3 and malnutrition 3. There were 5 (23.8%) progressive disease post-excision outside our facility. Excision biopsy was successful in 19 (85%) patients two of which had neoadjuvant cytotoxic therapy. Overall mortality was 5 (23.8%) (septicaemia, anaemia, respiratory distress, renal failure) and post-excision mortality was 11.8% (endotracheal tube blockage and progressive disease). CONCLUSION: Delay presentation (due to local belief, ignorance and poverty) malnutrition, sepsis, malignant transformation characterised presentation of children in this study and the lack of paediatric intensive care unit facility and intensivists compromised survival of children with EXGT.

Outcomes of surgical treatment of malrotation in children.

BACKGROUND: Abnormalities of rotation and fixation of the intestines are of intense interest to the pediatric surgeon, as they are frequently associated with volvulus which has catastrophic consequences when diagnosis is delayed or not even considered. This study evaluates the outcomes of surgical management of intestinal malrotation (IM) in children. MATERIALS AND METHODS: The medical records of all patients with symptomatic malrotation, who underwent surgery between January 2000 and September 2009, were reviewed. Patients' characteristics, management, complications, and survival were evaluated. RESULTS: Nine patients (eight boys and a girl) underwent surgery for malrotation at a median age of 15 days. Eight presented with acute symptoms and one with chronic symptoms. All the patients had symptoms of intermittent or complete upper intestinal obstruction, and malrotation was documented by an upper gastrointestinal contrast study in two of them. Volvulus was found at the time of surgery in seven patients, five of whom were neonates. One patient also had associated mesentery cyst. Seven patients were treated by Ladd's operation. One patient with massive bowel gangrene due to volvulus had right hemicolectomy. There was one perioperative death from anastomostic leak. Median length of stay was 9 days. Postoperative bowel obstruction was seen in two patients (one died), resulting in an overall mortality of 22.2%. CONCLUSIONS: Bowel gangrene from volvulus contributes to mortality, and small bowel adhesive intestinal obstruction is a cause of morbidity and mortality following surgery for IM. Neonates with bilious vomiting should raise the suspicion of malrotation until proven otherwise and given prompt intervention. There is a need for high index of suspicion in babies with bilious vomiting especially when recurrent to prevent devastating complications when present.

Outcomes of surgical treatment of malrotation in children

Background: Urethral mucosal prolapse is rare. This condition may be confused with tumour or sexual abuse in girls. This study aims at reporting the pathology presentation and therapeutic options of urethral prolapse in girls. Materials and Methods: A retrospective study was undertaken from January 2000 to December 2008. Authors analysed the clinical features and the treatment options. Results: There were nine cases of urethral prolapse. The ages ranged from 2.5 to 10 years (mean age: 5.08 years). The main presentation was vaginal bleeding (five cases). Physical examination revealed a soft; non-tender mass that bleeds on touch (six cases); with a length ranging from 0.75 to 1 cm. Urine culture in four patients revealed urinary infection that yielded Escherichia coli in three cases and the Staphylococcus aureus in one case. Six patients had surgical treatment while three had medical treatment. In those who had surgery; one had acute urine retention and one had recurrence that was treated successfully without operation. All the nine girls are cured. Conclusion: Urethral prolapse is a disease of the prepubertal girls of low socio-economic group. Diagnosis is clinical. The treatment of choice is surgical

Pediatric day case surgery: experience from a tertiary health institution in Nigeria.

BACKGROUND: The general observation that children achieve better convalescence in the home environment supports the need for adoption of day case surgery, which is gaining considerable acceptance in developing countries. Pediatric surgical service is in great demand in developing countries, and in-patient beds and surgical supplies are insufficient. METHOD: A prospective collection of data on all pediatric day surgeries (PDSs) by the pediatric surgical unit University of Ilorin Teaching Hospital (UITH, Ilorin, was done. Parents had pre-operative outpatient briefing and postoperative interviews on the second and ninth days for consultation regarding post-operative complications and events at home. Study period was between April 2005 and September 2007 (2(1/2) years). RESULTS: Of the 660 elective cases, 449 (68.02%) children were recruited as day cases. The male-to-female ratio was 14.3:1. Age ranged between 20 days and 15 years with a mean of 37.6 months and standard deviation (SD) of 34.4 months. Congenital hernias/ hydroceles were the highest indications (71.2%), followed by lump/ masses (12.9%), undescended testes (8.7%), umbilical hernias (4.8%) and thyroglossal duct cyst (2.5%). In 98.9% of cases, the parents resided within 20 km radius of the hospital, and 91.5% of them could reach the hospital within 1 hour. Fathers and mothers of 80.1% and 77.1% of children, respectively, had above-primary education. More than half of the fathers (55%) were civil servants, while 30% were self-employed. The mothers were civil servants in 37.3% of cases, and 34% were self-employed. The average number of outpatient clinic visits before surgery was 2-3 visits (41.2%) with mean interval to surgery of 4-5 weeks (60.3%). Logistics (investigations and availability of operation list) and patient's fitness for surgery were statistically significant delay factors (P= 0.001). CONCLUSION: Parents reported 14 children to be irritable at home due to pain, while the others reported satisfactory day case experience. No unplanned admission or mortality was recorded, and only 3 (0.8%) parents would not recommend day case surgery to other people. CONCLUSION: Pediatric day case surgery is feasible for well-selected and monitored cases in our environment. Term neonates with informed parents are suitable for pediatric day case surgery. There is a need for a day case center to reduce waiting list at UITH.

Bowel resection in Nigerian children.

BACKGROUND: Although bowel resections are commonly done for congenital malformations in children in developed countries, they usually follow neglected and preventable acquired diseases of the intestine in developing countries. OBJECTIVES: To determine the indications and outcome of bowel resections in children of a developing country in a university teaching hospital. MATERIALS AND METHODS: Data of the patients operated (from birth to 15 years) was retrospectively collected over eight years (January 1999 to December 2006). The biodata of children included the following: Indications for operation, type of operations, duration of admission, and outcome of treatment including complications. Patients with Hirschsprung's disease were excluded from the study because bowel resection forms part of their definitive surgical management. RESULTS: There were 70 patients (38 boys and 32 girls). The age ranged between four hours to 15 years (median, five months). There were 16 (22.9%) neonates, 26 (37.1%) infants, and 28 (40%) grown children. The indications were congenital anomalies in the 16 neonates. Also, 23 (88.5%) infants had intussusception, 2 (7.7%) had midgut vovulusm and 1 (3.8%) had congenital small intestine band. Among the grown children, typhoid ileal perforation (TIP) was seen in 14 (50.0%), intussusception in 5 (17.9%), and other causes in nine patients. Overall, intussusception was the most common indication for bowel resection, followed by TIP. A total of 24 patients developed 33 complications. Complications included wound infection in 47.8% and anastomotic leak in 42.8%. The duration of admission ranged between 4-35 days (median, 15 days). The overall mortality was 17.1% -; which was highest among neonates (56.3%), followed by the infants (26.9% -). CONCLUSION: Bowel resections are mainly done for intussusception and complications of TIP at our centre. Late presentation, preexisting malnutrition, and nonavailability of parenteral nutrition contributed to unacceptable morbidity and mortality.

Pyogenic liver abscess in children: is ruptured appendix still relevant as cause? Case report.

Pyogenic liver abscess [PLA] is a rare and life-threatening disease in children. Appendicitis was the leading source of PLA in the pre-antibiotic era, but it essentially has been eliminated in recent times. Most patients with persistent fever after exploratory laparatomy for perforated appendicitis are often found to have residual abdominal collection. We report a 12-year old girl with PLA after laparotomy for perforated appendix. She developed persistent fever and respiratory distress post operatively. Physicians had an impression of pneumonia but abdominal ultrasound showed cystic mass with mobile internal echoes within the right lobe of the liver suggesting an abscess. Patient was successfully managed by percutaneous drainage under ultrasound guidance. Culture of the pus yielded no growth. She was discharged after 7 weeks of hospital stay. Aetiology, evaluation and treatment modalities were reviewed.

Bowel resection in Nigerian children

Background : Although bowel resections are commonly done for congenital malformations in children in developed countries; they usually follow neglected and preventable acquired diseases of the intestine in developing countries. Objectives : To determine the indications and outcome of bowel resections in children of a developing country in a university teaching hospital. Materials and Methods: Data of the patients operated (from birth to 15 years) was retrospectively collected over eight years (January 1999 to December 2006). The biodata of children included the following: Indications for operation; type of operations; duration of admission; and outcome of treatment including complications. Patients with Hirschsprung's disease were excluded from the study because bowel resection forms part of their definitive surgical management. Results : There were 70 patients (38 boys and 32 girls). The age ranged between four hours to 15 years (median; five months). There were 16 (22.9) neonates; 26 (37.1) infants; and 28 (40) grown children. The indications were congenital anomalies in the 16 neonates. Also; 23 (88.5) infants had intussusception; 2 (7.7) had midgut vovulusm and 1 (3.8) had congenital small intestine band. Among the grown children; typhoid ileal perforation (TIP) was seen in 14 (50.0); intussusception in 5 (17.9); and other causes in nine patients. Overall; intussusception was the most common indication for bowel resection; followed by TIP. A total of 24 patients developed 33 complications. Complications included wound infection in 47.8and anastomotic leak in 42.8. The duration of admission ranged between 4-35 days (median; 15 days). The overall mortality was 17.1-; which was highest among neonates (56.3); followed by the infants (26.9-). Conclusion : Bowel resections are mainly done for intussusception and complications of TIP at our centre. Late presentation; preexisting malnutrition; and nonavailability of parenteral nutrition contributed to unacceptable morbidity and mortality

Pediatric day case surgery: Experience from a tertiary health institution in Nigeria

Background : The general observation that children achieve better convalescence in the home environment supports the need for adoption of day case surgery, which is gaining considerable acceptance in developing countries. Pediatric surgical service is in great demand in developing countries, and in-patient beds and surgical supplies are insufficient. Method : A prospective collection of data on all pediatric day surgeries (PDSs) by the pediatric surgical unit University of Ilorin Teaching Hospital (UITH, Ilorin, was done. Parents had pre-operative outpatient briefing and postoperative interviews on the second and ninth days for consultation regarding post-operative complications and events at home. Study period was between April 2005 and September 2007 (2½ years). Results : Of the 660 elective cases, 449 (68.02%) children were recruited as day cases. The male-to-female ratio was 14.3:1. Age ranged between 20 days and 15 years with a mean of 37.6 months and standard deviation (SD) of 34.4 months. Congenital hernias/ hydroceles were the highest indications (71.2%), followed by lump/ masses (12.9%), undescended testes (8.7%), umbilical hernias (4.8%) and thyroglossal duct cyst (2.5%). In 98.9% of cases, the parents resided within 20 km radius of the hospital, and 91.5% of them could reach the hospital within 1 hour. Fathers and mothers of 80.1% and 77.1% of children, respectively, had above-primary education. More than half of the fathers (55%) were civil servants, while 30% were self-employed. The mothers were civil servants in 37.3% of cases, and 34% were self-employed. The average number of outpatient clinic visits before surgery was 2-3 visits (41.2%) with mean interval to surgery of 4-5 weeks (60.3%). Logistics (investigations and availability of operation list) and patient's fitness for surgery were statistically significant delay factors (P= 0.001). Conclusion : Parents reported 14 children to be irritable at home due to pain, while the others reported satisfactory day case experience. No unplanned admission or mortality was recorded, and only 3 (0.8%) parents would not recommend day case surgery to other people. Conclusion: Pediatric day case surgery is feasible for well-selected and monitored cases in our environment. Term neonates with informed parents are suitable for pediatric day case surgery. There is a need for a day case center to reduce waiting list at UITH

Typhoid intestinal disease: 32 perforations in 1 patient.

Typhoid intestinal perforation is a common complication of typhoid fever in our environment. The occurrence of multiple intestinal perforations that involves both small and large bowel is increasingly being seen in our practice. We report a case of 32 intestinal perforations in a child. This is the highest number of perforations seen in any 1 patient in our search of the English literature. This article details our approach to management of this type of patient.

New method of hand anastomosis to complete the Duhamel operation for Hirschsprung's disease.

OBJECTIVE/PURPOSE: This paper describes a new method of hand anastomosis to complete the Duhamel operation for Hirschsprung's disease (HD). METHODOLOGY: All patients had diagnosis of Hirschsprung's disease confirmed by rectal biopsy and had defunctioning colostomy. At the definitive operation, the ganglionic bowel was brought down in a retro-rectal position and anastomosed at the anal canal just above the dentate line. At this anastomosis, the sutures at 11 and 1 o'clock were left long as stay sutures. An incision was then made down the new bowel at the antimesenteric border from the pelvic brim. Another incision was made down the back of the native rectum. A long-curved artery forceps was then passed into the incision in the native rectum out of the anal canal. This forceps was now hooked round the anastomosis at 12 o'clock and further pushed in until the point appears through the colotomy in the ganglionic bowel. The two layers of bowel between the forceps were incised. The forceps was now inserted to grab the long sutures at 11 o'clock and 1 o'clock in turn, and delivered through the pelvis. Anastomosis between the edges of the native rectum and the neorectum was then done with interrupted PDS inside and silk outside. RESULTS: Seven patients had the procedure done. Age ranged between 4 months and 4 years (mean 3.4 years). They were all males. One patient died early in the series from reaction to postoperative analgesia. Four older patients have bowel motions 2-3 times per day, do not soil at night, and are fully continent. CONCLUSION: This preliminary study shows that hand anastomosis could be used to complete Duhamel operation for patients with HD with satisfactory early results.

One-stage correction of intermediate imperforate anus in males.

This prospective study was designed to assess the safety, cost-effectiveness, and advantages of performing posterior sagittal anorectoplasty (PSARP) without colostomy on males with intermediate imperforate anus in a developing country. Fifteen consecutive males with intermediate imperforate anus were entered into the study. Chest and abdominal x-rays, skeletal surveys, renal ultrasound scans, and invertograms were done. Patients were resuscitated and Pena's PSARP done in prone positions. A 2-ml syringe vent was inserted into the new anus for 10 days. Babies were nursed prone postoperatively. Cephalosporin and metronidazole were given as perioperative antibiotics. All patients had intermediate anomalies. There were no other major associated congenital anomalies. A urethral catheter could not be inserted in one patient, and one patient who presented with septicemia and jaundice was deemed too ill to withstand a major operation; these two patients therefore had diverting colostomies. There were no problems with PSARP in the other 13 patients. One patient's father discharged him against medical advice on the 5th postoperative day; the mother had had postpartum hemorrhage, so they opted for traditional treatment because they could not provide blood donors. The skin wounds of 10 patients healed completely with removal of stitches; two boys had superficial wound infection. Parents who lived far from the hospital were taught how to dilate the anus. Follow-up has ranged between 3 months and 2 years. This prospective study shows that it is feasible for males with intermediate imperforate anus to have safe PSARP without colostomy. The advantages of one instead of three major operations are many, especially in developing countries. If this result can be reproduced in cases of high anomalies, colostomy may be unnecessary in many cases of anorectal malformations, with many benefits to these children and their families.

One-stage correction of imperforate anus and rectovestibular fistula in girls: Preliminary results.

BACKGROUND/PURPOSE: This prospective study was designed to assess the safety, cost effectiveness, and advantages of performing posterior sagittal anorectoplasty without colostomy on girls with imperforate anus and rectovestibular fistula. METHODS: Four girls with imperforate anus and rectovestibular fistula were entered into the study. Chest x-ray, renal ultrasound scan, and lateral fistulogram were done. Rectal pouches were washed through the fistula with NaCl and aqueous povidone-iodine solutions. Peña's posterior sagittal anorectoplasties were done in the prone positions. Cephalosporin and metronidazole were given as perioperative antibiotics. RESULTS: All patients had intermediate anomalies. There were no other major associated congenital anomalies. Washout through the fistula was easy. There were no particular problems with posterior sagittal anorectoplasty in the prone positions. Two patients had perianal skin excoriations; one had superficial infection of the posterior sagittal wound. Two patients have undergone follow-up for a year. All are having monthly dilatations. All patients pass stool without need of stool softeners or enemas. CONCLUSIONS: This preliminary study shows that it is feasible for girls with imperforate anus and rectovestibular fistula to have safe posterior sagittal anorectoplasty without colostomy. The advantages of one, instead of 3 major operations, are many, especially in developing countries.

Typhoid ileal perforation in Nigerian children: an analysis of 106 operative cases.

Typhoid ileal perforation (TP) is a major problem in developing countries and carries a high mortality. The purpose of this retrospective study from Nigeria was to review the outcome in children less than 15 years of age who underwent surgery for TP from 1984 to 1999. Demographic data, clinical features, results of investigations, findings at surgery, postoperative course, and complications were recorded. There were 55 boys and 51 girls. The median age at presentation was 10 years (range 3-14). The surgically confirmed perforation rate was 11.0%. The clinical features in children older than 5 years were similar to already documented patterns in the literature. In children less than 5 years old the predominant symptoms were fever and vomiting only. Therefore, in the very young a high index of suspicion is required to avoid delay in diagnosis. Ninety eight patients (92.5%) had simple double-layer closure of the perforation. The mean hospital stay among survivors was 23.6 +/- 18.8 days. The commonest postoperative complications were wound infection and enterocutaneous fistula. The overall mortality was 23.8%, increasing to 50% in children aged less than 5 years, although the difference was not statistically significant (P > 0.05). To improve survival in TP, attention should be focused on perioperative resuscitation and early intervention. The provision of potable water, adequate sanitation, and active immunisation are means to eradicate the disease.