Prognostic Factors in the Management of Empyema Thoracis in Northern Nigeria.

Background: Empyema thoracis portrays pleural effusion with demonstrable actively multiplying bacteria. It is a significant cause of morbidity, and commonly complicates parapneumonic effusions. It is important to identify those factors that can be used to prognosticate the outcome of its management in our locality so that those that are modifiable could be applied to improve management outcomes. Materials and Methods: A prospective cohort study of patients managed for empyema thoracis at the Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria from February 2017 to January 2018 was conducted. Eighty-three patients were enrolled for this study and recruitment into the study included all consecutive patients being managed for empyema thoracis in ABUTH, Zaria during the study period. Data collected included age, gender, aetiology, microbial isolates, BMI, initial and total empyema volumes, and duration before hospital presentation. The patients were subsequently managed and observed, and the outcome of management (duration of drainage and hospital stay, percentage of lung expansion, and need for decortication) was noted. Results: Patients in the paediatric age group correlated positively with an earlier presentation to the hospital. The duration before presentation correlated positively with the stage of the disease. The duration before presentation and the total empyema volume indexed to body surface area could prognosticate all four outcome parameters assessed. The age and stage of the disease prognosticated the lung expansion and the need for decortication. The initial empyema volume indexed to body surface area prognosticated the length of hospital stay. The presence of complications was a determinant of the need for decortication. Adolescents and adults had 2.1 times increased probability of requiring a decortication for successful management. Conclusion: The age, stage of the disease, duration before presentation, initial empyema volume indexed to body surface area, and total empyema volume indexed to body surface area can be used to prognosticate the outcome of empyema thoracis. With the onset of complication comes a higher chance of requiring decortication. Children are less likely to require decortication for satisfactory management of empyema thoracis.

Initial Experience with Central Venous Line Insertion in a Tertiary Health Institution in Nigeria.

BACKGROUND: Central venous catheterization is an uncommon procedure in most hospitals in the West African subregion. This article presents our initial experience with central line insertion. MATERIALS AND METHODS: Catheter sizes ranged from 5 fr for children and 7 fr for adult for intravenous therapy, while size 7 fr polyurethane catheters were used for children requiring hemodialysis and sizes 12-14 fr silicone catheters for adolescents and adults requiring hemodialysis'. Data were collected prospectively using a structured pro forma over a 2-year period (June 2010-May 2012) and analyzed with SPSS 15. RESULTS: A total of 77 lines were inserted four as tunneled lines and 73 as nontunneled lines. Forty-seven (61.0%) patients were male, 30 (39.0%) were female, with age range of 1-80 years. The success rate was 97.4%. The overall complication rate was 16.9%. CONCLUSION: Our initial experience with the use of central venous lines, was marked by a high success rate, few manageable complications and no mortality over the study period. Majority of insertions were done by the bedside under local anesthesia lending credence to the assertion that it is a relatively safe procedure that can be done by any adequately trained doctor and should, therefore, be encouraged in our hospitals.

Initial experience with central venous line insertion in a tertiary health institution in Nigeria

Background: Central venous catheterization is an uncommon procedure in most hospitals in the West African subregion. This article presents our initial experience with central line insertion. Materials and Methods: Catheter sizes ranged from 5 fr for children and 7 fr for adult for intravenous therapy, while size 7 fr polyurethane catheters were used for children requiring hemodialysis and sizes 12­14 fr silicone catheters for adolescents and adults requiring hemodialysis'. Data were collected prospectively using a structured pro forma over a 2-year period (June 2010­May 2012) and analyzed with SPSS 15. Results: A total of 77 lines were inserted four as tunneled lines and 73 as nontunneled lines. Forty-seven (61.0%) patients were male, 30 (39.0%) were female, with age range of 1­80 years. The success rate was 97.4%. The overall complication rate was 16.9%. Conclusion: Our initial experience with the use of central venous lines, was marked by a high success rate, few manageable complications and no mortality over the study period. Majority of insertions were done by the bedside under local anesthesia lending credence to the assertion that it is a relatively safe procedure that can be done by any adequately trained doctor and should, therefore, be encouraged in our hospitals

Sensitivity of Computed Tomography-guided Transthoracic Biopsies in a Nigerian Tertiary Institution.

INTRODUCTION: The indications for open biopsies for intrathoracic lesions have become almost negligible. This development was made possible by less invasive maneuvers such as computed tomography-guided (CT-guided) biopsy, thoracoscopy or video-assisted thoracoscopy, and bronchoscopy. CT-guided percutaneous lung biopsy was first reported in 1976. AIM OF STUDY: The aim of the study is to report our experience with CT-guided transthoracic biopsy. MATERIALS AND METHODS: Patients with clinical and radiological evidence of intrathoracic mass were counseled and consent obtained for the procedure. They were positioned in the gantry, either supine or prone. A scout scan of the entire chest was taken at 5 mm intervals. The procedure was carried out by the consultants and senior registrar. Following visualization of the lesion, its position in terms of depth and distance from the midline was measured with the machine in centimeter to determine the point of insertion of the trucut needle (14-18-G). The presumed site of the lesion was indicated with a metallic object held in place with two to three strips of plasters after cleaning the site with Povidone-iodine. After insertion, repeat scans were performed to confirm that the needle was within the mass. A minimum of 3 core cuts was taken to be certain that the samples were representative. The results were analyzed by the determination of means and percentages. RESULTS: Twenty-six patients underwent this procedure between 2011 and 2015. There were 15 males and 11 females (M:F = 1.4:1). The age range was between 30 and 99 years with a mean of 55 years. Histological diagnosis was obtained in 24 of the patients giving sensitivity of 92.3%. There were 3 mild complications giving a rate of 11.5%. The complications included a case of mild hemoptysis and two patients who had mild pneumothoraces which did not require tube thoracostomy. CONCLUSION: CT-guided biopsy is a reliable procedure for obtaining deep-seated intrathoracic biopsies with high sensitivity and minimal complication rate.

Sensitivity of computed tomography-guided transthoracic biopsies in a Nigerian tertiary institution

Introduction: The indications for open biopsies for intrathoracic lesions have become almost negligible. This development was made possible by less invasive maneuvers such as computed tomography-guided (CT-guided) biopsy, thoracoscopy or video-assisted thoracoscopy, and bronchoscopy. CT-guided percutaneous lung biopsy was first reported in 1976. Aim of Study: The aim of the study is to report our experience with CT-guided transthoracic biopsy. Materials and Methods: Patients with clinical and radiological evidence of intrathoracic mass were counseled and consent obtained for the procedure. They were positioned in the gantry, either supine or prone. A scout scan of the entire chest was taken at 5 mm intervals. The procedure was carried out by the consultants and senior registrar. Following visualization of the lesion, its position in terms of depth and distance from the midline was measured with the machine in centimeter to determine the point of insertion of the trucut needle (14­18-G). The presumed site of the lesion was indicated with a metallic object held in place with two to three strips of plasters after cleaning the site with Povidone-iodine. After insertion, repeat scans were performed to confirm that the needle was within the mass. A minimum of 3 core cuts was taken to be certain that the samples were representative. The results were analyzed by the determination of means and percentages. Results: Twenty-six patients underwent this procedure between 2011 and 2015. There were 15 males and 11 females (M:F = 1.4:1). The age range was between 30 and 99 years with a mean of 55 years. Histological diagnosis was obtained in 24 of the patients giving sensitivity of 92.3%. There were 3 mild complications giving a rate of 11.5%. The complications included a case of mild hemoptysis and two patients who had mild pneumothoraces which did not require tube thoracostomy. Conclusion: CT-guided biopsy is a reliable procedure for obtaining deep-seated intrathoracic biopsies with high sensitivity and minimal complication rate

Vascular surgeries in West Africa: challenges and prospects.

BACKGROUND: The field of vascular surgery is evolving in sub-Saharan Africa but the practice is bedeviled by lack of expertise and infrastructure challenges. The consequences are a low volume of operations and a dearth of data. Available data are not representative of the wider picture, therefore, this study was undertaken to evaluate the practice of vascular surgery in a tertiary institution, in the light of the prevailing challenges. METHODS: Data from all patients with vascular-related pathologies managed in our surgical outpatient clinic and accident and emergency wards were obtained from the clinic and in-patient records from January 2008 to December 2012. Age, sex, diagnosis, treatment, and complications were noted. There were 73 patients comprising 45 (61.6%) males and 28 (38.4%) females. The age range was 1-90 years (mean 43.5 years). RESULTS: The pathologies managed included end-stage renal disease (n = 36, 49.3%), nontraumatic and posttraumatic aneurysms (n = 13, 17.8%), vascular trauma (n = 12, 16.4%), peripheral vascular disease (n = 5, 6.9%), congenital vascular malformations (n = 4, 5.5%), and thrombotic diseases (n = 3, 4.1%). Fifty-four (74.0%) surgeries were performed, with a complication rate of 5.5% and 2.7% mortality. CONCLUSIONS: The practice of vascular surgery in Zaria, Nigeria, is fraught with challenges. The gap created by the dearth of skilled vascular surgeons is filled by competent cardiothoracic surgeons. Infrastructure decay and lack of prostheses limit the number and variety of operable cases. These challenges result in preventable morbidity and mortality.

Indications and complications of tube thoracostomy with improvised underwater seal bottles.

BACKGROUND: Tube thoracostomy is a lifesaving and frequently performed procedure in hospitals where the expertise and necessary tools are available. Where the ideal drainage receptacle is unavailable, the underwater seal device can be improvised with bottled water plastic can especially in emergency situations. AIMS AND OBJECTIVES: To determine the frequencies of the various indications and complications of tube thoracostomy with improvised underwater seal. MATERIALS AND METHODS: A cross-sectional study with a structured proforma was used for assessment over a 3-year period (May 2010-April 2013). The proforma was filled at the time of the procedure by the performing surgeon and patients were followed up with serial chest X-rays until certified cured. A 1.5 L bottled water container was used as the underwater seal receptacle. The data was analysed with SPSS 15 software program. RESULTS: A total of 167 patients were managed. There were 106 (63.5%) males and 61 (36.5%) females. The mean age was 34.85 ± 16.72 with a range of 1-80 years. The most frequent indication was for malignant/paramalignant effusion, 46 (27.5%). Others were trauma, 44 (26.3%), Parapneumonic effusion, 20 (12%), postthoracotomy 14 (8.4%), empyema thoracis 12 (7.2%), heart disease and tuberculous effusion 11 (6.6%) each, pneumothorax 8 (4.8%) and misdiagnosis 1 (0.6%). A hundred and one (60.5%) of the procedures were performed by registrars, 41 (24.6%) by consultants, house officers 15 (9%) and senior registrars 10 (6%). The overall complication rate was 16.8% with the more frequent complications been empyema (5.6%) and pneumothorax (3.6%). The average duration of tube placement was 13.02 ± 12.362 days and range of 1-110 days. CONCLUSION: Tube thoracostomy can be a relatively safe procedure with acceptable complication rates even with improvised underwater seal drainage bottles.

Zaria universal oxygenator holder phase I.

INTRODUCTION: The conduct of cardiopulmonary bypass surgery requires the use of equipment and devices like the oxygenator. The oxygenator comes in different makes and each manufacturer customizes the carrier or 'holder' of this device specific to their design. AIM: This paper presents an innovation designed to overcome the need to purchase a different holder for every oxygenator thereby cutting the cost. MATERIALS AND METHODS: A sheet of iron measuring 1.9 cm (width) × 0.1 cm (thickness) was used to design the holder circular main frame. Another sheet measuring 2 cm (width) × 0.6 cm (thickness) × 24 cm (length) was used to construct a V-shaped handle with the arms of the V attached to the main frame 7 cm apart. At the narrow base of the handle is a latch requiring two 13-gauge screws to attach the holder to the heart-lung machine. Within the circumference of the main frame are four T-shaped side arms which grip the oxygenator; located at 2, 5, 7 and 11 O'clock positions. The stem of the T consist of a 0.6 cm (thickness) × 13 cm (length) rod drilled through the main frame. The cross of the T consists of variable lengths of the same sheet as the mainframe attached to the stem by a screw mechanism. At the base of the T, is attached a circular handle (4 cm in diameter) made of 0.4 cm iron rod. RESULT: An oxygenator holder which weighs 1.75 kg with a total length of 54 cm (the diameter of the mainframe is 30 cm). Its advantages include (i) affordability, (ii) materials are locally accessible, (iii) versatility (iv) reproducibility. The disadvantages include, (i) it requires some time to fit, (ii) caution is required in fitting the oxygenator to avoid breakage, (iii) a spanner is required to lock the latch. CONCLUSION: The concept of a universal holder is pertinent, especially in resource poor environments to avoid purchasing a new holder whenever the usual oxygenator common to the centre is unavailable. This device is amenable to further modifications to meet the unforeseen challenges.

Teaching the surgical craft: surgery residents perception of the operating theater educational environment in a tertiary institution in Nigeria.

BACKGROUND: The transformation of a surgical trainee into a surgeon is strongly influenced by the quality of teaching in the operating theater. This study investigates the perceptions of residents about the educational environment of the operating theater and identifies variables that may improve the operating theater education of our trainees. MATERIALS AND METHODS: Residents in the department of surgery anonymously evaluated teaching in the operating room using the operating theater education environment measure. The residents evaluated 33 variables that might have an impact on their surgical skills within the operating theater. The variables were grouped into four subscales; teaching and training, learning opportunities, operating theater atmosphere and workload/supervision/support. Differences between male and female residents and junior and senior registrars were assessed using Mann-Whitney test. Statistical analysis was completed with the statistics package for the social sciences version 17. RESULTS: A total of 33 residents were participated in this study. Twenty nine (88%) males and 4 (12%) females. 30 (90%) were junior registrars. The mean total score was 67.5%. Operating theater atmosphere subscale had the highest score of 79.2% while workload/supervision/support subscale had the least score of 48.3%. There were significant differences between male and female resident's perception of workload/supervision/support P < 0.05; however, there was no significant differences in junior registrar versus senior registrar's perception of the education environment in all the subscales P > 0.05. CONCLUSION: This study has shown a satisfactory teaching environment based on the existing local realities of means, resources and tools and highlighted the need for improvement in workload/supervision/support in our institution. An acceptable learning environment in the operating theatre will produce surgeons that are technically competent to bridge the gap in the enormous unmet need for surgical care in Nigeria.

Junctional ectopic tachycardia following repair of congenital heart defects-experience in multimodal management from a West African Centre.

BACKGROUND: Postoperative junctional ectopic tachycardia (JET) is a rare and transient phenomenon occurring after repair of congenital heart defects. Report on this arrhythmia in the subregion is rare. We set out to determine the incidence of this arrhythmia and review the treatment and outcomes of treatment in our centre. METHODS: Retrospective search of the records of all patients aged 18 years and below admitted into the intensive care unit (ICU) following repair or palliation of a congenital heart defect over 5 years, from January 1, 2006 to December 31, 2010. A review of clinical notes, operative records, anaesthetic charts, cardiopulmonary bypass (CPB) records, nursing observation charts, electrocardiograms (ECGs) and out-patient follow-up records was undertaken. RESULTS: 510 children under 18 years were enlisted. 7 cases of postoperative JET were recorded, (1.37%). 184 (36.1%) of these were performed under CPB. All JET cases were from cases done under CPB, 3.8%. Median age was 3 years and median weight 11.3 kg. No patient was febrile at diagnosis. 4 patients had amiodarone administration, 5 had magnesium sulphate infusion, 2 patients had direct current shock (DCS) whilst 3 patients had all three therapeutic modalities. All patients had control of the arrhythmia with conversion to sinus rhythm and no recurrence. CONCLUSION: We report a JET incidence of 1.37% among children undergoing CPB for repair of congenital heart defects. We demonstrate the therapeutic effectiveness of amiodarone, magnesium sulphate infusions and DCS alone or in combination in the management of JET on various substrates with good outcome.