INTESTINAL OBSTRUCTION CAUSED BY APPENDICITIS: A SYSTEMATIC REVIEW.

BACKGROUND: The known complications of appendicitis include perforated appendicitis with generalised peritonitis, appendiceal mass, appendiceal abscess, sepsis, adhesion formation and in a few occasions, small bowel intestinal obstruction. AIM: To review published cases of intestinal obstruction due to appendicitis with a view to better understand the pathophysiology of this complication. METHODOLOGY: A search of the literature in the MEDLINE database, using PubMed and OvidSP, Scopus, Google Scholar and Cochrane Databases with the following MeSH terms: (Appendicitis or appendiceal mass, appendiceal abscess or appendiceal adhesion band) and (intestinal obstruction, intestinal herniation, intestinal strangulation, intestinal knotting and paralytic ileus) was done. Also, these searches were restricted according to the following MeSH limits: (a) January 1, 1950 to July 31, 2016, (b) English articles (c) Human. RESULTS: Overall, 27 articles reported 45 patients with intestinal obstruction due to appendicitis. Of the 30 (66.7%) patients that the gender was indicated, 22 (48.9%) were male while 8 (17.8%) were female. In 38 (84.4%) cases the cause was mechanical obstruction resulting from one or a combination of the following: (a) appendix laid across loops of bowel bound down by adhesions, (b) herniation through a ring or gap formed by the appendix tip being attached to its base, (c) appendix tip attached to the bowel causing a torsion, (d) kinking of the bowel, (e) complex knotting. Pre-operative diagnosis was a major challenge and so, none was approached through incision based on the McBurney's point.The outcome of treatment which was mostly achieved by immediate appendectomy followed by adhesiolysis was sufficient and often gave good results. CONCLUSION: This study has shown that appendicitis is an important cause of intestinal obstruction. Even though pre-operative diagnosis is still a major challenge, clinical evaluation and a high index of suspicion are key to diagnosis.

Drain Site Hernia: A Review of the Incidence and Prevalence.

BACKGROUND: Surgical drains prevent fluid accumulation such as peritoneal fluid, blood, pus or inflammatory exudates. However, complications may occur. The aim of this study is to review the incidence and prevalence of drain site hernia as a complication of surgical drains. MATERIAL AND METHODS: A search of the literature in the MEDLINE database, using PubMed and OvidSP, Scopus, Google Scholar and Cochrane Databases with the following MeSH terms: (Drain or surgical drain or drainage) AND (drain hernia, drain-site hernia, laparoscopic drain-site hernia)was done. Also, these searches done from 14th-31st Dec 2013 were restricted according to the following MeSH limits: (a) January 1, 1980 to December 14, 2013, (b) English articles (c) Human. RESULTS: Overall, 24 articles had 49 patients with drain site hernias. Of this, 7 (14. 3 %) post open surgery while 42 (85.7 %) post laparoscopic surgery. Seven (14.3 %) occurred immediately after the operation/removal of drain, 10 (20.4 %) several days to 2 week, while 32 (65.3 %) several months to years. Commonest organ of herniation was 13 (26.5 %) small bowel, while morbidities, arising from drain site hernias occurred in 17 (34.7 %) with the highest 7 (14.3 %) due to bowel strangulation. Previous reports have quoted the incidence of drain site hernia to be 3.4% (5 of 148), and 0.14% (8 of 5541). Mortality was extremely low (2.0 %). CONCLUSION: Attention is warranted for drain site hernias as a significant complication following placement of surgical drain. Incidence (0.1-3.4 %), though wide range, is quite significant in these patients. Therefore, unwanted surgical drain insertion should be avoided.

Quality of teaching provided by surgical residents: an evaluation of the perception of medical students.

BACKGROUND: Surgical residents teach and interact with Medical students during surgery clerkship. However, the quality of teaching by surgical resident as perceived by medical students has not been assessed in our setting. The aim of this report is to evaluate the quality of teaching provided by surgical residents as perceived by Medical students METHODS: This is a cross sectional study involving final year 2005-2006 medical students ofAhmadu Bello University Zaria, Nigeria. The characteristics and skills of surgical residents' teaching role as perceived by medical students were determined. The Information was obtained using a structured questionnaire. Data obtained was analyzed using SPSS version 11.0 RESULTS: A total of 120 medical students participated in the study. The age range was 24-36 years (mean 26.88 + 2.19). There were 87 (72.5%) males and 33 (27.5%) females. In assessing the qualities of a teacher among surgical residents, 83 (69%) of the students believed the surgical resident has good teaching skills, 101 (84%) believed they were committed to teaching, 118 (98%) they were available, 109 (91%) had inspirational ability. In assessing the qualities of a surgeon, 116 (97%) believed the surgical resident has enthusiasm for surgery, 106 (88%) empathy for patients, 78 (65%) fund for knowledge. Assessment of the qualities of a supervisor revealed 118 (98%) Got medical students involved, hands on, 78 (65%) set fair expectations, 113 (94%) Gave them feedbacks, 118 (98%) supervised them adequately. In term of the qualities of the person 107 (89%) believed a surgical resident is supportive, 94 (78%) considerate, 115 (96%) friendly, 108 (90%) fun to work with. Overall assessment perceived by medical students revealed Senior Registrar having better qualities of teaching than Registrar. These qualities were rated good and outstanding by majority of the medical students. CONCLUSION: Medical students' perception of teaching provided by surgical residents is encouraging in our setting. This emphasizes the important role of the surgical resident in undergraduate medical training. Thus, the teaching skills of surgical residents should be encouraged and sustained.

Management and outcome of gastric carcinoma in Zaria, Nigeria.

INTRODUCTION: Gastric cancer is the second leading cause of cancer death in the world. The objective of this study was to present the clinical evaluation, treatment and outcome of 179 patients with gastric carcinoma in Zaria, Nigeria. METHODS: Patients managed for histologically diagnosed gastric carcinoma were reviewed. The extent of surgical intervention was based on pre-operative and intra-operative staging balanced against the age and overall fitness of the patient. Mortality, morbidity and patient's survival were monitored. RESULTS: There were 179 patients, with a male to female ratio of 1.4:1. Their mean age was 51 ± 6.3. Ten (5.6%) patients presented with early gastric cancer. Overall, 155(86.6%) patients had surgical intervention including gastric resection in 87 (56.1%). Of the gastrectomies , 28.7% were curative (R0). Postoperative complications were seen in 43(27.7%) patients. Postoperative mortality in 25(16.1%) patients was significantly associated with peritoneal metastasis (p<0.001), preoperative comorbidity (p<0.01) and age more than 60 years (p<0.03). The overall median survival was 13.6 months while 70.1% and 21.8% of patients that underwent gastrectomy survived for 1 and 5 years respectively. CONCLUSION: Treatment of gastric cancer should be based on a reasonable choice of operation that must consider not only the survival benefits but also the surgical risks and postoperative quality of life.

Music in the operating theatre: opinions of staff and patients of a Nigerian teaching hospital.

BACKGROUND: The role of music during surgery has been studied, including its effect on theatre staff, users and patients. However, little attention has been paid to its application especially in our environment. METHODS: It was a prospective study, involving theatre staff, users, and patients. Their opinions on acceptability and the role of music in operating theatre were determined. Information was obtained by questionnaire. RESULTS: There were 162 respondents; age range 25 to 76 years (median age 39). There were 109 (67.2%) males and 53 (32.7%) female. One hundred and forty five (89.5%) respondents agree that music should be played in the operating theatre. One fifty eight, (97.5%) considered low tone of music to be most appropriate in the theatre while 3(1.9%), and 1(0.6%) considered moderate and high tone respectively to be most appropriate. One hundred and sixteen, (71.6%) preferred jazz music while 19(11.7%) reggae, 11(6.8%) African music, 13 (8.0%) others (not specify), 2 (1.2%) classical, and 1(0.6%) Irish folk. The majority of the respondents were aware of the role of music in terms of its anxiolytic effect, reduction of stress and enhancement of performance when familiar music is played. CONCLUSION: Music in the operating theatre has immeasurable effects. It can prevent distraction, minimize annoyance, reduce stress and diminish the anxiety of patients, staff and users.

Does general surgery clerkship make a future career in surgery more appealing to medical students?

BACKGROUND: Medical students' decreasing interest in surgical careers has raised much concern. This report is to ascertain the influence of surgical clerkship on the perceptions of medical students on prospects of a future career interest in surgery. METHODS: A cross sectional study, involving final year medical students. Information concerning their interest in a surgical career, what they thought of surgery before and after general surgery clerkship was obtained. RESULTS: A total of 120 medical students participated in the study. The age range was 24 - 36 years (mean 27+2). There were 87 (72.5%) males and 33(27.5%) females. Ten students (8.0%) were interested in surgery before their last surgery clerkship, 18 (15%) Obstetric and Gynaecology, 92(76.6%) others. Those that developed interest in surgery following the clerkship increased to 33 (27.5%) (P<0.001), 34 (28.3%) Obstetric & Gynecology, while other specialties reduced to 53 (44.2%). One hundred and one (84.2%) (M = 71, F = 30) students believe they had identified a role model or a mentor during the clerkship, either a consultant or a resident. Eighty eight (73.3%) (M = 62, F = 26) student who liked and loved surgery at the end of the clerkship identified surgical mentors during their time. CONCLUSION: General surgical clerkship has influence on future career in surgery among medical students. Focused and effective mentoring by faculty as well as early exposure of students to positive role models should help to reverse negative impressions held by students.

Drain site hernia in an adult: a case report.

BACKGROUND: Surgical drains, as useful as they are, have been noted not to be without complications. Small bowel herniation through a previous drain site is a rare complication of abdominal drain insertion. OBJECTIVE: To report a case of strangulated hernia through a drain site. METHODS: A 46-year-old civil servant was referred to our hospital from a general hospital with a two-week history of progressive abdominal pain and bulge in the right lower quadrant. She was evaluated clinically as with an ultrasonography. Results of tests indicated a laparatomy. RESULTS: She had a previous abdominal drain insertion when she had an emergency exploratory laparatomy for perforated typhoid enteritis in the same hospital 20 years prior to presentation. Exploratory laparatomy done revealed gangrenous loops of small bowel that herniated through a previous drain site with interstitial spread. Resection and end-to-end anastomosis was effected and internal end was closed with non absorbable suture (Nylon 1). CONCLUSION: Careful insertion and management of surgical drains are necessary so as to prevent hernia complications.

Mobile caecum and ascending colon syndrome in a Nigerian adult.

A mobile caecum and ascending colon is a rare congenital abnormality. Its presentation as a cause of right lower abdominal pain in an adult is usually mis-diagnosed as acute appendicitis. A 42-year-old civil servant presented with a 2-year history of recurrent right lower quadrant pain of the abdomen. The pain was sharp in nature and persistent in the last 2 weeks and centered mainly in the right side of the abdomen. No other associated symptoms were noted. Laboratory investigations did not reveal obvious abnormality. A diagnosis of acute on chronic lower quadrant pain of unknown etiology was made. The patient was resuscitated and had exploratory laparatomy. No abnormalities were found other than the caecum and the whole ascending colon, which were unattached to the posterior peritoneum. Appendectomy and caecopexy, using a lateral peritoneal flap were performed. The diagnosis of mobile caecal syndrome should be considered in patients with chronic right lower quadrant pain, and appendectomy and caecopexy offers a great relief.

Stress and distress of surgical practice: the trainee's view.

BACKGROUND: Stress is the body's non specific response to any pleasant or unpleasant demand placed upon it. Is surgical practice a stressful profession? METHOD: It's a prospective study, involving surgical residents in sub specialties of surgery. Information was obtained by administered questionnaire. Resident was expected to have spent three months in the surgical field. RESULTS: There were forty one (41) residents; age range was 25 year to 42 year (mean 33.44 +/- 4.81). There were 35 (85.4%) males and 6 (16.6%) females. Thirty eight, (92.7%) of the residents considered surgery to be a stressful profession. Thirty two, (78.1%) considered pediatrics subspecialty to be the most stressful of all. Lack of professionalism and workload were greatest sources of stress in 18 (43.9%) and 11 (26.8%) cases of the residents. In thirty seven, (90.2%) their academic exposures were not adequate. Despite all these short comings, the progress of the training was satisfactory in 26 (63.4%) residents. Thirty seven, (90.2%) of the residents would not specialize in surgery if given a second chance. CONCLUSION: Surgery, as a stressful profession is no longer a debatable issue and a surgical trainee perceives it that way. We recommend that coping mechanisms such as putting appropriate backup support, offer of flexible scheduling to allow time off for critical family and social events are absolutely necessary among our surgical trainees.

Surgical drains: what the resident needs to know.

BACKGROUND: Drains continue to be an important aspect of the management of surgical patients. Its use has been contentious. However, when indicated, it is important that drainage should be practiced with prudence. METHODS: Publications from both local and international journals through Medline, pub med and Google search (June-August, 2007) were reviewed. RESULTS: Drains remove content of body organs, secretion of body cavities and tissue fluids such as blood, serum, lymph and other body fluid that accumulate in wound bed after surgical procedures. Therefore, reduction of pressure to surgical site as well as adjacent organs, nerves and blood vessels, enhances wound perfusion and wound healing. Reduction of pain is also achieved. However, drains are now known not to be innocuous especially when they are poorly selected, wrongly used and left in situ for too long. Essentially, passive and active drains are the most practically useful type. CONCLUSION: Understanding the benefits and applications of surgical drains and tissue responses to constituent material is not only relevant to a practicing surgeon but would help to reduce the abuse of surgical drains.

Surgical Drains: What the Resident Needs to Know

Background: Drains continue to be an important aspect of the management of surgical patients. Its use has been contentious. However; when indicated; it is important that drainage should be practiced with prudence. Methods: Publications from both local and international journals through Medline; pub med and Google search (June-August; 2007) were reviewed. Results: Drains remove content of body organs; secretion of body cavities and tissue fluids such as blood; serum; lymph and other body fluid that accumulate in wound bed after surgical procedures. Therefore; reduction of pressure to surgical site as well as adjacent organs; nerves and blood vessels; enhances wound perfusion and wound healing. Reduction of pain is also achieved. However; drains are now known not to be innocuous especially when they are poorly selected; wrongly used and left in situ for too long. Essentially; passive and active drains are the most practically useful type.Conclusion: Understanding the benefits and applications of surgical drains and tissue responses to constituent material is not only relevant to a practicing surgeon but would help to reduce the abuse of surgical drains

Surgical Drains: What the Resident Needs To Know

Background: Drains continue to be an important aspect of the management of surgical patients. Its use has been contentious. However; when indicated; it is important that drainage should be practiced with prudence. Methods: Publications from both local and international journals through Medline; pub med and Google search (June-August; 2007) were reviewed. Results: Drains remove content of body organs; secretion of body cavities and tissue fluids such as blood; serum; lymph and other body fluid that accumulate in wound bed after surgical procedures. Therefore; reduction of pressure to surgical site as well as adjacent organs; nerves and blood vessels; enhances wound perfusion and wound healing. Reduction of pain is also achieved. However; drains are now known not to be innocuous especially when they are poorly selected; wrongly used and left in situ for too long. Essentially; passive and active drains are the most practically useful type.Conclusion: Understanding the benefits and applications of surgical drains and tissue responses to constituent material is not only relevant to a practicing surgeon but would help to reduce the abuse of surgical drains

Herniated gravid uterus: clinical course and result of treatment.

Herniated gravid uterus in an incisional hernia of the anterior abdominal wall is relatively rare. A 30-year-old house wife presented with a six month gravid uterus that had herniated through an incisional hernia of the anterior abdominal wall. She had non-operative management till term, when she then had elective lower caesarian section. Physiotherapy of the anterior abdominal wall muscles to improve their tone was done. She subsequently had keel's repair of the hernia. Aggressive physiotherapy of the anterior abdominal wall muscles followed by keel's repair may be an alternative surgical technique in patients with a moderate defect of incisional hernia.

Necrotizing fasciitis of the external genitalia following traditional circumcision.

BACKGROUND: Necrotizing fasciitis of the external genitalia is not common in children, and is particularly unusual after circumcision. METHOD: A case report of necrotizing fasciitis of the external genitalia in a one month old boy with discussion of relevant literature. RESULT: A one-month-old boy presented with necrotizing fasciitis of the external genitalia following traditional circumcision. Treatment consisted of early administration of intravenous broad-spectrum antibiotics and debridement. Skin grafting was not necessary as the wound contracted and healed by secondary intention with minimal scarring. CONCLUSION: Early institution of appropriate antibiotics and debridement should prevent morbidity and mortality from this uncommon condition.