One stage procedure in the management of acute sigmoid volvulus without colonic lavage.

BACKGROUND: There is a growing acceptance of one-stage primary resection and anastomosis of left-sided colon obstruction with on-table antegrade colonic lavage to reduce the risk of post-operative infectious complications and anastomotic dehiscence. The purpose of this study was to evaluate the safety of single-stage resection and anastomosis for acute left-sided colonic obstruction due to acute sigmoid volvulus, without intraoperative colonic lavage, in a consecutive series of patients admitted to our department. METHODS: Emergency resection of acute sigmoid volvulus was performed by an experienced senior surgeon (consultant grade). This was followed by primary anastomosis without on-table colonic lavage after a manual decompression. RESULTS: A total of 21 patients underwent bowel decompression, resection and primary colorectal anastomosis. Two of the patients who had ileosigmoid knotting and gangrenous bowel had double resection with primary ileoileal and colorectal anastomosis. There were two superficial wound infections. No death or clinical anastomotic failure were recorded in this series. The mean hospital stay was 10.3 days. CONCLUSION: Our results suggest that resection of acute sigmoid volvulus and primary anastomosis after decompression alone can be carried out safely in reasonably fit patients.

Open versus closed haemorrhoidectomy.

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

Outcome of primary closure of incised acute soft-tissue abscesses.

One hundred and six patients with acute soft tissue abscesses were involved in the study at the Accident and Emergency unit of Jos University Teaching Hospital (JUTH) from June, 1996 to April, 1997. The objective of the study was to assess the outcome of primary closure in the treatment of acute soft tissue abscesses using the healing rate, cost effectiveness, quality of scars and postoperative complications as parameters. The patients were divided into two groups: group A for primary closure, and group B for the conventional method. There was a statistically significant difference (P<0.05) in the healing time for study group A (6.96 +/-123.56) compared with control group B. Similarly group A was more cost effective (Total cost = N406 +/-123.56) compared with control group B (Total cost = N580.47 +/- 174.24). The difference was statistically significant (P

Open haemorrhoidectomy revisited.

The open method of haemorrhoidectomy has been criticized because of slow wound healing, severe pain and prolonged post operative care. This has led to a shift of interest to other methods of haemorrhoidectomy. These grounds of criticism need to be re-appraised for a rational conclusion and recommendation. Thirty nine consecutive patients who had open haemorrhoidectomy between 2nd and 3rd degree haemorrhoids from May, 1998 to April, 1999 were prospectively assessed for wound healing rate and complication rate. There were 26 males and 13 females (ratio 2:1). The average length of hospital stay was 3 days. Post operative pain and acute retention of urine were the commonest complications. The mean wound healing rate was 5 weeks, with a peak (30.8%) in the 5th post operative week. The mean cost of management was thirty eight U.S. Dollars ($38.00) or four thousand, five hundred and ninety three Naira. (N4,593.00). Open haemorrhoidectomy remains a safe and simple surgical technique that should not be discarded in complete preference to newer innovative methods.

Major amputations in Nigeria: a plea to educate traditional bone setters.

A study was made of 100 major amputations performed on 96 patients in two regional hospitals in a 10-year period in Nigeria. The objective of the study was to evaluate the outcome of major amputations in Nigeria. The median age of patients was 30 years with male to female ratio 3:1. Ninety of the 100 major amputations involved the lower limbs with the above-the-knee/elbow-the-knee ratio of 0.5. Trauma was the leading indication for 70 amputations, of these 60 were iatrogenic resulting from mismanaged fractures by the traditional bone setters. The non-traumatic indications were: diabetic limb gangrene (20); bone malignancies (9); and vascular insufficiency (1). Provisional amputation was offered in 60 cases, of these 10 had reamputation. There were eight (8.5%) mortalities. The functional outcome for this group was discouraging. Only 25 amputees affording successful prosthetic fitting and social rehabilitation. Major amputation in Nigeria foreshadows a dismal existence and emphasizes the need for health policies which are effective in controlling the risk factors.

Tru-cut biopsy of palpable breast lesions: a practical option for pre-operative diagnosis in developing countries.

OBJECTIVES: To establish the role of Tru-cut needle biopsy in the pre-operative diagnosis of breast lesions in a developing country. DESIGN: Prospective cross sectional study. SUBJECTS: 112 consecutive patients with palpable breast lesions who had both Tru-cut and excision biopsy as a pre-operative diagnostic procedure. RESULTS: Four (3.6%) patients had specimens that were inadequate for histological diagnosis. Tru-cut biopsy diagnosed 42 of the remaining 108 as malignant and 66 as benign, but only 40 and 61 respectively were confirmed to be correctly so by excision biopsy. Tru-cut biopsy, therefore, achieved a sensitivity of 88.9% (95% CI 79.7 to 98.1) specificity of 96.8% (95% CI 92.5 to 100) and an over all diagnostic accuracy of 93.5% (95% CI 88.9 to 98.2). There was a false positive rate of 4.8%, a false negative rate of 7.6% and a positive predictive value of 95.2%. The pathologist was able to make a correct specific histological diagnosis in 76.2% of all the adequate Tru-cut samples. CONCLUSION: If Tru-cut biopsy is done instead of excision biopsy, it will sufficiently reduce waiting time and reduce cost (four fold). It is well tolerated by patients. We regard the procedure as a useful adjunct and indeed a practical option for accurate pre-operative diagnosis of palpable breast lesions.

Traditional bone setter's gangrene.

Traditional bone setter's gangrene (TBSG) is the term we use to describe the sequelae sometimes seen after treatment with native fracture splints. Twenty five consecutive complications were recorded in 25 patients aged between 5-50 years with a median age of 10 years. The major complication of the native fracture splint treatment was distal limb gangrene necessitating proximal amputations in 15 cases.

Active prophylactic management of respiratory obstruction after standard thyroidectomy for giant goitre in the middle belt region of Nigeria.

Respiratory obstruction is a lethal complication of thyroidectomy for giant goitre. Prophylactic tracheal splintage by retaining the endotracheal tube in situ for 24 h post-operatively and its meticulous management in the intensive care unit (ICU) is a safe and rewarding practice. Over a 7-year period, 33 patients, all women who had standard thyroidectomy for giant goitre were managed accordingly. There was no incidence of post-operative respiratory distress, nor mortality in the series. The average duration of stay in ICU was 2 days for all patients and the average hospital stay was 6 days for 27 of the 33 patients (81.8%). We suggest that judicious post-thyroidectomy management of giant goitre patients in ICU with endotracheal tube in situ for 24 h improves their survival chances.

One-stage procedure in the management of acute sigmoid volvulus.

In a descriptive prospective study, twenty-seven patients with sigmoid volvulus and three with ileosigmoid knotting had primary resection of the redundant sigmoid colon with immediate anastomosis after intraoperative antegrade colonic irrigation. There was no clinical anastomotic leak nor mortality in any of our patients. Superficial wound infection occurred in four patients (13.3%). Intraoperative colonic irrigation time ranged between 25 to 50 minutes with a volume of saline/Hartmann's required to achieve a clean colon ranging between 1.5 to 5.0 litres. The duration of hospital stay ranged between 7 and 14 days. The result of this study suggests that resection of acute sigmoid volvulus and primary anastomosis after antegrade intraoperative colonic lavage is safe provided the patient is reasonably fit.

Comparative study of conservative resection and radical operation for thyroid carcinomas.

OBJECTIVE: To compare mortality and morbidity in management of thyroid cancers by total lobectomy (C-R) and near-total thyroidectomy (R-O) and to relate pathological subtype to prognosis. DESIGN: A retrospective study of patients with thyroid cancers that were managed during an eleven-year period. SETTING: Jos University Teaching Hospital, Nigeria. SUBJECTS: A total of 44 patients who underwent C-R (n = 26) and R-O (n = 18) were studied. INTERVENTION: A total of 509 goitrous specimens including the excised thyroid cancers were histopathologically studied. MAIN OUTCOME MEASURES: Cases were analysed for mortality and morbidity data in the two groups during a partial follow-up period of two years. RESULTS: Mortality figures for C-R was 4% versus 11 for R-O. Postoperative haemorrhage occurred in 14% for C-R versus six for R-O. Similarly, bilateral vocal cord paralysis occurred in 11% versus 22; voice changes in 11% versus 33, transitory hypoparathyroidism 8% versus 50, local recurrence in 18% versus eleven. Hypothyroidism occurred in all patients undergoing R-O and stitch granuloma in 11% of patients in C-R group versus six for R-O. Follicular carcinoma constituted 59% of the total number thyroid cancers with papillary cancer constituting 35%. CONCLUSION: C-R is recommended as the operation of choice for thyroid cancers.

Iodine deficiency disorders in pre-adolescent and adolescent children in Nigeria, West Africa.

An epidemiological study of iodine deficiency disorders covering 4230 pre-adolescent and adolescent school children, together with biochemical analysis of 741 urinary samples, 26 potable drinking water samples and 56 blood samples was conducted in the Plateau State of Nigeria, West Africa. Results indicate that about 2/3 of the region is goitre endemic due principally to iodine deficiency (ID) prevailing in the region as reflected by a low drinking water iodine (DWI) concentrations throughout most of the areas surveyed as well as by a reduced urinary iodide excretions (UIE) seen among the subjects. Urinary thiocyanate (SCN) level in contrast, was found to be significantly higher (P < .01) in the children from these areas as compared to that in Jos (the State capital), raising a possibility of its association with the increased GP seen for the region. Thyroid profile investigation carried out on the 56 goitrous school children from the iodine deficient Bassa region of the state shows two distinct groups. The major group (41 children) exhibited a low-normal to above normal serum T4, FT41 and T4/TBG levels in association with high-normal to above normal serum T3 and a mildly elevated serum TSH activity, suggesting that the group might be in a state of 'compensated euthyroidism'--due as a result of glandular metabolic adaptation to the prevailing ID. The other minor group (15 children) was in 'euthyroid hyperthyroxinaemia' based on a marked rise in serum T4, T3 TBG levels, while serum FT41, T4/TBG ratio and TSH levels were within mid normal range. Discovery of 9 cretins (0.21%) further signifies the magnitude of the problem in the region. It is concluded that a significant proportion of the children living in these areas may likely to suffer from partial thyroid insufficiency with its attendant consequences.

Experience in managing splenic trauma on the Jos Plateau.

We studied retrospectively, fifty eight (58) patients with splenic injury admitted to Jos University Teaching Hospital between October 1988 and September, 1995. Forty-nine were males while nine were females (M:F = 5.4:1). The age ranged from 5 to 50 years with a mean of 24.5 years. The highest incidence was recorded in the third decade of life. Road Traffic Accident (RTA) was the commonest (75.8%) cause of splenic injury; others were fall from heights 7 (12.1%), blows to the abdomen 5 (8.6%) and stab wounds to the abdomen 2 (3.5%). Of the 58 cases, 56 (96.5%) were blunt abdominal injuries while 2 (3.5%) were penetrating stab injuries. All had laparotomy. 13 (22.4%) sustained Upadhyaya and Simpson's type 1 injury, 18 (31.0%) type II, 12 (20.7%) type III and 15 (25.9%) type IV injuries. Of the 58 patients, 29 (50%) had total splenectomy without heterotopic autotransplantation (HAT); 21 (36.2%) had splenectomy with HAT, while 8 (13.8%) had splenorrhaphy with omentoplasty. The average number of units of blood transfused was 2.3 units per patient. There were four (6.9%) deaths--two as a result of shock and multiple organ failure and another two died as a result of pulmonary embolism. However the commonest post operative complications were chest and wound infections. The rate of splenic salvage in this study was low despite the fact that most of these patients sustained types I and II injuries. We believe a greater salvage rate could be achieved and the trend in our centre now is toward splenic conservation.

Management of childhood splenic trauma--the Jos experience.

We studied retrospectively 22 children who were managed for splenic injuries at Jos University Teaching Hospital between September 1988 and October 1995. Sixteen were males and six were females (M:F = 2.7:1) with their ages between five and 15 years and a mean of 10.3 years. Eleven were knocked down by vehicles while crossing the freeway, playing or hawking goods; seven fell from slippery mango trees after a downpour of rain while two were passengers in a vehicle that was involved in a head-on collision and another two were kicked in the abdomen as a result of assault. All had surgery. Four sustained Uphadhyaya and Simpson's Type 1 injuries while six sustained Type IV injuries. Twelve had total splenectomy, seven had total splenectomy with heterotopic autotransplantation of splenic wafers while three had splenorrhaphy augmented with omentoplasty. An average of 1.5 units of blood per patient were transfused. There was only one death. Considering that the majority (18) of these children sustained their splenic injuries while crossing the freeway (playing or hawking goods) and from falls from mango trees after the rains, we believe that there are preventable causes. Mandatory primary and junior secondary school education as well as legislature against child labour will help keep these children safe out of harm's way and thus drastically reduce the incidence of childhood splenic injuries in our environment.

Another look at acute appendicitis in tropical Africa: and the value of laparoscopy in diagnosis.

Acute appendicitis is believed to be one of the commonest causes of the acute abdomen in tropical Africa. Negative appendicectomy rates are usually above 20%, which is now considered unacceptably high because of increased risk to patients and the availability of diagnostic facilities to aid clinical decision-making. Our negative appendicectomy rate over a 4-year retrospective period was 29.7% in males, and 47% in females. These reduced to 11% and 10%, respectively, after the introduction of laparoscopy for doubtful cases of acute abdominal pain.

Laparoscopy in developing countries in the management of patients with an acute abdomen.

Surgeons in developing countries see a need to improve diagnosis and decision making in patients with an acute abdomen. Without the benefit of diagnostic aids such as computers and high-resolution ultrasonography, the rate of unnecessary laparotomy is often unacceptably high. The laparoscope is usually available in a developing country and its use easily acquired. Using laparoscopy in doubtful situations the unnecessary laparotomy rate was significantly reduced from 14.0 to 6 per cent (P < 0.05). Laparoscopy achieved a diagnostic accuracy of 86 per cent and prevented unnecessary laparotomy in 57 per cent of those in whom it was used.

Diagnosis of acute pancreatitis: a proposed sequence of biochemical investigations.

In 60 controls and 108 patients admitted with acute abdominal pain, Rapignost urinary amylase correctly identified (++) 18 of the 23 patients with acute pancreatitis (AP), with 8 results being equivocal (+), and 1 false negative. This is a suitable screening test for AP, but an equivocal result requires further investigation. In 14 patients with AP the serum amylase was over 1000 U/l with no false-positive results, whereas when 316 U/l was used as the diagnostic threshold, 22 cases were identified (but with 2 false positives). Serum lipase was 100% sensitive in the diagnosis of AP, but there were three false-positive results.