Management of Traumatic Diaphragmatic Injury-A Peep into Bowel Repair via Thoracotomy.

Background: Traumatic diaphragmatic injury (TDI) is a relatively rare condition, and there is a high tendency for it to be missed if thorough clinical assessment and imaging review are not carried out. The surgical approach for TDI can be challenging, especially with bowel perforation. Materials and Methods: This is a retrospective case series of all consecutive patients with TDI from two tertiary hospitals in the southern part of Nigeria between January 2013 and December 2019. The demographic data of the patients, type, cause, and clinical diagnosis, intraoperative findings, Injury Severity Score, and outcome were noted. The descriptive statistics were presented in percentages and fractions. Results: Fourteen (4.3%) of the 326 chest trauma patients had TDI with 57.1% from penetrating causes and 42.9% from blunt causes. The causes of the TDI were gunshot injuries (42.9%), road traffic crashes (35.7%), stab injury (14.3%), and domestic accidents (7.1%). The preoperative method of diagnosis was mainly by massive haemothorax necessitating open thoracotomy (42.9%) and mixed clinical evaluation, chest radiograph, and upper gastrointestinal contrast studies (35.7%), and the drainage of intestinal content following the insertion of a chest tube to initially drain haemothorax (21.4%) and other modality of diagnoses (7.1%). The operative finding was mainly intestine content in the chest (50%) and only diaphragmatic injury (35.7%). The major complication after surgery was empyema thoracis (14.3%) and the mortality rate (14.3%). Conclusion: Penetrating injury of the chest was the major factor responsible for the TDI, and even with bowel perforation and acute TDI, thoracotomy offered an effective surgical approach for all the patients.

Impact of Covid-19 on Residency Training in Tertiary Health Institutions in Nigeria: A National Survey.

Background: The emergence of COVID-19 had a massive impact on the health system globally. While there are many kinds of literature reporting the impact on postgraduate medical training in other parts of the world, this cannot be said about Nigeria. Methodology: This was a national cross-sectional study among Resident doctors via an online google form survey for 8-months. Stratified cluster design where the entire country was stratified into the six geopolitical zones, and Tertiary Health Institutions (THI) were randomly selected from each of these zones. Data from the 47-item google form were analysed with Statistical Package for Social Science (SPSS) version 23, and internal consistency reliability was measured by Cronbach's alpha coefficient. Categorical variables were compared using chi-square, and the p-value was <0.05. Results: A total of 239 residents from THI in all six geopolitical zones completed the survey. The mean± standard deviation of the age of respondents, years in practice, and years in residency were 36.3±4.4); 10.2±7.6 years, and 4.2±2.6 years, respectively. The Cronbach's alpha coefficient was 0.95. Less than half had delayed the progression of residency (44.4%). The least strongly positive impacts were related to recruitments (4.2%), laboratory testing (4.2%), and ward rounds (4.2%); and the more strongly positive disruptive impact was on postgraduate seminars (9.2%), research (8.4%), professional examinations (8.0%) and residents' clinical schedules (8.0%). Conclusion: COVID-19 has caused a considerable delay in residents' training programs, and resident doctors have great concerns regarding the pandemic. This impact is perceived by them in almost all aspects of the training.

Profile of Lung Cancer in two Niger Delta States of Nigeria: An Evaluation of 43 Cases.

Background: The data on the epidemiology of lung cancer in Niger delta states is scarce. Therefore, this study aims to determine the epidemiological profile of lung cancer in two Niger Delta states in Nigeria. Methodology: This was a retrospective analysis of all patients managed for histologically diagnosed lung cancer from Jan 2014 to Dec 2019 at two tertiary hospitals in Niger Delta states of Nigeria. The demographics, diagnoses, results of investigations, and outcomes were analysed using descriptive statistics. Results: Forty-three patients were reviewed with a male-to-female ratio of 1.5:1 and an age range between 13-89 years with a mean of 53.5+17.0 years. The following number of patients; 1(2.3%), 26(60.5%), 4 (9.3%) and 12(27.9%) were distributed according into the following age groups ;< 20, 20-59, 60-64 and >65 respectively. Eleven (25.6%) patients were smokers. The commonest symptoms were dyspnoea in 39(90.7%), cough in 35(81.4%), weight loss in 29(67.4%), chest pain in 28(65.1%), and change in voice (hoarseness of voice) in 8(18.6%); while the signs were respiratory distress in 33(76.7%), digital clubbing in 8(18.6%), superior vena cava syndrome in 2(4.7%).The left lung was commonly affected in 24(55.8%) patients, and the left upper lobe was the most common in 21 (20.2%), while the right upper lobe was the least in 13(12.6%) patients. The histological types were Adenocarcinoma in 26(60.5%), squamous cell carcinoma in 15(34.9%) patients, and small cell carcinoma in 2(4.7%) patients. Fifteen (34.9%) patients had elevated platelets. The modalities of pathologic diagnoses were: Mini-Thoracotomy10 (23.3%), Tru-cut biopsy 28 (65.1%), and Bronchoscopy 5 (11.6%).The mortality rate after six months following lung cancer diagnosis was 7(16.2%). Conclusion: In our environment, lung cancer may have a bimodal distribution, peaking in the middle age group and elderly patients who were mainly non-smokers. Elevation of platelets was observed in a significant number of patients.

Massive Pleural Fluid Collection in Adult Nigerians.

Background. There are no available literatures on massive pleural effusions (MPE) in our country. Aim. To determine the aetiology of MPE and compare the mortality rate between malignant and nonmalignant MPE in adult Nigerians. Methods. A prospective study of all the patients diagnosed with nontraumatic pleural fluid collections for one year in two tertiary federal hospitals in Southern Nigeria. A total of 101 consecutive patients with pleural fluid collections were studied. Diagnoses were made by clinical features and laboratory and radiological investigations. Results. Forty-eight patients (47.5%) had MPE with a mean age of 43 years ± 14.04 and 35 were females. Thirty patients (62.5%) were diagnosed with nonmalignant conditions (21 from pulmonary tuberculosis (PTB) and 9 from other causes). Haemorrhagic pleural collections were from malignancy in 12 (30.8%) and from PTB in 6 (15.4%). Straw-coloured collections were from malignancy in 9 (23.1%), from PTB in 8 (20.1%), and from posttraumatic exudative effusion in 3 (7.7%). Compared with nonmalignant MPE, patients with malignant collections had higher mortality within 6 months (8/18 versus 0/30 with a P value of 0.000). Conclusion. The presentation of patients with nontraumatic haemorrhagic or straw-coloured MPE narrows the diagnosis to PTB and malignancy with MPE cases being a marker for short survival rate.

Challenges with the establishment of congenital cardiac surgery centers in Nigeria: survey of cardiothoracic surgeons and residents.

BACKGROUND: There are gaps in understanding the challenges with the establishment of pediatric cardiac surgical practices in Nigeria. The aim of this study was to examine the prospects and challenges limiting the establishment of pediatric cardiac surgical practices in Nigeria from the perspectives of cardiothoracic surgeons and resident doctors. METHODS: A descriptive study was carried out to articulate the views of the cardiothoracic surgeons and cardiothoracic resident doctors in Nigeria. A self-administered questionnaire was used to generate information from the participants between December 2014 and January 2015. Data were analyzed using the SPSS version 21 statistical software package. RESULT: Thirty-one of the 51 eligible participants (60.7%) took part in the survey. Twenty-one (67.7%) were specialists/consultants, and 10 (32.3%) were resident doctors in cardiothoracic surgical units. Most of the respondents, 26 (83.9%) acknowledged the enormity of pediatric patients with cardiac problems in Nigeria; however, nearly all such children were referred outside Nigeria for treatment. The dearth of pediatric cardiac surgical centers in Nigeria was attributed to weak health system, absence of skilled manpower, funds, and equipment. Although there was a general consensus on the need for the establishment of open pediatric cardiac surgical centers in the country, their set up mechanisms were not explicit. CONCLUSIONS: The obvious necessity and huge potentials for the establishment of pediatric cardiac centers in Nigeria cannot be overemphasized. Nevertheless, weakness of the national health system, including human resources remains a daunting challenge. Therefore, local and international partnerships and collaborations with country leadership are strongly advocated to pioneer this noble service.

Surgical management of recalcitrant peripheral bronchopleural fistula with empyema: A preliminary experience.

BACKGROUND: Peripheral bronchopleural fistula (BPF) and empyema from necrotising infections of the lung and pleural is difficult to treat resulting in increased morbidity and mortality rates. The aim of this study was to show the effectiveness of the Latissimus Dorsi muscle (LDM) flap and patch closure techniques in the management of recalcitrant peripheral BPFs with the aid of thoracotomy. MATERIALS AND METHODS: Five patients with BPF and empyema out of 26 patients who were initially treated for empyema thoracis by single or multiple chest tube insertions and/or ultrasound-guided drainage were prospectively identified and followed up for 2 years, postoperatively. The postoperative hospital stay, dyspnoea score, function of the ipsilateral upper limb and any deformity of chest wall were assessed at follow-up visits by asking relevant questions. RESULTS: The mean age was 46.8 years (23-69 years) (4 males and 1 female). The cause of the BPF in 18 patients was Mycobacterium tuberculosis and 8 was pneumonia. The mean total months of the chest tube insertions was 1.5 months (range 2.5-6 months) prior to the thoracotomy and closure of fistula procedures performed on the 5 patients (with LDM flap in 4 patients and pleural patch in 1 patient). The complications recorded were: subcutaneous emphysema, residual pus and haemothorax in three patients. The mean postoperative hospital stay was 20.8 days (13-28 days);There was improved dyspnoea score to 1 or 2 in the 5 (19.2%) patients. There was no recurrence of BPF or residual pus in all the patients; no loss of function or deformity of the chest wall. CONCLUSION: The use of LDM Flap was effective in treating peripheral BFP without any adverse long-term outcome.

Superior repair: A useful approach for some anatomic variants of total anomalous pulmonary venous connection.

BACKGROUND: Total anomalous pulmonary venous connection (TAPVC) occurs when all the four pulmonary veins drain to the right atrium or to tributaries of the systemic veins. There have been various published techniques for the repair but none has been agreed on for the different anatomical variants that may be encountered during surgery. PATIENTS AND METHODS: Between January 2005 and June 2010 the data of 6 of 18 patients who had surgical repair using the superior approach were retrospectively reviewed.Three patients had long narrow venous stalk connecting the coronary sinus to venous confluence; two had the right pulmonary veins draining to superior vena cava (SVC) and left pulmonary veins to left lateral wall of SVC and one had an obstruction at entrance of Pulmonary Vein into venous confluence. RESULTS: Five patients initially had the superior approach while one had transatrial with unroofing of the coronary sinus. Two had a concomitant Wardens procedure. The mean aortic cross clamping was 87.5 (60-125) min, the mean cardiopulmonary bypass time should have min as unit of 127.8 (100-180), the mean Intensive Care Unit (ICU) stay of 2.5 (2-4) days and the mean hospital stay 8.2 (7-9) days. One patient died at early post-operation from low cardiac outputand five had an uneventful post-operative course and had remained stable until date. CONCLUSION: In our experience, the superior approach was an effective alternative approach for some anatomic variants of TAPVC that may be unexpectedly encountered during operation and also useful surgical approach for older children.

Recombinant-activated factor VII in the paediatric cardiac surgery: single unit experience.

BACKGROUND: The control of excessive bleeding after paediatric cardiac surgery can be challenging. This may make the use of recombinant-activated factor VII (rFVIIa) in preventing this excessive bleeding, after adopted conventional methods have failed, desirable. Our aim is to highlight our experience with the use of rFVIIa in preventing excessive bleeding after paediatric cardiac surgery. PATIENTS AND METHODS: The data for 14 patients who had rFVIIa for excessive haemorrhage after cardiac surgery from December 2009 to November 2010 was analysed. The perioperative blood loss from the chest drain before and after the administration of rFVIIa, use of blood products, international normalized ratio (INR) and activated partial thromboplastin (aPTT), before and after administration of rFVIIa, were analysed. RESULTS: The rFVIIa was successful in stopping bleeding in all the patients. The mean coagulation factors before rFVIIa were as follows: INR, 2.88 (1.82-4.5); aPTT, 65 seconds (33.4-95.1); after rFVIIa, the mean INR was 1.2 (0.82-1.56), mean APTT was 38.7 seconds (25.6-54.9). No thromboembolic events or allergic reactions or deaths were recorded. CONCLUSIONS: rFVIIa use is not only effective in stopping excessive perioperative bleeding but also safe and indirectly reduces transfusion of blood and its products.

Tension Pneumatocele due to Enterobacter gergoviae Pneumonia: A Case Report.

Pneumatocele formation is a known complication of pneumonia. Very rarely, they may increase markedly in size, causing cardiorespiratory compromise. Many organisms have been implicated in the pathogenesis of this disease; however, this is the first report of tension pneumatocele resulting from Enterobacter gergoviae pneumonia. We report a case of a 3-month-old Nigerian male child who developed two massive tension pneumatoceles while on treatment for postpneumonic empyema due to Enterobacter gergoviae pneumonia. Tube thoracostomy directed into both pneumatocele resulted in complete resolution and recovery. Enterobacter gergoviae is a relevant human pathogen, capable of causing complicated pneumonia with fatal outcome if not properly managed. In developing countries where state-of the-art radiological facilities and expertise for prompt thoracic intervention are lacking, there is still room for nonoperative management of tension pneumatocele especially in very ill children.

What size of vegetation is an indication for surgery in endocarditis?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the of vegetations in endocarditis is an indication for surgery. Altogether, 102 papers were found using the reported search; 16 papers were identified that provided the best evidence to answer the question. The authors, journal, date, country of publication, patient group, study type, relevant outcomes and results were tabulated. The vegetation size was classified into small (<5 mm), medium (5-9 mm), or large (≥10 mm) using echocardiography and a vegetation size of ≥10 mm was a predictor of embolic events and increased mortality in most of the studies with left-sided infective endocarditis. For large vegetations--that commonly resulted from the failure of antibiotics to decrease the vegetation size during 4-8 weeks' therapy--and complications such as perivalvular abscess formation, valvular destruction and persistent pyrexia necessitated surgical intervention. In a multicentre prospective cohort study of 384 consecutive patients with infective endocarditis, it was observed that a vegetation size of >10 mm and severe vegetation mobility were predictors of new embolic events. Equally, a meta-analysis showed that the echocardiographic detection of a vegetation size of ≥10 mm in patients with left-sided infective endocarditis posed significantly increased risk of embolic events. In another prospective cohort study of 211 patients, it was observed that there was an increased risk of embolization with vegetations of ≥10 mm. In similarly another study of 178 consecutive patients with infective endodarditis assessed by echocardiographic study, it was found out that there was a significantly higher incidence of embolism with a vegetation size >10 mm (60%, P<0.001). When using the area of the vegetation, a vegetation size of >1.8 cm(2) predicted the development of a complication. Assuming that the vegetation was a sphere, the calculated diameter will be 8 mm when using 4Ωr(2) for the area. However, for right-sided infection endocarditis, a vegetation size of >20 mm was associated with a higher mortality when compared with a vegetation size of ≤20 mm. There is strong evidence to suggest that a vegetation size of ≥10 mm especially for left-sided infective endocarditis is an indication for surgery.

Is double or single patch for sinus venosus atrial septal defect repair the better option in prevention of postoperative venous obstruction?

A best evidence topic in cardiac surgery was constructed according to a structured protocol. The question addressed was, 'Is double or single patch for sinus venous atrial septal defect repair the better option in prevention of postoperative venous obstruction?' Altogether seventy nine papers were found using the reported search; ten papers were identified that provided the best evidence to answer the question. The authors, journal, date, country of publication, patient group, study type, relevant outcomes and results of were tabulated. Three hundred and thirty four patients had single-patch with 7 (2.1%) having venous obstruction (venous obstruction; defined as obstruction at the atriocaval anastomosis and/or the right superior pulmonary vein) while 130 had double-patch with 3 (2.3%) having venous obstruction. However, when the three randomised studies were reviewed, 101 had single-patch and 67 had double-patch with 7 (7%) and 4 (6%) having venous obstruction respectively. Similarly, another randomised study that considered solely the two surgical options with eighteen patients who had single-patch repair as group A and 19 patients who had double-patch repair as group B with six patients in group A and 2 patients in group B having significant superior vena cava-right atrium pressure gradient of more than 6 mmHg. Nine patients in group A had a significant gradient causing turbulence across the right superior pulmonary vein at the level of the patch, whereas no patients in group B had turbulence across the pulmonary vein. The double-patch technique technically offered better results in terms of superior vena cava narrowing and gradient across the pulmonary vein without any increase in complications. However, in order to reduce postoperative venous obstruction while using the single-patch repair method, the adoption of the transcaval approach yielded excellent results, with unobstructed pulmonary and systemic venous flow as in 141 patients who had this method of repair only one patient had venous obstruction. In conclusion, the evidence was in support of the adoption of double-patch or the use of the transcaval repair technique when the single patch technique was used as a better option to avoid venous obstruction.

In patients with corrosive oesophageal stricture for surgery, is oesophagectomy rather than bypass necessary to reduce the risk of oesophageal malignancy?

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was, 'is there an increased risk of cancer in a non-resected corrosive oesophageal stricture?' Altogether, 133 papers were found using the reported search; six papers were identified that provided the best evidence to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these studies were tabulated. From the studies, 198 consecutive patients had corrosive oesophageal stricture resulting from corrosive oesophageal injury, 50 of whom (25.3%) developed oesophageal cancer. The interval between the burn and the diagnosis of scar carcinoma was 46.1 years and ranged between 25 and 58 years. The incidence of carcinoma of the oesophagus among patients from the study was significantly higher than that of the general population. In one review, seven (13%) of 54 consecutive patients treated by conservative means for caustic oesophageal stricture (COS) developed oesophageal cancer, leading to the conclusion that simultaneous resection of the oesophagus with reconstruction for such patients would provide a better probability of being completely cured of the disease. Furthermore, in patients with COS in need of operation who had a bypass procedure, it was pointed out that malignancy may develop even years after the bypass operation in the remaining part of the oesophagus and so total oesophagectomy was suggested instead of bypass. In another study, as many as 10 (31.3%) of 32 patients with corrosive oesophageal stricture developed cancer. That gave further credence to the arguments against conservative treatment or bypassing of corrosive oesophageal strictures. The risk of morbidity for intrathoracic oesophageal replacement in uncomplicated cases was 2.4%. There were basically two things that were agreed from the studies: that corrosive-induced carcinoma can occur with a reasonably high incidence if part or all of the oesophagus was left during reconstructive surgery; and that simultaneous resection of the oesophagus at the time of reconstruction in a patient with corrosive stricture offered a better outcome. The limitations of the present review were the lack of randomized controlled trials and no close follow-up.

Is recombinant activated factor VII effective in the treatment of excessive bleeding after paediatric cardiac surgery?

A best evidence topic in paediatric cardiac surgery was written according to a structured protocol. The question addressed was whether recombinant activated factor VII was effective for the treatment of excessive bleeding after paediatric cardiac surgery. Altogether 150 papers were found using the reported search; 13 papers were identified that provided the best evidence to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these studies were tabulated. A total of 311 children experienced excessive bleeding following cardiac surgery that was refractory to the conventional methods of achieving haemostasis. One hundred and ninety-two patients received the rFVIIa while 116 were in control arm from five studies. The primary end-point was on chest tube drainage, the plasma prothrombin time, the activated partial thromboplastin time after the administration of rFVIIa and the secondary end-point was reduction of blood products transfusion. Thrombosis was a complication in 8 patients (4.2%); three deaths (1.6%) but not attributable to thromboembolic events following the use of rFVIIa. Most of the studies failed to clearly state the doses but the extracted doses ranged between 30 and 180 µg/kg/dose, the interval between doses ranged between 15 and 120 min with a maximum of four doses. However, most of the patients had 180 µg/kg/dose with interval between dose of 2 h and maximum of two doses with dosage moderated with respect to weight, prior coagulopathy and responsiveness. There were two randomized studies with good sample size. One showed no significant differences in the secondary end points between the two arms and noted no adverse complications. However, the rFVIIa was used prophylactically. The other observed that there were no increase in thromboembolic events rather rFVIIa was effective in decreasing excessive bleeding that may complicate cardiac surgery in children. In conclusion, the studies were in support of the notion that the use of rFVIIa was effective in decreasing excessive bleeding which may complicate paediatric cardiac surgery, and care should be exercised when using it in the children on ECMO circuit.

Is oesophagectomy or conservative treatment for delayed benign oesophageal perforation the better option?

A best evidence topic was written according to a structured protocol. The question addressed was, 'Is oesophagectomy or conservative treatment for delayed benign oesophageal perforation the better option?' Seven papers were identified that provided the best evidence to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these studies were tabulated. A total of 147 patients from the studies had oesophageal perforation, while 86 had oesophagectomies for delayed oesophageal perforation (DOP; defined as a perforation diagnosed after 24 h) and 57 had conservative procedures. The mortality rate ranged from 0 to 18% for patients with oesophagectomies, increasing to 50% with double exclusion and reaching as high as 68% in primary repair. In one report, it was found that conservative procedures inflicted higher morbidity than oesophagectomy, which eliminated the perforation, the source of sepsis and the underlying oesophageal disease; another study came to the same conclusion. One study concurred that oesophageal perforation was a surgical disease and only a few cases qualified for conservative procedures. In a review of 34 patients who had DOP, 19 were treated with conservative procedures and 15 oesophagectomy; the mortality rate for patients treated by conservative procedures was 68%, whereas it was 13.3% for patients treated by oesophagectomy. In another study, among the patients treated with conservative procedures, at least one required an additional operation and about 33.3% of patients who survived had continued difficulty with swallowing. In four of the studies, the authors observed that oesophagectomy for DOP was a better surgical option, which decreased mortality, and one study compared the treatment outcome between conservative procedures and oesophagectomy. The primary end-point in all the studies was elimination of the source of sepsis by extirpating the perforated oesophagus in comparison with conservative procedures. However, the consensus of opinion in all the presented evidence was in support of the theory that oesophagectomy was safer and better than conservative procedures. In conclusion, oesophagectomy for DOP was superior to conservative procedures. The limitation of the present review was the lack of many randomized controlled trials.