Repair-oriented categorization of circumcision urethral injury in Benin city, Nigeria.

BACKGROUND: The wide spectrum of circumcision urethral injury/fistula makes selection of appropriate repair methods challenging in sub-Saharan Africa. This paper reports on the outcome of repair-oriented categorization in a Nigerian center. METHODS: Consecutive children presenting with circumcision urethral injury/fistula at the University of Benin Teaching Hospital were categorized into six repair-oriented groups in 2009-2011. RESULTS: 21 children were treated. Except in 2 cases, early neonatal circumcision at an average age of 8 days (range 4-14 days) had been performed, the majority (52%) by paramedics at home. Categories of injury/fistula based on severity ranged from isolated fistula (38%) which required fistula excision and repair (category A) to severe ventral urethral/coronal/glanular avulsion (29%) which required urethral plate tubularization/ventral penile reconstruction (category F). Overall, successful first-stage repair was achieved in 19 (91%) children. Meatal stenosis (2), urethral stricture (1), which responded to serial dilatation, and minor urinary leakage (2), which was closed at second stage, were the post-repair complications. Adequate penile size and straight penis on erection were achieved in all cases. Cosmetic outcome was excellent in 16 (76%) cases, good in 4 (19%) and fair in 1 (5%). CONCLUSION: Repair-oriented categorization, which could be useful to practitioners in similar settings, was satisfactory in managing urethral injury/urethrocutaneous fistula.

Pediatric road traffic accident deaths presenting to a Nigerian referral center.

INTRODUCTION: Road traffic accident (RTA) is a common cause of pediatric trauma death and disability, constituting a worldwide loss of financial resources and potential manpower. This study was designed to determine the causes, prehospital care, presentation, and injuries that resulted in deaths among pediatric victims of RTA in Nigeria, and to make suggestions, based on the study data, to reduce RTA deaths. METHODS: This is a retrospective analysis of pediatric RTA presenting to a Nigerian referral center. The records of all pediatric RTA between January 2006 and December 2010 at the University of Benin Teaching Hospital were analyzed for age, gender, causes of death, injury, rescue team prehospital treatment, injury to hospital arrival time, clinical condition on arrival, treatment, duration of hospitalization before death, challenges, and postmortem findings. RESULTS: Twenty-six (18%) of 143 pediatric RTA, comprising 18 males and 8 females, between less than one and 18 (mean 9.3 ± 5.2) years of age died. There was no significant statistical demographic difference observed when 15 (58%) deaths recorded among 67 (46.9%) children involved in motor vehicle accidents were compared with 11 (42%) involved in 76 (53.1%) motorcycle accidents (P = .31). More severe injuries resulting in the majority of deaths were associated with alcohol intoxication (P < .0001). Fourteen (54%) of the deaths were pedestrians, eight of whom were selling wares on the roadside; six were crossing roads that had no traffic signs or traffic control. Of the eight vehicle passengers who died, only two wore seat belts or used pediatric car seats, with no statistical significance compared to those who did not use seat belts or car seats (P = .37). Four of 14 front seat passengers and four of 32 rear seat passengers died (P = .222). Of motorcycle passengers, none of those who wore protective crash helmets died, while four died who were not wearing helmets. Passers-by and sympathizers served as rescuers provided emergency treatment, and presented the victims between one hour and four days after the accidents. Head injury in 14 (54%) cases was the most common cause of death. CONCLUSION: Pediatric RTA deaths in this study were due mainly to preventable causes. There is a need to stress road safety education to children, drivers, the general public and government policy formulators, and to adopt RTA preventive measures in this region of Nigeria.

Epidemiology and pattern of paediatric and adolescent trauma deaths in a level 1 trauma centre in Benin city, Nigeria.

BACKGROUND: Trauma is a common cause of death amongst children/adolescents, and data on its epidemiology and pattern are crucial for policy formulation. The aim of this study was to determine the epidemiology and pattern of paediatric/adolescent trauma death in a Nigerian referral trauma centre. METHODS: The clinical and autopsy data of all paediatric/adolescent trauma death at the University of Benin Teaching Hospital between 1999 and 2010 were analysed in a retrospective study. RESULTS: Of 905 trauma-related deaths, 78 (9%) involved children/adolescents who comprised 49 males and 29 females, with a male/female ratio 1.7:1 and a mean age of 9.2 ± 5 years (range <1-18 years). The Injury-Arrival time varied from 1h to 4 days (mean 18 h). Thirteen (17%) cases were dead on arrival (DOA), and majority of the deaths occurred within the first week on admission. Road traffic accident (RTA), accounting for 61 (78%) cases, was the leading cause of trauma death. Other causes included burns, eight (10%); gunshot injury, five (6%); and stab and sport injuries, two (3%) cases each. Head injury which occurred in 44 (56%) cases was the commonest cause of death, followed by haemorrhagic shock in 25 (32%), hypovolaemic shock in five (6%), septic shock in three (4%) and spinal cord injury in one (1%). CONCLUSION: Head injury following RTA was the major cause of paediatric/adolescent trauma deaths. Increased road safety campaign, appropriate injury control policies, legislations, enforcement, development of high-quality trauma system, and emergency medical services are advocated.

Audit of antibiotic therapy in surgical neonates in a tertiary hospital in Benin City, Nigeria.

OBJECTIVE: To report the outcome of commonly used antibiotic combinations in surgical neonates in sub-Saharan African settings. METHODS: A retrospective analysis that determines the outcome of commonly combined antibiotics in surgical neonates between January 2006 and December 2008 at two referral paediatric surgical centres in Benin city was carried out. RESULTS: Ampicillin ampiclox, metronidazole, gentamicin, cefuroxime and ceftriaxone were variously combined in the management of 161 neonates with a mean age at presentation of 9.2 ± 2.6 days, mean weight 3.1 ± 1.4 kg and a male:female ratio 1.6:1. Polymicrobial postoperative wound infections and sepsis caused by Staphylococcus aureus, Escherichia coli, Neisseria meningitidis, Klebsiella pneumonia, Pseudomonas aeroginosa and anaerobes, were mainly encountered. The most common aerobes isolated from wound cultures were S. aureus and P. aeroginosa while the ones from that of blood cultures were E. coli and K. pneumonia. Overall postoperative infections recorded were: wound infection 19 (11.8%), sepsis 16 (9.9%) and sepsis-related deaths 6 (3.7%). CONCLUSION: Combinations of gentamicin/metronidazole/cefuroxime and gentamicin/cefuroxime were adequate for gastrointestinal and extra-gastrointestinal neonatal operations, respectively, in these sub-Saharan African settings, which may be useful in similar regions.

Acquired rectovaginal fistula in babies of unknown and asymptomatic retroviral positive mothers.

BACKGROUND: Acquired rectovaginal fistulae managed in three babies of asymptomatic mothers not known to be retroviral positive are presented to heighten clinician suspicion of HIV infection in babies with unexplained cause of acquired rectogenital fistula in regions where routine antenatal HIV screening is not adopted. CASES: Between 2004 and 2008, three babies aged 6, 10, and 11 months with rectovaginal fistula secondary to perinatal HIV transfer from unknown and asymptomatic positive mothers were managed at the University of Benin Teaching Hospital, Nigeria. Screening of the mothers confirmed the infection, and multidisciplinary approach to treatment, prompt antiretroviral regimen, use of broad spectrum antibiotics, and surgical management gave encouraging results. CONCLUSION: Routine antenatal screening and suspicion of HIV infection in babies with unexplained cause of acquired rectovaginal fistula is advocated.

Omphalocele management using goal-oriented classification in African centre with limited resources.

In 2000-09, 96 children comprising 57 males and 39 females who were presented between 2 h and 1 week of birth with omphalocele were prospectively managed using goal-oriented classification at the University of Benin Teaching Hospital, Nigeria. All were born through spontaneous vaginal delivery, out of which 9 (9.4%) were preterm. Eighty-two (85.4%) mothers in villages with no supervised antenatal care/delivery and/or prenatal diagnosis presented their babies late. Thirty-three (34.4%) babies in group A, with defect size ≤ 4.5 cm and intact sac, were managed conservatively and had fascial closure after neonatal period, resulting in 32 (97%) survivors. Forty-two (43.8%) babies in group B, with defect size > 4.5 cm and intact sac, were managed conservatively and had fascial closures for 9 months to 5 years, resulting in 40 (95.2%) survivors. Group C comprised of 21 (21.9%) babies with defect of any size/ruptured sac and who had immediate repair, resulting in two (9.5%) survivors owing to lack of facilities (p < 0.0001). Hospital delivery and provision of facilities are advocated.

Audit of antibiotic therapy in surgical neonates in a tertiary hospital in Benin City, Nigeria

Objective: To report the outcome of commonly used antibiotic combinations in surgical neonates in sub-Saharan African settings. Methods: A retrospective analysis that determines the outcome of commonly combined antibiotics in surgical neonates between January 2006 and December 2008 at two referral paediatric surgical centres in Benin city was carried out. Results: Ampicillin ampiclox, metronidazole, gentamicin, cefuroxime and ceftriaxone were variously combined in the management of 161 neonates with a mean age at presentation of 9.2 ± 2.6 days, mean weight 3.1 ± 1.4 kg and a male:female ratio 1.6:1. Polymicrobial postoperative wound infections and sepsis caused by Staphylococcus aureus, Escherichia coli, Neisseria meningitidis, Klebsiella pneumonia, Pseudomonas aeroginosa and anaerobes, were mainly encountered. The most common aerobes isolated from wound cultures were S. aureus and P. aeroginosa while the ones from that of blood cultures were E. coli and K. pneumonia. Overall postoperative infections recorded were: wound infection 19 (11.8%), sepsis 16 (9.9%) and sepsis-related deaths 6 (3.7%). Conclusion: Combinations of gentamicin/metronidazole/cefuroxime and gentamicin/cefuroxime were adequate for gastrointestinal and extra-gastrointestinal neonatal operations, respectively, in these sub-Saharan African settings, which may be useful in similar regions

Post genital mutilation giant clitoral epidermoid inclusion cyst in Benin City, Nigeria.

OBJECTIVE: To report overall occurrence, and the mode of presentation and management of girls with post genital mutilation giant clitoral epidermoid inclusion cyst in an African subregion. METHODS: This is a prospective experience with female patients who presented at two centers in Benin City, Nigeria, between January 2005 and December 2009 with clitoral epidermoid inclusion cyst following underground traditional female genital mutilation performed on neonates. RESULTS: In total, 37 patients were seen with clitoral epidermoid inclusion cyst, 15 (40.5%) were post pubertal girls who could no longer cope with giant cyst that measured more than 3.5 × 6.5 cm in size at an average age of 17 (range 14-21) years. Ignorance, financial constraints, and the fear of possible prosecution by anti-female genital mutilation agencies were reasons for late presentation. Consequently, rapid increase in size of all cysts (100%), mass effect producing dragging discomfort in the vulva of 14 (93.3%) girls, social stigmatization of 12 (80%) girls by peers and spouses, sexual difficulty experienced by 10 (66.7%), and irritating bulge in the perineum of 10 (66.7%) girls, were the most common indications for surgical consultation. Outcomes of cystectomy that included total clitoridectomy performed on on an outpatient basis mainly with local anesthesia were encouraging with no incidence of recurrence recorded on 1-4 years postoperative follow-up. CONCLUSION: Late presentation of girls with giant post genital mutilation clitoral epidermoid inclusion cysts was common. More campaigns against female genital mutilation and government policy aimed at encouraging patients with complications to seek early medical attention, and free treatment for those who present early are advocated.

Typhoid ileal perforation in children in Benin city.

BACKGROUND: Typhoid ileal perforation is a common complication of typhoid fever, a multi-systemic infection, which is endemic in many developing countries. OBJECTIVE: This study reviews and compares the incidence, morbidity and mortality at the University of Benin Teaching Hospital with other referral centres located in areas with similar socioeconomic and population status. MATERIALS AND METHODS: The incidence, morbidity and mortality of typhoid ileal perforation in children treated among Edo People at the University of Benin Teaching Hospital, Nigeria, in the period from 1993 to 2007 were retrospectively studied and compared with centres in localities of similar socioeconomic and population status. RESULTS: Twelve children, all of middle class parents who resided in suburban community with poor water supply and substandard sewage disposal, accounted for 70.6% patients with typhoid ileal perforation managed over 15 years while 29.4% occurred in adults. The children comprised seven males and five females (M/F ratio 1.4:1), aged between five and 13 (average 9) years. This number seen over 15 years in this centre was extremely low when compared with other referral centres; as many as 191 patients were seen over 10 months in one of the centres. The few patients seen were traced to cultural beliefs in Benin City, which influenced proper sewage disposal by the about four million Edo people, especially those living in rural areas. Consequently, no child from the rural area with clean natural water supply or urban areas with pipe born water supply where sewages are disposed of properly had typhoid perforation. Unacceptably high morbidity (100%) and mortality (75%) due to late referrals were recorded in comparison with other centres. CONCLUSION: Proper sewage disposal may have influenced the low incidence in this centre but early referral is advocated so as to reduce the high associated morbidity and mortality.

Is nonoperative management of adhesive intestinal obstruction applicable to children in a resource-poor country?

BACKGROUND: Nonoperative management of adhesive intestinal obstruction gives good results in adults but there are scant studies on its outcome in children. This study reports outcomes and experiences with nonoperative and operative management of adhesive intestinal obstruction in children in a resource-poor country. PATIENTS AND METHODS: This is a retrospective analysis of records of children who were managed with adhesive intestinal obstruction at the University of Benin Teaching Hospital between January 2002 and December 2008. RESULTS: Adhesive intestinal obstruction accounted for 21 (8.8%) of 238 children managed with intestinal obstruction. They were aged between 7 weeks and 16 years (mean 3 +/- 6.4 years), comprising 13 males and eight females (ratio 1.6:1). Prior laparotomy for gangrenous/perforated intussusception (seven, 33.3%), perforated appendix (five, 23.8%), perforated volvulus (three, 14.3%), penetrating abdominal trauma (two, 9.5%) and perforated typhoid (two, 9.5%) were major aetiologies. Adhesive obstruction occurred between 6 weeks and 7 years after the index laparotomies. All the 21 children had initial nonoperative management without success, owing to lack of total parenteral nutrition and monitoring facilities. Outcomes of open adhesiolysis performed between 26 and 48 h in six (28.6%) children due to poor response to nonoperative management, 11-13 days in 12 (57.1%) who responded minimally and 2-5 weeks in three (14.3%) who had relapse of symptoms were encouraging. Exploration of the 21 adhesive obstructions confirmed small bowel obstruction due to solitary bands (two, 9.5%), multiple bands/adhesions (13, 61.9%) and encasement, including one bowel gangrene (six, 28.6%). Postoperatively, the only child who had recurrence during 1-6 years of follow-up did well after a repeat adhesiolysis. CONCLUSION: Nonoperative management was unsuccessful in this setting. Open adhesiolysis may be adopted in children to prevent avoidable morbidities and mortalities in settings with limited resources.

Falls from heights: epidemiology and pattern of injury at the accident and emergency centre of the University of Benin Teaching Hospital.

BACKGROUND: Knowledge of the epidemiology and the pattern of injury sustained following falls from heights may be crucial in formulating policy aimed at prevention and improved outcome of victims. This study aims to determine the epidemiology and the spectrum of injury sustained following falls from heights at a referral trauma centre in a developing country. METHODS: This study is a retrospective analysis of cases of falls from heights between June 2007 and May 2008 at the Accident and Emergency Center of the University of Benin Teaching Hospital. RESULTS: Eighty-four patients aged between 1 and 60 years (median: 24 years) comprising 54 males and 30 females with a male/female ratio of 1.8:1 were managed. All the falls were accidental and occurred mainly among males aged between 18 and 30 years, with a peak incidence between March and May, which coincided with rainy and harvest seasons (P<0.0001). Consequently, falls from moving vehicles 13 (15.5%); off the top of buildings at construction sites, eight (9.5%), staircase, six (7.1%); and treetops, six (7.1%) were common. Children fell mainly indoors from relatively lower heights. Eighty (95.2%) patients sustained injury that ranged from minor abrasions (12; 14.3%) to severe life-threatening head injury (15; 17.9%), which resulted in one (1.2%) death. Sympathisers and passersby were rescuers who gave first aid and brought the patients to the centre using hazardous public transport with a mean time lag of 12h (range: 2-48 h) between the falls and presentation. CONCLUSION: Falls from heights were common in Benin. Health awareness programmes and a proper government policy will reduce incidences and improve outcome.

Typhoid ileal perforation in children in Benin city

Background: Typhoid ileal perforation is a common complication of typhoid fever; a multi-systemic infection; which is endemic in many developing countries. Objective: This study reviews and compares the incidence; morbidity and mortality at the University of Benin Teaching Hospital with other referral centres located in areas with similar socioeconomic and population status. Materials and Methods: The incidence; morbidity and mortality of typhoid ileal perforation in children treated among Edo People at the University of Benin Teaching Hospital; Nigeria; in the period from 1993 to 2007 were retrospectively studied and compared with centres in localities of similar socioeconomic and population status. Results: Twelve children; all of middle class parents who resided in suburban community with poor water supply and substandard sewage disposal; accounted for 70.6patients with typhoid ileal perforation managed over 15 years while 29.4occurred in adults. The children comprised seven males and five females (M/F ratio 1.4:1); aged between five and 13 (average 9) years. This number seen over 15 years in this centre was extremely low when compared with other referral centres; as many as 191 patients were seen over 10 months in one of the centres. The few patients seen were traced to cultural beliefs in Benin City; which influenced proper sewage disposal by the about four million Edo people; especially those living in rural areas. Consequently; no child from the rural area with clean natural water supply or urban areas with pipe born water supply where sewages are disposed of properly had typhoid perforation. Unacceptably high morbidity (100) and mortality (75) due to late referrals were recorded in comparison with other centres. Conclusion: Proper sewage disposal may have influenced the low incidence in this centre but early referral is advocated so as to reduce the high associated morbidity and mortality

Neonatal intestinal obstruction in Benin, Nigeria.

BACKGROUND: Intestinal obstruction is a life threatening condition in the newborn, with attendant high mortality rate especially in underserved subregion. This study reports the aetiology, presentation, and outcome of intestinal obstruction management in neonates. MATERIALS AND METHODS: A prospective study of neonatal intestinal obstruction at the University of Benin Teaching Hospital, Benin, Nigeria, between January 2006-June 2008. Data were collated on a structured proforma and analysed for age, sex, weight, presentation, type/date of gestation/delivery, aetiology, clinical presentation, associated anomaly, treatment, and outcome. RESULTS: There were 71 neonates, 52 were males and 19 were females (2.7:1). Their age range was between 12 hours and 28 days (mean, 7.9 +/- 2.7 days) and they weighed between 1.8 and 5.2 kg (average, 3.2 kg). The causes of intestinal obstruction were: Anorectal anomaly, 28 (39.4%); Hirschsprung's disease, 8 (11.3%)' prematurity, 3 (4.2%); meconeum plug, 2 (2.8%); malrotation, 6 (8.5%); intestinal atresia, 8 (11.3%); necrotising enterocolitis (NEC), 4 (5.6%); obstructed hernia, 4 (5.6%); and spontaneous gut perforation, 3 (4.2%). Also, 27 (38%) children had colostomy, 24 (33.8%) had laparotomy, 9 (12.8%) had anoplasty, while 11 (15.4%) were managed nonoperatively. A total of 41 (57.7%) neonates required incubator, 26 (36.6%) needed total parenteral nutrition, while 15 (21.1%) require d paediatric ventilator. Financial constraint, late presentation, presence of multiple anomalies, aspiration, sepsis, gut perforation, and bowel gangrene were the main contributors to death. Neonates with lower obstructions had a better outcome compared to those having upper intestinal obstruction ( P < 0.0001). CONCLUSION: Outcomes of intestinal obstruction are still poor in our setting; late presentation, financial constraints, poor parental motivation and lack of basic facilities were the major determinants of mortality.