Duodenal obstruction due to missed pre-duodenal portal vein in a patient with intestinal malrotation.

Pre-duodenal portal vein (PDPV) is a rare anomaly and a rare cause of duodenal obstruction (DO), with only a few cases reported in the literature. We present an infant whose bilious vomiting persisted despite having Ladd's procedure for intestinal malrotation due to a missed diagnosis of DO from PDPV that was found at re-exploration. The patient was diagnosed with malrotation and had Ladd's procedure at 12 weeks of age, but bilious vomiting persisted post-operatively. The patient presented to us after 4 weeks, was clinically malnourished and dehydrated, resuscitation was done and re-exploratory laparotomy performed, where an obstructing PDPV was found and a duodeno-duodenostomy was performed anterior to PDPV. However, the patient died on post-operative day 7 probably from severe malnutrition due to delayed diagnosis and absence of parenteral nutrition. We conclude that PDPV may be a cause of DO in infants with malrotation and should be properly sought for during Ladd's procedure for possible bypass surgery if found.

Assessing the Cost Burden of Pediatric Neurosurgery in Kaduna, Nigeria.

BACKGROUND: Few studies have evaluated the cost burden borne by neurosurgical patients in the developing world and their potential implications for efficient and effective delivery of care. This study aims to assess the cost associated with obtaining pediatric neurosurgical care in a hospital in Kaduna. METHODS: All patients younger than 15 years who had a neurosurgical operation from July to December 2019 were included in the study. The characteristics of the patients were obtained using a proforma while the cost data were retrieved from the accounts unit of the hospital. The direct cost was obtained from the billing records of the hospital. Indirect cost was obtained using a questionnaire. The data obtained were analyzed using SPSS version 25 for Windows. RESULTS: A total of 27 patients were included in the study with a mean age of 7.2 years and a standard deviation of 4.95 years. The 2 most common procedures done were craniotomy for trauma and ventriculoperitoneal shunt insertion for hydrocephalus. The mean total cost of a neurosurgical procedure was $895.99. Intensive care unit length of stay was found to have a significant influence on the direct cost. The cost of surgery and investigation were the main contributors to the total cost of care with a mean of $618.3 and a standard deviation of $248.67. CONCLUSIONS: The mean cost of pediatric neurosurgical procedures in our setting is $895.99, which is 40.18% of our gross domestic product per capita. The main drivers of cost are the cost of operation, investigations, and intensive care unit length of stay.

Trapped fourth ventricle: A case report and review of literature.

INTRODUCTION AND IMPORTANCE: Trapped fourth ventricle (TFV) also known as isolated fourth ventricle (IFV) is a rare clinico-radiologic entity with only a few cases reported in the literatures. The aim of this article is to present the first case of this condition in our center and highlight the challenges of arriving at clinical diagnosis and treatment in a resource limited setting. CASE PRESENTATION: An 18 months old girl who had ventriculoperitoneal shunt insertion for post meningitic hydrocephalus 4 months earlier presented with restlessness, ataxia, fever and inability to control her neck of one-week duration. On examination she was restless and had retro-colis with a Glasgow Coma Scale (GCS) score of 11/15 (E4V2M5). She had an associated facial and abducent nerve palsies with global hypertonia, hyper-reflexia and muscle power of 3/5. She was initially treated for shunt infection and malfunction. However, shunt series and CSF analysis were within normal limits and CSF culture yielded no growth of microorganisms. A CT scan of the brain which was ordered earlier was delayed for 10 days due to financial constraints. The CT scan revealed a trapped fourth ventricle and slit lateral and third ventricle. She had emergency fourth ventriculoperitoneal shunt inserted on the left because of the pre-existing supratentorial shunt on the right. She did well after the surgery and was discharged on the 10th postoperative day. She was doing well 12 months after the surgery. RELEVANCE AND IMPACT: TFV may occur after insertion of VPS for post-meningitic hydrocephalus. This may present a diagnostic dilemma. Insertion of a second VPS may be an option in a resource limited setting.

Single versus Double Burr Hole for Drainage of Chronic Subdural Hematoma: Randomized Controlled Study.

BACKGROUND: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical emergencies. Most neurosurgeons currently drained CSDH through single or double burr holes; however, few studies have compared the 2 approaches to drainage. The aim of this study is to compare the recurrent rate following double and single burr hole for CSDH in our practice. METHODS: This is a randomized controlled study from January 2015 to December 2019 in a neurosurgical unit in Kaduna, Nigeria. All patients with imaging diagnosis of subacute or chronic subdural hematoma who enrolled in the study had either a single or double burr hole. Patients were followed up for 6 months after surgery to assess for recurrence. Data were analyzed using SPSS version 25 for Windows. The Fisher exact test was performed to compare the 2 treatment groups. A 2-sided P value < 0.05 was considered statistically significant. RESULTS: A total of 192 patients were enrolled in the study with 99 in the single-burr hole group and 93 in the double burr-hole group. The overall recurrence rate in this study was 2.6%. The recurrence rate in the single arm was 3%, and in the double arm it was 2.2%. There was no statistically significant difference in recurrence between the 2 groups (P = 1.000). CONCLUSIONS: A single burr hole is as efficacious as a double burr hole in terms of relief of symptoms and recurrence, and it has a shorter duration of surgery.

Paediatric day-case surgery in a new paediatric surgical unit in Northwestern Nigeria.

BACKGROUND: Day-case surgery is defined as when the surgical day-case patient is admitted for investigation or operation on a planned non-resident basis and who nonetheless requires facilities for recovery. A significant number of our patients were treated as day cases. This study was conducted to audit paediatric day-case surgery practice at our centre, to determine the indications as well as morbidity and mortality from day-case surgeries. PATIENTS AND METHODS: This is a prospective study over a period of 14 months. The patients scheduled for surgeries were assessed in the paediatric surgical outpatient clinic and information obtained for each of the patients included age, sex, diagnosis, type of operation, type of anaesthesia and post-operative complications. The data were analysed using SPSS version 15.0 for windows. RESULTS: A total of 182 patients were operated during the study period. The age range of patients was 0.5-156 months and the mean age was 46.6 months. There were 152 male patients (83.5%) and 30 female patients (16.5%). Most of the patients had intact prepuce for circumcision (34.1%). Two patients who had herniotomy developed superficial surgical site infections which were managed as outpatients. There were no readmissions or mortality. CONCLUSION: Intact prepuce for circumcision as well as hernias and hydroceles is the most common day cases in our centre and is associated with low morbidity and no mortality.

Microsurgical Endoscope-Assisted Gravity-Aided Transfalcine Approach for Contralateral Metastatic Deep Medial Cortical Tumors.

BACKGROUND: Traditional approaches to deep medial cortical tumors utilize transcortical or ipislateral interhemispheric approaches, which can result in cortical damage or retraction injury. To reduce these risks, the microscopic transfalcine approach has been previously described. OBJECTIVE: To describe this approach performed with endoscopic assistance for metastatic tumor resection, demonstrating appropriate and safe tumor resection without injury to the contralateral hemisphere. METHODS: Eleven consecutive patients harboring medial, deep metastatic tumors are reported. Tumor resection was performed with endoscopic assistance with 2 surgeons. Clinical outcomes are recorded. RESULTS: All 11 patients underwent safe tumor resection. Gross total resection was achieved in 73% of patients. The application of the angled endoscope allowed for further tumor resection in 91% of patients. There were no complications in these patients. The contralateral brain did not demonstrate clinical or radiographic injury as well. CONCLUSION: This series suggests that the endoscopic transfalcine approach in the lateral position can be a safe and effective approach for resecting medial interhemispheric metastatic tumors. It allows excellent tumor visualization, eliminates the need for brain retraction, minimizes parenchymal transgression, and improves surgical ergonomics. A familiarity of endoscopy and neuroanesthesia support is helpful when utilizing this approach.

Endoscopic and Gravity-Assisted Resection of Medial Temporo-occipital Lesions Through a Supracerebellar Transtentorial Approach: Technical Notes With Case Illustrations.

BACKGROUND: Traditional approaches to medial temporo-occipital intra-axial brain tumors carry the risk of visual or language deficits related to brain retraction or transgression of deep fiber tracts. To reduce these risks, the microscopic supracerebellar transtentorial approach with the patient in the sitting position has been previously described for lesions in relative proximity to the tentorium. OBJECTIVE: We describe this approach performed with endoscopic tumor resection to allow better visualization and a more ergonomic operating position. METHODS: Four consecutive patients harboring a medial temporo-occipital lesion are reported. All were operated on while in the sitting position using frameless navigation and a supracerebellar transtentorial approach. Tumor resection was performed by 2 surgeons with endoscopic visualization. RESULTS: Pathologies included intraparenchymal metastatic melanoma, cavernous hemangioma, and ganglioglioma, as well as an intraventricular metastatic tumor. The distance from the tentorium to the lesion ranged from 1 to 4 mm. Gross total resection was achieved in 3 of the 4 patients. The patient with a metastatic melanoma had an intentional near-total resection given the tumor encasing a branch of the posterior cerebral artery. The patient with the intraventricular tumor sustained a small but symptomatic infarct of the lateral geniculate region, resulting in a visual field deficit. CONCLUSION: This small series suggests that the endoscopic supracerebellar transtentorial approach with the patient in the sitting position can be a safe and effective approach for removing medial temporo-occipital lesions. It allows excellent tumor visualization, eliminates the need for brain retraction, minimizes parenchymal transgression, and improves surgical ergonomics. Significant experience in endoscopy and excellent neuroanesthesia support are recommended before undertaking this approach.