The transverse penile pedicled flap urethroplasty: description of a simplified technique for the dissection of the Fascio-cutaneous flap.

INTRODUCTION/OBJECTIVE: Urethroplasty is often required for long urethral strictures or urethral strictures that have recurred after repeated urethral dilatations or urethrotomy. The transvers penile skin pedicled flap is very versatile for the reconstruction of long urethral stricture. However the meticulous sharp dissection required to develop it takes a long time to do and may be associated with button hole injuries to the vascular pedicle and the penile skin. We describe a simplified technique of raising the flap which does not require sharp dissection and is very quick to accomplish. METHOD: Technique involves using a circumcising distal penile shaft skin incision to de-glove the penis by blunt dissection. The skin substitute, adequate to give appropriate urethra calibre is similarly dissected bluntly along with its vascular pedicle from the proximal penile skin. The techniques used to facilitate successful blunt dissection are described. RESULT: In 9 adults with long, multiple urethral strictures, the average time to develop the flap was 15 minutes and complication have been limited to temporary urethro-cutaneous fistula at the ventral part of the circular skin closure. These fistulae closed on conservative treatment. No patient suffered button-hole injuries to either the vascular pedicle or the penile skin. CONCLUSIONS: This modification to the standard sharp dissection is very quick to accomplish. It also avoids the creation of button-hole injuries to either the vascular pedicle or the penile skin. It should make the use of this versatile flap more attractive in the reconstruction of long urethral strictures in those who may wish to use this option for reconstruction of long urethral strictures.

Regional anaesthetic technique for laparoscopic appendicectomy in Ibadan.

BACKGROUND: Laparoscopy is now readily being deployed for abdominal surgeries in our centre, thanks to the surgeons' interest and the desire to follow best practice as obtained in other climes. General anaesthesia (GA) with intermittent positive pressure ventilation is usually the preferred mode of anaesthesia for this procedure. There are reports of laparoscopic surgery of abdomen performed under spinal and or epidural anaesthetic techniques. METHODS: With Intra-Abdominal Pressure (IAP) from CO2 insufflations limited to 10-12 mmHg, Laparoscopic Appendicectomy (LA) was performed under Combined Spinal Epidural (CSE) for ten consenting ASA 1 and II patients with mean age 23.6 years and BMI of 24.9 kg/m2 in University College Hospital Ibadan, Nigeria. Intra-operative events and ease of operation were studied; systemic drugs were administered if patients complained of pain and discomfort, and G.A if regional techniques and sedation failed. RESULTS: Eight(8) patients had the procedure completed under spinal anaesthesia supplemented with sedation, two (2) patients whose block went as high as T4 had no need of sedation. There were operative difficulties in four patients out of which 2 had sedations and the surgeons could continue operating. We converted to GA in two (2) patients when regional techniques and sedation failed. CONCLUSION: We concluded that with proper selection of patients and limiting IAP to 10-12 mmHg, LA can be safely performed with spinal anaesthesia with some supplementation.

Renal cell carcinoma in Ibadan: a 5-year clinicopathologic review.

BACKGROUND: To review all the cases of the patients with renal cell carcinoma seen during the study period and to determine the pattern of presentation, number of operable cases, histological types and outcome of treatment. MATERIALS AND METHODS: The data of the patients with renal cell carcinoma was retrieved from the Urology division audit book, theatre record books and case files from the health records department and pathology register in the department of pathology. The parameters studied were age, gender, pattern of presentation, number of patients who had surgery, histology types and the outcome of treatment. RESULTS: In total, there were 69 patients with renal cell carcinoma that accounted for 59.5% of all renal masses seen. The male to female ratio was 1:1. Their age ranged from 16 to 88 with a mean of 48 years and median of 50 years. The main clinical feature was loin swelling (100%) and others were loin pain (29%), hematuria (18.8%), weight loss (4%) and paraneoplastic syndrome (anaemia without haematuria) was seen in 2.9%. Ten percent of the cases had the classical triad of hematuria, loin pain and loin swelling. All cases were unilateral disease and 15 (21.7%) had metastasis at presentation. The pre-operative tests were abdominal ultrasound (94%), intravenous urography (45%) and CT-Scan (11.6%). Twenty eight patients (40.6%) had surgery of which 5 were unresectable. 37 of the patients (53.6%) were subsequently lost to follow-up. The 28 operative specimens were histologically confirmed and 85.7% were clear cell carcinoma. The 23 patients whose tumours were resected have remained symptom free, some up to 5 years. However the five patients with unresectable tumours died between 3 to 6 months of exploratory surgery. CONCLUSION: The patients with resectable tumour could remain disease free for a significant period afterwards despite late presentation. However, there is a high loss to follow-up rate.

Analgesic effect of intrathecal neostigmine combined with bupivacaine and fentanyl.

BACKGROUND: The spinal route of analgesia has consolidated its place as a major modality in the management of both acute and chronic pain. The search for ideal additives to local anaesthetic agents to prolong the analgesic effects poses a challenge to the anaesthetists. Neostigmine, an anticholinesterase, presents a novel approach to providing analgesia. Neostigmine, when given intrathecally, inhibits breakdown of an endogenous spinal neurotransmitter, acetylcholine, thereby inducing analgesia. We aimed to determine the analgesic and adverse effects of intrathecal neostigmine combined with hyperbaric bupivacaine and fentanyl. METHOD: Sixty male adults, ASA I-II requiring lower abdominal surgical procedures under spinal anaesthesia were randomly allocated to 2 groups: Neostigmine group, received intrathecal (IT) 0.5% hyperbaric bupivacaine 15 mg, fentanyl 25 microg and preservative-free neostigmine 25 microg while saline group, received same dose of bupivacaine and fentanyl plus 0.5 ml saline. The duration of analgesia, time to use first rescue analgesics and the incidence of adverse effects were recorded. RESULTS: The mean duration of effective analgesia was 485.6 +/- 37.6 minutes in neostigmine group compared with saline group, 316.0 +/- 49.15 minutes, p < 0.001. Total analgesic consumption 12 hours post-intrathecal injection was also less in the neostigmine group. The incidence of adverse effects such as hypotension, bradycardia, nausea and vomiting were not statistically significant in both groups, p > 0.05. CONCLUSION: This study showed that spinal neostigmine 25 microg added to hyperbaric bupivacaine and fentanyl provided a significantly longer surgical analgesia and insignificant adverse effects in male adults who had lower abdominal surgery under spinal anaesthesia.

An audit of mandibular defect reconstruction methods in a Nigerian Tertiary Hospital.

AIMS AND OBJECTIVES: To audit methods of mandibular defect reconstruction used in our institution. MATERIALS AND METHODS: A retrospective study of mandibular bone reconstruction at the University College Hospital Ibadan between January 2001 and December 2007. Relevant records were retrieved from patients' case notes and operation register. Comparative analysis of various methods of reconstruction was done by assessing treatment outcomes such as restoration of continuity and stability, graft infection, extrusion and fractures. RESULTS: Only 65 of the 82 patients that had mandibular continuity defect during the study period had reconstruction. Ameloblastoma accounted for 67% [n=55] of pathologies that required mandibular resection. Methods of reconstruction included non vascularised iliac bone anchored with either stainless steel wire (NVIBw) [n=38] or titanium plate (NVIBp) [n=9], titanium reconstruction plate [n=4] Steinman pin [n=12], rib graft [1] and acrylic plate temporisation [n=1]. The findings showed that titanium plate and NVIBp had the least complications in terms of infection, graft extrusion, fracture and wound dehiscence. NVIBw and Steinman pin had the highest infection rates. CONCLUSION: We recommend the use of NVIBp and titanium reconstruction plate as they have the least complication rate. We also advocate future prospective study.

Predictive variables for difficult intubations in oral and maxillofacial surgery.

SUMMARY: Many factors affect the difficulty of endotracheal intubation some of which are related to the condition of the patients. A few assessment tools have been developed to predict intubation difficulty but none is all inclusive thereby being inadequate for comprehensive and accurate evaluation. We assessed the usefulness of four categories of predictive variables namely; the LEMON score, Demographic indices, Tumour site and Intraoral Position of tumour (IOP), in predicting intubation difficulty among a group of patients with orofacial tumours. By statistical analysis, a significant correlation between predictions by LEMON score and actual intubation difficulty was observed while neck mobility (P=0.28) and Mallampati scores (P=0.49) were the most important criteria in the scoring system. Significant association was also observed with demographic indices and difficulty whereby the Optimal Interincisal Distance (OID) had the greatest impact (P=0.048). There was no difference in the difficulty posed by the different sites and intraoral positions of tumours in this study. We therefore suggest the adoption of the LEMON score and consideration of the demographic indices when assessing patients with orofacial tumours for intubation difficulty. Three important variables should be given greater value, these are, neck mobility, Mallampatti score and optimal interincisal distance.

The effects of magnesium sulphate-pretreatment on suxamethonium-induced complications during induction of general endotracheal anaesthesia.

To determine the effects of Magnesium-Sulphate-pretreatment on Suxamethonium-induced complications (serum potassium rise, fasciculations and apnea). Eighty-four adult patients were selected and randomly allocated into two study groups during induction of general endotracheal anaesthesia. Endotracheal intubation was facilitated with suxamethonium in group A, while in group B magnesium sulphate pretreatment and suxamethonium. Blood sample for serum potassium estimation was taken before induction and at 5 min after induction. Degree of fasciculations and duration of apnea were assessed clinically. Anaesthetic technique and monitoring of patient was standardized. This study showed statistically significant increase in serum potassium of Group A patients {average 0.34 mmol/L} from baseline value p value 0.00. Magnesium sulphate pretreatment significantly reduced suxamethonium-induced hyperkalaemia by an average of 0.3 mmol/L (p-value 0.01). The severity of fasciculations was also significantly reduced (p-value 0.00). There was no significant effect of magnesium pretreatment on duration of apnea during endotracheal intubation (p-value 0.41). Fourteen point six percent (14.6%) of patients that received magnesium pretreatment complained of feeling of heat or warmth but there was no life threatening dysrrhythmias observed in any of the eighteen patients that had continuous ECG monitoring. The study shows that magnesium sulphate pretreatment has significantly reduced suxamethonium-induced hyperkalaemia and severity of fasciculations during induction of general endotracheal anaesthesia, however there was no significant effect on the duration of apnea. The average of 0.034 mmol/L in Group B was not significant {p value 0.06}. We advocate the use of magnesium pretreatment in all patients at risk of these complications.

An evaluation of open tracheostomy in oral and maxillofacial surgery

This study was carried out to evaluate the indications; utilisation and the overall impact of tracheostomy on the practice of Oral and Maxillofacial Surgery at the University College Hospital; Ibadan; Nigeria. In a retrospective study of a total of 381 patients operated under general anaesthesia by the Department of Oral and Maxillofacial Surgery within the study period; 41 patients (10.8) were tracheostomised. There were 26 males and 15 females with a ratio of 1.7:1 and the mean age was 28.9 years (SD = 12.25; range of 5 - 65 years). Indications for tracheostomy were orofacial tumours 70.7 (n=29); trauma 19.5 (n=8); temporomandibular joint (TMJ) ankylosis 7.3 (n=3) and post operative airway obstruction 2.4 (n=1). Orofacial tumours account for a major part of the indication for tracheostomy as a surgical airway intervention which is safe and with low morbidity

Prevalence of venous thromboembolism at post-mortem in an African population: a cause for concern.

Venous thromboembolism (VTE) remains a fatal complication and a frequent cause of death among patients hospitalized for remediable and often minor conditions. Various prevalence and associated risk factors of VTE have been documented in different parts of the world. It has been reported that the prevalence of VTE in Africans and Asians is not as pronounced as it is in the Caucasians. However, there is still a relative paucity of information about the prevalence of VTE and its associated risk factors in Nigeria, which is an African population. Data was collected retrospectively from records of post-mortem reports at the University College Hospital, Ibadan, Nigeria between January 1991 and December 1998. Of the 989 autopsies documented within the 8-year period, 29 autopsies confirmed VTE. This indicates a prevalence of 2.9%. Sixty five percent of the subjects were older than 40 years and male to female ratio was 2.6:1. Hence the condition is more prevalent in males than females. Malignancy was the commonest predisposing risk factor for VTE (37.9%). Other predisposing factors included immobility for more than 4 days (27.6%), neuromuscular paralysis (24.1%), septicaemia (20.7%), multiple trauma involving the pelvis, abdomen and head (17.2%), major surgery (13.8%), congestive cardiac failure (3.4%) and obesity (3.4%). This study highlights the need to have a closer look at this grave but preventable and treatable health condition. VTE is a preventable and treatable condition, especially where haematological services, intensive care management and good pre-emptive physiotherapy are available. Thus, mortality from this condition should be considered as a cause for concern even in a poorly funded health care delivery system such as in Africa. It is therefore recommended that appropriate physical and pharmacological methods of prophylaxis should be prescribed according to the degree of risk of VTE in individual patients.

Combined general and epidural anaesthesia for excision of phaeochromocytoma--a unique and safe technique.

Surgical excision of phaeochromocytoma is usually associated with elevation of arterial blood pressure above 200 mmHg for some time irrespective of the use or not of preoperative alpha-adrenergic blockade. Attempts at controlling the elevated blood pressure usually involve the use of many drugs through induction, maintenance, termination and post operative period. We recently used a combined general and epidural anaesthesia for excision of a huge phaeochromocytoma in a 24 yr old Nigerian lady with a satisfactory outcome. The combined technique seemed to have modified the anaesthetic course considerably, resulting in the use of fewer drugs and a steady haemodynamic state which is very unusual in anaesthesising patients with phaeochromocytoma (see haemodynamic record Illustration II). Post-operative analgesia was provided with morphine given through the epidural catheter.

Surgery of toxic goitre in non-euthyroid patients: a preliminary report.

In recent years, the cost of medical care has skyrocketed and since medical treatment is not free, some drugs are now beyond the reach of some patients. One of such drugs is the antithyroid drug, carbimazole, which has been priced beyond the reach of our thyrotoxic patients. We have therefore been forced to operate on these patients whenever they present, even while thyrotoxic. The principle of our management is to anticipate the development of thyroid crises and to prevent its occurrence post-operatively by using saturated solution of potassium iodide (SSKI) or Lugol's iodine, propranolol, diazepam, and hydrocortisone. This is a preliminary report of the first twelve consecutive patients so treated.

Insecticide poisoning in pregnancy. A case report.

A 25-year-old multigravida drank an organochlorine insecticide in an attempt to commit suicide at 16 weeks of pregnancy. This resulted in the death of twin fetuses and vaginal bleeding. The pregnancy was terminated using gemeprost, syntocinon and later surgical evacuation of the uterus. She developed respiratory arrest after the fetuses were aborted and also after surgical evacuation. On both occasions, she was intubated and mechanically ventilated. We believe that organochlorine insecticides may be fetocidal. In addition, surges in blood levels may occur during termination of pregnancy, delivery or evacuation of retained products of conception.