Acute ileus following ventriculoperitoneal shunt: case report

A three month old girl with progressive hydrocephalus from birth had a ventriculoperitoneal (VP) shunt, during which the cerebrospinal fluid (CSF) was found to be xanthochromic. She developed acute ileus four hours post-operatively and continued to deteriorate. The shunt was exteriorised as an external ventricular drain. She did well and another VP shunt was inserted later. Acute ileus following VP shunt is not common, but can occur in the presence of xanthochromic CSF. It is advisable that when such CSF is encountered during VP shunt, the initial management should be external ventricular drainage, followed later by VP shunt when the CSF becomes clear. This can be life saving.

Gastrointestinal injuries from blunt abdominal trauma in children

OBJECTIVE

To determine the pattern, presentation and outcome of gastrointestinal injuries from blunt abdominal trauma in children.

DESIGN

A retrospective study.

SETTING

Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.

SUBJECTS

Twenty one children managed for gastrointestinal injuries from blunt trauma from 1984-2002.

MAIN OUTCOME MEASURES

The pattern, presentation, management and outcome of gastrointestinal injuries from blunt trauma.

RESULTS

In the 19 year period, 1984-2002, 92 children were treated for blunt abdominal trauma, 21(23%) of who had injuries to the gastrointestinal tract. Three presenting after 24 hours had evidence of peritonitis. In six children with isolated gastrointestinal tract (GIT) injury who presented within two hours, abdominal signs were vague at initial evaluation but became marked over a few hours at repeated examination. In eight with associated intraabdominal injuries, abdominal signs were marked at initial examination and five presented with shock. Free peritoneal air was present on plain abdominal and chest radiograph in three of ten patients, dilated bowel loops in six and fluid levels in one. Diagnostic peritoneal lavage or paracentesis was positive in four patients with isolated GIT injuries and eight with associated intraabdominal injuries. There were 24 injuries in the 21 patients consisting of 15 perforations, five contusions, two seromuscular tears, and two gangrene from mesenteric injury. The small intestine was involved in 11 patients, colon six, stomach five, duodenum one and rectum one. Seven (35%) patients had associated extraabdominal injuries. Treatment consisted of simple closure of perforations, over sewing of contusions, resection and anastomosis for gangrene and repair with protective stoma for the rectal injury. One patient each developed prolonged ileus, urinary tract infection and chest infection, respectively postoperatively. Mortality was 28%, all of who had associated intraabdominal or extraabdominal injuries.

CONCLUSION

Gastrointestinal injury from blunt abdominal trauma in children, though uncommon, carries a high mortality, usually from associated intraabdominal or extraabdominal injuries.

Osteomyelitis of the ischium: unusual presentation

A 7-year-old boy presented with urinary symptoms and umbilical discharge. A perivesical abscess was drained from which Staphylococcus aureus was cultured. He responded to antibiotics. Subsequently, he developed a discharging sinus in the gluteal region. A plain radiograph, which had previously been normal, confirmed osteomyelitis of the ischial bone.

Complications of scalp vein infusion in infants

The scalp vein is an invaluable route for venous access in infants. Complications are rarely reported.

Fournier's gangrene in neonates and infants

BACKGROUND

Fournier's gangrene is uncommon in childhood and little is known about the disease in this age group.

METHOD

A retrospective review was carried out of neonates and infants treated for Fournier's gangrene over a period of 16 years.

RESULTS

Twelve neonates and infants aged 5 days-3 months (median 3 weeks) were treated in our hospital. The precipitating cause was omphalitis in 7 babies, strangulated inguinal hernia in 2 and in 3 babies there was no identifiable cause. Gram-negative bacteria were cultured in 3 patients, but in most the culture was sterile. Treatment consisted of debridement of devitalised tissue and administration of broad-spectrum antibiotics. Primary closure was achieved in 1 baby and secondary closure in 2 others. In 7 babies the wound contracted rapidly and healed. There was no mortality.

CONCLUSION

Fournier's gangrene in neonates and infants in our environment is largely preventable. Early debridement and appropriate antibiotics give good results.

A rare left-sided abdominal wall defect

A 4-hour-old boy is presented here, who was born with a large abdominal wall defect situated in the left flank. Silo closure was necessary due to the large size of the defect. A Medline search up to December 2002 revealed only 2 other left-sided abdominal wall defects distant from the umbilicus. The possible embryology of this anomaly is discussed.

Adhesion intestinal obstruction in children in northern Nigeria

In developing countries, reports on adhesion intestinal obstruction in children are scanty. We report 30 children managed for adhesion intestinal obstruction during a 16-year period. The age range was 10 weeks-14 years (median 9 years). There were 24 boys and 6 girls. Postoperative adhesion was the cause in 13 (43%) patients, inflammatory in 11 (37%), and in 5 (17%) no cause could be identified. In one patient, adhesion followed missed ileal perforation from blunt abdominal trauma. Duration of symptoms was 1-21 days (median 4 days). Only four of the 13 patients with postoperative adhesion obstruction were managed conservatively initially, but this failed in all; one was found to have an intestinal perforation at laparotomy. The remaining nine had immediate laparotomy owing to presence of features of strangulation at presentation; two required intestinal resection for gangrene. All other patients had laparotomy soon after resuscitation. The resection rate for gangrene was 13% and 3% required closure of perforations. Postoperatively six (20%) patients developed eight infective complications. There was recurrence in three of 27 (11%) surviving patients within 3 months. Mortality was three (10%). The presentation of adhesion intestinal obstruction in children in northern Nigeria is late and morbidity and mortality are high. Early presentation should improve the outcome.

Acute scrotum in Nigeria: an 18-year review

One hundred and seventy-eight patients presenting with an acute scrotum during a period of 18 years (1978-1997) were reviewed retrospectively. Fifty per cent had testicular torsion, with a mean age of 23 years (range 3 weeks-55 years). Torsion was significantly more common in the cold harmattan season (October-early March). The salvage rate of torted testes was 52%. Inguinoscrotal hernia was the cause of testicular infarction in 10% and is an important contributor to male infertility. Twelve per cent of cases of suspected torsion were found to have epididymo-orchitis, at exploration. Twenty-three (13%) patients presented with scrotal gangrene (Fournier's gangrene) which did not result in testicular loss. There was significant morbidity following intervention by non-doctors, and misdiagnosis from unsuspecting physicians. The acute scrotum affecting young patients is a significant cause of male infertility and morbidity in Zaria. Early recognition, prompt treatment and re-education of those who may provide the first line care for such patients will reduce the morbidity and pathologic consequences following neglect.

Infected hydrocoele of the canal of Nuck in a neonate

Hydrocoele of the canal of Nuck is an uncommon presentation in the neonate and complications are rare. A 6-day-old girl presented with a right groin swelling from birth. The swelling remained static until age 3 days when it increased rapidly in size. There was no fever or gastrointestinal symptoms. Physical examination showed a large nontender mass extending from the right groin into the ipsilateral labium majus with distortion of the external genitalia. Needle aspiration yielded cloudy fluid, which gave a growth of Klebsiella on culture. A hydrocoele of the canal of Nuck was confirmed at surgery and was excised. Postoperative course was uneventful and there has been no recurrence at 2 years of follow-up.

Scrotoshisis, bilateral extra-corporeal testicular ectopia and testicular torsion

Although anomalies of testicular descent are common, scrotoschisis and extracorporeal testicular ectopia is rare with only 3 reported cases in literature. This is a report of a neonate presenting with scrotoschisis and bilateral extracorporeal testicular ectopia. The right testis underwent torsion before presentation, resulting in gangrene of that testis, requiring orchidectomy. The scrotum was explored and the viable left testis placed in the scrotum and fixed in that position. The left testis has remained normal at 9 months of follow up. The possible embryology and management of this curious anomaly is discussed.

Providing safe surgery for neonates in sub-Saharan Africa

Advances in neonatal intensive care, total parenteral nutrition and improvements in technology have led to a greatly improved outcome of neonatal surgery in developed countries. In many parts of sub-Saharan Africa, however, neonatal surgery continues to pose wide-ranging challenges. Delivery outside hospital, delayed referral, poor transportation, and lack of appropriate personnel and facilities continue to contribute to increased morbidity and mortality in neonates, particularly under emergency situations. Antenatal supervision and hospital delivery needs to be encouraged in our communities. Adequate attention needs to be paid to providing appropriate facilities for neonatal transport and support and training of appropriate staff for neonatal surgery. Neonates with surgical problems should be adequately resuscitated before referral where necessary but surgery should not be unduly delayed. Major neonatal surgery should as much as possible be performed by those trained to operate on neonates. Appropriate research and international collaboration is necessary to improve neonatal surgical care in the environment.

Complicated umbilical hernias in children

Umbilical hernia is a common problem in children, particularly in Africans, but complications in these hernias are thought to be rare. In a retrospective study of 47 children presenting for umbilical hernia repair in 14 years, 30 had complications. The complications included acute incarceration 15, recurrent incarceration 10 and spontaneous evisceration 5. Of the 15 with acute incarceration, 2 required bowel resection for gangrene, and an abscess formed in the hernia sac in one. The age of patients with acute incarceration was 2 months-8 years (median 5 years). The 10 with recurrent incarceration were aged 1-3 years (median 3 years). Of the 5 with spontaneous evisceration, one had umbilical sepsis and another intestinal obstruction from intussusception. These patients were aged 3-12 weeks (median 7 weeks). All the complications occurred in hernias that were 1.5 cm or more in diameter. The hernias were repaired using standard methods. Postoperatively, 2 patients developed wound infection. There was no mortality. Though complications of umbilical hernias appear to be rare, there is a need for more active observation of these hernias to identify complications early and treat promptly to avoid morbidity.

Perianal abscess and fistula in children in Zaria

Perianal abscess (PAA) and fistula-in-ano (FIA) are not uncommon in children, but reports from tropical Africa are uncommon. In a period of 17 years, 17 children aged 12 years and below were treated for these conditions in Zaria, Nigeria. There were 14 boys and 3 girls, aged 4 months-12 years (median 3 years), Eight had PAA (median age 3 years), 5 ischiorectal abscess (median age 5 years) and 4 FIA (median age 10 months). FIA followed pull through for anorectal malformation in 2 patients and in one it was preceded by PAA. PAA was associated with chronic fissure-in-ano in one patient and uncontrolled diabetes mellitus in one. One 16-month girl with an ischiorectal abscess developed severe perineal necrotising fascitis and separation and retraction of the anorectum. Escherichia coli was cultured in 2 patients with abscesses and staphylococcus aureus in another 2. Culture was sterile in 7 patients with abscesses. Treatment was by adequate incision and drainage for abscesses. Fistulectomy was the treatment for FIA, but in one patient a diversion colostomy was performed in addition as the fistula was a high one. The child who developed necrotising fascitis had debridement and diversion colostomy. FIA recurred in one patient necessitating repeat fistulectomy. Although the number of patients is small, perianal sepsis appears to be less common in our environment compared to developed countries. Some differences are highlighted.

Bilateral pneumothorax complicating miliary tuberculosis in children: case report and review of the literature

An 11-year-old boy presented with a 4-week history of fever and 2 weeks later developed a cough with breathlessness. His chest X-ray showed bilateral miliary shadows with pneumothorax on the left side. While on antituberculous therapy which was started on admission, he developed right-sided pneumothorax with significant collapse of the left lung. He was managed by tube thoracotomy with underwater seal but died 4 hours after the procedure was completed.

Colorectal perforation following barium examination in children

Barium contrast study is a frequently performed investigation in children, but colorectal perforation complicating the procedure is uncommon. A 2-month-old boy suspected of having Hirschsprung s disease developed an intraperitoneal rectal perforation following barium enema for which repair and diversion colostomy was performed. Another 4-year-old boy with Hirschsprung s disease and a transverse colostomy developed a colorectal perforation during distal colostogram using barium and was managed non-operatively. Both patients are well. The management of this uncommon complication is discussed.

Morbidity and mortality of inguinal hernia in the newborn

In an 11 year period, 17 newborns aged < or = 42 days had repair of 21 inguinal hernias. Eleven 52%) of the hernias were incarcerated or strangulated, necessitating bowel resection in 4 (36%) and orchidectomy for testicular infarction in 2 (18%). Only 4 babies with 7 hernias had elective herniotomy for uncomplicated hernia. In one baby with Hirschsprung's disease (bilateral hernia) and another with anorectal malformation, herniotomy was performed at the time of initial colostomy. Postoperatively, wound infection occurred in 4 (36%) of the 11 incarcerated or strangulated hernias (3 had bowel resection). One baby who had intestinal resection died from overwhelming infection. The median hospital stay in babies with uncomplicated hernia was one day and 4 days in those with complicated hernia. The morbidity of incarcerated and strangulated inguinal hernia in newborns is high, with attendant risk of bowel gangrene and testicular infarction. The principle of early referral and repair of inguinal hernias should be encouraged to avoid such morbidity and possible mortality.

Colostomy in the newborn: technical pitfalls

Colostomy is a commonly performed procedure in the neonatal period but the procedure is frequently underestimated. This report is aimed at raising awareness to technical errors made in performing the procedure. In a period of 4 years, 5 patients who had colostomy in the neonatal period developed problems, which were attributed to errors made in performing the procedure and have been retrospectively reviewed. In 3 patients, the sigmoid colon was erroneously used for transverse colostomy resulting in poor function. There was increased blood loss and increase in operation time from colostomy take down at subsequent definitive surgery in all 3. In one other patient, the ileum was mistaken for the transverse colon and opened, requiring closure; the closure leaked necessitating laparotomy, resection and anastomosis but death occurred from peritonitis. The fifth patient developed stoma necrosis due to ligation of the marginal artery and narrow fascial opening. Colostomy refashioning was necessary but death occurred from overwhelming infection. The colostomies were performed at a peripheral hospital and by unsupervised residents. Colostomy in the newborn can be associated with significant morbidity and mortality and great care is necessary to avoid these. Some technical points to avoid these errors are highlighted.

Major complications of omphalitis in neonates and infants

Omphalitis is a common problem in developing countries, and a wide range of complications requiring surgery may occur. We conducted a retrospective review of 19 neonates and infants treated for major complications of omphalitis: 13 boys and 6 girls aged 5-75 days (median 33 days). Five (26%) patients presented with spontaneous evisceration of small bowel through the umbilical cicatrix, resulting in intestinal gangrene in 1. Necrotizing fasciitis (NF) occurred in 5 (26%) patients involving mainly the scrotum, and in 2 involving the penis as well. Three (16%) patients had peritonitis, resulting in intra-abdominal abscesses in 2. Three (16%) had superficial abscesses, 2 (11%) had hepatic abscesses resulting in extensive destruction of the left lobe in 1, and 1 (5%) developed an adhesive intestinal obstruction. Although Staphylococcus aureus was the most commonly cultured organism, many cultures were sterile due to the use of antibiotics before presentation. Treatments consisted of repair of the umbilical cicatrix for evisceration (and intestinal resection for gangrene), radical debridement for NF, drainage and lavage for peritonitis, drainage of superficial abscesses, and lysis of adhesions. Broad-spectrum antibiotics were also given. No patient developed tetanus. One patient died from peritonitis. There was no death from NF. As serious complications may result from omphalitis in neonates and infants, with high morbidity and possible mortality, early recognition and prompt treatment are necessary for a good outcome.

The morbidity and mortality of right hemicolectomy for complicated intussusception in infants

Infants with intussusception in tropical Africa frequently present late. Intestinal resection for gangrene or perforation may warrant a right hemicolectomy. Over a period of 11 year, 15 (45.5%) of 33 infants with intussusception required bowel resection, 10 of which were right hemicolectomies. The age range of those who had right hemicolectomy was 3-9 months (median 6 months) and duration of symptoms 3-8 days (median 6 days). In addition to features of intussusception, seven (78%) infants were dehydrated and one was anaemic. Six (67%) of 9 infants developed procedure related complications postoperatively. Four (44%) had anastomotic dehiscence, associated with abdominal wound dehiscence in 2. In 3 of the patients, the anastomosis leaked again following repeat resection and anastomosis, necessitating relaparotomy and stoma formation. One (11%) patient each had wound infection and prolonged ileus respectively. Six (67%) patients died, including the 4 who had anastomotic dehiscence. The cause of death was overwhelming infection in 4 patients and aspiration of vomitus in two patients. Recommendations are made to minimize morbidity and mortality in these infants.

Spontaneous scrotal faecal fistula in infants

Two infants aged 29 and 43 days, respectively, presented with a spontaneous scrotal faecal fistula from a strangulated inguinal hernia. There was associated necrotising fasciitis of the scrotum in both patients, but the testes were spared. Resection and anastomosis along with debridement of the scrotal fasciitis was successful in both cases. This complication is rare: only three other cases have been reported in the world literature. The complication appears to occur mainly in developing countries, and is the result of late presentation. The principle of early referral and repair of childhood inguinal hernias should reduce this complication and the attendant morbidity and mortality.

The morbidity and mortality of laparotomy for uncomplicated intussusception in children

Non-operative management by pressure reduction is now the preferred treatment for uncomplicated intussusception in children. However, in many developing countries, laparotomy is routinely performed for such cases. This is a retrospective anlaysis of 24 children who had operative reduction of intussusception. The age range was 3 months--10 years (median 7 months) and duration of symptoms 12 hours--7 days (median 2 days). The main features were abdominal pain, vomiting and rectal bleeding. Ten (42%) patients had varying degrees of dehydration, which were corrected. At laparotomy, the intussusceptions were reduced without difficulty. Thirteen (54%) patients developed 15 procedure related complications including wound infection 6(25%), ileus 2(8%), stitch sinus 2(8%), incisional hernia 2(8%), intestinal obstruction from adhesions resulting in intestinal gangrene 2(8%) and aspiration pneumonia 1 (4%). Mortality was 2( 8%) from aspiration pneumonia and overwhelming infection due to intestinal gangrene from adhesive intestinal obstruction respectively. Laparotomy for uncomplicated intussusception in children is attended by significant morbidity and mortality. Many of such intususceptions, may be successfully managed by pressure reduction and children should not be denied the benefits of this form of treatment.

Small intestinal leiomyoma in childhood: a case report

A 6-year old girl presented with a painless, progressive abdominal mass for 4 weeks without alteration in bowel habits. Physical examination showed a non-tender, irregular and mobile abdominal mass. Abdominal ultrasonography was unable to define the exact origin of the mass. An ileal tumour was found at laparotomy necessitating resection and anastomosis. Histology confirmed an intestinal leiomyoma. The patient has remained well at 3.5 years of follow up. Leiomyomas of the small intestine are rare in childhood. This report discusses the presentation, diagnosis and management of this condition by briefly reviewing the literature.

Intralingual foregut duplication cyst: a case report

A 20-month old girl presented with an intralingual cyst from birth, which interfered with feeding but not respiration. The cyst was completely excised and histology of the wall showed an epithelial lining of stratified squamous and respiratory type epithelium. There has been no recurrence and function of the tongue has remained normal.

Isolated rupture of an accessory liver from blunt abdominal trauma in childhood

An accessory liver is uncommonly encountered in surgical practice. It can rarely cause acute abdominal pain. An isolated injury to an accessory liver from blunt trauma in a 10-year-old boy caused major intraperitoneal haemorrhage. Laparotomy and excision of the lacerated accessory liver lobe was necessary; the patient recovered uneventfully. The literature on accessory liver is reviewed.

Hirschsprung's disease in the newborn: experience in Zaria, Nigeria

In a 10-year retrospective review of 15 newborns aged < or = 42 days presenting with Hirschsprung's disease, there were 12 boys and three girls aged 4-42 days (median 18 days). Twelve babies presented with complete intestinal obstruction. In 12 babies, there was a history of delayed passage of meconium (after 2-6 days). One baby each developed caecal and sigmoid perforation. Barium enemas in three babies without complete intestinal obstruction suggested Hirschsprung's disease in two. Following resuscitation, the two infants who had perforated had caecostomy and sigmoid repair with right transverse colostomy, respectively. One infant had ileostomy for total colonic aganglionosis associated with ileal atresia. All the others had initial diversion colostomy. Rectal biopsies confirmed Hirschsprung's disease in all the babies. The ileum was injured during colostomy in one case, requiring repair. Postoperative anastomotic leakage occurred in the infant with ileal injury and colostomy necrosis occurred in another infant. Five babies (33%) died, three from overwhelming infection (caecal perforation, sigmoid perforation, ileal injury), one from hypokalaemia (ileostomy) and one from an unidentified cause. Few cases of Hirschsprung's disease present in the newborn period in our environment and, when they do, they usually present with complete intestinal obstruction with high morbidity and mortality.

Sigmoid volvulus and ileosigmoid knotting in children

Six children with acute intestinal obstruction from sigmoid volvulus (SV) (n=2) and ileosigmoid knotting (ISK) (n=4) are reported. The median age at presentation was 4.5 years (range 2 weeks-15 years). Abdominal pain, distention, vomiting, and constipation were the main features. Two patients with ISK had bowel gangrene. In three children there was no identifiable cause; two had a narrow attachment of the sigmoid mesocolon with redundant colon and one had adhesive bands. Treatment was by resection and colostomy in five cases and derotation of the torted colon in one. One child with SV died following a wound infection. There was no recurrence. SV and ISK are uncommon in children. There are usually no features specific for these conditions, and the diagnosis is established at laparotomy. The prognosis is good when there is aggressive resuscitation and prompt surgery.

Gastrointestinal obstruction from phytobezoar in childhood: report of two cases

This is a report of two children aged twenty seven months and six years respectively presenting with gastrointestinal obstruction from phytobezoar. In the 27-month old child, laparotomy and gastrotomy was performed to evacuate the bezoar. However, death occurred from hypokalaemia. The six-year old child had a sacro-abdomino-perineal pull through for anorectal malformation previously and the bezoar lodged just above the neoanus. Neoanal dilatation allowed removal of the bezoar and relief of the obstruction. There has been no recurrence. The literature on bezoar is briefly reviewed.

Bowel resection in children

BACKGROUND

In developed countries, most bowel resections in children are for congenital anomalies and massive resection and short bowel syndrome are frequent problems.

OBJECTIVE

To review indications, morbidity and mortality of bowel resection in children in a developing country.

DESIGN

A retrospective study.

SETTING

Ahmadu Bello University Teaching Hospital Zaria, Nigeria.

SUBJECTS

Forty six children aged < or = 12 years who had bowel resection in a period of five years.

RESULTS

The commonest indication was typhoid perforation 25 (54%), 21 (84%) of them aged > 5 years. Intussusception was the indication in eight (17%), six less than one year. Bowel resection was performed for congenital anomalies in nine (18%) patients, seven of them < 1 month (abdominal wall defect in four, intestinal atresia in two, strangulating inguinal hernia in one, strangulating band in one, Meckel's diverticulitis, one). Resection for trauma and neoplastic conditions were few (2.4% each). Twelve patients (26%) developed 17 complications including would infection in seven (15%) anastomotic dehiscence, five (11%), abdominal wound dehiscence, three (14%), intra-abdominal abscess and stitch sinus, one (2%) each respectively. Most of the complications followed right hemicolectomy for intussusception and resection for typhoid perforation. Massive bowel resection was necessary in only one patient. There were nine deaths (20%). The mortality was highest in neonates and infants (38%).

CONCLUSION

The indications for bowel resection in this environment differ from that in developed countries. Most of the indications (74%) are preventable by improvements in sanitation and early presentation and treatment. The morbidity and mortality are highest in neonates and infants and meticulous attention to technical details may minimise them.

Childhood achalasia in Zaria, Nigeria

OBJECTIVES

To study the presentation, management and outcome of achalasia of the oesophagus in children.

DESIGN

A retrospective case study.

SETTING

Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.

SUBJECTS

Seven children managed for achalasia of the oesophagus in a period of 19 years.

RESULTS

There were six boys and one girl. The median age at presentation was ten years (range three months to fifteen years). The median duration of symptoms before presentation was 20 months (range: 2-24 months). Three children were treated on several occasions for pneumonia before the diagnosis was made. Dysphagia, vomiting and regurgitation were the main presenting symptoms. Diagnosis was by barium oesophagogram. Six had modified Heller's myotomy via celiotomy and a Thal fundoplication in a three month old. Transthoracic Heller's myotomy was done in the seventh child. There was complete resolution of symptoms in six children. One patient had post-operative retrosternal pain, which was controlled by oral nifedipine.

CONCLUSION

Achalasia of the oesophagus should be excluded in children with recurrent chest infection. Modified Heller's myotomy without antireflux procedure via the abdominal route is effective in relieving symptoms of achalasia in children.

Anal injury and fissure-in-ano from sexual abuse in children

Ano-rectal injuries in children are generally uncommon, and those caused by sexual abuse are rarely reported in our environment. This is a report of two children aged 5 and 12 years who sustained anal injuries following anal sexual abuse. Both presented late with fissure-in-ano and were managed conservatively. Though fissure-in-ano is not uncommon in children, it might be necessary to exclude sexual abuse and undertake appropriate evaluation and treatment. The child must be protected from further abuse.

Intestinal malrotation: experience in Zaria, Nigeria

This report retrospectively reviews the presentation, management and outcome in 14 patients with intestinal malrotation. There were 7 males and 7 females, with a median age of 4 months (range 5 days-22 years). Most neonates and infants presented with persistent or recurrent vomiting while older children had recurrent abdominal pain. Five patients (36%) including 2, < 1 year and 3 older children developed midgut volvulus. Malrotation was an incidental finding at laparotomy for unrelated conditions in 2 patients (14%). Overall, preoperative diagnosis was not made in any patient. Associated congenital anomalies were present in 3 (21%) patients. Treatment was by Ladd's procedure in 12 (86%) patients and caecopexy in 2 (14%) without recurrence of symptoms in any. One patient each developed wound infection and adhesive intestinal obstruction requiring relaparotomy respectively. Mortality was 2 (14%) from overwhelming infection and hypokalaemia following midgut volvulus. Children presenting with recurrent or persistent abdominal pain, vomiting or failure to thrive may well have malrotation and should be investigated promptly and the condition corrected to avoid midgut volvulus which is attended by significant morbidity and mortality.

Cervical cystic hygroma: pre-, intra-, and post-operative morbidity and mortality in Zaria, Nigeria

The management of extensive cystic hygromas in the cervical region (CCH) presents difficult challenges. A retrospective study of 41 children with CCH treated over 24 years in Nigeria was carried out; there were 28 boys and 13 girls with an age range of 3 days to 10 years (median 6.5 months). Thirty-three (80%) presented with 34 life-threatening complications including infection in 11 (27%), rapid increase in cyst size in 10 (24%), respiratory obstruction in 7 (17%), and intracystic hemorrhage in 6 (15%). Complete excision was possible in only 14 of 34 (41%) patients, and injuries to neighboring structures occurred in 6 (18%) (facial nerve 2, recurrent laryngeal nerve 1, internal jugular vein 1, parotid duct 1, pharynx 1). Postoperatively, 8 (24%) patients developed 9 complications. Wound infections occurred in 5 incompletely-excised cysts and 2 patients had respiratory obstruction. One patient with a wound infection developed edema of the tongue lasting several days and drainage was prolonged (> 6 weeks) in 1. Five patients died, 3 from respiratory obstruction and 1 each from wound and chest infection. Four patients (12%) developed a recurrence within 5 years of surgery. The pre-, intra-, and post-operative morbidity were high in this series. Although complete excision is the ideal treatment for CCH, this need not be pursued if neighboring structures are liable to injury. When cysts are incompletely excised, antibiotic prophylaxis is necessary as the incidence of wound infection is high.

Emergency neonatal surgery in a developing country

With better understanding of neonatal physiology and improvements in diagnostic facilities and neonatal intensive care units (NICU), the outcome of neonatal surgery has improved in developed countries. In developing countries, however, neonatal surgery is problematic, particularly in the emergency setting, but there are few reports from these countries. A retrospective analysis of 154 neonates who had emergency surgery over a 10-year period at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, was undertaken. Emergency surgery represented 40% of surgical procedures in neonates in the hospital. The majority of the patients (94.8%) were delivered at home or in rural health centers. The median weight was 2.7 kg (range 2.0-3.7 kg). In 89 cases (58%) the indications for surgery were intestinal obstruction, anorectal malformations in 60(67%) and in 33(21%) complicated exomphalos or gastroschisis. Nine patients (6%) required surgery for ruptured neural-tube defects. A colostomy was the commonest procedure (51, 33%), 27(53%) of which were performed using a local anesthetic without adverse effects. Thirty-three abdominal-wall defects were closed by various methods (fascial closure 23, skin closure 6, improvised silo 4). Overall, 37 (24%) procedures were performed using local anesthesia. Fifty-nine patients (38%) developed postoperative complications (infections 33, respiratory insufficiency 16, colostomy complications 8, anastomotic leak 2). The mortality was 30.5%, 66% due to overwhelming infection, 28% to respiratory insufficiency, and 4.3% to multiple anomalies. Other factors considered to have contributed to morbidity and mortality were late referral and presentation and a lack of NICUs. Thus, emergency neonatal surgery is attended by high morbidity and mortality in our environment at the present time. Early referral and presentation and provision of NICUs should improve the outcome.

Right lobar pneumonia complicated by sub-phrenic abscess in a child

A 14-year old boy presented with chest and abdominal pain and fever for one week. He had been treated with several antibiotics at home and in a peripheral hospital for respiratory infection. Physical examination showed features of right lobar pneumonia and peritonitis. Chest radiograph showed consolidation in the right lower lung field and abdominal ultrasonography showed a subphrenic collection. At exploratory laparotomy, a right subphrenic abscess and general peritonitis without an intra-abdominal focus were found. The abscess was drained and broad-spectrum antibiotics given. Death, however, occurred from overwhelming infection. Subphrenic abscess complicating pneumonia is unusual but can be the cause of poor response to treatment. The diagnosis should be excluded in a child with pneumonia and persisting abdominal symptoms. Prompt treatment is necessary to avoid morbidity and mortality.

Necrotizing fasciitis of the scalp in a neonate

We report an 11-day-old baby who presented with necrotizing fasciitis of the scalp from which Escherichia coli was cultured. Treatment consisted of administration of parenteral broad-spectrum antibiotics and debridement. Skin grafting of the resulting scalp defect was not permitted by the parents. The wound healed with scar tissue over 3 months.

Neonatal intestinal perforation in a developing country

Between 1990 and 1999, 14 neonates with intestinal perforation were treated at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Median age at presentation was 9 days and median weight 2.65 kg. Five had high anorectal malformation, three Hirschsprung's disease and two ruptured exomphalos with bowel strangulation. Gastroschisis, strangulated inguinal hernia, ileal atresia and umbilical sepsis with evisceration accounted for one case each. Two of the perforations were iatrogenic during colostomy construction. Seven perforations were in the small bowel and seven in the colorectum. Three neonates had oedema and tenderness of the anterior abdominal wall, and pneumoperitoneum was seen in abdominal radiographs in two. All the infants had laparotomy, four under local anaesthesia, after resuscitation. Three had simple suture of the perforation, five had resection with primary anastomosis and six had exteriorization colostomy. Overall, eight (59%) died, five with colorectal perforation and three with small bowel perforation.

Meckel's diverticulitis due to Taenia saginata: case report

A thirteen-year old girl presented with acute right lower quadrant abdominal pain for which evaluation suggested appendicitis. At laparotomy, the appendix was normal but a Meckel's diverticulum with an impacted Taenia saginata (tapeworm) was found. The diverticulum was excised and histopathology confirmed diverticulitis from the parasite. Though Meckel's diverticulitis due to parasites has been reported, this is usually from ascaris. Tapeworm causing this complication is rare.

Acute (haematogenous) osteomyelitis of the skull in childhood

A 13-year old boy presented with a 2-week history of right frontotemporal headache, fever and progressive painful swelling in that region. There was no preceding trauma. Clinical and radiological evaluation confirmed osteomyelitis of the right frontal bone. Staphylococcus aureus was found to be the causative organism. The affected bone was debrided and appropriate antibiotics administered. A subdural abscess developed requiring drainage. Hospital stay was 8 weeks. Haematogenous (pyogenic) osteomyelitis of the skull is rare in childhood and diagnosis may be missed or delayed. A high index of suspicion is necessary to make an early diagnosis and to avoid morbidity and mortality.