Paediatric surgery in the rural setting: prospect and feasibility

This report is based on a 6-year experience with surgery in children in a rural hospital in Northern Nigeria. Paediatric surgery represents 6.6% of all paediatric work-load and 9.6% of all operative surgery. Majority of the operations were performed for congenital problems (40%) and less frequently infections (22%) and trauma (21%). Most of the infective and trauma problems were preventable. The mortality was 7.3%, due mostly to septic complications. Overall, 95% of the operations were not of complex nature and could be performed by general duty doctors with general surgical experience. These doctors who are more readily available in rural areas should be encouraged to perform these operations to reduce the economic and emotional burden on rural families. However, the more complex congenital conditions should always be referred early to specialist hospitals. Surgical conditions cause significant morbidity and mortality in children and should not be overlooked in the planning of child health care services in rural areas.

Colorectal adenocarcinoma in children and adolescents: a report of 8 patients from Zaria, Nigeria

Colorectal adenocarcinoma is predominantly a disease of the old and less than 1% of patients are below 20 years in most reports. Though increasingly younger patients are seen in Africa, most reports indicate that the disease is extremely rare in children and adolescents. This is a report of 8 patients below 20 years managed for colorectal adenocarcinoma in a 10-year period in Zaria, Nigeria. They represented 16.3% of all cases of colorectal adenocarcinoma seen at the institution, an incidence higher than that in other parts of Africa and developed countries. All the tumours were in the rectosigmoid region and are accessible to digital rectal examination and proctosigmoidoscopy. The histology was mucinous adenocarcinomas in 6 patients, 5 of who had a Duke's stage C or D disease and well-differentiated in 2 (Duke's stage B and C respectively). Haemorrhoids was found in association in 2 patients and schistosoma mansoni in one and were responsible for delay in referral and diagnosis. Only palliative treatment could be offered in most patients due to advanced disease. Three patients died within 7 months and one after 2 years from their disease. One patient died from sepsis following surgery. The outcome in 3 patients could not be ascertained. It is emphasized that children and adolescents with rectal bleeding must have digital rectal examination and proctosigmoiscopy as this is the only hope of making an early diagnosis.

Neonatal intestinal obstruction in Zaria, Nigeria

OBJECTIVE

To study the aetiology, morbidity and mortality of neonatal intestinal obstruction.

DESIGN

A retrospective study.

SETTING

Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.

SUBJECTS

One hundred and fifty one neonates (< or = 28 days) undergoing surgery for mechanical intestinal obstruction.

RESULTS

The male/female ratio was 3:1 and median age at presentation was four days (range five hours-28 days). Anorectal malformation was the commonest cause, 104 (68.9%), 86.5% of which were high anomalies and 13.5% low; the median age at presentation was three days. Fifty two per cent of colostomies for the high anomalies were performed using general anaesthesia and 48% local anaesthetic, but there was an increasing use of local anaesthesia over the years. Hirschsprung's disease accounted for 11 (7.3%) of the cases, representing 20% of all patients presenting with Hirschsprung's disease to this hospital; the median age was six days and in two patients the caecum and sigmoid colon respectively had perforated; nine patients had colostomy, one caecostomy and one ileostomy (total colonic aganglionosis). Eleven (7.3%) patients had incarcerated or strangulated ingunial hernia (ten) and congenital ventral hernia (one); the hernias were repaired in all patients and three required intestinal resection for gangrene, two of which had ipsilateral testicular gangrene, necessitating orchidectomy. Intestinal atresia was the fourth common cause of obstruction ten (6.7%), eight of which were jejunoileal atresias and two duodenal and the median age was seven days; one atresia was associated with Hirschsprung's disease and had ileostomy, all other jejunoileal atresias were resected and duodenoduodenostomy was performed for the duodenal atresias. Other less common causes of neonatal intestinal obstruction were incarcerated exomphalos, malrotation, hypertrophic pyloric stenosis, annular pancreas, and idiopathic ileal volvulus and meconium ileus respectively. Postoperative complications occurred in sixteen of 95 patients (16.8%) including colostomy or ileostomy complications 11, wound infection three and anastomotic dehiscence (two). The overall mortality was 21.1%, 70% from overwhelming infection and 30% respiratory embarrassment; the mortality from the various conditions were Hirschsprung's disease 43%, intestinal atresia 40%, incarcerated exomphalos 40%, anorectal malformation 18.5% and the only patient with volvulus died.

CONCLUSION

The morbidity and mortality of neonatal intestinal obstruction in this hospital has improved over previous years due largely to meticulous resuscitation before surgery but the problems of late presentation and poor neonatal intensive care facilities persist. The findings are at variance with those in developed countries.

Perineal burns from sitz bath in children: case reports

This is a report of 2 children aged < 18 months who sustained perineal and gluteal burns from sitz bath prescribed for fissure-in-ano and perianal pruritus from ascaris infestation respectively at peripheral hospitals. The management included regular cleaning of the burns wounds and open dressing with 1% silver sulphadiazine and administration of broad-spectrum antibiotics and tetanus prophylaxis. This natal cleft was parted regularly to avoid adhesion and anal stenosis. A plea is made for appropriate investigation and treatment of anorectal conditions in children. Arbitrary use of sitz bath is to be discouraged.

Management of undescended testes in children in Zaria, Nigeria

OBJECTIVE

To study the presentation, management and outcome of undescended testes in children in a northern Nigerian population.

DESIGN

Retrospective study.

SETTING

Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.

SUBJECTS

Thirty six children aged < or = 12 years with 43 undescended testes managed in 10 years.

INTERVENTIONS

Orchidopexy, orchidectomy, herniotomy.

RESULTS

The age at surgery was fourteen months to 12 years (median six years); four (11%) had correction before two years, 15 (42%) before five years and 21 (57%) at age > or = 5 years. Thirty two (74%) testes were palpable and eleven (26%) non-palpable. Evaluation was mainly clinical. Ultrasonography was performed for three non-palpable testes but was not helpful. Laparoscopy was not used in any patient. The condition was unilateral in 29 (81%) and bilateral in seven (19%). Forty five per cent of the testes were in the inguinal canal, 31% at the external ring, and 12% each at the internal ring and abdomen respectively. Ten (24%) testes were macroscopically atrophic (canalicular five, abdominal four, internal ring one). Orchidopexy was performed for 37 undescended testes and orchidectomy for four. Groin and scrotal haematoma developed following one orchidopexy. Following orchidopexy, four (10%) testes retracted necessitating repeat surgery.

CONCLUSION

There is a need to educate parents, traditional birth attendants, midwives and doctors in our environment to ensure earlier presentation and treatment.

Spina bifida cystica: selective management in Zaria, Nigeria

Management of spina bifida cystica in Zaria, Nigeria is selective. Over a period of 11 years, 77 children with this defect, 54 meningocoeles and 23 myelomeningocoeles, 66 (86%) situated in the lumbosacral region, were treated operatively. Forty-two (55%) had surgery in the neonatal period and 91% within 6 months of birth. Postoperative complications occurred in 19 of 68 patients (28%), including mild hydrocephalus, which resolved spontaneously (six, 9%), wound infection (six, 9%), leakage of cerebrospinal fluid (four, 6%) and meningitis (three, 4%). Mortality was 3% from both meningitis and cardiac arrest. Of 32 patients followed up for 3-5 years, 20 with meningocoeles were normal. Of 12 with myelomeningocoele, four had varying degrees of lower limb weakness, three double incontinence, two faecal incontinence, two had progressive hydrocephalus plus paralysis and double incontinence, and one had urinary incontinence. Therefore, 38% were functionally disabled and could not be adequately rehabilitated owing to poor facilities. While management of spina bifida cystica is more aggressive now in most developed countries, ours remains selective due to difficulty with multidisciplinary care and rehabilitation. Even with our selective management, the care of patients with functional handicap remains a challenge.

Sublingual gastric duplication cyst causing respiratory obstruction: case report

A four-month old girl presented with difficulty in feeding and respiratory obstructrion from a sublingual cyst. Respiratory obstruction was relieved by needle aspiration of the cyst, followed 14 days later by complete excision. Histology of the cyst wall confirmed it to be a gastric duplication cyst. Though the gastric mucosa has a high propensity to deviate to ectopic sites, sublingual location is uncommon. The treatment of such cysts is preferably complete excision. However, when the cyst wall is closely associated with vital structures, cyst mucosectomy or partial excision with stripping of the mucosa of the residual part may suffice.

Appendicitis versus genital disease in young women in tropical Africa

The differential diagnosis in women between acute appendicitis and acute gynaecological conditions on clinical examination is often difficult. A plea is made for the more widespread use of ultrasound and laparoscopy in the differential diagnosis of these conditions.

Anorectal injuries in children

Anorectal injuries (ARI) are uncommon in children in civil practice. In developed countries the injuries are mainly due to sexual abuse and firearms. This report reviews the experience in tropical Africa. A retrospective study of children aged 12 years or less managed for ARI over 10 years was undertaken. There were seven children, four girls and three boys. Four injuries were due to blunt trauma and three to penetrating trauma. Six patients presented within 6 h of injury and one after 24 h. Five had rectal bleeding, which was associated with vaginal bleeding in one girl. One girl each had vaginal bleeding and vaginal discharge without rectal bleeding. Diagnosis was by rectal examination and proctoscopy. In three patients a laparotomy was necessary to exclude an intraperitoneal rectal injury (IRI); this was positive in one case. One patient with abdominal findings had a laparotomy as the primary procedure. Overall, five patients had rectal injuries (extraperitoneal 3, intraperitoneal 2), which were associated with an anal injury in three while one patient had only an anal injury. An IRI was missed at initial assessment in one girl. Associated injuries were to the vaginal wall (3), urethra (1) and head (1). IRIs were treated by repair and proximal colostomy. Extraperitoneal injuries were treated by colostomy and drainage; in two patients the injuries were accessible and were repaired. Anal and external-sphincter injuries were repaired in two cases. Vaginal lacerations were repaired and other associated injuries treated accordingly. Three patients had wound infections. Faecal continence was maintained in all patients who had anal and external-sphincter injuries. One girl died of peritonitis from a missed IRI. It is concluded that ARI remains uncommon in children. Morbidity and mortality can, however, be high. Meticulous rectal palpation and visualisation is necessary to avoid missing injuries.

Blunt abdominal trauma in children: epidemiology, management, and management problems in a developing country

Trauma is the leading cause of death in children in developed countries. In tropical Africa, it is only beginning to assume importance as infections and malnutrition are controlled. In developed countries, the availability of advanced imaging modalities has now reduced the necessity for laparotomy to less than 10% following blunt abdominal trauma (BAT) in children. This report reviews the epidemiology, management, and unnecessary laparotomies for pediatric BAT in a developing country in a retrospective review of 57 children aged 15 years or less at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria over 12 years. The average age was 9 years and the male-female ratio 3.8:1. Seventy-four percent (74%) of abdominal injuries in children were due to blunt trauma. The commonest causes of injury were road traffic accidents (RTA) (57%), 88% in pedestrians and 59% in children aged 5-9 years. Falls were the cause of trauma in 36%, 60% of them aged 10-15 years. Other causes of injury were sports in 5% and animals in 2%. Diagnosis was clinical, supported by diagnostic peritoneal lavage or paracentesis. Two patients had ultrasonography, and none had computed tomography. Fifty-three patients had a laparotomy, 2 died before surgery, 1 was managed nonoperatively, and in 1 surgery was declined. There were 34 splenic injuries, 20 treated by splenic preservation, splenectomy in 13, and non-operative in 1. Fourteen gastrointestinal injuries were treated in 12 patients. Of 9 hepatic injuries, 4 were minor and were left untreated, 3 were repaired, 1 was packed to arrest hemorrhage, and a lacerated accessory liver was excised. Four injuries to the urinary tract (bladder contusion 2, bladder rupture 1, ruptured hydronephrotic kidney 1) were treated accordingly. There were 4 retroperitoneal hematomas associated with other intra-abdominal injuries and 2 pancreatic contusions. One lacerated gallbladder was treated by cholecystectomy and a ruptured left hemidiaphragm was repaired transperitoneally. In retrospect, 27 (51%) patients could have been managed by observation (splenic injury 20, liver injury 5, bladder contusion 2) using advanced imaging modalities. One patient developed an intra-abdominal abscess following splenorrhaphy. The average hospital stay was 17 days. Mortality was 8 (14.5%) from gastric perforation (3), liver injury (2), splenic injury (1), and 2 patients died before surgery. BAT in this population results predominantly from RTA in pedestrians. Laparotomy may be avoided in 51% of cases if advanced imaging modalities are readily available.

Intestinal atresia and stenosis: a retrospective analysis of presentation, morbidity and mortality in Zaria, Nigeria

Over a period of 19 years 22 children with intestinal atresia and stenosis were managed at the Ahmadu Bello University Teaching Hospital Zaria. The condition ranks as the fourth most common cause of neonatal intestinal obstruction after anorectal malformation, Hirschsprung's disease and strangulated inguinal hernia at the hospital. Three patients had duodenal atresia, 18 had jejunoileal involvement (atresia 15, stenosis 3) and one colonic atresia. The median age at presentation to the surgeon was 6 days (range 1 day-2 years). The common features were bilious vomiting and abdominal distension, the latter being more common in patients with lower atresia. Non-passage of meconium in the first 24 hours of birth occurred in 11 patients; mostly in those with lower jejunal, ileal and colonic involvement. Eight patients had associated anomalies, 5 of them with ileal atresia or stenosis. Diagnostic investigation was mainly plain abdominal radiography showing double-bubble shadow in duodenal atresia and varying degrees of air-fluid levels in other atresias. Contrast studies were not employed for diagnosis in any patient. The patients with duodenal atresia and had duodenoduodenostomy and duodenojejunostomy respectively while the jejunoileal atresia and stenosis were treated by resection and anastomosis. One patient with ileal atresia associated with total colonic Hirschsprung's disease and extensive atresia from terminal ileum down to descending colon had ileostomy. Postoperatively, 7 patients had infections of varying degrees and 3 anastomotic dehiscence. Mortality was 9 (41%) due mostly to septic complications and prematurity. While the survival of children with intestinal atresia and stenosis has improved over the years in developed countries, ours is still low (59%) due to late presentation and lack of neonatal intensive care facilities.

Ruptured exomphalos and gastroschisis: a retrospective analysis of morbidity and mortality in Nigerian children

The survival of infants with major abdominal-wall defects (AWD) has improved over the years in developed countries. In Zaria, northern Nigeria, survival from intact exomphalos (EX), has improved with the adoption of non-operative management. Ruptured EX (REX) and gastroschisis (GS), however, remain problematic. This is a report of the mortality in REX and GS in a retrospective review of 16 infants with REX and 14 with GS managed over 10 years at the Ahmadu Bello University Teaching Hospital, Zaria. The median age at presentation was 3 days and 24 h for REX and GS, respectively; 29 of the 30 patients were delivered at home. Two patients with REX and 4 with GS had associated anomalies involving mostly the gastrointestinal tract. Bowel or omental strangulation occurred in 13 patients, resulting in gangrene in 8. Fascial closure was achieved in 20 patients, skin closure only in 4, and in 4 improvised silo coverage was used, the latter associated with high infection rate. Neonatal intensive care units (NICU) and total parenteral nutrition (TPN) were not available. The overall mortality was 18.6% (gastroschisis 10, ruptured exomphalos 8, 11 from sepsis and 7 due to respiratory embarrassment). The management of these AWDs thus continues to be problematic in our environment, and mortality remains high. Provision of more modern supportive facilities (NICU and TPN) may improve the survival in our and similar environments.

Intestinal volvulus: aetiology, morbidity, and mortality in Nigerian children

In developed countries, intestinal volvulus in children is most frequently due to malrotation. To review the experience in Nigeria, a retrospective analysis of 28 patients managed over 25 years at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, was undertaken. There were 22 boys and 6 girls with an age range of 4 days to 14 years (median 4 years). There were equal numbers over and less than 5 years of age. Vomiting (89%) and abdominal distension (79%) were the most prominent features. Thirteen children (46%) had fever, associated with bowel gangrene in 5, while 8 (29%) presented with severe dehydration and shock. A plain abdominal radiograph was the only investigation performed, but the features were not specific for volvulus. In 11 children (39%) the volvulus was idiopathic, in 9 (32%) due to adhesions or bands, in 5 (18%) to malrotation, and in 1 each a Meckel's diverticulum, internal herniation, and ventriculoperitoneal shunt. Twenty-three patients had a small-bowel, 4 sigmoid, and 1 caecal volvulus. The bowel resection rate for gangrene was 46% (small bowel 9, sigmoid 3, caecum 1). All patients with malrotation had Ladd's procedure performed. Wound infections occurred in 10 patients (36%), complete wound dehiscence in 1, and recurrence in 1 (idiopathic terminal ileal volvulus). The mortality was 21%, mostly from overwhelming infection (2 neonates, 11-year-old, 3 >/= 5 years). Intestinal volvulus in our environment differs in aetiology from other reports. The resection rates are similar, however. This condition carries high morbidity and mortality.

Major injuries from "domestic" animals in children

Domestic animals are a potential cause of serious injury to handlers and children. In developed countries dogs are the most common cause of such injuries, but in developing countries childhood injuries from domestic animals have not been given much attention. A retrospective analysis of major injuries from domestic animal attacks in children aged 12 years or less in a developing country showed 17 injuries in 16 children. The locations were the abdomen (6), head and neck (4), extremities (3), external genitalia (3), and back (1). A big-horned cow was the cause of injury in 11 patients, a donkey in 4 and a ram in 1. Children under 10 years were injured by provoked animals, mostly as bystanders, while older children were handlers. Four abdominal injuries were penetrating with evisceration and contusion of bowel and required a laparotomy. One blunt splenic injury was managed non operatively and one by partial splenectomy. Two head injuries were managed non operatively. All other injuries were examined and explored with the child under general anaesthesia. These injuries were debrided and closed primarily or closure was delayed when contamination was heavy or adequate debridement was limited by vital neighbouring structures. Broad-spectrum antibiotics and tetanus prophylaxis were given for all open wounds. The average duration of hospital stay was 7.3 days. Three patients had wound infections resulting in long hospitalizations. Two patients died (12.5%), 1 from a severe head injury and 1 from an overwhelming infection. The management of major injuries from domestic animals in children requires meticulous evaluation and examination during general anaesthesia to establish the extent of injury and avoid missed injuries. Prevention of these injuries requires public education about the proper and compassionate handling of domestic animals.

Obstructing duodenal ulcers in a tropical population

OBJECTIVE

To characterise the pattern and pathology of obstructing duodenal ulcers in Zaria, Nigeria in the last seventeen years.

DESIGN

A retrospective study.

SETTING

Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.

PATIENTS

Fifty eight patients who had surgery for obstructing duodenal ulcer.

RESULTS

The mean age was 36.6 years and male/female was ratio 3.6:1. The frequency of obstruction has been on an increase, reaching a peak in 1995 and has remained high. This period coincided with a fall in the frequency of perforation. Obstruction was due to cicatrisation in 48%, cicatrisation and adhesions in 28%, adhesions alone in 16% and inflammatory oedema in eight per cent. Three patients with adhesion had evidence of sealed or treated perforation. Seventy one per cent of the adhesions occurred during the period of rapid rise in the frequency of obstruction. Truncal vagotomy and drainage was performed after three to five days of nasogastric drainage of the stomach. Post-operative gastric atony occurred in one patient and mortality was 1.7%. There was one short term recurrence.

CONCLUSION

Gastric outlet obstruction is now the commonest indication for duodenal ulcer surgery in this population. Obstruction need not be due to cicatrisation alone. Peripyloric adhesion, perhaps from previous perforation is often the cause of obstruction. Prolonged gastric drainage before and after surgery is not necessary. Truncal vagotomy and drainage is an effective treatment.

Penetrating abdominal injuries in children in Nigeria

This is a report of a retrospective study of 24 children managed for penetrating abdominal injury over 10 years, and it represents 34% of all abdominal injuries in children in that period. Falls onto sharp objects within and around the home were responsible for ten of the injuries, seven were injured by animal horns and four were sporting injuries. Violence and road traffic accidents were uncommon. Most patients (67%) had evisceration of omentum or intestine, and one of these was found at laparotomy to have a jejuno-jejunal intussusception. Seven children had injury to hollow viscera. There were three deaths, one each from overwhelming sepsis, tetanus and haemorrhage.

Incarcerated and strangulated inguinal hernias in children in Zaria, Nigeria

OBJECTIVE

To reappraise the problem of incarcerated and strangulated inguinal hernias in children in Zaria, Nigeria.

DESIGN

A retrospective study.

SETTING

Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.

PATIENTS

Eighteen children aged below two years with incarcerated and strangulated inguinal hernias managed over a 10 year period.

MAIN OUTCOME MEASURES

Incarceration and strangulation rate, resection rate, testicular infarction, wound infection.

RESULTS

The overall incarceration and strangulation rate was 4.8%. The rate in neonates was 80%, 33% in those less than six months and 21% in those below one year. There was no incarceration or strangulations after two years of age. The intestinal resection rate for gangrene was 11% (two neonates) and ipsilateral orchidectomy was necessary for testicular infarction in two neonates (11%). Wound infection occurred in three patients (17%) and there were no deaths. Overall, there has been an improvement in the incarceration and strangulation rate, resection rate and wound infection rate over earlier years (5.7%, 28% and 50% respectively for earlier years) due largely to early presentation. Testicular infarction, however, remains a major risk particularly in neonates.

CONCLUSION

The policy of early repair of inguinal hernias in children especially below two years and particularly in neonates should be continuously emphasised to avoid morbidity.

Typhoid ileal perforation in children: a scourge in developing countries

Over a 10-year period, 64 children aged < or = 12 years were treated for typhoid perforation, accounting for 56% of all cases of typhoid perforation at our institution. The perforation rates in the age groups < 1, 1-4, 5-9 and 10-12 years were 4%, 1.7%, 12.4% and 29.3%, respectively, with an overall perforation rate of 10.3%. The main features were fever (93.4%) and abdominal pain and tenderness (93.4%). Thirteen children (20.3%) had associated haemorrhage, presenting as haematochezia. The incidence of perforations was 52% during the rainy season and 48% during the dry season, but the disease occurred throughout the year with a peak in October, the beginning of the dry season, which was also the time of peak occurrence of typhoid without perforation. An average of 14 h (range 5-30) was required for resuscitation. Ketamine was used for anaesthesia in most cases. Treatment was by segmental resection (67%), wedge excision (17%) and simple closure (6%). Morbidity was high (53%), and wound infection (53%) and chest infection (30%) were the most common complications. There were 25 deaths (39%), most the result of overwhelming sepsis. Late presentation at > 7 days was associated with high mortality (p < 0.05). Typhoid perforation continues to be a scourge in children in developing countries and, in addition to preventive measures such as improved sanitation and the provision of safe water supplies, public enlightenment is necessary to ensure early presentation and improved survival.

Pyomyositis in children: analysis of 31 cases

In a 10-year period, 31 children with 35 pyomyositis were managed in Zaria, northern Nigeria. Twenty-two (71%) were less than 10 years of age, with a peak incidence at between 5 and 9 years. The leg muscles, mainly the quadriceps, were most frequently involved (51.4%), followed by the trunk muscles (25.7%), predominantly those of the anterior abdominal wall. Arm and shoulder girdle muscles were less frequently affected (11.4% each). Staphylococcus aureus was the most frequently cultured organism (75%) and was usually sensitive to cloxacillin and, to a lesser degree, to erythromycin and chloramphenicol. Incision and adequate drainage was usually very effective with recurrence at only one site. Antibiotics were used routinely. Involvement of the heart and lungs occurred in two children respectively, the former causing the only death. The average duration of hospital stay was 20 days.

Management of paediatric blunt splenic injury in Zaria, Nigeria

The management of paediatric blunt splenic injury is predominantly non-operative in developed countries at the present time. In developing countries however, imaging facilities for diagnosis and monitoring are frequently not readily available. Over a decade, 32 children had blunt splenic injury in Zaria. 28 (87.5%) injuries were isolated. Nineteen (59.4%) had grade II or III injuries and their spleens were preserved (splenorrhaphy, 12; partial splenectomy, 4; laparotomy only, 2; observation, 1) while 13 (40.6%) had grade IV or V injury necessitating total splenectomy. There was no difference in blood transfusion requirements in any group. The average duration of hospital stay was 17 days for splenic preservation and 20 days for total splenectomy. Mortality was 2 (6.3%), both patients had total splenectomy and one had associated liver injury. With adequate facilities, laparotomy would have been avoided in 16 (51.6%) patients. It is hoped that as appropriate imaging facilities become more readily available in developing countries, less children with blunt splenic injury will be subjected to surgery.

Tuberculous osteitis of the cranium: a case report

A 3-year old male presented with a 12-month history of painless scalp swellings associated with cough, fever and night sweats. Physical examination showed tender, fluctuant, pulsatile right frontotemporal and temporoparietal masses. Skull radiographs showed osteolytic skull lesions in the frontal and temporal bones. Microscopy of drained caseous material and histology of biopsies from the affected bone edges confirmed tuberculous osteitis. Though there was an initial response to antituberculous agents, the child died after 5 weeks from hepatic failure. Tuberculosis of the skull bones though rare, may become more common with the recent upsurge of tuberculosis worldwide. A high index of suspicion is necessary for early diagnosis and treatment.

Cholecystitis in children in Zaria, Nigeria

Much has been published on cholecystitis in childhood from Europe and North America but reports from tropical Africa are few. This is a report of seven children with cholecystitis seen over a 10-year period in Zaria, northern Nigeria. Six of the children had acalculous cholecystitis but a predisposing condition (adenomatous hyperplasia) was identifiable in only one. Five presented with complications (perforation, three; gangrene, one; empyema, one). One child without haemolytic disease had calculous cholecystitis and choledocholithiasis. Pre-operative diagnosis of cholecystitis was made in only three cases. Cholecystectomy, two as interval procedures, was safely performed in all patients. In environments such as ours, where cholecystitis in childhood is uncommon, awareness and a high index of suspicion are necessary for early diagnosis and prompt treatment in order to avoid potentially life-threatening complications.

Giant congenital epigastric hernia

Epigastric hernia is rare in children. When it occurs, as in adults, it is usually small. This is a report of a giant, congenital epigastric hernia which was repaired early to prevent complications. Though there was a brief period of postoperative respiratory difficulty, the final outcome was satisfactory. This case is interesting due to its massive size and congenital nature.

Amputation of the penis by human bite: a case report

A 3-year-old boy had his penis amputated by being bitten by a neglected psychiatric individual and presented late with urethral stricture. Initially, he had suprapubic diversion of urine and later meatoplasty. A plea is made for vigilance with children and appropriate care of individuals with psychiatric problems.

Peptic ulcer disease in childhood in Zaria, Nigeria

Over a 10-year period in a busy paediatric surgical unit, six children were operated upon for peptic ulcer disease, four of whom presented with complications (pyloric stenosis, two; perforation, one; bleeding, one). Truncal vagotomy with a drainage procedure was the operation of choice in five of the children in whom there were no complications. One child suspected of having Zollinger-Ellison syndrome had recurrence of symptoms. Symptoms of peptic ulcer disease in children are non-specific, and in our environment such symptoms are frequently considered to be due to parasitic infestation. Barium meal is not very sensitive in diagnosis in children, and the relative lack of availability of endoscopic services limits pre-operative diagnosis. It is suggested that peptic ulcer disease be considered in children who have persistent or recurrent abdominal pain of obscure aetiology.

Acute retropharyngeal abscess in children

Due to the wide availability of effective antibiotics, acute retropharyngeal abscesses have become increasingly rare. This is a retrospective report of ten children with this condition, managed over a 10-year period. Nearly all were aged 12 months or less and presented only when respiratory obstruction had developed. Owing to administration of antibiotics at home, cultures of pus specimens were sterile in most cases. The retropharyngeal space was widened on lateral, plan cervical radiography in five children. Four had drainage by external cervical incision, and in four drainage was by mouth, all under general anaesthesia. Tracheostomy was necessary in one child who developed respiratory obstruction and the abscess was drained by needle aspiration. One child died before drainage of the abscess. Parenteral antibiotics were administered also for 5 days. There was no recurrence in any case. Laryngeal spasm occurred post-operatively in two children, leading to death in one. Overall, two children died. The features and management of the disease are reviewed briefly to re-awaken awareness of the condition, especially in developing countries where it is most likely to be seen at the present time.

Postoperative intussusception in childhood: case report

An eight year old female had laparotomy for general peritonitis due to acute appendicitis. Postoperative course was uneventful until the seventh day when abdominal pain, and distension and vomiting ensued which did not respond to conservative management. At repeat laparotomy, an ileoileal intussusception was found and reduced without difficulty. Intussusception is an uncommon but important cause of postoperative intestinal obstruction. Since the typical features of intussusception are usually absent and radiology frequently unhelpful, a high index of clinical suspicion is necessary for early diagnosis and treatment to avoid strangulation and perforation.

Retrorectal cystic harmatoma (tailgut cyst) in an infant: case report

We report the case of a day old infant who presented with a large cystic swelling in the sacroccoygeal area distorting the gluteal folds and displacing the anus anteriorly. Rectal examination revealed less than twenty five per cent of the lesion in retrorectal space, plain x-rays did not show any calcification. The infant had excision surgery at seven days of age and did well thereafter. Although most TGC cases were reported in adults the present case fulfills the anatomical and histological criteria for diagnosis, and it may be the first such case in a child less than one month old.

The risk of infective thyroiditis in nodular goitres

Infective thyroiditis which was more common in the pre-antibiotic era is now rare in developed countries but continues to occur in less developed areas. Over a 10-year period in Zaria, Nigeria which is situated in an endemic goitre region, nine such patients were treated. All were females, 30-50 years of age and had pre-existing, long-standing multinodular goitres. During the period, 84 patients (including the nine patients) with endemic multinodular goitres were treated, giving an infective rate of 10.7% in these goitres. Treatment was by adequate incision and drainage in all patients with suppuration. Staphylococcus aureus was the commonest organism cultured and Streptococcus Pyogenes and Pseudomonas were the infective agents in a minority. Only one patient required thyroidectomy later, the goitre having disappeared in the other patients. One patient developed hypothyroidism requiring replacement therapy with thyroxine. Thyroid abscess remains an ever present risk in endemic multinodular goitres in our environment. Early presentation after onset of pain, prompt administration of appropriate antibiotics and thyroidectomy soon after is likely to reduce the risk of abscess formation in these goitres.

Surgery in a rural hospital: experience from northern Nigeria

Over a 5-year period in a rural hospital in Northern Nigeria, 949 patients were operated on, constituting 84.7% of all surgical admissions. Nearly one half were emergency procedures. The majority of the patients were young (mean age 36.0 years) and predominantly male (M:F = 1.5:1). A wide variety of surgical procedures were performed but overall 85% were not of a complex nature. Mortality was 4.8%, due mostly to septic complications. It is suggested that most of the surgical procedures in rural Africa can be performed by general duty doctors with surgical experience and they should be taught and encouraged to perform these operations. The importance of relevant research to solve local problems is highlighted and the planning of primary health care to include more primary surgery emphasised.

Pattern of peptic ulcer disease in Zaria, Nigeria

The pattern of peptic ulcer disease in Zaria has been that of an increasing frequency of perforation, reaching a peak of 45% by 1983. In a retrospective study of 88 consecutive patients managed surgically for duodenal and gastric ulcers between 1984 and 1995, 41% had gastric outlet obstruction and only 17% had perforation. However, the ratio of perforated duodenal ulcer: perforated gastric ulcer has more than doubled from 2.6:1 to 6.5:1. Until now the pattern of peptic ulcer disease in northern Nigeria was different from that in southern Nigeria and most parts of black Africa but this review suggests a reversion to the pattern in these other places. Though these findings may be due to the effects of a changing economy, they may represent a change in the intrinsic behaviour of peptic ulcers in our environment. Ulcer perforation continues to carry a high mortality and truncal vagotomy and drainage remains the surgical treatment of choice for duodenal and gastric ulcers in our institution.

Primary malignant melanoma of the anorectum: case report

A thirty year old Nigerian female presented with a large and advanced anorectal malignant melanoma. She had been treated for over eighteen months at a rural hospital for a mistaken diagnosis of haemorrhoids. The patient died before any form of treatment could be carried out. The rarity of this disease in the black Africa is highlighted and the characteristics of the disease briefly reviewed. The importance of digital and protoscopic rectal examination in patients bleeding per rectum is emphasised.

Role of a general surgeon in obstetrics and gynaecology in a rural setting

In a rural hospital in northern Nigeria, general surgeons performed 217 obstetric and gynaecologic operations over a five-year period. These operations were responsible for 23% of all operations at the hospital. Emergency operations were most frequent with caesarean section accounting for 90%. Eighty five per cent of the caesarean sections were performed for cephalopelvic dysproportion. The complications encountered were mostly septic complications, predominantly in patients who had caesarean section for obstructed labour. The overall mortality was 5.1% and neonatal mortality from caesarean section was 4.8%. It is concluded that in the abscence of an obstetrician and gynaecologist general surgery experience is required to manage obstetric and gynaecologic problems in rural areas. Such experience should be considered when recruiting doctors for rural hospitals in developing countries.

Blunt traumatic injury of the gallbladder in childhood

OBJECTIVE

To illustrate blunt traumatic injury of the gallbladder in childhood.

DESIGN

A case report.

SETTING

Hospital.

SUBJECT

An eight year old boy.

MAIN OUTCOME MEASURE

Incidence, history, treatment.

RESULT

The gallbladder was ruptured at the neck necessitating a cholecystectomy. The child has remained well at three months follow up.

CONCLUSIONS

Blunt traumatic injury of the gallbladder, though rare, does occur usually as a consequence of direct abdominal injury especially in children during sporting activities and fights. Minor injuries can be repaired but cholecystectomy is necessary in more extensive injuries or injury to the cystic duct and neck. A comprehensive history taking including direct questioning regarding trauma and a high index of suspicion are important for early diagnosis and prompt treatment.

Thyrotoxicosis in Zaria, Nigeria: an update

The total number of operations performed for thyroid diseases at the ABU Teaching Hospital, Zaria from January 1986 to December 1995 has reduced. Those performed for thyrotoxicosis have tripled (18.5% of all thyroid operations compared to 5.7% ten years ago). Younger patients (mean age 27.7 years, range 13-15 years) with thyrotoxicosis are being seen but the clinical features of the disease and its management at the centre have not changed. It is suggested that the apparent increase in incidence and earlier onset of thyrotoxicosis in this environment may be due to the increasing use of iodised salt to combat endemic goitre.

Meckel's diverticulum presenting as gastric outlet obstruction: case report

We report a case of gastric outlet obstruction simulating gastric antral neoplasm resulting from a perforated Meckel's diverticulum. Presentation of this nature has not been previously reported.

Comparison of three operations for typhoid perforation

BACKGROUND

Typhoid fever is a public health problem in the developing world and gut perforation remains the major complication with a high associated mortality rate. Even though most surgeons agree that elimination of peritoneal soilage and endotoxaemia by surgery offers the best hope of survival, the extent of surgery remains controversial. This prospective study compared the results of three operations for this condition.

METHODS

A total of 64 patients with clinical suspicion of typhoid perforation were treated by one of three operations (simple closure, wedge excision and anastomosis or segmental resection and anastomosis) at this hospital. The management protocol was the same for the three groups. The risk of reperforation, mortality rate and duration of hospital stay were compared.

RESULTS

The risk of reperforation and mortality rate were highest (two and 13 of 21 respectively) in patients who had wedge excision and lowest (zero and nine of 25 respectively) in those who had segmental resection. The risk of reperforation and mortality rate were zero and nine of 18 respectively in the simple closure group.

CONCLUSION

Segmental resection seems to be the best treatment for typhoid perforation and is recommended for surgeons practising in a similar environment.

Intussusception in children and adults in Zaria: a comparison

OBJECTIVES

To compare and contrast the symptomatology and the anatomical type of the intussusception in children and adults in Zaria.

DESIGN

Retrospective study.

SETTING

Hospital.

SUBJECTS

93 patients with intussusception.

MAIN OUTCOME MEASURES

Frequency of intussusception.

RESULTS

Colicky abdominal pain featured often enough in both groups with most symptoms and signs decreasing in frequency from infancy to adulthood. The ratio of small bowel to large bowel disease in infants, older children and adults was 1;8:1, 0;6:1 and 1:1 respectively. Infantile intussusception involving the small bowel was more common, and in older children large bowel involvement was commoner, while 50pc of adult intussusceptions were paradoxically small bowel. Overall, small bowel intussusception was most common with the ileocolic variety predominating.

CONCLUSIONS

The most common type of intussusception in our environment is the ileocolic variety.