Anaesthesia for ambulatory paediatric surgery: common techniques and complications

BACKGROUND

Ambulatory surgical care accounts for over 70% of elective procedures in Northern America. Ambulatory paediatric surgical practice is not widespread in Nigeria. This report examined clinical indicators for quality care in paediatric ambulatory surgery using common outcomes after day case procedures as benchmark.

METHODS

This was a cross-sectional study of children who were presented for ambulatory surgical care in the University of Benin Teaching Hospital. A standardized questionnaire was employed to record the age, gender, indication for surgery, type of anaesthesia, timelines for the surgery and associated complications.

RESULTS

A total of 93 patients had surgical procedures on ambulatory basis. The mean age of the patients was 4.1(4.0) yr and duration of surgical procedure 31.3(12.1) min. The male to female ratio was 3:1, and herniotomy was the most frequent procedure on ambulatory paediatric surgical care 60 (64.5%). The common anaesthetic techniques employed in the paediatric ambulatory setting were spontaneous respiration with face mask 40 (43%), Inhalation technique with tracheal intubations 31 (33.3%), general anaesthesia with relaxant technique five (5.4%), local infiltration with or without sedation eight (8.6%), GA plus caudal block eight(8.6%), and subarachnoid block one(1.1%). The indicators of quality care were unanticipated admission (5.4%), repeat hospital visit (4.3%), readmission (2.2%) and delayed discharge (21.5%).

CONCLUSION

The practices of paediatric surgery on ambulatory services are feasible in our setting. The observable complications are within acceptable limits. The timelines in the scheduling and discharge appear not to be optimal for an effective ambulatory service.

Genito-urinary reconstruction in southern Nigeria

BACKGROUND

Urologic cases constitute about 25% of a busy surgical practice in Nigeria with up to 50% of these cases being genito-urinary abnormalities in adults and children. As most urologic surgery in Nigeria is done by general surgeons, a knowledge of the disease pattern and effective techniques in management would be helpful in surgical training.

OBJECTIVE

To describe the disease pattern and surgical outcomes in patients undergoing genito-urinary reconstruction in southern Nigeria

METHODS

We retrospectively reviewed the medical records of patients who underwent genito-urinary reconstructive procedures by two urologists and one paediatric surgeon over a 7-year (1991-1998) period at two tertiary referral centres in southern Nigeria. We extracted data such as age, sex, nature of pathology, surgical therapy and outcomes. Patients with a follow up of 12 months were excluded. The pattern of genito-urinary disease, type and outcome of surgical therapy, and complications were determined.

RESULTS

Two hundred and twenty seven patients (121 men, 39 women, and 67 children) underwent genito-urinary reconstruction during the seven years spanning 1991-1998. The study population consisted of 160 adults and 67 children (< 15 years old). Mean patient age was 43 years with a range of 18-87 years for adults and three years (range 18 months-13 years) for children. Mean follow up duration was 15 months, (range--13 months-seven years). Urethral abnormalities comprised 69% (98/ 227) of the lesions. The most common abnormality was urethral stricture in 98 (43%) patients. Urethral strictures were reconstructed as follows; primary anastomosis 83 (84.6%), pedicled penile skin island 6 (6.1%), Blandy 2 stage, 4 (4%), meatoplasty three (3%) and meatotomy, two (2%). The overall complication rate for repair of urethral strictures was 4.08%. There were 79 (35%) congenital lesions, including hypospadias 62 (27%), pelvi-ureteric junction obstruction 13 (6%), bladder exstrophy 2 (0.8%), chordee without hypospadias, 2 (0.9%), and concealed penis 1 (0.4%). These were managed using the following techniques; MAGPI, 30 (48.3%), urethroplasty, 22 (10%) single stage 10 (45%), two-stage 12 (55%), and urethral mobilization 10 (16%). Vesico-vaginal fistula complicating obstructed labour and pelvic surgery was the main cause of urinary fistulae. Ten patients underwent microsurgical epididymo-vasostomy for obstructive azoospermia resulting in three pregnancies.

CONCLUSION

Lower urinary tract reconstruction represents a major proportion of urologic surgery in southern Nigeria. Management by urologic specialists results in good outcomes, therefore urologic training in this area should include a large component of lower urinary tract reconstruction.

One hundred and three concurrent IVF successes for donors and recipients who shared eggs: ethical and practical benefits of egg sharing to society

Egg sharing is a form of egg donation where complete strangers can collaborate anonymously to overcome their involuntary childlessness. In a retrospective analysis, results of egg sharing treatments were analysed in 37 consecutive donors and 39 recipients who had achieved concurrent success following IVF treatment. The interval between being accepted onto the programme and receiving treatment was less than 6 months for most patients. Births of 103 infants are expected. Multiple pregnancy rates were high and equivalent in both the groups (donors 32.4%, recipients 25.6%) despite the original number of eggs available being halved at egg collection and equal numbers being allocated to donors and recipients. On average fewer than six eggs were required for the birth of each baby. More successes are expected in time as 33 couples (43.4%) have their excess embryos stored for future use. The programme avoided the need to advertise for donors. This had particular significance for members of minority ethnic groups. It is surmised that promotion of concurrent treatment of egg sharers and recipients will attract funds from insurance providers or health boards who are unimpressed by IVF treatments with indifferent success rates and runaway costs. In the event of such funds materializing, meagre NHS resources for IVF treatment could be better focused. Overall, the benefit derived from applying the simultaneous treatment of anonymous donors and recipients is so compelling as to make it the preferred IVF option for qualifying couples.

Congenital peritoneal encapsulation of small intestine: a case report

Congenital peritonel encapsulation of the small intestine is a rare malformation. It is associated with clinical features which may cause diagnostic difficulties and more often it is recognised only at exploratory laparotomy. We present a case in a 15 year old female, who was treated and she had a good result. Embryological explanation for the pathology is also considered. It is a disease entity which should be recognised, especially when encountered at laparotomy and treated appropriately.

The posterior urethral valve uropathy: results of treatment

Nineteen children treated for posterior urethral obstruction due to congenital valve in the University of Benin Teaching Hospital, Benin City, Nigeria, over a 9-year period have been analysed. Their ages ranged from birth to 12 years. Results show that associated kidney pathology may be irreversible even after successful excision of the valve. This determines the final prognosis, which is worse the younger the child at presentation.

Management of peritonitis in perforated appendicitis in children

A prospective study on the management of severe acute appendicitis with gangrene and perforation was carried out using protocols that included schematized treatment. The schemes emphasized adequate preoperative treatment, meticulous operative technique of peritoneal toileting, generous use of appropriate antibiotics in combinations, and early graded patient's ambulation in the postoperative period. The average hospital stay was seven days, wound infection was of mild degree and less than 1%, and there was a low morbidity. Follow-up has shown no serious complications.

Chronic non-strangulating incompletely obstructing intussusception: with case report of a seven and a half year old Nigerian boy

One case of chronic intussusception (ileo-ileo colic) is reported. A seven and a half year old male had presented with colicky abdominal pain, vomiting, a palpable abdominal mass, infrequent passage of mucus or blood with stools and weight loss over a period of six weeks. There was delay in diagnosis due to unusual presentation and a low index of suspicion. The patient had been admitted to a peripheral general hospital for four weeks where he was treated for amoebic dysentery without improvement, before his transfer to our hospital where the diagnostic problem continued, until the paediatric surgical unit was called in.

Skin closure during appendicectomy: a controlled clinical trial of subcuticular and interrupted transdermal suture techniques

Over an 18-month period, 100 consecutive patients who underwent appendicectomy were randomly allocated to have skin closure either by interrupted transdermal or subcuticular techniques. Ninety cases were performed as emergencies within 6 h of admission. Only cases of acute uncomplicated appendicitis were included. Complications arising from the method of wound closure used were assessed. It was noted that the mean wound closure time and cost of material were significantly reduced in the group using the subcuticular technique (P less than 0.025). The wound infection rate was the same in both groups, but when all wound complications were taken together, there was a significantly higher incidence with the interrupted method. The results from this trial indicate that subcuticular wound closure during appendicectomy--an operation with a high risk of infection--is not associated with an increase in the incidence of wound complications and offers a cost and time-saving advantage.

Familial occurrence of cryptorchidism

A case of Cryptorchidism involving a father and all his four sons who are product of a nonconsanguineous marriage has been described. From a review of the literature, as well as evidence derived from the family history, it is suggested that the mode of inheritance may be autosomal dominant with incomplete penetrance or multifactorial.

Abnormal findings associated with undescended testis in Nigerian children

Children between the ages of 6 years and 12 years numbering 2200, were examined for general physical development and external abnormality to correlate these anomalies with frequency of undescended testis. Whereas the overall frequency of undescended testis in this population was 0.5%, this condition was present in 1% of boys with peri-umbilical hernia. Undescended testis should be looked for in children with external congenital anomalies, particularly of the anterior abdominal wall.

Embryonal cell carcinoma of testis in infants. Report of two cases and review of literature

Testicular tumours are rare in children, and Embryonal cell carcinoma is the commonest. Orchidectomy with high ligation of the cord and lymphadenectomy, with adjuvant chemotherapy and radiation therapy in different combination have been tried. We report two cases aged 2 months and 9 months treated by only orchidectomy and have remained well 3 years and 15 months respectively after surgery.

Acute gangrene of the scrotum in a one month old child

Since Fournier first described the fulminating idiopathic gangrene of the scrotum in 1883 there have been sporadic reports of cases from various parts of the world. The condition is, however, rare in infants. We present here a case of scrotal gangrene following circumcision, in a one month old baby.