Assessment of the impact of non-state actors in the support for obstetric fistula care: Matters arising

Aims: To review the impact of support of non-state actors on communal OF repair effort in fistula repair Centre. Methods: We reviewed the support given for OF repairs at Adeoyo Maternity Hospital, Ibadan from 2013 to 2018. The type of support was either Partial or Full support; involved support from various organizations such as Extended Hands, GWIN, Faith Hookes Foundation, Engenderhealth/USAID. Partial support was provided by above-listed organizations between 2013- 2016. However, sustained Full support was provided by Fistula carePlus/Engenderhealth/USAID between 2017 and 2018. Results: Partial support involved supply of equipment, health education, radio jingles, fistula repairs; while Full support included supply of medical consumable, mobilization of fistula clients/client mobilization using social workers, feeding of clients for minimum of 2 weeks, provision of power backup, mobilization and remuneration of OF surgeons and manpower, in addition to those listed above. One hundred, eighty-seven women benefitted from support. Fistula types ranging from obstetric, iatrogenic and traumatic fistula were repaired using both pooled effort and routine repair models. During partial support, 70(37.4%) women were repaired compared to 117 (62.6%) when sustained full support was provided. All women freely accepted participation in the supported repair program. Conclusions: There is a compelling improvement in patronage, access to care and opportunity to develop the skills of enthusiast among the health-workers; and thus a need for more commitment in our quest to eliminate obstetric fistula.

Evidence based classification/staging system for Obstetric Fistula: Planning and preliminary intervention in Nigeria

Aims: To review the classification systems of obstetric fistula (OF).  Methods: A two-day stakeholders’ meeting in Nigeria involving fistula surgeons, nurses, anesthetists, trainee, fistula desk officers at the federal and state government levels and other stakeholders was facilitated by Engender health. The meeting involved presentation of common classifications of obstetric fistula, critical analysis of each classification, group and plenary discussions. Presentation involved a critical analysis of classification parameters, strength and weakness. Three working groups designed classification criteria, prognostic scoring and suggested level of surgical skills needed to manage the patient. Outcome of each group work was presented and discussed in plenary. Each of the classification scenarios were modified by consensus and ratified at subsequent follow up meeting. Results: Three new classification systems of the OF were developed, and from these, a consensus classification was also developed in plenary. The initial three classifications developed from group work were similar to each other. Each classification considered size, location, previous repair, scaring, associated morbidity involvement of closing mechanism of the bladder neck, degree of urethral involvement and presence of transection of bladder neck (circumferential defect). The consensus classification, that was adopted, considered classification and prognostic scoring system. The four classification systems will be field tested to generate evidence for reliability and reproducibility. Conclusions: We believe a new classification system of obstetric fistula that will provide robust information to the managing team and patient is long overdue. This modest idea is a wake-up call for practitioners to design appropriate tool that is back up with reproducible evidence.

Genital tract fistula: Changing trends in presentation and outcome

Aims: To find out the clinical profile of obstetric fistula. Methods: A retrospective review of women presenting for OF repair in Ibadan, Oyo State from 2017-2018. All repairs were performed by the Oyo State fistula team at Adeoyo Maternity Hospital or University College Hospital, Ibadan. Two hundred and eighteen women were repaired during the period; information on socio-demographic and presentation characteristics was extracted. Data analysis was done using IBM SPSS version 25.0. Results: The commonest cause of genital tract fistula in this review was obstructed labour (68.5%), 44.9% of the women had caesarean delivery either to relieve obstruction or as elective procedure. Only 8.3% had elective caesarean section and 5.6% had gynaecologic surgery. Majority were urinary fistula (92.5%) and in the mid-vaginal (21.6%) location followed by juxta-cervical and ureterovaginal fistula (9.2%). Urethral involvement and severe vaginal fibrosis were seen in 12.4% and 61.3% of cases respectively. Conclusions: There is a need for continuing medical education on critical emergency obstetric care skills in order to improve maternal health care service delivery.

Stones before Touching the Sharpen Knives

Aims: To assess the effectiveness of training in fistula repair. Methods: A semi structured self-administered questionnaire was used to elicit responses from seven fistula surgeon trainees who trained for standard level of fistula repair during 2014-2018. Data analysis was done using SPSS 20.0. Results: The mean age and duration of medical practice of participants was 41.6 years (SD=5.6) and 14.9 years (SD=6.9) respectively. Almost all trainees were male 6 (85.7%) and five had postgraduate fellowships. Only one trainee (14.3%) had received previous formal training in fistula repair while four (57.1%) had previously done a surgical repair. All trainees participated and assisted in surgical repairs while 6 (85.7%) were the lead surgeon in at least 3 surgeries during training. Following training, four (57.1%) trainees witnessed an increase in the number of fistula patients presenting at their health facilities. Five trainees (71.4%) saw fistula cases that were beyond the level of their training. All trainees reported an increase in proficiency in fistula repair evidenced by successful outcomes of about 80% at first attempt. Lack of adequate infrastructural, personnel and social support for patients during and post training were cited by all trainees as barriers to the provision of adequate care for fistula repair. Conclusions: There is need for more commitment to training so as to address the treatment gap and eliminate the backlog of unrepaired fistula cases.

Profile of Obstetrics Fistula Clients; is the trend changing?

Aims: To assess the changes in the profiles of obstetric fistula clients. Methods: This was a retrospective review of the medical records of all obstetric fistula clients managed by the Oyo state fistula team at University College Hospital and Adeoyo Maternity Hospital Ibadan, Nigeria.  A proforma was used to extract information on socio-demographic and obstetric characteristics of clients and was analyzed using SPSS 25.0. Level of significance was set at P <0.05. Results: The median age and number of pregnancy with occurrence of fistula were 34 years and 2 respectively. Above a quarter (32.2%) had at least secondary level of education, three quarter (75.2%) were currently married and about half were traders. Only 20 (22%) booked the pregnancy that resulted in fistula with 44 (44.9%) delivering through cesarean section. Majority 70 (72.9%) of the fetuses were stillbirth. Conclusions: The widely held believe of a typical obstetric patient still holds but substantial cases of fistula occurred in multiparous women and at older age.

Surgical proficiency grading and outcome of fistula repair; does it really matter?

Aims: To measure and validate the outcome of fistula repair with FIGO surgical proficiency grading. Methods: Review of obstetric fistula managed at University College Hospital/Adeoyo fistula center was done. The lead expert fistula surgeon trainer at FIGO certified fistula training center graded all trainee surgeons and fistula complexity. Data was collected using a structured proforma. The fistula characteristics,level of surgeon and surgical outcomes were assessed. Analysis was done using SPSS version 25. Level of significance was set at P<0.05. Results: Out of the 216 fistulas reviewed, 86 (47.5%) were classified as complex fistula, 43 (23.8%) as simple, moderate 38(21%) and irreparable 14 (7.7%). Majority 146 (67.3%) were performed by advanced level surgeons and only 9 (4.1%) by standard level surgeons. Successful outcome for all levels was above 80% (Standard = 88.9%, Advanced = 81.4% and Expert=83.9%). Expectedly, surgeons at the expert level had a higher closure for complex fistula 86% vs 64.3% compared to advanced level. Conclusions: This preliminary study shows some sort of validation of the FIGO grading system with a high successful outcome of repair across all proficiency levels.

Polyp prevalence at colonoscopy among Nigerians: A prospective observational study

BACKGROUND

This study was aimed at identifying the prevalence, distribution, and clinicopathologic characteristic of colonic polyps among Nigerians undergoing colonoscopy at the Obafemi Awolowo University Teaching Hospitals complex, Ile-Ife, Nigeria. We also determined the polyp detection rate (PDR), polyps per colonoscopy (PPC) and adenoma detection rate (ADR).

MATERIALS AND METHODS

This is a prospective study of all colonoscopy examinations performed at the endoscopy unit of our hospital from January, 2007 to December 2013. The patient demographics, indications for colonoscopy, colonoscopic findings, number of the polyps, their sizes, possible risk factors in the individual case histories, and histopathological characteristics of the polyps.

RESULTS

During the study period, a total of 415 patients met the inclusion criteria and only 67 out of these had colonic polyps. The overall PDR was 16.1%. The age ranged was 2-87 years with a median of 57 years. Forty-three (64.2%) patients were 50 years or above and there were 40 (59.7%) males. Thirty-three (49.3%) patients were referred as a result of lower gastrointestinal bleeding, 14 (20.9%) for colorectal cancer (CRC) and 13 (19.4%) for routine screening. Thirty-nine (58.2%) patients had the polyps at the rectosigmoid region of the colon, 17 (25.4%) had the polyps located proximal to sigmoid colon and 11 (16.4%) patients had multiple polyps involving both segments. Adenomatous polyps was the most common (28 [47.5%]) histopathological finding of which two patients had adenomatous polyposis. Other findings include inflammatory polyps in 17 (18.8%) patients, 5 (8.5%) patients each had hyperplastic and malignant polyps, while 4 (6.8%) patients had juvenile polyps. The ADR was 6.8 and the PPC was 0.2. Statistically, patients 50 years and older were more likely to have adenomatous and hyperplastic polyps than those younger than this age (P = 0.010).

CONCLUSION

We conclude that polyps are probably not as rare among black Africans especially when they are above 50 years. Our histopathological finding of adenomatous change in a good proportion of the detected polyps show that they are likely to be associated with CRCs in our compatriots and as such we would recommend a routine screening colonoscopy for Nigerians aged 50 and above.

Comparing Lichtenstein with darning for inguinal hernia repair in an African population

PURPOSE

Being a relatively new entrant into our practice, mesh repair has not been compared with previously existing tissue-based techniques in our setting. This study is set out to compare darning with Lichtenstein technique of inguinal hernia repair in terms of frequency of post-operative complications, recovery and cost.

METHOD

Patients with uncomplicated, primary inguinal hernia were randomized to have their hernias repaired either by the Lichtenstein or darning technique. Details of their socio-demographic, hernia characteristics and intra-operative findings were recorded. Postoperatively patients were assessed for pain, wound site complications and recurrence. Both direct and indirect costs were calculated. Mean duration of follow-up was 7.5 months.

RESULT

Sixty-seven patients were studied. Thirty-three had Lichtenstein repair while 34 had darning repair. Lichtenstein repair was associated with less post-operative pain, less analgesic requirement, and shorter time of return to work activities, these were all statistically significant (p < 0.05). Frequency of post-operative complications was comparable in both groups with wound haematoma and scrotal oedema being the commonest. There was no recurrence in any of the groups. Total cost was comparable between the two groups.

CONCLUSION

Lichtenstein is superior to darning in terms of post-operative recovery while both techniques are comparable in terms of frequency of early post-operative complications and total cost.

Knowledge and use of emergency contraception by medical doctors on internship in a tertiary healthcare facility in Nigeria

CONTEXT

Emergency contraception (EC) is widely used to prevent unwanted pregnancy and it is largely adopted in many countries as over the counter drug to improve access.

AIMS

To determine and compare the correct knowledge, attitude and current use of EC among newly graduated medical doctors (MDs).

SETTINGS AND DESIGN

A cross-sectional study conducted among 255 newly graduated MDs at the University College Hospital, Ibadan, Nigeria.

MATERIALS AND METHODS

A pretested self-administered questionnaire was used to obtain data from consenting participants.

STATISTICAL ANALYSIS USED

Descriptive, bivariate, and multivariable analyses were performed, and statistical significance was set at 0.05. Statistical Package for Social Science version 15.0 (Chicago, IL, USA) software was used.

RESULTS

The mean age of the respondents was 27.2 years (standard deviation = 2.1). The commonest indication for emergency contraceptive use mentioned was rape-96.5%. About 70% support EC in Nigeria, while about a quarter (26.9%) routinely counsel women about ECP use. About 21% of respondents currently use EC. Logistic regression analysis revealed significant results for gender [odds ratio (OR) =3.64; 95% confidence interval (CI) OR = 1.31-10.01), religion (OR = 0.26; 95% CI OR = 0.11-0.630) and marital status (OR = 0.19; 95% CI = 0.07-0.56).

CONCLUSION

The correct knowledge and professional disposition toward EC as a form of contraception is low. We recommend that in-service training should focus more on EC to improve the quality of their knowledge and attitude towards it.

Imatinib (Glivec) and gastrointestinal stromal tumours in Nigerians

BACKGROUND

To assess the response and the impact on the overall survival (OS) on c-KIT-positive (CD117+) gastrointestinal stromal tumours (GISTs) patients treated with imatinib mesylate.

METHODS

Between July 2003 and December 2012, consenting patients with advanced c-kit-positive GISTs were enrolled to receive imatinib mesylate therapy at a dose of 400mg - 800mg daily, supplied gratis by Novartis Pharma (Basel, Switzerland) under its GIPAP initiative. Disease severity was based on tumour site, size and mitotic index at diagnosis. Clinical features together with drug toxicity, haematological and biochemical parameters were monitored. Overall survival (OS) reviewed at 12 months intervals over 5 years was computed using Kaplan-Meier

RESULTS

There were 27 patients in all (17 males and 10 females with a median age of 52 years (range 26 - 83). Twenty three patients, 15 males and 8 females that have been followed up for at least 6 months were evaluated, aged 26-83 years (median = 56). There were 17 (73.9%) gastric tumours and 6 extragastric including 3 cases of peritoneum and 1 each of small gut, colon and rectum. At diagnosis, 21 (91.3%) cases were high risk, and 1 each fell into the intermediate and low risks, respectively. Ten patients (43.4%) including 5 with metastases presented with unresectable lesions. Five patients (21.7%) had complete tumour resection, 5 (3 with metastases) had partial resections and 3 others with non-bulky, nonmetastatic diseases underwent no surgery. Imatinib was used as the primary therapy for all patients, except the 5 patients that underwent complete tumour resection. Nine (39.1%) patients were lost to disease progression with a median survival of 16.7 +/- 10.7 (+/- SE) (95% CI = 0-37.6) months. The overall survival at 2 years for all patients was 71.9%, which dropped to 65.9% at 4 years.

CONCLUSIONS

Although a small number of GISTs, imatinib induced an extended remission in patients with advanced disease, most of whom would have been dead within a few months of diagnosis.

Neo-adjuvant capecitabine chemotherapy in women with newly diagnosed locally advanced breast cancer in a resource-poor setting (Nigeria): efficacy and safety in a phase II feasibility study

The majority of clinical trials of neo-adjuvant therapy for breast cancer have been conducted in resource-rich countries. We chose Nigeria, a resource-poor country, as the major site for a phase II feasibility open-label multicenter clinical trial designed to evaluate the efficacy, safety, and tolerability of neo-adjuvant capecitabine in locally advanced breast cancer (LABC). Planned treatment consisted of 24 weeks of capecitabine at a dose of 1,000 mg/m(2) twice daily (2,000 mg/m(2) total per day). The primary endpoints were overall, partial, complete clinical response rate (OCR, PCR, CCR) and complete pathologic response (cPR). A total of 16 patients were recruited from August 2007 to April 2010. The study was terminated early as a result of slow accrual. After the first three cycles of therapy, PCR were seen in five of 16 patients (31%; 95% CI 11-59%). Of the remaining 11 patients, eight had no response (NR) or stable disease (SD), and three had progressive disease (PD). Seven patients proceeded with further therapy of which had SD. OCR at the end of eight cycles was 44% (95% CI 20-70%). Clinical response and radiologic response by ultrasonomammography were highly concordant (spearman correlation 0.70). The most common adverse effect was Grade 1 hand-foot syndrome, which was seen in 75% of patients. Despite several limitations, we successfully carried out this phase II feasibility study of neo-adjuvant capecitabine for LABC in Nigeria. Capecitabine monotherapy showed good overall response rates with minimal toxicity and further studies are warranted.

Adulthood hirschprung's disease: a report of 4 cases in Ile-Ife. Nigeria

BACKGROUND

Hirschsprung's disease in adulthood is very rare and is often misdiagnosed. We present four cases of adulthood Hirschsprung's disease seen in the last two decades to illustrate challenges accompanying its diagnosis and management.

METHOD

This descriptive case series included cases of histologically proven Hirschsprung's seen in adulthood at the Obafemi Awolowo University Teaching Hospitals Complex in the last two decades (1991-2011). The clinical data, radiological investigations, details of surgical treatment, histological diagnosis, outcomes and complications were analyzed.

RESULT

There were 4 adult patients, 3 males and 1 female with age ranging from 17 to 74 years (mean 23 years). Each patient presented with sub acute intestinal obstruction needing two staged procedures of initial colostomy followed by definitive procedure of low anterior resection (State procedure) in 3 patients and Swenson-Bill procedure in one. There was one mortality and good long term outcome in the remaining three.

CONCLUSION

This review presented the oldest patient presenting with adult Hirschsprung's and the highest mean age of any case series. Four patients with adulthood Hirschsprung's disease managed by two operative procedures enabled comparison of operative outcome with respect to complications and functional outcomes. Mortality seems to correlate with presentation at old age, which is usually due to life long self-management of chronic constipation. Though very rare, a high index of suspicion of adulthood Hirschprung's disease should be maintained in adult patients with recurrent chronic constipation needing lifelong laxative, enema or mechanical wash-out.

Presentation, distribution pattern, and management of diverticular disease in a Nigerian tertiary hospital

BACKGROUND

Colonic diverticular disease is one of the most common and costly gastrointestinal disorders among industrialized societies, which have recently been described among Africans. Presentations and distribution pattern of the disease among Africans appeared to be different from that described among the Western population. We embark on this study aimed at evaluating the presentation, distribution pattern, and the management of diverticulosis in our tertiary health facility.

MATERIALS AND METHODS

A prospective descriptive study of the cases of diverticular disease seen between January 2007 and December 2011 at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria.

RESULTS

During the 5-year study period, 40 cases were seen. The patients were aged 41-85 years with a median age of 64 years. There were 29 (72.5%) male and 11 (27.5%) female with an average male to female ratio of 3:1. The most common presentation was bleeding per rectum in 28 (70%) patients, which mostly needed transfusion. Ten (25%) patients presented with recurring abdominal pain, whereas one (2.5%) patient presented with abdominal mass and features of intestinal obstruction. Thirty patients were diagnosed on colonoscopy, eight on barium enema, and two on computerized tomography scan. Thirty-four (85%) patients had a pancolonic disease. All the patients were placed on high fiber diet and antibiotics namely ciprofloxacin and metronidazole. Five patients had recurrence within 6 months of follow up, of which one had emergency colectomy.

CONCLUSION

Diverticular disease is no longer a rare disease in Nigeria. It is a common cause of lower gastrointestinal bleeding in elderly patients. High index of suspicion for diverticular disease of the colon and its complications should increase in the country.

Selenium levels in neoplastic breast lesions

AIMS AND OBJECTIVES

The aim of this prospective case controlled study was to evaluate the tissue levels of selenium in patients with cases of fibroadenoma, cancer of the breast and in the controls in order to relate them to the occurrence of breast diseases.

SUBJECTS AND METHODS

Consecutive consenting patients who had histologically confirmed breast cancer and fibroadenoma attending the General surgical outpatients departments of Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, were recruited for the study. One gram of core disease breast tissues was taken for Selenium level estimation.

RESULTS

There were 127 female subjects;. 95 (74.8%) cases of fibroadenoma and 32 (25.2%) of breast cancer. While breast cancer was common on the left, fibroadenoma was more common on the right breast (? = 8.994; p=0.011). The median tissue level of selenium in patients with fibroadenoma was 0.0272 mg/g with a range of 0.0124 to 0.0576 mg/g and that of the cancer patients was 0.0178 mg/g with a range 0.0072 to 0.0436 mg/g. These were statistically significantly different ( p=0.001). Factors affecting tissue selenium level include age (p<0.001), overall stage of breast cancer (p<0.001), maximum length of breast mass (p=0.023), previous delivery (p=0.004), age at last confinement (p=0.007), parity (p<0.001), oestrogen receptor (ER) status (p<0.001) and progesterone receptor (PR) status (p=0.021).

CONCLUSION

Tissue selenium was lower in breast cancer than in fibroadenoma; Tissue selenium inhibits carcinogenesis; low tissue level of selenium therefore may be a factor in the development of breast cancer.

Spectrum of colonoscopy findings in Ile-Ife Nigeria

AIMS AND OBJECTIVES

Lower gastrointestinal (LGI) diseases are the leading causes of morbidity and mortality worldwide. Colonoscopy holds an important place in screening, diagnosing and treatment of these conditions. In Nigeria, as in many other developing countries, the facility for performing colonoscopy is rarely available. This prospective report seeks to evaluate the demographic data of patients presenting for colonoscopy, the pattern and validity of referral diagnosis versus colonoscopy findings in Ile-Ife, Nigeria.

SUBJECTS AND METHODS

All patients who had colonoscopy procedure done in the Endoscopy Unit of Obafemi Awolowo University Teaching Hospital Complex between January 2007 and December 2011 were included in the study.

RESULTS

During the study period, colonoscopy was carried out in 320 patients. One hundred and eighty two (56.9%) were males, while 138 (43.1%) were females. The median age was 59.5 years. Their ages ranged from 2-87 years. The most common indications were lower gastrointestinal bleeding and change in bowel habit which together accounted for 79.0%. No abnormality was seen in 93(29.1%) patients. Abnormal endoscopic findings included 66(20.6%) patients who had haemorrhoids, 50(15.6%) cases colorectal cancer, 33 (10.3%) patients had benign polyps and (30 (9.4%) patients had diverticular disease. Other findings were colitis, inflammatory bowel disease, rectovaginal fistula, vascular ectasia and extra luminal compression. Haemorrhoids, diverticulosis and polyps were the most common findings in patients presenting with lower gastrointestinal bleeding.

CONCLUSION

This present report showed that colonoscopy is a cheap, safe and effective method of investigating lower gastrointestinal disease in Ile-Ife, Nigeria. When the indication is based on symptoms, the diagnostic yield could be as high as 90%. The common causes of lower gastrointestinal bleeding in Ile-Ife, Nigeria include haemorrhoids, diverticulosis and polyps.

Relating tissue selenium to anthropometric and receptor status in Nigerian patients with breast cancer

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Background: The aim of this study was to identify the relationship of tissue selenium to anthropometric data and receptors status among Nigerian women with breast cancer. Methods: Consecutive consenting patients who had histologically confirmed breast cancer and fibroadenoma at Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, were recruited for the study. One gram of disease breast tissue was taken for selenium analysis from the subjects. The specimens were analyzed using graphite furnace atomic absorption spectrometer. Subjects’ demographics, anthropometric and breast cancer receptor status were recorded on a standard proforma. Results: There were 127 female subjects in the 2 groups. There were 95 (74.8%) cases of fibroadenoma and 32 (25.2%) of breast cancer. While the median tissue level of selenium in patients with fibroadenoma was 0.0272mg/g with a range of 0.0124 to 0.0576mg/g. The median tissue level of selenium in patients with breast cancer was 0.0178mg/g with a range 0.0072 to 0.0436mg/g. This was statistically significant (r=-0.613; p=0.0001). The anthropometric data of the patients such as weight, height, body mass index (BMI), body surface area, mid upper arm circumference and waist over hip ratio were correlated with tissue level of selenium and only waist over hip ratio and mid upper arm circumference were statistically significant (p<0.0001, 0.049 respectively). When association of the breast cancer receptor status was tested against the tissue level of selenium, while the ER and PR receptors were significantly related to tissue level of selenium (F= 41.765, p= <0.0001; F= 3.904, p=0.021), the HER receptor status was not (F= 1.100, p= 0.467).There was negative correlation between the tissue selenium and waist over hip ratio as well as tissue estrogen receptors status. Conclusions: Tissue selenium in patients with breast cancer was significantly low than that of fibroadenoma group. Similarly, tissue selenium is inversely related to waist over hip ratio and estrogen receptor status in subjects with breast cancer. It therefore implies that low tissue selenium may be an underlying factor in the occurrence of breast cancer in Nigeria.

Neoadjuvant capecitabine chemotherapy in women with newly diagnosed locally advanced breast cancer in a resource-poor setting (Nigeria): Efficacy and safety in a phase II feasibility study

e11554

Background: The majority of clinical trials of neoadjuvant therapy for breast cancer have been conducted in resource-rich countries. We chose Nigeria, a resource-poor country, as the major site for a phase II feasibility open label multicenter clinical trial designed to evaluate the efficacy, safety and tolerability of neoadjuvant capecitabine in locally advanced breast cancer. Methods: Planned treatment consisted of 24 weeks of capecitabine at a dose of 1000mg/m2 twice daily (2000mg/m2 total per day). Each cycle consisted of a 14-day period of therapy followed by a 7-day pause, and patients were evaluated after 3 cycles and taken off study if no response was documented. Responding patients were treated for no more than 8 cycles. The primary endpoints were partial, complete clinical response and pathologic complete response. Results: A total of 16 patients were recruited from August 2007 to April 2010. The study was terminated early as a result of slow accrual. After the first 3 cycles of therapy, partial clinical responses were seen in 5 of 16 patients (31%; 95% CI 11% - 59%). Of the remaining 11 patients, 8 had no response or stable disease, and 3 had progressive disease. Seven pateints proceeded with further therapy, two of them with stable disease but exactly in the border line of 25% increase. By physical examination, only 2 of the 6 patients had a documented complete clinical response, while by ultrasonomammography, partial responses were observed in 5 patients. Thus, overall response rate at the end of 8 cycles were 31.1% both by clinical examination and by ultrasonomammography. Clinical response by physical examination and radiologic response by ultrasonomammography were highly concordant (the spearman correlation between the two ratios was 0.70). The most common adverse effect was Grade 1 Hand and Foot Syndrome in 75% of patients. Conclusions: Despite several limitations, we successfully carried out this phase II feasibility study of neoadjuvant capecitabine for locally advanced breast cancer in Nigeria. Capecitabine monotherapy showed good overall response rates with minimal toxicity and further studies are warranted.

Characteristics of inflammatory bowel disease in three tertiary health centers in southern Nigeria

BACKGROUND

Inflammatory bowel disease (IBD) refers to two chronic inflammatory disorders of the gastrointestinal tract which is generally believed to be rare in most African countries. The objectives of the current study were to present the experience of three tertiary gastroenterology centers in southern part of Nigeria on IBD, highlighting the age distribution of the patients seen, management and the impact on the quality of their life in university-based community-type practices in Nigeria.

METHODS

This was a retrospective review of charts of inflammatory bowel disease seen between January 2007 and June 2010 at three teaching hospitals in Southern Nigeria. Diagnosis of IBD was made from clinical manifestations, colonoscopic and histopathological findings.

RESULTS

During the study period, 12 patients presented with clinical features consistent with inflammatory bowel disease. There were 8 (66.7%) males and 4 (33.3%) females and had ages ranged from 18 years to 80 years with a median of 26.5 years. Eight (66.7%) patients had ulcerative colitis while 4(33.3%) had Crohn's disease. Ten (83.3%) patients had severe disease with main clinical features being recurrent diarrhoea and passage of mucoid bloody stools. All the patients had treatments with sulphasalazine or mesalazine, steroids and antibiotics with good responses. One patient died following the occurrence of toxic megacolon.

CONCLUSION

Although IBD is uncommon in Nigeria, high index of suspicion is necessary by attending physicians managing patients with recurrent passage of mucoid bloody stools. Prompt gastroenterological referral and judicious use of colonoscopy and biopsy will assist in making the diagnosis.

Evaluation of two methods of preoperative hair removal and their relationship to postoperative wound infection

Introduction: When a surgical operation is to be conducted through a hair bearing part of the body, hair removal is often performed. This study aimed to evaluate the relationship of two methods of preoperative hair removal to postoperative wound infection in a developing country where razor shaving is very popular. Methodology: Consecutive consenting patients scheduled to have such operations were randomized into two groups. One group had hair removal by shaving with a razor blade while the other had hair removed by depilatory cream. Adequacy of hair removal and presence of skin injuries and/or reactions were noted preoperatively. Details of the procedures were recorded and patients were then assessed for postoperative wound infection. Results: A total of 165 patients were studied. Of the 79 patients who had hair removal by depilatory cream, hair was completely removed in 70 (88.6%) compared to 53 (61.6%) of the 86 patients who had razor hair shaving (p < 0.0001). Skin injuries were noted in 24 (27.9%) of the razor group and 3 (3.8%) of patients who had depilatory cream, (p = 0.001). Thirteen patients (7.9%) had postoperative wound infection including 2 (2.5%) in the depilatory cream group and 11 (12.8%) of the razor group. A significant association was found between preoperative skin injuries and postoperative wound infections. Conclusion: Preoperative hair removal with razor shaving predisposes to skin injuries which in turn significantly influence postoperative wound infection rates. Such injuries and resultant wound infection are fewer when depilatory cream is used for hair removal.

Laparoscopic cholecystectomy in Ile-Ife, Nigeria

BACKGROUND

Laparoscopic cholecystectomy is not yet routinely performed in most public tertiary hospitals in Nigeria.

OBJECTIVES

To assess the feasibility and early outcoe of laparoscopic cholecystectoy in Ile-ife, Nigeria.

METHOD

Consecutive patients who were selected for the procedure from June 2009 through December 2010 at the Ife State Hospital of the ObafemiAwolowo University Teaching Hospitals Complex, Ile-Ife were prospectively studied.

RESULTS

Eighteen female (75%) and six male patients had laparoscopic cholecystectomy within the study period. They were aged 19-83 years with a mean age of 33.4 years. Six (25%) patients had acute calculous cholecystitis while the rest presented with chronic calculous cholecystitis. Their Body Mass Indices ranged from 21 to 32kg/m2. Operation time ranged from 65 to 105 minutes. One procedure (4%) was converted to open due to bleeding from the gallbladder bed. Another patient who had a minor common bile duct injury presented with generalized dull abdominal pain on the sixth postoperative day. She had open repair of the injury over a T-tube. Three patients (12.5%) were discharged on the first postoperative day while 15 (62.5%) others were discharged on the second postoperative day. No mortality was recorded.

CONCLUSION

Laparoscopic cholecystectomy is feasible in our setting with outcome comparable to previous pioneering experiences in other African countries centre in spite of resource limitations.

An audit of laparoscopic surgeries in Ile-Ife, Nigeria

BACKGROUND

After several years of lagging behind due to several constraints, many general surgeons across Nigeria are now performing laparoscopic surgery. An audit of the procedure in our setting is required.

OBJECTIVE

To describe the outcome of consecutive laparoscopic general surgical procedures performed at the Obafemi Awolowo University Teaching Hospital, South-western Nigeria.

METHODS

All patients with general surgical conditions who had laparoscopic surgery from January 2009 through May 2010 in our hospital were prospectively studied and type of pre, intra and postoperative data including sex, age, indication for surgery, and outcome of the procedure were obtained and analysed.

RESULTS

Sixty-two patients (ages 18 to 72 years) had laparoscopic surgeries within the study period. Eighteen (29%) patients had laparoscopic cholecystectomy, 13 (21%) had laparoscopic appendicectomy, 10 (16.1%) had laparoscopic adhesiolysis, 7 (11.3%) laparoscopic biopsies of intraabdominal masses while 14(22.6%) others had diagnostic laparoscopies for a range of suspected abdominal conditions. All diagnostic procedures were performed as day cases while the duration of hospital stay was one to two days for the therapeutic procedures. Two(3%) procedures, including a biopsy of hepatic mass and a cholecystectomy were converted to open surgery due to significant haemorrhage. A minor bile duct injury was recorded in one patient who had cholecystectomy and superficial port site wound infections were noticed in two patients who had appendectomy. No mortality was recorded.

CONCLUSION

Our results show the feasibility of laparoscopic surgery in Nigeria. We advocate local adaptation and improvisations to increase the use of laparoscopic surgery in Nigerian hospitals.

Bowel preparation for colonoscopy: enema versus sodium phosphate

BACKGROUND

Colonoscopy is considered to be the gold standard investigation for assessing the colonic mucosa. Good bowel preparation is essential in order to achieve optimal visualisation of the mucosa. Traditionally water enema is used for bowel preparation in most centres in Nigeria. This prospective study was performed at the Gastrointestinal Endoscopy Unit of Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria between July 2008 and June 2009.

AIMS AND OBJECTIVES

This study compared patients' tolerability, adverse effects, efficacy and mean duration of colonoscopy of water enema and sodium phosphate (NaP) for bowel preparation toward colonoscopy.

PATIENTS AND METHODS

Standard structured questionnaire was completed by 64 patients and the colonoscopist assessing tolerability, adverse effect, efficacy and mean duration of the procedure.

RESULTS

There were sixty four patients aged between 22 to 86 years. The mean age was 58.16 ± 15.790. Thirty eight (59.4%) patients were in patients and 26 (40.6%) were out patients. Forty one (64.1%) patients had water enema while 23 (35.9%) patients were included in the NaP group. The median age for patients in both groups was 62.0 years. Patients in NaP group rated their bowel preparation as more tolerable and found the dietary restriction much easier than those in water enema group (p < 0.0001). Better colon cleansing score was found in patient in NaP group as compared with those in water enema group in all region of the colon. The procedure took significantly longer time in patients in water enema group as compared with those in NaP group (p < 0.0001).

CONCLUSION

NaP has a better bowel cleansing score for colonoscopy than water. It has better tolerability, side effect profile, efficacy and gives a shorter mean duration for the procedure.

Metastatic breast cancer in a Nigerian tertiary hospital

BACKGROUND

Late presentation of breast carcinoma is common in resource-limited countries with attendant poor outcome.

OBJECTIVE

To describe the pattern of clinical presentation and challenges of treating patients presenting with metastatic breast carcinoma in a Nigerian hospital.

METHOD

Clinical records of all patients who presented with metastatic breast carcinoma between January 1991 and December 2005 at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria were reviewed.

RESULTS

More than half of all histologically confirmed breast cancer patients seen within the study period presented with metastatic disease. Their ages ranged between 20-81 years with a mean age of 45.9 years. Only 3% (6 of 202) were males. Two-thirds had more than one secondary site on initial evaluation and the commonest sites were liver (63%), lung parenchyma (51%), pleura (26%) and contralateral breast in 25%. On immunohistochemistry, basal like tumours were found in 46.1%. Mastectomy was done in 37 patients with fungating breast masses while only one third of those referred to a nearby center for radiotherapy had it done. One year survival rate was 27%.

CONCLUSION

Metastatic disease is common in Nigeria and treatment is limited due to resource limitations. Improved awareness of the disease is advocated to reduce late presentation.

Bowel habits of urban and rural populations on the Jos, Plateau, Nigeria

BACKGROUND

Constipation and diarrhoea are frequent complaints amongst patients attending Gastroenterology Clinics. The normal bowel habits may vary among populations.

OBJECTIVE

To characterise and compare the bowel habits of rural and urban dwellers in a Nigerian population.

METHODS

Questionnaires were administered to 1236 adults aged 16 years and above recruited from two communities (rural and urban) using a two stage cluster sampling scheme based on existing administrative set up in a cross-sectional study. Information sought included socio-demographics, alcohol consumption, bowel habits and level of physical activity.

RESULTS

Adequate data for analysis were available in 1017 subjects giving a response rate of 509(93.1%) and 508(87.7%) for rural and urban populations respectively. The mean weekly bowel frequencies for the rural and urban populations were 10.8 ± 5.1 and 9.7 ± 4.9 (p=0.09) respectively. Four hundred and ninety-four (97%) subjects from the rural community and 493 (97%) from the urban opened their bowels between three times per day to three times per week. Constipation as identified by the passage of three or less motions per week was present in 14 (2.8%) of urban dwellers compared to 4 (0.8%) of the rural (p = 0.01). Bowel motions were more frequent in males than in females.

CONCLUSION

Bowel opening appears slightly more frequent among rural plateaus inhabitants than in urban dwellers. Constipation is more common in the urban than in the rural area.

Evaluation of tension-free mesh inguinal hernia repair in Nigeria: a preliminary report

BACKGROUND

Tension-free mesh inguinal hernia repair is becoming increasingly popular worldwide. However, reports are sparse in Nigeria.

OBJECTIVE

To evaluate the impact, outcome and cost implication of tension free inguinal hernia repair in a Nigerian setting.

METHODS

A prospective study of all consecutive adults patients with uncomplicated inguinal hernia who had mesh repair over a period of 12 months was undertaken. A large sheet of 900cm2 polyproylene mesh material was used for all the patients in the study. All wounds were opened on the third postoperative day while sutures were removed on the eight day. Patients were followed up for one year.

RESULTS

A total number of 30 patients had tension-free mesh ingunal hernia repair. Their ages ranged from 21 to 78 years (mean 47.2±15.5) years with a female to male ratio of 1:15. Complete inguinoscrotal hernia was the commonest type of groin hernia accounting for 40% of the cases. The repair of posterior wall which entailed placement of mesh was completed at a median time of 15 minutes. While two (6.7%) and one (3.3%) had wound oedema and groin pain respectively at one month, none of the patients had these complications or recurrence at a median of five months follow-up period.

CONCLUSION

Tension-free mesh inguinal hernia repair was well tolerated and affordable to our patients. Pain and infections, reported to be the common complications of this procedure were infrequent in this study. A larger study is recommended to help confirm these findings.

Determinants of splenectomy in splenic injuries following blunt abdominal trauma

INTRODUCTION

The management of splenic injuries has shifted from splenectomy to splenic preservation owing to the risk of overwhelming post-splenectomy infection (OPSI). This study aimed to identify the factors that determine splenectomy in patients with isolated splenic injuries, with a view to increasing the rate of splenic preservation.

PATIENTS AND METHODS

Files of 55 patients managed for isolated splenic injuries from blunt abdominal trauma between 1998 and 2007 were retrospectively analysed using a pro forma. Management options were classified into nonoperative, operative salvage and splenectomy.

RESULTS

The majority of patients suffered splenic injury as a result of motor vehicle accident (MVA) trauma or falls. Splenectomy was undertaken in 33 (60%) patients, 12 (22%) had non-operative management, and operative salvage was achieved in 10 (18%) patients. Significant determinants of splenectomy were grade of splenic injury, hierarchy of the surgeon, and hierarchy of the assistant.

DISCUSSION

MVA injury and falls accounted for the vast majority of blunt abdominal trauma in this study. The rate and magnitude of energy transferred versus splenic protective mechanisms at the time of blunt abdominal trauma seems to determine the grade of splenic injury. Interest in splenic salvage surgery, availability of technology that enables splenic salvage surgery, and the experience of the surgeon and assistant appear to determine the surgical management.

CONCLUSION

Legislation on vehicle safety and good parental control may reduce the severity of splenic injury in blunt abdominal trauma. When surgery is indicated, salvage surgery should be considered in intermediate isolated splenic injury to reduce the incidence of OPSI.

Preliminary experience with laparoscopic surgery in Ile-Ife, Nigeria

This study presents a pioneer experience with laparoscopic operations in a General Surgical unit of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. Consecutive patients who had laparoscopic operations from April through December 2008 were prospectively studied. Following clinical diagnosis, initial diagnostic laparoscopy was undertaken in all patients, followed by therapeutic open or laparoscopic procedures. All procedures were done under general anaesthesia. Duration of operation and outcome including complications were recorded. In all, there were 12 patients (8 males, 4 females), aged 15 to 50 years. Eight patients had clinical diagnoses of acute appendicitis, one each had undetermined right lower abdominal pain suspected ectopic gestation, adhesive intestinal obstruction and metastatic liver disease. The first 4 patients with inflammed appendix confirmed at laparoscopy had open appendicectomy. Of the next cohort of 5 patients, laparoscopic appendicectomy was completed in four but converted to open procedure in one. Normal findings were noted in the lady with suspected ectopic gestation. Laparoscopic adhesiolysis was done for adhesive intestinal obstruction while a laparoscopic liver biopsy was done for the patient with metastatic liver disease. Operative time ranged from 55-105 minutes with marked reduction in operation time as confidence and experience grew. No intraoperative complication was observed but one patient had superficial port site infection postoperatively. We conclude that with good patient selection and some improvisation, laparoscopic general surgical operations are feasible with acceptable outcome even in a poor resource setting.

Informed consent in surgery: an audit of practice in Ile-Ife, Nigeria

OBJECTIVES

This study was conducted to assess patients' knowledge of their diagnoses and proposed surgical procedures before giving consent for such procedures in the various surgical units of Obafemi Awolowo University Teaching Hospitals Complex, (OAUTHC), Ile-Ife.

MATERIALS AND METHODS

A structured questionnaire was administered to 80 consecutive patients who had just undergone an elective major surgery in general surgery, gyneacology, orthopaedics and surgical subspecialty units of the hospital.

RESULTS

Sixty patients (75%) gave consent themselves, while other consents were obtained from close relations. Thirty-seven (46.25%) respondents were informed of the diagnoses and procedure by the unit consultants but no consultant was involved in the completion of the consent form. Seventy-five (93.75%) respondents had a knowledge of the diagnoses, 68(85%) understood the procedure but only 21(26.25%) knew any alternative to the procedure, 29(36.25%) knew at least one complication of the procedure and 12(15%) knew an option or complication of anaesthesia. Forty-five (56.25%) of the consent forms were properly filled while other forms had one error or another.

CONCLUSION

Well structured and standardized method of obtaining informed consent from surgical patients should be adopted. While educating patients, the various alternatives to the procedure and possible complications should be carefully explained to the patients who should be carried along in decision making.

Fournier's gangrene complicating ruptured Richter's inguinal hernia

BACKGROUND

The deceptive entity of Richter's hernia typically presents with complications that are usually associated with high morbidity and mortality.

OBJECTIVE

The purpose of this case report is to highlight the association between Richter's groin hernia and Fournier's gangrene as demonstrated in a patient we managed recently.

METHODS

A case report of the management of an elderly patient who presented with Fournier's gangrene to a Nigerian tertiary institution following a neglected Richter's hernia on the right groin. The scrotal gangrene was managed by aggressive debridement and secondary closure while the ruptured caecal Richter's hernia was treated by a limited right hemicolectomy with end-to-end ileocolonic anastomosis and repair of the internal ring.

REPORT

We describe a rare case of Fournier's gangrene complicating a neglected caecal Richter's inguinal hernia in a 75-year-old Nigerian; highlighting the pathogenesis and management options.

CONCLUSION

Caecal Richter's hernia can be associated with Fournier's gangrene.

early experience with the use of prosthetic mesh as fascia replacement in structural abdominal wall reconstruction

Background: Abdominal wall defects occur from various causes and require reconstruction. autogenous tissue is often insufficient and incisional hernia often results. prosthetic mesh is a proven substitute to autogenous tissue but reports on its use is uncommon in our practice environment.Aim: the aim is to report our early experience with the use of prosthetic mesh in black patients in our practice environment.Materials and methods: the summaries of three patients with anterior abdominal wall defects which were managed with the use of a prosthetic mesh are presented as well as their intraoperative and postoperative photographs. one patient had intraperitoneal placement of the mesh and developed no complications.Results: one patient who had bowel resection developed a postoperative enterocutaneous fistula away from the site of the mesh and was managed conservatively. other patients had no complications.Conclusions: the use of prosthetic mesh is recommended.

Mirizzi syndrome caused by a bile pseudocyst

BACKGROUND

Mirizzi syndrome caused by bile pseudo cyst presents diagnostic and management challenges to the surgeon.

OBJECTIVE

To emphasize to clinicians the need to always recognize and correct associated liver derangements before surgery so as to prevent the usual accompanying high morbidity/mortality associated with Mirizzi syndrome.

CASE REPORT

We report an unusual and previously unreported pathology of post-cholecystectomy Mirizzi syndrome in a 35 year old female who developed a bile pseudo-cyst and which may possibly qualify for Mirizzi syndrome type 5--highlighting the need for maximum pre, -intra, and post-operative challenges for improved prognosis. The patient was lost from reactionary haemorrhage due to limited facilities.

CONCLUSION

There is a crying need in developing countries to have Critical Care centers and for Clinicians to recognize the necessity for adequate pre, intra and post-operative care of these high risk patients.

The severity, outcome and challenges of breast cancer in Nigeria

Breast cancer is a very common disease in Nigeria. It is often associated with a poor prognosis for a variety of reasons. This study was designed to investigate the challenges, severity, outcome and factors influencing the outcome of the management of breast cancer in a Nigerian Teaching Hospital with a view to finding ways to improve the current dismal outlook for patients with the disease. The clinical records of patients seen with breast cancer over an 8-year period (1996-2003) in the two units of the Teaching hospital were reviewed. The two units serve the urban, semi-urban and rural communities of some parts of southwestern Nigeria. Two hundred and twelve patients with breast cancer were seen over the 8-year period of the study. The mean age was 48 years (23-85 years). There were 211 female and one male. One hundred and three patients (48.7%) had either postprimary or tertiary education. A proportion of 66.7% were premenopausal, 79.2% had pregnancy early in life and were multi-parous. These also gave a history of prolonged breast-feeding of their children. The tumour was self-detected in 195 (92%). The mean duration of symptoms was 11.2 months (9 days-7 years). Pain in 100 patients (47%) was the most common symptom and the cancer was in the left breast in 113 (53.3%). Localized cancer was in the upper outer quadrant in 85 (40%), whereas the whole breast was involved in 55 patients (26%). Loco-regional features of advanced cancer were seen in 157 patients (74%). The tumour was fungating in 83 (39%) and there was clinical evidence of systemic metastasis in 28 patients (13%). One hundred and seventy-four (80.6%) patients had advanced disease (stages 3 and 4). Definitive surgery was possible in 185 patients (87.3%), neoadjuvant chemotherapy was required in 65 (30.6%), postoperative adjuvant chemotherapy in 178 (84%; drug combinations were CMF-cyclophosphamide, methotrexate, 5-fluorouracil, CMFP-CMF plus prednisone, and CAF-cyclophosphamide, adriamycin, 5-fluorouracil), tamoxifen was administered in all the patients. Only 70 (33.2%) patients were known to have received radiotherapy among those referred to the Radiotherapy unit, with associated fair treatment compliance after surgery. Outpatient clinic attendance was also very poor, only 27 (12.7%) were still being seen in the clinic, 83 patients (39%) were known to be dead and 102 patients were lost to follow-up. The mean follow-up period was 8.4 months (1 week-6 years). In conclusion, breast cancer is very common in our area of practice in Nigeria; the majority of our patients were young and premenopausal women presenting in the advanced stages of cancer. Treatment compliance was very poor. The majority of the patients were dead or lost to follow-up within a year of diagnosis.

Haematological parameters in sickle cell anaemia patients with and without splenomegaly

BACKGROUND

The aim is to investigate the clinical and haematologic effects of persistent splenomegaly (PS) and splenectomy in a population of Nigerians with sickle cell anaemia (SCA).

MATERIALS AND METHODS

SCA patients attending the Haematology clinic of the OAUTHC, Ile-Ife, were examined physically and haematologically. Patients with PS were compared with age and sex-matched controls without splenomegaly. Foetal haemoglobin (HbF), packed cell volume (PCV), reticulocyte count and the frequency of blood transfusion were noted for both groups. The clinical effects of splenectomy were documented in three patients who underwent the procedure because of symptomatic massive splenomegaly (> or = 10 cm).

RESULTS

Seventy-one patients, 40 males and 31 females, aged 16-48 (median, 21) years were studied. Nineteen (26.8%) had PS ranging from 3-22 cm (mean +/- SD = 9.4 +/- 4.4 cm; median = 7 cm). Ten of these had massive splenomegaly (spleen > or = 10 cm) varying from 10-22 cm (mean +/- SD = 12.3 +/- 3.8 cm; median = 12 cm). No significant differences were found between the mean values of HbF, PCV, reticulocyte count, frequencies of pain crisis, transfusion requirement, weights and heights in SCA with PS and age-sex matched controls without PS. Annual transfusion requirement showed a mild negative correlation with splenic size (r = -0.06), which was not statistically significant (p = 0.882). Significant haematologic improvement was confirmed in the 3 patients who underwent elective splenectomy for splenomegaly-induced hypersplenism.

CONCLUSIONS

We conclude that massive persistent splenomegaly is a recognised cause of significant morbidity in SCA patients as evident in the patients that underwent splenectomy. However, where it is mild to moderate, PS may not have significant adverse effect on the overall clinical picture of the disorder.

Antimicrobial susceptibility of Helicobacter pylori isolates of dyspeptic Nigerian patients

The resistance of Helicobacter pylori to antibiotic treatment is a growing global concern, but this has not been well studied in our environment. This study sought to determine: the susceptibility of the organism to common antimicrobial agents used in its eradication therapy. Twenty H. pylori isolates from dyspeptic patients were subjected to standard procedures for sensitivity testing and the determination of minimum inhibitory concentration against amoxycillin, ciprofloxacin, clarithromycin, erythromycin, metronidazole, rifampicin and tetracycline. The study showed marked in vitro multiple antimicrobial resistance to the commonly used eradication agents. All twenty isolates were however sensitive to ciprofloxacin. The findings of marked antimicrobial resistance may affect the effectiveness of currently recommended eradication regimes. In our environment, incorporating ciprofloxacin into the existing H. pylori antimicrobial therapy may improve the outcome of eradication.

Surgical audit in the developing countries

Audit assures provision of good quality health service at affordable cost. To be complete therefore, surgical practice in the young developing countries, as elsewhere, must incorporate auditing. Peculiarities of the developing countries and insufficient understanding of auditing may be, however, responsible for its been little practised. This article, therefore, reviews the objectives, the commonly evaluated aspects, and the method of audit, and includes a simple model of audit cycle. It is hoped that it will kindle the idea of regular practice of quality assurance by surgeons working in the young developing nations and engender a sustainable interest.

Helicobacter pylori in the dental plaque and gastric mucosa of dyspeptic Nigerian patients

BACKGROUND

Presence of helicobacter pylori (H.Pylori) in the dental plaques may be associated with the presence of the same organism in gastric mucosa.

OBJECTIVES

To assess and compare the prevalence of H. pylori in dental plaques and gastric mucosa of dyspeptic Nigerians.

METHODS

Sixty-six consecutive patients undergoing endoscopy for investigation of dyspepsia were included in the study. A predesigned questionnaire was used to collect information on socio-demographic and other factors. Each patient also had clinical dental examination. Dental plaque scrapping was collected before endoscopy for helicobacter pylori culture, and at endoscopy, two gastric biopsy specimens were taken for culture and histology.

RESULTS

The mean age (+/- SD) of the patients was 44.8 (+/- 17.4) years (range 5 to 80 years). The positivity rate of helicobacter pylori in gastric biopsy was 35 of 66 (53.0%) while the same for dental plaque was 46 of 66 (69.7%). The correlation (Spearman's) between gastric mucosa and dental plaque colonization with helicobactor pylori was significant (R = 0.30, P = 0.01). When concordant positivity of gastric biopsy culture and histology was taken as diagnostic, the sensitivity of dental plaque culture was found to be 82.9% and the specificity was 45.2%.

CONCLUSIONS

This study revealed that helicobactor pylori has a high prevalence in the dental plaque of the population that we have studied and may therefore be of potential relevance in screening for such infection.

Ectopic pregnancy involving the rectum

A case of advanced extrauterine pregnancy involving the rectum and with passage of fetal limb through the anus is presented. The patient probably had a heterotopic gestation.

Clinical pattern of perforated prepyloric and duodenal ulcer at Ile-Ife, Nigeria

High morbidity and mortality often attend perforation of duodenal ulcer. Over a 6-year period at Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria, 22 patients presented with prepyloric or duodenal ulcer perforations--a relatively low yearly rate of about four. Of the 15 patients evaluated, approximately three-quarters were working class young men and eight (53%) had no ulcer history. The high morbidity, and 20% mortality rate, observed were attributable to late presentation and the presence of advanced bacterial peritonitis in 67% of the patients at admission. Imprecise clinical features in those with small perforations led to misdiagnosis in a third of cases. Treatment of perforations in the majority (93%) of patients was by simple closure or truncal vagotomy and pyloroplasty. An increase in patients' awareness of the potentials of optimal operative management should encourage earlier presentation.

Cholecysto-choledochal fistula--Mirizzi syndrome (type II) in a Nigerian

Mirizzi syndrome is an uncommon cause of obstructive jaundice in which the common hepatic duct is obstructed by stones trapped within the neck of the cystic duct of the gall-bladder. In long standing cases the calculi may erode through into the common duct and may in fact, impact in the resulting fistula. This syndrome with its later progression is a rare complication of calculous disease of the gall-bladder worldwide. While it is perhaps encountered in the developing countries where cholelithiasis is not as prevalent as in the affluent countries, there has not been much documentation. This article reports on a Nigerian patient with a fistulous complication of Mirizzi syndrome (Type II) managed by cholecystectomy and choledochoduodenostomy and also presents a discussion of the condition.

Sources of intra-operative bacterial colonization of clean surgical wounds and subsequent post-operative wound infection in a Nigerian hospital

The incidence of postsurgical clean wound infection in 101 consecutive operations was 1.98%. Staphylococci were the predominant bacteria cultured from the anterior nares of the patients and attending surgical personnel--and were found to colonize the wounds. The nasal carriage rates of Staphylococcus aureus amongst the patients and surgical staff were 12.1% and 17.% respectively. Group III and non-typeable (NT) S. aureus strains accounted for about 65% of S. aureus isolates cultured from the anterior nares. A low incidence of nasal carriage of S. aureus isolates correlated with low incidence of wound sepsis. The operating room air seemed considerably contaminated but this did not reflect in high incidence of postsurgical wound sepsis. Our results suggest patients microflora and operating room air were the major sources of intra-operative bacterial colonization of wound at this centre.

Giant inguino scrotal hernia: a case report

Giant inguino--scrotal hernia is largely a problem of developing countries. A case of an unusually giant inguino-scrotal hernia is reported highlighting the problems encountered in management. Orchidectomy, bowel resection and relaxing epigastric incision were successfully employed in repairing the hernia. Hernias may not be difficult to manage if they ar not neglected. Efforts of health education need intensifying in this direction. We propose thorough peri-operative pulmonary exercises to cut down the post-operative pulmonary morbidity.

Experience with 29 cases of female ventral incisional hernias in Ile-Ife, Nigeria

Ventral incisional hernia, a major cause of postoperative morbidity after abdominal operations is reviewed in 29 adult female patients following 2042 major procedures during a 10-year period in Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria. All the patients were in the reproductive age group. The overall incidence of 1.4% is low but being a hospital incidence, the authors feel that it should not be deluding. Premature deliveries were associated with pregnancy coexisting with incisional hernia. Operations for complicated obstetric conditions and wound infections, were the major predisposing factors. It is noted that a reduction of the frequency of occurrence of incisional hernia and its complications in female patients can be achieved through a combination of health education and sound surgical technique with good wound care. An elective repair of hernia is most auspicious.

The predictive value of bacterial contamination at operation in post-operative wound sepsis

Wounds of 53 surgical patients were studied prospectively both clinically and bacteriologically. There were 26 males and 27 females with a mean age of 38.3 yr. Culture of fascia-deep wound swabs at closure of wound at the end of operation was related to culture if postoperative wound infection occurred. Overall wound infection rate was 15.1% with an infection rate for clean wounds of 3.7% being lowest and the dirty wound infection rate of 60% being highest. Pathogenic organisms in seven of eight infected wounds had been isolated at wound closure while in one instance they were different from organisms in the wound at closure. Risk of development of subsequent infection was significant if enteric organisms rather than Staphylococcus were isolated from the wound at closure. Wounds that had negative culture at the end of operation had no post-operative infection. The study underlines the importance of bacteriological analysis of wounds at the end of operation in identifying those at risk of post-operative infection and the probable causative pathogenic organisms. This will be useful in the choice of prophylactic antibodies for treatment of high-risk patients.

Gravid uterus in an anterior abdominal wall hernia of a Nigerian woman

A case of a gravid uterus in an incisional hernia in the anterior abdominal wall of a 27-year-old Nigerian woman is presented. The patient developed an ulceration of the anterior abdominal wall necessitating prolonged hospitalization. She was delivered by emergency lower segment cesarean section at 35 weeks gestational age because of premature labor. The patient unfortunately died from primary postpartum hemorrhage.

Burkitt's lymphoma in a 45-year-old Nigerian woman

A clinically advanced stage of Burkitt's lymphoma (BL) occurring unusually in a middle-aged perimenopausal woman in an endemic area is reported. Successful treatment was achieved by tumour debulking and intensive pulsed combination chemotherapy. BL needs to be considered in the differential diagnosis of abdominal swellings in adults in endemic areas.