Clinicopathologic Profile and Psychosocial Experiences of Nigerian Breast Cancer Survivors.

PURPOSE: Breast cancer survivors are a distinct category of patients with unique characteristics and needs. The population of survivors is expected to increase, given the rising incidence of breast cancer in Nigeria, and the improvements in breast cancer outcomes. This study evaluated the clinicopathologic characteristics and the psychosocial experiences of a cohort of Nigerian breast cancer survivors. METHODS: From an institutional breast cancer database, patients managed between January 2010 and December 2016 were evaluated. Clinicopathologic characteristics, treatment details, and survival estimates were assessed. These were compared with nonsurvivors managed during the same period. Survivors were defined as those who have been alive for at least 5 years from the date of presentation. Qualitatively, a purposive sample of 20 survivors was evaluated using one-on-one in-depth interviews to assess their experiences and coping mechanisms after treatment. RESULTS: Of the 355 patients in the database during the study period, there were 163 survivors (45.9%), while 192 (54.1%) died. Age, stage at presentation, tumor size, and receipt of multiple treatment modalities were significantly associated with survival. Five themes were identified in qualitative analysis: initial reaction to the diagnosis, experiences during treatment, social support, coping strategies, and advocacy. Strong family support and spirituality were prominent coping strategies identified in this cohort. CONCLUSION: Despite obvious infrastructural and manpower limitations, Nigerian patients who present early and receive multimodal therapy and different breast cancer treatments have better odds of survival. Survivors have some unmet psychosocial and physical needs requiring intervention.

Immediate lymph node extraction improves retrieval rate following axillary lymph node dissection: an effective approach to improving guideline-concordant breast cancer care in Nigeria.

Background: Axillary lymph node staging is essential for making therapeutic decisions and for prognostication. A minimum of ten lymph nodes is recommended for accurate staging. This study describes the process and outcomes of an audit cycle that resulted in a novel intervention instituted to improve concordance with guidelines. Methods: The study began with a retrospective audit of lymph node retrieval following axillary lymph node dissection (ALND). Subsequent phases evaluated the efficacy of immediate lymph node extraction before fixation by comparing the mean number of lymph nodes and the proportion of guideline-concordant cases to retrospective data and concurrent cases without the intervention. Results: The mean number of lymph nodes retrieved in the retrospective phase was 5.2, which is less than the recommended threshold. The intervention resulted in a significant increase in lymph node retrieval over the baseline rate (13.7 versus 5.2, p = 0.026). There was also a significantly higher number of lymph nodes following the intervention compared to concurrent cases managed during the same period without the intervention (13.7 versus 7.9, p = 0.004). The concordance rate was 89% in the intervention group compared to 47% in the non-intervention group (p = 0.019). There was no significant difference when the intervention was administered by either surgeons or pathologists (13.5 versus 12, p = 0.25). Conclusion: Immediate extraction of lymph nodes resulted in significant improvement of concordant lymph node retrieval in all phases of the study. We recommend that this practice be validated in larger cohorts for possible recommendation as an effective way of improving lymph node retrieval following ALND.

Drain after elective laparoscopic cholecystectomy. A randomized multicentre controlled trial.

BACKGROUND: Routine drainage after laparoscopic cholecystectomy is still debatable. The present study was designed to assess the role of drains in laparoscopic cholecystectomy performed for nonacutely inflamed gallbladder. METHODS: After laparoscopic gallbladder removal, 53 patients were randomized to have a suction drain positioned in the subhepatic space and 53 patients to have a sham drain. The primary outcome measure was the presence of subhepatic fluid collection at abdominal ultrasonography, performed 24 h after surgery. Secondary outcome measures were postoperative abdominal and shoulder tip pain, use of analgesics, nausea, vomiting, and morbidity. RESULTS: Subhepatic fluid collection was not found in 45 patients (84.9 %) in group A and in 46 patients (86.8 %) in group B (difference 1.9 (95 % confidence interval -11.37 to 15.17; P = 0.998). No significant difference in visual analogue scale scores with respect to abdominal and shoulder pain, use of parenteral ketorolac, nausea, and vomiting were found in either group. Two (1.9 %) significant hemorrhagic events occurred postoperatively. Wound infection was observed in three patients (5.7 %) in group A and two patients (3.8 %) in group B (difference 1.9 (95 % CI -6.19 to 9.99; P = 0.997). CONCLUSIONS: The present study was unable to prove that the drain was useful in elective, uncomplicated LC.

Recommendations of the Laparoscopic Surgery Society of Nigeria on the Conduct of Minimal Access Surgeries during and after the COVID-19 Pandemic in Nigeria.

BACKGROUND: COVID-19 pandemic has affected surgical practice worldwide. Laparoscopic procedures utilizing gas for pneumoperitoneum require specific consideration. METHOD: A panel of experts of the Laparoscopic Surgery Society of Nigeria (LASSON) was constituted to draft recommendations on the conduct of minimal access surgical (MAS) procedures during and after the pandemic in Nigeria. RESULTS: The Society strongly believes that laparoscopy and other (MAS) procedures can be safely performed during and after the current COVID-19 pandemic if appropriate safety measures are adhered to. The Society therefore makes the following recommendations for all units performing MAS in Nigeria: (1) Design clear cut measures to navigate the pandemic in each hospital. (2) Triage surgical services and procedures. (3) Encourage screening and testing of all patients (4) Provide adequate patient communication and consenting (5) Ensure compulsory use of Personal Protective Equipments (PPEs) (6) Minimize preoperative and intraoperative personnel (7) Envisage postoperative respiratory challenges and make adequate preparation for respiratory support: (8) Make specific considerations for the confirmed COVID 19 positive patients:(9) Private facilities offering MAS and endoscopic procedures should take special measures during the pandemic (10) Know your limits. CONCLUSION: The Society encourages all MAS practitioners to adhere to these recommendations.

The impact of neoadjuvant chemotherapy on patients with locally advanced breast cancer in a Nigerian semiurban teaching hospital: a single-center descriptive study.

BACKGROUND: There is a paucity of data on the response of breast cancer to neoadjuvant c in low-resources developing African countries such as Nigeria. We therefore decided to study the impact of neoadjuvant chemotherapy on breast cancer patients in Nigeria in the light of constrained resources. METHODS: This was a single-center retrospective descriptive study. Sixty-two patients with locally advanced breast cancer treated with neoadjuvant chemotherapy in the last 24 years in Obafemi Awolowo University Teaching Hospital Complex (OAUTHC), Ile-Ife, Nigeria, constituted the study population. The outcome measures were clinical tumor response, disease-free survival, overall survival, and chemotherapy toxicity profile. RESULTS: Patients ranged in age from 30 to 85 years (mean = 49.1 +/- SD 12.7 years) and included one male. After three cycles of chemotherapy, complete clinical response was observed in 4 patients (6.5%), partial clinical response in 28 patients (45.2%), no clinically measurable response in 24 patients (38.7%), and progressive disease in 6 patients (9.7%). Forty-one patients completed six cycles, of which 9 patients (22.0%) had complete clinical response and 12 patients (29.3%) had partial clinical response. Four of 30 patients (13.3%) with tumor size of 6-10 cm had complete clinical response, while no patient with a tumor bigger than 10 cm had complete clinical response. Of the 62 patients, 42 were followed up for more than 1 year. The 1-, 2-, and 5-year survival rates of this cohort were 66.7, 42.9, and 11.9%, respectively The median follow-up period was 9 months and the disease-free survival and overall survival rates at median follow-up period were 45 and 37%, respectively. CONCLUSION: There was a poor overall clinical response rate to neoadjuvant chemotherapy in the Black population studied. Late presentation with large tumor mass may be accountable for this.

Introduction of Suturing Skills Acquisition into Undergraduate Surgical Education: Early Experience from Ile-Ife, Nigeria.

BACKGROUND: Undergraduate medical students of the Obafemi Awolowo University, Ile-Ife, Nigeria, had over the years acquired various skills informally without structured training in basic skills in wound closure. The Department of Surgery introduced suturing skills acquisition workshop into the curriculum of the Final-Year Medical Students in 2016. This study describes the preliminary experience and the perception of the participants. METHODS: All students undergoing the senior rotations in surgery and surgical specialties were taken through a day suturing skills workshop at the surgical skills laboratory. Skills were demonstrated using validated narrative videos followed by practical sessions supervised by senior registrars and consultant surgeons. All participants were requested to complete a feedback form after the workshop. RESULTS: One hundred and eighty students were trained in six workshop sessions per year over two academic sessions. There were 128 (71.1%) male and 52 (28.9%) female students trained by 9 consultants and 13 senior registrars with 15-17 students in each session. Self-assessment feedback after the workshop revealed that all but 3 (1.7%) students felt very confident in handling basic instruments, 102 (56.7%) were confident of their proficiency in basic suturing, 68 (37.8) were less confident, whereas 10 (5.6%) were not confident looking ahead and 82 students (46.1%) wanted additional skills to attain proficiency in some common surgical procedures prior to graduation. CONCLUSION: The department achieved the aim of introducing suturing skills acquisition into undergraduate surgical education. In the future, other surgical skills acquisition workshops may be considered as desired by the students.

Early Experience with LigaSure Thyroidectomy in a Nigeria Teaching Hospital.

BACKGROUND: The principles of safe and efficient thyroid surgery had been established and the technique has remained the same for over the century without any major significant changes. The introductions of electrosurgical devices constitute a major shift in the technique of thyroid surgery. OBJECTIVE: We present our early experience with the use of LIGASURE vessel sealing system for the procedure of thyroidectomy. MATERIALS AND METHODS: This was a quasi-experimental study comparing outcome of LigaSure thyroidectomy in a prospective nonrandomized cohort with another retrospective cohort of preintervention clamp-and-tie thyroidectomy. RESULTS: A total of 30 patients with a clinical diagnosis of goiter were recruited into the study. There were two males and 28 females with a mean age of 42.6 years. Diagnosis was simple multinodular goiter 24 (80%), controlled toxic nodular goiter 3 (10%), grave disease 1 (3.3%), and multinodular goiter with retrosternal extension 2 (6.7%). The mean thyroid weight was 121.0 g. The mean duration of surgery was 59 min compared to 128 min for traditional technique (P < 0.01). The mean blood loss of 116 ml was significantly less than 328 ml following the traditional technique (P < 0.01). Mean duration of hospital stay was 1.9 days, compared to 3.55 days in the traditional technique group (P = 0.02). Troubling postoperative complications of change in voice quality occurred in only one patient (3.3%). CONCLUSION: LigaSure thyroidectomy was found to be easier and faster to carry out with no learning curve and easy to learn and adapt.

Trend Over Time for Cholecystectomy following the Introduction of Laparoscopy in a Nigerian Tertiary Hospital.

BACKGROUND: There still exist some concerns about the desirability of laparoscopic surgery in lower-middle income countries. We recently adopted laparoscopy for common general surgical procedures and observed many benefits. This study aims to describe the changing rate of cholecystectomy before and after the introduction of laparoscopy in our hospital. METHODS: We reviewed the records of cholecystectomies performed before and after the introduction of laparoscopic cholecystectomy (LC) in 2009 in a single general surgery unit of the Ife Hospital Unit of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. Cholecystectomy was reviewed as a percentage of general procedures performed, and postoperative length of stay was calculated. RESULTS: A total of 173 cholecystectomies were performed in the hospital between January 2005 and December 2015. The yearly number rose from 7 in 2005 to 31 in 2015 corresponding to 2.7% of total elective major general surgery procedures in 2005 and 9.1% in 2015. A marked progressive increase was observed in the number and rate of cholecystectomies from 2009 following introduction of LC. From 0% in 2005, LC rose to 90% of all cholecystectomies in 2015. The mean postoperative length of stay of patients undergoing cholecystectomy declined from 5.2 days in 2005 to 3 days in 2009 and 1.8 days in 2015. CONCLUSION: This study demonstrates an increased rate of cholecystectomy following the introduction of LC in our setting. We recommend increased adoption of laparoscopy and other forms of minimally invasive surgery across the country.

Early experience with laparoscopic surgery in children in Ile-Ife, Nigeria.

BACKGROUND: Laparoscopy is not yet routinely employed in many Paediatric Surgical Units in Nigeria despite the advantages it offers. This study describes the preliminary experience with laparoscopic procedures in a single centre. PATIENTS AND METHODS: A retrospective analysis of all children who had laparoscopic surgery between January 2009 and December 2013 at the Paediatric Surgical Unit of Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife was carried out. Their sociodemographic, preoperative and intraoperative data along with postoperative records were subjected to descriptive analysis. RESULTS: Eleven (44%) diagnostic and 14 (56%) therapeutic procedures were performed on 25 children whose age ranged from 5 months to 15 years (Median: 84 months, Mean: 103 ± 64.1 months), including eight (32%) females and 17 (68%) males. Indications included acute appendicitis in 12 (48%), intra-abdominal masses in six (24%), three (12%) disorders of sexual differentiation, two (8%) ventriculoperitoneal shunt malfunctions and impalpable undescended testes in two (8%) children. The procedures lasted 15-90 minutes (Mean = 54 (±21.6) minutes). Conversion rate was 17% for two patients who had ruptured retrocaecal appendices. No intra operative complications were recorded while three (12%) patients had superficial port site infections post-operatively. All diagnostic (11) and two therapeutic procedures were done as day case surgery. The mean duration of hospital stay was 3.1 (±3.3) days for those who had appendectomies. CONCLUSION: Laparoscopic surgery in children is safe and feasible in our hospital. We advocate increased use of laparoscopy in paediatric surgical practice in Nigeria and similar developing settings.

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.

Traumatic urologic injuries in Ile-Ife, Nigeria.

BACKGROUND: In a developing country with limited healthcare resources, traumatic injuries and their management pose a significant challenge to healthcare delivery. AIM: To highlight the challenges in the management of traumatic urologic injuries in patients in our setting. SETTING AND DESIGN: Patients presenting with traumatic injuries to the urinary tract, between January 1996 and December 2005, in a University Teaching Hospital in Southwestern Nigeria were the subjects of this study. PATIENTS AND METHODS: Clinical records of patients who had such injuries were reviewed. RESULTS: Ninety injuries occurred in 86 patients including 77 males and 9 females aged 14-68 years. Fourteen (15.5%) of the injuries involved the kidneys, urinary bladder was involved in 23 (25.6%) and the male urethra in 53 (58.9%) injuries. The mechanisms of injury were road traffic accidents in 52 (60.5%) patients, straddle injuries in 18 (20.9%), trauma to the back in 8 (9.3%), falls from a height in 6 (7.0%) and gunshot injuries in 2 (2.3%) patients. Associated injuries include pelvic fractures in 33 (38.4%) patients, limb bone fractures in 13 (14.1%), intestinal injuries in 12 (13.0%) and spinal injuries in 8 (8.7%) patients. In most patients, diagnosis was made based on clinical suspicion and minimal investigations such as abdominal ultrasound, urethrocystoscopy and/or urethrocystography. The outcome was good in most patients and mortality was recorded in only 2 (2.3%) patients who had concomitant spinal and burns injuries. CONCLUSION: Prompt management instituted on clinical suspicion of injuries presents a good outcome in patients in a limited resource setting.

A middle aged woman presenting with massive empyema of the gallbladder: a case report.

Empyema of gallbladder is generally a rare disease and it is even rarer in the traditional African population where incidence of cholelithiasis is much lower compared with the Caucasian population. This is a presentation to highlight massive empyema of the gallbladder in a 58 year old woman who had no prior history of gallstone disease and who was treated with open cholecystectomy. The outcome was successful and she was followed up for a year.

Incidental carcinoma of the prostate gland presenting with initial manifestation of disseminated intravascular coagulopathy (dic) in a middle aged man: a case report.

BACKGROUND: Incidental carcinoma of the prostate gland is a common clinical problem among elderly males but this malignancy presenting initially with features of Disseminated Intravascular Coagulopathy (DIC) in the African blacks is rare. Disseminateded intravascular coagulathy is the most frequent coagulation disorder in patients with prostate cancer, However DIC as a first manifestation of prostate cancer is unusual. CASE REPORT: This paper reports a case of a 56 year old Nigerian civil servant who presented initially with clinical features of DIC characterised by bleeding from multilple orifices but was subsequently diagnosed at autopsy to be infiltrating adenocarcinoma of the prostate. CONCLUSION: This rare case of DIC should be considered especially in elderly men when no other cause can be found for coagulopathy.

Paradox of wellness and nonadherence among Nigerian women on breast cancer chemotherapy.

CONTEXT: Intentional nonadherence among cancer patients is rare and may occur only when the benefits of treatment are not obvious to the patient. AIMS: To highlight a group of women on chemotherapy for breast cancer who defaulted from their medications because they were improving. SETTINGS AND DESIGN: A study was carried out of the reasons for nonadherence to medications among women receiving chemotherapy for breast cancer at a Nigerian teaching hospital between January 1993 and December 2002. MATERIALS AND METHODS: A retrospective review of patients' records was done. RESULTS: Of the 188 women who received chemotherapy during the study period, 152 (80.9%) defaulted from treatment at one point or another. The reasons for nonadherence were available in 101 patients. Among these, 18 (18.0%) reported nonadherence because they felt better after commencing chemotherapy. They were aged 31-50 years (Mean = 35.6 (SD3.2)). Six (33.3%) of them presented in AJCC Stage I, and 10 (55.6%) in stage II. Age and disease stage at presentation were found to have significant influence on their reason for nonadherence. Of the nine women on neo-adjuvant chemotherapy, six (66.7%) had complete response but defaulted and five (55.6%) re-presented within a year with metastatic disease. Three of the patients receiving systemic post-surgery chemotherapy presented within a year with local recurrence. Most of the other patients were subsequently lost to follow-up. CONCLUSIONS: Nonadherence due to wellness among breast cancer patients is associated with poor outcome. We propose a detailed prospective study to establish factors that may influence such behavior.