Expanding access to surgical care toward universal health coverage: Leveraging sustainable financing strategies for Sub-Saharan Africa.

The National Surgical Obstetric and Anaesthesia Plan is an invaluable country resource with the capacity to promote increased access to safe and affordable surgical and anaesthesia care if implemented. Although cost of implementation is only a fraction of Health Sector Strategic Plan cost in the countries with costed plans, it is important that the funding of the plans is based on sustainable financing strategies. This will ensure appropriate and timely implementation and sustainability of the plan itself. The aim of this review was to discuss and make recommendations on innovative and sustainable strategies for financing national surgical plans in sub-Saharan Africa.

Diagnostic accuracy of fine needle aspiration cytology for palpable breast lumps in a Nigerian teaching hospital.

BACKGROUND: Breast lump is a very common problem in the surgical units of many hospitals. Considering our unique socio-cultural and economic peculiarities, the ideal initial preoperative diagnostic tool for breast diseases should be cost-effective, simple with minimal physical and psychological trauma. AIMS: This study aimed to evaluate the diagnostic accuracy of Fine Needle Aspiration Cytology (FNAC) in the management of palpable breast lesions in our center. METHODSOLOGY: This is a prospective study that lasted for one year. Fine needle aspiration cytology was done after clinical examination of all patients who gave consent. Open surgical biopsy was used as a reference standard. RESULTS: One hundred and fifteen patients were enrolled. We found that unsatisfactory smears (C1) were seven (6.1%), benign smears (C2), 57 (49.6%), atypical smears (C3), five (4.3%), suspicious of malignancy smears (C4), six (5.2%) and unequivocally malignant smears (C5), 40 (34.8%). Fine needle aspiration cytology achieved high sensitivity (90.4%), specificity (93.7%), positive predictive value (92.2%), negative predictive value (92.2%) and overall diagnostic accuracy (92.2%) for breast lumps in this study. The false positive and negative rates of 7.8% each are both higher than values recommended by National Health Services Breast Screening Program (NHSBSP) of United Kingdom. CONCLUSION: In view of the high sensitivity, specificity and overall diagnostic accuracy combined with early retrieval of pathologic results on first clinic visit reported in this study, FNAC should become a useful tool in the management of breast lumps in our center.

Does preoperative chemical depilation make any difference in postoperative wound infection?

BACKGROUND: Preparation for surgery has traditionally included the removal of body hair from the intended surgical wound site. The effect of this practice on postoperative wound infection is yet to be fully elucidated. AIMS: This study sought to determine if preoperative chemical depilation reduces the risk of surgical site infection (SSI). METHODOLOGY: Two methods of preoperative hair removal: razor shaving and depilatory cream were compared. The eligible patients were randomized into two groups and the presence of postoperative wound infection was evaluated using the Southampton wound grading system. Data were analyzed using SPSS version 21 Chicago-Illinois, statistical significance was inferred at Pvalue ≤ 0.05. RESULTS: In total 100 patients were analyzed with 20 patients excluded due to co-morbidities and noncompletion of the study. The overall prevalence of SSI was 18.0% (7 (14.0%) and 11 (22.0%) in the depilatory cream and razor shaving groups, respectively). The difference in the rate of SSI was not statistically significant (P = 0.436). Hair was completely removed in 47 (94.0%) compared to 38 (76.0%) patients in the razor shaving group (P = 0.012) while skin injuries were noted in 21 (42.0%) vs 1 (2.0%) patients who had razor shaving and chemical depilation(P = <0.0001), respectively. CONCLUSION: There was no significant difference in SSI rates in patients that had preoperative chemical depilation when compared with razor shaving.

Assessing the Quality of Life of Patients with Breast Cancer Treated in a Tertiary Hospital in a Resource-Poor Country.

BACKGROUND: Very few studies have assessed the quality of life (QoL) of patients living with breast cancer in a resource-poor setting like Nigeria. The aim of our study was to comprehensively examine the measures of QoL in breast cancer patients using the Functional Assessment of Cancer Therapy-Breast (FACT-B) version 4 in order to deepen the literature on QoL among breast cancer patients to include non-Western/northern patient populations. PATIENTS AND METHODS: Purposive sampling of stable patients who attended general surgery clinics with histopathologically diagnosed breast cancer was done. Eligible patients were assessed using five domains of the FACT-B questionnaire including: the breast cancer-specific symptoms (BCS), emotional well-being (EWB), functional well-being (FWB), physical well-being (PWB), and social & family well-being (SWB). The questionnaire was administered in a face-to-face interview by trained research assistants. In addition, the five domains were compared among three different age categories, pre-menopausal and post-menopausal, and patients who have had surgery and chemotherapy alone. The SPSS (IBM Corp. Released in 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) and the Microsoft Excel (11. Corporation Microsoft, Redmond, WA, USA) were used for statistical analysis. Statistical significance was inferred when p <0.05. RESULTS: Among the 60 enrolled participants, total score of the five domains (n = 144) was 74.59 ± 17.72, FACT-G score (n = 108) was 53.49 ± 12.56, Trial outcome index (n = 112) was 49.20 ± 13.13, PWB (n = 28) was 10.95 ± 6.37, SWB (n = 28) was 18.41 ± 6.48, EWB (n = 24) was 6.98 ± 4.15, FWB (n = 28) was 17.15 ± 7.12, and the BCS (n = 36) was 21.10 ± 8.93. EWB was significantly less in post-mastectomy patients on adjuvant chemotherapy (p = 0.031) and pre-menopausal women (p = 0.041) as well as in patients less than 40 years when compared with patients more 50 years (p = 0.049). CONCLUSIONS: Breast cancer patients in resource-poor countries have a profoundly impaired quality of life. This study showed significantly lower emotional well-being domain scores in post-mastectomy patients on adjuvant chemotherapy, pre-menopausal women having breast cancer and in younger female patients. There is need to address this anomaly.

Mammographic findings of breast cancer screening in patients with positive family history in South-East Nigeria.

BACKGROUND: A positive family history of breast cancer is an important risk factor associated with the development of breast cancer in women. Early detection required regular screening in these women. OBJECTIVE: To determine the mammographic findings of breast cancer screening in patients with a positive family history in Iyienu, Southeast Nigeria. METHODOLOGY: Forty-three consenting females with a positive family history of breast cancer who underwent mammographic screening at Radiology Department, Iyienu Mission Hospital, Anambra State, were enrolled in the study. Mammographic findings were compared with those of females with a negative family history. RESULTS: The mean age was 49.6 years with a range of 35-69 years. The mammographic findings were asymmetric density, nipple retraction, tissue retraction, skin thickening, lymphadenopathy, and calcification within a mass with varying frequency for the right and left breasts. CONCLUSION: A significant statistical difference was found in lymphadenopathy and calcification for the right and left breasts, respectively, when compared with those without positive family history.

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.

Default from neoadjuvant chemotherapy in premenopausal female breast cancer patients: what is to blame?

BACKGROUND: Breast cancer is the most frequent cancer among women in most parts of the world including Nigeria. Neoadjuvant chemotherapy has been demonstrated to be a helpful strategy in the context of locally advanced breast cancer. AIMS: The purpose of this study was to investigate some factors that may contribute to low rate of acceptance and adherence to neoadjuvant chemotherapy. MATERIALS AND METHODS: A 1-year prospective study of premenopausal women with locally advanced breast cancer recommended for neoadjuvant chemotherapy from June 2009 to May 2010. RESULTS: Forty-four patients gave consent to be part of the study. The ages ranged from 26 to 51 years with a mean age of 42.1 years ± 7.7 years. Only 31 patients completed the four courses of NAC. Seventeen (38.6%) patients dropped out of treatment, before, during or after completing NAC. Ten of these defaulted due to inadequate funds to procure chemotherapy, three patients because they insisted on immediate mastectomy, and four of these patients refused surgery when they achieved complete clinical response, probably due to fear of mastectomy which is common among women in our environment. Twenty patients had dose deferment. CONCLUSION: Lack of funds to procure chemotherapy and refusal of additional modality of treatment are the two major factors responsible for default of NAC and its goal in patients with LABC.

Neoadjuvant chemotherapy for locally advanced premenopausal breast cancer in Nigerian women: early experience.

BACKGROUND: Breast cancer, the commonest female malignancy in Nigeria presents late, with bulky locoregional masses and predominantly in a pre and peri-menopausal setting. Treatment when feasible has been with mutilative surgery with a poor patient acceptance rate. Chemotherapy which is widely used in adjuvant and metastatic settings has recently been indicated in the neo-adjuvant setting. METHODS: Locally-advanced female breast cancer patients [AJCC Stages IIIA, IIIB, IIIC], seen in the breast clinic from July, 2006 to March 2007 were recruited into the study after informed consent. Patients received doxorubicin, 5-fluoro-uracil and cyclophsphamide by intravenous bolus or infusional injection on a three weekly regimen as day cases. The dominant lesion was assessed by calipers at each visit. Therapeutic clinical responses were assessed as none; partial, complete. RESULTS: During the period 32 women (33 breast cancers) were seen and recruited. The numbers steadily declined over time and only 28 completed the treatment modality. Mean pre-chemotherapy tumour size was 13.5cm which declined to 7 cm at the 5th. One patient (3.6%) exhibited complete clinical response, 25 (89%), partial response and 2 had no response. No serious toxicities were noted. CONCLUSION: Neo-adjuvant chemotherapy using anthracycline based regimens is efficacious and safe in reducing tumour bulk in locally advanced breast cancers. The use should be encouraged to make bulky tumours operable.

Giant fibrosarcoma prostuberans of abodominal wall: management problems in resources-constrained country.

BACKGROUND: Abdominal wall sarcomas represent less than 1% of adult malignancies. Dermatofibrosarcoma protuberans can grow to very large sizes and the recommended resection 2-3 cm from the macroscopic tumour margin can produce very large full thickness defects of the abdominal wall. Reconstruction of such defects can be quite challenging in resource constrained areas where patients present late with giant lesions. OBJECTIVE: To highlight the presentation and management challenges faced by the surgical oncologist and reconstructive surgeon in a resource constrained country when faced with giant Dermatofibrosarcoma protuberans of the abdominal wall. METHODS: Prospective study of patients with abdominal wall soft tissue sarcoma presenting to the authors. Cases of giant dermatofibrosarcoma protuberns who underwent surgery were analysed. RESULTS: Seven cases managed over an eight year period (January 2000 to December 2007). Age ranged from 27-70 yrs with slight female preponderance 1.5:1 F:M. Three presented with recurrent fungating masses. Only one could be reconstructed with prolene mesh. One recurrence was noted during the period under study. CONCLUSION: Poverty, ignorance and lack of necessary working tools are major challenges faced by the surgical oncologist and reconstructive surgeon in resource constrained areas and pose a major obstacle to the control of cancer in these areas.

Primary papillary transitional cell carcinoma of the breast: a case report.

BACKGROUND: Primary papillary transitional cell carcinoma of the breast is a rare occurrence worldwide and few cases ever have been reported. It may be mistaken for the benign intraductal papillary lesions or papillary adnexal neoplasms. CASE REPORT: A 66 year old woman who presented with a recurrent right breast mass. Histopathologic studies confirmed a diagnosis of Primary Papillary Transitional cell carcinoma. CONCLUSION: The need for a high index of suspicion of primary papillary transitional cell carcinoma of the breast must be considered, especially in suspected benign intraductal papillary lesions to facilitate adequate and timely diagnosis and management of this lesion.

Carcinoma of the gallbladder at the Nnamdi Azikiwe University Teaching Hospital--a 5-year retrospective study.

BACKGROUND: Carcinoma of the gallbladder is often missed because of the low index of suspicion. AIMS AND OBJECTIVES: To review the incidence, pattern and outcome of carcinoma of the gallbladder in our center and to highlight the need for early diagnosis. DESIGN: Retrospective survey of all cases of carcinoma of the gallbladder. SETTING: Nnamdi Azikiwe University Teaching Hospital serving rural, semi-urban and urban communities. PATIENTS AND METHODS: Patients who had histologically confirmed carcinoma in the general surgical units of the Nnamdi Azikiwe University Teaching Hospital over a 5-year period were reviewed and, from their case notes, the following information on sex, age, mode of presentation, time of diagnosis, stage of disease, treatment given and outcome were extracted. RESULTS: Twenty-one cases of gallbladder carcinoma were seen out of a total of 692 cases of different types of cancers seen in the general surgical units, giving an incidence of 3.04%. Six were males and 15 were females, age ranged between 39 and 72 years, a mean of 55; with the peak age in the 7th decade of life. Eleven patients (52.4%) presented with features of chronic cholecystitis and had cholecystectomy. Ten patients presented with obstructive jaundice in a stage too advanced for any form of palliative surgical treatment. The outcome was good in patients who presented with features of cholecystitis but who turned out to be cases of early carcinoma of the gallbladder because after five years of follow-up, none of them has shown any features of recurrence. There was no mortality in this group and the patients have remained in good health. However, the prognosis was poor in those patients who presented with obstructive jaundice. They remained very ill, with worsening general condition. They were discharged home on request of their relations and were lost to follow-up. CONCLUSIONS: Carcinoma of the gallbladder may present as cholecystitis. It is advisable for clinicians to have this in mind before, during and after cholecystectomy. Early presentation to hospital by patients would avert delay and improve early diagnosis, early treatment, and better outcome.

Primary jejuno-ileal neoplasms in eastern Nigeria.

Small intestinal neoplasms are uncommon with reported incidences of less than 1% of GI neoplasms. A retrospective review of cases of small intestinal neoplasms seen by the authors in a ten-year period is presented. Ten cases were seen during the period (8 females and 2 males). Seven patients were aged less than 20 years while the rest were aged above 2 years. Six patients presented with intestinal obstruction, 3 with features of chronic ill-health while 1 was an incidental finding. The ileum was involved in 5 patients, the jejunum in 4 while 1 showed multiple gut involvement. One patient had a benign lesion (Peutz-Jeghers Syndrome). The rest consisted of lymphosarcoma [5],adenocarcinoma [3] while 1 patient had leiomyo-sarcoma. Treatment offered included resection of small gut in 7 patients and ileo-colectomy in 3 patients. Three patients with lymphosarcoma had a full course of cytotoxic chemotherapy. The outcome was poor; 2 patients were alive after 3 years, 3 died within 6 months of surgery while the rest were lost to follow-up at variable periods after surgery. Neoplasms of the small gut presents late in our environment. Lymphosarcoma seems commoner in childhood and carries a better prognosis.

Breast cancer in eastern Nigeria: a ten year review.

BACKGROUND: Breast cancer, although reported to be the commonest female malignancy world-wide has not been extensively studied in Eastern Nigeria. METHODS: A study started in 1987 enrolled all patients with breast disease seen in the author's practice in 4 hospitals located in Eastern Nigeria. Record's of patients with breast cancer were extracted for this report. FINDING: Patients with breast cancer comprised 30% of all patients with breast disease with a male: female ratio of 1:67. The mean age was 44 years with a peak in 35-39 year range. Ninety-one percent of the patients were married, 69% premenopausal, 90% of the female patients were parous (Ave.. 5.35; range 1-11), 57% of these parous patients had their first full term pregnancy under 20 years of age and 90% had lactated. 64% had advanced disease on presentation (Manchester III & IV), the commonest sites of distant metastasis being vertebral column and lungs. 5% had bilateral disease at presentation, 4% gave a positive family history and 12% gave a history of previous benign breast disease. The commonest histological diagnosis was infiltrating ductal carcinoma. Only 7% presented within 1 month of discovery of symptoms while 15% waited longer than 1 year. CONCLUSION: Breast cancer in Eastern Nigeria follows a pattern similar to other parts of the third world with late presentation in mainly multiparous premenopausal patients. Efforts at public health education to encourage earlier presentation should be encouraged.

Survival following treatment of primary breast cancer in eastern Nigeria.

OBJECTIVE: To assess the survival patterns in female breast cancer patients treated in eastern Nigeria. DESIGN: A prospective study. SETTING: Nmadi Azikiwe University Teaching Hospital, Nnewi, Iyi-Enu Mission Hospital Onitsha and Aca Specialist Hospital, Nkpor, Onitsha, Nigeria. SUBJECTS: Female breast cancer patients undergoing treatment offered by a single surgical practice. INTERVENTION: The patients were offered modified radical mastectomy, multidrug chemotherapy and hormone therapy. The patients were subsequently followed up for significant periods or until death. Patients who did not complete the treatment or were lost to follow up were excluded from further analysis. RESULTS: Out of 124 patients seen during the period, seventy eight were evaluable. The mean age was 44 years, 63% were pre and peri-menopausal while 56% had advanced diseases (Stages III and IV) at presentation. The overall median survival was 31 months but was better for Stages I and II (42 months) than for Stages III and IV (20 months). There was a slight survival advantage for post-menopausal patients. Distant metastases were most often seen in the vertebral tree and in the lung fields. CONCLUSION: Survival from breast cancer is still poor in our set up. Efforts at earlier diagnosis must be aggressively pursued. Multi-centre trials are advocated in order to determine whether breast cancer pursues a more aggressive course in Nigerians.

Fibro-adenoma of the breast in Nigerian Igbos.

BACKGROUND: There has been a recent increase in interest in conservative treatment of benign disease. OBJECTIVE: To study the epidemiology, clinical features and management of fibro-adenoma of the breast in Nigerian Igbos. PATIENTS AND METHODS: Patients with breast disease presenting to the author at four Nigerian hospitals between 1986 and 1997 were enrolled in a prospective study. RESULTS: Patients with breast disease constituted a significant burden in general surgical practices, with fibro-adenoma present in 94 out of 284 patients with benign disease (33%) and 410 patients with breast disease (23%). The accuracy of clinical pre-operative diagnosis is excellent, especially in those aged under 25 years. Conservative treatment may be advisable for these patients if they can be kept under observation. Other worrisome discoveries include a high rate of teenage abortion and a significant delay in seeking medical help that has not reduced when compared with a previous study undertaken 30 years ago.

Postprostatectomy orchitis: reduction in incidence using perioperative ceftriaxone and postoperative ciprofloxacin.

Postoperative orchitis increases the morbidity and overall hospital stay after prostatectomy. A retrospective review of our initial series of 174 cases revealed an incidence of 6% which is similar to other studies. We reviewed our bacterial flora and antibiogram and subsequently started a prospective study combining peri-operative ceftriaxone and postoperative ciprofloxacin, which we compared to our previous series where we used perioperative ceftriaxone followed by postoperative gentamicin and ampicillin. There was an abolition of orchitis as a consequence and a significant reduction in the rate of wound infection. We conclude that a combination of ceftriaxone and ciprofloxacin is efficacious in reducing the rate of infective complications following prostatectomy. We recommend the use of these or similar drugs based on local microbial flora.

Sporadic Peutz-Jeghers syndrome in a Nigerian.

Peutz-Jeghers syndrome is a rare condition of muco-cutaneous pigmentation and polyposis of the gut. Reports of its occurrence from the Black world have been infrequent. A case is presented of an 18 year old Nigerian girl with pigmentation of the inner lips and soles of both feet, and recurrent attacks of abdominal pain necessitating two surgical procedures for intestinal obstruction with removal, in both cases, of polyps. Problems of complications and therapeutic modalities are discussed.

Paracolic abscesses from spontaneous perforation of granulomatous colitis.

Three cases of spontaneous perforation of granulomatous colitis are presented. The typical features are those of acute right iliac fossa pathology mimicking appendicitis. Differential diagnosis is difficult in our locality but includes essentially Crohn's colitis although tuberculous and other inflammatory colitis could not be definitively excluded. In the absence of facilities for laparoscopy or even ultrasound-guided percutaneous drainage the results of open laparotomy with right hemicolectomy were beneficial. As expected in our community follow up responses were poor making it difficult to predict long term outcomes. A plea is made for practitioners to bear unusual pathologies in mind during practice.