Development and practice of laparoscopic surgery in a Nigerian tertiary hospital.

BACKGROUND: For the benefits of less postoperative pain, early recovery and discharge, and better cosmesis, laparoscopic surgery is rapidly gaining acceptance amongst surgeons as a better alternative to traditional open procedures. In January 2015, bookings for laparoscopic surgery became a more regular feature on our operation list. AIMS: We reported the indications, management outcome, and challenges in patients who had laparoscopic surgery in our institution. This is to document the trends in our surgical practice. METHODOLOGY: This is a descriptive study of 137 patients who had laparoscopic surgery for general surgical indications in our institution over a period of 5 years. Patients data as collected from the records department were evaluated for demographic characteristics, medical comorbidities, type of procedures done, and perioperative outcome. Data analysis was performed using Statistical Package for Social Sciences (SPSS). RESULTS: A total of 137 Patients had laparoscopic general surgery between January 2015 and December 2019. There were 48 males and 89 females with a male-to-female ratio of 1:1.9. The mean age of the patients was 38.8 ± 3.4 years (range 16-87 years). Laparoscopic cholecystectomy (35%) and laparoscopic appendicectomy (29.9%) were the most common procedures performed. Five (3.7%) cases were converted to open surgery. Superficial surgical site infection (5.8%) following laparoscopic appendicectomy was the most common postoperative complication. There was no 30-day postoperative mortality. CONCLUSION: Laparoscopic surgery is safe and can be applied to wide variety of general surgical conditions in developing countries. Minimal postoperative morbidity of laparoscopy is a major benefit to the patients.

An Obstructing Small Bowel Phytobezoar in an Elderly Female Nigerian: A Case Report and Literature Review.

Small bowel obstruction secondary to phytobezoars is an unusual presentation in surgery. We present a case of an elderly female patient with an insidious onset of abdominal pain, abdominal distension, and bilious vomiting diagnosed radiologically to be small bowel obstruction. Exploratory laparotomy revealed a trapped mass of vegetable matter in the distal ileum. She had enterotomy with primary closure for removal of obstructing ileal phytobezoars. Her postoperative recovery was uneventful.

A COMPARISON OF THE OBJECTIVE STRUCTURED CLINICAL EXAMINATION AND THE TRADITIONAL ORAL CLINICAL EXAMINATION IN A NIGERIAN UNIVERSITY.

BACKGROUND: Assessment of clinical skills is essential in medical education. Ideally marks should be based on the student's competence alone. The limitations of the traditional long case examinations such as the patient and examiner variability are well known. The objective structured clinical examination (OSCE) was designed to overcome these limitations. Studies comparing the OSCE and the traditional long case examination in the same group of students are very sparse. AIM: To compare the objective structured clinical examination (OSCE) and the traditional long case examination by determining their correlations with other forms of assessment in undergraduate surgery. SETTING: This study was carried out at the College of Medicine, University of Lagos, Nigeria. METHODOLOGY: The results of 612 undergraduate students in our medical school of the University of Lagos, Nigeria over a period of 4 years (2012-2015) were analysed. The scores in the long case examination , objective structured clinical examination (OSCE) , multiple choice questions and Essays were analysed and compared using the Pearson's Correlation co-efficient. SPSS version 17 software was used and a P-value < 0.01 was regarded as statistically significant. RESULTS: Overall, there was a statistical significant positive correlation among most forms of assessment. The OSCE and the long case examination had a correlation of 0.374. Compared with the long case examination, the OSCE had a higher correlation with all other forms of assessment. The total clinical score (the sum of all long case examination and OSCE) however performed better than the OSCE or the long case examination alone as it had the highest correlation with all other forms of assessment. CONCLUSION: The OSCE has been shown to be better than the long case examination as an indicator of the student overall knowledge of surgery as it had a superior correlation with other forms of assessments. The total clinical score was however the best indicator of the student overall knowledge in Surgery as it had the best correlation with other forms of assessment. We recommend and encourage institutions that presently combine the OSCE and the long case examination to carry out similar analysis such as ours to determine the desirability of combining LCE and OSCE rather than outright replacement of LCE with OSCE.

Removal of orthopaedic implants from patients at the University College Hospital, Ibadan.

BACKGROUND: Removal of orthopaedic implants is often done after complete healing of fractures. Orthopaedic implants are removed for a variety of reasons such as patients' request after fracture union, implant failure and other complications arising from the use of implants. AIMS AND OBJECTIVES: To determine the indications and complications of removal of orthopaedic implants in our hospital. METHODS: A retrospective study of medical records of all patients who underwent removal of orthopaedic implants used for fracture fixation at a Nigeria teaching hospital during the five year period between 2007 and 2011. Information about age, sex, indications for fracture fixation, indications for removal of implant, types of implants removed, complications of implant removal and its treatment were studied. RESULTS: Thirty patients whose orthopaedic implants had been in place for a mean duration of 12 months before removal were included in the study. 80% of the implants were removed from the femur. Implant failure is the commonest indication for implant removal accounting for 60% of cases. CONCLUSION: Healed fractures and implant failure are the commonest indications for removal of orthopaedic implants in our centre. Implant removal should be advocated when they have failed or become symptomatic. However, appropriate patient selection and adequate surgical technique should be employed to achieve satisfactory outcome.

KRAS and BRAF mutations in Nigerian colorectal cancers.

PURPOSE: Activation of the KRAS oncogene is implicated in colorectal carcinogenesis and mutations have been reported in 30-50% of cases. BRAF mutation, though less common, is also reported and importantly associated with shorter progression-free interval. This study aims to determine the KRAS and BRAF mutation statuses of Nigerian colorectal cancers (CRC). METHODS: Mutation analysis was carried out on archival paraffin-embedded blocks of CRC tissues. KRAS codons 12, 13 and 61 and BRAF V600E were assessed by pyrosequencing after DNA extraction from 200 cases at the Leeds Institute of Molecular Medicine, St. James's University Hospital, UK. Mutation rates and the spectra were determined. RESULTS: Pyrosequencing was successful in 112 of 200 cases. KRAS mutation in codons 12 and 13 was demonstrated in 23 of 112 cases (21%); none in codon 61. BRAF mutation in codon 600 was demonstrated in 4.5%. CONCLUSION: This study shows that 21% of Nigerian CRC patients carry a KRAS mutation; half the rate in Caucasians; and that BRAF mutation also occurs in Nigerian CRC cancers.

Acute appendicitis in Lagos: a review of 250 cases.

OBJECTIVES: Acute appendicitis is common. This prospective study of 250 cases of acute appendicitis was performed to critically analyse the pattern of presentation, management, operative findings and treatment outcome. The effect of length and position of the appendix in relationship to acute inflammation was also determined. PATIENTS AND METHODS: Two hundred and fifty cases of acute appendicitis were studied, including those found to have appendicitis at surgery despite other preoperative diagnosis. Patient biodata, clinical signs and symptoms were recorded. Haematological and biochemical parameters were determined after which all patients with a diagnosis of acute appendicitis had appendicectomy under general anaesthesia. All relevant peri-operative data were recorded. Excised appendices were sent for histological examination. RESULTS: There were 133 males and 117 females giving a gender ratio of 1.2:1. The mean age was 25.7 +/- 10.3 years, with majority of cases (42.8%) occurring in the third decade of life. Abdominal pain (100%), fever (48.4%), anorexia (48.0%), vomiting (47.8%) were the common symptoms. Commonly elicited signs included right iliac fossa direct tenderness (74.4%), rebound tenderness (59.2%), localised guarding (42.8%) and right rectal wall tenderness (43.2%). The mean white cell count was not significantly elevated (mean 8538 +/- 4166 per mm3, P > 0.05). Sixty three percent (156/245) of all appendices were retrocaecal in position. Mean length of the appendices was 10.4 +/- 2.9 cm. The length and position of appendices were not significantly different between those who had acutely inflamed and normal appendices (P = 0.923) Two hundred and forty five patients (98%) with a diagnosis of acute appendicitis had appendicectomy. The commonest postoperative complication was wound infection (8%), overall complication rate was 13.5% and negative appendicectomy rate was 13.4%. CONCLUSION: The presentation, management and treatment outcome of acute appendicitis in our centre are similar to those of other centres in our sub-region. Complication rates were low.

The new pattern of urethral stricture disease in Lagos, Nigeria.

OBJECTIVES: The study is a follow up to two separate studies done in this centre 42 and 20 years ago on the changing pattern of urethral stricture disease(USD). It assesses the aetiology,the general pattern and treatment outcome in our centre. PATIENTS AND METHODS: This is an 8 year review of all cases of USD managed at the Lagos University Teaching Hospital between January 1998 to December 2005. Diagnosis was confirmed mainly by urethrographic studies and occasionally by endoscopy. Data collected included age, sex, aetiology, site and length of stricture, treatment and outcome. RESULTS: Eighty four patients (83 males and 1 female) with USD were seen within the period with a mean age of 43.1 years. Trauma was responsible for 60 (72.3%) cases, with road traffic accident topping the list with 29 (34.9%), with iatrogenic trauma now accounting for 17 (20.5%) of all cases of USD. Indwelling urethral catheter was responsible for 13 (76.5%) of iatrogenic cases. Purulent Urethritis was responsible for 22 (26.5%) of cases. Fifty (60.2%) cases were located in the anterior urethral while twenty three (39.8%) were in the posterior. Fifty seven patients had urethroplasty with a recurrence of 14% and 8 patients had urethral dilatation with 50% 1 year recurrence. CONCLUSION: Trauma is now the undisputed leading cause of USD in our environment. The incidence of post catheterisation strictures has also risen rapidly. Increased safety on our roads, improvement in medical education and quality of urethral catheters are suggested by this study in order to reduce the incidence of USD.

Penile fasciocutaneous flap urethroplasty: recent experience and challenges in a sub-Saharan African teaching hospital.

OBJECTIVE: To evaluate penile fasciocutaneous flap urethroplasty for complex anterior urethral strictures in circumcised West African men. METHODS: Between January 2002 and December 2006, 26 patients with anterior urethral strictures underwent penile fasciocutaneous flap urethroplasty (PFU), using a modification of the technique described by Quartey (Quartey JKM. J Urol. 1985;134:474-475). Of these patients, 21 had dorsal onlay patches and 5 had tubularize patches. Average follow-up was 19 months. RESULTS: There was a 100% immediate success rate with the dorsal onlay group. No recurrence was seen in all patients available for follow-up at 30 months. The tubularized flap had an immediate success of 80% but at 30 months it was only 40%. Troublesome postvoid dribbling was completely eliminated and complications were minor and few, which included 1 case of distal superficial dorsal penile skin loss, 1 case of urethrocutaneous fistula, and 2 cases of postvoid dribbling all of which were managed conservatively. CONCLUSIONS: PFU when used as a dorsal onlay gives excellent results at least in the immediate and intermediate periods in black West African population. A multiracial study to compare the effect of skin color on the short- and long-term outcome of PFU is also suggested.

Medical audit of diagnostic mammographic examination at the lagos university teaching hospital (luth), Nigeria.

PURPOSE: We studied the performance of diagnostic mammography in predicting malignancy among patients presenting with signs and symptoms of malignancy. MATERIALS AND METHODS: 310 patients who presented to the surgical out-patients of the Lagos University Teaching Hospital with signs and symptoms of breast cancer, between January 2002 and December 2003 had mammographic evaluation with a dedicated mammography unit. The mammographic appearances were prospectively classified using the BI-RADS assessment categorisation, and histological confirmation following surgical excision was correlated with mammography. RESULTS: The overall sensitivity of mammography in the study was 82.8% (CI 78.6 - 87%) while specificity, Positive predictive value (PPV) and accuracy were 90.7% (CI 87.5-93.9%), 69.97% (CI 46.6 - 74.8%), and 89% (CI 85.5-92.5%) respectively. Multivariate analysis showed that sensitivity and specificity generally declined as breast density increased. CONCLUSION: Diagnostic mammography is useful in characterising breast lesions. This study analyses the performance of mammography and shows that the resultant specificity is high, however it may have to be used in conjunction with needle biopsy to achieve improve sensitivity and avoid unnecessary benign surgical biopsies.

Complex Ebstein's anomaly in a 80 year old Nigerian woman.

There is a gradually growing interest in the subject of congenital heart diseases as many children born with them are now growing into adulthood. The reasons are twofold: increasing awareness among clinicians as well as major advances in the diagnosis and treatment of congenital heart diseases in children. A case of Ebstein's anomaly (EA), one of the most important congenital diseases of the tricuspid valve, in an 80 year old woman referred to the cardiology clinic of the University of Benin Teaching Hospital in Benin City, Nigeria, is hereby reported. It is a rare condition. The features demonstrated in this case report tend to suggest that there may be several adult survivors of congenital heart diseases. These may coexist with other systemic illnesses such as systemic hypertension.

Otolaryngologic manifestations of gastro-oesophageal reflux disease in Lagos.

BACKGROUND/AIM: Gastro-oesophageal reflux disease(GERD) is not an uncommon disease in Nigeria. The otolaryngologic (ORL) symptoms associated with GERD are varied. In the management of patients with ORL symptoms and disease, GERD is often not considered as a differential diagnosis The aim of this study is to identify patients with ORL complications of GERD from patients with ORL disease who have symptoms that mimic GERD using defined criteria in the light of limited diagnostic facilities. MATERIALS/METHODS: A prospective study was conducted over a two year period at Lagos University Teaching Hospital Lagos and two private Otolaryngology clinics,within Lagos, among patients who presented primarily with laryngeal and pharyngeal symptoms . They were evaluated using structured questionnaire for duration of regurgitation, heartburn ,symptoms of peptic ulcer disease, clinical examination, esophagogastro - duodenoscopy findings and outcome of laryngopharyngeal symptoms following anti-reflux therapy. RESULTS: A total of 92 patients were evaluated over a two year period .ORL diseases and symptoms at presentation were chronic laryngitis, chronic pharyngitis, globus pharyngeus, globus and chronic laryngitis, laryngeal carcinoma, cricopharyngeal spasm and throat hawking. History of symptoms of peptic ulcer disease and regurgitation was obtained in 47.8% and 65.2% respectively. Endoscopic findings revealed oesophageal reflux with gastroduodenits in 4.3%, Non specific gastritis in 17.4%, duodenal ulcer in 56.4%, and normal findings in 21.7%. Patients were treated medically with antacids, H2 antagonists, proton pump inhibitors and were followed up for 9-12 months. GERD was diagnosed in 4 (4.34%), 68 (73.9%) were diagnosed as non erosive reflux disease (NERD) and 20 (21.74%) with probable acid related problem that will need further evaluation . Following anti-reflux therapy 68 (73.9%) had disappearance of their laryngopharygeal symptoms for up to a year. ORL complications of GERD/NERD was seen in 72 (78.3%). CONCLUSION: GERD should be a differential diagnosis in patient with pharyngeal and laryngeal symptoms not associated with sinus disease in the presence or absence of positive peptic ulcer disease or regurgitation and the management should be multidisciplinary.

Evaluation of a locally-made urease test for detecting Helicobacter pylori infection.

We studied the efficacy of a home-made urease test (HUT) in the detection of Helicobacter pylori (HP) infection in patients undergoing upper gastrointestinal endoscopy. In the first phase of the study, two antral biopsies each were obtained from 43 patients for urease tests using the CLOtest and a home-made buffered 2% urea solution with phenol red as indicator at pH 6.8 (2% HUT). Twenty-six patients (60.5%) were HP positive, both by the 2% HUT and CLOtest with 100% concordance. In the second phase of the study three antral biopsies each and blood were obtained from 42 patients for the determination of HP status using a 10% HUT and a combination of culture and serology. Twenty-three patients (54.8%) were HP positive using the 10% HUT, while 32 patients (76.2%) were positive using the combination of 2 tests. Compared to this the sensitivity and specificity of the 10% HUT were 72% and 100% respectively. The CLOtest produced a colour change in a shorter time than the 2% and 10% HUT (median 1 hour versus 10 hours versus 16 hours p < 0.0001). In the third phase of the study, we observed that by doubling the biopsy size, the time required to obtain a colour change was significantly reduced (median 4.5 hours versus 10 hours p < 0.05). The HUT is easy to prepare, cheap, sufficiently sensitive and it is reliable enough to start treatment when positive. With 100% concordance and 1% the cost per test when compared to the commercially available CLOtest; the 10% HUT is hereby recommended for the detection of UP infection in our region.

Gastric antral juxtamucosal pH in helicobacter pylori positive and negative dyspeptic patients.

Maintenance of gastric juxtamucosal pH at a stable near neutral value may be the cumulative effect of the various components of the mucosal defense system. In order to assess the effect of helicobacter pylori (HP) infection on mucosal defense, we measured the gastric antral juxtamucosal pH in 40 dyspeptic patients by using a flexible glass pH microelectrode which can be passed down the instrument channel of standard gastroscopes. HP status was determined using serology, culture, histology and urease test. We also investigated the relationship between juxtamucosal pH and the severity of antral HP infection. The mean antral juxtamucosal pH in 26 (65%) HP positive patients was 6.49 +/- 0.20 compared to 6.19 +/- 0.21 in 14 (35%) HP negative patients (p < 0.00001). Other factors like age, sex, duodenogastric reflux or presence of chronic duodenal ulcer did not significantly affect juxtamucosal pH (p > 0.05). Subset analysis of data on HP positive patients (n = 26) revealed no significant correlations between antral chronic gastritis anti-HP IgG titre and antral juxtamucosal pH (p > 0.05). This study shows that HP increases gastric antral juxtamucosal pH. This finding supports the suggested role of HP in producing hypergastrinaemia and gastric acid hypersecretion.

Gastric acid secretion in Helicobacter pylori positive and negative dyspeptic Nigerians.

The pathological role of Helicobacter pylori is largely unproven in our region of high incidence of infection but very low incidence of serious gastroduodenal lesions. The aim of this study was to investigate the effect of H. pylori infection on gastric acid secretion. One week after gastroduodenoscopy, basal and pentagastrin (8 micrograms/kg) stimulated gastric acid secretion were measured in 39 dyspeptic Nigerians. H. pylori status was determined using urease test, culture, histology and serology, while gastritis was assessed using the Sydney system criteria. The median maximal acid output (MAO) and peak acid output (PAO) in mmol/h were significantly higher in H. pylori positive (29.3, range 7.4-81.6 and 34.4, range 7.6-144.0) than in H. pylori negative (16.6, range 4.2-44.1 and 22.4, range 5.6-48.6) patients, p = 0.019 and p = 0.029, respectively. Stimulated gastric acid secretion was significantly higher in patients with duodenal ulcer (n = 8) than in H. pylori negative (n = 11) patients, but was similar in non-ulcer dyspeptics (n = 20) and H. pylori negative patients. The median basal acid output was not significantly different between the groups of patients. Our patients (median age 32 years) had normal mucosa (12.1%), pangastritis with corpus predominance (12.1%), antrum-only gastritis (24.3%) and pangastritis with antral predominance (51.5%). In the subset of H. pylori positive patients (n = 28, 71.8%), there were no significant correlations between grade of antral chronic inflammation, gastritis index score, anti-H. pylori IgG titre and gastric acid secretion, p > 0.05. H. pylori infection increases MAO and PAO in our relatively young patients with antral predominant chronic gastritis.

Factors affecting mortality and morbidity in patients with abdominal gunshot wounds.

Risk factors that may independently predict mortality and morbidity in patients with abdominal gunshot wounds have not been fully elucidated. We prospectively studied the effects of 12 potential risk factors on mortality and morbidity in 82 patients with abdominal gunshot wounds who required laparotomy. Univariate analysis of these factors revealed that shock on admission, presence of penetrating colon injury and number of intra-abdominal organs injured (NOI)>2 were associated with greater than threefold increased incidence of death (p<0.05). Penetrating abdominal trauma index (PATI) score>15 was associated with twentyfold increased incidence of death (P<0.0001). Multivariate analysis showed that only PATI (P=0.001), number of postoperative complications per patient (N(comp)) (P=0.023) and presence of shock on admission (P=0. 028) were independently significant in predicting mortality. PATI was the only risk factor that independently predicted the development of postoperative infectious complications and N(comp) (P<0.0001). The type of gun used was not a significant risk factor (P>0.05). The 15 (18.3%) non-survivors were significantly older than survivors (P=0.02), had longer operations (P=0.004) and their NOI, PATI and N(comp) were significantly higher (P<0.001). The uniformly prolonged injury to surgery time in all patients contributed to the high incidence of infectious complications (62.2%) and mortality. PATI score was the most important factor found to be independently associated with mortality and morbidity in our subset of patients with prolonged injury to surgery time and high rate of colon injury.

Colorectal cancer in Lagos: a critical review of 100 cases.

This study critically analysed the clinical presentation, diagnosis, treatment and outcome in 100 patients with colorectal cancer seen over a twelve year period (1988 to 1999). Comparing our findings with those obtained three decades ago at our institution allowed for determination of time trends. There were 48 males and 52 females giving a sex ratio of approximately 1:1. On the average our patients were 10 to 15 years younger than their Caucasian counterparts and one third were 40 years in age or below. In almost two thirds (61%) of patients, the tumours were in the rectum and sigmoid colon. The tumours were resected in 58 (58%) patients, non-resectional surgery was offered to 28 patients, while 14 patients were inoperable, not fit or refused surgery. Overall 34 (34%) patients had distant metastases. The commonest (91.5%) histological type was adenocarcinoma. The postoperative complication rate was 40%, postoperative mortality was 23.3% and the crude one year survival rate was 64%. The clinicopathologic features of colorectal cancer have not changed over a period of three decades at our institution. Public enlightenment campaigns on cancer and facilities to adequately treat patients with colorectal cancer are required in our subregion.

Civilian abdominal gunshot wounds in Lagos.

This prospective study of 78 patients who sustained abdominal gunshot wounds was performed to evaluate the pattern of injuries, treatment outcome and the role of selective conservative management. Three (3.8%) patients died before laparotomy. Four (5.1%) patients with superficial wounds were managed by local wound care. Fourteen (18%) patients who had equivocal or minimal abdominal signs were selected for conservative management. Laparotomy was performed in 57 (73.1%) patients who presented with an acute abdomen. The commonly injured organs were the small bowel (56.1%), colon (38.6%), liver (22.8%) and stomach (19.3%). Prolonged injury to arrival and surgical intervention time were contributing factors to the high incidence of sepsis (63.2%) and mortality (22.8%) after laparotomy. Two patients selected for conservative management required delayed laparotomy, one of which was negative. A 10-fold increase in prevalence of abdominal gunshot wounds has occurred in our institution in the 1990s. Selective conservative management is feasible without the use of expensive investigations.

Histamine and tissue fibrinolytic activity in duodenal ulcer disease.

Patients with duodenal ulcer have lower gastroduodenal mucosal histamine and a reduced tissue fibrinolysis at the ulcer edge. In the duodenal mucosa fibrinolysis is regulated by the tissue-type and urokinase-type plasminogen activators; and inhibitors type 1 and type 2. Trends across ordered groups leading from mucosa of nonulcer control subjects, "normal" mucosa of ulcer patients, to ulcer edge were found in tissue-type plasminogen activator concentration, histamine concentration, and histamine methyltransferase activity. Concentrations of tissue-type activator, inhibitor type 1, and histamine were significantly lower at ulcer edge than at normal. An inverse correlation was found between histamine methyltransferase and plasminogen activator activities, methyltransferase and tissue-type activator, and methyltransferase and histamine. These results support the hypothesis that in active ulceration, reduction in tissue fibrinolytic activity is closely associated with enhanced release and metabolism of histamine.