Gracilis muscle interposition for pouch-vaginal fistulas: a single-centre cohort study and literature review.

BACKGROUND: First described by Parks and Nicholls in 1978, the ileal pouch-anal anastomosis (IPAA) has revolutionized the treatment of mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). IPAA is fraught with complications, one of which is pouch-vaginal fistulas (PVF), a rare but challenging complication noted in 3.9-15% of female patients. Surgical treatment success approximates 50%. Gracilis muscle interposition (GMI) is a promising technique that has shown good results with other types of perineal fistulas. We present the results from our institution and a comprehensive literature review. METHODS: A retrospective observational study including all patients with a PVF treated with GMI at our institution from December 2018-January 2000. Primary outcome was complete healing after ileostomy closure. RESULTS: Nine patients were included. Eight of nine IPAAs (88.9%) were performed for MUC, and one for FAP. A subsequent diagnosis of Crohn's disease was made in five patients. Initial success occurred in two patients (22.2%), one patient was lost to follow-up and seven patients, after further procedures, ultimately achieved healing (77.8%). Four of five patients with Crohn's achieved complete healing (80%). CONCLUSION: Surgical healing rates quoted in the literature for PVFs are approximately 50%. The initial healing rate was 22.2% and increased to 77.8% after subsequent surgeries, while it was 80% in patients with Crohn's disease. Given this, gracilis muscle interposition may have a role in the treatment of pouch-vaginal fistulas.

Pattern of Abdominal Trauma and Treatment Outcome in a Nigerian Tertiary Hospital.

BACKGROUND: Trauma is the leading cause of mortality in young adults, often with the involvement of the abdomen. AIMS: To report the pattern and treatment outcome of abdominal trauma in a Nigerian tertiary hospital. PATIENTS AND METHODS: A retrospective observational study of abdominal trauma cases managed in the University of Port Harcourt Teaching Hospital Port Harcourt, Rivers State, Nigeria from April 2008 to March 2013. The variables studied included socio-demographic, mechanism and type of abdominal injury, initial pre-tertiary hospital care, haematocrit level at presentation, abdominal ultrasound scan, treatment options, operative findings and outcome. Statistical analyses of the data were performed using IBM SPSS Statistics for Windows, Version 25.0 Armonk, NY, USA. RESULTS: A total of 63 patients with abdominal trauma were included with a mean age of 28.1 ± 7.0 years (16 - 60 years), of which 55 cases (87.3%) were males. A mean injury to arrival time of 33.75±53.1 hours and a median revised trauma score of 12 (8-12) were recorded among the patients. Penetrating abdominal trauma was seen in 42 (66.7%) and operative treatment was performed on 43 (69.3%) patients. At laparotomy, hollow viscus injury was predominant - 32/43(52.5%). A postoperative complication rate of 27.7% was recorded with 6(9.5%) mortality. The type of injury (B = -22.1), initial pre-tertiary hospital care (B = -25.9), RTS (B = -10.1) and age (B = -0.367) respectively all had a negative influence on mortality. CONCLUSION: Hollow viscus injury is frequently detected at laparotomy for abdominal trauma and negatively influences mortality. The more frequent use of diagnostic peritoneal lavage to detect cases that need urgent surgical intervention is strongly advocated in this low-middle-income setting.

CONTEXTE: Les traumatismes sont la principale cause de mortalité chez les jeunes adultes, et ils touchent souvent l'abdomen. OBJECTIF: Rapporter les caractéristiques et les résultats du traitement des traumatismes abdominaux dans un hôpital tertiaire Nigérian. PATIENTS ET MÉTHODES: étude rétrospective d'observation des cas de traumatismes abdominaux pris en charge à l'hôpital universitaire de l'université de Port Harcourt, dans l'État de Rivers, au Nigeria, d'avril 2008 à mars 2013. Les variables étudiées comprenaient les données sociodémographiques, le mécanisme et le type de lésion abdominale, les soins hospitaliers prétertiaires initiaux, le taux d'hématocrite à la présentation, l'échographie abdominale, les options thérapeutiques, les résultats opératoires et l'issue. Les analyses statistiques des données ont été réalisées à l'aide de IBM SPSS Statistics for Windows, version 25.0 Armonk, NY, USA. RÉSULTATS: Au total, 63 patients souffrant d'un traumatisme abdominal ont été inclus, avec un âge moyen de 28,1 ± 7,0 ans (16 - 60 ans), dont 55 cas (87,3 %) étaient des hommes. Le délai moyen d'arrivée des blessés était de 33,75±53,1 heures et le score traumatique révisé médian était de 12 (8-12). Des traumatismes abdominaux pénétrants ont été observés chez 42 (66,7 %) et un traitement chirurgical a été effectué chez 43 (69,3 %) patients. Lors de la laparotomie, les lésions des viscères creux étaient prédominantes (32/43 (52,5 %)). Un taux de complications postopératoires de 27,7 % a été enregistré, avec une mortalité de 6 (9,5 %). Le type de lésion (B=-22,1), les soins hospitaliers prétertiaires initiaux (B=-25,9), le RTS (B=-10,1) et l'âge (B=-0,367) ont tous eu une influence négative sur la mortalité. CONCLUSION: Les lésions du viscère creux sont fréquemment détectées lors d'une laparotomie pour un traumatisme abdominal et influencent négativement la mortalité. L'utilisation plus fréquente du lavage péritonéal diagnostique pour détecter les cas qui nécessitent une intervention chirurgicale urgente est fortement recommandée dans ce pays à revenu faible et moyen. Mots-clés: Traumatisme; Abdomen; Schéma; Traitement; Résultat.

Outcomes of gracilis muscle interposition for rectourethral fistulas caused by treatment of prostate cancer.

BACKGROUND: Gracilis muscle interposition (GMI) has been associated with favorable outcomes in treating complex perianal fistulas. Outcomes of GMI may vary according to the fistula etiology, particularly between rectovaginal fistulas in women and rectourethral fistulas (RUF) in men. The aim of this study was to assess the outcome of GMI to treat RUF acquired after prostate cancer treatment. METHODS: This retrospective cohort study included male patients treated with GMI for RUF acquired after prostate cancer treatment between January 2000 and December 2018 in the Department of Colorectal Surgery, Cleveland Clinic Florida. The primary outcome was the success of GMI, defined as complete healing of RUF without recurrence. Secondary outcomes were length of hospital stay and postoperative complications. RESULTS: This study included 53 male patients with a median age of 68 (range, 46-85) years. Patients developed RUF after treatment of prostate cancer with radiation (52.8%), surgery (34%), or transurethral resection of the prostate (TURP) (13.2%). Median hospital stay was 5 (IQR, 4-7) days. Twenty (37.7%) patients experienced 25 complications, the most common being wound infection and dehiscence. Primary healing after GMI was achieved in 28 (52.8%) patients. Fifteen additional patients experienced successful healing of RUF after additional procedures, for a total success rate of 81.1%. Median time to complete healing was 8 (range, 4-56) weeks. The only significant factor associated with outcome of GMI was wound dehiscence (p = 0.008). CONCLUSIONS: Although the initial success rate of GMI was approximately 53%, it increased to 81% after additional procedures. Complications after GMI were mostly minor, with wound complications being the most common. Perianal wound dehiscence was significantly associated with failure of healing of RUF after GMI.

Isolated Hepatic Sarcoidosis: A Case Report and Literature Review.

BACKGROUND: Sarcoidosis is a multi-systemic disorder of unknown aetiology that primarily involves the pulmonary system with the histological hall mark of a non-caseating granuloma. Isolated hepatic involvement is a manifestation of sarcoidosis. OBJECTIVE: We report an incidental finding of hepatic sarcoidosis in a hypertensive and diabetic patient who presented with abdominal pain and fatigue. METHODS: A case report of sole diagnosis of hepatic sarcoidosis from a Gastroenterology service in Port Harcourt metropolis Nigeria. A literature search was made using the words 'sarcoidosis' and 'hepatic' in PubMed Central, Cochrane and Google search engines. From the search results, literature in English were extracted and reviewed. RESULTS: The index case was referred on account of hepatomegaly with associated abdominal pain and fatigue. A diagnosis of isolated hepatic sarcoidosis was made from elevated liver enzymes, elevated angiotensin converting enzyme, sero-negative autoimmune studies, hepatomegaly with liver nodule on abdominal computerized tomography scan and non-caseating granuloma from liver biopsy. There was no evidence of other systems involvement. CONCLUSION: Hepatic sarcoidosis is rare in African literature more so as no specific laboratory or radiological test is diagnostic. Delayed diagnosis and underreporting of hepatic sarcoidosis are likely in our environment due to the elaborate evaluation needed.

CONTEXTE: La sarcoïdose est un trouble multisystémique d'étiologie inconnue qui touche principalement le système pulmonaire avec la marque de hall histologique d'un granulome non caséiforme. L'atteinte hépatique isoleé est une manifestation de la sarcoïdose. OBJECTIF: Nous rapportons la découverte fortuite d'une sarcoïdose hépatique chez un patient hypertendu et diabétique qui présentait des douleurs abdominales et de la fatigue. MÉTHODES: Un rapport de cas de diagnostic unique de sarcoïdose hépatique dans un service de gastro-entérologie de Port Harcourt au Nigeria. Une recherche documentaire a été effectuée en utilisant les mots " sarcoïdose " et " hépatique " dans les moteurs de recherche PubMed Central, Cochrane et Google. PubMed Central, Cochrane et Google. A partir des résultats de la recherche, la littérature en anglais a été extraite et examinée. RÉSULTATS: Le cas index a été référé en raison d'une hépatomégalie associée à des douleurs abdominale et fatigue associées. Un diagnostic de sarcoïdose hépatique isolée a été posé à partir de l'élévation des enzymes hépatiques, de l'élévation de l'enzyme de conversion de l'angiotensine, des études auto-immunes séro-négatives, hépatomégalie avec nodule hépatique sur la tomographie abdominale informatisée et tomographie abdominale assistée par ordinateur et granulome non caséiforme à la biopsie du foie. Il n'y avait aucun signe d'atteinte d'autres systèmes. CONCLUSION: La sarcoïdose hépatique est rare dans la littérature africaine d'autant plus que aucun test de laboratoire ou radiologique spécifique n'est diagnostique. Un diagnostic tardif et la sousdéclaration de la sarcoïdose hépatique sont probables dans notre environnement en raison de l'évaluation élaborée nécessaire. MOTS-CLÉS: Sarcoïdose, Foie.

Awareness and Practice of Laparoscopic Surgery among Trainee Surgeons in Nigerian Tertiary Hospitals.

BACKGROUND: The advent of laparoscopy has been a notable landmark in surgery; however, there is a slow progress to widespread utilization in West Africa. AIMS: To study the awareness and practice of laparoscopic surgery among trainee surgeons in Nigerian tertiary hospitals while highlighting measures to mitigate challenges. MATERIALS AND METHODS: A cross-sectional study conducted during a 2-week West African College of Surgeons update course in September 2018 at Ilorin, Kwara State, Nigeria. A structured questionnaire was distributed to registered trainee surgeons for completion. Data collated included demographics, cognitive knowledge, common procedures in centres, referrals, routine practice, performing laparoscopic surgeon, and routine practice. Statistical analysis was done using IBM SPSS Statistics for Windows version 20 Armonk NY USA. RESULTS: There were 184 registered trainee surgeons with 80 respondents from 26 Nigerian tertiary health facilities. The age range was 29 -51 years (mean 35.0 ± 4.4) and a mean training duration of 3.3 years (R2= 0.12). Seven (63.6%) senior registrars and 54(76.3%) registrars were reported as first assistants in laparoscopic surgeries performed but no unassisted surgery. Four (15.4%) represented centres had no laparoscopy equipment or expertise. A non-referral rate of 52/80(65.0%) for laparoscopic surgery was recorded. CONCLUSION: Laparoscopic surgery is practiced in some Nigerian tertiary hospitals with trainee surgeons actively involved in performing these surgeries. However, there is limited unassisted experience by trainee surgeons in the basic laparoscopic surgeries predominantly performed.

CONTEXTE: L'avènement de la laparoscopie a été un jalon notable en chirurgie; cependant, il y a un lent progrès vers une utilisation généralisée en Afrique de l'Ouest. OBJECTIFS: Étudier la sensibilisation et la pratique de la chirurgie laparoscopique chez les chirurgiens stagiaires dans les hôpitaux tertiaires nigérians tout en mettant en évidence les mesures visant à atténuer les défis. MATÉRIEL ET MÉTHODES: Une étude transversale menée au cours d'un cours de mise à jour de 2 semaines du Collège ouest-africain des chirurgiens en septembre 2018 à Ilorin, État de Kwara, Nigéria. Un questionnaire structuré a été distribué aux chirurgiens stagiaires enregistrés pour qu'il le remplisse. Les données rassemblées comprenaient les données démographiques, les connaissances cognitives, les procédures courantes dans les centres, les références, la pratique de routine, le chirurgien laparoscopique en exercice et la pratique de routine. L'analyse statistique a été effectuée à l'aide d'IBM SPSS Statistics pour Windows version 200 Armonk NY USA. RÉSULTATS: Il y avait 184 chirurgiens stagiaires enregistrés avec 80 répondants de 26 établissements de santé tertiaires nigérians. La tranche d'âge était de 29 à 51 ans (moyenne 35,0 ± 4,4) et une durée moyenne de formation de 3,3 ans (R2 = 0,12). Sept (63,6%) registraires principaux et 54 registraires (76,3%) ont été signalés comme premiers assistants dans les chirurgies laparoscopiques effectuées mais pas de chirurgie non assistée. Quatre (15,4%) centres représentés n'avaient ni équipement ni expertise de laparoscopie. Un taux de non-référence de 52/80 (65,0%) pour la chirurgie laparoscopique a été enregistré. CONCLUSION: La chirurgie laparoscopique est pratiquée dans certains hôpitaux tertiaires nigérians avec des chirurgiens stagiaires activement impliqués dans la réalisation de ces chirurgies. Cependant, l'expérience non assistée des chirurgiens stagiaires est limitée dans les chirurgies laparoscopiques de base principalement pratiquées. MOTS CLÉS: Chirurgie, laparoscopie, formation.

Castor Oil and Bisacodyl Versus Sodium Picosulphate Magnesium Citrate for Bowel Cleansing Prior to Colonoscopy in a Limited Resource Setting.

BACKGROUND: The cost and availability are among factors that determine bowel preparation regimen for colonoscopy. AIMS: To assess the efficacy of an alternative bowel preparation regimen of Castor oil/Bisacodyl (CaO/B) for colonoscopy in a limited resource setting. MATERIALS AND METHODS: A retrospective cohort study of patients undergoing colonoscopy in an endoscopy referral centre in Port Harcourt Rivers State Nigeria from June 2014 to September 2019. Patients who had bowel preparation prior to colonoscopy with CaO/B were grouped and compared with a control group of patients that received sodium picosulphate magnesium citrate (SPMC). The variables collated were sociodemographics, primary indication, comorbidities, quality of bowel preparation (Aronchick scale), polyp detection and caecal intubation. Statistical analysis was performed using IBM SPSS version 21. RESULTS: A total of 258 patients undergoing colonoscopy met the inclusion criteria with 118 prepared with CaO/B and 140 patients with SPMC. The mean age of patients in the groups were 53.9 ± 11.2 years and 54.7 ± 12.8 years respectively; a total of 192 males and 66 females with a near even distribution in both groups. Bowel preparation was Excellent/Good in 51 patients using CaO/B and 108 for SPMC (p = <0.0001). No statistical difference was noted in the caecal intubation and polyp detection rates between the 2 groups- p values 0.395 and 0.990 respectively. CONCLUSION: Castor oil/ Bisacodyl regimen is cheap but not consistently associated with adequate bowel preparation for colonoscopy. Expertise of endoscopists and copious lavage are crucial when CaO/B regimen is used for bowel cleansing.

Giant pseudocyst of the pancreas: A report of three cases.

BACKGROUND: A Pancreatic pseudocyst is usually a complication of pancreatitis but may follow abdominal trauma in children. Giant pseudocysts are rare and usually complicate chronic pancreatitis. AIM: To report 3 cases of giant pseudocysts of the pancreas managed in our Centre within a three-month-period. CASE REPORTS: Two female patients aged 22 years and 65 years respectively, and an 11-year-old boy presented with giant pancreatic pseudocysts (>10 cm in diameter each) to our unit and were successfully managed. They all underwent exploratory laparotomy and cysto-gastrostomy with good outcome. CONCLUSION: Giant pseudocysts of pancreas may not be as rare as they were thought to be. They can be effectively managed by cysto-gastrostomy.

Neoplastic and Non-Neoplastic Colorectal Polyps in Port Harcourt, Nigeria: A Single Centre Review of 496 Colonoscopies.

BACKGROUND: An understanding of the natural history of colorectal polyps is relevant to the management of colorectal cancer. AIM: To study the frequency, morphology, and histopathology of colorectal polyps in a metropolis of Niger Delta region, Nigeria. PATIENTS AND METHODS: A cross-sectional retrospective study of consecutive cases of colonoscopy performed at a referral endoscopy facility in Port Harcourt metropolis, Niger Delta region of Nigeria, from March 2014 to March 2020. Variables collated included demographics, primary indication, site, morphology and histopathology of colorectal polyps. Statistical analysis was performed using IBM SPSS version 20, Armonk. NY, USA. RESULTS: A total of 496 colonoscopies were performed during the study period. The age range of patients was 4 years to 92 years (mean 54.7± 13.0). There were 357 males and 139 females. The leading primary indications for colonoscopy were gastrointestinal bleeding, routine screening for colorectal cancer and abdominal pain/discomfort in 220 (44.4%), 89 (17.9%) and 66 (13.3%) cases respectively. Colorectal polyps were recorded in 111 (22.4%) patients with a M: F of 2.7:1 and peak incidence in the 6th decade of life 53 (47.7%) cases. Majority of the polyps were seen in the colon segments extending from rectum to splenic flexure 59 (63.4%). Inflammatory, adenomatous and hyperplastic polyps were seen in 51(50.0%), 39(38.2%) and 10(9.8%) cases respectively and a sole case of malignant polyp was recorded. CONCLUSION: Adult colorectal polyps are seen predominantly in males above 50 years of age, and in the left colon. Tubular adenoma with low grade dysplasia is the most prevalent neoplastic polyp.

Helicobacter pylori and precancerous lesions of the stomach in a Nigerian Metropolis: A Cohort Study.

INTRODUCTION: Helicobacter pylori (H. pylori)-related atrophic gastritis transits through a sequential pathway of intestinal metaplasia, dysplasia to gastric cancer. Gastroscopy offers early detection, treatment and surveillance of gastric cancer. AIMS: This study aims to study the prevalence of H. pylori infection and evaluate precancerous lesions (PCLs) of the stomach. PATIENTS AND METHODS: This is a case controlled study of patients with dyspepsia undergoing gastroscopy at a referral endoscopy facility in Port Harcourt metropolis of Nigeria. The variables studied included demographics, clinical, endoscopic, and histopathologic findings. Statistical analysis of data was done using IBM SPSS Statistics for Windows, Version 20.0. (Armonk, NY, USA). RESULTS: A total of 104 patients were included in the study. Age ranged from 20 to 80 years (mean 47.1 ± 14.4 years); 56 were males and 48 were females. H. pylori were detected in 40 (38.5%) mucosal biopsies. The prevalence of PCLs was: chronic atrophic gastritis 6.7% (7 cases); intestinal metaplasia 2.9% (3 cases); and dysplasia 5.8% (6 cases). There was no statistical significance in sex distribution of PCLs (P = 0.245). CONCLUSION: There is a low prevalence of H. pylori in this metropolitan population. Mandatory multiple topographically targeted biopsies, even with normal mucosal appearance, at gastroscopy in addition to surveillance of PCL are recommended for early detection of gastric cancer.

Ulcerated choledochocele: A case report.

BACKGROUND: The cystic dilatation of the biliary tract is an uncommon anomaly. Choledochocele, a cystic dilatation of the distal common bile duct, rarely presents clinically as massive gastrointestinal bleeding. AIM: This is to report a very rare disease condition and highlight minimal access options in surgical care. CASE SUMMARY: A 13 year-old boy was referred with a day history of sudden onset of passage of bright red blood per rectum with a fainting episode. There was no anal protrusion, jaundice, recurrent epigastric pain nor bleeding from any other orifice. An initial endoscopic assessment of the upper digestive tract showed profuse bleeding from a sub-mucosal mass in the region of ampulla of Vater. Emergency laparotomy revealed small intestine filled with blood from duodenum to ileum. A duodenotomy showed a cystic mass with an ulcerated mucosa at the dome containing bilious fluid in the second part of the duodenum. The cyst was de-roofed and marsupialized. Post-operative recovery was complicated by features of adhesive small bowel obstruction on the 9th post op day and treated by laparoscopic adhesiolysis. He was discharged home in good clinical state. CONCLUSION: Choledochocele is a differential diagnosis in the endoscopic finding of a submucosal mass in the second part of the duodenum. An initial oesophagogastroduodenoscopy endoscopy is necessary in the evaluation of massive lower gastrointestinal bleeding.

Volvulus complicating jejunal diverticulosis: A case report.

INTRODUCTION: Diverticular disease is uncommon among Africans though increasing number of cases is now being reported, mainly of colonic diverticulosis. This condition afflicts all parts of the gastrointestinal tract but commonly the colon. Jejunal diverticula are rare, usually asymptomatic but may lead to an acute abdomen. CASE PRESENTATION: A 68 year old female trader, who was referred from a peripheral center with insidious onset of severe colicky, generalized abdominal pain, repeated vomiting of recently ingested meal, no hematemesis. There was constipation and abdominal distension. The working diagnosis was dynamic intestinal obstruction of small bowel origin. She had emergency exploratory laparotomy following resuscitation. The findings were: volvulus of the jejunum and multiple jejunal diverticula. A resection of 80cm of the jejunum with most of the diverticula involved in the torsion was done with an end-to-end anastomosis of the jejunum. Her out-patient follow-up has been uneventful. DISCUSSION: Jejunal diverticular disease is rare in Africa. Our patient presented with small bowel obstruction due to volvulus. Other complications are discussed. CONCLUSION: Intestinal obstruction from diverticular disease is not always of colonic origin. It can occur in the jejunum.

Pilot study on laparoscopic surgery in port-harcourt, Nigeria.

BACKGROUND: Video-laparoscopic surgery has long been practiced in western countries; however documented practice of this minimal access surgical technique are recently emanating from Nigeria. To the best of our knowledge, this is the first documented study on laparoscopic surgery from the Niger Delta region. AIM: To evaluate the feasibility of laparoscopy as a useful tool for management of common surgical abdominal conditions in our environment. PATIENTS AND METHODS: This was a prospective outcome study of all consecutive surgical patients who had laparoscopic procedures in general and pediatric surgery units of our institution from August 2011 to December 2012. Data on patient's age, gender, indication for surgery, duration of hospital stay and outcome of surgery were collected and analyzed. RESULTS: A total of 15 laparoscopic procedures were performed during this study period with age range of 2-65 years; mean: 32.27 ± 17.86 years. There were 11 males and four females. Six laparoscopic appendicectomies, one laparoscopy-assisted orchidopexy, five diagnostic laparoscopy ± biopsy, one laparoscopic trans-abdominal pre-peritoneal herniorrhaphy for bilateral indirect inguinal hernia and two laparoscopic adhesiolysis for small bowel obstruction were performed. All were successfully completed except one conversion (6.7%) for uncontrollable bleeding in an intra-abdominal tumor. CONCLUSION: The practice of laparoscopic surgery in our environment is feasible and safe despite the numerous, but surmountable challenges. There is the need for adequate training of the support staff and a dedicated theatre suite.