An appraisal of the presentation and management of adult intussusception at a Nigerian Tertiary Hospital.

BACKGROUND: Intussusception in adults is considered rare in surgical practice. It is the causative lesion in a small proportion of cases of intestinal obstruction and lower gastrointestinal bleeding. In the last decade, the incidence of adult intussusception appears to be increasing at our centre. AIMS: This study aims to document the pattern of presentation and management outcome of adult intussusception at our institution during the last decade. We also observed the occurring trends of this lesion. PATIENTS AND METHODS: This was a 10-year retrospective study of consecutive adult patients with intussusception seen at our institution from July 2008 to June 2018. Information on biodata, clinicopathological features and management outcome retrieved from case notes and pathology records were analysed on a personal computer using SPSS version 23. RESULTS: Twenty adult patients who had intussusception were seen during this period. There were 9 (45%) males and 11 (55%) females giving a male-to-female ratio of 1:1.2. The mean age of presentation was 45 (range 18-66) years. Clinical features were abdominal pain (85%), abdominal distension (80%), vomiting (70%), rectal bleeding (70%) and palpable abdominal mass (35%). Majority of patients (70%) presented with features of intestinal obstruction. Idiopathic intussusception (55%) accounted for more than half of the cases with the jejunoileal variety (30%) as the most common pathological type. One patient who had intussusception in the postoperative period was treated with manual reduction at laparotomy. Bowel resections were performed in the remaining 19 (95%) patients. CONCLUSION: Adult intussusception is still uncommon in our general surgical practice. Bowel resection is the mainstay of treatment.

Prevalence of anaerobic bacteria in surgical site infections in Lagos University Teaching Hospital.

Background: Surgical site infection (SSI) is the second most common cause of nosocomial infection, after urinary tract infection. Sequelae of SSI include increased healthcare costs and worse patient outcomes. There is a paucity of research studies on the impact of anaerobic organisms on SSIs in Nigeria. The aim of this study was to determine the role of anaerobic bacteria in SSI encountered at the Lagos University Teaching Hospital (LUTH). Materials and Methods: A total of 438 patients were consecutively recruited into this study from general surgery, obstetrics and gynaecology and paediatric units of the LUTH from 1 July through 31 December 2019. Two surgical wound specimens were collected from all patients with suspected SSIs. One was for anaerobic culture using Brucella blood agar incubated in an anaerobic jar that secured anaerobiosis using the anaerobic gas pack. The other swab was used for aerobic culture on blood agar incubated on air at 37oC. Identifications and antibiotic sensitivity testing were performed according to standard laboratory procedures. Result: The overall incidence of SSI in the study was 12.3%. The incidence of anaerobic SSI was 1.1%. The distribution of anaerobic infections by medical specialty unit was as follows; general surgery (1.6%), obstetrics and gynaecology (0.8%) and paediatrics (0.9%). Bacteroides species was the only anaerobic isolate. The risk factors associated with the development of SSI by multiple logistic regression analysis were duration of surgery greater than 2 h (OR 1.418; 95% CI 1.834-9.286; P = 0.001) and NNIS risk index 2 and 3 - (OR 2.165; 95% CI 2.366-32.086; P = 0.001). Conclusions: The prevalence of anaerobic SSI was 1.1%. Duration of surgery greater than 2 h and NNIS risk index 2 and 3 were independent predictors of SSI.

Challenges and Prospects of Laser Haemorrhoidoplasty in a Low Resource Setting: The LUTH Experience.

Background: Haemorrhoids are the most common condition of the anal canal causing significant disability. Traditional excisional haemorrhoidectomy and its various modifications, while effective, may be attended by severe postoperative pain and other complications. Laser haemorrhoidoplasty is reported to be effective with fewer complications and shorter hospital stay. Objectives: The aim of this study was to report the outcome of intrahaemorrhoidal coagulation with 1470-nm diode laser at the Lagos University Teaching Hospital. Patients and Methods: The procedures were performed with a radially emitting laser fibre from Biolitec AG-CeramOptec (Bonn, Germany). The duration of symptoms, grade of the haemorrhoids, duration of the procedures, and postoperative complications were evaluated. Results: Eleven patients had laser haemorrhoidoplasty. There were seven males and four females. The age range was 23-71 years, with a median age of 47 years and an interquartile range (IQR) of 28-57 years. Duration of surgery ranged from 20 to 90 min, with a median of 33 min and IQR of 25-53 min. Postoperative pain was mild in eight patients and moderate in three. Ten patients were discharged as day cases and one 3 days later due to spinal anaesthesia-related headache and acute urinary retention. One patient later had an anal ulcer probably due to too much energy delivered during the procedure, this was managed conservatively. There was no postoperative wound infection, anal incontinence, anal stenosis, subcutaneous abscess, and fistula or recurrence. Conclusion: The advantages of laser haemorrhoidoplasty make it a readily acceptable form of treatment for haemorrhoids in our setting.

Clinicopathological Features and Treatment Outcome of Patients with Gastric Cancer in Lagos: Is the Outlook Getting Better?

Background: Gastric cancer (GC) is an important cause of morbidity and mortality in Nigeria. Significant advances in the management of GC in South-West Nigeria occurred in the last three decades. Patients and Methods: This was a retrospective comparative study of patients with GC that presented at our tertiary hospital in the last three decades. Information on clinicopathological features and treatment outcome were analysed. Data of two consecutive periods; 1991-2004 (Group I) and 2005-2018 (Group II) were compared. Results: Ninety-one patients were studied; Group I (47 patients), Group II (44 patients). The mean age was 56.4 ± 12.7 years and male-to-female ratio was 1.8 to 1.0. The predominant symptoms were epigastric pain in 81(89.0%) (43 vs. 38) and weight loss in 63(69.2%) (32 vs. 31), whereas the signs were epigastric tenderness in 44(46.1%) (24 vs. 20) and epigastric mass in 42(46.1%) (26 vs. 16). The overall mean duration of symptom was 12.3 ± 16.9 months. Barium meal diagnosed GC in 29(61.7%) patients in Group I vs. 4(9.1%) patients in Group II. Conversely, endoscopy diagnosed GC in 23(48.9%) patients in Group I vs. 37(84.1%) patients in Group II. Operations undertaken included palliative subtotal gastrectomy 26(28.6%), potentially curative subtotal gastrectomy 15(16.5%) and non-resectional surgeries in 27(29.7%) patients. The overall incidence of major post-operative complications was 33%. Thirty-nine (42.8%) of the studied patients were lost to follow up. The median postoperative survival for Groups I and II patients was 22 weeks and 58 weeks, P = 0.012, respectively. Conclusion: The outcome of management of patients with GC at our tertiary hospital has improved modestly in the past three decades. Patients are still presenting late with very advanced disease.

Management of Malignant Obstructive Jaundice: Defining the Relevance of Various Palliative Surgical Options in Resource-Challenged Settings: A Review Article.

Malignant obstructive jaundice (MOJ) constitutes an important surgical problem with high morbidity and mortality worldwide. Presentation is usually delayed with a majority of patients benefitting only from palliative treatment. Surgeons practicing in developing countries face herculean task in managing MOJ due to lack of minimally invasive endoscopic procedures. Palliative surgical procedures are associated with high morbidity and sometimes mortality. Abdominal pain, generalized pruritus, and gastric outlet obstruction are some of the symptoms of MOJ requiring palliation. Successful surgical palliation may improve the overall quality of life in patients with MOJ considered fit for surgery. Bypass procedures and regional nerve blocks constitute the most effective surgical palliation available to surgeons practicing in resource-limited settings. This review article discusses the indications, the role, and types of surgical bypass procedures in the management of MOJ in contemporary surgical practice. This is important for surgeons in countries where expertise and resources for the less morbid endoscopic and radiologic approaches are not available. Relevant articles up to January 2021 published in PubMed, Google Scholar, and Hinari on the surgical management of obstructive jaundice were reviewed for inclusion. We also reviewed some modern surgical textbook topics on obstructive jaundice.

Clinicopathological features, risk profile assessment, and the surgical outcome of gastrointestinal stromal tumors in Lagos, Nigeria.

Background: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. GISTs originate from the interstitial cells of Cajal and are most commonly found in the stomach. Most available reports on GISTs in the Sub-Sahara Africa were in case reports and case series. Aim: To report our local experience and challenges in the management of GISTs in 33 patients in Lagos, Nigeria. Methodology: This is a descriptive study of adult patients of 16 years and above managed for GISTs at the Lagos University Teaching Hospital and some Lagos private hospital facilities between January 2015 and March 2021. Information on the patients' demographic characteristics, clinicopathological features, surgery performed, and postoperative complications were retrieved from the hospital's medical records for analysis. Data analysis was carried out using IBM SPSS Statistics for Windows, Version 23.0., Armonk, NY, USA: IBM Corp. Results: Thirty-three patients comprising 19 males and 14 females with a male: female ratio of 1.4:1 were included in the study. The mean age at presentation was 52.5 years. Abdominal pain (69.7%) and anemic symptoms (45.4%) were the principal modes of presentation. Abdominal computed tomography (CT) scan revealed stomach as the primary source of GISTs in 75.8% of patients. Forty-five percent of the patients had CT features of local organ invasion and 27.2% had features of metastasis. Surgical resection was feasible in 28 (84.8%) patients. Postoperative mortality was recorded in two patients with recurrent GISTs. Histological cell types were spindle cell (57.6%), mixed spindle and epithelioid (24.2%), and epithelioid (18.2%). Joensuu high-risk tumors (64. 3%) were the most prevalent in our series. Conclusion: Advanced-stage disease and features of anemia were hallmarks of GISTs among patients in this series. Surgical resection of GIST may be possible in some cases of advanced disease. Spindle cell types and high-risk GISTs were the most common pathological varieties in our patients.

Résumé Contexte: Les tumeurs stromales gastro-intestinales (GIST) sont les tumeurs mésenchymateuses les plus courantes du tractus gastro-intestinal. Les GIST proviennent des cellules interstitielles de Cajal et se trouvent le plus souvent dans l'estomac. La plupart des rapports disponibles sur les GIST en Afrique subsaharienne étaient des rapports de cas et des séries de cas. Objectif: rendre compte de notre expérience locale et des défis dans la gestion des GIST chez 33 patients à Lagos, au Nigeria. Méthodologie: Il s'agit d'une étude descriptive de patients adultes de 16 ans et plus pris en charge pour des GIST à l'hôpital universitaire de Lagos et dans certains établissements hospitaliers privés de Lagos entre janvier 2015 et mars 2021. Informations sur les caractéristiques démographiques des patients, les caractéristiques clinicopathologiques, la chirurgie effectuée, et les complications postopératoires ont été extraites des dossiers médicaux de l'hôpital pour analyse. L'analyse des données a été effectuée à l'aide d'IBM SPSS Statistics pour Windows, version 23.0., Armonk, NY, États-Unis: IBM Corp. l'étude. L'âge moyen à la présentation était de 52,5 ans. Les douleurs abdominales (69,7 %) et les symptômes anémiques (45,4 %) étaient les principaux modes de présentation. La tomodensitométrie abdominale (TDM) a révélé que l'estomac était la principale source de GIST chez 75,8 % des patients. Quarante-cinq pour cent des patients présentaient des caractéristiques CT d'invasion d'organes locaux et 27,2 % présentaient des caractéristiques de métastases. La résection chirurgicale était réalisable chez 28 (84,8 %) patients. La mortalité postopératoire a été enregistrée chez deux patients avec des GIST récurrents. Les types de cellules histologiques étaient les cellules fusiformes (57,6 %), les cellules mixtes fusiformes et épithélioïdes (24,2 %) et les épithélioïdes (18,2 %). Les tumeurs à haut risque de Joensuu (64,3 %) étaient les plus répandues dans notre série. Conclusion: La maladie à un stade avancé et les caractéristiques de l'anémie étaient les caractéristiques des GIST chez les patients de cette série. La résection chirurgicale des GIST peut être possible dans certains cas de maladie avancée. Les types de cellules fusiformes et les GIST à haut risque étaient les variétés pathologiques les plus fréquentes chez nos patients. Mots clés: Bilan, tumeurs stromales gastro-intestinales, pathologie, risque, gestes chirurgicaux.

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.

Acute perforated appendicitis in adults: Management and complications in Lagos, Nigeria.

Background: Acute perforation of the appendix is one of the complications of appendicitis that is associated with increased morbidity and mortality and hence regarded as a surgical emergency. Risk factors for perforated appencidicits include extremes of age, male sex, pregnancy, immunosuppression, comorbid medical conditions and previous abdominal surgery. Objectives: This study focuses on the pattern of presentation, risk factors, morbidity and mortality of patients managed for perforated appendicitis in our centre. Subjects and Methods: We conducted a seven-year retrospective review of consecutive adult patients who had surgery for perforated appendicitis in our centre. Results: The perforation rate in the study was 28.5%. The peak age of presentation was between 21-30 years. Forty-two (71.1%) of the patients under study were males. Only 3 (5.1%) of the cohorts had history of recurrent abdominal pain. Majority of the patients were in the American Society of Anesthesiologists (ASA) II (44.1%) and III (42.4%) categories. Surgical site infections (SSI) (18.6%), wound dehiscence (15.2%) and pelvic abscess (13.5%) were the most common complications. The Incidence of SSI was found to correlate with male gender, (P = 0.041), co-morbidity (P = 0.037) and ASA score (0.03) at 95% confidence interval. Routine use of intraperitoneal drain after surgery for perforated appendicitis did not appear to reduce the incidence of pelvic abscess. No mortality in the studied population. Conclusion: Appendiceal perforation was more common in male patients with first episode of acute appendicitis. Previous abdominal surgery and comorbid medical conditions were of lesser risk factors for appendiceal perforation in our patients. Surgical site infection was the commonest complication after surgery.

RésuméContexte: La perforation aiguë de l'appendice est l'une des complications de l'appendicite associée à une augmentation de la morbidité et de la mortalité et donc considérée comme une urgence chirurgicale. Les facteurs de risque pour les applications perforées comprennent les extrêmes d'âge, le sexe masculin, la grossesse, l'immunosuppression, les conditions médicales concomitantes et la chirurgie abdominale antérieure. Objectifs: Cette étude se concentre sur le schéma de présentation, les facteurs de risque, la morbidité et la mortalité des patients pris en charge pour une appendicite perforée dans notre centre. Sujets et méthodes: Nous avons effectué une revue rétrospective sur sept ans de patients adultes consécutifs ayant subi une chirurgie pour une appendicite perforée dans notre centre. Résultats: Le taux de perforation dans l'étude était de 28,5%. L'âge maximal de présentation était entre 21-30 ans. Quarante-deux (71,1%) des patients étudiés étaient des hommes. Seulement 3 (5,1%) des cohortes avaient des antécédents de douleurs abdominales récurrentes. La majorité des patients étaient dans les catégories II (44,1%) et III (42,4%) de l'American Society of Anesthesiologist (ASA). Les infections du site opératoire (SSI) (18,6%), la déhiscence des plaies (15,2%) et les abcès pelviens (13,5%) étaient les complications les plus fréquentes. L'incidence de SSI a été trouvée corrélée avec le sexe masculin, (p = 0,041), la co-morbidité (p = 0,037) et le score ASA (0,03) à intervalle de confiance de 95%. L'utilisation systématique d'un drain intrapéritonéal après une chirurgie pour une appendicite perforée ne semble pas réduire l'incidence des abcès pelviens. Aucune mortalité dans la population étudiée. Conclusion: La perforation appendiculaire était plus fréquente chez les patients masculins présentant un premier épisode d'appendicite aiguë. La chirurgie abdominale antérieure et les conditions médicales comorbides étaient des facteurs de risque moins pour la perforation appendiculaire chez nos patients. L'infection du site opératoire était la plus courante après la chirurgie.

Stump Appendicitis due to Retained Fecalith after Laparoscopic Surgery.

Stump appendicitis is a rare cause of right iliac fossa pain in patients with a previous history of appendectomy for acute appendicitis. The presentation is often delayed and may pose a clinical diagnostic challenge to the surgeon. More often, a high index of suspicion backed with relevant radiologic investigations is required for diagnosis. Open and laparoscopic appendectomy may be complicated by stump appendicitis. We report our experience in a 49-year-old Nigerian who presented to us with recurrent right iliac fossa pain and abdominal distension of 2 weeks' duration. The patient had laparoscopic appendectomy 1 year prior to presentation to us. A diagnosis of stump appendicitis with small-bowel obstruction was made with an abdominal computed tomography scan. He had an open stump appendectomy and small-bowel adhesiolysis with a good postoperative outcome.

Survey of Basic Laparoscopic Training Exposure of Nigerian Postgraduate Trainees.

BACKGROUND: The practice of laparoscopy involves the use of training models that are different from conventional open surgery. These concepts are not captured in the traditional models of surgical residency training. Residency training in surgery has been seen as an ample opportunity for early introduction and training in laparoscopy. OBJECTIVES: This study aimed to assess the level of exposure and training experience of some surgical resident doctors in accredited training institutions in Nigeria on laparoscopy. METHODOLOGY: A cross-sectional survey was conducted among the resident doctors undergoing revision course in surgery at the National Orthopaedic Hospital, Igbobi, Lagos, and Lagos University Teaching Hospital, Lagos, in March 2018. Using the quantitative method of data collection, a pre-tested structured questionnaire was used to collect information on the demography and training exposure of the residents in laparoscopy. RESULTS: A total of 54 of 96 residents surveyed returned the questionnaire, giving a response rate of 56%. There were 53 (98.1%) males and 1 (1.9%) female. The age range of the respondents was between 30 and 46 years, with a mean of 34.2 ± 3.96 years. Thirty-two (59.3%) respondents had spent at least 2 years training in surgery. Thirty-six (66.7%) respondents had not participated in more than four laparoscopic procedures during their rotation. Forty-six percent of respondents reported that their experience in laparoscopy was mainly by observation of the procedures. Forty-nine (90.7%) of respondents surveyed had not attended any training program in laparoscopy. Eighty-one (81.0%) of respondents had a strong motivation and desire for future practice of laparoscopy. CONCLUSION: This study revealed that few Nigerian postgraduate trainees sampled in the survey were exposed and had training experience in laparoscopy.

Knowledge, attitudes and screening practices regarding prostatic diseases among men older than 40 years: a population-based study in Southwest Nigeria.

INTRODUCTION: Despite the global increase in awareness of prostatic diseases resulting from widespread availability of screening tools, there is no evidence that the knowledge, attitudes and screening practices of Nigerian men have improved regarding prostatic diseases. METHODS: A descriptive cross-sectional study amongst 305 community-dwelling men. Respondents were selected using multi-staged sampling techniques. Knowledge, attitudes and screening practices were determined based on responses to a semi-structured KAP questionnaire. Data were analyzed using SPSS version 18. Pearson's chi-square and Fisher's exact test (two-tail) with level of significance set at 0.05 were used to determine the level of statistical significance. Pearson's correlation coefficient was used to establish correlation between variables. RESULTS: Mean age of respondents was 63.4±11.8 years. Slightly less than half, 145(47.5%) were aware of prostate cancer (PCa) while only 99(32.5%) and 91(29.8%) were aware of BPH and prostatitis respectively. About a quarter (25.1%) had heard of PSA. The main sources of information were radio and television. Overall, 143(46.9%) respondents had good knowledge while 162(53.1%) had poor knowledge. Sexually transmitted disease was the commonest misconception as the cause of prostatic diseases. Overall, 44.3% had good attitudes. Only 31(10.2%) respondents had ever carried out screening for PCa. Only educational and occupational status had significant associations with level of knowledge and attitudes of participants. The only factor that influenced screening practices was educational status. CONCLUSION: There is a poor level of knowledge, attitudes and screening practices regarding prostatic diseases in Nigeria. We recommend a widespread public health education to improve knowledge, attitudes and screening practices for prostatic diseases.

Lower Urinary Tract Symptoms: Prevalence, Perceptions, and Healthcare-Seeking Behavior amongst Nigerian Men.

PURPOSE: The aim of this study was to determine the prevalence of lower urinary tract symptoms (LUTS) and the factors influencing the healthcare-seeking behavior of men with LUTS. MATERIALS AND METHODS: A cross-sectional survey was performed of 658 men selected using multi-staged sampling techniques. They were interviewed about LUTS and their healthcare-seeking behavior. The data were analysed using PASW Statistics ver. 18. Associations between specific factors and healthcare-seeking behavior were examined using the chi-square and Fisher exact tests. RESULTS: The overall prevalence of LUTS was 59.1%. Storage symptoms (48.2%) were more prevalent than voiding (36.8%) or post-micturition (29.9%) symptoms. Approximately a quarter (25.5%) had a poor quality of life (QoL) score. The average duration of symptoms before seeking help was 3.4 years. Almost half (46.8%) of the men with LUTS had never sought help. Perceptions of LUTS as an inevitable part of ageing, subjective feelings of wellness, financial constraints, and fear of surgery were the most common reasons for not seeking help. The most common reasons for seeking help were to moderate-severe symptoms, impaired QoL, and fear of cancer. Severe LUTS, impaired QoL, and the concomitant presence of erectile dysfunction, dysuria, or haematuria were clinical factors that positively influenced healthcare-seeking behavior. CONCLUSIONS: In this population-based study, we found that the prevalence of LUTS was very high amongst adult males. However, only about half of these men sought medical attention. Their healthcare-seeking behavior was influenced by severity of symptoms, QoL scores, and socio-demographic factors such as educational status.