Severe Chest Injury Revisited - An Analysis of The Jos University Teaching Hospital Trauma Registry.

BACKGROUND: Chest injury remains a major source of morbidity and mortality in trauma as approximately two-thirds of all severe traumas involve the chest. OBJECTIVE: To determine the changes in the profile management and outcome of severe chest injury in Jos University Teaching Hospital, Jos, Nigeria. MATERIALS AND METHODS: This is an analysis of the Trauma Registry of Jos University Teaching Hospital-a prospectively gathered database. Patients' entries with severe chest injuries for 7 years, from January 2012 to December 2018, were entered into a database and analyzed using the Epi Info Statistical Software, using simple statistics. RESULTS: In all, 162 patients presented with severe chest injury over a 7-year period, of whom 78 (48.1%) had polytrauma, while 84 (51.9%) had isolated chest injury. There were 139 males and 23 females, giving male: female ratio of 6:1. Over 95 (58.6%) of them were between 20 and 39 years. Blunt injury was predominant, constituting 66.7%. Motor vehicular crash was the most common mechanism of injury constituting 87 (53.7%), while gunshot injuries were responsible for 34 (21%). In managing these severe chest injuries, 146 (90%) of the patients had closed-chest tube thoracostomy as the definitive treatment, while 16 (9.9%) had thoracotomy. The mean and median duration of hospital stay was 13.3 and 10 days, respectively. The commonest complication was wound infection in 8 (4.9%) patients and a mortality of 5.9%. CONCLUSION: Blunt chest injury remains the commonest mechanism of chest injury but with an increasing proportion of penetrating injuries affecting predominantly young males. Most severe chest injury patients survive with simple interventions of resuscitation, and closed-chest tube thoracostomy for definitive treatment.

Experience in the management of the mass casualty from the January 2010 Jos Crisis.

BACKGROUND: On the 17 of January 2010, a sectarian crisis broke out in Jos the capital of Plateau state, Nigeria. It created a mass casualty situation in the Jos University Teaching Hospital. We present the result of the hospital management of that mass casualty incident. OBJECTIVE: To share our experience in the management of the mass casualty situation arising from the sectarian crisis of Jos in January 2010. METHODOLOGY: We retrospectively reviewed the hospital records of patients who were treated in our hospital with injuries sustained in the Jos crisis of January 2010. RESULTS: A total of 168 patients presented over a four day period. There were 108 males (64.3%) and 60 females (35.7%). The mean age was 26 ± 16 years. Injury was caused by gunshots in 68 patients (40.5%), machete in 56 (33.3%), falls in 22 (13.1%) and burning in 21 (13.1%). The body parts injured were the upper limbs in 61(36.3%) patients, lower limbs 44 (26.2%) and scalp 43 (25.6%). Majority, 125 (74.4%) did not require formal operative care. Fourteen (8.3%) patients had complications out of which 10 (6.0%) were related to infections. There were 5 (3.1%) hospital mortalities and the mean duration of hospital stay was 4.2 days. The hospital operations returned to routine 24 hours after the last patient was brought in. As a result of changes made to our protocol, management proceeded smoothly and there was no stoppage of the hospital response at any point. CONCLUSION: This civil crisis involved mostly young males. Injuries were mainly lacerations from machete and gunshot injuries. Majority of the victims did not require formal surgical operations beyond initial care. Maintaining continuity in the positions of the Incident commander and the mass casualty commander ensure a smooth disaster response with fewer challenges.

Redox activity and two-step valence tautomerism in a family of dinuclear cobalt complexes with a spiroconjugated bis(dioxolene) ligand.

A family of dinuclear cobalt complexes with bridging bis(dioxolene) ligands derived from 3,3,3',3'-tetramethyl-1,1'-spirobis(indane-5,5',6,6'-tetrol) (spiroH4) and ancillary ligands based on tris(2-pyridylmethyl)amine (tpa) has been synthesized and characterized. The bis(dioxolene) bridging ligand is redox-active and accessible in the (spiro(cat-cat))(4-), (spiro(SQ-cat))(3-), and (spiro(SQ-SQ))(2-) forms, (cat = catecholate, SQ = semiquinonate). Variation of the ancillary ligand (Mentpa; n = 0-3) by successive methylation of the 6-position of the pyridine rings influences the redox state of the complex, governing the distribution of electrons between the cobalt centers and the bridging ligands. Pure samples of salts of the complexes [Co2(spiro)(tpa)2](2+) (1), [Co2(spiro)(Metpa)2](2+) (2), [Co2(spiro)(Me2tpa)2](2+) (3), [Co2(spiro)(Me3tpa)2](2+) (4), [Co2(spiro)(tpa)2](3+) (5), and [Co2(spiro)(tpa)2](4+) (6) have been isolated, and 1, 4, and 6 have been characterized by single crystal X-ray diffraction. Studies in the solid and solution states using multiple techniques reveal temperature invariant redox states for 1, 2, and 4-6 and provide clear evidence for four different charge distributions: 1 and 2 are Co(III)-(spiro(cat-cat))-Co(III), 4 is Co(II)-(spiro(SQ-SQ))-Co(II), 5 is Co(III)-(spiro(SQ-cat))-Co(III), and 6 is Co(III)-(spiro(SQ-SQ))-Co(III). Of the six complexes, only 3 shows evidence of temperature dependence of the charge distribution, displaying a rare thermally induced two-step valence tautomeric transition from the Co(III)-(spiro(cat-cat))-Co(III) form to Co(II)-(spiro(SQ-cat))-Co(III) and then to Co(II)-(spiro(SQ-SQ))-Co(II) in both solid and solution states. This is the first time a two-step valence tautomeric (VT) transition has been observed in solution. Partial photoinduction of the VT transition is also possible in the solid. Magnetic and spectroscopic studies of 5 and 6 reveal that spiroconjugation of the bis(dioxolene) ligand allows electronic interaction across the spiro bridge, suggesting that thermally activated vibronic coupling between the two cobalt-dioxolene moieties plays a key role in the two-step transition evident for 3.

Gold-mediated C-I bond activation of iodobenzene.

Controversy resolved! A combination of gas-phase ion-molecule reactions and theoretical studies confirm bisligated mononuclear Au(I) complexes are unable to undergo oxidative addition of iodobenzene for Sonogashira coupling, but that the ligated gold clusters [Au(3)L(n)](+) (L=Ph(2)P(CH(2))(n)PPh(2); n=3-6) activate the C-I bond. DFT calculations on the transition states show that the linker size n tunes the cluster reactivity.

The progressive development of pyloric stenosis: a role for repeat ultrasound.

INTRODUCTION: Patients presenting in the first 3 months of life with nonbilious emesis are commonly studied by ultrasound. A negative study effectively rules out pyloric stenosis. However, the development of pyloric stenosis is a progressive and dynamic process. The rate of hypertrophy to the point of meeting diagnostic criteria is unknown and there is no data published in the literature regarding the role of repeat ultrasound in patients with persistent symptoms. During a prospective, randomized trial we identified 3 patients with negative ultrasounds who subsequently were diagnosed and treated for pyloric stenosis. We present this series as an illuminating depiction of the development of muscle hypertrophy in patients with pyloric stenosis. METHODS: Patients with pyloric stenosis and repeat ultrasound were identified from our prospective, randomized trial. All patients had sonographic pyloric measurements obtained at our institution. Data included patient age upon presentation, ultrasound-defined pyloric parameters, operation, and outcome. RESULTS: Three patients were identified with a negative ultrasound with a pyloric thickness ranging from 0.8 mm to 2.5 mm. Subsequent thickness on repeat ultrasound ranged from 3.5 to 6.2 mm. The rate of hypertrophy ranged from 0.17 mm/day to 0.5 mm/day. CONCLUSIONS: A negative pyloric sonogram may be due to the fact that the patient is in the very initial stages of development of pyloric stenosis. Caregivers should counsel parents to return if symptoms persist and there should be a low threshold for repeat ultrasound in these patients.

COMPLETE OESOPHAGEAL STRICTURE FOLLOWING THYROIDECTOMY FOR BENIGN GOITRE: A CASE REPORT.

Oesophageal injury leading to stricture is a dreaded disease with clinical course and prognosis that are dependent on the etiology, early recognition, and prompt and effective treatment. Commonly, iatrogenic oesophageal injury occurs during endoscopic procedures, and often in a diseased oesophagus. Though uncommon, injury can occur during thyroidectomy. We therefore present the case of a Nigerian woman with complete oesophageal stricture resulting from oesophageal injury sustained during thyroidectomy.

Pulmonary hypertension predicts mortality in infants with omphalocele.

OBJECTIVE: The objective of this study was to identify predictors of mortality in infants with omphalocele. METHODS: Medical records of infants with omphalocele born between January 1992 and June 2012, with follow-up toDecember 2012, were retrospectively reviewed. Survivors and non-survivors were compared. Evidence for pulmonary hypertension was sought between the second and seventh day after birth. All included infants had increased right ventricular pressures (RVP >40 mmhg) on echocardiogram on the second day of life with increased oxygen requirements, therefore, the finding of increased pressure was not considered a result of the transitional circulation. Logistic regression was used to evaluate the importance and independence of various factors. RESULTS: Of 51 infants whose records were reviewed, 13 died (25%) and 38 survived (75%). The median time to death was 34 days (range: 4 -408 days). The median follow-up time for those who died was 1.5 years (range: 0.01-15 years) and for survivors was 2.6 years (range: 0.08-15 years). Logistic regression revealed that respiratory insufficiency at birth (OR: 14.8; 95% CI: 2.5-85.0) and pulmonary hypertension (OR: 6.4; 95% CI: 1.1-39.0) were independently associated with mortality. CONCLUSION: Respiratory insufficiency after birth and pulmonary hypertension are independent predictors of mortality in infants with omphalocele.

Laparoscopic gastric bypass after failed open horizontal stapled gastroplasty.

The number of people in the population who have undergone an operative procedure for morbid obesity is likely to rise steadily as the awareness and popularity of bariatric surgery continues to develop. As this number increases, the number of patients with long-term failures and complications from these procedures will also rise. Although previous operations, particularly open procedures, normally deter surgeons from choosing a laparoscopic approach, the evolving technical skill of laparoscopic surgeons should allow for the reconsideration of these inhibitions. In this case, we present of laparoscopic Roux-en-Y gastric bypass on a 48-year-old woman who had undergone horizontal gastric stapling 20 years prior to presentation.

Hepatic control of perfusate homeostasis during normothermic extrocorporeal preservation.

BACKGROUND: We investigated the ability of the isolated porcine liver to maintain acid-base homeostasis in the perfusate and the impact of ischemia-reperfusion injury without or with extracorporeal perfusion. METHODS: Harvested livers were either stored for 24 hours in cold University of Wisconsin solution or preserved by continuous, normothermic, oxygenated sanguineous perfusion with supplemental nutrition, prostacyclin, and bile salts. After a further 24-hour period of reperfusion of both groups on an extracorporeal circuit, the perfusate was assessed for both biochemical indices of synthetic and metabolic liver function as well as hepatocellular injury and blood gas analysis. RESULTS: Livers injured by cold ischemia during preservation displayed inferior synthetic and metabolic functions. Perfused livers, which displayed minimal ischemic injury, produced more bicarbonate than the cold-stored organs, suggesting autoregulation of pH homeostasis in perfused livers in contrast to progressively worsening acidosis in cold-stored organs. CONCLUSIONS: Given proper physiologic substrate the porcine liver has the ability to maintain acid-base homeostasis, provided there is not a significant ischemia-reperfusion injury.

HIRSCHSPRUNG'S DISEASE IN AN ADULT: A CASE REPORT.

Hirschsprung's disease in the adolescents and adults is not a common diagnosis in our environment. However this may be as a result of misdiagnosis or late presentation as is the case with other causes of recurrent constipation in older age groups. We present a case of a 19-year old male who presented with recurrent episodes of constipation from infancy with none requiring any intervention except for the index presentation that lasted for 3 weeks with associated progressive abdominal distension. Diagnosis was made with a barium enema and full thickness rectal biopsy. He had staged procedures with an initial divided colostomy thereafter followed by a definitive Souave endorectal pull-through with a good short-term outcome.

Incidence, diagnosis, and outcomes of vocal fold immobility after esophageal atresia (EA) and/or tracheoesophageal fistula (TEF) repair.

BACKGROUND: The diagnosis of vocal fold paralysis in an infant is a devastating finding that may require a permanent tracheotomy. The incidence of congenital vocal fold paralysis is unknown, but it is thought to be more common in infants with anatomic anomalies in the aero-digestive system. Vocal fold paralysis after surgical repair of esophageal atresia and tracheoesophageal fistula is a rare finding often diagnosed after multiple failed extubations. Currently infants do not routinely undergo documentation of vocal fold motion prior to esophageal atresia repair. We report here on our experience with this rare complication. METHOD: A retrospective review was done of patients with esophageal atresia and/or tracheoesophageal fistula from 1985 to 2009. Patient demographics, operative techniques, and outcomes were collected. RESULTS: 150 patients were identified. Mean age at surgical intervention was 12 ± 33 days. Otolaryngology service was consulted for 13% of patients with postoperative failure. Awake fiberoptic laryngoscopy identified 3% of patients with vocal fold paralysis. Bilateral vocal fold paralysis was found in 3 patients, and 2 patients had unilateral vocal fold paralysis. Patients with bilateral paralysis were treated with tracheotomy; unilateral paralysis was treated expectantly. CONCLUSION: In this study, 3% of patients were diagnosed with vocal fold paralysis after esophageal atresia repair. The etiology of vocal fold paralysis in this study is difficult to assess. Pre-operative fiberoptic laryngoscopy is recommended to identify children with congenital vocal fold paralysis prior to surgical intervention, especially in those requiring revision surgery.

Management of anterior mediastinal masses in children.

BACKGROUND: Children with anterior mediastinal masses are at risk for life-threatening airway compromise during anesthesia, and can present a diagnostic and management challenge for pediatric surgeons. METHODS: We performed a retrospective chart review of all children presenting with an anterior mediastinal mass from 1994-2009. Parameters studied included demographics, historical and physical findings at diagnosis, radiographic evidence of airway compression, diagnostic studies, diagnosis, and complications. RESULTS: There were 26 patients with anterior mediastinal masses over a 15-year period. The mean age was 11.3 years, and there were no gender differences. The diagnoses were lymphoma (62%, 16/26), leukemia (15%, 4/26), and other (23%, 6/26). Diagnosis was made by CBC/peripheral smear in 2/4 patients with leukemia, by bone marrow biopsy in 2/4 patients with leukemia, by thoracentesis in 3/16 patients with lymphoma, by lymph node biopsies in 6/16 patients with lymphoma, and by biopsy of a mediastinal mass in 7/16 patients with lymphoma and in 6/6 patients with other diagnoses. Radiographic evidence of airway compression was seen in 62% (16/26) of children. Only 12% (3/26) had a tracheal cross-sectional area (TCA) <50%. Correlation of symptoms with anatomical airway obstruction or complications was poor. Pulmonary function studies were obtained in 38%, 10/26 children. Only 2 children had a PEFR (peak expiratory flow rate) <50% predicted. This data also correlated poorly with anatomical airway obstruction or complications. 3 patients had anesthesia-related complications: one desaturation during induction prior to median sternotomy, one with significant desaturation and bradycardia during biopsy under local anesthesia with minimal sedation, and one with prolonged (5 days) mechanical ventilation after general anesthesia. 2 of these patients had a TCA <50%, and 2 had SVC obstructions. There were no anesthesia-related deaths, and the overall survival was 85% (22/26). CONCLUSION: Anterior mediastinal masses in children should be approached in a step-wise fashion with multi-disciplinary involvement, starting with the least invasive techniques and progressing cautiously. The surgeon should have a well-defined and preoperatively established contingency plan if these children require general anesthesia for diagnosis.

Traumatic Intracranial Aerocele With Progressive Blindness - A case report.

BACKGROUND: Traumatic intracranial aerocele, also known as pneumocephalus, is an uncommon condition that may be asymptomatic or may present with progressive neurological deficits and life threatening conditions that demand urgent decompressive craniotomy to reduce the acute rise in intracranial pressure and the sequelae. AIMS & OBJECTIVES: A high degree of suspicion and continuous neurological monitoring are essential for the early detection and the prompt neurosurgical intervention demanded for the achievement of a good outcome in patients following traumatic acute severe head injury with life threatening neurological complications. METHOD: Presentation of a young motorcyclist who was not wearing a crash helmet and was involved in a road traffic accident in which he sustained a compound cranio-facial injury with loss of consciousness and symptomatic intracranial aerocele. RESULTS: The case of a 28-year old motorcyclist without a helmet, following a road traffic accident, sustained compound skull fracture with CSF rhinorrhea, ventricular aerocele and progressive blindness who recovered his vision fully following bitemporal decompressive craniotomy. CONCLUSION: A high index of suspicion enabled early detection and prompt decompressive craniotomy that stemmed the progressive loss of vision in this patient with an uncommon but symptomatic intracranial aerocele and cranio-facial compound head injury.

Laparoscopic excision of splenic cysts: a comparison to the open approach.

PURPOSE: The aim of this study was to evaluate the outcomes following excision of splenic cysts in children. METHODS: A retrospective chart review of all patients who underwent excision of a splenic cyst between 1990 and 2007 was performed. Age, cyst etiology, cyst size, preoperative imaging, and operative approach were evaluated. Outcome variables included length of postoperative hospitalization, cyst recurrence, postoperative imaging, the histologic lining of the cyst, and the need for additional procedures. RESULTS: During this 17-year period, 9 patients underwent excision of a splenic cyst. Four underwent an open operation and 5 had a laparoscopic procedure. In the open group, 2 patients underwent splenectomy, one patient had a partial splenectomy, and one cyst was aspirated and marsupialized. In the laparoscopic group, 4 patients underwent complete excision of the cyst and 1 underwent resection of the outer wall. The mean age was 12.3 years. Computed tomography was performed preoperatively in 8 patients and one child had an ultrasound study. The most common symptom was abdominal pain in 6 patients. Four patients had a history of recent abdominal trauma. The mean length of postoperative hospitalization was 2.75 days for the open group and 1.6 days for the laparoscopic cohort. One patient in the laparoscopic group had a recurrence. To date, no additional operations have been performed. CONCLUSIONS: Laparoscopic splenic cyst excision is comparable to open cyst excision and results in a decreased length of postoperative hospitalization.

Review of the technical variants in the repair of pectus excavatum.

INTRODUCTION: Many technical variations have been introduced for the surgical correction of pectus excavatum (PE). The authors reviewed the literature to provide a detailed overview of the general principles of pectus excavatum repair, bar insertion and removal techniques. MATERIALS AND METHODS: A comprehensive review of the literature was undertaken. RESULTS: A summary of the different approaches and techniques of pectus excavatum repair, bar insertion and removal is presented. Various procedures, their advantages and disadvantages, the techniques employed and associated complications are discussed in depth. CONCLUSION: Pectus excavatum repair has undergone many changes since its first description. Despite previous descriptions of evolving procedures, comparative overviews of surgical variations, outcomes after pectus bar insertion and removal techniques are rare in the literature. The authors reviewed the literature to summarize the previous and current understanding of techniques and highlight the variations.

A review of venovenous and venoarterial extracorporeal membrane oxygenation in neonates and children.

The use of extracorporeal membrane oxygenation (ECMO) has increased since its inception. As this modality gained wider acceptance, its application in a variety of disease states has increased. The initial use of ECMO required cannulation of both the carotid artery and internal jugular vein (VA ECMO). Ligation of the carotid artery and concern regarding potential long-term sequelae prompted the development of the single cannula venous only (VV ECMO) technique. Various reports in the literature have compared VV ECMO and VA ECMO. We present a review of the literature with regard to both physiology and clinical application.

Bowel obstruction after treatment of intra-abdominal tumors.

BACKGROUND: Tumors of the solid viscera are one of the most common types of pediatric malignancies. Due to the intra-abdominal location of many of these neoplasms, laparotomy and/or bowel resection are often necessary, predisposing patients to postoperative intestinal obstruction. Additionally, chemotherapy and radiation therapy may lead to acute and chronic bowel injury, also potentially predisposing these patients to postoperative bowel obstruction. We reviewed our data over an eleven-year period to identify the incidence of obstruction as well as factors associated with its development. METHODS: A retrospective data analysis of all patients diagnosed with intra-abdominal Wilms' tumor, rhabdomyosarcoma, neuroblastoma, and Hodgkin's and non-Hodgkin's lymphoma in a single institution from 1997 to 2007 was conducted. Data collected included demographic factors, operations, incidence of small bowel obstruction (SBO) and the use of adjuvant or neoadjuvant chemoradiation therapy. Patients who developed SBO were compared to those who did not develop obstruction. Data comparisons were analyzed statistically using Fisher's exact test, 2-tailed Student's t-Test, or chi-square proportional analysis with significance reported for p<0.05. RESULTS: A total of 291 patients were identified during the study period. Mean age at diagnosis was 8.1+/-5.8 years. Males accounted for 57% of all patients. Tumor distribution was as follows: Wilms' tumor: 56 (19%); non-Hodgkin's lymphoma: 71 (24%); Hodgkin's lymphoma: 64 (22%); rhabdomyosarcoma: 32 (11%); and neuroblastoma: 68 (24%). There were a total of 12 bowel obstructions in 11 patients (3.7%). Mean follow-up for all patients was 3.6+/-2.7 years. Children with bowel obstruction were more likely to be male (4.5:1, p=0.061) and younger (4.2 years versus 8.1 years; p=0.087). Wilms' tumor accounted for 45% of patients with bowel obstruction, but made up only 19% of the study population. The incidence of bowel obstruction in patients with Wilms' tumor was 8.9% compared to an overall incidence of 3.8% (p=0.043). CONCLUSION: Bowel obstruction is relatively uncommon after intra-abdominal malignancies in children. Wilms' tumor, rhabdomyosarcoma and Burkitt's lymphoma appear to be associated with the highest risk of bowel obstruction.

Outcome of congenital diaphragmatic hernia repair depending on patch type.

INTRODUCTION: Patch repair of a congenital diaphragmatic hernia is associated with a much higher rate of recurrence than when primary repair is feasible. The biosynthetic options for the repair materials continue to expand. We therefore reviewed our experience to benchmark complication rates as we progress with the use of new materials. METHODS: A retrospective review was conducted of all patients who underwent repair of congenital diaphragmatic hernia from January 1994 to May 2009. RESULTS: Of the 155 patients included in the study, 101 patients had primary closure and 54 received a diaphragmatic patch. The rates of recurrence, Small Bowel Obstruction (SBO), and subsequent abdominal operation were all significantly higher in the group of patients requiring patch repair. There were 3 types of patch repairs: 37 patients received a SIS patch, 12 had a nonabsorbable patch, and 5 received an AlloDerm patch. The incidence of SBO in patients with a nonabsorbable mesh was 17% and was associated with a 50% recurrence rate and 67% re-recurrence rate. SIS was associated with 19% incidence of SBO, a recurrence rate of 22% and a 50% re-recurrence rate, whereas AlloDerm had a 40% incidence of SBO, 40% recurrence rate, and 100% re-recurrence rate. DISCUSSION: As we move towards the next generation of materials, these data do not justify the continued comparison with nonabsorbable patches. We do not have enough comparative data to define a superior biosynthetic material, but we plan to use our data on SIS to benchmark our experience with future generation materials.