Outcome of Transanal Endorectal Pull-Through in Patients with Hirschsprung's Disease.

BACKGROUND: Transanal endorectal pull-through (TERPT) has become one of the preferred treatments for Hirschsprung's disease (HD) in our setting. This report aims to evaluate the current outcome of TERPT in the setting. MATERIALS AND METHODS: A retrospective review of 71 children who had TERPT for histologically-confirmed HD in 11 years (2006-2017) in Nigeria. RESULTS: There were 48 boys and 23 girls; aged 3 days-12 years at initial presentation (median = 10 months). Three (4.2%) patients had associated anomalies (duodenal atresia; anorectal malformation and sensorineural deafness with hypopigmented skin patches each). Age at TERPT was 2 months to 15 years (median = 3 years), with surgery waiting time of 1 month-14.9 years (median = 18 months). Sixty-six (93.0%) patients had rectosigmoid, four (5.6%) patients had long segment and one (1.4%) had total colonic disease. Five (7.0%) patients with large megacolon and one (1.4%) with the total colonic disease had assisted abdominal resection of the colon at TERPT. Seventeen (23.9%) patients had post-operative complications, including post-operative enterocolitis 8 (11.3%); anastomotic dehiscence 3 (4.2%); retained aganglionic segment 2 (2.8%); anastomotic stenosis 2 (2.8%), resulting in prolonged hospital stay (P = 0.0001; range = 1-30 days; median = 5 days). The mortality rate was 4.2% (3) from malignant hyperthermia in one patient and in 2 patients, the cause of mortality was unclear. Patients were followed up for 3-6 years (median = 3.5 years). Bowel movement stabilised to 2-4 times daily by 6 weeks after surgery. CONCLUSION: TERPT is a safe treatment for HD in this setting with good short-term outcomes. Longer follow-up is necessary to further evaluate the long-term bowel movement outcomes.!

Burden of Complicated Intra-Abdominal Infections in Children in Nigeria: Recent Experience and Systematic Review.

Background: Intra-abdominal infections encompass a wide range of conditions from uncomplicated appendicitis to fecal peritonitis. Little is known about the burden of complicated intra-abdominal infection (cIAIs) in children in low- and middle-income countries (LMICs). Method: This a report of recent experience and a systematic review of the burden in Nigeria. Results: Of 85 children with cIAIs, the most common primary cause was typhoid intestinal perforation (54; 63.5%) and complicated appendicitis (20; 23.5%). The complication rate after surgery was high, including surgical site infection (SSI) in 49 (57.6%), post-operative intra-abdominal abscess in 14 (16.5%), and complete abdominal wound dehiscence in 13 (15.3%). The rate of re-operation was 19 (22.4%) and 12 (14.1%) patients required re-admission for adhesion intestinal obstruction and unresolved SSI. Eight (9.4%) died from overwhelming infection. Systematic review revealed only a few publications, but these were mostly on specific causes of cIAIs and publications providing comprehensive data are lacking. Conclusion: Investment in research into cIAIs in children in LMICs is needed. Efforts need to be focused on the role of source control in reducing the high complication rate and mortality.

Perspectives on perioperative management of children's surgical conditions during the COVID-19 pandemic in low-income and middle-income countries: a global survey.

Background: Many organizations have issued recommendations to limit elective surgery during the coronavirus disease 2019 (COVID-19) pandemic. We surveyed providers of children's surgical care working in low-income and middle-income countries (LMICs) to understand their perspectives on surgical management in the wake of the COVID-19 pandemic and how they were subsequently modifying their surgical care practices. Methods: A survey of children's surgery providers in LMICs was performed. Respondents reported how their perioperative practice had changed in response to COVID-19. They were also presented with 26 specific procedures and asked which of these procedures they were allowed to perform and which they felt they should be allowed to perform. Changes in surgical practice reported by respondents were analyzed thematically. Results: A total of 132 responses were obtained from 120 unique institutions across 30 LMICs. 117/120 institutions (97.5%) had issued formal guidance on delaying or limiting elective children's surgical procedures. Facilities in LICs were less likely to have issued guidance on elective surgery compared with middle-income facilities (82% in LICs vs 99% in lower middle-income countries and 100% in upper middle-income countries, p=0.036). Although 122 (97%) providers believed cases should be limited during a global pandemic, there was no procedure where more than 61% of providers agreed cases should be delayed or canceled. Conclusions: There is little consensus on which procedures should be limited or delayed among LMIC providers. Expansion of testing capacity and local, context-specific guidelines may be a better strategy than international consensus, given the disparities in availability of preoperative testing and the lack of consensus towards which procedures should be delayed.

Motor vehicle accident is a risk factor for traumatic head injury among children in Abuja: analysis of the first trauma registry in Nigeria.

INTRODUCTION: Pediatric traumatic injury is a major public health concern that is poorly documented in lower and middle-income countries. This study analyzed data on pediatric injuries from a unique hospital trauma registry in Abuja, Nigeria. METHODS: Data were analyzed on 220 traumatically injured patients aged 21 years/less to describe injury characteristics and to determine the association between mechanism of injury and pediatric head injuries in Abuja, Nigeria, between 2014 and 2015. Bivariate analysis using Pearson's chi-square and adjusted logistic regression were conducted to characterize the population and identify risk factors for head injury. P-values<0.05 were considered statistically significant. All statistical analyses were performed using STATA v.15.1. RESULTS: The majority of patients were male (60.9%) with a mean age (SD) of 12.5±6.9 years. Head injuries were most common (49.6%), followed by chest (14.1%), abdomen (12.3%) and back (7.7%). The mechanism of injury was statistically significantly associated with head injury (p=0.027) with 63% of children in a motor vehicle accident sustaining a head injury. After adjusting for covariates, the odds of head injury were 3.8 times higher for children injured in a motor vehicle accidents (MVA) compared to those with falls (95%CI 1.40-10.40). CONCLUSION: This analysis reveals that motor vehicle accident is a risk factor for traumatic head injury among children in Nigeria. Therefore, efforts should be made to address motor vehicle accidents involving children. These data will help to inform age-related prevention and treatment strategies. The results of this study highlight the importance of collecting pediatric trauma data in developing countries.

When walking is bad for your back: a cohort study of risk factors for traumatic spinal injury in Abuja.

INTRODUCTION: This study evaluates characteristics and risk factors of traumatic spinal injuries (TSIs) treated at a trauma center in Abuja, Nigeria. TSIs are a global concern. They are frequently disabling, leading to economic, workforce, and quality of life strain. Little is known of the epidemiology of TSIs in Nigeria. METHODS: Data were collected from National Hospital Abuja's trauma registry on 3025 patients treated at the hospital between 2014 and 2017. Patient characteristics were compared between spinal and nonspinal injury groups. Multiple logistic regression was used to identify risk factors of TSIs. RESULTS: 15% (452) of all injuries were spinal. Road traffic crashes were a significantly greater cause of spinal (77.4%) than nonspinal (59.4%) injuries (p<0.0001). Pedestrians were involved in 19% (356) of total crashes, occupying a significantly larger proportion of spinal (18.6%) than nonspinal (10.6%) injuries (p<0.0001). Three variables were modeled as risk factors of crash-related TSIs: mode of transportation, age, and gender. Only mode of transportation demonstrated statistical significance, with involvement as a pedestrian showing an adjusted odds ratio of 1.38 (95% confidence interval: 1.03-1.85, p=0.0329). CONCLUSION: Determining characteristics and risk factors of TSIs is an essential step in addressing this health concern in Nigeria. Crashes are a significant cause of TSIs, and a quarter of TSI patients involved in a crash are pedestrians. Involvement in a crash as a pedestrian is associated with high risk of TSI. These results can help guide both the development of spinal injury prevention policies and the allocation of resources.

Choice of Future Location of Surgical Practice: A Survey of Surgical Trainees in Nigeria and Implications for Timely Access to Surgical Care.

BACKGROUND: There is inequity and maldistribution of the surgical workforce in Nigeria. Most specialists practice in second- and third-level hospitals often located in urban or semi-urban areas. A knowledge of the proposed choice of practice location of surgical trainees and the factors that influence the choice could provide insight into future surgical coverage and help in planning and policy-making. METHODS: This is a cross-sectional survey of surgical trainees attending the mandatory integrated revision and update course of the West African College of Surgeons. Anonymous structured questionnaires were self-administered to 200 trainees, of which 143 completed the questionnaires. RESULTS: The response rate was 71.5%. One hundred and six (74.1%) trainees preferred to work in a tertiary hospital on completion of training, 13 (9.1%) were in a Private Hospital, and 16 (11.2%) were undecided. Nearly all tertiary hospitals are in urban or semi-urban towns. The commonest factors influencing choice of practice location were proximity to family 19 (13.3%), proximity to hometown 11 (7.6%), availability of working facilities 10 (6.9%), income 7 (4.9%) and underserved areas 7 (4.9%). Of 122 (85.3%) trainees who agreed to work for some period each year (ranging from 1 week to 6 months) in a rural setting, 42 (29.3%) would do it without additional financial incentive. CONCLUSION: The choice of most surgical trainees not to work in a rural setting as specialists would exacerbate the ongoing surgical workforce maldistribution and inequity in Nigeria. However, the willingness of 85.3% to provide periodic rural surgical coverage could be leveraged in planning of initiatives to address the maldistribution.

Presentation and outcome of treatment of jejunoileal atresia in Nigeria.

BACKGROUND: Intestinal atresia is a common cause of neonatal intestinal obstruction. Previous reports from Nigeria have indicated a high mortality rate. This is a report of current outcome review from one tertiary center. PATIENTS AND METHODS: A retrospective analysis of infants managed for jejunoileal atresia in 10 years (2005-2014). The information retrieved from patients' records was analyzed using SPSS 17. RESULTS: There were 38 patients (19 boys and 19 girls) aged 1-28 days (median 4 days). Twenty-four patients (63.2%) presented after 48 h of life. Twenty-five (65.8%) had jejunal atresia and 13 (34.2%) had ileal atresia. Six patients had associated anomalies. The most common atresia was type III (39.5%, 15 patients). Twenty-eight (73.7%) patients had a resection of the atresia and anastomosis and others had enterostomies. Total parenteral nutrition and neonatal intensive care support were not available during the period of the study. Bowel function was established within 1 week and 27 (71.1%) patients commenced oral feeding. Twenty-six (68.4%) patients had postoperative complications resulting in prolonged hospital stay of 2-44 days (median = 13). Mortality was 34.2% (13 patients). Factors that significantly affected mortality were intestinal necrosis at presentation, postoperative complications, and severe malnutrition. CONCLUSION: Intestinal atresia is still associated with unacceptably high morbidity and mortality, due to late presentation, and lack neonatal intensive care services and parenteral nutritional support. Efforts need to be intensified to address these factors to improve outcome.

The Global Initiative for Children's Surgery: Optimal Resources for Improving Care.

BACKGROUND: The Lancet Commission on Global Surgery reported that 5 billion people lack access to safe, affordable surgical care. The majority of these people live in low-resource settings, where up to 50% of the population is children. The Disease Control Priorities (Debas HTP, Donkor A, Gawande DT, Jamison ME, Kruk, and Mock CN, editors. Essential Surgery. Disease Control Priorities. Third Edition, vol 1. Essential Surgery. Washington, DC: World Bank; 2015) on surgery included guidelines for the improvement of access to surgical care; however, these lack detail for children's surgery. AIM: To produce guidance for low- and middle-income countries (LMICs) on the resources required for children's surgery at each level of hospital care. METHODS: The Global Initiative for Children's Surgery (GICS) held an inaugural meeting at the Royal College of Surgeons in London in May 2016, with 52 surgical providers from 21 countries, including 27 providers from 18 LMICs. Delegates engaged in working groups over 2 days to prioritize needs and solutions for optimizing children's surgical care; these were categorized into infrastructure, service delivery, training, and research. At a second GICS meeting in Washington in October 2016, 94 surgical care providers, half from LMICs, defined the optimal resources required at primary, secondary, tertiary, and national referral level through a series of working group engagements. RESULTS: Consensus solutions for optimizing children's surgical care included the following: · Establishing standards and integrating them into national surgical plans.. · Each country should have at least one children's hospital.. · Designate, facilitate, and support regional training hubs covering all. · children's surgical specialties.. · Establish regional research support centers.. An "Optimal Resources" document was produced detailing the facilities and resources required at each level of care. CONCLUSION: The Optimal Resources document has been produced by surgical providers from LMICs who have the greatest insight into the needs and priorities in their population. The document will be refined further through online GICS Working Groups and the World Health Organization for broad application to ensure all children have timely access to safe surgical care.

Glove Perforation Rate in Surgery: A Randomized, Controlled Study To Evaluate the Efficacy of Double Gloving.

BACKGROUND: The risk of exposure of either the patient or the surgeon to communicable disease when the surgical glove is perforated is important. Both patients and the surgical team need to be protected from this risk. Therefore, we intended to determine the efficacy of double gloving in our center. METHODS: This was a prospective cohort study, involving (randomly selected) surgeons, who wore single or double latex surgical gloves during procedures. Gloves were collected and evaluated for perforations (using air insufflation and water leak methods). RESULTS: A total of 1,536 gloves were collected (512 single gloves and 1,024 double gloves), with 78 of 512 gloves perforated, giving a rate of 15.2%. Perforation rate was 15.2% in single gloves, 14.4% in double gloves, 15.5% in emergency operations, and 14.3% in elective surgery. It was highest (30.8%) among registrars in training, particularly when doing any deep (16.0%) surgery. Glove perforation rate was highest (17.4%) among general surgery procedures as opposed to pediatric surgery (14.6%), urology (13.9%), neurosurgery (11.7%), and plastic surgery (10.6%), with (42.1%) index finger injury. In unused (control group) gloves, the rate of perforation was (0.8%). There was a substantial difference in the overall perforation rate between single and double glove sets (15.2% versus 14.4%) (X(2) = 1748, p < 0.0001). However, among the double set, total gloves [outer and inner set] analysis revealed a perforation rate of 27.5% (141 of 512). Of this set, the number of inner gloves that perforated as a result of a through and through puncture from outer to the inner gloves gave a rate of 1.17% (six of 512). Thus, the protection offered by double gloves was 98.83% (X(2) = 280.9, p < 0.0001) even if the outer gloves were perforated. CONCLUSION: The use of double gloves has more than 90% protection to patient and the surgeon. Therefore, wearing double gloves should be encouraged in surgery.