Primary Fibrosarcoma of the Breast: Case Report of a Rare Breast Neoplasm.

Breast fibrosarcoma is an uncommon primary breast neoplasm. We report a case of a 57-year old woman who presented at our facility with a right breast mass having histomorphological and immunohistochemical features consistent with fibrosarcoma. She had simple mastectomy and an uneventful hospital stay. The mass recurred 4-weeks later for which she had supportive care and started on cyclical chemotherapy (Adriamycin, Cyclophosphamide and Dacarbazine). She was referred for haemostatic radiotherapy and her clinic follow-up scheduled.

Le fibrosarcome du sein est une tumeur primitive du sein rare. Nous rapportons le cas d'une femme de 57 ans qui s'est présentée dans notre établissement avec une masse mammaire droite présentant des caractéristiques histomorphologiques et immunohistochimiques compatibles avec un fibrosarcome. Elle a eu une mastectomie simple et un séjour à l'hôpital sans incident. La masse est réapparue 4 semaines plus tard pour laquelle elle a reçu des soins de soutien et a commencé une chimiothérapie cyclique (Adriamycine, Cyclophosphamide et Dacarbazine). Elle a été référée pour une radiothérapie hémostatique et son suivi clinique a été programmé.

Drain Site Hernia: A Review of the Incidence and Prevalence.

BACKGROUND: Surgical drains prevent fluid accumulation such as peritoneal fluid, blood, pus or inflammatory exudates. However, complications may occur. The aim of this study is to review the incidence and prevalence of drain site hernia as a complication of surgical drains. MATERIAL AND METHODS: A search of the literature in the MEDLINE database, using PubMed and OvidSP, Scopus, Google Scholar and Cochrane Databases with the following MeSH terms: (Drain or surgical drain or drainage) AND (drain hernia, drain-site hernia, laparoscopic drain-site hernia)was done. Also, these searches done from 14th-31st Dec 2013 were restricted according to the following MeSH limits: (a) January 1, 1980 to December 14, 2013, (b) English articles (c) Human. RESULTS: Overall, 24 articles had 49 patients with drain site hernias. Of this, 7 (14. 3 %) post open surgery while 42 (85.7 %) post laparoscopic surgery. Seven (14.3 %) occurred immediately after the operation/removal of drain, 10 (20.4 %) several days to 2 week, while 32 (65.3 %) several months to years. Commonest organ of herniation was 13 (26.5 %) small bowel, while morbidities, arising from drain site hernias occurred in 17 (34.7 %) with the highest 7 (14.3 %) due to bowel strangulation. Previous reports have quoted the incidence of drain site hernia to be 3.4% (5 of 148), and 0.14% (8 of 5541). Mortality was extremely low (2.0 %). CONCLUSION: Attention is warranted for drain site hernias as a significant complication following placement of surgical drain. Incidence (0.1-3.4 %), though wide range, is quite significant in these patients. Therefore, unwanted surgical drain insertion should be avoided.

The mobile phone as a tool in improving cancer care in Nigeria.

OBJECTIVE: The use of mobile phone as a tool for improving cancer care in a low resource setting. METHODS: A total of 1176 oncology patients participated in the study. Majority had breast cancer. 58.4% of the patients had no formal education; 10.7 and 9.5% of patients had college or graduate education respectively. Two out of every three patients lived greater than 200 km from hospital or clinic. One half of patients rented a phone to call. RESULTS: At 24 months, 97.6% (1132 patients) had sustained their follow-up appointments as against 19.2% (42 patients) who did not receive the phone intervention. 72.8% (14 102 calls) were to discuss illness/treatment. 14% of the calls were rated as emergency by the oncologist. 86.2% of patients found the use of mobile phone convenient/excellent/cheap. 97.6% found the use of the phone worthwhile and preferred the phone to traveling long distance to hospital/clinic. Also the patients felt that they had not been forgotten by their doctors and were been taken care of outside the hospital/clinic. CONCLUSIONS: Low resource countries faced with the burden of cancer care, poor patient follow-up and poor psychosocial support can cash in on this to overcome the persistent problem of poor communication in their healthcare delivery. The potential is enormous to enhance the use of mobile phones in novel ways: developing helpline numbers that can be called for cancer information from prevention to treatment to palliative care. The ability to reach out by mobile phone to a reliable source for medical information about cancer is something that the international community, having experience with helplines, should undertake with colleagues in Africa, who are experimenting with the mobile phone potential.

Progress in management of typhoid perforation.

Case fatality rate (CFR) for typhoid perforation (TP) has been on gradual but variable decline world wide. This review highlights the progress in management of TP from 1960 including the controversies, current principles of management and the advances associated with the best results of treatment. This is a review of publications on TP from 1960 to 2010 principally from Medline and Ovid databases. Main search terms used are typhoid and perforation. The median CFR by decade was estimated from studies that reported CFR. With advances in surgery and supportive care, median CFR for TP declined from over 50% in 1960 to single digits in the last decade in some countries but with West Africa lagging behind at 16%. Variations in CFR are attributed to differences in perforation-operation interval and quality of care. Opportunities now exist for patients with TP to recover from the disease but priority remains with prevention of enteric fever in endemic areas.

The doctrine of informed consent in surgical practice.

Physicians and other professionals in the field of medicine have to perform invasive and non-invasive procedures on patients as part of their duties. There is a legal basis upon which these procedures are done; this is called 'informed consent.' Sociocultural factors have strong influence on the sick role. These factors influence the application of informed consent in Nigeria.

Use of non-vascularized autologous fibula strut graft in the treatment of segmental bone loss.

BACKGROUND: Fractures resulting in segmental bone loss challenge the orthopedic surgeon. Orthopedic surgeons in developed countries have the option of choosing vascularized bone transfers, bone transport, allogenic bone grafts, bone graft substitutes and several other means to treat such conditions. In developing countries where such facilities or expertise may not be readily available, the surgeon has to rely on other techniques of treatment. Non-vascularized fibula strut graft and cancellous bone grafting provides a reliable means of treating such conditions in developing countries. MATERIALS AND METHODS: Over a period of six years all patients with segmental bone loss either from trauma or oncologic resection were included in the study. Data concerning the type of wound, size of gap and skin loss at tumor or fracture were obtained from clinical examination and radiographs. RESULT: Ten patients satisfied the inclusion criteria for the study. The average length of the fibula strut is 7 cm, the longest being 15 cm and the shortest 3 cm long. The average defect length was 6.5 cm. Five patients had Gustillo III B open tibial fractures. One patient had recurrent giant cell tumor of the distal radius and another had a polyostotic bone cyst of the femur, which was later confirmed to be osteosarcoma. Another had non-union of distal tibial fracture with shortening. One other patient had gunshot injury to the femur and was initially managed by skeletal traction. The tenth patient had a comminuted femoral fracture. All trauma patients had measurement of missing segment, tissue envelope assessment, neurological examination, and debridement under general anesthesia with fracture stabilization with external fixators or casts. Graft incorporation was 80% in all treated patients. CONCLUSION: Autologous free, non-vascularized fibula and cancellous graft is a useful addition to the armamentarium of orthopedic surgeon in developing countries attempting to manage segmental bone loss, whether created by trauma or excision of tumors.

Anatomical subsite and diagnostic implications of colorectal cancer in zaria (Guinea savannah)-1981-2005.

OBJECTIVE: To study the clinicopathological characteristics of Colorectal Cancer (CRC) in the Guinea Savannah region; identify sub site; ascertain any change in the anatomical sub-site between 1981-2005; relate tumour stage/differentiation, to age young =40 years and = 41years old patients Highlight option for diagnosis in the sub region. SETTING: There were 262 patients consisting of 125 retrospective and 137 prospective cases seen in the premier tertiary health institution in Northern Nigeria. RESULTS: The Male:Female ratio = 1.37:1, mean age 39.8 years, cluster age group 3rd-6th decade( 82.1%), patients = 40years constituted 48.2% . Main clinical features present for more than 6 months were bloody mucus discharge (83.5%), palpable rectal mass (67.9%), pain (67%), tenesmus (60.1%). Ignorance of the disease was rife amongst non-specialists, spiritualists and the patients. The left colon was eleven times more commonly affected than the right colon. The rectum was the commonest sub site (74.3%). In 2 out of every 3 patients, the tumour was digitally palpable per rectum. There was no shift in the distribution sub site in (1981-1990), and (1991-2005). 97.2% the tumours were adenocarcinoma. 68.9% patients had advanced disease Duke C or D. 3 out of every 4 patients (= 40 years age group) had advanced disease. Histological prognostic grade of tumour was inversely related to =40 years age group. Routine digital rectal examination as an investigative armamentarium,and public awareness may reduce the prevalence of advanced CRC in the low resource subregion,we advocate their use.

Delayed treatment of symptomatic breast cancer: the experience from Kaduna, Nigeria.

BACKGROUND: A cross-sectional study carried out at a teaching hospital in Kaduna, Nigeria, to investigate the extent and reasons for the delay between onset of symptoms and admission for treatment of symptomatic breast cancer. METHODS: The patients had histologically proven breast cancer and had been admitted for treatment. Data were obtained from interviews and patients' clinical and referral records. RESULTS: One hundred and eleven consecutive breast cancer patients were interviewed from July 2003 to June 2005. Only 12 (10.8%) could be admitted for treatment within a month of onset of symptoms. Delays were significantly associated with younger patients, elementary or no Western education, and domicile outside the Kaduna metropolitan area. Patients who were referred from, or received initial treatment at, peripheral hospitals had longer delays than those who came for first consultation at the teaching hospital. The proportion of early breast cancer cases (stages I and II) decreased from 45.9% at diagnosis to 25.2% at treatment, as concerns about mastectomy and hospital treatment led a significant number of the patients to temporarily abandon hospital treatment for alternatives, only to return with advanced cancers. The predominant reasons among the 99 patients who had delays of more than a month before admission were: ignorance of the seriousness of a painless breast lump (47.5%), non-acceptance of hospital treatment (46.5%), and preference for traditional treatment (38.4%). A significant number of patients referred from peripheral hospitals had inappropriate surgeries and biopsy management which contributed to the advanced stage on admission. CONCLUSION: This study shows that delayed treatment of symptomatic breast cancer at this centre in Nigeria is as much related to the quality of medical care as it is to local beliefs, ignorance of the disease, and lack of acceptance of orthodox treatment.

Stress and distress of surgical practice: the trainee's view.

BACKGROUND: Stress is the body's non specific response to any pleasant or unpleasant demand placed upon it. Is surgical practice a stressful profession? METHOD: It's a prospective study, involving surgical residents in sub specialties of surgery. Information was obtained by administered questionnaire. Resident was expected to have spent three months in the surgical field. RESULTS: There were forty one (41) residents; age range was 25 year to 42 year (mean 33.44 +/- 4.81). There were 35 (85.4%) males and 6 (16.6%) females. Thirty eight, (92.7%) of the residents considered surgery to be a stressful profession. Thirty two, (78.1%) considered pediatrics subspecialty to be the most stressful of all. Lack of professionalism and workload were greatest sources of stress in 18 (43.9%) and 11 (26.8%) cases of the residents. In thirty seven, (90.2%) their academic exposures were not adequate. Despite all these short comings, the progress of the training was satisfactory in 26 (63.4%) residents. Thirty seven, (90.2%) of the residents would not specialize in surgery if given a second chance. CONCLUSION: Surgery, as a stressful profession is no longer a debatable issue and a surgical trainee perceives it that way. We recommend that coping mechanisms such as putting appropriate backup support, offer of flexible scheduling to allow time off for critical family and social events are absolutely necessary among our surgical trainees.

Surgical management of achalasia in Zaria, Northern Nigeria.

BACKGROUND: Achalasia of the cardia is generally considered a rare disease. Because the cause is uncertain, treatment is palliative and directed at relieving distal oesophageal obstruction. In developed countries, several treatment options are available, but in developing countries, achalasia is usually treated by open surgical myotomy. We reviewed the outcome of management of achalasia in our patients and the influencing factors. PATIENTS AND METHODS: We retrospectively reviewed all adult patients treated for achalasia between 1991 and 2006. Diagnosis was based on clinical symptoms and barium swallow examination. The severity and frequency of dysphagia were determined before and after treatment. Barium examination was repeated 2 weeks after surgery or when the patient had recurrence of dysphagia, regurgitation or heartburn. Treatment was by modified Heller's operation, transabdominally without complementary antireflux procedure. Logistic regression modelling was performed to identify factors predictive of poor outcome. RESULTS: There were 47 patients, 31 (66.0%) males and 16 females, mean age (+/- standard deviation (SD) 34.6+/-9.8 years. All patients presented with dysphagia, which was severe in 31 cases (66.0%) and moderate in 14 (29.8%). Preoperative maximum oesophageal diameter ranged from 34 to 89 mm, mean 67.4+/-12.7mm. In 30 (63.8%) of the patients, the maximum diameter was >70 mm. Postoperative maximum diameter ranged from 28 to 72 mm, mean 37.5+/-8.2 mm (p=0.001). The mean preoperative diameter of the narrowest distal oesophagus was 4.6+/-2.5 mm, compared with the postoperative figure of 11.6+/-1.8 mm (p=0.015). Following surgery, 41 (87.2%) patients had complete relief of dysphagia, regurgitation and heartburn. Four patients continued to have heartburn after surgery. Patients with severe dysphagia or preoperative oesophageal dilatation >70 mm had the greatest likelihood of incomplete relief of symptoms after treatment. CONCLUSION: Achalasia can be accurately diagnosed on the basis of clinical symptoms and barium swallow examination. A modified Heller's operation provides lasting relief of symptoms. Patients with severe preoperative dysphagia or oesophageal dilatation are more likely to have poor outcome of treatment.

Management of appendiceal mass.

BACKGROUND: The management of appendiceal mass is surrounded with controversy. Traditional management has been conservative, with interval appendicectomy performed weeks after the mass had resolved. This remains the most common approach at many centers in the world. Recently, an increasing number of studies have challenged this approach. This article reviews some of the controversial issues in the management of appendix mass, assesses current practice and suggests an appropriate approach for the management of appendix mass. METHODS: A Medline, Pubmed and Cochrane database search were used to find such key words and combinations of: appendix, appendiceal, appendicular, interval, appendectomy, appendicectomy, mass, abscess, phlegmon, and appendicitis. Results were saved and managed by Reference manager 11. All articles were cross-referenced by the authors. RESULTS: A conservative management is still a highly acceptable approach for appendix mass. This should be followed with interval appendicectomy especially in patients with persistent right iliac fossa pain. CONCLUSION: We recommend initially conservative approach to the management of appendiceal mass especially in our environment.

Achalasia cardia and gastric outlet stenosis in a postmenopausal woman: case report.

The orderly contractility of the oesophagus and the regulated ability of the pyloric sphincter allow the influx and efflux of gastric contents. When these physiological processes are impaired, gastric luminal transit is altered as expected in achalasia cardia and gastric outlet obstruction. Movement across the inlet and outlet of the stomach is therefore altered. A case of a 58-year old woman diagnosed with simultaneous occurrence of achalasia cardia and gastric outlet stenosis resulting from chronic duodenal ulcer is presented. The diagnosis was based on clinical, radiological and intraoperative findings. This patient has remained well after a simultaneous anterior cardiomyotomy and H-M pyloroplasty. To my knowledge this is the first time that such an association causing gastric "inlet" and "outlet" obstruction has been reported.

Isolated rupture of an accessory liver from blunt abdominal trauma in childhood.

An accessory liver is uncommonly encountered in surgical practice. It can rarely cause acute abdominal pain. An isolated injury to an accessory liver from blunt trauma in a 10-year-old boy caused major intraperitoneal haemorrhage. Laparotomy and excision of the lacerated accessory liver lobe was necessary; the patient recovered uneventfully. The literature on accessory liver is reviewed.

Traditional bone setting: a risk factor in limb amputation.

Over a period of ten years a total of 225 limb amputations were performed at Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. The major pathology leading to amputation was trauma and gangrene due to inappropriate splintage of fractures (63.2%) by traditional bone setters. The male:female ratio was 4.6:1 and the ages ranged from two to 85 years. The commonest level of amputation was above elbow amputation (26.6%) followed by above knee amputation. Most of these amputations are preventable if the traditional bone setters avail themselves for training to recognise the impending features of limb ischaemia as well as the introduction of some refinement into their practice.

Meckel's diverticulum presenting as gastric outlet obstruction: case report.

We report a case of gastric outlet obstruction simulating gastric antral neoplasm resulting from a perforated Meckel's diverticulum. Presentation of this nature has not been previously reported.