CERVICAL LIPOSARCOMA IN A 22 YEAR OLD MAN- AN UNCOMMON PRESENTATION.

Liposarcomas are uncommon malignant growths, most of which occur in the retroperitoneum and lower extremities. Liposarcoma arising in the head and neck is an uncommon and a potentially life threatening malignancy. We present a 22 year-old male with a dedifferentiated cervical liposarcoma, who had local excision, with no recurrence at twenty months of follow-up. This patient has drawn our attention to the fact that although liposarcomas are rare in the neck and commonly occur in patients between 40 and 60 years, any neck swelling in the young with atypical features should raise suspicion as to the possibility of malignancy.

FACTORS DETERMINING THE RESULTS OF THE EXAMINATION OF THE WEST AFRICAN COLLEGE OF SURGEONS IN GENERAL SURGERY.

BACKGROUND: The general surgery results of the West African College of Surgeons (WACS) post-graduate fellowship examination could not be regarded as satisfactory when compared with the results of similar post-graduate examinations in some developed countries. For example the pass rate of the West African College of Surgeons examination was usually under 40% whereas the pass rate in oral examination in a similar post-graduate examination, the American Board of Surgery was 84% in 2006, 73% in 2012. The first time pass rate in general surgery of final year general surgery residents at the American Board of Surgery qualifying and certifying examinations were 74% - 78% between 2000 and 2007. AIM & OBJECTIVES: To identify the factors responsible for the high failure rate at the general surgery fellowship examinations of the West African College of Surgeons. STUDY DESIGN: Descriptive study .We studied and analyzed the West African College of Surgeons examination results for April 2012, October 2012, April 2013 and October 2013 with emphasis on the results, the conduct of the examination and the opinion from fellows about the examiners. Well structured questionnaires were sent to fellows who had passed all the various fellowship examinations of the West African College of Surgeons in general surgery to indicate their opinion about the examination, and the examiners. SETTING: University College Hospital, Ibadan, and Jos University Teaching Hospital, Jos, Nigeria. METHODOLOGY: The first part of the study dealt with an analysis of each section of the examination prospectively studied over a 2-year period. This consisted of four sets of examination results. The second part was a questionnaire-based study administered to Fellows who had passed the WACS final fellowship examination in general surgery. The questionnaire had three sections: primary, part 1 and part 2 and included basic demographics, date at attempts in each grade of the examinations and the outcome. It also included the views of the respondents on the conduct of the examination and outcome. The data were analyzed using Microsoft Excel. RESULTS: A total of 720 candidates with age range of 28 - 39 years and a mean of 33.2 years sat for the Part 1 Fellowship examinations in 2012 and 2013 with an average of 180 candidate per examination. At the Part 2 fellowship examination, 84 candidates with the age range of 31 - 42 year and a mean of 36.5 years sat the Part 2 Fellowship examination with an average of 21 candidates for each Part 2 examination in general surgery during the same period. The examinations held in April and October of each year. While an average of 28.8% of the candidates passed, an average of 71.2% of the candidates failed the Part 1 Fellowship examinations in 2012 and 2013. The aggregate clinical score was responsible for failure in 59.5% of the candidates. In the Part 2 Fellowship examination in general surgery during the same period, 31.5% of the candidates passed while an average of 68.5% of the candidates failed per examination. The aggregate clinical score was responsible for 53.3% of the candidates who failed the Part 2 examination. Furthermore, 60 - 69.7% of the candidates had a favourable opinion about the conduct of the examination, 54.5 - 63.6% rated the professionalism of the examiners high, even though the pass rate at the first attempts of the various grades of the examination by the respondents was about 50 percent. CONCLUSION: The clinical part of the examination is a major factor responsible for the high failure rate in the general surgery fellowship examinations of the West African College of Surgeons. In order to mitigate this, residents in training should be exposed to the clinical management of a wide range of cases in the discipline with majority of the operations performed by them under the direct supervision of their consultants.

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.

The evolution of surgical procedures in the management of duodenal and gastric ulcers.

Surgical procedures for the surgical management of duodenal ulcer had evolved through many stages, over the years. It started with gastroenterostomy alone, then followed by subtotal gastrectomy, vagotomy alone, vagotomy and gastro-jejunostomy, vagotomy and pyloroplasty, and highly selective vagotomy - all which started as open surgical procedures. Now unless there are complications the treatment is essentially medical following the work of Marshall and Warren. Currently, even when surgery is indicated, minimal invasive procedures are preferred. Four main types of pyloroplasties are well known. They are Weinberg, Heinecke-Mikulicz, Finney and Jaboulay. Vagotomy can be truncal, selective, and highly selective. Accepted surgical treatment for gastric ulcer is the distal gastric resection to include the ulcerated area, but not resecting more than 50-60% of the stomach. In the uncommon cases of Zollinger-Ellison syndrome, aggressive gastric surgery, the use of drugs, and the resection of the tumour have all been recommended in appropriate cases. With the discovery of Helicobacter pylori and its effective medical treatment, surgery has little role in the initial management of peptic ulcer disease. The place of the history of the surgical procedures employed earlier in the treatment of this disease would remain relevant.

What should constitute the clinical component in fellowship examinations in surgery.

The consensus of opinion is that in all medical examinations, a failure in the clinical aspect of the examination automatically means a failure in the whole examination regardless of what the total score may be. But opinion differs as to what constitutes the "clinical aspect" of the examination. Some think it should be the average score of only long case and short cases. Others think it should be the total score of long case, short cases and viva voce. Yet others think when the orals are of two parts it should be the average score of long case, short cases and a part of the orals. We therefore used the result of 197 surgical residents that sat for the part 1 fellowship examination of the West African College of Surgeons in April 2012 for this study. We collated the scores of various categories of clinical aspect of the examination to see whether there is any difference in the pass rate of the group.

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.

Thyroidectomy under local anaesthesia: how safe?

BACKGROUND: In order to compliment the inadequate health facilities in the rural areas in Nigeria, nongovernmental organisations provide adhoc outreach health camps that offer treatment in various medical specialties including surgery. SETTING: Rural outreach health camps. OBJECTIVE: To evaluate the safety of thyroidectomy under local anaesthesia at rural outreach setting with inadequate facilities for general anaesthesia. PATIENTS AND METHODS: This was a prospective descriptive study of 33 consecutive cases of thyroidectomy performed using field block with 1% lignocaine and adrenaline 1: 200,000 dilution during two free medical outreaches that held at Jos, Nigeria in March and October 2005 respectively, lasting two weeks each. RESULTS: A total of 33 primary thyroid operations were performed consisting of 30 subtotal thyroidectomies (91%), 2 lobectomies (6%) and one total thyroidectomy (3%), The patients were aged between 23 and 62 years with a mean age of 45.8 years. There were 3 males and 30 females with a male: female ratio of 1:10. There was no mortality but morbidity was 2/33 (6%) Two complications were recorded in 2 patients and were superficial surgical site infection (3%) and reactionary haemorrhage (3%). CONCLUSION: We conclude that thyroidectomy under local anaesthesia is a safe procedure in experienced hands at rural settings with inadequate facilities for general anaesthesia.

Clinicopathological features and molecular markers of breast cancer in Jos, Nigeria.

BACKGROUND: Several studies have suggested that breast cancer in black women is associated with aggressive features and poor survival. This study examines molecular markers along with clinical stage and pathological grade in breast cancer material from Jos, Nigeria. STUDY DESIGN: The histological diagnoses of 178 consecutive Nigerian patients with breast cancer were retrieved from their hospital records. A subset of 36 patients was staged and their tumours typed and graded. Immunohistochemical staining of sections from paraffin wax embedded tissues from these cases for the expression of oestrogen receptor (ER), progesterone receptor (PGR), Human ERBB2 (or HER2/neu), p53 and cyclin D1 (CCND1) was carried out using the avidin biotin complex (ABC) procedure. RESULTS: A majority of the cases were invasive ductal carcinoma (92.7%), high grade (grade 3, 70.6%) and of late clinical stage (stages III and IV, 58.3%). Only 25% and 27.8% of cases expressed ER and PGR respectively. The ERBB2 and CCND1 antigens were expressed in 25%, and 5.7% of cases respectively. The p53 protein was the most frequently expressed in this study (47.2% of cases). High grade tumours were significantly more likely to be ER and PGR negative (P = 0.006 and P = 0.002 respectively). CONLCLUSION: There is predominance of high grade, invasive ductal carcinomas which are likely to be ER and PGR negative but p53 positive. These features suggest a biologically aggressive form of breast cancer in Nigerian women with the possibility of poor response to both hormonal therapy and chemotherapy.

Typhoid intestinal perforation in north central Nigeria.

BACKGROUND: Typhoid intestinal perforation is a surgical problem with severe morbidity and high mortality in North Central Nigeria. PATIENTS AND METHODS: In order to determine the pattern and the prognostic indices, we studied 101 patients with typhoid intestinal perforation managed over a ten-year period RESULTS: Children constituted 49% of the cases and majority (78%) of the patients were in the low socio-economic strata. The incidence peaked to 67% between November and March - the dry season in Nigeria. The male/female ratio was 1.9:1 with a mean age of 19 years and a mean hospitalization period of 18 days. There were 167 perforations; four involved the large bowel and appendix, and in 72.2% cases, the perforation was single. The mortality rate was 13.9%, affected mostly children and significantly worsened by prolonged perforation-surgery interval > 72 hours, jaundice, convulsion, ASA V, faecal peritonitis and re-exploration for early intra-peritoneal complications. Morbidity rate was 65.3% and significantly affected more children than adults and associated with perforation-surgery interval of between 24 and 72 hours, haematochezia and multiple perforations. Moribund patients fared better when operated upon under local anaesthesia with adequate analgesia. The least traumatic but effective surgical procedure that could seal the perforations and keep the peritoneum clean gave the best results. Children who survived up to 5 days and adults who survived up to 10 days after surgery had better chances of survival. CONCLUSION: The most significant prognostic factor is late presentation which prolongs perforation-surgery interval and the other complication and mortality indices are directly influenced by it.

Male breast malignancy in Jos University Teaching Hospital.

BACKGROUND: Male breast malignancies are rare. Cancer of the male breast accounts for about 1% of all breast cancers. Poor level of awareness often results in late presentation and delayed diagnosis in our environment. PATIENTS AND METHODS: A retrospective study of all cases of male breast cancer (MBC) managed in Jos University Teaching Hospital over a 17-year period (January 1987-December 2003.) RESULTS: A total of 302 cases of breast malignancies were managed over the study period. Twenty-six (8.6%) of these were males giving a male:female ratio of 1:10.6. The ages of the 26 MBC cases ranged from 12 years to 85 years, with a mean of 57.9 years and median age of 67 years. The right breast was affected in 15 and the left in 11. Mean duration of symptoms before presentation was 6 months with a range of 3 months to 4 years. All the patients had history of breast lumps, 21 (80.8%) of which were painless. Skin ulceration and axillary node enlargement were present in 19(73.1%) and 24(92.3%) respectively. Five (19.2%) were stage II; 15(57.7%) stage III and 6(23.1%) stage IV. There were 23 (88.5%) carcinomas, 2 (7.7%) fibrosarcomas and a case of Hodgkin's lymphoma. Invasive ductal carcinoma was the most common histological type in 20 (76.9%) of all breast malignancy and 20 (87.0%) of all breast carcinomas. Modified radical mastectomy (mastectomy with axillary clearance with or without division of the pectoralis minor muscle) was done in 10(38.5%) patients. Two of these were fibrosarcomas. Simple mastectomy was done in 13 (50%) as toilet procedures for advanced disease. The only case of Hodgkin's lymphoma had chemotherapy. Bilateral orchidectomy (BO), Tamoxifen, chemotherapy and radiotherapy were offered in 7(26.9%), 13(50%), 17(65.4%) and 7(26.9%) patients respectively. Wound infection was the most common complication in 14(53.8%) patients. There was no case of hospital mortality. CONCLUSION: MBC accounts for 8.6% of all breast cancers in our centre. It affects elderly males. Late presentation with advanced disease and ulceration is a common feature in our environment.

Testicular torsion on the Jos Plateau.

In order to determine the pattern and the factors that influenced outcome, we retrospectively studied fifty-seven patients with torsion of the testis admitted to the Jos University Teaching hospital between August 1993 and July 2001. The age ranged from 2 to 55 years with a mean of 22.7 years. Majority (79%) of the patients were in the second and third decades of life. The main suspected precipitating factors in this study were cold weather and scrotal trauma: in 28% of the cases no cause could be ascertained. Eight (14%) patients presented within 4 hours and 35 (61%) presented after 24 hours of the onset of symptoms. Both sides were equally affected. Testicular pain, retraction and scrotal swelling were the most common presenting complaints. The highest incidence 65%) occurred between November and February when the weather on the Jos plateau is coldest. At surgery, 34 (60%) patients were found to have associated congenital anomalies; in 22 (39%) patients, the testis was non-viable. There was no mortality in this series and the complications were superficial wound infection (14%), testicular atrophy (7%) and sub-fertility (16%). High index of suspicion in a patient with acute scrotum, prompt and effective surgery will improve testicular salvage.

Acalculous cholecystitis in Nigerian children.

Sixteen children with acalculous cholecystitis (AC) were treated over a 9-year period (13 male and 3 female). Their ages ranged from 8 to 18 years (median 11). Eight (50%) presented with complications (perforation 4, gangrene 2, empyema 2); 13 (80%) presented with acute AC with a duration of symptoms of 2 weeks or less while 3 (20%) presented with chronic AC with symptoms present for more than 3 months. The diagnosis was made by ultrasound except in the patients with complications, who were diagnosed at laparotomy. Salmonella typhi was cultured in the bile and blood in 2 cases and the Widal titre was significantly elevated in 4 others. One child had chronic blockage of the cystic duct by a lymph node; in 9 there was no identifiable cause. Open cholecystectomy was successfully performed in 15 cases, while 1 child was managed non-operatively. The need for early diagnosis of cholecystitis in children is obvious if the potentially life-threatening complications of perforation and gangrene are to be avoided.

Adult intussusception: the Jos experience.

Twenty two consecutive cases of adult intussusception managed between January 1990 and December 1998 at Jos University Teaching Hospital formed the basis of this study. Thirteen (59.1%) of the patients were males and 9(40.9%) females, with a male to female ratio of 1:4:1 and a mean age of 49.6 years. Most patients were referred late to our service as a result of poor index of suspicion and misdiagnosis. Laparotomy was done in all the cases and in 5(22.7%) patients no cause could be found, but in the remaining 17(77.3%) definite causes were identified which were mainly polyps in 7(31.8%) patients and colonic malignancies in 4(18%). The ileocolic intussusception was the commonest variety. Sixteen (72.7%) patients had bowel resection for colonic carcinoma, gangrenous bowel and irreducibility of the intussusception while manual reduction was successful in the other 6(27.3%) patients. The morbidity rate was 22.7% and the complications were wound infection and adhesive intestinal obstruction. Two deaths were recorded with a mortality rate of 9.1%. The pattern of adult intussusception as seen in the western world was observed in this tropical highland.

Childhood intussusception: a 9-year review.

Sixty-four consecutive cases of intussusception in 48 infants and 16 older children managed at Jos University Teaching Hospital between January 1990 and December 1998 are reviewed. The age range was between 3 months and 15 years (mean 2.2 years) and the male to female ratio was 3.6:1. The quartet of abdominal pain, bloody mucoid stools, abdominal mass and palpable rectal mass was present in 70% compared with the classical triad (abdominal pain, bloody mucoid stools and abdominal mass) which occurred in only 32%. All the children had surgery. In 26 (41%) of the children, no associated cause was found, in three polyps formed the lead point and in five children a buried appendicectomy stump formed the lead point. In 30 (47%) other children, mesenteric lymphadenopathy and inflamed Peyer's patches were noted. Ileo-colic intussusception occurred in 32 (50%) children. Manual reduction was successful in 67%. Bowel resection for gangrene, irreducibility and an iatrogenic colonic tear was done in 30% of patients. Two (3%) had spontaneous reductions. There were four deaths. The commonest complications were wound infection and adhesive intestinal obstruction.

Chronic osteomyelitis in patients with sickle cell disease.

OBJECTIVE: To determine the baseline pattern and audit management modalities of chronic osteomyelitis in patients with sickle cell disease. DESIGN: A retrospective study. SETTING: Jos University Teaching Hospital, Jos, Nigeria from August 1993 to July 1997. PATIENTS: Twenty four patients with concomitant chronic sickle cell disease. INTERVENTIONS: Fifteen patients had operations; eleven had sequestrectomy and curettage while four had incision and drainage. Eight patients were treated with antibiotics alone and one patient refused surgery. MAIN OUTCOME MEASURES: The demographic data of patients, aetiological agents, culture and sensitivity patterns, aetiopathogenesis, treatment modalities and outcome were analysed. RESULTS: Twenty four (36.9%) out of 65 patients who had chronic osteomyelitis also had sickle cell disease. Male:female ratio was 1.2:1. The peak age incidence (37.5%) was in the first decade of life. Seventy five per cent of infections were haematogenous. The most frequently isolated organism was Staphylococcus aureus (58.8%) while the rest were Gram negative organisms. There was no case of Salmonella osteomyelitis. The most sensitive antibiotics were gentamicin and the third generation cephalosporins. Twelve patients (50%) had good results while eight (33.3%) were still undergoing treatment. Complications recorded were persistent discharging sinuses in two cases, recurrence of symptoms in one and pathological fracture with non-union in one patient. CONCLUSION: Though the incidence of Gram negative organisms in causation of chronic osteomyelitis in patients who have sickle cell disease is high (41.2%), Salmonella osteomyelitis may be related to endemicity of the organism in a given locality.

Intra-operative cardiac arrest--a tropical experience.

In order to determine the pattern of intra-operative cardiac arrests in a developing country, we reviewed 40 consecutives cases of cardiac arrests at the Jos University Teaching Hospital between January 1993 and December 1997. During this period 15,060 minor cases and 9800 medium/major surgical procedures were performed and an arrest rate of 1:15,060 for minor cases and 1:251 for medium/major cases were obtained. The age ranged between one day and 65 years with a mean of 29.8 years and a male/female ratio of 1:1.3 as there were 18 males and 22 females. Twenty-five (62.5%) arrests occurred outside work hours while fifteen (37.5%) cases arrested during work hours. The surgical procedures with high arrest rates in this study were: emergency laparotomy 8 (20%), emergency caesarian sections 7 (17.5%), thoracotomy 6(15%), emergency craniotomy 5(12.5%), emergency hysterectomy 4(10%) and therapeutic bronchoscopy for foreign bodies in the airway 4(10%). The arrests occurred in 30(75%) emergency procedures as opposed to 10(25%) elective cases. Only in 3 out of the 18, 318 day case procedures did the patients arrest. One patient arrested during local infiltration of lignocaine while the other 39(97.5%) arrested under general anaesthesia. There was no arrest with spinal anaesthesia. The predisposing factors for a patient to arrest on the operating table in our environment include emergency major surgery, poor risk patients with ASA 111 and above, surgery performed outside work hours, under general anaesthesia administered by nurse anaesthetists or junior anaesthetic residents. The success rate at resuscitation is highest with patients with ASA 1 & 11, operations performed during work hours and by senior surgeons and anaesthetists.

Cordylobia anthropophaga mastitis mimicking breast cancer: case report.

A case of furuncular myiasis of the breast due to infestation by the larva of Cordylobia anthropophaga in a young lady is presented. Some of the physical presentations of Cordylobia anthropophaga mastitis are similar to those of carcinoma of the breast. High index of suspicion in endemic areas, including patients who had visited such areas, the characteristic intense itching of the affected breast, the use of the magnifying hand lens and subsequent extraction of the offending maggots are the invaluable aids to diagnosis and treatment. The ulcer left on the breast after extraction of the maggot should be biopsied and the associated ill defined mass and skin changes must be seen to resolve completely before carcinoma of the breast can be safely ruled out. The various methods of extraction and the preventive measures are highlighted. Though furuncular myiasis has been reported to involve every part of domestic animals, this is the first reported case in literature involving the human breast.

Comparative study of conservative resection and radical operation for thyroid carcinomas.

OBJECTIVE: To compare mortality and morbidity in management of thyroid cancers by total lobectomy (C-R) and near-total thyroidectomy (R-O) and to relate pathological subtype to prognosis. DESIGN: A retrospective study of patients with thyroid cancers that were managed during an eleven-year period. SETTING: Jos University Teaching Hospital, Nigeria. SUBJECTS: A total of 44 patients who underwent C-R (n = 26) and R-O (n = 18) were studied. INTERVENTION: A total of 509 goitrous specimens including the excised thyroid cancers were histopathologically studied. MAIN OUTCOME MEASURES: Cases were analysed for mortality and morbidity data in the two groups during a partial follow-up period of two years. RESULTS: Mortality figures for C-R was 4% versus 11 for R-O. Postoperative haemorrhage occurred in 14% for C-R versus six for R-O. Similarly, bilateral vocal cord paralysis occurred in 11% versus 22; voice changes in 11% versus 33, transitory hypoparathyroidism 8% versus 50, local recurrence in 18% versus eleven. Hypothyroidism occurred in all patients undergoing R-O and stitch granuloma in 11% of patients in C-R group versus six for R-O. Follicular carcinoma constituted 59% of the total number thyroid cancers with papillary cancer constituting 35%. CONCLUSION: C-R is recommended as the operation of choice for thyroid cancers.