Daytime Versus Night-Time Emergency Abdominal Operations: Perspective from a Low-Middle-Income Country.

BACKGROUND: Emergency abdominal operations carry significant risk of mortality and morbidity. The time of the day when such operations are performed has been suggested as a predictor of outcome. A retrospective comparison of outcomes of daytime and night-time emergency abdominal operations was conducted. METHODS: Clinical data of patients who had abdominal operations over a five-year period were obtained. Operations were classified as 'daytime' (group A) if performed between 8.00 am and 7.59 pm or 'night time' if performed between 8.00 pm and 7.59 am (group B). Post-operative outcomes were compared. RESULTS: A total of 267 emergency abdominal operations were analysed: 161 (60.3%) were performed in the daytime while 106 (39.7%) were performed at night. The case mix in both groups was similar with appendectomies, bowel resections and closure of bowel perforations accounting for the majority. Baseline characteristics and intra-operative parameters were similar except that 'daytime' operations had more consultant participation (p = 0.01). Mortality rates (13.7% in group A and 12.3% in group B, p = 0.2), re-operation rates (9.3% in group A and 10.4% in group B, p = 0.7) and duration of hospital stay (group A-11.1 days, group B-12.4 days p = 0.4) were similar. ASA status, re-operation and admission into the intensive care unit were identified as predictors of mortality. CONCLUSION: Timing of emergency abdominal operations did not influence outcomes. In resource-limited settings where access to the operating room is competitive, delaying operations till daytime may be counterproductive. Patients' clinical condition still remains the most important parameter guiding time of operation.

Pattern and outcome of traumatic gastro- intestinal injuries in ile-ife.

AIMS AND OBJECTIVES: Trauma continues to assume a prominent role in the cause of disease in the developing world with increased westernization. This study highlights the pattern, management and outcome of gastrointestinal injuries following abdominal trauma in our hospital. PATIENTS AND METHODS: A descriptive retrospective study of all patients who had laparotomy following abdominal trauma at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife between January 2008 and April 2013. RESULTS: A total of 120 patients had laparotomy following abdominal trauma. Forty- five patients comprising 41 males and 4 females whose ages ranged between 14 and 65 years had gastrointestinal injuries. Majority (68.9%) were in the third and fourth decades with penetrating injury occurring in 55.6% .Causes of injury included gunshots (44.4%), road traffic accidents (37.8%), stabs (8.9%), falls (6.7%) and impalement (2.2%). The small intestine was the commonest site of injury (57.8 %) irrespective of the mechanism. Gut perforations accounted for 71.1% of all injuries. Two-thirds of patients had other associated injuries with retroperitoneal trauma being the commonest associated intra-abdominal injury. Majority (44.4%) had bowel resection and anastomosis with surgical site infection recorded in 35.6%. Overall mortality was 6.7% and this was significantly associated with pre-operative blood transfusion (p<0.05). CONCLUSION: Gut perforations from gunshot especially of the small intestine are the commonest gastro-intestinal injury in our setting. Pre-operative blood transfusion, perhaps indicating severity of injury, implies poor prognosis.

Selenium levels in neoplastic breast lesions.

AIMS AND OBJECTIVES: The aim of this prospective case controlled study was to evaluate the tissue levels of selenium in patients with cases of fibroadenoma, cancer of the breast and in the controls in order to relate them to the occurrence of breast diseases. SUBJECTS AND METHODS: Consecutive consenting patients who had histologically confirmed breast cancer and fibroadenoma attending the General surgical outpatients departments of Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, were recruited for the study. One gram of core disease breast tissues was taken for Selenium level estimation. RESULTS: There were 127 female subjects;. 95 (74.8%) cases of fibroadenoma and 32 (25.2%) of breast cancer. While breast cancer was common on the left, fibroadenoma was more common on the right breast (? = 8.994; p=0.011). The median tissue level of selenium in patients with fibroadenoma was 0.0272 mg/g with a range of 0.0124 to 0.0576 mg/g and that of the cancer patients was 0.0178 mg/g with a range 0.0072 to 0.0436 mg/g. These were statistically significantly different ( p=0.001). Factors affecting tissue selenium level include age (p<0.001), overall stage of breast cancer (p<0.001), maximum length of breast mass (p=0.023), previous delivery (p=0.004), age at last confinement (p=0.007), parity (p<0.001), oestrogen receptor (ER) status (p<0.001) and progesterone receptor (PR) status (p=0.021). CONCLUSION: Tissue selenium was lower in breast cancer than in fibroadenoma; Tissue selenium inhibits carcinogenesis; low tissue level of selenium therefore may be a factor in the development of breast cancer.

An audit of laparoscopic surgeries in Ile-Ife, Nigeria.

BACKGROUND: After several years of lagging behind due to several constraints, many general surgeons across Nigeria are now performing laparoscopic surgery. An audit of the procedure in our setting is required. OBJECTIVE: To describe the outcome of consecutive laparoscopic general surgical procedures performed at the Obafemi Awolowo University Teaching Hospital, South-western Nigeria. METHODS: All patients with general surgical conditions who had laparoscopic surgery from January 2009 through May 2010 in our hospital were prospectively studied and type of pre, intra and postoperative data including sex, age, indication for surgery, and outcome of the procedure were obtained and analysed. RESULTS: Sixty-two patients (ages 18 to 72 years) had laparoscopic surgeries within the study period. Eighteen (29%) patients had laparoscopic cholecystectomy, 13 (21%) had laparoscopic appendicectomy, 10 (16.1%) had laparoscopic adhesiolysis, 7 (11.3%) laparoscopic biopsies of intraabdominal masses while 14(22.6%) others had diagnostic laparoscopies for a range of suspected abdominal conditions. All diagnostic procedures were performed as day cases while the duration of hospital stay was one to two days for the therapeutic procedures. Two(3%) procedures, including a biopsy of hepatic mass and a cholecystectomy were converted to open surgery due to significant haemorrhage. A minor bile duct injury was recorded in one patient who had cholecystectomy and superficial port site wound infections were noticed in two patients who had appendectomy. No mortality was recorded. CONCLUSION: Our results show the feasibility of laparoscopic surgery in Nigeria. We advocate local adaptation and improvisations to increase the use of laparoscopic surgery in Nigerian hospitals.

Management of mass casualty: a review.

AIMS AND OBJECTIVES: The aim of this article is to discuss the management of mass casualty and sensitise authorities at various levels and trauma surgeons the need for awareness and training in the management of mass casualty. MATERIALS AND METHODS: Thorough Medline and bibliography search and available local literatures relevant to the management of mass casualty was reviewed. The available articles were reviewed in order to decipher the management pattern in various forms and degree of disasters resulting in mass casualty. RESULTS: Little attention was paid to mass casualty management in civilian population until mid nineties, even, in developed countries. Knowledge in this area has expanded in the last 10 years due to terrorist attacks in the United State America. In developing countries, nothing is known to be on the ground in form of planning for appropriate response to mass casualty. CONCLUSION: Mass casualty usually associated with straining of existing facilities, and with high morbidity and mortality. Pre-incident and adequate training is necessary to reduce morbidity and mortality from major incident which occurrence is often not predictable.

Short hospital stay after appendicectomy.

AIMS AND OBJECTIVES: To determine the applicability of short hospital stay after appendicectomy in rural and semi-urban Nigerian community. PATIENTS AND METHODS: A 30-month prospective study on patients with uncomplicated acute appendicitis was carried out The age ranged from 5-70 years, mean of 28.7 years, there was almost even sex distribution between male and female. All the patients presented with clinical evidences of acute appendicitis. RESULTS: The operative findings were inflamed and oedematous appendix in about 80%, minimal exudates drained in only about 25% of the patients. Postoperative wound complications occurred in 1.3-5% of patients. All the postoperative complications were successfully managed in the outpatient clinic. 71.8% were discharged on the 2nd postoperative day, 20.5% on 3rd postoperative day, 4 (5%) on 4th postoperative day and 1(1.3%) each on 5th and 7th day. There was postoperative pain tolerance and late mobilisation in those who stayed for 3-4 days; moderately severe wound infection was responsible for those who stayed for 5th- 7th day. CONCLUSION: Short hospital stay after appendicectomy was possible in majority of patients with uncomplicated acute appendicitis. Minimal postoperative fluid therapy and antibiotic administration was adequate in well-selected cases.

Determinants of splenectomy in splenic injuries following blunt abdominal trauma.

INTRODUCTION: The management of splenic injuries has shifted from splenectomy to splenic preservation owing to the risk of overwhelming post-splenectomy infection (OPSI). This study aimed to identify the factors that determine splenectomy in patients with isolated splenic injuries, with a view to increasing the rate of splenic preservation. PATIENTS AND METHODS: Files of 55 patients managed for isolated splenic injuries from blunt abdominal trauma between 1998 and 2007 were retrospectively analysed using a pro forma. Management options were classified into nonoperative, operative salvage and splenectomy. RESULTS: The majority of patients suffered splenic injury as a result of motor vehicle accident (MVA) trauma or falls. Splenectomy was undertaken in 33 (60%) patients, 12 (22%) had non-operative management, and operative salvage was achieved in 10 (18%) patients. Significant determinants of splenectomy were grade of splenic injury, hierarchy of the surgeon, and hierarchy of the assistant. DISCUSSION: MVA injury and falls accounted for the vast majority of blunt abdominal trauma in this study. The rate and magnitude of energy transferred versus splenic protective mechanisms at the time of blunt abdominal trauma seems to determine the grade of splenic injury. Interest in splenic salvage surgery, availability of technology that enables splenic salvage surgery, and the experience of the surgeon and assistant appear to determine the surgical management. CONCLUSION: Legislation on vehicle safety and good parental control may reduce the severity of splenic injury in blunt abdominal trauma. When surgery is indicated, salvage surgery should be considered in intermediate isolated splenic injury to reduce the incidence of OPSI.

Relations of the neck of groin hernias to pubic tubercle.

OBJECTIVE: The traditional anatomical and surgical teaching is that any hernia with the neck above and medial to the pubic tubercle are inguinal. Present day surgical authors and teachers mostly adhere to this teaching but observe a difference in this relationship in clinical demonstrations. This confuses most medical students and surgical residents. This all-important clinical teaching should hence be revisited. Hence this study was to ascertain and validate clinically the true relationship of pubic tubercle and the neck of groins hernia. DESIGN: Aprospective observational study. SETTING: Surgical Outpatient Clinic of Wesley Guild Hospital, Ilesa Unit of the Obafemi Awolowo University Teaching Hospital Complex, Nigeria. SUBJECTS AND MEASUREMENTS: Consecutive patients seen in the clinic with uncomplicated groin hernias were studied from January 1993 to December 2004. Examinations were done to ascertain the relationship of the groin hernias to the pubic tubercle. RESULTS: 96.8% of inguinal hernias have their necks above and lateral to pubic tubercle while all femoral hernia had their necks below and lateral to the pubic tubercle. CONCLUSION: Location above or below the pubic tubercle should be used as the sole difference between femoral and inguinal hernias in clinical demonstrations. More observations and inguinal dissections will be necessary for further clarification.

Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) Study: a WSES observational study.

Background: Timing and adequacy of peritoneal source control are the most important pillars in the management of patients with acute peritonitis. Therefore, early prognostic evaluation of acute peritonitis is paramount to assess the severity and establish a prompt and appropriate treatment. The objectives of this study were to identify clinical and laboratory predictors for in-hospital mortality in patients with acute peritonitis and to develop a warning score system, based on easily recognizable and assessable variables, globally accepted. Methods: This worldwide multicentre observational study included 153 surgical departments across 56 countries over a 4-month study period between February 1, 2018, and May 31, 2018. Results: A total of 3137 patients were included, with 1815 (57.9%) men and 1322 (42.1%) women, with a median age of 47 years (interquartile range [IQR] 28-66). The overall in-hospital mortality rate was 8.9%, with a median length of stay of 6 days (IQR 4-10). Using multivariable logistic regression, independent variables associated with in-hospital mortality were identified: age > 80 years, malignancy, severe cardiovascular disease, severe chronic kidney disease, respiratory rate ≥ 22 breaths/min, systolic blood pressure < 100 mmHg, AVPU responsiveness scale (voice and unresponsive), blood oxygen saturation level (SpO2) < 90% in air, platelet count < 50,000 cells/mm3, and lactate > 4 mmol/l. These variables were used to create the PIPAS Severity Score, a bedside early warning score for patients with acute peritonitis. The overall mortality was 2.9% for patients who had scores of 0-1, 22.7% for those who had scores of 2-3, 46.8% for those who had scores of 4-5, and 86.7% for those who have scores of 7-8. Conclusions: The simple PIPAS Severity Score can be used on a global level and can help clinicians to identify patients at high risk for treatment failure and mortality.

Abdominal tuberculosis in a Nigerian teaching hospital.

Abdominal tuberculosis (TB) alone or with disseminated TB is known to mimic other conditions with non-specific investigation findings. This study aims to evaluate the clinical presentations and investigation findings of patients in our setting. The clinical records of 47 patients diagnosed as abdominal TB between January 1986 and December 2005 at the Wesley Guild Hospital Unit of the Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria, were reviewed. Fifty-five percent of the patients were women and mean age was 28 years. Common presenting symptoms and signs were abdominal pain 76.6%; ascites 59.6%; weight loss 53.2%; fever 29.8%. Average duration of symptoms before presentation was 3 months. Thirteen percent of patients had earlier been treated for pulmonary tuberculosis in the hospital. ESR was elevated in 89%, ultrasound scans of abdomen were abnormal in 68%, showing ascites, hepatomegaly and or enlarged nodes. Mantoux test was positive in 33% and ascitic fluid was diagnostic for TB in 29%. Chest X-ray showed abnormal findings in 25% of the patients and sputum was positive for AFB in 14.3%. Three patients were HIV positive. Forty patients (85.1%) recovered after receiving anti-TB drugs for a period of 9-12 months. Seven patients, including the three with HIV infection died. Death of 2 patients was due to unrelated causes. We conclude that abdominal TB should be suspected in patients with chronic abdominal condition and ascites as no laboratory or radiological finding is gold standard in its diagnosis. However the condition carries good prognosis if promptly diagnosed and treated.

The severity, outcome and challenges of breast cancer in Nigeria.

Breast cancer is a very common disease in Nigeria. It is often associated with a poor prognosis for a variety of reasons. This study was designed to investigate the challenges, severity, outcome and factors influencing the outcome of the management of breast cancer in a Nigerian Teaching Hospital with a view to finding ways to improve the current dismal outlook for patients with the disease. The clinical records of patients seen with breast cancer over an 8-year period (1996-2003) in the two units of the Teaching hospital were reviewed. The two units serve the urban, semi-urban and rural communities of some parts of southwestern Nigeria. Two hundred and twelve patients with breast cancer were seen over the 8-year period of the study. The mean age was 48 years (23-85 years). There were 211 female and one male. One hundred and three patients (48.7%) had either postprimary or tertiary education. A proportion of 66.7% were premenopausal, 79.2% had pregnancy early in life and were multi-parous. These also gave a history of prolonged breast-feeding of their children. The tumour was self-detected in 195 (92%). The mean duration of symptoms was 11.2 months (9 days-7 years). Pain in 100 patients (47%) was the most common symptom and the cancer was in the left breast in 113 (53.3%). Localized cancer was in the upper outer quadrant in 85 (40%), whereas the whole breast was involved in 55 patients (26%). Loco-regional features of advanced cancer were seen in 157 patients (74%). The tumour was fungating in 83 (39%) and there was clinical evidence of systemic metastasis in 28 patients (13%). One hundred and seventy-four (80.6%) patients had advanced disease (stages 3 and 4). Definitive surgery was possible in 185 patients (87.3%), neoadjuvant chemotherapy was required in 65 (30.6%), postoperative adjuvant chemotherapy in 178 (84%; drug combinations were CMF-cyclophosphamide, methotrexate, 5-fluorouracil, CMFP-CMF plus prednisone, and CAF-cyclophosphamide, adriamycin, 5-fluorouracil), tamoxifen was administered in all the patients. Only 70 (33.2%) patients were known to have received radiotherapy among those referred to the Radiotherapy unit, with associated fair treatment compliance after surgery. Outpatient clinic attendance was also very poor, only 27 (12.7%) were still being seen in the clinic, 83 patients (39%) were known to be dead and 102 patients were lost to follow-up. The mean follow-up period was 8.4 months (1 week-6 years). In conclusion, breast cancer is very common in our area of practice in Nigeria; the majority of our patients were young and premenopausal women presenting in the advanced stages of cancer. Treatment compliance was very poor. The majority of the patients were dead or lost to follow-up within a year of diagnosis.

Giant renal oncocytoma masquerading as infiltrating renal cell carcinoma: case report and literature review.

Renal oncocytomas (RO) are tumours containing a population of cells with highly differentiated eosinophilic granular cytoplasm, extremely rich in mitochondria. It is estimated they account for about 3 to 7% of all solid renocortical tumours that were previously regarded as renal cell carcinoma. Based on their clinical behaviour and distinct pathologic features they are now regarded as benign renal tumours, often less than 5cm in diameter. We present a case of giant renal oncocytoma in a patient with synchronous bladder tumour, with pre-operative clinical, urographic and ultrasound features of locally advanced renal cell carcinoma (RCC). Findings at surgery included huge right renal tumour with infiltration to the duodenum; hepatic colic flexure; gall bladder; liver capsule and the greater omentum with small indurations at the base of the bladder. There was no tumour extension to the renal vein, no peritoneal seedling, no nodal metastasis and no ascites. Radical nephrectomy was carried out with good prognosis and without recurrence 52months post nephrectomy. This presentation, besides highlighting the possible giant nature of RO, also illustrates the malignant potential of RO to infiltrate contiguous structures and mimics infiltrating RCC. In view of the difficulties at establishing pre-operative diagnosis in this disease and because nephron-sparing surgery is curative, especially for the well-circumscribed tumours, RO should be considered in the management of patients with features of infiltrating RCC. A review of literature is also presented.

Comparing Lichtenstein with darning for inguinal hernia repair in an African population.

PURPOSE: Being a relatively new entrant into our practice, mesh repair has not been compared with previously existing tissue-based techniques in our setting. This study is set out to compare darning with Lichtenstein technique of inguinal hernia repair in terms of frequency of post-operative complications, recovery and cost. METHOD: Patients with uncomplicated, primary inguinal hernia were randomized to have their hernias repaired either by the Lichtenstein or darning technique. Details of their socio-demographic, hernia characteristics and intra-operative findings were recorded. Postoperatively patients were assessed for pain, wound site complications and recurrence. Both direct and indirect costs were calculated. Mean duration of follow-up was 7.5 months. RESULT: Sixty-seven patients were studied. Thirty-three had Lichtenstein repair while 34 had darning repair. Lichtenstein repair was associated with less post-operative pain, less analgesic requirement, and shorter time of return to work activities, these were all statistically significant (p < 0.05). Frequency of post-operative complications was comparable in both groups with wound haematoma and scrotal oedema being the commonest. There was no recurrence in any of the groups. Total cost was comparable between the two groups. CONCLUSION: Lichtenstein is superior to darning in terms of post-operative recovery while both techniques are comparable in terms of frequency of early post-operative complications and total cost.

Kidney transplantation in a developing economy: challenges and initial report of three cases at Ile Ife.

BACKGROUND: Kidney transplantation (KT) is globally adjudged the best alternative treatment for end stage renal disease (ESRD) in preference to life-long dialysis. This form of therapy was hitherto unavailable in Nigeria until our hospital and a private hospital embarked on a KT programme despite our depressed economy, and inadequate facilities. We present the initial report of KT performed in our hospital and the challenges of KT in our developing society. CASE REPORTS: Three patients with ESRD had living related KT between June 2002 and April 2003. The first patient died with functioning graft six and a half months post transplantation from complications of Diabetes mellitus and sepsis, while the remaining two still enjoy a good quality of life 35 months post transplantation. There were problems with procurement and monitoring of immunosuppressive drugs in the three patients. This report also illustrates the common causes of ESRD in Nigeria and some of the complications of KT. To our knowledge, these are the first reported cases of KT in Nigeria. CONCLUSION: Kidney transplantation is cost effective and offers a good quality of life for ESRD patients. Poverty, inadequate facilities and lack of donors are major problems facing KT in our society. Although KT requires high technical and material resources, with proper training, commitment and adequate funding, it is feasible, safe and cheaper on a long term basis for the management of patients with ESRD in a developing economy like ours. There is a need for government funding of KT programmes in developing countries.

Acute generalized peritonitis in African children: assessment of severity of illness using modified APACHE II score.

BACKGROUND: Generalized surgical acute abdomen is a significant cause of morbidity and mortality among children. Severity assessment is useful in order to prioritize treatment and reduce complications. Patients with a high severity score are often faced with high morbidity and mortality, thus, requiring more intensive treatment than those with low severity scores. The purpose of the present study was to assess the severity of the acute abdomen in paediatric patients using a modification of the acute physiological and chronic ill-health evaluation II score (APACHE II). METHODS: Children admitted and operated on for generalized acute abdomen over a period of 7 years from January 1993 to December 1999 were prospectively studied. A study proforma was drafted and demographic, clinical, preoperative, operative and postoperative data on each patient were entered. Each patient had severity of illness assessed using APACHE II parameters with minor modification to make it applicable to children. Postoperative outcome and severity of illness were compared to determine any correlation. RESULTS: There were 69 patients operated on within the period of the study. Age ranged from 3 months to 15 years, with a mean of 9.1 SD 4.3 years. Forty-two patients (61.2%) were male and 27 (39.8%) were female. Typhoid intestinal perforation accounted for 35 (50.7%) and intestinal obstruction with or without intestinal gangrene accounted for nine (13%). Modified APACHE II score ranged from 0 to 18, mean 8.5 SD 5. For survivors, the mean score was 8; for non-survivors, 13. Eight patients died (11.6%): four of 63 (6.4%) patients who scored 0-15 died; four of six (66.7%) patients who scored 16-18 (P < 00.05) died. A modified APACHE II score greater than 15 was associated with a significantly greater mortality. The data for postoperative morbidity and hospital stay were not conclusive. CONCLUSION: Although the APACHE II score was designed for adults, a modification can be suitably applied to predict mortality in children with generalized peritonitis. There will be a need to apply this to large number of patients in order to validate our finding.

Changing pattern of acute intestinal obstruction in a tropical African population.

A study of one hundred and forty-two patients with acute intestinal obstruction over a period of ten years (January 1985-December 1994) at Wesley Guild Hospital was undertaken to determine the pattern and outcome of this problem in a tropical African population. There was a preponderance of males over females; ratio 1.7:1. Mean age was 33 years and over half of the patients were aged between two and 30 years. There was a second peak age incidence among elderly patients between 50-80 years. Abdominal pain, vomiting and constipation were common symptoms, while abdominal distension and tenderness were common clinical findings. Intraperitoneal adhesions were responsible in 41.5%; there was associated intestinal volvulus in 25.4% of the cases of intraperitoneal adhesions. In 16.9%, strangulated external hernia was responsible for acute intestinal obstruction. Small intestinal volvulus was encountered in 20 cases (14.1%) and associated with adhesion in 75% of the cases. Intussusception occurred in 14.1% of cases of which 70% of the patients were below the age of 15 years. In 15 (10.6%) patients, there were volvulus of the sigmoid colon, with 80% (12 patients) having gangrenous bowel segments. Ascaris were responsible in 3.5% of the patients and large bowel tumour in 2.8%. Other rare causes were internal hernia and ileal pseudo obstruction. Adhesiolysis and intestinal resection were the commonest operative procedures. Common complications were wound infection in 16.2%, postoperative fever in 10.6% and chest infection in 9.1%. A mortality rate of 8.4% was recorded.

Prognostic factors in childhood inguinal hernia at Wesley Guild Hospital, Ilesa, Nigeria.

OBJECTIVE: To determine the pattern, outcome and the prognostic factors in childhood inguinal hernia. DESIGN: A five-year prospective study. SETTING: Wesley Guild Hospital, Ilesa, Nigeria. RESULTS: Two hundred and eight patients presented with 237 inguinal or inguinoscrotal hernias. Seventy one per cent were aged five years and below and 24% were infants. Male patients accounted for 94.7% of the cases. Mean duration of symptoms was 1.2 years in the patients without hernia complication but less than five months in complicated hernia. Symptoms of complication such as vomiting and abdominal pain occurred in 7.8% to 15% of children mainly under five years. Inguinoscrotal hernia was diagnosed in 76.5% of cases, of whom 53.8% presented on the right side, 32.3% on the left and 14% bilaterally. Undescended testes, low birthweight, anaemia and malnutrition presented in 22.6% of the cases. Incarcerated hernia was diagnosed in 16 patients (7.7%), all males, with ages ranging from two weeks to two years. Eighty nine per cent of the patients were operated upon as outpatients. Undescended testes constituted the commonest associated operative finding in about five per cent of the patients and one patient had non-rotation of the gut involved in strangulation. Statistical analysis showed that clinical pattern, outcome and the incidence of postoperative complication were significantly dependent on the sex, age and presence hernia complications. CONCLUSION: Inguinoscrotal hernia is commoner and predominantly in the male, majority of whom were below the age of five years. Most associated clinical and operative findings occurred in infants. Incarceration occurred more significantly in infants. Wound infection was the commonest complication. This and other complications were significantly affected by the age of the patients and incarceration.

Practice and acceptance of day-care surgery in a semi-urban Nigerian hospital.

OBJECTIVE: To determine the acceptability and practicability of day-care surgery in a semi-urban area of Nigeria. DESIGN: A twelve- month prospective study. SETTING: Wesley Guild Hospital, Ilesa, Nigeria. PATIENTS: Sixty seven consecutive patients with ASA I-II status and aged three months to 97 years were studied. INTERVENTION: Patients were operated as day-cases using general or local anaesthesia. MAIN OUTCOME MEASURES: Practicability, post-operative problems and acceptability. RESULTS: The mean age of patients studied was 27.26 years (SD 23.89), with males accounting for 61% of the 67 cases. Fifty eight per cent and 42% had general and local anaesthesia respectively. While all patients had post-operative support from family members, less than seven per cent had access to telephone or family doctor services. About 80% of the patients lived within 10 km from the hospital. Intermediate operations accounted for 60% of the cases, while minor ones accounted for 40%. The mean operating time was 30 minutes. Postoperative pain was the only significant problem encountered. This, however, decreased in the patients with time. Complication rate was 10.5%. CONCLUSION: A significant number of patients accepted and approved of the day stay surgery. Medical and surgical practitioners in semi-urban regions are encouraged and charged to accept the practice of short stay surgery.

Obstructed abdominal hernia at the Wesley Guild Hospital, Nigeria.

OBJECTIVE: To determine the incidence, pattern and outcome of obstructed abdominal wall hernia in a semi-urban and rural community. DESIGN: A proforma was drafted to study all consecutive patients operated for obstructed anterior abdominal wall hernia over a period of five years. Clinical findings, preoperative treatment, operative findings and postoperative outcome were documented. SETTING: Teaching hospital located in a semi-urban community comprising mostly agrarian population. PATIENTS: A total 110 adult patients with obstructed anterior abdominal wall hernia who had operative intervention and other postoperative management. RESULTS: There were 110 patients with 111 obstructed hernias, accounting for 26.4% of all abdominal wall hernias. The age ranged from 19-79 years with mean of 49.7 years. Males accounted for 81%. Inguinoscrotal hernia was the commonest occurring in 75.7%, 16.2% patients presented with inguinal hernia and five patients with femoral hernia. The greater proportion of inguinal hernia occurred in female. Eighty seven patients (79%) had emergency operations and elective in 23 patients (21%) who had spontaneous reduction while awaiting surgery. Ninety two percent of inguinoscrotal/inguinal hernia were indirect. Omentum was trapped in 52 hernias (47.%), while in 15 patients (13.6%), gangrenous bowel segments were discovered. Scrotal oedema was the commonest complication accounting for 21%, while wound infection occurred in 20%. There were three deaths in elderly men with clinical symptoms and signs of acute intestinal obstruction and gangrenous bowel segments, accounting for 2.7% of the patients. Twenty eight per cent of patients were discharged within the first and second postoperative days. Two patients spent 36 and 56 days each in the hospital. CONCLUSION: This study showed that 26.4% of abdominal hernia presented with obstruction. With inguinoscrotal hernia predominating: male accounted for 81% and 13.6% of the obstructed hernia contained gangrenous bowel segments. Post-operative complications were common, mortality occurring mainly in elderly patients with late presentation.

Priapism in southwestern Nigeria.

OBJECTIVES: To determine the aetiology, pattern of presentation, treatment regimen and outcome of management of priapism in our environment and to compare our findings with previous studies in this country and elsewhere. DESIGN: A 10-year retrospective study from January 1991 to December 2000. SETTING: Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria. PATIENTS AND METHODS: Hospital records of 16 patients managed for priapism over 10 years (January 1991 to December 2000) were analysed. Information extracted included the age, occupation, duration of symptoms, precipitating factors, past medical history, haemoglobin genotype, drug and social history, physical findings, treatment regimen, outcome of treatment, complications and duration of follow up. Eighteen patients were treated for priapism during the period but only sixteen case files available for analysis were reviewed in this study. RESULTS: The mean age of the 16 patients under review was 20.4 years (range: 2.5-38 years). Thirteen patients (81%) were single and 10 (62.5%) were students. All the patients presented late with pain and woody hard penis with mean duration of eight days (range; 7 hrs-30 days). Eleven patients (68.7%) had previous episodes of priapism. Fourteen patients (87.5%) had sickle cell disease (SCD) and two (12.5%) were psychiatric patients on oral chlorpromazine. Associated medical conditions include urinary tract infection, malaria, acute urinary retention, bone pain crises and acute psychosis. All the patients received initial conservative management. Six patients had needle aspiration with irrigation plus injection of 2 ml of adrenaline solution (1 ml 1/1000 adrenaline in 200 ml saline) in both corpora cavernosa. One (16.7%) out of the six patients achieved full detumescence with normal erection. The remaining five patients later had cavernotomy with full detumescence and normal erection in three (60%) and weak erection in two (40%). Eight patients had Cavernosa-glandular shunt, full detumescence and normal erection was achieved in five patients (62.5%) while three (37.5%) became impotent. Two of the three patients with impotence presented with the longest duration of symptoms (14 and 30 days respectively), while the third patient reported earlier after five days, but he had suffered more than six (>6) previous attacks of priapism. Duration of hospital stay was 3-10 days and the average duration of follow up was 80.7 weeks. CONCLUSION: Sickle cell disease account for 87.5% of priapism in our community. Late presentation and previous episodes of priapism, which are common features in most of these patients, are associated with poor prognosis with higher risk of impotence. Conservative management and aspiration with intracavernous adrenaline therapy appears ineffective in late case. However, good results obtained with surgery indicate that late presentation should not be a deterrent to surgical intervention. Surgeries in form of cavernotomy or cavernosa-glandular shunt, when carefully done, are effective and safe.