Steps to the Adoption of Stapling Technique for Low Rectal Anastomoses in a Nigerian Tertiary Hospital.

INTRODUCTION: Many patients who may otherwise benefit from anastomoses get a permanent colostomy for low rectal cancers in low- and middle-income countries because of lack of training and/or lack of equipment for low rectal anastomoses. Our local team provided stepwise training for stapled low rectal anastomoses. METHODS: Local surgeons with overseas formal training in colorectal surgeries facilitated periodical simulation-based training workshops on stapled low rectal anastomoses for surgeons and trainees over 3 y (2015-2017) in a Nigerian tertiary hospital. Additional training with live surgeries was conducted. RESULT: Twenty-six participants, including 12 consultant surgeons and 14 senior registrars, concluded hand-on training modules in both wet and dry laboratory sessions. Two-thirds of them also had opportunities to assist during live surgeries. After initial training, stapled low rectal anastomoses were carried out by a team of consultants operating together. With time, locally trained residents assisted consultants in carrying out the procedures. Of the 198 colorectal procedures carried out within the study period, 18 (0.09%) were rectal resections and anastomoses, of which 14 were stapled low rectal anastomoses. CONCLUSIONS: A locally facilitated simulation-based training program aided the adoption of a stapled technique of low rectal anastomoses in a Nigerian tertiary hospital. We propose that such training can promote the adoption of other modern techniques in our tertiary surgical practices.

Effect of Fascia Closure with Triclosan-Coated Polydioxanone Suture on Surgical Site Infection in Open Appendectomy Wounds: A Comparative Study.

Background: Interest in surgical site infections (SSI) has been sustained over the years because its occurrence may be ruinous to the overall success of surgical operations. The use of antimicrobial suture has been associated with a reduction in SSI, but its role in open appendectomy has not been evaluated. Objective: This study compared the effect of fascia closure with triclosan-coated polydioxanone (PDS) with plain PDS on SSI in appendectomy wounds. Materials and Methods: Ninety-three consecutive patients who had open appendectomy for uncomplicated acute appendicitis were randomised to either have fascia closure with triclosan-coated PDS (TCS) or plain PDS. Post-operative wound infection rates were compared. Results: SSI occurred in three of the 93 patients (3.2%), two of these occurred in the plain suture group, while one occurred in the TCS group (4.2% vs. 2.2%, P = 0.6). All three SSIs were superficial. Staphylococcus aureus was the predominant organism isolated in the infected wounds. Conclusion: The use of triclosan-coated polydioxanone for fascia closure in open appendectomy did not significantly affect the rate or severity of SSI. Further studies, perhaps evaluating the use of TCS in a different anatomical plane or complicated appendicitis are recommended.

Translation and psychometric assessment of the mastectomy module of the BREAST-Q questionnaire for use in Nigeria.

BACKGROUND: The majority of non-metastatic breast cancer patients in sub-Saharan Africa are recommended to have mastectomy. The impact of mastectomy on a predominantly young African patient population requires evaluation. The BREAST-Q is a validated patient-reported outcome measure of quality-of-life following breast surgery that has been translated into 30 languages-none in Africa. This study aimed to translate and assess the psychometric properties of the mastectomy module of the BREAST-Q for use in Nigeria. METHODS: The BREAST-Q mastectomy module was translated from English to Yoruba and its psychometric properties assessed using best practice guidelines. Translation was performed in 4 steps: forward translation (x2), back translation, back translation review, and cognitive interviews with post-mastectomy patients. The translated BREAST-Q instrument was administered to post-mastectomy patients (n = 21) alongside the EORTC-QLQ BR23 to evaluate construct validity. Test-retest reliability was evaluated using intraclass correlation coefficients (ICC); surveys were re-administered 4 weeks apart. RESULTS: The translation process identified English phrases not amenable to direct translation, including "emotionally healthy" and descriptions of pain ("nagging," "throbbing," "sharp"). Translations were amended to reflect local context and question intent. During cognitive interviews, patients provided suggestions to simplify complex phrases, e.g. "discomfort in your breast area.". Internal consistency within scales was over 0.70 for psychosocial wellbeing (α = 0.84-0.87), sexual wellbeing (α = 0.98-0.99), physical wellbeing in chest (α = 0.84-0.86), and satisfaction with care (α = 0.89-0.93). ICC for test-retest reliability was moderate (0.46-0.63). CONCLUSIONS: The Yoruba version of the BREAST-Q mastectomy module presents a unique opportunity to adequately capture the experiences of Nigerian women post mastectomy. This instrument is being used in a pilot study of Nigerian patients to identify targets for intervention to improve the patient experience and compliance with breast cancer surgery.

The iBreastExam versus clinical breast examination for breast evaluation in high risk and symptomatic Nigerian women: a prospective study.

BACKGROUND: The iBreastExam electronically palpates the breast to identify possible abnormalities. We assessed the iBreastExam performance compared with clinical breast examination for breast lesion detection in high risk and symptomatic Nigerian women. METHODS: This prospective study was done at the Obafemi Awolowo University Teaching Hospital Complex (OAUTHC) in Nigeria. Participants were Nigerian women aged 40 years or older who were symptomatic and presented with breast cancer symptoms or those at high risk with a first-degree relative who had a history of breast cancer. Participants underwent four breast examinations: clinical breast examination (by an experienced surgeon), the iBreastExam (performed by recent nursing school graduates, who finished nursing school within the previous year), ultrasound, and mammography. Sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) of the iBreastExam and clinical breast examination for detecting any breast lesion and suspicious breast lesions were calculated, using mammography and ultrasound as the reference standard. FINDINGS: Between June 19 and Dec 5, 2019, 424 Nigerian women were enrolled (151 [36%] at high risk of breast cancer and 273 [64%] symptomatic women). The median age of participants was 46 years (IQR 42-52). 419 (99%) women had a breast imaging-reporting and data system (BI-RADS) assessment and were included in the analysis. For any breast finding, the iBreastExam showed significantly better sensitivity than clinical breast examination (63%, 95% CI 57-69 vs 31%, 25-37; p<0·0001), and clinical breast examination showed significantly better specificity (94%, 90-97 vs 59%, 52-66; p<0·0001). For suspicious breast findings, the iBreastExam showed similar sensitivity to clinical breast examination (86%, 95% CI 70-95 vs 83%, 67-94; p=0·65), and clinical breast examination showed significantly better specificity (50%, 45-55 vs 86%, 83-90; p<0·0001). The iBreastExam and clinical breast examination showed similar NPVs for any breast finding (56%, 49-63 vs 52%, 46-57; p=0·080) and suspicious findings (98%, 94-99 vs 98%, 96-99; p=0·42), whereas the PPV was significantly higher for clinical breast examination in any breast finding (87%, 77-93 vs 66%, 59-72; p<0·0001) and suspicious findings (37%, 26-48 vs 14%, 10-19; p=0·0020). Of 15 biopsy-confirmed cancers, clinical breast examination and the iBreastExam detected an ipsilateral breast abnormality in 13 (87%) women and missed the same two cancers (both <2 cm). INTERPRETATION: The iBreastExam by nurses showed a high sensitivity and NPV, but lower specificity than surgeon's clinical breast examination for identifying suspicious breast lesions. In locations with few experienced practitioners, the iBreastExam might provide a high sensitivity breast evaluation tool. Further research into improved specificity with device updates and cost feasibility in low-resource settings is warranted. FUNDING: Prevent Cancer Foundation Global Community Grant Award with additional support from the P30 Cancer Center Support Grant (P30 CA008748).

Pattern of abdominal wall herniae in females: a retrospective analysis.

BACKGROUND: Gender differences are expected to influence the pattern and outcome of management of abdominal wall hernias. Some of these are left to speculations with few published articles on hernias in females. OBJECTIVES: To describe the clinical pattern of abdominal wall hernias in females. METHOD: A 5 year retrospective review. RESULT: There were 181 female patients with 184 hernias representing 27.9% of the total number of hernia patients operated. Mean age was 41.66±24.46 years with a bimodal peak in the 1(st) and 7(th) decades. Inguinal hernia accounted for majority (50.5%) but incisional hernia predominated in the 30-49 age group, while only inguinal and umbilical hernias were seen in the first two decades (p=0.04). There was no side predilection in the cases of inguinal hernia. There were 12 (6.6%) emergency presentations, most of which occurred in the 6th decade and above and none below 30 years (p=0.02). Umbilical (4 cases) and femoral hernias (3cases) accounted for most of these cases. Incisional hernia was the commonest cause of recurrent hernias. CONCLUSION: Inguinal hernia is the commonest hernia type in females followed by incisional hernias which also accounteds for most recurrent cases. Age appears to be a risk factor for developing complications.