Trends in childhood intussusception in a Nigerian tertiary hospital.

Background: Early presentation, high rate of successful non-operative treatment, low morbidity and mortality in childhood intussusception is common in High and Upper Middle-Income Countries but not in many Lower middle- and Low-income countries. Aim: To assess the trends in the profile, treatment modalities and outcomes of intussusception in our hospital. Materials and methods: Retrospective study over a 12-year period divided into two 6-year periods. Data entry/analysis was done using SPSS and various indices were compared between these two periods. Two-tailed t-test for two independent means was used to compare means while two-tailed Fisher exact tests were used to compare categorical variables. Results were presented as tables, means, ranges, percentages and a p-value less than 0.05 was deemed statistically significant. Results: There was a significant increase in the proportion of successful non-operative treatment (18.6% vs 34%, p=0.03), reduction in the incidence of operative manual reduction (27.1% vs 12.8%; p=0.026), reduction in operative treatment (78.5% vs 63.9%, p=0.034), increased utilization of pre-intervention ultrasound (75% vs96.7%, p<0.0001) and reduction in hospital stay duration (10.47 ±7.95days vs 7.24±4.86 days; p=0.004). Conclusions: Contribution of successful non-operative treatment to the overall treatment of intussusception significantly increased while that of operative manual reduction significantly reduced and bowel resection showed no change. Preoperative utilization of ultrasonography significantly increased while mean duration of admission reduced significantly, but late presentation, morbidity and mortality rates had no significant changes.

Childhood colostomies: patterns, indications and outcomes in a Nigerian University Teaching Hospital.

Background: Most childhood colostomies are done for decompression or diversion in gastrointestinal tract congenital anomalies. Colostomy may be sited in the transverse or sigmoid colon as loop or defunctioning (divided) colostomies. Current pattern seems towards construction of more sigmoid and defunctioning colostomies. Aims: To evaluate the patterns, indications and outcomes of childhood colostomies. Patients and Methods: Retrospective chart review of all colostomies performed in children below 15 years from September 2010 to August 2020. Results: There were 104 colostomies (55males; 49females; 65 sigmoid; 39 transverse colostomies; 3 loop; 101 defunctioning colostomies. Anorecatal Malformation (ARM)was indication in 32 males and 41 females; age range 2 days to 13 years. Hirschsprung's Disease (HD) was indication in 18 males and 4 females; age range 6 weeks to 15 years.In HD there were three loop colostomies (3/22) in transverse colon and 19 defunctioning colostomies (8 sigmoid, 11 transverse) while in ARM all 73 were defunctioning colostomies(P=0.01)In HD there were 14/22 transverse colostomies and 8/22 sigmoid colostomies while ARM had 24/73 transverse and 49/73 sigmoid colostomies (P =0.013)In HD 91% colostomies were done beyond infancy while in ARM 93% were before one year(P<0.0001). Mortalities were noted in 1.9% patients. Conclusion: Commonest indication for colostomy is ARM. There are more defunctioning than loop colostomies, and more sigmoid than transverse colostomies. of most colostomies in ARM were during infancy while mostly beyond infancy in HD.

Application of blended integrated revision course in clinical surgery in West Africa in response to Covid-19 pandemic: perception of trainee surgeons.

Background/Objective: This study assessed the surgery residents' evaluation of blended delivery of the 2020 Integrated Revision Course in Clinical Surgery (IRCCS) of the West African College of Surgeons undertaken as a result of COVID-19 pandemic. Methods: We performed a cross-sectional survey of 234 participants of the 2020 IRCCS using self-administered questionnaire. The survey assessed the previous traditional course and various aspects of the novel blended course using 5-point Likert scale. Results: Overall, 186 (79.5%) responded. The blended course had overall mean rating of 4.92 (on a 5-point scale) compared to 4.05 for the previous traditional course. Of the virtual aspect of the blended course, didactic lectures had the best mean rating of 4.32, while unmanned OSCE had the least with mean rating of 3.30. Aspects of the multicentre component of the blended course were rated highly with conduct of manned OSCE receiving the best mean rating of 4.26. The major challenge of the blended course format was poor internet connectivity (n =102; 54.8%). Conclusion: Blended format of surgical training course is well rated by the surgery residents, and may be an effective means of delivery of clinical and non-clinical course contents during periods of disruption.

Evaluation of maternal preferences for neonatal male circumcision in Enugu Nigeria.

BACKGROUND: Although circumcision in male neonates is one of the most common procedures performed in neonatal surgery, mothers' preferences concerning the aspects of circumcision are not well-known. Since mother is the likely parent to present child for circumcision, her preferences should be given adequate consideration. OBJECTIVES: The objective of this study is to evaluate maternal preferences for neonatal male circumcision in Enugu. METHODOLOGY: A cross-sectional study where questionnaire was distributed by the researchers to consenting pregnant women attending antenatal clinics in two teaching hospitals in Enugu. Data analysis was performed using the SPSS. The results presented as means, percentages and tables. Test for significance was done using the Chi-square test. RESULTS: Four hundred and sixty-one pregnant women participated in the study. Ninety-five percent (438/461) wanted circumcision and 83.5% (385/461) wanted it on or before the 8th day of life. The reasons were cultural/religious in 69% (302/447). Fifty-four percent (250/461) had no preferences as to methods, but for those who had, Plastibell was most preferred method in 28% (129/461) while 76% (235/309) preferred circumcision to be done in hospital. In 49.2% (227/461) preferred personnel were nurses but 79.6% (367/461) wanted doctors to attend to post-circumcision complications. In 79.2% (365/461), mothers will not insist on the use of anaesthesia for circumcision. Mothers with circumcised husbands were significantly more willing to circumcise a male child (P = 0.0018). Higher educational status of mother was significantly related to willingness to insist on the use of anaesthesia (P = 0.046) and use of analgesics after circumcision (P = 0.001). CONCLUSIONS: Most mothers prefer neonatal male circumcision by nurses, while preferring doctors for post-circumcision complications. These choices are not affected by parents' educational status. Mothers with circumcised husbands accepted circumcision more than those with uncircumcised husbands. Higher maternal education encourages anaesthesia during circumcision and post-circumcision analgesia.

Intussusception in children under five years of age in Enugu, Nigeria.

INTRODUCTION: intussusception is the invagination of a segment of the bowel into a distal segment. It occurs predominantly in infants worldwide. Following documentation of increased incidence after introduction of the first rotavirus vaccine (Rotashield, Wyeth-Lederle), it has become a standard recommendation to maintain surveillance for intussusception as newer rotavirus vaccines are introduced into EPI. Nigeria plans to introduce rotavirus vaccine in 2020. Pre-vaccine introduction surveillance will serve as a baseline to understand the epidemiology of intussusception in Nigeria. METHODS: from 2013 to 2017, prospective enrolment of under five children with intussusception was done following the WHO protocol and using the WHO case report form. Only children who met the Pan American Health Organization/World Health Organization (PAHO/WHO) protocol case definition for intussusception were enrolled. These children were monitored until discharge or death. Clinical features and outcome were recorded in the case report form. RESULTS: a total of 63 cases were enrolled, with age range of 3 to 42 months (median: 6 months, IQR: 5-9 months). Majority were within 4-6 months and 96% were < 12 months old. There were 41 males and 22 females (male to female ratio of 1.9:1). Duration of symptoms before presentation ranged from 2 hours to 15 days (median: 72 hours). Fifty-seven patients had abdominal ultrasound and 52 patients (83%) had surgery. Case fatality rate was 9% and duration of hospitalization ranged from 1 to 30 days (median 10 days, IQR 8-15 days). CONCLUSION: intussusception occurred most commonly in infants but well beyond the proposed age for rotavirus vaccination in the population studied. Late presentation and surgical intervention were common. This data provides a good baseline description of the epidemiology of intussusception.

A global point prevalence survey of antimicrobial use in neonatal intensive care units: The no-more-antibiotics and resistance (NO-MAS-R) study.

BACKGROUND: Global assessment of antimicrobial agents prescribed to infants in the neonatal intensive care unit (NICU) may inform antimicrobial stewardship efforts. METHODS: We conducted a one-day global point prevalence study of all antimicrobials provided to NICU infants. Demographic, clinical, and microbiologic data were obtained including NICU level, census, birth weight, gestational/chronologic age, diagnoses, antimicrobial therapy (reason for use; length of therapy), antimicrobial stewardship program (ASP), and 30-day in-hospital mortality. FINDINGS: On July 1, 2019, 26% of infants (580/2,265; range, 0-100%; median gestational age, 33 weeks; median birth weight, 1800 g) in 84 NICUs (51, high-income; 33, low-to-middle income) from 29 countries (14, high-income; 15, low-to-middle income) in five continents received ≥1 antimicrobial agent (92%, antibacterial; 19%, antifungal; 4%, antiviral). The most common reasons for antibiotic therapy were "rule-out" sepsis (32%) and "culture-negative" sepsis (16%) with ampicillin (40%), gentamicin (35%), amikacin (19%), vancomycin (15%), and meropenem (9%) used most frequently. For definitive treatment of presumed/confirmed infection, vancomycin (26%), amikacin (20%), and meropenem (16%) were the most prescribed agents. Length of therapy for culture-positive and "culture-negative" infections was 12 days (median; IQR, 8-14) and 7 days (median; IQR, 5-10), respectively. Mortality was 6% (42%, infection-related). An NICU ASP was associated with lower rate of antibiotic utilization (p = 0·02). INTERPRETATION: Global NICU antibiotic use was frequent and prolonged regardless of culture results. NICU-specific ASPs were associated with lower antibiotic utilization rates, suggesting the need for their implementation worldwide. FUNDING: Merck & Co.; The Ohio State University College of Medicine Barnes Medical Student Research Scholarship.

Evaluation of Impact of Perinatal Factors on Time to First Meconium Passage in Nigerian Neonates.

Background: Delayed meconium passage is usually a signal to congenital distal bowel dysfunction. Timing of meconium passage may vary depending on race, sex and several perinatal factors. Understanding the timing and associated perinatal factors in any given population will help in prompt diagnosis and adequate management of cases in that population. Objectives: To determine the timing of first meconium passage amongst Nigerian neonates, and evaluate the impact of various associated perinatal factors. Materials and Methods: A cross-sectional study using interviewer-administered questionnaires to obtain data from mothers of apparently normal infants attending the postnatal clinic of the University of Nigeria Teaching Hospital, Enugu, Nigeria. Data acquisition and analysis were done using SPSS version 20. A P-value of < 0.05 was adjudged statistically significant. Results: There were 276 male and 277 female infants. Mean birth weight was 3.4kg and mean gestational age at delivery 38.8weeks. The median age at presentation was 42days. Preterm deliveries were in 6.3%(32/510) and 3.7%(20/536) weighed less than 2.5kg at birth. Sixty-five percent (339/519) had spontaneous vertex delivery and 35%(180/519) had caesarean delivery. Passage of first meconium was within 24hours in 56.6%(307/543) and in 48hours 91.3%(496/543) had passed meconium. Fifty-four percent (54%, 288/537) commenced breastfeeding within 24hours and 85% (n=456/537) within 48hours. Exclusive breastfeeding was done in 61.5%(326/533) of subjects. Timing of first meconium passage was significantly affected by gestational age at delivery (p<0.001), mode of delivery (p<0.01), birth weight (p=0.02), first minute APGAR score (p<0.001), timing of commencement of breastfeeding (p<0.001) and feeding before breastfeeding is commenced (p = 0.02). Conclusion: Compared to other studies, we found smaller proportion of neonates passing meconium in the first 24 hours. Term neonates, birth weight ≥ 2.5kg, spontaneous vertex delivery, high Apgar score, commencement of breastfeeding within 24 hours of birth, feeding before breastfeeding is commenced, are perinatal factors associated with earlier first meconium passage.

Chronic bowel obstruction from colonic stenosis in early infancy-A report of two cases.

Bowel obstruction in early infancy may result from a variety of congenital anomalies involving parts of the small and large bowel. However, in infancy, chronic bowel obstructions from congenital or acquired stenosis of the colon are rare and can cause diagnostic quandary. We present two cases of an eleven-week old male and a nine-week old male with massive abdominal distension and features of chronic bowel obstruction dating from neonatal period. In the first case investigations were inconclusive and laparotomy revealed isolated stenosis of the ascending colon. In the second case colonic stenosis was suspected preoperatively and a barium enema done showed multiple colonic stenosis confirming our working diagnosis. The diagnostic dilemmas encountered in managing the first patient are discussed to highlight the need for high index of suspicion of this condition in infants with chronic constipation. The way experience in managing the first case influenced diagnosis of the second case is also highlighted.

Paediatric nephrectomy: Patterns, indications and outcome in a developing country.

Background: Patterns of and indications for nephrectomy vary in different age groups, geographical locations and time periods. In some series nephrectomies were mainly for malignant conditions while in others they were predominantly for non-malignant conditions. Such data on patterns, indications, and outcomes of nephrectomy in children is limited in our environment. Objectives: To evaluate nephrectomy in childhood at the Sub-Department of Pediatric Surgery University of Nigeria Teaching Hospital, Ituku/Ozalla Enugu with a focus on pattern, indications, and outcome. Materials And Methods: Medical records of all patients aged =16years who had nephrectomy from January 2007 to December 2016 were studied with emphasis on age, sex, side of nephrectomy, duration of symptoms before presentation, indication for nephrectomy, in-hospital complications, length of hospital stay, in-hospital mortality. SPSS version 15 was used for data entry and analysis. Results: There were 52 nephrectomies in 32 males and 20 females. They were for 35 malignant and 17 non-malignant conditions. Most of the malignancies were Wilms tumour (34/35) while non-malignant conditions were late-presenting pelvi-ureteric junction obstruction (9), large multi-cystic dysplastic kidneys (4), renal trauma with pedicle avulsion (1), posterior urethral valve with atrophic kidney (1), duplex system with nonfunctioning upper pole moiety (2). Mean age at nephrectomy was 5.10±3.66 years (range 7 weeks to 16 years); 59% of the nephrectomies were on the left and 41% on the right. Mean duration of hospital stay was 31.78±16.59 days (range 7-66 days). In-hospital mortality rate was 5.8%. Conclusions: In our unit, nephroblastoma is the main indication for pediatric nephrectomy and were the only indications in females; neglected pelvi-ureteric junction obstruction was the major non-malignant indication and occurred only in males; most nephrectomies were done in the age range of 1-5 years; nephron-sparing nephrectomy, major morbidity, re-operation are uncommon and in-hospital mortality from nephrectomy is still high at 5.8%.

Infantile hypertrophic pyloric stenosis - Our experience and challenges in a developing country.

BACKGROUND: This study aims to evaluate the experience and challenges in managing patients with infantile hypertrophic pyloric stenosis (IHPS). PATIENTS AND METHODS: From January 2007 to December 2015, data from patients with IHPS were retrospectively acquired and analyzed using SPSS version 15. Pearson correlation used to assess linear relationships and Student t-test to compare means. P < 0.05 was taken as statistically significant. Results were expressed as percentages, means ± standard deviation and illustrated in tables and graphs. RESULTS: Twenty-six cases were managed with the mean age at diagnosis of 49.16 ± 21.4 days. Mean birth weight was 3.7 kg and mean weight at presentation was 3.3 kg. Firstborn was affected in 29%; 91% were term deliveries; 9% were post-term; none was preterm; and 36% were exclusively breastfed. Mean duration of symptoms was 25.6 ± 18.9 days. Hyponatraemia was seen in 36%, hypokalaemia 37.5%, alkalosis 35% and hypochloraemia 62%. Mean pyloric tumour length was 22.85 ± 6.56 mm and pyloric wall thickness 5.51 ± 1.36 mm. There was a significant correlation between duration of symptoms and serum potassium level (R = -0.6326, P = 0.002). Mean symptom duration in patients with hypokalaemia was 39.88 ± 23.41 days and without hypokalaemia 17.15 ± 9.78 days (P = 0.006). Mean hospital stay was 9.45 ± 3.27 days. Four patients developed four complications and three patients died (11.5%). Mean age at presentation for pre-operative mortalities was 84 ± 39 days and 46 ± 17.98 days for others (P = 0.015). CONCLUSIONS: IHPS presents late in our environment and occurs mainly in term males. There is a significant positive relationship between duration of symptoms and serum potassium level and the mean duration of symptoms was significantly longer in those with hypokalaemia. Pre-operative mortality was significantly associated with longer duration of symptoms.

Transanal protrusion of intussusceptions in children.

BACKGROUND: The aim of the following study is to report our management experience and outcome of transanal protrusion of intussusceptions. PATIENTS AND METHODS: Retrospective analysis of all cases of intussusceptions protruding through the anal opening from January 2008 to June 2013. RESULTS: Of 62 cases of intussusceptions, transanal protrusion occurred in 10 patients (16% anal protrusion rate) with a male:female ratio of 2:3. They were aged 4-96 months (mean 22.6 ± 30.7, median 7.5 months). Six were infants while four were above 1 year. Duration of symptoms ranged from 2 to 14 days (mean 5.9 days ± 3.4) with only two patients presenting within 48 h. Clinical features included vomiting (100%), abdominal pains (100%), bloody mucoid stool (100%), abdominal distension (90%), and palpable left iliac fossa mass (70%). Three patients had preceding diarrhoea (30%) and two had preceding upper respiratory tract infection (20%). Duration of hospital stay ranged from 5 to 23 days (mean 12 days ± 5.6). Findings at surgery included seven ileocolic and two colocolic intussusceptions (one patient died before surgery). Operative procedures were right hemicolectomy (5), operative manual reduction (3), left hemicolectomy (1) giving a 67% bowel resection rate. One patient died giving a 10% mortality rate. CONCLUSION: Transanal protrusion occurred more in females and is associated with late presentation, older age, high bowel resection rate, and high mortality.