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.

Molecular and phenotypic profiling of colorectal cancer patients in West Africa reveals biological insights.

Understanding the molecular and phenotypic profile of colorectal cancer (CRC) in West Africa is vital to addressing the regions rising burden of disease. Tissue from unselected Nigerian patients was analyzed with a multigene, next-generation sequencing assay. The rate of microsatellite instability is significantly higher among Nigerian CRC patients (28.1%) than patients from The Cancer Genome Atlas (TCGA, 14.2%) and Memorial Sloan Kettering Cancer Center (MSKCC, 8.5%, P < 0.001). In microsatellite-stable cases, tumors from Nigerian patients are less likely to have APC mutations (39.1% vs. 76.0% MSKCC P < 0.001) and WNT pathway alterations (47.8% vs. 81.9% MSKCC, P < 0.001); whereas RAS pathway alteration is more prevalent (76.1% vs. 59.6%, P = 0.03). Nigerian CRC patients are also younger and more likely to present with rectal disease (50.8% vs. 33.7% MSKCC, P < 0.001). The findings suggest a unique biology of CRC in Nigeria, which emphasizes the need for regional data to guide diagnostic and treatment approaches for patients in West Africa.

Treatment of colorectal cancer in Sub-Saharan Africa: Results from a prospective Nigerian hospital registry.

BACKGROUND: Colorectal cancer (CRC) is the third most common cancer worldwide. Mortality for CRC is improving in high income countries, but in low and middle income countries, rates of disease and death from disease are rising. In Sub-Saharan Africa, the ratio of CRC mortality to incidence is the highest in the world. This study investigated the nature of CRC treatment currently being offered and received in Nigeria. METHODS: Between April 2013 and October 2017, a prospective study of consecutively diagnosed cases of CRC was conducted. Patient demographics, clinical features, and treatment recommended and received was recorded for each case. Patients were followed during the study period every 3 months or until death. RESULTS: Three hundred patients were included in our analysis. Seventy-one percent of patients received a recommended surgical operation. Of those that didn't undergo surgery as recommended, 37% cited cost as the main reason, 30% declined due to personal reasons, and less than 5% absconded or were lost to follow up. Approximately half of patients (50.5%) received a chemotherapy regimen when it was recommended, and 4.1% received radiotherapy when this was advised as optimal treatment. With therapy, the median overall survival for patients diagnosed with stage III and stage IV CRC was 24 and 10.5 months respectively. Overall, we found significantly better median survival for patients that received the recommended treatment (25 vs 7 months; P < .01). CONCLUSIONS: A number of patients were unable to receive the recommended treatment, reflecting some of the burden of untreated CRC in the region. Receiving the recommended treatment was associated with a significant difference in outcome. Improved healthcare financing, literacy, training, access, and a better understanding of tumor biology will be necessary to address this discrepancy.

Barriers to mammography screening in Nigeria: A survey of two communities with different access to screening facilities.

Delayed presentation of breast cancer is a common theme in most low- and middle-income countries. This study evaluates barriers to mammography screening in two Nigerian communities with different geographic access to screening facilities. A 35 item questionnaire was administered to women, 40 years and older, 1,169 (52.6%) in Ife Central Local Government where mammography services are offered and 1,053 (47.4%) in Iwo Local Government where there are no mammography units. Information on breast cancer screening practices and barriers to mammography screening were compared between the two communities. Most women had heard of breast cancer (Ife 94%, Iwo 97%), but few were aware of mammography (Ife 11.8%, Iwo 11.4%). Mammography uptake in Ife Central was 2.8% and 1.8% in Iwo, despite the former offering mammography services. Knowledge and practice of mammography were not statistically different between the two communities (p = 0.74, 0.1). Lack of awareness was the commonest reason cited for not having mammography in both communities. Others include lack of perceived need and cost. Awareness creation to ensure optimal utilisation of existing facilities, as well as innovative measures to address the barrier of cost, is required to improve breast cancer screening uptake in Nigeria.

Neo-adjuvant capecitabine chemotherapy in women with newly diagnosed locally advanced breast cancer in a resource-poor setting (Nigeria): efficacy and safety in a phase II feasibility study.

The majority of clinical trials of neo-adjuvant therapy for breast cancer have been conducted in resource-rich countries. We chose Nigeria, a resource-poor country, as the major site for a phase II feasibility open-label multicenter clinical trial designed to evaluate the efficacy, safety, and tolerability of neo-adjuvant capecitabine in locally advanced breast cancer (LABC). Planned treatment consisted of 24 weeks of capecitabine at a dose of 1,000 mg/m(2) twice daily (2,000 mg/m(2) total per day). The primary endpoints were overall, partial, complete clinical response rate (OCR, PCR, CCR) and complete pathologic response (cPR). A total of 16 patients were recruited from August 2007 to April 2010. The study was terminated early as a result of slow accrual. After the first three cycles of therapy, PCR were seen in five of 16 patients (31%; 95% CI 11-59%). Of the remaining 11 patients, eight had no response (NR) or stable disease (SD), and three had progressive disease (PD). Seven patients proceeded with further therapy of which had SD. OCR at the end of eight cycles was 44% (95% CI 20-70%). Clinical response and radiologic response by ultrasonomammography were highly concordant (spearman correlation 0.70). The most common adverse effect was Grade 1 hand-foot syndrome, which was seen in 75% of patients. Despite several limitations, we successfully carried out this phase II feasibility study of neo-adjuvant capecitabine for LABC in Nigeria. Capecitabine monotherapy showed good overall response rates with minimal toxicity and further studies are warranted.

Local adaptations aid establishment of laparoscopic surgery in a semiurban Nigerian hospital.

BACKGROUND: Establishing and sustaining the routine practice of laparoscopy in resource-limited settings is extremely challenging. We present our experience implementing laparoscopic surgery at the Obafemi Awolowo University Teaching Hospital in Western Nigeria and the associated modifications that were necessary for success. METHODS: We reviewed all laparoscopic cases performed at our institution from January 2009 through December 2011. Operating surgeons were trained locally. Laparoscopic equipment and instrumentation was procured by both local and foreign sources. RESULTS: One hundred eighty-one procedures were performed in 175 patients whose ages ranged between 18 and 72 years. The procedures included cholecystectomies (n = 48, 24.5 %), appendectomies (n = 36, 20 %), diagnostic laparoscopies for staging and biopsy of intra-abdominal masses (n = 53, 30.9 %), adhesiolyses (n = 18, 11.6 %), hernia repairs (n = 6, 3.2 %), colorectal surgeries (n = 2, 1.3 %), and others (n = 18, 8.4 %). Diagnostic procedures were performed as day cases. Duration of stay for hospital admissions was 1-3 days. There were four conversions to open operation due to technical difficulties with equipment. No deaths were recorded. Local adaptation techniques facilitated cost reduction. Overall, there was improvement in the acceptance of the laparoscopic procedures among our patients and coworkers. CONCLUSION: Our local institution has successfully adopted laparoscopic techniques to treat surgical diseases. Specific improvisations have helped establish and sustain this technology. We advocate similar local adaptations to increase the use of laparoscopic surgery in hospitals located in limited resource settings.

Laparoscopic appendectomy in a Nigerian teaching hospital.

OBJECTIVE: Laparoscopic appendectomy in a setting where resources are poor is still controversial. This study evaluates the impact of laparoscopy on the early outcome of acute appendicitis in a developing country. METHODS: All patients who underwent appendectomy from January 2010 through June 2011 at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria were recruited for this study. RESULTS: Of the 139 patients with acute appendicitis within the study period, 83 (59.7%) had open appendectomy (OA), 19 (13.7%) whose clinical and radiological findings suggested complicated appendicitis at presentation had laparotomy, while 37 (26.6%) had laparoscopic procedures. In the laparoscopy group, initial diagnostic laparoscopy in 4 (10.8%) patients revealed a normal appendix along with other findings that precluded appendectomy. Laparoscopic appendectomy (LA) was then performed in 33 (23.7%) patients with 2 of these (6.1%) requiring conversion to open laparotomy. Mean time for the LA procedure was higher than that observed for OA (56.2 vs 38.9 min). Patients in the LA group had a shorter mean postoperative stay (1.8 vs 3.0). Wound infection occurred in 2 (6.5%) patients from the LA group and 8 (9.6%) from OA. CONCLUSION: Laparoscopic appendectomy reduced the rate of unnecessary appendectomy and postoperative hospital stay in our patients, potentially reducing crowding in our surgical wards. We advocate increased use of laparoscopy especially in young women.

Global variation in the pattern of differentiated thyroid cancer.

BACKGROUND: The prevalence of differentiated thyroid cancer (DTC) is increasing worldwide. Iodine deficiency is a risk factor for follicular thyroid cancer (FTC). We compared DTC subtypes in an iodine-deficient country with a developed country. METHODS: A retrospective review of thyroid cancer at tertiary centers in West Africa and the United States. All patients diagnosed with thyroid cancer from 1980 to 2004 were retrieved from the West African Center's Cancer Registry Database. The study period was divided into two groups: 1980 to 1989 and 1990 to 2004. In the American center, a review of patients undergoing surgery for thyroid cancer from 1997 to 2008 was performed. RESULTS: At the African institution, 322 patients underwent thyroidectomy for cancer from 1980 to 2004. Overall, 31.5% had papillary thyroid cancer (PTC), and 30.3% had FTC. From 1980 to 1989, 27.3% had PTC and 35.8% had FTC. From 1990 to 2004, 35.7% had PTC and 24.8% had FTC. At the American institution, 105 patients underwent surgery for thyroid cancer from 1997 to 2008; 79% had PTC and 7.6% had FTC. CONCLUSIONS: FTC is still common in developing countries, whereas PTC is the predominant subtype in developed countries. Efforts to decrease iodine deficiency may improve outcomes by changing to a less aggressive subtype.