Effectiveness of Triclosan Coated Suture for Subcutaneous Wound Closure in Preventing Surgical Site Infection following Mesh Repair of Inguinal Hernia: A Pilot Study.

BACKGROUND: The role of prophylactic antibiotics in mesh repair of inguinal hernia is controversial and often based on institutional policies. Surgical site infection rate from earlier studies in Nigeria justifies the continued use of prophylactic antibiotics during hernia repair. With increased use of antibiotics comes the challenge of antibiotic resistance and toxicity. The use of antimicrobial coated suture may help avoid these challenges but its efficacy needs to be tested. OBJECTIVE: To compare Triclosan coated suture with intravenous antibiotics for the repair of inguinal hernia with mesh. METHODS: Patients with uncomplicated inguinal hernia undergoing mesh repair were randomized to either have intravenous antibiotics administered for prophylaxis or to have wound closure with Triclosan coated Vicryl 2/0 suture. Post operatively, wound infection rates were compared between the two groups. Follow up was for 1 year. RESULTS: We studied 49 patients with 59 hernias with a mean age of 53 years. Hernias were solitary in 75% of cases, the majority of which were right sided, while 25% were bilateral. There were 25 patients with 32 hernias in the Intravenous antibiotic group (Group A) and 24 patients with 27 hernias in the Triclosan suture group (Group B). Wound grades were similar between the two groups with one patient in the Triclosan group confirmed to have wound infection (4.2%) and none in the Intravenous antibiotics group (p=0.27). Wound infection was of the superficial type which resolved with wound care within 1 month. CONCLUSION: Triclosan coated suture may be safely used as an alternative to intravenous antibiotics for the mesh repair of inguinal hernia. Further studies are required to validate this finding.

RÉSUMÉ: Le rôle des antibiotiques prophylactiques dans la réparation par maille de la hernie inguinale est controversé et souvent basé sur les politiques institutionnelles. Le taux d'infection du site opératoire d'études antérieures au Nigeria justifie l'utilisation continue d'antibiotiques prophylactiques pendant la réparation d'une hernie. L'utilisation accrue des antibiotiques pose le défi de la résistance et de la toxicité aux antibiotiques. L'utilisation d'une suture enduite d'un antimicrobien peut aider à éviter ces défis, mais son efficacité doit être testée. OBJECTIF: Comparer la suture enduite de triclosan avec des antibiotiques intraveineux pour la réparation de la hernie inguinale avec un filet. MÉTHODES: Les patients présentant une hernie inguinale non compliquée subissant une réparation par filet ont été randomisés pour recevoir soit des antibiotiques par voie intraveineuse à titre prophylactique, soit une fermeture de la plaie avec une suture Vicryl 2/0 revêtue de triclosan. Après l'opération, les taux d'infection des plaies ont été comparés entre les deux groupes. Le suivi a duré 1 an. RÉSULTATS: Nous avons étudié 49 patients avec 59 hernies avec un âge moyen de 53 ans. Les hernies étaient solitaires dans 75 % des cas, majoritairement du côté droit, tandis que 25 % étaient bilatérales. Il y avait 25 patients avec 32 hernies dans le groupe antibiotique intraveineux (groupe A) et 24 patients avec 27 hernies dans le groupe suture au triclosan (groupe B). Les grades des plaies étaient similaires entre les deux groupes avec un patient dans le groupe Triclosan confirmé pour avoir une infection de la plaie (4,2%) et aucun dans le groupe antibiotiques intraveineux (p=0,27). L'infection de la plaie était de type superficiel qui s'est résolue avec le soin de la plaie en 1 mois. CONCLUSION: La suture enduite de triclosan peut être utilisée en toute sécurité comme alternative aux antibiotiques intraveineux pour la réparation par maille de la hernie inguinale. D'autres études sont nécessaires pour valider ce résultat. MOTS CLÉS: Hernie au triclosan, infection.

Comparative study of collagen and elastin content of abdominal wall fascia in inguinal hernia and non-hernia patients in an African population.

PURPOSE: Altered composition of collagen and elastin in abdominal fascia has been linked with the pathogenesis of hernias. This has not been studied amongst Africans who have hernia presentations which vary significantly from Caucasian cohorts. The aim of this study was to determine, and compare, the collagen and elastin contents of the transversalis fascia and rectus sheath of inguinal hernia patients with non-hernia controls. METHODS: Twenty-five patients with solitary, primary, uncomplicated inguinal hernia and twenty-five non-hernia controls were evaluated. Biopsies of the transversalis fascia and anterior rectus sheath were stained with Masson Trichrome and Verhöeff van-Gieson to isolate collagen and elastin respectively, which were quantified using the ImageJ/Fiji® image analysis software. RESULTS: Inguinal hernia patients were aged 19-85 years with a mean age of 45.2 years, mean body mass index (BMI) of 23.3 kg/m2 and mean duration of hernia of 42.5 months. Lateral hernias with no hernia defect or posterior wall defect [PL0] were the predominant clinical type. There were significantly lower collagen and higher elastin content in the transversalis fascia and rectus sheath of inguinal hernia patients [P < 0.001]. Regression analysis identified smoking and long duration of hernias as independent predictors of low collagen levels in this study CONCLUSION: Inguinal hernia patients in the study population demonstrated depleted collagen in the connective tissue of the inguinal canal. This might justify the routine use of prosthetic mesh for the reinforcement of the posterior wall during hernia repair.

Use of commercial mesh for hernia repair in a low resource setting: experience after 500 cases.

BACKGROUND: The use of mesh has revolutionized the management of hernias in many parts of the world. There is, however, limited experience on its use in sub-Saharan Africa. This study describes a single hospital experience after 500 cases of mesh hernia repairs in a sub-Saharan African country. METHODS: We reviewed the records of the first 500 cases of abdominal wall hernia operations performed using commercial mesh since year 2007. Socio-demographic characteristics, hernia type, method of repair and outcome data were analyzed and presented as descriptive statistics. RESULTS: The first 500 cases of mesh hernia repairs were performed between 2007 and 2017 during which a total of 1,175 hernia operations were carried out, mesh repair accounting for 42.5% of the total. There was a progressive rise in the uptake of mesh repairs over time, with mesh repairs overtaking tissue based repairs in the last few years of the review. Inguinal hernia was by far the commonest indication for mesh use (80.4%), followed by incisional hernia (9%). Polypropylene mesh was the most common type of mesh used in about 96.2% of cases. Overall, there were seven recurrences (1.4%) at a mean follow-up period of 15.3 months (1-108 months) CONCLUSION: In spite of resource limitations, the use of mesh for hernia repairs continues to rise and has overtaken tissue-based repairs in a sub-Saharan African setting. Results show good outcomes justifying continued use.

Percutaneous Endoscopic Gastrostomy in Ile-Ife, Nigeria:An Initial Report.

BACKGROUND: Protein-energy malnutrition is a common problem in critically ill patient and it is a major cause of accelerated morbidity and mortality in this group of patients. Recent dramatic advances in both enteral and parenteral nutritional support have ensured that most of these critically ill patients are adequately nutritionally supported. Unfortunately, most of these advancements in nutritional supports are far from the reach of most patients in developing countries. In this report, we highlighted the indications, success, challenges of the use of percutaneous endoscopic gastrostomy (PEG) in Nigeria patients. PATIENTS AND METHODS: All cases of PEG performed at the Endoscopy Unit of Obafemi Awolowo University Teaching Hospitals complex, Ile-Ife, Osun State from January 2011 and June 2012 were recruited into the study. The data obtained included the sociodemographic parameters, indication and duration of the procedure, complications, and follow up. RESULTS: During the 18 months study period 645 upper gastrointestinal endoscopic procedures were performed. Majority [601(93.2%)] of the cases were for diagnostic purposes. Six (0.9%) cases of PEG were performed. Most (5 of 6) of the patients had central nervous system impairment while only one had severe chronic facial infection with naso-oral fistula. The median age of patients was 60.5 years. The entire procedure including endoscopy lasted an average of 25 minutes with a range of 12-35 minutes. Only one case had peristoma infection which resolved with antibiotics and repeated dressing with povidone iodine. There was no episode of aspiration pneumonitis or procedure related mortality. The average follow up was 6 months with variable weight gain during the follow up period. CONCLUSION: PEG is a simple, cost effective and safe method to rehabilitate nutritionally all chronically ill patients in less developed countries such as Nigeria. The need to increase awareness and acceptability of PEG among physicians managing such patients and the society cannot be overemphasized.

Riedel's thyroiditis in a black African: A case report and review of literature.

Riedel's thyroiditis is a rare cause of the enlargement of the thyroid gland. The etiology is not fully known. There has been no report of Riedel thyroiditis in our country. We report a case of a 61-year-old man with the disease as well as review the literature. We present the case of 61-year-old carpenter seen in our clinic with 2½ years history of painless anterior neck swelling associated with hoarseness of voice. He had multiple hard nodules on the left lobe of the thyroid gland with multiple cervical lymph nodes enlargement. No feature of hypothyroidism or thyroiditis. Clinical diagnosis of malignant goiter was made although Fine-needle aspiration for cytology did not suggest malignancy. He had surgery, findings included nonresectable hard multinodular left thyroid lobe from which a wedge biopsy was taken, Histology of the specimen revealed Riedel's thyroiditis. He was managed with oral Prednisolone and Tamoxifen with remarkable improvement in his clinical symptoms. Riedel's thyroiditis is a rare disease. It can easily mimic malignant goiter hence proper histological diagnosis will be necessary to differentiate. Review of medical literature showed that Riedel thyroiditis has not been reported in a black African patient inhabiting the sub-Sahara Africa. This was a report of Riedel thyroiditis in a black Nigerian patient that was successfully managed on oral glucocorticoid, tamoxifen and L-thyroxine.

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.

Early Experience with Stapled Gastrointestinal Anastomoses in a Nigerian Hospital.

BACKGROUND: Hand-sewn gastrointestinal anastomoses has been the traditional approach to gastrointestinal anastomosis in Nigeria while stapled anastomoses are infrequently performed in few centers. OBJECTIVES: To describe the outcome of our initial experience with stapled gastrointestinal anastomoses in a semi-urban patient population. PATIENTS AND METHODS: Consecutive patients who had stapled gastrointestinal anastomoses between January 2011 and June 2014 in a Nigerian tertiary hospital were prospectively evaluated. Indications for operation, procedures performed and anastomoses constructed and postoperative outcome of each patient were documented. RESULTS: Nineteen patients including seven males and 12 females had stapled anastomoses within the period. Their ages ranged between 41 and 68 (mean 52.5) years. Six (31.6%) Roux-en-Y gastrojejunostomies, 6 (31.6%) ileo-colic, 3 (15.8%) ileo-ileal, 2 (10.5%) colo-colic, and 2 (10.5%) colo-anal anastomoses were performed. Indications include antral gastric cancer in 4 (21.1%), right colon cancer 4 (21.1%), ileal perforations in 3 (15.8%) while 2 (10.5%) each had left colon cancer, common bile duct obstruction, rectal cancer and ruptured appendix. Mean duration of operation was 108 ± 46 min and mean duration of postoperative stay was 5 ± 2.6 days. No intraoperative complications were recorded and no anastomotic leakage occurred. At a median follow-up of 5 months no staple related stricture had occurred. CONCLUSIONS: Stapled gastrointestinal anastomoses are associated with a good outcome in our center. We propose a prospective, large-population randomized comparison of the technique with hand-sewn anastomoses.

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.

ORAL CLINICAL LONG CASE PRESENTATION, THE NEED FOR STANDARDIZATION AND DOCUMENTATION.

BACKGROUND: The oral presentation of the clinical long case is commonly an implied knowledge. The challenge of the presentation is compounded by the examiners' preferences and sometimes inadequate understanding of what should be assessed. OBJECTIVES: To highlight the different opinions and misconceptions of trainers as the basis for improving our understanding and assessment of oral presentation of the clinical long case. METHODOLOGY: Questionnaire was administered during the West African College of Surgeons fellowship clinical examinations and at their workplaces. Eligibility criteria included being a surgeon, a trainer and responding to all questions. RESULTS: Of the 72 questionnaires that were returned, 36(50%) were eligible for the analysis. The 36 respondents were from 14 centers in Nigeria and Ghana. Fifty-two percent were examiners at the postgraduate medical colleges and 9(25%) were professors. Eight(22.2%) indicated they were unaware of the separate methods of oral presentation for different occasions while 21( 58.3%) respondents were aware that candidate used the "5Cs" method and the traditional compartmentalized method in long case oral presentation. Eleven(30.6%) wanted postgraduates to present differently on a much higher level than undergraduate despite not encountering same in literature and 21(58.3%) indicated it was an unwritten rule. Seventeen (47.2%) had not previously encountered the "5Cs" of history of presenting complaint in literature also 17(47.2%) teach it to medical students and their junior residents. CONCLUSION: This study has shown that examiners definitely have varying opinions on what form the oral presentation of the clinical long case at surgery fellowship/professional examination should be and it translates to their expectations of the residents or clinical students. This highlights the need for standardization and consensus of what is expected at a formal oral presentation during the clinical long case examination in order to avoid subjectivity and bias.

Percutaneous endoscopic gastrostomy in ile-ife, Nigeria: an initial report.

BACKGROUND: Protein-energy malnutrition is a common problem in critically ill patient and it is a major cause of accelerated morbidity and mortality in this group of patients. Recent dramatic advances in both enteral and parenteral nutritional support have ensured that most of these critically ill patients are adequately nutritionally supported. Unfortunately, most of these advancements in nutritional supports are far from the reach of most patients in developing countries. In this report, we highlighted the indications, success, challenges of the use of percutaneous endoscopic gastrostomy (PEG) in Nigeria patients. PATIENTS AND METHODS: All cases of PEG performed at the Endoscopy Unit of Obafemi Awolowo University Teaching Hospitals complex, Ile-Ife, Osun State from January 2011 and June 2012 were recruited into the study. The data obtained included the sociodemographic parameters, indication and duration of the procedure, complications, and follow up. RESULTS: During the 18 months study period 645 upper gastrointestinal endoscopic procedures were performed. Majority [601(93.2%)] of the cases were for diagnostic purposes. Six (0.9%) cases of PEG were performed. Most (5 of 6) of the patients had central nervous system impairment while only one had severe chronic facial infection with naso-oral fistula. The median age of patients was 60.5 years. The entire procedure including endoscopy lasted an average of 25 minutes with a range of 12-35 minutes. Only one case had peristoma infection which resolved with antibiotics and repeated dressing with povidone iodine. There was no episode of aspiration pneumonitis or procedure related mortality. The average follow up was 6 months with variable weight gain during the follow up period. CONCLUSION: PEG is a simple, cost effective and safe method to rehabilitate nutritionally all chronically ill patients in less developed countries such as Nigeria. The need to increase awareness and acceptability of PEG among physicians managing such patients and the society cannot be overemphasized.

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.

Presentation, distribution pattern, and management of diverticular disease in a Nigerian tertiary hospital.

BACKGROUND: Colonic diverticular disease is one of the most common and costly gastrointestinal disorders among industrialized societies, which have recently been described among Africans. Presentations and distribution pattern of the disease among Africans appeared to be different from that described among the Western population. We embark on this study aimed at evaluating the presentation, distribution pattern, and the management of diverticulosis in our tertiary health facility. MATERIALS AND METHODS: A prospective descriptive study of the cases of diverticular disease seen between January 2007 and December 2011 at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria. RESULTS: During the 5-year study period, 40 cases were seen. The patients were aged 41-85 years with a median age of 64 years. There were 29 (72.5%) male and 11 (27.5%) female with an average male to female ratio of 3:1. The most common presentation was bleeding per rectum in 28 (70%) patients, which mostly needed transfusion. Ten (25%) patients presented with recurring abdominal pain, whereas one (2.5%) patient presented with abdominal mass and features of intestinal obstruction. Thirty patients were diagnosed on colonoscopy, eight on barium enema, and two on computerized tomography scan. Thirty-four (85%) patients had a pancolonic disease. All the patients were placed on high fiber diet and antibiotics namely ciprofloxacin and metronidazole. Five patients had recurrence within 6 months of follow up, of which one had emergency colectomy. CONCLUSION: Diverticular disease is no longer a rare disease in Nigeria. It is a common cause of lower gastrointestinal bleeding in elderly patients. High index of suspicion for diverticular disease of the colon and its complications should increase in the country.

A review of the management of perforated duodenal ulcers at a tertiary hospital in south western Nigeria.

BACKGROUND: Gastro-duodenal perforations are common and may complicate peptic ulcer disease. Management is often by surgical closure. OBJECTIVE: To determine the patterns of presentation and mode of management of duodenal ulcer perforations. METHODS: Retrospective review of patients with duodenal ulcer perforations seen at the Obafemi Awolowo University Teaching Hospital between June 2001 and July 2011. Patients' records were reviewed for demography, duration of disease, probable risk factors, type of surgery and complications. Data obtained was analyzed using SPSS 15.0. RESULT: Forty- five patients were reviewed. There were 37 males (82.2%). Mean age was 39.7years (range 15-78years). There were 10 (22.6%) students and 8(17.8%) farmers. NSAIDs abuse (11), previous peptic ulcer disease (2), and no prior dyspeptic symptoms (20) constituted 24.4%, 4.4% and 44.4% respectively of cases. Seven (16%) patients presented less than 24 hours of onset of illness. Forty one perforations (91.1%) involved the first part of duodenum. Twenty two (49%) patients had Graham's omental patch. We had one (2.2%) failed repair and six (13.3%) mortalities. CONCLUSION: Late presentation of duodenal ulcer perforation is common with high mortality. Pragmatic surgical intervention with Graham's omentopexy with broad spectrum antibiotics is still commonly practiced.

Characteristics of inflammatory bowel disease in three tertiary health centers in southern Nigeria.

BACKGROUND: Inflammatory bowel disease (IBD) refers to two chronic inflammatory disorders of the gastrointestinal tract which is generally believed to be rare in most African countries. The objectives of the current study were to present the experience of three tertiary gastroenterology centers in southern part of Nigeria on IBD, highlighting the age distribution of the patients seen, management and the impact on the quality of their life in university-based community-type practices in Nigeria. METHODS: This was a retrospective review of charts of inflammatory bowel disease seen between January 2007 and June 2010 at three teaching hospitals in Southern Nigeria. Diagnosis of IBD was made from clinical manifestations, colonoscopic and histopathological findings. RESULTS: During the study period, 12 patients presented with clinical features consistent with inflammatory bowel disease. There were 8 (66.7%) males and 4 (33.3%) females and had ages ranged from 18 years to 80 years with a median of 26.5 years. Eight (66.7%) patients had ulcerative colitis while 4(33.3%) had Crohn's disease. Ten (83.3%) patients had severe disease with main clinical features being recurrent diarrhoea and passage of mucoid bloody stools. All the patients had treatments with sulphasalazine or mesalazine, steroids and antibiotics with good responses. One patient died following the occurrence of toxic megacolon. CONCLUSION: Although IBD is uncommon in Nigeria, high index of suspicion is necessary by attending physicians managing patients with recurrent passage of mucoid bloody stools. Prompt gastroenterological referral and judicious use of colonoscopy and biopsy will assist in making the diagnosis.

Spectrum of colonoscopy findings in Ile-Ife Nigeria.

AIMS AND OBJECTIVES: Lower gastrointestinal (LGI) diseases are the leading causes of morbidity and mortality worldwide. Colonoscopy holds an important place in screening, diagnosing and treatment of these conditions. In Nigeria, as in many other developing countries, the facility for performing colonoscopy is rarely available. This prospective report seeks to evaluate the demographic data of patients presenting for colonoscopy, the pattern and validity of referral diagnosis versus colonoscopy findings in Ile-Ife, Nigeria. SUBJECTS AND METHODS: All patients who had colonoscopy procedure done in the Endoscopy Unit of Obafemi Awolowo University Teaching Hospital Complex between January 2007 and December 2011 were included in the study. RESULTS: During the study period, colonoscopy was carried out in 320 patients. One hundred and eighty two (56.9%) were males, while 138 (43.1%) were females. The median age was 59.5 years. Their ages ranged from 2-87 years. The most common indications were lower gastrointestinal bleeding and change in bowel habit which together accounted for 79.0%. No abnormality was seen in 93(29.1%) patients. Abnormal endoscopic findings included 66(20.6%) patients who had haemorrhoids, 50(15.6%) cases colorectal cancer, 33 (10.3%) patients had benign polyps and (30 (9.4%) patients had diverticular disease. Other findings were colitis, inflammatory bowel disease, rectovaginal fistula, vascular ectasia and extra luminal compression. Haemorrhoids, diverticulosis and polyps were the most common findings in patients presenting with lower gastrointestinal bleeding. CONCLUSION: This present report showed that colonoscopy is a cheap, safe and effective method of investigating lower gastrointestinal disease in Ile-Ife, Nigeria. When the indication is based on symptoms, the diagnostic yield could be as high as 90%. The common causes of lower gastrointestinal bleeding in Ile-Ife, Nigeria include haemorrhoids, diverticulosis and polyps.

Audit of management of gallbladder cancer in a Nigerian tertiary health facility.

BACKGROUND: Gallbladder cancer is a rare malignancy with a variable incidence worldwide. It ranks number eight among all gastrointestinal cancer seen in Nigeria. It is associated with high mortality and morbidity because it is usually diagnosed very late. Adequate surgical resection is the only modality with hope of cure. This requires advanced surgical skills which is quite rare in most developing countries like Nigeria. In this current work, we audit the management and outcome of gallbladder cancer in our hospital, highlighting peculiarity associated with our setting. PATIENTS AND METHOD: Consecutive patients managed as cases of gallbladder cancer at Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria between January 1990 and December 2010 were studied retrospectively. Patient demographics, disease and treatment-related variables, and outcomes were analyzed by SPSS version 16.0. RESULTS: Thirty-one cases of gallbladder cancer were diagnosed over the 21-year period, and this accounts for about 0.3% of all cancer cases seen in our hospital. The median age of this patient cohort was 58 years (range 28 to 79 years). Seventeen (54.8%) patients were age below 60 while 14 (45.2%) were age 60 and above. Twenty-seven patients (87.1%) were female and four (12.9%) were male, with a male to female ratio approximately 1:7. Over 80% of the patients presented with a triad of upper abdominal pain, weight loss, and jaundice. Majority (67.7%) of the patients were diagnosed intraoperatively. Only four patients underwent complete resection as they had radical cholecystectomy including regional lymph node dissection and wedge resection of the gallbladder fossa of the liver. The stages of the resected patients were T3 in three patients and T2 in one. Overall 1- and 5-year survival rates for our entire patient cohort were 32% and 10%, respectively. CONCLUSION: In conclusion, this study showed that preoperative diagnosis of gallbladder cancer could be challenging in our environment. A triad of upper abdominal pain, jaundice, and weight loss with judicious use of available radiological modality will increase the chances of making the preoperative diagnosis of the cancer. It also showed that good outcome can be obtained when radical surgery is offered to these few patients within the limitation of resources in few patients with resectable tumor.

Evaluation of tension-free mesh inguinal hernia repair in Nigeria: a preliminary report.

BACKGROUND: Tension-free mesh inguinal hernia repair is becoming increasingly popular worldwide. However, reports are sparse in Nigeria. OBJECTIVE: To evaluate the impact, outcome and cost implication of tension free inguinal hernia repair in a Nigerian setting. METHODS: A prospective study of all consecutive adults patients with uncomplicated inguinal hernia who had mesh repair over a period of 12 months was undertaken. A large sheet of 900cm2 polyproylene mesh material was used for all the patients in the study. All wounds were opened on the third postoperative day while sutures were removed on the eight day. Patients were followed up for one year. RESULTS: A total number of 30 patients had tension-free mesh ingunal hernia repair. Their ages ranged from 21 to 78 years (mean 47.2±15.5) years with a female to male ratio of 1:15. Complete inguinoscrotal hernia was the commonest type of groin hernia accounting for 40% of the cases. The repair of posterior wall which entailed placement of mesh was completed at a median time of 15 minutes. While two (6.7%) and one (3.3%) had wound oedema and groin pain respectively at one month, none of the patients had these complications or recurrence at a median of five months follow-up period. CONCLUSION: Tension-free mesh inguinal hernia repair was well tolerated and affordable to our patients. Pain and infections, reported to be the common complications of this procedure were infrequent in this study. A larger study is recommended to help confirm these findings.

Bowel preparation for colonoscopy: enema versus sodium phosphate.

BACKGROUND: Colonoscopy is considered to be the gold standard investigation for assessing the colonic mucosa. Good bowel preparation is essential in order to achieve optimal visualisation of the mucosa. Traditionally water enema is used for bowel preparation in most centres in Nigeria. This prospective study was performed at the Gastrointestinal Endoscopy Unit of Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria between July 2008 and June 2009. AIMS AND OBJECTIVES: This study compared patients' tolerability, adverse effects, efficacy and mean duration of colonoscopy of water enema and sodium phosphate (NaP) for bowel preparation toward colonoscopy. PATIENTS AND METHODS: Standard structured questionnaire was completed by 64 patients and the colonoscopist assessing tolerability, adverse effect, efficacy and mean duration of the procedure. RESULTS: There were sixty four patients aged between 22 to 86 years. The mean age was 58.16 ± 15.790. Thirty eight (59.4%) patients were in patients and 26 (40.6%) were out patients. Forty one (64.1%) patients had water enema while 23 (35.9%) patients were included in the NaP group. The median age for patients in both groups was 62.0 years. Patients in NaP group rated their bowel preparation as more tolerable and found the dietary restriction much easier than those in water enema group (p < 0.0001). Better colon cleansing score was found in patient in NaP group as compared with those in water enema group in all region of the colon. The procedure took significantly longer time in patients in water enema group as compared with those in NaP group (p < 0.0001). CONCLUSION: NaP has a better bowel cleansing score for colonoscopy than water. It has better tolerability, side effect profile, efficacy and gives a shorter mean duration for the procedure.

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.