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.

Torsion of wandering spleen, an unusual cause of acute abdomen; a report of two cases.

BACKGROUND: Wandering spleen is an uncommon entity that is rarely considered in the evaluation of patients with acute abdominal conditions. OBJECTIVE: To report two cases of wandering spleen presenting with acute abdominal pain. METHODS: The clinical records of the patients including preoperative evaluation, intra-operative findings and postoperative care were reviewed RESULT: A 6 year old boy presented with right lumbar pain which worsened over a 36 hour period with findings of a tender right lumbar mass. Abdominal ultrasound showed a mass with echogenicity consistent with that of the spleen with no blood flow and an empty splenic bed. The pre-operative diagnosis was torsion of a wandering spleen. The second case was that of a 42 year old woman who presented with severe colicky lower abdominal pain which worsened over three days with a background history of progressively increasing lower abdominal mass which was tender and about 26 week gestational size at presentation. The initial diagnosis was torsion of an ovarian cyst. Abdomino-pelvic Ultrasound scan showed a heterogeneously hypo-echoic mass overlying the uterus and the left ovary with no blood flow. The presence of wandering spleen with torsion of the vascular pedicle was confirmed at laparotomy in both instances. Splenectomy was performed in both cases with good recovery. CONCLUSION: Torsion of a wandering spleen poses a diagnostic challenge. A high level of suspicion is required to make a diagnosis and institute appropriate treatment.

Giant fibroadenoma presenting like fungating breast cancer in a Nigerian teenager.

BACKGROUND: Giant fibroadenoma of the breast is a rare benign breast tumour which seldom grows to a giant size, it is even rarer for this benign tumour to grow rapidly, ulcerate spontaneously and present like a fungating breast tumour in a way mimicking breast cancer. CASE PRESENTATION: This is a presentation of a 14 year old premenarchal girl with a massive ulcerating and fungating left breast mass that was initially thought to be a fungating locally advanced breast carcinoma on clinical examination. Further examination of the morphology of the resected surgical specimen and histological examination confirmed it to be giant fibroadenoma of the breast. It was successfully managed by partial mastectomy and breast reconstruction with an excellent result and a high degree of patient satisfaction was achieved. CONCLUSION: Though a rare clinical entity benign breast tumour can present like a fungating breast cancer and this must be bore in mind especially in young adolescent patients presenting with ulcerating breast tumour.

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.

Neglected giant fibroadenoma of the breast presenting like a fungating breast cancer in a premenarchal Nigerian teenager.

BACKGROUND: Giant fibroadenoma of the breast is a type of rare benign breast tumour which can grow to a giant size, It is even rarer for this benign tumour to grow rapidly, ulcerate spontaneously and present like a fungating breast tumour in a way mimicking breast cancer. Carcinoma of the breast on the other hand has been on the increase so much that it has assumed an epidemiological dimension. In developing country such as Nigeria late presentation of breast cancer has remained a rule rather than exception and it is very common for patient to present with fungating breast lesion. STUDY DESIGN: This is a case presentation of a 14 year old premenarchal girl presenting with a massive ulcerating and fungating left breast mass that was initially thought to be a fungating locally advanced breast carcinoma on clinical examination. Further examination of the morphology of the resected surgical specimen and histological examination confirmed it to be giant fibroadenoma of the breast. RESULTS: The giant fungating breast tumour successfully managed by partial mastectomy and breast reconstruction with an excellent result and a high degree of patient satisfaction was achieved. CONCLUSION: Though a rare clinical entity benign breast tumour can present like a fungating breast cancer and this must be bore in mind especially in young adolescent patients presenting with ulcerating breast tumour.

Metastatic breast cancer in a Nigerian tertiary hospital.

BACKGROUND: Late presentation of breast carcinoma is common in resource-limited countries with attendant poor outcome. OBJECTIVE: To describe the pattern of clinical presentation and challenges of treating patients presenting with metastatic breast carcinoma in a Nigerian hospital. METHOD: Clinical records of all patients who presented with metastatic breast carcinoma between January 1991 and December 2005 at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria were reviewed. RESULTS: More than half of all histologically confirmed breast cancer patients seen within the study period presented with metastatic disease. Their ages ranged between 20-81 years with a mean age of 45.9 years. Only 3% (6 of 202) were males. Two-thirds had more than one secondary site on initial evaluation and the commonest sites were liver (63%), lung parenchyma (51%), pleura (26%) and contralateral breast in 25%. On immunohistochemistry, basal like tumours were found in 46.1%. Mastectomy was done in 37 patients with fungating breast masses while only one third of those referred to a nearby center for radiotherapy had it done. One year survival rate was 27%. CONCLUSION: Metastatic disease is common in Nigeria and treatment is limited due to resource limitations. Improved awareness of the disease is advocated to reduce late presentation.

Metastatic breast cancer in a Nigerian tertiary hospital

Background: Late presentation of breast carcinoma is common in resource-limited countries with attendant poor outcome. Objective: To describe the pattern of clinical presentation and challenges of treating patients presenting with metastatic breast carcinoma in a Nigerian hospital. Method: Clinical records of all patients who presented with metastatic breast carcinoma between January 1991 and December 2005 at the Obafemi Awolowo University Teaching Hospitals Complex; Ile-Ife; Nigeria were reviewed. Results: More than half of all histologically confirmed breast cancer patients seen within the study period presented with metastatic disease. Their ages ranged between 20-81years with a mean age of 45.9 years. Only 3(6 of 202) were males. Twothirds had more than one secondary site on initial evaluation and the commonest sites were liver (63); lung parenchyma (51); pleura (26) and contralateral breast in 25. On immunohistochemistry; basal like tumours were found in 46.1. Mastectomy was done in 37 patients with fungating breast masses while only one third of those referred to a nearby center for radiotherapy had it done. One year survival rate was 27. Conclusion: Metastatic disease is common in Nigeria and treatment is limited due to resource limitations. Improved awareness of the disease is advocated to reduce late presentation

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.

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.

Pattern of intestinal obstruction in a semiurban Nigerian hospital.

INTRODUCTION: Intestinal obstruction remains one of the commonest causes of acute abdomen worldwide. The pattern of intestinal obstruction varies from one place to another. We report the pattern of intestinal obstruction observed in a semi urban Nigerian hospital over a 5 year period. MATERIALS AND METHODS: Records of patient admitted and managed for intestinal obstruction between April 2001 and April 2006 at the federal medical centre, Owo, Southwestern Nigeria, were reviewed. Demographic data as well as parameters relating to the symptoms, duration, onset, type, diagnosis, intraoperative findings, as well as postoperative outcomes were retrieved. All data was entered into a personal computer and analyzed using SPSS for windows version 11. RESULTS: A total of 95 patients were managed during the period. The mean age was 39 years. The male:female ratio was 1.8:1. Adhesive intestinal obstruction was the commonest cause of symptoms in 44%, followed by volvulus in 14% and external hernias in 11% of the patients. A correct preoperative diagnosis was made in over 70% of the patients. Out of those with adhesive obstruction, 75% had a previous abdominal or groin operation while 57% had surgical exploration for failed conservative management. The mean duration of hospital stay was 6 days and the overall mortality rate was 20%. CONCLUSION: Adhesive intestinal obstruction is the commonest cause in this semi-urban population which was studied. Obstructed hernia is becoming increasingly less common as a cause of intestinal obstruction.

A five year analysis of death in accident and emergency room of a semi-urban hospital.

A 5 year retrospective survey of deaths at the Accident and Emergency Unit was carried out to determine the demographic pattern, causes and time spent before demise. There were 475 deaths, annual rate of 95 cases. Males in 279 (58.8%) and 186 females (41.2%), age ranged from 15-90 years, mean 44 SD +/- 21 years. Medical diseases in 354 (74.5%), trauma in 72 (15.2%) and surgical conditions 49 (10.3%) patients There were 135 (38%) cases of cardiovascular diseases and pulmonary diseases 115 (32.6%) patients. Tuberculosis and pneumonia were the most common of pulmonary conditions. Central nervous diseases and gastro-intestinal diseases in 46 (13%) and 40 (11.2) respectively, mainly infectious conditions. Road Traffic Accident caused death in 51 (70.5%), assaults in 8 (11.4%) cases, gunshot and poison 5 (6.8%) each, and snake bites in only 3 (4.5%) cases of trauma. Surgical acute abdomen with peritonitis occurred in 18 (36%) cases, pyomyositis with septicaemia in 7(133%), gastrointestinal bleeding 5 (10%) and burns in only 3 (6.7%) cases In conclusion, over two-thirds of deaths in accident and emergency unit were due to medical problems. The means of the age were in late thirties- mid forties, there was no significant difference in the mean age of those who died of medical, trauma and surgical problems. Trauma victims spent the shortest mean time in accident and emergency before death, the longest staying were the victims of medical diseases.