Changing trend in the management of omphalocoele in a tertiary hospital of a middle-income country.

BACKGROUND: The peri-operative management of omphalocoele in low- and middle-income countries is challenging owing to non-availability of neonatal intensive care units and equipment needed for the care of this anomaly. AIM: This study examined our experience in the management of omphalocoele and compared the pattern and outcome with a similar study from the same centre conducted four decades ago. METHODS: A retrospective study of neonates managed for omphalocoele from 2003 to 2017 (Group A) was performed. Their demographic characteristics, clinical presentation, management modality and outcome were obtained and statistical analysis was performed to determine the predictors of mortality. The findings were also compared with the findings of a similar study (Group B) published from this centre four decades ago from 1973 to 1978. RESULTS: A total of 95 patients were managed in Group A and 33 in Group B. Their ages ranged from 1 to 15 days with a median age of 1 day and a median gestational age at birth of 37 weeks (range - 36-43 weeks) in Group A and 5-72 h in Group B. There were 54 (56.8%) boys and 41 (43.2%) girls in Group A and 17 (51.5%) boys and 16 (48.5%) girls in Group B. Rupture of the sac was observed in 18 (18.9%) patients in Group A and 13 (39.4%) in Group B. Operative management was adopted for 55 (57.9%) patients in Group A compared to 14 (42.4%) in Group B. Mortality was recorded in 16 (16.8%) patients in Group A and 16 (48.5%) in Group B. Following further analysis in Group A, management outcome was noted to be significantly associated with the state of the sac (P = 0.011), presence of associated sepsis (P = 0.002) at presentation and management modality (P = 0.048) with only associated sepsis independently predicting mortality. CONCLUSION: Although epidemiological trend and clinical presentation are still similar, management outcome has improved over the years.

Experience with the management of anorectal malformations in Ibadan, Nigeria.

INTRODUCTION: anorectal malformation is a multi-systemic birth defect of the distal gastrointestinal tract, the management of which is challenging to the surgeons, the patients and the parents. The presence of associated congenital malformations may worsen the outcome with consequent psychosocial effects on the patients and the parents. The characteristics of anorectal malformations with the challenges associated with their management and the outcomes are therefore presented here. METHODS: all patients managed for anorectal malformations from January 2003 to December 2017 were studied. Patients´ demography, clinical presentations, types of malformations, associated anomalies, procedures performed, post-operative complications and management outcome were obtained and analysed. RESULTS: eighty-eight children with anorectal malformations comprising 61 (69.3%) boys and 27 (30.7%) girls were studied with 76 (86.3%) patients presenting within the first year of life. Low anorectal malformation was observed in 14 (15.9%) patients, 71 (80.7%) patients had intermediate or high malformations and cloacal malformation was present in 3 (3.4%) patients. Associated congenital malformations were observed in 18 (20.5%) patients with 10 (55.6%) patients associated with intermediate or high malformations and urogenital system was the most common system whose anomalies were associated with anorectal malformations in 12 (13.6%) patients. Anoplasty was performed on 14 (15.9%) patients, posterior sagittal anorectoplasty was performed on 67 (76.1%) patients, abdominosacroperineal pull through on 4 (4.6%) patients and posterior sagittal anorectovaginourethroplasty on 3 (3.4%) patients. Six (6.8%) neonates died. CONCLUSION: immediate post-operative outcome was good; however, good functional outcome can only be assessed in an atmosphere of good follow-up which is still a problem in our environment.

Impact of communication on the awareness of birth defects among adult women in Nigeria

OBJECTIVES: Birth defects are universal problems associated with poor management outcomes in children, especially in developing countries where its burden is enormous. Media advocacy is believed to help in reducing these poor outcomes. This study assessed the level of awareness of birth defects in women and the impact of the media in Nigeria. MATERIAL AND METHODS: This was a descriptive cross-sectional study of 778 women, conducted in the outpatient clinics of two major referral hospitals in Ibadan, Nigeria, from March to October 2019. RESULTS: Of the 778 women, 768 were administered a structured questionnaire and 10 women whose children have been managed for a congenital anomaly before were interviewed using an in-depth interview guide. Of the 768 respondents, 600 (78.1%) were in the third and fourth decades of life and 577 (75.1%) women have heard about birth defects before. A total of 348 (60.3%) and 134 (23.2%) women heard about it from the hospital and mass media, respectively, with 65.0% of them believing that the media were helping in educating people about birth defects. There was a statistically significant relationship between the awareness levels and the respondents' occupation (χ2 = 28.914, P < 0.001), educational status (χ2=43.325, P < 0.001), religion (χ2 = 10.376, P = 0.016), antenatal clinic attendance (χ2 = 5.035, P = 0.025), and history of previous mid-trimester abortion (χ2 = 7.689, P = 0.006). CONCLUSION: The level of awareness about birth defects is good but not enough; there is a need for greater media involvement in disseminating information on the occurrence of birth defects.

Trends in the publication of infantile hypertrophic pyloric stenosis in Africa: a systematic review

There are still global variations in the epidemiology of infantile hypertrophic pyloric stenosis, although the clinical presentations may be similar. Outcome of management, however, may depend on the degree of evolution of management of the anomaly. This review aimed at evaluating the trends of reporting of infantile hypertrophic pyloric stenosis from Africa. An evaluation of all publications from Africa on infantile hypertrophic pyloric stenosis focusing on epidemiology, evolution of management of the anomaly was carried out. Literature search of all publications from Africa on Infantile hypertrophic pyloric stenosis was conducted from January 1, 1951, to December 31, 2018. The articles were sourced from the databases of African Index Medicus, OvidSP, PubMed, African Journal Online, and Google Scholar. Extracted from these publications were information on the type of article, trend of reporting, the country of publication, demographic details of the patients, number of cases, clinical presentation, pre-operative management, type of surgical approach, and the outcome of management. Overall, 40 articles were published from 11 countries. Of these, 16 (40.0%) were published in the first 35 years (Group A, 1951­1985) and 24 (60.0%) published in the later 33 years (Group B, 1986­ 2018). Case reports 8 (20.0%) and case series 5 (12.5%) were predominant in Group A, whereas retrospective studies 12 (30.0%) predominated in Group B. The countries of publication included Nigeria (27.5%), South Africa (15.0%), Egypt (12.5%), Tanzania (10.0%), and Zimbabwe (10.0%). A total of 811 patients diagnosed and managed for infantile hypertrophic pyloric stenosis (IHPS) were reported. Their ages ranged from 1 day to 1 year with an incidence that ranged from 1 in 550 to 12.9 in 1000. There were 621 boys and 114 girls (M:F ­ 5.5:1). All the patients were breastfed with an average birth rank incidence of 42.4% among firstborns, 19.5% in second borns, 15.2% in third borns, 13.2% among fourth borns, and 10.0% among fifth borns and beyond. Associated congenital anomalies were reported in 5 (12.5%) studies with an incidence of 6.9­20% occurring in a total of 28 patients. All but 3 (7.5%) studies reported that open surgery was adopted to perform Ramstedt's pyloromyotomy on the patients. Reported post-operative complications include mucosal perforation in 8 (20.0%) studies, surgical site infection in 7 (17.5%), gastroduodenal tear 2 (5.0%), and hemorrhage and incisional hernia in 1 (2.5%) study each. Mortality was reported in 26 (65.0%) studies with a range of 1.8­50% and a mean mortality rate of 5.2%. There has been a change in the trend of reporting IHPS in Africa over the years, with increasing comparative studies on the modalities of management compared to case reports and series. Still very limited work has been done in the aspect of genetics and etiology of IHPS among Africans. There is a need to increase funding in this regard and to encourage multi-center collaborations in the study of this relatively rare condition

Outcome of Management of Neonatal Intestinal Obstruction at a Tertiary Center in Nigeria.

BACKGROUND: Intestinal obstruction in a newborn remains a significant emergency in pediatric surgery. Clinical presentation is often subtle with sudden deterioration of their clinical states. Clinical outcome in the developing countries is poor owing to a variety of factors. OBJECTIVE: The objective of this study is to identify the factors affecting the management outcome in our environment. PATIENTS AND METHODS: Data on clinical presentation, management, and outcome of all neonates managed for intestinal obstruction over a 13-year period at a tertiary center in Nigeria were retrospectively reviewed. Analysis of factors affecting the management outcome was also performed. RESULTS: One hundred and seventeen neonates comprising 85 (72.7%) boys and 32 (27.3%) girls were managed for intestinal obstruction. The age at presentation ranged from 0 to 29 days, with a mean of 6.86 ± 8.4 days. Seventy-five (64.1%) patients presented within a week of onset of symptoms and 42 (35.9%) patients later. Eighty-five patients (72.6%) presented with symptoms from birth. The most common causes of intestinal obstruction included anorectal malformation in 62 (53%) neonates and Hirschsprung's disease in 16 (13.7%) neonates. Other causes included obstructed inguinoscrotal hernias, duodenal atresia, jejunoileal atresia, malrotation, and annular pancreas. Eleven patients died with a mortality rate of 9.4%. The age at presentation (P = 0.001) and the presence of postoperative complications (P = 0.009) were significantly related to the duration of hospital stay. Furthermore, the presence of postoperative complications (P = 0.012) was significantly associated with postoperative mortality. CONCLUSION: Early presentation and postoperative complications significantly affected the morbidity and mortality associated with the management of neonates with intestinal obstruction.

Management outcome of thyroglossal cyst in a tertiary health center in Southwest Nigeria.

Thyroglossal duct cyst is a non-odontogenic congenital developmental cyst. It is predominantly a midline anterior neck swelling in children and total excision of the tracts prevents recurrence. Retrospective hospital record analysis of patients managed with histopathology results of thyroglossal cyst between 2003 and 2018. Comparing outcomes and technique of thyroglossal cyst excision in a resource challenged environment. A total of 37 patients comprising 22(59.5%) males and 15(40.5%) females (M:F 1.4:1) with age range of 13 days to 55 years (median 6 years) were managed. The majority were children less than 10 years of age. They all presented with a fluctuant midline progressive anterior neck swelling, in addition to anterior neck ulcer 1(2.7%), discharging sinuses 3(8.1%) and thyroglossal cyst duct infections, which were managed successfully with antibiotics. Central compartment neck dissection with excision of mid-portion of the hyoid bone was performed in all the patients. Rupture of thyroglossal duct cysts was observed in 7(18.9%) at surgery, but there was no recurrence. Surgical drain was not used and most patients were discharged within 48 hours postoperatively. Thyroglossal duct cyst was confirmed at histology without any evidence of mitotic changes. There was no recurrence for the Sistrunk's procedure in all specialties. The modification of the Sistrunk's procedure with mid-anterior neck dissection is effective in excising a thyroglossal duct cyst, hence preventing recurrence. Non-usage of wound drains and short hospital stay are cost effective.

Positioning the Umbilicus in African Newborns with Large Anterior Abdominal Wall Defects.

OBJECTIVE: We tried to determine the normal position of the umbilicus in African newborns with a potential application in aesthetically acceptable umbilical reconstruction. SUBJECTS AND METHODS: The study involves a cross-sectional study of 896 healthy neonates who underwent clinical abdominal examination and measurement of the distances between the xiphoid process and the umbilicus (XU), xiphoid process and the pubis (XP), umbilicus and the pubis (UP), umbilicus and the anterior superior iliac spine (UASIS), abdominal girth (AG), and inter anterior superior iliac spines (IASIS) distance. The gestational age at delivery, age at measurement, sex, AG measured across the umbilicus, birth weight (BW), body length, and body mass index of the newborns were recorded. The measurements were used to determine the location of the umbilicus and Pearson's correlation analysis performed to determine the relationships of the recorded neonatal parameters with the measurements. RESULTS: The mean XP was 11.97 ± 2.09 cm, XU = 7.94 ± 2.74 cm, UP = 4.26 ± 1.21 cm, UASIS = 5.79 ± 1.04 cm, and IASIS = 10.25 ± 1.54 cm. The BW, length, and AG significantly correlated with the distance between the XU, umbilicus and pubis, umbilicus and anterior superior iliac spine as well as the distance between the two anterior superior iliac spines. CONCLUSION: The position of the umbilicus is dependent on the selected participants' characteristics. We suggest that a UP: XU ratio of 0.55 should be used to position the umbilicus during umbilical reconstruction in African neonates.

Comparison between testicular volumes as measured with prader orchidometer and ultrasonography in Healthy Nigerian Newborns.

BACKGROUND: We compared the testicular volume (TV) measured with Prader orchidometer (PO) to the volume measured with ultrasonography in male neonates and their relationships with some selected neonatal characteristics. SUBJECTS AND METHODS: A cross-sectional study of all term male neonates who had clinical examination of their external genitalia performed and TV was measured using PO and ultrasonography. Information about the gestational age, birth weight, and birth length was also recorded to determine their relationships with TV measured. RESULTS: The mean TV measured with PO was 1.06 (standard deviation [SD] ± 0.24) ml for both sides. With ultrasonography, the mean left TV was 0.273 (SD ± 0.081) ml and the mean right TV was 0.272 (SD ± 0.079) ml. There were significant correlations between TV using both methods with the birth weight and length. CONCLUSION: TV measured with the two methods was comparable and correlates well with their birth weight and birth length.

Childhood intussusception: Impact of delay in presentation in a developing country.

BACKGROUND: The classical cases of intussusception are readily diagnosed clinically, and despite recent improvements in radiological techniques, the diagnosis of intussusception and success in its nonoperative reduction has been suboptimal, thus making operative management a veritable backup. This study examined the impact of delays in presentation on the rate of bowel resection, length of hospital stay, and appraised the outcome of operative treatment. PATIENTS AND METHODS: This was a retrospective study of consecutive children admitted and treated surgically for intussusception between January 2002 and December 2011 at the University College Hospital, Ibadan, Nigeria. RESULTS: The mean age at presentation was 13.4 months with a male: female ratio of 1.8:1. Fourteen patients (25.5%) presented within the first 24 h of onset of symptoms with majority (36.4%) presenting between 2 and 3 days of onset of symptoms. The primary surgical intervention was performed on 47 patients (85.5%), and the secondary operative intervention was performed on eight patients (14.5%) who had failed initial nonoperative management of intussusception. Manual reduction of intussusception was performed on 27 patients (49.1%), 26 patients had resection of gangrenous bowel with end-to-end anastomosis while two patients (3.6%) had spontaneous reduction of intussusception which was discovered at laparotomy. The mean duration of hospital stay was 12.1 days (range 3-60 days). The overall mortality was 5.5% (three patients), and three patients (5.5%) had recurrence of intussusception. CONCLUSION: Although mortality is reducing, a high rate of bowel resection is a consequence of delayed presentation and effort should be made to make an early diagnosis of intussusception and make prompt referral to improve outcome.

Childhood intussusception: A prospective study of management trend in a developing country.

BACKGROUND: The management of intussusception has evolved universally from the use of hydrostatic reduction through operative reduction to the use of pneumatic reduction for the acute and uncomplicated cases and surgical reduction for the complicated cases. However, the process of evolution has been very slow in the developing countries, especially sub-Saharan Africa, due to lack of requisite facilities and expertise to manage these patients nonoperatively. This study examined the trends in the management of childhood intussusception in a developing country, compared operative and nonoperative modalities of treatment, and assessed the impact of delayed presentation on the outcome of management. PATIENTS AND METHODS: This was a prospective study of the management of children with intussusception at the University College Hospital, Ibadan, Nigeria. RESULTS: Fifty-five consecutive cases of intussusception that presented to the Children Emergency Unit of the University College Hospital between January 2005 and December 2011 were prospectively studied. Details of sex, age of the patients, clinical presentation, duration of symptoms, mode of treatment, and incidence of recurrence were recorded and analyzed. The median age was 7 months. Moreover, the duration of symptoms varied from 1 to 21 days with a mean of 4 days. Twenty-two patients (40%) had attempted hydrostatic reduction; this was successful in 14 patients (63.6%), whereas 8 patients (36.4%) had failed reduction. In all, 41 patients (74.6%) had operative management of intussusceptions; primary operative intervention was carried out in 33 patients (60%) and secondary surgical management in 8 patients (14.5%) with failed hydrostatic reduction. At surgery, manual reduction of intussusception was carried out on 17 patients (30.9%) and resection of devitalized bowel with end to end anastomosis was carried out on the remaining 24 patients (43.6%). The incidence of surgical intervention for intussusception was 74.6%, mortality was 3.6%, and recurrence rate was 3.6%. CONCLUSIONS: Nonoperative management of intussusception should be adopted in carefully selected cases of intussusception in this subregion as it will help to reduce the financial burden on the parents while surgical management should be reserved for the complicated cases.