Acute appendicitis in Lagos: a review of 250 cases.

OBJECTIVES: Acute appendicitis is common. This prospective study of 250 cases of acute appendicitis was performed to critically analyse the pattern of presentation, management, operative findings and treatment outcome. The effect of length and position of the appendix in relationship to acute inflammation was also determined. PATIENTS AND METHODS: Two hundred and fifty cases of acute appendicitis were studied, including those found to have appendicitis at surgery despite other preoperative diagnosis. Patient biodata, clinical signs and symptoms were recorded. Haematological and biochemical parameters were determined after which all patients with a diagnosis of acute appendicitis had appendicectomy under general anaesthesia. All relevant peri-operative data were recorded. Excised appendices were sent for histological examination. RESULTS: There were 133 males and 117 females giving a gender ratio of 1.2:1. The mean age was 25.7 +/- 10.3 years, with majority of cases (42.8%) occurring in the third decade of life. Abdominal pain (100%), fever (48.4%), anorexia (48.0%), vomiting (47.8%) were the common symptoms. Commonly elicited signs included right iliac fossa direct tenderness (74.4%), rebound tenderness (59.2%), localised guarding (42.8%) and right rectal wall tenderness (43.2%). The mean white cell count was not significantly elevated (mean 8538 +/- 4166 per mm3, P > 0.05). Sixty three percent (156/245) of all appendices were retrocaecal in position. Mean length of the appendices was 10.4 +/- 2.9 cm. The length and position of appendices were not significantly different between those who had acutely inflamed and normal appendices (P = 0.923) Two hundred and forty five patients (98%) with a diagnosis of acute appendicitis had appendicectomy. The commonest postoperative complication was wound infection (8%), overall complication rate was 13.5% and negative appendicectomy rate was 13.4%. CONCLUSION: The presentation, management and treatment outcome of acute appendicitis in our centre are similar to those of other centres in our sub-region. Complication rates were low.

Bronchiectasis consequent upon prolonged foreign body retention.

OBJECTIVE: To review our experience with bronchiectasis complicating prolonged endobronchial retention of foreign bodies (FB) among patients with a history of aspiration of FB seen between 1975 and 1998. DESIGN: A retrospective review of clinical data of consecutive patients with a history of aspiration of FB treated during the time of study. SETTING: The Cardiothoracic Unit of the University College Hospital, Ibadan, directly serves a population of about 40 to 60 million in the South Western Nigeria and the community clinics. SUBJECTS: All patients with a history of FB aspiration (or suggestive of FB aspiration) from whom patients with prolonged FB retention were selected. MAIN OUTCOME MEASURES: Patients with a relevant history or chronic respiratory symptoms had their clinical examination findings, plain chest radiographic (or/and bronchographic) findings, treatment modalities and outcome studied. RESULTS: Sixteen patients among 203 patients who had tracheobronchial foreign bodies removed had this complication. The mean age at presentation was 13.0 +/- 17.3 years. Twelve patients (75%) retained inorganic materials and in four patients (25%) it was organic. The period of retention ranged between 4.8 to 108 months (mean 17.0 +/- 22.6 months). Main presenting symptoms were: productive cough, 16 patients; pyrexia, seven patients; combination of chest pain, fever and copious sputum, five patients. In none of the patients was the history of aspiration of FB definitely elicited before commencement of treatment. Symptoms were worst among patients who retained inorganic materials. All of the patients had bronchoscopy but retrieval of FB by this means was successful in one patient (6.3%). Six patients (37.5%) had thoracotomy and bronchotomy; nine patients had bronchotomy and lung resection [seven (77.8%) lobectomies, one (11.1%) pneumonectomy and one (11.1%) segmentectomy] as the definitive treatment. The one patient who had brochoscopic retrieval subsequently had lobectomy to control symptoms of bronchiectasis. Five out of six (83.3%) who had bronchotomy had persistent symptoms of bronchiectasis. All the nine (56.3%) who had lung resection remained asymptomatic at follow up. There was one mortality (6.3%) in the series--a 75 year old who died from poorly controlled Diabetes mellitus. CONCLUSION: Prevention of aspiration of FB is better than cure. In every medically treated child with persistent cough with or without a history of aspirated FB, the possibility of retained FB should be borne in mind.

Milk production by agropastoral Red Sokoto goats in Nigeria.

The mild yield characteristics of smallholder agropastoral Fulani Red Sokoto goats were evaluated using records obtained from a total of 92 does in 6 herds, collected over a 2-year period. The results indicated that the total yield was 79.8 +/- 3.2 kg, the daily yield 0.66 +/- 0.03 kg, the peak yield 1.21 +/- 0.07 kg and the day of peak production 28.7 +/- 2.1 day of lactation. The milk yield characteristics were highly variable with a coefficient of variability of 38.6% to 69.8%. The characteristics were significantly (p < 0.01-0.05) influenced by herd, season, parity and litter size of the dam. Highly positive and significant (p < 0.01) correlations (r = 0.66-0.99) existed between the total yield and the average daily yield, peak yield, initial yield and day 120 yield. A negative and significant (p < 0.05) correlation (r = -0.33) was observed between the peak day and the initial yield. The non-homogeneity of the milk yield characteristics in Red Sokoto does suggests the possibility of improving their daily productivity by selection of high yielding does. Selection for higher initial milk yield may also improve other milk yield characteristics.

Trans-oral irrigation for the management of cervical esophagogastric anastomotic leak.

Over a period of 8 years, 15 of the 65 patients who had transhiatal esophagectomy (THE) for esophageal diseases and cervical esophagogastrostomy had cervical oesophagogastric anastomotic leak. Seven of the 18 patients (38.9%) with corrosive esophageal strictures (CES) due to acid burns had anastomotic leaks while 2 out of 6 patients (33.3%) and 6 out of 41 patients (14.6%) were the incidences of anastomotic leaks among alkali burnt and carcinoma of the esophagus. Anastomotic leaks were more commonly associated with surgery for CES. They were managed by trans-oral irrigation with water after ingestion of either soft/solid diet or high protein, high carbohydrate fluid diet along with adequate jejunostomy feeding. The age of the patients ranged between 5 to 65 years (mean 38.8 +/- 15.7 year). Anastomotic leaks were diagnosed between 3rd to 10th postoperative day (mean 7.1 +/- 2.6 day). The period of transoral irrigation before closure of leakage ranged from 2 to 14 days (mean 6.1 +/- 2.9). In 12 patients (80%) anastomotic leakage closed within 5 days, (mean 3.9 +/- 1.0). Two weeks after closure, all the patients had bouginage and every two weeks for another 3 dilation. Four of the 15 patients needed repeated two monthly dilation for 8 to 12 months. There were no other complications nor mortality in this study. There was psychological acceptance of this minimally invasive procedure.

Gunshot injuries in adults in the Abha region of Saudi Arabia.

In the four-year period from 1996 to 1999, 42 adult patients (age 12 years and above) were admitted to the Assir Central Hospital, Abha, Saudi Arabia, following gunshot injuries. The mean annual admissions for gunshot injuries was 10.5 +/- 4.04 (range = 8-16 cases/annum). All the patients were males. The distribution of the patients' nationalities were: Saudis 66.7%, Yemenis 11.9%, Ethiopians 11.9%, Eritreans 7.1% and Sudanis 2.4%. In 38 cases, others shot the patient, while only one patient (2.4%) admitted to shooting himself accidentally. A pistol was used in 81% of cases while an air gun was used in 9.5% of the cases. Wound of entry analysis showed that gunshots were to the lower limbs in 20 cases (47.2%), the upper limbs in 22% and the chest in 13% of cases. Gunshots to the head and neck occurred in 7% and 2% of cases, respectively, while the abdomen was hit in 4% of cases. The injuries sustained included: superficial wounds (64.3%), haemothorax (9.5%), nerve injury (9.5%), lower limb fractures (9.5%), haematoma (7.1%), liver and kidney injuries (2.4%, respectively). Management included wound debridement and suturing (76.2%), thoracostomy tube drainage (14.3%), bullet removal (11.9%), internal fixation of fractures of long bones (9.5%), laparotomy and repair of gut (7.1%), nerve repair (4.8%), ulnar nerve graft (2.4%), and external fixation compound fracture of the tibia (2.4%). All the patients survived. The mean hospital stay was 15.45 +/- 23.06 days (range = 1-150 days). Although gunshot injuries are increasingly being reported from Saudi Arabia, the injuries are accidental and the morbidity appears to be low.

Carcinoid tumourlets associated with diffuse bronchiectasis and intralobar sequestration.

Innumerable carcinoid tumourlets may develop within pulmonary lobes should there be scarring from intralobar sequestration; these tumourlets may, in turn, be the cause of chronic lung disease. This report documents the incidental detection of multifocal carcinoid tumourlets in the lung of a 65-year-old man who had repeated episodes of lung infection, progressive dyspnea and haemoptysis; he lived at high altitude. The left lower lobe of the lung was resected surgically, during which procedure an aberrant systemic arterial supply was noticed. The patient had diffuse bronchiectasis and intralobar sequestration. The latter implies the development of abnormal lung tissue located within lobar tissue--but which does not communicate with the bronchial tree; it is supplied with arterial blood from a branch of the aorta--arising either above or below the diaphragm. There was loss of demarcation between the sequestered lung and the surrounding lower lobe lung parenchyma. The proliferation of pulmonary neuroendocrine cells in the form of tumourlets, had probably occurred as an adaptive response to the chronic hypoxia experienced. The combination of intralobar sequestration, bronchiectasis and carcinoid tumourlets, although uncommon, may arise when intralobar sequestration of the lung has not been resected at an incipient stage.

Factors affecting age at first lambing in Yankasa ewes.

Data on 133 primiparous Yankasa ewes covering a period of 8 years (1983-1991) were analysed by least squares method for the effects of season, year, litter size, birth weight, weaning age and weaning weight on age at first lambing (AFL). Results showed the AFL (+/-SE) to be 533.1 +/- 10.3 days. Only the effect of season on AFL was significant (P < 0.01) while year of lambing, birth weight, litter size, weaning age and weaning weight did not affect AFL significantly (P > 0.01). AFL was 476.9 +/- 23.3, 523.9 +/- 19.2, 549.8 +/- 19.7 and 581.9 +/- 19.5 days for late wet, early dry, late dry and early wet season born ewes respectively. AFL was significantly (P < 0.01) lowest for ewes born in the late wet season and highest for ewes born in the early wet season. There was no significant (P > 0.01) difference in AFL between ewes born in the early dry season and ewes born in the late dry season, and between late dry and early wet season born ewes.

Closed chest drainage without an underwater seal.

Six hundred and eighty-five patients requiring pleural drainage were referred to and managed by the Cardiothoracic Unit of the University College Hospital, Ibadan between June 1985 and September 1992. Two hundred patients, in which Aldon's urobag (e.g. Simpla S4 type) was used for pleural drainage were studied. The indications for pleural drainage were pyothorax or pyopneumothorax (106 patients), malignant pleural effusion (53 patients), tuberculous effusions (23 patients) and chest trauma (18 patients). In seven of these patients, the Aldon's urobag was used for out-patient care pleural drainage. Some of the reasons for discontinuing its use were major tracheobronchial injuries (2 patients), clotted haemothorax (5 patients), chronic empyema thoracis (10 patients) and loculated malignant pleural effusions. The few easily surmountable complications encountered were obstruction of the tube by blood clot and fibrinous coagulate, stoma necrosis and periosteal reaction. The advantages observed from the use of Aldon's urobag for pleural drainage were reduction in cost of pleural drainage, availability of this drainage system and its use for out-patient care when indicated.

Stab wounds in The Gambia.

Over a 24-month period (January 1990 to December 1991) 337 cases of stab wounds were managed at the Royal Victoria Hospital, Banjul, The Gambia. All stabbing occurred in and around Banjul and victims were predominantly male (99.1%). Stabbed subjects were mostly involved in fights (98.2%). The mean age of the subjects was 27.6 +/- 10.5 years. 155 subjects (46%) required emergency room treatment only while 182 (54%) needed hospitalisation. Superficial lacerations predominated (94.3%) while other major complications included haemothorax/pneumothorax (2.4%), haemopericardium/pneumopericadium (0.3%), cardiac lacerations (0.6%), and haemoperitoneum (2.4%). Visceral injuries managed were: Heart lacerations (2%), Liver lacerations (1.2%), lung lacerations (2.4%), peritoneal lacerations (0.6%), gut perforation (0.6%) and pericardial complications of inadequate initial management. Anaesthetic techniques used for major procedures including Thoracotomies and Laparotomies were simple to ensure safety and assure quick post anaesthetic recovery. All patients had an uneventful recovery. In a situation of restricted medical facilities, we have recorded successful management outcomes without resorting to mandatory exploratory celiotomy and expensive diagnostic procedures.

Ectopia cordis in a Nigerian child.

A female infant is described with a complete ectopia cordis and a single atrium who presented four hours after birth. There was complete deficiency of the sternum with the absence of pericardium over the heart. There was an associated omphalocele containing an enlarged liver. The infant died 45 hours after birth following an attempt to provide tissue covering. Additional intracardiac anomalies included a ventricular septal defect overriding aorta and total anomalous venous drainage.

Oesophageal reconstruction using the stomach.

Between January 1975 and December 1989, the Cardiothoracic Unit of the University College Hospital, Ibadan (U.C.H.) carried out 47 oesophageal replacement procedures using the stomach. The ages of the patients ranged from 3 to 75 years (mean = 53.2 +/- 19.3 years). There were 24 males and 23 females. The indications for oesophageal replacement were as follows: Carcinoma of the oesophagus--34 patients (73.9%), Corrosive stricture--9 patients (17.4%), peptic stricture--1 patient (2.2%), granulomatous oesophageal lesion--1 patient (2.2%), submucous cysts--1 patient (2.2%), oesophageal perforation--1 (2.2%). Twenty patients (58.8%) with oesophageal carcinoma died between 9 and 33 days after operation. The patients with oesophageal perforation, granulomatous lesion and submucous cysts died from sepsis 8, 13 and 6 days respectively after operation due to anastomotic leak. Three patients with corrosive stricture (24%) died 10, 13 and 15 days respectively after operation. All the other 21 (54.7%) patients survived with good results as judged by the absence of dysphagia. Eight of the fourteen surviving patients with carcinoma are lost to follow-up and are presumed dead. There were two intra-operative deaths (4.3%). The operative approaches used were: Transthoracic (21 patients; 9 deaths), Transhiatal oesophagectomy (14 patients; 9 deaths) and retrosternal route (12 patients; 8 deaths). In terms of morbidity, more complications were observed with the transhiatal oesophagectomy (Orringer's technique). It is concluded that whereas oesophagoplasty with the stomach offers good results in patients with benign strictures, the results with carcinoma of the oesophagus in our environment is poor.

Surgical treatment of persistent ductus arteriosus at the University College Hospital, Ibadan.

Seventy-seven patients aged from 5 days to 30 years underwent surgical correction of persistent ductus arteriosus (PDA) between July 1975 and December 1985. Forty-seven percent presented before 5 years of age while 20% were aged above 15 years. The male:female ratio was 1:2. Additional cardiovascular anomaly was present in 14 patients, 8 of which were ventricular septal defect. Majority presented with congestive heart failure and or failure to thrive. Surgical closure was effected by ligation in 67 cases, division and suture in 5 and unspecified in 5 cases. Operative mortality was 2(2.1%) cases. Complications with superficial wound infections occurred in a minority of patients. We conclude that despite a large left to right shunt in most patients, attested to by their symptomatic status, and late presentation surgical closure can be accomplished with minimal morbidity and mortality in centres with limited facilities.

Spontaneous pneumothorax in adult Nigerians.

A 6-year study was carried out in our hospital practice to determine the prevalence of spontaneous pneumothorax. Thirty patients with 32 episodes of pneumothorax were diagnosed. Tuberculosis was encountered in 9(30%) patients while no specific cause was found in 12(40%) patients. This study indicates that spontaneous pneumothorax is uncommon in the Nigerian, while the tuberculosis aetiology may be a pointer to the overall high prevalence of the disease in the community.

Catamenial pneumothorax: a case report.

A case of catamenial pneumothorax in a 17-year-old girl is presented. It is the first reported case in a Nigerian. Pleural blebs were found at thoracotomy and good response to dry sponge pleurodesis has been confirmed. The possibility of missed diagnosis of this entity in an environment where spontaneous pneumothorax is not uncommon is discussed.

Post-operative wound infection in thoracic patients: a preliminary report.

A retrospective study of 37 patients undergoing pulmonary resection, between 1975 and 1980, was performed to establish the incidence of wound infection and to determine contributory factors. Sixteen patients had suppurative lung disease while 11 had pulmonary tuberculosis. The majority of the patients received prophylactic antibiotic (Ampicillin and Cloxacillin) given intramuscularly or intravenously, prior to thoracotomy, and continued for several days post-operatively. Twenty of the 37 cases (54%) developed wound infection, defined as any purulent wound drainage in the post-operative period. The patients with infection (group A) did not differ from those without (group B) as regards presence of pyorrhoea or haemoptysis, the duration of operation or the quantity of blood infused during surgery. A significant difference in the duration of chest intubation was identified between group A (6 +/- 1.3 days) and group B (3 +/- 1.5 days) (P less than 0.001). The implication of the results towards the modification of post-operative management of patients is discussed.

Semen quality and sperm output of Yankasa rams at different ages.

Three groups of three Yankasa rams aged 1.4, 2.4, and 3.4 yr, weighing 32.8 +/- 0.8, 47.9 +/- 1.4, and 48.8 +/- 1.3 kg, and with scrotal circumferences measuring 26.8 +/- 0.9, 28.9 +/- 0.3, and 30.3 +/- 1.3 cm (mean +/- SEM), respectively, were used for this study. The rams were ejaculated once per day for 14 d using an artificial vagina and their semen quality and sperm output determined. For the three groups, ejaculate volume, sperm concentration, sperm motility, percentage of morphologically normal sperm, and total sperm output per ejaculate averaged 0.72 +/- 0.03, 0.90 +/- 0.04, and 0.88 +/- 0.03 ml; 3.421 +/- 0.133, 4.025 +/- 0.179, and 4.673 +/- 0.184 x 10(9)/ml; 83.2 +/- 2.3, 84.6 +/- 1.5, and 74.0 +/- 2.4%; 96.2 +/- 0.3, 96.0 +/- 0.4, and 95.4 +/- 0.4%; and 2.469 +/- 0.141, 3.663 +/- 0.237, and 4.163 +/- 0.247 x 10(9) sperm, respectively. Differences between groups were significant for all semen traits except for percentage of morphologically normal sperm. Total sperm output per ejaculate (Y; x 10(9)) was significantly correlated with scrotal circumference (X; cm) by the geometric regression equation Y = 0.000128 X(3.03) (r = 0.71; P < 0.05). Ejaculate characteristics were not influenced by day of collection except for percentage of morphologically normal sperm, which was significantly (P < 0.01) lower on the first day of collection.

Pneumopericardium following blunt chest injury: report of three cases.

Three cases of pneumopericardium following blunt chest injury are presented. All three patients were victims of road traffic accidents and were managed at the University College Hospital, Ibadan, Nigeria. One of the patients had a tension pneumopericardium, which was relieved by pericardiocentesis. The other two patients had only small amounts of pericardial air, which was absorbed after about 1 week. All three patients had multiple chest and associated injuries. The suspected mechanism of the pneumopericardium in the three patients is pleuropericardial rupture in the presence of an intrathoracic air leak. This is the first report of pneumopericardium following blunt injury of the chest in Nigeria. Only 16 previous cases have been reported in the world literature.

Osteomyelitis of the ribs in Ibadan.

Sixteen patients with pyogenic osteomyelitis of the ribs are reported; ages ranged from 3 months to 42 years and 10 were female. Right sided ribs were affected in 10 cases and single ribs in 12. Antecedent causes included empyema thoracis (56%) and blunt chest trauma (19%). Fourteen out of 16 patients presented with discharging chest wall sinuses and five patients had associated swellings on the chest wall. The duration of symptoms ranged from two to 36 months. The most common microorganism isolated was Staphylococcus aureus (50%). Rib excision (with drainage of the empyema in two cases) was curative in all 16 cases in this study.