SPONTANEOUS TRANSVAGINAL INTESTINAL EVISCERATION IN AN ELDERLY WOMAN.

Introduction: Transvaginal intestinal evisceration is a rare surgical emergency that is associated with morbidity and mortality. Only a few cases of transvaginal evisceration have so far been described. The predisposing risk factors associated with this clinical condition are multifactorial. Case presentation: We report a case of an 85-year-old female that presented with spontaneous small bowel evisceration through the vagina. The loops of the small bowel appeared edematous and thickened but there was demonstrable visible peristalsis. She had no previous laparotomy or vaginal surgery. An emergency laparotomy was performed, and the small bowel was reduced into the abdomen through the vaginal defect. Afterward, a total abdominal hysterectomy was performed with the closure of the vaginal vault. The postoperative period was uneventful. Conclusion: The spontaneous evisceration of bowel loops can be successfully managed when patients with such cases present early and promptly managed. Prompt diagnosis and surgical management are crucial to prevent complications. If the eviscerated viscera are non-viable, resection and restoration of bowel continuity are imperative. Management should be individualized and multidisciplinary.

A RARE METACHRONOUS COLONIC VOLVULUS.

Introduction: Colonic volvulus is a common cause of large bowel obstruction with the sigmoid colon most commonly affected. Volvulus of the transverse colon is an uncommon occurrence. Rarer still is a transverse colon volvulus developing after surgery for a sigmoid colon volvulus. Early diagnosis is critical as delay in detection and intervention is associated with the risk of complications - perforation, peritonitis, and death. Case presentation: We report the case of an 86-year-old man who presented with features of large bowel obstruction 14 months following a sigmoid colectomy for a sigmoid colon volvulus. Conclusion: A metachronous transverse colonic volvulus is uncommon. Preoperative diagnosis is challenging as there are no defining radiographic features compared to the volvulus of the sigmoid colon with the classical omega sign. Most cases are diagnosed intra-operatively. Bowel resection and anastomosis in a single stage is a safe option.

PERIOPERATIVE MORBIDITY AND MORTALITY AFTER EMERGENCY AND ELECTIVE COLON AND PROXIMAL RECTAL SURGERY IN IBADAN.

OBJECTIVE: While the epidemiology of benign colonic pathologies has not significantly changed in our region, colorectal cancer has steadily increased with a majority of patients presenting with late stage disease particularly large bowel obstruction. This study reviews the outcome of emergency and elective colon and proximal rectal cases with regards to perioperative morbidity and mortality. SETTING: All patients who had surgery for symptoms of lower gastrointestinal tract disease (caecum and proximal rectum) between January 2008 and January 2018 at University College Hospital, Ibadan were included. Data regarding elective or emergency presentation, peri-operative findings, operative details and postoperative course were recorded prospectively. RESULTS: Out of the 1618 patients with symptoms, 817 were operated on as emergencies (38.1%) and electives (61.9%). The median age of patients who had emergency and elective surgery were 56 (33-81) and 59 (27-87) respectively (p-0.05). Right hemicolectomy (152; 18.6%) was the commonest procedure, followed by anterior resection (115; 14.1%) and colostomy (114; 13.9%). Overall morbidity was 13.7% (elective 4.2%; emergency 9.5%), while mortality was 6.8% (elective 2.1%; emergency 4.7%). The commonest morbidities were superficial surgical site infection (SSSI) and wound dehiscence. Bowel perforation or gangrene was the most significant predictor of mortality. CONCLUSION: Large bowel obstruction complicated with perforation and gangrene is a major risk factor for morbidity and mortality in colorectal surgery.

Emergence of colorectal cancer in West Africa : accepting the inevitable - review

It seems not too long ago that colon and rectal cancer was called a 'rare' disease in rural Africa, however over the last 30 years in West Africa, published evidence has shown decade by decade increases in the incidence of Colorectal cancer (CRC). Therefore CRC should now be accepted as a recognized disease in native Africans; nevertheless we must acknowledge that the incidence is a fraction of what obtains in the developed countries of Europe and America. This presentation will attempt to examine the emergence of CRC within the West African axis over the last 4 decades

OUTCOME OF LAPAROTOMY FOR PERITONITIS IN 302 CONSECUTIVE PATIENTS IN IBADAN, NIGERIA.

BACKGROUND: Peritonitis is a life-threatening condition and requires urgent surgical management. Despite improvements in the care of patients with peritonitis, its management is still challenging and associated with significant morbidity and mortality. The aim of this study was to determine factors influencing the outcome in patients managed for peritonitis in a tertiary health institution in Nigeria. METHOD: A retrospective study involving 302 patients managed for peritonitis over a 3- year period. The biodata, clinical findings, diagnosis, pre-operative care, mode of anaesthesia, cadre of the surgeon, intraoperative findings, postoperative care, and the outcomes were retrieved from their records. RESULTS: Three hundred and two patients were operated on for peritonitis during the period. The mean age of the patients was 48 ± 12 years. Twenty (6.6%) patients had other co-morbidities, with hypertension being the most frequent. Ruptured appendicitis was the most common cause of peritonitis, 83(27.5). Twenty-eight (9.2%) patients had complications, 19 patients (6.5%) required intensive care unit admission, 25 patients (8.4%) required a second exploratory laparotomy. The mortality rate was 2.4%. There was a statistically significant association between an adverse outcome and presentation with shock, anaemia, jaundice and oliguria. CONCLUSION: The factors influencing outcome are similar to those of other Africa countries. However, the mortality rate in our study is lower. Peri-operative specific organ support and prompt surgical intervention should be instituted to improve outcome. We suggest a prospective study to elucidate the effect of these factors, and to determine the predictive power of the various scoring systems.

ADULT ABDOMINAL WALL HERNIA IN IBADAN.

BACKGROUND: Abdominal wall hernias are very common diseases encountered in surgical practice. Groin hernia is the commonest type of abdominal wall hernias. There are several methods of hernia repair but tension-free repair (usually with mesh) offers the least recurrent rate. AIM: To describe the clinical profile of anterior abdominal wall hernias and our experience in the surgical management of identified hernias. METHOD: The project was a retrospective study of all patients with abdominal wall hernia presenting into surgical divisions of University College Hospital Ibadan during a 6 year period (January 2008 to December 2013). Relevant information was retrieved from their case notes and analysed. RESULTS: The case records of 1215 (84.7%) patients out of 1435 were retrieved. Elective surgery was done in 981(80.7%) patients while 234 (19.3%) patients had emergency surgery. There were 922 (84.8%) groin hernias and post-operative incisional hernia accounted for 9.1% (111) of the patients. About half (49.1%) of those with incisional hernia were post obstetric and gynaecologic procedure followed by post laparotomy incisional hernias 16 (14%) and others (23.5%). The ratio of inguinal hernia to other types in this study is 3:1. Hollow viscus resection and emergency surgery were predictors of wound infection statistically significant in predicting wound infection (P < 0.001). Peri-operative morbidity/mortality at 28 days post operation was documented in 113 patients (12.1%). One year recurrence rate of groin hernia was 2.1%. CONCLUSION: The pattern of presentation and management of anterior wall hernias are still the same compared with the earlier study in this hospital. New modality of treatment should be adopted as the standard choice of care. Abdominal wall hernias are very common clinical presentation. Modified Bassini repair was the preferred method of repair due to its simplicity. Mesh repair is becoming more common in recent time but high cost and initial non-availability of the mesh limit its use in our centre.

Pregnancy, parturition, parity and position in the family. Any influence on the development of paediatric inguinal hernia/hydrocele?

AIM: To see if pre-partum factors have a relationship to the development of inguinal hernia in children. METHOD: A prospective study on children with hernia. On first contact, the affected child was examined and data like the age, sex, weight, blood group, the diagnosis, side of the lesion and other co-morbid conditions was recorded. The mother filled a questionnaire about her age, parity, illness during pregnancy, her mode of delivery and the patient's position in the family. RESULTS: There were 104 patients from 103 mothers, their ages ranged from 13 days to 14 years with the highest incidence in the 1-4 age group. The sex ratio was overwhelmingly male (M:F ratio was 38:1). Right sided hernias were predominant. Only 7% had a family history. The peak age group of the mothers was 26-32 years and about 33% of the mothers had some illness during pregnancy. The birth positions of the patients showed that majority of them were either 1st or 2nd born children. CONCLUSION: Women of ages 26-32 likelyto have children with inguinal hernia. Malaria during pregnancy is unlikely to have a role to play. 1st and 2nd born male children have a higher chance of having inguinal hernia.

Under-reporting of gossipiboma in a third-world country. A sociocultural view.

The paper looks at the reason for the low incidence of retained abdominal packs following an abdominal operation in a third world country like Nigeria. It is generally agreed that this unfortunate situation is underreported. The reason for under-reporting is now given a socio-cultural perspective. Fear of litigation as would hold in the western world does not seem to be paramount here. Other explanations like fear of being made a scapegoat for something which may be due to spiritual attacks may be paramount. The paper concludes by recommending that the removal of impediments to disclosure of this adverse surgical event will lie in education, discouragement of scapegoatism and improvement in hospital services in the third world.

A review of posttraumatic bowel injuries in ibadan.

Background. Bowel injuries are a leading cause of morbidity and mortality following trauma. Evaluating patients who sustained abdominal trauma with bowel injury may pose a significant diagnostic challenge to the surgeon. Prompt recognition and timely intervention is necessary to improve outcome. Aim. This study was undertaken to evaluate treatment and outcome of patients with bowel trauma. Methods. A 5-year retrospective study of all patients presenting with abdominal trauma requiring surgical intervention seen in the UCH Ibadan, Nigeria was undertaken. Results. There were 71 patients (59 males and 12 females). The majority of cases (70%) occurred between the 3rd and 5th decades of life. Some 37 patients (52%) sustained blunt abdominal injury, while 34 patients (48%) sustained penetrating abdominal injury. There were 27 patients with bowel injuries (38%). Isolated bowel injuries occurred in 19 patients (27%). The most common surgical operation performed was simple closure. There were 3 deaths in patients with bowel injuries. Conclusion. Most cases of bowel injury can be managed by simple closure, a technique that is not so technically demanding for surgeons in less-developed countries. This study has also incidentally identified a "rule of six" for patients with bowel injuries and abdominal trauma.

Gastrointestinal stromal tumour in Ibadan, Nigeria: a case report and review of current treatment.

Gastrointestinal stromal tumours (GIST), though rare, present to the gastric surgeon not infrequently making a heightened awareness of this condition a pre-requisite of prompt recognition and timely treatment.. We describe the presentation, diagnosis and the limitations of treatment and follow up of a patient with GIST in a developing country. Surgery still remains as the only readily available modality of treatment in developing countries.

Outcome of one hundred and forty-nine consecutive breast biopsies in Ibadan, Nigeria.

OBJECTIVE: To study the outcomes of one hundred and forty nine consecutive breast biopsies in both male and female patients in one arm of the general surgery division of the department of surgery, university college hospital Ibadan. METHODOLOGY: A retrospective study of the case files and histopathology reports of 149 patients who had biopsies of the breast from May 1996 to September 2004. RESULTS: The study showed that below the age of 30 years, there was no malignancy detected in 85 breast biopsies, however as the age increased it was seen that less than one out of four biopsies were malignant when the patients were aged between 31 and 40 years, rising to one out of four biopsies for the 41-50 and 51-60 age-groups. The 61-70 yielded roughly one out of three whilst two out of three breast biopsies were malignant in the 71-80 age-groups. CONCLUSIONS: Majority of breast lumps are benign and women have a probability of one chance in 10 that their biopsies may be malignant. However under 30 years this is unlikely. Above the age of 40 years the chance of malignancy rises to a one in four which will strongly support screening methods for women above 40 years. For record purposes, fibroadenoma is still the most common breast lesion in women under 30 years and invasive ductal carcinoma is the most common histopathological type of breast cancer in Ibadan, Nigeria.

Mucinous cystadenoma of the appendix: a case report.

INTRODUCTION: Tumours of the appendix are emerging as diseases of increasing concern due to a rising incidence1. We present a case of mucinous cystadenoma of the appendix in an elderly patient. To our knowledge, this is the first report of mucinous cystadenoma of the appendix from Nigeria.

Review of fine needle aspiration cytology in the management of goitres in Ibadan, Nigeria.

OBJECTIVE: The use of Fine Needle Aspiration Cytology (FNAC) in the investigation of goitres was introduced into our practice more than a decade ago. This is a review of its diagnostic accuracy for thyroid carcinoma seven years after the first evaluation and following the establishment of the 'FNAC Clinic'. METHOD: This is a retrospective study of patients who had FNAC of goitres and the histopathology of their thyroidectomy specimens between 1995 and 2004. The accuracy of the cytology reports were evaluated against the histology reports. The turnaround time of the patients for surgery was also determined. RESULTS: There were 130 females and 21 males with an age range of 7-86 years. The diagnostic accuracy of the procedure for carcinoma was 89% with a sensitivity of 35%, specificity of 97%, positive predictive value of 64%, and a negative predictive value of 91%. The average turnaround time for surgery was 178.7 +/- 248.7 days with a range of five days to three and a half years. CONCLUSION: The diagnostic accuracy of FNAC of goitre for carcinoma improved in the period under review. However, the long surgery turnaround time may reduce the usefulness of the procedure. The accuracy may be improved further by a protocol of ultrasound guidance, capillary collection with no-aspiration technique, on-site review of slides with a repeat of FNA as necessary.

Colon and rectal cancer in Ibadan, Nigeria: an update.

INTRODUCTION: Colorectal cancer was hitherto a rarity in the rural African in general and in Nigerians inclusive. Ibadan is a sprawling city in Western Nigeria with a population of about 2.5 million inhabitants. Lately, several publications from surgeons in this city have alluded to an increase in the number of colorectal cancer cases managed in the teaching hospital. OBJECTIVES: To examine the incidence of this disease over 10 years in order to confirm or exclude the apparent significant increase in colorectal cancer cases in Ibadan, Nigeria. METHOD: This is a retrospective study highlighting the age, sex, clinical features, operations performed and histopathological subtypes of patients who had surgery for colorectal cancer in the University College Hospital Ibadan between July 1995 and August 2004. RESULTS: Two and sixty-eight patients were seen over 10 years. The male:female ratio was 1.16:1. The mean age was 41 years and the peak age was the 51- to 60-years group. Fourteen per cent of the patients were 30 years and below. Sixty-two per cent of the patients had rectal carcinoma while 33.2% had colonic carcinoma. Around 60.7% of colonic lesions were right-sided. The most common histopathological subtype was adenocarcinoma (78.8%), mucinous adenocarcinoma was 10.8% and signet ring type was 2.6%. CONCLUSION: Colorectal cancer is a disease on the increase in Ibadan. The mean age of 41 years is much lower than in the Western world. The male:female ratio still favours male patients slightly. About one in seven patients are 30 years and below. Adenomatous polyps were absent in the resected specimens.

Colorectal cancer in Nigeria: 40 years on. A review.

This paper is a review of work done on colorectal cancer in Nigeria over the last 40 years showing geographic spread, age and sex ratios, predominant histopathology and paucity of polyposis coli syndromes. The male/female ratio is averagely equal, the peak age remains around 44 years, there is a significant subgroup of the under-30s and there are more rectal cancer cases than colon cancer cases. Of the colon cancer cases, the caecum seems to be the more favoured site. There seems to be quite a significant incidence of mucin-secreting adenocarcinoma subgroups which are said to carry a worse prognosis. Almost all the authors have stated the rarity of polyposis coli syndromes; a few have looked into the possibility of mismatch repair mutations as an aetiological factor.

Anal carcinoma in a tropical low socio-economic population in the new millennium: What has changed?

The paper is a retrospective look at the clinicopathological presentation of carcinoma of the anal canal in a tertiary health institution in Nigeria. Sixty-five patients were diagnosed with anal carcinoma over a five-year period (2002-2006) from a total of 394 patients who had malignancies of the colon, rectum and anus. The male: female ratio was 1.2: 1 showing a slight male predominance; the average age was 48 years; tenesmus, bleeding per rectum and anal pain were the most common presenting features. None of the patients tested positive to HIV during the duration of their stay in hospital. The most predominant histopathological subtype was adenocarcinoma - a departure from the hitherto squamous cell cancer dominance. Thus, only a few patients benefited from chemo-radiation; the majority had abdominoperineal resection while quite a significant proportion of patients (27.7%) declined any form of treatment for socio-cultural reasons.

Adenomatous polyposis coli in an elderly female nigerian.

Colorectal cancer is reported to occur in lower rates in Africans and some of the reasons adduced include a rarity of polyposis coli syndromes. Only two cases of polyposis coli have been documented in Nigeria in the last 15 years. The present case is an elderly lady who had radiologic and colonoscopic evidence of multiple colonic polyps. She had a colonic resection and the histology was reported as multiple polyposis coli, follicular hyperplasia and submucosal fibrosis in the appendix, and reactive hyperplasia in the mesenteric lymph nodes. There was no evidence of malignancy. This is the first case report of polyposis coli in a living elderly patient in Nigeria.

Informed consent for surgery: a historical review.

BACKGROUND: Many surgeons see the process of obtaining informed consent for an operation from a patient beginning and ending with the signature of the patient on the consent form. Indeed this is not so as this process is deeper than that and all operating specialists need to understand the origin of this process, the developments and the areas where interpretations may be difficult. This is to ensure that implementation of the process of informed consent is mutually beneficient to both patient and doctor. METHOD: Literature dealing with the origin and history of informed consent, its principles, various interpretations and experiences in various subspecialties was reviewed. RESULTS: The informed consent process arose from the proceedings of the Nuremberg trial in 1947 to ensure that such atrocities that were committed on human beings in the pursuit of medical research were never repeated. The basic tenet of the informed consent rests on the autonomy of the patient which is explained as being the legal embodiment of the concept that each individual has the right to make decisions affecting his/her well-being. Areas of possible controversy which includes the interpretation of competence and understanding of the patient in the light of adequate information from the doctor were also highlighted. CONCLUSION: It is apparent from the wealth of literature on this subject that there is still a problem regarding the lack of guidelines towards achieving the perfect informed consent.

An audit of peptic ulcer surgery in Ibadan, Nigeria.

BACKGROUND: Several operations are useful for peptic ulcer surgery, these include Vagotomy and pyloroplasty, Vagotomy and antrectomy, Vagotomy and gastrojejunostomy, and Highly Selective Vagotomy to name a few. Utilising any of these procedures may be due to the operator's preference or more importantly the suitability of the operation to the individual patient. This study was carried out to see the surgical presentation of chronic peptic ulcer disease patients and the form of ulcer-surgery utilised in the University College Hospital Ibadan, Nigeria. STUDY DESIGN: A retrospective study of all the patients who were operated on for complications of peptic ulcer disease between January 1990 and December 2003 at the above-mentioned institution by studying the case-files, ward admission records and operation room registers of such patients. RESULT: There were 122 patients, 90 male and 32 female with a Male:Female ratio of 3:1. Pyloric stenosis accounted for 56.6% of patients followed by perforation (29.5%), bleeding (9.8%) and gastric ulcer (4.1%). Yearly presentations seem to be reducing. Truncal vagotomy and drainage was performed in 78.64% of the patients, simple closure for perforation in 29.5%, partial gastrectomy for 4.1% while the remaining 2.4% had underunning of a bleeding vessel. CONCLUSION: Pyloric stenosis (also called gastric outlet obstruction) is the most common surgical presentation of peptic ulcer disease in the University College Hospital Ibadan and Truncal Vagotomy and drainage is the most common surgical procedure performed for peptic ulcer.

Hernia repair under local or intravenous Ketamine in a tropical low socio-economic population.

BACKGROUND: All over the world hernia surgery constitutes a significant portion of the operations performed by a general surgeon. Operations for hernias ideally should be within the purview of secondary health centres thus allowing the tertiary health centres to focus on research and/or manage unusual or difficult presentations of diseases. STUDY DESIGN: This prospective study reviews the management of hernias in the Catholic hospital Oluyoro in Ibadan by recording the demographic data, hernia characteristics and operations performed on 98 paediatric and 171 adult hernia patients who presented to the hospital between April 1996 and October 1998 with the use of intravenous Ketamine or local infiltration with xylocaine. RESULTS: In a 30-month period from April 1996 to October 1998, the author operated on 98 paediatric and 171 adult hernia patients. There were no paediatric mortalities but there was 1 adult mortality. CONCLUSION: This paper shows that hernia operations in paediatric and adult patients can be safely done under intravenous Ketamine or local infiltration with xylocaine injection in a secondary care health institution.