Expanding access to surgical care toward universal health coverage: Leveraging sustainable financing strategies for Sub-Saharan Africa.

The National Surgical Obstetric and Anaesthesia Plan is an invaluable country resource with the capacity to promote increased access to safe and affordable surgical and anaesthesia care if implemented. Although cost of implementation is only a fraction of Health Sector Strategic Plan cost in the countries with costed plans, it is important that the funding of the plans is based on sustainable financing strategies. This will ensure appropriate and timely implementation and sustainability of the plan itself. The aim of this review was to discuss and make recommendations on innovative and sustainable strategies for financing national surgical plans in sub-Saharan Africa.

Drain Site Hernia: A Review of the Incidence and Prevalence.

BACKGROUND: Surgical drains prevent fluid accumulation such as peritoneal fluid, blood, pus or inflammatory exudates. However, complications may occur. The aim of this study is to review the incidence and prevalence of drain site hernia as a complication of surgical drains. MATERIAL AND METHODS: A search of the literature in the MEDLINE database, using PubMed and OvidSP, Scopus, Google Scholar and Cochrane Databases with the following MeSH terms: (Drain or surgical drain or drainage) AND (drain hernia, drain-site hernia, laparoscopic drain-site hernia)was done. Also, these searches done from 14th-31st Dec 2013 were restricted according to the following MeSH limits: (a) January 1, 1980 to December 14, 2013, (b) English articles (c) Human. RESULTS: Overall, 24 articles had 49 patients with drain site hernias. Of this, 7 (14. 3 %) post open surgery while 42 (85.7 %) post laparoscopic surgery. Seven (14.3 %) occurred immediately after the operation/removal of drain, 10 (20.4 %) several days to 2 week, while 32 (65.3 %) several months to years. Commonest organ of herniation was 13 (26.5 %) small bowel, while morbidities, arising from drain site hernias occurred in 17 (34.7 %) with the highest 7 (14.3 %) due to bowel strangulation. Previous reports have quoted the incidence of drain site hernia to be 3.4% (5 of 148), and 0.14% (8 of 5541). Mortality was extremely low (2.0 %). CONCLUSION: Attention is warranted for drain site hernias as a significant complication following placement of surgical drain. Incidence (0.1-3.4 %), though wide range, is quite significant in these patients. Therefore, unwanted surgical drain insertion should be avoided.

Pattern of paediatric solid cancers seen in radiotherapy and oncology department, Ahmadu Bello University Teaching Hospital, Zaria - Nigeria.

UNLABELLED: Summary AIMS AND OBJECTIVES: To evaluate the Pattern of Paediatric solid cancers seen over 5 years in the Radiotherapy and Oncology Department of Ahmadu Bello University Teaching Hospital, Zaria-Nigeria. MATERIALS AND METHODS: The study involved patients aged 16 years and below diagnosed with solid cancers referred to the Radiotherapy and Oncology Centre for further management. Between January 2006 and December 2010, a total of 136 new patients with paediatric solid cancers were seen and evaluated. Only patients with histological confirmation were included in the study (136 out of 141 patients) irrespective of cancer type, sex, co-morbidity and performance status. Patients' folders were reviewed retrospectively with a structured pro forma. Information retrieved from patients folder included age, sex, histological type, stage and types of treatments received. Results were presented in tables. RESULTS: A total of 136 patients were evaluated with a mean age of 6.9 years (median of 5 years, age range 1.5 - 16 years). 74 patients (54.4%) were 5 years and below and 98 patients (72%) were 10 years and below. The sex ratio M:F was 1.3:1. At presentation at the Radiotherapy and Oncology centre, only 4 (3%) patients had early stage disease, 100 (73.5%) with locally advanced disease and 32 (23.5%) with metastatic disease. Retinoblastoma 48 (35.3%) was the commonest cancer seen followed by soft tissue sarcoma 20 (14.7%, all rhabdomyosarcoma), lymphomas 15 (11%) (9 Burkitt's and 6 Hodgkin's lymphoma), nephroblastoma 13 (9.6%), bone sarcoma 12 (8.8%) (8 Osteosarcoma and 4 Ewing's sarcoma), nasopharyngeal cancers 8 (5.9%), brain cancer 6 (4.4%), sacrococcygeal tumours 6 (4.4%) and other cancers accounted for 8 (5.9%). 116 (85.3%) patients received chemotherapy, 86 (63.2%) patients were scheduled for radiotherapy but only 21 (15.4%) received local field irradiation due to financial constraints and 43 (31.6%) had definitive surgery. Palliative care with medications was done in 22 (16.2%) patients. Of 48 patients with retinoblastoma, 30 affected left eye, 16 affected right eye and 2 patients were with bilateral retinoblastoma. The mean age for retinoblastoma was 3.8 years (median age of 3 years and mode is 3 years). The mean age for rhabdomyosarcoma was 8.7 yr (median age of 6.5 years). CONCLUSION: Paediatric solid cancers were found to be more common in males than females with more than half being diagnosed in children aged 5 years and below. Retinoblastoma and rhabdomyosarcoma were the most common neoplasms. Most patients presented with locally advanced and metastatic cancers. Geographic variation exists with histological types.

Quality of teaching provided by surgical residents: an evaluation of the perception of medical students.

BACKGROUND: Surgical residents teach and interact with Medical students during surgery clerkship. However, the quality of teaching by surgical resident as perceived by medical students has not been assessed in our setting. The aim of this report is to evaluate the quality of teaching provided by surgical residents as perceived by Medical students METHODS: This is a cross sectional study involving final year 2005-2006 medical students ofAhmadu Bello University Zaria, Nigeria. The characteristics and skills of surgical residents' teaching role as perceived by medical students were determined. The Information was obtained using a structured questionnaire. Data obtained was analyzed using SPSS version 11.0 RESULTS: A total of 120 medical students participated in the study. The age range was 24-36 years (mean 26.88 + 2.19). There were 87 (72.5%) males and 33 (27.5%) females. In assessing the qualities of a teacher among surgical residents, 83 (69%) of the students believed the surgical resident has good teaching skills, 101 (84%) believed they were committed to teaching, 118 (98%) they were available, 109 (91%) had inspirational ability. In assessing the qualities of a surgeon, 116 (97%) believed the surgical resident has enthusiasm for surgery, 106 (88%) empathy for patients, 78 (65%) fund for knowledge. Assessment of the qualities of a supervisor revealed 118 (98%) Got medical students involved, hands on, 78 (65%) set fair expectations, 113 (94%) Gave them feedbacks, 118 (98%) supervised them adequately. In term of the qualities of the person 107 (89%) believed a surgical resident is supportive, 94 (78%) considerate, 115 (96%) friendly, 108 (90%) fun to work with. Overall assessment perceived by medical students revealed Senior Registrar having better qualities of teaching than Registrar. These qualities were rated good and outstanding by majority of the medical students. CONCLUSION: Medical students' perception of teaching provided by surgical residents is encouraging in our setting. This emphasizes the important role of the surgical resident in undergraduate medical training. Thus, the teaching skills of surgical residents should be encouraged and sustained.

Timing of passage of first meconium and stooling pattern in normal Nigerian newborns.

BACKGROUND: The time of passing meconium and the subsequent stooling pattern is an important marker in the diagnosis of colonic motility problems in newborns, particularly in Hirschsprung's disease (HD). METHOD: A cross-sectional study of the passage of meconium and stooling pattern in 280 normal newborns was undertaken using questionnaires administered to mothers attending a postnatal clinic. RESULTS: There were 143 boys and 137 girls aged 6-49 days (median 19 days); 266 (95%) had been full-term infants, 252 (90%) normal deliveries and 28 (10%) delivered by caesarean section. The birthweight of 25 (9%) had been <2.5 kg. Of 267 infants whose mothers knew the time of first passing meconium, it had been delayed for up to 48 hours in 45 (16.9%) and up to 72 hours in 15 (5.6%), and six (2.2%) passed meconium after 72 hours. Overall, 201 (75.3%) passed meconium within 24 hours of birth, 246 (92.1%) within 48 hours and 261 (97.8%) within 72 hours. Irrespective of the time of passing meconium, 80 (31%) infants continued to pass stools at least once daily, 107 (42%) twice daily and 65 (24%) three or more times daily. Only 11 infants were on artificial milk along with breast milk; the remainder were exclusively breastfed. Mode of delivery, birthweight and artificial milk had no effect on time of passing meconium and the subsequent stooling pattern. CONCLUSION: This study has shown that only 76% of normal infants passed first meconium within 24 hours and, by 3 days of life, a small minority still had not passed meconium. Nearly all normal infants being breastfed should defaecate at least once daily. These findings should be useful in the evaluation of newborns suspected to have HD in this and similar settings.

Echocardiographic findings in children with surgically correctable non-cardiac congenital anomalies.

BACKGROUND: Congenital cardiac anomalies may co-exist with non-cardiac congenital malformations and, for those requiring surgical correction, there can be an anaesthetic risk. AIM: To estimate the burden of congenital heart disease (CHD) in children with surgically correctable non-cardiac congenital malformations. PATIENTS/METHODS: Records of 120 children aged between 1 week and 11 years [mean (SD) 0.6 (1.5) years] undergoing corrective surgery for non-cardiac congenital malformations were examined. Results of clinical cardiac examination and surgical and echocardiographic findings were analysed. RESULTS: Cleft lip or palate was the commonest surgical anomaly (46, 38.3%), followed by ano-rectal malformation (32, 26.7%). Forty-two children (35.0%) had an abnormal echocardiographic scan. A cardiac abnormality was detected clinically and confirmed by echocardiography in ten patients (8.3%), which represents 24% of all the cardiac abnormalities. The commonest cardiac anomalies were atrial septal defect (ASD) (30 children, 25%), followed by ventricular septal defect (VSD) (seven children, 5.8%). The frequency of ASD was highest in children with a cleft lip or palate (14/46, 30.4%). CONCLUSIONS: Over one-third of patients undergoing surgical correction of congenital malformations have co-existing CHD. Echocardiography is important for pre-surgical evaluation. No association between type of CHD and specific non-cardiac congenital malformations was found.

Role of astrovirus in intussusception in Nigerian infants.

Intussusception (IS) is a form of intestinal obstruction in which a segment of the bowel prolapses into a more distal segment. Viral infections, mostly adenovirus, enteroviruses, human herpesvirus and Epstein-Barr virus are reported in 20-50% of childhood cases of IS. Between January and July 2004, six stool specimens collected from infants 0- to 8-months old diagnosed and admitted for IS were investigated for the presence of rotavirus, astrovirus and adenovirus antigens. Astrovirus antigen was detected in three of the six stool specimens by enzyme immune assay (EIA) and confirmed in two specimens by reverse transcription-polymerase chain reaction (RT-PCR). Rotavirus, non-enteric adenovirus and astrovirus were detected by EIA, as mixed infections in a single specimen. The rotavirus strain revealed a SGI+II, mixed G1G2G8P[6] genotype and had no visible electrophoretic profile. A larger study is needed to determine the extent of involvement of astroviruses in IS in infants and the virus should be included in studies investigating the aetiology of IS.

Challenges of managing paediatric abdominal trauma in a Nigerian setting.

BACKGROUND: The management of abdominal trauma (particularly blunt trauma) has undergone tremendous revolution in the last 30 years with significant reduction in morbidity and mortality in developed countries. The aim of this report is to highlight the challenges of managing abdominal trauma in children in Nigeria based on our experience in Zaria, northern Nigeria. METHOD: This is a retrospective review of 82 children managed for abdominal trauma from 1991 2002 at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Information regarding demographics, mechanism of injury, haemodynamic status at presentation, clinical and radiologic evaluation, management, intraoperative findings and outcome, were extracted from case notes, operation notes and discharge summary notes. RESULTS: Fifty seven (69.5%) children had blunt trauma, mostly from traffic accidents (32, 57%) and falls (20, 36%), and 25 (30.5%) penetrating trauma mainly from falls onto sharp objects (7 of 18 patients) and animal-related injuries (5 of 18 patients). In the management of those with blunt trauma, advanced imaging modalities were usually not available and this resulted in an unnecessary laparotomy rate of 51% (laparotomy considered unnecessary because the patients remained haemodynamically stable after resuscitation and any intraperitoneal bleeding had stopped by the time oflaparotomy and no active operative measure was required to control bleeding). The management of penetrating trauma was more straightforward as this was guided by evidence of peritoneal penetration. Mortality from blunt trauma was 14.5% (8 of 55 patients) from exsanguinations before surgery 2, gastric perforation 3, hepatic laceration 2 and splenic injury one. Mortality from penetrating trauma was 12% (3 of 25 patients) from tetanus, overwhelming infection and haemorrhage respectively. The overall mortality from abdominal injury was 13.8% (11 of 80 patients) and were mostly avoidable if the patients presented early, and received some resuscitation before arrival at our hospital. CONCLUSION: The management of blunt abdominal trauma in children in Nigeria is faced with several challenges, which are mainly absence of an organised trauma system and lack of appropriate facilities. These need to be addressed in order to improve the care of these injuries.

Transanal protrusion of intussusception in infants is associated with high morbidity and mortality.

BACKGROUND: Although anal protrusion of intussusception in infants is well recognised, it is rarely reported and confusion with rectal prolapse often results in delayed diagnosis and treatment. This report highlights the problems of diagnosis and the morbidity and mortality associated with this condition. METHOD: A retrospective case series of five infants presenting to Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria with anal protrusion of intussusception over a period of 5 years. During that time, 17 children were treated for intussusception at ABUTH. RESULTS: The anal protrusion rate of intussusception was 29%. The five infants were three girls and two boys aged 4-18 months (median 8). The duration of symptoms was between 6 and 28 days (median 21). The features were mainly protruding anal mass, diarrhoea and vomiting. Abdominal pain and passage of bloody stools occurred late. There was delay in referral and treatment owing to misdiagnosis as rectal prolapse. The intussusception was ileocolic in four patients and in one the type could not be ascertained before death. Two patients had perforation of the involved intestine and another had gangrene of the intestine, necessitating intestinal resection. In one patient, there was no bowel compromise and only open reduction was necessary. Two patients died from overwhelming infection, one before surgery and another after surgery. CONCLUSION: The risk of morbidity and mortality in anal protruding intussusception is high. As early features might not be typical of intussusception, a high index of suspicion is necessary to avoid confusion with rectal prolapse so as not to delay diagnosis and treatment.

Surgical drains: what the resident needs to know.

BACKGROUND: Drains continue to be an important aspect of the management of surgical patients. Its use has been contentious. However, when indicated, it is important that drainage should be practiced with prudence. METHODS: Publications from both local and international journals through Medline, pub med and Google search (June-August, 2007) were reviewed. RESULTS: Drains remove content of body organs, secretion of body cavities and tissue fluids such as blood, serum, lymph and other body fluid that accumulate in wound bed after surgical procedures. Therefore, reduction of pressure to surgical site as well as adjacent organs, nerves and blood vessels, enhances wound perfusion and wound healing. Reduction of pain is also achieved. However, drains are now known not to be innocuous especially when they are poorly selected, wrongly used and left in situ for too long. Essentially, passive and active drains are the most practically useful type. CONCLUSION: Understanding the benefits and applications of surgical drains and tissue responses to constituent material is not only relevant to a practicing surgeon but would help to reduce the abuse of surgical drains.

Pseudoprune belly syndrome; its' associations and management challenge in a developing country: a case report.

BACKGROUND: Pseudo prune belly syndrome is an incomplete expression of the triad syndrome. Its incidence is poorly documented worldwide. We are not aware of any documented cases in Nigeria in recent times. Diagnosis is clinical; however, ultrasound scan plays key role in the overall assessment of the patient. METHOD: It is a report of an 8 day old boy who had pseudo prune belly syndrome with associated micro colon and rectal atresia managed at the Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, in October, 2005. CONCLUSION: Management of this patient was challenging due to lack of frozen section facility parenteral nutrition and finance. Awareness of the associated conditions and how to manage them is emphasized for good outcome.

Hazards of surgical diathermy.

BACKGROUND: Surgical diathermy is an invaluable facility widely used in the operating theatre. Its application in surgical practice is rapidly expanding. However, its use may be accompanied with hazards, which this review is intended to highlight. METHODS: Publications from local and international journals were reviewed. RESULTS: The role of diathermy in surgical practice has expanded beyond imagination in recent years. The patient, surgeon and the theatre staff are frequently exposed to hazards such as burns injury, electrocution, hypoxic stress, inhalation of diathermy plume, and gene mutation. However, strict adherence to preventive measures such as proper connection and handling of diathermy machine, avoidance of inflammable theatre gases, the use of suction device, theatre scavenging system and diathermy plume extraction system could significantly reduce the hazards. CONCLUSION: Continuous exposure to electrocautery appliances in surgical practice is associated with potential risks. Optimizing health and safety in work place should be an ongoing goal. Hence, all methods geared toward the reduction of these risks to health should be emphasized.

INTESTINAL OBSTRUCTION CAUSED BY APPENDICITIS: A SYSTEMATIC REVIEW.

BACKGROUND: The known complications of appendicitis include perforated appendicitis with generalised peritonitis, appendiceal mass, appendiceal abscess, sepsis, adhesion formation and in a few occasions, small bowel intestinal obstruction. AIM: To review published cases of intestinal obstruction due to appendicitis with a view to better understand the pathophysiology of this complication. METHODOLOGY: A search of the literature in the MEDLINE database, using PubMed and OvidSP, Scopus, Google Scholar and Cochrane Databases with the following MeSH terms: (Appendicitis or appendiceal mass, appendiceal abscess or appendiceal adhesion band) and (intestinal obstruction, intestinal herniation, intestinal strangulation, intestinal knotting and paralytic ileus) was done. Also, these searches were restricted according to the following MeSH limits: (a) January 1, 1950 to July 31, 2016, (b) English articles (c) Human. RESULTS: Overall, 27 articles reported 45 patients with intestinal obstruction due to appendicitis. Of the 30 (66.7%) patients that the gender was indicated, 22 (48.9%) were male while 8 (17.8%) were female. In 38 (84.4%) cases the cause was mechanical obstruction resulting from one or a combination of the following: (a) appendix laid across loops of bowel bound down by adhesions, (b) herniation through a ring or gap formed by the appendix tip being attached to its base, (c) appendix tip attached to the bowel causing a torsion, (d) kinking of the bowel, (e) complex knotting. Pre-operative diagnosis was a major challenge and so, none was approached through incision based on the McBurney's point.The outcome of treatment which was mostly achieved by immediate appendectomy followed by adhesiolysis was sufficient and often gave good results. CONCLUSION: This study has shown that appendicitis is an important cause of intestinal obstruction. Even though pre-operative diagnosis is still a major challenge, clinical evaluation and a high index of suspicion are key to diagnosis.

Computer technology and the surgeon: what the resident needs to know.

BACKGROUND: Computer technology is now a well established resource in medicine and medical sciences. Surgery in developed countries has taken great advantage of this resource. This review is intended to highlight important aspects of computers in surgery and also encourages surgeons in Nigeria to acquaint themselves with its influences. METHODS: Publications from local and international journals as well as standard surgical texts were reviewed. RESULTS: The role of computers in surgery spans the areas of patient care, training, research, communication as well as surgical administration. Though a compliment to the surgeon, it has its problems including overwhelming information requiring careful scrutiny; computer fraud, hacking and viruses; copyright laws; the 'threat' of a well-informed patient population; and the risk of over dependence. Surgery in Nigeria and most of African is yet to maximize its benefits. CONCLUSION: The application of computers in surgery will in the near future make surgical knowledge and practice become more simplified and less time with increased productivity will be required even for highly technical procedures.

Acute ileus following ventriculoperitoneal shunt: case report.

A three month old girl with progressive hydrocephalus from birth had a ventriculoperitoneal (VP) shunt, during which the cerebrospinal fluid (CSF) was found to be xanthochromic. She developed acute ileus four hours post-operatively and continued to deteriorate. The shunt was exteriorised as an external ventricular drain. She did well and another VP shunt was inserted later. Acute ileus following VP shunt is not common, but can occur in the presence of xanthochromic CSF. It is advisable that when such CSF is encountered during VP shunt, the initial management should be external ventricular drainage, followed later by VP shunt when the CSF becomes clear. This can be life saving.

Necrotizing fasciitis of the external genitalia following traditional circumcision.

BACKGROUND: Necrotizing fasciitis of the external genitalia is not common in children, and is particularly unusual after circumcision. METHOD: A case report of necrotizing fasciitis of the external genitalia in a one month old boy with discussion of relevant literature. RESULT: A one-month-old boy presented with necrotizing fasciitis of the external genitalia following traditional circumcision. Treatment consisted of early administration of intravenous broad-spectrum antibiotics and debridement. Skin grafting was not necessary as the wound contracted and healed by secondary intention with minimal scarring. CONCLUSION: Early institution of appropriate antibiotics and debridement should prevent morbidity and mortality from this uncommon condition.

A rare left-sided abdominal wall defect.

A 4-hour-old boy is presented here, who was born with a large abdominal wall defect situated in the left flank. Silo closure was necessary due to the large size of the defect. A Medline search up to December 2002 revealed only 2 other left-sided abdominal wall defects distant from the umbilicus. The possible embryology of this anomaly is discussed.

Fournier's gangrene in neonates and infants.

BACKGROUND: Fournier's gangrene is uncommon in childhood and little is known about the disease in this age group. METHOD: A retrospective review was carried out of neonates and infants treated for Fournier's gangrene over a period of 16 years. RESULTS: Twelve neonates and infants aged 5 days-3 months (median 3 weeks) were treated in our hospital. The precipitating cause was omphalitis in 7 babies, strangulated inguinal hernia in 2 and in 3 babies there was no identifiable cause. Gram-negative bacteria were cultured in 3 patients, but in most the culture was sterile. Treatment consisted of debridement of devitalised tissue and administration of broad-spectrum antibiotics. Primary closure was achieved in 1 baby and secondary closure in 2 others. In 7 babies the wound contracted rapidly and healed. There was no mortality. CONCLUSION: Fournier's gangrene in neonates and infants in our environment is largely preventable. Early debridement and appropriate antibiotics give good results.

Postoperative intussusception in childhood: case report.

An eight year old female had laparotomy for general peritonitis due to acute appendicitis. Postoperative course was uneventful until the seventh day when abdominal pain, and distension and vomiting ensued which did not respond to conservative management. At repeat laparotomy, an ileoileal intussusception was found and reduced without difficulty. Intussusception is an uncommon but important cause of postoperative intestinal obstruction. Since the typical features of intussusception are usually absent and radiology frequently unhelpful, a high index of clinical suspicion is necessary for early diagnosis and treatment to avoid strangulation and perforation.

Surgery in a rural hospital: experience from northern Nigeria.

Over a 5-year period in a rural hospital in Northern Nigeria, 949 patients were operated on, constituting 84.7% of all surgical admissions. Nearly one half were emergency procedures. The majority of the patients were young (mean age 36.0 years) and predominantly male (M:F = 1.5:1). A wide variety of surgical procedures were performed but overall 85% were not of a complex nature. Mortality was 4.8%, due mostly to septic complications. It is suggested that most of the surgical procedures in rural Africa can be performed by general duty doctors with surgical experience and they should be taught and encouraged to perform these operations. The importance of relevant research to solve local problems is highlighted and the planning of primary health care to include more primary surgery emphasised.