Anthony Taiwo Adenekan

Strangulated tension viscerothorax with gangrene of the stomach in missed traumatic diaphragmatic rupture.

Acquired diaphragmatic hernias are usually posttraumatic in occurrence. In patients who have blunt trauma and associated diaphragmatic hernia, the diagnosis may be missed or delayed, often leading to poor treatment outcomes. We present a rare occurrence of tension viscerothorax due to missed traumatic diaphragmatic rupture in a 25-year-old woman whose condition was complicated by gangrene and perforation of the fundus as well as questionable viability of the anterior wall of the body of the stomach. The patient had a successful emergency transabdominal suture plication of the diaphragm and gastroplasty and has remained symptomless 3 months postoperatively.

Pre-operative haematological investigations in paediatric orofacial cleft repair: Any relevance to management outcome?

AIM AND OBJECTIVES To determine the value of routine pre-operative haematologic investigations in children undergoing orofacial cleft repair. BACKGROUND Although routine pre-operative laboratory screening tests are carried out traditionally, some studies suggest that they are not absolutely necessary in the management of elective surgical patients. MATERIALS AND METHODS This is a prospective cohort study carried out at a tertiary health facility located in Nigeria. A review of the laboratory investigations in 116 paediatric orofacial cleft patients undergoing surgery during a 6-year period was undertaken. Pre-operative laboratory investigations and peri-operative transfusion records were analysed for the frequency and impact of abnormal results on treatment plan and outcome using the Statistical Packages for the Social Scientists 16.0. RESULTS All the children had pre-operative packed cell volume (PCV) check on admission for surgery. The PCV ranged from 23% to 43%, mean was 32.9 (±3.7%). Twenty-two children (18.6%) had sub-optimal PCV (<30%). Patients with the lowest PCV values (23% and 26%) were transfused pre-operatively. The lowest post-operative PCV was 23%, mean 30.8 (±3.3%). There was no occasion of post-operative blood transfusion. Eighty-six patients (72.9%) had full or partial serum electrolyte and urea analysis. Screening for sickle-cell disease was rarely done. Fourteen intra- and post-operative complications were recorded. None of these were predictable by the results of pre-operative screening tests carried out. All the children were discharged home in satisfactory condition. CONCLUSIONS Routine laboratory testing has minimal impact on management and outcome of orofacial cleft surgeries. However, haematocrit screening may be appropriate, particularly in clinically pale patients.

Perioperative adverse airway events in cleft lip and palate repair

Abstract Background: Airway-related problems account for the majority of anaesthetic morbidity in paediatric anaesthesia, but more so for cleft lip and palate repair. The aim of this study was to assess the frequency, pattern, management and outcome of adverse airway events during the perioperative period in cleft lip and palate patients. Method: This was a prospective cohort study conducted in a tertiary hospital in a suburban south-western Nigerian town. One hundred and sixteen patients who had cleft lip and palate repair over a five-year period were included. The demographic data, surgical diagnosis, congenital anomalies, procedures performed, medical problems, perioperative anaesthetic and surgical complications were studied. Results: Adverse airway events were observed in six patients (4.6%). These included postoperative chest infection (n=2), failed intubation (n=1), difficult intubation (n=1), post-extubation bronchospasm (n=1), and laryngeal oedema (n=1). All, except one, who developed complications were patients with combined cleft lip and palate. No mortality was recorded. Conclusion: Adverse perioperative airway events in cleft lip and palate surgery are common and are more likely to be associated with combined cleft lip and palate than with isolated lip or palate defects. These complications usually occur immediately following extubation or in the early postoperative period. The severity may necessitate intensive care unit admission and specialised care.

Paediatric day-case neurosurgery in a resource challenged setting: Pattern and practice

Background: It has been generally observed that children achieve better convalescence in the home environment especially if discharged same day after surgery. This is probably due to the fact that children generally tend to feel more at ease in the home environment than in the hospital setting. Only few tertiary health institutions provide routine day-case surgery for paediatric neurosurgical patients in our sub-region. Objective: To review the pattern and practice of paediatric neurosurgical day-cases at our hospital. Patients and Methods: A prospective study of all paediatric day-case neurosurgeries carried out between June 2011 and June 2014. Results: A total of 53 patients (34 males and 19 females) with age ranging from 2 days to 14 years were seen. Majority of the patients (77.4%) presented with congenital lesions, and the most common procedure carried out was spina bifida repair (32%) followed by ventriculoperitoneal shunt insertion (26.4%) for hydrocephalus. Sixty-eight percentage belonged to the American Society of Anesthesiologists physical status class 2, whereas the rest (32%) belonged to class 1. General anaesthesia was employed in 83% of cases. Parenteral paracetamol was used for intra-operative analgesia for most of the patients. Two patients had post-operative nausea and vomiting and were successfully managed. There was no case of emergency re-operation, unplanned admission, cancellation or mortality. Conclusion: Paediatric day-case neurosurgery is feasible in our environment. With careful patient selection and adequate pre-operative preparation, good outcome can be achieved.

A 10-year retrospective review of perioperative mortality in pediatric general surgery at Ile-Ife Hospital, Nigeria

BACKGROUND/PURPOSE The analysis of perioperative mortality as well as surgery- and anesthesia-related death in pediatric patients may serve as a potential tool to improve outcome. The aim of this study is to report the 24-h and 30-day overall, and surgery and anesthesia-related, mortality in a tertiary hospital. METHODS This is a retrospective review of perioperative mortality in children ≤15years at a general pediatric surgery unit. All pediatric general surgery cases operated under general anesthesia between January 2007 and December 2016 were included in the study and data analyzed. RESULTS A total of 4108 surgical procedures were performed in 4040 patients. The age was 1day to 15years with a median age of 2years. The all cause 24-h mortality was 34 per 10,000 procedures and the all cause 30-day mortality was 156 per 10,000 procedures. Septicemia was the most common cause of death. The determinants of mortality were neonatal age group (Adjusted Odd Ratio (AOR)=0.033, 95% CI=0.015-0.070, p=0.001), emergency surgery (AOR=90.91, 95% CI=27.78-333.33, p=0.001), higher ASA status (AOR=0.014, 95% CI=0.005-0.041, p=0.001) and multiple operative procedures (AOR=38.46, 95% CI=10.64-142.85, p=0.001). CONCLUSIONS Neonatal age group, children with poorer ASA status, emergency and multiple surgeries were predictors of perioperative mortality. LEVEL OF EVIDENCE Retrospective study.

Early experience with open heart surgery in a pioneer private hospital in West Africa: the Biket medical centre experience

Introduction More than forty years after the first open heart surgery in Nigeria, all open heart surgeries were carried out in government-owned hospitals before the introduction of such surgeries in 2013 at Biket Medical Centre, a privately owned hospital in Osogbo, South-western Nigeria. The aim of this paper is to review our initial experience with open heart surgery in this private hospital. Methods All patients who underwent open heart surgery between August 2013 and January 2014 were included in this prospective study. The medical records of the patients were examined and data on age, sex, diagnosis, type of surgery, cardiopulmonary bypass details, complications and length of hospital stay were extracted and the data was analysed using SPSS version 16. Results Eighteen patients comprising of 12 males and 6 females with ages ranging between 8 months and 52 years (mean= of 15.7 +/- 15 years) were studied. Pericardial patch closure of isolated ventricular septal defect was done in 7 patients (38.9%) while total correction of isolated tetralogy of Fallot was carried out in 5 patients (27.8%). Two patients had mitral valve repair for rheumatic mitral regurgitation. Sixty day mortality was 0%. Conclusion Safe conduct of open heart surgery in the private hospital setting is feasible in Nigeria. It may be our only guarantee of hitch free and sustainable cardiac surgery.

Clinical Audit of Paediatric Magnetic Resonance Imaging Under Sedation at a Nigerian Tertiary Institution

Summary Background Magnetic resonance imaging (MRI) in paediatric patients requires them to be calm during the procedure to avoid motion artefacts in the acquired images. Sedation and/or anaesthesia is a way to achieve this. We evaluated all paediatric MRI sedations since installation of an MRI device in our hospital. Material/Methods We retrospectively reviewed 69 paediatric MRI sedations performed over a 5-year period using records of patients’ biodata, MRI date, indication, findings and scan time, sources of referral, body region scanned, type, dose, related adverse events and route of administration of sedatives as well as image quality. Results The median age and weight of the patients were 24 months {range of 0.3 months (10 days) to 132 months (11 years)} and 11.5 kg (range of 2.6 kg to 42 kg), respectively. Males constituted 50.7% of the patients. Most participants (94.2%) were in-patients of the hospital, mainly (60.0%) referred from the paediatric unit, with slightly over one third (36.2%) of the studies performed in 2015. The commonest indication and scanned body region were macrocephaly (18.8%) and the brain (76.8%), respectively. Hydrocephalus (17.4%) was the commonest MRI finding. Sedation was planned in 66 (95.7%) patients and was successful in 68 (98.6%). Midazolam and the IV route were the commonest sedative agent and route of administration, respectively. Image quality determined by age was fair to good in 68 (98.6%) patients with only 1 patient requiring re-scanning due to motion blur. No adverse events with sedation were recorded. Conclusions Midazolam via the IV route with or without oral route is the drug of choice for MRI sedation in children in our institution with a success rate of about 99%.

Sedation practice among Nigerian radiology residents

Background: Providing safe and effective sedation to patients, especially those with multiple medical problems, can be challenging for radiology residents and fellows. This study aimed to determine knowledge, attitude and practice of Nigerian radiology residents concerning sedation.

Pediatric adenotonsillectomy in a low resource setting: Lessons and implications

Objectives: To examine the practices related paediatric adenotonsillectomy in our setting especially in relation to blood request and transfusion, routine investigations, post-operative analgesic practice and complications. Methods: We reviewed the record of paediatric patients who had adenotonsillectomy in our facility over a 5-year period to obtain relevant information to our study. Results: There were 33 males and 19 females with mean age of 3.27 ± 2.76 years. Sinus tachycardia was found in 11(21.2 %) of the subjects and T wave anomaly in 1(1.9%) of the subject. Thirty-five (67.3%) patient had adenotonsillectomy, 13(25.0 %) adenoidectomy only and 4(7.7%) tonsillectomy only. Majority of the patients (24, 46.2%) were classified as ASA physical status I. Pre-operative blood request rate was high (49, 94.3%) though the transfusion rate was 1.9 % (1 patient). Acetaminophen combined with other analgesics was used for post-operative analgesia for most of the patients. There was significant weight gain post-operatively among patient Conclusions: Cold steel adenotonsillectomy is safe and effective in our environment. We believe that there is no justification for routine pre-operative blood request as a preconditions for surgery. We also like to suggest that post-operative pain management be streamlined taking into consideration the available analgesics in our setting.

Trans-thoracic open ligation of the persistent ductus arteriosus in Ile-Ife, Nigeria

Background: Surgical ligation of a patent ductus arteriosus (PDA) is often the only available option in resource-poor countries such as Nigeria in order to prevent pulmonary hypertension and other complications of a patent ductus. Objective: The purpose of our study was to review our surgical experience, highlighting our techniques at a University Teaching Hospital in Nigeria. Materials and Methods: This is a retrospective audit of the patients who had trans-thoracic open surgical (TTOS) patent ductus ligation over a 5-year period (2009-2013). Result: Sixteen patients (2 boys and 14 girls) aged 4 months-19 years (Mean = 7.1 ± 6.7 years) had TTOS PDA ligation utilizing a triple suture ligation technique. Only three (18.8%) were asymptomatic pre-operatively. Eleven (68.9%) had isolated PDA and others had associated cardiac and extracardiac lesions. The most common post-operative complication was chylothorax, which occurred in two patients (12.5%), and most patients (75%; n = 12) were discharged home by the 5 th post-operative day. Conclusion: Careful attention during transthoracic open surgical closure of the persistent ductus arteriosus will ensure a safe procedure associated with relatively few complications and short post-operative hospital stay.