Christopher Bode

Cardiothoracic Anesthesia, Respiration and Airway Modified Mallampati test, thyromental distance and inter-incisor gap are the best predictors of difficult laryngoscopy in West Africans (Le test de Mallampati modifié, la distance thyromentonnière et l'espace entre les incisives sont les meilleurs prédicteurs de difficultés laryngoscopiques chez des Africains de l'Ouest)

Objectif Determiner la capacite de predire les difficultes de visuali-sation du larynx (DVL) a partir des indices preoperatoires suivants, pris isolement et en combinaison : le test de Mallampati modifie (TMM), la distance thyromentonniere (DTM), la distance sternomentionniere (DSM), la longueur horizontale de la mandibule (LHM) et l’espace inter-incisive (EII).PurposeTo determine the ability to predict difficult visualization of the larynx (DVL) from the following preoperative airway predictive indices, in isolation and combination: modified Mallampati test (MMT), thyromental distance (TMD), sternomental distance (SMD), horizontal length of the mandible (HLM) and inter-incisor gap(IIG).MethodsThree hundred and eighty consecutive patients undergoing general anesthesia were evaluated using the MMT, TMD, SMD, HLM and IIG and the cut-off points for the airway predictors were Mallampati III and IV; # 6.5 cm, # 13.5 cm, # 9.0 cm and # 4.0 cm respectively. During direct laryngoscopy, the laryngeal view was graded using the Cormack and Lehane (CL) classification. CL grades III and IV were considered difficult visualization. Sensitivity, specificity and positive predictive value for each airway predictor in isolation and in combination were determined. Logistic regression analysis was used to determine independent predictors of DVL. Results: Difficulty to visualize the larynx was found in 13 (3.4%) patients. The sensitivity, specificity and the positive predictive value for the five airway predictors were: MMT (61.5%; 98.4%; 57.1 %), TMD (15.4%; 98.1%; 22.2%), SMD (0%; 100%; 0%), HLM (30.8%, 76.0%; 4.3%) and IIG (30.8%; 97.3%; 28.6%). The best combination of predictors was MMT/TMD/IIG with a sensitivity, specificity and positive predictive value of 84.6%; 94.6%; 35.5% respectively. Logistic regression analysis showed that weight, MMT, IIG and TMD were independent predictors of DVL.ConclusionMMT, TMD and IIG appear to provide the optimal combination in prediction of DVL in a West African population.RésuméObjectifDéterminer la capacité de prédire les difficultés de visuali-sation du larynx (DVL) à partir des indices préopératoires suivants, pris isolément et en combinaison : le test de Mallampati modifié (TMM), la distance thyromentonnière (DTM), la distance sternomentionnière (DSM), la longueur horizontale de la mandibule (LHM) et l’espace inter-incisive (EII).MéthodeNous avons évalué 380 patients consécutifs devant subir une anesthésie générale en utilisant le TMM, la DTM, la DSM et l’EII; les points limites des prédicteurs d’intubation ont été les classes de Mallampati III et IV; # 6,5 cm, # 13,5 cm, # 9,0 cm et # 4,0 cm respectivement. La visualisation laryngoscopique directe a été cotée selon la classification de Cormack et Lehane (CL). Les classes de CL III et IV étaient une visualisation difficile. La sensibilité, la spécificité et la valeur prédictive positive de chaque prédicteur d’intubation pris isolé-ment et en combinaison ont été déterminés. On a déterminé les pré-dicteurs indépendants des DVL par l’analyse de régression logistique.RésultatsLa visualisation du larynx a été difficile chez 13 (3,4 %) patients. La sensibilité, la spécificité et la valeur prédictive positive des cinq prédicteurs d’intubation ont été : le TMM (61,5 %; 98,4 %; 57,1 %), la DTM (15,4 %; 98,1 %; 22,2 %), la DSM (0 %; 100 %; 0 %), la LHM (30,8 %; 76,0 %; 4,3 %) et l’EII (30,8 %; 97,3 %; 28,6 %). La meilleure combinaison de prédicteurs a été TMM/DTM/EII avec une sensibilité, une spécificité et une valeur pré-dictive positive de 84,6 %; 94,6 %; 35,5 % respectivement. L’analyse de régression logistique a montré que le poids, le TMM, l’EII et la DTM étaient des prédicteurs indépendants des DVL.

Duplication cyst of ascending colon presenting as an ileal volvulus in a child: A case report and review of literature

Alimentary tract duplications are uncommon congenital anomalies that may be found anywhere along the gastrointestinal tract. They have a diverse presentation and often times present with complications of intestinal obstruction and/or lower gastrointestinal haemorrhage. We report a very rare finding of a colonic duplication cyst which presented as an ileal volvulus in a young girl. While available investigations were non-specific, the child survived on account of an early decision to operate. She had resection of the duplication cyst and ileo-colic anastomosis. She made good recovery post-operatively. A high index of suspicion is necessary on the part of clinicians to recognise this condition. Early operative intervention is necessary in the developing world setting where state of the art investigations are not available for accurate pre-operative diagnosis.

Cardiothoracic anesthesia, respiration and airway modified mallampati test, thyromental distance and inter-incisor gap are the best predictors of difficult laryngoscopy in West Africans

Objectif Determiner la capacite de predire les difficultes de visuali-sation du larynx (DVL) a partir des indices preoperatoires suivants, pris isolement et en combinaison : le test de Mallampati modifie (TMM), la distance thyromentonniere (DTM), la distance sternomentionniere (DSM), la longueur horizontale de la mandibule (LHM) et l’espace inter-incisive (EII).PurposeTo determine the ability to predict difficult visualization of the larynx (DVL) from the following preoperative airway predictive indices, in isolation and combination: modified Mallampati test (MMT), thyromental distance (TMD), sternomental distance (SMD), horizontal length of the mandible (HLM) and inter-incisor gap(IIG).MethodsThree hundred and eighty consecutive patients undergoing general anesthesia were evaluated using the MMT, TMD, SMD, HLM and IIG and the cut-off points for the airway predictors were Mallampati III and IV; # 6.5 cm, # 13.5 cm, # 9.0 cm and # 4.0 cm respectively. During direct laryngoscopy, the laryngeal view was graded using the Cormack and Lehane (CL) classification. CL grades III and IV were considered difficult visualization. Sensitivity, specificity and positive predictive value for each airway predictor in isolation and in combination were determined. Logistic regression analysis was used to determine independent predictors of DVL. Results: Difficulty to visualize the larynx was found in 13 (3.4%) patients. The sensitivity, specificity and the positive predictive value for the five airway predictors were: MMT (61.5%; 98.4%; 57.1 %), TMD (15.4%; 98.1%; 22.2%), SMD (0%; 100%; 0%), HLM (30.8%, 76.0%; 4.3%) and IIG (30.8%; 97.3%; 28.6%). The best combination of predictors was MMT/TMD/IIG with a sensitivity, specificity and positive predictive value of 84.6%; 94.6%; 35.5% respectively. Logistic regression analysis showed that weight, MMT, IIG and TMD were independent predictors of DVL.ConclusionMMT, TMD and IIG appear to provide the optimal combination in prediction of DVL in a West African population.RésuméObjectifDéterminer la capacité de prédire les difficultés de visuali-sation du larynx (DVL) à partir des indices préopératoires suivants, pris isolément et en combinaison : le test de Mallampati modifié (TMM), la distance thyromentonnière (DTM), la distance sternomentionnière (DSM), la longueur horizontale de la mandibule (LHM) et l’espace inter-incisive (EII).MéthodeNous avons évalué 380 patients consécutifs devant subir une anesthésie générale en utilisant le TMM, la DTM, la DSM et l’EII; les points limites des prédicteurs d’intubation ont été les classes de Mallampati III et IV; # 6,5 cm, # 13,5 cm, # 9,0 cm et # 4,0 cm respectivement. La visualisation laryngoscopique directe a été cotée selon la classification de Cormack et Lehane (CL). Les classes de CL III et IV étaient une visualisation difficile. La sensibilité, la spécificité et la valeur prédictive positive de chaque prédicteur d’intubation pris isolé-ment et en combinaison ont été déterminés. On a déterminé les pré-dicteurs indépendants des DVL par l’analyse de régression logistique.RésultatsLa visualisation du larynx a été difficile chez 13 (3,4 %) patients. La sensibilité, la spécificité et la valeur prédictive positive des cinq prédicteurs d’intubation ont été : le TMM (61,5 %; 98,4 %; 57,1 %), la DTM (15,4 %; 98,1 %; 22,2 %), la DSM (0 %; 100 %; 0 %), la LHM (30,8 %; 76,0 %; 4,3 %) et l’EII (30,8 %; 97,3 %; 28,6 %). La meilleure combinaison de prédicteurs a été TMM/DTM/EII avec une sensibilité, une spécificité et une valeur pré-dictive positive de 84,6 %; 94,6 %; 35,5 % respectivement. L’analyse de régression logistique a montré que le poids, le TMM, l’EII et la DTM étaient des prédicteurs indépendants des DVL.

Swenson’s pull-through in older children and adults: Peculiar peri-operative challenges of surgery

INTRODUCTION The definitive treatment of Hirschsprungs disease is removal of the aganglionic bowel by a pull-through surgery. In most cases this surgery is performed in infancy or the neonatal period as presentation in older children and adulthood is rare. Nevertheless, pull-through in this age group may be necessary and present peculiar challenges. MATERIALS/METHODS A prospective study of patients above 5 years with Hirschsprungs disease who presented at LUTH, Lagos between January 2007 and July 2010. RESULTS There were fourteen patients (10 males and 4 females). The median age was 9 years (range 5-31 years). All the patients presented with constipation and abdominal distension. Seven patients presented with intestinal obstruction necessitating colostomy. Thirteen patients had short segment Hirschsprungs disease limited to the rectosigmoid. The only exception had long segment disease with the transition zone located at the transverse colon. Ten patients (71.4%) had colostomy before definitive pull-through while four patients (28.6%) had primary pull-through procedure without a colostomy. The definitive pull-through procedure done in all the patients was Swensons abdomino-perineal pull-through and all the patients had a 2-layered colo-anal anastomoses. Due to the rigid pelvis in these patients, as well as possible scarring, simple blunt dissection was difficult in these cases. The median length of follow up was 11 months (range 6-28 months). There was one case (7.1%) of mortality. CONCLUSION Older patients with Hirschsprungs disease present with intestinal obstruction and poor nutritional status that may necessitate preoperative colostomy. Swensons pull-through in them poses peculiar challenges of mobilization of bowel and achieving a reliable colo-anal anastomosis, however, outcome is comparable with surgery in younger children if these challenges are overcome.

Reverse gastric tube oesophageal substitution for staged repair of oesophageal atresia and tracheo-oesophageal fistula

The management of oesophageal atresia and tracheo-oesophageal atresia (OATOF) is very challenging. While in developed countries survival of patients with this condition has improved, the outcome in many developing countries has been poor. Primary repair through a thoracotomy (or video-assisted thoracoscopic surgery where available) is the gold standard treatment of OATOF. However, in our setting where patients typically present late and with minimum support resources such as Neonatal Intensive Care Unit and total parenteral nutrition; staged repair may be the only hope of survival of these patients and this communication highlights the essential steps of this mode of treatment.

A single-institution experience with hydrostatic reduction for childhood intussusception: A preliminary report

Background/purposeHydrostatic reduction for intussusception has the benefit of achieving reduction without the need for general anaesthesia or surgery and the possible attendant complications. This has made it the most popular interventional modality in many centres today. Hydrostatic reduction was added to our armamentarium in the treatment of childhood intussusception recently and this report represents our initial experience. MethodsThis study is a prospective review of all cases of intussusception that presented at the Emergency Department at the Lagos University Teaching Hospital between February 2012 and May 2014. Eligibility for hydrostatic reduction was based on internationally recognized criteria, which included absence of peritonitis and shock. Data were analyzed using the statistical package for social sciences (version 20). The &khgr;2-test was used to compare categorical variables, and a P value of 0.05 was considered significant. ResultsA total of 66 patients were seen within the study period. Thirty-eight were male (57.6%) and 28 were female (42.4%). The age range was 3–84 months and the mean age was 12.0±30.8 months. Twenty-six patients (39.4%) underwent hydrostatic reduction, of which 11 (42.3%) were successful. There was a correlation between the duration of symptoms and successful hydrostatic reduction (P<0.05), with five of the 11 (45.5%) presenting within 24 h of symptoms. ConclusionAlthough less than half of the patients presenting with childhood intussusception were eligible for hydrostatic reduction, the method remains a feasible option in our environment in spite of late presentation by most of our patients. The duration of presenting symptoms was the most important determinant of successful hydrostatic reduction.

Routine haemoglobin electrophoresis screening in day case herniotomy in Nigerian children: Is it evidence-based?

Background: To determine the prevalence of haemoglobinopathies in children who require day case herniotomy in our centre and ascertain if routine screening is necessary in all patients who require herniotomy. Materials and Methods: A 12-month retrospective analysis of patients requiring herniotomy in our centre. Data including age, sex, diagnosis, haemoglobin electrophoresis status, surgical outcome and hospital stay were analysed. Results: Ninety-five patients had complete records. There were 84 boys and 11 girls. M:F ratio: 7.6:1. The mean age was 3.2 ± 0.6 years. Fifty-five point eight per cent of the patients had right inguinal hernias while 35.8% had left inguinal hernias. Eight patients (8.4%) had bilateral inguinal hernias. Twenty-six patients (27.4%) had haemoglobinopathies while 69 patients (72.6%) had homozygous Haemoglobin A. The Sickle Cell trait (HbAS) was found in 22 patients (23.2%) while the HbAC was found in three patients (3.2%). One patient (1.1%) had Sickle Cell disease (Haemoglobin SS). He had had blood transfusion and previous history of jaundice. All patients survived and all patients were discharged on the day of surgery (mean hospital stay: 4hrs (range: 2.5 hrs–12 hrs)) except the patient with Sickle Cell disease who was admitted a day before surgery and discharged a day after the operation. Conclusion: One in four children coming for day case herniotomy in our centre had the Sickle Cell trait while only 1% had the Sickle Cell disease. These findings are in keeping with the prevalence in the Nigerian population. Routine screening may not be necessary for all patients coming for herniotomy in our centre. Clear indication(s) should be outlined for screening.

Primary Swenson's pull-through for adult Hirschsprung's disease: A report of two cases from Southwest Nigeria

Hirschsprungs disease is commonly diagnosed (up to 90% in developed countries) in the neonatal period and infancy although late presentation into adulthood still occurs albeit uncommon. Adult Hirschsprungs disease (AHD) is defined as the presentation with features of Hirschsprungs disease to the hospital for the 1 st time or being diagnosed for the 1 st time after the age of 10 years. The standard treatment for AHD is staged: An initial colostomy, a pull-through procedure and a closure of the colostomy. The colostomy is performed to decompress the bowel of the huge fecal load, to allow the proximal megacolon to shrink and thus reduce the coloanal disproportion that will result during anastomosis and also to allow the nutritional rehabilitation of the patient resulting from the chronic constipation. Recent reports suggest that primary pull-through is possible in adults either as an open procedure or laparoscopically assisted. This is a report two cases of AHD managed in our center and who had primary Swensons pull-through without a stoma. The need for patient selection is emphasized for a good outcome.

Le test de mallampati modifié, la distance thyromentonnière et l’espace entre les incisives sont les meilleurs prédicteurs de difficultés laryngoscopiques chez des Africains de l’Ouest

Objectif Determiner la capacite de predire les difficultes de visuali-sation du larynx (DVL) a partir des indices preoperatoires suivants, pris isolement et en combinaison : le test de Mallampati modifie (TMM), la distance thyromentonniere (DTM), la distance sternomentionniere (DSM), la longueur horizontale de la mandibule (LHM) et l’espace inter-incisive (EII).PurposeTo determine the ability to predict difficult visualization of the larynx (DVL) from the following preoperative airway predictive indices, in isolation and combination: modified Mallampati test (MMT), thyromental distance (TMD), sternomental distance (SMD), horizontal length of the mandible (HLM) and inter-incisor gap(IIG).MethodsThree hundred and eighty consecutive patients undergoing general anesthesia were evaluated using the MMT, TMD, SMD, HLM and IIG and the cut-off points for the airway predictors were Mallampati III and IV; # 6.5 cm, # 13.5 cm, # 9.0 cm and # 4.0 cm respectively. During direct laryngoscopy, the laryngeal view was graded using the Cormack and Lehane (CL) classification. CL grades III and IV were considered difficult visualization. Sensitivity, specificity and positive predictive value for each airway predictor in isolation and in combination were determined. Logistic regression analysis was used to determine independent predictors of DVL. Results: Difficulty to visualize the larynx was found in 13 (3.4%) patients. The sensitivity, specificity and the positive predictive value for the five airway predictors were: MMT (61.5%; 98.4%; 57.1 %), TMD (15.4%; 98.1%; 22.2%), SMD (0%; 100%; 0%), HLM (30.8%, 76.0%; 4.3%) and IIG (30.8%; 97.3%; 28.6%). The best combination of predictors was MMT/TMD/IIG with a sensitivity, specificity and positive predictive value of 84.6%; 94.6%; 35.5% respectively. Logistic regression analysis showed that weight, MMT, IIG and TMD were independent predictors of DVL.ConclusionMMT, TMD and IIG appear to provide the optimal combination in prediction of DVL in a West African population.RésuméObjectifDéterminer la capacité de prédire les difficultés de visuali-sation du larynx (DVL) à partir des indices préopératoires suivants, pris isolément et en combinaison : le test de Mallampati modifié (TMM), la distance thyromentonnière (DTM), la distance sternomentionnière (DSM), la longueur horizontale de la mandibule (LHM) et l’espace inter-incisive (EII).MéthodeNous avons évalué 380 patients consécutifs devant subir une anesthésie générale en utilisant le TMM, la DTM, la DSM et l’EII; les points limites des prédicteurs d’intubation ont été les classes de Mallampati III et IV; # 6,5 cm, # 13,5 cm, # 9,0 cm et # 4,0 cm respectivement. La visualisation laryngoscopique directe a été cotée selon la classification de Cormack et Lehane (CL). Les classes de CL III et IV étaient une visualisation difficile. La sensibilité, la spécificité et la valeur prédictive positive de chaque prédicteur d’intubation pris isolé-ment et en combinaison ont été déterminés. On a déterminé les pré-dicteurs indépendants des DVL par l’analyse de régression logistique.RésultatsLa visualisation du larynx a été difficile chez 13 (3,4 %) patients. La sensibilité, la spécificité et la valeur prédictive positive des cinq prédicteurs d’intubation ont été : le TMM (61,5 %; 98,4 %; 57,1 %), la DTM (15,4 %; 98,1 %; 22,2 %), la DSM (0 %; 100 %; 0 %), la LHM (30,8 %; 76,0 %; 4,3 %) et l’EII (30,8 %; 97,3 %; 28,6 %). La meilleure combinaison de prédicteurs a été TMM/DTM/EII avec une sensibilité, une spécificité et une valeur pré-dictive positive de 84,6 %; 94,6 %; 35,5 % respectivement. L’analyse de régression logistique a montré que le poids, le TMM, l’EII et la DTM étaient des prédicteurs indépendants des DVL.