Donald E. Meier

The outcome of suprapubic prostatectomy: A contemporary series in the developing world

OBJECTIVES To assess the appropriateness of the technique of suprapubic prostatectomy using a removable bladder neck partition suture for use in a developing world hospital and to provide contemporary open prostatectomy outcome data currently lacking in the worlds literature. METHODS From 1984 to 1994, 240 consecutive patients presenting to a developing world hospital with acute urinary retention underwent suprapubic prostatectomy using a removable bladder neck partition suture. The average length of time from bladder decompression until operation was 2.5 months. The outcome of these cases was retrospectively analyzed. RESULTS The overall early complication rate was 19.6%. There were no deaths. The transfusion rate was 4.6%. Clot retention occurred in 6.7%, and 2.9% required return to the operating room for evaluation. For the second half of the series, the early complication rate decreased to 8.3%, the clot retention rate to 0.8%, and the transfusion rate to 1.7%. Other early and late complications were minimal. The length of delay from decompression until operation did not affect outcome. CONCLUSIONS The technique of suprapubic prostatectomy using a removable bladder neck partition suture is appropriate for use in developing world hospitals because of its low morbidity and mortality rates. The outcome in this contemporary series of open prostatectomy cases compares favorably with the outcome from reported contemporary transurethral resection of the prostate (TURP) series. These data demonstrate that suprapubic prostatectomy is an acceptable option when the patients anatomy or the state of local medical facilities precludes TURP.

Incidence of umbilical hernia in African children: redefinition of "normal" and reevaluation of indications for repair.

Abstract. This study was undertaken to assess the degree of ubiquity of umbilical hernias (UHs) in Nigerians and to determine if a laissez faire approach to the presence of UHs is justified. A prospective evaluation was conducted of the umbilical area of 4052 Nigerians living in the vicinity of the Baptist Medical Centre (BMCO) in Ogbomoso, Nigeria. The diameter of the fascial defect was measured with the subject supine and the protrusion of the umbilical skin with the subject erect. Subjects were divided into three groups: group 1 (1 month to 18 years old); group 2 (older than 18 years); and group 3 (pregnant women in an antenatal clinic). “Outies” (defined as any protrusion of the umbilical tip past the periumbilical skin) were present in 92% of group 1, 49% of group 2, and 90% of group 3 subjects. UHs (defined as protrusion of at least 5 mm and diameter of at least 10 mm) were present in 23% of group 1, 8% of group 2, and 15% of group 3 subjects. Spontaneous closure of UHs seems to occur until age 14. A retrospective analysis identified 11 patients undergoing emergency operations for UH-related problems during the past 15 years. With a low incidence and 0% mortality rate associated with management of these emergencies, a policy of prophylactic repair is not justified at BMCO. Because most of the children we examined had outies, repair for cosmetic reasons is rarely requested. The only logical indication for repair of UHs at BMCO is incarceration, and this rarely occurs.

Intussusception in children: international perspective.

Abstract. Fifty consecutive cases of children with intussusception treated at a hospital in a developing country were compared with 50 consecutive cases treated at an American inner city children’s hospital and 50 consecutive cases treated at an American referral children’s hospital. The plan was to recommend ways of improving the treatment of children with intussusception in the developing world. Nonoperative reduction was attempted in the two American hospitals but was not available in the developing world hospital where all children were treated operatively. Children in the developing world hospital had a significantly longer duration of symptoms, an increased incidence of nonviable bowel, and a mortality of 18%. There were no deaths in either American hospital. The poorer outcome for developing world children was related to delay in treatment, the higher incidence of nonviable bowel, and the lack of adequate nursing care for acutely ill children. The use of nonoperative reduction would not have significantly improved the mortality rate among the developing world children. The mortality can best be reduced by: (1) earlier recognition and treatment of the intussusception; and (2) improvement in the postanesthetic care with better monitoring leading to prompt recognition and treatment of postoperative complications.

Tetanus: Continuing Problem in the Developing World

Despite diligent efforts by the World Health Organization and the governments of developing world countries, tetanus persists as a global health problem. This retrospective study was undertaken to assess the outcome for victims of tetanus presenting to the Baptist Medical Centre in Ogbomoso, Nigeria and to develop better management techniques for future patients. Sixty patients (46 males, 14 females) with nonneonatal tetanus were seen over a 5-year period (1995–1999). The mean age was 26 years, and 74% were 30 years or younger. All patients were treated with antitetanus serum, antibiotics, wound débridement (when a wound was identified), and antispasmodics. No patients underwent tracheostomy or gastrostomy. The mortality rate was 44%. Factors significant for predicting mortality were age greater than 14 years, occupation as a farmer, short incubation period, short symptom duration, high degree of severity on presentation, and high temperature during hospital care. The best hope for improvement in the treatment of tetanus in our institution is more conscientious titration of antispasmodics to control spasms without causing significant respiratory depression. The only real hope for reducing the global mortality for tetanus, however, lies in renewed immunization efforts by all health care providers in developing world countries, not just community health workers.

Perforated typhoid enteritis: Operative experience with 108 cases

A retrospective review of 108 consecutive patients with perforated typhoid enteritis managed operatively over a 4-year period at Baptist Medical Centre, Ogbomoso, Nigeria is presented. There were 75 males and 33 females with an average age of 19.7 years. Presenting symptoms were fever, abdominal pain, vomiting, and either diarrhea or constipation. One hundred patients (93 percent) underwent debridement of the perforation and two-layer bowel closure. Postoperative morbidity included intraabdominal abscess, wound dehiscence, and subsequent bowel perforation. Most of the 35 deaths (32 percent mortality) were attributed to overwhelming sepsis which progressed despite aggressive operative management and antibiotic administration. The key to improved survival in this deadly disease lies not in a better operation or improved perioperative care but in the prevention of typhoid fever by providing safe drinking water and improved sanitation methods for all of the global community.

Prospective Randomized Comparison of Two Preoperative Skin Preparation Techniques in a Developing World Country

Povidone-iodine (PI) is a scarce and expensive item for some hospitals in developing countries. This prospective, randomized study was performed at Baptist Medical Centre (BMCO) in Ogbomoso, Nigeria to determine if the use of PI for preoperative skin preparation would result in a lower postoperative wound infection rate and to identify other factors influencing the infection rate. Two hundred patients undergoing inguinal hernia repair were randomized to receive skin preparation with either: (1) locally available, inexpensive market soap and methylated spirit or (2) imported PI. The two groups were equally stratified. The overall postoperative wound infection rate was 5.5%, and there was no significant difference between the groups (5.1% vs. 5.9%). Factors that did not affect the infection rate included gender, age, type of anesthesia, type or duration of the operative procedure, and number of breaks in optimal technique. There were eight abscesses and three cases of cellulitis without suppuration diagnosed an average of 10 days postoperatively. Staphylococcus was the only bacterium identified on Gram stain or culture. The expense of procuring PI is not justified at BMCO. Available funds may better be used for preoperative antibiotics or for improvement in hospital infrastructure, which should result in fewer breaks in optimal operating room technique.

Antegrade continent enema management of chronic fecal incontinence in children

BACKGROUND/PURPOSE Fecal incontinence impedes social and psychological development in children. Conventional bowel management with rectal enemas, medication, and biofeedback frequently will provide intervals free of fecal soiling sufficient for children to be socially continent. METHODS This report details the improvement achieved by antegrade irrigation of the colon when conventional bowel management programs have failed to provide satisfactory intervals free of fecal soiling. Twenty-three children had conduits performed to administer antegrade continent enemas in the colon from December 1993 to May 1997. RESULTS Twenty of the children were available for evaluation. One child was lost to follow-up, and two were noncompliant with the irrigation program. Fourteen of the 20 children are out of diapers. Four of the six wearing diapers, do so for urinary, not fecal incontinence. Two patients (10%) still require diapers for fecal incontinence. Parents were pleased with the efficacy of antegrade irrigation and the decrease in family stress with the elimination of fecal soiling. CONCLUSIONS Ninety percent of the children available for follow-up benefited from antegrade irrigations of the colon. The antegrade irrigations were an improvement over conventional bowel management programs because a predictable interval free of soiling could be established. This allowed families to plan activities and improved the self-esteem of their children.

Management of asymptomatic patients following stab wounds to the chest

A patient with stab wounds to the chest may have negative physical findings, and normal radiologic examinations and still develop delayed pneumothorax or hemothorax. The frequency and time intervals of these complications have not been established. One hundred ten asymptomatic patients with chest stab wounds were prospectively studied. All patients had normal chest radiographs on initial evaluation. Ten patients (9%) developed a delayed pneumothorax or hemothorax. Careful radiologic examination using inspiratory and expiratory chest films revealed all positive findings by 6 hours postadmission. Asymptomatic patients with chest stab wounds can be safely managed without hospitalization.

Typhoid Intestinal Perforations in Nigerian Children

Abstract. This study was a retrospective analysis of 75 children with perforated typhoid enteritis treated at the Baptist Medical Centre in Ogbomoso, Nigeria over a 4-year period. The mean age was 11.4 years. The usual symptoms were fever and abdominal pain, with a mean duration of 10.5 days. The diagnosis of perforation was usually based on the history and physical examination alone. The time interval from hospital presentation to operation was 11 hours, during which intravenous crystalloid and antibiotics were administered. Among the 75 children, 53 (71%) had a single perforation, and 22 had multiple perforations. Débridement and two-layered closure was performed in 71 (95%) and resection with anastomosis in 4 (5%). Ileus resolution was usually not complete until the eighth postoperative day, and the mean time until the surviving children were afebrile was 10 days. Complications other than death occurred in 7 (9%) children, and there were 15 deaths (20% mortality). All deaths were attributed to overwhelming sepsis, and all but one of the deaths occurred during the first 72 postoperative hours. The only factor statistically significant as a predictor of mortality was the duration of abdominal pain. Improvement in perioperative management including intensive care nursing and more effective antibiotics, although expensive, could result in decreased mortality. A significant decrease in mortality can occur only when the prevention of typhoid fever becomes a higher priority than its treatment.

Parathyroid carcinoma in a child.

Parathyroid carcinoma is a rare cause of hypercalcemia in children but should be considered in a child presenting with an extremely elevated serum calcium level. The authors report the fifth case of parathyroid carcinoma in a child less than 16 years of age.