Jo Adeniran

Typhoid ileal perforation in Nigerian children: an analysis of 106 operative cases

Abstract. Typhoid ileal perforation (TP) is a major problem in developing countries and carries a high mortality. The purpose of this retrospective study from Nigeria was to review the outcome in children less than 15 years of age who underwent surgery for TP from 1984 to 1999. Demographic data, clinical features, results of investigations, findings at surgery, postoperative course, and complications were recorded. There were 55 boys and 51 girls. The median age at presentation was 10 years (range 3–14). The surgically confirmed perforation rate was 11.0%. The clinical features in children older than 5 years were similar to already documented patterns in the literature. In children less than 5 years old the predominant symptoms were fever and vomiting only. Therefore, in the very young a high index of suspicion is required to avoid delay in diagnosis. Ninety eight patients (92.5%) had simple double-layer closure of the perforation. The mean hospital stay among survivors was 23.6 ± 18.8 days. The commonest postoperative complications were wound infection and enterocutaneous fistula. The overall mortality was 23.8%, increasing to 50% in children aged less than 5 years, although the difference was not statistically significant (P > 0.05). To improve survival in TP, attention should be focused on perioperative resuscitation and early intervention. The provision of potable water, adequate sanitation, and active immunisation are means to eradicate the disease.

One-stage correction of intermediate imperforate anus in males.

This prospective study was designed to assess the safety, cost-effectiveness, and advantages of performing posterior sagittal anorectoplasty (PSARP) without colostomy on males with intermediate imperforate anus in a developing country. Fifteen consecutive males with intermediate imperforate anus were entered into the study. Chest and abdominal x-rays, skeletal surveys, renal ultrasound scans, and invertograms were done. Patients were resuscitated and Peña’s PSARP done in prone positions. A 2-ml syringe vent was inserted into the new anus for 10xa0days. Babies were nursed prone postoperatively. Cephalosporin and metronidazole were given as perioperative antibiotics. All patients had intermediate anomalies. There were no other major associated congenital anomalies. A urethral catheter could not be inserted in one patient, and one patient who presented with septicemia and jaundice was deemed too ill to withstand a major operation; these two patients therefore had diverting colostomies. There were no problems with PSARP in the other 13xa0patients. One patient’s father discharged him against medical advice on the 5th postoperative day; the mother had had postpartum hemorrhage, so they opted for traditional treatment because they could not provide blood donors. The skin wounds of 10xa0patients healed completely with removal of stitches; two boys had superficial wound infection. Parents who lived far from the hospital were taught how to dilate the anus. Follow-up has ranged between 3xa0months and 2xa0years. This prospective study shows that it is feasible for males with intermediate imperforate anus to have safe PSARP without colostomy. The advantages of one instead of three major operations are many, especially in developing countries. If this result can be reproduced in cases of high anomalies, colostomy may be unnecessary in many cases of anorectal malformations, with many benefits to these children and their families.

Salmonella intestinal perforation: (27 perforations in one patient, 14 perforations in another) Are the goal posts changing?

The pathology of salmonellosis after a faeco-oral transmission was first clearly described by Jenner in 1850. Over the years, the pathological manifestations in different tissues of the body have been described. The ileum is however mostly involved leading to enlarged Peyers patches, ulceration, and sometimes bleeding and perforation. Efforts at control have largely been improvement in public water supply, safe disposal of waste, and general public health measures. Despite these measures, intestinal perforation from salmonellosis remains the commonest cause of emergency operation in children above 3 years. The incidence continues to rise, so also the mortality, despite new antibiotics and improvement in facilities in the hospitals. Even more disturbing is that we now see more perforations per patient, and more involvement of the colon. Three recently managed patients with multiple ileal/colonic perforations were reviewed. Presenting problems, delay in referral, choice of antibiotics and postoperative complications were noted. One patient had 27 perforations and another 14 perforations. Both survived. Is salmonella changing? Are our patients changing? Is the environment changing? Are the goal posts changing? This article details our recent experience with this dreadful disease, reviews the new literature and makes suggestions for the way forwards.

Bowel resection in Nigerian children

BACKGROUNDnAlthough bowel resections are commonly done for congenital malformations in children in developed countries, they usually follow neglected and preventable acquired diseases of the intestine in developing countries.nnnOBJECTIVESnTo determine the indications and outcome of bowel resections in children of a developing country in a university teaching hospital.nnnMATERIALS AND METHODSnData of the patients operated (from birth to 15 years) was retrospectively collected over eight years (January 1999 to December 2006). The biodata of children included the following: Indications for operation, type of operations, duration of admission, and outcome of treatment including complications. Patients with Hirschsprungs disease were excluded from the study because bowel resection forms part of their definitive surgical management.nnnRESULTSnThere were 70 patients (38 boys and 32 girls). The age ranged between four hours to 15 years (median, five months). There were 16 (22.9%) neonates, 26 (37.1%) infants, and 28 (40%) grown children. The indications were congenital anomalies in the 16 neonates. Also, 23 (88.5%) infants had intussusception, 2 (7.7%) had midgut vovulusm and 1 (3.8%) had congenital small intestine band. Among the grown children, typhoid ileal perforation (TIP) was seen in 14 (50.0%), intussusception in 5 (17.9%), and other causes in nine patients. Overall, intussusception was the most common indication for bowel resection, followed by TIP. A total of 24 patients developed 33 complications. Complications included wound infection in 47.8% and anastomotic leak in 42.8%. The duration of admission ranged between 4-35 days (median, 15 days). The overall mortality was 17.1% -; which was highest among neonates (56.3%), followed by the infants (26.9% -).nnnCONCLUSIONnBowel resections are mainly done for intussusception and complications of TIP at our centre. Late presentation, preexisting malnutrition, and nonavailability of parenteral nutrition contributed to unacceptable morbidity and mortality.