Jy Chinda

Challenges in the management of early versus late presenting congenital diaphragmatic hernia in a poor resource setting.

BACKGROUND Despite the advances in management, congenital diaphragmatic hernia (CDH) has continued to pose a significant challenge to paediatric surgeons. This is amplified in a setting like ours where there is a dearth of facilities to cope with the problem of CDH. This study was undertaken to highlight the peculiarities of the management of CDH in a poor resource setting. METHODS All confirmed cases of CDH were prospectively documented from 2003 till date. RESULTS Seven children were treated from 2003 till date. The diaphragmatic defect was on the left side in six (83.8%) and on the right side in one (17.7%). All the patients had primary closure of the defect without patch via an abdominal approach. The three patients presenting at birth died while the remaining four patients survived. CONCLUSION With inadequate neonatal intensive care facilities, the severe early presenting CDH has a dismal prognosis. In contrast, the late presenting CDH poses more diagnostic challenges; but once identified and appropriate treatment instituted, it has an excellent prognosis. We recommend that physicians should include CDH in the differential diagnosis of patients with birth asphyxia and in patients with chronic respiratory symptoms with failure to thrive.

The epigastric heteropagus conjoined twins

Conjoined twins are rare and are classified as symmetrical or asymmetrical, in which a member, the host (autosite), is near normal and bears the parasite, which is incomplete, smaller, and fully dependent for growth on it. This form of conjoined twins is referred to as heteropagus and when attached to the epigastrium of the autosite is called epigastric heteropagus. Only 44 cases of epigastric heteropagus twins have been previously reported in the world literature. We hereby report the successful separation of a pair of heteropagus twins.

Cleft lip and palate surgery in children: Anaesthetic considerations

BACKGROUND The Care of cleft patients is very challenging. Team cleft care is usually lacking in many developing countries due to shortage of qualified manpower. This study is aimed at highlighting anaesthetic challenges in the management of cleft in children. PATIENTS AND METHODS This was a study of cleft lip and palate patients who were managed during team cleft care activities at University of Maiduguri Teaching Hospital and Federal Medical Centre Nguru both in north eastern Nigeria from January to June 2009. RESULTS One hundred and six cleft patients presented for surgical repair under general or local anaesthesia. Fifteen (14%) patients all of whom children were unfit for general anaesthesia due to various medical reasons. Ninety-one (86%) cleft patients comprising 53(50%) children and 38(36%) adults had cleft repair under halothane general endotracheal anaesthesia and local anaesthesia, respectively. There was no anaesthetic complications recorded under local anaesthesia. Fifteen percent of children who received general endotracheal anaesthesia suffered various anaesthetic complications which included hypoxia (3.8%), laryngospasm (1.9%), kinking of endotracheal tube (5.7%), inadvertent extubation (1.9%) and pulmonary aspiration (1.9%). There was no mortality or anaesthesia-related morbidity at the time of discharge in all the cases. CONCLUSION We conclude that anaesthesia for cleft lip and palate repair in hospital based team-cleft care activities in our environment is relatively safe. We recommend general anaesthesia with controlled ventilation for children and local anaesthesia for adult and older children who can cooperate.

Giant omental lipoma in a 13-year-old adolescent girl

Although lipoma is a common benign mesenchymal tumor, its occurrence in the omentum is a rare finding. We report an unusual case of omental lipoma in a 13-year-old adolescent girl. The mass was completely excised and weighed 12.3 kg. The patient is alive and well with no evidence of recurrence at 4 months of follow-up.

Appendicovesical fistula associated with Hirschsprung’s disease

Appendicovesical fistulae are rare. Only 112 cases in all ages have been reported previously in the world literature. Our case is that of a 1-year-old boy who presented during the neonatal period with missed appendiceal perforation associated with a long segment Hirschsprung’s disease. The case is discussed.

Epidemiology and management of head injury in paediatric age group in North-Eastern Nigeria

Background: Paediatric head injury (HI) is the single most common cause of death and permanent disability in children world over, and this is increasingly becoming worrisome in our society because of increased risks and proneness to road traffic accidents on our highways and streets. The study set to determine causes and management of HI among children in our society. Patients and Methods: A retrospective review of all children aged 0-15 years with traumatic head injury (THIs) who were managed at the University of Maiduguri Teaching Hospital between July, 2006 and August, 2008. Results: A total of 45 children with THIs presented to the casualty unit of the hospital; 30 (66.7%) were boys and 15 (33.3%) were girls. Three (6.7%) children were less than 1 year of age, 21 (46.7%) were between 1 years and 6 years while 16 (35.6%) and 5 (11.0%) were aged 7-11 years and 12-15 years respectively. Thirty six (80.0%) of the children were pedestrians, 6 (13.4%) fell from a height, while 2 (4.4%) and 1 (2.2% were as a result of home accident and assault, respectively. Twenty one patients (46.7%) had mild HI, while 53.3% had moderate to severe category. Forty one (91.1%) of children were managed as in-patients, mostly (95.1%) by conservative non-operative management, while 4 (8.9%) were treated on the out-patient basis. The mortality rate was 17.8%. Conclusion: H1 among children is of a great concern, because of its incremental magnitude, due to increasing child labour and interstate religious discipleship among children, with attendant high mortality and permanent disabilities. Necessary laws and legislations should be formulated and implemented with organized campaigns and public enlightenment to prevent and mitigate this menace.

MECONIUM PERITONITIS IN NIGERIAN CHILDREN

BACKGROUND Meconium peritonitis is a rare disease with a fatal outcome. In Nigeria and Africa, there are only the occasional case reports on the subject matter. METHODS This is a 10-year retrospective study of all patients with meconium peritonitis treated at the University of Maiduguri Teaching Hospital, Maiduguri, Borno State, the Lagos University Teaching Hospital, Lagos State, Obafemi Awolowo University Teaching Hospitals complex, Ile-Ife, Osun State and the Federal Medical Centre Gombe, Gombe State, Nigeria. RESULTS There were 10 neonates comprising 6 girls and 4 boys. The median age at presentation was 4 days (range 2-6 days). Six of the mothers of the children with meconium peritonitis had a supervised antenatal care and 4 had antenatal ultrasonography but meconium peritonitis was missed. The most common clinical presentation was abdominal distension at birth in 9 of 10 patients. The abdominal X-rays showed calcification and homogenous opacity in 4 patients and pneumoperitoneum in 2 patients. At laparotomy, all the patients had inflammatory adhesion bands and matted bowel loops. The generalized type was the commonest form observed (7 patients) and giant pseudocyst was noted in 2 patients. The commonest sites of perforation were the ileum in 4 patients and jejunum in 3 patients. In one patient the perforation had sealed at laparotomy. Intestinal obstruction was the commonest cause of meconium peritonitis in 7 of 10 patients. In the remaining 3 patients the cause is unknown. The commonest procedure performed was resection and anastomosis (4 patients). The mortality rate was high (50%). CONCLUSION Our data revealed the rarity of meconium peritonitis and intestinal obstruction as the commonest cause. It is recommended that in patients with an unidentifiable cause a rectal biopsy should be done to rule out Hirschsprungs disease. Early diagnosis, proper operative procedure and meticulous post-operative care should improve their survival.

Exstrophy anomalies: Preliminary review of 18 cases in Maiduguri, North-eastern Nigeria

BACKGROUND Exstrophy anomalies, although rare, pose a tremendous challenge to both surgeons and surrogates. Management is intricate and experience with large members is restricted to a few centres worldwide. This report is a review of 18 cases of these anomalies managed in University of Maiduguri Teaching Hospital (UMTH) over 8 years, highlighting the intricacies of management, and contributes to the existing data bank on this subject matter in our environment. MATERIALS AND METHODS We reviewed the records of all cases of anomalies that were managed in the index hospital from December 2002 to December 2010. RESULTS Eighteen cases were studied. The youngest was a 2-day-old neonate and the oldest was 6 years at repair, with a median age of 4 months. There were 7 boys and 9 girls with bladder exstrophy, and the remaining two were girls with cloacal exstrophy, giving a male-female ratio of 7:11 for the exstrophy anomalies. Eight patients (33.5%) had associated congenital anomalies; 16.7% had undescended testes (UDT), anorectal malformation (ARM) and patent processus vaginalis (PPV); and duplicate bladder occurred in 5.6% of the patients. All but one patient had bilateral posterior iliac osteotomy at bladder closure. Out of the 17 patients that had osteotomy, 76.5% had satisfactory bladder closure (no complication), 5.9% had superficial wound dehiscence, 11.8% had bladder neck dehiscence and 5.9% had complete disruption. The lone patient that did not undergo osteotomy had complete bladder dehiscence. Postoperative immobilization was done for 3 weeks for 16 cases; one was discontinued after 1 week because of complication. The longest follow-up was for 2 years and the shortest for 2 weeks. Four patients (22.2%) did not turn up for follow-up. CONCLUSION Exstrophy anomalies although rare remain a major challenge in paediatric surgery. Iliac osteotomy, among other technical considerations, remains a cornerstone for successful bladder closure.